Orotracheal
Intubation
1. Adequately
ventilate/oxygenate.
- pre-oxygenate 3 minutes at 100%
2. Get all equipment ready:
- suction, laryngoscope with working bulb, ETT tube (sizing below)
- end-tidal CO2 detector, stethoscope, end-tidal CO2 detector.
- drugs; induction and paralytic
--> commonly etomidate (0.3 mg/kg IV) and succinylcholine (1.5
mg/kg IV)
--> beware propofol causes hypotension so do not use if
hypotensive
3. Check cuff for leak by inflating/deflating.
4. Connect laryngoscope and check bulb is bright.
5. Have assistant manually immobilise head and neck without
flexion/extension.
- in-line mobilisation
- cricoid pressure.
6. Hold laryngoscope in left hand.
7. Insert laryngoscope into right side of mouth, displacing tongue
to
left.
8. Identify epiglottis and vocal cords.
- backward pressure cricoid cartilage can help prevent
regurgitation.
- backward upward rightward pressure (BURP) doesn't protect airway,
but
helps visualise cords.
9. Insert tube into trachea without pressure on teeth or oral
tissues.
- size 7 for women, 8 for men (as per size)
- age/4+4 for children.
- teeth at 21-23cm mark, secured.
- using an L-shape configuration may aid placement.
- verify placement with a capnography set
10. Inflate cuff to a good seal - do
not
over-inflate.
- takes 3-8 ml of air to inflate
11. Check placement with bag-valve-to-tube ventilation.
12. Observe chest excursion.
13. Auscultate to ascertain tube position (chest bilaterally and
stomach).
- avoid common complication of mainstem intubation
14. Secure tube.
- and reassess the tube if the pt moves.
15. If not quickly achieved, discontinue and resume
ventilation.
Reattempt.
16. Get a chest XR to help determine placement.
- shd be 2-5cm above carina.
17. Attach a CO2 measuring device - reliable.
18. Attach pulse oximetry.
Complications
i) oesophageal intubation --> hypoxia.
ii) R bronchus intubation --> L lung collapse.
iii) inability to intubate
iv) induction of vomiting --> aspiration
v) trauma to airway --> bleeding aspiration
vi) damage of teeth
vii) rupture leak of ET cuff
viii) cervical cord injury