Tracheal Intubation

The placement of a flexible plastic tube into the trachea (wind pipe) to maintain an open airway or to serve as a conduit through which to administer drugs. It is frequently performed in critically ill or anesthetized patient to facilitate ventilation of the lungs, including mechanical ventilation and to prevent possible asphyxiation or airway obstruction.

Indications
When illness or or a medical procedures prevents a person from maintaining a clear airway, breathing and oxygenating the blood. Depressed Level of Consciousness conduit for induction of general anesthetics (nitrous oxide and volatile anesthetics, may diminished or abolish respiratory drive) Stroke, non-penetrating head injury, intoxication or poisoning may result in depressed level of consciousness dynamic collapse of the extrinsic muscles of the airway can obstruct the airway, impending the free flow of air in the lungs. Tracheal intubation is often required to restore patency of the airway and protect the tracheo bronchial tree from pulmonary aspiration of gastric contents.

 Hypoxemia maybe necessary for 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 gases to the blood. Maybe awake or alert are atypically critically ill with a multisystem disease or multiple severe injuries (cervical spine injury, multiple rib fractures, severe pneumonia, acute respiratory distress syndrome (ARDS), neardrowning, arterial partial pressure of oxygen less than 6o mmHg while breathing an inspired O2 concentration (FiO2) of 50% or greater, and with elevated arterial carbon dioxide greater than 45 mmHg in setting of acidemia would prompt intubation.

 Airway Obstruction- foreign body becomes lodge in the airway, 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, smoke inhalation or burns within or near the airway or epiglottis Generalized seizure or angioedema would require intubation Manipulation of the airway diagnostic or therapeutic manipulation of the airway

Methods to confirm placement:

No single method for confirming tracheal tube placement has been shown 100% reliable. Multiple methods for confirmation of correct tube placement is now widely considered to be the standard of care. Direct visualization as the tip of the tube passes through the glottis or using the device bronchoscope, equal breath sounds will be heard upon listening to the chest using stethoscope, no sounds upon listening over the area of the stomach.

 Equal bilateral rise and fall of the chest wall will be evident with ventilatory excursions. Small amount of water vapor will be evident within the lumen of the tube with each exhalation and there will be no gastric content in the tube at any time. mid-trachea roughly 2 cm (1 inch) above the bifurcation of the carina in the x-ray, measuring instruments

Cricothyrotomy
Incision made through the skin and cricothyroid membrane to establish a patent airway during certain life threatening situations ( obstruction from a foreign body, angioedema, or massive facial trauma) Cricothyrotomy is easier and quicker to perform than tracheostomy does not require manipulation of the spine and is associated with fewer complications.

 The easiest method to perform this technique is the needle cricothyrotomy (also referred to as percutaneous dilational cricothyrotomy) in which a large bore (12 14 gauge) intravenous catheter is used to puncture the cricothyroid membrane Oxygen then can 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 establish. The small diameter of the cricothyrotomy catheter is insufficient for elimination of carbon dioxide (ventilation). After an hour of apneic oxygenation through a needle cricothyrotomy one can expect a PaCO2 of greater than 250 mmHg and an arterial pH of less than 6.72 despite an oxygen saturation of 98%

 A more definitive airway can be established by performing a surgical cricothyrotomy in which a 5 -6 mm endotracheal tube or tracheostomy tube can be inserted through a larger incision.

Intraosseous Cannulation
For patients in extremis from respiratory failure or shock, securing vascular access is crucial, a long with establishing an airway and ensuring adequacy of breathing and ventilation. Peripheral intravenous catheter insertion is often difficult if not impossible in infants and young children with circulatory collapse. Provides a route for administering fluids, blood and medications. An IO line is as efficient as an intravenous route and can be inserted quickly, even in the most poorly perfused patients.

Pathophysiology
The marrow of long bones has a rich network of vessels that drain into a central venous canal, emissary veins, and ultimately the central circulation. Therefore the bone marrow functions as a noncollapsible venous access route when peripheral veins may have collapse because of vasoconstriction. The intraosseous route allows medications and fluids to enter the central circulation in a few seconds.

Age
Intraosseous insertion was typically recommended for use in children younger than 6 years however, it is now recognized to be safe and effective to older children and adults. The problems with IO use in older patients arise from the increased difficulty of insertion through thicker cortex of the bone and the smaller marrow cavity. Inability to enter the marrow cavity may increase the likelihood of fracturing the bone.

Procedure
The most common site recommended for intraosseous (IO) insertion is the proximal tibia because it provides a flat surface with a thin layer of overlying tissue and ease of identifying landmarks. Also, it is distant from the airway and chest, where resuscitation attempts are in progress. The procedure for IO insertion in the proximal tibia is as follows:

 Identify the tibial tuberosity, just below the knee, by palpation. Locate a consistent flat area of bone 2 cm distal and slightly medial to the tibial tuberosity. (Identifying these landmarks helps avoid hitting the growth plate.) Support the flexed knee by placing a towel under the calf

 If time permits, cleanse the area with an iodine solution and drape it. Perform insertion using sterile gloves and technique. Inject local anesthetic (1% lidocaine) into the skin, into the subcutaneous tissue, and over the periosteum, especially if the patient is awake.

 Insert the IO needle through the skin and subcutaneous tissue; this should occur easily. Upon reaching the bone, hold the needle with the index finger and thumb as close to the entry point as possible and, with constant pressure on the needle with the palm of the same hand, use a twisting motion to advance the needle through the cortex until reaching the marrow. A 10-15 caudal angulation may be used to further decrease the risk of hitting the growth plate, but direct entry parallel to the bone is acceptable

 Advance the needle from the cortex into the marrow space, at which point a popping sensation or lack of resistance is felt. Do not advance the needle any further. The first indication of proper placement occurs when the needle stands up on its own. At this point, remove the inner trocar, attach a syringe to the needle, and aspirate bone marrow. Obtaining marrow confirms placement.

 If marrow is not aspirated, push a 5-mL to 10mL bolus of isotonic sodium chloride solution through the syringe. Resistance to flow should be minimal, and extravasation should not be evident. Observing the calf area is important. If flow is good and extravasation is not evident, connect the intravenous (IV) line with a 3-way stopcock at the needle, and secure the needle with gauze pads and tape.

 Although fluid may run from the IV line by gravity, the rate is too slow for resuscitation. Faster rates of infusion occur by drawing up 30-mL to 60-mL aliquots from the intravenous bag and administering manual fluid boluses via the stopcock. Administering medications this way is much easier, as well, and it provides more accurate administration of fluid to small infants. As an alternative for larger boluses, an intravenous pump or pressure bag can be used to increase flow.