Quiz 1 Flashcards
Pharynx
A tube connecting the nasal cavity, mouth, larynx, and esophagus
Approximately 13 cm in length (in adults)
Extends from the base of the skull to the cricoid cartilage (at level of C)
Muscular wall is composed of skeletal muscle-This means that there is voluntary control which allows us to hold our breath
Indication for Intubation
- Failure of airway maintenane or protection
- Failure of ventilation or oxygenation
- Anticipated clinical course
FAILURE OF AIRWAY MAINTENANCE AND PROTECTION
The patient who requires establishing of an airway also requires a way to protect their airway
Breathing on you own does not necessarily mean they can protect their airway
Gag Reflex
The gag reflex is a way to show that the pt. can protect their airway
However the gag reflex is ubiquitous and clinically a GCS assessment (less than 8 intubate) and the ability to both manage and swallow secretions can be more valuble
Causes of Respiratory Failure
- Hypercapneic Failure
- Hypoxemic Failure
Hypercapneic Failure
Second degree to impairment of ventilation
Type II Respiratory Failure
Generally due to: CNS dsyfunction, neuromuscular weakness, chest wall deformity, other pulmonary or metabolic conditions
Hypoxemic Failure
Type I Respiratory Failure
Most often caused through a V/Q mismatch
Diffusion surface area reduced (pulmonary edema, pneumonia, atelectasis)
Dead space ventilation (pulmonary embolism)
R -> L Shunt (airway obstruction, alveoar hypoventilation, cardiac shunt, and non pulmonary)
Goals of Intubation
Isolate Airway
Keep airway patent
Reduce risk of aspiration
Faciliate trachea suctioning
Delivery high fiO2 if needed
Provide route for administering certain drugs (NAVEL)
Ensure deliervy of an adequate tidal volume (6-8 ml/kg) to maintain adequate lung inflation and ventilation
Endotracheal Tubes-General
Inserted into the airway and sit at the distal end below the larynx and 2-5 cm above the carina (in adults)
Open at both ends
Proximal End of Endotracheal Tube
Standard 15 mm connector that can attach to the manual resuscitators or ventilators
Distal End of Endotracheal Tube
Beveled and rounded to help prevent trauma
Has the cuff attached to this end. The cuff is attached to the one-way inflating valve. The cuff seals the airway and needs to be inserted before insertion.
Endotracheal Tube-Parts
Murphy Eye-Where you can ventilate if the tube becomes blocked by secretions
E vap tube-Helps with suction
Radio-Opaque Line is used to see in x-ray to make sure that the placement is correct
Diameter is measure in mm and length is measured in cm
Laryngoscope
Used to visualize the larynx
There are many differnt kinds but they all have-handle (light source), blade (light source at distal 1/3)
There are two basic shapes-Straight (intended to pick up epiglottis) or curved (inserted to vallecula, depress hypoepiglottic ligament, and elevate epiglottis)
Average for adults is a size 3
Contradidications for Nasal Intubation
Apnea
Advantages of Oral Intubations
Faster than nasal intubation
Less likely to kink, bending of kinking of the tube will increase ETT resistance (to airflow, suction, and passage of any tube)
Disadvantages of Oral Intubation
More liekly to stimulate gag reflex
Can interfere with oral hygiene
Production of oral secretions may be stimulated (swallowing secretions difficult)
Patients may bite down on oral tube obstructing it creating more resistance to the point that they may lose the airway
Nasal Intubation Advantages
Route of choice when oral intubation is impossible
Easier insertion in pt. with impaired neck or jaw movement
pt. can not bite on nasal tube
Greater comfort-Awake intubations or long term intubations
What may make oral intubation unaccessible
Muscle Spasm, Seizures
Maxillofacial surgery or fractured mandible
Certain surgical procedures that require unobstructed oral access
Nasal Intubation Disadvantages
Soft tissue trauma and hemorrhage
Insertion may be limited by nares
Potential development for sinusitis or middle ear infection with lng term intubation
More difficult procedure for inexpienced practictioners
Oral Intubation Indications
Apnea (b/c it is quicker)
Nasal Fractures
Coagulopathy
Nasl obstruction
Deviated septum, polyps, coryza (nosebleeds), inflammed adenoids, foreign bodies, hematomas
Nasal Intubation Indications
Dyspenic patients who would worsen and can not tolerate the supine position
Oral cavity not accessible
inability to obtain sniffing position
When paralyzing agents are contradindicated (renal failure, burns)
Cartilage of Larynx
There is 9 Cartilages of the Larynx
2 Arytenoid Cartilages
2 Cuneiform Cartilages
2 Corniculate Cartilages
1 Thyroid Cartilage
1 Cricoid Cartilage
1 Epiglottis Cartilage
Trachea Measurements
Extends from the larynx to the main stem bronchi 12-15 cm in length
~2 cm in diameter
16-20 C-shaped cartilage rings
Carina Topography
Carina sits behind “angle of Louis” anteriorly and level of T4 posteriorly
pH indication for intubation
pH of 7.25 or less means you will need to do on intubation
Induction
Ther period from the start of anaesthesia to the establishment of a depth of anaesthesia adequate for operation (unconsious)
Intubation (endotracheal)
Passage of a tube through the nose or the mouth into the trachea for maintenance of the airway auring anaesthesia, or in a patient with an imperilled (at risk) airway
RSI
The administration, after preoxygenation of a potent induction agent followed immediately by a rapidly acting neuromuscular blocking agent to induce unconscious and motor paralysis for tracheal intubation
To render the patient unconsious and paralyzed and thn to intubate the trachea without the use of BMV
7 Ps of RSI
- Preparation
- Preoxygenation
- Pretreatment
- Paralysis of Induction
- Positioning-HOB
- Placement with Proof-CO2, polymetric, ausculatation (listen to stomach first), mist on tube, chest rise
- Postintubation Management-CXR to see placement
RSI-Preparation
T-minus 5-10 minutes
Assessed for difficultly of intubation (LEMON), monitoring equitment has been attached (SpO2, ECG, BP), drugs prepared, intubation equitment ready
Will occur at the same time as preoxygenation
L.E.M.O.N
Used to assess how difficult the intubation will be
L-Look Externally (if it looks difficult it probably will be)
E-Evaluate 3-3-2 Rule (3 finger in you mouth, 3 for chin length, and 4 hyoid cartilage to ligament).Mandible of Adequate Size ( to allow tongue displacement).
M-Mallampati Score
O-Obstruction/Obesity
N-Neck Mobility
LEMON-Look Externally
Examine the neck and mouth
DCAP BLS TIC-Deformity, Contusion, Abrasion, Puncture, Burn, Lacration, Swelling, Tenderness, Instability, Crepidious
Bleeding
Tracheal Deviation
JVD
Massess
Mallampati Score
Class One-Can view soft palate, uvula, facus, pillars
Class Two-Can view soft palate, uvula, and facus visible
Class Three-Soft Palate, base of uvula visible
Class Four-Hard palate only visible
LEMON-Neck Mobility
C-Spine mobility assessed by measureing the distance from lower border fo mandible to thyroid notch at full neck extension
Distance should be greater the 4 finger in adults
RSI-Equitment Preparation
Oxygen equitment and bagger-assembled and checked
Suction Equitment-Assembled, cheked, and turn on
Laryngoscope-Assembled and checked
Endotracheal Tube-Opended, Distal End lubricated, Stylet inserted and shaped, cuff checked and deflated, syringe attached
Tube Securign Device-Opened/Made/PreCut
Tube Placement Confirmation Device
Endotracheal Tube Size-Infant
Infant >1000g Tube Size 2.5 and Diameter 9-11
Infant 1000-2000g Tube Size 3.0 and Diameter 9-11
Infant 2000-3000g Tube Size 3.5 and Diameter 10-12
Infant >3000g Tube Size 4.0 and Diameter 11-12
Endotracheal Tube Size-Children and Adults
Generally women should be intubated with a number 7 or 7.5 orotraheal tube
A man is generally intubated with an 8-8.5 orotracheal tube
Another way to solve (Does not work for infants) is
(Age / 4) + 4= Tube Size
Laryngoscope Blade
The blade will depend upon the pat as straight blades are preferred in neonates
Also who is performing the laryngosope will have a preferrence
RSI-Preoxygenation
T Minus 3-5 min
Eastablish an oxygen reservior within the lungs, blood, and body tissue
Allow for several minutes of apnea time before desaturation to 90%-8 min for a healthy 70 kg adult (will be different if patient is obese or have other health conditions)
Once sat reach 90% after they will start to drop rapidly as desats from 90-0% will occur in 120 seconds
Preoxygenation of Patient
Usually done with manual resuscitator-3-5 minutes to obtain highest SpO2
100% O2 provides patient with reservere during intubation procedure
RSI-Pretreament
T Minus 3 min
Administration of drugs to mitigate adverse effects associated with intubation or underlying co-morbities
Drugs include-Lidocaine (Prevent gagging) and Fentanyl (relax pt. and prevent ICP)
Gagging increases ICP
Paralysis With Induction
T-Zero We are not ready to intubate as pt. is sedated and paralyzed
Rapidly acting induction (sedation) agent given by IV push-Midazolam, propofol, etomidate, katamine
Neuromuscular blocking agent (paralytic) which are fast acting and a shirt duration-Succinylcholine, rocuronium
DO NOT PARALYZE WITHOUT SEDATION
RSI-POSITIONING
Make any final adjustment to patient position as the patient goes unconsious and flaccid
Want them in sniffing position
Sellick Manoeuver (Optional)-Push back on cricoid cartilage
No Bagging at this time
T Plus 20-30 seconds
RSI-Placement with Proof
ETT inserted
Stylet removed and cuff inflated
Tube placement confirmed
T Plus 45-60 seconds
Insertion of Laryngoscope
Insert blade into the right of the mouth and sweep tongue to the left
Displacement of the Epiglottis
Look for the arytenoids and epiglottis and if seen proceed to visulize the glottis
if they are not seen the blade is liklely to have gone in too far
Curved (MacIntosh) Blade: Tip in the vallecula, resting on the hyoepiglottic ligemant. Lift and apply pressure flipping the epiglottis forward
Straight (Miller) Blade: Advance blade tip over posterior surface of epiglottis
BURP
For grade 3 or 4 Mallmpati Score we use this
B-Backwards
U-Upwards
R-Rightwards
P-Pressure
May bring the glottis down into view, improve view by full 1 grade
Assess Position of the Tube
Visulization
CO2 Detecteion
Esophageal Detection Device (EDD)
CO2 Detection
Most Reliable
Capnometry
Colormetry-Up to 6 breaths, Color change from purple to yellow is good and no color change is bad
Be careful to use during cardiac arrest
Esophageal Detection Device (EDD)
Deflate bulb attached directly to 15mm connector of ETT
If bulb inflate it is good
use immediatly after intubation before bagging resumes
Tube Depth of Intubation
21-23 cm ATT is good
<18 ATT or >25 be very careful
tube depth alone give no indication of esophasgus or trachea
Fibreoptic Bronchoscopy
Visulization of the tracheal rings through a cameria in the brochscopy
Only true gold standard
Postintubation Management
ETT Secured
PPV initiated
Chest XRay obtained (Distal tip 2-5 cm above carina)
Hypotension is present is treated (may be caused due to the sedation agents used)
Long term sdation ordered and given
Cuff pressure ajusted
T plus one minute
ETT Cuff
Seals the airway during positive pressure vetilation
Prevent or minimize aspiration
Cuff Pressure
Early tracheal tube had low volume and high pressure cuffs which caused major airway damage
Now the norm is high volume and low pressure in order to reduce the incidence of airway damage. Over inflation of the cuff is equal to using the older low volume high pressure cuff
The new high volume low pressure cuff makes contact with a greater surface are and therefore less pressure is required to seal the airway
Acceptable Cuff Pressure
20-25 mmHg
25-35 cmH2O
If cuff pressure is too high tracheal mucosal perfusion pressure has been exceeded which may result in tracheomalacia, tracheal stenosis
If cuff pressure is too low is can result in secretions that will leak into the trachea and bronchi which may result in ventilator assisted pneumonia
Maintenance of Cuff Pressure
Minimal Occulding Volume or Pressure Technique (MOV)-Injecting small amount of air until no leak is heard at PIP
Minimal Leak Test (MLT)-Inject small amount of air until leak is no longer heard then withdraw a small amount of air is heard at PIP (technique not recommended
MOV and MLT are used when it is not possible to measure cuff pressure, as whenever possible a cuff pressure manometer should be used
During a positive pressure breath, airways expand on inspiration. Therefore pressure in the trachea is less on inspiration than expiration. This means that the amount of ischemia that may result depends upon cuff pressure and the rate of PPV
Nasotracheal Intubation-Direct Visulization
Open Mouth
Insert Laryngoscopy
Visualize Glottis
Displace Epiglottis
Use Magill Forceps to manipulate the tube into the glottic inlet
Advance Tube
Nasotracheal Intubation-Blind Insertion
Apply Sellick’s Manouver-Aligns axis advancing tube with trachea and occuldes esophasgus
Listen for breath sounds as tube approach the glottis
Advance tube though glottic (preferrably on inspiration)
Nasotracheal Intubation Depth
28 cm at nares for men
26 cm at nares for women
Extubation Criteria
Is the patient getting better, is their inital condition resolved/imprved?
Is there any impeding conditions that may require ventilatory support?
Can patient manage secretions?
Can the patient protect their own airway through an adequate cough (requires minimal suctioning)
Extubation-Clincally Stable
CNS Assessment-Adequate CNS function needed to stable ventilatory drive and cough. LOC, anxiety, depression, and dyspnea can impact weaning success
Airway Evaulation-Can pt. maintain airway, what is the risk of aspiration (they may be able to protect the airway but not ventilate). What is their LOC, secretions, cough, positive cuff leak test (means no swelling in airway and they are breathing past the cuff)
Oxygenation-P/F Ratio (PO2 to FiO2 Ratio) needs to be greater than 300
Respirtory Muscle Strength-MIP or NIF is -20 cmH2O
Stable VS, hemodynamics, nutiriotional status, functioning GI Tract
Cuff Leak Test
1) Can the patient breath spontaneously- Are they initiating each breath on their own
2) Suction mouth and upper airway
3) Deflate the cuff
4) Briefy occlude the EET
5) If the patient is unable to breathe around the occulasion, then the laryngeal edema should be expected
Spontaneous Breathing Trial
After a 30-120 min spontaneous breathing trial pt. that can be extubated should have the following
- Resolution to their disease
- Hemodynamic Stability
- Adequate Oxygenation-Low FiO2 needs and PEEP
- Adequate Ventilatiory Status-PaCO2, normal pH
Equitement for Extubation
Resuscitation Bag, O2 source, and O2 mask
Suctioning
Saline to help with secretions
Syringe (10 mL) for cuff deflation
After You Extubate
Watch for signs of O2 failure and Ventilation Failure
- Decreased SpO2
- Increased FiO2
- Increased WOB
- Decreased LOC
An exubation is considered successful is patient is able to remain extubated for 24 hours
Complications During and Immediately After Extubation List
Airway Obstruction-Due to laryngeal edema causing stridor (smoke, epiglottitis, angioedema) or compression of airway (tumor, abscess, trauma, post op). Only 1% will experience stridor and of that 1% require reintubation
Hoarseness-Will occur in up to 70% of extubated ICU patients, oral intubation and large tubes will increase risk. If does no resolve for 2 weeks it indicates that there is a serious complication (vocal cord paralysis)
Cough-About 25% of ICU pt. following prolonged intubation will develop cough
Sore Throat-15% of short term intubation and 40% of long term intubations have a sore throat
Aspiration-Sensory deficit and incompetent laryngeal reflexes post extubation will increase risk of aspiration, especially in pt. with an impaired cough
Odynophagia-Painful swallowing or talking. If severe may indicate glottic infection or ulceration (very rare)
Vocal Cord Paralysis-Permanent bilateral vocal cord paralysis is very rare but unilateral transient cord paralysis is common
After Extubation-Stridor
Very rare but if occurs use cool aerosol with supplemental O2
Tx with nebulized 1:1000 epinephrine
Tx with Heliox mixtures by NRBM
Children are at a greater risk
Tracheotomy Access Incision
Procedure of establishing to the trachea via neck
Tracheostomy
Opening created by a tracheotomy
May be permenant or temporary
Usually associated with a tracheostomy tube
Unable to phonate as insufficent air passing through the vocal cords
Tracheostomy Tube
An Artifical airway inserted into the trachea via a tracheostomy
Laryngectomy
Surgical incision into the larynx
Usually a permanent stoma is linking the trachea to the surface of the neck
Trachea no longer in communication with pharynx
Unable to phonate as the vocal cords are no longer there
Stoma
An opening between two cavivties or canals or between such and the of the body
Often used interchangeably with trachesostomy
Tracheotomy-Indications
Upper airway trauma or obstruction
Continuing need for artifical airway after a prolonged period of oral/naso intubation
To facilitate removal of secretions
Inability to wean from artifical airway
Long term care patients with neuromuscular diseases
Obstructive Sleep Apnea-At night everything is floppy making it harder to breath
Parts of Tracheostomy Tube
Plastic
Rigid (Common)
Bent 90
15 mm Connecter (common)
May be cuffed or uncuffed
may be fenestrated or unfenestrated
Trach-Inner Cannula
Used for suctioning
Used for ventilation
Can be removed for cleaning
Inner diameter limits airflow
Trach-Outer Cannula
Provides rigidity that can be used to protect the airway
May or may not be fensatrated
May or may not be cuffed
Outer diameter customizes fit
Trach Tubes-Obturator
Makes the passage through tissues less trauamtic during insertion
Prevents blood or muscus form entering tube while being inserted
Removed when the trach is in place
Kept at pt. bedside and may be needed if trach tube gets dislodgeed and has to be reinserted
Trach-Cuff
Optional
Comes in various sizes at the distal end of the tube
Designed to seal and protect airway and to maintain position of tube
All cuffs inflated by syringe via attachment pilot balloon and accessible at all times
Can cause ischemia if over pressurized
Trach Care
It is a shared responsibility between the RN, RTs, and pt.
Done dily or as needed
the trach will need to be change every 3 months
Trach Care Steps
- Assemble and check equitment
- Assess the patient
- Explain the procedure
- Suction (if needed)
- Remove and clean inner canula
- Clean stoma site
- Change the ties (if needed)
- Re-insert inner cannula
- Reassess the pt.
- Chart procedure
New Trach Care
Trach care is only done if needed during first 24 hour post op
Inner Canula-Check q1h during first 24 hrs post op and clean q4h or prn during first 24 hours post op
Trach care is done aseptically for the 72 hours post op
Trach Humidifcation
the selction of humidifcation device should be based on pt. needs and assessment of the aireway and includes the volume an thickness of secretions as well as the history of mucus plugging or tube occulasion
Devices that can be used-Artifical nose, humidifer, large volume neb, instillation neb
Trach Communication
phonation requires airflow through vocal cords at a sufficient force and a tracheostomy will negate that process
Device that can be use includes-passey muir valves (most common), talking trachs, artifical larynx, Blom-Singer valve (cheap so everyone can afford it)
Loss of Airway Patency
Causes of loss of airway patency can be divided into 2 general categories
Central Causes-Any condition that leads to a depression of the CNS (i.e. <8)
Peripheral Causes-Airway obstruction caused by something originating outside the body
Central Causes of Loss of Airway Patency
When the CNS is depressed and comes from within the body
The causes of CNS depression varies
Most common cause of upper airway obstruction is the tongue
Includes-Decrease in cardiac output, TBI, Anesthesia, drug overdose, hypoxemia/hypercarbia, hypothermia/hyperthermia, metbolic derrangements
Central Causes-Decrease in Cardiac Output
Acute myocardial infarction (MI)
Cardiac tamponade-But when cause through a infection it is considered to be a peripheral cause
CHF
V fib or V tach
Hypovolemic Shock
Septic Shock
Massive Pulmonary Embolism
Mechanisms of Upper Airway Obstruction
Decrease in tone of submandibular muscles leads to posterior displacement of tongue against the posterior pharyngeal wall While in a comatose state the position of the chin will worsen the obstruction • C-spine adopts a semi flexed position, narrowing the distance between the tongue and posterior pharyngeal wall • Epiglottis gravitates towards the larynx partially occluding the airway • Negative pressure cause by respiratory efforts in presence of obstruction draws tongue towards the airway
Peripheral Causes
Peripheral causes come from outside of the body Peripheral causes include Infection Infection • Viral and bacterial infection laryngotracheobronchitis (e.g. croup) • Parapharyngeal and retropharyngeal abscess • Lingual tonsillitis • Hematomas or abscess of the tongue or floor of the mouth • Epiglottitis (also known as supraglottitis) • Similar to croup but the patient will have low energy and is very serious and in this case we do not manipulate the airway Neoplastic • Laryngeal carcinomas • Hypopharyngeal and lingual (tongue) carcinomas Physical and Chemical Agents • Foreign bodies • Chocking something shoved up a nose • Thermal injuries-Can cause swelling • Caustic Injuries- Can cause swelling • Inhaled toxins Allergic/Idiopathic • Angiotensin converting enzymes inhibitors induced angioedema Traumatic • Blunt and penetrating neck and upper airway trauma
Signs of Loss of Airway Patency
• Tachypnea and dyspnea • Noisy snoring respirations • Paradoxical breathing • Tracheal tug or retractions • Nasal flaring o Usually seen in babies • Expiratory Grunting o Is a compensation for collapse o Usually seen in babies o Cardiac dysrhythmias • Pressure in chest and low oxygen levels will affect the heart • Stridor • Absence of breath sounds or visible chest movement • Cyanosis o Can be misleading due to polycythemia or hypothermia o Will be check at the inside of the lips
Peripheral Causes-Infection
Viral and bacterial infection laryngotracheobronchitis (e.g. croup)
Parapharyngeal and retropharyngeal abscess
Lingual tonsillitis
Hematomas or abscess of the tongue or floor of the mouth
Epiglottitis (also known as supraglottitis)
Similar to croup but the patient will have low energy and is very serious and in this case we do not manipulate the airway
Peripheral Causes-Neoplastic
Laryngeal carcinomas Hypopharyngeal and lingual (tongue) carcinomas
Peripheral Causes-Physical and Chemical Agents
Foreign bodies Chocking something shoved up a nose Thermal injuries-Can cause swelling Caustic Injuries- Can cause swelling Inhaled toxins
Peripheral Causes- Allergic/Idiopathic
Angiotensin converting enzymes inhibitors induced angioedema
Peripheral Causes- Traumatic
Blunt and penetrating neck and upper airway trauma
Central Causes-Hypoxemia/Hypercarbia
COPD, Asthma, ARDS, Pneumonia, moderate PEs
Central Causes-Metabolic Derangements
Hypo/hyperglycemia
hypo/hypernatremia
hypokalemia (lead to heart malfunction)
metabolic acidosis
hepatic encephalopathy
Signs of Loss of Airway Patency
Tachypnea and dyspnea
Noisy snoring respirations
Paradoxical breathing
Tracheal tug or retractions
Nasal flaring-Usually seen in babies
Expiratory Grunting-Is a compensation for collapse and usually seen in babies
Cardiac dysrhythmias-Pressure in chest and low oxygen levels will affect the heart
Stridor
Absence of breath sounds or visible chest movement
Cyanosis-Can be misleading due to polycythemia or hypothermia, will be check at the inside of the lips
Presentation of Obstructed Airway
Hot Potato Voice- Horse Voice
Difficultly in Swallowing Secretions
Drooling is a very serious sign
Dyspnea
STRIDOR-Means a complete obstruction is imminent
Cough
Stridor
High pitched inspiratory sound
Indicated that airway has already lost at least 50% of its usual caliber
Complete obstruction may be imminent
The volume and pitch are related to the velocity of air flow-Air flow is dependent on patient’s level of consciousness and inspiratory muscle strength
Often audible but may be detected early via auscultation over the trachea-Can normally be heard without a stethoscope
If it is epiglottitis don’t place the stethoscope near the throat just keep them calm
Establishing and Maintaining Patient Airways Manuevers
Head-tilt/ Chin-Lift
Jaw Thrust Maneuver
Occasionally opening the airway is all that is require to re-establish the airway
Oropharyngeal Airways (OPAs)
Rigid, curved devices with an air passage, placed through the mouth with the end resting distal to the tongue above the glottis opening
Oropharyngeal Airways (OPAs) Indication for Use
- Used in patients with decreased submandibular tone
- Obtunded 2 degrees to any of the central cause of airway obstruction
- Anesthesia
- Deep sedation
- Used when manually ventilating a patient
- Used as aid for deep suctioning
- Used as a bite block
- Some model used to facilitate intubation
OPA Contraindications for Use
Patients with obvious oral trauma
Awake or semi-conscious patients
May cause vomiting or gagging
IMPORTANT-If a patent is awake enough to spit or tongue the device out then they are too awake for the device to be used
OPA Sizing
Proper sizing
Place the airway next to the face with the flange at the mouth and the tip of the airway should reach the angle of the jaw (tragus of the ear)
Complications of OPA
May cause trauma to the lips, mouth, or teeth-Rare
May cause pressure necrosis
Difficult to perform mouth care
May cause gagging and vomiting-May push the tongue back
Nasopharyngeal Airways (NPAs)
AKA nasal trumpet
Soft or semi-rigid hollow tube placed through the nares, the tip lying distal to the tongue above the glottic opening
May be sized in mm I.D. or French sizes
NPA Indications for Use
- Semi-awake patients who require some airway maintenance and do not tolerate the OPA
- Ay be used when insertion of OPA is difficult or contraindicated
- Maybe used to facilitate deep suctioning
- Pierre-Robin Syndrome (in neonates)
- Micrognathia-Tiny Chin
- Mandibular hypoplasia
Contraindications of NPA
Obvious nasal trauma
Deformities of the nose
Basal fractures of the nose (Racoon eyes and battle sign)-This may indicate skull fractur but use history to help determine
Coagulation disorder-NPA can cause nosebleeds
Complication from Use of NPA
If too long can enter into the esophagus causing gastric distension and hypoventilation
May cause vomiting and laryngospasm (big issue with infection) in semi-conscious patient
Injury of nasal mucous with bleeding
Sinusitis
Bypassing natural defenses
Otitis Media (ear infection)
Intubation of meninges (basal skull fracture)
Occlusion of airway by secretions
Tissue necrosis
Resuscitator
Used when pt. is not breathing on their own
Manual Resuscitator
Bag-Valve-Mask (BVM)
Bag-Mask Ventilator (BMV)
“Bagger”
“Portable handheld devices that provide a means of delivering positive pressure to a patient’s airway”
“Deliver room air (R/A), oxygen air-oxygen mixtures via a mask or through an adapter that attaché directly to a patients ET”
You will know you are giving enough air if there is chest rise
Manual Resuscitator
Hand squeezing a bag provides the mechanical force necessary to generate a positive pressure
Requires an oxygen source to deliver FiO2 greater than 0.21
In the baby and child versions they will have pop off valves
Commonalities in Bag
- Universal connector (15/22 mm)
- This allows them all to be connected to trachs
- Requires an O2 sources for FiO2 >0.21
- Oxygen flow meter
- 50 psi source
- Wall outlet
- Cylinder
- Originally designed for use during CPR
Self Inflating Manual Resuscitator
Does not require a compressed gas source for operation
Re-usable or disposable
Self Infalting Resuscitator Parts
- Self –inflating bag
- (volume depends on patient population)
- Air inlet/Oxygen Reservoir attachment site
- Oxygen Inlet
- Patient Outlet
- Valve assembly
- One way, non-rebreathing
- Oxygen reservoir (required for high FiO2)
- Pressure release (pop-off) valve (optional)
- Pressure Gauge / Guage attachment site (optional)
Classess of Non-Rebreathing Valves
- Spring-Loaded
- Diaphragm
- Duckbill (most common)
- Leaf-type
- Fishmouth
Pneumatic Resuscitators
- Used when unable to bag
- Commonalities
- Universal connector (15/22 mm)
- This allows them all to be connected to trachs
- Requires an O2 sources for FiO2 >0.21
- Oxygen flow meter
- 50 psi source
- Wall outlet
- Cylinder
Safety Mechanisms of Resuscitators
- Non-Rebreathing Valve (Self-Inflating)
- Prevents rebreathing of exhaled gases
- High Pressure Pop-Off Valves (self-Inflating)
- Prevents delivery of overly high pressure to patient (infant and children only)
- Maximum circuit pressure control (T-Piece Resuscitator)
- Will take away the variability of the pressure delivered in a breath
- Standard 15/22 mm connectors
- Allows for easy connection and disconnection
Quality Control Mechanisms
- Operation manual should specify
- BVM device underwent safety and standard testing
- Criteria was met
Standard Construction for Resuscitators
- Resuscitators capable of delivering FiO2 > or = 0.95
- Must be able to operate at-Extreme temperatures and Relative humidity 40-96%
- Deliver Vt > or equal to 600 ml into test lung for adult baggers
- With compliance of 0.2L/cmH2O
- With resistance of 20 cmH2O/L/sec
- Non-rebreathing valve withstand oxygen flow rate up to 30lpm
- If valve malfunctions due to foreign obstruction (e.g. vomitus), must be restored within 20 seconds
- Must have standard 15/22 mm connectors
- Adult resuscitators not have pressure limiting system
- Resuscitators for infants and children have pressure relief valve that limits PIP to:
- 40 +/- 10 cmH2O for children
- 30 +/- 5 cmH2O for infants
- When incorporating pressure limiting system, override capability must exist and must be apparent to operator
- Resuscitator able to operate after being dropped from height of 1 meter on to concrete floor
- Easily disassembled for sterilization and disinfection purposes
- Should not be possible to accidentally interchange parts
- making unit malfunction
- not function at all
Mask Seal
Hand Positioning-Single Hand
Lift chin up to the mask
Proper Ventilation
Connect bag to mask and O2
Should not use entire volume of bag
Assess for mask seal
Should feel some resistance in the bag.
Does the chest rise?
Can you hear a leak?
Steps to improve mask seal
Remove mask and reseat to face
Is airway patent
Head tilt chin lift?
OPA
Suction oropharynx
Two hand mask seal
Reinserting patient’s false teeth
Assessment of effective ventilation.
Goal is for visible chest rise
Chest rise and fall with ventilation
Breath sounds with ventilation
Improving SpO2
Capnograph waveform-end tidal CO2 (confirmation of intubation and can tell us about effectiveness of CPR by seeing if you are pumping enough blood through the body)
Ventilating the Patient
- 12 breaths per minute
- Every 5 seconds
- Target 500-600 mls for an adult
- Ti 1.0s
- Decrease insufflation of stomach with gentle ventilation
- Esophageal sphincter opening pressures ~25cmH2O
BMV Golden Rules
Manual ventilation skill with proper equipment is a fundamental premise of advanced airway management
Anybody (almost) can be oxygenated and ventilated with a bag and a mask
The art of bagging should be mastered before the art of intubation
What Will Make Resuscitation Difficult
M.O.A.N.S.
-
M- Mask Seal
- Bushy beards, trauma
-
O- Obesity/Obstruction
- ↑ weight of chest, ↓ diaphragmatic excursion
- ↑ Resistance 2° to swelling, adipose tissue
-
A- Age
- Older than age 55 (not a hard,fast rule)
-
N- No Teeth
- Face tends to cave in
-
S- Stiff, Snoring Hx
- Lungs resistant to ventilation (asthma, COPD)
Describe three major hazards associated with manual resuscitation. Which is the most common?
- Delivery of excessive high airway pressure (most common)
- Common in intubated patients
- Defective nonrebreathing valve
- Can cause an inspiratory leak and tidal volume escaping through the exhalation port and not delivered to the patient
- Faulty pressure-relief valves
- Can cause gas delivery at excessively high pressures and increases the risk of barotrauma
- What is the difference between tracheotomy and tracheostomy?
A tracheostomy is a surgically created hole at the front of the neck into the trachea. The procedure of creating this hole and placing a tube within it (through which the patient breathes) is called a tracheotomy.
List factors considered when determining whether the patient should have a tracheotomy/tracheostomy.
Indications of a tracheotomy include:
- Upper airway obstruction or trauma
- Continuing need for artificial airway after a prolonged period of oro/nasotracheal intubation
- To facilitate removal of secretions from tracheobronchial tree when patient is unable to raise secretions
- Inability to wean from artificial airway even after being weaned off of mechanical ventilation
- Long term care patients with neuromuscular disease
- Obstructive sleep apnea
Briefly describe the two main methods of tracheotomy.
Cricothyroidotomy is a surgical incision to the trachea which passes through the cricothyroid membrane and results in the insertion of an endotracheal tube or a tracheostomy tube. Under this method, a single horizontal incision is done through the skin to the trachea.
Percutaneous dilatory tracheostomy (PDT) is the more common method of tracheotomy due to its effectiveness, simplicity, and low incidence of complications. This method is performed mostly in the ICU if the patient is in the unit and intubated for more than 7 days. PDT is performed mostly with the Ciaglia method: a guide wire is placed between the first and second or second and third tracheal rings and plastic dialators is pushed through the soft tissue until the appropriate size is met. This method is usually aided with the use of a bronchoscopy.
Describe the four mechanisms of airway emergencies in patients with artificial airways and how to troubleshoot these situations. Which mechanism is the most common?
DOPE:
Displacement: Reposition (if possible) or remove tube and bag until reintubation is possible.
Obstruction: (Most Common!) Many different causes, but move patient’s head/neck to reposition, deflate cuff, suction catheter through tube, or flush tube with saline or mucus shaving device
Pressure: The pressure of the cuff on the ETT can cause issues if under-inflated or over-inflated. If under-inflated, air and secretions can leak around the cuff and cause ventilation issues. Over-inflation can cause the trachea to become inflamed and cause further ventilatory issues.
Equipment: Anything that causes a stoppage in the flow of oxygen to the patient. Check the tubing or vent to see if any kinks have developed, and have back-ups. You can also remove tube and bag patient until they can be reintubated.
