Reading...
Play button
Play button
Use LEFT and RIGHT arrow keys to navigate between flashcards;
Use UP and DOWN arrow keys to flip the card;
H to show hint;
A reads text to speech;
310 Cards in this Set
- Front
- Back
|
Major Structures of Upper Airway
|
Nose
Mouth Jaw Nasopharynx Oropharynx Pharynx Epiglottis Larynx |
|
|
Major Structures of Lower Airway
|
Trachea
Carina Bronchus Bronchioles Lungs Alveoli Pulmonary capillaries |
|
|
What anatomical structure divides the upper airway from the lower airway?
|
Larynx
|
|
|
What is the Pharynx and what is it comprised of?
|
Muscular tube from the nose and mouth to the esophagus and trachea.
Composed of Nasopharynx - facial bones Oropharynx Laryngopharynx (hypopharynx) which opens the larynx anteriorly and the esophagus posteriorly |
|
|
What is the purpose of the upper airway?
|
To warm, filter and humidify
|
|
|
What are Turbinates?
|
Bones that protrude form the lateral walls of the nasal cavity and extend into the nasal cavity. Increase surface area of nasal mucosa and improves warming, filtering and humidifying
|
|
|
What is the nasal septum?
|
Rigid partition composed of the ethmoid bones and the vomer bones and cartilages
|
|
|
What are Sinuses and paranasal sinuses?
|
Lateral walls and openings, located frontal, maxillary that prevent contaminates from entering the respiratory tract and act as tributaries for fluid to flow to and from the eustachian tubes and tear ducts
|
|
|
What is CSF fluid called when it leaks through the nose? The ears?
|
Cerebrospinal Rhinorrhea
Cerebrospinal Otorrhea |
|
|
How is the oropharynx created?
|
Forms the posterior portion of the oral cavity, which is bordered superiorly by the hard and soft palates, laterally by the cheeks and inferiorly by the tongue
|
|
|
Where is the tongue attached?
|
Large muscle that is attached by the mandible and the hyoid bone
|
|
|
How is the Hyiod bone attached?
|
Small horse shoe shaped bone that is attached to the jaw, epiglottis, thyroid and the tongue
|
|
|
How is the palate formed and what does it separate?
|
Forms the roof of the mouth and separates the nasopharynx from the oropharynx
|
|
|
What is the hard palate?
|
Anteriorly located created by the maxilla and palatine bone
|
|
|
What is the soft palate?
|
Posteriorly located to the hard palate and is extended by the palataglossal arch, posterior border of the oral cavity
|
|
|
What is the Uvula?
|
Soft tissue that extends from the palatoglossal arch at the base of the tongue to the posterior aspect of the oral cavity
|
|
|
What is the Palatopharyngeal Arch?
|
Entrance to the throat...pharynx
|
|
|
What are tonsils and what do they do?
|
Lymphatic tissue that trap bacteria and fight infection
|
|
|
What is another name for Pharyngeal tonsils and where are they located?
|
Adenoids and found posterior nasopharyngeal wall
|
|
|
What is the function of the lower airway and where is it located?
|
Functions to exchange o2 and co2, runs from the 4th cervical vertebrae to the xiphoid process and internally from the glottis to the pulmonary capillary membrane
|
|
|
What is the larynx made of and what does it signify?
|
Formed by many independent cartilaginous structures and it separates the upper and lower airways
|
|
|
What is the Thyroid cartilage and where is it located?
|
Shield shaped structure formed by two plates that forms a V anteriorly forming a laryngeal prominence known as the adam's apple. It is suspended from the Hyoid bone by the thyroid ligament and anterior to the glottic opening
|
|
|
What is the Cricoid cartilage and where is it located?
|
Cricoid ring, the only airway structure that forms a complete ring. It is inferior to the thyroid cartilage, 1st ring of trachea and lowest part of the larynx
|
|
|
What is the cricoid membrane used for and where is it located?
|
Site for a Cricothyrotomy and it is bordered laterally and inferiorly by the vascular thyroid gland
|
|
|
Where is the glottis located and what is its purpose?
|
Space between the vocal cords and narrowest part of the adult airway. Airway patency here requires heavy muscle tone. Lateral borders are the vocal cords and during inhalation, it opens to provide minimum resistance to airflow
|
|
|
What three things are attached to the epiglottis and what is its purpose?
|
Thyroepiglottic ligament at the thyroid cartilage, Glossoepiglottic ligament at the base of the tongue and Hyoepiglottic ligament and the hyoid bone (position of the tongue and the glottis move with the hyoid bone.
Prevents food and liquid from entering the glottic opening |
|
|
What is the Vallecula?
|
Anatomical space, pocket, between the base of the tongue and epiglottis
|
|
|
Where is the Arytenoid cartilage located and what is its purpose?
|
Pyramid shaped, forms posterior attachment of vocal cords. As the Arytenoids pivot, the vocal cords open and close. It regulates the air through the larynx and controls the production of sound
|
|
|
What the 2 sets of cartilage surrounding the glottic opening?
|
Corniculate and cuniform cartilage
|
|
|
What is the Piriform Fossae and where is it located?
|
two pockets of tissue that laterally border the larynx
|
|
|
What is a Laryngospasm?
|
Spasmodic closure of vocal cords and seals off the airway as a defensive reflex but usually only lasts a few seconds
|
|
|
What and where is the Trachea?
|
Aka the Windpipe is the conduit for air entry into the lungs. It is a tubular 10 to 12 cm long set of c shaped cartilaginous rings. It begins below the cricoid cartilage and descends anteriorly down chest to the 5th and 6th thoracic vertebrae in the mediastinum
|
|
|
What is the mediastinum?
|
Space in the thoracic cage between the lungs that contain the heart, great vessels, esophagus and trachea
|
|
|
Where is the esophagus located?
|
Posterior to the trachea
|
|
|
Where is the sternal angle of Louis?
|
Where the Carina and Bronchi meet
|
|
|
What are goblet cells?
|
Cells that contain cilia, beta 2 adrenergic receptors located in the lining of the trachea and bronchi that produce mucous and trap contaminants. Cilia move back and forth to sweep foreign material out of the airway. When the Beta 2 receptors are stimulated bronchodilation occurs
|
|
|
How much air do the lungs hold?
|
6 L
|
|
|
What is parenchyma?
|
The mass of tissues that make up the lungs
|
|
|
How many lobes in each lung?
|
Right has three and left has two
|
|
|
What is the Visceral pleura?
|
Slippery other membrane around the lungs that stops friction during respiration
|
|
|
What is Parietal pleura?
|
Pleura that lines the inside of the thoracic cavity
|
|
|
Where are alveoli located and what is their purpose?
|
Balloon clusters of single layer air sacs where o2 and co2 exchange via diffusion. They increase the surface area of lungs. As the lungs expand during inhalation the alveoli become thinner and ease diffusion.
|
|
|
What is Surfactant?
|
Phospholipid compound that lines the alveoli that decrease surface tension on alveoil walls and keeps them expanded
|
|
|
What is Atelectasis?
|
When the amount of pulmonary surfactant is decreased and the alveloi walls collapse
|
|
|
What is ventilation?
|
Physical act of moving air in and out of lungs
|
|
|
What is oxygenation?
|
The loading of 02 molecules onto hemoglobin in the blood stream
|
|
|
What is respiration?
|
The exchange of 02 and co2 in the alveoli and tissues in the body
|
|
|
What is pulmonary ventilation?
|
The moving of air in and out of the lungs. Necessary for respiration and oxygenation.
|
|
|
What happens during inhalation?
|
The active muscular part of breathing. The diaphragm and intercostal muscles contract. The Diaphragm descend and the intercostals lift the ribs up and out. They both enlarge the thorax in all directions
|
|
|
What is the diaphragm?
|
Skeletal muscle that is innervated by the phrenic nerve. it is voluntary and involuntary (somatic)
|
|
|
What happens when the co2 in the blood increases?
|
Autonomic regulation of breathing resumes under the control of the brain-stem
|
|
|
In what ways are pediatric s airways different than adults?
|
They have a larger occiput, smaller mandible, larger tongue, floppier epiglottis, smaller airway, larynx more superior and anterior, underdeveloped cricoid cartilage, narrowest part of the airway is the cricoid ring and non optimal thoracic cavity
|
|
|
What is negative pressure ventilation?
|
During inhalation the thoracic cage expands and the air pressure within the thorax decreases creating a vacuum. The Vacuum pulls air through the trachea causing the lungs to fill.
|
|
|
When air pressure inside the thorax equals the air pressure out side of the body what happens?
|
Air stops moving. Oxygen and co2 move from an area of high pressure to an area of low pressure through diffusion until the pressures are equal. At this point air stops moving and inhalation stops.
|
|
|
What is a positive pressure ventilation?
|
Forces air into the lungs when apnea or decreased tidal volume occurs
|
|
|
What is partial pressure?
|
Amount of gas in air or dissolved in liquid (blood). o2 and co2 can stay in blood as long as partial pressure exists
|
|
|
How is partial pressure measured?
|
by millimeters per mercury (mmhg). O2 in alveoli is 104 mmhg and co2 in alveoli from blood is 40 mmhg
|
|
|
What is PAo2?
|
Deoxygenated arterial blood from heart has a partial pressure of o2 that is lower than the partial pressure of o2 in the alveoli.
|
|
|
How does the body attempt to equalize positive pressure?
|
02 diffuses across alveolar capillary membrane into the blood. Co2 diffuses into alveoli and is eliminated as waste on exhalation. They continue to diffuse until partial pressure in air and blood is equal. This process occurs in reverse when arterial blood reaches the tissues. o2n diffuses into the tissue fluid and then into the cells, co2 diffuses out of the cells and into the fluid and the blood.
|
|
|
What is alveolar volume?
|
The amount of air that reaches the alveoli
Calculation: tidal volume - dead space = alveoli volume |
|
|
What is Tidal volume?
|
It measures the depth of breathing. the amount of air moved in and out of the respiratory tract in one breath.
Normal for adults= 5 to 7 ml/kg 500 ml Normal for Peds = 6 to 8 ml/kg |
|
|
What is dead space volume?
|
Portion of the tidal volume that doesnt reach the alveoli and doesnt participate in gas exchange. its the air that remains in the area of the mouth to the bronchioles approx. 150 ml
|
|
|
What is physiological dead space?
|
Respiratory dead space that is created by intrapulmonary obstructions or alveolar collapse (atelectasis)
|
|
|
What is minute volume?
|
Amount of air moved through respiratory tract including the dead space in one minute
Calculation : Minute volume= tidal volume-respiratory rate |
|
|
What is alveolar minute volume?
|
Actual amount of air that reaches alveoli and participates in pulmonary gas exchange each minute
Calculation: (tidal volume-dead space) x respiratory rate AMV is decreased with normal resp. but reduced tidal volume AMV increased if normal resp but increase tidal volume |
|
|
What is inspiratory reserve volume?
|
Amount of air that can be inhaled in addition to normal tidal volume @ 3000ml
|
|
|
What is functional reserve capacity?
|
Amount of air forced from lungs in one exhalation
|
|
|
What is expiratory reserve volume?
|
amount of air exhaled after normal exhalation @ 1200 ml
|
|
|
What is residual volume?
|
air that remains in lungs after full exhalation @ 1200 ml
|
|
|
What is vital capacity?
|
amount of air that can be forcefully exhaled after full inhalation @ 4800 ml
|
|
|
What is the total lung capacity?
|
Maximum amount of air the lungs can hold @ 6000 ml
Total lung capacity = vital capacity + residual volume |
|
|
What is exhalation?
|
Passive process and no muscular effort
|
|
|
What is the physical process of exhalation?
|
Chest expands then the stretch receptors in chest walls and bronchioles send a signal to apneustic center via vagus nerve to the inhibits respiratory center which produces exhalation
|
|
|
What is the Hering Breur reflex?
|
Stops the over inflation of the lungs and terminates inhalation.
Diaphragm and muscles relax increasing pulmonary pressure, the lungs recoil and passively remove air, air pressure in the thorax is higher that outside pressure and the air is pushed out through the trachea |
|
|
How is ventilation regulated?
|
Changes in 02 demand alter the rate and depth of ventilation. Primarily by the PH balance of CSF which is directly related to amount of co2 dissolved in plasma part of the blood (PAco2)
|
|
|
What is the drive to breath based on?
|
Ph changes in the blood and the co2 levels. When o2 levels rise the respiratory system suspends breathing until the co2 levels increase and stimulates the respiratory center to breath again.
|
|
|
What is the Medulla oblongata?
|
The primary involuntary (autonomic) respiratory center that controls breathing in brain stem. It is connected to the respiratory muscles by the vagus nerve and controls rate, depth and rhythm
|
|
|
What are the Pons?
|
Located in the apneuistic center and is the secondary control of respiration if the medulla fails. It works by controlling the amount of respiration. Increases the number of respirations per minute
|
|
|
What is Apneustic?
|
Prolonged gasping respirations followed by short ineffective respirations that may be caused by brainstem insult
|
|
|
What is Pneumotaxic?
|
Part of the pons that assists in creating shorter faster respirations
|
|
|
What is the goal of chemical control of ventilations?
|
Keep the blood concentrations of o2 and co2 and its acid-base balance in narrow ranges
|
|
|
Where are the 3 places chemoreceptors are located?
|
Carotid bodies and aortic arch that measure the amount of co2 in arterial blood and central that monitors the PH of the CSF in medulla that balance the CSF (cerebrospinal fluid)
|
|
|
What is PAo2?
|
Amount of oxygen dissolved in plasma. Carotid and aortic bodies respond to decrease in PAo2 by sending messages to the respiratory centers to increase breathing
|
|
|
What two things control ventilation?
|
Co2 in the blood and PH levels in the CSF
|
|
|
What is the dorsal respiratory group?
|
Chemoreceptors stimulate dorsal group in the medulla to increase the respiratory rate by removing more co2 or acid from the body. Dorsal is responsible for initiating inspiration based on information received from its chemoreceptors
|
|
|
What is the ventricle respiratory group?
|
Primarily responsible for motor control of inspiratory and expiratory muscles
|
|
|
What five things factor into ventilation control?
|
Fever - Increase metabolism and increased respiration
Medications, Pain and emotions, Hypoxia - Increased respirations to get more o2, Acidosis - Increase respirations to eliminate acids |
|
|
What happens to respirations when the metabolism is either high or low?
|
When metabolism is high, respirations are high and more co2 is eliminated. When metabolism is low, respirations are low
|
|
|
What is oxygenation?
|
process of loading o2 molecules onto hemoglobin in blood and requires that air used for ventilation has and adequate percent of 02. If no oxygenation there is no ventilation however you can have ventilation without oxygenation
|
|
|
What is the fraction of inspired O2?
|
FIO2 is the percentage of o2 in inhaled air. It increases with supplemental o2. Room air has 21% so FIO2 is 0.21%. A non rebreather mask has 90% so FIO2=0.9%
|
|
|
What is Hemocrit and the values for men and women?
|
Hemocrit values are the % of red blood cells in whole blood. For men it is 45-52% and for women 37-48%
|
|
|
What is SA02?
|
Arterial blood gases. Proportional amount of o2 dissolved in plasma (PAO2)
|
|
|
What happens when PAO2 decreases?
|
Hemoglobin releases o2 molecules to make them available for cellular respiration
|
|
|
What is the Oxyhemolglobin disassociation curve?
|
Basically acid and alkali and o2 and co2 work in tandem for homeostasis. When acid (PH) deceases, CO2 increases. When Alkali (PH) increases, O2 decreases
|
|
|
What is respiration?
|
the exchange of o2 and co2 allows the cells to receive o2 and remove waste
|
|
|
What is ATP and how is it made?
|
Adenosine phosphate = cell combines with nutrients (glucose, etc) and o2 to produce energy and waste
|
|
|
What three things does respiration promote?
|
Ventilation
Diffusion of o2 and co2 between blood and pulmonary alveoli Transports o2 and co2 throughout body |
|
|
What is external respiration?
|
Pulmonary Exchange of o2 and co2 between alveoli and blood in pulmonary capillaries
|
|
|
What gases comprise fresh air and their %?
|
Oxygen at 21%, Nitrogen @ 78% and Carbon Dioxide at 0.3%
|
|
|
What gases comprise exhaled air and their %?
|
Oxygen 16%, CO2 3-5%, Remainder is nitrogen
|
|
|
What is the internal process of external respiration?
|
Air goes to alveoli to surfactant (which increases surface area) which keeps them expanded and aids in the exchange of o2 and co2. O2 diffuses through the alveolar membrane and hitches to hemoglobin.
|
|
|
What is the path of Hemoglobin?
|
Hemoglobin picks up fresh o2 as it crosses alveolar membrane then returns to the left side of the heart then out to the rest of the body. 96 to 100% of hemoglobin receptors contain o2
|
|
|
What is internal respiration?
|
Cellular respiration. Exchange of 02 and c02 in systemic circulation and the cells of the body
|
|
|
What are the 2 types of internal cellular respirations?
|
Aerobic - o2 in the mitochondria of the cells convert glucose into energy. Without enough 02 glucose will not turn into energy and lactic acid will build up in the cells and the cells will become hypoxic
Anaerobic - cant meet the metabolic demands of the cell and if it not corrected the cell will die. Mitochondria eats the o2 to convert glucose to energy and co2 accumulates in the cell. |
|
|
What are positive pressure ventilations?
|
Force air into the lungs, more air is needed to achieve normal oxygenation/ventilation of normal breathing, affects venous return to heart (reload), decreases BP due to extra pressure in the chest...could cause hypotention
|
|
|
What are negative pressure ventilations?
|
Normal respirations that equalize internal and external pressure when the diaphragm contracts
|
|
|
What is the hypoxic drive?
|
COPD pts have increased arterial co2 levels and PH in CSF. The hypoxic drive stimulates breathing when arterial o2 levels fall. Chemoreceptors become satisfied with minimum levels of 02 Located in brainstem.
|
|
|
What is hypoxia? How does it present?
|
Tissues and cells don't receive enough o2, death may occur quickly. Pt may be restless, irritable, apprehensive, anxious. Pt may be tachy, with cyanosis, thready pulse and dyspnea
|
|
|
What is the perfusion ratio and mismatch?
|
Increased air flow and blood flow mist be directed to the same place..ventilation and perfusion must be matched
|
|
|
What is the v/q mismatch?
|
When ventilation and perfusion dont match and hypoxemia occurs...no oxygen to the tissues
|
|
|
What is the average amount of air in ventilation? In resting aveolar volume? Pulmonary blood circulation?
|
Ventilation is 6 l/min
Resting alveolar volume is 4 l/min Pulmonary blood circulation 5 l/min |
|
|
How many liters per minute involved in the v/q mismatch?
|
4:5 l/min and is highest at the apices and lowest at the bases
|
|
|
What happens when ventilation is compromised but not circulations?
|
If there is no gas exchange there is no o2 in circulation
|
|
|
What is respiratory splinting?
|
A pt with flail segment may breath shallowly in an attempt to relieve pain = decreased pulmonary ventilation
|
|
|
What is hypoventilation?
|
When co2 production exceeds the bodys ability to eliminate it by ventilation also known as PAco2. Co2 exceeds ability to expel and co2 can be depressed to the point that it wont keep up with the metabolism
|
|
|
What is hyperventilation?
|
CO2 elimination exceeds co2 production. When someone is having an anxiety attack and is breathing deeply and rapidly co2 goes out faster than it can be produced
|
|
|
What is hypercarbia?
|
Deceased minute volume equals decreased co2 elimination and an increased build up of co2
|
|
|
What is Hypocarbia?
|
Increased minute volume equals and increase in co2 elimination and a decrease in co2
|
|
|
What are 2 external factors that effect oxygenation and respiration?
|
Atmospheric pressure and partial pressure o2 (pao2)
|
|
|
What are three internal factors that effect oxygenation and respiration?
|
Pneumonia, pulmonary edema and COPD. Decreased surface area on alveoli equals damage to alveoli and fluid in the lungs
|
|
|
What occurs when there is an excess of lactic acid and a low PH?
|
Dysrhythmias, coma, shock, hypoglycemia, infection, hormone imbalance, decrease in o2 and glucose resulting in the body's inability to produce energy
|
|
|
What is intrapulmonary shunting?
|
Blood to the lungs from right side of the heart bypasses alveoli and returns to the left side of the heart in an unoxygenated state
|
|
|
What occurs when o2 doesnt get to the blood and causes a circulatory compromise?
|
Tension pneumothorax, open pneumothoraxi (sucking chest wound), Hemothorax, hemopneumothorax, pulmonary embolism
|
|
|
What causes an acid/base imbalance?
|
Hypoxia, hypoventilation and hyperventilation
|
|
|
What is the fastest way to eliminate acid in the body?
|
Through the respiratory system. Can be expelled as co2 from the lungs.
|
|
|
How does the renal system regulate the Ph levels?
|
filters cut hydrogen by creating h2o and co2 which expels gases from the lungs and by retaining bicarb
|
|
|
What causes acidosis?
|
Bradypnea, tachypnea, labored breathing, shallow breathing (reduced tidal volume)
|
|
|
What causes alkalosis?
|
respiration rate and volume to high
|
|
|
What are some acid/base disorders?
|
Respiration acidosis and alkalosis caused by fluctuations in respiration. Metabolic acidosis and alkalosis caused by fluctuation in PH by available bicarb
|
|
|
What are some signs of adequate breathing?
|
responsiveness, alert, speak in complete sentences, patent airway, 12 to 20 breaths per minute, adequate tidal volume, regular inhalation and exhalation, clear sounds bilaterally, effortlessness
|
|
|
What are some signs of inadequate breathing?
|
Sepsis. trauma, brainstem insult, poor o2 environment, renal failure, airway obstruction, respiratory muscle impairment, spinal cord injury, CNS impairment (drug OD)
|
|
|
What are the signs and symptoms to observe when assessing adequate breathing?
|
Position, orthopnea (positional dyspnea), adequate chest rise (tidal volume), gasping (air hunger), CTC, nasal flaring, pursed lips, retractions (skin pulling at ribs), accessory muscle use, asymmetric chest wall movement and quick breaths followed by prolonged exhalation
|
|
|
Name 2 sets of accessory muscles
|
Sternocleidomastoid (neck muscles) and Pectoris major (chest muscles)
|
|
|
What are some signs of inadequate ventilation?
|
Breathing at a rate lower than 12 and higher than 20, irregular rhythm, apnea, diminished, absent or noisy breath sounds, abdominal breathing, reduced exhaled air in nose and mouth, reduced tidal volume, inadequate chest rise, use of accessory muscles, shallow depth of breathing, CTC, retractions and dyspna
|
|
|
What is paradoxal motion?
|
Opposite normal chest movement as in a flail segment
|
|
|
What is pulsus paradoxus?
|
Systolic drops more than 10 mmhg during inhalation as in COPD, tamponade, intrathoracic pressure and asthma attack
|
|
|
What are protective reflexes?
|
Coughing, sneezing and gagging
|
|
|
What does sighing periodically do?
|
Hyper inflates the lungs and reexpands collapsed alveoli
|
|
|
What is the gag reflex?
|
Spastic pharyngeal and esophogeal reflex caused by stimulation of posterior pharynx in an attempt to protect from foreign bodies
|
|
|
What are cheyne stokes respirations?
|
Gradually increased rate and depth of respirations followed by decreased respiration with periods of apnea as a result of brainstem insult
|
|
|
What are kussmal respirations?
|
deep and rapid respirations as a result of diabetic ketocidosis
|
|
|
What are Biot or ataxic respirations?
|
irregular pattern, rate and depth with periods of apnea as a result of ICP
|
|
|
What are apneustic respirations?
|
prolonged gasping inhalation followed by very short ineffective exhalation as a result of brainstem insult
|
|
|
What are agonal respirations?
|
slow, shallow, irregular and gasping when the heart has stopped but the brain is still sending signals to muscles to respire. Cerebral anoxia when there is no o2 in the brain
|
|
|
How are breath sounds created?
|
Breath sounds are created as the air moves through the tracheobronchial tree and the size of the airway determines the breath sounds. the sounds represent airflow to the alveoli
|
|
|
What are tracheal breath sounds?
|
Bronchial breath heard over the trachea or sternum
|
|
|
What are vesicular breath sounds?
|
Softer, muffled like wind through the trees
|
|
|
What are bronchovescular breath sounds?
|
Tracheal and vescula sounds heard where airway and alveoli are in the upper part of the sternum and between the scapula
|
|
|
How to access for breath sounds?
|
Listen for the duration of breath the length of inhalation and exhalation in one breath, the intensity of airflow and rate and the pitch is it higher or lower than normal
|
|
|
What is the I/E ratio?
|
Exhalation is usually twice as long as inhalation
|
|
|
What effect the intensity of sound?
|
Airflow rate, consistency of flow throughout inspiration, patient position, site of auscultation and the thickness of the chest wall
|
|
|
What are abnormal breath sounds?
|
Breath sounds that are either continuous or discontinuous
|
|
|
Where is wheezing heard and what does it indicate?
|
Constricted lower airway, high pitched and heard with asthma, it is continuous
|
|
|
Where is rhonchi heard and what does it indicate?
|
Continuous, low pitched, mucous filled in larger lower airway heard with bronchitis and pulmonary edema
|
|
|
Where are crackles heard and what do they indicate?
|
Also known as rales, airflow causes mucous/fluid filled airways to move to smaller lower airway. Can be cleared by coughing. indicated collapsed airway or popped alveoli. Discontinuous inspiratory cycle with reduced lung volume as in COPD
|
|
|
Where is stridor heard and what does it indicate?
|
Foreign body obstruction or aspiration from infection swelling or disease Trauma with in or above glottic opening
|
|
|
What is a pleural friction rub?
|
Inflammation causes pleura to thicken. Pleural space decreased and visceral/parietal space rub together causing a stabbing pain
|
|
|
What is the importance of ETo2 placement?
|
Detects the amount of co2 in exhaled air
Helps to determine ventilation adequacy Analyzes the levels of arterial (pao2) at the end of exhalation Checks good airway placement since there is no co2 in esophagus |
|
|
What is a capnometer?
|
quantitative information in real time
|
|
|
How does a capnographer register?
|
In a graphic representation
|
|
|
How does a wave form capnographer register? And when is it used?
|
Quantitative in real time with a graphic representation. Used in cardiac arrest to indicate spontaneous return of circulation
|
|
|
What are the phases of capnographic waveform and what does each represent?
|
A-B phase is the initial phase of exhalation and the respiratory baseline, the gas sample is deadspace and there is no co2
B phase is a mixture of alveolar gas and deadspace gas where there is an abrupt rise in co2 B-C phase is and expiratory upslope C-D phase is expiratory/alveolar plateau when gas is in the alveoli D phase is the maximum reading for co2 D-E phase fresh gas in inspiratory represented by a downstroke and waveform returns to zero |
|
|
Describe colormetric capnography
|
It is quantitative and takes about 6 to 8 positive pressure breaths to register. It is used for initial co2 check immediately after Et is placed and should turn from purple to yellow
|
|
|
What can the colormetric capnographer indicate?
|
Chest compression adequacy, spontaneous circulation and can be interrupted by sever acidosis
|
|
|
What are the indications for mouth to mouth of mouth to nose resuscitation?
|
Most basic, when the pt is apneic and there are no alternatives. High risk of disease transmission
|
|
|
What are the indications of mouth to mask resuscitation?
|
There is a physical barrier in place with a one way valve. Better seal than mouth to mouth can use both hands. Gives adequate tidal volume and air of 16%. Can sustain life for a limited time. Take a deep breath and deliver one breath over one second. Look for exhalation and adequate chest rise
|
|
|
What are the indications for using a BVM?
|
With o2 and a good seal you can deliver 100% o2. There is less tidal volume and higher 02 concentration. Accuracy depends on mask seal. Amount of gas in the reservoir bag for and adult is @ 1200 to 1600 and fro peds @ 500-700 ml. Delivered tidal volume should be about 500 to 600 ml and should promote chest rise
|
|
|
What happens if you deliver ventilations too fast with a BVM?
|
Can cause gastric distension, aspiration, decreased venous return to the heart (preload) from increased intrathoracic pressure
|
|
|
What are the ventilation rates for adults and peds, apneic with and without a pulse?
|
Adults apneic with a pulse 10-12 bpm
Adults apneic without a pulse 8-10 bpm Peds apneic with a pulse 12-20 bpm Peds apneic without a pulse 8-10 bpm |
|
|
What are the steps to ventilate a pt?
|
Kneel at head
Hyperextend neck Suction as needed Insert opa Deliver a breath to adults once every 5 to 6 seconds Deliver a breath to a ped once every 3 to 5 seconds Squeeze bag as pt inhales |
|
|
What is pulse oximetery?
|
Measures how well a persons hemoglobin is saturated with o2 (spo2)
Assess pulsating blood vessels In a nonsmoker with an o2 sat of less than 95% suspect hypoxia |
|
|
When is pulse oximetry useful?
|
During suctioning, if low abort
Deterioration in trauma victim, could indicate pneumothorax Deterioration in pt with cardiac disease could indicate Chf in MI High risk respiratory pt indicated asthma pt with attack or emphysemia in decline Vascular status in orthopaedic trauma indicated fractured extremity to identify pulse distal to fracture |
|
|
When would you get erroneous readings in the pulse ox?
|
ambient light
Pt motion poor perfusion - shock, cardiac arrest abnormal hemoglobin Nail polish venous pulsations indicates rt sided heart failure or system back up |
|
|
What are the four types of hemoglobin?
|
Oxyhemoglobin (hbo2) occupied with oxygen
Reduced hemoglobin - after o2 has been released to cells Methemoglobin (methb) oxidation of iron Carboxyhemoglobin (coHb) hemoglobin loaded with co2, o2 maybe present but not high enough to register |
|
|
What is peak expiratory flow measurment?
|
Hand held device that measures the force behind exhalation. Bronchoconstriction as in asthma can be measured with peak rate of forceful exhalation (with device)
|
|
|
What is the difference between peak expiratory flow and decreased peak expiratory flow?
|
If the pt is responding to treatment they will have peak expiratory flow if they are deteriorating they will have decreased peak expiratory flow
|
|
|
How do you determine peak expiratory flow?
|
Based on gender, age and height
Healthy flow is between 350 and 750 ml Have the pt seated with legs dangling and have them repeat the drill x3 and take the best reading |
|
|
What is arterial gas analysis?
|
Quantitative information about respiratory system based on the PH balance, co2, o2 of blood from a superficial artery like femoral or radial. indicates adequate ventilation. For the gas to remain in balance alveolar volume and perfusion of alveolar capillaries must be equal
|
|
|
What causes an increase in ETco2?
|
Hypoventilation in spontaneous breathing
Ventilating too slow in an apneic pt with a pulse or without a pulse Can indicate the return of ventilation |
|
|
What can cause a decease in ETco2?
|
Ventilating to rapidly or hyperventialtion of a pt with spontaneous breathing
Misplaced tube of prolonged arrest in a pt without a pulse |
|
|
What is a yankeur suction catheter?
|
aka tonsil tip, suctions the pharynx in an adult and is preferred for peds
|
|
|
What is a whistle tip suction catheter?
|
Aka french, non rigid and can be used in pt with clenched teeth or stoma. can be used in naso or oropharynx and down et tube
|
|
|
What is the process for suctioning?
|
Preoxygenate because suctioning removes o2
Max of 15 seconds in adults and 10 seconds in children Measure from the corner of the mouth to the earlobe Dont pass the back of the tongue Use sweep technique before suctionsin Suction on the way out |
|
|
When should an airway obstruction be suspected in a child?
|
When they have difficulty breathing and no fever. a partial blockage will cause snoring respirations
|
|
|
What is a laryngospasm?
|
Spasmodic closure of the vocal cords caused by trauma while intubating or burns
|
|
|
What is laryngeal edema?
|
Narrowing or closing of the glottic opening due to anaphylaxis or inhalation injury
|
|
|
What are some signs of airway obstruction?
|
choking, gagging, stridor, dyspnea
|
|
|
What is aphonia?
|
Inability to speak
|
|
|
What is dysphonia?
|
Difficulty speaking
|
|
|
How do you relieve airway obstructions caused by laryngeal spasm or edema?
|
Aggressive ventilation to force air past narrowed airway
Pull up jaw to adjust airway Muscle relaxer |
|
|
What is airway patency?
|
Good muscle tone keeps the trachea open
|
|
|
How do you treat a mild airway obstruction?
|
Leave it alone and let the pt cough
|
|
|
How does a severe airway obstruction present?
|
Week ineffective breathing, absent cough, inspiratory stridor and cyanosis
|
|
|
What is lung compliance?
|
Ability of alveoli to expand when air is drawn into the lungs during negative pressure ventilation or pushed into the lungs during positive pressure ventilation
|
|
|
What is the importance of giving supplemental o2 to a hypoxic pt?
|
During an AMI the myocardium is hypoxic even though the rest of the body is ventilated. Giving o2 helps compensatory mechanisms
|
|
|
What are 3 regulator/flow meters?
|
Therapy - gas flow meter at 50 psi
Pressure compensated flow meter with a float ball in a calibrated tube controlled by a needle valve and controlled by gravity Bourdon gauge flowmeter is not affected by gravity and is calibrated to record flow rate |
|
|
Discuss the non rebreather
|
Delivers 90 to 100% fio2
Used in shock and hypoxia Dont use with apnea or poor respiratory effort delivers o2 passively, a shallow breather wont benefit |
|
|
Discuss a nasal canula
|
Delivers 24-44% o2
Pt with COPD for long term therapy Mostly used in pt who cant tolerate a NRB used in low concentrations |
|
|
Discus Partial rebreathing mask
|
Lacks oneway valve between mack and reservoir
Doesnt allow room air on inhalation Residual air is rebreathed 6 to 10 lpm 02 is delivered at 35 to 60% |
|
|
Discuss Venturi mask
|
Room are plus airflow
Adapter provides o2 at 24, 28, 35 and 40% o2 Used for chronic respiratory issues and COPD |
|
|
What is an automatic ventilator?
|
Consistent flow rate controls upper airway pressure
|
|
|
What is an automatic transport ventilator?
|
Uses wall mounted o2
Sets tidal volume, ventilation rate for pt based on age and condition Connects to an advance airway Hands free Delivers preset volume at present ventilatory rate Requires o2 at 5lpm |
|
|
What is a pressure relief valve on the atv?
|
Hypoventilation in pt with inadequate lung compliance airway resistance or obstruction
|
|
|
What is continuous positive pressure? CPAP
|
Has a high inspiratory flow and is used to treat respiratory distress, sleep apnea, acute pulmonary edema and acute bronchospasm
|
|
|
How does CPAP increase pressure in the lungs?
|
Opens collapsed alveoli, prevents further collapse
Pushes ore o2 across alveoli membrane Forces fluid back into pulmonary circulation Improves pulmonary compliance |
|
|
What are the indications of CPAP?
|
Respiratory distress when pts compensatory mechanisms cant keep up with o2 demand. It only treats symptoms
Make sure the pt is alert and can follow commands Must be obvious signs of respiratory distress Used after submersion Use is breathing rapidly at a rate of 26 or more Pulse ox under 90% |
|
|
What are the contraindications of CPAP?
|
Do not use in respiratory arrest, hypoventilation, pneumothorax or chest trauma, tracheostomy, gi bleeding or vomiting, AMS, mask wont seal
|
|
|
What is positive end expiratory pressure (PEEP)?
|
Pt exhales against resistance
Pressure determined by a valve Manually adjusted by a mamometer Prefixed settings Therapeutic range of 5-10 cm of h2o Some have continuous flow vs demand Most deliver fio2 of 30 to 35% Some can deliver up to 80% |
|
|
What are the complications with PEEP?
|
Causes claustrophobia
Can cause a pneumothorax or barotrauma Increased thoracic pressure can cause hypotension and impeded venous return to the heart (preload) Possible aspiration |
|
|
What are the considerations with gastric distention?
|
Can cause aspiration
Pushes diaphragm upwards limiting the space for the lungs to expand Shows resistance with BVM ventilations |
|
|
What does a gastric tube do and when should its use be considered?
|
Removes air and liquid from the stomach and can allow charcoal to be administered through tube
Consider if pt needs positive pressure ventilation for extended periods of time and not tubed If gastric distention interferes with ventilations Do not use if airway isnt patent or esophogeal disease |
|
|
What is a nasogastric tube, what are its indications and how is it used?
|
In through nose to nasopharynx to esophagus to stomach
Can be used for gastric lavage when stomach needs to be decontaminated after toxic ingestion Always preoxygenate Do not use if there are facial injuries or skull fracturs because you might inadvertantly place tube in fracture or cranial vault Might interfer with bvm mask seal Measure from the nose to the ear to the xiphoid process Encourage the pt to swallow while insertion Confirm by auscultating over epigastrum while injecting 30 to 50 ml of air No reflux should be evident |
|
|
What is an orogastric tube, what are its indications and how is it used?
|
Preferred to nasogastic in an unresponsive pt with no gag reflex
Carries no risk of nasal bleeding and is safer to use in pt with facial trauma Can use larger tubes in case of gastric lavage Not great with conciuos pt Use post et insertion |
|
|
How do you insert a orogastc tube?
|
Place patient in a neutral position
Measure from the mouth to the xiphoid process Run the rub midline from the oropharynx to the stomach Auscultate over the esophagus Push 30 to 50 ml of air Observe for gastric contents in tube Listen to lung fields to ensure et tube is not displaced Suction and secure |
|
|
What is a laryngectomy?
|
Removal of the larynx
Called a neck breather creates a stoma - midline and anterior |
|
|
What is a partial larygectomy?
|
A portion of the larynx is removed and the pt breaths through the stoma, nose and mouth
|
|
|
How do you suction a stoma?
|
Pt has less efficient cough and needs more assistance
Limit to 10 second Preoxygenate Inject 3 ml of saline Instruct pt to exhale Insert until resistance is felt @ 12 cm |
|
|
How do you ventilate a stoma?
|
Mouth to stoma or BVM
Use a peds mack Seal nose and mouth to prevent leakage Release nose and mouth on exhalation 2 rescuers one for seal and one for squeeze Use french tip, soft catheter, before ventilation and only in partial laryngectomy |
|
|
What is stenosis?
|
Tube becomes dislodged and narrowing of the stoma occurs causing swelling of the tissue
|
|
|
How do you deal with dental appliances?
|
if they fit leave them in place because it keeps the shape of the face and structures in tact, which helps with seal
|
|
|
How do you suction a pt with facial trauma?
|
Highly vascular and bleeding could be an issue
Suction for 15 seconds, ventilate for 2 minutes and continue until tube is clear and secured Use jaw thrust Be aware of stridor could indicate laryngeal edema |
|
|
What are the two reasons for advanced airway placement?
|
Failure to maintain patent airway and failure to adequately oxygenate and ventilate
|
|
|
What are the 6 types of ET tube methods?
|
Orotracheal
nasotracheal Digital intubation Ttransillumination Face to face Retrograde |
|
|
What are 5 types of intubation airways?
|
King LT
Laryngeal Mask (LMA) Cobra Combitube Cricothyrotomy |
|
|
5 ways of predicting a difficult airway
|
History
Anatomical Recent surgery or trauma Neoplastic Cancer |
|
|
What is LEMON and what does it stand for?
|
Assessment for difficult airway placement
Look externally Evaluate 3-3-2 Mallampati Obstruction Neck Mobility |
|
|
What are you looking for when assessing for ET placement?
|
How difficult it will be. Does the pt have a short neck, obese, dental conditions
|
|
|
What is the 3-3-2 rule?
|
3- Open the mouth 3 finger widths (5cm), less than 3 indicates difficult airway
3- Length of mandible 3 finger widths, measure the tip of the chin to the hyoid bone, smaller mandibles have less room to move tongue out of the way 2- At least 2 finger widths, Distance from hyoid bone to the thyroid notch |
|
|
What is the Mallampati classification?
|
It predicts complications. Evaluate the oropharyngeal structures with the pt seated upright with legs dangling and fully open their mouth. Not valuable in conscious pt only good if they loose consciousness
|
|
|
What type of obstructions are you looking for when evaluating airway placement ability?
|
Foreign bodies, obesity, hemotomas and masses
|
|
|
What is the idea neck position for advanced airway Placement and what issues can you run into?
|
"Sniffling" position which is slightly elevated and extended
Problems with trauma and elderly. If they cant be placed in this position, et may be difficult |
|
|
What is Endotracheal Intubation?
|
Passing of a tube through the glottic opening and sealing the tube with a cuff inflated against the tracheal wall
|
|
|
What are the advantages of ET?
|
Provision of a secure airway, Protection from aspiration, alternative medication route as a last resort
|
|
|
What are the disadvantages of ET??
|
Special equipment needed, physiological functions of the upper airway bipassed
|
|
|
What are some complications associated with ET?
|
Bleeding, hypoxia, laryngeal swelling, laryngospasm, vocal cord damage, mucosal necrosis, barotrauma, gastric distention
|
|
|
Name the parts of the ET equipment
|
Laryngoscope handle and blade
10 cc syringe Tube Cuff with a one way valve Pilot balloon with inflamation port Distal tip with a murphy's eye |
|
|
What is the Murphy's eye?
|
Distal end of the tube enables ventilation even if the tip becomes occluded with blood, tracheal wall etc
|
|
|
What are the sizes of the ET tubes?
|
From 2.5 to 9 cm diameter
Lengths 12 to 32 cm Distal cuffs from 5-9 cm not in childrens Women 7 to 8 Men 7.5 to 8.5 Children 2.5-4.5 without balloons |
|
|
Why are there no distal cuffs on tubes to intubate children?
|
They have a funnel shaped cricoid ring that forms an anatomical seal with the tube
|
|
|
What is a good approximation of the glottic opening?
|
The internal diameter of the nostril
|
|
|
What is a good approximation of the airyway size?
|
The diameter of the patients little finger
|
|
|
What types of laryngoscope blades are there and what do you need to know about them?
|
Miller - straight blade used to lift floppy epiglottis, extends beneath and lifts, used in children
Mac - curved blade, conforms to the tongue and the pharynx places in the valeculla instead of beneath the epiglotis Sizes 0-4 Peds 0,1,2 Adults 3 and 4 "Tight, white and bright" |
|
|
What are Magill forcepts?
|
They are clamps that are used to remove airway obstructions and guide the ET tube tip through the glottic opening
|
|
|
What are the indications for using an advance airway?
|
Airway control as the response of coma, respiratory arrest and/or cardiac arrest, ventilatory support before impending failure long term, absence of gag reflex, traumatic brain injury, unresponsive, airway compromise from burns or trauma ,last resort medication administration
|
|
|
What are the contraindications of using an advanced airway?
|
Intact gag reflex, cant open the mouth, cant visualize the glottic opening and copious secretions
|
|
|
What do you need to do to prepare for intubation?
|
Preventilate the patient with 100% o2 and get a pulse ox reading of 95 to 100%, get the proper sized tube, check that the cuff inflates with 10 cc of air, and make sure your blade is tight bright and white
|
|
|
Why do you preoxygenate before intubating?
|
Use the bvm with 100% o2, for apneic or hyperventilating pt preoxygenate for 2 to 3 minuts, forced apnea will occur from the intubating and may cause hypoxia which will occur suddenly or slowly
|
|
|
What is the proper positioning for the pt for intubating?
|
The 3 axis of the mouth, pharynx and larynx should be aligned on the same plane. Optimal is the "sniffling" Position where the neck is extended a at the c6 and c7 in a 30 degree angle. Extend and evelate the occiput 2.5 to 5 cm
|
|
|
What do you look for when inserting the blade?
|
Vocal cords are white fiberous bands that lie vertically within the glottic opening
|
|
|
What is a Gum Bougie?
|
A flexible tube that is @ 1cm in diameter and 60 cm long. Place a 30 degree bend at the tip and insert into the glottic opening without damaging the tracheal walls. Slide the tube over the bougie into the trachea for placement and then remove the bougie.
|
|
|
How do you insert the tube?
|
Pass from the rt side of the mouth, continue to insert until the proximal end of the cuff is 1 to 2 cm past the vocal cords. Do not pass the tube down the blade.
|
|
|
What is the BURP maneuver?
|
Backward, upward, rightward and apply pressure to the lower third of the thyroid cartilage. Improves the glottis and the vocal cords
|
|
|
What are the ventilation rates for an apneic patient and one in cardiac arrest?
|
Adult apneic with a pulse 1 breath ever 5 to6 seconds, 10 to 12 breaths a minute
Pediatric apneic with a pulse 1 breath every 3 to 5 seconds, 10 to 12 breaths a minute If in cardiac arrest 1 breath every 6 to 8 seconds, 8 to 10 breaths a minute |
|
|
What are the 5 ways you check ET placement?
|
Observe the vocal cords
See if there is condensation in the tube Auscultate over the apices for + breath sounds and over the epigastrum for absent sounds Apply the ETco2 detector and see if changes from purple to yellow Attach wave form capnography |
|
|
What is indicated if you only hear breath sounds over the rt side of the chest?
|
The ET tube has been inserted to far
|
|
|
What are the 2 types of esophogeal detector devices?
|
A bulb and a syringe
|
|
|
How do you use a syringe to detect placement of ET tube?
|
Attach to the end of the tube, withdraw the attached plunger to create negative pressure. If the tube is in the trachea the syringe will remove air and the plunger wont move when released. If the tube is in the esophagus a vacuum will be created and the plunger will move when released
|
|
|
How do you use the bulb to detect ET tube placement?
|
Squeeze the tube and then attach to ET if the bulb remains collapsed and inflates slowly than the tube is in the esophgus. if the bulb briskly inflates then the tube is in the trachea
|
|
|
What is the average depth of the et tube?
|
21 to 25 cm
|
|
|
What is another name for a nasotracheal intubation and what must be present?
|
Blind intubation and the pt must have spontaneous breathing
|
|
|
What are the indications for Nasotracheal intubation?
|
Pt must be breathing spontaneously with need for ventilatory assistance and/or the pt is responsive with AMS and an intact gag reflex with COPD, asthma or pulmonary edema
|
|
|
What are the contraindications of Nasotracheal intubation?
|
Apneic pt in respiratory or cardiac arrest, head trauma, CSF drainage, anatomic abnormalities (deviated septum, nasal polyps), blood clotting issues
|
|
|
What are the advantages of nasotracheal use?
|
Responsive and breathing, lower risk of vomiting, intact gag reflex, no blade needed, no fulcrum of the teeth, can be used on a pt with a clenched jaw, sniffling position isnt needed, easy to secure and no tube biting
|
|
|
What are the disadvantages of nasotracheal tube?
|
It is a blind technique, you cant visualize the vocal cords, and it is harder to confirm placement
|
|
|
What complications can occur with the nasotracheal tube?
|
Bleeding from the vascular tissues of the nose which could lead to aspiration, might cause vomiting, use a vasoconstricting agent in nose first
|
|
|
What equipment is used in nasotracheal intubation?
|
Use an ET tube 1 to 1.5 smaller than for orotracheal, tube should be slightly smaller than the rt nostril, Use an ENDOTROL tube which is more flexible with a trigger, When you pull the trigger it moves the tip of the rube anteriorly and increase the tube curvature (no need for stylet), movement of air helps to confirm placement
|
|
|
What two devices help to confirm nasotracheal placement?
|
Humid Vent One attaches to the tube to prevent secretions fro being expelled.
BAAM (Beck airway airflow monitor) that has a whistle attched to the end of the tube which makes a nose when air goes in and out |
|
|
How do you place the nasotracheal tube?
|
Use spontaneous respirations
Advance the tube as the pt inhales which is when the vocal cords are the widest Insert in the rt nostril, the curvature of the tube with correct the orientation If you use the left nostril, rotate the tube 180 degrees as it enters the nasopharynx Aim the tip toward the ear not the eye Follow the nasal cavity floor Position the tube over the glottic opening so the pt inhales the tube Move the pt head to ensure optimal placement Instruct the pt to take a deep breath and advance the tube causing negative pressure |
|
|
What is Digital intubation?
|
Only use if traditional methods are not available
Also called blind or tactile intubation Directly palpate the glottic structures Elevate the epiglottis with index finger while advancing the tube Do not use with an apneic patient |
|
|
What are the indications for digital intubation?
|
Dont have or a broken laryngoscope
All other efforts have failed Confined spaces Obese patients or patients with short necks Copious secretions Cant move the head or trauma No visible landmarks |
|
|
What are the contraindications of digital intubation?
|
Intact gag reflex
Responsive patient Breathing patient |
|
|
What are the advantages of digital intubation?
|
No laryngoscope needed
Can use if you cant see the vocal cords Can be used in a trauma since the patient doesnt need to be in a sniffling position |
|
|
What are the disadvantages of digital intubation?
|
You have to put your fingers in the mouth and you could get bitten
Can only used in unresponsive patients, apneic with a bite block Infections Need long dexterous fingers |
|
|
What equipment is used with digital intubation?
|
Stylet
Etco2 detector Tube securing device Bite block |
|
|
What are the 2 tube configurations needed with digital intubation?
|
Open J - with the stylet, form a J shape with the distal end
U Handle - bend the tube into a U shape with the proximal half in a 90 degree angle toward the dominant had |
|
|
What is your and the pt position for digital intubation?
|
Intubator should be a the left side of the head and the pt doesnt need to be in the sniffling position (good for trauma)
|
|
|
What is the digital intubation technique?
|
Preoxygenate
Make sure the tube is 1 to 1.5 times smaller than use din orotracheal intubation Use index finger as a leverage point Bend the tube appropriately Insert bite block and insert sideways toward molars Insert middle finger of left hand into the right side of the mouth Insert tube alonfg te left side of the index finger and guide the tip toward the glottic opening Pass the tube @ 2inches beyond the finger and stabilize Push 5 to 10 cc of air into distal cuff |
|
|
What is trans-illumination intubation?
|
There is a bright light source placed inside the trachea that emits bright will circumscribed light that is visible on the outside of the trachea and external soft tissue
|
|
|
What is a lighted stylet?
|
A malleable stylet with a bright light source at the distal end
|
|
|
What are the indications for trans-illumination intubation?
|
When all other means have failed
|
|
|
What are the contraindications of trans-illumination intubation?
|
Gag reflex intact
Airway obstruction Consider the amount of soft tissue over trachea, might not work in obese patients or those with short necks Stylet must fit in the ET tube which doesnt occur in tubes smaller than a 6.0 indicating that this method wont work with pediatrics |
|
|
What are the advantages of trans-illumination intubation?
|
No larygoscope needed
Adds visual parameters Dont need to see the glottic opening Can pass through copious secretions No sniffling position needed as in trauma |
|
|
What are the disadvantages of trans-illumination intubation?
|
The equipment might not be available and wont work in brightly lit areas
|
|
|
What are the complications of trans-illumination intubation?
|
Misplacement into the esophagus
|
|
|
What is the technique of trans-illumination intubation?
|
Position the stylet in the tube but not beyond the distal end
Bend the tube into the proper shape with a 90 degree angle at the cuff which acts as a pivot point so the light will be in the correct place Place the patient in a neutral position with the neck slightly extended which moves the epiglottis Displace the jaw with thumbs and fingers With the lit stylet in dominant hand insert the tube midline with tip directed to the laryngeal prominence Goal is to lift the epiglottis with the tube/stylet combo The light should be visible at the midline of the neck with a tightly circumscribes light below the thyroid cartilage Once the light is visible below the thyroid cartilage advance the tube 2 to 4 cm into trachea and stablize with dominant hand Withdraw the lit stylet Check placement the same way you check for orotracheal placement |
|
|
What is Retrograde intubation and how is it performed?
|
Only use when other methods have failed and when protocols are in place
A needle is placed percutaneously with in the trachea via the cricoid membrane Wire is place toward the head through the needle upward through the trachea into the mouth The wire is visualized and secured The tube is then placed over the wire and guided into the trachea Remove the wire |
|
|
What are the indications for retrograde intubation?
|
Upper airway obstructions
Copious secretions Failure to intubate with less invasive methods |
|
|
What are the contraindications for retrograde intubation?
|
Lack of familiarity with the procedure
Laryngeal trauma Unrecognizable or distorted landmarks Clotting disorder Hypoxia |
|
|
What are the complications with retrograde intubation?
|
Hypoxia
Cardiac dyrythmias Medical/mechanical trauma Infections ICP |
|
|
What is Face to Face intubation?
|
AKA Tomahawk
Intubation with medics face at the same level as the patients face when other positions are not possible |
|
|
How do you perform a face to face intubation?
|
Similar to orotracheal
No need to put the patients head in a sniffling position Manually stabilize the head by another medic With the Mac blade held in the right hand with the blade facing downward (like a hatchet) and the ET tube in the left hand Insert the blade in toward the right and sweep to the left with vocal cords visualized Pull mandible down to see better |
|
|
What is the percentage of failed intubation and what are the reasons an intubation fails?
|
About 5%
Failure to maintain acceptable o2 saturation during or after intubation A total of 3 failed attempts Inexperienced intubator |
|
|
What is tracheal suction?
|
Passing of a suction catheter into the tracheaobronchial area to remove pulmonary secretions
|
|
|
What are the complications with tracheal suctioning?
|
Avoid if you can and only use if secretions wont allow for ventilation
Can cause arrhythmia or cardiac arrest |
|
|
What is the procedure for tracheal suctioning?
|
Use a soft tip (french or whistle tip) catheter
Preoxygenate for 2 to 3 minutes Inject 3 to 5 ml of sterile h2o Insert the catheter until the tip meets resistance Suction while the tube is being extracted Suction for no more than 10 seconds |
|
|
What is field extubation?
|
Process of removing the ER tube
Consider when patient is unreasonably intolerable, combative, or gagging Better to sedate than extubate Contact medical control |
|
|
What are the risks associated with extubation?
|
Patient wont be able to protect his own airway
Laryngospasm or swelling Dont so if you cant reintubate Can cause reoccuring respiratory failure if the patient cant protect his airway |
|
|
What is the procedure for extubation?
|
Explain to the patient what is about to happen
Have the patient sit up and face forward incase of vomiting Have suctioning equipment ready Deflate the distal cuff of the ET tube as the patient exhales to avoid aspiration On the patients next exhalation remove the tube anatomically in one smooth motion |
|
|
When do you intubate a pediatric patient?
|
Only when BVM ventilations arent adequate
|
|
|
What are the indications for pediatric intubation?
|
Cardiopulmonry arrest
Respiratory arrest or failure Traumatic brain injury Unresponsive Inability to maintain a patent airway Need for prolonged ventilation Last line medication administration |
|
|
What are the anatomic differences between pediatrics and adults?
|
Pediatrics have a larger, rounder occiput that stay in a flexed position when supine
The tongue is larger that the mandible Epiglottis is omega shaped and floppier Trachea is shorter, smaller, narrower more anterior and superior Narrowest part of the trachea is the cricoid ring that lie below the vocal cords and funnel shaped Cant use a tube with a cuff because it could damage the tracheal cartilage or the cricoid ring |
|
|
What type and size of larygoscope blade do you use on a pediatric patient?
|
Miller is preferred due to the floppy epiglottis
If you use a Mac position the tip into the vallecula to lift the jaw and epiglottis to visualize the vocal cords Measure the blade from the mouth the the tragus Size 0 miller for a premature Size 1 miller for newborn to one year Size 2 Miller for a 2 yr old to adolescent Size 3 miller or mac for an adolescent and older |
|
|
How do you measure the length and diameter of an ET for a pediatric?
|
Measuring the length of the patient is better than going by age and weight
Formula: (age (years) + 16) / 4 Little finger diameter and the size of the nares can be used to estimate the tube size |
|
|
What are the tube size and insertion depths for pediatrics?
|
Premature 2.3-3 and 8cm
Infant 3-3.5 and 8-9.5 cm Infant to one 3.5-4 and 9.5-11 cm Toddler 4-5 and 11-12.5 cm Preschool 5-5.5 and 125-14 cm School age 5.5-6.5 and 14-20 cm Adolescent 7-8 with cuff and 20-23 cm |
|
|
Thing to know about the tubes used in pediatrics
|
Cuffed tubes not generally used on a child under 10 years unless authorized
Tubes under a 5.0 dont have cuffs Insert the tube 2-3 cm below the vocal cords If you used a cuffed tube insert it just below the vocal cords If an uncuffed tube insert the length that the tube is 3x the interior diameter of the tube: if the tube has an interior diameter of 4.0 then multiply by 3 and insert the tube to the depth of 12 cm Tubes from 2.5 to 6.0 dont have a stylet |
|
|
Pediatric intubation complications?
|
Respiratory failure and arrest are the most common causes on cardiac arrest
Stimulation of the parasympathetic nervous system can cause bradycardia Use Atropine before intubation of 0.02mg/kg to prevent stimulation of the vagus nerve which can induce bradycardia |
|
|
What is the technique for pediatric intubation?
|
Place child in the sniffling position
Apply thumb pressure on the chin Guide the tube into the trachea until the black band is positioned just beyond the vocal cords @ 2-3 cm |
|
|
How do you confirm that the ET tube is properly placed with a pediatric?
|
Check CTC
Check the pulse ETco2 detector on peds above 15 kg @ 35 lbs Use a bulb or syringe but not on peds under 20 kg @ 44 lbs |
|
|
What is the DOPE mnemonic and when should it be used?
|
Use DOPE if deterioration occurs
D - displacement - reauscultate breath sounds over the apices and epigastrum, make sure the sounds are bilateral and not over the right side, if gastric gurgling is heard remove the tube O - Obstruction - too many secretions or if there is BVM resistance - remove the tube P - pneumothorax - sounds are stronger on the left and decreased or absent on the right, use needle decompression E - Equioment failure - use 100% o2, check bvm for tears, check to make sure the o2 is being administered and replace if damaged |
|
|
What are the complications associated with pediatric intubation?
|
Unrecognized esophageal intubation and check repositioning
Could induce vomiting and cause aspiration Hypoxia from prolonged intubation attempt Damage to teeth and soft tissues or intraoral structures |
