Thacheal ion and Bronchial Intubation

8/14/2019 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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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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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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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



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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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Thacheal ion and Bronchial Intubation