Procedure Competency Assessment Tool
Oral Endotracheal Intubation

Definitions related to this topic

Anesthesia- Loss of sensation resulting from pharmacologic depression of nerve function or from neurological dysfunction.

Arytenoids- Denoting cartilage (arytenoid cartilage) and muscles (oblique and transverse) arytenoid muscles) of the larynx.

Cuffed tubes- an inflated cuff surrounds a tube and is not inflated until after the tube is placed in the trachea.  They are used to minimize the aspiration of foreign material into the bronchus.  A cuffed tube should be used if there are excessive upper airway secretions or hemorrhage to prevent materials from entering the lungs.  Cuffs also minimize air and pressure links around the tube.

Edema- An accumulation of an excessive amount of watery fluid in cells, tissues, or serous cavities.

Esophagus- The portion of the digestive canal between the pharynx and stomach.  It is about 25cm long and consists of three parts: the cervical part, from the cricoid cartilage to the thoracic inlet; the thoracic part, from the thoracic inlet to the diaphragm; and the abdominal part, below the diaphragm to the cardiac opening of the stomach.

Granulomas- Indefinite term applied to nodular inflammatory lesions, usually small or granular, firm, persistent, and containing compactly grouped mononuclear phagocytes.

Hyperextension- Extension of a limb or part beyond the normal limit.

Intubation- the insertion of a tubular device into a canal, hollow organ, or cavity.

Larynx- The organ of voice production; the part of the respiratory tract between the pharynx and the trachea; it consists of a framework of cartilages and elastic membranes housing the vocal folds and the muscles that control the position and tension of these elements.

Middle ear effusion- the escape of fluids from the middle ear.

Oral cavity- The mouth.

Sepsis- The presence of various pus-forming and other pathogenic organisms, or their toxins, in the blood or tissues; septicemia is a common type of sepsis.

Sinusitis- Inflammation of the lining membrane of any sinus, especially of one of the paranasal sinuses.

Stenosis- A stricture of any canal; especially, a narrowing of one of the cardiac valves.

Stenting- A supporting device that is used to keep the glottis open.

Synechia- Any adhesion; specifically, adhesion of an inflamed iris to the cornea or lens.

Traumatic intubation- infers that local tissue irritation or damage occurs because of the procedure.

Ulcers- A lesion on the surface of the skin or on a mucous surface, caused by superficial loss of tissue, usually with inflammation.
Vocal hypofunction- Term used to describe the inadequate    muscular tone in the laryngeal mechanism and associated structures or symptoms.

Types of intubation

Endotracheal intubation-  the passage of a tube through the nose or mouth into the trachea for maintenance of the airway during anesthesia or for maintenance of an imperiled airway.  This is considered a relatively temporary procedure. The type of intubation used depends on the patient's condition and on the purpose of intubation.

Nasogastric intubation- the insertion of an endotracheal tube through the nose and into the stomach to relieve excess air from the stomach or to instill nutrients or medications.

Nasotracheal intubation- (blind) the insertion of an endotracheal   tube through the nose and into the
Trachea. The tube is passed without using a laryngoscope to view the glottis opening.  This technique may be used without hyperextension, therefore it is useful when a client or patient has cervical spinal trauma and with patients who have clenched teeth.  Indications for this type include intraoral operative procedures, during which the endotracheal tube could easily be displaced or obscure
The operative site.  Bleeding is not unusual after intubation.  The tubes are usually smaller than those used for orotracheal intubation.  This can also be performed with direct visualization with a laryngoscopic examination. Blind intubation is only used if there are indications that the larynx cannot be visualized.

Orotracheal intubationthe insertion of an endotracheal tube through the mouth and into the trachea. This type is performed much more frequently than nasotracheal intubation.

Fiber optic intubation-(awake) a fiber optic scope issued that has an eyepiece to visualize the larynx and handle to control the tip.  It is usually 2 1/2 - 3 feet long.  It is inserted in the patient's throat and guided to the larynx and glottis opening.  The endotracheal tube is then slid over the fiber optic scope into the trachea.  This procedure is usually used when patients are unable to flex and extend their head for any reason.  Usually, the patient’s throat is numbed with local anesthetics. Patients are sedated and made comfortable.  Sometimes the patient is put to sleep.  If general anesthesia is used an assistant is mandatory, because one person cannot monitor the patient, administer general anesthesia, and perform fiberoptic endoscopic examination.

Tracheostomy intubationplacing a tube by incising the skin over the trachea and making a surgical wounding order to create an airway.  For the best results, it is performed over a previously placed endotracheal tube in an operating room. However, this is also performed as an urgent, lifesaving procedure.

Speaking tracheostomy tubes- specifically designed tracheostomy tubes that allow the ventilator-dependent client to speak by enabling air to enter the larynx without compromising the patient's or client's ventilation.  They keep the air that is needed to ventilate the lungs separate from the air supply for speech.  Currently, there are two types of designs to allow for independent voice control.
a. Electromechanical solenoid- controls the flow from the compressed air source.
b. Air compressor- it can be turned on and off to supply regulated air to the tracheostomy tube.

Indications for Intubation

  • To provide an airway in the trachea.
  • Control of pulmonary ventilation
  •  For anesthesia (intracranial, intrathoracic, and most intraabdominal operations mandate)
  • To relieve excess air from the stomach or to instill nutrients or medications.
  •  After induction of general anesthesia, to minimize the possibility of aspiration of gastric contents.
  •  For patients in respiratory distress. 
Effects of Intubation  

Major Complications:

1) Tube obstruction.

2) Local tissue damage due to infection or pressure necrosis in the nose, oral cavity, larynx, or subglottic trachea.

3) Endobronchial (causes left lung to collapse) or esophageal intubation
·       Vocal fold scarring or fibrosis after prolonged endotracheal or nasogastric intubation.
·       Damage to the vocal mechanism during intubation or extubating or from protracted intubation.
·       Stenosis and other laryngotracheal complications frequently are secondary to prolonged intubation.
·       Edema caused by the irritation from nasogastric, nasotracheal and orotracheal tubes.
·       Occult Sepsis has also been linked to intubation.
·       Sinusitis and middle ear effusion have also been noted.

Injuries may include:

1) Dislocation of arytenoids or mandible

2) Interarytenoid fixation

3) Vocal fold paralysis

4) Synechia of vocal folds or laryngeal web

5) Perforation of the piriform sinus or esophagus

6) Laryngeal and tracheal stenosis

7) Ulcers and granulomas on the vocal processes of Arytenoids.

8) Damage to the oral mechanism (e.g. Mouth, teeth, palate, and tongue)

Treatments include steroids, antibiotics, and surgery.  It is recommended to remove fresh granulation tissue before the development of firm subglottic stenosis after intubation injury.

·       Cuffed tubes may also contribute to infection, tracheal stenosis, esophageal erosion, and innominate artery fistulation.

·       Interference with swallowing.
·       Vocal hypofunction is an effect of long term intubation.
·       Laryngeal webbing may be a result.
·       Intubation may increase risk of death in patients who have suppressed immune systems.
·       Laryngospasm
·       Perforation of the trachea or esophagus
·       Retropharyngeal dissection
·       Fracture or dislocation of the cervical spine
·       Trauma to eyes
·       Hemorrhage
·       Aspiration of secretions, blood, gastric contents, or foreign bodies.
·       Hypoxemia, hypercarbia
·       Bradycardia, tachycardia
·       Hyperextension
·       Increased intracranial or intraocular pressure
·       Excoriation of nose or mouth.
·       Dysphonia (hoarseness), aphonic
·       Paralysis of vocal folds or hypoglossal, lingual nerves.
·       Sore throat
·       Laryngeal incompetence
·       Tracheal collapse
Vocal fold granulomata or synechiae

Competencies for Intubation

·       99% of the time, it is anesthesiologists who intubate in the hospital setting.

·       Involves more than proficiency with tracheal intubation techniques.

·       Must understand the physiologic consequences.

·       Must understand the complications of endotracheal intubation.

·       Must have knowledge of the anatomy of the airway.

·       Must have knowledge of the innervation of the airway.

·       Must have knowledge of the pathologic conditions of the airway.

·       Must have knowledge of the methods of assessment.

·       Must be able to recognize patients in whom airway management may be difficult and be able to formulate and implement alternative plans in various clinical situations.

·       Must be familiar with all equipment and procedures used In intubation.

Procedures and Equipment for Intubation 

Management of patients having surgery:

·       Case history: the patient is questioned about signs and symptoms suggestive of airway abnormalities, such as hoarseness or shortness of breath.  The patient is also questioned about information on prior surgery, trauma, neoplasia involving the airway, and prior anesthetic experiences.

Physical examination: The patient's head is viewed in profile and palate should be examined for cleft.  Many congenital syndromes make it difficult or impossible to intubate.  The presence of protruding teeth may complicate intubation and may cause difficulties in producing a seal.  Temporal mandibular joint mobility should be assessed.  The patient's cervical spine mobility must be evaluated because endotracheal intubation usually involves the extension of the neck.  The distance between the lower border of the mandible and the thyroid notch with the patient's neck fully extended should be measured with a ruler or intubation gauge.  If the measurement is less than 6cm, it will be impossible to visualize the larynx.  The neck should be palpated so that masses and tracheal deviation can be detected.

 Airway Equipment:

·       Masks:  Connell anatomic mask is used most frequently in adults.  They are available in a variety of sizes and have a malleable body that allows it to be shaped to fit the patient’s face.

·       Airways:  Available in several sizes and types.  Most are made of plastic, although some are designed for metal, including one designed for use during fiberoptic endotracheal intubation.

·       Laryngoscopes:  Composed of handle and blade.  Curved and straight blades are the two general types.  Personal preference primarily determines the type of blade used for intubating adults.

·       Endotracheal Tubes:  Numbered according to the internal diameter.  The approximate size and length of the tube is determined by the patient's age and size.

·       Ancillary Equipment:-Malleable metal or firm rubber stylets are used to maintain the desired curve of the endotracheal tube during intubation.-Soft plastic or rubber tooth protectors/guards can lessen the chance of damage to the teeth.

·       Once it is determined that endotracheal intubation is necessary:  the anesthesiologist must decide whether nasotracheal or orotracheal intubation is most appropriate; choose the type and size of the laryngoscope and tube to use, decide whether the patient is to be intubated while awake or after  induction of anesthesia, and decide a muscle relaxants can be used separately.

Procedures in the Operating Room

Ø Before Intubation:

The anesthesia cart located in the operating room has all the medication that is used frequently and those that are used very rarely that is needed on an emergency basis.  There is no time to go and get them; because if something is happening to toe patient the diagnosis must be made and treated immediately.  The different kinds of medication are to put patients to sleep or muscle relaxants (paralyze muscles.)  

There are also narcotics that are used frequently in anesthesia that require a code number that is recorded to get them. The narcotics are 10 to 1000 times more potent than morphine. Syringes with needles are used to draw out medication as needed.  The patient comes into surgery and as they come in syringes are normally ready and medications are drawn up.  One of the first things given to the patient is a sedative through an I tube that is in place.  

The patient is put on the operating table or bed.  The patient is then hooked up to the following monitors:  heart (EKG), and blood pressure cuff. The cuff checks pressure from continuous readings to 15-30 minute intervals, depending on the interval selected.  

The standard of care is that blood pressure needs to be taken a minimum of every five minutes during surgery.  There is also a clip attached to a patient's finger that checks the amount of oxygen in the blood.  Once the patient is hooked up to all the monitors, they can be put to sleep.  

The patient is informed during the procedures, what and why it is being done.  There are different techniques and script of what is said before the patient is put to sleep.  One example is, "Try to think of a nice place to go on vacation."  This technique is used so that the patient might have a nice dream while they are asleep.  While the patient is thinking, the anesthesiologist begins administering the anesthetic.  The anesthetic is in actuality a hypnotic to put the patient to sleep.  The patient must be hooked up to the anesthesia machine to stay asleep.  

Intubation comes in at this time.

During Intubation:

When the patient is asleep, they are given a muscle relaxant that relaxes their muscles including the vocal folds to allow them to open up.  A blade and handle is selected for the laryngoscope to visualize the larynx and intubate the patient (e.g. Miller blade straight blade and Macintosh curved blade.)  

The anesthesiologist places a hand on the head of the patient and pushes down, which picks up their mandible and allows the mouth to open.  The tip of the blade is inserted and slid over the tongue to the base of the tongue.  Next, the anesthesiologist pulls up and away from the patient in roughly 45-degree angle.  

The key is to make sure that the patient is definitely asleep before this is done.  The tube is selected at this time.  

The tube is placed right between the vocal folds and as soon as the top part of the cuff passes the vocal folds the anesthesiologist stops.  Sometimes styles are used to help in intubation.  

The cuff is inflated and the patients hooked up to the anesthesia machine.

After Intubation:

The mask is removed.  The anesthetic is turned on.  There are three choices of gasses.  The machine is turned on to automatic.  The machine breathes for the patient and administers gas anesthesia to the patient.  The throat is suctioned out.  

After surgery, the patient must be awake and responsive before it is safe to extubate the endotracheal tube (e.g. lift your head for five seconds or Squeeze finger of an anesthesiologist.)

Tips to Minimize Complications 

·       Tubes should only be placed when indicated.

·       Frequent tube suctioning

·       Optimal mouth care

·       Secure and adequate fixation of the tube

·       The right size of the tube should be used to avoid unnecessary pressure on the vocal folds and inside lining of the larynx.

·       An appropriate handle and blade should be used

·       Make sure that a neutral position is maintained where the tube emerges from the mouth or nose so that unnecessary pressure is avoided

·       Cuffs should only be inflated when necessary only at minimum pressure.

·       Teeth guards/protectors should be used specifically on the top teeth.

Infant intubation:

·       Must be familiar with anatomic differences of the infant larynx.

·       Work gently and ensure adequate relaxation.

·       Tube selection is very important.

·       Lubricants must be used carefully.

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