Exam 2 - Airway Equipment (Ericksen) Flashcards
1
Q
What does the face mask allow for?
A
- gas admin to pt from breathing system w/o any apparatus in pts mouth
2
Q
What is the goal of providing mask ventilation to a pt?
A
- provide pos. pressure gas movemement through the pts unprotected airway
- there is nothing in the airway to prevent aspiration
- LES relaxes - food comes up
3
Q
What are 2 examples of when we would use a face mask?
A
- preoxygenation/denitrogenation (induction to get best chance of successful intubation w/o de-satting)
- entire anesthetic case
4
Q
What are examples of surgeries/procedures where a face mask can be used to ventilate for the entire anesthetic?
A
- ear tubes
- elderly ear wax removal
- non-invasive cases that don’t need invasive airway
5
Q
Components of the face mask
Body:
A
- transparent
- provides the shape
6
Q
Components of the face mask
Seal:
A
- inflatable cushion
- maintenance of airway pressure 20-25cmH2O w/ minimal leak (this is good)
7
Q
Components of face mask
Connector:
A
- 22mm internal diameter
- circular ring w/ prongs for straps
8
Q
Components of face mask
What 3 other things may be included on/with a face mask?
A
- pacifier - infants (keep them comfy while they inhale the gas)
- ports for bronch or upper endoscopy
- Scents for pedi
9
Q
Face Mask Ventilation
One-handed method:
- how should hand be positioned?
- what do we need to be cautious of?
- considerations for children:
A
- form a C w/ 3 fingeres on the ridge
- make sure we are not compressing the facial nerve/artery (watch where palm is)
- children - use less fingers (3 total)
10
Q
Face Mask Ventilation
Two-handed method/Technique:
* what are examples when we would need to use this?
A
- someone else will be bagging for you
- lots of adipose, edentulous
- helps create a better seal to better ventilate pt
11
Q
Difficult Mask Ventilation
MOBEOB
A
Many Otters Bring Extra Oranges Back
* M: male
* O: over 55
* B: beard
* E: edentulousness
* O: OSA/snoring
* B: BMI > 30kg/m2
12
Q
What 4 techniques can we use to overcome difficult mask ventilation?
A
- oral airway, nasopharyngeal airway
- two-handed technique
- cut the damn beard
- tegaderm over the beard/mouth
13
Q
What happens if despite adjuncts, we still cannot mask ventilate?
A
go to the emergency adjunct difficult airway algorithm)
14
Q
When is it good to use mask straps?
A
- helpful for people w/ small hands & pts w/ big faces (edentulous/big beards)
- if you need your hands free to do other things
15
Q
With what type of ventilation can we use mask straps?
What do we need to ensure before placing them?
A
- can only be used for spontaneous ventilation
- need to ensure pt is asleep and comfortable (claustrophobic)
16
Q
How does an OPA (oropharyngeal airway) work?
A
- lifts the tongue & epiglottis away from the posterior pharyngeal wall
- relieves airway obstruction
- decreases the WOB during spont. ventilation
17
Q
What position can make airway opening better?
What causes obstruction r/t anesthesia?
A
- sitting the pt up can open the airway
- when we put the pt to sleep - everything falls back toward posterior pharyngeal wall and obstructs the airway
18
Q
When can an OPA be placed an removed?
A
- placed: after pt is under anesthesia & if they are still obstructing after positioning changes
- removed: when they are awake enough to remove it themselves
19
Q
How are OPAs designed?
A
- most made of plastic
- bite portion needs to be firm enough that pt cannot close lumen from biting
- sizing: color coded/size on the side in mm
20
Q
How do we measure a pt for an OPA?
A
- corner of mouth to the angle of the jaw or the earlobe
21
Q
What should be depressed before we insert an OPA?
A
- pharyngeal and laryngeal reflexes
- they don’t have to be paralyzed - just sleepy & reflexes depressed
22
Q
What potential things can happen if a pt is not deep enough and we try to place an OPA?
A
- vomiting
- coughing/spit it out
- pt takes it out
- laryngospasm/bronchospasm
- we usually only see problems on induction w/ OPAs - not emergence
23
Q
What are the 2 methods of insertion for an OPA?
A
- upside down method - can get caught on tissue
- tongue depressor method
- Dr. Ericksen lifts the jaw w/ 4x4s and places it
24
Q
Where (anatomically) is a bite block placed?
A
- b/w the upper and lower teeth/gums
25
What does a bite block prevent and where do we use them?
* prevents biting on ETT, bronchoscope, endoscope
* used in endoscopy & out pt procedures
26
When are the 2 best times to place a bite block?
1. When the pt is awake and give them directions to hold down on it
2. w/ the propofol yawn
**after this the pts jaw will be tight and it will take a while to relax**
27
Who are **nasopharyngeal airways (NPA)** tolerated in?
What situations are NPAs preferable in?
* pts w/ intact airway reflexes
* preferable w/ loose teeth, oral trauma, gingivitis, limited mouth opening
28
What are the 5 contraindications for an NPA?
1. basilar skull fx
2. nasal deformity
3. Hx of epistaxis (not absolute contraindication)
-- depends on pt & what is going on w/ them
-- on anticoagulants = NO NPA
4. pregnancy (very vascular & increase blood vol.)
5. Coagulopathy
29
How 2 meds can we use to stop a nose bleed?
Afrin & Phenylephrine
30
What does an NPA resemble?
* shortened tracheal tube/ETT
31
# NPA design
What is the purpose of the flange on the NPA?
* located on the outer edge to prevent complete passage through nasal cavity
32
Which is more stimulating: OPA or NPA?
OPA
* NPA less irritating when they are waking up - they may just feel a little nasal pressure
33
# NPA design:
how is an NPA sized?
in outer diameter in French Scale
* 10F - 36F
34
How is an NPA removed?
have pt take a deep breath & cough - pull it out
35
# NPA Insertion
How do we size for a NPA?
**correct size important**
* bony manidble or nostril to the external auditory meatus
36
NPA insertion:
after insertion, where is it located?
**LUBRICATE**
* don't be forceful - try other nare
* will be located ~10mm above epiglottis
37
What are the 6 complications of OPAs & NPAs?
1. airway obstruction (incorrect placement - OPA)
2. ulceration of nose or tongue
3. dental/oral damage
4. laryngospasm
5. latex allergy (older NPAs - green in color)
6. Retention/swallowing - size matters!
38
# OPA & NPA complications
What causes airway obstruction w/ the OPA?
* not seated well (in b/w tongue & back of soft palate)
-- pt de-satting, not getting Vt
* the OPA will protrude if not seated well
39
# OPA/NPA complications
What causes ulceration of nose/tongue?
* if they are left in for too long
* prone/lateral position causing pressure & ulceration
40
# OPA/NPA complications
what is an alternative to an OPA that we can use in prone pts?
4x4 gauze roll as a soft bite block
41
# OPA/NPA complications
What causes a laryngospasm?
* inadequately anesthetized patient
* ensure they are deep before placement
42
Who created supraglottic airways?
Dr. Archie Brain
43
What is the defintion of a supraglottic airway?
* intermediate bridge b/w face mask & endotracheal tube
* less invasive
* can be used w/ spont. ventilation or PPV
44
What are the differences b/w the 2 generations of supraglottic airways?
* 1st gen: don't have a gastric lumen (no place to put gastric tube)
* 2nd gen: allows you to place a gastric tube down
45
# LMA classic
how is it shaped?
* like a tracheal tube proximally
* elliptical mask distally
46
Where does the LMA classic sit?
* in the hypopharynx & surrounds the supraglottic structure
47
Describe the cuff on an LMA classic:
What types of LMA classics do they make?
* inflatable cuff
* latex free, reusable, disposable
48
Is the cuff empty when we insert the LMA classic?
No, helps to have a little bit of air in it
* as you seat it and get it in place then you inflate the cuff
49
Is the LMA classic 1 MRI compatible?
No, it has a metal spring
* if the LMA has a plastic spring then it can go in MRI
50
What size LMA will a neonate/infant up to 5kg get?
1
51
What size LMA will an infant b/w 5-10kg get?
1.5
52
What size LMA will an infant/child b/w 10-20kg get?
2
53
What size LMA will children b/w 20-30kg get?
2.5
54
What size LMA will children b/w 30-50kg get?
3
55
What size LMA will adults b/w 50-70kg get?
4
56
What size LMA will adults b/w 70-100kg get?
5
57
What size LMA will adults >100 kg get?
6
58
What are the only 2 **1/2 sizes** of LMA?
1.5: infant b/w 5-10kg
2.5: children b/w 20-30kg
59
Should we have other sizes of LMA available when inserting?
YES - size up and down 1!!
60
# Incorrect sizing of LMA
What happens if an LMA is **too small**?
gas leaks during positive pressure
* not forming seal against glottis
* not passing enough gas or adequate vol. to pt
61
# Incorrect sizing of LMA
What happens if an LMA is **too large**?
* won't seat over glottis
* greater incidence of sore throat - could be hours later or next day
* **possible pressure on lingual, hypoglossal, and recurrent laryngeal nerves**
-- deflate, take it out, size down
62
# Incorrect sizing of LMA
how will we be able to tell if it is too big?
* it will protude out of the mouth
63
What is the process for inserting an LMA?
1. well lubricated;cuff mostly down
-- avoid too much lube: won't seat well
2. held like pencil
3. upward against the hard palate
4. follows the posterior pharyngeal wall
5. smooth motion
6. **should feel it curve down in the airway and come to a stop**
64
# LMA insertion
What will you see/feel when the balloon(cuff) is inflated on an LMA?
* the neck will bulge and LMA may "rise" up slightly
65
# LMA Insertion
What can we do with a difficult placement of an LMA?
* jaw lift
* pull tongue forward
* slightly inflate balloon
* may change to diff. technique
66
What is the LMA unique?
* single use, disposable
* made of PVC
* stiffer & cuff less compliant vs LMA classic (cuff less flimsy as cuff on LMA classic)
* insertion same as LMA classic
67
What is the LMA proseal?
* wire reinforced, shorter than LMA classic
* **is a 2nd generation LMA**
* gastric access w/ OGT
-- when seated right - hole points to esophagus
-- **requires right size and that it is seated appropriately for gastric tube to go in right hole**
68
What is the **IGEL LMA**?
* medical grade thermoplastic elastomer
* has a gastric channel
* has a conduit for intubation
* **NO CUFF**
69
What does the **IGEL LMA** provide a seal of?
* noninflatable, anatomical seal of the pharyngeal, laryngeal, & perilaryngeal structures
* **PROTECTS AIRWAY BETTER THAN LMAs**
70
Insertion of **IGEL LMA**:
* inserted the same way as LMA
* adequate lubrication!
* everything covering the airway - risk of aspiration decreased
-- cuff is blocking off esophagus
71
What are the advantages of LMAs? (5)
1. ease & speed of placement
2. improved hemodynamic stability
3. reduced anesthetic requirement - don't have to be paralyze or have a lot of gas (can do w/ just prop)
4. no muscle relaxtion needed
5. avoidance of some of the risks of tracheal intubation (still @ risk of coughing and sore throat)
-- lower risk w/ appropriately size LMA
72
What are 3 disadvantages of LMAs?
1. smaller seal pressures than ETTs (increased risk of inadequate ventilation esp. w/ high airway pressures)
2. no protection from laryngospasm (not through the cords)
3. little protection from gastric regurgitation and aspiration (1st gen)
73
What LMA provides the best protection against gastric regurgitation & aspiration?
1. IGEL - gastric opening & blocks off esophagus
2. 2nd generation LMAs - gastric opening
74
What is the Shikani Optical Stylet?
* stainless steel, lighted stylet
* malleable distal tip
* uses an eye piece
* has O2 port for insufflation
75
How is the Shikani optical stylet inserted?
neutral position
* inserted midline
* advanced into trachea w/ light pressure keeping tip **anterior** at all times
* **in peds & adult sizes**
76
The Shikani Optical Stylet can be used as a ________ ________.
This allows you to verify what?
* light wand
* verifies ETT placement, or placement of DLT
77
4 Advantages to Optical Stylet:
1. Easy to use for routine & difficult intubations
2. trachea visualized, lower risk of esophageal intubation
3. decreased incidence of sore throat (less trauma)
4. less C-spine movemement over conventional DL
78
3 Disadvantages to Optical Stylet
1. longer intubation time (familiarity)
2. cannot be used w/ nasal intubations
3. cannot be adjust into precise directions like traditional malleable stylet (only distal tip)
79
What are the 4 types of video laryngoscopes we talked about in class?
1. Glidescope
2. Co-pilot
3. King
4. McGrath
80
What are the 6 advantages to Video Laryngoscope?
1. magnified anatomy
2. some scopes have curved/straight blades to mimic laryngoscopes
3. operator & assistant can see
4. decreased c-spine movemement (less head/neck adjustment)
5. furhter distance from infections pts (less transmission)
6. demonstrates correct technique in legal cases
81
3 limitations to Video laryngoscopes
1. requires video system (needs batteries/charged)
2. portability varies
3. can still fail and have difficulties
82
What are the 3 strongest predictors of failure w/ a VL?
1. altered neck anatomy w/ presence of surgical scar
2. radiation changes
3. mass (oral, face, neck)
83
# Complications of Laryngoscopy
Dental Injury: what are the most likely damaged?
What do tooth protectors do?
* upper incisors - restored or weakened teeth
* tooth protectors: placed on upper teeth in DL
-- protect from blade causing direct surface damage
-- does not gurantee safety from dental trauma
-- **mostly serve as a reminder to be vigilant**
84
# Complications of Laryngoscopy
What causes Cervical spinal cord injury?
* aggressive head positioning
* ex: meemaw w/ poor ROM
* **assess in pre-op & document!!**
85
# Complications of Laryngoscopy: Cervical spinal cord injury
What is manual in-line stabilization?
* removal of the c-collar **by the surgeon**
* and they hold in-line stabilization while you intubate
* DOCUMENT the surgeon did it
* **better than c-collar during DL**
* use GLIDESCOPE or FIBER OPTIC!
86
# Complications of Laryngoscopy
Damage to other structures: what causes abrasions/hematomas?
* dry mouth
87
# Complications of Laryngoscopy
Damage to other structures: what can cause lingual &/or hypoglossal nerve injury?
when placing blade - hit soft tissue
* go in slowly & recognize structures
88
# Complications of Laryngoscopy
Damage to other structures: what can cause arytenoid subluxation?
* hitting the arytenoids w/ the blade
* go slow
89
# Complications of Laryngoscopy
Damage to other structures: what do we need to be cautious of w/ Hx of anterior TMJ dislocation?
do not force the mouth open
90
# Complications of Laryngoscopy
What foreign bodies can be swallowed/aspirated?
What do we have to do?
* light bulbs
* teeth
* go to x-ray, CT, endoscopy, bronch
91
# Tracheal Tubes Genreal Principles
What changes the resistance in a breathing system?
* ID of the tube: **most important factor in determining resistance to gas flow in the ETT**
* tube length: shorter tube (less resistance), longer tubes = increased resistance
* configuration changes (adding more connectors, turns = more resistance)
* corrugation
92
What are the 10 Manufacturing Requirements for Tracheal Tubes?
1. low cost
2. lack of tissue toxicity
3. easy sterilization (unless disposable)
4. non-flammability
5. smooth & non-porous surface to prevent secretion build-up, allow passage of suction cath or bronch & prevent trauma
6. sufficient body to maintain its shape
7. sufficient wall strength
8. conforms to pt anatomy
9. lack of reaction w/ anesthetic agents & lubricants
10. latex-free
93
# Tracheal tube Design
How are the walls designed and what does this decrease?
* the internal & external walls are circular
* decreases kinking
94
# Tracheal Tube Design
Where could an ETT be shortened?
* machine end
* decreases resistance
95
# Tracheal tube Design
How is the pt end of the ETT?
* slanted bevel - helps view **larynx**
96
# Tracheal Tube Design
What is the purpose of the murphy eye?
* provides an alternate pathway for gas flow if the beveled end is occluded from secretions
97
# Tracheal Tube Design
What are the 2 biggest problems w/ the murphy eye?
* Magill forceps can get locked into the murphy eye
* fiber optic scope can get kinked/caught in murphy eye
98
What is a RAE tube?
Ring-Adair-Elwin tube
* Right angle tube
* used to keep ETT out of surgeons way: head/neck surgeries
* increased tube diameter - increased distance from tip to curve (resistance)
99
How do you insert a RAE (Ring-Adair Elwin) tube?
* temp. straightened in insertion
* may not need stylet
* if you use one and straighten it out for placement - when you remove stylet it goes back to original shape
* easy to secure (oral flips down over chin and is taped)
100
What are the disadvantages to a RAE (right angle) tube?
* difficult to pass suction/scope
* increases airway resistance (bend in tube)
101
What are other names for an Armored Tube?
* reinforced
* anode
* spiral embedded tubes
102
What are the Advantages to an Armored tube?
* useful when tube is likely to be bent or compressed
-- resistance to kinking & compression
* head, neck, tracheal surgeries
-- more durable
-- surgeon will move it how they need it
-- they will NOT lose your airway
103
What are the Disadvantages w/ Armored tubes?
* Need stylet or forceps to get tube down
* difficult w/ nasal intubation (could be done)
* contains stainless steel in the tube - metal spiral that spirals down entire tube
-- reinforces it/keeps shape
* cannot be shortened
* damaged when biting
* NOT MRI compatible
104
What is a laser-resistant tube?
* metallic or silicone and metal mixture
* probably not MRI compatible
* Reflects laser beams used in oral surgeries
-- CO2, or KTP (potassium titanyl phosphate)
105
# Laser-Resistant tubes
How are the cuffs?
**double cuffs**
**fill w/ methylene blue crystals & saline solution**
* the methylene blue crystals are already int here
106
Which cuff do we inflate first on a laser-resistant tube?
* distal first
* than proximal
* **the point of them is so if one bursts - the surgeon sees methylene blue - but there is still one protecting the airway**
107
Where are the tube markings on the tube and how are they read?
* on bevel side above cuff
* read from pt side to machine
108
What are the 6 safety standards that have to be marked on an ETT?
1. word oral or nasal or oral/nasal
2. tube size in ID in mm
3. manufacturer name
4. graduated markings in cm from pt end
5. cautionary note - single use only if disposable
6. radiopaque marker at pt end (see on x-ray)
109
What is the typical cuff pressure and volume?
* 18-25mmHg (8-10mL air)
110
Why do we need to monitor cuff pressure when giving N2O?
* causes cuff inflation/expansion
* can lead to mucosal necrosis if > 25mmHg pressure
111
What is a high-vol/low-pressure cuff?
* area of contact larger, does not displace tracheal walls
* pressure applied to trachea < mucosal perfusion pressure
* may not prevent fluid leakage past cuff or NGT/temp probes around cuff
112
What is a low-vol/high-pressure cuff?
* small contact area w/ trachea
* needs more pressure to get seal
* distends & deforms trachea into circular shape
* **off the market b/c pressure on trachea > mucosal perfusion pressure = mucosal necrosis**
113
Changes in cuff pressure
nitrous:
hypothermic cardiopulm bypass:
increased altitude:
coughing, straining, changes in muscle tone:
1. nitrous: **increased**
2. hypothermic cardiopulm bypass: **decreased** (cold-induced vasoconstriction & contraction of microvasc. on tracheal wall)
3. increased altitude: **increased** (boyle's law)
4. coughing, straining, muscle tone: **increased**
