Endotracheal Intubation Clinical Book 2023-2024 PDF

Critical care and emergency Nursing Module Title: Endotracheal Intubation Objectives based on competence: 1. Define endotracheal intubation 2. Know purpose, indication and complications of endotracheal tube. 3. Explain advantages of ETT 4. Describe contraindications of ETT...

Critical care and emergency Nursing Module Title: Endotracheal Intubation Objectives based on competence: 1. Define endotracheal intubation 2. Know purpose, indication and complications of endotracheal tube. 3. Explain advantages of ETT 4. Describe contraindications of ETT 5. Select the optimum size of endotracheal tube 6. Prepare the patients for endotracheal tube insertion. 7. Perform nursing care of endotracheal tube. 8. Collect equipment needed for tube insertion Definition of Endotracheal Intubation It refers to inserting a tube directly into the trachea through the nose (nasotracheal) or mouth (orotracheal). Definition of ETT It is a flexible plastic curved tube inserted through nose or mouth to the trachea. What Size Endotracheal Tube?  Adult male 7.5-8.5  Adult female 6.5-7.5  Pediatric 4+ AGE/4 ETT Depth of insertion Chest radiograph is obtained immediately after the insertion to confirm proper tube placement, which is about 2 to 3 cm above the carina. N.B The length of time that an ET tube remains in place is somewhat controversial; however, in most cases after 2 to 4 weeks, if a patient still requires an artificial airway N.B The nurse’s role in intubation includes patient assessment; monitoring vital signs, pulse oximetry and suctioning and collaborating with additional support staff as needed. Indications for Intubation  Inadequate oxygenation (decreased arterial PO2) that is not corrected by supplemental oxygen via mask/nasal.  Need to control and remove pulmonary secretions.  Pulmonary impairment (acute respiratory failure, COPD…)  Cardiovascular impairment (Ex: cardiac arrest )  Neurological impairment (myasthenia gravies, poisoning) 20  Critical care and emergency Nursing  Any patient in deep coma who cannot protect his airway (Gag reflex absent.).  Any patient in imminent danger of upper airway obstruction (e.g. Burns of the upper airways).  Any patient with decreased GCS ≤ 8  During general anesthesia. Equipment: - Endotracheal tubes with different size Stylet: flexible instrument inserted into the ETT to stiffen it to help direct insertion of tube to the glottic opening and avoid laryngeal trauma. - Local anesthetic jelly (for nasal approach) - Magill forceps (to remove foreign bodies obstructing airway). - Laryngoscope with fresh batteries and blades curved or straight. - Manual resuscitation bag with mask connected to oxygen source. - Oxygen source and connecting tubes. - Syringe for cuff inflation Portable suction apparatus (ready with different catheter size for suction). - Lubricating agent (K-Y jelly). - Oropharyngeal airway. - Endotracheal tube securing apparatus or adhesive tape. - Sedative agent for intubation of combative patient (as valium). - Stethoscope. - Pulse oximeter to monitor oxygen saturation. Procedure Steps Rationale 1. Patient Assessment: A. Assess the level of - To determine the need for sedation conscious, anxiety, or paralytic agents. respiratory difficulty -To allow for selection of the most B. History of trauma when spinal cord injury is appropriate method for intubation. suspected -To allow for sedation, paralysis of C. Need for pre-medications. agitated patient. 2. Patient Preparation:  Explain the procedure and -To enhance patient understanding and reason for intubation. to decrease anxiety.  Initiate intravenous access -To be readily available for patient’s before intubation and give Premeditation as doctor need for any medications and to allow order more controlled intubation. 21  Critical care and emergency Nursing  Position the patient -To allow for visualization of larynx appropriately: and vocal cords.  For non-trauma patient: Place -To prevent secondary injury if the patient in hyperextension cervical cord injury is present. position (sniffing position)  For trauma patient: Maintain in- fixed position (Jaw thrust maneuver) Nurse Preparation: 1. Wash hand 2. Wear gloves, mask Steps: 3. Insert oropharyngeal airway (only -To assist in maintaining upper airway in unconscious patient). patency. 4. Set up suction apparatus. -To prepare for oropharyngeal suction 5. Remove dentures if present. And as needed. Suction the mouth as needed. 6. Preoxygenate by 100% oxygen for -To allow visualization of vocal cords 3 to 5 minutes providing frequent by aligning the three axes of the 7. Assist the physician during mouth, pharynx, and trachea. To insertion as required prevent hypoxemia. 8. The tongue should be swept to one side & the laryngoscope should be lubricated by normal saline 9. Visualize the vocal cords and larynx 10. Place ETT through the cord 11. Attempt ventilation through the  To prevent teeth fracture ETT 12. Check the correct position of the tube 13. Inflate the cuff with the minimal amount of air required to occlude the trachea. 14. Confirm tube placement while bagging with 100% oxygen once -To adjust cuff pressure. the endotracheal tube has been placed.  Observe for symmetric chest wall 22  Critical care and emergency Nursing movement and any signs of -To assist in verification of correct respiratory distress tube placement in the trachea  Auscultate lung bases and apices for -To minimize risk of right bronchus bilateral breath sounds. intubation.  Auscultate over epigastrium (if air movement or gurgling is heard) 15. Evaluate oxygen saturation (SpO2) -To allow for identification of 16. Connect endotracheal tube to esophageal intubation. oxygen source or mechanical ventilator 17. Record the distance from proximal end of tube to the point where tube reaches the teeth. 18. Secure tube to the patient’s face with adhesive tape. 19. Reconfirm tube placement: Note the distance from proximal end of tube to the point where tube reaches the teeth. (Common tube - placement is 21cm for women and 23 cm for men in patients with normal weight and height). 20. Verify confirmation of correct tube position by chest x-ray. 21. Maintain tube cuff pressure at 20 to 25 mmHg. 22. Hyperoxygenate and suction endotracheal tube as needed. 23. Inspect nares or oral cavity once per shift while the patient is intubated. 24. Reporting and recording: Report the following conditions if they persist despite nursing interventions:  Absent or unequal breath sounds,  Cuff pressure ≤ 20 to 25 mmHg  Inability to pass a suction catheter  frothy, or bloody secretions  Significant change in the amount or 23  Critical care and emergency Nursing character of secretions  Redness, necrosis, or skin breakdown Record the following  Vital signs before, during and after intubation,  Oxygen saturation.  Type of intubation ( oral or nasal)  Use of any medications  Size of endotracheal tube,  Depth of endotracheal tube insertion  Measurement of cuff pressure Immediate post intubation care: 1. Check vital signs every 15- 20 min until they are stable 2. Observe for signs of hypoxemia, nasal bleeding, tooth avulsion 3. ABG drawn from 10-20 minutes 4. Frequent check for signs of right bronchus intubation  Decreased chest expansion Decreased breath sounds over the left side Complications  Trauma/bleeding to nasal, oral, esophageal, tracheal, or laryngeal sites  Fractured teeth  Transient cardiac arrhythmias.  Hypoxia  Aspiration  Displacement of tube (right mainstem intubation or gastric intubation)  Laryngeal damage, paralysis, and necrosis 24