| Tracheal intubation | |
|---|---|
 Anesthesiologist using the Glidescopevideo laryngoscope to intubate thetrachea of amorbidly obese elderly person with challengingairway anatomy | |
| Specialty | Anesthesiology,emergency medicine,critical care medicine |
| ICD-9-CM | 96.04 |
| MeSH | D007442 |
| OPS-301 code | 8-701 |
| MedlinePlus | 003449 |
Tracheal intubation, usually simply referred to asintubation, is the placement of a flexible plastictube into thetrachea (windpipe) to maintain an openairway or to serve as a conduit through which to administer certain drugs. It is frequently performed in critically injured, ill, or anesthetized patients to facilitateventilation of the lungs, includingmechanical ventilation, and to prevent the possibility ofasphyxiation or airway obstruction.
The most widely used route is orotracheal, in which anendotracheal tube is passed through the mouth andvocal apparatus into the trachea. In a nasotracheal procedure, an endotracheal tube is passed through the nose and vocal apparatus into the trachea. Other methods of intubation involve surgery and include thecricothyrotomy (used almost exclusively in emergency circumstances) and thetracheotomy, used primarily in situations where a prolonged need for airway support is anticipated.
Because it is aninvasive and uncomfortablemedical procedure, intubation is usually performed after administration ofgeneral anesthesia and aneuromuscular-blocking drug. It can, however, be performed in the awake patient withlocal ortopical anesthesia or in an emergency without any anesthesia at all. Intubation is normally facilitated by using a conventionallaryngoscope,flexible fiberoptic bronchoscope, orvideo laryngoscope to identify thevocal cords and pass the tube between them into thetrachea instead of into the esophagus. Other devices and techniques may be used alternatively.
After the trachea has been intubated, a balloon cuff is typically inflated just above the far end of the tube to help secure it in place, to prevent leakage of respiratory gases, and to protect thetracheobronchial tree fromreceiving undesirable material such as stomach acid. The tube is then secured to the face or neck and connected to a T-piece, anesthesia breathing circuit,bag valve mask device, or amechanical ventilator. Once there is no longer a need for ventilatory assistance or protection of the airway, the tracheal tube is removed; this is referred to as extubation of the trachea (or decannulation, in the case of a surgical airway such as a cricothyrotomy or a tracheotomy).
For centuries,tracheotomy was considered the only reliable method for intubation of the trachea. However, because only a minority of patients survived the operation, physicians undertook tracheotomy only as a last resort, on patients who were nearly dead. It was not until the late 19th century, however, that advances in understanding ofanatomy andphysiology, as well an appreciation of thegerm theory of disease, had improved the outcome of this operation to the point that it could be considered an acceptable treatment option. Also at that time, advances inendoscopic instrumentation had improved to such a degree that direct laryngoscopy had become a viable means to secure the airway by the non-surgical orotracheal route. By the mid-20th century, the tracheotomy as well as endoscopy and non-surgical tracheal intubation had evolved from rarely employed procedures to becoming essential components of the practices ofanesthesiology,critical care medicine,emergency medicine, andlaryngology.
Tracheal intubation can be associated withcomplications such as broken teeth or lacerations of thetissues of theupper airway. It can also be associated with potentially fatal complications such aspulmonary aspiration of stomach contents which can result in a severe and sometimes fatal chemicalaspiration pneumonitis, or unrecognized intubation of theesophagus which can lead to potentially fatalanoxia. Because of this, the potential for difficulty or complications due to the presence of unusual airway anatomy or other uncontrolled variables is carefully evaluated before undertaking tracheal intubation. Alternative strategies for securing the airway must always be readily available.
Tracheal intubation isindicated in a variety of situations when illness or a medical procedure prevents a person from maintaining a clear airway, breathing, andoxygenating the blood. In these circumstances,oxygen supplementation using asimple face mask is inadequate.
Perhaps the most common indication for tracheal intubation is for the placement of a conduit through whichnitrous oxide orvolatile anesthetics may be administered.General anesthetic agents,opioids, and neuromuscular-blocking drugs maydiminish or evenabolish therespiratory drive. Although it is not the only means to maintain a patent airway during general anesthesia, intubation of the trachea provides the most reliable means of oxygenation andventilation[1] and the greatest degree of protection against regurgitation and pulmonary aspiration.[2]
Damage to the brain (such as from a massivestroke,non-penetrating head injury,intoxication orpoisoning) may result in adepressed level of consciousness. When this becomes severe to the point ofstupor orcoma (defined as a score on theGlasgow Coma Scale of less than 8),[3] dynamic collapse of the extrinsicmuscles of the airway can obstruct the airway, impeding the free flow of air into the lungs. Furthermore, protective airway reflexes such ascoughing andswallowing may be diminished or absent. Tracheal intubation is often required to restore patency (the relative absence of blockage) of the airway and protect the tracheobronchial tree from pulmonary aspiration of gastric contents.[4]
Intubation may be necessary for a patient withdecreased oxygen content andoxygen saturation of the blood caused when their breathing is inadequate (hypoventilation), suspended (apnea), or when the lungs are unable to sufficientlytransfer gasses to the blood.[5] Such patients, who may be awake and alert, are typically critically ill with a multisystem disease ormultiple severe injuries.[1] Examples of such conditions includecervical spine injury,multiple rib fractures, severepneumonia,acute respiratory distress syndrome (ARDS), or near-drowning. Specifically, intubation is considered if thearterialpartial pressure of oxygen (PaO2) is less than 60 millimeters of mercury (mm Hg) while breathing an inspired O2 concentration (FIO2) of 50% or greater. In patients withelevated arterial carbon dioxide, an arterial partial pressure of CO2 (PaCO2) greater than 45 mm Hg in the setting ofacidemia would prompt intubation, especially if a series of measurements demonstrate a worseningrespiratory acidosis. Regardless of the laboratory values, these guidelines are always interpreted in the clinical context.[6]
Actual or impending airway obstruction is a common indication for intubation of the trachea. Life-threatening airway obstruction may occur when aforeign body becomes lodged in the airway; this is especially common in infants and toddlers. Severeblunt orpenetrating injury to the face or neck may be accompanied byswelling and an expandinghematoma, or injury to thelarynx, trachea or bronchi. Airway obstruction is also common in people who have sufferedsmoke inhalation or burns within or near the airway orepiglottitis. Sustainedgeneralized seizure activity andangioedema are other common causes of life-threatening airway obstruction which may require tracheal intubation to secure the airway.[1]
Diagnostic or therapeutic manipulation of the airway (such as bronchoscopy,laser therapy orstenting of thebronchi) may intermittently interfere with the ability to breathe; intubation may be necessary in such situations.[4]
Syndromes such asrespiratory distress syndrome,congenital heart disease,pneumothorax, andshock may lead to breathing problems in newborn infants that require endotracheal intubation and mechanically assisted breathing (mechanical ventilation).[7] Newborn infants may also require endotracheal intubation during surgery while undergeneral anaesthesia.[7]
The vast majority of tracheal intubations involve the use of aviewing instrument of one type or another. The modern conventional laryngoscope consists of a handle containing batteries that power a light and a set of interchangeableblades, which are either straight or curved. This device is designed to allow the laryngoscopist to directly view the larynx. Due to the widespread availability of such devices, the technique of blind intubation[8] of the trachea is rarely practiced today, although it may still be useful in certain emergency situations, such as natural or man-made disasters.[9] In the prehospital emergency setting, digital intubation may be necessitated if the patient is in a position that makes direct laryngoscopy impossible. For example, digital intubation may be used by a paramedic if the patient is entrapped in an inverted position in a vehicle after a motor vehicle collision with a prolonged extrication time.
The decision to use a straight or curved laryngoscope blade depends partly on the specific anatomical features of the airway, and partly on the personal experience and preference of the laryngoscopist. The Miller blade, characterized by its straight, elongated shape with a curved tip, is frequently employed in patients with challenging airway anatomy, such as those with limited mouth opening or a high larynx. Its design allows for direct visualization of the epiglottis, facilitating precise glottic exposure.[10]Conversely, the Macintosh blade, with its curved configuration reminiscent of the letters "C" or "J," is favored in routine intubations for patients with normal airway anatomy. Its curved design enables indirect laryngoscopy, providing enhanced visualization of the vocal cords and glottis in most adult patients.[11]
The choice between the Miller and Macintosh blades is influenced by specific anatomical considerations and the preferences of the laryngoscopist. While the Macintosh blade is the most commonly utilized curved laryngoscope blade, the Miller blade is the preferred option for straight blade intubation. Both blades are available in various sizes, ranging from size 0 (infant) to size 4 (large adult), catering to patients of different ages and anatomies. Additionally, there exists a myriad of specialty blades with unique features, including mirrors for enhanced visualization and ports for oxygen administration, primarily utilized by anesthetists and otolaryngologists in operating room settings.[12][10]
Fiberoptic laryngoscopes have become increasingly available since the 1990s. In contrast to the conventional laryngoscope, these devices allow the laryngoscopist to indirectly view the larynx. This provides a significant advantage in situations where the operator needs to see around an acute bend in order to visualize the glottis, and deal with otherwise difficult intubations.Video laryngoscopes are specialized fiberoptic laryngoscopes that use adigitalvideo camera sensor to allow the operator to view the glottis and larynx on a video monitor.[13][14] Other "noninvasive" devices which can be employed to assist in tracheal intubation are thelaryngeal mask airway[15] (used as a conduit for endotracheal tube placement) and theAirtraq.[16]
An intubating stylet is a malleable metal wire designed to be inserted into the endotracheal tube to make the tube conform better to the upper airway anatomy of the specific individual. This aid is commonly used with a difficult laryngoscopy. Just as with laryngoscope blades, there are also several types of available stylets,[17] such as the Verathon Stylet, which is specifically designed to follow the 60° blade angle of the GlideScope video laryngoscope.[18]
The Eschmann tracheal tube introducer (also referred to as a "gum elastic bougie") is specialized type of stylet used to facilitate difficult intubation.[19] This flexible device is 60 cm (24 in) in length, 15French (5 mm diameter) with a small "hockey-stick" angle at the far end. Unlike a traditional intubating stylet, the Eschmann tracheal tube introducer is typically inserted directly into the trachea and then used as a guide over which the endotracheal tube can be passed (in a manner analogous to theSeldinger technique). As the Eschmann tracheal tube introducer is considerably less rigid than a conventional stylet, this technique is considered to be a relatively atraumatic means of tracheal intubation.[20][21]
The tracheal tube exchanger is a hollowcatheter, 56 to 81 cm (22.0 to 31.9 in) in length, that can be used for removal and replacement of tracheal tubes without the need for laryngoscopy.[22] The Cook Airway Exchange Catheter (CAEC) is another example of this type of catheter; this device has a centrallumen (hollow channel) through whichoxygen can be administered.[23] Airway exchange catheters are long hollow catheters which often have connectors for jet ventilation, manual ventilation, or oxygen insufflation. It is also possible to connect the catheter to a capnograph to perform respiratory monitoring.
The lighted stylet is a device that employs the principle oftransillumination to facilitate blind orotracheal intubation (an intubation technique in which the laryngoscopist does not view the glottis).[24]
A tracheal tube is a catheter that is inserted into the trachea for the primary purpose of establishing and maintaining a patent (open and unobstructed) airway. Tracheal tubes are frequently used forairway management in the settings of general anesthesia, critical care, mechanical ventilation, and emergency medicine. Many different types of tracheal tubes are available, suited for different specific applications. An endotracheal tube is a specific type of tracheal tube that is nearly always inserted through the mouth (orotracheal) or nose (nasotracheal). It is abreathing conduit designed to be placed into the airway of critically injured, ill or anesthetized patients in order to perform mechanicalpositive pressure ventilation of the lungs and to prevent the possibility of aspiration or airway obstruction.[25] The endotracheal tube has a fitting designed to be connected to a source of pressurized gas such as oxygen. At the other end is an orifice through which such gases are directed into the lungs and may also include a balloon (referred to as a cuff). The tip of the endotracheal tube is positioned above thecarina (before the trachea divides to each lung) and sealed within the trachea so that the lungs can be ventilated equally.[25] A tracheostomy tube is another type of tracheal tube; this 50–75-millimetre-long (2.0–3.0 in) curved metal or plastic tube is inserted into a tracheostomystoma or a cricothyrotomy incision.[26]
Tracheal tubes can be used to ensure the adequateexchange of oxygen andcarbon dioxide, to deliver oxygen in higher concentrations than found in air, or to administer other gases such ashelium,[27]nitric oxide,[28] nitrous oxide,xenon,[29] or certain volatile anesthetic agents such asdesflurane,isoflurane, orsevoflurane. They may also be used as a route for administration of certain medications such asbronchodilators,inhaled corticosteroids, and drugs used in treatingcardiac arrest such asatropine,epinephrine,lidocaine andvasopressin.[2]
Originally made fromlatex rubber,[30] most modern endotracheal tubes today are constructed ofpolyvinyl chloride. Tubes constructed ofsilicone rubber, wire-reinforced silicone rubber orstainless steel are also available for special applications. For human use, tubes range in size from 2 to 10.5 mm (0.1 to 0.4 in) in internal diameter. The size is chosen based on the patient's body size, with the smaller sizes being used for infants and children. Most endotracheal tubes have an inflatable cuff to seal the tracheobronchial tree against leakage of respiratory gases and pulmonary aspiration of gastric contents, blood, secretions, and other fluids. Uncuffed tubes are also available, though their use is limited mostly to children (in small children, thecricoid cartilage is the narrowest portion of the airway and usually provides an adequate seal for mechanical ventilation).[13]
In addition to cuffed or uncuffed, preformed endotracheal tubes are also available. The oral and nasal RAE tubes (named after the inventors Ring, Adair and Elwyn) are the most widely used of the preformed tubes.[31]
There are a number of different types ofdouble-lumen endo-bronchial tubes that have endobronchial as well as endotracheal channels (Carlens, White and Robertshaw tubes). These tubes are typicallycoaxial, with two separate channels and two separate openings. They incorporate an endotracheal lumen which terminates in the trachea and an endobronchial lumen, the distal tip of which is positioned 1–2 cm into the right or left mainstem bronchus. There is also the Univent tube, which has a single tracheal lumen and an integratedendobronchial blocker. These tubes enable one to ventilate both lungs, or either lung independently. Single-lung ventilation (allowing the lung on the operative side to collapse) can be useful duringthoracic surgery, as it can facilitate the surgeon's view and access to other relevant structures within thethoracic cavity.[32]
The "armored" endotracheal tubes are cuffed, wire-reinforced silicone rubber tubes. They are much more flexible than polyvinyl chloride tubes, yet they are difficult to compress or kink. This can make them useful for situations in which the trachea is anticipated to remain intubated for a prolonged duration, or if the neck is to remain flexed during surgery. Most armored tubes have a Magill curve, but preformed armored RAE tubes are also available. Another type of endotracheal tube has four small openings just above the inflatable cuff, which can be used for suction of the trachea or administration of intratracheal medications if necessary. Other tubes (such as the Bivona Fome-Cuf tube) are designed specifically for use in laser surgery in and around the airway.[33]
No single method for confirming tracheal tube placement has been shown to be 100% reliable. Accordingly, the use of multiple methods for confirmation of correct tube placement is now widely considered to be thestandard of care.[34] Such methods include direct visualization as the tip of the tube passes through the glottis, or indirect visualization of the tracheal tube within the trachea using a device such as a bronchoscope. With a properly positioned tracheal tube, equal bilateralbreath sounds will be heard uponlistening to the chest with a stethoscope, and no sound upon listening to the areaover the stomach. Equal bilateral rise and fall of the chest wall will be evident with ventilatory excursions. A small amount ofwater vapor will also be evident within the lumen of the tube with each exhalation and there will be no gastric contents in the tracheal tube at any time.[33]
Ideally, at least one of the methods utilized for confirming tracheal tube placement will be ameasuring instrument. Waveformcapnography has emerged as thegold standard for the confirmation of tube placement within the trachea. Other methods relying on instruments include the use of acolorimetric end-tidal carbon dioxide detector, a self-inflating esophageal bulb, or an esophageal detection device.[35] The distal tip of a properly positioned tracheal tube will be located in the mid-trachea, roughly 2 cm (1 in) above the bifurcation of the carina; this can be confirmed bychest x-ray. If it is inserted too far into the trachea (beyond the carina), the tip of the tracheal tube is likely to be within theright main bronchus—a situation often referred to as a "right mainstem intubation". In this situation, the left lung may be unable to participate in ventilation, which can lead todecreased oxygen content due toventilation/perfusion mismatch.[36]
Tracheal intubation in the emergency setting can be difficult with the fiberoptic bronchoscope due to blood, vomit, orsecretions in the airway and poor patient cooperation. Because of this, patients with massive facial injury, complete upper airway obstruction, severely diminished ventilation, or profuse upper airway bleeding are poor candidates for fiberoptic intubation.[37] Fiberoptic intubation under general anesthesia typically requires two skilled individuals.[38] Success rates of only 83–87% have been reported using fiberoptic techniques in the emergency department, with significantnasal bleeding occurring in up to 22% of patients.[39][40] These drawbacks limit the use of fiberoptic bronchoscopy somewhat in urgent and emergency situations.[41][42]
Personnel experienced in direct laryngoscopy are not always immediately available in certain settings that require emergency tracheal intubation. For this reason, specialized devices have been designed to act as bridges to a definitive airway. Such devices include the laryngeal mask airway, cuffedoropharyngeal airway and the esophageal-tracheal combitube (Combitube).[43][44] Other devices such as rigid stylets, the lightwand (a blind technique) and indirect fiberoptic rigid stylets, such as the Bullard scope, Upsher scope and the WuScope can also be used as alternatives to direct laryngoscopy. Each of these devices have its own unique set of benefits and drawbacks, and none of them is effective under all circumstances.[17]
Rapid sequence induction and intubation (RSI) is a particular method of induction of general anesthesia, commonly employed in emergency operations and other situations where patients are assumed to have a full stomach. The objective of RSI is to minimize the possibility ofregurgitation and pulmonary aspiration of gastric contents during the induction of general anesthesia and subsequent tracheal intubation.[34] RSI traditionally involves preoxygenating the lungs with a tightly fitting oxygen mask, followed by the sequential administration of an intravenoussleep-inducing agent and a rapidly acting neuromuscular-blocking drug, such asrocuronium,succinylcholine, orcisatracurium besilate, before intubation of the trachea.[45]
One important difference between RSI and routine tracheal intubation is that the practitioner does not manually assist the ventilation of the lungs after the onset of general anesthesia andcessation of breathing, until the trachea has been intubated and the cuff has been inflated. Another key feature of RSI is the application of manual 'cricoid pressure' to the cricoid cartilage, often referred to as the "Sellick maneuver", prior to instrumentation of the airway and intubation of the trachea.[34]
Named for British anesthetist Brian Arthur Sellick (1918–1996) who first described the procedure in 1961,[46] the goal of cricoid pressure is to minimize the possibility of regurgitation and pulmonary aspiration of gastric contents. Cricoid pressure has been widely used during RSI for nearly fifty years, despite a lack of compelling evidence to support this practice.[47] The initial article by Sellick was based on a small sample size at a time when hightidal volumes,head-down positioning andbarbiturate anesthesia were the rule.[48] Beginning around 2000, a significant body of evidence has accumulated which questions the effectiveness of cricoid pressure. The application of cricoid pressure may in fact displace the esophagus laterally[49] instead of compressing it as described by Sellick. Cricoid pressure may also compress the glottis, which can obstruct the view of the laryngoscopist and actually cause a delay in securing the airway.[50]
Cricoid pressure is often confused with the "BURP" (Backwards Upwards Rightwards Pressure) maneuver.[51] While both of these involve digital pressure to the anterior aspect (front) of the laryngeal apparatus, the purpose of the latter is to improve the view of the glottis during laryngoscopy and tracheal intubation, rather than to prevent regurgitation.[52] Both cricoid pressure and the BURP maneuver have the potential to worsen laryngoscopy.[53]
RSI may also be used in prehospital emergency situations when a patient is conscious but respiratory failure is imminent (such as in extreme trauma). This procedure is commonly performed by flight paramedics. Flight paramedics often use RSI to intubate before transport because intubation in a moving fixed-wing or rotary-wing aircraft is extremely difficult to perform due to environmental factors. The patient will be paralyzed and intubated on the ground before transport by aircraft.
A cricothyrotomy is an incision made through the skin andcricothyroid membrane to establish a patent airway during certain life-threatening situations, such as airway obstruction by a foreign body, angioedema, or massive facial trauma.[54] A cricothyrotomy is nearly always performed as a last resort in cases where orotracheal and nasotracheal intubation are impossible or contraindicated. Cricothyrotomy is easier and quicker to perform than tracheotomy, does not require manipulation of the cervical spine and is associated with fewer complications.[55]
The easiest method to perform this technique is the needle cricothyrotomy (also referred to as apercutaneous dilational cricothyrotomy), in which a large-bore (12–14gauge)intravenous catheter is used to puncture the cricothyroid membrane.[56] Oxygen can then be administered through this catheter viajet insufflation. However, while needle cricothyrotomy may be life-saving in extreme circumstances, this technique is only intended to be a temporizing measure until a definitive airway can be established.[57] While needle cricothyrotomy can provide adequate oxygenation, the small diameter of the cricothyrotomy catheter is insufficient for elimination of carbon dioxide (ventilation). After one hour ofapneic oxygenation through a needle cricothyrotomy, one can expect aPaCO2 of greater than 250 mm Hg and an arterialpH of less than 6.72, despite an oxygen saturation of 98% or greater.[58] A more definitive airway can be established by performing a surgical cricothyrotomy, in which a 5 to 6 mm (0.20 to 0.24 in) endotracheal tube or tracheostomy tube can be inserted through a larger incision.[59]
Several manufacturers market prepackaged cricothyrotomy kits, which enable one to use either a wire-guided percutaneous dilational (Seldinger) technique, or the classic surgical technique to insert a polyvinylchloride catheter through the cricothyroid membrane. The kits may be stocked in hospital emergency departments and operating suites, as well as ambulances and other selectedpre-hospital settings.[60]
Tracheotomy consists of making an incision on the front of the neck and opening a direct airway through an incision in the trachea. The resultingopening can serve independently as an airway or as a site for a tracheostomy tube to be inserted; this tube allows a person to breathe without the use of his nose or mouth. The opening may be made by a scalpel or a needle (referred to as surgical[59] and percutaneous[61] techniques respectively) and both techniques are widely used in current practice. In order to limit the risk of damage to therecurrent laryngeal nerves (the nerves that control thevoice box), the tracheotomy is performed as high in the trachea as possible. If only one of these nerves is damaged, the patient's voice may be impaired (dysphonia); if both of the nerves are damaged, the patient will be unable to speak (aphonia). In the acute setting, indications for tracheotomy are similar to those for cricothyrotomy. In the chronic setting, indications for tracheotomy include the need for long-term mechanical ventilation and removal of tracheal secretions (e.g., comatose patients, or extensive surgery involving the head and neck).[62][63]
There are significant differences in airway anatomy and respiratory physiology between children and adults, and these are taken into careful consideration before performing tracheal intubation of anypediatric patient. The differences, which are quite significant in infants, gradually disappear as the human body approaches a mature age andbody mass index.[64]
For infants and young children, orotracheal intubation is easier than the nasotracheal route. Nasotracheal intubation carries a risk of dislodgement ofadenoids and nasal bleeding. Despite the greater difficulty, nasotracheal intubation route is preferable to orotracheal intubation in children undergoing intensive care and requiring prolonged intubation because this route allows a more secure fixation of the tube. As with adults, there are a number of devices specially designed for assistance with difficult tracheal intubation in children.[65][66][67][68] Confirmation of proper position of the tracheal tube is accomplished as with adult patients.[69]
Because the airway of a child is narrow, a small amount of glottic or trachealswelling can produce critical obstruction. Inserting a tube that is too large relative to the diameter of the trachea can cause swelling. Conversely, inserting a tube that is too small can result in inability to achieve effective positive pressure ventilation due to retrograde escape of gas through the glottis and out the mouth and nose (often referred to as a "leak" around the tube). An excessive leak can usually be corrected by inserting a larger tube or a cuffed tube.[70]
The tip of a correctly positioned tracheal tube will be in the mid-trachea, between thecollarbones on ananteroposterior chest radiograph. The correct diameter of the tube is that which results in a small leak at a pressure of about 25 cm (10 in) of water. The appropriate inner diameter for the endotracheal tube is estimated to be roughly the same diameter as the child's little finger. The appropriate length for the endotracheal tube can be estimated by doubling the distance from the corner of the child's mouth to theear canal. Forpremature infants 2.5 mm (0.1 in) internal diameter is an appropriate size for the tracheal tube. For infants of normalgestational age, 3 mm (0.12 in) internal diameter is an appropriate size. For normally nourished children 1 year of age and older, two formulae are used to estimate the appropriate diameter and depth for tracheal intubation. The internal diameter of the tube in mm is (patient's age in years + 16) / 4, while the appropriate depth of insertion in cm is 12 + (patient's age in years / 2).[33]
Endotrachael suctioning is often used during intubation in newborn infants to reduce the risk of a blocked tube due to secretions, a collapsed lung, and to reduce pain.[7] Suctioning is sometimes used at specifically scheduled intervals, "as needed", and less frequently. Further research is necessary to determine the most effective suctioning schedule or frequency of suctioning in intubated infants.[7]
In newborns free flowoxygen used to be recommended during intubation however as there is no evidence of benefit the 2011NRP guidelines no longer do.[71]
Tracheal intubation is not a simple procedure and the consequences of failure are grave. Therefore, the patient is carefully evaluated for potential difficulty or complications beforehand. This involves taking themedical history of the patient and performing aphysical examination, the results of which can be scored against one of several classification systems. The proposed surgical procedure (e.g., surgery involving the head and neck, orbariatric surgery) may lead one to anticipate difficulties with intubation.[34] Many individuals have unusual airway anatomy, such as those who have limited movement of their neck or jaw, or those who have tumors, deep swellingdue to injury orto allergy, developmental abnormalities of the jaw, or excess fatty tissue of the face and neck. Using conventional laryngoscopic techniques, intubation of the trachea can be difficult or even impossible in such patients. This is why all persons performing tracheal intubation must be familiar with alternative techniques of securing the airway. Use of the flexible fiberoptic bronchoscope and similar devices has become among the preferred techniques in the management of such cases. However, these devices require a different skill set than that employed for conventional laryngoscopy and are expensive to purchase, maintain and repair.[72]
When taking the patient's medical history, the subject is questioned about any significantsigns orsymptoms, such asdifficulty in speaking ordifficulty in breathing. These may suggest obstructinglesions in various locations within the upper airway,larynx, or tracheobronchial tree. A history of previous surgery (e.g., previouscervical fusion), injury,radiation therapy, ortumors involving the head, neck andupper chest can also provide clues to a potentially difficult intubation. Previous experiences with tracheal intubation, especially difficult intubation, intubation for prolonged duration (e.g., intensive care unit) or prior tracheotomy are also noted.[34]
A detailedphysical examination of the airway is important, particularly:[73]
Many classification systems have been developed in an effort to predict difficulty of tracheal intubation, including theCormack-Lehane classification system,[74] the Intubation Difficulty Scale (IDS),[75] and theMallampati score.[76] The Mallampati score is drawn from the observation that the size of thebase of the tongue influences the difficulty of intubation. It is determined by looking at the anatomy of the mouth, and in particular the visibility of the base ofpalatine uvula,faucial pillars and thesoft palate. Although such medical scoring systems may aid in the evaluation of patients, no single score or combination of scores can be trusted to specifically detect all and only those patients who are difficult to intubate.[77][78] Furthermore, one study of experienced anesthesiologists, on the widely used Cormack–Lehane classification system, found they did not score the same patients consistently over time, and that only 25% could correctly define all four grades of the widely used Cormack–Lehane classification system.[79] Under certain emergency circumstances (e.g., severe head trauma or suspected cervical spine injury), it may be impossible to fully utilize these the physical examination and the various classification systems to predict the difficulty of tracheal intubation.[80] A Cochrane systematic review examined the sensitivity and specificity of various bedside tests commonly used for predicting difficulty in airway management.[81] In such cases, alternative techniques of securing the airway must be readily available.[82]
Tracheal intubation is generally considered the best method for airway management under a wide variety of circumstances, as it provides the most reliable means of oxygenation and ventilation and the greatest degree of protection against regurgitation and pulmonary aspiration.[2] However, tracheal intubation requires a great deal of clinical experience to master[83] and serious complications may result even when properly performed.[84]
Four anatomic features must be present for orotracheal intubation to be straightforward: adequate mouth opening (full range of motion of the temporomandibular joint), sufficient pharyngeal space (determined by examining theback of the mouth), sufficient submandibular space (distance between the thyroid cartilage and the chin, the space into which the tongue must be displaced in order for the larygoscopist to view the glottis), and adequate extension of the cervical spine at the atlanto-occipital joint. If any of these variables is in any way compromised, intubation should be expected to be difficult.[84]
Minor complications are common after laryngoscopy and insertion of an orotracheal tube. These are typically of short duration, such as sore throat, lacerations of the lips orgums or other structures within the upper airway, chipped, fractured or dislodged teeth, and nasal injury. Other complications which are common but potentially more serious includeaccelerated orirregular heartbeat,high blood pressure, elevatedintracranial andintrocular pressure, andbronchospasm.[84]
More serious complications includelaryngospasm,perforation of the trachea oresophagus, pulmonary aspiration of gastric contents or other foreign bodies, fracture or dislocation of the cervical spine,temporomandibular joint orarytenoid cartilages, decreased oxygen content,elevated arterial carbon dioxide, andvocal cord weakness.[84] In addition to these complications, tracheal intubation via the nasal route carries a risk of dislodgement of adenoids and potentially severe nasal bleeding.[39][40] Newer technologies such as flexible fiberoptic laryngoscopy have fared better in reducing the incidence of some of these complications, though the most frequent cause of intubation trauma remains a lack of skill on the part of the laryngoscopist.[84]
Complications may also be severe and long-lasting or permanent, such as vocal cord damage, esophageal perforation andretropharyngeal abscess, bronchial intubation, or nerve injury. They may even be immediately life-threatening, such as laryngospasm and negative pressurepulmonary edema (fluid in the lungs), aspiration, unrecognized esophageal intubation, or accidental disconnection or dislodgement of the tracheal tube.[84] Potentially fatal complications more often associated with prolonged intubation or tracheotomy include abnormal communication between the trachea and nearby structures such as theinnominate artery (tracheoinnominatefistula) or esophagus (tracheoesophageal fistula). Other significant complications include airway obstruction due toloss of tracheal rigidity,ventilator-associated pneumonia andnarrowing of the glottis or trachea.[33] The cuff pressure is monitored carefully in order to avoid complications from over-inflation, many of which can be traced to excessive cuff pressurerestricting the blood supply to the tracheal mucosa.[85][86] A 2000 Spanish study of bedside percutaneous tracheotomy reported overall complication rates of 10–15% and procedural mortality of 0%,[61] which is comparable to those of other series reported in the literature from the Netherlands[87] and the United States.[88]
Inability to secure the airway, with subsequent failure of oxygenation and ventilation is a life-threatening complication which if not immediately corrected leads todecreased oxygen content, brain damage,cardiovascular collapse, and death.[84] When performed improperly, the associated complications (e.g., unrecognized esophageal intubation) may be rapidly fatal.[89] Without adequate training and experience, the incidence of such complications is high.[2] The case of Andrew Davis Hughes, from Emerald Isle, NC is a widely known case in which the patient was improperly intubated and, due to the lack of oxygen, sustained severe brain damage and died. For example, amongparamedics in several United States urban communities, unrecognized esophageal orhypopharyngeal intubation has been reported to be 6%[90][91] to 25%.[89] Although not common, where basicemergency medical technicians are permitted to intubate, reported success rates are as low as 51%.[92] In one study, nearly half of patients with misplaced tracheal tubes died in the emergency room.[89] Because of this, theAmerican Heart Association'sGuidelines for Cardiopulmonary Resuscitation have de-emphasized the role of tracheal intubation in favor of other airway management techniques such as bag-valve-mask ventilation, the laryngeal mask airway and the Combitube.[2] Higher quality studies demonstrate favorable evidence for this shift, as they have shown no survival or neurological benefit with endotracheal intubation over supraglottic airway devices (Laryngeal mask or Combitube).[93]
One complication—unintentional and unrecognized intubation of the esophagus—is both common (as frequent as 25% in the hands of inexperienced personnel)[89] and likely to result in a deleterious or even fatal outcome. In such cases, oxygen is inadvertently administered to the stomach, from where it cannot be taken up by thecirculatory system, instead of the lungs. If this situation is not immediately identified and corrected, death will ensue from cerebral and cardiac anoxia.
Of 4,460 claims in theAmerican Society of Anesthesiologists (ASA) Closed Claims Project database, 266 (approximately 6%) were for airway injury. Of these 266 cases, 87% of the injuries were temporary, 5% were permanent or disabling, and 8% resulted in death. Difficult intubation, age older than 60 years, and female gender were associated with claims for perforation of the esophagus or pharynx. Early signs of perforation were present in only 51% of perforation claims, whereas latesequelae occurred in 65%.[94]
During theSARS andCOVID-19 pandemics, tracheal intubation has been used with aventilator in severe cases where the patient struggles to breathe. Performing the procedure carries a risk of the caregiver becoming infected.[95][96][97]
Although it offers the greatest degree of protection against regurgitation and pulmonary aspiration, tracheal intubation is not the only means to maintain a patent airway. Alternative techniques for airway management and delivery of oxygen, volatile anesthetics or otherbreathing gases include thelaryngeal mask airway, i-gel, cuffed oropharyngeal airway,continuous positive airway pressure (CPAP mask), nasalBiPAP mask, simple face mask, and nasal cannula.[98]
General anesthesia is often administered without tracheal intubation in selected cases where the procedure is brief in duration, or procedures where the depth of anesthesia is not sufficient to cause significant compromise in ventilatory function. Even for longer duration or more invasive procedures, a general anesthetic may be administered without intubating the trachea, provided that patients are carefully selected, and therisk-benefit ratio is favorable (i.e., the risks associated with an unprotected airway are believed to be less than the risks of intubating the trachea).[98]
Airway management can be classified into closed or open techniques depending on the system of ventilation used. Tracheal intubation is a typical example of a closed technique as ventilation occurs using a closed circuit. Several open techniques exist, such as spontaneous ventilation, apnoeic ventilation or jet ventilation. Each has its own specific advantages and disadvantages which determine when it should be used.
Spontaneous ventilation has been traditionally performed with an inhalational agent (i.e. gas induction or inhalational induction using halothane or sevoflurane) however it can also be performed using intravenous anaesthesia (e.g. propofol, ketamine or dexmedetomidine). SponTaneous Respiration using IntraVEnous anaesthesia and High-flow nasal oxygen (STRIVE Hi) is an open airway technique that uses an upwards titration of propofol which maintains ventilation at deep levels of anaesthesia. It has been used in airway surgery as an alternative to tracheal intubation.[99]
The earliest known depiction of a tracheotomy is found on two Egyptian tablets dating back to around 3600 BC.[100] The 110-pageEbers Papyrus, anEgyptian medical papyrus which dates to roughly 1550 BC, also makes reference to the tracheotomy.[101] Tracheotomy was described in theRigveda, aSanskrit text ofayurvedic medicine written around 2000 BC inancient India.[102] TheSushruta Samhita from around 400 BC is another text from the Indian subcontinent on ayurvedic medicine and surgery that mentions tracheotomy.[103]Asclepiades of Bithynia (c. 124–40 BC) is often credited as being the first physician to perform a non-emergency tracheotomy.[104]Galen ofPergamon (AD 129–199) clarified the anatomy of the trachea and was the first to demonstrate that the larynx generates the voice.[105] In one of his experiments, Galen used bellows to inflate the lungs of a dead animal.[106]Ibn Sīnā (980–1037) described the use of tracheal intubation to facilitate breathing in 1025 in his 14-volume medical encyclopedia,The Canon of Medicine.[107] In the 12th century medical textbookAl-Taisir,Ibn Zuhr (1092–1162)—also known as Avenzoar—ofAl-Andalus provided a correct description of the tracheotomy operation.[108]
The first detailed descriptions of tracheal intubation and subsequentartificial respiration of animals were fromAndreas Vesalius (1514–1564) of Brussels. In his landmark book published in 1543,De humani corporis fabrica, he described an experiment in which he passed areed into the trachea of a dying animal whose thorax had been opened and maintained ventilation by blowing into the reed intermittently.[106]Antonio Musa Brassavola (1490–1554) ofFerrara successfully treated a patient withperitonsillar abscess by tracheotomy. Brassavola published his account in 1546; this operation has been identified as the first recorded successful tracheotomy, despite the many previous references to this operation.[109] Towards the end of the 16th century,Hieronymus Fabricius (1533–1619) described a useful technique for tracheotomy in his writings, although he had never actually performed the operation himself. In 1620 the French surgeonNicholas Habicot (1550–1624) published a report of four successful tracheotomies.[110] In 1714, anatomist Georg Detharding (1671–1747) of theUniversity of Rostock performed a tracheotomy on a drowning victim.[111]
Despite the many recorded instances of its use sinceantiquity, it was not until the early 19th century that the tracheotomy finally began to be recognized as a legitimate means of treating severe airway obstruction. In 1852, French physicianArmand Trousseau (1801–1867) presented a series of 169 tracheotomies to theAcadémie Impériale de Médecine. 158 of these were performed for the treatment ofcroup, and 11 were performed for "chronic maladies of the larynx".[112] Between 1830 and 1855, more than 350 tracheotomies were performed in Paris, most of them at theHôpital des Enfants Malades, apublic hospital, with an overall survival rate of only 20–25%. This compares with 58% of the 24 patients in Trousseau's private practice, who fared better due to greater postoperative care.[113]
In 1871, the German surgeonFriedrich Trendelenburg (1844–1924) published a paper describing the first successful elective human tracheotomy to be performed for the purpose of administration of general anesthesia.[114] In 1888, SirMorell Mackenzie (1837–1892) published a book discussing the indications for tracheotomy.[115] In the early 20th century, tracheotomy became a life-saving treatment for patients affected with paralyticpoliomyelitis who required mechanical ventilation. In 1909, Philadelphia laryngologistChevalier Jackson (1865–1958) described a technique for tracheotomy that is used to this day.[116]
In 1854, a Spanishsinging teacher namedManuel García (1805–1906) became the first man to view the functioning glottis in a living human.[117] In 1858, French pediatricianEugène Bouchut (1818–1891) developed a new technique for non-surgical orotracheal intubation to bypass laryngeal obstruction resulting from adiphtheria-related pseudomembrane.[118] In 1880, Scottish surgeonWilliam Macewen (1848–1924) reported on his use of orotracheal intubation as an alternative to tracheotomy to allow a patient with glottic edema to breathe, as well as in the setting of general anesthesia withchloroform.[119] In 1895,Alfred Kirstein (1863–1922) of Berlin first described direct visualization of the vocal cords, using an esophagoscope he had modified for this purpose; he called this device an autoscope.[120]
In 1913, Chevalier Jackson was the first to report a high rate of success for the use of direct laryngoscopy as a means to intubate the trachea.[121] Jackson introduced a new laryngoscope blade that incorporated a component that the operator could slide out to allow room for passage of an endotracheal tube or bronchoscope.[122] Also in 1913, New York surgeonHenry H. Janeway (1873–1921) published results he had achieved using a laryngoscope he had recently developed.[123] Another pioneer in this field was SirIvan Whiteside Magill (1888–1986), who developed the technique of awake blind nasotracheal intubation,[124][125] the Magill forceps,[126] the Magill laryngoscope blade,[127] and several apparati for the administration of volatile anesthetic agents.[128][129][130] The Magill curve of an endotracheal tube is also named for Magill. SirRobert Macintosh (1897–1989) introduced a curved laryngoscope blade in 1943;[131] the Macintosh blade remains to this day the most widely used laryngoscope blade for orotracheal intubation.[10]
Between 1945 and 1952,optical engineers built upon the earlier work ofRudolph Schindler (1888–1968), developing the first gastrocamera.[132] In 1964,optical fiber technology was applied to one of these early gastrocameras to produce the first flexible fiberoptic endoscope.[133] Initially used inupper GI endoscopy, this device was first used for laryngoscopy and tracheal intubation by Peter Murphy, an English anesthetist, in 1967.[134] The concept of using a stylet for replacing or exchanging orotracheal tubes was introduced by Finucane and Kupshik in 1978, using acentral venous catheter.[135]
By the mid-1980s, the flexible fiberoptic bronchoscope had become an indispensable instrument within the pulmonology and anesthesia communities.[13] Thedigital revolution of the 21st century has brought newer technology to the art and science of tracheal intubation. Several manufacturers have developed video laryngoscopes which employdigital technology such as theCMOSactive pixel sensor (CMOS APS) to generate a view of the glottis so that the trachea may be intubated.[32]
high-risk aerosol-producing procedures such as endotracheal intubation may put the anesthesiologists at high risk of nosocomial infections
Anaesthesiologists and other perioperative care providers are particularly at risk when providing respiratory care and tracheal intubation of patients with COVID-19
The most consistent association of in-creased risk of transmission to healthcare workers (based on studies done during the SARS outbreaks of 2002–2003) was found for tracheal intubation.
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