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Airway Management.

Airway Management Therapuetics and diagnositcs

What are the three areas of skill for airway management? Insert and maintain artificial airways. Proficient in airway clearance. Assist physcicians in performing procedures related to airway management.
What are the two categories of airways? Pharyngeal airways Tracheal airways
What are the two types of pharyngeal airways? Oropharyngeal airways (OPA) Nasopharyngeal airways (NPA)
What are the two types of tracheal airways? Endotracheal tubes tracheostomy tubes
The oropharyngeal airway is inserted into the mouth between the lips and teeth
The Oropharyngeal airway is made of metal plastic or rubber
What are the components of an oropharyngeal airway? bit, flange, air channel
What are the indications of an OPA? 1. Prevent airway obstruction by tongue. 2. Bite block 3. Increase effectiveness of bag/mask ventilation
What is a contraindication of an OPA? A conscious patient due to gag reflex
What are complications of the OPA? laryngospasm/cough vomiting/aspiration (do not tape in place) Airway obstruction lip or tongue damage dental damage.
You should never place an OPA in the presense of a space occupying forign body/ lesion obstruction
When you place an OPA you can use a tongue depressor and the tip should be above the epiglottis
The OPA is sized from the angle of the jaw to the corner of the mouth
What are the most common OPA sizes for the adult airway 80 and 90
What are the two types of OPA Berman Guedel
The Berman OPA has a side air channel
The Guedel OPA has a Center air channel
The OPA rests at the base of the tongue
The OPA can be used to help facilitate bag mask ventilation
Aside from facilitating bag mask ventilation a patient should be spontaneously breathing when using an OPA
The nasopharyngeal airway (NPA) is also known as the nasal trumpet
The NPA is inserted into the nose and rests behind the tongue just above the epiglottis
The NPA is made of plastic or rubber
All NPA's have a flange and a beveled end
The bevel on the NPA assists with ease of insertion
What are the indications of the NPA? 1. increase effectiveness of bag/mask ventillation 2. aid with suctioning and bronchoscopy. 3. management of facial anomolies 4. eliminates risk of oral damage.
What are the complications of an NPA laryngospasm/cough nosebleeds sinus infections damage to turbinates cranial vault intubation
The NPA is better tolerated by a conscious patient
The NPA is only used in the adult population
The NPA is prime for seizure patients and is good to assist in NTS
When using the NPA you should be mindful if the patient is on anticoagulant therapy
The NPA is stabilized by the flange
How do you size an NPA? Measure from the tip of the nose to the earlobe
The NPA is sized in French and normal is 26-36 french
The nasopharyngeal airway is placed like so 1. Head tilt 2. h20 soluble lube 3. slowly advance 4. should rest above the epiglottis 5. can observe placement with a tongue depressor
Tracheal intubation tube is inserted through the mouth or nose thru the glottis and into the trachea.
What are the indications of tracheal intubation 1. To bypass an upper airway obstruction. 2. To protect the airway from aspiration. 3. To apply positive pressure ventilation. 4. To aid clearance of secretions 5. To deliver high oxygen concentrations.
You can instill drugs down an ET tube. Generally the dose is 2 X the normal dose
Drugs to be instilled: NAVEL Narcan Atropine Valium/Versed Epinephrine Lidocaine
What are the advantages of oral intubation? 1. Faster,easier, less traumatic, more comfortable. 2. larger tube is tolerated. 3. Easier suctioning. 4. Less airflow resistance. 5. Decreased work of breathing 6. Decreased risk of tube kinking 7. Avoids nasla nad paranasal complications.
What are the disadvantages of oral intubation? Greater risk of self extubation Greater risk of mainstem intubation Risk of tube occlusion from biting Risk of injury to oral structures greater risk of retching, vomiting, and aspiration
Oral intubation is the prefered method during CPR becaus it is fast
The hazards of oral intubation include hypotension (Vagus) Bradycardia aspiration trauma (vocal cord paralysis)
The ET Tube sized in millimeters (inside diameter)
The centimeter markings indicate the placement of the tube
The stylet gives more ridgitity
An adult male et tube size 8 mm
An adult female 7.5 mm
You should aim not to go below 7.5 mm
During nasal intubation the tube is 1/2 size smalelr vs. orally
The advantages of nasal intubation greater comfort less salivation improved swallowing,communication, oral care avoid occlusion from biting and damage to oral structures better stabilization reduced risk of mainstem intubation does not require muscle relaxants or sedatives
The disadvantages of nasal intubation include nasal/paranasal complications more difficult to perform Spontaneous breathing is required for procedure (for blind) Smaller tube is necessary difficulty suctioning increased airflow resistance increased WOB difficulty passing bronchoscope
The curved laryngoscope is the Mcintosh
The Mcntosh laryngscope size 3 or 4 for adults
The Mcintosh is not typically used in neonates
The Mcintosh is designed to fit into the vellecula space and indirectly picks up the epiglttis
The Miller laryngoscope is the straight blade
The miller should directly lift the epiglottis
The miller blade is used in neonates
The average adult size is the 2 or 3 blade
Difficult intubations are reported in 1.5%-15% of patients
Impossible intubations are reported in less than 1% of intubations
Stage I visualization class supraglotic structures, laryngeal inlet, vocal cords
Stage II visualization class epiglottis, laryngeal inlet, posterior aryepiglottic folds
Stage III. Visualization class epiglottis only
Stage IV. visualization class epiglottis not visable
The Lemon Law Look at anatomy Examine the airway Mallempati score (4 stages) Obstructions Neck mobility
Obesity Rapid desaturation, difficult intubation, ventilation
Facial hair hides small chin, can make bagging difficult or impossible
Large teeth Hide airway, obscure tube passage
Jagged teeth lacerate the ballon
The 332 rule mouth open (3 fingers) Mentum to hyoid (3 fingers) Floor of mouth to thyroid cartilage (2 fingers)
Mouth open 3 fingers allows for insertion of tube/laryngoscope
Mentum to hyoid predicts ability to lift tongue into mandible
Floor of mouth to thyroid cartilage if high larynx, airway tucked underbase of tongue hard to visualize
Mappempati socre with patient seated extend neck, open mouth, stick out tonge. Visualize base of tonge, facial pillars, uvula, pharynx
Airway obstructions? Angioedema Hematoma Dentures (remove dentures)
Neck mobility? Surger rheumatoid arthritis osteoarthritis others
The neck mobility cervical spine rigidity: reduces ability to align anatomical axes Inability to mobilize neck can make intubation difficult or impossible
Endotracheal Tube is semirigid and made out of PVC (implant tested by American Society for testing and materials)
Endrol Tube contains loop near proximal end of the tube and controls direction of tube (good for anterior vocal cords)
Components of tube 15 mm adaptor Pilot balloon spring loaded valve murpheys eye radiopaque strip
The pilot balloon shows cuff integrity
The murpheys eye allows for collateral ventillation
The spring loaded valve seals off the cuff
The double lumen tube is also known as the Carlens tube
The Double lumen tube is more difficult to insert and usually uses a bronchoscope
The double lumen tube requires longer suction catheter causes increased airway resistance used for unilateral lung disease used for thoracic surger has a double lumen cuff
The EVAC tube is also known as hi-low tube
The EVAC tube has a suction tube and suction port
What are the supplies for oral intubation? oxygen flow meter and tubing manual resusscitator suction setup oropharyngeal airway laryngoscope endotracheal tubes stylet stethoscope (5 point auscultation) tape 10 cc syringe towels for positioning gloves,gowns,masks eyewear
The lightbulb on laryngoscope is important always have extra batteries and bulbs
The intubated stylet adds rigidity to the tube also called Bougie
What is the sellick maneuver? Cricoid presssure for the anterior vocal cords
Where should the cuff on the ETT rest? 2 to 3 cm below the vocal cords2-4
Where should the tip of the ETT rest? 2-4 cm above the carina
What should the tube depth of the ETT be for the adult male/female? 21-23 cm at the lip
How long should you hyperinflate and hyperoxygenate for the oral intubation procedure? 2 to 3 minutes
What is an extra piece of equipment you may need for nasal intubation? Magill forceps for direct visualization only.
What position should the patient be in for nasal intubation? Direct- supine blind (fowlers position)
During a blind nasal intubation procedure you will hear a harsh cough and then vocal silence
How do you confirm placement of the airway? Auscultation observation of chest movement PetC02 Esophageal detection device light wand fiberoptic laryngoscopy
The fiberopteric laryngoscopy is the most accurate way to confirm placement
Chest x rays should not be used to confirm placement. Only, position in the airway
What are the advantages of a rigid fiberoptic scope Direct airway visualization minimal neck movement may overcome difficult view useful in disrupted airway durable, sturdy instruments
What are the disadvantages of the rigid fiberoptic scope? Expensive expertise requires practice visual field easily impaired by blood and secretions. not readily available
What are advantages of the lightwand (trachlight)? minimal neck movement useful adjunct to laryngoscopy portable and inexpensive usable in bloody airway provides definitive airway
What are the disadvantages to trachlight? blind technique may damage airway usually requires darkened room expertise requires practice
A tracheotomy is usually considered if ET tube is in for longer than 7 days
What are the indications of a tracheotomy? prolonged intubation to overcome upper airway obstruction trauma/surgery
A tracheotomy is performed by a physician/surgeon Respiratory therapist may assist
What are the advantages of the tracheotomy? More comfortable less tube movement better communication lower airway resistance easier suctioning easier to replace than ETT
what are the disadvantages of the tracheotomy? Surgical procedure hemorrhage SQ emphysema pneumothorax pneumomediastinum permanent scar
Where is the tracheotomy usually done? 3 rings below the thyroid
What are the two types of tracheotomy methods? Standard percutaneous dilational method
The Percutaneous dilational method has less complications minimal scaring ETT not removed until placement
The Tracheostomy Tube is made of PVC Rigid
The tracheostomy tube is tested by the American society for testing and materials
What are common tracheostomy tube sizes? 8 & 6 Even sizes
The trache is no more than 2/3 to 3/4 the inside diameter of the trachea because air needs to pass to facilitate speech.
What are the parts of the tracheostomy tube? Flange (size is on this) cuff filling tube pilot balloon spring loaded valve inner cannular obturator
An uncuffed tracheostomy tube is used when there is no major concern about aspiration or being able to protect airway
The fenestrated tracheostomy tube can facilitate speech be cuffed or uncuffed inner cannula must also be fenestrated
The metal tracheostomy tube is called the Jackson trach
The Jackson trach is for long term use sleep apnea obesity can clip on 15 mm adaptor/cuff
What are the complications of intubation during the procedure? cardiac arrest airway trauma mainstem bronchus intubation pumponary aspiration esophageal intubation
What are the complications of intubation while tube is in place? airway trauma sinusitis otitis self-extubation meachanical problems with tube patient discomfort
What are the complications of intubation post extubation? sore throat stridor odynophagia pulmonary aspiration poor cough
What is the number one complication post extubation? hoarseness
Complications may sometimes occur later post extubation
Airway trauma can occur as laryngeal lesions tracheal lesions
Laryngeal lesions glottis and vocal cord swelling laryngeal and vocal cord ulcerations vocal cord polyps and granulomas vocal cord paralysis laryngeal stenosis
Tracheal lesions tracheal granulomas tracheal stenosis tracheomalacia treacheosophageal fistula tracheoimominate fistula
An RSI is a rapid sequence intubation
In an RSI patient is given Sedative (Versed, Valium, Propofol) Paralytic (succynlcholine) lidocaine (anti arythmic
The RSI is given to prevent bagging so aspiration risk is cut down
A passy muire valve should never be put on when cuff is inflated
Neontal traches lack a cuff
The methelyne blue test checks for aspiration
Shiley is a common trache brand name
The tracheal button Allows for general access
The Bivona Foam Cuff Pulls air out to deflate, reinflates on its own
The Bivona Waterfilled cuff 4-5 cc h20 into cuf
What are the benefits of a bivona cuff? There is less chance of trauma and has more contour to the airway
The Bivona may not be the best choice in the case of decreased lung compliance
Overweight patients can benefit from the XLT trache
What are some airway damage indicators? 1. Difficulty maintaining cuff pressure. 2. Tracheal dilation on cxr. 3. Abnormal PFT
Checking cuff pressures must be done during positive pressure ventilation.
Minimal Occluding Volume (MOV) The least amount of volume to seal airway. Most common technique
MOV 1. Pull out air until leak is heard. 2. Put just enough air back until leak is no longer heard.
Minimal Leak Technique (MLT) 1. Take out air until you hear leak. 2. Put air back till you don't hear it. 3. Pull out till you hear a slight leak at peak pressure of every breath.
The most common suction catheter size 14 French
How to determine suction catheter size Method 1 (Inside Diameter *3.14)/2 Do not round up
How to determine suction catheter size Method 2 (Inside diameter*2) then use next lowest size
How do you prevent airway trauma? Use sedation when necessary. Use nasal tubes vs. oral tubes when possible. Use correct sizing tubes. Avoid changing tubes. Avoid unnecessary coughing or efforts to talk. Limit Cuff pressure; Aesepsis Use trache collar instead of briggs.
Airway maintenance 1. securing tube and maintain proper placement. 2. provide cuff care 3. Aid secretion clearance 4. Ensure humidification 5. minimize possibility of infection. 6. provide for patient communication. 7 troubleshoot emergencies
What do you need to secure ETT? Tape, Velcro attachments, harness
What do you need to secure tracheostomy? Velcro attachments, ties
The tip of tube should be positioned approximately 2-4 cm above the carina.
YOu should always record what values for positioning on the ETT? Size and cm markings
Unplanned extubations occur in what percentage of intubated patients? 2-13 percent. #1 contributing factor: lack of secure placement
The Ideal method for securing ETT allows minimal tube movement; is comfortable for the patient, allows for oral hygiene, preserves skin integrity; easy to apply; requires minimal maitenance.
ETT securing tips. Rotate tube provide oral care trim tube use swivel connector support vent circuit get help when securing airway
What are the 2 classifcation of cuffs? High volume, low pressure Low volume, high pressure
When maintaining cuff pressure, it is important to keep cuff pressure below tracheal capillary perfusion pressure.
Tracheal capillary perfusion pressure valuse 20-25 mm HG
You must keep cuff pressure less than 20 mm Hg or less than 25 cmH20
If you have not got a pressure manometer you can use minimal leak technique or minimal occluding volume technique to inflate the cuff
What are alternative cuffs used to prevent overinflation? Lanz CUff ETT, Foam Cuff, Water filled cuff
The Lanze cuff has external pop off valve wont allow pressure to go greater than 16-18 mm HG
How can you tell if patient has retention of secretions? 1. Auscultate 2. Sp02 monitor 3. percussion/vibration 4. CXR
What are the types of suctioning methods? 1. open system 2. closed system 3. bronchoscopy
Open system suction catheters whistle tip (most common) coude catheter (angled end) red robin (less rigid) Ring tip (prevents damage)
What are suctioning complicataions? hypoxemia bradycardia atelectasis airway trauma bronchospasm contamination of lower resp. tract arrhythmias increased icp (coughing) preferential suctioning of right pronchus.
A leukins trap is used to go in line with suction for sputum sample
Inspired air should provide relative humidity of 100% at body temp; 44 mg/L
Heat humidification systems to 32-35 degrees celcius
Provide at least 30 mg/L humidity
Decreased humidity will mean thick secretions
cool air means decreased ciliary function
What are some common types of humidification systems? Fisher Paykel, Concha Therm, HME, heated large volume jet nebulizer
What are reasons for increased infection risk? bypassed upper airway filtration increased aspiration of pharyngeal material. contaiminated equipment impaired mucociliary clearance increased mucosal damage due to tube or suctioning ineffective clearance via cough
How do you guard against infection? consistently wash hands between patients. Prevent retained secretions use sterile technique when suctioning keep airways clear decrease pharyngeal aspiration
What are some ways of communicating using alternative methods? Writing signing picture boards
Tracheostomy patients may benefit from fenestrated tracheostomy tubes passy-Muir valves
What are emergency airway situations? tube obstruction cuff leak accidental extubation
What are examples of tube obstruction? kinking or biting herniation of cuff over tube jamming of tube opening against tracheal wall mucus plugging
What are clinical signs of an airway emergency? various degrees of respiratory distress. Changes in breath sounds air movement through mouth
In preparation for airway emergency replacement airways should always be kept near the patient
If there is kinking reposition the head/neck
If there is biting use an OPA or bite block
In the event of a herniated cuff deflate/reinflate try to pass suction catheter to determine if cuff is herniated
In the event the tip of the tube is on the tracheal wall reposition the airway and head/neck
In the event of a mucus plug lavage, try to pass suction, then resort to extubation
In the event of plugged trache stick ett down the trache. Put gauze over stoma and bag
You should always suction prior to extubation
Extubation is the removal of the ETT
What are indications of extubation Patient can: Keep upper airway patent. Protect lower airway from aspiration. Clear secretions from lower respiratory tract. Breath withouth mechanical ventilation.
What are the percentages of extubation failures? 5-15% of cases
A practitioner who extubates should be able to intubate
Before you extubate you should also make sure the underlying cause is resolved. Check hemodynamics, ABG/Lab values, wean drugs
Decannulation is the removal of the tracheostomy tube
Decannulation requires the use of progressively smaller tubes.
What can be used to maintain a trach stoma? A tracheal button
When decannulating you should assess swallowing ability
The Laryngeal mask airway (LMA) is inserted blind
The LMA is for short term use and mainly used in the OR
YOu don't have to visualize the ____ for the LMA larynx
The LMA is less complicated than ETT and requires ventilating pressures of less than 20 cm H20 for a good seal
The main sizes for adult LMA's are #4 and #5's
The Esophageal obturator (EOA) is inserted into the esophagus and mainly used by EMTs.
The EOA is difficult to obtain proper mask fit and ventilation. You should always intubate prior to removal of an EOA
The Esophageal-Tracheal Combitube is used in place of an EOA insert tube, inflate both cuffs
With the Combitube there is a 94-98% probability of esophageal placement
The Esophageal Tracheal combitube requires thorough assessment to determine placement. Must ventilate through appropriate lumen
The ETT exchanger is inserted through the ETT, Then the ETT is withdrawn and removed. A new ETT can be slipped over the tube exchanger and threaded down the lung
Oxygen can be insufflated through tube exchanger during procedure.
The Esophageal-Tracheal Combitube is inflated as such 1000 CC in big cuff 16cc little cuff
For impossible intubation, the ett is thread over a guidewire in retrograde intubation
Regrograde intubation puncture cricothryorid membrane. Thread wire through vocal cords. Exit nose or mouth. Guide endotracheal tube through vocal cordds over wire.
Advantages of retrograde definitive airway minimal neck movement does not require full mouth open
Disadvantages of retrograde takes time requires skill not recommended in cannot intubate/cannot ventilate patient
Average NTS catheter size 14 french
What are supplies for tracheostomy care? suction supplies oxygen therapy hydrogen peroxide sterile q-tibs dressings and ties inner cannula
Procedure for tracheostomy care suction patient insert clean or new inner cannula clean stoma site replace dressings and ties auscultate chest
To reduce inflammation post extubation you can give Decadron
The Fi02 should be less than 40% before extubation
To check for swelling prior to extubation you can try the leak test or deflate/occlude ETT
granulomas are scar tissue
malacia is softening
stenosis narrowing
tracheoinnominate fistula is burst vessel
Created by: kparkerlehman
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