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
