Airway

Question 1

What are the indications for intubation?

Answer 1

1. Inability to protect airway
2. Inability to oxygenate
3. Inability to ventilate
4. Projected clinical course

Question 2

Waht are the predictors of difficult BVM?

Answer 2

MOANS

1. Mask seal
2. Obstruction or obesity
3. Age >55y
4. No teeth
5. Stiffness of chest - eg asthma, COPD, pregnancy, obesity

Question 3

What are the predictors of difficulty intubation?

Answer 3

LEMON

• Look
  
  • Bull-neck
  • Overbite
• Evaluate 3-3-2
  
  • 3cm mouth opening
  • 3cm hyo-mental distance
  • 2cm from floor of mouth to top of thyroid cartilage
• Mallampati - sitting, mouth maximally open, tongue out
  
  • I - Soft palate, uvula and tonsillar pillars visible
  • II - Soft palate and most of uvula
  • III - Soft palate and base of uvula
  • IV - Only hard palate
• Obstruction or obesity
• Neck mobility
  
  • Collar
  • Ank-spond

Question 4

What are the predictors of difficult LMA use?

Answer 4

RODS

• Restricted mouth opening
• Obstruction / obesity
• Distorted anatomy
• Stiffness of lungs

Question 5

What are the predictors of difficult surgical airway?

Answer 5

SMART

• Surgery - previous neck surgery
• Mass - abscess, haematoma
• Access - obesity, oedema
• Radiation - previous neck radiation
• Tumor

Question 6

Name and describe the classification system for airway view on laryngoscopy.

Answer 6

Cormack-Lehane System

• Grade 1: Full view of glottis (approx 2/3)
• Grade 2a: Partial view of glottis (20%)
• Grade 2b: Posterior extremity/arytenoids only
• Grade 3: Epiglottis only
• Grade 4: no view of glottis or epiglottis

Question 7

What is the definition of a failed airway?

Answer 7

1. 3x failed attempts by experienced operator
2. Failure to oxygenate using BVM or EGD
3. Grade 4 view on first attempt by experienced operator

Question 8

What are the considerations when intubating a head injured patient?

List the RSI approach.

Answer 8

• Minimise hypoxia
• Minimise hypotension
• Stabilise ICP

Fentanyl 1mcg/kg (first) + 1mg/kg ketamine + 1.2mg/kg roc

Question 9

Discuss your RSI checklist.

Answer 9

• Plan
  
  • ​HOp killers - Haemodynamics, oxygenation, pH
  • Drugs - Ketamine + Rocuronium +/- Fentanyl
  • Post-tube analgesia/sedation
  • ? push-dose epi
  • Failed intubation plan -> verbalise it!
  • Cric evaluation
• Patient
  
  • ​Denitrogenated >3mins - NC + NRB/BVM
  • Apnoeic oxygenation - NC @15L/min
  • Oxygenation >= 95% (? CPAP)
  • Look in mouth - teeth, dentures, range neck
  • Positioning - tragus to sternal notch, face parallel to ceiling - ? ramping
  • Pulse ox - visile or audible
  • Access - 2x, reliable and tested, ?IO
• Equipment
  
  • ​Airway trolley - OPA, NPA, Bougie, SGA, Scalpel
  • BVM +/- PEEP valve with ETCO2
  • VL
  • Backup DL
  • Suction x2
• PPE
  
  • ​Eye, face, hand protection
• Briefing
  
  • ​Roles
  • Drug sequence
  • AIrway plan
  • ELM/head elevation/collar/NRB