Exam 3- Airway Equipment II (7/6/23) Flashcards
Name the components of the laryngoscope.
- Handle
- Blade
- Light source (usually fiberoptic)
Manufactured as a single piece or detachable blade/handle
Which hand should handle the laryngoscope?
- Left Hand
Source of power for the laryngoscope light.
- Disposable batteries in the handle of the laryngoscope
- Typically C-Size Batteries
Most laryngoscope blades form a ________ angle to blade when ready for use.
- right
What does the blade of the laryngoscope do to the tongue and epiglottis?
- Tongue: Manipulates and compresses soft tissue
- Epiglottis: Tip of blade will directly or indirectly elevates epiglottis
What are the two types of laryngoscope blades?
- Mac (Curved)
- Miller (Straight)
What is the purpose of the blade spatula?
- Compresses the tongue into the mandibular space
What is the purpose of the flange?
- The flange (if present) is used to move the tongue laterally and create a visual lumen
Typical Mac sizes for adults
- Mac #3 (most common)
- Mac #4
Describe the tongue of a Mac blade compared to a Miller blade.
- Mac blade tongue has a gentle curve
- Miller blade has a straight tongue with a slight upward tip
Typical Miller sizes for adults
- Miller #2 (most common)
- Miller #3
Which laryngoscope blade has been shown to cause greater cervical spine movement?
- Macintosh Blade
Which laryngoscope blade is great for smaller mouths and longer necks?
- Miller Blade
Which laryngoscope blade will be used to minimize the movement of the cervical spine?
- Miller Blade
Which laryngoscope blade makes intubation easier because the blade requires adequate mouth opening.
- Macintosh Blade
When would you want to use a Miller #3 blade?
- Tall person
- Long neck
The laryngoscope blade requires less force, less head extension, and less cervical spine movement.
- Miller Blade
When using a Mac Blade, after epiglottis is visualized, the tip advanced into the _________.
Vallecula
When using a Mac Blade, the pressure applied at the right angle of the blade and the handle moves the ______ and ________forward.
- Base of the tongue
- Epiglottis
The Miller Blade will lift the ______.
- Epiglottis
If the Miller Blade is inserted too far, what structures can it elevate?
- Larynx
- Esophagus
What can happen if the Miller Blade is withdrawn too far?
- Epiglottis flips down and covers the glottis
How can the Miller Blade be used as a Macintosh?
- Miller Blade can also be inserted into the vallecula
What is the optimal position for the patient undergoing direct laryngoscopy?
- Sniffing position
The sniffing position will have a ______ degree neck flexion (lower cervical).
The sniffing position will have a ______ degree head extension at the atlanto-occiptal level.
- 35 degree
- 80-90 degree
In the sniffing position, there should be an imaginary horizontal line that connects the _______ and ________.
- external auditory meatus
- sternal notch
Steps to inserting laryngoscope blade.
- Right hand opens mouth (“scissor”) to keep the lips free to accommodate blade insertion
- Insert blade on right side of the mouth
- Advance blade, keeping tongue to the left and elevated
- Epiglottis comes into view
What are some interventions for difficult airways?
- Maintain a neutral position and use an OPA
- Flexible fiberoptic scope
- Video laryngoscope
What is the maneuver to displace the larynx to get the glottis in view?
- BURP (Backwards Upward Rightward Pressure)
___________ patients will require elevation of the shoulder and upper back.
- Obese
Use ramping technique for these patients so they can have a horiztonal ear to sternal notch line.
What can be used to ramp a patient?
- Troop Elevation Pillow
- Folded Blankets
Describe a Shikani Optical Stylet.
- 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?
- Neutral Position
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.
- Anterior (pointed up)
Shikani Optical Stylet can be used as a ________, check ETT placement, or placement of double-lumen ETT
- Light wand
Advantages of the Shikani Optical Stylet
- Easy to use for routine and difficult intubations
- Trachea is visualized. Esophageal intubation should not occur
- Decreased incidence of sore throat
- Results in less C-spine movement over conventional laryngoscopy
Disadvantages of the Shikani Optical Stylet
- 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
What are the advantages of using a video laryngoscope?
- Magnified anatomy
- Some scopes have curved/straight blades to mimic laryngoscopes
- Operator and assistant can see
- May result in decreased c-spine movement
- 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?
- Altered neck anatomy with the presence of a surgical scar, radiation changes, or mass
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?
- Dental Injury
What is most likely damaged during laryngoscopy?
- Upper incisors
- Restored or weakened teeth
What can help mitigate laryngoscopy-related dental injury?
- Tooth protectors (placed on upper teeth during DL)
- 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?
- Do not aggressively position the head
- Manual in-line stabilization (remove C-collar before intubation, have neurosurgeon remove C-collar)
What will happen to the tongue if there is a hypoglossal nerve injury?
- Tongue will deviate to the side when it is stuck out
- Tongue will look wrinkled on the side that it is deviated to
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?
- Internal Diameter of the tube
- Tube Length
- Configuration changes (if tube knots up)
- Connectors
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?
- Prevent/mitigate trauma
- Prevent/mitigate secretion buildup
- Allow passage of suction catheter or bronchoscope
How does the ETT design decrease kinking?
- Circular internal and external walls
What part of the ETT provides an alternate pathway for gas flow?
- Murphy eye
What does RAE Tube stand for?
- Ring-Adair-Elwin (RAE) Tube
What are the advantages of RAE Tubes?
- Facilitate surgery around the head and neck
- 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?
- Difficult to pass suction/scope
- Increases airway resistance
What are other names for Armored Tubes?
- Reinforced Tube
- Anode Tube
- Spiral Embedded Tubes
What are the advantages of Armored Tubes?
- Useful when tube is likely to be bent or compressed
- Resistance to kinking and compression
- Useful in head, neck, tracheal surgeries
What are the disadvantages of Armored Tubes?
- Need a stylet or forceps
- Difficult to use during nasal intubation
- Cannot be shortened
- Tube can be damaged if bitten
What makes up the laser-resistant tubes?
- Metallic or silicone/ metal mixture
What kind of laser’s do laser-resistant tubes reflect?
- CO2 Laser
- KTP (Potassium-titanyl-phosphate) Laser
What is Laser-Resistant Tube’s cuff filled with?
- The cuff is filled with methylene blue crystals and 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 ID 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)
Inflatable balloon near patient’s end of the tube
- Cuffs
Characteristics of an ETT Cuff.
- Strong
- Tear-resistant
- Thin
- Soft
- Pliable
The cuff must not herniate over what part of the ETT?
- Muphy eye
- 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.
- 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.
- 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. (maintains circulation)
- Low Risk to Tracheal Mucosa
Disadvantages of High-Volume, Low-Pressure Cuffs
- 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
- May not prevent fluid leakage
- Easy to pass NGT, esophageal stethoscopes around cuff
Describe the Low-Volume, High-Pressure Cuffs.
- Has small area of contact with trachea
- Requires large amount of pressure to achieve a seal
- Distends and deforms the trachea to a circular shape
Advantages of Low-Volume, High-Pressure Cuffs.
- Better protection against aspiration
- Better visibility during intubation
- Lower incidence of sore throat
Disdvantages of Low-Volume, High-Pressure Cuffs.
- Pressure exerted on trachea probably above mucosal perfusion pressure
- Can cause mucosal damage
- Should be replaced with a low-pressure cuff if postoperative intubation is required
Factors that can cause changes in cuff pressure.
- Use of nitrous (↑ pressure)
- Hypothermic cardiopulmonary bypass (↓ pressure)
- Increases in altitude (↑ pressure)
- Coughing, straining, and changes in muscle tone (↑ pressure)
What are common controversies involving airway equipment?
- Use of a stylets
- 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
Use _________ for nasal intubation to mitigate bleeding and pre-dilate nasal passage.
- vasoconstrictors (Afrin/Cocaine)
Inadvertent bronchial intubations are most common in:
- Emergencies (Code Blue)
- Pediatrics (shorter distance to carina)
- Females (shorter right mainstem)
Inadvertent bronchial intubation can lead to _________ if left in place for too long.
- atelectasis
The distance to the carina _________(decreases/increases) with Trendelenburg and laparoscopy.
- Decreases
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
What can accumulate above the cuff of the ETT?
- Fluids
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
Signs and Symptoms of Vocal Cord Granuloma?
- Persistent hoarseness
- Fullness
- Chronic cough
- Intermittent loss of voice
Treatment of 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.
- Bougie
The bougie has a polyester base with resin coating.
The distal end of the bougie is angled _______- degrees.
- 30-45 degrees
Introduce Bougie with anterior positioning of the tip.
Be Gentle.
You should feel the clicks of the tracheal rings.
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
The rationale for lung isolation in thoracic procedure
- Deflating the lung to increase safety profile and surgical exposure
The rationale for lung isolation to control contamination or hemorrhage
- Can prevent material in one lung from contaminating other
- Allows one lung to be ventilated while other hemorrhages
The rationale for lung isolation in unilateral pathology
- Isolate fistulas, ruptured cysts, or other issues with the diseased lung while allowing unilateral ventilation
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
What are the pediatric sizes for the double-lumen tube?
- 26 Fr
- 28 Fr
- 32 Fr
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?
- Stiffness
- Size
The DLT is advance through the larynx with angled tip anterior into the ________.
- Trachea
When 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?
- 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
- 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%)
