2. Airway Management Flashcards
airway assessment
is mandatory for provision of any anaesthetic, whether general,
regional, local, or ‘only’ sedation. It is also essential before managing the airway, even in
emergency settings.
A targeted history and clinical examination can be supplemented by
special investigations if needed
difficult mask mask ventilation
can’t oxygenate
difficult laryngoscopy or intubation
can’t intubate
difficult (or impossible) supraglottic
can’t rescue
difficult front- of neck access
can’t fona
difficult mask ventilation acronym
BONES
difficult intubation acronym
LEMON
Difficult (or impossible) supraglottic acronym
RODS
difficult front of neck access/ cricothyroidotomy acronym
SHORTY
Difficult mask ventilation: BONES
B- beards
O- obesity/ obstruction
N- no teeth
E- elderly
S- stiff lungs or snoring
Difficult Intubation: LEMON
L- Look externally (does the airway look difficult?
E -Evaluate the 3-3-2:
**3 fingers thyromental distance
**3 fingers interincisal distance
**2 fingers thyrohyoid distance
M -Mallampati classification
O -Obstructions
N- Neck mobility
(or you can use the “Four D’s”
Difficult (or impossible) supraglottic: RODS
R Restricted mouth opening
O Obstructions or morbid Obesity
D Distorted or dysmorphic anatomy
S Stiff lungs (e.g. bronchospasm)
Difficult front-of-neck access: SHORTY
S Scars or surgery to the neck
H Haematomas (bleeding into the neck)
O Obesity or Obstruction
R Radiotherapy to the neck
T Trauma or tumours of the anterior neck
Y (Very) Young patients
S Scars or surgery to the neck
H Haematomas (bleeding into the neck)
O Obesity or Obstruction
R Radiotherapy to the neck
T Trauma or tumours of the anterior neck
Y (Very) Young patients
The FOUR D’s pf Airway Assessment
disproportion
distortion
dysmobility
dentition
disproportion
- Macroglossia (big tongue)
- Micrognathia (small chin)
- High arched palate
- Bony abnormalities
- Short thick neck
distortion
- Airway trauma
- Epiglottitis
- Abnormal larynx (e.g. laryngeal tumours)
dysmobility
Limited mouth opening (< 3 cm)
- Fixed cervical spine (e.g. ankylosing spondylitis)
- Cervical spine injury
dentition
- Gap between upper teeth (‘passion’ gap)
- Protruding upper teeth (‘buck’ teeth)
Sets of bedside tests sued to predict possibility of a difficult intubation
- Thyromental, interincisor and thyrohyoid distances (“3-3-2”)
- Mallampati classification / score
- Neck mobility (extension at the atlanto-occipital joint)
Thyromental, interincisor and thyrohyoid distances (“3-3-2”)
-Thyromental distance:
The thyromental distance is the distance in the midline from the mentum (chin) to the
thyroid notch. This measurement is performed with the patient’s neck fully extended. A
thyromental distance of < 3 finger-breadths, or < 6 cm in adults, is predictive of a difficult
intubation.
-Interincisor distance:
The interincisor distance is the distance between the incisors when the patient opens
their mouth as widely as possible. A distance of < 3 finger-breadths, or < 4 cm in adults,
is predictive of a difficult intubation.
-Thyrohyoid distance:
The thyrohyoid distance is the distance of the lower mandible in the midline from the
mentum (chin) to the thyroid notch. This measurement is performed with the patient’s
neck in the neutral position. A thyromental distance of < 2 finger-breadths, or < 3-4 cm
in adults, is predictive of a difficult intubation.
The Mallampati description
This test is performed with the patient in the sitting position, the head held in a neutral position,
the mouth wide open, and the tongue protruding to the maximum. Patients do not phonate when
assessing the Mallampati score, but saying “aaaah” will provide an indication of tissue mobility.
The subsequent classification is assigned based upon the pharyngeal structures that are visible.
The Mallampati classification:
Class I = visualisation of the soft palate, fauces, whole uvula, anterior and posterior pillars
Class II = visualisation of the soft palate, fauces and most of the uvula
Class III = visualisation of the soft palate and only the base of the uvula
Class IV = only hard palate visible, soft palate is not visible at all
a hoarse voice, stridor or difficulty in phonation
suggests difficulty in managecment of the airway
neck mobility
measure the extension of the antlanto occipital joint
Why is preparation crucial for airway management?
Preparation is crucial because airway management demands full attention and quick response to emergencies.
What are the three main categories of preparation mentioned?
The three main categories of preparation are -
-equipment,
-drugs (induction and emergency) , and
-patient positioning/preoxygenation.
What equipment is essential for airway management?
Essential equipment includes introducers, masks, airways, laryngoscopes, endotracheal tubes, and suction devices.
What does the acronym IMALES stand for?
IMALES stands for
-Introducer,
-Masks,
-Airways,
-Laryngoscopes,
-Endotracheal Tubes, and
-Suction.
Why is it important to check the equipment before starting airway management?
It’s essential to check the equipment to ensure everything is in working order and readily available in case of emergencies.
What are the crucial monitors for safe airway management?
The crucial monitors are the capnograph and pulse oximeter.
What drugs are necessary for airway management?
induction agents
neuromuscular blockers
inotropes/ vasopressors
induction agents
propofol,
ketamine,
etomidate
neuromuscular blockers
(succinylcholine,
rocuronium
inotropes/vasopressors
usually ephedrine
Why is neuromuscular blockade important?
Neuromuscular blockade ensures muscle relaxation, facilitating easier airway management.
What is the role of inotropes/vasopressors during airway management?
Inotropes/vasopressors are used to manage post-intubation hypotension.
What are the two key factors in patient preparation for airway management?
The two key factors are positioning and preoxygenation.