Tracheal intubation is generally considered the most definitive means of airway control. The decision to tracheally intubate must consider the patient's physiologic status, anticipated patient care needs, operator experience, and features related to preparation for the procedure. This chapter discusses the indications for tracheal intubation in greater detail as well as the preparation for intubation and the key steps and modifications of the actual procedure.
GENERAL PREPARATION
Preparation is the key to successful airway management. Two general areas of preparation should be addressed before undertaking the first attempt at definitive airway management in a clinical setting. The first is mental and physical preparedness. The second is the assembly of essential intubation equipment.
Mental and physical preparation comes from reading about the procedures, discussing the principles and details with instructors, practicing the techniques on intubation mannequins or in the animal laboratory, and finally performing the technique under supervision in a controlled clinical setting. Studies addressing various approaches to tracheal intubation are generally performed under optimal conditions (i.e., with equipment available and appropriate preparatory training). Also, often hidden within the study findings are individual learning curves. Therefore, it is overly optimistic to expect to match the success reported in the literature when first attempting a new intubation technique. However, the goal of preparation is to be as high on the learning curve as possible prior to the first clinical application of a new intubation technique. Further, continued rehearsal and application of the techniques that have been learned are important for skill maintenance.
Each approach to tracheal intubation has a preferred training format. Orotracheal intubation, for example, may be simulated with a mannequin, whereas retrograde intubation is best learned using an animal or cadaver model. Orotracheal intubation is likely to be successful on the first attempt, whereas considerable practice is required for facile use of the scope for fiberoptic intubation. In preparation for managing critical airway problems, maximal hands-on training is desirable.
The second general area of preparation is material preparedness (i.e., the immediate availability of all essential equipment required to optimally perform the airway maneuvers that are within the capabilities of the care provider). This may be accomplished by the wall-mounting of essential resuscitation equipment. [1] Alternatively, dedicated adult and pediatric airway carts may be used for placement of the equipment in an open, organized, and labeled manner that can be regularly checked. [2] The worst moment to realize that a vital piece of equipment is missing is when a patient's life depends on it. The importance of this concept cannot be overstated. Technical expertise cannot substitute for the lack of essential equipment.
In airway management, failure has ominous consequences. Mental, physical, and material preparation maximizes the chances of success.
AIRWAY ANATOMY
Requisite for a discussion of procedures in airway management is a common understanding of airway anatomy and its terminology . The following terms are used frequently :
Arytenoid cartilages
the paired cartilages forming the posterior aspect of the laryngeal inlet nasal cavity, from the external nares to the choana.
Nasopharynx
from the end of the nasal cavity (choana) to the level of the soft palate.
Oropharynx
soft palate to the upper border of the epiglottis.
Hypopharynx (laryngopharynx)
epiglottis to the lower border of the cricoid cartilage.
Vallecula
the space at the base of the tongue formed posteriorly by the epiglottis and anteriorly by the anterior pharyngeal wall.
Laryngeal inlet
the opening to the larynx bounded anterosuperiorly by the epiglottis, laterally by the aryepiglottic folds, and posteriorly by the arytenoid cartilages.
Piriform fossae (recesses)
the pockets on both sides of the laryngeal inlet separated from the larynx by the aryepiglottic folds.
Corniculate cartilage
the posteromedial portion of the arytenoid cartilage.
Cuneiform cartilage
the anterolateral prominence of the arytenoid cartilage.
Glottis
the vocal apparatus, including the true and false cords and the glottic opening.
Glottic opening (rima glottidis)
the opening into the trachea as seen from above through the vocal cords.
GENERAL PREPARATION
Preparation is the key to successful airway management. Two general areas of preparation should be addressed before undertaking the first attempt at definitive airway management in a clinical setting. The first is mental and physical preparedness. The second is the assembly of essential intubation equipment.
Mental and physical preparation comes from reading about the procedures, discussing the principles and details with instructors, practicing the techniques on intubation mannequins or in the animal laboratory, and finally performing the technique under supervision in a controlled clinical setting. Studies addressing various approaches to tracheal intubation are generally performed under optimal conditions (i.e., with equipment available and appropriate preparatory training). Also, often hidden within the study findings are individual learning curves. Therefore, it is overly optimistic to expect to match the success reported in the literature when first attempting a new intubation technique. However, the goal of preparation is to be as high on the learning curve as possible prior to the first clinical application of a new intubation technique. Further, continued rehearsal and application of the techniques that have been learned are important for skill maintenance.
Each approach to tracheal intubation has a preferred training format. Orotracheal intubation, for example, may be simulated with a mannequin, whereas retrograde intubation is best learned using an animal or cadaver model. Orotracheal intubation is likely to be successful on the first attempt, whereas considerable practice is required for facile use of the scope for fiberoptic intubation. In preparation for managing critical airway problems, maximal hands-on training is desirable.
The second general area of preparation is material preparedness (i.e., the immediate availability of all essential equipment required to optimally perform the airway maneuvers that are within the capabilities of the care provider). This may be accomplished by the wall-mounting of essential resuscitation equipment. [1] Alternatively, dedicated adult and pediatric airway carts may be used for placement of the equipment in an open, organized, and labeled manner that can be regularly checked. [2] The worst moment to realize that a vital piece of equipment is missing is when a patient's life depends on it. The importance of this concept cannot be overstated. Technical expertise cannot substitute for the lack of essential equipment.
In airway management, failure has ominous consequences. Mental, physical, and material preparation maximizes the chances of success.
AIRWAY ANATOMY
Requisite for a discussion of procedures in airway management is a common understanding of airway anatomy and its terminology . The following terms are used frequently :
Arytenoid cartilages
the paired cartilages forming the posterior aspect of the laryngeal inlet nasal cavity, from the external nares to the choana.
Nasopharynx
from the end of the nasal cavity (choana) to the level of the soft palate.
Oropharynx
soft palate to the upper border of the epiglottis.
Hypopharynx (laryngopharynx)
epiglottis to the lower border of the cricoid cartilage.
Vallecula
the space at the base of the tongue formed posteriorly by the epiglottis and anteriorly by the anterior pharyngeal wall.
Laryngeal inlet
the opening to the larynx bounded anterosuperiorly by the epiglottis, laterally by the aryepiglottic folds, and posteriorly by the arytenoid cartilages.
Piriform fossae (recesses)
the pockets on both sides of the laryngeal inlet separated from the larynx by the aryepiglottic folds.
Corniculate cartilage
the posteromedial portion of the arytenoid cartilage.
Cuneiform cartilage
the anterolateral prominence of the arytenoid cartilage.
Glottis
the vocal apparatus, including the true and false cords and the glottic opening.
Glottic opening (rima glottidis)
the opening into the trachea as seen from above through the vocal cords.
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