Airway Management Flashcards
Enotracheal Tube made from
pliable polyvinyl chloride (PVC) inserted through the mouth or nose and into the trachea
Enotracheal Tube sizes
2.5-9mm (adult average 8mm I.D) Occluding 75% of airways, reducing resistance
Bronchoscopy sizes
5.5mm-6mm
ETT Parts
- 15mm adapter for ambu/ventilator
- Cuff
- Pilot Balloon
- Length markings in cm
- Tube markings include outside and inside diameter
- Beveled tip
- Murphys Eye
- Radiopaque line
Cuff
seals the trachea in order to apply positive pressure ventilation and protect against aspiration
Pilot balloon
used to monitor cuff pressure
Length/ inside diameter/ internal diameter measurements
Length- cm
outside diameter- in mm
Internal diameter- I.D
Beveled tip
angle of tip minimizes mucosal trauma
Murphys eye
used to ventilate in the event that the bevel tip becomes occluded
radiopaque line
used to identify positioning on xray
Who needs to be intubated
Airway
Ventilation
Oxygenation
pts- Epiglotitis, Neuro, Drug OD
Epiglotitis
is not an emergency- goes smoothly
Indications for Emergency intubation
Persistent apnea Traumatic Upper airway obstruction obstructive angloedema- swelling neonatal or pediatric disorders cardiopulmonary arrest
Mallampati Score
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
RSI
Rapid Sequence intubation
Intubation- rsi- medications
Sedative drugs -Propofol -Ketamine -Etomidate Paralytic drugs -Succinylcholine- fast acting -Rocuronium
Propfol
Sedative drug- white and fast acting
When do you sedate a pt?
Pt is agitated or cant manipulate the mandible
Paralytic drugs
no neurological assessment
Equipment for Endotracheal intubation
-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
Essential Intubation Equipment- absolutes
-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)
Sizes for ETT
adult 6.5, 7, 7.5, 8…. 8 is ideal
Can intubate with bronchoscope?
yes
Left side of bed
Scope/ tube
Right side of you
Yankauer
Stylet
wire that helps manipulate ETT, dont want it to be pertruding out of the end of ETT
Cricoid pressure
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
Laryngoscope blades
Miller and Macintosh
Miller blade
L
Straight blade
-directly lifts the epiglottis in order to visualize the vocal cords
Macintosh blade
C
Indirectly lifts epiglottis
-is inserted into the vallecula, which is the space between the epiglottis and the tongue
Laryngoscope Blade Sizes
00- preemie 0- preemie 1- infant 2- child 3- adult 4- adult
ETT sizes
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
Tube placement- oral intubation on average
Males: between 21-23cm
Females: between 19-21cm
Placement 3-5 cm above carina (done with CXR)
Tube placement importance
could be in rt mainstem, clarify right away
Oral intubation steps
- Assemble and check equipment
- Position the patient
- Pre-Oxygenate and hyperinflate
- Insert Laryngoscope
- visualize the glottis
- displace the epiglottis
- Insert the tube
- Assess the tube position
Steps to assemble and check equipment
Suction- yankauer
Oxygen- usually NRB and BVM (sometimes NC)
Laryngoscope- working condition-blade size
Inflate cuff- verify - deflate
Position the patient step
Sniffing position- towel to assist
-Under head or shoulders , whatever to get best view
Pre-oxygenate and hyperinflate step
bag and mask ventilation
Oral/ nasal airway
NRB mask
Insert laryngoscope steps
- 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
Visual markers as the blade progresses against the tongue
Arytenoid cartilage
Epiglottis
Displace the epiglottis step
Depends on blade, pull the scope up and out, do not rock the blade back= leverage against teeth
Insert the tube step
- 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
Bedside Assessment for correct tube placement, right away
- Listen over stomach-left side
- Listen to bilateral breath sounds- bases first
- Observe for bilateral chest rise (right main stem intubation isnt bilateral)
- Colorimetry
Other bedside assessment for correct tube placement
- End tidal CO2 detector- capnometry
- Light wand-stylet
- Fiberoptic laryngoscope/ bronchoscope (wont need cxr)
- Esophageal detection device
After placement is confirmed…
secure ET tube to face with a commercial ETT holder or tabe
-then order chest xray
Colorimetry
picks up % of CO2
-norm= 5
35-45mmhg
as breaths given, yellow-> blue
Esophageal detection device
looks similar to bulb
- squeeze bulb
- attach to ET, let go
- Trachea will reexpand bulb
- esophagus wont change
ETAD- Hollister anchor fast
not cheap Minimum pressure points -more room to sweat - can move side to side every 24 hours and retape
When prone using ETAD
switch to ET taping, stay away from lips= softer tissue
Tincture of benzoin
rub where tap goes, help with adhesion
Thomas tube holder
What we used during lab
- Temporary hold
- no access to mouth= poor oral care
- has bite block built in
Repositioning ETT
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
Securing the airway consideration
- Tincture of benzoin
- Clean and dry face
- May need to shave patient
CXR
tube at adequate depth
- aortic arch
- 4th rib
- measure from carina
Complications with oral intubation
- 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
Difficult intubations occur because of
- Inability to open the mouth
- position of the patient
- Unusual anatamy
When transporting?
always have ambu near
Nasotracheal intubation
-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
Risk of what during nasotracheal intubation
sinitus, cannot use stylet
Direct Nasotracheal intubation
- 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
Blind/ indirect Nasotracheal intubation
- 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
Lidocaine
spray for numbing
Racemic Epi
vasoconstriction
Cuff
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
Cuff Pressure Acceptable range
20-30 cmH2O
If cuff pressure is <20 cmH2O
You risk aspiration (add air to the cuff)
If cuff pressure is > 30cmH2O
you risk tracheal wall damage
1 mmHg=
1.3595 cmH2O
1 cmH20=
0.7355388 mmHg
NBRC- keep cuff pressure
< 25mmHg
Little ppl dont need cuffs why
cricoid makes seal
2 things matter choosing cuff pressure
size of airway and size of tube
Cuff pressure manometer
Measures in cmH2O
- risk: cuff can lose air / leak when pushed on
- Read during inspiration/ avoid leaks/ aspiration
Put in bigger tube if
above cmH2O and still leaking, but reality- inflate more
MLT
minimal leak technique
MOP
Minimum occluding pressure- also called minimal occluding volume (MOV)
MLT and MOP both require
a syringe for manipulating cuff pressure and stehoscope- lateral neck
Push air into cuff=
create volume, create minimal leak by checking during inspiration
Micro aspiration
pt aspirating with no one being aware of it- pt not coughing
Minimizing aspiration
- 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)
VAP protocol- consistent care
- 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
Dont pull tube if
Pt needs pressure
pt needs 100% fio2
below 40%-okay to wean
During an intubation attempt, what two landmarks should you see as you advance the laryngoscope
Arytenoid Cartilage, Epiglottis
What does the term intubation mean
Passing of a tube into a body aperture (vocal cords)
Can a standard ET tube be used for a blind intubation? what does blind intubation mean?
Yes, indirect intubation means you dont see the tip of the tube as it goes through the epiglottis
What size blades are used to intubate an adult patient
3 and 4
What are the two different laryngoscope blades and how are they used to visualize the vocal cords
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
When is placing an artificial airway (intubation) contraindicated?
When pt is DNI
what hand should you hold the laryngoscope with and why
left to visualize the scope chanel
List the two reasons to establish an artificial airway
Patient cant protect their airway or theyre not able to ventilate/ oxygenate
What is the normal ranch for cuff pressure? what are you trying to prevent
20-30 mmH2O, it minimizes aspiration risk and avoids cutting off the blood supply
Whats the difference between Endotracheal intubation and nasotracheal intubation? what are teh differences in tube placement/ depth
One is through the mouth= 20-24
One through the nose= to hub
Can you intubate with a LMA? (laryngeal mask airway)
No its above the gottis (not passing through aperture)
How much time do you have when attempting to intubate a pt
30 seconds
What type of intubation technique would use magill forceps
Direct Nasotracheal= visualizing cords
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
lidocaine
What initial FiO2 do we choose on the ventilator
whatever patient was on before, safe FiO2 60% or less (add pressure to improve oxygenation from there)
Vt range (ml/kg)
6-8
How do we provide humidity and heat to an intubated patient
HME- passive humidity
Heated wire circuit/ active humidity
VAP protocol. what can we influence?
Keep head elevated 30-45% and perform subglottic suctioning
IBW
50+2.3 (CM-60) = 70.1 kg
FiO2
Lpm x 4 = ?? + 21 = FiO2%
RR norm
12-20bpm
PEEP
+5
Vt
(from IBW) Kg x 6, kg x 8
answer-answer
Establishing an airway progressing to mechanical ventilation
-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
Initial settings
IBW- Tidal volume RR- Normal Minute Ventilation PEEP LPM Converted to % I:E ratio
When does expiratory and inspiratory limbs matter
During active humidity
When to switch HME to active heat
Hypothermic pt
Thick secretions- hydrate
HME becomes seccluded
High Minute ventilation
Heated Wire Circuit
- heating wires
- Temperature probes
- Passover Reservoir
- Heater
- Sterile water for inhalation
- Correct expiratory filter
Wire does what in heated wire circuit
Keeps gas hot and reduces rainout,
reduces condensation, maintain heated gas, maintain heated circulation insp and exp
Temp probes do what
monitor pressure on inspiratory side
Difficult airway and specialty tubes
Pilot tube repair Bougie LMA Combitube King airway Hi-Lo evac ETT Independent lung ventilation tubes
Bougie
Use when having a hard time visualizing cords
- facing anterior
- “click” when in trachea= then slip ETT over
- Coude tip= directional tip
LMA= Laryngeal Mask Airway
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
LMA technique
- Make sure cuff is deflated all the way
- Lube the backside of laryngeal mask
- guide with index finger along the hard palate down into the oropharynx until resistance is met
- Inflate the cuff to a maximum of 60cmH20
- Ventilate and assess
- Exhaled CO2? capnography
- Secure tube to mouth
Two Major Limitations of LMA
- Pt must be unconscious
- If ventilation pressures are higher than 20cmH2O, then there is risk of gastric distention
+LMAS DONT PROTECT AGAINST ASPIRATION
Combitube
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
King Airway
- 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
1 pilot balloon in the king airway
inflates both cuffs
Special ET Tubes
- Mallinckrodt Hi-Lo Evac ET Tube
- Wire Reinforced ETT
- Carlens Tube
- Robertshaw Tube
- Double Lumen
- High Frequency Jet Ventilation
Mallinckrodt Hi-Lo Evac ET tube
Suction lumen above the cuff- continuous suction of 20-30cmH2O
Wire Reinforced ETT
Prevent kinking
Carlens Tube
- Intubate left mainstem
- Hook that is designed to catch the carina
Robertshaw Tube
Selective for either right or left main stem
Double lumen
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
High frequency jet ventilation
- Port that allows injection of high flow
- Port for monitoring pressures
