Reanimación Neonatal: lección 5 INTUBACION ENDOTRAQUEAL

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Curso de Reanimación neonatal, lección 5 de 9.
Lección 5: INTUBACION ENDOTRAQUEAL
American Heart Association. American Academy of Pediatrics.

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  • In Lesson 5 you will learn
    The indications for endotracheal intubation during resuscitation
    How to select and prepare the appropriate equipment needed for endotracheal intubation
    How to use the laryngoscope to insert an endotracheal tube
    How to determine if the endotracheal tube is in the trachea
    How to use the endotracheal tube to suction meconium from the trachea
    How to use the endotracheal tube to administer positive-pressure ventilation
  • Endotracheal intubation may be performed at various points during resuscitation as indicated by the asterisk (*) in the flow diagram.
  • A person experienced in endotracheal intubation should be immediately available to assist at every delivery. Endotracheal intubation may be performed at various points during resuscitation as indicated by the asterisk (*) in the flow diagram. The timing of intubation will be determined by many factors, one of which is the skill of the people performing resuscitation. People who are not adept at intubation should call for help and focus on providing effective mask ventilation, rather than wasting valuable time trying to intubate too early.
  • Masks that fit over the laryngeal inlet have been shown to be an effective alternative for assisting ventilation when positive-pressure ventilation by bag and mask or mask and T-piece resuscitator is ineffective and attempts at intubation are not feasible or are unsuccessful. However, there are limited data about the use of laryngeal mask airways for neonatal resuscitation. Use of the laryngeal mask airway is covered in the Appendix to this lesson.
  • Each delivery room, nursery, and emergency department should have a complete set of the following items kept together and readily available:
    Laryngoscope with an extra set of batteries and extra bulbs.
    Blades: No. 1 (term newborns), No. 0 (preterm newborns); straight rather than curved blades are preferred.
    Endotracheal tubes with inside diameters of 2.5, 3.0, 3.5, and 4.0 mm (not tapered).
    Stylet (optional).
    Carbon dioxide (CO2) monitor or detector (a new recommendation).
    Suction setup with 10F or larger suction catheter, plus sizes 5F or 6F and 8F for suctioning the endotracheal tube.
    Roll of tape, ½ or ¾ inch, or endotracheal tube securing device.
    Scissors.
    Oral airway.
    Meconium aspirator.
    Stethoscope (neonatal head preferred).
    Positive-pressure device, pressure gauge (optional for self-inflating bags), and oxygen tubing. Self-inflating bag must have oxygen reservoir.
  • Sterile disposable endotracheal tubes should be used and handled with clean technique. They should be of uniform diameter throughout the length of the tube and not tapered near the tip. Cuffs are not recommended with endotracheal tubes for newborns.
    Most endotracheal tubes for newborns have a black line near the tip of the tube, which is called a vocal cord guide. Such tubes are meant to be inserted so that the vocal cord guide is placed at the level of the vocal cords.
    The length of the trachea in a premature newborn is less than that of a term newborn (3 cm vs 5-6 cm). Therefore, the smaller the tube, the closer the vocal cord guide is to the tip of the tube.
    Centimeter markings along the tube help to identify the appropriate depth of insertion.
    Many endotracheal tubes are much longer than the length necessary for orotracheal use. The extra length will increase resistance to airflow. Shortening the endotracheal tube to 13 to 15 cm makes it easier to handle during intubation and lessens the chance of inserting the tube too far. Remove the connector from the distal end of the tube, and cut the tube diagonally to make it easier to reinsert the connector. Replace the endotracheal tube connector. The fitting should be tight so that the connector does not inadvertently separate during insertion or use.
  • The appropriate size of the endotracheal tube is determined from the newborn’s weight and/or gestational age. The table gives the tube size for various weights and gestational age categories.
    The use of a stylet may be helpful to provide rigidity and curvature to the tube, thus facilitating intubation. When inserting the stylet, it is essential that
    The tip does not protrude from the end hole or side hole of the endotracheal tube (to avoid trauma to the tissues).
    The stylet is secured so that it cannot advance farther into the tube during intubation.
    The stylet can be removed from the tube easily.
    Instructor Tip: Do not set endotracheal tube under radiant warmer while waiting for the birth. A warm tube will be floppy and difficult to insert.
  • Select the appropriately sized blade and attach it to the laryngoscope handle.
    No. 0 blade for preterm newborns and No. 1 for term newborns. Check the light to determine that the batteries and bulb are working.
    Suction equipment should be available and ready for use.
    Adjust the suction source to 100 mm Hg by occluding the end of the suction tubing.
    Connect a 10F or larger suction catheter to suction secretions from the mouth.
    Smaller suction catheters (see chart) should be available for suctioning the tube if necessary.
    Endotracheal Tube Size Catheter Size
    2.5 5F or 6F
    3.0 6F or 8F
    3.5 8F
    4.0 8F or 10F
  • A resuscitation device and mask capable of providing 90% to 100% oxygen should be on hand to ventilate the newborn between intubation attempts or if intubation is unsuccessful.
    The oxygen tubing should be connected to an oxygen source and be available to deliver 100% free-flow oxygen and to connect to the resuscitation device. The oxygen flow should be turned to 5 to 10 L/min.
    A stethoscope is needed to check for improving heart rate then for bilateral breath sounds.
    Cut a strip of adhesive tape to secure the tube to the face, or prepare an endotracheal tube holder, if used at your hospital.
  • During the intubation procedure, the assistant plays a very important role. The intubator should never have to look away from the baby’s oropharynx. The assistant needs to anticipate the intubator’s needs and follow directions of the intubator.
    Free-flow oxygen should be provided during the procedure. If suction is needed, the assistant should hand the suction catheter to the intubator and occlude the port at the intubator’s request.
    The endotracheal tube needs to be handled cleanly and handed to the intubator so that it does not have to be turned around prior to insertion.
  • The assistant monitors the heart rate by tapping it out on the bed or quietly stating the heart rate periodically. The length of time for the attempt should be timed and not go much beyond 20 seconds. The assistant should be quietly supportive during this stressful period.
    If an intubation attempt is not successful, the assistant may help provide positive-pressure ventilation between attempts. (Ventilation is not possible if intubating to suction meconium.)
    CO2 detection is not appropriate when intubating for the purpose of suctioning meconium from the trachea. However, when intubating to ventilate the newborn, increasing heart rate and CO2 detection are the primary methods for confirming endotracheal tube placement. A rapid increase in heart rate is indicative of effective positive-pressure ventilation. If the heart rate does not rise after intubation, use the CO2 detector as the next indicator for confirming proper placement of the endotracheal tube. If the heart rate does not rise, and CO2 is not detected after several breaths, consider removing the tube, resuming bag-and-mask ventilation, and repeating the intubation process.
    Instructor Tip: Accidental extubation is more likely if one person holds the tube and another ventilates. The same person should hold the tube and ventilate. The assistant is then free to auscultate and secure the tube.
  • The anatomic landmarks that relate to intubation are labeled on the slides.
    Epiglottis: a lidlike structure overhanging the entrance to the trachea
    The vallecula and esophagus (anatomical parts #2 and #3) are not visible on this slide. See slide 5-14 to see the location of the vallecula and esphagus.
    2. Vallecula: a pouch formed by the base of the tongue and the epiglottis
    3. Esophagus: the food passageway extending from the throat to the stomach
    4. Cricoid: the lower portion of the cartilage of the larynx
    5. Glottis: the opening of the larynx leading to the trachea, flanked by the vocal chords
    6. Vocal cords: mucous membrane-covered ligaments on both sides of the glottis
    7. Trachea: the windpipe or air passageway, extending from the throat to the main bronchi
    8. Main bronchi: the 2 air passageways leading from the trachea to the lungs
    9. Carina: where the trachea branches into the 2 main bronchi
  • The anatomic landmarks that relate to intubation are labeled on the slides.
    Epiglottis: a lidlike structure overhanging the entrance to the trachea
    Vallecula: a pouch formed by the base of the tongue and the epiglottis
    Esophagus: the food passageway extending from the throat to the stomach
    4. Glottis: the opening of the larynx leading to the trachea, flanked by the vocal chords
    5. Vocal cords: mucous membrane-covered ligaments on both sides of the glottis
  • The correct position of the newborn for intubation is the same as for mask ventilation.
    Place the newborn on a flat surface with the head in the midline position and the neck slightly extended. It may be helpful to place a roll under the newborn’s shoulders to maintain slight extension of the neck.
    This “sniffing” position aligns the trachea for optimal viewing by allowing a straight line of sight into the glottis once the laryngoscope has been properly placed.
    It is important not to hyperextend the neck, because this will raise the glottis above the line of sight and narrow the trachea.
    If there is too much flexion of the head toward the chest, you may not be able to directly visualize the glottis.
  • By snapping the laryngoscope blade into position on the handle, the light should turn on. Hold the laryngoscope in your left hand between your thumb and first 2 or 3 fingers, with the blade pointing away from you. One or 2 fingers should be left free to rest on the newborn’s face to provide stability.
    The laryngoscope is designed to be held in the left hand by both right- and left-handed persons. If held in the right hand, the closed curved part of the blade will block the view of the glottis, making insertion of the endotracheal tube impossible.
    Instructor Tip: Place the laryngoscope in the left hand of the operator, or lay it on the left side of the radiant warmer mattress.
  • During an actual resuscitation, the process of intubation needs to be completed very quickly, within approximately 20 seconds. The newborn will not be ventilated during this process, so quick action is essential.
    Stabilize the newborn’s head with your right hand. It may be helpful to have a second person hold the head in the desired “sniffing” position. Free-flow oxygen should be provided throughout the procedure.
  • Slide the laryngoscope blade over the right side of the tongue, pushing the tongue to the left side of the mouth and advancing the blade until the tip lies in the vallecula, just beyond the base of the tongue. You may need to use your right index finger to open the newborn’s mouth to make it easier to insert the laryngoscope.
  • Lift the blade slightly, thus lifting the tongue out of the way to expose the pharyngeal area. When lifting the blade, raise the entire blade by pulling up in the direction the handle is pointing. Do not elevate the top of the blade by using a rocking motion and pulling the handle toward you.
  • If the tip of the blade is correctly positioned in the vallecula, you should see the epiglottis at the top, with the glottis opening below. You should also see the vocal cords appearing as vertical stripes on each side of the glottis.
    If these structures are not immediately visible, you should quickly adjust the blade until the structures come into view. Applying downward pressure on the cricoid may help bring the glottis into view.
    Suctioning secretions also may help improve your view.
    The most common reason for unsuccessful intubation attempts is not adequately visualizing the glottis.
  • While holding the tube in your right hand, introduce it into the right side of the newborn’s mouth. When the vocal cords are apart, insert the tip of the tube until the vocal cord guide is at the level of the cords. If the cords are together, wait for them to open. Do not touch the closed cords with the tip of the tube because it may cause spasm of the cords. If the cords do not open before 20 seconds have elapsed, stop and ventilate with bag and mask.
  • Stabilize the tube with one hand, and remove the laryngoscope with the other. With the right hand held against the face, hold the tube firmly at the lips and/or use a finger to hold the tube against the newborn’s hard palate. Use your left hand to carefully remove the laryngoscope without displacing the tube. Be careful not to press the tube so tightly that the tube becomes compressed and obstructs airflow.
  • This actual intubation of the trachea will give the student a realistic picture of the landmarks of the neonatal airway.
  • If there is meconium in the amniotic fluid and the newborn is not vigorous (depressed muscle tone, depressed respirations, and pulse <100 beats per minute [bpm]), the trachea should be intubated and suctioned.
    Connect the endotracheal tube to the meconium aspirator, which has been connected to a suction source.
    Occlude the suction-control port on the aspirator to apply suction to the endotracheal tube, and gradually withdraw the tube as you continue suctioning meconium that may be in the trachea.
    Repeat intubation and suctioning as necessary, unless the newborn’s heart rate indicates that positive-pressure ventilation is needed.
  • Judgment is required when suctioning meconium. You will need to delay resuscitation for a few seconds while you suction meconium, but do not delay more than is absolutely necessary.
  • An increasing heart rate and CO2 detection are the primary methods for confirming endotracheal tube placement.
    When listening to breath sounds, be sure to use a small stethoscope and place it laterally and high in the chest wall (in the axilla). Be cautious when interpreting breath sounds in newborns because they are easily transmitted. Sounds heard over the anterior portion of the lungs may be coming from the stomach or esophagus, and breath sounds can be transmitted to the abdomen.
    Detection of CO2 in the endotracheal tube can serve as confirmatory evidence that the tube is in the trachea rather than in the esophagus. Two basic types of CO2 detectors are available.
    Colorimetric devices connected to the endotracheal tube change color in the presence of CO2. This device is the most commonly used method.
    Capnographs rely on the placement of a detector device placed at the end of the endotracheal tube connector or a port through which exhaled air is aspirated. The capnograph will display a specific CO2 level and should read more than 2% to 3% CO2 if the tube is in the trachea.
    Instructor Tip: Colorimetric devices connected to the endotracheal tube change color in the presence of CO2. This color change should persist after 6 breaths, as CO2 may have been blown into the stomach during positive-pressure ventilation, causing an initial color change that does not persist.
    Remember: Yellow = Y for “Yes, we’re intubated.” Purple = P for “Problem, we’re not detecting CO2.”
  • An increasing heart rate and CO2 detection are the primary methods for confirming endotracheal tube placement. If the tube is positioned correctly, you should also observe these additional signs of correct tube placement.
  • The colormetric device for CO2 detection changes from purple to yellow in the presence of exhaled CO2. Babies with very poor cardiac output may exhale insufficient CO2 to be detected reliably by CO2 detectors.
    Instructor Tip: Remember that purple means “problem” and yellow means “yes,” the tube is properly positioned.
  • It is very important to be certain that the tube is in the trachea. A misplaced tube is worse than having no tube at all. If the patient does not appear to be improving and the tube is possibly not in the trachea, use your right hand to hold the tube in place while you use your left hand to reinsert the laryngoscope so that you can visualize the glottis to see if the tube is passing between the vocal cords; and/or remove the tube, use positive-pressure ventilation until the heart rate is stabilized, and repeat the intubation procedure.
    Instructor Tip: The endotracheal tube is not in the trachea if the baby has an audible cry or regurgitates through the tube.
  • If the tube is correctly placed, the tip will be located in the mid-trachea, midway between the vocal cords and the carina. If it is in too far, it will generally be down the right main bronchus, and you will be ventilating only the right lung.
    If the tube is correctly placed, you will hear breath sounds of equal intensity on each side of the chest.
    If the tube is in too far, you will hear breath sounds on the right side that are louder than any sounds you hear on the left side. If that is the case, pull back the tube very slowly while listening to the left side of the chest. When the tip reaches the carina, you should hear the breath sounds increase on the left side.
    Instructor Tip: Parents are sensitive to statements made by the team. It is preferable to say, “I hear breath sounds louder on the right,” than to say, “You’re down too far,” or “You’ve intubated the right mainstem bronchus.”
  • The tip-to-lip measurement can be used to estimate if the tube has been inserted the correct distance. Adding 6 to the newborn’s weight in kilograms will give a rough estimate of the correct distance from the tube tip to the vermilion border of the upper lip. This rule is unreliable in those babies who have congenital anomalies of the neck and mandible.
  • If the endotracheal tube is to remain in the trachea beyond the initial resuscitation, a chest radiograph should be obtained for confirmation of correct tube position. Take an anterior-posterior view of the chest with the baby’s head in a neutral position. A lateral view is not usually necessary to confirm position.
    If a tube is incorrectly placed in a mainstem bronchus, you should hear unilateral breath sounds or unequal breath sounds and hear no air entering the stomach and observe no gastric distention.
    The corrective action is to withdraw the tube slowly until breath sounds are equal bilaterally.
    If a tube is incorrectly placed in the esophagus, the heart rate will not rise and the CO2 detector will not indicate exhaled CO2. You may hear air sounds because of air entering the stomach, and gastric distention may be noted. However, the chest will not move with each breath.
    The corrective action is to remove the tube, oxygenate the newborn with mask ventilation, and reintroduce the endotracheal tube.
  • You can’t continue most resuscitation actions during intubation. To minimize hypoxia, the following steps are helpful:
    Pre-oxygenate the baby with positive-pressure ventilation and 100% oxygen before intubation attempts.
    Hold 100% free-flow oxygen by the baby’s face while the intubation is ongoing.
    Limit attempts to no longer than 20 seconds. If unsuccessful, remove the laryngoscope and give positive-pressure ventilation with the mask and then try again.
  • Discussion:
    The larygneal mask is a latex-free airway device that can be inserted into the airway without using a laryngoscope.
    It looks like an inflatable “life raft” attached to a tube.
    The 3 parts include: (1) the inflatable mask, (2) the airway tube with 15-mm connector, (3) the inflation line with a pilot balloon to monitor the inflation of the mask.
    After it is inserted, the “life raft” is inflated and fills the hypopharynx. The inside of the “raft” faces the vocal cords and has an opening to the airway tube.
    Nothing is inserted between the vocal cords; the mask covers the laryngeal opening and makes a low pressure seal directing air from the airway tube through the vocal cords and into the trachea.
    Size 1 is the smallest size and is too large for babies less than 1,500 g.
  • Discussion:
    The laryngeal mask has been used for resuscitation in place of either face-mask ventilation or intubation, but it is not currently recommended for routine use.
    The laryngeal mask is most valuable when both face-mask ventilation and endotracheal intubation have failed to achieve effective ventilation. This may occur in newborns with craniofacial anomalies, like cleft palate with a small mandible (eg. Robin syndrome) or large tongues (Down syndrome).
    You cannot suction meconium effectively through a laryngeal mask and it should not be used in place of endotracheal intubation to suction the airway of a newborn born through meconium-stained fluid.
    There are no studies evaluating the use of laryngeal masks during chest compressions or for the use of emergency medications (eg, epinephrine). It is, however, reasonable to attempt to use a laryngeal mask in both of these situations if endotracheal intubation is unfeasible or unsuccessful.
    Because the laryngeal mask maintains a low-pressure seal against the walls of the pharynx, air may start to leak around it when using higher ventilating pressures (>22 cm H2O).
  • The laryngeal mask can be inserted with either hand; use your dominant hand.
    The mask should be deflated before insertion.
    Place the baby’s head in the “sniffing” position, just as you would for endotracheal intubation.
    When you hold the laryngeal mask, hold it like a pen. The tip of your index finger will fit at the point where the mask meets the airway tube. The top of the mask looks like the passenger compartment of the “life raft” and has an opening to the airway tube. This part will be facing upward when you hold it.
    When you insert the mask into the baby’s mouth, the top of the mask (passenger compartment of the “life raft”) faces the baby’s tongue. The back of the mask looks like the bottom of the “raft” and it has no opening. This part faces the baby’s palate during insertion.
    You can apply a small amount of water-soluble lubricant to the back of the mask to help it slide along the baby’s palate easier. For most newborns, it is not necessary because their mouths are already moist.
  • When you remove your index finger from the baby’s mouth, hold the tube with your other hand so that it does not slide out by accident.
    When you attach the syringe to the inflation line valve, you will need to “push and twist.”
    Never inflate with more than 4 mL of air.
    When you inflate the mask, do not hold the airway tube. The laryngeal mask may move slightly outward when the mask is inflated. This happens as the mask seals into place.
    After placement, you should note bilateral breath sounds, and an end-tidal CO2 monitor should change color.
    You should not hear a large air leak from the baby’s mouth or see a growing bulge in the baby’s neck. These are signs that the laryngeal mask is not properly placed.
  • The laryngeal mask can be inserted with either hand; use your dominant hand.
    The mask should be deflated before insertion.
    Place the baby’s head in the “sniffing” position, just as you would for endotracheal intubation.
    When you hold the laryngeal mask, hold it like a pen. The tip of your index finger will fit at the point where the mask meets the airway tube. The top of the mask looks like the passenger compartment of the “life raft” and has an opening to the airway tube. This part will be facing upward when you hold it.
    When you insert the mask into the baby’s mouth, the top of the mask (passenger compartment of the “life raft”) faces the baby’s tongue. The back of the mask looks like the bottom of the “raft” and it has no opening. This part faces the baby’s palate during insertion.
    You can apply a small amount of water-soluble lubricant to the back of the mask to help it slide along the baby’s palate easier. For most newborns, it is not necessary because their mouths are already moist.
  • Reanimación Neonatal: lección 5 INTUBACION ENDOTRAQUEAL

    1. 1. Lección 5: INTUBACIÓN ENDOTRAQUEAL
    2. 2. Intubación Endotraqueal Contenido de la Lección: • Indicaciones de la intubación • Equipo • Uso de laringoscopio • Determinación de la colocación de la cánula ET • Aspiración de meconio de la tráquea • Ventilación con presión positiva vía cánula endotraqueal 5-2
    3. 3. Intubación Endotraqueal: Indicaciones • Para succionar la tráquea en presencia de meconio cuando el neonato está no vigoroso • Para mejorar la eficiencia de la ventilación después de varios minutos de ventilación con bolsa y máscara o bien que sea inefectiva la ventilación bolsa-máscara • Para facilitar la coordinación entre masaje cardíaco y ventilación • Para administrar adrenalina mientras está disponible el acceso venoso umbilical  5-3
    4. 4. Intubación Endotraqueal: Indicaciones Especiales • • • Prematuridad extrema Suministro de Surfactante Sospecha de Hernia Diafragmática Una persona con experiencia en intubación endotraqueal debe estar rápidamente disponible en cada nacimiento  5-4
    5. 5. Alternativas de Intubación Endotraqueal : Máscara Laríngea de Ventilación 5-5
    6. 6. Intubación Endotraqueal : Equipo e Insumos • El equipo debe estar limpio y protegido de contaminación 5-6
    7. 7. Características de las Cánulas Endotraqueales : • Estériles y deshechables • De diámetro uniforme (sin punta adelgazada) • Con marcas en centímetros y guía de cuerdas vocales • Sin globo 5-7
    8. 8. Cánulas Endotraqueales : Tamaño apropiado • Seleccione el tamaño de la cánula en base al peso y a la edad gestacional • Considere su acortamiento a 13 – 15 cms • Estilete opcional Tamaño (mm) Peso Edad gestacional (g) (semanas) 2.5 menor a 1,000 menor a 28 3.0 1,000-2,000 28-34 3.5 2,000-3,000 34-38 3.5-4.0 mayor a 3,000 mayor a 38 (diámetro interno) 5-8
    9. 9. Preparación del Laringoscopio: Equipo Tamaño correcto de la hoja del laringoscopio: – No. 0 para Prematuros – No. 1 para RN de término  • • • Pruebe la luz del laringoscopio Ajuste la fuente de succión a 100 mm de Hg Use una sonda gruesa de succión (mayor o igual a 10F) para las secreciones orales • Sondas 5F a 8F para aspirar la cánula endotraqueal 5-9
    10. 10. Preparación para la Intubación • Prepare el dispositivo de reanimación y la máscara • Abra el oxígeno • Tome un estetoscopio • Corte la cinta adhesiva o prepare el fijador 5-10
    11. 11. Asistiendo la Intubación El (la) asistente durante el procedimiento debe • Asegurarse que el equipo esté preparado • Corregir la posición del bebé, estabilizar la cabeza • Suministrar oxígeno a flujo libre • Proveer succión • Entregarle la cánula endotraqueal al reanimador que esté intubando • Aplicar presión en el cricoides si se le solicita 5-11
    12. 12. Asistiendo la Intubación El (la) asistente durante el procedimiento debe • Suministrar ventilación con presión positiva entre los intentos de intubación • Conectar la cánula endotraqueal al dispositivo de reanimación • Conectar el detector de CO2 • Auscultar la frecuencia cardíaca para detectar mejoría • Observar si el detector de CO2 cambia de color • Auscultar ruidos respiratorios y observar movimientos del tórax • Ayudar a fijar la cánula endotraqueal 5-12
    13. 13. Intubación Endotraqueal : Anatomía de la Vía Aérea Superior 5-13
    14. 14. Intubación Endotraqueal : Puntos de Referencia Anatómicos 5-14
    15. 15. Intubación Endotraqueal : Posicionando al Neonato 5-15
    16. 16. Intubación Endotraqueal : Siempre Sostenga el Laringoscopio con la Mano Izquierda  5-16
    17. 17. Intubación Endotraqueal : Paso 1: Preparando La Inserción • Estabilice la cabeza del neonato en posición de “olfateo” • Suministre oxígeno a flujo libre durante el procedimiento  Click on the image to play video 5-17
    18. 18. Intubación Endotraqueal : Paso 2: Inserte el Laringoscopio • Deslice el laringoscopio sobre el lado derecho de la lengua • Empuje la lengua hacia el lado izquierdo de la boca • Avance la hoja hasta que la punta se encuentre justamente en la base de la lengua  5-18
    19. 19. Intubación Endotraqueal : Paso 3: Levante la hoja • • • • Levante la hoja ligeramente Levante la hoja completa no sólo la punta Visualice el área faríngea No use movimientos de palanca  5-19
    20. 20. Intubación Endotraqueal : Paso 4: Visualice los Puntos de Referencia • Identifique los puntos de referencia. Las cuerdas vocales se ven como pliegues verticales a cada lado de la glotis o como una letra “V” invertida • El aplicar presión hacia abajo del cricoides, puede facilitar la visualización de la glotis • Realice aspiración si es necesario  5-20
    21. 21. Intubación Endotraqueal : Paso 5: Inserte el Tubo • Inserte el tubo en el lado derecho de la boca manteniendo la parte curva del tubo en el plano horizontal • Si las cuerdas estan cerradas, espere a que se abran • Inserte la punta del tubo endotraqueal hasta que la guía de cuerdas vocales esté a nivel de las cuerdas • Limite los intentos a 20 seg.  Click on the image to play video 5-21
    22. 22. Intubación Endotraqueal : Paso 6: Retire el Laringoscopio • Sostenga firmemente el tubo contra el paladar del bebé mientras retira el laringoscopio • Sostenga el tubo en su lugar mientras retira el estilete, si éste ha sido usado Click on the image to play video 5-22
    23. 23. Intubación Endotraqueal Click on the image to play video 5-23
    24. 24. Succionando Meconio Vía Tubo Endotraqueal • Conecte el tubo endotraqueal a la fuente de succión • Ocluya el puerto de succión para aspirar • Retire gradualmente el tubo endotraqueal • Repita la intubación y succión las veces que sean necesarias hasta que la FC del neonato indique que requiere ventilación con presión positiva Click on the image to play video 5-24
    25. 25. Succionando Meconio Vía Tubo Endotraqueal • Succiones solamente por 3 a 5 minutos mientras va retirando el tubo • Si no se obtiene meconio, proceda con la reanimación • Si se obtiene meconio, evalúe la frecuencia cardíaca – Sin bradicardia significativa → Reintube, y succione nuevamente – Con bradicardia significativa → Administre ventilación con presión positiva 5-25
    26. 26. Intubación Endotraqueal : Evaluando la Posición del Tubo Signos de correcta posición del tubo • Mejoría de signos vitales (frecuencia cardíaca, coloración y actividad) • Presencia de CO2 exhalado a través del detector de CO2 • Ruidos respiratorios en ambos campos pulmonares, pero ausentes en el estómago • No hay distensión gástrica debido a la ventilación  5-26
    27. 27. Intubación Endotraqueal : Evaluando la Posición del Tubo Signos de correcta posición del tubo • • • Vapor en el tubo durante la espiración Movimiento torácico en cada respiración Confirmación por Rayos X si el tubo va a mantenerse después de la reanimación inicial • Visualización directa del tubo que pasa a través de las cuerdas vocales  5-27
    28. 28. Detección de CO2 Click on the image to play video 5-28
    29. 29. Intubación Endotraqueal : Comprobando la Posición del Tubo El tubo no está en la tráquea si • El recién nacido permanece cianótico o bradicárdico • Si el detector de CO2 no indica CO2 exhalado • • • • • No hay sonidos respiratorios en los pulmones El abdomen se distiende Se oye ruido de aire en el estómago No hay vapor en el tubo endotraqueal con la espiración El tórax no se mueve simétricamente durante la ventilación con presión positiva 5-29
    30. 30. Intubación Endotraqueal : Localización del Tubo en la Tráquea 5-30
    31. 31. Intubación Endotraqueal : Localización del Tubo en la Tráquea Medida punta-labio Peso (kg) 1* 2 3 4 Profundidad de inserción (cm del labio superior) 7 8 9 10 * RN con peso menor a 750 g pueden requerir solo 6 cm de inserción 5-31
    32. 32. Intubación Endotraqueal : Confirmación Radiológica  Correcta Incorrecta 5-32
    33. 33. Intubación Endotraqueal : Limitando la Hipoxia durante la Intubación • Pre-oxigene mediante ventilación con presión positiva (a menos que la intubación se realice para aspirar meconio) • Provea de oxígeno a flujo libre durante la intubación • Limite los intentos a 20 segundos 5-33
    34. 34. Intubación Endotraqueal : Máscara Laríngea • Es un dispositivo de vía aérea que puede utilizarse para dar ventilación con presión positiva • Es una mascarilla inflable adosada a un tubo para vía aérea • El tamaño 1 es la mascarilla más pequeña que se fabrica; puede ser grande para bebés que tienen peso < 1.500 Kg 5-34
    35. 35. Intubación Endotraqueal : Cuando debe ser considerada la Máscara Laríngea • “No se puede ventilar y no se puede intubar” – Malformaciones craneofaciales (ej:, paladar hendido) – Mandíbula pequeña – Lengua grande • Limitaciones – No puede succionarse meconio a través de la máscara – Se desconoce si es efectiva durante el masaje cardíaco o para aplicación de medicamentos endotraqueales – Es probable que no pueda emplearse para ventilación con altas presiones debido a fuga de aire alrededor de la máscara – Demasiado grande para bebés de peso muy bajo para edad gestacional (VLBW) 5-35
    36. 36. Insertando la Mascara Laríngea 1. Sostenga el tubo con su mano dominante como si fuera una pluma, con el globo desinflado 2. Abra la boca del bebé y colóquela con la parte posterior o plana de la máscara contra el paladar. 3. Usando su dedo índice, guíe la máscara a lo largo del paladar hasta la garganta hasta que sienta resistencia 4. Estabilice el tubo con la otra mano y retira su dedo índice de la boca del bebé 5-36
    37. 37. Intubación Endotraqueal : Insertando la Mascara Laríngea Parte II 5. 6. 7. Conecte una jeringa de 5 mL a la línea con válvula e infle la máscara con 2 a 4 mL de aire. Conecte un dispositivo de presión positiva al adaptador de 15 mm • Un monitor de CO2 exhalado puede conectarse entre el adaptador y el dispositivo de presión positiva Asegure la máscara laríngea como lo haría con un tubo endotraqueal Click on the image to play video 5-37
    38. 38. Fin de la Lección 5 5-38

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