group 9 ambulatory.pptx...................

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1. Oral/Nasal Intubation and Tracheostomy A Comparative Overview in Airway Management FACULTY OF ALLIED HEALTH SCIENCES ANESTHESIA TECHNOLOGY

2. Introduction to Airway Airway management is a critical skill in anesthesia, emergency, and critical care. Oral and nasal intubation provide temporary airway access. Tracheostomy offers a long-term solution when upper airway access is compromised or prolonged ventilation is needed. Choosing the appropriate technique depends on clinical context, urgency, and patient-specific factors.

3. Anatomy of the Airway Upper Airway : Includes nose, nasal cavity, pharynx (nasopharynx, oropharynx, laryngopharynx), and larynx. Lower Airway : Begins at the trachea, divides into bronchi, bronchioles, and ends at the alveoli. Pharynx : A shared pathway for food and air, divided into three parts. Larynx (voice box) : Contains vocal cords; critical for speech and protection during swallowing. Trachea (windpipe) : A rigid, cartilaginous tube leading to the bronchi; crucial for air conduction. Key Landmarks for Intubation : Epiglottis, vocal cords, glottic opening, and carina. Proper anatomical knowledge reduces the risk of complications during intubation or tracheostomy.

4. Intubation “ The process through which a tube is insert into the trachea for proper ventilation of the patient in emergency, surgery and ICU stay.” Types on the basis of insertion Oral intubation Nasal intuation

5. Equipments for intubation Endotracheal tubes (ETT) – various sizes (cuffed or uncuffed ) Laryngoscope – with appropriate blades (Macintosh, Miller) Suction apparatus Bag-valve-mask (BVM) – for preoxygenation and ventilation Stylet – to shape and guide the ETT Capnograph or CO₂ detector – to confirm tube placement Oxygen source and face mask Monitoring devices – SpO ₂, ECG, BP

6. Additional equipments Additional for Oral Intubation : Oral airway ( Guedel airway) Bite block to protect tube and teeth Tongue depressor (especially in pediatric cases) Additional for Nasal Intubation : Vasoconstrictor drops (e.g., xylometazoline ) Lubricant (water-based) Magill forceps to guide tube Topical anesthetics for nasal/oral mucosa Nasal airway or trumpet (optional for passage dilation)

7. Oral intubation “A technique where a tube is inserted through the mouth into the trachea to maintain an open airway.” Commonly performed in emergency situations, surgical procedures, and critical care settings. Provides a secure and controlled route for mechanical ventilation. Considered the most frequent method of airway access in anesthesia and resuscitation. Requires the use of a laryngoscope for visualization of the vocal cords. Performed under general anesthesia or deep sedation in most cases.

8. Indications of oral intubation Airway protection in unconscious or unresponsive patients (e.g., GCS < 8). Respiratory failure requiring mechanical ventilation. General anesthesia during surgeries. Cardiac or respiratory arrest (as part of advanced life support). Airway obstruction due to trauma, swelling, or foreign body. Facilitation of suctioning and secretion clearance. Prevention of aspiration in patients with impaired gag or cough reflex.

9. Containdications Severe facial or oral trauma – risk of bleeding, distortion of anatomy. Fracture of the mandible or maxilla – can make oral access difficult or unsafe. Trismus (lockjaw) – inability to open the mouth adequately. Obstructing oral tumors or infections – prevent safe passage of the tube. Oropharyngeal bleeding or edema – obscures the view and increases aspiration risk. Cervical spine injury – neck movement should be minimized; oral intubation may exacerbate injury. Need for awake or fiberoptic intubation where oral route is not tolerated or feasible.

10. Procedure Preparation : Assess airway ( Mallampati score), gather equipment (ET tube, laryngoscope, stylet, suction). Positioning : Sniffing position (neck flexed, head extended) to align airway axes. Pre-oxygenation : 100% oxygen for 3–5 minutes to increase oxygen reserve. Induction : Administer sedative and paralytic agents (e.g., propofol , succinylcholine). Laryngoscopy : Insert laryngoscope to visualize vocal cords. ET Tube Insertion : Gently insert the tube through the cords into the trachea. Confirmation : Check for bilateral breath sounds, chest rise, and use end-tidal CO₂ detector.

11. Nasal intubation “A method of airway access where an endotracheal tube is inserted through the nose into the trachea.” Preferred when oral access is restricted (e.g., jaw surgery, oral trauma). Can be performed blindly, with direct visualization, or using fiberoptic bronchoscopy. Often better tolerated in semi-conscious or awake patients. Helps maintain a more secure tube position in long-term intubation. Requires careful nasal preparation to reduce trauma and bleeding.

12. Indications Limited mouth opening due to trauma, temporomandibular joint disorders, or oral surgery. Maxillofacial injuries where oral route is contraindicated. Cervical spine injury with need to avoid neck movement. Awake intubation in patients with predicted difficult airway. Ongoing oral procedures requiring unobstructed access to the mouth. Long-term mechanical ventilation , especially in ICU settings

13. Contra-indications Severe midface trauma – can obstruct or damage nasal passages and sinuses. Coagulopathy or active nasal bleeding – increases risk of significant hemorrhage. Nasal polyps or tumors – may obstruct passage or cause trauma. Deviated nasal septum – can make tube insertion difficult or impossible. Sinus infections or upper respiratory tract infections – risk of spreading infection to sinuses or lungs.

14. Procedure Preparation : Assess nasal patency; use vasoconstrictor drops (e.g., xylometazoline ) to reduce bleeding. Lubrication : Apply water-based jelly to the endotracheal tube. Sedation & Anesthesia : Provide topical anesthesia to nasal passages and pharynx. Insertion : Gently advance the tube through the nostril to the oropharynx. Guidance : Use Magill forceps or fiberoptic scope to direct the tube into the trachea. Confirmation : Verify placement using capnography, chest rise, and bilateral breath sounds.

15. Comparison Aspect Oral Intubation Nasal Intubation Speed Faster (immediate access) Slower (requires more preparation) Comfort Less comfortable for awake patients More comfortable for awake patients Risk of Bleeding Lower Higher (due to nasal passage trauma) Use in Trauma Suitable for facial trauma Preferred for maxillofacial injuries Duration Typically short-term Suitable for long-term ventilation Ease of Insertion Easier in emergency situations More difficult, requires technique Oral Access Obstructs mouth and airway access Leaves the mouth free for oral care

16. Tracheostomy Tracheostomy is a surgical procedure in which an opening is created in the trachea to facilitate direct access to the airwa y. It is typically performed when long-term airway management is needed or when other intubation methods are not suitable. A tracheostomy tube is inserted through the opening to maintain airway patency. Can be either temporary or permanent depending on patient needs. Provides a safer and more comfortable alternative for prolonged mechanical ventilation. Often used in patients who require extended ventilation or have upper airway obstruction.

17. Indications Prolonged mechanical ventilation (>7-10 days) in ICU patients. Upper airway obstruction due to tumors, burns, or trauma. Neurological conditions (e.g., spinal cord injury, stroke) with prolonged respiratory support. Chronic respiratory failure in conditions like COPD or restrictive lung diseases. Tracheal or laryngeal surgery requiring an airway bypass. Severe facial or jaw trauma making intubation difficult or impossible. Airway protection in patients with impaired swallowing and risk of aspiration.

18. Procedure Preparation : Ensure proper equipment (tracheostomy tube, suction, sterile supplies, sedation, and local anesthesia). Positioning : The patient is usually placed in a supine position with the neck extended (or in a semi-sitting position if required). Incision : A transverse incision is made over the trachea, typically between the second and third tracheal rings. Dissection : Soft tissues and muscles are dissected to expose the trachea. Tracheal Opening : A small incision is made in the tracheal wall, and the tracheostomy tube is inserted. Tube Insertion : The tracheostomy tube is placed and secured in position. Post-insertion Care : Confirm placement with a chest X-ray and monitor for complications like bleeding or infection.

19. Complications Bleeding : Post operative bleeding is common and can range from minor to severe. Infection : Risk of wound infection, tracheal stenosis, or aspiration pneumonia. Airway Obstruction : Blockage of the tracheostomy tube due to mucus buildup or displacement. Tube Displacement : Accidental removal or displacement of the tracheostomy tube. Tracheal Injury : Damage to the trachea or surrounding structures during insertion. Fistula Formation : Development of an abnormal connection between the trachea and esophagus. Speech and Swallowing Issues : Difficulty in speaking or swallowing due to the tracheostomy tube.

20. Tracheostomy post operative care Secure tube placement and ensure proper fixation to prevent dislodgement. Humidified oxygen to prevent drying of airway secretions. Regular suctioning to clear secretions and maintain airway patency. Monitor for complications like infection, bleeding, or blockage. Daily site inspection for tracheostomy to check for signs of infection or granulation tissue. Oral hygiene and skin care around the stoma are essential. Weaning protocols for ventilated patients should be initiated when appropriate.

21. Comparison Aspect Oral Intubation Nasal Intubation Tracheostomy Duration Short-term (emergency, surgeries) Short or long-term (ICU, awake) Long-term (prolonged ventilation) Speed Quickest method Slower (requires more steps) Surgical, longer preparation time Comfort Less comfortable for conscious patients More comfortable for awake patients More comfortable for long-term ventilation Indications Emergency, surgeries, mechanical ventilation Facial trauma, jaw issues, long-term ventilation Prolonged mechanical ventilation, airway obstruction Risks Aspiration, difficult in trauma Bleeding, nasal injury, sinusitis Infection, bleeding, tube displacement Airway Access Oral cavity, trachea Nasal cavity, trachea Direct tracheal access

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