You have devoted a considerable amount of time and energy in training to be comfortable in airway management. As part of the care of the intubated patient, you want to make sure the endotracheal tube is correctly placed in the trachea and your patient’s airway is secure. Show Verification of endotracheal tube placement is imperative for the oxygenation, ventilation, and airway protection of your patient. A tube in the esophagus, or in the hypopharyngeal space, may be incorrectly thought to be in position and may place your patient at undue risk of hypoxemia or aspiration. Therefore, confirmation of proper endotracheal tube placement should be completed in all patients at the time of initial intubation. Unfortunately, at this time no technique used for confirmation of endotracheal tube placement has been proven to be 100% accurate.1-7 A variety of techniques may enhance your ability to confirm airway placement; comfort with these techniques is essential to your practice. Visualization of the endotracheal tube passing through the vocal cords remains the optimal method for initial endotracheal tube placement. Unfor-tunately, direct visualization is not always possible, especially in the anatomically difficult airway or an airway that is obscured by blood, secretions, or vomitus. Other physical examination methods such as auscultation of the lungs and epigastrium, visualization of bilateral chest rise, and fogging of the tube may be helpful but are not sufficiently reliable to confirm placement of the tube between the vocal cords. What makes confirmation even more difficult is that esophageal intubation may remain undetected despite chest radiography and pulse oximetry results that appear to confirm proper tube placement.1-7 These methods cannot exclude esophageal intubation in all situations, and for this reason, additional methods should be used to verify correct initial placement of the endotracheal tube. Techniques to Confirm Tube PlacementTo supplement traditional methods, a variety of additional techniques and commercially available products help to identify misplaced tubes. These include repeat direct laryngoscopy, qualitative and quantitative end-tidal carbon dioxide detection, esophageal detector devices, and, most recently, ultrasound, and transthoracic impedance.8-21 ALERTDon appropriate personal protective equipment (PPE) based on the patient’s signs and symptoms and indications for isolation precautions. Refer to the American Heart Association (AHA) interim guidelines for resuscitation of the patient with coronavirus disease 2019 (COVID-19) or a person under investigation (PUI) (Box 1).undefined#ref2">2 In a patient with a suspected spinal cord injury, inline cervical immobilization of the head must be maintained during endotracheal (ET) intubation. Use pulse oximetry during intubation so that oxygen desaturation can be detected quickly. If the saturation is inadequate, stop the attempt and start ventilation by bag-mask device. Be prepared for a rescue airway to be placed if the intubation attempts fail. Nasotracheal intubation is not recommended in pregnant patients due to the fragility of the nasal mucosa and risk for subsequent bleeding.4 OVERVIEWET intubation is performed to establish and maintain a patent airway, facilitate oxygenation and ventilation, reduce the risk of aspiration, and assist with the clearance of secretions. Indications for ET intubation include:
ET tube size reflects the size of the internal diameter of the tube (Figure 1). Tubes range in size from 2.0 mm for neonates to 10.0 mm for large adults.1 Typically, biological female patients require a 7.0- to 8.0-mm tube and biological male patients require a 7.5- to 9.5-mm tube with a 15-mm connector.1 The tube should be large enough to facilitate airflow and small enough to pass the vocal cords without damaging them. ET intubation can be done via the nasal or oral routes. The skill of the practitioner performing the intubation and the patient’s clinical condition determine the route used. Nasal intubation is relatively contraindicated in a trauma patient with facial fractures or suspected fractures at the base of the skull, or postoperatively after cranial surgeries, such as a transsphenoidal hypophysectomy. Nasotracheal intubation is also not recommended in pregnant patients because of the fragility of the nasal mucosa and risk for subsequent bleeding.4 Nasal intubation should only be considered in spontaneously breathing patients.1 For a patient with suspected spinal cord injuries, inline cervical immobilization of the head must be maintained during ET intubation. Improper intubation technique may result in trauma to the teeth, soft tissues of the mouth or nose, vocal cords, and posterior pharynx. Primary and secondary confirmation of ET intubation must be performed.5
ETCO2 monitoring devices have been shown to be reliable indicators of expired carbon dioxide in a patient with perfusing rhythms.5 During cardiac arrest (nonperfusing rhythms), there may not be sufficient expired carbon dioxide due to low pulmonary blood flow.1 If carbon dioxide is detected using an ETCO2 detector, it is a reliable indicator of proper tube placement. If carbon dioxide is not detected, the use of an esophageal detector device or ultrasound performed by an experienced operator is recommended.5 Many methods can be used to secure an ET tube, including tape and commercial devices. The nurse should secure the tube in place immediately after insertion to prevent unplanned extubation. EDUCATION
ASSESSMENT AND PREPARATIONAssessment
Preparation
PROCEDURE
MONITORING AND CARE
EXPECTED OUTCOMES
UNEXPECTED OUTCOMES
DOCUMENTATION
REFERENCES
Adapted from Wiegand, D.L. (Ed.). (2017). AACN procedure manual for high acuity, progressive, and critical care (7th ed.). St. Louis: Elsevier. AACN Levels of Evidence
What is the best way to secure an endotracheal tube?Emergency physicians should secure Endotracheal tubes (ETT) properly in order to prevent unplanned extubation (UE) and its complications. Despite various available endotracheal tube holders, using bandages or tape are still the most common methods used in this regards.
Which of the following is the most reliable indicator of successful endotracheal intubation?Waveform capnography provides 100% sensitive and specific results about the verification of the correct endotracheal tube location. This is why waveform capnography is considered as a standard method for the primary verification of the ETT placement3 .
|