Page 217 - Clinical Application of Mechanical Ventilation

Airway Management in Mechanical Ventilation 183

During Intubation

Trauma to the teeth and Trauma to the teeth and soft tissues can occur during intubation since ET intubation
soft tissues can occur during is often done in emergency situations. Difficult intubations compound the problem
intubation.
and lead to injuries when the patient has one or more of these conditions: obesity,
receding chin, overbite, rigid or short neck, or blood or vomitus in oropharynx.
Esophageal intubation is the most dangerous complication. It may occur when it is
Esophageal intubation is performed by an inexperienced practitioner or under awkward patient positions (e.g.,
commonly done by inexperi-
enced practitioners. patient lies on the floor). Esophageal intubation frequently leads to vomiting and aspira-
tion, thus making subsequent intubation attempts more difficult or nearly impossible.
Prolonged or repeated intubation attempts lead to hypoxia and, if uncorrected,
The ASA Task Force on the dangerous arrhythmias may occur. Excessive stimulation of the vagus nerve can
Management of the Difficult cause bradycardia. Arrhythmias induced by hypoxia and bradycardia caused by vagal
Airway recommends a limit of
three intubation attempts to stimulation may be reversed by removing the ET tube and oxygenating the patient
minimize patient injury. until a normal sinus rhythm returns. The ASA Task Force on the Management of
the Difficult Airway recommends a limit of three intubation attempts to minimize
patient injury (Mort, 2004).
vagus nerve: The pneumogastric
or tenth cranial nerve. Its superior
and recurrent laryngeal nerves and
their branches adjoin the upper While Intubated
end of trachea and are sensitive to
stimulation by the endotracheal
tube or suction catheter. Complications that occur while the patient is intubated vary greatly according to
the duration of ET tube placement and the airway management techniques. As a
general rule, the longer an ET tube is in place, the more likely that complications
will occur while the patient is intubated.
Failure to remove re- Since normal mucocillary functions of the mucosal membrane and the cough
tained secretions could lead to reflex are lost with an ET tube in place, retention of secretions must be removed
pneumonia and atelectasis.
promptly. If secretions are thick, irrigation with saline solution or acetylcysteine
‚
(Mucomyst) should be done before suctioning. Failure to remove retained secretions
may lead to pneumonia and atelectasis (Chang, 1995).
For an orally intubated Kinking of an ET tube may be corrected by repositioning the connection between
patient, the distance marking
on the ET tube (e.g., 22 cm) the ET tube and the circuit. Inadvertent extubation may be prevented by properly
is the distance from the distal
end of the ET tube to the sedating the patient or by using temporary restraints on the forearms.
patient’s lips or incisors. The position of the ET tube should be checked frequently by chest auscultation and
concurrently when a routine chest radiograph is done. Once the ET tube is properly
placed, the distance marking on the ET tube (centimeter mark) should be noted on
the ventilator flow sheet. This reference number provides a quick reference point but
should not be used as a substitute for routine assessment of the ET tube position.

Immediately after Extubation

Extubation of a semicon- Laryngospasm usually occurs as a result of extubation when the patient is semicon-
scious patient may stimulate scious. Extubation during this excitement stage tends to stimulate the vocal cords
the vocal cords and lead to
reflex spasm. and lead to reflex protective spasm. For this reason, extubation should be done when
the patient is either deeply anesthesized or, preferably, fully awake (Whitten, 1997).

Copyright 2013 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s).
Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.