Airway Assessment 3 Flashcards
What is the goal of the sniffing position?
Improves the ability to intubate and ventilate
Draw a line from anterior ear to sternum
What are the axis that should be aligned for the sniffing position?
Oropharyngeal
Pharyngeal
Laryngeal
What are the 2 methods used to place the pt in the sniffing position?
Manual Method and Pillow method
Manual Method
Pulling jaw forward moves tongue and epiglottis off pharynx
Pillow method
Used most often in obese pts
Be sure to pad under arms
Signs of airway obstruction
Snoring
Grunting
Stridor (around larynx)
Loss of breath sounds
Climbing or absent CO2
Loss of fog in mask or ETT
Nasal flaring
Desaturation
Retractions/rocking
What is described as rocking motion of the tracheal or thoracic areas and is considered a compensatory mechanism to overcome an obstruction?
Retractions
SUPRAsternal retractions (tracheal tugging) vs SUBsternal/intercoastal retractions
Causes of Airway obstruction
OSA
Soft tissue relaxation
Foreign body/trauma
Vocal cord issues
Polyps
Infections
Swelling
Laryngospasm
Use caution when giving pre-op sedation to high risk patients
Something to keep in mind
Interventions for airway obstruction
Jaw thrust
Head repositioning
Oral/nasal airway
Mask ventilate if apneic
Determine underlying cause
Effects of airway obstruction
Inc WOB/fatigue
Interference of O2 supply and CO2 elimination
Difficulty in obtaining/maintaining adequate inhalation anesthesia
Oral airways are measured from the corner of the _____ to the tip of the earlobe.
Mouth
Most adults 9cm (large pts 10cm)
If sedation is too light with the insertion of an oral airway, what will happen?
Pts w/ intact gag reflex will not tolerate it
Advantages of an oral airway
Larger tube
Inserted quickly w/ little trauma
Easier suctioning
Less airflow resistance
Reduced risk of tube kinking
Disadvantages of an oral airway
Gagging/coughing/salivation/irritation can be induced
Tube fixation is difficult
Gastric distention from frequent swallowing
Mucosal irritation/ulcerations of mouth
Nasal airways are measured from the tip of the ______ to the tip of the earlobe.
Nose
30Fr small adults
34Fr Large adults
Sizes range from 26-34Fr
T/F Pts semi-wide awake will tolerate nasal airway
True
Contraindications for nasal airways
Hemorrhagic d/o
Pts on anticoagulants
Deformity
Basilar skull fx
Advantages of nasal airways
Long-term comfort
Decreased gagging/salivation
Improved mouth care
Better tube fixation
Improved communications
Disadvantages of nasal airways
Pain/discomfort
Nasal/Paranasal complications (epistaxis, sinusitis, otitis)
Difficult placement, smaller tube
Difficult suctioning
Increased resistance
What is the Gold Standard for airway management
ETTs
What ways can you achieve ETT intubation?
Awake vs asleep
Oral vs nasal
Blind vs Direct
ETT sizing
according to INTERNAL diameter in mm
Adult male: 7.5-8
Adult female: 6.5-7
Peds 16+age/4 or diameter of little finger
ETT average distance teeth to larnyx
Women: 20-21 cm
Men 22-23 cm
ETT positioning
21 is fun
22 will do
23 should not be
What happens when the tube is moved with repositioning?
EXTENSION head movement WITHDRAWS tube 1.9cm
FLEXION head movement ADVANCES tube 1.9cm
Recommended ETT cuff pressure
20-30mmHg
High volume/Low pressure cuff (Hi/Lo) or tapered cuffs prevents what?
VAP
Prevention of excessive pressure on trachea from cuff
Diffuse intra-cuff pressure over a large area
Tracheal wall pressure is 15-30mmHg
Cap Perfusion pressure is tracheal mucosa is 32mmHg ->cannot go above this, no perfusion= low sores/skin breakdown
Diffusion of Nitrous Oxide is 34x more soluble in blood than ______?
Nitrogen
Where does Nitrous oxide move into an enclosed space surrounded by a COMPLIANT wall which allows GAS to EXPAND?
Intestine
Chest
Gas embolism
Where does Nitrous oxide move into an enclosed space surrounded by a NON-COMPLIANT wall which causes an INC in PRESSURE?
Middle ear
nasal sinus
T/F: Transfer of N2O to inside ETT cuff may cause considerably decrease in cuff volume and pressure.
False: It will INCREASE volume and pressure
What type of surgeries should you not use N2O?
Trauma
Abdominal cases
Pneumothorax
Middle ear issues/surgeries
All types of ETTs have a _____mm connection piece
15mm
Cuff with pilot balloon ETT
Cuff pressure 20-20mmHg
Cuffless ETT
Infants & Children
Radio-opaque ETT
Line from top to bottom for CXR
Tip of ETT
Bevel on left side of visualization/placement
Murphy Eye on ETT
Alternate gas passing area
Laser ETT
Fire retardant
Cuff filled with sterile water
Reinforced Wire Tubes
Used for mouth sx, insert w/ fiberoptic
Metal; need mobility in tube not for ICU/transport resist kinking
NIMS ETT
used with thyroid surgery, has electrodes that alarm if they’re close to hitting a nerve
Oral & nasal rae tubes
Has a bend for ENT procedures
Endotrol tube
finger loop to control the end of the ETT
Stylets
Should not extend past tip of ETT
Should be removed just after the tip of the ETT is beyond the glottis
Lubricate the stylet for easy removal (water soluble jelly)
Laryngoscope/blade Handle
Light source “C” batteries or fiberoptic
What are the 2 types of blades?
Straight (Miller, Wisconsin, Phillips) or
Curved (Macintosh)
Blade sizing
Sizing range from 0-4, size denotes length of blade, smaller the #, shorter the blade
Macintosh Blade
Tip of blade is curved-placed in the VALLECULA (to elevate the epiglottis)
Advance tip into vallecula, lift along axis of handle, tip of blade indirectly elevates epiglottis
Advantages of Macintosh blades
Miller Blade
Straight blade with a curved tip-tip under EPIGLOTTIS to directly elevate it (“pushes on epiglottis”)
Advance tip to underside of epiglottis, lift at 45 degree angle, tip of blade picks up epiglottis
Advantages of Miller Blade
Good in small cross-sectional dimensions
Useful for narrow oral cavities or prominent upper teeth
Ankylosis
Wisconsin Blade
straight blade with larger cross-sectional dimension, squared tip
Phillips Blade
straight blade with wider surface, tip more upturned than miller
Preparation for Laryngoscopy
Test the tube’s cuff inflation system (inflate/remove syringe, assure valve works)
Lock desired blade onto handle & test the light
Position pt/laryngoscopist (pt in comfortable position on OR table; height of table to position best for the person going to intubate-pt’s head at your XIPHOID process)
Preoxygenation/Denitrogenation (issues with obesity-maximize FRC, claustrophobia-allow pt to hold mask, RSI-not bagging…caution with excess sedation)
Final Step → assure an adequate depth of anesthesia!! (lash test)
_________ is used to open the mouth (1st & 3rd fingers) - fingers removed after blade insertion and ID of epiglottis edge
Scissoring
Blade Insertion
Laryngoscope held in left hand; open mouth with right hand; insert blade from right side of mouth & move into midline (be careful of teeth, do not pinch lips, deflect tongue left) NO ROCKING →LIFT TOWARD BELLY, NOT TOWARD FRONT TEETH
Techniques to visualize Epiglottis
Slow advance inward & toward midline, right hand keeps lips from rolling between teeth & blade (avoid pressing on pt eye), advance until epiglottis seen –may only see arytenoids
If blade is too deep in pharynx may mistake esophagus (the goose!) for the glottis – back out
What can you achieve with LMA?
PPV
Seal around the laryngeal opening
Why is a LMA indicated?
Routine airway
Rescue airway
Resuscitation airway
Contraindicated for LMA
Full stomach
Pregnancy > 14 weeks
Acute abd/thorax case
Decreased pulmonary compliance
Gross obesity
Hiatal hernia
Pharyngeal pathology (must sit correctly)
Obstruction below larynx
Potential Problems with LMAs
Inadequate level of anesthesia (coughing, aspiration, laryngospasm)
Nitrous oxide diffusion (cuff under 60 mmHg)
Incorrect position of LMA
Sizing of LMA
Based on gender, weight, anatomy → use a large size with less air – do not exceed maximum amount of air
Aspiration Risk regarding LMA use
DO NOT USE with increase aspiration risk
Avoid inadequate anesthesia
Avoid gastric distention
No lubrication on anterior surface (no lido gel)
Mask Ventilation Techniques
can be 1 person or 2 people
Requires a good mask fit and adequate volume of oxygen/air delivered
Rests on patient’s bridge of nose, maxillary bones, & mandible
Be careful of eyes → no direct pressure or air flow → risk of corneal abrasion
Keep dentures in for masking
Purpose of mask ventilation
Denitrogenation & Pre-Oxygenation (O2 in FRC)
How to properly hold mask
Held in left hand with thumb & first finger around the mask (C), middle & ring fingers on ramus of mandible, little finger maintains anterior displacement of the mandible (E)
What is the most common reason for not getting maximum O2?
Loose fitting mask
Endotracheal intubation indication
Compromise or inaccessibility of the airway
Long surgical procedure needing relaxation
Surgical procedure on the head/neck/abdomen
Need for controlled or PPV
Inability to maintain patent airway with mask/airway
Disease process involving the airway
Risk of aspiration from a full stomach
ETT placement confirmation
onnect to source of ventilation & verify by at least 2 methods
End-tidal CO2 (6 breaths required to confirm in lungs)
Auscultation: 3 areas (epigastric, left lung, right lung)
Tube # placement → deep tube # = most sensitive detector of Esophageal intubation detection
ONCE CONFIRMED, SECURE THE TUBE
ETT tube verification OUTSIDE the OR
CO2 colorimetry
Auscultation
Esophageal detection device
CXR
What should you chart after intubation?
induction meds
Ability to mask ventilate
# times DL
Grade view of intubation
Verification of placement
# at teeth or lip
Nasotracheal Intubation indications
Intraoral operations
Oral tube would interfere with surgeon access
Long-term ventilation anticipated
Hx needed for nasotracheal intubations
Unexplained nosebleeds
Hx broken nose
Hx deviated septum
Nasally inhaled substance abuse
Prep for nasotracheal intubations
Nasal tube should be 0.5 - 1 size smaller than orotracheal tube
Let sit in warm NS/sterile water to soften tip
Nasal trumpet well lubed
What forceps are used to guide nasotracheal tubes in place?
Magill forceps
When are nasotracheal intubations contraindications?
LaForte fx
Steps for Nasotracheal Intubation
Evaluate patency of nares
Prepare nares (Afrin or neo, lido gel)
Dilate with nasal airways
Insert ETT like a nasal airway
Perform laryngoscopy, find end of ETT & use Magill forceps to put in glottis
How to blindly insert nasotracheal tube?
Best with endotrol tube (finger loop) …only used with spontaneously breathing patients, prep normally, listen for breathing & advance with inspiration
Cormack-Lehane classification/grade
Class 1: see top where cords meet
Class 2: See arytenoids, some cords
Class 3: See epiglottis only
Class 4: See nothing
Anterior Larynx (misnomer): d/t limited head extension
