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Intubation being practiced on a dummy (conventional technique using a laryngoscope).

In medicine, intubation refers to the placement of a tube into an external or internal orifice of the body. Although the term can refer to endoscopic procedures, it is most often used to denote tracheal intubation. Tracheal intubation is the placement of a flexible plastic tube into the trachea to protect the patient's airway and provide a means of mechanical ventilation. The most common tracheal intubation is orotracheal intubation where, with the assistance of a laryngoscope, an endotracheal tube is passed through the mouth, larynx, and vocal cords, into the trachea. A bulb is then inflated near the distal tip of the tube to help secure it in place and protect the airway from blood, vomit, and secretions. Another possibility is nasotracheal intubation where a tube is passed through the nose, larynx, vocal cords, and trachea. Image File history File links Information_icon. ... http://www. ... Laryngoscope in use intubating a dummy A laryngoscope is a medical instrument that is used to obtain a view of the glottis by direct laryngoscopy. ... medicines, see medication and pharmacology. ... Endoscopic images of a duodenal ulcer A flexible endoscope. ... The trachea, or windpipe, is a tube that has an inner diameter of about 12mm and a length of about 10-16cm. ... Diagram of an endotracheal tube (10) that has been inserted into the airway of a patient. ... Voicebox redirects here. ... For the article about nose in humans, see human nose Human nose in profile Elephants have prehensile noses Dogs have very sensitive noses Anatomically, a nose is a protuberance in vertebrates that houses the nostrils, or nares, which admit and expel air for respiration in conjunction with the mouth. ...

Risk v. benefit

Tracheal intubation is a potentially dangerous invasive procedure that requires a lot of clinical experience to master.^[1] When performed improperly (e.g., unrecognized esophageal intubation), the associated complications will rapidly lead to the patient's death.^[2] Subsequently, tracheal intubation's role as the "gold standard" of advanced airway maintenance was downplayed (in favor of more basic techniques like bag-valve-mask ventilation) by the American Heart Association's Guidelines for Cardiopulmonary Resuscitation in 2000,^[3] and again in 2005.^[4]

Risk management

No single method for confirming tube placement has been shown to be 100% reliable. Accordingly, the use of multiple methods to confirm correct tube placement is now the standard of care. At least one of the methods utilized should be an instrument. Waveform capnography is emerging as the gold standard instrument for the confirmation of correct tube placement and maintenance of the tube once it is in place. In tort law, the standard of care is the degree of prudence and caution required of an individual who is under a duty of care. ... Capnography is the indirect monitoring of carbon dioxide (CO2) concentrations in a patients blood. ... In medicine, a gold standard test is the diagnostic test that is regarded as definitive in determining whether an individual has a disease process. ...

Methods to confirm correct tube placement

• Direct visualization of the tube passing through the vocal cords
• Clear and equal bilateral breath sounds on auscultation of the chest
• Absent sounds on auscultation of the epigastrium
• Equal bilateral chest rise with ventilation
• Fogging of the tube
• An absence of stomach contents in the tube

Laryngoscopic view of the vocal folds. ... Breath sounds refer to the specific sounds identified through auscultation of the respiratory system with a stethescope. ... The epigastrium is the upper central region of the abdomen. ... Ventilation good and very bad Ventilation is air circulation of air, typically between a room, a tunnel, etc. ...

Instruments to confirm correct tube placement

• Colorimetric end tidal CO2 detector
• Waveform capnography
• Self inflating esophageal bulb
• Pulse oximetry (patients with a pulse)

Pulse oximetry is a non-invasive method which allows health care providers to monitor the oxygenation of a patients blood. ...

Tube maintenance

• Secure the tube in place with a commercial device
• Consider the use of a cervical collar to prevent motion of the airway
• Reconfirm tube placement after each physical move of the patient
• Reconfirm tube placement after any unexplained change in the patient's clinical status
• The use of continuous pulse oximetry (patient with a pulse)
• Continuous waveform capnography (most useful)

Indications

Tracheal intubation is performed in various medical conditions:

• Comatose or intoxicated patients who are unable to protect their airways. In such patients, the throat muscles may lose their tone so that the upper airways obstruct or collapse and air can not easily enter into the lungs. Furthermore, protective airway reflexes such as coughing and swallowing, which serve to protect the airways against aspiration of secretions and foreign bodies, may be absent. With tracheal intubation, airway patency is restored and the lower airways can be protected from aspiration.
• General anesthesia. In anesthetized patients spontaneous respiration may be decreased or absent due to the effect of anesthetics, opioids, or muscle relaxants. To enable mechanical ventilation, an endotracheal tube is often used, although there are alternative devices such as face masks or laryngeal mask airways.
• Diagnostic manipulations of the airways such as bronchoscopy.
• Endoscopic operative procedures to the airways such as laser therapy or stenting of the bronchi.
• Patients who require respiratory support, including cardiopulmonary resuscitation.

In medicine, a coma (from the Greek koma, meaning deep sleep) is a profound state of unconsciousness. ... In medicine, aspiration is the entry of secretions or foreign material into the trachea and lungs. ... This article or section may be confusing for some readers, and should be edited to be clearer. ... This article needs additional references or sources to facilitate its verification. ... A muscle relaxant is a drug which decreases the tone of a muscle. ... // The LMA was invented in the 1980s by the British anaesthetist, Dr. Archie Brain. ... This drawing shows a bronchoscope inserted through the mouth, trachea, and bronchus into the lung; lymph nodes along trachea and bronchi; and cancer in one lung. ... Experiment with a laser (likely an argon type) (US Military) In physics, a laser is a device that emits light through a specific mechanism for which the term laser is an acronym: light amplification by stimulated emission of radiation. ... Endoscopic image of self-expanding metallic stent in esophagus, which was used to palliatively treat esophageal cancer. ... Wikibooks has more about this subject: First Aid/CPR Cardiopulmonary resuscitation (CPR) is an emergency first aid procedure for a victim of cardiac arrest. ...

Types of tubes

Conventional intubation.

There are various types of tracheal tubes for oral or nasal intubation. Tubes may be either flexible or preformed and relatively stiff. Adult tubes have an inflatable cuff to seal the lower airways against air leakage and aspiration of secretions. Special double-lumen endotracheal tubes have been developed for lung and other intra-thoracic surgery. These tubes allow one-lung ventilation while the other lung can be collapsed to make surgery easier. Smaller pediatric tubes generally are uncuffed, due to concerns over blood flow to the trachea due to improper tube size or overinflation of the cuff[1], although some conditions require infants and children to have cuffed tubes to provide high-pressure ventilations[2].
Image File history File links Inserting_an_endotracheal_tube. ... Image File history File links Inserting_an_endotracheal_tube. ...

Techniques

Nasal intubation

Several techniques exist. Tracheal intubation can be performed by direct laryngoscopy (conventional technique), in which a laryngoscope is used to obtain a view of the glottis. A tube is then inserted under direct vision. This technique can usually only be employed if the patient is comatose (unconscious), under general anesthesia, or has received local or topical anesthesia to the upper airway structures (e.g., using a local anesthetic drug such as lidocaine). Image File history File links Chapter5figure69b-nasotracheal_intubation. ... Image File history File links Chapter5figure69b-nasotracheal_intubation. ... Laryngoscope in use intubating a dummy A laryngoscope is a medical instrument that is used to obtain a view of the glottis by direct laryngoscopy. ... The space between the vocal cords is called the glottis. ...

Rapid sequence induction (RSI) is a variation of the standard technique for patients under anesthesia. It is performed when immediate definitive airway management through intubation is required, and especially when there is a risk of aspiration. For RSI, a short acting sedative such as etomidate, propofol, thiopental or midazolam is normally administered, followed shortly thereafter by a paralytic such as succinylcholine or rocuronium. RSI is only correctly performed using an induction agent with a 1 arm-brain circulation time. The only agents classically used are those with 1 arm brain circulation times and are Thiopentone and etomidate. This provides the shortest induction time, and provided the appropirate dose based on body mass is used, protects against awareness during the RSI. Propofol and midazolam (in combination with other induction agents) may be used for induction where there is more time, however, propofol is increasingly being used to good effect for RSI. Rapid sequence induction (RSI, also incorrectly referred to as rapid sequence intubation) is an advanced medical protocol which permits the intubation of conscious patients who require advanced airway support. ... In medicine, aspiration is the entry of secretions or foreign material into the trachea and lungs. ... A sedative is a substance which depresses the central nervous system (CNS), resulting in calmness, relaxation, reduction of anxiety, sleepiness, slowed breathing, slurred speech, staggering gait, poor judgment, and slow, uncertain reflexes. ... Etomidate is a short acting intravenous anaesthetic agent used for the induction of general anaesthesia and for sedation for short procedures such as reduction of dislocated joints and cardioversion. ... Midazolam (marketed under brand names Versed®, Hypnovel®, Dormicum® and Dormonid®, pronounced ) is a drug which is a benzodiazepine derivative. ... Suxamethonium chloride (also known as succinylcholine, or scoline) is a white crystalline substance, it is odourless and highly soluble in water. ...

Another alternative is intubation of the awake patient under local anesthesia using a flexible endoscope or by other means (e.g., using a video laryngoscope). This technique is preferred if difficulties are anticipated, as it allows the patient to breathe spontaneously throughout the procedure, thus ensuring ventilation and oxygenation even in the event of a failed intubation. Local anesthesia is any technique to render part of the body insensitive to pain without affecting consciousness. ... Endoscopic images of a duodenal ulcer A flexible endoscope. ...

Some alternatives to intubation are

• Tracheotomy - a surgical technique, typically for patients who require long-term respiratory support
• Cricothyrotomy - an emergency technique used when intubation is unsuccessful and tracheotomy is not an option, a needle cricothyroidotomy can be performed by paramedics.

Because the life of a patient can depend on the success of an intubation, it is important to assess possible obstacles beforehand. The ease of intubation is difficult to predict. One score to asses anatomical difficulties is the Mallampati score,^[5] which is determined by looking at the anatomy of the oral cavity and based on the visibility of the base of uvula, faucial pillars and the soft palate. It should however be noted that no single score or combination of scores can be trusted to detect all patients who are difficult to intubate. Therefore, persons performing intubation must be familiar with alternative techniques of securing the airways. Completed tracheostomy: 1 - Vocal cords 2 - Thyroid cartilage 3 - Cricoid cartilage 4 - Tracheal cartilages 5 - Balloon cuff A tracheotomy or tracheostomy is a surgical procedure performed on the neck to open a direct airway through an incision in the trachea (the windpipe). ... In cricothyrotomy, the incision or puncture is made through the cricothyroid membrane inbetween the thyroid cartilage and the cricoid cartilage. ... A Paramedic is a specialized health care professional who responds to medical and trauma emergencies in the pre-hospital (out-of-hospital) environment for the purpose of stabilizing and transporting the patient to an appropriate medical facility, usually by ambulance. ... Oral cavity. ... Human heart and lungs, from an older edition of Grays Anatomy. ... The mouth, also known as the buccal cavity or the oral cavity, is the opening through which an animal or human takes in food. ... Diagram showing the uvula, tonsils, soft palate, and tongue Uvula without tonsils (after tonsillectomy) The uvula (IPA: ) is a small, mucosa-covered set of muscles, musculus uvulae, hanging down from the soft palate, near the back of the throat. ... The fauces (a Latin plural word for throat; the singular faux is rarely found), in anatomy, is the hinder part of the mouth, which leads into the pharynx. ... The soft palate, or velum, is the soft tissue comprising the back of the roof of the mouth. ...

History

The first report of endotracheal intubation and following artificial respiration of animals originates from the year 1543. Andreas Vesalius pointed out in this report that such a measure could sometimes be life-saving. It remained unnoticed however. Andreas Vesalius or Andreas Vesal (1514 - Belgian anatomist and the author of the first complete textbook on human anatomy: De Humanis Corporis Fabrica (On the workings of the Human Body) (Basel, 1543). ...

In the year 1869 the German surgeon Friedrich Trendelenburg accomplished the first intubation of humans for anaesthesia. He introduced the tube through a temporary tracheotomy. Friedrich Adolf Trendelenburg (November 30, 1802 - January 24, 1872) was a German philosopher and philologist. ... Anesthesia (AE), also anaesthesia (BE), is the process of blocking the perception of pain and other sensations. ... Completed tracheostomy: 1 - Vocal cords 2 - Thyroid cartilage 3 - Cricoid cartilage 4 - Tracheal cartilages 5 - Balloon cuff A tracheotomy or tracheostomy is a surgical procedure performed on the neck to open a direct airway through an incision in the trachea (the windpipe). ...

In 1878 the British surgeon McEwen performed the first oral intubation.

In the years of the First World War in particular Magill and Macintosh achieved profound improvements in the application of intubation. The most used replaceable spatula of the laryngoscope is named after Macintosh. After Magill the Magill curve of an endotracheal tube and the Magill pliers for positioning the tubus during nasal intubation are named. Ypres, 1917, in the vicinity of the Battle of Passchendaele. ...

Technology

It has been suggested that Tracheoscopic Ventilation Tube be merged into this article or section. (Discuss)

Image File history File links Please see the file description page for further information. ... This article or section does not adequately cite its references or sources. ...

Laryngoscope

Historically, the most common device used for intubation has been the laryngoscope. Although it has proven sufficient throughout history, many serious problems can arise from its misuse (ex. dental trauma). Newer technologies have fared better in reducing problematic incidence. Laryngoscope in use intubating a dummy A laryngoscope is a medical instrument that is used to obtain a view of the glottis by direct laryngoscopy. ...

Fiber Optics

Another common technology used for intubation has been fiber optics. Although this system provides better visibility, it still has drawback such as inadequate controls and sporadic visibility failure. It is also considered very slow relative to the laryngoscope. Fiber Optic strands An optical fiber in American English or fibre in British English is a transparent thin fiber for transmitting light. ...

Image Sensor

The latest technology used to intubate is a computer system utilizing CMOS image sensors. Visibility failures still occur but to a lesser extent. Also, this technology is still extremely expensive and little used, but progress has been made to reduce visibility failures and costs. The most notable products in this field are the GlideScope by Verathon and newcomer Tracheoscopic Ventilation Tube (TVT) by ETView. Static CMOS Inverter Complementary metal–oxide–semiconductor (CMOS) (see-moss, IPA: ), is a major class of integrated circuits. ... Hello--80. ... This article or section does not adequately cite its references or sources. ...

References

1. ^ von Goedecke, A., Herff, H., Paal, P., "Field Airway Management Disasters," Anesth Analg, 2007;104:481-483.
2. ^ ACLS: Principles and Practice. pp. 135-180. Dallas: American Heart Association, 2003. ISBN 0-87493-341-2.
3. ^ ACLS: Principles and Practice. pp. 135-180. Dallas: American Heart Association, 2003. ISBN 0-87493-341-2.
4. ^ 2005 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Part 7.1: Adjuncts for Airway Control and Ventilation. Circulation 2005;112:IV-51-IV-57
5. ^ Mallampati S, Gatt S, Gugino L, Desai S, Waraksa B, Freiberger D, Liu P (1985). "A clinical sign to predict difficult tracheal intubation: a prospective study.". Can Anaesth Soc J 32 (4): 429-34. PMID 4027773. 

External links

Airway devices for intubation

Relevant journal articles

• Fridrich P, Frass M, Krenn CG, Weinstabl C, Benumof JL, Krafft P. The UpsherScope in routine and difficult airway management: a randomized, controlled clinical trial. Anesth Analg. 1997 Dec;85(6):1377-81.
• Mallampati SR, Gatt SP, Gugino LD, Desai SP, Waraksa B, Freiberger D, Liu PL. A clinical sign to predict difficult tracheal intubation: a prospective study. Can Anaesth Soc J. 1985 Jul;32(4):429-34.
• Adnet F, Borron SW, Racine SX, Clemessy JL, Fournier JL, Plaisance P, Lapandry C. The intubation difficulty scale (IDS): proposal and evaluation of a new score characterizing the complexity of endotracheal intubation. Anesthesiology. 1997 Dec;87(6):1290-7.
• Ovassapian A. Conduct of anesthesia. In: Shields TW, ed. General thoracic surgery. 4th ed.Baltimore:Williams & Wilkins, 1994:307–23.

• de Menezes Lyra R. Glottis simulator. Anesth Analg. 1999 Jun;88(6):1422-3.[3]

• Smith, N Ty. Simulation in anesthesia: the merits of large simulators versus small simulators. Current Opinion in Anaesthesiology. 13(6):659-665, December 2000.