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Definitions related to this topic
Anesthesia- Loss of sensation resulting from pharmacologic depression of nerve function or from neurological dysfunction.
Arytenoids- Denoting a cartilage (arytenoid cartilage) and muscles (oblique and transverse) arytenoid muscles) of the larynx.
Cuffed tubes- an inflated cuff surrounds a tube and is not inflated until after the tube is placed in the trachea. They are use to minimize the aspiration of foreign material into the bronchus. A cuffed tube should be used if there are excessive upper airway secretions or hemorrhage to prevent materials from entering the lungs. Cuffs also minimize air and pressure links around the tube.
Edema- An accumulation of an excessive amount of watery fluid in cells, tissues, or serous cavities.
Esophagus- The portion of the digestive canal between the pharnyx and stomach. It is about 25cm long and consists of three parts: the cervical part, from the cricoid cartilage to the thoracic inlet; the thoracic part, from the thoracic inlet to the diaphragm; and the abdominal part, below the diaphragm to the cardiac opening of the stomach.
Granulomas- Indefinite term applied to nodular inflammatory lesions, usually small or granular, firm, persistent, and containing compactly grouped mononuclear phagocytes.
Hyperextension- Extension of a limb or part beyond the normal limit.
Intubation- the insertion of a tubular device into a canal, hollow organ, or cavity.
Larynx- The organ of voice production; the part of the respiratory tract between the pharynx and the trachea; it consists of a framework of cartilages and elastic membranes housing the vocal folds and the muscles which control the position and tension of these elements.
Middle ear effusion- the escape of fluids from the middle ear.
Oral cavity- The mouth.
Sepsis- The presence of various pus-forming and other pathogenic organisms, or their toxins, in the blood or tissues; septicemia is a common type of sepsis.
Sinusitis- Inflammation of the lining membrane of any sinus, especially of one of the paranasal sinuses.
Stenosis- A stricture of any canal; especially, a narrowing of one of the cardiac valves.
Stenting- A supporting device that is used to keep the glottis open.
Synechia- Any adhesion; specifically, adhesion of an inflamed iris to the cornea or lens.
Traumatic intubation- infers that local tissue irritation or damage occurs because of the procedure.
Ulcers- A lesion on the surface of the skin or on a mucous surface, caused by superficial loss of tissue, usually with inflammation.
Vocal hypofunction- Term used to describe inadequate muscular tone in the laryngeal mechanism and associated structures or symptoms.
Types of intubation
Endoctracheal intubation- the passage of a tube through
the nose or mouth into the trachea for maintenance of the
airway during anesthesia or for maintenance of an imperiled
airway. This is considered a relatively temporary
procedure. The type of intubation used depends on the
patient's condition and on the purpose for intubation.
Nasogastric intubation- the insertion of an
endotracheal tube through the nose and into the
stomach to relieve excess air from the stomach or to
instill nutrients or medications..
Nasotracheal intubation- (blind) the insertion of
an endotracheal tube through the nose and into the
trachea. The tube is passed without using a
laryngoscope to view the glottic opening. This
technique may be used without hyperextension,
therefore it is useful when a client or patient
has cervical spinal trauma and with patients who have
clenched teeth. Indications for this type include
intraoral operative procedures, during which the the
endotracheal tube could easily be displaced or obscure
the operative site. Bleeding is not unusual after
intubation. The tubes are usually smaller than those
used for orotracheal intubation. This can also be
performed with direct visualization with a laryngoscopic
examination. Blind intubation is only used if there are
indications that the larynx can not be visualized.
Orotracheal intubation- the insertion of an
endotracheal tube through the mouth and into the
trachea. This type is performed much more frequently
than nasotracheal intubation.
Fiberoptic intubation-(awake)- a fiberoptic scope is
used that has an eyepiece to visualize the larynx and a
handle to control the tip. It is usually 2 1/2 - 3 feet
long. It is inserted in the patient's throat and guided to
the larynx and glottic opening. The endotracheal tube is
then slid over the fiberoptic scope into the trachea. This
procedure is usually used when patient's are unable to
flex and extend their head for any reason. Usually the
patient's throat is numbed with local anesthesics.
Patients are sedated and made comfortable. Sometimes
the patient is put to sleep. If general anesthesia is used
an assistant is mandatory, because one person can not
monitor the patient, administer general anesthesia, and
perform fiberoptic endoscopic examination.
Tracheostomy intubation- placing a tube by incising
the skin over the trachea and making a surgical wound
in order to create an airway. For the best results it is
performed over a previously placed endotracheal tube in
an operating room. However this is also performed as an
urgent, life-saving procedure.
Speaking tracheostomy tubes- specifically designed
tracheostomy tubes that allow the ventilator-dependent
client to speak by enabling air to enter the larynx without
compromising the patient's or client's ventilation. They
keep the air that is needed to ventilate the lungs separate
from the air supply for speech. Currently, there are two
types of designs to allow for independent voice control.
a. Electro-mechanical solenoid- controls the flow from
a compressed air source.
b. Air compressor- it can be turned on and off to
supply regulated air to the tracheostomy tube.
Indications for Intubation
To provide an airway in the trachea.
Control or pulmonary ventilation
For anesthesia (intracranial, intrathoracic, and most
intraabdominal operations mandate)
To relieve excess air from the stomach or to instill nutrients
or medications.
After induction of general anesthesia, to minimize the
possibility of aspiration of gastric contents.
For patients in respiratory distress.
Effects of Intubation
Major Complications:
1) tube obstruction
2) local tissue damage due to infection or pressure
necrosis in the nose, oral cavity, larynx, or subglottic
trachea.
3) Endobronchial (causes left lung to collapse) or esophageal
intubation
Possible antecedent to voice disorders- Cotton (1991) found
that better voices resulted when the duration of the stenting
was less than 12 weeks.
Vocal fold scarring or fibrosis after prolonged endotracheal
or nasogastric intubation.
Damage to the vocal mechanism during intubation or
extubation or from protracted intubation.
Stenosis and other laryngotracheal complications frequently
are secondary to prolonged intubation.
Edema caused by the irritation from nasogastric,
nasotracheal and orotracheal tubes.
Occult Sepsis has also been linked to intubation.
Sinustis and middle ear effusion has also been noted.
Injuries may include:
1) dislocation of arytenoids or mandible
2) interarytenoid fixation
3) vocal fold paralysis
4) synechia of vocal folds or laryngeal web
5) perforation of the piriform sinus or esophagus
6) laryngeal and tracheal stenosis
7) ulcers and granulomas on the vocal processes of
arytenoids.
8) damage to oral mechanism (e.g.mouth, teeth, palate, and
tongue)
Treatments include steroids, antibiotics, and surgery. It is recommended to remove fresh granulation tissue before development of a firm subglottic stenosis after intubation injury.
Cuffed tubes may also contribute to infection, tracheal
stenosis, esophageal erosion, and innominate artery
fistulization.
Interference with swallowing.
Vocal hypofunction is an effect of long term intubation.
Laryngeal webbing may be a result.
Intubation may increase risk of death in patients who have
suppressed immune systems.
Laryngospasm
Perforation of the trachea or esophagus
Retropharyngeal dissection
Fracture or dislocation of cervical spine
Trauma to eyes
Hemorrhage
Aspiration of secretions, blood, gastric contents, or foreign
bodies.
Hypoexmia, hypercarbia
Bradycardia, tachycardia
Hyperextension
Increased intracranial or introcular pressure
Excuriation of nose or mouth.
Dysphonia (hoarseness), aphonia
Paralysis of vocal folds or hypoglossal, lingual nerves.
Sore throat
Laryngeal incompetence
Tracheal collapse
Vocal fold granulomata or synechiae
Procedures and Equipment for Intubation
Management of patients having surgery
Case history: patient is questioned about signs and
symptoms suggestive of airway abnormalities, such as
hoarseness or shortness of breath. The patient is also
questioned about information on prior surgery, trauma,
neoplasia involving the airway, and prior anesthetic
experiences.
Physical examination: patient's head is viewed in profile and
palate should be examined for cleft. Many congenital
syndromes make it difficult or impossible to intubate. The
presence of protruding teeth may complicate intubation and
may cause difficulties producing a seal. Temporalmandibular
joint mobility should be assessed. The patient's cervical spine
mobility must be evaluated, because endotracheal intubation
usually involves extension of the neck. The distance between
the lower border of the mandible and the thyroid notch with
the patient's neck fully extended should be measured with a
ruler or intubation gauge. If the measurement is less than 6
cm, it will be impossible to visualize the larynx. The neck
should be palpated, so that masses and tracheal deviation can
be detected.
Airway Equipment:
Masks: Connell anotomic mask is used most frequently in
adults. They are available in a variety of sizes and have a
malleable body that allows it to be shaped to fit the patient's
face.
Airways: Available in several sizes and types. Most are
made of plastic, although some are designed of metal, including
one designed for use during fiberoptic endotracheal intubation.
Laryngoscopes: Composed of handle and blade. Curved and
straight blades are the two general types. Personal preference
primarily determines the type of blade used for intubating
adults.
Endotracheal Tubes: Numbered according to the internal
diameter. The approximate size and length of the tube is
determined by the patient's age and size.
Ancillary Equipment:
-Malleable metal or firm rubber stylets are used to maintain
the desired curve of the endotracheal tube during intubation.
-Soft plastic or rubber tooth protectors/guards can lesson the
chance of damage to the teeth.
Once it is determined that endotracheal intubation is
necessary: the anesthesiologist must decide whether
nasotracheal or orotracheal intubation is most appropriate;
choose the type and size of the laryngoscope and tube to use,
decide whether the patient is to be intubated while awake or
after induction of anesthesia; and decide a muscle relaxant can
be used separately.
Procedures in the Operating Room:
Before Intubation:
The anesthesia cart located in the operating room has all the
medication that is used feequently and those that are used
very rarely that are needed on an emergency basis. There is no
time to go and get them; because if something is happening to
a patient the diagnosis must be made and treated
immediately. The different kinds of medication are to put
patients to sleep or muscle relaxants (paralyze muscles.) There
are also narcotics that are used frequently in anesthesia that
require a code number that is recorded to get them. The
narcotics are 10 to 1000 times more potent than morphine.
Syringes with needles are used to draw out medication as
needed. The patient comes into surgery and as they come in
syringes are normally ready and medications drawn up. One of
the first things given to the patient is a sedative through an IV
tube that is in place. The patient is put on the operating table
or bed. The patient is then hooked up to the following
monitors: heart (EKG), and blood pressure cuff. The cuff
checks pressure from continuous readings to 15-30 minute
intervals, depending on the interval selected. The standard of
care is that blood pressure needs to be taken a minimum of
every five minutes during surgery. There is also a clip attached
to a patient's finger that checks the amount of oxygen in the
blood. Once the patient is hooked up to all the monitors, they
can be put to sleep. The patient is informed during the
procedures, what and why it is being done. There are different
techniques and script of what is said before the patient is put
to sleep. One example is, "Try to think of a nice place to go on
a vacation." This technique is used so that the patient might
have a nice dream while they are asleep. While the patient is
thinking, the anesthesiologist begins administering the
anesthetic. The anesthetic is in actuality a hypnotic to put the
patient to sleep. The patient must be hooked up to the
anesthesia machine to stay asleep. Intubation comes in at this
time.
During Intubation:
When the patient is asleep, they are given a muscle relaxant
that relaxes their muscles including the vocal folds to allow
them to open up. A blade and handle is selected for the
laryngoscope to visualize the larynx and intubate the patient
(e.g. Miller blade = straight blade and Macintosh = curved
blade.) The anesthesiologist places hand on head of patient
and pushes down, which picks up their mandible and allows
the mouth to open. The tip of the blade is inserted and slid
over the tongue to the base of the tongue. Next, the
anestesiologist pulls up and away from the patient in a
roughly 45 degree angle. The key is to make sure that the
patient is definitely asleep before this is done. The tube is
selected at this time. The tube is placed right between the
vocal folds and as soon as the top part of the cuff passes the
vocal folds the anesthesiologist stops. Sometimes stylets are
used to help in intubation. The cuff is inflated and the patient
is hooked up to the anesthesia machine.
After Intubation:
The mask is removed. The anesthetic is turned on. There are
three choices of gasses. The machine is turned on to
automatic. The machine breathes for the patient and
administers gas anesthesia to the patient. The
throat is suctioned out. After surgery, the patient must be
awake and responsive before it is safe to extubate the
endotracheal tube (e.g.ask patient to lift head for five seconds or
squeeze finger of anesthesiologist.)
Tips To Minimize Complications
Tubes should only be placed when indicated.
Frequent tube suctioning
Optimal mouth care
Secure and adequate fixation of the tube
The right size of tube should be used to avoid unnecessary
pressure on the vocal folds and inside lining of the larynx.
An appropriate handle and blade should be used
Make sure that a neutral position is maintained where the
tube emerges from the mouth or nose so that unnecessary
pressure is avoided
Cuffs should only be inflated when necessary only at
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