ACLS:

Airway Management:
Endotracheal Intubation
 The Difference Between
 Life and Death

 Dr. VIVEK MITTAL.

Associate professor.
AIMSR, Bathinda.
 AIRWAY—
 The endotracheal intubation is
considered the optimal method of
managing the airway during cardiac
arrest.

 Intubation attempts by unskilled

providers can produce complications-----
------
Cont----
 Trauma to the oropharynx
 Interruption of compressions and
ventilations for unacceptably long
periods
 Hypoxemia from prolonged intubation
attempts .
 Failure to recognize tube misplacement
or displacement
CONT-
 Intubation is performed by inexperienced
providers .
 Monitoring of tube placement is
inadequate.
 The optimal method of managing the
airway during cardiac arrest will vary based
on 1)Provider experience,
 2) Characteristics of the EMS or healthcare
system.
 3) Patient's condition.
 cont---
 The endotracheal tube keeps the airway
patent.
 Permits suctioning of airway secretions.
 Enables delivery of a high concentration
of oxygen
 Provides an alternative route for the
administration of some drugs.
 cont--
 Facilitates delivery of a selected tidal
volume.
 Protect the airway from aspiration.
 INDICATIONS(ACLS)
 Indications for emergency endotracheal
intubation are
 (1) the inability of the provider to
ventilate the unconscious patient
adequately with a bag and mask .
 (2) the absence of airway protective
reflexes (coma or cardiac arrest).
 ACLS
 During CPR providers should minimize
the number and duration of interruptions
in chest compressions, with a goal to
limit interruptions to no more than 10
seconds. insert the laryngoscope
blade with the tube ready at hand—as
soon as the compressing provider
pauses compressions.
 ACLS
 Compressions should be interrupted
only for the time required by the
intubating provider to visualize the vocal
cords and insert the tube; this is ideally
less than 10 seconds.
The compressing provider should be
prepared to resume chest compressions
immediately after the tube is passed
through the vocal cords.
 ACLS

The provider should use both clinical

assessment and confirmation devices to
verify tube placement immediately after
insertion and again .
 Continuous waveform capnography
is recommended in addition to clinical
assessment as the most reliable method of
confirming and monitoring correct


 ACLS
 If waveform capnography is not
available, an EDD or nonwaveform
exhaled CO2 monitor in addition to
clinical assessment is reasonable .
How do you confirm the correct
placement of the ET Tube?

 PrimaryConfirmation
 Secondary Confirmation
Primary Confirmation By Physical
Exam
 Confirm tube placement immediately
 Look n listen over the epigastrium and
observe the chest wall for movement
 If stomach gurgling and no chest wall
expansion, esophagus intubated:
remove ET tube
 Reattempt intubation after
reoxygenation
Primary Confirmation: cont.
 If chest wall rises and stomach not
gurgling,
perform 5-point auscultation
 If still doubt, use laryngoscope to see
the tube passing through the vocal cords
(best)and Secure the tube
 Look for moisture condensation on the
inside of the tracheal tube (not 100%:
false + with esophageal intubations)
Secondary Confirmation
 End-Tidal CO2 Detectors
 Commercial device that reacts with a color
change to CO2 exhaled from the lungs:
MELLO YELLOW
 Continuous waveform capnography
.Qualitative detection device indicates
exhaled CO2 indicates proper tracheal tube
placement
 Absence of CO2 (unless prolonged CPR),
indicates esophageal intubation
 Post intubation, chest-x-ray.
Endotracheal tube(ET) trachea, endotracheal tube
(arrows) and location of carina (^).
Cont----
Esophageal Detector Devices.
The EDD consists of a bulb that is
compressed and attached to the
endotracheal tube. If the tube is in the
esophagus , the suction created by the
EDD will collapse the lumen of the
esophagus or pull the esophageal tissue
against the tip of the tube, and the bulb
will not re-expand.
Cont--
 The EDD may also consist of a syringe
that is attached to the endotracheal
tube; the provider attempts to pull the
barrel of the syringe. If the tube is in the
esophagus, it will not be possible to pull
the barrel (aspirate air) with the syringe.
Complications
 Hypoxia
 Long duration of procedure
 Esophageal intubation ( not visualizing vocal
cords)
 Intubation of a bronchus ( right more
common)
 Failure to secure the placement
 Failure to recognize misplacement of tube
 Aspiration
 Pneumothorax
Complications: continued
 Trauma and adverse effects
 Broken teeth
 Oral lacerations
 Vocal cord injury
 Pharyngeal-esophageal perforation
 Short-term laryngeal edema
 Release of high levels of epinephrine and
norepinephrine stimulated by tracheal
intubation:
can cause elevated blood pressure, tachycardia,
arrhythmias
Postintubation Airway
Management
 After inserting and confirming correct
placement of an endotracheal tube, the
provider should record the depth of
the tube as marked at the front teeth
or gums and secure it
 There is significant potential for
endotracheal tube movement with head
flexion and extension and when the
patient is moved from one location to
another.
 cont--
.Continuous monitoring of endotracheal
tube placement with waveform
capnography .
The endotracheal tube should be
secured with tape or a commercial
device . Devices and tape should be
applied in a manner that avoids
compression of the front and sides of
the neck, which may impair venous
return from the brain.
 cont---
 These devices may be considered
during patient transport . After tube
confirmation and fixation to confirm that
the end of the endotracheal tube is
properly positioned above the carina
Ventilation after advance airway
placement.
 Monitoring of ventilatory parameters
during CPR.
1) respiratory rate
2)minute ventilation,
3) peak airway
pressure.
4)SpO2.
will influence
outcome
 cont-------
 Positive pressure ventilation leads to----
 1) increases intrathoracic
pressure ,
 2)reduce venous return ,
 3)reduce cardiac output(
especially in patients with hypovolemia
or obstructive airway disease)
 cont------

Because cardiac output is lower than

normal during cardiac arrest, the need
for ventilation is reduced.
 Following placement of an advanced
airway, the provider delivering
ventilations should perform 1 breath
every 6 to 8 seconds (8 to 10
breaths per minute) without pausing
in applying chest compressions .
Automatic Transport Ventilators

 In both out-of-hospital and in-hospital

settings----
Automatic transport ventilators
(ATVs) can be useful for ventilation of
adult patients in noncardiac arrest who
have an advanced airway in place .
. Providers should always have a bag-
mask device available for backup.
Suction Devices

 Both portable and installed suction

devices should be available for
resuscitation emergencies.
 Portable units should provide adequate
vacume and flow for pharyngeal suction.
 The suction device should be fitted with
large-bore, nonkinking suction tubing
and semirigid pharyngeal tips.

 cont-----
 . The installed suction unit should be
powerful enough to provide an airflow of
>40 L/min at the end of the delivery tube
and a vacuum of >300 mm Hg when the
tube is clamped.

 The amount of suction should be

adjustable for use in children and
intubated patients.
BASIC
THINGS KNOW
BEFORE INTUBATION.
Indications: Endotracheal Intubation

 Respiratory Failure: Hypoxia, Hypercapnia,

tachypnea, or apnea ; ie. ARDS, asthma,
pulmonary edema, infection, COPD
exacerbation
 Inability to ventilate unconscious patient
 Maintenance or protection of an intact
airway
 Cardiac Arrest
 Medication administration
Contraindications:
 Inability of patient to extend head
 Moderate to severe trauma to the
cervical spine or anterior neck
 Infection in the epiglottal area
 Mandibular fracture or trismus.
 Uncontrolled oropharyngeal
hemorrhage.
AIRWAY ASSESSMENT
2) Interincisor gap : normal -> more than 3
cms
AIRWAY ASSESSMENT
3) Mallampati classification: Class
3,4 -> may be difficult intubation
Soft palate

Uvula
 AIRWAY ASSESSMENT
Laryngoscopic view

grade 3,4 -> risk for

difficult intubation
AIRWAY ASSESSMENT
5) Flexion and extension of neck
 AIRWAY ASSESSMENT
6) Movement of temperomandibular joint
(TMJ)

Grind
1) Laryngoscope : handle and blade
 LARYNGOSCOPIC BLADE
 Macintosh (curved) and Miller (straight) blade
 Adult : Macintosh blade, small children : Miller
blade

Miller blade Macintosh blade

Equipment
 Laryngoscope
 Blades: curved (MacIntosh) and straight
(Miller)
 Endotracheal tubes of various sizes:
 Neonates and full term infants: no. 0 and 1
 Adult women: 7.0 mm i.d. tube
 Adult men: 8.0 to 8.5 mm i.d. tube
 Pediatric size: (age in years/4) + 4 or width
of fingernail of the fifth digit
2) Endotracheal tube
4) Bevel
5) Murphy’s eye
 7) Tube markings

 Z-79
 Disposible (Do not reuse)
 Oral/Nasal
 Radiopaque marker
 Endotracheal tube
1) Size of endotracheal tube : ID
Male: ID 8.0 mms . Female : ID 7.5
mms
 New born - 3 months : ID 3.0 mms
 3-9 months : ID 3.5 mms
 9-18 months : ID 4.0 mms
 2- 6 yrs : ID = (Age/3) +
3.5
 > 6 yrs : ID = (Age/4)
+ 4.5
 6) Depth of endotracheal tube :
Midtrachea or below vocal cord ~ 2
cms
 Adult -> Male = 23 cms ,Female = 21
cms
 Children
Oral endotracheal tube = (Age/2) +
12 (cm)
Nasal endotracheal tube = (Age/2) +
15 (cm)
Continue Equipment for ET intubation:

 Lubricant, Malleable stylet

 10-ml syringe (to inflate ET cuff)
 Oxygen and manual bag valve mask
 Suction apparatus
 Stethoscope
 Sterile gloves and goggles
 Oropharyngeal airway
 CO2 Detector
Flexion at lower cervical spine
Extension at atlanto-occipital
joint
Sniffing
position
ALL THE BEST

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