Textbook

Question 1

Colorimetric

Answer 1

It is a cheaper device as compared to capnometry
It is similar to ph paper
It is portable and disposable
It is commonly used in hospitals
Both colorimetric and capnometry are effective in detecting esophageal intubation. However, best assessed by capnometry.
Inspired air consists of approx 0.04% co2 and end-tidal contains approx 5%. When colorimetric is placed after intubation, CO2 abrupt increase during expiration of pt is an indicator it is in respiratory tract. If colorimetric it changes color from yellow to purple, if capnometry its display is evident with an increase in number because if tube is in the esophagus the level of CO2 remains near zero. However, if pt recently had a carbonated fluid, CO2 may be released via esophagus.
It is important to note, when a pt is in cardiac arrest, expired CO2 level may be zero (body is still making but as no respiration happening and poor pulmonary blood flow) giving a false-negative result.
Waveform capnometry is another method of CO2 analysis. Which is helpful to assess the effectiveness of chest compressions during cardiopulmonary resuscitation. If the exhaled CO2 begins to fall—> that means that means chest compression not effective,
If exhaled CO2 begins to increase—> that means chest compression are effective.
So what do yo think, if the CO2 level increases, does that mean the person is back to normal..meaning the spontaneous breath has returned?
Yes, as the spontaneous circulation returns, the significant Co2 to the lungs also increases. In general, CO2 level increases with the return of spontaneous circulation due to the significant increase in the amount of CO2 returned to the lungs. However, CO2 analysis, both colorimetric and capnometry(number and waveform), are unreliable indicator for main stem bronchial intubation.

Question 2

What is the ETT size for adult male and female?

Answer 2

Female- 19-21cm at teeth
Male-21-23cm at teeth
Size can always be adjusted between the range, depending on the bilateral breath sound & chest X-ray findings

Question 3

How can we find out the ett placement without the chest X-ray?

Answer 3

By using a flexible laryngoscope or bronchoscope, as well as video laryngoscope in anticipated difficult intubation. This should be done after the re-oxygenation.

More precise placement of the ETT can be achieved by moving the bronchoscope from the tube tip to the carina and simultaneously measuring the distance.

Question 4

Can we secure tube before correct placement is confirmed in emergency situation?

Answer 4

No, never.
After ett passage and cuff inflation, the first thing to do is
1) to listen for equal and bilateral breath sounds as the patient is being ventilated, and listen to epigastrium gurgling sounds over stomach
2) In addition to point 1, observe for adequate and equal chest expansion.

Question 5

Combination of decreased breath sounds and decreased chest wall movement on the left side indicate?

Answer 5

There are 2 reasons-
1) right main stem intubation- which is corrected by slowly withdrawing the tube while listening for return of left side breath sounds
2) pre-existing pathology in the left lung. Such as atelectasis, pleural effusion.

Question 6

Felxible light wand lights on which anatomical landmark?

Answer 6

Just above the Thyroid cartilage.

Question 7

Do we take chest x-ray before securing the ETT or after to avoid any mishap?

Answer 7

It is always after. Other techniques such as equal chest and bilateral air entry should be confirmed via stethoscope and by visualizing at the same time. Later after re-oxygenation and tube stabilization an X-ray can be done to confirm position.

Question 8

What is the most common complication of emergency intubation?

Answer 8

Tissue trauma

Question 9

The most serious complication of emergency intubation is?

Answer 9

Acute Hypoxemia, hypercapnia, bradycardia, and cardiac arrest. All of these can be avoided by ventilating and oxygenating the patient before, during and after intubation and strictly adhering to intubation time limits (30 seconds).

Question 10

In addition to minimizing complication by adequate ventilation and oxygenation and adhering to proper time limit during intubation what are other steps can minimize the complications?

Answer 10

Sedation and anesthesia can reduce complication and facilitate intubation in semi-comatose(unconscious) or combative patient(awake and fighting). Muscle relaxant is given to pt who cannot be controlled by sedation alone. Rt has to mindful that patient when given paralyzed via muscle relaxant has no ability to compensate for hypoxemia or hypercapnia, hence he should be adequately BVM all the time.

Question 11

When do we use a boogie?

Answer 11

When difficult airway is anticipated, specially when you can see the glottic but having difficulties passing the ETT through the glottic opening.

Question 12

Nasotracheal intubation can be done blindly and under direct visualization? True or false

Answer 12

True; blindly when the person is awake and breathing spontaneously.
For direct- visualization is achieved by standard or flexible laryngoscope.

*equipement prep, patient position and preoxygenation is same as in oral intubation. Except 3% lidocaine and 0.25% phenyl-e-rhinestone are applied to the nasal mucosa for local anesthesia and vasoconstriction of the the nasal passage.

Question 13

To help advance the tube past the vocal cord in nasal intubation neck flexion or neck extension would be helpful?

Answer 13

Neck flexion is helpful to advance the tube pass vocal cord. Confirmation and stabilization of tube is same as oral intubation.

Question 14

Blind passage in nasal intubation is in which position?

Answer 14

Supine or sitting position.The breath sounds become louder and more tubular when the tube passes through the larynx. Successful passage of the tube passes through the larynx usually is indicated by a harsh cough, followed by vocal silence. If sound disappears, the tube is in the esophagus or moving towards the esophagus.

Question 15

What is the difference between tracheotomy and tracheostomy?

Answer 15

The one with is means the hole made for the procedure.
The procedure means tracheotomy

Question 16

Tracheotomy is the preffered …….route for overcoming…….or……..with pts with poor airway protective reflexes.

Answer 16

Primary, upper airway obstruction or trauma. These also mean the indication for trach.
The other indications is the Continous need for artificial airway after oral or nasal intubation. If the pt still needs artificial airway after approx 7 to 14 days, then tracheostomy is commonly considered.

Question 17

What is one main benefit of tracheostomy versus oral or nasal intubation.

Answer 17

Elimination of vocal cord injury. The others include increased pt comfort, less need for deep sedation, easier removal of secretion, decreased work of breathing, and potentially shorter weaning time.

Question 18

Factors to consider in switching from ETT to trach

Answer 18

Prolonged time on artificial reliance, pts tolerance of ETT, pts overall condition including cardiovascular, infection status and nutritional, pts ability to tolerate a surgical procedure, relative risks of continued endotracheal intubation vs. trach.

Question 19

Patients translaryngeally intubated and mechanically ventilated for respiratory failure, based on what points are the decision made for the need for trach

Answer 19

1- if pt still needs artificial airway after 7-14 days
2- daily re-evaluation of duration of intubation, if extubation looks probable within 7-10 days of intubation then continue translaryngeal intubation, but extubation doesnot look probable then consider trach
3- on day 7- is extubation probable in next 5-7 days? Yes- then continue translaryngeal intubation, if not then consider trach.
4- more than 21 days for sure consider trach.

Above info based on the algorithm on page 767 eg as 12th edition.

Question 20

What is the procedure for surgical tracheotomy?

Answer 20

1-local anesthetic and mild sedation if pts condition permits
2- if ETT in place, do not remove it until just before the insertion of TT
3- This keeps the pt ventilated and gives additional stability to the trachea
4- in traditional surgical tracheostomy the incision is made in the neck between 2nd and 3rd tracheal ring horizontally or through the 2nd and 3rd ring vertically. Very little cartilage is removed to promote Better closure after decannulation.

Question 21

What is the procedure for dilation tracheotomy?

Answer 21

Initial steps to prepare patient are similar steps as in the traditional tracheotomy. (Local anesthesia + sedation)
In traditional trach- ETT is removed JUST BEFORE the insertion of TT, and in Dilation trach- ETT is withdrawn/retracted after the dissection to the anterior wall, to keep the tip of the tube inside the larynx.

Question 22

During tracheotomy, is there chances for leak around the ETT cuff? Big small?

Answer 22

Yes, large leak. Which requires adjustment of the mechanical ventilator. If the pt condition is such that he cannot tolerate large leak and the mechanical ventilator setting adjustment is not enough, then percutaneous dilation trach should be avoided and surgical procedure should be done.

Question 23

Where is the insertion made for percutaneous dilation?

Answer 23

Either between the cricoid and the 1st tracheal ring, or
Between the 1st and 2nd tracheal ring.

Question 24

What is an alternative of using multiple dilators in percutaneous dilation?

Answer 24

Instead of using multiple dilators, ascending to larger dilator and then slipping TT over it, an alternative is to use single dilator with increasing diameter from the proximal to the distal end.

Question 25

Tracheotomy can be done using…….or ……. for vision?

Answer 25

The procedure can be performed under direct vision with bronchoscope passing through the ETT or an LMA.

• that means bronchoscope can be passed through both ETT and LMA.

Question 26

Which one is better, percutaneous dilatation or surgical trach?

Answer 26

Percutaneous Dilatation is rapid, has fewer complications from the surgical site and better cosmetic appearance after decannulation.

Question 27

What are the conta-indications for dilatation percutaneous?

Answer 27

Absolute-

When there is a need for emergency surgical airway

Relative-

children younger than 12 years of age
Abnormal anatomy, poor landmarks secondary to body habitual, occluding thyroid mass.
PEEP less than 15cmH2O (i think because he is getting better, so he doesn’t need a prolonged support by doing trach)
Coagulopathy
Pulsating blood vessel over the tracheotomy site
History of difficult intubation
Infection, burn, or malignancy at tracheotomy site.

Question 28

Comparison of percutaneous tracheotomy and open surgical tracheotomy

Answer 28

Percutaneous tracheotomy

Advantages
May be done in intensive care unit
Sedation and local anesthetic given
Stoma usually stabilizes in 5 days

Disadvantages
Not done in children younger than 12 yrs
May be difficult to insert because of calcified cartilaginous rings

Open surgical tracheotomy

Advantages
Done in patients with poor landmarks because of abnormal anatomy or body habitus.
May be done emergently
Done in children younger than 12 years,

Disadvantages
General anesthesia given.
Stoma usually takes longer to stabilize (7-10 days)
Usually done in operating room.

Question 29

How do we know the TT size is correct for the pt?

Answer 29

If it occupies two-thirds to three-quarters of the internal tracheal diameter.

Question 30

TT with inner cannulas using which sizing?

Answer 30

Jackson sizing

Question 31

TT Is selected with the age category, and within the age category the exact size of the tube chosen depends on the patients height, weight, and airway anatomy. True or false

Answer 31

True

Question 32

To choose TT that fits a patient properly, it is important to consider not only the internal and external diameter of the tube but also the length and shape of the tube. True or false.

Answer 32

True.

Question 33

What is the main difference between TT?

Answer 33

Length
Adult is longer than pediatric
Pediatric is longer than neonatal.

Typical pediatric size=
(16+ age)/4
Or
(Age/4)+4

Question 34

What is laryngectomy?

Answer 34

Removal of voice box/larynx. Usually done for treating laryngeal cancer. In this case the trachea is attached to the stoma. Pt breathes through permanent stoma.

Question 35

What is tranesophageal puncture (TEP)?

Answer 35

It is when a small opening between the posterior wall of the trachea and esophagus is made. The surgeon inserts a small device called prosthesis, that has a one way valve. This device allows the patient to speak when the pt occludes the stoma during EXHALATION. Some use a thumb and some have an adjustable valve attached. So basically prosthesis aids in speaking during exhalation

Question 36

Is there any other method, apart from occluding the stoma and use of prosthesis for the laryngectomy pt to speak?

Answer 36

Yes, by holding an electro-larynx against the the throat. This is Battery operated device, that creates vibrations that are transmitted through the pharynx and mouth to produce a voice.

Question 37

What are the risk of laryngectomy?

Answer 37

Hematoma
Wound infection
Fistulas
Stoma stenosis(narrowing of the stoma due to scarring)
Leaking around tracheoesophageal prosthesis
Difficulty swallowing and eating
Problems speaking.

Question 38

The laryngectomy can be complete or partial. Explain

Answer 38

Yes, if it is total, then there is no communication between the upper airway and the trachea. The trachea is attached to the stoma directly as the voice box is removed. And prosthesis is inserted through TEP.
In case if the laryngectomy is partial, the there is communication between the upper airway and the trachea.

When a pt has total laryngectomy and requires BVM, then we BVM over the stoma using a pediatric mask to fit closely.
When a pt has partial laryngectomy and requires BVM, then BVM through the nose and mouth with standard adult mask, as there is still communication between the upper airway and trachea.

Question 39

What is the risk associated when the TT or artificial airway doesnot conform exactly as patients anatomy?

Answer 39

Ischemia and ulceration may result, due to pressure on soft tissue.

Question 40

When artificial airway is used, there can be what kind of traumas?

Answer 40

Patient moving head, or if the tube is moved, friction like injuries can result. TT does not pass the larynx, structural injury resulting from these airways is limited to tracheal sites (not upper airway). Laryngeal dysfunction may occur secondary to a lack of stimulation from airflow or restricted movement due to equipment.

Question 41

What are the most common laryngeal injuries associated with ETT intubation?

Answer 41

Glottic edema- occurs as a result of pressure from the ETT or trauma during intubation (transient, they are of primary concern after extubation, as swelling can worsen over 24 hrs after extubation, hence pts should be evaluated periodically for delayed development of glottic edema). Symptoms include hoarseness and stridor.

Vocal cord inflammation- occurs as a result of pressure from the ETT or trauma during intubation (transient, they are of primary concern after extubation, as swelling can worsen over 24 hrs after extubation, hence pts should be evaluated periodically for delayed development of glottic edema). Symptoms include hoarseness and stridor.

Laryngeal or vocal cord ulceration- this may cause hoarseness soon after extubation, symptoms resolve spontaneously and no Tx indicated.

Vocal cord polyps or granulomas-they develop more slowly, over weeks or months. Symptoms include difficulty swallowing, hoarseness and stridor. If symptoms tend to be more severe or persistent, the polyp or granulomas may be removed surgically.

Question 42

What the less common and more serious laryngeal injuries associated with ETT intubation?

Answer 42

Vocal cord paralysis- this is likely in extubated pts with hoarseness and stridor that doesnot resolve with Tx or time. However, in some pts the symptoms may resolve within 24 hrs and full movement of the vocal cords can return over several days. If the obstructive symptoms continue, tracheotomy may be indicated.

Laryngeal stenosis- occurs when the normal tissue of the larynx is replaced by scar tissue, which causes stricture and decreased mobility. Symptoms are similar to vocal cord paralysis- stridor and hoarseness. Laryngeal stenosis DOESNOT RESOLVE SPONTANEOUSLY, surgical correction is usually required. Some pt require permanent tracheostomy.

Question 43

What is the difference between laryngeal stenosis and glottic stenosis?

Answer 43

Laryngeal Stenosis: Laryngeal stenosis is a broader term that refers to the narrowing of any part of the larynx, which includes the vocal cords (glottis), subglottic region (below the vocal cords), and supraglottic region (above the vocal cords). Laryngeal stenosis can occur due to various causes, including scar tissue formation from trauma, inflammation, previous surgeries, infections, or congenital abnormalities. This condition can affect breathing and voice function.

Glottic Stenosis: Glottic stenosis specifically refers to the narrowing of the glottic area, which is the space between the vocal cords. The glottis is the most critical part of the larynx for controlling airflow and producing sound when the vocal cords vibrate. Glottic stenosis can result from factors such as injury, inflammation, infections, or surgical procedures involving the vocal cords

Question 44

What is the primary symptom of glottic edema and vocal cord inflammation?

Answer 44

Hoarseness and stridor.

Hoarseness is common in most extubated pts. And usually resolves quickly.

Stridor is more serious than hoarseness, indicating significant decrease in the diameter of the airway. Stridor is treated with racemic epinephrine 2.25% solution or levoepinephrine aerosol 1:1000. The goal is to reduce edema by mucosal vasoconstriction. A steroid may be added to further reduce the inflammation as well. These techniques are more in children than adults.

Question 45

How does mucosal vasoconstriction help in resolving edema?

Answer 45

Mucosal vasoconstriction refers to the narrowing of blood vessels within the mucous membranes that line the airway. This process involves the contraction of the smooth muscle surrounding these blood vessels. When these blood vessels constrict, the blood flow to the area is reduced. This mechanism has several effects that contribute to reducing swelling or edema in the airway:

Reduced Blood Flow: Constricted blood vessels allow less blood to flow to the area. This means that fewer inflammatory cells, fluid, and proteins can reach the inflamed or edematous tissue, helping to limit the extent of the swelling.
Decreased Fluid Leakage: Inflammation and swelling often involve the leakage of fluid from blood vessels into the surrounding tissue. Vasoconstriction helps to minimize this fluid leakage, which can lead to a reduction in tissue swelling.
Decreased Inflammatory Response: Blood vessels play a role in delivering immune cells and signaling molecules to areas of inflammation. By limiting blood flow through vasoconstriction, the influx of immune cells and inflammatory mediators is also reduced, which can help to dampen the overall inflammatory response.
Increased Clearance: Vasoconstriction can enhance the efficiency of the lymphatic system, which helps to clear excess fluid and waste products from tissues. This improved clearance can aid in resolving edema and swelling.
In the context of the respiratory tract and airway, mucosal vasoconstriction is often used as a therapeutic approach to manage conditions like swelling, inflammation, or edema that can obstruct the airway and lead to breathing difficulties. Medications like epinephrine (or its derivatives like racemic epinephrine and levoepinephrine) are vasoconstrictors that are administered through inhalation. When these medications are inhaled, they act on the blood vessels in the respiratory mucosa to constrict them, thereby reducing swelling and improving airflow.

It’s important to note that while vasoconstriction can be helpful in the short term to manage acute conditions, it’s not a definitive treatment for the underlying cause of swelling or edema. Addressing the root cause of the inflammation or edema is essential for long-term management.

Question 46

In patient who have previous history of failed extubation due to glottic edema or who have had a prolonged intubation, what approach should be taken to avoid the expected glottic edema?

Answer 46

Intravaneous steroids and/or diuretics may be given 24hrs before extubation.

Question 47

Name all the tracheal lesions?

Answer 47

Granulomas

Tracheomalacia-It is the softening of the cartilaginous rings, which causes collapse of the trachea during inspiration and expiration. It appears as a variable obstruction with different inspiratory and expiratory pattern. Eg: variable extra thoracic Obstruction, when the extra thoracic trachea is floppy, the flow volume loop shows flattening of the inspiratory limb and the expiratory limb is norma.It can occur separately or with tracheal stenosis.

Tracheal stenosis- It is the narrowing of the lumen of the TRACHEA, which can occur as fibrotic scarring, causing the airway to narrow. In pt with ETT, most often occurs at the cuffs site. In pt with TT, often occurs at the cuff site, tube tip or stoma sites, out of which stoma site is the most common. Stenosis at stoma site is associated with too large a stoma, infection of the stoma, movement of the tube, frequent tube changes, and advanced age. It appears as fixed obstructive pattern, with flattening of both the inspiratory and the expiratory limbs of the flow volume loop.It can occur separately or with tracheal malacia.
Tracheoesophageal fistulas
Tracheoinnominate artery fistulas

Question 48

What are the less common but more serious type of tracheal lesions?

Answer 48

Tracheoesophageal fistula- It is the direct communication between the trachea and the esophagus. It is a rare complication for both ETT intubation and Tracheotomy. If someone has this spontaneously after tracheotomy, then it is due to incorrect technique. Later development is related to sepsis(aspiration pneumonia, enters lungs, and the blood stream), malnutrition, tracheal erosion from the cuff and tube, esophageal erosion from the nasogastric tube. Diagnosis based on aspiration history, abdominal distention (air forced into the esophagus during +ve MV), and endoscopic examination of the trachea and esophagus. Tx- surgical closure of the defect.
Tracheoinnominate artery fistula- this condition occurs when a TT causes tissue erosion through the innominate artery. Resulting in massive hemorrhage and most cases death. This is also a rare complication, which is caused by improper low positioning of the stoma or excessive movement of the tube. Pulsation of the TT may be the only clue before the actual hemorrhage. When hemorrhage begins, hyperinflation of the cuff may slow the bleeding, but the patient still needs surgical intervention. Even with proper corrective action, only 25% of patients who develop this serious complication survive.

Question 49

What is a possible sign of tracheal damage before extubation?

Answer 49

Difficulty in sealing the trachea with the cuff
Evidence of tracheal dilation on chest xray

Question 50

What is the possible sign and symptoms of postextubation problems?

Answer 50

Difficulty with expectoration
Dyspnea
Stridor

All these problems occur acutely, but they may also develop over several months and are only present when the radius is reduced by 50% to 75%. Dyspnea at rest may not be seen until the diameter of the trachea is less than 5mm.

Question 51

How is tracheal lesions quantified/diagnosed?

Answer 51

Tomography
Fluoroscopy
Pulmonary function test

Question 52

How are injuries due to artificial airways quantified/diagnosed(specially post extubation)?

Answer 52

Physical examination
Air tomography
Fluoroscopy
Laryngoscopy
Bronchoscopy
MRI
PFT studies

Question 53

In case of tracheal lesion, what treatments can be given?

Answer 53

Laser- if the lesion is small, as the Tx depends in the length and circumference of the lesion.

If fewer than 3 tracheal rings involved- resection and end-to-end anastomosis may be indicated.
If more than 3 tracheal rings- staged repair may be required.
Stents may be placed to maintain the potency of the airway.

Question 54

How to prevent all the complication in ETT intubation and TT?

Answer 54

Minimize movement of the tube- which is the primary reason for injury.
Use of sedation
Nasotracheal are easier to stabilize and move lesser than orotracheal tubes.
Use of swivel adapters- to minimize traction when respiratory equipments are used with tracheostomies
T-collar for all O2 therapies
Selection of correct size airway.
ETT and TT once in place should not be changed unless necessary.
Discourage patient from unnecessary coughing or efforts for talking, as this can help minimize the vocal cord closure around the ETT.
Maintaining cuff pressures to 20-30 cmH2O, for ETT and TT, to minimize tracheal wall injury, if the airway is in place solely for suctioning or to bypass an obstruction, a cuff may not be needed.

Question 55

True or false
Infection of Tracheal stoma is linked to tracheal stenosis?

Answer 55

True, due to infected secretions, tracheitis and mucosal destruction happens. Sterile technique is very important to use when doing TT suctioning or cleaning.

Question 56

How is good Tracheostomy care performed?

Answer 56

Use of aseptic cleaning of stoma using sterile normal saline for routine care and soiled tracheostomy dressing should be changed as needed.
If sutures are present, it is recommended to remove them ideally by 5 to 7 days after tracheostomy was performed.
In case of pressure injury- use hydro-colloid dressing under the flange.

Question 57

What is the most common way to secure the ETT?

Answer 57

Using Tape, silk tape for shorter time, cloth tape for longer time. However, several commercial stabilizers can result in less skinndamage, tube movement, and self extubation than using tape.

Question 58

How many finger gap should be kept to secure the TT via tube holder

Answer 58

Skin damage can be minimized by keeping the ties loose enough to slip one finger underneath easily.

Question 59

Proper placement of the tube tip of ETT or TT should be where?

Answer 59

3-5 cm above carina, or between the second and fourth tracheal rings.

Question 60

What happens to the ETT during flexion and extension of the neck.

Answer 60

Flexion- ETT moves towards the carina
Extension- ETT moves/pulled towards the larynx.

Question 61

Does the vocal cord move with a pt having ETT in place? What abt airflow? And what abt TT

Answer 61

None can move.
Standard TT allows for movement of vocal cord but prevent airflow

Question 62

For conscious pt, there are methods and type of TT that can allow for speaking. Mention and describe few.

Answer 62

Talking TT- where the gas flow through a separate inlet, and escapes just above the TT, allowing phonation. Issue is when the outlet is occluded with secretion. As well as high gas flow rates causes dryness and irritation. Lastly, on new tracheostomy, this method causes air leaks due to continous gas flow.

Fenestarted TT- this type has a special speech cannula that allows ventilator dependant patients to speak with cuff fully inflated. In this type of TT, the speech cannula is inserted during inhalation,the flap valve(proximal) opens and the flexible bubble valve expands blocking the fenestrations. During exhalation the flap valve closes and the bubble valve collapses which allows air to pass through the fenestrations, so that the pt can speak.

Speaking valve(one way valve), alternative to fenestrations speaking TT- this type of TT is attached on the external opening of TT(proximal). With This device in place and the TT cuff deflated, the pt inhales around and through the tube and exhales only around the tube through the larynx. Speech is coordinated with exhalation through the larynx. A pt who is a good candidate for a speaking valve should be stable and able to communicate and has low risk of aspiration. There are several type of speaking valve available, they can be used on spontaneously breathing or ventilator-dependent pts. When using the speaking valve,the cuff on the tube must be completely deflated to allow air flow around the tube. This deflation of the cuff causes a leak on inspiration and a decrease in tidal volume delivery during MECHANICAL VENTILATION. However, an increase in the set tidal volume during initial trials of the valve should compensate for this. During the initial placement of the speaking valve, the pts ability to exhale around the TT should be assessed by measuring the tracheal pressure during the exhalation with the valve in place. If the tracheal pressure is greater than 5cmH2O, it may indicate that there is increased resistance during exhalation, which is due to the TT size relative to the trachea, or the tube position, or inadequate cuff deflation or upper airway abnormality. Solution is that the tube needs to be changed to a smaller size, or to a cuff less tube, or to a tube with TTS cuff. Then the speaking valve can be placed again, and the tracheal pressure is measured again. Hence, a speaking valve can aid in communication and can safely be used if the tracheal pressure is less than 5cmH2O.

Question 63

Why tracheal airways increases the incidence of pulmonary infection?

Answer 63

Bypassing the upper airway- filtration
Increased aspiration of pharyngeal secretions
Contaminated equipment or solutions
Impaired mucociliary clearance in trachea
Increased mucosal damage owing to tube or suctioning
Ineffective clearance via cough.

Question 64

What are the various techniques to decrease pharyngeal aspiration?

Answer 64

1- elevation of bed to 30 degrees to prevent reflux
2- use of medications for stress ulcer prophylaxis, such as sucralfate, that maintains normal gastric ph.
3- continuous aspiration of sub glottic secretions.

Question 65

What is the most common cause of airway obstruction in critically ill patient?

Answer 65

Retained secretions.

Question 66

Name one non invasive technique for clearing secretions

Answer 66

Apart from close and open suctioning which is invasive, mechanical insulator-exsufflator (cough assist), primarily used to facilitate secretion clearance in pts with impaired cough, specially those with neuromuscular disease such as ALS, spinal muscular atrophy(SMA), muscular dystrophy(MD).

Question 67

Mention two reasons why cuff pressure is used(within the acceptable range)?

Answer 67

To seal the airway for mechanical ventilation
To prevent or minimize aspiration
But if the cuff pressure is higher than the range, then tracheal stenosis and tracheopmalacia are associated with the cuff use. If it exceeds the mucosal perfusion pressure then ischemia, necrosis, ulceration, and exposure of cartilage may result.

Question 68

What is the norm in context to volume and pressure?

Answer 68

Since 1970, high residual volume and low pressure cuff is the norm. The cuff doesnt need to be fully inflated, as the diameter of the cuff is greater than the diameter of the trachea, resulting in less cuff pressure. These cuff transmits less pressure on the tracheal wall than the older designs. However low pressure cuffs doesnt reduce the incidence of tracheal damage, as they have not entirely eliminated the problem.

Question 69

True or false. Minimal occluding volume and minimal leak inflation techniques are no longer recommended because they increase the risk of silent aspiration.

Answer 69

True.

Question 70

High cuff pressures are result of??

Answer 70

As machine as designed to add or withdraw pressure. If the pressure increases it means that the need to over-inflate the cuff to seal the airway is required. Which is due to smaller tube selection for pts trachea.
Or
The position of the tube is too high in the trachea
Or
Pt has developed tracheaomalacia (softening of the tracheal tissue).
Or
High airway pressures generated by the MV, which is due to maintaining adequate tracheal seal by addition of air.

Question 71

Which type of cuff is designed to seal the trachea with atmospheric pressure?

Answer 71

Foam cuff- commonly used for only pt who already developed tracheal injury. This makes mechanical ventilation difficult and doesnot minimize aspiration, however it minimizes tracheal mucosal trauma.

Before insertion the foam cuff must be deflated completely. Once inserted and in position, the pilot ballon tube is opened to atmosphere and the foam expands against the wall of trachea and stops on its own as it encounters tracheal wall. If too much air leaks and volume loss occurs around the tube, then the pilot tube is placed in line with the ETT.

Question 72

Explain TTS

Answer 72

It is an alternative cuff design, apart from foam cuff. The cuff is made of porous silicone material. And can be inflated only with sterile water and not air. This is a low volume, high pressure cuff designed to maximize airflow around the tube when it is deflated. It should be inflated only intermittently for airway protection, or short term ventilation.

Question 73

Ultra thin polyurethane cuffs helps in….

Answer 73

Prevention of silent aspiration and thereby VAP. It is cylinder sharp or inverted pear shape design cuff.

Question 74

True or false
Keeping cuff pressure between 20-30 cm H2O helps minimize aspiration and injury?

Answer 74

True

Question 75

True or false
Aspiration is more common in spontaneously breathing pt than in pts receiving positive pressure ventilation

Answer 75

True- this is because the movement of pharyngeal secretions past the cuff during the negative pressure phase of a spontaneous inspiration.

Question 76

Which test helps determine whether aspiration is occurring?

Answer 76

Swallowing test. Blue color is added t pts feeding or by pt swallowing small amount of blue food color in water. If patient when suctioned, a blue color or tinge of it found then he is aspirating if not then not aspirating. But sometimes this test is false negative, the pt is actually aspirating but no blue color found on suctioning, then we proceed towards the modified barium swallowing test for surely concluding if he is aspirating.

If pt aspirating then we switch the tube to specialized ETT, to suction above the cuff, if unsuccessful to switch then we perform oropharyngeal suctioning. Bed should be elevated 30 degrees or more. Feeding tube can be inserted in duodenum by confirming position by imaging.

Question 77

True or false
The use of slightly higher cuff pressure during and after feedings may minimize aspiration

Answer 77

True

Question 78

What is the PPE for Trach care/change?

Answer 78

Goggles and mask or face shield.
Other equipement include- sterile gloves
Suction equipment
Resus bag
Oxygen
Trach care kit (basin and brush)
Spare inner cannula
Hydrogen peroxide and sterile water
Cotton tip
Precut gauze or precut foam dressing
Tube tie or Velcro
Another TT of same size
New TT with component parts and another tube one size smaller
Water soluble lubricant
10-12 ml syringe

Question 79

What are the steps for trach care.

Answer 79

1- assemble and check equipment
2-explain the procedure to the patient.
3- suction pt- TT is shorter than ETT, so a catheter is inserted just to the end of TT, to avoid mucosal injury to the carina.
4- clean inner cannula- if present and non disposable
5- clean and examine the stoma site- clean the stoma site with normal saline, then place a clean dressing either foam or normal. If stoma site is swollen, red, with pus, foul smell—>inform the physician
6- replace clean inner cannula- if present, if marked disposable then insert new.
7-reassess pt- all the vitals. Breath sounds etc.

• an extra trach tube of the same size and another one size smaller should be kept readily available in or near the pts room in case of accidental decannulation.

Question 80

What are the steps for changing tracheostomy tube.

Answer 80

If a tube needs to be changed for some reason, like due to mucus plus, damage to cuff, different size needed, and if all this encounters before the stoma heals which is before 7-10 days, then it is best done by the physician.
Intubation equipment are always kept handy.
Step 1- assemble and prepare equipment- same size new tube and an extra small size tube (in case of partial closure of stoma site and difficulty reinserting same size)with water soluble lubricant.
Step 2- explain procedure to patient
Step 3- prepare equipment- sterile technique must always be maintained for the distal portion of the cannula which goes into trachea. The inner cannula is removed and placed on sterile surface. The obturator is inserted. The tie is attached to one side of the flange of the tube. The cuff is inflated and deflated, leak check is done. Lubricant applied to distal portion of cannula.
Step 4- Prepare patient- pts neck extended so the stoma is accessible. Pt suctioned and hyper-oxygenated.
Step 5- remove old tube- the tie is cut. Cuff deflated and tube removed anatomically. Stoma site inspected of any granulomas or ulceration.
Step 6- insert new tube, confirm placement and assess patient. New tube picked by proximal portion(flange). The tip of the obturator is inserted in the stoma and tube is advanced. While holding the flange of the tube against the neck, the obturator should be removed immediately. Assess airflow through the tube.pt assessed for proper tube placement and tolerance of the procedure. If insertion of new tube is difficult, stand by tube(one size smaller) is inserted.
Step 7- secure tube- inner cannula if present is inserted. If a cuff is present, it should be inflated to appropriate pressure with appropriate medium(air or sterile water in case of TTS cuff). Airflow reassessed and O2 therapy or ventilator connected.
Step 8- reassess pt- suctioning may be required again. Vitals checked. And tolerance of pt.

Question 81

What are the 3 airway emergency situations?

Answer 81

Tube obstruction
Cuff leaks
Unplanned extubation

Question 82

What are the clinical signs seen during airway emergencies

Answer 82

Degrees of respiratory distress
Changes in breath sounds- decreased breath sounds are common findings in airway emergencies, which can be due to tube obstruction, which is the most common causes of airway emergencies
Air movement through the mouth
Changes in pressure if pt mechanically ventilated.

Question 83

Which is one of the most common cause of airway emergencies?

Answer 83

Tube obstruction—> which can be due to
1- kinking, pt biting on tube,
2- herniation of the cuff over the tube tip,
3- obstruction of the tube orifice against the tracheal wall.
4- mucous plugging

Question 84

Important note on tube obstruction

Answer 84

1) Tube obstruction can be partial or full, and pt can either spontaneously breathing or on MV.

Spontaneously breathing pt:

Tube obstruction partial- pt exhibits decreased breath sounds and decreased airflow through the tube.
Complete obstruction- pt exhibits severe distress, no breath sounds heard, no gas flow through the tube.

MV pt:

Tube obstruction partial-
if pt receiving volume control ventilation, the peak inspiratory pressure increases, causing the High pressure alarm to sound.
If pt receiving pressure control ventilation, the delivered tidal volumes decreases.

Complete tube obstruction- pt exhibits severe distress, no breath sounds heard, no gas flow through the tube.

2) Tube obstruction can also be due to kinking or wrong position of tube against the tracheal wall. It can be reversed by moving the pts head and neck or repositioning the tube.

3) herniation of the cuff over the tube-deflating the cuff in such cases relieves the obstruction.

4) still an obstruction due to an unknown reason- pass the suction catheter through the tube. The distance covered, or the place it stops helps to determine the site of obstruction. If the catheter does not travel much beyond the tube tip and insertion does not cause coughing the likely problem is a herniated cuff or mucous plug. If mucous plug, it can be removed using suction catheter, in case of mucous plus instillation of sterile normal saline into the tube to facilitate mobilizing the plug is helpful and not recommended routinely otherwise. In addition, if mucous plug is thick, then a mucous shaving device is inserted. It has a ballon which is inflated once inside the ett and it scraps all the mucous from inside the tube as withdrawn slowly.
5) nothing works- then the airway should be removed and replaced. Be mindful if the pt is fresh trach(4-5 days), then the sutures are still there, which is pulled during change of tube to keep the stoma open. In the process of replacing airway, after obstruction removed, pt should be stored with ventilation and oxygenation. If trach then stoma should be covered with a gauze pad and pt should be manually ventilated with a mask. Now when oxygenation and ventilation stored, insert the airway.

Question 85

Cuff leaks causes…

Answer 85

System leak, resulting in loss of delivered volume or decreased inspiratory pressure or both.

Question 86

A small leak can noticed….and large leak can be noticed…

Answer 86

Small- is slowly. My noting the decreasing cuff pressures over time. It can also be from the pilot valve in the pilot balloon, which can be repaired by replacement of new valve, which is an alternative until tube changed.
Large- due to ruptured cuff. Much rapid onset. Breath sounds are decreased. However a spontaneously breathing pt has air movement through the tube. If the pt receiving positive pressure ventilation and there is cuff leak, the airflow is felt at the mouth. Which makes sense, as air is also escaping upwards due to lost of seal.
Ruptured cuff requires extubation and reintubation urgently if pt on MV. Can be done via standard reintubation or ETT exchanger(cook catheter).
Important note: before coming to a conclusion that there is a cuff leak, the depth of the tube and the size of the tube should be checked, because if the ETT is positioned too high in the trachea, and near the glottic opening, it can mimic a cuff leak. This tube would look shallow. In this case, advance the tube slightly and reassess the leak.

Question 87

True or false

Low pressure cuff exerts high pressure at high inflation volumes.

Answer 87

True. The need for high volume for a good seal usually indicates that the ETT or TT is too small for the pt. And if more and more air is blown, probably, tracheomalacia has encountered.

Question 88

If a pt have encountered tracheomalacia due to high pressure cuff, how can that be corrected

Answer 88

High pressure in the cuff, leads to tracheomalacia, and further dilation of trachea, which now requires even more high pressure to seal the cuff. Now the problem is the trachea is damaged and the pt needs the tube, the smaller tube should be replaced with larger one to allow a good seal at the acceptable cuff pressures. It is necessary to reposition the tube so that the cuff site is not the same as the original damaged site.

Question 89

How do we know the tube is out?

Answer 89

1- decreased breath sounds
2- decreased airflow through the tube
3- the ability to pass a catheter to its full length without meeting an obstruction or eliciting a cough.
4- with positive pressure ventilation, airflow through the mouth or into the stomach may be heard and a decrease in delivered volumes or pressures occurs.

In these cases tube should be completely removed and ventilatory support provided with BVM until pt can be reintubation,or the TT reinserted.

Question 90

True or false
Resus efforts are same in pts with a tracheostomy versus laryngectomy.

Answer 90

False, it differs greatly.
In Tracheostomy- cover the stoma with gauze, provide manual ventilation to upper airway.
In laryngectomy- provide manual ventilation via a small mask to the stoma site, because there is no longer communication between upper airway and lower airway.
In partial laryngectomy- may be able to ventilate via the upper airway because the separation was not complete. Attempts at both routes may be necessary to determine which approach results in the best ventilation.

Question 91

Permanent tracheostomy is common in pts with?

Answer 91

Surgically treated throat or laryngeal cancer. And pts requiring long term positive pressure ventilation.

Question 92

When is pt ready for extubation?

Answer 92

When the reason for intubation, original need for artificial airway no longer exists.

Question 93

Basic assessments for positive extubation

Answer 93

1- ability to maintain adequate oxygenation and ventilation without support
2- ability of the pt to protect airway by the presence of a gag reflex.
3- ability to manage secretions based on cough strength
4- the quantity and thickness of secretions
5- the patency of the upper airway.

If a pt has was admitted due to resp condition, and that has resolved, he can be extubated but if the decision for extubation is not same as discontinuing MV.
Discontinue MV- resp condition has resolved
Discontinuing airway or ready for extubation- above reasons.
If the resp condition has resolved but the upper airway problem is still present, for eg no gag reflex, then the pt needs tracheostomy and the ventilator can be removed before extubation.

Question 94

Explain the cuff leak test, which is done to check the glottic edema or presence of stridor post extubation for those intubated more than 6 days.

Answer 94

To predict the occurrence of glottic edema, the cuff is totally deflated. The leak around the tube is assessed during positive pressure ventilation in a volume controlled mode.
The percent of cuff leak should be approx 15% or greater.
Patient expiratory tidal volume is 500mls with cuff inflated, on deflation it is 400mls, difference is 100mls. 100mls is divided by 500mls=20%, which suggest no upper airway edema or obstruction.

Question 95

Steps involved in oro and Nasotracheal extubation.

Answer 95

Step 1- assemble needed equipments
Suction catheter-2 correct size
Sterile Gloves
Tonsil suction
10-12ml syringe
O2 and aerosol therapy equipment
BVM and mask
Aerosol nebulizer with racemic epinephrine and normal saline
All intubation equipments
Step 2- suction ETT and pharynx above cuff- now discard the first suction kit
Step 3- oxygenate pt after suctioning- 100% for 5 minutes.
Step4- deflate cuff- while applying positive pressure, to push the any pooled secretion above the cuff in to the oropharynx which is suctioned through yankeur. Another important thing now is that the RT should listen for an audible leak around the tube. If no audible tube after deflation, then the physician should be informed.
Step 5- remove tube- while doing this we have to make sure the vocal cord are maximally abducted and secretions are not aspirated. Abduction of vocal cords can be achieved by 2 methods- one by giving large breath via BVM and tube removed at peak inspiration. Second, the pt coughs and the tube is pulled during the expulsion expiratory phase. This technique also results in maximal abduction of the vocal cords.
Step 6- apply appropriate oxygen and humidity therapy- Pts who have been receiving MV may still require O2 therapy, usually at a higher FiO2. Other pts require some O2. Apply a cool mist immediately after extubation.
Step 7- assess or reassess pt
Auscultation. If stridor present or decreased air entry, indicated upper airway problems.
RR
Breathing pattern
HR
BP
SPO2
Mild hypertension and tachycardia immediately after extubation are common and resolve spontaneously. Racemic epi should be available. ABG should be taken.
If hoarseness, soar throat and cough is seen after extubation, that is normal. But if laryngospasm, which is rare but serious complication is seen then it is problematic. Laryngospasm is transient, lasting several seconds,hence oxygenation should be maintained with high FiO2 and application of positive pressure. But if it doesnt go, neuromuscular agent is to be given, and BVM the pt or reintubation if needed.
To avoid aspiration, due to weak close of vocal cords, oral feeding and specially liquids should be withheld for 24 hrs after extubation. Pt may still aspire with intact gag reflex.
Extubation failure, is defined as sudden need for reinsertion of airway because of airway problems. Often occurs within 8hrs of extubation.