cover almost all intubation techniques

1. ENDOTRACHEAL INTUBATION IN
ORAL & MAXILLOFACIAL SURGERY
Dr. Padmasree Patowary

2. CONTENTS
 Introduction
 Historical prospective
 Indication and contraindication
 Armamentarium
 Procedure for Endotracheal Intubation
 Types of intubations
I. Orotracheal intubation
II. Nasoendotracheal intubation
III. Retrograde intubation
IV. Retromolar intubation
V. Submental intubation
VI. Fibroptic intubation
 Complications
 Conclusion.

3. Introduction
Maintaining the airway is an essential step in oral and
maxillofacial surgical cases, which are performed under
general anesthesia or maxillofacial trauma. There are various
techniques for maintaining the airway ranging from, head tilt –
chin lift to surgical airway.
Endotracheal intubation provides an artificial medium between
the atmosphere and the patient’s trachea for the purpose of
alveolar gas exchange or protection of the lungs from
inappropriate substances.

4. Historical prospective
Endotracheal intubation for the
purpose of providing anaesthesia
was first described by William
Mac Ewan in 1878 when he
passed a tube from the mouth into
the trachea, using fingers as a
guide in the conscious patient.

5. Routine
To provide anaesthesia
Emergency
Airway obstruction
Respiratory distress
Oxygenation failure (hypoxia)
Ventilation failure
Mental status alteration
Indications

6. Contraindication
1. Severe airway trauma or obstruction that does not permit safe
way of an endotracheal tube. Emergency cricothyrotomy is
indicated in such cases.
2. Cervical spine injury.
3. Mallampati Classification of class III / IV or other
determination of potential difficult airway.

7. Intubation can be achieved in following ways:
1. After induction of general anaesthesia (by IV or
inhalation method).
a. Oral—orotracheal intubation.
b. Nasal—nasotracheal intubation.
2. Awake intubation
a. Blind oral
b. Blind nasal
c. Retrograde
d. By use of fiberoptic scope.
Procedure for Endotracheal Intubation

8. Anatomy of airway

9. Upper Airway Anatomy
• Anterior Nares
• Vestibule
• Mucosal Lining
• Septum
• Nasal conchea
• Posterior Nares
• Nasopharynx
• Oropharynx
• Pharynx
• Larynx
• Epiglottis
• Vocal Folds
• Glottis

10. Lower Airway Anatomy
• Trachea
• C-shaped cartilaginous
rings
• Carina
• Right main bronchus
• Left main bronchus
• Bronchial Tree
• Bronchioles
• Alveolar ducts
• Alveolar sacs
• Alveoli
– ̴300,000,000
• Capillaries

11. Armamentarium
i. Anesthetic Mask
ii. Laryngoscope
iii. Endotracheal Tubes
iv. Airways
v. Laryngeal Mask Airway (LMA)
vi. Magill’s forceps
vii. Ambu Bag
viii. Stylet

12. Mask is an essential part of any anaesthetic
breathing system during the induction phase
(beginning) of anaesthesia.
A mask allows administration of gases from
the breathing system, without introducing any
invasive equipment (e.g. an endotracheal tube)
into the patient’s airway. Face-masks are
designed to fit the patient’s face
perfectly without any leaks.
• Parts:
I. Connector or mount
II. Body
III. Edge or seal
• Sizes: 1, 2, 3, 4, 5.
Anesthetic Mask

13. Laryngoscope : handle and blade

14. LARYNGOSCOPIC BLADE
• Macintosh (curved) blade (most popular)
• Miller (straight) blade (useful for neonates and small children)

15. Laryngoscope is designed for
doing direct laryngoscopy
(directly viewing the vocal
cords) and to pass an endo
tracheal tube into the larynx
under vision.
• Parts: Handle, blade with
light bulb.
• Sizes (for the blades) Neonate
(infant), Paediatric (child),
adult and extra large.

16. Endotracheal tube is a specially designed tube with one end
straight and the other being obliquely cut (beveled end).
Beveled end enters the trachea.
It is used for the surgical procedures in which it is not feasible to
administer anaesthetic gases via mask, procedures which are long-
lasting, procedures in which there are chances of having blood,
secretions, pus, vomiting etc. in the oral cavity or where patient
needs to be given muscle relaxants and controlled breathing.
Endotracheal Tubes

17. It is always passed with direct laryngoscopy under vision after
anaesthetizing the patient, except in cases, where patients are unable to
open mouth, e.g. T.M. joint ankylosis or when a difficult intubation is
expected.
Age Weight
(Inner) diameter
(mm)
New born 3 kg 2.5–3.0
0–6 months 3.5 kg 3.0–3.5
6–12 months 7 kg 3.5–4.0
1–3 years 10–12 kg 4.0–4.5
4–7 years 16–18 kg 5.0–5.5
8–10 years 24–30 kg 5.5–6.5
Adult female 7.0-7.5
Adult male 8.0-9.0

18. Types of endotracheal tube
include
1. oral (south pole) or nasal
(north pole)
2. cuffed or uncuffed
3. preformed (e.g. RAE (Ring,
Adair, and Elwyn) tube
4. reinforced tubes
5. double-lumen endobronchial
tubes.

19. The purpose of introducing an airway is to lift the tongue and
epiglottis away from the posterior pharyngeal wall and prevent
them from obstructing the space above the larynx.
Airways
I. Oropharyngeal (Oral) Airway (Placed from Lips to
Pharynx)
II. Nasopharyngeal (Nasal) Airway (Placed from the Nose to
the Pharynx)

20. Oropharyngeal airway: In basic airway
management, the oropharyngeal airway is
used to provide a right airway to make
possible for chest ventilation. In advanced
airway management, it can be inserted
following endotracheal intubation to act
as a bite-block to protect the endotracheal
tube.
• Parts: Flange, bite portion, air/suction
channel (curved portion)
• Sizes: 1, 2, 3, 4.

21. Nasopharyngeal airway is a tube that is designed to be inserted into
the nose to secure an open airway. When a patient becomes
unconscious, the muscles in the jaw commonly relax and can allow
the tongue to slide back and obstruct the airway. The purpose of the
flared end is to prevent the device from becoming lost inside the
patient's nose.
•Parts: Flange or a movable disc attached to a tube
• Sizes (diameter)
— 7.0/7.5 for adult males
— 6.5/7.0 for adult females
— Same/one size smaller than an appropriate endotracheal tube for
children

22. Laryngeal Mask Airway
(LMA)
Most popular supraglottic airway in emergency and short
procedures. Consist of a tube with an inflatable cuff that is
inserted into the pharynx . Very useful device in “can’t intubate
/ can’t ventilate” scenario.
Parts: Mask, tube at an angle of 30 degrees, black
line on tube to face upper incisors and pilot balloon.
• Sizes: 1, 1.5, 2, 2.5, 3, 4, 5.

23. Designed by Dr Archie Brain in UK in 1981 and released in 1988

24. Indications:
• When endotracheal intubation is not necessary or it is
difficult
Contraindications:
• Non-fasted patients
• Obstructive or abnormal lesions of the oropharynx

25. Advantages:
• Allows rapid access
• Does not require laryngoscope
• Relaxants not needed
• Provides controlled airway
• Ventilation
• Tolerated at lighter anesthetic planes
Disadvantages:
• Does not fully protect against aspiration in the non-fasted patient
• Requires re-sterilization

26. Magill’s forceps is an instrument, which is
most often used for guiding an endotracheal
tube, from the pharynx into the larynx during
nasal intubation. It is also used to pack the
throat with a roller gauze during oral and
pharyngeal surgery, to pick up a broken or
dislodged tooth lying in the oral cavity or to
pass a ryles (nasogastric) tube. It is L-shaped
and it has no catch. It is available in two
sizes—adult and paediatric.
Magill’s forceps

27. •It is a combination of a self-inflating bag, a non- rebreathing valve
and a facemask.
• As it is useful for ventilating a patient in emergency situation, it
should always be available in the operation theater as handy as
possible.
•If any problem occurs with anaesthesia machine or a breathing
system, which cannot be diagnosed or corrected quickly, this bag will
allow the user to ventilate the patient with room air (with or without
oxygen) till the problem is solved.
Ambu Bag

28. It is also useful and should be
available during patient transport. It
can also be used for administering
anaesthesia in the absence of an
anaesthesia machine, e.g., in rural set-
up or field situations.

29. A stylet can be inserted inside an
endotracheal tube to make it more rigid, or
to change the shape of the tube.
It is recommended that it can be used in all
emergency intubations.
In this way, if the shape of the tube needs to
be modified, the stylet is already in place.
The stylet should be lubricated before
insertion into the endotracheal tube, so that
it is easy to remove.
Stylet

30. I. Orotracheal intubation
II. Nasoendotracheal intubation
III. Retromolar intubation
IV. Submental intubation
V. Retrograde intubation
VI. Fibroptic intubation
Types of Endotracheal intubation

31. Orotracheal Intubation
• The oral route for intubating is preferred since it can usually be
performed more rapidly and provides for better visualization.
• In addition, the mouth can accommodate a larger tube than the
nose.

32. INDICATIONS
-Failure to oxygenate adequately.
-Failure to ventilate adequately.
-Failure of or need for airway maintenance or protection.
-Expected need for intubation based on progression of underlying
physiologic process.
CONTRAINDICATIONS
-Do Not Intubate (DNI) order
-Partial tracheal transection
-Difficult airway (relative)

33. Mallampati classification
Soft palate
Uvula

34. Head positioning for tracheal intubation. A . Neutral position. B. Head
elevated. C.“Sniffing” position with a flexed neck and extended head. Note that
flexing the neck while extending the head lines up the various axes and allows
direct laryngoscopy. D. Ramped position with elevation of the upper part of the
back, neck, and head.

36. Trachlight
• Light-guided intubation using the trachlight is a safe and
gentle technique for both oral and nasal endotracheal tube
placement and positioning .
• A well defined circumscribed glow can be seen in the
anterior neck when the endotracheal tube and light enter into
the glottic opening.

38. Advantages
• Minimal neck movement
• Useful for laryngoscopy
• Portable and inexpensive
• Functional in bloody airway
• Provides definitive airway
Disadvantages
• Blind technique
• May damage airway
• Expertise requires practice

39. Conformation
• Chest lift
• Movement of moisture column in ETT
• Auscultation
• Improvement and maintenance of SpO2
• Exhaled carbon dioxide

40. Nasoendotracheal intubation
• Nasal intubation is applied for dental procedures performed
in the hospital, dental office when possible.
• Although many who provide anesthesia services are familiar
and comfortable with nasal intubation techniques, some are
uncomfortable because of lack of experience or fear of
nasopharyngeal bleeding and trauma.
• It has been observed from experiences in various settings
that many approaches may be adapted to the technique of
achieving nasal intubation

41. • Most commonly for dental procedures and intraoral (eg, mandibular
reconstructive procedures) and oropharyngeal surgeries
• Major maxillofacial surgeries
• Securing the airway questionable cervical spine stability or severe
degenerative cervical spine disease
• Mass lesions or structural abnormalities
• Limited mouth opening (eg : trismus).
Indications

42.  Absolute contraindications
• Suspected inflammation of the epiglottis
• Midface instability
• Coagulopathy
• Suspected fractures in base of the skull
• Sleeping Apnea
 Relative contraindications
• Large nasal polyps
• Suspected nasal foreign bodies
• Recent nasal surgery
• Upper neck hematoma or infection
• History of frequent episodes of epistaxis
• Prosthetic heart valve (increased risk of bacteremia during the insertion)
Contraindications

43. Technique of Nasotracheal Intubation
Examine both nostrils to determine which is larger.
Spray the nasal passages and back of the throat with an
appropriate topical anesthetic and vasoconstrictor (neosynephrine)
in order to numb the mucosa and reduce bleeding.
 Use of xylocaine jelly and a nasal airway before intubation, it
may increase anesthesia and reduce bleeding. Remove the airway
before intubation.

44. Pre-oxygenate the patient at 100% and keep the patient on Oxygen
by a cannula in the mouth during the entire procedure.
Check the balloon on an appropriately sized nasotracheal tube.
 Firmly seat the 15 mm adapter in the proximal end of the tube and
lubricate the distal 4 cm with xylocaine jelly. Position the patients head
in midline neutral position if possible.
 Patient may be sitting or supine position.
Tell the patient that patient may feel like gagging or coughing when
the tube is inserted. Advise the patient to resist gagging or coughing.
Reassure and calm the patient.

45.  With gentle pressure, insert the tube directed towards the
occipital protuberance on the back of the skull with the bevel
turned towards the nasal septum. Do not aim the tube up towards
the vertex of the skull. If the tube will not pass on one side, try the
other. Some resistance may be encountered when the tube reaches
the posterior nasopharynx . At this point some gentle manipulation
may need for pass the resistance. Turn the tube 1/4 turn after
reaching the nasopharynx . Do not force it.

46. When the tube has reached the oropharynx at the back of the
mouth, pay attention at the end of the tube for air moving in and out
with each respiration. Gently but decisively push the tube further
into the nostril and tube is enter into the trachea. Do not force the
tube down as structures in the larynx. If properly placed, the tube
will easily slip into the trachea.
Confirm tube position in the same manner as for an orotracheal
procedure. Control bleeding by gently pinching the nostrils around
the tube. Secure tube with tape.

47. Retromolar Intubation
Patients with panfacial trauma require specific considerations for
securing airway intraoperatively. The necessity of intraoperative
restoration of dental occlusion by maxillomandibular fixation
(MMF) makes the presence of oral endotracheal tube unfeasible.
Nasotracheal intubation is contraindicated in certain conditions –
viz fracture of base of skull, fracture of naso-orbital-ethmoid
complex, etc.In such cases, retromolar intubation, a non-invasive
technique of securing airway in patients with panfacial trauma,
avoids both submento-tracheal intubation and tracheostomy.

48. •Orotracheal intubation is done
initially with a flexometallic
tracheal tube using standard
general anaesthesia technique. The
aim is to place the orotracheal tube
in the retromolar space (space
behind the last upper and lower
erupted molar teeth) .
• The orotracheal tube is grasped
with gloved fingers and is placed
into the retromolar space.
Technique

49. • The tube is then fixed by a wire
ligature to the molar/premolar
tooth.
• The wire ligature is the same that
is used for MMF. It fixes the
retromolar tracheal tube with the
tooth in a “figure of eight”
fashion.
• The retromolar tracheal tube
allows adequate dental occlusion.

50. Advantages
If retromolar intubation can be done with adequate dental
occlusion, then tracheostomy and submento - tracheal intubation
techniques can be avoided the.
Disadvantages
1. In some patients, the retromolar space is not adequate. After
retromolar placement of the tracheal tube dental occlusion is not
possible. Therefore, intraoperative MMF cannot be done.

51. 2.The tracheal tube can interfere with the main surgical field that
may be partially draped.
3.The tracheal tube can also interfere with positioning and
application of dental fixation devices, especially in patients with
bilateral maxillary/ mandibular fractures.

52. Submental Intubation
Submental route of endotracheal intubation is a simple, safe
and useful technique in maxillofacial trauma, where oral and
nasal endotracheal intubation cannot be performed. It avoids
the need for tracheostomy.

53. Technique
• After a standard orotracheal intubation, a
temporary draping of the mouth and chin
was carried out.
• Then, a 2-cm skin incision was made in
the median region of the submental area,
directly adjacent to the lower border of
the mandible.

54. • The muscular layers (platisma and mylohyoid muscles) were
traversed by blunt dissection using a Kelly forceps that was
always in contact with the lingual cortex of the mandible.
• The mucosal layer on the floor of the mouth was incised over
the distal end of the forceps, and the forceps were then opened,
creating a tunnel. During the dissection it is important that the
width of the submental access should be sufficient to pass the
tube without any interference.

55. •It is important to make sure that the
tube has not been displaced during its
passage through the submental
tunnel.
•After the surgery, the submental
intubation was converted to an
orotracheal intubation by replacing
the tube in the mouth and carrying
out extubation in the classical
manner.
Minimal scar postoperative.

56. •If the patient needed long-period postoperative ventilation, the
orotracheal intubation was maintained until extubation was
complete.
•The suture was done with 5-0 nylon in the skin and 4-0 vycril in
the internal layers.

57. Retrograde Intubation
Ankylosing spondylitis (AS) patients are most challenging.
Sound clinical judgment is critical for timing and selecting the
method for airway intervention. The retrograde intubation
technique is an important option when fiberoptic bronchoscope is
not available, and other method is not applicable for gaining
airway access for surgery in supaine position.

58. Indications
1. Facial Anomalies:
a. Maxillary hypoplasia
b. Mandibular hypoplasia
c. Mandibular hyperplasia
2. Temporomandibular joint pathology:
a. Ankylosis or reduced movment

59. 3. Anomalies of the mouth and tongue:
a. Microstomia (burns, trauma scarring)
b. Diseases of the tongue (burns, trauma, Ludwig angina)
all lead to tongue swelling
c. Tumors of the mouth and tongue (hemangioma,
lymphangioma)
d. Macroglossia (Down syndrome, hypothyroidism)
4. Problem with teeth (missing left upper incisors, protruding
upper incisors)

60. Contraindication
• Adequate mouth opening and easily performed orotracheal
intubation
• Relative contraindication: Systemic coagulopathy, infection in
the skin overlying the cricothyroid membrane.

62. Fiberoptically guided tracheal intubation represents one of the
most important advances in airway management to occur in
the past thirty years. Perhaps its most important role is in
management of the anticipated difficult airway. This is a
situation in which the dangers of encountering the life-
threatening "can't intubate, can't ventilate" situation can be
avoided by placement of an endotracheal tube while the patient
is awake.
Fiberoptic Intubation

63. Indications:
• Predictable difficult intubation (upper airway abnormality)
• Cases where neck extension is not desirable
• Nasal fiberoptic intubation in Oral Submucous Fibrosis
Contraindications:
• Inability to oxygenate
• Major bleeding

64. 1. Eye piece
2. Diopter ring for focusing
3. Control lever
4. Working channel port
5. Body
6. Insertion cord
7. Light source
8. Suction valve and port
Fiberoptic Bronchoscope

65. Technique
• Oral or nasal route is preferable
• Jaw thrust maneuver to improve visualization
• After the broncoscope is lubricated and loaded with
endotracheal tube it is introduced strictly in the midline
following the base of the tongue, pass the uvula, behind
epiglottis and between the vocal cords.
• Once the carina is visualized endotracheal tube is introduced
by rotating movement over the broncoscope.

67. Complications

68. 1) During intubation
2) During remained intubation
3) During extubation
4) After extubation

69. During intubation
• Trauma to lip, tongue or teeth
• Hypertension and tachycardia
• Pulmonary aspiration.
• Laryngospasm
• Bronchospasm
• Laryngeal edema
• Arytenoid dislocation
• Increased intracranial pressure
• Spinal cord trauma in cervical spine injury

70. During remained intubation
• Accidental extubation or endobronchial intubation.
• Disconnection from breathing circuit Pulmonary aspiration.
• Lip or nasal ulcer in case with prolong period of intubation.
• Sinusitis in case with prolong nasoendotracheal intubation.
• Esophageal intubation
• Epistaxis

71. • Laryngospasm
• Pulmonary aspiration
• Edema of upper airway
During extubation
After extubation
• Sore throat
• Tracheal infection (Prolong intubation)
• Laryngeal granuloma

72. Conclusion
Airway management is the most important skill required of an
anaesthesiologist and also for oral and maxillofacial surgeons.
Endotracheal intubation is a skill based on the knowledge of airway
anatomy, equipments for airway manipulation, also the use of
pharmacological agents and experience.

73. REFERENCES
• Miller’s Anesthesia, 7th Edition by Ronald D. Miller.
• Clinical Anesthesiology, 4th Edition by G. Edward Morgan, Jr.,
Maged S. Mikhail, Michael J. Murray.
• Bailey & Love’s Short Practice of Surgery, 25th Edition.
• M Polansky. Airway Management: The Basics Of Endotracheal
Intubation. The Internet Journal of Academic Physician Assistants
1996;(1):1.
• Christopher Kabrhel, Todd W. Thomsen, Gary S. Setnik, Ron M.
Walls. Orotracheal Intubation. N Engl J Med 2007;356:e15
• Endotracheal intubation: MedlinePlus Medical Encyclopedia
• Textbook of OMFS , 3rd edition by Neelima malik
• Malhotra N. Bhardwaj Chari P. :SUBMENTAL ENDOTRACHEAL
INTUBATION:A USEFUL ALTERNATIVE TO TRACHEOSTOMYINDIAN
JOURNAL OF ANAESTHESIA, OCTOBER 2002 2002; 46 (5) : 400-402

74. THANK YOU