RU2796059C1 - Method of puncture retrograde intubation of the trachea in a rabbit for artificial lung ventilation in veterinary clinical practice and experiment - Google Patents

Abstract

FIELD: veterinary medicine.

SUBSTANCE: invention relates to veterinary medicine and is a method of puncture retrograde intubation of the trachea in a rabbit for artificial lung ventilation in veterinary clinical practice and experiment . The invention is carried out as follows: in a pre-anesthetized and fixed in the position "on the back" of an animal with a cotton-gauze roller under the neck (in the position of hyperextension), the angle of the thyroid cartilage, the arch of the cricoid cartilage of the larynx and trachea are palpated through the skin along the anterior median line. Fix it with your fingers thyroid and cricoid cartilage of the larynx. With a Tuohy (Huber Point) type epidural anesthesia needle with an outer diameter of 16 G (1.65 mm) and a white polypropylene mandrel, the trachea is punctured through the pre-shaved skin along the anterior median line under the lower edge of the cricoid cartilage arch. Remove the mandrel from the needle. A 5.0 ml syringe filled with 0.9% NaCl solution is attached to the Tuohy needle pavilion. They pull the plunger of the syringe "on themselves" and over the air bubbles they make sure that the needle is in the trachea. The syringe is disconnected and through the lumen of the needle, the plane of the cut of the tip of which is positioned cranially, a flexible twisted wire conductor is inserted until it appears from the oral slit or from one of the nostrils, an intubation tube with an inflated cuff of 2.5 is put on it and carried into the trachea, the conductor is removed, the cuff is inflated, the intubation tube is fixed.

EFFECT: method prevents the possibility of introducing an intubation tube guide in the aboral (caudal) direction, reducing the time to o ensure the precision of manipulations, to reduce the risk of traumatization of the trachea, esophagus, large blood vessels and thyroid gland at the site of the procedure, to minimize the likelihood of emphysema in the intermuscular and interfacial spaces of the neck and mediastinum, to eliminate the need for suturing puncture holes in the trachea and on the ski.

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Description

The invention relates to practical and experimental veterinary medicine and can be used for artificial lung ventilation (ALV). ALV is necessary during operations on the lungs, heart, aorta, thoracic esophagus, diaphragm due to the fact that any kind of thoracotomy is accompanied by the development of pneumothorax and collapse of the lungs, resulting in hypoxia (acute respiratory failure) and death.

There are a number of methods [1-8] for tracheal intubation in rabbits, however, they are not without drawbacks. Known methods include the following: tracheal intubation by direct laryngoscopy [1], blind intubation [2], tracheostomy intubation [3], retrograde intubation [4, 5], endoscopy-guided intubation [6], video endoscopy-guided intubation [7], capnography-guided intubation [8]. However, none of these methods as a whole meets all the necessary criteria for widespread and safe use: speed, precision, atraumaticity, accessibility and reliability of this procedure.

One of the methods of tracheal intubation in small animals is the method of tracheal intubation in rats according to A.Kh. Kogan [1]. The animal is fixed belly up to the operating table with a long rod, on which the tooth holder is placed. The tooth holder, put on the teeth, is installed in the outer position and fixed with a screw. A cotton swab moistened with ether is placed near the muzzle. After making sure that anesthesia is of sufficient depth, proceed to tracheal intubation. The tongue is grasped with anatomical tweezers, it is partially removed from the oral cavity, a tongue holder is applied, the tongue is pulled outward as much as possible, it is pressed to the bottom of the oral cavity, the tongue holder handle is fixed with an arterial clamp to the skin of the abdomen. With a cotton swab, the pharynx is freed from mucus. Under visual control of the "frontal" magnifier, the laryngoscope is inserted into the oral cavity and pharynx with the left hand. Then, a polyethylene endotracheal tube fixed with the fingers of the right hand is inserted into the larynx, the laryngoscope is removed, and the presence of the tube in the trachea is checked with a cotton swab brought to the outer opening of the tube. The disadvantage of this method is the mandatory preliminary anesthesia and the possibility of trauma to the larynx and trachea. According to numerous studies, special difficulties arise when intubating the trachea in rabbits, since their tongue is very small and its shape is such that it closes the larynx even with the deepest anesthesia.

There is also known a "blind" method of tracheal intubation in a rabbit with a rubber children's endotracheal tube No. 2.5 [2]. In accordance with this method, the rabbit is laid on its back with its stomach up, its head is free. The assistant introduces two bindings on the lower and upper incisors and opens the mouth as much as possible, and lowers the rabbit's head as low as possible so that an obtuse angle of 102-103˚ is formed between the spine and the head. The second assistant pulls the tongue to the side with the tongue holder, after which the anesthesiologist lifts the epiglottis with the skin by 1-2 mm with the left hand, inserts the endotracheal tube with the right hand and, having reached the stop with the larynx, makes a turn to the right by 90 °. In this case, there is a characteristic sound of the passage of the endotracheal tube into the trachea. The endotracheal tube freely enters the trachea, as evidenced by the fluctuation of the fleece at its outer edge. However, the method is difficult to implement, since, according to many authors, problems with tracheal intubation in rabbits are associated with the peculiarities of their anatomy of the oral cavity, which disrupt the visualization of the larynx and blind tracheal intubation.

One of the classical methods is tracheal intubation in a rabbit through a tracheostomy [3]. An incision is made along the midline of the neck from the middle of the thyroid cartilage 4-5 cm caudally in an animal previously anesthetized and fixed in the machine. After dissection of the skin with hooks, the sternohyoid muscles are moved apart and the trachea is isolated. A strong silk thread is brought under the trachea. Fixing the trachea with hooks or fingers, cut longitudinally 2-3 cartilaginous rings or cut the trachea across 1/3 of the diameter. A conductor for an endotracheal tube is inserted into the incision of the trachea in the form of a metal, glass or plastic tracheal cannula-tee, which is fixed by tying a silk ligature around the trachea. After that, an endotracheal tube is passed through the installed conductor. Significant disadvantages of this method are: the involvement of an assistant in the procedure; a high degree of trauma to the trachea and a violation of the integrity of the respiratory tract; high probability of damage to organs and blood vessels in the neck; the duration of the procedure; the need for suturing soft tissues and skin, processing and removing skin sutures on the neck.

Known retrograde method of tracheal intubation [4]. After premedication, the rabbit is laid on its back, the surgical field is shaved, the head is left free, the mouth is opened as much as possible, introducing two knittings on the lower and upper incisors. Then the head is thrown back as much as possible, bending the neck. Palpation on the anterior surface of the neck determines the trachea and marks the puncture site. A conductor is inserted into the muscle needle. The trachea is punctured with a muscular needle with a conductor 4-5 cm below the larynx. The needle is removed. An introducer with an inner diameter of 2.0 mm is inserted through the conductor into the trachea, and a guide device for the endotracheal tube in the form of a metal bougie with a diameter of up to 2.0 mm with a rounded end is introduced along it to prevent injury to the trachea. They continue to advance the guide device - bougie, bring it into the oral cavity. The endotracheal tube is advanced along the guide device - buzhu - from the oral cavity into the trachea. The bougie is removed from the lumen of the endotracheal tube. Significant disadvantages of the method are: the use of a "muscle" needle with a sharp cut of the tip of the tip; unreliability of fixation of an easily displaced trachea during its puncture with a needle; the use of an introducer with an internal sufficiently large diameter and a guide device in the form of a metal bougie. All of the above indicates a high degree of possibility of damage to the esophagus and large vessels of the neck, the trauma of manipulation in general. The closest in technical essence and the achieved result to the claimed is a method of retrograde tracheal intubation in a rabbit for artificial ventilation in the experiment [5]. The method is carried out as follows. After intramuscular anesthesia, the rabbit is laid on its back, the head is left free. One knitting is introduced on the upper incisors so that the head lies flat, the neck is extended. Palpation through the skin along the midline of the neck from the middle of the thyroid cartilage 3-4 cm caudally find the trachea. Fixing the trachea with fingers, puncture it between the second and third rings with a 18 G needle with a 5.0 ml syringe filled with saline. The presence of the needle in the lumen of the trachea is determined by the intake of air when the syringe plunger is pulled, then the syringe is removed and a wire guide is inserted through the needle until it emerges from the oral or external nasal opening, on which an endotracheal tube of size 2.5 with a cuff is put on and it is passed into the trachea , the conductor is removed, the cuff is moderately inflated, and the tube is firmly fixed, artificial ventilation of the lungs is started. The disadvantages of this method are: the lack of preoperative diagnostic techniques such as electrocardiography (ECG), echocardiography (EchoCG), radiography of the chest cavity (OHP) and ultrasound (ultrasound) of the neck for the timely detection of possible pathologies of internal organs, the presence of which may have a negative impact on the course of the operation; reliable standard rabbit mouth expanders (Kruuse) are not used, which greatly facilitate tracheal intubation; lack of objective control over the state of the animal during anesthesia using a heart monitor (heart rate (HR), ECG, pulse oximetry (SpO²), respiratory rate (RR), body temperature); insufficient fixation of only an easily displaced trachea during its puncture with a needle, which can lead to injury to the esophagus, thyroid gland, large blood vessels in the neck with the development of a hematoma of the neck and mediastinum with their possible suppuration and the occurrence of neck phlegmon and mediastinitis; the model of the puncture needle and the features of the cut of the tip of its tip, as well as the presence or absence of a mandrel in the needle, are not indicated, since these factors can drastically affect the success of the procedure. The use of needles for intramuscular and intravenous injections, as well as needles for epidural anesthesia (spinal needles) such as Quincke, Greene, Pitkin, can lead to traumatization of soft tissues, organs and vessels with sharp edges of the cuts of the needle tips. The use of spinal needles such as Sprotte, Whitacre (PencilPoint) makes it extremely difficult to guide the guidewire. All of the above types of needles are completely devoid of external marking of the needle length in cm (10 mm), which makes it difficult to visually control the depth of insertion of the needle into the trachea and provokes potential damage to the cervical esophagus. The absence of a mandrin in the needle can lead to obturation of its lumen by soft tissues during puncture.

In addition to the methods discussed above, the following high-tech, very reliable and atraumatic methods of tracheal intubation are known: endoscopy-guided intubation [6], videoendoscopy-guided intubation [7], capnography-guided intubation [8], but the main common disadvantage of these methods is the need to use expensive equipment, and therefore low availability for real use in veterinary practice and experiment.

The technical result of the claimed method is the method of puncture retrograde tracheal intubation in a rabbit for artificial lung ventilation (ALV) in veterinary and clinical practice is the expansion of the arsenal of means of tracheal intubation for artificial lung ventilation.

The technical result is achieved by the fact that rabbits with clipped and shaved anterolateral neck surface are percutaneously punctured along the anterior midline under the lower edge of the cricoid cartilage of the larynx with a needle for epidural anesthesia of the Tuohy type (Huber Point) with an outer diameter of 16 G (1.65 mm) with a white polypropylene mandrin, which has a precise positioning of the needle in the position of the cut plane of the needle tip cranially; after puncture of the trachea, the mandrin is removed and a disposable syringe with a capacity of 5.0 ml with 0.9% NaCl solution is attached to the needle pavilion to determine if the needle is in the trachea; then the syringe is disconnected and a flexible twisted wire guide is inserted until it emerges from the oral fissure or from one of the nostrils, after which an endotracheal tube with an inflatable cuff of size 2.5 is put on it; the endotracheal tube is inserted into the trachea, the conductor is removed, the cuff is inflated and the endotracheal tube is fixed, and additionally, before the start of tracheal intubation, possible pathologies of the internal organs of the animal are identified using ECG, echocardiography, radiography of the OGP and ultrasound of the neck; use of an operating table (mechanical or electro-hydraulic), the tabletop of which can be tilted to the right and left, raised or lowered at the cranial or caudal ends; application of a mouth expander for rabbits (Kruuse); connection of a cardiac monitor for intraoperative monitoring of the functions of the cardiovascular and respiratory systems (ECG, heart rate, SpO², respiratory rate, body temperature); tracheal puncture is carried out in the position of the animal on the back along the anterior midline of the neck through the previously shaved skin of the neck under the lower edge of the cricoid cartilage of the larynx, having previously fixed the cartilages of the larynx with the fingers, with a needle for epidural anesthesia of the Tuohy type (HuberPoint) with an outer diameter of 16 G (1.65 mm) with a white polypropylene mandrin, with the positioning of the cut plane of the curved tip of the needle point cranially, with marking the length of the needle in 1.0 cm increments, with “wings-stops” and stops for fingers with an anti-slip pattern-coating; insertion of a flexible twisted wire guide into the needle.

These tasks in the method of puncture retrograde tracheal intubation in a rabbit for artificial lung ventilation in veterinary clinical practice and experiment are solved as follows.

Before tracheal intubation, the rabbit is given an ECG, echocardiography, an overview X-ray of the UGP, an ultrasound of the neck to exclude possible developmental anomalies and acquired diseases of the heart, large blood vessels, thyroid gland, esophagus, and diaphragm; evaluate the results of diagnostic studies and decide on the possibility of implementing this manipulation. General anesthesia (narcosis) is carried out using standard dosages of propofol and zoletil using an automatic electronic syringe dispenser (infusomat).

The animal is fixed on the operating table, equipped with the function of tilting the tabletop in different directions and raising and lowering it, in the “on the back” position with a cotton-gauze roller under the neck in the position of its hyperextension. A rabbit mouth expander (Kruuse) is installed. The sensors of the heart monitor are connected to the animal to control heart rate, respiratory rate, ECG, SpO², body temperature. Shear and shave off the hair from the skin of the anterior and anterolateral surface of the neck. The prepared skin area is treated with an antiseptic solution and the surgical field is isolated with sterile wipes. The angle of the thyroid cartilage, the arch of the cricoid cartilage of the larynx and the trachea are palpated along the anterior midline through the skin. The thyroid and cricoid cartilages of the larynx are fixed with fingers.

Tuohy type epidural needle (Huber Point), 16 G (1.65 mm) OD, with white polypropylene mandrel, with external needle length markings in 1.0 cm increments, with “wing-stops” and finger rests, with an anti-slip coating pattern is positioned so that the cutting plane of the curved tip of the needle point is facing cranially. The fixed trachea is punctured with a Tuohy needle along the anterior midline of the neck under the lower edge of the cricoid cartilage of the larynx. The mandrin is removed from the lumen of the needle. A disposable 5.0 ml syringe with 0.9% NaCl solution is attached to the Tuohy needle pavilion. Sip the plunger of the syringe "toward itself" and, by the appearance of air bubbles in the liquid in the syringe, make sure that the needle is in the tracheal cavity.

The syringe is disconnected from the needle. A flexible twisted wire guide is inserted into the lumen of the positioned needle and carried out with translational movements until it appears from the oral fissure or one of the nostrils of the rabbit. An endotracheal tube of size 2.5 with a cuff is put on this end of the conductor and passed into the trachea. The guidewire is removed through the tube, the cuff is moderately inflated. The reliability of fixation of the endotracheal tube in the trachea is checked. The pavilion of the endotracheal tube is fixed with a strong synthetic thread by loosely tying it around the animal's neck so as not to cause compression of the neck vessels, especially the external jugular vein.

Distinctive features of the proposed method is the implementation of preoperative preparation of the animal by performing ECG, EchoCG, radiography of the OGP, ultrasound of the neck; fixing the animal on the operating table, equipped with the functions of tilting in different directions, raising and lowering the tabletop; monitoring heart rate, respiratory rate, ECG, SpO² and body temperature by connecting the animal to a cardiac monitor; using a rabbit mouth expander (Kruuse); using a Tuohy type epidural needle (Huber Point) with an outer diameter of 16 G (1.65 mm) for tracheal puncture with a white polypropylene mandrin, with an external marking of the needle length with with a 1.0 cm step, with “wings-stops” and finger stops, with an anti-slip coating pattern, with a curved tip, which: minimize potential anesthetic complications and surgical risks of trauma to the esophagus, thyroid gland and large vessels of the neck; allow you to adequately control the course of the manipulation and make it technological, precise, ergonomic, with the least time costs; make it possible to widely use this technical solution in veterinary clinical practice and experimental research activities.

The method is implemented as follows: in an animal previously anesthetized and fixed in the “on the back” position with a cotton-gauze roller under the neck (in the hyperextension position), the angle of the thyroid cartilage, the arch of the cricoid cartilage of the larynx and the trachea are palpated through the skin along the anterior midline, after which they are fixed thyroid and cricoid cartilages of the larynx with fingers. Then, with a Tuohy-type epidural needle (HuberPoint) with an outer diameter of 16 G (1.65 mm) and with a white polypropylene mandrel, the trachea is punctured through the pre-shaved skin along the anterior midline under the lower edge of the cricoid cartilage arch. After tracheal puncture, the mandrin is removed from the needle and a 5.0 ml syringe filled with 0.9% NaCl solution is attached to the pavilion of the Tuohy needle. Sip the plunger of the syringe “toward yourself” and by the air bubbles make sure that the needle is in the trachea. The syringe is disconnected and through the lumen of the needle, the cut plane of the tip of which is positioned cranially, a flexible twisted wire guide is inserted until it emerges from the oral fissure or from one of the nostrils, an endotracheal tube with an inflatable cuff of size 2.5 is put on it and passed into the trachea, the guide is removed , the cuff is inflated, the endotracheal tube is fixed. EFFECT: method makes it possible to prevent the possibility of introducing a conductor for an endotracheal tube in the aboral (caudal) direction, to reduce the time before the start of mechanical ventilation, to ensure the precision of manipulations, to reduce the risk of trauma to the trachea, esophagus, large blood vessels and thyroid gland at the site of the procedure, to minimize the likelihood of emphysema in the intermuscular and interfascial spaces of the neck and in the mediastinum, to eliminate the need for suturing puncture holes in the trachea and on the skin.

The advantages of the claimed method are: minimization of the possibility of anesthetic and operational risk due to the preoperative complex of diagnostic studies (ECG, echocardiography, radiography of the OGP, ultrasound of the neck); use of an operating table with a variable table top geometry and a mouth expander for rabbits (Kruuse); connection of a cardiac monitor for intraoperative control of vital functions; reduction of time before the start of mechanical ventilation; stability of fixation of the larynx and trachea; preventing the possibility of introducing a conductor for an endotracheal tube in the aboral (caudal) direction; ensuring precision of manipulations; reducing the risk of trauma to the trachea, esophagus, thyroid gland and blood vessels at the site of the procedure; minimizing the likelihood of emphysema and suppurative processes in the intermuscular and interfascial spaces of the neck and mediastinum; elimination of the need for suturing puncture holes in the trachea and on the skin.

The advantages of the claimed method are: timely early detection of possible existing pathologies of the UGP and the neck with a preliminary ECG, echocardiography, plain radiography of the UGP, ultrasound of the neck in the preoperative period; minimizing anesthetic and operational risk at all stages before and during the procedure; ensuring high reliability, manufacturability, precision and speed of manipulation in combination with its low injury rate.

The claimed method of puncture retrograde tracheal intubation in a rabbit for artificial lung ventilation was used in 25 rabbits, which were simulated experimental myocardial infarction, and allowed: to ensure the maximum reduction in the possibility of anesthetic complications and the risk of injury to organs and large vessels of the neck; adequately and objectively control the progress of the manipulation and make it accessible, technologically advanced, precise, ergonomic and fast.

INFORMATION SOURCES

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3. Lopukhin, Yu. M. Lopukhin. Experimental Surgery. / Yu.M. Lopukhin. M.: Medicine, 1971. - 344 p.

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Claims (1)

A method for puncture retrograde tracheal intubation in a rabbit for artificial lung ventilation (ALV) in veterinary clinical practice and experiment, including cutting and shaving wool from the anterolateral surface of the rabbit neck through skin puncture of the trachea along the anterior midline under the lower edge of the cricoid cartilage of the larynx with a needle for epidural anesthesia type Tuohy Huber Point with an outer diameter of 16 G with a white polypropylene mandrin, precise positioning of the needle in the position of the cut plane of the needle tip cranially, removal of the mandrel, attachment of a disposable syringe with a capacity of 5.0 ml with 0.9% NaCl solution to the pavilion of the needle for determination finding the needle in the trachea, disconnecting the syringe, inserting a flexible twisted wire guide until it emerges from the oral fissure or from one of the nostrils, putting on an endotracheal tube with an inflatable cuff size 2.5, passing the tube into the trachea, removing the guidewire, inflating the cuff, fixing an endotracheal tube, characterized in that, in addition, before the start of tracheal intubation, possible existing pathologies of the internal organs of the animal are identified using ECG, echocardiography, radiography of the OGP and ultrasound of the neck; use of an operating table, the tabletop of which can be tilted to the right and left, to raise or lower the cranial or caudal ends; application of the Kruuse rabbit mouth expander; connection of a heart monitor for intraoperative monitoring of the functions of the cardiovascular and respiratory systems, namely ECG, heart rate, SpO², respiratory rate, body temperature; puncture of the trachea in the position of the animal on the back along the anterior midline of the neck through the pre-shaved skin of the neck under the lower edge of the cricoid cartilage of the larynx, having previously fixed the cartilages of the larynx with the fingers, with a needle for epidural anesthesia of the Tuohy Huber Point type with an outer diameter of 16 G with a white polypropylene mandrel, with positioning the plane of the cut of the curved tip of the needle point cranially, with marking the length of the needle in 1.0 cm increments, with “wings-stops” and stops for fingers with an anti-slip pattern-coating; insertion of a flexible twisted wire guide into the needle.