managing the airway Flashcards
1
Q
describe anesthesia masks
A
- hard, transparent plastic
- inflatable cushion rim
- designed to achieve an effective seal
- various sizes, shapes to fit faces
- pediatric masks different/flavored
- 22 mm orifice fits breathing circuit
- hooks/strap
- easy to see fog, vomit, and secretions
2
Q
describe one-handed bag-mask ventilation
A
- hold mask with left hand, bag in right hand
- downward pressure using thumb and index finger
- middle and ring fingers on mandible not soft tissue (pulling on soft tissue will cause tongue to obstruct)
- middle and ring finger extend atlanto-occipital joint
- little finger moves jaw anteriorly (jaw thrust) (too much pressure too long can cause glossopharyngeal nerve injury)
- release jaw during expiration to prevent ball-valve
- positive pressure less than 20 cmH2O (esophageal may open with > 20 cmH2O); loss = poor seal
3
Q
describe two-handed mask ventilation
A
- both hands on mask; bag handled by 2nd person
- thumbs pressing mask downward against face
- index fingers on mandible moving it anteriorly (jaw thrust; atlanto-occipital joint extension)
- avoid excessive pressure on bridge of nose
- full beard
4
Q
what may be down for endentulous patients when performing mask ventilation?
A
leave dentures in place for better mask seal
5
Q
what can be done to mask for a better seal?
A
inflate the mask
6
Q
what can be used to separate the tongue and posterior pharynx during mask ventilation?
A
oral and nasal airways
7
Q
what can be done for a full beard patient to give an adequete mask seal?
A
- shave beard
- vasoline beard
- cover with large transparent tegaderm with mouth hole
8
Q
what should be continuously monitored during Monitored Anesthesia Care, whether moderate or deep, to monitor the adequacy of ventilation?
A
capnography
9
Q
what happens during MAC without artificial airway in place?
A
- airway tone reduced
- tongue obstructs (use oral or nasal airway)
- difficult to detect apnea
- difficult to detect reduced airflow and volume (rocking and reduced chest wall movement)
10
Q
what are indications for tracheal intubation?
A
- airway protection: full stomach, pregnancy, aspiration risk
- initiate and maintain patent airway: airway pathology (LMA for normal airway)
- pulmonary toilet needed
- PPV (paralyzed: head, neck, chest, abd surgeries); LMA cant use > 20 cmH2O
- airway compromise; inaccessible/shared airway
- inability to maintain control with mask
11
Q
describe endotracheal tubes
A
- transparent, non-irritating polyvinyl chloride
- softens and molds to contour of airway
- length in cm, internal diameter in 0.5 mm increments (2.5-9.0 mm)
- combustible, produces acid and toxins
- cutting tube reduces risks of obstruction (smaller length, greater diameter= less airway resistance)
- bevel opens to left when concave curve anterior
- murphy eye (extra escape if bevel clogged) guards obstruction; to the right
- cuff or cuffless
12
Q
describe cuffs of ETTs
A
- high volume =greater area seal, less pressure, less injury
* inflate less than 20 torr since tracheal perfusion 30 torr
13
Q
what are recommended equipment for induction and intubation?
A
- oral and nasal airways and tongue blade
- stylet and lubricant
- 2 ETTs (different sizes) with a 5-10 cc syringe (check ETT connection and balloon)
- 2 laryngoscope handles
- 2 laryngoscope blades (miller and macintosh)
- suction with rigid suction tip
- ETT tape or securing device
- drugs for sedation and paralysis
- tooth guard
- positive pressure ventilation equipment
- LMA (difficult airway possibility)
- intubating accessories (intubating forceps, bougie, stylet)
14
Q
describe the Miller laryngoscope blade
A
- straight blade
- lifts the epiglottis directly
- smaller than the curved “Mac” and fits in mouths with smaller opening
- epiglottis is lifted out of the line of vision (blade ends up slightly right of midline)
- better for “anterior” larynx (receding chin, protruding upper incisors)
15
Q
describe the Macintosh laryngoscope blade
A
- curved blade
- tip placed in the vallecula to indirectly lift the epiglottis, thus minimizing trauma
- better displacement of the tongue leftward for better visualization (blade ends up in the middle of the mouth)
- less temptation to “lever” against upper teeth
16
Q
describe the markings on ETTs
A
- internal diameter (I.D.) in mm (size on the tube)
- external diameter (O.D.) in mm
- certification of “implantation testing” (I.T.)
- blue radiopaque line to allow visualization on x-ray
17
Q
describe the construction of ETTs
A
- clear, polyvinyl chloride (visualize secretions and fogging)
- connector loosely inserted (should be firmly inserted)
- beveled patient end to the left (to aid in insertion through the cords and the visualization of insertion
- Murphy eye- hole near patient end to the right (opposite bevel) on Murphy tubes that allow ventilation even if end of ETT is against the carina or side of the trachea
18
Q
describe cuff use with ETTs
A
- allows positive-pressure ventilation
- minimizes aspiration risk
- uncuffed ETTs used in some pediatrics
- types: **low pressure, high volume; high pressure low volume
19
Q
describe low pressure, high volume cuffs
A
- larger mucosal contact
- lower incidence of mucosal damage
- higher incidence of sore throat, aspiration, spontaneous extubation, and difficult intubations (bigger, floppy cuff)
- “minimal leak”- pressures of 15-25 torr
20
Q
describe high pressure, low volume cuffs
A
- higher incidence of tracheal mucosal ischemic damage
- only for a short duration
- can have pressures up to 250 torr on tissues
21
Q
what factors affect cuff pressure?
A
- volume of air used to inflate cuff
- diameter of the cuff in relation to the trachea (ederly have bigger trachea)
- tracheal and cuff compliance (stenotic trachea?)
- intrathoracic pressure: asthmatics, bronchitis, smoker, recent URI (cuff pressures increase with coughing)
- nitrous oxide use (can diffuse into air-filled cuff to increase the pressure)
