13 Feb Airway Assessment Techniques and Management (Exam 2) Flashcards
What is the primary confirmation of tube placement during intubation?
Visualization of the tube passing through the vocal cords
This confirmation is crucial for ensuring proper placement.
Pneumonic
List criteria associated with difficult mask ventilation.
**Mnemonic=OBESE
* Obesity (BMI>30)
* Beards
* Edentulous (No teeth)
* Snorer/Obstructive sleep apnea
* Elderly (Age>55)
A Mallampati 3 or 4 is also listed.
These factors increase the likelihood of ventilation difficulties.
You hate the Mnemonic OBESE for predicting a difficult airway, what is another one?
BOOTS
- Beard – gel it down
- Obesity
- Older
- Toothless – “gather” cheek, 2 people needed
- Sounds – snoring, stridor
Also, Inability to maintain O2 saturations >90% with BMV
When life gives you LEMONS, think it’s going to be a difficult intubation. What does LEMONS stand for?
- L- Look – abnormal face, trauma, unusual anatomy
- Evaluate – 3-3-2 rule (3 finger mouth opening, fingers along the floor of the mandible, 2 fingers between the space between the superior notch of the thyroid cartilage, and neck/mandible junction
- Mallampati score – I-IV, relates mouth opening to size of tongue
- Obstruction/obesity – tumor, infection
- Neck mobility
- Stand around and look for something to do? I don’t know, there wasn’t an S on the slide…
Run through the ASA difficult airway algorithm for adult patients in your head and check your work on the next card.
Fill in the blank: Patients with larger ______ tend to be more difficult to ventilate.
BMI is textbook answer.
- Short or thick neck >43 cm = difficulty w/ intubation and is more predictive than high BMI
True or False: All patients with beards can be effectively ventilated using a face mask.
False
Facial hair can prevent a proper seal during ventilation.
What is the significance of the 332 rule in airway evaluation?
Three fingers in the mouth (mouth opening), three fingers along the floor of the mandible , two fingers between thyroid and neck mandible junction (thyromental distance)
This rule helps assess airway difficulty.
What is the ASA difficult airway algorithm?
A guideline for managing patients suspected of having a difficult airway
It includes steps to evaluate and manage airway difficulties.
What is the recommended action if mask ventilation fails?
Consider a supraglottic airway
This can provide an alternative means of ventilation.
What does ‘passive oxygenation’ refer to?
Using a nasal cannula to oxygenate during apnea
This method can maintain oxygen levels even when ventilation is not possible.
What is a common mistake when trying to ventilate beard patients?
Using KY jelly to create a seal
This often exacerbates the problem rather than solving it.
What factors can increase the risk of aspiration during intubation?
- Infection
- Obstructive sleep apnea
- Not fasting (NPO)
These factors can complicate the intubation process.
What should be done if a patient cannot open their mouth during airway assessment?
Consider nasal intubation or fiber optic techniques
This is necessary if oral intubation is not feasible.
What is the first decision to make when managing a known difficult airway?
Whether to perform the procedure while the patient is awake or post induction.
What are some indications for keeping a patient awake during intubation?
- Anticipated difficulty in placing an instrument in the airway
- Increased risk of aspiration
- Increased risk of desaturation
- Suspected difficulty with invasive airway procedures
What anatomical feature could make a surgical airway difficult to perform?
A large goiter obstructing the cricothyroid membrane.
What should be done to prepare for a difficult airway situation?
- Identify the cricothyroid membrane (and mark it if there is time)
- Prepare backup airway equipment
- Have a plan for jet ventilation
What technique is commonly used for awake intubation?
Trans tracheal block using lidocaine.
What is the purpose of pre-oxygenation during intubation?
To optimize oxygen levels in the patient before intubation.
True or False: An awake intubation means the patient must be fully alert.
False.
What are some medications used during awake intubation?
- Ketamine
- Propofol
- Sedatives
What should be done if intubation attempts are unsuccessful?
Consider stopping the attempts to avoid causing more trauma.
What is ‘get home syndrome’ in the context of airway management?
The tendency to push for intubation even when conditions worsen, leading to potential patient harm.
In what situations might you want to intubate a patient early?
- Neck trauma
- Angioedema
- Burns
What factors influence the decision to perform rapid sequence intubation (RSI)?
- Urgency of the situation
- Patient stability
- Anticipated airway difficulty
What is the role of glycopyrrolate in airway preparation?
To dry up secretions in the airway before intubation.
What is a preferred method for topicalizing the airway?
Using nebulized 4% lidocaine.
What positioning is recommended for awake fiber optic intubation?
Sitting upright to prevent airway collapse.
How should should you set up prior to performing direct laryngoscopy (DL)?
- Laryngoscope on the left
- Suction on the right
- Intubation tube on the chest
Fill in the blank: The technique of using a needle to access the trachea for intubation is called _______.
needle cricothyrotomy
What should be done to manage a patient with a full stomach before intubation?
Consider placing an NG tube to decompress the stomach.
Why is it important to avoid multiple doses of sedatives during intubation?
To prevent excessive sedation and respiratory depression.
What is the presumed purpose of cricoid pressure during intubation?
To compress the esophagus and improve visualization of the laryngeal structures
Although cricoid pressure is considered standard care for emergent intubations, it has been largely disproven in terms of its effectiveness.
True or False: Cricoid pressure is effective in preventing vomiting during intubation.
False
Cricoid pressure is supposed to occlude the esophagus to prevent vomiting, but it often complicates visualization.
What is the Bougie used for in intubation?
It is an introducer for an endotracheal tube, aiding difficult intubations.
- Tracheal rings can be felt as a bumping sensation signaling to the provider that they are in the trachea and not the esophagus.
The Bougie has a curved (Coudé) tip that helps guide the tube into the trachea.
If you aren’t careful, your laryngoscope blade can catch the lip during intubation and lead to bleeding and/or swelling. How do you prevent this?
Sweeping the lip out of the way before lifting the blade can prevent this issue.
- Yes this a very simple question but do your patient a favor and always think about this before plunging in with a cold blade :)
What are some medications historically used for sedation during intubation?
- Lidocaine
- Atropine
- Fentanyl
- Propofol
- Neuromuscular blockers
Historically, large doses of fentanyl were used, which could lead to complications like rigid chest (especially if the fent is given rapidly).
What is the effect of large doses of fentanyl on ventilation?
It can cause rigid (wooden) chest, making ventilation difficult
- This complication necessitates the use of neuromuscular blockers to facilitate ventilation.
Fentanyl may also induce muscle rigidity by activating spinal motor neurons through its actions on the pons
What is the duration of action for succinylcholine versus rocuronium?
- Succinylcholine: 5-10 minutes
- Rocuronium: 30-90 minutes
The choice of neuromuscular blocker can depend on the duration of required muscle relaxation.
What are complications of/contraindications when using succinylcholine?
- rhabdomyolysis
- existing hyperkalemia
- multiple sclerosis
- ALS
- muscular dystrophies / inherited myopathies
- denervating injuries > 72 hours old (e.g. stroke, spinal cord injury)
- burns > 72 hours old
- crush injury > 72 hours old
- tetanus, botulism, and other exotoxin infections
- severe infections >72 hours old (esp. intra-abdominal infections)
- immobilization (including patients found down)
This is particularly concerning in trauma patients who may already be at risk.
Why might cricoid pressure make intubation more difficult?
It can obstruct visualization of laryngeal structures
Cricoid pressure does not effectively occlude the esophagus as intended.
What alternative to succinylcholine has become more acceptable due to new reversal agents?
What would be the contraindications to using this newer NMBD?
Rocuronium
- There are no real contraindications to Roc unless the patient has an allergy (unfortunately you will probably be the one to find out if they have one)
With the availability of reversal agents, rocuronium can now be used more freely.
What physiological effects should be considered when intubating a patient?
- Hypotension
- Hypoxemia
- Metabolic acidosis
These factors can often be optimized prior to intubation.
What is the advantage of using a backup IV or IO access?
To ensure access in case of complications during critical situations
- It’s important to have multiple access points to avoid delays in treatment.
2 is 1 and 1 is none “Lord Corndog”
How can you optimize blood pressure before intubation?
Sedatives low and paralytics high
Increasing blood pressure before sedation can help maintain hemodynamic stability.
Fill in the blank: The _______ can be used to ventilate a patient while intubating.
LMA
You can place and ETT through the LMA so don’t be afraid to use it while you figure out your difficult airway!
What is the recommended approach when using rocuronium for intubation?
Consider higher doses than the standard 1.2 mg/kg
- Literature supports that increasing the dose can decrease onset time.
What are you going to do? Paralyze them more?
Why do we give patients sedation before intubation?
To prevent them from remembering the procedure and to avoid spikes in blood pressure during the procedure
Sedatives like midazolam and ketamine can help achieve this.
What is the advantage of ketamine in patients during intubation?
It provides cardiovascular stability by causing a sympathetic surge and increased contractility
Ketamine is often preferred for its hemodynamic benefits.
What is the recommended practice for administering paralytics before intubation?
Use a high dose of paralytic for rapid onset
This ensures quicker muscle relaxation for intubation.
What is a common concentration for pushing epinephrine?
10 micrograms per milliliter
Achieved by drawing 0.1 mL of a 1 mg/mL solution into a flush.
How can phenylephrine be diluted for administration?
Dilute 10 mg in a 100 mL bag to achieve 100 micrograms/mL or a 250 mL bag for 40 micrograms/mL
Push doses typically range from 50 to 100 micrograms.
What is the common dosage format for vasopressin?
20 units in a vial, diluted to 20 mL
Allows for administration of 1 to 2 units at a time.
What can be used to prevent desaturation during intubation?
Nasal cannula at 10 to 15 liters or a bag valve mask with PEEP
This helps maintain oxygen saturation during the procedure.
What medication can be administered to treat pulmonary edema while pre-oxygenating?
Lasix or nitroglycerin
Nitroglycerin acts quickly, while Lasix takes longer to work.
What is the effect of sitting a patient upright during intubation?
Enhances lung expansion and reduces aspiration risk
Gravitational forces help improve lung function.
What should be considered when dealing with acidotic patients?
Assess CO2 levels before administering bicarbonate
Rapid bicarbonate administration can worsen acidotic conditions if CO2 levels are already high.
What is a critical consideration for patients at risk of aspiration?
Consider placing an NG tube to decompress the stomach
Upright positioning can also help reduce aspiration risk.
What is a common misconception about patient positioning during intubation?
That all patients must be supine for intubation
Sitting patients up can improve airway access and reduce aspiration risk.
What are the risks of rapid bicarbonate administration in acidotic patients?
Can lead to high incidence of ventricular arrhythmias D/T elevated CO2 levels
Slow administration is preferred to mitigate risks.
How can you optimize pre-oxygenation in a patient with a difficult airway?
Use nasal cannula and bag valve mask simultaneously with PEEP
This improves oxygenation while preparing for intubation.
What should you do if you encounter difficulty intubating a patient?
Cric them immediately!
Kidding…Consider using an LMA if initial attempts fail
Considering whether or not to cric your patient should always be in your mind if there is difficulty but be sure that you have exhausted all options if there is time to do so.
- You don’t want to put a hole in your patient’s neck before you try to bag them right?
An LMA (Laryngeal Mask Airway) can simplify the ventilation process and an ETT can be placed through the LMA so once the LMA establishes the airway, risk decreases substantially.
True or False: It is acceptable to panic in the operating room if something goes wrong.
False
Maintaining composure is crucial in high-pressure medical environments.
Fill in the blank: When you have difficulty with ventilation, you should not hesitate to put in an _______.
LMA
What is the purpose of airway assessments?
To evaluate and manage potential airway obstructions and complications.
What are turbinates?
Thin, cartilaginous structures in the nasal cavity covered with vascular tissue.
These bleed easily, be careful!
How can you avoid causing bleeding when inserting a nasal airway?
By passing the airway across the top of the hard palate.
What divides the nasal cavity into two sides?
The septum.
What is a common issue with the septum during airway management?
It can be punctured, leading to complications.
What is a necessary measure to prevent trauma when performing airway procedures?
Using vasoconstrictors.
What is a medically accepted use of cocaine in airway management?
As a vasoconstrictor when applied to nasal passages.
What are the two types of medications commonly found in Afrin nasal spray?
- Phenylephrine & Oxymetazoline
- Of course it’s important…Know which one your pharmacy stocks before giving it because Phenlephrine can have SNS effects where Oxymetazoline will not.
What can be applied to a nasal airway to ease insertion?
Lidocaine jelly.
What is the primary concern when examining the mouth during airway assessment?
The presence and condition of the teeth.
Teeth are expensive to repair/replace and you will probably have to pay for it.
What role does the tongue play in airway obstruction?
It can fall back and block the airway.
What should be assessed about the tongue during an airway examination?
Its mobility and moisture level.
It’s hard to move your laryngoscope across sandpaper.
What is the anatomical term for the ‘dangly thing’ in the throat?
The uvula.
What is a common issue that can arise from large tongues during airway management?
Airway obstruction.
What is the unique characteristic of the cricoid cartilage?
It is the only complete ring in the trachea.
What can alter airway structures during surgical procedures?
Why is this important?
- Surgeons performing laryngectomies or other airway surgeries.
- This can make it more difficult to intubate and could change the distance for your ETT.
What is the primary function of the larynx?
To serve as the gateway to the trachea and facilitate sound production.
What is the cricothyroid membrane?
The thin tissue layer located below the laryngeal prominence (thyroid cartilage pointy bit).
What is the hardest part of performing a surgical cricothyrotomy?
Deciding to perform the procedure.
What is the typical length of the adult trachea?
10 to 15 centimeters.
What anatomical feature of the trachea is shaped like a ‘C’?
The tracheal cartilage.
What is the esophagus located in relation to the trachea?
It is located posteriorly to the trachea.
What are the two critical questions to ask when assessing an airway?
Can I intubate the patient? Can I ventilate them?
Ventilating the patient is more important than intubating.
Why is good airway assessment important?
To avoid surprises with a difficult airway.
Not assessing a patient can lead to bad decisions.
What is more critical in an emergency: intubation or ventilation?
Ventilation.
Ventilation can keep a patient alive until further help arrives.
What should be done before inducing anesthesia?
Assess the airway and develop a plan.
Options are limited after anesthesia induction.
What is the most important history that should be reviewed for airway assessment?
Previous difficult intubation history.
Information can be gathered from patient interviews or medical records.
What physical signs may indicate a difficult airway?
Sore throat, cut lip, broken tooth after previous intubation.
These may indicate previous intubation difficulties.
What is the significance of a patient’s facial structure in airway management?
It can indicate potential difficulties such as fractures or orthodontic appliances.
Visual inspection can provide immediate clues about airway challenges.
What is micrognathia?
A condition characterized by a recessed jaw
Micrognathia can complicate airway management during anesthesia.
What is a warning sign of airway burns?
Burns on the face, soot, singed nasal hairs
These signs indicate potential airway damage from heat or chemicals.
True or False: A high BMI is always indicative of a difficult airway.
False
A high BMI does not necessarily mean an equally challenging airway inside.
What is the standard mouth opening measurement for intubation assessment?
Three finger breaths (Prefer>6cm opening)
This measurement helps estimate the ease of intubation.
Fill in the blank: ACE inhibitors can cause _______.
Angioedema
Angioedema can lead to significant airway obstruction.
What should be considered when treating ACE inhibitor-induced angioedema?
Supportive care, vasoconstrictors, antihistamines, no further ACE inhibitors
Transaminic acid and no SFP are effective treatments.
What is a high arched palate associated with?
Potential airway complications and other syndromes
A high arched palate can lead to structural issues affecting intubation.
What should be done if a patient has no teeth?
Consider using an oral airway for ventilation
Lack of teeth can lead to soft tissue collapse in the airway.
What percentage of closed claims against anesthesia providers involve dental injuries?
About 25%
Dental injuries often occur during airway management procedures.
What is a common cause of dental injuries during anesthesia?
Scissor mouth opening technique
Improper technique can lead to tooth damage.
What is the risk of using a laryngoscope on patients with prominent upper incisors?
Potential for damaging the incisors
Prominent teeth can obstruct the view during intubation.
When is it easier to manage a difficult airway?
When keeping the patient spontaneously ventilating
Maintaining spontaneous ventilation can prevent airway collapse.
What should be done if a patient presents with a tongue that is excessively swollen?
Consider nasal intubation or keeping the patient awake
A swollen tongue can obstruct the airway and complicate intubation.
What is an important consideration when dealing with patients who have had chemotherapy and radiation?
Tissue fragility
Chemotherapy and radiation can make oral tissues sensitive and prone to bleeding.
What is the most common side for teeth to get knocked out during procedures?
Left side of the mouth
This is due to a tendency to shift everything over to that side.
What device is often placed in patients during recovery that can lead to dental injuries?
Oral airway
It can break or knock out teeth if the patient bites down on it.
What is the purpose of the sniffing position in intubation?
To align oral, differential, and laryngeal axes
What anatomical feature should be level with the chest in the sniffing position?
Ear
This alignment helps in achieving the ideal intubating position.
What are some common conditions that restrict neck mobility?
- Cervical compression
- Degenerative disc disease
- Rheumatoid arthritis
- Down syndrome (issues with atlanto-occipital extension)
What is the sternomental distance used for in intubation?
To measure from the manubrium to the chin for assessing intubation difficulty
- >12.5cm preferred
What is the preferred submandibular space measurement for intubation?
Three finger breaths
- Tip of chin to thyroid notch
What is the Malampati classification used for?
To evaluate oropharyngeal structures
- Helps determine airway visibility during intubation
What is the scoring range of the Malampati test?
1 to 4
In Malampati Class 1, what structures are visible?
- Faucial pillars
- Entire uvula
- Soft palate
In Malampati Class 2, what structures are visible?
Fauces, portion of the uvula, and soft palate
In Malampati Class 3, what structures are visible?
Base of the uvula and soft palate
In Malampati Class 4, what can be seen?
Only the hard palate
What is the upper lip bite test, AKA the bulldog test used for?
To assess the ability to extend the lower jaw (prognathic)
What is the burp maneuver in intubation?
What directions are involved in the burp maneuver?
External manipulation of laryngeal structures
- Backwards (towards the esophagus)
- Upwards (cephalad)
- To the right
- Pressure
What is the difference between the Malampati and Cormack-Lehane classifications?
Malampati evaluates external airway (oropharyngeal structures), Cormack-Lehane evaluates internal airway (Laryngeal View)
In Cormack-Lehane Class 1, what view is obtained?
Entire glottic aperture visible
What is indicated when only the posterior glottis is visible in Cormack-Lehane Class 2?
Partial view of the glottic opening
What is indicated when only the posterior glottis is visible in Cormack-Lehane Class 3?
No part of the glottis and only epiglottis
What is indicated when only the posterior glottis is visible in Cormack-Lehane Class 4?
Epiglottis cannot be seen
What is the ideal patient positioning for intubation?
Align the three axes: oral, differential, and laryngeal
What is the recommended technique for lifting a patient’s head for intubation?
Elevate the head and neck slightly, not just extend the neck
