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Indications of intubationIndications of intubation
Resuscitation (CPR)Resuscitation (CPR) Prevention of lung soilingPrevention of lung soiling Positive pressure ventilation (GA)Positive pressure ventilation (GA) Pulmonary toiletPulmonary toilet Patent airway (coma or near coma)Patent airway (coma or near coma) Respiratory failure(CO2 retention )Respiratory failure(CO2 retention )
Requirement of successful Requirement of successful intbatinintbatin
1-Normal roomy 1-Normal roomy mandiblemandible
2-Normal T-M, A-O 2-Normal T-M, A-O , and C-spine, and C-spine
Requirements of successful Requirements of successful intubationintubation
3-Alignment of 3 axes or3-Alignment of 3 axes or
Assuming sniffing positionAssuming sniffing position
-Any anomaly in these 3 joints-Any anomaly in these 3 joints
A-O, T-M or C-spine can resultA-O, T-M or C-spine can result
In difficult intubationIn difficult intubation
Requirement of successful Requirement of successful intubationintubation
Proper equipmentProper equipment
-Bag and mask,oxygen source-Bag and mask,oxygen source
-Airways oro and nasopharyngeal-Airways oro and nasopharyngeal
-Laryngosopes different blades-Laryngosopes different blades
-ETT different sizes-ETT different sizes
-suction on-suction on
Management Management
I-History:I-History: previous history of difficulty is the best previous history of difficulty is the best
predictorpredictorInquire about:-Nature of difficultyInquire about:-Nature of difficulty -No of trials-No of trials -Ability to ventilate bet trials-Ability to ventilate bet trials -Maneuver used-Maneuver used -Complications-ComplicationsII-Snoring and sleep apnea( prdictors of II-Snoring and sleep apnea( prdictors of
DMV)DMV)
ExaminationExamination
-Look for any obvious anomaly -Look for any obvious anomaly Morbid obesity(BMI)Morbid obesity(BMI) SkullSkull FaceFace JawJaw Mouth,teethMouth,teeth Neck Neck
ExaminationExamination
I-The 3 joints movementsI-The 3 joints movements A-O joint(15-20 degrees)A-O joint(15-20 degrees)
Presence of a gap bet the Presence of a gap bet the
Occiput and C1 is essentialOcciput and C1 is essential The cervical spine(range>90)The cervical spine(range>90) T.M joint:-interdental gap(3 fingers)T.M joint:-interdental gap(3 fingers) -subluxation (1 finger)-subluxation (1 finger)
ExaminationExamination
II-Measurements of the mandibleII-Measurements of the mandible
-Thyro-mental distance (head -Thyro-mental distance (head extended)extended)
Normally 6.5 cmNormally 6.5 cm
Less than 6 cm=expect difficultyLess than 6 cm=expect difficulty
Tests to predict difficultyTests to predict difficulty
Mallampatti test:Mallampatti test:
Based on the hypothesisBased on the hypothesis
That when the base of theThat when the base of the
Tongue is disproportionallyTongue is disproportionally
Large it will overshadow theLarge it will overshadow the
larynxlarynx
-Simple easy test,correlates with what is seen during -Simple easy test,correlates with what is seen during laryngoscopy or Cormack-Lehene grades ,butlaryngoscopy or Cormack-Lehene grades ,but
1-moderate sensitivity and specificity(12% false +ve)1-moderate sensitivity and specificity(12% false +ve)
2-Inter observer variation2-Inter observer variation
3-Phonation increases false negative view3-Phonation increases false negative view
II-Wilson testII-Wilson test
-Consists of 5 easily assessed factors-Consists of 5 easily assessed factors Body wight(n=0 ,>90=1,>110=2)Body wight(n=0 ,>90=1,>110=2) Head and neck movementHead and neck movement Jaw movementJaw movement Receding jawReceding jaw Buck teethBuck teeth
Each factor assigned as o ,1 ,2 max is Each factor assigned as o ,1 ,2 max is 1010
Difficult airwayDifficult airway
Expected from history,examinationExpected from history,examination
Secure airway while awake under LASecure airway while awake under LA
Unexpected different optionsUnexpected different options
Priority for maintenance of patent Priority for maintenance of patent airway and oxygenationairway and oxygenation
Confirm tube positionConfirm tube position
Direct visualization of ETT between Direct visualization of ETT between cordscords
Bronchoscopy ;carina seenBronchoscopy ;carina seen Continuous trace of capnographyContinuous trace of capnography 3 point auscultation3 point auscultation Esophageal detector deviceEsophageal detector device Other as bilateral chest Other as bilateral chest
movement,mist in the tube,CXRmovement,mist in the tube,CXR
Rapid sequence Rapid sequence inductioninduction
IndicationsIndications Technique: Technique:
-Preoxygenation-Preoxygenation
-IV induction with sux-IV induction with sux
-Cricoid pressure-Cricoid pressure
-Intubate, inflate the cuff ,confirm -Intubate, inflate the cuff ,confirm positionposition
-Release cricoid and fix the tube-Release cricoid and fix the tube
Complications of Complications of intubationintubation
1-Inadequate 1-Inadequate ventilationventilation
2-Esophageal 2-Esophageal intubationintubation
3-Airway obstruction3-Airway obstruction
4-Bronchospasm4-Bronchospasm
5-Aspiration5-Aspiration
6- Trauma6- Trauma
7-Stress response7-Stress response
RecommendationsRecommendations
Adequate airway assessment to pick up Adequate airway assessment to pick up expected D.A to be secured awakeexpected D.A to be secured awake
Difficult intubation cart always readyDifficult intubation cart always ready Pre oxygenation as a routinePre oxygenation as a routine
Maintenance of oxygenation not the Maintenance of oxygenation not the intubation should be your aimintubation should be your aim
Use the technique you are familiar withUse the technique you are familiar with Always have plan B,C,D in unexpected D.AAlways have plan B,C,D in unexpected D.A