Overview of Tracheal Rapid Sequence Intubation
Rapid sequence intubation (RSI) is a quick method used by doctors to manage a patient’s breathing when there’s a risk of food or fluid entering the lungs – a situation also known as aspiration. This technique is used by various healthcare professionals, including doctors in emergency situations, critical care, and anesthesiologists.
RSI is especially needed when a patient is struggling to breathe and can’t get enough oxygen or ventilation. It’s also used to protect the airway of a patient who may not be fully conscious. When preparing for RSI, the doctor has to carefully plan out the procedure for it to be successful. They need to evaluate the patient’s risk levels, position the patient correctly, and have a good understanding of the body’s structure involved in the process. They must also have all necessary medical supplies ready at hand, including back-up alternatives in case something goes wrong with the initial plan.
Anatomy and Physiology of Tracheal Rapid Sequence Intubation
Before a medical procedure involving your airway starts, doctors need to check a few things to make sure they can easily access and manage your airway (the path air takes to get to your lungs). There are some helpful tools doctors use to do this, one of which is the L.E.M.O.N. technique.
In the L.E.M.O.N. technique:
* L stands for “Look externally.” Doctors will look at your face for things like injuries, beards, loose teeth, dentures, or large incisors – as these could make accessing the airway more difficult.
* E stands for “Evaluate the 3-3-2 rule.” Doctors will check if 3 fingers fit between your upper and lower front teeth, if 3 fingers fit between the tip of your chin and a bone in your neck called the hyoid, and if 2 fingers fit between the hyoid bone and another neck bone. If there’s less space than this, it could be harder to manage the airway.
* M stands for “Mallampati score.” This is a system doctors use to see how much of the back of your throat and a small piece of tissue called the uvula they can see. The more they can see, the easier it will be to manage your airway.
* O stands for “Obstruction or Obesity.” If you have something blocking your airway (like a tumor), or if you’re obese (Body Mass Index >30), managing your airway might be more difficult.
* N stands for “Neck mobility.” Doctors will check how much your neck can move. If your neck can’t be easily moved into a good position because of an injury, a neck brace, or stiffness, it can make airway management harder.
How you’re positioned during the procedure is very important. Your neck needs to be bent forward at the lower part and extended at the upper part, like the way your neck positions itself when you smell something. This position, called the “sniffing position,” gives doctors the best view of the airway pathway.
The epiglottis, a small flap of tissue at the base of the tongue that keeps food from entering your windpipe, is an important landmark doctors will look for during the procedure. The space between the tongue and the epiglottis is called the vallecula which also serves as a guide for doctors. They’ll place the tip of a tool called a Macintosh blade here, and moving the blade downwards and towards the body reveals your vocal cords.
Doctors also use a system called the Cormack and Lehane Grading system to estimate how successful the procedure will be. It rates your airway based on how many vocal cords they can see. The more vocal cords they can see, the higher the chance of a successful procedure.
Why do People Need Tracheal Rapid Sequence Intubation
Rapid Sequence Intubation (RSI), or placing a breathing tube quickly, is often used to help patients who are struggling to breathe or are unable to get enough oxygen. This can be due to severe lung conditions or issues that affect their ability to breathe properly. RSI is also used when a patient can’t protect their airway because they’re not fully conscious. This method might also be used when someone is having a severe upper stomach bleed and there’s a high risk they could accidentally breathe food or stomach acid into their lungs, a situation known as aspiration.
When a Person Should Avoid Tracheal Rapid Sequence Intubation
There are a few specific situations where a quick tube placement for breathing (rapid sequence intubation) shouldn’t be done. One of these is if someone’s upper airway is completely blocked. Another is if it’s not possible to see important points on the face or in the throat area, which would require surgically creating a pathway for air.
There are also things that might make this procedure more likely to fail, but don’t completely rule it out. This could be due to injuries to the breathing pathway, unusual body structures, or the skill level of the doctor. These can be checked using a helpful tool called L.E.M.O.N. or the Cormack and Lehane Grading system that was mentioned before.
Equipment used for Tracheal Rapid Sequence Intubation
When a medical professional is preparing to perform rapid sequence intubation (which is inserting a tube through the mouth and into the lungs to assist with breathing), they require several tools and supplies. These include:
* A specific kind of breathing tube that can be inflated and uses a sterile lubricant
* A device called a laryngoscope, which allows the doctor to view the throat
* Suction equipment
* A bag valve mask, which can be used to help a patient breathe
* A monitor to measure the levels of carbon dioxide that the patient is exhaling
* Various drugs to make the procedure comfortable for the patient
* A tool known as a tracheal tube inducer or bougie
* An alternate type of airway device, like a laryngeal mask airway
* A video-assisted laryngoscope to enhance view
* Pulse oximetry to measure the oxygen levels in the blood
* An IV access for medication
* Emergency medications, also known as push dose pressors.
Before this procedure begins, the doctor needs to ensure that the room is well lit and needs to check the light source on the laryngoscope. The doctor will also ensure the tube to be inserted can inflate properly, and there is pulse oximetry set up to monitor oxygen levels in blood.
Endotracheal Tube Size:
The tube’s size may vary depending on the patient; commonly, a tube with a 7.0- to 7.5-mm internal diameter is used for women, with a slightly larger 7.5- to 8.0-mm tube used for men. Smaller tubes might not allow certain procedures, like bronchoscopy that involves examining the lung’s airways, if needed.
Blade Selection:
Laryngoscope blades, which help give the best view of the throat during the procedure, are typically either Macintosh or Miller blades. The Macintosh blade, curved to follow the shape of the tongue, helps move the throat’s structures to give a clear view of the voice box. The sizes vary depending on the patient, with a Macintosh 3 fitting most average adults and a Macintosh 4 being longer if needed. On the other hand, a flat Miller blade is used to lift the epiglottis (the flap that covers your windpipe when you’re swallowing) to reveal the vocal cords.
Induction Agents:
Induction agents are medications that help make the process comfortable for the patient. While the full details about these drugs go beyond this conversation, the doctor will choose from several common ones, each with different features.
How is Tracheal Rapid Sequence Intubation performed
Before starting the process to put a breathing tube in your windpipe (a procedure known as intubation), everything needs to be properly prepared – this includes you (the patient), the medical team, and all necessary equipment. The medical team will give you certain medications to make you feel relaxed and to temporarily block muscle activity.
Once you are relaxed and unable to move, they will use a special mask to provide you with as much oxygen as possible. This mask, known as a bag valve mask, is carefully sealed onto your face to make sure your lungs get all the oxygen they need.
After waiting for about a minute for the medications to fully work, the medical professional performing the procedure will open your mouth. This is done using a technique known as the “scissoring technique,” where they insert their right thumb and middle finger into your mouth and open your mouth wide.
They then insert a special instrument called a laryngoscope into your mouth. This instrument has a light and is used to move your tongue aside and view inside your throat. They are looking for a small flap called the epiglottis and a pocket-shaped space known as the vallecula. Once these are found, the laryngoscope is carefully positioned to secure a clear view of your airway.
If there is any debris blocking their view, a suction tool may be used to clear it out. Pressure might also be applied to a spot on your neck to adjust and visualize an area known as the glottis. The glottis is the part of your throat that contains your vocal cords.
Next, a special tube called an endotracheal tube is passed between the vocal cords and into the windpipe (trachea). Once the tube is in place, the guide (stilette) used to help insert the tube is removed.
The tube is then advanced (pushed in more deeply) according to a formula based on your height. This ensures that the tube is at the right depth in your windpipe to help you breathe.
After the tube is at the correct depth, a special cuff on the end of the tube is inflated. This secures the tube in place and prevents air from leaking out. Several checks are then performed to verify the tube is in the right place – they include observing a particular type of graph which measures the amount of carbon dioxide in your exhalated air, noticing condensation on the tube, and listening to whether air is flowing into both your lungs equally.
Finally, an X-ray of your chest is taken to see if the tube is in the correct position.
Possible Complications of Tracheal Rapid Sequence Intubation
When a doctor has difficulty placing a breathing tube with the standard procedure, there are a variety of tools that can assist them.
One of these tools is a video-assisted laryngoscope, which helps the doctor get a better look at the voice box area in your throat. Sometimes, the configuration of one’s anatomy can make it challenging for the doctor to place the breathing tube. In these cases, they may opt to use a tool called a bougie. A bougie is a long rod-like instrument that has a curve at its end. The doctor would gently insert this tool into the person’s airway and try to position the breathing tube in the windpipe. The bougie can help the doctor feel the distinct bumps of the windpipe, thus guiding them in properly placing the tube.
If the breathing tube can’t be placed in the windpipe, another option is to use a device called a laryngeal mask airway. This is placed above the voice box and can help keep the airway open. Its use is considered when traditional methods are not successful.
