RSPT 1311 2d and 2e exam review

Combined with intubation lab quizz

Indications for intubation

• Provide and maintain patency of an airway,

• facilitate tracheal suctioning,

• protect the airway from aspiration or obstruction,

• and need for mechanical ventilation.

Suction equipment purpose during intubation

To suction out secretions and debris

to open the airway for good visualization and intubation.

Position for intubation

Head positioned with a towel roll under shoulders and neck flexed, with the head tilted back for a 'sniffing' position.

Miller laryngoscope blade

(straight) lifts the epiglottis directly, used for pediatrics/neonates;

Macintosh laryngoscope blade

(curved) lifts epiglottis indirectly, used for larger pediatrics and adults.

Methods for bedside assessment of tube position

Auscultation,

CO2 reader,

condensation,

and X-ray.

Clinical situations for nasotracheal intubation

Severe airway trauma that does not permit oral intubation and

oral surgery.

Steps of intubation

Assemble equipment,

position patient,

preoxygenate,

insert laryngoscope,

visualize glottis,

displace epiglottis,

insert tube,

assess tube placement,

stabilize tube.

Equipment required for intubation

O2 flowmeter and tubing,

resuscitation bag,

laryngoscope,

suction apparatus,

sterile suction catheters,

tongue depressor,

lubricant,

syringe,

endotracheal tubes,

stylet,

Yankauer,

Co2 detector

stethoscope,

tape/ETT holder,

Magill forceps,

local anesthetic.

Low CO2 reading after intubation suggests

The tube is likely in the esophagus.

Action for ET tube cuff leak during ventilation

Instill air into the cuff for a pressure of 20-25 cm H20.

Risk factor for ET tube cuff causing mucosal damage

Maintaining intracuff pressure of 38 cm H20 and using a low-volume, high-pressure cuff.

Indications for an oropharyngeal airway

Unconscious patient at risk of airway obstruction,

soft tissue obstruction,

bite block for intubation,

and facilitating suctioning.

Indications for a nasopharyngeal airway

Need for frequent NT suctioning and those recently extubated after facial surgery.

Determine ET tube in the right mainstem bronchus

CO2 reader changes color,

but auscultation shows breath sounds only in the right lobe;

visual asymmetrical chest rise.

Laryncoscope

Used with intubation to provide direct visualization of glottis

Laryngoscope blade size for 6-12years old

Miller 2

Macintosh 3

Laryngoscope blade size for adults

Miller 3

Macintosh 3

ETT size 12 years

6.0-7.0

Distance at teeth 17-19 cm

ETT size age 16/small women

6.5-7.0

Distance from teeth: 18-20cm

ETT size women

7.5-8.0

Distance from teeth: 19-21cm

ETT size men

8.0-9.0

Distance from teeth: 21-23cm

For blind insertion with nasotracheal intubation, patient must…

Breathe spontaneously

Nasotracheal Intubation

Indicated in cases of inability to clear secretions,
visible secretions,
increased work of breathing,
or suspected aspiration.

Normal Cuff Pressure

The normal cuff pressure is 20-25 mm Hg.

Name artificial airway complications?

Tube obstruction

Herniation of cuff over tip

Obstruction of tube orifice against tracheal wall

mucus plugging

Cuff leaks

Include tracheal and esophageal perforation,

laryngeal abrasion,

vocal cord trauma,

how to troubleshoot tube obstruction

kinking or biting tube – obstruction is reversed by moving patients head or repositioning tube

troubleshooting Herniation of cuff over tip

deflate cuff,
if deflating fails to overcome obstruction, try to pass suction catheter through tube

troubleshooting mucus plugging

suction tube if installation of sterile normal saline is not necessary

troubleshooting cuff leaks

if pilot tube or valve is leaking, tube needs to be changed asap

ruptured cuff requires extubation and re-intubation or using endotracheal tube exchanger

What to keep at bedside for emergency airway troubleshooting?

Additional trach of current size

TT one size smaller

manual resuscitation bag and mask

Gauze pads (for pts with tracheostomies)

Vallecula

An anatomical depression immediately beyond the base of the tongue.

Epiglottis

A flat cartilage that extends from the base of the tongue backward and upward.

Maximum Intubation Attempt Time

The maximum time allotted for an intubation attempt is 30 seconds.

Ventilation Between Intubation Attempts

Ideally, 3-5 minutes should be spent ventilating a patient between intubation attempts.

Signs of Accidental Extubation

Decreased breath sounds,
airflow,
and the ability to pass a catheter without obstruction.

Preventing Nosocomial Infection

Strategies include humidification,
sterile suction,
minimizing circuit breaks,
and oral care.

What are the 4 indicators for extubation readiness?

RSBI
MIP
Vital Capacity
Cuff Leak

Rapid Shallow Breathing Index (RSBI) Calculation

RSBI = respiratory rate / Tidal Volume;
<105 = Success,
>105 = Failure.

Cuff Leak Calculation

Cuff Leak = (cuff inflated volume - cuff deflated exhaled volume) / cuff inflated volume; leak must be >15%.

Define Maximum inspiratory pressure.

aka Negative inspiratory force.

How is MIP utilized to determine extubation

readiness?

This helps us see if muscles are working.

The amount of negative pressure a patient can generate in 20sec when inspiring against an occluded measuring

What value is indicative of weaning success with MIP

< -30 cm H2O

Can be obtained from ventilator maneuvers or manual maneuvers

Define vital capacity.

The amount of air that can be exhaled after a maximum inspiration

What is vital capacity measuring?

The sum of:

the inspiratory reserve volume

tidal volume

expiratory reserve volume

In the medically ventilated patient, it is the measurement of a patients largest VT over a 40second period

What measurement in Vital Capacity indicates extubation readiness?

>10ml/kg

Clinical Indicators for Weaning from Ventilator

-when original need for the artificial airway no longer exists.

-Ability to maintain adequate oxygenation and ventilation without mechanical support

-Decreased quantity and thickness of secretions

-Presence of Upper airway patency

-Presence of intact gag reflex

-Ability to clear airway secretions

Weaning

the gradual transition from full invasive ventilatory support to spontaneous ventilation with minimal support

Liberation

discontinuation of mechanical ventilatory support

Wean + extubate leads to it.

Vent settings for weaning readiness?

minimal FiO2 (<50%)

Minimal PEEP (<8 cm H2O)

PaO2 >60 mm Hg

pH 7.35 – 7.45

PaCO2 35-45 mm Hg (approx. 50 for COPD pt)

Vd/Vt <60%

MV <10 L/min

Provide the contraindications of extubation

Acute respiratory failure

inability to maintain patent airway

impairment of mental status, oxygenation, ventilation, and expectoration (MOVE)

Hemodynamic instability

Plan to return to operating room in the next 24hours (safer to not take them off, and put them right back on)

Use of paralytic agents (no control of their muscles for breathing)

Process of extubation

-assembly the needed equipment

-suction the ETT and pharynx above the cuff

-oxygenate patient well after suctioning

-deflate the cuff

-remove the tube

-apply appropriate oxygen and humidity therapy

-assess and reassess the patient

What does suctioning ETT and Pharynx above cuff for extubation help with?

-assists in prevention of aspiration of secretions after deflating cuff

-minimizes possibility of ventilator associated pneumonia (VAP)

Why do we oxygenate patient well after suctioning prior to extubation?

-Hypoxemia is often a side effect of extubation due to stress of cardiovascular side effects

-suggested administration of increased FiO2 for a minimum of 5min prior to extubation

appropriate oxygen and humidity therapy after extubation

• ensure oxygen and aerosol supplies are at hand

• cool mist may be indicated to minimize stridor

Hazards of Extubation

Include hypoxemia,
stridor,
hoarseness,
sore throat,
and complications like vocal cord paralysis.
Laryngospasm

Laryngospasm

Purpose of Coughing Before Extubation

To prevent swallowing any secretions during the extubation process.

Why is cuff leak test performed?

Helps assess the presence of glottic edema, or the possibility of stridor post extubation

Helps assess the success of extubation.

It should be performed on individuals with a high-risk of post extubation issues (history of airway trauma, prolonged intubations, presence of factors that may lead to laryngeal swelling)

Cuff leak test steps

Oral care

Subglottic suctioning

Completely deflate the cuff – this determines the presence of laryngeal edema (no leak is bad)

what percentage of leak should lead to considering extubation?

A significant leak will be present in a patent airway indicated by a leak >15%

Equipment for extubation

-sunctioning kits (2)
-yaunker
-10-20ml syringe
-oxygen therapy and aerosol therapy equipment
-manual resuscitator and mask
-nebulizer, racemic epinephrine, and normal saline
-intubation cart or box

no leak during extubation means

possible swelling in airway
stop + reinflate cuff + talk to the team
patient might need more time, steroids

Extubation to trach is indicated with who?

In those where respiratory failure may be resolved, but airway patency is an ongoing issue

Patients with prolonged ventilation needs, difficulty weaning off mechanical ventilation, or chronic respiratory conditions.

Airway patency is the main concern → long term airway needed