LECTURE 12 (Tracheal intubation)

Question 1

What is the Pharynx?

Answer 1

The upper part of the throat posterior to the nasal cavity, mouth and larynx

CONSISTS OF:
- Nasopharynx - base of the skull to the soft palate
- Oropharynx - soft palate to the epiglottis
- Hypopharynx - epiglottis to the cricoid ring (posteriorly)

Question 2

What is the Larynx?

Answer 2

The anterior structures of the throat (voice box) from the tip of the epiglottis to the inferior border of the cricoid cartilage, including the laryngeal inlet

Question 3

What is the Laryngeal inlet?

Answer 3

The opening to the larynx bounded anterosuperiorly by the epiglottis, laterally by the aryepiglottic folds and posteriorly by the arytenoid cartilage

Question 4

What is the Arytenoid/Posterior cartilage?

Answer 4

The posterior aspect of the laryngeal inlet separating the glottis from the oesophagus

Question 5

What are the indications for Tracheal Intubation?

Answer 5

• CPR
• Trauma
• Intracranial bleeding/Stroke
• Unconsciousness
• Respiratory insufficiency
• Cardiac failure
• Suspected intoxication

Question 6

What must you do before intubation?

Answer 6

1) Attach necessary monitoring devices and administer oxygen
2) Establish intravenous access
3) Draw up essential medications and label them if time permits
4) Confirm the intubation equipment is available and functioning
5) Reassess oxygenation and maximise pre-oxygenation
6) Position the patient correctly

Question 7

What are the Indications, Contraindications and Complications of Bag-mask ventilation?

Answer 7

INDICATIONS:
- Initial ventilation
- Rescue ventilation after failed intubation

CONTRAINDICATIONS:
- Application of face mask is impossible

COMPLICATIONS:
- Inability to ventilate
- Gastric inflation

Question 8

What are the Indications, Contraindications and Complications of Direct Laryngoscopy?

Answer 8

INDICATIONS:
- Routine emergency intubation
- Difficult airway

CONTRAINDICATIONS:
- Limited mouth opening
- Upper airway distortion or swelling
- Kyphosis (extreme curvature of upper body)
- Copious blood or secretions

COMPLICATIONS:
- Hypoxic brain injury
- Cardiac arrest
- Aspiration
- Upper airway trauma
- Dental trauma

Question 9

What are the different ways to assess proper tube placement?

Answer 9

• Observe the tube pass through the vocal cords
• End-tidal CO2 measurements
• Auscultation of breath sounds over chest
• Auscultation over stomach (gurgling indicates oesophageal placement)
• Chest radiograph
• Aspiration technique (30-40mL of air is aspirated without resistance)
• Ultrasound
• Lighted stylet down the endotracheal tube

Question 10

What is Foreign body aspiration?

Answer 10

When an aspirated solid or semisolid object may lodge in the larynx or trachea -> If the object is large enough to cause nearly complete obstruction of the airway, Asphyxia may rapidly cause death

Question 11

Describe the Pathophysiology of Foreign body aspiration

Answer 11

Near-total obstruction of the LARYNX/TRACHEA can cause immediate asphyxia and death -> If object is beyond the CARINA, location will depend on patient’s age and physical position during aspiration -> Angles by the mainstem bronchi are identical in children -> found on either bronchi with equal likelihood -> Adult right bronchi is shorter and straighter -> More likely found in right lung

Question 12

What are the signs and symptoms of the severity of airway obstruction?

Answer 12

• If patient has efforts to cough out the object
• If patient can cry
• If there is stridor
• Absence of breathing efforts
• Confusion + decreased level of consciousness

Question 13

What is a Tracheostomy?

Answer 13

A surgical opening into the trachea and a potential route of infection

Question 14

What are the contraindications of a tracheostomy dressing change?

Answer 14

The original dressing should remain in tact 24-48 hours after surgery -> Increased risk of bleeding associated with stoma formation -> dressing shouldn’t be changed until consultation with the surgeon

Question 15

How many people should changing a tracheostomy dressing require?

Answer 15

2 people

Explanation: One to secure the tracheostomy and the other to assess and dress the stoma site

Question 16

What will be seen if infection is suspected in the tracheostomy site?

Answer 16

• Red area
• Excoriated
• Painful
• Discoloured
• Exudate is present

[Microbiology swab should be sent for culture + Stoma should be cleaned with 0.9% NaCl]

Question 17

Why is Tracheal suction necessary?

Answer 17

An effective cough requires closure of the glottis, then reopening of the glottis once an adequate intrathoracic pressure is achieved -> With tracheostomy, closing of glottis is compromised -> patient’s ability to remove secretions is reduced -> natural mechanisms of warming and humidifying gases are lost -> secretions become thick and dry inhibiting mucociliary transport

Question 18

Why should suction be used only when indicated and not in regular intervals?

Answer 18

Suctioning can cause distress, is uncomfortable and is associated with airway changes and cardiovascular instability

Question 19

How can suctioning lead to Hypoxia?

Answer 19

The act of suctioning reduces vital lung volume from the lungs and upper airway -> risk of trauma, hypoxia and other side effects

Question 20

What are the Indications of a Tracheostomy tube change?

Answer 20

• Minimising risk of post-op infection and granulation tissue formation around the tube
• Changing from a non-fenestrated to a fenestrated tube to facilitate weaning and communication with tracheostomy speaking valve
• Downsizing tracheostomy tube

Question 21

What are the complications associated with Tracheostomies?

Answer 21

• Blockage + dislodgement of tracheostomy tube
• Bleeding
• Coagulopathy (presents with respiratory difficulty)