LAB C: AAM Q&A Flashcards
What are the indications for endotracheal tube intubation?
- patients requiring anesthesia and as a lifesaving procedure for critically ill or injured patients.
It ensures oxygenation, effective ventilation, and airway protection.
What are the 4 P’s?
Prevent Obstruction
Prevent Aspiration
Provide Bronchial Hygiene
Provide Positive Pressure Ventilation (PPV) & adjuncts that improve oxygenation.
What are some immediate complications of endotracheal tube intubation?
- Spinal cord injury
*Epistaxis - Tooth trauma
- Retropharyngeal Trauma
- Subcutaneous or mediastinal emphysema
- Perforation of esophagus or pharynx
What are more?
- Laceration of pharynx/larynx
*Arytenoids dislocation
*aspiration
*Pneumothorax - Esophageal intubation/gastric distention
- bronchial intubation
- Hypoxemia
- Inadequate ventilation
What are some more?
- laryngeal spasm
- bronchospasm
Cartiac dysrhythmias
*hypotension
*airway obstruction + damage to trachea - Ruptured cuff –> inadequate ventilation
- Tracheal bleeding
c) What type of endotracheal tube would be preferred when performing Transoral endoscopic laryngeal laser surgery (TLS) surgery for removal of a laryngeal tumor?
Laser tube (various configurations)
What type of endotracheal tube would be preferred when performing Independent lung ventilation in the ICU for asymmetric lung disease?
Endobronchial Tube
How about if the patient requires intubation and two weeks of mechanical ventilation in the ICU?
Hi Lo Evac Tube
Why is it important to monitor endotracheal cuff pressure?
Monitoring ensures that blood flow to the tracheal mucosa is not impeded.
- Excessive pressure can cause necrosis, tracheomalacia, tracheoesophageal fistula, tracheoinnominate artery fistula, mucosal ulceration, and severe hemorrhage.
- A tracheoinnominate artery fistula is a life-threatening event.
what is normal cuff pressure range?
20-25cm H2O
What are some likely problems if cuff pressure is above optimal value?
mucosal blood flow interruption, ischemia, avascular necrosis, inflammation, hemorrhage and/or ulceration, granuloma formation, exposure of cartilage, tracheomalacia, tracheal stenosis.
What happens if cuff pressure below normal range?
- Aspiration
*Leaks in volume/pressure delivery.
What is the function performed by the Rae ET Tube, and what clinical situations would you advocate for the use of these specialty tubes?
Use –> Direct airway connection away from surgical field.
Would use it when trying to position airway and anesthesia circuit/equipment away from operative field for surgical procedures.
what is the difference between the 2 tubes?
Nasal –> Longer and straighter. Allows for longer distance (nates to vocal cords)
* Points away from oral cavity, toward forehead.
Shorter –> The oral one (Mouth to vocal cords).
* Points down toward chin or side of mouth.
What is a similarity between the 2 tubes?
They both point away from center of the face to allow for clear surgical site/area.
What are the key features of the double lumen Endobronchial Tube?
*Can ventilate lungs via one ventilator or isolate each lung solo.
- Sed for surgical applications, and for management of asymmetrical lung disease.
- Either right or left mainstem can be intubated with bronchial side of the tube, the tracheal lumen positioned above the carina.
- both cuffs inflated and selective lung ventilation can occur (one or both).
*independent lung ventilation can be optimized for asymetrical lung disease.
What are the key features of this tube?
- ability to isolate one lung
*Cuff seal separation of bronchi - Special cuffs to diminish risk of misplacement and leak
- bronchial lumen different for both sides.
Describe how the EBT would be positioned in a patient
Right side –> Account for length of mainstem is (2.0-2.5cm long) and lower angle.
- Left is 40-50 degree angle, more stable position as longer mainstem is not as sensitive to tube migration.
*Cuff designs should protect from inadvertent RUL bronchus obstruction with right sided tubes.
What are the differences in size between a left and right mainstem bronchi and left and left and right endobronchial tube?
Right mainstem bronchi: 1.4cm diameter + 2.5cm length
Left mainstem bronchi –> 1cm diameter + 5cm length.
*Right more hard to maintain EBT position.
Identify key features of the Evac ETTube
The dorsal lumen of tube opens above the cuff (allows for drainage of subglottic space + for continuous aspirations of subglottic secretions).
What is the purpose of the “Above cuff aspiration port”?
Is a port that opens to a channel in ETT wall.
- Connected to a line with end connector that can be hooked to suction or manual aspiration.
What patients would you intubate with a HI Lo Evac Tube?
- Ventilator dependent patients
- Prolonged intubation cases, who are at risk for VAP due to build-up of secretions and micro aspirations of supra-cuff secretions above the cuff.
Why is this tube “Preferred” ETT to use for intubation of critical care patients?
- Allows RT to clear supra-cuff secretions that build on the cuff.
What happens when armored tube is bent, twisted, and/or compressed
They can’t be compressed or collapsed as spiral embedded wires keeps them patent at acute angles.
Describe indications for spiral embedded (armoured) tube
*Emergent applications
*Where anatomic malformations-tumours or tortured airways can result in tube kinking.
*Sub-mental intubations + surgical airways.
*Cricothyroidotomy.
Is this tube bite proof?
No!
*When bitten –> Results in compression + obstruction + tube damage + need for extubation and/or reintubation if indicated
What are other features?
- position indicator marks that show tube position through vocal cords
*Indicate distance from tube tip and from above cuff.
*soft silicone tip reduces tissue damage during placement and while in position.
a) Metal Laser flex ETT
b) Cuffed laser resistant ETT
Describe device a)
- Stainless steel, airtight, flexible, and laser resistant.
*Reflected beams from tube must be defocused to laser beam.
*Shaft on tube may be wrapped in aluminum and teflon tape.
- Double cuff designs assure teacheal seal should one cuff be struck by laser beam.
For b), what should be done?
*inner cuff should be filled with air or sterile isotonic saline.
*Outer cuff may also be filled with sterile isotonic saline.
*If outer cuff destroyed by laser, yellow inner cuff completely seals trachea.
What procedures may necessitate need for intubation with a laser tube?
*Endoscopic treatment of subglottic and tracheal stenosis (enables precise incisions with minimal thermal damage, preserving viable cells for re-epithelialization of injured area).
*Endoscopic laser surgery used to treat early stage laryngeal tumours.
What procedures may necessitate the need for intubation with this tube?
*Treatment of subglottic + tracheal stenosis, because it enables precise incisions with minimal thermal damage.
*Endoscopic laser surgery used to treat early laryngeal tumours.
Comment on cuff inflation for a laser tube.
*Inner cuff should be filled with air or sterile isotonic saline.
*Outer cuff filled with sterile isotonic saline.
*If outer cuff destroyed by laser beam, yellow inner cuff completely seals trachea.
Identify special features that Laser tubes may incorporate into the tube cuff that allows the user to know that the cuff has been damaged by a laser strike during the procedure? Check with your instructor.
The Xomed laser shield tube has methylene blue inside the cuff, fill with saline or water, the blue dye will leak out if punctured and show a breach of the cuff has occurred by the laser. This will alert the surgeon during the procedure that the laser tube’s cuff has been ruptured.
Describe how the cuff seals airway in comparison to standard ETT cuffs.
- Foam cuff has large diameter high residual volume cuff composed of polyurethane foam covered by silicone sheath.
- Cuff can be connected to breathing circuit by means of pilot tube. Cuff expands to seal airway with changes in respiratory cycle + airway pressure.
Why is proper size important? What happens if cuff too small?
*Proper size –> To maintain seal + benefit from pressure-limiting advantages of foam-filled cuff.
- Too small –> Foam inflate to unrestricted size + not touch tracheal wall. Loss of ventilation + Loss of protection against aspiration.
When is this usseful?
*Cases of tracheomalacia (softened cartilage), as it conforms to tracheal wall preventing airway collapse + limits cuff pressure.
What approximate pressure is exerted against tracheal wall from inflated foam cuff?
Does not exceed 20mmHg (27cmH2O).
If you were to prepare this tube for an intubation (insertion into a patient’s airway), describe the steps.
- Check cuff + sheath for integrity. Lubricate tip and cuff.
- Before insertion, use large syringe and withdraw air from pilot tube connected to cuff.
- Maintain (-) pressure on syringe (draw back on it), and intubate or cannulate patient.
- Detach syringe, open pilot tube line. This allows air to go in foam and sponge cuff to inflate.
Assume this tube is in a patient’s airway with the “Red Pilot Port” in the Open position. How would you deflate the cuff prior to removal of this tube?
A syringe attached to pilot port evacuates air in the cuff.
*once cuff deflated, intracuff pressure at below ambient levels.
*Tube can be removed while maintaining deflated state of cuff.
Give examples of where thys cuff pressure device would be appropriate clinically.
*Patients who have developed tracheal injury related to the cuff.
*When excess cuff pressures are required with pneumatic cuffs to seal/
*Foam cuff designed to address issues of high lateral tracheal wall pressures that lead to complications like tracheal ulceration, necrosis, stenosis.
Describe the purpose of the “Pressure Easy” device
*It continuously monitors tracheal cuff pressure. Its indicator window signals cuff pressure between 20-30cmH2O.
*Airway pressure auto-feedback feature boosts cuff pressure to ensure proper sealing when high pressures used during ventilation.
What advantages does this device offer?
*Single-patient use
*Reduces potential for infection + eliminates sterilization issues with quarantined or isolated patients.
- Does away with managing inventory of manometers, issues of availability + Calibrating + replacement of reusable manometers.
How does this device function during the inspiratory phase of positive pressure ventilation and during the expiratory phase of positive pressure ventilation?
The airway pressure auto-feedback feature boosts cuff pressure to ensure proper sealing when high pressures used during ventilation.
Describe why it is important to regulate cuff pressure in intubated patients.
Excessive cuff pressure can cause avascular changes that degrade tracheal mucosa, tracheal cartilage, and adjacent tissues.
- Life threatening events can result.
