Oral and Nasal Intubation

Question 1

Oral and Nasal Intubation Indication

Answer 1

1.Provide a patent airway
2. Access for suctioning
3. Means for mechanical ventilation
4. Protect the airway ( from aspiration or obstruction
5. Direct instillation of medication
6. When administering the meds through the ET tube you must double the normal IV dose, and flush with 10ml of saline

Question 2

Oral and Nasal Intubation Direct instillation of medication

Answer 2

-Narcan narcotic overdose
-Atropine bradycardia
-Valium/ Versed sedative
-Epinephrine, asystole
-Lidocaine PVC

Question 3

Complication of Intubation

Answer 3

-1. Infection, fever, secretion, etc
-2. Cuff pressure is directly related to capillary pressures. It should be equal to or less than 20mmHG or 20 cwp normal range is 20-30 mmHG or cwp
-3.Laryngospasm most serious
-4.Right mainstem bronchus intubation (oral ET tube inserted >25 cm)
-5. Risk of ventilator acquired/ associated pneumonia

Question 4

Cuff pressure

Answer 4

-Pressure >5mmHG -Vessel Lymphatic -Results Edema
-Pressure >10 mmHG -Vessel vein result edema
-Pressure > 20 mmHG vessel artery results necrosis

Question 5

Equipment
-Laryngoscope
-Handle

Answer 5

-A. Always held on left hand
-B. Hold batteries for light

Question 6

Equipment
-Laryngoscope
-Blades

Answer 6

Curved/ Macintosh- fits into vallecula, indirectly raises epiglottis
Straight/ miller blades- fits directly under the epiglottis (preferred for infants intubation

Question 7

-Laryngoscope
-Blades
Troubleshooting

Answer 7

If light doesn’t work
Tighten bulb
Check handle attachment
Change Blades
Check Batteries

Question 8

-Laryngoscope
-Blades
Blade sizes

Answer 8

Adult size 3,4,5,
Pedi size 2
Term Infant 1
Pre term infant size 0,00,000

Question 9

direct lighting laryngoscope system

Answer 9

-The direct lighting laryngoscope system uses a handle composed of hollow metal chamber that contains batteries for the light bulb within the laryngoscope blade. When the blade is inserted into the handle of a fully extended, the bulb makes contact with the battered source and lights up

Question 10

fiber optic lighting system laryngoscope

Answer 10

-The fiber optic lighting system laryngoscope is similar to the direct lighting system except that a fiber optic bundle is pressure activated when seated on the handle. Many blades using the fiber optic bundle have the light running down the entire length of the blade

Question 11

Intubation
Procedure

Answer 11

-1. POsition PTs head in sniffing position (slight hyperextension)
.2. Adequately hyperoxygenate (resuscitation bag with 100% O2 for 2 min)
-3. Hold Laryngoscope in left hand, ET tube in right hand
-4. Insert blade down right side of moth, sweep tongue to the left
-5. Advance blade, lift epiglottis, visualize cords (curve blade tip into vallecula, straight blade tip under epiglottis) have suction available
-6. Cricoid pressure (selleck manuever) s indicated if larynx is in an anterior location
-7. Inset tube inflated cuff, assess tube position, ventilate, and oxygenate
-8. Minimal occluding volume or minimal leak technique can be used to inflate cuff

Question 12

Minimal occluding volume or minimal leak technique can be used to inflate cuff

Answer 12

-A. Minimal occluding volume (mov) Listen for air leak cuff inflated during positive pressure ventilation, stop inflating at minimal volume necessary to eliminate air leak via trach or endotracheal tube
-B Minimal leak technique (MLT) slowly inject air into cuff during positive pressure inspiration until leak stops, a small amount of air is removed to allow a slight leak during peak inspiration

Question 13

Very Helpful when selecting which blade to use

Answer 13

-Generally the straight blade (Miller) is used for infants and pediatric intubation. This is especially true for infants under 6-12 months of age due to the ore anterior airway, the large tongue, and the floppy epiglottis of the infant and young child. For children older than 6-8 years of age, the curved (Mac) blade is generally used. HOwever the choice of blade is often by personal preference

Question 14

Assessment of Tube POsition

Answer 14

Inspection, look for bilateral chest expansion during inspiration
Auscultation, breath sounds should be heard on both sides of the chest
Capnography or CO2 detectors (will discuss more at the end)
Chest X-ray the radiopaque line on the endotracheal tube can be easily visualized to assess placement. The tip of the tube should be 2cm or 1 inch above carina or at the aortic knob/ notch

Question 15

How to care for an Intubated PT
-Suctioning

Answer 15

Maintain Patency , if thick, then add saline to thin down

Question 16

How to care for an Intubated PT
HUmidification

Answer 16

A.) Prevent dehydration of tissue (100% humidity @ 37 Degrees Celsius)
b.) Best way to prevent obstruction, because it keeps the secretions thinned down. Without humidity, the PT dries up causing mucus plugging

Question 17

How to care for an Intubated PT
3.) Cuff pressure

Answer 17

A.) Minimal Leak
B.) Minimal occluding Volume
c.) Use high volume/ Low pressure cuff (equal to or < 20mmHg or 30 mmHg or CWP

Question 18

SUPPLIES NEEDED FOR ORAL iNTUBATION

Answer 18

-CO2 Detector

-Varies size of ET Tube

-Varies blades and handles

-Suction equipment set up

-10Ml saline syringe

-Ambu bag with mask

-Tube tie

-Bite Block

-Stylet

-Crash Cart

-Lube

Question 19

Special Tube used to Evaluate the level of difficulty Prior to Intubation

Answer 19

Mallampati Test/ Grade Test

-View Obtained during Mallampati Test:

Faucial Pillars, soft palate and uvula visualized

Facial pillars and soft palate visualized, but uvula masked by the base of the tongue

Only soft palate visualized

Soft Palate not seen.

Clinically, Class 1, and Class2 usually produce an easy intubation and class 3 or 4 suggest a significant chance that the PT will probably be difficult to intubate. The results from this test are influenced by the ability to open mouth, the size and mobility of the tongue and other intra- oral structures.

-Note always chart your findings. To perform, the PT sits in front of the anesthetist and opens the mouth wide. The PT is assigned a grade according to the best view obtained

Question 20

Grade Test

Answer 20

-Grade 1, the vocal cords are Visible

	-Grade 2 the vocal cords are only partly visible

	-Grade 3 only the epiglottis is seen

	-Grade 4 the epiglottis cannot be seen

-Always do thee CLASS TEST PRIOR to the grade test

Question 21

Stylet

Answer 21

Used only to aid in oral intubation

Shapes the tube and makes it easier for insertion

Make sure stylet isn;t sticking out. If it does have a stopper to stop advancement, and then bend the stylet to prevent it from going further

Question 22

Magill Forceps

Answer 22

a.)Must be used in nasal intubation

b.) It works by placing the magill forceps in the mouth and grabbing the tube- Thus allowing you place the Nasotracheal tube through the cords

Question 23

-Tube Sizes

Answer 23

ET Tube sizes

	a.) Pre term infant 2.5-3.0

	b.) Full term infant 3.0-3.5

	c.) Adult Male= 8.0-10.0mm

	d.) Adult Female= 7.0-8.0


-Approximate formula to figgut=re up et tube size for adults. WT in KG of IBW divided by 10= size of tube

-Example : PT weighs 100 kg divided by 10=10

Question 24

Marking Once Tube is Inserted

Answer 24

-ET tube marking at the lip should be 21 to 25 cm

-Nasal endo tracheal tube should be 26 to 29cm at the lip

Question 25

Different types of Cuff

Answer 25

-High pressure, low volume, low compliance -Low pressure, high volume, high compliance, floppy cuff -Remember the normal cuff pressure should be 20mmHG to 30 mmHG or cwp or less

Question 26

Cufflator

Answer 26

-Use to monitor cuff pressure. Provides you with the actually cuff pressure

Question 27

Double Lumen Tube (DLT)/ Endobronchial

Answer 27

-Design -A. A tube with two independent lumina of different lengths, the long lumen is inserted into either the left or right mainstem and the shorter lumen is placed in the trachea above the carina -B. Each lumen can ventilate each lung separately of they can be connected via WYE and share a ventilation source  -C. The tube has two cuffs, one cuff is a low pressure, high volume cuff abd the other cuff is smaller and a high pressure, low volume cuff (right or left mainstem bronchus tube -D. To confirm correct placement the bronchial cuff has a radiopaque line

Question 28

Indications for DLT

Answer 28

Unilateral lung disease to improve ventilation and oxygenation Bronchopleural fistula, tracheobronchial tree disruption, and surgical openings of a large airway t stop or promote healing and ventilate other areas of the lung Used in surgery during a pneumonectomy, lobectomy, esophageal resection and aortic aneurysm repair To provide airway protection in preventing blood or secretions from entering the unaffected lung 

Question 29

Esophageal Tracheal Combitube design

Answer 29

The esophageal tracheal combitube (ECT) is an option for emergency airway management that has similarities to the esophageal obturator The distal end of the ETC combines a tracheal lumen and esophageal lumen into one tube The proximal end of the ETC separates these two lumens into separate color coded tubes A large cuff is attached to the proximal end an another cuff is attached to the distal end of the combitube 

Question 30

Esophageal Tracheal Combitube Insertion

Answer 30

The device is placed blindly into either the trachea or the esophagus and both cuffs are inflated  It is more common for the tube to enter the esophagus. In this event the esophagus works tubes will be occluded by the distal balloon Ventilation will provide through the longer, blue colored #1 tube and gas will be forced through small perforation in the walls of the proximal openings and into the trachea  In this position the combitube works like the familiar esophageal obturator airway (EOA)

Question 31

Esophageal Tracheal Combitube Assessment

Answer 31

Careful PT assessment is essential to identify the presence of gastric sounds or bilateral breath sounds so that appropriate port is used for ventilation The ETC should not be used in pediatric PT or in very short adults The airway is disposable so throw it away

Question 32

Esophageal Tracheal Combitube The advantages when using this tube

Answer 32

Can be rapidly inserted Does not require visualization of the larynx

Question 33

Esophageal Tracheal Combitube Disadvantage when using this tube

Answer 33

Placement of the ET tube is difficult with combitube in place Cannot be used in PT with gag reflex

Question 34

HI-Lo Evac tube

Answer 34

Indication for the use if oral or nasal endotracheal intubation that requires continuous endotracheal intubation that requires continuous aspiration of subglottic secretions CASS A separate suction port is incorporated into the endotracheal tube just above the cuff Continuous suction is provided via separate pilot tube connected to a vacuum pressure of 20mmHg CASS has been shown to reduce the incidence of ventilator acquired/ associated pneumonia (VAP)

Question 35

How long to stay in the airway when intubating

Answer 35

-We don't want to go longer than 30 seconds per attempt. If our first attempt is unsuccessful then re-oxygenate the PT and try for a second attempt.

Question 36

LMA

Answer 36

-Laryngeal mask airway (LMA) ventilation is a method for providing rescue ventilation to unconscious PT or PT without a gag reflex that is technically easier than use of most other effective ventilation methods. It is used by anesthesiologist in many settings that previously required endotracheal intubation

Question 37

LMA supraglottic airway

Answer 37

      • The laryngeal mask airway (LMA) is a commonly used supraglottic airway. The LMA is an orally introduced supraglottic airway tube with a cuffed mask at one end that forms a low-pressure seal around the laryngeal inlet. LMA ventilation has several advantages over other methods.

Question 38

LMA vs. ET tube, BMV

Answer 38

      • Unlike endotracheal tubes, LMAs can be successfully inserted blindly and by inexperienced operators.       • Unlike bag-valve-mask (BVM) ventilation, LMAs avoid the difficulties of attaining and maintaining an adequate face-mask seal, they bypass soft tissue obstruction of the upper airway, and they cause less gastric insufflation than BVM ventilation.

Question 39

LMA various designs, and when to remove

Answer 39

      • Some available types of LMAs allow passage of an endotracheal tube (intubating LMAs) or a gastric decompression tube. Some have a fixed, anatomically correct shape that further optimizes ease of insertion. Some newer mask designs replace the inflatable cuff with a gel-filled cuff that molds to the airway.       • LMAs, like the other supraglottic airways are temporary airways that must, after several hours, be removed or be replaced by a definitive airway, such as an endotracheal tube or surgical airway (cricothyrotomy or tracheostomy).

Question 40

Indications for Laryngeal Mask Airway

Answer 40

      • Apnea, severe respiratory failure, or impending respiratory arrest in which endotracheal intubation cannot be accomplished       • Certain elective anesthesia cases       • LMAs are useful in situations where bag-valve-mask ventilation is difficult:       • Patients with severe facial deformity (traumatic or natural), thick beard, or other factors that interfere with the face mask seal

Question 41

Contraindications to Laryngeal Mask Airway

Answer 41

      • Absolute contraindications             • (do-not-resuscitate order or specific advance directive) may be in force             • Maximum mouth opening between incisors < 2 cm (nasotracheal intubation or a surgical airway would be indicated in this case)             • Impassable upper airway obstruction (surgical airway would be indicated in this case)       Relative contraindications             • Increased risk of regurgitation: Prolonged prior BVM ventilation, obesity, pregnancy > 10 weeks, patients who have not fasted or have upper gastrointestinal issues (eg, previous surgery, bleeding, hiatal hernia, gastroesophageal reflux disease, peptic ulcer disease). In emergencies, use of an LMA can proceed even with these relative contraindications.             • Need for high pressure ventilation

Question 42

LMA Complications

Answer 42

      • Complications include              • Vomiting and aspiration (shouldn't be done if Gag reflex is in place.              • Tongue edema due to prolonged placement or balloon overinflation              • Dental or oropharyngeal soft tissue trauma during insertion

Question 43

Equipment for Laryngeal Mask Airway

Answer 43

      • Equipment for Laryngeal Mask Airway             • Gloves, mask, gown, and eye protection (ie, universal precautions)             • 30- to 60-mL syringe             • Sterile water-soluble lubricant or anesthetic jelly             • Laryngeal mask airway             • Bag-valve apparatus             •  Oxygen source (100% oxygen, 15 L/minute)             • Suctioning apparatus to clear the pharynx as needed             • Pulse oximeter, capnometer (end-tidal carbon dioxide monitor), and appropriate sensors.                -Drugs to aid intubation = paralytic              -Equipment for alternate methods of airway control should LMA insertion fail (eg, equipment for bag-valve mask ventilation, endotracheal intubation, cricothyrotomy)

Question 44

Additional Considerations for Laryngeal Mask Airway

Answer 44

      • The inflatable cuff around the rim of the mask forms a low-pressure seal around the laryngeal inlet that allows positive pressure ventilation.       • Use low-pressure ventilation with a LMA to prevent air from escaping the low-pressure seal and causing gastric insufflation.       • If the seal is inadequate, lower the cuff pressure somewhat. If this approach does not work, a larger mask size should be tried. Overinflation of the cuff will make a poor seal worse.       • LMAs do not protect the airway from aspiration. However, some types of LMA feature improved laryngeal seals as well as ports for insertion of gastric decompression tube

Question 45

Relevant Anatomy for Laryngeal Mask Airway

Answer 45

• Aligning the ear with the sternal notch may help open the upper airway and establishes the best position to view the airway if endotracheal intubation becomes necessary.

Question 46

Head and Neck Positioning LMA

Answer 46

      • A: The head is flat on the stretcher; the airway is constricted. B: Establishing the sniffing position, the ear and sternal notch are aligned, with the face parallel to the ceiling, opening the airway.       • Slide the LMA as shown in the lab. After you are halfway down then you use your point finger to paloon to desired pessure and chaeek tor chest rise and use CO2 detector. Remember, LMAS are not protect from aspiration and only should be done on someone without a gag reflex (unconscious).

Question 47

If cervical spine injury is a possibility: LMA

Answer 47

      • Position the patient supine or at a slight incline on the stretcher. Avoid moving the neck and use only the jaw thrust maneuver or chin lift without head tilt to manually facilitate opening of the upper airway       • LMAs that are anatomically contoured can be inserted without any neck manipulation or need for finger insertion into the mouth. They may cause posterior pressure on the cervical spine; however, they are generally considered safe for patients with unstable cervical spine injury.