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

 minimum pressure.

Teeth guards/protectors should be used specifically on the top

teeth.

Infant intubation:

Must be familiar with anatomic differences of the infant

larynx.

Work gently and ensure adequate relaxation.

Tube selection is very important.

Lubricants must be used carefully.