Intubation trachéale

The intubation trachéale (IT) is a gesture of Anesthésie or Réanimation, frequently used in emergency Médecine, which consists in placing in the Trachée through the glottic opening a probe whose higher end emerges by the mouth (intubation oro-trachéale) or the nostrils (intubation naso-trachéale).

It ensures the freedom and the sealing of the air routes and allows the assisted Ventilation.

Intubation is a technical epic carried out according to a well defined protocol. It is carried out easily most of the time, but the possibility of a difficult Intubation must always be required by using certain predictive criteria. In the event of impossible intubation with the technique of reference by laryngoscopy, of the alternative techniques exist.

In France, intubation trachéale is a regulated act and exclusively carried out by a Médecin (urgentist or anesthetist reanimator) or a Infirmier anesthetist.

One of the determining factors of intubation trachéale is the nature of the Sédation used. Thus of many drugs reserved before for the anesthesia-reanimation, like the central analgesics, the anesthetic intravenous ones and the curares, must be controlled.

History

Contrary to the Tracheotomy which are one of oldest surgical operations and which would have a long story going back to several millenia ''', intubation trachéale exists since good less longer.

Hippocrates (- 460 with - 377) would have proposed, in the event of suffocation, to insert a small pipe in the throat of the patient to insufflate air there. For some it would be the description of a tracheotomy, for others, rather that of an intubation.

One lends to the Arab doctor Avicenne (980 with 1037) the first intubations trachéales' in the event of suffocation, using money or gold nozzles (Book III of the Canon) '.

Towards 1878 - 1880 William MacEwen describes an anesthesia during a preventive intubation trachéale, before the ablation of a tumor of the base of language '.

In the beginning, the first intubations trachéales were carried out at the time of the episodes asphyxic of the Diphtérie. Until the end of the 19th century, the only chance of hello was to carry out a tracheotomy, then burdened with a heavy mortality. The American pediatrist Joseph O' Dwyer (1841-1898) invented the method of intubation which bears its name and which was published in NR. Y. Medical Newspaper under the title " Intubation off the Larynx".

Franz Kuhn (1866-1929), a German surgeon, is the first to regularly use intubation trachéale at the time of the anesthesias towards 1900, but this practice will be applied in hospital routine only well later, towards 1945

the formation by simple trade-guild should not begin on the patient but must start with a training on mannequin to pass then to a training on the patient. Indeed the training on mannequin allows a realization of the gesture without involving of risk for the patient. Certain mannequins are provided with sensors making it possible to alert in the event of risk of dental traumatisms and reproduce the normal anatomy in a faithful way. In spite of their realism, the reproduction of the real conditions is to date only approximate.
the training with the Operating room suite, once the practice on mannequin acquired, makes it possible to continue the control of the technique, under conditions of optimal framing and safety. Obtaining a diploma of emergency Médecine (CAMU in France) requires besides a training course with the operating room suite.

the teaching of certain techniques like the use of a laryngé mask (ML) or intubation with a laryngé mask of intubation (MLI) can be done with the operating room suite after a training on mannequin.

Within the framework of the urgency and reanimation préhospitalière, the detection of difficult intubation is made even more delicate.

Preparation

The checking of the material, the conditioning of the patient with installation of a monitoring of the electrocardiogram, blood pressure, saturation out of oxygen and sometimes of expired CO2 and pose it of a reliable venous access constitute the first time.

Oxygenation preliminary to the general anesthesia, or preoxygenation, makes it possible to reduce the risk of Hypoxémie during the induction and the security of the air routes by increasing the reserves of the oxygen organization. Thus out of pure oxygen, the replacement of alveolar nitrogen by oxygen (denitrogenation) and the increase in the tissue oxygen reserves make it possible to double the time of apnea up to 6 minutes.

The method of reference is spontaneous ventilation during three minutes out of pure oxygen (FIO2 = 1). The material, in particular the facial mask, must be tight. The co-operation of the patient is paramount and is facilitated by good preliminary information.

Sedation - anesthesia

Intubation trachéale can be realized under local anesthesia of the nasal fossae, the pharynx and the vocal cords, by way nasotrachéale by using a technique “with the blind man” or a fibroscopy. A light sedation using a Benzodiazépine makes it possible to increase the well-being of the patient and operator.

If intubation is required by an act having to be carried out under general anesthesia, the selected anesthetic technique depends on the surgical indication. One will be able - or not to use a myorelaxant according to the surgical need and the need for an intubation with fast sequence.

In the event of difficult risk of intubation, one employs drugs of short action (for example, Propofol, Rémifentanil and succinylcholine

So finally it is the installation of the intubation trachéale which requires an anesthesia, the indication of intubation must be particularly considered. Indeed, one is in the case perilous of an anesthesia in urgency, at a patient which one knows only little the antecedents and confronted at the risk of brutal aggravation of the situation.

Techniques

Intubation trachéale can be carried out with various materials, various drugs and different technical. The context in which with place intubation also plays a part in the technique to be used.

In the urgency, the techniques most frequently used are:

Intubation without sedation nor blockers neuromusculaires (BNM)
Intubation with patient waked up (“Awake intubation”)
oral Intubation with major sedation (but without BNM)
Intubation in fast sequence (ISR)
Intubation orotrachéale with special instruments
Cricothyroïdotomie with the needle or surgical

Intubation by laryngoscopy

It is about the technique of the most common intubation. A Laryngoscopie is practiced in order to visualize the Glotte and it tube passed through the vocal cords with direct visualization. It is more common to pass the tube by the mouth but it can also be last by the nose in certain facial cases of trauma, surgeries ORL or in the children.

Alternatives

Use of a metal chuck in order to increase rigidity or to modify the shape of the endotracheal probe.
Pressure on the thyroid Cartilage in order to facilitate the visualization of the glottis.
Operation of Sellick.

Intubation with the blind man

It consists to introduce the probe trachéale by a nostril and to direct it while being based on the listening of the air blast during spontaneous breathing. Its advantage is not to require a laryngoscopy, in particular in the event of impossibility of opening the mouth and of respecting spontaneous breathing. It can be carried out under simple local anesthesia of the nostril and the pharynx. Its limits are the need for a sufficient spontaneous breathing, the relative slowness of the procedure and the risk to start potentially noxious bleedings.

Intubation under fibroscopy

It is about the best technique during intubation trachéale envisaged difficult. It consists, after having introduced a flexible fibroscope into the probe, to guide it through the opening glottic under direct control of the sight, generally while passing by a nostril. This technique requires a good formation, a material expensive and fragile and is effective only at one patient presenting a spontaneous breathing. The presence of bleeding or secretions makes its realization much more delicate.

Intubation retrogresses

It consists in carrying out a puncture of the trachea through the skin, has to thread in the trachea a guide plastic or metal who will arise by the glottis then by the mouth, and to make use of this guide to install the probe of intubation.

Other techniques of difficult intubation

Luminous chuck

Called also technical by transluminescence, it is about a foldable rigid chuck to the end of which a source of light is. The chuck is slipped into the tube like a traditional chuck. They then passed by the mouth without laryngoscopy. The light filtering through fabrics makes it possible to check the good position of the tube.

Candle or chuck of Eschmann

It is about a long relatively rigid plastic stem of which the end (approximately 2 cm) form a light angle. The stem is inserted at the time of a laryngoscopy. The end of the stem is pointed upwards. The friction of the end of the stem on the trachéaux Anneaux makes it possible to know that this one is in good position without visualizing the glottis. The probe of intubation then is threaded on the chuck and is slipped until into the trachea, the laryngoscopy being maintained to raise the épiglotte. The chuck is then withdrawn and probes it connected to the respiratory circuit.

Exchanger of tube

It is about a long stem intended to be last in the endotracheal probe before the withdrawal of this one. In the event of failure of the extubation (absence of permeability of the respiratory tracts or respiratory insufficiency) another endotracheal probe could be inserted easily while slipping it along the exchanger. Certain models of exchanger are also provided with an internal conduit allowing ventilation to the manual reanimator or with a Dispositif of ventilation " JET"

Fastrach®

It is about a laryngé mask (see higher) allowing ventilation then the introduction by its means of a probe of intubation trachéale.

Swelling of the small baloon

At the end introduced into the trachea, the Sonde of intubation comprises a small baloon which allows, once inflated with the air, to ensure the good protection of the air routes. The ideal pressure of inflation is of 20 mmHg (pressure in millimetre of mercury is 27 cmH2O, correspondence of pressure in centimetres of water), it ensures a good sealing of the air routes while being slightly in lower part of the pressure of blood perfusion of the mucous membrane trachéale. That Ci is likely to be injured when the pressure exerted by the small baloon exceeds 30 cmH2O by preventing a correct vascularization locally. It is recommended to regularly supervise the pressure of the small baloon using a pressure gauge. In certain cases, in particular in box hyperbare, the small baloon is inflated with water.

Checking of success

It is necessary to take as of the insertion of the tube of measurements to check that the tube is well positioned in the trachée.
Raccorder with a balloon reanimator or the circuit of anesthesia and while ventilating, to check the following points:

Rising of the symmetrical thorax of way and immobility of the abdomen.
the presence of condensation in the tube with the expiry is not a reliable sign. It can as well be observed in the event of intubation trachéale as oesophagienne.
the measurement of a partial CO2 pressure in the expired air (PETCO2) is the method of reference to control the absence of intubation œsophagienne. The capnogrammes must be visualized and stable on at least 6 ventilatory cycles.
Use of an inspector of position oesophagienne (VPO).
With the sounding, the murmur vésiculaire must be heard in a symmetrical way, on the right like on the left, one checks the absence of “glouglou” to the stomach. The pulmonary sounding axillaire is the best means of detecting selective intubation. This sounding must be renewed after each change of position of the patient.
the pulmonary Radiographie is a current way to check the adequate depth of insertion of the tube in intensive care unit. It is carried out in anesthesia only in case of doubt.

Fixing

Successful intubation is immediately followed fixing of the endotracheal probe. The choice of the type of fixing depends on the practices of the hospital, the context and the duration envisaged of intubation. Various devices can be used:

common medical adhesive tape;
nonadhesive ribbon (Doyer method);
adhesive bands for endotracheal tubes;
rigid system of harness with velcro.

Whatever the system used, a perfect fixing of the tube trachéal is essential because of the gravity of the accidents related on the displacement or the loss of the probe of intubation. In the event of intubation by the mouth a rigid nozzle standard nozzle of Guedel is installation in order to prevent the risk of bite and obturation of the probe.

Complications of intubation trachéale

Mechanical complications

selective bronchial intubation occurs in the very large majority of the cases in the bronchus right stock, whose angulation compared to the trachea is weaker. The signs of bronchial intubation are an asymmetry with the sounding with a murmur vésiculaire absent or decreased on the left, an asymmetry of rising of the thorax during blowing, a CO2 rate expired low, the diagnosis is sometimes posed by radiography. A bronchial intubation can also occur by secondary displacement of the probe, because of an insufficient fixing or of mobilization of the head.
intubation oesophagienne is the introduction of the probe of intubation into the esophagus. The signs are an absence of murmur vésiculaire, a resistance to blowing, a gastric dilation and rumbles with the sounding of the épigastre. In the absence of spontaneous ventilation, it evolves to a respiratory distress. Ignored it can involve a gastric rupture or oesophagienne dramatic.
the secondary obstruction of the probes by coudure, displacement, bite, accumulation of secretions is always possible and its prevention requires a Draconian monitoring.
Of the traumatic lesions can occur, caused either by the laryngoscope with lesions of the lips, of the teeth, hemorrhages oral or pharyngées or by the probe of intubation with lesions of the vocal cords, cartilages aryténoïdes, trachea. Gravity is very variable being able to go from the simple nuisance to a respiratory distress.
the mobilization of the neck at one polytraumatized can involve the secondary displacement of a fracture of the cervical rachis, until there unperceived.

General complications

intubation trachéale involves an acceleration of the heart rate and an increase in the blood pressure, sometimes badly supported among fragile or old patients.
the inhalation of the contents of the stomach, or Syndrome of Mendelson can occur before or at the time of the installation of the probe of intubation.
Of the pharyngées and laryngées pains is brought back in 15 to 30% of the cases and generally disappears into three to four days.
a laryngospasme can occur before the installation or shrinking of the probe of intubation. The vocal cords close in a practically tight way then, involving an impossibility of assisting breathing with the facial mask.

Late complications

Of the lesions of the vocal cords can be seen during prolonged intubations.
a sténose (reduction in the gauge) of the trachea can be pulled by a too inflated small baloon.
Of the paralyzes of the vocal cords by nervous attack was also described.

Alternative techniques for the access to the air routes

Facial mask

Ventilation with the facial mask is as often as possible and makes it possible to ensure a survival while waiting for the use of a suitable technique or the assistance of an expert.

The COPA

Or Cuffed OroPharyngeal Airway is a oropharyngée nozzle with small baloon which ensures the sealing of the oro- and of the nasopharynx and the freedom of the air routes.

The laryngé mask

It consists in introducing into the mouth a tube provided with a bulky small baloon, marrying once inflated the shape of the larynx. This technique generally makes it possible to practice a controlled ventilation but does not prevent the risk of inhalation of the gastric contents. Its employment requires a major general anesthesia and a maintenance of the open vocal cords.

The Combitube

The combitube is composed of a probe with two channels, provided with two small baloons, introduced with the blind man into the mouth. If the distal part is in the esophagus, it is possible to ventilate the lungs by the other channel, in the contrary case, one ventilates by the distal channel, as for a traditional probe.

Tracheotomy of rescue

By a trained operator, it takes only a few seconds. A doctor would have thus practiced a tracheotomy on a child during an air flight using a multi-fonction pocket knife. Kits of minitracheotomy nowadays allow this gesture under conditions much lifting.

Oxygenation of rescue

The insertion of a needle of good gauge in the trachea by direct puncture transcutanée between two trachéaux rings makes it possible to deliver oxygen under pressure (3 to 4 bar) at a high frequency (1 Hz). This technique makes it possible to await more favorable conditions.

Characteristics

Intubation trachéale with the operating room suite

It is with the operating room suite that the greatest number of intubations trachéales is carried out. The technical requirements are ideal there with an trained team. The various devices in the event of difficult intubation are joined together there on a carriage immediately available. The gesture is generally carried out “cold”, at a well prepared patient and under major general anesthesia. In spite of that, difficult intubations can occur and rare severe accidents still occur.

Intubation trachéale with the urgencies and into pre hospital

The character of the urgency, the presence of traumatic lesions, the agitation of the patient, the repletion of the stomach, are as many factors complicating the gesture. The recourse to techniques preserving spontaneous ventilation as far as possible must be considered.

Into pre hospital, “lifting” positions made necessary by the circumstances (exiguous places, desincarceration) can complicate even more the problem.

Intubation in fast sequence

Gallery

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