Advanced Airway

Management & Intubation

The Difference Between
Life and Death
By: Norman Wilkinson, NREMT-P
Flight Paramedic
EMS/ECC Instructor

Topics For Discussion

Basic anatomy and

physiology.
Advantages of
endotracheal intubation.
Indications of intubation.
Contraindications of
intubation.
Complications of
intubation.
Equipment required for
intubation.

Technique of
endotracheal intubation.
Rules of endotracheal
intubation.
Tube sizes.
Rules and principals of
suctioning.
Other airway adjuncts.
Conclusion.
Difficult intubations.

Anatomy and Physiology

The airways can be divided in to parts namely:
The upper airway.
The lower airway.

The Upper Airway

The Lower Airway

Indications for Intubation

Ant patient in deep coma who cannot protect his

airway.(Gag reflex absent.).
Any patient in imminent danger of upper airway
obstruction (e.g. Burns of the upper airways).
Any patient with decreased L.O.C, GCS <= 8.
Severe head and facial injuries with
compromised airway.

Contraindications for Intubation

Patients with an intact gag reflex.

Patients likely to react with laryngospasm
to an intubation attempt. e.g. Children
with epiglottitis.
Basilar skull fracture avoid naso-tracheal
intubation and nasogastric/pharyngeal
tube.

Complications Associated With

Intubation

Trauma of the teeth, cords, arytenoid cartilages, larynx

and related structures.
Nasotracheal tubes can damage the turbinates, cause
epistaxis, and even perforate the nasopharyngeal
mucosa.
Hypertension and tachycardia can occur from the
intense stimulation of intubation; This is potentially
dangerous in the patient with coronary heart disease.
Transient cardiac arrhythmias related to vagal
stimulation or sympathetic nerve traffic may occur .

Complications Continued

Damage to the endotracheal tube cuff, resulting

in a cuff leak and poor seal.
Intubation of the esophagus, resulting in gastric
distention and regurgitation upon attempting
ventilation.
Baro-trauma resulting from over ventilating with
a bag without a pressure release
valve( phneumothorax).

Complications Continued

Over stimulation of the larynx resulting in

laryngospasm, causing a complete airway
obstruction.
Inserting the tube to deep resulting in unilateral
intubation (right bronchus).
Tube obstruction due to foreign material, dried
respiratory secretion and/or blood.

Equipment Required for

Successful Intubation

Equipment Cont

Laryngoscope with relevant size blades.

Magill forceps.
Flexible introducer.
10-20 ml syringe.
Oropharangeal airways all sizes.
Tape or adhesive plaster.
E.T tubes relevant sizes.
Bag-valve-mask with oxygen connected.
Suction unit with Yankauer nozzle and endotracheal
suction catheter.

Technique of Endotracheal
Intubation

Technique Cont

Position the patient supine, open the airway with a

head-tilt chin-lift maneuver.(Suspected spinal
injury, attempt naso-tracheal intubation, spine in
neutral position.).
Open mouth by separating the lips and pulling on
upper jaw with the index finger.
Hold laryngoscope in left hand, insert scope into
mouth with blade directed to right tonsil.
Once right tonsil is reached, sweep the blade to
the midline keeping the tongue on the left.

Technique Cont

This brings the epiglottis into view. DO NOT LOOSE

SIGHT OF IT!
Advance the blade until it reaches the angle between the
base of the tongue and epiglottis.( volecular space)
Lift the laryngoscope upwards and away from the nose
towards the chest. This should bring the vocal cords into
view. It may be necessary for a colleague to press on the
trachea to improve the view of the larynx.
Place the ETT in the right hand. Keep the concavity of
the tube facing the right side of the mouth.
Insert the tube watching it enter through the cords.

Technique Cont

Insert the tube just so the cuff has passed the

cords and then inflate the cuff.
Listed for air entry at both apices and both
axillae to ensure correct placement using a
stethoscope.

Rules of Intubation

Always have a suction unit available.

An intubation attempt should never exceed 30
seconds.
Oxygenate the patient pre and post intubation
with a bag-valve-mask.(100% O2).
Have sedative medication available if needed.
(e.g. Midazolam 15mg/3ml)
Always recheck tube placement manually
guided by oxygen saturation readings.(Spo2).

Tube sizes

Newborn to 4 kg - 2.5 mm (uncuffed).

1-6 months 4-6 kg 3.5 mm (uncuffed).
7-12 months 6-9 kg 4.0 mm (uncuffed).
1 year 9 kg 4.5 mm (uncuffed).
2 years 11 kg 5.0 mm (uncuffed).
3-4 years 1416 kg - 5.5 mm (uncuffed).
5-6 years 1821 kg 6.0 mm (uncuffed).
7-8 years 22-27 kg 6.5 mm ( uncuffed).

Tube Sizes
9-11 years 28-36 kg 7.0 mm(cuffed).
14 to adults 46+ kg 7.0 80 mm (cuffed).
Adult female 7.0 8.0mm (cuffed).
Adult male 7.5 8.5 mm (cuffed).
The size of the tube may also be determined by the
size of the patients little finger.
N.B patients below the age of 8 require uncuffed ETT
due to damage caused by the cuff in younger
patients. Always monitor the ECG activity during
intubation.

4 Rules of Suctioning

Never suction further than you can see.

Always suction on the way out.
Never suction for longer than15 seconds.
Always oxygenate the patient before and
after suctioning.

Other Airway Adjuncts

Kombi-tube.
Oropharangeal airways/tubes.
Nasopharyngeal airways/tubes.
Oro-tracheal tubes.
Naso-tracheal tubes.

Conclusion

Always oxygenate patient before and after

intubation.
Do not attempt intubation unless you are
totally skilled, rather perform bag-valvemask ventilation.
Always monitor the spo2 readings.
Always reconfirm tube placement from
time to time.