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Tracheal Intubation //Tracheal Intubation http://www.expertconsultbook.com/expertconsult/b/book.do?m... Tracheal Intubation Technique As previously discussed, because of differences in anatomy, there are differences in techniques for intubating the trachea of infants and children compared with adults.[1–4,17–19,99,114,115] Because of the smaller dimensions of the pediatric airway there is increased risk of obstruction with trauma to the airway structures. A technique to be avoided is that in which the blade is advanced into the esophagus and then laryngeal visualization is achieved during withdrawal of the blade. This maneuver may result in laryngeal trauma when the tip of the blade scrapes the arytenoids and aryepiglottic folds. There are several approaches to exposing the glottis in infants with a Miller blade. One philosophy consists of advancing the laryngoscope blade under constant vision along the surface of the tongue, placing the tip of the blade directly in the vallecula and then using this location to pivot or rotate the blade to the right to sweep the tongue to the left and adequately lift the tongue to expose the glottic opening. This avoids trauma to the arytenoid cartilages. One can thus lift the base of the tongue, which in turn lifts the epiglottis, exposing the glottic opening. If this technique is unsuccessful, one may then directly lift the epiglottis with the tip of the blade (see Video Clip 12-1, Coming Soon). Another approach is to insert the Miller blade into the mouth at the right commissure over the lateral bicuspids/incisors (paraglossal approach). The blade is advanced down the right gutter of the mouth aiming the blade tip toward the midline while sweeping the tongue to the left. Once under the epiglottis, the epiglottis is lifted with the tip of the blade, thereby exposing the glottic aperture. By approaching the mouth over the bicuspids/incisors, dental damage is obviated. This is a particularly effective approach for the infant and child with a difficult airway. Whichever approach is used, care must be taken to avoid using the laryngoscope blade as a fulcrum through which pressure is applied to the teeth or alveolar ridge. If there is a substantive risk that pressure will be applied to the teeth, then a plastic tooth guard may be applied to cover the teeth at risk. Optimal positioning for laryngoscopy changes with age. The trachea of older children (6 years of age and older) and adults is most easily exposed when a folded blanket or pillow is placed beneath the occiput of the head (5–10 cm elevation), displacing the cervical spine anteriorly.[116] Extension of the head at the atlanto-occipital joint produces the classic “sniffing” position.[99,][117,][118] These movements align three axes: those of the mouth, oropharynx, and trachea. Once aligned, these three axes permit direct visualization of laryngeal structures. They also result in improved hypopharyngeal patency.[29,][31,][67,][75,][117,][118] Figure 12-14 demonstrates maneuvers for positioning the head during airway management. In infants and younger children, it is usually unnecessary to elevate the head because the occiput is large in proportion to the trunk, resulting in adequate anterior displacement of the cervical spine; head extension at the atlanto-occipital joint alone aligns the airway axes. When the occiput is displaced excessively, exposure of the glottis may actually be hindered. In neonates, it is helpful for an assistant to hold the shoulders flat on the operating room table with the head slightly extended. Some practitioners have adopted the practice of placing a rolled towel under the shoulders of neonates to facilitate tracheal intubation. This technique is a major disadvantage when the laryngoscopist stands but may be an advantage when he or she is seated, as otolaryngologists usually are. 1 of 9 29/08/10 12:19 PM //Tracheal Intubation http://www.expertconsultbook.com/expertconsult/b/book.do?m... Figure 12-14 Correct positioning for ventilation and tracheal intubation. With a patient flat on the bed or operating table (A), the oral (O), pharyngeal (P), and tracheal (T) axes pass through three divergent planes (B). A folded sheet or towel placed under the occiput of the head (C) aligns the pharyngeal (P) and tracheal (T) axes (D). Extension of the atlanto-occipital joint (E) results in alignment of the oral (O), pharyngeal (P), and tracheal (T) axes (F). The validity of the three-axis theory (alignment of the mouth, oropharynx, and trachea) to describe the optimal intubating position in adults has been challenged.[119–122] Some authors challenge the notion that elevating the occiput improves conditions for visualization of the laryngeal inlet based on evidence from both MRI and clinical investigation.[119,][121] No comparable studies have been performed in children. An investigation of 456 adults used as their own controls found that neck extension alone was adequate for visualization of the larynx in most adults. However, for obese patients or those with limited neck extension, an optimal intubating position was not determined.[119] Others have argued in favor of the superiority of the sniffing position but with varying support of the three-axis theory.[123–129] Even if the tracheas of only a few patients are intubated more easily when placed in the sniffing position compared with only head extension, the routine application of the sniffing position would appear to remain the best clinical practice. Laryngoscopy can be performed while the child is awake, anesthetized, and breathing spontaneously, or with a combination of anesthesia and neuromuscular blockade. Most tracheal intubations in children who are awake 2 of 9 29/08/10 12:19 PM //Tracheal Intubation http://www.expertconsultbook.com/expertconsult/b/book.do?m... are performed in neonates, an approach not usually feasible or humane in older awake and uncooperative children. Awake intubation in the neonate is generally well tolerated and, if performed smoothly, is not associated with significant hemodynamic changes.[130] However, data suggest that even preterm and full-term infants are better managed with sedation and paralysis so as to minimize adverse hemodynamic responses. [131–134] Selection of Laryngoscope Blade A straight blade is generally more suitable for use in infants and young children than a curved blade because it better elevates the base of the tongue to expose the glottic opening. Curved blades are satisfactory in older children. The blade size chosen depends on the age and body mass of the child and the preference of the anesthesiologist. Table 12-1 presents the ranges commonly used. Table 12-1 -- Laryngoscope Blades Used in Infants and Children Blade Size Age Miller Wis-Hipple Macintosh Preterm 0 - - Neonate 0 - - Neonate-2 years 1 - - 2-6 years − 1.5 1 or 2 6-10 years 2 − 2 Older than 10 years 2 or 3 − 3 Endotracheal Tubes Since 1967, all materials used in the manufacture of tracheal tubes have been subjected to rabbit muscle implantation testing in accordance with the standards promulgated by the Z79 committee. If the material caused an inflammatory response, it could not be used in the manufacture of tracheal tubes. This resulted in the elimination of organometallic constituents, such as those used in the manufacture of red rubber tracheal tubes. The selection of a proper size ETT depends on the individual child.[135] The only size requirement for a manufacturer is that they standardize the internal diameter (ID) of an ETT. The external diameter (OD) may vary, depending on the material from which the ETT is constructed and its manufacturer. This diversity in external diameter mandates the need to check for proper ETT size and leak around the tube. An appropriately sized uncuffed ETT may be approximated according to the patient's age and weight (Table 12-2).[136] ETTs of half ID size above and below the selected size should be available because of the variability of patient anatomy. The use of the diameter of the terminal phalanx of either the second or fifth digit is unreliable.[137] Children with Down syndrome will often require a smaller than anticipated ETT.[138] After intubation and stabilization of the child, if there is no air leak around the tube below 20 to 25 cm H2O (short-term intubation perhaps as high as 35 cm H2O) peak inflation pressure (PIP), the ETT should be changed to the next half size smaller. An air leak at this pressure is recommended because it is believed to approximate capillary pressure of the adult tracheal mucosa. If lateral wall pressure exceeds this amount, ischemic damage to the subglottic mucosa may occur.[139] Be aware, however, that if a child is intubated without the aid of muscle relaxants, laryngospasm around the ETT may prevent any gas leak and mimic a tight-fitting ETT.[140] When anesthesia has been deepened, an air leak could become evident. Changes in head position may also increase or decrease the leak.[140] These maneuvers are important for making the occasional diagnosis of unrecognized subglottic stenosis (see Fig. 36-3A). Table 12-2 -- Endotracheal Tubes Used in Infants and Children[*] Age Size (mm ID) 3 of 9 29/08/10 12:19 PM //Tracheal Intubation http://www.expertconsultbook.com/expertconsult/b/book.do?m... Age Size (mm ID) Preterm 1000 g 2.5 1000-2500 g 3.0 Neonate-6 months 3.0-3.5 6 months-1 year 3.5-4.0 1-2 years 4.0-5.0 Older than 2 years (age in years + 16)/4 ID, internal diameter. * Uncuffed; one half size smaller for cuffed ETT, see text. Traditional teaching has advocated the use of uncuffed ETTs for children
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