Airway Flashcards
What are the General considerations of an Airway exam?
What is the AANA Standard I and Standard III?
- Airway assessment is most important component of the physical exam!
- The anesthetist must conduct an airway assessment for every patient who receives ANY type of anesthesia
AANA Standard I - a practitioner shall perform a thorough and complete pre-anesthesia assessment, allowing the practitioner to (Standard III) formulate a patient-specific plan for anesthesia care
Purpose
- To predict ease or difficulty of airway management
- To develop an plan for airway management
- Must consider type of surgery, type of anesthetic, safety factors
What are the components of an airway assessment?
- History-anesthesia history, past medical history, past surgical history
- Questions related to Airway
- Physical Exam
- Documentation
What is part of the anesthetic history?
•Previous anesthesia history with airway management:
- Have you ever had an anesthetic in the past?
- Were you told of any airway problems?
- Was there severe sore throat or dental damage?
- Were you advised to have an awake or fiberoptic intubation?
- Do you have any records or documentation?
- Any breathing difficulties? Breathing tube? Ventilator?
•Note- The history of a previously easy airway does not rule out possibility of difficulty w ventilation or intubation.
What is part of their medical history?
Co-morbidities may effect airway management
- Lesions/tumors/infections of larynx
- Thyroid disease
- Cancer
- GERD
- Diabetes
- Obesity
- Genetic Disorders
- Rheumatoid Arthritis
- Musculoskeletal
- Scleroderma
- Trauma to head/neck/face
- Radiation therapy to neck
What is part of the surgical history?
Surgical hx may effect airway management
- Tracheostomy or scar
- Neck dissection
- Radiation
- UVPP
- Cervical neck instrumentation (fusion)
What are some questions related to airway?
- Cough-recent? Productive?
- COPD?-use of inhalers? Steroids?
- Asthma?-use steroids? Bronchodilators?
- Snoring? Nightly?
- Obstructive Sleep Apnea? Use of CPAP? Surgery?
What are you looking for regarding the physical assessment observation/inspect as part of the airway assessment?
- General appearance
- Facial deformities, burns, radiation scars?
- Neck anatomy-size circumference + length
- Goiter?
- Trachea midline?
- Mandible-Size & shape; maxillary overgrowth? receding?
- Facial hair?-full beard, moustache? goatee?
- Nares-size? Open? Mouth breathing? Flaring?
- Mouth-lips, tongue, tissues-color, size, condition?
- Cervical spine-limited extension or flexion, possible unstable? collar?
- Body mass index?
- Age?
Ask the patient to open the mouth as wide as possible
- TMJ –degree of motion? Dislocations?
- Interincisor distance (measured from upper (maxillary) to lower (mandibular) incisors) Normal > 4cm or >2 fingerbreadths
- Size & mobility tongue
- Palate- high or arched?
- Any mass seen?
Dental Assessment
- poor dentition
- loose teeth
- chipped teeth
- capped
- removable bridges
- dentures
- Thyromental distance- Distance from mandible to prominence of thyroid cartilage (thyro-mental) - normal 6.5 cm (65 mm) or 3-4 fingerbreadths (3FB)
- Hyoidmental distance- Distance hyoid to mandible (hyoid-mental) -normal 2FB
- Cervical Range of Motion -atlanto-occipital joint- flexion 85 degrees, extension 70degrees, looking over shoulder 80 degrees, head to ear 40 degrees
- Listen to BBS/ upper airway sounds for snoring, stridor
Neck Size:
- male = 15- 16 inches (38-40 cm);
- women = 13-14 inches (33-35 cm)
- 17 inches or > 40 cm neck size – 5% chance of difficult airway
- Increases 1.3% for every 1 cm increase in neck size
- Mallampati Classification I-IV
- DVL view of Vocal cords
Explain the Mallampati Classification I-IV
- Relates the size of base of tongue to the oral cavity
- Visualization pharyngeal structures- soft palate, fauces, uvula, and pillars
- During this assessment the patient is seated upright with the head in neutral position. The patient is asked to open the mouth as wide as possible and to stick out the tongue.
- Patients encouraged NOT to phonate or say “ahh”, as phonation can inappropriately elevate the soft the palate.
What does the DVL view of the vocal cords look like?
Epiglottis, vocal cords, arytenoids
What are you aligning in the sniffing position?
- Oral axis
- Pharyngeal axis
- Laryngeal axis
By adding a pillow and head extension
What do you see in a normal larynx?
What are the components of an airway set up?
- Laryngoscope /Blades 2 types, sizes
- Oral/nasal airways several sizes
- Suction
- Tongue depressor
- Syringe on cuff
- ET Tubes 2-3 sizes (open one intend to use)
- Ambu-bag
- LMA/Lubricant
- Stylets
What are the indications for a mask airway?
- Difficult airway NOT present
- Surgeon does not need access to head/neck (BMT-ok)
- No airway bleeding/secretions
- Case of short duration
- No table position changes- head available
- No instrumentation of airway required
- Avoid CV stimulation of direct laryngoscopy
•Ventilation by mask requires the ability to achieve a seal between the mask & face. Obstruction should be easily relieved w airway/ chin lift
What are the indications for a LMA?
- Supraglottic airway-Dr. Archie Brain. Introduced into practice 1988
- Inserted blindly into pharynx-ease and speed of placement
- Less invasive than ETT and more definitive airway than mask
- Improved hemodynamic stability
- No need for muscle relaxation
- Avoid risks of intubation- trauma to teeth, coughing on emergence, severe sore throat
- Ineffective ventilation when high airway pressures required
- No protection from laryngospasm
What are the indications for intubation?
- Airway protection
- Maintenance of patent airway
- Application of positive pressure ventilation
- Maintenance of adequate oxygenation
- Deliver predictable FiO2
- Provide positive end-expiratory pressure
- Deliver supplementary O2 before and w difficulty throughout
- Management choices:
- Awake vs. after induction
- Video assisted
- Preservation vs. ablation of spontaneous ventilation
- Invasive vs. non-invasive approach to initial approach
