Cardiopulmonary cerebral resuscitation is a matter of seconds. It is generally accepted that cessation of oxygen supply to the brain for more than 5 min will cause irreversible damage. Tracheal intubation is the first step in cardiopulmonary resuscitation, and the timely and effective restoration of ventilation is the key to the success or failure of resuscitation in patients with acute and critical illnesses or respiratory and cardiac arrests. Studies have shown that the establishment of a patent airway and effective breathing within 3 min is the most important aspect of CPCR[3]. The survival rate was 43% when basic life support was started within 4 min and follow-up life support was started within 8 min after cardiac arrest, while the survival rate was only 10% when follow-up life support was started within 8–16 min[4, 5]. Thus, in order to achieve early and effective oxygen supply, tracheal intubation, airway patency and restoration of ventilation have become important measures in cardiopulmonary resuscitation and resuscitation of patients with acute and critical respiratory dysfunction. It also facilitates oxygenation and sputum inhalation, which plays a pivotal role in resuscitating patients. If the patient's SaO2 is ≤ 90% or it is estimated that the patient's spontaneous breathing can no longer maintain his systemic oxygen demand, and there is no hope of recovery in the short term, emergency tracheal intubation should be performed to establish an artificial airway and give mechanical ventilation treatment. Successful emergency intubation can save time for the patient.
The establishment of an artificial airway is the first step in the implementation of mechanical ventilation, and three methods are usually used: transoral tracheal intubation, transnasal tracheal intubation, and tracheotomy. Tracheotomy is rarely used because of its complexity, trauma, and comorbidities[6]. The success rate of transnasal tracheal intubation is 79%, with a one-time success rate of 61%, but compared with transoral visual intubation, blind transnasal intubation is time-consuming, less successful, and has more complications[7]. In contrast, transoral visual intubation is simple and easy to perform successfully. Tracheal intubation is one of the important steps in establishing artificial ventilation, which provides safe respiratory access for acute and critically ill patients, facilitates the removal of respiratory secretions, corrects hypoxemia and hypercapnia, effectively improves respiratory function, reduces the work of respiratory muscles and circulatory burden, decreases the oxygen consumption of the body, helps to alleviate the contradiction between the supply and demand of oxygen to the heart, brain, kidney and other important organs, and provides an opportunity to treat the primary disease.
In this paper, 975 patients were resuscitated, of which 920 patients were resuscitated with tracheal intubation. We have learned that most patients can be successfully intubated according to the conventional intubation procedure. Those who were awake, agitated or mildly impaired in consciousness were less tolerant to intubation and could be given isoproterenol 50mg or (and) succinylcholine 30mg intravenously.
Of the 920 patients who underwent tracheal intubation, 22 were successfully intubated for the second time. The main reasons for the failure of intubation in this group were: ①inexpert technique, incomplete exposure of the vocal canal, inadvertent entry into the esophagus; ②poor placement of the intubation tube with convulsions, irritability or resistance of the patient; ③obstruction of the operation by the gastric tube already placed before intubation; ④edema of the patient's pharynx and larynx, unclear tissue structure; ⑤spasm of the larynx or trachea; ⑥head and jaw trauma causing difficulty in opening. If the intubation fails due to technical reasons, the intubation technique should be improved. For patients with failed intubation due to patient reasons, appropriate treatment measures should be taken, such as awake, agitated, convulsing, resistant or mildly impaired consciousness patients who are uncooperative or poorly tolerant to intubation, a small amount of anesthetic or sedative can be given, which not only reduces cardiovascular reactions during intubation, but also facilitates the smooth progress of intubation.
The main reason for the failed intubation in 5 cases was that the patient had severe restriction of neck movement due to atlanto-occipital implant fusion. In such patients, we should use sedatives and inotropes with caution, preserve the patient's voluntary breathing, and immediately contact an otolaryngologist for tracheotomy to avoid laryngeal edema and even life-threatening risks due to failed tracheal intubation attempts.
In order to improve the success rate of resuscitation of critically ill patients and the quality of life of patients after cardiopulmonary resuscitation, therefore, rapid and successful intubation and emergency effective oxygen supply to patients is indeed a proven emergency measure to improve the success rate of resuscitation, and is widely used in all kinds of severe acute poisoning, cardiopulmonary cerebral resuscitation, multiple trauma, craniocerebral injury and other acute and critically ill patients in the field and in-hospital resuscitation[8, 9]. To this end, we need to pay attention to the following aspects.
Clear indications for emergency tracheal intubation and timely intubation. Previously, tracheal intubation was only used for patients in respiratory arrest in order to save their lives. Our experience has confirmed that even if the patient is still conscious, but the patient's spontaneous breathing can no longer maintain the systemic oxygen demand, when there is no hope of recovery in the short term, emergency tracheal intubation should be performed to establish an artificial airway and give mechanical ventilation as soon as possible.
Master the operation of tracheal intubation skills: ① Do a good job before intubation oxygen, oral secretions of effective suction, and strive for a clear view of the oral cavity, in order to facilitate intubation; ② Tilt the patient's head back, jaw up, so that the mouth, pharynx, larynx 3 axes as far as possible in the same direction; ③ Awake or laryngeal spasm intubation is more difficult to show the vocal folds, the use of 1% Lidocaine for the root of the tongue, oropharynx to the vocal folds spray for surface anesthesia; ④ Some cases should be the anterior part of the catheter can be bent appropriately to facilitate the catheter into the vocal canal, for example, in patients with short neck or obstructed mouth opening and unable to visualize; ⑤ When the laryngoscope is placed into the epiglottis, the epiglottis is picked upward and backward with moderate force and proper method to reveal the vocal canal as much as possible to achieve visualization of the intubation; ⑥ In patients with spontaneous breathing, the vocal canal opens and closes with breathing, and the tracheal tube should be delivered when the vocal canal is opened, which can reduce laryngeal This can reduce the laryngeal, bronchospasm and choking reaction, and the success rate of intubation is high; ⑦ Inflate the balloon after intubation, listen to the symmetrical breathing sounds of both lungs, and confirm that the catheter is located in the trachea. After the failure of tracheal intubation, timely rescue.
The main reasons for the failure or difficulty of tracheal intubation: short neck in obese people, which makes it difficult to lift the laryngoscope to fully expose the vocal canal; difficulty in opening the mouth due to dental closure and laryngospasm; incomplete removal of large amounts of secretions or gastric reflux in the oropharynx; poor posture or restricted posture; difficulty in extending the neck back. Measures to deal with failed tracheal intubation: ① Positive pressure ventilation with a simple respirator; ② Find the cause of failure and reintubate; ③ For those who have difficulty in revealing the vocal cords, in emergency situations, try to pick up the epiglottis, and blind intubation with a purpose can also be successful; ④ Remedial measures: cricothyroid puncture or incision; fiberoptic bronchoscopy guided endotracheal intubation, etc.
The tracheal tube is misplaced into the esophagus in time to determine and correct. The methods commonly used to determine the misplaced tracheal tube into the esophagus: direct observation of the tube through the vocal cords; lung auscultation, especially at the axillary midline; observation of thoracic movement; cyanosis of the lips and SaO2 decrease; the presence of gastric contents in the tube; gastric dilatation, the expansion of the drainage bag if a gastric tube has been placed; whether water vapor coalesces in the tube. If the catheter position is suspected to be wrong, laryngoscopy should be performed and corrected immediately.
Prevention of tracheal intubation complications. The incidence of complications in this group is 5.9%, mainly including: ① Intubation is an invasive operation, which may cause bleeding, congestion and edema of the pharyngeal mucosa; ② Emergency intubation, if the patient's teeth are closed, the incisors may fall off when the patient is forced to open with the mouthpiece; ③ The stimulation of the throat and organs by tracheal intubation may cause violent choking, laryngeal and bronchial spasm, increased heart rate and blood pressure; ④ Severe autonomic reflexes may lead to arrhythmia, bradycardia, or even cardiac arrest; ⑤ The catheter may be inserted too deeply into one side of the bronchus by mistake, resulting in one-lung ventilation, causing hypoventilation, hypoxia, and pulmonary atelectasis; ⑥ When the catheter is inserted too shallowly or the catheter balloon is underinflated, the patient's position change may cause accidental decannulation; ⑦ The tube may be twisted, or the airway may be blocked by sputum crusts formed by the sticky secretions inside the tube; ⑧ Lung infection. The main method of prevention is to operate with standardization, skill and speed, and moderate force.