The specific operation process and detailed steps of disposable tracheal intubation

Endotracheal intubation refers to inserting a special tracheal tube into the patient's trachea through the mouth or nose. It is a technique for endotracheal anesthesia and patient rescue, and it is also a reliable means to keep the upper airway open. Tracheal or endobronchial intubation is a safety measure for anesthesia.

Indications

1. Under general anesthesia: those with difficulty in ensuring smooth airway, such as intracranial surgery, thoracotomy, general anesthesia in a prone or sitting position, etc.; such as neck tumors compressing the trachea, jaw, face, neck, facial features, etc. Major anesthesia surgery, extremely obese patients; general anesthetics that can significantly inhibit breathing or use muscle relaxants; endotracheal intubation should be performed.

2. Intratracheal intubation plays an important role in the rescue of critically ill patients. Respiratory failure requires mechanical ventilation, cardiopulmonary resuscitation, drug poisoning, and severe neonatal asphyxia, all must undergo endotracheal intubation.

3. Certain special anesthesia, such as combined use of hypothermia, hypotension and intravenous procaine combined anesthesia.

Contraindications

1. Contraindications: laryngeal edema, acute laryngitis, submucosal hematoma of the larynx, intubation injury can cause severe bleeding; unless first aid, endotracheal intubation is contraindicated.

2. Contraindications: Patients with incomplete respiratory obstruction have intubation indications, but rapid induction intubation is contraindicated. Patients with coexisting hemorrhagic blood diseases (such as hemophilia, thrombocytopenic purpura, etc.). Intubation injury can easily induce bleeding or hematoma in the laryngoglottis or trachea submucosa, and secondary acute obstruction of the respiratory tract, so it should be listed as a relative contraindication. If an aortic aneurysm compresses the trachea, intubation may cause the aortic aneurysm to rupture, which should be listed as a relative contraindication. Anesthetizers who have not mastered the basic knowledge of intubation, those who are unskilled in intubation technology or incomplete intubation equipment should be listed as relative contraindications.

advantage

1. Keep the airway unobstructed to facilitate the removal of secretions in the trachea and bronchus.

2. It is convenient to implement assisted breathing and artificial respiration.

3. The anesthesiologist can stay away from the operation area, especially for craniocerebral, maxillofacial, facial features and neck surgery.

4. It can reduce the ineffective space of the respiratory tract of patients with respiratory failure, which is convenient for oxygen inhalation and assisted breathing.

Tracheal intubation

Item preparation

1. Negative pressure suction

2. Endotracheal tube: Adult males usually use 7.5€€8.0 No. 0 endotracheal tube, the intubation depth is generally 22€€24cm, and adult women use 7.0€€7. 5th endotracheal tube, the intubation depth is generally 21€ €23cm.

3. Prepare a suitable laryngoscope, guide wire in the catheter, suction tube, dental pad, syringe, etc.;

3. Prepare anesthesia mask and ventilation device;

4. Stethoscope, oxygen saturation monitor.

Surgical procedure

1. The patient lies on his back, with his head tilted back, so that the mouth, pharynx and throat are in a straight line

2. The operator stands on the patient's head and holds the laryngoscope in his left hand. Keep your sight parallel to the axis of the patient’s larynx.

3. Insert the laryngoscope correctly: the operator uses the right thumb and index finger to pull out the upper and lower teeth and lips of the patient, and the left hand holds the laryngoscope handle with correct gestures, and sends the lens into the patient’s mouth from the right corner of the mouth, and the left hand tail finger homeopathically Push the lower lip of the patient away, and do not press the lip between the lens and the teeth to avoid injury; then move the laryngoscope to the left, push the tongue away, and keep the laryngoscope on the midline of the mouth to avoid the tongue blocking the line of sight ; After the laryngoscope enters the oral cavity, the operator should move the right hand to the patient’s forehead in time, press the forehead down with the tiger’s mouth, and always keep the patient’s head tilted back.

4. Slowly advance the laryngoscope along the midline with the left hand. After the uvula, raise the laryngoscope in situ to see the epiglottis, and expose the patient’s uvula and epiglottis (anatomical landmarks) in turn; place the lens on the epiglottis Above (that is, the epiglottis is below the lens), continue to penetrate between the epiglottis and the base of the tongue to the bottom of the epiglottis blind cavity; then force the laryngoscope forward and upward 45° to lift the laryngoscope to lift the epiglottis and fully expose the glottis below.

5. After lifting the epiglottis and exposing the glottis by lifting the laryngoscope, the left and right vocal cords and the gap between them can be seen immediately; the operator holds the tracheal tube with a writing brush in his right hand, and faces the oblique opening of the tube front On the left, the lens is fed into the mouth along the metal groove on the right side of the lens. Directly looking at the gap between the left and right vocal cords, gently rotate the catheter so that it can be inserted into the trachea through the glottis smoothly. The catheter is required to be delivered at one time. , The intubation was successful once. If the glottis is unsatisfactory during the intubation process, please ask the assistant to gently press the laryngeal knot from the neck back or push it to one side to get a good view.

6. Adjust the depth of the intubation: When the tracheal tube passes 1.0cm through the glottis, immediately ask the assistant to remove the guide wire from the lumen, continue to feed the tube forward 5.0cm, adjust and confirm the reading of the catheter scale from the incisor Between 21~23cm; at this time, the cuff has completely passed through the glottis, and the tip of the catheter is at least 2cm away from the tracheal carina (can be confirmed by a chest X-ray). Note that it is not allowed to insert the guide wire to the end at one time during intubation. The guide wire must be removed first, and then the catheter is advanced (6.0cm under the glottis) to prevent the hard guide wire from causing a strong attack on the patient’s trachea Excitation and injury; the tracheal tube should not be sent too deep, and it must be prevented from entering one side of the bronchus and causing one-lung ventilation.

7. Confirm the position of the catheter: first put in the tooth pad, and then take out the laryngoscope (the order cannot be reversed), (please helper) immediately inflate the catheter balloon with a syringe by 5~8ml. Immediately, the assistant connects the resuscitation balloon to the tracheal tube, and begins to pinch the ball for effective artificial ventilation (stop the operation timing at this moment), and the simple intubation process is completed within 20 seconds; observe whether there are symmetrical undulations on both sides of the chest during the pinch ball ventilation , Use a stethoscope to listen to the patient’s upper abdomen to check whether there is a sound of air and water (oral), and then determine the correct position of the intubation.

8. Then fix the catheter: first put in the dental pad, and then take out the laryngoscope (the order cannot be reversed). The two fixed wings of the dental pad should be placed between the patient’s teeth and the lips; The tracheal tube and the tracheal tube are fixed to the cheek. In order to prevent it from loosening, the tape should be wound around the tube and the dental pad, and then tied and fixed together. After the tracheal tube is fixed, the resuscitation balloon is then connected to the positive pressure to ventilate the oxygen, the ball is first pinched, and the artificial ventilator is prepared at the same time.

Precautions

1. Closely monitor blood oxygen saturation, heart rate and blood pressure during each operation.

2. Evaluate the patient's airway before intubation, and estimate the difficulty of intubation, and prepare in advance. The method of judging the difficulty of intubation can be found in intubation via fiberoptic bronchoscope. If it is judged that tracheal intubation may be difficult, the following methods can be considered: intubation through fiberoptic bronchoscope; retrograde insertion; percutaneous puncture tracheostomy tube introduction; cricothyrotomy, etc.

3. The intubation operation should not exceed 30~40s. If an operation is unsuccessful, oxygen should be given to the mask immediately, and the above steps should be repeated after the blood oxygen saturation rises.

4. Pay attention to adjusting the airbag pressure to avoid excessive pressure to cause tracheal mucosal damage. At the same time, the pressure should not be too low, and there will be a gap between the airbag and the trachea. There is no need to deflate or inflate the airbag regularly.

5. Airbag leaks. The necessary preparations for emergency replacement of the artificial airway should be made routinely, including: preparing the same model (or smaller) tracheal intubation, emergency intubation equipment, mask, artificial respiration bag, etc. Once the air bag leaks, it should be replaced in time.

6. Accidental extubation.

Fix the tracheal intubation correctly and firmly, check it daily, and replace the fixing tape or fixing band in time.

Check the depth of the tracheal intubation, the distal end of the intubation should be 3~4cm away from the carina, too shallow and easy to prolapse.