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Endotracheal Tube and Neonate

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100% with a leak pressure of less than 20 cm H2O --successfully extubated ... Histopathology of endotracheal. Intubation. An Autopsy study of 99 cases. Arch Path. ... – PowerPoint PPT presentation

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Title: Endotracheal Tube and Neonate


1
Endotracheal Tube and Neonate
2
Archives of Otolaryngology -- headneck surgery.
vol.117 No.8,Augest 1991
  • 100 with a leak pressure of less than 20 cm H2O
    --successfully extubated
  • 100 with a leak of greater than 30 cm H2O
    --failure
  • 60 with a leak pressure in the range of 21 to 30
    cm H2O --successfully extubated

3
Archives of Otolaryngology -- headneck surgery.
119(8)815-9, 1993 Aug.
  • Risk factors for acquired laryngotracheal
    stenosis in newborn infants are poorly known.
  • The size of the endotracheal tube appears to be a
    major risk factor for acquired laryngotracheal
    stenosis in the neonate.

4
Pediatric Pulmonology. 7(2)116-20, 1989
  • 37 month period
  • flexible fiberoptic bronchoscopies in 77 neonates
  • Bronchoscopy has been found valuable in the
    management of emergency situations such as
    suspected tube blockage or malposition and
    difficult intubations.

5
AANA Journal. 66(3)299-303, 1998 Jun.
  • The traditional age-base(AB) formula(age in
    year16) divided by 4
  • Using the Broselow pediatric resuscitation tape.
  • The AB formula is reliable and easily applied.
  • Age is not available, the Broselow pediatric
    resuscitation tape allows reliable.

6
(No Transcript)
7
Anesthesia Analgesia. 97(6)1857-1858, 2003
  • ETT allow small air leak at peak inflation
    pressure of 20-30 cm H2O.
  • Inspiratory and expiratory tidal volume(ITV and
    ETV)
  • 10-15 ml/kg tidal volume and an appropriate RR
  • Apply PEEP of 4-5cm and increase gradually(1-2cm
    H2O at a time) until the PIP to 25 cm H2O(PEEPlt10
    cm H2O)
  • A difference of 10 tidal volume but less than
    5ml between the ITV and ETV? suitability of the
    ETT.
  • No further increase in the difference between the
    ITV and ETV, the ETT is deemed an oversized one.

8
  • Endotracheal Intubation
  • and
  • Tracheal Stenosis

9
Textbook-Millers Anesthesia
10
  • Uncuffed endotracheal tubes have been used in
    children younger than 6 8 years
  • Gas leak in the peak inflation pressure1520
    cmH2O (2030 cmH2O)
  • If no leak is detected in the pressure of 40
    cmH2O, shift to smaller size.
  • Cuff pressures that afford good (but not perfect)
    protection (20 to 25 mm Hg) are just below the
    perfusion pressure of the tracheal mucosa (25 to
    35 mm Hg).

11
  • Laryngotracheal Stenosis

12
  • The most common cause ischemia secondary to
    intubation.
  • Sites
  • Adult glottis, posterior site
  • Children subglottis

13
Risk factors
  • GE reflux,
  • Bacterial colonization,
  • Systemic illness
  • Malnutrition
  • Hypoxia, Anemia
  • Movement
  • Cuff pressure
  • Tube size
  • Tube shape
  • Intubation duration
  • Repeated intubation

14
Normal Subglottic Area
15
elliptical congenital subglottic stenosis (SGS)
16
Spiral subglottic stenosis
17
4-month-old infant with acquired grade III
subglottic stenosis from intubation
18
Literature Search
  • 12 incidence of laryngeal stenosis in patients
    with tracheal intubation for 11 days or longer, a
    5 incidence between 6-10 days of intubation, and
    a 2 incidence with less than 6 days intubation.
  • Whited RE. Laryngeal dysfunction following
    prolonged intubation. Ann Otol Rhinol Laryngol
    197988474-8

19
  • 19 of the patients who had translaryngeal
    intubation developed significant stenosis, which
    was defined as gtgt10 reduction in the air column
    diameter, with stenosis occurring either at the
    subglottic area or the cuff.
  • Stauffer JL, Olson DE, Petty TL. Complications
    and consequences of endotracheal intubation and
    tracheotomy a prospective study of 150
    critically ill adult patients. Am J Med
    19817065-76

20
  • Almost all patients who undergo translaryngeal
    intubation suffer some degree of stenosis
  • Heffner JE. Timing of tracheotomy in
    ventilator-dependent patients. Clin Chest Med
    199112611-25

21
  • Histologic study demonstrated
  • Focal or complete loss of mucosal epithelium in
    contact with the orotracheal tube for even one
    hour.
  • The ischemic nature of the necrosis.
  • That perichondritis of the vocal process is
    increasingly frequent after 48 hours of
    intubation.
  • The infestation of the ulcer site by
    microorganisms is common after 24 hours of
    intubation.
  • ( 15 min 176 hrs of intubation duration )
  • William H. Donnelly. Histopathology of
    endotracheal
  • Intubation. An Autopsy study of 99 cases. Arch
    Path.
  • 881969.

22
  • Contencin P, Narcy P. Size of endotracheal tube
    and neonatal
  • acquired subglottic stenosis. Arch Otolaryngol
    Head Neck Surg.
  • 1993 Aug119(8)815-9

23
  • In the 1970s and 1980s, estimates of the
    incidence of subglottic stenosis were in the
    range of 0.9 8.3 of intubated neonates.
  • All studies published after 1983 reported an
    incidence of neonatal subglottic stenosis as lt
    4.0, and all studies published after 1990
    reported an incidence as lt 0.63.
  • The current incidence of neonatal subglottic
    stenosis is likely between 0.0 2.0.
  • Walner, David L. Loewen, Mark S. Kimura,
    Robert E. Neonatal Subglottic Stenosis-Incidence
    and Trends. Laryngoscope. 111(1)48-51, January
    2001
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