ため に 必ず 知って おく べき 全 て の こと 。 [ Int ubation ] 인튜베이션 Assisting / Intubation 준비를

사실 빠른 intubation assisting의 핵심은 간호사로서 물건이나 장비가 제대로 갖춰졌는지, 그리고 이 장비들을 환자의 신장, 나이, 상태, 상황에 맞게 잘 준비했는지가 전문적인 nurse인지 아닌지를 결정하는 것이 아닐까 싶다. 그리고 intubation 상황에 맞게 약준비, 각단계마다 뭐가 필요한지 알고 상황에 맞게 준비하는 능력, intubation 후에 무슨일이 일어날지 확인하고 의사에게 물어보고 confirm 받기까지 하면 완벽한 간호사라고 칭찬받지 않을까 생각하는데... 그게 어려워...

 

Rapid Sequence Intubation

Rapid sequence intubation ( RSI ) is an airway management technique that produces inducing immediate unresponsiveness ( induction agent ) and muscular relaxation ( neuromuscular blocking agent ) and is the fastest and most effective means of controlling the emergency airway

● the cessation of spontaneous ventilation involves considerable risk if the provider does not intubate or ventilate the patient in a timely manner ● RSI is particularly useful in the patient with an intact gag reflex , a " full " stomach , and a life threatening injury or illness requiring immediate airway control

 

RSI Part 1 : Equipment인 튜베이션을 잘 할 수 있도록 하는 포인트는 미리 준비물을 환자석 옆에 비치해 두는 것이다.중요한 순간에 물건이 없으면 인투바이온이 지연될 수 있어. Intubation Cart 중에 무엇이 있으며, 그 항목들이 어떤 것이며, 어떤 상황에서 내가 꺼내야 하는지를 알아야 한다.[준비물]

 Cardiac monitor with audible QRS tone  Oxygen saturation monitor  Rebreathing circuit ( bag ) , mask ( appropriate size ) and oxygen source  Airway appropriate size

 Stylet

아마도 intubation cart의 stylet 란에서 이 3개의 stylet이 발견될 것이다.

Stylets 처음에는 Glidescope용 stylet * 함부로 구부려서는 안됨;;

두 번째와 세 번째를 보면, 여기서 stylet과 introducer를 혼동하는 경우가 있다.(비슷해서 가끔 intubation cart에서 잘못 꺼내서 이것을 style로 준비한 경험이;;;)

Bougie

Introducer, 흐 bougie or Eschmann Style로도로도. 더 flexible하고, eleastic하고 무엇보다 키~~~이루다(E-tube안에 꽂으면 bougie가 더 길어서 계속 나온다)

왜 Bougie가 더 오래 elastic인지 이유는 아래 동영상을 보면 알 수 있다.

Introducer VS regular Stylet의 차이점을 잘 알리는 동영상

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

어떻게 stylet을 꺾냐?

< How to shape Stylet ? > " ' straight - to - the - cuff ' 1 . lubricate stylet with water soluble gel . 2 . insert stylet into ETT . 3 . bend the stylet into the desired shape . 4 . optimal shape for intubation direct laryngoscopy is ' straight - to - the - cuff ' with a a ' hockey stick ' bend at the cuff of no more than 35 degrees .

필자도 한국에서는 꽤 오래전에 첫 번째 방법으로 intubation을 준비했는데 외국에 오면 모두들 이 "straight to cuff" 방법을 사용했다. 이유는

' Straight to Cuff tube / stylet aids in maneuverability and laryngeal view . With the main body perfectly straight , with about a 35 degree angle beginning just behind cuff . The stylet stopped before the tip of the tube ' https : // youtu . be7ps3 IDquCRE ここ で 大事 な こと ！！의사가 glidescope 쓴다고 한다: glidescope용 stylet+laryngoscopesplastic cover준비(스타일렛 구부리지 말 것)

 

 Appropriate size ETT , one 0 . 5mm smaller and 0 . 5mm larger ( internal diameter measurement mm ET tube ) < 여기서 잠깐 >

Matching ET Tube Size to a Patient

 

1. Find the size marking on the ET tube.The outside diameter (OD) and internal diameter (ID) of an ET tube should be marked on the side of the tube. Typical ID sizes range from 3.5 mm for small infants to 8.5 mm for adult males.[2]In general, when referring to the size of an ET tube, you are talking about the internal diameter. This is because the internal diameter determines the amount of air that can be supplied to the person who has been intubated .

 

2. Check the length marking on the ET tube. ID 크기가 작을수록 길이도 짧아진다. 그래서 사이즈 선택이 중요하다.Smaller ID/OD ET tubes come in shorter lengths, as they are typically used on people who have a shorter distance between their mouth and their trachea. In general, ET tubes sized 7.0-9.0 mm are long enough to insert the tube 20–25 centimetres (7.9–9.8 in) down the throat, although the overall length can vary.There are specific length markings along the tube to allow the person inserting it to know how much of the tube is down the throat . Some doctors choose to cut the ends of ET tubes so they are a specific length for each patient . This is especially common with pediatric patients , as the lengths required can vary drastically .

 

3. Base your choice of ET tube size on sex and height in adults.ET tube sizes for people over 18 years old are usually based on the sex of the patient and how tall they are.- ET tube sizes 7.0 to 8.0 mm are used for females- ET tube sizes 8.0 to 9.0 mm for males.If the person is small in stature, meaning they are around 5 feet (1.5 m) tall, the smaller size is used.If they are bigger in stature, closer to 6 feet (1.8 m) tall, the bigger size is used . Remember , the size of ET tubes refers to the internal diameter of the tube .

 

[Pediatric]Use age for picking an ET tube size for infants and children.You need to be careful when sizing an ET tube on a child. Because their bodies are so small, you need to be more exact in your measurements than with adults. With this in mind, size ET tubes based on the child's specific age:Newborn: 2.5 - 4.0 mmInfant under 6 months: 3.5 - 4.0 mmInfant between 6 months and 1 year: 4.0 - 4.5 mmChild 1 and 2 years: 4.5 - 5.0 mmChild over 2 years : divide the child ' s age by 4 and add 4 m

 

 

 Appropriate sized laryngoscope

( Attach blade and check light and have spare light , blades and batteries to hand ) < 여기서 잠깐 > laryngoscope 종류들을 intubation 방법에 따라 알아보자 .

( 1 ) Direct : Macintosh blade ( 가장 한국에서 많이 보는 .. ) , Miller blade

( 2 ) Video ( indirect ) : Glidesc ope / , C - MAC

https://youtu.be/mIPjkp-B THQ

(3) Fiberoptic (긴급시 자주 사용); 실제 한국에 있을 때 broncho할 때 사용할 경우 본 (sedation이 필요한 paralysis가 아니라)

( 4 ) Blind ( supraglottic ) https://youtu.be/gnkYGRMaw7o

 

 

 

 

 

 

 Wall suction with yankauer  Suction catheters , appropriate size

 Gauze and K-Y Jelly Nasogastric tube prn(보통 intubation 후 L-tube도 함께 넣고 x-ray를 한 번에 찍어서 위치를 확인) Elast tape Securitying ETT fix할 때 여러 가지 ETT fix를 한다.

 Ventilator with appropria te settings checked by anaesthetist ( 미리 Calibration 되어있는 , full - standby 가 돼있는 ventilator 는 필수로 준비해야 함 )  Stethoscope  Scissors  Trolley or clear surface for equipment

 

Optional :

 Gum elastic bougie ( older child )  End tidal CO2 detector  Restrains

 

 

[ 정리 ! ] Intubation 할떄 Quick Guide

 

 

SOAPMESuction — at least one working suction, place it between mattress and bedOxygen — NRBM and BVM attached to 15 LPM of O2, preferably with nasal prongs for apneic oxygenationAirways — 7.5 ET tube with stylet fits most adults, 7.0 for smaller females, 8.0 for larger males,test balloon by filling with 10 cc of air with a syringe — Stylet – placed inside ET tube for rigidity, bend it 30 degrees starting at proximal end of cuff ( i . e . straight to cuff , then 30 degree bend ) — Blade

– Mac 3 or 4 for adults – curved blade — Miller 3 or 4 for adults – straight blade — Handle – attach blade and make sure light source works — Backups – ALWAYS have a surgical cric kit available ! — have video laryngoscope , LMA and bougie at bedside

Pre - oxygenate – 15 LPM NRBMMonitoring equipment / Medications — Cardiac monitor , Ventilator , pulse ox , BP cuff opposite arm with IV — Medications drawn up and ready to be givenEnd Tidal CO2

 

 

RSI Part 2 Patient preparation : Preoxygenation , Sedation , Positioning https://youtu.be/g-Aa0bOsPoE 

 

PositioningIntubation 한다 하면 바로 supine 해놓고 배개 빼고 작은 타올을 대준다(Spinal cord injury 환자는 당연히 No)The angle of the axis of the mouth to the larynx is 90°. That of the pharynx to the trachea is obtuse. Aligning them is merely a matter of applied mechanics. You make this alignment by moving the patient's head and neck into optimal position and then using the laryngoscope blade to make the final adjustment .PreoxgenationHow to Preo xygenation ? 포인트는 의식 없을 시 15L / mi via Bagging !!!

Sedation ( medication 게시 판에 더 자세히 게시할 예정 ) < 이 분야는 따로 나눠야 할듯하다 ㅜㅜ >https://youtu.be/TPWOSOKLtsMInduction agents● Ketamine 1.5-2 mg/kg IBW● Etomidate 0.3-0.4 mg/kg TBW● Fentanyl 2-10 mcg/kg TBW● Midazolam 0.1-0.3 mg/kg TBW● Propofol 1-2.5 mg/kg IBW + (0.4 x TBW) (others simply use 1.5 mg/kg x TBW as the general guide)● Thiopental 3-5 mg/kg TBWNeumuscular blockers:● Suxamethonium 1-2 mg/kg TBW● Rocuronium 0.6-1.2 mg/kg IBW● Vecuronium 0.15-0.25 mg/kg IBWRSI Part 3 : Intubation / Post Intubation

1) Ballooning Intubation 후 stylet을 뺀 후 환자의 liplevel에 맞춘 cm를 확인하고 일단 간호사에게 ballooning을 부탁할 것이다.

Check that the depth marker is at the opening of the mouth.There are length markers all along the length of the tube. When the tube is in place properly in an adult, it should indicate a depth of anywhere from 20 to 25 cm at the corner of the mouth.If the mark on the tube is positioned correctly at the vocal cord, the depth marker at the mouth should also be in the correct position.Later on, this mark will be an easy way for doctors and nurses to ensure that the tube continues to be in the correct position .

 

 

 

2 ) Monitoring the Tube ' s Pressure and PositionCarina ( 기관분기부 ) 에서 상방 3 - 5cm 위에 있는지 . Female : 20 - 21cm / Male ( 22 - 23cm )

Verify proper insertion . Onc e you have applied oxygen to the tube , make sure the chest is rising and falling . Then verify that the tube is in the right position . This can be done with an X - ray or an ultrasound . [ 12 ]The tip of the ET tube should be between 3 – 7 centimetres ( 1 . 2 – 2 . 8 in ) from the bottom of the trachea .

The carina is the point at the bottom of the trachea where it splits into the bronchi . You do not want the ET tube to go this far down , as it could damage this area .

3 ) Measure the air pressure in the ET tube .

balloon이 너무 많으면 airway 점막에 injury를 줄 수 있다. x선에 ballooning이 너무 많으면 눈에 띈다. Ideal = 25-30mmHg, cuff pressure monitor에서 green zone에 있으면 okay.Once the ET tube is in, it's a good idea to measure the amount of pressure being created by respiration through the tube. This can be done with a pressure regulator.Measuring the pressure created in the airway will help prevent damage to the trachea and the lungs.A safe pressure at the cuff of the ET tube is between 20 and 30 cmH2O.

 

3) Record the position of the ET tube so movement can be identified. <매 듀티마다 체크!>Recording the positioning of a tube at insertion will allow you to make sure it hasn't moved over time. Write down the measurement printed on the tube at a specific position in the mouth, such as at the front teeth or the lips.When checking on the patient later, you can ensure that the tube is still in the proper position by referencing this documentation .

 

4) Put a CO2 detector on the ET tube.You can also ensure that the tube is inserted correctly by putting a CO2 detector on it. If the detector senses any amount of CO2 being exhaled, it will simply change color. This shows that the patient is receiving oxygen properly, as CO2 is a byproduct expelled only when oxygen is supplied.These monitors are single use. When they sense CO2, the face of the monitor changes color irreversibly . Because of this , they are typically used just once right after intubation .

 

Reference

https://www.wikihow.com/Measure-an-ET-TubeAn endotracheal (ET) tube is used to help a person breathe. It is placed down the throat and into the trachea through the mouth. In order to position it deeply enough into the trachea, but not so deep that it causes internal injuries, the...www.wikihow.comhttps://litfl.com/rapid-sequence-intubation-rsi/Rapid sequence intubation (RSI) is an airway management technique that produces inducing immediate unresponsiveness ( induction agent ) and muscular relaxation ( neuromuscular blocking agent ) and is the fastest and most effective means of controlling the emergency airwaylitfl . com https://resusreview.com/2013/rapid-sequence-intubation-checklist/https : // www.wikihow.com/Measure-an-ET-Tube  

How to Measure an ET Tube

https://airwayjedi.com/2016/04/01/position-head-intubation/Patient position can make intubation easy , or hard . This article discusses how to obtain a good sniffing position to succeed in first pass intubation . airwayjedi . com https://litfl.com/rapid-sequence-intubation-rsi/