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Tracheal Intubation Tintinalli Chap. 19

Tracheal Intubation Tintinalli Chap. 19. Nicholas Cardinal, DO. Indications. Correction of hypoxia or hypercarbia Prevention of impending hypoventilation Ensuring maintenance of a patent airway Secondary Indications Provision of a route for resuscitative medication administration

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Tracheal Intubation Tintinalli Chap. 19

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  1. Tracheal IntubationTintinalli Chap. 19 Nicholas Cardinal, DO

  2. Indications • Correction of hypoxia or hypercarbia • Prevention of impending hypoventilation • Ensuring maintenance of a patent airway • Secondary Indications • Provision of a route for resuscitative medication administration • To permit temporizing paralysis during diagnostic testing

  3. Endotracheal Tubes • Have appropriate size and another 0.5-1.0 mm smaller • Adult males • 8.0-8.5 mm • Adult females • 7.5-8.0 mm

  4. Laryngoscope Blades • Straight Miller blade • Number 3 or 4 • Physically lifts epiglottis • Mechanically easier to insert • Curved Macintosh blade • Number 2 or 3 • Placed in vallecula above the epiglottis • Indirectly lifts the epiglottis • Less trauma and less likely to stimulate airway reflex • Allows more room for adequate visualization

  5. Positioning • Sniffing Position • Flexion of lower neck with extension at the atlantooccipital joint • Alligns the oropharyngeal-laryngeal axis

  6. Assistance During Intubation • Cricoid Pressure (Sellick maneuver) • “Burp” Technique • Larynx is manually displaced posteriorly, superiorly, and laterally to the right • “Gum Elastic Bougie” • Eschmann Tracheal Tube Introducer/Stylet • Thin, flexible • Blindly inserted and ETT threaded over

  7. Tube Placement • Minimum of 2 cm above the carina • From corner of patient’s mouth • Men • Approximately 23 cm • Women • Approximately 21 cm

  8. Cuff Pressure • Minimum of 25 cm H2O to prevent aspiration • Less than 40 cm H2O to prevent mucosal ischemia

  9. Confirmation • “When in doubt, take it out.” • There is no clinically reliable substitute for direct visualization of the tube passing through the vocal cords. • Clinical Assessment • Auscultation • Tube Condensation • Symmetrical Chest Wall Expansion

  10. Confirmatory Adjuncts • End-tidal CO2 Detectors/Monitors • Detect/Measure CO2 in expired air • Capnometers • colormetric • Capnography • Real time CO2 waveforms • End-tidal CO2 Pressure Monitoring • May not occur even with proper ETT placement • States of low pulmonary perfusion • Massive obesity • Severe Pulmonary Edema • False Positive Detection • Gastric Distention from BVM • Ingestion of carbonated beverages • Few minutes following sodium bicarbonate bolus • Nebulizer • Epinephrine through ETT • Esophageal Detection Devices • Fit over 15-mm ETT connector • Do not depend on adequate cardiac output or pulmonary perfusion • Rely on anatomic differences between the trachea and esophagus

  11. Complications of Endotracheal Intubation • Obstruction • Secretions • Clot • Cuff Displacement • ETT cuff leaks • Arytenoid Cartilage Avulsion/Displacement • Intubation of Pyriform Sinus • Pharyngeal-esophageal Perforation • ChordalSynechiae • Commissural Stenosis • SubglotticStenosis • Most disastrous • Usually occurs in patients with poorly secured tubes or who are combative

  12. Alternative Airway Management • Nasotracheal Intubation • Helpful in situations where laryngoscopy or cricothyroidotomy may be difficult and neuromuscular blockade hazardous • Severely dyspneic patients who are awake and cannot tolerate supine position • CHF, COPD, Asthma • Difficulty aligning the oropharyngeal-laryngeal axis • Arthritis, masseter spasm, temperomandibular dislocation, recent oral surgical procedures • Others • Persistent trismus from seizures, facial trauma, infection, tetanus, decorticate-decerebrate rigidity, neuromuscular disorders/dystrophies

  13. NTI Tube Placement • Optimal Depth • Men • 28 cm at nares • Women • 26 cm at nares

  14. Complications of NTI • Epistaxis • Inadequate topical vasoconstriction • Excessive tube size • Poor technique • Anatomic defects • Obstruction • Retropharyngeal lacerations • Retropharyngeal abscesses • Nasal Necrosis • Paranasal Sinusitis • Risk correlates with duration

  15. Contraindications of NTI • Complex nasal fractures • Massive midfacial fractures

  16. Other Alternative Airway Techniques • Digital Intubation • Transillumination with lighted stylet • Laryngeal Mask Airway • Role is limited in ED d/t inability to protect against aspiration • Intubating LMA • Flexible Fiberoptic Laryngoscope • Indirect Fiberoptic Laryngoscopes • Retrograde Tracheal Intubation

  17. Rapid Sequence Intubation • Combined administration of a sedative and a neuromuscular blocking agent to facilitate intubation

  18. Pretreatment Agents • Attenuate pathophysiologic responses to largyngoscopy and intubation • Reflex Sympathetic Response • Causes increased heart rate and blood pressure • May be harmful in patients with intracranial hemorrhage, myocardial ischemia, or aortic dissection • Vagal Response • Predominates in children • Can result in significant bradycardia

  19. Pretreatment Agents

  20. Induction Agents

  21. Barbiturates • Avoid use in patients with hypotension, LV dysfunction, asthma, and porphyria • Thiopental • Short-acting sedative • Causes hypotension secondary to myocardial depression and venous dilatation • Methohexital • Twice as potent as thiopental • Ultra short-acting

  22. Ketamine • A phencyclidine derivative • Potent bronchodilator • Dissociative amnesia • Avoid in elderly patients and those with head injuries • “Emergence Phenomenon” • May occur as consciousness returns • Benzodiazepines may attenuate • Nightmares • Visual Hallucinations • Dissociative Sensations

  23. Etomidate • Non-barbiturate, non-receptor hypnotic • No analgesic activity • Does not blunt sympathetic response • Consider in patients with hypovolemia, closed head injury • Advantages • Protection from myocardial and cerebral ischemia • Minimal histamine release • Stable hemodynamic profile • Short duration of action

  24. Propofol • Highly lipophilic, rapid-acting sedative • No analgesic activity • Advantages • Antiemetic • Anticonvulsant • Lowers ICP

  25. Fentanyl • Not 1st line • Both sedative and analgesic activity • Neutral BP

  26. Paralytic Agents • Facilitate tracheal intubation • Improve mechanical ventilation • Help control intracranial hypertension • Decrease peak airway pressure

  27. Depolarizing Neuromuscular Blocking Agents • High affinity for cholinergic receptors of the motor endplate • Resistant to acetylcholinesterase • Produce transient muscle fasciculations followed by paralysis • Induction agent should be given prior unless significant head injury or overdose

  28. Succinylcholine • Most commonly used paralytic agent for tracheal intubation • More rapid onset and shorter duration than that of the nondepolarizing agents

  29. Relative Contraindications of Succinylcholine • Burns • Muscle Trauma • Crush Injuries • Myopathies • Rhabdomyolysis • Narrow-angle Glaucoma • Renal Failure • Neurologic Disorders • Guillain-Barre • Spinal Cord Injury

  30. Nondepolarizing Agents • Compete with acetylcholine for cholinergic receptors • Usually can be antagonized by anticholinesterase agents

  31. Reversal of Nondepolarizing Agents • Rarely necessary in the ED • Should not be attempted prior to some sign of motion or spontaneous recovery • Enzyme inhibitors will have no effect until at least 40% of spontaneous recovery has occured • Requires atropine 0.01 mg/kg IV to prevent muscarinic side effects

  32. Edrophonium • Acetylcholinesterase inhibitor • Faster onset and fewer side effects than neostigmine

  33. Difficult Airway • 2-3% of tracheal intubations prove impossible with standard techniques

  34. Identification of Difficult BVM • 2 out of 5 is predictive • Facial Hair • Obesity • Edentulous • Advanced Age • Snoring • Management • Better Positioning • Jaw Thrust • Two Person Bagging • Oral/Nasal Airways • Lubricant on Beard

  35. Factors Predictive of Intubation Difficulty • Facial Hair • Obesity • Short Neck • Small or Large Chin • Buckteeth • High arched Palate • Airway Deformity • Cervical Spine Immobility

  36. Mallampati’s Criteria • Class I • Faucial pillars, soft palate, and uvula can be visualized • Class II • Uvula is masked by base of tongue • Class III • Only base of uvula can be visualized • Up to 5% failure rate • Class IV • None of the structures can be visualized • Up to 20% failure rate

  37. Suspected Acute Intracranial Hypertension • Direct laryngoscopy can elevate ICP • Pretreatment with IV lidocaine or fentanyl may help blunt this response • Induction agents including Thiopental, Fentanyl, and Etomidate directly decrease ICP • Consider Nondepolarizing Agent as Succinylcholine may increase ICP • Keep MAP above 90 mmHg which will usually keep cerebral perfusion pressure above 70 mmHg • Maintain PaO2 of 100 mmHg • PEEP greater than 5 cm H2O will impair cerebral venous drainage • Avoid prophylactic hyperventilation therapy for 1st 24 hours after injury • Avoid extensively tight ETT straps, tight cervical collars, and Trendelenberg positioning which can potentiate elevated ICP

  38. Intubation of Patients with Cardiopulmonary Disease • Hypotension • Medications decrease sympathetic tone • Mechanical ventilation increases intrathoracic pressure which decreases venous return and preload

  39. Trauma Airway Management • Cervical Spine • Avoid barbiturates and benzodiazepines in hypotensive patients • Etomidate is induction agent of choice • Avoid ketamine if intracranial injury

  40. Aspiration • Occurs when tone of LES is insufficient to deal with increased intragastric pressure and protective laryngeal airway reflexes are depressed • Iatrogenic Causes • BVM Ventilation • Nasogastric Tubes • Paralytic Agents • Predisposing Conditions • Trauma • Bowel Obstruction • Obesity • Overdose • Pregnancy • Hiatal Hernia • Seizures

  41. Suctioning • Left Lateral Trendelenburg Position • Helps get tongue out of the way facilitating endotracheal suctioning • Use well-lubricated, soft, curved-tip catheter • Complications • Hypoxia • Cardiac Dysrhythmias • Hypotension • Pulmonic Collapse • Direct Mucosal Injury

  42. Mechanical Ventilatory Support • Modes • Controlled • Apneic patients • Assist-control (A/C) • Allows patient to trigger a cycle by inhaling • If not triggered, ventilator will deliver a controlled breath • Intermittent Mandatory Ventilation (IMV) • Unsynchronized delivery of ventilator-generated tidal volumes • SIMV is synchronized • Tidal Volume • Initially set at 10ml/kg • Peak Airway Pressure • Maintained below 35-45 cm H2O to prevent barotrauma • PEEP/CPAP • Consider if decreased pulmonary compliance prevents delivery of adequate tidal volume or if hypoxia persists despite 100% FiO2

  43. Extubation • Rarely indicated in ED • “Bucking” • Give 1-2 ml of 4% lidocaine down ETT • PostextubationLaryngospasm • Stridor following extubation • Treat with oxygen by positive pressure and nebulizedracemic epinephrine

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