Term Indications
Pharyngeal Airways Types: Oropharyngeal and Nasopharyngeal
Pharyngeal Airways Indications Used To Protect the Airway
Oropharyngeal * Unconscious Patient * Support Base Of Tongue * Bite Block (With ET tube or seizure) * Facilitate oral suctioning
Nasopharyngeal * Conscious patient * Support base of tongue * Facilitate deep tracheal suctioning * Use to decrease trauma during nasotracheal suctioning
Complications of Pharyngeal Airways * This airway should be left unsecured * Gagging- remove airway suction give oxygen * Vomiting * Laryngospasm * Airway obstruction- remove, replace may be too small
Complications of Nasopharyngeal Airways * Trauma to mucosal (most common) – use a water-soluble water based lubricant. * Epistaxis (nasal bleeding) – change every 24 hrs * Increased airway resistance- use the largest size
Equipment Oropharyngeal Airways Size Determination length should be equal to the distance from the angle of the jaw to the tip of chin to past corner of the mouth.
Equipment Nasopharyngeal Airways Size Determination Outside diameter of airway should be equal to inside diameter of patient external nares. The length of the airway is from tip of the earlobe to center of nostrils.
Airway Insertion Technique Oral insert opposite its anatomic shape(upside down) to the back of the throat and then rotate into its correct position
Airway Insertion Technique Nasal inserted the way it’s anatomically shaped with water soluble lubricant
Term Definition
Intubation Step:1 Position Patient Head in sniffing position slight hyperextension
Intubation Step:2 Adequately hyperoxygenate (resuscitation bag with 100% for 2 minutes
Intubation Step:3 Hold laryngoscope in left hand ET Tube in right hand
Intubation Step:4 Insert blade down the right side of the mouth, sweep tongue to the left.
Intubation Step:5 Advance blade, lift epiglottis visualize vocal cords, (curve blade tip) = vallecula (straight blade tip) = epiglottis have suction available
Intubation Step:6 Cricord Pressure = (Selleck Maneuver) is indicated if the larynx is in an anterior location
Intubation Step:7 Insert tube, inflate cuff, assess tube position, ventilate, and oxygenate
Minimal Occluding Volume (MOV) technique used to inflate cuff = 20-25 mmHg/25-30 cmH20 listen for air leak as cuff is inflated during positive pressure ventilation: STOP inflating at minimum volume necessary to eliminate air leak via trach or ET Tube
Minimal Leak Technique (MLT) slowly inject air into the cuff during positive pressure inspiration until leak STOPS; A small amount of air is removed to allow a slight leak during peak inspiration. Remove the small amount to PREVENT aspiration
Assessment Of Tube Position Notice Sequence 1. Inspection (look for bilateral chest expansion during inspiration) 2. Auscultation (breath sounds should be heard bilateral) 3. Capnography (CO2 Detector) 4. Chest X-ray ( tip of tube 2cm or 1 in ABOVE carina or at aortic knob/notch
Tube Maintenance Suctioning Maintain patency
Tube Maintenance Humidification * Prevent dehydration of tissue (100% Humidity @ 37.C) * Best way to prevent obstruction
Tube Maintenance Cuff Pressure *Minimal leak *Minimal occluding volume *Use high volume/low-pressure cuff =to or< 20mmHg)
Question Answer
Extubation Step:1 Suction Airway below and then above the cuff
Extubation Step:2 Deflate Cuff
Extubation Step:3 Have patient inspire deeply
Extubation Step:4 Remove the tube at PEAK INSPIRATION- to prevent vocal cord damage
Extubation Step:5 Have the patient cough To clear any remaining secretions
Extubation Step:6 Administer Oxygen and Humidity if/as indicated
Extubation Step:7 Observe any complications * Laryngeal Edema ( Stridor) * Respiratory Obstruction
Complications and management: Severe Respiratory Distress Marked/Inspiratory Stridor REINTUBATE the patient
Complications and management: Moderate Distress/Stridor Oxygen, cool mist aerosol, and racemic epinephrine, to reduce swelling
Complications and management: Mild/Stridor/ Sore Throat Provide Humidity, Oxygen and/or racemic epinephrine as necessary
Post-Extubation Complications: Vocal Cord Polyps due to chronic inflammation
Post-Extubation Complications: Mucosal ulceration torn mucosal, doesn’t require re intubation
Post-Extubation Complications: Tracheomalacia softening or dilation of tracheal cartilage
Post-Extubation Complications: Tracheostenosis gradual obstruction (narrowing) that occurs with healing causing stridor
Indications Treatments
Indications for Nasal Or Oral Intubation * Provide a patent airway * Access for suctioning * Means for mechanical ventilation * Protect the airway (aspiration, obstruction) * Direct instillation of medication
Direct instillation Of Medication can be put in ET tube (Cant Get an IV started) N.A.V.E.L *NARCAN *ATROPINE *VALIUM *VERSED/VALIUM *EPINEPHRINE *LIDOCAINE*
Procedure in how to medications down the ET tube Double the normal IV dose and flush with 10mL of saline
Physiological and Psychological Alternatives HME by pass filtration humidification provide adequate humidity
Physiological and Psychological Alternatives Cough less effective (suction prn)
Physiological and Psychological Alternatives Disrupt mucus transport (suction prn)
Physiological and Psychological Alternatives loss of personal dignity be supportive
Physiological and Psychological Alternatives unable to communicate provide method of communication
Complications of Intubations Infection, Cuff pressure, Laryngospasm, Right main stem bronchus intubation, Risk of ventilator acquired pneumonia
Infection fever, secretions
Cuff Pressure > 5mmHg Vessel = Lymphatic Results = Edema
Cuff Pressure > 10mmHg Vessel = Vein Results = Edema
Cuff Pressure > 20mmHg Vessel = artery Results = necrosis
Laryngospasm most serious complication
Right Main Stem Intubation Oral ET tube > 25mmHg
Question Answer
Laryngoscope Handle *Always held in the left hand *Batteries for light
Types of Blades Curved/McIntosh Blade Straight/Miller Blade
Curved/ McIntosh fits into the vallecula, indirectly raises epiglottis (Adult) can’t see vocal cords Advance Blade
Straight/Miller fits directly under the epiglottis (Preferred for Infant)
Laryngoscope Troubleshoot: If light doesn’t work * Tighten bulb * Check handle attachment * Change blade * Change batteries
Blade Sizes Adult: Size 3 Pediatric Size: 2 Term Infant: Size 1 Pre-Term: Size 0
Stylet Used to aid in ORAL intubation Shapes the tube for easier insertion End is to be recessed 1 cm above ET Tube
Magill Forceps Used to aid in nasal intubation Inserted in mouth to lift tube into trachea
Endotracheal Tubes Tube Sizes Pre/Full Term Infants: Preterm Infant 2.5- 3.0 Full-term Infant 3.0-3.5
Endotracheal Tubes Tube Sizes Adult: Male wt in kg 10 8.0-9.0
Endotracheal Tubes Tube Sizes Adult: Female 7.0-8.0
Tube Markings Oral Intubation: 21-25 cm mark at lip Nasal Intubation: 26-29 cm mark at nare
Cuff Types * High-Pressure Low Volume, Low Compliance * Low Pressure, High Volume, High Compliance, Floppy Cuff * Cuff pressure should not exceed 20mmHg in order to allow circulation to the tracheal mucosa
Monitoring Cuff Pressure Measured with a 3-way stopcock, syringe, pressure manometer Cufflator: used to eliminate syringe, and manometer and stopcock cuff pressure should not exceed 25cmH20 If cuff reads 0 check connections
Endotracheal Tubes Double- Lumen, Esophageal Tracheal Combitube, Laryngeal Mask Airway, Hi-Lo Evac Tubes
Double Lumen (Carlen’s Tube)(DLT) ET Tube with 2 independent lumens of different lengths longer Tube: inserted in either the left or right main stem shorter Tube: placed in the trachea above the carina
Double Lumen (Carlen’s Tube)(DLT)2 Each Lumen can ventilate one lung separately or they can be connected via wye and share ventilation source
Indications for double lumen ETT * Independent lung ventilation * Lung Abscess Unilateral lung disease * Pneumonectomy, Lobectomy, Esophageal Resection, Aortic * Aortic repair * Bronchopleural Fistulas Trauma to 1 lung
Esophageal Tracheal Combitube EMERGENCY TRANSPORT * Option for emergency airway management * placed blindly
Laryngeal Mask Airway (LMA) Positioned directly over the opening into the trachea (hypopharynx) Intubate through the LMA Do Not Remove, Until Intubated
Hi-Lo Evac Tube indicated for the use of oral or nasal endotracheal intubation that requires continuous aspiration of subglottic secretions continuous suction is provided via pilot tube connected to a vacuum 20mmHg
Hi-Lo Evac Tube Helps With: Method used to reduce incidence of Ventilator Acquired
Term Definition
Indications And Advantages Preferred method of providing an airway for patients who require long-term ventilation When upper airway is obstructed that prevents intubation
Indications And Advantages: Not an emergency should be done in a sterile condition with the patient intubated. ET tube is removed ONLY as trach tube is inserted
Indications And Advantages: Inner Cannula can be cleaned by brushing or rinsing with hydrogen peroxide
Indications And Advantages Patient is able to eat and even speak with tracheal speaking device
Complications of Tracheostomy Immediate Within 24 Hours *Bleeding (major hazard) *Pneumothorax * Air Embolism * Subcutaneous emphysema
Complications of Tracheostomy Late: (24- 48 Hours) * Infection *Hemorrhage *Obstruction * T-E fistula
Tracheostomy Cuff Inflation Always inflated when eating positive pressure ventilation
Tracheostomy Care Cuff Obstructed cuff should be changed if: cuff is obstructed unable to pass a catheter you must ventilate, remove tube, ventilate, and insert new tube
Tracheostomy Care Tube Too Small Very high cuff pressure (>20mmHg) needed to seal the cuff Change To Larger Tube
Tracheostomy Care Punctured Cuff Unable To seal cuff Replace the tube(if seal required)
Tracheostomy Care After Removal of Tracheostomy Tube *Do not suture the stoma closed * Apply sterile dressing and/or antibiotic to site * Clean periodically with hydrogen peroxide * Have patient to cough to clear secretions
Tracheostomy Tubes Standard Trach Tube, Fenestrated Tube, Tracheal Button, Extended Trach Tube, Jackson Trach Tube, Bivona ( Kamen-Wilkinson), Tracheal Speaking Devices
Fenestrated Tube has an opening used for weaning and temporary mechanical ventilation Not for emergencies plugging tube- deflate the cuff, remove inner cannula, then plug tracheostomy Allow patient to breathe through upper airway and speak
Tracheal Button * To maintain stoma * used for patients with Sleep Apnea * Allows tracheal suction and phonation with least amount of airway resistance * Uncuffed, cannot be utilized for resuscitation
Extended Trach Tube * adjustable flanges that allow adjustments of horizontal distance. * Indicated for patients who are obese or use cervical collars
Jackson Trach Tube * Metal trach tube * Comes with an inner cannula * Not for resuscitation
Bivona ( Kamen-Wilkinson) * Must evacuate air prior to use * Air must be evacuated to extubate * Has no inner cannula * Does not have a pilot balloon
Tracheal Speaking Devices Has a One- Way speaking valve cuff must be deflated
Perform Tracheostomy Care Step: 1 Assemble and check equipment
Perform Tracheostomy Care Step: 2 Explain the procedure to the patient
Perform Tracheostomy Care Step: 3 Suction the patient to ensure airway patent
Perform Tracheostomy Care Step: 4 Clean the inner cannula by soaking it in a solution of hydrogen peroxide and water and rinse with sterile water
Perform Tracheostomy Care Step: 5 Clean the stoma site using cotton applications dipped in the hydrogen peroxide solution, replace gauze dressing
Perform Tracheostomy Care Step: 6 Change trach Tube
Perform Tracheostomy Care Step: 7 Replace inner cannula
Perform Tracheostomy Care Step: 8 Reassess the patient and record the procedure.
Question Answer
Compare and Contrast the main indication for Oral and Nasal Pharyngeal Airways OROPHARYNGEAL NASOPHARYNGEAL Unconscious PT Conscious PT Base on Tongue Base on Tongue Bite Block Tracheal Suctioning Oral Suctioning Use to decrease Trauma
The main indication for OROPHARYNGEAL Pharyngeal Airways OROPHARYNGEAL Unconscious PT Support Base on Tongue Bite Block (ET tube Or Seizure) Facilitate Oral Suctioning
The main indication for NASOPHARYNGEAL Pharyngeal Airways NASOPHARYNGEAL Conscious PT Support Base on Tongue Facilitate Deep Tracheal Suctioning Use to decrease Trauma during Nasotracheal Suctioning
List the complications which could be associated with Oral Pharyngeal Airways suggest a solution to prevent each complication This airway should be left unsecured Gagging- remove airway, suction airway, give oxygen Vomiting Laryngospasm Airway Obstruction-remove, clear-out or replace, may also be too small
List the complications which could be associated with Nasal Pharyngeal Airways suggest a solution to prevent each complication Trauma to mucosa (most common) use water soluble or water based lubricant Epistaxis (nasal bleeding) change every 24 hours Increased Airway Resistance- use the largest size that will fit
How should the respiratory therapist determine the appropriate size airway for an ORAL PT Length should be equal distance from angle of jaw to tip of chin or from the angle of jaw
How should the respiratory therapist determine the appropriate size airway for a NASAL PT Outside diameter of airway should be equal to inside diameter of patients external nares. Length of airway is from tip of earlobe to center of nostrils
Describe the insertion techniques for Oral airways inserted opposite its anatomic shape (upside down) to back of throat and then rotated into its correct position
Describe the insertion techniques for Nasal airways inserted the way it is anatomically shaped with water soluble lubricant
List five purpose for ENDOTRACHEAL Intubation Provide a PT Airway Access for Suctioning Means for Mechanical Ventilation Protect the Airway (Aspiration, Obstruction) Direct instillation of Medication
List four drugs that can be safely administered by direct instillation into an endotracheal tube. Nacan Narcotic Overdose Atropine Bradycardia Valium/Versed Sedative Epinephrine Asystole Lidocaine PVC NAVAL
How should the respiratory therapist respond to the following physiological changes brought about by ENDOTRACHEAL Intubation? By-passing normal humidification mechanisms Provide Adequate Humidity
How should the respiratory therapist respond to the following physiological changes brought about by ENDOTRACHEAL Intubation? Disruption of normal mucus clearnce Suction PRN
How should the respiratory therapist respond to the following physiological changes brought about by ENDOTRACHEAL Intubation? Inability of the PT to communicate Provide Method of Communication
What Level of Cuff Pressure (mmHg) would obstruct the following? Arterial Capillary Blood Flow >20 mmHg Results in Necrosis
What Level of Cuff Pressure (mmHg) would obstruct the following? Venous Blood Flow >10 mmHg Results in Edema
What Level of Cuff Pressure (mmHg) would obstruct the following? Lympatic >5 mmHg Results in Edema
Describe the procedure for ENDOTRACHEAL INTUBATION Head in Sniffing Position, Adequately Hyperoxygenate Hold laryngoscope in left-hand ET in right-hand Insert blade down the right side of mouth Advance Blade. lift epiglottis, visualize cords, have suction Cricoid pressure, Insert tube, Inflate cuff
Describe how to perform the following cuff pressure assessments MIDDLE OCCLUDING VOLUME (MOV) Listen for air leak as cuff is inflated during pos-pressure ventilation stop inflating at minimum volume necessary to eliminate air leak via trach or endotracheal tube
Describe how to perform the following cuff pressure assessments MINIMAL LEAK TECHNIQUE (MLT) slowly inject air into the cuff during pos-pressure inspiration until leak stops a small amount of air is removed to allow a slight leak during peak inspiration
Identify three methods to determine correct position of an ENDOTRACHEAL TUBE INITIAL METHOD Insepection- look for bilateral chest expansion during inspiration
Identify three methods to determine correct position of an ENDOTRACHEAL TUBE SECOND METHOD Ausculation breath sounds should be heard on both sides of the chest
Identify three methods to determine correct position of an ENDOTRACHEAL TUBE BEST METHOD Chest x-ray- the radiopaque line on the endotracheal tube can be easily visualized to assess placement. tip of tube 2 cm or 1in above carina or at the Aortic Knob/Notch
How Should the respiratory therapist maintain airway patency? Suctioning
What level of humidification should be maintained in order to prevent dehydration? 100% Humidity @ 37 oC Best way to prevent obstruction
List two ways to measure cuff pressure Minimal leak, Minimal occluding volume Use high volume/low-pressure cuff (equal to or ,20 mmHg pressure)
Name two types of Laryngoscope blades commonly used to intubate adult patients and describe how each is used. Laryngoscope-handle, always hold in left hand, hold batt for light blades Curved/Macintosh-fits into vallecula, indirectly raises epiglottis Stright/Miller blades-fits directly under the epiglottis (preferred for infant intubation)
What steps should the therapist take if the light on the Laryngoscope blade does not work Tighten bulb, Check handle attachment, Change blades, Check Batteries
What size laryngoscope blade is commonly used for ADULT PT Size 3
What size laryngoscope blade is commonly used for TERM INFANT Size 1
When is a stylet useful? Used only to Aid in ORAL INTUBATION
During what procedure are MAGIll forceps used? Used in the Aid in NASAL INTUBATION inserted in mouth to lift tube into trachea
List the approximate Endotracheal tube sizes for PRE-TERM INFANT 2.5-3.0 mm
List the approximate Endotracheal tube sizes for FULL-TERM INFANT 3.0-3.5 mm
The appropriate endotracheal tube size for ADULT MALES ranges between __to __ mm and For ADULT FEMALES _ to _ mm. ADULT MALES 8.0 to 9.0mm ADULT FEMALES 7.0 to 8.0 mm
A PT receiving mechanical ventilation is being transported to radiology for CT scan. the therapist is arranging equipment the low volume alarm, begins to sound, Notes that the oral endotracheal tube is taped at the 28cm mark. The tube should be between 21 cm -25 cm
ORAl endotracheal tube should be taped at 21-25cm mark at PT lips
NASAL endotracheal tube should be taped 26-29cm mark at PT nare
compare and contrast the two basic types of ENDOTRACHEAL tube cuffs High Pressure, Low volume, – Low compliance cuff Low pressure, High volume-High Compliance, floppy cuff (preferred type)
Double-LUmen ENDOTRACHEAL tube/ENDOBRONCHEAL TUBE describe the structure of this type of tube? tube with two independent lumens of different lengths; the longer lumen is inserted into either the left or right mainstem and the shorter lumen is placed in the above the carina each lumen can ventilate one lung separately
List four indications for using this type of tube? Independent lung ventilation Unilateral lung disease to improve ventilation and oxygenation or to provide airway protection to the unaffected lung Used during surgery, disruption and surgical openings of openings of a large airway
List ADVANTAGES of using an ESOPHAGEAL TRACHEAL COMBITUBE Can be readily inserted Does not require visualization of the larynx
List DISADVANTAGES of using an ESOPHAGEAL TRACHEAL COMBITUBE Placement of an endotracheal tube is difficult with combitube in place Cannot be used in PT with a gag reflex
Where should the LARYNGEAL MASK AIRWAY (LMA)be properly positioned? Consists of an inflatable mask that is positioned directly over the opening into the trachea (HYPOPHARYNX)
List the two indications for use of the LARYNGEAL MASK AIRWAY (LMA) Short term ventilation When intubation is not possible
When is a Hi-Lo EVac tube been shown to reduce the incidence of? Ventilator Acquired/ Associated Pneumonia (VAP)
What level of continuous suction is applied to this type of Hi-Lo EVac tube? Continous suction is provided via separate pilot tube connected to a vacuum pressure of 20 mmHg
Why should the ETT be removed at peak inspiration? to prevent vocal cord damage
Identify possible complications of extubations and how to manage each one. Severe Respiratory distress and/or Marked Inspiratory stridor REINTUBATE the PT
Identify possible complications of extubations and how to manage each one. MODERATE DISTRESS STRIDOR Oxygen, cool mist aerosol and racemic epinephrine as necessary to reduce swelling
Identify possible complications of extubations and how to manage each one. MILD DISTRESS/STRIDOR SORE THROAT Provide humidity, oxygen and/or racemic epinephrine as necessary
PT in the ICU is extubated after being on pos-pressure ventilation for three weeks. Two days later exhibits stridor. Therapist should the PT for evidence of? TRACHEOSTENOSIS
Other Post-extubation Complications Vocal cord polyps Due to chronic inflammation
Other Post-extubation Complications Mucosal ulceration torn mucosa does not require reintubation
Other Post-extubation Complications Tracheomalacia softening or dilation of tracheal cartilage
Other Post-extubation Complications Tracheostenosis gradual obstruction (narrowing) that occurs with healing causing stridor
Term Definition
Modifying Bronchial Therapy Infants and Children Consideration Size of thorax, Fear, Positioning
Modifying Bronchial Therapy Adult Consideration The duration will depend on patient need and/ tolerance
Modifying Bronchial Therapy Chest tubes may require modified technique
Modifying Bronchial Therapy Coordination of Tx. If CPT, is done by another department or other therapy (IPPB, IS etc.)should be scheduled prior to coordinate with chest physical therapy
Modifying Bronchial Therapy Patient Assessment: Auscultation & Inspection changed/ improved breathe sounds color, chest expansion
Modifying Bronchial Therapy Patient Assessment: Cough & Toleration sputum and characteristic and amount fatigue, and work of breathing (WOB), pain
Modifying Bronchial Therapy Patient Assessment: Vital Signs & Chest X-Ray pulse, respirations, ECG improved pattern
Modifying Bronchial Therapy Patient Assessment Evaluation after every treatment based on obtained treatment, limit to only involve segments
Discontinuing Bronchial Hygiene Clear Breath Sounds, Ambulating well, Strong cough, Afebrile for 24 hours, Hazards occur (dizziness, SOB, cyanosis)
Question Answer
Tracheostomy is preferred over endotracheal tube intubation in what instance? Preferred method of providing an airway for patients who require long-term ventilation
List two possible IMMEDIATE complications of the tracheostomy procedure? Bleeding- major hazard Pneumothorax
List two possible LATE complications of the tracheostomy procedure? Infection Hemorrhage
Under what circumstances should the tracheostomy tube cuff be INFLATED? The PT is eating PT is on positive pressure ventilation
What does it mean if the therapist recommends a fenestrated tracheostomy tube? Used for weaning and temporary mechanical ventilation with inner cannula
Briefly, describe the features of a standard tracheostomy tube. White plastic trach tube May have an inner cannula for easy cleaning Has a soft cuff
What is the purpose of the TRACHEAL BUTTON? Used to maintain stoma, Use in some PT with sleep apnea, Allows tracheal suction and phonation with least amount of airway resistance,
When using tracheal speaking valve, the tracheostomy tube cuff must be? Cuff must be deflated
Describe the steps necessary for performing tracheostomy care? Suction the PT to ensure airway is patent, Clean the inner cannula, clean the stoma site, change trach ties, replace inner cannula, reassess PT & record the procedure
In what circumstances is an extended tracheostomy tube indicated? for PT who are obese or use cervical
After a Laryngectomy procedure, the PT will no longer have a connection between? No longer any connection between the PT UPPER and LOWER respiratory tract
List three purposes/goals of postural drainage Improve mobilization of secretions Prevent accumulation of secretions Improve ventilation
What are three indications for performing postural drainage? Accumulated or retained secretions an ineffective cough Ciliary dysfunction/ ciliary dyskinesia
List five examples of pulmonary disorders that disrupt the normal bronchial hygiene mechanism and could benefit postural drainage Bronchiectasis, Cystic Fibrosis COPD, Acute atelectasis, Lung abscess
The contraindications/hazards of postural drainage are; Unstable Cardiovascular System Unstable Pulmonary System Unstable post-operative status Untreated Tuberculosis
Prone PT lying face down
Supine PT lying on spine (best for post-craniotomy PT)
Fowlers, Semi Fowlers or Reverse Trendelenburg; best position for hypoxic PT, obese PT with dyspnea, post-op abdominal PT and PT with pulmonary edema
Lateral Fowlers very obese PT with air hunger
Lateral Flat best position to prevent aspiration
For post-craniotomy PT Supine
PT with Unliteral Consolidation Place the affected lung up to allow it to drain and to increase perfusion to the unaffected lung
Question Answer
The last reflex a patient loses when progressing into unconsciousness is the: a. Laryngeal reflex b. Gag reflex c. Tracheal reflex d. Carinal reflex Carinal reflex
The most commonly used airway for ventilating a patient with a manual resuscitator is: a. Nasopharyngeal airway b. Oropharyngeal airway c. Nasal trumpet d. Tracheostomy tube Oropharyngeal airway
A nasopharyngeal airway is also commonly called a ___________________________. Nasal Trumpet
LMA stands for: a. Laryngoscopic manual airway b. Loss of major airway c. Laryngeal mask airway d. Laryngeal manual airway Laryngeal Mask Airway
Oropharyngeal airways are indicated for ___________________________ patients. unconscious
True or False Incorrect placement of an oropharyngeal airway (OPA) can push the tongue further back into the pharynx worsening the obstruction. TRUE
When encountering resistance upon insertion of a nasopharyngeal airway (NPA) in the right nare, you should: a. Lubricate the airway with lots of petroleum jelly and try again b. Try the left nare c. Twist and push harder d. Ask the nurse to do it b. Try the left nare and c. Twist and push harder
The most common airway maneuver used to ventilate an apneic patient during CPR is a. Triple airway maneuver b. Jaw thrust c. Head-tilt/chin-lift d. Heimlich maneuver c. Head-tilt/chin-lift
What is the proper way to estimate the appropriate length of a nasal airway? d. Measure from the patient’s earlobe to the tip of the nose
What type of airway maneuver is depicted in the following picture? Head-tilt/Chin-lift
When is the jaw thrust technique indicate to help maintain an open airway? a. When foreign body obstruction is present b. After trauma to the head c. In cases of suspected neck injury d. During most CPR efforts c. In cases of suspected neck injury
True or False A laryngeal mask airway can be used for short term ventilation of an unconscious patient. TRUE
An unconscious patient begins gagging during your attempt to insert an oropharyngeal airway. The correct action to take at this time would be to: Insert a nasal airway
Which of the following is a hazard of insertion of an oropharyngeal airway? a. Nose bleed b. Vomiting c. Pain upon insertion d. Increased airway resistance d. Increased airway resistance
What is the position of a correctly sized properly inserted oropharyngeal airway? Distal tip at the base of tongue, flange outside the teeth
Term Definition
Autogenic Drainage Purpose Breathing exercise to improve mucus clearance, primarily in cystic fibrosis and bronchiectasis.
Autogenic Drainage Procedure Patient is instructed to breathe at low volumes (ERV) to loosen secretions from the small airways
Autogenic Drainage Purpose2 Patient then increases his/her volume by breathing in the normal tidal volume range, but exhaling ERV
Breathing ERV Volume Purpose: Last Stage This range of breathing volumes helps breathe at high lung volumes
External Percussive Device High Frequency Wall Compression Device Non-stretch, inflatable vest covers the patients chest and abdomen. Variable air-pulse generator injects small gas volumes into and out of the vest, creating and oscillatory motion against the patients chest.
High Frequency Wall Compression Device Therapy Levels 5-25 Hz (300-1500 cycles/min) for 30 minutes 1-6 times/day
Question Answer
Tracheotomy an incision into. The procedure establishing access to the trachea
Tracheostomy forming a new opening. The opening created by the tracheotomy procedure
stoma hole in trachea without tube in place
tracheostenosis narrowing of the lumen of the trachea
tracheal granumola caused by abrasion of tube tip or at the stoma site
TE fistula hole between the trachea and the esophagus
Tracheomalacia softening of the tracheal cartilage
Why would you choose a trach Pt needed artificial airway more than 7-10 days, pt tolerance for ET tube, pt ability to tolerate surgery, relative risks of continuing ET tube
When is the incision collar incision 2 cm from the suprasternal notch; incision through the 2nd and 3rd tracheal rings
On x ray where is trach tip 4-6 cm above carina
Complications of trach bleeding, pneumothorax, air embolism, subcutaneous emphysema….Late complications: infection, hemorrhage, tracheal stenosis
How to minimize infection use sterile technique during suction, wash hands etc,, and regular change of dressing
Advantages of trach tubes long term, more comfortable, less movement in trachea, allows speaking and eating, more efficient suctioning, resistance to airflow is less because it is wider, shorter and less curved
What is the shiley weaning tool; has fenestration (hold in outer cannula only), this forces the pt to ventilate through fenestration and around tube
How to use fenestrator or shiley when inner cannula is removed you deflate cuff and cap outer cannula
Problems with shiley possible formation of granular tissue at fenestration site (tissue plugs up the hole)
What does the Spiral wire embedded tube do help prevents bending and kinking
What is the Jackson metal tube for long term use, no cuff
Fenestrated tube hole located at curve of outer cannula, the purpose is to allow pt to try breathing without the use of tube (remove inner cannula)
Foam cuff (Bivona) cuff inflates when exposed to room air, not when air is added to pilot tube
Lanz tube has pressure relief valve in pilot, releases pressure when it exceeds limit…. It automatically maintains intracuff pressure at 30 cmH20 to help reduce the risk of tracheal damage during long term intubations
Pitt speaking tube allows patient to speak while on ventilator with cuff inflated
What does the Pitt look like 2 thin tubes attached to trach tube, one for cuff and one to be occluded forcing air up over vocal cords… The end of line occluded to create speech is attached to gas source (flowmeter) (cuff stays inflated)
Passy- Muir speaking valve one-way valve attaches to the 15 mm adaptor, allows for speech and secretion management
how does passy muir work Its a one-way valve that allows air only during inspiration Blue-colored used with vents….White spontaneously breathing, shorter tube
Trach button aid in weaning from trach tube. It keeps stoma open. It extends from skin to just insdide the tracheal wall.
What does trach button look like short, soft hollow tube which fits in stoma in place of trach tube
Olympic tracheostomy button hard plastic device that keeps stoma open, does not bend and does not have a cuff, does not maintain closed circuit, therefore, mechanical ventilation is not possible. (one-way valve for speech)
If pt is on vent and needs trach care (cleaning) remove inner cannula and re insert clean tube as fast as possible! Hit alarm silence on vent
When will you do a tracheostomy change out When you need a new one, when the patient’s condition is unstable, edema around site that may make change difficult
Methods for weaning from tracheostomy tube Tracheostomy buttons, fenestrated tubes, progressively smaller trach tubes
What is the laryngeal mask airway hollow tube with a spoon shaped mask. The mask has a cuff attached to the end of it which inflates to permit the area around the tracheal glottis and epiglottis to be sealed. It sits on the esophageal sphincter
what is the biggest problem with the LMA regurgitation during insertion
What are the indications for LMA when intubation is difficult or mask is difficult when using bag, pt who fears vocal cord damage, respiratory arrest, elective surgery or bronchoscopy
Hazards of LMA pt with full stomach (aspiration risk), it may leak if ventilating pressure is greater than 20 cmH20
Esophageal tracheal combitude 2 tubes in 1 that will operate as a functional airway device regardless of whether the tube is inserted into the esophagus or trachea
Indications for ETC unconscious, apneic adults, C-spine injury, lack of equipment
Advantages of ETC minimal training, airway regardless of location,
Disadvantages of ETC if inserted too far, the pharyngeal balloon can obstruct the glottis
What is the most common causes of airway obstruction tube obstruction
What are the causes of airway obstruction kinking of tube, herniation of cuff over tube tip, jamming of tube orifice against tracheal wall, mucous plugging
How do you know there is an obstruction peak airway pressure on ventilator increase, decreased breath sounds, decreased air flow through tube
How do you know if there is COMPLETE obstruction respiratory distress, no breath sounds, no gas through tube
If kinked/jammed tube what do you do move head slightly
If potential herniation what do you do deflate cuff
If obstruction is in tube remove inner cannula
When will you need to remove entire airway and replace it? if all the methods are not working
On x ray where should trach tube be 4-6 cm above the carina
Question Answer
Which airway is preferred during an emergency? oral
Why is the trach preferred? stability, long term (7-10 days)
On x-ray where will trach fall 4-6 cm of carina
What is trachea granoma excessive tissue (lot of rubbing)
How do you diagnose a TE fistula abdominal distention, aspiration. (it’s stomach content comes up into the trachea
What is an obturator a rounded tip applicator to put the trach in so it won’t scratch the tissue
How do trach pt’s communicate board, hands, passy muir (deflate cuff), other speaking tubes
What do you do with a PITT speaking tube you can leave cuff inflated
Advantages of trach vs oral oral care, easier for pt, more efficient suctioning, decrease airway resistance
What are complications for trachs infection, pneumothorax, bleeding, granuola, hemorrhage,
What do want with pressure and volume low pressure, high volume
Advantage of lanz tube only inflate to 30 cmH20 that way it won’t over inflate, one-way valve
If you needed to increase pressure what can you use MLT or MOV
What is the bovina cuff foam cuff, inflates only by atmospheric pressure
What is jackson long term, metal tube
What is fenestrate allows weaning from trach tube and speech
INflate or deflate cuff when bagging deflate
Cuffonometer 25 then increases
What do when weaning remove inner cannula, deflate the cuff, and insert a red plug.
Term Definition
Suctioning Purpose Patent Airway, Specimen Collection, Stimulate Cough
Suctioning Indications Accumulated Secretions, Obstructed Airway, Depressed Cough, Inability to swallow
Suctioning Hazards of Suctioning Trauma to Mucosa (most common) lubricate catheter( nasal- tracheal-suctioning) use gentle technique
Suctioning Hazards of Suctioning Contamination use aseptic technique
Suctioning Hazards of Suctioning Hypoxemia-leading to tachycardia, arrhythmia (most severe)
Suctioning Hazards of Suctioning Bradycardia from vagus nerve stimulation
Suctioning Hazards of Suctioning suctioning to vigorous may cause bleeding
Suctioning Procedure 100% O2pre and post suction. oxygenate for 1-2 minutes Close cardiac monitoring to detect iatrogenic hypoxemia. Sterile catheter, solutions, and gloves each time. Suction ET tube then mouth, change after suction mouth then ET tube
Suctioning Equipment: Vacuum regulators Used to adjust vacuum pressure
Suctioning Equipment: Vacuum regulators Adults 100-120mmHg
Suctioning Equipment: Vacuum regulators Child 80-100mmHg
Suctioning Equipment: Vacuum regulators Infants 60-80mmHg
Suctioning Equipment: Vacuum regulators Adjust with tubing occluded A built in shut off device in the collection bottle prevents aspirated secretions from entering the regulator and vacuum system when the bottle is full
Suctioning Equipment: Suction Catheter Specimen Collection Each designed to reduce trauma to mucosa must have a beveled tip with 2 opening to decrease tracheal damage and a thumb port
Suctioning Equipment: Suction Catheter Coude Tip Suction LEFT mainstem
Suctioning Equipment: Suction Catheter Ballard allow the patient to receive ventilation and oxygenation during suctioning.
Suctioning Equipment: Suction Catheter Ballard indicated for patients with high PEEP and oxygen requirements, pulmonary infection, frequent suctioning, hemodynamic instability. Plastic sleeve to prevent contamination
Suctioning Equipment: Sizes ideal catheter length 20-22 in French Units(Circumference) External no greater than ET tube internal diameter
Suctioning Equipment: Suction Catheter size Formula ID SIZE/2 x 3
Suctioning Equipment: Suction Catheter Yankauer/Tonsil used to suction mouth nose, throat aseptic technique
Suctioning Equipment: Lukens Trap Sterile Suction Trap used to collect sputum specimen placed in an upright position between the suction catheter and suction tube. flush catheter with sterile water or isotonic saline
Modify Suction Difficultly Remove Secretions having difficult removing secretions verify appropriate cath size for patient ET Tube
Modify Suction Left Mainstem Bronchus Change To Coude Tip
Modify Suction Pt. Special Needs to Closed system Pt. has an infection, High PEEP levels, or desaturation during suctioning.
Modify Suction Alter Negative Pressure INCREASE: To remove Thick Tenacious Secretions DO NOT EXCEED recommended vacuum pressure
Modify Suction Instill irrigating solutions: Normal Saline 5-10mL Normal Saline- to dilute secretions too thick to aspirate through suction catheter
Modify Suction Instill irrigating solutions: Acetylcsteine 5-10mL of 10% Solution of Acetylcysteine (Mucomyst) can be used for thick secretions
Modify Suction Alter Frequency Suctioning is Hazardous and should be done (PRN)ONLY
Modify Suction Duration/Cardiac Arrhythmias Catheter should be in the airway no longer than 15secs If cardiac arrhythmias occur: STOP suction and decrease the amount of time in the airway
Modify Suction Adverse Reactions Suctioning should be STOPPED if hazards occur. The level of vacuum should be reduced and further suctioning should be gone gently and in less time.
Modify Suction Troubleshooting check catheter for patency, assure vacuum system working properly, change or empty a full collection bottle, check all connections