Cirugía en la clínica de pequeños animales Cirugía sin sangrado parte 02

 

Cirugía en la clínica de pequeños animales Cirugía sin sangrado parte 01

 

 

a. Increased secretions

(1) Necessitating more frequent suctioning

(2) Loosening of tape

b. Infant activity

c. Procedures requiring repositioning infant

d. Tube slippage

E. Technique (See also Endotracheal

Intubation on the Procedures

Website, and Appendix D for

Techniques of Intubation Specific to

Unique Patient Needs) Orotracheal

Intubation (Table 36.2)

1. Position infant with the head in midline and the neck

slightly extended, pulling chin into a “sniff” position

(Fig. 36.4). The head of the infant should be at operator’s eye level.

It may be helpful to place a roll under the baby’s

shoulders to maintain slight extension of the neck.

2. Put on gloves.

3. Clear oropharynx with gentle suctioning.

4. Empty stomach.

5. Bag-and-mask ventilate and preoxygenate infant as indicated by clinical condition. Follow heart rate and oxygenation.

6. Turn on the laryngoscope light, and hold the laryngoscope in left hand with thumb and first three fingers,

with the blade directed toward patient.

a. Put thumb over flat end of laryngoscope handle.

b. Stabilize the infant’s head with right hand.

The laryngoscope is designed to be held in the

left hand, by both right- and left-handed individuals. If held in the right hand, the closed, curved part

of the blade may block the view of the glottis, as

well as make insertion of the endotracheal tube

impossible.

7. Open infant’s mouth and depress tongue toward the left

with the back of right forefinger (Fig. 36.5).

a. Continue to steady head with third fourth and fifth

fingers of right hand.

b. Do not use the laryngoscope blade to open mouth.

8. Under direct visualization, insert the laryngoscope

blade, sliding over the tongue until the tip of the blade

A B

Fig. 36.3. A: Normal epiglottis obscuring glottis. This amount of clear secretions does not require suctioning for visualization. B: Same airway as in Figure 36.1 after surgical removal of cyst. Glottic opening is

visible just beneath epiglottis. Gentle tracheal, pressure, or decreasing neck extension while lifting tip of

laryngoscope blade, will improve visibility.

Fig. 36.4. Appropriate sniff position for intubation. Note that

the neck is not hyperextended; the roll provides stabilizing

support.

 

A B

Fig. 36.1. A: Vallecula cyst, causing stridor and proximal airway

obstruction. B: Endotracheal tube passes beneath cyst. C: Same

patient after laser surgical treatment.

Table 36.1

Endotracheal Tube Diameter

for Patient Weight and

Gestational Age

Tube Size (ID mm) Weight (g) Gestational Age (wk)

2.5 <1,000 <28

3.0 1,000–2,000 28–34

3.5 2,000–3,000 34–38

4.0 >3,000 >38

238 Section VI ■ Respiratory Care

b. Secure tube carefully in position to avoid dislodgement, kinking, or movement.

(1) Vary contact point from side to side to prevent

damage to developing palate and palatal ridges

(7,8).

(2) Note relationship of head position to intratracheal depth of tube on radiograph (9).

9. Do not leave endotracheal tube unattached from continuous positive airway pressure; the natural expiratory

resistance is lost by bypassing the upper airway.

10. Recognize that in neonates, endotracheal tubes are

often pushed in too far because of the short distance

from the glottis to the carina. Use a standardized graph

or location device (2,5).

11. Recognize the association of a short trachea (fewer than

15 tracheal cartilage rings) with certain syndromes:

DiGeorge syndrome, skeletal dysplasias, brevicollis,

congenital rubella syndrome, interrupted aortic arch,

and other congenital syndromes involving the tracheal

area (10).

Fig. 36.2. Anatomic view of neonatal upper airway. The glottis

sits very close to the base of the tongue, so visualization is easiest

without hyperextending the neck.

Table 36.2 Trouble-Shooting Problems with Endotracheal Intubation

Problem Suggested Approach for Solution

Infant’s tongue gets in way. Push tongue aside with finger before inserting blade.

Secretions prevent visualization. Suction prior to intubation attempt.

Tube seems too big to fit through vocal cords. Verify correct tube size for patient weight and gestational

age.

Vocal cords are closed. Decrease angle of neck extension.

Apply traction to blade.

Apply a short puff of air through the tube onto the vocal

cords.

Select smaller tube size.

Evaluate for airway stenosis.

Unsure of appropriate tube length. Await spontaneous breath.

Apply gentle suprasternal pressure.

Difficult to ventilate after intubation. Insert tube just past vocal cord.

Predetermine tube length.

Obtain chest radiograph with head in neutral position to

confirm tube position relative to carina.

Swelling of neck and anterior chest. Verify that tube is in trachea.

Verify that tube is not in bronchus.

Consider tube and/or airway obstruction.

Consider pulmonary air leak into mediastinum/pericardium (Fig. 38.8A, B)

Blood return from endotracheal tube. Evaluate for tracheal perforation.

Tube slips into main bronchus. Avoid neck hyperextension.

Secure tape fixation.

Maintain correct lip-to-tip distance.

Unplanned extubation. Regularly verify correct tube distance.

Secure tape and replace as necessary.

Support neck when moving infant.

Avoid neck hyperextension or traction on tube.

Secure infant’s hands.

Chapter 36 ■ Endotracheal Intubation 239

12. Identify and prevent the factors that are most likely to

contribute to spontaneous extubation (11).