Intubation Tips

Adverse respiratory events (AREs) are leading causes of post-operative morbidity and mortality. Anesthesia is the use of medicine to prevent or reduce the feeling of pain or sensation during surgery or other painful procedures (such as getting stitches). Giving as an injection or through inhaled gases or vapours, different types of anesthesia affect the nervous system in various ways by blocking nerve impulses and, therefore, pain.

Anesthesia can help control your breathing, blood pressure, blood flow, and heart rate. It may be used to:

1. Relax you,
2. Block pain,
3. Make you sleepy or forgetful,
4. Make you unconscious for your surgery.

Adverse Respiratory Events (ARE)
Adverse outcomes of such events are fatal and lead to Death & Brain Damage. Three mechanisms of injury are reported to account for highest adverse respiratory events:
Inadequate Ventilation: Insufficient Gas Exchange can produce the adverse outcome. Esophageal Intubation: Incubation between the two sides of the esophagus inadvertently.
Difficult tracheal intubation: Tracheal Intubation is the placement of a flexible plastic tube into the trachea (windpipe) to maintain an open airway. It is performed facilitate ventilation of lungs in severely ill, anesthetized patients.

Other’s are as listed below:

• Airway Obstruction
• Inadequate inspired oxygen delivery
• Aspiration
• Endobronchial Intubation
• Premature Extubation

Residual neuromuscular blockade is an important postoperative complication associated to the use of neuromuscular blocking drugs and is commonly observed in the post-anesthesia care unit (PACU) after non-depolarizing neuromuscular blocking agents (NMBAs) are administered intra-operatively. Incomplete neuromuscular recovery can be minimized with acceleromyography monitoring. The risk of adverse respiratory events during early recovery from anesthesia can be reduced by intra-operative acceleromyography use.

Reintubation is a serious adverse respiratory event and the consequences include increased cardiac and respiratory complications, prolonged length of stay at the PACU, intensive care unit (ICU) and hospital, prolonged mechanical ventilator support, higher costs, and increased mortality. Overweight and obesity have also been identified as risk factors for postoperative respiratory complications. Most adverse respiratory events are considered preventable with improved monitoring such as:

• Pulse Oximetry
• Capnometry
• Combination of Both

Closed observation of the clinical factors and appropriate monitoring by well trained people are factors necessary to prevent adverse outcome.

In case you have a concern or query you can always consult an expert & get answers to your questions!

Adverse respiratory events (AREs) are leading causes of post-operative morbidity and mortality. Anesthesia is the use of medicine to prevent or reduce the feeling of pain or sensation during surgery or other painful procedures (such as getting stitches). Giving as an injection or through inhaled gases or vapours, different types of anesthesia affect the nervous system in various ways by blocking nerve impulses and, therefore, pain.

Anesthesia can help control your breathing, blood pressure, blood flow, and heart rate. It may be used to:

1. Relax you
2. Block pain
3. Make you sleepy or forgetful
4. Make you unconscious for your surgery

Adverse Respiratory Events (ARE)
Adverse outcomes of such events are fatal and lead to death & brain damage. Three mechanisms of injury are reported to account for highest adverse respiratory events:

1. Inadequate Ventilation: Insufficient Gas Exchange can produce the adverse outcome.
2. Esophageal Intubation: Incubation between the two sides of the esophagus inadvertently.
3. Difficult tracheal intubation: Tracheal Intubation is the placement of a flexible plastic tube into the trachea (windpipe) to maintain an open airway. It is performed facilitate ventilation of lungs in severely ill, anesthetized patients.

Other’s are as listed below:

• Airway Obstruction
• Inadequate inspired oxygen delivery
• Aspiration
• Endobronchial Intubation
• Premature Extubation

Residual neuromuscular blockade is an important postoperative complication associated to the use of neuromuscular blocking drugs and is commonly observed in the post-anesthesia care unit (PACU) after non-depolarizing neuromuscular blocking agents (NMBAs) are administered intra-operatively. Incomplete neuromuscular recovery can be minimized with acceleromyography monitoring. The risk of adverse respiratory events during early recovery from anesthesia can be reduced by intra-operative acceleromyography use.

Reintubation is a serious adverse respiratory event and the consequences include increased cardiac and respiratory complications, prolonged length of stay at the PACU, intensive care unit (ICU) and hospital, prolonged mechanical ventilator support, higher costs, and increased mortality. Overweight and obesity have also been identified as risk factors for postoperative respiratory complications. Most adverse respiratory events are considered preventable with improved monitoring such as:

• Pulse Oximetry
• Capnometry
• Combination of Both

Closed observation of the clinical factors and appropriate monitoring by well trained people are factors necessary to prevent adverse outcome.

In case you have a concern or query you can always consult an expert & get answers to your questions!

Adverse respiratory events (AREs) are leading causes of post-operative morbidity and mortality. Anesthesia is the use of medicine to prevent or reduce the feeling of pain or sensation during surgery or other painful procedures (such as getting stitches). Giving as an injection or through inhaled gases or vapours, different types of anesthesia affect the nervous system in various ways by blocking nerve impulses and, therefore, pain.

Anesthesia can help control your breathing, blood pressure, blood flow, and heart rate. It may be used to:

1. Relax you,
2. Block pain,
3. Make you sleepy or forgetful,
4. Make you unconscious for your surgery.

Adverse Respiratory Events (ARE)
Adverse outcomes of such events are fatal and lead to Death & Brain Damage. Three mechanisms of injury are reported to account for highest adverse respiratory events:
Inadequate Ventilation: Insufficient Gas Exchange can produce the adverse outcome. Esophageal Intubation: Incubation between the two sides of the esophagus inadvertently.
Difficult tracheal intubation: Tracheal Intubation is the placement of a flexible plastic tube into the trachea (windpipe) to maintain an open airway. It is performed facilitate ventilation of lungs in severely ill, anesthetized patients.

Other’s are as listed below:

• Airway Obstruction
• Inadequate inspired oxygen delivery
• Aspiration
• Endobronchial Intubation
• Premature Extubation

Residual neuromuscular blockade is an important postoperative complication associated to the use of neuromuscular blocking drugs and is commonly observed in the post-anesthesia care unit (PACU) after non-depolarizing neuromuscular blocking agents (NMBAs) are administered intra-operatively. Incomplete neuromuscular recovery can be minimized with acceleromyography monitoring. The risk of adverse respiratory events during early recovery from anesthesia can be reduced by intra-operative acceleromyography use.

Reintubation is a serious adverse respiratory event and the consequences include increased cardiac and respiratory complications, prolonged length of stay at the PACU, intensive care unit (ICU) and hospital, prolonged mechanical ventilator support, higher costs, and increased mortality. Overweight and obesity have also been identified as risk factors for postoperative respiratory complications. Most adverse respiratory events are considered preventable with improved monitoring such as:

• Pulse Oximetry
• Capnometry
• Combination of Both

Closed observation of the clinical factors and appropriate monitoring by well trained people are factors necessary to prevent adverse outcome. If you wish to discuss about any specific problem, you can consult a general surgeon.

Adverse respiratory events (AREs) are leading causes of post-operative morbidity and mortality. Anesthesia is the use of medicine to prevent or reduce the feeling of pain or sensation during surgery or other painful procedures (such as getting stitches). Giving as an injection or through inhaled gases or vapours, different types of anesthesia affect the nervous system in various ways by blocking nerve impulses and, therefore, pain.

Anesthesia can help control your breathing, blood pressure, blood flow, and heart rate. It may be used to:

1. Relax you,
2. Block pain,
3. Make you sleepy or forgetful,
4. Make you unconscious for your surgery.

Adverse Respiratory Events (ARE)
Adverse outcomes of such events are fatal and lead to Death & Brain Damage. Three mechanisms of injury are reported to account for highest adverse respiratory events:
Inadequate Ventilation: Insufficient Gas Exchange can produce the adverse outcome. Esophageal Intubation: Incubation between the two sides of the esophagus inadvertently.
Difficult tracheal intubation: Tracheal Intubation is the placement of a flexible plastic tube into the trachea (windpipe) to maintain an open airway. It is performed facilitate ventilation of lungs in severely ill, anesthetized patients.

Other’s are as listed below:

• Airway Obstruction
• Inadequate inspired oxygen delivery
• Aspiration
• Endobronchial Intubation
• Premature Extubation

Residual neuromuscular blockade is an important postoperative complication associated to the use of neuromuscular blocking drugs and is commonly observed in the post-anesthesia care unit (PACU) after non-depolarizing neuromuscular blocking agents (NMBAs) are administered intra-operatively. Incomplete neuromuscular recovery can be minimized with acceleromyography monitoring. The risk of adverse respiratory events during early recovery from anesthesia can be reduced by intra-operative acceleromyography use.

Reintubation is a serious adverse respiratory event and the consequences include increased cardiac and respiratory complications, prolonged length of stay at the PACU, intensive care unit (ICU) and hospital, prolonged mechanical ventilator support, higher costs, and increased mortality. Overweight and obesity have also been identified as risk factors for postoperative respiratory complications. Most adverse respiratory events are considered preventable with improved monitoring such as:

• Pulse Oximetry
• Capnometry
• Combination of Both

Closed observation of the clinical factors and appropriate monitoring by well trained people are factors necessary to prevent adverse outcome. If you wish to discuss about any specific problem, you can consult a General Surgeon.

Adverse respiratory events (AREs) are leading causes of post-operative morbidity and mortality. Anesthesia is the use of medicine to prevent or reduce the feeling of pain or sensation during surgery or other painful procedures (such as getting stitches). Giving as an injection or through inhaled gases or vapours, different types of anesthesia affect the nervous system in various ways by blocking nerve impulses and, therefore, pain.

Anesthesia can help control your breathing, blood pressure, blood flow, and heart rate. It may be used to:

1. Relax you,
2. Block pain,
3. Make you sleepy or forgetful,
4. Make you unconscious for your surgery.

Adverse Respiratory Events (ARE)
Adverse outcomes of such events are fatal and lead to Death & Brain Damage. Three mechanisms of injury are reported to account for highest adverse respiratory events:
Inadequate Ventilation: Insufficient Gas Exchange can produce the adverse outcome. Esophageal Intubation: Incubation between the two sides of the esophagus inadvertently.
Difficult tracheal intubation: Tracheal Intubation is the placement of a flexible plastic tube into the trachea (windpipe) to maintain an open airway. It is performed facilitate ventilation of lungs in severely ill, anesthetized patients.

Other’s are as listed below:

• Airway Obstruction
• Inadequate inspired oxygen delivery
• Aspiration
• Endobronchial Intubation
• Premature Extubation

Residual neuromuscular blockade is an important postoperative complication associated to the use of neuromuscular blocking drugs and is commonly observed in the post-anesthesia care unit (PACU) after non-depolarizing neuromuscular blocking agents (NMBAs) are administered intra-operatively. Incomplete neuromuscular recovery can be minimized with acceleromyography monitoring. The risk of adverse respiratory events during early recovery from anesthesia can be reduced by intra-operative acceleromyography use.

Reintubation is a serious adverse respiratory event and the consequences include increased cardiac and respiratory complications, prolonged length of stay at the PACU, intensive care unit (ICU) and hospital, prolonged mechanical ventilator support, higher costs, and increased mortality. Overweight and obesity have also been identified as risk factors for postoperative respiratory complications. Most adverse respiratory events are considered preventable with improved monitoring such as:

• Pulse Oximetry
• Capnometry
• Combination of Both

Closed observation of the clinical factors and appropriate monitoring by well trained people are factors necessary to prevent adverse outcome.

Adverse respiratory events (AREs) are leading causes of post-operative morbidity and mortality. Anesthesia is the use of medicine to prevent or reduce the feeling of pain or sensation during surgery or other painful procedures (such as getting stitches). Giving as an injection or through inhaled gases or vapours, different types of anesthesia affect the nervous system in various ways by blocking nerve impulses and, therefore, pain.

Anesthesia can help control your breathing, blood pressure, blood flow, and heart rate. It may be used to:

1. Relax you
2. Block pain
3. Make you sleepy or forgetful
4. Make you unconscious for your surgery

Adverse Respiratory Events (ARE)
Adverse outcomes of such events are fatal and lead to Death & Brain Damage. Three mechanisms of injury are reported to account for highest adverse respiratory events:

1. Inadequate Ventilation: Insufficient Gas Exchange can produce the adverse outcome. Esophageal Intubation: Incubation between the two sides of the esophagus inadvertently.
2. Difficult tracheal intubation: Tracheal Intubation is the placement of a flexible plastic tube into the trachea (windpipe) to maintain an open airway. It is performed facilitate ventilation of lungs in severely ill, anesthetized patients.

Other’s are as listed below:

1. Airway Obstruction
2. Inadequate inspired oxygen delivery
3. Aspiration
4. Endobronchial Intubation
5. Premature Extubation

Residual neuromuscular blockade is an important postoperative complication associated to the use of neuromuscular blocking drugs and is commonly observed in the post-anesthesia care unit (PACU) after non-depolarizing neuromuscular blocking agents (NMBAs) are administered intra-operatively. Incomplete neuromuscular recovery can be minimized with acceleromyography monitoring. The risk of adverse respiratory events during early recovery from anesthesia can be reduced by intra-operative acceleromyography use.

Reintubation is a serious adverse respiratory event and the consequences include increased cardiac and respiratory complications, prolonged length of stay at the PACU, intensive care unit (ICU) and hospital, prolonged mechanical ventilator support, higher costs, and increased mortality. Overweight and obesity have also been identified as risk factors for postoperative respiratory complications. Most adverse respiratory events are considered preventable with improved monitoring such as:

1. Pulse Oximetry
2. Capnometry
3. Combination of Both

Closed observation of the clinical factors and appropriate monitoring by well trained people are factors necessary to prevent adverse outcome.

Mechanical ventilation is the artificial method of assisting a person to breathe with the help of a device called ventilator. It is employed when a person’s spontaneous breathing who has been affected and cannot breathe on his/her own.

When is Mechanical Ventilation indicated?

Several injuries or other medical conditions could call for assisted breathing-

• Apnea (inhalation muscles become non-functional) that leads to intoxication and respiratory arrest
• Lung injury or trauma that leads to an inadequate exchange of gases between the lungs
• Acute asthma that requires intubation
• Chronic obstructive pulmonary disease
• Obesity hypoventilation syndrome
• Respiratory acidosis (excessive carbon dioxide in the blood)
• Respiratory distress like tachypnea that leads to rapid breathing
• Hypoxemia (too little oxygen in the blood)
• Muscular dystrophy (weakening of skeletal muscles)
• Amyotrophic lateral sclerosis (neurons controlling the voluntary muscles die)

Duration of artificial respiration

1. It is used for the entire duration of a surgery.
2. Long-term ventilation is necessary for people suffering from chronic illnesses who have been hospitalized. In such cases, special measures are taken to stabilize the trachea.
3. It can be used by ailing persons at home as well.

How is mechanical ventilation performed?

1. A tube is inserted into the trachea. This process is called intubation. The tube goes in through the mouth or nose (endotracheal tube). The tube is kept in place with a metal strap that goes around the head. The other end of the tube is attached to the ventilator. The ventilator pumps oxygen and other gases into the lungs. It can be a painful process, and before surgeries, it is performed under anaesthesia.

2. The tube can be inserted through a surgical hole in the throat. This process is called tracheotomy.

When the ventilator applies pressure to blow air into the lungs, it is called positive pressure. the exhalation can be done by the person himself/herself or if spontaneous respiration is compromised, the ventilator will help pump out the carbon dioxide.

Both types of tubes affect a person’s ability to speak because they pass through the vocal chords. Tracheotomy is performed on people who will require ventilation for long stretches of time because endotracheal tubes are uncomfortable and sometimes painful.

Risks associated with artificial ventilation:

1. The gravest risk is that of pneumonia. A person who is undergoing ventilation is already physically weak. And that makes the person susceptible to a wide range of diseases. The tube that is inserted into the trachea allows the entry of different types of bacteria. The result is Ventilation Associated Pneumonia (VAP). Because the tube is always present in the trachea, a person cannot cough. Coughing flushes out many bacteria. VAP is curable with antibiotics.

2. Endotracheal tubes may also lead to a sinus infection

3. Pneumothorax is yet another risk linked with artificial ventilation. Air leaks from the lungs and this causes pain and in extreme cases may even lead to the collapse of the lungs.

4. Because air is pushed into the lungs with pressure, it might cause lung damage.

5. Too much oxygen is also harmful to the lungs.

Taking a person off ventilation

This process is called weaning. The ventilator is turned off but still attached to the person. The person is allowed to breathe on his/her own. If there are difficulties, the ventilator is turned back on. It is like a trial run. Gradually the individual develops the ability to breathe on his/her own.

Mechanical ventilation is a painful and often risky method. But when a person is unable to breathe, it is the only way to save his/her life.

What is ECMO?
Like dialysis for unfunctional kidney, Ecmo for unfunctional lung.

Ecmo stands for extracorporeal membrane oxygenation. It is a method of giving oxygen for the body when icu pateint lungs and/or heart are not able to supply oxygen on their own. 

Why ICU pateint put on ECMO?

Doctors place ICU patients on ECMO when patients are not able to supply oxygen to the body.

ICU patients’ lungs fail for a number of reasons including pneumonia, lung cancer, pulmonary edema, pulmonary embolism and COPD.

 When a patient’s lungs fail, he/she first is intubated (breathing tube) and hooked up to a ventilator (breathing machine).
 However, sometimes lungs are so damaged that providing oxygen through intubation is not enough.

This is when doctors turn to v-v ecmo.
A heart can fail for many reasons including heart attack, pulmonary embolism, bad valve disease, or worsening heart failure. When a heart fails, doctors try to fix the underlying problem. They may also start medications (called ionotropes) to help improve the pump function of the heart. If medications are not enough, doctors will turn to v-a ecmo.

How long can someone stay on ecmo?

That is a complicated question. Due to the risks of ecmo discussed above, doctors try to keep patients on ecmo for as short a time as possible. Often patient will be on ecmo for several days up to 1-2 weeks. Every day, several blood and imaging tests are done to determine if a patient is ready to come off ecmo. As the technology of ecmo improves, hopefully side effects will decrease and patients can remain on ecmo for longer periods of time.

What is the difference between ecmo and a ventilator (breathing machine)?

Both ecmo and a ventilator aim to provide oxygen to the body when the patient’s own lungs and breathing are failing. The ventilator assists the patient’s own lungs by pushing oxygen with pressure into the lungs. Ecmo instead provides oxygen directly via a catheter placed in a patient’s vein or artery. We almost always try oxygenating a patient with a ventilator first. However, when a patient’s lungs are too sick for this, we turn to ecmo to assist in providing oxygen to the body. V-v ecmo provides oxygen through a vein. This blood then has to travel to the heart and be pumped around the rest of the body through arteries. Therefore, with v-v ecmo or with a ventilator, a patient must have a well-functioning heart to get the oxygen pumped throughout the body. V-a ecmo has the additional advantage of pumping blood directly to arteries. This “by-passes” the heart and is therefore the method of ecmo we use when a patient’s heart is failing.

Appendicitis, also commonly referred to as epityphlitis, is generally an inflammation that is triggered by bacterial, fungal, or viral infections. Since the appendix happens to empty into the colon with lesser efficiency and because the lumen is also small, it experiences some form of obstruction, being otherwise vulnerable to infections. This then manifests in the form of a primary factor that causes appendicitis. The pain that generates from this affected region remains localized primarily within the right lower quadrant of your abdomen.

The inflamed appendix then gradually fills up with pus. Appendectomy is considered to be the only curative procedure to treat a case of appendicitis. Pre-operative care is always stressed upon immensely so as to provide the best results to the patients:

1. Complete bed-rest and relaxation is suggested to patients once the symptoms have been put under the light of clinical examination.
2. Intubation is then provided if necessary.
3. Patients also require to fast during the period right before the operation.
4. Antibiotics must be prescribed in order to prepare the patient for surgery.
5. Radiological and laboratory examinations are then carried out.
6. Blood sugar levels must be established to decide if the patient is ready to undergo surgery or not.
7. Patients who have any previous record of hypertension may be prone to experiencing some amount of anxiety right before the operation itself. If such a case arises, the surgery might be cancelled to avoid any incidence of complications.
8. Mental preparation must be taken by the patient himself since psychological and physiological stress has a way of jeopardizing the operation.
9. Presence of friends and family helps immensely to stabilize and relax the patients.
10. The patient must be explained the very nitty-gritty of the surgery and how it’s going to take place so that he may not face anxiety.
11. A sedative might be introduced to the patient to help him relax.

Along with the aforementioned factors, a number of things need to be taken care of if the question of appendicitis arises. Since operations are primarily carried out as emergency surgeries, there is little that can be done at the last moment itself. Ensure that the person has an empty stomach and is stable enough to undergo the procedure.

Implications of cough before and after surgery: it's prevention and treatment are key to judicious management

Patients with cough frequently present to clinicians working in both primary and secondary care. Acute cough, which often follows an upper respiratory tract infection, may be initially disruptive but is usually self limiting and rarely needs significant medical intervention. Chronic cough often points towards some underlying lung pathology but many a times it presents as the sole manifestation of some throat pathology as well. Even with a clear diagnosis, cough can be difficult to control and, for the patient, can be associated with impaired quality of life. Any surgery may have some implications on the course of cough for any cause, whatsoever. On the other hand, surgery, per say, may create some situations which lead to distressing cough.

Acute cough before surgery:

May occur as an exacerbation of chronic underlying lung disease eg. Asthma, copd or lung fibrosis or an acute viral illness, commonly. The chronic disease should be evaluated in terms of lung function to predict post-operative risk for prolonged ventilation. Any acute viral illness causing distressing cough may entail delaying the surgery for 6 weeks, depending on the assessment of concerned anaesthesiologist. This is due to the fact that an acute viral infection may make the person more susceptible to the ill effects of anaesthetic agents. Another issue regarding the effect of violent cough in some specific form of surgery like cataract extraction is the adverse operative outcome due to raised pressure in eyes with every bout. So, the cough needs to get controlled by applying vigorous measures, depending on the cause and extent of cough, in such special cases.

Post- operative cough:

There could be several causes occurring not very rarely in many post-operative cases. The causes may be:
I) effect of anaesthetic gases
Ii) laryngeal swelling due to placement of plastic tube in airways during any prolonged surgery
Iii) segmental lung collapse due to lack of chest wall movement
Iv) infection in lower airways due to any compromised immune status or pre-existing illness
V) partial damage of a nerve named phrenic nerve in any upper abdominal surgery, causing partial immobility to the diaphragm
Most of the conditions deserve separate attention, but common post-operative measures taken to mitigate cough, are:
a) post-operative deep breathing exercises
b) incentive spirometry
c) chest physiotherapy
d) steam inhalation, mostly for tracheal problems regarding intubation
e) inhaled bronchodilators as and when necessary
f) suitable antibiotics, as needed

Good effect of cough, post-operatively

Mainly after thoracic and upper abdominal surgeries, cough-reflex is very important. The natural defence mechanism to clear the airways, is utterly needed in these cases to prevent post-operative pneumonia. The only precaution to be taught is, the patient has to immobilise the operative site with a clinching pillow, while coughing, to prevent wound dehiscence and other complications.
To summarise, cough as a reflex to clear the airways, is welcome proposition to prevent stasis of secretions and subsequent infection. But, distressing and uncontrolled cough is a real worrisome phenomenon, needing meticulous prevention and control before and after surgery, to avoid untoward complications.