Airway ManaQ_e_m_e_n_t

When you can't breathe, nothing else matters. American Lung Association Motto Airway management i one of my favorite subjects. It is very satisfying to help patients breathe better in such a dramatic fashion. While there i no substitute for experience, Chapter 33 will help you learn how to use equipment, tubes, and techniques to deal with airway emergencies. You will want to become an expert in every aspect of this subject so that you can become a skilled knowledgeable provider and a resource for other health care professionals. The chapter has a ton of material but it all falls into three basic areas: Airwa clearance devices and techniques Insertion and maintenance of artificial airways Special airway management procedures

Patients \ ho can't clear their own secretions are at risk for all kinds of problems Uke increased work of breathing, atelectasis, and lung infections. It's our job to get in there and clean out those airways. Respiratory therapists (RTs) suction both the upper and lower airways. .

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assess thy patient. use the correct vacuum setting. use the right catheter size. preoxygenate and hyperinflate thy patient. withdraw 1 to 2 em prior to suctioning. suction on withdrawal only. limit the duration to 10 to 15 seconds. reoxygenate and hyperinflate after each attempt. only in'igate when indicated. morutor thy patient.

1.

Oral suctioning alone is usually accomplished with a rigid plastic tube called a tonsil tip. What's the other common name for this devite\ '

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2. Why do you need to be careful when you're putting a device in someone's mouth? (Hint: Did you ever stick your toothbrush too far into the back of your mouth?)

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Endotracheal suctioning is a vital, but potentially risky procedure. Closely following the rules will greatly reduce your chances of causing an adverse reaction. The AARC Clinical Practice Guidelines in your textbook give a good overview of this subject.

COMPLICATION A. B. C. D. E. F. 4. Hypoxemia Cardiac arrhythmia Hypotension Atelectasis Mucosal trauma Increased ICP

CAUSE

PREVENTION

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Discuss the advantages and disadvantages of closed-system multiuse catheters. A. Advantages:

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

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How should you position a patient for nasotracheal suctioning?

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Establishing the Artificial Airway Complete the following paragraph by writing in the correct term(s) in the blank(s) provided.

Q tubes are long, semirigid tubes, usually made of chloride or some other type of plastic. A typical ET tube has nine basic parts. The proxima end (s cking out of. he mouth) has

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There are three specialized endotracheal tubes you should know about: double-lumen, jet ventilation tubes, and CASS tubes. Pay attention, this is board material!

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

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Describe two common troubleshooting

procedures used when the laryngoscope does not light up properly.

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How long may you attempt intubation? Why do you think we have a rule like this one?

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Compare the use of the )tiller

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Your textbook describes eight methods for bedside assessment of correct tube position. While none of these methods absolutely confirms position, they are essential assessments to make right after the tube is placed. Heart association says there should be three surveys of intubation. Fill in the information from Box 33-4 on page 709 of your textbook.

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

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Chapter 33 Airway Management

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TRACHEOTOMY

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What is the primary indication for performing a tracheotomy?

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INJURY
A. B. C. D. E. F. Glottic edema Vocal cord inflammation Laryngeal ulceration Polyp/granuloma Vocal cord paralysis Laryngeal stenosis

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Once placement of an artificial airway is successfully completed the real fun begins. As an RT, you will be expected to secure the airway. maintain adequate humidification, manage secretions, care for that cuff, and troubleshoot problems that arise-some of which are life threatening.

How do fi~on (in cm)? /

and extension of the neck affect tube motion? What is the average distance the tube will move

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A trach can be temporarily closed with a finger (the patient's finger or yours, with a glove of course!). A more effective solution in the long run is the Passy Muir valve. What do you need to do with the cuff? How about the ventilator?

46.

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

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

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Describe three techniques that can be used to decrease the risk of infection. A.

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Describe the two alternative cuff inflation techniques. A. MO -

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RTs and nursing personnel may share some of the tracheostomy care duties. These tubes require daily care to keep the wound clean and the tube functioning properly.

Your textbook makes changing a trach tube sound simple. It can be a harrowing experience. The first change is often performed by the surgeon. Be especially careful when: The neck is thick. The site is inflamed or infected. The trach is fresh.

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

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

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Extubation is a procedure commonly performed by the RT. You will need to be familiar with the indications for extubation and techniques used to minimize risk during this procedure. 66. The decision to remove the airway and to remove the ventilator are NOT THE SAME! What kind of patients might need to remain intubated even after the ventilafor is removed?

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Describe the two different strategies for removing the tube itself. A. B.

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List two or three of the most common problems that occur after extubation.

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76.

State the three methods for weaning from a tracheostomy tube. Give one advantage and one disadvantage for each technique. Thi i national exam material.

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You might need to have a few more airway tricks up your sleeve. LMAs are increasingly popular devices, especially in the operating room and the EMS settings. Combitubes are also a part of the prehospital setting. Both of these tubes are now a part of Ad "anced Cardiac Life Support (ACLS) training. Emergency cricothyroidotomy may be needed if the upper airway is ob tructed. Paramedics may put these in but RTs usually do not.

While rigid scopes are usually used in the operating room, flexible bronchoscopy is often done at the bedside with the RT playing a key role in patient preparation and monitoring during the procedure. 80. State one advantage and three disadvantages of the rigid bronchoscope.

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Give an example of a specific drug and the general goal for each of the following classes of premedication used in bronchoscopy. DRUG CLASS A. B. C. D. Tranquilizer Drying agent Narcotic-analgesic Anesthetic on a nonintubated patient? What about after the EXAMPLE GOAL

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What drugs would RTs nebulize prior to the procedure procedure?

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Case 1 During your first day of clinical training in the ICU, a patient sustains a cardiac arrest. Your clinical instructor asks you to assist in preparing the equipment needed for endotracheal intubation. The patient is a small 56-year-old woman.

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A colorimetric CO2 detector is attached to the ET tube. The end-tidal CO2 is 2% on exhalation and 0% on inhalation as the chest rises with bagging. What does this suggest regarding the effectiveness of the chest compressions?

After your heart-pounding initiation into resuscitation, it is time to check the other ventilator patients in the unit. A 19-year-old woman with a head injury is receiving mechanical ventilation via a cuffed NO.8 tracheostomy tube with an inner cannula. As you enter the room, the high-pressure alarm is sounding.

What size suction catheter is suggested using the Rule of Thumb found in Egan's?

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After suctioning, you will need to check the cuff pressure. What is a safe cuff pressure?

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Chapter 33 is the longest one we've had so far! That must mean this is extremely important material. The NBRC agrees! The Examination Matrix says you must perform procedures to achieve maintenance of the airway including artificial

airway care, adequate humidification, cuff monitoring, positioning, and removal of secretions. They go on to include modification of the management of artificial airways including changing the type of humidification, inflating or deflating the cuff, and initiating suctioning. You should be able to assemble and check the function of the airways and the intubation equipment. Finally, you need to assist the physician in performing bronchoscopy, tracheostomy, and, of course, intubation. The actual number of airway questions varies from exam to exam, but you should be prepared for at least six to eight questions on any given test.

95.

Which of the following will decrease the risk of damage to the trachea from the endotracheal tube cuff? I. minimal leak technique II. maintaining cuff pressures of 30 to 35 cm H20 III. minimum occluding volume technique IV. inflating the cuff to 25 mm Hg ~ I and II c.!V I and III C. II and III D. III and IV The diameter of the suction catheter should be no larger than A. one-tenth the inner diameter of the ET tube ~ one-third the. inner ~iameter of the ET tube ~_>)lle-half the lllner dIameter of the ET tube D. three-fourths the inner diameter of the ET tube A patient with a tracheostomy tube no longer requires mechanical ventilation. All of the following would facilitate weaning from the tracheostomy except a(n) _ A fenestrated tracheostomy tube . B.' cuffed tracheostomy tube . tracheostomy button D. uncuffed tracheostomy tube Extubation is performed on a patient with an endotracheal tube. Presence of which of the following suggests the presence of upper airway edema? A. rhonchi B. crackles wheezes stridor of the following are useful in nasotracheal intubation except a laryngoscope handle stylette Miller blade Magill forceps _

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100.

While performing endotracheal suctioning, an RT notes that flow through is minimal and secretion clearance is sluggish. Which of the following are possible causes of this problem? I. The vacuum setting is greater than 120 mm Hg. II. The suction canister is full of secretions. III. There is a leak in the system. IV. The tube cuff is overinflated. A. I and II B. I and IV (C:""''II and III ~IIIandIV

101.

Rapid, initial determination endotracheal tube placement can be achieved by I. auscultation II. arterial blood gas analysis III. measurement of end-tidal CO2 IV. measurement of SP02 A. I and II '2I:l9 I and III C. II and IV D. III and IV

102.

103.~iCh . . C. D. 104.

A patient with a tracheostomy tube shows signs of severe airway obstruction. A suction catheter will only pass a short distance into the tube. The RT should _ A. remove the tracheostomy tube B. inflate the cuff of the tube C. ventilate the tube with positive pressure remove the inner cannula of the following can be used to assess pulmonary circulation during closed-chest cardiac compressions? capnometry arterial blood gas analysis pulse oximetry blood pressure monitoring

Prior to performing bronchoscopy, an RT is asked to administer a nebulized anesthetic to the patient. What medication is most appropriate to place in the nebulizer? A. Versed B. atropine morphine \E) lidocaine

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Here's an idea that could help you learn a topic as huge, complex, and important as this one: digital flashcards. Take photographs of equipment, scan pictures from books, and download from the Internet to create a pile of pictures. Set up a slide show and you've got digital flashcards. My students find this a fun and effective way to learn, and they help each other out on the project.

When I searched Google for "endotracheal tube PowerPoint presentations," I got about 35,000 hits! You can do better than that! Try The Internet Journal of Airway Management: www.ijam.at. It has good stuff and a cool "virtual airway museum." E-medicine has a good area on tracheostomy at www.emedicine.com/entitopic356.htm. There is literally an astonishing amount of material on airway management on the Internet, so you need to have a pretty good idea of what you are looking for when you start to search. You'll want to narrow things down with "artificial airway emergencies," not "airway emergencies," if that's what you're hoping to find. If you do use Google, try switching to images or video mode; you might be pretty surprised at what you get!