ETTs Flashcards
Exam 4
Who is considered the first to perform intubation anesthetic?
Sir William Macewen in 1880
What did Franz Kuhn contribute to endotracheal intubation?
in what year?
Modified the ETT and made it easier for intubation
1901
What are the primary reasons for intubation?
- Oxygenation
- Positive pressure ventilation
- Airway protection
- Pulmonary toilet
What is considered the ‘gold standard’ for airway protection?
Endotracheal intubation
What are absolute indications for endotracheal intubation?
7 of them
- Full stomach (At risk for aspiration)
- Lung isolation and one-lung ventilation
- Critically ill patients
- Surgery of the head and neck where SGA would be in the way
- Failed placement of a SGA
Lung disease or abnormalities
Postop intubation/vent support is needed
NMBDs needed for surgery
What is an endotracheal tube (ETT) primarily made of?
Plastic, disposable, single-use materials
What is the purpose of the Murphy eye in an ETT?
Allows ventilation if the end is occluded by soft tissue or secretions
What are the two types of cuffs in endotracheal tubes?
- High pressure, low volume
- Low pressure, high volume
Name 5 differences in pediatric airways compared to adult airways:
Larger tongue can cause airway obstruction
larynx is higher in the neck
epiglottis is shorter/stubbier
vocal cords are angled
funnel-shaped larynx
What is the formula for pediatric ETT sizing?
Internal diameter in mm = (age in years)/4 + 4 (for uncuffed tube)
What does the ‘leak test’ confirm in uncuffed tubes?
Gas leak is heard at 15-20 cm H2O; no leak means tube is too big, excessive leak means tube is too small
What is the recommended cuff pressure during intubation?
Less than 25 cm H2O
What factors can alter cuff pressure?
- Volume of air
- Cuff diameter
- Compliance of trachea and cuff
- Intrathoracic pressure
- Diffusion of N2O into the cuff
Increased cuff pressure can cause what 3 things?
- Sore throat
- Vocal cord dysfunction
- Recurrent laryngeal nerve injury
what is the Green (ideal range) of a cuff manometer reading for an ETT and LMA?
ETT- 22-32 (or a max of 30)
LMA- 32-60
What is the insertion depth for male and female ETTs?
- Male: 22-23 cm at teeth
- Female: 21 cm at teeth
What is the three measurements in the 3-3-2 rule used for?
Predicting difficult intubation
What are the three measurements of the 3-3-2 rule?
- Three fingers between upper and lower teeth (interincisor distance)
- Three fingers from anterior mandible to anterior neck (hyoid-mental distance)
- Two fingers between floor of mandible and thyroid notch (hyoid-thyroid cartilage distance)
What are the advantages of a fiberoptic bronchoscope (FOB) during intubation?
Provides confirmation of ETT placement and better visualization of the airway
no need to align the axes
What is a double-lumen tube used for?
Single-lung ventilation
What are the contraindications for retrograde intubation?
- Abnormal anatomy
- Infection at the site
- Difficulty accessing the cricothyroid membrane
- Coagulopathy
- Stenosis of the trachea
What is transtracheal jet ventilation used for?
Emergency airway management when intubation and ventilation fail
What complications can arise from transtracheal jet ventilation?
- Barotrauma
- Pneumothorax
What is a needle cricothyrotomy?
An emergency procedure to establish an airway through the cricothyroid membrane using a needle and cannula.
It is used when traditional intubation is not possible.
What is required for expiration during needle cricothyrotomy?
Expiration is passive.
What can occur if there is a barotrauma during needle cricothyrotomy?
Pneumothorax can occur.
What does transtracheal jet ventilation require?
A 12- to 16-gauge catheter or a 6 Fr catheter.
What pressure is needed to drive the jet ventilator during transtracheal jet ventilation?
15 psi.
What are the complications associated with transtracheal jet ventilation?
Barotrauma and pneumothorax.
What is the purpose of a cricothyrotomy?
Used as an emergent airway or may be clinically indicated as a temporary airway.
Where should the incision be made during a cricothyrotomy?
In the lower third of the cricothyroid membrane.
What complications can arise from a cricothyrotomy?
Injury to the esophagus, trachea, vocal cords, thyroid gland, incorrect insertion of the cannula.
What type of endotracheal tube is used for head and neck surgery?
Armored ETT.
What is a disadvantage of armored tubes?
Once kinked, it will not return to its original shape, leading to airway obstruction.
What is the SHERIDAN® LTS™ MICROLARYNGEAL ETT designed for?
Microlaryngeal or tracheal surgery.
What is the primary use of Combitube?
A pre-hospital airway device for adult population only
What should be done if breath sounds are heard during Combitube insertion?
Use it as a regular ETT.
What is the purpose of laser tubes in surgery?
Used for surgery of the trachea or larynx and can withstand laser beams.
What material are laser tubes typically made from?
Polyvinyl chloride (PVC) or soft rubber.
What is the function of the SACETT® Endotracheal Tube?
Specifically designed to reduce VAP by removing secretions from above the cuff.
What are the advantages of High-Flow nasal oxygenation (HFNO)?
Easy set-up, high tolerability, * Ability to produce positive airway pressure and a high fraction of inspired oxygen and to influence the clearance of carbon dioxide
What is the difference between awake and deep extubation?
Awake can maintain a patent airway; deep avoids coughing and bucking but at risk for obstruction
What should be included in extubation preparation?
Suction airway, alveolar recruitment maneuvers, insert bite block, ensure cuff is fully deflated, positive pressure, have a PLAN
What can coughing or bucking on the ETT cause?
increased HR
increased intraadominal and intraocular pressures
increased arterial BP
increased CVP
increased bleeding or wound dehiscence
What is laryngospasm?
A forceful involuntary spasm of the laryngeal musculature caused by sensory stimulation of the superior laryngeal nerve
What can cause negative pressure pulmonary edema?
Large negative intrathoracic pressure from laryngospasm or biting on the ETT.
What are some signs of negative pressure pulmonary edema?
- Wheezing within 60 minutes post-surgery
- Pink frothy fluid in the airway. (HALLMARK SIGN)
What is the treatment for negative pressure pulmonary edema?
Maintain patent airway, supplemental O2, mechanical ventilation may be necessary.
usually resolves in 12-24 hours evidenced by CXR
What is the onset time for negative pressure pulmonary edema after airway obstruction?
A few minutes to 2-3 hours.
What is essential during awake extubation?
Use of bite blocks.
what are relative indications for ETT?
3 of them
patient position during surgery
known or suspected diff airway
prolonged surgical time
Describe cuffed ETTs?
provides a seal
protects lungs from gastric contents entering the lungs
positive pressure ventilation
what population are uncuffed ETTs typically used for?
infants and neonates
air in the ETT cuff ____ with change from room temp to body temp
expands
true/false, there is a disposable manometer?
true, it is a single-use disposable called AG Cuffill Manometer
ET tube size will be dictated by what 3 things?
the reason for placement
patient size and gender
airway pathologic conditions
the smaller the ETT, the _____ the work of breathing from airway resistance
greater
Teh large the ETT, the more chance of injury to the _______ and greater incidence of a sore throat
tracheal mucosa
what is the adapter size for an ETT?
15 mm
the length marked on the outside of the ETT is measured in what?
centimeters
if there is no cardiac output, ____ will not be present
CO2
used for procedures where a low profile is needed or where access to the mouth is limited:
oral and nasal RAE
used when the oral route is unavavailable or would hamper surgical access
nasal RAE
contraindicated in basal skull fractures or maxillary fractures
Nasal RAE
Name all the supplies needed for intubation preparation?
suction
appropriately sized ETTs
stylet
larygnoscope handle and blades
syringe for inflating the cuff
name all the predictors of a difficult laryngoscopy
long upper incisors
prominent overbite
inability to protude mandible
small mouth opening
mallampati III or IV
high arched palate
short thyromental distance
short, thick neck
limited cervical mobility
name ways to confirm ETT placement
chest and rise fall
condensation in the tube
ETCO2
pulse ox
bilateral breath sounds
name 5 reasons when a fiberoptic bronchoscope is used:
awake intubation for known difficult airway
neck must remain netural
confirm placment of doulbe-lumen tube
limited mouth opening
poor dentition
has a coude tip to help maneuver through the glottic opening, should be able to feel the tracheal rings
gum elastic bougie
When to use a right-sided tube:
- Left main bronchus distorted anatomy
- Descending thoracic aortic aneurysm compressing the left main bronchus
- Left pneumonectomy
- Lung transplant on the left side
name the steps/process to perform retrograde intubation
A. Needle is inserted through the CTM, the guidewire is advanced in a cephalad direction and will exit the nose or mouth
B. Guide catheter is advanced to the puncture site then the guidewire is removed
C. The guide catheter is advanced a few centimeters; ETT is advanced over the guide
used when a double-lumen tube is not practical
bronchial blockers
when would you use an invasive airway?
- When noninvasive attempts have failed
- Obstructed airway
- Tumor/carcinoma of the larynx
what are the two kinds of invasive percutaneous airways?
transtracheal jet ventilation
cricothryotomy
T/F High flow nasal oxygenation interferes with bag mask ventilation, intubation, and surgical procedures in airway
FALSE
- Used for surgeries where nerve damage is possible, such as thyroid surgery
- Stainless steel contact electrical electrodes
Evoked Potentials ETT
what do you want to use when extubating a difficult airway?
an airway exchange catheter
* Inserted through the ETT and remains in place until the possibility of
what are some causes of negative pressure pulmonary edema
epiglottits
tumor
post extubation laryngospams
obesity
hiccups
OSA
name this tube
murphy tracheal tube
whats this bad boy
a fiberoptic bronchoscope (FOB)
whats the desired shape of the ETT
hockey stick curve
what ETT introducer can be placed over a fiberoptic scope?
the aintree catheter
what kind of tube is this
a laser tube
how many cuffs does a laser tube have?
dos (2)
what is the double cuff of the laser tube typically filled with?
normal saline or blue dye to easily visualize cuff rupture
name this guy
evoked potential ETT
name complications associated with extubation
there’s a ton so give me like 5
laryngospasm/bronchospasm
upper airway obstruction
hypoventilation
hemodynamic changes (HTN, tachy)
coughing,straining, wound dehiscence
NPPE
arytenoid dislocation
aspiration
paradoxical vocal cord motion
name the airway risk factors associated with increased extubation risk
known diff airway
airway deterioration (like bleeding, edema, trauma)
restricted airway access
obesity and OSA
aspiration risk
name the general risk factors for increased extubation risk
CV disease
resp disease
neuromuscular disease
metabolic derangements
special surgical requirements
