Chapter 7: Airway Management and Ventilation

Question 1

What is the most common site for airway obstruction?

Answer 1

Pharynx - soft palate and epiglottis

Question 2

What are some common causes for pharyngeal airway obstruction?

Answer 2

Vomit/blood
Tongue
Regurgitation
Trauma
Foreign Body

Question 3

What are some common causes for laryngeal airway obstruction?

Answer 3

Oedema from burns, inflammation or anaphylaxis

Spasm due to airway stimulation or foreign material

Question 4

What can cause airway obstruction below the larynx?

Answer 4

Bronchial secretions
Mucosal oedema
Bronchospasm
Pulmonary oedema
Aspiration of gastric contents

Extrinsic compression at any level

Question 5

What is seesaw breathing?

Answer 5

Complete airway obstruction in a patient who is making respiratory efforts causes paradoxical chest and abdomen movement called see-saw breathing

Question 6

What signs may be seen in airway obstruction?

Answer 6

See-saw breathing
Use of accessory muscles
Reduced air entry 
Stridor/wheeze/gurgling/snoring
Intercostal and subcostal recession
Tracheal tug

Question 7

How do you identify complete airway obstruction in patients with apnoea?

Answer 7

Spontaneous breathing movements are absent

Failure to inflate lungs during attempted positive pressure ventilation

Question 8

How should patients with a tracheostomy or permanent tracheal stoma with an airway obstruction be managed?

Answer 8

Remove tube/stoma and replace

Ventilate by sealing stoma

Question 9

What are the signs of severe choking?

Answer 9

Not able to speak
Unable to breathe
Breathing sound wheezy
Attempts at coughing silent
Patient may be unconscious

Question 10

What are the signs of mild choking?

Answer 10

Respond to question

Able to speak cough and breathe

Question 11

How would you manage someone who is choking with a mild airway obstruction?

Answer 11

Encourage them to cough

Continually assess for deterioration

Question 12

How would you manage someone who is choking with severe airway obstruction?

Answer 12

Conscious - 5 back blows and 5 abdominal thrusts

Unconscious - start CPR

Question 13

How do you give back blows?

Answer 13

• 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

Question 14

When and how do you do abdominal thrusts?

Answer 14

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

Question 15

What should be done if 5 back blows and 5 abdominal thrusts hasn’t relieved airway obstruction?

Answer 15

Continue alternating back blows and abdominal thrusts

If pt become unconscious - begin CPR

Once appropriate individual arrive - laryngoscopy and remove FB with Magill forceps

Question 16

How should the airway be opened in a patient with suspected C Spine injury?

Answer 16

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

Question 17

What airway adjuncts are available to use?

Answer 17

Oropharyngeal (Guedel)

Nasopharyngeal

Question 18

What oxygen should you give when doing CPR?

Answer 18

100% O2 until ROSC is achieved

After this, give high flow until Sa02 can be measured reliably

Question 19

What can you use to remove fluid in an airway obstruction?

Answer 19

Suction - wide bore rigid sucker (Yankauer)

Use cautiously if intact gag reflex

Fine bore may be req. if limited mouth opening

Question 20

What is the issue with high pressure airways due to inspiratory flows that are too high when ventilating?

Answer 20

Gastric inflation occurs –> regurgitation and subsequent pulmonary aspiration

Also gastric inflation further reduce lung compliance making ventilation more difficult

Question 21

What tidal volume do you aim to provide when ventilating a patient? How quickly should it be given

Answer 21

6-7mL/kg

Give over 1s

Question 22

How much oxygen can you give in a self-inflating bag?

Answer 22

Air = 21%
High flow oxygen directly to bag = 45%
High flow oxygen in reservoir = 85%

Question 23

How can you reduce risk of gastric inflation?

Answer 23

Apply cricoid pressure

Question 24

What ways can you ventilate a patient?

Answer 24

Mouth to mask ventilation
Self-inflating bag/bag-valve mask
Automatic resuscitators
Passive oxygen delivery
Laryngeal mask airway
I-Gel airway
Proseal LMA

Question 25

What are the limitations of a laryngeal mask airway?

Answer 25

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

Question 26

What are the benefits and weaknesses of the proseal laryngeal mask airway over a standard LMA?

Answer 26

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

Question 27

What are the advantages to intubation over bag mask ventilation?

Answer 27

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

Question 28

What are the disadvantages to tracheal intubation over bag mask ventilation?

Answer 28

Risk of unrecognised misplaced tube Prolonged time without chest compressions Comparatively high failure rate

Question 29

What can be done in circumstances where intubation is contraindicated?

Answer 29

Use of anaesthetic drugs Videolaryngoscopy Flexible fiberoptic laryngoscopy

Question 30

What equipment is required for tracheal intubation?

Answer 30

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

Question 31

What is done after intubation?

Answer 31

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

Question 32

What does the clinical assessment involve when confirming a tracheal tube is located correctly?

Answer 32

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

Question 33

How can CO2 be detected to confirm tracheal tube placement?

Answer 33

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

Question 34

What factors may cause problems during intubation?

Answer 34

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

Question 35

What aids are available for intubation?

Answer 35

Videolaryngoscopes Introducers - bougie Suction

Question 36

When is a cricothyroidotomy considered?

Answer 36

Impossibile to ventilate or pass tracheal tube Tracheostomy too time consuming, hazardous or insufficient staff/equipment

Question 37

What are the options for a cricothyroidotomy and how is it done?

Answer 37

Surgical - leave airway that is protected by cuffed tube Needle - wide bore cannula but temporary and prone to kinking