Term
| parameters for respiratory failure |
|
Definition
| - Resp failure conventionally defined as an arterial partial pressure of oxygen (paO2) of less than 60 mm Hg on a fractional concentration of inspired gas (FiO2) of less than 0.5 or an arterial partial pressure of carbon dioxide (PaCO2) of more than 50 mm Hg |
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Term
|
Definition
| the vol of air moved in/out of the lungs during quiet breathing |
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Term
|
Definition
| space in the respiratory system in which air does not undergo significant gaseous exchange |
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Term
|
Definition
| the greatest volume of air that can be expelled from the lungs after taking the deepest possible breath. |
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Term
| • Know how to respond to severe respiratory failure in patients. |
|
Definition
- Sup O2
- Pulse ox, Pa)2, PaCO2, PvCO2 monitoring
- Hypoxemia caused y hypovent,diffusion impairment and low V/Q units (shunt effect) will improve w/ O2 supp
- O2 admin will not result in increase in PaO2 in true capillary shunt (zero V/Q) units . the blood through these never interfaces w/ alveolar gas and therefore is not oxygenated. Because of sigmoidal shape of hemoglobin saturation curve, increasing the PO2 to those well-ventilated alveoli doesn’t help improve the O2 of the blood leaving the lung, already at max capacity
- Sup O2 will reverse the hypoxemia caused by hypoventilation but hypercapnia will persistuntil the underlying cause of the hypoventilation is addressed.
- If cause of resp fail can’t be quickly found/reversed, pt should be intubated/ventilated |
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Term
| • Know what causes disorders of the chest wall and pleural function. |
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Definition
- Flail chest
- Pleural effusion
- Pneumothorax
- Hemothorax
- Kyphoscoliosis
- Contracted scars over thorax |
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Term
| • Know the various diagnostic tests for evaluating patients with upper airway disease. |
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Definition
- Radiography
- Laryngeal exam
- Flexible endoscopy
- Bronchoscopy
- Bx
- Endotracheal wash
- Computed tomography |
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Term
| • Know the emergency treatment(s) for an animal with upper airway disease. |
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Definition
- Minimizing stress
- Providing o2 therapy
- External cooling if needed
- Anti-inflammatory therapy if indicated |
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Term
| • What are the systemic sequelae to upper airway disease in small animals? |
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Definition
- Incl aspiration pneumonia
- Noncardiogenic pulmonary edema
- heatstroke |
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Term
| • What are the main indications for tracheal intubation? |
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Definition
- 3 main indications are
- Provision of a patent airway in a pt w/ upper airway obstruction
- Protection against aspiration in a pt w/o normal airway protection reflexes
- Admin of O2, gaseous anesthetics or positive pressure ventilation |
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Term
| • When breathing normal room air, complete upper airway obstruction or apnea will lead to hypoxemia within approximately how many minutes? |
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Definition
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Term
| • Preoxygenation of a patient with 100% oxygen via a tight-fitting facemask can prevent hypoxemia for up to how many minutes of airway obstruction or apnea? |
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Definition
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Term
| • What is retrograde intubation, how is it performed, and what are the indications for it? |
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Definition
- Another method for securing the airway in certain conditions
- Requires retrograde placement of a guidewire or catheter via the cricothyroid membrane into the trachea and rostrally into the oropharynx
- An ET tube (or fiberoptic bronchoscope via the suction port or a tube changer followed by an ET tube) is then threaded over the guidewire and into the trachea |
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Term
| • What are the possible problems that may be associated with endotracheal intubation? |
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Definition
- Can be assoc w/ equipment or pt related complications
- Soft or very small ET tubes can crimp due to the acute angle created as the tube passes from the oropharynx toward the larynx, reducing the airflow through the tube. This can lead to hypoventilation and subsequent hypercapnia and hypoxemia
- Bending can also create addtl pressure at the end of the tube that can damage the dorsal larynx or tracheal mucosa
- Over-inflated cuff or too-lg tube can cause pressure-induced tracheal necrosis
- For prolonged intubation, pad oral soft tissues that are contacting as prolonged contact can cause sm areas of necrosis
- In rare cases of more extreme damage caused to trachea by tubes, subq emphysema or even pneumothorax are possible
- Tubes may be advanced too far and end in a mainstream bronchus (usually right). This may lead to inadvertent overinflation of the intubated lung and impaired gas exchange
- Should premeasure tubes and do bilateral thoracic auscultation to help avoid this
- ET intubation can cause increased intracranial pressure and intraocular pressure as well as sig increase in BP and HR. smooth and rapid intubation is vital |
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Term
| • Care must be taken to prevent damage to which nerve when a tracheotomy is performed? |
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Definition
| - Left recurrent laryngeal nerve |
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Term
| • What are the indications for a temporary tracheostomy? |
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Definition
- Life-threatening upper airway obstruction
- Oral or pharyngeal sx when oral endotracheal intubation in undesirable
- Airway obstruction from edema and inflammation after pharyngeal or laryngeal sx
- Long-term ventilator support for critically ill pts
- Removal of tracheal foreign bodies
- Access to the trachea provided by tracheostomy allows air to enter distal to obstructions and reduces damage to the oral cavity from prolonged intubation |
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Term
| • What are the major goals of tracheostomy tube management? |
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Definition
- To prevent tube obstruction
- To facilitate removal of airway secretions
- To minimize the risk of airway trauma or nosocomial pneumonia |
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Term
| • What are the major problems that can occur in patients with tracheostomy tubes? |
|
Definition
- Tube occlusion or dislodgement
- Subq emphysema
- Pneumothorax
- Aspiration of fluid/foreign bodies
- Pneumonia
- Arrhythmias and vagally mediated bradycardia and collapse can occur during suctioning or tube manipulation |
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Term
| • What should be done to remove secretions from the airway and reduce the likelihood of tube tracheostomy occlusion? |
|
Definition
|
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Term
| • Know the possible causes of patient hypoxemia |
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Definition
- Hypoventilation
- Ventilation-perfusion mismatch
- Diffusion impairment
- Decreased O2 content of inspired air
- Intrapulmonary or cardiac shunting |
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Term
| • What are the possible causes of global hypoxemia? |
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Definition
- Can occur in a variety of critical illnesses incl
- Pulmonary parenchymal, neuromuscular, pleural cavity, chest wall, and cardiac dz |
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Term
| • Know the principles for providing supplemental oxygenation to patients. |
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Definition
- Should be provided whenever
- Pt’s PaO2 is less than 70 mm Hg or SaO2 is less than 93% in room air
- Admin can be divided into invasive/noninvasive techniques |
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Term
| • Know the principles and practical aspects of hyperbaric chamber utilization |
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Definition
- Provides 100% o2 under supraatmospheric pressures (>760 mm Hg) to increase the % of dissolved o2 in pt’s bloodstream by 10 – 20%
- Dissolved o2 can diffuse readily into damaged tissues
- Recc for tx of severe soft tissue lesions incl burns, shearing injuries, infxn, and osteomyelitis, also ruptured tympanum and pneumothorax
- Rarely used in vet med due to $/space
- Also once pressurized to supraatmospheric levels, cannot be opened for pt access should complications occur |
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Term
| • What are the indications for the use of hyperbaric oxygen? |
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Definition
| - Recc for tx of severe soft tissue lesions incl burns, shearing injuries, infxn, and osteomyelitis, also ruptured tympanum and pneumothorax |
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Term
| • How can oxygen supplementation be provided to patients? |
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Definition
- Noninvasive
Flow-by
Face mask
Oxygen hood
O2 cage
- Invasive
Nasal and nasopharyngeal o2
Transtracheal o2
- Hyperbaric o2 |
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Term
| • Which parasite(s) are known to migrate through the lungs and cause pulmonary associated disease? |
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Definition
- Most common migratory – toxocara canis
- Other migratory
- ancylostoma caninum (dogs only)
- strongyloides stercoralis (cats only) |
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Term
| primary lung parasites incl |
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Definition
- paragonimus kellicotti
- aelurostrongylus abstrusus
- capillaria aerophila
- filaroides hirthi
- dirofilaria immitis (HW) can also cause an allergic inflame response when lg #s of antimicrofilarial antibodies entrap microfilariae w/in the pulmonary capillaries |
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Term
| • Know the two main pathophysiologic forms of pulmonary edema. |
|
Definition
- High-pressure edema – cardiogenic edema – most common form of high-pressure edema. Result of left-sided CHF. w/ dogs usually hx of clinical signs consistent w/ heart dz (cough, exercise intolerance, usually heart murmur) may have acute signs, esp if stressed. w/ cats usually no premonitory clinical signs. Due to chronic progression of heart dz, compensatory mech result in fluid retention to maintain cardiac output and, although beneficial short-term, this eventually leads to signs of congestion which is in its most life-threatening form is pulmonary edema
- Increased permeability edema – increase in permeability caused by direct injury to the microvascular barrier or alveolar epithelium by chemical damage and inflammatory mediators. w/ SIRS and dz assoc w/ systemic vasculitis at increased risk.can also be caused by infxs dz. Acute resp distress syndrome (ARDS) is most severe form and is very difficult to manage. Other causes incl pulm thromboembolism, ventilator-assoc lung injury, toxic lung injury such as volatile hydrocarbons and cisplatin in cats, and smoke inhalation. A # of chem irritants in smoke can directly injure the resp tract and inactivate surfactant, causing a combo of atelactisis and increased-permeability edema |
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Term
| • What can cardiogenic pulmonary edema cause or result in? |
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Definition
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Term
| • What can cardiogenic pulmonary edema cause or result in? (short answer) |
|
Definition
- High-pressure edema – due to increased pulmonary capillary hydrostatic pressure. Cardiogenic edema and fluid overload most common forms
- Increased-permeability edema – due to damage of the micro-vascular barrier and alveolar epithelium in more severe cases |
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Term
| • What is the most useful initial test to identify the cause of pulmonary edema induced dyspnea? |
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Definition
| - Thoracic radiographs – can be highly stressful and should be avoided in most severely dyspneic pt until initial stabilization w/ empiric therapy has been attempted. Most dogs will tolerate a quick lateral rad. Cats should not be placed in lat recum as most will find this very stressful. Most cats will tolerate sitting in sternal recum |
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Term
| • Which drugs are used to treat or manage cardiogenic pulmonary disease? |
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Definition
- Key to managing is reduction of pulmonary capillary pressures by reducing preload. Promotion of forward flow also imp in pts w/ lg regurgitant fractions
- Two groups of drugs – diuretics and vasodilators
- Furosemide most freq used diuretic, useful due to rapid onset of action. Excessive use can cause hypovolemia as result of excessive reduction in preload
- Vasodilators less commonly used, for acute most useful group are nitric oxide donors which incl nitroprusside and glycerol trinitrate (nitroglycerin). These act rapidly to cause vasodilation, reducing preload and afterload
- Nitroprusside
Balanced vasodilator that may cause hypotension due to arteriolar dilation
Short half-life so admin IV as CRI
Gen goal w/ therapy is to reduce MAP or (sys) by 10 to 15 mmHg from baseline pressure
In hypotensive pts, must be used w/ positive inotrope but even in pts w/ severe left ventricular dysfunction, shown to have beneficial cardiopulmonary effects
Poss side effects: hypotension, increase in V/P mismatch, reflex tachy (common). Mainly venodilator so minimal effects usually, mostly safe
- Nitroglycerin
Avail as paste for axilla
¼” cats, ¼ - 2” doses dogs q 6 – 8 hrs
Tachyphylaxis (acute decrease in response to drug) occurs rapidly, as little as 24 hrs
Gloves, rub in well, headaches in ppl
- Others:
- B-agonists such as Terbutaline
Act via cyclic adenosine monophosphate (cAMP) to increase fluid reabsorption from alveolar space
Caution in cats with pulm edema
May worsen cardiac fxn in pts w/ hypertrophic, restrictive, hyperthyroid-induced cardiomyopathy |
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Term
| • What is the prognosis for an animal with pulmonary edema? |
|
Definition
- Diverse causes
- Usually if no serious underlying dz then prog good
- If evidence of multisystemic dz and severe increased permeability edema = guarded
- Prog for cardiogenic edema related to severity of dz
- Cats – prog w/ CHF not good, < 1.5 – 2 yrs
- If respond well to furosemide and vasodilators then prog sl better
- Pts who require PPV (pos press vent) gen poor outcome, $ also |
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Term
| • What is the term for a rapid series of sharp percussions of the patient's chest using cupped hands and closed fingers? |
|
Definition
coupage
- Creates vibrational energy to loosen secretions
- Several min over affected lung areas in SA pts
- Not needed in pts that are coughing spontaneously/freq
- Contraindicated in pts w/ coagulopathy, chest pain or fractious |
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Term
| • How often should recumbent patients be turned to prevent atelectasis? |
|
Definition
| - Q 1 – 2 hrs and supported in upright position at least BID, also short walks daily |
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Term
| • What are the common or indicated treatments for bacterial pneumonia? |
|
Definition
|
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Term
| • What are the most common CBC findings in patients with bacterial pneumonia? |
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Definition
- Neither sensitive nor specific
- WBC count cannot be used reliably to confirm or rule out |
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Term
| • What are the clinical signs of aspiration pneumonia and pneumonitis? |
|
Definition
- Acute-onset resp distress
- Poss w/ cyanosis, cough, collapse, pyrexia (fever), mucopurulant nasal d/c
- Freq abnormal lung sounds |
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Term
| • What is the mainstay for the diagnosis of aspiration pneumonia? |
|
Definition
- Thoracic rads
- Typically develop alveolar pattern as a result of displacement of air from alveoli by fluid accumulation and cellular infiltration
- In dog/cat, typicaly affects rt middle lung lobe and ventral parts of other lobes
- Lesion dist affected by pt position at aspiration |
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Term
| • How is aspiration pneumonia typically diagnosed? |
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Definition
| - Hx, clinical suspicion and rads |
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Term
| • Know the best method for managing aspiration and the possible subsequent pneumonia that might result. Hint: Prevention is always the best medicine. |
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Definition
- Prevention
- Fasting
- Prokinetic agents
- Antiemetic agents
- Gastric alkalinization |
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Term
| • What are the proposed criteria for the identification of ALI and ARDS in dogs? |
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Definition
- Preexisting severe acute critical illness/injury (pulm or extrapulm)
- Increased RR/effort
- Bilateral pulm infiltrates on thoracic rads
- Sig hypoxemia defined as PaO2/FiO2 of 200 to 300 (ALI)
- PaO2/FiO2 of less than 200 to 300 (ARDS)
- No evidence of left atrial hypertension as assessed via either ECG or pulm artery catheterization |
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Term
| • What is the role of pulse oximetry in the diagnosis of possible ALI or ARDS in patients? |
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Definition
| - Not a replacement for arterial blood gases (which may be difficult to obtain in sm/fractious pts) but marked desaturation (<90%) should be considered indicative of severe hypoxemia and appropriate measures taken |
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|
Term
| • How long following the initial traumatic impact may pulmonary contusions continue to worsen? |
|
Definition
|
|
Term
| • The lesions associated with pulmonary contusions typically resolve within how many days, unless complications such as pneumonia or acute respiratory distress syndrome ensue? |
|
Definition
|
|
Term
| • What are the possible causes of atraumatic pulmonary hemorrhage? |
|
Definition
- Infectious (bacterial, viral, parasitic)
- Coagulopathies
- Cardiac failures (heart failure, pulm hypertension)
- Neoplasia
- Anatomic (lung lobe torsion)
- Environmental (aspiration pneumonia, FB)
- Misc (exercise-induced pulm hemorrhage in racing greyhounds)
- Iatrogenic (FNA, percutaneous bx) |
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Term
| • Know the possible causes of pulmonary thromboembolism (PTE). |
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Definition
| - Formation of clot material (in the right side of the heart or at a distant site in the venous system) that breaks free and lodges in the pulmonary vasculature |
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Term
| • Pulmonary thromboembolism (PTE) is a complication of which possible diseases? |
|
Definition
- IMHA
- Neoplasia
- Sepsis
- Protein-losing nephropathy and enteropathy
- Cardiac dz
- Hyperadrenocorticism
- Central catheter use
- Hemodialysis
- Total parenteral nutrition
- Hip replacement sx
- trauma |
|
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Term
| • What are the risk factors for PTE? |
|
Definition
| - Hypercoagulability, endothelial damage, stasis of blood flow |
|
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Term
| • What are the diagnostic results that can be used to support a diagnosis of PTE in a patient? |
|
Definition
- Positive D-dimer concentrations
- Echocardiographic detection of echogenic material in the pulm artery or evidence of acute right ventricular overload
- Perfusion deficits on nuclear scintigraphy |
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Term
| • What is commonly, and uncommonly, used to treat PTE? |
|
Definition
- Mgmt. of primary condition
- Support of oxygenation
- Limitation of further growth of the clot w/ anticoagulants or (rarely) thrombolytic agents |
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Term
| • What is the definitive diagnostic procedure for pulmonary embolization? |
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Definition
| - Selective pulmonary angiography |
|
|
Term
| • What drugs are used to treat or prevent pulmonary embolization? |
|
Definition
- Anticoagulation w/ heparin or warfarin therapy,
- Newer platelet-inhibiting drugs such as clopidogrel and ticlopidine, are under investigation
- Thrombolysis using streptokinase, an enzyme that activates plasminogen conversion to plasmin
- To prevent – heparin, low-molecular-wt heparin, aspirin, warfarin |
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|
Term
| • What are the common results or problems associated with smoke inhalation? |
|
Definition
- Upper Resp Tract – direct thermal injury can cause laryngeal obstruction
- Lower RT – injury from irritant gases and superheated particulate matter can result in atelectasis, pulm edema, decreased lung compliance, and acute resp distress syndrome (ARDS) |
|
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Term
| • What is the immediate priority to hasten carbon monoxide elimination in patients that have suffered smoke inhalation? |
|
Definition
| - Hypoxia from carbon monoxide poisoning is presumed to be the main cause of acute death |
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|
Term
| • What are the three major mechanisms that can cause atelectasis? |
|
Definition
- Compression
- Oxygen absorption
- Depletion of surfactant |
|
|
Term
| • What factors can put patients at risk for atelectasis? |
|
Definition
- Critically ill pts at risk because they
Are often recumbent
Recv high inspired o2 levels
Can have decreased lung expansion |
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Term
| • What are the main causes of atelectasis? |
|
Definition
- Inadequate lung expansion
- Extramural airway compression
- Intraluminal and mural obstruction
- Anatomic predisposition
- Anesthesia
- Prolonged recumbency factors in critically ill pts |
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Term
| • What are the clinical symptoms of animals with pleural space disease? |
|
Definition
- Tachypnea
- Open-mouth breathing
- Orthopnea
- Cyanosis
- Short, shallow breathing w/ an increased abdominal component
- Thoracic auscultation often reveals muffled or absent breath sounds over affected areas of the thorax |
|
|
Term
| • Which structures form the pleural space in patients? |
|
Definition
- Pleural space is a potential space formed by the parietal and visceral pleura
- Normally contains a few ml of serous fluid to facilitate motion of the lungs in relation to the thoracic cavity and to each other |
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Term
|
Definition
| - An accumulation of purulent exudate w/in the thoracic cavity |
|
|
Term
|
Definition
| - A pleural space effusion w/ a hematocrit that is 25% gtr than that of the peripheral blood |
|
|
Term
|
Definition
| - A type of pleural effusion resulting from lymphatic fluid (chyle) accumulating in the pleural cavity |
|
|
Term
| • What is a chylous effusion and what are the signs associated with it? |
|
Definition
- Lymphatic fluid (chyle)
- Opaque and white or pink
- Weight loss
- Electrolyte abnormalities (pseudoaddisonian)
- Lymphopenia
- Hypoproteinemia
- Dehydration
- Fibrosing pleuritis |
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|
Term
| • Blind thoracentesis should be performed between which intercostal spaces? |
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Definition
| - 7th and 9th intercostal spaces |
|
|
Term
| • What is the best guide to safely performing thoracentesis for fluid removal? |
|
Definition
|
|
Term
| • Know the specific technique for performing a thoracentesis. |
|
Definition
| - Pg 132 silverstein/hopper |
|
|
Term
| • What are the indications for performing, or not performing, a thoracentesis? |
|
Definition
To perform
- Pneumothorax
- Pleural effusions (chyle, transudate, blood)
Contraindications
- Severe coagulopathies
- Thrombocytopenia
- thrombocytopathia |
|
|
Term
| • What are the indications for chest tube placement? |
|
Definition
- Tension pneumothorax
- Ongoing air leakage despite repeated thoracentesis
- Pyothorax
- Chylothorax
- Penetrating chest injury
- After thoracic sx
- Performance of pleurodesis |
|
|
Term
| • Know the anatomical structures associated with chest tube placement |
|
Definition
- Appropriate intercostal space (7th, 8th or 9th)
- Hold chest tube w/ tip aligned to 2nd rib to estimate insertion length
- Sm skin incision overlying the desired intercostal space midway between the dorsal midline and center of lateral thorax
- Blunt dissection w/ hemostat through sq tissue/musle layers
- Pleura penetrated bluntly w/ lg hemostat or carmalt forceps (stop ventilation during this to minimize lung injury)
- Open hemostat tips to create opening for tube
- Introduce tube into thorax and advance toward uppermost elbow
- Once tube tip well inside, can remove hemostat
- Should be inserted roughly at level of 2nd rib
- All tube fenestrations w/in cavity
- Withdraw stylet and clamp tube w/ hemostat or tube clamp or connect to suction device |
|
|
Term
| • What are the common diseases of the chest wall? |
|
Definition
- Congenital anomalies
- Neoplasia
- Trauma-induced abnormalities (rib fx, flail chest, penetrating wounds)
- Cervical spine dz
- Neuromuscular dz |
|
|
Term
| • Which diseases or problems associated with the chest wall can result in seriously compromised respiratory function? |
|
Definition
- Flail chest
- Penetrating wounds |
|
|
Term
| • What are the nonrespiratory look-alike problems of small animals? |
|
Definition
- Respiratory compensation for metabolic acidosis
- Decreased o2 content
- Pain
- Anxiety
- Stress
- Drugs
- Hyperthemia
- Hypovolemia
- Abdominal enlargement
- Metabolic derangements
- Neurologic dz |
|
|
Term
| • Where are the oxygen-sensing receptors located in the body? |
|
Definition
| - Centrally and peripherally |
|
|
Term
| • An increase in which chemical in the blood will lead to an increase in the hydrogen ion concentration? |
|
Definition
| - Carbon dioxide (metabolic acidosis) |
|
|
Term
| • What is the most common acid-base abnormality in small animals? |
|
Definition
|
|
Term
| • Which metabolic diseases can affect the normal respiratory pattern of small animals? |
|
Definition
- Metabolic acidosis disorders may cause increased rate and depth reflecting an attempt to normalize systemic pH by blowing off CO2
- Metabolic dz or lyte imbalances may result in tachypnea
- Hyperadrenocorticism/hyperthyroidism |
|
|
Term
| • Which chemical or ion imbalance may result in respiratory muscle weakness causing ineffective respiration, resulting in hypoventilation and hypoxemia? |
|
Definition
|
|
Term
| • What are the specific indications for arterial catheterization? |
|
Definition
- Measurement of direct arterial blood pressure
- Obtain blood samples for blood gas analyses |
|
|
Term
| • Where are arterial catheters placed? |
|
Definition
| - Dorsal pedal, femoral, coccygeal and auricular arteries |
|
|
Term
| • What supplies are needed to place an arterial catheter? |
|
Definition
- Electric clippers/blades
- Antimicrobial scrub soln
- Over the needle catheters (20-, 22, and 24- gauge
- ½ and 1” white tape
- T-port or luer-lock male adapters (w/ heparinized saline)
- Cotton balls
- 3 ml syringes w/ hep saline
- Sharpie to label cath
- Stickers “not for IV infusion” |
|
|
Term
| • What are the contraindications for placing arterial catheters? |
|
Definition
- Abrasions, burns, pyoderma over site of cath placement
- Thromboembolic dz or hypercoagulability
- Coagulopathy
- Ambulatory pt that will d/c cath
- NEVER to be used for blood sample, drug to fluid infusion |
|
|
Term
| • Why is orogastric lavage performed? |
|
Definition
| - Important means of removing ingesta from stomach after ingestion of toxins or excessive food |
|
|
Term
| • Why is general anesthesia usually recommended for orogastric lavage? |
|
Definition
| - Must be intubated to protect airway |
|
|
Term
| • What the indications for orogastric lavage? |
|
Definition
- Removal of toxins from stomach
- Removal of food from stomach
- Gastric decompression |
|
|
Term
| • Be able to describe the process for performing orogastric lavage. |
|
Definition
- Pt in sternal or lateral recum w/ cuffed Etube in place
- Measure orogastric tube from tip of nose to last rib
- Insert lubed tube through mouth, to level of last rib, into stomach
- Attach distal end of oro tube to the lavage pump, and instill tap water warmed to body temp into stomach
- Monitor for resp distress or excessive abdo distension
- Separate distal end of tube from lavage pump and allow fluid and gastric contents to flow into a second collection bucket
- Save specimens for ater analysis for toxins, if needed
- Once effluent fluid is clear and stomach empty, kink tube tightly at level of mouth and quickly remove. Kinking tube will help prevent backflow of contents and fluid into esophagus or lungs |
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