Airway Management Flashcards
Indications for OPA
Unconscious pt
Support base of tongue
Bite block
Facilitate oral sx
Facilitate bag/mask ventilation
Indications for NPA
Conscious pt
Support base of tongue
Facilitate/decrease trauma in NT sx
Pierre robin syndrome
Following ENT surgery
How should the NPS respond if a child with an OPA begins to gag?
Remove, airway, suction, give oxygen
How should the specialist prevent mucosal trauma while inserting NPA?
Water-soluble lube
How to determine correct size in OPA
Angle of jaw to corner of mouth
How to determine correct size of NPA
Earlobe to tip of nostril
Describe technique of inserting OPA
Insert upside down to back of throat then rotate to correct position
Why are uncuffed tubes typically used in infants and children under 8 y/o?
Narrowest part of aw is the cricoid cartilage in infants, tube secures itself
5 indications for intubation
Maintain patent aw
Access for sx
Provide mechanical ventilation
Protect airway
Administer meds
How to pre-oxygenate neonates prior to intubation
Adjust FiO2 to maintain target SPO2
How to pre-oxygenate peds prior to intubation
100% for 5 minutes
Recommend medications for intubation
Sedatives: -lam, -pam
Neuromuscular blockade: succs, vec
Patient placement during intubation
Supine in sniffing position
Avoid _______ in positioning the head of neonates and infants during intubation
Hyper-extension
Miller blade is preferred in what population?
Neonates
What is indicated if the vocal cords are not easily visualized?
Cricoid pressure (sellick meneuver)
Uncuffed tube placement procedure
Vocal cord guide at level of vocal cords, halfway between vocal cords and carina (Middle third of trachea)
Cuffed tube placement procedure
Below vocal cords, 1-2cm above carina (middle third of trachea)
Used to guide nasal intubation
Magill forceps
How to confirm tube placement
Look, listen, capnograph/CO2 detector
Best: CXR
How often should cuff pressure be measured
Every 8 hrs
Methods for measuring cuff pressure
3-way stopcock, pressure manometer, cufflator
Cuff pressure should not exceed
20 cmH20
If the cuff pressure exceeds 20cmH20, the NPS should consider
A bigger tube
Describe MLT
Slight leak during peak inspiration
When should the ETT be replaced?
Unable to pass sx catheter
Cuff pressure >20
In uncuffed: ventilating pressure exceeds 20cmH20 without an air leak
Unable to add air to cuff
Items required for intubation
Blade
Correct size tube and one smaller
Laryngoscope
Bag
What should the NPS do if the laryngoscope light doesn’t work?
Tighten bulb
Switch blade
Check batteries
3 laryngoscope visualization devices
Flexible fiberoptic laryngoscope
Lighted stylets
Video laryngoscope
Tube size/laryngoscope size:
<1000g <28wk GA
2.5/miller 00
Tube size/laryngoscope size:
1000-2000g 28-34wk GA
3.0/miller 0
Tube size/laryngoscope size:
2000-3000g 34-38wk GA
3.5/miller 0
Tube size/laryngoscope size:
>3000g >38wk GA
3.5-4.0/miller 1
Insert ETT to (cm):
23-24wks 500-600g
5.5
Insert ETT to (cm):
25-26wks 700-800g
6.0
Insert ETT to (cm):
27-29wks 900-1000g
6.5
Insert ETT to (cm):
30-32wks 1100-1400g
7.0
Insert ETT to (cm):
33-34wks 1500-1800g
7.5
Insert ETT to (cm):
35-37wks 1900-2400g
8.0
Insert ETT to (cm):
38-40wks 2500-3100g
8.5
Insert ETT to (cm):
41-43wks 3200-4200g
9.0
What types of tubes are typically used in children<= 8y/o
Uncuffed
What types of cuffs should pediatric pts have?
Low pressure, high volume floppy cuffs
Cuff pressure should not exceed
20cmH20
Laryngoscope blade, ETT size, and sx catheter size:
6mos
Miller 1, 3.5, 8Fr
Laryngoscope blade, ETT size, and sx catheter size:
1yr
Miller 1, 4.0, 8Fr
Laryngoscope blade, ETT size, and sx catheter size:
2yr
Miller 2, 4.5, 10Fr
Laryngoscope blade, ETT size, and sx catheter size:
4yr
Miller 2, 5.0, 10Fr
Laryngoscope blade, ETT size, and sx catheter size:
6yr
Miller 2, 5.5, 10Fr
Laryngoscope blade, ETT size, and sx catheter size:
8yr
Miller 2/mac 2, 6.0, 10Fr
Laryngoscope blade, ETT size, and sx catheter size:
10 yr
Miller 3/mac 3, 6.5, 12 Fr
Laryngoscope blade, ETT size, and sx catheter size:
12 yr
Miller 3/mac 3, 7.0, 12 Fr
Laryngoscope blade, ETT size, and sx catheter size:
>12yr
Miller/mac 3, 7.0-8.5, 12 Fr
Formula to calculate tube size
(Age + 16) / 4
Formula to calculate tube length/insertion depth
Tube size x 3
If ETT is too small:
Increased airway resistance
Poor seal for ventilation, large leak
If ETT is too large:
Decreased perfusion to airway wall
Necrosis/stenosis
No air leak heard at high ventilating pressures (>30cmH20)
Vocal cord damage
3 objectives for tube maintenance
Adequate humidity
Suction to maintain patent aw
Use MLT
Sudden deterioration of intubated child could be from
Displacement
Obstruction
Pneumothorax
Equipment failure
Indications for LMA
Short term ventilation
Difficult aw
Aw management prior to hospitalization
Where in the pharynx should the LMA be placed
Above epiglottis
How should the NPS place the ETT when an LMA is present?
Through LMA lumen
What conditions indicate that the patient is ready for extubation
Stable ventilation and oxygenation
Hemodynamically stable
Adequate SBT
Minimal vent settings
Able to protect airway
Positive leak
At what point in the respiratory cycle should the ETT be removed
On inspiration
What to do if severe respiratory distress and/or marked inspiratory strider occurs post-extubation?
Reintubate
What to do if moderate distress/stridor occurs post-extubation
Give oxygen
Cool mist aerosol/racemic
Steroids/heliox
What to do if mild distress/stridor occurs post-extubation
Provide humidity/oxygen as necessary
Strategies to prevent VAP
Handwashing
Oral care
HOB 30-45 degrees
Minimize intubation time (daily SBT/NIV)
Gentle suctioning
Vent circuit care (in-line sx, drain, etc)
MDI
Hi-lo
3 indications for tracheotomy
Long-term intubation
Upper airway obstruction prevents intubation
Ongoing need for pulmonary hygiene
5 advantages of tracheostomy
Easier to stabilize, suction, tolerate
Pt can eat
Pt can talk
Provides for long-term ventilation
Fewer hazards/less airway resistance than ETT
Immediate complications of trach
Bleeding
Pneumo
Air embolism
SubQ
Inadvertent decan
Later complications of trach
Infection
Hemorrhage
Obstruction
TE Fistula
Accidental decan
Advantage of fenestrated trach
Weaning, speaking
When should a tracheal button be recommended?
Maintain stoma
When should a trach tube be changed out?
1 week post op
Every 1-2 weeks
When the trach tube cuff should be inflated
During eating
On PPV
Low Vte alarm
Factors increasing risk of unplanned extubation/decan
Improperly secured
Misplaced ETT
Lack of adequate sedation
Lack of restraints
Procedures
Equipment readily available for re-insertion of tube
Manual bag/mask
Oxygen
Sx
Laryngoscope
Replacement tube (same size and one smaller)
Conditions that may increase the difficulty of endotracheal intubation
Craniofacial syndromes
Orofacial trauma
Airway infections (epiglottitis)
LT stenosis/obstruction
3 methods to managing difficult airway
LMA
Flexible fiberoptic intubation
Laryngoscope visualization devicesh
How many attempts allowed for intubation?
3
ETT insertion procedures requiring physician
Retrograde intubation
Cricothyrotomy
Emergency trach
3 purposes of suctioning
Maintain patent aw
Stimulate cough
Specimen collection
Four indications for suctioning
Accumulated secretions
Obstructed airway
Depressed cough
Inability to swallow
Mos common hazard of suctioning
Trauma to mucosa
Most severe hazard of suctioning
Bradycardia
When is the catheter advanced during NT suctioning?
During inspiration
When suctioning mouth and nose, which comes first?
Mouth
What FiO2 should be used when suctioning neonates? Peds?
Increase by 10-20%
100% for 1-2 minutes
Vacuum pressure range for neo and peds
60-80mmHg
80-100mmHg
Vacuum pressure should be measure with tubing ____
Occluded
What happens to the vacuums pressure when the suction collection bottle is full?
Shuts off
Formula to determine catheter size
(ID of tube/2) x 3
How many openings should there be on standard suction catheter?
2
Purpose of the coude catheter
Angled to help suction left mainstem
Indications for closed/in-line catheters
High oxygen/PEEP
Infection
Frequent suctioning
Reduce VAP
Hemodynamic instability
Time limit for sx catheter in aw
10 sec
Time limit for sx applied
5 sec
Purpose of bulb suction device
Safest way to clear oropharynx
Purpose of oral suction device
Suction mouth and throat
Vacuum pressure for meconium aspirtator
80-100
