AW Managment Flashcards
(212 cards)
1
Q
Reasons for altered AW patency
A
CNS depression from O.D. or anesthesia
Cardiac arrest
Loss of consciousness
Sleep apnea
2
Q
Loss of consciousness diminishes what reflexes?
A
Gag
Swallow
Laryngeal
Tracheal
Carinal
3
Q
Etiology of upper AW obstruction? (part or complete blockage)
A
Posterior tongue block
Foreign matter
Allergic reaction
Infection
Anatomical abnormalities
Trauma
4
Q
How to assess AW patency?
A
Speak to patient if awake (they will indicate)
If not awake, lack of breathing sounds, or chest rise
5
Q
First step to successfully resuscitation?
A
Skillful AW management
6
Q
Gold standard of securing AW?
A
Endotracheal tube
7
Q
Steps to head tilt/ chin lift?
A
Stand at side of patient
Place palm on forehead
Place fingers under bony part of chin
Tilt head backward using palm while lifting chin
8
Q
What do you use if you suspect a spinal cord injury?
A
Modified Jaw Thrust
9
Q
Indication for manual resuscitation
A
Apnea
Cardiac arrest
Impaired cough
Uncontrolled secretions
Increase O2 tension
To facilitate suctioning
Hyper inflate lungs
Need to transport unstable or intubated pt.
10
Q
What do you do before bagging?
A
Pull out reservoir
Attach to source on at least 15L/min
Select best size mask
Attach mask to bag
Occlude patient side
Squeeze bag and feel for resistance
11
Q
What happens if a NPA is too short?
A
Fails to separate soft palate from tongue
12
Q
What happens if NPA is too long?
A
Can enter vallecula and become occluded by soft tissue
Esophagus
Enter larynx and stimulate cough reflex
Can stimulate gag and vomit
13
Q
Process of insertion of NPA?
A
Measure NPA
Lubricant with water-soluble lubricant
Position patient in sniff
Introduce NPA with bevel toward nasal septum
Advance until airflow is established (start with right)
Retract AW if it meets resistance
14
Q
Steps to insert an OPA?
A
Remove foreign matter
Hyper-extend neck
Open mouth with cross finger technique
Insert AW with tip aimed up
Aw should reach uvula
Rotate 180
Rest flange at top of lip
Tamps if necessary
15
Q
Complications of OPA?
A
Iatrogenic trauma and AW hyperactivity
Minor trauma of pinching lips and tongue (common)
Ulceration and necrosis of oropharyngeal form long-term contact (days)
16
Q
Volume of air ventilated?
A
400-500 cc
17
Q
How often should you ventilate?
A
Every 5-6 seconds (10/minutes)
18
Q
What should rescuers do during resuscitation?
A
Watch chest rise
Periodically auscultation to ensure adequate ventilation
19
Q
What are other necessary measurements to obtain during bag mask ventilation?
A
Pulse oximetry and capnography
20
Q
What is a suction tip called?
A
Yankauer
21
Q
What are the four types of manual resuscitators?
A
Self-inflating bag/valve/mask
Flow Inflating
T-Piece
Automatic
22
Q
Signs that determine need for an artificial airway?
A
Upper respiratory obstruction or infection
Neuromuscular disease (particularly in crisis)
CNS damage
Pulmonary failure
Cardiac failure or insufficiency
23
Q
Signs that indicate use for a supraglottic Aw?
A
Maintain airway
Allows administration of gases
Permit manual or mechanical ventilation
Used in controlled or emergency when
intubation cannot be done
Blind insertion (orally)
Temporary airway
24
Q
Examples of a supraglottic Aw?
A
Laryngeal mask airway
Laryngeal tube airway
Combitube
25
Indications for Laryngeal tube insertion
Blindly inserted for emergency AW management
Can be first choice or backup
26
Hazard of the supraglottic Aw
Aspirations with conscious and unconscious patients (awake may gag)
Hypoventilation
Oropharyngeal mucosal injury
Injury to larynx, esophagus and related structures
Esophagus disease (strictures, varices)
Abnormal anatomy
Displacement of glottis
Moving head can move tube
27
What is the magill curve
A curve in endotracheal tube to conform to anatomy of airway (12-16 cm)
28
Description of endotracheal tube
Wide bore conduit
Can be placed through nose
Made of PVC (thermoplastic) initially rigid but warms to BT and become softer for comfort (polymeric silicone can also be used)
Has a radio opaque line for x-ray placement
29
Specific ETT for specific procedures?
Oral surgery: RAE tube
Lung surgery: a double lumen tube
30
When do we use ETTs
Artificial airway
Bypass oral cavity and pharynx
31
When do we place nasotracheal tubes?
Awake patient
Poor visualization
Oral cavity
Mobilization of neck contraindicated
32
Impact of ETT diameter
Larger tubes have less Aw resistance (easier to suction pass bronchoscope)
Larger tube increases damage
Inner diameter decreases with time (can be critical at starts 24hrs after intubation)
33
Inner diameter of endotracheal tube?
Goes up by 0.5 mm (2.5-10mm)
34
Usual size of ETT by gender?
Females: 7-8 mm
Males: 8-9 mm
35
The four types of manual resuscitation?
The self-inflating bag/valve/mask
Flow inflating
T-piece
Automatic
36
Features on the BMV
Pressure relief bag w/ mechanisms to override
A pressure-sampling port to allow monitoring PIP
Exhalation valve has a splash guard (boops and secretions)
Exhalation valve can help deliver PEEP
37
Function of BMV
Smooth-bore oxygen tubing carries O2 from source
One-way valve at O2 inlet
When the bag is squeezed, one way valve near patient opens and near inlet closes
Fresh O2 flow is diverted to a tail at rear
Exhaled gas flows from mask out an additional one-way valve
38
BMV inner and outer diameter
A standard 15 mm internal diameter fits on endotracheal tube 22 mm external diameter slips in mask
39
Application for self-inflating BVM
Adult respiratory care
Medication installation
Aerosolized medication delivery
40
What influences the FiO2 delivery through a manual resuscitator?
Correct seal
O2 flow rate
Reservoir
BVM should deliver close to 100 FiO2
Stroke volume
Refill time
RR
41
When is breath delivered for the breathing patient?
When the pressure drop is felt/ pressure triggered
42
When is a breath delivered with the apeanic patient?
Time triggered (5-6 seconds)
43
Assessing appropriate breath delivery?
Chest rise
Look for condensation in mask
Listen for leaks
Watch for gastric distention
End-tidal CO2
44
Effects of poor bagging technique?
High RR age stroke volume can decrease venous return to heart
Pressure greater than 25cmH2O can cause gastric insufflation
If against spontaneous breaths can work against the patient
45
Trouble shooting BMV problems?
A substantial decrease in pressure to deflate bag can suggest O2 inlet valve failure
If patient cannot exhale, non-rebreathing valve may be broke or jammed
Sudden lose in resistance suggest pressure sampling port has popped open
46
Hazards of BVM?
Hypoxia
Equipment failure
Poor technique
Cross-contamination
Difficult or impossible to measure VT
Difficult or impossible to measure pressure
FiO2 can’t be measured
47
Contradictions for BVM
Awake intolerant patients
Untreated pneumothorax
Facial trauma
Total upper Aw obstruction
Should be guided by the type of Aw available and patient needs
48
cons of the Automatic resuscitators
Lacks consistency, sophistication in delivery, and alarm function
49
Can you set the maximum pressure for the O2 powered demand valve resuscitator
Yes
50
Is the Demand-valve resuscitation a one hand device
Allows two-handed mask seal
51
Reasons you wouldn’t perform resuscitators?
Patient had (do not intubate)
Resuscitation has been deemed to be futile
Resuscitation can be dangerous to rescuer
52
Does the flow inflating resuscitators non-rebreathing valve close during inspiration or expiration
Lack non-rebreathing mask
53
Coordinating tasks needed with flow inflating resuscitators
Adjust gas source
Control outflow resistance from bag through flow control valve to regulate CPAP
Control force of manual compression of the bag
Maintain proper seal
54
Application for flow inflating resuscitators?
Operating room
Delivery room
Neonatal intensive care
Not often with adults
55
T-piece resuscitator flow range
Compressed gas source delivers 5-15 L/m
56
Equipment for an intubation?
Laryngoscope
ETT
Stylet
Syringe
Suction catheter
CO2 detector
OPA
NPA
Bag-valve-mask
Nasal cannula
57
Laryngoscopes use?
Visualize larynx for diagnostic, procedure, therapeutic intervention
Most common: secure Aw
3 components: handle, blade, light source
58
Benefit of pen light /slender handle?
Improve balance for smaller blades
59
Benefit of the stubby handle?
Thicker and shorter for patients with thick necks or barrel chest
60
Benefits of large handles?
Used for larger patients
61
Benefits of adjustable handle?
Can be positioned for patients with cervical spine injury, halo traction, and obesity
62
Use for the Oxford blade?
Neonates, infantes, and children
Helps with cleft palate
63
Macintosh blade design?
Used for adults
Reverse “z” shape
Variety of flange styles:
Shape
Height
Light position
Light type
64
Miller usage?
Adults- infants with flexible Aw
65
Factors of hard intubation that video laryngeal scope is used for?
Restricted oropharyngeal
Blood/secretions in Aw
Cervical spine immobilization
Obesity
66
What is the lighted stylet used for?
Blind
Awake
Laryngo-scope assisted intubation
Lubricant light wand before
67
Design for the Bougie stylet?
Blunt ended malleable wand and twice the length of the ETT
(Contradicted by children less than 8)
68
What are tube exchangers?
Semi rigid tube with O2 hole
Marked by depth and used to exchange ETT without laryngoscope
Used when ETT fails
69
What flow does the demand valve deliver
Constant 30Lpm
70
How many mLs does the demand valve resuscitator deliver
500 mL
71
Is the RR automatically set on the demand valve resuscitator
No, it can be set or manually triggered by a button
72
How does the Demand-valve resuscitation device prevent GI distension
You can limit the pressure delivery
73
What were the flaws of the older Demand-valve resuscitation device
Many of them were reported for malfunctioning
74
Where is the Demand-valve resuscitation device used
Mostly military, rescue and EMS circumstance
75
Who strongly favors the Demand-valve resuscitation device
Emergency medicine physician
76
Diameter of the flow inflating resuscitators mask connector
Has 15 mm inner diameter and 22 mm outer
77
What feature of the flow inflating resuscitators that allows the RT to bag, assess
Designed in a 90 degree angle so RT can bag standing next to them or at head of bed
78
How does the flow inflating resuscitators flow control valve regulate flow
Flow control valve regulates resistance (NOT flow, source regulates)
79
What happens if the flow going to the bag isn’t great than the patients VT (flow inflating resuscitators)
The bag will collapse
80
What does the pressure manometer display
Peak inspiratory pressure
81
What does a Anesthesia bag do
Has a medication port for med delivery to tracheal airway ( if patient is intubated)
82
What feature does the flow inflating resuscitators have to prevent too much pressure reaching patient
Pressure pop off valve
83
What do experiences practitioners think about the mapleson bag
They find it sensitive to changes in patient compliance
84
Who mostly operates the mapleson bag
Anesthesiologist
(Properly trained practitioners)
85
What population is the mapleson bag usually used on
Neonates and infantes
86
What T-piece resuscitator is used for infants
Neopuff
87
What powers and who operates the T-piece resuscitators
Gas powered
Manually operated
88
How does the T-piece resuscitators deliver flow and pressure
Provides ventilation at a set flow and delivers consistent PIP
89
What allows adjustment of inspiratory pressure using T-piece resuscitators
Incoming gas flows through spring loaded valve that allows adjustable PIP
90
Where is inspiratory pressure displayed on a T-piece resuscitator
Manometer
91
Do you need a humidifier for the T-piece resuscitators
No, you can use a non humidified circuit
92
What interface can you use with the T-piece resuscitator
Mask and endotracheal tube
93
Does the automatic resuscitator need to be tethered
Provides ventilation w/o being tethered to device
94
Automatic resuscitator use
Used for transport or emergencies
95
Benefits of the automatic resuscitator
Easy setup, little time, expedites transport
May improve compression to ventilation
96
What does “lemon” stand for
Look
Evaluate
Mallampati
Obstruction
Neck
97
Aspects of “look”
Trauma
Facial hair
Neck mass
Large tongue
Dentures
98
Aspects of “evaluation” (3-3-2)
<3 fingers between incisors
<3 between hyoid and mental
2 fingers between hyoid and tracheal cartilage
(Difficult air way)
99
Aspects of “mallampati”
Equal or greater than 3 is difficult
100
Aspects of “Obstruction”
Obstruction or obesity restricts visualization
101
Aspects of “neck”
Mobility and any restriction can cause difficulty passing
102
Positioning of head for intubation
Sniffing
103
How do you properly position patient for intubation
Elevated head
Extend head at neck
Align ears horizontally with sternal notch
104
Positioning the head of obese patients
Rolls can be utilized to elevate head
External auditory meatus is aligns with sternal notch
105
Minimal size required for bronchoscopy
7.5 mm
106
What angle does the stylet create proximal to the cuff
35 degrees
107
What is rapid sequence intubation (RSI)
Utilization of fast acting and short lived medication.
(Enhances chance of first pass success w/o aspiration)
108
What is the time period of RSI medication administration
<30 seconds (minimize time of apnea)
109
Medications used during RSI
Etomidate-sedative
Succinylcholine or rocuronium-paralytic
110
Goal of pre-oxygenation
Slow down the decline of Oxy-Hemoglobin
111
Preferred device for pre-oxygenation
Non-rebreather
112
Benefits of tracheotomy tube over endo
Endotracheal tube may not be used long-term
Patient can be taken off ventilator
Reduced risk of infection
Reduces need for sedation
Patient can talk and eat
113
Different material that can be used to make tracheostomy
Plastic
Silicone
Nylon
Metal
114
What’s unique about the silicone tracheostomy
Bivona: Does not need an inner cannula
115
Difference between nylon and metal tracheostomy
Not fenestrated
useful in decannulation process or ambulatory setting
116
Can you still get a metal tracheostomy
Yes, reusable, and customizable
May be fenestrated
117
Problem with metal tracheostomy
Ridged, flange angle is fixed, lacks 15 mm connector.
118
Parts of a tracheostomy tube
Flange
outer cannula
Cuff inflating line
Cuff
Pilot ballon
Inner cannula
Obturator
119
What does the pilot ballon do
Allows positive pressure ventilation and prevents aspiration
120
Function of the uncuffed tracheostomy
Maintain patency of stoma
Patients that don’t need mechanical ventilation
121
What does uncuffed tracheostomy do
Allow mechanical ventilation
Protect against aspiration
122
Patients that usually have uncuffed tracheostomy
Children and weaning
123
Function of tight to shaft tube
Mechanical ventilation and or minimize aspiration, while maximizing airflow
(Patients who need short term cuff inflation)
Expanded with sterile water (saline crystallize)
124
Benefits of foam cuff
Reduces pressure against the tracheal wall
125
Function of the foam cuff
Inserted after removing air from silicone cuff, allowing foam to collapse against outer cannula
After inserted pilot ballon port is open and cuff re-expands
126
Indication for a proximal tube
Thick necks
127
Indication for a distal tube
Long neck
Damage
(May have an adjustable flange)
128
Fenestrated trach capping hazard
When fenestrated excessive airflow resistance can occur
An unfenestrated inner cannula will suffocate the patient
129
What does the cuff have to look like to allow patients to speak
It has to be inflated
130
Indication for talking trach tube
Patients with vocal cord but need mechanical ventilation
131
How many liter go through the 1-several openings above the cuff to allow talking
4-6L/min
132
Where does air go to allow talking
Tubing port is occluded, and air goes to larynx allowing speech
133
First step before using a laryngoscope
Confirm light source is functioning and blade is locked in place
134
What side of the mouth and what angle do you slide in the laryngoscope
On the right side of the patients mouth
45 degree angle against the tongue
135
Which way do you push the tongue
Toward the left side of the mouth
136
Where do you insert a straight blade
Down the midline to reach the epiglottis
137
What does a straight blade lift
The mandible, tongue, and epiglottis as a unit
138
What kind of stylet and blade does a video laryngoscope use
A curved blade
A ridged stylet
139
What should you use if your first attempt at intubation is unsuccessful
A bougie:
A flexible device with an anteriorly angulated tip when VC are hard to see.
140
What does the introduction of the bougie allow
Indirect identification of cartilaginous ridges of anterior airway
141
When would you use a bougie first
If you anticipate a difficult airway
142
How many “cc”s is the syringe filled with air
5-10cc
143
Desired depth of distal tip of tube in women
19-21
144
Desired depth of distal tip in men
21-23
145
What will the extratracheal carbon dioxide waveform read
“0”
146
How far should the distal tip of the endotracheal tube be from the carina
2-6cm
147
What does the endotracheal tubes CO2 correlate with
Arterial partial pressure
148
What is the tracheal capillary perfusion pressure
25-35mmHg
149
What does low cuff pressure cause
Contributes to aspiration
150
Kettering’s cuff recommended pressure in cm H2O and mmHg
25-35 cm H2O
20-25 mmHg
151
What is the minimal occlusive volume technique (MOVT)
Air is added to a cuff to create a seal, so there is no leaks during inspiration
152
What is the Minimum Leak Technique
Just enough air is removed from cuff to allow a small leak during inspiration to test patency
153
Manual pressure test
Pilot ballon is gently pressed to estimate appropriate cuff pressure (subjective)
154
What is the most accurate way to test cuff pressure
A device is used
155
What happens if cuff pressure is too high
Mucosal damage can occur (ischemia/ decreased perfusion)
156
Hazard of low cuff pressure other than dislodging
Supraglottic content can enter the airway(oral and stomach)
157
Hazard of intubation
Mucosal or structural injury
Sympathies response (HR, BP, bronchospasm and laryngospasm)
Tube obstructed with secretions
Tube kink
Over, under, or uneven cuff
Vent associated pneumonia (VAP)
158
What do we assess before extubation
Original problem
Quantity and thickness of secretions
Upper Aw pantency
Intact gag
Able to clear secretions
Can breath without invasive ventilator
159
Steps for extubation
Assemble needed equipment
Suction
Oxygenate patient
Deflate cuff and listen
Remove tube
Apply oxygen with humidity/cool mist
Asses and reassess patient
(Good movement during auscultation)
160
How does subglottic or above the cuff suctioning work
Cuffed tube with an opening above the cuff. The opening is attached to the suction
161
Where do the arms go for the Montgomery T-Tubes
One arm goes to the trachea and the other goes to the subglottic space
162
Where do the Montgomery T-Tubes provide support
Stenotic airway (tracheal stenosis, tracheomalacia, reconstruction)
163
What size adapter is available for the Montgomery
15mm
164
Is the cuff inflated with the speaking valve
No, it allows air to enter via upper airway and trachea
165
During exhalation what happens to the speaking valves
Valves close or increases resistance redirecting air toward the larynx
166
What about the patient would contradict the speaking valves
Unconscious
Unstable respiratory status
Large amount of secretions
High O2 requirement
167
What kind of valves are most of the diaphragm speaking valves
Flapper valves
168
How does the flapper bias closed valve work
Closed except during inspiration when tracheal negative pressure opens valve
(May have more air loss affecting speech quality)
169
How does bias open valve work
Always open except during expiration
(May requires greater effort to achieve airflow)
When speaking valve used trach tube shouldn’t be 2/3 size of airway
170
How do the passkey valves work
Closed bias
171
What type of speaking valves is the Shirley speaking valve
Flappy valves
172
What are Tracie phone assist speaking valves
Unidirectional diaphragm valve
173
What are Shikani-French speaking valve
Ball valve design
174
What are trach buttons
Used to wean patients some w/ inner cannulas or caps that allow occlusion
175
Describe the trach buttons shape of
Straight, rigid, or hollow cannula that latches between skin and anterior wall of trachea
176
Proper care of trach tube
Secure
Provide means for communication
Ensure adequate humidification
Minimize nosocomial infection
Facilitate secretion clearance
Provide cuff care
Troubleshoot airway problems
177
Tracheostomy tube care (think check-off)
Assemble and check equipment
Explain procedure
Suction
Remove and clean inner cannula
Clean and examine site
Change tie/holder
Clean or replace cannula
Reassess patient
178
Hazards off tracheostomy care
Hypoxia
Dyspnea
Bleeding
Decannulation
179
Early complication with artificial airway
Laryngeal lesion
MOST COMMON:
Glottic edema
Vocal cord inflammation
Laryngeal/ vocal cord ulceration
Vocal cord polyps or granulomas
180
What are the less common but serious early artificial airway complications
Vocal cord paralysis and stenosis
181
Late complication with artificial airway
Granulomas
Tracheomalacia
Tracheal stenosis
Tracheoesophageal
Tracheoinnominate artery fistula
182
Procedure of decannulation (weaning process)
Fenestrated tube
Progressively smaller tube
Tracheostomy button
Remove trach
183
Assessing for decannulation
Original problem gone
Quantity and thickness of secretions
Upper airway patency
Intact gag reflex
Ability to clear secretions
Can sustain breathing
184
What kind of pressure does suction use
Negative pressure
185
What anatomy can suction be preform on
Oropharynx
Trachea
Mainstem Bronchi
186
Should you do tracheal suction through the mouth
No, it can cause gagging
187
Parts of the suction catheter
Tip
Catheter
Thumb-control valve
Handle
Connector for vacuum
188
Reasons respiratory therapist could consider preforming suctioning
Maintain patent airway
Specimen collection
Stimulate cough
Remove secretions
Clear obstructed airways
Patient was a depressed cough
Loss of airway reflexes
189
Suction pressure for adults
Less than 200mmHg (torr)
190
Suction pressure for neonates
Less than 120 mmHg (torr)
191
Explain a open suction
A sterile process that requires patient to be disconnected from the ventilator
192
Explain a closed suction
A sterile process that can be done while the patient is attached to the ventilator
193
First step in suctioning
Never do suction because of a schedule
Assess: breath sounds (coarse crackles)
194
Second step in suctioning (assemble and check)
Select size
External diameter should be not more than half of internal artificial airway
195
Formula for sizing catheter
Size x 3/2 = proper size
196
Third step for suctioning (oxygen)
Hyper-oxygenate patient
100% for 30-60 seconds (pediatric-adults)
10% neonates
197
Fourth step for suctioning
Insert catheter
198
Fifth step in suctioning
Suction for <15 seconds
199
Sixth step in suctioning
Re-oxygenate
200
Last step in suctioning
Monitor patient and assess outcomes
201
Who gets nasotracheal suction
Patients who do not have artificial airway
202
What position do patients assume to perform nasotracheal suction
Sniffing
203
What are non-hypoxia concerns when preforming nasotracheal suction and how do we avoid them
Gaging and regurgitation
Don’t preform immediately after meals
204
What do we do if patients have adverse effects of nasotracheal suction
Prepare to reposition and suction oropharynx
205
What does positioning in the sniffing position do
Aligns opening of the larynx with the lower pharynx
206
Advantages and function of the whistle tip catheter
Extra holes for pressure relief
Extra holes also minimize risk of biopsy
207
Advantages and function of Coude directional tip catheter
Extra holes for pressure relief
Extra holes minimize risk of biopsy
Could be directed toward right or left main stem using radiopaque line
208
Advantages and function of Aeroflot catheter tip
Tube for bronchial suction with a traumatic ring tip
One central hole and four side holes to protect mucosa from invagination and trauma
Uniformly distributed flow
209
Why use continuous suction vs intermittent suction
Continuous while withdrawing provides more efficient removal of secretions
210
How to avoid hypoxia during suctioning
Oxygenate before, during and after
211
How do you avoid atelectasis during suctioning
Limit negative pressure
Minimize suction time
Use appropriate sized suction
Avoid disconnecting from ventilator
212
How to minimize water based complications from suctioning
Don’t regularly use normal saline into artificial airway prior to suction.
Only use if needed to mobilize thick secretions
