Endotracheal intubation pt.1

Question 1

What is endotracheal intubation?

Answer 1

A procedure in which a flexible plastic tube is placed into the trachea to maintain and secure a patient’s airway as well as provide oxygenation and ventilation. Obtaining first-pass success is also a goal

Question 2

What are the different techniques available for endotracheal intubation?

Answer 2

There are multiple techniques available, including the visualization of the vocal cords with a laryngoscope or video laryngoscope, direct placement of the endotracheal tube into the trachea via cricothyrotomy, and fiberoptic visualization of the vocal cords via the nasal or oral route

Question 3

What are the most common techniques for endotracheal intubation?

Answer 3

Direct and video laryngoscopy are the two most common approaches utilized for endotracheal intubation

Question 4

What does the upper airway consist of?

Answer 4

Consists of the oral cavity and pharynx, including the nasopharynx, oropharynx, hypopharynx, and larynx

Question 5

Role of the upper airway

Answer 5

These structures humidify and warm the air, and serve as a conduit to the lower airway

Question 6

Blood supply of the upper airway

Answer 6

external and internal carotid arteries

Question 7

Nerve supply of upper airway

Answer 7

Trigeminal nerve provides sensory innervation to the mucous membranes of the nasopharynx, while the facial nerve and glossopharyngeal nerve innervate the oropharynx

Question 8

Trachea surface characteristics

Answer 8

Soft and membranous posteriorly with cartilaginous D-shaped rings anteriorly

Question 9

Trachea diameter

Answer 9

Adult internal tracheal diameters vary between 15 mm and 20 mm

Question 10

Where in the trachea is it more likely for a foreign object to dislodge?

Answer 10

• The angle between the trachea and the left mainstem bronchus is more acute, making foreign object dislodgement into the left mainstem less likely
• The obtuse angle between the trachea and the right mainstem bronchus makes it more prone to right mainstem intubation if the endotracheal tube is advanced too distally.

Question 11

Larynx innervation

Answer 11

the recurrent/inferior laryngeal nerve/inferior (right and left, branches of vagus nerve)and superior laryngeal nerve
- - Superior to the vocal cords, the larynx is innervated by the superior laryngeal branch of the vagus nerve, which provides afferent innervation at the base of the tongue and vallecula. These vagal fibers contribute to circulatory changes with direct laryngoscopy.
- - The inferior laryngeal nerve or recurrent nerve is the principal nerve responsible for the innervation of all intrinsic muscles of the larynx, except for the cricothyroid muscle (external branch of superior laryngeal nerve)
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Question 12

Anatomical landmark for emergency cricothyrotomy

Answer 12

The cricoid cartilage which is a ring-shaped that sits inferior to the cricothyroid membrane

Question 13

Which anatomical landmark which when identified can easy vocal visualization during intubation?

Answer 13

Identification of the cricoid cartilage and manipulation of the airway often facilitates vocal cord visualization during intubation

Question 14

What is the hyoepiglottic ligament and its relevance in intubation?

Answer 14

Identification of the cricoid cartilage and manipulation of the airway often facilitates vocal cord visualization during intubation

Question 15

Neck anatomical landmark considerations in children vs adults

Answer 15

• Compared to an adult, a child’s head is proportionally larger, leading to a flexed position of the neck when supine
• Applying a shoulder roll to extend the head can overcome neck flexion.
• The larger tongue in children more easily obstructs the airway. The child’s larynx is also more superior and anterior compared to adults.
• These features contribute to the more acute angle between the epiglottis and glottis of children, which makes vocal cord visualization more difficult when using a laryngoscope.
• Children also have a shorter trachea, which makes right mainstem bronchus intubation more likely

Question 16

What are indications for endotracheal intubation?

Answer 16

• There are many indications for endotracheal intubation, including poor respiratory drive, altered mental status, questionable airway patency, hypoxia, and hypercarbia
• These indications are assessed by evaluating the patient’s mental status, conditions that may compromise the airway, level of consciousness, respiratory rate, respiratory acidosis, and level of oxygenation.
• In the setting of trauma, a Glasgow Coma Scale of 8 or less is generally an indication for intubation.

Question 17

What is increased CO2 in the blood called?

Answer 17

Hypercapnia or hypercarbia

Question 18

What are considerations and contraindications when deciding on endotracheal intubation?

Answer 18

• Patients whose respiratory status might improve with less invasive methods should be tried on modalities such as non-invasive positive pressure ventilation or other modes of oxygenation
• Severe orofacial trauma can obstruct oropharyngeal intubation due to significant bleeding or disruption of the facial and upper airway anatomy.
• Cervical spine manipulation during intubation can be harmful to patients with spine injury and immobility
• In the setting of these clinical situations, other modes of ventilation and oxygenation should be undertaken if the clinical condition allows.
• If a definitive airway is required, providers should be prepared for the potential of a surgical airway.
• There are no absolute contraindications to intubation, and the decision to place a definitive airway should take into consideration each patient’s unique clinical condition