Endotracheal Intubation

endotracheal intubation is an important

part of airway management it is best

learned through practice under expert

supervision in our opinion first on a

mannequin and then on elective

uncomplicated and fasted patients this

lesson aims to prepare you for these

practice sessions and our narrow focus

is teaching the manual skills that will

increase your chances of success your

intubation should always be preceded by

an airway assessment what equipment and

personnel does the patient in front of

you require are the complications you

suspect may arise and is everyone on

board with the plan if they do first

place the patient in an optimal position

with the pillow tucked underneath the

shoulders raise the head relative to the

body into the so-called sniffing

position your goal is to achieve a line

of sight to the vocal cords in order to

pass the tube through them into the

trachea this requires a laryngoscope we

will teach the traditional direct

laryngoscopy but for filming purposes we

use a video laryngoscope that has the

same shape have the patient inhale 100%

oxygen through a tight-fitting mask when

the measured expiratory or entitle

oxygen concentration exceeds 80% you've

loaded up an oxygen reserve in the

periphery of the lungs

if this monitoring is unavailable pre

oxygenate for a minimum of three minutes

pre-oxygenation can be further improved

especially in the obese by tilting the

table and by applying a positive end

expiratory pressure this extra oxygen in

the patient buys you potentially

life-saving time if you have unexpected

airway difficulties precious time to

call for help or try more advanced

techniques administer the analgesic and

await the onset

n'gou Skippy is very painful and

requires drugs to alleviate sympathetic

response and airway reflexes next

administer the hypnotic the patient

gradually loses consciousness airway

muscle tone and respiratory drive from

this point on the patient's breathing is

your responsibility a paralytic

facilitates intubation traditionally we

would first have confirmed successful

face mask ventilation but no evidence

has shown that this prevents airway


therefore the emerging consensus is to

administer it as soon as the patient is

unconscious open the airways a

two-finger chin lift may be all it takes

if this isn't enough to be able to

ventilate the patient the next step is a

jaw thrust open the patient's mouth with

your thumbs on the patient's chin and

place your fingers firmly behind the

angle of the mandible and lift straight

up in a decisive manner successful

ventilation is confirmed by observing

the chest wall rising and regular

end-tidal co2 waves on the monitor

if you cannot ventilate the patient at

this point you need to use other

equipment and techniques that we will

demonstrate in forthcoming videos while

you wait full onset of the drugs take a

moment to make sure that you have

achieved absolute optimal positioning

before proceeding to laryngoscopy do not

forget that while you may hold the blade

this is very much a team effort open the

patient's mouth with your right hand and

hold the laryngoscope in your left not

too tight with three or four fingers as

close to the blade as possible for

precision and control insert the blade

in the right side of the mouth carefully

pushing the tongue aside the aim is to

create an unobstructed line-of-sight to

the larynx by pushing the tongue to the

left and lifting the epiglottis exposing

the vocal cords

this requires precision not brute force

a common mistake at this point is

leaning forward as it feels this will

give a better view it doesn't stand

upright with a left arm at a 90 degree

angle tucked in towards your body this

allows for better ergonomics better

communication with the team and a better

overview of the ventilator the timer and

the patient let's see the laryngoscopy

once again advanced the blade until you

see the epiglottis and placed the tip in

the vallecula the recess at the base of

the tongue at this point you can start

to apply some force in the direction of

the laryngoscope shaft sometimes a light

external force on the larynx can make

the vocal chords spring into view ask

for your assistance hand and move it to

apply backwards a prince rightward

pressure or burp for short make sure you

don't pinch the lips and do not exert

any pressure on the front incisors by

now you hopefully have a clear view of

the opening of the trachea a dark slit

between the pale vocal cords

insert the tube carefully sometimes a

gentle rotation is required to pass the

vocal cords advance the tip until the

cuff has disappeared and the vocal cords

are between the two black lines ask for

inflation of the cuff and carefully

retract the laryngoscope hold the tube

firmly while you confirm that it's

lodged in the trachea and not the

esophagus the gold standard is return of

entitled carbon dioxide over several

respiratory cycles be very cautious when

interpreting the other signs

traditionally used auscultation fines on

both lungs condensation in the tube and

the symmetric rise of the chest wall as

these may very well be positive despite

an esophageal intubation when you're

absolutely certain that the tube is in

the trachea secure it with tape and

initiate mechanical ventilation

congratulations you have now performed

an endotracheal intubation

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