Airway Flashcards
Contraindications for awake nasal intubation “blind” nasaotracheal intubation
- nasal fx.
- nasal obstruction
- coagulopathy or bleeding disorder
- acute infection (sinusitis, mastoiditis)
- basilar skull fx.
- intra-nasal or pharyngeal abscess
Indications for awake nasal intubation “blind” nasaotracheal intubation
- Questionable airway (obesity, difficult anatomy, u/a to open mouth r/t trauma, wired shut, pain, etc…)
- Oral& maxillofacial sx. Pt. u/a to open mouth
- Spontaneous breathing pt. in respiratory distress (ICU, ER, etc)
- Cervical fx.
- Neuro injury
- trismus or jaw fx.
Advantages of awake nasal intubation “blind” nasaotracheal intubation
- more stable tube fixation
- less chance of kinked tube
- Greater comfort in an awake pt.
- Away from oral sx. site
Disadvantages of awake nasal intubation “blind” nasaotracheal intubation
- small tube size increased resistance
- additional equipment needed (Magill forcepts, vasoconstrictor)
- increase bleeding
- may be more difficult to direct NET than under direct visualization
- Patient cooperation mandatory
- Very stimulating for pt.
Which nare should be used for nasal intubation
-Nare that the patient breathes the easiest through. If no difference, use the right nare)
Why is the right nare preferred for nasal intubation?
When inserted in the right nare, the bevel of most tracheal tubes will face the flat nasal septum, reducing damage to turbinates
Purpose of using a NPA prior to nasal inttubation
- spread local anesthetic
- assess patency
Which nare do you apply the vaso-constrictor to prior to nasal intubatiob?
Both
Position of head during an awake nasal intubatiion
amended /”sniffing” position (slight flexion oh head forward with head turned to left or right)
What size NET is usually used
7 or 8
How do you actually insert the NET
slowly and gently along the floor of nose innnto the pharynx where you will feel least resistance. Listen for breath sounds (BS) and continue to insert as long BS are maximal & tubular in quality. (If hey diminish re-direct towards glottis)
What type of tube is good for NET intubation and why?
Endotrol r/t bent tip
What does it mean if a patient starts coughing during NET insertion? What should be done?
- Coughing indicates correct positioning
- Cont. to advance tube through vocal cords
What should be done if the NET doesn’t go into trachea?
Pull back to maximal breath sounds are heard and re-direct tube
Causes of epistaxis during NET insertion
- too large tube
- not enough lubricant
- rough/ vigorous instrumentation
Where might the NET be if it wasn’t placed in the trachea
- vallecula
- on the anterior commisure
- against closed glottis during laryngospasm
- esophagus
- pyriform sinus
What should be maintained while assessing a difficult airway situation?
Masked ventilation
What should be maintained if a patient has a full stomack during a difficult intubation
cricoid pressure
Define “Difficult airway”
Any intubation that takes a skiiilled anesthetist more than 3 attempts or 10 minutes
If intubation is unsuccessful what should be done?
- Allow pt. to awaken or an attempt at an awake intubation
- If NDMR used, ventilate patient until reversal is posible
When should a glidescope or fiberoptic intubation be done?
Before the field is obscured with blood, edema, secretions, etc..
Complete this sentence: It takes longer to do a tracheostomy than_________________
it takes for CNS damage to occur
It is strongly recommended that every operating suite be equipt with what airway supplies?
-intubation cart containing: adult & pediatric fiber optic endoscope, a light source, assortment of laryngoscopes& blades, airways, ET tubes & stylets, cricothyrotomy set and means for transtracheal jet ventilation, and equipment for retrograde intubation
What is the next option if unable to ventilate a pregnant mom with a baby in distress?
Get an LMA if you can’t ventilate
If a patient a patient refuses awake intubation or a difficult airway isn’t recognized before anesthesia induced how will the airway initially be managed.
-airway ordinarily first controlled by mask ventilation before conventional laryngoscopy.
What is done next after noting a difficult airway with multiple attempts
- Change position/ technique
- Allow pt. to awaken/attempt awake intubation
- If NDMR used, ventilate pt. until reversal is possible
When should glidescope/ fiberoptic intubation be attempted?
Before field is obscured w/ blood, secretions/ edema
Steps for a cricothyroidotomy for airway placement
Puncture cricothyroid membrane IV catheter> aspirate air> remove needle & syringe> advance catheter> reattach syringe> aspirate air (to assure placement)> discard syringe> connect ot O2 source> insert 3mm ETT adapter into catheter hub (for attachment of anesthesia circuit/ resuscitation bag) or insert adapter from 7mm ETT into barrel of 3ml syringe after plunger removed> hook up to Jet ventilation
What medication can be given to help with difficult airway intubation and why?
- Robinul
- Prevent spasms & difficulties (dries secretions)
When might tracheostomy or cricothyroidotomy be the 1st choice for an airway
- pt. refuses awake intubation
- difficult airway not recognized before anesthesia induced
- Absolutely unable to ventilate or intubate pt.
Is awake fiberoptic intubation for emergent or non emergent cases
Non-emergent (most useful for a non-bloody, non-emergent problem). Can be used when difficult airway is expected
Indications for an awake fiberoptic intubation
- Predict difficult anatomical airway
- upper airway mass/ swelling
Steps for awake fiber optic intubation
insert into mouth or nose> able to view once tip of scope emerges from obturator> enter trachea above carina> use as a guide over which the ETT is advanced> verify postioning> remove bronchoscope> induce IV anesthesia
When is retrograde intubation used
In emergencies when it is IMPOSSIBLE to ventilate or intubate Pt.
Steps for retrograde intubation
Enter cricothyroid membrane w/ 18g needle w/ bevel cephalad @ 45 degree angle> aspirate air to confirm trachea entry> insert a 0.25-0.35 guide wire (110-150cm) through needle> thread through vocal cords> pharynx> out mouth> remove needle & clamp skin> thread ETT over guide wire into trachea> confirm placement> withdraw guide wire> connect to anesthesia circuit.
What type of airway for a Laforte fracture (nasal & jaw )
awake tracheostomy
When is transtracheal ventilation (Cricothyroidotomy) used
-life sustaining measure if u/a to mask ventilate or intubate
What pt. population CAN’T you use cricothyroidotomy for ventilation and why?
kids <12yrs due to cricoid is the narrowest part of their passageway
What type of ventilating is most effective through a needle catheter
Jet Ventilation
How does a pt. exhale during transtracheal ventilation
-passively through upper airway
What type of tubing used w/ jet ventilation and Why?
- Non compliant tubing
- Used in order to bypass the compliant resevoir bag & corrugated tubing of circle system
Where does the non-compliance tubing attach
-attaches to machine commom outlet via 4mm ETT adapter A 1/4” hose barb with a male luer lock fitting inserted in other end of tubing for connection to transtracheal catheter
Describe jet ventilation
-allows O2 on pressure
-pt. ventilates in puffs
(problem is with exhalation. air being pushed in 1 way. pt. passively moves air out)
purpose of light wand stylet
- lights trachea
- utilized to assist w/ blind intubation techniques
Another name for “Aintree” intubating catheter and its uses?
- Bougie catheter
- Used with fiberoptic bronchoscope
- Used as an AEC (airway exchange catheter)
Steps using the bougie catheter
(give sm. dose of propofol)> LMA placement> go through LMA with Bougie catheter advancing anteriorly> once in place, pull LMA out> use exchange catheter to place ETT
How is a Glidescope/ Airtraq
straight down the middle w/ out weeping the tongue
Difference in handling a glidescope/ Airtraq from a regualr ETT
handle tube from the top vs. the middle like traditional ETT
What type of medication should be given before intubation with a Glidescope/ Airtraq
antisialoguge
Features of a glidescope/ airtraq
- place clinician view around base of tongue
- lighted hand holds laryngoscope/ camera
- Useful in any position
- less traumatic than direct laryngoscopy
- 3D view vs. straight plane of traditional laryngoscope
When is the ideal time to intubate & why
- When pt. still adequately anesthetized
- Decreases likelihood of coughing & laryngospasms
Other than pts. @ risk for aspiration, when else is an awake extubation performed
-pts. that re-intubation would be difficult (difficult intubation, neck sx., bandages & bulky dressings, jaw wired )
Where is suctioned performed prior to intubation & why
- oropharynx
- to prevent secretions proximal to cuff from draining onto trachea.(prevent laryngospasm)
When is the ETT removed & why
- during inspiration
- vocal cords are open
Why would one apply pressure to reservoir bag as the ETT is being REMOVED
- inflate lungs so initial gas flow is outward
- facilitates cough & expulsion of aspirated material
What should always be available during extubation if needed?
- Succinylcholine
- Suction
- O2
- Re-intubation equipment
What should be done if pt vigorously bucking vent.? What is this a sign of
- vigorous bucking means return of cough reflex
- decide to remove tube or wait until pt. more awake (assure pt. nit in stage II)
S/S of stage II anesthesia that should be assessed prior to extubation
- enlarged pupils***
- breath holding***
- tachycardia
- tearing
- coughing
- divergent gaze
What can bucking the vent cause?
- Hypoxia
- Increased CSF (cerebral congestion)
- intra-abdominal tension (suture strain)
Lidocaine dose…when to give and why
1-1.5mg/ kg IV.
- Give 2 min. prior to extubation
- Helps with cough, HTN,m tachycardia associated w/ emergence
What precaution should be taken when administering lidocaine prior to intubation
- wait until respirations are regular before administering.
- Lidocaine can deepen anesthesia
Indications for an awake extubation
- Full stomach
- Actual/ potential airway swelling
- Difficult intubation or mask ventilation
- Obese
- NGT
- Intoxicated pre-op
- hx. of OSA
- oral/ maxillary surgery/ fixation
***Criteria for awake extubation (5)
- Sustained head lift >5 sec.
- able to hold eyes open
- TOF + w/ sustained tetany
- equal, strong grasps
- Responds to commands
What type of suction catheter should be used at the end of the case before extubation
- thin, deep suction catheter
- don’t use yanker (doesn’t get deep enough)
Steps for awake extubation
- 100% O2> suction pharynx PRN
- Deflate cuff completely
- Ask pt. to take a deep breath & remove tube w/inspiration
- Ask pt. to take another deep breath (assure adequate gas exchange)
- Face mask O2
- A LITTLE peep on bag. Let pt. take breath DON’T VENTILATE
- May transport to PACU with 02
**Deep extubation indications
- asthmatics
- eye cases (prevent increase IOP)
- Neuro cases (prevent increased ICP)
- hernia repair (no straining)
- Pediatrics (increased risk for reactive airways)
- Any procedure where coughing/ bucking is detrimental (Neck/ throat sx.)
What is a (non-clinical) reason why you would NOT (or use caution) extubate deep.
if you didn’t perform induction/ intubation
What’s optimal respiratory status for deep extubation
Regular respirations & small Tv (tidal volume)
Which patients would you not extubate deep
don’t extubate anyone deep that you wouldn’t mask (pt. not NPO, pregnant women, beards, anatomical challenged, etc..)
***What are the most serious immediate hazards after extubation of trachea
- laryngospasm
- vomiting
Steps for deep extubation
- assure spontaneous RR (decrease Tv& RR)
- Don’t turn agent off (may increase if increased RR or Tv)
- Turn off N20, increase O2 concentration to 100%
- assist w/ respirations (deepen anesthetic)
- Can give Lidocaine 1mg/kg;sm. dose propofol or narcotic
- Gently suction pharynx & assure no cough/ gag
- If cough or gag deepen w/ agent or propofol
- Deflate cuff (if bucks> reinsert> deepen anesthesia)
- Gently remove tube & leave in OPA
- apply mask & awaken ( a little peep on bag. allow to breath..DON’T ventilate. Watch RR and gently assist.
**Precautions utilized during extubation if suspect pt. is in stage II & why use precautions
- Admin. O2 &Wait for pt. to emerge further
- Pt. @ risk for laryngospasm or vomiting (hyperreflexia)
What is used as a bridge to extubation for difficult extubations
- AEC (airway exchange catheters) USE one SMALLER than ETT
- Tube exchange catheters
- Central lumen with rounded, atraumatic ends, oxygen source port
What patient population would be included as difficult extubation
- Difficult intubation
- Post. sx. edema
- Full stomach
- Obesity
- Poor airway
- OSA
Contraindications to extubation
- Inadequate resp. exchange
- Sx. procedure comprimises airway (swelling, wiring, etc..)
- Protective reflexes haven’t returned (elderly, critically ill)
- difficult intubation/ mask ventilation (OSA, beard, obese)
- Plan for vent. post op (cardiac sx. Neuro, big bowel cases)
- prolong sx.
- Cyanosis &/ or poor ABGs
***Example of when surgery procedures comprimise airway
- long prone position cases (increased facial edema)***
- oral sx
- head/ neck sx.
- Neck injury
Other S/S that contraindicate extubation
- non sustained head lift/ poor hand grasp
- NDMR overdose
- Unable to open eyes
- Floppy “fish out of water” movements (give reversal until maxed)
- breath holding & coughing (don’t extubate)
Type of pts. that experience a decrease in return of protective reflexes
- elderly
- critically ill
What’s considered “inadequate respiratory exchange” that will prevent extubation
- NIP <20
- Decreased respiratory effort & Tv
- Increased / decreased RR
- Variable respiratory patterns
Type of pts. that are categorized as difficult intubation or mask ventilation
obese, beard, OSA
Pts. that post op ventilation can be planned
- Large bowel sx.
- Neuro sx. cases
- Cardiac Sx.
- Increase blood lost & crystalloids given (r/t 3rd spacing)
What medications SHOULD NOT be given to obese pts.
- Dilaudid (opioids)
- especially not at end of case or post op in OR
- Make sure pt. fully awake
Variations noted to awake intubations
- Extubate inReverse trendelenberg
- Extubate over tube changer (AEC)
What are the contributing factors to tracheal collapse
soft tissue collapse associated w/ anesthetics
What is the mainstay for the difficult intubation algorithm
awake intubation
w far should the cook catheter be inserted
20-22cm
What size cook AEC should be used
11 or 14fr
