Tracheal intubation and bronchial intubation

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Definition
Endotracheal intubation is inserting a special tube into the trachea through oral or nares via laryngeal. If this special tube is inserted into the bronchus ,we call it endobronchial intubation.

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Applications
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
⑴Neck mobility The atlanto-occipital joint (环枕关节) and cervical spine mobility particularly with extension It is related to aligning the oral, pharyngeal, and laryngeal axes (口、咽、 喉三轴线重叠) .
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Normal head extension: 165-90 degrees Head extension < 80 degrees:
representing increasing limitation and increased potential for difficult laryngoscopy Diseases: cervical spine rheumatoid arthritis or tuberculosis with atlantoaxial subluxation (颈椎风湿性关节炎或结核合并 环枢关节半脱位) , cervical spine fracture, severe cervical spondylosis (颈椎关节强硬) , morbid obesity, burn and so on.

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⑵The thyromental distance (颏甲 距 离)
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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⑶Mouth opening
Normal: 4-5 cm (about two large
fingerbreadths) < 2.5 cm: difficult laryngoscopy

Diseases: temporomandibular joint
ankylosis (颞下颌关节强直) , arthritis, burn, trauma, radiation, transtemporal craniotomy (经颞骨颅骨切开术) , large tongue.
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⑷Teeth
Dentures Loose teeth Edentia Protuberant upper incisors

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⑸Mallampati classes

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⑹Nose: nasal obstruction, nasal trauma, epistaxis
(鼻出血) and nasopharyngeal surgery

⑺Pharynx: inflammatory masses such as tonsillar
hyperplasia, retropharyngeal abscess

⑻Larynx: laryngitis, laryngeal stenosis
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⑼Trachea: tracheal stenosis resulted from: the extrinsic airway compression of cervical mass, thyromegaly (巨大甲状腺 肿) and aorta aneurysm (主动脉瘤) tracheal trauma tracheotomy luminal tumors
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2. Equipment of endotracheal intubation
⑴ Endotracheal Tubes ① Material: rubber, plastic or polyvinylchloride Demand: The tube is free of toxic, irritant or allergenic properties. The tube wall should be smooth and as thin as possible.

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②Types
Internal diameter (ID) size: It reflects the internal 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 π, and is therefore higher for thicker-walled tubes than for thinner-walled tubes with the same ID. F size = ID size×4 + 2
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③Choice of endotracheal tube sizes Adults : adult males 8.0 mm ID adult females 7.0 mm ID Given the variation between individuals, a tube of 1 mm ID size smaller or larger may be available for an individual patient. nasal intubation 7.0 ~ 7.5mm ID

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Children:
formula: age + 18 (French size) or age/4 + 4.5 (ID size) Variation between individuals requires the availability of 0.5 mm ID smaller and larger tube 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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④Distance of insertion
adult males about 23 cm at the lips, with the tube tip to be placed in the midtrachea and an appropriate 4 cm above the carina. adult females about 21 cm children can be estimated from the formula: 12 + (age/2).

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⑵ Cuff
①Function to protect the airway from aspiration and air leak on positive-pressure inspiration. ②Types and characteristics low-volume, high-pressure cuffs high-volume, low-pressure cuffs

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⑶ Laryngoscope
①Configuration and classification laryngoscope handle laryngoscope blade: straight blade curved blade

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②Advantages and disadvantages of both laryngoscopes Laryngoscope Move tongue and epiglottis Allows visualization of cords and glottis Miller- straight --Lift epiglottis --pediatrics Macintosh- curved --Fits in vallecula --More room for visualization --Reduced trauma/ gag reflex

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③Fiberoptic bronchoscope

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⑷ Other equipment for endtracheal intubation ①Connector ②Stylet: It is a rigid implement usually made of a flexible metal or rubber. ③Forceps: Magill forceps and Rovenstine forceps ④Bite block ⑤Sprayer

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⑸ Preparation before endotracheal intubation endotracheal tubes laryngoscope other 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
⑴ 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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⑵ Local anesthesia Indications: difficult intubation, severe risk for airway obstruction or aspiration. ①Topical anesthesia(Surface anesthesia) ②The superior laryngeal nerve (SLN) blocking ③Transtracheal anesthesia

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⑶Local 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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Routes for Intubation Orotracheal Nasotracheal Tracheotomy Classification On the base of intubating path: oral endotracheal intubation nasal endotracheal intubation On the base of glottis visulization: visualized intubation blind intubation

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1.Indications and Advantages
⑴ Indications General anesthesia Respiratory treatment Cardiopulmonary resuscitation

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⑵ Advantages Controls the airway Facilitates ventilation/ O2 Prevents gastric inflation Allows for direct suctioning Medication administration

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⑶ 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 inserted into the glottis

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Advantages of Oral Intubation
Larger tube can be inserted Tube can be inserted usually with more speed and ease with less trauma Easier suctioning Less airflow resistance Reduced 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-extubation Gastric distention from frequent swallowing of air Mucosal irritation and ulcerations of mouth (change tube position)
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3. Nasal endotracheal intubation
⑴ 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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⑵ Contraindications  coagulopathy or other severe bleeding diathesis  severe intranasal disorder  basilar skull fracture  cerebrospinal fluid leak

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⑶ Classfication Visualized nasal intubation Blind nasal intubation

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Advantages of Nasal Intubation
More comfort long term Decreased gagging Less salivation, easier to swallow Improved mouth care Better tube fixation Improved communication

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Disadvantages of Nasal Intub.
Pain and discomfort Nasal and paranasal complications, I.e., epistaxis, sinusitis, otitis More difficult procedure Smaller tube needed Increased airflow resistance Difficult suctioning Bacteremia

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4. Intubation of difficult airway
⑴ Fiberoptic bronchoscope intubation ⑵ Retrograde endotracheal intubation ⑶ Anterograde endotracheal intubation (4)Laryngeal mask airway (5)Esophageal-Tracheal Combitube

5. Tube exchanging

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6. Tracheotomy

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Displacement
Tracheal tubes can be displaced after correct insertion. This is particularly likely when the patient is moved or the position changed. Flexion or extension of the head, or lateral neck movement, has been 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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Confirmation of tracheal intubation

 Clinical signs used to confirm tracheal intubation
• 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 Disadvantages
⑴Indications “wet lung” patients: severe emptysis pulmonary abscess bronchodilatation bronchopleural fistula tracheoesophageal fistula traumatic fraction of bronchus tracheoplasty or bronchoplasty

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⑵Advantages  Prevent contamination or spillage: infection ,hemorrage ,brochopulmonary lavage Control of the distribution of ventilation: bronchopleural fistula Enhance surgical exposure: pneumonectomy ⑶Disadvantages 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 <24 bpm Spontaneous Vt > 5mL/kg IBW

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Extubation Procedure
Assemble Equipment - intubation equipment - in addition to intubation equipment, O2 device and humidity, SVN (smallvolume nebulizer ) with racemic epinephrine Suction ET tube Oxygenate patient Unsecure tube, deflate cuff
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Extubation proced. (cont’d.)
Place suction catheter down tube and remove ET tube as you suction Apply appropriate O2 and humidity Assess/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 injury Causes : The laryngoscope is used improperly. Laryngoscopy is particularly difficult. There is dental/periodontal disease.

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Complications during larngoscopy and intuation
2. Hypertension and arrhythmia Cause Stress reaction to laryngoscopy and intubation→plasm catecholamine increase Prevention Maintaining adequate anesthetic depth Administration 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 manipulation Inexperienced practitioner Diagnosis Absence of bilateral breath sounds, chest movement, epigastric auscultation Reservoir bag not filling during expiration Routine monitoring of end-tidal CO2
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Complications while the tube is in place
1. Endotracheal tube obstruction  bevel against tracheal wall Clot, mucus kinking 2. Inadvertent extubation 3. Inadvertent Endobronchial intubation

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Complications while the tube is in place
4. Bucking Causes Laryngoscopy is performed under inadequate anesthesia or without the use of muscle relaxant Prevention Maintenance of adequate anesthetic depth Adequate muscle relaxant Administration of appropriate fentanyl, lidocaine intravenously before laryngoscopy
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Complications while the tube is in place
5. Bronchospasm Causes Laryngoscopy 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 IVβ2-agonists, lidocaine Pulmonary toilet
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Immediate and delayed complications after extubation
1.Laryngospasm 2.Aspiration and foreign body obstraction Patients with a full stomach Tongue falling back to retropharyngeal wall 3.Tracheal Collapse 4. Pharyngitis, Laryngitis
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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 an
ingenious supraglottic airway device that is designed to provide and maintain a seal around the laryngeal inlet for spontaneous ventilation and allow controlled ventilation 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. (作为传统面罩的替代品,以消 除面罩和操作者的手对手术的影响。) To establish an emergency airway in awkward settings for intubation such as the lateral or prone positions. (在插管 较为 困难的体位下,如侧卧位或俯卧位,建 立紧急气道。)

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3.Advantages and indications Be employed to establish an airway in the patient in whom either mask ventilation or tracheal intubation is difficult. (用于面 罩通气和气管内插管困难的病人建立通 气道。) Be used to provide a conduit to facilitate fiberoptic, gum bougie-guided or blind oral tracheal intubation. (可提供一个通道, 以利于经纤支镜或引导管引导气管内插 管或盲探插管。)
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4.Disadvantages and contraindications
Pulmonary aspiration, laryngospasm, soft tissue injury. Need for neck extension in the patient with cervical spine disorder. Failure to function properly in the presence of local pharyngeal or laryngeal disease. In patients with diminished pulmonary compliance or increased airway resistance, adequate ventilation may not be possible because of the high inflation pressures required and the resultant leaks. Contraindicated in any of the conditions associated with an increased risk for regurgitation and aspiration.
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Thank You

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