Airway Flashcards

Question

Discuss approach to airway in neonates and children

Answer 1

ETT size = (age/4)+4 Length at the nose: (age/2)+15 Length at the lips: (age/2) +12 LMA by weight

Answer 2

Epi: 10mic/kg Epi infusion: 0.1-0.5 mcg/kg/min fluids 10-20ml/kg up to 40ml/kg Defib 4J/KG Amioderone 5mg/kg Atropine 20mcg/kg Propofol 4mg/kg Sux for laryngospasm 0.5-1mg/kg Sux for RSI 2mg/kg Roc 0.6-1 mg/kg Vec 0.1 mg/kg

Answer 3

Traditionally uncuffed tube are used for children under the age of 8. The benefits of a cuffed tube are thought to be: accurate ETCO2 monitoring; protection from aspiration; less tube changes due to air leaks; and continuous lung recruitment Concern is that cuffed tubes can lead to trauma can lead to erosion, infection, cricoid perichondritis, and ultimately SGS Uncuffed tubes Can use cuffed tubes a size lower for paeds under 8

Answer 4

Scaple bougei tube in everyone older than 10 needle cricothyrotomy on children under 10 due to very small cricothyroid cartilage and high rates of layrengeal injury and long term complications with scaple

Answer 5

- Prominent occiput: neck is flexed in a neutral position -- larynsgoscopy is difficult in this position -- folded towel under back to acheive neutrality - Small mandible: less anterior excursion and smaller mouth opening - Large Tounge: Causes obstruction and interferes with view - Larger tonsils and adenoids: can cause obstruction risk of trauma and bleeding with NPA - Superior laryngeal position: Located oposite the c3-4 vertebra compared to c4-5 in adults - more difficult laryngoscopy - Large floppy epiglottis: projecgts further into the airway and cover more of the glottis - straight blade - Short trachea - easier to right main and accidentally extubate - Narrow trachea --\> more disposed to obstruction - need to needle cric as small target, concern with SGS with cuffed tubes - Soft trachea and cricoid - trachea may collapse with cricoid pressure - Anatomic subglottic narrowing- effective seal without cuff, resolved at 10-12

Answer 6

1) Increased intrathoracic pressures Signs: high airway pressure altered breath sounds Intervention: Reduce resp rate, less force if BVM, increated expiration time and IV fluid bolus 2) ongoing fluid loss or bleeding signs: signs of shock, SI \>0.8, POCUS with hyperdynamic heart and collapsing IVC 3) induction agent effect Signs: transient responds to fluids Intervetion: fluids inotropes as needed, tie 4) PE Signs: POCUS, distended JVP, possible hypoxemia Intervetion: fluid bolus , norad infusion 5) tamponade Signs: POCUS, JVP Intervention: FLuids, pericardiocentesis 6) Cardiogenic Signs: ECG, Crackles, CXR, POCUS Intervention: inopressor, minimise PEEP 7)anaphylctic/sepsis

Answer 7

1)ETT malposition (dilodged or oeophageal) Signs: nil or decreased bilatearl breath sounds, nil CO2, low PIP INtevention: re-intubate 2) Mainstem intubation signs: unilatearl breath sounds, CXR Intervention: pull tube back 3) ETT cuff malfunction signs: leak or low MV, loss of pilot balloon pressure Intervention: exchange ETT 4) Mucous pluggin Signs: increased secretions: high resistance to BMV, high PIP Intervention: ETT sucntioning 5) Rapid desaturaiton (obesity, late term preganncy, inadequate preoxygneation, intrapulmonary shunt) signs: sudden drop post induction and NMB intervetnion: Rescure mask and oral and nasal airways 6) profound shock or anaemai 7) penumothorax 8) oxygen apparatus malfunction

Answer 8

Intubation wihtout medicaiton in a person who has arrested or is agonal

Answer 9

A technique in which sedative and local anaethetics are used to facilitate intubation in an spontaneously breathing patient. Topical anaethesia may be ahcived by spray nebulization or local anaethetic nerve block. Ketamine is an approaptie dissocaiteive providing, anaethesia, analgesia and maintenance of protective airway reflexes. Dose of 0.5mg/kg are effective. Dexmedatomidine ahve also been used. After sedation and local gentle direct, video, flexi endoscope or fibreoptic intuabtion is perfromed to determine whether the flottis ivisible and intubation is possible, If visible intuabtion can occur on first look or the operator confident that the glottis cna be visualised may opt for RSI to beneift from pretreatment induction and paralysis.

Answer 10

Sux: -Dose 1.5mg/kg IV, inubation level paraylsis at 45-60 seconds and duration of 6-10 minutes Roc: 1.2mg/kg, intubation level paralysis 45-60 seconds an duration approx 45 minutes, relative contraindiation is a predicted difficult ariway given duatrion of paralysis however can be reveresed with suggamadex

Answer 11

Tracheo -Advantages: * Ease of replacement * Speech, mobility and swallowing encahnges * Patient can be nursed outside of ICU * Ease of suctioning * patient comfort Disadvantages * Complications at cuff site * stomal complications * possible contribution to ultimate laryngeal injury * tracheoinominate artery fistula formation * possible increase in pulmonary infection * access to mediastinum by infectious agents after local surgery * high mortality for inadvertent deccnulation before tract formation Intuabtion Advantage * Rapid insertion by skilled consultant in most setting * lack of need for surgical procedure * lack of stomal complications Disadvantages * Complications at cuff site * larygneal complications * replacement requires skill at all times * generally requires ICU level supervision * injuries at nose or mouth

Answer 12

Early * Obstruction: percutaneous tracheostomy tubes can become obstructed by the posterior membranous trachea following intial placement * Subcut epmpysema and pneumo * Haemorrage Late * Tracheal stenosis and malacia * Tracheoarterial fistula (life threatening usualy to the inoinate artery) * Rare now but if occurs * Over inflate the tacheostomy balloon * Place ETT below level of stoma * place finger through stoma to apply pressure and stop bleed * Reduced phonation * Tracheo-oesophageal fistula

Answer 13

1. Two wavelengths are used (660 and 940) Deoxy absorbs more light at 660nm and oxy absorbs more light at 940nm 2) BEER law - the concentration of a given solute in a solvent is determined by the amount of light that is absorbed at a specific wavelength. ie. the concentration of oxy and deoxy can be determined from their absorption of the two wavelengths 3) Determination of pulsatile signal - absorption over time signal from arterial blood is pulsatile whereas signal from venous hb and tissue is not - when the ateries pulsate the distance travelled by light through them changes - one can therefore use Lamberts law (equal parts in the same absorbing medium absorb equal fraction of the light that enter them) - Thus one can compare the ratio of pulsatile and nonpulsatile absorbance to produce R the ratio of absorbance at any given time 4) Calibration with emperically measured data - R is meaningless unless it can be related to o2 sats - a series of saturation measurements and R values have been collected from healthy individuals in the 100-75% sat range and extrapolate to 0% - This array of data is used by the pulse ox control circuit as a lookup table to p

Answer 14

**Phase 1** is the inspiratory baseline which is due to inspired gas with low level of CO2 **Phase 2** is the beginning of expiration which occurs when the anatomical dead space and alveolar gas from the alveolir/bronchiolies transition - the transition from phase 2-3 is the alpha angle - the alpha angle can be used to assess the VQ of the lung. VQ mismatch will have an alpha angle greater than 90 degrees **Phase 3** the alveolar plateau where the last of the alveolar gas is sampled. This is normally the PET co2 - the transition from phase 3 to 0 is the beta angle - the beta angle can be used to assess rebreathing. If this occurs the gnle is greater than 90 degrees **Phase 0** reflecting the inspiratory downstroke and the beginning of respiration

Answer 15

Approach is same as any intubated patient DOPES * Dispalcement of the tube * Obstruction of the tube * Patient - especially pneumo, PE pulomnary oedema, collapse and bronchospasm * Equiptment * Stacked breaths Approach * ABCD- CPR if necessary and call appropriate team as per patient * Administer high flow to both mouth and stoma site (if laryngectomy nil need for o2 to the nose) * Remove the inner cannula and chekc if tube is patient or dispalced * Pass a suction catheter down and suction * If unable to pass than tube is either blocked or dispalced * If able to passs thant the tube could still ahve parital blockage * Only replace tracheostomy if \>7 days if not call ENT * If blocked tube * Remove tracheostomy * Attempt to oxygentate and ventilate via the mougth * if unsuccessful attempt via the stoma * If unsuccessful intubate past the stoma if larynx intact * If unsuccessful intubation the stoma

Answer 16

1. ambient light 2. inevitable difference with ABG ox due to processing artifact 3. Inability to detct po2 or discrimintate between HB sepcies e.g carboxyhaemoglobin 4. Spurius resuts in the presence of CO or MetHB 5. Errors to detect pulse with poor perfusion non pulstaile ECMO flow or patient movement 6. Increasing inaccuracy in the extrapolated range of calibration values

Answer 17

1. Basic preconditions - Resolution of conditions which had required the intubation and venttilation - Patient directed mode of ventilation (PSV) - HD stable - Adequate muscles strength 2) Airway protection - able to follow commands - good cough reflex on suctioning good gag on oropharyngeal suctioning 3) gas exhange - spo2 \>90% on fio2 \<40% - normal acid base status 4) Lung mechanics - Peep \<8 - good TV 5ml/kg - VA 10ml/kg