Indications

Contraindications

Equipment

See Figure 213-1.

Figure 213-1 Suggested intubation equipment.

Cricoid Pressure (Sellick Maneuver)

Providing or performing cricoid pressure may help protect against regurgitation of gastric contents; it also increases visibility by moving the trachea into the visual field of the person intubating. To perform cricoid pressure (Sellick maneuver), first find the thyroid cartilage (Adam’s apple), and then the small indentation beneath it (cricothyroid membrane). The cartilage beneath this small indentation is the cricoid bone. Cricoid pressure is performed by pinching the extended thumb, index, and middle finger together into a double “V,” or tripod. This is then placed on the cricoid bone and pressed down with enough pressure to occlude the esophagus (Fig. 213-2). The pressure should be applied toward the patient’s back and the head somewhat. Cricoid pressure should not be released until intubation is completed and confirmed and the cuff inflated.

Figure 213-2 Sellick maneuver. Either the practitioner or assistant uses the thumb and index and middle fingers pinched into a double “V” or tripod. Posterior pressure is then applied to the cricoid to avoid aspiration and bring the larynx into view. Note the upward and forward direction of forces applied in a nonfulcrum manner by the laryngoscope.

note: The effectiveness of the Sellick maneuver has been questioned. Because of the wide variation in pressure applied by operators, cricoid pressure should be removed if there is difficulty in visualizing the airway.

Airway Assessment

Begin with the patient on 100% nonrebreather mask if spontaneously breathing. The jaw thrust maneuver can be used to keep the airway open (Fig. 213-3), or begin bag-valve-mask breathing with a second assistant providing cricoid pressure (Sellick maneuver). The practitioner should be familiar with the anatomic landmarks (Fig. 213-4). Many airway management failures can be traced to lack of airway assessment. Patients can be classified into three groups (shades) based on two criteria: anticipated difficulty in intubation and ability to maintain oxygen saturation greater than 90% by bag-valve-mask ventilation. Airway assessment is critical. An experienced person can assess an airway in less than 4 seconds, and an inexperienced person should be able to do so in less than 8 seconds.

Figure 213-3 Jaw thrust. Rotate mandible forward with index fingers. Arrow indicates motion to bring soft tissues forward to relieve airway obstruction.

Figure 213-4 Anatomic landmarks of the head and neck.

The mnemonic for assessing difficulty in intubation is 332-NUTS:

Meeting all these criteria indicates a low-risk intubation; conversely, the fewer the criteria present, the higher the risk. Although the last two categories, tension pneumothorax and “soup,” do not strictly determine the anatomic difficulty of intubation, establishing their absence is a vital part of early airway assessment. The Mallampati system has previously been used to assess the uvular portion of the mnemonic; however, it is important to note that this classification was designed to assess a patient sitting upright with voluntary mouth opening—a condition rarely encountered in clinical practice outside anesthesiology. A simpler method is to open the mouth with the thumb while standing to either side of the patient’s head. (Standing at the head of the patient changes the angle of view, and may produce a false result). If any portion of the uvula can be seen, then intubation will likely be unimpeded by this factor. The three risk groups (shades) are as follows:

Standard Orotracheal Intubation

Technique

The cricoid pressure technician should initiate cricoid pressure using the Sellick maneuver as soon as the respiratory therapist begins bagging. This will reduce stomach insufflation and the risk for vomiting. The cricoid pressure technician also watches the oxygen saturation of the patient and announces saturations below 90% to the practitioner. In addition, this technician holds the endotracheal tube and passes it to the practitioner so the practitioner can focus uninterrupted on the intubating view.

“Tilt” or position of the patient and the practitioner is often overlooked, but this is probably the most critical component of successful intubation. If the patient is not suspected of having neck problems that could be worsened by movement, place the patient in the “sniffing” position with the neck flexed and the head extended backward (Fig. 213-5). The neck may be flexed by raising the head several inches using a folded towel or firm pillow. It is important to remember that the padding should be placed under the head and not between the shoulders (see Fig. 213-4).

Figure 213-5 Proper head position is important for successful endotracheal intubation. Axes of the mouth, pharynx, and larynx need to be aligned. A, Divergent axes. B, Axes in line, or “sniffing position.”

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