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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 mid-
trachea 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 23
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 31
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 (small-
volume 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 76


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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