Module 3 Flashcards
Intubation: a procedure to maintain the ? urgent: can occur planned: -for known ?
upper airway
in field
surgery
decline in medical status (COVID 19)
Reasons for intubation: respiratory failure: inadequate inadequate ... (usually ?)
apnea
oxygenation (hypoxia)
ventilation (hypercarbia - too much carbon dioxide)
surgery (planned)
Endotracheal tubes: various ? number of the tube refers to the ? tube has markings in ? note the ? the tube is ? can check for ? distal tip should be approx?
sizes
inner diameter of tube
2 cm increments / depth of tube ending at teeth or lips
radiopaque / adequate placement on X-ray
4 cm in adults
Inflant epiglottis:
… shaped
configuration
narrow, tubular/omega shaped
changes / opens with growth (age)
COVID-19 considerations/precautions for intubation:
… procedures
-
-
aerosol generating procedures
- suctioning (prior to intubation)
- intubation itself
Goal - extubation:
the patient can breathe ? and can be?
work toward extubation with ?
less ? more ?
adjustment to ?
decrease ?
-potential
independently/ taken off ventilator and be extubated
ventilator weaning trials
vent support/ spontaneous breaths
-sedation
-sedative medications
vicious circle
potential for injury: placing having removing need for ?
endotracheal tube
endotracheal tube in place
tube (self-extubation)
re-intubation and then exudation another time
Post-intubation injury:
research findings and versus common sense
duration of intubation
size of ETT
type of ETT
patient age , weight, height
did not correlate to degree of laryngeal injury
Laryngeal injury from prolonged intubation:
how many had degree of laryngeal injury
most common:
other injuries included
vocal process
vocal fold
…
95%
arytenoid edema, arytenoid erythema an dinterarytenoid tissue edema
granuloma
immobility
subglottic edema/narrowing
Laryngopharyngeal reflux:
GERD is an important factor in ?
-
exposure to acid results in?
laryngeal and tracheal injury in intubated patients in both Operating room or ICU
Nasal gastric tube (NGT)
mucosal injury to larynx and reduced mucocillary flow in trachea
Right versus left injury with intubation:
left sided vocal fold injury is more?
this is attributed to
prevalent
right-sided insertion of orotracheal tube and left-handed hold of laryngoscope
VF paralysis:
considerations:
surgical-cardiothoracic/thoaracic :
ETT cuff/tracheostomy tube cuff
RLN compression between ? with cuff inflated ?
left RLN more susceptible due to court - lower through chest around aorta
ETT cuff and lamina of thyroid cartilage/ RLN can sustain damage
Post-extubation dysphagia risk: consistent risk factors for dysphagia found by ? - - - -
of these factors it is not fully established which factor increases
ICU and length of hospital stay
multiple intubations
sepsis
poor functional status
increases risk for post-extubation dysphagia
How long should a patient be intubated before consideration for tracheostomy placement ?
optimal time frame is not ?
varies from ?
also considerations for ?
average time oral intubation is about ? before consideration for completion of tracheotomy
set in stone
case to case
covid-19
10-14 days (in non-covid scenario)
Tracheotomy:
procedure whereby
tracheostomy: surgically created
incision made into tracheostomy through neck
opening that remains in neck
Tracheotomy: indications: relief of bypass a ? provides means of enables efficient after initial management with endotracheal intubation , if prolonged airway or ventilator assistance required, covert to ?
upper airway obstruction compromised upper airway assisted mechanical ventilation tracheobronchial toilet tracheotomy early to prevent laryngeal or tracheal injury
tracheotomy: surgical technique
.. position , neck ?
in children vertical entry into trachea through the? without removal of ?
in adults some surgeons remove ?
some surgeons create a ? just below levels of
supine/ extended
2nd,3rd, 4th tracheal rings/ cartilage
anterior portion of 3rd 4th tracheal rings
surgical flap/ TVFs
Cricothyrotomy:
used in ? scenario
preferred over
convert to ?
cannot intubate cannot ventilate
tracheotomy for emergency airway management
tracheotomy early to prevent subglottic stenosis
Percutaneous dilation tracheotomy completed in the ICU :
reduced
for patients too?
cost and reduced operating room resources
unstable to transport to OR
PDT patient selection: adult ? contraindications: -anatomic differences including -circoid -midline -high -
uncorrectable ? PEEP > non-intubated patients with .. patients morbidly ?
personnel ?
intubated patients ICU
below sternal notch
neck mas
brachiocephalic artery
goiter
coagulopathy (bleeding) 15cm water acute airway obstruction pediatric obese patients
2 critical care doctors, respiratory therapist, nurse
Tracheotomy procedure percutaneous tracheostomy placement -small incision in series of ? used to ? a specialised ? placed done at takes ?
trachea dilators/ increase size of tracheostoma tracheostomy tube bedside 20-30
Tracheostomy tubes sizes:
a properly fitted tube should not occupy more than ?
sized on any variety of ?
2/3rds of inner diameter of trachea
classification system
Flange or neck plate: attached to rests on provides support for has printed info about
proximal end of outer cannula
skin of patients neck
tracheostomy tube
size, type, manufacturer of tube
Obturator:
tool used to
has a ? that protrudes beyond the end of the outer cannula to ease?
insert trach
rounded tip/ ease insertion
Universal connector: standard size connection site for ? attachment point for inner cannula is
15mm
inline suctioning if on ventilator
speaking valve
attached to this
cuff is fully inflated if
must be deflated for
on ventilator support
speaking valve use
outer cannula:
larger ?
may be ? or?
length and diameter of outer cannula ? depending on
diameter than inner
fenestrated or non-fenestrated
varies/ size of tracheotomy tube
cuff: assists in providing a ?
types ?
closed ventilatory system / patient on ventilator or has copious secretions
air filled
foam
fluid filled
Cuff inflation techniques:
minimal occlusal volume: injecting air into cuff until no ?
minimal leak technique:
cuff is ? then a small amount removed until ? this has potential to exert less pressure on ? and potentially decrease ?
cuff manometry:
range
leak appreciated
inflated until no leak hear/ small leak detected / tracheal wall/ complications with associated increased pressure (stenosis/tissue death)
ideal
20-25 mm Hg
fenestrations:
used to assist with ?
weaning/decannulation
suctioning:
open suction system
- a suction catheter is inserted into the ?
the catheter is advanced until
suction catheter is withdrawn and suction pressure is applied as the ?
-secretions are cleared from suction with either ?
-additional passes may be necessary to
trach tubę using sterile technique -resistance is met -catheter moves up trachea -sterile water or normal saline clear additional secretions
Closed inline suction:
designed to permit suctioning without
housed in
disconnecting patient from ventilator
plastic sleeve - infection control
comm. options for trach patient non-verbal - - -
verbal: - -.. tube -talking -... speech -... valve
comm. boards
writing
Mac
electrolarynx fenestrated tube talking trach. tube leak speech trach speaking valve
fenestrated designed primarily to
-reintroduce ?
and facilitate
airflow to upper airway
speech
complications from use of fenestratedL growth of ? blockage of blockage of clinical
granulation tissue
fenestrations by secretions
fenestrations against tracheal lumen
clinical errors
talking trach:
cuffed trach have an ? for airflow up the ?
designed for patients who cannot
airflow is reduced from ? vocal intensity may be
oxygen side port attached to outer cannula / glottis to facilitate comm.
tolerate cuff deflation
normal/ reduced
potential prob. with talking trach. -secretions can ? requires requires ... oropharyngeal ? due to ?
occlude fenestrations and or air port supplemental oxygen supply activation/manual dexterity expense dryness / continuous airflow
one-way trach. speaking valves:
allows for inspiration through and expiration through
requires
trach tubę/ larynx
cuff deflation
Brands: Shiley (SSV) phonate speaking valve
Pssy-muir -closed position ? design fits the universal -can be used ? PMV 2000 and PMV 2001 designed with a small ? to prevent
no leak
15mm hub any size trach.
interchangeably on/off ventilator
small ring attach to secure it to prevent loss
Ventilator valve:PMV 007
for use with
can also be utilised
not ?
disposable ventilator tubing
off of vent
low-profile
metal trach:
PMV 2020
only works with ?
can also be used with ?
improved pilling weck metal jackson trach. tubes
adults, paediatric, and neonatal Bivona non-foam filled cuffed trach. tube
Passy0Muir Valve O2 adapter: allows for easy ? delivers O2 in? avoids avoids
inhalation of low flow supplemental oxygen and humidity
in front of diaphragm of PMV
air trapping
drying of secretion
What do you ask as SLP: medical ? when was trach ? per PMV literature valve use can be attempted ? what are the patient's what kind of trach does the patient ? is trach. has cuff ever been
hx - intubation length/ # of extubations placed 48-72 hours following trach. surgery oxygen levels have and why cuffed deflated
contraindications to PMV:
severe
excessive
VF?
tracheal or laryngeal obstruction
excessive secretions
paralysis
Contraindications from PMV literature unconscious or inflated foam-filled severe unmanageable severe risk for Beverly reduced the device is not intended for use with ? do not use during
comatose patients trach cuff cuffed tube airway obstruction thick secretions aspiration reduced lung elasticity endotracheal tube or other artificial airways sleep
Valve selection: 007 PMV : obviously patient is on ? but , ask: if on vent weaning -could patient use the valve? -is there a chance patient may not fully - if so use ? for proximal XLT Shiley
ventilator
also when on vent support
wean or will return to vent
aqua colored valve
aqua colored valve
is cost a factor ? consider
outpatient versus inpatient
visibility:
PMV 005
PMV 2001 (purple) vs PMV 2000 (clear)
If valve placement appropriate first:
tell patient
educate them that breathing will feel
the patient will have sensation of air going through ? a normal thing they have not
educate patient
what you plan to do
different
larynx /experienced in some time
Reassure patient: I will we will monitor let them know it canoe share ?
stay with you whole time
vital signs
be removed immediately
David muir’s story
Cuff deflations completed by? or with ? inform patient deflate ? suction ? - the secretions sitting on the cuff with ? elicits ?
RN or RT / SLP as team player
prior to deflation slowly prior to and during deflation fall down further into trachea coughing
finger occlusion of the trach:
resist urge to ?
instruct patient to take deep breath and then say ?
not all instances of audible voice are ?
visible ?
no audible air ?
audible ?
open pMV prior to finger occlusion test AH same effort/strain despite cues to relax release upon removal of finger air release
consider holding off on PMV placement if:
exhibits significant amount of ?
if patient’s oxygen saturation levels ?
if patients voice is
if patient is demonstrating (cannot tolerate )
audible air release upon removal of finger
drop consistently during occlusion trial
strained
poor secretion management (cuff deflation)
if valve placement not successful: ask physician to: consider consider change to change to ? (not if) ... consultation
trach downsize
fenestrated tube
cuff less trach (patient receiving vent support)
otolaryngology
The PMV is placed: monitor: monitor : look for ? check for change in remove PMV and check for ? ... retention
o2 saturation levels / candidate for increase in supplemental O2
heart rate/ decrease and increase not good
respiratory rate
audible air release from trach (CO2 retention)
For PMV use in-line with vent
RT - may need to use
RT - may need to remove
rt- will likely need to adjust
depending on vent setting patient may need to adjust ?
once weaned from vent we may see a decline in ?
adaptor to attach valve
in-line suction set-up
vent settings
timing of speech - forced breath by vent
voice production once pt off of vent (no longer powered by vent)
leak speech: expired air that leaks past and passes through ? this usually occurs when the track tube is not ?
-on a?
trach tubę/ glottis allowing pt to verbalise / fitting snugly against trachea or slightly deflated
ventilator
voicing without speaking valve:
finger
trach
occlusion
tube plug/capped inner cannula
purpose of ventilator:
move air ?
maintain
and out of lungs through artificial means
respiratory function
types of ventilator:
negative pressure: ventilators - old
moves air into lungs by creating
results in ?
positive pressure
most commonly
simply
iron lung
negative pressure around lung
vacuum, of air rushing in
used
forces air into lungs
full ventilatory support: ventilator does
partial: work of breathing
all work
shared between pt and ventilator
common ventilator modes:
controlled mechanical ventilation
full:
ventilator is doing
a pt receives a preset ? and preset
any spontaneous inspiratory attempts will
CMV is a ? mode ,after a certain Time interval the ventilator cycles into
ventilatory support
all the work
number of breaths per minute
not result in ventilation
time sequenced mode/ inspiratory phase
Assist control ventilation:
a preset ? are delivered however this mode will also ?
when patient initiates breath, the ventilator will deliver
in this mode patient will have a ? and a ?
this mode is helpful for ?
respiratory rate and tidal volume/ assist patient’s own spontaneous breathing efforts
full preset tidal volume amount
spontaneous rate / mechanical rate
pt with respiratory muscle fatigue
Synchronized intermittent mandatory ventilation:
SIMV is one of the most ?
like Assist control, SIMV is also ? ventilaton
allows the patient to intiiate ?
the ventilator is programmed for preset ? however when patient initiates a breath ?
can be used to begin?
comonly used
partial support
spontaneous breaths of varying tidal volumes
respiratory rate and tidal volume / varies according to the patient’s effort
ventilator weaning
pressure support ventilation:
is a …. that does not provide any ?
this mode assists spontaneous breaths with a pre-set amount of ?
the added pressure lets the patient take a ? than would be possible?
this mode is typically used with the patient who can ? but is unable to ?
this mode can be used ? or in combo with?
spontaneous mode of ventilation/ preset breath rate or tidal volume
pressure during inspiratory phase
deeper breath/ independently
initiate adequate number of breaths / inflate lungs adequately
alone / ventilator modes
Rate: number of ?
adults
children
infants
breaths delivered to the patient by ventilator
-breaths per minute
12-20
30-40
60-80
Tidal volume:
TV is the amount of air moved ?
based on patients
the ventilator measures how much air is ? as well as how much air is ?
if the measures diverge various ?
into and out of the respiratory tract during breathing cycle
weight
being delivered to patient/returned to ventilator
alarms will sounds
PEEP:
normal peep
2-5 cm H20
Continuous positive airway pressure:
a mode of ventilation that applies ?
the positive pressure helps to prevent ? improve? and enhance?
positive pressure on inspiration and expiration to a spontaneously breathing patient
alveolar collapse, functional residual capacity, oxygenation
Trach. weaning patient is ? tolerating? trach has likely been ? patient is tolerating
may have done a ?
breathing spontaneously
cuff deflation
downsized
speaking valve or capping
24 hours trach capping trial
decann.
typically closes within
3-5 days
COVID CONSIDERATIONS:
ventilator use is last?
high flow of air from ventilator can cause ?
for these patients doctors try to maintain lowest ?
ECMO ?
resort
further lung damage (barotrauma)
flow
alternative - extracorporeal membrane oxygenation
