COOK Medical Blue Rhino G2-Multi Instrucciones De Uso página 13

3. Use ventilator changes and sedation to control patient respiration. A PEEP (Positive End Expiratory Pressure) level
of 5-10 is recommended.
4. Instruct the clinician managing the airway to loosen the fixation tapes of the in-place endotracheal tube and
deflate the cuff, making necessary changes in tidal volume, frequency, etc., to evaluate compensation needed for
air leak. Reinflate the endotracheal tube cuff. Continuous oximetry monitoring should be employed.
5. Prep and drape the anterior neck area.
6. Generously lubricate the surface of the appropriately sized loading dilator and load the tracheostomy tube onto
the dilator. Ensure that the tracheostomy tube's tip fits snugly on the dilator. (Fig. 2) Ensure that the balloon is
completely deflated. Thoroughly lubricate tracheostomy tube assembly.
Tracheostomy Procedure
NOTE: Dual cannula tracheostomy tubes may also be placed using the following technique. The inner cannula must
be removed for introduction. Always check the fit of the dilator to the tracheostomy tube prior to insertion.
1. Palpate landmark structures (thyroid notch, cricoid cartilage) to ascertain proper location for tracheostomy
tube placement. Access and, ultimately, tube placement is ideally made at the level between the first and
second tracheal cartilages or between the second and third tracheal cartilages whenever feasible. (Fig. 3)
2. After introducing local anesthesia, make a 1.5-2.0 cm skin incision (vertical or horizontal) at the chosen insertion
site. (Fig. 5)
3. If desired, use a curved mosquito clamp to gently dissect vertically and transversely down to the anterior tracheal
wall. (Fig. 6) With a finger tip, dissect the front of the trachea, in the midline, free of any tissues and identify the
cricoid cartilage. Displace the isthmus of the thyroid downward, if present. NOTE: An adequate skin incision and
blunt dissection of the subcutaneous tissue can minimize the need for excessive force and torque throughout
the procedure. Excessive force and rotation may lead to long-term complications (e.g., stenosis).
4. Deflate the endotracheal tube cuff and withdraw to an appropriate distance above the insertion site, yet still
within the trachea. Re-inflate the cuff once the proper position of the endotracheal tube has been reached.
5. Attach a syringe half-filled with fluid to the introducer needle and seek the tracheal air column by directing
the needle, in the midline, posterior. Verify entrance into the tracheal lumen via aspiration on the syringe
resulting in air bubble return. (Fig. 7) Alternatively, if using bronchoscopy, visualize the needle entering
the trachea.
NOTE: It is important that the needle not impale the endotracheal tube. To ensure that the endotracheal
tube is not impaled, gently move it in and out 1 cm. If the tube is impaled, the needle will be seen and felt
to also move. If this occurs, it will be necessary to withdraw the needle, pull back the endotracheal tube,
and then reinsert the needle. NOTE: Proper positioning and alignment may help minimize complications (e.g.,
stenosis).
6. With the needle tip positioned in the trachea, local anesthesia may be injected (if necessary).
7. When free flow of air is obtained, with no impalement of the endotracheal tube, remove the inner needle of the
introducer needle assembly and advance the outer FEP sheath several millimeters. NOTE: If using an introducer
needle without a sheath, proceed to step 9.
8. Attach a syringe to the FEP sheath and re-confirm position within the tracheal lumen by visualizing free flow of
air into the syringe when aspirated. (Fig. 8) Alternatively, re-confirm position by visualizing the FEP sheath in the
trachea with the bronchoscope. Remove the syringe.
9. Introduce the J-tipped wire guide several cm into the trachea. (Fig. 9) NOTE: The wire should advance freely,
without resistance. If resistance is encountered, do not force wire guide. Confirm correct FEP sheath or introducer
needle placement via bronchoscopy, then advance wire guide into the trachea until the distal mark on the wire
guide reaches skin level.
10. Remove the FEP sheath or introducer needle while maintaining wire guide position within the tracheal lumen.
(Fig. 9)
11. Maintaining the wire guide's position at the skin level mark, dilate the initial tracheal access site by advancing the
short, 14 French introducer dilator over the wire guide with a slight twisting motion. (Fig. 10)
12. Remove the dilator while maintaining wire guide position.
13. Activate the hydrophilic coating by immersing the distal end of the Blue Rhino G2-Multi dilator in sterile water
or saline.
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