Manual Ventilation Devices

Question 1

Manual Ventilation Equipment includes:

Answer 1

1. Masks
2. Airway adjuncts (oral or NP airways)
3. Manual Ventilators (resuscitation devices) such as self inflating (Ambu bag) and non-self inflating (flow-inflating) bag

Question 2

Basics of Non Rapid Sequence General Anesthesia Induction

Answer 2

1. Pre-Anesthesia Safety Check (APSF)
2. Apply monitors (Minimally: ECF, NIBP, Pulse Ox)
3. Pre-oxygenation
4. Induction Drugs (render patient unconscious and apnea and possibly paralyzed)
5. Mask ventialtion*******
6. Airways management Device Placement and securement

Question 3

Positive Pressure Manual Ventilation

Answer 3

1. The ability to use your hands to breathe for a patient is an essential anesthesia skill.
   - Through the use of manual ventilation device (AMBU)
   - use of manual ventilation mode on anesthesia machine
2. Even more important that intubation
3. Worse case scenario: cant intubate, cannot ventilation (difficult airway algorithm)

Question 4

Manual Ventilation Indications (5)

Answer 4

1. Bridge to placement of more secure airway (ETT, supraglottic airway)
2. Anesthesia machine ventilator failure or circuit malfunction
3. Excessive sedation and respiratory depression in MAC Case
4. Transporting patients to ICU or from satellite anesthesia locations to PACU
5. Any emergency code situations or loss of airway

Question 5

Manual ventilation relative Contraindications for GA

Answer 5

1. Full stomach or increased risk of aspiration risk is number one*
2. Anticipated or known difficult airway=RSI
3. Facial trauma or anomalies of the face which would make mask ventilation difficult

Question 6

Mask Ventilation Technique

Answer 6

1. Optimal “Ramped” Position
2. Use of oral or NP airways
3. Correct mask size and fit
4. Jaw Thrust and proper hand positions

Question 7

Supine airway anatomy

Answer 7

1. Obstruction further increase with decrease pharyngeal muscle tone (due to sedation or muscle relaxants)
2. Ramping position will help alleviate this*

Question 8

What position helps alleviate upper airway obstruction?

Answer 8

1. Bringing the EAC up to or at the sternal level will help alleviate upper airway obstruction and enhance intubation view

Question 9

Oral airway positioning technique

Answer 9

1. Scissor mouth open and pull jaw forward
2. Insert airway “upside down” and turn 180 degrees as you approach posterior pharynx (this pushes tongue out of the way)
3. Flange should rest above teeth
4. Use tongue blade to displace tongue and insert airway if needed

Question 10

Sizing oral airways

Answer 10

1. Flange should go from mouth to earlobe

Question 11

Size and fit of mask

Answer 11

1. Proper size and fit to obtain a good seal
   - should sit over the bridge of patient’s nose without putting pressure on the eyes
   - sides should seal just lateral to nasal folds with the bottom of the face mask sitting between lower lip and chin
   - in the awake patient the mask if held in this position either by hand of by attaching a hardness behind head
   - standard sizes 4-5 fit the majority of adults
   - sizes 0-3 are for pediatric use

Question 12

Who to use oral airways on?

Answer 12

1. Edentulous patients (lacking teeth)
2. Down syndrome and pediatric patients with large tongues
3. Sleep apnea patients
4. Never really hurst to place one (be careful with loose teeth)
5. Make sure patient is deep enough

Question 13

What stage of anesthesia can laryngospasms occur in besides induction and emergence?

Answer 13

1. Second stage of anesthesia
2. Vocal cords slam shut to prevent liquid, blood, or anything from getting into lungs
3. When patients are deeply asleep they lose this protective airway reflex

Question 14

Sizing of Nasopharyngeal Airways and insertion

Answer 14

1. Flange should reach from nose to earlobe
2. Gentle insertion with bevel towards septum (stop if resistance) is felt.
   - If using left nostril, insert with bevel towards septum and turn 180 degrees with NP airway is about half way in

Question 15

NP airways

Answer 15

1. Great for when patient cannot open mouth
2. Tolerated better for those with intact gag reflex
3. May cause nose bleeds- caution with anti coagulated patients- never force NP airway
4. Contraindicated in patient with basilar skull fracture

Question 16

Chin lift, Jaw thrust

Answer 16

1. Use fingers to physically push the posterior angles of mandible upwards

Question 17

Jaw Thrust one handed technique

Answer 17

1. Place correct sized mask over the nose and mouth
2. Use non dominant hand to position face mask, holding the body of mask between your thumb and index finger
3. Use your remaining 3 fingers to support the jaw, with your little fingers hooked behind the angle of mandible. Be careful not to place pressure on sub-mandibular tissues as they can occlude airway esp. in meds
4. Life the mandible upwards, towards and into the mask to create air-tight seal
5. Slight head extension may improve patency
6. Ventilate the patient with your dominant hand by squeezing the bag (when using vent, your bag will not fill if you don’t have a good deal)
7. Continuously assess the adequacy of the technique by observing bilateral chest movement, listening for air leaks and assessing for chest rise and ETCO2 tracing

Question 18

2 Handed Technique

Answer 18

1. Use the thumbs to stabilize the mask while the index and middle fingers are used to bring the angle of the jaw forward
   - works better for small hands

Question 19

Risk Factors for difficult mask airway

Answer 19

1. Facial hair
2. Lack of teeth
3. Obesity, OSA
4. Facial anomolies
   - don’t forget the supraglottic airway option if you can’t mask or go directly to intubation

Question 20

Self-inflating Devices: Closed Reservoir

Answer 20

1. Closed reservoir has a bag with a valve that will let air in if bag becomes empty. Oxygen accumulates in the reservoir bag.
2. The bag needs to be large enough to contain a tidal volume, or the balance of gas entering the bag will be air
3. Has non-rebreathing valve: important so that patient cannot rebreathe CO2 from the bag
4. Pressure limiting valve: 60 CmH2O. Children 45 cmH2O

Question 21

Non-Rebreathing valves

Answer 21

1. Valve that ensures that exhaled gas does not mix with fresh gas entering the self-inflating bag and allows exhaled gas to escape into atmosphere

Question 22

Self-Inflating Device: Open Reservoir

Answer 22

• open end allows air to enter

- some oxygen will be lost if flow is too high as it is open to atmosphere

Question 23

PEEP Vale

Answer 23

• allows you to adjust PEEP on bag

- bigger patients may need more PEEP to keep alveoli open

Question 24

Oxygen Reservoir

Answer 24

• usually either bags or lengths of large bore tubing
• allows accumulation of oxygen during the inhalation phase and release of the stored oxygen into the self inflating bag during exhalation when the bag is refilling
• increase FIO2

Question 25

Flow-Inflating Device is dependent on what?

Answer 25

-oxygen flow rate and adjustment of pressure relief valve

Question 26

Circle breathing circuit

Answer 26

• gas flow in a circular pathway through separate inspiratory and expiratory channels
• CO2 is removed through an absorbent

Question 27

Adjustable pressure limit (APL) or “pop off” valve

Answer 27

• only gas exit from the breathing system during spontaneous, assisted or manually controlled ventilation if there are NO circuit leaks
• APL is used to control the pressure in the breathing circuit, which in turn adjusts bag filling
• higher gas flows will pressurize the circuit more quickly
• breathing system bag will become e actacile monitoring device*