Airway Equipment Flashcards
1
Q
Basic Airway Equipment
A
- suction (functional and readily available)
- 2 oral and 2 nasal airways
- face mask
- laryngoscope handles and blades (functional)
- multiple sizes of ETT with stylets and pilot balloons checked
- O2 supply
- ambu bag
2
Q
oral airway
A
follows natural curvature of the tongue and lifts tongue and epiglottis away from posterior pharyngeal wall, thereby preventing obstruction
3
Q
oral airway sizing
A
- size specified by overall length
- multiple sizes available
- small = 80mm
- medium = 90mm
- large = 100mm
- determine proper size by measuring from corner of mouth to edge of mandible (around earlobe)
4
Q
Oral airway placement
A
- NOTE - only place when in deep sedation, not well tolerated in light sedation (gag, cough, vomit, laryngospasm, bronchospasm)
- tongue blade and proper sized oral airway
- use the tongue blade to push down on the tongue
- go in at 90 degrees in one corner of the mouth
- turn with the curve facing the roof of the mouth
- ensure tongue was not pushed further back and that you can mask ventilate
- avoid trauma to teeth and soft tissues
5
Q
common types of oral airways
A
- berman
- guedel
- ovassapian (used for fiberoptic intubation)
- COPA (cuffed)
6
Q
nasal airway
A
artificial airway that passes through the nose, goes behind the tongue, and rests just above the epiglottis
7
Q
clinical uses of nasal airway
A
- relieve upper airway obstruction
- facilitation of pharyngeal suctioning
- nasal dilation for nasal intubation
- fiberoptic guide
8
Q
nasal airway proper sizing
A
- size denoted by internal diameter in millimeters
- measure from patient nare to earlobe
9
Q
nasal airway proper placement
A
- use water soluble lube to lubricate outside of nasal airway
- better tolerated in awake or lightly anesthetized patients (versus an oral airway) - provokes less airway stimulation than hard oral airway
- be careful of bleeding - may be necessary to prep nares with vasoconstrictor
10
Q
relative contraindications for nasal airway
A
- coagulopathy or hemorrhagic disorder
- anticoagulant therapy
- pregnancy
- basilar skull fracture
- nasal infection
- deformities of nose
- history of nosebleeds requiring treatment
- septal defect
11
Q
oral/nasal airway complications
A
- airway obstruction
- tongue/soft tissue damage
- central nervous system trauma
- uvula edema
- dental damage
- laryngospasm, coughing
- ulceration/necrosis
- latex allergy
12
Q
face mask body
A
- rubber or plastic
- variety of shapes and sizes for adults and children
- transparent masks preferable over black or opaque
13
Q
face mask seal (aka rim or flap)
A
- part of face mask that comes into contact with patient’s face
- may be inflated or deflated to allow for better fit
14
Q
face mask connector
A
- fitting with a 22mm internal diameter
- ring with hooks may be present to fit mask straps
15
Q
face mask sizing
A
- use smallest mask that works
- least dead space
- easier to hold
- less risk for eye injury
16
Q
mask straps
A
- helps to hold mask firmly on the face, decreasing the presence of leaks
- avoid pressure damage - do not place on too tightly (can have facial nerve damage)
17
Q
mask ventilation
A
- head-tilt, chin-lift
- jaw thrust
18
Q
one-handed mask ventilation
A
- fingers kept on bone rather than soft tissue
- requires TIGHT seal
- downward displacement of the mask with the thumb and first finger
- upward displacement of the mandible with the other three fingers, with little finger at angle of mandible
- mandibular displacement combined with upper cervical extension and chin lift pull tongue soft tissues off posterior pharyngeal wall, relieving obstruction
19
Q
two-handed mask ventilation
A
- use thumbs for downward displacement of mask, and fingers on both hands to provide upward displacement of mandible
- requires assistant to provide manual ventilation
20
Q
causes of unsuccessful mask ventilation
A
- obstruction (like the tongue or other soft tissue)
- laryngospasm
- foreign body
- poor technique
21
Q
difficult mask ventilation
A
- facial edema
- prominent nares
- receding jaw
- obesity
- beards
- edentulous
- drainage tubes
- tumors/infections
22
Q
face mask advantages
A
- low incidence of sore throat
- less anesthetic depth needed
- no muscle relaxant necessary
- cost efficient for short cases
23
Q
face mask disadvantages
A
- hands are “tied up”
- user fatigue
- higher fresh gas flows often needed
- more difficulty in maintaining airway vs LMA
- unprotected airway
24
Q
face mask complications
A
- skin problems (dermatitis, necrosis)
- nerve injury (facial nerve CN VII)
- aspiration (no protection)
- eye injury (blindness from occlusion of retinal artery)
- movement of cervical spine
- latex allergy
- lack of correlation between PaCO2 and ETCO2 due to dilution from high FGF
- environmental pollution
25
Laryngeal Mask Airway (LMA)
- supraglottic airway device designed to secure the airway by providing a circumferential seal around the laryngeal inlet with an inflatable cuff
- allows for spontaneous or assisted ventilation
26
LMA components
- 15mm connector
- curved airway tube
- elliptical spoon shaped cuffed mask
- inflation pilot balloon and valve
- aperture bars that prevent epiglottis from obstructing mask
27
reusable LMA
- made from medical grade silicone to withstand steam autoclaving for sterilization
- max use per LMA is 40 times
28
LMA 1
- patient weight <5 kg
- max cuff vol - 4 cc
- cuff volume test - 6 cc
- largest ETT - 3.5
29
LMA 1.5
- patient weight 5-10 kg
- max cuff vol - 7 cc
- cuff volume test - 10 cc
- largest ETT - 4.0
30
LMA 2
- patient weight 10-20 kg
- max cuff vol - 10 cc
- cuff volume test - 15 cc
- largest ETT - 4.5
31
LMA 2.5
- patient weight 20-30 kg
- max cuff vol - 14 cc
- cuff volume test - 21 cc
- largest ETT - 5.0
32
LMA 3
- patient weight 30-50 kg
- max cuff vol - 20 cc
- cuff volume test - 30 cc
- largest ETT - 6.0
33
LMA 4
- patient weight 50-70 kg
- max cuff vol - 30 cc
- cuff volume test - 45 cc
- largest ETT - 6.0
34
LMA 5
- patient weight 70-99 kg
- max cuff vol - 40 cc
- cuff volume test - 60 cc
- largest ETT - 7.0
35
LMA 6
- patient weight >100 kg
- max cuff vol - 50 cc
- cuff volume test - 75 cc
- largest ETT - 7.0
36
LMA inspection
- always inspect before use
- inflate cuff with recommended amount of air and assure cuff holds pressure for at least 2 min
- test integrity of cuff by over-inflating with max volume (50% more)
- during over inflation, check pilot balloon (it should remain elliptical, spherical means loss of integrity)
- deflate cuff, apply manual pressure to cuff to assure surface is smooth
- check 15 mm connector for tight fit
37
LMA placement
- lubricate posterior surface of cuff
- airway reflexes must be obtunded
- absence of motor response to jaw thrust is a good indicator of anesthetic depth for LMA insertion
- optional - assessment of ability to manually ventilate
- mask fully deflated
- grasp by the tube like holding a pen close to the cuff
- place tip of LMA against inner surface of patient's upper teeth
- press tip against hard palate
- slide mask posteriorly, following hard palate
- continue advancing until you can no longer reach into mouth
- grasp tube firmly with other hand and remove placing hand
- inflate cuff
- mask will rise when seated properly in the hypopharynx
- assess adequacy of ventilation
- keep airway pressure below 20 cmH2O
- secure and place bite block
38
problems with LMA insertion
- tip of mask can fold over on itself
| - can progress further and cause epiglottis into down-folded position, creating an airway obstruction
39
LMA removal
- deep vs. awake
| - mask deflation (partial inflation can help remove secretions)
40
LMA considerations
- dead space - increases this
| - WOB - increases this if patient breathes spontaneously
41
LMA contraindications
- anyone at risk for aspiration
- patient with delayed gastric emptying
- hiatal hernia
- morbidly obese
- >14 weeks pregnant
- glottic or subglottic obstruction
- supraglottic pathology interfering with placement
- extremely limited mouth opening
- trauma
- acute abdomen
- thoracic injury
- patients with fixed decreased pulm compliance (pulmonary fibrosis)
- peak airway pressures > 20 cmH2O
- patients who cannot adequately answer questions regarding medical history
42
adverse effects of LMA
- aspiration of gastric contents (1:5000)
- sore throat (10%)
- rare hypoglossal nerve injury, tongue cyanosis, vocal cord paralysis
- larygnospasm
43
endotracheal intubation indications
- risk of pulmonary aspiration
- head/neck procedures
- intracranial or intrathoracic procedures
- intraabdominal procedures
- procedures requiring mechanical ventilation
- positioning where airway is unavailable to anesthesia
- airway anomalies
44
endotracheal tube size
- numbered according to internal diameter
| - 0.5mm increments from 2.5-9.0mm
45
endotracheal tube materail
- polyvinyl chloride (PVC)
- American Society for Testing Material (ASTM) standard 21 applies to ETT constriction
- marking F-29, Z-79, or I.T. on an ETT means it has been tested and shown to cause no toxicity
46
men ETT size and depth
8.0 or 9.0 mm at 24-26 cm at the lip
47
women ETT size and depth
7.0 or 8.0 mm at 20-22 cm at the lip
48
general guidelines for children ETT
- size in mm = 4 + [age/4]
| - depth in cm = 12 + [age/2]
49
murphey eye
- prevents alternate pathway for air flow if bevel were to become occluded (like up against the tracheal mucosa)
- tip of stylet should not go beyond this area
50
cuff system
- purpose is to provide seal between ETT and tracheal wall
- cuff pressure 20-25 mmHg recommended
- uncuffed ETT used in children < 8 yo (airleak at 15-20 cmH2O)
51
high volume/low pressure cuff
- larger area of contact with the trachea, but it adapts and conforms to tracheal wall
- less risk for tracheal damage
- long term intubation in ICU
- compliant - designed to accommodate a relatively large volume of inflation before cuff pressure increases
52
low volume/high pressure cuff
- small area of tracheal contact
- can distend trachea and cause tracheal damage/necrosis
- short term use
53
cuff system purpose
- prevent escape of gas
- centers ETT
- prevents tracheal trauma
- protects against aspiration
54
preparation of tube for intubation
- 15mm adaptor connection (to hook up to vent)
- stylet
- check cuff
55
MacIntosh
- curved blade
- tip advanced to valleculae and indirectly lifts the epiglottis
- less trauma to epiglottis
- introduce blade into mouth on the right, and sweep tongue to left
56
Miller
- straight blade
- directly lifts the epiglottis
- usually less force to keep midline and requires less head extension
57
equipment needed for oral tracheal intubation
- laryngoscope handle x2
- laryngoscope blade x2
- 2 oral airways
- 2 nasal airways
- oral ETT (2 different sizes) with stylet
- suction
- stethoscope
- backup airway plan
58
distance from teeth to vocal cords
12-15 cm
59
distance from vocal cords to carina
10-15 cm
60
where should cuff of ETT sit
at midpoint between vocal cords and carina (about T5)
- men ~24-26cm
- women ~20-22cm
- add 2-4cm depth with nasal intubations
61
Hose follows the nose
- ETT can advance 1.9 cm with head flexion
- ETT can withdraw 1.9 cm with head extension
- ETT can move 0.7cm with rotation of head
62
confirming ETT placement
- direct visualization of ETT passing through cords
- presence of ETCO2 continuous waveform
- absence of stomach gurgling sound
- equal bilateral breath sounds
- fogging of ETT
- refilling of ventilatory bag with exhalation
63
diagnosis of esophageal intubation
- gastric contents in ETT
- ETCO2 waveform gradual decline
- reservoir bag collapses due to no return of airway gases
- auscultation
- gastric distention
- absence of chest wall motion
64
physiology response to laryngoscopy and intubation
- CV (HTN, tachycardia or reflex bradycardia, arrythmias, myocardial ischemia)
- increased IOP
- increased ICP
- bronchospasm
65
complications during laryngoscopy and intubation
- dental injury
- damage to soft tissue and nerves
- c-spine injury
- damage to ETT cuff
- esophageal intubation
- submucosal dissection
- bleeding
- laryngospasm, bronchospasm, coughing
- aspiration
- eye injry
- CV changes
- hypoxemia and hypercarbia with prolonged intubation attempts
66
complications of laryngoscopy and intubation
- upper airway edema
- glottic and subglottic granulation tissue leading to stenosis
- vocal cord dysfunction
- vocal cord granuloma
- arytenoid dislocation
67
failures of direct laryngoscopy
- poor patient positioning
- poor technique (inexperience, ego)
- inadequate preop assessment
- poor preparation
- backup techniques not available and ready
- adjunctive measures not utilized
68
deep extubation
- muscle relaxants fully reversed
- pt spontaneously breathing with adequate minute ventilation
- no response to suctioning
- contraindicated - patients with difficult airway, risk of aspiration, surgery that may produce airway edema
69
awake extubation
- patient able to maintain and protect airway
- purposeful movement
- eyes open
- reaction to suctioning
- DO NOT EXTUBATE IN STAGE 2
70
subjective criteria for awake extubation
- follows commands
- clear oropharynx (no active bleeding, secretions cleared)
- intact gag reflex
- sustained head lift for 5 seconds
- sustained hand grasp
- adequate pain control
- minimal end expiratory concentration of inhaled anesthetics
71
objective criteria for awake extubation
- vital capacity >15 mL/kg
- peak voluntary negative inspiratory pressure >25 cmH2O
- tidal volume >6 mL/kg
- 4/4 twitches on TOF with sustained tetany >5sec
- SpO2>90% (PaO2>60mmHg)
- RR<35
- PaCO2<45
72
extubation technique
- 100% O2 (conflicting literature, smallest effective)
- suction oropharynx and hypopharynx
- close APL
- deflate cuff; do not pull pilot balloon away from inflation tube
- remove ETT while applying positive pressure on bag
- apply positive pressure and 100% with FM immediately following extubation
73
causes of ventilatory compromise during tracheal extubation
- residual anesthetic
- poor central respiratory effort
- decreased respiratory drive in response to CO2 or O2
- reduced tone of upper airway musculature
- reduced gag and swallow reflex
- surgical airway edema/compromise
- vocal cord paralysis
- subglottic edema
- laryngospasm
- bronchospasm
74
acute complications after extubation
- laryngospasm
- vomiting
- aspiration
- sore throat
- hoarseness
- laryngeal edema
- subglottic edema
75
chronic complications after extubation
- mucosal ulceration
- tracheitis
- tracheal stenosis
- vocal cord paralysis
- arytenoid cartilage dislocation (leads to flaccid cords and airway edema)
76
nasal intubation indication
- maxillofacial or mandibular surgery
- oral/dental surgery
- anything that requires ETT out of surgical site
77
nasal intubation contraindications
- coagulopathy
- basilar skull fracture
- severe intranasal disorder
- CSF leak
- extensive facial fractures
78
equipment needed for nasal intubation
- laryngoscope handle x2
- laryngoscope blade x2
- magill forceps
- oral airways
- nasal airways (3 graduated sizes to dilate nares)
- neosynephrine spray
- water soluble lubricant
- nasal tubes x2
- tape
- suction
- stethoscope
- backup airway plan
79
complications of nasal intubation
- epistaxis
- tracheal or esophageal trauma
- displaced adenoids or polyps, resulting in bleeding and airway obstruction
- bacteremia
- sinusitis
