2025 Airway Management Exam 2 Flashcards
Lectures 3-6: Airway Management and Equipment, Airway Evaluation, LMAs, Intubation
Airway Basics: What Does the Human Airway Do
Protection
Physical protection from aspiration
Lymphatic protection from microorganisms
Conduction
O2 in
CO2 out
Anesthetic gases and vapors
Air conditioning
Heat
Humidification
Anesthesia and Airway: What do we do to the Human Airway
Protection
Continue physical protection from aspiration
Not compromise protection from microorganisms
Conduction
Support O2 in
Support CO2 out
Supply and remove anesthetic gases and vapors
Air conditioning
Minimize heat loss
Minimize water vapor loss
Supportive Oxygen Therapy
Low flow devices
Nasal cannulas
Simple face masks
Partial rebreathing masks
Nonrebreathing masks
Tracheostomy collars
Depend on room air entrainment to meet the patient’s peak inspiratory and minute ventilatory demands
With changes in VT, RR, O2 reservoir FiO2 can vary dramatically
Nasal Cannula
For every 1L/min of O2 = 4% Increase in O2%
FiO2 of 24-44%
Anesthesia (Monitored Anesthesia Care)
Need a gas sampling line to monitor for spontaneous respirations
2 Variations Essentially
Nasal Cannula without CO2 monitoring
Nasal Cannula sampling line (CO2 monitoring)
Used when patient under anesthesia is asleep, common would be during MAC, make sure they are breathing
A lot of providers will just jump to mask if have to go more than 4 L/min in fear of drying out patients nose
Face Masks
Simple
FiO2 35-60% (6-10L/min)
Partial rebreathing
FiO2 60-90% (6-10L/min)
Non rebreathing
FiO2 Almost 100% (10-15L/min)
Venturi Mask
24-50% (Variable)
Simple Mask
FiO2 35-60% (6-10L/min)
Some providers prefer to use a simple mask post surgery when delivering patient to PACU… can see the fog to know they are breathing
Partial Rebreathing Mask
FiO2 60-90% (6-10L/min)
Nonrebreathing Mask
FiO2 Almost 100% (10-15L/min)
Rebreather Mask Function
Rebreather Mask Diagram
High Flow Devices
Have flow rates and reservoirs large enough to provide the total inspired gases reliably
Flows in excess of 30-40 L/min (or 4x minute volume)
Venturi masks, aerosol masks, and T-pieces powered by air-entrainment nebulizers or air oxygen blenders
Ability to deliver predictable, consistent, and measurably high and low FiO2s despite ventilatory pattern
Venturi Mask
24-50% (Variable)
Provides predictable and reliable FIO2 values of 24-50% (independent of patient’s respiratory pattern)
Air entrainment based on Bernoulli principle
Rapid velocity of gas moving through a restricted orifice
Fixed FiO2 model (color coded)
OR
Variable FiO2 model (graded adjustment)
Venturi Effect
Potential Passageways for Relieving Obstruction
Oral route
Obstruction from tongue (common), obese (there excess fat tissue collapsing into back of throat)
Nasal route
Obstruction from trauma typically (broken nose)
Airway During Anesthetic
Airway Obstruction: Oral
Obstruction relieved by:
Repositioning the head
Displacing the mandible anteriorly
How to Support Airway
Physical maneuver
Jaw thrust
Head Tilt/Chin lift
Adjuncts for physical support
Oral airway (OPA)
Nasal airway (NPA)
What Happens to Airway During Anesthesia
Unconscious patient
ATTEMPTNG to spontaneously breath, but airway obstructed
Management
O2
Airway support
Physical maneuver – jaw thrust maneuver
Instrumentation for physical support – (oral airway),(nasal airway)
Assistance for breathing – positive-pressure ventilation with bag-mask
Assist respirations
Controlled respirations, if bradypneic or apneic
Unconscious patient with neuromuscular blockade
Patient has been paralyzed - NOT ATTEMPTING to spontaneously breathe and airway may be open or closed
Management
Positive-pressure ventilation
Bag-mask
LMA
ETT
Oropharyngeal Airway (OPA) Basics
Two types of OPAs
Guedel
Body
Central lumen
Flange
Berman
Body
Central I beam
Side air channels
Flange
What are the structural and functional differences between them?
How do you size an OPA?
How do you insert an OPA with minimum trauma?
What purpose does a tongue depressor serve for OPA insertion?
What are the contraindications for using an OPA?
When do you remove an OPA?
Indications – OPA
Airway maintenance in the sedated and unconscious patient
Protects an endotracheal tube (ETT) from being bitten and occluded
This puts patient at risk for front tooth damage and also tongue swelling if left in place for a long period of time
Facilitates airway suctioning
OPA: Sizing
General Sizing
Flange at corner of mouth
Tip at angle of mandible
Most woman are: 9 or 90
Most men are: 10 or 100
Adult Sizes
Large: 100 mm flange to tip
(Guedel 5)
Medium: 90 mm flange to tip (Guedel 4)
Small: 80 mm flange to tip (Guedel 3)
Child Sizes
Lengths: 40-80 mm (Guedel
sizes 000 to 3)
OPA: Insertion (2 Ways) and Removal
Use a tongue depressor to pull tongue forward in the mouth (not required)
OR
can Insert upside-down and rotate 180° (but this risks tooth and/or palate damage)
Removal
Typically removed as they are waking up or start grabbing at it
OPA Complications
Oral airway too short
Pushes tongue into airway
Oral airway too long
Obstructs larynx by forcing down epiglottis
Vomiting and laryngospasm in the awake patient
Nasopharyngeal Airway (NPA)
What are the structural and functional components of NPAs?
How do you size a NPA?
How do you insert a NPA with minimum trauma? What are the contraindications for using a NPA?
What are the anatomic
Considerations for insertion of a NPA?
When do you remove a NPA?
Indications
Airway maintenance
Oral airway placement difficult
Semiconscious patient not tolerating OPA
Dilation of nasal passage for nasal intubation
NPA: Sizing
Airway diameter should not be too large
Should not blanche the nasal ala
Length: Tip of the nose to the tragus of the ear
Adult
Large: 8-9 mm Internal Diameter (I.D.), 34 fr
Medium 7-8 mm Internal Diameter (I.D.), 30 fr
Small 6-7 mm Internal Diameter (I.D.), 28 fr
Child
Diameters: 12F (~3mm ETT) to 36F
Alternatively may use a shortened ETT
French size / 3 = Diameter in millimeters
NPA: Insertion
Lubricate with water soluble lubricant or anesthetic jelly (not required)
Gently insert into nostril
Along floor of nostril, perpendicular to face
Parallel to turbinates
If resistance occurs
Try slight tube rotation
Try other nostril
Check for respirations following placement
NPA: Complications
Esophageal intubation (if too long)
Laryngospasm (if too long)
Vomiting (less likely than with OPA)
Nasal mucosa injury (turbinates specifically) and secondary blood aspiration
Epistaxis
Tissue Necrosis (if left in too long)
Airway and Anesthesia: What We Can Use to Control the Airway
Positive-pressure ventilation
Bag-mask ventilation
Laryngeal mask airway (LMA)
Endotracheal tube (ETT)
Spontaneous ventilation (Negative Pressure)
Bag-mask ventilation
Laryngeal mask airway (LMA)
Most common use… commonly called a glorified oral airway… very useful for a spontaneous breathing patient
Endotracheal tube (ETT)
Bag/Valve/Mask (BVM)
Every Anesthesia Machine needs an Ambu bag with the machine
Face Masks for BVMs
Resuscitation
Malleable, transparent body
22 mm connection
Air-cushion seal
No retaining ring
Anesthesia
Opaque body or
Transparent body
22 mm connection
Air-filled seal
Retaining ring
How to BVM
Mask is pressed against nasal bridge with thumb.
Ensure that there is no pressure on the eyes
Index finger exerts downward pressure on the base of the mask over the chin.
Little finger should engage the angle of the mandible.
How to BVM Picture
Suction Devices
Suction Saves Lives
Oral secretions
Bloody secretions
Yankauer suction tips
Gentle curve to fit airway
Multiple holes at tip
Suction Catheters and Canisters
General Rules
Conscious patient – talking, swallowing, …
Unconscious patient – breathing with patent airway
O2
Unconscious patient – attempting to breath but airway obstructed
O2
Airway support
Physical maneuver – jaw thrust maneuver
Adjunct for physical support – OPA, NPA
Assistance for breathing – positive-pressure ventilation
Unconscious patient with neuromuscular blockade
O2
Positive-pressure ventilation – BVM, LMA*, ETT
Why examine and evaluate a patient’s airway preoperatively?
To determine ease or difficulty of airway manipulation (intubation, mask ventilation)
To prepare the anesthetist… Selection of airway devices, techniques, and procedures
… generally want to secure airway with patient awake
Minimize harm during subsequent airway management
Determine airway-related risks in order to:
discuss them with the patient avoid risk-related problems
The airway exam will prepare the anesthetist to:
Establish correct anatomic position for the patient
Obtain correct position for laryngoscopist
Establish alignment of axes
Secure the airway
Choose safest anesthesia technique
Evaluation of the airway will aid the anesthetist in the determination of anticipated ease or difficulty with airway management techniques
Airway techniques:
Patient maintains own airway
Oral and nasal airways
Bag-mask ventilation
Direct laryngoscopy (tracheal intubation)… see with your two eyes
Indirect laryngoscopy (glidescope)… see through a video monitor
Blind Airway Techniques (LMA, Combitube, etc.)
Fiberoptic bronchoscopy
Cricothyrotomy/cricothyroidotomy
Tracheostomy
Generic questions one should ask every patient:
Previous intubations (previous difficult airway)
Dental problems (loose, chipped, broken, removable)
Arthritis (TMJ and neck mobility)
Diabetes (gastric motility->delayed emptying)
NPO status (aspiration risk)
Heartburn/GERD (aspiration risk)
3 things should be evaluated separately based on history, examination, and diagnostic tests.
Ability to ventilate
Ability to intubate
Risk of aspiration
Factors Characterizing a Normal Airway:
Interincisor distance (mouth opening) >4 cm or two finger-breadths
Mallampati Class 1 or 2
Thyromental distance >6 cm – three finger breadths from tip of mandible to thyroid notch w/neck fully extended
At least 9 cm from symphysis of mandible to mandibular angle
Slender neck without masses, full range of motion
Ability to extend atlantooccipital joint (normal extension is 35 degrees)
How Do We Predict Difficult Mask Ventilation
(DMV)?
In a general adult population, DMV was reported in 5% of the patients.
Maintenance of airway patency and oxygenation are the main objectives of face-mask ventilation.
Difficult mask ventilation was defined as the inability of an unassisted anesthesiologist to maintain the measured oxygen saturation as measured by pulse oximetry > 92% or to prevent or reverse signs of inadequate ventilation during positive-pressure mask ventilation under general anesthesia.
Physical Examination for Mask Ventilation
Prepare for mask ventilation difficulty if:
Beard
Facial scars
Facial injuries/dressings
Edentulous (IF have dentures, ask to remove them so don’t fall out)
Any airway obstruction
– (e.g. after multiple DL’s)
Risk factors for difficult intubation:
Mouth opening less than 4cm
Thyromental distance less than 6cm
Mallampati class 3 or 4
Neck movement less than 80 degrees
Inability to advance the mandible (prognathism)
Obese
Positive history of difficult intubation
Physical Examination: DL difficulty relatively likely…What to look for: Neck
Neck Mobility
How Neck Mobility Affects Positioning:
Those with Rheumatoid Arthritis need to be careful with
Neck Mobility (1)
Neck Mobility (2)
Used when someone is really obese
Physical Examination: DL difficulty relatively likely…What to look for: Temporomandibular disease
Physical Examination: DL difficulty relatively likely…What to look for: Size of Physical Attributes
Size/Obesity
Neck size and ROM
Face
Lips
Mouth/Tongue/Teeth
Physical Examination: DL difficulty relatively likely…What to look for: Size/Obesity
Physical Examination: DL difficulty relatively likely…What to look for: Lips
Focus on the three requirements for successful DL:
Mouth must open (at least a little)
Three axes (tracheal, pharyngeal, oral) must be at least somewhat aligned in the sniffing position
There must be a place big enough to put the tongue, and space to see
The amount of the posterior pharynx you can visualize is important and correlates with the difficulty of intubation. Visualization of the pharynx is obscured by a large tongue (relative to the size of the mouth), which also interferes with visualization of the larynx on laryngoscopy.
Evaluation of Airway – MOUTHS
Mandible – length and subluxation
Opening – Measure mouth opening
Uvula – can you see it
Teeth – Dentition – large or loose teeth
Head – flex, extension, rotation
Silhouette – Upper body abnormalities:
kyphosis, large breast
Oropharyngeal Examination
(OPE)
OPE:MALLAMPATI OVERVIEW
Open Mouth as wide as can and push tongue out… it DOES NOT include a say “ahhh”
OPE:MALLAMPATI
CLASS I
OPE: MALLAMPATI
CLASS II
OPE: MALLAMPATI
CLASSIII
OPE: MALLAMPATI
CLASS IV
OPE: MOUTH
OPE: PALATE
OPE: PHARYNX
Pharyngitis - severe
Going to be rubbing up against tissue so might want to give Decadron on the 8-12 mg range
OPE: GUMS (1)
Gingival hyperplasia
OPE: GUMS (2)
GINGIVITIS
OPE: GUMS (3)
Periodontitis
OPE: TEETH
OPE: MAXILLA/MANDIBLE
OPE: MAXILLA/MANDIBLE
OPE: MOUTH OPENING
OPE: MOUTH OPENING
Atlanto-occipital Gap
C-Spine Mobility
C-Spine Mobility
Important to note Pain and/or Paresthesia prior to the surgery… also need to note motor weakness
Larynx
Thyromental Distance
Mandibular Length
Physical Exam (3-3-2)
Interphalangeal Joint Gap
(Prayer sign)
Will be indicative of join immobility on other parts of the body
Upper Lip Bite Test
The “Awake” Look
Laryngoscopy Grades
Grade 1: Full view of the glottis
Grade 2: Only the posterior commissure is visible
Grade 3: Only the epiglottis is seen
Grade 4: No epiglottis or glottic structure visible, only soft palate
Laryngeal Mask Airways (LMAs)
LMA Development:
Dr Archie Brain, British anesthesiologist, London Hospital, 1981
Cadaveric specimens
The laryngeal mask airway: a new concept in airway management.
AIJ Brain. Br J Anaesth 55: 801, 1983.
Alternative to face mask and to endotracheal tube
Developed from the Goldman Dental Nose Piece – used for airway maintenance during dental extractions
Commercial product in United Kingdom: 1988
Ubiquitous in United Kingdom: 1990
FDA approval in US: 1991
World-wide use: 2000
LMA Description
Specially designed airway that seats over the larynx to allow ventilation in normal patients. The LMA may be a useful adjunct in patients who are inadequately ventilated by mask.
The Laryngeal Mask Airway is an alternative airway device used for anesthesia and airway support
It consists of an inflatable silicone mask and rubber connecting tube
It is inserted blindly into the pharynx, forming a low-pressure seal around the laryngeal inlet and permitting gentle positive pressure ventilation
All parts are latex-free
Construction
Silicone
30o between airway tube
and body of mask
Basic components
15 mm connector
Airway tube
Cuff
Inflation system
Valve
Pilot balloon
Pilot tube
When to Use LMA
The Laryngeal Mask Airway is an appropriate airway choice when:
Mask ventilation can be used
(except in the Difficult Airway Algorithm) … can take the place of Mask Ventilation
Endotracheal intubation is not necessary (when they do not have to be paralyzed is a big indicator)
MAC procedures are good with LMA
LMA Function
Establishes airway
with supraglottic seal
(above the vocal cords)
Disposable LMAs
LMA Indications
Indications
Administration of general anesthesia
Establish unsecured airway emergently
Facilitate endotracheal intubation
Adjunct to FOB airway management
Decadron is a drug to be used to help with swelling and bleeding in the airway
LMA Advantages
Advantages:
Allows rapid access
Does not require laryngoscope
Does not require neuromuscular blockade for placement or maintenance
(just need Propofol, and some lidocaine for the sting of the Propofol)
Provides airway for spontaneous or controlled ventilation (can be used PPV, but not a first choice)
Tolerated at lighter anesthetic planes
Advantages (compared to):
Less stimulating during use (ETT)
Less ↑ in intrathoracic and intraabdominal pressures during emergence (ETT)
Less cardiovascular response (ETT)
Less ↑ in IOP (ETT)
Frees practitioner’s hands (mask)
Provides seal for PPV (OAW or NAW)
LMA Disadvantages
Does not protect against aspiration in the non-fasted patient
Standard LMA not recommended for use with ventilator… though it is used all the time
Requires re-sterilization if Original LMA
Learning curve for insertion
Over-estimated ease of use
(can be harder to correctly insert and seat compared to an ETT)
Not a Secure Airway
LMA Contraindications
Non-fasted patients
(the only true absolute contraindications)
Risks of aspiration (GERD, not NPO, hiatal hernia, obesity, pregnancy, bowel obstruction, acute pancreatitis, ….)
Morbidly obese patients
Obstructive or abnormal lesions of the oropharynx
Maxillofacial Trauma
Respiratory disease with low compliance and/or high resistance
Patient position or surgery limiting airway access
Upper airway pathology (infection, hematoma, cyst, ….)
LMA Process
LMA Management
Preparation
Deflate* (those with cuff)
Lubricate* (never put on anterior side)
Induction of general anesthesia
Preoxygenate
IV induction with minimum apneic period
(lidocaine, may or may not use Fentanyl, Propofol)
Insertion
Oral cavity
Oropharynx
Hypopharynx
Inflation
After seating
Volume per LMA size
Observe pilot balloon
rise
Confirmation
Observe chest rise
Auscultation
Capnography
Securing
Tape to zygomatic region*
Prevent torque on the tube (by having circuit go back behind head)
Maintenance
Observe airway integrity
Prevent torque
Removal
Patient breathing, awake & cooperative
OR
Patient breathing and asleep may have to revert to bag-and-mask ventilation if they obstruct
Extubating Criteria
1) Spontaneous breathing (breathing on own)
2) Taking adequate tidal volumes
*** so can absolutely have a sleeping patient that is meeting those criteria
LMA Insertion Technique
Insertion
Finger(s)
Tongue depressor
Introducer
LMA Insertion Problems
Jam into vallecula (pull out start over)
Push epiglottis down over glottic opening (pull out start over)
Get caught on glottic opening (adjust with little pull back, might have to pull out and start over)
LMA Implementation
Good Seal:
EtCO2
Bi lat rise and fall of chest
Misting in tube
Adequate inspiratory pressures
No weird sounds
LMA: ProSeal
Special Features:
Suction gastric contents
Basic components
Cuff
Drainage system
External drain tube with connector
Internal drain tube
Drain tube orifice
Integral bite block
Introducer strap
LMA: ProSeal Parts
LMA: Fast-trach LMA
Special Features:
May be used as a rescue airway and fiberoptic conduit when intubation is difficult, hazardous or unsuccessful
It can be used for bronchoscopy in the awake or asleep patient
LMA: C-Trach
Video screen used to visualize glottis
Same as Fast-trach with added video screen
LMA: AMBU Version
Ambu AuraOnce
LMA: Cookgas AirQ
A LMA you could intubate through
Can suction through it
*** KNOW WHICH ONES YOU CAN DO THIS WITH FOR TESTS
LMA: Cookgas AirQ (sizes)
King (Extraglottic Airway)
I-Gel
Nothing to inflate
Technically can suction through it
Has a bite block
Most woman - 4
Most men - 5
LMA Success Tips
Tips for Success:
Begin with ASA I & II patients
Learn and use standard insertion technique
Use appropriate size and do NOT overinflate
Maintain adequate anesthetic depth
May consider using a bite block to prevent kinking of the tube when the patient bites down
Use PSV if PPV needed w/LMAs
LMA Aspiration Risk
What is the risk of aspiration with the LMA™ airway?
The incidence of clinically detectable regurgitation with the LMA™ airway into the pharynx has been reported in various publications at approximately 0.1%.
The incidence of aspiration with the LMA™ airway is low and is comparable to the incidence of aspiration associated with outpatient general anesthesia with the face mask or endotracheal tube.
Reduce LMA Aspiration Risk
The following are practical guidelines to minimize risk of aspiration:
Carefully select the patient and surgical procedure according to approved indications and contraindications
Avoid inadequate anesthesia upon insertion of the LMA™ airway and during surgery
(Test papillary reflex of eye)
Avoid lubrication of anterior surface, excessive lubrication, or use of lidocaine gels containing non-aqueous solvents or silicones*
Trouble Inserting LMA
Why do I have trouble inserting the LMA™ device?
Some of the most common mistakes made while inserting the LMA™ airway include :
Inadequate anesthesia may cause coughing or breath-holding
Immediately deepen anesthesia and manually ventilate the patient
Suboptimal head/neck position
When inserting the LMA-ProSeal™, LMA-Unique™, LMA-Classic™, and LMA-Flexible™, keep the patient’s head in the sniff position… just try to get best sniffing as possible
When inserting the LMA-Fastrach™, keep the patient’s head in the neutral position
Incorrect mask deflation - Attempting to insert the LMA™ airway with the cuff partially inflated increases the chances of a down-folded epiglottis
Failure to press the LMA™ airway into the palatopharyngeal curve during insertion
Follow the recommended insertion techniques described in the LMA literature
Lack of water-soluble lubricant on the posterior surface of the LMA™ cuff
Using a mask that has surpassed its useful life of 40 insertions
The cuff and airway tubes of the reusable LMA™ devices are manufactured from silicone. With each use, the silicone degrades and loses flexibility. Prior to use, be sure to perform the manufacturer recommended Pre- Use Performance Tests listed in the product instruction manuals
LMA with Positive Pressure Ventilation
How do I use the LMA™ device with positive pressure ventilation?
Positive pressure ventilation (PPV) via the LMA™ device is an established technique, effective in both children and adults
Use Pressure Control over Volume Control
Before attempting PPV with the LMA™ airway, the clinician should be experienced using the LMA™ airway with spontaneously-breathing patients
The following are practical points to review when using the LMA™ airways with PPV:
Use tidal volumes of approximately 6-8 ml/kg
Maintain peak inspiratory pressures within the maximum airway seal pressure, on average, 30 cm H2O or less with the LMA-ProSeal™ and 20 cm H2O or less with the other LMA™ airways… 20 is kind of the limit generally
Control end-tidal CO2 by altering respiratory rate
Leaks during PPV may be attributable to light anesthesia, inadequate muscle relaxant (if used), use of too small an LMA™ airway, a reduction in lung compliance related to the surgical or diagnostic procedure, patient factors, or displacement of the LMA™ airway by head turning or traction.
During the recovery period, reverse the muscle relaxant or allow it to wear off before switching off the anesthetic agents at the end of the procedure. With gentle, assisted ventilation, the patient should be allowed to start breathing
Manage an Airleak with LMA
How do I manage an air leak with the LMA™ airway?
An air leak may have several causes.
Prior to insertion, be sure the LMA™ device is in proper working order, doesn’t have a hole in the mask or inflation line, and has passed all the recommended Pre-Use Tests.
Inadequate anesthesia can cause an air leak around the mask of the LMA™ device. Deepen the level of anesthesia to see if the leak subsides.
Air Leaks can be caused by:
An improperly placed LMA™ airway
a mask with too little or too much air in the cuff
an LMA™ cuff that has folded back on itself
and/or too small an LMA™ device for size of the patient
Check the position of the LMA™ cuff and
reinsert or replace, as necessary
Do not simply add more air to the cuff as adding air may increase tension in the cuff, pushing it away from the laryngeal opening
When using assisted or positive pressure ventilation with the LMA™ device, high airway pressures can cause the mask to leak
Reduce the airway pressure by:
lowering the tidal volume
lowering the inspiratory flow rate
increasing muscle relaxation
or treating bronchospasm if present
Length of time for LMA
How long can I leave the LMA™ airway in place?
The maximum duration for which an LMA™ airway can safely be used is not yet known; however, there is increasing evidence that the LMA™ airway may be safe for elective procedures in healthy patients lasting 4 to 8 hours in the hands of experienced users (8 hours is way too long, Professor Chrobak would say 4 is the most)
If the LMA™ airway is used for prolonged periods
the respiratory function must be closely monitored
use a heat and moisture exchanger (HME)
LMA Removal with Cuff Inflated
Can I remove the LMA™ airway with the cuff inflated?
Provided the patient is awake and airway reflexes have returned, cuff deflation prior to removal is not essential
However, it is preferable to remove the LMA™ airway deflated to prevent damage to the cuff from sharp teeth
In most situations, clinicians prefer to remove the LMA™ with cuff inflated, primarily to remove secretions that collect on top of the cuff (this is a personal preference)
This is particularly true of patients undergoing nasal/throat surgery where bleeding from above the airway has collected on the LMA™ cuff
Rarely it may be difficult to remove the LMA™ airway inflated due to the cuff becoming caught under the base of the tongue
It should also be noted that if intubation has been performed using the LMA- Classic™, LMA-Unique™, or LMA-Fastrach™ as a conduit, removal of the LMA™ airway with the cuff inflated may inadvertently dislodge or move the endotracheal tube
LMAs and MRIs
Is the LMA™ device safe in the MRI environment?
The LMA-ProSeal™, i-Gel, LMA-Classic™, and LMA- Flexible™, and LMA-Fastrach™ endotracheal tube are MRI safe when properly positioned and secured with tape
LMAs and Laser Surgery
The LMA-Classic™, LMA-Flexible™, and LMA- Unique™ have been studied in vitro with various types of lasers and clinical reports have appeared in the literature; however, there are no recommendations for use of the LMA™ airways in laser surgery.
LMA Sizing
1 = Neonates/Infants up to 5 kg
1½ = Infants 5-10 kg
2 = Infants/children 10-20 kg
2½ = Children 20-30 kg
3 = Children 30-50 kg
4 =Adults 50-70 kg
5 = Adults 70-100 kg
6 = Large Adults over 100 kg
*** Know these for test questions
ORAL ENDOTRACHEAL INTUBATION: WHAT EQUIPMENT WILL YOU NEED?
APPROPRIATELY SIZED LARYNGOSCOPE
APPROPRIATELY SIZED ETT
7.0/6.5 - most woman
8.0/7.5 - most men
** But can change based on patients size/height
** Also can change on the procedure being done (bronchoscopy maybe 8.5/9.0)
MEDICATIONS
1st - Fentanyl… dose doesn’t really matter in the beginning (for the stimulation to come)
2nd - Lidocaine… for sting of Propofol
3rd - Propofol
4th - Muscle Relaxant… choice based on circumstances
*** LMAs just need Propofol, maybe Lidocaine for the Propofol sting
O2
METHOD FOR VENTILATION
Minimum Ambu Bag
LARYNGOSCOPE
DESIGNED TO:
ENTER THE MOUTH
DISPLACE SOFT TISSUE
ELEVATE THE EPIGLOTTIS
DIRECTLY OR INDIRECTLY
ENDOTRACHEAL TUBES
WHAT EQUIPMENT WILL YOU NEED?
Don’t Forget the STYLET
8 years and under consider using an uncuffed tube
LARYNGOSCOPE: Blade Parts
Laryngoscopes
Handles (where the batteries are)
Blades
Light Source (always double check when getting equipment)
With a Big Tongue consider Mac due to the bigger Web
LARYNGOSCOPES: Macintosh
LARYNGOSCOPES: Miller
ENDOTRACHEAL TUBES
ETT COMPONENTS
TUBE
DISTAL (PATIENT) END
PROXIMAL (MACHINE)
END
At Distal End
BEVEL
MURPHY EYE
CUFF
CUFF
PERMANENTLY ATTACHED
PERMEABLE TO GASES AND VAPORS
CUFF INFLATION SYSTEM
(See Picture)
CONNECTOR
Always make to tighten after opening bag
MACHINE END
15 MM OD
MACHINE TAPERED
FLANGE
PATIENT END
STRAIGHT OR CURVED (curved you would see with ENT surgeons and very specific)
ETT: CONVENTIONAL
OETT - Oral Endotracheal Tube
NETT - Nasal Endotracheal Tube
ETT: ANODE OR REINFORCED
SPECIALTY TUBES: RAE
Top pic is Oral RAE without a cuff
Bottom pic is Nasal RAE
Oral surgery, ophthalmology, ent, facial
Right angle endotracheal tube
SPECIALTY TUBES:
UNCUFFED PEDIATRIC ENDOTRACHEAL TUBE
Uncuffed is only in Peds
Leak Test
Below 20, it is too small
Above 20, have to figure out where the point is it leaks with the pressure
SPECIALTY TUBES:
ENDOBRONCHIAL TUBE
Sized in French
Higher the number, bigger the tube
STYLET
MATERIAL
COPPER, ALUMINUM (REGULAR)
STAINLESS STEEL (GLIDESCOPE)
NO LOOSE COMPONENTS
RETAIN SHAPE
REMOVE EASILY WITH THUMB ACTION
DISTAL SHAPE
HOCKEY STICK
ARCUATE
PROXIMAL SHAPE
LOOP AT 90O TO LONG AXIS
PREPARING ETT
DONT FORGET TO SEAT CONNECTOR WHEN REMOVING TUBE FROM PACKAGING
INSERTING AN ETT (1)
INSERTING AN ETT (2)
INSERTING AN ETT (3)
INSERTING AN ETT (4)
INTUBATION TECHNIQUES: BEFORE YOU GET STARTED
MAKE SURE THAT YOU HAVE ALL OF YOUR EQUIPMENT PREPARED, IN THE ROOM AND READY
MAKE SURE THAT YOU CAN PROVIDE YOUR PATIENT WITH BAG-MASK VENTILATION
MAKE SURE PATIENT POSITION IS OPTIMIZED
HAVE A BACK-UP PLAN B AND PLAN C
ETT: EQUIPMENT
O2 SOURCE AND SELF INFLATING VENTILATION BAG
FACE MASK
ORAL AND NASAL AIRWAYS
TRACHEAL TUBES
STYLET
SYRINGE FOR CUFF INFLATION
SUCTION
LARYNGOSCOPE HANDLES
LARYNGOSCOPE BLADES
PILLOW, TOWEL, BLANKET, OR FOAM FOR HEAD POSITIONING
STETHOSCOPE
Indications for ETT
GOALS OF A PROFICIENT INTUBATION
ACCOMPLISH INTUBATION WITHIN 30 SECONDS
PROTECT THE PATIENT AGAINST
HYPOXIA
ASPIRATION OF GASTRIC CONTENTS (Have Suction on the Ready)
TRAUMA
MEMORY OF THE INTUBATION
HYPOXIA – HOW TO PREVENT IT DURING ATTEMPTS AT INTUBATION:
ETCO2 we want over 85% is the indicator have a good Preoxygenation
Always a Pulse Ox on, minimum 88%
ASPIRATION OF GASTRIC CONTENTS
THE VOLUME OF ACIDIC ASPIRATES THAT WILL IMMEDIATELY CAUSE ALVEOLAR CAPILLARY BREAKDOWN:
PH LESS THAN 2.5 AND VOLUMES GREATER THAN 25 ML (0.4 ML/KG)
INTUBATION TECHNIQUES
HOW TO INTUBATE:
HOW TO INTUBATE:
FLEX THE CERVICAL SPINE (SNIFFING POSITION)
EXTEND THE ATLANTO- OCCIPITAL JOINT
OPEN THE MOUTH
SCISSOR TECHNIQUE
NATURAL OPENING UPON
POSITIONING
INSERT LARYNGOSCOPE
RIGHT SIDE OF THE MOUTH
DISPLACE THE TONGUE
RIGHT TO LEFT
ELEVATE THE EPIGLOTTIS
FORWARD AND UPWARD MOTION
EXPOSE THE VOCAL CORDS
GUIDE THE ENDOTRACHEAL TUBE THROUGH THE VOCAL CORDS UNDER DIRECT VISION (I.E. YOUR EYES SEE IT PASS THROUGH THE VOCAL CORDS)
NEVER TAKE YOUR EYES OFF THE PRIZE!
INTUBATION METHODS
OROTRACHEAL INTUBATION BY DIRECT VISION
MOST COMMON METHOD
PATIENT IS PUT INTO THE SNIFFING POSITION TO ALIGN THE AXES
LARYNGOSCOPY IS PERFORMED
INTRODUCE THE BLADE RIGHT SIDE OF MOUTH
BLADE REMAINS LATERAL TO THE TONGUE
ELEVATE THE EPIGLOTTIS
CONFIRMATION OF ENDOTRACHEAL TUBE IN TRACHEA
CONFIRMATION OF ENDOTRACHEAL
TUBE IN TRACHEA
METHODS USED TO VERIFY TUBE PLACEMENT:
END- TIDAL CO2 MONITORING
CAPNOGRAPHY/CAPNOMETRY
ETCO2 DETECTOR (CHANGES FROM PURPLE TO YELLOW)
AUSCULTATION – MOST “PRACTICAL”
MOVEMENT OF CHEST AND EPIGASTRIUM
DIRECT VISION
VITAL SIGNS
CONDENSATION IN THE TUBE
PULSE OXIMETRY
TUBE MARKING
- 21-23 CM AT INCISORS
CUFF PALPATION
CHEST X-RAY
Capnometry for ETT Confirmation
If after induction, you have a sudden drop to say 22 with good waveform… you know might have hypoperfusion - RUN A PRESSURE
Auscultation for ETT Confirmation
Tube In or Out of the Trachea
TUBE NOT IN TRACHEA, CAPNOGRAM SUGGESTS TUBE IS IN TRACHEA
BAG/MASK VENTILATION PRIOR TO INTUBATION
ANTACIDS IN STOMACH
RECENT INGESTION OF CARBONATED BEVERAGES
TUBE IN PHARYNX
SUSPICION OF ESOPHAGEAL INTUBATION:
INDICATIONS FOR EXTUBATION
POOR OR NO CHEST MOVEMENTS
CYANOSIS DEVELOPING WITHIN 10 MINUTES
FAILURE TO OXYGENATE
ANOMALOUS TUBE LENGTH
TACHYCARDIA AND HYPERTENSION
INCREASING ABDOMINAL DISTENSION
NO CO2 DETECTED BY CAPNOGRAPH
ABSENCE OF CONDENSATION IN THE TRACHEAL TUBE
FAILED INTUBATION COMMON CAUSES:
NASOTRACHEAL INTUBATION TECHNIQUES
INDICATIONS:
RESPIRATORY FAILURE WITH TRISMUS (lockjaw)
TRAUMA PATIENTS WITHOUT SIGNIFICANT MIDFACIAL TRAUMA OR MIDFACE INSTABILITY (BLIND TECHNIQUE)
SURGICAL NECESSITY OR SURGEON’S PREFERENCE
NASOTRACHEAL INTUBATION: PREPARATION
EQUIPMENT
THE SAME AS OROTRACHEAL INTUBATION, WITH THE ADDITION OF MAGILL FORCEPS.
WATER SOLUBLE LUBRICANT (K-Y JELLY)
ALWAYS HAVE OXYGEN AND SUCTION IMMEDIATELY AVAILABLE
WARM BOTTLE OF STERILE WATER
SEDATION MAY OR MAY NOT BE REQUIRED
SELECT AN ENDOTRACHEAL TUBE WHOSE INTERNAL DIAMETER IS A HALF-SIZE SMALLER THAN YOU WOULD NORMALLY USE FOR ORAL INTUBATION.
LUBRICATE THE TUBE AND SELECTED NOSTRIL WITH K-Y JELLY.
APPLY AFRIN OR PHENLEPHRINE TO CONSTRICT NASAL VASCULATURE
CONSIDER SERIAL DILITATION WITH NASAL AIRWAYS
NASOTRACHEAL INTUBATION: Positioning
NASOTRACHEAL INTUBATION: TUBE INSERTION
DIRECT VISION:
INSERT TUBE INTO NARE WITH BEVEL POINTING TOWARD THE SEPTUM
DIRECT IT VERTICALLY DOWNWARD, AT A RIGHT ANGLE UNTIL IT REACHES THE OROPHARYNX WITH STEADY, CONSTANT PRESSURE
EXPOSURE
OPEN THE MOUTH AS YOU WOULD WHEN PERFORMING AN OROTRACHEAL INTUBATION.
VISUALIZATION
VISUALIZE THE VOCAL CORDS WITH A LARYNGOSCOPE BLADE
TUBE PLACEMENT
YOU MAY BE ABLE TO DIRECT NASOTRACHEAL TUBE DIRECTLY PAST THE VOCAL CORDS; IF NOT
MAGILL FORCEPS WILL LIKELY BE REQUIRED TO DIRECT THE TUBE INTO THE VOCAL CORDS.
NASOTRACHEAL INTUBATION: Tube Placement
Using Magil Forceps
BLIND NASOTRACHEAL INTUBATION
TECHNIQUE:
PERFORMED ON AN AWAKE, SEDATED, OR ANESTHETIZED PATIENT
THE PATIENT MUST BE BREATHING SPONTANEOUSLY
PREPARE THE NOSTRILS
PLACE THE TUBE IN THE NOSTRIL AND THEN ADVANCE THE TUBE INTO THE OROPHARYNX
Performing Technique
FLEX THE CERVICAL SPINE
LISTEN AND FEEL FOR BREATH SOUNDS
SLOWLY ADVANCE THE TUBE, WHEN IT ENTERS THE AIRWAY, THE PATIENT WILL COUGH
NASOTRACHEAL INTUBATION: COMPLICATIONS:
NASAL BLEEDING–USUALLY CONTROLLED BY PINCHING NOSTRILS TOGETHER
ESOPHAGEAL INTUBATION–TUBE POSITION MUST BE CONFIRMED USING THE SAME TECHNIQUES AS FOR ORAL INTUBATION. VERIFY TUBE POSITION FREQUENTLY.
TRAUMA TO NASO AND OROPHARYNX, ESOPHAGUS–SOME BLEEDING MAY OCCUR. SUCTION IF NEEDED. THIS IS A GENTLE PROCEDURE, DO NOT FORCE THE TUBE.
NASAL STRUCTURAL DAMAGE MAY RESULT IF TUBE IS REMOVED WITH BALLOON INFLATED
RIGHT OR LEFT MAINSTEM INTUBATION
ASPIRATION
VAGAL STIMULATION
LARYNGOSPASM
VOCAL CORD DAMAGE
PNEUMOTHORAX
ANOXIA
NASOTRACHEAL INTUBATION: Absolute verse Relative Contradictions
ABSOLUTE
1. APNEA (IF BLIND TECHNIQUE)
- SUSPECTED EPIGLOTTITIS
- MIDFACE INSTABILITY
- BLEEDING DISORDERS OR THOSE ON ANTICOAGULATION THERAPY
RELATIVE
1. SUSPECTED BASILAR SKULL FRACTURE
- NASAL FOREIGN BODIES OR LARGE NASAL POLYPS
- RECENT NASAL SURGERY OR A HISTORY OF FREQUENT EPISODES OF EPISTAXIS
- UPPER NECK HEMATOMAS OR INFECTIONS
AIRWAY MANEUVERS
MANUAL AIRWAY MANIPULATIONS USUALLY DONE BY AN ASSISTANT AND USED TO FACILITATE INTUBATION OR TO PROTECT PATIENTS AGAINST ASPIRATION
AIRWAY MANEUVERS: BURP MANEUVER:
USED TO IMPROVE VISUALIZATION OF THE AIRWAY DURING ROUTINE AND DIFFICULT INTUBATION
THE ‘BURP’ MANEUVER (CONSISTING OF BACKWARD, UPWARD AND RIGHT-SIDED PRESSURE ON THE THYROID AND CRICOID CARTILAGES) WAS INTRODUCED BY KNILL IN 1993 TO IMPROVE THE GLOTTIC VIEW DURING ENDOTRACHEAL INTUBATION.
THREE DISTINCT COMPONENTS:
POSTERIOR PRESSURE ON THE LARYNX AGAINST THE CERVICAL VERTEBRAE
(BACKWARD)
SUPERIOR PRESSURE ON THE LARYNX AS FAR AS POSSIBLE (UPWARD)
LATERAL PRESSURE ON THE LARYNX TO THE RIGHT (RIGHT)
*BY ADDING PRESSURE TO THE PRECEDING TERMS, THE ACRONYM BECOMES
BURP
AIRWAY MANEUVERS: OELM
OPTIMAL EXTERNAL LARYNGEAL MANIPULATION
IMPLIES THAT ONE SHOULD EXPERIMENT WITH THE OPTIMAL MANEUVER ON THE LARYNX TO IMPROVE VISUALIZATION.
AIRWAY MANEUVERS: Sellick’s Maneuver
AIRWAY MANEUVERS: Sellick’s Maneuver (2)
THE APPLICATION OF CRICOID PRESSURE IN THE PRESENCE OF NECK EXTENSION FREQUENTLY IMPEDED THE LARYNGOSCOPIST’S VIEW OF THE LARYNX DURING ATTEMPTS AT INTUBATION
THE “SNIFFING” POSITION WAS ADOPTED AS THE STANDARD DURING CRICOID PRESSURE
APPLIED BY PLACING THE THUMB AND MIDDLE FINGER ON EITHER SIDE OF THE CRICOID CARTILAGE AND THE INDEX FINGER ABOVE TO PREVENT MOVEMENT OF THE CRICOID
AIRWAY MANEUVERS: Sellick’s Maneuver (3)
High Missed Question: Steps to properly ventilate
Steps to take if not properly ventilating someone
Less invasive to more invasive
High Missed Question: GERD
Controlled GERD vs Uncontrolled GERD
