1. -ENDOTRACHEAL INTUBATION
and LARYNGOSCOPY
-Dr Nisar Ahmed Arain
Assistant Professor
-Anesthesia/Critical care/ER

2. ENDOTRACHEAL INTUBATION LECTURES
INCLUDE THE FOLLOWING IN 5a, and 5b
1-The basic Technique
2-Requirements of Tracheal intubation
3-Examination and investigations of
correct Placement of endotracheal
tube (ETT)
4-Differet ETT’s and their use
5-Fixation of the ETT

3. -SPECIALIZED ENDOTRACHEAL
TUBE TYPES
-ARMORED TUBE
It is flexible and wire – reinforced
ADVANTAGES
--It resists kinking, therefore it is used in Head and Neck
operations or in abnormal positions as Prone position
DISADVANTAGES
--It may be kinked by extreme pressure e.g
a-Biting by an awake patient because the lumen will
tend to remain occluded and the tube will need
replacement. Most of the Armored tubes are very
malleable and need a stylet for their insertion.

4. -SPECIALIZED ENDOTRACHEAL
TUBE TYPES
ARMORED TUBE contd.

5. -Performed Tracheal Tubes (Oral and Nasal)
-RING – ADAIR – ELWYN (RAE)
--They have been designed, in 1975, by
Wallace H Ring,
John C Adair and
Richard A Elwyn.
They are used to direct the breathing
circuit away from the field of surgery
in HEAD AND Neck surgeries with
decreasing the Risk of kinking
--The RAE oral tubes direct the breathing
circuit to the feet of the patient
(some times it is called south – Facing
--While the RAE Nasal tubes direct the
breathing circuit to the Head of the patient
(sometimes it is called North – Facing)

6. -TE DISTIGUISHED FEATURES OF RAE TUBES.
--In comparison to slandered ET tubes is there pre – formed
bend. The Pre – forming during manufacturing reduces the
risk of kinking and obstruction which could occur if a
“slandered” ET tube was bent into the same shape as RAE
tube. A black marker Bar is imprinted on the tube at the
point of maximum angle of the bend
--DISADVANTAGES OF THE RAE TUBE
--One disadvantage of the Nasal and the oral RAE tube is that
depth of tube insertion is very much pre – determined by the
tube’s pre – formed shape i.e th bend of the oral and nasal
RAE will always want to sit just at the lower lip and at the
nostril respectively, not allowing you much flexibility as to
how deeply you can place the tube into the trachea. In some
patients specially very short or Tall once, it might be difficult
to achieve a good tube “Fit” together with the correct
insertion depth which avoids accidental bronchial intubation
or cuff placement between the vocal cords
-RING – ADAIR – ELWYN
(RAE) contd.

7. -RING – ADAIR – ELWYN
(RAE) contd.

8. ADVANTAGES
--It is L – shaped and its distal end has a fixed length therefore,
it has the advantages of a deceased risk of bronchial intubation,
and a decreased risk of kinking with flexed head during surgery
--The tube can be made of rubber or plastic and can be cuffed or
uncuffed the bevel is oval in shape and faces posteriorly and an
introducing stylet is supplied to aid the insertion of the tube.
--Its thick wall adds to the tube’s external diameter making it wider
for a given internal diameter. This is undesirable especially in
pediatric anesthesia.
DISADVANTAGES
--The distance form the bevel to the curve of the tube is fixed. If the
tube too long the problem cannot be corrected by withdrawing the
tube and shortening it because this means losing its anatomical Fit
-OXFORD TUBE

9. - OXFORD TUBE contd.

10. -LASER RESISTANT
ENDOTRACCHEAL TUBES
-They are used in LASER surgery
FEATURES
--1-Like standard endotracheal tubes, laser tubes are made
of poly – vinyl – chloride (PVC) which is flammable in the
presence of oxygen and an ignition source i.e LASER light
--2-The PVC core of the LASER tubes is therefore wrapped in
two layers one metallic foil layer which protects the actual
tube from the LASER light, and an outer non – reflective layer

11. -LASER RESISTANT
ENDOTRACCHEAL TUBES

12. -LASER RESISTANT
ENDOTRACCHEAL TUBES
--The cuff of the laser tube is not protected in anyway and therefore
most are vulnerable to laser light. The pilot balloon contains blue
dye granules which dissolved when filled with water or saline.
The Dyed water in the cuff serves two functions.
--1-It acts as an indicator in case the cuff bursts. Puncture of the cuff
from the laser beam causes the dye to spill under the cuff pressure.
--2-It acts as fire prevention / a fire extinguisher.
--3-The cuff of the laser tube is of the high pressure – low volume design.

13. -LASER RESISTANT
ENDOTRACCHEAL TUBES contd.

14. -LASER RESISTANT
ENDOTRACCHEAL TUBES contd.
-DIRECT LARYNGOSCOPY
---They are instruments used for direct examination of the larynx
and intubating the trachea.
COMPONENTS
--1-The handle houses the power source (Batteries) and is designed
in different sizes
--2-The blade is fitted to the handle and can be either curved or
straight. There is a wide range of designs for both curved and
straight blades
Types of Blades:
There are many types of the blades and Laryngoscopes. Most of
the Ordinary laryngoscopes have either curved or straight blades.

15. -TYPES OF LARYNGOSCOPES

16. -CURVED BLADE
TECHNIQUE
--The blade is introduced to the base of epiglottis at the vallecula then it is elevated
forward pressuring on the hyo – epiglottic ligament to elevate the epiglottis and
expose the vocal cords
--The blade touches the upper surface of epiglottis (supplied by the Glossopharyngeal
nerve
INDICATIONS
--In patients with small upper airway room to pass the endotracheal tube e.g
--small narrow mouth
--Palate or
--Oropharynx
DISADVANTAGES
--It is useless with large floppy infantile U shaped epiglottis
TYPES
--English Macintosh blade (The most common) There are Four sizes available and
There is a disposable blade
--American Macintosh blade

17. - TYPES OF LARYNGOSCOPES

18. -TYPES OF LARYNGOSCOPES

19. -STRAIGHT BLADE
TECHNIQUE
--The blade is introduced under the lower surface of the Epiglottis
then it elevated forward, lifting the epiglottis to expose the
vocal cords.
--The blade touches the lower posterior surface of epiglottis
(Supplied by Vagus Neve)
INDICATIONS
--In patients with
a- smaller mandibular space
b- anterior larynx
c- large incisors or
d- large infantile U shaped floppy epiglottis
--In infants with large infantile epiglottis

20. -STRAIGHT BLADE contd.
-DISADVANTAGES
--As it touches the lower posterior
surface of the epiglottis, it stimulates
the Vagus nerve causing Bradycardia
and spasm. Therefore, anticholinergics
are essential before its usage especially
in pediatrics
EXAMPLE
Millar blade:- There are 4 sizes

21. -THE McCoy LARYNGOSCOPE
---It is based on the standard Macintosh blade.
It has a hinged Tip which is operated by the
liver mechanism present on the back of the
handle.
--It is suited for both routine use and in cases of
difficult intubation
--A more recent McCoy design has a straight blade
with a hinged Tip

22. -THE McCoy LARYNGOSCOPE contd.

23. -LARYNGOSCOPE
-Should be examined for the following points
--THE SIZE:-Always proper blade size should be chosen. In infants, Miller size-1 is used and for
infants > 2.5 Kg. While Miller size-0 is used for smaller infants
--THE LIGHT INTENSITY:-It is tested as it should remain constant (a blinking light indicates poor
electrical contact while Fading indicates Low strength of batteries
--SPARE:-Laryngoscope should be prepared
--THE TYPE:-Either straight or curved blade
-In infants, it is better to use a straight blade (Miller) laryngoscope due to the large floppy
U – shaped epiglottis where it is introduced until the epiglottis is reached. The epiglottis is
elevated from its under surface by the blade, but it may cause Vagal Nerve stimulation
because the under surface of the epiglottis is supplied by the Vagus Nerve

24. --Failure of one laryngoscopic intubation should force
the anesthesiologist to perform the second intubation
attempt in optimum conditions, which include:-
--1-A reasonably experienced anesthesiologist should be
available (the experience of using the Laryngoscope
is usually maximally reached after 2 to 3 years of experience
--2-No significant resistive muscle tone should be present
(There is good muscle relaxation)
--3-Sniffing position should be made
-OPTIMAL / BEST LARYNGOSCOPIC
-INTUBATION ATTEMPT

25. --4-Optimal laryngeal manipulation:- (Pressuring thyroid cartilage
posteriorly or laterally) should be done by a trained assistant,
instructed by the anesthesiologist. This may improve laryngoscopic
grade by one degree
--5-The length of the blade of the laryngoscope may be changed to a
larger size(either Macintosh or a Miller)
--6-The type of the blade (sometimes) may be changed according to
the patient as
a-The Macintosh blade is preferred in patients with little upper
airway room to pass the endotracheal tube e.g small narrow
mouth, palate or oropharynx
b-The Miller blade is preferred in patients with small mandibular
space (i.e anterior larynx, Large incisors, or large floppy infantile
epiglottis
-OPTIMAL / BEST LARYNGOSCOPIC
INTUBATION ATTEMPT

26. --No oxygen is delivered to the patients lungs, resulting in severe Hypoxia that may cause death.
Therefore, if there is doubt regarding the position of the Endotracheal tube or Unexplained
Hypoxia that occurred after intubation, removal of the tube and ventilation by Mask may be
life saving
ESOPHAGEAL INTUBATION CAN BE DETECTED BY THE FOLLOWING
A- RELIABLE SIGNS
--1-CAPNOGRAPHY:-For consistent rise and fall of end – tidal CO2 (more than 30 mm Hg for
3 to 5 consecutive breaths) with normal wave form. It is the most reliable method
--2-Direct visualization of the Tip of the tube passing via the vocal cords
--3-FIBROPTIC BRONCHOSCOPY:-By seeing tracheal rings and carina via the Endotracheal tube.
--4-A WEE ESOPHAGEAL DETECTOR:-To detect the esophagus as through which air is introduced
inside the tube. If the tube lies in the trachea, the esophageal detector is Re – inflated, but
if the tube lies in the Esophagus, the esophageal detector remains deflated because the
air will not return from the stomach back to the detector
--5-A colorimetric End – Tidal CO2 detector (A disposable chemical indicator) to detect the expired
end – tidal CO2
--6-Trnstracheal illumination by a special light stylet via the tube
-ERRORS OF ENDOTRACHEAL
TUBE POSITIONING

27. -CO2 DECTOR DEVICES

28. --1-Bilateral 4 quadrant auscultation of breath sounds with
absence of Gastric Gargling.
--2-Chest X Ray to see the position of the tube, It is a common
practice in intensive care units
--3-Absence of Cyanosis (Hypoxia) or high pulse oximeter reading
is unreliable, because if the patient is well pre – oxygenated
Cyanosis(Hypoxia) can be delayed upto 5 minutes
--4-Expiratory condensation of PVC tubes (Breath holding)
--5-Chest or Abdominal movements with ventilation
--6-Refilling of the Anesthetic reservoir bag
-UNRELIABLE SIGNS