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The biggest draw of YouTube Go is that it enables you to watch videos even when you're saving data, or when you're in a region or country that doesn't provide fast downloading of data. For instance, you're on a 2G network in India, a country that also faces a huge percent of mobile network issues, this utility is designed to make it all feasible. You can set a size cap in megabytes for all the videos you'll watch, limiting the bandwidth and data they consume.
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In its simplest form, the endotracheal tube is a tube constructed of polyvinyl chloride that is placed between the vocal cords through the trachea. It serves to provide oxygen and inhaled gases to the lungs and protects the lungs from contamination, such as gastric contents or blood. The advancement of the endotracheal tube has closely followed advancements in anesthesia and surgery. Modifications have been made to minimize aspiration, isolate a lung, administer medications, and prevent airway fires. Despite these advances, more research to optimize its use is necessary. For example, endotracheal tubes are implicated in the development of ventilator-associated pneumonia, which remains a major concern. This activity describes the indications, contraindications, and techniques involved in endotracheal tube placement and highlights the role of the interprofessional team in the care of patients undergoing this procedure.
Objectives:Identify indications and contraindications for endotracheal tube placement.Describe potential complications of endotracheal tube placement.Outline the anatomy that is relevant to the placement of an endotracheal tube.Summarize a structured, interprofessional team approach to provide effective care to and appropriate surveillance of patients undergoing endotracheal tube placement.Access free multiple choice questions on this topic.
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The endotracheal tube (ETT) was first reliably used in the early 1900s.[1] In its simplest form, it is a tube constructed of polyvinylchloride (PVC) that is placed between the vocal cords through the trachea to provide oxygen and inhaled gases to the lungs. It also serves to protect the lungs from contamination such as gastric contents and blood. The advancement of the endotracheal tube has closely followed advancements in anesthesia and surgery.[2] Modifications have been made to minimize aspiration, isolate a lung, administer medications, and prevent airway fires. Despite advances with the endotracheal tube, more research to optimize its use is necessary. For example, ventilator-associated pneumonia (VAP) is a major concern, and the ETT itself is felt to be a primary agent for the development of VAP.[2]
To facilitate placement through the vocal cords and to provide improved visualization ahead of the tip, the ETT has an angle or slant known as a bevel. As the endotracheal tube approaches the cords, the left-facing bevel provides an optimal view.
The main indication to use an endotracheal tube is to secure a definitive airway. A definitive airway is the placement of an ETT in the trachea with an inflated cuff below the vocal cords. The main reasons to secure a definitive airway are an inability to maintain airway patency, inability to protect the airway against aspiration, failure to ventilate, failure to oxygenate, and anticipation of a deteriorating course leading to respiratory failure.
The primary (relative) contraindications to the placement of an ETT in the oropharynx is severe airway trauma or obstruction that does not allow safe placement of the tube, severe cervical spine injury which requires complete immobilization, and those patients with Mallampati III/IV classification suggesting potentially difficult airway management.
Select an appropriate size endotracheal tube and remove it from the package. Lubricate the distal end and balloon (if not emergency placement). Attach a proper size syringe (10 to 20 cc) filled with air to the pilot balloon and test the balloon by blowing it up and then deflating it. Place a stylet into the ETT and bend it to an appropriate shape. Place the tube with the stylet and attached syringe back in the package ready for use. Repeat the same procedure with a tube one size smaller in case of difficult intubation. Set aside an end-tidal CO2 detector.
Several mechanical complications can occur with the ETT resulting in a loss of function. A defective balloon will result in a loss of ability to protect the airway from aspirate and may make mechanical ventilation difficult. The loss of the universal 15 mm connector (either missing or defective) essentially makes the ETT nonfunctional as the mechanical ventilator or bag-valve-mask cannot interface with it. Some complications from the physical placement of the tube include bleeding, infection, perforation of the oropharynx (especially with the use a rigid stylet), hoarseness (vocal cord injury), damage to teeth/lips, or esophageal placement.
Intubation, or placement of an endotracheal tube, is an important life-saving skill. All clinicians who work in emergency rooms, operating rooms, peri-operative areas, and intensive care units (all places with intubated patients) must understand the basics and mechanics of an endotracheal tube. This knowledge is necessary for appropriate ventilator settings and the management of intensive care-level patients.
An interprofessional team is necessary to make sure that an ETT is placed appropriately, especially in the emergency department setting. As there is not one definitive method to ensure appropriate ETT placement, an interprofessional team working together to confirm several means of tube placement is necessary to ensure optimal patient outcomes. For example, after emergent intubation in the emergency department, a respiratory therapist may ensure a good color change of the end-tidal CO2 detector while also securing the ETT. Simultaneously, nursing staff may auscultate over the lung fields and abdomen to ensure good quality, equal breath sounds in the thoracic cavity with absent breath sounds in the abdomen. The physician will be monitoring the pulse ox while ordering a stat portable chest x-ray to confirm placement of the tube. It has become more common and standard of care to have a constant waveform monitor for end tidal CO2 for intubated patients, especially in the OR and ICU. Collaboration, closed-loop communication, and the principles of crisis resource management are necessary for the success of teams working in acute care environments.[8]
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For your convenience, tubes are available for rent within the park. Visitors are welcome to bring their own tubes or rent from outside vendors. All tubes cannot exceed 60 inches in any two directions.
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You will have individual help and advice about tube feeding in hospital and at home. Health professionals who support tube feeding include nurses, dietitians and pharmacists, but job titles can vary between areas. The main professionals who help you are:
"Percutaneous" means through the skin. The procedure creates a passageway from the skin on the back to the kidney. A surgeon uses special instruments passed through a tiny tube in your back to locate and remove stones from the kidney.
You may have a flexible tube (catheter) passed through the urethra, bladder and ureter into the kidneys. The urethra is the tube where urine exits the body. The ureter is the tube connecting a kidney to the bladder. Through this catheter, your doctor can put a specialized tracer substance into the kidney that outlines structures inside the kidney so that they're more visible during imaging. Or, a tiny camera may be threaded through the catheter, which allows your doctor to see the needle as it's placed in the kidney and other work during surgery.
The surgeon may then place a different tube, called a nephrostomy tube, in this same passageway. The nephrostomy tube allows urine to drain directly from the kidney into a bag worn outside the body during recovery. For complicated cases, this tube also leaves access to the kidney if more kidney stones or fragments of kidney stones need to be removed during the recovery time.
If you have drainage tubes in the kidney left after surgery, you'll need to watch for any bleeding. If you notice blood or thick clumps of ketchup-like blood in your urine or drainage tube, go to the emergency department.
You may have ultrasound, X-ray or a CT scan to check for any stones that may be left and to make sure that urine is draining as usual from the kidney. If you have a nephrostomy tube, your surgeon will remove it after giving you a local anesthetic.