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Tracheal intubation

January 07, 2024

Tracheal intubation, usually simply referred to as intubation, is the placement of a flexible plastic tube into the trachea (windpipe) to maintain an open airway or to serve as a conduit through which to administer certain drugs. It is frequently performed in critically injured, ill, or anesthetized patients to facilitate ventilation of the lungs, including mechanical ventilation, and to prevent the possibility of asphyxiation or airway obstruction.

Tracheal intubation
Anesthesiologist using the Glidescope video laryngoscope to intubate the trachea of a morbidly obese elderly person with challenging airway anatomy
ICD-9-CM96.04
MeSHD007442
OPS-301 code8-701
MedlinePlus003449
[edit on Wikidata]

The most widely used route is orotracheal, in which an endotracheal tube is passed through the mouth and vocal 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 the cricothyrotomy (used almost exclusively in emergency circumstances) and the tracheotomy, used primarily in situations where a prolonged need for airway support is anticipated.

Because it is an invasive and uncomfortable medical procedure, intubation is usually performed after administration of general anesthesia and a neuromuscular-blocking drug. It can, however, be performed in the awake patient with local or topical anesthesia or in an emergency without any anesthesia at all. Intubation is normally facilitated by using a conventional laryngoscope, flexible fiberoptic bronchoscope, or video laryngoscope to identify the vocal cords and pass the tube between them into the trachea 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 the tracheobronchial tree from receiving 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 a mechanical 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 of anatomy and physiology, as well an appreciation of the germ 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 in endoscopic 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 of anesthesiology, critical care medicine, emergency medicine, and laryngology.

Tracheal intubation can be associated with complications such as broken teeth or lacerations of the tissues of the upper airway. It can also be associated with potentially fatal complications such as pulmonary aspiration of stomach contents which can result in a severe and sometimes fatal chemical aspiration pneumonitis, or unrecognized intubation of the esophagus which can lead to potentially fatal anoxia. 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.

Indications edit

Tracheal intubation is indicated in a variety of situations when illness or a medical procedure prevents a person from maintaining a clear airway, breathing, and oxygenating the blood. In these circumstances, oxygen supplementation using a simple face mask is inadequate.

Depressed level of consciousness edit

Perhaps the most common indication for tracheal intubation is for the placement of a conduit through which nitrous oxide or volatile anesthetics may be administered. General anesthetic agents, opioids, and neuromuscular-blocking drugs may diminish or even abolish the respiratory 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 and ventilation[1] and the greatest degree of protection against regurgitation and pulmonary aspiration.[2]

Damage to the brain (such as from a massive stroke, non-penetrating head injury, intoxication or poisoning) may result in a depressed level of consciousness. When this becomes severe to the point of stupor or coma (defined as a score on the Glasgow Coma Scale of less than 8),[3] dynamic collapse of the extrinsic muscles of the airway can obstruct the airway, impeding the free flow of air into the lungs. Furthermore, protective airway reflexes such as coughing and swallowing 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]

Hypoxemia edit

Intubation may be necessary for a patient with decreased oxygen content and oxygen saturation of the blood caused when their breathing is inadequate (hypoventilation), suspended (apnea), or when the lungs are unable to sufficiently transfer gasses to the blood.[5] Such patients, who may be awake and alert, are typically critically ill with a multisystem disease or multiple severe injuries.[1] Examples of such conditions include cervical spine injury, multiple rib fractures, severe pneumonia, acute respiratory distress syndrome (ARDS), or near-drowning. Specifically, intubation is considered if the arterial partial 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 with elevated arterial carbon dioxide, an arterial partial pressure of CO2 (PaCO2) greater than 45 mm Hg in the setting of acidemia would prompt intubation, especially if a series of measurements demonstrate a worsening respiratory acidosis. Regardless of the laboratory values, these guidelines are always interpreted in the clinical context.[6]

Airway obstruction edit

Actual or impending airway obstruction is a common indication for intubation of the trachea. Life-threatening airway obstruction may occur when a foreign body becomes lodged in the airway; this is especially common in infants and toddlers. Severe blunt or penetrating injury to the face or neck may be accompanied by swelling and an expanding hematoma, or injury to the larynx, trachea or bronchi. Airway obstruction is also common in people who have suffered smoke inhalation or burns within or near the airway or epiglottitis. Sustained generalized seizure activity and angioedema are other common causes of life-threatening airway obstruction which may require tracheal intubation to secure the airway.[1]

Manipulation of the airway edit

Diagnostic or therapeutic manipulation of the airway (such as bronchoscopy, laser therapy or stenting of the bronchi) may intermittently interfere with the ability to breathe; intubation may be necessary in such situations.[4]

Newborns edit

Syndromes such as respiratory distress syndrome, congenital heart disease, pneumothorax, and shock 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 under general anaesthesia.[7]

Equipment edit

Laryngoscopes edit

Main article: Laryngoscopy
 
Laryngoscope handles with an assortment of Miller blades (large adult, small adult, child, infant and newborn)
 
Laryngoscope handle with an assortment of Macintosh blades (large adult, small adult, child, infant and newborn)
 
Laryngoscopy

The vast majority of tracheal intubations involve the use of a viewing instrument of one type or another. The modern conventional laryngoscope consists of a handle containing batteries that power a light and a set of interchangeable blades, 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 Macintosh blade is the most widely used curved laryngoscope blade,[10] while the Miller blade[11] is the most popular style of straight blade.[12] Both Miller and Macintosh laryngoscope blades are available in sizes 0 (infant) through 4 (large adult). There are many other styles of straight and curved blades, with accessories such as mirrors for enlarging the field of view and even ports for the administration of oxygen. These specialty blades are primarily designed for use by anesthetists and otolaryngologists, most commonly in the operating room.[13]

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 a digital video camera sensor to allow the operator to view the glottis and larynx on a video monitor.[14][15] Other "noninvasive" devices which can be employed to assist in tracheal intubation are the laryngeal mask airway[16] (used as a conduit for endotracheal tube placement) and the Airtraq.[17]

Stylets edit

 
An endotracheal tube stylet, useful in facilitating orotracheal intubation

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,[18] such as the Verathon Stylet, which is specifically designed to follow the 60° blade angle of the GlideScope video laryngoscope.[19]

The Eschmann tracheal tube introducer (also referred to as a "gum elastic bougie") is specialized type of stylet used to facilitate difficult intubation.[20] This flexible device is 60 cm (24 in) in length, 15 French (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 the Seldinger 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.[21][22]

The tracheal tube exchanger is a hollow catheter, 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.[23] The Cook Airway Exchange Catheter (CAEC) is another example of this type of catheter; this device has a central lumen (hollow channel) through which oxygen can be administered.[24] 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 of transillumination to facilitate blind orotracheal intubation (an intubation technique in which the laryngoscopist does not view the glottis).[25]

Tracheal tubes edit

Main article: Tracheal tube
 
A cuffed endotracheal tube, constructed of polyvinyl chloride
 
A Carlens double-lumen endotracheal tube, used for thoracic surgical operations such as VATS lobectomy

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 for airway 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 a breathing conduit designed to be placed into the airway of critically injured, ill or anesthetized patients in order to perform mechanical positive pressure ventilation of the lungs and to prevent the possibility of aspiration or airway obstruction.[26] 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 the carina (before the trachea divides to each lung) and sealed within the trachea so that the lungs can be ventilated equally.[26] A tracheostomy tube is another type of tracheal tube; this 2–3-inch-long (51–76 mm) curved metal or plastic tube is inserted into a tracheostomy stoma or a cricothyrotomy incision.[27]

Tracheal tubes can be used to ensure the adequate exchange of oxygen and carbon dioxide, to deliver oxygen in higher concentrations than found in air, or to administer other gases such as helium,[28] nitric oxide,[29] nitrous oxide, xenon,[30] or certain volatile anesthetic agents such as desflurane, isoflurane, or sevoflurane. They may also be used as a route for administration of certain medications such as bronchodilators, inhaled corticosteroids, and drugs used in treating cardiac arrest such as atropine, epinephrine, lidocaine and vasopressin.[2]

Originally made from latex rubber,[31] most modern endotracheal tubes 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 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, the cricoid cartilage is the narrowest portion of the airway and usually provides an adequate seal for mechanical ventilation).[14]

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.[32]

There are a number of different types of double-lumen endo-bronchial tubes that have endobronchial as well as endotracheal channels (Carlens, White and Robertshaw tubes). These tubes are typically coaxial, 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 integrated endobronchial 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 during thoracic surgery, as it can facilitate the surgeon's view and access to other relevant structures within the thoracic cavity.[33]

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.[34]

Methods to confirm tube placement edit

 
An endotracheal tube in good position on CXR. Arrow marks the tip.
 
An endotracheal tube not deep enough. Arrow marks the tip.

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 the standard of care.[35] 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 bilateral breath sounds will be heard upon listening to the chest with a stethoscope, and no sound upon listening to the area over the stomach. Equal bilateral rise and fall of the chest wall will be evident with ventilatory excursions. A small amount of water 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.[34]

Ideally, at least one of the methods utilized for confirming tracheal tube placement will be a measuring instrument. Waveform capnography has emerged as the gold standard for the confirmation of tube placement within the trachea. Other methods relying on instruments include the use of a colorimetric end-tidal carbon dioxide detector, a self-inflating esophageal bulb, or an esophageal detection device.[36] 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 by chest 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 the right 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 to decreased oxygen content due to ventilation/perfusion mismatch.[37]

Special situations edit

Emergencies edit

Tracheal intubation in the emergency setting can be difficult with the fiberoptic bronchoscope due to blood, vomit, or secretions 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.[38] Fiberoptic intubation under general anesthesia typically requires two skilled individuals.[39] Success rates of only 83–87% have been reported using fiberoptic techniques in the emergency department, with significant nasal bleeding occurring in up to 22% of patients.[40][41] These drawbacks limit the use of fiberoptic bronchoscopy somewhat in urgent and emergency situations.[42][43]

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, cuffed oropharyngeal airway and the esophageal-tracheal combitube (Combitube).[44][45] 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.[18]

Rapid-sequence induction and intubation edit

 
Laryngoscopes prepared for emergency anaesthesia
Main article: Rapid sequence induction

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 of regurgitation and pulmonary aspiration of gastric contents during the induction of general anesthesia and subsequent tracheal intubation.[35] RSI traditionally involves preoxygenating the lungs with a tightly fitting oxygen mask, followed by the sequential administration of an intravenous sleep-inducing agent and a rapidly acting neuromuscular-blocking drug, such as rocuronium, succinylcholine, or cisatracurium besilate, before intubation of the trachea.[46]

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 and cessation 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.[35]

Named for British anesthetist Brian Arthur Sellick (1918–1996) who first described the procedure in 1961,[47] 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.[48] The initial article by Sellick was based on a small sample size at a time when high tidal volumes, head-down positioning and barbiturate anesthesia were the rule.[49] 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[50] 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.[51]

Cricoid pressure is often confused with the "BURP" (Backwards Upwards Rightwards Pressure) maneuver.[52] 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.[53] Both cricoid pressure and the BURP maneuver have the potential to worsen laryngoscopy.[54]

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.

Cricothyrotomy edit

Main article: Cricothyrotomy
 
In cricothyrotomy, the incision or puncture is made through the cricothyroid membrane in between the thyroid cartilage and the cricoid cartilage
 
Cricothyrotomy kit

A cricothyrotomy is an incision made through the skin and cricothyroid membrane to establish a patent airway during certain life-threatening situations, such as airway obstruction by a foreign body, angioedema, or massive facial trauma.[55] 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.[56]

The easiest method to perform this technique is the needle cricothyrotomy (also referred to as a percutaneous dilational cricothyrotomy), in which a large-bore (12–14 gauge) intravenous catheter is used to puncture the cricothyroid membrane.[57] Oxygen can then be administered through this catheter via jet 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.[58] 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 of apneic oxygenation through a needle cricothyrotomy, one can expect a PaCO2 of greater than 250 mm Hg and an arterial pH of less than 6.72, despite an oxygen saturation of 98% or greater.[59] 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.[60]

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 selected pre-hospital settings.[61]

Tracheotomy edit

Main article: Tracheotomy
 
Diagram of a tracheostomy tube in the trachea:
1 - Vocal folds
2 - Thyroid cartilage
3 - Cricoid cartilage
4 - Tracheal rings
5 - Balloon cuff

Tracheotomy consists of making an incision on the front of the neck and opening a direct airway through an incision in the trachea. The resulting opening 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[60] and percutaneous[62] techniques respectively) and both techniques are widely used in current practice. In order to limit the risk of damage to the recurrent laryngeal nerves (the nerves that control the voice 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).[63][64]

Children edit

 
A premature infant weighing 990 grams (35 ounces), intubated and requiring mechanical ventilation in the neonatal intensive-care unit

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 any pediatric patient. The differences, which are quite significant in infants, gradually disappear as the human body approaches a mature age and body mass index.[65]

For infants and young children, orotracheal intubation is easier than the nasotracheal route. Nasotracheal intubation carries a risk of dislodgement of adenoids 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.[66][67][68][69] Confirmation of proper position of the tracheal tube is accomplished as with adult patients.[70]

Because the airway of a child is narrow, a small amount of glottic or tracheal swelling 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.[71]

The tip of a correctly positioned tracheal tube will be in the mid-trachea, between the collarbones on an anteroposterior 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 the ear canal. For premature infants 2.5 mm (0.1 in) internal diameter is an appropriate size for the tracheal tube. For infants of normal gestational 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).[34]

Newborn infants edit

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 flow oxygen used to be recommended during intubation however as there is no evidence of benefit the 2011 NRP guidelines no longer do.[72]

Predicting difficulty edit

 
Tracheal intubation is anticipated to be difficult in this child with a massive ameloblastoma

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 the medical history of the patient and performing a physical 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, or bariatric surgery) may lead one to anticipate difficulties with intubation.[35] Many individuals have unusual airway anatomy, such as those who have limited movement of their neck or jaw, or those who have tumors, deep swelling due to injury or to 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.[73]

When taking the patient's medical history, the subject is questioned about any significant signs or symptoms, such as difficulty in speaking or difficulty in breathing. These may suggest obstructing lesions in various locations within the upper airway, larynx, or tracheobronchial tree. A history of previous surgery (e.g., previous cervical fusion), injury, radiation therapy, or tumors involving the head, neck and upper 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.[35]

A detailed physical examination of the airway is important, particularly:[74]

  • the range of motion of the cervical spine: the subject should be able to tilt the head back and then forward so that the chin touches the chest.
  • the range of motion of the jaw (the temporomandibular joint): three of the subject'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 especially for problems such as maxillary hypoplasia (an underdeveloped upper jaw), micrognathia (an abnormally small jaw), or retrognathia (misalignment of the upper and lower jaw).
  • the thyromental distance: three of the subject's fingers should be able to fit between the Adam's apple and the chin.
  • the size and shape of the tongue and palate relative to the size of the mouth.
  • the teeth, especially noting the presence of prominent maxillary incisors, any loose or damaged teeth, or crowns.

Many classification systems have been developed in an effort to predict difficulty of tracheal intubation, including the Cormack-Lehane classification system,[75] the Intubation Difficulty Scale (IDS),[76] and the Mallampati score.[77] The Mallampati score is drawn from the observation that the size of the base 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 of palatine uvula, faucial pillars and the soft 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.[78][79] 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.[80] 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.[81] A Cochrane systematic review examined the sensitivity and specificity of various bedside tests commonly used for predicting difficulty in airway management.[82] In such cases, alternative techniques of securing the airway must be readily available.[83]

Complications edit

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[84] and serious complications may result even when properly performed.[85]

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 the back 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.[85]

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 or gums or other structures within the upper airway, chipped, fractured or dislodged teeth, and nasal injury. Other complications which are common but potentially more serious include accelerated or irregular heartbeat, high blood pressure, elevated intracranial and introcular pressure, and bronchospasm.[85]

More serious complications include 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, decreased oxygen content, elevated arterial carbon dioxide, and vocal cord weakness.[85] In addition to these complications, tracheal intubation via the nasal route carries a risk of dislodgement of adenoids and potentially severe nasal bleeding.[40][41] 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.[85]

Complications may also be severe and long-lasting or permanent, such as vocal cord damage, esophageal perforation and retropharyngeal abscess, bronchial intubation, or nerve injury. They may even be immediately life-threatening, such as laryngospasm and negative pressure pulmonary edema (fluid in the lungs), aspiration, unrecognized esophageal intubation, or accidental disconnection or dislodgement of the tracheal tube.[85] Potentially fatal complications more often associated with prolonged intubation or tracheotomy include abnormal communication between the trachea and nearby structures such as the innominate artery (tracheoinnominate fistula) or esophagus (tracheoesophageal fistula). Other significant complications include airway obstruction due to loss of tracheal rigidity, ventilator-associated pneumonia and narrowing of the glottis or trachea.[34] The cuff pressure is monitored carefully in order to avoid complications from over-inflation, many of which can be traced to excessive cuff pressure restricting the blood supply to the tracheal mucosa.[86][87] A 2000 Spanish study of bedside percutaneous tracheotomy reported overall complication rates of 10–15% and procedural mortality of 0%,[62] which is comparable to those of other series reported in the literature from the Netherlands[88] and the United States.[89]

Inability to secure the airway, with subsequent failure of oxygenation and ventilation is a life-threatening complication which if not immediately corrected leads to decreased oxygen content, brain damage, cardiovascular collapse, and death.[85] When performed improperly, the associated complications (e.g., unrecognized esophageal intubation) may be rapidly fatal.[90] 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, among paramedics in several United States urban communities, unrecognized esophageal or hypopharyngeal intubation has been reported to be 6%[91][92] to 25%.[90] Although not common, where basic emergency medical technicians are permitted to intubate, reported success rates are as low as 51%.[93] In one study, nearly half of patients with misplaced tracheal tubes died in the emergency room.[90] Because of this, the American Heart Association's Guidelines 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).[94]

One complication—unintentional and unrecognized intubation of the esophagus—is both common (as frequent as 25% in the hands of inexperienced personnel)[90] 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 the circulatory 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 the American 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 late sequelae occurred in 65%.[95]

During the SARS and COVID-19 pandemics, tracheal intubation has been used with a ventilator in severe cases where the patient struggles to breathe. Performing the procedure carries a risk of the caregiver becoming infected.[96][97][98]

Alternatives edit

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 other breathing gases include the laryngeal mask airway, i-gel, cuffed oropharyngeal airway, continuous positive airway pressure (CPAP mask), nasal BiPAP mask, simple face mask, and nasal cannula.[99]

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 the risk-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).[99]

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.[100]

History edit

Main article: History of tracheal intubation
Tracheotomy

The earliest known depiction of a tracheotomy is found on two Egyptian tablets dating back to around 3600 BC.[101] The 110-page Ebers Papyrus, an Egyptian medical papyrus which dates to roughly 1550 BC, also makes reference to the tracheotomy.[102] Tracheotomy was described in the Rigveda, a Sanskrit text of ayurvedic medicine written around 2000 BC in ancient India.[103] The Sushruta Samhita from around 400 BC is another text from the Indian subcontinent on ayurvedic medicine and surgery that mentions tracheotomy.[104] Asclepiades of Bithynia (c. 124–40 BC) is often credited as being the first physician to perform a non-emergency tracheotomy.[105] Galen of Pergamon (AD 129–199) clarified the anatomy of the trachea and was the first to demonstrate that the larynx generates the voice.[106] In one of his experiments, Galen used bellows to inflate the lungs of a dead animal.[107] 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.[108] In the 12th century medical textbook Al-Taisir, Ibn Zuhr (1092–1162)—also known as Avenzoar—of Al-Andalus provided a correct description of the tracheotomy operation.[109]

The first detailed descriptions of tracheal intubation and subsequent artificial respiration of animals were from Andreas Vesalius (1514–1564) of Brussels. In his landmark book published in 1543, De humani corporis fabrica, he described an experiment in which he passed a reed into the trachea of a dying animal whose thorax had been opened and maintained ventilation by blowing into the reed intermittently.[107] Antonio Musa Brassavola (1490–1554) of Ferrara successfully treated a patient with peritonsillar 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.[110] 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 surgeon Nicholas Habicot (1550–1624) published a report of four successful tracheotomies.[111] In 1714, anatomist Georg Detharding (1671–1747) of the University of Rostock performed a tracheotomy on a drowning victim.[112]

Despite the many recorded instances of its use since antiquity, 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 physician Armand Trousseau (1801–1867) presented a series of 169 tracheotomies to the Académie Impériale de Médecine. 158 of these were performed for the treatment of croup, and 11 were performed for "chronic maladies of the larynx".[113] Between 1830 and 1855, more than 350 tracheotomies were performed in Paris, most of them at the Hôpital des Enfants Malades, a public 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.[114]

In 1871, the German surgeon Friedrich Trendelenburg (1844–1924) published a paper describing the first successful elective human tracheotomy to be performed for the purpose of administration of general anesthesia.[115] In 1888, Sir Morell Mackenzie (1837–1892) published a book discussing the indications for tracheotomy.[116] In the early 20th century, tracheotomy became a life-saving treatment for patients affected with paralytic poliomyelitis who required mechanical ventilation. In 1909, Philadelphia laryngologist Chevalier Jackson (1865–1958) described a technique for tracheotomy that is used to this day.[117]

Laryngoscopy and non-surgical techniques
 
The laryngoscopy. From García, 1884

In 1854, a Spanish singing teacher named Manuel García (1805–1906) became the first man to view the functioning glottis in a living human.[118] In 1858, French pediatrician Eugène Bouchut (1818–1891) developed a new technique for non-surgical orotracheal intubation to bypass laryngeal obstruction resulting from a diphtheria-related pseudomembrane.[119] In 1880, Scottish surgeon William 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 with chloroform.[120] 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.[121]

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.[122] 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.[123] Also in 1913, New York surgeon Henry H. Janeway (1873–1921) published results he had achieved using a laryngoscope he had recently developed.[124] Another pioneer in this field was Sir Ivan Whiteside Magill (1888–1986), who developed the technique of awake blind nasotracheal intubation,[125][126] the Magill forceps,[127] the Magill laryngoscope blade,[128] and several apparati for the administration of volatile anesthetic agents.[129][130][131] The Magill curve of an endotracheal tube is also named for Magill. Sir Robert Macintosh (1897–1989) introduced a curved laryngoscope blade in 1943;[132] 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 of Rudolph Schindler (1888–1968), developing the first gastrocamera.[133] In 1964, optical fiber technology was applied to one of these early gastrocameras to produce the first flexible fiberoptic endoscope.[134] Initially used in upper GI endoscopy, this device was first used for laryngoscopy and tracheal intubation by Peter Murphy, an English anesthetist, in 1967.[135] The concept of using a stylet for replacing or exchanging orotracheal tubes was introduced by Finucane and Kupshik in 1978, using a central venous catheter.[136]

By the mid-1980s, the flexible fiberoptic bronchoscope had become an indispensable instrument within the pulmonology and anesthesia communities.[14] The digital revolution of the 21st century has brought newer technology to the art and science of tracheal intubation. Several manufacturers have developed video laryngoscopes which employ digital technology such as the CMOS active pixel sensor (CMOS APS) to generate a view of the glottis so that the trachea may be intubated.[33]

See also edit

Notes edit

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References edit

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External links edit

 
Wikimedia Commons has media related to Tracheal intubation.
  • Video of endotracheal intubation using C-MAC D-blade and bougie used as introducer.
  • Videos of direct laryngoscopy recorded with the Airway Cam (TM) imaging system
  • Examples of some devices for facilitation of tracheal intubation
  • Tracheal intubation live case 2022

January 07, 2024
tracheal, intubation, usually, simply, referred, intubation, placement, flexible, plastic, tube, into, trachea, windpipe, maintain, open, airway, serve, conduit, through, which, administer, certain, drugs, frequently, performed, critically, injured, anesthetiz. Tracheal intubation usually simply referred to as intubation is the placement of a flexible plastic tube into the trachea windpipe to maintain an open airway or to serve as a conduit through which to administer certain drugs It is frequently performed in critically injured ill or anesthetized patients to facilitate ventilation of the lungs including mechanical ventilation and to prevent the possibility of asphyxiation or airway obstruction Tracheal intubationAnesthesiologist using the Glidescope video laryngoscope to intubate the trachea of a morbidly obese elderly person with challenging airway anatomyICD 9 CM96 04MeSHD007442OPS 301 code8 701MedlinePlus003449 edit on Wikidata The most widely used route is orotracheal in which an endotracheal tube is passed through the mouth and vocal 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 the cricothyrotomy used almost exclusively in emergency circumstances and the tracheotomy used primarily in situations where a prolonged need for airway support is anticipated Because it is an invasive and uncomfortable medical procedure intubation is usually performed after administration of general anesthesia and a neuromuscular blocking drug It can however be performed in the awake patient with local or topical anesthesia or in an emergency without any anesthesia at all Intubation is normally facilitated by using a conventional laryngoscope flexible fiberoptic bronchoscope or video laryngoscope to identify the vocal cords and pass the tube between them into the trachea 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 the tracheobronchial tree from receiving 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 a mechanical 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 of anatomy and physiology as well an appreciation of the germ 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 in endoscopic 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 of anesthesiology critical care medicine emergency medicine and laryngology Tracheal intubation can be associated with complications such as broken teeth or lacerations of the tissues of the upper airway It can also be associated with potentially fatal complications such as pulmonary aspiration of stomach contents which can result in a severe and sometimes fatal chemical aspiration pneumonitis or unrecognized intubation of the esophagus which can lead to potentially fatal anoxia 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 Contents 1 Indications 1 1 Depressed level of consciousness 1 2 Hypoxemia 1 3 Airway obstruction 1 4 Manipulation of the airway 1 5 Newborns 2 Equipment 2 1 Laryngoscopes 2 2 Stylets 2 3 Tracheal tubes 2 4 Methods to confirm tube placement 3 Special situations 3 1 Emergencies 3 1 1 Rapid sequence induction and intubation 3 1 2 Cricothyrotomy 3 2 Tracheotomy 3 3 Children 3 4 Newborn infants 4 Predicting difficulty 5 Complications 6 Alternatives 7 History 8 See also 9 Notes 10 References 11 External linksIndications editTracheal intubation is indicated in a variety of situations when illness or a medical procedure prevents a person from maintaining a clear airway breathing and oxygenating the blood In these circumstances oxygen supplementation using a simple face mask is inadequate Depressed level of consciousness edit Perhaps the most common indication for tracheal intubation is for the placement of a conduit through which nitrous oxide or volatile anesthetics may be administered General anesthetic agents opioids and neuromuscular blocking drugs may diminish or even abolish the respiratory 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 and ventilation 1 and the greatest degree of protection against regurgitation and pulmonary aspiration 2 Damage to the brain such as from a massive stroke non penetrating head injury intoxication or poisoning may result in a depressed level of consciousness When this becomes severe to the point of stupor or coma defined as a score on the Glasgow Coma Scale of less than 8 3 dynamic collapse of the extrinsic muscles of the airway can obstruct the airway impeding the free flow of air into the lungs Furthermore protective airway reflexes such as coughing and swallowing 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 Hypoxemia edit Intubation may be necessary for a patient with decreased oxygen content and oxygen saturation of the blood caused when their breathing is inadequate hypoventilation suspended apnea or when the lungs are unable to sufficiently transfer gasses to the blood 5 Such patients who may be awake and alert are typically critically ill with a multisystem disease or multiple severe injuries 1 Examples of such conditions include cervical spine injury multiple rib fractures severe pneumonia acute respiratory distress syndrome ARDS or near drowning Specifically intubation is considered if the arterial partial 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 with elevated arterial carbon dioxide an arterial partial pressure of CO2 PaCO2 greater than 45 mm Hg in the setting of acidemia would prompt intubation especially if a series of measurements demonstrate a worsening respiratory acidosis Regardless of the laboratory values these guidelines are always interpreted in the clinical context 6 Airway obstruction edit Actual or impending airway obstruction is a common indication for intubation of the trachea Life threatening airway obstruction may occur when a foreign body becomes lodged in the airway this is especially common in infants and toddlers Severe blunt or penetrating injury to the face or neck may be accompanied by swelling and an expanding hematoma or injury to the larynx trachea or bronchi Airway obstruction is also common in people who have suffered smoke inhalation or burns within or near the airway or epiglottitis Sustained generalized seizure activity and angioedema are other common causes of life threatening airway obstruction which may require tracheal intubation to secure the airway 1 Manipulation of the airway edit Diagnostic or therapeutic manipulation of the airway such as bronchoscopy laser therapy or stenting of the bronchi may intermittently interfere with the ability to breathe intubation may be necessary in such situations 4 Newborns edit Syndromes such as respiratory distress syndrome congenital heart disease pneumothorax and shock 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 under general anaesthesia 7 Equipment editLaryngoscopes edit Main article Laryngoscopy nbsp Laryngoscope handles with an assortment of Miller blades large adult small adult child infant and newborn nbsp Laryngoscope handle with an assortment of Macintosh blades large adult small adult child infant and newborn nbsp LaryngoscopyThe vast majority of tracheal intubations involve the use of a viewing instrument of one type or another The modern conventional laryngoscope consists of a handle containing batteries that power a light and a set of interchangeable blades 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 Macintosh blade is the most widely used curved laryngoscope blade 10 while the Miller blade 11 is the most popular style of straight blade 12 Both Miller and Macintosh laryngoscope blades are available in sizes 0 infant through 4 large adult There are many other styles of straight and curved blades with accessories such as mirrors for enlarging the field of view and even ports for the administration of oxygen These specialty blades are primarily designed for use by anesthetists and otolaryngologists most commonly in the operating room 13 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 a digital video camera sensor to allow the operator to view the glottis and larynx on a video monitor 14 15 Other noninvasive devices which can be employed to assist in tracheal intubation are the laryngeal mask airway 16 used as a conduit for endotracheal tube placement and the Airtraq 17 Stylets edit nbsp An endotracheal tube stylet useful in facilitating orotracheal intubationAn 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 18 such as the Verathon Stylet which is specifically designed to follow the 60 blade angle of the GlideScope video laryngoscope 19 The Eschmann tracheal tube introducer also referred to as a gum elastic bougie is specialized type of stylet used to facilitate difficult intubation 20 This flexible device is 60 cm 24 in in length 15 French 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 the Seldinger 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 21 22 The tracheal tube exchanger is a hollow catheter 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 23 The Cook Airway Exchange Catheter CAEC is another example of this type of catheter this device has a central lumen hollow channel through which oxygen can be administered 24 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 of transillumination to facilitate blind orotracheal intubation an intubation technique in which the laryngoscopist does not view the glottis 25 Tracheal tubes edit Main article Tracheal tube nbsp A cuffed endotracheal tube constructed of polyvinyl chloride nbsp A Carlens double lumen endotracheal tube used for thoracic surgical operations such as VATS lobectomyA 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 for airway 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 a breathing conduit designed to be placed into the airway of critically injured ill or anesthetized patients in order to perform mechanical positive pressure ventilation of the lungs and to prevent the possibility of aspiration or airway obstruction 26 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 the carina before the trachea divides to each lung and sealed within the trachea so that the lungs can be ventilated equally 26 A tracheostomy tube is another type of tracheal tube this 2 3 inch long 51 76 mm curved metal or plastic tube is inserted into a tracheostomy stoma or a cricothyrotomy incision 27 Tracheal tubes can be used to ensure the adequate exchange of oxygen and carbon dioxide to deliver oxygen in higher concentrations than found in air or to administer other gases such as helium 28 nitric oxide 29 nitrous oxide xenon 30 or certain volatile anesthetic agents such as desflurane isoflurane or sevoflurane They may also be used as a route for administration of certain medications such as bronchodilators inhaled corticosteroids and drugs used in treating cardiac arrest such as atropine epinephrine lidocaine and vasopressin 2 Originally made from latex rubber 31 most modern endotracheal tubes 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 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 the cricoid cartilage is the narrowest portion of the airway and usually provides an adequate seal for mechanical ventilation 14 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 32 There are a number of different types of double lumen endo bronchial tubes that have endobronchial as well as endotracheal channels Carlens White and Robertshaw tubes These tubes are typically coaxial 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 integrated endobronchial 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 during thoracic surgery as it can facilitate the surgeon s view and access to other relevant structures within the thoracic cavity 33 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 34 Methods to confirm tube placement edit nbsp An endotracheal tube in good position on CXR Arrow marks the tip nbsp An endotracheal tube not deep enough Arrow marks the tip 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 the standard of care 35 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 bilateral breath sounds will be heard upon listening to the chest with a stethoscope and no sound upon listening to the area over the stomach Equal bilateral rise and fall of the chest wall will be evident with ventilatory excursions A small amount of water 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 34 Ideally at least one of the methods utilized for confirming tracheal tube placement will be a measuring instrument Waveform capnography has emerged as the gold standard for the confirmation of tube placement within the trachea Other methods relying on instruments include the use of a colorimetric end tidal carbon dioxide detector a self inflating esophageal bulb or an esophageal detection device 36 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 by chest 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 the right 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 to decreased oxygen content due to ventilation perfusion mismatch 37 Special situations editEmergencies edit Tracheal intubation in the emergency setting can be difficult with the fiberoptic bronchoscope due to blood vomit or secretions 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 38 Fiberoptic intubation under general anesthesia typically requires two skilled individuals 39 Success rates of only 83 87 have been reported using fiberoptic techniques in the emergency department with significant nasal bleeding occurring in up to 22 of patients 40 41 These drawbacks limit the use of fiberoptic bronchoscopy somewhat in urgent and emergency situations 42 43 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 cuffed oropharyngeal airway and the esophageal tracheal combitube Combitube 44 45 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 18 Rapid sequence induction and intubation edit nbsp Laryngoscopes prepared for emergency anaesthesiaMain article Rapid sequence induction 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 of regurgitation and pulmonary aspiration of gastric contents during the induction of general anesthesia and subsequent tracheal intubation 35 RSI traditionally involves preoxygenating the lungs with a tightly fitting oxygen mask followed by the sequential administration of an intravenous sleep inducing agent and a rapidly acting neuromuscular blocking drug such as rocuronium succinylcholine or cisatracurium besilate before intubation of the trachea 46 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 and cessation 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 35 Named for British anesthetist Brian Arthur Sellick 1918 1996 who first described the procedure in 1961 47 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 48 The initial article by Sellick was based on a small sample size at a time when high tidal volumes head down positioning and barbiturate anesthesia were the rule 49 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 50 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 51 Cricoid pressure is often confused with the BURP Backwards Upwards Rightwards Pressure maneuver 52 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 53 Both cricoid pressure and the BURP maneuver have the potential to worsen laryngoscopy 54 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 Cricothyrotomy edit Main article Cricothyrotomy nbsp In cricothyrotomy the incision or puncture is made through the cricothyroid membrane in between the thyroid cartilage and the cricoid cartilage nbsp Cricothyrotomy kitA cricothyrotomy is an incision made through the skin and cricothyroid membrane to establish a patent airway during certain life threatening situations such as airway obstruction by a foreign body angioedema or massive facial trauma 55 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 56 The easiest method to perform this technique is the needle cricothyrotomy also referred to as a percutaneous dilational cricothyrotomy in which a large bore 12 14 gauge intravenous catheter is used to puncture the cricothyroid membrane 57 Oxygen can then be administered through this catheter via jet 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 58 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 of apneic oxygenation through a needle cricothyrotomy one can expect a PaCO2 of greater than 250 mm Hg and an arterial pH of less than 6 72 despite an oxygen saturation of 98 or greater 59 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 60 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 selected pre hospital settings 61 Tracheotomy edit Main article Tracheotomy nbsp Diagram of a tracheostomy tube in the trachea 1 Vocal folds 2 Thyroid cartilage 3 Cricoid cartilage 4 Tracheal rings 5 Balloon cuffTracheotomy consists of making an incision on the front of the neck and opening a direct airway through an incision in the trachea The resulting opening 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 60 and percutaneous 62 techniques respectively and both techniques are widely used in current practice In order to limit the risk of damage to the recurrent laryngeal nerves the nerves that control the voice 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 63 64 Children edit nbsp A premature infant weighing 990 grams 35 ounces intubated and requiring mechanical ventilation in the neonatal intensive care unitThere 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 any pediatric patient The differences which are quite significant in infants gradually disappear as the human body approaches a mature age and body mass index 65 For infants and young children orotracheal intubation is easier than the nasotracheal route Nasotracheal intubation carries a risk of dislodgement of adenoids 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 66 67 68 69 Confirmation of proper position of the tracheal tube is accomplished as with adult patients 70 Because the airway of a child is narrow a small amount of glottic or tracheal swelling 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 71 The tip of a correctly positioned tracheal tube will be in the mid trachea between the collarbones on an anteroposterior 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 the ear canal For premature infants 2 5 mm 0 1 in internal diameter is an appropriate size for the tracheal tube For infants of normal gestational 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 34 Newborn infants edit 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 flow oxygen used to be recommended during intubation however as there is no evidence of benefit the 2011 NRP guidelines no longer do 72 Predicting difficulty edit nbsp Tracheal intubation is anticipated to be difficult in this child with a massive ameloblastomaTracheal 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 the medical history of the patient and performing a physical 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 or bariatric surgery may lead one to anticipate difficulties with intubation 35 Many individuals have unusual airway anatomy such as those who have limited movement of their neck or jaw or those who have tumors deep swelling due to injury or to 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 73 When taking the patient s medical history the subject is questioned about any significant signs or symptoms such as difficulty in speaking or difficulty in breathing These may suggest obstructing lesions in various locations within the upper airway larynx or tracheobronchial tree A history of previous surgery e g previous cervical fusion injury radiation therapy or tumors involving the head neck and upper 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 35 A detailed physical examination of the airway is important particularly 74 the range of motion of the cervical spine the subject should be able to tilt the head back and then forward so that the chin touches the chest the range of motion of the jaw the temporomandibular joint three of the subject 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 especially for problems such as maxillary hypoplasia an underdeveloped upper jaw micrognathia an abnormally small jaw or retrognathia misalignment of the upper and lower jaw the thyromental distance three of the subject s fingers should be able to fit between the Adam s apple and the chin the size and shape of the tongue and palate relative to the size of the mouth the teeth especially noting the presence of prominent maxillary incisors any loose or damaged teeth or crowns Many classification systems have been developed in an effort to predict difficulty of tracheal intubation including the Cormack Lehane classification system 75 the Intubation Difficulty Scale IDS 76 and the Mallampati score 77 The Mallampati score is drawn from the observation that the size of the base 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 of palatine uvula faucial pillars and the soft 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 78 79 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 80 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 81 A Cochrane systematic review examined the sensitivity and specificity of various bedside tests commonly used for predicting difficulty in airway management 82 In such cases alternative techniques of securing the airway must be readily available 83 Complications editTracheal 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 84 and serious complications may result even when properly performed 85 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 the back 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 85 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 or gums or other structures within the upper airway chipped fractured or dislodged teeth and nasal injury Other complications which are common but potentially more serious include accelerated or irregular heartbeat high blood pressure elevated intracranial and introcular pressure and bronchospasm 85 More serious complications include 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 decreased oxygen content elevated arterial carbon dioxide and vocal cord weakness 85 In addition to these complications tracheal intubation via the nasal route carries a risk of dislodgement of adenoids and potentially severe nasal bleeding 40 41 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 85 Complications may also be severe and long lasting or permanent such as vocal cord damage esophageal perforation and retropharyngeal abscess bronchial intubation or nerve injury They may even be immediately life threatening such as laryngospasm and negative pressure pulmonary edema fluid in the lungs aspiration unrecognized esophageal intubation or accidental disconnection or dislodgement of the tracheal tube 85 Potentially fatal complications more often associated with prolonged intubation or tracheotomy include abnormal communication between the trachea and nearby structures such as the innominate artery tracheoinnominate fistula or esophagus tracheoesophageal fistula Other significant complications include airway obstruction due to loss of tracheal rigidity ventilator associated pneumonia and narrowing of the glottis or trachea 34 The cuff pressure is monitored carefully in order to avoid complications from over inflation many of which can be traced to excessive cuff pressure restricting the blood supply to the tracheal mucosa 86 87 A 2000 Spanish study of bedside percutaneous tracheotomy reported overall complication rates of 10 15 and procedural mortality of 0 62 which is comparable to those of other series reported in the literature from the Netherlands 88 and the United States 89 Inability to secure the airway with subsequent failure of oxygenation and ventilation is a life threatening complication which if not immediately corrected leads to decreased oxygen content brain damage cardiovascular collapse and death 85 When performed improperly the associated complications e g unrecognized esophageal intubation may be rapidly fatal 90 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 among paramedics in several United States urban communities unrecognized esophageal or hypopharyngeal intubation has been reported to be 6 91 92 to 25 90 Although not common where basic emergency medical technicians are permitted to intubate reported success rates are as low as 51 93 In one study nearly half of patients with misplaced tracheal tubes died in the emergency room 90 Because of this the American Heart Association s Guidelines 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 94 One complication unintentional and unrecognized intubation of the esophagus is both common as frequent as 25 in the hands of inexperienced personnel 90 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 the circulatory 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 the American 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 late sequelae occurred in 65 95 During the SARS and COVID 19 pandemics tracheal intubation has been used with a ventilator in severe cases where the patient struggles to breathe Performing the procedure carries a risk of the caregiver becoming infected 96 97 98 Alternatives editAlthough 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 other breathing gases include the laryngeal mask airway i gel cuffed oropharyngeal airway continuous positive airway pressure CPAP mask nasal BiPAP mask simple face mask and nasal cannula 99 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 the risk 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 99 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 100 History editMain article History of tracheal intubation TracheotomyThe earliest known depiction of a tracheotomy is found on two Egyptian tablets dating back to around 3600 BC 101 The 110 page Ebers Papyrus an Egyptian medical papyrus which dates to roughly 1550 BC also makes reference to the tracheotomy 102 Tracheotomy was described in the Rigveda a Sanskrit text of ayurvedic medicine written around 2000 BC in ancient India 103 The Sushruta Samhita from around 400 BC is another text from the Indian subcontinent on ayurvedic medicine and surgery that mentions tracheotomy 104 Asclepiades of Bithynia c 124 40 BC is often credited as being the first physician to perform a non emergency tracheotomy 105 Galen of Pergamon AD 129 199 clarified the anatomy of the trachea and was the first to demonstrate that the larynx generates the voice 106 In one of his experiments Galen used bellows to inflate the lungs of a dead animal 107 Ibn Sina 980 1037 described the use of tracheal intubation to facilitate breathing in 1025 in his 14 volume medical encyclopedia The Canon of Medicine 108 In the 12th century medical textbook Al Taisir Ibn Zuhr 1092 1162 also known as Avenzoar of Al Andalus provided a correct description of the tracheotomy operation 109 The first detailed descriptions of tracheal intubation and subsequent artificial respiration of animals were from Andreas Vesalius 1514 1564 of Brussels In his landmark book published in 1543 De humani corporis fabrica he described an experiment in which he passed a reed into the trachea of a dying animal whose thorax had been opened and maintained ventilation by blowing into the reed intermittently 107 Antonio Musa Brassavola 1490 1554 of Ferrara successfully treated a patient with peritonsillar 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 110 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 surgeon Nicholas Habicot 1550 1624 published a report of four successful tracheotomies 111 In 1714 anatomist Georg Detharding 1671 1747 of the University of Rostock performed a tracheotomy on a drowning victim 112 Despite the many recorded instances of its use since antiquity 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 physician Armand Trousseau 1801 1867 presented a series of 169 tracheotomies to the Academie Imperiale de Medecine 158 of these were performed for the treatment of croup and 11 were performed for chronic maladies of the larynx 113 Between 1830 and 1855 more than 350 tracheotomies were performed in Paris most of them at the Hopital des Enfants Malades a public 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 114 In 1871 the German surgeon Friedrich Trendelenburg 1844 1924 published a paper describing the first successful elective human tracheotomy to be performed for the purpose of administration of general anesthesia 115 In 1888 Sir Morell Mackenzie 1837 1892 published a book discussing the indications for tracheotomy 116 In the early 20th century tracheotomy became a life saving treatment for patients affected with paralytic poliomyelitis who required mechanical ventilation In 1909 Philadelphia laryngologist Chevalier Jackson 1865 1958 described a technique for tracheotomy that is used to this day 117 Laryngoscopy and non surgical techniques nbsp The laryngoscopy From Garcia 1884In 1854 a Spanish singing teacher named Manuel Garcia 1805 1906 became the first man to view the functioning glottis in a living human 118 In 1858 French pediatrician Eugene Bouchut 1818 1891 developed a new technique for non surgical orotracheal intubation to bypass laryngeal obstruction resulting from a diphtheria related pseudomembrane 119 In 1880 Scottish surgeon William 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 with chloroform 120 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 121 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 122 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 123 Also in 1913 New York surgeon Henry H Janeway 1873 1921 published results he had achieved using a laryngoscope he had recently developed 124 Another pioneer in this field was Sir Ivan Whiteside Magill 1888 1986 who developed the technique of awake blind nasotracheal intubation 125 126 the Magill forceps 127 the Magill laryngoscope blade 128 and several apparati for the administration of volatile anesthetic agents 129 130 131 The Magill curve of an endotracheal tube is also named for Magill Sir Robert Macintosh 1897 1989 introduced a curved laryngoscope blade in 1943 132 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 of Rudolph Schindler 1888 1968 developing the first gastrocamera 133 In 1964 optical fiber technology was applied to one of these early gastrocameras to produce the first flexible fiberoptic endoscope 134 Initially used in upper GI endoscopy this device was first used for laryngoscopy and tracheal intubation by Peter Murphy an English anesthetist in 1967 135 The concept of using a stylet for replacing or exchanging orotracheal tubes was introduced by Finucane and Kupshik in 1978 using a central venous catheter 136 By the mid 1980s the flexible fiberoptic bronchoscope had become an indispensable instrument within the pulmonology and anesthesia communities 14 The digital revolution of the 21st century has brought newer technology to the art and science of tracheal intubation Several manufacturers have developed video laryngoscopes which employ digital technology such as the CMOS active pixel sensor CMOS APS to generate a view of the glottis so that the trachea may be intubated 33 See also editIntratracheal instillationNotes edit a b c Benumof 2007 Ezri T and Warters RD Chapter 15 Indications for tracheal intubation pp 371 8 a b c d e International Liaison Committee on Resuscitation American Heart Association European Resuscitation Council 2005 2005 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations Part 4 Advanced life support Resuscitation 67 2 3 213 47 doi 10 1016 j resuscitation 2005 09 018 PMID 16324990 Advanced Trauma Life Support Program for Doctors 2004 Committee on Trauma American College of Surgeons Head Trauma pp 151 76 a b Kabrhel C Thomsen TW Setnik GS Walls RM 2007 Videos in clinical medicine orotracheal intubation The New England Journal of Medicine 356 17 e15 doi 10 1056 NEJMvcm063574 PMID 17460222 Mallinson Tom Worrall Mark Price Richard Duff Lorna 2022 Prehospital endotracheal intubation in cardiac arrest by BASICS Scotland clinicians doi 10 13140 RG 2 2 24988 56969 Doherty 2010 Holcroft JW Anderson JT and Sena MJ Shock amp Acute Pulmonary Failure in Surgical Patients pp 151 75 a b c d Bruschettini Matteo Zappettini Simona Moja Lorenzo Calevo Maria Grazia 2016 03 07 Frequency of endotracheal suctioning for the prevention of respiratory morbidity in ventilated newborns The Cochrane Database of Systematic Reviews 3 5 CD011493 doi 10 1002 14651858 CD011493 pub2 hdl 2434 442812 ISSN 1469 493X PMC 8915721 PMID 26945780 James NR 1950 Blind Intubation Anaesthesia 5 3 159 60 doi 10 1111 j 1365 2044 1950 tb12674 x S2CID 221389855 Benumof 2007 Christodolou CC Murphy MF and Hung OR Chapter 17 Blind digital intubation pp 393 8 a b Scott J Baker PA 2009 How did the Macintosh laryngoscope become so popular Pediatric Anesthesia 19 Suppl 1 24 9 doi 10 1111 j 1460 9592 2009 03026 x PMID 19572841 S2CID 6345531 Miller RA 1941 A new laryngoscope Anesthesiology 2 3 317 20 doi 10 1097 00000542 194105000 00008 S2CID 72555028 Amornyotin S Prakanrattana U Vichitvejpaisal P Vallisut T Kunanont N Permpholprasert L 2010 Comparison of the Clinical Use of Macintosh and Miller Laryngoscopes for Orotracheal Intubation by Second Month Nurse Students in Anesthesiology Anesthesiology Research and Practice 2010 1 5 doi 10 1155 2010 432846 PMC 2911595 PMID 20700430 Benumof 2007 Berry JM Chapter 16 Conventional laryngoscopic orotracheal and nasotracheal intubation single lumen tube pp 379 92 a b c Benumof 2007 Wheeler M and Ovassapian A Chapter 18 Fiberoptic endoscopy aided technique p 399 438 Hansel J Rogers AM Lewis SR Cook TM Smith AF April 2022 Videolaryngoscopy versus direct laryngoscopy for adults undergoing tracheal intubation Cochrane Database Syst Rev 2022 4 CD011136 doi 10 1002 14651858 CD011136 pub3 PMC 8978307 PMID 35373840 Brain AIJ 1985 Three cases of difficult intubation overcome by the laryngeal mask airway Anaesthesia 40 4 353 5 doi 10 1111 j 1365 2044 1985 tb10788 x PMID 3890603 S2CID 35038041 Maharaj CH Costello JF McDonnell JG Harte BH Laffey JG 2007 The Airtraq as a rescue airway device following failed direct laryngoscopy a case series Anaesthesia 62 6 598 601 doi 10 1111 j 1365 2044 2007 05036 x PMID 17506739 S2CID 21106547 a b Benumof 2007 Hung OR and Stewart RD Chapter 20 Intubating stylets pp 463 75 Agro F Barzoi G Montecchia F 2003 Tracheal intubation using a Macintosh laryngoscope or a GlideScope in 15 patients with cervical spine immobilization British Journal of Anaesthesia 90 5 705 6 doi 10 1093 bja aeg560 PMID 12697606 El Orbany MI Salem MR 2004 The Eschmann tracheal tube introducer is not an airway exchange device Anesthesia amp Analgesia 99 4 1269 70 author reply 1270 doi 10 1213 01 ANE 0000133955 92363 B1 PMID 15385401 Armstrong P Sellers WF 2004 A response to Bougie trauma it is still possible Prabhu A Pradham P Sanaka R and Bilolikar A Anaesthesia 2003 58 811 2 Anaesthesia 59 2 204 doi 10 1111 j 1365 2044 2003 03632 x PMID 14725554 S2CID 7977609 Hodzovic I Latto IP Wilkes AR Hall JE Mapleson WW 2004 Evaluation of Frova single use intubation introducer in a manikin Comparison with Eschmann multiple use introducer and Portex single use introducer Anaesthesia 59 8 811 6 doi 10 1111 j 1365 2044 2004 03809 x PMID 15270974 S2CID 13037753 Sheridan endotracheal tubes catalog PDF Hudson RCI 2002 Loudermilk EP Hartmannsgruber M Stoltzfus DP Langevin PB June 1997 A prospective study of the safety of tracheal extubation using a pediatric airway exchange catheter for patients with a known difficult airway Chest 111 6 1660 5 doi 10 1378 chest 111 6 1660 PMID 9187190 S2CID 18358131 Davis L Cook Sather SD Schreiner MS 2000 Lighted stylet tracheal intubation a review PDF Anesthesia amp Analgesia 90 3 745 56 doi 10 1097 00000539 200003000 00044 PMID 10702469 S2CID 26644781 a b US patent 5329940 Adair Edwin L Endotracheal tube intubation assist device published 1994 07 19 issued July 19 1994 Tracheostomy tube Dictionary of Cancer Terms National Cancer Institute 2011 02 02 Tobias JD 2009 Helium insufflation with sevoflurane general anesthesia and spontaneous ventilation during airway surgery Canadian Journal of Anesthesia 56 3 243 6 doi 10 1007 s12630 008 9034 1 PMID 19247745 Chotigeat U Khorana M Kanjanapattanakul W 2007 Inhaled nitric oxide in newborns with severe hypoxic respiratory failure PDF Journal of the Medical Association of Thailand 90 2 266 71 PMID 17375630 Archived from the original PDF on 2012 03 11 Retrieved 2010 08 30 Goto T Nakata Y Morita S January 2003 Will xenon be a stranger or a friend the cost benefit and future of xenon anesthesia Anesthesiology 98 1 1 2 doi 10 1097 00000542 200301000 00002 PMID 12502969 S2CID 19119058 Macewen W 1880 Clinical observations on the introduction of tracheal tubes by the mouth instead of performing tracheotomy or laryngotomy British Medical Journal 2 1022 163 5 doi 10 1136 bmj 2 1022 163 PMC 2241109 PMID 20749636 Ring WH Adair JC Elwyn RA 1975 A new pediatric endotracheal tube Anesthesia amp Analgesia 54 2 273 4 doi 10 1213 00000539 197503000 00030 PMID 1168437 a b Benumof 2007 Sheinbaum R Hammer GB Benumof JL Chapter 24 Separation of the two lungs pp 576 93 a b c d Barash Cullen and Stoelting 2009 Rosenblatt WH and Sukhupragarn W Management of the airway pp 751 92 a b c d e Miller 2000 Stone DJ and Gal TJ Airway management pp 1414 51 Wolfe T 1998 The Esophageal Detector Device Summary of the current articles in the literature Salt Lake City Utah Wolfe Tory Medical Archived from the original on 2006 11 14 Retrieved 2009 01 29 Benumof 2007 Salem MR and Baraka A Chapter 30 Confirmation of tracheal intubation pp 697 730 Morris IR 1994 Fibreoptic intubation Canadian Journal of Anesthesia 41 10 996 1007 discussion 1007 8 doi 10 1007 BF03010944 PMID 8001220 Ovassapian A 1991 Fiberoptic assisted management of the airway ASA Annual Refresher Course Lectures 19 1 101 16 doi 10 1097 00126869 199119000 00009 a b Delaney KA Hessler R 1988 Emergency flexible fiberoptic nasotracheal intubation a report of 60 cases Annals of Emergency Medicine 17 9 919 26 doi 10 1016 S0196 0644 88 80672 3 PMID 3415064 a b Mlinek EJ Jr Clinton JE Plummer D Ruiz E 1990 Fiberoptic intubation in the emergency department Annals of Emergency Medicine 19 4 359 62 doi 10 1016 S0196 0644 05 82333 9 PMID 2321818 American Society of Anesthesiologists Task Force on the management of the difficult airway 2003 Practice guidelines for the management of the difficult airway an updated report Anesthesiology 98 5 1269 77 doi 10 1097 00000542 200305000 00032 PMID 12717151 S2CID 39762822 Benumof 2007 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pseudoscience and Sellick Canadian Journal of Anesthesia 49 5 443 7 doi 10 1007 BF03017917 PMID 11983655 Smith KJ Dobranowski J Yip G Dauphin A Choi PT July 2003 Cricoid pressure displaces the esophagus an observational study using magnetic resonance imaging Anesthesiology 99 1 60 4 doi 10 1097 00000542 200307000 00013 PMID 12826843 S2CID 18535821 Haslam N Parker L Duggan JE 2005 Effect of cricoid pressure on the view at laryngoscopy Anaesthesia 60 1 41 7 doi 10 1111 j 1365 2044 2004 04010 x PMID 15601271 S2CID 42387260 Knill RL 1993 Difficult laryngoscopy made easy with a BURP Canadian Journal of Anesthesia 40 3 279 82 doi 10 1007 BF03037041 PMID 8467551 Takahata O Kubota M Mamiya K Akama Y Nozaka T Matsumoto H Ogawa H 1997 The efficacy of the BURP maneuver during a difficult laryngoscopy Anesthesia amp Analgesia 84 2 419 21 doi 10 1097 00000539 199702000 00033 PMID 9024040 S2CID 16579238 Levitan RM Kinkle WC Levin WJ Everett WW June 2006 Laryngeal view during laryngoscopy a 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Casselbrant M 1990 The Bullard laryngoscope A new indirect oral laryngoscope pediatric version Anesthesia amp Analgesia 70 1 105 8 doi 10 1213 00000539 199001000 00019 PMID 2297088 Theroux MC Kettrick RG Khine H 1995 Laryngeal mask airway and fiberoptic endoscopy in an infant with Schwartz Jampel syndrome Anesthesiology 82 2 605 doi 10 1097 00000542 199502000 00044 PMID 7856930 Kim JE Chang CH Nam YT 2008 Intubation through a Laryngeal Mask Airway by Fiberoptic Bronchoscope in an Infant with a Mass at the Base of the Tongue PDF Korean Journal of Anesthesiology 54 3 S43 6 doi 10 4097 kjae 2008 54 3 S43 permanent dead link Hackell R Held LD Stricker PA Fiadjoe JE 2009 Management of the difficult infant airway with the Storz Video Laryngoscope a case series Anesthesia amp Analgesia 109 3 763 6 doi 10 1213 ANE 0b013e3181ad8a05 PMID 19690244 Benumof 2007 Rabb MF and Szmuk P Chapter 33 The difficult pediatric airway pp 783 833 Sheridan RL 2006 Uncuffed endotracheal tubes should not be used in seriously burned children Pediatric Critical Care Medicine 7 3 258 9 doi 10 1097 01 PCC 0000216681 71594 04 PMID 16575345 S2CID 24736705 Zaichkin J Weiner GM February 2011 Neonatal Resuscitation Program NRP 2011 new science new strategies Advances in Neonatal Care 11 1 43 51 doi 10 1097 ANC 0b013e31820e429f PMID 21285656 Rozman A Duh S Petrinec Primozic M Triller N 2009 Flexible bronchoscope damage and repair costs in a bronchoscopy teaching unit Respiration 77 3 325 30 doi 10 1159 000188788 PMID 19122449 S2CID 5827594 Benumof 2007 Reed AP Chapter 8 Evaluation and recognition of the difficult airway pp 221 35 Zadrobilek E 2009 The Cormack Lehane classification twenty fifth anniversary of the first published description Internet Journal of Airway Management 5 Adnet F Borron SW Racine SX Clemessy JL Fournier JL Plaisance P Lapandry C 1997 The intubation difficulty scale IDS proposal and evaluation of a new score characterizing the complexity of endotracheal intubation Anesthesiology 87 6 1290 7 doi 10 1097 00000542 199712000 00005 PMID 9416711 S2CID 10561049 Mallampati SR Gatt SP Gugino LD Desai SP Waraksa B Freiberger D Liu PL 1985 A clinical sign to predict difficult tracheal intubation a prospective study Canadian Anaesthetists Society Journal 32 4 429 34 doi 10 1007 BF03011357 PMID 4027773 Shiga T Wajima Z Inoue T Sakamoto A 2005 Predicting difficult intubation in apparently normal patients a meta analysis of bedside screening test performance Anesthesiology 103 2 429 37 doi 10 1097 00000542 200508000 00027 PMID 16052126 S2CID 12600824 Gonzalez H Minville V Delanoue K Mazerolles M Concina D Fourcade O 2008 The importance of increased neck circumference to intubation difficulties in obese patients Anesthesia amp Analgesia 106 4 1132 6 doi 10 1213 ane 0b013e3181679659 PMID 18349184 S2CID 22147759 Krage R van Rijn C van Groeningen D Loer SA Schwarte LA Schober P 2010 Cormack Lehane classification revisited British Journal of Anaesthesia 105 2 220 7 doi 10 1093 bja aeq136 PMID 20554633 Levitan RM Everett WW Ochroch EA October 2004 Limitations of difficult airway prediction in patients intubated in the emergency department Ann Emerg Med 44 4 307 13 doi 10 1016 j annemergmed 2004 05 006 PMID 15459613 Roth D Pace NL Lee A Hovhannisyan K Warenits AM Arrich J Herkner H May 2018 Airway physical examination tests for detection of difficult airway management in apparently normal adult patients Cochrane Database Syst Rev 5 5 CD008874 doi 10 1002 14651858 CD008874 pub2 PMC 6404686 PMID 29761867 Levitan 2004 Levitan RM The limitations of difficult airway prediction in emergency airways pp 3 11 von Goedecke A Herff H Paal P Dorges V Wenzel V 2007 Field airway management disasters PDF Anesthesia amp Analgesia 104 3 481 3 doi 10 1213 01 ane 0000255964 86086 63 PMID 17312190 a b c d e f g Benumof 2007 Hagberg CA Georgi R and Krier C Chapter 48 Complications of managing the airway pp 1181 218 Sengupta P Sessler DI Maglinger P Wells S Vogt A Durrani J Wadhwa A 2004 Endotracheal tube cuff pressure in three hospitals and the volume required to produce an appropriate cuff pressure BMC Anesthesiology 4 1 8 doi 10 1186 1471 2253 4 8 PMC 535565 PMID 15569386 Benumof 2007 Pousman RM and Parmley CL Chapter 44 Endotracheal tube and respiratory care pp 1057 78 Polderman KH Spijkstra JJ de Bree R Christiaans HM Gelissen HP Wester JP Girbes AR May 2003 Percutaneous dilatational tracheostomy in the ICU optimal organization low complication rates and description of a new complication Chest 123 5 1595 602 doi 10 1378 chest 123 5 1595 PMID 12740279 Hill BB Zweng TN Maley RH Charash WE Toursarkissian B Kearney PA 1996 Percutaneous dilational tracheostomy report of 356 cases Journal of Trauma and Acute Care Surgery 41 2 238 43 doi 10 1097 00005373 199608000 00007 PMID 8760530 a b c d Katz SH Falk JL 2001 Misplaced endotracheal tubes by paramedics in an urban emergency medical services system PDF Annals of Emergency Medicine 37 1 32 7 doi 10 1067 mem 2001 112098 PMID 11145768 Jones JH Murphy MP Dickson RL Somerville GG Brizendine EJ 2004 Emergency physician verified out of hospital intubation miss rates by paramedics Academic Emergency Medicine 11 6 707 9 doi 10 1197 j aem 2003 12 026 PMID 15175215 Pelucio M Halligan L Dhindsa H 1997 Out of hospital experience with the syringe esophageal detector device Academic Emergency Medicine 4 6 563 8 doi 10 1111 j 1553 2712 1997 tb03579 x PMID 9189188 Sayre MR Sackles JC Mistler AF Evans JL Kramer AT Pancioli AM 1998 Field trial of endotracheal intubation by basic EMTs Annals of Emergency Medicine 31 2 228 33 doi 10 1016 S0196 0644 98 70312 9 PMID 9472186 White L Melhuish T Holyoak R Ryan T Kempton H Vlok R December 2018 Advanced airway management in out of hospital cardiac arrest A systematic review and meta analysis PDF Am J Emerg Med 36 12 2298 2306 doi 10 1016 j ajem 2018 09 045 PMID 30293843 S2CID 52931036 Domino KB Posner KL Caplan RA Cheney FW 1999 Airway injury during anesthesia a closed claims analysis Anesthesiology 91 6 1703 11 doi 10 1097 00000542 199912000 00023 PMID 10598613 S2CID 6525904 Zuo Mingzhang Huang Yuguang Ma Wuhua Xue Zhanggang Zhang Jiaqiang Gong Yahong Che Lu 2020 Expert Recommendations for Tracheal Intubation in Critically ill Patients with Noval Coronavirus Disease 2019 Chinese Medical Sciences Journal 35 2 105 109 doi 10 24920 003724 PMC 7367670 PMID 32102726 high risk aerosol producing procedures such as endotracheal intubation may put the anesthesiologists at high risk of nosocomial infections World Federation Of Societies of Anaesthesiologists Coronavirus www wfsahq org 25 June 2020 Anaesthesiologists and other perioperative care providers are particularly at risk when providing respiratory care and tracheal intubation of patients with COVID 19 Clinical management of severe acute respiratory infections when novel coronavirus is suspected What to do and what not to do PDF World Health Organization p 4 The most consistent association of in 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Journal 77 3 146 52 PMC 2604469 PMID 18956794 Magill I 1920 Forceps for intratracheal anaesthesia British Medical Journal 2 571 670 doi 10 1136 bmj 2 571 670 PMC 2338485 PMID 20770050 Magill I 1926 An improved laryngoscope for anaesthetists The Lancet 207 5349 500 doi 10 1016 S0140 6736 01 17109 6 Magill I 1921 A Portable Apparatus for Tracheal Insufflation Anaesthesia The Lancet 197 5096 918 doi 10 1016 S0140 6736 00 55592 5 Magill I 1921 Warming Ether Vapour for Inhalation The Lancet 197 5102 1270 doi 10 1016 S0140 6736 01 24908 3 Magill I 1923 An apparatus for the administration of nitrous oxide oxygen and ether The Lancet 202 5214 228 doi 10 1016 S0140 6736 01 22460 X Macintosh RR 1943 A new laryngoscope The Lancet 241 6233 205 doi 10 1016 S0140 6736 00 89390 3 History of endoscopes Volume 2 Birth of gastrocameras Olympus Corporation 2010 History of endoscopes Volume 3 Birth of fiberscopes Olympus Corporation 2010 Murphy P 1967 A fibre optic endoscope used for nasal intubation Anaesthesia 22 3 489 91 doi 10 1111 j 1365 2044 1967 tb02771 x PMID 4951601 S2CID 33586314 Finucane BT Kupshik HL 1978 A flexible stilette for replacing damaged tracheal tubes Canadian Anaesthetists Society Journal 25 2 153 4 doi 10 1007 BF03005076 PMID 638831 References editBarash PG Cullen BF Stoelting RK eds 2009 Clinical Anesthesia 6th ed Philadelphia Lippincott Williams amp Wilkins ISBN 978 0 7817 8763 5 Benumof JL ed 2007 Benumof s Airway Management Principles and Practice 2nd ed Philadelphia Mosby Elsevier ISBN 978 0 323 02233 0 Bhishagratna KL ed 1907 Sushruta Samhita Volume1 Sutrasthanam Calcutta Kaviraj Kunja Lal Bhishagratna Committee on Trauma American College of Surgeons 2004 ATLS Advanced Trauma Life Support Program for Doctors 7th ed Chicago American College of Surgeons ISBN 978 1 880696 31 6 Doherty GM ed 2010 Current Diagnosis amp Treatment Surgery 13th ed New York McGraw Hill Medical ISBN 978 0 07 163515 8 Habicot N 1620 Question chirurgicale par laquelle il est demonstre que le chirurgien doit assurement practiquer l operation de la bronchotomie vulgairement dicte laryngotomie ou perforation de la fluste ou du polmon in French Paris Corrozet Jackson C 1922 A manual of peroral endoscopy and laryngeal surgery PDF Philadelphia W B Saunders ISBN 978 1 4326 6305 6 Archived from the original PDF on 2010 02 19 Retrieved 2010 08 03 Levitan RM 2004 The Airway Cam Guide to Intubation and Practical Emergency Airway Management 1st ed Wayne Pennsylvania Airway Cam Technologies ISBN 978 1 929018 12 3 Longe JL ed 2005 The Gale Encyclopedia of Alternative Medicine L R The Gale Encyclopedia of Alternative Medicine Volume 4 S Z 2nd ed Farmington Hills Michigan Gale Cengage ISBN 978 0 7876 7424 3 Mackenzie M 1888 The case of Emperor Frederick III full official reports by the German physicians and by Sir Morell Mackenzie New York Edgar S Werner Miller RD ed 2000 Anesthesia Volume 1 5th ed Philadelphia Churchill Livingstone ISBN 978 0 443 07995 5 Singer CJ ed 1956 Galen on Anatomical Procedures Translation of the Surviving Books with Introduction and Notes London Oxford University Press Wellcome Historical Medical Museum ISBN 978 0 19 924016 6 External links edit nbsp Wikimedia Commons has media related to Tracheal intubation Video of endotracheal intubation using C MAC D blade and bougie used as introducer Videos of direct laryngoscopy recorded with the Airway Cam TM imaging system Examples of some devices for facilitation of tracheal intubation Free image rich resource explaining various types of endotracheal tubes Tracheal intubation live case 2022 Retrieved from https en wikipedia org w index php title Tracheal intubation amp oldid 1191993834, wikipedia, wiki, book, books, library,

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