iot dificilstudenti08.ppt

8/19/2019 IOT DIFICILSTUDENTI08.ppt

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Libertatea cailor aeriene

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Protezarea cailor respiratorii

• Intubatia orotraheala/ nazotraheala (IOT/INT)

• Intubatia dificila

• Abordul chirurgical al caii aeriene

– Cricotiroidotomia – Traheostomia



VENTILATIA

Obiectivul final este sa pompam aer

in plamani.



Istoric• 1543 VESALIUS• !De Humani Corporis Fabrica"#$• pag 658

Cea mai timpurie raportare a intubatiei traheale

printr%un ori&iciu la ni'elul traheei pentru resuscitare $se poate spune ca viata poate fi readusa…o

deschizatura trebuie facuta in trunchiul traheei incare se introduce un tub vei sufla in acesta si

pla!anul se va ridica din nou"

1543

http://vesalius.northwestern.edu/













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CR

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Libertatea cailor aeriene

• CP

• P*+PITA,

• AN*+T*-I*



Intubatia Tra!eostomia

NormalaDificila

"r#enta

• $unctia intercricotiroi%iana &HF'V

• (initra!eostomia

• Tra!eostomia c!irur#icala

• Tra!eostomia percutana

Colaborare ATI ) ORL



Intubatia orotraheala (IOT)

• *'aluarea pacientului

• Pozitionarea pacientului

• .ateriale necesare• +ec'enta mane'relor

• Complicatii



*'aluarea pacientului



Formula a Dr. *innions+ un

mo% simplu %e a retine mai multe teste,

L oo e0ternall1#

E 'aluate the 2%2%3 rule#

( allampati#

O bstruction4

N ec mobilit1#

http://images.google.ro/imgres?imgurl=http://idata.over-blog.com/0/09/03/31/images/john-lemon.jpg&imgrefurl=http://antigone.over-blog.net/photo-285715-john-lemon_jpg.html&h=489&w=352&sz=16&hl=ro&start=129&tbnid=f5jnKzkJ4g9AtM:&tbnh=130&tbnw=94&prev=/images%3Fq%3Dlemon%26start%3D120%26gbv%3D2%26ndsp%3D20%26svnum%3D10%26hl%3Dro%26sa%3DN



L+ Loo- Eternall/

• Arsuri

• Trauma

&aciala

• Antec

ana&ila0ie

• +tridor

• Corp strain

• Obez / pitic

• 5at scurt muscular

• Piept mare/ lat

• etrognatie (6entures)

• 6inti de cal % incisi'iii (7uc Teeth)

http://images.google.com/imgres?imgurl=http://www.cpr.org.tw/heart/image/baby_FBAO08.jpg&imgrefurl=http://www.cpr.org.tw/heart/heart_3.htm&h=640&w=480&sz=45&hl=ro&start=1&sig2=skZ8-goK-Ae2ljbZbAeU_A&um=1&tbnid=XSDjFQBlNhiLSM:&tbnh=137&tbnw=103&ei=6qpQRvqEPJeK-gKXjc2MDQ&prev=/images%3Fq%3DFBAO%26svnum%3D10%26um%3D1%26hl%3Dro%26sa%3DN

http://images.google.ro/imgres?imgurl=http://www.fugly.com/media/IMAGES/Babes/ridiculously_large_breasts.jpg&imgrefurl=http://www.fugly.com/images/11917/ridiculously_large_breasts.html&h=604&w=450&sz=42&hl=ro&start=2&tbnid=-TGrM68a5eYb_M:&tbnh=135&tbnw=101&prev=/images%3Fq%3Dlarge%2Bbreasts%26gbv%3D2%26svnum%3D10%26hl%3Dro

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http://www.iacuc.arizona.edu/training/cats/medicating.html

http://www.iacuc.arizona.edu/training/cats/medicating.html



E+ Evaluarea re#ulii 0)0)1

• 6eschide gura 8 2 degete

• 9alca mai lata de 2 degete

• 8 3 degete de la &alca la gat

http://images.google.ro/imgres?imgurl=http://www1.istockphoto.com/file_thumbview_approve/405188/2/istockphoto_405188_peace_sign_two_fingers_isolated.jpg&imgrefurl=http://www.istockphoto.com/imageindex/405/1/405188/Peace_sign_two_fingers_isolated.html&h=380&w=253&sz=22&hl=ro&start=42&um=1&tbnid=Jefb8xaiUgu5vM:&tbnh=123&tbnw=82&prev=/images%3Fq%3Dtwo%2Bfingers%26start%3D40%26ndsp%3D20%26svnum%3D10%26um%3D1%26hl%3Dro%26sa%3DN

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(+ (allampati

• Clasa I : intubatie usoara ;;<

• Clasa I= : intubatie di&icila ;;<

• laringoscopia

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(allampati2 Cormac! si Le!an% A2 oralsi *2 ve%erea la larin#oscopie

># +e 'izualizeaza pilierii? palatul moale siu'ula

3# +e 'ad pilierii sipalatul moale? iaru'ula este ascunsa

sub baza limbii2# +e 'ede doar palatul

moale

@# Nu se 'ede nici

palatul moale

Clasa I se 'ad corzile 'ocaleClasa II corzile 'ocale se

'izualizeaza partial

Clasa III se 'ede doar epiglota

Clasa I= nu se 'ede nici epiglota

Clasa I : intubatie usoara ;;<

Clasa I= : intubatie di&icila ;;<



O+ Obstruction3

• +ange+ange

• =arsatura=arsatura

• 6inti (!chiclets$)6inti (!chiclets$)• *piglota (edem glotic? &umatori")*piglota (edem glotic? &umatori")

• ProtezeProteze

• TumoriTumori• 6i'ersi corpi straini6i'ersi corpi straini

http://en.wikipedia.org/wiki/Image:Foreign_Body.jpg





A%enom larin#ian



REIN4E5 EDE(A 6 "mflarea pliurilormucoasei la nivelul cor7ilor vocale la

fumatori



$oate arata asa+



N+ Nec- (obilit/

• Precautii la suspiciune de traumatism

cer'ical

• .al&ormatii

• Acces di&icil



Pozitionarea pacientului



$o7itionarea capului ptr IOT

• A Pozitie neutra#• B Capul ridicat#

• C Pozitia !sni&&ing? cu gatul&lectat si capul in e0tensie#

• 6e remarcat &aptul ca &le0iagatului si e0tensia capuluialiniaza di'ersele a0e sipermite intubatia# Aceastapozitie creeaza cea mai scurtadistanta si linia cea mai dreaptadintre dinti si corzile 'ocale#

• .N



Alinierea aelor888

• perna Popitz :&le0ie

cer'icala si usoara

e0tensie atlanto%

occipitala# 9le0ia aliniazaa0ul &arige% laringe#

*0tensia mai mare a

capului :ade'arata

!sni&&ing position#!



$e%iatrie



Aspect normal al tra!eei a%ult si copil



on%a pe%iatrica

• ,a nou%nascuti si copii? urmatoarea &ormula are op

acuratete mare in e'aluarea diamensiunii corecte a

sondei traheale (@B'arsta)/@

• *stimarea dimensiunii sondelor endotraheale pediatrice

&acuta prin latimea unghiei degetului mic



Dimensiunile si po7itia son%eiIOT functie %e varsta

9 : $rematur 3# 2#2 ;< ;<

Nou)nascutla termen

2#D @#D–@#3 ;1 ;;

;6= luni 2# @#E–@#F ;> ;;

=6;1 luni @#D #2–#G ;= ;1

1 ani @# G#D–G#2 ;? ;0

> ani #D G#E–E#D 1< ;>

= ani # E#2–E#G 11 ;@6;=

? ani G#D F#D–F#3 1> ;=6;

;< ani G# F#E–;#2 1= ;6;?

;1 ani E#D ;#2–>D 1?60< ;?611

B;> ani E#D (&emales) ;#2–>D 1?60< 1<61>

F#D (males) >D#E–>>#2 0160>

Age Internal 6iameter (mm) *0ternal 6iameter (mm) 9rench Hnit 6istance Inserted &rom ,ips &or Tip Placement in the .idtracheaB

Appro0imate size? Jhich 'aries amongmanu&acturers#

: BAdd 3 to 2 cm &or nasal tubes#cm

http://www.mdconsult.com/das/book/body/71085084-6/0/1255/1180.html






!en /ou cant breat!2not!in# else matters



(ateriale ptr intubatie

• ,aringoscop cu lame di'erse

• +onde di'erse

• .andren/ buKii etc

• .asti laringiene 2 L @

• +et de punctie cricotiroidiana canula>@gauge si sistem de insu&latie Ket

• +istem &unctional de aspiratie

• Hn asistent antrenat



Larin#oscopul

http://images.google.ro/imgres?imgurl=http://www.footecmedical.com/Pictures/Laryngoscope7623.JPG&imgrefurl=http://www.footecmedical.com/Laryngoscopes.htm&usg=__KzjuCnCUe4_0fNYwqt-7w6ATHC8=&h=289&w=300&sz=15&hl=ro&start=16&sig2=q_ywTF2xviJ8k9dYKxmy6A&tbnid=s28XAfLixTeSuM:&tbnh=112&tbnw=116&ei=EeskSZaDJIvo7QXL64Ba&prev=/images%3Fq%3Dlaryngoscope%26gbv%3D2%26hl%3Dro%26sa%3DG



+onda IOT cu/ &ara balonas



• Preo0igenare

• Abord 'enos

• Toate materialele / aparatele pregatite si 'eri&icate

http://images.google.ro/imgres?imgurl=http://www.microglass.it/3_USI_GENERALI/3_USI_GENERALI_PICS/siringes_bd.jpg&imgrefurl=http://www.microglass.it/3_USI_GENERALI/3_USI_GENERALI_PAGES/3main_siringhe.htm&h=296&w=235&sz=14&hl=ro&start=1&tbnid=DeYG-3ZNYKke-M:&tbnh=116&tbnw=92&prev=/images%3Fq%3D%2Bsiringes%26gbv%3D2%26svnum%3D10%26hl%3Dro%26sa%3DG



ecventa IOT

$ iti t li i i l i



$o7itionarea corecta a clinicianului2pacientului2 si asistentei in momentul IOT



$robleme frecvente asociate larin#oscopiei

• A, ,ama laringoscopuluisub miKlocul limbii? cu

Kumatatile limbii atarnandin parti si obstruand glota#

• B, ,imba nu este impinsa

indeaKuns spre stanga?obstruand ast&el glota#

• C ? Pozitionarea corecta alamei cu limba ridicata sila stanga#

• D, Htilizarea lamei curbe(.acIntosh)#

• E, Htilizarea lamei drepte(.iller)#



Aspect normal al #lotei la a%ult



Aspect normal al tra!eei la a%ult



cala Cormac-)Le!ane lalarin#oscopie

• grade > tot laringele 'isibil

• grade 3 glota partial 'isibila

• grade 2

• grade @



Verificarea IOT

http://images.google.ro/imgres?imgurl=http://www.sierrabiotech.com/dia_lift.jpg&imgrefurl=http://www.sierrabiotech.com/papr_4.htm&h=187&w=400&sz=57&hl=ro&start=198&tbnid=HKo1ymtUXc0c-M:&tbnh=70&tbnw=150&prev=/images%3Fq%3Dthoracic%2Bmovements%26start%3D180%26gbv%3D2%26ndsp%3D20%26svnum%3D10%26hl%3Dro%26sa%3DN



IOT incorect



Confirmarea corectei plasari ason%ei IOT

• *0pansiunea torace la 'entilatia manuala

• Obser'area pasaKului sondei printre corzi• Auscultarea ambelor campuri pulmonare B

a0ile cu stetoscopul

• Capnogra& si detector eso&agian



end%tidal CO3 detector sau capnogra&

not use&ul in cardiopulmonar1 arrest

because CO3 ma1 not be detected e'en Jhen the tube is correctl1

placed in the trachea because o& a lac o& pulmonar1 circulation



Fiarea son%ei IOT

• 9# importanta fi#areacorecta a sondei$

• +e poate &olosi

leucoplast saudispoziti'e de &i0are

• Nu se lipesc buzele

• .ustata? barba etc



Controlul ra%iolo#ic

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CALL FOR HEL$ 8888

tri#a %upa o mana %e autor

IOT %ificila













Inci%enta IOT %ificile

• >%2 <

• 6g prin laringoscopie

• ,a 3DDD operatii/an 3D%ED IOT di&icile"#• .*ITA *9OTH, de a 5A+I +O,HTII



$roblema

• A loo bac JhatMs learnt &rom bitter

• 6i&&icult airJa1 is an interdisciplinar1 problem

• The diagnostics JasnMt? isnMt? and? apparentl1? JonMtbe accurate

• Hpdated noJledge? 'igilance? adeuatemonitoringand standardization is the e1 &or success%+tandards o& +a&e Anesthesia Practice (A+A? >;FG)%

Difficult AirGa/ Al#orit!m AA2 ;09• Alternati'e airJa1 de'ices re'olutionized outcomes

• *'er groJing interest &or a proper education



Dimensiunea problemei

;< 1<<1

%onco!pliance &ith standardized action plan as &ell

as the absence of preplanned strate'( in case of

difficulties see!s to be the !ain proble!

American Society of Anesthesiologists Task Force on Management of the



Difficlt Air!ay" #ractice gi$elines for the management of the $ifficlt

air!ay% Anesthesiology &8"5'&, ('')%*



Difficult airGa/ al#orit!m



Con&irm Tracheal Intubation or ,.A Placement Jith *0haled CO3

Ec!ipamentul necesar si de



Ec!ipamentul necesar si de

verificat inainte %e intubatie >D# Puneti seringa de um&lat balonasul sondei inpartea dreapta a capului pacientului#O optiune

este de a atasa seringa la balonasul e0tern al

sondei#

>># 6aca pacientul este treaz? imobilizati%i mainile#

>3# +coateti protezele pacientului (puteti intazia

aceasta mane'ra pana imediat inainte de

intubatie daca pacientul este 'entilat la balon si

pe masca)#>2# =eri&icati deri'atiile de pe monitor si ritmul

cardiac imediat dupa incercarea de intubare#

>@# =eri&icati pozitionarea optima a capului gatul in

usoara &le0ie si capul in e0tensie pe gat (daca

situatia o permite)# Acest lucru poate &i &acilitat

prin plasarea unui prosop sub occiputul

pacientului pentru a%l ridica cu >Dcm#

># +a a'eti un sistem de aspiratie pentrudetectarea eso&agului si un detector al etCO3#

>G# adiologia trebuie anuntata in 'ederea unei

radiogra&ii toracice postintubatie#

># Hn asistent trebuie sa &ie prezent in sala sa

urmareasca monitorul? presiunea arteriala? sisaturatia in O3 in timp ce e'alueaza pacientul

pentru semne de decompensare# Asistentul trebuieinstruit sa anunte medicul daca au trecut mai multde 2D sec &ara 'entilatie#

3# +a e0iste o linie 'enoasa care sa &unctioneze &oartebine# O01gen trebuie administrat la pacient#

2# Trageti drogurile necesare (e0#? atropina? lidocaina?

curara? agent de inductie)#

@# Atasati circuitul balon%'al'a%masca la sursa de o0igen(rata > ,/min)#

# 6aca este ne'oie? mandrenul se introduce cu atentiesi corect in sonda traheala#

G# =eri&icati integritatea balonasului sondei traheale#

E# A'eti la indemana leucoplast#

F# =eri&icati sursa de lumina a laringoscopului# +a a'etio sursa de lumina in plus? o gama 'ariata de lamesi sonde traheale#

;# 6eschideti aspiratia orala si puneti%I 'ar&ul sub salteain partea stanga a capului pacientului# Pregatitiaspiratia pentru utilizare postintubatie#



(ateriale ptr IOT %ificila



DE RETIN"T8888

• .andren

• .asca laringiana

• Combitube

• .initraheostomia/ punctia

intercricotiroidiana

• 7ronho&ibroscopia



$ipe Jue%el

• NeJborn Pin @ cm

• In&ant 7lue cm

• +mall Child 7lac G cm

• Child hite E cm• +mall Adult 5reen F cm

• .ed Adult elloJ ; cm

• ,arge Adult ed >D cm

•,arge Adult Orange >> cm



(ANDREN2 #!i%2 intro%uctor

I t b ti i t l i ti



Intubatia prin transluminatieTrachlightQ



Dispo7itive supra#lotice



(asca larin#iana



Combi)tube

• +e plaseaza orb si permite 'entilatia in urgenta ? daca seplaseaza &ie in eso&ag &ie in trahee



Fleible intubation fiberscopes

• the 5old +tandard &or di&&icult airJa1 management



*ron!ofibroscopia

• Imagine de di'iziune normala a bronsiei



(asca pentru fibroscopie

• masca ptr &ibroscopie

permite &ibroscopia si

'entilatia simultana a

pacientului pentru a

creste con&ortul si

calitatea in'estigatiei#



INT INT"*ATIE na7ala oarba

• +onda mai mica

• Curbura sondei

• ,ezare cornete % secretii

Complicatiile intubatiei



Complicatiile intubatieioroKna7o)tra!eale

• la plasarea son%ei

• in timpul V(

• %upa etubare

• la sc!imbarea son%ei• intubatia DIFICILA



IOT nereusita



Abor%ul c!irur#ical al CR



RAlJa1s bear in mind that the tracheotom1 is not the ultimate obKecti'e#

T!e ultimate obective is to pipe air %oGn t!e lun#s.

Tracheotom1 is onl1 a means to that end$ –

Che'alier Sacson



The onl/ indication

&or a surgical airJa1 is

the inabilit/ to establish anairJa1 b1 an1 other method#



Tra!eostomia

• Punctia intercricotiroidiana BU9S=

• .initraheostomia/ cricotiroidotomia ur#ena

• Traheostomia chirurgicala

• Traheostomia percutana % NH ur#ena

Re#iunea anterioara a #atului



Re#iunea anterioara a #atuluilarin#ele



>#corzi 'ocale 3#cartilaK tiroid 2# cartilaK cricoid @#

cartilaK tiroid # balon sonda



Dispo7itive infra#lotice

Cricotiroi%otomia pe ac



Cricotiroi%otomia pe ac

• "r#enta • Punctia cu &le0ula groasa

a membranei

intercricotiroidiene#

• +e ataseaza la acdispoziti' balon/ 'al'a

• Nu se poate 'entila

spontan

• Nu elimina CO3: acidoza

• Timp scurt



,ocalizare/palpare

membrana cricotiroidiana



,ocalizare membrana cricotiroidiana



Pozitionarea corecta ptr punctia

cricotiroidiana (intercricotiroidiana)



Set 'entilatia la

cricotirotomia pe ac

'et ventilatia )!i#!)freMuenc/



'et ventilatia !i#! freMuenc/ventilation HFV9

• U9= &urnizeaza =T V 3 m,/g la &rec'ente

8 GD V 3@DD resp/min#

Cricotiroi%os9tomia K



Cricotiroi%os9tomia K

minitra!eostomia

• +e &ace cu canula mica @%G 9• +e trans&orma precoce in traheostomie

Ptr e'itarea stenozei subglotice

Trusa ptr cricotiroi%os9tomieK



p 9minitra!eostomie

Canula pozitionata corect



Canula pozitionata corect

in trahee

+tabilizarea laringelui cu e&ectuarea



inciziei la piele (>%3 cm) deasupra

membranei cricotiroidiene

*&ectuarea unei incizii orizontale lai l (> 3 ) d i i i i



piele(>%3 cm) deasupra inciziei

prin membrana cricotiroidiana

9olosirea unei pense curbe



9olosirea unei pense curbe?

cu dilatarea membranei cricotiroidiene

I i d IOT (G D)



Inserarea unei sonde IOT (G#D)

sau canule (G#D)

H &l b l l i



Hm&larea balonasului

C &i i i i l i



Con&irmarea pozitiei canulei

9i l i &i iti i



9i0area canulei? recon&irmarea pozitiei

canulei? e'aluarea pacientului

Tipuri de canule de traheostoma



p

Aparat Transtra!eal et ventilation asamblat



Aparat Transtra!eal et ventilation asamblat%in componente accesibile in sala %e operatie

@ ,i&ePortW *ndotracheal Tube Adapters

Conectors/ Catheter .ount Tubings

obinet 2 cai

Tra!eostomia c!irur#icala



a eosto a c u # ca a

TruseTruse

ptr traheostomieptr traheostomie

perc tanapercutana dilatati a (TPD)dilatativa (TPD)



percutanapercutana dilatativa (TPD)dilatativa (TPD)

Pregatire material TPDPregatire material TPD



Pregatire material TPDPregatire material TPD



Te!nica T$D



Complicatii peroperatorii



• 5ra'e –

stop cardiac/deces – Pt0/pneumomediastin

• .edii – hTA – desaturare

– lez#trahee – malpozitia canulei – con'ertire la chirurgie – aspiratie

• .inore – hemoragie – di&icultatea canularii – cale &alsa

– em&izem subcutan

Complicatii postoperatorii



5ra'e – deces

– &istula traheo%eso

– mediastinita

– sepsis

– hemoragie intratraheala

– Pt0

– obstructie canula

– deplasare canula

– stenoza trahee

Medii pneumonii atelectazii

aspiratie lezare cartilaj

Minore hemoragie ext infectie plaga traheita cicatrizare vicioasa

Avantae



• In T#I#

• Cost redus

• Nursing• Alimentatie PO

• +e'rare =.

• Cicatrizare rapida

• +echele minime

Ori&iciul traheal dupa



decanulare



Cn% nu poi respira2 nimic nu mai contea7...

T!e !app/ en%



pp/

iot dificilstudenti08.ppt

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