Airway compromise Flashcards
1
Q
What is often the cause of an obstructed airway in patients requiring resuscitation?
A
loss of consciousness
2
Q
What is necessary to do if aiway obstrction is identified and why?
A
- prompt assessment, airway opening, and ventilation
- prevent secondary hypoxic damage to brain and other vital organs
- also without adequate oxygenation, an arrested heart may not restart
3
Q
What are 2 types of airway obstruction?
A
partial or complete
4
Q
Where in the respiratory tract can airway obstruction occur?
A
anywhere, from nose to level of trachea and bornchi
5
Q
Where is the commonest site of airway obstruction in the unconscious patient?
A
the pharynx - more often at soft palate and epiglottis rather than tongue
6
Q
What are 5 causes of airway obstruction at the level of the pharynx?
A
- Unconscious patient: soft palate/epiglottis
- Vomit or blood
- Regurgitation of gastric contents
- Trauma to airway
- Foreign bodies
7
Q
What are 4 causes of airway obstruction at the level of the larynx?
A
- Oedema caused by burns
- Inflammation
- Anaphylaxis
- Upper airway stimulation/inhaled foregin body can cause laryngospasm
8
Q
What are 5 causes of airway obstruction below the level of the larynx?
A
- Excessive bronchial secretions
- Mucosal oedema
- Bronchospasm
- Pulmonary oedema
- Aspiration of gastric contents
9
Q
What are the 3 key things to do initially to recognise airway obstruction?
A
LOOK, LISTEN and FEEL
if patient talking it is patent
- Look: for chest and abdominal movements
- Listen + feel: for ariflow at mouth and nose
10
Q
What are 5 signs of partial airway obstruction?
A
air entry diminished and noisy:
- Inspiratory stridor - obstruction at larynx or above
- Expiratory wheeze suggests obstruction of lower airways - tend to collapse and obstruction during expiration
- Gurgling suggests liquid or semisolid material in upper airways
- Snoring arises when pharynx partially occluded by tongue or palate
- Crowing or stridor is sound of laryngeal spasm or obstruction
11
Q
What movements may be seen in airway obstruction?
A
if airway obstructed, abdomen pushed out as chest is drawn in during attempts to inspire - often described as ‘see-saw’ breathing
also accessory muscles used - neck and shoulder
12
Q
What are 3 possible visible signs of airway obstruction?
A
- see-saw breathing
- use of accessory muscles of neck and shoulders
- intercostal and subcostal recession
13
Q
What indicates complete airway obstruction?
A
complete absence of breath sounds
14
Q
What should be done during an attempt to relieve airway obstruction?
A
whenever possible, give high-concentration oxygen
arterial blood oxygen saturation (SaO2) or pulse oximetry (SpO2) will guide further use of oxygen as airway patency improves
15
Q
What concentration of oxygen saturations should inspired oxygen be adjusted to maintain?
A
94-98%
16
Q
What are 2 general signs of choking i.e. foreign body airway obstruction?
A
- attack occurs while eating
- patient may clutch neck
17
Q
What are 6 signs of severe airway obstruction during choking?
A
- Patient unable to speak
- Patient may respond by nodding to question ‘are you choking’
- Patient unable to breathe
- Breathing sounds wheezy
- Attempts at coughing are silent
- Patient may be unconsciuos
18
Q
What are 2 signs of mild airway obstruction in choking?
A
- patient speaks and answers yes to question ‘are you choking’
- patient able to speak, cough and breathe
19
Q
What is the treatment of mild airway obstruction during choking?
A
encourage pt to continue coughing, but do nothing else
20
Q
What are the 6 key steps to managment of a choking patient with severe airway obstruction?
A
- give up to 5 back blows (etween scapulae, heel of hand, from side of patient, lean patient forwards, support with other hand in front of chest)
- check to see if each back blow has relieved the airway obstruction
- if 5 back blows fail to relieve the airway obstruction give up to 5 abdominal thrusts (clenched fist under xiphisternum, grasp fist with other hand, pull sharply inwards and up)
- if still not relieved, alternate 5 back blows and 5 abdo thrusts
- if become unconscious, call resus team and start CPR
- as soon as individual with appropriate skills present, look with laryngoscope and attempt to remove foreign body with Magill’s forceps
21
Q
What should you do if a patient with severe airway obstruction from choking is unconscious?
A
start CPR
22
Q
What are the 2 options for airway manoervres to relieve upper airway obstruction?
A
- Head tilt + chin lift
- Jaw thrust
23
Q
How is head tilt chin lift performed?
A
one hand on forehead, tilt head back. finger tips of other hand under point of patient’s chin, gently lift to stretch anterior neck streuctures
24
Q
How is a jaw thrust airway manoevre performed?
A
apply head tilt
identify angle of mandible and apply steady upward and forward pressure with index and other fingers behind angle of mandible
use thumbs to open the mouth slightly by downward displacement of the chin
25
When are airway manoevres most likely to clear the airway obstruction?
if obstruction is from relaxation of the soft tissues
26
How can you tell if an airway manoeuvre has worked?
look listen and feel
27
If the airway is still obstructed following an airway manoeuvre, what can you do next?
* look and remove any solid foreign body in mouth with forceps or suction
* remove broken or displaced dentures but leave well-fitting dentures in place (help maintain contours of mouth which improves seal for ventilation by mouth-to-mask or bag-mask techniques
28
How does airway management change in a patient with suspected cervical spine injury?
* maintain head, neck, chest and lumbar region in the **neutral position** during resuscitation
* excessive head tilt could worsen the injury and damage cervical spinal cord
* establish clear upper airway using **jaw thrust or chin lift in combo with manual in-line stabilisation** of head and neck by an assistant
* if life-threatening airway obstruciton persists, **add head tilt a small amount at a time until airway open**
29
What are 3 situations when you should have a high suspicion for cervical spine injury?
1. if victim has fallen
2. has been struck on head or neck
3. has been rescued after diving into shallow water
30
What are 2 key adjuncts to basic airway techniques and how are they used together?
oropharyngeal and nasopharyngeal airways
they overcome soft palate obstruction and backward tongue displacement in an unconscious patient, but head tilt and jaw thrust may also be necessary
31
What is another name for an oropharyngeal airway?
Guedel
32
How is the size of a Guedel airway needed estimated?
from distance between patient's incisors and angle fo the jaw
33
What are the most common sizes of Guedel airways that are used?
2 (small), 3 (medium), 4 (large)
34
In which type of patients can oropharyngeal airways be used and why?
unconscious patients only - in semi-comatose patient, may provoke vomiting or laryngospasm
if pt intolerant of oral airway, they do not need one
35
How is an oropharyngeal airway (Guedel) inserted?
* open patient's mouth, check nothing that could be pushed into larynx. suction if necessary
* introduce upside down then rotate 180 degrees as passes beyond hard palate and into oropharynx
* after insertion, check airway by look, listen and feel approach while maintaining alignment of head and neck with head tilt, chin lift or jaw thrust as neceesary
36
How can a nasopharyngeal airway be tolerated in patients vs oropharyngeal?
in a patient who is not deeply unconscious, it is tolerated better than an oropharyngeal airway
37
What are 3 situations when a nasopharyngeal airway may be especially helpful?
1. Clenched jaw
2. Trismus
3. Maxillofacial injuries
38
What is particular situation when the use of a nasopharyngeal airway should be performed with care?
base of skull fracture
39
Which sizes of nasopharyngeal airways are suitable for adults?
6-7mm
40
What can happen if the nasopharyngeal tube used is too long?
may stimulate the laryngeal or glossopharyngeal reflexes and cause laryngospasm or vomiting
41
What effect is common when using a nasopharyngeal airway (that means care should be taken)?
nosebleeds - 30% of patients
42
What are the steps for nasopharyngeal airway insertion?
* lubricate airway using water-soluble jelly
* insert airway bevel-end first, vertically along floor of nose with slight twisting action.
* try right nostril first. if obstruction met, try left
* once in place, check for patency and ventilation by look, listen and feel
* if necessary maintain correct alignment of the head and neck with chin lfit or jaw thrust techniques
43
During resuscitation, what form of oxygen should be given and until when?
with 100% oxygen, until return of spontaneous circulation (ROSC) is achieved
once ROSC achieved, continue giving until oxygen sats of arterial blood can be reliably measured then adjust accordingly
44
What is the maximum oxygen concentration which can be delivered using a standard oxygen mask (e.g. Hudson mask)?
up to 50% inspired oxygen
45
What form of oxygen should initially be given during resuscitation?
mask with reservoir bag (non-rebreathing mask), can deliver oxygen concentration of 85% at flows of 10-15L
46
What is the target oxygen saturation once blood oxygen concentration can be measured reliably?
* 94-98%
* 88-92% if patient has COPD
47
What should be used to perform suction to clear the airway?
wide-bore rigid sucker (Yankauer) to remove liquid (blood, saliva and gastric contents)
48
What should you be careful of when performing suction?
if patient has an intact gag reflex, suction can provoke vomiting
49
What can be used to perform suction if patients have limited mouth opening and how can this be performed?
fine-bore flexible suction catheters
can also be passed through oropharyngeal or nasopharyngeal airways
50
What type of things causing airway obstruction can cause difficulty for suction?
* thick vomit - large bore sucker and good suction needed
* large chunks of food may have to be removed by hand or Magill's forceps
51
What needs to be added to airway management if patients have no or inadequate breathing?
artificial ventilation
52
How effective is expired air ventilation (i.e. rescue breathing with mouth-to-mouth or mouth-mask-mask breaths)?
effective, but rescuer's expired oxygen concentration is only 16-17% so should replace ASAP with ventilation and oxygen-enriched air
53
What are 2 adjuncts to avoid direct person-to-person contact from mouth-to-mouth ventilation?
1. pocket mask
2. self-inflating bag
54
How is a pocket-mask used for ventilation?
similar to anaesthetic face masks, enables mouth-to-mask ventilation
has a unidirectional valve to direct patient's expired air away from rescuer
55
How can supplemental oxygen be given when using a pocket mask without an oxygen port?
place oxygen tubing under one side of mask, ensure adequate seal
56
What are 2 things which increase the risk of gastric inflation and subsequent regurgitation when using a pocket mask?
1. blowing too hard because of misalignment of the head and neck obstructing the airway and/or tidal volumes that are too large
2. incompetent oesophageal sphincter of all patients in cardiac arrest
57
How should breaths be delivered using a pocket mask and mouth-to-mask ventilation?
* **give each breath over 1 second**, giving volume that corresponds to visible chest movement - compromise between giving enough volume, minimising risk of gastric inflation, and allowing enough time for chest compressions
* **2 ventilations after every 30 chest compressions**
58
At what rate should oxygen be delivered via the port on a pocket mask?
10L /min
59
What is a self-inflating bag?
can be connected to a face mask (bag-mask), supraglottic airway (e.g. LMA, i-gel) or a tracheal tube
as bag squeezed, contents delivered to patient's lungs
on release, expired gas diverted to the atmosphere via a one-way valve
bag refills automatically via
60
When concentration of air does the bag valve mask (self-inflating bag) deliver without supplemental oxygen?
ambient air - 21% oxygen
61
When concentration of air does the bag valve mask (self-inflating bag) deliver with supplemental oxygen attached?
if high-flow oxygen directly attached to bag, increases to around 45%
62
How can the self-inflating bag deliver the highest possible oxygen concentration?
if reservoir system is attached and oxygen flow is high (10-15L/ min): 85%
63
What are 2 disadvantages of the self-inflating bag to deliver oxygen?
1. use requires skill
2. when used with a face mask, difficult to achieve a gas-tight seal while simultaneously performing a jaw thrust with one hand and squeezing bag with the other
64
What is the risk of excessive compression of the self-inflating bag for ventilation?
can inflate the stomach, further reducing ventilation and greatly increasing risk of regurgitation and aspiration
65
How can the difficulty of using a self-inflating bag and having multiple tasks to perform at once be overcome?
2 people perform it: one holds face mask in place, using both hands and jaw thrust, other squeezes bag
66
What type of airways can be used during CPR to enable more effective ventilation than bag-mask ventilation?
supraglottic airways
67
What are the 2 examples of supraglottic airways?
1. laryngeal mask airway
2. i-gel
68
What are 4 advantages of using supraglottic airways?
1. may enable more effective ventilation than bag-mask ventilation
2. reduce risk of gastric inflation
3. easier to insert than a tracheal tube
4. can generally be inserted without having to stop chest compressions
69
What is a laryngeal mask airway (LMA)?
wide bore tube wtih elliptical **inflated** cuff, sits above laryngeal opening
70
How likely is gastric inflation with an LMA?
unlikely provided tidal volumes do not generate high inflation pressures during intermittent positive pressure ventilation (\>20 cm H2O)
71
Why is LMA useful to use in potential cervical spine injury?
does not require vigorous movements to align the head and neck
72
How many times can the conventional LMA (LMA Classic) be used?
can be sterilied and reused up to 40x
73
In which scenarios are LMAs a particularly useful artificial airway?
in the cannot ventilate, cannot intubate scenario - atempted intubation by skilled personnel has failed and bag-mask ventilation is impossible
74
What is the ProSeal LMA (PLMA) - Supreme?
disposable form of LMA, more appropriate than reusable version for use during CPR as can form improved seal, has gastric drainage channel
75
What should happen to to chest compressions during LMA insertion?
try and insert without stopping chest compressions, if necessary try to limit any pause in chest compressions to maximum of 5 seconds
76
What sizes of LMA are usually most appropriate?
size 5 appropriate for most men, size 4 for most women
77
How is an LMA inserted into place?
* apply lubricating jelly to outer face of cuff area
* hold like a pen, insert into mouth with upper surface applied to palate untli reaches posterior pharyngeal wall
* press mask backward and down around corner of pharynx until resistance felt - locates in back of pharynx
* slight 45 degree twist will often aid placement if initial attempts beyond pharynx are difficult
78
How is the LMA inflated once inserted in the back of the pharynx?
* connect inflating syringe and inflate the cuff with air
* maximum 40ml for size 5, 30ml for size 4
* do not hold LMA during inflation
* should lift slightly out of mouth as cuff finds correct position
79
What should be done if the LMA cannot be inserted within 30 seconds?
oxygenate the patient using a pocket mask or bag-mask before reattempting LMA insertion
80
How can a clear airway be confirmed once an LMA is inserted and what is done after this?
* listen over chest during inflation and seeing bilateral chest movement
* large, audible leak suggests malposition of LMA (small leak acceptale if chest rise adequate)
* secure LMA with bandage or tape
81
What are 3 limitations of the LMA?
1. if high airway resistance or lungs stiff (pulmonary oedema, bronchospasm, COPD), risk of large leak arond cuff causing hypoventilation
2. uninterrupted chest compressions likely to cause some gas leak from LMA cuff when ventilation atempted
3. theoretical risk of aspiration of stomach contents because LMA doesn't sit within larynx (but not common)
82
What happens to the air that leaks from an LMA if there is high airway resistance/ stif lungs?
most escapes through patient's mouth, some may be forced into stomach
83
What should be done if the is gas leak from the LMA cuff when ventilation is attmpted, due to continuous chest compressions?
attempt continuous chest compressions initially, but abdandon if persistent leaks and hypoventilation
84
What should be done if a good airway is not achieved with the LMA?
withdraw the LMA, deflate the cuff and make a new attempt at insertion, ensuring good alignment of head and neck and strict adherence to correct insertion technique
85
What is the i-gel airway?
has cuff made of jelly-like material, doesn't require inflation
stem incorporates a bite block and narrow oesophageal drain tube that allows NG tube to be passed through
86
What are 3 advantages of the i-gel airway?
1. easy to insert without stopping CPR
2. requires only minimal training
3. forms good laryngeal seal
87
How is an i-gel inserted?
* lubricate
* grasp lubricated i-gel firmly along integral bite block
* position with cuff outlet facing towards chin of patient
* patient sniffing morning air position, head extened and neck flexed
* introduce leading soft tip into mouth of patient towards hard palate
* glide downwards and backwards along hard palate with continuous but gentle push until definitive resistance felt
88
What should happen with the rest of CPR while an i-gel is being inserted?
continue or stop for max 5s
89
What sizes of i-gel are usually most appropriate?
size 4 good for most adults, but small females may require size 3, tall men size 5
90
Where should the i-gel be once inserted?
tip of i-gel should be at upper oesophageal opening and cuff against larynx
incisors shuold be resting on integral bite-block
91
How should ht eline at the middle of the integral bite-block on i-gels be used?
represents approx position of teeth when i-gel positioned correctly but only a guide, may not be exactly at teeth depending on pt height/size
92
What can cause airway obstruction in a patient with a tracheostomy tube or permanent tracheal stoma (usually following laryngectomy)?
blockage of trachestomy tube or stoma
93
What is the first step in management of airway obstruction in patients wiht tracheostomies or permanent tracheal stomas?
remove any obvious foreign material from stoma or tube
94
What information is important to know about a patient with a tracheostomy tube/stoma in an airway emergency?
whether patient has normal upper airway and tracheostomy tube, or has had a laryngectomy
95
How is a patient with a normal upper airway and tracheostomy tube managed in airway obstruction?
* some can be unblocked by removing inner tube
* if trachoestomy tube blocked and inner tube can't be removed, remove tracheostomy tube and ventilate patient's lungs by sealing stoma (hole at the front)
* use standard airway and ventilation techniques with stoma occluded by airtight dressing
* can replace tracheostomy tube if you're trained to
96
How is a patient with a laryngectomy managed in airway obstruction?
give oxygen and assist ventilation via the stoma, not the mouth
mouth-to-stoma, or holding small face mask over the stoma, or by inserting tracheal tube into the stoma, depending on your skills
97
At what point do you convert to continuous ventilation breaths rather than the 30 compression: 2 breath ratio?
once supraglottic airway or endotracheal tube inserted
