E2 - Airway Equipment II Flashcards
Describe a Shikani Optical Stylet. 3
- 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 and how is it inserted?
A. supine and inserted from the left
B. left lateral and inserted midline
C. right lateral and inserted midline
D. neutral and inserted midline
D. Neutral Position and stylet inserted midline
Shikani Optical Stylet will advance into the trachea with light pressure, and the tip should remain _________ at all times to avoid injury.
A. anterior
B. posterior
C. midline
D. lateral
A. Anterior (pointed up)
Shikani Optical Stylet uses: Select 3.
A. double-lumen ETT
B. mac Blade
C. bronchoscope
D. light wand
E. check ETT placement
F. easier extubation
A. double lumen ETT
D. Light wand
E. check ETT placement
What is an advantage of the Shikani Optical Stylet?
A. allows more C-spine movement than conventional laryngoscopy
B. trachea is visualized
C. increase incidence of sore throat
D. harder for easy intubations
B. Trachea is visualized. Esophageal intubation should not occur
- Easy to use for routine and difficult intubations
- Decreased incidence of sore throat
- Results in less C-spine movement over conventional laryngoscopy
What is a disadvantages of the Shikani Optical Stylet?
A. too flexible
B. might cause nasal intubation
C. longer intubation time
D. too similar to a traditional malleable stylet
C. 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
Go, Cut, King, Mhmm
What are some advantages of using a video laryngoscope? Select 2.
A. operator and assistant can see
B. minimized anatomy
C. may result in decreased C spine movement
D. cannot be used in legal cases
E. closer distance to patient
A. Operator and assistant can see
C. May result in decreased c-spine movement
Also:
* Magnified anatomy
* Some scopes have curved/straight blades to mimic laryngoscopes
* Further distance from infectious patients
* Demonstrates correct technique in legal cases
What are the limitations of using a video laryngoscope?
- Requires video system
- Portability varies (Glidescope needs to be plugged in)
What is the strongest predictor of failure when using a video laryngoscope?
A. a longer intubation time
B. altered neck anatomy with presence of a mass
C. worse visualization of epiglottis
D. increased c-spine movement
B. Altered neck anatomy with the presence of a surgical scar, radiation changes, or mass
so like a failed intubation may still happen w/ a video laryngscope
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?
A. cut lip
B. dental injury
C. c-spine injury
D. lingual abrasion
B. Dental Injury
LIKELY TO BE A TEST QUESTION LOL
What is most likely damaged during laryngoscopy? Select 2.
A. Tongue
B. C spine
C. Upper incisors
D. buccal
E. restored or weakend teeth
F. arytenoid subluxation
C. Upper incisors
E. Restored or weakened teeth
What can help mitigate laryngoscopy-related dental injury?
A. scissoring appropriately
B. tooth protectors
C. using video
D. ask them which teeth are damaged
D. Tooth protectors - placed on upper teeth during DL
it 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?
A. place a c collar
B. stabilize the head in-line and let nsgy intubate patient
C. remove the c collar
D. do not aggressively position the head
D. Do not aggressively position the head
* Manual in-line stabilization (remove C-collar before intubation, BUT have neurosurgeon remove C-collar!)
* DO NOT let nsgy intubate the patient!
How many teeth does a healthy adult patient have?
- 32 teeth
What ETT properties will contribute to the change in resistance in the breathing system? Select 2.
A. connectors
B. outer diameter of the tube
C. less corrugated tubing
D. tube length
A. Connectors
D. Tube Length
ALSO:
* INTERNAL Diameter of the tube
* Configuration changes (if tube knots up)
Manufacturing Requirments of ETT
- Low cost
- Lack of tissue toxicity
- Easy sterilization
- Non-flammability
- Smooth, non-porous surface
- Sufficient body to maintain its shape
- Sufficient wall strength
- Conforms to patient anatomy
- Lack of reaction with anesthetic agents and lubricants
- Latex-free
What is the function of having a smooth, non-porous surface of the ETT?
A. prevent secretion buildup
B. allow passage of suction catheter
C. prevent trauma
D. all of the above
D. all of the above
* Prevent/mitigate trauma
* Prevent/mitigate secretion buildup
* Allow passage of suction catheter or bronchoscope
Why is the slanted bevel (patient end) of the ETT important?
A. can be shortened for shorter necks
B. decreases kinking
C. helps view larynx
D. provides alternate pathway for gas flow
C. helps view larynx
What part of the ETT provides an alternate pathway for gas flow?
A. circular walls
B. murphy eye
C. slanted bevel
D. machine end
B. Murphy eye
What does RAE Tube stand for?
A. Ring-Air-Erwin
B. Ring-Adair-Elwin
C. Ring-Air-Elwin
D. Ring-Adair-Erwin
B. Ring-Adair-Elwin (RAE) Tube
What are the advantages of RAE Tubes?
A. useful for open belly cases
B. decreased tube diameter
C. can be placed without administration of muscle relaxer
D. facilitate surgery around head and neck
D. Facilitate surgery around the head and neck
Also:
* Temporarily straightened during insertion
* Increased tube diameter… increased distance from tip to curve
* Easy to secure
* Nasal fiberoptic intubation.
What are the disadvantages of RAE Tubes? Select 2.
A. difficult to pass suction/scope
B. suction/scope may slide too deep
C. decreases airway resistance
D. increases airway resistance
A. Difficult to pass suction/scope
D. Increases airway resistance
What are other names for Armored Tubes?
- Reinforced Tube
- Anode Tube
- Spiral Embedded Tubes
RAS
What are the advantages of Armored Tubes?
- Useful when tube is likely to be bent or compressed b/c it is Resistance to kinking and compression
- Useful in head, neck, tracheal surgeries
What are the disadvantages of Armored Tubes? Select 2.
A. can’t be shortened
B. tube can be damaged if bitten
C. harder to secure
D. can’t be used during head, neck, or tracheal surgeries
E. resistant to kinking
A. Cannot be shortened
B. Tube can be damaged if bitten
Also:
* Need a stylet or forceps
* Difficult to use during nasal intubation!!
Which type of ETT requires stylet or forceps?
armored tubes
AKA reinforced / amode / spiral embedded tubes
which 2 types of ETT can be used for head and neck surgeries?
A. RAE tube
B. laser-resistant tube
C. reinforced tube
D. slanted tube
A. RAE tube
C. reinforced tube (aka armored, amode, or spiral embedded tubes)
What mixture makes up the laser-resistant tubes?
- Metallic or silicone/ metal mixture
What 2 kinds of laser beams do laser-resistant tubes reflect?
A. CO laser
B. CO2 laser
C. ATP laser
D. KTP laser
E. MTP laser
B. CO2 Laser
D. KTP (Potassium-titanyl-phosphate) Laser
What are the Laser-Resistant Tube’s cuff filled with? Select 2
A. methylene violet
B. methylene blue
C. lactated ringers
D. saline
E. ethyl violet
F. ethyl blue
The cuff is filled with B. methylene blue crystals and D. saline so that, if the laser bursts the cuff, this will be detected quickly by the surgeon.
Which cuff is filled first in the Laser-Resistant Tube?
- Distal 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 the safety standards of the ETT markings?
- The word oral or nasal or oral/nasal
- Tube size in Internal Diameter 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)
What is the inflatable balloon near patient’s end of the tube called?
Cuff
Characteristics of an ETT Cuff.
- Strong
- Tear-resistant
- Thin
- Soft
- Pliable
What 2 parts of the ETT must the cuff not herniate over?
A. internal diameter
B. murphy eye
C. graduated markings
D. bevel
E. radiopaque marker
B. Muphy eye
D. Bevel
What is the recommended cuff pressure?
How much air is that?
- 18-25 mmHg
- 8-10 mL of air
Monitor cuff pressure frequently with a manometer if using ________, as this causes cuff inflation/expansion.
A. desflurane
B. sevoflurane
C. isoflurane
D. nitrous
D. Nitrous
What are the two different types of cuffs?
Which one is more common?
- High-volume, Low-pressure Cuff (more common)
- Low-volume, High-pressure Cuff
Describe the High-Volume, Low-Pressure Cuffs. Select 2
A. occludes trachea by stretching tracheal wall
B. area of contact to trachea is smaller
C. cuff adapts shape to tracheal wall shape
D. area of contact to trachea is larger and doesn’t adapt to wall shape
E. pressure applied to trachea is less than mucosal perfusion pressure
C. cuff adapts shape to tracheal wall shape
And:
* Thin compliant wall
* Occludes trachea without stretching tracheal wall
* Area of contact larger but cuff adapts shape to tracheal wall shape
Advantages of High-Volume, Low-Pressure Cuffs
- Easy to regulate pressure
- Pressure applied to trachea less than mucosal perfusion pressure. (aka maintains circulation to tracheal mucosa = no necrosis :))
What is a disadvantage of High-Volume, Low-Pressure Cuffs?
A. easier to insert deep
B. may not prevent fluid leakage
C. harder to pass NGT around cuff
D. cuff is likely to be torn which means less likely to have sore throat
B. May not prevent fluid leakage
* 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
- Easy to pass NGT, esophageal stethoscopes around cuff
Describe the Low-Volume, High-Pressure Cuffs:
Select 2
A. small area of contact with trachea
B. requires small amount of pressure to achieve seal
C. distends and deforms the trachea
D. large area of contact with trachea
A. Has small area of contact with trachea
C. Distends and deforms the trachea to a circular shape
and, Requires large amount of pressure to achieve a seal
What is an advantage of Low-Volume, High-Pressure Cuffs?
A. higher incidence of a sore throat
B. may obscure the view of tube tip and larynx
C. better protection against aspiration
D. pressure applied to trachea is less than mucosal perfusion pressure
C. Better protection against aspiration
And:
* Better visibility during intubation
* Lower incidence of sore throat
Disdvantages of Low-Volume, High-Pressure Cuffs.
A. don’t protect against fluid leakage
B. pressure exerted on trache is below mucosal perfusion pressure
C. do not distend trachea well enough
D. can cause tracheal necrosis
D. Can cause mucosal damage/necrosis; because Pressure exerted on trachea probably above mucosal perfusion pressure
Should be replaced with a low-pressure cuff if postoperative intubation is required!!
What are 3 factors that can cause an increase in cuff pressure?
A. use of nitrous
B. decreases in altitude
C. increases in altitude
D. hypothermic cardiopulmonary bypass
E. coughing & straining
F. increased gas flow
A. Use of nitrous (↑ pressure)
C. Increases in altitude (↑ pressure)
E. Coughing, straining, and changes in muscle tone (↑ pressure)
Hypothermic cardiopulmonary bypass (↓ pressure)
What are 4 common controversies involving airway equipment?
- Use of a stylet
- Securing ETT
- Use of Bite blocks/airways while intubated
- Is it bad to intubate the esophagus?
List endotracheal tube complications
- Trauma
- Inadvertent bronchial intubation
- Fluid accumulation above the cuff
- Upper airway edema
- Vocal cord granuloma
tubog
inadvertenly
flopped
up
vanilla cake
Use _________ for nasal intubation to mitigate bleeding and don’t forget to pre-dilate nasal passage.
A. lidocaine spray
B. vasodilators
C. stylet
D. cocaine
D. vasoconstrictors (Afrin/Cocaine)
Where do you keep stylet while intubating?
A. past the murphy eye
B. inside tube
C. at the tip of the tube
D. remove it right before intubating
B. INSIDE tube (and don’t pass murphy’s eye)
Inadvertent bronchial intubations are most common in:
A. females
B. geriatrics
C. longer distances to carina
D. slower intubations
A. Females (shorter right mainstem)
And:
* in Emergencies (Code Blue)
* Pediatrics (shorter distance to carina)
Inadvertent bronchial intubation can lead to _________ if left in place for too long.
A. adaptation of lung to V/Q mismatch
B. right pneumothorax
C. atalectasis
D. mainstem shift to left
C. atelectasis
The distance to the carina _________(decreases/increases) with Trendelenburg and laparoscopy.
Decreases
making it more likely for ETT to be dislodged into right mainstem
What marking would you secure an ETT on a male patient?
Female patient?
Male: 23 cm at the teeth
Female: 21 cm at the teeth
Why is upper airway edema dangerous in young children?
Peak incidence age?
- Cricoid cartilage completely surrounds the subglottic area
- 1-4 years old
Complications of airway edema can occur as early as _____ hours post to 48 hours postop.
- 1-2 hours
Who is more prone to vocal cord granuloma?
- Adults
- Females
Vocal cord granulomas are masses that result from irritation.
What are the causes of Vocal Cord Granuloma?
- Trauma
- ETT too large
- Infection
- Excessive cuff pressure
What is a s/sx of Vocal Cord Granuloma?
A. intermittent loss of voice
B. acute cough
C. trouble swallowing
D. sore throat
A. Intermittent loss of voice
AND:
* Persistent hoarseness
* Fullness
* Chronic cough
What is the treatment for 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:
A. forceps
B. armored tube
C. video laryngoscope
D. bougie
D. Bougie
has a polyester base with resin coating w/ distal end angled 30-45 degrees
What is important to note when using a bougie?
A. do not use with blind intubations
B. introduce posterior positioning of the tip
C. you should feel the clicks of the tracheal rings
D. be firm
C. you should feel the clicks of the tracheal rings
RMBR: be gentle, and introduce bougie with ANTERIOR positioning of the tip
tip is angled 30-45 degrees
What are these called?
What are they used for?
Considerations?
- Magill forceps
- Used primarily with nasal intubations to directs tube into the larynx
- Considerations: Possible damage to tube cuffs and lodged in Murphy eye
What’s the rationale for lung isolation (deflating the lung) in a thoracic procedure?
A. increase surgical interference
B. increase safety profile and surgical exposure
C. increase ability for thorax to be opened
D. increase likelihood of a pneumothorax
B. Deflating the lung to increase safety profile and surgical exposure
What’s the rationale for lung isolation to control contamination or hemorrhage?
A. can ventilate one lung while they remove the other lung
B. can deflate a lung to stop it from hemorrhaging
C. allow one lung to be ventilated while other hemorrhages
D. can deflate the diseased lung to remove it
C. Allows one lung to be ventilated while other hemorrhages
also, Can prevent material in one lung from contaminating other
The rationale for lung isolation in unilateral pathology
- Isolate fistulas, ruptured cysts, or other issues with the diseased lung while allowing unilateral ventilation
so kinda similar concept to controlling contamination/hemorrhage
Anatomy of the Right Mainstem
- Shorter, straighter, larger diameter
- 25 degree takeoff from trachea
- RUL tracheal takeoff very close to origin
- Avg length - 2.5 cm from carina to take-off
Anatomy of the Left Mainstem
- 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
think: an adult is in their 30-40s / kids are still in their 20s
What are the pediatric sizes for the double-lumen tube?
- 26 Fr
- 28 Fr
- 32 Fr
my little sister is 26 and still consider her a kid
Which Double-Lumen Tube (DLT) is commonly used?
- Left Double-Lumen Tube
Procedures that will require a Right Double-Lumen Tube.
- Left pneumonectomy
- Left lung transplantation
- Left mainstem bronchus stent in place
- Left tracheo-bronchus disruption
Insertion of DLT is placed similarly as a standard ETT, but more difficult due to what 2 things?
A. stiffness
B. shorter
C. size
D. sliding too easily
A. Stiffness
C. Size
The DLT is advance through the larynx with angled tip anterior into the ________.
- Trachea
For inserting the DLT, when the bronchial cuff passes the cords, the tube is turned ____ degrees
- 90 degrees
Bronchial portion points toward the appropriate bronchus
DLT verification of the location of the bronchial port with a ________.
- fiberoptic scope
The blue bronchial cuff of the DLT is just below the _______ in the appropriate bronchus.
- 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?
A. pull back on the blue cuff
B. clamp either tracheal or bronchial connector
C. deflate the regular cuff
D. turn the cuff another 90 degrees
B. Clamping either the tracheal or bronchial connector
What are some DLT complications?
- Tube malpositions
- Hypoxemia
What can cause DLT malposition and unsatisfactory lung collapse?
- Bronchial lumen in the wrong mainstem (needs reinsertion)
- Tube too proximal in airway (correct with fiberoptic)
What can cause hypoxemia with a DLT?
- Malpositioning of DLT (needs reinsertion)
- Patient comorbidities (may need PEEP or intermittent 2-lung ventilation)
What are the indications for Bronchial-Blockers?
When DLT is not advisable like with:
* 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
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%)
