SHIVALIK INSTITUTE OF NURSING

BHATTAKUFfER

PRESENTATION
ON

ENDOTRACHEAL INTUBATION
AND
TRACHEOSTOMY

SUBJECT: ADVANCE NURSING PRACTICE

SUBMITTED TO: SUBMITTED BY:

MS.MEENU SHARMA KANIKA SHARMA

( LECTURER) M.Sc. NURSING 1ST YEAR

ENDOTRACHEAL INTUBATION

ANATOMY OF AIRWAY :

Respiratory tract, describes the organs of the respiratory tract that allow air flow during ventilation.
They reach from the nares and buccal opening to the blind end of the alveolar sacs. They are
subdivided into different regions with various organs and tissues to perform specific functions. The
airway can be subdivided into the upper and lower airway, each of which has numerous subdivisions
as follows.

Upper Airway
The pharynx is the mucous membrane-lined portion of the airway between the base of the skull and the
esophagus and is subdivided as follows:
 Nasopharynx, also known as the rhino-pharynx, post-nasal space, is the muscular tube from the
nares, including the posterior nasal cavity, divide from the oropharynx by the palate and lining
the skull base superiorly
 The oro-pharynx connects the naso and hypopharynx. It is the region between the palate and
the hyoid bone, anteriorly divided from the oral cavity by the tonsillar arch
 The hypopharynx connects the oropharynx to the esophagus and the larynx, the region of
pharynx below the hyoid bone.
The larynx is the portion of the airway between the pharynx and the trachea, contains the organs for
production of speech. Formed of a cartilaginous skeleton of nine cartilages, it includes the important
organs of the epiglottis and the vocal folds (vocal chords) which are the opening to the glottis.
Lower Airway
The trachea is a ciliated pseudostratified columnar epithelium-lined tubular structure supported by C-
shaped rings of hyaline cartilage. The flat open surface of these C rings opposes the esophagus to
allow its expansion during swallowing. The trachea bifurcates and therefore terminates, superior to the
heart at the level of the sternal angle.
The bronchi, the main bifurcation of the trachea, are similar in structure but have complete circular
cartilage rings.
 Main bronchi: There are two supplying ventilation to each lung. The right main bronchus has a
larger diameter and is aligned more vertically than the left
 Lobar bronchi: Two on the left and three on the right supply each of the main lobes of the lung
 Segmental bronchi supply individual bronchopulmonary segments of the lungs.
Bronchioles lack supporting cartilage skeletons and have a diameter of around 1 mm. They are initially
ciliated and graduate to the simple columnar epithelium and their lining cells no longer contain
mucous producing cells.
 Conducting bronchioles conduct airflow but do not contain any mucous glands or seromucous
glands
 Terminal bronchioles are the last division of the airway without respiratory surfaces
 Respiratory bronchioles contain occasional alveoli and have surface surfactant-producing They
each give rise to between two and 11 alveolar ducts.
Alveolar is the final portion of the airway and is lined with a single-cell layer of pneumocytes and in
proximity to capillaries. They contain surfactant producing type II pneumocytes and Clara cells.
 Alveolar ducts are tubular portions with respiratory surfaces from which the alveolar sacs bud.
 Alveolar sacs are the blind-ended spaces from which the alveoli clusters are formed and to
where they connect. These are connected by pores which allow air pressure to equalize
between them. Together, with the capillaries, they form the air-blood barrier.
DEFINITION OF ENDOTRACHEAL INTUBATION:

Endotracheal intubation assistingin passing of a slender hollow tube into trachea through nose or
mouth to facilitate artificial ventilation and resuscitation, using aseptic technique.

PURPOSE:

 To treat acute respiratory failure, persistent hypoxemia, persistent rise in pCO2 .

 To maintain patient airway
 To ensure adequate oxygenation is fracture cervical vertebrae , spinal cord injury
 To provide ventilatory assistance when indicated

OBJECTIVE :

To insert an endotracheal tube into trachea to provide a patent airway vantilatory support or to
maintain secretions.

INDICATION:

 CNS depression
 Neuromuscular disease
 Chest wall injury
 Upper airway obstruction
 Anticipated upper airway obstruction(edema, soft tissue swelling due to head and neck trauma)
 Aspiration prophylaxis
 Fracture of cervical vertebrae and spinal cord injury

PRECAUTIONS :

1. Avoid damage to the clients teeth and soft tissue, which can be caused by improper use of the
laryngoscope and tubes or by unnecessary force during the procedure.
2. Ensure the availability of an oxygen source. Ventilate the client with a mutual resuscitator
using 100 % oxygen if intubations cannot be accomplished within a reasonable period.
3. Have suction equipments setup and operable at the clients bedside before performing the
procedure.
4. Avoid bronchial intubation by correctly positioning the endotracheal tube above the level of the
carina.
5. Be alert for signs of esophageal intubation. These signs include abdominal distention, belching
and lack of breath sound in the lung fields after intubatation.
CLIENT/FAMILY TEACHING:

 If the client is conscious , explain the need for endotracheal intubation and explain the
procedure.
 Explain sensations that may be experienced during the procedure.
 Explain the need for endotracheal intubation and explain the procedure of the family.

Articles Required:

 Sandbag/towel roll.
 Suction apparatus with tubing
 Suction catheter (Fr-14)
 Ambubag and mask
 Oxygen source and tubing
 Laryngoscope with appropriate size blade
 Magill’s forceps
 Endotracheal tube of appropriate size
 Stiletto
 Xylocaine gel
 Disposable syringe 10 ml
 Oral airway
 Cotton tape/ Dynaplast
 Sterile gloves
 Facemask

Parts of Endotracheal Tube :

 PROCEDURE:

Sr. Nursing Action Rational

No
1. Explain procedure to patient if conscious and get consent from Promotes acceptance of procedure
patient and relatives. and cooperation for procedure
from patients.
2. Place patient in the supine position with head extended by Promotes access to the trachea.
keeping sandbag or towel roll under the neck.
3. Check for loose teeth and dentures or foreign body in throat,if Avoid the danger of loose teeth or
so remove with Magill’s forceps foreign body causing airway
obstruction in unconscious
patients.

4. Seal mouth and nose with mask and Ambu bag and initiate
bagging with oxygen.
5. Provide laryngoscope
6. Suction oral cavity Provide a clear field of work and
prevents aspiration when
performing oral tracheal insertion
7. Provide lubricated endotacheal tube with stiletto in situ Facilitates insertion without
chances of injury.
8. Presscricothyroid cartilage with thumb and index finger against Permits clear visualization of
esophagus. oropharynx for insertion.
9. Assist while endotracheal tube is introduced into treacea and
remove stiletto The tube when inserted should have the 22cm
marking at the incisor teeth
10 Verify placement of tube by auscultation, listening/feeling for Confirm tube placement
airflow through tube and observe for bilateral chest movement
11. Connect ambubag with oxygen attached to endotracheal tube
and continue bagging
12. Inflate cuff of the endotracheal suctioning if necessary Prevents changes of tube
displacement and aspiration `
13. Insert an oral airway and apply endotracheal suction if
necessary
14. Fix endotracheal tube in position by using adhesive tape. Tube
should be fixed at the midline to prevent pressure ulcer at the
angle of mouth
15. Connect to ventilator if necessary.

PROCEUREDURAL CARE:

1. Place patient in lateral position

2. Arrange for chest X-ray to be taken in order to check placement of ET tube.
3. Apply endotracheal suctioning if secretion are present
4. Watch for chest movement, ET tube kinking , obstruction with secretion and blood ,leakage of
tube cuff, change in position of tube and over inflation of cuff.
5. Document type and size of tube used chest movement vital sign and patients tolerance of
procedure
6. Check ABGs periodically .
SPECIAL CONSIDERATION :

Check pressure using manometer (if available ) for detecting under inflating or over inflation of cuff. If
under inflated, it can lead to aspiration and displacement of tube. Over inflation can lead to tracheal
injury and ulceration leading to stenosis.

AFTER CARE
 Discard soiled items in appropriate receptacle.
 Remove towel and place in laundry.
 Reposition client.
 Remove gloves and face shield, discard in receptacle, and wash hands. Place clean items
(e.g., tincture of benzoin, mouthwash, access swabs) in place of storage.
 Compare respiratory assments before and after ET tube care
 Observe depth and position of ET tube according to physician recommendation.
 Assess security of tape by gently tuggipg at tube.
 Assess skin around mouth and oral mucous membranes for intactness and pressure areas.
 Note appropriate depth of ET tube, frequency of ET tube care, pressure sore care needed, and
 designated intervals.
 Record in nurses notes: assessments before and after care, supplies used, client tolerance
 of procedure, and frequency and extent of ETtube care.
SUCTIONING TECHNIQUE

Suctioning is the pocess of sucking the removal of gas or fliud from a cavity or rather container by
means of reduced pressure.
Suctioning is done when a patient is usable to clear respiratory tract secrection with coughing, the
nurse must use suctioning to clear the airways.

TYPES :
1. Oropharyngeal and nasopharyngeal
2. Orotrachial and nasotracheal
3. Tracheal

Oropharyngeal And Nasopharyngeal :

The orophaynx extends behind the mouth fom the soft palate above the level of the hyoid bone and
contains the tensil. The nasopharyx is located behind the nose and extends to the level of soft palate.
This suctioning is used when the patient is able to cough effecively, but is unable to clear secretions by
expectorating or swallowing.
Orotrachial And Nasotracheal:
It is necessary when the client on pulmonary secretion is unable to cough and does not have an
artificial airway present.
Tracheal :
Tracheal suctioning is accomplished though an atificial airway such as endotracheal tube or
tracheotomy tube.

EQUIPMENTS:
1. Laryngoscope with curved or straight blade and working light sources.
2. Endotracheal tube with low pressure cuff and adapter to connect tube to he ventilator style to
guide the endotracheal tube.
3. Oral airway
4. Syringe of 10 ml.
5. Suction source
6. Suction catheter
7. Sterile towel
8. Gloves
9. Face shield
10. Esuscitation buy and mask connected to O2 source

PROCEDURE :
Peparation Phase :
1. Assess the patient’s heart rate , level of counsciousness and respiratory status.
Performance Phase :
1. Remove the patien’s dental bridgework and plates
2. Remove headboard of bed
3. Prepare equipment
4. Aspirate stomach contents if nasogastric tube is in place
5. If time inform the patient of impending inability to talk and discuss altrnative means of
communication
6. If the patient is confused it may be necessary to apply soft wrist restraints.
7. Put on gloves and face sheild
8. During oral intubation if cervical spine is not injured place patient’s head in a “sniffing”
position anasthetic sprat if time is a valuable.
9. Spray te back of the patient’s throat with anesthesia spray if time is available
10. Ventilate and oxygenate the patient with the resuscitation bag and mask before intubations.
11. Hold the handle of the larangoscope in the left hand and hold the patient mouth open with the
right hand by placing crossed finger on the teeth
12. Insert the curve blade of the laryngosope along the right side of the tongue, push the tongue to
the right side of the tongue, push the tongue to the left and use right thumb and index finger to
pull patient’s lower lip away from lower teeth,
13. Lift the laryngoscope forward, to expose the epiglottis
14. Lift the laryngoscopes forward at 450 angle to expose glottis and visualize vocal cords.
15. As the epiglottis is lifted forward the vertical opening of thr larynx between the vocal cord will
come into view.
16. Once the vocal cord is vasualized insert the tube into the right corner of the mouth and pass the
tube, while keeping vocal cords in constant view
17. Gently push the tube through the triangular space formed by the vocal cords and back wall of
trachea
18. Stop insertion just after the tube cuff has disappeared from vein beyond the cords.
19. Withdraw laryngoscope, while holding endotracheal tube attach bag to endotracheal tube , and
ventilate the patient.
20. Inflate cuff with the minimal amount of air required to occlude the tracheal
21. Insert bite block if necessary
22. Ascertain expansion of both side of the chest by observation and auscultaion of breath sound
23. Record distance from proximal end of tube to the point where the tube reaches the teeth
24. Secure tube to the patient’s face with adhesive tape or apply a commercially available
endotracheal tube stabilization device
25. Obtain chest X-ray to verify tube position
ENDOTRACHEAL EXTUBATION
Objective :
To remove either an oral or nasal endotracheal tube after it has been determined that the client can
breath without assistance and the secretion can be removed without an airway in place
Client/Family Teaching
1. Discuss the procedure for removing the endotracheal tube
2. Describe the suctioning process that will be used concurrently with theextubation procedure.
3. Encourage the client to cough and breath deeply, after the endotracheal tube is removed.
4. Describe the benfits of coughing and deep breathing and explain why these procedures will
reduce the risk of reintubation

Precautions :
1. Extubation should only be attempted after the client is well rest, especially in clients who have
been intubated for long periods. Extubation may be more successful in the morning than in the
late afternoon or evening
2. Never remove an endotracheal tube unless the personnel who are trained to reintubate are
present. If respiration faliure follow extubation, the patients airway must be re-established
3. A suction setup with sterile catherters and gloves must be present during the extubation process
to remove secretion in the client’s airway
Procedure
Assessment Phase:
1. Can the client’s (ABC) value be maintained without assisted ventilation
2. Has the client underlying condition improved to the point at which an artificial airway is no
longer required
3. Does the cliet have spontaneous respiration with out the assistance of a ventilator
4. Will the client require supplemental oxygen after extubation
Planning Phase:
1. Sterile suction cather
2. Sterile gloves
3. Scissors
4. Water soluble lubricant
5. Vacuum source lubricant
6. Unit dose container of sterile normal saline or 6ml syringe filled with normal saline
7. Aerosol setup with supplement oxygen
a. Emergency airway box
b. Manual resuscitator
c. Laryngoscope anmd blades
d. Endotracheal tube
Implementation Phase :
1. Elevate head of bed to semi-Fowler’s position or as high as client can tolerate
2. Assemble equipment for suctioning as prescribed in previous section on blind endotracheal
suctioning
3. Assemble equipment to give supplemental oxygen after endotracheal tube is removed
4. Remove tape or other means of securing tube in place
5. Using sterile technique, suction to section to secretion from the endotracheal tube.
6. Increase client’s fraction of inspired oxygen (FiO2).
 7. Insert syring into one way valve in pilot ballon and be prepared to deflate cuff.
8. Instruct client to breathe deeply. Reinsert suction catheter 1 to 2 inches below end of
endotracheal tube, deflate cuff and apply suction while endotracheal tube is removed
9. Supplemental oxygen and aerosol should be administered to client as needed.
10. Tracheotomy tubes are removed in approximately same way as endotracheal tube is removed
.Sterile dressing should be applied to stoma after tube is removed Permanent closure to stoma
usually occurs within few days of extubation.
11. After reoygenation, encourage clientto cough and breathe deeply to suction oropharynx.
12. Correctly dispose tubes, cathers and gloves
Related Nursing Care :
1. Encourage client to cough and breath deep.
2. Suction as needed to remove secretion from oropharynx and trachea.
Caution: Do not leave client unattended. Observe for any sign of respiratory failure and airway
obstration
3. Prevention of complication of extubation.
TRACHEOSTOMY
DEFINITION :

Assisting in creating a surgical opening into the anterior wall of trachea and inserting a tube to
maintain patent airway .

PURPOSE :

 To bypass upper airway obstruction and trauma

 To remove tracheo bronchial secretion
 To promote long-term use of mechanical ventilator
 To prevent aspiration of oral or gastric secretion in unconscious or paralyzed patient.
 To replace endotracheal tube when long-term mechanical ventilation is required.

PARTS OF TRACHEOSTOMY TUBE :

1. Outer tube or outer cannula

2. The inner tube or inner cannula
3. The obdurater or pilot
4. It is used as a guide to the outer tube

USE OF TRACHEOSTOMIES:

1. To facilitate prolonged artificial ventilation

2. To bypass serious upper respiratory obstruction
3. To prevent aspiration of blood, secretion
4. or food into the lungs
5. To provide easier access top the lower airway than in through nose or mouth

INDICATIONS FOR TRACHEOSTOMY

1. Apnoea
2. Respiratory obstruction
3. Circulatory arrest
4. Exanguinating haemorrhage
5. Carcinoma of the larynx
6. Diphtheria,Ludwig’s angina
7. Head injury , neck injury or chest injury
8. Respiratory failure
9. Fracture of the larynx or trachea.
10. In case of foregin body in hypophyrynx or larynx
11. Patient with severe bums, especialy around hand, neck and face
12. Patient who have or had thyroidectomy or radical neck dissection
13. Patient with neurological disorder, drug overdose bulbar paralysis or cerebovascular accidents
14. Patient with severe pulmonary edema
15. Patient with severe emphysema
16. Weak. Feeble patient
17. Canine biting
ARTICLES :

Tracheostomy Set Containing:

 Toothed dissecting forceps-1

 Curved mosquito forceps-2
 Straight mosquito forcps-2
 Artery forceps-2
 Allis forceps-2 needle holder
 Double hook retractors-2
 Blunt hook
 Cricoid hook
 Sharp scissors
 Tracheal dilator
 Gallipots-2
 Cuting edge suture needle with cotton thead
 Vaseline gauze

A Clean Tray Containing

 Suction cathater with connection (sterile)

 Hand towel
 Kidney basin
 Scalpel blade(sterile)
 Gloves (Sterile)
 Mask
 Apron
 Antiseptic solution
 Local anesthetic (Xylocaine2%)
 Syringes (Sterile)
 Needle (Sterile)
 Sandbag
 Spot Light
 Tracheostomy tube

TYPES OF TRACHEOSTOMY TUBE

1. Cuffless:
2. Cuffed

Procedure:

Nursing action Rationale

Explain procedure to the patient if conscious and
get consent from patient and relative
Place patient in supine position with full extention
of neck and head
Remove gown and expose neck
Keep sucton and oxygen ready for use
Allays anxiet and facilitates patient co-operation
Promotes visualization of site of insetion for the
procedure
Facilitates timely use of articles
Assist in preparing sink and administering local Reduce risk of infection
anesthetic Reduce sensation of pain
Assist and support patient as incision is made and
provide suitable tracheostomy tube for insertion
Assist in securing tracheostomy tube to neck Reduce chances of tube displacement
while tying with tape
Assist while tube is bein sutured in place Reduce chances of tube displacement
Plce vaseline gauze around tube
Assist patient to a comfortable position
Replace equipment
Document time,tube size,purpose of tracheostomy

POSTPROCEDURE CARE :

1. Connect to ventilator (if needed)

2. Place patient in semi-Fowler’s position
3. Check vital sign
4. Administer analgesics and sedative per order
5. Watch for complication like bleeding espiratory faliure and blockage of tracheostomy tube with
secretion
6. If mental tube is inserted , leave the stillete in a sterile tray at teh bedside
7. Keep suction apparatus and suction tube ready at bedside
PROVIDING TRACHEOSTOMY CARE
Definition :
Tracheostomy care include changing a tracheostomy inner tube , cleaning tracheostomy site and
changing dressing around the site.
Procedure :
1. To maintain airway patency
2. To prevent infection at the tracheostomy site
3. To facilitate healing and preven skin excoriation around the tracheostom site
4. To promote confort
5. To ssess condition of ostomy
Equipment:
1. Tracheostomy care kit containing
a. Gallipots (3)
b. Sterile towel
c. Sterile nylon brush/ube brush
d. Stertile gauze squares
e. Cotton twill ties or tracheostomy tie tapes
f. Sterile bowl for solution
2. A Clean tray containing:
a. Sterile suction catheter
b. Hydrogen peroxide
c. Normal saline
d. Sterile gloves-2 pair
e. Clear scissors
f. Face mask and eye shield
g. K Basin
h. Waterproof pad
3. Suction apparatus

Procedure :
Nursing action Rationale
Assess condition of stoma : (redness, swelling , Presence of any of three indicate infection and
charatr of secretion , presence of purulence or culure test may be warranted
bleeding.
Examine neck for subcutaneous emphysema Indicate air leak subcutaneous tissue
evidened by crepitus around the ostomy site
Explain procedure t the patient and teach means of Obtain cooperating from patient
communication such as eye blinking or riing a finger
to indicate pain or distess
Assist patient to a Fawler’s position andplace Promotes lungs expantion
waterproof pad or chest Prevent soiling of linen
Wash hand thoroughly Prevent cross-infection
Assemble equipments,
a. Open the sterile traheostomy kit, pour Hydrogen preoxide and saline removes mucus
hydrogen peroxide and sterile noraml saline an crust which promote bacterial growth
in separat gallipots
 b. Open other sterile supplies as needed Enhance performance phase of pocedure
including serile applicators, suction kit and
tracheostomy kit
c. Put on face mask and eye shield Protects the nurse
Don sterile gloves. Place sterile towel on patient’s Maintain aseptic technique
chest
Suction the full length of tracheostomy tube and Remove serection
pharynx throughly
Rinse the serection catheter an discard it
Unlock the inner cannula and remove it by gently Hydrogen peroxie moisenes and loosens dried
pulling it out toward in line wit its curvature Place secrection
the inner cannula in the below with hydrogen
peroxide solution
Remove the soiled tracheostmy dressing , discard
the dressing and gloves
Then a secondpair of sterile gloves
Clean the flange of the tube usng aterile applicatiors Using the appication or gauze once only,
or gauze moistened with hydrogen peroxide an then avoids contaminating a clean area with a soiled
with norma saline .Use each applicators once only gauze
Clean the stroma area with gauze (make only a
single sweep with each gauze sponge before
discarding)
 Half strength hydrogen peroxide (mixed Hydrogen peroxide helps to lossen the crusted
with normal saline) may be used. secretion
 Throughly cleanse area uasing gauze squares Hydrogen peroxide is irrritating to the skin and
moistened with sterile normal saline inhibits healing if no removed horoughly
Dry the stoma with dry starile gauze
An infected wound may be cleaned with gauze
saturated with an aniseptic soluion, the dried.
A thin layer of antibiotic ointment may be applied to Help prevent wound infection
the a stoma with cotton swab.
Cleaning the inner cannula
 Remove the inner cannula from the soaking
solution .
 Clean the lumen and entire cannula
thoroughly using the brush
 Rainse the cleaned cannula by rinsing it with Through rinsing is important to remove
sterile normal saline (agitating the cannula in hyrogen peroxide from inner cannula
the containe with saline clean it well).
 Gently tap the cannula against the inside of Remove solution adhering on the cannula
the sterile saline container after rinsing
Replace the inner cannula and secure it in place
 Insert the inner cannula by grasping the outer
flange and pushing in the direction of its
curvature
 Lock the cannula in place by turning the lock This secure the flange of the inner cannula o
into position the outer cannula
Apply sterile dressing
 Open and refold a 4x4 gauze dressing into a Avoid using cotton-flange 4x4 gauze gauze.
‘V’ shape and place under the flange of the Cotton or gauze fibber can be aspirated by the
tracheostoy tube . do not cut gauze piece patient potentially creating a tracheal abscess.
 Ensue that the tracheostomy tube is securely Excessive movement of the tracheosomy tube
 supported while appling dressing irritates the trachea.
Change the tracheostomy tie
a. Leave he soiled tape in place until the new Leave tape in place ensure that tube will not be
one is applied expelled if patient coughs or moves
b. Cut a piece of tape the is twice the neck This action provides a secure attachment with
circumference plus 10m . Cut the end of the knot .Diagonal cut facilitates insertion of tape
tape diagonally into opening of neckplate.
c. Apply the new tape
 Grasp slit end of clean tape and pull it
though opening on one side of the
tracheostomy tube.
 Pull the end of the tape securely though
the slit end of the tracheostomy tube on
the other side
 Tie the tapes a the side of the neck in a
square knot
 Alternate knot from side to side each Prevents irritation and aids in rotation of
time tapes are changed pressure site
 Ties should be tight enough to keep tube Excessive tightness compresses jugular veins,
securely in he stoma, and loose enough decreases blood circulation to theskin and
to permit two fingers to fit between the result in discomfort for patient.
tape and neck.
d. Remove old tapes carefully
Document all relevant information in the chart
 Suctioning done
 Tracheosomy care carried out
 Dressing changed
 Other observation

SPECIAL CONSIDRATION :
1. Tracheostomy dressing should be done every 8 hours or whenever dressing are soiled
2. Tracheostomy tubes may come with disposable inner cannula without the inner cannula . If
disposable inner cannula is present then replace the one the is inside with a new one
3. If only single lumen is present, then suction the traheostomy tube and clean the neck plate and
tracheoastomy site.
BIBLIOGRAPHY :
• Jacob Annamma, Clinical Nursing Procedure: The Art of Nursing Practice. 3th Edition.
JAYPEE Publication, Page No:400-402,397-399.
• Fundamentals of nursing a procedure of manual, first edition reprint 2012,published by
secretary general TNAI, Page No: 500, 504.

• Clement I, Basic Concepts of Nursing Procedure.2th Edition. JAYPEE Publication. New Delhi ,
Page No:257-262, 263-266.
• Gupta LC , Practical Nursing Procedure,3st Edition. JAYPEE Publication. New Delhi , Page
No:305-306
• https://www.verywellhealth.com/endotracheal-tube-information-2249093
• https://www.healthline.com/health/endotracheal-intubation