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APLS > Support of the Airway and Ventilation > Flashcards

Support of the Airway and Ventilation Flashcards

1
Q

Describe the primary assessment and resuscitation of airway and breathing.

A

SUPPORT OF THE AIRWAY AND VENTILATION

PRIMARY ASSESSMENT AND RESUS

  • Primary assessment
    • rapid physiological examination
    • aim: identify immediately life-threatening emergencies
    • treat problems as they are identified, then re-assess + continue primary assessment
  • A
    • ? patent/ airway obstruction
    • ? stridor
      • self-ventilation where possible
      • O2 - encourage but do not force
      • keep calm - parental involvement, do not inspect airway
    • Mx
      • Trauma
        • Immobilise C-spine as appropriate
        • consider <<c>> - simultaneously control major haemorrhage </c>
      • O2
      • airway opening manoeuvres (head tilt chin lift, jaw thrust) - if obstruction/ altered consciousness
      • suction +/- foreign body removal
      • airway adjuncts e.g. oropharyngeal/ nasopharyngeal airway, LMA, i-gel (if obstruction persists)
      • I+V
  • B
    • LOOK, LISTEN, FEEL for breath (10 secs)
    • LOOK:
      • skin colour
      • symmetrical movement of chest
      • WOB / resp distress, depression or arrest
      • Chest injury –> ? tension/ open PTX, haemothorax, flail segment
    • LISTEN:
      • BS (auscultate) - wheeze/ crackles –> ? asthma, bronchiolitis, pneumonia, heart failure, inhaled foreign body
      • stridor
      • lateralised ventilatory deficit –> ?haemoPTX, inhaled foreign body, consolidation, collapse, effusion
    • FEEL: expansion, percussion
    • Mx
      • RR, Sats, capnometry (intubated)
      • high-flow O2 (resp distress, high RR)
      • BVM (resp arrest or depression)
      • supraglottic airway (i.e. pharyngeal - nasopharyngeal, oropharyngeal = guedel, LMA/ i-gel)
      • I+V / surgical airway
        • may need to loosen cervical collar if it impairs airway access
        • check position with auscultation + capnometry
        • Consider failed intubation algorithm (see image)
        • early in severe trauma (even if airway not compromised)
        • BEWARE coughing, vomiting, bucking –> raised ICP (will need GA - perform neuro assessment BEFORE)
      • OGT/ NGT - decompress the stomach
    • Specific conditions:
      • PTX? –> needle decompression + chest drain
      • Massive haemothorax –> chest drain + blood products (simultaneous)
      • Sedative / paralysing drugs –> reversal agent
      • Acute severe asthma –> inhaled/ IV b-agonists, steroids, aminophylline, magnesium
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2
Q

Describe the secondary assessment of airway and breathing.

A

AIRWAY AND BREATHING

SECONDARY ASSESSMENT

  • Thorough physical examination
    • airway, neck, chest incl. the back of the chest
    • swelling? bruising? wounds?
    • SYMMETRY
      • chest movement
      • air entry
  • Ix as appropriate
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3
Q

What should you do at any time the patient deteriorates?

A

Stop! Breathe!

Return to PRIMARY ASSESSMENT

Cycle back through ABCDEFG

RESUSCITATION of life-threatening problems as identified

SECONDARY ASSESSMENT

EMERGENCY Mx

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4
Q

What is bucking?

A

BUCKING

  • violent expiratory contraction of skeletal muscles
  • reflex response to chemical or physical irritation e.g. insertion of ETT, inhalation of concentrated vapours
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5
Q

What are the responsibilities of the team members at the head of the bed? Who usually performs this role?

A

TEAM ASPECTS OF AIRWAY MANAGEMENT

HEAD OF THE BED

  • anaesthetist of paeds intesivist
    • a skilled assistant (help with drugs and equipment if intubation needed)
  • Role
    • manage airway
    • protect C-spine
    • coordinate rolling manoeuvres during secondary survey / transfer e.g. to imaging/ ICU
    • identify scalp lacerations (sig. blood loss in children)
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6
Q

What is the difference b/w LMA and i-gel?

A

Both are supraglottic airways (sit above the glottis).

  • LMA = laryngeal mask airway
    • inflatable cuff
    • reusableor or disposable (newer)
    • +/- channel for suctioning gastric contents
  • i-gel
    • non-inflatable cuff
    • disposable
    • considered easier to use by many
    • channel for suctioning gastric contents
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7
Q

What are the two types of pharyngeal airways?

A

PHARYNGEAL AIRWAYS

  1. Oropharyngeal (guedel)
  2. Nasopharyngeal
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8
Q

When and why are Guedel (oropharyngeal) airways used?

A

OROPHARYNGEAL AIRWAY

GUEDEL

WHEN & WHY

  • Unconscious or obtunded
  • short-term
  • to create a patent airway channel b/w the tongue and the posterior pharyngeal wall
  • first intervention if manual airway opening manoeuvres fail
  • stabilisation of ETT
  • NOT if gag reflex present (vomiting)
  • remove as the pt becomes more conscious
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9
Q

How do you size oropharyngeal and nasopharyngeal airways?

A

SIZING

PHARYNGEAL AIRWAYS

  • Oropharyngeal (guedel)
    • centre of the incisors to the angle of the mandible
  • Nasopharyngeal
    • lateral edge of the nostril to the tragus of the ear
    • diameter - just fits into the nostril w/o blanching
    • can use shortened ETT with a large safety pin if too wide
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10
Q

When are nasopharyngeal airways contraindicated?

A

Base of skull fractures (anterior)

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11
Q

How do you calculate the approximate inflation volume of an LMA?

A

LMA

Approximate inflation volume (ml) =

(LMA size x 10) - 10

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12
Q

What benefit do i-gel and LMA confer over BVM?

A

i-gel & LMA Vs. BVM

  • lower risk of aspiration as less gastric distension
  • however seal is less effective than an ETT
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13
Q

How long should intubation take? What should be done if it is not achieved in this time frame?

A

INTUBATION

  • no longer than 30 secs
  • failure or desaturating –> re-ventilate w/ BVM before re-attempting
  • O2 sats should not fall during intubation
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14
Q

Describe the different types of laryngoscopes. Is there any benefit of one over another?

A

LARYNGOSCOPES

  • Use the type that gives the best view of the vocal cords
  • Fibreoptic light guide - green bands in handle and blade show compatibility
  • Use size appropriate for age
  • Can intubate with a laryngoscope that is too long but now w/ one that is too short
  • Straight or curved blade
  • Straight-bladed
    • e.g. Miller, Robertshaw
    • lift the epiglottis and uncover vocal cords
  • Curved-bladed
    • e.g. Macintosh
    • move the epiglottis by lifting from in front
    • tip of the blade in the vallecula (mucosal pocket)
    • less vagal stimulation as vallecula innervated by glossopharyngeal nerve (but pt shoudl ve anaethetised so shouldn’t matter)
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15
Q

Should cuffed or uncuffed tracheal tubes be used?

A

ETT

  • traditionally uncuffed - lower risk of mucosal airway damage
  • can also used cuffed
    • may be easier to ventilate if non-compliant (stiff) lungs e.g. severe bronchiolitis
    • counterbalance risk of airway damage with failure to ventilate properly
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16
Q

What size of tube (diameter and length) should be used in children? Should there be air leak?

A

ETT size

  • Uncuffed
    • choose a size that gives a relatively gas tight fit
    • air leak audible when inflation is continued to pressures slightly above max normal inflation pressure
    • prevents damage to mucosa at level of cricoid ring & oedema following extubation
  • Cuffed
    • do not overinflate cuff
    • monitor cuff pressure - same reason
  • INTERNAL DIAMETER
    • > 1 yo, uncuffed : internal diameter (mm) = (age/4) + 4
    • cuffed: (age/4) + 3.5
    • 1 year: size 4.5
    • 6 months: size 4
    • neonates < 3kg: uncuffed 3.0 or 3.5
    • pre-term: even smaller
  • LENGTH (cm) - use NON-SHORTENED, predicted length helpful to gauge length at lips, still do clinical check for placement
    • ORAL: (age/2) +12
    • NASAL: (age/2) +15
17
Q

If tracheal suction is needed after intubation, what size of tracheal catheter should be used? What is the risk of using a suction catheter that is too large?

A

Tracheal suction after intubation

  • To remove bronchial secretions or aspirated fluids
  • Size = 2 x internal diameter of ETT
  • e.g. ETT 3mm –> suction catheter French gauge 6
  • Ifsuction catheter is too large then instead of suctioning the ETT contents, the ETT is occluded and suction pressure is transmitted to lungs –> atelectasis
18
Q

What checks should be performed immediately after intubation and when taking over for an intubated patient?

A

MONITORING AN INTUBATED PATIENT

CHECKS TO BE PERFORMED AFTER INTUBATION & WHEN TAKING OVER

  • Pulse oximeter
    • assess oxygenation not ventilation
    • sats drop SLOWLY if ETT in oesophagus
    • not appropriate for rapidly checking correct ETT position
  • Capnometer
    • gold standard for checking correct intubation
    • responds rapidly to falls in expired CO2
    • no expired CO2 = oesophageal intubation
    • sudden drop to 0 = equipment disconnection, ventilator failure, extubation
    • gradual fall in ETCO2 = drop in CO (the lungs are still ventilated but CO2 washed out more slowly over several breaths) e.g.
      • cardiac arrest
      • inadequate cardiac compressions
      • PE
  • Auscultate
    • both axillae
      • NB in small pt’s BS sounds may transmit across the chest even if only one side is ventilated
      • Asymmetrical –> ? endobronchial intubation
    • stomach
      • air entry –> ? oesophageal intubation
19
Q

What are the limits of capnometry?

A

LIMITS OF CAPNOMETRY

  • Low/ zero cardiac output states
    • little or no expired CO2
  • Endobronchial intubation
    • not detected
    • auscultate both axillae
    • look for asymmetrical chest movement
  • Uncuffed ETT that is too small
    • large leak - especially if PEEP used
    • expiration around the tube, not through it
    • capnometer gives 0 or very low reading
20
Q

Describe the assessment of potential airway and ventilator problems in an intubated patient. Use a mnemonic.

A

AIRWAY AND VENTILATOR PROBLEMS IN AN INTUBATED PATIENT

DOPE

  • D - Displaced ETT
    • Endobroncial
      • Signs
        • asymmetrical chest movements
        • unilateral BS
        • SPO2 falling
      • Mx: slight withdraw ETT –> re-auscultate
    • Oesophageal
      • no ETCO2 on capnometry
      • remove ETT, mask ventilate, re-intubate
  • O - Obstructed tube
    • Kinked
      • examine visible tube for kinks
      • straighten and fix securely
    • Blocked e.g. mucus, blood
      • high index of suspicion esp. if small ETT and non-humidified gases used for ventilation
      • thick mucus plugs at tube tip
      • suction the tube
      • not resolved –> remove, mask ventilate, re-intubate
  • P - PTX (Tension)
    • Signs
      • high peak ventilator pressure
      • rapid fall in SPO2 & CO
    • needle decompression
  • E - Equipment problems
    • Check for:
      • breathing system disconnection
      • leaks
      • O2 supply failure / disconnection
      • ventilator function
      • deflated ETT cuff
    • If problem not immediately obvious then hand ventilate whilst equipment checked
21
Q

Describe the management of a blocked tracheostomy.

A

BLOCKED TRACHEOSTOMY Mx

  1. Stimulate
  2. Shout for help
  3. Head tilt chin lift (trache exposed and opens upper airway)
  4. O2 to face and trache
  5. Suction catheter - assess patency of trache
  6. NO PATENCY –> replace the tube (same size)
    • easier if established trache
    • care if newly created trache - until stoma track is established there is risk of creating a blind-ending false track during replacement
  7. NO –> half a size smaller
  8. NO –> thread a lubricated suction catheter through the smaller trache and try to guide into stoma
  9. NO –> remove trache
  10. LOOK, LISTEN, FEEL for breathing over tracheostomy (JUMP TO THIS STEP IF REPLACEMENT SUCCESSFUL AT ANY STAGE)
  11. BREATHING –> recovery position, continue to assess
  12. NO BREATHING –> 5 rescue breaths (ventilate)
    • tube replacement successful –> BVM (attach self inflating bag) or mouth to trache
    • unsuccessful but fully/ partially patent upper airway –> occlude stoma and BVM or mouth to mouth
    • unsuccessful and no patent upper airway –> stoma ventilation
  13. ALL ELSE FAILS –> SURGICAL AIRWAY (CRICOTHYROIDOTOMY)
    • IV cannula or purpose made cricothyroidotomy cannulae (less liable to kink than IV cannulae and have flange for suturing to neck)
    • through cricothyroid membrane
    • O2 1 L/ year of age/ min
    • oxygenation but no ventilation
    • To achive partial ventilation: can cut side hole in oxygen tubing or put Y-connector b/w cannula and O2 supply
    • high failure rate - membrane hard to feel in young pts
    • many ENT surgeons prefer an open tracheostomy

APLS (25 decks)

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