Chapter 37 Airway Management

What device to you need to include when you want to collect a sputum specimen during suctioning?

"Sputum trap" aka "specimen container"

8 basic steps of tracheotomy care

1. Assemble and check equipment (PPE, suction, trach kit, spare inner cannula (disposal), hydrogen peroxide, and sterile water , cotton tip applicator, precut gauze, trach tube of same size and smaller size, 10-12 mL syringe) 2. Explain procedure to patient 3. Perform endotracheal suctioning 4. Clean inner cannulas or dispose of it 5. Clean the stoma and change the dressing 6. Change the ties or velcro holder 7. Replace inner cannulas 8. Assess the patient

List the nine methods for bedside assessment of correct tube position

1. Auscultate chest and abdomen 2. Observe chest movement 3. Tube length at teeth 4. Esophageal detection device 5. Light want 6. Capnometry 7. Colorimetry 8. Fibrotic laryngoscope or bronchoscope 9. Video laryngoscope

List three of the most common problems that occur after extubation

1. Hoarseness 2. Sore throat 3. cough and trouble swallowing

List four possible reasons why a tube may become obstructed

1. Kinking or biting on the tube (oral ETT) 2. Herniation of the cuff over the tube tip 3. Jamming of the tube orifice against the tracheal wall 4. Mucus plugging

List five types of equipment you will want to assemble prior to extubation

1. suction equpiment 2. O2/aerosol equipment 3. Manual resuscitator and mask 4. Aerosol nebulizer and racemic epinephrine (PRN) 5. Intubation equipment

What temperature range must be maintained in a heated humidification system to provide adequate inspired moisture?

37 to 35 degrees Celsius

Tracheoinnominate fistula is a rare but serious complication. What are the clues, and what are the immediate and corrective actions to take?

A pulsating tracheostomy tube may be the only clue. Once hemorrhage begins, hyperinflation of the cuff may help but surgery is needed. Only 25% of these patients will survive.

Describe the two techniques used for nasal intubation

A. Blind: insert tube through nose in an upright position, listening through the tube for breath sounds B. Direct visualization: Visualize the larynx with a laryngoscope. Advance the tube into the larynx with the use of magil forceps

Give two examples of clinical situations where nasotracheal intubation might be preferred over oral intubation

A. Cervical spine injuries B. Maxillofacial injuries

List three advantages of the LMA

A. Easy to insert B. No special equpiment C. Avoids trauma

List at least two anatomic landmarks in addition to the glottis that should be visualized prior to intubation.

A. Epiglottis B. Glottis, arytenoid

High-frequency jet ventilation tubes look like standard tubes with two additional lines. What are they?

A. One line is for the high pressure injection B. The other can be used for humidification, liquids, and pressure monitoring

3 advantages of percutaneous technique compared w/ traditional surgical trachotomy

A. Rapid B. Avoids the need for transport to operating room C. Lower incidence of intraoperative and postoperative complications

Three airway emergencies

A. Tube obstruction B. Cuff leaks C. Accidental extubation

List two disadvantages of the LMA

A.Risk of aspiration does not protect airway B. Only ventilates at low pressures

Fenestrated tube technique for weaning from trach tube

Advantage: easy to suction and ventilate Disadvantage: malposition, granuloma

Tracheostomy button technique for weaning from a trach tube

Advantage: low resistance, suction Disadvantage: no cuff

Progressive smaller tube technique for weaning from a trach tube

Advantage: stoma healing, gradual Disadvantage: impairs cough, obstructs easily

What simple technique is used to assess tube obstructions that are not relieved by repositioning the head or deflating the cuff?

Attempting to pass a suction catheter through the tube

Hypotension

Cause: Cough, vagal stimulation Prevention: Stop suctioning, administer O2 and ventilation, notify nurse and PCP

Cardiac arrhythmia

Cause: Hypoxia, vagal stimulation Prevention: Pre-oxygenation and post-oxygenation on 100%

Hypoxemia

Cause: Reduces lung volume Prevention: Pre-oxygenate with 100% oxygen

Increased ICP

Cause: cough Prevention: Topical anesthetic

Bacterial colonization of lower airway

Cause: pushed down during procedure Prevention: Do not instill normal saline

Atelectasis

Cause: suctioning Prevention: limit amount of negative suction pressure used

Mucosal trauma

Cause: vacuum technique Prevention: Use appropriate suction pressure, technique

Prior to insertion, how should the Rt test the tube?

Check for leaks

What is the final step of confrimation of endotraceal tube placement?

Chest X-Ray

What is the worst problem that results from inadequate humidification of the artificial airway?

Complete obstruction of the tube and asphyxiation

What therapeutic modality is usually applied immediately after extubation?

Cool mist with O2 as needed are applied. It is equally common to use cannulas or mask if the patient does not have any complications

What special catheter is used to facilitate entry into the left mainstem bronchus?

Coude catheter with bent tip

Describe the method for performing a "cuff-leak test". What does Egan's suggest as a percentage of leak that should lead to considering extubation?

Deflate the cuff and assess leaking around tube during positive pressure ventilation. Compare the exhaled volumes and quantify the leak. 15% or greater is a good percentage of leak for considering extubation

What is the most common material used to secure endotracheal tubes? Tracheostomy tubes?

ET tubes are secured with tape. Tracheostomy tubes are secured with cloth ties. Commercial harnesses are available for both tubes.

Continuous aspiration of subglottic secretions is the generic name for the Hi-Lo Evac Tube. What is the reported beneift of the subglottic suction (i.e., CASS or Hi-Lo Evac) tube?

Evac tubes are intended to reduce the incidence of VAP

How do flexion and extension of the neck affect tube motion? What is the average distance the tube will move (in cm)?

Extension (head up) moves the tube up Flexion moves tube down The tube may move as much as 1.0 cm in either direction

If you cannot clear the obstruction, what action should you be prepared to take?

Extubation and anual ventilation by bag and mask followed by reintubation

What device can be used as an alternative to heated humidifiers for short-term humidification of the intubated patient?

Heat and mositure exhangers

What is the disadvantage of using capnographic or colorimetric analysis of carbon dioxide to assess intubation in a cardiac arrest victim?

If the patient has poor blood flow or no perfusion, the device won't be able to detect intubation.

There are also carlen's or endobronchial, tubes. What is the name of the special type of ventilation used with this tube?

Independent lung ventilation (ILV)

What is the recommended safe cuff pressure? What is the consequence of elevated cuff pressures?

Keep the cuff pressures b/w 2- and 30 which will maintain tracheal mucosal capillary blood flow. If cuff pressure exceeds the mucosal perfusion pressure, ischemia, ulceration, and necrosis may result. If too low, lung infections are more likely secondary to material above the cuff sliding past the cuff and into the lungs

Drugs used to numb the airway and reflexes

Lidocaine will numb the nose; benzocaine for the throat

What effects will occur with a duff leak when a patient is being mechanically ventilated?

Loss of delivered volume and decreased inspiratory pressures

COMPARE THE USE OF THE MILLER AND MACINTOSH LARYNGOSCOPE BLADES DURING THE INTUBATION PROCEDURE.

Macintosh fits into valleculla (base of tongue) and lifts epiglottis indirectly -- Think APPLE (the mac curves like an apple) Miller slips under epiglottis and directly lifts epiglottis out of the way to allow visualization of the glottis. Miller is more commonly used in pediatric patients because epiglottis is not as rigid as an adults and must be lifted out of the way.

Advantages of closed-system multiuse catheters (ballard)

Maintains PEEP, oxygenation, lowers exposure to body fluids; decreases risk of cross contamination, may decrease cost

Drugs used to sedate the patient

Muscle relaxant; versed

Drugs used to paralyze the patient

NMBA; succinylcholine

What specialized airway is used to facilitate repeated nasal suctioning>

Nasopharyngeal airway

How long should you attempt intubation? WHy do you think we have a rule like this?

No more than 30 seconds; otherwise patient will become hypoxic

What is the preferred route for establishing an emergency tracheal airway?

Orotracheal or oral intubation

What additional troubleshooting step can often be performed on patients with tracheostomies?

Remove inner cannulas and check to see if plugged

Wht is the most common cause of airway obstruction in the critically ill patient?

Retained secretions

How si the patient's head positioned to align the mouth, pharynx, and laryn?

Sniffing position and rolled towel under the head

A common complication of extubation is glottic edema. How will you recognize and treat this problem?

Stridor indicates glottic edema and racemic epinephrine can be given to reduce swelling. Reintubation may be needed.

Injury: Polyp/granuloma

Symptoms: Difficulty swallowing, hoarseness Treatment: Stridor if symptoms do not resolve surgical removal may be indicated

Injury: Glottic edema

Symptoms: Harseness, Stridor Treatment: Racemic steroids epinephrine

Injury: Laryngeal ulceration

Symptoms: Hoarseness Treatment: 0 treatment indicated

Injury: Vocal cord inflammation

Symptoms: Hoarseness Treatment: Racemic epinephrine, steroids

Injury: vocal cord paralysis

Symptoms: Hoarseness, Stridor Treatment: trach may be needed

Injury: Laryngeal stenosis

Symptoms: stridor, hoarseness Treatment: surgical correction/tracheotomy

What is a "talking trach"? What are some of the problems with these devices?

Talking tracheostomy tubes allow a flow of O2 or air to be directed above the cuff and through the vocal cords, which allows the patient to talk. These are bulky and difficult to use.

Describe the sequence for removing an ET during the tracheotomy procedure. REMEMBER THIS!

The ET tube should remain in place until just prior to inserting the tracheostomy tube. As you insert the trach, the cuff of the ET is deflated and it is removed more or less at the same time as the trach is pushed into place.

When using a Passy-Muir Valve, what do you need to do with the cuff? How about the ventilator?

The cuff needs to be deflated; sometimes the tube is changed. The tidal volume can be increased to compensate for this.

What is the primary indication for performing a tracheotomy?

The need for an artificial airway for a prolonged period of time

What may happen when the tube is too small for the patient's trachea?

They increase the risk of silent aspiration

The decision to removed the airway and the decision to remove the ventilator are not the same. What kind of patients might need to remain intubated even after the ventilator is removed?

Those with poor airway control or excessive secretions

Describe two common troubleshooting proedures used when the lryngoscope does not light up properly

Tighten the bulb, check the batteries, replace the bulb

Why is suction equipment needed for intubation?

To clear vomit/secretions, so you can visualize the vocal cords

Describe the tracheoesophageal fistula in terms of cause, complications, and treatment

Tracheoesophageal fistula is caused by tracheal erosion from cuffs, esophageal erosion from NG tubes, malnutrition, or poor surgical technique. Aspiration may occur. Treatment involves surgical closure of the opening.

Compare the location of placement in percutaneous and traditional surgical tracheotomy

Traditional surgical trachotomy places the tube in the neck over the second or third tracheal ring. Percutaneous trach tubes are placed between the cricoid cartilage and the first ring, or between the first and second tracheal rings.

What type of lung disease requires the use of a double-lumen ET tube?

Unilateral lung disease

What other actions must be taken before making any attempt to intubate>

Ventilate and preoxygenate the patient

Disadvantages of closed-system multiuse catheters (ballard)

Weight, airway resistance, and ventilator triggering

What is the name of the device commonly used to suction secretions or fluids from the oropharynx?

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