Airway Access - Endotracheal Intubation

Introduction

Patient with respiratory failure/cardiopulmonary failure/unconscious, it is important to control their airway and breathing as well. and this can be achieved by intubation.

There are other procedures of keeping airway patent but in this article I'm putting more emphasies as per the title.

Indications for (EI)

• In order to protect and maintain airway.
•  For Direct trachea suctioning.
• If bag and mask ventilation or continuous positive airway pressure (CPAP) is insufficient.
• If prolonged positive pressure ventilation is indicated.
• IF (newborn) Diaphragmatic hernia is diagnosed

Contra-indications

• If you are not inexperienced, DO NOT INTUBATE, please perform bag and mask ventilation; as u wait for referal or help.

Equipment

• Laryngoscope.
• Suction catheter and device.
• Blades: Stylet (optional).Straight blade for infants, curved blades for an older child. Size 0 for neonates, 1 for infants, 2 for children.
• Endotracheal tube - appropriate size as shown.
• Pair of Scissors and adhesive tape.
• Bag and mask with high oxygen flow.
• Pulse oximeter.
• Sedation ( Morphine or Midazolam).
• Muscle relaxant (Succinylcholine).
• Size of ETT (mm):
  2.5 for < 1kg
  3.0 for 1-2kg
  3.5 for 2-3kg
  3.5 - 4.0 for > 3kg
• Oral ETT length in cm.

              For neonates: 6 + (weight in kg) cm
              For Children:  > 1 year: ETT size (mm) = 4 plus (age in years /4)
                     Oral ETT length (cm) = 12 plus (age in years /2)
Procedure
 1. Position infant with head in midline and slightly extended.
 2. Continue bag and mask ventilation with 100% oxygen till well saturated. In newborns adjust FiO2 accordingly until oxygen saturation is satisfactory. (Refer NRP Program 6th edition).
 3. Sedate the child with : -IV Midazolam (0.1-0.2 mg/kg) or IV Morphine (0.1-0.2 mg/kg).
                                       -admin. muscle relaxant if still struggling IV Succinylcholine (1-2 mg/kg).
 Caution: before giving muscle relaxant, you must  the patient  bag well or have good intubation skills.
 4. Monitor vital signs throughout the procedure.
 5. Introduce the blade between the tongue and the palate with left hand and advance to the back of the tongue while assistant secures the head.
 6. When epiglottis is seen, lift blade upward and outward to visualize the vocal cords.
 7. Suction secretions if necessary.
 8. Using the right hand, insert the ETT from the right side of the infant's mouth; a stylet may be required.
 9. Keep the glottis in view and insert the ETT when the vocal cords are opened till the desired ETT length while assistant applies cricoid pressure.
10. If intubation is not done within 20 seconds, the attempt should be aborted and re-ventilate with bag and mask.
11. Once intubated, remove laryngoscope and hold the ETT firmly with left hand. Connect to the self-inflating bag and positive pressure ventilation.
12. Confirm the ETT position by looking at the chest expansion, listen to lungs air entry and also the stomach.
13. Secure the ETT with adhesive tape.
14. Connect the ETT to the ventilator or resuscitation bag.
15. Insert orogastric tube to decompress the stomach.
16. Check chest radiograph.
Complication

• Oesophageal intubation/injury.
• Right lung intubation.
• Trauma to the upper airway.
• Pneumothorax.
• Subglottic stenosis (late).

Relative contra-indications for Succinylcholine are increased intra-cranial pressure(ICP),malignant hyperthermia, neuromuscular disorders,  renal failureand hyperkalaemia .
References

1.Advanced Paediatric Life Support - The Practical Approach. BMJ Books, APLS 5th Edition 2011, Chapters 20 & 21.
2.American Heart Association Textbook for Neonatal Resuscitation NRP 5th Edition 2006.
3.American Heart Association Textbook of Paediatric Advanced Life Support 2002
4.APLS - The Pediatric Emergency Medicine Resource. Gausche-Hill M, Fuchs S, Yamamoto L. 4th Edition 2004, Jones and Bartlett Publishers.