Procedures and Equipment for Intubation 

Management of patients having surgery:

   Case history:  patient is questioned about signs and 

    symptoms suggestive of airway abnormalities, such as 

    hoarseness or shortness of breath.  The patient is also 

    questioned about information on prior surgery, trauma, 

    neoplasia involving the airway, and prior anesthetic 

    experiences.

   Physical examination:  patient's head is viewed in profile and 

   palate should be examined for cleft.  Many congenital 

   syndromes make it difficult or impossible to intubate.  The 

   presence of protruding teeth may complicate intubation and 

   may cause difficulties producing a seal.  Temporalmandibular 

   joint mobility should be assessed.  The patient's cervical spine 

   mobility must be evaluated, because endotracheal intubation 

   usually involves extension of the neck.  The distance between 

   the lower border of the mandible and the thyroid notch with 

   the patient's neck fully extended should be measured with a 

   ruler or intubation gauge.  If the measurement is less than 6 

   cm, it will be impossible to visualize the larynx.  The neck 

   should be palpated, so that masses and tracheal deviation can 

   be detected.

Airway Equipment:

    Masks:  Connell anotomic mask is used most frequently in  

    adults.  They are available in a variety of sizes and have a 

   malleable body that allows it to be shaped to fit the patient's 

   face.

  Airways:  Available in several sizes and types.  Most are 

    made of plastic, although some are designed of metal, including 

    one designed for use during fiberoptic endotracheal intubation.

  Laryngoscopes:  Composed of handle and blade.  Curved and 

   straight blades are the two general types.  Personal preference 

   primarily determines the type of blade used for intubating 

   adults.

  Endotracheal Tubes:  Numbered according to the internal 

   diameter.  The approximate size and length of the tube is 

   determined by the patient's age and size.

   Ancillary Equipment:

   -Malleable metal or firm rubber stylets are used to maintain  

     the desired curve of the endotracheal tube during intubation.

   -Soft plastic or rubber tooth protectors/guards can lesson the 

    chance of damage to the teeth.

Once it is determined that endotracheal intubation is 

necessary:  the anesthesiologist must decide whether 

nasotracheal or orotracheal intubation is most appropriate; 

choose the type and size of the laryngoscope and tube to use, 

decide whether the patient is to be intubated while awake or 

after  induction of anesthesia; and decide a muscle relaxant can 

be used separately.

Procedures in the Operating Room:

  This information is courtesy of Emilio Rivera, M.D. (personal  communication, March 2001) an  Anesthesiologist at Memorial Medical Center, Las Cruces, N.M.

Before Intubation:  

    The anesthesia cart located in the operating room has all the     

    medication that is used feequently and those that are used 

   very rarely that are needed on an emergency basis.  There is no 

   time to go and get them; because if something is happening to 

   a patient the diagnosis must be made and treated 

   immediately.  The different kinds of medication are to put  

   patients to sleep or muscle relaxants (paralyze muscles.)  There 

    are also narcotics that are used frequently in anesthesia that 

    require a code number that is recorded to get them. The 

   narcotics are 10 to 1000 times more potent than morphine.  

   Syringes with needles are used to draw out medication as 

   needed.  The patient comes into surgery and as they come in 

   syringes are normally ready and medications drawn up.  One of 

   the first things given to the patient is a sedative through an IV 

   tube that is in place.  The patient is put on the operating table 

   or bed.  The patient is then hooked up to the following 

   monitors:  heart (EKG), and blood pressure cuff. The cuff 

   checks pressure from continuous readings to 15-30 minute 

   intervals, depending on the interval selected.  The standard of 

   care is that blood pressure needs to be taken a minimum of 

    every five minutes during surgery.  There is also a clip attached 

    to a patient's finger that checks the amount of oxygen in the 

    blood.  Once the patient is hooked up to all the monitors, they 

    can be put to sleep.  The patient is informed during the 

   procedures, what and why it is being done.  There are different 

    techniques and script of what is said before the patient is put 

    to sleep.  One example is, "Try to think of a nice place to go on 

    a vacation."  This technique is used so that the patient might 

    have a nice dream while they are asleep.  While the patient is 

    thinking, the anesthesiologist begins administering the 

    anesthetic.  The anesthetic is in actuality a hypnotic to put the 

    patient to sleep.  The patient must be hooked up to the 

    anesthesia machine to stay asleep.  Intubation comes in at this 

    time.  

During Intubation:

    When the patient is asleep, they are given a muscle relaxant 

    that relaxes their muscles including the vocal folds to allow 

    them to open up.  A blade and handle is selected for the 

    laryngoscope to visualize the larynx and intubate the patient 

    (e.g. Miller blade = straight blade and Macintosh = curved 

    blade.)  The anesthesiologist places hand on head of patient 

    and pushes down, which picks up their mandible and allows 

    the mouth to open.  The tip of the blade is inserted and slid 

    over the tongue to the base of the tongue.  Next, the 

    anestesiologist pulls up and away from the patient in a 

    roughly 45 degree angle.  The key is to make sure that the 

    patient is definitely asleep before this is done.  The tube is 

    selected at this time.  The tube is placed right between the 

    vocal folds and as soon as the top part of the cuff passes the 

    vocal folds the anesthesiologist stops.  Sometimes stylets are 

    used to help in intubation.  The cuff is inflated and the patient 

    is hooked up to the anesthesia machine.  

After Intubation:

   The mask is removed.  The anesthetic is turned on.  There are 

    three choices of gasses.  The machine is turned on to 

    automatic.  The machine breathes for the patient and 

    administers gas anesthesia to the patient.  The 

    throat is suctioned out.  After surgery, the patient must be 

    awake and responsive before it is safe to extubate the 

    endotracheal tube (e.g. lift your head for five seconds or     

    squeeze finger of anesthesiologist.)