Airway Flashcards
Airway Abscess & Infection
Considerations
Goals
Conflicts
Airway Abscess & Infection
Considerations
Emergency with risk of aspiration & acute airway obstruction
Difficult intubation & BMV with potential for complete airway obstruction (life threatening emergency):
Difficult topicalization
Trismus
Distorted anatomy, tissue edema, immobile tissue
Copious secretions
Potential for airway soilage from abscess rupture
Shared airway
Possible sepsis, pneumonia, mediastinitis & need for early goal directed therapy
Risk factors & co-morbidities:
Adults: HIV, IV drug use, diabetes, head & neck malignancies, alcohol
Immunosuppression
Pediatrics: upper respiratory tract infections
Potential for postoperative re-obstruction post extubation & disposition to ICU/high acuity unit
Goals
Consider pre-op abscess draining
Secure airway safely & effectively, always consider awake fiberoptic intubation (AFOI), surgical airway, ‘double set-up’
Manage sepsis with early goal directed therapy
Prevent abscess rupture & lung soilage
Conflicts
Uncooperative pediatric patient vs. difficult airway
Full stomach & need for RSI vs. difficult airway
Full stomach & need for RSI plus need for deep plane of anesthesia vs. risk of hemodynamic instability (sepsis)
AFOI does not visualize ETT passing abscess & therefore potential to rupture it
Airway Trauma
Considerations
Goals
Conflicts
Airway plan
Airway Trauma
Considerations
Emergency, full stomach
Trauma with ATLS approach
Difficult intubation & bag mask ventilation with possibility of complete obstruction
Plan for surgical airway backup
Co-existing injuries: unstable C-spine, traumatic brain injury, tracheobronchial disruption, vascular injury
Trauma considerations
Goals
Safe establishment of airway (spontaneous ventilation, get tube beyond injury)
Minimize C-spine movement
Conflicts
Full stomach vs difficult airway vs need for double lumen tube
Uncooperative or pediatric patient vs difficult airway
Airway Plan
Determine location of trauma: supraglottic, laryngotracheal, infracarinal
Bypass area of trauma during airway management
Supraglottic
Most preferred technique is tracheostomy
Awake vs. double setup after attempting direct laryngoscopy/video laryngoscopy/fiberoptic bronchoscopy
Laryngotracheal
Use awake, spontaneous ventilation technique under direct vision (fiberoptic bronchoscopy)
Infracarinal
Injury causing bronchopleural fistula with air leak, risk of tension pneumothorax &/or difficult ventilation during positive pressure ventilation
Secure airway with lung isolation: double lumen tube, bronchial blocker, single lumen tube placed endobronchially
Maintain spontaneous ventilation or rapid sequence induction while avoiding positive pressure ventilation until lung isolation
Expanding Neck Hematoma
Considerations
Goals
Conflicts
Expanding Neck Hematoma
Considerations
Emergency situation with little or no time to optimize
Anatomical airway distortion & edema resulting in a difficult airway:
Systematic & multidisciplinary approach critical, double set-up is key!
Release of sutures & evacuation of hematoma may be life-saving & may eliminate the need for a crash intubation
Unless impossible, spontaneous ventilation should be maintained & awake fiberoptic intubation attempted in the OR
Direct laryngoscopy (awake or anesthesized) is an option & should be part of the management algorithm
Potentially full stomach & risk of aspiration in cases of delayed hematoma formation
Medical & surgical control of hematoma once patient stabilized:
Likely need for return to OR for neck exploration
Possible need to reverse coagulopathy, thrombocytopenia, platelet dysfunction
Theoretical potential for hemodynamic instability due to compression of carotid sinus with resulting bradycardia/hypotension
Simultaneous management of medical comorbidities:
E.g. coronary artery disease in carotid endartarectomy patients
Goals
Immediate assessment & decisive airway plan
Safe airway management preserving spontaneous ventilation, upper airway tone & patient cooperation
Temporize as necessary to maintain airway patency
Always have surgical backups prepared
Conservative & cautious extubation strategy
Conflicts
Uncooperative, agitated patient requiring an awake technique
Emergency airway management required in an out of OR setting
Microlaryngoscopy & Airway Laser
Considerations
Goals
Conflicts
Airway Management Options
Safety Precautions
Microlaryngoscopy & Airway Laser
Considerations
Indication for surgery, location of airway lesion, presence of obstruction
Potential for dynamic airway obstruction with induction, positive pressure ventilation & paralysis:
Double setup with rigid bronchoscope available
Shared airway with need to optimize surgical conditions/safety
Individualized ventilation technique (communicate with surgeon):
Closed system: laser-safe ETT
Open system:
Low-frequency jet ventilation
High-frequency jet ventilation
Spontaneous ventilation (especially pediatrics)
Total IV anesthetic (TIVA)
Motionless surgical field
Complications:
Airway obstruction, laryngospasm
Laser: airway fire, burns, venous air embolism with YAG laser (deeper), pneumothorax
Jet ventilation: barotrauma, abnormal ventilation/oxygenation
Unprotected airway & aspiration risk
Goals
Optimize surgical conditions: motionless field, no risk of combustion
Adequate oxygenation & ventilation, secure airway
Depth of anesthesia sufficient to suppress hemodynamic response
Clear, constant communication with surgery team
Good postoperative care: prone to laryngeal spasm & edema
Conflicts
Contraindication to jet ventilation & need for airway laser
Full stomach & laser surgery: laser ETT vs jet ventilation
Airway Management Options
Broadly classified into 1) closed system, 2) open system
Closed system (intubation):
General anesthesia with ETT (microlaryngoscopy tube or laser tube)
Open system (no intubation, tubeless technique):
Topical/local anesthesia with sedation
General anesthesia without intubation
Apnea & intermittent intubation/bag mask ventilation
Tubeless spontaneous ventilation technique
Jet ventilation with Sanders technique: supraglottic vs subglottic, via catheter/rigid scope
High-frequency jet ventilation
Considerations:
ETT/microlaryngoscopy tube: ↑ risk of airway fire & obstructs surgeon’s visualization
Jet ventilation avoids the risk of ETT complications (kinked, obstructed, displaced, damaged, ignited)
Risks/complications:
Difficulty maintaining oxygenation/ventilation in morbid obesity, stiff thorax, restrictive/obstructive pneumopathy, lung fibrosis, reduced alveolar-capillary diffusion capacity (pulmonary edema)
Risk of dynamic hyperinflation if obstructed airway with barotrauma (subcutaneous emphysema, pneumothorax/pneumomediastinum, tracheobronchial injury), hypoxemia, hypercarbia/hypocarbia, gastric distension & regurgitation due to scope malalignment, possible vocal cord motion if supraglottic, drying of laryngeal mucosa, distal spread of particulate matter with potential tracheobronchial viral or tumor seeding
Safety Precautions
Locked doors, signs on doors
N95 mask for everyone if risk of viral particles
Eye protection for patient & personnel
Fire safety equipment (laser tube with methylene blue & saline into cuff/saline for extinguishing fire)
Difficult airway equipment
ENT surgeon present with rigid bronchoscopy
Penetrating Neck Injuries
Considerations
Goals
Conflicts
Penetrating Neck Injuries
Considerations
Emergency case with little or no time to optimize
Trauma patient & need for ATLS approach
Potential for serious & life threatening injuries:
Laryngeal/tracheobronchial tree disruption
Tension/open pneumothorax, massive hemothorax
Major vascular disruption
Esophageal tear
Spinal cord injury, nerve injury
Difficult airway management & possible need for awake fiberoptic bronchoscopic intubation
Goals
ATLS resuscitation & primary survey
Identify associated injuries
Key principles of airway management:
Avoid PPV & neuromuscular blockade until airway secured distal to injury
No cricoid pressure
Direct visualization probably the best method of airway management & double set-up always the safest option
Conflicts
Full stomach/RSI vs potentially challenging airway
Uncooperative patient vs. awake fiberoptic bronchoscopic intubation
Securing airway vs. consequences of PPV
Rigid Bronchoscopy
Considerations
Goals
Conflicts
Rigid Bronchoscopy
Considerations
Indication for surgery, presence of central airway obstruction & major comorbidities:
Risk of complete airway obstruction with an inability to ventilate
Risk of dynamic hyperinflation with hemodynamic collapse
Typically urgent/emergent cases in physiologically distressed patients
Shared & unprotected airway:
Aspiration risk, potentially challenging ventilation, potential loss of airway access
Need for GA with TIVA, neuromuscular blockade +/- depth of anesthesia monitoring & CO2 monitoring with invasive arterial catheter
Considerations for surgical technique: stenting, laser, endobronchial electrosurgery, argon plasma coagulation, & balloon bronchoplasty
Procedure specific complications: hemorrhage, airway trauma, perforation, fire, systemic gas embolism, & dissemination of postobstructive pneumonia
Goals
Avoidance of complete airway obstruction during induction of anesthesia
Avoidance of dynamic hyperinflation & cardiovascular compromise
Conflicts
Full stomach vs. unsecured airway
High oxygen requirements with risk of fire ignition
Jet ventilation through obstructing stenoses with risk of air trapping & barotrauma
Tracheostomy
Considerations
Goals & Conflicts
Considerations for the patient with a tracheostomy
Tracheostomy
Considerations
Shared airway
Possible difficult airway
Close communication with surgeon, backup plan discussed
Indication for tracheostomy & concomitant injuries (traumatic brain injury, C-spine injury)
Potentially critically ill patient with limited reserve, multi-organ failure
Potential catastrophic complications:
Loss of airway, hemorrhage, pneumothorax, pneumomediastinum, subcutaneous emphysema, aspiration, false passage/tracheal disruption
Airway fire (low FiO2, limited cautery use)
Goals & Conflicts
Optimize underlying disease state: assessment of stability for elective tracheostomy (high FiO2 & ventilator support, high dose inotropes/vasopressors, raised ICP, severe volume overload, coagulopathy/DIC)
Surgical plan discussed along with backups & additional equipment
Reduce risk of aspiration: NPO status, gastric suction applied
Motionless surgical field (paralysis)
Low FiO2 (protect against airway fire) vs. high FiO2 requirements
Considerations for the patient with a tracheostomy
Difficult airway:
Difficult BMV & supraglottic device ventilation (air leak)
Dangerous placement of ETT (direct vision preferred)
Indications for tracheostomy:
Pulmonary toilet
Respiratory failure/chronic ventilation
Threatened airway
Aspiration risk
Comorbid disease:
ICU patient with multi-organ failure, sepsis, lung injury, etc
Neuromuscular disorders, chronic high spinal cord injury
Complications of long term tracheostomy:
Tracheoinnominate fistula, suctioning injuries, trachea/stoma site infection/bleeding, laryngomalacia, tracheomalacia, tracheal rupture, tracheal stenosis
Ensure emergency tracheostomy equipment available:
Various sizes of cuffed/uncuffed tracheostomy tubes, suction catheters, graspers, ambubag & ties
