RU2067422C1 - Method for performing tracheal intubation - Google Patents

Abstract

FIELD: medicine. SUBSTANCE: method involves attaching a mask to intubation laryngoscope, creating anesthesia state in a patient, carrying out direct tracheal laryngoscopy and intubation. Laryngoscopy, supporting free passability of respiratory ways by means of laryngoscope stiletto and intubation tube introduction are carried out under visual control through a transparent screen of oral mask, by means of which artificial lung ventilation is carried out and narcosis state during tracheal intubation is supported. The mask is made from transparent film having irregular form opening for laryngoscope stiletto to be placed in its center. Sleeve for hermetically sealing the laryngoscope branches from the opening. EFFECT: excluded hypoxia during intubation; enhanced effectiveness of treatment; excluded traumatic complications..

Description

 The invention relates to medicine, namely to anesthesiology and intensive care.

A known method of tracheal intubation, which consists in the introduction of an intravenous narcotic substance and muscle relaxant, followed by laryngoscopy and the introduction of an endotracheal tube into the trachea against the background of lack of breathing [1]
However, the time of intubation is limited by a breathing pause. The anatomical features of a number of patients / small mouth, large fleshy tongue, cicatricial changes in the larynx, full patients with a short neck, forward bite of the upper jaw displaced forward / sharply complicates the manipulation and thereby increase the time of intubation sometimes by more than 1-1.5 minutes, which causes hypoxia in the patient. At the slightest symptoms of hypoxia / cyanosis / it is necessary to stop laryngoscopy, remove the laryngoscope and begin artificial respiration through the mask of the anesthesia-respiratory apparatus, then, after elimination of hypoxia, intubation attempts are again made. In this case, repeated injections of the laryngoscope blade can injure the mucous membrane of the oropharynx, cause bleeding, and thereby complicate intubation. In addition, artificial ventilation of the lungs through the mask, and between the laryngoscopy, can be difficult, and in some cases impossible due to the closure of the respiratory tract by the root of the tongue and epiglottis, which cannot be eliminated by extending the lower jaw, tilting the head back and blindly introducing the mouth duct, which leads to severe hypoxia .

 A known method of tracheal intubation is the introduction of an intravenous narcotic substance and muscle relaxant, followed by the introduction into the oropharynx of a laryngoscope blade equipped with an injection device representing a needle with an internal diameter of 1 mm fixed longitudinally in the gutter of the laryngoscope blade. During laryngoscopy, oxygen is supplied through the needle through a needle at a pressure of 1.5 atm, an oxygen stream leaving the needle, entering the respiratory tract through the glottis, additionally carries with it a portion of air. Thus, injection ventilation is carried out from the beginning of direct laryngoscopy to the introduction of the endotracheal tube into the trachea / 2 /.

This method has the following disadvantages, limiting its use:
and / for its implementation, a direct stream of oxygen into the trachea is necessary, which is achieved by installing the end of the laryngoscope with an injection needle opposite the entrance to the larynx. With complex intubations, this is impossible, since in this case the entrance to the larynx is not visible, as a result, an oxygen stream enters the walls of the pharynx, is reflected from them and exits through the mouth opening, as a result of which there is no lung ventilation, hypoxia increases.

 b / when a jet of oxygen enters the esophagus, the stomach quickly overbears, which increases the risk of regurgitation and aspiration into the lungs of the gastric contents.

 in / for the implementation of this method requires a specially defined for this laryngoscope and a source of compressed oxygen.

 g / respiratory circuit during injection ventilation is not closed, so it is impossible to use inhaled anesthetics to regulate the depth of anesthesia.

 The closest technical solution is the method of tracheal intubation, which consists in the introduction of an intravenous narcotic substance and muscle relaxant, followed by the introduction of a laryngoscope blade into the oropharynx, direct laryngoscopy and the introduction of an endotracheal tube into the trachea against the background of injection ventilation through microtrache previously applied prior to anesthesia under local anesthesia. through which a metal injection tube with a diameter of 1.3-3 mm is introduced so that the axis of the tube is parallel to the axis of the trachea and. Upon the onset of the surgical stage of anesthesia and muscle relaxation, oxygen supply begins at a pressure of 4 atm. through an injection tube inserted into the trachea, and a laryngoscope inserted into the oropharynx, squeezing up the root of the tongue and epiglottis, provides free air flow into the larynx, since the injection effect occurs with an open glottis. The phase change of breathing is carried out using a valve device with foot control. Thus, they perform artificial ventilation of the lungs from the moment of introducing muscle relaxants until the end of intubation, when the endotracheal tube passes beyond the glottis, anesthesia-breathing apparatus is connected to it, and oxygen supply through the injection tube is stopped / 3 /.

This method has the following disadvantages:
a / it is designed for the preliminary application of a microtracheostomy before the patient is anesthetized, in the case of the alleged complex intubation, and therefore is not applicable in general practice, when the anesthetist encounters difficult intubation after the introduction of muscle relaxants and even more so during emergency intubation, for example, during resuscitation;
b / microtracheostomy is an additional operation and trauma that can lead to serious complications, such as infection, mediastinitis, subcutaneous emphysema, perichondritis, followed by tracheal stenosis;
c / microtracheostomy under local anesthesia is poorly subjectively tolerated by patients due to powerful reflexogenic zones in this area, which causes coughing and various reflex circulatory disorders;
g / the difficulty of applying a microtracheostoma in patients with a short, thick neck / poor anatomical landmarks /, the impossibility of applying it during the inflammatory process and a burn in the neck;
d / requires a source of compressed oxygen, which limits the application of the method;
f / you can not use inhaled anesthetics to regulate the depth of anesthesia during laryngoscopy and intubation, since the respiratory circuit is not closed.

 The purpose of the invention is the prevention of intra-intubation hypoxia, the possibility of maintaining anesthesia with inhalation anesthetics, simplifying the method and increasing its noninvasiveness.

 This goal is achieved by the introduction of an intravenous narcotic substance and muscle relaxants, followed by direct laryngoscopy and the introduction of an endotracheal tube into the trachea against the background of mask mechanical ventilation. To do this, a flat elastic mouth mask is put on the laryngoscope and hermetically fixed with respect to its handle by the sleeve of the mask, which tightly closes the mouth opening, after the laryngoscope blade is inserted into it, and the nose is clamped with a nose clip. Anesthesia-breathing apparatus is connected to the mask fitting by means of which artificial ventilation of the lungs and maintenance of anesthesia are performed. Reliable airway patency is provided by squeezing the root of the tongue and epiglottis with the blade of a laryngoscope under visual control through the mask screen. Upon finding the glottis, an endotracheal tube is inserted through the nose through it under visual control through the mask screen. To prevent leakage of the respiratory mixture, the tube connector is closed with a stopper for the period of its advancement, and the tube, when it is advanced, is gently squeezed with fingers through the wings of the nose. After the introduction of the endotracheal tube into the trachea, ventilation of the lungs through the mask is stopped. If it becomes necessary, during the use of the mask, to introduce an anesthetic tool through the mouth (for example, a suction tube), the right corner of the mask is bent to the handle of the laryngoscope. When applying the proposed method for tracheal intubation, a flat elastic mouth mask made of a transparent plastic film is used. The face screen of the mask is equipped with a figured hole having the shape of a laryngoscope blade profile, a sleeve of plastic film departs from the edges of this hole perpendicular to the outer surface of the screen.

 The method is as follows.

 The patient is injected intravenously with a narcotic substance / hexanal /, upon reaching the surgical stage of anesthesia, muscle relaxants / dithillin / are administered to relax the muscles. Upon the onset of muscle relaxation, the anesthesiologist inserts a laryngoscope into the patient’s oropharynx, while the mask is shifted backward along the blade to its joint with the handle of the laryngoscope, and the right corner of the mask is bent to the handle of the laryngoscope and pressed to it by the fingers of the left hand holding the laryngoscope. With the blade of a laryngoscope, the root of the tongue and epiglottis are pressed upwards, thereby providing free entry to the larynx, after which the right corner of the mask is released and the anesthesiologist fingers the right hand against the side buttons of the mask, pushes the face screen of the mask down the blade and presses it to the patient’s mouth, its perimeter. After that, the nurse puts a nasal clip on the patient’s nose and connects the anesthesia-respiratory apparatus to the mask fitting, through which artificial ventilation of the lungs is performed. If necessary, anesthetic (nitrous oxide, fluorotan or ether) is added to the inhaled mixture through the dosimeter of the anesthesia apparatus. Simultaneously with artificial lung ventilation, an adequate level of anesthesia and a visual search for the glottis through a transparent mask screen are selected. Moreover, the mask sleeve allows you to freely manipulate the laryngoscope blade in the oropharynx when searching for the entrance to the larynx, without violating the tightness of the respiratory circuit. If it is necessary to perform manipulations through the mouth, aspirating saliva that interferes with laryngoscopy, the right corner of the mask is bent to the handle of the laryngoscope and pressed to it with the fingers of the hand holding the laryngoscope, while opening the right corner of the mouth. Mechanical ventilation stops at this moment. Then, through the open right corner of the mouth, a suction tube is inserted into the oropharynx. After saliva is aspirated, the suction is removed from the oral cavity, the right corner of the mask is released, and the mask is pressed again to the patient's mouth, resuming artificial ventilation of the lungs, interrupted at the time of aspiration. Upon finding the glottis, remove the nasal clip and the endotracheal tube, the connector of which is closed by a plug, is inserted through the nose into the trachea. In this case, the assistant / nurse /, standing to the left of the anesthesiologist, gently squeezes the endotracheal tube through the wings of the nose with the fingers of the right hand, and presses the mask screen against the patient's fingers with the fingers of the left hand, thus ensuring the tightness of the respiratory circuit. An anesthetist promotes an endotracheal tube through the nose against a background of mechanical ventilation, with visual inspection through a transparent mask screen. Artificial lung ventilation is stopped, immediately after which the cork is removed from the tube connector and anesthesia-breathing apparatus is connected to it.

 An example implementation of the method.

 Patient M., 40 years old, medical history N 271. Received 02/21/89. to the Department of Maxillofacial Surgery of the Chelyabinsk City Clinical Hospital for Emergency Medicine for a traumatic fracture of the right articular process of the lower jaw. Concomitant pathology hypertension / working blood pressure / blood pressure / 140/80 mm Hg /. A strong-build patient, with a height of 174 cm, weight 90 kg, attracts attention, in terms of upcoming intubation, a short thick neck. The mouth opens 2 cm. Due to the nature of the upcoming operation, it was planned to carry out nasotracheal intubation anesthesia. 02/22/89, taken to the operating room. The patient was given an infusion of saline into the ulnar vein of the arm.

 A flat mouth mask was put through the sleeve onto the laryngoscope blade and fixed to its handle, above its connection with the blade, a strip of duct tape, around the handle of the laryngoscope and over the sleeve film. The indicated preparation of the mask for intubation took 10 seconds.

 Then the patient was intravenously injected with 500 mg of hexenal and 2 ml of fentanyl, upon reaching the surgical stage of anesthesia, when blood pressure decreased from 150 to 110/70 mm Hg. 160 mg of dithillin was administered intravenously. Upon the onset of muscle relaxation, the anesthesiologist introduced the laryngoscope blade into the oropharynx of the patient, while the mask was moved backward along the blade to its joint with the handle, and the right corner of the mask was bent to the handle and pressed to it by the fingers of the left hand holding the laryngoscope. The root of the tongue and epiglottis were pressed with the blade of the laryngoscope, they provided free entrance to the larynx. After that, the right corner of the mask was released, and the anesthesiologist, resting on the side buttons of the mask, with the fingers of his right hand, pushed the mask screen down the blade and pressed it around the perimeter of the patient’s mouth. Then the nurse put a nasal clip on the patient’s nose and connected the anesthesia-breathing apparatus “RO-6” to the mask fitting. Artificial ventilation of the lungs began, with the following parameters: tidal volume of 0.7 l, minute volume of ventilation 10 l / min, resistance in the respiratory circuit 17 cm aq. Art. oxygen flow 5 l / min. Blood pressure during laryngoscopy rose to 170/80 mm Hg. and the number of heartbeats / ChES / from 100 to 120 in 1 min. Fluorotane pairs up to 1.7 vol. Were added to the inhaled mixture through the vaporizer of the anesthesia apparatus and blood pressure during intubation decreased to 120/80 mm RT. Art. and ChES up to 90 strokes in 1 min. With direct laryngoscopy through the screen of the mask, the entrance to the esophagus, the lower part of the vocal cords and the accumulation of saliva, which interferes with the vision, are visible. The right corner of the mask is bent to the handle of the laryngoscope, and pressed to it by the finger of the hand holding the laryngoscope. Through the opening right corner of the mouth, a suction tube was inserted into the oropharynx and saliva was aspirated. Then the suction tube is removed from the oropharynx, and the right corner of the mask is released and it is again pressed to the patient's mouth. Resumed artificial ventilation of the lungs, interrupted during saliva aspiration. Continued laryngoscopy through the mask screen. A pillow was placed under Jackson’s head to create an improved position, after which the visibility improved significantly and he was able to see the glottis completely. The clip was removed from the nose and the anesthesiologist inserted an endotracheal tube closed by a stopper through the nose and began to push it through the nasal passage into the trachea, under visual control through the mask screen. At the same time, while moving the tube into the trachea, the assistant / nurse / with the fingers of his left hand pressed the mask screen to the patient's face, and with the fingers of his right hand gently pressed the endotracheal tube through the wings of the nose to prevent depressurization of the respiratory circuit. Immediately after the tube was inserted into the trachea, the tube was removed from it, the ventilation of the lungs through the mask was stopped, and the anesthesia-breathing apparatus was connected to the endotracheal tube connector. Thus, the search for the entrance to the larynx and the introduction of the endotracheal tube into the trachea continued for 8 minutes, and the interruption of ventilation of the lungs associated with bending the mask to aspirate saliva for 15 seconds. All this time, the patient's condition is stable: lips, pink, blood pressure 120-110 / 80 mm Hg Heart rate of 90-80 beats per 1 min, chest excursion is good, breathing is even when listening to the lungs. There are no signs of hypoxia. All manipulations were performed calmly, slowly, against the background of adequate ventilation and anesthesia, which together allowed intubation to be performed atraumatically. Subsequently / after intubation / maintenance of anesthesia: fluorotan 1.5-1.7 vol. dithillin fractionally. The course of anesthesia is smooth, the duration of the operation is 2 hours 40 minutes. At the end of the operation, the patient was extubated and in satisfactory condition was transferred to the ward of maxillofacial surgery.

 The use of the invention allows to eliminate intra-intubation hypoxia due to the use of an oral mask for artificial ventilation of the lungs during laryngoscopy and tracheal intubation using an intubation laryngoscope.

 At the same time, reliable airway patency during mask ventilation is provided by squeezing the root of the tongue and epiglottis with the blade of a laryngoscope, under visual control through the mask screen, which improves the effectiveness of mask ventilation.

 Adding inhalation anesthetics to the inhaled mixture makes anesthesia more intuitive during intubation, which, combined with artificial ventilation of the lungs, makes it possible to take laryngoscopy and tracheal intubation carefully and atraumatically.

 When using the proposed method does not require sophisticated equipment. The mask for its implementation is simple in design, which, combined with the cheapness of the transparent plastic film from which it is made, allows it to be used once for each patient and, accordingly, to increase the hygiene and asepticity of intubation.

 The simplicity and speed of attaching the mask to the laryngoscope allows you to use this method of intubation in emergency situations, for example, during resuscitation, or when complex intubation is detected after the introduction of muscle relaxants. In addition, the proposed method of intubation can be used to teach the method of intubation with an endotracheal laryngoscope.

Claims (1)

 A method of tracheal intubation, including direct laryngoscopy and insertion of a tube into the trachea against the background of mechanical ventilation, characterized in that, in order to simplify intubation, reduce trauma and ensure inhalation regulation of the level of anesthesia, the lungs are ventilated through an oral mask, while laryngoscopy is performed without violation of the tightness of the respiratory circuit.