laryngoscopy/endotracheal intubation

Question 1

What is the gold standard of airway management

Answer 1

Endotracheal intubation

Question 2

Tubes are numbered according to their

Answer 2

Internal diameter

Question 3

What are ETT constructed of

Answer 3

Polyvinyl choliride (pvc)

Question 4

What is the body that governs the construction of ETTs

Answer 4

ASTM standard 21

American society of testing and materials

Question 5

Size selection and depth of ETT insertion for men

Answer 5

8.0 or 9.0 at 24-26 at lip

Question 6

Size selection and depth of ETT insertion for women

Answer 6

7.0 or 8.0 at 20-22 at lip

Question 7

Size selection and depth of ETT insertion for children

Answer 7

Size: 4 + age/4
Depth: 12 + age/2

So for a 12 year old you would choose 7.0 to 18cm

**later slide - in children, advance tube until 2nd dark line on distal tube sits at or just below cords

Question 8

What lowers resistance of a tube

Answer 8

Shorter tube

Wider tube *** most important factor is internal diameter of the tube

Question 9

What is the purpose of the Murphy’s eye?

Answer 9

To allow for another path of air flow in case of distal occlusion

***don’t put stylet below level of murpy’s eye

Question 10

What is the purpose of the pilot balloon

Answer 10

Helps you to gauge the pressure/air in the cuff

Question 11

What is the purpose of the cuff

Answer 11

Provides a seal between ETT and tracheal wall - prevents aspiration and gas escape, centers tube in trachea and prevents tracheal trauma from bevel of ETT

Question 12

High volume low pressure cuff

Answer 12

Compliant cuffs - larger area of contact with trachea but more adaptable to wall so less chance of tracheal damage

Can handle higher volumes without causing a huge increase in pressure

Used for long term intubation

Question 13

Low volume high pressure cuff

Answer 13

Small area of tracheal contact, can distend trachea and cause tissue necrosis/mucosal damage

These are only used for short term intubation ideally

Question 14

What is ideal cuff pressure to create a seal but avoid tissue damage

Answer 14

20-25mmHg

**tracheal mucosa perfusion pressure is 25-30mmHg

Question 15

Uncuffed tubes

Who do we use them on and how do we test for air leak

Answer 15

Children <8yo

We test for airleak at pressure 15-20 cm H20

Question 16

When would you use a laser safe ETT

Answer 16

ENT cases or other cases with a laser close to the tube/airway

Question 17

Preparing your ETT for intubation

Answer 17

Make sure your 15mm connector is snug

Place the stylet - hockey stick formation

Check cuff

Question 18

When would you use a double lumen ETT

Answer 18

Thoracic/lung cases where you may need to isolate a lung

Question 19

Which laryngoscopes is curved and where do you place it

Answer 19

McIntosh. Tip advanced to valleculae = indirectly lifts epiglottis

Question 20

Which laryngoscope has a straight blade

Answer 20

Miller
Lifts epiglottis directly
Usually requires less force and you enter midline

Question 21

What is the distance from the teeth to the vocal cords

Answer 21

12-15cm

Question 22

What is the distance from the vocal cords to the carina

Answer 22

10-15 cm

Question 23

How many cm do you add to tube depth with nasal intubation

Answer 23

3-4cm

Question 24

Where is the carina located (spinal cord level)

Answer 24

T5

Question 25

What happens to ETT with head flexion

Answer 25

1.9 cm advance (hose follows nose)

Question 26

What happens to ETT with head extension

Answer 26

1.9 cm withdraw (hose follows nose)

Question 27

How much dose an ETT move with rotation of head

Answer 27

0.7 cm

Question 28

How to confirm ETT placement

Answer 28

Visualize ETT through cords ETCO2 - “continuous”/3 consecutive breaths Absence of gurgling sounds over stomach with vent Equal bilateral breath sounds (or whatever baseline is) Fogging ETT Refilling of reservoir bag with exhalation

Question 29

Mainstem bronchus intubation S/S

Answer 29

Unilateral breath sounds Unilateral chest expansion ETT too deep Increased airway pressure

Question 30

Esophageal intubation S/S

Answer 30

``` Gastric contents in ETT ETCO2 waveform but will drop off Reservoir bag collapses, because no return Gurgling in stomach Gastric distention No chest wall movement ```

Question 31

Physiologic responses to laryngoscopy

Answer 31

``` Hypertension Tachycardia/reflex bradycardia Arrhythmia Myocardial ischemia Increased IOP/ICP Bronchospasm ```

Question 32

Deep extubation

Answer 32

Muscle relaxants fully reversed, pt spontaneously breathing with adequate minute ventilation, no response to suctioning CONTRAINDICATED in patients with a difficult airway, are an aspiration risk, or surgery that may produce airway edema

Question 33

Awake intubation

Answer 33

Pt can maintain and protect airway | Purposeful movement, eyes open, react to suctioning

Question 34

Can you extubate in phase 2

Answer 34

NO

Question 35

Subjective criteria for awake extubation

Answer 35

``` Follows commands Clear oropharynx Intact gag reflex Head lift > 5 seconds Sustained grasp Pain controlled Minimal end expiratory concentration of inhaled anesthetics ```

Question 36

Objective criteria for awake extubation

Answer 36

``` Vital capacity >15ml/kg Peak voluntary negative Inspirators pressure >25 cm O2 Tidal volume >6ml/kg Sustained tetanic contraction Spo2>90% RR<35 PACO2 <45 ```

Question 37

How do we extubate

Answer 37

``` 100% O2 - debatable Suction oropharynx and hypopharynx Close APL Deflate cuff Remove ETT while applying positive pressure on bag ``` Apply positive pressure and 100% with face mask immediately following extubation

Question 38

Potential causes of ventilatory compromise during tracheal extubation

Answer 38

``` Residual anesthetic Poor central effort Decreased resp drive to CO2 Reduced muscle tone Reduced gag/swallow reflex Vocal cord paralysis Edema Laryngospasm/bronchospasm ```

Question 39

Acute complications after extubation

Answer 39

Laryngospasm, vomiting, aspiration, sore throat, hoarseness, laryngeal or subglottic edema

Question 40

Chronic complications after extubation

Answer 40

Mucosal ulceration, tracheitis, tracheal stenosis, vocal cord paralysis, arytenoid cartilage dislocation

Question 41

What happens with arytenoid cartilage dislocation

Answer 41

Leads to flaccid cords and airway edema

Question 42

Nasal intubation indications

Answer 42

Maxillofacial or mandicular surgery | Oral/dental surgery

Question 43

Contraindications of a nasal intubation

Answer 43

``` Coaguplopathy Basilar skull fracture Severer intranasal disorder CSF leak Extensive facial fractures ```

Question 44

Which tonsils are the ones that are at most increased risk for bleeding with nasal intubation

Answer 44

Pharyngeal tonsils

Question 45

What do you need for nasal intubation

Answer 45

Magill forceps | Neosynephrine spray

Question 46

How do you dilate the nares for NT intubation

Answer 46

NP tubes in both nares (X3 times up a size each time to gradually dilate, while mask ventilating in between each placement)

Question 47

Which blade should you use in a NT intubation

Answer 47

MAC - this leaves more room in your mouth for the Magill forceps

Question 48

Do you use a stylet during an NT intubation

Answer 48

NO that’s mean

Question 49

Complications of NT intubation

Answer 49

Epistaxis Tracheal/esophageal trauma Bacteremia/sinusitis Displaced adenoids or polyps = bleeding and airway obstruction