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    Tracheal intubation , usually referred toas intubation , is the placement of a

    flexible plastic tube into the windpipe tomaintain an open airway or to serve as aconduit through which to administer certain drugs

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    route

    route is "orotracheal", in which an endotrachealtube is passed through the mouth and vocalapparatus into the trachea.

    In a "nasotracheal" procedure, an endotrachealtube is passed through the nose and vocalapparatus into the trachea.Other routes for intubation include thecricothyrotomy (used almost exclusively inemergency circumstances) and the tracheotomy,

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    After intubation, a high-volume, low-pressurecuff is typically inflated near the far end of thetube to help secure it in place and protect the

    tracheobronchial tree against leakage of respiratory gases and pulmonary aspiration of acid from the stomach and other undesirablematerial.

    The tube is then secured to the face or neck andthe near end of the tube is connected to a T-piece, anesthesia breathing circuit, bag valvemask device, or a mechanical ventilator.

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    protection from gastric aspiration and secretionsaccess and maintenance-in difficult airway and difficult

    surgical positions/proceduresprovide positive pressure ventilation- can be done for

    shorter periods with a maskoxygenation- to provide a controlled concentration of

    oxygen up to 100%, also provides for complete scavengingsecretions- facilitates removal of secretions via suctioning

    critically injured, illanesthetized patients to facilitate positive pressure

    ventilation of the lungs,

    mechanical ventilation,prevent asphyxiation or airway obstruction.

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    comatose or intoxicated patients with a depressedlevel of consciousness (defined as a GlasgowComa Scale -8intubation should be considered in worseningrespiratory acidosis.Regardless of the laboratory values, theseguidelines should always be put if the arterial

    partial pressure of oxygen (PaO2) is less than60 millimeters of mercury (mm Hg) while breathingan inspired O2 concentration ("FIO2") of 50% or greater.

    For hypercapneic patients, an arterial partialpressure of CO2 (PaCO2) greater than 45 mm Hgin the setting of acidemia should promptintubation,

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    Anesthetic agents, opioids, or neuromuscular-blocking drugs maydiminish or even abolish spontaneous ventilation.Diagnostic or therapeutic manipulation interfere with the ability tobreath

    situations in which oxygen supplementation using a simple face maskis not sufficient to maintain adequate tissue oxygenation.

    apnea or hypoventilation that often occurs in the setting of closedhead injury,

    intoxication or poisoning,

    cervical spine injury, flail chest,severe pneumonia,acute respiratory distress syndrome (ARDS),near-drowning.sustained seizure activity,facial fractures,

    expanding neck hematoma,laryngeal or tracheobronchial injury,airway burns, inhalation injury),multisystem disease or injuries.

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    detailed physical examination of the airway lso important. Of particular importance arethe range of motion of the cervical spine: the subject should be able totilt the head back and then forward so that the chin touches the chest.the range of motion of the temporomandibular joint: three of thesubject's fingers should be able to fit between the upper and lower incisors.the size and shape of the upper jaw and lower jaw, looking especiallyfor problems such as maxillary hypoplasia, micrognathia, or retrognathia.the thyromental distance: three of the subject's fingers should be ableto fit between the Adam's apple and the chin.the size and shape of the tongue and palate relative to the size of themouth.the teeth, especially noting the presence of prominent maxillaryincisors, any loose or damaged teeth, or crowns .

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    Eq uipmentL

    aryngoscopes

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    conventional laryngoscope consists of a handlecontaining batteries and a set of interchangeableblades.Two basic styles of laryngoscope blade arecommercially available: the straight blade andthe curved blade.The Macintosh blade is the most widely used of the curved laryngoscope blades, while the Miller

    blade is the most popular style of straight blade.Both Miller and Macintosh laryngoscope bladesare available in sizes 0 (neonatal) through 4(large adult

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    Besides the conventional laryngoscopes,many other devices have been developedas alternatives to direct laryngoscopy.These include a number of indirectfiberoptic viewing laryngoscopes such asthe flexible fiberoptic bronchoscope,Bullard scope, UpsherScope, and theWuScope

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    Several types of video laryngoscopes are also currently available,such as the Glidescope,McGrath laryngoscope, Daiken MedicalCoopdech C-scope V L P-100, the Storz C-Mac, Pentax AWS VideoMacintosh Intubating L aryngoscope System (VMS) and the BerciDCI.

    Other "noninvasive" devices which can be employed to assist intracheal intubation are the laryngeal mask airway(used as a conduitfor endotracheal tube placement), the lighted stylet, and the AirTraq.Due to the widespread availability of such devices, the technique of blind digital intubation of the trachea is rarely practiced today,although it may still be useful in certain emergency situations, suchas natural or man-made disasters

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    stylet

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    The Eschmann tracheal tube introducer (often incorrectly referred toas a "gum elastic bougie") is another specialized type of stylet,which can also be used to facilitate difficult intubation.This flexible device is 60 cm (24 in) in length, 15 French (5 mmdiameter) with a small "hockey-stick" angle at its distal tip.

    Unlike the stylet, the Eschmann tracheal tube introducer is typicallyinserted directly into the trachea and then used as a guide over which the endotracheal tube can be passed (in a manner analogousto the Seldinger technique).

    As the Eschmann tracheal tube introducer is considerably less rigidthan a conventional stylet, this technique is considered to be arelatively atraumatic means of tracheal intubation.

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    Tracheal tubes

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    A cuffed endotracheal tube, constructed of polyvinyl chlorideTracheal tubes are frequently used for airway management in the settings of general

    anesthesia, critical care, mechanical ventilation and emergency medicine.endotracheal tube is a specific type of tracheal tube that is nearly always insertedthrough the mouth (orotracheal) or nose (nasotracheal).

    It is a breathing conduit designed to be placed into the airway of critically injured, ill

    or anesthetized patients in order to perform mechanical positive pressure ventilationof the lungs and to prevent the possibility of aspiration or airway obstructionThe proximal end of the endotracheal tube has a fitting designed to be connected to asource of pressurized gas such as oxygen.The distal end has an orifice through which such gases are directed into the lungsand may also include a balloon (referred to as a "cuff").The distal tip of the endotracheal tube is positioned above the carina and sealedwithin the trachea such that the lungs can be ventilated equally.

    A tracheostomy tube is another type of tracheal tube; this 23-inch-long (5176 mm)curved metal or plastic tube may be inserted into a tracheostomy stoma to maintainpatency of the lumen

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    Originally made from red latex rubber, most modern endotrachealtubes today are constructed of polyvinyl chloride.

    Tubes constructed of silicone rubber, wire-reinforced silicone rubber or stainless 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 pediatric and neonatal patients.

    Most endotracheal tubes have an inflatable cuff to seal thetracheobronchial tree against leakage of respiratory gases andpulmonary aspiration of gastric contents, blood, secretions and other

    fluids.Uncuffed tubes are also available, pediatric patients (in smallchildren, the cricoid cartilage, the narrowest portion of the pediatricairway, usually provides an adequate seal for mechanicalventilation)

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    Methods to confirm tube placement

    direct visualization as the tip of the tube passesthrough the glottisequal bilateral breath sounds .Equal bilateral rise and fall of the chest wallwater vapor no- gastric contentsWaveform capnography

    colorimetric end-tidal carbon dioxide detector Chest x ray

    water vapor Waveform crap hy

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    Intubation in emergency

    Fiberoptic intubation under generalanesthesia

    Esophageal tracheal intubationL aryngeal mask airwayNasopharyngeal airway

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    R apid-se q uence induction andintubation

    method of induction of general anesthesia, inemergency operations and other situations wherepatients are assumed to have a "full stomach".The objective of RSI is to minimize regurgitation and

    pulmonary aspiration of gastric contents during theinduction of general anesthesia and subsequent trachealintubation.] RSI traditionally involves preoxygenating the lungs witha tightly-fitting oxygen mask, followed by the sequentialadministration of an intravenous hypnotic agent and arapidly-acting neuromuscular-blocking drug, beforeintubation of the trachea

    Sellick maneuver is often confused with the "BURP

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    children

    Internal diameter of tube (mm) = (patient'sage in years + 16) / 4

    Appropriate depth of insertion of orotracheal tube (cm) = 12 + (patient's agein years / 2)

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    C omplications

    orotracheal tube include dental trauma,laryngospasm,perforation of the trachea or esophagus,

    pulmonary aspiration of gastric contents or other foreign bodies,fracture or dislocation of the cervical spine,temporomandibular joint or arytenoid cartilages,hypoxemia,hypercapnia,

    cardiac dysrhythmias,, increased intracranial or intraocular pressure and vocal cord

    paresis.dislodgement of pharyngeal tonsils and potentially severe nasalbleeding

    flexible fiberoptic laryngoscopy reduces complication

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