RT 130 Airway management / Intubation

Question 1
Which artificial airway is considered the airway of choice in an emergency
Oral endotracheal intubation
Question 2
What are the advantages and disadvantages of oral intubation?
Advantages:
-Easier, faster and less traumatic and more comfortable to insert
-Larger tube can be tolerated
-Easier suctioning
-Less airflow resistance, decrease work of breathing
-Easier passage of bronchoscope
-Reduced risk of tube kinking
-Ideally used for short term intubation
-Avoidance of nasal and paranasal complications: Epistaxis, sinusitis, otitis media
Disadvantages:
-Aesthetically displeasing, especially long term
-Greater risk of self extubation or inadvertent extubation
-Greater risk of mainstem intubation
-Risk of tube occlusion due to biting/ bite block may be necessary
-Poorly tolerated in conscious patient due to gagging
-Risk of injury to lips, teeth, tongue, palate and oral soft tissues
-Greater risk of vomiting, retching and aspiration
Question 3
What are the advantages and disadvantages of nasal intubation
-More difficult than oral tracheal intubation
-May be performed with aid of laryngoscope or done blindly
-Route of choice with cervical spine injuries and maxilofacial injiries
-Patient my breath spontaneously for blind techniqe
-Spray of racemic epinephrine and lidocaine used for vasoconstriction and anesthesia
What are Magill forceps used for?
-guide tube into glottic opening
What is versed and anecting/Succinyicholine used for?
Versed: sedation
Acectine/ Succinylcholine: temporary paralsis
Question 4
What equipment is required for endotracheal intubation?
-Oxygen flowmeter and tubing
-Suction apparatus (flexible suction catheter and Yankauer/ tonsil suction)
-Manual resuscitation bag and mask
-Oropharyngeal airways
-Laryngoscope(2) with assorted blades
-Endotracheal tubes(3 sizes)
-Tongue depressor
-Stylet
-Stethoscope
-Tape, syringe, lubricating jelly
-Magill forceps, anesthetic
-Towels for positioning
-CDC barrier precautions(gloves, mask, gown, eye gear)
-Possible neuromuscular blocking agents: paralyzing agents
Question 5
What doe the acronym SALT describe?
-Suction: Must have suction prior to intubating because of gag reflex and possibility of reflux
-Airway: Need an oropharayngeal airway to help keep airway open for ventilation
-Laryngoscope: tow kinds of blades: mac and Miller, check light source
-Tube: Endotracheal tube for insertion into trachea, check balloon for patency
What is a stylet?
-Like obturator but for endotracheal tube. Let’s you be able to curve tube anyway that works best
What is the endotracheal tube size for 16 year old?
6.5-7.5 with tube length of : 18-20
Question 6
Compare and contrast the two blades, which are used for endotracheal intubation
The Mac is a curved blade
The Miller is a straight blade
Question 7
List the landmarks for oral intubation
-As the blade reaches the base of the tongue the epiglottis and arytenoids cartilage are seen. If not seen blade has gone to far and is in esophagus
-With the curved blade the tip is place in valleculla and the epiglottis is displaced indirectly by lifting up and forward/ visualize vocal cords and glottis
Question 8
Describe the correct method for oral endotracheal intubation
-Step 1 Assemble and check equipment
-Step 2 Position Patient
-Step 3: Preoxygenate patient
-Step 4: Insert Laryngoscope blade
-Step 5: Visualize glottis
-Step 6: displace the epiglottis
-Step 7: Insert the tube/ inflate cuff/ ventilate patient
-Step 8 Assess tube position
-Step 9: Stabilize the tube
Question 9
What is the typical length (from teeth to tip) of an ET tube for the adult male and female patient
Female: 19-21 centimeters
Male: 21-23 centimeters
Question 10
What is the range for ET tube size for adult male and female patient
female: 7.0-8.0 with tube length of 19-21
Male: 8-9.0 with tube length of 21-23
How far in the tube can you place the stylet?
-Never to extend beyond the tip of tube
How is the patient aligned for endotracheal intubation?
-Align mouth, pharynx and larynx
-Cervical flexion combined with extention of the head
-Placement of towels under head will help with positioning(usually for babies)
How long should it take to intubate?
-No longer than 30 seconds
What do you do if intubation fails?
Hyperoxygenate patient 3-5 minutes
How do you insert a laryngoscope?
Use left hand to hold laryngoscope
-Right hand is used to open mouth
-Insert blade into right side of mouth and move it toward center
-The tongue will be displaced to left
-Advance the blade along the curve of the tongue until you visualize the epiglottis
What happens if you do not hear any breath sounds after you intubate?
– tube went into esophagus
How much do you inflate the cuff?
5-10ml
Question 11
What is the initial method, which should be used to verify endotracheal tube placement
-Ideally tip of tube should be 2-4 cm above carina
-First listen for equal and bilateral breath sounds when patient is being ventilated…5 points
-Observe chest for equal and adequate expansion
-Decreased breath sounds and decreased movement on left side may indicate right mainstem intubation(endobronchial intubation)
-Listen to abdomen: air movement or gurgling indicates esophageal intubation
-Direct visualization of the tube passing through the vocal cords
-fogging of tube
-An absence of stomach contents in the tube
Question 12
What are the additional methods used to verify endotracheal tube placement
-Portable chest xray: used for verification of final position
–Colorimetric CO2 detector
-Waveform capnography
Self inflating esophageal bulb
-Light wand
-Esophageal detection device
-Pulse ox
How long is the tube is nasally intubated?
-Add 2 cm
Capnometry or CO2 analysis
-Inspired air contains .04% CO2
-Expired air contains 6% co2
-Placement of tube in trachea will cause CO2 levels to rise sharpley
-Placement of tube in esophagus will cause CO2 levels to be near zero
-Colorimetric CO2 analysis such as easy cap device will cause a change in color when CO2 is present
Why would the CO2 reading be low in a patient with cardiac arrest?
Poor pulmonary blood flow
What is the easy cap?
-Yellow to purple (or purple to yellow) represents proper placement of endotube
-Purple on inspiration
-Yellow on expiration
How many breaths are required for accuracy on easy cap?
6 breaths
What is the most accurate technology to evaluate endotracheal tube position in patients who have adequate tissue perfusion?
End tidal carbon dioxide detection which is Easy Cap
Esophageal detection device (EDD) or Large syringe
-Connects to 15mm patient connector
-first, squeeze bulb, connect to tube, release bulb, if air is aspirated into bulb or air can be aspirated into a syringe the tube is in the trachea
-The bulb or syringe will not fill if tube is in the esophagus since the esophagus will collapse over the opening
-Not recommended for under 1
Fiberoptic Laryngoscopy
-Absolute confirmation may be made by inserting a fiberoptic laryngoscope directly into the ET tube
-Visualization of the carina distal to the tip of the tube confirms placement
-More precise placement may be made by moving scope from tube tip to carina while measuring distance
What is the traditional method for verifying tube placement after it has been taped in place
chest x ray
A light wand
-Flexible stylet with a lighted tip is inserted into the tube
-During intubation a characteristic glow will be seen above the thyroid cartilage if the tube is in the trachea
-This light seen under the skin is known as the jack o lantern effect
After intubation if the tube is in the trachea the entire airway should light up
Question 13
What medication is commonly used for sedation in a patient undergoing intubation
Versed
Question 14
What medication is commonly used for temporary paralysis in a patient undergoing intubation?
Anectine /Succinylcholine
Question 15
What medication will cause an extended paralysis for a patient undergoing intubation?
How does the patient sit for blind nasotracheal intubation
sitting up or supine
What can we put down the tube besides oxygen and a suction catheter?
-Narcan
-Atropine
-Valium
-Epinephrine
-Lidocaine
What are the most serious complications for emergency airways?
-Most common is tissue trauma
-Most serious: Acute hypoxemia, hypercapnia, bradycardia, cardiac arrest