**8. Confirmation of tracheal intubation**

Confirmation of the correct position of the endotracheal tube (ET) is mandatory for all patients during initial intubation. There are several methods [27, 31, 32]:

**297**

includes:

sedation.

*Management of New Special Devices for Intubation in Difficult Airway Situations*

• Auscultation of respiratory sounds in six areas: apex, bases, trachea and

The most reliable methods are direct visualization of ET placement in the trachea (by direct laryngoscopy or fiber-optic bronchoscopy) and measurement of expired CO2 by capnography. Even if the tracheal tube is observed to pass through the vocal cords and its position is verified by chest expansion and auscultation during positive pressure ventilation, staff should obtain additional confirmation of the location of the tracheal tube in three ways: capnography, a CO2 wave at the end of

Capnography measures and displays exhaled CO2 throughout the respiratory cycle. A persistent waveform with ventilation should be observed: during expiration, the capnography does not initially read CO2, but as the anatomical dead space is exhaled, there is an increase in exhaled CO2 to a plateau, which falls to 0% with the start of inspiration. The presence of exhaled CO2 confirms the placement of the endotracheal tube. However, capnography can produce false positives and false negatives. If gastric insufflation has occurred by mask ventilation or after ingestion of carbonated fluids, capnography may produce a false positive after esophageal intubation. In cardiac arrest, states of low cardiac output, and extremely low pulmonary blood flow, a false negative can occur [31, 32]. Esophageal sensing devices aid in detecting the location of the ET based on the anatomical difference between the trachea (a firm spine) and the esophagus (a folding spine). A self-inflating bulb is in ET after placement. Air must collapse the

Other imprecise methods include visualization of condensed water vapor in ET,

There is not a sufficient basis to evaluate the benefits of an extubation strategy for DA. For the DA management guidelines, an extubation strategy is considered a

The extubation strategy will depend on the surgery or situation that led to ICU hospitalization, in addition to the patient's condition and the skill of the physician. The recommended strategy for extubation of the DA, according to the literature,

• The relative merit of extubation awake versus extubation under the effects of

• Various situations can harm ventilation after the extubation of the patient.

• An airway management plan should be implemented if the patient cannot

• Short-term use of a device that can serve as a guide for accelerated re- intubation.

*Cheney test*: A spark plug or catheter-like device is passed distally into the trachea. The purpose of this test is to detect the impact of the tip in the carinal or bronchial lumen. Generally, the advancement of a spark plug to a depth of 30 to 35 cm can allow appreciation of blockage of distal structures compared to unre-

*DOI: http://dx.doi.org/10.5772/intechopen.97400*

• Measurement of expired CO2 by capnography.

the exhalation, or with an esophageal sensing device [27, 31].

esophagus, while the trachea must remain permeable.

stricted advancement if the ET is in the esophagus [27, 31].

maintain adequate ventilation after extubation.

**9. DA extubation strategy: Recommendations for extubation**

chest wall movement, and Cheney test.

logical extension of the intubation strategy.

• Use of self-inflating esophageal detectors.

epigastrium.

• Direct visualization of ET passing between the vocal cords.


*Special Considerations in Human Airway Management*

○ Blood or discharge.

○ Fungal tumors in the larynx.

○ Full stomach with risk of aspiration.

*7.3.1.4 Complications of FBO-guided intubation*

○ Laryngospasm and bronchospasm.

○ Haemodynamic disorders and arrhythmias.

○ Regurgitation or vomiting. Aspiration.

○ Gastric distension. Rupture of the stomach.

○ Barotrauma: in the narrow upper respiratory tract.

○ Arrhythmias: bradycardia due to nasal stimulation (naso-cardial reflex) or stimulation of the region of the recurrent and superior laryngeal nerve.

Confirmation of the correct position of the endotracheal tube (ET) is mandatory for all patients during initial intubation. There are several methods [27, 31, 32]:

• Direct visualization of ET passing between the vocal cords.

○ Haemodynamic disorders: hypertension or hypotension is justified by a

○ Stridor or oedema of the glottis.

○ Esophageal perforation.

○ Pulmonary barotrauma.

diminished stimulus.

○ Esophageal intubation.

○ Regurgitation and vomiting.

○ Gastric distension: stomach rupture [45].

**8. Confirmation of tracheal intubation**

○ Bleeding, epistaxis.

○ Eye trauma.

○ Coagulation disorders.

○ Emergencies [33, 34, 44].

○ Esophageal intubation.

○ Major fractures.

○ Hypoxemia.

○ Sore throat.

○ Tissue trauma.

**296**

The most reliable methods are direct visualization of ET placement in the trachea (by direct laryngoscopy or fiber-optic bronchoscopy) and measurement of expired CO2 by capnography. Even if the tracheal tube is observed to pass through the vocal cords and its position is verified by chest expansion and auscultation during positive pressure ventilation, staff should obtain additional confirmation of the location of the tracheal tube in three ways: capnography, a CO2 wave at the end of the exhalation, or with an esophageal sensing device [27, 31].

Capnography measures and displays exhaled CO2 throughout the respiratory cycle. A persistent waveform with ventilation should be observed: during expiration, the capnography does not initially read CO2, but as the anatomical dead space is exhaled, there is an increase in exhaled CO2 to a plateau, which falls to 0% with the start of inspiration. The presence of exhaled CO2 confirms the placement of the endotracheal tube. However, capnography can produce false positives and false negatives. If gastric insufflation has occurred by mask ventilation or after ingestion of carbonated fluids, capnography may produce a false positive after esophageal intubation. In cardiac arrest, states of low cardiac output, and extremely low pulmonary blood flow, a false negative can occur [31, 32].

Esophageal sensing devices aid in detecting the location of the ET based on the anatomical difference between the trachea (a firm spine) and the esophagus (a folding spine). A self-inflating bulb is in ET after placement. Air must collapse the esophagus, while the trachea must remain permeable.

Other imprecise methods include visualization of condensed water vapor in ET, chest wall movement, and Cheney test.

*Cheney test*: A spark plug or catheter-like device is passed distally into the trachea. The purpose of this test is to detect the impact of the tip in the carinal or bronchial lumen. Generally, the advancement of a spark plug to a depth of 30 to 35 cm can allow appreciation of blockage of distal structures compared to unrestricted advancement if the ET is in the esophagus [27, 31].
