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Principles and Practices of Resp II > Airway Management > Flashcards

Airway Management Flashcards

1
Q

Enotracheal Tube made from

A

pliable polyvinyl chloride (PVC) inserted through the mouth or nose and into the trachea

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2
Q

Enotracheal Tube sizes

A

2.5-9mm (adult average 8mm I.D) Occluding 75% of airways, reducing resistance

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3
Q

Bronchoscopy sizes

A

5.5mm-6mm

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4
Q

ETT Parts

A
  1. 15mm adapter for ambu/ventilator
  2. Cuff
  3. Pilot Balloon
  4. Length markings in cm
  5. Tube markings include outside and inside diameter
  6. Beveled tip
  7. Murphys Eye
  8. Radiopaque line
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5
Q

Cuff

A

seals the trachea in order to apply positive pressure ventilation and protect against aspiration

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6
Q

Pilot balloon

A

used to monitor cuff pressure

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7
Q

Length/ inside diameter/ internal diameter measurements

A

Length- cm
outside diameter- in mm
Internal diameter- I.D

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8
Q

Beveled tip

A

angle of tip minimizes mucosal trauma

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9
Q

Murphys eye

A

used to ventilate in the event that the bevel tip becomes occluded

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10
Q

radiopaque line

A

used to identify positioning on xray

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11
Q

Who needs to be intubated

A

Airway
Ventilation
Oxygenation
pts- Epiglotitis, Neuro, Drug OD

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12
Q

Epiglotitis

A

is not an emergency- goes smoothly

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13
Q

Indications for Emergency intubation

A 
Persistent apnea
Traumatic Upper airway obstruction
obstructive angloedema- swelling
neonatal or pediatric disorders
cardiopulmonary arrest
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14
Q

Mallampati Score

A

Class 1: Soft palate, fauces, uvala, pillars seen (easiest intubation
Class 2: Soft palate, fauces, portion of uvula
Class 3: Soft palate, base of uvula
Class 4: hard palate only

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15
Q

RSI

A

Rapid Sequence intubation

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16
Q

Intubation- rsi- medications

A 
Sedative drugs
-Propofol
-Ketamine
-Etomidate
Paralytic drugs
-Succinylcholine- fast acting
-Rocuronium
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17
Q

Propfol

A

Sedative drug- white and fast acting

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18
Q

When do you sedate a pt?

A

Pt is agitated or cant manipulate the mandible

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19
Q

Paralytic drugs

A

no neurological assessment

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20
Q

Equipment for Endotracheal intubation

A 
-Oxygen flowmeter and oxygen delivery device
(nonrebreather or bag valve mask)
-Suction set up
-Sterile suction kit (inline)
-Yankauer (oral suction)
-Manual resusicitation bag and mask
-Oropharyngeal airways
-Laryngoscope with assorted blades
-Endotracheal tube (3 sizes)
-Tongue depressor
-Stylet
-Stethoscope
-Tape
-Bite block
-Syringe
-Lubricating jelly
-Magill forceps- nasal
-Local anesthetic spray
-towels
-CDC barrier precautions-PPE
-IV access for potential administration of sedation, analgesics, and paralytic drugs
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21
Q

Essential Intubation Equipment- absolutes

A

-O2 source and BVM(NC, Ambu, NRB)
-Working suction equipment with yankauer
-Laryngoscope- with stylet and surgilube
-ETT
Syringe (10-12cc-big enough to inflate cuff)

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22
Q

Sizes for ETT

A

adult 6.5, 7, 7.5, 8…. 8 is ideal

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23
Q

Can intubate with bronchoscope?

A

yes

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24
Q

Left side of bed

A

Scope/ tube

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25
Q

Right side of you

A

Yankauer

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26
Q

Stylet

A

wire that helps manipulate ETT, dont want it to be pertruding out of the end of ETT

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27
Q

Cricoid pressure

A

Use fingers and apply downward pressure on cricoid to bring anterior airway down

  • Close esophagus off so gastric cant leak into airway (oropharynx)
  • Bring Anterior airway into view
  • Wont push air into stomach
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28
Q

Laryngoscope blades

A

Miller and Macintosh

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29
Q

Miller blade

A

L
Straight blade
-directly lifts the epiglottis in order to visualize the vocal cords

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30
Q

Macintosh blade

A

C
Indirectly lifts epiglottis
-is inserted into the vallecula, which is the space between the epiglottis and the tongue

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31
Q

Laryngoscope Blade Sizes

A 
00- preemie
0- preemie
1- infant
2- child
3- adult
4- adult
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32
Q

ETT sizes

A

2.5-4.0 mm diameter (ID): infant
3.0-5.0mm: 6mo- 3 years
Tube should be same diameter as childs pinky
4.5-7.0mm: 5-12 years
6.5-9.0mm: 16- adult

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33
Q

Tube placement- oral intubation on average

A

Males: between 21-23cm
Females: between 19-21cm
Placement 3-5 cm above carina (done with CXR)

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34
Q

Tube placement importance

A

could be in rt mainstem, clarify right away

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35
Q

Oral intubation steps

A
  1. Assemble and check equipment
  2. Position the patient
  3. Pre-Oxygenate and hyperinflate
  4. Insert Laryngoscope
  5. visualize the glottis
  6. displace the epiglottis
  7. Insert the tube
  8. Assess the tube position
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36
Q

Steps to assemble and check equipment

A

Suction- yankauer
Oxygen- usually NRB and BVM (sometimes NC)
Laryngoscope- working condition-blade size
Inflate cuff- verify - deflate

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37
Q

Position the patient step

A

Sniffing position- towel to assist

-Under head or shoulders , whatever to get best view

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38
Q

Pre-oxygenate and hyperinflate step

A

bag and mask ventilation
Oral/ nasal airway
NRB mask

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39
Q

Insert laryngoscope steps

A
  • Right hand scissor technique to open mouth
  • Jaw must be pliable-easy to manipulate
  • Insert scope with left hand-always
  • Enter on right side of mouth
  • Move toward the center and sweep/displace tongue to the left
  • advance blade until epiglottis is visualized
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40
Q

Visual markers as the blade progresses against the tongue

A

Arytenoid cartilage

Epiglottis

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41
Q

Displace the epiglottis step

A

Depends on blade, pull the scope up and out, do not rock the blade back= leverage against teeth

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42
Q

Insert the tube step

A
  • right side
  • Advance without obscuring view of glottis
  • Advance until cuff passes through vocal cords
  • Stabalize with right hand and remove laryngoscope-note depth
  • Remove stylet
  • inflate cuff
  • Ventilate and oxygenate
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43
Q

Bedside Assessment for correct tube placement, right away

A
  • Listen over stomach-left side
  • Listen to bilateral breath sounds- bases first
  • Observe for bilateral chest rise (right main stem intubation isnt bilateral)
  • Colorimetry
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44
Q

Other bedside assessment for correct tube placement

A
  • End tidal CO2 detector- capnometry
  • Light wand-stylet
  • Fiberoptic laryngoscope/ bronchoscope (wont need cxr)
  • Esophageal detection device
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45
Q

After placement is confirmed…

A

secure ET tube to face with a commercial ETT holder or tabe

-then order chest xray

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46
Q

Colorimetry

A

picks up % of CO2
-norm= 5
35-45mmhg
as breaths given, yellow-> blue

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47
Q

Esophageal detection device

A

looks similar to bulb

  • squeeze bulb
  • attach to ET, let go
  • Trachea will reexpand bulb
  • esophagus wont change
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48
Q

ETAD- Hollister anchor fast

A 
not cheap
Minimum pressure points
-more room to sweat
- can move side to side
every 24 hours and retape
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49
Q

When prone using ETAD

A

switch to ET taping, stay away from lips= softer tissue

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50
Q

Tincture of benzoin

A

rub where tap goes, help with adhesion

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51
Q

Thomas tube holder

A

What we used during lab

  • Temporary hold
  • no access to mouth= poor oral care
  • has bite block built in
52
Q

Repositioning ETT

A

Moving side to side to protect lips/mouth from breakdown
-Skin assessment
-Subglottic suctioning- below glottis (vocal cords)
-prevent ventulation aquired pneumonia (VAE/VAP)
done before ext. and before side to side

53
Q

Securing the airway consideration

A
  • Tincture of benzoin
  • Clean and dry face
  • May need to shave patient
54
Q

CXR

A

tube at adequate depth

  • aortic arch
  • 4th rib
  • measure from carina
55
Q

Complications with oral intubation

A
  • Tissue trauma
  • Acute Hypoxemia, Hypercapnia, bradycardia
  • Cardiac arrest
  • Pt must be intubated within 30 sec, if unable resume bag and mask ventilation for 3-5 minutes in between attempts
56
Q

Difficult intubations occur because of

A
  • Inability to open the mouth
  • position of the patient
  • Unusual anatamy
57
Q

When transporting?

A

always have ambu near

58
Q

Nasotracheal intubation

A

-Performed blindly or direct visualization
-Lidocaine (2%) spray for numbing
-Racemic Epi (.25%) spray for vasoconstriction
-Insertion depth at nare:
28cm- hub (15mm adaptor) males
26cm- hub females

59
Q

Risk of what during nasotracheal intubation

A

sinitus, cannot use stylet

60
Q

Direct Nasotracheal intubation

A
  • Advance ETT through naris into pts oropharynx
  • Insert laryngoscope and visualize the glottis
  • grasp tube with magill forceps above the cuff and guide through the vocal cords
61
Q

Blind/ indirect Nasotracheal intubation

A
  • Supine or sitting up
  • Advance ETT through naris and toward larynx
  • Listen for air through the ETT and advance (darth vador)
  • Breath sounds should become louder
  • A harsh cough followed by vocal silence is characteristic when ET tube is placed into trachea
62
Q

Lidocaine

A

spray for numbing

63
Q

Racemic Epi

A

vasoconstriction

64
Q

Cuff

A

Large inflatable balloon near the distal tip of the endotracheal or tracheostomy tube

  • Most are low pressure high volume
  • Important to monitor to avoid trachea wall damage caused by compression of airway capillaries
  • Cuff pressure is measured and documented in cmH2O
65
Q

Cuff Pressure Acceptable range

A

20-30 cmH2O

66
Q

If cuff pressure is <20 cmH2O

A

You risk aspiration (add air to the cuff)

67
Q

If cuff pressure is > 30cmH2O

A

you risk tracheal wall damage

68
Q

1 mmHg=

A

1.3595 cmH2O

69
Q

1 cmH20=

A

0.7355388 mmHg

70
Q

NBRC- keep cuff pressure

A

< 25mmHg

71
Q

Little ppl dont need cuffs why

A

cricoid makes seal

72
Q

2 things matter choosing cuff pressure

A

size of airway and size of tube

73
Q

Cuff pressure manometer

A

Measures in cmH2O

  • risk: cuff can lose air / leak when pushed on
  • Read during inspiration/ avoid leaks/ aspiration
74
Q

Put in bigger tube if

A

above cmH2O and still leaking, but reality- inflate more

75
Q

MLT

A

minimal leak technique

76
Q

MOP

A

Minimum occluding pressure- also called minimal occluding volume (MOV)

77
Q

MLT and MOP both require

A

a syringe for manipulating cuff pressure and stehoscope- lateral neck

78
Q

Push air into cuff=

A

create volume, create minimal leak by checking during inspiration

79
Q

Micro aspiration

A

pt aspirating with no one being aware of it- pt not coughing

80
Q

Minimizing aspiration

A
  • Good oral care-subglottic suctioning
  • Elevate head of bed with tube feedings
  • Methylene blue dye test-in stomach-bad to see suctioned out
  • Keep cuff pressure adequate (20-30cmH2O)
  • Make sure you have appropriate size tube (ET/trach)
81
Q

VAP protocol- consistent care

A
  • Elevate head of bed between 30-45 degrees(check handrail)
  • Daily sedation vacation- take of every am or reduce
  • Daily assessment of readiness for extubation-challenge pt
  • Peptic ulcer disease prophylaxis- stomach issues
  • Deep vein thrombosis prophylaxis (thinners)
  • Oral care
82
Q

Dont pull tube if

A

Pt needs pressure
pt needs 100% fio2
below 40%-okay to wean

83
Q

During an intubation attempt, what two landmarks should you see as you advance the laryngoscope

A

Arytenoid Cartilage, Epiglottis

84
Q

What does the term intubation mean

A

Passing of a tube into a body aperture (vocal cords)

85
Q

Can a standard ET tube be used for a blind intubation? what does blind intubation mean?

A

Yes, indirect intubation means you dont see the tip of the tube as it goes through the epiglottis

86
Q

What size blades are used to intubate an adult patient

A

3 and 4

87
Q

What are the two different laryngoscope blades and how are they used to visualize the vocal cords

A

Miller- Directly lifts the epiglottis in order to visualize the vocal cords.
Macintosh- inserted into the vallecula, which is the space between the epiglottis and the tongue

88
Q

When is placing an artificial airway (intubation) contraindicated?

A

When pt is DNI

89
Q

what hand should you hold the laryngoscope with and why

A

left to visualize the scope chanel

90
Q

List the two reasons to establish an artificial airway

A

Patient cant protect their airway or theyre not able to ventilate/ oxygenate

91
Q

What is the normal ranch for cuff pressure? what are you trying to prevent

A

20-30 mmH2O, it minimizes aspiration risk and avoids cutting off the blood supply

92
Q

Whats the difference between Endotracheal intubation and nasotracheal intubation? what are teh differences in tube placement/ depth

A

One is through the mouth= 20-24

One through the nose= to hub

93
Q

Can you intubate with a LMA? (laryngeal mask airway)

A

No its above the gottis (not passing through aperture)

94
Q

How much time do you have when attempting to intubate a pt

A

30 seconds

95
Q

What type of intubation technique would use magill forceps

A

Direct Nasotracheal= visualizing cords

96
Q

What medication can be used to numb the nasal passages, oropharynx, and or larynx in order to assist in the comfort during conscious or semi-conscious intubation

A

lidocaine

97
Q

What initial FiO2 do we choose on the ventilator

A

whatever patient was on before, safe FiO2 60% or less (add pressure to improve oxygenation from there)

98
Q

Vt range (ml/kg)

A

6-8

99
Q

How do we provide humidity and heat to an intubated patient

A

HME- passive humidity

Heated wire circuit/ active humidity

100
Q

VAP protocol. what can we influence?

A

Keep head elevated 30-45% and perform subglottic suctioning

101
Q

IBW

A

50+2.3 (CM-60) = 70.1 kg

102
Q

FiO2

A

Lpm x 4 = ?? + 21 = FiO2%

103
Q

RR norm

A

12-20bpm

104
Q

PEEP

A

+5

105
Q

Vt

A

(from IBW) Kg x 6, kg x 8

answer-answer

106
Q

Establishing an airway progressing to mechanical ventilation

A

-Establish reason for artificial airway placement
(cardio-pulmonary resuscitation, compromised airway, trauma, post surgical… ABG, Significant mental changes)
-Assess LOC- IV access sedate - BVM- Oral airway- hyperoxygenate/ inflate
-Intubate-stabilize tube depth - assess airway placement - secure - confirm CXR - continue bag to tube
-Prepare ventilator - attach to patient - inline suction- heat and humidity - arm restraints- assess airway and pulmonary mechanics - document

107
Q

Initial settings

A 
IBW- Tidal volume
RR- Normal
Minute Ventilation
PEEP
LPM Converted to %
I:E ratio
108
Q

When does expiratory and inspiratory limbs matter

A

During active humidity

109
Q

When to switch HME to active heat

A

Hypothermic pt
Thick secretions- hydrate
HME becomes seccluded
High Minute ventilation

110
Q

Heated Wire Circuit

A
  • heating wires
  • Temperature probes
  • Passover Reservoir
  • Heater
  • Sterile water for inhalation
  • Correct expiratory filter
111
Q

Wire does what in heated wire circuit

A

Keeps gas hot and reduces rainout,

reduces condensation, maintain heated gas, maintain heated circulation insp and exp

112
Q

Temp probes do what

A

monitor pressure on inspiratory side

113
Q

Difficult airway and specialty tubes

A 
Pilot tube repair
Bougie
LMA
Combitube
King airway
Hi-Lo evac ETT
Independent lung ventilation tubes
114
Q

Bougie

A

Use when having a hard time visualizing cords

  • facing anterior
  • “click” when in trachea= then slip ETT over
  • Coude tip= directional tip
115
Q

LMA= Laryngeal Mask Airway

A

Above glottis, places blindly during difficult airway

  • inserted into the oropharynx the tip resting at the upper esophagus sphincter
  • Used predominantly in surgery
  • Airway is covered in ACLS, an alternative to standard ETT intubation
  • Occludes pharynx
  • Doesnt protect against aspiration
116
Q

LMA technique

A
  1. Make sure cuff is deflated all the way
  2. Lube the backside of laryngeal mask
  3. guide with index finger along the hard palate down into the oropharynx until resistance is met
  4. Inflate the cuff to a maximum of 60cmH20
  5. Ventilate and assess
  6. Exhaled CO2? capnography
  7. Secure tube to mouth
117
Q

Two Major Limitations of LMA

A
  1. Pt must be unconscious
  2. If ventilation pressures are higher than 20cmH2O, then there is risk of gastric distention
    +LMAS DONT PROTECT AGAINST ASPIRATION
118
Q

Combitube

A

Inserted blindly into oropharynx landing in either the esophagus or trachea
1. Contains two external openings (lumens)
-stomach
-Passively vent. lungs
2. Two 15mm Adapters for ambu bag/ ventilator
3. Two cuffs
-One to seal the oropharynx
-The other to seal either the esophagus or trachea
If the tube goes into esophagus, ventilation is accomplished through a series of holes. The oropharynx cuff prevents air from leaving the mouth

119
Q

King Airway

A
  • Latex free and single pt use
  • two ventilation outlets- in front of the larynx for efficient ventilation and allows passage of fiberoptic bronchoscope or tube exchange catheter
  • Bilateral eyes- additional eyelets to supplement ventilation
  • Distal cuff- blocks entry of esophagus. Reduces possibility of gastric insufflation
  • port on back used to suction gastric
120
Q

1 pilot balloon in the king airway

A

inflates both cuffs

121
Q

Special ET Tubes

A
  • Mallinckrodt Hi-Lo Evac ET Tube
  • Wire Reinforced ETT
  • Carlens Tube
  • Robertshaw Tube
  • Double Lumen
  • High Frequency Jet Ventilation
122
Q

Mallinckrodt Hi-Lo Evac ET tube

A

Suction lumen above the cuff- continuous suction of 20-30cmH2O

123
Q

Wire Reinforced ETT

A

Prevent kinking

124
Q

Carlens Tube

A
  • Intubate left mainstem

- Hook that is designed to catch the carina

125
Q

Robertshaw Tube

A

Selective for either right or left main stem

126
Q

Double lumen

A

For independent lung ventilation

  • Stiffer and bulkier
  • Must be rotated into specific bronchi
  • Ensured placement with bronchoscope
  • Increased resistance because of smaller lumen with each tube
127
Q

High frequency jet ventilation

A
  • Port that allows injection of high flow

- Port for monitoring pressures

Principles and Practices of Resp II (5 decks)

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