Airway Management Flashcards
Extrinsic Factors that affect Ventilation
Trauma or Foreign Body Airway Obstruction
Intrinsic Factor that affects Ventilation
Tongue is most common. Allergic Reaction, Infection, Unresponsiveness.
Early Signs of Hypoxia:
Restlessness, Irritability, Tachycardia, Anxiety
Late Signs of Hypoxia
AMS, Cyanosis, Weak PUlse
Approx Time for amount of Brain Damage recieved
0-1 Min: Cardiac Irritability
0-4 Min: Brain Damage not likely
4-6 Min: Brain Damage is possible
6-10 Min: Brain Damage Very Likely
More than 10 Mins: Irreversible Brain Damage
How much estimated blood in chest cavity w/flail chest (2+ ribs broken in 2 or more places)
500mL
Average ET tube sizes
Female: 7, 7.5, 8
Male: 7.5, 8, 8.5
Carbon Dioxide production exceeds elimination
Hypoventilation
CO2 elimination exceeds production
Hyperventilation
Factors Affecting Oxygentation & Respiration In Ambient Air
Ambient Air - High Altitude (Partial pressure decreases)
- Closed Environment (oxygen deceases)
Toxic gases displace O2 in the environment.
Factors Affecting Oxygentation & Respiration
(Internal Factors)
Conditions that reduce surface area for gas exchange also decrease oxygen supply.
Nonfunctional alveoli inhibit diffusion
Fluid in the alveoli inhibits gas exchange.
Submersion Victims
Pulmonary Edema
Exposure to environ. Conditions or occupational hazards
Factors Affecting Oxygentation & Respiration - Hypoglycemia
●Oxygen and glucose levels decrease
Factors Affecting Oxygentation & Respiration - Infection
●Increases metabolic needs
●Disrupts homeostasis
Factors Affecting Oxygentation & Respiration - Hormonal Imbalances
May result in ketoacidosis
Factors Affecting Oxygentation & Respiration - Circulatory Comprimise
●Inadequate perfusion
●Oxygen demands will not be met.
●Obstruction of blood flow is typically related to trauma.
●Inhibits gas exchange at the tissue level
Acid Base Balance: Can be disrupted by:
●Hypoventilation
●Hyperventilation
●Hypoxia
Acid Base Balance: Respiratory and renal systems help maintain homeostasis.
●Tendency toward stability in the body
●Requires balance between acids and bases
●Acid in the body can be expelled as carbon dioxide from the lungs.
●Acidosis can develop if respiratory function is inhibited.
●Alkalosis can develop if the respiratory rate is too high.
●Respiratory acidosis/alkalosis
●Metabolic acidosis/alkalosis
Hope much blood could be expected in chest with a flail chest?
500mL
What can lower ICP? How?
Hyperventilation. Constricting veins, decreasing pressure in skull.
In a normal adult w/normal RR? How many liters of O2 are they inhaling? What’s the formulary to determine this?
How do you recognize Adequate Breathing?
Responsive/Alert/Able to Speak
RR: 12-20
Depth
Pattern - Regular? Irregular?
Breath Sounds
Inadequate Breathing:
Fewer than 12 BPM, More than 20BPM
Cyanosis: Indicator of low O2 content
Preferential Positioning:
Upright Sniffing
Tripod Position
Potential Causes of Inadequate Breathing:
●Severe infection
●Trauma
●Brainstem injury
●Noxious or oxygen-poor environment
●Renal failure
●Upper and/or lower airway obstruction
●Respiratory muscle impairment
●Central nervous system impairment
●Airway management steps:
Open the airway.
●Clear the airway.
●Assess breathing.
●Provide appropriate intervention(s).
Evaluation of Inadequate Breathing includes:
●Visual observation
●Auscultation
●Palpation
Structures of the upper airway
Nose. Nasal cavity. Sinuses, tongue, pharynx, and larynx
Structures of the lower airway
Trachea, bronchi, bronchioles, alveoli
What separates the upper and lower airway
Glottis
Ventilation
Physical act of moving air in and out of
Oxygenation
Process of o2 loading onto hemoglobin
Respiration
Exchange of o2 and co2
Internal- cellular
External- pulmonary
Inhalation
Active part of ventilation
Exhalation
Passive part of ventilation
V/Q mismatch
Failure to match ventilation and perfusion
Decreased ventilation= decreased oxygenation. Lack of o2 causes you to retain co2
Positions to Note Inadequate Breathing
●Orthopnea
●Chest rise/fall
●Skin
●Flared nostrils
●Pursed lips
●Retractions
●Use of accessory muscles
●Asymmetric chest wall movement
●Quick breaths, long exhalation
●Labored breathing
Hypoventilation
decrease in RR rate resulting in decreased ventilation, body inability to eliminate CO2
Hyperventilation
Increased RR leads to CO2 elimination exceeds production
Circulatory compromise
caused by trauma (break in container), obstruction (clot), heart failure/cardiac tamponade (pump failure), anemia (decreased red blood cells, decreased o2 carrying capacity) hemorrhagic shock (decreased blood volume, poor tissue perfusion) vasodilator shock (vessels dilate, causes poor tissue perfusion)
Atelectasis
Non-Functioning Alveoli
Potential Causes: Submersion, Pulmonary Edema
Partial Pressure
of gas dissolved in blood
PaCO2
Partial Pressure of CO2 in blood
Things that cause circulatory comprimise:
Inadequate Perfusion
O2 demands not met
Obstruction of blood flow from trauma
Heart Conditions
Blood loss
PaO2
Partial Pressure of O2 in blood
Tidal Volume
Air moved in and out on the lungs in 1 breath. Average 500ml
Where do you hear wheezes?
“Wheezes in the Theezes”
Lower Bronchioles
Can be heard on Inspiration and Expiration
Inspiratory Reserve Volume
Additional amount of air that can be inhaled after normal tidal volume. Average 3000ml
Where do you hear Rhonchi?
“Rhonchi in the Bronchi”
Upper chest, each side of sternum
Caused by Mucous
Expiratory Reserve Volume
Amount of air that remains in lungs after maximal exhalation, prevents alveolar collapse, happens when a person “gets the wind knocked out of them.” Average 1200ml
Vital Capacity
amount of air moved in and out of the lungs with maximum inspiration and expiration
Where do you hear crackles?
“Crackles in the backles”
Heard in the back
CHF, Fluid, Pulmonary Edema
Lowered Respiratory Rates causes…
Reduced tidal volume, leading to decreased in alveolar volume and overall minute volume.
Stridor
Brassy, crowing, high pitch
Upper Airway
Heard on Inspiration
Signs of Inadequate Breathing
Fewer than 12, greater than 20BPM
Irregular Rhythm
Diminished, absent, or noisy sounds
●Flared nostrils
●Pursed lips/Staccato speech
●Retractions
●Use of accessory muscles
●Asymmetric chest wall movement
●Quick breaths, long exhalation
●Labored Breathing/Dyspnea/Shallow
How to assess Cheyene-Stokes breathing
Feel for air movement
Observe chest for symmetry
Note any paradoxical motion
Assess for pulses paradoxus (Systolic BP drops more than 10mmhg during inhalation.
Normal Inspiration/Expiration Ratio: 1:2
Expiration is prolonged with lower airway obstruction.
Expiration is short with tachypneic patients.
FiO2
Fraction intake of O2 on a vent. (Room air 0.21%, NC 0.44%)
If you have a pt on 100% O2, your FiO2 is 1%
Positive-Pressure Ventilations
Forced air into the lungs
Negative-pressure ventilations
Uses subatomspheric (outside) pressure to the chest wall during inhalation, normal ventilation.
(Uses internal and external pressures to trigger breathing, causing the pressures to change inside and outside of the lungs)
Respiratory alkalosis
Caused by hyperventilation, blow off too much CO2 than the body produces
What are reasons a pulse ox would read inaccurately
Bright lights
Pt movement
Poor perfusion
Nail Polish
Venous Pulsations
Abnormal Hemoglobin (Carbon Monoxide)
Respiratory Acidosis
Caused by Hypoventilation, any reduced tidal volume, unable to blow off CO2
Signs of Adequate Ventilation
Normal rate, depth, and pattern of inhalation and exhalation
Normal RR for age groups
Adult: 12-20
Child: 12-37
Infant:30-53
3-5yo - 22-34
Biot Respirations
Irregular pattern, rate, and depth, w/ periods of apnea
Apneustic Respirations
Prolonged gasping inhalation, w/ short exhalations
Tracheal Breath sounds
Bronchial breath sounds heard over the trachea
Vesicular breath sounds
Normal sounds you hear when you assess breathing, soft muffled sounds
TREAT YOUR PT…
NOT YOUR MONITOR
Peak Expiratory Flow Measurement
Measured to evaluate bronchoconstriction.
Take 3 readings and take best rate: Norm is 350ml-750ml
Varies based on sex, height, & age.
Increasing shows improvement, decreasing shows pt condition is deteriorating.
Arterial Blood Gas Analysis - Measures acid/base status.
PH/HCO3 (bicarbonate) - Acid/base balance.
PaCO2 indicates effectiveness of ventilation.
PaO2 & Sa O2 indicate oxygenation.
End-Tidal CO2 Assessment - ETCO2 detects carbon dioxide in exhaled air (35-45mm hg)
Indicates: Adequacy of perfusion
(increased reading shows inadequate ventilations)
(low reading shows hyperventilations)
Effectiveness of chest compressions - Perfusion to resume CO2 production and increase CO2
ROSC - low reading and suddenly regulates
Low ETCO2 despite adequate chest compressions indicates severe acidosis, minimal CO2 return to lungs
Key features of normal capnographic waveform
●Contour
●Baseline level
●Rate and rise of the carbon dioxide level
Normal capnographic waveform phases
●Phase I (A-B): Initial stage of exhalation
●Phase II (B-C): Expiratory upslope
●Phase III (C-D): Expiratory or alveolar plateau
●Phase IV (D-E): Inspiratory downstroke
Waveform Duration (width) on capnography
Duration of Ventilation
Space between waveforms on capnography
Respiratory Rate
Capnography - Tall waveforms & high ETCO2 value
Hypoventilation
Capnography - Small waveforms and low ETCO2
Hyperventilations
How do you position an unconscious pt w/adequate respirations?
In Left Lateral Recumbment -
to prevent tongue from blocking airway, secretions to accumulate in mouth, or aspiration
Contraindications for Jaw Thrust Manuever
Resistance to opening the mouth
Disadvantages of Jaw Thrust Manuever
Cannot maintain if pt becomes responsive
Difficult to maintain for an extended time, thumb must remain in place
Requires 2nd rescuer
Difficult to use w/BVM
No protection against aspiration
Next priority after opening the airway
Suctioning
Removes material from the mouth or throat quickly and efficiently
Ventilating w/secretions in mouth will force material into the lungs.
What can cause Pulses Paradoxus?
Drop in 10mm Hg on inhalation
Tension Pneumothorax -
Diminished breath sounds, JVD, decrease in BP, tracheal deviation
Cardiac Tamponade -
Protective Respiratory Reflexes
Coughing
Sneezing
Gagging
Sighing
Hiccuping
Where to check breath sounds?
Start in L axillary
●Pitch: Higher or lower than normal (stridor or wheezing)
●Intensity of sound depends on:
●Airflow rate
●Constancy of flow throughout inspiration
●Patient position
●Site selected for auscultation
What is the average Peak Expiratory Flow Measurement
550mL
If capnography number is high? What does it mean and what do you do?
Respiratory Acidosis, retaining CO2, increase ventilation rate
Low ETCO2 reading indicates what? What does you do?
Alkalosis, Hyperventilation - Slow ventilations
Colorimetric - What would cause purple?
Yellow (Yes)
Tan (Think about it)
Purple (Pull)
D - Dislodgment
O - Obstruction (Pericardial Tamponade, Tension Pneumonia, blood, Mucous)
P - Pneumothorax
E - Equipment Failure
Shark Fin Waves on Capnography
Air trapped in lungs (asthma)
Why Left Lateral Recumbent Position?
To prevent pressure on Vena Cava.
To prevent tongue from blocking airway.
To prevent aspirating emesis.
What’s the problem with an OPA that is an improper size?
Could push pt’s tongue back into pharynx, creating an obstruction.
Rough airway insertion can injure the hard palate, result in oral bleeding & create risk of vomiting & aspiration.
Contraindications for NPA
Face or Skull Fx
S/S:
Raccoon eyes
CSF from nose
●Foreign body
●Typical victim:
Middle-aged or older, dentures, alcohol
●Signs may include:
●Choking
●Gagging
●Stridor
●Dyspnea
●Aphonia (can’t speak)
dysphonia (difficulty speaking)
Laryngeal Injury
●Fracture of the larynx increases airway resistance by decreasing airway size.
●Penetrating and crush injuries to the larynx can compromise the airway.
Laryngeal Spasm
●Laryngeal spasm
●Spasmodic closure of vocal cords
●Completely occludes airway
●Causes include:
●Intubation trauma
●Extubation
Laryngeal edema
●Glottic opening narrows or totally closes
●Causes include:
●Epiglottitis
●Anaphylaxis
●Inhalation injury
●Laryngeal edema
●May be relieved by:
●Aggressive ventilation
●Forceful upward jaw pull
●May be relieved by muscle relaxants
●May recur; transport patient to hospital for evaluation
Sign of mild upper airway obstructive:
Cough
Encourage pt to continue coughing
●Patient is responsive, able to exchange air.
●Usually has noisy respirations and coughing
●Should be left alone
●Closely monitor the patient’s condition.
●Be prepared to intervene.
Sign of severe upper airway obstructive
●Inability to breathe, talk, or cough
●May grasp at throat, turn cyanotic, make frantic movements
●Cough is weak, ineffective, or absent.
●Marked respiratory distress
●Weak inspiratory stridor and cyanosis
How much O2 is delivered through a nasal cannula? What are contraindications for NC?
●Apnea
●Poor respiratory effort
●Severe hypoxia
●Mouth breathing
Partial Rebreathing Mask
●Lacks one-way valve
●Flow rates of 6 to 10 L/min
●35% to 60% oxygen
Venturi Mask
●Draws room air into the mask along with oxygen
●Can deliver 24%, 28%, 35%, or 40% oxygen
Used for Chronic Respiratory Problems
How often are O2 tanks supposed to be inspected?
Hydrostatically tested every 5 years.
To ensure it can still sustain the high pressure required.
Laryngeal Spasm
Spasmodic closure of the vocal cords, completely occluding airway.
Often cause by trauma from aggressive intubation techniques
Nonrebreathing Mask
●Preferred in prehospital setting
●90% to 100% oxygen
●Mask, reservoir bag
●Indications
●Spontaneously breathing patients
●Contraindications
●Apnea and poor respiratory effort
Tracheostomy Masks
●Cover stoma
●Strap goes around neck
●May not be available in emergency settings
●Improvise with face mask
Laryngeal Edema
Causes the glottic opening to become extremely narrow or totally closed.
Commonly caused by epiglotitis, anaphylaxis, or inhalation injury.
Can be relieved by aggressive ventilations that push past the narrowed airway.
D tank - Contains 350LPM
TANK PRESSURE - SAFE RESIDUAL PRESSURE X’S FLOW RATE PER MIN = DURATION OF FLOW PER MINUTE
(2,000-200) x 0.16=288
288/4=72
Contraindications to CPAP (pg 1)
●Unable to follow verbal commands
●Respiratory arrest or agonal respirations
●Unable to speak
●Hypoventilation
●Hypotension
●Pneumothorax or chest trauma
●Closed head injury
How to measure for OG tube?
Figure out ET size then multiply times 2
One of the most common mistakes with respiratory or cardiac arrest is:
To perform advanced interventions prior to basic interventions.
mnemonic used to predict a difficult airway
L - Look Externally - Short/Thick necks, obesity, dental issues
E - Evaluate - (3-3-2) mouth 3, chin/hyoid 3, hyoid/thyroid 2
M - Mallampati Classification - Pt sitting upright, visualize oropharyngeal structures
O - Obstruction - Foreign Body, obesity, masses, hematoma
N - Neck Mobility’s - Sniffing position, trauma pts, elderly
Primary Reason for Advanced Airway
To Maintain patent airway
To adequately oxygenate and ventilate
Reasons for possible difficult airway:
Anatomic:
●Congenital abnormalities
●Recent surgery
●Trauma
●Infection
●Neoplastic diseases
Externally:
●Short, thick necks
●Morbid obesity
●Dental conditions
CPAP does what
Increase pressure in lungs
Opens collapsed alveoli
Pushes O2 across alveolar membrane
Forces interstitial fluid back into circulation
CPAP contraindications (pg 2)
●Facial trauma
●Cardiogenic shock
●Tracheostomy
●GI bleeding, nausea, or vomiting
●Recent GI surgery
●Unable to sit up
●Unable to fit CPAP system
●Cannot tolerate mask
Complications of CPAP
●Patients may feel claustrophobic and resist.
●High volume of pressure can cause a pneumothorax.
●Increased pressure in the chest cavity can result in hypotension.
●Air may enter the stomach.
Gastric Distention is likely to occur when:
●Excessive pressure is used to inflate the lungs
●Ventilations are performed too fast or too forcefully
●Airway is partially obstructed during ventilation attempts
Why is Gastric Distention harmful?
●Promotes regurgitation, can lead to aspiration
●Pushes diaphragm up, limits lung expansion
●Signs include:
●Increased diameter
●Distended abdomen
●Increased resistance to bag-mask ventilations
How do you determine size of ET tube to use?
Total Laryngectomy
Breathes through stoma, cannot ventilate mouth/nose
There is no longer a connection between the UA and LA
Partial Laryngectomy
Can breathe through mouth/nose/stomach
Endotracheal Intubation -
ET tube passes through glottic opening and is sealed with a cuff inflated against the tracheal wall.
Endotracheal Intubation
Advantages/Disadvantages
●Advantages:
●Secure airway
●Protection against aspiration
●Disadvantages:
●Special equipment
●Physiologic functions bypassed
Endotracheal Intubation Complications
●Bleeding
●Hypoxia
●Laryngeal swelling
●Laryngospasm
●Vocal cord damage
●Mucosal necrosis
●Barotrauma
ET Tubes sizes
●2.0 to 10.0 mm in inside diameter
●12 to 32 cm in length
●5.0 to 10.0 mm equipped with distal cuff
0-Preemie
1-Infantry
2-Toddlers
3-4 - Adult sizes
Endotracheal Intubation Contraindications
●Intact gag reflex
●Inability to open mouth because of trauma, dislocation of the jaw, or a pathologic condition
●Inability to see the glottic opening
●Copious secretions, vomitus, or blood in airway
Preoxygentaion
●Critical before intubating
●2–3 minutes for apneic or hypoventilating patient
●Prevents hypoxia from occurring
●Monitor SpO2 and achieve as close to 100% saturation as possible.
●Visualization of glottic opening
●Place tip of curved blade in vallecular space.
●Position straight blade directly under epiglottis.
●Gently lift until glottic opening is in full view.
After you have seen the ET tube cuff pass roughly 0.5 to 0.75 inch beyond the vocal cords:
Gently remove the blade.
●Secure tube with right hand.
●Remove stylet from tube.
●Inflate the distal cuff with 5 to 10 mL of air, and then detach the syringe from the inflation port.
●Note depth of tube at teeth to determine possibility of migration.
●Have your assistant attach the bag-mask device to the ET tube and continue ventilation.
How to determine proper placement of ET tube:
- Visualize tube going through vocal cords.
- No epigastric noises.
- B chest rise & fall.
- BBS equal.
- Mist in Tube
- Colorimetric 5-7 breaths to change colors
- 35-45 Capnography
- HR returning to normal
- O2 SAT improving
- Skin returning to normal
- EDD ball
Steps for securing the ET tube
●Note the centimeter marking on the ET tube.
●Remove the ventilation device.
●Position the tube in the center of the mouth.
●Place the securing device over the tube.
●Reattach the ventilation device, auscultate, and note the capnography reading and waveform.
