Tracheobronchial Tree

By,Dr. Yogesh Kumar Chhetty

Under the guidance of:

Dr. Rajan Nanda&Dr. Hemlata Ametha

THE COMPONENTS OF THE RESPIRATORY SYSTEM

Upper respiratory system

• Nose

• Nasal cavity

• Paranasal sinuses

• Pharynx

Lower respiratory system

• Larynx

• Trachea

• Bronchi

• Lungs

UPPER RESPIRATORY SYSTEM

THE NOSE, NASAL CAVITY, AND PHARYNX• Nose is primary passageway for air

entering respiratory system

• Air enters paired external nares that open into nasal cavity

• Vestibule : portion of nasal cavity contained within flexible tissues of external nose

• Vestibule contains coarse hair that trap foreign particles

• Nasal septum : divides cavity into right & left halves

• Bony portion of nasal septum is formed by perpendicular plate of ethmoid & vomer

• Anterior portion of septum is formed by hyaline cartilage

NASOPHARYNX

• Superior part of pharynx

• Connected to posterior portion of

nasal cavity via internal nares

• Separated from oral cavity by soft

palate

• Lined by respiratory epithelium

• Pharyngeal (adenoid) tonsil is located

on posterior wall

• Lateral walls contain openings of

auditory tubes

OROPHARYNX

• Extends between soft palate & base of

tongue at level of hyoid bone

• Posterior portion of oral cavity &

posterior & inferior portions of

nasopharynx communicates directly with

oropharynx

• At boundary between naso & oropharynx

epithelium changes from respiratory

epithelium to stratified squamous

epithelium

• Soft palate supports uvula & two pairs of

pharyngeal arches

• Anterior palatoglossal arch

• Posterior palatoglossal arch

Palatine tonsil

lies in between

LARYNGOPHARYNX• Includes that portion of pharynx lying between hyoid bone & entrance to esophagus

• Most inferior portion of pharynx

• Lined by stratified squamous epithelium

THE GLOTTIS

THE LARYNX• Inspired air leaves pharynx by passing through a narrow opening – glottis

• Larynx surrounds & protects glottis

• Larynx begins at C3 & ends at C6 vertebral levels

• Larynx essentially is a cylinder whose cartilaginous walls are stabilized by ligaments & muscle

THE ANATOMY OF THE LARYNX

THE TRACHEA• Trachea is a tough, flexible tube with diameter of

1.2cm & length of 10-15cm

• Begins anterior to C6 vertebra in a ligamentous attachment to cricoid cartilage

• Ends in mediastinum at level of T4 vertebra in the supine and T6 in the standing position

• Branches to form right & left primary bronchi

• Lining of trachea consists of respiratory epithelium overlying a layer of looser connective tissue (lamina propria)

• Trachea contains 16-20 incomplete C shaped tracheal cartilages

• Each tracheal cartilage is bound to neighboring cartilages by elastic annular ligaments

• Tracheal cartilages stiffen tracheal walls & protect airway

• Also prevent its collapse or overexpansion as pressures change in respiratory system

THE TRACHEA• Each tracheal cartilage is C shaped

• Closed portion of C protects anterior & lateral

surfaces of trachea

• Open portion of C faces posteriorly toward

oesophagus

• Because cartilages do not continue around

trachea, posterior tracheal wall can easily distort

during swallowing permitting passage of large

masses of food

• Trachealis : An inelastic ligament & band of

smooth muscle connecting ends of each

tracheal cartilage

PRIMARY BRONCHI• Right & left primary bronchi

• Carina marks line of separation between 2 bronchi

• It’s a very sensitive structure and its stimulation leads to unwanted effects. So ETT and catheter should be kept away from it

• Has cartilaginous C shaped supporting rings

• Right primary bronchus – shorter 2.5cm(Lt - 4.5cm), larger diameter than left & descends towards lung at a steeper angle, angle with the vertical is 250 (Lt – 450.)

• Aorta arches over the left main bronchus

• Due to the peculiar characteristics of rt main bronchus chances of ETT to be positioned in the Rt side are more

• In children the angle of both the Rt and the Lt are the same i.e 550 upto an age of 3 years

TERTIARY BRONCHI

THE BRONCHI

1º BRONCHI

2º BRONCHI (LOBAR BRONCHI)

3º BRONCHI (SEGMENTAL BRONCHI)

SUPPLIES AIR TO SINGLE BRONCHOPULMONARY SEGMENT

10 RIGHT 8/9 LEFT

RIGHT

SUPERIOR LOBAR

MIDDLE LOBAR

INFERIOR LOBAR

LEFT

SUPERIOR LOBAR

INFERIOR LOBAR

23 generations of dichotomous

branhes are present from the trachea till

alveolar sacs

THE BRONCHI AND LOBULES OF THE LUNG

BRIEF HISTORY

1878 - William Macewen passed a tube in

trachea from the mouth for the first time

1893 - Eisenmenger gave a description of the

cuffed ETT

1906 - Green introduces the pilot balloon

1960 - Plastic replaces red rubber as material

for construction

1969 – Introduction of modern day ETT with

high volume low pressure cuff

INDICATIONS FOR INTUBATION Respiratory failure

Protection of the airway from aspiration

Decreased LOC (coma score <8/15)

Secretion clearance

Upper airway obstruction

Raised ICP treatment

Facilitate tracheobronchial toilet

CPR

Surgery

Non NBM patients

Anaesthesia requiring PPV

Head and neck surgeries which may compromise airway

Surgeries requiring neuromuscular blocking agents

In patients likely to develop laryngospasm

OBJECTIVE MEASURES INDICATING THE NEED FOR INTUBATION

RR >35

VC <15 ml/kg

PaO2 <60 on >40% oxygen

PaCO2 >50 (except in chronic

retainers)

A-a gradient > 300 on 100% oxygen

INTUBATION EQUIPMENT

Endotracheal Tube and stylet

Laryngoscope

Sterile water-soluble jelly

Syringe to inflate cuff

Adhesive tape or tube fixation device

Bite block to prevent biting oral ET tube

Suction Equipment, bag- mask, O2

Local anesthetic

Stethoscope

PREPARATION FOR INTUBATION

Suction Equipment Oxygen Airway Patient position Monitors Esophageal Detection Device

LARYNGOSCOPE

Blade and handle

Blade -

has a flange, spatula, light,

and tip

- curved blade (Macintosh)

- straight blade (Miller, Wisconsin)

Blade size: 0 - 1 infant, 2 from 2-8 years 3 from age 10-

adult, large adult- 4

LARYNGOSCOPIC BLADE

Macintosh (curved) and Miller (straight) blade

Adult : Macintosh blade, small children : Miller blade

Miller blade Macintosh bladeCurved tip

Mccoy blade

STRAIGHT BLADE (MILLER)

CURVED BLADE (MACINTOSH)

ENDOTRACHEAL TUBE ET TUBE SIZE

For children lesser than 6 years

- Tube size = age/3 + 3.5(ETT ID in mm)

For children more than 7 years

-Tube size = age/4 + 4.5(ETT ID in mm)

DEPTH OF INSERTION

Adult

Adult - Male = 20-21 cms ,Female = 19-20 cms

Children

Oral endotracheal tube = (Age/2) + 12 (cm)

Nasal endotracheal tube = (Age/2) + 15 (cm)

ENDOTRACHEAL TUBE CUFFED AND UNCUFFED

High volume Low pressure cuff

Low volume High pressure cuff

STYLET

SNIFFING POSITION

Neck flexion of 25-350

Head extension of 850

In adults a head elevation of 8-10 cms

In paediatric age group of less than 8

years there is no need of head elevation

SNIFFING POSITION

ROUTES FOR INTUBATION

Orotracheal Nasotracheal Tracheotomy

ORAL INTUBATION

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

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)

NASAL INTUBATION

ADVANTAGES OF NASAL INTUBATION

More comfort long term

Decreased gagging

Less salivation, easier to swallow

Improved mouth care

Better tube fixation

Improved communication

DISADVANTAGES OF NASAL INTUBATION

Pain and discomfort

Nasal and paranasal complications, I.e., epistaxis,

sinusitis, otits

More difficult procedure

Smaller tube needed

Increased airflow resistance

Difficult suctioning

Bacteremia

CONTRAINDICATION FOR NASOTRACHEAL INTUBATION

1 ) Fracture base of skull 2) Nasal fractures or grossly

distorted septum 3 ) Coagulopathy 4 ) Nasal cavity obstruction 5 ) Retropharyngeal abscess

CONTRAINDICATION FOR ENDOTRACHEAL INTUBATION

1) Severe airway trauma 2 ) Cervical spine injury 3Aneurysm of the arch of aorta 4) Laryngeal edema 5) Severe laryngitis

ORAL INTUBATION PROCEDURE

Assemble and check equipment

- suction equipment

- laryngoscope

- select proper size tube, check

tube

Position patient

- align mouth, pharynx, larynx -

“SNIFFING” position

PATIENT POSITIONING

Preoxygenate the patient

- bag-valve mask

- *intubation attempt should take no longer than 30 sec, if

unsuccessful, then ventilate again with bag and mask for

3-5 minutes

Insert laryngoscope

Laryngoscope is gently held in the left hand at the junction of the

handle and the blade, while the right hand’s thumb and middle

finger gently open the patients’ mouth in a scissoring action.

Laryngoscope is inserted from the right side of the mouth and the

tongue is displaced towards left as the laryngoscope is introduced.

ORAL PROCEDURE (CONTD..)

On deeper entry into the oral cavity, the curved Macintosh

blade is positioned into the space between the base of the

tongue and the pharyngeal surface of the epiglottis. The

tongue and the pharyngeal soft tissue are then lifted to

expose the glottic opening.

ORAL PROCEDURE (CONTD..)

The direction of the lifting force is always along the axis of the laryngoscope

handle. The blade should never be used as a lever and the teeth as a

fulcrum.

Insert ET tube from the right corner of mouth - do not use laryngoscope

blade to guide tube

- once you see the tube pass

the glottis, advance the cuff past the cords by

2 -3 cm

Hold tube with right hand and remove laryngoscope & stylet

- inflate cuff with 5 - 10 cc of air

- ventilate with bag

ORAL PROCEDURE (CONTD..)

ORAL PROCEDURE (CONTD..)

Inflate cuff with 5 - 10 cc of air (10-20 cm of H2O)

Ventilate with “bag”

Assess tube position

- auscultation of chest & epigastric

- cm mark at teeth

- capnometry

Stabilize / Fix Tube tube/Confirm placement

CONFIRMATION OF THE POSITION OF ENDOTRACHEAL TUBE

Intubation under vision

Chest movements / Auscultation in epigastric area

Bilateral Air Entry with Stethoscope

Feeling of inflated cuff in suprasternal notch

Movement of the bag

Fogging of the endotracheal tube

Capnography

Fibreoptic bronchoscopy

Chest X-Ray

WHAT ARE THE POTENTIAL COMPLICATIONS OF

ENDOTRACHEAL INTUBATION?

FACTORS FOR SUSCEPTIBILITY Extrinsic factors

Diameter of ETT

Duration of intubation

Traumatic or multiple intubations

Patient factors

Poor tissue perfusion (i.e. sepsis, organ failure, etc)

LPR

Abnormal larynx

Wound healing, keloid

Movement

During ventilator use

During suctioning

During coughing

During transport