Airway Assessment 2 Flashcards
What is the most favorable test for difficult INTUBATION?
Mallampati
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
Mallampati pt instructions
Instruct pt to open mouth and stick out tongue maximally while in the SITTING position.
No PHONATION!
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
LEMON Airway Assessment (KNOW!!!!!)
Look externally
Evaluate 3-3-2 rule
Mallampati
Obstruction
Neck mobility
What should you anticipate if abnormal findings during the LEMON airway assessment?
Inc potential for difficult airway, direct laryngoscopy
4 D’s (KNOW!!!!)
Dentition
Distortion
Disproportion
Dysmobility
Dentition Examples
Prominent upper incisors
Receding chin
Distortion Examples
Edema
Blood
Vomitus
Tumor
Infection
Disproportion Examples
Dec TMD (thyromental distance)
Inc neck circ
Mallampati >3
Dysmobility Examples
TMJ dz
Limited c-spine mobility
What are considered Thick Neck Measurements in females and males
Female >37cm
Male >42 cm
Inter-incisor gap/TMJ fxn
Distance of 4 cm or less is normal
Distance of <2 cm assist with difficult direct layngoscopy
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
Cranio-cervical mobility
Turn head and touch chin to shoulders
Touch chin to chest
Limitation of what joint will impair direct laryngoscopy
Atlanto-occipital joint
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)
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.
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
Risks for difficult mask ventilation
Age >55
Beard
No teeth
Hx of snoring
BMI >26
Mallampati >2
Macroglossia
Small TMD
Stiff lungs
Complications from difficult mask ventilation
Injury to buccal branch of the facial nerve
Injury to eye (corneal abrasion)
Bruising
Inflation of stomach (vomiting, aspiration)
What reflex is triggered during a difficult mask airway that results in apnea and bradycardia?
Oculo-cardiac reflex
Vent parameter that helps lower complications from difficult mask airway
Keep PIPs under 20
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!!
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
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
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
3
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
