2 Airway Management Flashcards
Goals of Airway Management
Ventilation - if you can ventilate, it’s not an emergency
Oxygenation
7 P’s
Preparation Pre-oxygenation Pre-treatment Paralysis w/ induction Positioning Placement w/ proof Post-Intubation management
Pharynx
oro-, naso-, hypo-
- glossopharyngeal nerve innervates posterior wall of pharynx
- vagus nerve for gag reflex
Hypopharynx location & innervation
C5-6, vagus nerve, RLV, SLN
epiglottis to inferior cricoid cartilage
Larynx Functions
- protects lower airway
- patency
- gag & cough reflex
- phonation
3 single cartilages of Larynx
Epiglottis
Thyroid
Cricoid
3 unpaired cartilages of Larynx
Arytenoid
Cuneiform
Carniculate
Intrinsic & Extrinsic Muscles of Larynx control…
Extrinsic control - move entire larynx, elevators & depressors
Intrinsic control -
Lower Respiratory Tract
structures below cricoid cartilage
Trachea
inferior cricoid cartilage down to carina (10-20cm)
Only full ring of cartilage in trachea…
cricoid, then 16-20 c-shaped rings
Airway Evaluation
- central to any plan, must be thorough
- consider equipment, staff experience
Potential causes of difficult intubation
- inadequate pre-op assessment
- anesthetist
- equipment
- inexperience
ASA definition of difficult to ventilate
when signs of inadequate ventilation cannot be reversed by mask ventilation
OR
the pts oxygen saturation cannot be maintained above 90% with mask ventilation
ASA definition of difficult to intubate
a trained anesthetist provider, using conventional laryngoscopy, requires more than 3 attempts or more than 10 minutes to complete tracheal intubation
ASA definition of difficult airway
a trained anesthetist experiences difficulty with facemask ventilation, laryngoscopy, intubation or all of the above
LEMON
Look externally Evaluate 3-3-2 rule Mallampati Obstruction/Obesity Neck mobility--> atlanto-occipital range
BONES
*mnemonic for if mask ventilation will be difficult
Beard
Obesity
No teeth
Elderly (>55y/o, loose airway elasticity)
Snoring
4 D’s
*predict how difficult laryngeal visualization may be Disproportion Distortion Dismobility Dentition
Anticipated Difficult Airway…
-cricothyroid membrane should be identified and marked prior to surgery
Anticipated Difficult Airway…
-cricothyroid membrane should be identified and marked prior to surgery
Cricothyrotomy
- cricothyroid membrane
- 14F angiocath, 3.0 ETT adapter + bag
- needle vs surgical
3 options for airway management…
- ) awake intubation
- ) quick look - sedated, no paralytic, decreased risk of failed BVM
- ) induction & paralysis - classic
Pre-oxygenation technique
- ) tidal volume breathing for 3-5 min
- ) deep breaths x4 within 30 seconds (preferred)
**increase arterial oxygen tension, good for pts with limited FRC
Initial intubation attempts after GA unsuccessful –>
- ) call for help
- ) return of spontaneous ventilation - sux, prop, LMA
- ) awakening patient
Initial intubation attempts after GA unsuccessful –>
- ) call for help
- ) return of spontaneous ventilation - sux, prop, LMA
- ) awakening patient
LMA/SGA
- intubation conduit
- size based on ideal weight, typically sz 4
Laryngeal Scope Blades
Mac
Miller
Wis
Heine
Fiberoptic Intubation
- nasal or oral
- useful for tricky intubation or when putting in double lumen tube
Video Assits
glidescope
McGrath
Tube Changer
bougie- helpful if you can’t see cords at all - feel tracheal cartilage
Light wand
Eschmann stylet
Invasive Airway Access
Jet ventilation
percutaneous intubation
retrograde intubation
surgical airway
Plan A
Initial Strategy
elective intubation
RSI
-bougie, blade, video scope
Plan B
Secondary intubation strategy
- NOT appropriate for elective RSI
- classic LMA
- fiberoptic intubation through LMA
Plan C
Maintain oxygenation & ventilation
- attempt to wake pt up, consider suggamedex if available
- facemask, NP airway, LMA
Plan D
rescue techniques –> can’t intubate, can’t ventilate
-needle cricothyroidotomy
Upper Airway Obstruction
- emergent
- s/s hoarse, muffled voice, difficulty swallowing, secretions, stridor, dyspnea
Lower Airway Obstruction
management- optimize ventilation & oxygenation
-high peak pressure, low TV, impaired ventilation
Pts with OSA…
bring CPAP to PACU
Obese pts…
- position
- pre-oxygenate (limited FRC)
- have alternate plans
- will desat quicker, limit delays
Extubation Criteria
- hemodynamic stability
- normothermia
- ability to maintain airway (TOF >0.9, lift head for 5 sec) capacity >15ml/kg
- ability to oxygenate
- acceptable analgesia
