Airway Assessment 2 Flashcards by Dana Colclough

What is the most favorable test for difficult INTUBATION?

Mallampati

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Mallampati Classifications (KNOW!!!!)

Class I: soft palate, fauces (arched opening) uvula, & anterior/posterior pillars
Class II: Everything except tonsillar pillars
Class III: Just base of uvula & hard palate
Class IV: hard palate only

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Mallampati pt instructions

Instruct pt to open mouth and stick out tongue maximally while in the SITTING position.

No PHONATION!

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12-pt Airway Assessment (KNOW!!!!)

Length of upper incisors
Involuntary: Maxillary teeth anterior to mandibular teeth.
Voluntary: Protrusion of the mandibular teeth anterior to the maxillary teeth
Intercisor distance
Oropharyngeal Class (Mallampatti exam)
Narrowness of palate
Mandibular space length (Thyromental distance)
Mandibular space compliance
Length of neck
Thickness of neck
Palpation of cricoid membrane
Cervical range of motion

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LEMON Airway Assessment (KNOW!!!!!)

Look externally
Evaluate 3-3-2 rule
Mallampati
Obstruction
Neck mobility

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What should you anticipate if abnormal findings during the LEMON airway assessment?

Inc potential for difficult airway, direct laryngoscopy

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4 D’s (KNOW!!!!)

Dentition
Distortion
Disproportion
Dysmobility

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Dentition Examples

Prominent upper incisors
Receding chin

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Distortion Examples

Edema
Blood
Vomitus
Tumor
Infection

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Disproportion Examples

Dec TMD (thyromental distance)
Inc neck circ
Mallampati >3

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Dysmobility Examples

TMJ dz
Limited c-spine mobility

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What are considered Thick Neck Measurements in females and males

Female >37cm
Male >42 cm

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Inter-incisor gap/TMJ fxn

Distance of 4 cm or less is normal

Distance of <2 cm assist with difficult direct layngoscopy

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How to test Thyromental Distance and what is the average length?

Lower border of mandible and thyroid notch

Approx 3 fingerbreadths, normally > 6.5 cm

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Cranio-cervical mobility

Turn head and touch chin to shoulders

Touch chin to chest

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Limitation of what joint will impair direct laryngoscopy

Atlanto-occipital joint

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Which test assesses mobility of TMJ function and will determine if the jaw can be pulled forward for DL or jaw thrust for obstruction?

Mandibular Protrusion test or Upper lip bite test (ULBT)

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Which test is most favorable test for difficult laryngoscopy?

Mandibular Protrusion test or Upper lip bite test (ULBT)

The most sensitive test of all was the upper lip bite test.

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What determines if a pt is a difficult to mask ventilate?

Inability of an unassisted experienced anesthesia provider to maintain an SaO2>=92%

Or inability to prevent or reverse signs of inadequate vent at any point during the anesthetic

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Risks for difficult mask ventilation

Age >55
Beard
No teeth
Hx of snoring
BMI >26
Mallampati >2
Macroglossia
Small TMD
Stiff lungs

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Complications from difficult mask ventilation

Injury to buccal branch of the facial nerve
Injury to eye (corneal abrasion)
Bruising
Inflation of stomach (vomiting, aspiration)

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What reflex is triggered during a difficult mask airway that results in apnea and bradycardia?

Oculo-cardiac reflex

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Vent parameter that helps lower complications from difficult mask airway

Keep PIPs under 20

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Chest rise, fogging in the mask, CO2 waveform, a good seal, quietness, and ability to feel air in the bag are signs of what?

Effective mask ventilation! Whooo hooo!!

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Preoxygenation/Denitrogenation Methods

FGF of 5-8L/min FiO2 100% Tidal volume breath: 3-5 mins for max preoxy Goal: ETO2>90%, ETN2<5% or 8 deep breaths in 2 mins, 4 deep breaths in 30 secs Good capnography waveform, good seal around mask

Issues with Preoxygenation/Denitrogenation

Obesity Claustrophobia RSI Caution with excessive sedation

________ is noisy inspiration from turbulent gas flow in upper airways (usually obstruction)

Stridor

Causes of stridor

Objects Swelling Fx Thyroid Neck Trauma

What is the upper airway infection that causes a barking noise and airway diameter to potentially be cut in half or to be 4.5mm in children?

Croup

Always address/correct Slide 94!

Go to the slide

Consider ________ for airway complications

Intubation

Heliox (____% helium with ____% oxygen)

70; 30

T/F: Heliox is less dense than air, able to flow through turbulent airways, and can help with CO2 elimination

True

Diffusion rate of O2 with the assistance of heliox

Diffusion of O2 happens from alveoli to blood at a much faster rate than O2. 200-250ml/min compared to CO2 at 8-20ml/min

What is "stiff joint syndrome"?

Glycosylation of tissue proteins from chronic hyperglycemia

Stiff joint syndrome is associated with _______.

Diabetes

During which complication is food and material settled into a "pouch"?

Zenker's Diverticulum

T/F: It is preferred that cricoid pressure is utilized with Zenker's Diverticulum.

False. Cricoid pressure can dislodge food particles

Should antacids be used with Zenker's?

No, the pH in the diverticulum is alkalotic (same as saliva). Usually doesn't cause aspiration PNA.

Zenker's Diverticulum considerations

View with endoscopy Awake intubation DO NOT blindly place NGT d/t risk of perforation of pouch Keep head up 20 degrees

Obesity Implications for airway management

Preop eval significantly r/t difficult intubation Judicious admin of sedative/narcotics Optimal positioning with padding Masking, oral, & nasal airways Consider RA when applicable Extubate fully awake after NMB reversal

T/F: OSA is only a partial obstruction of lower airway during sleep.

False: OSA can be periodic, partial, or complete obstruction of the UPPER airway during sleep

S&S of OSA

Episodic O2 desat & inc CO2 Variations in HR & BP inc intrathoracic pressure

What pre-op assessment is used to help diagnose OSA?

STOP-BANG

Snoring Tiredness Observed Apnea High bP BMI >35 Age>50 Neck size >43male, >41 female Gender (males)

Risk scores for STOP-BANG

0-2 Low risk 3-8 High risk

What medication is given in preop to help eliminate bleeding from the insertion of nasal trumpets?

Afrin, placed in both nares

Which nare is typically used for nasal trumpet insertion?

Right nare

What type of pt should be evaluated for aspiration d/t increased gastric volumes, more acidic pH, and may be recommended for preop meds?

Obese patient

What acronym is used for airway prep/setup?

MAIDENS

M: Machine check, including O2 tank A: Airways, oral, nasal, tongue depressor I: Intubation, handles, blades, tubes, stylets, magill forceps D: Drugs, Emergency drugs E: Emergency-ambu, bougie, LMA N: Nerve stimulator S: Sucton-yankaur, catheters, stethoscope

What position lines up the axis and improves the ability to ventilate and intubate?

Sniffing-position

What are the 2 methods to accomplish the sniffing position?

Manual Method: Pulling jaw forward, moves tongue and epiglottis off pharynx Pillow Method: Used often in obese patients

Airway equipment

Oral/Nasal airways, ETTs, Laryngoscope/blade, LMA

Where is the MAC blade placed?

In the vallecula (To elevate the epiglottis)

Where is the Miller blade placed?

Blade tip under epiglottis to directly elevate

___________ blade advantages: decrease in damage teeth, space avail in oropharynx for ETT

MAC blade

_________ blade advantages: good in small cross-sectional dimensions. Useful in pts w/ narrow oral cavities. Prominent upper teeth ankylosis

Miller blade

Pt hx

Loose/false teeth GERD Prior dif airway NPO status Hoarseness/dysphagia Masking issues Heavy beard Short neck (muscular) Thick Neck (W>37, M>42 cm) Tracheal deviation

Oral Cavity Exam

Protruding teeth Length of incisors loose/broken, chipped teeth, Crowns/caps/dentures If you see it, chart it!

Inter-incisor gap/TMJ fxn

Measures the degree of mouth opening, trismus, spasm of jaw popping

Inter-incisor gap values

4 cm=normal <2cm= difficult direct laryngoscopy

What assesses the ability to displace the tongue?

Thyromental distance

The Mandible/Protrusion Test/Upper Lip Bite Test is the most favorable/most sensitive test for ___________?

Difficult LARYNGOSCOPY Looks at incisor length & mobility of TMJ

Mandible Protrusion Test/ULBT Classifications

Class I: Over vermillion border Class II: Barely touching Class III: Cannot get to the border

Neck Circumference >_____ is a predictor for difficult airway

40cm

T/F: What to do if you can't get a good seal for mask ventilation?.....Freak out!

False: Reposition using 2 handed mask Use mask straps Get help

How would you know if airway management is required?

Blunting or removal of pts own protective ventilatory drive? Regional use?

Who should complete the airway exam if a pt's airway is manipulated?

YOU or who ever is manipulating the airway! This should ALWAYS occur

Supralaryngeal ventilation?

Face mask or LMA Could be challenging if someone has dec pulm compliance

Ways to minimize the risk of aspiration?

NGT to sxn prior to induction NPO status Hx of vomiting Bicitra for pH Reglan H2 blocks

An adequately preoxygenated, healthy adult should maintain oxyhemoglobin saturation for _________ mins and child _______ mins

5-9; 2-4

Stridor management

Heliox Nebulized epi Decadron 4-8mg q 8-12hrs

What is the 1st consideration for a patient with stridor?

Should the pt be intubated or can it be delayed?

Which types of pts cannot tolerate an apneic period?

Restrictive disease (intrinsic & extrinsic) Obesity Other Acute processes

Chronic kyphotic, spine disorders, ankylosing spondylitis, neuromuscular diseases (MS), muscular dystrophy, and fibrosis are considered what type of diseases?

Restrictive Diseases

Why are obese patients unable to tolerate and apneic period?

Dec FRC (esp supine/prone) Abdominal contents pushing on lungs Vt dec when supine (Atelectasis, inc intrapulm shunting, impaired oxygenation)

Other acute processes that may dec the apneic period

Pulm edema ARDS, Pneumothorax Pleural effusions PNA

Preoxygenation goal

ETO2>90%

Denitrogenation goal

ETN2 <5%

What complication is related to Juvenile DM?

Stiff Joint Syndrome

T/F: Stiff joint syndrome is the glycosylation of tissue proteins from chronic hyperglycemia

True Abnormal sugar/protein metabolism changes collagen and elastin fibers in dermis

Is the atlanto-axial joint motion improved or limited with a diabetic pt?

Limited

What hand sign is used to determine if a diabetic pt might have airway complications?

Prayer sign vs palmar test

Airway/Resp issues for obese pts?

Dec FRC Inc O2 consumption Inc CO2 production Higher min volume required to maintain normocarbia Dec chest wall compliance Chronic hypoxemia Polycythemia Pulm HTN Diff surgical if necessary, visualize cricoid

Considerations for potential airway complications

Preop eval Judicious use of sedatives/narcotics Optimal positioning Masking/oral/nasal airways Consider regional anesthesia Extubate fully aware after reversal

Long term consequences of OSA:

HTN CV changes RVH Afib Increased stroke risk Declining cognition Resp Failure

Cardiac complications, cardiac arrest, and shock are increased ____fold in OSA pts

The collapsing of what tissue causes OSA pts to awake a lot?

Pharyngeal tissue Get adrenergic surge-pressure builds up

A sleep study is recommended when over ____ events/hr over ____ secs

15;10

Pre-op recommendations for pts with OSA

Eval @ risk pts prior to DOS Thorough H&P Inform pt for potential airway Inpt instead of Outpt sx Nasal trumpet CPAP/BIPAP use Eval for potential diff airway

Post-op recommendation for pts with OSA?

Poss keep for observation to ensure pain is managed adequately w/o them going home and stop breathing d/t medication

Even after corrective sx the pt should be assumed to remain at risk for OSA complications unless a _______ sleep study has been obtained.

Normal