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Flashcards in managing the airway Deck (53)
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describe anesthesia masks

-hard, transparent plastic
-inflatable cushion rim
-designed to achieve an effective seal
-various sizes, shapes to fit faces
-pediatric masks different/flavored
-22 mm orifice fits breathing circuit
-easy to see fog, vomit, and secretions


describe one-handed bag-mask ventilation

-hold mask with left hand, bag in right hand
-downward pressure using thumb and index finger
-middle and ring fingers on mandible not soft tissue (pulling on soft tissue will cause tongue to obstruct)
-middle and ring finger extend atlanto-occipital joint
-little finger moves jaw anteriorly (jaw thrust) (too much pressure too long can cause glossopharyngeal nerve injury)
-release jaw during expiration to prevent ball-valve
-positive pressure less than 20 cmH2O (esophageal may open with > 20 cmH2O); loss = poor seal


describe two-handed mask ventilation

-both hands on mask; bag handled by 2nd person
-thumbs pressing mask downward against face
-index fingers on mandible moving it anteriorly (jaw thrust; atlanto-occipital joint extension)
-avoid excessive pressure on bridge of nose
-full beard


what may be down for endentulous patients when performing mask ventilation?

leave dentures in place for better mask seal


what can be done to mask for a better seal?

inflate the mask


what can be used to separate the tongue and posterior pharynx during mask ventilation?

oral and nasal airways


what can be done for a full beard patient to give an adequete mask seal?

-shave beard
-vasoline beard
-cover with large transparent tegaderm with mouth hole


what should be continuously monitored during Monitored Anesthesia Care, whether moderate or deep, to monitor the adequacy of ventilation?



what happens during MAC without artificial airway in place?

-airway tone reduced
-tongue obstructs (use oral or nasal airway)
-difficult to detect apnea
-difficult to detect reduced airflow and volume (rocking and reduced chest wall movement)


what are indications for tracheal intubation?

-airway protection: full stomach, pregnancy, aspiration risk
-initiate and maintain patent airway: airway pathology (LMA for normal airway)
-pulmonary toilet needed
-PPV (paralyzed: head, neck, chest, abd surgeries); LMA cant use > 20 cmH2O
-airway compromise; inaccessible/shared airway
-inability to maintain control with mask


describe endotracheal tubes

-transparent, non-irritating polyvinyl chloride
-softens and molds to contour of airway
-length in cm, internal diameter in 0.5 mm increments (2.5-9.0 mm)
-combustible, produces acid and toxins
-cutting tube reduces risks of obstruction (smaller length, greater diameter= less airway resistance)
-bevel opens to left when concave curve anterior
-murphy eye (extra escape if bevel clogged) guards obstruction; to the right
-cuff or cuffless


describe cuffs of ETTs

*high volume =greater area seal, less pressure, less injury
*inflate less than 20 torr since tracheal perfusion 30 torr


what are recommended equipment for induction and intubation?

-oral and nasal airways and tongue blade
-stylet and lubricant
-2 ETTs (different sizes) with a 5-10 cc syringe (check ETT connection and balloon)
-2 laryngoscope handles
-2 laryngoscope blades (miller and macintosh)
-suction with rigid suction tip
-ETT tape or securing device
-drugs for sedation and paralysis
-tooth guard
-positive pressure ventilation equipment
-LMA (difficult airway possibility)
*intubating accessories (intubating forceps, bougie, stylet)


describe the Miller laryngoscope blade

*straight blade
*lifts the epiglottis directly
-smaller than the curved "Mac" and fits in mouths with smaller opening
-epiglottis is lifted out of the line of vision (blade ends up slightly right of midline)
-better for "anterior" larynx (receding chin, protruding upper incisors)


describe the Macintosh laryngoscope blade

*curved blade
*tip placed in the vallecula to indirectly lift the epiglottis, thus minimizing trauma
-better displacement of the tongue leftward for better visualization (blade ends up in the middle of the mouth)
-less temptation to "lever" against upper teeth


describe the markings on ETTs

-internal diameter (I.D.) in mm (size on the tube)
-external diameter (O.D.) in mm
-certification of "implantation testing" (I.T.)
-blue radiopaque line to allow visualization on x-ray


describe the construction of ETTs

-clear, polyvinyl chloride (visualize secretions and fogging)
-connector loosely inserted (should be firmly inserted)
-beveled patient end to the left (to aid in insertion through the cords and the visualization of insertion
-Murphy eye- hole near patient end to the right (opposite bevel) on Murphy tubes that allow ventilation even if end of ETT is against the carina or side of the trachea


describe cuff use with ETTs

-allows positive-pressure ventilation
-minimizes aspiration risk
-uncuffed ETTs used in some pediatrics
-types: **low pressure, high volume; high pressure low volume


describe low pressure, high volume cuffs

-larger mucosal contact
-lower incidence of mucosal damage
-higher incidence of sore throat, aspiration, spontaneous extubation, and difficult intubations (bigger, floppy cuff)
-"minimal leak"- pressures of 15-25 torr


describe high pressure, low volume cuffs

-higher incidence of tracheal mucosal ischemic damage
-only for a short duration
-can have pressures up to 250 torr on tissues


what factors affect cuff pressure?

-volume of air used to inflate cuff
-diameter of the cuff in relation to the trachea (ederly have bigger trachea)
-tracheal and cuff compliance (stenotic trachea?)
-intrathoracic pressure: asthmatics, bronchitis, smoker, recent URI (cuff pressures increase with coughing)
-nitrous oxide use (can diffuse into air-filled cuff to increase the pressure)


how does the size of ETT tube affect flow?

-radius of ETT has greatest effect on resistance to flow
-secretions of long-term intubated patients are more easily cleared with larger ETT
-vent weaning is easier d/t less resistance


what factors should be considered when choosing ETT size?

-size of patient's glottis (younger-smaller; older-larger)
-reason for intubation
-pathology of airway
-attempts allowed (if only one attempt, use smaller size)
-length of intubation (post-op, use larger size)
-maturity of airway (peds most narrow opening is subglottic opposed to adults which is supraglottic, right between vocal cords)
*compromise between maximizing flow with a large size and minimizing airway trauma with a smaller size


what is associated with larger size ETTs?

-incidence of sore throat is greater
*unless contraindicated, use smaller tube for a healthy patient who will be extubated at the end of the case to decrease risk of sore throat


what are average ETT sizes for males and females?

male: 7.5-9.0 mm I.D. (rarely 9.0)
female: 7.0-7.5 mm I.D.


describe anode or armored ETTs

-reinforced with wire in the wall of the ETT to resist kinking
*head and neck surgeries, prone cases
*if wall does become bent (pt. bites it), it remains bent and requires replacement
-very floppy, requires stylet for insertion


describe laser-shielded tubes

-made of silicone impregnated with metal particles, spiral wound stainless steel ETT, or wrapped with metal foil
*prevent puncture or ignition by laser heat
*cuff remains unprotected and should be filled with methylene blue stained saline so that perforation may be quickly recognized
-some have double cuffs; distal cuff maintains the seal if proximal cuff is ruptured
*pts. with polyps and ENT lasers them off


describe nasal and oral rae tracheal tubes

-performed with angles placed at the site of emergence from the nose or mouth to minimize kinking and obstruction to flow
-nasal rae: tube directed to forehead
-oral rae: tube directed toward chin
*good for ENT cases where tube wont be in the way and warmness wont cause kinking


describe endobronchial tubes

-double lumen used for selective one-lung ventilation
-the bronchial tip is placed in a main bronchus
-has both a tracheal cuff and a bronchial cuff
*surgery on one lung


describe a nasal ETT

-softer plastic to minimize trauma to nasal mucosa
-ring on connector end (tension here causes the cuffed end to angle upward to direct the tip anteriorly during nasal intubation)
*oral surgery