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Yohanes WH George,SpAn
Definitions
What is Airway Management? How does it differ from spontaneous, manual or assisted Ventilations?
Palate
Roof of mouth Separates oro- & nasopharynx Anterior=hard palate; Posterior=soft palate
Epiglottis
Prevents aspiration Directs air vs. other
Vallecula
pocket formed by the base of tongue & epiglottis
thyroid cartilage
first tracheal cartilage - shield shaped cartilage anterior but smooth muscle posterior Adams Apple Glottic opening directly behind
Arytenoid cartilage
posterior attachment of vocal bands
Cricothyroid membrane
membrane between cricoid & thyroid cartilage site for surgical and needle airway placement
carotid arteries
branches across and lie closely alongside trachea
jugular veins
branch across and lie close to trachea
Location
From the glottic opening to pulmonary capillary membrane
Bronchi
Branch into secondary & tertiary bronchi that branch into bronchioles
Alveoli
Balloon-like clusters Site of gas exchange Lined with surfactant
increases surface tension eases expansion surfactant or alveoli not inflated atelectasis
Ventilation
Defined as movement of air into & out of lungs Inspiration
stimulus from respiratory center of brain (medulla) transmitted via phrenic nerve to diaphragm diaphragm flattens during contraction intercostal muscles contract ribs elevate and expand results in intrapulmonic pressure (pressure gradient) results in air being drawn into lungs & alveoli inflated
Ventilation
Expiration
Stretch receptors in lungs signal respiratory center via vagus nerve to inhibit inspiration Hering-Breuer Reflex Natural elasticity of lungs passively expires air (in non-diseased lung)
Ventilation
Chemoreceptors
Carotid bodies & Aortic arch Stimulated by PaO2, PaCO2 or pH PaCO2 considered normal neuroregulatory control of ventilations
Hypoxic Drive
default regulatory control Senses changes in Pa02
Ventilation
Other stimulations or depressants to ventilatory drive
body temp: w/ fever & w/hypothermia drugs/meds: increase or decrease pain: increases but occasionally decreases emotion: increases acidosis: increases sleep: decreases
Ventilation
Ventilation
Measurement of Gases
Total Pressure
combined pressure of all atmospheric gases 760 mm Hg or torr at sea level
Partial Pressure
Pressure exerted by each gas of a mixture Atmospheric
Nitrogen 597.0 torr (78.62%); Oxygen 159.0 torr (20.84%); Carbon Dioxide 0.3 torr (0.04%); Water 3.7 torr (0.5%)
Measurement of Gases
Partial Pressures
Alveolar
Nitrogen 569.0 torr (74.9%); Oxygen 104.0 torr (13.7%); CO2 40.0 torr (5.2%); Water 47.0 torr (6.2%)
Respiration
Ventilation vs. Respiration Exchange of gases between a living organism and its environment External Respiration
exchange between lungs & blood cells
Internal Respiration
exchange between blood cells & tissues
Respiration
How are O2 and CO2 transported?
Diffusion
definition gases dissolved in water and pass through alveolar membrane
FiO2
% of oxygen in inspired air (e.g. FiO2 = 0.95)
Respiration
Oxygen Content of Blood
dissolved O2 crosses pulm cap membrane and binds to Hgb of RBC Transport = O2 bound to hemoglobin (97%) or dissolved in plasma O2 Saturation: % of hemoglobin saturated with oxygen (usually carries >96% of total) O2 content divided by O2 carrying capacity
Respiration
Oxygen saturation affected by:
low Hgb (anemia, hemorrhage) inadequate oxygen availability at alveoli poor diffusion across pulm membrane (pneumonia, pulm edema, COPD) Ventilation/Perfusion (V/Q) mismatch
blood moves past collapsed alveoli (shunting) alveoli intact but blood flow impaired
Respiration
Carbon Dioxide content of blood
Byproduct of work (cellular respiration) Transported as bicarbonate (HCO3- ion) 20-30% bound to hemoglobin Pressure gradient causes CO2 diffusion into alveoli from blood increased level - hypercarbia
Deoxygenated
Heart
Oxygenated
PO2 40 & PCO2 46 - Systemic circulation - PO2 100 & PCO2 40 Tissue cell PO2 <40 & PCO2 >46
Diagnostic Testing
Pulse Oximetry Peak Expiratory Flow Testing Pulmonary Function Testing End-Tidal CO2 Monitoring Laboratory Testing of Blood
Arterial Venous
Causes of Hypoxemia
Environment
lower partial pressure of atmospheric O2
Transport
inadequate hemoglobin level in blood hemoglobin bound by other gas
Medical
pulm alveolar membrane distance
pneumonia, pulmonary edema, COPD
Causes of Hypoxemia
Traumatic
Reduced surface area for gas exchange
pneumothorax, hemothorax, atelectasis
Foreign Body
partial or complete choking, gagging, stridor, aphonia, dysphonia
Aspiration
increased mortality destroys bronchiolar tissue increased risk of infection increases pulm alveolar membrane distance
Visual Assessment
Skin color Flaring of nares Pursed lips Retractions Accessory Muscle Use Altered Mental Status Inadequate Rate or depth of ventilations
Rise & Fall of chest Audible gasping, stridor, or wheezes Obvious pulm edema (fulminant)
Palpation
Air movement at mouth and nose chest wall
paradoxical motion retractions
Pulsus Paradoxus
Systolic BP drops > 10 mm Hg w/inspiration
may detect change in pulse quality common in COPD, asthma, pericardial tamponade
Duration
Constant Recurrent
Provocation/Palliation
Interventions
past evals/admits meds ever intubated before?
Respiratory Patterns
Central Neurogenic Hyperventilation
increased ICP
Kussmaul
acidosis
Agonal
brain anoxia
Biots
increased ICP
Delivery Devices
nasal cannula partial rebreather mask non-rebreather mask venturi mask small volume nebulizer
Regulators Humidifier
Airway Devices
Oropharyngeal airway Nasopharyngeal airway
Other Types
tracheostomy with tube tracheostomy with stoma
Tracheobronchial suctioning
lubricate catheter 3-5 cc sterile water or saline insert catheter until resistance is felt
orogastric
usually used in unresponsive patients larger tube may be used safe in facial trauma
Cuffed vs Uncuffed
Advantages
secures airway route for a few medications optimizes ventilation and oxygenation
without it
Assess patients airway for difficulty Assemble & check equipment (suction) Hyperventilate patient (30-120 sec)
Selection
Typical Adult ET Tube Sizes
Male - 8.0, 8.5 Female - 7.0, 7.5, 8.0
Blade
Mac - 3 or 4 Miller - 3
Tube Depth
Usually 20 - 22 cm at the teeth
Equipment Review
Pediatric Differences
Anatomic Differences Depth (cm)
Tube ID x 3 12 + (age/2) easily dislodged
Intubation vs BVM
Tube Positioning
Contraindications
None when demonstrated need caution with tracheal transection
No . 2 15 ml
No. 1 100 ml
No. 1
No .2 15 ml
No. 1 100 ml
Combitube
Indications Contraindications
Height Gag reflex Ingestion of corrosive or volatile substances Hx of esophageal disease
LMA
Contraindications
hypersensitivity hypotension
Advantages
enables to provider to intubate patients who otherwise would be difficult or impossible to intubate minimizes patient resistance to intubation reduces risk of laryngospasm
Contraindications
Absence of indications
Rarely needed
Procedure
Intubate if not already done Prep site and equipment Vertical incision to anterior axillary line Horizontal incision only if necessary Cover and protect