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Airway Assessment 3 Flashcards

1
Q

What is the goal of the sniffing position?

A

Improves the ability to intubate and ventilate
Draw a line from anterior ear to sternum

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2
Q

What are the axis that should be aligned for the sniffing position?

A

Oropharyngeal
Pharyngeal
Laryngeal

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3
Q

What are the 2 methods used to place the pt in the sniffing position?

A

Manual Method and Pillow method

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4
Q

Manual Method

A

Pulling jaw forward moves tongue and epiglottis off pharynx

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5
Q

Pillow method

A

Used most often in obese pts

Be sure to pad under arms

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6
Q

Signs of airway obstruction

A

Snoring
Grunting
Stridor (around larynx)
Loss of breath sounds
Climbing or absent CO2
Loss of fog in mask or ETT
Nasal flaring
Desaturation
Retractions/rocking

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7
Q

What is described as rocking motion of the tracheal or thoracic areas and is considered a compensatory mechanism to overcome an obstruction?

A

Retractions

SUPRAsternal retractions (tracheal tugging) vs SUBsternal/intercoastal retractions

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8
Q

Causes of Airway obstruction

A

OSA
Soft tissue relaxation
Foreign body/trauma
Vocal cord issues
Polyps
Infections
Swelling
Laryngospasm

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9
Q

Use caution when giving pre-op sedation to high risk patients

A

Something to keep in mind

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10
Q

Interventions for airway obstruction

A

Jaw thrust
Head repositioning
Oral/nasal airway
Mask ventilate if apneic
Determine underlying cause

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11
Q

Effects of airway obstruction

A

Inc WOB/fatigue
Interference of O2 supply and CO2 elimination
Difficulty in obtaining/maintaining adequate inhalation anesthesia

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12
Q

Oral airways are measured from the corner of the _____ to the tip of the earlobe.

A

Mouth

Most adults 9cm (large pts 10cm)

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13
Q

If sedation is too light with the insertion of an oral airway, what will happen?

A

Pts w/ intact gag reflex will not tolerate it

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14
Q

Advantages of an oral airway

A

Larger tube
Inserted quickly w/ little trauma
Easier suctioning
Less airflow resistance
Reduced risk of tube kinking

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15
Q

Disadvantages of an oral airway

A

Gagging/coughing/salivation/irritation can be induced
Tube fixation is difficult
Gastric distention from frequent swallowing
Mucosal irritation/ulcerations of mouth

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16
Q

Nasal airways are measured from the tip of the ______ to the tip of the earlobe.

A

Nose

30Fr small adults
34Fr Large adults

Sizes range from 26-34Fr

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17
Q

T/F Pts semi-wide awake will tolerate nasal airway

A

True

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18
Q

Contraindications for nasal airways

A

Hemorrhagic d/o
Pts on anticoagulants
Deformity
Basilar skull fx

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19
Q

Advantages of nasal airways

A

Long-term comfort
Decreased gagging/salivation
Improved mouth care
Better tube fixation
Improved communications

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20
Q

Disadvantages of nasal airways

A

Pain/discomfort
Nasal/Paranasal complications (epistaxis, sinusitis, otitis)
Difficult placement, smaller tube
Difficult suctioning
Increased resistance

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21
Q

What is the Gold Standard for airway management

A

ETTs

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22
Q

What ways can you achieve ETT intubation?

A

Awake vs asleep
Oral vs nasal
Blind vs Direct

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23
Q

ETT sizing

A

according to INTERNAL diameter in mm

Adult male: 7.5-8
Adult female: 6.5-7
Peds 16+age/4 or diameter of little finger

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24
Q

ETT average distance teeth to larnyx

A

Women: 20-21 cm
Men 22-23 cm

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25
ETT positioning
21 is fun 22 will do 23 should not be
26
What happens when the tube is moved with repositioning?
EXTENSION head movement WITHDRAWS tube 1.9cm FLEXION head movement ADVANCES tube 1.9cm
27
Recommended ETT cuff pressure
20-30mmHg
28
High volume/Low pressure cuff (Hi/Lo) or tapered cuffs prevents what?
VAP
29
Prevention of excessive pressure on trachea from cuff
Diffuse intra-cuff pressure over a large area Tracheal wall pressure is 15-30mmHg Cap Perfusion pressure is tracheal mucosa is 32mmHg ->cannot go above this, no perfusion= low sores/skin breakdown
30
Diffusion of Nitrous Oxide is 34x more soluble in blood than ______?
Nitrogen
31
Where does Nitrous oxide move into an enclosed space surrounded by a COMPLIANT wall which allows GAS to EXPAND?
Intestine Chest Gas embolism
32
Where does Nitrous oxide move into an enclosed space surrounded by a NON-COMPLIANT wall which causes an INC in PRESSURE?
Middle ear nasal sinus
33
T/F: Transfer of N2O to inside ETT cuff may cause considerably decrease in cuff volume and pressure.
False: It will INCREASE volume and pressure
34
What type of surgeries should you not use N2O?
Trauma Abdominal cases Pneumothorax Middle ear issues/surgeries
35
All types of ETTs have a _____mm connection piece
15mm
36
Cuff with pilot balloon ETT
Cuff pressure 20-20mmHg
37
Cuffless ETT
Infants & Children
38
Radio-opaque ETT
Line from top to bottom for CXR
39
Tip of ETT
Bevel on left side of visualization/placement
40
Murphy Eye on ETT
Alternate gas passing area
41
Laser ETT
Fire retardant Cuff filled with sterile water
42
Reinforced Wire Tubes
Used for mouth sx, insert w/ fiberoptic Metal; need mobility in tube not for ICU/transport resist kinking
43
NIMS ETT
used with thyroid surgery, has electrodes that alarm if they’re close to hitting a nerve
44
Oral & nasal rae tubes
Has a bend for ENT procedures
45
Endotrol tube
finger loop to control the end of the ETT
46
Stylets
Should not extend past tip of ETT Should be removed just after the tip of the ETT is beyond the glottis Lubricate the stylet for easy removal (water soluble jelly)
47
Laryngoscope/blade Handle
Light source “C” batteries or fiberoptic
48
What are the 2 types of blades?
Straight (Miller, Wisconsin, Phillips) or Curved (Macintosh)
49
Blade sizing
Sizing range from 0-4, size denotes length of blade, smaller the #, shorter the blade
50
Macintosh Blade
Tip of blade is curved-placed in the VALLECULA (to elevate the epiglottis) Advance tip into vallecula, lift along axis of handle, tip of blade indirectly elevates epiglottis
51
Advantages of Macintosh blades
52
Miller Blade
Straight blade with a curved tip-tip under EPIGLOTTIS to directly elevate it (“pushes on epiglottis”) Advance tip to underside of epiglottis, lift at 45 degree angle, tip of blade picks up epiglottis
53
Advantages of Miller Blade
Good in small cross-sectional dimensions Useful for narrow oral cavities or prominent upper teeth Ankylosis
54
Wisconsin Blade
straight blade with larger cross-sectional dimension, squared tip
55
Phillips Blade
straight blade with wider surface, tip more upturned than miller
56
Preparation for Laryngoscopy
Test the tube’s cuff inflation system (inflate/remove syringe, assure valve works) Lock desired blade onto handle & test the light Position pt/laryngoscopist (pt in comfortable position on OR table; height of table to position best for the person going to intubate-pt’s head at your XIPHOID process) Preoxygenation/Denitrogenation (issues with obesity-maximize FRC, claustrophobia-allow pt to hold mask, RSI-not bagging…caution with excess sedation) Final Step → assure an adequate depth of anesthesia!! (lash test)
57
_________ is used to open the mouth (1st & 3rd fingers) - fingers removed after blade insertion and ID of epiglottis edge
Scissoring
58
Blade Insertion
Laryngoscope held in left hand; open mouth with right hand; insert blade from right side of mouth & move into midline (be careful of teeth, do not pinch lips, deflect tongue left) NO ROCKING →LIFT TOWARD BELLY, NOT TOWARD FRONT TEETH
59
Techniques to visualize Epiglottis
Slow advance inward & toward midline, right hand keeps lips from rolling between teeth & blade (avoid pressing on pt eye), advance until epiglottis seen –may only see arytenoids If blade is too deep in pharynx may mistake esophagus (the goose!) for the glottis – back out
60
What can you achieve with LMA?
PPV Seal around the laryngeal opening
61
Why is a LMA indicated?
Routine airway Rescue airway Resuscitation airway
62
Contraindicated for LMA
Full stomach Pregnancy > 14 weeks Acute abd/thorax case Decreased pulmonary compliance Gross obesity Hiatal hernia Pharyngeal pathology (must sit correctly) Obstruction below larynx
63
Potential Problems with LMAs
Inadequate level of anesthesia (coughing, aspiration, laryngospasm) Nitrous oxide diffusion (cuff under 60 mmHg) Incorrect position of LMA
64
Sizing of LMA
Based on gender, weight, anatomy → use a large size with less air – do not exceed maximum amount of air
65
Aspiration Risk regarding LMA use
DO NOT USE with increase aspiration risk Avoid inadequate anesthesia Avoid gastric distention No lubrication on anterior surface (no lido gel)
66
Mask Ventilation Techniques
can be 1 person or 2 people Requires a good mask fit and adequate volume of oxygen/air delivered Rests on patient’s bridge of nose, maxillary bones, & mandible Be careful of eyes → no direct pressure or air flow → risk of corneal abrasion Keep dentures in for masking
67
Purpose of mask ventilation
Denitrogenation & Pre-Oxygenation (O2 in FRC)
68
How to properly hold mask
Held in left hand with thumb & first finger around the mask (C), middle & ring fingers on ramus of mandible, little finger maintains anterior displacement of the mandible (E)
69
What is the most common reason for not getting maximum O2?
Loose fitting mask
70
Endotracheal intubation indication
Compromise or inaccessibility of the airway Long surgical procedure needing relaxation Surgical procedure on the head/neck/abdomen Need for controlled or PPV Inability to maintain patent airway with mask/airway Disease process involving the airway Risk of aspiration from a full stomach
71
ETT placement confirmation
onnect to source of ventilation & verify by at least 2 methods End-tidal CO2 (6 breaths required to confirm in lungs) Auscultation: 3 areas (epigastric, left lung, right lung) Tube # placement → deep tube # = most sensitive detector of Esophageal intubation detection ONCE CONFIRMED, SECURE THE TUBE
72
ETT tube verification OUTSIDE the OR
CO2 colorimetry Auscultation Esophageal detection device CXR
73
What should you chart after intubation?
induction meds Ability to mask ventilate # times DL Grade view of intubation Verification of placement # at teeth or lip
74
Nasotracheal Intubation indications
Intraoral operations Oral tube would interfere with surgeon access Long-term ventilation anticipated
75
Hx needed for nasotracheal intubations
Unexplained nosebleeds Hx broken nose Hx deviated septum Nasally inhaled substance abuse
76
Prep for nasotracheal intubations
Nasal tube should be 0.5 - 1 size smaller than orotracheal tube Let sit in warm NS/sterile water to soften tip Nasal trumpet well lubed
77
What forceps are used to guide nasotracheal tubes in place?
Magill forceps
78
When are nasotracheal intubations contraindications?
LaForte fx
79
Steps for Nasotracheal Intubation
Evaluate patency of nares Prepare nares (Afrin or neo, lido gel) Dilate with nasal airways Insert ETT like a nasal airway Perform laryngoscopy, find end of ETT & use Magill forceps to put in glottis
80
How to blindly insert nasotracheal tube?
Best with endotrol tube (finger loop) …only used with spontaneously breathing patients, prep normally, listen for breathing & advance with inspiration
81
Cormack-Lehane classification/grade
Class 1: see top where cords meet Class 2: See arytenoids, some cords Class 3: See epiglottis only Class 4: See nothing Anterior Larynx (misnomer): d/t limited head extension

AFN Assessment (7 decks)

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