Test 3 Part 6 Flashcards
stridor usually indicates what?
some type of obstruction
patient has stridor, how do you tx?
- should the patient be intubated or can it be delayed?
- heliox (70% helium w/ 30% O2)
- Nebulized Epi
- Decadron 4-8 mg q 8-12 hr
how does DM have airway implications?
- juvenile DM relationship with stiff joint syndrome
- limited atlanto-axial joint motion
if patient presents with DM, you could have them do a prayer sign test to determine if they have “stiff joints” how is this done?
put hands in praying position; if palmar surfaces of the phalangeal joints cannot be approximate despite maximal effort –> prayer sign is +
STOP - BANG for OSA
- snoring
- tiredness
- observed apnea
- high blood pressure
- BMI > 35
- Age > 50
- Neck circumfrence (> 43 males; 41 females)
- male gender
preoperative recommendations for OSA
- develop protocol so at risk pts are evaluated prior to day of surgery
- thorough H&P
- inform pt and family of increased risk
- pre and post-op use of CPAP/BIPAP
- evaluate for potential difficult airway
- consider inpatient surgery rather than outpatient
airway and respiratory issues d/t obesity
- decreased FRC
- increased O2 consumption and CO2 production, even at rest
- Requirement for higher minute volume to maintain normocarbia
- decreased chest wall compliance
- chronic hypoxemia, polycythemia, pulmonary HTN
- difficult surgical airway if necessary - ensure/mark crcioid
perioperative issues with obese pts with implications for airway managaement
- preop eval
- significantly r/t difficult intubation
- judicious admin of narcotics/sedative
- optimal positioning with extra padding
- masking, oral, and nasal airways
- consider regional anesthesia when applicable
- extubate fully awake after full reversal of NMB
Airway preparation/setup: MAIDENS
- machine check, including O2 tank
- Airways, including oral, nasal, and tongue depressor
- intubation supplies: handles, blades, tubes, stylets, magill
- Drugs including emergency drugs
- Emergency supplies - ambu, bougie, LMA
- Nerve stimulator
- suction - yankaur, catheters, stethoscope
flexing the neck and neck extension using a pad will put the pt in ________________ position; and lines up the _____________, __________, & ___________
sniffing position; oral axis; pharyngeal axis, laryngeal axis
extension of the neck without head elevation aligns the ____________ & __________, but not the _____________
pharyngeal axis and laryngeal axis; oral axis
_______________ position will improve ability to __________ & _________
sniffing; ventilate; intubate
chin lift/jaw thrust is a manual position method that does what?
moves the tongue and epiglottis off the pharynx
what is the most common positioning method used for obese patients for optimal ventilation and intubation
pillow method
T/F: it is okay to use an oral airway with awake pt
false; gag reflex still intact –> vomiting and aspiration
how do you fit a pt for an oral airway
measure corner of mouth to tip of ear lobe
most adults will use a ____ mm oral airway; very large adults will need a _____mm
9; 10
oral airway can be effective for ventilation in a sedated pt because it functions to….
displace the relaxed tongue
how do you pick the correct size nasal airway?
measure from tip of nose to tip of earlobe
for nasal airway, sizes range from __________ - __________
26; 34 fr
nasal airway size for smaller adults will be ______ Fr, and larger adults will need ______Fr
30; 34
which nare do you usually insert the nasal airway?
right –> usually larger and straighter
when you insert a nasal airway, what way should the tip be aimed
posterior
T/F: semi-awake pts will tolerate a nasal airway
true
contraindications to inserting a nasal airway
- hemorrhagic d/o
- if on anticoagulants
- deformity
- basilar skull fracture
how does an LMA function?
forms a seal around the laryngeal opening which allows for positive pressure ventilation
indications for LMA
- routine airway
- rescue airway
- resuscitation airway
C/I to LMA
- full stomach
- pregnancy > 14 wks
- acute abdomen/thoracic
- decreased pulmonary compliance (restrictive)
- gross obesity
- hiatal hernia
- pharyngeal pathology
- obstruction below larynx
potential problems that can be encountered with LMA
- inadequate level of anesthesia
- coughing
- aspiration
- laryngospasm
- Nitrous oxide diffusion
- cuff under 60 cm H20
- incorrect positioning of LMA
sizing of LMA is based on?
- gender
- weight
- anatomy
indications for ET intubation?
- compromise or inaccessibility of airway
- long surgical procedure needing relaxation
- surgical procedure on head, neck, abdomen
- need for controlled Positive pressure ventilation
- inability to maintain a patent airway with a mask or airway device
- Dz process involving the airway
- risk of aspiration from full stomach
what is the gold standard of airway management
Endotracheal intubation
what are the different methods to inserting a ETT
- awake vs asleep
- oral vs nasal
- blind vs direct
ETT should typically be about __________ cm in females; and ____________ cm in males at the teeth
20-21; 22-23
what size ETT should typically be used in males
7.5 - 8.0
what size ETT should typically be used in females?
6.5-7.0
how do you determine what size ETT to place in peds pts if older than 16 y/o?
age divided by 4
how do you determine size of ETT to place in peds patient that is < 16 y/o
diameter of little finger
what size ETT would you expect to use in infants?
3 - 3.5
if pt has ETT you know that extension of the neck will withdraw the tube anywhere from _________ - __________; average of about ______ cm
0.2 - 5.2; 1.9
if pt has ETT you know that flexion of the neck will ADVANCE the tube anywhere from ______ - _______ cm with an average of about ________
0 - 3.1; 1.9
with ETT extension of the neck ______________ the tube; and flexion ____________ the tube
withdraws; advances
what is the recommended pressure of an ETT cuff ?
20 - 30 mmHg
what are the 2 basic types of intubation blades
straight and curved
what blades are straight
Miller, Wisconsin, Phillips
Advantages of a miller blade
good in small cross sectional dimensions
useful in pts with narrow oral cavities
useful in pts with prominent upper teeth (ankylosis)
if using a miller blade for intubation, the tip of the blade should be directly under the _________________ to directly elevate it
epiglottis
a ____________ blade is curved
mac
if using a mac for intubation, the tip of the blade is placed in the ______________ to elevate the epiglottis
velleculae
advantages of mac blade
less potential to damage teeth
more space available in the oropharynx for endotracheal tube
sizing of blades
0-4
sizing of blade is referring to _______________; the smaller the number the ____________ the blade
length; shorter
how many methods of ETT verification should be done?
two
what are teh different ETT verification methods (if in the OR)
- End-tidal CO2
- Auscultation of three areas: epigastric, left lung field, right lung field
- Esophageal detection device
how does an esophageal detection device work for ETT verification
theres a bulb, you squeeze the bulb and then if it reinflates youre in the trachea;
if in the stomach it will not re-inflate unless there is a lot of air in the stomach
how would you verify ETT placement if in a setting outside of the OR
- CO2 colorimetry
- auscultation
- esophageal detection device
- CXR
what is the limitation to color change devices for ETT placement?
are not accurate during cardiac arrest
advantages of oral intubation
- larger tube inserted
- tube inserted with more speed/ease & less trauma
- easier suctioning
- Less airflow resistance
- reduced risk of tube kinking
disadvantages of oral intubation
- gagging, coughing, salivation, and irritation induced with intact airway reflexes
- tube fixation is difficult
- gastric distenstion from frequent swallowing of air
- mucosal irritation and ulcerations of mouth
advantages to Nasal intubation
- more comfort long term
- decreased gagging/salivation
- improved mouth care
- better tube fixation
- improved communication
