Week 2 PP5

Simply explain airway anatomy (4)

• Air enters through nasal cavity or mouth, passing epiglottis

• Travels down trachea, splints into bronchi leading to each lung

• Right lung has 3 lobes, left has two - both have double layered pleural

• Bronchi branch into smaller bronchioles - exchange O2 and CO2

Explain where the larynx is located and its purpose (3)

• Anterior portion of neck

• Passageway for air between pharynx and trachea

• Critical role in breathing and protecting trachea against food aspiration

Explain the location and purpose of the vocal cords (2)

• Located inside the larynx

• Mucous membranes folds that vibrate when air passes through them

What are the parts of the vocal cords and where are they located (3)

• Supraglottic is above the vocal cords

• Glottis includes the vocal cords

• Subglottis is found below

Where is the epiglottis located (2)

• Leaf shaped flap of cartilage located behind the tongue at the top of the larynx

• During swallowing - folds down to cover glottis - prevents food + liquid from entering trachea + directing instead towards the oseophagus

Why does the left lung only have 2 lobes (1)

• Acommodate space for the heart

How does pulmonary circulation work (3)

• Pulmonary arteries carry deoxygenated blood from the heart to the lungs

• Oxygenated in the lungs

• Oxygen-rich blood then returns to the heart via the pulmonary veins, completing the pulmonary circuit

How does gas exchange work (2)

• Oxygen from inhaled air passes through alveolar wall into the blood in the surrounding capillaries

• CO2 moves from the blood into the alveoli to be exhaled

Explain the anatomy and purpose of ciliated structures in the lower airway structures (3)

• Airway epithleium is lined with ciliated columnar epithelial cells

• Mucous cells within the epithelium secrete a protective mucus layer

• Captures foreign particles + pathogens, which are then moved by the cilia to help keep the airways closer

Explain the role of tissue layers in the lower airway structures (3)

• Below ciliated epithelium are layers of stem cells + lamina propria

• Proivde structural support

• Play a role in regenerating the epithelium, indicating the tissues ability to repair and maintain itself

Explain the role of the basement membrane in the lower airway structures (3)

• Forms foundation of epithelial cell layer

• Seperates it from underlying tissues and anchoring the cells in place

• Essential for the integrity and function of respiratory epithelium

Explain how the cough reflex works (2)

• Rapid expulsion of air from lungs

• Triggered by irritation or obstruction in the airway

What is the purpose of the cough reflex

Clear trachea and bronchi of mucus, foreign particles, microbes or other irritants

Explain how the sneeze reflex works (2)

• Forceful expulsion of air from the lungs through the nose and mouth

• Triggered by irritation in the nasal mucosa and serves to expel irritants from the nasal cavity

What is asthma and what is it characterised by (2)

• Chronic inflammatory disorder of the ariway

• Characterised by reversible airflow obstruction, bronchial hyperresponsiveness and an underlying inflammation

What is COPD and what is it characterised by (2)

• A collection of lung conditions including emphysema and chronic bronchitis

• Cause obstructed airflow from the lungs, leading to decrease in airway elasticity, chronic bronchial obstruction and tissue destruction

What is an upper respiratory tract infection and what can it lead to (3)

• Infections such as common cold, laryngitis and pharyngitis

• Cause inflammation and swelling of airway

• Leads to temporary narrowing and obstruction

What is laryngeal cancer

A type of malignancy that can cause airway obstruction due to tumour growth within the larynx

What are some symptom/complications with laryngeal cancer (3)

• Hoarseness

• Difficulty breathing

• Other airway-compromising symptoms

Explain obstructive sleep apnoea (2)

• A disorder where the airway repeatedly becomes blocked

• Limiting the amount of air that reaches the lungs, causing frequent awakenings and reduced oxygentation during sleep

Explain the concept of foreign body aspiration (2)

• Inhalation of objects into the airways can cause partial or complete obstruction

• Leading to immediate respiratory distress and requiring urgent medical intervention

Explain tracheal stenosis (2)

• Narrowing of trachea due to scarring, inflammation or other disease processes

• Can restrict airflow and lead to difficulty breathing and increased susceptibility to respiratory infections

What are the three types of categories for airway threats and give an example of each

1. Hyper-acute - e.g. Epiglottis compromise

2. Acute - e.g. Croup

3. Acute on chronic - e.g. asthma or tumour growth

What are the four types of bacteria that cause bacterial airway infections

1. Streptococcus

2. Pneumonia

3. Haemophilius influenza

4. Moraxella catarrhalis

What infections does bacteria cause in the upper respiratory tract vs the lower respiratory tract (2)

• Upper: Sinisitus, Pharyngitis

• Lower: Bronchitis, Pneumonia

What are symptoms of bacterial airway infections (5)

• Often more severe than viral

• High fever

• Productive cough with thick mucous or pus

• Chest pain

• Difficulty breathing

What is the treatment of bacterial respiratory infections (2)

• Antibiotics

• Supportive care - hydration and rest

What are some viruses that cause viral airway infection (3)

• Influenzar

• Respiratory syncytial virus (RSV)

• Coronavirus (SARS CoV-2 which causes COVID-19)

Do viral airway infection causes lower or upper respiratory tract infections (1)

• Can affect both upper and lower tracts

What are symptoms of viral airway infections (6)

• Less severe than bactieral

• Runny nose

• Sore throat

• Cough

• Fever

• Fatigue

What is the treatment of viral respiratory infections (4)

• Antiviral for specific strains

• Rest

• Hydration

• Over counter pain/fever relievers

Define anaphylaxis

A severe life-threatening allergic reaction that can cause airway constriction, swelling of the throat and a significant drop in blood pressure

What is angioedema

• Swelling of the deeper layers of the skin, often seen with urticaria (hives)

Why is angioedema problematic

Can progress to involve mucosal tissuesof the airway, leading to obstruction

What can severe case of Urticaria comprise of (2)

• Extension to throat and respiratory mucosa

• Causing itching, swelling and potential airway narrowing

What is bronchospasm and what symptoms does it cause (4)

• Smooth muscle of the bronchial airways tightens

• Wheezing

• Coughing

• Difficulty breathing

How do allergens cause mucosal oedema

Cause inflammation and oedema of the airway mucosa, narrows airway lumen + can restrict airflow

Explain laryngeal oedema as a symptom of an allergic reaction

• Swelling of larynx = particulary dangerous manifestation

• Rapidly lead to complete airway obstruction - stridor or change in voice can be early signs

What is the purpose of suctioning (2)

• Performed to remove mucus, blood, vomit or other secretions obstructing airway

• Ensure clear air passage for effective breathing + oxygenation

How do you determine the correct suctioning catheter (2)

• Based on patients size

• Based on nature of material needing to be removed

What is involved in a pre-suction assessment (4)

Evaluate patients

• Oxygenation

• Ventilation status

• Airway patency

• Need for suctioning

What is important to monitor during suctioning

Patients vital signs - assess tolerance to procedure

What is important hygiene + safety wise during suctioning (2)

• Use aspetic technique

• Wear appropriate PPE

What is involved in oxygenation in suctioning (2)

• Pre-oxygenate with supplemental O2 before suctioning to prevent hypoxaemia

• Re-oxygenate after each suction pass as needed

What is the correct technique to suctioning (3)

• Introduce catheter without applying suction

• Apply suction, gently withdrawing catheter in rotating motion

• In this way effectively clears secretions without causing trauma to the airway mucosa

Why must we limit suctioning time (2)

• Minimise hypoxaemia

• Minimise potential arrythmias

How long should each suction attempt be limited too

10-15 for adults, even shorted for children and infants

What are the technqiues to open airways (5)

1. Positioning - recovery, semi-fowlers

2. Head tilt-chinlift

3. Jaw thrust manoeuvre

4. Oropharyngeal

5. Nasopharyngeal

When should a head tilt-chin lift not be used

When patient has suspected cervical spine injury

How can different positioning help open the airway

Semi-fowlers: Improves diaphragm movement + can assist in opening and maintaining the airways

How does the head tilt-chin lift work (2)

• Tilt patients head back and lift the chin to open the airway

• Helps relieve obstruction, lifts tongue away from posterior pharyngeal wall

How does the jaw thrust manouevre work (2)

• Place fingers behind the angel of the lower jaw and lift with both hands

• Displacing jaw forward and upwards without moving the neck = opening the airway

What kind of patients would a oropharyngel airway be inserted into

• Unconscious patient - without gag reflex

How is oropharyngeal airway measured

• Patients incisior to angle of jaw

What kind of patient is the nasopharyngeal airway inserted into

• Used in patients with gag reflex (conscious)

How is nasopharyngeal airway measured

Chosen based on distance from the nostril to the ear lobe

What are the four types of emergency airway interventions for ventilation

1. Bag-valve mask ventilation

2. Endotracheal intubation

3. Supraglottic ariway devices - e.g. LMA

4. Cricothyroidotomy

What is bag-mask ventilation

• Temporary ventilation support

Explain the procedure of endotracheal intubation

• Insertion of tube through the mouth or nose into the trachea to establish a secure airway

When is ETT indicated

• For patients unable to protect their ariway or are in need of mechanical ventilation

When are LMA’s commonly used

• Shorter elective procedures - easier insertion in comparison with ETT

Describe the procedure Cricothyroidotomy

Incision through skin and cricothyroid membrane to insert a tube directly into the trachea allowing for emergency ventilation

When is a cricothyroidotomy performed

• Last resort in cases of severe airway obstruction

• When intubation is not possible

What are the decision making processes in airway management

1. Assessment and evaluation

• Airway assessment

• Signs of obstruction

• History

2. Risk identification

• Facial trauma, obesity, pregnancy

• Underlying medical conditions

3. Selection of intervention

• Type of airway management

4. Monitoring and reassessment

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Describe how compressions should be performed on an adult

1. Centre of chest

2. 5-6cm depth

3. 100-120 min

4. Ratio 30: 2 until airway secured

What are the three types of airway pharmacology

1. Bronchodilators

2. Anti-inflammator agents

3. Sedatives and analgesics

What is the mechanism of action for a bronchodilator

Relaxes smooth muscle bands that constrict the airways in the lungs, widening the airways (bronchodilation).

What are the types of bronchodilators (2)

1. B2 adrenergic agonists

• Short acting = Salbutamol

• Long acting = Salmeterol, Formeterol

2. Anticholinergics

• Ipraptropium (short acting)

• Tiotropium (long acting)

What purpose do anticholinergics provide (3)

• Block muscarinic receptors in the airways

• Reduce bronchoconstriction and mucus secretion

• Primarily used in COPD

What can some negative side effects of bronchodilators be (3)

• Tachycardia

• Palpitations

• Tremor

What is the mechanism of action for anti-inflammatory agents

Crucial role in managing chronic respiratory conditions by reducing inflammation, swelling, and mucus production in the airway

What are the two types of anti-inflammatory agents used for respiratory

• Corticosteroids

• Leukotriene modifiers

How does corticosteroids manage respiratory conditions (2)

• Suppressing the immune response

• Reduce airway inflammation, oedema and hyperresponsiveness

What are examples Table (2) and inhaled (2) of Corticosteroids for respiratory conditions

• Tablet: Prednisolone, Methylprednisolone

• Inhaled: Fluticasone and Budesonide

How can corticosteroids be administered (2)

• Orally, intravenously or via inhalation

• Route is dependent on severity of the condition + desired speed of action

What are leukotriene modifier

Block the action of leukotrienes - inflammatory chemicals the body releases in response to allergens or other triggers

What are two examples of Leukotriene modifiers (used for chronic asthma)

1. Montelukast

2. Zafirlukast

What side effects of long term corticosteroid use (3)

• Osteoporosis

• Adrneal suppression

• Increased risk of infection

What are side effects of inhaled corticosteroids (2)

• Oral thrush

• Hoarseness

(prevented through proper technique + mouth rinsing)

What are adverse effets of Leukotriene modifiers (2)

• Liver enzyme elevation

• Neuropsychiatric events

What are examples of sedatives/analgesia (3)

1. Midazolam

2. Propofol

3. Dexmedetomidine

What is the function of sedatives in respiratory management (2)

• Faciliate procedures like endotracheal intubation, mechanical ventilation

• Ensure patient comfort during invasive support

What are examples of muscle relaxants used for intubation (2)

• Succinylcholine

• Rocuronium

What are muscle relaxants used for in intubation (3)

• Achieve muscle paralysis

• Facilitate endotracheal intubation

• Improve conditions for surgical procedures

What is Succinylcholine’s favoured use (2)

• Rapid sequence intubation

• Quick onset and short duration of action

What is Rocuronium’s favoured use (2)

• Used when longer paralysis is need

• Or for patients with contraindications for succinylcholine

What is importnat to monitor during sedation/paralysis and why

Continous monitoring:

1. Sedation depth

2. Neuromuscular function

3. Ventilation

What examples of reversal agents for sedatives (2)

• Flumazenil

• Benzodiazepines

What examples of muscle relaxants for sedatives (1)

• Neostigmine for non-depolarising agents

What is the mechanism of action for adrenaline

Acts on alpha and beta-adrenergic receptors throughout the body, leading to vasoconstriction, bronchodilation, and increased heart rate and myocardial contractility

What are adrenalines affect during anaphylaxis (3)

• Decreasing swelling

• Relieving wheezing

• Breathing difficulties

What is adrenalines purpose when used in cardiac arrest

To increased coronary and cerebral perfusion pressure during CPR

What are negative side effects of adrenaline (4)

• Palpitations

• Tremors

• Hypertension

• Arrythmias

What adverse should we monitor for in an airway medication administration (4)

1. Bronchospasm

2. Cardiac arrythmias

3. Hypotension

4. Hyperglycaemia

What are the differences in anatomy/physiology respiratory wise for children (10)

1. Narrow nasal passage

• Nose breathers from 4-6 months

2. Immature respiratory centres

3. Large head and prominent occiput

4. Soft trachea

5. Smaller calibre airways

6. Inefficent intercostal and accessory muscles

7. Abdominals breathers - rely on diaphragm as principle muscle

8. Smaller functional residual capacity (more prone to alveolar collapse)

9. Compliant chest wall with horizontal short ribs

10. Large tongue - rapidly growing tonsils and adenoids

What is involved in the Paediatric Assessment triangle (3)

1. Appearance

2. Work of breathing

3. Circulation

What is involved in appearance in the paediatric assessment triangle (5)

1. Tone

2. Interactiveness

3. Gaze

4. Cry

5. Consolabilty

What is involved in work of breathing in the paediatric assessment triangle (4)

1. Breath sounds

2. Positioning

3. Retractions

4. Nasal flaring

What is involved in circulation in the paediatric assessment triangle (3)

1. Pallor

2. Mottling

3. Cyanosis

What can you look for when assessing WOB in infants/children (7)

1. Chest recession or retractions

2. Accessory muscle use

3. Nasal flaring

4. Tracheal tug

5. Grunting

6. Gasping

7. Head bobbing in fants