LAB C: AAM Q&A

Question 1

What are the indications for endotracheal tube intubation?

Answer 1

• patients requiring anesthesia and as a lifesaving procedure for critically ill or injured patients.

It ensures oxygenation, effective ventilation, and airway protection.

Question 2

What are the 4 P’s?

Answer 2

Prevent Obstruction

Prevent Aspiration

Provide Bronchial Hygiene

Provide Positive Pressure Ventilation (PPV) & adjuncts that improve oxygenation.

Question 3

What are some immediate complications of endotracheal tube intubation?

Answer 3

• Spinal cord injury
  *Epistaxis
• Tooth trauma
• Retropharyngeal Trauma
• Subcutaneous or mediastinal emphysema
• Perforation of esophagus or pharynx

Question 4

What are more?

Answer 4

• Laceration of pharynx/larynx
  *Arytenoids dislocation
  *aspiration
  *Pneumothorax
• Esophageal intubation/gastric distention
• bronchial intubation
• Hypoxemia
• Inadequate ventilation

Question 5

What are some more?

Answer 5

• laryngeal spasm
• bronchospasm
  Cartiac dysrhythmias
  *hypotension
  *airway obstruction + damage to trachea
• Ruptured cuff –> inadequate ventilation
• Tracheal bleeding

Question 6

c) What type of endotracheal tube would be preferred when performing Transoral endoscopic laryngeal laser surgery (TLS) surgery for removal of a laryngeal tumor?

Answer 6

Laser tube (various configurations)

Question 7

What type of endotracheal tube would be preferred when performing Independent lung ventilation in the ICU for asymmetric lung disease?

Answer 7

Endobronchial Tube

Question 8

How about if the patient requires intubation and two weeks of mechanical ventilation in the ICU?

Answer 8

Hi Lo Evac Tube

Question 9

Why is it important to monitor endotracheal cuff pressure?

Answer 9

Monitoring ensures that blood flow to the tracheal mucosa is not impeded.

• Excessive pressure can cause necrosis, tracheomalacia, tracheoesophageal fistula, tracheoinnominate artery fistula, mucosal ulceration, and severe hemorrhage.
• A tracheoinnominate artery fistula is a life-threatening event.

Question 10

what is normal cuff pressure range?

Answer 10

20-25cm H2O

Question 11

What are some likely problems if cuff pressure is above optimal value?

Answer 11

mucosal blood flow interruption, ischemia, avascular necrosis, inflammation, hemorrhage and/or ulceration, granuloma formation, exposure of cartilage, tracheomalacia, tracheal stenosis.

Question 12

What happens if cuff pressure below normal range?

Answer 12

• Aspiration
  *Leaks in volume/pressure delivery.

Question 13

What is the function performed by the Rae ET Tube, and what clinical situations would you advocate for the use of these specialty tubes?

Answer 13

Use –> Direct airway connection away from surgical field.

Would use it when trying to position airway and anesthesia circuit/equipment away from operative field for surgical procedures.

Question 14

what is the difference between the 2 tubes?

Answer 14

Nasal –> Longer and straighter. Allows for longer distance (nates to vocal cords)
* Points away from oral cavity, toward forehead.

Shorter –> The oral one (Mouth to vocal cords).
* Points down toward chin or side of mouth.

Question 15

What is a similarity between the 2 tubes?

Answer 15

They both point away from center of the face to allow for clear surgical site/area.

Question 16

What are the key features of the double lumen Endobronchial Tube?

Answer 16

*Can ventilate lungs via one ventilator or isolate each lung solo.

• Sed for surgical applications, and for management of asymmetrical lung disease.
• Either right or left mainstem can be intubated with bronchial side of the tube, the tracheal lumen positioned above the carina.
• both cuffs inflated and selective lung ventilation can occur (one or both).

*independent lung ventilation can be optimized for asymetrical lung disease.

Question 17

What are the key features of this tube?

Answer 17

• ability to isolate one lung
  *Cuff seal separation of bronchi
• Special cuffs to diminish risk of misplacement and leak
• bronchial lumen different for both sides.

Question 18

Describe how the EBT would be positioned in a patient

Answer 18

Right side –> Account for length of mainstem is (2.0-2.5cm long) and lower angle.

• Left is 40-50 degree angle, more stable position as longer mainstem is not as sensitive to tube migration.

*Cuff designs should protect from inadvertent RUL bronchus obstruction with right sided tubes.

Question 19

What are the differences in size between a left and right mainstem bronchi and left and left and right endobronchial tube?

Answer 19

Right mainstem bronchi: 1.4cm diameter + 2.5cm length

Left mainstem bronchi –> 1cm diameter + 5cm length.

*Right more hard to maintain EBT position.

Question 20

Identify key features of the Evac ETTube

Answer 20

The dorsal lumen of tube opens above the cuff (allows for drainage of subglottic space + for continuous aspirations of subglottic secretions).

Question 21

What is the purpose of the “Above cuff aspiration port”?

Answer 21

Is a port that opens to a channel in ETT wall.

• Connected to a line with end connector that can be hooked to suction or manual aspiration.

Question 22

What patients would you intubate with a HI Lo Evac Tube?

Answer 22

• Ventilator dependent patients
• Prolonged intubation cases, who are at risk for VAP due to build-up of secretions and micro aspirations of supra-cuff secretions above the cuff.

Question 23

Why is this tube “Preferred” ETT to use for intubation of critical care patients?

Answer 23

• Allows RT to clear supra-cuff secretions that build on the cuff.

Question 24

What happens when armored tube is bent, twisted, and/or compressed

Answer 24

They can’t be compressed or collapsed as spiral embedded wires keeps them patent at acute angles.

Question 25

Describe indications for spiral embedded (armoured) tube

Answer 25

*Emergent applications *Where anatomic malformations-tumours or tortured airways can result in tube kinking. *Sub-mental intubations + surgical airways. *Cricothyroidotomy.

Question 26

Is this tube bite proof?

Answer 26

No! *When bitten --> Results in compression + obstruction + tube damage + need for extubation and/or reintubation if indicated

Question 27

What are other features?

Answer 27

* position indicator marks that show tube position through vocal cords *Indicate distance from tube tip and from above cuff. *soft silicone tip reduces tissue damage during placement and while in position.

Question 28

a) Metal Laser flex ETT b) Cuffed laser resistant ETT Describe device a)

Answer 28

* Stainless steel, airtight, flexible, and laser resistant. *Reflected beams from tube must be defocused to laser beam. *Shaft on tube may be wrapped in aluminum and teflon tape. * Double cuff designs assure teacheal seal should one cuff be struck by laser beam.

Question 29

For b), what should be done?

Answer 29

*inner cuff should be filled with air or sterile isotonic saline. *Outer cuff may also be filled with sterile isotonic saline. *If outer cuff destroyed by laser, yellow inner cuff completely seals trachea.

Question 30

What procedures may necessitate need for intubation with a laser tube?

Answer 30

*Endoscopic treatment of subglottic and tracheal stenosis (enables precise incisions with minimal thermal damage, preserving viable cells for re-epithelialization of injured area). *Endoscopic laser surgery used to treat early stage laryngeal tumours.

Question 31

What procedures may necessitate the need for intubation with this tube?

Answer 31

*Treatment of subglottic + tracheal stenosis, because it enables precise incisions with minimal thermal damage. *Endoscopic laser surgery used to treat early laryngeal tumours.

Question 32

Comment on cuff inflation for a laser tube.

Answer 32

*Inner cuff should be filled with air or sterile isotonic saline. *Outer cuff filled with sterile isotonic saline. *If outer cuff destroyed by laser beam, yellow inner cuff completely seals trachea.

Question 33

Identify special features that Laser tubes may incorporate into the tube cuff that allows the user to know that the cuff has been damaged by a laser strike during the procedure? Check with your instructor.

Answer 33

The Xomed laser shield tube has methylene blue inside the cuff, fill with saline or water, the blue dye will leak out if punctured and show a breach of the cuff has occurred by the laser. This will alert the surgeon during the procedure that the laser tube’s cuff has been ruptured.

Question 34

Describe how the cuff seals airway in comparison to standard ETT cuffs.

Answer 34

* Foam cuff has large diameter high residual volume cuff composed of polyurethane foam covered by silicone sheath. * Cuff can be connected to breathing circuit by means of pilot tube. Cuff expands to seal airway with changes in respiratory cycle + airway pressure.

Question 35

Why is proper size important? What happens if cuff too small?

Answer 35

*Proper size --> To maintain seal + benefit from pressure-limiting advantages of foam-filled cuff. * Too small --> Foam inflate to unrestricted size + not touch tracheal wall. Loss of ventilation + Loss of protection against aspiration.

Question 36

When is this usseful?

Answer 36

*Cases of tracheomalacia (softened cartilage), as it conforms to tracheal wall preventing airway collapse + limits cuff pressure.

Question 37

What approximate pressure is exerted against tracheal wall from inflated foam cuff?

Answer 37

Does not exceed 20mmHg (27cmH2O).

Question 38

If you were to prepare this tube for an intubation (insertion into a patient’s airway), describe the steps.

Answer 38

1. Check cuff + sheath for integrity. Lubricate tip and cuff. 2. Before insertion, use large syringe and withdraw air from pilot tube connected to cuff. 3. Maintain (-) pressure on syringe (draw back on it), and intubate or cannulate patient. 4. Detach syringe, open pilot tube line. This allows air to go in foam and sponge cuff to inflate.

Question 39

Assume this tube is in a patient’s airway with the “Red Pilot Port” in the Open position. How would you deflate the cuff prior to removal of this tube?

Answer 39

A syringe attached to pilot port evacuates air in the cuff. *once cuff deflated, intracuff pressure at below ambient levels. *Tube can be removed while maintaining deflated state of cuff.

Question 40

Give examples of where thys cuff pressure device would be appropriate clinically.

Answer 40

*Patients who have developed tracheal injury related to the cuff. *When excess cuff pressures are required with pneumatic cuffs to seal/ *Foam cuff designed to address issues of high lateral tracheal wall pressures that lead to complications like tracheal ulceration, necrosis, stenosis.

Question 41

Describe the purpose of the "Pressure Easy" device

Answer 41

*It continuously monitors tracheal cuff pressure. Its indicator window signals cuff pressure between 20-30cmH2O. *Airway pressure auto-feedback feature boosts cuff pressure to ensure proper sealing when high pressures used during ventilation.

Question 42

What advantages does this device offer?

Answer 42

*Single-patient use *Reduces potential for infection + eliminates sterilization issues with quarantined or isolated patients. * Does away with managing inventory of manometers, issues of availability + Calibrating + replacement of reusable manometers.

Question 43

How does this device function during the inspiratory phase of positive pressure ventilation and during the expiratory phase of positive pressure ventilation?

Answer 43

The airway pressure auto-feedback feature boosts cuff pressure to ensure proper sealing when high pressures used during ventilation.

Question 44

Describe why it is important to regulate cuff pressure in intubated patients.

Answer 44

Excessive cuff pressure can cause avascular changes that degrade tracheal mucosa, tracheal cartilage, and adjacent tissues. * Life threatening events can result.