2025 Airway Management Exam 3 Flashcards
Lectures 7: Airway Complications
What is a Claim
A financial demand made to an insurance company by a person alleging injury sustained from medical care
What is a Closed Claim
It is a claim that has been resolved
6% of all claims concerned airway injury
Difficult intubation 39%
87% of injuries were temporary
8% resulted in death
21% inappropriate standard of care
Closed Claims Summary
For your information – use it to your benefit
Many claims involve the most basic airway problems
Many difficult airways are not predicted
Anesthesia – because of the protocols, guidelines, and training in place, it has become one of the safest specialties of medical practice
Omission, Commission, & Communication
Errors of omission
Failure to:
Recognize the magnitude of a problem
Make appropriate observations
Act in a timely manner
Errors of commission
Include:
Trauma to lips, nose, or laryngotracheal mucosa
Forcing sharp instuments into areas in which they do not belong
Introducing air or secretions into regions of the body in which further complications will ensue
Most frequent cause of fatal errors d/t ignoring, inadequate experience & skills, and not calling for help
Complications Arising During Intubation
Eyes
Lips
Teeth
Larynx
Pharynx
Esophagus
Trachea
Bronchi
Complications Arising During Intubation: Eyes
Complications Arising During Intubation: Lip Trauma
Taping Lip
Biting on OPA
Complications Arising During Intubation: Pharyngeal Mucosal Damage
Pharyngeal Perforation
Death occurred in 81% and was caused by mediastinitis
Lacerations and contusions
Localized infection
Sore throat
- Associated with difficult intubation
Complications Arising During Intubation: Tooth Damage
Complications Arising During Intubation: Laryngeal Injuries
Complications Arising During Intubation: Esophageal Trauma
Complications Arising During Intubation: Tracheal/Bronchial Injuries
Let Syringe Rebound when filling bulb on Intubation
Can every couple of hours deflate all the way, then move the ETT every so slightly
Complications Arising During Intubation: Lung
Complications Arising During Intubation: Hypoxemia
Complications Arising During Intubation: Acute Hypoxic Encephalopathy
Complications Arising During Intubation: Failure of O2 at the Source
Complications Arising During Intubation: Failure of O2 at the Delivery Site
Big one is Ventilator Disconnect
Complication = Start at Patient and working back to Machine
Complications Arising During Intubation: Improper Procedure Leading to Hypoxemia
Complications Arising During Intubation: Inability to Intubate or Ventilate Due To…
Obesity
Age
Beard
Macroglossia
Mallampati grade III of IV
History of snoring
Short thyromental distance
Any reason at all
Complications Arising During Intubation: Vomiting and Aspiration
Cricoid Pressure - some believe it helps, some don’t
0.4 ml/kg for Peds
Complications Arising During Intubation: Vomiting and Aspiration (Pathophysiological Processes)
Complications Arising During Intubation: Preventative Measures After Aspiration and After Intubation
Change to FiO2 to 100% immediately if not already at
Complications Arising Immediately after Intubation
High Fentanyl dosage (200-250 mcg) to really blunt the airway reaction to intubation if they have a Hx of hypertension, tachy, arrhythemia???
Hypoxemia - bag till you get them up over 90, then can go to ventilator
Complications Arising Immediately after Intubation: Accidental Esophageal Intubation
Accidental esophageal Intubation
** The most reliable method for tracheal intubation and continuously monitoring tracheal intubation is capnometry**
Wave Form
Numbers
Chest Rise
Misting in Tube
… all this together is what confirms proper ETT placement
DELAYED DIAGNOSIS
Preoxygenated patient with good respiratory function
… could of exceeded 20mmHg, which opens esophageal lower sphincter, so you were putting O2 into the stomach - which is what is showing on capnometry for a while
An accidental extubation with movement of patient… be OCD about taping the tube
An endotracheal tube may slide up and down in the trachea
Accidentally extubated attempting to insert a nasogastric tube… if the airway is really dry
Complications Arising Immediately after Intubation: Ingestion of Laryngoscope Lightbulb
Complications Arising Immediately after Intubation: Accidental Endobronchial Intubation
Identified by:
Asymmetrical movement of chest wall
Increase in Peak Inspiratory Pressures (PIP)
CO2 waveform
Auscultation of chest
Called “Main stemming”
Complications Arising Immediately after Intubation: Bronchospasm
Complications Arising Immediately after Intubation: Difficulty with Ventilation
First deliver 100% O2 until problem solved
Maybe caused from:
Endobronchial tube placement (to include Main Stem)
Bronchospasm
Pneumothorax
Ask yourself these questions:
Is the problem related to disease process in the patient?
Is it related to tube placement?
Is it caused by the oxygen delivery system?
Is it due to obstruction of the tube?
Kinked or even Mucus in the tube
Complications Arising Immediately after Intubation: Obstruction of the Tube
Complications Arising Immediately after Intubation: Laryngeal Intubation
Complications Arising Immediately after Intubation: Accidental Extubation
Failure to secure tube properly
Want to tape as close to the corner of the mouth as possible… if tube has to be in middle of the mouth, tape as close to lips as possible
Tension on the tube
… do you need to hook up an extension?
Transportation/repositioning of patient
Complications Arising Immediately after Intubation: Tension Pneumothorax
Immediate Treatment is Necessary
Cardinal signs:
Marked cyanosis
Deteriorating vital signs
Diminished breath sounds
Decreased pulmonary compliance
How do you treat?
Insert a large bore needle into the affected side of the chest beneath the second rib or have a surgeon place a chest tube
Complications Arising Immediately after Intubation: Rupture of Trachea or Bronchus
Mainly associated with endobronchial tube usage
Predisposing factors:
Trauma
Age
Preexisting disease
Tissue Fragility
Anatomic difficulties
Blind, or rushed intubation
Inadequate positioning
Poor visualization
Inexperience
Complications Arising Immediately after Intubation: Hypertension, Tachycardia, Arrhythmias
Caused by laryngoscopy and intubation
(this is the high Fentanyl dosage idea…)
Increase in BP
Arrhythmias
Increase BP and HR due to vasomotor stimulation (adult)
Bradycardia during Intubation – vagally mediated
(Children)
Complications Arising Immediately after Intubation: Elevated ICP
Endotracheal intubation provokes increases in ICP
Dangerous in patients with:
Intracranial aneurysm (big time problem, attending should be there)
Intracranial bleeding
Elevated ICP
Complications Arising Immediately after Extubation: Laryngospasm
If patient is trying to take a deep breath with a closed glottis, they could be giving themselves negative pressure injury
Incidence
8.7 per 1,000 patients (all age groups)
17.4 per 1,000 (ages 0-9)
Highest range between 1 and 3 months, and children with upper respiratory tract infections – 95.8/1,000
5/1000 patients who develop laryngospasm develop cardiac arrest
Factors that influence its development:
Inadequate anesthesia
Premature extubation**
Semicomatose state
Aspiration
Presence of a nasogastric tube
Clinical Features:
Sudden onset
Absence of air movement in or out
(SaO2) saturation falls rapidly
Hypoxemia
Cardiac arrest
Treatment:
Positive pressure ventilation (may be ineffective)
Firm jaw thrust… Larsons Maneuver
Propofol (50-100 mg depending on patient, higher if big drinker and big marijuana smoker)
Small dose of neuromuscular blocking drugs:
Succinylcholine (10-20 mg)
Prevention
Timely extubation – deep
Patient bucking – allow them to wake up or enter Stage I before extubation
Lidocaine 2 mg/kg can be given for coughing 2-3 minutes prior to extubation
… better options
Complications Arising Immediately after Extubation: Airway Obstruction
Can occur immediately after a premature extubation
Patients may not have recovered from:
Anesthesia
Narcotic and sedative drugs
Neuromuscular blocking agents
Complications Arising Immediately after Extubation: Sore Throat
Most common complaint of patients
Abrasions to the oropharynx and nasopharynx
Doubled in those that are intubated vs. those who weren’t
Greater in patients with nasogastric tube
Greater in female than male
Proportional to the internal diameter of the endotracheal tube
In areas that are Dry (like Colorado), LMAs can cause a sore throat
Complications Arising Immediately after Extubation: Vocal Cord Damage
Postintubation Croup
Occurs with edema of the vocal cords – seen in children
Treatment: humidified O2, racemic epinephrine, dexamethasone (8-10 mg (increased dose))
Neural Injury: Recurrent Laryngeal Nerve Injury (RLN)
Unilateral or bilateral vocal cord paralysis
Possible causes include:
Possible cuff pressure on one or both of RLN’s
Anterior RLN compressed against lamina of thyroid cartilage by cuff
Nitrous oxide can diffuse into the cuff and increase pressure, applied to the tracheal mucosa
Normal capillary pressure 25-30mmHg
Complications of Endotracheal Intubation: Summary
Pay attention to details
Be vigilant
Avoid Hypoxemia
Never use force when placing an endotracheal tube
Confirm placement of the endotracheal tube
