INTUBATION (Latin in in, inside + tuba a pipe) — introduction of special tubes to a gleam of a throat, tracheas and bronchial tubes for the purpose of recovery and improvement of passability of respiratory tracts or carrying out an inhalation anesthesia.
For the first time in 1858 with the idea of an intubation. J. A. E. Bouchut made a speech at a meeting of the Parisian academy. The essence of the method offered them consisted in introduction to a throat by means of a guttural curved catheter of a hollow silver cylindrical tube. However this idea did not get approval. 0'dvayer (J. The ruble of O'Dwyer) in 1885 published original work about And., having offered for this purpose a rubber tube then And. was widely adopted at first in America, and then in Europe. In Russia the first And. K. A. Raukhfus in 1890 carried out. In Moscow And. it was entered by A. A. Poliyevktov (1899) in N. F. Filatov's clinic. The INTUBATION under control of sight was offered A. F. Pushkin; further it was applied A. I. Kolomiychenko, by B. And. Ratner, and it was implemented in wide a wedge, practice. And. bronchial tubes apply at the one-pulmonary anesthesia for the first time developed and implemented in practice by Goll and Waters (I. Gall, R. Waters, 1932). Separate And. primary bronchi it was applied to a research of function of lungs by Yakobeus, Frenkner and Björkman (H. Yacobaeus, R. Frenckner, S. Biorkman, 1932). Depending on a way of introduction of an endotracheal tube distinguish And.: orotracheal, nazotrakhealny, And. through a tracheostoma; depending on time — single, prolonged (i.e. within several days); depending on the purposes — endobronchial, one-pulmonary, separate And. primary bronchi.
Carefully executed and correctly carried out INTUBATION, allows to provide adequate external respiration and to avoid tracheostomies (see). And. has certain advantages before a tracheostomy — lack of the complications inherent in the last (aspiration pneumonia, bleeding, emphysema).
the Applied O'Dvayer, Sevestr, Baye's earlier firm tubes, etc., and also special sets (e.g., Colin, Fruen, etc.), introduktor, extubators practically lost the value and are not made by the medical industry. Modern intubation tools include endotracheal tubes, conductors, mandrins for them, intubation nippers for introduction and removal of tubes, connectors for connection of tubes with the narcotic or respiratory device, laryngoscopes with the direct and bent blades, teeth spreaders for prevention of a prelum of a gleam of tubes.
As intubation nippers it is possible to use Gartmann's nippers or nippers from trakheobronkhoskopichesky set of Friedel (see. Bronkhoezofagoskop ). The endotracheal tubes made of dense rubber or plastic are most widespread, endotracheal tubes from metal or the rubberized silk fabric are less often applied. For various ways I. apply tubes of various designs (fig. 1). During the carrying out a one-pulmonary anesthesia use special endotracheal tubes (fig. 2) allowing to switch off one lung from the act of external respiration, and for separate And. bronchial tubes — dvukhprosvetny tubes (fig. 3) which give the chance periodically to block the right or left primary bronchus. (At resuscitation) apply plastic or rubber endotracheal tubes to an endotracheal anesthesia and artificial ventilation of the lungs. The last are to inflatable cuffs and without them; children's tubes are issued without inflatable cuff. During the inflating of a cuff the Hermeticism between respiratory tracts and a wall of a tube is created. In the absence of a cuff the Hermeticism is created by means of a tamponade of a throat and an oral cavity gauze tampons. The form, length and diameter of endotracheal tubes are defined by an estimated technique And. and specific topografoanatomichesky features of a structure of respiratory tracts of the patient. At endotracheal And. the end of an endotracheal tube shall be located about 2 cm above bifurcation of a trachea. Length of an endotracheal tube for adults fluctuates from 19 to 26 cm - for children — from 10 to 21 cm, outer diameter for adults — from 8,0 to 12,3 mm, for children — from 3,6 to 12,3 mm. In the USSR the following numbers endotracheal tubes are issued: 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 an endotracheal tube from a trachea it is carefully washed out in running warm water with soap. The gleam of a tube is processed a gauze tampon (it is impossible to use a cotton plug or «hedgehog» since threads of cotton wool or a bristle can be a source of an infection at hit in respiratory tracts of the patient). After rinsing in warm water remove the remains of fatty lubricant (Unguentum Glycerini) ether. Sterilization of a tube about is exhausted autoclaving or boiling within 3 min. For strength retention and elasticity of thermoplastic tubes they are kept in antiseptic solutions (levomycetinum 1:1000, etc.) - Often apply tubes of one-time use.
Indications and contraindications
the most widespread indication Existing earlier for so-called classical And. — a diphtheritic croup — in modern a wedge, became practice a rarity. Most widely apply And. a trachea and bronchial tubes for carrying out an anesthesia and at resuscitation.
And. tracheas it is shown at the large operative measures demanding regulation of the vital functions of an organism at the operations and manipulations which are followed by disturbance of functions of external respiration during the rendering reanimatol. help. Absolute contraindications to And. at an anesthesia and resuscitation is not present, diseases of a throat, a throat are relative (acute inflammatory processes, tuberculosis, cancer, etc.).
In otorhinolaryngological practice And. it is shown at stenoses of a throat, trachea and bronchial tubes, acute laryngotracheitis of a virus etiology, p an initial stage of a diplegia of nizhnegortanny nerves when still there are no inflammatory changes of a mucous membrane of a throat. And. it is shown also at an edematous and infiltrative form of acute laryngotracheitis. According to I. B. Soldatov, etc., prolonged And. is necessary during transition of a stage of incomplete compensation of a stenosis of a throat to a stage of a decompensation. Carrying out And. in an end-stage of a stenosis of a throat is inefficient since by this time in an organism of the patient irreversible changes develop. And. it is contraindicated at decubituses, ulcers, specific granulomas, injuries and new growths of a throat. From repeated And. it is necessary to refuse at a numerous vykashlivaniye of an endotracheal tube or at its bystry obstruction by films, crusts or a dense phlegm. At long finding of an endotracheal tube in a trachea (from 4 to 6 days) in some cases the Tracheostomy is shown.
The equipment of an intubation
Each doctor starting to And., shall own intubation tools and study anatomic features of upper respiratory tracts of this patient. It matters both for selection, and for introduction of an endotracheal tube. For 1 — 2 hour
prepost premedication (enter subcutaneously 1 ml of Promedolum and atropine, to children according to age in the reduced dose). At And. in otorhinolaryngology most often carry out an anesthesia (mask or intravenous), more rare, hl. obr. at adults — local anesthesia.
For performance And. for the purpose of carrying out the general endotracheal anesthesia it is necessary: a) suppression of protective gag and guttural reflexes; b) relaxation of chewing and cervical muscles; c) the correct position of the head and neck at the moment And. At the same time against the background of preliminary premedication optimal conditions for most And. the general intravenous anesthesia (drugs of short and ultrashort action) or a mask inhalation anesthesia (nitrous oxide, Ftorotanum, etc.) in combination with muscular relaxants creates. At the patients who are in a terminal state (at resuscitation), And. carry out without premedication under control of a direct laringoskopiya. If necessary carry out an aspiration toilet of a stomatopharynx.
An intubation through a mouth (orotracheal)
It is applied most often. In advance picked up tube is entered, as a rule, by means of the laryngoscope though there are also other ways — blindly or to the touch that well only to the specialist. Position of the patient — usually lying on spin, the head is thrown most back back, the chin is raised up, the mandible is pushed forward — classical situation according to Jackson (fig. 4, 1). The line drawn from upper cutters to a trachea becomes straight, but the distance from cutters increases to a glottis. This defect is eliminated at the «improved» Jackson's (fig. 4, 2) position, at Krom the head of the patient is raised over the level of a table on 8 — 10 cm of Laringoskopiya and And. are carried out at the time of full relaxation of muscles and an apnoea against the background of preliminary insufflation of oxygen. At use of the direct laryngoscope it will be out so that the end of a blade it was possible to raise an epiglottis up. After that, having convinced that the glottis is visible, carefully, after additional local anesthesia by greasing or spraying of anesthetics enter an endotracheal tube on a gleam of the laryngoscope by means of nippers or without them (fig. 5). In the conditions of local anesthesia at the kept spontaneous breath the endotracheal tube is entered into a trachea at the time of a breath.
During the use of the curve laryngoscope the end of a blade is brought to a root of language and lift it up, behind it the epiglottis rises; at the same time the good review of a glottis allowing to enter an endotracheal tube into a trachea opens.
At tactile And. by means of II and III fingers of the left hand take away an epiglottis of a kpereda and under control of a finger carry out a tube to a glottis.
At an intubation through a mouth blindly the head of the patient is as much as possible thrown back back, language is fixed in the extended situation, the tube is entered into a glottis strictly on the centerline.
An intubation through a nose (nazotrakhealny)
This way I. carry usually out at a local anesthesia, and enter a tube under control of the laryngoscope or blindly. Position of the patient — sitting or lying, the head is thrown back kzad, the neck is extended. The mucous membrane of upper respiratory tracts is irrigated or greased with solution of novocaine, Dicainum, Pyromecainum. The laryngoscope is entered into an oral cavity and, having seen a glottis, by means of intubation nippers enter a tube through the closing nasal stroke into a trachea (fig. 6) at the time of a breath of the patient.
The Nazotrakhealny intubation is applied by hl. obr. at maxillofacial operations, at anomalies, the deformations of the person and neck complicating introduction of a tube through a mouth and at throat operations.
An intubation through a tracheostoma
At throat and throat operations quite often make endotracheal And. through previously created tracheostoma. At the same time use a tube for a trachea with an inflatable cuff obturator for creation of tightness of a trachea.
The one-pulmonary intubation and separate intubation of primary bronchi are applied to protection of a healthy lung against infection and prevention of implantation metastasises, to creation of Hermeticism of respiratory tracts at bronchial fistulas, at reconstructive trachea and bronchial tubes operations, at operations at height of pulmonary bleeding, to simplification of technical performance of operation.
Endobronchial And. usually carry out under control of a direct laringoskopiya in the conditions of the general anesthesia and an apnoea. It has specific features depending on localization of defeat, character and problems of surgical intervention, a design of endobronchial tubes.
At one pulmonary anesthesia the tube is entered into a throat, a trachea and under control of sight carried out to the corresponding bronchial tube. And. the left bronchial tube is more difficult since it departs from a trachea under more acute angle (40 — 45 °). At And. the right bronchial tube overlapping of the mouth of the right superlobar bronchial tube and disturbance of ventilation of an upper share is possible.
Separate And. primary bronchi carry out dvukhprosvetny tubes (fig. 3). Gained the greatest distribution And. the tubes like Karlens which are reliably fixed on Kiel tracheas by means of a spur. For simplification of advance of dvukhprosvetny tubes through a glottis use special conductors, tie a spur silk thread to a tube, and sometimes resort to turn of a tube. After introduction to a glottis the tube is turned on 180 ° counterclockwise (a spur up), at further advance turned on 90 ° clockwise before fixing on Kiel.
For prevention of complications it is important to establish and fix endotracheal and endobronchial tubes in the correct situation, controlling visually (on excursions of a thorax), auskultativno or radiological. During an anesthesia it is necessary to watch passability of tubes, warning the shift, excesses, a prelum, obstruction.
Complications at an intubation
Complications during operation at And. arise at non-compliance with necessary conditions: insufficient oppression of reflex irritability of a throat and relaxation of muscles, the wrong position of the patient, anomalies of upper respiratory tracts, restriction of mobility of maxillary joints, lack of practical skill at the anesthesiologist. In time And. injuries of teeth, a mandible, a mucous membrane of a throat and a throat can be observed. At And. in Nov injury of a mucous membrane of the nasal courses is followed by bleeding. And. against the background of an apnoea St. 30 — 40 sec. can lead to a heavy hypoxia. The reirritation of branches of a vagus nerve at insufficient oppression of reflex irritability of a throat can bring to to a laryngospasm (see), to disturbance of cordial activity. After traumatic And., during the use of tubes of a large diameter, at excessive inflating of a cuff obturator, long stay of a tube in a trachea in the early postoperative period edematization is possible throats (see), laryngostenosis (see) up to asphyxia; within several days the ambassador I. the phenomena of an acute faringolaringotrakheit can be observed. In some cases And. it is feasible only at a fibrobronkhoskopiya in the conditions of local anesthesia.
A frequent mistake — introduction of a tube to a gullet. The excessive zaprokidyvaniye of the head back, especially at the child, considerably complicates carrying out And., as at the same time the entrance to a throat deviates kzad and becomes almost unavailable to introduction to it of an endotracheal tube.
In otorhinolaryngological practice during the carrying out And. in the conditions of local anesthesia there can be a spastic closing of a glottis; in such cases it is necessary to wait several seconds and during a breath of the patient to enter a tube into a trachea. In certain cases in view of anatomic conditions (a short neck at the corpulent patient, a narrow glottis, long upper cutters, a short mandible, large fleshy language, limited mobility of a mandible and cervical department of a backbone) And. it is extremely difficult or almost impossible. In these conditions it is necessary to try to throw back as much as possible the head, to enclose the roller under shoulders or to use the laryngoscope of other form and the sizes (instead of direct — a curve). The most serious complication And. the injury of a throat with formation of the false course is. It results from violent disturbance of an integrity of a mucous membrane and penetration of a tube through a guttural ventricle or a pear-shaped sine in glubzhelezhashchy fabrics. Penetration of an infection through the formed false course can lead to phlegmon of a throat, to a mediastinitis (see). Therefore at formation of the false course further attempts And. shall be stopped, and to the patient the Tracheostomy is made. Owing to the long pressure of a tube upon a mucous membrane of a throat and its injury development of decubituses is possible. Emergence of an intubation granuloma and cicatricial membrane, representing manifestation of a productive inflammation on site of disturbance of an integrity of an epithelium of a mucous membrane of a throat belongs to late complications. The granuloma appears usually in 3 — 5 weeks the ambassador I., is more often in the field of a voice shoot of an arytenoid cartilage in the form of the tumor of bright pink color sitting on the wide basis. Further the granuloma is condensed, her leg becomes thinner, it becomes covered by an epithelium and becomes similar to a polyp. The intubation granuloma leads to disturbance of a voice, and sometimes and to difficulty of breath.
Care of the intubated patient
the Intubated patient shall be under constant observation of medical staff. It is necessary because rather narrow gleam of an endotracheal tube can be corked patol, a secret of respiratory tracts at any time. In such cases make suction of a secret the catheter entered into a tube; at inefficiency — carry out repeated And. For prevention of extraction by the patient of an endotracheal tube (spontaneous extubation) it is necessary to fix elbow joints a splint, and a tube an adhesive plaster to a cheek.
Food and drink of the patient is carried out through a mouth, at impossibility of usual food apply probe.
Bibliography S. D. Intubation's noses in therapy of patients with a diphtheritic croup, M., 1958, bibliogr.; Ostrovsky G. G., Chagall E. L. and Shul-m and V. Shch. Trakheostomiya's N and the prolonged nazotrakhealny intubation at treatment of severe forms of the acute stenosing laryngotracheobronchites, Zhurn. ushn., Nov. and throats, Bol., No. 6, page 48, 1975, bibliogr.; V. M falcons. Modification of a method of an intubation of newborns, Akush, and ginek., No. 10, page 77, 1967; And 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.
And. a trachea and bronchial tubes at an anesthesia and resuscitation — Bunyatyan A. A., Ryabov G. A. and Manevich A. 3. Anesthesiology and resuscitation, M., 1977; About r about in I. S. General anesthesia, M., 1964; Kassil V. L. and Ryabova H. M. Artificial ventilation of the lungs in resuscitation, M., 1977, bibliogr.; Cars At. Anesthesia at intrathoracic operations, the lane with English, M., 1967; Resustsitation, the theory and practice of revival, under the editorship of M. Sykh, the lane with polsk., Warsaw, 1976; The Guide to anesthesiology, under the editorship of T. M. Darbi-nyan, M., 1973.
O. A. Dolina (anest.), D. I. Tarasov (ENT specialist.).