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Clinical lab > Airway Management > Flashcards

Airway Management Flashcards

1
Q

In simple terms, airway management is the process of what?

A

Ensuring an open pathway for air to travel between the patients lungs and the outside world while reducing the risk of aspiration

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2
Q

CNS depression, cardiac arrest, LOC and even sleep can reduce what function that maintains airway patency?

A

Muscle tone

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3
Q

What conditions can depress the airway tone in a patient?

A

CNS depression
Cardiac arrest
Loss of consciousness
Sleep

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4
Q

What can cause CNS depression?

A

Drug overdose
Anesthesia

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5
Q

A patient who has lost consciousness is at an increased risk of aspiration due to what?

A

Loss or diminished swallow, gag, laryngeal, tracheal and carinal reflexes

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6
Q

The gag, laryngeal, tracheal and carinal reflexes can be reduced resulting in an increased risk of aspiration. Why does the risk of aspiration increase when these reflexes are suppressed?

A

These reflexes all initiate the the cough reflex so if they are suppressed, foreign bodies, secretions or vomit in the airways can result in aspiration

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7
Q

Give some examples of situations that could cause partial or complete airway obstruction

A

Posterior displacement of the tongue
Foreign objects
Allergic reactions
Infections
Anatomical abnormalities
Trauma

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8
Q

What is the most common cause of airway obstruction in unconscious patients?

A

Posterior displacement of the tongue

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9
Q

T/F: Neurologic tissue can be severely damaged by hypoxic conditions within minutes

A

True. duh.

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10
Q

If the patient is conscious, how can you assess their airway patency?

A

By asking them to speak
Observing whether or not they are distressed and obviously having trouble breathing. Grabbing their neck and gasping generally is a good sign that they arent breathing very efficiently

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11
Q

What is the gold standard for securing an airway?

A

Endotracheal intubation

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12
Q

T/F: Basic airway management will protect against aspiration of gastric contents should vomiting occur?

A

False. Basic airway management will not protect against aspiration of gastric contents

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13
Q

Why is it important to have suction equipment ready during airway procedures

A

To clear secretions and material that could be aspirated on

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14
Q

What is the purpose of the jaw thrust or the head tilt/chin lift maneuver?

A

Open airway and reposition the tongue so that is is not obstruction the airway

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15
Q

What is the definition of manual resuscitation?

A

Method of providing artificial ventilation by the care giver

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16
Q

When is manual resuscitation administered?

A

Manual resuscitation is administered to patient who are unable to sustain adequate spontaneous ventilation

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17
Q

T/F: an impaired cough is not an indication for manual resuscitation

A

False

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18
Q

T/F: Manual resuscitation can be used to hyper inflate the lungs and increase oxygen tension

A

True

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19
Q

What are the indications for manual resuscitation?

A

Emergent respiratory failure
Apnea
Cardiac arrest
Impaired cough
Increase oxygen tension
Facilitate suctioning
Hyper inflation of the lungs
Transporting an unstable or intubated patient

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20
Q

What position should a patient be in for manual resuscitation

A

Supine

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21
Q

What should always be done to the bag before placing it on the patient?

A

Bag should be tested for leaks by blocking the patient side and squeezing the bag. If resistance is not felt, check valves or toss bag and get a new one

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21
Q

The goals of airway management include:

A

Decreasing the risk of aspiration
Ensuring and open pathway between a patients lung and the outside environment

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22
Q

What are some common causes of airway obstructions?

A

Infections (croup)
Foreign matter in airway
Anatomical abnormalities
Allergic reactions
Trauma

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23
Q

T/F: Collapsed lung tissue constitutes an airway obstruction

A

False

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24
Q

What is the function of an Oropharyngeal airway (OPA)?

A

Assists in airway patency
Prevents tongue from falling onto the back of the throat and obstructing the airway

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25
Q

An oropharyngeal airway should be used on a patient that:

A

Does not have a gag reflex
Unconscious

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26
Q

If a patient has a gag reflex, what adjunct airway should be used?

A

Nasopharyngeal airway (NPA)

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27
Q

What will happen if an NPA (Nasopharyngeal airway) is too short?

A

An NPA that is too short will fail to separate the soft palate and the tongue from the posterior pharynx

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28
Q

What can happen if an NPA (nasopharyngeal airway) is too long?

A

NPA could enter the vallecula and become occluded with soft tissue
NPA could enter the esophagus and cause gastric distention
NPA could enter the larynx and stimulate a cough reflex

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29
Q

What could happen if an NPA is too long and enter the larynx?

A

Could stimulate a cough reflex
Could stimulate a gag reflex and cause vomiting

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30
Q

An NPA (nasopharyngeal airway) has been inserted into a patient but you do not observe chest rise/fall when performing manual resuscitation. What could the problem be?

A

The NPA is the wrong size
Too short = can separate soft palate and tongue from posterior pharynx
Too long = NPA is in esophagus

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31
Q

How do you properly size a NPA?

A

Place flared end again the lateral edge of the nostril and the other end against the tragus of the ear. If the tube does not reach the tragus or over shoots it, it is the wrong size
Or measure from the tip of the nose to the tragus of the ear

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32
Q

What position should a patient be in when inserting an NPA?

A

Sniffing position

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33
Q

What direction should the bevel be facing when the NPA is inserted?

A

Downwards towards the septum

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34
Q

T/F: When inserting an NPA, you should force through any resistance it encounters

A

False. If resistance is encountered the airway should be retracted

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35
Q

How is an oropharyngeal airway sized?

A

Flared end should be placed at the lip commissure (corner of the mouth) and the distal tip should reach the angle of the jaw

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36
Q

Which way should an OPA be inserted into the mouth?

A

With the tip up towards the roof of the mouth until it reaches the uvula at which point it is rotated 180 degrees to direct the tip down toward the pharynx

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37
Q

What is an absolute contraindication for OPA use?

A

If a patient can cough or still has a gag reflex an OPA should not be used because it may induce vomiting which could lead to aspiration making literally everyones day worse

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38
Q

Should an OPA be placed if a patient has a foreign body obstructing the airway.

A

No. remove foreign body if possible and then place OPA
If foreign body is not removable, call funeral home

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39
Q

What are the two most common complications that can occur with the use of OPAs?

A

Iatrogenic trauma
Airway hyperreactivity
Minor pinching of the lips and tongue is common

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40
Q

How many ventilations should patients who are being manually resuscitated receive?

A

10 per minute with ventilations lasting approximately one second

yeah bullshit

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40
Q

What can occur if an OPA is left in place for too long? (days)

A

Ulceration and necrosis of oropharyngeal structures from pressure and long term contact have been reported
Basically skin breakdown due to constant pressure

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41
Q

Approximately what tidal volume should be delivered when performing manual resuscitations?

A

400-500 mL

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42
Q

What should providers giving manual resuscitation check to ensure that the patient is receiving adequate ventilation

A

Watch for chest rise and fall
Periodically auscultate the lungs to ensure ventilation
Oxygen saturation if available
Capnography if available

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43
Q

Watch for chest rise and fall
Periodically auscultate the lungs to ensure ventilation
Oxygen saturation if available
Capnography if available

A

Use C-E grip
Middle, ring and little fingers under mandible and pull jaw upward into mask
Index fingers and thumb create C and press mask down into face

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44
Q

What are the 4 kinds of manual resuscitators

A

Self inflating bag/valve/mask
Flow inflating
T-piece
Automatic

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45
Q

A BMV has a sampling port that allows providers to do what?

A

Allows monitoring of PIP that the bag is delivering

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46
Q

If, when bagging, the pressure relief valve is popping off, what does this mean and what should you do?

A

it means that there is either low compliance in the lungs or there is an obstruction
You should ensure patient is correctly positioned, confirm that there is nothing in the mouth, then flip the pressure relief override and keep bagging

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47
Q

T/F: There is no way to measure PEEP when using a BMV

A

False. The exhalation valve can fit a PEEP valve so that monitoring residual pressure in the lungs is possible
Its accuracy is probably debatable though

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48
Q

T/F: when bagging a patient, exhaled gas returns to the bag via a two way valve

A

False. There are 2 separate 1 way valves built into the bag. One prevents exhalations from entering the bag and another prevents ventilations from not being delivered to the patient

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49
Q

T/F: a BMV can be utilized to deliver aerosolized medication

A

True…apparently

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50
Q

What FiO2 should a BMV deliver?

A

A BMV should deliver close to 100% FiO2 if mask has made a proper seal to the face

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51
Q

What are the applications of a self inflating BMV?

A

Adult respiratory care
Medication instillation
Aerosolized medication delivery

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52
Q

What factors can influence the FiO2 delivered through manual resuscitation?

A

Oxygen flow rate
The presence of a reservoir

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53
Q

You are called to the ED to assess a patient. During your assessment, the patient becomes unresponsive and requires manual resuscitation. The patient is apneic, how will breaths in this situation be “triggered”?

A

The breaths will be time triggered with the provider giving one breath every 6 seconds

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53
Q

ou are called to the ED to assess a patient. During your assessment, the patient becomes unresponsive and requires manual resuscitation. The patient is breathing, how will breaths in this situation be “triggered”?

A

Breaths will be triggered when the patient inhales. The provider will feel the drop in pressure as they hold the bag or watch for chest rise and deliver oxygen to the patient by squeezing the bag

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54
Q

What should the flow be set to when bagging a patient?

A

15 l/m or flush

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55
Q

When bagging a patient, how can a provider assess for appropriate breath delivery?

A

Watch for chest rise and fall
Look for condensation on the inside of the mask
Listen for leaks around the mask
Watch for gastric distention

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56
Q

You are bagging a patient and the bag has an end tidal CO2 monitor on it. As you look at the patients CO2 waveform, you notice that the waveform is flat. What does this mean?

A

A flat waveform indicates that there is no gas exchange occurring during ventilation

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57
Q

T/F: patient can draw spontaneous breaths through the one way valve with a good mask seal

A

True

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58
Q

T/F: Placing the mask on a patient ensures that gas is flowing to the patient

A

False

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59
Q

What factors influence FiO2 delivery when using a manual resuscitator?

A

Stroke volume
Refill time
Respiratory rate

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60
Q

How will a higher respiratory rate influence FiO2 delivery when using a manual resuscitator? A lower rate?

A

A higher rate will decrease FiO2
A lower rate will increase FiO2

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60
Q

What factors influence FiO2 delivery when using a manual resuscitator?

A

Stroke volume
Refill time
Respiratory rate
Whether or not the patient was a dick

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61
Q

How does refill time when using a manual resuscitator effect delivered FiO2?

A

Shorter refill time decreases FiO2
Longer refill time increases FiO2

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62
Q

How does stroke volume when using a manual resuscitator effect FiO2?

A

Larger breaths decrease FiO2
Smaller breaths increase FiO2

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63
Q

What are common errors practitioners make when bagging patients?

A

bagging to quickly (its really easy to do)
Bagging out of sync with patient breaths

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63
Q

What effect can bagging rapidly have on a patient?

A

Bagging too rapidly could potentially hyperinflate the lungs and decrease venous return to the heart
Putting to much pressure into the patient could result in gastric insufflation

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63
Q

What pressures can cause gastric insufflatio

A

Pressures greater than 25 cm of water

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64
Q

A patient is being bagged but cannot exhale. How would you know this is happening in a patient that isnt awake and what could be the cause?

A

You do not see the chest fall
The non rebreathing valve may be jammed or broken

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64
Q

You are bagging a patient and suddenly you notice the pressure required to deflate the bag has substantially decreased. What could cause this?

A

The oxygen inlet valve could have failed

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64
Q

What are the hazards associated with BMVs?

A

Hypoxia
Equipment failure
Poor technique (hey its me)
Cross contamination
Cant measure tidal volume on squish bag. Too much bad. Too little bad.
FiO2 is not guaranteed

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64
Q

You are bagging another patient (lucky you) and while bagging you suddenly notice a lack of resistance. What could be the cause?

A

A leak in the system ‘
The pressure sampling port may have popped open
The patient never existed and you suddenly remember youre schizophrenic

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65
Q

What are contraindications for BMV?

A

Awake, bitchy patient
Untreated tension pneumo
Facial trauma (whiny patient)
Total upper airway obstruction

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66
Q

What are the scenarios where an automatic resuscitator would be applicable?

A

Transporting patients
Does not require being tethered to a device
Mass casualty scenarios where there are not enough vents

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67
Q

What are the disadvantages of automatic resuscitators?

A

Consistency (same)
Sophistication in breath delivery (Same)
Lack of alarm function

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68
Q

What liter flow does an oxygen powered demand valve resuscitator deliver?

A

30 lpm

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69
Q

What tidal volume does an oxygen powered demand valve resuscitator deliver?

A

500 ml

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70
Q

T/F: A DVR (demand valve resuscitator) cant be triggered by the operator

A

False, a respiratory rate can be set or the device can be manually triggered by the operator

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71
Q

What are the advantages of DVR (demand valve resuscitator)?

A

Allow for a 2 handed mask seal
Can limit pressure delivery to reduce gastric distention
Useful in emergency medicine

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72
Q

What are some disadvantages of DVRs?

A

Occasionally reported to malfunction easily, generally limited to older versions

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73
Q

What are absolute contraindications for resuscitators?

A

Patient has a DNI
Resuscitation has been determined to be futile (ie patient has been decapitated)
Resuscitation poses an immediate danger to rescuers (decapitated body has been zombified and now craves human flesh)

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74
Q

What is one of the main differences between a BMV and a flow inflating resuscitator?

A

Flow inflating resuscitators lack a non rebreathing valve

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75
Q

What regulates flow with a flow inflating resuscitator?

A

Not the flow control valve, apparently
The gas source regulates flow

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76
Q

What does the flow control valve regulate in a flow inflating resuscitator?

A

NOT flow
The flow control valve regulates resistance

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77
Q

How do you provide ventilations with a flow inflating resuscitator?

A

Flow from source plus hand squeeze pressure

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77
Q

T/F: Proper flow regulation can provide CPAP or PEEP when using a flow inflating resuscitator

A

True

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78
Q

T/F: The bag is supposed to deflate completely when using a flow inflating resuscitator

A

False, the flow going to the bag MUST be greater than flow going to a patient or the bag will deflate and you will deprive your patient of oxygen

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79
Q

Who are flow inflating resuscitators most commonly used on?

A

Infants and neonates

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80
Q

T/F: The bag is supposed to deflate completely when using a flow inflating resuscitator

A

False, the flow going to the bag MUST be greater than flow going to a patient or the bag will deflate and you will deprive your patient of oxygen

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81
Q

T/F: Flow inflating resuscitators are most commonly used by proctologists

A

False. Flow inflating resuscitators are most commonly used by anesthesiologists

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82
Q

True/False. Flow inflating resuscitators are most commonly used by proctologists

A

False. They are mainly used by anesthesiologists but require a trained practitioner

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83
Q

How do you regulate CPAP when using a flow inflating resuscitator?

A

Control outflow resistance via the flow control valve to regulate CPAP

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84
Q

What coordinating tasks are need to be performed when using a flow inflating resuscitator?

A

Adjust flow of gas from O2 source to bag
Control outflow resistance via flow control valve
Control force of manual compression of the bag
Maintain adequate face seal

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85
Q

Where are flow inflating resuscitators most commonly used?

A

Operating room
Delivery rool
Neonatal intensive care

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85
Q

What is the only infant t-piece resuscitator available?

A

Neopuff

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86
Q

How does a t-piece resuscitator provide ventilation?

A

With constant PIP

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87
Q

What is the flow rate on a t-piece resuscitator?

A

5-15 lpm

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88
Q

What patient interfaces are used with a t-piece resuscitator?

A

Interfaces with a mask or an endotracheal tube

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88
Q

What are the applications for a supraglottic airway device?

A

Maintain airway (duh)
Administration of gasses or airway instrumentation
Permit administration of manual or mechanical ventilation

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89
Q

What situations call for an artificial airway?

A

Upper respiratory tract obstruction or infection
Neuromuscular disease
Central nervous system damage
Pulmonary failure or insufficiency
cardiac/circulatory failure or insufficiency
Ed being left unsupervised

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89
Q

When are supraglottic airways used?

A

Primarily used in emergencies where intubation cannot be accomplished

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90
Q

Describe the positioning of the distal cuff after a laryngeal tube has been inserted

A

Cuff is located at the beginning of the esophagus

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91
Q

When is a laryngeal tube used?

A

can be used as a first choice for airway management of as a backup device if endotracheal intubation was unsuccessful

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92
Q

What risks do supraglottic airways pose to the glottis?

A

They can displace it

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93
Q

Patients who are awake and have a supraglottic airway in place are at risk for what?

A

Gagging and asperating

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94
Q

What can be damaged as a result of supraglottic airways?

A

Oropharyngeal mucosal membranes
Larynx
Esophagus
Pretty much any structure in the mouth that could be damaged by jamming a giant tube in there

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95
Q

T/F: hypoventilation is not a potential hazard of supraglottic airways

A

False. Blind insertions can lead to incorrect alignments and hypoventilation

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96
Q

T/F: Unconscious patients with a supraglottic airway in place are not at risk of aspiration

A

False.

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97
Q

T/F: Supraglottic airways are at risk of being moved if the position of the head is changed

A

True

98
Q

How is an endotracheal tube different than a supraglottic airway in terms of placement?

A

The tube of an ET extends through the patients airway, past the glottis and through the vocal cords. The end of the tube rests approximate 5-7 cm above the carina

99
Q

Where should the cuff be relative to the glottis when using an ET tube?

A

Distal to the glottis

100
Q

What is a unique trait of the material that the ET tube is made out of?

A

The plastic is rigid at room temperature but after placement will soften in order to conform to the airway and improve patient comfort

101
Q

T/F: endotracheal tubes can only be inserted in the mouth

A

False, they are usually inserted via the mouth, but can also be placed through the nose

102
Q

What is the purpose of the Magill curve?

A

To conform to the anatomy of the airway

103
Q

How do you confirm the placement of an ET tube? (gold standard)

A

The tube has a radio opaque line which allows us to see it in an x ray and confirm proper placement

104
Q

T/F: sometime ET tube are coated in gold due to its antimicrobial properties

A

False. Tubes can be coated in silver for its antimicrobial properties

105
Q

When is nasotracheal intubation favored?

A

Patient is awake
Poor visualization of the vocal cords
Oral cavity surgery
Mobilization of the neck is contraindicated

106
Q

A patient undergoing oral surgery would be best served by which kind of airway management?

A

A RAE tube

107
Q

What kind of airway management device would be best suited for a patient undergoing lung surgery?

A

A double lumen tube

108
Q

What size of endotracheal tube is generally used for adult males?

A

8-9 mm

109
Q

What does the dimension of the endotracheal tube is the sizing based on?

A

The internal diameter

110
Q

What size of ET tube is generally used for adult females?

A

7-8 mm

111
Q

What are the advantages of larger ETTs?

A

Larger tubes have less airway resistance
Easier to suction
Easier to pass a bronchoscope

112
Q

What are the disadvantages of larger ETTs?

A

Larger tubes have a greater capacity to cause damage

112
Q

What is the purpose of subglottic suction?

A

Subglottic suction is thought to reduce ventilator associated pneumonia (VAP)

112
Q

What are the advantages of a spiral wire reinforced ETT?

A

Very flexible
Resistant to kinking

112
Q

When are uncuffed ETTs used?

A

Neonates

113
Q

Describe the functions of a triple lumen ETT

A

Main lumen ventilates
Insufflation lumen provides jet ventilation, medication administration, gas sample collection and secretion clearance

113
Q

What purpose does the cuff on an endotracheal tube serve?

A

Ensures adequate seal
Airway protection from aspiration
Optimal positioning

113
Q

Describe the advantages of a high volume low pressure cuff over a high pressure low volume cuff

A

HVLP cuff exerts low and equal lateral tracheal pressure minimizing tracheal injury
HPLV cuff exerts high pressure unevenly resulting in tracheal erosion
HVLP cuff also provides a better seal than a HPLV cuff

114
Q

Which cuff style is the most commonly used?

A

HVLP, cylindrical

115
Q

What is the advantage of a low profile cuff ETT?

A

Improves visualization of the vocal cords
LVLP

116
Q

What is the advantage of a tapered ETT cuff?

A

Better fitting cuff to trachea resulting in a better seal

117
Q

What is different about a foam endotracheal tube cuff?

A

HLVP, self expands, air is evacuated during insertion

118
Q

What is the function of the laryngoscope?

A

Used to visualize the epiglottis

119
Q

Describe what a stylet is and what it is used for

A

A slender and pliable rod or wire that is placed inside the tube to make insertion easier

120
Q

What pieces of equipment should an RT gather for an intubation?

A

ETT
Stylet
Syringe
Laryngoscope
Suction catheter
BVM
Carbon dioxide detector
Nasal or oral airway
lubricant

121
Q

What are the 3 components of a laryngoscope?

A

Handle
Blade
Light source

122
Q

What kind of handle would you want for a patient who is certified thiccc?

A

Either a stubby handle or a large handle

123
Q

What are slender laryngoscopes best for?

A

Improved balance with smaller blades

124
Q

When using a macintosh blade, where should the tip be placed?

A

Tip of the blade is inserted into the vallecula (the thing Ed thinks the tongue is) to lift the epiglottis and expose the glottis

125
Q

Macintosh blades are typically used on ______ and miller blades are typically used on _______

A

Adults
Children, infants

126
Q

Where is the tip of a miller blade inserted?

A

Beneath the epiglottis and with lift the glottis is exposed beneath

127
Q

Why is the miller blade suitable for children and infants/

A

They have more flexible airways

128
Q

What are some drawbacks to using a straight laryngoscope blade?

A

Narrow design necessitates careful paraglossal placement without sweeping the tongue from the extreme right corner of the mouth
Narrow blade limits the area for landmark identification down the barrel
Hard to introduce the blade along side the tongue and reach the larynx

129
Q

Describe a wisconsin laryngoscope blade

A

Straight spatula and flange expands slightly to distal part of the blade
Claims to increase visual field and reduce trauma

130
Q

Describe a phillips blade

A

Straight with a curved distal tip

131
Q

Describe an oxford blade

A

Blade with overhand and a broad flat lower surface, helps with cleft palate
Used on neonates, infants and children

132
Q

What kind of blade is used with neonates, infants and children?

A

Oxford

133
Q

Describe a siker blade

A

Curved blade with a mirror at the proximal tip. Distal part of the blade is 3’’ long

134
Q

What patient characteristics make for a difficult intubation?

A

Restricted oropharyngeal opening
Blood or secretions in airway
Cervical spine immobilization
Obesity

135
Q

What is the advantage to video laryngeal scopes?

A

Allows for visualization of glottis opening even when there is an inability to align oral, pharyngeal and laryngeal axes

136
Q

What allows the video laryngoscope to allow for minimal head manipulation?

A

Rigid fiber optics

137
Q

When using a stylet what should you make sure to do?

A

Make sure the end of the stylet is not protruding from the ETT

138
Q

What is a frova intubation introducer?

A

Combination tuber exchanger and stylet

139
Q

What is a bougie

A

Blunt ended malleable wand about twice the length of the ETT
Can be used for tube exchanges

140
Q

A patient being younger than eight contraindicates what intubation tool?

A

Bougie

141
Q

Describe tube exchangers

A

Semi rigid but malleable hollow tubes with oxygen holes
Marks graduated depths
Designed to exchange an ETT without a laryngoscope

142
Q

What is the common pneumonic used for airway evaluation?

A

LEMON

143
Q

What do you do in the L phase of intubation assessment?
Look for…

A

External signs of trauma, facial hair, neck masses, large tongue or dentures

144
Q

What do you do in the E phase of intubation assessment?

A

Evaluate using the 3-3-2 rule
Less than 3 fingers between incisors
3 fingers between the hyoid bone and the mental protuberance
2 fingers between the hyoid bone and the thyroid cartilage
These apparently mean the airway could be difficult

145
Q

What do you do in the M phase of intubation assessment?

A

Mallampati
Class of 3 or greater means its gonna be a rough time

146
Q

What do you do in the O phase of intubation assessment?

A

Check for obstructions that might prevent visualization of the vocal cords

147
Q

What do you do during the N phase of intubation assessment?

A

Assess patients neck for any restriction to mobility which could hinder shoving a tube down their throat

148
Q

What does the mallampati score assess?

A

Ability to visualize the soft palate and/or uvula
Higher the score, the less you can see, the more difficult intubation will be

149
Q

What is the optimal positioning for intubation? Why?

A

Sniffing position
Aligns the oral, pharyngeal and laryngeal axes

150
Q

How is sniffing position achieved?

A

Elevating the patients head
Extending the head at the neck
Aligning ears horizontally with the sternal notch?

151
Q

What is the minimum ETT size required for a bronchoscopy?

A

7.5 mm

152
Q

Approximately what angle should be created using the stylet?

A

35 degree

153
Q

What should be done to the cuff on the ETT tube prior to insertion?

A

Cuff should be inflated to check for leaks

154
Q

What is used in RSI situations to improve the likelihood of first pass success and minimize aspiration?

A

Medications that have a rapid onset and short duration of action

155
Q

What medications are typically used on a patient about to undergo RSI?

A

A sedative - etomidate
A paralytic - succinylcholine (succ) or rocuronium (roc)

156
Q

What is the goal of preoxygenation?

A

Slow the decline of oxyhemoglobin during apnea

157
Q

When do you preoxygenate patients who are going to be intubated?

A

Before the administration of paralytics and sedatives

158
Q

What is the preferred source of preoxygenation?

A

Rebreather mask
High FiO2 and no rebreathing of exhaled air
Can also be done with high flow nasal cannula at 15 l/m

159
Q

What checks should be done with the laryngoscope prior to intubation?

A

Does the light work?
Is it lock in place?
Is it the right kind?

160
Q

T/F: the laryngoscope can be used in either hand

A

It can FUCKING not. Left hand only

161
Q

What can be done if an attempt at intubation fails?

A

Use a bougie to get past the epiglottis and then use it as a guide to insert the ETT

162
Q

What is the desired depth from the incisors to the distal tip of the ETT in women?

A

19-21 centimeters

163
Q

What is the desired depth from the incisors to the distal tip of the ETT in men?

A

21-23 centimeters

164
Q

How can you confirm that the ETT tube is in the correct position?

A

Auscultate chest
Look for chest rise and fall
End tidal carbon dioxide monitor
Condensation in tube
Xray

165
Q

What is the gold standard for ETT placement confirmation?

A

End tidal carbon dioxide monitoring

166
Q

You intubate a patient and auscultate to check placement. You only hear air movement on one side. Which side do you hear movement on and why? What should you do?

A

You would only hear movement on the right side due to the trajectory of the RMS bronchus
The tube should be backed up so that it is 2-6 centimeters above the carina

166
Q

What can happen if the ETT cuff is pressurized to high?

A

Can cause decreased perfusion and ischemia
Ie mucosal damage

167
Q

What can happen if the ETT cuff pressure is too low?

A

Can contribute to aspiration

168
Q

What pressure should the ETT cuff be inflated to?

A

25-35 cm of water
20-25 mmHg

169
Q

Describe the minimal occlusive volume technique for checking cuff pressure

A

air is added to the cuff to make a seal until there is no air leak on inspiration while on mechanical ventilation

170
Q

Describe the minimum leak technique for checking cuff pressure

A

Just enough air is removed from the cuff to allow for a small leak on inspiration

171
Q

Describe the manual technique for checking cuff pressure

A

Pilot balloon is gently pressed to estimate appropriate pressure

172
Q

Describe pressure monitoring as a technique for checking cuff pressure

A

You use a device to check the pressure

173
Q

What are the hazards associated with intubation?

A

Mucosal or structural injury
Sympathetic response
Tube obstructed with secretions
Tube kink
Over under uneven inflation of the cuff

174
Q

What are sympathetic responses that can be triggered by intubation?

A

Tachycardia
Bradycardia
hyper/hypotension
Bronchospasm
Laryngospasm

175
Q

When assessing a patient for extubation, what factors do you consider to assess readiness?

A

Original problem is no longer present
The quality and quantity of their secretions
Whether or not they can clear said secretions
Presence of an intact gag reflex
Upper airway patency
Ability to breathe without invasive ventilator

176
Q

How do you assess airway patency in an intubated patient

A

Deflate the cuff, listen for airway movement

177
Q

What should you do prior to extubation (besides assessment and deflating cuff)?

A

Suction ETT tube
Suction pharynx above cuff

178
Q

How can you assess your patient strength and mental state prior to extubation?

A

See if they follow commands
Have them wiggle toes, fingers
Have them try to lift their head
Have them flip off a doctor

179
Q

What should you have your patient do immediately post extubation?

A

Speak

180
Q

Where do you auscultate to assess for stridor?

A

sides of the throat

180
Q

What is your patient going to ask for immediately post extubation? Can they have it? Why or why not?

A

A drink
Fuck no
Need to assess ability to swallow

180
Q

What can happen post extubation in some patients?

A

Airway inflammation closes airway

180
Q

Where is the cuff attached in a trach tube?

A

The outer cannula

181
Q

What are the benefits of a tracheostomy tube?

A

ETT tubes are not meant to be used long term
Patient can be taken on and off vent
Reduced risk of infection
Reduces need for patient sedation
Patient can talk
Patient can eat (technically but it takes time)

181
Q

What portion of the tracheostomy tube keeps it from going too deep?

A

The flange

181
Q

Describe the cannula of a trach tube

A

Curved or angled stiff/flexible hollow tube. Serves as the body of the trach

182
Q

What is a plastic trach tube called?

A

A shiley

183
Q

What is a silicone trach tube called

A

Bivona

184
Q

What is the function of the obturator?

A

Fits inside the outer cannula and occludes distal lumen (plugs the hole) with a rounded tip to facilitate insertion
Only used during insertion

185
Q

When is a cuffed trach tube used?

A

When a patient needs positive pressure ventilation
Helps protect against aspiration

186
Q

When are uncuffed trach tubes used?

A

Patients with no need for mechanical ventilation
Children
Weaning

187
Q

What can be used if a patient sometimes needs a cuffed trach tube but other times doesnt?

A

A tight to shaft trach tube
Deflated cuff sits tight around cannula

188
Q

How is the cuff in a tight to shaft trach tube inflated?

A

With sterile water
Saline can crystalize

189
Q

Where is the proximal portion of the trach tube?

A

Right behind the flange

190
Q

Where is the radial portion of the trach tube

A

Its the bendy bit

191
Q

If a patient has a large neck or some weird anatomical variation, what would be required to successfully trach them?

A

A tube with an increased proximal length, ie a proximal length tube

192
Q

A patient has an injury in their trachea and a normal trach might poke said injury. What should you do?

A

Use a distal extended length tube to bypass any trachial abnormalities or injuries

192
Q

On fenestrated canulas, where is the fenestration located in relation to the cuff?

A

The fenestration is above the cuff

193
Q

What are hazards associated with capping fenestrated canulas?

A

Excessive airflow resistance can occur

194
Q

What can occur if an unfenestrated trach tube is capped?

A

Patient can suffocate

195
Q

In what situation would a montgomery T-Tube be useful?

A

In patients who need a trach tube but are having issues with airway patency due to tracheal stenosis, tracheomalacia or reconstruction

196
Q

Describe a montgomery t tube

A

A semi rigid plastic tube with a t shape
1 arm goes to the trachea
1 arm goes to subglottic space

197
Q

When a speaking valve is in place, should the cuff be inflated or deflated? Why?

A

Cuff should be deflated to allow air to be redirected through the larynx and vocal cords
If cuff is not deflated, patient will not be able to exhale

198
Q

When are speaking valves contraindicated?

A

If the patient is unconscious
If the patient has an unstable respiratory status
If the patient has a large amount of secretions
If the patient requires a large amount of oxygen

199
Q

Most valves on on speaking valves are classified as what?

A

Flappers

200
Q

Describe a bias closed speaking valve

A

Valve is open during inspiration
Closed during expiration to allow for speech
May have more air loss which will affect speech quality

201
Q

Describe a bias closed valve

A

Valve closed during expiration
May require greater effort to achieve airflow

201
Q

A shikani-French valve is what kind of speaking valve?

A

Ball valve

201
Q

A tracoe phon assist valve is what kind of speaking valve?

A

Unidirectional diaphragm valve

201
Q

When using a speaking valve, what should the size of the tube be relative to the airway?

A

No more than 2/3rds

201
Q

A Passy-Muir valve is what kind of speaking valve?

A

Bias closed valved

201
Q

A shiley phonate is what kind of speaking valve?

A

A flapper valve

202
Q

What is the application of trach buttons?

A

Used to wean patients from tracheostomy tubes

203
Q

Describe a trach button

A

Straight, rigid, flexible or hollow cannula which latches between the skin and the anterior wall of the trachea
Used to wean patients off of trach tubes

204
Q

Describe the steps associated with trach tube care

A

Assemble and check equipment
Explain procedure to patient
Suction patient if secretions are present
Remove and clean inner cannula
Clean and examine stoma site
Change ties/holder
Replace clean inner cannula
Reassess patient

205
Q

Describe the hazards associated with tracheostomies and stoma care

A

Dyspnea
Hypoxia
Bleeding
Decannulation

206
Q

What are early complications associated with artificial airways?

A

Laryngeal lesions
Vocal cord paralysis
Vocal cord stenosis

206
Q

What are the most common injuries to the larynx as a result of artificial airways?

A

Glottic edema
Vocal cord inflammation
Vocal cord polyps or granulomas

207
Q

What are examples of complications that arise later with artificial airway use?

A

Trachial lesions
Granulomas
Tracheomalacia
Tracheal stenosis
Tracheoesophageal and tracheoinnominate artery fistula

208
Q

What would you assess in order to determine if a patient is ready to be decannulated?

A

That the original problem is no longer present
Quantity and thickness of secretions
Ability to clear said secretions
Presence of an intact gag reflex
Ability to sustain breathing
Upper airway patency

209
Q

T/F: Suctioning cannot be performed on the bronchi

A

False. Suctioning can be performed on the oropharynx, trachea, and bonchi

209
Q

What steps would you take in order to decannulate a patient (not assessment)

A

Integrate fenestrated tube
Progressively use smaller tubes
Implement trach buttons
Yoink the trach

210
Q

Why should suctioning through the mouth be avoided in some situations?

A

Can cause gagging

211
Q

Reasons to suction a patient can include

A

Maintaining airway patency
Specimen collection
Stimulating a cough
Removing secretions
Clearing an obstructed airway
If a patient has a depressed cough
If a patient has a loss of airway reflexes

212
Q

What is another way of saying mmHg?

A

Torr

212
Q

When suctioning adult patients, what is the pressure range for performing suction?

A

Less than 200 mmHg

213
Q

When suctioning neonates and children, what is the pressure range for performing said suction?

A

Less than 120 mmHg

214
Q

T/F: Open suction is not a sterile technique

A

False. Open suctioning is a sterile technique

215
Q

T/F: Open suctioning requires that patients be disconnected from the ventilator

A

True

216
Q

Describe closed suctioning

A

Sterile technique
Closed inline catheter is attached to ventilator circuit which allows suction catheter to be advanced in pts endotracheal airway without ventilator disconnection

217
Q

What are the advantages of closed suctioning?

A

Sterile
Easier than open suctioning
No ventilator disconnect
Less icky

218
Q

T/F: Patients should be suctioned on a schedule

A

False. Patients should only be suctioned when they need to be suctioned

219
Q

What are indications that a patient may need suctioning?

A

You can see secretions
You can hear them when they breath
Low O2 sat
Pressure alarm on vent because of increased airway resistance

220
Q

How do you determine the proper size of a suction catheter?

A

ID of ETT x 3 = x -> x/2 = size
Round down, tubes only come in size intervals of 2

220
Q

When hyperoxygenating adult and pediatric patients for suctioning, what should their FiO2 be?

A

100%

220
Q

T/F: you should not hyperoxygenate before suctioning

A

False. Suctioning will temporarily make it very hard for the patient to breath so in order to prevent them from rapidly desatting they should be hyperoxygenated prior to suctioning

221
Q

When hyperoxygenationg neonates prior to suction, what should their FiO2 be?

A

FiO2 should be increased by 10%

221
Q

How long can you suction a patient for?

A

Up to 15 seconds
Feels a lot longer than it is

222
Q

What situation would call for nasaotracheal suctioning?

A

Patient has retained secretions but doesnt have an artificial airway in place

223
Q

What position should the patient be in for nasotracheal suctioning?

A

Sat up
Sniffing position

224
Q

When should you avoid nasotracheal suctioning?

A

Immediately after meals as it may cause patient to gag and throw up

225
Q

What should you do to the NT catheter prior to insertion?

A

Lather that thing up in some good old lubriCAN
Water based, of course

226
Q

At what point should the advancement of the NT suction catheter be stopped?

A

Advance until patient coughs or resistance is felt

226
Q

What should you do if you meet resistance when inserting NT suction catheter?

A

Assess depth
Gently twist to see if you can get around obstruction
If unable, try other nostril

227
Q

What should you instruct the patient to do when inserting the NT suction catheter?

A

Be in sniffing position
Stick out their tongue or cough which will allow the catheter to get past the vocal cords

228
Q

What are the advantages of the whistle tip catheter?

A

Multiple holes at tip serve as pressure relief and prevent or reduce chances of airway biopsy

229
Q

What is the purpose of the Coude directional tip catheter?

A

Can be directed toward the right or left mainstem by lining up the radioopaque line with desired suction target

230
Q

What are the advantages of the aeroflow catheter tip?

A

Uniform suction
Design decreases chances of damaging the mucosa from invagination and avoid suction trauma

231
Q

Describe the design of the aeroflow catheter tip

A

Has a “ring” tip with a central hole at the distal portion and 4 holes on the side farther up the catheter

232
Q

Is it better to apply continuous suction or intermittent suction?

A

Continuous suction while withdrawing catheter is believed to be more efficient at removing secretions

233
Q

What steps should you take to avoid atelectasis during suctioning?

A

Limit the amount of negative pressure used
Keep duration of suctioning as short as possible
Use appropriately sized suction catheter
Avoid disconnection from the ventilator

234
Q

When is it appropriate to instill sterile normal saline into a patients airway?

A

When it is needed to mobilize thick secretions
Should be done sparingly

235
Q

Why would you want to collect a sputum sample?

A

ID bacteria in airway
Test for some types of cancer

236
Q

What is used to collect sputum from a patient during suctioning?

A

A lukens trap

Clinical lab (4 decks)

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