ENDOTRACHEAL INTUBATION –
Emergency Nursing Care
The nurses working in the causality services may have to help the doctors in endotracheal intubation in order to save the life of the patient.
Definition:
Endotracheal intubation means passing of an endotracheal tube into the trachea through the nose or mouth for the following purposes:
1. To administer oxygen
2. To remove secretions
3. To ventilate the lungs using a resuscitation bag or respiration
4. To establish and maintain an airway
5. To administer anaesthetics (in the operation theatre).
The endotracheal intubation has certain advantages and disadvantages. They are:
1. The intubation can be done rapidly and an incision on the throat can be avoided. It is less time consuming and the results are predictable.
2. Suctioning through the endotracheal tube is less effective and it is more traumatic because it can cause extensive and permanent damage to the larynx and the vocal cord.
3. In cases of severe burns and laryngeal oedema, the endotracheal tube is less practical.
Endotracheal Tubes:
A wide variety of endotracheal tube are in use of oro-tracheal or naso-tracheal intubation. They are available with cuffs and without cuffs. Oro-tracheal tubes are larger than the naso-tracheal tubes. As in the case of tracheostomy tubes, the endotracheal tubes have no inner tubes which can be removed for cleaning. The size of each tube is marked in mm on the outer side of each tube.
Approximate size of the endotracheal tubes for different age groups is as follows:
Newborn Infants – 2.5 mm to 4 mm
0 to 1 year – 4 mm to 4.5 mm
Children up to 10 years – 5 mm to 7 mm
Children above 10 years – 7 mm to 8 mm
Adults – 8 mm to 9.5 mm
(An another endotracheal tube, one size smaller than what is anticipated should be at hand before intubation is attempted)
NURSES’S RESPONSIBILITY IN THE ENDOTRACHEAL INTUBATION
The intubation of the trachea is the responsibility of the doctor. However, the nurse helps him in the procedure by preparing the patient and keeping articles ready for use.
Preparation of Articles:
1. Endotracheal tubes of different sizes with an adaptor to connect to the ventilator or Ambu bag.
2. Syringes to inflate the cuff.
3. Laryngoscope to visualize the larynx and to depress the tongue during the insertion.
4. Flexible copper stylet – to be used as a guide during the insertion and to give the tube greater rigidity.
5. Extra syringes and needles – for medication.
6. Lubricant to lubricate the tube.
7. Ambu bag to ventilate the lungs.
8. Oral airway to keep in the mouth of the patient after the intubation to prevent the patient biting on to and occluding an endotracheal tube.
9.Gauze wipes, to clean the secretions.
10. Gloves to maintain asepsis.
11.Adhesive plaster – to fix the endotracheal tube in place.
12. Magill’s intubating forceps – to direct endotracheal tube into the trachea.
13. Oxygen supply.
14. Suction apparatus.
15. Anaesthetics (if required)
Procedure:
It will be fearful experience for the patient, if the patient is conscious. Explain the procedure to the patient and his relatives to win their confidence and co-operation.
Remove the dentures, if any, to prevent dislodging and obstructing the airway. An anaesthetic may be administered if the patient is conscious. Orotracheal intubation is best performed by direct laryngoscopy with the patient in supine position. To obtain maximum laryngeal exposure, the head and neck is tilted to bring mouth, larynx and trachea in line. The doctor passes the tube after visualizing the larynx. Immediately after passing the tube, its location is observed by observing the patient’s breathing or by artificially inflating the lungs and by auscultation of the lungs.
Finally the cuff is inflated and the tube is fixed to the patient’s face. An airway is passed into the mouth to prevent the patient biting on the endotracheal tube. Oxygen may be supplied or it may be connected to a respirator if the patient is to be resuscitated.
After care of the patient:
1. Never leave the patient alone.
2. Watch and maintain an open airway.
3. Remove secretions by effective suctioning.
4. Prevent displacement of the tube.
5. Watch for complications such as laryngeal oedema, tracheal stenosis, haemorrhage etc.
6. Provide for the humidification of the air by boiling a kettle of water in the patient’s unit.
7. Prevent infection introduced into the lungs.
8. Prevent contamination of the inhaled air.
9. Maintain adequate nutrition of the patient by naso-gastric feeding or by giving intravenous fluids. They should never be fed on oral feeds as long as the tube is in the mouth.
10. Maintain the oral hygiene of the vital signs.
11. Carefully watch and record the vital signs.
12. Apply suction if there is much secretions.
13. Give oxygen if the patient is cyanosed.
14. Keep an emergency tracheostomy tray with tracheostomy tubes of correct size at the bed side of the patient for emergency care