Air management Flashcards
Gag reflex nerve
Vagus
3 unpaired carilages
Thyroid, cricoid, epliglottis
3 paired cartilages
Arytenoid, cuneiform, corniculate
Difficult to ventilate def (ASA)
when signs of inadequate ventilation cannot be reversed by mask ventilation or the pts oxygen sat cannot be maintained above 90% with mask ventilation
Difficult to intubate definition
a trained anesthesia provider, using conventional laryngoscopy, requires more than 3 attempts or more than 10 minutes to complete tracheal intubation.
Difficult airway definition
A trained anesthetist experiences difficulty with facemask ventilation, laryngoscopy, intubation, or all of these.
Lemon Law
Look externally, Evaluate the 3-3-2 rule, Mallampati, Obstruction?/Obesity, Neck mobility
3-3-2 rule
3 fingers fit in mouth-inter incisor distance, 3 fingers fit from mentum to hyoid cartilage, 2 fingers fit from the floor of the mouth to the top of the thyroid cartilage
Thyro-mental distance
Measure from upper edge of thyroid cartilage to chin with head fully extended. Short is an anterior larynx, >7cm is easy intubation <6cm difficult airway
Mallampati classification (PUSH)
1- Pillars, uvula, soft, hard palate, 2-Uvula base, soft, hard palate, 3-soft/hard palate 4- hard palate only
Possible obstructions
blood, vomitus, teeth, epiglottis, dentures, tumors, impacted objects.
Atlanto-Occipital angle
35 degrees.
Mask ventilation difficult? BONES
Beard, Obesity, No teeth, Elderly, Snoring
Laryngeal visualization difficult? 4 D’s
Disproportion, Distortion, Dismobility, Dentition,
Difficulty with SGA (LMA)
Restricted mouth opening, Obstruction, Distortion of airway, Stiff lungs,
Difficulty with cricothyrotomy
Distorition of neck anatomy, Obesity or short neck, Trauma in or around neck, Impediments limiting access to neck (halo, fixed flexion) Surgery
Maneuvers for airway/intubation
Positioning-Sniffing position, Neck positioning, Ramping-elevate shoulders, neck, and head, Apneic oxygenation, Cricoid pressure
Options for airway
Awake intubation,
quick look,
Induction and paralysis
Quick look without
Muscle relaxation, includes sedation
Tidal volume breathing for pre-oxygentaiton time
3-5min
Pre-oxygenation Deep breaths
4 times within 0.5 minutes
Plan A for intubation
Elective (4 attempts) or RSI (3 attempts),
Optimise position,
use bougie or stylet,
alternative blade/scope,
alternative operator
Plan B intubation
Classic LMA, Intubating LMS,
Fibreoptic intubation trough LMA, malleable fibreoptic stylet, fibreoptic scope,
Not appropriate in elective RSI
Plan C for intubation
Maintain oxygenation and ventilation,
Attempt to wake patient up,
Consider suggamadex if available,
face mask, nasopharyngeal airway, guedel airway, classic LMA, Intubating LMA
Plan D intubation
Rescue Technique,
Needle cricothyroidotomy (pediatric or easy anatomy),
Scalpel-bougie-ETT (adult or easy anatomy)
Scalpel-finger-needle (impossible anatomy)
Only full ring of cartilage in trachea
Cricoid
Number of C-shaped rings in tracha
16-20
Even with proper eval, what percentage of difficult airways are picked up
15-50%
What is the Thyro-mental distance
Measure from upper edge of thryoid cartilage to chin with the head fully extended.
Short disance= an anterior larynx
>7cm is usually easy intubation
<6cm= difficult airway
Eschmann Stylet
Bougie
Common LMA size in adults
4 (50-70kg) 30cc cuff
5 (70-100kg) 40cc cuff
6 (>100kg) 50cc cuff
Upper Airway Obstruction s/s
Hoarse,
muffled voice,
difficulty swallowing,
secretions,
STRIDOR,
DYSPNEA,
EMERGENCY
Lower Airway Obstruction signs
high peak pressures, low tidal volumes, impaired ventilation
Considerations for obese airway
position, preoxygenate, 2nd plan, alternate adjuncts, assistants, desaturate much quicker(limit time delay)
Age consideration for dentures
Endentulous (leave dentures in place for masking and lma)
Tracheal Extubation Criteria Global
Acceptable hemodynamic status,
Normothermia,
Ability to maintain patent airway,
Adequate muscle strength,
Acceptable metabolic indicators,
Accpetable hematologic indicators
Adquate respiratory mechanics
Ability to maintain adequate oxygenation
Adequate analgeisa for optimal resp effort,
Criteria to maintain patent airway
Laryngeal and cough reflex
Appropriate level of consciousness
Criteria for adequate muscle strength (extubation)
head lift >5sec with constant hand grip,
Reversal of neuromuscular blockade( TOF>.9, tetanic response to 100Hz 5 seconds, and double burst stimulation without fade.)
Criteria for acceptable metabolic indicators (extubation)
Electrolytes within acceptable limits,
acid-base balance within accept
Vital capacity for extubation
>15mL/kg
Maximal negative inspiratory force(NIF)
> -20cm H2O
Tidal volume for extubation
at least 4-5mL/kg
PaCO2 for extubation
<50mmHg
