Page 202 - Clinical Application of Mechanical Ventilation

168 Chapter 6

oxygen desaturation ( SpO ), deteriorating vital signs, cyanosis, stomach disten-
2
➞
tion, and aspiration.
Esophageal intubation In almost all instances, esophageal intubation can be avoided by confirming that
can be avoided by inserting
the ET tube through the vocal the ET tube passes through the vocal cords under direct vision. If the vocal cords
cords under direct vision. are invisible or cannot be positively identified, the ET tube must not be inserted.
Another experienced physician or practitioner should attempt to reintubate. Valu-
able time must not be wasted when a difficult intubation is encountered.

Esophageal detection device. The esophageal detection device (EDD) is a simple tool
(e.g., esophageal syringe or bulb) to detect esophageal intubation in an emergency
setting (Kasper & Deem, 1998). This device (e.g., bulb) provides a negative-pres-
sure test using a compressible and self-inflating bulb with two openings. The upper
end contains a one-way valve to allow air to escape from the bulb. The lower end
has an adaptor that connects to the endotracheal tube. After intubation, the bulb is
attached to the endotracheal tube and then compressed. With tracheal placement,
the bulb draws air from the trachea and should reinflate to its original shape within
10 sec. With esophageal placement, the bulb receives little or no air from the con-
stricted esophagus and it remains deflated (Wilkins et al., 2003). A false negative
may occur if the tube is in the esophagus and the stomach is full of air. The EDD
test results must match the patient’s clinical signs following an intubation attempt.

RAPID SEQUENCE INTUBATION

Rapid sequence intubation (RSI) describes an urgent need to gain control of a pa-
rapid sequence intubation
(RSI): Intubation with an endo- tient’s airway. It has been done safely and successfully in both adult and pediatric pa-
tracheal tube under controlled tients (Davis et al., 2002; Dufour et al., 1995; Sagarin et al., 2002). RSI is done using
settings.
an endotracheal tube under controlled settings to optimize the intubation conditions,
to protect the airway against aspiration, and to facilitate ventilation and oxygenation.

Indications and Contraindications

Indications for rapid sequence intubation include airway obstruction, severe brain
injury, severe hypoxemia, abnormal respiratory frequency, and hemodynamic insta-
bility (Table 6-7).
RSI should not be performed if a patient is able to sustain adequate ventilation
and oxygenation while breathing spontaneously. It should not be attempted if the
provider is unfamiliar with the proper procedure, intubation supplies, and drugs
used in RSI. Following unsuccessful RSI attempts, surgical approach should be
considered in special circumstances such as airway trauma or difficult anatomy.

Practice Guidelines

The procedure for RSI varies among different protocols. However, each protocol
typically consists of the following elements: preparation, pre-RSI medications,

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