Exam 2 Airway Equipment I [6/25/24] Flashcards
1
Q
This airway equipment allows gas administration to the patient from the breathing system without any apparatus in the patient’s mouth.
A
- Face Mask
S3
2
Q
The administration of oxygen before induction of anesthesia does what?
A
- Preoxygenation
- Denitrogenation
S3
3
Q
Can a face mask be used for entire anesthetic?
A
yes, may be used for entire anesthetic
* for example: non invasive cases, or pedatric cases
S3
4
Q
What is the goal of masking?
A
to provide positve pressure
S3- lecture
5
Q
How do we know if we are masking appropriately?
A
- chest rise
- tidal volume
- ETCO2
- O2 saturations
S3-lecture
6
Q
What are the three components of the Face Mask?
A
- Body- Transparent, Provides shape
- Seal - Inflatable cushion, 20 to 25 cm H2O with minimal leak
- Connector- 22 mm internal diameter, circular ring with prongs for straps
S4
7
Q
Face Mask may have scent, pacifier or ports. What are these?
A
- Scent: for pediatrics to spray good scents
- Pacifier: attached to the mask which also allows for gas inhalation.
- Ports: little hole where the endoscopist can perform the bronch.
S4-lecture
8
Q
What is one-handed method placement for face mask?
A
- C shaped
- Dont smother the face or you’ll compress the facial nerve/artery.
S5- lecture
9
Q
What is the two-handed method/technique for face mask?
A
- Double C + chin lift
- someone else bags for you
- Use: Pt with big face, edentulous [no teeth]
S6- lecture
10
Q
Criteria associated with difficult mask ventilation
A
- Obese, BMI > 30 kg/m2
- Beard (big bushy ones)
- Edentulousness
- Snore/OSA
- Elderly >55
- Male
- Mallampata 3 or 4
OBESE M
S-7
11
Q
Ways to Overcome Difficult Mask Ventilation
A
- Oral airway OR nasopharyngeal airway [if no CI for nasopharngeal, insert it bc oral can be hard to place]
- Two-handed technique
- Cut the beard (let the pt know beforehand)
- Tegaderm over mouth to create seal for face mask
S8
12
Q
What should you NOT give if your patient can not mask ventilate?
A
- Do not give paralytics
S8- Andy
13
Q
What should you do if you can not mask ventilate the patient?
A
- Emergency adjunct (difficult airway algorithm)
- wont have test question on this alogrhytm
S8
14
Q
What might be used to hold the face mask in place and allows the CRNA’s hand to be free?
A
- Mask Straps
S9
15
Q
When should you use mask straps?
When should you NOT use mask straps?
A
- Use for:
- large face, large beard
- no teeth
- need hands free for other task
- sponatenous ventilation [pt can be sedated to be comfortable]
- Dont use for:
- controlled ventilation
S9-lecture
16
Q
What is an OPA and how does it work?
A
- An oropharyngeal airway is a device used to maintain or open the airway by lifting the tongue and epiglottis away from the posterior pharyngeal wall.
- OPA decreases the work of breathing during spontaneous ventilation.
S11
17
Q
When should you remove the OPA?
A
- remove when pt is ready to remove it. This means they can support their own airway
- OPA are poorly tolerated in awake pts
S11 lecture
18
Q
Why should you not put an OPA in an awake patient?
A
- Patient will fight you
- Gag reflex still intact
- High risk of laryngospasm
S11- Andy
19
Q
Most OPA are made of ____
A
- Plastic
S12
20
Q
The bite portion of an OPA must be firm enough that the patient cannot close the lumen by ____.
A
- biting (duh)
- make sure pt has good teeth when using this, if poor dentition dont use
S12
21
Q
The OPAs are color-coded by size, which is measured in ______.
A
- millimeters
- not all OPA’s are color coded, the size will be on the side
S12
22
Q
How should the size of the OPA be determined?
A
- OPA should be used to measure from the corner of the mouth to the angle of the mandible or the earlobe for appropriate sizing.
S13
23
Q
What reflexes should be depressed when placing an OPA?
A
- Pharyngeal Reflexes
- Laryngeal Reflexes
S13
24
Q
What are the two methods to OPA insertion?
A
- Approach with OPA backward and use 180-degree turn method [left]
- Use a tongue depressor to insert OPA method [right]
S13
25
Why is a bite block used?
* Prevents patient from biting on the ETT, bronchoscope, or endoscope
| S14
26
Bite block placement
* A bite block is placed between the upper and lower teeth and gums
| S14
27
When pt is getting endoscopy, when do you place the bite block?
While the pt is awake, before the pt goes to sleep because they start clinching when going to sleep
| S14- lecture
28
A type of airway adjunct designed to be inserted through the nasal passage down into the posterior pharynx to secure an open airway.
* Nasopharyngeal airway (NPA)
* Nasal trumpet
| S15- Andy
29
NPAs are tolerated in patients with intact ____.
* Airway Reflexes
| S15
30
When would NPA be contraindicated?
* Basilar skull fracture
* Nasal deformity
* Hx of epistaxis [*not an absolute CI*]
* Pregnancy (very vascular)
* Coagulopathy
* Chronic NSAID use
**N**asal **C**ontraindications **C**onsist of **B**oring **P**atient **H**istories
| S15
31
NPAs are preferably used with these patients
* Loose Teeth
* Oral Trauma
* Gingivitis
* Limited Mouth Opening
* poor dentention
| S15
32
Design of NPA
* Resembles shortened tracheal tube
* Flange at outer end to prevent complete passage
* Less stimulating than OPA
* Sized by outer diameter in French scale [**10-36**]
| S16
33
Correct size is important for NPA, how should the size of the NPA be determined?
* Nostril to the external auditory meatus
| S17
34
How can you mitigate epistaxis during NPA insertion?
* Lubricate NPA thoroughly
| S17
35
The bevel of the NPA should rest above the ____.
* Epiglottis
* *10 mm above the epiglottis*
| S17- andy
36
What should you do if unable to insert NPA in one nostirl?
* do not force
* remove and insert in the other nostril
* *make sure adequate lubrication*
| S17-lecture
37
What are some complications of airways ?
* Airway obstruction (incorrect placement)
* Ulceration of the nose or tongue
* Dental/oral damage
* Laryngospasm
* Latex allergy (some older NPAs usually green in color)
* Retention/swallowing
DULLAR
| S18
38
when is airway obstruction usually complication of airway placement?
- usually seen with OPA bc it’ll sit in the hardpalate. Pt will be desatting or unable to to get adequate Vt.
- Can protude out.
| S18-lecture
39
How do you prevent the complication of retention/swallowing of an airway?
size appropriately
| S18-lecture
40
Why would a laryngospasm occur as a complication of airways?
pt is inadequetly anestheized
| S18- lecture
41
When should you remove an NPA or OPA?
* When the patient can remove the NPA or OPA themselves
* Follow commands
| might be a duplicate
42
When would you not want to place in OPA?
- when pts are prone b/c of the added pressure can cause ulceration of nose/tongue
- also wont be able to assess for problems
| S18-lecture
43
* Airway device that can be inserted into the pharynx to allow ventilation, oxygenation, and administration of anesthetic gases without the need for endotracheal intubation.
* This was the intermediate bridge between a face mask and ETT.
* Supraglottic Airway
| S20
44
Who created the Supraglottic Airway?
What year was it created?
* Dr. Archie Brain
* 1982/1983
| S20
45
What is the benefit of SGA/LMA?
less invasive
| S20
46
The LMA classic is shaped like a ____ proximally.
* Tracheal Tube
| S21
47
The LMA classic is shaped like a ____ mask distally.
* Elliptical
| S21
48
Where does the LMA classic sit when inserted properly?
What provides the seal?
* Sits in hypopharynx and surrounds the supraglottic structure
* An inflatable cuff provides seal
| S21
49
The LMA classic is ____ free and can be ____, or ____
latex free
reusable
disposable
| S21
50
When can SGA or LMA be used?
* Can be used in both spontaneous ventilation and PPV
| S20
51
The following LMA sizes are used on what patient sizes?
* 1
* 1.5
* 2
* 2.5
* 3
* 4
* 5
* 6
| S22-Erickson we need to know this chart!
52
How big of a syringe is needed to inflate an LMA classic?
How much pressure of water is needed to inflate the LMA classic?
* 20 cc syringe
* 60 cmH2O
| andy
53
Some LMA Classics are "reusable." How many times can they be reused, according to Dr. Ericksen?
* 40 times
| S21???
54
Whats the difference between 1st and 2nd generation of SGA/LMA?
- 1st: doesnt have gastric lumen so cant have a gastric tube
- 2nd: has gastric lume.
| S20
55
What happens if the LMA size is too small?
* Gas leaks during positive pressure
| S23
56
What happens if the LMA size is too large?
* Won’t seat over glottis
* Greater incidence of sore throat
* Possible pressure on lingual, hypoglossal, and recurrent laryngeal nerves
| S23
57
How many LMAs should you take out during pre-op?
* Two LMA's
* The size that you think and one size above or below
| S23- lecture???
58
Insertion of LMA
* Needs to be well lubricated; cuff down
* Deflate the cuff as much as possible
* held like a pencil
* Place LMA upward towards the hard palate
* Follow the posterior pharyngeal wall
* Smooth motion
* Should feel it curve downward in the airway, then come to a stop
* Inflate balloon
| S24
59
When the LMA balloon is inflated, what happens to the patient's neck?
* Neck bulges and LMA may “rise” slightly
| S25
60
What can you do to troubleshoot a difficult LMA placement?
* Jaw lift
* Pull the tongue forward
* Slightly inflate the balloon
* Change to a different technique
Just Perform Slight Changes if you have a difficult time placing an LMA
| S25
61
What is an LMA unique?
* *S*ingle-use and disposable LMA device
* *M*ade of PVC
* ***S*tiffer**: cuff is less compliant than LMA classic
* Same insertion technique of LMA classic
* *E*asier to place than the Classic LMA
MESS
| S26
62
What is an LMA Proseal?
* Wire reinforced LMA
* Shorter than Classic LMA
* Gastric access - OGT can be passed through to decompress the stomach to decrease the risk of aspiration
| S27
## Footnote
Must have right size and be seated correctly in order to get gastric access
63
Why would CRNAs have reservations about placing LMAs in diabetic patients?
* Gastroparesis in DM pt leading to ↑ aspirations
* D/t autonomic neuropathy affecting the vagus nerve.
* Chronic hyperglycemia can damage the vagus nerve.
* Gastroparesis has been reported in 30-50% of Type I and II diabetics.
* Food can still be in the stomach > 48 hours. Your mileage may vary...
| ????
64
What is an IGEL LMA?
* LMA with no cuff
* Medical-grade thermoplastic elastomer
* Noninflatable, anatomical seal of the pharyngeal, laryngeal, and peri-laryngeal structure (seat well w/ good airway protection)
* Gastric access - OGT
* Conduit for intubation
Con Gel Might Not Last
| S28
65
Which LMA creates the most adequate seal of the supraglottic structure per lecture?
* IGEL LMAs
| S28- lecture
66
Advantages of LMA
* Ease and speed of placement (as fast as 5 secs)
* Improved hemodynamic stability
* Reduced anesthetic requirements
* No muscle relaxation needed
* Avoidance of some of the risks of tracheal intubation
| S30
67
Disadvantages of LMA
* **Smaller seal pressures** than ETTs (seal pressure to seal glottis is lower than ETT which increases risk of inadequate ventilation d/t not being passed through vocal cords)
* **Ineffective ventilation when higher pressures are needed.**
* No protection from **laryngospasm**
* Little protection from **gastric regurgitation and aspiration** (First-generation LMA: LMA Classic and LMA Unique)
| S31 and lecture
68
List the LMA types from best to worst for prevention of gastric regurgitation and aspiration
IGEL
LMA proseal
Unique and Classic
| S31 and lecture
69
Name First Generation LMAs
* LMA Classic
* LMA Unique
| S31 and lecture
70
Name Second Generation LMAs
* LMA Proseal
* LMA IGEL
71
What are the parts of a direct rigid laryngoscope?
* Manufactured as a single piece or detachable blade/handle
* light source is light bulb or fiberoptic
* Handle
* Blade
| S33
72
Describe the Handle of a direct Rigid laryngoscope
* Part held in hand [*usually non-dominant hand*]
* Provides power for light…. most use disposable batteries
* Most form right angle to blade when ready for use
| S33
73
Describe the blade of the Direct Rigid Laryngoscope
* Inserted into mouth
* Different sizes; increasing number = increased size
* Tongue: manipulates and compresses soft tissue
* Tip: directly or indirectly elevates epiglottis
| S33
74
Most blade alterations change the ____ from the ____ to ____ and there are differences as noted in how they are used.
angle
tongue to handle
| S34
75
what are the 2 types of rigid direct Laryngoscopes
Macintosh and Miller
| S35
76
Describe a Macintosh Blade
* Tongue has gentle curve
* #3 and #4 useful for adults
* Has been shown to cause greater cervical spine movement than with Miller
* Makes intubation easier because blade requires adequate mouth opening due to blade size
| S35
77
Describe Miller Blades
* Tongue is straight with slight upward tip
* #2 and #3 for adults
* Force, head extension, and cervical spine movement is less
* Great for smaller mouths and longer necks
| S35
78
How do you view the epiglottis with macintosh?
* After epiglottis is visualized, tip advanced into vallecula
* Pressure at right angle of the blade and the handle to move base of tongue and epiglottis forward to lift the vallecula (epiglottis lifts up like a garage door and you can drive the tube in per erickson)
* Can be used like Miller to elevate tip of epiglottis
| S36
79
* How do you view the epiglottis with a miller blade?
* What happens if the blade is inserted too far?
* What happens if the blade is withdrawn too far?
* Blade lifts epiglottis
* If blade inserted too far, it elevates larynx or esophagus
* If withdrawn too far, epiglottis flips down and covers glottis
* Can use like a Macintosh to insert into the vallecula
| S37
80
Describe the optimal positioning for laryngoscopy
* “Sniffing” position is ideal
- 35 degree lower cervical flexion; 80 to 90 degree head extension at the atlanto-occipital level
- Create an imaginary horizontal line connects the external auditory meatus and sternal notch
| S38
81
When you advance the blade for laryngoscopy, what are the landmarks you look for with a miller blade?
Mac blade?
* Miller target:
- vocal cord
- bypassing the epiglottis
* MAC target:
- look for epiglottis
- slide in velecula
- see the vocal cords
| S41
82
What are the steps for advancing the blade?
* Right hand opens mouth (“scissor”) to keep the lips free to accommodate blade insertion
* Blade inserted on right side of mouth
* Advance blade, keeping tongue to left and elevated
* Epiglottis comes into view
| S38
83
What techniques can we use for difficult airways and direct laryngoscopy?
* Flexible fiberoptic scope or video largyngoscope
* Maintain a neutral position and use of an OPA
* Can be awake or “asleep”
| S39
84
What technique can be used with direct laryngeal laryngoscopy to displace the larynx?
BURP
Backward, upward, rightward, pressure
| S40
## Footnote
basically, we are moving the larynx to get a better view of the glottis
85
What is SO important in the OR?
Positioning!
| S41
86
Obese patients require elevation of the ____ and ____.
We place them in a ____ position to create a horizontal line that connects the ____ and ____.
* shoulders and upper back
* ramped position
* external auditory meatus and sternal notch
| S41
87
What devices can be used to place patients int he ramped position?
troop elevation pillow
folded blankets
| S41
88
What is the purpose of the blade spatula?
* Compresses the tongue into the mandibular space
| andy
89
What is the purpose of the flange?
* The flange (if present) is used to move the tongue laterally and create a visual lumen
| andy
90
When using a Mac Blade, after epiglottis is visualized, the tip advanced into the _________.
Vallecula
| andy
