Airway Management

Question 0

What are the different ways to manage a pts airway?

Answer 0

Airway clearance/maintenance
Recovery position
Head tilt, chin lift
Oropharyngeal airway (guedel)
Nasopharyngeal airway
Laryngeal mask airway
Oral endotracheal tube
Tracheostomy

Question 1

Descriptions of sounds for each of these obstructions:

Gurgling, snoring, crowing, inspiratory strider, expiratory wheeze

Answer 1

Gurgling = liquid in mouth/upper airways
Snoring = pharynx is partially obstructed
Crowing = laryngeal spasm
Inspiratory stridor = obstruction above/at level of larynx
Expiratory wheeze = airways collapse during expiration

Question 2

What are the different techniques for airway clearance?

Answer 2

Coughing
Nebulisers
Suction
Humidification
Position (upright unless unconscious)
Physio
Cough assist devices

Question 3

What are the indications for oral intubation?

Answer 3

Hypoventilation
PaO2 8 kPa (severe type 1 + 2 respiratory failure)
GCS <8 (head injury)
Trauma
Surgery
Airway protection
Drug overdose

Question 4

Considerations for intubation

Answer 4

Is there and ICU bed available
Purpose of intubation
Underlying condition = is this reversible?

Question 5

What are the nursing considerations for intubation?

Answer 5

Equipment
Drugs
Pt preparation
Procedure
How will pt be ventilated post intubation?
Obs
Documentation

Question 6

What does the respiratory tract consist of?

Answer 6

Nose and mouth
Pharynx
Epiglottis
Larynx and vocal cords
Trachea
Car is and bronchi

Question 7

What is the functions of the nose and mouth for airway management?

Answer 7

Intake of air
Warming and humidification of air
Filtering and expulsion of matter (sneezing)

Question 8

What is the function of the pharynx for airway management?

Answer 8

Cavity at the back of the nose and mouth (oro/naso pharynx)

Question 9

What is the function of the epiglottis in airway management?

Answer 9

A leaf shaped structure

Closure protects airway during swallowing

Question 10

Role of the larynx and vocal cords in airway management?

Answer 10

Positioned above the trachea, housing the vocal cords

Air must move across the cords to allow vibrations and enable phonation

Question 11

What is the structure of the trachea?

Answer 11

Cartilagenous tube, extending from larynx to 5th thoracic vertebra
Structure = a series of horizontal incomplete rings of hyaline cartilage
Open portion of rings face oesphagus allows for slight expansion during swallowing
Tracheal walls = mucosa, submucosa, cartilagenous layer and adventitia

Question 12

Role of the carina and bronchi in airway management

Answer 12

Carina (base of the bifurcation) = highly sensitive and initiates cough (easily damaged)
Right bronchi = more anterior and wider so it’s easier to inadvertently pass a tracheal tube into it

Question 13

What is dead space?

Answer 13

The volume of gas in each breath that doesn’t take part in alveolar gas exchange (150 mls / 30% of each breath)

Question 14

What is tidal volume?

Answer 14

The volume of gas breathed in or out in a normal breath (7-10 mls/kg)

Question 15

What is alveolar ventilation rate?

Answer 15

AVR is respiratory minute volume (MV) - dead space (MV - DS = AVR)

MV = TV x RR

Question 16

Why are pts vulnerable to obstruction and aspiration?

Answer 16

Unconscious pts = tongue falls to the back of the pharynx obstructing the flow of gas down the trachea
Proximity of the oesphagus to the airway = loss of Gloria closure leading to and increased chance of aspiration

Question 17

Who is vulnerable to obstruction and aspiration?

Answer 17

Unconscious pts = sedated, head injury, drugs, hypothermia
Loss of swallow, cough, gag reflexes, stroke pts
Mechanical injury or obstruction = trauma, tumours, foreign body

Question 18

What equipment is needed for intubation?

Answer 18

Laryngoscope (in working order)
Styler or an introducer
Endotracheal tubes (ETT) (right size cut to length, check ballon inflates)
Working suction
Cardiac monitor
Pulse oximeter
End tidal CO2 detector

Question 19

What drugs are needed for intubation?

Answer 19

In an arrest, drugs are not needed
Sedation/induction agent (ketamine, sodium thiopental, etomidate, propofol) - check BP
Muscle relaxant/paralysing agent (rocuronium, pancuronium, vecuronium, atracurium)
Atropine and other emergency drugs
Reversal agents (neostigmine, sugammadex)

Question 20

How do you prepare a pt for intubation?

Answer 20

Position on back
Suction on
Pre-oxygenate using bag valve mask

Question 21

What is the procedure for intubation?

Answer 21

1. Open airway
2. Laryngoscope in L hand
3. ETT tube in R hand
4. View vocal cords
5. Slide ETT tube into airway along blade of laryngoscope until black line level with vocal cords
6. Inflate balloon and attach catheter mount and waters 2L rebreathing bag
7. Check tube positioning in lungs

Question 22

When is cricoid pressure used?

Answer 22

Pressure applied during intubation of a or where nil by mouth can’t be ascertained or where gastric reflux is likely

Question 23

What is the procedure for applying cricoid pressure?

Answer 23

The pressure applied must generate an occlusive pressure inexcess of oesophageal or gastric pressure
Correct amount of pressure = 20-30 newtons/2-3 kg
Application requires a dedicated rescuer who must maintain the pressure until the airway is secured by endotracheal intubation

Question 24

What are the indications for a or requiring a tracheostomy?

Answer 24

Pts requires long term ventilation (>5 days or complex weaning form ventilation)
Unable to protect own airway (stroke, head injury, loss of gag, loss of swallow, loss of cough reflexes)
Obstruction (tumours, surgical oedema, trauma)

Question 25

What are different types of tracheostomy?

Answer 25

Surgical (surgical opening with internal suturing, lower down the trachea)
Percutaneous (bedside procedure using dilational technique, just below the cricoid cartilage - between 1st+2nd or 2nd+3rd tracheal rings)

Question 26

What are the key details for a or with a tracheostomy?

Answer 26

It reduces dead space and work of breathing
Facilitates airway clearance through suction
Requires humidification
Finest rated tubes allow speech
Reuse of aspiration

Question 27

What are the different types of humidification?

Answer 27

Cold water humidifiers (50% relative humidity)
Hot water humidifiers (100% relative humidity)
Condensers (heat moisture exchange)
Aerosol generators (nebulisers)

Question 28

What are the different types of suction?

Answer 28

Oropharyngeal - yankeur

Tracheal

Question 29

What are the important things to remember when undertaking tracheostomy care ?

Answer 29

Suction pressure = 120 mmHg
Max 3 catheter passes
Catheter extraction = suction upto 10 secs, allow 20-39 secs between passes
Catheter size = no more than 1/2 the inner diameter of internal tracheal tube
Pre measure distance needed for insertion (aim 0.5 - 1cm past the distal end of the tube)

Question 30

What is the benefit of positive pressure ventilation?

Answer 30

Invasive or non invasive
Ability to manipulate ventilation to improve blood gases and reverse acidosis
Can increase tidal volume to blow off CO2
Can control RR
Can apply mode of ventilation that allow pt to do some breathing

Question 31

Complications for pts on supportive ventilation

Answer 31

Need to protect pts airway (risk of tube blockage)
Invasive ventilation increases risk of chest infection (ventilator acquired pneumonia)
Prescience of oral tube very uncomfortable
Risk of biting down on tube
Oral hygiene difficult
Large tidal volumes can cause barotrauma (pressure damage)
High O2 levels can cause inflammation (risk of ARDS)