Читать книгу Ottawa Anesthesia Primer - Patrick Sullivan - Страница 98

Tim O’Connor MD and Ilia Charapov MD

 Learning Objectives

1 To review the subjective and objective criteria for tracheal intubation and extubation.

2 To review a goal-directed and patient-oriented approach to the pharmacology of medications used for tracheal intubation.

3 To acquire an appreciation of the specific considerations for tracheal intubation with an emphasis on: the patient’s presenting medical condition, the identification, anticipation, and management of a difficult airway, and the rational use of various airway devices in specific patient scenarios.

4 To review complications of tracheal intubation and positive pressure ventilation.

 Key Points

1 Identifying the goals and conflicts for intubation provides the framework to develop a patient-specific goal-oriented plan for tracheal intubation.

2 When tracheal intubation fails, bag-mask ventilation or placement of a laryngeal mask airway device (LMAD) may be used as a rescue plan. All efforts should focus on ensuring adequate oxygenation.

3 “Awake” fiberoptic bronchoscopy (FOB) remains the gold standard for elective intubation in patients with a difficult airway.

4 A wide array of new airway devices provides clinicians with many equally valid ways to manage a difficult airway apart from FOB.

5 Insertion of an extraglottic airway, such as a laryngeal mask airway device (e.g., LMA™) may be life saving in the “cannot intubate, cannot ventilate” scenario.

6 There are two immediate clinical tools to confirm tracheal intubation: end-tidal carbon dioxide (ETCO2) measurement and visualization of the endotracheal tube (ETT) passing through the glottis.

7 Clinical experience is correlated directly with successful intubation at first attempt. Enlist expert assistance for anticipated difficult intubations.

8 Always have a backup airway plan.

Background:

Chapter 6 presented an overview of the technical skills required to perform tracheal intubation in adults. This chapter uses clinical cases to illustrate the decision process used to:

 Assess a patient’s need for tracheal intubation

 Identify pharmacologic goals for intubation Choose an appropriate intubation technique

 Develop a plan to manage an identified difficult airway

 Anticipate and manage problems related to positive pressure ventilation.