PURPOSE This interdisciplinary clinical support document provides guidelines for the safe establishment of an artificial airway. POLICY STATEMENTS Endotracheal intubation will be performed by the Most Responsible Physician (MRP) or delegate. INDICATIONS Endotracheal intubation may be indicated under the following circumstance such as: 1. To maintain or establish a patent airway in a patient with a deteriorating and/or decrease in level of consciousness (LOC) 2. To provide adequate ventilation and oxygenation when a patient is no longer capable or is deteriorating 3. To protect the airway from obstruction or impending obstruction 4. To prevent aspiration 5. To provide bronchial hygiene when a patient cannot regulate their own secretion clearance SITE APPLICABILITY Endotracheal intubation is only performed in patient care areas where the appropriately trained personnel and intubation equipment are readily available. This includes the Emergency Department (ED) (refer to policies; CC.19.03 - Intubation in Pediatric Trauma Guidelines and CC.19.03A Intubation in Pediatric Trauma Quick Reference Guide) and Pediatric Intensive Care Unit (PICU) with the exception of Code Blue situations where endotracheal intubation may occur outside of these designated areas as part of the resuscitation process. PRACTICE LEVEL/COMPETENCIES Endotracheal intubation will be performed by a physician or designate. Physician Basic skill for PICU/ED medical staff Registered Respiratory Therapist (RRT) Assisting with endotracheal intubation is a basic skill as outlined in the Respiratory Therapy National Competency Profile. Registered Nurse (RN) Assists with medication administration and documentation DEFINITIONS Endotracheal tube (ETT): a tube inserted (through the nose or the mouth) into the trachea to maintain a patent passageway. This is used to deliver oxygen and/or mechanical ventilation to the lungs. Intubation: The act of placing an endotracheal tube into the trachea. EQUIPMENT Personal Protective Equipment (PPE) Mask Eye Protection Gown Gloves BCCH Intubation Checklist Intubation Cart Safety Equipment (refer to Appendix 3) Page 1 of 5
Appropriate size manual resuscitator (500 ml resuscitation bag < 25 kg, 1000 ml resuscitation bag 25 kg) attached to free flowing oxygen Appropriate size mask Appropriate size oropharyngeal airway (OPA) Airway Equipment (refer to appendix 3) Appropriate size endotracheal tube and one size smaller Laryngoscope with appropriate size blade (May substitute for video laryngoscope as needed) Magill forceps (for nasal intubation) Appropriate size laryngeal mask airway (LMA) 5 cc syringe End Tidal CO2 (ETCO2) or if unavailable use a colorimetric device Lubricated stylet Water based lubricant Endotracheal tube anchoring device Oral anchoring device options Anchorfast Neobar with pre-cut short cloth tapes Nasal anchoring device options Adhesive spray & cotton swabs Mastisol Measuring tape Pre-cut long cloth tapes Other Equipment Pulse oximetry monitoring ECG monitoring Yankauer suction Patent IV Intubation medications as directed by the MRP PROCEDURE OBTAIN all necessary equipment listed above. WASH hands and DON appropriate PPE including gloves, goggles and masks. COMPLETE the Intubation Checklist. Any team member may lead this process. During an emergency, the checklist review should be deferred and the airway access expedited. EXPLAIN procedure to patient if conscious Respiratory Therapist Role ENSURE the manual resuscitator is functional and attached to oxygen at a flowrate of 8-10 LPM. ATTACH correct size mask to the manual Rationale/Comments Ensures all team members proper protection Ensures correct patient, at the correct time in the correct location. Ensures all team members are present Ensures all equipment is accounted for and is functioning according to specifications Identifies alternative plan for unsuccessful attempt(s). Identifies any anticipated difficult intubations and notifies other care providers if their expertise is required (i.e. Anesthesia). Ensures safety equipment is functional. Page 2 of 5
resuscitator. CHECK suction is functional and regulator is set at 80 to 100 mmhg (MAX). PLACE all safety equipment at head of bed (HOB). OBTAIN correct size laryngoscope blade and handle (may use video laryngoscope). CHECK light source for brightness replace batteries if necessary. OBTAIN the correct size ETT and one size smaller. CHECK the cuff of ETT by filling with 1-3 cc of air as required to adequately inflate cuff. REMOVE syringe and check for any leaks from distal cuff to proximal pilot balloon. DEFLATE cuff. INSERT one lubricated stylet in each ETT. PLACE laryngoscope, ETT with inserted stylet, ETCO2 device, syringe, tapes and anchoring device at HOB. ENSURE the patient has pulse oximetry monitoring. TURN ON QRS volume on monitor if ECG monitoring is available. ATTACH ETCO2 to monitor, and place at HOB PRE-OXYGENATE patient with a tight sealed facemask for a minimum of 2 minutes or until pulse oximetry is 100%. The placement of high flow nasal prongs as an adjunct to the face mask delivery of oxygen may be used to prolong the time before desaturation during the apneic period SUCTION patient s mouth and pharynx with a yankauer as required clearing secretions considering before paralysis and during laryngoscopy. Nursing Role CHECK IV access is functional ENSURE all intubation medications are prepared as per MRP request OPTIMIZE patient position under the guidance of the MRP and with the assistance of the respiratory therapist. If a neck injury is suspected DO NOT perform head extension and neck flexion ETT Placement Procedure Cuff should inflate and stay inflated after the syringe is removed to ensure proper function. Ensure stylet does not go beyond the distal end of the ETT. Correct curvature of distal end by manipulating stylet straight to cuff (curvature may vary for video laryngoscopy). The use of oxygen in patients with a cyanotic heart defect requires discussion with the MRP. A spontaneously breathing patient may require CPAP support to promote full saturation Patient supine, neck flexed with the head extended at the atlanto-occipital junction. Most patients are easily intubated in the neutral position. Newborns may need a small roll under their shoulder to counter the over flexion from the large occiput. Over-extension should be avoided as it brings the larynx more superior and makes visualization more challenging. Page 3 of 5
HOLD laryngoscope in the palm of the left hand INSERT the laryngoscope blade into the right side of the patients mouth, watching not to catch the corner of the lip or lever on the teeth/gums ADVANCE the laryngoscope blade along the patients tongue further into the oropharynx while displacing the tongue to the left. VISUALIZE the epiglottis INSERT ETT into mouth LIFT the laryngoscope blade UPWARD and FORWARD, displacing the epiglottis anteriorly, revealing the glottic opening and vocal cords. VISUALIZE the larynx and ADVANCE the ETT through the right side of the patient s mouth behind the mandible. Under direct vision, ADVANCE the ETT through the vocal cords until the cuff s proximal black line is just past the glottic opening. REMOVE stylet from the ETT and the laryngoscope blade from the patient s mouth. INFLATE ETT cuff with air. CONNECT ETT to ETCO2 monitor and manual resuscitator bag VENTILATE and oxygenate the patient. CONFIRM ETT placement by: Visualization of capnograph waveform on monitor (may be a delay of 2-3 breaths) Visualization of adequate chest rise with manual breath Presence of mist in the ETT on exhalation Confirmation of breath sounds on auscultation. SECURE ETT using chosen anchoring device CONNECT patient to appropriate mechanical ventilator as per the Invasive Mechanical Ventilation Policy and begin following monitoring procedure as per protocol REQUEST for chest x-ray to confirm appropriate tube placement. A MacIntosh (curved ) laryngoscope blade is placed into the vallecular space A Miller (straight ) laryngoscope blade is placed under the epiglottis Be sure NOT to lever on the patient s teeth as this may result in broken/chipped teeth. DO NOT let go of the ETT until it is secured into place. This will ensure that tube does not become displaced.. Auscultate over the epigastric area to rule out esophageal intubation Page 4 of 5
POST PROCEDURE To ensure all items required for intubation are available and functional on the PICU Intubation Cart and on the Emergency Department intubation cart the Respiratory Therapist will check, verify functional operation where indicated and record their findings with a in the appropriate box aligning with each item as outlined in Appendix 1 Pediatric Intensive Care Unit Intubation Cart Check List following each intubation. RT initials and dates the checklist to indicate the verification has been completed. The checklist remains with the intubation cart in a binder. If it is determined during patient admission to PICU or post intubation procedure that the patient has a complex airway through a combination of history, presence of a syndrome known to be associated with difficult airways, clinical examination or previous anesthetic history. A Difficult Airway Sign (Appendix 2) must be posted at the head of the bed. DOCUMENTATION Physician Document intubation as per Intubation Documentation Progress Notes Set. Respiratory Therapist Document the intubation procedure and the patient response to procedure on the RT flow sheet. Fill out RT flow sheet as per ventilation settings inclusive of ETT placement. Refer to Invasive Mechanical Ventilation Policy. Registered Nurse Document the intubation procedure and the patient response to procedure in the nursing notes. Document patient vital signs on the patient care flowsheet as per unit standards. Document medications administered on the patient care flowsheet and/or the medication administration record as per unit standards. REFERENCES BC Children s Hospital. (1991-01). Intubations. Cairo, J, Pilbeam, S., (2010) Mosby s Respiratory Care Equipment: Eighth edition, Jeanne Wilke. Fraser Health Authority. (2009-04). Airway Management: Assisting Intubation NICU (A) Fraser Health Authority. (2000-07). Endotracheal Tube: Adult Intubation (A) IWK Health Centre. (2004-01). Endo Tracheal Intubation Assisting with Procedure. White, G (2003). Basic Clinical Lab Competencies for Respiratory Care: An integrated approach, Fourth edition, Delmar Cengage Learning. Page 5 of 5