Module 3 Flashcards by Sydney Klyczek

Intubation: 
a procedure to maintain the ? 
urgent: can occur
planned: 
-for 
known ?

upper airway
in field

surgery
decline in medical status (COVID 19)

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Reasons for intubation: 
respiratory failure: 
inadequate 
inadequate 
... (usually ?)

apnea
oxygenation (hypoxia)
ventilation (hypercarbia - too much carbon dioxide)
surgery (planned)

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Endotracheal tubes: 
various ? 
number of the tube refers to the ? 
tube has markings in ? note the ? 
the tube is ? can check for ? 
distal tip should be approx?

sizes
inner diameter of tube
2 cm increments / depth of tube ending at teeth or lips
radiopaque / adequate placement on X-ray
4 cm in adults

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Inflant epiglottis:
… shaped
configuration

narrow, tubular/omega shaped

changes / opens with growth (age)

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COVID-19 considerations/precautions for intubation:
… procedures
-
-

aerosol generating procedures

suctioning (prior to intubation)
intubation itself

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Goal - extubation:
the patient can breathe ? and can be?
work toward extubation with ?

less ? more ?
adjustment to ?
decrease ?
-potential

independently/ taken off ventilator and be extubated

ventilator weaning trials

vent support/ spontaneous breaths
-sedation
-sedative medications
vicious circle

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potential for injury: 
placing 
having 
removing 
need for ?

endotracheal tube
endotracheal tube in place
tube (self-extubation)
re-intubation and then exudation another time

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Post-intubation injury:
research findings and versus common sense

duration of intubation
size of ETT
type of ETT
patient age , weight, height

did not correlate to degree of laryngeal injury

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Laryngeal injury from prolonged intubation:
how many had degree of laryngeal injury

most common:

other injuries included
vocal process
vocal fold
…

95%

arytenoid edema, arytenoid erythema an dinterarytenoid tissue edema

granuloma
immobility
subglottic edema/narrowing

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Laryngopharyngeal reflux:
GERD is an important factor in ?
-
exposure to acid results in?

laryngeal and tracheal injury in intubated patients in both Operating room or ICU
Nasal gastric tube (NGT)

mucosal injury to larynx and reduced mucocillary flow in trachea

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Right versus left injury with intubation:
left sided vocal fold injury is more?
this is attributed to

prevalent

right-sided insertion of orotracheal tube and left-handed hold of laryngoscope

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VF paralysis:
considerations:
surgical-cardiothoracic/thoaracic :

ETT cuff/tracheostomy tube cuff
RLN compression between ? with cuff inflated ?

left RLN more susceptible due to court - lower through chest around aorta

ETT cuff and lamina of thyroid cartilage/ RLN can sustain damage

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Post-extubation dysphagia risk: 
consistent risk factors for dysphagia found by ? 
-
-
-
-

of these factors it is not fully established which factor increases

ICU and length of hospital stay
multiple intubations
sepsis
poor functional status

increases risk for post-extubation dysphagia

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How long should a patient be intubated before consideration for tracheostomy placement ?
optimal time frame is not ?
varies from ?
also considerations for ?
average time oral intubation is about ? before consideration for completion of tracheotomy

set in stone
case to case
covid-19
10-14 days (in non-covid scenario)

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Tracheotomy:
procedure whereby

tracheostomy: surgically created

incision made into tracheostomy through neck

opening that remains in neck

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Tracheotomy: indications: 
relief of
bypass a ? 
provides means of  
enables efficient 
after initial management with endotracheal intubation , if prolonged airway or ventilator assistance required, covert to ?

upper airway obstruction 
compromised upper airway 
assisted mechanical ventilation 
tracheobronchial toilet 
tracheotomy early to prevent laryngeal or tracheal injury

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tracheotomy: surgical technique
.. position , neck ?
in children vertical entry into trachea through the? without removal of ?

in adults some surgeons remove ?

some surgeons create a ? just below levels of

supine/ extended

2nd,3rd, 4th tracheal rings/ cartilage

anterior portion of 3rd 4th tracheal rings

surgical flap/ TVFs

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Cricothyrotomy:
used in ? scenario

preferred over

convert to ?

cannot intubate cannot ventilate

tracheotomy for emergency airway management

tracheotomy early to prevent subglottic stenosis

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Percutaneous dilation tracheotomy completed in the ICU :
reduced
for patients too?

cost and reduced operating room resources

unstable to transport to OR

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PDT patient selection: 
adult ? 
contraindications: 
-anatomic differences including 
-circoid 
-midline 
-high 
-

uncorrectable ? 
PEEP >
non-intubated patients with 
.. patients 
morbidly ?

personnel ?

intubated patients ICU

below sternal notch
neck mas
brachiocephalic artery
goiter

coagulopathy (bleeding) 
15cm water 
acute airway obstruction 
pediatric 
obese patients

2 critical care doctors, respiratory therapist, nurse

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Tracheotomy procedure 
percutaneous tracheostomy placement
-small incision in 
series of ? used to ? 
a specialised ? placed
done at 
takes ?

trachea 
dilators/ increase size of tracheostoma
tracheostomy tube 
bedside 
20-30

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Tracheostomy tubes sizes:
a properly fitted tube should not occupy more than ?

sized on any variety of ?

2/3rds of inner diameter of trachea

classification system

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Flange or neck plate: 
attached to 
rests on 
provides support for 
has printed info about

proximal end of outer cannula
skin of patients neck
tracheostomy tube
size, type, manufacturer of tube

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Obturator:
tool used to
has a ? that protrudes beyond the end of the outer cannula to ease?

insert trach

rounded tip/ ease insertion

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``` Universal connector: standard size connection site for ? attachment point for inner cannula is ```

15mm inline suctioning if on ventilator speaking valve attached to this

cuff is fully inflated if | must be deflated for

on ventilator support | speaking valve use

outer cannula: larger ? may be ? or? length and diameter of outer cannula ? depending on

diameter than inner fenestrated or non-fenestrated varies/ size of tracheotomy tube

cuff: assists in providing a ? | types ?

closed ventilatory system / patient on ventilator or has copious secretions air filled foam fluid filled

Cuff inflation techniques: minimal occlusal volume: injecting air into cuff until no ? minimal leak technique: cuff is ? then a small amount removed until ? this has potential to exert less pressure on ? and potentially decrease ? cuff manometry: range

leak appreciated inflated until no leak hear/ small leak detected / tracheal wall/ complications with associated increased pressure (stenosis/tissue death) ideal 20-25 mm Hg

fenestrations: | used to assist with ?

weaning/decannulation

suctioning: open suction system - a suction catheter is inserted into the ? the catheter is advanced until suction catheter is withdrawn and suction pressure is applied as the ? -secretions are cleared from suction with either ? -additional passes may be necessary to

``` trach tubę using sterile technique -resistance is met -catheter moves up trachea -sterile water or normal saline clear additional secretions ```

Closed inline suction: designed to permit suctioning without housed in

disconnecting patient from ventilator | plastic sleeve - infection control

``` comm. options for trach patient non-verbal - - - ``` ``` verbal: - -.. tube -talking -... speech -... valve ```

comm. boards writing Mac ``` electrolarynx fenestrated tube talking trach. tube leak speech trach speaking valve ```

fenestrated designed primarily to -reintroduce ? and facilitate

airflow to upper airway | speech

``` complications from use of fenestratedL growth of ? blockage of blockage of clinical ```

granulation tissue fenestrations by secretions fenestrations against tracheal lumen clinical errors

talking trach: cuffed trach have an ? for airflow up the ? designed for patients who cannot airflow is reduced from ? vocal intensity may be

oxygen side port attached to outer cannula / glottis to facilitate comm. tolerate cuff deflation normal/ reduced

``` potential prob. with talking trach. -secretions can ? requires requires ... oropharyngeal ? due to ? ```

``` occlude fenestrations and or air port supplemental oxygen supply activation/manual dexterity expense dryness / continuous airflow ```

one-way trach. speaking valves: allows for inspiration through and expiration through requires

trach tubę/ larynx cuff deflation

Brands: Shiley (SSV) phonate speaking valve ``` Pssy-muir -closed position ? design fits the universal -can be used ? PMV 2000 and PMV 2001 designed with a small ? to prevent ```

no leak 15mm hub any size trach. interchangeably on/off ventilator small ring attach to secure it to prevent loss

Ventilator valve:PMV 007 for use with can also be utilised not ?

disposable ventilator tubing off of vent low-profile

metal trach: PMV 2020 only works with ? can also be used with ?

improved pilling weck metal jackson trach. tubes adults, paediatric, and neonatal Bivona non-foam filled cuffed trach. tube

``` Passy0Muir Valve O2 adapter: allows for easy ? delivers O2 in? avoids avoids ```

inhalation of low flow supplemental oxygen and humidity in front of diaphragm of PMV air trapping drying of secretion

``` What do you ask as SLP: medical ? when was trach ? per PMV literature valve use can be attempted ? what are the patient's what kind of trach does the patient ? is trach. has cuff ever been ```

``` hx - intubation length/ # of extubations placed 48-72 hours following trach. surgery oxygen levels have and why cuffed deflated ```

contraindications to PMV: severe excessive VF?

tracheal or laryngeal obstruction excessive secretions paralysis

``` Contraindications from PMV literature unconscious or inflated foam-filled severe unmanageable severe risk for Beverly reduced the device is not intended for use with ? do not use during ```

``` comatose patients trach cuff cuffed tube airway obstruction thick secretions aspiration reduced lung elasticity endotracheal tube or other artificial airways sleep ```

``` Valve selection: 007 PMV : obviously patient is on ? but , ask: if on vent weaning -could patient use the valve? -is there a chance patient may not fully - if so use ? for proximal XLT Shiley ```

ventilator also when on vent support wean or will return to vent aqua colored valve aqua colored valve

is cost a factor ? consider outpatient versus inpatient visibility:

PMV 005 PMV 2001 (purple) vs PMV 2000 (clear)

If valve placement appropriate first: tell patient educate them that breathing will feel the patient will have sensation of air going through ? a normal thing they have not

educate patient what you plan to do different larynx /experienced in some time

``` Reassure patient: I will we will monitor let them know it canoe share ? ```

stay with you whole time vital signs be removed immediately David muir's story

``` Cuff deflations completed by? or with ? inform patient deflate ? suction ? - the secretions sitting on the cuff with ? elicits ? ```

RN or RT / SLP as team player ``` prior to deflation slowly prior to and during deflation fall down further into trachea coughing ```

finger occlusion of the trach: resist urge to ? instruct patient to take deep breath and then say ? not all instances of audible voice are ? visible ? no audible air ? audible ?

``` open pMV prior to finger occlusion test AH same effort/strain despite cues to relax release upon removal of finger air release ```

consider holding off on PMV placement if: exhibits significant amount of ? if patient's oxygen saturation levels ? if patients voice is if patient is demonstrating (cannot tolerate )

audible air release upon removal of finger drop consistently during occlusion trial strained poor secretion management (cuff deflation)

``` if valve placement not successful: ask physician to: consider consider change to change to ? (not if) ... consultation ```

trach downsize fenestrated tube cuff less trach (patient receiving vent support) otolaryngology

``` The PMV is placed: monitor: monitor : look for ? check for change in remove PMV and check for ? ... retention ```

o2 saturation levels / candidate for increase in supplemental O2 heart rate/ decrease and increase not good respiratory rate audible air release from trach (CO2 retention)

For PMV use in-line with vent RT - may need to use RT - may need to remove rt- will likely need to adjust depending on vent setting patient may need to adjust ? once weaned from vent we may see a decline in ?

adaptor to attach valve in-line suction set-up vent settings timing of speech - forced breath by vent voice production once pt off of vent (no longer powered by vent)

leak speech: expired air that leaks past and passes through ? this usually occurs when the track tube is not ? -on a?

trach tubę/ glottis allowing pt to verbalise / fitting snugly against trachea or slightly deflated ventilator

voicing without speaking valve: finger trach

occlusion tube plug/capped inner cannula

purpose of ventilator: move air ? maintain

and out of lungs through artificial means respiratory function

types of ventilator: negative pressure: ventilators - old moves air into lungs by creating results in ? positive pressure most commonly simply

iron lung negative pressure around lung vacuum, of air rushing in used forces air into lungs

full ventilatory support: ventilator does partial: work of breathing

all work shared between pt and ventilator

common ventilator modes: controlled mechanical ventilation full: ventilator is doing a pt receives a preset ? and preset any spontaneous inspiratory attempts will CMV is a ? mode ,after a certain Time interval the ventilator cycles into

ventilatory support all the work number of breaths per minute not result in ventilation time sequenced mode/ inspiratory phase

Assist control ventilation: a preset ? are delivered however this mode will also ? when patient initiates breath, the ventilator will deliver in this mode patient will have a ? and a ? this mode is helpful for ?

respiratory rate and tidal volume/ assist patient's own spontaneous breathing efforts full preset tidal volume amount spontaneous rate / mechanical rate pt with respiratory muscle fatigue

Synchronized intermittent mandatory ventilation: SIMV is one of the most ? like Assist control, SIMV is also ? ventilaton allows the patient to intiiate ? the ventilator is programmed for preset ? however when patient initiates a breath ? can be used to begin?

comonly used partial support spontaneous breaths of varying tidal volumes respiratory rate and tidal volume / varies according to the patient's effort ventilator weaning

pressure support ventilation: is a .... that does not provide any ? this mode assists spontaneous breaths with a pre-set amount of ? the added pressure lets the patient take a ? than would be possible? this mode is typically used with the patient who can ? but is unable to ? this mode can be used ? or in combo with?

spontaneous mode of ventilation/ preset breath rate or tidal volume pressure during inspiratory phase deeper breath/ independently initiate adequate number of breaths / inflate lungs adequately alone / ventilator modes

Rate: number of ? adults children infants

breaths delivered to the patient by ventilator -breaths per minute 12-20 30-40 60-80

Tidal volume: TV is the amount of air moved ? based on patients the ventilator measures how much air is ? as well as how much air is ? if the measures diverge various ?

into and out of the respiratory tract during breathing cycle weight being delivered to patient/returned to ventilator alarms will sounds

PEEP: | normal peep

2-5 cm H20

Continuous positive airway pressure: a mode of ventilation that applies ? the positive pressure helps to prevent ? improve? and enhance?

positive pressure on inspiration and expiration to a spontaneously breathing patient alveolar collapse, functional residual capacity, oxygenation

``` Trach. weaning patient is ? tolerating? trach has likely been ? patient is tolerating ``` may have done a ?

breathing spontaneously cuff deflation downsized speaking valve or capping 24 hours trach capping trial

decann. | typically closes within

3-5 days

COVID CONSIDERATIONS: ventilator use is last? high flow of air from ventilator can cause ? for these patients doctors try to maintain lowest ? ECMO ?

resort further lung damage (barotrauma) flow alternative - extracorporeal membrane oxygenation