Chapter 7: Airway Management and Ventilation

Question 1

What is the most common site for airway obstruction?

Answer 1

Pharynx - soft palate and epiglottis

Question 2

What are some common causes for pharyngeal airway obstruction?

Answer 2

1. Vomit/blood
2. Regurgitation
3. Tongue
4. Trauma
5. Foreign Body

Question 3

What are some common causes for laryngeal airway obstruction?

Answer 3

1. Oedema - burns, inflammation or anaphylaxis
2. Spasm - airway stimulation or foreign material

Question 4

What can cause airway obstruction below the larynx?

Answer 4

1. Bronchial secretions
2. Bronchospasm
3. Mucosal oedema
4. Pulmonary oedema
5. Aspiration of gastric contents
6. Extrinsic compression at any level

Question 5

What is seesaw breathing?

Answer 5

1. Complete airway obstruction
2. In a patient who is making respiratory efforts
3. Causes paradoxical chest and abdomen movement
4. Called see-saw breathing

Question 6

What signs may be seen in airway obstruction?

Answer 6

1. Stridor/wheeze/gurgling/snoring
2. Use of accessory muscles
3. Tracheal tug
4. Intercostal and subcostal recessions
5. Reduced air entry
6. See-saw breathing

Question 7

How do you identify complete airway obstruction in patients with apnoea?

Answer 7

1. Spontaneous breathing movements are absent
2. Failure to inflate lungs during attempted PPV

Question 8

How should patients with a tracheostomy or permanent tracheal stoma with an airway obstruction be managed?

Answer 8

1. Remove tube/stoma & replace
2. Ventilate by sealing stoma

Question 9

What are the signs of severe choking?

Answer 9

1. Can’t speak
2. Can’t breathe
3. Breathing sound wheezy
4. Attempts at coughing silent
5. Pt. may be unconscious

Question 10

What are the signs of mild choking?

Answer 10

1. Able to breathe
2. Able to cough
3. Able to speak
4. Respond to question

Question 11

How would you manage someone who is choking with a mild airway obstruction?

Answer 11

1. Encourage them to cough
2. Continually assess for deterioration

Question 12

How would you manage someone who is choking with severe airway obstruction?

Answer 12

1. Conscious - 5 back blows and 5 abdominal thrusts
2. Unconscious - start CPR

Question 13

How do you give back blows?

Answer 13

1. Stand to side & slightly behind patient
2. Support chest with 1 hand
3. Lean patient forward
4. Give 5 sharp blows between scapulae with heel of hand
5. Check to see if airway obstruction relieved after each blow

Question 14

When and how do you do abdominal thrusts?

Answer 14

If back blows fail = give 5 abdominal thrusts

1. Stand behind pt
2. Put both arms round upper abdomen
3. Place clenched fist under xiphisternum and
4. Grasp with other hand
5. Pull sharply inwards and upwards
6. Repeat 5 times

Question 15

What should be done if 5 back blows and 5 abdominal thrusts hasn’t relieved airway obstruction?

Answer 15

1. Continue alternating back blows and abdominal thrusts
2. If pt become unconscious - begin CPR
3. Once appropriate individual arrive - laryngoscopy and remove FB with Magill forceps

Question 16

How should the airway be opened in a patient with suspected C Spine injury?

Answer 16

1. Maintain head, neck, chest and lumbar region in neutral position
2. Can use jaw thrust or chin lift with manual in line stabilisation
3. NO HEAD TILT

Can add head tilt if life threatening airway obstruction persist

Question 17

What airway adjuncts are available to use?

Answer 17

Oropharyngeal (Guedel)

Nasopharyngeal

Question 18

What oxygen should you give when doing CPR?

Answer 18

1. 100% O2 until ROSC is achieved
2. After this, give high flow until Sa02 can be measured reliably

Question 19

What can you use to remove fluid in an airway obstruction?

Answer 19

1. Suction - wide bore rigid sucker (Yankauer)

2. Use cautiously if intact gag reflex
3. Fine bore may be req. if limited mouth opening

Question 20

What is the issue with high pressure airways due to inspiratory flows that are too high when ventilating?

Answer 20

1. Gastric inflation
2. Risk of regurgitation
3. Risk of subsequent pulmonary aspiration
4. Gastric inflation further reduce lung compliance - ventilation more difficult

Question 21

What tidal volume do you aim to provide when ventilating a patient? How quickly should it be given

Answer 21

6-7 mL/kg

Give over 1s

Question 22

How much oxygen can you give in a self-inflating bag?

Answer 22

1. Air = 21%
2. High flow oxygen directly to bag = 45%
3. High flow oxygen in reservoir = 85%

Question 23

How can you reduce risk of gastric inflation?

Answer 23

Apply cricoid pressure

Question 24

What ways can you ventilate a patient?

Answer 24

1. Mouth to mask ventilation
2. Self-inflating bag/bag-valve mask
3. Automatic resuscitators
4. Passive oxygen delivery
5. LMA - I-Gel airway, Proseal LMA

Question 25

What are the limitations of a laryngeal mask airway?

Answer 25

1. Risk of significant **leak** if high airway **resistance** or poor lung compliance - **hypoventilation** 2. Uninterrupted chest **compressions** can lead to gas **leak** 3. Theoretical risk of **aspiration** but v low 4. **Difficult insertion** if pt. not deeply unconscious 5. **Won't work** if airway **obstruction** cause epiglottis to fold over laryngeal inlet

Question 26

What are the benefits and weaknesses of the proseal laryngeal mask airway over a standard LMA?

Answer 26

1. Additional **posterior cuff** and **gastric drain tube** - **improved** laryngeal **seal** enabling ventilation at higher pressure - regurgitated **fluids** can be **drained** Weaknesses 1. More **difficult** to **insert** 2. Relatively **expensive** 3. Req. **sterilisation** between uses

Question 27

What are the advantages to intubation over bag mask ventilation?

Answer 27

1. Maintenance of patent airway that is **protected** from **aspiration** 2. Ability to provide **adequate tidal volume** during uninterrupted chest compressions 3. **Free up** recur **hands** 4. Ability to **suction airway secretions**

Question 28

What are the disadvantages to tracheal intubation over bag mask ventilation?

Answer 28

1. Risk of unrecognised **misplaced tube** 2. Prolonged **time without** chest **compressions** 3. Comparatively **high failure rate**

Question 29

What can be done in circumstances where intubation is contraindicated?

Answer 29

1. Use of anaesthetic **drugs** 2. **Videolaryngoscopy** 3. **Flexible fiberoptic** laryngoscopy

Question 30

What equipment is required for tracheal intubation?

Answer 30

1. **Laryngoscope** 2. Cuffed tracheal **tubes** 3. **Syringe** - cuff inflation 4. Equipment to confirm correct placement - aspirate / stethoscope 5. Water soluble lubricating **jelly** 6. Magill **forceps** 7. **Bougie**/semi-rigid stylet 8. **Tape** to secure 9. **Suction** apparatus

Question 31

What is done after intubation?

Answer 31

1. **Inflate cuff** of tracheal tube - prevent leak 2. **Connect tube** to ventilating device 3. **Confirm correct placement** - clinical assessment and waveform capnography 4. **Secure tube** 5. **Continue ventilation** with high flow O2

Question 32

What does the clinical assessment involve when confirming a tracheal tube is located correctly?

Answer 32

1. Check for **condensation** of tube 2. Observe chest **expansion bilaterally** 3. **Auscultate** lung fields bilaterally in axillae (should hear breath sounds) and over epigastrium (shouldn't hear here)

Question 33

How can CO2 be detected to confirm tracheal tube placement?

Answer 33

1. End tidal CO2 **capnograph** 2. Disposable colorimetric end tidal CO2 detectors (**litmus paper**): - **purple** if **<0.5%** - **tan** if **0.5-2%** - **yellow** if **>2%** 3. Non waveform **electronic digital** end tidal CO2 device

Question 34

What factors may cause problems during intubation?

Answer 34

1. **Facial** burns and **trauma** 2. Upper **airway pathology** - cancer, infection, swelling 3. **Loose teeth** or dental prosthesis 4. **Clenching** of teeth 5. Gastric **regurgitation** 6. **Oesophageal intubation** 7. Possible **C Spine Injury**

Question 35

What aids are available for intubation?

Answer 35

1. **Videolaryngoscopes** 2. Introducers - **bougie** 3. **Suction**

Question 36

When is a cricothyroidotomy considered?

Answer 36

1. **Can't intubate** 2. **Can't ventilate** 3. Tracheostomy **too time consuming**, hazardous 3. **Insufficient** staff/**equipment**

Question 37

What are the options for a cricothyroidotomy and how is it done?

Answer 37

**Surgical** - leave airway that is protected by cuffed tube **Needle** - wide bore **cannula** but **temporary** and prone to **kinking**