Airway Assessment (Exam 2) Flashcards
What are the (7) airway structures?
- Nose
- Internal Nasal Cavity
- Mouth
- Pharnyx
- Larynx
- Laryngeal Cartilage
- Trachea
What are the (3) parts of the Internal Nasal Cavity:
- divided by septum
- Cribriform plate
- Turbinates
Name the (2) main parts of the mouth
- Roof
- Floor
Name (4) structures that make up the Roof of the mouth?
- Maxilla and palatine bones
- Hard palate
- soft palate
- teeth
Name the (3) structure that make up the Floor of the Mouth?
- Tongue
- Mandible
- Teeth
The Heard palate is formed by parts of the ________ and _______ _______. It makes up __/__ of the roof of the mouth?
- Maxilla and palatine bones
- 2/3rds
Name the Job of the Pharynx?
- Maintain airway patency
What is the primary cause of upper airway obstruction during anesthesia? And how do you prevent this?
- Loss of Pharyngeal muscle tone.
- Chin lift
What and Where is the Pharynx?
- Muscular Tube
- Base of the skull to lower boarder of cricoid cartilage.
Name the (3) Parts of the Pharynx?
From Top to Bottom
* Nasapharynx
* Oropharynx
* Hydropharynx
Where does the Nasopharynx end?
- Soft Palate
Where does the Oropharynx start and end?
- Starts: Soft Palate
- Ends: Epiglottis
*occupied by the tongue
Where does the Hypophaynx start and end?
- Epiglottis to cricoid cartilage
Name (3) reasons why is the Larynx Important?
- Inlet to trachea
- Phonation
- Airway Protection
Where does the Larynx start and end?
- Epiglottis
- lower end of cricoid cartilage. @ C6**
Name (2) places the Vocal Cords are Attached?
- arytenoid
- Thyroid notch (laryngeal prominence)
Name the (3) Unpaired Laryngeal Cartilage.
- Thyroid
- Cricoid – complete ring
- Epliglottis
Name the (3) Paired Laryngeal Cartilage.
- Arytenoid
- Corniclate
- Cineiform
What is the largest of the cartilages and what does it support?
- Thyroid Cartilage
- Supports most of the soft tissue.
How long is the trachea and what is it’s shape?
- 10 to 15 cm (adults)
- C-shaped cartilage
What closes the trachea posteriorly and what is the trachea anteriorly bound?
- longitudinal trachealis muscle
- bound by tracheal rings
What is the only difference between lethal injection and General Anesthesia?
- GA does not bolus potassium.
What do people die of the most with anesthesia?
- lack of ventilation
What question chould you ask yourself before initiating anesthesia in any person?
- Can I ventilate/intubate this patient?
What should you do if you are not able to ventilated/intubate a patient?
- Maintain spontaneous ventilation
- Use awake endotracheal intubation
- Create a surgical airway
What is more valuable than any pre-surgical test?
- Complete Patient History
What are the best ways to obtain a good history for your patient?
** Direct questioning of the patient. **
* Review of anesthesia and surgical records
Name (6) RED flags in a patient’s anesthesia history?
concerns
- Past difficult intubation
- Report of excessive sore throat
- Report of cut lip/broken teeth
- Recent onset of hoarsness
- History of OSA
- Lesions intra-orally…. base of tonguelingual tonsils
What is the most predictive factor in a patient’s history that will indicate difficult airway management? What might be some clues to this in their history?
Past difficult intubation
* Pt remembered the intubation
* Was awake for the intubation
* accessory devices were used
* Multuiple attempts were documented.
Name (6) criterias we are looking for while completing an airway evaluation?
- visual of face and neck
- mouth opening
- eval oropharyngeal anatomy and dentition.
- neck ROM
- submandibular space
- ability of pt to slide mandible anteriorly.
What findings concern us when we do a visual inspection?
- Facial deformites
- head/neck cancers
- burns
- goiter
- short/thick necks > 43 cm
- receding mandible
- beards
- c-collar
What is more predictive to a difficult intubation than a high BMI?
- Short/thick neck
- > 43 cm
Describe a normal Inter-incisor distance
- Prefer > 6 cm
- 3 finger breadths (patients)
What intercisor distance is indicative of a difficult intubation?
- < 3cm
- or 2 fingerbreaths
What pathologic characterisics will contribute to a difficult airway?
Abnormal Oropharyngeal Anatomy
* Tumor
* Palate deformities (high arched palate, cleft palate)
* Macroglossia
During your dental assessment, what can indicates problem during intubation?
- long upper incisiors
- poor dentition/loose teeth
- cosmetic work
- edentulousness
What accounts for 25% of all insurance claims against anesthesia providers? And what percentage of them occur during tracheal intubation?
- Dental Injuries
- 75% during tracheal intubation
Name (5) common causes of Dental Injuries?
- Laryngeal blade
- Rigid suction catheters
- Oropharyngeal airway placement
- Rigourus removal of airways
- Biting down on ETT/LMA/airways during emergence.
Your patient is freaking out and labored breathing against an inflated ETT. What would this causes and how should you treat it?
- Negative Pressure Pulmonary Edema
- Deflate the balloon on the ET cuff.
What are the 2 most injured teeth during intubation? and what side?
* Left Anterior Maxillary centrals (47%) and lateral incisors (20%).
* Laryngeal blade is on the left side.
What is the sniffing position and why do we use the postion?
- Cervical flexion and atlanto-occipital extension
- Aligns oral, pharnygeal and laryngeral axis.
In the sniffing postition, where should your ear be in relation to the sternum?
- Ear should be at the level of the sternal notch.
What is the Sternomental Distance?
- Distance between sternal notch and chin.
*** > 12.5 cm preferred.
How do you measure the sternomental distance?
- Head in full extension
- Mouth Closed
What does the Thyromental distance evaluate? What is the prefered Distance?
- Submandibular compliance
* >6.5 cm (3 fingers breadths) - Tip of chin to thyroid notch
How do we assess Prognathic ability?
- Upper lip bite test
- Extension of lower incisors beyond upper incisors
How would you instruct a patient to complete a mallampati test?
- Sit upright with head in neutral postion
- Mouth open
- Tongue protruded
- No phonation
Describe the Mallampati Test
- Visibility of oropharyngeal structures
- Class I -IV
- Comparing tongue to oropharyngeal space
Mallampati Class I
- Fauces
- pilars
- entire uvular
- soft palate
Mallampati Class 2
- Fauces
- portion of uvula
- soft plate
Mallampati Class 3
- Base of the uvula
- soft palate
Mallampati Class 4
Only hard palate
Laryngeal Manipulation: BURP
External manipulation and backward, upward, rightward pressure
Laryngeal Manipulation: OELM
Optimal External Laryngeal Manipulation
* Use of the right hand to guide the position and pressure is exerted by an assistant’s hand on the larynx
Cormack-lehane Classifiction
- Classification of laryngeal view
- Grade I-IV
- Trying to achieve the best view during DL
CL -Grade 1
- Entire glottis
- 68- 74% of patients
- <1 % difficulty
CL- Grade 2
* only the posterior portion of the glottis
* can be corrected by lifting blade or preforming laryngela postioning.
CL- Grade 3
* No part of the glottis and only epiglottis
* 1.2 - 1.6 % of patients
* 80-87.5% difficult intubation
CL- Grade 4
- Epiglottis cannot be seen
- Very rare
Criteria Associated with difficult mask ventilation: OBESE-M
OBESE - M
* Obesity (BMI > 30)
* Beard
* Edentulous (no teeth)
* Snorer, OSA
* Elderly, male (>55 yo)
- Mallampati 3 or 4
Predicting The Difficult Airway: BOOTS- I
BOOTS
* Beard - gel (NIRL)
* Obesity
* Older
* Toothless
* Sounds - snoring, stridor
* Inability to maintain O2 > 90% w/ BVM
Difficult Intubation: LEMON
LEMON
* Look (abn face, trauma, unusual anatomy)
* Evaluate (3-2-2)
* Mallampati score
* Obstructions/obesity
* Neckmobility
Difficult airways: 3-2-2 Rule
- 3 finger mouth opening, fingers along the floor of the mandible
- 2 fingers between the space between the superior notch of the thyroid cartilage
- 2 fingers between neck/mandible junction
Criterial Associated with difficult airway
Test question
- Large Upper Incisors
- Strong overbite
- Inability to pertrude mandible
- Small inter-incisiors distance
- Mallampati 3/4
- Large tongue
- Narrow, high arch palate
- Short Thyromental distance
- Excessive manibular soft tissue
- Short, thick neck
- Decreased cervical ROM
Difficult Airway Algorithm: When would you chose between an awake or post-induction airway?
- Suspected difficult laryngoscopy
- Suspected difficult ventilation with face mask/supraglottic airway
- Significant increased risk of aspiration
- Increased risk of rapid desaturation
- Suspected difficult emergency invasive airway
Answer YES to 4 = awake intubation
During Intubation we should…….
- Optimize oxygenation throughout
- Limit attempts, consider calling for help
- Limit attempts and consider awakening the patient.
- Limit attempts and be aware of the passage of time.
- WHEN IN DOUBT, CALL FOR A FRIEND.
- The patient will compensate until they can’t.
- If something doesn’t work, try something else.
- Try an LMA
- Phone a friend.
- Be proactive and not reactive.
- Always have a plan B.
Difficult Airway Simplication
Per Dr Cornelius
- Evaluate all your patients
- Figure out the difficult patients
- Have a plan B and C for difficult intubations
- General Anesthesisa w/ ETT
- Superglottic airway (LMA) and ventilation
- Call for help
- Video Laryngoscope
Patient that can’t be intubated or ventilated will end up with a …….?
Surgical cricothyroidotomy
Decision to Intubate: Intubate Early
- Dynamic Situation
- Bullets: Neck trauma
- Snake Bites: Anaphylaxis/angioedema
- Burns: Thermal and Caustic airway injuries.
Decision to Intubate: Airway Complications
- Mouth and Neck infections
- Tumors
- Foreign bodies
- bleeds
Decision to Intubate: Airway (Examples)
- Stridor
- Phonation
- Swallowing
- secretions
- dysnpnea
Decision to Intubate: Breathing
- Failure of oxygenation or ventilation
- After trying NIV
Decision to Intubate: Circulation
- supporting tissue oxygen delivery by unloading muscle of respiration
- Ex: Sepsis
Decision to Intubate: Disability
- CNS catastrophes
- CNS depression
- Ongoing seizures
- weakness
assess ability to swallow and handle secretions -
Decision to Intubate: Expected Course
- Anticipate decline
- tranfer to radiology
- transfer to another institution
Decision to Intubate: Feral
- Need for prompt, aggressive sedation
- Protection for the patient
- Protection for others
When should you RSI over Awake Intubation?
- Urgency = quick
* ** peri-arrest
* dynamic airway** - Difficult airway features
* Known easy airway
* normal anatomy - Vomiting Risk
* Upper GI bleed
* bowel obstruction
* vomiting in ED
When should you Awake Intubate vs RSI?
- Urgency = slow, not a fast procedure
* stable GI bleed for endo
* slowly progressing neuromuscular weakness requiring transfer - Difficult airway feacture
* fixed deformity of the neck
* cannot open mouth.
Awake Technique
- Glycopyrolate 0.2 mg or Atropine 0.1 mg/kg
- suction and dry mouth with gauze
- Nebulized with Lidocaine – NO EPI
- Atomized Lidocaine to oropharynx
- Viscous Lidocaine – w/ tongue depressor
- Lightly sedate w/ Versed 2-4 mg or Ketamine 20 mg q 2 min
- intubate awake/pass bougie while awake
- Paralyze, then pass tube.
Local Anesthesia for Intubation
- dry
- nebulize
- atomize
- topicalize
IV sedation for Intubation
- **KETAMINE: High Secretions
- Versed
- fentanyl
- Dexmedetomidine
Laryngoscopy: Steps to prepare
- Position patient
- find the epiglottis
- optimize the head: sniff and head tilt
- seat the blade
- optimize the larynx– intubated
- FAILED: ventilate, change something, use a bougie
Bougie
- self- confirming
- intubate epilglottis-only views
- leave laryngoscope in
- lubricate tube,pull back and rotate if you get stuck
- black strip is 25 cm ( @ lip, mid trachea in an adult male)
If you are unable to intubate a patient, what is the best device to ventilate?
LMA
Why would we NOT use etomidate for intubation?
- Adrenal suppression
- lower’s seizure thresholds
Reasons to use Ketamine for Intubation
- Reactive airway changes
- IM RSI
- Hypotension
- Sepsis
Reason to NOT use Ketamine for Intubation
- Hypertension/tachycardia
- high ICP
What will wear off faster during an RSI: Propofol or Parlaytic?
Propofol
Can I use a half -dose paralytic during Intubation?
NO
Absolute Contraindications w/ Succinylcholine
- Rhadomyolysis
- hyperkalemia
- MS/ALS
- Muscular dystrophy
- denervating >72 hours old
- crash injuries > 72 hours old
- sever infections >72 hours
- immobilization
- Predisposition to MH
- bradycardia
- fasciculations – increased ICP
Succinycholine Duration
5 - 10 minutes
Rocuronium Duration
30 - 90 minutes
What are Physiologic Killers?
- Hypotension
- Hypoxemia
- Metablic Acidosis
What IV access do you need to have before attempting to intubate anyone?
- 2 peripheral IVs (atleast)
- or IO if unable to obtain IV access.
- bonus points for bolus of IV fluids to maintain SBP > 140 mmHg
What is the induction agent and paralytic agent of choice for Shock patients?
- ketamine (0.5 mg/kg)
- Rocuronium (1.6mg/kg)
What are our push dose pressors?
- Epinephrine
- Phenylephrine
- Vasopressin
always dilute
What should you do if your patient is combative/uncooperative and needs intubated?
- Precedural sedation for preoxygenation
- Ketamine 0.5 - 1mg/kg
When should you avoid giving Bicarb?
- Patient is already tachypneic
- increasing circulating CO2 could worsen acidosis leading to arrythmias.
- High CO2 levels, Bicarb breaks down into H2O and CO2
You have a trauma patient that needs intubated, but you can’t get a good view, what should you do?
- Mobilize the neck
- EXCEPTION IS WITH A DIAGNOSIS OF OR OBVIOUS CERVICAL SPINE INJURY.
In what situations do you have a Higher Aspiration Risk during intubation?
- Upper GI Bleed
- Bowel Obstruction
- Pre-induction vomiting
What interventions should you do during a High Risk for Aspiration Intubation?
- NGT prior to intubation
- Intubation in semi-upright position
- Bag early, but less.
Oxygenation while securing ETT:
- NC @ 15 LPM + NRB @ 15 LPM
- Keep PEEP Valve closed –> alveoli recruitment
- SPO2 not > 95%: think Lung Shunt physciology
- Can use APL as PEEP valve on vent
How do you convert a nasal airway to ETT (French to CM)
- 4cm: 1 Fr
