Gostaríamos de agradecer ao departamento de anestesia do Hospital Infantil de Michigan por seus esforços e financiamento deste projecto. Gostaríamos de agradecer ao departamento de BMC no Hospital St Jude Children Research para o seu trabalho de arte.

<ol><li> Um tamanho de tubo endotraqueal adequado para a idade do paciente para intubação endotraqueal deve ser escolhido. Usamos a fórmula: ETT size = idade (anos) / 4 +4. </li><li> Nós escolhemos um tamanho menor do tubo endotraqueal sem balonete para ser inserido por via nasal, caso a entubação endotraqueal falha após o paciente é colocado para dormir. </li><li> Antes da inserção do tubo nasal, medimos a distância aproximada do nariz ao nível das cordas vocais, que normalmente é ao nível da cartilagem tireóide mid. </li><li> Depois o paciente é anestesiado e, após uma fracassada tentativa de ventilação entubação endotraqueal e falhou, o bem lubrificado um tamanho menor do tubo endotraqueal será inserido por via nasal a um nível um pouco acima das cordas vocais. </li><li> É preciso assegurar uma boa vedação da boca e narinas do paciente. O circuito de anestesia pode ser ligado ao conector do tubo ET, e com vedação adequada da boca e do nariz, os pulmões podem ser adequadamente ventilados. </li></ol> Após a selagem do nariz e da boca, dos pulmões estão adequadamente ventilado como confirmado por ETCO2 forma de onda, peito subindo do paciente e boa saturação de oxigênio no oxímetro de pulso.

<ol>
	<li>Heidegger, T., Gerig, H. J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Algorithms+for+management+of+the+difficult+airway.">Algorithms for management of the difficult airway.</a> Curr Opin Anaesthesiol. 17, 483-484 (2004).</li><li>Krafft, P., Schebesta, K. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Alternative+management+techniques+for+the+difficult+airway:+esophageal-tracheal+Combitube.">Alternative management techniques for the difficult airway: esophageal-tracheal Combitube.</a> Curr Opin Anaesthesiol. 17, 499-504 (2004).</li></ol>

Esta técnica é comparável a um dispositivo supraglótico das vias aéreas, como uma máscara laríngea da via aérea 1 ou um combitubo 2, sendo que ambos foram sucesso descrito como técnicas de salvamento em situação CICV para garantir a ventilação e oxigenação como técnica não-cirúrgicos. Esta técnica ETT, entretanto, tem a facilidade de disponibilidade e prontidão, não necessitando de nenhum treinamento ou equipamento especial. Em casos de CICV e, especialmente, em neonatos e cria...

<table><tbody><tr><td>ETT size appropriate for patient&amp;rsquo;s age: ETT=age/4 +4</td><td></td><td></td><td></td></tr><tr><td>tape to protect the eyes</td><td></td><td></td><td></td></tr><tr><td>decongestant and lubricant to use in the nostril</td><td></td><td></td><td></td></tr><tr><td>ASA standard anesthesia monitors</td><td></td><td></td><td></td></tr><tr><td>red rubber suction catheter</td><td></td><td></td><td></td></tr><tr><td>Anesthesia circuit and mask</td><td></td><td></td><td></td></tr></tbody></table>

a novel rescue technique for difficult intubation and difficult ventilation

Descrevemos uma técnica não cirúrgica novela para manter a oxigenação e ventilação em um caso de dificuldade de intubação e ventilação difícil, que funciona especialmente bem com ajuste máscara pobres. Não pode entubar, não pode ventilar &quot;(CICV) é uma situação potencialmente fatal. Neste vídeo, apresentamos uma simulação da técnica utilizada em um caso de onde CICV oxigenação e ventilação foram mantidos através da inserção de um tubo endotraqueal (ETT) por via nasal até o nível do naso-faringe, enquanto vedação da boca e narinas de ventilação com pressão positiva de sucesso. Um paciente de 13 anos foi levado ao centro cirúrgico para a incisão e drenagem de um abcesso no pescoço e laryngobronchoscopy direta. Após pré-oxigenação, a anestesia foi induzida por via intravenosa. Ventilação com máscara foi encontrado para ser extremamente difícil por causa do inchaço dos tecidos moles. A máscara não poderia encaixar corretamente no rosto devido ao inchaço facial significativa também. A laringoscopia direta foi tentada sem visualização da laringe. Saturação de oxigênio era difícil de manter, com saturações caindo para 80%. , A fim de oxigenar e ventilar o paciente, um tubo endotraqueal foi então introduzida por via nasal após spray nasal com descongestionante nasal e lubrificantes. O tubo foi empurrado suavemente e cegamente na hipofaringe. A boca eo nariz do paciente foram selados com a mão e ventilação com pressão positiva foi possível com 100% de O 2, com boa saturação de oxigênio durante esse período de tempo. Assim que o paciente era estável e bem sedado, um broncoscópio rígido foi introduzido pelo otorrinolaringologista mostrando edema subglótica e epiglótico extensa, e um efeito de massa do abscesso, contribuindo para o compromisso das vias aéreas. A via aérea foi fixada com um tubo ETT pelo vídeo otolaryngologist.This vai mostrar uma simulação da técnica em um paciente submetido a anestesia geral para restaurações dentárias.

Watch this Scientific Journal Video about A Novel Rescue Technique for Difficult Intubation and Difficult Ventilation at JoVE.com

A Novel Rescue Technique for Difficult Intubation and Difficult Ventilation

Nós descrevemos uma técnica para manter a oxigenação e ventilação utilizando um tubo endotraqueal inserido por via nasal ao nível do naso-faringe, enquanto vedação da boca e narinas de ventilação com pressão positiva de sucesso.

A Técnica de Resgate Novel para intubação difícil e Ventilação Difícil

We describe a novel non surgical technique to maintain oxygenation and ventilation in a case of difficult intubation and difficult ventilation, which ...

a-novel-rescue-technique-for-difficult-intubation-difficult

Research

JoVE Journal

Medicine

21.4K visualizações.  Children’s Hospital of Michigan. Nós descrevemos uma técnica para manter a oxigenação e ventilação utilizando um tubo endotraqueal inserido por via nasal ao nível do naso-faringe, enquanto vedação da boca e narinas de ventilação com pressão positiva de sucesso.

Vídeo: A Novel Rescue Technique for Difficult Intubation and Difficult Ventilation

Endotracheal Intubation in Mice via Direct Laryngoscopy Using an Otoscope

Mice, both wildtype and transgenic, are the principal mammalian model in biomedical research currently. Intubation and mechanical ventilation are necessary for whole animal experiments that require surgery under deep anesthesia or measurements of lung function. Tracheostomy has been the standard for intubating the airway in these mice to allow mechanical ventilation. Orotracheal intubation has been reported but has not been successfully used in many studies because of the substantial technical difficulty or a requirement for highly specialized and expensive equipment. Here we report a technique of direct laryngoscopy using an otoscope fitted with a 2.0 mm speculum and using a 20 G&#160;intravenous catheter as an endotracheal tube. We have used this technique extensively and reliably to intubate and conduct accurate assessments of lung function in mice. This technique has proven safe, with essentially no animal loss in experienced hands. Moreover, this technique can be used for repeated studies of mice in chronic models.

Endotracheal Intubation in Mice via Direct Laryngoscopy Using an Otoscope

We have developed a simple, reliable, and relatively inexpensive method for endotracheal intubation in mice via direct laryngoscopy using an otoscope with a 2.0 mm speculum. This technique is atraumatic and can be used for repeated measurements in chronic experiments. We find it superior to tracheostomy or previously reported nonsurgical techniques.

Entubação endotraqueal em Ratos<em&gt; Via</em&gt; Laringoscopia direta Usando um otoscópio

Mice, both wildtype and transgenic, are the principal mammalian model in biomedical research currently. Intubation and mechanical ventilation are ...

Medicina

Repeated Orotracheal Intubation in Mice

The literature describes several methods for mouse intubation that either require visualization of the glottis through the oral cavity or incision in the ventral neck for direct confirmation of cannula placement in the trachea. The relative difficulty or the tissue trauma induced to the subject by such procedures can be an impediment to an investigator&#8217;s ability to perform longitudinal studies. This article illustrates a technique in which physical manipulation of the mouse following the use of a depilatory to remove hair from the ventral neck permits transcutaneous visualization of the trachea for orotracheal intubation regardless of degree of skin pigmentation. This method is innocuous to the subject and easily achieved with a limited understanding of murine anatomy. This refined approach facilitates repeated intubation, which may be necessary for monitoring progression of disease or instillation of treatments. Using this method may result in a reduction of the number of animals and technical skill required to measure lung function in mouse models of respiratory disease.

The goal of this article is to describe a refined method of intubation of the laboratory mouse. The method is noninvasive and, therefore, ideal for studies that require serial monitoring of respiratory function and/or instillation of treatments into the lung.

Intubação Orotraqueal Repetida em Camundongos

The literature describes several methods for mouse intubation that either require visualization of the glottis through the oral cavity or incision in the ...

The Rigid Tube as an Alternative in Controlling the Problematic Airway

The unexpected problematic airway represents a large proportion of anesthesia-related morbidity and mortality. The retromolar or paraglossal approach is an alternative to the majority of the rigid instruments used for tracheal intubation, which follow the midline to access the glottis. This single-center, prospective case-series study offers an option to conventional laryngoscopy in case of a poor glottic view, introducing an instrument (the rigid tube for laryngoscopy) that uses the retromolar approach to accomplish tracheal intubation. If after anesthesia induction, the modified Cormack-Lehane glottis view grade &#62;2b, the intubation is carried further with the rigid tube. The tube follows the direction of the thyroid cartilage while advancing from the labial commissure, displacing the tongue to the contralateral side. Adjusting the position of the larynx with the nondominant hand by gently pushing the thyroid cartilage and following an imaginary line towards it while advancing it improves the time needed for proper glottis visualization. Once the epiglottis is in sight, the practitioner progresses slowly, lifting the epiglottis and aiming the tip of the tube more anteriorly. When the glottis appears in the visual field, the intubating tube introducer is placed in the trachea, and a lubricated cuffed intubating tube is advanced over the introducer after the rigid tube is extracted. This tool was tested on 30 patients with an unsatisfactory glottic view when using the Macintosh laryngoscope and obtained excellent results with respect to intubation time and complications. The reduced visual field is the main limitation of this method, which requires a training period for reasonable expertise. This simple, robust, and cheap instrument could be a rescue option in case of a difficult airway.

Presented here is a protocol of tracheal intubation over an intubating tube introducer using a rigid tube for laryngoscopy with an attached light source. The main characteristics of this maneuver are the retromolar approach and the use of the thyroid cartilage as a landmark while advancing the rigid tube.

O tubo rígido como alternativa no controle das vias aéreas problemáticas

The unexpected problematic airway represents a large proportion of anesthesia-related morbidity and mortality. The retromolar or paraglossal approach is ...

Endotracheal Intubation Using a Flexible Intubation Endoscope as a Standardized Model for Safe Airway Management in Swine

Endotracheal intubation is often a basic requirement for translational research in porcine models for various interventions that require a secured airway or high ventilation pressures. Endotracheal intubation is a challenging skill,&#160;requiring a minimum number of successful endotracheal intubations to achieve a high success rate under optimal conditions, which is often unachievable for non-anaesthesiology researchers. Due to the specific porcine airway anatomy, a difficult airway can usually be assumed. The impossibility of establishing a secure airway can result in injury, adverse events, or death of the laboratory animal. Using a prospective, randomized, controlled evaluation approach, it has been shown that fiberoptic-assisted endotracheal intubation takes longer but has a higher first-pass success rate than conventional intubation without causing clinically relevant drops in oxygen saturation. This model presents a standardized regimen for endoscopically guided endotracheal intubation, providing a secured airway, especially for researchers who are inexperienced in the technique of endotracheal intubation via direct laryngoscopy. This procedure is expected to minimize animal suffering and unnecessary animal losses.

The use of pigs in research has increased in recent years. Nevertheless, pigs are characterized by difficult airway anatomy. By demonstrating how to perform endoscopically guided endotracheal intubation, the present protocol aims to further increase laboratory animals' safety to avoid animal suffering and unnecessary death.

Intubação endotraqueal usando um endoscópio de intubação flexível como modelo padronizado para o manejo seguro das vias aéreas em suínos

Endotracheal intubation is often a basic requirement for translational research in porcine models for various interventions that require a secured airway ...

An Educational Video Demonstration of How to Prone a Critically Ill Intubated Patient

Early in the coronavirus disease 2019 (COVID-19) pandemic, it was reported that prone position was beneficial for mechanically ventilated COVID-19 patients with acute respiratory distress syndrome (ARDS). However, for staff in some small and large hospitals, experience with this intervention was low. Select hospitals were able to assemble proning teams; but, as facilities began to experience staffing shortages, they found proning teams unsustainable, and less specialized staff needed to learn how to safely prone patients.
Proning is a high-risk procedure-a lack of a standard approach can result in staff confusion and poor patient outcomes, including unintentional endotracheal tube (ET) loss, vascular access dislodgement, and skin breakdown. Given the acuity and high patient volume, translating a complex procedure into written policy may not be entirely effective. Critical care nurses, respiratory therapists, physical therapists, wound nurses, nurse practitioners, physician assistants, and medical doctors need to be prepared to safely perform this procedure for an acutely ill COVID-19 patient.
Communication, teamwork, and multidisciplinary collaboration are critical for complication avoidance. Interventions to prevent tube and vascular access dislodgement, skin breakdown, and brachial plexus and soft tissue injury must be implemented during the procedure. Repositioning the patient in the prone position, as well as returning the patient to supine positioning, should be components of a comprehensive proning plan.

Proning a critically ill patient with severe acute respiratory distress syndrome (ARDS) is a complex but beneficial procedure. Excellent communication skills, team work, and multidisciplinary collaboration are critical for patient and staff safety. A standard procedure should be utilized when proning ventilated patients with tubes, drains, and vascular access devices.

Um vídeo educativo de demonstração de como prover um paciente intubado gravemente doente

Early in the coronavirus disease 2019 (COVID-19) pandemic, it was reported that prone position was beneficial for mechanically ventilated COVID-19 ...

Endotracheal Intubation of Rabbits Using a Polypropylene Guide Catheter

Endotracheal intubation in rabbits can be challenging due to their unusual anatomy. Achieving a patent airway during anesthesia is critical for the avoidance of airway obstruction, prevention of gastric tympany, and to allow ventilatory support. Due to the difficulty of intubation, alternative methods such as the use of laryngeal mask airways or laryngeal tubes have been explored. However, these methods do not result in direct access to the trachea and thus may present a risk for development of complications. In addition, lack of direct intubation of the trachea can result in personnel exposure to waste anesthetic gases. Numerous methods for endotracheal intubation have been described, including blind placement, use of a fiberoptic laryngoscope or endoscope, and cricoid placement. Despite these numerous publications, many still struggle to achieve success. Here we provide a detailed description of an intubation technique that can be taught with minimal training with a short time to proficiency. Briefly, after administration of injectable anesthesia and proper positioning of the rabbit, a polypropylene catheter is placed into the trachea by direct visualization using a laryngoscope. The catheter is then used as a guide to direct the endotracheal tube into the trachea. This method allows for intubation without the need for expensive equipment and can be performed by a single individual without the need for an assistant. In conclusion, this technique can be easily taught and performed at very little cost in any clinical or research setting.

Endotracheal intubation in rabbits is challenging due to their unusual anatomy. Here we present a technique for direct intubation of the trachea using a polypropylene catheter as a guide. This method utilizes relatively inexpensive supplies, requires minimal training, and can be easily performed in any clinical setting.

Intubação endotraqueal de coelhos utilizando um cateter guia de polipropileno

Endotracheal intubation in rabbits can be challenging due to their unusual anatomy. Achieving a patent airway during anesthesia is critical for the ...

Biologia

Um Protocolo de Não Intubação para Cirurgia Toracoscópica Videoassistida com Respiração Autonômica Preservada

Non-Intubated Video-Assisted Thoracoscopic Surgery

Double-lumen intubation under general anesthesia is currently the most commonly performed intubation technique for pneumonectomy, wedge resection of the lung, and lobectomy. However, there is a high incidence of pulmonary complications arising from general anesthesia with tracheal intubation. Non-intubation with the preservation of voluntary breathing is an alternative to anesthesia. Non-intubation procedures minimize the adverse effects of tracheal intubation and general anesthesia, such as intubation-related airway trauma, ventilation-induced lung injury, residual neuromuscular blockade, and post-operative nausea and vomiting. However, the steps for non-intubation procedures are not detailed in many studies. Here, we present a concise non-intubated protocol for the performance of video-assisted thoracoscopic surgery with preserved autonomic breathing. This article identifies the conditions necessary to convert from non-intubated to intubated anesthesia and also discusses the advantages and limitations of non-intubated anesthesia. In this work, this intervention was performed on 58 patients. In addition, the results of a retrospective study are presented. Compared with intubated general anesthesia, patients in the non-intubated video-assisted thoracic surgery group had lower rates of post-operative pulmonary complications, shorter operative times, less intraoperative blood loss, shorter PACU stays, a lower number of days to chest drain removal, less post-operative drainage, and shorter hospital stays.

Autor em destaque: Uma cirurgia toracoscópica videoassistida não intubada com analgesia multimodal e anestesia inalatória com sevoflurano 

Here, we present a non-intubated protocol for performing video-assisted thoracoscopic surgery with preserved autonomic breathing.

Cirurgia Toracoscópica Videoassistida Não Intubada

Double-lumen intubation under general anesthesia is currently the most commonly performed intubation technique for pneumonectomy, wedge resection of the ...

<meta charset="utf8"></head><body>Protocolo de intubação endotraqueal baseado em traqueotomia para modelos de ratos não sobreviventes

Endotracheal Intubation via Tracheotomy and Subsequent Thoracotomy in Rats for Non-Survival Applications

Endotracheal intubation and subsequent ventilation are often basic requirements for translational research in rat models for various interventions that require controlled or high ventilation pressures or access to the thoracic cavity and organs. Conventional endoorotracheal intubation using the anatomically existing route through the mouth is well suited for survival experiments. However, this procedure poses some challenges, including generally higher levels of the required experience and technical skill, more advanced equipment, and greater time effort with relevant intubation failure rates and complications such as tracheal perforation, temporary systemic hypooxygenation, and relevant aerial leakage.
This manuscript, therefore, presents a detailed step-by-step protocol for endotracheal intubation through tracheotomy in non-survival rat models when guaranteed intubation success, constant oxygenation levels, high ventilation pressures, or open thoracotomy are required.
The protocol emphasizes the importance of meticulous surgical technique to ensure consistent and reliable outcomes, especially for researchers who are inexperienced or lack routine in the technique of endoorotracheal intubation via direct laryngoscopy. This procedure is, therefore, expected to minimize animal suffering and unnecessary animal losses.

<meta charset="utf8"></head><body>Intubação endotraqueal via traqueotomia e subsequente toracotomia em ratos para aplicações de não sobrevivência

Here we introduce a standardized procedure for endotracheal intubation via tracheotomy followed by thoracotomy in rats, aimed at enhancing the precision and reproducibility of non-survival applications requiring invasive ventilation and exposure of thoracic organs in in vivo rat models.

Intubação endotraqueal via traqueotomia e subsequente toracotomia em ratos para aplicações de não sobrevivência

Endotracheal intubation and subsequent ventilation are often basic requirements for translational research in rat models for various interventions that ...

A Técnica de Resgate Novel para intubação difícil e Ventilação Difícil

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