iot dificilstudenti08.ppt
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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
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VENTILATIA
Obiectivul final este sa pompam aer
in plamani.
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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
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CR
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Libertatea cailor aeriene
• CP
• P*+PITA,
• AN*+T*-I*
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Intubatia Tra!eostomia
NormalaDificila
"r#enta
• $unctia intercricotiroi%iana &HF'V
• (initra!eostomia
• Tra!eostomia c!irur#icala
• Tra!eostomia percutana
Colaborare ATI ) ORL
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Intubatia orotraheala (IOT)
• *'aluarea pacientului
• Pozitionarea pacientului
• .ateriale necesare• +ec'enta mane'relor
• Complicatii
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*'aluarea pacientului
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Formula a Dr. *innions+ un
mo% simplu %e a retine mai multe teste,
L oo e0ternall1#
E 'aluate the 2%2%3 rule#
( allampati#
O bstruction4
N ec mobilit1#
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L+ Loo- Eternall/
• Arsuri
• Trauma
&aciala
• Antec
ana&ila0ie
• +tridor
• Corp strain
• Obez / pitic
• 5at scurt muscular
• Piept mare/ lat
• etrognatie (6entures)
• 6inti de cal % incisi'iii (7uc Teeth)
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E+ Evaluarea re#ulii 0)0)1
• 6eschide gura 8 2 degete
• 9alca mai lata de 2 degete
• 8 3 degete de la &alca la gat
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(+ (allampati
• Clasa I : intubatie usoara ;;<
• Clasa I= : intubatie di&icila ;;<
• laringoscopia
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(allampati2 Cormac! si Le!an% A2 oralsi *2 ve%erea la larin#oscopie
># +e 'izualizeaza pilierii? palatul moale siu'ula
3# +e 'ad pilierii sipalatul moale? iaru'ula este ascunsa
sub baza limbii2# +e 'ede doar palatul
moale
@# Nu se 'ede nici
palatul moale
Clasa I se 'ad corzile 'ocaleClasa II corzile 'ocale se
'izualizeaza partial
Clasa III se 'ede doar epiglota
Clasa I= nu se 'ede nici epiglota
Clasa I : intubatie usoara ;;<
Clasa I= : intubatie di&icila ;;<
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O+ Obstruction3
• +ange+ange
• =arsatura=arsatura
• 6inti (!chiclets$)6inti (!chiclets$)• *piglota (edem glotic? &umatori")*piglota (edem glotic? &umatori")
• ProtezeProteze
• TumoriTumori• 6i'ersi corpi straini6i'ersi corpi straini
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A%enom larin#ian
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REIN4E5 EDE(A 6 "mflarea pliurilormucoasei la nivelul cor7ilor vocale la
fumatori
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$oate arata asa+
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N+ Nec- (obilit/
• Precautii la suspiciune de traumatism
cer'ical
• .al&ormatii
• Acces di&icil
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Pozitionarea pacientului
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$o7itionarea capului ptr IOT
• A Pozitie neutra#• B Capul ridicat#
• C Pozitia !sni&&ing? cu gatul&lectat si capul in e0tensie#
• 6e remarcat &aptul ca &le0iagatului si e0tensia capuluialiniaza di'ersele a0e sipermite intubatia# Aceastapozitie creeaza cea mai scurtadistanta si linia cea mai dreaptadintre dinti si corzile 'ocale#
• .N
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Alinierea aelor888
• perna Popitz :&le0ie
cer'icala si usoara
e0tensie atlanto%
occipitala# 9le0ia aliniazaa0ul &arige% laringe#
*0tensia mai mare a
capului :ade'arata
!sni&&ing position#!
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$e%iatrie
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Aspect normal al tra!eei a%ult si copil
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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
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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
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!en /ou cant breat!2not!in# else matters
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(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
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Larin#oscopul
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+onda IOT cu/ &ara balonas
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• Preo0igenare
• Abord 'enos
• Toate materialele / aparatele pregatite si 'eri&icate
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ecventa IOT
$ iti t li i i l i
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$o7itionarea corecta a clinicianului2pacientului2 si asistentei in momentul IOT
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$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)#
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Aspect normal al #lotei la a%ult
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Aspect normal al tra!eei la a%ult
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cala Cormac-)Le!ane lalarin#oscopie
• grade > tot laringele 'isibil
• grade 3 glota partial 'isibila
• grade 2
• grade @
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Verificarea IOT
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IOT incorect
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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
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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
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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
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Controlul ra%iolo#ic
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CALL FOR HEL$ 8888
tri#a %upa o mana %e autor
IOT %ificila
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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
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$roblema
• A loo bac JhatMs learnt &rom bitter
• 6i&&icult airJa1 is an interdisciplinar1 problem
• The diagnostics JasnMt? isnMt? and? apparentl1? JonMtbe accurate
• Hpdated noJledge? 'igilance? adeuatemonitoringand standardization is the e1 &or success%+tandards o& +a&e Anesthesia Practice (A+A? >;FG)%
Difficult AirGa/ Al#orit!m AA2 ;09• Alternati'e airJa1 de'ices re'olutionized outcomes
• *'er groJing interest &or a proper education
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Dimensiunea problemei
;< 1<<1
%onco!pliance &ith standardized action plan as &ell
as the absence of preplanned strate'( in case of
difficulties see!s to be the !ain proble!
American Society of Anesthesiologists Task Force on Management of the
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Difficlt Air!ay" #ractice gi$elines for the management of the $ifficlt
air!ay% Anesthesiology &8"5'&, ('')%*
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Difficult airGa/ al#orit!m
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Con&irm Tracheal Intubation or ,.A Placement Jith *0haled CO3
Ec!ipamentul necesar si de
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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#
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(ateriale ptr IOT %ificila
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DE RETIN"T8888
• .andren
• .asca laringiana
• Combitube
• .initraheostomia/ punctia
intercricotiroidiana
• 7ronho&ibroscopia
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$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
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(ANDREN2 #!i%2 intro%uctor
I t b ti i t l i ti
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Intubatia prin transluminatieTrachlightQ
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Dispo7itive supra#lotice
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(asca larin#iana
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(asca larin#iana
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Combi)tube
• +e plaseaza orb si permite 'entilatia in urgenta ? daca seplaseaza &ie in eso&ag &ie in trahee
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Fleible intubation fiberscopes
• the 5old +tandard &or di&&icult airJa1 management
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*ron!ofibroscopia
• Imagine de di'iziune normala a bronsiei
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(asca pentru fibroscopie
• masca ptr &ibroscopie
permite &ibroscopia si
'entilatia simultana a
pacientului pentru a
creste con&ortul si
calitatea in'estigatiei#
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INT INT"*ATIE na7ala oarba
• +onda mai mica
• Curbura sondei
• ,ezare cornete % secretii
Complicatiile intubatiei
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Complicatiile intubatieioroKna7o)tra!eale
• la plasarea son%ei
• in timpul V(
• %upa etubare
• la sc!imbarea son%ei• intubatia DIFICILA
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IOT nereusita
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Abor%ul c!irur#ical al CR
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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
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The onl/ indication
&or a surgical airJa1 is
the inabilit/ to establish anairJa1 b1 an1 other method#
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Tra!eostomia
• Punctia intercricotiroidiana BU9S=
• .initraheostomia/ cricotiroidotomia ur#ena
• Traheostomia chirurgicala
• Traheostomia percutana % NH ur#ena
Re#iunea anterioara a #atului
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Re#iunea anterioara a #atuluilarin#ele
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>#corzi 'ocale 3#cartilaK tiroid 2# cartilaK cricoid @#
cartilaK tiroid # balon sonda
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Dispo7itive infra#lotice
Cricotiroi%otomia pe ac
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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
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,ocalizare/palpare
membrana cricotiroidiana
8/19/2019 IOT DIFICILSTUDENTI08.ppt
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,ocalizare membrana cricotiroidiana
8/19/2019 IOT DIFICILSTUDENTI08.ppt
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Pozitionarea corecta ptr punctia
cricotiroidiana (intercricotiroidiana)
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Set 'entilatia la
cricotirotomia pe ac
'et ventilatia )!i#!)freMuenc/
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'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
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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
8/19/2019 IOT DIFICILSTUDENTI08.ppt
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p 9minitra!eostomie
Canula pozitionata corect
8/19/2019 IOT DIFICILSTUDENTI08.ppt
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Canula pozitionata corect
in trahee
+tabilizarea laringelui cu e&ectuarea
8/19/2019 IOT DIFICILSTUDENTI08.ppt
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inciziei la piele (>%3 cm) deasupra
membranei cricotiroidiene
*&ectuarea unei incizii orizontale lai l (> 3 ) d i i i i
8/19/2019 IOT DIFICILSTUDENTI08.ppt
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piele(>%3 cm) deasupra inciziei
prin membrana cricotiroidiana
9olosirea unei pense curbe
8/19/2019 IOT DIFICILSTUDENTI08.ppt
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9olosirea unei pense curbe?
cu dilatarea membranei cricotiroidiene
I i d IOT (G D)
8/19/2019 IOT DIFICILSTUDENTI08.ppt
http://slidepdf.com/reader/full/iot-dificilstudenti08ppt 89/106
Inserarea unei sonde IOT (G#D)
sau canule (G#D)
H &l b l l i
8/19/2019 IOT DIFICILSTUDENTI08.ppt
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Hm&larea balonasului
C &i i i i l i
8/19/2019 IOT DIFICILSTUDENTI08.ppt
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Con&irmarea pozitiei canulei
9i l i &i iti i
8/19/2019 IOT DIFICILSTUDENTI08.ppt
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9i0area canulei? recon&irmarea pozitiei
canulei? e'aluarea pacientului
Tipuri de canule de traheostoma
8/19/2019 IOT DIFICILSTUDENTI08.ppt
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p
Aparat Transtra!eal et ventilation asamblat
8/19/2019 IOT DIFICILSTUDENTI08.ppt
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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
8/19/2019 IOT DIFICILSTUDENTI08.ppt
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a eosto a c u # ca a
TruseTruse
ptr traheostomieptr traheostomie
perc tanapercutana dilatati a (TPD)dilatativa (TPD)
8/19/2019 IOT DIFICILSTUDENTI08.ppt
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percutanapercutana dilatativa (TPD)dilatativa (TPD)
Pregatire material TPDPregatire material TPD
8/19/2019 IOT DIFICILSTUDENTI08.ppt
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Pregatire material TPDPregatire material TPD
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Te!nica T$D
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Complicatii peroperatorii
8/19/2019 IOT DIFICILSTUDENTI08.ppt
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• 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
8/19/2019 IOT DIFICILSTUDENTI08.ppt
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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
8/19/2019 IOT DIFICILSTUDENTI08.ppt
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• In T#I#
• Cost redus
• Nursing• Alimentatie PO
• +e'rare =.
• Cicatrizare rapida
• +echele minime
Ori&iciul traheal dupa
8/19/2019 IOT DIFICILSTUDENTI08.ppt
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decanulare
8/19/2019 IOT DIFICILSTUDENTI08.ppt
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Cn% nu poi respira2 nimic nu mai contea7...
T!e !app/ en%
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