Exam 2 Airway Equipment: Part 2 (6/27/24) Flashcards
This rigid indirect laryngoscope is stainless steel, lighted stylet with malleable distal tip; and design utilizes eye piece
Shikani Optical Stylet
Describe the importance of the structure designated on the Shikani Optical stylet:
This is an oxygen port that allows for oxygen insufflation if necessary during induction.
During insertion of the Shikani optical stylet, what do we want to ensure to do at all times to avoid injury?
Light pressure, and maintain the tip anteriorly
3 uses of the Shikani Optical Stylet, per lecture.
- Light Wand
- Check ETT placement
- Check placement of DLT
Optical Stylet Advantages:
With the use of an optical stylet the ___ is visualized, making _____ less likely to occur.
With the use of an optical stylet the Trachea is visualized, making Esophageal Intubation less likely to occur.
Advantages and Disadvantages to Optical Stylet use
Increased or Decreased: Use of an Optical Stylet compared to conventional laryngoscopy.
C-spine movement:
Incidence of sore throat:
Visualization of Trachea:
Intubation Times:
Ability to adjust stylet into a precise direction:
C-spine movement: Decreased
Incidence of sore throat: Decreased
Visualization of Trachea: Increased
Intubation Times: Increased
Ability to adjust stylet into a precise direction: Decreased
Optical Stylets cannot be used with ___.
Nasal Intubations
Examples of Video Laryngoscopes:
- Glidescope
- Co-Pilot
- King
- McGrath
Increased or Decreased C-Spine movement with video laryngoscopes?
Decreased C-Spine movement
What are the strongest predictors of failure while using a video laryngoscope?
- Altered neck anatomy (with surgical scar presence)
- Radiation changes
- Presence of a mass
What is the most frequent anesthesia-related claim?
Dental Injury
(Upper Incisors, restored/weak teeth)
Complications of Laryngoscopy:
- Dental Injury
- Cervical Spinal cord injury (Aggressive Head Positioning)
- Damage to “other structures”
- Swallowing/aspirating of foreign body
What “other structures” could be damaged during laryngoscopy?
- Abrasions/Hematomas to the upper lip
- Lingual/hypoglossal nerve injury
- Arytenoid subluxation
- Anterior TMJ dislocation
What are some factors in regard to tracheal tubes that can change the resistance in the breathing system:
* Internal Diameter (MOST!)
* Tube Length
* Configuration changes
* Connectors
What is the reasoning behind having the Internal and external walls be circular?
Decreases Kinking
At which end of the ETT can it be shortened?
Machine End
Because the ETT has a slanted bevel we can view the ___ easier.
Larynx
What is the purpose of the Murphy Eye?
Provides an alternate pathway for gas flow
Select all that apply:
Which tubes, per lecture, are indicated for surgeries of the head and neck?
A. RAE Tubes
B. Spiral-Embedded Tubes
C. Right Double Lumen Tubes
D. Anode Tubes
E. Re-inforced Tubes
A, B, D, E
Advantages/Diasadvantages to RAE tube use
Increased or Decreased with the use of a RAE Tube:
Tube Diameter:
Distance from tip to curve:
Ease of securement:
Ability to pass a suction device or scope:
Airway Resistance:
Tube Diameter: Increased
Distance from tip to curve: Increased
Ease of securement: Increased
Ability to pass suction/scope: Decreased
Airway Resistance: Increased
3 other names for “Armored Tubes”
- Reinforced
- Anode
- Spiral Embedded
With what surgeries may armored tubes be used?
Head, Neck, Tracheal Surgeries
Disadvantages to Armored tube use:
- Need a stylet or forceps
- Difficult to use during nasal intubation
- Cannot be shortened
- Damaged when biting
Your surgeon walks into the OR and says they need to use this fancy new device on the patient’s mouth…
What tube should we use?
What do we fill these tubes with?
Laser-Resistant Tubes
Fill the distal cuff first with saline so it combines with the methylene blue crystals, followed by the proximal cuff.
Where are the tube markings located at?
On the bevel side above the cuff
Is the ETT size based on internal or external diameter?
Internal Diameter
Apropriate cuff pressure and volume of air for optimal ETT placement:
18-25 mmHg
8-10 mls of air
What is an important cuff consideration if we are using nitrous for a procedure?
Monitor the cuff pressure frequently because the nitrous can cause cuff inflation and expansion.
What kind of cuff is this?
High Volume, Low pressure
What kind of cuff is this?
Low volume, high pressure
Which cuff?
Larger area of contact:
More likely to have sore throat:
Better visibility during intubation:
Pressure to trachea < Mucosal Perfusion pressure:
Needs to be replaced if post-op intubation is required:
Requires large amount of pressure to achieve a seal:
Easier to pass NGT into trachea:
Larger area of contact: High V, Low P
More likely to have sore throat: High V, Low P
Better visibility during intubation: Low V, High P
Pressure to trachea < Mucosal Perfusion pressure: High V, Low P
Needs to be replaced if post-op intubation is required: Low V, High P
Requires large amount of pressure to achieve a seal: Low V, High P
Easier to pass NGT into trachea: High V, Low P
Increased or Decreased cuff pressures:
Use of Nitrous:
Hypothermic CPB:
Decrease in Altitude:
Coughing, Straining, muscle tone changes:
Use of Nitrous: Increase
Hypothermic CPB: Decrease
Decrease in Altitude: Decrease
Coughing, Straining, muscle tone changes: Increase
Where should the stylet be in order to prevent trauma of the airway during Endotracheal intubation?
Keep the stylet inside the tube.
(Above the Murphy’s eye)
List of complications that can occur with ETT placement:
- Trauma
- Inadvertent bronchial intubation
- Fluid accumulation above the cuff
- Upper airway edema
- Vocal cord granuloma
In which 2 patient populations may we encounter inadvertent bronchial intubation?
Why?
- Peds: Straighter anatomy
- Females: Shorter anatomy
Inadvertent bronchial intubation leads to ___ and is typically in which bronchus?
Leads to atelectasis
Typically right mainstem
Why can laparoscopy and trendelenburg positioning possibly lead to inadvertent bronchial intubation?
Distance to carina decreases making it easier to accidentally advance into the right or left mainstem.
Approximate ETT marking at the teeth for males and females:
Males: 23 cm at the teeth
Females: 21 cm at the teeth
Upper airway edema is particularly dangerous in this population:
When is the “Peak incidence”?
When are the earliest signs seen?
Young children
Peak: 1-4 years old
Signs: 1 or 2 hrs - 48 hrs post-op
Avoid irritating stimuli - URI, anesthetic depth
Vocal cord granuloma is common in ___
female adult patients
What are some causes of vocal cord granuloma?
Trauma
ETT Too large
Infection
Excessive cuff pressure
Signs and Symptoms of vocal cord granuloma:
Treatment?
- Persistent hoarseness
- Fullness
- Chronic cough
- Intermittent loss of voice
Laryngeal eval and voice rest
If using a bougie as an airway adjunct, we want to introduce it with the tip positioned ____.
The distal end should be angled ___ to ___ degrees.
Anteriorly
30-45 degrees
If we are intubating “blind” we should still know where we are with bougie use because…?
We should be able to feel the clicking sensation across the tracheal rings
Describe the uses of the Magill forceps:
What are possible adverse effects of using Magill forceps?
- Primarily used for nasal intubations
- Directs the tube into the larynx
Possible damage to tube cuffs and lodged in murphy eye
What are some indications for “Lung Isolation”?
- Thoracic Procedures
- Hemorrhage control
- Unilateral Pathology
Anatomical description of the Right Mainstem:
- Shorter, Straighter, Larger diameter
- 25 degree takeoff from trachea
- Right Upper lobe tracheal takeoff is very close to origin
What is the degree of takeoff from the trachea for the Left mainstem?
45 degrees
Average length from carina to take off on both the Right and Left Mainstems?
Right: 2.5 cm
Left: 5.5 cm
Adult/Pediatric Double-Lumen Tube sizes
Adult: 35, 37, 39, 41 Fr
Peds: 26, 28, 32 Fr
Adults = odd, Peds = even
Primarily we use Double-Lumen tubes on which side?
LEFT
What are some procedures in which we would use a Right Double-Lumen tube?
- Left pneumonectomy
- Left lung transplantation
- Left mainstem bronchus stent in place
- Left tracheo-bronchus disruption
Are double-lumen tubes harder or easier to place?
Why?
They are more difficult to place due to the stiffness and size.
Describe the process of inserting a DLT:
- Advance through the larynx, tip angled anteriorly into the trachea
- Bronchial cuff passes the cords
- Bronchial portion is turned 90 degrees TOWARD the apropriate bronchus
- Verify correct placement of bronchial port with a fiberoptic scope
- Visualize the blue bronchial cuff just below the carina in the correct bronchus
- Inflate bronchial balloon under direct visualization
Once correct placement of a DLT has been visualized directly, what do want to ensure regarding the bronchial cuff?
Ensure bronchial cuff does not herniate over the carina
How do we isolate one lung with a DLT?
By clamping either the tracheal or bronchial connector
While using a DLT, if the bronchial lumen is in the wrong mainstem, what should we do?
Reinsert the DLT
While using a DLT, if the tube is too proximal in the airway, what should we do?
Correct with fiberoptic
With hypoxemia as a complication for DLT placement, what are some considerations for us? Especially if the patient has comorbidities.
- May need PEEP in the dependent lung
- May need to consider intermittent 2 lung ventilation (prevents worsening V/Q mismatch)
What are these devices called?
Bronchial-Blocking Devices
Indications For Bronchial-Blockers:
- Nasal intubation
- Difficult intubation
- Patients with tracheostomy
- Subglottic stenosis
- Need for continued postoperative intubation
- If a single-lumen tube is already in place
What can be done with a bronchial blocker that can NOT be done with a DLT?
They can block a segment of lung without isolating entire lung
