Page 6
Indications:
When you are unable to open airway using head tilt-chin lift or jaw thrust maneuvers.
If you have difficulty forming a seal with the face mask.
If the patient requiring continued ventilatory support.
When the patient has a high risk for aspiration (provide an ETT or Combitube).
Remember, a patient should be unconscious or sedated without an active gag reflex before instrumentation of the airway occurs with an ETT, Combitube, or LMA.
Endotracheal Tube (ETT)
Requires additional instrument for insertion (laryngoscope, glidescope, fiberoptic).
Laryngoscope blades (average adult size): MAC 3 or 4, Miller 2 or 3
ETTs require mastery of technique for consistent appropriate placement.
Average size of ETT for orotracheal intubation for adults is 7.5mm.
The ETT is placed into the trachea, having direct visualization of the vocal cords.
Average depth of intubation:
adult male is 23cm
adult female is 21cm
Tracheal cuff of the ETT is then inflated.
Allows for positive pressure ventilation.
Reduces risk of aspiration.
Helps maintain placement of ETT.
Confirm placement of ETT.
Secure in place of ETT.
Esophageal-Tracheal Combitube
Gently advance the combitube into the mouth midline along the base of the tongue.
Assure tube rotation of the combitube is following the curvature of the pharynx.
Cease advancement of the tube once the heavy black rings reach the patient’s teeth.
The Combitube is blindly placed into the esophagus 80% of the time and into the trachea 20% of the time.
The combitube provides ventilatory access irregardless of tracheal or esophageal intubation.
Inflate the pharangeal cuff with 100ml of air. Prevents leak through the nose and mouth. Helps secure placement.
Inflate the tracheal cuff with 15ml of air. Prevents ventilation of stomach. Reduces risk of aspiration of stomach content.
First attempt confirmation of esophageal intubation by ventilating through the esophageal tube. (See “Secondary ABCD” section regarding placement confirmation)
If placement not confirmed through esophageal tube:
Attempt confirmation of tracheal intubation by ventilating through the tracheal tube. (See “Secondary ABCD” section regarding placement confirmation)
Once placement has been confirmed:
Mark which tube should be used for ventilation.
Secure tube in place.
Both cuffs must be inflated to appropriately ventilate a patient in the case of esophageal intubation.
Laryngeal Mask Airway (LMA)
Visualization of the vocal cords is not required for insertion.
When inserting the LMA have the laryngeal cuff deflated.
Guide in the LMA cuff without folding back the tip, pressing it against the hard palate.
Advance the LMA till the cuff lies in the pharynx.
After placement, inflate the laryngeal cuff and check for an adequate seal by using positive pressure ventilation.
Positive pressure ventilation is generally kept under 20 CmH2O to prevent inflation of the stomach. LMA’s are contraindicated for the morbidly obese patient.
The patient is still at high risk of aspiration, even with an appropriately placed LMA. LMA’s are contraindicated in patients with GERD, full stomachs, and pregnant women.