Basic Airway Equipment for Intubatation, by Dr. Traci Wolbrink.
Healthcare workers in all healthcare settings should always adhere to the latest
World Health Organization guidelines
on hand hygiene and barrier precautions before and after contact with a patient,
bodily fluids or patient surroundings.
For more information, please watch our video entitled Hand Hygiene.
Hi, my name is Traci Wolbrink and I am a pediatric intensivist at Children's Hospital Boston.
In this video I’ll be talking to you about the equipment and supplies that you need to
get yourself ready to intubate a patient.
So the first thing you’ll want to make sure is that you have an oxygen source and a bag
for your patient. So here I have a self-refilling, or self-inflating, or AMBU bag, whatever you’d
like to call it. And it’s connected to my oxygen source which I will turn on here. You
will also want to make sure that you have suction available and that you’ve turned
it on. And you check to make sure that it is working. And I’ll leave both of these
near the top of my bed so that when we get ready to perform laryngoscopy they are readily
available.
The next thing that I want to make sure is that you have a mask that is an appropriate
size for your patient. So you want to choose a mask that covers around the nose and mouth
of your patient but is not too big so that you have a lot of leaking either from around
your eyes or chin or that is too small so that it does not adequately cover your nose
and mouth. So for this patient, this size mask is probably appropriate. You can see
it covers the entire nose and mouth of the patient without going much beyond to the chin
and eyes of the patient. If I were to get a mask that was too large for the patient,
you would see that I would have a difficult time creating a seal because if I make it
so that it fits near the chin you see that there will be a lot of leaking around the
eyes and vice versa if I make it fit around the eyes there is a lot of leaking here around
the chin. It is always better to go with a smaller mask rather than a larger mask. And
even with this small mask you can see that even though it is on the small side it still
mostly covers around the mouth and the nose. So if you have the choice, always goes smaller
rather than bigger. But this mask would be the most appropriate for this patient here
and I’m going to connect it to my bag.
So the next thing that you may want to consider is having an oral airway in place, especially
if the patient is difficult to mask-ventilate. When you are choosing the size of an oral
airway you want to make sure that you choose one that will be an appropriate size so you
will go from the angle of the mouth to either the tragus or the jaw. So if I measure here
from the angle of the mouth to my tragus or the angle of the jaw it’s the same distance
and this one would be an appropriate size for this patient.
What you are attempting to do is pull the tongue forward so you want the hooked part
downward facing. And you will want to in order to put this in you want to open the mouth
and assuming that the patient is well anesthetized because if you are putting in an oral airway
you want to make sure that your patient is either obtunded or has been well anesthetized
because if you apply an oral airway to a patient’s that awake they are likely to vomit and the
aspirate. So to put it in, you are going to open the airway and then either using a tongue
depressor or your finger to hold the tongue in place, you’ll slide this in the corner
of the mouth, slide this into the posterior of the oropharynx and slide this into place.
A well-placed oral airway is going to sit just at the gums and is actually going to
pull the tongue forward. If you put on that is too small in you may actually be pushing
the tongue back into the posterior oropharynx and you may actually be causing more occlusion
than without the airway. So you want to make sure this is properly applied.
If you have a patient that is mildly awake with obstructive symptoms you can use a nasal
airway. And a rule of thumb is that the nasal airway should approximate the patient’s
pinky finger so around the same size and in order to measure the nasal airway, you are
going to go from the nare again to the tragus or the angle of the jaw. So here again where
this disk is at the nare reaches the tragus here or the angle of the jaw. And when you
go to put this in, you are going to want to have some lubricant, you are going to want
to lube up your nasal airway and you’ll want ot insert it into the patient’s nose.
And you’ll want to do that with a gentle motion and you’ll do it the same way that
you do with a nasogastric tube and you’ll want to insert it all the way to the disk.
Both of these are going to help you bypass any obstruction from the oropharynx or tongue
and are going to help you ventilate a little bit better.
The next thing that you are going to want to have ready is you are going to want to
choose a laryngoscope. You are going to want to choose a handle with a light source that
works as you can see here. This is a fiber optic system, and then you are going to want
to choose a Mac or a Miller blade. A Mac blade is going to be curved and a Miller blade is
going to be straight. Generally you should use whatever blade you feel most comfortable
using, however it may be advantageous in patients that are less than two years of age to use
a straight blade or a Miller blade and that is because patients that are younger developmentally
have an omega shaped floppy epiglottis and if you can actually use the Miller blade to
lift the epiglottis out of your view, you are actually going to have a better view of
your vocal cords. A Mac blade is used by inserting it along
the base of the tongue into the vellecula and pulling upwards. The epiglottis will lie
underneath your blade and if it’s large and floppy, you may not be able to pull the
epiglottis out of your use and therefore in young pediatric patients a Miller blade may
be advantageous. So you are going to want to put your Miller blade on and check to make
sure your light source works. For this patient, our two year old patient, I am going to be
using a Miller 1.
Next you are going to want to choose an endotracheal tube. There is a lot of debate over whether
you want to use a cuffed or un-cuffed endotracheal tube. In developmentally, the pediatric airway
is actually more funnel shaped below the vocal cords and the narrowest part of a pediatric
airway is actually subglottic. And so therefore on young children some people choose to use
an uncuffed endotracheal tube, however if you are using higher pressures or anticipating
the need to be on mechanical ventilation for a long time or considering aspiration risks,
you are actually going to want to choose a tube with a cuff and you are going to want
to make sure that you monitor cuff pressures every day and you monitor how much cuff inflation
you have by checking for a leak and adjusting the air that is in your cuff on a daily basis.
So for our patient, I am going to use the age in years divided by 4 plus 4 which is
two years which is divided by 4 which is 0.5 plus 4 which equals a 4.5 uncuffed endotracheal
tube would be accurately sized for this patient. If you want to choose a cuffed endotracheal
tube you should go one half size smaller so an appropriately sized tube might be a 4.0
cuffed endotracheal tube for this patient. We will also have available one tube that
is one size smaller and one size larger than what we are expecting to use for this patient.
So I am planning on using a 4.0 cuffed endotracheal tube for this patient so I would have a 3.5
cuffed endotracheal tube and a 4.5 cuffed tube also available.
Once I have chosen my 4.0 cuffed endotracheal tube, I want to do 2 things. I want to take
a syringe and check to make sure my cuff actually works. So I’ll take my syringe and put some
air in my syringe, insert it into my pilot balloon and administer some air. We can see
that my pilot balloon is nice and taut as well as the balloon here. So it seems as if
the cuff is working. I’ll remove the air, a very important step and prepare the tube
by inserting a stylet in, making sure that the stylet does not go beyond the end of the
tube and by giving myself sort of what’s called a hockey stick, so an ability for me
to angle my endotracheal tube anteriorly if I need to while performing laryngoscopy.
The last thing that I want to have available is an end-tidal CO2 monitor or an end-tidal
color change device. In most institutions it is considered a gold standard to have an
end-tidal CO2 monitor in place. But you may only have a color changing device and with
that you want to make sure that if you are using a color change device that you give
at least 6 breaths after you intubate the patient before using the color change device
because if you have an esophageal intubation you may get some CO2 from the stomach but
most people will consider that after 6 breaths the color change should not be seen any longer
because the CO2 should be washed out of the stomach.
The last equation I wanted to mention was the depth of the endotracheal tube. Most people
will say that you should insert this tube to three times what the length of this endotracheal
tube is. So for instance, this is a 4.0 cuffed endotracheal tube and 3 times 4 is 12, so
when I go to perform laryngoscope, a likely appropriate depth will be a depth of 12cm
for this patient. You are going to need to confirm this both with breath sound confirmation
as well as a chest x-ray.
So this concludes our video. Thank you.