Tracheal Intubation

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Introduction

Intubation is considered the gold-standard of  ‘securing the airway’ by passing a tracheal tube usually via the mouth but sometimes via the nose.   Other options need to be considered in a CICO event. Other elective methods for long-term management include formal tracheostomy.  With the advent of the laryngeal mask and other supra-glottic devices, a third option exists of securing the airway for brief periods of time but with a greater risk of aspiration in the unfasted patient.

Indications

  • Prevent or manage airway obstruction
  • Control breathing and gas exchange e.g. respiratory failure, raised intracranial pressure
  • Gain control over the patient‘s behaviour where no safer alternative exists e.g. for CT scanning or aeromedical transport

Preparation and approaches

  • Rapid Sequence Induction – Usually performed in an Emergency or non-fasted patient.  Introduction of anaesthetic agent and fast acting muscle relaxant to achieve amnesia and airway muscle paralysis and minimise likelihood of aspiration.  No active mechanical ventilation of the patient occurs prior to passage of tube.
  • Elective IV Induction – Usually performed in Elective setting with fasted patient.  As above with slower-acting muscle relaxant.  Active ventilation occurs during period of apnea
  • Gaseous induction – Intubating conditions achieved via inhalational agent in spontaneously breathing patient.  Often used in paediatrics.  Avoid IV cannula.  Risk of laryngospasm.
  • Delayed Sequence Induction – Slow titration of anaesthetic agent
  • Awake – In situations where patient is kept alert and spontaneously ventilating because risk of loss of precipitous airway or where there is a risk of a CICO scenario

Technique

Laryngoscopy and intubation

Complications

  • Esophageal intubation *
  • Right main bronchus intubation *
  • Trauma

*May occur later due to inadequately securing the tube or head and neck movement

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