Airway Assessment 4 Flashcards
Key points regarding Direct Laryngoscopy
Requires direct line of sight
Requires increased lifting force
Increased stress response
Cervical instability
The following are reasons to use what type of technique for intubation?
Failed intubation
Initial attempt at the predicted difficult intubation
Instruction of the novice on normal airway
Video-assisted
Advantages of video-assisted
Eliminates need for line of sight, requires less lifting force, less stress response, less cervical instability, less dental/pharyngeal trauma, less need for mouth opening
Disadvantages of video-assisted
expensive, not always easier to pass tube, loose depth perception, overconfidence, loose skills on DL
Administration of what medication should be given 15-20 mins prior to fiberoptic intubations to dry up secretions?
Glycopyrrolate
Fiberoptic intubation indications
Previous difficult airway
Suspected difficult airway
Unstable neck fractures/limited motion
Halo/stabilization devices
Small mouth opening/Minimal jaw movement
Post airway evaluations/diagnostic
Common failures with fiberoptic intubations
Rushed technique (inadequate sedation, inadequate secretion drying)
Lack of experience (be careful with bending of scope) Failure to adequately anesthetize the airway
Nasal cavity bleeding/inadequate lubrication
Scope too large
Fogging
Normal Induction Sequence (Peri-induction Sequence)
All airways should ALWAYS be ready to go
Suction ready and on high
Pre-oxygenate with 100% FiO2 for 3-5 minutes
Administer induction agents (evaluate LOC, lash test-if blink then still light). Negative Lash test - lash doesn’t move at all (what you want)
Attempt mask ventilation (reposition head if needed) - need to see lungs inflate. Ensure that you can ventilate them before administering muscle relaxant.
Administer muscle relaxant - wait for medication to work
Intubate
Confirm breath sounds
Continue anesthetic
Secure the ETT
Rapid Sequence Intubation description
the simultaneous administration of a potent sedative agent & a NMB to induce unconsciousness and motor paralysis for tracheal intubation
Advantages of RSI
Prevent aspiration, rapid control of airway
Indications for RSI
full stomach, trauma, pregnancy, bowel obstruction, risk of aspiration
Technique for RSI
(end tidal O2 > 90% prior to push drugs)
Pre-oxygenate well
Administer induction agents → be aware of timing of muscle relaxants
Cricoid pressure (increased with drug pushes)
DO NOT ventilate (no masking…apneic period waiting for succ)
Perform direct laryngoscopy
Confirm placement
Continue anesthetic
Secure the ETT
Modified RSI
give a few gentle breaths prior to intubation
Maintain cricoid pressure
For those unable to tolerate an apneic period → reactive airway disease, increased ICP, not able to tolerate apnea
Cricoid pressure is also called ________ maneuver
Sellicks
Cricoid pressure: Stabilizing the cricoid cartilage with thumb & middle finger, apply anterior to posterior pressure (about ? lbs) with index finger
5
Purpose of utilizing Cricoid pressure
To shut the epiglottis so no stomach material coming in
Cricoid Pressure contraindications
cricotracheal injury
active vomiting
unstable C-spine
BURP
Backward, Upward, Rightward Pressure
Upward pressure may increase visibility of glottis; esophagus slightly left of trachea
Physiologic response to intubation
May become complications
Cardiovascular responses to intubation
tachycardia, dysrhythmias, HTN
Attenuation of Cardio response to intubation
appropriate anesthesia depth
Local anesthesia (IV lidocaine, lido spray on cords during induction)
Adjunct medications (fentanyl, esmolol, Neo prepared for BP drop)
Respiratory responses to intubation
hypoxia, hypercarbia, increased resistance to ventilation, laryngospasm, bronchospasm
Attenuation of Resp response to intubation
pre-O2, adequate mask ventilation, sympathomimetic inhalers, NMB, inhalation agents deepened
CNS response to intubation
Inc ICP
Ocular response to intubation
Inc IOP
Intubation Complications
Vocal cord damage, trauma or ischemia to mucosa (high cuff pressure)
Damage to arytenoid cartilage (voice changes)
Dental damage
Hoarseness or sore throat (most common postoperative complaint)
Injury to lips, gums, tongue, pharyngeal tissue
TMJ damage
HTN, Tachycardia, hypotension, bradycardia, arrhythmias, spinal column injury (in line stabilization, DL vs VL vs fiberoptic)
Tracheal Stenosis, Esophageal perforation (traumatic intubation, dysphagia, neck pain, subcutaneous emphysema)
Extubation complications
Patient doesn’t “fly” → unable to keep SaO2 up, CO2 normal, or continues to need assistance to not obstruct, and to maintain good TV/RR
Airway edema/macroglossia post-extubation
(may not be immediate) → causes: aggressive blood & fluid resuscitation & trendelenburg or prone position
Increased ICP, IOP
Bleeding from surgical site (coughing & increased BP)
Spasm involving vocal cord closure & aryepiglottic folds folding over glottis is called?
Laryngospasm
Which CN nerve is involved with laryngospasms?
Sensory stimulation of Vagus N via the RLN & SLN
S&S of Larygospasms
Decreased SaO2, HTN
Signs of Negative pressure pulmonary edema (NPPE)
acute respiratory failure, dyspnea, tachypnea, pink frothy sputum, stridor, severe agitation
Pulm changes with NPPE
Inc in negative intrathoracic pressure
Inc in PVR (& volume)
Inc in pulm capillary transmural pressure (>32mmHg)
Disruption in pulm cap-alveolar membrane –edema remains even after obstruction is relieved
Early detection of NPPE
diagnosis based on precipitating event, may be immediate or delayed, more often in patients with cardiac anomalies
Types of early detection of NPPE
Type 1: immediately after acute onset of airway obstruction (laryngospasm, epiglottitis, coup, LMA/ETT blockage, laryngeal tumor, post op vocal cord paralysis, strangulation, drowning)
Type 2: occurs after relief of chronic airway obstruction (post tonsillectomy, post adenoidectomy, choanal stenosis, post removal of upper airway tumor, hypertrophic redundant uvula)
Tx of NPPE
PEEP + diuretic and steroids (controversial)
Tx of Laryngospasms
Positive pressure (MASK!), Succinylcholine, Larson Maneuver (vigorous jaw thrust, pulls false cords/folds away)
Reflex spasm in bronchial smooth muscle is called what?
Bronchospasm
Bronchospasms can be from tracheal irritation and stimulation of the ________ nerve.
Vagus
T/F:Bronchospasm can be allergenic (histamine related)
True
Bronchospasm Symptoms
wheezing, increased CO2, hypoxia, high PIP
Tx of Bronchospasms
Deepen anesthetic w inhalation agents (bronchodilators), Albuterol, Beta2 agonists (epi, terbutaline)
Tracheal perforation vs tear
most often with routine or difficult intubation
What is the most sensitive indicator of endobronchial intubation?
Tube depth
Women 20cm
Men 22cm
What should you do if you think that you did a esophageal intubation?
Take it out
Relies on clinical assessment
Airway Fire 3 Key Factors
Fuel source
Ignition
Oxidizer
Airway fires
Communication is a must! Esp w/ laser cases
What is filled in laser tube cuffs to help extinguish fire and used for notification of ETT fire?
Sterile water or
NS + methylene glue
Do you stop drop and roll if airway fire occurs?
Nah
Yell out for help/fire
Remove ETT immediately
Shut off airway gas
Remove drapes, gauze
Sterile water in the airway
Mask ventilate
Aspiration Pneumonitis is considered to be what?
aspiration of acidic gastric contents (volume & pH dependent)
Giving what makes pH more favorable that helps prevent Asp Pneumonitis?
Bicitra
Wide spectrum of lung injury and high mortality rate occurs with what complication?
Asp Pneumonitis
