CHAPTER 4 MANAGEMENT OF THE AIRWAY
PRETEST QUESTIONS
1. A patient has just been intubated, and the CO2 detector placed on the proximal end of the ET tube reads 1.5%. The respiratory therapist should suspect which of the following?
2. Opening the patient’s airway using an oropharyngeal airway is most beneficial when which of the following causes the obstruction?
3. McGill forceps are used during which of the following procedures?
4. The physician wants to begin weaning a patient from a tracheostomy tube. How may this best be accomplished?
5. You are called to a patient’s room because a ventilator alarm is sounding. You hear an audible leak around the patient’s ET tube during a ventilator breath and notice the exhaled volume reading is 150 mL less than the set VT. You check the cuff pressure and find that it is 12 mm Hg. Which of the following is the appropriate action to take?
C. While listening with a stethoscope at the larynx, instill air into the cuff until a slight leak is heard on inspiration.
6. You want to pass a suction catheter into the patient’s left lung to obtain a sputum specimen. What is the most appropriate method of accomplishing this?
REVIEW
CRT Exam Content Matrix: IB1a-b, 2b, 7d, IIIB1, III I1a-d
RRT Exam Content Matrix: IB1a-b, 2b, 7d, IIIB1, III I1a-c
1. Tongue falling back against the posterior wall of the pharynx, which is caused by unconsciousness or CNS abnormality; patients with macroglossia (enlarged tongue) are at greater risk
1. If the patient is conscious and has a partial airway obstruction, the patient should be monitored closely and allowed to try to relieve the obstruction on his or her own.
2. If the patient is conscious and has a complete airway obstruction caused by food or a foreign object, abdominal thrusts must be performed until the object is dislodged. (See Chapter 6 on cardiopulmonary respiration [CPR].)
1. This airway maintains a patent airway by lying between the base of the tongue and the posterior wall of the pharynx, preventing the tongue from falling back and occluding the airway.
2. This airway must only be used on the unconscious patient because a conscious patient would gag on the airway, which could potentially lead to aspiration.
3. This airway should never be taped in place because the airway must be easily removable to prevent vomiting and aspiration if the patient becomes conscious.
d. Using the cross-finger technique, open the patient’s mouth and insert the airway with the tip pointing toward the roof of the mouth.
b. If the airway is inserted improperly, the base of the tongue may be pushed into the back of the throat, obstructing the airway.
a. Oropharyngeal airways may be used in the unconscious, orally intubated patient to prevent the patient from biting the ET tube.
1. This airway maintains a patent airway by lying between the base of the tongue and the posterior wall of the pharynx.
a. Select the proper size by measuring the airway from the tip of the nose to the earlobe. The outside diameter of the airway should be equal to the inside diameter of the patient’s internal nares.
d. Place tape around the flanged end to secure the airway in place. (A safety pin may be inserted through the flange and the pin taped to the face.)
1. The laryngeal mask airway (LMA) is designed to be used as an alternative to a face mask for achieving and maintaining control of the airway during surgery when tracheal intubation is not necessary or in emergencies when ET intubation cannot be accomplished after several attempts.
2. For the airway to be inserted successfully, the patient must be anesthetized so that the upper airway reflexes are obtunded; otherwise, laryngospasm may occur.
3. The LMA consists of a tube that is fused to an elliptical, spoon-shaped mask. When inserted, the tube protrudes from the patient’s mouth and is connected to a manual resuscitator via a standard 15-mm adapter.
4. The mask resembles a miniature face mask and has an inflatable rim that is filled with air via a pilot valve–balloon system.
5. The tube opens into the middle of the mask through three vertical slits that prevent the tip of the epiglottis from falling back and blocking the lumen of the tube.
6. The LMA is inserted through the mouth and into the pharynx after being lubricated with a water-soluble gel. The device is advanced until resistance is met. Then the mask is inflated, providing a low-pressure seal around the laryngeal inlet. The posterior aspect of the tube is marked with a black line, which should be seen midline against the patient’s upper lip when the airway is placed properly (see Figure 4-5).
7. LMAs are available in all sizes and can be used in patients of all ages, from neonates to adults.
a. This airway can be quickly inserted to provide ventilation when bag-mask ventilation is not adequate and ET intubation cannot be accomplished.
a. Using the index finger, advance the LMA until resistance is met. The tip of the LMA should rest against the upper esophageal sphincter in the hypopharynx. The cuff should be inflated until no leak is heard. To determine proper position, auscultate the lungs bilaterally. Capnography may also be used to confirm an adequate airway.
b. To determine whether mild laryngospasm is present as a result of light anesthesia, auscultate the anterolateral neck for the presence of wheezing.
c. Because the LMA does not protect the airway from regurgitation, the patient must not eat for several hours before insertion.
1. The esophageal–tracheal combitube (ETC) is similar to an EOA but is a double-lumen tube. The tubes run parallel to each other.
2. Once the tube is inserted, a pharyngeal balloon that occludes the pharynx is inflated to prevent air from leaking out the nose or mouth. Because of this, a mask is not necessary. A cuff is located on the distal end of the tube.
3. Once the airway is advanced beyond the pharynx, it enters into either the trachea or the esophagus. It makes no difference which structure it enters.
4. A balloon at the distal end of the tube is inflated and will seal off either the trachea or the esophagus. If the tube rests in the trachea, that lumen is used to ventilate the patient just like an endotracheal tube. If the tube rests in the esophagus, the patient is ventilated through holes in the upper part of the tube below the pharyngeal cuff, like those on the EOA.
5. To determine which tube to ventilate through, attach the resuscitator bag to tube No. 1 (esophageal tube) and begin bagging. If the chest rises, breath sounds are auscultated over the lungs and no air is heard over the epigastric region; the ETC is in the esophagus, and ventilation is occurring through the holes above the distal cuff. The use of a CO2 detector is very helpful in determining tube placement.
6. If the chest does not rise or sounds are only heard over the epigastrium, the resuscitator bag should be attached to the other tube (No. 2) and ventilation started. If the ETC is in the trachea, the chest should rise. Confirm the placement by auscultating over the epigastrium and the chest. The use of CO2 detector is very helpful.
c. May be useful for patients with suspected neck injury because the head does not need to be hyperextended
f. If placed in the esophagus, allows suctioning of gastric contents without interruption of ventilation
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