LO7 Advanced Airways

Question 1

Tracheobronchial suctioning

Answer 1

Involves passing a suction catheter into the tracheal tube to remove pulmonary secretions

Monitor patient’s cardiac rhythm and oxygen saturation during the procedure

Question 2

what can Tracheobronchial suctioning cause

Answer 2

cause cardiac dysrhythmias

Question 3

Follow these steps for performing tracheobronchial suctioning as an in-line suction device:

Answer 3

Use routine precautions and wear PPE

Check prepare and assemble your equipment

Connect section to the in-line suction catheter

Pre-oxygenate the patient

Gently advance the in-line suction catheter down the tracheal tube until resistance is felt

Action in a rotating motion while withdrawing the catheter into the side arm of the in-line device. Monitor patient’s cardiac rhythm and oxygen saturation during the procedure

Resume ventilation and oxygenation

Question 4

Causes of airway obstructions

Answer 4

the tongue laryngeal edema, laryngeal spasm, trauma and aspiration

Question 5

Laryngeal spasm

Answer 5

Results in spasmodic closure of the vocal cords completely including the airway it is often caused by trauma during aggressive intubation

relieved by positive pressure ventilation using a bag mask

Question 6

Laryngeal edema

Answer 6

causes the glottic opening to become extremely narrow or totally close conditions that commonly causes problems include laryngeal trauma, epiglottis, anaphylaxis or inhalation injury

relieved by positive pressure ventilation using a bag mask

Question 7

Laryngeal injury

Answer 7

Airway patency depends on good muscle tone to keep the trachea open

Fracture of the larynx increases airway resistance by decreasing airway size secondary to decreased muscle tone, laryngeal oedema and Ventilatory effort

Question 8

Emergency medical care for foreign body airway obstruction

Answer 8

Manage any unresponsive person as if he or she has a compromised airway open and maintain the airway with appropriate manual maneuver assessed for breathing and provide artificial ventilation if necessary

If after opening the airway you are unable to ventilate the patient will you feel resistance when ventilating re-open the airway and attempt to ventilate the patient

Question 9

lung compliance

Answer 9

is the ability of the alveoli to expand when air is drawn into the lungs either during negative pressure ventilation or positive pressure ventilation poor lung compliance is characterized by increased resistance during ventilation attempts

Question 10

If the response of patient with a severe airy obstruction becomes unresponsive

Answer 10

carefully position him or her supine on the ground and begin chest compressions perform 30 chest compressions and then open the airway and look in the mouth attempt to remove foreign body if you can see it

Question 11

Surgical and nonsurgical cricothyrotomy

Answer 11

Two methods of securing a patient’s airway can be used when conventional techniques and methods fail the open surgical cric and Translaryngeal catheter ventilation nonsurgical or needle cric

Question 12

Open cricothyrotomy

Answer 12

Involves opening the cricothyroid membrane with a scalpel and inserting a tracheal tube directly into the subglottic area of the trachea

The open cric involves incising the patients skin and cricthyroid membrane and inserting a tracheal tube

Question 13

Indications of open cric

Answer 13

Indicated only when you were unable to secure a patient’s airway with a more conventional mean and are unable to oxygenated ventilate the patient it is the last resort

indications that may preclude conventional airway management include severe foreign body upper airway obstruction that cannot be extracted and direct laryngoscopy airway, obstruction from swelling, facial trauma and the ability to open the patient’s mouth

Question 14

contraindications of open cric

Answer 14

the ability to secure a patent airway by less invasive means or lack of familiarity training to perform a cric

Other contraindications include in ability to identify the correct anatomical landmarks, crushing injury to the larynx and trachea transection, you’re lying anatomical abnormalities and age younger than eight years

Question 15

Advantages and disadvantages

Answer 15

Can be performed quickly and is easier than a tracheostomy

Be performed without manipulating the cervical spine

disdvantages include difficulty in performing the procedure and children and patients with short muscular or fat necks

more difficult to perform than a needle cricothyrotomy

Question 16

open cric complications

Answer 16

Bleeding is usually the result of inadvertent laceration of the external jugular vein

After the incision has been made gently insert the tube will minimize the risk of perforating the esophagus or damaging the laryngeal nerves

In too long results and hypoxia

Expect to miss placement when subcutaneous emphysema is encountered after performing a cric

Question 17

Subcutaneous emphysema

Answer 17

occurs when air infiltrates the subcutaneous layers of the skin and is characterized by crackling sensation when palpated

Question 18

Technique for performing open cricothyrotomy

Answer 18

Identify the cricothyroid membrane by palpating the V notch of the thyroid cartilage which feels like a high sharp bump

Stabilize the larynx between your thumb and middle finger while you palpate with your index finger slide your index finger down into the depression between the thyroid and cricoid cartilage

While stabilizing the larynx with one hand make a 1 to 2 cm vertical incision over the cricothyroid membrane in bariatric patients the vertical incision may need to be longer and deeper

Puncture the cricothyroid membrane and make a horizontal incision approximately 1 cm in each direction from the midline insert the scalpel handle into the opening and rotate
Insert a tube into the trachea

Manually stabilize the trachea tube with your thumb and index finger carefully remove the stylet and inflate the distal cuff

Attach the bag mask device in ventilate

Confirm correct to placement by attaching ET CO2

Question 19

Needle Cricothyrotomy

Answer 19

Also uses the cricothyroid membrane as an entry pointed to the airway

A 14 to 16 gauge over the needle IV catheter is inserted through the cricothyroid membrane and into the trachea

Oxygen is achieved by attaching a high-pressure jet ventilator to help with the catheter

Translaryngeal catheter ventilation is commonly used as a temporary measure to oxygenate a patient until more definitive airway can be obtained

Question 20

needle cric indications

Answer 20

inability to ventilate the patient by less invasive techniques

only when you were unable to secure a patent airway with more conventional means

complete foreign body airway obstruction that cannot be extracted with forceps and direct laryngoscopy, airway obstruction from swelling, massive facial trauma, inability to open the patient’s mouth uncontrolled oropharyngeal bleeding

Question 21

needle cric contraindications

Answer 21

in patients who have severe airway obstruction above the site of catheter insertion

Only oxygenate the patient do not adequately ventilated as a result patients PaCO2 and ET CO2 levels will rise quickly

Question 22

what does The high pressure ventilator used with needle cricothyrotomy do

Answer 22

increases intrathoracic pressure possibly resulting in barotrauma and risk for pneumothorax

Question 23

Barotrauma

Answer 23

can be caused by over inflation of the lungs with the jet ventilator so care must be taken to open the release valve only until the patient’s chest adequately rises

Question 24

Advantages of neeedle cric

Answer 24

Faster and easier to perform and is associated with lower risk of causing damage to adjacent structures

Allows for subsequent intubation attempts because they use a small bore catheter allowing a tracheal tube to easily pass beside it

Question 25

Disadvantages of needle cric

Answer 25

include using a small bore tube to ventilate the patient does not provide protection from aspiration as a tracheal tube would Requires specialized high-pressure jet ventilator to deliver adequate tidal volume

Question 26

Complications of needle cric

Answer 26

improper catheter placement can result in severe bleeding secondary to damage of adjacent structures Excessive air leakage around the insertion site can cause subcutaneous emphysema especially if the patient has undetected laryngeal trauma

Question 27

ventilating a patient with a jet ventilator

Answer 27

Extreme care must be exercise when ventilating a patient with a jet ventilator the release valve should be open just long enough for the adequate chest rise took her over inflation of the lungs can result in barotrauma which carries the risk of pneumothorax conversely opening the release valve for two short period of time can cause hypoventilation resulting in adequate oxygenation and ventilation

Question 28

Technique for performing needle cricothyrotomy

Answer 28

Draw up approximately 3 mL of sterile water or saline into a 10 mL syringe and attach to the IV catheter Place the patient had in a neutral position and locate the cricothyroid membrane While you are stabilizing the patience lyrics carefully insert the needle into the midline of the membrane at a 45° angle toward the feet you should feel a pop After the pop is felt insert approximately 1 cm further and then aspirate the syringe if the catheter has been correctly place you should be able to easily aspirate air and see bubbling in the syringe if blood is aspirated you should reevaluate Attach one end of the oxygen tubing to the catheter in another end to the jet ventilator begin ventilation and observed adequate chest rise Auscultation of breath and epigastric sounds will confirm correct placement Secure the catheter by placing a folded gods pad under the catheter and taping it in place continue ventilation and reassess

Question 29

Advanced Airway Management 2 reasons

Answer 29

Not a substitute for basic techniques and maneuvers 1. Failure to maintain a patent airway 2. Failure to adequately oxygenate and ventilate

Question 30

MOANS

Answer 30

M mask seal: problems getting a good seal with the mask O obese: obese people are difficult to bag mask ventilate because of their increased body weight A aged- older people tend to be difficult to bag mask ventilate due to loss of connective tissue and bony structure on their face N no teeth: forming a good seal with the mask is difficult in edentulous patients S stiff lungs: patients underlying lung disease require higher pressures to ventilate and this may be difficult to do with bag mask ventilation

Question 31

LEMON

Answer 31

L look: look externally for obvious anatomic deformities E Evaluate the 3-3-2 rule: the width from the front of the chin to the hyoid bone should be at least three fingerbreaths wide, the width of the patients mouth opening should be at least three fingerbreadths wide, and the distance from the mandible to the thyroid bones should be at least two fingerbreaths wide M Mallampati classification: oral access is assessed using the Mallampati classification O obstruction: you can anticipate a difficult intubation if there is obstruction in the airway such as epiglottis, neck injury, tumor N neck mobility: if a patient has limited neck mobility

Question 32

Cormack- Lehane Classification

Answer 32

Has applicability in an emergent setting because it classifies views obtained by direct laryngoscopy based on the structures seen prior to inbutbation

Question 33

Tracheal Intubation

Answer 33

passing a tracheal tube through the glottic opening and sealing the tube with a cuff inflated against the tracheal wall

Question 34

Orotracheal intubation

Answer 34

when the tube is passed into the trachea through the mouth

Question 35

Nasotracheal intubation

Answer 35

when the tube is passed into the trachea through the nose

Question 36

indications of tracheal intubation

Answer 36

present or impending respiratory failure, apnea, inability of the patient to protect on airway, control of ventilation

Question 37

contraindications for tracheal intubation

Answer 37

none in emergency situations however with inexperienced personnel other advanced airways may be easier

Question 38

advantages/ disadvantages of tracheal intubation

Answer 38

advantages: provides a secure airway, protects against aspiration, provides an alternate route to IV/IO for certain medications disadvantages: special equipment required; physiological functions of the upper airway bypassed

Question 39

complications of tracheal intubation

Answer 39

bleeding, hypoxia, laryngeal swelling, laryngospasm, vocal cord damage, mucosal necrosis, barotrauma, dental injury, inadvertent tube displacement

Question 40

The basic structure of tracheal tube

Answer 40

includes the proximal end, the tube, the cuff and pilot balloon and distal tip Sizes range from 5 to 9 mm

Question 41

Murphy eye

Answer 41

the opening of the bevelled tip on the distal end of the tube to facilitate insertion It enables ventilation to occur even if the tip becomes included by blood, mucus, or tracheal wall

Question 42

A tube that is too small for a patient will lead to a tube that is too large can

Answer 42

A tube that is too small for a patient will lead to an increase resistance to airflow and difficulty in ventilating a tube that is too large can be difficult to insert it may cause trauma

Question 43

tracheal tube sizes

Answer 43

An adult woman will require a 7-8 mm tube while an adult man will require a 7.5 to 8.5 mm tube

Question 44

good approximation of the diameter of the glottic opening

Answer 44

The internal diameter of the nostrils

Question 45

Straight miller blade

Answer 45

Design so that the tip will extend beneath the epiglottis and lift it up particularly useful in infants

Question 46

Curved macintosh blade

Answer 46

less likely to be levelled against the teeth by an inexperienced paramedic and is usually preferred by beginners the blade follows the outline of the pharynx the tip of the curved blade is placed in the valley Kula rather than beneath the epiglottis It directly lifts the epiglottis to expose the vocal cords

Question 47

Blade sizes

Answer 47

range from 0 to 4 size 012 are appropriate for infants and children three and four are adult sizes

Question 48

Stylet

Answer 48

a semi rigid wire that is inserted in the tracheal tube to mound and maintain the shape of the tube enables you to guide the tip of the tube over the arts annoyed cartilage even if you can’t see the entire glottic opening It should be lubricated and the end should be formed like a hockey stick curve

Question 49

Magill forceps 2 uses

Answer 49

first they are used to remove area obstructions under direct visualization second they are used to guide the tip of the tracheal tube through the glottic opening

Question 50

Orotracheal intubation by direct laryngoscopy

Answer 50

Involves inserting a tracheal tube through the mouth and into the trachea while visualizing the glottic opening with the laryngoscope

Question 51

Orotracheal intubation indications

Answer 51

airway control needed as a result of coma, respiratory arrest/cardiac arrest, then territory support, absence of gag reflex, Trumatic brain injury, unresponsiveness or impending airway compromise

Question 52

Orotracheal intubation contraindications

Answer 52

an intact egg reflects, in ability to open the patient’s mouth because of trauma, dislocation of the jar, inability to see the glottic opening, copious secretions or vomitus blood

Question 53

Orotracheal intubation advantages and disadvantages

Answer 53

Advantages: Direct visualization of anatomy into placement, ideal method for confirming placement, may be performed in breathing or apnoeic patients Disadvantages: require special equipment

Question 54

Orotracheal intubation Complications

Answer 54

dental trauma, laryngeal trauma, misplacement

Question 55

Preoxygenation

Answer 55

Adequate preoxygenation with a bag mask device and 100% oxygen is critical step prior to intubating a patient Deoxygenate and apnoeic or hyper ventilating patient for 2 to 3 minutes monitor the SPO2 and she was closest 100% During the intubation attempt deliver high flow oxygen via nasal canula

Question 56

Positioning the patient

Answer 56

The airway has three axis is the mouth, the pharynx, and the larynx which must all be aligned to visualize the airway This is most effectively achieved by placing the patient in the sniffing position

Question 57

A bundle of care:

Answer 57

includes preoxygenation, passive high flow oxygen, the sniffling position and head elevation along with delayed sequence intubation agent

Question 58

Laryngoscope blade insertion

Answer 58

Hold the laryngoscope cope with your left hand as far down the handles possible if the patient’s mouth is not open use the scissor technique or the tongue jaw lift maneuver insert the blade into the right side of the patient’s mouth and then sweep the tongue gently to the left side while moving the blade into the midline ---This is a critical step because if you simply insert the blade in the midline the tongue will hang over both sides and all you’ll see is tongue Placed the little finger of your left hand under the patient’s chin to help lift the jaw and prevent levering against the patient’s teeth Slowly advance the blade while sweeping the tongue to the left exert gentle traction at a 45° angle to the floor as you lift the patient straw continue advancing until the epiglottis comes interview

Question 59

Visualization of the glottic opening

Answer 59

After you identify the epiglottis placed the tip of the curved blade in the valecullar space which is above the epiglottis or the straight blade directly under the epiglottis and lift until you see the glottic opening You should see the vocal cords in the arytenoid cartilage

Question 60

Bimanual laryngoscopy

Answer 60

if you’re having difficulty seeing the glottic opening take your right hand and manipulate the larynx directly observing after abuse optimize an assistant to maintain the optimum laryngeal position as you insert the tracheal tube

Question 61

BURP maneuver

Answer 61

during external laryngeal manipulation the intubator plies backward upward rightward pressure to the lower 1/3 of the thyroid cartilage

Question 62

Bougie

Answer 62

emi flexible device approximately 1 cm in diameter and 60 cm long it is rigid enough that it could be easily directed to the glottic opening but flexible enough that it does not cause damage to the trachea walls It is inserted through the glottic opening under direct laryngoscopy Enables you to feel the ridges of the trachea wall and becomes a guide for the tracheal tube by simply sliding the tracheal tube over it pass the cords and into the proper position

Question 63

Tracheal tube insertion

Answer 63

After you visualize the glottic opening pick up the preselected tracheal tube in your right hand insert the tube from the right corner the patient’s mouth as you see the two passing the vocal cords rotate the tube to the right and direct the tip of the tracheal tube downward into the trachea Advance the tracheal tube until the proximal end of the cuff is 1 to 2 cm possible chords you must see the tip of the two past to the vocal cords if you cannot see the vocal cords do not insert the tube Do not try and pass the tube down the barrel of the laryngeal scope blade

Question 64

Ventilation laraygnoscopy

Answer 64

After you have seen the cup of the tracheal to pass approximately 1.5 cm beyond the vocal cords gently remove the blade hold the tube securely and remove the stylet from the tube Inflate the distal cuff with 5 to 10 mL of air Play some in-line capnography monitor If the tube is properly position you were here quite epigastrium and equal breath sounds bilaterally however epigastric sounds may be transmitted to lungs in patients with obesity leading you to believe you have inadvertently intubated the esopha

Question 65

Bilaterally absent breath sounds after tube placement

Answer 65

are gurgling over the epigastrium when auscultating during ventilation indicates that you have intubated the esophagus rather than the trachea you must remove the tube and be prepared to suction

Question 66

If copious vomitus is being admitted from the tracheal tub

Answer 66

do not remove it instead inflate the distal calf turn the tube sideways to allow the bombers to be admitted and continue ventilation with bag mask device if vomitus is not being emitted from the tube you can remove it and resume bag ventilation

Question 67

Breath sounds are heard only on the right side of the chest after tube insertion

Answer 67

the tube has likely been advance to far and entered the right mainstem bronchi us

Question 68

Follow these steps to reposition the tube

Answer 68

Loosen or move the tube securing device Deflate the distal cuff Place your stethoscope over the left side of the chest Well ventilation continue slowly retract the tube while simultaneously listening for breath sounds over the left side of the chest Stop as soon as bilaterally equal breath sounds are heard Note the depth of the tube at the patient’s teeth Reinflate the distal cuff Secure the tube Resume ventilations --Increased resistance during ventilation’s may indicate gastric distention, oesophageal intubation or tension pneumothorax

Question 69

Nasotracheal intubation

Answer 69

Insertion of a tube into the trachea through the nose Blind nasotracheal intubation is an excellent technique for establishing control over the airway and situation where does either difficult or hazardous to perform laryngoscopy

Question 70

Nasotracheal intubation indications

Answer 70

indicated for patients who are breathing spontaneously but require definitive airway management to prevent further deterioration Responsive patients or patients with an altered mental status and with an intact gag reflects who are in respiratory failure secondary to condition such as COPD asthma or pulmonary oedema

Question 71

Contraindicated Nasotracheal intubation

Answer 71

apnoea patients because they should receive oral tracheal intubation Contraindicated in patients with head trauma and facial fractures and evidence of cerebral spinal fluid drainage from nose Contraindications include anatomic abnormalities, patients with nasal polyps or patients who frequently use cocaine

Question 72

Advantages and disadvantages of Nasotracheal intubation

Answer 72

primary advantage is that it can be performed to patients who are awake and breathing Another major advantage of needs a tracheal intubation is that there’s no need for laryngoscope which eliminates the risk of trauma to the teeth or soft tissues of the mouth Does not require the patient to be placed in a sniffing position which makes it ideal for spinal injuries Patient cannot bite tube Disadvantage you cannot use one of the major tube confirmation methods

Question 73

Technique for nasotracheal intubation

Answer 73

The tube is advance as a patient inhales at which point the vocal cords are open at the widest which facilitates placement of tube into trachea Insert the tube into the nostril with the bevel facing toward the nasal septum In the tip of the tube straight back toward the ear the goal is to follow the floor of the nasal cavity until the tube enters the nasal pharynx As a tube is advanced into the nasal pharynx you will begin to hear air rushing in and out of the tube as the patient breaths As the patient inhales the negative pressure created by inhalation facilitates movement of the tube for the glottic opening If you do not see soft tissue bulge and no air is moving through the tube the tube has been entered into the esophagus When the tube has been properly positioned inflate the distal calf with minimal amount of air necessary to achieve airtight seal

Question 74

Digital intubation

Answer 74

Involves directly palpating the glottic structures and evaluating the epiglottis with your middle finger while guiding the tracheal tube into the trachea by field does not require laryngoscope Most advantageous in cases of equipment failure

Question 75

Digital intubation indications and contra

Answer 75

only in patients who are deeply unresponsive and apnoeic and who have a bite block in their mouth This technique is absolutely contra indicated if the patient is breathing, it’s not deeply unresponsive or has an intact gag reflex