Interventions-Manual Ventilation Flashcards

1
Q

The American Society for Testing and Materials (ASTM) and the International Standards Organization (ISO) recommend that manual resuscitators be capable of delivering a minimum fractional inspired oxygen of ________ with an oxygen flow of _____L/min.

A

0.85; 15

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2
Q

Little’s Area (Kiesselbach’s Plexus)

A

A highly vascular area located on the anterior aspect of the nasal septum in each nostril

Most nosebleeds will often originate from this area

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3
Q

Nasopharynx

A

In theory it is a passage for air alone

Extends from the base of the skull to the uvula

Contains pharyngeal tonsils (adenoids) and tubal tonsils

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4
Q

5 Openings to Nasopharynx

A

The nasopharynx contains 5 openings which is important during intubation as we can have infection

These openings are

  • 2 eustachian tubes
  • 2 Internal nares
  • 1 opening to the oropharynx
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5
Q

Oropharynx

A

Extends from tip of uvula to upper rim of the epiglottis

Common pathway for food and air

Contains palatine tonsils, which are commonly removed during tonsillectomy

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6
Q

Larynx

A

Conducts air into the lungs

Acts a switch mechanism to ensure that food bypasses the trachea and proceeds down the esophagus

Larynx is the most heavily sensory inervated organ in the body.

Stimulation of unaesthetized larynx causes very strong sympathetic response-HR and BP may double.

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7
Q

Cartilage of the Larynx

A

There is 9 Cartilages of the Larynx

  • 2 Arytenoid Cartilages
  • 2 Cuneiform Cartilages
  • 2 Corniculate Cartilages
  • 1 Thyroid Cartilage
  • 1 Cricoid Cartilage
  • 1 Epiglottis Cartilage
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8
Q

Trachea

A

When we are intubating we want to go into the trachea we have to manipulate things because if we don’t manipulate things then the path of least resistance for intubation is through the esophagus

If doing an emergency cricoid cartilage you don’t have to go through the cric you can go through a ring that is not continuous but C shaped

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9
Q

Thyroid Cartilage

A

Thryroid cartilage forms anterior wall of larynx

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10
Q

Trachea Measurements

A

Extends from the larynx to the main stem bronchi

12-15 cm in length

~2 cm in diameter

16-20 C-shaped cartilage rings

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11
Q

Carina Topography

A

Carina sits behind “angle of Louis” anteriorly and level of T4 posteriorly

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12
Q

Loss of Airway Patency

A

Causes of loss of airway patency can be divided into 2 general categories

Central Causes-Any condition that leads to a depression of the CNS (i.e. <8)

Peripheral Causes-Airway obstruction caused by something originating outside the body

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13
Q

Central Causes of Loss of Airway Patency

A

When the CNS is depressed and comes from within the body

The causes of CNS depression varies

Most common cause of upper airway obstruction is the tongue

Includes-Decrease in cardiac output, TBI, Anesthesia, drug overdose, hypoxemia/hypercarbia, hypothermia/hyperthermia, metbolic derrangements

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14
Q

Central Causes

Decrease in Cardiac Output

A

Acute myocardial infarction (MI)

Cardiac tamponade-But when cause through a infection it is considered to be a peripheral cause

CHF

V fib or V tach

Hypovolemic Shock

Septic Shock

Massive Pulmonary Embolism

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15
Q

Mechanisms of Upper Airway Obstruction

A

Decrease in tone of submandibular muscles leads to posterior displacement of tongue against the posterior pharyngeal wall

While in a comatose state the position of the chin will worsen the obstruction

C-spine adopts a semi flexed position, narrowing the distance between the tongue and posterior pharyngeal wall

Epiglottis gravitates towards the larynx partially occluding the airway

Negative pressure cause by respiratory efforts in presence of obstruction draws tongue towards the airway

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16
Q

Peripheral Causes

A
  • Peripheral causes come from outside of the body
  • Infection
  • Abscess
  • Neoplastic (carcinomas)
  • Physical and Chemical Agents
  • Thermal
  • Caustic Injuries- Can cause swelling
  • Inhaled toxins
  • Allergic/Idiopathic
  • Traumatic
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17
Q

Signs of Loss of Airway Patency

A

• Tachypnea and dyspnea • Noisy snoring respirations • Paradoxical breathing • Tracheal tug or retractions • Nasal flaring o Usually seen in babies • Expiratory Grunting o Is a compensation for collapse o Usually seen in babies o Cardiac dysrhythmias • Pressure in chest and low oxygen levels will affect the heart • Stridor • Absence of breath sounds or visible chest movement • Cyanosis o Can be misleading due to polycythemia or hypothermia o Will be check at the inside of the lips

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18
Q

Peripheral Causes-Infection

A

Viral and bacterial infection laryngotracheobronchitis (e.g. croup)

Parapharyngeal and retropharyngeal abscess

Lingual tonsillitis

Hematomas or abscess of the tongue or floor of the mouth

Epiglottitis (also known as supraglottitis)

Similar to croup but the patient will have low energy and is very serious and in this case we do not manipulate the airway

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19
Q

Peripheral Causes-Neoplastic

A

Laryngeal carcinomas Hypopharyngeal and lingual (tongue) carcinomas

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20
Q

Peripheral Causes-Physical and Chemical Agents

A

Foreign bodies Chocking something shoved up a nose Thermal injuries-Can cause swelling Caustic Injuries- Can cause swelling Inhaled toxins

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21
Q

Peripheral Causes- Allergic/Idiopathic

A

Angiotensin converting enzymes inhibitors induced angioedema

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22
Q

Peripheral Causes- Traumatic

A

Blunt and penetrating neck and upper airway trauma

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23
Q

Central Causes-Hypoxemia/Hypercarbia

A

COPD, Asthma, ARDS, Pneumonia, moderate PEs

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24
Q

Central Causes-Metabolic Derangements

A

Hypo/hyperglycemia

hypo/hypernatremia

hypokalemia (lead to heart malfunction)

metabolic acidosis

hepatic encephalopathy

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25
Q

Signs of Loss of Airway Patency

A

Tachypnea and dyspnea

Noisy snoring respirations

Paradoxical breathing

Tracheal tug or retractions

Nasal flaring-Usually seen in babies

Expiratory Grunting-Is a compensation for collapse and usually seen in babies

Cardiac dysrhythmias-Pressure in chest and low oxygen levels will affect the heart

Stridor

Absence of breath sounds or visible chest movement

Cyanosis-Can be misleading due to polycythemia or hypothermia, will be check at the inside of the lips

26
Q

Presentation of Obstructed Airway

A

Hot Potato Voice- Horse Voice

Difficultly in Swallowing Secretions

Drooling is a very serious sign

Dyspnea

STRIDOR-Means a complete obstruction is imminent

Cough

27
Q

Stridor

A

High pitched inspiratory sound

Indicated that airway has already lost at least 50% of its usual caliber

Complete obstruction may be imminent

The volume and pitch are related to the velocity of air flow-Air flow is dependent on patient’s level of consciousness and inspiratory muscle strength

Often audible but may be detected early via auscultation over the trachea-Can normally be heard without a stethoscope

If it is epiglottitis don’t place the stethoscope near the throat just keep them calm

28
Q

OPA Contraindications for Use

A

Patients with obvious oral trauma

Awake or semi-conscious patients

May cause vomiting or gagging

IMPORTANT-If a patent is awake enough to spit or tongue the device out then they are too awake for the device to be used

29
Q

OPA Sizing

A

Proper sizing

Place the airway next to the face with the flange at the mouth and the tip of the airway should reach the angle of the jaw (tragus of the ear)

30
Q

Complications of OPA

A

May cause trauma to the lips, mouth, or teeth-Rare

May cause pressure necrosis

Difficult to perform mouth care

May cause gagging and vomiting-May push the tongue back

31
Q

NPA Indications for Use

A
  • Semi-awake patients who require some airway maintenance and do not tolerate the OPA
  • Ay be used when insertion of OPA is difficult or contraindicated
  • Maybe used to facilitate deep suctioning
  • Pierre-Robin Syndrome (in neonates)
    • Micrognathia-Tiny Chin
    • Mandibular hypoplasia
32
Q

Contraindications of NPA

A

Obvious nasal trauma

Deformities of the nose

Basal fractures of the nose (Racoon eyes and battle sign)-This may indicate skull fractur but use history to help determine

Coagulation disorder-NPA can cause nosebleeds

33
Q

Complication from Use of NPA

A

If too long can enter into the esophagus causing gastric distension and hypoventilation

May cause vomiting and laryngospasm (big issue with infection) in semi-conscious patient

Injury of nasal mucous with bleeding

Sinusitis

Bypassing natural defenses

Otitis Media (ear infection)

Intubation of meninges (basal skull fracture)

Occlusion of airway by secretions

Tissue necrosis

34
Q

Manual Resuscitator

A

Hand squeezing a bag provides the mechanical force necessary to generate a positive pressure

Requires an oxygen source to deliver FiO2 greater than 0.21

In the baby and child versions they will have pop off valves

35
Q

Commonalities in Bag

A
  • Universal connector (15/22 mm)
    • This allows them all to be connected to trachs
  • Requires an O2 sources for FiO2 >0.21
    • Oxygen flow meter
    • 50 psi source
      • Wall outlet
      • Cylinder
  • Originally designed for use during CPR
36
Q

Self Inflating Manual Resuscitator

A

Does not require a compressed gas source for operation

Re-usable or disposable

37
Q

Self Infalting Resuscitator Parts

A
  • Self –inflating bag
    • (volume depends on patient population)
  • Air inlet/Oxygen Reservoir attachment site
  • Oxygen Inlet
  • Patient Outlet
  • Valve assembly
    • One way, non-rebreathing
  • Oxygen reservoir (required for high FiO2)
  • Pressure release (pop-off) valve (optional)
  • Pressure Gauge / Guage attachment site (optional)
38
Q

Classess of Non-Rebreathing Valves

A
  • Spring-Loaded
  • Diaphragm
    • Duckbill (most common)
    • Leaf-type
    • Fishmouth
39
Q

Pneumatic Resuscitators

A
  • Used when unable to bag
  • Commonalities
  • Universal connector (15/22 mm)
    • This allows them all to be connected to trachs
  • Requires an O2 sources for FiO2 >0.21
    • Oxygen flow meter
    • 50 psi source
      • Wall outlet
      • Cylinder
40
Q

Safety Mechanisms of Resuscitators

A
  • Non-Rebreathing Valve (Self-Inflating)
    • Prevents rebreathing of exhaled gases
  • High Pressure Pop-Off Valves (self-Inflating)
    • Prevents delivery of overly high pressure to patient (infant and children only)
  • Maximum circuit pressure control (T-Piece Resuscitator)
    • Will take away the variability of the pressure delivered in a breath
  • Standard 15/22 mm connectors
    • Allows for easy connection and disconnection
41
Q

Stamdard Construction for Resuscitators

A
  • Resuscitators capable of delivering FiO2 > or = 0.95
  • Must be able to operate at-Extreme temperatures and Relative humidity 40-96%
  • Deliver Vt > or equal to 600 ml into test lung for adult baggers
    • With compliance of 0.2L/cmH2O
    • With resistance of 20 cmH2O/L/sec
  • Non-rebreathing valve withstand oxygen flow rate up to 30lpm
  • If valve malfunctions due to foreign obstruction (e.g. vomitus), must be restored within 20 seconds
  • Must have standard 15/22 mm connectors
  • Adult resuscitators not have pressure limiting system
  • Resuscitators for infants and children have pressure relief valve that limits PIP to:
    • 40 +/- 10 cmH2O for children
    • 30 +/- 5 cmH2O for infants
  • When incorporating pressure limiting system, override capability must exist and must be apparent to operator
  • Resuscitator able to operate after being dropped from height of 1 meter on to concrete floor
  • Easily disassembled for sterilization and disinfection purposes
  • Should not be possible to accidentally interchange parts
    • making unit malfunction
    • not function at all
42
Q

Proper Ventilation

A

Connect bag to mask and O2

Should not use entire volume of bag

Assess for mask seal

Should feel some resistance in the bag.

Does the chest rise?

Can you hear a leak?

43
Q

Steps to improve mask seal

A

Remove mask and reseat to face

Is airway patent

Head tilt chin lift?

OPA

Suction oropharynx

Two hand mask seal

Reinserting patient’s false teeth

44
Q

Assessment of effective ventilation.

A

Goal is for visible chest rise

Chest rise and fall with ventilation

Breath sounds with ventilation

Improving SpO2

Capnograph waveform-end tidal CO2 (confirmation of intubation and can tell us about effectiveness of CPR by seeing if you are pumping enough blood through the body)

45
Q

Ventilating the Patient

A
  • 12 breaths per minute
    • Every 5 seconds
  • Target 500-600 mls for an adult
  • Ti 1.0s
    • Decrease insufflation of stomach with gentle ventilation
    • Esophageal sphincter opening pressures ~25cmH2O
46
Q

What Will Make Resuscitation Difficult

A

M.O.A.N.S.

  • M- Mask Seal
    • Bushy beards, trauma
  • O- Obesity/Obstruction
    • ↑ weight of chest, ↓ diaphragmatic excursion
    • ↑ Resistance 2° to swelling, adipose tissue
  • A- Age
    • Older than age 55 (not a hard,fast rule)
  • N- No Teeth
    • Face tends to cave in
  • S- Stiff, Snoring Hx
    • Lungs resistant to ventilation (asthma, COPD)
47
Q

Describe three major hazards associated with manual resuscitation. Which is the most common?

A
  • Delivery of excessive high airway pressure (most common)
    • Common in intubated patients
  • Defective nonrebreathing valve
    • Can cause an inspiratory leak and tidal volume escaping through the exhalation port and not delivered to the patient
  • Faulty pressure-relief valves
    • Can cause gas delivery at excessively high pressures and increases the risk of barotrauma
48
Q
  1. What is the difference between tracheotomy and tracheostomy?
A

A tracheostomy is a surgically created hole at the front of the neck into the trachea. The procedure of creating this hole and placing a tube within it (through which the patient breathes) is called a tracheotomy.

49
Q

List factors considered when determining whether the patient should have a tracheotomy/tracheostomy.

A

Indications of a tracheotomy include:

  • Upper airway obstruction or trauma
  • Continuing need for artificial airway after a prolonged period of oro/nasotracheal intubation
  • To facilitate removal of secretions from tracheobronchial tree when patient is unable to raise secretions
  • Inability to wean from artificial airway even after being weaned off of mechanical ventilation
  • Long term care patients with neuromuscular disease
  • Obstructive sleep apnea
50
Q

Briefly describe the two main methods of tracheotomy.

A

Cricothyroidotomy is a surgical incision to the trachea which passes through the cricothyroid membrane and results in the insertion of an endotracheal tube or a tracheostomy tube. Under this method, a single horizontal incision is done through the skin to the trachea.

Percutaneous dilatory tracheostomy (PDT) is the more common method of tracheotomy due to its effectiveness, simplicity, and low incidence of complications. This method is performed mostly in the ICU if the patient is in the unit and intubated for more than 7 days. PDT is performed mostly with the Ciaglia method: a guide wire is placed between the first and second or second and third tracheal rings and plastic dialators is pushed through the soft tissue until the appropriate size is met. This method is usually aided with the use of a bronchoscopy.

51
Q

Describe the four mechanisms of airway emergencies in patients with artificial airways and how to troubleshoot these situations. Which mechanism is the most common?

A

DOPE:

Displacement: Reposition (if possible) or remove tube and bag until reintubation is possible.

Obstruction: (Most Common!) Many different causes, but move patient’s head/neck to reposition, deflate cuff, suction catheter through tube, or flush tube with saline or mucus shaving device

Pressure: The pressure of the cuff on the ETT can cause issues if under-inflated or over-inflated. If under-inflated, air and secretions can leak around the cuff and cause ventilation issues. Over-inflation can cause the trachea to become inflamed and cause further ventilatory issues.

Equipment: Anything that causes a stoppage in the flow of oxygen to the patient. Check the tubing or vent to see if any kinks have developed, and have back-ups. You can also remove tube and bag patient until they can be reintubated.

52
Q

Humidification and Warming Provided by the Mouth

A

The mucosal cavity of the mouth will provide humidification and warming of inspired air

Much less efficient than nose

53
Q

Laryngopharynx

A

A passage way from the epiglottis of the esophagus to cricoid cartilage (C6)

54
Q

The patient connectors of a resuscitator valve must have which of the following inside diameter to outside diameter?

A

15:22 mm (ID:OD)

55
Q

Inability to maintain an adequate mask seal during manual ventilation will cause:

A

Lower tidal volumes to be delivered

56
Q

A reservoir on a manual resuscitator does which of the following?

A

Allows for higher oxygen concentrations to be delivered

57
Q

Compression of a 2.0 L manual resuscitator bag is not moving the patient’s chest. Possible causes include which of the following?
I. The diaphragm valve is missing
II. The mask seal is inadequate
III. The oxygen level is too low
IV. The bag volume is too small
V. The leaf valve is missing

A

I, II, V

58
Q

What is the average tidal volume delivered with one-handed compression of a manual bagger?

A

250 ml

59
Q

Compression of a 2.0 L manual resuscitator bag is not moving the patient’s chest. Possible cause(s) include which of the following?
I. Mask seal is inadequate
II. Oxygen reservoir bag is missing
III. Oxygen flow rate is too low
IV. The bagger volume is too small

A

I

60
Q

Which of the following assessments would acutely determine effective manual ventilation?

A

Chest expansion

61
Q

Which of the following would decrease gastric insufflations during manual resuscitation?

a) Deliver volumes of 1000 mls
b) Use a 0.5-sec inspiratory time
c) Limit ventilating pressures to less than 25 cmH2O
d) Squeeze the entire bag volume slowly over 1 second

A

Limit ventilating pressures to less than 25 cmH2O

62
Q

Which of the following are complications associated with the placement of an oropharyngeal airway?
I. Gagging
II. Vomiting
III. Esophageal injury
IV. Dissection of the posterior pharyngeal wall

A

I and II