Endotracheal intubation

Endotracheal intubation

Indications

An artificial airway in the form of an endotracheal tube is passed through the mouth (orotracheal) or nose (nasotracheal) to facilitate

· an airway

· tracheobronchial suction

· protection of the airway from inhalation of secretions, blood or vomit

· delivery of high F10₂

In most adults the distance from the teeth to mid- trachea is 18-24cm. Oral tubes are inserted to a distance from the teeth of 21cm in females and 23cm in males to ensure that the tip of the tube is at mid-tracheal level. This is a guide only.

Requirements

Resuscitation trolley with appropriate size ETT (8.00mm for females and size 9.0mm for males), Magill’s forceps, the cuff bundle, Mcintosh laryngoscope, handventilating set with black facemask size 4 attached and connected to oxygen. The laryngoscope should be tested to ensure that the light housed in the blade works satisfactorily. A cuff bundle includes a 10 ml syringe, guarded forceps, lubricant and white tape to secure E.T.T. Ensure that suction is available at the bedside; including a yanker’s sucker attached at the head of the bed.

Drugs for administration prior to procedure may include an I V induction agent e.g. sodium thiopental, and will include IV midazolam, fentanyl and a short acting depolarizing agent IV suxamethonium. The patient should have an intravenous access for administration of drugs.

Procedure

· check that the hand ventilating assembly and mask, oxygen, suction, and laryngoscope are in working order

· open appropriate size ETT and check cuff for leak using a 10cc syringe

· lubricate ETT if requested be anaesthetist

· explain the procedure to the patient (regardless of conscious state)

· preoxygenate with 100% 02 using hand ventilating bag and mask.

· administer sedation/analgesia and neuromuscular blocking agent as requested

· cricoid pressure may be required as requested to prevent oesophageal reflux

· the ETT is passed through the vocal chords

· ETT mount and HME is connected to the ETT and the patient is ventilated with 100% 0₂

· the assistant inflates cuff slowly until there is no air leak

· auscultation of both sides of chest is essential.

· The ETT tube is secured with cotton tape

· Chest x-ray is ordered to check position of ETT

· The length of insertion of the ETT is documented on the flow chart.

NB.Tube may be cut by critical/cardiac RN to length post chest x-ray.

Complications

· aspiration of vomitus

· oesophageal intubation/right main bronchial intubation

· vocal cord damage, trauma to gums, tongue, lips and teeth

· hypoxia, life threatening arrhythmias, hypotension, cardiac arrest

Nursing care protocol

· X-rays must be taken with patient flat as ventilated patients are often heavily sedated, they are unable to support themselves, therefore must never be sat above 45^o

· all turns (repositioning) carried out by 3 staff, one to support the head and ETT

ETT repositioning

Essential in preventing pressure necrosis of the lip

· the cuff must be deflated daily during the repositioning procedure to prevent damage to vocal cords

· the ETT (oropharyngeal) must be re-positioned daily alternating left and right side of mouth, preferably before routine chest x-ray

· the ETT must be repositioned by two RNs one of whom has post graduate CCU/ICU qualification