What is tracheal intubation? Tracheal intubation: technique, complications, contraindications. What does intubation mean?

Tracheal intubation - ensuring normal patency of the airways by introducing a special tube into the trachea. Used to ventilate the lungs during resuscitation procedures, endotracheal anesthesia or airway obstruction. In otolaryngology, there are many supraglottic devices, but only intubation has been and remains the only reliable way to ensure airway patency.

Orotracheal intubation is one of the most common medical procedures.

During the procedure, an endotracheal tube (ETT) is passed through the entire oropharynx between the vocal cords and directly into the trachea.

At the next stage, the cuff, which is located in the area of the distal tip of the tube, increases many times in volume, which ensures tightness and protection of the airways from aspiration of bloody secretions and gastric juice.

Indications and contraindications

Almost all medical staff should be proficient in airway ventilation techniques. If there are vital indications, medical procedures should be performed by medical teams at the pre-hospital stage. Intubation in intensive care often becomes planned and is carried out for preventive purposes with the help of muscle relaxants and induction anesthesia.

Conventionally, all contraindications and indications for artificial ventilation can be divided into absolute and relative.

Indications for medical manipulation include:

1. Absolute:

aspiration syndrome;
airway obstruction;
traumatic brain injuries;
pulmonary-cardiac resuscitation (LCR);
deep coma of various origins.

2. Relative:

eclampsia;
thermal inhalation injuries;
pulmonary edema;
shock of various origins;
strangulation asphyxia;
pneumonia;
pulmonary failure;
status epilepticus.

If there are relative indications for the procedure, the decision on artificial ventilation of the respiratory tract is made individually and depends on the cause of the patient’s emergency condition.

It is impossible to intubate patients in prehospital conditions if there are direct contraindications.

This can cause serious complications, which include hypercapnia, bronchospasms, hypoxia, etc. Artificial ventilation of the lungs using ETT is contraindicated in case of oncology of the airways, skull deformation, spinal damage, severe swelling of the larynx and pharynx, ankylosis of the temporomandibular joints and contractures.

Intubation instruments

How is tracheal intubation performed? The technique of carrying out medical manipulations is described in detail in the next section and consists of competently introducing the necessary instruments into the upper respiratory tract. Equipment used to intubate patients should consist of:

laryngoscope - a medical instrument that is used to facilitate visualization of the larynx; Laryngoscopes with curved tips, which provide a wide view of the respiratory tract, are considered the least traumatic;
trocar - a surgical instrument that is used to penetrate human cavities; the standard device consists of a special stylet (conductor) equipped with a handle;
surgical clamp - metal scissors with dull blades, which are used to cleanse the oral cavity of viscous secretions;
ventilation bag - a rubber bulb that connects to the ETT for manual ventilation of the lungs;
endotracheal tubes - thin tubular devices that are made of thermoplastic materials; after insertion, the tube in the trachea increases in size at the level of the cuff, which ensures obstruction of the lumen between the medical equipment and the walls of the respiratory tract;
tools for sanitation - an aspirator and a special catheter designed to cleanse the trachea of liquid secretions, blood and gastric juice.

All patients admitted to the Emergency Department can be classified as patients with a full stomach, which obliges the medical staff to carry out a full induction using Sellick (a method of pressing on the cricoid cartilage), which prevents the aspiration of mucus and gastric juice.

Muscle relaxation and general anesthesia are necessary conditions for performing the necessary medical procedures.

With complete relaxation of the body, the risk of damage to the mucous membrane of the airways is greatly reduced.

However, in the prehospital setting it is almost impossible to achieve optimal conditions.

Intubation technique

In most cases, intubation is performed through the mouth, due to the ability to control the actions performed using direct laryngoscopy. During therapy, the patient's position should be exclusively horizontal. The maximum possible alignment of the neck is achieved by placing a small bolster under the cervical spine joint.

What is the technique for tracheal intubation?

the patient is put under anesthesia using special drugs (relaxants, barbiturates);
for 2-3 minutes the specialist performs artificial ventilation of the respiratory tract using an oxygen mask;
with the right hand, the resuscitator opens the patient’s mouth, after which he inserts a laryngoscope into the oral cavity;
the blade of the instrument is pressed against the root of the tongue, which allows the epiglottis to be pushed upward;
After exposing the entrance to the pharynx, the doctor inserts an endotracheal tube.

Inept manipulations by the intubator can lead to hypoxia or collapse of one of the patient's lungs.

To resume ventilation of the non-breathing lung, the specialist pulls the tube back slightly. The complete absence of whistling sounds in the lungs may indicate penetration of the ETT into the stomach. In such a situation, the doctor removes the tube from the oropharynx and resuscitates the patient by hyperventilating the lungs with 100% oxygen.

Intubation of newborns

Tracheal intubation in newborns is one of the most common medical procedures used for meconium aspiration, abdominal wall pathology, or diaphragmatic hernia. Often, artificial ventilation in children is necessary to create peak inspiratory pressure, which allows normal lung function.

How is newborn intubation performed? To reduce the likelihood of complications, the ETT is administered through the nasopharynx. During the procedure, the specialist performs the following actions:

using an oxygen mask, ventilates the lungs until satisfactory saturation is achieved;
with the help of an aspirator and a thin tube, the bronchi and respiratory tract are completely cleared of mucus, meconium and foamy secretions;
to visualize the entrance to the pharynx, the specialist presses the outside of the larynx with his little finger; the tip of the ETT is lubricated with xylocaine cream, and then carefully inserted through the nasal canal into the trachea;
during auscultation of breathing, the resuscitator determines the intensity of noise in each of the lungs; at the final stage, an artificial respiration apparatus is connected to the ETT through special adapters.

Important! If a child is connected to a ventilator for a long time, this can lead to the development of bradycardia (slow heart rate).

Intubated children are observed for several days in the intensive care unit. If there are no complications and respiratory function is restored, the intubation instruments are carefully removed.

Difficult intubation

“Difficult intubation” is a situation characterized by repeated attempts to correctly position the ETT in the trachea. Medical manipulations at the prehospital stage are associated with poor conditions for resuscitation procedures. Failure to provide medical care in a timely manner can cause asphyxia and even death.

Intubation outside the operating room is used in extreme cases, i.e. if there are vital indications.

The category of patients with very high risks of tube intubation includes:

women during gestation;
persons with serious cranial and jaw injuries;
overweight patients (grade 3-4 obesity);
patients suffering from diabetes mellitus;
persons with thermal inhalation injuries.

In all of the above cases, the use of intubation becomes much more complicated. To assess the patient's condition, the doctor ventilates the lungs using an oxygen mask.

If oxygenation (oxygen treatment) does not produce the desired results, the intensivist should ventilate with an ETT. Obstruction of the airways can lead to hypoxia, so in the most extreme case, the doctor performs a conicotomy, i.e. dissection of the larynx.

Possible complications

Complications after resuscitation procedures arise primarily as a result of improper insertion and fixation of the ETT. Certain anatomical features of the patient, such as obesity or limited spinal mobility, greatly increase the risk of complications. Common consequences of intubation include:

circulatory arrest;
aspiration of gastric juice;
destruction of teeth or dentures;
intubation of the digestive tract;
atelectasis (collapsed lung);
perforation of the oropharyngeal mucosa;
damage to the throat ligaments.

In most cases, complications arise due to the incompetence of the specialist and the lack of control of the measured characteristics using appropriate equipment. It is important to understand that improper placement of the endotracheal tube leads to tracheal rupture and death.

Important nuances

Timely determination of the correct installation of the endotracheal tube is an important technical nuance that should be taken into account by a specialist. If the ETT cuff is not inserted deep enough, expansion can cause vocal cord rupture and tracheal damage. To check the correct installation of intubation equipment, the following is carried out:

hemoximetry - a non-invasive method for determining the level of blood oxygen saturation;
capnometry - numerical display of the partial pressure of CO2 in inhaled and exhaled air;
Auscultation - physical diagnosis of the patient’s condition by the sounds produced in the lungs during lung function.

An endotracheal tube is inserted into the trachea not only if there are vital indications, but also during anesthesia. General anesthesia, which is accompanied by the patient losing consciousness, can cause breathing problems or airway obstruction. To reduce the risk of aspiration of gastric juice and foamy secretions, an ETT or laryngeal mask is often used during surgical procedures.

Health is the highest human value. In some cases, surgery is required to maintain health. When used, intubation is required - this is the insertion of a special tube into the trachea. Despite its simplicity, this is also a unique operation associated with risks and technical difficulties.

Purpose of intubation

Intubation (what this manipulation means will be described in the article) can also be used at the prehospital stage when providing emergency care.

Intubation can provide:

conducting the patient's breathing, in particular, controlled and assisted;
normal airway patency regardless of the patient’s position;
no risk of suffocation due to vomit, mucus, blood, foreign objects and ligament spasm;
the ability to remove foreign bodies from the bronchi and trachea;
the ability to straighten areas of the lungs;
improving conditions for eliminating pulmonary edema.

Intubation is performed (this is the insertion of a tube into the trachea) in case of difficulty breathing as a result of pulmonary edema, severe poisoning, respiratory failure, however, in case of violations of the structure of the facial part of the skull, inflammation and other injuries in the cervical region and cervical spine, this procedure cannot be performed.

Instruments for intubation

There is a certain set of instruments that are used to perform intubation (this is an operation to facilitate breathing). For this you need:

different in outer diameter, length, with and without a cuff, with one or two lumens (for children, uncuffed tubes are used);
laryngoscope with straight and curved blades: the composition includes a handle into which a battery is inserted, and a blade with a light bulb (the blades can be quickly changed if necessary);
anesthetic forceps (have a curved shape);
conductor - a thin metal rod, which, despite the material used, is soft (necessary in difficult cases of intubation);
local anesthetic nebulizer (rarely used, since most often intubation is the process of inserting a tube into the trachea, carried out in emergency cases when the patient is under general anesthesia or unconscious).

Types of intubation

Depending on the purpose of this medical procedure, pulmonary intubation (what it is, described above) is of two types:

orotracheal - a tube is inserted into the trachea through the mouth;
nasotracheal - insertion of an endotracheal tube through the nose (in this case, the size of the tubes should be slightly smaller).

Separately, it is necessary to highlight tracheostomy, however, this operation is only vaguely reminiscent of intubation, since it is performed by anesthesiologists using a completely different technology, but the goal is almost the same - to ensure airway patency.

Technology of pulmonary intubation

Intubation is the insertion of a tube into the trachea. It is carried out in two ways, depending on whether the patient is conscious or not. In the first case, local anesthesia is performed. The patient needs to breathe deeply, and while inhaling, the tube is advanced through the glottis. The doctor makes sure that the tube goes into the trachea and not into the esophagus.

When the patient is unconscious, the direct laryngoscopy method is used. In this case, the head should be extended as much as possible; it is better to put a cushion under it. The doctor independently opens the patient’s mouth, runs the laryngoscope blade along the back of the tongue, thereby moving it to the left, and then advances the laryngoscope into the trachea. After this, the tube is inserted while inhaling.

Bowel intubation

There is such a thing as intestinal intubation, or intraoperative intestinal decompression. This manipulation is carried out to eliminate intestinal contents. There are three types of intestinal intubation:

nasogastric;
retrograde through the rectum;
retrograde through intestinal fistula.

Intubation of the small intestine through the appendicostomy is also performed to prevent or treat postoperative paresis in patients.

Special probes are used for this, which can be single-channel, dual-channel and multi-channel, but the first two are most often used.

Like any other operation, intubation (manipulation to make breathing easier) can have complications. Most often this is suffocation, damage to teeth and mucous membranes, and spasms. However, if the entire procedure is carried out according to the rules, then there will be no complications, and the patient’s life will be saved.

INTUBATION(lat. in in, inside + tuba tube) - insertion of special tubes into the lumen of the larynx, trachea and bronchi in order to restore and improve airway patency or conduct inhalation anesthesia.

First in 1858 with the idea of intubation. Bouchut spoke at a meeting of the Paris Academy. The essence of the method he proposed was to introduce a hollow silver cylindrical tube into the larynx using a laryngeal curved catheter. However, this idea was not approved. J. R. O'Dwyer published an original work on I. in 1885, proposing a rubber tube for this purpose, after which I. became widespread, first in America and then in Europe. In Russia, the first I. was carried out by K. A. Rauchfus in 1890. In Moscow, I. was introduced by A. A. Polievktov (1899) in the clinic of N. F. Filatov. INTUBATION under vision control was proposed by A. F. Pushkin; later it was used by A.I. Kolomiychenko, V.A. Ratner, and it was introduced into wide practice. Bronchial airway is used for one-pulmonary anesthesia, first developed and put into practice by Gall and Waters (I. Gall, R. Waters, 1932). Separate I. of the main bronchi was used to study lung function by Jacobeus, Frenckner and Bjorkman (H. Yacobaeus, R. Frenckner, S. Biorkman, 1932). Depending on the method of insertion of the endotracheal tube, I. are distinguished: orotracheal, nasotracheal, I. through tracheostomy; depending on the time - single, extended (i.e. over several days); depending on the purpose - endobronchial, one-pulmonary, separate I. of the main bronchi.

Carefully performed and correctly carried out INTUBATION allows you to ensure adequate external respiration and avoid tracheostomy (see). I. has certain advantages over tracheostomy - the absence of complications inherent in the latter (aspiration pneumonia, bleeding, emphysema).

Intubation instruments

The previously used solid tubes of O'Dwyer, Sevester, Bayeux, etc., as well as special sets (for example, Collen, Fruen, etc.), introducers, extubators have practically lost their importance and honey. are not produced by industry. Modern intubation instruments include endotracheal tubes, conductors, mandrels for them, intubation forceps for inserting and removing tubes, connectors for connecting tubes to an anesthesia or breathing apparatus, laryngoscopes with straight and curved blades, dental spacers to prevent compression of the lumen of the tubes.

Hartmann forceps or forceps from the Friedel tracheobronchoscopic set can be used as intubation forceps (see Bronchoesophagoscope). The most common are endotracheal tubes made of thick rubber or plastic; less commonly used are endotracheal tubes made of metal or rubberized silk fabric. For various methods of I., tubes of various designs are used (Fig. 1). When carrying out one-lung anesthesia, special endotracheal tubes are used (Fig. 2), which make it possible to turn off one lung from the act of external respiration, and for separate I. bronchi, double-lumen tubes are used (Fig. 3), which make it possible to periodically block the right or left main bronchus. For endotracheal anesthesia and artificial ventilation (during resuscitation), plastic or rubber endotracheal tubes are used. The latter are available with or without inflatable cuffs; Children's tubes are produced without an inflatable cuff. When the cuff is inflated, a seal is created between the airway and the wall of the tube. In the absence of a cuff, sealing is created using tamponade of the pharynx and oral cavity with gauze swabs. The shape, length and diameter of the endotracheal tubes are determined by the intended I. technique and the individual topographical and anatomical features of the structure of the patient's respiratory tract. For endotracheal I., the end of the endotracheal tube should be located approximately 2 cm above the tracheal bifurcation. The length of the endotracheal tube for adults ranges from 19 to 26 cm, for children - from 10 to 21 cm, the outer diameter for adults - from 8.0 to 12.3 mm, for children - from 3.6 to 12.3 mm. The following numbers of endotracheal tubes are produced in the USSR: 000, 00, 0, 1, 2, 3, 4, 5, 6, 7, 8, 9.

Sterilization of rubber endotracheal tubes is carried out as follows: after extubation (removal) of the endotracheal tube from the trachea, it is thoroughly washed in running warm water and soap. The lumen of the tube is treated with a gauze swab (you cannot use a cotton swab or a “hedgehog” swab, since threads of cotton wool or bristles can be a source of infection if they enter the patient’s respiratory tract). After rinsing in warm water, remove the remaining grease (glycerin ointment) with ether. The tube is sterilized by autoclaving or boiling for 3 minutes. To maintain the strength and elasticity of thermoplastic tubes, they are kept in antiseptic solutions (chloramphenicol 1:1000, etc.) - Disposable tubes are often used.

Indications and contraindications

The previously existing most common indication for the so-called. classical I. - diphtheria croup - has become a rarity in modern wedge practice. I. of the trachea and bronchi are most widely used for anesthesia and resuscitation.

I. of the trachea is indicated for major surgical interventions that require the regulation of vital functions of the body, during operations and manipulations accompanied by impaired external respiration functions, and during the provision of resuscitation. help. There are no absolute contraindications to I. during anesthesia and resuscitation; diseases of the pharynx and larynx (acute inflammatory processes, tuberculosis, cancer, etc.) are relative.

In otorhinolaryngological practice, I. is indicated for stenosis of the larynx, trachea and bronchi, acute laryngotracheitis of viral etiology, and the initial period of bilateral paralysis of the lower laryngeal nerves, when there are still no inflammatory changes in the mucous membrane of the larynx. I. is also indicated for the edematous-infiltrative form of acute laryngotracheitis. According to I.B. Soldatov et al., extended I. is necessary during the period of transition from the stage of incomplete compensation of laryngeal stenosis to the stage of decompensation. Carrying out I. in the terminal stage of laryngeal stenosis is ineffective, because by this time irreversible changes have developed in the patient’s body. I. is contraindicated for bedsores, ulcers, specific granulomas, injuries and neoplasms of the larynx. Repeated I. must be abandoned when the endotracheal tube is repeatedly coughed up or when it quickly becomes blocked with films, crusts, or thick sputum. When the endotracheal tube is in the trachea for a long time (from 4 to 6 days), in some cases a tracheostomy is indicated.

Intubation technique

Each doctor who begins I. must own intubation instruments and study the anatomical features of the upper respiratory tract of a given patient. This has implications for both selection and insertion of the endotracheal tube.

Premedication is carried out 1 - 2 hours beforehand (1 ml of promedol and atropine are administered subcutaneously, for children in a reduced dose according to age). When I. in otorhinolaryngology, anesthesia (mask or intravenous) is most often performed, less often, Ch. arr. in adults, local anesthesia.

To perform I. for the purpose of general endotracheal anesthesia, it is necessary: a) suppression of protective pharyngeal and laryngeal reflexes; b) relaxation of the chewing and neck muscles; c) the correct position of the head and neck at the time of I. At the same time, against the background of preliminary premedication, optimal conditions for I. itself are created by general intravenous anesthesia (short and ultra-short-acting drugs) or mask inhalation anesthesia (nitrous oxide, fluorotane, etc.) in combination with muscle relaxants. In patients who are in a terminal condition (during resuscitation), I. is performed without premedication under the control of direct laryngoscopy. If necessary, suction toilet of the oropharynx is performed.

Intubation by mouth (orotracheal)

Used most often. A pre-selected tube is inserted, as a rule, using a laryngoscope, although there are other methods - blindly or by touch, which is only accessible to a specialist. The patient's position is usually lying on his back, the head is thrown back as much as possible, the chin is raised up, the lower jaw is pushed forward - the classic Jackson position (Fig. 4, 1). The line drawn from the upper incisors to the trachea straightens, but the distance from the incisors to the glottis increases. This drawback is eliminated with the “improved” Jackson position (Fig. 4, 2), in which the patient’s head is raised above the table level by 8-10 cm. Laryngoscopy and I. are carried out at the moment of complete muscle relaxation and apnea against the background of preliminary oxygen insufflation . When using a direct laryngoscope, it is carried out so that the end of the blade can be used to lift the epiglottis upward. After this, making sure that the glottis is visible, carefully, after additional local anesthesia by lubricating or spraying anesthetics, insert the endotracheal tube through the lumen of the laryngoscope with or without forceps (Fig. 5). Under local anesthesia and spontaneous breathing maintained, the endotracheal tube is inserted into the trachea at the moment of inhalation.

When using a curved laryngoscope, the end of the blade is brought to the root of the tongue and raised upward, followed by the epiglottis; this opens a good view of the glottis, allowing you to insert the endotracheal tube into the trachea.

With tactile I., using the II and III fingers of the left hand, the epiglottis is retracted anteriorly and, under finger control, the tube is passed into the glottis.

When performing blind intubation through the mouth, the patient's head is tilted back as much as possible, the tongue is fixed in an extended position, and the tube is inserted into the glottis strictly along the midline.

Intubation through the nose (nasotracheal)

This method of I. is usually carried out under local anesthesia, and the tube is inserted under the control of a laryngoscope or blindly. The patient's position is sitting or lying down, the head is thrown back, the neck is extended. The mucous membrane of the upper respiratory tract is irrigated or lubricated with a solution of novocaine, dicaine, pyromecaine. The laryngoscope is inserted into the oral cavity and, having seen the glottis, using intubation forceps, a tube is inserted through the lower nasal passage into the trachea (Fig. 6) at the moment the patient inhales.

Nasotracheal intubation is used in Sec. arr. during maxillofacial operations, with anomalies, deformations of the face and neck that make it difficult to insert a tube through the mouth, and during operations on the pharynx.

Intubation through tracheostomy

During operations on the pharynx and larynx, endotracheal I. is often performed through a pre-formed tracheostomy. In this case, a tracheal tube with an inflatable obturator cuff is used to create a tightness of the trachea.

Single-lung intubation and separate intubation of the main bronchi are used to protect a healthy lung from infection and prevent implantation metastases, to create a seal in the airways in case of bronchial fistulas, during reconstructive operations on the trachea and bronchi, during operations at the height of pulmonary hemorrhage, to facilitate the technical performance of the operation.

Endobronchial I. is usually performed under the control of direct laryngoscopy under conditions of general anesthesia and apnea. It has specific features depending on the location of the lesion, the nature and objectives of the surgical intervention, and the design of the endobronchial tubes.

During single pulmonary anesthesia, the tube is inserted into the larynx, trachea and, under visual control, passed into the corresponding bronchus. I. of the left bronchus is more complex, because it departs from the trachea at a more acute angle (40-45°). With I. of the right bronchus, the mouth of the right upper lobe bronchus may be blocked and the ventilation of the upper lobe may be impaired.

Separate I. of the main bronchi is carried out using double-lumen tubes (Fig. 3). The most widely used tubes are Carlens-type tubes, which are securely fixed to the carina of the trachea using a spur. To facilitate the advancement of double-lumen tubes through the glottis, special conductors are used, the spur is tied to the tube with a silk thread, and sometimes the tube is turned. After insertion into the glottis, the tube is turned 180° counterclockwise (spur up), and with further advancement it is turned 90° clockwise until it is fixed on the carina.

To prevent complications, it is important to install and fix endotracheal and endobronchial tubes in the correct position, monitoring visually (by chest excursions), auscultation or x-ray. During anesthesia, it is necessary to monitor the patency of the tubes, preventing displacement, kinks, compression, and blockage.

Complications during intubation

Complications during surgery for I. arise when the necessary conditions are not met: insufficient inhibition of reflex excitability of the larynx and muscle relaxation, incorrect position of the patient, anomalies of the upper respiratory tract, limited mobility of the jaw joints, and lack of practical skills of the anesthesiologist. During I., damage to the teeth, lower jaw, mucous membrane of the pharynx and larynx may occur. With I., damage to the mucous membrane of the nasal passages is accompanied by bleeding. I. against the background of apnea St. 30-40 sec. may lead to severe hypoxia. Overstimulation of the branches of the vagus nerve with insufficient suppression of the reflex excitability of the larynx can lead to laryngospasm (see), disturbance of cardiac activity. After traumatic I., when using large-diameter tubes, with excessive inflation of the obturator cuff, prolonged stay of the tube in the trachea in the early postoperative period, the development of laryngeal edema (see), laryngostenosis (see) up to asphyxia is possible; within a few days after I., symptoms of acute pharyngolaryngotracheitis may be observed. In some cases, I. is feasible only with fiberoptic bronchoscopy under local anesthesia.

A common mistake is inserting a tube into the esophagus. Excessive tilting of the head back, especially in a child, significantly complicates I., since in this case the entrance to the larynx deviates posteriorly and becomes almost inaccessible for inserting an endotracheal tube into it.

In otorhinolaryngological practice, when performing I. under local anesthesia, spastic closure of the glottis may occur; in such cases, you should wait a few seconds and, while the patient is inhaling, insert the tube into the trachea. In some cases, due to anatomical conditions (short neck in an obese patient, narrow glottis, long upper incisors, short lower jaw, large fleshy tongue, limited mobility of the lower jaw and cervical spine), I. is extremely difficult or practically impossible. Under these conditions, it is necessary to try to tilt your head back as much as possible, place a bolster under your shoulders, or use a laryngoscope of a different shape and size (instead of a straight one, a curved one). The most serious complication of I. is injury to the larynx with the formation of a false passage. It occurs as a result of violent disruption of the integrity of the mucous membrane and penetration of the tube through the laryngeal ventricle or pyriform sinus into the underlying tissues. Penetration of infection through the resulting false passage can lead to phlegmon of the larynx, mediastinitis (see). Therefore, if a false tract is formed, further attempts at I. should be stopped, and the patient must undergo a Tracheostomy. Due to prolonged pressure of the tube on the mucous membrane of the larynx and its trauma, bedsores may develop. Late complications include the appearance of endotracheal granuloma and cicatricial membrane, which are a manifestation of productive inflammation at the site of disruption of the integrity of the epithelium of the laryngeal mucosa. Granuloma usually appears after 3-5 weeks. after I., most often in the area of the vocal process of the arytenoid cartilage in the form of a bright pink tumor, sitting on a broad base. Subsequently, the granuloma becomes denser, its stalk becomes thinner, it becomes covered with epithelium and becomes similar to a polyp. Intubation granuloma leads to voice impairment and sometimes difficulty breathing.

Caring for an intubated patient

An intubated patient should be under constant supervision by medical staff. This is necessary because the relatively narrow lumen of the endotracheal tube can become clogged with patol at any time, with secretions from the respiratory tract. In such cases, the secretion is suctioned with a catheter inserted into the tube; if ineffective, repeat I. To prevent the patient from removing the endotracheal tube (spontaneous extubation), it is necessary to fix the elbow joints with a splint, and the tube with an adhesive plaster to the cheek.

The patient eats and drinks through the mouth; if normal nutrition is not possible, tube feeding is used.

Bibliography Nosov S. D. Intubation in the treatment of patients with diphtheria croup, M., 1958, bibliogr.; Ostrovsky G. G., Shagal E. L. and Shulman V. Shch. Tracheostomy and prolonged nasotracheal intubation in the treatment of severe forms of acute stenotic laryngotracheobronchitis, Zhurn. ear., no. and throats, Bol., No. 6, p. 48, 1975, bibliogr.; Sokolov V. M. Modification of the method of intubation of newborns, Obstetrics and Gynecology, No. 10, p. 77, 1967; A 1 1 e n T. H. a. Steven I. M. Prolonged nasotracheal intubation in infants and children, Brit. J. Anaesth., v. 44, p. 835, 1972; Crysdale W. S. Nasotracheal intubation in management of delayed decanulation, Ann. Otol. (St Louis), v. 83, p. 802, 1974, bibliogr.; F e r 1 i with R. M. Tracheostomy or endotracheal intubation, ibid., p. 739.

I. trachea and bronchi during anesthesia and resuscitation- Bunyatyan A. A., Ryabov G. A. and Manevich A. 3. Anesthesiology and resuscitation, M., 1977; Zh about r about in I. S. General anesthesia, M., 1964; Kassil V. L. and Ryabova N. M. Artificial ventilation in resuscitation, M., 1977, bibliogr.; Mashin U. Pain relief during intrathoracic operations, trans. from English, M., 1967; Resuscitation, theory and practice of revival, ed. M. Sykha, per. from Polish, Warsaw, 1976; Guide to Anesthesiology, ed. T. M. Darbi-nyan, M., 1973.

O. A. Dolina (anest.), D. I. Tarasov (ENT).

Tracheal intubation is the most effective way to help with respiratory disorders. At the prehospital stage, intubation through the mouth under visual control using direct laryngoscopy is most appropriate. For this you need: a laryngoscope with straight and curved blades of various sizes and self-powered lighting system, a nebulizer of local anesthetic solutions (for example, 2% trimecaine solution), sterile endotracheal tubes appropriate sizes (preferably disposable thermoplastic tubes with inflatable cuffs), connectors for connecting a ventilator to an endotracheal tube, an aspirator with catheters for suction, any simple manually operated device for ventilation.

To intubate an unconscious patient, place him on his back, place a pillow or some other device under the back of his head, and extend the occipital-cervical joint. Then the patient’s mouth is opened, the removable dentures are removed and the oropharynx is quickly cleaned. Can be carried out spray local anesthesia oral cavity and upper respiratory tract.

Before intubation itself, it is advisable, in the absence or obvious insufficiency of spontaneous breathing, to perform mechanical ventilation using a mask with oxygen-enriched air.

Next, the first and second fingers of the right hand spread the patient’s lips and jaws, and with the left hand, the laryngoscope is inserted so that its blade passes along the midline between the palate and the tongue, pressing the tongue upward. The blade is drawn deeper, protecting the patient’s teeth with the right hand, while first the uvula and then the epiglottis appear in the field of view. When working with a curved blade, its end is inserted between the root of the tongue and the epiglottis, pressing the root of the tongue upward. In this case, the epiglottis moves anteriorly and the glottis opens. If a straight blade is used, then its end is picked up by the epiglottis and pressed to the root of the tongue, which provides a good view of the entrance to the glottis. in patients with long and thin necks it is preferable laryngoscopy using a straight blade, and in obese patients with a short and wide neck - using a curved blade.

If the entrance to the larynx is poorly visible, then you should carefully press on the cartilage of the larynx from the outside towards the spine. It must be remembered that the entrance to the esophagus is located behind the larynx and has a funnel shape.

After the entrance to the glottis has become clearly visible, under visual control with the right hand, an endotracheol tube of the appropriate size is inserted into the trachea 3-4 cm so that the inner end of the tube is located above the bifurcation of the trachea (the upper edge of the cuff drops below the level of the vocal folds). The cuff on the tube is then carefully inflated to seal the gap between the tube and the tracheal wall. In the absence of tubes with an inflatable cuff, sealing is achieved using tight oral tamponade and throat with a damp gauze bandage, the end of which must be brought out. By careful auscultation of the chest, the correct placement of the tube in the trachea is checked and the tube is secured in the desired position using a gauze strip or adhesive tape, passing the latter from ear to ear through both cheeks. When intubation is performed correctly, breathing sounds should be heard clearly and evenly over all areas of the lungs.

The main dangers and complications of tracheal intubation are the possibility of damage to the teeth and upper respiratory tract, as well as incorrect position of the tube (entry into the esophagus, into one of the main bronchi, etc.) and its kinks. To prevent these complications, it is necessary to carry out laryngoscopy and intubation without violence, carefully and in compliance with all the listed rules, then carefully monitoring the free patency of the tube and the uniformity of chest movement during spontaneous breathing or mechanical ventilation.

Successful and properly produced tracheal intubation using a good plastic tube with an inflatable cuff, functionally it currently appears to be a completely complete replacement for tracheostomy. In addition, intubation is much easier.

Orotracheal intubation is one of the most common medical procedures.

During the procedure, an endotracheal tube (ETT) is passed through the entire oropharynx between the vocal cords and directly into the trachea.

Indications and contraindications

Conventionally, all contraindications and indications for artificial ventilation can be divided into absolute and relative.

Indications for medical manipulation include:

1. Absolute:

aspiration syndrome;
airway obstruction;
traumatic brain injuries;
pulmonary-cardiac resuscitation (LCR);
deep coma of various origins.

2. Relative:

eclampsia;
thermal inhalation injuries;
pulmonary edema;
shock of various origins;
strangulation asphyxia;
pneumonia;
pulmonary failure;
status epilepticus.

If there are relative indications for the procedure, the decision on artificial ventilation of the respiratory tract is made individually and depends on the cause of the patient’s emergency condition.

It is impossible to intubate patients in prehospital conditions if there are direct contraindications.

Intubation instruments

laryngoscope - a medical instrument that is used to facilitate visualization of the larynx; Laryngoscopes with curved tips, which provide a wide view of the respiratory tract, are considered the least traumatic;
trocar - a surgical instrument that is used to penetrate human cavities; the standard device consists of a special stylet (conductor) equipped with a handle;
surgical clamp - metal scissors with dull blades, which are used to cleanse the oral cavity of viscous secretions;
ventilation bag - a rubber bulb that connects to the ETT for manual ventilation of the lungs;
endotracheal tubes - thin tubular devices that are made of thermoplastic materials; after insertion, the tube in the trachea increases in size at the level of the cuff, which ensures obstruction of the lumen between the medical equipment and the walls of the respiratory tract;
tools for sanitation - an aspirator and a special catheter designed to cleanse the trachea of liquid secretions, blood and gastric juice.

Muscle relaxation and general anesthesia are necessary conditions for performing the necessary medical procedures.

With complete relaxation of the body, the risk of damage to the mucous membrane of the airways is greatly reduced.

However, in the prehospital setting it is almost impossible to achieve optimal conditions.

Intubation technique

What is the technique for tracheal intubation?

the patient is put under anesthesia using special drugs (relaxants, barbiturates);
for 2-3 minutes the specialist performs artificial ventilation of the respiratory tract using an oxygen mask;
with the right hand, the resuscitator opens the patient’s mouth, after which he inserts a laryngoscope into the oral cavity;
the blade of the instrument is pressed against the root of the tongue, which allows the epiglottis to be pushed upward;
After exposing the entrance to the pharynx, the doctor inserts an endotracheal tube.

Inept manipulations by the intubator can lead to hypoxia or collapse of one of the patient's lungs.

Intubation of newborns

How is newborn intubation performed? To reduce the likelihood of complications, the ETT is administered through the nasopharynx. During the procedure, the specialist performs the following actions:

using an oxygen mask, ventilates the lungs until satisfactory saturation is achieved;
with the help of an aspirator and a thin tube, the bronchi and respiratory tract are completely cleared of mucus, meconium and foamy secretions;
to visualize the entrance to the pharynx, the specialist presses the outside of the larynx with his little finger; the tip of the ETT is lubricated with xylocaine cream, and then carefully inserted through the nasal canal into the trachea;
during auscultation of breathing, the resuscitator determines the intensity of noise in each of the lungs; at the final stage, an artificial respiration apparatus is connected to the ETT through special adapters.

Important! If a child is connected to a ventilator for a long time, this can lead to the development of bradycardia (slow heart rate).

Intubated children are observed for several days in the intensive care unit. If there are no complications and respiratory function is restored, the intubation instruments are carefully removed.

Difficult intubation

Intubation outside the operating room is used in extreme cases, i.e. if there are vital indications.

The category of patients with very high risks of tube intubation includes:

women during gestation;
persons with serious cranial and jaw injuries;
overweight patients (grade 3-4 obesity);
patients suffering from diabetes mellitus;
persons with thermal inhalation injuries.

In all of the above cases, the use of intubation becomes much more complicated. To assess the patient's condition, the doctor ventilates the lungs using an oxygen mask.

Possible complications

circulatory arrest;
aspiration of gastric juice;
destruction of teeth or dentures;
intubation of the digestive tract;
atelectasis (collapsed lung);
perforation of the oropharyngeal mucosa;
damage to the throat ligaments.

Important nuances

hemoximetry - a non-invasive method for determining the level of blood oxygen saturation;
capnometry - numerical display of the partial pressure of CO2 in inhaled and exhaled air;
Auscultation - physical diagnosis of the patient’s condition by the sounds produced in the lungs during lung function.