Ebook Manual of ICU procedures: Part 1

(BQ) Part 1 book Manual of ICU procedures presents the following contents: Airway and respiratory procedures (endotracheal intubation, fiberoptic intubation, video laryngoscopy, surgical tracheostomy,...), vascular and cardiac procedures (tunneling of central venous catheter, intraosseous cannulation, umbilical vascular catheterization,...).

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Lucknow, Uttar Pradesh, India

Foreword

Arvind Kumar Baronia

New Delhi | London | Philadelphia | Panama

The Health Sciences Publisher

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Mobile: +08801912003485

E-mail: jaypeedhaka@gmail.com

Website: www.jaypeebrothers.com

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The views and opinions expressed in this book are solely those of the original contributor(s)/author(s) and do not

necessarily represent those of editor(s) of the book.

means, electronic, mechanical, photo copying, recording or otherwise, without the prior permission in writing of

the publishers

All brand names and product names used in this book are trade names, service marks, trademarks or registered

trademarks of their respective owners The publisher is not associated with any product or vendor mentioned in

this book.

Medical knowledge and practice change constantly This book is designed to provide accurate, authoritative

information about the subject matter in question However, readers are advised to check the most current

information available on procedures included and check information from the manufacturer of each product to be

administered, to verify the recommended dose, formula, method and duration of administration, adverse effects

and contra indications It is the responsibility of the practitioner to take all appropriate safety precautions Neither

the publisher nor the author(s)/editor(s) assume any liability for any injury and/or damage to persons or property

arising from or related to use of material in this book.

This book is sold on the understanding that the publisher is not engaged in providing professional medical services

If such advice or services are required, the services of a competent medical professional should be sought.

Every effort has been made where necessary to contact holders of copyright to obtain permission to reproduce

copyright material If any have been inadvertently overlooked, the publisher will be pleased to make the necessary

arrangements at the first opportunity.

Inquiries for bulk sales may be solicited at: jaypee@jaypeebrothers.com

Manual of ICU Procedures

First Edition: 2016

ISBN: 978-93-5152-422-9

Printed at

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Dedicated to

All men and women (including our patients) who, over the years, have contributed to develop standards for procedures, which being done

in critically ill patients, to improve safety with

better skills.

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Assistant Professor

Department of Physiotherapy

School of Allied Health Sciences

Manipal University

Manipal, Karnataka, India

Aditya Kapoor DM FACC

Professor

Department of Cardiology

Sanjay Gandhi Postgraduate

Institute of Medical Sciences

Afzal Azim MD PDCC FICCM

Additional Professor

Department of Critical Care Medicine

Amit Keshri MS

Assistant Professor

Unit of Neuro-otology

Department of Neurosurgery

Lucknow

Uttar Pradesh, India

Amol Kothekar MD IDCC

Assistant Professor

Intensive Care Medicine

Department of Anesthesia

Critical Care and Pain

Tata Memorial Hospital

Mumbai

Maharashtra, India

Anju Dubey MD

Assistant Professor

Department of Transfusion Medicine

All India Institute of Medical Sciences

Rishikesh, Uttarakhand, India

Armin Ahmed MD PDCC

Senior Research Associate Department of Critical Care Medicine Sanjay Gandhi Postgraduate Institute of Medical Sciences Lucknow, Uttar Pradesh, India

Arun G Maiya PhD PT

Dr TMA Pai Endowment Chair in Exercise Science and Health Promotion

Professor Department of Physiotherapy School of Allied Health Sciences Manipal University

Manipal, Karnataka, India

Arun K Srivastava MS MCh

Associate Professor Department of Neurosurgery Sanjay Gandhi Postgraduate Institute of Medical Sciences Lucknow, Uttar Pradesh, India

Arun Sharma MD PDCC

Consultant Critical Care Medicine Santokba Durlabhji Memorial Hospital Jaipur, Rajasthan, India

Atul P Kulkarni MD

Professor and Head Division of Critical Care Department of Anesthesia Critical Care and Pain Tata Memorial Hospital Mumbai, Maharashtra, India

Atul Sonker MD

Additional Professor Department of Transfusion Medicine Sanjay Gandhi Postgraduate Institute of Medical Sciences Lucknow, Uttar Pradesh, India

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viii Manual of ICU Procedures

Banani Poddar MD

Professor

Sir Ganga Ram Hospital

New Delhi, India

Biju Pottakkat MS MCh PDF FICS

Additional Professor and Head

Devesh Dutta MD FNB

Consultant

Department of Anesthesiology

Fortis Escorts Heart Institute

New Delhi, India

Devesh K Singh MS MCh

Senior Resident

Department of Neurosurgery

Dharmendra Bhadauria MD DM

Assistant Professor Department of Nephrology and Renal Transplantation Sanjay Gandhi Postgraduate Institute of Medical Sciences Lucknow, Uttar Pradesh, India

Divyesh Patel MD IDCCM

Consultant Intensivist Deenanath Mangeshkar Hospital Pune, Maharashtra, India

Eti Sthapak MS

Assistant Professor Department of Anatomy Era’s Lucknow Medical College and Hospital Lucknow, Uttar Pradesh, India

Fahri Yetisir MD

Associate Professor Department of General Surgery Atatürk Training and Research Hospital Ankara, Turkey

Gaurav Srivastava MD

Clinical Fellow Department of Hematology Peter MacCallum Cancer Center Melbourne, Australia

Girija Prasad Rath MD DM

Additional Professor Department of Neuroanesthesiology All India Institute of Medical Sciences New Delhi, India

Harsh Vardhan MD DM

Assistant Professor Department of Nephrology Indira Gandhi Institute of Medical Sciences Patna, Bihar, India

Hemanshu Prabhakar MD

Additional Professor Department of Neuroanesthesiology All India Institute of Medical Sciences New Delhi, India

Hemant Bhagat MD DM

Associate Professor Department of Anesthesia and Intensive Care Postgraduate Institute of

Medical Education and Research Chandigarh, India

Hira Lal MD

Additional Professor Department of Radiodiagnosis Sanjay Gandhi Postgraduate Institute of Medical Sciences Lucknow, Uttar Pradesh, India

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JV Divatia MD FICCM FCCM

Professor and Head

Department of Anesthesia,

Mumbai, Maharashtra, India

Jyoti Narayan Sahoo MD PDCC

Consultant Intensivist

Apollo Health City

Hyderabad, Telangana, India

Kamal Kataria MS

Research Associate

Department of Trauma Surgery

JPN Apex Trauma Center

New Delhi, India

Kamal Kishore MD

Associate Professor

Kapil Dev Soni MD

Assistant Professor

Critical and Intensive Care

JPN Apex Trauma Center

New Delhi, India

Kirti M Naranje MD

Assistant Professor

Department of Neonatology

Institute of Medical Sciences Lucknow, Uttar Pradesh, India

Manish Gupta MD FNB EDIC

Senior Consultant and Head Department of Critical Care Medicine Max Superspecialty Hospital New Delhi, India

Manish Paul MD

Clinical Observer Department of Critical Care Medicine Sanjay Gandhi Postgraduate Institute of Medical Sciences Lucknow, Uttar Pradesh, India

Mohan Gurjar MD PDCC FICCM

Associate Professor Department of Critical Care Medicine Sanjay Gandhi Postgraduate Institute of Medical Sciences Lucknow, Uttar Pradesh, India

MS Ansari MS MCh

Additional Professor Department of Urology Sanjay Gandhi Postgraduate Institute of Medical Sciences Lucknow, Uttar Pradesh, India

Namita Mehrotra MD

Assistant Professor Department of Radiodiagnosis Sanjay Gandhi Postgraduate Institute of Medical Sciences Lucknow, Uttar Pradesh, India

Narendra Agrawal MD DM

Consultant Hemato-oncology and Bone Marrow Transplantation Rajiv Gandhi Cancer Institute and Research Center New Delhi, India

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x Manual of ICU Procedures

Neeta Bose MD

Associate Professor

Gujarat Medical Education and

Research Society Medical College

Vadodara, Gujrat, India

Neha Singh MD

Assistant Professor

Institute of Medical Sciences and SUM Hospital

Bhubaneswar, Odisha, India

Nikhil Kothari MD PhD

Assistant Professor

Critical Care and Pain Medicine

Jodhpur, Rajasthan, India

King George’s Medical University

Nitin Garg MD FNB EDIC

Senior Consultant and Head

Rockland Hospital

New Delhi, India

Oskay Kaya MD

Associate Professor

Department of General Surgery

Dı şkapı Yıldırım Beyazit Research

and Training Hospital

Ankara, Turkey

Pradeep Bhatia MD

Professor and Head

Critical Care and Pain Medicine

Jodhpur, Rajasthan, India

Pralay K Sarkar MD DM MRCP (UK) FCCP

Assistant Professor

Division of Pulmonary and

Critical Care Medicine

Department of Medicine

Baylor College of Medicine

Ben Taub General Hospital

Houston, Texas, USA

Prasad Rajhans MBBS MD FICCM

Chief Intensivist Deenanath Mangeshkar Hospital, Pune Consultant in Emergency

Medical Services Symbiosis International University Pune, Maharashtra, India

Prashant Saxena MD EDIC FCCP

Consultant Department of Pulmonology, Critical Care and Sleep Medicine Saket City Hospital

New Delhi, India

Praveer Rai MD DM

Additional Professor Department of Gastroenterology Sanjay Gandhi Postgraduate Institute of Medical Sciences Lucknow, Uttar Pradesh, India

Puja Srivastava MD

Senior Resident Department of Clinical Immunology Sanjay Gandhi Postgraduate Institute of Medical Sciences Lucknow, Uttar Pradesh, India

Puneet Goyal MD DM

Associate Professor Department of Anesthesiology Sanjay Gandhi Postgraduate Institute of Medical Sciences Lucknow, Uttar Pradesh, India

Puneet Khanna MD

Assistant Professor Department of Anesthesiology All India Institute of Medical Sciences New Delhi, India

Rabi N Sahu MS MCh

Additional Professor Department of Neurosurgery Sanjay Gandhi Postgraduate Institute of Medical Sciences Lucknow, Uttar Pradesh, India

Raj Kumar Mani MD

Director Critical Care Pulmonology and Sleep Medicine Saket City Hospital

New Delhi, India

Rajanikant R Yadav MD

Assistant Professor Department of Radiodiagnosis Sanjay Gandhi Postgraduate Institute of Medical Sciences Lucknow, Uttar Pradesh, India

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Ravinder Kumar Pandey MD

New Delhi, India

Sanjeev Bhoi MD

Additional Professor Department of Emergency Medicine JPN Apex Trauma Center

All India Institute of Medical Sciences New Delhi, India

Sanjeev K Bhoi MD DM

Assistant Professor Department of Neurology Sanjay Gandhi Postgraduate Institute of Medical Sciences Lucknow, Uttar Pradesh, India

Saswata Bharati MD FIPM

Ex-Assistant Professor Department of Anesthesiology Calcutta National Medical College Kolkata, West Bengal, India

Saurabh Saigal MD IDCC PDCC EDIC

Assistant Professor Department of Trauma and Emergency Medicine All India Institute of Medical Sciences Bhopal, Madhya Pradesh, India

Saurabh Taneja MD FNB

Consultant Department of Critical Care Medicine Sir Ganga Ram Hospital

New Delhi, India

Sumit Ray MD FICCM

Senior Consultant Department of Critical Care Medicine Sir Ganga Ram Hospital

New Delhi, India

Sushma Sagar MS FACS

Additional Professor Department of Trauma Surgery JPN Apex Trauma Center All India Institute of Medical Sciences New Delhi, India

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xii Manual of ICU Procedures

Usha K Misra MD DM

Professor and Head

Department of Neurology

V Darlong MD

New Delhi, India

Vandana Agarwal MD FRCA

Associate Professor

Department of Anesthesia,

Mumbai, Maharashtra, India

Vijai Datta Upadhyaya MS MCh

Associate Professor

Department of Pediatric Surgical

Superspecialty

Vikas Agarwal MD DM

Department of Clinical Immunology

Virendra K Arya MD

Visiting Professor

Department of Anesthesia and

Perioperative Medicine

Winnipeg Regional Health Authority

University of Manitoba, Canada

Cardiac Anesthesia Unit

Advanced Cardiac Center

and Intensive Care

Postgraduate Institute of Medical

Education and Research

Chandigarh, India

Vishal Shanbhag MD IDCCM

Intensivist Kasturba Medical College Manipal University, Manipal, India Physician and Specialist

Critical Care Medicine Hamad Medical Corporation Doha, Qatar

Vivek Ruhela MD

Senior Resident Department of Nephrology and Renal Transplantation Sanjay Gandhi Postgraduate Institute of Medical Sciences Lucknow, Uttar Pradesh, India

VN Maturu MD

Senior Resident Department of Pulmonary Medicine Postgraduate Institute of

Medical Education and Research Chandigarh, India

Zafar Neyaz MD

Associate Professor Department of Radiodiagnosis Sanjay Gandhi Postgraduate Institute of Medical Sciences Lucknow, Uttar Pradesh, India

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Arvind Kumar Baronia MD

Professor and Head Department of Critical Care Medicine Sanjay Gandhi Postgraduate Institute of Medical Sciences

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As specialty, critical care medicine is now entering in its adulthood, there is a

lot of scope for improvement in teaching and training in this field Critical care

medicine is a unique specialty, where the sickest patients are being managed

with a wide spectrum of procedures In fact, there is need of hour to have a book

with a compilation of all common procedures being done in critically ill patients

for education and training purpose, despite easily available information on

individual topic in current era

Manual of ICU Procedures has 61 chapters, covering almost all relevant

procedures, including simple as well as more complex, done in critically and

acutely ill patients

The book has five different sections, such as airway and respiratory procedures, vascular and cardiac procedures, neurological procedures, gastrointestinal/

abdominal/genitourinary related procedures; while section miscellaneous covers

a few other procedures This book will be helpful to various clinicians across

specialty including critical care physicians, emergency physicians, anesthetists,

pulmonologists, pediatricians, general physicians and general surgeons

The splendid chapters are written by experts with their vast experience and knowledge from various specialties, keeping in mind that it is also intended for the

trainee students to help them to understand the procedures Most of the chapters

outline somewhat similar with headings such as introduction, indication,

contra-indication, applied anatomy, technique and equipment, preparation, steps of

procedure, the post-procedure care, and complication/problem associated with

the procedure

All the procedures described in the book may not be necessarily done by critical care physicians depend upon the local ICU policy, but understanding

these procedures will lead towards the optimal management of critically ill

patients As ever-evolving fast information and technology, changes may happen

in procedure’s technique and equipment, author advice to keep updated on

these issues in the future Readers should also be aware that complications and

problems for each procedure are highlighted briefly in the chapter, which may

not cover exhaustive list This is highly recommended by the author that being

nature of patients, procedures are supposed to learn under supervision as per

local policy, to achieve better skills while taking utmost care for safety to the

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I am indebted to all contributors, from various institutes and specialties, without their contribution, the book was not possible They kept patience with

me while making changes in the chapter for improvement and provided good

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Section 1 Airway and Respiratory Procedures

Ravinder Kumar Pandey, Rakesh Garg, V Darlong

Indication 3 • Contraindication 4 • Applied Anatomy and Physiology 4 • Technique and Equipment 5 • Preparation 8 • Procedure 11 • Complication/Problem 15

Pradeep Bhatia

Indication 17 • Contraindication 17 • Applied Anatomy 18

• Technique and Equipment 18 • Preparation 20 • Procedure 24

• Post-procedure Care 27 • Complication/Problem 27

Neeta Bose

Amol Kothekar, JV Divatia

Manish Paul, Banani Poddar

• Indication 62 • Contraindication 63 • Technique and Equipment 63

• Preparation 64 • Procedure 65 • Complication/Problem 68

6 Double Lumen Endotracheal Tube Placement 71

Kamal Kishore

• Technique and Equipment 72 • Preparation 73 • Procedure (For Left-Sided Double Lumen Tube) 74 • Post-procedure Care 76 • Complication/Problem 76

Kapil Dev Soni, Sanjeev Bhoi

• Technique 80 • Preparation 80 • Procedure 81

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Indication 129 • Contraindication 132 • Anatomical Details and Physiological Considerations 133 • Technique and Equipment 135

• Preparation 137 • Procedure 139 • Post-procedure Care 142

• Complication/Problem 144

11 Bronchoalveolar Lavage (BAL) and Mini-BAL 146

Sanjay Singhal

Indication 146 • Contraindication 147 • Technique 147 • Preparation 148

• Procedure 150 • Post-procedure Care 151 • Complication/Problem 152

Pralay K Sarkar

VN Maturu, Ritesh Agarwal

14 Non-invasive Ventilation for Acute Respiratory Failure 187

Raj Kumar Mani, Prashant Saxena

Indications of Non-invasive Ventilation 187 • Contraindications of Non-invasive Ventilation 188 • Technique and Basic Principles of Non-invasive Ventilation 188 • Preparation for Non-invasive Ventilation 194

• Starting, Monitoring and Weaning of Non-invasive Ventilation 196

• Complications of Non-invasive Ventilation 198

Sanjay Singhal, Mohan Gurjar

Indications for Uses of Aerosol Therapy 200 • Contraindication 200

• Principles of Aerosol Therapy 200 • Preparation 205

• Procedures for Delivering Aerosol Therapy 205 • Post-procedure Care 208

• Complication and Preventive Measures 209

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Contents xxi

Puneet Khanna, Girija Prasad Rath

Indication 210 • Contraindication 210 • Applied Anatomy and Pathophysiology 211 • Clinical Aspect and Technique 212

• Preparation 214 • Procedure 215 • Post-procedural Care 215

17 Manual Chest Physiotherapy in Ventilated Patients 218

Rajendra Kumar

Section 2 Vascular and Cardiac Procedures

Nikhil Kothari, Arun Sharma

19 Venous Cannulation: Central Venous Catheter 246

Afzal Azim, Abhishek Kumar

20 Venous Cannulation: Peripherally Inserted Central Catheter 261

Vandana Agarwal, Atul P Kulkarni

21 Tunneling of Central Venous Catheter 268

Dharmendra Bhadauria, Vivek Ruhela

Nishant Verma, Rakesh Lodha

23 Umbilical Vascular Catheterization 288

Kirti M Naranje, Banani Poddar

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Indication 322 • Technique and Basic Principles of Pressure Transducer 323

• Transducer Preparation and Pressure Measurement 328

• Troubleshooting 333

Jugal Sharma, Aditya Kapoor

Indication 336 • Contraindication 336 • Applied Anatomy and Physiology 336

Saurabh Taneja, Sumit Ray

Indication 345 • Contraindication 345 • Applied Physiology and Anatomy 346

Saswata Bharati, Nirvik Pal, Devesh Dutta

Indication 353 • Contraindication 354 • Technique and Basic Principles 355

Sushma Sagar, Kamal Kataria

Indication 386 • Contraindication 386 • Applied Physiology 387

• Technique 387 • Preparation and Procedure 388

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Contents xxiii

Section 3 Neurological Procedures

Bhaskar P Rao, Neha Singh

Rabi N Sahu, Kuntal Kanti Das, Arun K Srivastava

Devesh K Singh, Arun K Srivastava, Kuntal Kanti Das, Rabi N Sahu

Indication 435 • Contraindication 436 • Applied Anatomy and Physiology 436 • Technique and Basic Principles 439

Hemanshu Prabhakar

Indication 447 • Contraindication 448 • Applied Anatomy and Physiology 448

Sanjeev K Bhoi, Jayantee Kalita, Usha K Misra

Indication 454 • Contraindication 454 • Technique and Basic Principles 455 • Preparation 456 • Procedure 456

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Zafar Neyaz, Praveer Rai, Hira Lal

42 Percutaneous Endoscopic Gastrostomy 497

Samir Mohindra, Kundan Kumar

Indication 497 • Contraindication 498 • Technique and Equipment 498

43 Balloon Tamponade in Upper GI Bleed 506

Praveer Rai

Indication 506 • Contraindication 506 • Technique and Equipment 506

Manish Gupta, Nitin Garg

Indication 512 • Contraindication 513 • Technique 513 • Preparation 515 Procedure 515 • Post-procedure Care 517 • Complication/Problem 518

45 Intra-abdominal Pressure Monitoring 520

RK Singh

Indication 520 • Contraindication 521 • Applied Pathophysiology 521

Prasad Rajhans, Divyesh Patel

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Contents xxv

Hira Lal, Rajanikant R Yadav, Zafar Neyaz

49 Dynamic Abdominal Wall Closure for Open Abdomen 556

Fahri Yetisir, A Ebru Salman, Oskay Kaya

Indication 556 • Contraindication 556 • Technique 558 • Preparation 558 Procedure 559 • Post-procedure Care 560 • Complication/Problem 561

Vijai Datta Upadhyaya, Eti Sthapak

• Technique and Equipment 564 • Preparation 566

• Procedure (In Male Patient) 566 • Post-procedure Care 572

Vijai Datta Upadhyaya

52 Peritoneal Dialysis Catheter Placement 585

Basant Kumar, MS Ansari

Harsh Vardhan, Dharmendra Bhadauria

Indication 598 • History and Basic Principle 598 • Modalities of Renal Replacement Therapy 599 • Preparation 608 • Procedure 608

Section 5 Miscellaneous

54 Bone Marrow Aspiration and Biopsy 615

Gaurav Srivastava, Barnali Banik, Narendra Agrawal

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Mobilization 646 • Technique and Basic Principles of Mobilization 647

• Preparation and Assessment 650 • Physiotherapy Treatment 652

58 Surveillance of ICU-acquired Infection 658

Armin Ahmed, Richa Misra

Objective 658 • ICU-acquired Infection and Surveillance System 658

60 Blood Component Handling at Bedside 674

Atul Sonker, Anju Dubey

Blood Components: Basic Properties 674 • Bedside Handling of Blood Components 678 • Adverse Reaction Due to Blood Components 684

Puja Srivastava, Anupam Wakhlu, Vikas Agarwal

Definitions 690 • Prevention from Needle-stick Injury 691

• Post-exposure Prophylaxis 692 • Post-exposure Counseling 699 Index 703

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Manish Paul, Banani Poddar

6 Double Lumen Endotracheal Tube Placement

Ravindra M Mehta, Rohan Aurangabadwalla

11 Bronchoalveolar Lavage (BAL) and Mini-BAL

Sanjay Singhal

12 Thoracentesis

Pralay K Sarkar

13 Tube Thoracostomy

VN Maturu, Ritesh Agarwal

14 Non-invasive Ventilation for Acute Respiratory Failure

Raj Kumar Mani, Prashant Saxena

15 Aerosol Drug Delivery

Sanjay Singhal, Mohan Gurjar

16 Prone Positioning

Puneet Khanna, Girija Prasad Rath

17 Manual Chest Physiotherapy in Ventilated Patients

Rajendra Kumar

Airway and Respiratory

Procedures

SECTION 1

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The adequate oxygenation is paramount in a critically ill patient In such patients,

ventilatory assistance with patent airway may be required for optimizing the

oxygenation.1 Effective bag and mask ventilation is an important skill required

in such cases It may not only provide optimal ventilation till the establishment

of definite airway but also prove to be life-saving where endotracheal intubation

has failed and surgical or other definitive airway management technique has

been explored.2-4 Hence, positive-pressure ventilation using bag-mask-valve

device provides positive-pressure ventilation and thus may be life-saving

Though bag and mask ventilation appears to be simplest as well as single most

important emergency airway management technique but it has been reported

that in 2–5% of patients, bag and mask ventilation is difficult even by experienced

anesthesiologists.5,6 Hence, a good knowledge and understanding of the airway

anatomy, airway equipment, skill and regular practice is paramount for effective

and successful bag and mask ventilation The learning curve for bag and mask

ventilation has been studied in interns and the authors reported a failure rate of

less than 20% after 25 attempts of bag and mask ventilation.7 This emphasizes the

need for training and regular practice to maintain such an important skill of bag

and mask ventilation using bag-mask-valve device

INDICATION

The bag and mask ventilation may be life-saving in critically ill patients.8 Broadly,

the bag and mask ventilation is required for any patient requiring ventilatory

assistance to maintain oxygenation till a definitive airway with mechanical

ventilation using ventilator is initiated The indications include:8,9

– Neuromuscular diseases

• Failure of oxygenation:

– Increased metabolic demand, sepsis– Lung diseases with desaturation

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4 Section 1: Airway and Respiratory Procedures

CONTRAINDICATION

Bag-mask ventilation is contraindicated only in a selected group of patients like

complete upper airway obstruction or severe facial trauma (due to inadequate

mask seal and risk of aspiration due to bleeding) Before initiating bag and

mask ventilation, any visible foreign body in oral cavity should be removed The

technique of bag-mask ventilation requires caution in patients with suspected

cervical spine instability and should be avoided in patients with full stomach as

well as those planned for rapid sequence intubation (RSI).10-12

APPLIED ANATOMY AND PHYSIOLOGY

The upper airway comprises of nose oral cavity and pharynx.2,5,8,9 The pharynx

may be further divided into nasopharynx, oropharynx and laryngopharynx Any

insult of these anatomical structures may compromise the passage of airway

to glottis and then to lungs The provision of artificial airway may bypass these

structures to maintain passage of the air/oxygen to lungs The lower airway is

made up of trachea, bronchus and its divisions till alveoli It provides smooth

passage of air from upper airway till alveolar capillary membrane for its diffusion

into the blood and then to body tissues Any abnormality in these structures may

again compromise the oxygenation of the tissues and cells Not only these internal

complex but also the supportive structures like ribcage (ribs and muscles) and

diaphragm may also hamper the transfer of oxygen from outside into the blood

There are anatomical differences in the airway of children and adults and are important for airway management.13 The occiput of children is large and when

laid supine may lead to neck flexion leading to airway obstruction The tongue

is relatively larger with respect to oral cavity and can cause airway obstruction

Even a trivial trauma in the airway or tongue can lead to edema which may cause

airway obstruction The epiglottis is large and floppy; larynx is more anterior

and more angulated All these airway differences in children make their airway

more prone for obstruction and lead to difficult airway management including

bag and mask ventilation Children also have high respiratory rate and oxygen

metabolism They have lesser functional residual capacity and increased chest

wall compliance leading to their faster desaturation as compared to adults in

cases of any airway compromise

Ventilation is the movement of air in and out of the lungs Inspiration is an active process and requires the work of muscles including intercostal muscles

and diaphragm But in cases of labored breathing, certain accessory muscles are

also activated to maintain optimal ventilation On the other hand, exhalation is

passive process and may sometimes be an issue in conditions like obstructive

lung disease

The hypoxemia/hypoxia may happen due to inadequate alveolar oxygenation, alveolocapillary diffusion abnormalities, increased dead space, ventilation-

perfusion mismatch, or inadequate supply of oxygenated blood to cells In

presence of such problems, supplementing with high concentration of oxygen

may temporarily prevent hypoxia at tissue levels till the definitive measures

are taken care of During airway management, oxygen reserves may further be

increased with preoxygenation The preoxygenation can be accomplished by

providing 100% oxygen with tight-fitted mask for approximately three minutes

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and feel” Patient should be exposed and looked for chest rise (both sides), or any

abnormal pattern in breathing movement The rate, rhythm, quality and depth of

breathing movements should be assessed Listen for any abnormal breath sound

like gurgling, gasping, crowing, wheezing, snoring and stridor Also, auscultation

of chest needs to be done for checking the air entry on both sides and for assessing

any abnormal breath sound like rhonchi or crepts Feel for the air movements at

the external nares These assessments should be done in addition to other signs

of inadequate oxygenation like presence of cyanosis The sign of inadequate

is appropriate technique using airway adjuncts, if required A good seal is required

along with maintenance of a patent airway Mask holding can be done by either

one-hand technique or two-hand technique (see below) Certain adjuncts like

oral or nasal airway may aid in maintaining a patent airway This is achieved by

providing a support to oral structures, especially tongue and thus making the

hypopharynx patent for airflow

Cricoid Pressure (Sellick’s Maneuver)

Sellick’s maneuver provides external force to the anterior cricoid ring This

compresses the esophagus against the vertebra and prevents air entry into the

stomach and also prevents regurgitate entering the airway during

positive-pressure ventilation.16,17 The cricoid ring can be found by palpating the Adam’s

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apple and then identifying the ring just inferior to it During this maneuver,

one person will provide artificial ventilation and the second person will place

his two fingers on this ring and firmly press it backward while maintaining the

patient’s ventilation.18,19 However, there are also conflicting reports and some

controversies on whether cricoid pressure is really effective Nevertheless, cricoid

pressure is currently recommended and should be performed when possible

during resuscitation and all RSIs.20,21 The excessive force must not be applied so as

to avoid tracheal compression leading to airway obstruction It should be noted

that this technique will cause discomfort in the conscious patient and should be

limited to those patients who are unconscious This maneuver should be avoided

if the patient is vomiting or begins to vomit

Bag and Mask Ventilation in Children

The pediatric airway is always challenging due to some anatomical differences as

compared to adult airway This imposes some difficulty in airway management

with regards to effective ventilation.22,23 Children have large occiputs which may

make the neck flexed and thus may obstruct the airway Also, too much extension

may cause airway obstruction To overcome such issues, a roll may be inserted

under the shoulder on the back Children have a relatively large tongue that may

fall back into the oropharynx, which can cause airway obstruction Otherwise

innocuous materials like edema, secretions, vomitus or foreign body may obstruct

the relatively narrow airway of the children Any nasal secretions or obstructions

may functionally obstruct the airway as infants are obligate nasal breathers

Usually, airway suctioning is not required for newborns as suctioning may itself delay and hamper adequate oxygenation.24 This may also cause trauma

leading to airway edema in a narrow airway and thus may cause further airway

obstruction But presence of blood clots, vernix, or particulate meconium needs

to be cautiously removed without causing undue trauma

The availability of various sizes of mask makes selection of appropriate mask easier Some of us prefer circular mask with cushioned rim, as it appears to have

better seal with lesser trauma especially to eyes and nose The adequacy of

tidal volume needs to be judged with visible chest rise As per American Heart

Association (AHA) guideline (2010) ventilation rate should be 10–12 per minute

irrespective of children age (i.e same for both children and infant).25

Equipment

The following equipment are required for initiating the bag and mask ventilation

(Fig 1):

• Bag-valve-mask with reservoir: These are available in various sizes, types and

with additional features The sizes available include newborn, infant, child and adult (Fig 2) Bag-valve-mask (BVM) comprises of self-inflating bag, a non-rebreathing unidirectional valve, oxygen reservoir, ports for attachment

of oxygen and a mask (Fig 3) The unidirectional valve functions in both spontaneous and mechanical positive-pressure ventilation The assembly

is connected to an oxygen source which delivers oxygen with a minimum flow rate of 12–15 L/min This technique allows delivery of 90% oxygen.15Otherwise, only room air with 21% oxygen is entrained and thus reduces the delivered fraction of oxygen Facemasks are available in various designs,

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Fig 1 Equipment required for initiating the bag and mask ventilation

Fig 2 Different sizes of the bag and mask (self-inflating bag)

sizes and construction materials The masks are available in both opaque and transparent material but transparent one has a benefit of observing the patient mouth for any secretions or vomitus The face mask size should be appropriately chosen based on patient size, i.e the mask is chosen so as

to cover the patient’s face, i.e mouth and nose with upper margin over the bridge of nose and lower margin over the chin The BVM has standard 15/22 respiratory fitting to ensure a proper fit with other respiratory equipment like face masks and endotracheal tubes The working of BVM includes delivery

of oxygen on squeezing the bag through the mask At this point, the inlet is closed by diaphragm valve When the squeeze of the bag is released, a passive expiration by the patient will occur While the patient exhales, oxygen enters the reservoir to be delivered to the patient when next time the bag is squeezed

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In certain bag-mask-valve assemblies, especially in assemblies for infants, there is provision of an adjustable positive end expiratory pressure (PEEP) valve for better positive-pressure ventilation

of mandible (Figs 4 and 5) The OPA may be inserted by two techniques In one technique, OPA is inserted into the oral cavity with its concavity facing toward head and rotating it by 180 degrees when resistance to its further insertion

is met and then pushing it further The other technique requires tongue depressor Here, the tongue is depressed and OPA inserted directly into the oral cavity The size of NPA is measured from tip of the nose to the tragus of the ear (Figs 6 and 7) The NPA is lubricated and inserted into the more patent nares while facing posteriorly keeping it perpendicular to the face

PREPARATION

The patient may require bag and mask ventilation to assist the ventilation

in cases where equipment for definitive airway is being arranged or in cases

where the airway is difficult and conventional technique of securing the airway

has failed To buy time, till the expertise and special equipment like fiberoptic

bronchoscopy is being arranged, bag and mask ventilation may be used as rescue

technique to maintain oxygenation The assessment mandating the different

Fig 3 Parts of the self-inflating bag

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modality of airway assistance has been discussed above Appropriately done

bag and mask ventilation is usually effective Certain anatomical features give

an indication of difficult bag and mask ventilation These predictors include

presence of beard, edentulous patient, a body mass index greater than 26 kg/m2,

age older than 55 years, and a history of snoring.14 Other predictors of difficult

mask ventilation include oropharyngeal malproportion (Mallampati class III

or IV) and limited jaw protrusion.14

Figs 4A to C Adequacy of oropharyngeal airway size: (A) Small; (B) Correct; (C) Large

Fig 5 Placement of oropharyngeal airway

C

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Apart from BVM assembly and airway adjuncts, other accessory things required for bag and mask ventilation include:

Figs 6A to C Adequacy of nasopharyngeal airway size: (A) Small; (B) Correct; (C) Large

Fig 7 Placement of nasopharyngeal airway

C

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• Open the airway: The opening of the airway may require head-tilt chin-lift

maneuver or the jaw thrust The head-tilt needs to be avoided in patients of cervical spine injuries

• Suction: The oral cavity should be looked for any visible foreign body If visible,

remove the foreign body and perform suctioning for secretions or blood

• Airway adjunct: In cases of airway obstruction due to tongue fall, placement

of an airway adjunct like OPA or NPA is required Use OPA in patients who are unresponsive and do not have a gag reflex In case of conscious patient with airway obstruction due to tongue fall, placement of an NPA is desirable but should be avoided in events of head injury

Fig 8 Universal precautions material

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The excessive pressure should be avoided as downward pressure may lead

to tongue fall and pressure at submandibular area may also compromise the airway by pushing the tongue against the palate After optimal mask holding, bag is squeezed with the other hand to observe visible chest rise In case of difficult ventilation, a two-hand technique can be used (Figs 11 and 12).27

In this technique, one person holds the mask with both the hands and the other person squeezes the bag for ventilation The mask holding includes encirclement using thumb and index finger of the both the hands around the mask (Fig 10) The rest of the three fingers support the mandible and provide jaw thrust while maintaining a good tight seal The other technique

of the mask holding is using the thenar eminences of both the hands over

Fig 9 Head and neck position in a volunteer (pillow below head and head tilt)

Fig 10 Technique of mask holding (“EC” technique)

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Fig 12 Two-hand technique of mask holding (“thumb holding” method)

the mask and rest of the fingers lift up the mandible (Fig 12) Here as well, the other person squeezes the bag to provide mechanical ventilation

• Ventilation:

– Ensure the bag is attached to oxygen source with oxygen turned on to

a flow of 15 L/min Allow the reservoir to fill with oxygen prior to the first ventilation After achieving adequate mask seal, self-inflating bag

is squeezed so as to have visible chest rise Also, look for any gastric distension In that case, patient needs to be repositioned, so that air does not go to stomach During resuscitation, squeeze it over 1 second and wait for expiration to happen which is a passive procedure For optimal and effective ventilation, good mask seal and adequate bag squeezing

Fig 11 Two-hand technique of mask holding (“encircling” method)

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is required However, over and aggressive bag-mask ventilation causes stomach inflation and increases the risk of aspiration The goal is to achieve adequate gas exchange while keeping the peak airway pressures low

Squeezing the bag forcefully and abruptly creates a high-peak airway pressure and is more likely to inflate the stomach

– For effective ventilation, tidal volume required is 6–7 mL/kg per breath.28 The respiratory rate is kept at 10–12 breaths/min in patients with function-ing heart On the other hand, for patients with cardiopulmonary arrest, respiratory rate required is 8–10 breaths per minute In case of respiratory distress, BVM may be used to assist the patient respiratory efforts If PEEP

is required (adults only) connect the PEEP valve firmly to the expiratory flow diverter

• Assessment of adequacy of ventilation: Effective ventilation and oxygenation

should be judged by chest rise, breath sounds, pulse oximeter (SpO2), and exhaled CO2 monitoring (capnography).29,30 The presence of gastric distension indicates gastric insufflation during BMV

– Two-handed technique may be used in cases of ineffective mask ventilation with one-hand technique

In case of ineffective bag and mask ventilation, laryngeal mask airway (LMA) may be required for optimal ventilation till a definitive control of airway is done

Procedure Steps for Children

• Open and clean the airway.

– Careful head extension: Excessive extension of neck needs to be avoided

to prevent obstruction of the airway

– The mouth is opened and gentle suction of the oral cavity is done once or twice

• Make a mask seal

• Ventilation is initiated to target a visible chest rise for optimal ventilation

Observe any gastric inflation

– In case of ineffective ventilation: Recheck an optimal mask seal if leak is observed

– Patient positioning needs adjustment with optimal jaw thrust and avoiding excessive downward pressure or over the mandible

– OPA, NPA or LMA may be inserted if the problem of ineffective ventilation persists

• The effectiveness of ventilation is confirmed by observing:

– Increase in heart rate to more than 100 beats/min – Visible chest rise

– Rise in saturation

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– Supply of oxygen– Appropriateness of bag and valve mechanism– Adequacy of size and seal of the mask– Need of airway adjunct like OPA, NPA and LMA

• Patient:

– Clinical differential diagnosis– Position:

- Ear-sternal notch position

2 Levitan R Mask ventilation, rescue ventilation, and rescue intubation In: Levitan

R (Ed) The Airway Cam Guide to Intubation and Practical Emergency Airway Management Wayne, PA: Airway Cam Technologies, Inc 2004 p 49.

3 McGee J, Vender J Nonintubation management of the airway: Mask ventilation In:

Hagberg C (Ed) Benumof’s Airway Management, 2nd edition Philadelphia: Mosby

2007 p 345.

4 Yentis SM Predicting difficult intubation—worthwhile exercise or pointless ritual?

Anaesthesia 2002;57:105.

5 Kheterpal S, Han R, Tremper KK, Shanks A, Tait AR, O’Reilly M, et al Incidence and

predictors of difficult and impossible mask ventilation Anesthesiology 2006;105:

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10 Gausche M, Lewis RJ, Stratton SJ, Haynes BE, Gunter CS, Goodrich SM, et al Effect

of out-of-hospital pediatric endotracheal intubation on survival and neurological outcome: a controlled clinical trial JAMA 2000;283(6):783-90.

11 Schneider R, Murphy M Bag/mask ventilation and endotracheal intubation In:

Walls R, Murphy M (Eds) Manual of Emergency Airway Management, 2nd edition

14 Pandit JJ, Duncan T, Robbins PA Total oxygen uptake with two maximal breathing

techniques and the tidal volume breathing technique: a physiologic study of preoxygenation Anesthesiology 2003;99:841-6.

15 The American Heart Association in Collaboration with the International Liaison

Committee on Resuscitation Guidelines 2000 for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Part 6: Advanced cardiovascular life support: Section 3: Adjuncts for oxygenation, ventilation and airway control Circulation 2000;102:95.

16 Sellick BA Cricoid pressure to control regurgitation of stomach contents during

induction of anaesthesia Lancet 1961;2:404.

23 Grein AJ, Weiner GM Laryngeal mask airway versus bag-mask ventilation or

endotracheal intubation for neonatal resuscitation Cochrane Database Syst Rev

2005;2:CD003314.

24 Carrasco M, Martell M, Estol PC Oronasopharyngeal suction at birth: effects on arterial

oxygen saturation J Pediatr 1997;130:832-4.

25 Travers AH, Rea TD, Bobrow BJ, Edelson DP, Berg RA, Sayre MR, et al Par 4: CPR

overview: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Circulation 2010;122(18 Suppl 3):

S676-84.

26 Meier S, Geiduschek J, Paganoni R, Fuehrmeyer F, Reber A The effect of chin lift, jaw

thrust, and continuous positive airway pressure on the size of the glottic opening and

on stridor score in anesthetized, spontaneously breathing children Anesth Analg

30 Lee WW, Mayberry K, Crapo R, Jensen RL The accuracy of pulse oximetry in the

emergency department Am J Emerg Med 2000;18:427.

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Endotracheal intubation is the most commonly performed procedure in the

intensive care unit (ICU), in which a tube is placed into the trachea to maintain

an open airway, to allow the free flow of air to and from the lungs in unconscious

patients and in trauma patients who cannot maintain a patent, protected

airway; and also to support ventilation, who are unable to breathe adequately

on their own Airway control is vital to improve pulmonary gas exchange during

hemodynamic instability and respiratory failure, as well as to protect the patient

from aspiration Oral or nasal airways are often used to keep the airway patent

temporarily during preparation for endotracheal intubation Oxygen, anesthetics

or some medications can also be delivered through the tube

INDICATION

• Cardiac arrest

• Respiratory arrest

• Airway obstruction

• Imminent risk of upper airway obstruction (e.g upper airway burns)

• Facial injuries associated with compromised airway

• Altered mental status for protection from aspiration

• Head injury [Glasgow coma scale (GCS <8)]

• Need to control and remove pulmonary secretions

• Need for invasive ventilation in respiratory failure with inadequate oxygena

tion (which is not corrected by oxygen supplementation through mask/nasal cannula) or inadequate ventilation and hypercarbia

• Severe hemodynamic instability and shock

• General anesthesia with muscle relaxants

CONTRAINDICATION

For Both Oral and Nasal Intubations

• Patients with an intact gag reflex

• Partial transection of the trachea (can lead to complete transection)

• Patients with highrisk of laryngospasm during intubation (e.g children with

epiglottitis)

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• Caution with unstable cervical spine that requires inline cervical stabilization

makes endotracheal intubation difficult (relative contraindication)

• Severe airway trauma or obstruction providing very small area to place the

endotracheal tube (ETT) as attempts to intubate may worsen the condition resulting in severe respiratory obstruction Emergency cricothyrotomy/

tracheostomy is indicated in such cases (relative contraindication)

For Nasal Intubation

• Basilar skull fracture and cerebrospinal fluid (CSF) rhinorrhea

• Nasal polyp, abscess, adenoids or foreign body

• Bleeding disorders

• Previous nasal surgery is only relative contraindication

APPLIED ANATOMY

The upper airway (Fig 1) starts at the nostrils/oral cavity, to the hypopharynx

and larynx The high vascular areas of nasal and septal mucosa, the little’s area

and the Kiesselbach’s plexus may bleed profusely during nasal route intubation

especially in presence of bleeding disorder. The epiglottis is attached to the base

of the tongue by a median and two lateral glossoepiglottic folds The larynx is a

5–7 cm long structure Its upper boundary starts at the tip of the epiglottis, opposite

the third to fourthcervical vertebra Its lower end is at the lower border of the

cricoid cartilage, which lies at the level of sixth cervical vertebra The structural

rigidity of the larynx is provided by the three median cartilages: the epiglottis,

thyroid cartilage and cricoid cartilage along with the hyoid bone The six smaller

cartilages of the larynx (3 pairs) are functionally involved with the movements

of the vocal cords (Fig 2) These are the arytenoids, the corniculates and the

cuneiforms The arytenoid cartilages are pyramidshaped and articulate with

the superior margin of the cricoid lamina On their summit, are the corniculate

cartilages; on their anterior aspect, the cuneiform cartilages The vocal ligaments

are attached posteriorly to the apex of the arytenoids and corniculates The

cuneiforms extend laterally, between the layers of the vocal cords, from the

anterior aspect of the arytenocorniculate complex The trachea is a membranous

and Dshaped cartilaginous tube, with incomplete cartilaginous ring and extends

from the lower part of the larynx, at the level with the sixth cervical vertebra, up to

the upper border of the fifth thoracic vertebra, where it ends by dividing into the

two bronchi, one for each lung It is about 11 cm long and its diameter is greater

in the male (25–27 mm) than in the female (21–23 mm)

TECHNIQUE AND EQUIPMENT

In 1885, Joseph O’Dwyer, an American pediatrician and obstetrician, inserted

metal tubes between the vocal cords in patients with diphtheria and in patients

requiring surgery The first direct laryngoscopy was performed in 1895 by Alfred

Kirstein with an external light source In 1913, Chevalier Jackson designed a

laryngoscope and was the first to perform intubation with it Laryngoscope was

later modified by Magill, Miller and Macintosh.1,2

The traditional and most commonly used method of intubation is oral intubation using direct laryngoscopy Nasal intubation in ICU is better tolerated

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than oral tube, requires less sedation and leaves the oral cavity clear to maintain

oral hygiene The disadvantages of nasal intubation are—it is more difficult than

oral intubation and may result in bleeding due to the rich blood supply to the

nasal mucosa A nasal tube may create a false passage beneath nasal mucosa,

or in patients with basal skull fractures, into the cranium If kept for a long time,

nasal tube may be associated with infection of the paranasal air sinuses Other

methods of intubation include blind nasal intubation, intubation using video

laryngoscope, intubating laryngeal mask airway (LMA) and fiberoptic techniques

Fig 2 Laryngoscopic view of glottis

Source: With permission from http://www.airwaycam.com

Fig 1 Upper airway anatomy

Source: With permission from http://www.airwaycam.com

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Equipment

Most commonly used ETTs are made out of polyvinyl chloride and have a

radiopaque line that helps verify the tube position by Xray To make it easier to

pass through the vocal cords and to give you a better vision ahead of the tip, ETTs

tip have a cut called a bevel Some ETTs have an additional opening at the tip

called a Murphy’s, which provides an alternative channel for gas flow, if the main

opening of the ETT gets blocked or placed against the tracheal wall The ETT cuff

forms a seal against tracheal wall that prevents gas leaking during positive pressure

ventilation and also prevents aspiration of secretions and regurgitated gastric

contents There are two types of cuff Highvolume, lowpressure cuffs have a

lower risk of tracheal wall ischemia and necrosis compared to lowvolume high

pressure cuffs, particularly if used for a prolonged period of time In longterm

ventilated patients, subglottic secretions can accumulate above the cuff of the ETT

that provides medium for bacterial growth and increases the risk of ventilator

associated pneumonia (VAP) Especially designed tubes are available that permits

frequent or continuous elimination of subglottic secretions to decrease the risk

• Suction machine and catheters

• Oropharyngeal, nasopharyngeal airways (Figs 3 and 4, respectively)

• Nonrebreathing mask

• Oxygen source (15 L/minute flow)

• Bag valve mask

• Appropriate size ETTs (Adults: 7.5 mm; Children: Size roughly equal to the

diameter of little finger) (Fig 5) and a 10cc syringe

• Stylet, Magill’s forceps, Bougie (Figs 6 to 8, respectively)

• Laryngoscope blades, different types (Figs 9A to C)

• Adhesive tape

Fig 3 Oropharyngeal airway

Source: Fexicare

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Tài liệu tham khảo	Loại	Chi tiết
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