Overview of Endotracheal Tube Intubation Techniques
Being able to put a breathing tube down a person’s throat is a skill that many medical professionals need. This is done to help with breathing and to ensure the person gets enough oxygen. There are various ways this can be done. Some methods include seeing the vocal cords using a tool known as a laryngoscope or a video laryngoscope, directly placing the tube into the windpipe through a small cut in the neck, or seeing the vocal cords using a thin, flexible instrument that sends images back to a screen, which can be done through the nose or mouth. In this text, we’ll be focusing mostly on using the laryngoscope and video laryngoscope in emergency situations.
Anatomy and Physiology of Endotracheal Tube Intubation Techniques
The upper airway includes parts such as the oral cavity and the area in the back of the throat, which includes the nasopharynx, oropharynx, hypopharynx, and larynx. These parts help to moisturize and warm the air we breathe. Their blood supply comes from two major arteries in the neck, the external and internal carotid arteries. Some nerves, including the trigeminal nerve and the facial nerve, help with sensation in this area.
The trachea, or windpipe, is the tube through which air passes to reach our lungs. It is soft at the back and has cartilaginous rings at the front. In adults, the trachea is usually between 15 and 20 mm wide. This helps doctors identify the windpipe as separate from the esophagus, which conducts food to the stomach, and assists during procedures such as intubation. The windpipe splits into the right and left bronchi, which carry air to the lungs, at the level of the fifth spinal bone in the chest.
The area above the vocal cords in the throat gets its sensation from a nerve branch called the superior laryngeal branch of the vagus nerve. This nerve is part of the reason why some people can experience changes in heart rate or blood pressure during procedures involving this area. Between the vocal cords and the windpipe, there is a cartilage called the cricoid cartilage, which can help doctors see the vocal cords more clearly during intubation.
A structure called the hyoepiglottic ligament connects the hyoid bone to the larynx and helps to lift the epiglottis (a flap of tissue at the base of the tongue that prevents food and drink from entering the windpipe) during procedures like intubation.
For children, these landmarks are similar but some differences need to be considered. For example, a child’s head is proportionally larger, requiring some adjustment in their position to visualize these areas. Children have larger tongues, which can obstruct viewing the airway. Furthermore, the airway’s position and angle can make it more difficult to visualize certain areas. Lastly, a child’s windpipe is shorter, which may increase the chance of tubes going unnecessarily into the right bronchus during intubation.
Why do People Need Endotracheal Tube Intubation Techniques
Endotracheal intubation is a critical procedure often performed in emergency situations. It involves inserting a tube into the lungs via the mouth or nose to help a patient breathe better. The procedure aims at safeguarding the patient’s airway and succeeding on the first attempt.
Endotracheal intubation might be necessary if the person has difficulty breathing, if their airway might become blocked, or if they have abnormally low levels of oxygen or high levels of carbon dioxide in their blood. Doctors would need to evaluate the patient’s alertness, possible conditions that could obstruct the airway, consciousness levels, breathing pace, and blood oxygen and acid levels to rank the need for intubation.
In case of injuries, doctors use a measure called the Glasgow Coma Scale to assess consciousness in trauma patients. If this score is 8 or less, it usually means the patient needs to be intubated for their safety.
When a Person Should Avoid Endotracheal Tube Intubation Techniques
When thinking about a procedure known as endotracheal intubation, which involves placing a tube down a patient’s throat to help them breathe, it’s important to weigh the benefits against the risks, just like with any other medical procedure. If a patient’s breathing could improve with less complex methods, these should be tried first. Such methods may include things like non-invasive positive pressure ventilation, which uses a mask to push air into the lungs, or other ways to supply the body with more oxygen.
However, in some situations, endotracheal intubation can be challenging or harmful. For example, severe injuries to the mouth or face can make it difficult to place the tube in the throat without causing additional harm, especially if there’s a lot of bleeding or the structure of the face and airways (the passages where air travels to get to the lungs) has been significantly altered. And, if a patient has a neck/spine injury, the steps involved in placing the tube could potentially cause more harm.
If it’s not feasible to use the traditional intubation in these situations, doctors should consider other ways to provide ventilation (breathing support) and oxygen if the patient’s condition allows. If it’s absolutely necessary to secure the patient’s airway, medical providers should be ready to potentially create a surgical airway—a more invasive procedure to provide an airway.
However, there are no hard and fast rules against intubation. The decision whether to proceed with the procedure is determined based on the patient’s specific situation and individual health condition.
Equipment used for Endotracheal Tube Intubation Techniques
When doctors are about to do two types of procedures to look at your vocal cords and airways, called direct and video laryngoscopy, they will need a number of different items to help ensure everything goes smoothly:
First off, they have to get ready:
- They need a way to give you medication through your vein, this is called intravenous access
- They will check your heart rate and blood pressure, a process known as hemodynamic monitoring.
- An instrument called a stethoscope to listen to the heart and lungs.
- A device called a pulse oximeter, which measures how much oxygen is in your blood.
- A monitor that measures the amount of carbon dioxide you breathe out, known as an End-tidal carbon dioxide (EtCO2) monitor.
- A tool to clear away any fluids called a suction catheter, which is always turned on.
- A cart filled with equipment and drugs that can be used if your heart stops, named a cardiac arrest cart.
- Certain medications to make you relaxed and to block pain during the procedure (paralytic, sedative, and/or dissociative agents).
- And finally, a machine that can restore a normal heartbeat called a Defibrillator.
Then, they want to make sure you have enough oxygen, a process known as pre-oxygenation:
- A nasal cannula or high-flow nasal cannula to provide oxygen through the nose.
- A bag-valve mask with varying sizes is used to provide air manually if needed.
- A PEEP valve or Positive end-expiratory pressure valve helps you breathe out.
- There will also be oral and nasal tubes of many sizes available.
- A non-rebreather mask, which is a mask that delivers large amounts of oxygen.
- And of course, extra oxygen just in case it’s needed.
For the direct laryngoscopy, the following items are needed:
- A handheld device called a laryngoscope, which has batteries and different types of blades.
- Different sizes of a tube known as an endotracheal tube.
- A bendable wire called a malleable stylet.
- A 10cc syringe.
- And tape to secure any materials in place.
For the video laryngoscopy, they will use:
- A video laryngoscope connected to a power source.
- And a rigid or malleable stylet, the type used depends on the brand of video laryngoscope.
Lastly, some back up equipment just in case:
- A laryngeal mask airway, which is used as an alternative to the endotracheal tube.
- A device called a Bougie to help guide the endotracheal tube.
- A cricothyrotomy tray which has all the equipment needed to make a hole in your neck for breathing, if necessary.
- And Magill forceps, which are used to guide a tube into your lungs.
Who is needed to perform Endotracheal Tube Intubation Techniques?
When a doctor decides that a patient needs help breathing and needs to be intubated (have a tube placed in their windpipe), that doctor is typically the most qualified to lead the medical team during this procedure. It’s the doctor’s job to assign different roles to the rest of the team.
The doctor or another team member who’ll perform the intubation stands by the head of the patient’s bed. The nurse responsible for giving medicine usually stands to the patient’s left, or close to where the medicine will be given.
A special health care worker, the respiratory assistant, has the job of helping the patient breathe. If needed, they can adjust the position of the breathing tube. They also have the endotracheal tube (the tube used for intubation) ready to hand over to the doctor. The respiratory assistant generally stands on the patient’s right side.
In some cases, another helper may be required if the patient’s neck needs to be kept steady. This person stands to the left of the doctor or team member who is performing the intubation, ready to hold the patient’s neck in the correct position.
Preparing for Endotracheal Tube Intubation Techniques
When a doctor needs to insert a tube into a patient’s airway (a procedure called intubation), they start by checking the patient’s throat and neck. This lets them know whether there might be any problems or difficulties during the procedure. Some things that might make intubation more challenging include a history of difficult intubations, problems moving the neck, obesity, or injuries to the face or neck.
One common checklist that doctors use might be remembered as “LEMON.” LEMON stands for: Look, Evaluate, Mallampati, Obstruction, and Neck. It’s essentially a way for doctors to examine the patient’s external features such as signs of trauma, facial hair, large tongues or dentures; evaluate if the patient’s mouth or neck is unusually small or restricted; figure out if the patient’s airway might be difficult to intubate; check if the patient’s throat is obstructed or if they’re obese, which may restrict the doctor’s view of the vocal cords; and assess the patient’s neck mobility, as any restriction can make it harder to insert the tube.
After the exterior examination of the patient, the doctor will position the head to get the best possible view of the vocal cords for intubation. For obese patients, additional support might be used under the head to get it to the correct elevation.
The size of the tube that will be inserted into patient’s windpipe or trachea (called an endotracheal tube) can vary. For the most part, a size 7.0 is used for women and a size 8.0 for men. This can change depending on patients’ height or if a specific procedure called bronchoscopy will be required later. For children, there are different equations to figure out the size they need. The tube will be prepared by making a certain shape and testing the inflation section, called the cuff.
In many emergency situations, doctors use a method called Rapid Sequence Intubation (RSI). This involves giving certain medications that work very fast and for a short period to make the patient unconscious and still. This strict timing helps to minimize the time that the patient can’t breathe by themselves. If a patient is combative or very confused, a different method called Delayed Sequence Intubation (DSI) may be used, in which a certain medication allows the patient to remain cooperative while they are provided oxygen before intubation is performed. In certain cases where intubation might be difficult, doctors might choose to perform the procedure while the patient is awake, after giving them medication to numb the throat and to lower secretions.
Before the procedure starts, the patient will be provided with as much pure oxygen as possible. This is called pre-oxygenation. It helps the oxygen level in the blood stay high even during the short period that the patient can’t breathe by themselves. The oxygen can be given through a mask or other methods depending on the patient’s breathing capacity. This is continued until the correct oxygen levels are achieved.
During the moments when the patient can’t breathe on their own (apnea), a process called apneic oxygenation is used. Here, oxygen continues to move into the lungs due to pressure differences, even when the person is not actively breathing. This can be achieved by providing oxygen through the nose, which can allow for adequate oxygen levels for approximately 10 minutes. This all helps the patient remain safe during the intubation procedure.
How is Endotracheal Tube Intubation Techniques performed
Intubation is a procedure used to maintain an open airway in patients who cannot breathe on their own. Preparing and positioning a patient properly is crucial for successful intubation. To begin, the doctor will check the light source of the laryngoscope (a tool used to view the throat) and ensure the blade is securely fixed. The doctor will hold the laryngoscope in their left hand and insert it into the patient’s mouth. They then continue to push back the tongue and look for the vocal cords, all while maintaining a steady, upward pressure.
If they are using a curved laryngoscope, they’ll locate a small space in the throat called the vallecula and place the laryngoscope’s tip there. By applying upward pressure, they are able to lift a thin leaflet of tissue known as the epiglottis, making the vocal cords visible. The doctor then coordinates with a respiratory assistant to insert an endotracheal tube. This tube ensures the airway remains open and functional. It’s inserted to the right of the laryngoscope blade and passes through the vocal cords. The length of the tube that should be inserted varies, but there are markings on some tubes to help guide the doctor.
If visibility remains limited, the doctor may adjust the airway with their right hand to get a better view. Once a good position is achieved, the assistant’s hand will take over to keep it steady while the doctor places the endotracheal tube.
If a straight laryngoscope is used instead, the doctor slides the blade in the direct center of the airway to locate the epiglottis. This blade lifts the tongue and epiglottis collectively, with the blade’s tip going under the epiglottis to reveal the vocal cords. This is slightly different from the technique used when a curved blade is in play.
In cases where it is expected that intubation might be difficult, doctors can opt to use a video laryngoscope, which gives a more detailed, real-time view of the throat. However, each tool and method has its merits and drawbacks, so the doctor will adjust the approach based on the patient’s specific needs.
During problematic intubations, a flexible tool called a bougie can be used. This device, equipped with an angled tip, helps locate hard-to-see parts of the airway. An endotracheal tube is then guided over the bougie, directed through the airway.
Once the endotracheal tube is set, a small balloon-like part of the tube, called the cuff, is inflated to keep the tube steady. The guide wire is removed, and the other end of the tube is attached to devices that monitor the patient’s carbon dioxide output and provide ventilation. Proper placement of the tube is confirmed using a carbon dioxide monitor and by ensuring even breathing sounds from both lungs.
After intubation, it’s absolutely crucial to confirm that the endotracheal tube is correctly placed in the trachea (the tube that connects the throat to the lungs) and not too close to the point where the trachea splits into the lungs. The most common way to confirm this placement is by tracking the amount of carbon dioxide exhaled with each breath. Breath sounds are also listened to, ensuring they are equal in both lungs and absent over the stomach. Lastly, a chest x-ray is performed to ensure the tube is perfectly positioned.
Possible Complications of Endotracheal Tube Intubation Techniques
When getting ready for a procedure called intubation, where a tube is inserted in your throat to help you breathe, doctors have to think about possible problems that might happen. One of these is called hypoxemia, a condition where the body doesn’t get enough oxygen. This can happen due to multiple failed attempts to insert the tube, the tube is not properly placed, or the procedure itself is unsuccessful. To make sure this doesn’t happen, doctors will increase the oxygen levels in your body before the procedure and continue to provide oxygen even when you’re not breathing on your own.
Another thing your doctor will check is where the tube is placed. If it’s in the wrong place, it could cause issues. In some cases, when it’s hard to insert the tube, doctors will decide which method is best to use – either the standard procedure, another more advanced procedure, or inserting the tube while you’re awake using special instruments.
Some complications could also affect your heart. For example, during the procedure, your heart rate could drop or some medications used could cause low blood pressure. Both of these could lead to serious heart problems. To avoid this, doctors might do some things to improve your health before the procedure, like giving certain medications. They will make sure that they have reliable access to your veins so they can give you medications quickly if needed.
In addition, there could be other complications like cuts in your mouth or throat from the tube, damage to your teeth, or accidentally inhaling vomit or objects like dentures. After the procedure, there might be damage to internal parts of your throat caused by pressure from the tube. Rarely, the tube can cause a tear in your windpipe. To avoid these issues, doctors will carefully place the tube and monitor the pressure inside it.
What Else Should I Know About Endotracheal Tube Intubation Techniques?
Endotracheal intubation – which is a way to help someone breathe by inserting a tube into their windpipe – is a skill that’s critical for healthcare workers in emergency medicine and intensive care units. It’s not just about knowing how to do it, but also knowing who needs it and being aware of the possible risks and complications.
When getting ready to carry out this procedure, healthcare teams need to make sure of several things. They need to position the patient correctly, adequately prepare the patient by giving them oxygen, have the right equipment at hand, plan their team’s roles and actions, and be ready to try other approaches if the first one doesn’t work.
For example, if the team starts by using a method called direct laryngoscopy (a procedure where a doctor uses a device to look at the throat and voice box), they need to have alternative tools and techniques ready – such as video laryngoscopy (where a camera is used), a bougie (a thin, flexible instrument), a laryngeal mask airway (a mask that forms an airtight seal over the larynx), and tools for a procedure called cricothyrotomy (creating an opening in the neck to help someone breathe).
Preparing and practicing regularly is the key to making sure the team can successfully perform this lifesaving procedure in the emergency setting.
