one of the most common things that you'll come across in taking care of patients in the icu is the management of their airway for different reasons we have many tools at our disposal to try and assist our patients breathing but sometimes we need to take control and manage their airway and breathing for them through intubation which i'll discuss now [Music] all right you guys welcome back to another video lesson from icu advantage my name is eddie watson and my goal is to give you guys the confidence to succeed in the icu by making these complex critical care subjects easy to understand i truly hope that i'm able to do just that and if i am i do invite you to subscribe to the channel down below when you do make sure you hit that bell icon and select all notifications so you never miss out when i release a new lesson as always the notes for this lesson as well as all the previous videos are available exclusively to the youtube and patreon members you can find links to join both of those down in the lesson description below also don't forget to head over to icuadvantage.com or follow that link down in the lesson description to take a quiz on this lesson test your knowledge while also being entered into a weekly gift card as well as don't forget that you can help support this channel through the purchase of an icu advantage sticker again those are found at the website icuadvanage.com forward slash support link down in the description all right so in this lesson i'm going to talk about the basics of what intubation is why it is that we use it and really some of the risks that can come about with its use so let's start things off talking about what is intubation so when it comes to airway management and subsequent advanced airway placement we really have several options available to us the most common that we're gonna see is our endotracheal intubation but this does also include things like the tracheostomy tubes which i did discuss in that previous lesson so intubation or endotracheal intubation really consists of the insertion of a flexible tube aka the endotracheal tube through the patient's vocal cords and into their trachea now this tube can be inserted either through their mouth so this is our oro tracheal or through the nose which would be our nasotracheal having this tube in place really allows us to control the patient's airway ensuring they have a good open airway and allowing us to control their ventilation and oxygenation so the primary way of us doing this is going to be through the use of a ventilator but we can also achieve this using a bag valve mask as well so having an endotracheal tube in place gives us much better control over the volume of breaths so our ventilation the frequency of those breaths as well as the percentage of oxygen that we're delivering to them also having this tube in place fully secures the patient's airway and protects it from aspiration so make sure and watch the previous lesson on endotracheal tubes if you haven't already as i discuss some of this stuff over there now this is an invasive and uncomfortable thing for our patient and while it's often needed it does come with some of its own risks which i'll talk about in just a bit here all right so why do we intubate people so let's talk about some of the indications for that there are actually a lot of different reasons why we would need to do so but it really boils down to helping patients protect their airway ventilating or oxygenating the underlying reasons for needing this help could be the result of whatever disease process they have going on or it could be the result of some medical procedure or surgery that really prevents the patient from doing so particularly with their airway protection and ventilation so let's talk about some of the common reasons why we would intubate someone so first and foremost is going to be respiratory failure so this can either be hypercapnic hypoxic or combination of the two and so here we may need to take over their breathing to ensure proper ventilation for that co2 clearance to assist them in their respiratory effort or they may be requiring high levels of oxygen to battle hypoxia now sometimes we are able to try non-invasive means of support first but other times things are happening pretty quickly and we really need to quickly jump into intubating the patient right away having an et tube in place does also give us better control over things like peep as well as access to more advanced ventilator modes that we can help to better optimize oxygenation for our patient example this would be something like aprv now another indication is going to be our decreased mental status or our altered mental status so here a decreased mental status can really prevent our patients from protecting their own airway and interfere with their proper breathing so typically if their gcs is less than or equal to 8 then we intubate kind of a catchy phrase to help us remember it this can also apply though to rapidly deteriorating mental status especially if it's combined with respiratory compromise so this is something that's common in patients with brain injury strokes and overdoses another indication is going to be for a medical procedure and this is a pretty common case here and applies to medical procedures requiring sedation as well as surgery and the use of anesthesia these medications can impact both their level of consciousness and their ability to protect their own airway as well as impacting the patient's ability to breathe on their own some procedures we can sedate the patient without actually needing to intubate them but especially in cases of egds and tees that we're often going to intubate prior so we can properly sedate them as well as protect their airway during the procedure and then there are some procedures like bronchoscopy which are going to require an et tube being in place in order to perform it another indication is going to be our airway issues so if the patient has some sort of injury or impending issue such as swelling or edema that's at imminent risk of compromising their airway we will intimate to protect that airway and keep it open so this can also include cases of trauma which impact the patient's face neck and chest another indication is gonna be for aspiration so sometimes the patient airway will be at risk from aspiration either from issues preventing them from clearing their own airway or in cases of significant bleeding such as trauma esophageal varices epistaxis etc and then finally last major indication i'm going to talk about is going to be apnea so if our patients just aren't breathing then we need to intervene and take over that for them and so this could be the result of something like a drug overdose or a brain injury all right so now let's talk about some of our contraindications for intimation and first while this isn't necessarily a true contraindication in the normal sense a big reason not to intubate is if it's against your patient's wishes make sure you know their code and intubation status as sometimes they may be deteriorating and not able to respond so knowing their code status is definitely something important for you to know that said in some of these moments obviously the next of kin or the healthcare power of attorney at this point is going to be able to make those decisions for them and they certainly can reverse course on what the patient had previously stated if the patient's unable to speak for themselves so that said the real big and obvious contraindication is going to be if there is some sort of obstruction or injury that's going to prevent safely passing a tube into the trachea so this could be the result of trauma to the orofacial area or a foreign body that prevents safely intubating acute cervical spine fractures may also make this challenging but with a skilled practitioner it is still possible to intubate without actually manipulating the neck in a way that could cause more damage that said if we do have one of these situations in which we can't safely pass a tube into the trachea and they do have a need for the airway to be secured then a surgical airway such as a trach or a crike may be necessary at this point so while intubation is definitely considered to be our best airway management method that we have available to us there are potential complications that can come from its use now this technique really requires a good deal of clinical experience to truly master and even then with a skilled successful intubation complications can still arise the first and most obvious complication is going to be from a failed intubation so this is where the practitioner is unable to successfully place that endotracheal tube into their airway and this can be the result of many different things such as the patient's anatomy if there's edema obstruction trauma bleeding secretions if the patient is actively vomiting also the patient's lack of reserve needing a quick and successful attempt as well as even just the practitioner's skill they can all potentially have an effect on whether or not this is a successful intimation or not sometimes it can be difficult to view the airway properly or to actually advance that endotracheal tube past those vocal cords so this can lead to aborting the attempt and returning back to our bag valve masking of the patient even worse though sometimes the endotracheal tube can end up in the patient's esophagus and it's important to know that this is a medical emergency when this happens so in these cases our patients are not going to be ventilated and oxygenated immediately like in other aborted attempts so i'm going to discuss this more in the next lesson but in these cases it needs to be immediately removed and then intubation needs to be reattempted now the big concern with our failed intubation though is going to be that while we do pre-oxygenate the patient usually before attempting the intubation during the attempt we're not able to ventilate them and deliver oxygen thus this can lead to hypercapnia and potentially life-threatening hypoxia and cardiac arrest so this can make emergent intubations with patients who are already compromised and especially those who don't have much reserve extremely stressful and intense situations now another big concern during intubation is actually pulmonary aspiration so until that endotracheal tube is in place and that cuff is inflated there's gonna be a risk of aspiration into the lung now our common culprits here are going to be secretions blood and probably the biggest is going to be stomach contents and emesis so this can ultimately lead to pneumonia worsening respiratory failure for the patients and acute respiratory distress syndrome now we do have techniques such as rapid sequence intubation which i'll discuss in a future lesson to really help to minimize these risks but they certainly do happen now other complications can come about during the intubation itself such as the laryngospasm bleeding perforation of the trachea or esophagus fractured or dislodged teeth which can then become aspirated c-spine fractures damage to cartilage of the jaw or vocal cord damage and paralysis now in addition to those complications of the intubation itself as discussed in the previous endotracheal tube lesson our biggest concern is gonna be infection and pneumonia so the endotracheal tube provides a pathway for organisms to get into the lungs and ventilator acquired pneumonia or vap is a big concern for intubated patients so this can lead to additional complications longer intubation times longer icu and hospital stays as well as increased morbidity and mortality and you can think about this that by having this endotracheal tube in place we're really bypassing the normal respiratory defenses for preventing infection by having this tube in place there now also as mentioned in the last lesson we do have the risk of injury from the cuff itself if it's overly inflated or even potentially if the patient is intubated for an extended period of time extended periods of intubation can also lead to tracheal stenosis erosion and necrosis now being intubated also reduces the patient's cough effectiveness and their ability to properly clear secretions which it is important for us to be able to clear those for them especially when it comes to keeping that tube patent and then also last but not least this is just an uncomfortable thing for patients i mean if you think about it you've got this tube that's the size of your pinky or your ring finger that's going back in through the back of your mouth down into your windpipe i don't know about you guys but i've got a pretty decent gag reflex so having that in place definitely sounds like something that would be uncomfortable for me oftentimes we need to have the patients sedated in order to tolerate this tube as well as get their compliance with the ventilator but that also has its own potential consequences including delirium as well as at some point they do need to be awake in order to participate in our breathing trials and work to get them liberated or extubated this can be very uncomfortable and really potentially traumatizing for the patient so it's important to kind of understand that perspective now with all of this stuff mentioned really know that some complications can be acute in nature and others can have potentially long-term consequences as well as the potential for those fatal mistakes therefore it is really important that you are prepared have knowledge and experience in this process to help avoid any potential mistakes as well as to catch any issues that may come up along the way in fact in the next lesson i'm going to be talking more about the process of intubation itself as well as our part in that process so hopefully this lesson has given you a basic understanding of what intubation is some of those reasons on why we use it and some of the concerns that we're looking out for with its use in place so i hope that you guys found this information useful if you did please leave me a like on the video down below it really helps youtube know to show this video to other people out there as well as leave me a comment down below i love reading the comments that you guys leave and i try to respond to as many people as i can make sure you subscribe to this channel if you haven't already and a special shout out to the awesome youtube and patreon members out there the support that you're willing to show me and this channel is truly appreciated so thank you guys so very much if you'd be interested in showing additional support for this channel you can find links to both the youtube and patreon membership down below head on over there and check out some of the perks that you guys get for doing just that as well as check out some of the links to other nursing gear as well as some awesome t-shirt designs i have down there as well make sure you guys 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