Airway & Airway Management Flashcards

Question

Outline 5 strategies to improve safety of endotracheal intubations

Answer 1

1. Standardised pre-RSI checklist 2. Standardised difficult airway algorithm instituted 3. RSI performed only by adequately experienced operators 4. Standardised equipment availability including VL equipment 5. Mandated use of NP apnoeic oxygenation 6. Mandated use of bougie or stylet for all intubation attempts 7. Regular training on AIRWAY drills for staff with provision of cadaveric workshops

Answer 2

1. New circuit for a new patient 2. Semi-recumbent position 30-45 deg 3. Maintenance of Endotracheal tube cuff pressure of ~20 mmHg 4. Subglottic suctioning 5. Mouth cares 6. Avoid flushing of condensate into lower airway

Answer 3

1. No reversible causes found 2. Non shockable rhythm 3. No ROSC or Age > 80 yrs 4. Non witnessed arrest 5. Persistently low EtCO2 (<10 mmHg) during CPR in intubated pts after 20 mins 6. No cardiac activity on POCUS

Answer 4

1. Toxicological cause - full neurological recovery after 4 hours of CPR is possible 2. Post thrombolysis (2 hrs post) 3. Hypothermia (get core temp to at least 32C before ceasing) 4. Asthma - correct for hyperinflation 5. Pregnancy - prior to resuscitative C-section 6. Persistent VF in young people until reversible / therapeutic options exhausted

Answer 5

Greatest predictor of CV collpase with RSI meds and transition to PPV * Hypotension (SBP < 100 and SI > 0.8) * Hypoxia (SpO2 < 93%) * Acidosis / Alkalosis * Underlying respiratory conditions - severe asthma, COPD, pulmonary HTN, RH failure * Medications/medical conditions - ↑ICP, AMI, tachydysrhythmias, obesity, pregnancy, advanced age * Sepsis

Answer 6

1. Wave rises during expiration and falls during inspiration 2. Peak amplitude is consistent and increasing over 7 breaths 3. Peak amplitude is > 7.5 mmHg *Gastric CO2 will give capnography for up to 5 breaths with EtCO2 < 7 and amplitude is inconsistent and not rising * *In cardiac arrest: EtCO2 normally still > 15 however may drop near or below 7.5 after prolonged CPR , will still have normal rise and fall *

Answer 7

Is this a crash airway? If NOT, is this a difficult airway? If NOT, then proceed to RSI

Answer 8

Crash airway in a patient who is agonal/near death/ in circulatory collapse and needs immediate intubation attempt without the use of drugs as their state of near arrest is predicted to be unresponsive to direct laryngoscopy. If first attempt fails, give a large dose of Sux to ensure airways are sufficiently relaxed. If unable to intubate despite 3 attempts or unable to maintain oxygenation, then it proceeds to a failed airway.

Answer 9

Difficult airway is determined by the pre-intubation airway assessment → if yes, then RSI with double setup can be initiated ONLY * if the operator is forced to act (due to patient's current/expected deterioration) or * intubation is likely to be successful and oxygenation via BVM/SGA is possible Otherwise, proceed with awake intubation if time allows * awake technique done by direct/flexible/rigid VL If uanble to tolerate awake intubation or failed - attempt with flexible endoscopy, rigid bronchoscopy, intubating LMA, blind nasotracheal intubation, or cricothyrotomy *"Forced to act" scenario - where patient is rapidly deteriorating with impending respiratory arrest and clinician is compelled to take one best chance at securing the airway by giving RSI drugs - if this fails -> goes to failed airway algorithm *

Answer 10

* Significant risk of airway difficulty anticipated * Nasal or oral ETT is feasible * Compliant patient * Low risk of vomiting * Sufficient time for preparation

Answer 11

1. Ideally performed with anaesthetics in OT 2. Pretreat with IV 0.2mg glycopyrrloate + IV 4mg Ondansetron 10-15 mins prior to if possible - for dry mouth and blunt gag reflex 3. Suction and pad dry mouth with gauze 4. Topicallise airway with nebulised 2% Lignocaine 8mls (or 4 mls of 4%) at 5 L/min followed by viscous Lignocaine gargle + use Mucosal Atomisation Device with 3mls of 4% Lignocaine or cophenylcaine spray to spray vocal cords and trachea under direct laryngoscopy 5. Lightly sedate with a dissociation dose of Ketamine 20mg (or 10mg propofol and 10mg ketamine) 6. Preoxygenate vai NRB mask or NIV, position and continue with 15L/min NP oxygenation 7. If patient coughs while passing bougie then: * Trans-cricoid injection of Lignocaine * Push another 50mg Ketamine as soon as bougie is passed through cords * Use mucosal atomisation device to spary 2-3 mls of 4% Lignocaine to cords and trachea

Answer 12

1. 5 x sprays of cophenylcaine to each nostril while pt inspiring 2. Gargle Lignocaine viscous/spray oropharynx with cophenylcaine 3. Prime fibreoptic with size 7 ETT over the scope 4. Advance fiberoptic into nasopharynx until cords visualised 5. Spray cords and trachea with lignocaine 6. Cannulate trachea and advance ETT over scope

Answer 13

Scalpel-finger-bougie technique is preferred method for R hand dominant person: 1. Stand on patient's right side and immobilise larynx and palpate CTM with left hand 2. Make a 5 cm vertical incision midline over the CTM → using finger/forceps blunt dissect to the CTM 3. Make a horizontal incision through CTM → withdraw blade and immediately insert your finger 4. Dilate hole with your gloved finger (do not remove finger) and insert bougie through incision 5. Direct bougie down the trachea using volar pad of your finger - may feel tracheal clicks over bougie 6. Pass either cuff ETT size 4 or standard ETT size 6 over bougie until balloon passes through CTM 7. Inflate cuff + remove bougie + secure ETT with cloth tie 8. Confirm location with continuous waveform capnography + CXR

Answer 14

Contraindications: * Child < 10 years old * Airway secured by less invasive means * Trauma with disrupted CTM or transection of trachea Complications: * Failure * Extratracheal placement with subcut emphysema * Damage to larynx/perforation of posterior trachea * Fistula formation, subglottic stenosis and voice changes are some of the long term complications

Answer 15

* Use IV cannula size 14G in adults and 18G in children * Neck in extension (neutral if c-spine injury) + skin prep +/- LA * Attach saline filled syringe to cannula * Insert needle through CTM at 45 deg in caudal position * Draw back on syringe whilst advancing needle * Confirm endotracheal placement by aspiration of air (bubbles) * Advance cannula over needle until hub is at the skin * Secure cannula to skin and attach to jet insufflation circuit High flow Jet Ventilation * 1-3 mL/Kg * 50 mmHg (adults) * Passive expiratiorn important (NPA/OPA helps) * I:E 1:5 and RR 12

Answer 16

1. SpO2 < 90% despite good two-person BVM ventilation 2. If in a CICO situation or 3 x failed attempts at laryngoscopy by experienced operator(s) 3. Skilled operator concludes intubation would be impossible even after a single attempt ==> FAILED AIRWAY If in CICO → proceed with surgical airway If the patient can be oxygenated (via BVM/SGD) but not able to be intubated → the alternative methods such as fiberoptic or intubating LMA may be used Otherwise, maintain oxygenation with SGD or proceed with surgical airway

Answer 17

1. Replace N2 with O2 in the gas-exchanging portion of lungs → to ↑safe apnoeic time 2. Needs at least 8 x TV breaths or ideally 3 mins before induction and continued duing the apnoeic oxygenation phase via NP at 15L/min of O2 3. Time to desat < 90% after proper oxygenation in: * Healthy 70kg male: 6-8 mins * Young children (10kg) <4 mins * Adults with chronic illness/obesity <3 mins * Near full term pregnancy: <3 mins If patient has inadequate spontaneous ventilation → use BVM with reservoir bag 15L O2 and gentl bagging synchromised with pt's breathing If adequate spontaneous ventilation in cooperative patient → HFNP or NIV with 100% O2 or flush flow O2 via NRB can be used as well If adequate spont ventilation in uncooperative pt → Sedate with Ketamine 0.5-1 mg/kg IV or 3-5mg/kg IM with aliquots of 0.5mg/kg titrated to effect with HFNP, NIV or NRB - this is delayed sequence intubation

Answer 18

1. Lignocaine 1.5mg/kg IV - mitigates bronchospasm in reactive airway disease and to prevent airway reflexes raising ICP in head injury 2. Fentanyl 3 mcg/kg IV - sympatholytic - mitigates the sympathetic discharge in cardiovascular disease and in head injury - give slowly to prevent chest wall rigidity 3. Nebulised Salbutamol 2.5-5mg in reactive airways 4. Atropine 20 mcg/kg IV in children < 5 years to prevent bradycardia Reactive airways - Ketamine 1mg/kg, Lignocaine 1.5 mg/kg Cardiovascular: Fentanyl 3-5 mcg/kg Elevated ICP: Lignocaine 1-1.5 mg/kg, Fentanyl 3-5 mcg/kg

Answer 19

Common causes: 1. High intrathoracic pressure 2. Induction agent effects 3. Significant prior or ongoing fluid loss / haemorrhage 4. Obstructive shock: PE, cardiac tamponade, cardiogenic shock 7. Distributive shock: Sepsis, anaphylaxis 8. Older pt with poor CV reserve

Answer 20

1. If conventional resuscitation and critical care support is failing 2. Underlying condition is reversible 3. ECMO is a temporizing measure till he disease process has ran its course or definitive treatment can be arranged

Answer 21

V-A ECMO: * Access major vein (IJ or Femoral) and major artery (Carotid) * Able to provide circulatory support and oxygenation * Used for pts with primary heart failure V-V ECMO: * Access to 2 x major veins (IJ or Femoral) or use a double lumen catheter to access 1 major vein * Lacks need to access and repair major artery * Provides oxygenation but lower than VA as oxygenated blood returns to venous side * Does not provide circulatory support * Well suited for reversible respiratory failure

Answer 22

* Thrombosis * Bleeding * Haemolysis * Infection * Limb ischaemia

Answer 23

Establish aetiology of arrest Prevent further ischaemic and reperfusion injuries Assess severity of injury for prognostication

Answer 24

1. Location: middle lower third of chest 2. Rate: 100-120 beats per min 3. Depth: 5 cm with full recoil 4. Minimise interruptions to CPR 5. Switch providers q2 mins or earlier if tired

Answer 25

Use SIMV-VC mode **ARDS/Acute Lung Injury ** * Goals: recruitment, shunt reduction, avoiding atelectatic trauma, achieve adequate oxygenation * TV 6 mL/Kg (lower end of normal) * RR 14 (standard) * I:E ratio = 2:1 (reverse normal to ensure adequate recruitment) * PEEP 10-15 cm H2O (much higher than normal) * May need to lower TV and accept higher PCO2 to ensure Pplat < 30 cm H2O **ASTHMA/COPD** * Goals: adequate exhalation and avoid breath stacking and volutrauma while maintaining adequate oxygenation * TV 5-8 mL/kg * RR 8-10 (lower than normal to ensure exhalation with permissive hypercapnoea) * I:E ratio = 1:4-5 (long exhalation time) * PEEP 0 (for asthma), 5 for COPD - just enought for tubing * May need to consider permissive hypercapnoea but maintain pH > 7.15 * Asthmatics may need to accept higher peak pressures but aim Pplat < 30 **HEAD INJURY ** * Goals: avoid reduction in venous return and maintain CO2 at lwoer limit of normal * TV 6-8 mL/kg * RR 16 (marginally elevated) * I:E ratio = 1:2 (normal) * PEEP 5 (normal) - avoid high PEEP if possible and aim PCO2 35-40 * Tape rather than tie ETT **METABOLIC ACIDOSIS** * Goals: ensure adequate RR to maintain / improve compensation for metabolic acidosis * TV 8-10 mL/kg (higher than normal) * RR 20-30 (mimic RR prior to intubation) * I:E ratio = 1:1 or 1:2 * PEEP 5 (normal) * Begin with high RR and titrate as guided by serial gases **SEVERE OBESITY ** * Goals: Avoid atelectasis and shunting due to obesity * TV 8-10 mL/kg (use Ideal body weight) * RR 14 (standard) * I:E ratio= 1:2 (normal) * PEEP 10-15 (higher than normal) to maximise recruitment

Answer 26

Improvement from underlying pathology that required intubation (toxidrome or suspected head injury in intoxicated pt ith normal CTB) * Easy intubation (high POGO or Cormack-Lehane score 1/2) * Passed spontaneous breathing trial on minimal ventilator settings - Sats > 95%, PaO2 >60 on 40% FiO2 on PEEP <= 5 with RR btw 6-30) * No ongoing haemodynamic compromise (HR < 100, SBP > 100) * Passed awakening trial with patient rousable, able to follow commands and strong enough to lift head off pillow and raise arms in air for 15 seconds Also palliated patients can be extubated in ED without meeting the above criteria

Answer 27

1. Continuous mechanical ventilation (CMV) - Assist control (A/C) * Ventilator will detect breathing and give whatever pressure/volume set at * Gives 100% of a breath when it senses + back up rate * For pts in total respiratory failure * Bad if pt is extremely tachypnoeic (DKA/ASA) 2. Intermittent mandatory ventilation (IMV) -SIMV * Gives a breath with support every time pt triggers, but doesn't add if they take extra 3. Continuous spontaneous ventilation - pressure support, CPAP, BiPAP

Answer 28

Someone trying to take a breath DDx: - Hypoxia, Hypercarbia, Inadequate anaesthesia

Answer 29

Obstructive pattern - prolonged phase 2-3 DDx: - Obstructive lung disease (asthma, copd) - bronchospasm - kinked ETT - leaks in system

Answer 30

Grade I - entire glottic aperture seen Grade II - only a portion of the glottis seen IIa - aryternoids + part of cords IIb - arytenoids alone Grade III - epiglottis only Grade IV - not even epiglottis seen

Answer 31

Endotracheal cuff leak