Airway Flashcards
List the causes of upper airway obstruction
Infection- epiglottitis
Foreign body
Trauma- penetrating/ blunt
Anatomical- Tracheomalacia / supraglottic stenosis
Immunology- anaphylaxis/ angioemdema
CNS- head injury/ ICH/
Toxicology- drugs
Neoplasia- base of tongue/ larynx/ trachea
Predictor of difficult BVM
And Difficult LMAs
BVM- fit- beard/ dentures/ jaw
Obesity
Obstruction
Age >55
No teeth
Stiffness- c spine
LMA - restricted mouth opening
Obesity and obstruction
Distorted anatomy
Stiffness lung wall and chest wall.
Predictors of difficult intubation
L- look- size tongue and jaw
E- evaluate 3/3/2 rule 3cm between incisors 3 cm thyomental distabce and 2cm hyoid to thyroid distance
M- maladaptive score
O- obesity and obstruction
N neck mobility
T TMJ distinction/ trauma or tumour
E xperience
Predictor of difficult surgical airways
S- surgery prior to area
M ass- abscess or tumour to area
A access and anatomy
Radiation prior
T trauma or tumour
What is Malampati score
Score system to determine how much on view of upper airway.
Grade 1- soft palate/ faucial pillars and uvula
Grade 2 soft palate/ faucial pillars and masked base uvula
Grade 3 only soft palate
Grade 4- hard palate only
Increasing grade increasing difficulty
What is ASA score
1- healthy- non smoker no etoh
2- mild systemic disease- etoh/ smoker BMI>30/DM/HTN
3- severe not incapacitating- minor functional limitation
4- Severe consistent life threat- cVA/ sepsis/ MI
5- moribund- massive trauma ruptured AAA
6- brain dead- organ donation
Why is Cormack- Lehane- direct laringoscopy
Grading system
Grade1 - full view glottis 68% pop
Grade 2a- partial view Glottis - 24% pop
Grade 2b- only posterior glottis - 6.5%
Grade 3- only epiglottis -1.2%
Grade 4 - neither glottis or epiglottis rate
Indications to intubate in DEM
1-obtunded - GCS<8/ no gag/ can’t manage secretions
2- TCA overdose- hyperventilate
3- hypoxia to increase O2 delivery
4- increased WOB- take over ventilation
5- head injury- agitation/ hyperventilate
6- protect airway- burns/ anaphylaxis
7- volatile hydrocarbon ingestion
8- life threatening huperthermia- tube and muscle relaxant
9- bleeding- upper GI/ epistaxis
10- facial or neck burns
Contraindications for intubation
1- increased aspiration risk
2- suspect or known difficult tube
3- inabilaity to perform a surgical airway
4- upper airway obstruction- foreign body ro cancer
5- haemodynamically unstable
Size of blade for intubation and ETT size
Size 4 blade- adult average
Peadiatrics < 1=0 1=1 >2=2 >10=3 - use straight blade due to floppy eppiglottis
ETT
Adult female 7.5 and Male 8
Peadiatric age/4 + 4
Adult 20-23 cm teeth and peads 3xETT size
Complications after intubation
1- hypotension- anaphylaxis to anaesthetics? Tension pneumothorax/ AMI/ induction drugs
2- hypoxia- dislodged ETT/ obstruction/ pneumothorax/ equipment fail- vent/ tube/ ICC/ breath stacking or bronchospasm/ mucous plugging
3- cuff perforated/ cuff leak
4- trauma
5- endobronchial tube
6- fail to tube- surgical
7- aspiration
8- patient aware
Causes laringospasm
Ketamine induction
Irritation vocal cords by ETT
Incomplete paralysis
Aspiration
Foreign body
Hypo Ca2+
Post intubation steps
1- BP/HR/ECG
2- rpt VbG or ABG o2
3- check ventilator settings
4- insert NGT decompress
5- IDC/ art line
6- analgesia and sedation-
Morphine- 50mg/50ml saline run 1-20mghr
Propofol- neat 1000mg/100ml- 10-100mghr
Fentanyl- 10-200mcg/hr 1-20ml/hr
Midazolam 1-20mg/hr
Look features anaphylaxis and malignant hyperthermia
CXR- check tube and NGT
Disposition- ICU
Complications of surgical airway
Fail-> hypoxia
Damage to surrounding structures
Infection
Bleeding
Surgical emphysema
Always set up two airway surgical kits
How to manage blocked Tracheostomy
Suspect block-> pt cough-> apply 100% 02 to face and tracheostomy. Attempt to pass suction catheter
1- able to pass- partial obstruction remove inner lumen suction/ saline neb and new inner tube
2- unable to suction- remove inner lumen- deflate cuff and remove trache new tube or RSI and surgical airway
Reasons to extubate in DEM
Assess risk
A- grade 1 or 2 airways boy
B- saO2 >95% on Fio2 <40% TV> 6ml/kg PEEP<5 RR<30
C- SBP>100 HR<100 stable and unsupported
D- obeys commands has gag or cough to tube and no weakness
F- fluid neutral
Just prior to extubation 15 mins Fio2 100% and have NIV waiting bipap/ airway set up observe post 1-2 hours in Resus
Could do in etoh/ GHB/ opiate OD
Or palliative if not for organ donation
How to manage Laryngospasm
1- call for help
2- suction ++ (secretions maybe trigger)
3- FIO2 BVM 100% PEEP >5cm apply PPV
4- jaw thrust painful stimulus breaks spasm
5- deepens sedation ketamine deeper or propofol 2mg/kg
6- paralysis and intubate- ROC 1-1.2mg/kg
Sux 1-2mg/kg
IM sux 3-4 mg/kg
FONA- surgical airway
Note peads- laringospasm and bradycardia txt- atropine 20mcg/ kg IV
LMA - size
Indications
Advantages and disadvantages
Complications
Indicated- rescue airway/ facilitate blind insertion bougie railroad/ improve O2- CPR and then RSI after or fasted pt elective anaesthesia
R- restricted mouth open
O- obstruction- can’t vent
D- distorted anatomy
S- splinted lung- asthma
Advantages- easier than ETT/ rapid airway/ blind insert
Disadvantages- not definitive/ difficult vent- high airway pressures
Size
1= <5kg
1.5=<10kg
2=10-20kg
2.5=20-30kg
3= <60kg
4=<80kg
5= >80kg
Complications
1- can’t get seal or vent
2- aspiration
3- partial airway obstruction
4-Laringospasm
5- cough
6- trauma
Post intubation emergency steps
High airway pressure or hypoxia
1- ETT problem- displaced? Look/CXR. Obstructed suction/ kinked -replace/ check cuff leak
2- patient
- bronchospasm- breath stack? Listen txt.
- compliance- collapse or consolidation PTX or APO
- peripheral PTX or APO
External - abdo distension- NGT/ burns- escharotomy/ position of
4- cough or bite tube- deepen sedation
5- stacking (bronchodilators/ increase I:E ratio)
6- drugs missed or given
7- check ventilator and tubing
8- check SaO2 probes
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