ACLS: Cases: Respiratory Arrest
What is the proper breath to give with a bag-valve mask?
600 mL Vt sufficient to provide chest rise over 1 second
How can you confirm correct place to of ET tube?
With continuous waveform capnography
What are basic airway skills used to ventilate a patient?
- Head tilt- chin lift - Jaw thrust without head extension (suspected cervical spine trauma) - Mouth-to-mouth ventilation - Mouth-to-nose ventilation - Mouth-to-barrier device (using a pocket mask) ventilation - Bag-mask ventilation
What are the names of some advanced airways?
- Laryngeal mask airway - Laryngeal tube - Esophageal-tracheal tube - ET tube
What signs can cause you to suspect probable respiratory failure?
- Marked tachypnea - Bradypnea, apnea - Increased, decreased, or no respiratory effort - Poor to absent distal air movement - Tachycardia (Early - Bradycardia (Late) - Cyanosis - Stupor, coma (late)
What are points to be careful of while inserting an NPA?
- NPA can irritate mucosa or lacerate adenoidal tissue and cause bleeding, with possible aspiration of clots into the trachea -> suction necessary - Improperly sized NPA may enter esophagus and cause gastric inflation and possible hypoventilation - An NPA may cause laryngospasm and vomiting - Use caution in patients with facial trauma because of the risk of misplace meant into the cranial cavity through a fractured cribriform plate
What are three points to be aware of while using an OPA?
- OPAs that are too large may obstruct the larynx or cause trauma to the laryngeal structures - OPAs that are too small or inserted improperly may punch base of tongue posteriorly and obstruct the airway - Insert OPA carefully to avoid soft tissue trauma to the lips and tongue - May create vomiting and laryngospasm if used with a patient with a cough or gag reflex
What are extra devices that can be used on a bag-mask device?
- One-way valves to prevent the patient from rebreathing exhaled air - Oxygen ports for administering supplementary oxygen - Medication ports for administering aerosolized and other medications - Suction ports for clearing the airway - Ports for quantitative sampling of end-tidal CO2
What do you do if you encounter resistance while inserting a NPA?
- Slightly rotate tube to facilitate insertion at the angle of the nasal passage and nasopharynx- Attempt placement through the other nostril because patients have different sized nasal passages
What are clinical signs of respiratory distress?
- Tachypnea - Increased respiratory effort (nasal flaring, retractions) - Inadequate respiratory effort (hypoventilation or bradypnea) - abnormal airway sounds (Stridor, wheezing, grunting) - tachycardia - Pale, cool skin - Changes in level of consciousness/agitation - Use of abnormal muscles to assist in breathing
What suction pressure is necessary?
-80 to -120 is necessary
What are the four steps to putting in a OPA
1. Clear mouth and pharynx of secretions, blood, or vomit by using rigid pharyngeal suction if possible 2. Select proper size (corner of mouth to angle of mandible) (should align with glottis opening) 3. Insert OPA so that it is upward toward hard palate 4. As OPA passes through oral cavity turn it 180degrees into proper position
What are the steps for oropharyngeal Suctioning?
1. Measure catheter before Suctioning and do not insert any further than distance from tip of nose to earlobe - Gently insert suction catheter or device into oropharynx beyond the tongue 2. Apply suction by occluding the side opening of the catheter while with-drawing with a rotating or twisting motion - If using rigid suction device (Yankauer), place tip gently into oral cavity. Advance by pushing the tongue down to reach the oropharynx if necessary
What are the three steps to insert in a NPA?
1. Select proper size of NPA: Compare outer circumference of NPA to inner aperture of nares. Length is from tip of patients nose to earlobe 2. Lubricate airway with water-soluble lubricant or anesthetic jelly 3. Insert the airway through nostril in posterior direction perpendicular to the plane of the face. Pass gently along floor of the nasopharynx
What are the steps to performing ET tube?
1. Use sterile technique to reduce likelihood of airway contamination 2. Gently insert catheter into ET tube. Be sure the side openings so not occluded during insertion 3. Apply suction by occluding the side opening only while withdrawing the catheter with a rotating or twisting motion. Suction attempts should not exceed 10 seconds. Administer 100% O2 before suction attempt.
What is the normal RR and Vt that maintains normal oxygenation and elimination of CO2?
12-16 BPM and 8-10 mL/kg
What kind of tidal volumes should be used for respiratory arrest?
500-600 mL (6-7 mL/kg) - Consistent with tidal volume that produces visible chest rise
How can a patient with an airway obstruction be properly ventilated with bag-mask ventilation?
A pressure-relieve valve on your device may prevent delivery of a sufficient tidal volume in these patients. Ensure that the bag-mask allows you to bypass the pressure-relief valve and use high pressures, if necessary, to achieve visible chest expansion
What is a patient trying to overcome when maintaining adequate gas exchange?
Airway obstruction, reduced lung compliance me or lung tissue disease
What is a nasopharyngeal airway?
An alternative to OPA. A soft rubber or plastic uncuffed tube that provides a conduit for airflow between nares and the pharynx
What is the most common method of providing positive pressure ventilation?
Bag-mask device
Why is excessive ventilation unnecessary?
Causes gastric inflation (which then causes regurgitation and aspiration). Also causes increased intrathoracic pressure which then decreases venous return to heart and diminishes CO
What is respiratory arrest?
Cessation (absence) of breathing
Who do you need to adjust suction force for?
Children and intubated patients
What is respiratory failure?
Clinical state of inadequate oxygenation, ventilation, or both
What is respiratory arrest usually caused by?
Drowning or head injury
In the case of a patient in respiratory arrest with a pulse, how should the ventilations be given?
Every 5-6 seconds with bag-mask device or any advanced airway device. Then recheck the pulse every 2 minutes
How does an OPA used?
Fits over the tongue to hold it and the soft hypo pharyngeal structures away from the posterior wall of the pharynx
What is the basic airway opening technique and how would you do this with a suspected neck injury?
Head-tilt-chin lift. If neck injury just use jaw thrust with no head tilt
When can NPA be used but an OPA not used?
In semi or fully conscious patients
What is the most common cause of upper airway obstruction in the unconscious/unresponsive patient?
Loss of tone in the throat muscles
What does severe respiratory distress look like?
Marked tachypnea, significantly increased respiratory effort, deterioration in skin Colorado, and changes in mental status
What does mild respiratory distress look like?
Mild increase in respiratory effort, mild tachypnea, and changes in airway sounds
What are signs of increase respiratory effort?
Nasal flaring, retractions, and use of accessory muscles
When should an OPA not be used and why?
Not used in semi or fully conscious patients because it may stimulate gagging and vomiting
What is the ventilation rate with an advanced airway placed?
Once every 6 seconds
What should wall mounted suction units be capable of?
Providing airflow greater than 40L/min at the end of delivery tube and a vacuum of more than -300 mmHg
What is tachypnea?
RR above 20bpm
What is bradycardia?
RR below 12bpm
What is hypoventilation and what is required at that time?
RR below 6 bpm and requires assisted ventilation with a bag-mask device with an advanced airway and 100% O2
Where are soft flexible suction catheters used?
Used in mouth or nose. Soft or flexible catheters available in sterile wrappers and also used for ET tube deep suctioning. Suctioning through a NPA
Where is an oropharyngeal airway used?
Used in patients who are at risk for developing airway obstruction from the tongue or from relaxed upper airway muscles
Where are rigid catheters (Yankauer) Used?
Used to suction oropharynx. Better for think secretions and particulate matter
