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Laryngoscopy and Intubation
RTT 213
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Why Intubate?
•As part of general anesthesia
•Protect airway against aspiration
•Allow positive pressure ventilation (PPV)
•Allow airway suctioning (toilet)
•Allow drugs to be given in a “code blue” where IV access  is not yet available
–= epinephrine
–= lidocaine
–= atropine
•=
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Methods of Tracheal Intubation=
•Blind Metho= ds (including digital)
•Use of a laryngoscope
–Macintosh (curved blade)
–Miller (straight blade)
–Bullard laryngoscope
•Trachlite a= nd similar methods
•Fiberoptic Intubation&#= 13;
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 Endotracheal Tubes
»
•   Endotracheal tubes (E= TTs) are commonly used in general = anesthesia for a variety of reasons 
–q Regular ETT   q Double Lumen ETTs
–q RAE Tubes   q Reinforced ETTs
–q Laser Tubes    q Univent ETT
–q Carden ETT   q Endotrol ETT
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ETT Design
•Sh= aft            ( I= D about 8 mm in adults )
•ETT= tip                ( smoothed to = avoid trauma )
•Mu= rphy eye         ( nea= r ETT tip )
•Cu= ff            ( allows seal with tracheal mucosa  )
•Cuff inflation system                 ( syringe, valve ) =
•15 = mm connector               ( to breathing circuit )<= /span>
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ETT Design&#= 13;
<= span class=3DBB style=3D'position:absolute;left:-4.49%'>•ETTs are numbered according to their inner diameter and also have lengthwise centimeter markings as well.
•
•Most ETTs are made of clear nontoxic plastic and are designed for single use.
•
•
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     Radio-Opaque ETT<= span style=3D'font-size:91%'> Markings
•   A radio-opaque marker at the distal end of the ETT allows one to verify its correct position above to carina on chest x-ray. 
• = ;
•
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ETT Cuffs
•   Most endotracheal tub= es have inflatable cuffs at their distal end= s which are inflated with air to provide a seal  with the tracheal mucosa to allow positive pressure ventilation and redu= ce the risk of the airway being so= iled with oropharyngeal secretio= ns or regurgitated material from the stoma= ch.
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ETT Cuff Inflation Pressure=
•The cuff should be inflated to a pressure of about 25 mmHg.
=
• Excessive cuff pressure lead to ischemi= a = of the tracheal mucosa that can lead to tracheal stenosis.
=
•Even so, temporary muc= osal ciliary = denudation often occurs when despite cuff pressures under 25 mmHg. =
<= span style=3D'font-family:Arial;visibility:hidden'>• = ;
<= span style=3D'visibility:hidden'>•
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ETT Sizes and Lengths
•A size 7.5 mm ID tube is often used for adult women and 8.5 mm ID for adult men. 
=
•The centimeter markings at the lips are usually chosen to be 21 cm for women and 23 cm for men but will obviously vary with height. 
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ETT Length
a= Length refers to the distance from the lips to the midtrachea. 
= aAdd 3 cm to this amount for nasal = intubation.
= aThese are initial guidelines only; the final <= /span>length chosen will depend on clinical, x-ray and/or fiberoptic findings.
•
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= Oral ETT Parameters
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ID for Pediatric ETTs
•   One common pediatric formula for the internal diameter (ID, in mm) ETT size is
•
•   ID =3D     4.0 mm   +   age in year= s
•                                     16
•
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Pediatric ETT Length
•  One common pediatric formula for ETT length is
•
•  Oral ETT length (cm) = =3D  12 + age / 2
•
•  Nasal ETT length (cm) = =3D 15 + age / 2
•
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•   Indirect laryngoscopy using small mirrors inserted into the oropharynx is often done in medical office practice to look for glottic pathology. 
Indirect Laryngoscopy
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  Direct Laryngoscopy
•   Direct laryngoscopy in the OR may also be done to further explore (eg. biopsy) airway pathology, but is far more commonly done to allow intubation (the insertion of an endotracheal tube (ETT) through the vocal cords into the trachea).
•
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 Get a Good View
•   The key to easy intubation is a full view of the vocal cords at laryngoscopy.  This achieved with full muscle relaxation, the right laryngoscope and correct head position (sniffing position).
•
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Normal Glottis
3Dairway01
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Edematous Glottis
3Dairway13
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Difficult Airway<= /span>
•   If a good view of the epiglottis and cords is not achievable with good technique, the patient is said to have a difficult airway.
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Image Credits =
<= span class=3DBB style=3D'position:absolute;left:-4.53%'>•Normal Glottis<= span style=3D'mso-tab-count:1;width:11.45%'> Dr. John Sherry II
<= span class=3DBB style=3D'position:absolute;left:-4.53%'>•Epiglottitis Dr. John Sherry II
<= span class=3DBB style=3D'position:absolute;left:-4.53%'>•Edematous Glott= is Dr. John Sherry II
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END OF MODULE 2
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