Thacheal ion and Bronchial Intubation

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    Tracheal intubation

    and

    bronchial intubation

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    DefinitionDefinition

    Endotracheal intubationis inserting a

    special tube into the trachea through

    oral or nares via laryngeal.If this special tube is inserted into

    the bronchus ,we call itendobronchial

    intubation.

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    ApplicationsApplications

    General anesthesia

    Treatment of airway obstruction, difficult

    respiration

    Cardiopulmonary cerebral resuscitation

    Treatment of severe acute emptysis

    Examination of pulmonary function

    Pulmonary toilet

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    Intubation can be performed with

    the patient awake (local anaesthesia)or under general anaesthesia.

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    Section 1

    Preanesthesia Preparation and Anesthesia

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    1.Physical Examination and Evaluation of

    the Airway

    Neck mobility

    The atlanto-occipital joint and cervical spine mobility particularly with

    extension

    It is related to aligning the oral,pharyngeal, and laryngeal axes

    .

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    Normal head extension: 165-90 degrees

    Head extension 80 degrees:representing increasing limitation and

    increased potential fordifficult laryngoscopy

    Diseases: cervical spine rheumatoidarthritis or tuberculosis with atlantoaxial

    subluxation

    , cervical spine fracture,

    severe cervical spondylosis , morbid obesity, burn and so on.

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    The thyromental distance From the inner surface of the mandible to

    the thyroid cartilage during neck extension

    Normal:3-4 cm (two large fingerbreadths)

    in adults. 3cm: exposure

    of the glottis

    may be

    inadequate.

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    Mouth openingNormal: 4-5 cm (about two large

    fingerbreadths)

    2.5 cm: difficult laryngoscopy

    Diseases: temporomandibular jointankylosis , arthritis,

    burn, trauma, radiation, transtemporalcraniotomy , large

    tongue.

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    Teeth Dentures

    Loose teeth

    EdentiaProtuberant upper incisors

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    Mallampati classes

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    Nose: nasal obstruction, nasal trauma, epistaxis and nasopharyngeal

    surgery

    Pharynx: inflammatory masses such as tonsillarhyperplasia, retropharyngeal abscess

    Larynx: laryngitis, laryngeal stenosis

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    Trachea:tracheal stenosisresulted from:

    the extrinsic airway compressionof

    cervical mass, thyromegaly and aorta aneurysm

    tracheal trauma

    tracheotomy

    luminal tumors

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    2. Equipment of endotracheal intubation

    Endotracheal Tubes

    Material: rubber, plastic

    or polyvinylchloride

    Demand: The tube is freeof toxic, irritant or allergenic

    properties. The tube wall

    should be smooth and as thin

    as possible.

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    Types Internal diameter (ID) size: It reflects theinternal diameter of the tube. Tubes are

    manufactured in 0.5 mm ID increments from

    2.0 to 9.0 mm.French size: It reflects the circumference

    of the tube, it is the product of external

    diameter and , and is therefore higher for

    thicker-walled tubes than for thinner-walledtubes with the same ID.

    F size ID size4 2

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    Choice of endotracheal tube sizes Adults adult males 8.0 mm ID

    adult females 7.0 mm ID

    Given the variation between individuals, atube of 1 mm ID sizesmallerorlargermay be

    available for an individual patient.

    nasal intubation 7.0 7.5mm ID

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    Children:

    formula: age 18 (French size)orage/4 4.5 (ID size)

    Variation between individuals requires the

    availability of 0.5 mm ID smallerand largertube

    sizes. Uncuffed endotracheal tubes have generally

    been used in children younger than 5 years old.

    If there is a suspicion of laryngeal or tracheal

    disease in any age group, smaller tubes should be

    available.

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    Distance of insertion adult males about23 cmat the lips,

    with thetube tipto be placed in themid-

    trachea and an appropriate4 cmabove the

    carina.

    adult females about21 cm

    children can be estimated from the

    formula:12 + (age/2).

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    CuffFunction to protect the airway from aspiration

    and air leak on positive-pressure inspiration.

    Types and characteristicslow-volume, high-pressure cuffs

    high-volume, low-pressure cuffs

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    Laryngoscope

    Configuration and classificationlaryngoscope handle

    laryngoscope blade: straight blade

    curved blade

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    Advantages and disadvantages of both

    laryngoscopes

    LaryngoscopeMove tongue and epiglottis

    Allows visualization of cords and glottisMiller- straight

    --Lift epiglottis

    --pediatrics

    Macintosh- curved--Fits in vallecula

    --More room for visualization

    --Reduced trauma/ gag reflex

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    Fiberoptic bronchoscope

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    Other equipment for endtracheal intubation

    Connector

    Stylet:It is a rigid implement usually made of

    a flexible metal or rubber.

    Forceps: Magill forceps and Rovenstine forceps

    Bite block

    Sprayer

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    Preparation before endotracheal intubation

    endotracheal tubes

    laryngoscopeother essential items stylet, bite block, oxygen

    source, bag and mask, airway, lubricant, tape, reliable

    suction, anesthetic and monitoring apparatus.

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    3. Anesthesia for endotracheal intubation

    Anesthesia induction rapid-sequence induction

    intravenous induction and intubation:

    rapidly acting intravenous induction agents

    and rapidly acting muscle relaxant inhalational induction and intubation

    Indications:Patients are not likely to

    present difficult intubation.

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    Local anesthesia

    Indications:difficult intubation, severe risk forairway obstruction or aspiration.

    Topical anesthesia(Surface anesthesia)

    The superior laryngeal nerve (SLN) blocking

    Transtracheal anesthesia

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    Local anesthesia combines general anesthesia

    Indication:difficult intubation patients who

    have the ability to maintain mask ventilation.

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    Section 2 Endotracheal Intubation

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    Classification

    On the base ofintubating path:

    oral endotracheal intubation

    nasal endotracheal intubationOn the base ofglottis visulization:

    visualized intubation

    blind intubation

    Routes for Intubation

    Orotracheal

    Nasotracheal

    Tracheotomy

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    1.Indications and Advantages

    Indications

    General anesthesia

    Respiratory treatmentCardiopulmonary resuscitation

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    AdvantagesControls the airwayFacilitates ventilation/ O2

    Prevents gastric inflationAllows for direct suctioningMedication administration

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    Contraindications

    absolute contraindications:

    laryngeal edema

    acute airway inflammation

    relative contraindications:

    tracheal compression of aorta aneurysm

    coagulopathy or other severe bleeding

    diathesis

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    2. Visualized oral endotracheal intubationIn

    Mask ventilation

    Head position for visualized

    oral endotracheal intubation

    Laryngoscope insertion

    Endotracheal tube was insertedinto the glottis

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    Advantages of Oral IntubationAdvantages of Oral Intubation

    Larger tube can be insertedTube can be inserted usually with more

    speed and ease with less traumaEasier suctioningLess airflow resistanceReduced risk of tube kinking

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    Disadvantages of Oral Intubation

    Gagging, coughing, salivation, and

    irritation can be induced with intact airway

    reflexes

    Tube fixation is difficult, self-extubationGastric distention from frequent

    swallowing of airMucosal irritation and ulcerations of mouth

    (change tube position)

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    3. Nasal endotracheal intubation

    Indications:surgery in the oral cavity anatomic distortion or upper airway

    diseases which limit direct laryngoscopy long time mechanical ventilation postoperation difficult airway situations

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    Contraindications

    coagulopathy or other severe bleeding diathesis severe intranasal disorder

    basilar skull fracture cerebrospinal fluid leak

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    Classfication

    Visualized nasal intubation

    Blind nasal intubation

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    Advantages of Nasal Intubation

    More comfort long termDecreased gaggingLess salivation, easier to swallow

    Improved mouth careBetter tube fixationImproved communication

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    Disadvantages of Nasal Intub..

    Pain and discomfortNasal and paranasal complications, I.e.,

    epistaxis, sinusitis, otitis

    More difficult procedureSmaller tube neededIncreased airflow resistanceDifficult suctioning

    Bacteremia

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    4. Intubation of difficult airway

    Fiberoptic bronchoscope intubation

    Anterograde endotracheal intubation

    Retrograde endotracheal intubation

    5. Tube exchanging

    (4)Laryngeal mask airway

    (5)Esophageal-Tracheal Combitube

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    6. Tracheotomy

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    DisplacementTracheal tubes can be displaced after correctinsertion. This is particularly likely when the patient

    is moved or the position changed. Flexion or

    extension of the head, or lateral neck movement, hasbeen shown to cause movement of the tube of up to 5

    cm within the trachea. Tracheal tubes should be fixed

    securely to minimise accidental extubation and the

    correct positioning should be checked regularly.

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    C fi ti f t h l i t b ti

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    Confirmation of tracheal intubation

    Clinical signs used to confirm tracheal intubatio

    Direct visualisation of tracheal tube through vocal cords

    Palpation of tube movement within the trachea

    Chest movements

    Breath sounds

    Reservoir bag compliance and refill

    Condensation of water vapour on clear tracheal tubes

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    Section 3 Endobronchial Intubation

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    1.Indications Advantages and DisadvantagesIndications

    wet lung patients: severe emptysis

    pulmonary abscess

    bronchodilatationbronchopleural fistula

    tracheoesophageal fistula

    traumatic fraction of bronchus

    tracheoplasty or bronchoplasty

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    AdvantagesPrevent contamination or spillage:

    infection ,hemorrage ,brochopulmonary lavageControl of the distribution of ventilation:

    bronchopleural fistulaEnhance surgical exposure: pneumonectomy

    Disadvantages

    right-to left intrapulmonary shunt :arterial hypoxemia

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    2. Double-lumen endobronchial intubation

    Types Carlens double-lumen endobronchial tubes

    White double-lumen endobronchial tubes

    Robertshaw double-lumen endobronchial tubes

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    Section 4 Extubation

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    Liberating from ETT

    Obtain weaning parameters:

    NIF (Negative inspiratory force) > -20 cmH2O

    VC >10-15 mL/kg

    Ve < 12 lpm

    RR >10 or 5mL/kg IBW

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    Extubation ProcedureExtubation Procedure

    Assemble Equipment

    - intubation equipment

    - in addition to intubation

    equipment, O2 device

    and humidity, SVN (small-

    volume nebulizer with

    racemic epinephrineSuction ET tubeOxygenate patientUnsecure tube, deflate cuff

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    Extubation proced. (contd.)Extubation proced. (contd.)

    Place suction catheter down tube and

    remove ET tube as you suction

    Apply appropriate O2 and humidityAssess/Reassess the patient

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    Section 5 Complications of Endotracheal

    and Endobronchial Intubation

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    Complications during larngoscopy and intuation

    1. Teeth and soft tissue injury1. Teeth and soft tissue injury

    Causes The laryngoscope is used improperly.

    Laryngoscopy is particularly difficult.

    There is dental/periodontal disease.

    C li i d i l d i iC li ti d i l d i t ti

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    Complications during larngoscopy and intuationComplications during larngoscopy and intuation

    2. Hypertension and arrhythmiaCause Stress reaction to laryngoscopy and

    intubationplasm catecholamine increase

    Prevention

    Maintaining adequate anesthetic depthAdministration of appropriate fentanyl,

    lidocaine, nitroglycerin or esmolol intravenously

    before laryngoscopy

    Sufficient topical anesthesia with lidocaine

    Preoxygenate and adequately ventilate the patient

    to prevent hypoxemia and hypercarbia

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    Complications during larngoscopy and intuation

    3. Esophageal intubation

    Causes

    Difficult intubation

    Improper manipulationInexperienced practitioner

    Diagnosis

    Absence of bilateral breath sounds, chest

    movement, epigastric auscultationReservoir bag not filling during expiration

    Routine monitoring of end-tidal CO2

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    Complications while the tube is in place

    1.1. Endotracheal tube obstructiontube obstruction

    Clot, mucus

    kinking

    2. Inadvertent extubation

    bevel against tracheal wall

    3. Inadvertent Endobronchial intubation

    C li ti hil th t b i i l

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    Complications while the tube is in place

    4. BuckingCauses

    Laryngoscopy is performed under

    inadequate anesthesia or without the use of muscle

    relaxantPrevention

    Maintenance of adequate anesthetic depth

    Adequate muscle relaxant

    Administration of appropriate fentanyl, lidocaineintravenously before laryngoscopy

    C li ti hil th t b i i l

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    Complications while the tube is in place

    5. Bronchospasm

    CausesLaryngoscopy is performed under inadequate anesthesia

    Aspiration

    Treatment

    Stop irritate ion at once

    Deepening anesthesia with intravenous or inhaled

    agents

    Administration of aminophylline, steroid, and ketamine

    intravenously

    Administration of inhaled or IV2-agonists, lidocaine

    Pulmonary toilet

    Immediate and delayed complications

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    Immediate and delayed complications

    after extubation

    1.Laryngospasm

    2.Aspiration and foreign body obstraction

    Patients with a full stomachTongue falling back to retropharyngeal wall

    3.Tracheal Collapse

    4. Pharyngitis, Laryngitis

    Immediate and delayed complications

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    Immediate and delayed complications

    after extubation

    5. Laryngeal edema, Subglottic edema

    6. Vocal cord paralysis

    7. Arytenoid cartilage dislocation

    8. Maxillary sinusitis

    9. Pneumonia

    10. Tracheal stenosis

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    Section 6 Application of Laryngeal Mask Airway

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    Outline: The laryngeal mask airway (LMA) is aningenious supraglottic airway device that is designed

    to provide and maintain a seal around the laryngeal

    inlet for spontaneous ventilation and allow controlledventilation at modest levels (up to 15 cmH2O) of

    positive pressure. The overall role of the LMA in

    clinical anesthesia would appear to be somewhat

    between that of the face mask and that of the

    endotracheal tube.

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    1.Configuration

    Airway mask

    Airway tube

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    LMA is currently available in seven sizes for

    neonates, infants, young children, older children,

    and small, normal, and large adults.

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    2.Method of use

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    3.Advantages and indications

    Be used as a substitute for the classic

    mask airway to eliminate the presence of a

    relatively large mask and practitioners

    hand that may interfere with surgical

    access.

    To establish an emergency airway in

    awkward settings for intubation such as thelateral or prone positions.

    3 Ad d i di i

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    3.Advantages and indications

    Be employed to establish an airway inthe patient in whom either mask ventilation

    or tracheal intubation is difficult.

    Be used toprovide a conduit to facilitate

    fiberoptic, gum bougie-guided or blind oral

    tracheal intubation.

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    4.Disadvantages and contraindications

    Pulmonary aspiration, laryngospasm, soft tissue injury.Need forneck extensionin the patient with cervical

    spine disorder.Failure to function properly in the presence oflocal

    pharyngeal orlaryngeal disease.In patients withdiminished pulmonary compliance or

    increased airway resistance, adequate ventilation may

    not be possible because of the high inflation pressures

    required and the resultant leaks.

    Contraindicatedin any of the conditions associatedwith an increased risk forregurgitation and aspiration.

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    Thank You