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Exam 4

Indications

pt loses ability to breathe spontaneously
-upper airway obstruction (foreign body obstruction)
-lower airway obstruction (bronchospasm)
-altered drive to breathe (drug overdose)

Benefits

restore gas exchange within minutes

Increase Raw

artificial airways
-increase Raw
-the smaller the tube, the higher the Raw & WOB
-more curves in the tube will increase Raw

common cause of upper airway obstruction

tongue occludes the airway
-elevating & extending head may alleviate obstruction by placing mouth, pharynx, & larynx in alignment

Head tilt

tilt head back to relieve soft tissue obstruction (tongue is moved farther from hard & soft palates to get patent airway)
-one hand under neck & one on forehead, lift neck & tilt head back
-contraindicated w/head/neck injury

Jaw thrust

both hands on jaw at ramus on each side & lift jaw forward (tongue is moved farther from hard & soft palates to get patent airway
-tx of choice for suspected neck injury

swallow

1st reflex in upper airway; receptors in oropharynx cause involuntary reflex that move object to esophagus
-lack of this reflex may allow oral secretions to pool

gag reflex

oropharynx vagal receptors will cause gagging w/stimulation;may induce vomiting; strong reflex
-may be depressed w/anesthesia, drugs, lidocaine

laryngeal reflex

stimulation of larynx will cause epiglottis to slam shut & vocal cords to come together - laryngospasm (food goes down the wrong pipe)

tracheal reflex

stimulation of trachea will cause cough (sensitive to foreign body)

carinal reflex

extremely sensitive; cough reflex

loss of consciousness & causes of upper airway obstruction

as lose consciousness, reflexes are lost in descending order from swallow to carinal
-LOC is reflected in presence or absence of reflexes
-regained in ascending order from carinal to swallow

oral pharyngeal device

most common to get patent airway obstruction

Guedel airway

must extend past posterior portion of tongue to allow airflow
-can be used as bite block in orally intubated pts

Guedel airway components

hollow channel for air passage
buccal flange
bite portion
curved portion to fit anatomy

Berman airway

similar to Guedel, but doesn't have central channel

Sizing oral pharyngeal airways

length in mm
correct size from angle of jaw to lips or earlobe to lips

Insertion technique

insert upside down with tip riding along hard palate until past tongue then rotate 180 degrees
-flange pops out of mouth if airway tip is not past posterior tongue

contraindications to oropharyngeal airways

-pts who are conscious or have airway reflexes (can cause gag,vomit, dental damage by biting)

nasopharyngeal airways (nasal trumpet/nasal airway)

better tolerated in semi-awake pt who have some reflexes
-proximal end is flared so doesn't slip down

nasopharyngeal airway sizing

size by holding airway along side of head
-tip should extend past angle of jaw
-tip lies just past base of tongue separating tongue from posterior pharynx

nasal trumpet insertion

insert parallel to floor of pharynx & slightly medially
-follow anatomy posteriorly
-if resistance, may twist

nasal airway advantages

to protect nose from trauma of nasotracheal suction
-better tolerated than oral airways
-improved oral hygiene
-improved communication
-greater comfort

hazards & contraindications to nasal airways

-pts w/bleeding concerns
-deviated septum
-basal skull fracture
-sinus infection if left in long term

laryngeal mask airway (LMA)

small, triangular shaped inflatable mask secured to tube. when inflated, tip rests against upper esophagus lying under base of tongue
-seals the esophageal sphincter & patent airway for PPV
-disposable & reusable types
-placed blindly, 15mm connector

LMA advantages

reduces amt of aspiration compared to unprotected airway
-insertion simple

LMA insertion

cuff check, deflate & evert, lubricate
-insert (may extend head, may use finger to guide)
-tube is advanced until fully seated & resistance is felt
-inflate
-should move about 1cm out as inflated
-check breath sounds

Combitube

double lumen device gives patent airway; insert blindly;may use w/difficult intubations or in field
-2 cuffs to seal esophagus & pharynxx
-lubricate & orally insert; advance until resistance
-inflate esophageal cuff w/15 ml & pharyngeal cuff w/ 100 ml
-if esophageal lumen goes into trachea, ok to ventilate like an ETT
-if lumen goes into esophagus, ok due to series of holes near hypopharynx that will allow for ventilation of lungs

Endotracheal Tubes (ETT)

best choice for secure airway
-secretion removal, PPV, meds, aspiration prevention, bronchoscopy
-requires skill & equipment (laryngoscope)
-ventilate & oxygenate before, b/w, & after

Components of ET tube

plastic tube w/beveled tip to reduce trauma, sidehole (murphy eye), cuff attached to pilot balloon w/spring-loaded valve, 15 mm standard connector
-distance markers in cm & radiopaque marker along length
-murphy eye allows gas flow if bevel tip is obstructed

Collapse ETT tube

created spiral wire-embedded tubes

Bend ETT tube

RAE tube

Fires in surgery

metal tubes & water filled cuffs

Double lumen ETT

unilateral lung disease; independent ventilation, 2-15mm connectors, 2 lumens, 2 cuffs, 2 distal openings, 1 cuff seals trachea, other seals opposite bronchus
-can deliver diffrent ventilation to each lung

Indications for Double-lumen ET's (DLET)

lung resection
lung protection from unilateral contamination
lung transplant

Tracheostomy tubes (TT)

outer cannula provides structure
flange prevents tube slippage into trachea
removable inner cannula
obturator for tube insertion
radiopaque indicator

tracheotomy

surgical procedure that established access to trachea via neck incision
-preferred route for long term pt who needs artificial airway or after prolonged period of oral or nasal intubation

Percutaneous Tracheotomy Procedure

dissection to trachea, insert needle & sheath into trachea b/w cricoid & 1st ring or b/w 1st & 2nd ring
guide wire through sheath
sheath removed & dilator passed over guidewire
larger & larger dilators used until stoma large enough for TT
rapid procedure w/ less complications than traditional surgery

Indication for trach

patent airway following intubation or when can't intubate
-protect lower airway
-suction
-long term vent

cuffed disposable TT

PVC; no inner cannula; changed every 7 days

cuffed TT w/ disposable or removable inner cannula

remove inner cannula to clean or if obstructed

cuffed fenestrated

window in outer cannula
-remove inner cannula
-plug it & deflate cuff
-pt can breathe through upper airway
-assess upper airway function
-helps wean
-allows speech

Jackson tube

nondisposable reusable silver trach w/ removable inner cannula

Bivona foam cuff

foan cuff that self inflates
-once in place, pilot tube opened to atm
-foam expands by itself, sealing airway

tracheostomy button

aids in weaning from trach
-spacer rings to adjust length of button
-adapter available for ventilation

Kistner button

has one way valve can be inserted over tube
inhale thru tube
during exhalation, valve closes forcing air up thru upper airway
makes speech possible

Olympic trach talk

appliance used w/ trach
aerosol T w/ one way valve
trach cuff deflated
inhale thru tube
when exhale valve closes & forces air to upper airway
makes speech possible

Passy-Muir valve

one way valve device placed on the trach tube
during insp. allows pt to inhale thru TT
during exhalation, valve closes & forces air thru upper airway so pt can speak

recommended cuff pressure

20-25 mmHg

Pilot balloon purpose

monitors cuff status & pressure

Purpose of the obturator

assists in trach insertion

Purpose of trach button

maintain patency of stoma & for weaning off trach

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