Tracheal Intubation

CHAPTER 213 Tracheal Intubation



Airway emergencies can be some of the most daunting situations a practitioner encounters. Radical advances in airway management have been made and are reviewed here.







Airway Assessment


Begin with the patient on 100% nonrebreather mask if spontaneously breathing. The jaw thrust maneuver can be used to keep the airway open (Fig. 213-3), or begin bag-valve-mask breathing with a second assistant providing cricoid pressure (Sellick maneuver). The practitioner should be familiar with the anatomic landmarks (Fig. 213-4). Many airway management failures can be traced to lack of airway assessment. Patients can be classified into three groups (shades) based on two criteria: anticipated difficulty in intubation and ability to maintain oxygen saturation greater than 90% by bag-valve-mask ventilation. Airway assessment is critical. An experienced person can assess an airway in less than 4 seconds, and an inexperienced person should be able to do so in less than 8 seconds.




The mnemonic for assessing difficulty in intubation is 332-NUTS:









Meeting all these criteria indicates a low-risk intubation; conversely, the fewer the criteria present, the higher the risk. Although the last two categories, tension pneumothorax and “soup,” do not strictly determine the anatomic difficulty of intubation, establishing their absence is a vital part of early airway assessment. The Mallampati system has previously been used to assess the uvular portion of the mnemonic; however, it is important to note that this classification was designed to assess a patient sitting upright with voluntary mouth opening—a condition rarely encountered in clinical practice outside anesthesiology. A simpler method is to open the mouth with the thumb while standing to either side of the patient’s head. (Standing at the head of the patient changes the angle of view, and may produce a false result). If any portion of the uvula can be seen, then intubation will likely be unimpeded by this factor. The three risk groups (shades) are as follows:






Standard Orotracheal Intubation




Technique


The cricoid pressure technician should initiate cricoid pressure using the Sellick maneuver as soon as the respiratory therapist begins bagging. This will reduce stomach insufflation and the risk for vomiting. The cricoid pressure technician also watches the oxygen saturation of the patient and announces saturations below 90% to the practitioner. In addition, this technician holds the endotracheal tube and passes it to the practitioner so the practitioner can focus uninterrupted on the intubating view.


“Tilt” or position of the patient and the practitioner is often overlooked, but this is probably the most critical component of successful intubation. If the patient is not suspected of having neck problems that could be worsened by movement, place the patient in the “sniffing” position with the neck flexed and the head extended backward (Fig. 213-5). The neck may be flexed by raising the head several inches using a folded towel or firm pillow. It is important to remember that the padding should be placed under the head and not between the shoulders (see Fig. 213-4).


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May 14, 2017 | Posted by in GENERAL & FAMILY MEDICINE | Comments Off on Tracheal Intubation

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