Airway Management Flashcards
What are the different ways to manage a pts airway?
Airway clearance/maintenance Recovery position Head tilt, chin lift Oropharyngeal airway (guedel) Nasopharyngeal airway Laryngeal mask airway Oral endotracheal tube Tracheostomy
Descriptions of sounds for each of these obstructions:
Gurgling, snoring, crowing, inspiratory strider, expiratory wheeze
Gurgling = liquid in mouth/upper airways
Snoring = pharynx is partially obstructed
Crowing = laryngeal spasm
Inspiratory stridor = obstruction above/at level of larynx
Expiratory wheeze = airways collapse during expiration
What are the different techniques for airway clearance?
Coughing Nebulisers Suction Humidification Position (upright unless unconscious) Physio Cough assist devices
What are the indications for oral intubation?
Hypoventilation PaO2 8 kPa (severe type 1 + 2 respiratory failure) GCS <8 (head injury) Trauma Surgery Airway protection Drug overdose
Considerations for intubation
Is there and ICU bed available
Purpose of intubation
Underlying condition = is this reversible?
What are the nursing considerations for intubation?
Equipment Drugs Pt preparation Procedure How will pt be ventilated post intubation? Obs Documentation
What does the respiratory tract consist of?
Nose and mouth Pharynx Epiglottis Larynx and vocal cords Trachea Car is and bronchi
What is the functions of the nose and mouth for airway management?
Intake of air
Warming and humidification of air
Filtering and expulsion of matter (sneezing)
What is the function of the pharynx for airway management?
Cavity at the back of the nose and mouth (oro/naso pharynx)
What is the function of the epiglottis in airway management?
A leaf shaped structure
Closure protects airway during swallowing
Role of the larynx and vocal cords in airway management?
Positioned above the trachea, housing the vocal cords
Air must move across the cords to allow vibrations and enable phonation
What is the structure of the trachea?
Cartilagenous tube, extending from larynx to 5th thoracic vertebra
Structure = a series of horizontal incomplete rings of hyaline cartilage
Open portion of rings face oesphagus allows for slight expansion during swallowing
Tracheal walls = mucosa, submucosa, cartilagenous layer and adventitia
Role of the carina and bronchi in airway management
Carina (base of the bifurcation) = highly sensitive and initiates cough (easily damaged)
Right bronchi = more anterior and wider so it’s easier to inadvertently pass a tracheal tube into it
What is dead space?
The volume of gas in each breath that doesn’t take part in alveolar gas exchange (150 mls / 30% of each breath)
What is tidal volume?
The volume of gas breathed in or out in a normal breath (7-10 mls/kg)
What is alveolar ventilation rate?
AVR is respiratory minute volume (MV) - dead space (MV - DS = AVR)
MV = TV x RR
Why are pts vulnerable to obstruction and aspiration?
Unconscious pts = tongue falls to the back of the pharynx obstructing the flow of gas down the trachea
Proximity of the oesphagus to the airway = loss of Gloria closure leading to and increased chance of aspiration
Who is vulnerable to obstruction and aspiration?
Unconscious pts = sedated, head injury, drugs, hypothermia
Loss of swallow, cough, gag reflexes, stroke pts
Mechanical injury or obstruction = trauma, tumours, foreign body
What equipment is needed for intubation?
Laryngoscope (in working order) Styler or an introducer Endotracheal tubes (ETT) (right size cut to length, check ballon inflates) Working suction Cardiac monitor Pulse oximeter End tidal CO2 detector
What drugs are needed for intubation?
In an arrest, drugs are not needed
Sedation/induction agent (ketamine, sodium thiopental, etomidate, propofol) - check BP
Muscle relaxant/paralysing agent (rocuronium, pancuronium, vecuronium, atracurium)
Atropine and other emergency drugs
Reversal agents (neostigmine, sugammadex)
How do you prepare a pt for intubation?
Position on back
Suction on
Pre-oxygenate using bag valve mask
What is the procedure for intubation?
- Open airway
- Laryngoscope in L hand
- ETT tube in R hand
- View vocal cords
- Slide ETT tube into airway along blade of laryngoscope until black line level with vocal cords
- Inflate balloon and attach catheter mount and waters 2L rebreathing bag
- Check tube positioning in lungs
When is cricoid pressure used?
Pressure applied during intubation of a or where nil by mouth can’t be ascertained or where gastric reflux is likely
What is the procedure for applying cricoid pressure?
The pressure applied must generate an occlusive pressure inexcess of oesophageal or gastric pressure
Correct amount of pressure = 20-30 newtons/2-3 kg
Application requires a dedicated rescuer who must maintain the pressure until the airway is secured by endotracheal intubation
What are the indications for a or requiring a tracheostomy?
Pts requires long term ventilation (>5 days or complex weaning form ventilation)
Unable to protect own airway (stroke, head injury, loss of gag, loss of swallow, loss of cough reflexes)
Obstruction (tumours, surgical oedema, trauma)
What are different types of tracheostomy?
Surgical (surgical opening with internal suturing, lower down the trachea)
Percutaneous (bedside procedure using dilational technique, just below the cricoid cartilage - between 1st+2nd or 2nd+3rd tracheal rings)
What are the key details for a or with a tracheostomy?
It reduces dead space and work of breathing
Facilitates airway clearance through suction
Requires humidification
Finest rated tubes allow speech
Reuse of aspiration
What are the different types of humidification?
Cold water humidifiers (50% relative humidity)
Hot water humidifiers (100% relative humidity)
Condensers (heat moisture exchange)
Aerosol generators (nebulisers)
What are the different types of suction?
Oropharyngeal - yankeur
Tracheal
What are the important things to remember when undertaking tracheostomy care ?
Suction pressure = 120 mmHg
Max 3 catheter passes
Catheter extraction = suction upto 10 secs, allow 20-39 secs between passes
Catheter size = no more than 1/2 the inner diameter of internal tracheal tube
Pre measure distance needed for insertion (aim 0.5 - 1cm past the distal end of the tube)
What is the benefit of positive pressure ventilation?
Invasive or non invasive
Ability to manipulate ventilation to improve blood gases and reverse acidosis
Can increase tidal volume to blow off CO2
Can control RR
Can apply mode of ventilation that allow pt to do some breathing
Complications for pts on supportive ventilation
Need to protect pts airway (risk of tube blockage)
Invasive ventilation increases risk of chest infection (ventilator acquired pneumonia)
Prescience of oral tube very uncomfortable
Risk of biting down on tube
Oral hygiene difficult
Large tidal volumes can cause barotrauma (pressure damage)
High O2 levels can cause inflammation (risk of ARDS)
