Flashcards in Exam 3 Deck (188):
Treatment for "sucking chest wound"
Covering the wound with occlusive dressing that is secured on three sides.
Air enters the pleural space through an opening in the chest wall.
No associated external wound
Causes of closed pneumothorax
Rupture of small blebs on visceral pleura, injury to lungs from broken ribs, excessive pressure during ventilation, esophageal tear, laceration or puncture of lungs during subclavian catheter insertion
What do you do if the object that causes an open chest wound is still present?
Do not remove it until a physician is present. Stabilize the impaled object with a bulky dressing.
A pneumothorax with rapid accumulation of air in the pleural space that can cause high intrapleural pressures
Results of a tension pneumothorax
Compression of the lung on the affected side and pressure on the heart and great vessels pushing them away from the affected side. As pressures increases, venous return is decreased and cardiac output falls.
Causes of tension pneumothorax
Open or closed pneumothorax; mechanical ventilation, resuscitative measures, chest tubes that are clamped or blocked,
Symptoms of a tension pneumthorax
dyspnea, chest pain radiating to the shoulder, tracheal deviation, decreased or absent breath sounds on the affected side, neck vein distention, and cyanosis.
Accumulation of blood in the pleural space from an intecostal blood vessel, the internal mammary arter, lung, heart or great vessel.
presence of lymphatic fluid in the pleural space.
Causes of clyothorax
The thoracic duct is disrupted traumatically or from malignancy and fills the pleural space.
Conservative treatment of clyothorax
chest drainage, bowel rest and paraenteral nutrition. Octreotide, surgery and pleurodesis.
Clinical manifestations of pneumothorax
Small mind tachycardia and dyspnea. If it occurs largely, respiratory distress may be present including shallow, rapid respirations, dyspnea, air hunger, oxygen desat, chest pain, cough with or without hemoptysis, no breath sounds. C-xray shows presence of air or fluid in pleural space and reduction of lung volume.
Management of tension pneumothorax
EMERGENCY!! Insert a arge bore needle into the anterior chest wall at the fourth or fifth intercostal space to release the trapped air. A chest tube is then inserted and connected to water-seal drainage.
Treatment for pneumothorax
Aspirate air/fluid with a large bore needle. (Thoracentesis). Insert a chest tube and attach a water-seal drainage. Repeated spontaneous may be surgically treated with pleurectomy, stapling, and pleurodesis.
Chest tubes used to do what?
Chest Tubes are inserted into the pleural space to remove air and fluid and to allow the lung to reexpand.
Chest Tube Insertion
Positioned seated on the edge of the bed with arms supported on a bedside table or supine with midaxillary area of the affected side exposed.
Chest x-ray is available to confirm the affected side.
Area is cleansed with an antiseptic solution.
Chest wall prepared with a local anesthetic and a small incision is made over a rib. The chest tube is advanced up and over the top of the rib to avoid intercostals nerves and blood vessels. For removal of air, a smaller tube (14F to 22F) is used and is directed anteriorly and superiorly as air rises. For removal of fluid, a larger tube (28F to 40F) is used and directed posteriorly and inferiorly. The chest tube is connected to a pleural drainage system. The incision is closed with sutures and the chest tube is secured. The wound is covered with a dressing. Some physicians prefer to seal the wound with petroleum gauze. Monitor patient for comfort levels, as insertion and presence of chest tube is painful.
Chest tube for air removal
A smaller tube (14F to 22F) is used and is directed anteriorly and superiorly as air rises
Chest tube for fluid removal
A larger tube (28F to 40F) is used and directed posteriorly and inferiorly
Intervention for disconnected chest tube
Reestablishment of the water seal system immediately and attachment of a new drainage system as soon as possible. Some hospitals immerse the tube in sterile water until system can be reestablished.
Chest tube removal procedure
Removed 24 hrs after being on gravity drainage and when the lungs are reexpanded and fluid drainage has ceased. Gather supplies and petroleum jelly dressing. Explain procedure, give pain meds 15 min before, cut suture, pt hold breath or bear down, remove tube, cover with dressing. Do CXR to evaluate for reaccumulation or pneumothorax.
Insufficient CO2 removal results in what
a decrease in arterial O2 (PaO2) and saturation. (SaO2)
Hypercapnia produces what
an increase in arterial CO2. (PaCO2)
When does respiratory failure occur?
When one or both of the gas exchanging functions are inadequate....(transfer of O2 and CO2 between inhaled tidal volumes and circulating blood volume within the pulmonary capillary bed)
Two types of respiratory failure
Hypoxemic or hypercapnic
Primary problem with hypoxemic respiratory failure
inadequate O2 transfer between the alveoli and the pulmonary capillary bed.
Hypoxemic respiratory failure is defined as
PaO2 less than 60 mmHg when the patient is recieving an inspired O2 concentration of >60%.
Hypercapnic respiratory failure is defined as
PaCO2 greater than 48mmHg in combination with acidemia (arterial pH less than 7.35).
Four physiologic mechanisms that may cause hypoxemia and subsequent hypoxemic respiratory failure
1. mismatch between ventilation (V) and perfusion (Q), commonly referred to as V/Q mismatch
3. diffuse limitations
In normal lungs, the volume of blood perfusing the lungs each minute is
4 to 5 L/ min
What is the V/Q mismatch?
MIsmatch between ventilation and perfusion. Examples of causes are pneumonia, atelectasis, asthma and pulmonary emboli. Normally VQ is 1:1.
when blood exits the heart without having participated in gas exchange.
when blood passes through an anatomic channel in the heart (ventricle septal defect) and bypasses the lungs
Occurs when blood flows through the pulmonary capillaries without participating in gas exchange.
When are intrapulmonary shunts seen>
In conditions in which the alveoli is filled with fluids, like in ARDS, pneumonia, and pulmonary edema.
Treatment for patients with shunts
Usually require mechanical ventilation and a high fraction of inspired O2 (FiO2) to improve gas exchange.
What is diffuse limitation
Occurs when gas exchange across the alveolar-capillary membrane is compromised by a process that thickens, damages, or destroys the membrane.
When does diffuse limitation cause hypoxemia
during exercise more than at rest because the blood moves more rapidly through the lungs which decreases the time for diffusion of O2 across the alveolar capillary membrane.
Classic sign of diffusion limitation
Hypoxemia that is present during exercise but not during rest.
What is alveolar hypoventilation
Generalized decrease in ventilation that results in an increase in PaCO2 and consequent decrease in PaO2.
Hypercapnic respiratory failure results from what
An imbalance between ventilatory supply and ventilatory demand.
When does hypercapnia occur
When ventilatory demand exceeds ventilatory supply and the PaCO2 cannot be sustained within normal limits.
Primary problem with hypercapnic respiratory failure
The inability of the respiratory system to remove sufficient CO2 to maintain a normal PaCO2.
Four groups that can cause a limitation in ventilatory supply
1. abnormalities of airways and alveoli
2. abnormalities of CNS
3. abnormalities of the chest wall
4. neuromuscular conditions
Failure of oxygen utilization primarily occurs when?
In septic shock. Adequate O2 may be deliveered to the body tissues, but imparied O2 extraction or diffuse limitation exists at the cellular level. This results in abnormally high amount of O2 returning in venous blood because its not extracted at the tissue level.
80 to 100 mmHg
When does hypoxemia occur
the amount of O2 in arterial blood is less than normal values
when does hypoxia occur
when the PaO2 falls sufficiently to cause signs and symptoms of inadequate oxygenation.
Normal IE ratio
Inspiratory to expiratory ratio is normally 1:2, meaning that expiration is twice as long as inspiration.
Oxygen Treatment for hypoxemia due to v/q mismatch
For V/Q mismatch, supplemental oxygen administered 1 to 3 L/min per nasal cannula, or 24% to 32 % by simple face mask or venturi mask should improve the PaO2 and SaO2.
Oxygen Treatment for hypoxemia secondary to intrapulmonary shunt
PPV, which provides O2 therapy and humidification, decreases the work of breathing, and reduces respiratory muscle fatigue. It also assists in opening collapsed airways and decreases shunt.
PPV is provided how?
via endotracheal tube or noninvasively by means of a tight fitting mask.
What levels of PaO2 and SaO2 must the selected O2 delivery system provide?
maintain PaO2 >= to 55 to 60mmHg and SaO2 >= to 90% at the lowest O2 concentration possible.
What will high concentrations of O2 cause?
It will replace nitrogen gas normally present in the alveoli, causing instability and atelectasis.
Oxygen treatment for patients with chronic hypercapnia (patients with COPD)
O2 through a low-flow device such as nasal cannula at 1 to 2 L/min or a venturi mask at 24% to 28%.
Performing augmented coughing, how to?
By placing the palm of your hand or hands on the patient's abdomen below the xiphoid process. As the patient ends a deep inspiration and begins and expiration, move your hand forcefully downward, increasing abdominal pressure and facilitating the cough.
A series of coughs performed while saying the word "huff". It prevents the glottis from closing during the cough.
The patient assumes a sitting position, breaths three or four times in and out through the mouth, and coughs while bending forward and pressing a pillow inward against the diaphragm.
Used to instill sterile normal saline solution to elicit a cough and to perform suctioning.
Absent gag reflex, hx of aspiration, and the need for long-term mechanical ventilation.
Contraindications for NIPPV
patients with absent respirations, decreased LOC, high O2 requirements, facial trauma, hemodynamic instability
Form of NIPPV in which constant positive pressure is delivered to the airway during inspiration and expiration
Bilevel positive airway pressure, a form of NIPPV in which different positive pressure levels are set for inspiration and expiration
Hemoglobin level that typically ensures adequate oxygen saturation of the hemoglobin
>= 9g/dL (90g/L)
What is ARDS
ARDS is a sudden and progressive form of acute respiratory failure in which the alveolar capillary membrane becomes damaged and more permeable to intravascular fluid.
Causes of ARDS
Sepsis, direct lung injury, Systemic inflammation response syndrome (SIRS), MODS, aspiration of gastric contents, viral or bacterial pneumonia, severe massive trauma, chest truama, embolism, inhalation of toxic substances, near drowning, o2 toxicity, radiation pneumonitis,
Pathophysiology of ARDS
Due to stimulation of the inflammatory and immune systems, which causes an attraction of neutrophils to the pulmonary interstitium. The neutrophils cause a release of mediators that produce changes in the lungs.
What does ascites result from?
(1) Protein shift into lymph space and lymphatic system cannot carry it off and they leak into cavity pulling additional fluid. (2) Hypoalbunemia (3) hyperaldosteronism causing an increase Na+ reabsortion
Treatment for ascites
Sodium restriction, diuretics, and fluid removal. Na+ to 2g/day or 250-500mg/day for severe. K+sparing diuretics in combo with loop diuretics. Paracentesis to remove fluids (temporary fix). Peritoneovenous shunt to reinfuse the ascitic fluid into venous system. TIPS
Complications of peritoneovenous shunts
thrombus formation, infection, fluid overload, DIC, variceal hemorrhage, shunt occlusion.
First step when variceal bleed occurs
Stabilize the patient and manage the airway. IV therapy is administered and may include blood products.
Drug therapy for varicial bleeds
Drug therapy includes Sandostatin, vasopressin, nitroglycerin, and beta blockers.
Prophylactic treatment for non bleeding variceal bleeds
Nonselective beta blockers (propanolol [Inderal])
Side effects of Vasopressin
decreased coronary blood flow, dysrhythmias, and increased BP.
What does vasopressin do?
produces vasoconstriction of arterial bed, decreases portal blood flow and decreases portal hypertension.
Why use nitroglycerin with variceal bleeds
reduces side effects of vasopressin while enhancing its beneficial effect.
Who should VP be used cautiously with
Older adult because of the risk of cardiac ischemia.
Safety alert for balloon inflation for gastric varices
Deflate balloon for 5 minutes every 8 to 12 hrs per policy to prevent necrosis.
What does the balloon tamponades do for gastro varicies
applies pressure to bleeding. Controls the hemorrhage by mechanical ventilation of the variciies.
Why give lactulose and neomycin for varicies
To prevent hepatic encephalopathy from breakdown of blood and the release of ammonia in the intestines
Why give antibiotics with ascites
To prevent bacterial infections.
What does propanolol do for long term management of varicial bleeds & what are risks
reduces portal venous pressure, and can be given to prevent recurrent GI bleeding. BUT it can cause hepatic encephalopathy because of reduced hepatic blood flow.
What is TIPS
Transjugular intrahepatic portosystemic shunt is a nonsurgical procedure in which a tract (shunt) between systemic and portal venous systems is creasted to redirect portal blood flow.
What does TIPS do
reduces portal venous pressure and decompresses the varicies, thus controlling bleeding.
Goal of treatment for hepatic encaphalopathy and how?
Reduce ammonia formation. With lactulose, anbx such as neopmycin sulfate or flagyl or vanc, catharics/enemas,
Lactulose does what therapeutically?
Traps the ammonia in the gut and excretes it from the colon.
Why give Anbx for hepatic encephalopathy
Reduces bacterial flora in colon (Bacterial action on protein in the feces results in ammonia production).
Nutritional therapy for cirrhosis
High in calories (3000/day), high carbs, mod to low fats, protein decrease, For ascites--low sodium (2g.day),
Why high carbs for patients with cirrhosis
to prevent hypoglycemia and catabolism
Foods high in sodium
Table salt, baking soda, baking powder, canned soups & vegetable, frozen foods, salted crackers, ships, nuts, smoked meats and fish, breads, olives, pickles, ketchup, beer, antacids, carbonated beverages,
Risk factors for cirrhosis
alcohol ingestion, malnutrition, hepatitis, biliary obstruction, obesity, right sided heart failure
Indications for paracentesis
Used to decrease the amount of fluid in the peritoneal cavity, like in ascites caused by cirrhosis.
Nursing care for paracentesis
Have the patient void prior to prevent puncture of the bladder. The patient sits on the side of the bed or is in high folwers position.
Patient Monitoring: Following the procedure, monitor the patient for signs of hypovolemia and electrolyte imbalances and check the dressing for bleeding and leakage.
Nursing care for dyspnea with ascites
Place in semi fowlers or fowlers position for maximal repiratory efficiency and use pillows ot support the arms and chest as they will increase comfortability and ability to breathe.
Hypokalemia is manifested....
cardiac dysrhythmias, hypotension, tachycardia, generalized muscle weakness
Water excess is manifested how
muscle cramping, weakness, lethargy, and confusion
Signs of varicies
hematemesis and melena.
What do you do if patient with cirrhosis has hematemesis
assess patient for hemorrhage, call physician and be ready to assist with treatment to control bleeding. Pt admitted to ICU and airway must be maintained
Balloon tamponade nursing care
Explain use of tube and how its inserted. Balloon should be checked for patentcy, Physician inserts thru nose or mouth, inflated with 250 ml air, retracted until resistance is met, tube secured at nostrils. Position verified by xray.
Saline lavage use
Used to prevent blood from degrading to ammonia.
Most common complication of balloon tamponade
What do you do id the gastric balloon breaks or deflates?
Cut the tube or deflate the balloon. Keep scissors at bedside.
How to minimize regurgitation with balloon tamponade therapy
Oral and pharangeal suctioning and keeping in semi fowlers position
Assessment parameters and patho of pancreatitis
Treatment for pseudocysts
Internal drainage system procedure with an anastomosis between the pancreatic duct and the jejunum.
Two local complications of acute pancreatitis
Pseudocyst and abscess
Treatement for abscess of pancreas
Prompt surgical drainage to prevent sepsis.
What can trypsin activate?
Prothrombin and plasminogen causing pulmonary emboli, intravascular thrombi and DIC.
What drugs should be avoided with paralytic ileus
What do you monitor when IV lipids are ordered
Diet for pancreatitis
NPO at first to reduce pancreatic secretions. Then enteral feedings via nasojejunal tube are initiated. WHen food is allowed, small frequent feedings. High in carbs. Abstain from alcohol. May be given supp fat-soluble vitamins
During feeding of pancreatitis patient and patient reports pain, as increasing abdominal girth or elevations in pancreatic enzymes, what is wrong?
Suspect intolerance to food
Signs of hypocalcemia
jerking, irritability muscular twitching, numbness or tingling around the lips and in finger, positive chvosteks signs and trousseaus sign.
What to treat hypocalcemia
Good position for pancreatitis
Flexing the trunk and drawing knees to abdomen may decrease pain. Side lying with head elevated 45 degrees decreases tension on abdomen and decrease pain.
When to take antacids
After meals or at bedtime.
What is the breakdown of heme
If you have a buildup of bilirubin in the blood, what can it mean?
Producin too many RBCs or something wrong with the liver (not conjugating the bilirubin)
What will happen if biliruben isnt conjugated?
It will go to the blood. Causing jaundice
Who is NAFLD seen in?
Patient with metabolic syndrome, obese, rapid weight loss, strict diets. Statins for hyperlipidemia is hard on liver
CLinical manifestations of NAFLD
Usually asymptomatic. Increased ALT and AST.
Diagnosis for NAFLD is made how?
AST & ALT, liver biopsy
Liver biopsy risks
Risks of bleeding because the liver is involved in coagulation
Teaching about weight loss for NAFLD
Teach to lose weight slowly because rapid loss can cause liver failure
Palmar erythema and spider angiomas are the result of what
Due to an increase in estrogen because the liver can no longer metabolize steroid hormones.
What are palmar erythemas
red areas on the palm that blanches
What are spider angiomas
small dilated vessels that have the look of spider webs, seen on face
Portal hypertension can lead to what?
What is the esophageal balloon port on the Blake Moor Tube used for
WHen you inflate it, it tamponades/puts pressure on the vessel and stops bleeding
What is the gastric balloon port on the Blake Moor Tube used for
To put tension on the gastric sphincter which prevents regurgitation
What is the third (gastric) port at the end on the Blake Moor Tube used for
Used to decompress the stomach and remove fluids
Administering pancreatic enzymes
Give with fruit, do not give with protein
Signs of retroperitoneal bleed
Collins signs and grey turners signs
Drug therapy for chronic pancreatitis
Take pancreatic enzymes
Indications for ET Tube Intubation (5)
Indications for an ET tube intubation: upper airway obstruction, apnea, high risk for aspiration, inneffective clearance of secretions, and respiratory ditress.
Why insert a tracheotomy?
When the need for artificial airway is expected to be long term (14 days +)
What reduces the work of breathing?
A larger bore ET Tube because there is less airway resistance. It is easier to remove secretions and perform fiberoptic broncoscopy if needed.
When is Nasal ET tube used?
Nasal ET intubation is used when head and neck manipulation is risky.
What do you do to avoid a patient obstructing or biting down on an ET tube
Sedation with a bite block
What do you use to do mouth care with a patient with ET tube in place?
Pediatric oral sized products for brushing, suctioning, and cleaning.
Nasal intubation is contraindicated in what patients?
Patients with facial fractures, suspected fractures at the base of the skull and postoperative after cranial surgeries
nasal intubation has been linked with an increased incidence of what
increased incidence of sinus infections and VAP.
Patient undergoing intubation & ventilation will need to have what at bedside?
Patient undergoing intubation will need to have Ambu bag attached to O2, suctioning equipment at bedside and IV access.
Endotracheal intubation procedure
Obtain consent, explain procedure, get ambu bag with O2, suction & IV access, remove dentures, administer Versed, fentanyl, anectine (paralytic), atropine (reduce secretions), monitor O2 status, preoxygen with 100% O2 3-5 min before and in between attempts, attempts <30 sec, inflate cuff, confirm placement, connect to O2, secure, suction, bite block, portable x ray, record and mark at exit, ABGs within 25 minutes.
RSI is not indicated in who?
comatose or cardiac arrest
What is RSI
Rapid sequence intubation, rapid concurrent admin of a paralytic and sedative during emergency airway management to decrease aspiration, combativeness or injury to patient
Monitor ET tube placement how oftein
every 2 to 4 hrs
If ET tube is not placed properly,,,,what you do?
emergency, stay with patient, maintain airway, maintain ventilation, get assistance, ventilate with BMV and 100%.
Malpositioning of ET tube places them at risk of waht
To avoid ET tube cuff damagin the trachea....
To avoid the cuff damaging the trachea, inflate the cuff with air and measure and monitor the cuff pressure. Maintain cuff pressure at 30 to 25 mmHg. Measure Q8hrs.
What does it mean when adequate cuff pressure on the ET tube isnt maintained or larger volumes of air are needed to keep the cuff inflated
The cuff could be leaking or there could be tracheal dilation at the cuff site
What you do when adequate cuff pressure on the ET tube isnt maintained or larger volumes of air are needed to keep the cuff inflated
Notify physician to repositon and change the ET tube.
What is the best indicator of alveolar hyper/hypoventilation
Decreased PaCo2, increased pH indicated respiratory alkalosis
Increased PaCO2, decreased pH indicating respiratoryu acidosis
Decreased PaCo2, increased pH indicates what alkalosis
repiratory alkalosis or alveolar hyperventilation
Increased PaCO2, decreased pH indicates what
respiratory acidosis or Alveolar hypoventilation
Indications for suctioning ET tube (7)
visible secretions in tube, sudden onset of resp distress, suspected aspiration of secretions, increase in peak airway pressures, auscultations of adventitious breath sounds over trachea/bronchi, increase in RR and or sustained coughing, and sudden or gradual decrease in PaO2 and or SpO2
Closed suctioining technique for ET tube should be reserved for who
Should be used for patient requiring high levels of PEEP, high FiO2, bloody or infected pulmonary secretions, require frequent suctioning.
How do you tell if a patient doesnt tolerate ET tube suctioning well
If a patient doesn’t tolerate suctioning well, they will have decreased SpO2, increased or decreased BP, sustained coughing, and development of dysrthymias
What do you do if a patient doesnt tolerate suctioning well?
Stop the procedure, and manually hyperventilate with 100% O2. Limit each suction to <10 secs. Avoid excessive suctioning when severe bradycardia and hypoxemia.
What indicated mucosal damage has occured with ET tube suctioning
The presence of bloody streaks or tissue shreds in aspiratrd secretions may indicate mucosal damage has occured.
What helps in thining or removing secretion
dequately hydrate patient (oral or IV) and provide humidification of inspired gases may assist in thinning secretions. Do not instil normal saline. Postural drainage, percussion, and turning the patient Q2hrs may help move secretions into larger airways.
How often do you repositon and retape the ET tube
every 24 hrs or as needed
Signs of unplanned extubation
Signs of unplanned extubation is patient speaking, activation of low pressure ventilation alarm, absent or diminished breath sounds, respiratory distress, and gastric distention
Preventing unplanned extubation
You can prevent unplanned extubation by ensuring the ET tube is secured and observing and supporting ET tube during repositioning, procedures, and patient transfers. Provide sedation and analgesia and immobilizIng hands with restraints.
If unplanned extubation occurs, what do you do?
If unplanned extubation occurs, stay with patient and call for help. Maintain airway and support ventilation.
Normal Serum Amylase
Normal serum Lipase
Risk factors for developing NAFLD
obesity, DM, hypertriglyceridemia, severe weight loss, syndromes with insulin resistance
Cirrhosis can be caused by
alcohol intake, viral hepatitis, malnutrition, biliary obstruction, right sided heart failure,
Manifestations of cirrhosis
jaundice, skin lesions (spider agiomas), hematologic problems )thrombocytopenia, leukopenia, anemia, coag d/o), endocrine problems, peripheral neuropathy
a persistent increase in blood pressure in the portal venous system, is characterized by increased venous pressure in the portal circulation
, tortuous veins at the lower end of the esophagus, are the most life-threatening complication of cirrhosis.
Bleeding esophageal varicies
accumulation of serous fluid in the peritoneal or abdominal cavity, and may be accompanied by dehydration, hypokalemia, and peritonitis.
characteristic symptom of hepatic encephalopathy
Asterixis (flapping tremors)
Diagnostic tests for cirrhosis
elevations in liver enzymes, decreased total protein, fat metabolism abnormalities, and positive liver biopsy.
Diet for cirrhosis
is high in calories (3000 cal/day) with high carbohydrate content and moderate to low-fat levels. Sodium restrictions are placed on the patient with ascites and edema.
Treatment for fulimant hepatic failure
Causes of fulimant hepatic failure
Acetaminophen with alcohol
Clinical manifestations of acute pancreatitis
Abdominal pain located in the left upper quadrant is the predominant symptom of acute pancreatitis. Other manifestations include nausea, vomiting, hypotension, tachycardia, and jaundice.
Nursing diagnosis for acute pancreatitis
acute pain, fluid volume deficit, imbalanced nutrition, and ineffective self-health management.
The pancreas becomes progressively destroyed as it is replaced with fibrotic tissue.
Clinical manifestations of chronic pancreatitis
abdominal pain; symptoms of pancreatic insufficiency, including malabsorption with weight loss; constipation; mild jaundice with dark urine; steatorrhea; and diabetes mellitus.
Major concern with esophogeal balloon tamponade
Aspiration and choking on saliva. cannot use esophagus to swallow saliva