E2- Airway Equipment II Flashcards
1
Q
Name the components of the laryngoscope.
A
- Handle
- Blade
- Light source (usually fiberoptic)
Manufactured as a single piece or detachable blade/handle
2
Q
Which hand should handle the laryngoscope?
A
- Left Hand
3
Q
Source of power for the laryngoscope light.
A
* Disposable batteries in the handle of the laryngoscope
* Typically C-Size Batteries
4
Q
Most laryngoscope blades form a ________ angle to blade when ready for use.
A
- right
5
Q
What are the 2 parts of the blade?
A
- Tongue: Manipulates and compresses soft tissue
- Tip - elevates epiglottis - direct or indirectly
6
Q
What are the two types of laryngoscope blades?
A
- Mac (Curved)
- Miller (Straight)
7
Q
%%%%%%%%%%%
What is the purpose of the blade spatula?
A
- Compresses the tongue into the mandibular space
8
Q
%%%%%%%%%
What is the purpose of the flange?
A
- The flange (if present) is used to move the tongue laterally and create a visual lumen
9
Q
Typical Mac sizes for adults
A
- Mac #3 (most common)
- Mac #4
10
Q
Describe the tongue of a Mac blade compared to a Miller blade.
A
- Mac blade tongue has a gentle curve
- Miller blade has a straight tongue with a slight upward tip
11
Q
Typical Miller sizes for adults
A
- Miller #2 (most common)
- Miller #3
12
Q
Which laryngoscope blade has been shown to cause greater cervical spine movement?
A
- Macintosh Blade
13
Q
Which laryngoscope blade is great for smaller mouths and longer necks?
A
- Miller Blade
14
Q
Which laryngoscope blade will be used to minimize the movement of the cervical spine?
A
- Miller Blade
Uses LESS force, head extension, c-spine movement
15
Q
Which laryngoscope blade makes** intubation easier** because the blade requires adequate mouth opening.
A
- Macintosh Blade
16
Q
%%%%%%%
When would you want to use a Miller #3 blade?
A
- Tall person
- Long neck
17
Q
The laryngoscope blade requires less force, less head extension, and less cervical spine movement.
A
- Miller Blade
18
Q
When using a Mac Blade, after epiglottis is visualized, the tip advanced into the _________.
A
Vallecula
19
Q
When using a Mac Blade, the pressure applied at the right angle of the blade and the handle moves the ______ and ________forward.
A
- Base of the tongue
- Epiglottis
20
Q
The Miller Blade will lift the ______.
A
- Epiglottis
21
Q
If the Miller Blade is inserted too far, what structures can it elevate?
A
- Larynx
- Esophagus
22
Q
What can happen if the Miller Blade is withdrawn too far?
A
- Epiglottis flips down and covers the glottis
23
Q
How can the Miller Blade be used as a Macintosh?
A
- Miller Blade can also be inserted into the vallecula
24
Q
How can Mac blade be used like a Miller?
A
Directly elevate tip of epiglottis
25
What is the optimal position for the patient undergoing direct laryngoscopy?
* Sniffing position
26
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
27
In the sniffing position, there should be an imaginary horizontal line that connects the _______ and ________.
* external auditory meatus
* sternal notch
28
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
29
What are some interventions for difficult airways?
* Maintain a neutral position + use an OPA
* Flexible fiberoptic scope
* Video laryngoscope
* awake or asleep
30
What is the maneuver to displace the larynx to get the glottis in view?
* BURP (Backwards Upward Rightward Pressure)
31
___________ patients will require elevation of the shoulder + upper back.
* Obese
## Footnote
Use ramping technique for these patients so they can have a horiztonal ear to sternal notch line.
32
What can be used to ramp a patient?
* Troop Elevation Pillow
* Folded Blankets
33
When ramping, create an imaginary horizontal line that connects?
External auditory meatus + sternal notch
34
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
35
What kind of position will the patient have for a Shikani Optical Stylet?
* Neutral Position
* inserted midline
36
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)
37
Shikani Optical Stylet can be used as a ________, check ETT placement, or placement of double-lumen ETT
* Light wand
38
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
39
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
40
Name the four most common Video Laryngoscopes.
* Glidescope
* Co-Pilot
* King
* McGrath
41
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
42
What are 2 limitations of using a video laryngoscope?
* Requires video system - batteries/power source
* Portability varies
43
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
44
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
45
What is the most frequent anesthesia-related claim?
* Dental Injury
46
What is most likely damaged during laryngoscopy?
* Upper incisors
* Restored or weakened teeth
47
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
48
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)
49
Laryngoscopy causes damage to 4 structures
1. **Abrasions**/hematomas – upper lip
2. **Lingual or hypoglossal** nerve injury – placing blade + hitting them
3. **Arytenoid** subluxation – don’t hit arytenoid with blade
4. Anterior **TMJ** dislocation – don’t force mouth open
50
What 2 things are most likely to be swallowed / aspirated?
* light bulbs
* teeth
51
How many teeth does a healthy adult patient have?
* 32 teeth
52
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
53
What is the most important factor causing resistance of ETT?
Internal diameter
54
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
55
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
56
How does the ETT design decrease kinking?
* **Circular** internal *and* external walls
57
The slanted bevel helps _____ _____?
view larynx
58
What part of the ETT provides an alternate pathway for gas flow?
* Murphy eye
59
* What does RAE Tube stand for?
* Are they cuffed?
* What are they made of?
* Ring-Adair-Elwin (RAE) Tube
* YES
* metal !! (MRI)
60
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.
61
What are 2 disadvantages of RAE Tubes?
* Difficult to pass suction/scope d/t angle
* Increases airway resistance
62
What are 3 other names for Armored Tubes?
* Reinforced Tube
* Anode Tube
* Spiral Embedded Tubes
63
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
64
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
65
* 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)
66
What kind of laser's do laser-resistant tubes reflect?
* CO2 Laser
* KTP (Potassium-titanyl-phosphate) Laser
67
* 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
68
Which cuff is filled first in the Laser-Resistant Tube?
* Distal + internal Cuff first
* Proximal Cuff second
69
Location of ETT markings
* Bevel side above the cuff
70
How do you read the ETT markings?
* From patient side (balloon) to machine side
71
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)
72
Inflatable balloon near patient's end of the tube
* Cuffs
73
Characteristics of an ETT Cuff.
* Strong
* Tear-resistant
* Thin
* Soft
* Pliable
74
The cuff must not herniate over what part of the ETT?
* Muphy eye
* Bevel
75
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
76
**Monitor cuff pressure** frequently with a manometer if using ______, as this causes cuff inflation/expansion.
* Nitrous
77
# **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
78
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
79
2 Advantages of High-Volume, Low-Pressure Cuffs
1. * Easy to regulate pressure
1. * Pressure applied to trachea less than mucosal perfusion pressure. (maintains circulation)
* Low Risk to Tracheal Mucosa
80
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
81
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
82
3 Advantages of Low-Volume, High-Pressure Cuffs.
* Better protection against aspiration
* Better visibility during intubation
* Lower incidence of sore throat
83
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
84
* ***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)
85
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?
86
List endotracheal tube 5 complications
1. * Trauma
1. * Inadvertent bronchial intubation
1. * Fluid accumulation above the cuff
1. * Upper airway edema
1. * Vocal cord granuloma
87
* ____ occurs from excessive force + repeated attempts.
* keep stylet ____ tube
* Trauma
* Inside
88
Use _________ for nasal intubation to mitigate bleeding and pre-dilate nasal passage.
* vasoconstrictors (Afrin/Cocaine)
89
Inadvertent bronchial intubations are most common in:
* Emergencies (Code Blue)
* Pediatrics (shorter distance to carina)
* Females (shorter right mainstem)
90
Inadvertent bronchial intubation can lead to _________ if left in place for too long.
* atelectasis
91
The distance to the carina decreases during what two things? Why?
* Trendelenburg and laparoscopy.
* Insufflation + shifting abdomen cephalad
92
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*
93
What can accumulate above the cuff of ETT?
* Fluids
94
* 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
95
* 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
96
* What is vocal cord granuloma?
* Who is more prone ?
* mass that result from irritation
* Adults + Females
97
What are the 4 causes of Vocal Cord Granuloma?
* Trauma
* ETT too large
* Infection
* Excessive cuff pressure
98
4 Signs and Symptoms of Vocal Cord Granuloma?
* Persistent hoarseness
* Fullness
* Chronic cough
* Intermittent loss of voice
99
Treatment of Vocal Cord Granuloma
* Laryngeal evaluation (ENT appt)
* Voice rest
100
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
## Footnote
The bougie has a polyester base with resin coating.
101
* The distal end of the bougie is angled _______- degrees.
* with _____ position in order to feel tracheal rings
* 30-45 degrees
* anterior
## Footnote
Introduce Bougie with anterior positioning of the tip.
Be Gentle.
You should feel the clicks of the tracheal rings.
102
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**
103
3 uses for lung isolation
1. thoracic procedures
2. control contamination or hemorrhage
3. unilateral pathology
104
The rationale for lung isolation in thoracic procedure
* Deflating the lung to increase **safety profile** and surgical **exposure**
105
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**
106
The rationale for lung isolation in unilateral pathology
* Isolate **fistulas**, ruptured **cysts**, or other issues with the diseased lung while allowing unilateral ventilation
107
# 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
108
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
109
What are the adult sizes for the double-lumen tube?
* 35 Fr
* 37 Fr
* 39 Fr
* 41 Fr
## Footnote
ODD that *geriatric* pregnancy is 35-41
110
What are the pediatric sizes for the double-lumen tube?
* 26 Fr
* 28 Fr
* 32 Fr
## Footnote
That means "*pediatric*" pregnancy could be evenly 26-32
111
Which Double-Lumen Tube (DLT) is commonly used?
* Left Double-Lumen Tube
112
# **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
113
Insertion of DLT is placed **similarly** as a standard ETT, but more difficult due to what?
* Stiffness
* Size
114
The DLT is advance through the larynx with angled tip __________ into the ________.
* Anterior
* Trachea
115
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
116
DLT verification of the location of the bronchial port with a ________.
* fiberoptic scope
117
The __________ bronchial cuff of the DLT is just below the _______ in the appropriate bronchus.
* blue
* carina
118
Inflate DLT's bronchial balloon under ___________to verify proper placement
* direct visualization
119
Ensure DLT's bronchial cuff does not herniate over the ______.
* carina
120
How can you isolate a lung with the DLT?
* Clamping either tracheal or bronchial connector
121
What are 2 DLT complications?
* Tube malpositions
* Hypoxemia
122
What 2 cause DLT malposition + unsatisfactory lung collapse? Treatment?
* Bronchial lumen in the **wrong mainstem** = reinsertion
* Tube **too proximal** in airway = correct with fiberoptic
123
* What can cause hypoxemia with a DLT?
* Treatments?
* Malpositioning of DLT = reinsertion)
* Patient comorbidities = PEEP or intermittent 2-lung ventilation
124
Picture of DLT Insertion
125
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)
126
The function of the Bronchial Blocker.
* Can block a segment of the lung without isolating the entire lung
| *DLT cannot do this*
127
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
128
What two teeth have the highest incidence of dental injuries?
Left Central Incisor (47%)
Left Lateral Incisor (20%)
