Troubleshooting Endotracheal Intubation:

Navigating Challenges for Optimal Airway Management.

Endotracheal tube intubation plays a vital role in securing a patient's airway during anesthesia and critical care procedures. However, even with a clear view of the larynx, anaesthetists can encounter obstacles that hinder the smooth passage of the tube. In this guide, we explore the common challenges faced during endotracheal tube intubation and provide practical troubleshooting strategies to overcome them. From optimizing patient positioning to addressing complications like oesophageal or endobronchial intubation, understanding and resolving these issues are crucial for ensuring successful airway management and patient safety. Join us as we delve into the world of troubleshooting endotracheal tube intubation, equipping anaesthetists with the knowledge and techniques to navigate challenges with confidence and expertise.

Problems encountered during endotracheal intubation:
1. Inadequate view of larynx and vocal cords:
It is not uncommon for the anaesthetist to achieve a good view of the larynx, yet have difficulty in passing the tube between the vocal cords.
1. Always check that the patient is in the optimal position.
2. Passage of the tube can be facilitated if an assistant retracts the right side of the mouth laterally and the tube has an optimal shape (consider a stylet).
3. You can perform external laryngeal manipulation (ELM) with your right hand and then ask your assistant to replicate this to improve the laryngeal view. Some refer to this manoeuvre as BURP (backwards, upwards, rightwards pressure). ELM should also be applied when a suboptimal view of the larynx is obtained at laryngoscopy.
4. Good views on a Macintosh videolaryngoscope screen and difficulty passing a tube can be a sign of poor laryngoscopy technique. Focusing on optimising the direct view first, prior to looking at the screen, should ensure optimal technique.
2. Oesophageal intubation:
1. Signs of oesophageal intubation include:
1. Capnography: absent or decaying trace – THIS IS CRUCIAL
2. Progressive hypoxia (may take 3 minutes or more for onset)
3. Abnormal sounds heard in axillae or epigastrium.
2. Action plan:
1. Remove ETT (If in doubt, pull it out)
2. Default to bag and mask ventilation (+/– adjunct)
3. Administer 100 % oxygen
4. Call for senior help
3. Endobronchial intubation.
Occurs when the ETT is advanced too far, entering one of the main bronchi (most commonly the right). The best way to avoid endobronchial intubation is to insert the ETT to the correct distance in the first place, and then ensure it does not move while it is being secured.
1. Signs of bronchial intubation:
1. Uneven chest expansion
2. Reduced breath sounds unilaterally (can be subtle)
3. High airway pressures
4. Desaturation to around 85–88% (may take several minutes).
2. Action Plan:
1. Administer 100 % oxygen
2. Observe the chest and auscultate both axillae
3. Deflate the cuff and withdraw the ETT carefully until breath sounds are heard bilaterally
4. ensure adequate re-expansion of non-ventilated lung – patient may require hand ventilation, continuous positive airway pressure (CPAP) or positive-end expiratory pressure (PEEP).