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 Tongue Regurgitation Trauma Foreign Body
What are some common causes for laryngeal airway obstruction?
Oedema from burns, inflammation or anaphylaxis
Spasm due to airway stimulation or foreign material
What can cause airway obstruction below the larynx?
Bronchial secretions Mucosal oedema Bronchospasm 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?
See-saw breathing Use of accessory muscles Reduced air entry Stridor/wheeze/gurgling/snoring Intercostal and subcostal recession Tracheal tug
How do you identify complete airway obstruction in patients with apnoea?
Spontaneous breathing movements are absent
Failure to inflate lungs during attempted positive pressure ventilation
How should patients with a tracheostomy or permanent tracheal stoma with an airway obstruction be managed?
Remove tube/stoma and replace
Ventilate by sealing stoma
What are the signs of severe choking?
Not able to speak Unable to breathe Breathing sound wheezy Attempts at coughing silent Patient may be unconscious
What are the signs of mild choking?
Respond to question
Able to speak cough and breathe
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 and slightly behind patient
- Support chest with one hand and lean patient forward
- Give sharp blow 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 and 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 occurs –> regurgitation and subsequent pulmonary aspiration
Also gastric inflation further reduce lung compliance making ventilation more difficult
What tidal volume do you aim to provide when ventilating a patient? How quickly should it be given
6-7mL/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 Laryngeal mask airway 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
Other - water soluble lubricating jelly, Magill forceps, bougie/semi-rigid stylet, tape to secure, suction apparatus
What is done after intubation?
Connect tube to ventilating device
Inflate cuff of tracheal tube - prevent leak
Confirm correct placement - clinical assessment and waveform capnography
Continue ventilation with high flow O2
Secure tube
What does the clinical assessment involve when confirming a tracheal tube is located correctly?
Observe chest expansion bilaterally
Auscultate lung fields bilaterally in axillae (should hear breath sounds) and over epigastrium (shouldn’t hear here)
Check for condensation of tube
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
Insecure/loose teeth or dental prosthesis
Gastric regurgitation
Clenching of teeth
Oesophageal intubation
Possible C Spine Injury
What aids are available for intubation?
Videolaryngoscopes
Introducers - bougie
Suction
When is a cricothyroidotomy considered?
Impossibile to ventilate or pass tracheal tube
Tracheostomy too time consuming, hazardous or 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
