AIRWAY AND 02 SKILL SHEET

Question 1

PEEP improves oxygenation, improves ventilation and reduces the workload of breathing, via the following physiological effects:

Answer 1

> The expiratory pressure assists small and medium sized airways to remain open during expiration, preventing lung collapse. Once collapsed, significant additional pressure is required to re- expand them.
The positive pressure in the thoracic cavity reduces the preload (filling) of the right ventricle by reducing venous return to the heart (this will be further compounded by GTN administration).
The positive pressure in the thoracic cavity increases the afterload of the right ventricle. This reduces blood flow through lung vessels, reducing the amount of fluid entering the lungs.
The expiratory pressure increases the amount of air remaining in the lungs at the end of expiration (also called the functional residual capacity) and this causes the lungs to be more expanded. From this more expanded resting position, less work
is required to inspire as a result of the non-linear compliance of the lungs, particularly when the lungs are wet.

Question 2

PEEP Indications

Answer 2

> When a manual ventilation bag is being used to provide ventilation.
Cardiogenic pulmonary oedema if CPAP is indicated but unavailable.

Question 3

PEEP Contraindications:

Answer 3

> Cardiac arrest for an adult or child (excludes neonates).

Question 4

PEEP Cautions:

Answer 4

– Ventilation is occurring via an ETT or LMA and the patient has signs of shock.
– PEEP is being applied using a manual ventilation bag and mask, and the patient has an altered level of consciousness, vomiting or signs of shock.

Question 5

PEEP setting for cardiogenic pulmonary oedema

Answer 5

> Apply PEEP set to 10 cmH2O. Do not assist with the patient’s breathing unless it is ineffective.
Increase the PEEP to 15 cmH2O if the patient is not improving

Question 6

PEEP for neonate

Answer 6

Apply PEEP set to 5 cmH2O, including during cardiac arrest.

Question 7

PEEP for child

Answer 7

Do NOT attach PEEP during cardiac arrest
> Apply PEEP set to 5 cmH2O for all other conditions

Question 8

PEEP for adult

Answer 8

> Do NOT attach PEEP during cardiac arrest
Apply PEEP set to 5 cmH2O if the patient has TBI, COPD, asthma or signs of shock
Apply PEEP set to 10 cmH2O for all other conditions

Question 9

PEEP increases intracranial pressure in patients with TBI by

Answer 9

reducing venous return from the brain. In this setting, there is a balance between the benefit of PEEP improving oxygenation and the risk of PEEP increasing intracranial pressure. This is why PEEP is set to 5cm H2O for these patients.

Question 10

PEEP is not applied to adults and children during CPR because

Answer 10

an increase in intrathoracic pressure reduces the blood flow achieved during CPR. If ROSC is achieved it is appropriate to apply PEEP, but this is not an immediate priority.

Question 11

flow rate and indication for nasal prongs

Answer 11

1-4L/min
when patient requires minimal 02, chronic respiratory condition or won’t tolerate a mask

Question 12

flow rate and indication for simple mask

Answer 12

6-8L/min
breathing adequate, needs support 02

Question 13

flow rate and indication for reservoir mask

Answer 13

10-15 L/min
breathing adequate, requires high flow 02 such as deacersed LOC or extremely low 02

Question 14

flow rate and indication for BVM

Answer 14

breathing absent, inadequate 10/15L/min

Question 15

what happens when 02 is administered

Answer 15

02 is a vasoconstrctor, causing less perfusion to tissue and organs, it can also increase inflammation AND BP

Question 16

indication for 02

Answer 16

-airway obstruction
-resp distress
severe shock
-severe TBI
- less than 94% ORA

Question 17

The physiological effects of CPAP

Answer 17

A The positive pressure assists small and medium sized airways to remain open during expiration, reducing lung collapse. This also may aid expiration in patients with bronchospasm by reducing dynamic hyperinflation.
A The positive pressure during inspiration means that less work is required, reducing the work of breathing.
A The positive pressure in the thoracic cavity reduces the preload (filling) of the right ventricle by reducing venous return to the heart.
A The positive pressure in the thoracic cavity increases the afterload of the right ventricle. This reduces blood flow through lung vessels, reducing the amount of fluid entering the lungs.
A The expiratory pressure increases the amount of air remaining in the lungs at the end of expiration (the functional residual capacity) and this causes the lungs to be more expanded. From this more expanded resting position, less work is required for inspiration because of the non-linear compliance of the lungs, particularly when the lungs are wet.
A CPAP allows the clinician to postpone or prevent invasive techniques in patients who present with acute respiratory failure.

Question 18

Indications of CPAP

Answer 18

A Cardiogenic pulmonary oedema with moderate to severe respiratory distress,
or
A Asthma, COPD, or undifferentiated respiratory problem with severe respiratory distress that is not improving with treatment,
or
A An SpO2 of less than 92% due to a respiratory problem despite treatment (less than 88% if COPD or known chronic hypoxia).

Question 19

CPAP contrindications

Answer 19

A Active vomiting, or
A Ineffective breathing.

Question 20

CPAP cautions

Answer 20

A An altered level of consciousness, or A Signs of shock, or
A Clinical suspicion of pneumothorax.

Question 21

CPAP reduces cardiac output and should be used with caution in patients showing signs of shock. The reduction in cardiac output may be significant in patients with:

Answer 21

– A clinical condition reducing right ventricular filling, such as hypovolaemia.
– A clinical condition increasing right ventricular afterload, such as pulmonary embolism.

Question 22

possible complications of CPAP

Answer 22

A Mask seal
A Tolerance/anxiety
A Reduced cardiac output.

Question 23

medical air indication

Answer 23

Medical air (air) is indicated when administering nebulised bronchodilators to patients with chronic obstructive pulmonary disease (COPD).

Question 24

OPA indication

Answer 24

OPAs should be routinely placed in patients requiring airway support unless there is a good reason not to.

Question 25

OPA contras

Answer 25

> Patients who are conscious.
Patients who are semi-conscious, and have a gag
reflex (as this may induce vomiting).

Question 26

OPA insertion for adult v kids

Answer 26

1 Measure the OPA from the corner of the mouth to the bottom of the ear.
2 Insert the OPA into the mouth:
– Adults and large children: The OPA is inserted into the patient’s mouth with the concave upward position. Once the tip reaches the back of the tongue, rotate it 180 degrees. If this is unsuccessful, try inserting the OPA with the concave position down (as for small children and infants).
– Small children and infants: the OPA is inserted in the concave downward position.
3 The flange should sit against the teeth/gums and inside the lips. The lips can act as a guard to prevent expulsion of the OPA.

Question 27

NPA indication

Answer 27

When a patient requires airway support but has trismus, damage to the oral cavity or a gag reflex.

Question 28

how to put in NPA

Answer 28

1 Measure the NPA from the nostril to the ear lobe. 2 Lubricate the NPA and insert it into the largest
looking nostril, aiming straight back.
3 If you encounter resistance, rotate the tip of the NPA slightly and continue to push however, significant force must not be applied.
4 Try the other nostril if insertion is unsuccessful.

Question 29

Location of LMA

Answer 29

An LMA is a supraglottic airway device; when it is placed properly it sits below the pharynx but above the glottis, where the trchea opening is

Question 30

LMA indication

Answer 30

> GCS of 3 and airway is poor despite OPA/NPA and jaw thrust.
Cardiac arrest, providing an endotracheal tube cannot be placed.
Rescue airway in a failed intubation.

Question 31

complications and cautions of LMA

Answer 31

> Trismus/restricted mouth opening. > Gag reflex present.
Active vomiting.
Upper airway obstruction.
Distorted airway (either from trauma or pre-existing condition).

Question 32

steps of LMA insertion

Answer 32

1 Clear the airway and position the patient supine.
2 Select the appropriate size of LMA relative to the patient.
3 Prepare the LMA by lubricating the mask.
4 Insert the LMA in the appropriate orientation.
5 Attach a manual ventilation bag and check adequate ventilation is achieved. Troubleshoot if there is not adequate ventilation.
6 Secure the LMA with a Thomas tube holder.

Question 33

indication for suction

Answer 33

Significant amounts of vomit or blood, that threatens airway patency and/or limits adequate ventilation.

Question 34

contras for suction

Answer 34

Do not suction saliva or pulmonary oedema fluid. These fluids do not cause harm, and suctioning increases hypoxia because the oxygen mask needs to be removed.

Question 35

Potential complications
of the procedure suction

Answer 35

> Damage to the oropharynx.
Hypoxia (from prolonged suctioning attempts without ventilation).
Stimulation of gag reflex and cough reflex.
Bradycardia and/or hypotension (suctioning can
stimulate the vagus nerve

Question 36

steps of suctioning

Answer 36

1 Safety: apply appropriate PPE before managing the patient’s airway. This should include gloves and safety glasses as a minimum.
2 Patient positioning: patients with an altered level of consciousness should be placed on their side unless there is a good reason not to.
3 Clear the airway:
a Clear the airway manually if the patient is unresponsive. This can be done with an OPA or your fingers if there is a significant amount of solid material present.
b Remove any airway adjuncts present if there is significant vomiting.
4 Prepare equipment:
a Position assembled suction unit conveniently.
b Ensure the suction unit remains upright.
c Ensure the Ducanto/soft suction catheter is connected to the suction tubing.
5 Apply suction:
a While sitting at the patient’s head, open the
patient’s mouth.
b Turn the suction unit to maximum power.
– Note; The Ducanto suction catheter does not have a vent hole in which to cover, unlike the Yankeur catheter that was previously utilised.
c Under direct vision, suction the contents from the patient’s mouth and nose. When using a rigid catheter, suction no further than you can see.
d Take no longer than 10 seconds to suction the airway and be sure not to suction beyond the oral cavity or to the level that can be seen on visual inspection.

Question 37

indication for Use of laryngoscope and Magill forceps

Answer 37

> Foreign body airway obstruction, and
The patient is unconscious and not moving
sufficient air, and
The foreign body cannot be removed under direct
vision with a finger sweep.

Question 38

general rule fir laryngoscope size

Answer 38

Adults will usually require a size 4, and children will usually require a size 2.