Trachea intubation complications
Trachea intubation complications – the pathological states arising at introduction of an intubatsionny tube to airways. Symptoms depend on a type of undesirable consequences. Emergence of the diffusion cyanosis barking cough, a blood spitting is possible. In the absence of timely sanitation at distance rattles, gurgle are heard. After removal of the equipment there is a sore throat. Methods of diagnostics include a direct laringoskopiya, survey of an oral cavity, an entrance to a trachea. If necessary the bronkhoskopiya, a radiographic research of airways is conducted. Treatment provides removal of a phlegm by means of an electrosuction, the IT correct installation, introduction of gemostatik, anesthetics, resolvents.
Trachea intubation complications
The undesirable phenomena during an intubation and after its end arise with various frequency. Infections of a throat are diagnosed for 1 patient on one thousand, hypostasis and paralysis of vocal chords – at 3 patients from one thousand. The Yatrogenny complications connected with a heavy intubation and a short thick neck of the patient are noted in 5-10% of cases. The mistakes of the doctor caused by inexperience and violation of an algorithm of manipulation make no more than 0,5% of total of laringoskopiya. Difficulties authentically are more often observed during the work with the heavy patients having the increased body weight, the suffering endemic craw or organic changes of the top airways. This group for 60% consists of women, for 40% – of men.
Reasons of complications of an intubation of a trachea
Difficulties directly at introduction of a tube arise because of a medical error more often. At long ventilation by means of endotrakhealny access some processes happening in airways are not determined with work of the anesthesiologist/resuscitator. Directly the problems which are coming to light after an ekstubation also are not always accompanied by actions of the expert. Are among common causes of pathology:
- Wrong installation of a blade. The laryngoscope should not press on teeth in the lower direction. The tool can lean on them, however rigid pressure needs to be avoided. Otherwise damage of the chewing device with the subsequent hit of fragments in digestive or airways is possible.
- Wrong situation. Wrong introduction of the intubatsionny equipment to a gullet provokes stomach restretching, can become the regurgitation reason. If the patient is intubirut according to vital indications, respiratory insufficiency remains and progresses that can lead to a lethal outcome.
- Trachea injury. Complications develop when using tubes of the big size, their inaccurate introduction, an intubation without medicamentous sedation if the patient is in consciousness. Similar negative consequences usually arise in urgent situations, to a thicket are observed at the patients who are in a condition of psychomotor excitement.
- Nasal intubation. Practices at LOR-interventions, mandibular abscesses, operations in the sphere of maxillofacial and plastic surgery. Use of the tubes which are not suitable by the size, uneasy behavior of the patient, an istonchennost of a mucous membrane and a superficial arrangement of vascular network becomes the reason of a travmatization of an internal nose.
- Phlegm congestion. Lack of timely sanitation exponentiates impassability of a tube and development of a hypoxia. The secret can form firm congestions, stick to equipment walls. Such consequences are eliminated by a bronkhoskopiya with visual control. It is possible to clear respiratory bodies by means of a standard electrosuction not always.
- Obsemeneny bacterial flora. Hit of the activator happens at violation of the rules of an asepsis in the course of an intubation and IVL. Clinical displays of an infection can come to light as during ventilation (in several days), and after removal of a tube.
- Individual reactions. Arise as the response of an organism to introduction of a foreign matter. Are more often shown several hours later from the ekstubation moment. Can lead to violation of passability of a trachea, inflammatory infiltration of fabrics, respiratory insufficiency. Practically are not connected with actions of the doctor and behavior of the patient.
Changes depend on complication type. At injuries of airways there is bleeding, blood aspiration, development of pneumonia or a bronchospasm is possible. Because of violation of integrity of a mucous membrane the probability of infectious processes as entrance gate for pathogenic flora are formed increases. Hypostasis or a spasm of vocal chords, a tube obturation a bronchial secret result in mechanical respiratory insufficiency. The necessary amount of air does not come to lungs, the hypoxia is formed, fabrics experience oxygen starvation, work of a brain, all vital systems is broken.
Infectious defeats become the reason of an inflammation, the general intoxication, hypostasis of the struck zone. At distribution of process there is a risk of development of infectious and toxic shock. The main danger of wrong introduction of IT to a gullet is the remaining respiratory insufficiency. Restretching of a stomach does not involve threat for the patient's life, but creates difficulties during an ekstubation (risk of inhalation of gastric contents).
Complications are admissible to be systematized for the reasons (mechanical, infectious), on extent of influence of the doctor (yatrogenny, not depending on actions of the expert, an autoaggression), on pathogenesis (a defiant hypoxia, bleeding). However the main is classification by time of development of negative consequences. According to modern representations there are following kinds of pathology:
- At an intubation. At input of a tube the patient has fractures of teeth, bleedings, ruptures of mucous membranes, damages of zaglotochny space, sredosteniye emphysema. Formation of an atelektaz of an opposite lung and one-pulmonary ventilation at hit in a bronchial tube, stomach restretching at wrong introduction of endotrakhealny equipment to a gullet is possible. At irritation of the wandering nerve bradycardia up to cardiac arrest develops.
- After an intubation. Obstruction of a hose owing to its excess or a zakusyvaniye can be defined by the patient. At long VVL or IVL the congestion of the phlegm preventing mix passing, formation of decubitus, hernial protrusion of a cuff is observed. If the patient is mobile, an equipment exit from a trachea, twisting, an emphasis of the lower opening in a windpipe wall can come to light.
- During removal of IT. Difficulties with extraction of the equipment arise at not completely blown off cuff. Injuries of airways, ruptures of a mucous membrane are noted. Directly after IT exit from a trachea fall of the last with the subsequent suffocation is possible. If the patient is in passive situation on a back, there is a risk of aspiration of saliva with development of aspiration pneumonia.
- After extraction of a tube. In the first days emergence of morbidity, throat hypostasis is found. Infectious complications are shown from 1 to 3 days of independent breath in time. In the late period ulcers, fibrosis of a throat and trachea, a stenosis of nostrils at a nasal intubation are diagnosed. A complication time long time remain not diagnosed, are diagnosed incidentally at the subsequent interventions in other occasion.
Symptoms of complications of an intubation of a trachea
The complications arising at input of an endotrakhealny tube and carrying out ventilation differ in variety of symptomatology. Fractures of teeth are visible visually. At a mouth of the patient there are fragments, the affected tooth is looked through. At a travmatization of mucous membranes the expiration of blood from a mouth and a nose is noted. In position of the patient on a back accumulates in a zone of a rotoglotka that allows to notice it at a laringoskopiya. Hit of the equipment in a gullet is characterized by rhythmical swelling and fall of a stomach, lack of respiratory noise in lungs. At a unilateral intubation one lung is listened, the second is "mute".
Zakusyvaniye of a contour is defined by the patient visually. Obstruction by a phlegm leads to emergence of typical rattles. In both cases the device IVL warning system which publishes the specific signal testifying to impassability of airways becomes more active. At the patient diffusion cyanosis, decrease SpO2, tachycardia, concern, excitement is observed. Aspiration of a phlegm after an ekstubation is shown by the progressing respiratory insufficiency, symptoms develop within several hours. The state decompensation at a collapse of a trachea occurs practically at once.
At hypostasis of a throat the barking cough, short wind of the mixed type, a voice osiplost comes to light. The massive phenomena lead to simptomokompleks of ODN. Stenoses become the reason of constant short wind, moderate hypoxia, subjective heavy feeling of a breath. Ulcers exponentiate emergence of a chronic inflammation, infectious complications, tracheitis, bronchitis. Can be followed by capillary bleeding with a blood spitting (about 15 ml of blood a day are allocated) or a gemorragiya (more than 15 ml).
Diagnosis is made on the basis of data of fizikalny inspection. If necessary tool and laboratory techniques can be applied. In most cases it is possible to define a pathological state directly in the operating room or the block of intensive therapy. Late complications of an intubation of a trachea come to light in the general office during an out-patient aftercare of the patient. The following diagnostic procedures are used:
- Fizikalny inspection. At survey to VDP and the general assessment of a condition of the patient clots of blood and a phlegm in a rotoglotka at injuries are found, cyanosis and lack of an excursion of a thorax at the IT incorrect installation. Auskultation of lungs allows to define degree of conductivity of breath and to reveal sites to which air does not come.
- Tool inspection. The main method – a bronkhoskopiya. During its carrying out the doctor studies a condition of airways, validates installation of the equipment. If necessary the X-ray analysis, a computer tomography can be applied. By results of all researches, the tube has to stand in a trachea. In emergency situations it is possible to estimate correctness of the procedure according to a kapnosat – at an intubation in a gullet of pCO2 it will be equal to zero.
- Laboratory inspection. It is required at suspicion on late complications. Capillary bleedings lead to development of anemia, infectious processes become the emergence reason in blood of nonspecific changes – increases in SOE, a leykotsitoz. It is possible to determine existence of a hypoxia by blood pH shift in the sour party and to change of gas composition of blood.
Treatment of complications of an intubation of a trachea
At wrong installation of a tube it is taken and make a repeated attempt. Before it it is necessary to carry out oxygenation of 100% by oxygen within 2-4 minutes. If new attempts do not result in success, application of a method of a nasal intubation or introduction of IT on a finger with use of a stiletto is possible. In situations when these techniques are inefficient, installation of a laringealny mask or noninvasive ventilation is allowed. At the need for long artificial aeration the trakheostomiya is made.
Injuries of a mucous membrane are the indication for a medical bronkhoskopiya. By means of this procedure the bleeding stop is implemented, assessment of weight of damages is carried out. Introduction of haemo static means is recommended. Repeated attempts of an intubation are not made. As possible options are considered noninvasive ventilation (only after a hemostasis), a trakheostomiya. Appointment of reparative means is allowed. Antibiotics of a broad spectrum of activity are applied to prevention of infectious complications.
At violation of passability of a tube sanitation of TBD by means of a suction or the bronchoscope is carried out. It is necessary to carry out the procedure each 2-4 hours or is more often. For reduction of the quantity separated atropine is used. If the patient in consciousness has also a snack on IT teeth, gipnotik, antipsychotic medicines are entered. The dosage is selected so that not to suppress attempt of independent breath. If necessary introduction of miorelaksant of peripheral action with the subsequent transfer to compulsory ventilation is allowed.
The suffocation arising soon after an ekstubation demands repeated introduction of a tube. It is necessary to connect the patient to the device IVL not in all cases. Often complications are caused by fall of a trachea at which the general ability to independent breath is not lost. Fibroses and stenoses korrigirut quickly in a planned order after a complete recovery of the patient. Infectious processes eliminate by means of antibiotics. For knocking over of hypostasis of a throat use inhalations of bronchial spasmolytics, glucocorticosteroids, vasoconstrictive means.
Forecast and prevention
The forecast is favorable. At timely diagnostics and delivery of health care of a complication are not followed by the delayed consequences or death of the patient. In case of violations of passability of DP without correctional actions suffocation and death becomes an outcome. Zakusyvaniye the patient does not lead a hose to similar consequences. Difficulties at an intubation can be lethal at wrong actions of the doctor and preliminary introduction to the patient of muscular relaksant. If ventilation was not provided in time, there is a stop of warm activity against the background of a hypoxia.
Prevention consists in careful studying by the doctor by the intensivist of an algorithm of actions at a difficult intubation, preparation of the necessary equipment. For bystry knocking over of complications it is necessary to have Ambu's bag, set for the emergency trakheostomiya or a konikotomiya, a laringealny mask, the respiratory device, a set of medicines for resuscitation, a defibrillator, . In order to avoid trachea decubituses at long IVL replacement of IT is made by each 4 days. The amount of the air entered into a manzhetka should not exceed 30 ml. Diameter of tubes is selected in strict accordance with the sizes of a body of the patient. After an ekstubation the patient has to be in ORIT not less than 3-5 hours.
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2. Practical skills on anesthesiology and resuscitation. Trachea intubation / educational and methodical grant Prasmytsky O. T. - 2015.
3. Algorithms of actions at critical situations in the anesthesiology / recommendation of the World organization of societies of anesthesiologists under the editorship of Bruce MacCormick (Great Britain), the Russian edition Nedashkovsky E. V., Kuzkov V. V.