critical care medicine
How To Do Orotracheal Intubation Using Video Laryngoscopy
Step by Step Description of Orotracheal Intubation Using Video Laryngoscopy
Maneuvers to create a patent airway and to ventilate and pre-oxygenate the patient are always indicated before attempting tracheal intubation. Once a decision to intubate has been made, do the following: Prepare the necessary equipment, including ancillary equipment such as a suction device. Be prepared to use an alternate technique (eg, How To Insert a Laryngeal Mask Airway , Correctly position the patient (see figure Head and neck positioning to open the airway and Establish IV access. Ventilate and pre-oxygenate the patient with 100% oxygen (oxygenation with a non-rebreather mask is adequate if the patient is spontaneously breathing; if the patient does not have adequate spontaneous ventilations, use bag-valve-mask ventilation with supplemental passive nasal cannula [or high-flow nasal cannula if available] Turn on the video laryngoscope, and verify the light and camera are working. Inflate the balloon cuff of an appropriately sized endotracheal tube to verify it does not leak. Position the patient’s head and neck, if possible, as you would for How To Insert an Oropharyngeal Airway . Do rapid sequence intubation (ie, using Drugs to Aid Intubation ). If the airway is anticipated to be difficult and the patient has an intact gag reflex, use an induction agent such as Clear the oropharynx, if necessary, of obstructing secretions, vomitus, or foreign material. Continue oxygenation. For spontaneously breathing patients, apply a non-rebreather mask at 100% fraction of inspired oxygen (FiO2) for 3 to 5 minutes before intubation. For patients who are not spontaneously breathing, give about 8 vital capacity breaths at maximum oxygen concentration using a bag-valve-mask. Insert the video laryngoscope blade into the patient's mouth, following the curve of the tongue. Once the tip of the video laryngoscope blade is behind the patient's tongue, look at the video laryngoscope monitor and manipulate the blade so the glottic opening is in the middle of the upper half of the video screen. Optimize the view with bimanual laryngoscopy. This is accomplished by manipulating the larynx with the operator's right hand while operating the video laryngoscope with the left hand. Applying backwards, upward, and rightward pressure on the thyroid cartilage will usually optimize the view. The operator can position an assistant's hand to maintain the view while inserting the endotracheal tube. Looking away from the screen and back at the patient, insert the endotracheal tube in the right side of the mouth and pass it behind the tongue, carefully avoiding damaging the balloon on the teeth. At this point, watch the monitor to guide the tip of the tube through the vocal cords. Because some stylets used with certain video laryngoscopes are rigid, this maneuver may require having an assistant pull the stylet out 1 to 2 cm while the tube is gently advanced. Then advance the tube an additional 3 to 4 cm. Inflate the cuff and fully remove the stylet. Ventilate the patient (8 to 10 breaths/minute, each about 6 to 8 mL/kg or 500 mL and lasting about 1 second). If unable to intubate, use of adjuncts such as the bougie may be helpful. If adjunct use does not result in a successful airway, quickly pursue an alternate airway, which may involve rescue How To Do a Percutaneous Cricothyrotomy as an interim either to a supraglottic airway (eg, laryngeal mask airway, 