Tracheobronchial Tree
Transcript of Tracheobronchial Tree
By,Dr. Yogesh Kumar Chhetty
Under the guidance of:
Dr. Rajan Nanda&Dr. Hemlata Ametha
THE COMPONENTS OF THE RESPIRATORY SYSTEM
Upper respiratory system
• Nose
• Nasal cavity
• Paranasal sinuses
• Pharynx
Lower respiratory system
• Larynx
• Trachea
• Bronchi
• Lungs
UPPER RESPIRATORY SYSTEM
THE NOSE, NASAL CAVITY, AND PHARYNX• Nose is primary passageway for air
entering respiratory system
• Air enters paired external nares that open into nasal cavity
• Vestibule : portion of nasal cavity contained within flexible tissues of external nose
• Vestibule contains coarse hair that trap foreign particles
• Nasal septum : divides cavity into right & left halves
• Bony portion of nasal septum is formed by perpendicular plate of ethmoid & vomer
• Anterior portion of septum is formed by hyaline cartilage
NASOPHARYNX
• Superior part of pharynx
• Connected to posterior portion of
nasal cavity via internal nares
• Separated from oral cavity by soft
palate
• Lined by respiratory epithelium
• Pharyngeal (adenoid) tonsil is located
on posterior wall
• Lateral walls contain openings of
auditory tubes
OROPHARYNX
• Extends between soft palate & base of
tongue at level of hyoid bone
• Posterior portion of oral cavity &
posterior & inferior portions of
nasopharynx communicates directly with
oropharynx
• At boundary between naso & oropharynx
epithelium changes from respiratory
epithelium to stratified squamous
epithelium
• Soft palate supports uvula & two pairs of
pharyngeal arches
• Anterior palatoglossal arch
• Posterior palatoglossal arch
Palatine tonsil
lies in between
LARYNGOPHARYNX• Includes that portion of pharynx lying between hyoid bone & entrance to esophagus
• Most inferior portion of pharynx
• Lined by stratified squamous epithelium
THE GLOTTIS
THE LARYNX• Inspired air leaves pharynx by passing through a narrow opening – glottis
• Larynx surrounds & protects glottis
• Larynx begins at C3 & ends at C6 vertebral levels
• Larynx essentially is a cylinder whose cartilaginous walls are stabilized by ligaments & muscle
THE ANATOMY OF THE LARYNX
THE TRACHEA• Trachea is a tough, flexible tube with diameter of
1.2cm & length of 10-15cm
• Begins anterior to C6 vertebra in a ligamentous attachment to cricoid cartilage
• Ends in mediastinum at level of T4 vertebra in the supine and T6 in the standing position
• Branches to form right & left primary bronchi
• Lining of trachea consists of respiratory epithelium overlying a layer of looser connective tissue (lamina propria)
• Trachea contains 16-20 incomplete C shaped tracheal cartilages
• Each tracheal cartilage is bound to neighboring cartilages by elastic annular ligaments
• Tracheal cartilages stiffen tracheal walls & protect airway
• Also prevent its collapse or overexpansion as pressures change in respiratory system
THE TRACHEA• Each tracheal cartilage is C shaped
• Closed portion of C protects anterior & lateral
surfaces of trachea
• Open portion of C faces posteriorly toward
oesophagus
• Because cartilages do not continue around
trachea, posterior tracheal wall can easily distort
during swallowing permitting passage of large
masses of food
• Trachealis : An inelastic ligament & band of
smooth muscle connecting ends of each
tracheal cartilage
PRIMARY BRONCHI• Right & left primary bronchi
• Carina marks line of separation between 2 bronchi
• It’s a very sensitive structure and its stimulation leads to unwanted effects. So ETT and catheter should be kept away from it
• Has cartilaginous C shaped supporting rings
• Right primary bronchus – shorter 2.5cm(Lt - 4.5cm), larger diameter than left & descends towards lung at a steeper angle, angle with the vertical is 250 (Lt – 450.)
• Aorta arches over the left main bronchus
• Due to the peculiar characteristics of rt main bronchus chances of ETT to be positioned in the Rt side are more
• In children the angle of both the Rt and the Lt are the same i.e 550 upto an age of 3 years
TERTIARY BRONCHI
THE BRONCHI
1º BRONCHI
2º BRONCHI (LOBAR BRONCHI)
3º BRONCHI (SEGMENTAL BRONCHI)
SUPPLIES AIR TO SINGLE BRONCHOPULMONARY SEGMENT
10 RIGHT 8/9 LEFT
RIGHT
SUPERIOR LOBAR
MIDDLE LOBAR
INFERIOR LOBAR
LEFT
SUPERIOR LOBAR
INFERIOR LOBAR
23 generations of dichotomous
branhes are present from the trachea till
alveolar sacs
THE BRONCHI AND LOBULES OF THE LUNG
BRIEF HISTORY
1878 - William Macewen passed a tube in
trachea from the mouth for the first time
1893 - Eisenmenger gave a description of the
cuffed ETT
1906 - Green introduces the pilot balloon
1960 - Plastic replaces red rubber as material
for construction
1969 – Introduction of modern day ETT with
high volume low pressure cuff
INDICATIONS FOR INTUBATION Respiratory failure
Protection of the airway from aspiration
Decreased LOC (coma score <8/15)
Secretion clearance
Upper airway obstruction
Raised ICP treatment
Facilitate tracheobronchial toilet
CPR
Surgery
Non NBM patients
Anaesthesia requiring PPV
Head and neck surgeries which may compromise airway
Surgeries requiring neuromuscular blocking agents
In patients likely to develop laryngospasm
OBJECTIVE MEASURES INDICATING THE NEED FOR INTUBATION
RR >35
VC <15 ml/kg
PaO2 <60 on >40% oxygen
PaCO2 >50 (except in chronic
retainers)
A-a gradient > 300 on 100% oxygen
INTUBATION EQUIPMENT
Endotracheal Tube and stylet
Laryngoscope
Sterile water-soluble jelly
Syringe to inflate cuff
Adhesive tape or tube fixation device
Bite block to prevent biting oral ET tube
Suction Equipment, bag- mask, O2
Local anesthetic
Stethoscope
PREPARATION FOR INTUBATION
Suction Equipment Oxygen Airway Patient position Monitors Esophageal Detection Device
LARYNGOSCOPE
Blade and handle
Blade -
has a flange, spatula, light,
and tip
- curved blade (Macintosh)
- straight blade (Miller, Wisconsin)
Blade size: 0 - 1 infant, 2 from 2-8 years 3 from age 10-
adult, large adult- 4
LARYNGOSCOPIC BLADE
Macintosh (curved) and Miller (straight) blade
Adult : Macintosh blade, small children : Miller blade
Miller blade Macintosh bladeCurved tip
Mccoy blade
STRAIGHT BLADE (MILLER)
CURVED BLADE (MACINTOSH)
ENDOTRACHEAL TUBE ET TUBE SIZE
For children lesser than 6 years
- Tube size = age/3 + 3.5(ETT ID in mm)
For children more than 7 years
-Tube size = age/4 + 4.5(ETT ID in mm)
DEPTH OF INSERTION
Adult
Adult - Male = 20-21 cms ,Female = 19-20 cms
Children
Oral endotracheal tube = (Age/2) + 12 (cm)
Nasal endotracheal tube = (Age/2) + 15 (cm)
ENDOTRACHEAL TUBE CUFFED AND UNCUFFED
High volume Low pressure cuff
Low volume High pressure cuff
STYLET
SNIFFING POSITION
Neck flexion of 25-350
Head extension of 850
In adults a head elevation of 8-10 cms
In paediatric age group of less than 8
years there is no need of head elevation
SNIFFING POSITION
ROUTES FOR INTUBATION
Orotracheal Nasotracheal Tracheotomy
ORAL INTUBATION
ADVANTAGES OF ORAL INTUBATION
Larger tube can be inserted
Tube can be inserted usually with more
speed and ease with less trauma
Easier suctioning
Less airflow resistance
Reduced risk of tube kinking
DISADVANTAGES OF ORAL INTUBATION
Gagging, coughing, salivation, and irritation
can be induced with intact airway reflexes
Tube fixation is difficult, self-extubation
Gastric distention from frequent
swallowing of air
Mucosal irritation and ulcerations of mouth
(change tube position)
NASAL INTUBATION
ADVANTAGES OF NASAL INTUBATION
More comfort long term
Decreased gagging
Less salivation, easier to swallow
Improved mouth care
Better tube fixation
Improved communication
DISADVANTAGES OF NASAL INTUBATION
Pain and discomfort
Nasal and paranasal complications, I.e., epistaxis,
sinusitis, otits
More difficult procedure
Smaller tube needed
Increased airflow resistance
Difficult suctioning
Bacteremia
CONTRAINDICATION FOR NASOTRACHEAL INTUBATION
1 ) Fracture base of skull 2) Nasal fractures or grossly
distorted septum 3 ) Coagulopathy 4 ) Nasal cavity obstruction 5 ) Retropharyngeal abscess
CONTRAINDICATION FOR ENDOTRACHEAL INTUBATION
1) Severe airway trauma 2 ) Cervical spine injury 3Aneurysm of the arch of aorta 4) Laryngeal edema 5) Severe laryngitis
ORAL INTUBATION PROCEDURE
Assemble and check equipment
- suction equipment
- laryngoscope
- select proper size tube, check
tube
Position patient
- align mouth, pharynx, larynx -
“SNIFFING” position
PATIENT POSITIONING
Preoxygenate the patient
- bag-valve mask
- *intubation attempt should take no longer than 30 sec, if
unsuccessful, then ventilate again with bag and mask for
3-5 minutes
Insert laryngoscope
Laryngoscope is gently held in the left hand at the junction of the
handle and the blade, while the right hand’s thumb and middle
finger gently open the patients’ mouth in a scissoring action.
Laryngoscope is inserted from the right side of the mouth and the
tongue is displaced towards left as the laryngoscope is introduced.
ORAL PROCEDURE (CONTD..)
On deeper entry into the oral cavity, the curved Macintosh
blade is positioned into the space between the base of the
tongue and the pharyngeal surface of the epiglottis. The
tongue and the pharyngeal soft tissue are then lifted to
expose the glottic opening.
ORAL PROCEDURE (CONTD..)
The direction of the lifting force is always along the axis of the laryngoscope
handle. The blade should never be used as a lever and the teeth as a
fulcrum.
Insert ET tube from the right corner of mouth - do not use laryngoscope
blade to guide tube
- once you see the tube pass
the glottis, advance the cuff past the cords by
2 -3 cm
Hold tube with right hand and remove laryngoscope & stylet
- inflate cuff with 5 - 10 cc of air
- ventilate with bag
ORAL PROCEDURE (CONTD..)
ORAL PROCEDURE (CONTD..)
Inflate cuff with 5 - 10 cc of air (10-20 cm of H2O)
Ventilate with “bag”
Assess tube position
- auscultation of chest & epigastric
- cm mark at teeth
- capnometry
Stabilize / Fix Tube tube/Confirm placement
CONFIRMATION OF THE POSITION OF ENDOTRACHEAL TUBE
Intubation under vision
Chest movements / Auscultation in epigastric area
Bilateral Air Entry with Stethoscope
Feeling of inflated cuff in suprasternal notch
Movement of the bag
Fogging of the endotracheal tube
Capnography
Fibreoptic bronchoscopy
Chest X-Ray
WHAT ARE THE POTENTIAL COMPLICATIONS OF
ENDOTRACHEAL INTUBATION?
FACTORS FOR SUSCEPTIBILITY Extrinsic factors
Diameter of ETT
Duration of intubation
Traumatic or multiple intubations
Patient factors
Poor tissue perfusion (i.e. sepsis, organ failure, etc)
LPR
Abnormal larynx
Wound healing, keloid
Movement
During ventilator use
During suctioning
During coughing
During transport