12/17/08

Nasotracheal Intubation

• Blind
• Pt must be breathing spontaneously
• Indications
  • Conscious patients
  • Possible spinal injury
  • Trismus (clenched teeth)
• Contraindications
  • Head injury
• Equipment
  • Smaller size tube
  • No scope
• Technique
  • Preoxygenate
  • Advise to inhale
  • Lube with KY
  • Aim tip towards ear
  • Position just above glottis opening
  • Auscultate and otherwise confirm placement

Digital Intubation

• No scope
• Blood
• Bite block
• Left hand open epiglottis using index and middle fingers along right side of mouth, advance tube with right hand along left side of mouth
• Pass tube 2 inches past your fingers
• Use bite block
• Not for peds

   

ET Suction

• Sterile technique
• May cause arrhythmias and vagal response
• Avoid unless causing obstruction
• Pre and post oxygenate
• Pour sterile water down ET tube
• Introduce catheter and engage suction on way out for <15 sec

Extubation

• Hyperogygenate
• Have equipment
• Confirm responsiveness
• Lean forward
• Suction oropharynx
• Deflate cuff
• Extubate as pt coughs or exhales

Pediatrics

• Miller blade (floppy epiglottis)
• Preemie – size 0
• Size of pinky or >1 year age/4+4= size
• Use Braslow tape
• Smaller size are cuffless
• Curve stylet upwards, airway more anterior and superior
• Can cause parasympathetic response – counter with Atropine Sulphate
• Sniffing position
• Record depth of tube
• Confirm proper placement
• Breath sounds travel easily in children

DOPE (troubleshooting a deteriorating patient)

• Displacement – re-auscultate
• Obstruction – suction
• Pneumothorax – absent sounds on one side
• Equipment failure –

CPAP (Continuous Positive Airway Pressure)

• Used in CHF, obvious difficulty, oxygenated (maintain own airway)- increases pressure in the alveoli to keep fluid in vascular space and out of lungs
• Contraindications
  • AMS
  • No patent airway
  • COPD
  • More…
• Connect to o2 tank. Set pressure to 5cm at minimum – increase to 10cm max.
• Introduce slowly to patient

Chest decompression

• Evacuate air in the pleuritic space
• Indications (all required)
  • JVD
  • Obvious dyspnea
  • Tracheal deviation

Procedure

• Landmark: 2^nd intercostal space – (above third rib – below ribs contains vasculature and nerves)
• Listen for air escape
• Create a flutter valve – use a glove finger

12/7/08

Patient Airway – No airway, no patient

Upper Airway – Major function, warmer, filter and humidly air.

Turbinates – three bony shelves in nasal passage – increases surface area

Sinuses – Cavities formed by the cranial bones

• Fractures of these bones may cause cerebrospinal fluid to leak from the nose or the ears.
• Significant bleeding from sinus fractures
• Prevent contaminants from entering the respiratory tract

LeFort Fractures – facial fractures

Hyoid bone, beneath mandible, anchors tongue, only non articulating bone in the body, attached with tendons

Palate – Hard and Soft

Adenoids and tonsils : lymphatic tissue that filter bacteria, severe swelling can cause airway obstruction

Vallecula – between base of tongue and epiglottis –It is an important landmark in intubation;

Larynx – divides upper and lower airways

• Anatomy – In order, Superior to inferior;
  • Laryngeal prominence (Adam’s Apple)
  • Thyroid Cartilage (V shape, shield) –Directly anterior to glottic opening
  • Cricothyroid membrane – site for surgical access to airway – bordered laterally and inferiorly by thyroid gland
  • cricoid cartilage – lowest portion of larynx – first ring of trachea, only upper airway structure that forms a complete ring
• Interior Airway Structures
  • Glottis – space between vocal cords – narrowest point of adult airway
  • Arytenoid cartilage – posterior attachment of vocal cords
  • Pyriform fossae – Two pockets of tissue on the lateral borders of the larynx – may cause tenting if tube placed there inadvertently

     

• Sellick Maneuver or BURP (Backward Upward Rightward Pressure)used to manipulate the larynx into view during intubation
• If you don’t see landmarks, you may be looking down the esophagus, pull back on laryngoscope and epiglottis should come into view

Lower airway

• Externally from 4^th cervical vertebrae to xyphoid process
• Trachia,(enters lung at hilum) Bronchi, smaller bronchi, bronchioles, alveoli (functional site for respiration (i.e. gas exchange)
• Trachia bifurcates at the Carina
• R has 3 lobes, L has 2 lobes
• Visceral pleura and parietal pleura
• Ventilation vs Respiration
• Shunting (blood bypasses the alveoli and does not exchange gasses)
• Alveoli lined with surfactant
• Atelectasis
• Avg adult 6L of air volume
• Tidal volume (Vt), 5-7Ml/kg adult, 6-8mL/kg (500 mL)
• Alveolar volume = tidal volume minus dead space(Vd)
• Minute volume (Vm)– amount of air that passes over a minute (Vt – Vd x Resp Rate)
• Functional reserve capacity – amount you can force out in single exhalation – (about 1200mL)
• Ventilation- Inhalation 1/3^rd Exhalation 2/3

Regulation of ventilation

• Primary reglated by PH levels in CSF
• Phrenic nerve- innervates the diaphragm
• Intercostals nerves – innervates the intercostals muscles
• Hering-Bruer reflex –stretch receptors tells the brain that the chest wall is fully expanded – ending inspiration
• Apneustic center – increase respiratory rate
• Pneumotaxic center – counters by inhibiting inspiration
• Chemoreceptors – monitor CO2, O2 and PH levels
• Respiratory drive – primary drive – driven by CO2
• Hypoxic drive – secondary drive driven by O2 (seen in COPD patients)
• Inhalation, muscles contract, pressure decreases – move air into lungs via negative pressure
• Exhalation, muscles relax – pressure increases, air forced out of lungs (passive)

Respiration

• Diffusion
• SaO2 measures saturation of hemoglobin, can be O2 or Co2 – use a pulse oximeter
• Hypercarbia
• Hypocarbia

Abnormal CO2 Concentrations

• As metabolic rate goes up more CO2 is produced
• Hypoventilation – co2 production exceeds body’s ability to eliminate it (hypercarbia)
• Hyperventilation – co2 elimination exceeds production (hypocarbia)
• Minute volume – decreased minute volume causes a decrease in co2 elimination

ET Tube

• Sizes 5.5 up have pilot cuff –
• 5.5 and down are cuffless – for peds
• Age + 16 / 4 = tube size (pediatrics)
• Keep spo2 above 90, hyperventilate before attempts

ETT Verification

• Seeing pass through cords
• Moisture in tube
• Etco2
• Auscultate lungs and abdomen
• Esophageal detector

Tape and secure. Put an oral airway in to hold tongue and prevent biting, record placement level