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8-Intubation and tfffffffracheostomy.pdf
1.
2. Asso. Prof. Ameera Al-Sumat, MD
Senior Consultant Internist & Pulmonary diseases
Deanship of Graduate Studies and Scientific Research
21 September University of Medical & Applied Sciences
4. Presented by :
Haneen AL-shaabi
Ramzee AL-Zabedee
Supervised by:
DR : Ameera Al-Sumat
5. Introduction:
Management of the airway (access and maintenance) is of essential i
mportance in the care of any patient. Airway patency may be affecte
d because of a medically induced (e.g., anesthesia) or disease-related
(e.g., cardiac arrest, loss of consciousness) condition. The airway pa
tency can also be affected in conscious patients in conditions such as
neuromuscular disorders or drug anaphylaxis.
The respiratory practitioner has a wide selection of equipment he or
she can use to secure and maintain airway patency. The practitioner
needs to be familiar with the indications, proper use, and limitations
of airway management equipment because all such devices have the
potential to harm as well as help
6. Endotracheal Intubation
Definition : placement of a tube into the
trachea to maintain an patent airway.
Indication:
- Decreased level of consciousness
- Risk of regurgitation
- Depressed or absent gag reflex
- Respiratory failure
- Respiratory arrest or cardiac arrest
7. Contraindications :
None in emergency situations
Advantages:
- Ensures a patent airway
-Reduces the risk of regurgitation or aspiration
-Improves ventilation
-Provides route for the administration of oxygen
Disadvantages :
Bypasses the function of the upper airway
8. Intubation Kit: The Equipment Needed
- Gloves
- ET tubes, typically sizes 5 through 9 with a stylet
- 10-mL syringe
- Laryngoscope handle
- BVM
- Series of different blades, both Miller (straight) and (Macintosh (curved
- Carbon dioxide detector (disposable)
- Nasopharyngeal airway of different sizes
- Oropharyngeal airway of different sizes
- Water-based lubricant
- Gauze tape
- Extra batteries for the handles
- ET tube holder (this could be cloth tape or other means of securing the ET
tube)
- Stethoscope
9.
10. Choosing the ET Tube:
The basic components of the ET tube :
- proximal end
- The tube
- The end proximal to the patient will have a standard 15/22-mm adapter, whi
ch is considered universal.
- The tube length is indicated by graduated markers with numbers printed to in
dicate the millimeter length.
- Radiopaque line (a line that runs the length of the tube), so the clinician can v
erify placement within the airway on a chest radiograph.
- ET tubes vary in size from 2 to 10 mm(internal diameter)
.
Size :
The size range for females is 7 to 7.5 mm, and for males the size range is 7.5 to 8.
5 mm.
11. General Guide to Choice of Endotracheal Tube
Note : the ET tube size 5 or greater will have a cuff, whereas tubes s
maller than 5 are typically cuffless
12.
13. Intubation Procedure
:Quick Airway Assessment
It is important to do a quick airway assessment to help determine what will be th
e best route of airway management. Part of the quick assessment is to consider if
there has been any physical damage to the face, nasal sinus, mandible, and nec
k. During this initial assessment the clinician also will need to be mindful of any
cervical damage due to trauma
14. Adjunctive Devices Prior to Intubation:
:Upper airway devices
-Oropharyngeal airway :The appropriate size of an is determine
d by the measurement from the corner of the patient’s mouth to th
e angle of the jaw
The sizes range from 0 to 5, with 0 being the smallest and 5 the la
rgest.
This device holds the airway and tongue into position from the po
sterior pharynx, but it does not isolate the trachea
15.
16. -Nasopharyngeal Airway: The measurement will begin from the
nare to the bottom of the ear canal. This point will be slightly abo
ve the earlobe
17. Supraglottic Airway Devices
Supraglottic airways are designed for blind insertion in the upper a
irway in case of failed traditional endotracheal intubation or as an
alternative to intubation or mask ventilation
-Laryngeal mask airways (LMAs) are devices that have an inflata
ble mask that fits over the larynx.
18. A esophageal/tracheal tube: is a disposable double lumen tube t
hat has an esophageal (or tracheal) opening and a pharyngeal ope
ning
19. Medications Needed :
Medications used during a rapid sequence intubation (RSI) can var
y widely, but there are typically certain standards that are used alm
ost universally
27. Advantages :
- It can be done on a patient who is awake and breathing .
- - can be done successfully because most of the gag reflex come
s from the upper oral cavity in the throat, and by doing the nasal
tracheal intubation the clinician bypasses this area.
Contraindication :
29. Note :The ET tube tip should be about 1 in (2 to 3 cm) above the c
arina.
Complications of intubation :
- Hypoxia during insertion
- Dysrthymia
- Tracheal trauma
- Laryngospasm
- Barotrauma
- Bronchial intubation
- Esophageal intubation
30. Tracheostomy Tubes
Definition :
is a surgical procedure in which an opening (stoma) is create
d in the trachea. The stoma is usually cannulated with a tube
(tracheostomy tube) to maintain airway patency and allo
w function (e.g., breathing) and therapy (e.g.,suction).
31. Tracheostomy history
◼ The tracheostomy is one of the oldest surgical procedure.
◼ It can be traced back to Egyptian tablets from 3600 B.C
and Indian in the early years.
◼ Extensive history of tracheostomy can be best divided int
o five periods.
◼ 1546.first well-documented tracheostomy by Antonius m
usa brasavola.
◼ 1921 chevalier Jackson- standardized the technique of t
he tracheostomy.
◼ 1953 seldinger introduced PCT.
◼ 1969 modern percutaneous tracheostomy(PCT).
◼ 1990 griggs et developed another guidewire dilating forc
eps for PCT.
32. ANATOMY:
◼ Trachea lies in midline of the neck exte
nding from cricoid cartilage (C6) superi
orly to the tracheal bifurcation at the le
vel of sternal angle (T5).
◼ Comprises 16-20 C shaped cartilage rin
gs.
◼ Becomes intra- thoracic at 6th cartilagin
ous ring
◼ Length 10-12cm.
◼ Diameter 15-20mm.
33. Important structures to be careful while perfor
ming tracheostomy.
◼ Arteries of central neck.
◼ Common carotid.A
◼ Carotid bifurcation.
◼ Internal carotid. A
◼ Ext. carotid A. and br
◼ Superficial veins of central neck
◼ Ext.jugular vein and ant.jugular vein.
◼ Deep veins of central neck.
◼ Internal jugular vein.
35. Upper airway obstraction.
◼ Tumors of oropharynx, larynx, and upper trachea.
◼ Infection-epiglottitis, severe tracheobronchitis).
◼ Bilateral vocal cord paralysis.
◼ Trauma (laryngeal, maxillofacial fractures ).
◼ Foreign body obstruction.
◼ Subglottic or tracheal stenosis.
36. ◼ PULMONARY VENTILATION AND TOILET.
◼ Prolonged of ventilation.
◼ Facilitation of ventilation support.
◼ Inability of patient to manage secration.
◼ prevention of aspiration.
◼ ELECTIVE PROCEDURE.
◼ Adjunct to major head and neck surgery.
◼ Adjunct to management of major head and neck trauma.
37. A tracheostomy tube made from :
plastic (i.e., rubber, Teflon, silicone polyethylene, or PVC).
metal (i.e., silver or stainless steel) hollow, curved tube)
38. Types of tracheostomy :
Uncuffed
Uncuffed tracheostomy tubes maintain the stoma patent a
nd may allow mechanical ventilation but do not protect
against aspiration.
Indications:
- in children (0–6 years old)because the cricoid ring is na
rrower and the tracheal and laryngeal cartilage
are softer
- when there is no need for mechanical ventilation (e.g.,
laryngectomy, tumors, or severe sleep apnea)
- when patients areweaned off tracheostomy
39. Cuffed
A cuff in the distal portion of the outer cannula, when inflated, ha
s the following functions:
(1) directs the air from the trachea to the inner cannula, (2)decrea
ses the amount of oral/esophageal secretions that enter the airway
, and
(3) facilitates the administration of positive pressure ventilation.
40. Foam Cuff
The Bivona Fome-Cuf uses a polyurethane foam that is inside a silicone cuff.
The goal is to reduce the pressure induced by the tracheostomy cuff on the trac
heal wall, thereby reducing tracheal wall injury (e.g., stenosis). The tracheosto
my tube is inserted by evacuating the air from the silicone cuff surrounding the
foam, which causes the collapse of the foam against the outer cannula. When t
he cannula is inserted, the pilot port is open to ambient(atmospheric) pressure,
and the foam expands
41. Tight-to-Shaft (TTS) Cuff
The TTS cuff is designed to allow mechanical ventilation and/or
minimize aspiration while maximizing the airflow in patients wh
o need short-term cuff inflation.
42. Fenestrated
A fenestrated tracheostomy tube has one or more openings in the p
osterior wall of the outer cannula (Figure 6-21). These openings, or
fenestrations, allow air to pass through the outer cannula.
43. Complication of tracheostomy:
◼ Immediate:-
◼ Haemorrhage.
◼ Cardiac arrest.
◼ Apnea
◼ Air embolism.
◼ Local damage(thyroid cartilage,cricoid cartilage,recurrent laryngeal nerve).
◼ Pneumothorax/pneumomediastinum.
◼ Intermediate:-
◼ Dislodgement/displacement of the tube.
◼ Subcutaneous emphysema.
◼ Pneumothorax/pneumomediastinum.
◼ Scabs and crusts.
◼ Infection.
◼ Tracheal necrosis.
◼ Tracheo-esophageal fistula.
◼ dysphagia
◼ Late:-
◼ Tracheal stenosis.
◼ Difficulty with decannulation.
◼ Tracheocutaneous fistula/scar.
44. Removal of tube
◼ If no longer indication exist can consider tube removal
◼ Should be done in a step wise fashion
◼ Uncuffed fenestrated small size tube should be inserted
◼ Close the tube during day time
◼ Tube close during day and night time (24Hrs)
◼ If patient tolerate can decannulate
45. Tracheostomy .vs. intubation
◼ Increased patient mobility.
◼ More secure airway.
◼ Increased comfort.
◼ Improved airway suctioning.
◼ Early transfers of ventilator-dependent patient from ICU.
◼ Enhanced phonation and communication.
◼ Decreased airway resistance for promoting wea
ning from mechanical ventilation.
◼ Decreased risk for nosocomial pneumonia in pat
ient subgroups.
