**3. Endotracheal intubation management**

After the administration of an induction agent and neuromuscular blocker with rapid effect and high potency to provide adequate mask ventilation, direct laryngoscopy and intubation are performed. Suxamethonium is often preferred because it provides fast and ideal intubation conditions. Non-depolarizing muscle relaxants such as rocuronium, atracurium, and vecuronium can also be used because they provide acceptable intubation conditions. An important point to consider is that if sufficient mask ventilation is provided, muscle relaxants can be given. Preoxygenation applied to patients gains time for intubation. Patients with a high-risk group (coronary artery disease, cerebral aneurysm) may be given additional pharmacological agents to provide hemodynamic stability. Different techniques, equipment, and agents can be used. Insertion of endotracheal tube into the trachea is essential. Anesthetic agents are not needed in patients under GCS 4 and with cardiac arrest [18, 25].

Generally, Macintosh and Miller blades are used for a direct laryngoscopy. The Macintosh blade is inserted into the gap called vallecula between the tongue base and the pharyngeal surface of the epiglottis. It provides a good passage for minimal epiglottic trauma and endotracheal tube. Miller blade extends to the laryngeal surface area of the epiglottis, making it easier to open the glottis but narrowing the oropharyngeal angle of view. There should be a certain distance between the operator's eye and the patient's airway. A close look at the patient will narrow the angle of vision. The laryngoscope's blade is moved from left to right in the airway by providing adequate mouth opening without damaging the lips and tongue. The blade should never be leaning on the upper jaw and upper incisors, and intubation should not be done by leaning on there. Pressing out of the cricoid cartilage is beneficial for better visualization of the glottis gap [4, 28].

The endotracheal intubation tube is held in the right hand and moved from the right of the patient's mouth toward the vocal cords. If there is a problem of routing the tube, it may be possible to orient the tube anteriorly using a probe. The cuff of the endotracheal tube is fixed after passing the vocal cords and is inflated with an air of 3–4 mL.

#### **3.1. Rapid sequence intubation (RSI) indications**

**a.** Equipment: intravenous (IV) catheter, laryngoscope, and blade, endotracheal tube in appropriate size, injector to inflate cuff, Magill forceps, nasal/oral airway, aspiration catheter,

**b.** Drugs: atropine, midazolam, lidocaine (1–4%), lidocaine gel, propofol, suxamethonium,

**c.** Patient history and airway evaluation: difficult airway assessment, risk of aspiration of

**e.** The oxygen source must be switched on and tied; the ambu, anesthesia device, and mechanical ventilator must be in working position, and its circuit must be plugged in.

**f.** Patient position: the use of a small cushion together with the head extension brings the oral, pharyngeal, and laryngeal axis to the same alignment. If cervical trauma is present,

Comparison of intubation performed under emergency conditions and intubation performed

Cases where the NIV is contraindicated (coma, postoperative agitation, delirium, noncooperative patients, patients with gastric distention risk) may be in the semi-urgent or urgent category [31, 32]. It is decided according to the deterioration of the clinical course of the patient

After the administration of an induction agent and neuromuscular blocker with rapid effect and high potency to provide adequate mask ventilation, direct laryngoscopy and intubation are performed. Suxamethonium is often preferred because it provides fast and ideal intubation conditions. Non-depolarizing muscle relaxants such as rocuronium, atracurium, and vecuronium can also be used because they provide acceptable intubation conditions. An

whose blood gas is followed and having spontaneous respiration.

**3. Endotracheal intubation management**

**Emergency Elective**

Difficult intubation may not be predictable. Predict airway difficulty.

There may be a risk of full stomach/aspiration. Safely perform the intubation.

the head is fixed in neutral position, and endotracheal intubation is performed.

There may not be enough time for preparation. Prepare equipment and assistants for intubation. It can be difficult to reach experienced personnel. Confirm availability of help in an emergency.

Patient status may not be stable. Patient is more stable than emergency situations.

tube changer, guide wire, nasogastric tube, tube fixation.

**d.** Aspiration catheter in various sizes should be kept ready.

gastric contents.

64 Tracheal Intubation

under elective conditions.

thiopental, non-depolarizing muscle relaxants, morphine/fentanyl.

Adequate time and equipment often may not be available for endotracheal intubation. In some cases, it may be decided to intubate very quickly. For example, in various clinical situations that threaten the patient's life, time loss is more dangerous than the risks associated with rapid sequence intubation. In general, rapid sequence intubation is applied in situations indicated below [15, 38]:


in the enclosed area, the carboxyhemoglobin (COHb) value of the patient at the time of admission to hospital, and the presence of coated phlegm are important. The accidents by oxygen therapy that is applied at home in diseases such as chronic obstructive pulmonary may cause inhalation damage, and it can be understood from the story of the patient [40]. Computed tomography (CT) is meaningful to understand the degree of inhalation damage and to see the anatomic changes, and it is valuable to calculate the V/Q (ventilation/ perfusion) ratio to evaluate the gas change [41]. Tracheobronchial protease inhibitors in plasma and alveolar fluid have also been investigated in this regard and are valuable in terms of understanding the degree of damage [42]. Although observing the degree of damage in the fiber optic bronchoscope is useful, previous studies have shown that it has no correlation with ARDS [43]. In conclusion, if the inhalational damage is at the upper level of the glottis, the physical findings are more important to decide on intubation (participation of auxiliary breathing muscles to respiration, audible respiratory sounds). But if there is a damage at the lower level of the glottis, it is necessary to assess the thickness of the bronchial wall (BWT) in the COHb level and computed tomography [44, 45]. In cases of shock, inadequate oxygenation, or coma, it is difficult to make an early intubation deci-

Indications for Endotracheal Intubation http://dx.doi.org/10.5772/intechopen.76172 67

sion because the intubation tube causes edema around the glottis [39].

and intubated under general anesthesia.

**IV.** Conditions requiring rapid sequence intubation (RSI):

tions are observed.

**b.** Ludwig's angina: it is an aggressive cellulitis that affects submandibular and sublingual tissue areas, placed on the mouth base and mylohyoid diaphragm as bilateral. Endotra-

**c.** Epiglottitis: it is a rare but life-threatening case. It is seen in children between 1 and 6 years of age. The cause is *Haemophilus influenzae* type B. Unlike viral croup, there is no cough or very few. Fever is very high and toxic appearance is present. The child sits still to open the airways, the mouth is open and secretions flow. There is a lack of appetite for food because it is difficult to swallow. Oral examination with tongue pushers is very dangerous and can lead to complete obstruction of the respiratory tract and death. Minutes are important even in this disease, and the patient should be taken to the intensive care unit immediately

**d.** Bacterial tracheitis: it is a rare but dangerous case. Clinically, it resembles heavy viral croup. However, there is a high fever and a toxic appearance. The cause is usually *Staphylococcus aureus* or *Haemophilus influenzae*. In tracheal intubation, dense and viscous secre-

**III.**In the case of chronic obstructive pulmonary disease, asthma, restrictive lung disease, tumors, granulomatous diseases, and pulmonary retention of systemic diseases, the patient

**a.** Patients with a full stomach: patients are accepted to be full in the case of feeding with clear liquids up to 4 hours before intubation and feeding with solid foods up to 8 hours. In cases where intra-abdominal pressure increases (pregnancy, ascites), gastrointestinal

may need to be intubated, decided as a result of the laboratory evaluation.

passages out of action (ileus) and the patient's story cannot be reached.

cheal intubation is required because it will be associated with respiratory distress.


#### **3.2. General overview of intubation indications**


in the enclosed area, the carboxyhemoglobin (COHb) value of the patient at the time of admission to hospital, and the presence of coated phlegm are important. The accidents by oxygen therapy that is applied at home in diseases such as chronic obstructive pulmonary may cause inhalation damage, and it can be understood from the story of the patient [40]. Computed tomography (CT) is meaningful to understand the degree of inhalation damage and to see the anatomic changes, and it is valuable to calculate the V/Q (ventilation/ perfusion) ratio to evaluate the gas change [41]. Tracheobronchial protease inhibitors in plasma and alveolar fluid have also been investigated in this regard and are valuable in terms of understanding the degree of damage [42]. Although observing the degree of damage in the fiber optic bronchoscope is useful, previous studies have shown that it has no correlation with ARDS [43]. In conclusion, if the inhalational damage is at the upper level of the glottis, the physical findings are more important to decide on intubation (participation of auxiliary breathing muscles to respiration, audible respiratory sounds). But if there is a damage at the lower level of the glottis, it is necessary to assess the thickness of the bronchial wall (BWT) in the COHb level and computed tomography [44, 45]. In cases of shock, inadequate oxygenation, or coma, it is difficult to make an early intubation decision because the intubation tube causes edema around the glottis [39].


**c.** Lack of intubation:

66 Tracheal Intubation

• Failure to protect the airway

for tests and procedures):

• Septic shock

**II.**Upper airway edema:

vere chronic obstructive pulmonary disease

• If the airway is not protected or intubation fails

who needs urgent computerized tomography

**3.2. General overview of intubation indications**

**I.** The presence of depressive mental disorders:

• Hematoma in the enlarged neck region

• Diffuse pulmonary edema, diffuse pneumonia, or emphysema

• Cerebral hemorrhages requiring close control of blood pressure

• Acute respiratory distress syndrome (ARDS), pulmonary embolism

• Cyanide toxicity, carbon monoxide, local anesthetic toxicity, methemoglobinemia

**e.** Expected clinical course or deterioration (e.g., need for status epilepticus control, except

• Patient with a life-threatening injury (such as a chest tube), or with a nonsurgical trauma,

• Loss of airway opening as a result of spinal fracture and edema in the cervical region

**a.** Patients with GCS 8 and lower head trauma, having indications for intubation:

**d.** For airway control within 24–48 hours following overdose drug intake

**b.** Associated with increased intracranial pressure, associated with surgical situation

**c.** In the presence of hypoxemia and hypercarbia, which increases morbidity and mortality

**a.** Inhalation damage: it is among the life-threatening conditions. The inhalation injury without skin burns has a mortality rate of around 10%; if the skin is burned, the mortality is doubled. Fluid resuscitation is needed and the risk of pneumonia is increased. There is an indication of early intubation because the upper airways are precarious [39]. This is because it is difficult to make a clinical decision about inhalation injury. The burn story

**d.** Failure of oxygenation (pulmonary shunt):

• Long-term breathing effort resulting in fatigue or failure in respiratory muscles, as in se-

**a.** Patients with a full stomach: patients are accepted to be full in the case of feeding with clear liquids up to 4 hours before intubation and feeding with solid foods up to 8 hours. In cases where intra-abdominal pressure increases (pregnancy, ascites), gastrointestinal passages out of action (ileus) and the patient's story cannot be reached.

**b.** Loss of sympathetic stimulation: rapid sequence intubation need may occur in cases where gastric emptying time is prolonged, as in gastric dilation and diabetic patients.

• Seizure

• Apnea.

• Diaphragm hernia.

paralysis.

• Cardiac disease

• Drug intoxication, poisoning

• Acute laryngospasm, epiglottitis, inspiratory stridor

Considering intubation for the newborn patient group to be difficult, it is also crucial to have full preparation; aspirator and ancillary equipment should be kept ready [55]. Intubation

Indications for Endotracheal Intubation http://dx.doi.org/10.5772/intechopen.76172 69

• Bradycardia (pulse below 100). The most important cause of bradycardia is hypoxia.

• Extended NIV. Respiratory distress syndrome: lack of surfactant and structurally lower gas

Rapid sequence intubation (RSI) is a method in which a number of neuromuscular blockers and sedative agents are used to make intubation safer, easier, faster, and less traumatic. It is a safe way for emergency service pediatricians experienced on the advanced airway manage-

RSI has 7 P rule (preparation, preoxygenation, premedication, paralysis with sedation, protection of the airway, passage of the tube and confirmation, and post-intubation management).

**1.** To eliminate protective airway reflexes and spontaneous respiration with sedation and

**2.** The most important determinant of the choice of sedative and paralytic agent is the response of the patient to the drug and the effects of the drug on the patient. Diseases such

**3.** Systematic preparation for the implementation of the method is necessary to make the

as asthma and tendency to hypotension should be questioned in particular.

**4.** Preoxygenation with 100% oxygen, two intravenous vascular access.

• In cases where tracheal aspiration is required (baby painted with meconium). • Inadequate positive-pressure ventilation applied through airway and mask.

• Need for application of chest pressure (cardiac arrest). Endotracheal drug intake.

*3.3.2. Indications of endotracheal intubation in newborns*

indications of a newborn can be classified as follows:

exchange area and excessive respiratory activity.

ment and sedative paralytic dosage [51].

intubation faster and safer.

*3.3.3. Rapid sequence intubation (RSI) protocol in pediatric patients*

The success of the method depends on the following criteria:

• Stubborn cyanosis. Premature babies can be intubated electively.


#### **3.3. Deciding on endotracheal intubation in pediatric patients**

Inadequate airway management can cause cessation of attempts to save lives and even cause cardiac arrest and death. Various airway equipments have been developed to provide adequate ventilation and oxygenation so far [46]. Although supraglottic airway devices developed for this purpose are available, they should be used cautiously because of the possibility of displacement, not suitability for patients with full stomach, and the possibility of increasing airway edema [33, 47]. If the patient is unable to breathe through the mask, oxygenation is inadequate, or in case of bleeding, edema or big foreign material in the upper airway, the patient should be intubated immediately [46, 48]. As in adult patients, the process of nasal preoxygenation with high flow provides the advantage of reducing inspiratory resistance, filling the nasopharyngeal dead area, reducing the metabolic work caused by gas exchange (conditioning), and supporting respiration through improving airway conductance and clearance. Lower levels of positive airway pressure are applied in children compared to adults. For newborns, 2 l/min is high-flow rate, whereas for older children, 4–6 lt/min is accepted as high [49].

#### *3.3.1. Indications of endotracheal intubation in pediatric patients*

If the child trauma patient is awaking, talking, or crying, being able to maintain breathing, he will be treated with supportive therapy as a conservative (oxygen supply with a facial mask or nasal cannula). If intubation is decided, the safest and most appropriate technique is applied according to the condition of the patient (traumatic injury, cord damage, the special anatomy of pediatric patients, and experience of the practitioner) [50]. Studies have shown that respiratory arrest is more likely in adults than in children and usually mediated by extrinsic factors [51]. The need for emergency intubation, number of recurrent interventions, tube diameter, and existing cardiovascular disease brings some complications such as desaturation, hypotension, and bradycardia. If we review intubation indications in general in children [50, 52–54]:


• Seizure

**b.** Loss of sympathetic stimulation: rapid sequence intubation need may occur in cases where

Inadequate airway management can cause cessation of attempts to save lives and even cause cardiac arrest and death. Various airway equipments have been developed to provide adequate ventilation and oxygenation so far [46]. Although supraglottic airway devices developed for this purpose are available, they should be used cautiously because of the possibility of displacement, not suitability for patients with full stomach, and the possibility of increasing airway edema [33, 47]. If the patient is unable to breathe through the mask, oxygenation is inadequate, or in case of bleeding, edema or big foreign material in the upper airway, the patient should be intubated immediately [46, 48]. As in adult patients, the process of nasal preoxygenation with high flow provides the advantage of reducing inspiratory resistance, filling the nasopharyngeal dead area, reducing the metabolic work caused by gas exchange (conditioning), and supporting respiration through improving airway conductance and clearance. Lower levels of positive airway pressure are applied in children compared to adults. For newborns, 2 l/min is high-flow rate, whereas for older children, 4–6 lt/min is accepted as high [49].

If the child trauma patient is awaking, talking, or crying, being able to maintain breathing, he will be treated with supportive therapy as a conservative (oxygen supply with a facial mask or nasal cannula). If intubation is decided, the safest and most appropriate technique is applied according to the condition of the patient (traumatic injury, cord damage, the special anatomy of pediatric patients, and experience of the practitioner) [50]. Studies have shown that respiratory arrest is more likely in adults than in children and usually mediated by extrinsic factors [51]. The need for emergency intubation, number of recurrent interventions, tube diameter, and existing cardiovascular disease brings some complications such as desaturation, hypotension, and bradycardia. If we review intubation indications in general in children [50, 52–54]:

gastric emptying time is prolonged, as in gastric dilation and diabetic patients.

**V.** Persistent hypotension that needs vasopressor support:

**3.3. Deciding on endotracheal intubation in pediatric patients**

*3.3.1. Indications of endotracheal intubation in pediatric patients*

• Cardiac dysfunction, hypovolemia, sepsis

**VI.** Organ failure:

68 Tracheal Intubation

• Renal failure, hepatic failure

• Traumatic brain injury • Hemorrhagic shock

• Respiratory failure due to pneumonia

• Foreign material in airways, upper airway obstruction

• Pulmonary secretion control, therapeutic hyperventilation

• Muscle and metabolic diseases

• Elective surgical procedure


#### *3.3.2. Indications of endotracheal intubation in newborns*

Considering intubation for the newborn patient group to be difficult, it is also crucial to have full preparation; aspirator and ancillary equipment should be kept ready [55]. Intubation indications of a newborn can be classified as follows:


#### *3.3.3. Rapid sequence intubation (RSI) protocol in pediatric patients*

Rapid sequence intubation (RSI) is a method in which a number of neuromuscular blockers and sedative agents are used to make intubation safer, easier, faster, and less traumatic. It is a safe way for emergency service pediatricians experienced on the advanced airway management and sedative paralytic dosage [51].

RSI has 7 P rule (preparation, preoxygenation, premedication, paralysis with sedation, protection of the airway, passage of the tube and confirmation, and post-intubation management).

The success of the method depends on the following criteria:


**5.** Atropine 0.02 mg/kg IV, lidocaine 1.0 mg/kg IV, etomidate 0.3 mg/kg IV, or thiopental 4.0 mg/kg IV.

which may cause hypotension, and the recommended dose is 1.5 mg/kg. The recommended dose of midazolam which has anxiolytic, sedative, and anticonvulsant properties is 0.3 mg/kg. It should not be forgotten that it may cause respiratory depression because it is slightly more than the sedation dose. It is cheap, is easy to access, and is a drug that clinicians are accus-

Indications for Endotracheal Intubation http://dx.doi.org/10.5772/intechopen.76172 71

After endotracheal intubation, pediatric patients should be treated with extra caution. A delicate balance should be established in drug selection, dosage adjustment, and mechanical ventilator settings. Children are at risk for acute hypoxemia; although dead-space ventilation is

Because preoxygenation is not sufficient during intubation, high-flow oxygen therapy with a nasal cannula, that is, apneic oxygenation, can enable us to pass the apneic period, without hypoxemia [49]. Intubation in one attempt, especially with video laryngoscopes, minimizes the risk of vagal stimulation due to hypoxemia, hypercarbia, and multiple attempts. Univariate analysis of studies has shown that the use of neuromuscular blockage for intuba-

Intensive care unit and emergency tracheal intubation cases of 3 years, involving 3366 pediatric patients, were investigated; it was observed that fentanyl (64%) and midazolam (58%) as induction agents and rocuronium (64%) and vecuronium (20%) as muscle relaxants had been used, and succinylcholine (0.7%) and etomidate (1.6%) had been less preferred. It was observed that vagolytic agents (51% of infants and 28% of babies over 1 year old) and ketamine (27%) had been preferred in unstability hemodynamic conditions (39%). However, it was found that

Intensive care patients may be intubated more difficult than those in the operating room. Previous studies have shown that saturations decrease faster in respiratory failure and they remain under the risk of hypoxemia. Intubation timing should be optimal to avoid desaturation. If patients with hypoxic respiratory failure have spontaneous breathing, it is important when to switch to invasive ventilation. On this subject, some of the criteria related to intensive

**1.** The presence of evidence for persistent or worsening respiratory failure: respiration at 40 F/min, situations in which respiratory and tracheal secretion increase, and acidosis (below pH 7.35), situations in which saturation does not exceed 90% for 5 minutes despite

**2.** Systolic blood pressure under 90 mmHg or mean arterial pressure less than 65 mmHg or

Preoxygenation is a common and time-saving approach to prevent desaturation in patients who are treated in intensive care unit when intubation is done. Special protocols have been

the use of ketamine was not associated with low prevalence of hypotension [63].

care patients with respiratory complaints were introduced in the study of Florali.

**3.4. Intubation indications in intensive care and rapid decision-making**

similar to adults, oxygen consumption is much higher [61].

tomed to [60].

tion reduces complications [62].

Criteria used in the study of Florali [9]:

oxygen therapy

the need for vasopressors

**3.** Deterioration of neurological condition and GCS under 12


In children, especially infants, vagal response to the laryngoscopy and tracheal intubation is much more than in adults [51]. Due to this medication, bradycardia and even an asystole in children who were given succinylcholine were reported in the literature [56].

A common recommendation from the American pediatric association is that rapid sequence intubation is done with atropine in the following situations [57]:


The use of atropine in rapid sequence intubation is still controversial. Following atropine, sinus tachycardia, mydriasis, xerostomia, a decrease in the amount of urine, and hyperthermia can be seen. In addition to the side effects, when used in premedication, salivation and secretion reduction effect is not fast, so it is important to be careful when using it and to determine its indications well. Atropine makes it difficult for the patient to be evaluated in terms of neurologic and cardiological aspects, and its effect on cardiac muscle may last for several hours. Since small doses have a bradycardia-initiating effect, the smallest dose should be at least 0.1 mg. The recommended dose is 0.02 mg/kg [58, 59]. Succinylcholine is contraindicated in children with muscular dystrophy because it forms the rhabdomyolysis and the hyperkalemia that threatens life. It should be avoided in patients with a risk of malignant hyperthermia, large body burn, multi-trauma, spinal cord injury, intracranial injury, brain tumors, and penetrating eye traumas. Rocuronium is an agent that offers better intubation than succinylcholine. The preferred dose is 1 mg/kg.

Etomidate is an imidazole derivative and acts as a well-known sedative agent. Its effect begins immediately, providing hemodynamic stable intubation. The effect on adrenal cortex and mechanisms of action of myoclonic jerk side effect in induction were investigated. Patients who have undergone a convulsion after etomidate have previously been reported to have convulsion story. The recommended dose is 0.3 mg/kg. Thiopental sodium, an ultrashort acting barbiturate, should be used with caution because of its known systolic blood pressurelowering effect, although anticonvulsive properties are preferred. Its dosage is 3–5 mg/kg, but not recommended for children. Ketamine is a sedative and hypnotic agent. It is favorable in terms of protecting the upper airway reflexes, but not recommended in cases where it will increase intracranial pressure. It has an anticonvulsive and a bronchodilator effect. The recommended dose is 1–2 mg/kg. Propofol may be preferred in children under 3 years of age, which may cause hypotension, and the recommended dose is 1.5 mg/kg. The recommended dose of midazolam which has anxiolytic, sedative, and anticonvulsant properties is 0.3 mg/kg. It should not be forgotten that it may cause respiratory depression because it is slightly more than the sedation dose. It is cheap, is easy to access, and is a drug that clinicians are accustomed to [60].

After endotracheal intubation, pediatric patients should be treated with extra caution. A delicate balance should be established in drug selection, dosage adjustment, and mechanical ventilator settings. Children are at risk for acute hypoxemia; although dead-space ventilation is similar to adults, oxygen consumption is much higher [61].

Because preoxygenation is not sufficient during intubation, high-flow oxygen therapy with a nasal cannula, that is, apneic oxygenation, can enable us to pass the apneic period, without hypoxemia [49]. Intubation in one attempt, especially with video laryngoscopes, minimizes the risk of vagal stimulation due to hypoxemia, hypercarbia, and multiple attempts. Univariate analysis of studies has shown that the use of neuromuscular blockage for intubation reduces complications [62].

Intensive care unit and emergency tracheal intubation cases of 3 years, involving 3366 pediatric patients, were investigated; it was observed that fentanyl (64%) and midazolam (58%) as induction agents and rocuronium (64%) and vecuronium (20%) as muscle relaxants had been used, and succinylcholine (0.7%) and etomidate (1.6%) had been less preferred. It was observed that vagolytic agents (51% of infants and 28% of babies over 1 year old) and ketamine (27%) had been preferred in unstability hemodynamic conditions (39%). However, it was found that the use of ketamine was not associated with low prevalence of hypotension [63].

#### **3.4. Intubation indications in intensive care and rapid decision-making**

Intensive care patients may be intubated more difficult than those in the operating room. Previous studies have shown that saturations decrease faster in respiratory failure and they remain under the risk of hypoxemia. Intubation timing should be optimal to avoid desaturation. If patients with hypoxic respiratory failure have spontaneous breathing, it is important when to switch to invasive ventilation. On this subject, some of the criteria related to intensive care patients with respiratory complaints were introduced in the study of Florali.

Criteria used in the study of Florali [9]:

**5.** Atropine 0.02 mg/kg IV, lidocaine 1.0 mg/kg IV, etomidate 0.3 mg/kg IV, or thiopental

**6.** Sellick's maneuver application: if Sellick's maneuver is performed while the patient is vomiting, there is a risk of esophageal perforation; therefore, the head should be placed

In children, especially infants, vagal response to the laryngoscopy and tracheal intubation is much more than in adults [51]. Due to this medication, bradycardia and even an asystole in

A common recommendation from the American pediatric association is that rapid sequence

The use of atropine in rapid sequence intubation is still controversial. Following atropine, sinus tachycardia, mydriasis, xerostomia, a decrease in the amount of urine, and hyperthermia can be seen. In addition to the side effects, when used in premedication, salivation and secretion reduction effect is not fast, so it is important to be careful when using it and to determine its indications well. Atropine makes it difficult for the patient to be evaluated in terms of neurologic and cardiological aspects, and its effect on cardiac muscle may last for several hours. Since small doses have a bradycardia-initiating effect, the smallest dose should be at least 0.1 mg. The recommended dose is 0.02 mg/kg [58, 59]. Succinylcholine is contraindicated in children with muscular dystrophy because it forms the rhabdomyolysis and the hyperkalemia that threatens life. It should be avoided in patients with a risk of malignant hyperthermia, large body burn, multi-trauma, spinal cord injury, intracranial injury, brain tumors, and penetrating eye traumas. Rocuronium is an agent that offers better intubation

Etomidate is an imidazole derivative and acts as a well-known sedative agent. Its effect begins immediately, providing hemodynamic stable intubation. The effect on adrenal cortex and mechanisms of action of myoclonic jerk side effect in induction were investigated. Patients who have undergone a convulsion after etomidate have previously been reported to have convulsion story. The recommended dose is 0.3 mg/kg. Thiopental sodium, an ultrashort acting barbiturate, should be used with caution because of its known systolic blood pressurelowering effect, although anticonvulsive properties are preferred. Its dosage is 3–5 mg/kg, but not recommended for children. Ketamine is a sedative and hypnotic agent. It is favorable in terms of protecting the upper airway reflexes, but not recommended in cases where it will increase intracranial pressure. It has an anticonvulsive and a bronchodilator effect. The recommended dose is 1–2 mg/kg. Propofol may be preferred in children under 3 years of age,

**7.** Succinylcholine 1.0 mg/kg IV or rocuronium 0.6–1.0 mg/kg IV.

intubation is done with atropine in the following situations [57]:

• Children under the age of 5 who are given succinylcholine

• Patients developing bradycardia during intubation

than succinylcholine. The preferred dose is 1 mg/kg.

children who were given succinylcholine were reported in the literature [56].

4.0 mg/kg IV.

70 Tracheal Intubation

down in case of vomiting.

**8.** Intubation after 1 minute.

• All children under 1 year old


Preoxygenation is a common and time-saving approach to prevent desaturation in patients who are treated in intensive care unit when intubation is done. Special protocols have been developed to standardize the treatment of preoxygenation. The number 10 scalar Montpellier protocol or its modified form, number 8 scalar, is used for preoxygenation [64]. Preoxygenation is known to be used in rapid sequence intubation.

Contraindications: it is contraindicated in such situations, upper airway obstruction, larynx

Indications for Endotracheal Intubation http://dx.doi.org/10.5772/intechopen.76172 73

The experienced practitioner, who can always detect incorrect intubation, and additional personnel facilitate airway management and may help us avoid complications. There is always a need of the presence of aspirator working at the bedside to prevent aspiration risk. Longacting muscle relaxants are not given in patients who cannot be ventilated with a mask. If the patient is hemodynamically unstable and the induction drugs cannot be applied, if the patient has a difficult airway history, and if severe airway obstruction is detected during examination

The author is grateful to Dr. İbrahim Tayfun Şahiner for his valuable contributions to the lan-

The author declares that there is not any conflict of interest and funding for this study.

Department of Anesthesiology and Reanimation, Erol Olcok Training and Research

Medicine. 1996;**14**(7):617-619. DOI: 10.1016/S0735-6757(96)90073-X

[1] Karch SB, Lewis T, Young S, Hales D, Ho CH. Field intubation of trauma patients: Complications, indications, and outcomes. The American Journal of Emergency

[2] Lockey D, Davies G, Coats T. Survival of trauma patients who have prehospital tracheal intubation without anaesthesia or muscle relaxants: Observational study. BMJ.

trauma, large thyroid gland, infection in the area of cricothyroid, and coagulopathy.

and/or laryngoscopy, awake intubation can be performed.

guage assessment and editing process of the study.

Address all correspondence to: yelizsahiner@gmail.com

Hospital, Hitit University School of Medicine, Corum, Turkey

**3.7. Additional conditions**

**Acknowledgements**

**Conflict of interest**

**Author details**

Yeliz Şahiner

**References**

2001;**323**(7305):141

Preoxygenation application routes:


#### **3.5. Indications of nasotracheal intubation**

Nasotracheal intubation is technically similar to intubation but difficult to administer. Firstly, a vasoconstrictor is dripped through an open nostril, and then the tube developed for nasal intubation is driven forward. While the tube Magill is seen in the oral cavity in the laryngoscope being directed toward the vocal cords with the help of Magill forceps, an assistant staff helps to drive the tube forward. Since the tube may curl and cause trauma to the nose, it is necessary to use the spiral tube and select the largest suitable tube diameter. Resistance in ventilation, nasal bleeding, pressure necrosis, and adenoid trauma may occur in the respiratory tract depending on the diameter of the selected tube. It is contraindicated in sinusitis, local abscesses, in cranial fractures, and in zygoma fractures.

It is indicated in maxillofacial and dental surgery and in cases where the jaw opening is limited. In the past, difficult intubation was called blind nasal intubation, but nowadays it is not preferred because there is the chance to reach video laryngoscopy, fiber optic intubation, lighted probes, and similar tools and equipment with the developing technology [65–68].

#### **3.6. Indications of retrograde intubation**

Retrograde intubation surgery is an alternative technique to cricothyroidotomy. Following preoxygenation, the cricothyroid area is given local anesthesia. Following the arrival of air from the injector entered with the Seldinger technique, the guide wire is moved through the needle and removed with Magill forceps from the mouth. The endotracheal tube is then driven over the wire. The wire is passed through Murphy's eye, and the guide wire is stretched while the tube is driven. The guide wire is drawn back after the procedure [69].

Indications: lack of glottic imaging due to secretion, vomiting or bleeding, and failure in conventional methods, in cases where intubation cannot be performed. Patients with a congenital anomaly, upper airway tumor, acute epiglottitis, severe kyphosis, cervical arthrosis, or trauma.

Contraindications: it is contraindicated in such situations, upper airway obstruction, larynx trauma, large thyroid gland, infection in the area of cricothyroid, and coagulopathy.

#### **3.7. Additional conditions**

developed to standardize the treatment of preoxygenation. The number 10 scalar Montpellier protocol or its modified form, number 8 scalar, is used for preoxygenation [64]. Preoxygenation

with a high-flow nasal cannula.

**d.** If rapid intravenous administration of 500 ml of fluids per hour is not clinically contraindicated, sedative, hypnotic agent and muscle relaxant medication are followed by intubation. Intubation made by two personnel who are skilled must be reviewed in terms of

Nasotracheal intubation is technically similar to intubation but difficult to administer. Firstly, a vasoconstrictor is dripped through an open nostril, and then the tube developed for nasal intubation is driven forward. While the tube Magill is seen in the oral cavity in the laryngoscope being directed toward the vocal cords with the help of Magill forceps, an assistant staff helps to drive the tube forward. Since the tube may curl and cause trauma to the nose, it is necessary to use the spiral tube and select the largest suitable tube diameter. Resistance in ventilation, nasal bleeding, pressure necrosis, and adenoid trauma may occur in the respiratory tract depending on the diameter of the selected tube. It is contraindicated in sinusitis,

It is indicated in maxillofacial and dental surgery and in cases where the jaw opening is limited. In the past, difficult intubation was called blind nasal intubation, but nowadays it is not preferred because there is the chance to reach video laryngoscopy, fiber optic intubation, lighted probes, and similar tools and equipment with the developing technology [65–68].

Retrograde intubation surgery is an alternative technique to cricothyroidotomy. Following preoxygenation, the cricothyroid area is given local anesthesia. Following the arrival of air from the injector entered with the Seldinger technique, the guide wire is moved through the needle and removed with Magill forceps from the mouth. The endotracheal tube is then driven over the wire. The wire is passed through Murphy's eye, and the guide wire is stretched while

Indications: lack of glottic imaging due to secretion, vomiting or bleeding, and failure in conventional methods, in cases where intubation cannot be performed. Patients with a congenital anomaly, upper airway tumor, acute epiglottitis, severe kyphosis, cervical arthrosis, or trauma.

the tube is driven. The guide wire is drawn back after the procedure [69].

with nasal intermittent positive-pressure ventilation.

) over 15 L/min, which permits

is known to be used in rapid sequence intubation.

O 100% O<sup>2</sup>

**3.5. Indications of nasotracheal intubation**

**3.6. Indications of retrograde intubation**

**c.** Applying non-rebreather mask (non-accumulating CO<sup>2</sup>

maximum oxygen flow, also known as flush flow rate.

RSI. Capnography is used for intubation verification [64].

local abscesses, in cranial fractures, and in zygoma fractures.

Preoxygenation application routes:

**a.** Using 10/5 cm H<sup>2</sup>

72 Tracheal Intubation

**b.** Using 40 L/min 100% O<sup>2</sup>

The experienced practitioner, who can always detect incorrect intubation, and additional personnel facilitate airway management and may help us avoid complications. There is always a need of the presence of aspirator working at the bedside to prevent aspiration risk. Longacting muscle relaxants are not given in patients who cannot be ventilated with a mask. If the patient is hemodynamically unstable and the induction drugs cannot be applied, if the patient has a difficult airway history, and if severe airway obstruction is detected during examination and/or laryngoscopy, awake intubation can be performed.
