E2- Airway Equipment II Flashcards
Name the components of the laryngoscope.
- Handle
- Blade
- Light source (usually fiberoptic)
Manufactured as a single piece or detachable blade/handle
Which hand should handle the laryngoscope?
- Left Hand
Source of power for the laryngoscope light.
* Disposable batteries in the handle of the laryngoscope
* Typically C-Size Batteries
Most laryngoscope blades form a ________ angle to blade when ready for use.
- right
What are the 2 parts of the blade?
- Tongue: Manipulates and compresses soft tissue
- Tip - elevates epiglottis - direct or indirectly
What are the two types of laryngoscope blades?
- Mac (Curved)
- Miller (Straight)
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What is the purpose of the blade spatula?
- Compresses the tongue into the mandibular space
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What is the purpose of the flange?
- The flange (if present) is used to move the tongue laterally and create a visual lumen
Typical Mac sizes for adults
- Mac #3 (most common)
- Mac #4
Describe the tongue of a Mac blade compared to a Miller blade.
- Mac blade tongue has a gentle curve
- Miller blade has a straight tongue with a slight upward tip
Typical Miller sizes for adults
- Miller #2 (most common)
- Miller #3
Which laryngoscope blade has been shown to cause greater cervical spine movement?
- Macintosh Blade
Which laryngoscope blade is great for smaller mouths and longer necks?
- Miller Blade
Which laryngoscope blade will be used to minimize the movement of the cervical spine?
- Miller Blade
Uses LESS force, head extension, c-spine movement
Which laryngoscope blade makes** intubation easier** because the blade requires adequate mouth opening.
- Macintosh Blade
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When would you want to use a Miller #3 blade?
- Tall person
- Long neck
The laryngoscope blade requires less force, less head extension, and less cervical spine movement.
- Miller Blade
When using a Mac Blade, after epiglottis is visualized, the tip advanced into the _________.
Vallecula
When using a Mac Blade, the pressure applied at the right angle of the blade and the handle moves the ______ and ________forward.
- Base of the tongue
- Epiglottis
The Miller Blade will lift the ______.
- Epiglottis
If the Miller Blade is inserted too far, what structures can it elevate?
- Larynx
- Esophagus
What can happen if the Miller Blade is withdrawn too far?
- Epiglottis flips down and covers the glottis
How can the Miller Blade be used as a Macintosh?
- Miller Blade can also be inserted into the vallecula
How can Mac blade be used like a Miller?
Directly elevate tip of epiglottis
What is the optimal position for the patient undergoing direct laryngoscopy?
- Sniffing position
The sniffing position will have a ______ degree neck flexion (lower cervical).
The sniffing position will have a ____ degree head extension at the** atlanto-occiptal level.**
- 35 degree
- 80-90 degree
In the sniffing position, there should be an imaginary horizontal line that connects the _______ and ________.
- external auditory meatus
- sternal notch
Steps to inserting laryngoscope blade.
- Right hand opens mouth (“scissor”) to keep the lips free to accommodate blade insertion
- Insert blade on right side of the mouth
- Advance blade, keeping tongue to the left and elevated
- Epiglottis comes into view
What are some interventions for difficult airways?
- Maintain a neutral position + use an OPA
- Flexible fiberoptic scope
- Video laryngoscope
- awake or asleep
What is the maneuver to displace the larynx to get the glottis in view?
- BURP (Backwards Upward Rightward Pressure)
___________ patients will require elevation of the shoulder + upper back.
- Obese
Use ramping technique for these patients so they can have a horiztonal ear to sternal notch line.
What can be used to ramp a patient?
- Troop Elevation Pillow
- Folded Blankets
When ramping, create an imaginary horizontal line that connects?
External auditory meatus + sternal notch
Describe a Shikani Optical Stylet.
- Stainless steel lighted stylet with a malleable distal tip
- Design utilizes an eyepiece for DL
- Oxygen port for oxygen insufflation
What kind of position will the patient have for a Shikani Optical Stylet?
- Neutral Position
- inserted midline
Shikani Optical Stylet will advance into the trachea with ________ pressure, and the tip should remain _________ at all times to avoid injury.
*Light pressure
* Anterior (pointed up)
Shikani Optical Stylet can be used as a ________, check ETT placement, or placement of double-lumen ETT
- Light wand
4 Advantages of the Shikani Optical Stylet
- Easy to use for routine and difficult intubations
- Trachea is visualized. Esophageal intubation should not occur
- Decreased incidence of sore throat
- Results in less C-spine movement over conventional laryngoscopy
3 Disadvantages of the Shikani Optical Stylet
- Longer intubation time
- Cannot be used with nasal intubation. (not flexible)
- Cannot be adjusted into a precise direction compared to a traditional malleable stylet
Name the four most common Video Laryngoscopes.
- Glidescope
- Co-Pilot
- King
- McGrath
What are 6 advantages of using a video laryngoscope?
- Magnified anatomy
- Some scopes have curved/straight blades to mimic laryngoscopes
- Operator and assistant can see
- May result in decreased c-spine movement
- Further distance from infectious patients
- Demonstrates correct technique in legal cases
What are 2 limitations of using a video laryngoscope?
- Requires video system - batteries/power source
- Portability varies
What is 3 strongest predictor of failure when using a video laryngoscope?
- Altered neck anatomy with the presence of a surgical scar
- radiation changes
- mass
7 Complications of Laryngoscopy
- Dental Injuries
- Cervical Spinal Cord Injury
- Swallowing of foreign body (lightbulbs, teeth)
- Abrasions/Hematoma
- Lingual/ Hypoglossal nerve injury
- Arytenoid Subluxation
- Anterior TMJ dislocation
What is the most frequent anesthesia-related claim?
- Dental Injury
What is most likely damaged during laryngoscopy?
- Upper incisors
- Restored or weakened teeth
What can help mitigate laryngoscopy-related dental injury?
- Tooth protectors (placed on upper teeth during DL)
- Protects from blade causing direct surface damage
- Does not guarantee safety from dental trauma
How do you prevent cervical spinal cord injury during a laryngoscopy?
- Do not aggressively position the head
- Manual in-line stabilization (remove C-collar before intubation, have neurosurgeon remove C-collar)
Laryngoscopy causes damage to 4 structures
- Abrasions/hematomas – upper lip
- Lingual or hypoglossal nerve injury – placing blade + hitting them
- Arytenoid subluxation – don’t hit arytenoid with blade
- Anterior TMJ dislocation – don’t force mouth open
What 2 things are most likely to be swallowed / aspirated?
- light bulbs
- teeth
How many teeth does a healthy adult patient have?
- 32 teeth
What ETT properties causes change in resistance in the breathing system?
- Internal Diameter of the tube
- Tube Length
- Configuration changes (if tube knots up)
- Connectors
What is the most important factor causing resistance of ETT?
Internal diameter
Manufacturing Requirments of ETT
- Low cost
- Lack of tissue toxicity
- Easy sterilization
- Non-flammability
- Smooth, non-porous surface
- Sufficient body to maintain shape
- Sufficient wall strength
- Conforms to patient anatomy
- Lack of reaction with anesthetic agents and lubricants
- Latex-free
What is 3 function of having a smooth, non-porous surface of the ETT?
- Prevent/mitigate trauma
- Prevent/mitigate secretion buildup
- Allow passage of suction catheter or bronchoscope
How does the ETT design decrease kinking?
- Circular internal and external walls
The slanted bevel helps _____ _____?
view larynx
What part of the ETT provides an alternate pathway for gas flow?
- Murphy eye
- What does RAE Tube stand for?
- Are they cuffed?
- What are they made of?
- Ring-Adair-Elwin (RAE) Tube
- YES
- metal !! (MRI)
What are 5 advantages of RAE Tubes?
- Facilitate surgery around the head and neck
- Temporarily straightened during insertion
- Increased tube diameter… increased distance from tip to curve
- Easy to secure
- Nasal fiberoptic intubation.
What are 2 disadvantages of RAE Tubes?
- Difficult to pass suction/scope d/t angle
- Increases airway resistance
What are 3 other names for Armored Tubes?
- Reinforced Tube
- Anode Tube
- Spiral Embedded Tubes
What are 3 advantages of Armored Tubes?
- Useful when tube is likely to be bent or compressed
- Resistance to kinking and compression
- Useful in head, neck, tracheal surgeries
What are 4 disadvantages of Armored Tubes?
- Need a stylet or forceps
- Difficult to use during nasal intubation
- Cannot be shortened
- Tube can be damaged if bitten
- What makes up the laser-resistant tubes?
- When are they used?
- Metallic or silicone/ metal mixture
- surgeries that need laser to burn something off (oral cavity)
What kind of laser’s do laser-resistant tubes reflect?
- CO2 Laser
- KTP (Potassium-titanyl-phosphate) Laser
- What is Laser-Resistant Tube’s cuff filled with?
- Is the cuff laser resistant?
- Why double cuff?
- The cuff is filled with methylene blue crystals + saline so that, if the laser bursts the cuff, this will be detected quickly by the surgeon.
- NOT laser resistant
- So that if burst one still have another
Which cuff is filled first in the Laser-Resistant Tube?
- Distal + internal Cuff first
- Proximal Cuff second
Location of ETT markings
- Bevel side above the cuff
How do you read the ETT markings?
- From patient side (balloon) to machine side
What are 6 safety standards of the ETT markings?
- The word oral or nasal or oral/nasal
- Tube size in ID in mm (7.0, 7.5, etc)
- Name of manufacturer
- Graduated markings in centimeters from patient’s end
- Cautionary note… single use only if disposable
- Radiopaque marker at patient’s end (CXR for positioning)
Inflatable balloon near patient’s end of the tube
- Cuffs
Characteristics of an ETT Cuff.
- Strong
- Tear-resistant
- Thin
- Soft
- Pliable
The cuff must not herniate over what part of the ETT?
- Muphy eye
- Bevel
What is the recommended cuff pressure?
What happens if too much pressure?
How much air is that?
- 18-25 mmHg
- mucosal necrosis
- 8-10 mL of air
Monitor cuff pressure frequently with a manometer if using ______, as this causes cuff inflation/expansion.
- Nitrous
KNOW DIFFERENCES
What are the two different types of cuffs?
Which one is more common?
- High-volume, Low-pressure Cuff (more common = what we use)
- Low-volume, High-pressure Cuff
Describe the High-Volume, Low-Pressure Cuffs.
- Thin compliant wall
- Occludes trachea without stretching tracheal wall
- Area of contact larger but cuff adapts shape to tracheal wall shape
2 Advantages of High-Volume, Low-Pressure Cuffs
- Easy to regulate pressure
- Pressure applied to trachea less than mucosal perfusion pressure. (maintains circulation)
* Low Risk to Tracheal Mucosa
- Pressure applied to trachea less than mucosal perfusion pressure. (maintains circulation)
5 Disadvantages of High-Volume, Low-Pressure Cuffs
- More difficult to insert
- May obscure the view of the tube tip and larynx
- Cuff is more likely to be torn during intubation
- More likely to have a sore throat
- May not prevent fluid leakage
- Easy to pass NGT, esophageal stethoscopes around cuff
Describe Low-Volume, High-Pressure Cuffs.
- Has small area of contact with trachea
- Requires large amount of pressure to achieve a seal
- Distends and deforms the trachea to a circular shape
3 Advantages of Low-Volume, High-Pressure Cuffs.
- Better protection against aspiration
- Better visibility during intubation
- Lower incidence of sore throat
3 Disdvantages of Low-Volume, High-Pressure Cuffs.
- Pressure exerted on trachea probably above mucosal perfusion pressure
- Can cause mucosal damage
- Should be replaced with a low-pressure cuff if postoperative intubation is required
- MATCHING
- 4 Factors that can cause changes in cuff pressure.
- Do they increase or decrease pressure?
- Use of nitrous (↑ pressure)
- Hypothermic cardiopulmonary bypass (↓ pressure)
- Increases in altitude (↑ pressure)
- Coughing, straining, and changes in muscle tone (↑ pressure)
What are 4 common controversies involving airway equipment?
- Use of a stylets
- Securing ETT
- Use of Bite blocks/airways while intubated - not while lateral/prone
- Is it bad to intubate the esophagus?
List endotracheal tube 5 complications
- Trauma
- Inadvertent bronchial intubation
- Fluid accumulation above the cuff
- Upper airway edema
- Vocal cord granuloma
- ____ occurs from excessive force + repeated attempts.
- keep stylet ____ tube
- Trauma
- Inside
Use _________ for nasal intubation to mitigate bleeding and pre-dilate nasal passage.
- vasoconstrictors (Afrin/Cocaine)
Inadvertent bronchial intubations are most common in:
- Emergencies (Code Blue)
- Pediatrics (shorter distance to carina)
- Females (shorter right mainstem)
Inadvertent bronchial intubation can lead to _________ if left in place for too long.
- atelectasis
The distance to the carina decreases during what two things? Why?
- Trendelenburg and laparoscopy.
- Insufflation + shifting abdomen cephalad
What marking would you secure an ETT on a male patient?
Female patient?
- Male: 23 cm at teeth
- Female: 21 cm at teeth
REMEMBER :: females drink at 21 ,, males should wait til 23
What can accumulate above the cuff of ETT?
- Fluids
- Where does upper airway edema occur?
- Why is upper airway edema dangerous in young children?
- Peak incidence age?
- Along the length of tube
- Cricoid cartilage completely surrounds the subglottic area
- 1-4 years old
- Complications of airway edema can occur as early as _____ hours post to ____ hours postop.
- Avoid _______ stimuli – URI + Anesthetic depth
- 1-2 hours to 48 hrs
- irritating
- What is vocal cord granuloma?
- Who is more prone ?
- mass that result from irritation
- Adults + Females
What are the 4 causes of Vocal Cord Granuloma?
- Trauma
- ETT too large
- Infection
- Excessive cuff pressure
4 Signs and Symptoms of Vocal Cord Granuloma?
- Persistent hoarseness
- Fullness
- Chronic cough
- Intermittent loss of voice
Treatment of Vocal Cord Granuloma
- Laryngeal evaluation (ENT appt)
- Voice rest
This airway adjunct is typically used to aid tracheal intubation in poor laryngoscopic views or diffcult ETT passage.
* has a ______ base with resin coating
- Bougie
- polyester
The bougie has a polyester base with resin coating.
- The distal end of the bougie is angled _______- degrees.
- with _____ position in order to feel tracheal rings
- 30-45 degrees
- anterior
Introduce Bougie with anterior positioning of the tip.
Be Gentle.
You should feel the clicks of the tracheal rings.
What are these called?
What are they used for?
Considerations?
- Magill forceps
- Used primarily with nasal intubations to directs tube into larynx
- Considerations: Possible damage to cuffs and lodged in Murphy eye
3 uses for lung isolation
- thoracic procedures
- control contamination or hemorrhage
- unilateral pathology
The rationale for lung isolation in thoracic procedure
- Deflating the lung to increase safety profile and surgical exposure
The rationale for lung isolation to control contamination or hemorrhage
- Can prevent material in one lung from contaminating other
- Allows one lung to be ventilated while other hemorrhages
The rationale for lung isolation in unilateral pathology
- Isolate fistulas, ruptured cysts, or other issues with the diseased lung while allowing unilateral ventilation
KNOW DIFFERENCES
Anatomy of the Right Mainstem
angle, length, takeoff
- Shorter, straighter, + larger diameter
- 25 degree takeoff from trachea
- RUL tracheal takeoff = close to origin (proximal)
- Avg length = 2.5 cm from carina to take-off
Anatomy of the Left Mainstem
angle, length, takeoff
- 45 degree takeoff from trachea
- LUL tracheal takeoff = more distal
- Avg length 5.5 cm from carina to take-off
What are the adult sizes for the double-lumen tube?
- 35 Fr
- 37 Fr
- 39 Fr
- 41 Fr
ODD that geriatric pregnancy is 35-41
What are the pediatric sizes for the double-lumen tube?
- 26 Fr
- 28 Fr
- 32 Fr
That means “pediatric” pregnancy could be evenly 26-32
Which Double-Lumen Tube (DLT) is commonly used?
- Left Double-Lumen Tube
KNOW! TEST QUESTION
4 Procedures that will require a Right Double-Lumen Tube.
- ANYTHING on LEFT side
1. * Left pneumonectomy
1. * Left lung transplantation
1. * Left mainstem bronchus stent in place
1. * Left tracheo-bronchus disruption
Insertion of DLT is placed similarly as a standard ETT, but more difficult due to what?
- Stiffness
- Size
The DLT is advance through the larynx with angled tip __________ into the ________.
- Anterior
- Trachea
When inserting the DLT, when the _________ cuff passes the cords, the tube is turned ____ degrees. _____________ portion points toward the appropriate bronchus
- bronchial
- 90 degrees
- bronchial
DLT verification of the location of the bronchial port with a ________.
- fiberoptic scope
The __________ bronchial cuff of the DLT is just below the _______ in the appropriate bronchus.
- blue
- carina
Inflate DLT’s bronchial balloon under ___________to verify proper placement
- direct visualization
Ensure DLT’s bronchial cuff does not herniate over the ______.
- carina
How can you isolate a lung with the DLT?
- Clamping either tracheal or bronchial connector
What are 2 DLT complications?
- Tube malpositions
- Hypoxemia
What 2 cause DLT malposition + unsatisfactory lung collapse? Treatment?
- Bronchial lumen in the wrong mainstem = reinsertion
- Tube too proximal in airway = correct with fiberoptic
- What can cause hypoxemia with a DLT?
- Treatments?
- Malpositioning of DLT = reinsertion)
- Patient comorbidities = PEEP or intermittent 2-lung ventilation
Picture of DLT Insertion
What are 7 indications for Bronchial-Blockers?
- When DLT is not advisable
- Nasal intubation
- Difficult intubation
- Patients with tracheostomy
- Subglottic stenosis
- Need for continued postoperative intubation
- If a single-lumen tube is already in place (critically ill pts)
The function of the Bronchial Blocker.
- Can block a segment of the lung without isolating the entire lung
DLT cannot do this
4 Difficulties with Bronchial-blockers
- Right upper lobe bronchus takeoff is high
- Tracheal bronchus
- Fixation by staples during surgery
- Perforation by suture needle or instrumentation
What two teeth have the highest incidence of dental injuries?
Left Central Incisor (47%)
Left Lateral Incisor (20%)
