Under the guidance of: Dr. Rajan Nanda & Dr.

Hemlata Ametha

By, Dr. Yogesh Kumar Chhetty

THE COMPONENTS OF THE RESPIRATORY SYSTEM

Upper respiratory system
Nose Nasal cavity

Paranasal sinuses
Pharynx

Lower respiratory system

Larynx Trachea

Bronchi
Lungs

UPPER RESPIRATORY SYSTEM

THE NOSE, NASAL CAVITY, AND PHARYNX

Nose is primary passageway for air entering respiratory system Air enters paired external nares that open into nasal cavity Vestibule : portion of nasal cavity contained within flexible tissues of external nose Vestibule contains coarse hair that trap foreign particles

Nasal septum : divides cavity into right & left halves

Bony portion of nasal septum is formed by perpendicular plate of ethmoid & vomer Anterior portion of septum is formed by hyaline cartilage

NASOPHARYNX
Superior part of pharynx

Connected to posterior portion of

nasal cavity via internal nares Separated from oral cavity by soft

palate
Lined by respiratory epithelium Pharyngeal (adenoid) tonsil is located on posterior wall Lateral walls contain openings of auditory tubes

OROPHARYNX
Extends between soft palate & base of tongue at level of hyoid bone

Posterior portion of oral cavity &

posterior & inferior portions of nasopharynx communicates directly with oropharynx

At boundary between naso & oropharynx epithelium changes from respiratory epithelium to stratified squamous

epithelium
Soft palate supports uvula & two pairs of pharyngeal arches Anterior palatoglossal arch Posterior palatoglossal arch Palatine tonsil lies in between

LARYNGOPHARYNX
Includes that portion of pharynx lying between hyoid bone & entrance to esophagus Most inferior portion of pharynx

Lined by stratified squamous epithelium

THE GLOTTIS

THE LARYNX
Inspired air leaves pharynx by passing through a narrow opening glottis Larynx surrounds & protects glottis Larynx begins at C3 & ends at C6 vertebral levels Larynx essentially is a cylinder whose cartilaginous walls are stabilized by ligaments & muscle

THE ANATOMY OF THE LARYNX

THE TRACHEA
Trachea is a tough, flexible tube with diameter of 1.2cm & length of 10-15cm Begins anterior to C6 vertebra in a ligamentous attachment to cricoid cartilage Ends in mediastinum at level of T4 vertebra in the supine and T6 in the standing position Branches to form right & left primary bronchi Lining of trachea consists of respiratory epithelium overlying a layer of looser connective tissue (lamina propria) Trachea contains 16-20 incomplete C shaped tracheal cartilages Each tracheal cartilage is bound to neighboring cartilages by elastic annular ligaments Tracheal cartilages stiffen tracheal walls & protect airway Also prevent its collapse or overexpansion as pressures change in respiratory system

THE TRACHEA
Each tracheal cartilage is C shaped Closed portion of C protects anterior & lateral surfaces of trachea Open portion of C faces posteriorly toward oesophagus

Because cartilages do not continue around trachea, posterior tracheal wall can easily distort during swallowing permitting passage of large masses of food
Trachealis : An inelastic ligament & band of smooth muscle connecting ends of each tracheal cartilage

PRIMARY BRONCHI
Right & left primary bronchi Carina marks line of separation between 2 bronchi

Its a very sensitive structure and its stimulation leads to unwanted effects. So ETT and catheter should be kept away from it
Has cartilaginous C shaped supporting rings

Right primary bronchus shorter 2.5cm(Lt 4.5cm), larger diameter than left & descends towards lung at a steeper angle, angle with the vertical is 250 (Lt 450.) Aorta arches over the left main bronchus
Due to the peculiar characteristics of rt main bronchus chances of ETT to be positioned in the Rt side are more

In children the angle of both the Rt and the Lt are the same i.e 550 upto an age of 3 years

TERTIARY BRONCHI

RIGHT SUPERIOR LOBAR

THE BRONCHI
LEFT

MIDDLE LOBAR
INFERIOR LOBAR

1 BRONCHI

SUPERIOR LOBAR

INFERIOR LOBAR

2 BRONCHI (LOBAR BRONCHI)

3 BRONCHI (SEGMENTAL BRONCHI)

23 generations of dichotomous branhes are present from the trachea till alveolar sacs

SUPPLIES AIR TO SINGLE BRONCHOPULMONARY SEGMENT

8/9 LEFT

10 RIGHT

THE BRONCHI AND LOBULES OF THE LUNG

BRIEF HISTORY

1878 - William Macewen passed a tube in trachea from the mouth for the first time

1893 - Eisenmenger gave a description of the

cuffed ETT

1906 - Green introduces the pilot balloon 1960 - Plastic replaces red rubber as material for construction

1969 Introduction of modern day ETT with high volume low pressure cuff

INDICATIONS FOR INTUBATION

Respiratory failure

Protection of the airway from aspiration

Decreased LOC (coma score <8/15) Secretion clearance Upper airway obstruction Raised ICP treatment Facilitate tracheobronchial toilet CPR Surgery

Non NBM patients Anaesthesia requiring PPV Head and neck surgeries which may compromise airway Surgeries requiring neuromuscular blocking agents In patients likely to develop laryngospasm

OBJECTIVE MEASURES INDICATING THE NEED FOR INTUBATION

RR >35 VC <15 ml/kg PaO2 <60 on >40% oxygen PaCO2 >50 (except in chronic retainers) A-a gradient > 300 on 100% oxygen

INTUBATION EQUIPMENT

Endotracheal Tube and stylet

Laryngoscope
Sterile water-soluble jelly Syringe to inflate cuff

Adhesive tape or tube fixation device

Bite block to prevent biting oral ET tube Suction Equipment, bag- mask, O2 Local anesthetic Stethoscope

PREPARATION FOR INTUBATION

Suction Equipment Oxygen Airway Patient position Monitors Esophageal Detection Device

LARYNGOSCOPE

Blade and handle Blade - has a flange, spatula, light, and tip - curved blade (Macintosh) - straight blade (Miller, Wisconsin)

Blade size: 0 - 1 infant, 2 from 2-8 years 3 from age 10adult, large adult- 4

LARYNGOSCOPIC BLADE
Macintosh (curved) and Miller (straight) blade

Adult : Macintosh blade, small children : Miller blade

Miller blade Macintosh blade

Curved tip Mccoy blade

STRAIGHT BLADE (MILLER)

CURVED BLADE (MACINTOSH)

ENDOTRACHEAL TUBE

ET TUBE SIZE
For children lesser than 6 years

- Tube size = age/3 + 3.5(ETT ID in mm)

For children more than 7 years

-Tube size = age/4 + 4.5(ETT ID in mm)

DEPTH OF INSERTION
Adult
Adult - Male = 20-21 cms ,Female = 19-20 cms Children

Oral endotracheal tube = (Age/2) + 12 Nasal endotracheal tube = (Age/2) + 15

(cm) (cm)

ENDOTRACHEAL TUBE CUFFED AND UNCUFFED

High volume

Low volume

Low pressure cuff High pressure cuff

STYLET

SNIFFING POSITION

SNIFFING POSITION Neck flexion of 25-350

Head extension of 850

In adults a head elevation of 8-10 cms In paediatric age group of less than 8 years there is no need of head elevation

ROUTES FOR INTUBATION

Orotracheal Nasotracheal Tracheotomy

ORAL INTUBATION

ADVANTAGES OF ORAL INTUBATION

Larger tube can be inserted Tube can be inserted usually with more speed and ease with less trauma

Easier suctioning Less airflow resistance Reduced risk of tube kinking

DISADVANTAGES OF ORAL INTUBATION

Gagging, coughing, salivation, and irritation can be induced with intact airway reflexes Tube fixation is difficult, self-extubation

Gastric distention from frequent

swallowing of air Mucosal irritation and ulcerations of mouth (change tube position)

NASAL INTUBATION

ADVANTAGES OF NASAL INTUBATION

More comfort long term Decreased gagging Less salivation, easier to swallow Improved mouth care Better tube fixation

Improved communication

DISADVANTAGES OF NASAL INTUBATION

Pain and discomfort

Nasal and paranasal complications, I.e., epistaxis,

sinusitis, otits More difficult procedure Smaller tube needed Increased airflow resistance Difficult suctioning Bacteremia

CONTRAINDICATION FOR NASOTRACHEAL INTUBATION

1) Fracture base of skull 2) Nasal fractures or grossly distorted septum 3) Coagulopathy 4) Nasal cavity obstruction 5) Retropharyngeal abscess

CONTRAINDICATION FOR ENDOTRACHEAL INTUBATION

1) Severe airway trauma 2) Cervical spine injury 3) Aneurysm of the arch of aorta 4) Laryngeal edema 5) Severe laryngitis

ORAL INTUBATION PROCEDURE

Assemble and check equipment - suction equipment - laryngoscope - select proper size tube, check tube

Position patient

- align mouth, pharynx, larynx

SNIFFING position

PATIENT POSITIONING

ORAL PROCEDURE (CONTD..)

Preoxygenate the patient - bag-valve mask - *intubation attempt should take no longer than 30 sec, if unsuccessful, then ventilate again with bag and mask for 3-5 minutes

Insert laryngoscope

Laryngoscope is gently held in the left hand at the junction of

the handle and the blade, while the right hands thumb and middle finger gently open the patients mouth in a scissoring action. Laryngoscope is inserted from the right side of the mouth and the tongue is displaced towards left as the laryngoscope is introduced.

ORAL PROCEDURE (CONTD..)

On deeper entry into the oral cavity, the curved Macintosh blade is positioned into the space between the base of the tongue and the pharyngeal surface of the epiglottis. The tongue and the pharyngeal soft tissue are then lifted to expose the glottic opening.

ORAL PROCEDURE (CONTD..)

The direction of the lifting force is always along the axis of the laryngoscope handle. The blade should never be used as a lever and the teeth as a fulcrum.

Insert ET tube from the right corner of mouth - do not use laryngoscope blade to guide tube - once you see the tube pass the glottis, advance the cuff past the cords by 2 -3 cm

Hold tube with right hand and remove laryngoscope & stylet - inflate cuff with 5 - 10 cc of air - ventilate with bag

ORAL PROCEDURE (CONTD..)

Inflate cuff with 5 - 10 cc of air (10-20 cm of H2O) Ventilate with bag Assess tube position

- auscultation of chest & epigastric

- cm mark at teeth - capnometry

Stabilize / Fix Tube tube/Confirm placement

CONFIRMATION OF THE POSITION OF ENDOTRACHEAL TUBE

Intubation under vision Chest movements / Auscultation in epigastric area Bilateral Air Entry with Stethoscope Feeling of inflated cuff in suprasternal notch Movement of the bag Fogging of the endotracheal tube

Capnography
Fibreoptic bronchoscopy Chest X-Ray

WHAT ARE THE POTENTIAL COMPLICATIONS OF ENDOTRACHEAL INTUBATION?

Edema Granuloma Healed fibrous nodule Interarytenoid adhesion Posterior glottic stenosis Subglottic stenosis Healed furrows Ductal cysts

Hematoma Laceration Subluxation of arytenoid cartilage Loss of mobility of cricoarytenoid joint Vocal cord paralysis Nasogastric tube syndrome

FACTORS FOR SUSCEPTIBILITY

Extrinsic factors
Diameter of ETT

Duration of intubation
Traumatic or multiple intubations

Patient factors
Poor tissue perfusion (i.e. sepsis, organ failure, etc) LPR Abnormal larynx Wound healing, keloid

Movement
During ventilator use During suctioning During coughing

During transport