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Questions and Answers
What do the 2010 AHA guidelines for BLS CPR state about the routine use of crico-thyroid pressure during BVM ventilation?
What do the 2010 AHA guidelines for BLS CPR state about the routine use of crico-thyroid pressure during BVM ventilation?
Which of the following is considered the best method to avoid gastric inflation during BVM ventilation according to the 2010 CPR Guidelines?
Which of the following is considered the best method to avoid gastric inflation during BVM ventilation according to the 2010 CPR Guidelines?
What is the main reason for the no longer recommended routine use of crico-thyroid pressure during BVM ventilation?
What is the main reason for the no longer recommended routine use of crico-thyroid pressure during BVM ventilation?
Despite the change in guidelines, why might the Sellick maneuver still be taught and used?
Despite the change in guidelines, why might the Sellick maneuver still be taught and used?
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Where is the cricoid cartilage located in relation to the thyroid prominence?
Where is the cricoid cartilage located in relation to the thyroid prominence?
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Approximately how much force is required to perform crico-thyroid pressure to overcome gastric pressure in the esophagus?
Approximately how much force is required to perform crico-thyroid pressure to overcome gastric pressure in the esophagus?
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To what range in cmH2O does the esophageal sphincter opening pressure correspond?
To what range in cmH2O does the esophageal sphincter opening pressure correspond?
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In which situation might the crico-thyroid pressure aid during a medical procedure?
In which situation might the crico-thyroid pressure aid during a medical procedure?
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Which feature is true about the cricoid cartilage location relevant for performing the Sellick maneuver?
Which feature is true about the cricoid cartilage location relevant for performing the Sellick maneuver?
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What is considered by the American Society of Anesthesiology as definitive airway management?
What is considered by the American Society of Anesthesiology as definitive airway management?
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Which of the following is NOT one of the main indications for definitive airway management?
Which of the following is NOT one of the main indications for definitive airway management?
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Why might intubation be indicated for a patient with obtunded airway protective reflexes?
Why might intubation be indicated for a patient with obtunded airway protective reflexes?
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What is necessary for positive pressure ventilation to properly function?
What is necessary for positive pressure ventilation to properly function?
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For what reason might medication administration be included in the indications for endotracheal intubation?
For what reason might medication administration be included in the indications for endotracheal intubation?
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What is the role of endotracheal intubation related to the respiratory care skills required?
What is the role of endotracheal intubation related to the respiratory care skills required?
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Which reflex is NOT mentioned as being important for protecting the respiratory tract from aspiration?
Which reflex is NOT mentioned as being important for protecting the respiratory tract from aspiration?
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What condition might necessitate frequent airway suctioning as an indication for intubation?
What condition might necessitate frequent airway suctioning as an indication for intubation?
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What is the primary objective in securing the airway during intubation?
What is the primary objective in securing the airway during intubation?
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Which skill is stated as being essential for respiratory care practitioners (RCPs)?
Which skill is stated as being essential for respiratory care practitioners (RCPs)?
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Which component of the laryngoscope directly aids in visualizing the larynx by moving anatomical structures?
Which component of the laryngoscope directly aids in visualizing the larynx by moving anatomical structures?
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Which type of laryngoscope blade is specifically mentioned as having a curved shape?
Which type of laryngoscope blade is specifically mentioned as having a curved shape?
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What is the primary role of the handle in a laryngoscope?
What is the primary role of the handle in a laryngoscope?
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Which tool is described as a thin, rigid rod used to assist with intubation?
Which tool is described as a thin, rigid rod used to assist with intubation?
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What is the function of the bougie during laryngoscopy?
What is the function of the bougie during laryngoscopy?
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Which anatomical structure is lifted by the laryngoscope blade to allow intubation?
Which anatomical structure is lifted by the laryngoscope blade to allow intubation?
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Why must clinicians be familiar with the Macintosh and Miller blade types?
Why must clinicians be familiar with the Macintosh and Miller blade types?
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What happens when the blade is locked to the handle of the laryngoscope?
What happens when the blade is locked to the handle of the laryngoscope?
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Which of the following is not a function of the laryngoscope?
Which of the following is not a function of the laryngoscope?
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Which of the following actions is critical to avoid when using a laryngoscope blade?
Which of the following actions is critical to avoid when using a laryngoscope blade?
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For what reason must the laryngoscope be held in the left hand?
For what reason must the laryngoscope be held in the left hand?
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How should the Macintosh blade be inserted into the patient's mouth?
How should the Macintosh blade be inserted into the patient's mouth?
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Which element is unique to the Miller blade compared to the Macintosh blade?
Which element is unique to the Miller blade compared to the Macintosh blade?
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What common factor should influence the choice of laryngoscope blade size?
What common factor should influence the choice of laryngoscope blade size?
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What must left-handed clinicians learn when using a laryngoscope?
What must left-handed clinicians learn when using a laryngoscope?
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Where is the light bulb located on the Macintosh blade?
Where is the light bulb located on the Macintosh blade?
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What is the primary reason the Macintosh blade is preferred over the Miller blade?
What is the primary reason the Macintosh blade is preferred over the Miller blade?
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What space does the rounded end of the Macintosh blade fit into?
What space does the rounded end of the Macintosh blade fit into?
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How does the Macintosh blade lift the epiglottis?
How does the Macintosh blade lift the epiglottis?
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What happens if the Macintosh blade is incorrectly inserted down the middle of the mouth?
What happens if the Macintosh blade is incorrectly inserted down the middle of the mouth?
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For which patients is the Macintosh #4 blade usually preferred?
For which patients is the Macintosh #4 blade usually preferred?
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What feature of the Macintosh blade helps increase room for visualization during tube placement?
What feature of the Macintosh blade helps increase room for visualization during tube placement?
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What is the correct method for inserting the Macintosh blade into a patient’s mouth?
What is the correct method for inserting the Macintosh blade into a patient’s mouth?
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What mechanism does the Macintosh blade use to avoid stimulating the airway protective reflexes?
What mechanism does the Macintosh blade use to avoid stimulating the airway protective reflexes?
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Why is the Miller blade considered easier to insert in certain patients?
Why is the Miller blade considered easier to insert in certain patients?
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What usually causes a 'failed intubation' attributed to an 'anterior larynx'?
What usually causes a 'failed intubation' attributed to an 'anterior larynx'?
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What is the primary function of a stylet during intubation?
What is the primary function of a stylet during intubation?
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When should the stylet ideally be removed during intubation?
When should the stylet ideally be removed during intubation?
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Which precaution should be taken when using a stylet?
Which precaution should be taken when using a stylet?
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In what scenario is the use of a bougie more likely necessary?
In what scenario is the use of a bougie more likely necessary?
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How is the endotracheal tube advanced into the trachea when using a bougie?
How is the endotracheal tube advanced into the trachea when using a bougie?
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What risk is present if the style makes the endotracheal tube too rigid?
What risk is present if the style makes the endotracheal tube too rigid?
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Which feature distinguishes a bougie from a stylet?
Which feature distinguishes a bougie from a stylet?
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Why should the stylet not be used routinely in hospital practice?
Why should the stylet not be used routinely in hospital practice?
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What is the role of the laryngoscope during the use of a bougie?
What is the role of the laryngoscope during the use of a bougie?
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What should be done once the endotracheal tube is in place when using a bougie?
What should be done once the endotracheal tube is in place when using a bougie?
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What is the primary purpose of the radiopaque line found on endotracheal tubes?
What is the primary purpose of the radiopaque line found on endotracheal tubes?
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Which feature of endotracheal tubes helps prevent occlusion if the distal end becomes blocked?
Which feature of endotracheal tubes helps prevent occlusion if the distal end becomes blocked?
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What is the main consideration when selecting the size of an endotracheal tube?
What is the main consideration when selecting the size of an endotracheal tube?
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Where should the tip of the endotracheal tube be placed after it passes through the larynx?
Where should the tip of the endotracheal tube be placed after it passes through the larynx?
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Why are internal diameters important in the sizing of endotracheal tubes?
Why are internal diameters important in the sizing of endotracheal tubes?
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Which component of an endotracheal tube aids in securing it to ventilators or anesthesia machines?
Which component of an endotracheal tube aids in securing it to ventilators or anesthesia machines?
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Study Notes
BVM Ventilation: Preventing Gastric Insufflation
- The 2010 AHA guidelines for BLS CPR no longer recommend the routine use of the crico-thyroid pressure (Sellick maneuver) during BVM ventilation.
- Crico-thyroid pressure may reduce alveolar ventilation more than it prevents air from entering the stomach.
- The best way to avoid gastric inflation during BVM ventilation is to use only enough volume and pressure to produce visible chest rise.
- Crico-thyroid pressure (Sellick Maneuver) can be used to compress the esophagus in unconscious patients and possibly reduce gastric inflation.
- The maneuver can also aid in visualizing the larynx during intubation.
- The cricoid cartilage is located inferior to the thyroid prominence and the cricothyroid membrane.
- To perform the Sellick Maneuver, hold the cricoid between digits and press back against the cervical vertebrae with a force of about 20-30 Newtons.
- The esophageal sphincter opening pressure is about 20-25 cmH2O (approximately 1961 to 2542 Newtons).
Emergency Airway Management: Introduction
- The American Society of Anesthesiology is the primary source for expertise and information on airway management.
- Endotracheal intubation is considered the definitive airway management.
- RCPs (Respiratory Care Practitioners) provide definitive emergency airway support by performing endotracheal intubation.
Indications for Definitive Airway Management
- Secure the airway:
- Prevent or eliminate upper airway obstruction, especially by collapse of soft tissue.
- Protect the respiratory tract:
- Prevent aspiration, especially of gastric contents.
- Indicated when patients' airway protective reflexes are obtunded by medication, injury, or disease.
- Indicated when the patient requires frequent airway suctioning.
- Provide positive pressure modalities:
- Ventilatory support (PPV) requires an occlusive airway seal to eliminate pressure leaks.
- Provide a route for administering oxygen under positive pressure to overcome hypoxemia caused by V/Q imbalance due to atelectasis.
- Medications can be administered through the endotracheal tube.
Endotracheal Intubation
- Meets all the indications for airway management listed above.
- An essential respiratory care tactile and visual skill that can be mastered by any clinician with adequate practice.
- Evaluating and treating a patient who may require emergency airway management and ventilatory support is an essential RCP skill.
Laryngoscope Equipment
- The laryngoscope is a rigid instrument used to examine the larynx and facilitate tracheal intubation
- It consists of two separate parts: the handle, which contains a battery to power the bulb at the tip of the blade, and the blade itself
Laryngoscope Blades
- Laryngoscope blades come in many different shapes to manage various anatomical and pathological situations
- Clinicians must be familiar with at least two commonly used blade types: curved (Macintosh) and straight (Miller)
- Each blade type has its own advantages and disadvantages
Accessories
- Bougie: a flexible tube used to guide the laryngoscope into the trachea
- Stylet: a thin, rigid rod used to help intubate the trachea
Laryngoscope Blades
- Anesthesia practitioners typically use Macintosh (curved) and Miller (straight) laryngoscope blades for intubation.
- Both blades come in various sizes, and the choice depends on patient anatomy, personal preference, and institutional policy.
- The laryngoscope is designed for right-handed individuals, so it must be held in the left hand; left-handed clinicians must adapt to using it with their left hand.
Macintosh Blade
- Inserted into the right side of the patient's mouth
- The tongue is gently swept to the left and raised anteriorly by the blade's flange
- The blade is curved and has a flange on the right side
- The locking fitting on the left side holds the blade securely in place
- The light bulb is placed above the locking fitting
Miller Blade
- The blade is straight and has a blunt tip
- Never press the blade against the teeth to avoid dental trauma and potential lawsuits.
Laryngoscope Blades
Macintosh (Curved) Blade
- Has a rounded end that causes less trauma to pharyngeal tissues
- Fits into the vallecula, the space between the base of the tongue and the epiglottis
- Lifts the epiglottis passively by pulling tissue folds attached to the tongue base and hyoid bone
- Does not directly lift the epiglottis, unlike the straight blade
- Less likely to stimulate airway protective reflexes when used correctly
- Allows more room for visualization during tube placement, especially in obese patients
- Correctly inserted into the right corner of the patient's mouth
- Flange pushes the tongue toward the left side of the oropharynx as the blade is moved toward the mid-line
- Incorrect insertion down the middle of the mouth can force the intubator's line of sight posteriorly
- Usually, the Macintosh #3 is used for most adult patients, and the #4 is used for large and obese patients
Miller (Straight) Blade
- Used to directly lift the epiglottis and flatten the tongue
- Easier to insert, especially in patients without large maxillary central incisors
- Directly lifts the epiglottis, unlike the curved blade
Equipment for Intubation
- A stylet is a long, malleable rod that facilitates intubation by allowing the flexible endotracheal tube (ETT) to be bent into a curve.
- The stylet is not meant to make the tube rigid, but rather to help guide it into the trachea.
- The stylet is inserted into the tube prior to laryngoscopy and bent to resemble a hockey stick.
- After insertion, the stylet is removed, and the tip should never protrude beyond the distal end of the ETT.
- The stylet is not necessary for routine intubations, only when a curved ETT is required.
The Bougie
- A bougie is a thin, straight, semi-rigid device with a bent tip, used in difficult intubations.
- Only a small percentage of intubations (less than 4%) should be difficult.
- The bougie is carefully advanced into the larynx and through the cords until the tip enters a mainstem bronchus during laryngoscopy.
- An assistant then threads an ETT over the end of the bougie, into the larynx, while the laryngoscope and bougie are held in position.
- Once the ETT is in place, the bougie is removed.
Endotracheal Tubes
- Made of polyvinyl chloride
- Feature a radiopaque line from top to bottom
- Have depth markings in centimeters from the distal end of the tube
- Equipped with a high-volume, low-pressure inflatable balloon
- Have a hole above the beveled distal end known as the Murphy's eye
- Have 15 mm connectors for anesthesia machines, ventilators, or bag-mask devices
Tube Sizing
- Sizes are designated in millimeters of internal diameter
- Sizing is a compromise between minimizing airway trauma during insertion and maximizing ventilation flow and minimizing airway resistance
Insertion Technique
- View the larynx via laryngoscopy
- Introduce the ETT through the right side of the mouth
- Directly observe the tip of the tube passing into the larynx between the abducted, separated cords
- Pass the tube 1 cm past the cords
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Description
Learn about the guidelines for BVM ventilation, the role of crico-thyroid pressure, and the best way to avoid gastric inflation during BVM ventilation.
