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Tracheal intubation

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Tracheal intubation
Tracheal intubation being practiced on a mannequin (orotracheal technique using a laryngoscope.
ICD-9-CM96.04
MeSHD007442

Tracheal intubation (often simply referred to as intubation) is the placement of a flexible plastic tube into the trachea to protect the airway and provide a means of mechanical ventilation. The most common route for tracheal intubation is orotracheal where, with the assistance of a laryngoscope, an endotracheal tube is passed through the oropharynx, glottis, and larynx into the trachea. A high-volume, low-pressure cuff is then typically inflated near the distal tip of the tube to help secure it in place and protect the airway from blood, gastric contents and other secretions. Another route for tracheal intubation is nasotracheal, where an endotracheal tube is passed through the nasopharynx, glottis, and larynx into the trachea. Other routes for intubation of the trachea include the cricothyrotomy (used almost exclusively in emergency circumstances), and the tracheotomy (used primarily in circumstances where a prolonged need for airway support is anticipated).

After the trachea has been intubated and the tube has been secured to the face or neck, the proximal end of the tube is connected to a T-piece, anesthesia breathing circuit, bag valve mask device, or a mechanical ventilator. Once there is no longer a need for ventilatory assistance and/or protection of the airway, the tracheal tube may be removed; this is referred to as extubation of the trachea (or decannulation, in the case of a surgical airway such as a cricothyrotomy or a tracheotomy).

History

Pre-19th century

See also: Tracheotomy
This portrait, though undated, supports the view that tracheotomy was practiced in ancient history.

Tracheotomy was first depicted on Egyptian artifacts in 3600 BCE.[1] It was described in the Rigveda, a Hindi text, circa 2000 BCE.[1] Homerus of Byzantium is said to have written of Alexander the Great saving a soldier from suffocation in 1000 BCE by making an incision with the tip of his sword in the man's trachea.[1] Hippocrates condemned the practice of tracheotomy. Warning against the unacceptable risk of death from inadvertent laceration of the carotid artery during tracheotomy, he instead advocated the practice of tracheal intubation.[2] Because surgical instruments were not sterilized at that time, infections following surgery also produced numerous complications, including dyspnea, often leading to death.[3]

Despite the concerns of Hippocrates, it is believed that an early tracheotomy was performed by Asclepiades of Bithynia, who lived in Rome around 100 BCE. Galen and Aretaeus, both of whom lived in Rome in the second century AD, credit Asclepiades as being the first physician to perform a non-emergency tracheotomy.[citation needed] Antyllus, another Roman physician of the second century AD, supported tracheotomy when treating oral diseases. He refined the technique to be more similar to that used in modern times, recommending that a transverse incision be made between the third and fourth tracheal rings for the treatment of life-threatening airway obstruction.[2] Antyllus (whose original writings were lost but not before they were preserved by the Greek historian Oribasius) wrote that tracheotomy was not effective however in cases of severe laryngotracheobronchitis because the pathology was distal to the operative site.[3] In AD 131, Galen clarified the anatomy of the trachea and was the first to demonstrate that the larynx generates the voice.[citation needed]

By AD 700, the tracheotomy was well described in Indian and Arabian literature, although it was rarely practiced on humans.[3] Circa AD 1020, Avicenna described tracheal intubation in The Canon of Medicine in order to facilitate breathing.[4] The first correct description of the tracheotomy operation for treatment of asphyxiation was described by Ibn Zuhr in the 12th century,[5]

From 1500 to 1833 there are only 28 known reports of successful tracheotomy.[6] Although the Renaissance saw significant advances in science and surgery, and surgeons became increasingly open to experimental surgery on the trachea, nevertheless the mortality rate failed to improve.[6] The next known report on tracheal intubation and subsequent artificial respiration of animals was in 1543, when Andreas Vesalius pointed out that the technique could be life-saving.[citation needed] The next known report of human tracheotomy was in 1546, performed on a patient suffering from complications of a peritonsillar abscess; this patient apparently made a complete recovery.[2] In the late 16th century, anatomist Hieronymus Fabricius described a useful technique in his writings, although he had never actually performed a tracheotomy. He advised using a vertical incision and a straighter, shorter cannula that would prevent the tube from advancing too far into the trachea. He counseled that the operation should be performed only as a last option.[3] The first tracheotomy to be described on a pediatric patient was in 1620, after a boy began to ashyxiate on a bag of gold he had swallowed. The object became lodged in his esophagus, obstructing his trachea. The tracheotomy allowed the surgeon to manipulate the bag so that it passed through his alimentary tract, apparently with no further sequelae.[3]

19th century

See also: Endoscopy

In the early 19th century, the tracheotomy finally began to be recognized as a legitimate means of treating severe airway obstruction. In 1832, French physician Pierre Bretonneau employed it as a last resort to treat a case of diphtheria.[7] In 1852, Bretonneau's student Armand Trousseau reported a series of 169 tracheotomies (158 of which were for croup, and 11 for "chronic maladies of the larynx")[8] Trousseau's claimed 73% mortality rate was hailed as "very satisfying".[3] If the procedure is delayed until the patient is close to death, the body will have already incurred major damage due to anoxia. Despite this, surgeons continued to postpone the tracheotomy until it was too late to be effective. In 1869, the German surgeon Friedrich Trendelenburg reported the first successful elective human tracheotomy to be performed for the purpose of administration of general anesthesia.[citation needed] In 1878, the Scottish surgeon William Macewen reported the first orotracheal intubation.[citation needed] At last, in 1880 Morrell Mackenzie's book discussed the symptoms indicating a tracheotomy and when the operation is absolutely necessary.[2]

While all these surgical advances were taking place, many important developments were also taking place in the science of optics. Many new optical instruments with medical applications were invented during the 19th century. In 1805, German physician Philipp von Bozzini used a device he invented and called the lichtleiter (or light-guiding instrument) to examine the human urinary bladder, rectum, nasopharynx and laryngopharynx.[9][10] The practice of gastric endoscopy in humans was pioneered by United States Army surgeon William Beaumont in 1822 with the cooperation of his patient Alexis St. Martin, a victim of an accidental gunshot wound to the stomach.[11] In 1853, Antoine Jean Desormeaux of France examined the human bladder using a device he invented and called the endoscope (this was the first time this term was applied to this practice).[citation needed] In 1854, a singing teacher named Manuel Garcia became the first man to view the functioning glottis in its entirety. Garcia developed a tool that used two mirrors for which the sun served as an external light source.[12] Using this device, he was able to observe the function of his own glottic apparatus and the uppermost portion of his trachea. His findings were presented at the Royal Society of London in 1855.[10] In 1868, Adolph Kussmaul of Germany performed the first esophagogastroduodenoscopy on a living human. The subject was a sword-swallower, who swallowed a metal tube with a length of 47 centimeters and a diameter of 13 millimeters.[citation needed] On 2 October 1877, Berlin physician Maximilian Nitze and instrument maker Josef Leiter introduced the cystourethroscope[13] and in 1881, Polish physician Jan Mikulicz-Radecki created the first rigid gastroscope for practical applications.[14][15][16] All previous observations of the glottis and larynx had been performed under indirect vision (using mirrors) until 23 April 1895, when Alfred Kirstein of Germany first described direct visualization of the vocal cords. Kirstein performed the first direct laryngoscopy in Berlin, using an esophagoscope he had modified for this purpose; he called this device an autoscope.[17] It is believed that the death in 1888 of Kaiser Frederick from laryngeal cancer motivated Kirstein to develop the autoscope. [18]

20th century

The 20th century saw the transformation of the practices of endoscopy and tracheal intubation from rarely employed procedures to essential components of the practices of anesthesia, critical care medicine, emergency medicine, gastroenterology, pulmonology, and surgery. Until 1913, surgery involving the mouth and nose was performed by mask inhalation anesthesia, topical application of local anesthetics to the mucosa, rectal anesthesia, or intravenous anesthesia. While otherwise effective, these techniques did not protect the airway from obstruction and also exposed patients to the risk of aspiration of blood and mucus into the tracheobronchial tree. In 1913, Chevalier Jackson, a professor of laryngology at Jefferson Medical College in Philadelphia, Pennsylvania, was the first to report a high rate of success for the use of direct laryngoscopy in orotracheal intubation.[19] Jackson introduced a new laryngoscope blade that had a light source at the distal tip, rather than the proximal light source used by Kirstein.[20] This new blade incorporated a component that the operator could slide out to allow room for passage of an endotracheal tube or bronchoscope.[9][20]

That same year, Henry Janeway published results he had achieved using another new laryngoscope he had recently developed.[21] An American anesthesiologist practicing at Bellevue Hospital in New York City, Janeway believed that direct intratracheal insufflation of volatile anesthetics would provide improved conditions for surgery of the nose, mouth and throat. With this in mind, he developed a laryngoscope designed for the sole purpose of tracheal intubation. Similar to Jackson's device, Janeway's instrument incorporated a distal light source. Unique however was the inclusion of batteries within the handle of the laryngoscope. Additional features included a central notch for maintaining the tracheal tube in the midline of the oropharynx during intubation, and a slight curve to the distal tip of the blade to help guide the tube through the glottis. The success of this design led to its subsequent use in other types of surgery in addition to surgery of the nose, mouth and throat. Janeway was instrumental in popularizing the widespread use of direct laryngoscopy and tracheal intubation in the practice of anesthesiology.

After World War I, further advances were made in the field of intratracheal anesthesia. Perhaps most notable among these were those made by Sir Ivan Whiteside Magill (1888–1986). Working at the Queen's Hospital for Facial and Jaw Injuries in Sidcup with Sir Harold Gillies (a surgeon) and E. Stanley Rowbotham (an anesthetist), Magill developed the technique of awake blind nasotracheal intubation.[22][23][24][25][26][27] Magill devised a new type of angulated forceps (the Magill forceps) that are still used today to facilitate nasotracheal intubation in a manner that is little changed from Magill's original technique.[28] Other devices invented by Magill include the Magill laryngoscope blade,[29] as well as several apparati for the administration of volatile anesthetic agents.[30][31][32] The Magill curve of an endotracheal tube is also named for Magill.

Robert Macintosh also achieved significant advances in techniques for tracheal intubation when he introduced his new curved laryngoscope blade in 1943.[33] The most widely used curved laryngoscope blade is named after Macintosh.[34] In 1932, Rudolph Schindler of Germany introduced the first semi-flexible gastroscope.[35] This device had numerous lenses positioned throughout the tube and a miniature light bulb at the distal tip. The tube of this device was 75 centimeters in length and 11 millimeters in diameter, and the distal portion was capable of a certain degree of flexion. Between 1945 and 1952, optical engineers (notably Karl Storz of Germany, Harold Hopkins of England, and Mutsuo Sugiura of the Japanese Olympus Corporation) built upon this early work, leading to the development of the first gastrocamera.[36] In 1964, Fernando Alves Martins of Portugal applied optical fiber technology to one of these early gastrocameras to produce the first gastrocamera with a flexible fiberscope.[37][38] Initially used in esophagogastroduodenoscopy, newer devices were developed in the late 1960s for use in bronchoscopy, rhinoscopy, and laryngoscopy. The concept of using a fiberoptic endoscope for tracheal intubation was introduced by Peter Murphy in 1967.[39] By the mid-1980s, the flexible fiberoptic bronchoscope had become an indispensable instrument within the pulmonology and anesthesia communities.

In the early 20th century, physicians began to use the tracheotomy in the treatment of patients afflicted with paralytic poliomyelitis who required mechanical ventilation. The currently used surgical tracheotomy technique was described in 1909 by Chevalier Jackson.[40] However, surgeons continued to debate various aspects of the tracheotomy well into the 20th century. Many techniques were described and employed, along with many different surgical instruments and tracheal tubes. Surgeons could not seem to reach a consensus on where or how the tracheal incision should be made, arguing whether the "high tracheotomy" or the "low tracheotomy" was more beneficial. Ironically, the newly developed inhalational anesthetic agents and techniques of general anesthesia actually seemed to increase the risks, with many people suffering fatal postoperative complications. Jackson emphasised the importance of postoperative care, which dramatically reduced the death rate. By 1965, the surgical anatomy was thoroughly and widely understood, antibiotics were widely available and useful for treating postoperative infections, and other major complications of tracheotomy had also become more manageable. The current perioperative mortality rate for tracheotomy is less than 1%.[41][42]

21st century

The "digital revolution" has brought newer technology to the art and science of tracheal intubation. Several manufacturers have developed video laryngoscopes which employ digital technology such as the CMOS active pixel sensor (CMOS APS) to generate a view of the glottis so that the trachea may be intubated. The Glidescope video laryngoscope is one example of such a device.[43][44]

Indications

Tracheal intubation (orotracheal, nasotracheal, cricothyrotomy, or tracheotomy) is indicated under any of the following circumstances:[45]

Predicting difficulty of tracheal intubation

All persons performing tracheal intubation must be familiar with alternative techniques of securing the airway. Because the life of a patient can depend on the success of tracheal intubation, it is important to assess possible obstacles beforehand. The history is helpful in this respect. The diagnosis and/or proposed surgical procedure may offer clues to a potentially difficult airway. The subject should be questioned about any significant signs or symptoms, such as dysphonia or dyspnea. Such findings may suggest obstructing lesions in various locations within the pharynx, larynx, or tracheobronchial tree. It is also important to elicit any history of previous surgery (e.g., previous cervical fusion), trauma, radiation therapy, or tumors involving the head, neck, and mediastinum, as well as any prior experiences with tracheal intubation (especially prior tracheotomy).

A detailed physical examination is also critical to evaluation of the airway. Specifically, one should evaluate:

  1. the range of motion of the cervical spine: the subject should be able to tilt the head back and then forward so that the mentum touches the chest.
  2. the range of motion of the temporomandibular joint: three of the subject's fingers should be able to fit between the upper and lower incisors.
  3. the size and shape of the maxilla and mandible, looking especially for problems such as maxillary hypoplasia, prominent maxillary incisors or retrognathia.
  4. the thyromental distance: three of the subject's fingers should be able to fit between the thyroid cartilage and the mentum.
  5. the size and shape of the tongue and palate relative to the size of the oral cavity:
  6. the teeth, especially noting the presence of any loose or damaged teeth or crowns.

Besides the physical examination, many classification systems have been developed in an effort to predict difficulty of tracheal intubation, including the Cormack-Lehane grading system,[47][48] the Intubation Difficulty Scale (IDS),[49] and the Mallampati score.[50] The Mallampati score is determined by looking at the anatomy of the mouth and based on the visibility of the base of uvula, faucial pillars and the soft palate.

Such medical scoring systems correlate to some extent with the degree of difficulty of laryngoscopy and tracheal intubation, and may aid in the evaluation of factors linked to difficult tracheal intubation. It should however be noted that no single score or combination of scores can be trusted to detect all patients who are difficult to intubate. No system has yet been devised that can claim 100% positive predictive value, or 100% sensitivity and specificity. Furthermore, one recent study has demonstrated that even among experienced anesthesiologists, only 25% could correctly define all four grades of the widely used Cormack–Lehane classification system, and intra-observer reliability (reproducibility of results) was poor.[51] While perfection may be an unrealistic expectation from a statistical standpoint, the grave consequences of failed tracheal intubation require the highest possible degree of certainty in predicting the difficulty of intubation.

Equipment

Laryngoscopes

Main article: Laryngoscope
Laryngoscope handles with an assortment of Miller blades (large adult, small adult, pediatric, infant, and neonate).
Laryngoscope handle with an assortment of Macintosh blades (large adult, small adult, pediatric).

The vast majority of tracheal intubations involve the use of a "scope" of one type or another. Since its introduction by Kirstein in 1895, the most common device used for this purpose has been the conventional laryngoscope. Today, the typical conventional laryngoscope consists of a handle, usually containing batteries, and a set of interchangeable blades. Two basic styles of laryngoscope blade are commercially available: the straight blade and the curved blade. The Macintosh blade is the most widely used of the curved laryngoscope blades,[34] while the Miller blade[52] is the most popular style of straight blade.[53] There are many other styles of straight and curved blades (e.g., Phillips, Robertshaw, Sykes, Wisconsin, Wis-Hipple, etc.) with accessories such as mirrors for enlarging the field of view and even ports for the administration of oxygen. These specialty blades are primarily designed for use by anesthetists, most commonly in the operating room.

Besides the conventional laryngoscopes, many other devices have been developed as alternatives to direct laryngoscopy. These include a number of indirect fiberoptic viewing laryngoscopes such as the flexible fiberoptic bronchoscope, Bullard scope,[54] UpsherScope,[55][56] and the WuScope.[57] These devices are widely employed for tracheal intubation, especially in the setting of the difficult intubation (see below). Several types of video laryngoscopes are also currently available, such as the Glidescope,[43][44] McGrath laryngoscope,[58] Daiken Medical Coopdech C-scope VLP-100,[59] the Storz C-Mac,[60] Pentax AWS,[61][62][63][64] Video Macintosh Intubating Laryngoscope System (VMS)[65] and the Berci DCI[66]. Other "noninvasive" devices which are commonly employed for tracheal intubation are the laryngeal mask airway[46] (used as a guide for endotracheal tube placement), the lighted stylet,[67][68] and the AirTraq.[69] Due to the widespread availability of such devices, the technique of blind digital intubation[70] of the trachea is rarely practiced today, though it may still be useful in emergency situations under austere conditions such as natural or man-made disasters.

Stylets

File:Tracheal tube-stylet.JPG
An endotracheal tube stylet, useful in facilitating orotracheal intubation.

An intubating stylet is a malleable metal wire which can be inserted into the endotracheal tube to make the tube conform better to the laryngopharyngeal anatomy of the specific individual, thus facilitating its insertion. It is commonly employed under circumstances of difficult laryngoscopy. Just as with laryngoscope blades, there are also several types of available stylets. The Verathon Stylet is a rigid stylet that is curved to follow the 60° angulation of the blade of the GlideScope® video laryngoscope.[43]

The Eschmann tracheal tube introducer (often referred to as a gum elastic bougie) is another specialized type of stylet, which can also be used to facilitate difficult intubation.[71][72] This flexible device is 60 cm in length, 15 French (5 mm diameter) with a small "hockey-stick" angle at its distal tip. Unlike the stylet, the Eschmann tracheal tube introducer is typically inserted directly into the trachea and then used as a guideover which the endotracheal tube can be passed (in a manner analogous to the Seldinger technique). As the Eschmann tracheal tube introducer is considerably less rigid than a conventional stylet, this technique is considered to be a relatively atraumatic means of tracheal intubation.

The concept of using a stylet for replacing or exchanging orotracheal tubes was introduced by Finucane and Kupshik in 1978, using a central venous catheter.[73] The modern tracheal tube exchanger is a hollow catheter, 56-81 cm in length, that can be used for removal and replacement of tracheal tubes without the need for laryngoscopy.[74] The Cook Airway Exchange Catheter (CAEC) is another example of this type of catheter.[75]

Tracheal tubes

File:Endotracheal tube colored.png
Diagram of an endotracheal tube (blue, A; Cuff inflation tube B) that has been inserted into the airway (C) of a patient. D: Esophagus

Tracheal tubes are commonly used for airway management in the settings of general anesthesia, critical care, mechanical ventilation, and emergency medicine. They may also be used as an alternative route for many medications, in the event an intravenous infusion cannot be established. The tube is inserted into the trachea in order to ensure that the airway is not closed off and that air is able to reach the lungs. The tracheal tube is regarded as the most reliable available method for protecting a patient's airway.

Sir Ivan Whiteside Magill (1888–1986) was an Irish born anesthetist who is famous for his involvement in much of the innovation and development in modern anesthesia. Originally a general practitioner, he accepted a post at the Queen's Hospital, Sidcup in 1919 as an anesthetist. The hospital had been established for the treatment of facial injuries sustained in the World War I. Working with plastic surgeon Harold Gillies, he was responsible for the development of numerous items of anesthetic equipment but most particularly the single-tube technique of endotracheal anesthesia. This was driven by the immense difficulties of administering "standard" anesthetics such as chloroform and ether to men with severe facial injury using masks; they would cover the operative field. Following the closure of the hospital, and the diminishing numbers of patients seen from the war era, he continued to work with Gillies in private practice but was also appointed to the Westminster Hospital and Brompton Hospital in London. He was Knighted by Queen Elizabeth II in 1960.

The original tubes were cut from a roll of rubber industrial tubing by his assistant, hence the natural curve of the tube. A curved metal adaptor was designed (Magill oral & nasal connectors) and a 4" black rubber connecting hose to fit to the anesthetic circuit was adapted from an MG brake hose and named the 'catheter mount' by Magill's theatre technician at Westminster Hospital. Originally, there was no inflatable cuff, the tube was packed either side of the sub-glottis by two green anesthetic swabs, with ribbon gauze sewn on by hand to aid extraction at extubation of the trachea. Anesthetic gel or ointment was used to lubricate the tube and provide some relief for the patient's throat soreness after the procedure.

A typical cuffed endotracheal tube, constructed of polyvinyl chloride.

Portex Medical (England and France) produced the first cuffless plastic 'Ivory' tracheal tubes, in conjunction with Magill's design later adding a cuff as manufacturing techniques became more viable, these were glued on by hand to make the famous Blue-line tube copied by many other manufacturers. Mallinckrodt GmBH developed the disposable endotracheal tube and produced a plethora of design variations, adding the 'Murphy Eye' to their tubes in case of 'accidental' placement of the tube to avoid right bronchial occlusion. David S. Sheridan was one of the manufacturers of the American markets "disposable" plastic endotracheal tube now used routinely in surgery. Previously, red rubber (Rusch-Germany) tubes were used, then sterilized for re-use.

Tracheal intubation usually requires general anesthesia and muscle relaxation but can be achieved in the awake patient with local anesthesia or in an emergency without any anesthesia, although this is extremely uncomfortable. It is usually performed by visualising the glottis by means of a hand-held laryngoscope that has a variety of curved and straight blades, with a light source. Intubation can also be performed using a flexible fiberoptic bronchoscope, video laryngoscope, or simply with the use of the attendant's fingers (this technique is referred to as blind digital intubation). The goal is to position the end of the tracheal tube two centimeters above the bifurcation of the lungs or the carina. If inserted too far into the trachea it often goes into the right main bronchus (because the right main brochus is less angled than the left.

Most tracheal tubes today are constructed of polyvinyl chloride, but specialty tubes constructed of silicone rubber, latex rubber, or stainless steel are also widely available. Most tubes have an inflatable cuff to seal the trachea and bronchial tree against air leakage and aspiration of gastric contents, blood, secretions, and other fluids. Uncuffed tubes are also available, though their use is limited mostly to pediatric patients (in small children, the cricoid cartilage, the narrowest portion of the pediatric airway, often provides an adequate seal for mechanical ventilation).

A Carlens double-lumen endotracheal tube, commonly used for thoracic surgical operations such as VATS lobectomy.

Types of tracheal tube include oral or nasal, cuffed or un-cuffed, preformed (e.g. RAE tube), reinforced tubes, double-lumen tubes and tracheostomy tubes. For human use, tubes range in size from 2-10.5 mm in internal diameter (ID). The size is chosen based on the patient's body size, with the smaller sizes being used for pediatric and neonatal patients. Tubes larger than 6 mm ID usually have an inflatable cuff. Originally made from red rubber, most modern tubes are made from polyvinyl chloride. Those placed in a laser field may be flexometallic. Robertshaw (and others) developed double-lumen endo-bronchial tubes for intra-thoracic surgery. These allow single-lung ventilation whilst the other lung is collapsed to make surgery easier. The deflated lung is re-inflated as surgery finishes to check for fistulas (tears). Another type of endotracheal tube has a small second lumen opening above the inflatable cuff, which can be used for suction of the nasopharngeal area and above the cuff to aid extubation (removal). This allows suctioning of secretions which sit above the cuff which helps reduce the risk of chest infections in long-term intubated patients. A shortened tube, a tracheostomy tube, can be inserted through an opening in the neck (a tracheostomy) into the trachea. This is often a temporary stoma, but patients can live with them permanently.

The "armored" endotracheal tubes are cuffed, wire-reinforced, silicone rubber tubes which are quite flexible but yet difficult to compress or kink. This can make them useful for situations in which the trachea is anticipated to remain intubated for a prolonged duration, or if the neck is to remain flexed during surgery. Polyvinyl chloride tubes are relatively stiff in comparison. Preformed tubes (such as the oral and nasal RAE tubes, named after the inventors Ring, Adair and Elwyn) are also widely available for special applications. These may also be constructed of polyvinyl chloride or wire-reinforced silicone rubber. Other tubes (such as the Bivona® Fome-Cuf® tube) are designed specifcally for use in laser surgery in and around the airway. Various types of double-lumen endotracheal (actually, endobronchial) tubes have been developed (Carlens,[76] White, Robertshaw, etc.) for ventilating each lung independently—this is useful during pulmonary and other thoracic operations.

A tracheostomy tube is a 2-3 inch-long curved metal or plastic tube that may be inserted into a tracheostomy stoma to maintain patency of the lumen. Several types of tracheostomy tube are available, depending on the requirements of the patient, including Shiley, Bivona (a silicon tube with metal rings that are good for airways with damage to the tracheal rings or otherwise not straight), and fenestrated.

A tracheal button is a rigid plastic cannula about 1 inch in length that can be placed into the tracheostomy after removal of a tracheostomy tube, to maintain patency of the lumen. It is generally used in people with obstructive sleep apnea, who wear it during during waking hours and remove it while sleeping to ensure a patent airway and reduce the risk of asphyxiation. Since the tube does not extend far into the trachea, it is easy to breathe and speak with the device in place.

Methods to confirm tube placement

No single method for confirming tracheal tube placement has been shown to be 100% reliable. Accordingly, the use of multiple methods for confirmation of correct tube placement is now widely considered to be the standard of care. Such methods include direct visualization of the tip of the tube as it passes through the glottis. Additionally, one should be able to hear equal bilateral breath sounds on auscultation of the chest, and no sound upon auscultation of the epigastrium. Equal bilateral rise and fall of the chest wall should be evident with ventilatory excursions. A small amount of water vapor should also be evident within the lumen of the tube with each exhalation, and there should be no gastric contents in the tube at any time.

Ideally, at least one of the methods utilized for confirming tracheal tube placement should be an instrument. Waveform capnography has emerged as the gold standard for the confirmation of tube placement within the trachea. Other methods relying on instruments include the use of a colorimetric end-tidal carbon dioxide detector, a self-inflating esophageal bulb, or an esophageal detection device.[77] Pulse oximetry is also widely used as a tertiary confirmation measure, but this technique has important limitations, most notably a significant delay in the decrease in oxygen saturation, especially if the subject has been pre-oxygenated.

Tracheal tube maintenance

The tube is secured in place with tape or a tracheal tube holder. A cervical collar is sometimes used to prevent motion of the airway. Tube placement should be confirmed after each physical move of the patient and after any unexplained change in his/her clinical status. Continuous pulse oximetry and continuous waveform capnography are often used to monitor the tube's correct placement.

An excessive leak can sometimes be corrected through the placement of a larger (0.5 mm larger in internal diameter) tracheal tube, and in difficult-to-ventilate pediatric patients children it is often necessary to use cuffed tubes to allow for high pressure ventilation if the leak is too great to overcome with the ventilator.[78]

Special situations

Emergency intubation

Personnel experienced in direct laryngoscopy are not always immediately available in certain settings that require emergency tracheal intubation. For this reason, specialized devices have been designed to act as bridges to a definitive airway. Such devices include the laryngeal mask airway, cuffed oropharyngeal airway, and the Combitube.[79] Other devices such as rigid stylets, the lightwand (a blind technique) and indirect fiberoptic rigid stylets, such as the Bullard scope, Upsher scope, and the WuScope can also be used as alternatives to direct laryngoscopy. Each of these devices have its own unique set of benefits and drawbacks, and none of them is effective under all circumstances.

Rapid-sequence induction and intubation

Rapid-sequence induction and intubation (RSI) refers to a special method of induction of general anesthesia, commonly employed in emergency operations, and other situations where patients are assumed to have a "full stomach". RSI involves pre-oxygenating the lungs with a tightly-fitting oxygen mask, followed by the sequential administration of an intravenous hypnotic agent and a rapidly-acting neuromuscular-blocking drug, prior to intubation of the trachea. One important difference between RSI and routine tracheal intubation is that the practitoner does not ventilate the lungs after the onset of general anesthesia and apnea.

Another key feature of RSI is the application of manual pressure to the cricoid cartilage, often referred to as the Sellick maneuver, prior to instrumentation of the airway and intubation of the trachea. Named for British anaesthetist Brian Arthur Sellick (1918–1996) who first described the procedure in 1961,[80] the Sellick maneuver (sometimes referred to as the application of cricoid pressure) is a method of preventing regurgitation and pulmonary aspiration of gastric contents, in addition to helping to bring the glottis into view during laryngoscopy and tracheal intubation. Pulmonary aspiration of gastric contents can result in a severe chemical aspiration pneumonitis that has a high mortality rate; proper use of the Sellick maneuver can minimize the occurrence of this dreaded complication. Cricoid pressure has been widely used during rapid sequence intubation for decades, despite a lack of compelling evidence to support this practice.[81][82] The initial article by Sellick was based on a small sample size at a time when high tidal volumes, head-down positioning, and barbiturate anesthesia were the rule.[83] Recent studies have shown that incorrect application of cricoid pressure may displace the esophagus laterally, instead of compressing it as described by Sellick.[84][85] Several studies demonstrate some degree of glottic compression,[86][87][88] reduction in tidal volume, and increase in peak pressures.[89][90][91][92][93][94]

Nasotracheal intubation

Nasotracheal intubation

Difficult intubation

Many individuals have unusual airway anatomy, such as those who have limited range of motion of the cervical spine or temporomandibular joint, or who have oropharyngeal tumors, hematomas, angioedema, micrognathia, retrognathia, or excess adipose tissue of the face and neck. Using conventional laryngoscopic techniques, intubation of the trachea can be difficult in such people. Use of the flexible fiberoptic bronchoscope and similar devices has become among the preferred techniques in the management of such cases. Among the drawbacks of these devices are their high cost of purchase, maintenance and repair.[95][96] Another drawback is that intubation with one of these devices can take considerably longer than that achieved using conventional laryngoscopy; this limits their use somewhat in urgent and emergent situations.

Cricothyrotomy

Main article: Cricothyrotomy

A cricothyrotomy is an incision made through the skin and cricothyroid membrane to establish a patent airway during certain life-threatening situations, such as airway obstruction by a foreign body, angioedema, or massive facial trauma. Cricothyrotomy is nearly always performed as a last resort in cases where orotracheal and nasotracheal intubation are impossible or contraindicated. Cricothyrotomy is easier and quicker to perform than tracheotomy, does not require manipulation of the cervical spine, and is associated with fewer complications.[97]

The quickest and easiest method of to perform this technique is the needle cricothyrotomy, in which a large-bore (12-14 gauge) intravenous catheter is used to puncture the cricothyroid membrane. Oxygen can then be administered through this catheter via jet insufflation. However, while needle cricothyrotomy may be life-saving in extreme circumstances, this technique is only intended to be a temporizing measure until a definitive airway can be established.[45] In practice, needle cricothyrotomy is little better than apneic oxygenation inasmuch as the small diameter of an intravenous catheter allows for adequate oxygenation but not for elimination of carbon dioxide (ventilation). After one hour of apneic oxygenation through a needle cricothyrotomy, one can expect a PaCO2 of greater than 250 millimeters of mercury and an arterial pH of less than 6.72, despite an oxygen saturation of 98% or greater.[98] A more definitive airway can be established by performing a surgical cricothyrotomy, in which a 5-6 mm endotracheal tube or tracheostomy tube can be inserted through a larger incision.

Tracheotomy

Main article: Tracheotomy

Pediatric patients

Most of the general principles of anesthesia can be applied to children, but there are some significant anatomical and physiological differences between children and adults that can cause problems, especially in neonates and children weighing less than 15 kg. For infants and young children, oral intubation is easier than nasal. Nasal route carries risk of dislodgement of adenoid tissue and epistaxis, but advantages include good fixation of tube. Because of good fixation, nasal route is preferable to oral route in children undergoing intensive care and requiring prolonged intubation. The position of the tube is checked by auscultation (equal air entry on each side and, in long-term intubation, by chest X-ray). Because the airway of a child is narrow, a small amount of oedema can produce severe obstruction. Edema can easily be caused by forcing in a tracheal tube that is too tight. (If length of the tube is suspected to be large, immediate changing it to the smaller size is suggestible.)

The appropriate length for the endotracheal tube can be estimated by doubling the distance from the corner of the child's mouth to the ear canal. The tip of the tube should be at midtrachea, between the clavicles on an AP chest X-ray. The correct diameter of the tube is that which results in a small leak at a pressure of about 25 cm of water. The appropriate inner diameter for the endotracheal tube is roughly the same diameter as the child's little finger. For normally nourished children 2 years of age and older, the internal diameter of the tube can be calculated using the following formula:

  • Internal diameter of tube (mm) = (patient's age in years + 16) / 4

For neonates, 3 mm internal diameter is accepted while for premature infants 2.5 mm internal diameter is more appropriate.

As with adults, there are a number of devices specially designed for assistance with difficult tracheal intubation in pediatric patients.[99][100]

Complications

Tracheal intubation is an invasive procedure that requires a great deal of clinical experience to master.[101] When performed improperly (e.g., unrecognized esophageal intubation), the associated complications may be rapidly fatal.[102] Consequently, in recent editions of its Guidelines for Cardiopulmonary Resuscitation the American Heart Association has de-emphasized the role of tracheal intubation in advanced airway maintenance, in favor of more basic techniques like bag-valve-mask ventilation.[103] Despite these concerns, tracheal intubation is still considered the definitive technique for airway management, as it allows the most reliable means of oxygenation and ventilation, while providing the highest level of protection against vomitus and regurgitation.

Although the conventional laryngoscope has proven effective across a wide variety of settings and patients, its use and misuse can result in serious complications (e.g., trauma to oropharyngeal and dental structures). Newer technologies such as flexible fiberoptic laryngoscopy have fared better in reducing the incidence of such complications, though the most common cause of intubation trauma remains a lack of skill on the part of the laryngoscopist.

Even when properly performed, significant complications may result as a result of tracheal intubation, especially for prolonged duration. Such complications include dental trauma, vocal cord paresis, tracheoinnominate fistula, tracheomalacia, tracheoesophageal fistula, or even frank rupture of the trachea.

The cuff pressure must be monitored carefully in order to avoid complications from over-inflation, many of which can be traced to excessive cuff pressure causing ischemia of the tracheal mucosa.[104]

See also

References

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Bibliography

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