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2011-12-03 20:12:36
Crafton Hills College RESP 131 Intubation

Crafton Hills College RESP 131 Intubation
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  1. What is included in the anatomy of the nasal cavity?
    • the external nares, septum, turbinates
    • Paranasal sinuses
  2. What is included in the anatomy of the oral cavity?
    Hard palate, soft palate, uvula, tongue, lingual tonsils, palatine folds, palatine tonsils
  3. What is included in the anatomy of the pharynx?
    nasopharynx, oropharynx, and laryngopharynx (hypopharynx)
  4. What is included in the anatomy of the larynx?
    epiglottis, cartilages, vallecula, glottis, true vocal cords, false vocal cords
  5. What is included in the anatomy of the sinuses?
    • - symmetrically paired spaces adjacent to the nasal cavity within the cranium
    • There are four sets of sinuses: Frontal, maxillary, sphenoidal, and ethmoidal
  6. The adult trachea is ______, __ to 13 cm in length & 2 to __ cm in diameter
    tubular; 10; 2.5
  7. The trachea bifurcates at the level of the ______ costal cartilage or angle of Louis (fifth or sixth thoracic vertebra).
  8. The ______ is the area where the trachea bifurcates into the left and right main stem bronchi
  9. The _____ main stem bronchus is wider and shorter than the _____.
    right; left
  10. Uvula extends from the ______ of the soft palate at the back of the mouth.
  11. This is a leaf-shaped elastic cartilage covered by a mucus membrane that attaches to the hyoid bone anteriorly and by its pointed stalk to the thyroid cartilage below.
  12. Extending posteriorly from the arytenoids to the thyroid cartilage anteriorly are the ____________.
    vocal cords
  13. The ________ encompass the corniculate and the cuneiform cartilages.
  14. The _______ lies directly posterior to the trachea.
  15. What pressure(s) will cause the esophagus to open?
    20 to 25 cm H2O in the pharynx
  16. What are the indications for endotracheal intubation?
    • AARC:
    • 1. Airway compromise
    • 2. respiratory failure (and to facilitate ventilation)
    • 3. Need to protect the airway
  17. What are the conditions requiring emergency tracheal intubation?
    • Emergency situations:
    • 1. Persistent apnea
    • 2. Cardiopulmonary arrest
    • 3. Accidental extubation of mechanically ventilated patient
    • 4. Upper airway or laryngeal edema
    • 5. Loss of protective reflexes
    • 6. Coma with increased ICP
    • 7. Massive upper airway bleeding
  18. How do you determine the assessment of need for the indications?
    • Inability to adequately protect the airway
    • Apnea
    • Hypoxemia, hypercarbia, and/or acidemia
    • Respiratory distress
    • Partially obstructed airway
    • Complete airway obstruction
  19. What conditions causes respiratory
    • - Skeletal
    • A. Congenital chest wall deformities
    • B. Crushed chest
    • - Neuromuscular
    • A. Prolonged action of muscle relaxants
    • B. Myasthenia gravis
    • C. Poisoning (botulism, persticides)
    • - Central Nervous System (CNS)
    • A. Stroke
    • B. Tumors
    • C. Trauma
    • D. Infection
    • E. Depressant drug overdose
    • - Upper Respiratory Tract
    • A. Trauma (mechanical or chemical)
    • B. Foreign bodies
    • C. Infections
    • D. Tumors
    • E. Congenital anomalies
    • - Pulmonary
    • A. Pneumonia
    • B. Tumors
    • C. Pneumothorax
    • D. Chronic obstructive pulmonary disease (COPD)
    • E. Postoperative pulmonary resections
    • F. Effusions
    • G. Bronchiectasis
    • H. Emphysema
    • - Cardiac or Circulatory
    • A. Arrest
    • B. Failure
    • C. Pulmonary embolism
  20. What are the contraindications for endotracheal intubation?
    • - when the patient�s desire not to be resuscitated has been clearly expressed and documented in the patient�s medical record or other valid legal document
    • - It is not necessary, at the time, and/or there are other methods with lesser consequences that would do the job
  21. What are the Predisposed complications of tracheal intubation?
    • Age:
    • - Young children have relatively small airways.
    • - As a result, any trauma leading to mucosal swelling will be much more serious and cause more severe airway obstruction.
    • - It is extremely important when choosing tube size to make the proper choice.
    • Sex:
    • - The female larynx is smaller than that of males of the same size, height, and age.
    • - The tendency is to use the same size for male and female.
    • Operation of Intubation:
    • - The longer the tube is in place, the greater the tissue damage in the area surrounding the inflated cuff.
    • Traumatic Intubation:
    • - Rough insertion of the tube will predispose the patient to immediate and later laryngeal complications
    • Cuff Pressure:
    • - If the tube is overinflated, this will lead to tissue damage and the possible development of tracheal stenosis.
    • - It is best to use the minimal occlusive volume (MOV) technique.
    • Vocal Cord and Tube Motion:
    • - Excessive tube motion, whether due to patient movement or the tube connections, will lead to damage to the laryngeal and tracheal mucous membranes.
    • Tube Size:
    • - Use of appropriate tube size based on the patient age, sex, and body size will avoid trauma to the larynx.
    • Physical State of Patient:
    • - A patient with a short, thick neck is more difficult to intubate than the patient with a long, slender neck and is therefore more prone to injury during intubation.
  22. What are some Traumatic-Mechanical complications of tracheal intubation?
    • - During Intubation:
    • Fracture-luxation of cervical spinal column (spinal cord injury)
    • Eye trauma
    • Epistaxis
    • Tooth trauma
    • Retropharyngeal dissection
    • Subcutaneous, mediastinal emphysema
    • Perforation of esophagus or pharynx
    • Laceration of pharynx or larynx
    • Arytenoid dislocation
    • Aspiration (blood, tooth, laryngoscope bulb, gastric contents, tumor tissue, adenoid)
    • Pneumothorax
    • Esophageal intubation (gastric distention)
    • Bronchial intubation (hypoxemia)
    • - With tube in place:
    • Fracture-luxation of cervical spinal cord
    • Ventilatory obstruction
    • Rupture of trachea
    • Emphysema, pneumothorax
    • Ruptured cuff
    • Tracheal bleeding
    • Aspiration
    • - During Extubation:
    • Trauma to glottis by inflated cuff
    • Difficult or impossible extubation
    • Ventilatory obstruction
  23. What are some Reflex complications of tracheal intubation?
    • - During Intubation:
    • Laryngeal spasm
    • Bronchospasm
    • Cardiac arrythmias
    • Arterial hypotension
    • - During Extubation:
    • Laryngeal spasm
  24. What are some possible Late complication of tracheal intubation?
    • Sore jaw
    • Sore throat, dysphagia
    • Sore skeletal muscles
    • Paresis or paralysis of tongue
    • Paresis or paralysis of vocal cords
    • Lingual nerve injury
    • Ulceration of lips, mouth, pharynx
    • Laryngitis, sinusitis, respiratory tract infection
    • Stricture of nostril
    • Laryngeal edema
    • Laryngeal ulceration
    • Laryngeal granulomas or polyps
    • Synechiae of vocal cords
    • Laryngotracheal membranes and webs
    • Perichondritis or chondritis of larynx
    • Tracheal stenosis
  25. What are the predisposing factors of Intubation?
    • Age:
    • - Young children have relatively small airways.
    • - As a result, any trauma leading to mucosal swelling will be much more serious and cause more severe airway obstruction.
    • Sex:
    • - The female larynx is smaller than that of males of the same size, height, and age
    • Operation of Intubation:
    • - The longer the tube is in place, the greater the tissue damage in the area surrounding the inflated cuff
    • Traumatic Intubation:
    • - Rough insertion of the tube will predispose the patient to immediate and later laryngeal complications
  26. What are the precautions, hazards and/or complications of orotracheal intubation?
    • Failure to establish a patent airway, to intubate the trachea, or recognize esophageal intubation
    • Trauma to nose, mouth, tongue, pharynx, larynx, vocal cords, trachea, esophagus, spine, eyes, teeth
    • Aspiration and/or infection (pneumonia, sinusitis, otitis media)
    • ET tube problems (cuff, pilot balloons, kinking, occlusion, extubation)
    • Autonomic or protective neural responses (hypo/hypertension, brady/tachycardia, dysrhythmias, laryngospasm, bronchospasm)
    • Bleeding
  27. What are the possible hazards/complications related to emergency ventilation?
    • Inadequate O2 delivery
    • Hypoventilation or hyperventilation
    • Gastric insufflation and/or rupture
    • Barotrauma
    • Reduced venous return
    • Aspiration, vomiting
    • Prolonged interruption of ventilation for intubation
    • Movement of unstable cervical spine
  28. What is the proper procedure for orotracheal intubation?
    • Step 1: Verify order
    • Step 2: Assemble and Check Equipment
    • Step 3: Position the Patient
    • Step 4: Preoxygenate and Ventilate the Patient
    • Step 5: Insert the Laryngoscope
    • Step 6: Visualize the Landmarks (Glottis)
    • Step 7: Displace the Epiglottis
    • Step 8: Insert the Tube
    • Step 9: Assess and Confirm Tube Position
    • Step 10: Stabilize the Tube
    • Step 11: Confirm Tube Placement
  29. What equipment is needed to perform orotracheal intubation?
    • Oxygen flowmeter and tubing
    • Suction apparatus
    • Flexible suction catheters
    • Yankauer (tonsillar) tip
    • Manual resuscitator bag and mask
    • Oropharyngeal airway(s)
    • Laryngoscope with assorted blades (2)
    • Endotracheal tubes (3 sizes)
    • Tongue depressor
    • Stylet
    • Stethoscope
    • Tape
    • Syringe
    • Lubricating jelly
    • Magill forceps
    • Local anesthetic (spray)
    • Towels (for positioning)
    • CDC barrier precautions (gloves, gowns, masks, eyewear)
  30. How do you assemble and check the equipment used to perform orotracheal intubation?
    • Assemble suction equipment, both catheters and Yankauer, and check suction pressure prior to intubation.
    • Obtain laryngoscope with preferred blade of proper size and check the brightness and tightness of light bulb.
    • Obtain the size tracheal tube size desired, one larger and one smaller.
    • Inspect all three tubes:
    • - Inflate cuff to check for leaks
    • - With the cuff inflated, check internal diameter to make certain it is not compromised. Also, check for symmetrical cuff inflation.
    • Lubricate tip and cuff of tube with water-soluble lubricant. Have additional lubricant available for other two tubes.
  31. What is the proper positioning of the head for the patient?
    The head must be placed in the �sniffing� position, flexed at the neck and extended at the junction of spine and skull (atlanto-occipital joint).
  32. What are the landmarks, in order of visualization, during intubation?
    • Uvula
    • Epiglottis
    • Arytenoids (corniculate and cuneiform cartilages)
    • False vocal cords (vestibular folds)
    • True vocal cords
    • It should be remembered that it is not necessary to visualize all of the vocal cords
  33. What is the proper positioning of the laryngoscope blade, their uses, and their differences?
    • To achieve orotracheal intubation, hold laryngoscope in left hand, introduce the blade into right side of mouth, and displace the tongue to the left.
    • Is designed for the right handed person only (lefty's have to learn how to use right hand)
  34. What is the proper insertion of the tube?
    • The tube tip should be introduced into the right corner of the mouth and passed along an axis which intersects the line of the laryngoscope blade at the glottis
    • The tube is directed toward the glottis with the bevel parallel to the cords
    • Should there be any movement of the vocal cords, the moment that they are open widest should be chosen for insertion of the tube
    • The tip of the tube should be seen passing between the cords and then advanced until the cuff has passed the cords by 2 to 3 cm
  35. How do you assess and confirm tube position and placement?
    • Auscultate, listen for equality of breath sounds as the patient is being manually ventilated with oxygen.
    • Air movement or gurgling sounds over the epigastrium indicate possible esophageal intubation.
    • Observe the chest wall for adequate and equal chest expansion
  36. What do you do to monitor for assessment of Outcome for endotracheal intubation?
    • Tracheal intubation is confirmed by detection of CO2 in the exhaled gas
    • Tracheal intubation is confirmed by endoscopic visualization of the carina or tracheal rings through the tube
    • The position of the endotracheal tube in the airway and the depth of insertion should be appropriate on chest radiograph
    • Ideally the tip of an endotracheal tube should be positioned in the trachea about 5 cm above the carina
  37. How do you stabilize an E.T. tube?
    • This may be done once placement is confirmed by auscultation.
    • Do not secure the tube until you have assessed placement by the recommended methods.
    • Secure the tube to the skin above the lip and on the cheeks using tape while holding the tube in its correct position (check centimeter depth marking)
  38. What type of blade is this?
  39. What type of blade is this?
  40. What type of blade is this?
  41. What size of Laryngoscope blade should be used on a Neonate, Premature?
  42. What size of Laryngoscope blade should be used on an Infant?
  43. What size of Laryngoscope blade should be used on a Child?
  44. What size of Laryngoscope blade should be used on a Medium Adult?
  45. What size of Laryngoscope blade should be used on a Large Adult?
  46. What are the correct types of blade and your reason, when intubating a neonatal patient?
    a Miller blade, because they often have a long, pliable epiglottis which is difficult to elevate with a curved blade inserted into the vallecula
  47. What is the correct size tube for an average adult male?
    8.5-9.5 mm I.D.; 37-40 French
  48. What is the correct size tube for an average adult female?
    8.0-8.5 mm I.D.; 34-36 French
  49. If a Neonate is < 800 grams, what size tube should be used?
    12 French 2.4 mm I.D.
  50. If a Neonate is < 2,000 grams, what size tube should be used?
    14 French 3.0 mm I.D.
  51. If a Neonate is < 4,400 grams, what size tube should be used?
    16 French 3.5 mm I.D.
  52. What is the depth in centimeters that a tube should be placed for an adult?
    23 cm from the teeth to just above the carina
  53. What is the depth in centimeters that a tube should be placed for a neonate?
    • 2.5 mm = 7 cm
    • 3.0 mm = 8 cm
    • 3.5 mm = 9 cm
  54. Crit Thinking 1. You have been asked by the nursing supervisor to supply an adult intubation tray for the emergency roon. List all the equipment that you would recommend.
    • 10 mm syringe
    • Adult, pediatric, and infant E.T. tubes
    • Batteries
    • Cloth-tape
    • CO2 detector
    • Gloves
    • Laryngoscope with Miller and Macintosh blade
    • LTA kit or local anesthesia
    • Magill forceps
    • A manual resuscitator with bag mask valve device and various masks
    • Normal saline solution
    • Oropharyngeal airways
    • Oxygen connection tubing, oxygen nipple adapter, and flow-meter
    • Oxygen Gas Source
    • ScissorsSpare bulbs
    • Stylets
    • Suction catheters
    • Suction source
    • Tincture of benzoin
    • Water-soluble lubricant
    • Yankauer
  55. Crit Thinking 2. When would a topical anesthetic be indicated during the intubation procedure? What anesthetics can be used?
    • For patients prone to hypersensitive airways, or who have a strong cough or gag reflex – elective intubation where patient is alert
    • Zyloccaine (most commonly used).
  56. Crit Thinking 3. In a restless, fighting patient requiring immediate oral intubation, what pharmacological agent(s) could be used to facilitate intubation?
    A sedative such as Valium or Morphine, with or without neuromuscular blocker, such as Succinylcholine (Anectine is brand name), or Vecuronium (Norcuron).
  57. Crit Thinking 4. Describe in specific radiologic terms the proper location of an endotracheal tube.
    2-5 cm above carina between 2nd and 3rd intercostal space, at level of aortic knob
  58. Crit Thinking 5. The emergency medical technicians have brought in a 65-year-old victim in cardiac arrest. The patient had been ventilated with a manual resuscitator and mask. As you attempt to ventilate, the patient vomits.
    • - A. What would be your immediate actions?
    • 1.Remove the mask
    • 2.Turn the patient to the side as a unit
    • 3.Scoop out the mouth with a finger sweep
    • 4.Suction
    • 5.Resume ventilation
    • - B. During your next attempt to intubate, you observe a large piece of undigested steak blocking your view of the glottis. How would you clear the airway, and what equipment would be needed?
    • Attempt finger sweep
    • If unsuccessful, use Magill forceps