Endotracheal Intubation: Indications and Equipment

• Endotracheal intubation involves inserting a tube into the trachea via the mouth or nose.
• It ensures the airway is open and maintained correctly
• Mechanical ventilation is possible through intubation
• This process helps in the suction of secretions
• It aids in preventing aspiration of gastric contents

Indications for Endotracheal Intubation

• Respiratory failure means intubation is required
• Apnea, or cessation of breathing, necessitates intubation
• Airway obstruction from foreign bodies or swelling requires intervention
• A decreased level of consciousness and loss of protective reflexes is an indication
• Needed for prolonged mechanical ventilation after major surgery or trauma

Equipment Needed for Intubation

• Laryngoscope with blades of different sizes, such as curved Macintosh and straight Miller blades, are needed
• Endotracheal tubes of various sizes are needed
• A stylet gives rigidity during insertion
• Syringe (10 mL) use to inflate the endotracheal tube cuff
• Suction equipment is required to clear secretions
• An oxygen source and bag-valve-mask (Ambu bag) are required for pre-oxygenation
• An end-tidal CO2 detector is needed to confirm correct tube placement
• A securing device, either tape or a commercial holder, is required to secure the tube
• Gloves, a mask, and eye protection is needed for standard precautions

Preparation for Intubation

• Use a bag-valve-mask to pre-oxygenate the patient with 100% oxygen
• Align the airway by properly positioning the patient with the "sniffing position" (neck flexed, head extended)
• Ensure all required equipment is properly assembled and checked
• Confirm suction is available
• Facilitate intubation by giving medications as prescribed (sedatives, neuromuscular blocking agents)

Intubation Procedure

• Open the patient's mouth and insert the laryngoscope blade on the left side
• Advance the blade, displacing the tongue to the left
• See the vocal cords are visible
• Gently insert the endotracheal tube through the vocal cords
• Inflate the cuff with the correct air amount, usually 5-10 mL
• Afterwards, remove the stylet
• Attach the bag-valve-mask and ventilate

Confirmation of Tube Placement

• Listen for bilateral breath sounds
• Observe chest rise with ventilation
• Confirm exhaled carbon dioxide presence using an end-tidal CO2 detector
• Get a chest X-ray to ascertain the tube placement in the trachea, above the carina

Securing the Endotracheal Tube

• Use tape or a commercial endotracheal tube holder to secure the tube
• Note the tube placement in cm at the lip or teeth
• Observe the patient's respiratory status and vital signs.

Potential Complications

• Hypoxia can arise from prolonged intubation attempts or insufficient ventilation
• Esophageal intubation, insertion into the esophagus instead of the trachea is a risk
• Right mainstem bronchus intubation happens when the tube goes too far into the right bronchus
• Gastric contents can be aspirated
• Trauma can happen to the teeth, tongue, or airway
• Laryngospasm, a sudden vocal cord spasm, can occur
• Hypotension or hypertension may occur due to the procedure's stress and medications
• Arrhythmias might occur due to hypoxia or vagus nerve stimulation

Nursing Care Post-Intubation

• Keep checking respiratory status, including oxygen saturation, respiratory rate, and breath sounds
• Monitor vital signs (heart rate, blood pressure)
• Keep the endotracheal tube securely placed
• Prevent infection by providing oral care
• Maintain an open airway by suctioning secretions as needed
• Give medications as prescribed (sedatives, analgesics)
• Even if the patient cannot speak, communicate to provide reassurance
• Watch for complications like ventilator-associated pneumonia (VAP)
• Regularly reposition the patient to prevent pressure ulcers
• Provide nutritional support

Ventilator-Associated Pneumonia (VAP) Prevention

• To reduce aspiration, elevate the head of the bed to 30-45 degrees
• Reduce bacterial colonization by providing frequent oral care with chlorhexidine
• Use closed suction systems to lower contamination risk during suctioning
• Before and after contact with the patient or respiratory equipment, practice proper hand hygiene.
• Assess daily readiness to wean from mechanical ventilation to reduce intubation time

Endotracheal Tube Sizes

• Adult females typically use a 7.0 - 7.5 mm internal diameter (ID) tube
• Adult males typically use a 8.0 - 8.5 mm internal diameter (ID) tube
• Pediatric tube size estimation: (Age in years / 4) + 4 (uncuffed tubes), or (Age in years / 4) + 3.5 (cuffed tubes)

Laryngoscope Blades

• Curved (Macintosh) blades of sizes 1-4, are placed in the vallecula, indirectly lifting the epiglottis
• Straight (Miller) blades sizes 0-3, directly lift the epiglottis

Rapid Sequence Intubation (RSI)

• Rapid administration of a sedative and neuromuscular blocking agent occurs via RSI.
• The technique helps quickly secure the airway in emergency situations
• Preparation, preoxygenation, medication administration, cricoid pressure application (Sellick maneuver), intubation, and tube placement confirmation are key steps

Weaning and Extubation

• Weaning is the gradual ventilator support reduction, enabling the patient to breathe spontaneously.
• Extubation is removing the endotracheal tube.
• Extubation criteria: ability to maintain adequate oxygenation and ventilation, stable vital signs, and intact gag reflex
• Monitor the patient following extubation, for respiratory distress signs, like stridor or increased breathing effort.