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Airway Management.
Airway Management Therapuetics and diagnositcs
| Question | Answer |
|---|---|
| What are the three areas of skill for airway management? | Insert and maintain artificial airways. Proficient in airway clearance. Assist physcicians in performing procedures related to airway management. |
| What are the two categories of airways? | Pharyngeal airways Tracheal airways |
| What are the two types of pharyngeal airways? | Oropharyngeal airways (OPA) Nasopharyngeal airways (NPA) |
| What are the two types of tracheal airways? | Endotracheal tubes tracheostomy tubes |
| The oropharyngeal airway is inserted into the mouth | between the lips and teeth |
| The Oropharyngeal airway is made of | metal plastic or rubber |
| What are the components of an oropharyngeal airway? | bit, flange, air channel |
| What are the indications of an OPA? | 1. Prevent airway obstruction by tongue. 2. Bite block 3. Increase effectiveness of bag/mask ventilation |
| What is a contraindication of an OPA? | A conscious patient due to gag reflex |
| What are complications of the OPA? | laryngospasm/cough vomiting/aspiration (do not tape in place) Airway obstruction lip or tongue damage dental damage. |
| You should never place an OPA in the presense of a | space occupying forign body/ lesion obstruction |
| When you place an OPA you can | use a tongue depressor and the tip should be above the epiglottis |
| The OPA is sized from | the angle of the jaw to the corner of the mouth |
| What are the most common OPA sizes for the adult airway | 80 and 90 |
| What are the two types of OPA | Berman Guedel |
| The Berman OPA has a | side air channel |
| The Guedel OPA has a | Center air channel |
| The OPA rests at | the base of the tongue |
| The OPA can be used to help | facilitate bag mask ventilation |
| Aside from facilitating bag mask ventilation a patient should be spontaneously breathing when using an | OPA |
| The nasopharyngeal airway (NPA) is also known as the | nasal trumpet |
| The NPA is inserted | into the nose and rests behind the tongue just above the epiglottis |
| The NPA is made of | plastic or rubber |
| All NPA's have a | flange and a beveled end |
| The bevel on the NPA assists with | ease of insertion |
| What are the indications of the NPA? | 1. increase effectiveness of bag/mask ventillation 2. aid with suctioning and bronchoscopy. 3. management of facial anomolies 4. eliminates risk of oral damage. |
| What are the complications of an NPA | laryngospasm/cough nosebleeds sinus infections damage to turbinates cranial vault intubation |
| The NPA is better tolerated by a | conscious patient |
| The NPA is only used in | the adult population |
| The NPA is prime for | seizure patients and is good to assist in NTS |
| When using the NPA | you should be mindful if the patient is on anticoagulant therapy |
| The NPA is stabilized by the | flange |
| How do you size an NPA? | Measure from the tip of the nose to the earlobe |
| The NPA is sized in French and normal is | 26-36 french |
| The nasopharyngeal airway is placed like so | 1. Head tilt 2. h20 soluble lube 3. slowly advance 4. should rest above the epiglottis 5. can observe placement with a tongue depressor |
| Tracheal intubation tube is inserted through the | mouth or nose thru the glottis and into the trachea. |
| What are the indications of tracheal intubation | 1. To bypass an upper airway obstruction. 2. To protect the airway from aspiration. 3. To apply positive pressure ventilation. 4. To aid clearance of secretions 5. To deliver high oxygen concentrations. |
| You can instill drugs down an ET tube. | Generally the dose is 2 X the normal dose |
| Drugs to be instilled: NAVEL | Narcan Atropine Valium/Versed Epinephrine Lidocaine |
| What are the advantages of oral intubation? | 1. Faster,easier, less traumatic, more comfortable. 2. larger tube is tolerated. 3. Easier suctioning. 4. Less airflow resistance. 5. Decreased work of breathing 6. Decreased risk of tube kinking 7. Avoids nasla nad paranasal complications. |
| What are the disadvantages of oral intubation? | Greater risk of self extubation Greater risk of mainstem intubation Risk of tube occlusion from biting Risk of injury to oral structures greater risk of retching, vomiting, and aspiration |
| Oral intubation is the prefered method during CPR becaus it is | fast |
| The hazards of oral intubation include | hypotension (Vagus) Bradycardia aspiration trauma (vocal cord paralysis) |
| The ET Tube sized in | millimeters (inside diameter) |
| The centimeter markings indicate the | placement of the tube |
| The stylet gives more | ridgitity |
| An adult male et tube size | 8 mm |
| An adult female | 7.5 mm |
| You should aim not to go below | 7.5 mm |
| During nasal intubation the tube is | 1/2 size smalelr vs. orally |
| The advantages of nasal intubation | greater comfort less salivation improved swallowing,communication, oral care avoid occlusion from biting and damage to oral structures better stabilization reduced risk of mainstem intubation does not require muscle relaxants or sedatives |
| The disadvantages of nasal intubation include | nasal/paranasal complications more difficult to perform Spontaneous breathing is required for procedure (for blind) Smaller tube is necessary difficulty suctioning increased airflow resistance increased WOB difficulty passing bronchoscope |
| The curved laryngoscope is the | Mcintosh |
| The Mcntosh laryngscope size | 3 or 4 for adults |
| The Mcintosh is not typically used in | neonates |
| The Mcintosh is designed to fit into the | vellecula space and indirectly picks up the epiglttis |
| The Miller laryngoscope is | the straight blade |
| The miller should directly lift the | epiglottis |
| The miller blade is used in | neonates |
| The average adult size is the | 2 or 3 blade |
| Difficult intubations are reported in | 1.5%-15% of patients |
| Impossible intubations are reported in less than | 1% of intubations |
| Stage I visualization class | supraglotic structures, laryngeal inlet, vocal cords |
| Stage II visualization class | epiglottis, laryngeal inlet, posterior aryepiglottic folds |
| Stage III. Visualization class | epiglottis only |
| Stage IV. visualization class | epiglottis not visable |
| The Lemon Law | Look at anatomy Examine the airway Mallempati score (4 stages) Obstructions Neck mobility |
| Obesity | Rapid desaturation, difficult intubation, ventilation |
| Facial hair | hides small chin, can make bagging difficult or impossible |
| Large teeth | Hide airway, obscure tube passage |
| Jagged teeth | lacerate the ballon |
| The 332 rule | mouth open (3 fingers) Mentum to hyoid (3 fingers) Floor of mouth to thyroid cartilage (2 fingers) |
| Mouth open 3 fingers | allows for insertion of tube/laryngoscope |
| Mentum to hyoid | predicts ability to lift tongue into mandible |
| Floor of mouth to thyroid cartilage | if high larynx, airway tucked underbase of tongue hard to visualize |
| Mappempati socre | with patient seated extend neck, open mouth, stick out tonge. Visualize base of tonge, facial pillars, uvula, pharynx |
| Airway obstructions? | Angioedema Hematoma Dentures (remove dentures) |
| Neck mobility? | Surger rheumatoid arthritis osteoarthritis others |
| The neck mobility | cervical spine rigidity: reduces ability to align anatomical axes Inability to mobilize neck can make intubation difficult or impossible |
| Endotracheal Tube is semirigid and made out of | PVC (implant tested by American Society for testing and materials) |
| Endrol Tube | contains loop near proximal end of the tube and controls direction of tube (good for anterior vocal cords) |
| Components of tube | 15 mm adaptor Pilot balloon spring loaded valve murpheys eye radiopaque strip |
| The pilot balloon | shows cuff integrity |
| The murpheys eye | allows for collateral ventillation |
| The spring loaded valve | seals off the cuff |
| The double lumen tube is also known as the | Carlens tube |
| The Double lumen tube is more difficult to insert and usually uses a | bronchoscope |
| The double lumen tube requires | longer suction catheter causes increased airway resistance used for unilateral lung disease used for thoracic surger has a double lumen cuff |
| The EVAC tube | is also known as hi-low tube |
| The EVAC tube | has a suction tube and suction port |
| What are the supplies for oral intubation? | oxygen flow meter and tubing manual resusscitator suction setup oropharyngeal airway laryngoscope endotracheal tubes stylet stethoscope (5 point auscultation) tape 10 cc syringe towels for positioning gloves,gowns,masks eyewear |
| The lightbulb on laryngoscope is important | always have extra batteries and bulbs |
| The intubated stylet | adds rigidity to the tube also called Bougie |
| What is the sellick maneuver? | Cricoid presssure for the anterior vocal cords |
| Where should the cuff on the ETT rest? | 2 to 3 cm below the vocal cords2-4 |
| Where should the tip of the ETT rest? | 2-4 cm above the carina |
| What should the tube depth of the ETT be for the adult male/female? | 21-23 cm at the lip |
| How long should you hyperinflate and hyperoxygenate for the oral intubation procedure? | 2 to 3 minutes |
| What is an extra piece of equipment you may need for nasal intubation? | Magill forceps for direct visualization only. |
| What position should the patient be in for nasal intubation? | Direct- supine blind (fowlers position) |
| During a blind nasal intubation procedure you will hear a harsh cough and then | vocal silence |
| How do you confirm placement of the airway? | Auscultation observation of chest movement PetC02 Esophageal detection device light wand fiberoptic laryngoscopy |
| The fiberopteric laryngoscopy is | the most accurate way to confirm placement |
| Chest x rays should not be used to confirm placement. Only, | position in the airway |
| What are the advantages of a rigid fiberoptic scope | Direct airway visualization minimal neck movement may overcome difficult view useful in disrupted airway durable, sturdy instruments |
| What are the disadvantages of the rigid fiberoptic scope? | Expensive expertise requires practice visual field easily impaired by blood and secretions. not readily available |
| What are advantages of the lightwand (trachlight)? | minimal neck movement useful adjunct to laryngoscopy portable and inexpensive usable in bloody airway provides definitive airway |
| What are the disadvantages to trachlight? | blind technique may damage airway usually requires darkened room expertise requires practice |
| A tracheotomy is usually considered if ET tube is in for longer than | 7 days |
| What are the indications of a tracheotomy? | prolonged intubation to overcome upper airway obstruction trauma/surgery |
| A tracheotomy is performed by | a physician/surgeon Respiratory therapist may assist |
| What are the advantages of the tracheotomy? | More comfortable less tube movement better communication lower airway resistance easier suctioning easier to replace than ETT |
| what are the disadvantages of the tracheotomy? | Surgical procedure hemorrhage SQ emphysema pneumothorax pneumomediastinum permanent scar |
| Where is the tracheotomy usually done? | 3 rings below the thyroid |
| What are the two types of tracheotomy methods? | Standard percutaneous dilational method |
| The Percutaneous dilational method | has less complications minimal scaring ETT not removed until placement |
| The Tracheostomy Tube is made of | PVC Rigid |
| The tracheostomy tube is tested by the | American society for testing and materials |
| What are common tracheostomy tube sizes? | 8 & 6 Even sizes |
| The trache is no more than 2/3 to 3/4 | the inside diameter of the trachea because air needs to pass to facilitate speech. |
| What are the parts of the tracheostomy tube? | Flange (size is on this) cuff filling tube pilot balloon spring loaded valve inner cannular obturator |
| An uncuffed tracheostomy tube is used | when there is no major concern about aspiration or being able to protect airway |
| The fenestrated tracheostomy tube can | facilitate speech be cuffed or uncuffed inner cannula must also be fenestrated |
| The metal tracheostomy tube is called the | Jackson trach |
| The Jackson trach is for | long term use sleep apnea obesity can clip on 15 mm adaptor/cuff |
| What are the complications of intubation during the procedure? | cardiac arrest airway trauma mainstem bronchus intubation pumponary aspiration esophageal intubation |
| What are the complications of intubation while tube is in place? | airway trauma sinusitis otitis self-extubation meachanical problems with tube patient discomfort |
| What are the complications of intubation post extubation? | sore throat stridor odynophagia pulmonary aspiration poor cough |
| What is the number one complication post extubation? | hoarseness |
| Complications may sometimes occur | later post extubation |
| Airway trauma can occur as | laryngeal lesions tracheal lesions |
| Laryngeal lesions | glottis and vocal cord swelling laryngeal and vocal cord ulcerations vocal cord polyps and granulomas vocal cord paralysis laryngeal stenosis |
| Tracheal lesions | tracheal granulomas tracheal stenosis tracheomalacia treacheosophageal fistula tracheoimominate fistula |
| An RSI is | a rapid sequence intubation |
| In an RSI patient is given | Sedative (Versed, Valium, Propofol) Paralytic (succynlcholine) lidocaine (anti arythmic |
| The RSI is given to | prevent bagging so aspiration risk is cut down |
| A passy muire valve should never be put on when | cuff is inflated |
| Neontal traches lack a | cuff |
| The methelyne blue test checks for | aspiration |
| Shiley is a | common trache brand name |
| The tracheal button | Allows for general access |
| The Bivona Foam Cuff | Pulls air out to deflate, reinflates on its own |
| The Bivona Waterfilled cuff | 4-5 cc h20 into cuf |
| What are the benefits of a bivona cuff? | There is less chance of trauma and has more contour to the airway |
| The Bivona may not be the best choice in the case of | decreased lung compliance |
| Overweight patients can benefit from the | XLT trache |
| What are some airway damage indicators? | 1. Difficulty maintaining cuff pressure. 2. Tracheal dilation on cxr. 3. Abnormal PFT |
| Checking cuff pressures must be done during | positive pressure ventilation. |
| Minimal Occluding Volume (MOV) | The least amount of volume to seal airway. Most common technique |
| MOV | 1. Pull out air until leak is heard. 2. Put just enough air back until leak is no longer heard. |
| Minimal Leak Technique (MLT) | 1. Take out air until you hear leak. 2. Put air back till you don't hear it. 3. Pull out till you hear a slight leak at peak pressure of every breath. |
| The most common suction catheter size | 14 French |
| How to determine suction catheter size Method 1 | (Inside Diameter *3.14)/2 Do not round up |
| How to determine suction catheter size Method 2 | (Inside diameter*2) then use next lowest size |
| How do you prevent airway trauma? | Use sedation when necessary. Use nasal tubes vs. oral tubes when possible. Use correct sizing tubes. Avoid changing tubes. Avoid unnecessary coughing or efforts to talk. Limit Cuff pressure; Aesepsis Use trache collar instead of briggs. |
| Airway maintenance | 1. securing tube and maintain proper placement. 2. provide cuff care 3. Aid secretion clearance 4. Ensure humidification 5. minimize possibility of infection. 6. provide for patient communication. 7 troubleshoot emergencies |
| What do you need to secure ETT? | Tape, Velcro attachments, harness |
| What do you need to secure tracheostomy? | Velcro attachments, ties |
| The tip of tube should be positioned approximately | 2-4 cm above the carina. |
| YOu should always record what values for positioning on the ETT? | Size and cm markings |
| Unplanned extubations occur in what percentage of intubated patients? | 2-13 percent. #1 contributing factor: lack of secure placement |
| The Ideal method for securing ETT | allows minimal tube movement; is comfortable for the patient, allows for oral hygiene, preserves skin integrity; easy to apply; requires minimal maitenance. |
| ETT securing tips. | Rotate tube provide oral care trim tube use swivel connector support vent circuit get help when securing airway |
| What are the 2 classifcation of cuffs? | High volume, low pressure Low volume, high pressure |
| When maintaining cuff pressure, it is important to | keep cuff pressure below tracheal capillary perfusion pressure. |
| Tracheal capillary perfusion pressure valuse | 20-25 mm HG |
| You must keep cuff pressure | less than 20 mm Hg or less than 25 cmH20 |
| If you have not got a pressure manometer you can use | minimal leak technique or minimal occluding volume technique to inflate the cuff |
| What are alternative cuffs used to prevent overinflation? | Lanz CUff ETT, Foam Cuff, Water filled cuff |
| The Lanze cuff has | external pop off valve wont allow pressure to go greater than 16-18 mm HG |
| How can you tell if patient has retention of secretions? | 1. Auscultate 2. Sp02 monitor 3. percussion/vibration 4. CXR |
| What are the types of suctioning methods? | 1. open system 2. closed system 3. bronchoscopy |
| Open system suction catheters | whistle tip (most common) coude catheter (angled end) red robin (less rigid) Ring tip (prevents damage) |
| What are suctioning complicataions? | hypoxemia bradycardia atelectasis airway trauma bronchospasm contamination of lower resp. tract arrhythmias increased icp (coughing) preferential suctioning of right pronchus. |
| A leukins trap is used | to go in line with suction for sputum sample |
| Inspired air should provide relative humidity of | 100% at body temp; 44 mg/L |
| Heat humidification systems to | 32-35 degrees celcius |
| Provide at least | 30 mg/L humidity |
| Decreased humidity will mean | thick secretions |
| cool air means | decreased ciliary function |
| What are some common types of humidification systems? | Fisher Paykel, Concha Therm, HME, heated large volume jet nebulizer |
| What are reasons for increased infection risk? | bypassed upper airway filtration increased aspiration of pharyngeal material. contaiminated equipment impaired mucociliary clearance increased mucosal damage due to tube or suctioning ineffective clearance via cough |
| How do you guard against infection? | consistently wash hands between patients. Prevent retained secretions use sterile technique when suctioning keep airways clear decrease pharyngeal aspiration |
| What are some ways of communicating using alternative methods? | Writing signing picture boards |
| Tracheostomy patients may benefit from | fenestrated tracheostomy tubes passy-Muir valves |
| What are emergency airway situations? | tube obstruction cuff leak accidental extubation |
| What are examples of tube obstruction? | kinking or biting herniation of cuff over tube jamming of tube opening against tracheal wall mucus plugging |
| What are clinical signs of an airway emergency? | various degrees of respiratory distress. Changes in breath sounds air movement through mouth |
| In preparation for airway emergency | replacement airways should always be kept near the patient |
| If there is kinking | reposition the head/neck |
| If there is biting | use an OPA or bite block |
| In the event of a herniated cuff | deflate/reinflate try to pass suction catheter to determine if cuff is herniated |
| In the event the tip of the tube is on the tracheal wall | reposition the airway and head/neck |
| In the event of a mucus plug | lavage, try to pass suction, then resort to extubation |
| In the event of plugged trache | stick ett down the trache. Put gauze over stoma and bag |
| You should always suction prior to | extubation |
| Extubation is the | removal of the ETT |
| What are indications of extubation | Patient can: Keep upper airway patent. Protect lower airway from aspiration. Clear secretions from lower respiratory tract. Breath withouth mechanical ventilation. |
| What are the percentages of extubation failures? | 5-15% of cases |
| A practitioner who extubates should be able to | intubate |
| Before you extubate you should also | make sure the underlying cause is resolved. Check hemodynamics, ABG/Lab values, wean drugs |
| Decannulation is | the removal of the tracheostomy tube |
| Decannulation requires the use of | progressively smaller tubes. |
| What can be used to maintain a trach stoma? | A tracheal button |
| When decannulating you should assess | swallowing ability |
| The Laryngeal mask airway (LMA) is inserted | blind |
| The LMA is for | short term use and mainly used in the OR |
| YOu don't have to visualize the ____ for the LMA | larynx |
| The LMA is | less complicated than ETT and requires ventilating pressures of less than 20 cm H20 for a good seal |
| The main sizes for adult LMA's are | #4 and #5's |
| The Esophageal obturator (EOA) | is inserted into the esophagus and mainly used by EMTs. |
| The EOA | is difficult to obtain proper mask fit and ventilation. You should always intubate prior to removal of an EOA |
| The Esophageal-Tracheal Combitube | is used in place of an EOA insert tube, inflate both cuffs |
| With the Combitube there is a 94-98% probability of | esophageal placement |
| The Esophageal Tracheal combitube requires | thorough assessment to determine placement. Must ventilate through appropriate lumen |
| The ETT exchanger is inserted through the | ETT, Then the ETT is withdrawn and removed. A new ETT can be slipped over the tube exchanger and threaded down the lung |
| Oxygen can be | insufflated through tube exchanger during procedure. |
| The Esophageal-Tracheal Combitube is inflated as such | 1000 CC in big cuff 16cc little cuff |
| For impossible intubation, the ett is thread over a guidewire in | retrograde intubation |
| Regrograde intubation | puncture cricothryorid membrane. Thread wire through vocal cords. Exit nose or mouth. Guide endotracheal tube through vocal cordds over wire. |
| Advantages of retrograde | definitive airway minimal neck movement does not require full mouth open |
| Disadvantages of retrograde | takes time requires skill not recommended in cannot intubate/cannot ventilate patient |
| Average NTS catheter size | 14 french |
| What are supplies for tracheostomy care? | suction supplies oxygen therapy hydrogen peroxide sterile q-tibs dressings and ties inner cannula |
| Procedure for tracheostomy care | suction patient insert clean or new inner cannula clean stoma site replace dressings and ties auscultate chest |
| To reduce inflammation post extubation you can give | Decadron |
| The Fi02 should be less than | 40% before extubation |
| To check for swelling prior to extubation you can | try the leak test or deflate/occlude ETT |
| granulomas are | scar tissue |
| malacia is | softening |
| stenosis | narrowing |
| tracheoinnominate fistula is | burst vessel |
Created by:
kparkerlehman
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