Chapter 7: Airway Management and Ventilation Flashcards
What is the most common site for airway obstruction?
Pharynx - soft palate and epiglottis
What are some common causes for pharyngeal airway obstruction?
- Vomit/blood
- Regurgitation
- Tongue
- Trauma
- Foreign Body
What are some common causes for laryngeal airway obstruction?
- Oedema - burns, inflammation or anaphylaxis
- Spasm - airway stimulation or foreign material
What can cause airway obstruction below the larynx?
- Bronchial secretions
- Bronchospasm
- Mucosal oedema
- Pulmonary oedema
- Aspiration of gastric contents
- Extrinsic compression at any level
What is seesaw breathing?
- Complete airway obstruction
- In a patient who is making respiratory efforts
- Causes paradoxical chest and abdomen movement
- Called see-saw breathing
What signs may be seen in airway obstruction?
- Stridor/wheeze/gurgling/snoring
- Use of accessory muscles
- Tracheal tug
- Intercostal and subcostal recessions
- Reduced air entry
- See-saw breathing
How do you identify complete airway obstruction in patients with apnoea?
- Spontaneous breathing movements are absent
- Failure to inflate lungs during attempted PPV
How should patients with a tracheostomy or permanent tracheal stoma with an airway obstruction be managed?
- Remove tube/stoma & replace
- Ventilate by sealing stoma
What are the signs of severe choking?
- Can’t speak
- Can’t breathe
- Breathing sound wheezy
- Attempts at coughing silent
- Pt. may be unconscious
What are the signs of mild choking?
- Able to breathe
- Able to cough
- Able to speak
- Respond to question
How would you manage someone who is choking with a mild airway obstruction?
- Encourage them to cough
- Continually assess for deterioration
How would you manage someone who is choking with severe airway obstruction?
- Conscious - 5 back blows and 5 abdominal thrusts
- Unconscious - start CPR
How do you give back blows?
- Stand to side & slightly behind patient
- Support chest with 1 hand
- Lean patient forward
- Give 5 sharp blows between scapulae with heel of hand
- Check to see if airway obstruction relieved after each blow
When and how do you do abdominal thrusts?
If back blows fail = give 5 abdominal thrusts
- Stand behind pt
- Put both arms round upper abdomen
- Place clenched fist under xiphisternum and
- Grasp with other hand
- Pull sharply inwards and upwards
- Repeat 5 times
What should be done if 5 back blows and 5 abdominal thrusts hasn’t relieved airway obstruction?
- Continue alternating back blows and abdominal thrusts
- If pt become unconscious - begin CPR
- Once appropriate individual arrive - laryngoscopy and remove FB with Magill forceps
How should the airway be opened in a patient with suspected C Spine injury?
- Maintain head, neck, chest and lumbar region in neutral position
- Can use jaw thrust or chin lift with manual in line stabilisation
- NO HEAD TILT
Can add head tilt if life threatening airway obstruction persist
What airway adjuncts are available to use?
Oropharyngeal (Guedel)
Nasopharyngeal
What oxygen should you give when doing CPR?
- 100% O2 until ROSC is achieved
- After this, give high flow until Sa02 can be measured reliably
What can you use to remove fluid in an airway obstruction?
- Suction - wide bore rigid sucker (Yankauer)
- Use cautiously if intact gag reflex
- Fine bore may be req. if limited mouth opening
What is the issue with high pressure airways due to inspiratory flows that are too high when ventilating?
- Gastric inflation
- Risk of regurgitation
- Risk of subsequent pulmonary aspiration
- Gastric inflation further reduce lung compliance - ventilation more difficult
What tidal volume do you aim to provide when ventilating a patient? How quickly should it be given
6-7 mL/kg
Give over 1s
How much oxygen can you give in a self-inflating bag?
- Air = 21%
- High flow oxygen directly to bag = 45%
- High flow oxygen in reservoir = 85%
How can you reduce risk of gastric inflation?
Apply cricoid pressure
What ways can you ventilate a patient?
- Mouth to mask ventilation
- Self-inflating bag/bag-valve mask
- Automatic resuscitators
- Passive oxygen delivery
- LMA - I-Gel airway, Proseal LMA
What are the limitations of a laryngeal mask airway?
- Risk of significant leak if high airway resistance or poor lung compliance - hypoventilation
- Uninterrupted chest compressions can lead to gas leak
- Theoretical risk of aspiration but v low
- Difficult insertion if pt. not deeply unconscious
- Won’t work if airway obstruction cause epiglottis to fold over laryngeal inlet
What are the benefits and weaknesses of the proseal laryngeal mask airway over a standard LMA?
- Additional posterior cuff and gastric drain tube
- improved laryngeal seal enabling ventilation at higher pressure
- regurgitated fluids can be drained
Weaknesses
- More difficult to insert
- Relatively expensive
- Req. sterilisation between uses
What are the advantages to intubation over bag mask ventilation?
- Maintenance of patent airway that is protected from aspiration
- Ability to provide adequate tidal volume during uninterrupted chest compressions
- Free up recur hands
- Ability to suction airway secretions
What are the disadvantages to tracheal intubation over bag mask ventilation?
- Risk of unrecognised misplaced tube
- Prolonged time without chest compressions
- Comparatively high failure rate
What can be done in circumstances where intubation is contraindicated?
- Use of anaesthetic drugs
- Videolaryngoscopy
- Flexible fiberoptic laryngoscopy
What equipment is required for tracheal intubation?
- Laryngoscope
- Cuffed tracheal tubes
- Syringe - cuff inflation
- Equipment to confirm correct placement - aspirate / stethoscope
- Water soluble lubricating jelly
- Magill forceps
- Bougie/semi-rigid stylet
- Tape to secure
- Suction apparatus
What is done after intubation?
- Inflate cuff of tracheal tube - prevent leak
- Connect tube to ventilating device
- Confirm correct placement - clinical assessment and waveform capnography
- Secure tube
- Continue ventilation with high flow O2
What does the clinical assessment involve when confirming a tracheal tube is located correctly?
- Check for condensation of tube
- Observe chest expansion bilaterally
- Auscultate lung fields bilaterally in axillae (should hear breath sounds) and over epigastrium (shouldn’t hear here)
How can CO2 be detected to confirm tracheal tube placement?
- End tidal CO2 capnograph
- Disposable colorimetric end tidal CO2 detectors (litmus paper):
- purple if <0.5%
- tan if 0.5-2%
- yellow if >2% - Non waveform electronic digital end tidal CO2 device
What factors may cause problems during intubation?
- Facial burns and trauma
- Upper airway pathology - cancer, infection, swelling
- Loose teeth or dental prosthesis
- Clenching of teeth
- Gastric regurgitation
- Oesophageal intubation
- Possible C Spine Injury
What aids are available for intubation?
- Videolaryngoscopes
- Introducers - bougie
- Suction
When is a cricothyroidotomy considered?
- Can’t intubate
- Can’t ventilate
- Tracheostomy too time consuming, hazardous
- Insufficient staff/equipment
What are the options for a cricothyroidotomy and how is it done?
Surgical - leave airway that is protected by cuffed tube
Needle - wide bore cannula but temporary and prone to kinking
