BLOCK 6: AIRWAY MANAGEMENT Flashcards
(384 cards)
1
Q
how long can brain cells survive without oxygen before permanent damage occurs
A
6 minutes
2
Q
the upper airway includes all structures above ___
A
the glottis
3
Q
what is the glottis
A
space between the vocal cords
4
Q
what is the first and largest anatomic structure to manipulate when managing patient’s airway
A
tongue
5
Q
if the tongue is not managed during airway what does it tend to do
A
fall back into the posterior pharynx
6
Q
2 things the uvula does
A
prevents food we eat from going up your nose and triggers gag reflex when stimulated
7
Q
what is the muscular tube that extends from nose and mouth to the esophagus and trachea
A
pharynx
8
Q
the pharynx starts and ends where
A
starts: nose and mouth
ends: esophagus and trachea
9
Q
what composes the pharynx (3 in order from top to bottom)
A
nasopharynx, oropharynx, laryngopharynx
10
Q
where does the lower airway start and end
A
starts: glottis
ends: pulmonary capillary membrane
11
Q
what marks where the upper airway ends and lower airway begins
A
larynx
12
Q
shield-shaped structure palpable on the anterior neck
A
thyroid cartilage
13
Q
superior part of the thyroid cartilage that forms a V shape
A
thyroid notch
14
Q
what is laryngeal prominence also known as
A
Adam’s apple
15
Q
where is the laryngeal prominence
A
immediately inferior to the thyroid notch
16
Q
where is the thyroid cartilage located
A
directly anterior to glottic opening and vocal cords
17
Q
what does the cricoid cartilage form
A
the lowest portion of the larynx
18
Q
what is special about the cricoid cartilage
A
only circumferential ring of the trachea
19
Q
which structure is more prominent in males?
which structure is more prominent in females?
A
laryngeal prominence in males
the cricoid ring in females
20
Q
where are cricothyrotomies performed
A
the cricothyroid membrane
21
Q
what is the narrowest protion of the adult airway
A
glottis
22
Q
what is the leaf-shaped cartilaginous structure
A
epiglottis
23
Q
what closes over the trachea during swallowing
A
epiglottis
24
Q
what 3 things must be visualized before inserting ET tube
A
epiglottis, glottis, and vocal cords
25
physical act of moving air into and out of the lungs
ventilation
26
process of loading oxygen molecules onto hemoglobin molecules in the bloodstream
oxygenation
27
exchange of oxygen and carbon dioxide in the alveoli and tissues of the body
respiration
28
what is the active part of ventilation?
what is the passive part of ventilation?
active: inhalation
passive: exhalation
29
what is external respiration also called
pulmonary respiration
30
what is internal respiration also called
cellular respiration
31
what is external respiration
exchanging oxygen and carbon dioxide between alveoli and blood in pulmonary capillaries
32
what is internal respiration
exchanging of oxygen and carbon dioxide between systemic circulation and cells of the body
33
what type of problem is an overdose on CNS depressors
ventilation problem
34
what type of problem is a person trapped in a place devoid of oxygen
oxygenation problem
35
circulation of blood within an organ or tissue in adequate amounts to meet the current needs of the cells
perfusion
36
what is a dangerous condition in which the tissues and cells do not receive enough oxygen
hypoxia
37
early signs of hypoxia (5)
restlessness, irritability, apprehension, tachycardia, anxiety
38
late signs of hypoxia (3)
change in mental status, weak/thready pulse, cyanosis
39
how to assess cyanosis in dark skinned patients
mucous membranes (lips, gums, inner eyelids, and nailbeds)
40
what is dyspnea
shortness of breath
41
how does gas exchange occur
simple diffusion
42
what is a failure to match ventilation and perfusion called
V/Q mismatch
43
what contributes to most abnormalities in oxygen and carbon dioxide exchange
V/Q mismatch
44
what is normal resting minute ventilation
6L/min
45
what is normal resting alveolar volume
4L/min
46
what is normal pulmonary artery blood flow
5L/min
47
what is the ratio of ventilation to perfusion
4:5L/min or 0.8L/min
48
the ventilation-to-perfusion ratio is highest where? lowest where?
highest: apex of the lung
lowest: base of the lung
49
what is the most common airway obstruction in an unresponsive patient and what are the two indicators
tongue - improper head/neck position and snoring respirations
50
what two neuromuscular disorders can affect the ability of the CNS to control breathing
muscular dystrophy and poliomyelitis
51
how does muscular dystrophy affect the CNS's ability to control breathing
degeneration of muscle and its contractility as well as curvature of the spine
52
how does poliomyelitis affect the CNS's ability to control breathing
affects the nerves that regulate ventilation and result in paralysis
53
what three conditions are bronchoconstriction associated with
allergic reactions, asthma, and COPD
54
intrinsic factors that cause airway obstruction (3)
infection, allergic reactions, unresponsiveness
55
extrinsic reactions that cause airway obstruction (2)
trauma and foreign body airway obstruction
56
what is respiratory splinting
purposely breathing shallow to alleviate pain caused by injury such as flail chest
57
hypoventilation
CO2 production exceeds body's ability to eliminate it or CO2 elimination is depressed and can't keep up with normal metabolism
58
hyperventilation
CO2 elimination exceeds carbon dioxide production
59
if the pH of blood is too high, what happens to the patient's breathing and why
shallow/slow breaths in attempt to retain carbon dioxide
60
if the pH of blood is too low, what happens to the patient's breathing and why
hyperventilation to expel more carbon dioxide
61
what two examples can cause hyperventilation/pH acidity
hyperglycemic ketoacidosis and aspirin OD
62
decrease in minute volume leads to ____
hypercapnia
63
increase in minute volume leads to ____
hypocapnia
64
what is hypercapnia
buildup of CO2 in the blood
65
what is hypocapnia
decrease of CO2 in the blood
66
how does hypoventilation affect minute volume
goes down
67
how does hypoventilation affect CO2 elimination
goes down
68
how does hypoventilation affect CO2 levels
goes up (hypercapnia)
69
how does hyperventilation affect minute volume
goes up
70
how does hyperventilation affect CO2 elimination
goes up
71
how does hyperventilation affect CO2 levels
goes down (hypocapnia)
72
what two things have key roles in the process of respiration
atmospheric pressure and partial pressure of oxygen
73
what happens to percentage of oxygen, partial pressure, and total atmospheric pressure at higher altitudes
oxygen - stays the same
partial pressure - decreases
total atmospheric pressure - decreases
74
what is PaO2
partial pressure of oxygen
75
what makes it difficult to breathe at high altitudes
low PaO2
76
carbon monoxide has a ___x higher affinity for hemoglobin than oxygen
250
77
what is intrapulmonary shunting
blood entering the lungs from the right side of the heart bypasses the alveoli and returns to the left side of the heart in an unoxygenated state
78
what does fluid accumulation in the alveoli lead to
anaerobic respiration and increase in lactic acid accumulation
79
what is anemia
deficiency of red blood cells
80
hemorrhagic vs vasodilatory shock
hemorrhagic: decrease in blood volume caused by internal/external bleeding
vasodilatory: increase in size of blood vessels causing decrease in BP and blood flow
81
what is the fastest way the body can eliminate excess H+ ions
creating water and carbon dioxide
82
four main clinical presentations of acid-base disorders
respiratory acidosis and alkalosis
metabolic acidosis and alkalosis
83
side effect of positive pressure ventilation in patients
decreased cardiac output and preload, increased afterload, and hypotension
84
what draws air into the chest cavity
negative-pressure ventilation
85
normal adult resp rate
12-20
86
normal child resp rate
12-37
87
normal infant (1month-1year) resp rate
30-53
88
what is a clear indicator of a depressed or absent gag reflex
pooling of secretions in patient's mouth
89
what is the gag reflex
spastic pharyngeal and esophageal reflex triggered by stimulating the uvula or posterior pharynx
90
low oxygen level in arterial blood
hypoxemia
91
deficiency of oxygen at the tissue and cellular levels
hypoxia
92
lack of oxygen that results in tissue and cellular death
anoxia
93
difference between hypoxemia and hypoxia treatment
hypoxemia can be reverse by administering supplemental oxygen and hypoxia require more aggressive oxygenation and ventilatory support
94
what is adventitious breath sounds
abnormal
95
what is the upright sniffing position
patient is sitting up with head moved forward until the earlobes are on the same vertical plane as the manubrium of the sternum
96
what is the tripod position
patient is sitting up and leaning forward with elbows bent
97
proper airway management order (4)
opening airway
clearing airway
assessing breathing
providing appropriate interventions
98
what is orthopnea
positional dyspnea
99
what is breathing retractions
skin pulling between and around the ribs during inhalation
100
what muscles are used during accessory muscle use breathing
sternocleidomastoid muscles, pectoralis major muscles, abdominal muscles
101
what are staccato speech patterns
one or two word dyspnea
102
what is paradoxical motion and what does it indicate
opposite of normal chest movements (inward movement of chest segment during inhalation and outward movement of chest segment during exhalation) indicating flail chest
103
what is pulsus paradoxus and what does it indicate
drop in systolic BP of more than 10, change in pulse quality, or disappearing of pulse during inhalation indicating decompensating COPD, pericardial tamponade, or other increase in intrathoracic pressure
104
what is sneezing caused by
irritation of the nasal cavity
105
what is hiccupping
sudden inhalation caused by spasmodic contraction of the diaphragm cut short by closure of the glottis
106
what creates breath sounds
air moving through the tracheobronchial tree
107
what type of respiratory pattern is gradual increasing rate and depth of respirations followed by gradual decrease of respirations with intermittent periods of apnea and what is it associated with
Cheyne-Stokes respirations
brainstem injury
108
what type of respiratory pattern is deep, rapid respirations and what is it associated with
Kussmaul respirations
diabetic ketoacidosis
109
what type of respiratory pattern is irregular pattern, rate, and depth of breathing with intermittent periods of apnea and what is it associated with
Biot (ataxic) respirations
intracranial pressure
110
what type of respiratory pattern is prolonged, gasping inhalation followed by extremely short, ineffective exhalation and what is it associated with
Apneustic respirations
increased intracranial pressure
111
what type of respiratory pattern is slow, shallow, irregular or occasional gasping breaths and what is it associated with
agonal gasps
cerebral anoxia (shortly after heart has stopped but brain is still sending signals to the muscles)
112
what type of respiratory pattern is tachypneic hyperpnea (rapid, deep respirations) and what is it associated with
central neurogenic hyperventilation
increased intracranial pressure or direct brain injury
113
what is the inspiratory/expiratory ratio
1:2 (expiration time is twice as long as inspiration)
114
the I/E in patients with lower airway obstruction or asthma may be what ratio
1:4 or 1:5
115
what is the I/E ratio in patients with tachypnea
1:1
116
wheezing is what pitch and represents what
continuous high-pitched
constricted lower airway (asthma)
117
rhonchi is what pitch and represents what
continuous low-pitched
mucus or fluid in larger lower airways (pulmonary edema)
118
what is crackles and represents what
also known as rales
discontinuous
airflow causes mucus or fluid into the smaller lower airways
119
what is stridor and represents what
high-pitched during inspiration
foreign body aspiration, infection, swelling or trauma immediately above the glottic opening
120
what causes pleural friction rub
inflammation causing pleurae to thicken, allowing visceral and parietal pleurae to rub together
121
what does a pulse oximeter measure
percentage of saturated hemoglobin in arterial blood and patient's pulse
122
when auscultating breath sounds emergently, where do you auscultate
bilaterally at the third or fourth intercostal space in the midaxillary line
123
normal oxygenated patient should have what SpO2 level
greater than 95%
124
less than 95% SpO2 in nonsmoker suggests what
hypoxemia
125
SpO2 less than 90% accompanied with respiratory distress signals a need for what
aggressive oxygen therapy
126
hemoglobin loaded with oxygen
oxygemoglobin
127
hemoglobin from which oxygen has been released to the cells
reduced hemoglobin
128
compound formed by oxidation of iron on the hemoglobin
methemoglobin
129
hemoglobin loaded with carbon monoxide
carboxyhemoglobin
130
peak expiratory flow rate in healthy adults
350-750mL
131
what is used to evaluate bronchoconstriction and with what tool
peak rate of forceful exhalation with peak expiratory flowmeter
132
what ABG measurements are used to evaluate patient's acid-base status and what is the normal range of both
pH and Hco3-
pH: 7.35-7.45
Hco3-: 21-28mEq/L
133
what ABG measurement is used to evaluate patient's effectiveness of ventilation and what is the normal range
PaCO2
35-45mm Hg
134
what ABG measurements are used to evaluate patient's oxygenation and what is the normal range of both
PaO2 and SaO2
PaO2: 80-100mm Hg
SaO2: above 95%
135
what is the "smoke of metabolism"
carbon dioxide
136
how many ATP does aerobic metabolism create from each glucose molecule
38
137
how many ATP does anaerobic metabolism create from each glucose molecule
2
138
what is the recommended method of monitoring placement of advanced airway device
capnography
139
what reading approximates the arterial PaCO2 level and by how close
ETCO2 level is usually 2-5mmHg lower than arterial PaCO2 levels
140
what happens to CO2 levels after ROSC
abrupt and sustained increase
141
colorimetric carbon dioxide detector function
treated paper turns from purple to yellow during exhalation signifying presence of carbon dioxide
142
Phase 1 (A-B) of capnography waveform
respiratory baseline
initial stage of exhalation (dead space gas free of CO2)
143
Phase II (B-C)
expiratory upslope
alveolar gas mixes with dead space gas
144
Phase III (C-D)
alveolar plateau
all alveolar ga, max CO2 level
145
Phase IV (D-E)
inspiratory downstroke
displaces CO2 causing waveform to return to base level
146
what happens to waveform during hypoventilation
high waveforms, prolonged alveolar plateau, and longer-than-normal intervals between waveforms
147
what happens to waveform during hyperventilation
small waveforms, short alveolar plateau, shorter-than-normal intervals between waveforms
148
what is "shark fin" waveform
caused by bronchospasms
gradual upsloping phase II (B-C)
149
how is rebreathing CO2 shown on waveform
waveforms elevate and never return to the baseline at the end of the inspiratory downstroke phase IV (D-E)
150
cause of too high CO2 in apneic with a pulse patient
positive-pressure ventilation is too slow
151
cause of too low CO2 in apneic with a pulse patient
positive-pressure ventilation is too fast
152
cause of too high CO2 in apneic and pulseless patient
positive-pressure ventilation is too slow or could indicate ROSC
153
cause of too low CO2 in apneic and pulseless patient
misplaced ET tube, prolonged arrest, inadequate chest compressions, positive-pressure ventilation is too fast
154
preferred technique for opening the airway of a patient without cervical spine trauma
head tilt-chin lift maneuver
155
assessing breathing in an unresponsive patient should take no longer than ____
10 seconds
156
preferred technique for opening the airway of a patient with suspected cervical spine trauma
jaw-thrust maneuver
157
which maneuver to use on a jaw-fracture and why
jaw-thrust to keep tongue away from back of throat
158
preferred technique for opening a patient's airway for suctioning or inserting an airway
tongue-jaw lift maneuver
159
mechanical or vacuum-powered suction units should be capable of at least ___ mm Hg with ___ seconds
300, 4
160
tonsil-tip catheter and what they are good options for
large diameter and rigid
suctioning oropharynx in adults, kids, and infants
large volumes of fluid rapidly
161
all names for rigid pharyngeal suction tips
tonsil-tip, Yankauer, DuCanto
162
whistle-tip catheters and what they are good options for
smaller diameter, soft nonrigid catheters
suctioning oropharynx/nasopharynx, down an ET tube, or stomas
163
all names for nonrigid plastic catheters
French or whistle-tip catheters
164
be careful not to stimulate the back of the throat especially in young children/infants because
can induce a vagal response and cause bradycardia
165
how to measure for proper sized catheter
from corner of the mouth to the earlobe or angle of the jaw
166
apply suction in a ___ motion
circular
167
an oropharyngeal (oral) airway is designed to do what
hold the tongue away from the posterior pharyngeal wall
168
rough airway insertion can do what
injure the hard palate and cause oral bleeding
169
nasopharyngeal (nasal) airway size range
12Fr-36Fr
170
contraindication to nasopharyngeal airways
facial or skull fractures, can enter the cranial vault through the hole caused by the fracture
171
in adults, sudden foreign body airway obstruction usually occurs ____
in children, it usually occurs ____
during a meal
while eating or playing with small toys
172
typical foreign body obstruction patient
middle-aged or older
wears dentures
consumed alcohol or has a condition (stroke) that decreases airway reflexes
173
dysphonia
difficulty speaking
174
aphonia
inability to speak
175
what is a laryngeal spasm and what is it usually caused by
spasmodic closure of the vocal cords, completely occluding the airway
usually caused by trauma during overly aggressive intubation attempt
176
what is laryngeal edema and what is it usually caused by
causes glottic opening to become extremely narrow or totally closed
usually caused by epiglottitis, anaphylaxis, inhalation injury (burns to upper airway)
177
most effective means of dislodging mild airway obstruction
forceful cough
178
what is lung compliance
ability of alveoli to expand when air is drawn or pushed into the lungs during ventilation
179
what is poor lung compliance characterized by
increased resistance during ventilation attempts
180
at what oxygen level in the air can side effects start to occur
19%
181
Heimlich maneuver aka ___
abdominal thrust maneuver
182
what to do instead of Heimlich in patients with advanced stages of pregnancy or morbid obesity
chest thrusts
183
what is a direct laryngoscopy and what do you use to remove the foreign body from the upper airway
visualization of the airway with a laryngoscope
Magill forceps
184
what can giving a patient who does not need oxygen cause
oxidative stress and hyperoxic injury
185
most common oxygen cylinder class and amount in field
D cylinder - 350L of oxygen
186
most common oxygen cylinder class and amount stored on the ambulance
M cylinder - 3,000L of oxygen
187
when to replace oxygen cylinder with new one (safe residual pressure)
200psi or lower
188
formula for determining duration of flow for oxygen cylinder
(tank pressure PSI - 200PSI) x (cylinder constant/flow rate in L/min) = duration of flow in minutes
189
do not subject oxygen cylinders to temperatures greater than ___ degrees (F/C)
125F / 50C
190
have the oxygen cylinder hydrostatically tested every ____
10 years
191
pressure of gas in a full oxygen cylinder
2,000psi
192
what is a therapy regulator
reduces high pressure of gas in oxygen cylinder to a safe range of about 50psi
193
which flowmeter, the pressure-compensated or the Bourdon-gage flowmeter, is affected by gravity and how do you have to treat it differently
pressure-compensated, must remain in upright position
194
what usually causes hiccups
swallowed air which leads to spasming of the diaphragm
195
where to listen for lung sounds
second, fifth, and seventh intercostal space
196
nonrebreathing mask flow rate and FIO2
12-15L/min, 90%
197
nasal cannula flow rate and FIO2
1-6LPM, 24-44%
198
partial rebreathing mask flow rate and FIO2
6-10LPM, 35-60%
199
tracheal normal breath sounds
inspiratory/expiratory are both loud
200
bronchial normal breath sounds
inspiratory are shorter than expiratory, both are loud
201
bronchovesicular normal breath sounds
inspiratory/expiratory are both medium intensity
202
vesicular normal breath sounds
inspiratory sounds last longer than expiratory sounds, both are faint
203
two treatment options for patients with severe respiratory distress or failure
positive-pressure ventilation with bas-mask device or CPAP
204
what can aggressive positive-pressure ventilation do to patient
impair patient's hemodynamics and push air into stomach
205
formula for cardiac output
stroke volume x pulse rate
206
what is gastric distention
air in the stomach
207
what happens to air movement during PPV
air forced into lungs
208
what happens to blood movement during PPV
intrathoracic pressure is increased, venous return/preload is impaired, stroke volume and cardiac output are reduced
209
what happens to airway wall pressure during PPV
more volume is required to have same effects as normal breathing which results in walls being pushed out of their normal anatomic shapes
210
what happens to esophageal opening pressure during PPV
air is forced into the stomach causing gastric distention resulting in vomiting and aspiration
211
what happens to overventilation during PPV
forcing volume and rate results in increased intrathoracic pressure, gastric distention, and decreased cardiac output (hypotension)
212
how much air can patient receive with mouth-to-mask technique
up to 55%
213
max suctioning time for adults, children, and infants
adult: 15 seconds
child: 10 seconds
infant: 5 seconds
214
ventilation rate for 12-14 (onset of puberty) and older
1 breath every 6 seconds for 10 breaths/min
215
ventilation rate for infants/peds up to onset of puberty
1 breath every 2-3 seconds for 20-30 breaths/min
216
adult bag-mask device reservoir bag volume
1200-1600mL
217
pediatric bag-mask device reservoir bag volume
500-700mL
218
infant bag-mask device reservoir bag volume
150-240mL
219
how much tidal volume to deliver to adult via bag-mask to produce visible chest rise
500-600ml (6-7mL/kg)
220
deliver each breath with bag-mask over what period of time
1 second
221
when should you also wear a protective gown when managing airway
significant blood splashing or if the patient is suspected of having infection respiratory infection (SARS, TB, covid)
222
what technique to use for single rescuer bag-mask ventilation
EC clamp technique
223
what to do if the patient's stomach rather than the chest is rising and falling
reposition the head, if spinal injury is present then reposition the jaw
224
what does the automatic transport ventilator AC mode do
assist/control - controls work of breathing but allows patient to set the respiratory rate
225
what does the automatic transport ventilator SIMV mode do
synchronized intermittent mandatory ventilation - sets the respiratory rate and volume/pressure delivered and syncs with each patient-initiated breath
226
what does the automatic transport ventilator pressure support mode do
uses positive pressure to overcome airway resistance to increase patient's spontaneous breaths (requires patient to be able to initiate breath)
227
ATV is set based on what and why
the patient's ideal body weight, not actual body weight because adult lungs do not increase in size or hold more volume due to increased body weight
228
how much oxygen does ATV consume
5 L/min
229
what can happen if the ATV's pressure relief valve fails or if ventilation is too fast/too forceful
barotrauma
230
atelectasis
alveolar collapse
231
what about pediatrics makes it more difficult to achieve effective mask-to-face seal compared to adults
flat nasal bridge
232
length-based resuscitation tape can be used to estimate appropriate size of bag-mask valve for patients up to what weight
75lbs/34kgs
233
accidentally placing pressure on pediatrics' eyes while ventilating can do what
stimulate oculocardiac reflex which can decrease HR and BP
234
contraindications for CPAP
unable to protect airway, hypoventilation, hypotension, pneumothorax, head/facial injury, cardiogenic shock, tracheostomy, GI bleeding, nausea/vomiting, recent GI surgery
235
what generates PEEP and what is PEEP
patient exhaling against resistance (expiratory positive airway pressure) generates PEEP
PEEP: positive end-expiratory pressure
236
therapeutic PEEP range
5-10cm H2O
237
CPAP units can empty a D cylinder in ___ minutes
5-10
238
CPAP FIO2 level
30-35%
239
possible effects of CPAP
pneumothorax from barotrauma, increased pressure in chest cavity leading to hypotension, gastric distention
240
who should get humidified O2
burn patients
241
how is BPAP different from CPAP
bilevel positive airway pressure - delivers two pressures
1. inspiratory positive airway pressure to open lower airways
2. lower expiratory positive airway pressure to help keep lower airways open
242
how to perform assisted ventilation
match the first 5-10 breaths then slowly adjust the rate
243
how is invasive gastric decompression performed
inserting gastric tube through mouth or nose into patient's stomach and removing contents with suction
244
use caution when inserting NG/OG tubes on which patients and never use NG/OG tubes on which patients
caution: esophageal disease (tumors, varices, strictures)
never: non-patent esophagus
245
how to confirm proper placement of NG/OG tube
auscultate over epigastrium while injecting 20-30mL of air into the tube and/or observe for gastric contents in tube (no reflux around tube)
246
what is gastric lavage
cleaning out the stomach's contents (usually patients who ingested toxins)
247
laryngectomy
surgical removal of larynx
248
tracheostomy
surgical opening of trachea
249
stoma
orifice that connects trachea to outside air
250
limit suctioning of stoma to ___
10 seconds
251
how to suction a stoma
inject 3mL of sterile saline through stoma into trachea, tell patient to exhale, insert catheter without providing suction until resistance is felt (no more than 12cm), suction while withdrawing catheter
252
what adapter size must be on tracheostomy tube to be compatible with ventilatory devices
15/22mm
253
if a tracheostomy tube becomes dislodged, what can occur
stenosis (narrowing) of the stoma
254
which dental appliances to leave in and which to remove
leave in place: well-fitted ones maintain facial structure
remove: loose-fitted ones could become an airway obstruction
255
what obstruction often contain sharp metal ends that can easily lacerate the pharynx or larynx
bridges
256
facial injuries should increase your index of suspicion for ____
cervical spine injury
257
do not proceed to advanced airway management too early, do it only for two reasons:
failure to maintain patent airway and/or failure to adequately oxygenate and ventilate
258
mnemonic to guide assessment of difficult airway
LEMON
Look externally
Evaluate 3-3-2
Mallampati classification
Obstruction
Neck mobility
259
difficulties for airway just by looking at patient
short, thick necks
morbid obesity
dental conditions like overbite or buck teeth
260
what is the evaluate 3-3-2 of LEMON
3 - patient's mouth should open at least 3 fingerbreadths
3 - length of mandible should be at least 3 fingerbreadths long (from tip of chin to hyoid bone)
2 - distance from hyoid bone to thyroid notch should be at least 2 fingerbreadths wide
261
what is the Mallampati classification
oropharyngeal structures visible in an upright, seated position in full conscious, alert patient who is able to open mouth
262
what is the Cormack-Lehane classification
classifies views obtained by laryngoscopy based on the structures seen
263
Class I of Mallampati classification
entire posterior pharynx is fully exposed
264
Class II of Mallampati classification
posterior pharynx is partially exposed
265
Class III of Mallampati classification
posterior pharynx cannot be seen; base of uvula is exposed
266
Class IV of Mallampati classification
no posterior pharyngeal structures can be seen
267
Class I of Cormack-Lehane classification
full view of epiglottis, arytenoid cartilage, and vocal cords is available
268
Class II of Cormack-Lehane classification
epiglottis is in full view but only a portion of the glottis or arytenoid cartilage can be seen
Class 2a: partial view of the glottis
Class 2b: arytenoids or posterior part of vocal cords barely visible
269
Class III of Cormack-Lehane classification
only epiglottis can be seen - glottis nor arytenoid cartilage is visible
270
Class IV of Cormack-Lehane classification
neither epiglottis nor glottis is visible
271
ideal position for visualization and intubation
sniffing position - ears aligned with sternal notch
272
what is endotracheal intubation
ET tube passed through glottic opening and tube is sealed with cuff inflated against tracheal wall
273
disadvantage of ET intubation
bypasses warming, filtering, and humidifying functions of the upper airway
274
what is the use of the ET tube's pilot balloon
indicates whether distal cuff is inflated or deflated after the tube has been inserted
275
what is the purpose of the ET tube's Murphy eye
enables ventilation to occur even if the tip becomes occluded by blood, mucus, or tracheal wall
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ET tube diameter and length size range
diameter: 2-10mm
length: 12-32cm
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what ET sizes are equipped with distal cuff
5-10mm
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normal ET tube size for adult female and adult male
female: 7-7.5mm
male: 7.5-8mm
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what is the stylet used for
guides the tip of the tube over the arytenoid cartilage and through the vocal cords
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how should a stylet be formed and where should it be placed in ET tube
"hockey stick curve"
at least 0.5inch (1cm) back from the end of ET tube
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normal ET tube size for pediatrics
2.5-5mm
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why are distal cuffs not needed for pediatrics
the cricoid ring (narrowest part of peds airway) forms a seal with the ET tube
283
good estimates of the diameter of the glottic opening
diameter of nostril or little finger
length-based tape for peds
284
what is the laryngoscope straight and curved blade called
straight: Miller
curved: Macintosh
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what population is the straight laryngoscope blade used for and why
infants and small children because the tip directly lifts up the epiglottis
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where is the tip of the curved laryngoscope blade placed
vallecula (space between epiglottis and base of the tongue)
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blade sizes for laryngoscopes
0-4
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blade sizes for children and adults
children: 0, 1, 2
adults: 3(average size), 4 (larger people)
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how long to preoxygenate an apneic or hypoventilating patient before intubation
2-3 minutes to as close to 100% as possible
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what are the piriform fossae
pockets on both sides of laryngeal inlet
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what are the aryepiglottic folds
soft tissue separating larynx from piriform fossae
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three axes of the airway
oral, tracheal, pharyngeal
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in most supine patients, the sniffing position can be achieved by ____
elevating the occiput 1-2 inches
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what side to insert blade into patient's mouth and why
right side to sweep the tongue to the left side of mouth
295
what is the critical structure to identify during laryngoscopy
epiglottis
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bougie bend at the distal tip
30 degrees
297
what is the bougie used for
epiglottis-only views to facilitate intubation
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when you meet resistance with the bougie, you know that it is where
at the level of the carina
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what is the purpose of the bend at the end of the distal tip of the bougie
enables you to feel the tracheal rings
300
once the ET tube passes through the vocal cords, what do you do with the tube
rotate it to the right and direct the tip downward to follow the trachea
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how far to advance the ET tube
until proximal end of the cuff is 0.5 to 0.75inches past the vocal cords
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what is the most reliable method of confirming the tube has entered the trachea
visualizing the ET tube passing between the vocal cords
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how much air to inflate into the distal cuff
5-10mL
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what can overinflating the distal cuff cause
ischemia or necrosis of the tracheal wall which leads to tracheal stenosis (narrowing)
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how to determine if the tube migrated after placement
note the depth of the ET tube at patient's teeth after placement
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if copious vomit is being emitted from the ET tube, ___
do NOT remove it
inflate distal cuff, turn tube to the side, and ventilate with bag-mask device
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what does breath sounds only on right side of chest indicate and how to correct it
tube was advanced too far and entered the right main stem of bronchus
deflate cuff, slowly retract tube while listening for breath sounds over left side of chest until bilateral breath sounds are present
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what is the most reliable method for confirming and monitoring placement of ET tube
waveform capnography
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with a firmly secured tube, the tip can move ____
2 inches
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if the patient's head is hyperflexed, what happens to the tube? if the head is hyperextended?
ET tube can be pulled out of the trachea
Et tube could be pushed farther into the trachea and into a main stem bronchus
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what is nasotracheal intubation and what is the other term for it
insertion of ET tube into trachea through nose without directly visualizing the vocal cords
"blind" intubation
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nasotracheal intubation is only performed on what patients
patients with spontaneous breathing
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contraindications of nasotracheal intubation
head trauma, deviated septum, nasal polyps, frequent cocaine use, blood-clotting abnormalities
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standard ET tubes should be how much smaller when inserted nasally
1-1.5 mm smaller
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how to advance nasotracheal tube
advanced as patient inhales
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which nostril for nasotracheal intubation, how to adjust if you have to use other nostril
right nostril, if left nostril must be used, rotate tube 180 degrees
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devices used to determine maximum airflow during nasotracheal intubation
humid-vent 1, beck airway airflow monitor (BAAM), stethoscope with head removed
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if you see a soft-tissue bulge on either side of the airway after inserting nasopharyngeal tube, what probably happened
the tube has probably been inserted into the piriform fossa
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what is the definition of a "failed airway"
failure to maintain adequate ventilation and oxygenation regardless of techniques of airway management being used
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tracheobronchial suctioning
passing a suction catheter into the ET tube to remove pulmonary secretions
321
what can tracheobronchial suctioning cause
cardiac dysrhythmias and cardiac arrest
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what to do before tracheobronchial suctioning
preoxygenation and inject 3-5mL of sterile water down ET tube to loosen extremely thick pulmonary secretions
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what can happen when extubation is performed on responsive patients
high risk of laryngospasm and upper airway swelling
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complications with sedation in airway management are usually what
undersedation and oversedation
325
examples of benzodiazepine sedative-hypnotics
diazepam (valium) and midazolam (versed)
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examples of dissociative anesthetics
ketamine (ketalar)
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examples of opioid sedative-analgesics
fentanyl (sublimaze) and alfentanil (alfenta)
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examples of non-opioid/nonbarbiturate sedative-hypnotics
etomidate (amidate)
329
two major classes of sedatives commonly used in airway management and what they do
analgesics: decrease perception of pain
sedative-hypnotics: induce sleep and decrease anxiety (do not reduce pain)
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benzodiazepines produce what
anterograde amnesia
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midazolam vs diazepam
midazolam is 2-4x more potent than diazepam, faster acting, and shorter duration of action
332
potential side effects of benzodiazepines
respiratory depression and hypotension
333
what is a benzodiazepine antagonist
Flumazenil (Romazicon)
334
what is a dissociative anesthetic
produces anesthesia by distorting patient's perception of sights/sounds and inducing dissociation
335
what is reemergence phenomenon
occurs during half-life of ketamine when patient is awakening - causes pleasant dreams, vivid nightmares, or delirium
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what are opioids
act as CNS depressant and produce insensibility or stupor
337
how much more potent is fentanyl than morphine
70-150x
338
alfentanil in comparison to fentanyl
alfentanil is less potent with faster onset of action, shorter duration of action, and eliminated from body quicker
339
what sedative causes myoclonic muscle movement
Etomidate (Amidate)
340
how long after receiving IV dose of paralytic will a patient become totally paralyzed
1-2 minutes
341
how do depolarizing neuromuscular blockers work
competitively bind with ACh receptor sites - causes depolarization of muscle and prevents future signs for depolarization
342
example of depolarizing neuromuscular blocker
succinylcholine chloride (anectine)
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what does succs cuase
fasciculations
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succs onset, duration, contraindications, and side effect
onset: 60-90 secs
duration: 5-10mins
contraindications: conditions that can result in hyperkalemia (burns, crush injuries, blunt trauma)
side effects: bradycardia
345
how do nondepolarizing neuromuscular blockers work
bind to ACh receptor sites, do not cause depolarization of muscle fiber
346
examples of nondepolarizing neuromuscular blockers
vecuronium, pancuronium, rocuronium
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glottic opening in infancy, age 7, and adult
infancy: C1
age 7: C3-4
adult: C4-5
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what should be avoided after administering a paralytic agent if possible
bag-mask ventilation
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if your choice of paralytic is succs, consider what two medication administrations
defasciculating dose of 10% of normal dose of nondepolarizing paralytic and atropine sulfate to decrease bradycardia risks
350
ETT size for pediatric patient formula
(age/4) + 4
351
if patient is hemodynamically unstable (systolic BP less than 90mm Hg) what should be considered over benzos
ketamine or etomidate
352
two signs of adequate paralysis
apnea and laxity of mandible
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what to do with patient who requires ET intubation but cannot be preoxygenated due to mental status
DSI (delayed sequence intubation)
354
how to perform DSI
administer dissociative dose of ketamine, administer 15LPM via nonrebreathing mask and NC, after maintaining oxygen for 3mins, administer paralytic
355
what is denitrogenation
replacing alveolar nitrogen with oxygen
356
what degree to have bed elevated to for RSI
15-30 degrees
357
what is the single-lumen airway blindly inserted into the esophagus
King LT Airway
358
main disadvantage of the LMA
does not protect against aspiration and may increase risk of it
359
what size ET tube can be passed through a size 3 or 4 LMA
6mm
360
i-gel allows for passage of what size gastric tube
10Fr
361
iGel size 3 color and weight
yellow
30-60kgs
362
iGel size 4 color and weight
green
50-90kgs
363
iGel size 5 color and weight
orange
over 90kgs
364
where are the superior cricothyroid vessels located
run at transverse angle across upper third of cricothyroid membrane
365
where are the carotid arteries located
run vertically lateral to the cricothyroid membrane
366
where does the ET tube or tracheostomy get inserted during cricothyrotomy
subglottic area (below vocal cords) of the trachea
367
age contraindicated for surgical cricothyrotomy
under 8 years old (use needle cricothyrotomy)
368
how to make your cut for a surgical cric
vertical 0.5-0.75inches
369
crics on obese patients run a risk of what
false passage of the tube undermining the subcutaneous tissue
370
what is subcutaneous emphysema
air infiltrates the subcutaneous (fatty) layers of the skin
characterized by "crackling" sensation when palpated
371
what to use to cut for cric
number 10 scalpel
372
what gauge needle for needle cric
12-16 gauge
373
how to insert needle for needle cric
45 degrees caudally (towards feet)
374
what is the cylinder constant for D
0.16
375
what is the cylinder constant for M
1.56
376
what age range is croup most common in
6 months - 6 years
377
what time of year is croup more prominent in northern areas
October-March
378
what two conditions are commonly mistaken for epiglottitis until an abscess is seen
peritonsillar abscess and retropharyngeal abscess
379
what is diphtheria
bacterium attacks and kills epithelial tissue creating a pseudomembrane
380
what is aspiration pneumonitis
gastric acid irritates the lung tissue after it is aspirated
381
what increases risk of aspiration in patients with tube feedings
if they are placed supine immediately after a large feeding
382
three most chronic obstructive lower airway diseases
emphysema, chronic bronchitis, asthma
383
how is bronchospasm different from edema
bronchospasm: muscle contracts causing entire tube to narrow
edema: wall of tube swells causing only lumen to narrow
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