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bronchial intubation
1
Definition
2
Applications
General anesthesia
Treatment of airway obstruction, difficult
respiration
Cardiopulmonary cerebral resuscitation
Treatment of severe acute emptysis
Examination of pulmonary function
Pulmonary toilet
3
Intubation can be performed with
the patient awake (local anaesthesia)
or under general anaesthesia.
4
Section 1
Preanesthesia Preparation and Anesthesia
5
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
8
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.
9
⑶Mouth opening
Normal: 4-5 cm (about two large
fingerbreadths)
< 2.5 cm: difficult laryngoscopy
10
⑷Teeth
Dentures
Loose teeth
Edentia
Protuberant upper incisors
11
⑸Mallampati classes
12
⑹Nose: nasal obstruction, nasal trauma, epistaxis
(鼻出血) and nasopharyngeal
surgery
13
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
14
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.
15
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
16
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
17
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.
20
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
21
⑶ Laryngoscope
①Configuration and classification
laryngoscope handle
laryngoscope blade: straight blade
curved blade
22
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 23
③Fiberoptic bronchoscope
24
⑷ Other equipment for endtracheal intubation
①Connector
②Stylet: It is a rigid implement usually made of
a flexible metal or rubber.
25
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.
26
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.
27
⑵ Local anesthesia
③Transtracheal anesthesia
28
⑶Local anesthesia combines general anesthesia
Indication: difficult intubation patients who
have the ability to maintain mask ventilation.
29
Section 2 Endotracheal Intubation
30
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 31
1.Indications and Advantages
⑴ Indications
General anesthesia
Respiratory treatment
Cardiopulmonary resuscitation
32
⑵ Advantages
Controls the airway
Facilitates ventilation/ O2
Prevents gastric inflation
Allows for direct suctioning
Medication administration
33
⑶ Contraindications
absolute contraindications:
laryngeal edema
acute airway inflammation
relative contraindications:
tracheal compression of aorta aneurysm
coagulopathy or other severe bleeding
diathesis
34
2. Visualized oral endotracheal intubationIn
Mask ventilation
Laryngoscope insertion
35
36
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38
39
Advantages of Oral Intubation
40
Disadvantages of Oral Intubation
41
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
42
⑵ Contraindications
43
⑶ Classfication
Visualized nasal intubation
44
45
Advantages of Nasal Intubation
46
Disadvantages of Nasal Intub.
47
4. Intubation of difficult airway
5. Tube exchanging
48
6. Tracheotomy
49
50
51
52
53
54
55
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.
56
57
Confirmation of tracheal intubation
58
Section 3 Endobronchial Intubation
59
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
60
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
61
2. Double-lumen endobronchial intubation
Types :
Carlens double-lumen endobronchial tubes
White double-lumen endobronchial tubes
Robertshaw double-lumen endobronchial tubes
62
63
Section 4 Extubation
64
Liberating from ETT
65
Extubation Procedure
Assemble Equipment
- intubation equipment
- in addition to intubation
equipment, O2 device
and humidity, SVN (small-
volume nebulizer ) with
racemic epinephrine
Suction ET tube
Oxygenate patient
Unsecure tube, deflate cuff
66
Extubation proced. (cont’d.)
67
Section 5 Complications of Endotracheal
and Endobronchial Intubation
68
Complications during larngoscopy and intuation
69
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
71
Complications while the tube is in place
2. Inadvertent extubation
72
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
73
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
74
Immediate and delayed complications
after extubation
1.Laryngospasm
3.Tracheal Collapse
4. Pharyngitis, Laryngitis
75
Immediate and delayed complications
after extubation
8. Maxillary sinusitis
9. Pneumonia
77
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.
78
1.Configuration
Airway mask
Airway tube
79
LMA is currently available in seven sizes for
neonates, infants, young children, older children,
and small, normal, and large adults.
80
2.Method of use
81
82
3.Advantages and indications
84
85
4.Disadvantages and contraindications
86
Thank You
87