Airway Flashcards
List indications to secure airway (intubate)
1) the ability of the patient to maintain and protect there own airway –Gag reflex is an unreliable assessment as is missing in 12-25% of patients – Ability to manage and swallow secretion and ability to phonate and follow commands are more reliable intdicators – in general patient who require airway maneuver to establish a patent airway or who easily tolerate oral adjuncts require intubation
2) failure of ventilation or oxygenation -
3) the predicted course and likelihood of deterioration - active resus, pain control, need for invasive procedures and imaging outside of the ED and inevitable OT dictate the need for early airway control- Classic is Tox
4) pain management
5) transport
Discuss physiologically difficult intubation
HHARMMS
Hypotension – Fluid loading, Norad, Reduce induction agent by 20%
Hypoxia- Preoxygenation including thinking about PPV
Acidosis – RR matching
Respiratory conditions – optimise as much as possible
Medications
Medical conditions
Sepsis
Discuss difficult BVM
MOANS
\M: mask seal compromise or difficulty
O: obstruction or obesity – supraglottic obstruction
A: advanced age
N: non teeth, edentulous patients
S: stiffness or resistance to ventilation (asthma, COPD, APO, restrictive lung disease, term pregnancy)
Discus difficult direct laryngoscopy
LEMON
L: look externally - bruised and bloodied face -combative -C-spine immobilisation
E: Evaluate 332 -Glottic visualization necessitates that the mouth opens adequately the sub mandibular space is adequate to accommodate the toungue and the larynx be positioned low enough in the neck to be accessible -332 rule - 3 fingers mouth opening, 3 hyo-mental and 2 between hyoid and thryoid - receding mandible and high riding layrnx make direct visualisation impossible
M: mallinpati
O: obstruction or obesity: -epiglottitis, head and neck cancer, ludwigs angina, neck haematoma, glottis swellgin or glottic polyps can compromise laryngoscopy, passage of the tube or BVM
N: neck mobility
S: poor saturation – not a direct contirbutor to laryngscopy but limits time for intubation –> NIV for pre-oxygenation
Difficult extraglottic device placement
RODS
R: restricted mouth opening
O obstruction or obesity
D: distorted anatomy
S: stiffness – neck/lungs
Difficult cricothyrotomy
SMART – difficult cric can be anticipated whenever there is limited access to the anterior neck or obstructed laryngeal landmarks. -
S:surgery -
M: mass (abcess, haematoma)
A: access/anatomy problems (obesity, oedema)
R: radiation – leading to scarring over the nec,k
T: tumor/trauma
Describe Mallinpati score and anatomy assoicated with each + implications
Class I: Soft palate, uvula, fauces, pillars visible.
Class II: Soft palate, major part of uvula, fauces visible.
Class III: Soft palate, base of uvula visible.
Class IV: Only hard palate visible
Class 1-2 –> easy
class3-4 –> increasingly difficult
Discuss different oxygen delivery devices and the fio2 they can deliver
Non rebreather can hypothetically achieve 100% oxygen however firm seal is almost impossible ot achieve so at best achieves 70-80%
Nasal prong 24-40% depending on flow
Hudson 35-60%
Nonrebreather 80% (100% if full seal)
Discuss RSI
Nearly simulatneous administration of a potent sedative and a neuromuscular blocker for the purpose of intubation.
Provides optimal intubating conditions and has long been thought to minimise the risk or of aspiration.
Central concept is to take the patient from a strating point IE concious and breathing to a state of unconciousness with complete neuromuscular paralysis
What are the 7 Ps of rapid sequence intubation
- Preparation
- Pre-oxygenation
- Pre-treatment
- Positioning
- Paralysis with induction
- Placement of tube
- Post intubation management
Discuss pre-oxygenation – (mechanisms, technique, special pop)
Administration of 100% ogygen for 2 minutes of normal tidal volume breathing establish adequate oxygen reservoir to permit 6-8 minutes of safe apnea before desaturation to 90% - this time is condiderably shorter in children, obese adults, late term pregnant women and patient who are acutely ill or injured
If time is insufficient 8 vital capacity breaths with highflow are equal to the above
Obese patient can have available apnoeic period increased by preoxygenating in upright position and contining apnoeic oxygenation via NP at 5-15L/Min during intubation attempts
Primary mechanisms is denitrogenation of the lung – oxygen washout
Discuss factors that reduce safe apnoea time
critical illness
inadequate preoxygenation
obesity
pregnancy
shunt physiology
airway occlusion
increased oxygen consumption (e.g. high metabolic rate, fasciculations from suxamethonium)
anaemia or dyshaemoglobinaemia
Discuss the purpose of pre-treatment medication in RSI
Pre-treatment medication is used to control the physiological response to laryngoscpy and intubation. ]
Fentanyl 3mcg/kg can be used as a sympothelytic 3 minutes prior to inubatuion to avoid spikes in BP and reduce incrase in sheer forces. Specifically improtant for ICP, Aortic disease, ACS and neurovascular emergency
Bronchodilators to avoid or optimise ventilation
Discuss optimising positioing for airway (Neonate, children, adult, obese, pregant)
Adult: Position the patient with ear-to-sternal notch alignment, n the morbidly build a ramp under the patients and shoulders to achieve this, Avoid excessive atlanto-occipital extension
Infant: Have a comparitivly large occiput- place 1-2 folded towels under trunk to achive neutral airway
Ramp and left lateral for preganat ladies
Discuss confirmation of ETT placement
Co2
POCUS
EXAM
CXR
O2
Fogging of tube
Direct look
Discuss what constitutes a failed airway
Failed intubation without ability to brings spo2 above 90% 3x failed attempts
Discuss apnoeic oxygenation
takes advantage of a physiological principle termed aventilatory mass flow even though muscles have been paralysed circulation and diffusion of oxygen continue creating a gradient promoting passive movement of O2
