ET Intubation Procedure and Indications

Introduction to ET Intubation

• ET intubation is a procedure in which an ET tube is placed inside the trachea through the mouth or nostrils.
• It is simpler than tracheotomy, a surgical procedure that creates an airway opening by cutting into the trachea.
• ET intubation is preferred as the initial means of establishing an artificial airway.

Indications for ET Intubation

• General indications: patient requires an artificial airway for a brief period (e.g., 10 days or less) and full recovery is expected.
• Relief of airway obstruction:
  • Epiglottitis
  • Facial burns and smoke inhalation
  • Vocal cord edema
• Protection of the airway:
  • Prevention of aspiration
  • Absence of coordinated swallow
• Facilitation of suctioning:
  • Excessive secretions
  • Inadequate cough
• Support of ventilation:
  • Ventilatory failure / respiratory arrest
  • Chest trauma
  • Postanesthesia recovery
  • Hyperventilation to ↓ intracranial pressure

ET Tube Insertion

• An ET tube may be inserted orally (oral intubation) or nasally (nasal intubation) through the larynx into the trachea.
• Intubation through the mouth is the preferred method of establishing an artificial airway.
• Oral route provides quick access to the lungs in emergency situations and allows the passage of a larger ET tube than the nasal route.

Initial Intubation Procedure

• Prior to intubation, the patient must be assessed to rule out any potential contraindications.
• The degree of difficulty in intubation due to anatomical structures can be evaluated by using the Mallampati classification method:
  • Class 1 (easiest)
  • Class 2 (difficult)
  • Class 3 (more difficult)
  • Class 4 (most difficult)

Equipment Needed for ET Intubation

• Required equipment:
  • Laryngoscope handle
  • Blade
  • ET tube
  • 10-mL syringe
  • Water-soluble lubricant
  • Tape
  • Stethoscope
• Optional supplies:
  • Stylet
  • Topical anesthetic
  • Magill forceps

ETT Sizes Estimation

• Size refers to the internal diameter (ID) of the tube in millimeters (mm).
• ETT sizes for different age groups:
  • Neonate (, 1000 grams): 2.5 mm ID
  • Neonate (1000 to 2000 grams): 3.0 mm ID
  • Neonate (2000 to 3000 grams): 3.5 mm ID
  • Neonate (. 3000 grams): 4.0 mm ID
  • Child (1 to 2 years): 4.5 mm ID
  • Child (2 to 12 years): 4.5 + (age/4) mm ID
  • Adult female: 7.0 or 7.5 mm ID
  • Adult male: 7.5 or 8.0 mm ID

Length of ETT

• Length of ETT for different age groups:
  • Neonates: 6 + weight (in cm)
  • >2 years: age/2 + 12 (in cm)
  • Adult:
    • Male: 21-24 cm
    • Female: 18-21 cm

Procedure for Oral Intubation

• Steps for oral intubation:
  • Assemble and test supplies
  • Lubricate the deflated cuff with a water-soluble lubricant
  • Inform or explain the procedure to the patient
  • Bag-mask ventilate and preoxygenate the patient with 100% oxygen
  • Tilt the head back and place in the sniffing position
  • Open the mouth, apply anesthetic spray
  • Hold the laryngoscope handle and insert the blade into the right side of the opened mouth
  • Slide the blade to the base of the tongue and sweep the blade to the left
  • Maneuver the tip of the straight blade underneath the epiglottis
  • Lift the handle and blade up anteriorly to displace the tongue and attached soft tissues
  • Locate the epiglottis, larynx, and vocal cords
  • Insert the ET tube through the vocal cords under direct vision
  • Inflate the cuff and confirm endotracheal tube placement
  • Verify proper depth of ET tube placement with a chest radiograph

Complications of ET Intubation

• Complications during intubation:
  • Trauma to lip, tongue, or teeth
  • Hypertension and tachycardia or arrhythmia
  • Pulmonary aspiration
  • Laryngospasm
  • Bronchospasm
  • Esophageal intubation
• Complications during remained intubation:
  • Obstruction from kinking, secretion, or overinflation of the cuff
  • Accidental extubation or endobronchial intubation
  • Disconnection from the breathing circuit
  • Pulmonary aspiration
• Complications during extubation:
  • Laryngospasm
  • Pulmonary aspiration
  • Edema of the upper airway
• Complications after extubation:
  • Sore throat
  • Hoarseness
  • Tracheal stenosis (Prolong intubation)
  • Laryngeal granuloma