Chapter 33 Airway Management When you cant breathe nothingWord格式.docx

1、Cardiac arrhythmiaHypoxia, vagal stimulationPre- and post-oxygenation on 100%C.HypotensionCough, vagal stimulationTopical anestheticD. AtelectasisSuctionHyperinflation before and after procedureE. Mucosal traumaVacuum, techniqueUse appropriate suction pressure, techniqueF. Increased ICPCough4. Refer

2、ence: pages 696-698 A. no disconnection, lower risk of infection, fewer problems with hypoxia B. weight, airway resistance, ventilator triggering5. Reference: page 695 Coude catheter with bent tip6. Reference: page 698; Figure 33-4, page 700 sniffing position7. Reference: page 698 water-soluble lubr

3、icant8. Reference: page 700 nasal airway, which is commonly called a nasal trumpet9. Reference: sputum trap is its common name also called a specimen containerWORD WIZARDendotracheal, polyvinyl, 15, length, beveled, Murphy, cuff, positive, pilot, valve, radiopaquetracheostomy, silver, outer, cuff, f

4、lange, inner, 15 mm, obturatorET TUBES10. Reference: pages 703-704 Unilateral lung disease that may call for independent lung ventilation （ILV）, where each lung is ventilated separately.11. Reference: page 704 A. One line is for the high-pressure injectionB. The other line can be used for humidifica

5、tion, liquids, and pressure monitoring.12. Reference: pages 704-705 Evac tubes are intended to reduce the incidence of VAP.INTUBATION PROCEDURES13. Reference: page 706oral route14. Reference: A. anesthesiologist, emergency department doctor, or pulmonary specialist B. respiratory therapist C. parame

6、dic D. RN （usually nurse anesthetist）15. Reference: to clear vomit or secretions so you can visualize the vocal cords16 Reference: Tighten the bulb. Check batteries. Replace the bulb.17. Reference: Table 33-2, page 707 By weight; we also use babys length on the Braslow tape.18. Reference: Table 33-2

7、, page 707 Similarly by size, but females usually get smaller tubes than males. No. 8 is the standard size for adults. Small females may get 6.5-7.5, whereas larger males may be intubated with a No. 9.19. Reference: pages 706-707 Check the cuff for leaks.20. Reference: page 707sniffing position and

8、rolled towel under the head21. Reference: page 707 Ventilate and preoxygenate the patient.22. Reference: page 707no more than 30 seconds; otherwise, the patient will become hypoxic23. Reference: page 708epiglottis, arytenoid cartilage, glottis24. Reference: page 708The MacIntosh blade fits into the

9、vallecula （at the base of the tongue） and lifts the epiglottis indirectly. The Miller blade slips under the epiglottis and directly lifts the epiglottis out of the way to allow visualization of the glottis. The Miller is more commonly used in pediatric patients as their epiglottis is not as rigid as

10、 an adults and must be lifted out of the way. 25. Reference: Box 33-4, page 709 Primary Survey: A. Listen for equal and bilateral breath sounds. B. Listen for air in the epigastrium. C. Observe the chest wall for equal and adequate expansion.Secondary Survey: A. colorimetry B. Check the depth of ins

11、ertion against the tube markings. Normal depth in males is 21 to 23 cm for oral intubation, normal depth in females is 19 to 21 cm. C. Use the EDD to check for esophageal intubation. D. Use a light wand to check for tracheal intubation. E. Use of capnometry to detect the presence of CO2. Tertiary Su

12、rvey: Fiberoptic laryngoscopy or bronchoscopy set the gold standard as you actually visualize the trachea, carina, etc. distal to the endotracheal tube. 26. Reference: page 710 Cardiac arrest victims have poor pulmonary blood flow thus very low levels of expired carbon dioxide. This can render these

13、 devices ineffective in the assessment of proper tube placement.27. Reference: page 711chest radiograph28. Reference: page 712 A. cervical spine injuries B. maxillofacial injuries29. Reference: pages 712-713 A. BlindInsert the tube through the nose in an upright patient, listening through the tube f

14、or breath sounds. Advance the tube on inspiration as the airway opening will be at its widest. B. Direct visualization Visualize the larynx with a laryngoscope. Advance the tube into the larynx with the use of Magill forceps. .30. Reference: Table 33-1, page 704 A. O B. N C. O D. O E. O F. N G. N H.

15、 O I. O J. N K. NTracheotomy31. Reference: page 713 The primary indication is the need for an artificial airway for a prolonged period of time.32. Reference: page 713Preferred route to overcome airway obstruction or trauma, or to best manage the airway for long-term care of patients with neuromuscul

16、ar disease.33. Reference: page 713The ET tube should remain in place until just prior to inserting the tracheostomy tube. As you insert the trach, the cuff of the ET is deflated and it is removed more or less at the same time as the trach is pushed into place.PERC ME UP!34. Reference: page 713Tradit

17、ional surgical tracheostomy places the tube in the neck over the second or third tracheal ring. Percutaneous trach tubes are placed between the cricoid cartilage and the first ring, or between the first and second tracheal rings.35. Reference: page 714 A. rapidB. avoids the need for transport to the

18、 operating roomC. lower incidence of intraoperative and postoperative complicationsAirway Trauma36. Reference: pages 715-716INJURYSYMPTOMSTREATMENTGlottic edemaHoarseness, stridorRacemic epinephrine, steroidsB. Vocal cord inflammationHoarsenessUsually resolves quicklyLaryngeal ulcerationNo treatment

19、Polyp/granulomaDifficulty swallowing, hoarseness, stridorIf symptoms do not resolve, surgical removal is indicated.Vocal cord paralysisTracheostomy may be needed. F.Laryngeal stenosis Stridor, hoarsenessSurgical correction of tracheostomy37. Reference: page 716 A. granulomas B. tracheomalacia C. tra

20、cheal stenosis38. Reference:PATHOLOGYMalaciaSoftening of ringsCollapse of tracheaResectionStenosisNarrowingFibrous scarringLaser resection39. Reference: page 717 Tracheoesophageal fistula is caused by tracheal erosion from cuffs, esophageal erosion from NG tubes, malnutrition, or poor surgical techn

21、ique. Aspiration may occur. Treatment involves surgical closure of the opening.40. Reference: A pulsating tracheostomy tube may be the only clue. Once hemorrhage begins, hyperinflation of the cuff may help, but surgery is needed. Seventy-five percent of these patients will die.Care and Feeding of Yo

22、ur New ARTIFICIAL Airway41. Reference: ET tubes are secured with tape. Tracheostomy tubes are secured with cloth ties. Commercial harnesses are available for both types of tubes.42. Reference: page 717; Figure 33-25, page 718 Extension （head up） moves the tube up. Flexion moves the tube down. The tu

23、be may move as much as 1.9 cm in either direction.Talk to me43. Reference: page 718 talking tracheostomy tubes and Passy-Muir valves, writing boards44. Reference: Talking tracheostomy tubes allow a flow of oxygen or air to be directed above the cuff and through the vocal cords, which allows the pati

24、ent to talk.45. Reference: page 718The cuff is deflated and the ventilator volume is increased.HUMIDIFICATION46. Reference: page 719 complete obstruction of the tube and asphyxiation47. Reference: page 720 32 to 3548. Reference: heat-moisture exchangers, sometimes called an artificial nose49. Refere

25、nce: A. bypass upper airway filtration B. increase aspiration from the pharynx C. contaminated equipment or solutions D. impaired mucociliary clearance in trachea Also mucosal damage from tube or suctioning; ineffective cough50. Reference: A. adhering to sterile technique with suctioningB. using ase

26、ptic or sterile equipmentC. handwashing51. Reference: retained secretionsCUFF CARE52. Reference: high residual volume, low pressure53. Reference: Keep the cuff pressures below the 20 to 25 mm Hg （or below 25 to 30 cm H2O） which will maintain tracheal mucosal capillary blood flow. If cuff pressure ex

27、ceeds the mucosal perfusion pressure, ischemia, ulceration, and necrosis may result. If cuff pressures are too low, lung infections are more likely secondary to material above the cuff sliding past the cuff and into the lungs. 54. Reference: page 755 A. Minimal occluding volumeSlowly inflate the cuf

28、f. Stop immediately when you can no longer hear air escaping around the cuff during a positive pressure inspiration. Adjustments to cuff volume may be required with changes in patient position or if peak ventilating pressures change.B. Minimum leakFill the cuff as noted above. Then remove a small am

29、ount of air until a slight leak is heard at the very end of a positive pressure inspiration.55. Reference: page 722 Cuff pressures will have to be elevated, maybe excessively so, to achieve a seal.56. Reference: page 723 A methylene blue test is performed by adding methylene blue to the patients tube feedings, or by adding it to some