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Yr 4 - ACC > Anaesthetics: Airway > Flashcards

Anaesthetics: Airway Flashcards

1
Q

Indications for a nasopharyngeal airway (NGA)?

A

Reduced GCS and an intact gag reflex.

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2
Q

Who should an NPA be used with caution in?

A
  • Basal skull fracture
  • Nasal polyps
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3
Q

What are 3 advantages of an NPA?

A

1) Can be suctioned through

2) Can be tolerated by patients with a higher level of consciousness

3) Does not require mouth to be open

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4
Q

What are 2 disadvantages of an NPA?

A

1) Poor technique can cause bleeding

2) No protection against vomiting

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5
Q

Size of NPA for an average size male?

A

7 mm

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6
Q

Size of NPA for an average size female?

A

6 mm

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7
Q

What direction should NPA be inserted?

A

With bevel facing nasal septum (rotate where appropriate).

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8
Q

Indications for an oropharyngeal airway (OPA)?

A

Unresponsive patient with an ABSENT gag reflex

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9
Q

Contraindications for an OPA?

A

Any patient with an intact gag reflex

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10
Q

What are 2 disadvantages of an OPA?

A

1) risk of pushing tongue back and making obstruction worse

2) no protection against vomiting

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11
Q

How can an OPA be sized?

A

Angle of jaw to level of incisors

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12
Q

What should you check for before inserting an OPA?

A

Check for foreign bodies - suction if required.

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13
Q

What can an error in insertion of an endotracheal tube (ETT) result in?

A

Oeseophageal intubation: accounts for around 5% of major airway complications.

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14
Q

How can you tell if there is oesophageal intubation?

A

End tidol CO2 trace will not be seen on monitor.

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15
Q

What is next step for COPD patients who have type 2 (hypercapnic) respiratory failure, or respiratory acidosis that does not improve with initial medical therapy?

A

Non-invasive positive-pressure ventilation.

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16
Q

What can be given to aid intubation in RSI?

A

The administration of the induction agent (e.g. Propofol or Sodium Thiopentone) and paralysing agent (e.g. Suxamethonium or Rocuronium).

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17
Q

What are the steps of RSI?

These can be remembered by the ‘seven P’s’

A

1) Preparation

2) Preoxygenation

3) Pretreatment

4) Paralysis

5) Protection & positioning

6) Placement and proof

7) Post-intubation management

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18
Q

What does ‘preparation’ step involve in RSI?

A

Involves ensuring the environment is optimised, equipment is available and staff are ready.

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19
Q

What does ‘preoxygenation’ step involve in RSI?

A

Involves the administration of high flow oxygen for 5 minutes prior to the procedure

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20
Q

What does ‘pretreatment’ step involve in RSI?

A

May involve administration of opiate analgesia or a fluid bolus to counteract the hypotensive effect of anaesthesia.

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21
Q

What does ‘paralysis’ step involve in RSI?

A

The administration of the induction agent (e.g. Propofol or Sodium Thiopentone) and paralysing agent (e.g. Suxamethonium or Rocuronium).

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22
Q

What does ‘protection & positioning’ step involve in RSI?

A

Cricoid pressure should be applied to protect the airway following paralysis. In line stabilisation may be required in some cases.

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23
Q

What does ‘placement & proof’ step involve in RSI?

A

Intubation is performed via laryngoscopy, with proof obtained (direct vision, end-tidal CO2, bilateral auscultation)

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24
Q

What does ‘post-intubation management’ step involve in RSI?

A

Taping or tying the endotracheal tube, initiating mechanical ventilation and sedation agents

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25
Q

What is a tracheostomy?

A

Tracheostomies are used to bypass the upper airway, allowing a patient’s trachea to be ventilated through the front of the neck.

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26
Q

Indications for a tracheostomy?

A

1) Upper airway obstruction (can bypass upper airway)

2) During head and neck surgery

3) To assist in artificial ventilation

27
Q

What is tracheostomy weaning?

A

Tracheostomy weaning is the process whereby you will be assessed and progressed with your breathing, with the end goal of the tracheostomy being removed and you are able to breathe unaided.

28
Q

What airway management can be used to facilitate long term weaning?

A

Tracheostomy

29
Q

Whoat is an endotracheal tube (ETT)?

A

A flexible plastic tube with an inflatable cuff (balloon) at one end and a connector at the other.

30
Q

Typical ETT size for women?

A

7mm

31
Q

Typical ETT size for men?

A

8mm

32
Q

What device can assist intubation when the vocal cords cannot be visualised?

A

A bougie:

1) The bougie is inserted into the trachea.

2) The endotracheal tube slides along the bougie into the correct position in the airway.

3) The bougie is then removed, and the endotracheal tube remains in place.

33
Q

How does a supraglottic airway device (SAD) work?

A

The tip of the SAD will be located at the top of the oesophagus. The cuff will fit around the opening of the larynx, forming a seal between the device and the airway.

34
Q

When are oropharyngeal (Guedel) airways often used?

A

These are most often used when ventilating the patient via a face mask and bag prior to inserting an SAD or ETT.

35
Q

Indications for a tracheostomy?

A

1) Respiratory failure where long-term ventilation may be required (e.g., after an acquired brain injury)

2) Prolonged weaning from mechanical ventilation (e.g., ICU patients that are weak after critical illness)

3) Upper airway obstruction (e.g., by a tumour or head and neck surgery)

4) Management of respiratory secretions (e.g., in patients with paralysis)

5) Reducing the risk of aspiration (e.g., in patients with an unsafe swallow or absent cough reflex)

36
Q

What are the 4 steps to take in the case of unanticipated difficulty intubating a patient?

A

Plan A - laryngoscopy with tracheal intubation

Plan B - supraglottic airway device

Plan C - face mask ventilation and wake the patient up

Plan D - cricothyroidotomy

37
Q

What is an arterial line?

A

An arterial line is a special type of cannula inserted into an artery (e.g., the radial artery).

38
Q

Purpose of arterial lines?

A

1) The blood pressure can be accurately monitored in real-time.

2) Arterial blood samples (for ABG monitoring) can be taken from the line.

39
Q

Are medications ever given through an arterial line?

A

No

40
Q

What is a central line?

A

A central line is also called a central venous catheter. This is essentially a long thin tube with several lumens (usually 3-5) that is inserted into a large vein, with the tip located in the vena cava.

41
Q

What 3 veins may a central line be inserted into?

A

1) internal jugular vein

2) subclavian vein

3) femoral vein

42
Q

Advantages of a central line?

A

1) They last longer and are more reliable than peripheral cannulas

2) They can also be used for medications that would be too irritating to be given through a peripheral cannula (e.g., inotropes, amiodarone or fluids with a high potassium concentration).

43
Q

What medications may be given through a central line?

A

Inotropes, amiodarone or fluids with a high potassium concentration (these may be too irritating to give peripherally).

44
Q

What is a peripherally inserted central catheter (PICC line)?

A

A type of central venous catheter.

A long, thin tube is inserted into a peripheral vein (e.g., in the arm) and fed through the venous system until the tip is in a central vein (the vena cava or right atrium).

45
Q

What is NIV?

A

A form of breathing support delivering air, usually with added oxygen, via a facemask by positive pressure.

Used in respiratory failure.

Note - The term NIV is often used interchangeably with BiPAP (Bi-level Positive Airway Pressure).

46
Q

Describe inspiratory vs expiratory pressure in NIV?

A

NIV delivers DIFFERING air pressure depending on inspiration and expiration.

The inspiratory positive airways pressure (iPAP) is HIGHER than the expiratory positive airways pressure (ePAP).

47
Q

What is CPAP?

A

CPAP supplies CONSTANT fixed positive pressure throughout inspiration and expiration.

48
Q

Indications for CPAP?

A

Chronic setting: severe obstructive sleep apnoea.

Acute setting: type 1 respiratory failure e.g. pulmonary oedema (recruiting collapsed alveoli).

49
Q

Main indication for NIV (BiPAP)?

A

In the acute setting, NIV is used in type 2 respiratory failure with respiratory acidosis (for example in a COPD exacerbation).

50
Q

What is positive airway pressure?

A

Refers to the pressure OUTSIDE the lungers being GREATER than the pressure inside the lungs.

This results in air being forced INTO the lungs (down the pressure gradient), requiring less respiratory effort.

In addition, the amount of air remaining in the lungs after expiration (the ‘functional residual capacity’) is increased, expanding the chest and lungs.

51
Q

What does recruitment refer to?

A

Recruitment refers to a process where bronchioles and alveoli which would normally collapse at the end of expiration, are kept open (more lung volume is ‘recruited’).

52
Q

How does recruitment assist in breathing?

A

The phase of breathing that requires the most energy is the process of overcoming the pressure required to re-expand collapsed segments of the lungs.

Therefore, by keeping these open, gas exchange efficiency is increased as less energy is required to breathe, and there is more surface area for gas exchange.

53
Q

What are 3 key indications for NIV?

A

1) COPD with respiratory acidosis (pH <7.35)

2) Hypercapnic respiratory failure secondary to chest wall deformity (scoliosis, thoracoplasty) or neuromuscular disease

3) Weaning from tracheal intubation

These indications assume that optimal medical management is already in place.

54
Q

What are 4 key indications for CPAP?

A

1) Hypoxia in the context of chest wall trauma despite adequate anaesthesia and high flow oxygen (pneumothorax should be ruled out using a chest x-ray prior to commencing CPAP)

2) Cardiogenic pulmonary oedema

3) Pneumonia: as an interim measure before invasive ventilation or as a ceiling of treatment

4) Obstructive sleep apnoea.

55
Q

Contraindications for CPAP/NIV?

A

1) Vomiting/excess secretions (aspiration risk)

2) Confusion/agitation*

3) Impaired consciousness*

4) Bowel obstruction*

5) Facial burns/trauma

6) Recent facial/upper GI/upper airway surgery*

7) Inability to protect airway*

8) Pneumothorax (undrained)*

*If NIV is the ceiling of care, it may be used in these cases, or if there is a plan in place for conversion to tracheal intubation.

56
Q

What factors should be continuously monitored after commencement of CPAP/NIV?

A

1) O2 sats

2) ECG

3) BP

4) RR

5) HR

6) Consciousness level

7) ABG: performed prior to commencement and 30-60 minutes after any change in settings until the patient is stable (minimum of 1, 4 and 12 hours after initiation).

57
Q

What complications can CPAP/NIV result in?

A

1) If ePAP is set too high, venous return can be impaired leading to hypotension.

2) If iPAP is set too high, it can impair venous return, cause the mask to leak, reduce patient tolerance and cause stomach inflation increasing the risk of aspiration.

3) NIV can cause pressure sores due to the tight-fitting mask, particularly over the bridge of the nose.

58
Q

What are the 4 basic settings on a mechanical ventilator that help maintain adequate gas exchange?

A

Aid CO2 removal:
1) RR
2) Volume of gas provided to patient everytime they breathe in (tidal volume)

O2 delivery:
1) FiO2 (fraction of inspired O2)
2) Positive end expiratory pressure (PEEP)

59
Q

How is PEEP helpful in O2 delivery?

A

PEEP helps to maintain alveolar recruitment, preventing the alveoli from collapisng at the end of expiration (keeping lungs open).

60
Q

What are the 2 main ways that a ventilator can provide a tidal volume to a patient?

A

1) Pressure control –> the ventilator provides a flow of gases to the lung until a set pressure is reached in the lungs

2) Volume control –> the ventilator provides a flow of gases to the lung until a set volume is reached

61
Q

What is the typical combination of drugs used for intubating a patient/putting them on a ventilator?

A

This is usually propofol with a short-acting opioid (e.g. alfentanil).

62
Q

Adverse effects of mechanical ventilation?

A

1) Volutrauma (lungs expanded too much –> can cause pneumothorax, inflammation etc)

2) Barotrauma (lungs exposed to too high pressure –> can cause pneumothorax etc)

3) Ventilator assisted pneumonia (VAP)

4) Vocal cord trauma

5) Tracheal stenosis

6) Haemodynamic instability

7) Delirium

63
Q
A

Yr 4 - ACC (73 decks)

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