Chapter 13 Airway Management and Ventilation Flashcards
facial injuries increase index of suspicion for c spine injuries. what manoeuvre should you use to manage the airway
use the jaw-thrust manoeuvre and keep the patients head in a vertical position
when ventilating patients with facial trauma what should you cognisant of
stay alert of ventilation compliance, sounds that may indicate laryngeal edema
what considerations apply when dealing with dental appliances
if they fit tight leave them in place, if they are loose or have potential to dislodge you will want to remove them.
what do you need for a perform bag-mask device-to-stoma
two paramedics are needed, one to seal the nose and mouth, the other the operate the device
what is the required manoeuvre to ventilate a patient with a stome
there are no required manoeuvres to ventilate a PT with a stoma, just make sure you use an infant- or child sized mask to get a proper seal
how long should you suction a patient with a stoma
limit suction to a maximum of 10 seconds
how many minutes can the brain survive for without oxygen, before permanent brain damage occurs?
6 minutes
function of upper airway
warm, filter and humidify air as it enters the body through the nose and mouth
pharynx is composed of what 3 parts
- nasopharynx
- oropharynx
- laryngopharynx
turbinates function
increase the surface area of the nasal mucosa, improving the processes of warming, filtering, and humidification of inhaled air
what complications exist for a needle cricothyrotomy
improper placement can result in severe bleeding secondary to damage of adjacent structures, excessive air leakage can cause subcutaneous emphysema, subsequent obstruction may occur
what is a total laryngectomy
surgical removal of the entire larynx, people who have had this are called a neck breather
how is a laryngectomy performed
performed by making a tracheostomy, thus creating a stoma, orifice that connects the trachea to the outside air
what complications are there with an open cricothyrotomy
minor bleeding, severe bleeding result of inadvertent laceration of external jugular vein. must be done quickly or it will cause hypoxia in the patient, could result in cardiac arrhythmias, permanent brain damage, cardiac arrest, create a false passage
what complications exist for a cricothyrotomy
improper placement can result in severe bleeding secondary to damage of adjacent structures, excessive air leakage can cause subcutaneous emphysema, subsequent obstruction may occur
when is a failure to intubate called
defined when failure to maintain an acceptable oxygen saturation level during or after one or more failed intubation attempts, or a total of three failed intubation attempts by an experienced intubator
cavities formed by the cranial bones are?
sinuses
what is RSI
rapid sequence intubation, represents a culmination and integration of all your airway skills. includes safe smooth induction of sedation and paralysis followed immediately by intubation
most common cause of anatomic upper airway obstruction?
tongue
adenoids are
lymphatic tissue that filters bacteria
tonsils function
help trap bacteria
two pockets of tissue on the lateral borders of the larynx?
piriform fossae
function of the lower airway
exchange oxygen and carbon dioxide
at what does the trachea divide into the right and left mainstream bronchi?
carina
bronchus that is shorter and straighter?
right bronchus
what are the indications and contraindications for a needle cricothyrotomy
indic; inability to vent, unable to secure airway through a more conventional method.
Cont; severe airway obstruction above site of catheter
what size of needle do you use for a cricothyrotomy
14 to 16 gauge needle
what complications are there with an open cricothyrotomy
minor bleeding, severe bleeding result of inadvertent laceration of external jugular vein. must be done quickly or it will cause hypoxia in the patient, could result in cardiac arrhythmias, permanent brain damage, cardiac arrest, create a false passage
blood vessels and bronchi enter each lung at the?
hilum
approximately how much L of air can adult lungs hold?
6
number of lobes per lung
right- three lobes
left- two lobes
minute volume definition, and how to determine
amount of air that moves in and out of the respiratory tract per minute, determined by tidal volume X respiratory rate
parietal pleura function
lines the inside of the thoracic cavity
surfactant function
proteinaceous substance that lines alveoli, which decrease surface tension on the alveolar walls and keeps them expanded
are advanced airways necessary?
in most situations you can secure an a patent airway using basic methods, in rare situations however factors preclude the use of conventional methods and you must use an advanced method
when is a failure to intubate called
defined when failure to maintain an acceptable oxygen saturation level during or after one or more failed intubation attempts, or a total of three failed intubation attempts by an experienced intubator
atelectasis definition
condition where the amount of pulmonary surfactant is decreased or the alveoli are not inflated, and they collapse
tidal volume definition
volume of air that is inhaled or exhaled during a single respiratory cycle
normal tidal volume in adults and infants/children
adult- 5-7 mL/kg
infant/child- 6-8mL/kg
inspiratory reserve volume definition
amount of air that can be inhaled in addition to the normal tidal volume
dead space definition
any portion of the airway where air lingers but does not participate in gas exchange
anatomic dead space definition
includes the trachea and larger bronchi, where residual gas may remain at the end of inhalation
alveolar volume definition
remaining volume of inhaled air, that does not reach the alveoli and does not participate in gas exchange
alveolar volume is equal to?
tidal volume-dead space volume
minute volume definition
amount of air that moves in and out of the respiratory tract per minute
how much time do you have to intubate before you have to stop and ventilate
if you cannot intubate within 30 seconds stop and ventilate the patient with a bag-mask device and 100% oxygen before trying again
what is RSI
rapid sequence intubation, represents a culmination and integration of all your airway skills. includes safe smooth induction of sedation and paralysis followed immediately by intubation
what are the general steps for RSI
prep of patient and equip, preoxygenation and passive oxygenation, premedication, sedation and paralysis, intubation, maintenance of paralysis and sedation
minute alveolar volume definition, and how to determine
amount of air that actually reaches the alveoli per minute and participates in gas exchange, determined by (tidal volume-dead space volume) X respiratory rate
functional residual capacity definition
amount of air that can be forced from the lungs in a single exhalation
expiratory reserve volume definition
amount of air that you can exhale following normal exhalation
residual volume definition
air that remains in the lungs after maximal expiration
fraction of inspired oxygen (FIO2) definition
percentage of oxygen in inhaled air
ventilation definition
physical act of moving air in and out of the lungs
breakdown of ventilation cycle
inspiration 1/3
expiration 2/3
two types of nerves that affect breathing
phrenic nerves- supply the diaphragm
intercostal nerves- supply the intercostal muscles
3 regions of respiratory centre in the medulla
- respiratory rhythmicity centre
- apneustic centre
- pneumotaxic centre
second control of breathing
hypoxic drive
external respiration definition
exchange of gasses between the lungs and the blood cells in the pulmonary capillaries
internal respiration definition
exchange of gases between the blood cells and tissues
pulse oximeter function
reads percentage of hemoglobin that is saturated with oxygen, normally greater than 95%
conditions that reduce the surface area for gas exchange
flail chest, diaphragmatic injury, simple or tension pneumothorax, open pneumothorax, hemothorax, and hemopneumothorax
injury caused by severe compression of the chest
traumatic asphyxia
condition where blood entering the lungs from the right side of the heart will bypass the alveoli and will return to the left side of the heart in an unoxygenated state
intrapulmonary shunting
two ways hypoventilation can occur
- carbon dioxide production can exceed the body’s ability to eliminate it
- carbon dioxide elimination can be depressed to the extent that it no longer keeps up with normal metabolism
hyperventilation definition
carbon dioxide elimination exceeds carbon dioxide production
hypercapnia definition
carbon dioxide builds up in the blood
hypocapnia definition
carbon dioxide level in the blood falls
major components of air
- nitrogen 78.62%
- oxygen 20.84%
- carbon dioxide 0.04%
- water vapour 0.50%
normal adult respiratory rate (at rest)
between 12-20 breaths/min
preferential positioning, two types
-tripod position (elbows out)
-semi-fowler (semi-sitting)
patients with respiratory distress will avoid a supine position
hypoxemia definition
decrease in arterial oxygen levels
hypoxia definition
lack of oxygen to the body’s cells and tissues
anoxia definition
absence of oxygen that results in cellular and tissue death
pulsus paradoxus definition
systolic blood pressure drops more than 10 mmHg during inhalation
Analysis of arterial blood gases (ABGs) function
provide the most comprehensive quantitative information about the respiratory system
end-tidal carbon dioxide detectors function
detect the presence of carbon dioxide in exhaled air
colourimetric carbon dioxide detector function
probides qualitative information regarding the presence of carbon dioxide in the patient’s exhaled breath
capnometer function
provides quantitative information, in real time, by both detecting and measuring exhaled carbon dioxide levels
capnographer function
provides a quantitative graphic representation of exhaled carbon dioxide levels
waveform capnography function
provides quantitative, real-time information regarding the patients exhaled carbon dioxide level
4 phases of waveform
phase 1: (A-B) respiratory baseline, initial stage of exhalation
phase 2: (B-C) expiratory upslope
phase 3: (C-D) expiratory or alveolar plateau
phase 4: (D-E) inspiratory downstroke
if patient is in a prone position, and you need to get them into a supine position how would you do so`
log roll the patient as a unit
manual airway maneuvers (3)
- head tilt-chin lift manoeuvre
- jaw-thrust manoeuvre (with or without head tilt)
- tongue jaw lift manoeuvre
special type of curved forceps
magill forceps
suctioning time limits for adult,child,infant
adult 15 seconds
child 10 seconds
infant 5 seconds
plastic-tip catheter with large diameter and that is rigid, good option for suctioning pharynx
yankauer catheter (tonsil-tip catheter)
soft plastic, nonrigid catheters that can be placed in the oropharynx or nasopharynx or down tracheal tube
french or whistle-tip catheter
how to measure suction catheter
from corner of the mouth to the earlobe
oropharyngeal airway device
curved, hard plastic device that fits over the back of the tongue, designed to hold the tongue away from the posterior pharyngeal wall
should only be used in unresponsive patients without a gag reflex
nasopharyngeal airway device
soft rubber tube that is inserted through the nose into the posterior pharynx behind the tongue, allowing passage of airway from nose to the lower airway
measured from tip of nostril to angle of the jaw
used on unresponsive patients
colors and sizes of oxygen tanks
silver, chrome, green, or some combination of the 3
D tank- 350 L, typically carried from ambulance to patient
M tank- 3450 L, remains on unit as main supply
E tank- 625 L
what pressure you need to change oxygen cylinders at
200 psi or below, 200 psi is the safe residual pressure
2 types of flowmeters
- pressure-compensated flowmeter, incorporates a float ball within a tapered calibrated tube
- bourdon-gauge flowmeter, not affected by gravity and can be placed in any position
nonrebreathing mask device
preferred device for delivering oxygen to spontaneously breathing patients in the prehospital setting
good mask-to-face seal and a flow rate of 15 L/min, capable of delivering approximately 90% inspired oxygen
includes one-way valve preventing patient from exhaling into it
nasal canula device
flow rate of 1 to 6 L/min
deliver an oxygen concentration of 24% to 44%
simple face mask device
full mask enclosure with open side ports, room air drawn through side ports on inhalation, exhaled vented through holes on each side of mask
can deliver between 40-60% oxygen at 10 L/min
venturi mask device
draws room air into the mask along with the oxygen flow, allowing for administration of highly specific oxygen concentrations
can deliver 24-50% oxygen flow rate of 6-12 L/min
hi-ox mask device
modification of the nonrebreathing mask, like the nonrebreather the patient inhales oxygen from the reservoir bag via one-way valve, unlike the nonrebreather the exhaled breath passes through another one-way valve and then through a high-efficiency filter before exiting the mask
small-volume nebulizer device
used primarily to deliver aerosolized medications
oxygen humidifier device
small bottle of water through which the oxygen leaving the cylinder becomes moisturized before it reaches the patient
methods of positive pressure ventilation (3)
- mouth to mask
- two person bag mask device
- one person bag mask device
mouth to mask ventilation, inlet valve vs. no inlet valve
- with no inlet valve you will deliver 16% oxygen to the patient
- with inlet valve connected to a source at a flow rate of 15 L/min can deliver up to 55% oxygen
one-person bag-mask ventilation device
- most common device to ventilate in prehospital setting
- at a flow rate of 15 L/min and reservoir attached can almost deliver 100% oxygen
two-person bag-mask ventilation device
- much more efficient than one-person technique
- disadvantage is that it requires extra personnel
what is the major advantage of a multimumen airway
it cannot be improperly placed, effective ventilation is possible if the tube enters the esophagus or trachea
during the expiratory phase, the patient exhales against a resistance called?
positive end-expiratory pressure (PEEP)
what is the major risk of extubation
over estimation of the patients ability to protect his or her own airway
what is the major complication associated with the combitube
unrecognised displacement of the tube into esophagus
what are important things to remember when performing tracheobroncial suctioning
first rule is DO NOT DO IT IF YOU DONT HAVE TO, avoid suctioning unless secretions are so massive they interfere with ventilation, preoxygenation before suctioning is vital, try not to exceed 10 to 15 seconds
most CPAP devices are set to deliver a fixed FIO2 level of?
30-35% however some can deliver as high as 80%
insertion of NG tube
through the nose, into the nasopharynx, through the esophagus, and into the stomach
what are the contraindications of nasotracheal intubation
contraindicated in apneic patients, head trauma and mid face fractures, deviated septum, nasal polyps, frequent cocaine users
how does an esophageal detector device work
if tube is in trachea air is easily drawn into the syringe and plunger does not move when released. however the esophagus is flaccid, if tube is in the esophagus a vacuum is created as the plunger is withdrawn, and plunger moves back toward zero when released
primary requirements for advanced airway management (2)
- failure to maintain a patient airway
- failure to adequately oxygenate and ventilate
what is the proper tube insertion technique
after visualizing the glottic opening, insert the tube from the right corner of the PTs mouth. As you pass through the vocal cords, rotate the tube to the right and direct the tip downward
what must you do before you extubatne in the pre hospital setting
you must always preoxygenate the the patient before you extubate
how do you perform proper laryngoscope blade insertion
position yourself at the top of the PTs head. hold it in your left hand as far down as possible, insert blade into right side of mouth, use flange of blade to sweep tongue gently to the left side of mouth. slowly advance blade into vallecula (curved) beneath the epiglottis(straight). exert gentle traction at a 45’ angle to the floor.
what is digital intubation
aka blind or tactile intubation, involves directly palpsting the glottic structures and elevating the epiglottis with your middle finger
what are the indications of nasotracheal intubation
indicated for patients breathing spontaneously but require definitive airway management, responsive patients or PTs with altered mental status and intact gag reflex
how do you confirm proper tube placement
visualizing the tube being placed is the first and most reliable method., a second method is auscultation of even and proper breath sounds
what is the proper tube insertion technique
after visualizing the glottic opening, insert the tube from the right corner of the PTs mouth. As you pass through the vocal cords, rotate the tube to the right and direct the tip downward
what is a bougie
bougie is a small flexible device approx 1cm in diameter and 60cm long. the angle of the distal tip facilitates entry into the glottic opening and feel the ridges of the tracheal wall
how do you perform proper laryngoscope blade insertion
position yourself at the top of the PTs head. hold it in your left hand as far down as possible, insert blade into right side of mouth, use flange of blade to sweep tongue gently to the left side of mouth. slowly advance blade into vallecula (curved) beneath the epiglottis(straight). exert gentle traction at a 45’ angle to the floor.
what is a bundle of care
includes preoxygenation, passive high- flow oxygenation, and the sniffling position.
indications for orotracheal intubation by direct laryngoscopy
airway control needed as result of coma, respiratory arrest, cardiac arrest, ventilation support before impending respiratory failure, absent gag reflex
how many different sizes of laryngoscope blades are there
0-4. 0,1,2 are appropriate for infants, children. 3 &4 are for adults
what is the advantage of a curved laryngoscope
less likely to be levered against the teeth
