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Thursday, 29 March 2012

Respiratory management with intubation for emergency personnel (SURGERY)


Chapter I

INTRODUCTION

Since the surgery, the medical community has actually attempted to perform acts of anesthesia aims to reduce and eliminate pain or pain. (Anonymous, 1989) In principle, a patient will be unconscious to perform actions that are performed physical such as hitting, choking, and so forth. It had to be done so that the patient does not feel pain, and finally jumped off the table which resulted in disruption of the proceedings of operation. (Anonymous, 1986).
Since the introduction of ether gas usage by William Thomas Greene Morton in 1846 in Boston United States, then gradually in ways that physical violence is often done to achieve a state of anesthesia becoming obsolete. Discovery was a turning point in the history of surgery, because it opens up the possibility of surgical horizons broader, easier and humane. (Anonymous, 1986).
In an operation, a surgeon can not work alone in dissecting patients while creating a state of anesthesia. Required the presence of an anesthetist to seek, handle and maintain a state of anesthesia the patient. The job of an anesthesiologist in an operating event include:
A. Relieve pain and emotional stress during the process of doing surgery or other medical procedures.
2. To manage common medical measures to the patients operated, keeping the functions of the organs of the body goes in the normal range so that patient safety is maintained.
3. Create the best possible operating conditions so that the surgeon can perform their duties easily and effectively.

One business that absolutely must be performed by an anesthesiologist is to maintain the functioning of organs in normal patients, with no significant effect due to the surgical process. Airway management became one of the most important part in an act of anesthesia. Because some of the effects of drugs used in anesthesia may affect the state of the airway goes well.

One attempt to maintain the patient's airway with endotracheal intubation action, namely by inserting a tube into the upper respiratory tract. Because the main requirements that must be considered in the general anesthesia is to keep the airway and breathing are always free to run smoothly and orderly. In fact, according to Halliday (2002) use of endotracheal intubation is also recommended for neonates with complicating factors that can interfere with the airway. This paper will elaborate on endotracheal intubation, and will only be limited to the issue.
Chapter II
Anatomy and Physiology


2.1 Anatomy - Upper Respiratory Physiology.

            Endotracheal intubation in action we must first understand the anatomy and physiology of the upper airway where intubation was installed. In the discussion of the anatomy and physiology, the authors will elaborate on some matters relating to the physiology of the oropharynx cavity, naso pharynx and some will be more emphasized in the larynx.
Human respiratory system has a picture of a common design that can be attributed to a number of important activities. This system would essentially consist of surface respiration and branched into conducting passages that make up the respiratory tree. Surface respiration is an area of approximately 200 m2, and forming something very thin, moist barrier to air and blood capillaries surrounding the millions of bags called alveoli that eventually form a mass of lung (Williams, 1995: 1630).


2.2 Internal and External Respiration

            Respiration is a combination of physiological processes in which oxygen is inhaled and carbon dioxide released by cells in the body. This is an important process of gas exchange. Respiration is divided into two phases. The first phase of external expiratory in the same sense with breathing. It is a combination of movement and skeletal muscle, where the air for the first time pushed into the lungs and then removed. These events include the inspiration and expiration. Phase to another is internal respiration which includes transfer / movement of the molecules of the respiratory gases (oxygen and carbon dioxide) through the membrane, fluid displacement, and the cells of the body as needed.

2.3 Respiratory Organs
Respiratory tract include: (a) nasal cavity (b) of the larynx (c) trachea (d) bronchi (e) lung and (f) pleura. Pharynx has two functions: to the respiratory system and digestive system. Some of the muscles involved in breathing process. The diaphragm is the most important respiratory muscle in addition to the internal and external muscular intercostalis some other muscles.

2.4 Pharynx and Larynx

          Pharyngeal relationship with the process of respiration. Pharynx is often mentioned is part of the digestive system and also part of the respiratory system. This is the path of the air and food. Air into the cavity of the mouth or nose through the pharynx and into the larynx. Nasopharynx is located in the posterior nasal cavity is connected through the posterior nares. Air into the pharynx, down past the base of the pharynx and then into the larynx.

           Control to open the pharynx, with the exception of the esophagus and open auditiva tuba, all of the passage opening into the pharynx can be closed voluntarily. This control is very important in the respiratory and feeding time, for opening the course of the digestive tract must be closed while eating and swallowing food or will enter into the larynx and the posterior nasal cavity.

2.4.1 Larynx

This organ (sometimes referred to as the Adam's Apple) lies between the root of the tongue and trachea. The larynx consists of nine cartilages and ligaments around along with a number of muscles that control movement. Rigid cartilage in the larynx walls forming a hollow hole that can guard against collapses. In this regard, it forming the trachea and the larynx is different from the other holes in the building. Except when the larynx is still open at certain times such as adduction of the vocal cords while speaking or swallowing. Vocal cords are located in the larynx, therefore spending it as an organ sound is the air path between the pharynx and larynx.
Upper parts of the larynx area, while the bottom of the narrow and cylindrical. Laryngeal cartilage is the largest cartilage and the V-shaped thyroid cartilage. Cartilage is composed of two cartilages are quite wide, which at the front to form a subcutaneous projection known as Adam's Apple or laryngeal prominence. This cartilage attached to bone via membrane hyotiroidea tongue, a sheet of the broad ligament and cartilage cricoid by an "elastic cone" of a ligament which consists mainly of yellow elastic tissue.
Cricoid cartilage is smaller but thicker ring consists of the front, but extends into a plate-like structure to form the bottom and back of the larynx.

Arytenoid cartilage totaled two lies in the upper limit of the area next to the posterior cricoid. These are small and shaped cartilage piramid.Epiglotis, leaf-shaped cartilage located at the base of the tongue and the thyroid cartilage at anterior median linea. Cartilage was widened by oblique and upper back.

Laryngeal cavity, the cavity begins at the confluence between the pharynx and larynx as well as the end of the bottom of the cricoid cartilage where the room is going to continue with the trachea. This section is divided into two parts by the vocal fold and ventricular fold horizontally. Vocal fold or vocal cords are two strong ligementum which extends from the angle between the front of the two cartilages aritenoid on the back. Ventricular fold is often referred to as the false vocal folds are composed of mucous membrane and tucked into a band of connective tissue. The folds are in addition to the original vocal. Space between the vocal folds is called the glottis, the shape varies according to vocal fold tension.

Function of the larynx, which regulate the tension of the vocal cords which further regulate the sound. Larynx also receive air from the pharynx to the trachea and passed to prevent food and water into the trachea. The second function is largely controlled by intrinsic laryngeal muscular.
Sound settings. Both laryngeal muscles that separate the vocal fold or bring together, in fact they can close the glottis airtight, like when someone lift a heavy load or the strain at defecation and also at one time hold your breath when drinking. When these muscles relax, air is held in the chest cavity will be issued with an opening pressure of a sudden causing snoring sounds.
Air drainage on tracheal, glottis open almost all the time so the air in and out through the larynx. But will close during swallowing. Which is above the epiglottis glottis larynx serves as a cover. It will be forced to close the glottis when swallowing food through it at the time. Epiglottis is also very involved at the time of intubation set, because it can be used as a benchmark to see the vocal cords are white that surrounds the hole.


 CHAPTER 3
 Endotracheal intubation


3.1 Definition of endotracheal intubation.

According to Hendrickson (2002), intubation is to enter a hole or tube through the mouth or through the nose, with a target of the upper airway or trachea. At its core, is the act of inserting Endotrakhea intubation tube into the trachea so endotrakha airway and breathing easy freeway aided and controlled (Anonymous, 2002).

3.2 Objectives Endotrakhea intubation.
The purpose of this action is to clean the intubation endotrakhea trakheobronchial channels, maintaining the airway to remain patent, prevent aspiration, and facilitate the provision of ventilation and oxygenation for surgery patients. Basically, the purpose of endotracheal intubation:

a. Facilitate the provision of anesthesia.
b. Maintain an airway to keep it free and to maintain the smooth breathing.
c. Prevent possible aspiration of gastric contents (in a state of unconsciousness, the stomach is full and there is no cough reflex).
d. Facilitate the suctioning of secretions trakheobronchial.
e. The use of mechanical ventilation time.
f. Cope with acute laryngeal obstruction.

3.3 Indications and contraindications.

Indications for endotracheal intubation by Gisele implementation in 2002 include:
a. State of inadequate oxygenation (due to decreased arterial oxygen pressure, etc.) that can not be corrected with the supply of oxygen through a nasal mask.
b. State of inadequate ventilation due to increased carbon dioxide in arterial pressure.
c. The need to control and remove pulmonary secretions or as bronchial toilet.
d. Organize protection for patients with life-threatening circumstances or patients with a reflex that occurs due to blockage.

In other sources (Anonymous, 1986) mentioned indications endotracheal intubation include:
a. Maintain a free airway in difficult circumstances.
b. Operations in the head, neck, mouth, nose and throat, because in such cases is very difficult to use a face mask without disrupting the work of the surgeon.
c. In many abdominal operations, to ensure a quiet breathing and no tension.
d. Operations intra torachal, so that the airway is always patent, suction done easily, facilitate respiration control and facilitate intra-pulmonary pressure control.
e. To prevent contamination of the trachea, such as intestinal obstruction.
f. In patients who easily arise laringospasme.
g. Tracheostomi.
h. Fixation in patients with vocal chords.

In addition to endotracheal intubation is indicated in cases in the operating room, there is some indication of endotracheal intubation in some cases, nonsurgical, among others:
a. Asphyxia neonatorum heavy.
b. To melakukn resuscitation in patients with respiratory congestion, depression or abcent and often cause aspiration.
c. Laryngeal obstruction due to heavy exudate Inflamatoir.
d. Patients with signs of atelectasis and exudation in the lungs.
e. In patients who are not expected to realize a longer period than 24 hours should be intubated.
f. On post operative respiratory insufficiency.

By Gisele, 2002 there are some contra indications for endotracheal intubation does include:
a. Some of the state of airway trauma or obstruction that is not possible to undertake intubation. Actions to be performed is cricothyrotomy in some cases.
b. Cervical trauma requiring immobilization of vertebrae servical state, making it very difficult to do intubation
3.4 Position Patient for Intubation action.

Picture of the true classic in the neck flexion is mild, while the head in a state of extension. This is called Sniffing in the air position. A common mistake is extends to the head and neck.



Position for intubation
Sources: http://www.aic.cuhk.edu.hk/web8/Hi% 20res/Laryngoscopy% 201.jpg
. 3.5 The tools for intubation
The tools are used in an act of endotracheal intubation (Anonymous, 1989), among others:

a. Laryngoscope, the tool used to view the larynx. There are two types of laryngoscope are:

i. Blade curvature (McIntosh). Laryngoscope is used in adults.
ii.Blade straight. Laryngoscope with a straight blade (ie blade Magill) have different techniques. Usually used in patients infants and children, because they have the epiglottis is relatively longer and stiffer. Trauma to the epiglottis with a straight blade is more common.




b. Endotracheal pipe. Usually made of rubber or plastics. Disposable plastic tube and more do not irritate the tracheal mucosa. For certain operations such as in head and neck region that is required can not be bent pipes that have a nylon or steel spiral. To prevent leakage of airway, endotracheal tube has most of the balloon (cuff) on the distal ujunga. There are two types of balloon is a balloon with a volume large and small. Balloon small volume of high pressure tends to mucosal cells and reduce capillary blood flow, which can cause ischemia. Large volume surrounding the balloon larger mucosal areas with a lower pressure than the smaller volume. Pipe without balloons are usually used in children because of the narrowest part of the airway is the cricoid cartilage. In adults is usually used with a balloon because the tube is the narrowest part of the trachea. Pipe commonly used in adults with an internal diameter for men ranged from 8.0 to 9.0 mm and females 7.5 to 8.5 mm. For a long oral intubation tube that goes 20-23 cm. In children used the formula: 
The length of the incoming pipe (mm) = The formula is approximate and should be provided pipe 0.5 mm larger and smaller. For younger children can usually be predicted by looking at the size of his little finger. 

c. Pipe oropharynx or nasopharynx. This tool is used to prevent airway obstruction due to collapse of the tongue and pharynx in patients who are not intubated.


d. Endotrakhea plaster to fix the pipe after the act of intubation.
e. Stilet or intubation forceps. Commonly used to adjust the curvature of the endotracheal tube as an aid when the pipe insertion. Intubation forceps (McGill) is used to manipulate the nasal endotracheal tube, or nasogastric tube through the oropharynx.

f. A vacuum or suction.

3.6 Actions intubation.

In carrying out an act of intubation, need to follow some predefined procedures (Anonymous, 1989), among others:

a. Preparation.
Patients should be positioned in the supine sleeping position, occiput elevated by using the pedestal head (could use the pillow hard enough or infusion bottle 1 gram), so that the head of the state of extension and tracheal and laryngoscope are in a straight line.

b. Oxygenation.
After anesthesia and given muscle paralytic, do oxygenation by administering 100% oxygen at least done for 2 minutes. Facemask held with his left hand and a balloon with your right hand.


c. Laryngoscope.
The patient's mouth open with his right hand and held laryngoscope handle with your left hand. Leaves laryngoscope is inserted from the left corner and the field of view will open. Leaf driven laryngoscope into the oral cavity. The handle is lifted with the left arm and will be visible uvula, pharynx and epiglottis. Extension of the head is maintained with the right hand. Removed so that it looks aritenoid epiglottis and vocal cords that look whitish V-shaped

d. Endotracheal tube installation.
Pipe is inserted through the right-hand corner of your mouth right up to the balloon tube through the vocal cords right. If necessary, before entering the pipe assistant was asked to press the larynx to the posterior vocal cords so that would be clearly visible. When the interrupt, stilet be revoked. Ventilation or oxygenation is given by the right hand and left hand balloon pump fixate. The balloon leaves the pipe was developed and subsequently released laryngoscope tube fixed with tape.

e. Controlling the location of the pipe.
Certainly expand when given chest vents. During ventilation, performed chest auscultation with a stethoscope, breath sounds are expected to the right and left alike. When the chest is pressed there was air flow in endotracheal tube. Endotracheal intubation in the event there will be signs of a different right breath sounds breath sounds left, sometimes arise wheezing sound, more secretions and airway resistance was more severe. If there is a vent to one side like this, the pipe is pulled slightly to vent both lungs together. Whereas in case of intubation into the esophagus or gastric epigastrum the region will expand, while the sound of ventilation (with a stethoscope), sometimes out of gastric fluid, and the longer the patient will appear more blue. For this pipe removed and intubation performed again after being given adequate oxygenation.

f. Ventilation.
Provision of ventilation in accordance with the needs of the patient concerned.
3.7 Step-by-step installation
A. Prepare equipment and patient
2. Wash your hands
3. Wear a mask covering the nose and mouth and gloves
4. Adjust the position of the patient, the head extension, neck flexion
5. The right hand holds the patient's lips and open mouth
The left hand holds laringoscope, insert the blade of the right of the mouth, carrying part of the tongue to the left until you see the uvula and the epiglottis.
6. From the outside tap the thyroid cartilage to help open the epiglottis
7. Insert the endotracheal tube with a tilt to the right direction and after entering the turn toward the middle
8. Fill the balloon with the syringe is empty endotracheal
9. Connect with ventilator endotracheal / bag
10. Listen to breath sounds with a stethoscope into the esophagus, too right or too left of the bronchus
11. Fixation using a plaster



Intubation steps




3.8 Drugs Used.

The following are medications commonly used in endotracheal intubation measures (Anonymous, 1986), among others:

a. Suxamethonim (Succinil Choline), short-acting muscle relaxant is the most popular drugs for rapid intubation, easily and automatically when combined with a barbiturate IV with doses of 20 -100 mg, given once the patient is anesthetized, working less than 1 minute and the effect lasts a few minutes. Barbiturates are also good suxamethonium for nasal intubation blind, suxamethonium may be given IM when I.V. difficult for example in infants.
b. Thiophentone non depolarizing relaxants: a good method for the direct vision intubation. After administration of nondepolarizing / thiophentone, then the provision of O2 with a positive pressure (2-3 minutes) after laryngoscopy can do this. This method is not suitable for those who learned intubation, which may be faced with patients with vocal cord apneu that does not appear.
c. Cyclopropane: mendepresi blind vision and made breathing difficult intubation.
d. I.V. Barbiturates should not be used thiopentone alone in intubation. Laryngeal irritability rising, while the relaxation of the muscles does not exist and in large doses can mendepresi breathing.
e. N2O/O2, can not be used for intubation when used without the addition of other substances. addition of ethylene triklor facilitate blind intubation, but did not provide the necessary relaxation for laryngoscopy.

f. Halothane (Fluothane), this agent quickly relaxes the muscles of the larynx and pharynx and can be used without relaxants for intubation.
g. Local analgesia can be used in ways as follows:
- Sucking lozenges anagesik.
- Spray the mouth, pharynx, cord.
- Blockade of bilateral superior laryngeal nerves.
- Trans-tracheal injection.

These methods can be combined with a valium IV so that patients can be more calm. By itself in emergency circumstances. Intubation can be performed without anesthesia. Also on necnatus can diintubai without anesthesia.

Complications of endotracheal intubation 3.9.

A. Laryngoscope and the complications of intubation (Anonymous, 1989)
a. Malposition of esophageal intubation, endobronchial intubation laryngeal cuff and malposition.
b. The airway trauma in the form of tooth decay, lip lacerations, tongue or mucosa of the mouth, throat injury, dislocation of the mandible and dissection retrofaringeal.
c. Reflex disorders include hypertension, tachycardia, increased intracranial pressure, increased intraocular pressure and spasm of the larynx.
d. Malfunction of a perforated tube cuff.

B. Complications of endotracheal tube entry.

a. Malposition of the place itself extubation, endobronchial intubation to laryngeal cuff and malposition.
b. Trauma airway inflammation and ulceration of the mucosa, and nasal skin excoriation
c. Tubal malfunction of obstruction.

C. Complications after extubation.

a. Airway trauma in the form of edema and stenosis (glottis, or trachea subglotis), shortness or hoarse voice (granuloma or paralysis of the vocal cords), malfunctions and aspirations of the larynx.
b. Reflex spasm of laryngeal disorders.

3.8 Drugs Used.

The following are medications commonly used in endotracheal intubation measures (Anonymous, 1986), among others:

a. Suxamethonim (Succinil Choline), short-acting muscle relaxant is the most popular drugs for rapid intubation, easily and automatically when combined with a barbiturate IV with doses of 20 -100 mg, given once the patient is anesthetized, working less than 1 minute and the effect lasts a few minutes. Barbiturates are also good suxamethonium for nasal intubation blind, suxamethonium may be given IM when I.V. difficult for example in infants.
b. Thiophentone non depolarizing relaxants: a good method for the direct vision intubation. After administration of nondepolarizing / thiophentone, then the provision of O2 with a positive pressure (2-3 minutes) after laryngoscopy can do this. This method is not suitable for those who learned intubation, which may be faced with patients with vocal cord apneu that does not appear.
c. Cyclopropane: mendepresi blind vision and made breathing difficult intubation.
d. I.V. Barbiturates should not be used thiopentone alone in intubation. Laryngeal irritability rising, while the relaxation of the muscles does not exist and in large doses can mendepresi breathing.
e. N2O/O2, can not be used for intubation when used without the addition of other substances. addition of ethylene triklor facilitate blind intubation, but did not provide the necessary relaxation for laryngoscopy.

f. Halothane (Fluothane), this agent quickly relaxes the muscles of the larynx and pharynx and can be used without relaxants for intubation.
g. Local analgesia can be used in ways as follows:
- Sucking lozenges anagesik.
- Spray the mouth, pharynx, cord.
- Blockade of bilateral superior laryngeal nerves.
- Trans-tracheal injection.

These methods can be combined with a valium IV so that patients can be more calm. By itself in emergency circumstances. Intubation can be performed without anesthesia. Also on necnatus can diintubai without anesthesia.

Complications of endotracheal intubation 3.9.

A. Laryngoscope and the complications of intubation (Anonymous, 1989)
a. Malposition of esophageal intubation, endobronchial intubation laryngeal cuff and malposition.
b. The airway trauma in the form of tooth decay, lip lacerations, tongue or mucosa of the mouth, throat injury, dislocation of the mandible and dissection retrofaringeal.
c. Reflex disorders include hypertension, tachycardia, increased intracranial pressure, increased intraocular pressure and spasm of the larynx.
d. Malfunction of a perforated tube cuff.

B. Complications of endotracheal tube entry.

a. Malposition of the place itself extubation, endobronchial intubation to laryngeal cuff and malposition.
b. Trauma airway inflammation and ulceration of the mucosa, and nasal skin excoriation
c. Tubal malfunction of obstruction.

C. Complications after extubation.

a. Airway trauma in the form of edema and stenosis (glottis, or trachea subglotis), shortness or hoarse voice (granuloma or paralysis of the vocal cords), malfunctions and aspirations of the larynx.
b. Reflex spasm of laryngeal disorders





REFERENCE


1. Anonim, (1986), Kesimpulan Kuliah Anestesiologi, edisi pertama, Aksara Medisina, Jakarta.
2. Anonim, (1989), Anestesiologi, edisi pertama, Bagian Anestesiologi dan Terapi Intensif Fakultas Kedokteran Universitas Indonesia, Jakarta.
3. Anonim, (2002), Endotracheal Intubation, http://www.medicinet.com/script/main/art.asp?li=mni&articlekey=7035
4. Gail Hendrickson, RN, BS., (2002), Intubation, http://www.health.discovery.com/diseasesandcond/encyclopedia/1219.html
5. Gisele de Azevedo Prazeres, MD., (2002), Orotracheal Intubation, http://www.medstudents.com/orotrachealintubation/medicalprocedures.html
6. Halliday HL., (2002), Endotracheal Intubation at Birth for Preventing Morbidity and Mortality in Vigorous, Meconium-stained Infants Bord at Term, http://www.update-software.com/ceweb/cochrane/revabstr/ab000500.html
7. Mansjoer Arif, Suprohaita, Wardhani W.I., Setiowulan W., (ed)., (2002), Kapita Selekta Kedokteran, edisi III, Jilid 2, Media Aesculapius Fakultas Kedokteran Universitas Indonesia, Jakarta.
8. Michael B. Dobson, (1994), Penuntun Praktis Anestesi, EGC-Penerbit Buku Kedokteran, Jakarta.
9. Tjunt & Earley, (1995), Anatomy and Physiology, FA Davis Company, Philadelphia.
10. William, R. Peter, (1995), Gray’s Anatomy, Churchil Livingstone, New York.

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