(3) isolates the airway preventing aspiration; (4) prevents gastric insufflation during positive

Transcription

1 I. Subject: Endotracheal Intubation II. Policy: Respiratory Therapists certified in endotracheal intubation will intubate in cases of emergency including: A. Respiratory arrest B. Overt respiratory failure characterized by observed, severe hypoventilation and decreased level of consciousness, in which subsequent respiratory arrest appears eminent. III. Indications: Indications for tracheal intubation included: A. Respiratory arrest B. Acute respiratory failure C. Tracheo-bronchial secretion removal D. Relief of upper airway obstruction E. Airway protection in CNS depression F. Support of ventilation IV. Rationale: Endotracheal intubation is an airway maintenance technique which involves the passage of a hollow tube, usually made of polyvinyl chloride, directly into the lumen of the trachea. The tube is inserted orally or nasally, usually via laryngoscopy. Endotracheal intubation is the preferred technique for airway control during CPR because it (1) facilitates positive pressure ventilation and oxygenation; (2) facilitates suctioning of the trachea and bronchi; (3) isolates the airway preventing aspiration; (4) prevents gastric insufflation during positive 1

2 pressure ventilation; and (5) provides a route for the administration certain drugs used during CPR. Adult endotracheal tubes generally possess inflatable cuffs to seal the airway. Pediatric and infant sized tubes may not possess a cuff. Cuff designs that have high residual volumes and low pressure seals are used. Foam cuffs are also available to reduce the pressure against the tracheal mucosa. A continuous aspiration subglottic suction (CASS) ET tube may be utilized to prevent pooling of oral secretions above the endotracheal tube cuff. V. Materials: Bite Block Tongue Depressor Laryngoscope Straight blade of appropriate size (Wisconsin; Miller) Curved blade of appropriate size (McIntosh) Stylet Syringe (10cc) Suction Catheter Yankuer Suction Tip Manual resuscitator attached to O2 source with appropriate sized mask Viscous Xylocaine (2%) Cloth Tape Appropriate Sizes of Endotracheal Tubes CO2 detector All necessary equipment should be within reach and should be checked prior to procedure. Glidescope (optional) (Distal portion of endotracheal tubes should remain sterile) VI. Procedure: A. Prior to any attempt at intubation, the operator should assess the anatomy of the face, jaw and neck. Note how wide the mouth will be open, and explore for false teeth that should be removed. Certain anatomic features can interfere with visualizing the glottis. Patient with prominent incisors are quite difficult to intubate by standard technique. 2

3 Individuals with short, thick, necks, or neck trauma also present difficulties because the head cannot or should not be freely moved. Unless complete obstruction exists, the patient should be given oxygen and, if necessary, ventilated with bag and mask prior to intubation. B. While the patient is being hyperventilated, you should choose the appropriate blade style and tube size. The appropriate blade is considered the blade the therapist feels comfortable with for that patient's anatomy. For infants and children, the following formula may be used to select ET tube ID size: age (years) 4 Tube insertion length may be estimated by multiplying tube diameter (mm) X 3. The result is in cm. You should also have one tube larger and smaller for the pediatric patient. The normal tube for an adult male is (oral) and for a female. Tube insertion length in adult males is typically cm. Tube insertion length in adult females is typically cm. Add 2-3 cm for nasal placement. Test cuff integrity by inflating with air prior to insertion. C. Orotracheal Intubation- 1) Positioning- The patient should be positioned on a firm surface, with the head placed in a slight extension and the jaw forward. Hyperextension for the neck should be avoided as it produces a marked angulation between the tracheal and pharyngeal air columns, thus hampering visualization. One seeks to align the oral, pharyngeal, and tracheal planes. Extension of the head decreases the angle between the oral plane and the other two, while flexion of the neck brings the pharyngeal plane more into alignment with the tracheal plane. For the supine patient, correct positioning may be achieved by elevating the head on a supporting cushion to flex the neck, and then extending the head by moving the chin up and back. 2) Visualization- Hold the laryngoscope handle and blade in the left hand and insert it into the right side of the mouth. The blade is designed to push the tongue to the left and to enable visualization along the right side of the blade. Then lift the handle up and toward the ceiling over the patient's feet. DO 3

4 NOT lever the blade against the upper teeth in attempting to "see the cords", as this is the prime cause of dental fractures incurred during tracheal intubation. If the curved blade is used, the tip of blade should be placed in the vallecula on the operator's side of the epiglottis. The lifting of the blade in this position will raise the vallecula and the attached epiglottis to give a good view of the cords and arytenoids. The straight blade is used in a fashion similar to that of the curved blade, except that the epiglottis is actually lifted with the tip of the blade. The straight blade often gives a better view of the cords then does the curved blade, but allows less room in the mouth in which to manipulate the endotracheal tube. Pressure applied to the trachea will often facilitate visualization when using the curved blade. This procedure is may be contraindicated when using the straight blade. 3) Insertion of Tube- Passage of the ET tube is aided with the use of a stylet. Care must be taken to insure that it does not project beyond the tube because this can cause tracheal puncture. The tube is passed along the side of the blade and into the glottis. The tube is best held flat in the vertical plane, with the curve of the tube from left to right. This lessens the chance of intubating the esophagus. Place the tip of the tube in the glottis, remove the stylet, and rotate the curve into the proper plane as it is guided down the trachea. The tube is positioned so that its cuff is below the vocal cords and the laryngoscope is removed. Once in the trachea, the tube can be held firmly in place by gripping it between the thumb and index finger. The cuff is inflated using the minimum volume required to seal the airway. The chest is auscultated to insure the presence of bilateral breath sounds. The endotracheal tube should be passed to 22cm mark in the average adult male and 21cm in an average adult female. If advanced too far into the trachea, the tube will pass into one of the main bronchi, usually the right. If this occurs, as evidenced by the absence of breath sounds on a given side, deflate the cuff and pull the tube back until breath sounds are heard bilaterally and re-inflate the cuff. The pilot balloon tube should not be clamped. 4

5 D. GlideScope Orotracheal Intubation- 1) Looking directly into the patient s mouth and with the GlideScope in the left hand, introduce the video laryngoscope into the midline of the oral pharynx. 2) The GlideScope video laryngoscope may be used to produce a Macintosh indirect lift of the epiglottis or a Miller lift. 3) With the laryngoscope inserted, look to the monitor to identify the epiglottis, then manipulate the scope to obtain the best glottic view. 4) Use of an endotracheal tube stylet is recommended. The GlideRite Rigid Stylet is designed to complement the angle of the GlideScope video laryngoscope to facilitate intubation. A malleable stylet may be used with a angle. 5) Looking directly into the patient s mouth, not at the screen, carefully guide the distal tip of the tube into position near the tip of the laryngoscope. (It is important to look into the mouth at this step to avoid injuring the tonsils or soft palate.) 6) Look to the monitor to complete the intubation; gently rotate or angle the tube to redirect as needed. 7) To aid the passage of the endotracheal tube, withdraw the stylet (approx. 5 cm) while gently advancing the ETT. A 1 cm adjustment (withdrawal) of the laryngoscope also may be beneficial to reduce the viewing angle and allow the glottis to drop. E. Nasotracheal Intubation- Nasotracheal intubation may be necessary in clinical situations in which visualization for oral intubation is difficult such as neck trauma. This route is not preferred due to the increased risk of sinus, and subsequently, lower airway infection. 1) The positioning of the patient is the same as that described for oral intubation. If conscious and cooperative, the patient should be asked to judge which nasal passage is larger, by alternately occluding each nostril and determining the ease of breathing through the open one. A topical anesthetic is applied to the nasal mucosa and back of the throat. A vasoconstrictor may be used to 5

6 further increase the patency of the nostril and to prevent or minimize any bleeding from nasal mucosal trauma. 2) After waiting a few minutes for the nasal spray to act, or less if dictated by urgency of the need to provide an airway, a nasal tube lubricated with local anesthetic jelly or ointment is introduced into the nostril. It is guided slowly but firmly into the nasal passage, going up from the nostril (to avoid the large inferior turbinate), then backward and down into the nasopharynx in a pathway which may be visualized as an inverted "U". The curve of the tracheal tube should be aligned to facilitate passage along this curved course. As the tube passes through the nose into the nasopharynx, it must turn downward to pass through the pharynx. Making this turn, it may impact against the posterior nasopharyngeal wall and resist any attempt to push it further. The tube should be pulled back a short distance, and the patient's head should be extended further to facilitate attempts to pass this point smoothly and atraumatically. 3) Once the tube has made the bend into the nasopharynx and is descending into the oropharynx, its course must be straight toward the glottis. If the tube veers off to either side as it is advanced, it will not pass through the vocal cords. The proper method is to begin the passage of the tube with its curve in the correct plane, then maintain this position during its passage. The tube is advanced as long as breath sounds are tubular. 4) If blind passage is not possible, the procedure may have to be done under direct vision. The laryngoscopy for nasal intubation is identical to that described for oral intubation. With the glottis exposed, the tracheal tube position may be seen, and any lateral malposition of the tube tip may be corrected by rotation of the proximal end. 5) If the tube is in the midline but too posterior and this is not correctable by extension of the head, the tube must be grasped in the pharynx with McGill forceps and directed anteriorly through the vocal cords. As the tube enters the trachea, it is advanced only to the point at which the cuff is entirely below the vocal cords. F. Fixation- The tube can be secured with an endotracheal tube holder (bite block, or with tape and oral airway). 6

7 1. If an Anchorfast bite block is used, wash the sides of the patients face with mild soap, rinse and dry, and apply adhesive flaps to skin. Make sure that the pilot balloon of the endotracheal tube lies in the tube holder tract below the tube. Secure the tube to the holder with the flexible band and lock in place. G. Proper Placement Verification- 1) Immediately after intubation the location of the endotracheal tube is verified by listening over the epigastrium for any gurgling as positive pressure is applied to the tracheal tube. If gurgling is heard, the tube should be left in place, the cuff inflated and the application of positive pressure discontinued. A second tracheal tube should be placed under direct visualization into the trachea. Verification of proper tube placement is made by breath sounds in both lung apices and a silent epigastrium. 2) Additionally, waveform capnography or a carbon dioxide detection device such as the Easy Cap may be used. Positive placement is indicated by a color change of the medium with exposure to exhaled CO2. Verify color change with each exhalation over 5-10 breaths and in the presence of adequate pulmonary perfusion. 3) A chest X-ray may be done following intubation to insure proper placement since auscultation does not insure that proper suctioning of both bronchi can be accomplished. Proper tube tip location is in the middle of the trachea near the level of the aortic knob or at the base of the heads of the clavicles. H. Extubation- 1) Pre-oxygenate the patient with 100% oxygen. 2) The patient must be suctioned vigorously before extubation so that aspiration of secretions does not occur. Mouth and pharynx suctioning is done to remove all secretions and materials proximal to the cuff. A continuous aspiration subglottic suction (CASS) ET tube may facilitate this process. Then, another sterile suction catheter is introduced into the endotracheal tube for suctioning. 3) The tube cuff is deflated completely. 7

8 4) Once suctioning is completed, all securing tape is removed, and the alert patient is instructed to inhale deeply to increase the lumen of the trachea maximally. If the patient is unconscious, this may be accomplished by manual inflation with a manual resuscitator. 5) The endotracheal tube is then removed in a smooth and continuous motion. 6) Coughing is encouraged and supplemental O2, if necessary, is connected immediately. VII. Possible Complications 1) Pneumothorax 2) Subcutaneous mediastinal emphysema 3) Lip, Laryngeal and/or pharyngeal laceration 4) Bleeding 5) Laryngeal and/or tracheal edema 6) Ulcerations 7) Tracheal stenosis, necrosis, malacia, granulomas 8) Vocal cord paralysis 9) Dental injury 10) Esophageal intubation 11) Esophageal perforation 12) Aspiration 13) Tachycardia, bradycardia, hypotension, hypertension, myocardial ischemia, cardiac arrhythmia 14) Eye trauma/corneal abrasion 15) Temporomandibular joint dislocation 16) Elevated intracranial pressure 17) Cervical spine injury 18) Respiratory tract infections 19) Laryngospasm VIII. Documentation: Documentation of endotracheal intubation performed by Respiratory Therapy personnel should be made in the Airway section of the Respiratory Therapy flowsheet in the patient s medical record and include the date and time performed, the route of insertion, the tube size 8

9 and position, as well as the presence of breath sounds over the lung fields and presence of color change on CO2 detector or proper CO2 waveform and level. The position of the tube should be noted. Any complications should be noted. 9