Equipment Tracheal intubation

1 equipment

1.1 laryngoscopes
1.2 stylets
1.3 tracheal tubes
1.4 methods confirm tube placement

equipment
laryngoscopes


laryngoscope handles assortment of miller blades (large adult, small adult, child, infant , newborn)



laryngoscope handle assortment of macintosh blades (large adult, small adult, child, infant , newborn)

the vast majority of tracheal intubations involve use of viewing instrument of 1 type or another. modern conventional laryngoscope consists of handle containing batteries power light , set of interchangeable blades, either straight or curved. device designed allow laryngoscopist directly view larynx. due widespread availability of such devices, technique of blind intubation of trachea practiced today, although may still useful in emergency situations, such natural or man-made disasters. in prehospital emergency setting, digital intubation may necessitated if patient in position makes direct laryngoscopy impossible. example, digital intubation may used paramedic if patient entrapped in inverted position in vehicle after motor vehicle collision prolonged extrication time.

the decision use straight or curved laryngoscope blade depends partly on specific anatomical features of airway, , partly on personal experience , preference of laryngoscopist. macintosh blade used curved laryngoscope blade, while miller blade popular style of straight blade. both miller , macintosh laryngoscope blades available in sizes 0 (infant) through 4 (large adult). there many other styles of straight , curved blades, accessories such mirrors enlarging field of view , ports administration of oxygen. these specialty blades designed use anesthetists , otolaryngologists, commonly in operating room.

fiberoptic layngoscopes have become increasingly available since 1990s. in contrast conventional laryngoscope, these devices allow laryngoscopist indirectly view larynx. provides significant advantage in situations operator needs see around acute bend in order visualize glottis, , deal otherwise difficult intubations. video laryngoscopes specialized fiberoptic layngoscopes use digital video camera sensor allow operator view glottis , larynx on video monitor. other noninvasive devices can employed assist in tracheal intubation laryngeal mask airway (used conduit endotracheal tube placement) , airtraq.

stylets

an endotracheal tube stylet, useful in facilitating orotracheal intubation

an intubating stylet malleable metal wire designed inserted endotracheal tube make tube conform better upper airway anatomy of specific individual. aid commonly used difficult laryngoscopy. laryngoscope blades, there several types of available stylets, such verathon stylet, designed follow 60° blade angle of glidescope video laryngoscope.

the eschmann tracheal tube introducer (often incorrectly referred gum elastic bougie ) specialized type of stylet used facilitate difficult intubation. flexible device 60 cm (24 in) in length, 15 french (5 mm diameter) small hockey-stick angle @ far end. unlike traditional intubating stylet, eschmann tracheal tube introducer typically inserted directly trachea , used guide on endotracheal tube can passed (in manner analogous seldinger technique). eschmann tracheal tube introducer considerably less rigid conventional stylet, technique considered relatively atraumatic means of tracheal intubation.

the tracheal tube exchanger hollow catheter, 56 81 cm (22.0 31.9 in) in length, can used removal , replacement of tracheal tubes without need laryngoscopy. cook airway exchange catheter (caec) example of type of catheter; device has central lumen (hollow channel) through oxygen can administered.

the lighted stylet device employs principle of transillumination facilitate blind orotracheal intubation (an intubation technique in laryngoscopist not view glottis).

tracheal tubes


a cuffed endotracheal tube, constructed of polyvinyl chloride



a carlens double-lumen endotracheal tube, used thoracic surgical operations such vats lobectomy

a tracheal tube catheter inserted trachea primary purpose of establishing , maintaining patent (open , unobstructed) airway. tracheal tubes used airway management in settings of general anesthesia, critical care, mechanical ventilation , emergency medicine. many different types of tracheal tubes available, suited different specific applications. endotracheal tube specific type of tracheal tube inserted through mouth (orotracheal) or nose (nasotracheal). breathing conduit designed placed airway of critically injured, ill or anesthetized patients in order perform mechanical positive pressure ventilation of lungs , prevent possibility of aspiration or airway obstruction. endotracheal tube has fitting designed connected source of pressurized gas such oxygen. @ other end orifice through such gases directed lungs , may include balloon (referred cuff). tip of endotracheal tube positioned above carina (before trachea divides each lung) , sealed within trachea lungs can ventilated equally. tracheostomy tube type of tracheal tube; 2–3-inch-long (51–76 mm) curved metal or plastic tube inserted tracheostomy stoma or cricothyrotomy incision.

tracheal tubes can used ensure adequate exchange of oxygen , carbon dioxide, deliver oxygen in higher concentrations found in air, or administer other gases such helium, nitric oxide, nitrous oxide, xenon, or volatile anesthetic agents such desflurane, isoflurane, or sevoflurane. may used route administration of medications such bronchodilators, inhaled corticosteroids, , drugs used in treating cardiac arrest such atropine, epinephrine, lidocaine , vasopressin.

originally made latex rubber, modern endotracheal tubes today constructed of polyvinyl chloride. tubes constructed of silicone rubber, wire-reinforced silicone rubber or stainless steel available special applications. human use, tubes range in size 2 10.5 mm (0.1 0.4 in) in internal diameter. size chosen based on patient s body size, smaller sizes being used infants , children. endotracheal tubes have inflatable cuff seal tracheobronchial tree against leakage of respiratory gases , pulmonary aspiration of gastric contents, blood, secretions , other fluids. uncuffed tubes available, though use limited children (in small children, cricoid cartilage narrowest portion of airway , provides adequate seal mechanical ventilation).

in addition cuffed or uncuffed, preformed endotracheal tubes available. oral , nasal rae tubes (named after inventors ring, adair , elwyn) used of preformed tubes.

there number of different types of double-lumen endo-bronchial tubes have endobronchial endotracheal channels (carlens, white , robertshaw tubes). these tubes typically coaxial, 2 separate channels , 2 separate openings. incorporate endotracheal lumen terminates in trachea , endobronchial lumen, distal tip of positioned 1–2 cm right or left mainstem bronchus. there univent tube, has single tracheal lumen , integrated endobronchial blocker. these tubes enable 1 ventilate both lungs, or either lung independently. single-lung ventilation (allowing lung on operative side collapse) can useful during thoracic surgery, can facilitate surgeon s view , access other relevant structures within thoracic cavity.

the armored endotracheal tubes cuffed, wire-reinforced silicone rubber tubes. more flexible polyvinyl chloride tubes, yet difficult compress or kink. can make them useful situations in trachea anticipated remain intubated prolonged duration, or if neck remain flexed during surgery. armored tubes have magill curve, preformed armored rae tubes available. type of endotracheal tube has 4 small openings above inflatable cuff, can used suction of trachea or administration of intratracheal medications if necessary. other tubes (such bivona fome-cuf tube) designed use in laser surgery in , around airway.

methods confirm tube placement

an endotracheal tube in position on cxr. arrow marks tip.



an endotracheal tube not deep enough. arrow marks tip.

no single method confirming tracheal tube placement has been shown 100% reliable. accordingly, use of multiple methods confirmation of correct tube placement considered standard of care. such methods include direct visualization tip of tube passes through glottis, or indirect visualization of tracheal tube within trachea using device such bronchoscope. positioned tracheal tube, equal bilateral breath sounds heard upon listening chest stethoscope, , no sound upon listening area on stomach. equal bilateral rise , fall of chest wall evident ventilatory excursions. small amount of water vapor evident within lumen of tube each exhalation , there no gastric contents in tracheal tube @ time.

ideally, @ least 1 of methods utilized confirming tracheal tube placement measuring instrument. waveform capnography has emerged gold standard confirmation of tube placement within trachea. other methods relying on instruments include use of colorimetric end-tidal carbon dioxide detector, self-inflating esophageal bulb, or esophageal detection device. distal tip of positioned tracheal tube located in mid-trachea, 2 cm (1 in) above bifurcation of carina; can confirmed chest x-ray. if inserted far trachea (beyond carina), tip of tracheal tube within right main bronchus — situation referred right mainstem intubation . in situation, left lung may unable participate in ventilation, can lead decreased oxygen content due ventilation/perfusion mismatch.