Airway Management CHP 30 p 415 PACU CC
Patients arrive in the PACU still experiencing the depressant effects of anesthesia. They may be obtunded, which renders them unable to maintain their own airway. Loss of important airway reflexes soon leads to airway obstruction. In some instances, the obtunded patient's tongue and epiglottis fall back on the posterior pharyngeal wall, further occluding the airway.
Indications of airway obstruction include increase respiratory effort, retraction of the muscles of respiration, a rocking chest motion, abnormal or absent breath sounds, cyanosis, sx assoc with hypoxemia and hypercarbia.
What to do:
Place the patient supine, position a pillow beneath the head, tilt the head backward, and extend the neck. --> Lift the lower jaw upward using moderate pressure.
(head-chin lift maneuver)
Basic life support - Head tilt Chin lift Jaw thrust
https://www.youtube.com/watch?v=XNZed1oBeTA
Manual Airway Techniques
https://www.youtube.com/watch?v=vLNzHcKNPtY
If spontaneous respiratory effort is absent, positive pressure breathing must be initiated.
BMU Bag Mask Unit
Bag-valve-mask (BVM)
For optimal airway management, the PACU nurse should be positioned behind the patient's head.
Secure the mask over patient's mouth and nose with the neck extended. The lower jaw should be lifted at its angle with the other fingers of the hand holding the mask. The thumb of the hand should be placed on top of the mask. Moderate downward pressure provides compression over the bridge of the nose to reduce air leaks. Start bagging.
Bag Valve Mask Ventilation
https://www.youtube.com/watch?v=rOZVljYnmxc
An assitant should auscultate the chest and assess the quality of breath sounds. If PACU nurse alone, check for chest rising with inspiration bagging and falls with expiration. (crude estimate of ventilation)
If breath sounds are not audible during auscultation, or if the crude estimate of ventilation is inconclusive, an appropriately sized oropharyngeal airway should be inserted and BVM ventilation resummed
EMS Skills - Bag Valve Mask Ventilation
https://www.youtube.com/watch?v=O3vR8DQW1U0
Insertion of oral airway .... use tongue blade to displace tongue forward.
https://clinicalgate.com/assessment-and-management-of-the-airway/
Insert OPA
https://www.youtube.com/watch?v=SvoJfxRbpkg
… the blanch of oral airway should rest on pt’s lips…..
The oral airway is noxious to conscious or lightly sedated patients… inappropriate use of oral airway include bradycardia, retching(gag,almost vomiting), vomiting, and laryngospasm.
The OPA relieves an airway obstruction by providing a mechanical conduit for air to pass between the base of the tongue and the posterior oropharynx.
A rough method for choosing the correct oropharyngeal airway (OPA) size is to hold the airway beside the patient's mandible, orienting it with the flange at the patient's mouth and the tip directed toward the angle of the mandible. The tip of an appropriately sized OPA should just reach the angle of the patient's mandible.
Placement:
PACU RN should open the pts mouth with the right hand and place a tonghe blade toward the posterior aspect of the tongue with the left hand. Slight pressue should be applied to draw the tongue forward. With the OPA held in the right hand, the nurse should slip the airway in over the tongue blade into the oropharynx. The airway should not be twisted or forced into place, and placement should be accomplished quickly avoiding trauma to the soft tissue and teeth.
In comparison to OPA, nasopharyngeal airway is less stimulating to the irritant receptors in the upper airway, especially in awake or slightly sedated pts. The nasopharyngeal airway should be lubricated with a local anesthetic water-soluble lubricant, such as 1% lidocaine gel or ointment, and gently passed with the right hand through the nostril along the curvature of the nasopharynx into the oropharynx.
EMS Skills - Nasopharyngeal Airway Insertion
The NP airway should never be forced. If resistant is encountered on placement, the other nostril should be considered unless otherwise indicated.
After OPA or NPA has been placed properly, ventilation should be attempted. Assess ventilatory effort continuosly. If apnea persists, positive-pressure breathing should be initiated via bag mask with adequate tidal volumes.
For a normal healthy adult, the perianesthesia nurse should consider tidal volume, TV/VT of 8 to 12 ml/kg at a rate of 12 to 14 breath/min as initial settings. For prevention of 02 delivery into the stomach, pressure on the bag-mask should not exceed 25 cm H2O.
(Tidal Volume: The amount of air that enters the lungs during normal inhalation at rest. The average tidal volume is 500ml. The same amount leaves the lungs during exhalation. )
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