Advanced airway management Flashcards
what are the indications for intubation
- failure to maintain or protect airway
- failure of ventilation or oxygenation
- expected decline/ decompensation in clinical status
- cardiac arrest
failure to maintain or protect airway
- comatose (GSC <8/15) (prevents aspiration)
*airway trauma (e.g. facial fracture)
failure of ventilation or oxygenation
- SaO2 < 90% on high flow oxygen
- or PaO2 <7.9 kPa on FiO2> 40%
- ventilation failure (rising CO2)
categories of a potentially difficult airway
- anatomically difficult intubation
- physiologically difficult intubations
anatomically difficult airway management predictors
- moans
- lemon
- rods
- short
MOANS
diffucult bag valve mask ventilation
LEMON
difficult laryngoscopy and intubation
RODS
difficult extra-glottic device placement (LMA)
SHORT
difficult cricothyroidotomy
difficult BVM
M- mask seal problems (beards)
O- obstruction/ obesity
A- age>55 (poor muscle and tissue tone)
N- no teeth (face caves in)
S- stiff lungs (high pressure to BVM)
difficult surgical airway
L- look externally
E- evaluate the 3-3-2 rule
M- mallampati
O- obstruction/ obesity
N- neck mobility- limited
look externally
body habitus, head and neck anatomy (short neck), mouth (small opening, loose teeth or prominent teeth), jaw abnormalities (significant malocclusion and beards
3-3-2 rule
- can you fit 3 fingers between the incisors
- is the mandible length 3 fingers from the mentum to the hyoid bone
- is the distance between the hyoid to the thyroid 2 fingers
mallampati
class I and class II- adequate oral access
class III- moderate difficulty
class IV- high degree of difficulty
obstruction or obesity
conditions such as epiglottis, head and neck cancer. Ludwig’s angina, neck hematoma, foreign body or thermal injury can compromise laryngoscopy, the passage of the endotracheal tube (ETT), BVM, or all three
neck mobility
neck mobility can be significantly reduced in patient with trauma (cervical collar) or the elderly and those with arthritis
difficulty surgical airway
S- surgery or disrupted airway
H- hematoma (infection/ abscess)
O- obesity
R- radiation therapy- previous
T- tumor
difficult extra glottic device
R- restricted mouth opening
O- obstruction
D- disrupted or distorted airway
S- stiff neck
what do you do if an anatomically difficult airway is predicted
- you have back- up devices that will suit the condition
*you have a plan for intervention should there be a problem
physiologically difficult airways
- hypoxic patients
*metabolically deranged (severely acidotic patients)
rapid sequence intubation (IRS)
- RSI is the administration, after pre- oxygenation, of a potent induction agent followed immediately by a rapidly acting neuromuscular blocking agent to induce unconsciousness and motor paralysis for tracheal intubation
where is RSI used
in emergency care
which patients do not need RSI
patients who are intubated during cardiac arrest
why RSI
- emergency patient have full stomachs
- preoxygenation allows for safe apnea period without bag valve mask ventilation and the associated risk of gastric distention and aspiration
- sedation and paralysis together allow for optimal intubating conditions (get the tube in first time)
- use of short acting drugs allows for rapid return of spontaneous ventilation
stages of RSI
10 min- preparation
5 min- preoxygenation
2 min- pretreatment
0 min- paralysis with induction
+30s- placement of tube
+45s- proof of tube position
+90s- post intubation monitoring
preparation (SOAP ME)
S- suction
O- oxygen : preoxygenation nd delivery device
A- airway devices (laryngoscope/ETT/ OPA) and alternative airways
P- position patient correctly
M- monitors to use during procedure (BP/ 3 lead/ Sats) and medication for intubation
E- equipment to confirm (stethoscope, ETCO2, EDD)
Steps for Rapid Sequence Intubation
- preparation of equipment
- preparation of the patient
- preparation of the team
- positioning
- pre- oxygenation
- pretreatment/ preload
- placement of tube
- proof of tube positioning
- post intubation monitoring
what is the aim of preoxygenation
aims to increase oxygenation and remove nitrogen from lungs
how do we pre-oxygenate
give 100% oxygen for 3-5 min or 8 vital capacity
what do we use for pretreatment
- crystalloid fluid bolus 10mll/kg
*fentanyl 1-3 mcg/kg or - lignocaine 1.5 mg/kg
name induction agents
ketamine
etomidate
fentanyl
midazolam
propofol
thopental
name preferred agents for paralysis with induction
suxamethonium 102 mg/ kg TBW
rocuronium 0.6-1.2 mg/ kg IBW
vecuronium 0.15- 0.25 mg/kg IBW
placement of the tube: which side do you stand
right side
placement of the tube: how do we use the laryngoscope
insert it between down and epiglottis and swipe tongue towards the mandible/ jaw
placement of the tube: insertion of the tube
- tip of ett (endotracheal tube) advanced through the cords
- depth: black line at cords/ cuff through cords
3.confirm with edd - then inflate balloon
- check placement
secure ett
proof of tube position
- capnography (end tidal CO2)= gold standard
- direct visualization of ETT through cords
- esophageal detector device (EDD)
- misting of ETT
- equal rise and fall of chest
- 5 point auscultation
- epigastrium= absent sounds
- axilla and bases both sides have good air entry
Esophageal detector device (EDD) if in oesophageus
if in esophagus will not re-expand as esophagus will collapse round edd
falses of EDD
- falsely re-expands if in stomach due to air
- falsely doesn’t re-expand if small child (,20kg) or obesity
end tidal CO2 monitoring function
to look at end tidal CO2 to assess if in trachea
end tidal CO2 monitoring: qualitative
yellow= yes
*ph sensitive filter paper
*turns yellow if >2-5kPa pCO2
*only qualitative
quantitative= capnography
*infrared detection
*waveform analysis
problems with qualitative: false positives
gas cooldrinks
gastric distention from BVM
problems with qualitative: false negatives
cardiac arrest
massive PE
massive obesity
saturation monitor
pulse oximeter detects Hb oxygen saturation peripherally. it is a delayed response
when to be careful when using pulse oximeter
*nailpolish
*high ambient light
*carbon monoxide poisoning
*no pulse in patient
*hypotensive
*hypothermic
post intubation monitoring
*3 lead ECG monitoring for rhythms
*sat monitoring
*ABGs (PaO2 and PaCO2)
*BP (non- invasive or invasive)
*Capnography if available
*CXR for ETT placement
what happens if SATS DROPS
D- displacement of ETT (bronchi/ RMB/ oesophagus)
O- obstruction of ETT/ circuit
P- pneumothorax
E- equipment failure
S- stomach full of air (especially children)
complications of intubations
*trauma
*infection- pneumonia
*laryngospasm/ bronchospasm
*esophageal intubation
*right main bronchus intubation
*tension pneumothorax
if you cannot intubate
ventilate
rescue devices for intubation
LMA(laryngeal mask airway)
Combitube
if you cannot intubate, cannot ventilate
surgical airway- cricothyroidotomy
