Airway Management Techniques and Risks in Unconscious and Critical Patients Essay

Methods of Tongue Relocation

It is essential to note that the following methods should be used to improve gas exchange and airway opening in unconscious patients. First, the simplest way is to use the technique of tilting the head or lifting the palate to dislodge the tongue from the patient’s throat. Individuals with some medical knowledge should perform this procedure. The patient’s head should be tilted backward, with pressure applied to the forehead or the back of the neck.

For semi-conscious patients, nasopharyngeal airways can be used. These are flexible tubes with one end expanding and the other end beveled, which are inserted through the nostrils into the throat (Takamori et al.,2021). Thus, it helps prevent airway obstruction and ensure continuous gas exchange, even in a semi-conscious state.

Indications, Medications, and Hazards of Rapid Sequence Intubation

Rapid Sequence Intubation should be performed when respiratory failure or inadequate breathing is indicated to protect the airway. Additionally, sedatives should be administered during the procedure. These include etomidate and ketamine, which can be used with neuromuscular blockers. These drugs are necessary because they enable rapid patient preparation for Rapid Sequence Intubation.

It is crucial to emphasize that the procedure has a long list of dangers, but it is required, as failure to supply oxygen to the airways will kill the patient (Takamori et al.,2021). Hence, the main complications are lip and gum trauma, hypoxia, trephine perforation, tachycardia or bradycardia, increased intracranial pressure, and cervical spine injury.

Indications and Complications of Oral and Nasopharyngeal Airway

For the oral airway, it is recommended that the patient be unconscious or semi-conscious, have a severe trauma with a blocked airway, not be gas-exchanging, or have weak muscle tone. Meanwhile, complications such as vomiting of various kinds are possible, and the insertion of the instrument may damage the gums, teeth, or even lips. Moreover, complications include aggravation of the obstruction by tongue position changes, nosebleeds, and airway displacement (Takamori et al., 2021).

The nasopharyngeal airway should be used only if patients are unconscious or semi-conscious, have oral cavity injuries, and the mouth cannot be used for the procedure. Furthermore, there are cases in which patients can be administered oxygen only through the nasal route and experience persistent vomiting (Takamori et al., 2021). In this case, complications may include nosebleeds, particularly if the mucous membrane is injured during the procedure, tissue injury due to improper technique, or the development of sinusitis and impaired mucociliary clearance.

Indications and Complications of LMA’s and Combitubes

LMA’s should be used in cases of apnea and severe respiratory failure, and it is impossible to use a ventilation bag. Meanwhile, the main complications of this technique are vomiting and aspiration, tongue swelling due to prolonged placement, or excessive balloon pressure. In addition, the procedure can injure the teeth and oropharynx if performed incorrectly.

The combitubes method should be used in cases of apnea, severe respiratory distress, or a threat of respiratory collapse when endotracheal intubation is unavailable (Takamori et al., 2021). Finally, the method is also beneficial for patients with significant facial disfigurement, thick beards, or other facial features that may compromise the mask’s tight fit (Takamori et al., 2021). Some of the typical problems are vomiting and aspiration during tube insertion or after placement in patients with a restored gag reflex, trauma to the teeth or soft tissues of the oropharynx during tube introduction, and tongue edema.

Specialty Tubes

Most adult patients have inserted tubes with a diameter greater than 8 millimeters; these tubes have low resistance to airflow and facilitate the aspiration of secretions. Such devices, in contrast to narrow ones, allow the bronchoscope to be inserted if necessary, and smaller tubes are used when working with infants and children over one year of age. For adults, there are no general indications for selecting a special tube, except for the diameter.

For children, the diameter is determined by a special calculation. For instance, for a 4-year-old child, an endotracheal tube with a 5 mm diameter would be appropriate (Takamori et al., 2021, p. 4). Moreover, for children, in some cases, the tube is equipped with a rigid stiletto, which allows it to be flattened against the distal edge of the cuff. The tube is then bent at a 35-degree angle to facilitate insertion.

Difficult Airway Scenarios for Intubation and Recommendations

Laryngoscopy should be successful on the first attempt. Repeated use of the laryngoscope in adults and children more than three times in a row increases the rate of hypoxemia and can lead to asphyxia. Therefore, the clinician should visualize the epiglottis and vocal cords before inserting the device, and both straight and curved blades should be used when elevating the epiglottis. After determining the larynx’s structure, the doctor inserts an endotracheal tube into the patient’s trachea; if the product’s movement is complex, the specialist rotates it clockwise by 90 degrees (Takamori et al., 2021, p. 5).

Flexible fiber-optic endoscopes and optical stilettos are highly maneuverable; however, their endoscopes are challenging to master and more sensitive to blood and secretions, as they cannot divide or separate tissue. As a result, this leads to delaying the time of the procedure, which poses a threat to oral trauma. Therefore, in practice, it is essential to identify the laryngeal landmarks on the fiberoptic image before proceeding with the procedure.

The Methods of Confirmation of the Correct Positioning of the Endotracheal Tube

Firstly, it is a direct visualization: the tube lies between the vocal cords. Secondly, auscultation is the same on both sides of the chest, and the absence of sounds is noted in the epigastric region. Other confirmatory signs include a symmetrical increase in chest volume during inspiration and tube fogging.

In addition, the absence of intestinal contents in the endotracheal tube is also a sign. Not all of these methods guarantee correct intubation tube placement, and they are supplemented by verification with diagnostic devices. For instance, capnography is considered the gold standard for confirming the correct position of the intubation tube (Takamori et al., 2021). However, there are also devices such as colorimetric detectors and pulse oximetry.

Airway Risks for the Intubated Patient

The primary airway risks for the intubated patient are vomiting reactions, sore throat, and hoarseness. Furthermore, bleeding and a hole in the soft palate can occur due to airway damage. Moreover, the sinuses, larynx, and trachea can be injured, causing a bacterial infection. Meanwhile, the procedure requires doctors to be qualified and trained, as well as a team of specialists to be present, to respond quickly in case of problems (Takamori et al., 2021). It is also imperative to use mask ventilation devices, supraglottic breathing apparatus, and suction devices to clear the airways.

Reference

Takamori, R., Shirozu, K., Hamachi, R., Abe, K., Nakayama, S., & Yamaura, K. (2021). Intubation technique in a patient with tracheobronchopathia osteochondroplastica. The American Journal of Case Reports, 22, 1-10.