kettering section b: airway care Flashcards
1
Q
Kettering’s 8 points on cough control techniques.
A
- Postion — sitting upright or leaning slightly forward
- Relaxation — between efforts to reduce fatigue
- Volume building — multiple inhalations
- Multiple coughs, single inhalation — double/triple cough method
- Avoid coughing too hard or too long — to forestall fatigue, wheezing, air trapping
- Serial coughs — small breath and cough, larger breath and cough, then deep breath and hard cough
- Huff coughing — coughing with open glottis
- Splinting — press pillow over incised area to enhance strength of cough
2
Q
Who does Kettering feel should do huff coughing?
A
• May be more effective in patients with COPD
• May be more effective with patients with head trauma to prevent elevations in intracranial pressure
3
Q
Kettering’s purposes of bronchial hygiene therapy.
A
• Mobilize secretions
• Prevent accumulation of secretions
• Improve ventilation
4
Q
Kettering’s indications for bronchial hygiene therapy
A
• Accumulated or retained secretions
• Ineffective cough
• Ciliary dysfunction/ciliary dyskinesia
5
Q
Conditions Kettering says call for bronchial hygiene therapy.
A
• Bronchiectasis
• Cystic fibrosis
• COPD
• Acute atelectasis
• Lung abscess
• Pneumonia
• Post-operative condition
• Prolonged bedrest
6
Q
Kettering’s points for hazards and contraindications for bronchial hygiene therapy.
A
• Unstable cardiovascular system
• Unstable pulmonary system
• Unstable post-operative status
• Untreated tuberculosis
7
Q
What position for bronchial hygiene best suits a post-craniotomy patient? (K)
A
Supine
8
Q
What position for bronchial hygiene best suits patients with very low blood pressure?
A
Trendelenburg
9
Q
These body positions—Fowler’s, some-Fowler’s, or reverse Trendelenburg
—best serve which patient groups?
A
• Hypoxic patients
• Obese patients with dyspnea
• Post-operative abdominal surgery patients
• Patients with pulmonary edema
10
Q
K: What body position serves very obese patients with air hunger?
A
Lateral Fowler’s.
11
Q
K: What body position is best to prevent aspiration?
A
Lateral flat
12
Q
What should a therapist do if a patient aspirates in a certain body position?
A
Suction airway
—and then place patient in opposite position for postural drainage.
13
Q
K: What body position best serves a patient with unilateral consolidation?
A
Position affected lung up—
To allow it to drain
To direct perfusion to the unaffected lung
14
Q
K: Hazards and contraindications to chest percussion for secretion clearance.
A
• Soft tissue trauma
• Rib cage trauma/fractured ribs
• Hemoptysis/pulmonary hemorrhage
• Metastatic conditions
• Pulmonary emboli
• Pleural effusion
• Tuberculosis
• Untreated pneumothorax—absolute contraindication
15
Q
K: Describe technique of chest percussion for secretion clearance.
A
• Cup hands with thumbs next to fingers, wrists relaxed
• Percussion rhythmically over area to be drained
• Prefer mechanical percussion or vibration devices if patient does not tolerate manual percussion
• Change methods when a mechanical device malfunctions—use manual percussion
16
Q
Describe Positive Expiratory Pressure therapy.
A
Applying expiratory positive airway pressure using a one-way inspiratory valve and a one-way expiratory flow resistor. The expiratory valve prevents end-expiratory pressures from falling to zero. (K)
17
Q
How should PEP therapy be set?
A
- Set expiratory pressures to range from 10-20cmH2O at mid-exhalation.
- Have patient use fro 15-20-minute intervals 3-4 times/day. (K)
18
Q
What should be the effects of PEP therapy?
A
- May improve secretion expectoration
- May reduce residual volume (decrease hyperinflation)
- May improve airway maintenance (i.e. cystic fibrosis, pneumonia) (K)
19
Q
What conditions should prompt therapist to discontinue PEP therapy?
A
- Sinusitis
- Epistaxis
- Middle ear infection (K)
20
Q
How should therapist instruct patient to perform PEP therapy?
A
- Inhale larger-than-normal tidal volume
- Exhale actively but not forcefully
- Make exhalation 2-3 times longer than inhalation. (K)
21
Q
What do vibratory/oscillatory PEP devices do, mechanically?
A
Combine positive expiratory pressure therapy with high-frequency oscillations at the airway. (K)
22
Q
What is the goal of OPEP therapy?
A
To remove secretions from the airways. (K)
23
Q
Name examples of OPEP therapy.
A
- Flutter
- Acapella
- Quake
- Aerobika (K)
24
Q
What is autogenic drainage?
A
A set of breathing exercises used to improve mucus clearance.v
25
How should a therapist instruct a patient in autogenic drainage?
* Breathe at low lung volumes (ERV range) to loosen secretions from small airways.
* Increase volume by breathing in normal Vt range but exhaling to ERV (to accumulate secretions in the middle airways).
* Breathe at high lung volumes. (K)
26
What patient population is best suited to use autogenic drainage?
Primarily patients with cystic fibrosis and bronchiectasis. (K)
27
What is the purpose of suctioning?
* Maintain patent airway
* Collect specimens
* Stimulate cough (K)
28
What are indications for suctioning?
* Accumulated secretions
* Obstructed airway
* Depressed cough
* Inability to swallow (K)
29
What are the hazards of suctioning, and how should they be countered?
* Trauma/bleeding in mucosa (most common) (lubricate catheter (in the case of ENT suctioning), use gentle technique
* Contamination (use aseptic technique)
* Hypoxemia (leading to tachycardia, arrhythmias [most severe])
* Bradycardia (from stimulation of vagus nerve) (K)
30
Describe procedure for suctioning ETT.
* Oxygenation with 100% oxygen--1-2 minutes--required before and after suctioning.
* Monitor EKG to detect problems caused by iatrogenic hypoxemia.
* Use sterile catheter, solutions, and gloves each time.
* Suction ETT first; then suction mouth. Discard catheter.
* Suction ETT with fresh catheter. (K)
31
How does practitioner set vacuum regulator pressure for suctioning?
* Set 100-120mmHg for adult
* Set pressure with tubing occluded. (K)
32
What is a vacuum regulator?
A built-in shut-off device in the collection bottle that prevents aspirated secretions from entering the regulator and vacuum system when the bottle is full. (K)
33
How should an airway suction catheter be designed?
* Must have a beveled tip with at least 2 openings to decrease tracheal damage
* Must have a thumb port to provide intermittent suctioning (K)
34
Formula for ideal catheter size for ETT suctioning.
(internal diameter in mm / 2) X 3
35
Kettering's points for proper use of Lukens trap.
* Use to collected sputum specimen
* Place in upright position between suction catheter and suction tubing
* Flush catheter with sterile water or isotonic saline
* No not flush with bacteriostatic of hypertonic saline
* Use saline for cytology samples
36
Kettering--If suctioning is not working, how can it be modified?
* Change size and type of catheter
* Alter negative pressure
* Alter frequency of suctioning
* Alter duration of suctioning
37
Kettering--How can size and type of catheter be altered for difficulty in suctioning?
* Verify that catheter size is appropriate for endotracheal tube
* Change to Coude catheter to direct suctioning to left mainstem bronchus
* Change to closed suction catheter if patient has infection, PEEP therapy, or desaturates during suctioning
38
Kettering: How can negative pressure be altered when suctioning needs to be modified?
* Increase negative pressure to remove thick, tenacious secretions
* Do not exceed recommended vacuum pressures
39
Kettering: How can suctioning frequency be altered when suctioning needs to be modified?
Suctioning, because it is hazardous, should be performed only when necessary (and therefore scheduled as PRN)
40
Kettering: How should duration of suctioning be altered when suctioning needs to be altered?q
* Suction catheter should be in the airway no longer than *fifteen seconds*
* If cardiac arrhythmias occur, stop suctioning and decrease amount of time in the airway
41
Kettering: How should be suctioning be handled when adverse effects occur?
* Suctioning should be stopped
* Reduce level of suctioning
* Continue suctioning more gently and in less time
42
Kettering: What troubleshooting should be kept in mind for difficulty suctioning?
* Check catheter for patency
* Assure vacuum system is working
* Change or empty a full collection bottle
* Check all connections
43
Kettering guidelines for sizing endotracheal tubes.
* Adult males: 7.5-8.5 mm
* Adult females: 6.5-8 mm
* Adult: weight in kilograms / 10 = approximate size
44
Kettering on approximate tube depths for oral and nasal intubation.
Oral: approximately 21-25 cm at the lip
Nasal: approximately 26-29 at the naris
45
Kettering's old school cuff pressure measurement system.
Three-way stopcock, syringe, pressure manometer.
46
Kettering notes on Cufflator for measuring cuff pressures.
* Eliminates manometer/syringe/stopcock clumsiness
* Calibrated in cmH2O
* Set cuff pressure below 25 cmH2O or 20 mm Hg to allow circulation to tracheal mucosa
47
If cuff pressure measures zero, what should operator do?
Check tightness of connection between manometer and pilot balloon.
48
Indications for tracheostomy (Kettering).
* Requirement for long-term ventilation
* Upper airway obstruction (preventing intubation)
49
Advantages of tracheostomy (Kettering).
* Easier to stabilize, suction, tolerate than ET tubes
* Allows patient to eat and to speak
* Reduces airway resistance relative to oral/nasal ET tubes
* Offer fewer hazards
50
Immediate complications of tracheostomy tubes (Kettering)
* Bleeding (major hazard)
* Pneumothorax
* Air embolism
* Subcutaneous emphysema
51
Late complications of tracheostomy tubes (Kettering)
* Infection
* Hemorrhage
* Obstruction
* T-E fistula
52
When should cuff of tracheostomy tube be inflated? (Kettering)
* When patient is eating
* When patient is on positive pressure ventilation
53
Kettering's points on fenestrated tracheostomy tubes.
* Have opening in *outer* cannula above the cuff
* Used for weaning, allowing, with an inner cannula, temporary mechanical ventilation
* Not used for code or in emergencies
* Allows patient to breath through upper airway and speak
54
How does operator cap fenestrated tracheostomy tube? (Kettering)
* Deflate cuff
* Remove inner cannula
* Then cap the tube
55
Kettering's points for tracheal button.
* Used to maintain stoma (tracheostomy opening)
* Used in some patients to treat sleep apnea
* Allows tracheal suction and phonation with least amount of airway resistance
* Cannot be used for resuscitation because uncuffed
56
Kettering's points for extended tracheostomy tubes
* Adjustable flanges allow adjustment of horizontal distance
* Indicated for patients who are obese or use cervical collars
57
Kettering's points for Jackson tracheostomy tubes
* Metal trach tube
* Comes with inner cannula
* Not for resuscitation or positive pressure ventilation
* Does not have a cuff
* No mri (Johns Hopkins)
* Need to alert airport personnel for metal detectors (Johns Hopkins)
58
What are those self-inflating cuff tracheostomy tubes called?
Kamen-Wilkinson Foam / Bivona Cuff tracheostomy tube.
59
Kettering--features of bivona cuff tracheostomy tube.
* Foam-filled cuff
* Evacuate air prior to insertion
* Pilot tube is open to the atmosphere and foam expands to seal trachea
* Air must be evacuated to extubate patient
* Do not inflate cuff with a syringe
* Has no inner cannula
* Does not have a pilot balloon
60
Kettering points for laryngectomy
* To treat upper airway carcinoma, patient's larynx is removed surgically.
* Surgery leaves no connection between patient's upper and lower respiratory tract.
* Patient cannot be orally or nasally intubated.
* Patient breathes through a laryngectomy tube initially.
* Laryngectomy tube is removed after 3-6 weeks, leaving patient with a permanent stoma.
61
Kettering: What is the purpose of a laryngectomy tube?
To maintain a patent airway after a laryngectomy has been performed.
62
How do laryngectomy tubes compare to tracheostomy tubes?
* Laryngectomy tubes are made of soft, pliable material
* Laryngectomy tubes, while available in various sizes, are generally shorter in length than standard tracheostomy tubes
* Laryngectomy tubes may have an inner cannula
* Laryngectomy tubes do not have an inflatable cuff
63
Kettering: Name the generic class of ETT with lumen for subglottic suctioning.
Continuous Aspiration of Subglottic Secretions (CASS)
64
Kettering: Trade names for CASS ETTs.
* Hi-Lo Evac
* Sealguard Evac
*TaperGuard Evac
65
Kettering: Where is additional lumen in CASS ETT located?
To opening just above ETT cuff.
66
Ketttering: How are CASS tubes managed?
Continuous suction is applied via separate pilot tube connected to a vacuum pressure of 20 mmHg.
67
Kettering: What is indication for CASS ETT?
Risk of Ventilator Acquired/Associated Pneumonia (VAP)
68
Kettering: How does CASS ETT reduce risk of VAP?
* Minimizes microaspiration
*Reduces tracheal colonization
69
Kettering: How does size of CASS compare to size of standard ETTs?
CASS is 1 mm larger than standard tube--e.g, 7.5 ID is same size as standard 8.5 ID.
70
Kettering: What is disadvantages of CASS ETTs?
Their larger diameter may increase risk of airway trauma.
They cost about 15 times more than standard ETTs.
71
Kettering: What are the supposed advantages of silver-coated/antibacterial-coated endotracheal tubes?
* Limit bacterial colonization
* Limit biofilm formation on lumen of ETT
* Reported to decrease VAP--with little objective evidence
72
Kettering: What is the disadvantage of silver-coated/antibacterial-coated endotracheal tubes?
* They cost approximately 100 times more than the standard tube.
73
What ETTs are promoted to decrease cuff channel formation? What are their commercial names?
Polyurethane cuffed endotracheal tubes with brand names Microcuff and Sealguard.
74
Per Kettering qualities of polyurethane cuffed endotracheal tubes.
* Designed to prevent cuff channel formation
* Cuff channels allow microaspiration
* Promoted to decrease VAP, though RC 201008 found "insufficient evidence"
* Cost approximately 4x more than standard ETT
75
What endotracheal tubes are promoted as limiting bacterial colonization?
Silver-coated antibacterial-coated endotracheal tubes.
76
Qualities of the silver-coated antibacterial coated endotracheal tube, per Kettering.
* Silver-coated/impregnated material
* Limits biofilm formation in lumen of ETT
* Limits bacterial colonization
* Reported to decrease VAP/little objective evidence
* Costs approximately 100 times more than standard tube
77
Names applied to endotracheal tubes with two lumens.
Double-lumen / endobronchial / Carlens
78
Kettering notes on design of double-lumen endotracheal tubes.
* Two separate lumens each of different length
* Longer lumen is placed into right mainstem bronchus
* Shorter lumen is paced in trachea above carina to access left mainstem bronchus
* Lumens allow ventilation of each lung independently or, with wye attachment, two lungs together
* Bronchial cuff has radiopaque line to confirm correct placement
79
Indications for double-lumen endotracheal tube (Kettering)
* Uncontrolled unilateral hemoptysis
* Need to protect airway of unaffected lung in certain cases of unilateral lung disease (e.g., lung abscess)
* Need to improve ventilation or oxygenation of patient with unilateral lung disease
* Bronchopleural fistulas
* Tracheobronchial tree disruptions
* Surgical opening of a large airway to stop or promote healing and ventilate other areas of the lung
* Select surgeries: pneumonectomy; lobectomy; esophageal resection; aortic aneurysm repair
80
Kettering's 9 indications for endotracheal intubation
1. Acute airway obstruction: trauma to mandible or larynx
2. Inhalation injury: smoke, noxious chemicals, foreign bodies
3. Infection: retropharyngeal abscesses
4. Hematoma, tumor
5. Laryngeal edema, laryngeal spasm (anaphylactic response)
6. Need for access for suctioning: debilitated patients, copious secretions
7. Loss of protective reflexes; head injury, drug overdose cerebrovascular accident
8. Severe hypoxemia: ARDS, atelectasis, secretions, pulmonary edema
9. Hypercapnea: Hypoventilation, neuromuscular failure, drug overdose
81
How would Kettering have one approach intubating patient with head or neck injury?
* Use advanced intubation tools, such as bronchoscopy
* Avoid head tilt, chin lift by using modified jaw thrust
82
Kettering's assessment notes for thyromental distance.
* Distance between mandible and anterior neckline
* Normal: 6.5 cm
* Abnormal: < 5 cm -- indicating difficult airway
* Common anesthesia technique is 3 fingers between jawline and larynx
83
Describe the classes in the Mallampati classification
Class 1: Soft palate, uvula, fauces, pillars visible
Class 2: Soft palate, uvula fauces visible
Class 3: Soft palate, base of uvula visible
Class 4: Hard palate only visible
84
Which classes in Mallampati classification are considered difficult airways?
Class 3 and 4.
85
What do you call the application of cricoid pressure while intubating?
Sellick maneuver
86
Kettering list of major ways to confirm endotracheal tube placement.
* Visualization
* Auscultation--listen for bilateral breath sounds
* CO2 detection (capnogaph; colormetric or etCO2 monitor--AHA recommends quantitative waveform capnography during resuscitation)
* CXR: top of properly placed ETT will be at lease 1 inch above carina, at the level of aortic knob
87
Kettering list of minor ways to confirm endotracheal tube placement
* Visualization of cords during insertion of tube
* Ease of manual ventilation
* Expiratory fogging of endotracheal tube
* Palpation of the larynx
* Coughing through endotracheal tube
* Loss of voice
* Absence of progressive abdominal distension
* Squeeze bulb syringe--empty bulb, attach to ETT--if fails to re-fill, then ETT is in the easily collapsible esophagus
88
Kettering's five areas of complications from endotracheal intubation.
* Trauma from forceful use of laryngoscope and tube placement
* Formation of granulation tissue ulcers from excessive cuff pressure
* Reflex glottic closure and laryngospasm
* Right mainstem bronchus intubation
* Gastric aspiration
89
Kettering: details of endotracheal intubation--Trauma from forceful use of laryngoscope and tube placement
* Injury to laryngeal, nasal, & pharyngeal tissue
* Dental trauma (e.g., dislodged tooth)
* Mandibular dislocation
* Spinal injury
90
Kettering: details of endotracheal intubation--Formation of granulation tissue ulcers from excessive cuff pressure
* Mucosal ischemia
* Tracheal stenosis
* Tracheal malacia
* Tracheoesophageal fistula
91
Kettering: details of endotracheal intubation--Reflex glottic closure and laryngospasm
* Prevents intubation
* Limits spontaneous ventilation
* Ventilate via bag/mask until spasm subsides
* Topical lidocaine can minimize risk
* Administer succinylcholine if situation becomes urgent
* Repeated spasms may result in intubation failure
92
Kettering: details of endotracheal intubation--Right mainstem bronchus intubation
* Assessment reveals: asymmetrical chest movement; breath sound diminished or absent on left; decreased SpO2
* Deflate cuff and withdraw ET tube
93
Kettering: details of endotracheal intubation--Gastric aspiration
* May occur during intubation procedure from stimulation of oropharynx
* May be prevented by application of cricoid pressure (Sellick maneuver) to seal esophagus and improve visualization of vocal cords
* Risk may be reduced by administration of ranitidine (Zantac) and/or metoclopramide (Reglan)
94
Kettering's list of supraglottic airways:
* King tube
* Laryngeal mask airway
* Combitube
95
Kettering's notes for King tube.
* Color-coded s/m/l
* Easy insertiom
* Short learning curve
* Allows positive pressure ventilation
96
Kettering description of LMA
An inflatable mask that is positioned directly over the opening into the trachea (hypopharynx)
97
Kettering virtues of LMA
* Insertion does not require a laryngoscope
* A standard ETT can be inserted directly through some LMAs into the trachea if necessary
* Spontaneous breathing through the airway is possible
* The low-pressure seal of the LMA around the laryngeal opening is insufficient to stimulate the larynx to spasm
*
98
Kettering disadvantages of LMA
* High-pressure assisted ventilation has been shown to create gastric insufflation
* Contraindicated if a risk of aspiration exists
99
Kettering--procedure for LMA insertion
* Place patient in sniffing position
* Administer sedation to same level used for elective intubation
* Hold jaw of patient open
* Advance mask and cuff along hard palate using the index finger and position at the back of the tongue
* Advance tube until resistance if felt as mask settles over the esophagus and larynx
* Inflate cuff around laryngeal opening--a small amount of movement (1-2 cm) is felt in the cricoid cartilage
* Inflate the cuff just enough air to obtain a seal, corresponding to a cuff pressure of approximately 60 cmH2O
* Frequently only half of the maximum volume is requires to achieve an adequate seal. Do not over-inflate the cuff.
* The airway can be removed when the patient is alert enough to open mouth on command
100
Indications for LMA (Kettering)
* Need for short-term ventilation where more invasive intubation is not merited
* When intubation is not possible by oral or nasal route (e.g., facial or nasal injuries)
101
Contraindication for LMA (Kettering)
Risk of aspiration
102
Kettering: Describe the construction of the Combitube.
* Distal end: A tracheal lumen and an esophageal lumen are combined into one tube
* Proximal end: Two lumens are separated and color-coded.
* A large cuff is attached to the proximal end
* A smaller cuff is attached to the distal end
* The single tube has apertures between the two tubes
* Below the cuffs, the end of the tube is open
103
Kettering instructions for Combitube use.
* Place device blindly--it will enter trachea or esophagus.
* If device enters esophagus, as is more common, the esophagus will be occluded by the distal balloon.
* Ventilation will be supplied through the longer, blue-colored #1 tube. Gas will be forced through apertures in the side of the tube between the two cuffs.
* If the device enters the trachea, ventilation is provided directed into trachea using the shorter, clear-colored #2 tube. This #2 tube will work like a standard oral endotracheal tube.
104
How should patient be assessed after intubation with Combitube?
Careful assessment of bilateral breath sounds and gastric sounds so that proper tube for ventilation will be selected.
105
Kettering advantages of Combitube.
* Can be inserted rapidly
* Does not require visualization of the larynx
106
Kettering disadvantages of Combitube
* Placement of ETT is difficult with Combitube in place
* Cannot be used in patients with a gag reflex
107
Kettering on use of flexible fiberoptic bronchoscope for intubation.
* Useful in cases where upper airway anatomy is distorted by trauma or tumors or when cervical spinal injury prevents manipulation of the neck
* Allows visualization of the vocal cords
* Allows ETT to slide over scope into trachea with visual confirmation
108
Kettering: three styles of videolaryngoscopes
* Illuminated stylet/light wand
* Guide channel
* Video laryngoscope
109
Commercial names of illuminated stylet/light wands
* Bonfils
* Video RIFL (rigid flexible laryngoscope)
110
Kettering points on illuminated stylet/wands
* Illuminates skin as it enters larynx
* Little light is seen if it enters esophagus
* Used in blind intubation
* Limited success with patients with bull neck and/or obesity
111
Commercial names of guide channel video intubation devices
* AirTraq
* Pentax Airway Scope (AWS)
(Pieters 2016)
112
Kettering points on guide channel video intubation devices
* Holds ETT within a guide channel
* Screens are very small
* Very portable
113
Commercial names of video laryngoscopes
* Storz C-MAC
* GlideScope
(Pieters 2016)
114
Kettering points on video laryngoscopes
* MacIntosh blade with video
* View screen and enhanced view
* Advantage to skilled intubators
* Glidescope offers disposable blades and flexible video bundle
* Pre-formed rigid stylet used to facilitate intubation
115
Kettering notes on needle cricothyrotomy
* May be indicated when intubation has failed
* Insert large-bore (14-gauge) needle through cricothyroid membrane
* Can be attached to a high frequency jet ventilator
* 3 mL syringe can be attached to the needle
--Connect to a 7 mm ID ETT adaptor for ventilation
--High airway resistance will make conventional ventilation difficult
116
Kettering notes on airway exchange catheter.
* Small diameter tube
* Allows oxygenation and ventilation
* Acts as stylet
* Endotracheal tube slides over it and into trachea
* Used to replace damaged ETTs
* Decreases re-intubation time and risks
117
Kettering notes on gum elastic bougie
* Small diameter semi-flexible tube
* Acts as stylet
* Endotracheal tube slides over it and into trachea
* Facilitates difficult intubation
* Used to replace damaged ETTs
* No oxygenation or ventilation possible through bougie
* Decreases re-intubation time and risks
118
Kettering on older technology of tube introducer. When was it used? How did it work?
* "Used when vocal cord defy intubation"
* Flexible guidewire was inserted into cricothyroid membrane and fed through the mouth
* Wire was inserted into ETT
* ETT was slid down wire into trachea
* "Seldom used since new technologies now available"
119
Kettering on percutaneous dilation tracheostomy
* Performed at bedside
* Bronchoscope used to secure trachea channel and guide needle puncture
* Series of dilators used to expand puncture until sufficient for tracheostomy tube
* Frequently performed as a non-emergent procedure
120
Kettering: *The* major complication of intubation.
Hemodynamic instability, as the introduction of positive pressure ventilation provokes hypotension.
121
Kettering: What should induction agents used prior to intubation do?
* Produce unconsciousness
* Optimize intubation conditions
* Minimize hemodynamic response
122
Ketterings list of induction agents
* Propofol
* Etomidate
* Ketamine
* Midazolam
* Fentanyl
123
Kettering notes on propofol as an induction agent for intubation
* Rapid onset
* Short duration of action
* Superior to etomidate or thiopental
* Major disadvantage is hypotension
124
Kettering notes on etomidate as induction agent for intubation
* Fast onset
* Rapid recovery from a single dose
* Maintains hemodynamics: does not affect heart rate, blood pressure, cardiac output
125
Kettering notes on ketamine as an induction agent for intubation
* Little effect on respiratory or cardiovascular system
* Central nervous system effect which increases ICP, CPP, cerebral oxygen consumption
* Used since 1965
126
Kettering notes on midazolam as an induction agent for intubation
* Sedative
* Intermediate on set (15 minutes)
* Moderate duration (2-3 hours)
* Complications include PVC, tachycardia, bigeminy
127
Kettering notes on fentanyl as an induction agent for intubation
* Opioid analgesic
* Complications include: bradycardia, cardiac arrest, hypo- or hypertension, respiratory depression
128
Kettering notes on neuromuscular blocking agents for intubation
* Improve effectiveness of bag/mask ventilation and intubation conditions
* Helpful in emergent or difficult intubation
* Rapid response is crucial
129
Kettering notes on succinylcholine as an induction agent for intubation
* Depolarizing NMBA
* Fast onset (30 seconds)
* Short duration of action (5-10 minutes)
* Commonly used in rapid sequence intubation
* Major complication is hyperkalemia
* Limited use in patients with bradycardia & arrhythmias
130
Kettering notes on rocuronium as an induction agent for intubation
* Non-depolarizing NMBA
* Rapid onset (60-90 seconds)
* Intermediate duration (30-60 minutes)
* Best alternative when succinylcholine is contraindicated
131
Kettering on rapid sequence intubation
* Indicated when risk of aspiration is high
* Consists of pre-oxygenation followed by induction agent and muscle relaxant in rapid sequence
* Induction is performed after waiting 45-60 seconds (while induction agent and muscle relaxant take effect) without mask ventilation
132
Kettering's description of preparation for rapid sequence intubation procedure
* Evaluate airway (mallampati, thyromental distance
* Difficult airway suspected? Obtain additional equipment (videolaryngescope, bronchoscope)
* Ensure adequate IV access
* Ensure vasopressors available to treat hypotension
133
Kettering's description of rapid sequence intubation procedure
* Position patient and pre-oxygenate
* Give induction medications
* Perform intubation
* Confirm intubation: observation, auscultation, PetCO2, CXR
134
What's the generic name for Vest therapy?
High Frequency Chest Wall Compression
135
What does K note for therapy with HFCWC?
"5-25Hz for 30 minutes, 1-6 times daily" (Egans 11th p. 967)
136
What does IPV stand for again?
Intrapulmonary Percussive Ventilation
137
What is the brand name for the IPV device named in K?
Percussionaire IPV-1
138
How does K describe IPV's unique therapy?
A combination of high-frequency pulse delivery (100-250 cycles/min) of sub-tidal volume and a dense aerosol.
139
How does K describe the therapeutic virtues of IPV?
*Percussive ventilation improves ventilation past obstructions in the airway, thereby delivering more aerosol to distal airways
* (Coughing helps facilitate removal of retained secretions and further improves ventilation.)
*Dense aerosol delivery promotes bronchial hygiene, reduces edema, and relieves bronchospasm with the appropriate medication
140
What tip does K offer for initial setting on IPV?
Start source pressure (the control that regulates the velocity of the percussive pulses) for most patients at 30 psi.
141
What are Kettering points for modifying bronchial hygiene (CPT) therapy?
* Positioning: Avoid Trendelenburg in patients with head injury
* Duration: Gauge by patient need and/or tolerance
* Special conditions: Consider modifying technique for patients with chest tubes or bone fractures
* If CPT is done by another person or department, coordinate other respiratory care with person delivering CPT.
142
Kettering: by what criteria does a practitioner evaluate effectiveness of bronchial hygiene therapy?
* Auscultation: Changed/improved breath sounds
* Inspection: Color, chest expansion
* Cough: Volume and characteristics of sputum
* Toleration: Fatigue, WOB, pain
* Vital signs: HR, RR, BP, EKG
* CXR: Improved pattern
* All but CXR should be observed after every treatment. Based on obtained data, limit or do only the involved segments
143
Kettering: By what criteria should bronchial hygiene therapy be discontinued?
* Clear breath sounds
* Clear CXR
* Ambulating well
* Strong cough
* Afebrile for 24 hours
* Therapy provokes adverse effects: dizziness, SOB, cyanosis, etc.
144
Kettering: Describe speaking devices for tracheostomy tubes.
* One-way valve that attaches to tracheostomy tube
* During inspiration, valve opens and air enters the lungs through the tube
* During exhalation, valve closes and air passes around cuff and through the vocal cords
* Cuff must be deflated
145
Kettering description of procedure for tracheostomy care.
* Assemble and check equipment
* Explain procedure to patient
* Suction patient to ensure patent airway
* Clean inner cannula by soaking it in a solution of hydrogen peroxide and water--then rinse with sterile water
* Clean the stoma site with using cotton applicators dipped in the water-hydrogen peroxide solution. Replace gauze dressing
* Change trach ties
* Replace inner cannula
* Reassess patient and record the procedure
146
Kettering: How should tracheostomy be cared for after removal of tracheostomy tube?
* Do not suture closed the stoma
* Apply sterile dressing and/or antibiotic to site
* Clean periodically with hydrogen peroxide
* Have patient cough to clear secretions
147
Kettering: When should tracheostomy tube be changed?
* When tube is obstructed (If unable to pass a suction catheter, remove the tube, ventilate, and insert a new tube)
* When tube is too small (i.e., very high cuff pressures [>20 mmHg] needed to seal cuff)-- change to larger tube
* When cuff of tube is punctured (unable to seal cuff)--replace the tube if a seal is required.
* All other problems can be treated without replacing the endotracheal or tracheostomy tube
148
Kettering: What actions should practitioner take in response to leak in cuff, pilot balloon or pilot valve
* Place stopcock in pilot balloon valve
* Insert blunt needle into pilot line
* Clamp pilot line
* Replace the tube
149
Name video intubation scopes with screen built onto the blade.
Coopdech VLP-100
McGrath
(Pieters 2016)
