Airway equipment Flashcards
Allows gas administration to the patient from the breathing system without any apparatus in patients mouth
Face Masks
Face masks are used for….
Preoxygenation/denitrogenation
May be used for entire anesthetic
Body of face masks
Transparent; see secretions, lip color, mist
Provides shape
Seal of face mask (airways pressure maintained)
Inflatable cushion
20 to 25 cm H2O with minimal leak
Connector size for face mask
22 mm internal diameter- female
Circular ring with prongs for straps
Difficult Mask Ventilation factors (6)
Male
Over 55
Beard
Edentulousness
OSA/snoring
BMI > 30 kg/m2
If having to Two-Handed Method/technique, what should happen?
ask for help
Overcoming Difficult Mask Ventilation ideas (4)
-Oral airway OR nasopharyngeal airway
-Two-handed technique
-Cut the beard
Tegaderm (over mouth)
Cant mask ventilate at all turns into….
Emergency adjunct (difficult airway algorithm)
if cant mask ventilate then dont….
dont give paralytic
Lifts tongue and epiglottis away from the posterior pharyngeal wall to relieve any obstruction and help open the airway
OroPharyngeal Airways (OPA)
OPAs hemodynamic effect
Decreases work of breathing during Spont Vent
Bite portion of the OPA must be——-
Bite portion must be firm enough that patient cannot close lumen by biting
Design and size of OPAs
plastic
color coded
Size designated in millimeters (up to 100 mm)
white OPAS dont have…
dont have hole in the front like the color coded opas. hole can be an insertion point for a scope
measurement markers for OPAs
Corner of mouth to the angle of the jaw or the earlobe
What reflexes should be depressed for OPA insertion?
Pharyngeal and laryngeal reflexes should be depressed
Placed between upper and lower teeth and gums
Bite Blocks
What device goes in place before anesthesia ?
bite block
Where are bite blocks used?
Endoscopy
Prevents biting on ETT, bronchoscope, endoscope
Device that is Tolerated in patients with intact airway reflexes
Nasopharyngeal Airways (NPA)
What is used to dilate the nasal cavity for nasal intubation?
Nasopharyngeal Airways (NPA)
When are NPAs preferable? (4)
Preferable with loose teeth, oral trauma, gingivitis, limited mouth opening
Contraindications for NPAs (5)
Basilar skull fracture
Nasal deformity
Hx of epistaxis
Pregnancy
Coagulopathy (chronic NSAID use)
Purpose of flange on NPA
flange at the end site outside the nose
Can get in the way of getting the nasal cannula to seat
Flange at outer end to prevent complete passage
what resembles a shortened tracheal tube
NPA
What is less stimulating than an OPA
NPA
How are NPAs sized
Sized by outer diameter in French scale
As french number increases______
diameter increases
Measurement points for NPA
Bony mandible or nostril to the external auditory meatus
Insertion of NPA
insert parallel to nasal floor
when proximal end/ beveled in the nasal passage it should come to rest ABOVE the epiglottis. shouldn’t be in the epiglottis or past the epiglottis. sh
Complications of Airways (Oral or Nasal) (6)
Airway obstruction (incorrect placement)
Ulceration of nose or tongue
Dental/oral damage
Laryngospasm
Latex allergy (some older NPAs usually green in color)
Retention/swallowing (mostly with npa)
Old NPAs are usually_____ and have what?
green and have latex
When is the best time to remove oral or nasal airways?
let them take it out.
who and when was the supraglottic airway made
Dr. Archie Brain in the 80s
Intermediate bridge between face mask and endotracheal tube
Supraglottic Airways
When can Suprglottic airways be used
Spont Vent (SV)
PPV
LMA classic mask shape
Elliptical mask distally
What is the proximal and distal shape of an LMA classic
Shaped like a Tracheally Tube proximally
Elliptical mask distally
Where does an LMA classic sit
Sits in hypopharynx and surrounds the supraglottic structure
What size syringe do you use for an LMA Classic and inflate pressure
at least a 20 ml to take out all the air out of the mask and need to inflate to an air pressure of 60 cmH20
LMA Classic mask inflation pressure
60cmH20
Sizing for LMA
go up by half size
smaller size = smaller pt
3456 = whole number.
What happens if you size too small for an LMA classic?
Gas leaks during positive pressure
Problems with too large of an LMA (3)
-Won’t seat over glottis
-Greater incidence of sore throat
-Possible pressure on lingual, hypoglossal, and recurrent laryngeal nerves
look for bulge in neck = too big
How to instert LMA?
Well lubricated; cuff down
Held like pencil
Upward against the hard palate
Follows the posterior pharyngeal wall
Smooth motion
Should feel it curve around downward in the airway then come to a stop
What happens when you inflate balloon of LMA?
When balloon inflated (if it has a balloon), neck bulges and LMA may “rise” up slightly
what to do For difficult LMA placement?
For difficult placement, jaw lift, pull tongue forward, slightly inflate balloon or may change to different technique
What is LMA unique made of?
Made of PVC
single use/ disposable
LMA unique vs LMA classic
Stiffer, cuff less compliant vs LMA Classic
Insertion same; resembles LMA Classic
What LMA has wire reinforcement?
LMA proseal
What is shorter than the Classic LMA?
LMA proseal
What is the special feature LMA proseals have?
Gastric access port-> esophaguss -> OGT -> decompress stomach.
wire reinforced
What has a Medical-grade thermoplastic elastomer
IGEL LMAS (NO CUFF)
IGEL LMAS (NO CUFF) features/ seals to
Noninflatable, anatomical seal of the pharyngeal, laryngeal, and perilaryngeal structures- prevent aspiration
Gastric channel
conduit for intubation
IGel has anatomical seal of the______
Noninflatable, anatomical seal of the pharyngeal, laryngeal, and perilaryngeal structures
Advantages of LMAs (5)
-Ease and speed of placement
-Improved hemodynamic stability- less stimulating then ETT
-Reduced anesthetic requirements
-No muscle relaxation needed
-Avoidance of some of the risks of tracheal intubation
Disadvantages of LMAs (3)
-Smaller seal pressures than ETTs
-No protection from laryngospasm
-Little protection from gastric regurgitation and aspiration
(First-generation= pre proseal)
What do the smaller seal presures with LMAs compared to ETT lead to?
ineffective ventilation and higher airway pressures are needed.
how can a laryngoscope be manufactured?
Manufactured as single piece or detachable blade/handle
What is the light source on a laryngoscope?
Light source is light bulb or fiberoptic
Where is the power for the light on a laryngoscope provided?
Handle: Provides power for light…. most use disposable batteries
Which hand is the laryngoscope held in?
left hand
What is formed when the blade and handle are ready to use?
Right angle
What part of the laryngcope is inserted into the mouth?
blade
sizing for laryngoscope blades
Different sizes; increasing number… increased size
Size of batteries for laryngoscope light
C size batteries
unscrews from bottom
tongue of the blade does what?
Tongue: manipulates and compresses soft tissue
Tip of the blade does what?
Tip: directly or indirectly elevates epiglottis
Mac can only go where?
into the vallecula
Most alterations in larygoscope change the _________ and there are differences as noted in how they are used
Most alterations change the angle from tongue to handle and there are differences as noted in how they are used
Macintosh blade sizes useful for adults
3 and #4 useful for adults
Has been shown to cause greater cervical spine movement
Macintosh blades
Makes intubation easier because blade requires adequate mouth opening due to blade size
Macintosh blades
Tongue is straight with slight upward tip
Miller blades
Miller blade size for adults
2 and #3 for adults
Blade that Force, head extension, and cervical spine movement is less
Miller blades
Blade that is Great for smaller mouths and longer necks
Miller blade
If miller blade is inserted too far ______-
If blade inserted too far, it elevates larynx or esophagus
If miller blade is withdrawn too far____
If withdrawn too far, epiglottis flips down and covers glottis
“Sniffing” position
Optimal position
35 degree lower cervical flexion; 80 to 90 degree head extension at the atlanto-occipital level
Create an imaginary horizontal line connects the external auditory meatus and sternal notch
Advancing the blade process
Right hand opens mouth (“scissor”) to keep the lips free to accommodate blade insertion
Blade inserted on right side of mouth
Advance blade, keeping tongue to left and elevated
Epiglottis comes into view
Difficult airways interventions
Flexible fiberoptic scope or video largyngoscope
Maintain a neutral position and use of an OPA
Can be awake or “asleep”
How to displace larynx
BURP
Backward
Upward
Rightward
Pressure
How to make a ramped position
Troop Elevation Pillow
Folded blankets
What does a ramped position create?
Create an imaginary horizontal line connects the external auditory meatus and sternal notch
Stainless steel, lighted stylet with malleable distal tip; design utilizes eye piece
Shikani Optical Stylet
What is the oxygen port on an Shikani Optical Stylet used for?
Oxygen port for oxygen insufflation
Shikani Optical Stylet allows the patient to…..
maintain a Neutral position, inserted midline; available in adult and peds sizes
Shikani Optical Stylet insertion
Stylet advanced into trachea; light pressure and tip ANTERIOR at all times to avoid injury
Can be used as a light wand, check ETT placement, or placement of double-lumen ETT
Shikani Optical Stylet
Optical Stylet Advantages (4)
-Easy to use for routine and difficult intubations
-Trachea is visualized, esophageal intubation should not occur
-Decreased incidence of sore throat
-Results in less c-spine movement over conventional laryngoscopy
Optical Stylet DISADVANTAGES (3)
-Longer intubation time
-Cannot be used with nasal intubation (Because its not flexible)
-Cannot be adjusted into a precise direction compared to a traditional malleable stylet
Video Laryngoscopes types (4)
Glidescope, Co-Pilot, King, and McGrath
Advantages of video laryngoscopes (6)
-Magnified anatomy
-Some scopes have curved/straight blades to mimic laryngoscopes
-Operator and assistant can see
-May result in decreased c-spine movement
-Further distance from infectious patients
-Demonstrates correct technique in legal cases
Limitations of video laryngoscopes
Requires video system
Portability varies
Strongest predictors of failure: altered neck anatomy with presence of a surgical scar, radiation changes, or mass
Most frequent anesthesia-related claim
Dental injury
Teeth Most likely damaged
Upper incisors
Restored or weakened teeth
Tooth protectors
Placed on upper teeth during DL
Protects from the blade causing direct surface damage
Does not guarantee safety from dental trauma
Damage to other structures during laryngocopy (4)
-Abrasions/hematomas
-Lingual &/or hypoglossal nerve injury (caused by increased pressure or stretching nerve)
-Arytenoid subluxation
Anterior TMJ dislocation
Lingual nerve injury will result in…..
sensation problems with tongue and pain. not always immediate
How to know if someone has a hypoglossal nerve injury
when tongue stuck out = deviates to the side.
side that deviates that side will be scalloped or wrinkled
Things that contribute to the changes in resistance in the breathing system are______ (4)
Internal Diameter of tube
Tube length- shorter = less resistance
Configuration changes
Connectors
ETT manufacturing requirements (10)
-Low cost
-Lack of tissue toxicity
-Easy sterilization (unless disposable)
-Non-flammability
-Smooth, non-porous surface to prevent secretion buildup, allow passage of suction catheter or bronchoscope and prevent trauma
-Sufficient body to maintain its shape
-Sufficient wall strength
-Conforms to patient anatomy
-Lack of reaction with anesthetic agents and lubricants
-Latex-free
What decreases kinking in tracheal tubes?
Internal and external walls circular
What end of tracheal tube can be shortened?
machine end
What does the slanted bevel of the tracheal tube do?
Helps view larynx
What on the tracheal tube Provides an alternate pathway for gas flow?
Murphy eye
Ring-Adair-Elwin (RAE) Tube advantages (4)
-Facilitate surgery around head and neck
-Temporarily straightened during insertion
-Increased tube diameter… increased distance from tip to curve
-Easy to secure
magills forceps and murpys eye
for nasal intubation as the patient end entered the nasal cavity and use the magills to direct to trachea, the forceps can get caught in the Murphys eye
Also called “reinforced” or “anode” or “spiral embedded” tubes
Armored Tubes
Advantages of armored tubes
Useful when tube is likely to be bent or compressed
Resistance to kinking and compression
Head, neck, tracheal surgeries
Disadvantages or armored tubes
Need a stylet or forceps
Difficult to use during nasal intubation
Cannot be shortened
Damaged when biting
Laser-Resistant Tubes are made of….
Metallic or silicone and metal mixture
Laser-Resistant Tubes reflect what laser beams
CO2 or KTP laser
potassium titanyl phosphate (KTP)
Laser-Resistant Tubes cuffs contain…..
Cuffs contain methylene blue crystals
Saline
cuffs are Not laser resistant
Laser-Resistant Tubes double cuffs fill with and sequence
Double cuffs
Fill with methylene blue saline solution
Distal cuff first, then proximal cuff
Purpose of methylene blue in laser resistance tube cuffs
methylene blue seen = cuff is leaking
What side are ETT markings on
On bevel side above the cuff
How are tube makings read
Read from pt side to machine side (cm)
Tube marking safety standards (6)
-The word oral or nasal or oral/nasal
-Tube size in ID in mm
-Name of manufacturer
-Graduated markings in centimeters from patient end
-Cautionary note… single use only if disposable
-Radiopaque marker at patient end
What are Radiopaque marker at patient end used for
see position on x ray
normal ETT cuff pressure and mls
Cuff pressure = 18 - 25 mm Hg; usually 8 - 10 mL of air
ETT cuffs should not …….
Must not herniate over murphy eye or bevel of tube
measuring cuff pressure with manometer is recommended when….
Monitor cuff pressure frequently if using nitrous as this causes cuff inflation/expansion
High-volume, Low-pressure Cuff features
Thin compliant wall
Occludes trachea without stretching tracheal wall
Area of contact larger but cuff adapts shape to tracheal wall shape
advantages of High-volume, Low-pressure Cuff (2)
-Easy to regulate pressure
-Pressure applied to trachea less than mucosal perfusion pressure
Disadvantages of High-volume, Low-pressure Cuff (5)
More difficult to insert, may obscure the view of the tube tip and larynx
Cuff is more likely to be torn during intubation
More likely to have a sore throat (covering more of the wall)
May not prevent fluid leakage
Easy to pass NGT, esophageal stethoscopes around cuff
Low-volume, High-pressure Cuff features
Has small area of contact with trachea
Requires large amount of pressure to achieve a seal
Distends and deforms the trachea to a circular shape
Advantages of Low-volume, High-pressure Cuff (3)
-Better protection against aspiration
-Better visibility during intubation
-Lower incidence of sore throat
Disadvantages of Low-volume, High-pressure Cuff (2)
-Pressure exerted on trachea probably above mucosal perfusion pressure
-Should be replaced with a low-pressure cuff if postoperative intubation is required
causes of Changes in Cuff Pressure (4)
-Use of nitrous
-Hypothermic cardiopulmonary bypass (decrease cuff pressure)
-Increases in altitude
-Coughing, straining, and changes in muscle tone
Why does hypothermia decrease cuff pressure
cold induced vasoconstriction/ contraction of microvasular -> dilating
What can cause ETT trauma (3)
-Excessive force, repeated attempts
-Varies with skill, difficulty of airway, and amount of muscle relaxation
-Keep stylet INSIDE tube
-Use vasoconstrictors for nasal intubation and pre-dilate nasal passage
Inadvertent bronchial intubation
seen commonly in….
Emergencies; pediatric and female pts
peds and female = shorter to carina and R mainstem is shorter distance
bronchial intubation can lead to….
atelectasis
Distance to carina decreases with ………
Trendelenburg and laparoscopy
Securing ett positions
Approx 21 cm mark at teeth - female
23 cm at teeth - male
Reason why R mainstem bronchus is intubated more often
shorter
straighter - (L = 45 degree angle)
Fluid accumulation above the cuff can lead to_______
Inadvertent bronchial intubation
Where can upper airway edema happen?
Anywhere along path of tube
Upper airway edema is dangerous in young children because_______
and peak incidence
Dangerous in young children (cricoid cartilage completely surrounds subglottic area)
more anterior
Peak incidence between 1-4 y/o
Earliest signs of upper airway edema
Earliest signs 1-2 hrs postop to 48 hours postop
How to avoid upper airway edema
Avoid irritating stimuli - URI, anesthetic depth
Vocal cord granuloma is common in….
Common in adults; females
s/s of vocal cord ganuloma (4)
S/S: Persistent hoarseness, fullness, chronic cough, intermittent loss of voice
treatment for vocal cord granuloma
Treatment: laryngeal evaluation, voice rest
Causes of vocal cord granuloma (4)
Trauma, ETT too large, infection, and excessive cuff pressure
Bogies are made of….
Polyester base with resin coating
bougies angle
Distal end angled 30-45 degrees
How is bougies introduced
Introduced with anterior positioning of the tip
reasons to use bougies
Blind intubation if glottic exposure is absent
ETT passage is difficult
Advance gently
Feel clicking sensation across tracheal rings
what are magill forceps used for
Used primarily with nasal intubations
Should be immediately available
Directs tube into larynx
Possible damage to tube cuffs and lodged in murphy eye
Right mainstem features
Shorter, straighter, larger diameter
25 degree takeoff from trachea
Larger diameter
RUL tracheal takeoff very close to origin
Avg length 2.5 cm from carina to take-off
Left mainstem features
45 degree takeoff from trachea
LUL tracheal takeoff more distal
Avg length 5.5 cm from carina to take-off
Indications for Lung Isolation (3)
Thoracic procedure
Control of contamination or hemorrhage
Unilateral pathology
Double- lumen tubes adult sizes
35, 37, 39, 41 Fr
Double-Lumen Tubes peds size
Pediatric sizes: 26, 28, 32 Fr
Primarily we use _____ DLT
left
When is a Right DLT used (4)
Left pneumonectomy, left lung transplantation, left mainstem bronchus stent in place, left tracheo-bronchus disruption
Once the bronchial cuff of double lumen tube is placed past the cords what is the next step?
the tube is turned 90 degrees
Bronchial portion points toward the appropriate bronchus
___bronchial cuff is just below the____ in the appropriate bronchus
Blue bronchial cuff is just below the carina in the appropriate bronchus
DLT Complications
Tube malposition
Hypoxemia
what can cause Unsatisfactory lung collapse
Bronchial lumen in wrong mainstem - reinsertion
Tube too proximal in airway - correct with fiberoptic
What can cause Hypoxia with DLT? (2) and 2 solutions
Malpositioned tube- reinsertion
Patient comorbidities
-May need PEEP to dependent lung
-Consider intermittent 2 lung ventilation
When DLT is not advisable (7)
-Nasal intubation
-Difficult intubation
-Patients with tracheostomy
-Subglottic stenosis
-Need for continued postoperative intubation
-If a single-lumen tube is already in place
-Critically ill pts
use bronchial blocker instead
Can block a segment of lung without isolating entire lung
Bronchial-Blockers
Cannot be done with DLT
Difficulties with Bronchial-blockers (4)
-Right upper lobe bronchus takeoff is high
-Tracheal bronchus
-Fixation by staples during surgery
-Perforation by suture needle or instrumentation
