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Endotracheal Tube

DEFINITION
An endotracheal tube is a flexible plastic tube that is placed through the mouth into the trachea (windpipe) to help a patient breathe. The endotracheal tube serves as an open passage through the upper airway. The process of inserting the tube is called endotracheal intubation.

PURPOSE
The purpose of endotracheal intubation is to permit air to pass freely to and from the lungs in order to ventilate the lungs. Endotracheal tubes is connected to a ventilator, which delivers oxygen to the lungs.There are many reasons why an endotracheal tube may be placed,this include;
- To support breathing for patient with respiratory distress
- General surgery
- To protect airway against aspiration 
- To visualize the airway
- Foreign body removal

PROCEDURE
Equipment needed
- Laryngoscopes 
- Endotracheal tube
- Lubricating gel
- Gum elastic
- Mechanical ventilator
- Anesthetic agents
- Ambubag
- Face mask
- Oxygen
- Plaster
- Syringe
- Stethoscope 

Intubation
During intubation, a physician usually stands at the head of the bed looking towards the patient's feet and with the patient lying flat. The positioning will vary depending on the setting and whether the procedure is being done with an adult or child. With children, a jaw thrust is often used.
 
The endotracheal tube with the assistance of a lighted laryngoscope  is inserted through the mouth after moving the tongue out of the way. The scope is then carefully threaded down between the vocal cords and into the lower trachea.
 
When it's thought that the endotracheal tube is in the proper location, the doctor will listen to the patient's lungs and upper abdomen to make sure that the endotracheal tube was not inadvertently inserted into the esophagus. Other signs that suggest the tube is in the proper position may include seeing chest movement with ventilation and fogging in the tube.
 
When a doctor is reasonably sure the tube is in position, a balloon cuff is inflated to keep the tube from moving out of place. (In infants, a balloon may not be needed). The tube is then taped to the patient's face and patient is connected to a mechanical ventilator.

AFTER PROCEDURE
After the endotracheal tube is in place and a patient connected to a ventilator, health care providers will continue to monitor the tubing, settings, and provide breathing treatments and suctioning as needed. Careful attention to oral care will also be provided. Due to the location of the tube, patients who are conscious will be unable to talk while the tube is in place.

COMPLICATIONS
- Bleeding from the mouth
- Infection 
- Temporary hoarseness after removing the tube
- Pneumothorax 
- Tracheal stenosis
- Vocal cord paralysis
- Tracheomalacia
- Persistent need for ventilatory support
- Atelectasis
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Horla

Arterial Blood Gas (ABG)

The arterial blood gas (ABG) measures the acid-base balance (pH) and oxygenation of an arterial blood sample. An ABG can be used to assess respiratory compromise, status peri- or post-cardiopulmonary arrest, and medical conditions that cause metabolic abnormalities (such as sepsis, diabetic ketoacidosis, renal failure, toxic substance ingestion, drug overdose, trauma or burns). An ABG can also be used to evaluate the effectiveness of oxygen therapy, ventilatory support, fluid and electrolyte replacement.

CLINICAL SIGNIFICANCE 
pH
7.35-7.45
The pH tells you if your patient is acidotic or alkalotic. It is a measurement of the acid content or hydrogen ions [H+] in the blood. Low pH indicates a higher concentration of hydrogen ions (acidosis) while a high pH indicates a lower concentration of hydrogen ions (alkalosis).

PaCO2
35-45 mm Hg
The PaCO2 level is the respiratory component of the ABG. It is a measurement of carbon dioxide (CO2) in the blood and is affected by CO2 removal in the lungs. A higher PaCO2 level indicates acidosis while a lower PaCO2 level indicates alkalosis.

HCO3-
22-26 mEq/L
The HCO3- level is the metabolic component of the ABG. It is a measurement of the bicarbonate content of the blood and is affected by renal production of bicarbonate. A lower HCO3- level indicates acidosis while a higher HCO3- level indicates alkalosis.

PaO2
80-100 mm Hg
The PaO2 level is a measurement of the amount of oxygen dissolved in the blood. A PaO2 level less than 60% results in tissue hypoxia.

SaO2
95-100%
SaO2, or oxygen saturation, refers to the number of hemoglobin binding sites that have oxygen attached to them. How easily oxygen attaches to hemoglobin can be affected by body temperature, pH, 2,3- diphosphoglycerate levels, and CO2 levels.

ABG ANALYSIS
Steps
Clinical significance
Step 1: Analyze the pH
pH < 7.35 = acidosis pH > 7.45 = alkalosis
Determine if the pH is within the normal range, or reflects acidosis or alkalosis.

Step 2: Analyze the PaCO2
PaCO2 > 45 = acidosis PaCO2 < 35 = alkalosis
Carbon dioxide is produced in the tissues of the body and eliminated in the lungs. Changes in the PaCO2 level reflect lung function.

Step 3: Analyze the HCO3-
HCO3- < 22 = acidosis HCO3- > 26 = alkalosis
Bicarbonate is produced by the kidneys. Changes in the HCO3- level reflect metabolic function of the kidneys.

Step 4: Match the PaCO2 or HCO3- with pH
If pH < 7.35 and PaCO2 > 45 and HCO3- level is normal, the patient has
respiratory acidosis.
If pH < 7.35 and HCO3- < 22 and PaCO2 level is normal, the patient has
metabolic acidosis.
If pH > 7.45 and PaCO2 < 35 and the HCO3- level is normal, the patient has respiratory alkalosis.
If pH is > 7.45 and HCO3- > 26 and the PaCO2 level is normal, the patient has metabolic alkalosis.

Step 5: Assess for compensation by determining whether the PaCO2 or the HCO3- go in the opposite direction of the pH
When a patient has an acid-base imbalance, the respiratory and metabolic systems try to correct the imbalances the other system has produced.

If pH 7.35-7.40, PaCO2 > 45, and HCO3- > 26, the patient has
compensated respiratory acidosis.
If pH 7.35-7.40, PaCO2