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.