Chapter 77 - Intubation and Tracheotomy

Question 1

how to estimate ET tube size in kids ages 1-12

Answer 1

Age/4 + 3 if cuffed

Age/4 + 4 if uncuffed

Question 2

mortality rate of trachea-innominate fistula

Answer 2

73%

Question 3

Which trach incision can be used in kids to decrease risk of subglottic stenosis: horizontal or vertical?

Answer 3

vertical

Question 4

which H/N location absorbs the greatest amount of cocaine?

Answer 4

trachea

Question 5

Which cuff pressure will compromise capillary blood flow to the trachea?

Answer 5

34 cm H2O

Question 6

How to treat airway fire

Answer 6

Turn off O2 - Saline - remove tube - reintubate - IV steroids/ABx - bronch to remove charred tissue - delayed extubation

Question 7

ET tube size for neonate

Answer 7

2.5-3

Question 8

tube size for 1-6 mo and 6-12 mo

Answer 8

3-3.5

3.5-4

Question 9

tube size for toddler

Answer 9

4-5

Question 10

tube size for adult female

Answer 10

6-7

Question 11

tube size for adult male

Answer 11

7-8

Question 12

Describe Cormack-Lehane airway grades

Answer 12

I- entire glottis
II- partial glottis
III- epiglottis only
IV- can’t see epiglottis

Question 13

Blockage at what part of the airway would produce stertor

Answer 13

OP/NP

Question 14

Use of heliox with airway obstruction

Answer 14

21:79 O2:He
less dense –> can get higher flow rate –> less turbulent flow means more air to distal lungs –> also decreases pressure gradient needed to move air across obstruction
Helium is inert, insoluble

Question 15

how do IV steroids decrease airway inflammation/edema

Answer 15

reduced capillary dilation
decreased plasma extravastation
decreased inflammation

Question 16

Indications for fiberoptic intubation

Answer 16

h/o prior difficult intubation requiring fiberoptic
micrognathia
C-spine issue (unstable, fused disk)
facial trauma
obstruction above glottis
need awake intubation (cannot mask ventilate)
trismus

Question 17

Why place trach tube between second and third tracheal rings

Answer 17

higher: erode or fracture cricoid cartilage –> subglot sten
lower: risk to innominate artery

Question 18

where to make skin incision for trach

Answer 18

two fingerbreadths above sternal notch

Question 19

Steps to cricothyroidotomy

Answer 19

find CTM (1cm tall)
vertical skin incision
horizontal CTM incision
retract wound open
pass tube

Question 20

can you do a cricothyroidotomy in young patients?

Answer 20

infants and young children do not have a CTM – they need emergent tracheotomy

Question 21

how to treat subcutaneous emphysema after trach

Answer 21

cut sutures, inflate cuff

stat CXR to evaluate cause

Question 22

factors contributing to TI fistula

Answer 22

overinflated cuff
poorly fit tube
poor wound healing

TI fistula occurs with erosion of trach tube through tracheal wall into innominate

Question 23

how to treat urgent post-trach bleed

Answer 23

inflate cuff
if uncuffed, insert 6.0 cuffed and inflate
if innominate artery bleed, stick finger in, compress innominate between finger and sternum –> OR

Question 24

when to use Bjork flap

Answer 24

if going to have trach long term
helps you keep a patent stoma if accidental decannulation
increases risk of tracheocutaneous fistula after decannulation

Question 25

theoretically can trach tubes increase aspiration risk?

Answer 25

possibly, due to decreased hyolaryngeal elevation

Question 26

when to use cuffed trach tube

Answer 26

if need positive airway pressure to ventilate

to slow aspiration

Question 27

risks/benefits of percutaneous trach

Answer 27

risks: blunt objects –> crush tracheal rings –> stenosis/malacia; transect high-riding innominate
benefits: shorter, cost-effective, similar long term complications

Perc uses dilational/Seldinger technique