Introduction

The indications and contraindications for endotracheal intubation are given in T.a.b.!e...1.. The contraindications are relative and must be weighed against the result of doing nothing at all. However, basic life support or hand ventilation with oral airway, face mask and rebreathing bag, and oxygen may be more beneficial than an inexperienced person attempting intubation or dealing with the consequences of a failed intubation.

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Table 1 Indications and contraindications for endotracheal intubation

Preparation of the patient is summarized in Tabj,§.2,.

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Table 2 Preparation of the patient

The patient should be examined as carefully as possible, and resuscitated with volume and inotropes as necessary to improve cardiovascular status. This is important as induction of anesthesia often leads to myocardial depression and hypotension, which are made worse if there is pre-existing volume depletion. While preparations are being made for intubation, the airway should be cleared, using artificial airways if necessary, and oxygenation optimized.

A brief assessment of the likelihood of a difficult intubation should be made so that either more experienced help can be summoned or appropriate equipment can be made available. Precautions against pulmonary aspiration of gastric contents should be taken by turning the unconscious patient into the lateral position, initially at least, and having an assistant apply cricoid pressure when anesthesia is induced. Insertion of a gastric sump tube prior to anesthesia is inappropriate.

The cervical spine should be protected by a hard collar, sandbags, or an assistant's hands if there is suspicion of injury or pre-existing disease such as rheumatoid arthritis.

The patient should be placed in the most appropriate position for intubation, preferably supine, with the head slightly elevated, flexing the cervical spine, and extended on the neck (Fig 1). The sitting position may be preferable in those who are too dyspneic to lie flat, or who are at major risk of gastric regurgitation (e.g.

achalasia of the esophagus), or to prevent contamination of normal lung by infected secretions (e.g. bronchopleural fistula). The lateral position should be used when there is bleeding in the upper airway or to prevent spread of infected pulmonary secretions, with the infected side downwards.

Fig. 1 (a) When the patient is lying supine with the neck and cervical spine in the neutral position, the angle between the line of the oral cavity and the laryngeal inlet is almost 90°. (b) When the cervical spine is flexed slightly, by providing a pillow, the angle is more obtuse. (c) With head extension they are almost in the same plane.

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