Airway Management/Mask/Intubation Flashcards
Release jaw during expiration to prevent
ballvalve
describe One-handed bag-mask Ventilation
[EC clamp]
Mask is held with left hand, bag in right hand
Downward pressure using thumb and index finger
Middle & ring fingers on mandible not soft tissue extending jaw
describe Two-handed mask ventilation
[TE clamp]
Both hands on mask, bag handled by 2nd person
Thumbs pressing mask downward against face
Index fingers on mandible moving it anteriorly
Jaw thrust
Atlanto-occipital joint extention
What is a very IMPORTANT value to monitor during ventilation?
CO2
4 disadvantages of MAC without Artificial Airway
-Airway tone reduced
-Tongue obstructs
-Difficult to detect apnea
-Difficult to detect reduced airflow and volume
Rocking and reduced chest wall movement
where is the tongue when airway is obstructed?
the tongue and epiglottis fall back to the anterior posterior wall
What leads to obstruction in an anesthetized patient?
loss of airway muscle tone
7 Indications for Tracheal Intubation
- Airway protection
- Initiate and maintain patent airway
- Pulmonary toilet needed
- Positive pressure ventilation
- Long surgical procedures
- Airway compromise, inaccessible/shared airway
- Inability to maintain control with mask
what type of patients are in need of tracheal intubation for Airway protection purposes?
Full stomach, pregnancy, aspiration risk
do Paralyzed patients need tracheal intubation?
yes! Positive pressure ventilation
why do you need two laryngoscope handles?w
in case the battery is out on one of them
Laryngoscope straight blade?
miller
laryngoscope curved blade?
macintosh
Lifts the epiglottis directly
Epiglottis is lifted out of the line of vision; better for “anterior” larynx
miller blade
compare miller to mac blade in regards to size
Smaller than the curved “Mac” and fits in mouths with smaller opening
Tip placed in the vallecula to indirectly lift the epiglottis, thus minimizing trauma
macintosh blade
what does a mac blade do to the tongue
Better displacement of the tongue leftward for better visualization
Less temptation to “lever” against the upper teeth
Transparent, non-irritating polyvinyl chloride
Softens and molds to contour of airway
Endotracheal Tubes
how are Endotracheal Tubes measured
mm and measures the internal diameter of the tube
High volume cuff =
greater seal area, less pressure, less injury
you want the cuff pressure to be inflated __ why?
<20 torr, trachea capillary perfusion pressure 30 torr
low volume cuff =
Low seal area, high pressure seal, more effective, more ischemia
what are the 4 American National Standard for Anesthetic Equipment Markings on the ETT
Internal diameter (I.D.) in mm
External diameter (O.D.) in mm
Certification of “Implantation Testing” (I.T.)
Radiopaque line to allow visualization on x-ray
what has greatest effect on ETT to the resistance to flow
Radius of ETT
why choose small ETT?
to minimize trauma, short term intubations
other than cause tracheal seal, what does ET cuff do?
Allows positive-pressure ventilation
Minimizes aspiration risk
Hi-Lo = High volume Low Pressure cuff characteristics
Larger mucosal contact
Lower incidence of mucosal damage
Higher incidence of sore throat, aspiration, spontaneous extubation, and difficult intubation (bigger, floppy cuff)
“Minimal leak” – pressures of 15-25 torr
Low volume, High Pressure cuff characteristics
Higher incidence of tracheal mucosal ischemic damage
Only for use in short duration
Can have pressures up to 250 torr on tissues
4 Factors affecting Cuff pressure
Volume of air used to inflate cuff
Diameter of the cuff in relation to the trachea
Tracheal and cuff compliance
Intrathoracic pressure – cuff pressures increase with coughing
what can diffuse into the air-filled cuff to increase the pressure?
nitrous
Factors to consider ETT size?
Size of patient’s glottis Reason for intubation Pathology of the airway Attempts allowed (only one attempt – smaller) Length of intubation Maturity of airway
average ETT size female?
7-7.5 mm
average male ETT size?
7.5-9 mm
Reinforced with wire in the wall of the ETT to resist kinking
Head and neck surgeries, prone cases
Anode or armored tube
what happens if wall of anode or armored tube becomes bent?
you have to replace it
Very floppy, requires stylet for insertion
Anode or armored tube
Preformed with angles placed at the site of emergence from the nose or mouth to minimize kinking and obstruction to flow.
Nasal Rae and Oral Rae TT
tube directed toward the forehead
nasal rae
tube directed toward the chin
oral rae
Made of silicone impregnated with metal particles, spiral wound stainless steel ETT, or wrapped with metal foil
Prevent puncture or ignition by laser heat
Laser-shielded tubes
how should you fill cuffs of laser shielded tubes?
The cuff remains unprotected and should be filled with methylene blue stained saline so that perforation may be quickly recognized.
Double lumen used for selective one-lung ventilation
The bronchial tip is placed in a main bronchus.
Has both a tracheal cuff and a bronchial cuff.
endobronchial tube
nasal ETT characteristics
- Softer plastic to minimize trauma to nasal mucosa
- Ring on connector end; tension causes the cuffed end to angle upward to direct the tip anteriorly during nasal intubation.
use for Uncuffed ETT?
Pediatric use
Minimize postintubation croup
why use a bougie?
Inability to visualize glottis or guide ETT into proper position – insert distal tip of bougie over arytenoids – slide ETT over guide as CVL are slid over a guidewire into a vessel
Anesthetizes airway blunting stimulation of laryngoscopy, reflexes. Minimizes irritation of propofol
2% lidocaine, local anesthetic
Blunt stimulation and reflexes and SNS outflow due to laryngoscopy
IV narcotics
patient is unconscious with suppression of reflexes
IV anesthetic: (propofol, thiopental)
Facilitates ventilation bag mask by relaxing muscles of neck, jaw and thoracic cage. Allows atraumatic tracheal intubation by opening cords
paralytic
goal of positioning for tracheal intubation
align 3 airway axes; oral, pharyngeal and laryngeal (some refer to as tracheal axis)
smallest intubation triangle possible
where do you insert blade of laryngoscope?
right side
grade 1
no difficulty seeing structures
grade 2
only posterior extremity of glottis seen
grade 3
only epiglottis seen
grade 4
no recognizable structures
what does BURP stand for and why would you do this
Backward – posteriorly against vertebrae
Upward - cephalad
Right
Pressure
improve view of cords
average ETT positioning marking?
20 for female, 22 male
most reliable way to verify ETT placement?
ventilation
ways to verify ETT placement?
Chest rise
ETT fogging
Bilateral breath sounds, also listen over epigastrium
ETCO2 – does not rule out endobronchial intubation
Indications, advantages for nasal intubations
Oral intubation difficult – awake patient
Oral placement would interfere with surgical site
Anticipate prolonged intubation
More stable ETT fixation
More tolerable technique to conscious patient
Disadvantages nasal intubations
Tissue trauma – nasal mucosa, epistaxis, incidental adenoid damage
Transmission of infection (URI) to trachea and lungs
If smaller tube, increased resistance and secretions more difficult to suction.
patients that nasal intubation contraindicated
mid-facial trauma, fracture nose, nasal obstruction, or basilar skull fracture
cetacaine (benzocaine) can cause methemeglobin with doses
> 200-300 mg (1.5 ml)
cetacaine (benzocaine) use
Effective only on mucus membranes
Controls pain, gag reflex
how do you introduce tube during nasal intubation?
with bevel directed laterally to avoid damage to turbinates
describe angles of tube during nasal intubation
Insert the ETT along the floor of the nose – the angle should be perpendicular to the face and the proximal end should be angled from the cephalad side.
