Ch. 4: Management of the Airway

Question 1

What are the 6 main cause of upper airway obstruction?

Answer 1

1. Tongue falling back against the posterior wall of
   the pharynx, which is caused by unconsciousness or central nervous system (CNS) abnormality; patients with macroglossia (enlarged tongue) are at greater risk
2. Edema, or postextubation inflammation and swelling of the glottic area
3. Bleeding
4. Secretions
5. Foreign substances
6. Laryngospasm

Question 2

List the 6 signs of partial upper airway obstruction

Answer 2

1. Crowing, gasping sounds on inspiration (stridor)
2. Inability to cough (with a slight obstruction, the
   patient may be able to cough)
3. Increasing respiratory difficulty
4. Good to poor air exchange (depending on the
   severity of the obstruction)
5. Exaggerated chest and abdominal movement
6. Cyanosis (depending on the severity of the obstruction)

Question 3

List the 7 signs of complete upper airway obstruction

Answer 3

1. Inability to talk
2. Increased respiratory difficulty with no air
   movement
3. Cyanosis
4. Sternal, intercostal, and epigastric retractions
5. Use of accessory muscles of the neck and chest
6. Extreme panic
7. Unconsciousness and respiratory arrest if obstruction is not removed

Question 4

List the indications of an LMA (4)

Answer 4

a. Difficult face mask fit
b. Unsuccessful intubation and difficulty ventilating with bag mask
c. Unavailability of personnel trained in ET intubation
d. Elective surgical procedures

Question 5

Contraindications of LMA (2)

Answer 5

a. Health care provider not trained in the use of the LMA
b. If risk of aspiration exists

Question 6

Disadvantages of LMA (4)

Answer 6

a. Does not provide protection against aspiration
of gastric contents
b. Cannot be used if the mouth cannot be opened more than 0.6 inches (1.5 cm)
c. May not be effective when airway anatomy is abnormal
d. May be difficult to provide adequate ventilation if high airway pressures are required

Question 7

During resuscitative procedures when cardiac output and blood pressure are low, gas exchange is reduced and the CO2 detector may read near 0, even when the ET tube is in the trachea.

Answer 7

KNOW THIS.

Question 8

If the tube is inserted too far, it will enter the _______.

Answer 8

right mainstem bronchus

Question 9

What is the average distance from the teeth to the carina for males and females?

Answer 9

27 cm in males and 25 cm in females

Question 10

The carina is seen on radiographs at the __________ rib.

Answer 10

fourth rib or at the fourth thoracic vertebra

Question 11

For ET tube extubation, when should you withdraw the tube?

Answer 11

At peak inspiration

Question 12

What is the major clinical sign of glottic edema?

Answer 12

Inspiratory stridor

Question 13

Never exceed _____ seconds per intubation attempt.

Answer 13

15-20

The blade and tube in the back of the throat may stimulate the vagus nerve, which may lead to bradycardia.

Question 14

If the patient is conscious and has a partial airway obstruction, what should be done?

Answer 14

The patient should be monitored closely and allowed to try to relieve the obstruction on his or her own.

Question 15

If the patient is conscious and has a complete airway obstruction caused by food or a foreign object, what must be done?

Answer 15

abdominal thrusts must be performed until the object is dislodged.

Question 16

If the patient is unconscious and has a partial or complete airway obstruction that is most likely caused by the tongue, what can you do to help relieve the obstruction?

Answer 16

The head tilt and chin lift maneuver will help relieve the obstruction by moving the tongue forward.

Question 17

The physician wants to begin weaning a patient from a tracheostomy tube. How can this best be accomplished?

Answer 17

Change to a fenestrated tracheostomy tube.

Question 18

This airway maintains a patent airway by lying between the base of the tongue and the posterior wall of the pharynx, preventing the tongue from falling back and occluding the airway.

Answer 18

Oropharyngeal Airway

Question 19

Explain why an oropharyngeal airway should only be used on unconcious patients.

Answer 19

A conscious patient would gag on the airway, potentially leading to aspiration.

Question 20

Why should an oropharyngeal airway NEVER be taped in placed?

Answer 20

The airway must be easily removable to prevent vomiting and aspiration if the patient becomes conscious.

Question 21

Proper insertion of the oropharyngeal airway

a. Measure the airway from the ________ to ensure proper length.
b. Remove foreign substances from the mouth.
c. Hyperextend the neck.
d.** Using the cross-finger technique, open the patient’s mouth, and insert the airway with the tip pointing toward the roof of the mouth.
e. Observe the airway passing the uvula, and rotate the airway _.

Answer 21

a. Measure the airway from the corner of the lip to the angle of the jaw to ensure proper length.
b. Remove foreign substances from the mouth.
c. Hyperextend the neck.
d. Using the cross-finger technique, open the patient’s mouth, and insert the airway with the tip pointing toward the roof of the mouth.
e. Observe the airway passing the uvula, and rotate the airway 180 degrees.

Question 22

What are the hazards of the oropharyngeal airway? (4)

Answer 22

1. Gag or fight the airway (Remove it immediately)
2. If inserted wrong, the base of the tongue may be pushed back, obstructing the airway
3. If airway is too large, epiglottis may be pushed into the larynegeal area
4. If airway is too small, it may be aspirated or ineffective in relieving the obstruction.

Question 23

What type of oropharyneal airway is made of hard plastic and have a groove down either side to guide a suction catheter to the glottic area?

Answer 23

Berman

Question 24

What type of oropharyngeal airway is made of a soft, pliable material that has an opening through the middle to allow the passing of a suction catheter into the glottic area?

Answer 24

Guedel

Question 25

This airway maintains a patent airway by lying between the base of the tongue and the posterior wall of the pharynx.

Answer 25

Nasopharyngeal airway

Question 26

The nasopharyngeal airway is most commonly used to facilitate what?

Answer 26

Nasotracheal suctioning

Question 27

List the hazards of nasopharyneal airways.

Answer 27

a. An airway that is too small may be aspirated. b. Nasal irritation may result. To prevent nasal irritation, alternate nostrils daily.

Question 28

This airway is tolerated by the conscious patient and still allows the patient to eat, drink, and speak.

Answer 28

Nasopharyngeal airway

Question 29

How do you select the proper size of a nasopharygeal airway?

Answer 29

Select the proper size by measuring the airway from the tip of the nose to the earlobe. The outside diameter of the airway should be equal to the inside diameter of the patient’s internal nares.

Question 30

When inserting a nasopharyngeal airway, the flanged end should rest against ________, and the distal tip should rest _________.

Answer 30

the nose, and the distal tip should rest behind the uvula.

Question 31

When are LMA generally supposed to be used?

Answer 31

The LMA is designed to be used as an alternative to a face mask for achieving and maintaining control of the airway during surgery when tracheal intubation is not necessary, or in emergencies when ET intubation cannot be accomplished after several attempts.

Question 32

# True or false? LMAs can be used in patients of all ages, from neonates to adults.

Answer 32

True

Question 33

The LMA is inserted through the mouth and into the pharynx after being lubricated with a water- soluble gel. The device is advanced until _______.

Answer 33

resistance is met.

Question 34

# [](http://) List the advantages of the LMA (8)

Answer 34

1. Can be quickly inserted to provide ventilation 2. Delivered VT may be greater than bag-mask ventilation 3. Less gastric insufflation 4. Ventilates equally as well a ET tube 5. Simpler training 6. No risk of esophageal or bronchial intubation 7. Less risk of trauma 8. Less coughing, sore throat, hoarseness and laryngospasm

Question 35

Describe the insertion technique of the LMA

Answer 35

Using the index finger, advance the LMA until resistance is met. The cuff should be inflated until no leak is heard.

Question 36

# **Laryngeal Mask Airway (LMA)** To determine whether mild laryngospasm is present as a result of light anesthesia, what should you do?

Answer 36

Auscultate the anterolateral neck for the presence of wheezing.

Question 37

____________________ is a double-lumen tube. The tubes run parallel to each other.

Answer 37

Esophageal Tracheal Combitube (ETC)

Question 38

List the indications of an ETC. (3)

Answer 38

* Difficult face mask fit * Unsuccessful intubation and difficulty ventilating with bag mask * No one available that has been trained in ET intubation

Question 39

Contraindications of ETC (5)

Answer 39

* Patient with an intact gag reflex * Patient with known or suspected esophageal disease * Patient known to have ingested a caustic substance * Suspected upper airway obstruction because of laryngeal foreign body or pathology * Patient less than 4 feet tall

Question 40

List the advantages of the ETC. (7)

Answer 40

* Minimal training and retraining required * Visualization of the upper airway or use of special equipment not required for insertion * May be useful for patients with suspected neck injury because the head does not to be hyperextended * Face mask not needed * Can provide a patent airway with either tracheal or esophageal placement * If placed in the esophagus, allows suctioning of gastric contents without interruption of ventilation * Reduces the risk of aspiration of stomach contents

Question 41

List the disadvantages of the ETC (5)

Answer 41

* Proximal port may be occluded with secretions * Difficulty in determining proper tube location resulting in ventilation through wrong tube * Soft tissue trauma because of rigidity of the tube * Cannot suction the trachea if the tube is in the esophagus * Esophageal trauma from poor insertion technique

Question 42

# **Esophageal Tracheal Combitube (ETC)** To determine which tube to ventilate through, attach the resuscitator bag to tube No. 1 (esophageal tube) and begin bagging. If the chest rises and if breath sounds are auscultated over the lungs and no air is heard over the epigastric region, the ETC is in the ____________, and ventilation is occurring through the holes above the distal cuff.

Answer 42

Esophagus ## Footnote If the chest does not rise, or if sounds are heard only over the epigastrium, the resuscitator bag should be attached to the other tube (No. 2) and ventilation started. If the ETC is in the trachea, the chest should rise.

Question 43

# **THE KING AIRWAY** This esophageal airway is similar to the ETC. Explain the only difference.

Answer 43

It is s a single-lumen tube rather than a double-lumen tube.

Question 44

What type of patients is the King Airway used on?

Answer 44

Difficult to intubate patients to provide for adequate ventilation.

Question 45

# **THE KING AIRWAY** This airway uses two cuffs, an oropharyngeal and an esophageal cuff, that are inflated through a single channel to provide a ventilation seal. The cuffs should be inflated with ________ mL of air depending on the size of the patient.

Answer 45

45 to 90

Question 46

# **THE KING AIRWAY** Just as with the ETC, a resuscitator bag is attached to a 15-mm connector on the proximal end of the airway. Ventilation, which occurs through holes in between the cuffs, is directed through the trachea. Once adequate ventilation is achieved, the cuff pressure should be adjusted to ________ cm H2O.

Answer 46

60

Question 47

# **THE KING AIRWAY** Three sizes are available, and the appropriate size is based on the patient’s height:

Answer 47

* #3 tube for patients 4 to 5 feet tall * #4 tube for patients 5 to 6 feet tall * #5 tube for patients over 6 feet tall

Question 48

Indications of ET tubes (4)

Answer 48

a. Relief of upper airway obstruction resulting from laryngospasm, epiglottitis, or glottic edema b. Protection of the airway. The airway has four protective reflexes c. Facilitation of tracheal suctioning d. Assistance in manual or mechanical ventilation

Question 49

List some hazards of ET tubes (10)

Answer 49

* Contamination of trachebronchial tree * Cough mechanism reduced * Damage to the vocal cords * Laryngeal or tracheal edema * Mucosal damage leading to tracheal stenosis * Tube occlusion with inspissated secretions * Loss of patient’s dignity * Loss of patient’s ability to talk * Tracheal malacia * Increased airway resistance (Raw)

Question 50

What does it mean if the light source is dim or is yellowish in color on your laryngoscope blade?

Answer 50

The batteries are weak and should be replaced

Question 51

How should you maneuver the MacIntosh blade?

Answer 51

The curved blade (Macintosh) should be inserted between the epiglottis and the base of the tongue (vallecula). With a forward and upward motion, raise the epiglottis to expose the glottis and vocal cords.

Question 52

End-tidal CO2 levels are generally around what percent?

Answer 52

6%

Question 53

How should you maneuver the Miller blade?

Answer 53

The straight blade (Miller) should be placed under the epiglottis and lifted upward and forward to expose the cords

Question 54

If the tube is in the esophagus, the end-tidal CO2 reading remains would be what?

Answer 54

Near 0%

Question 55

An easier and less expensive method of monitoring exhaled CO2 levels is with the use of a disposable colorimetric CO2 detector on the proximal end of the ET tube. How does it work?

Answer 55

It will change from purple to yellow confirming that at least 6% of CO2 is in the exhaled air. It confirms that the tube is in the airway, but does not mean it is in the correct position.

Question 56

What does IT (implantation tested) mean?

Answer 56

Indicates that the material in the tube is nontoxic and does not cause tissue reaction when implanted in rabbit tissue

Question 57

List some complications of the ET tube.

Answer 57

* Poorly tolerated by conscious or semiconscious patients * Difficult to stabilize because of the movement of the tube * Stimulates oral secretions * Gagging caused by tube irritation * More difficult to pass suction catheter as a result of the curvature of the tube and poor stabilization * Hard to communicate * Harder to attach equipment to a poorly stabilized ET tube * Patient may bite the tube, occluding air flow and setting off the ventilator high-pressure alarm, which ends inspiration prematurely * Erodes corners of patient’s mouth

Question 58

# **ENDOTRACHEAL TUBE MARKINGS** What does Z-79 mean?

Answer 58

Z-79 Committee for Anesthesia and Respiratory Therapy Equipment for the American National Standards Institute. This committee ensures that the tube manufacturer is using material that is not toxic to tissues.

Question 59

# **NASOTRACHEAL INTUBATION** Nose should be anesthetized with lidocaine spray. A vasoconstrictor, such as ________, may be used to shrink nasal mucosal blood vessels for easier tube insertion.

Answer 59

phenylephrine hydrochloride (NeoSynephrine) drops

Question 60

Magill forceps are used during which of the following procedures?

Answer 60

Nasotracheal intubation

Question 61

Advantages of nasotracheal tubes (vs. oral tubes) (6)

Answer 61

(1) Easier to stabilize (2) Better tolerated by the patient because gagging is not as likely (3) Less potential for inadvertent extubation (4) Easier to attach equipment (5) Easier to pass suction catheter (6) Easier for patient to eat or drink

Question 62

Complications of nasotracheal tubes

Answer 62

(1) Pressure necrosis of the nasal tissue (2) Sinus obstruction leading to sinusitis (3) Obstruction of eustachian tube resulting in middle-ear infections (4) Septal deviation (5) Bleeding during intubation or extubation

Question 63

This tube has a port to allow for continuous or intermittent suctioning of subglottic secretions. These secretions, if not removed, may drain down past the ET tube cuff to the lower airway, increasing the incidence of infection.

Answer 63

High-Lo Evac tube

Question 64

Insert tracheostomy tubes through an incision (stoma) made between the ____________ tracheal rings.

Answer 64

Second and third

Question 65

List the indications of tracheostomies

Answer 65

a. To bypass upper airway obstruction b. To prevent problems posed by oral or nasal ET tubes c. To allow patient to swallow and receive nourishment d. For long-term airway care (ET tubes should be left in no longer than 3 to 4 weeks)

Question 66

Immediate complications of tracheostomy tubes occurring within the first 24 hours and associated with the tracheotomy procedure: List some examples

Answer 66

a. Pneumothorax b. Bleeding c. Air embolism from tearing of pleural vein d. Subcutaneous emphysema

Question 67

# **TRACH CARE** Never make a dressing by cutting the gauze pad to the proper size. Cotton filaments from the gauze pad may be absorbed into the stoma and may result in an abscess.

Answer 67

Just in case.

Question 68

If there is doubt about proper tube placement, remove the tube, cover the stoma with a sterile 4-inch gauze pad, and ventilate the patient by bag-mask ventilation.

Answer 68

Okay.

Question 69

If, after changing a tracheostomy tube, you observe subcutaneous emphysema and respiratory distress and can auscultate little or no air movement, what is likely the problem?

Answer 69

The tube is malpositioned and must be removed immediately; ventilate the patient with bag and mask.

Question 70

Which type of tracheostomy tube is used to aid in **weaning** the patient from a tracheostomy tube and to allow the patient to talk?

Answer 70

Fenestrated tracheostomy tube ## Footnote With the inner cannula removed, air may pass through the hole (fenestration) in the outer cannula, which allows for weaning from the tracheostomy tube and enables speech. **If ventilation is necessary, the inner cannula may be reinserted and the cuff reinflated.**

Question 71

This airway consists of a short, hollow tube that is used to replace the tracheostomy tube but can still maintain a patent stoma, in case problems arise. The patient has complete use of the upper airway.

Answer 71

Tracheostomy button (laryngectomy tube)

Question 72

# **CUFF CARE** Tubes should employ ________-volume, ____________- pressure cuffs only.

Answer 72

**high-volume, low- pressure cuffs** | Also called "floppy cuffs"

Question 73

Why is the minimal leak technique not recommended?

Answer 73

It may lead to silent aspiration of pharyngeal secretions, resulting in lower airway bacterial contamination, increasing the risk of VAP.

Question 74

For the Passy-Muir speaking valve to work, should the cuff be inflated or deflated?

Answer 74

DEFLATED ## Footnote The valves may be used on spontaneously breathing patients or ventilator patients. If the valve is attached to a ventilator patient, the tidal volume must be increased to compensate for gas loss through the upper airway.

Question 75

If the peak inspiratory pressure (PIP) on the ventilator decreases after the minimal leak has been determined, what should you do?

Answer 75

The leak technique should be redone at the lower pressure.

Question 76

Maximum cuff pressure is ______.

Answer 76

30 cm H2O

Question 77

If the cuff is inflated above 30 cm H2O and a leak is still heard, continue inflating the cuff using the minimal-occluding-volume technique. It may be that the ET tube is too small and that more air must be taken into the cuff to adequately seal the airway. In this case the cuff pressure does not relate to the pressure on the tracheal wall.

Answer 77

To be safe, replace the ET tube with a larger one.

Question 78

Never leave the catheter in the airway for more than _________________.

Answer 78

15 seconds

Question 79

How to do you determine the proper catheter size?

Answer 79

To estimate the proper catheter size, multiply the internal diameter of the ET tube by 2; then use the next smallest catheter size.

Question 80

What is the angled-tip catheter used to suction the left mainstem bronchus called?

Answer 80

Coude suction catheter

Question 81

List the hazards of tracheal suctioning

Answer 81

* Hypoxemia * Arrythmias * Hypotension * Atelectasis * Tissue trauma

Question 82

What is the suction level for adults?

Answer 82

-100 to -120 mm Hg (-150 mm Hg maximum)

Question 83

Cool aerosol should be utilized for ________ hours after extubation to help reduce glottic edema.

Answer 83

12-24

Question 84

If laryngospasm occurs post-extubation, administer a high FiO2 concentration and, if it persists for more than 1 to 2 minutes, administer what?

Answer 84

a bronchodilator via a handheld nebulizer

Question 85

If you hear marked or severe stridor, what must done?

Answer 85

Intubate

Question 86

If postextubation distress cannot be relieved, ___________ must be suspected.

Answer 86

Subglottic edema

Question 87

When is vocal cord ulceration susepected?

Answer 87

Suspected if hoarseness continues for more than 1 week

Question 88

What is the normal cuff pressure range?

Answer 88

20-30 **cmH20** 15-22 **mm Hg** | PAY ATTENTION to the measurements