Airway Basic Flashcards
What are the common components of airway examination?
Lemon is recommended but think about emergency or comatose patients.
Common are- Pts mouth opening, dental examination, cervical range of motion, and thyromental distance.
what are the two model of pre operative airway physical examination and to define classes…
LEMON, and Mallampati classification of airway classes.
Areas of concern for pre operative airway physical examination….some main ones which i may not remember
Prominent overbite- also explained as relation of maxillary and ,mandibular incisors during normal jaw closure.
Tip of chin should touch chest
Patient should be sitting upright and the individual should not be asked to phonate (because it can elevate palate)
What are the predictors of difficult intubation
Mallampati class of 3 or 4
Thyromental distance of less than 6cm (3 finger=6cm, 2 finger= 4cm)
Mouth opening of less than 4cm (2 finger)….but Deidre said 3
Reduced atlantoocipal neck extension
Increased BMI
Large neck circumference (thick neck)
Sniffing position aligns what three things
Long axes of Mouth, pharynx and larynx…helps in a tighter fit for a BVM as well as ETT intubation.
Sniffing position is head elevated and and neck extended advance the jaw.
With jaw thrust the tongue…..
Is moved farther from hard and soft palates and patent upper airway is achieved.
…….. is a non invasive means of ventilating and ……. A pt
Anesthesia face mask…..oxygenation…
What is th standard attachment size for BVM or ventilator tubing,
15-mm (the whole size )
Around 6-8 sizes
3, 4 and 5 typically for adults.
The anesthesia mask should not be…..
Pushed on the pts face, rather the pts mandible should be pulled up into the mask. Two hand technique can be used if patient obese, difficult airway or bearded pt.
What is the ventilator pressure used for BVM the pt?
<20cmH2O…to prevent gas into the patients stomach
What facilitates in FMV?
Jaw thrust, maximized sniffing position, two handed mask technique, OPA,NPA all facilitates in successful FMV
How do we know the effective ventilation being performed on the patient?
Condensation, ETCO2, Taut, refilling bag in case of Non-inflating bag, bilateral breath sounds, symmetric chest rise.
True or false,
Even if the patient is not intubated, providing FMV allows for adequate oxygenation and ventilation(CO2 removal) and is effective until a definitive a/w is established
True.
True or false, beard is the only modifiable risk factor
True…but either occlusive adhesive dressing or applying water soluble lubricant .
Lack of teeth is considered a factor which reduces the seal of the mask during ventilation
True
What should be done with patient with reduced lung and chest wall compliance?
Increase ventilator pressure >20
How much tidal volume is recommended for BVM?
8 ml/kg
LMA can be used as a conduit for blind intubation…true or false
True, blind or fiber optic intubation with a cuffed ETT can be performed though LMA to establish a definitive or secure airway.
What is alternative to BVM?
LMA. Particularly benefit obese, pregnant and difficult airway patients.
what is gold standard for airway management?
ETT, as
~it allows ventilation with high levels of positive pressure,
~direct route for drug delivery and suctioning in the lower airway for secretion removal,
~prevent foreign body aspiration into the lung,
~provide bronchoscopic examination of the peripheral airway
What are the risk when placing Ett?
Hypoxia
Hyper carbia
Cardiovascular changes
If airway latency and gas exchange cannot be established by simple means then…
Go for invasive procedures such needle or surgical cricothyrotomy, dnt waste time on Ett insertion from mouth or nose
What’s the standard connector size of ETT
15 mm, to connect BVM, Or anything else like ETCO2 or ventilator
A cuff attached to a pilot balloon with a …….valve
Spring loaded.
Ett that lacks Murphy eyes are called……
Magill-type tubes.
Ett are sized by….
Internal diameter..ID
Why is uncuffed Ett used for children?
Becuz if we think about inflating it..then we need to opt for a smaller Ett ID keeping in mind the airway size(diameter), so if we go for uncuffed we can select a higher ID and instead not inflate it and provide more and better ventilation.
It inflate cuff—> smaller ID of Ett—> airway lumen already smaller in diameter.
As well as cricoid is the narrowest part of children until age 6, where placing the Ett snug fits below larynx and provides Positive pressure ventilation.
What are the indications of intubation?
1)Airway compromise/obstruction—>due to retained secretion, foreign body, structural changes from edema, tumors or trauma, anaphylaxis
2) airway protection—> general anesthesia, accidental extubation, lack of cough or gag, risk of aspiration.
3)respiratory failure- ventilation failure(cannot remove CO2), oxygenation failure, apnea.(we need to breath for pt.
What are the contraindication of intubation?
Absolute-
patient refusal
Medically futile
Medical directives
Relative-
No specific, benefits vs harm…but check for cardiac history as stimulation of a gal nerve can lead to reduced bp, reduced heart rate, hypotension and in worse case cardiac arrest.
So two things to keep in mind while intubating the pt.
If the sedation and paralytic are insufficient, it can increase patients heart rate indicating he can still feel but not that much that he could respond. May be sedation is enuf but not the paralytic. In this scenario we may not necessarily be stimulating his vagal nerve.
The other thing is stimulation of vagal nerve…if you see a drop in pts bp, heart rate, could be due to stimulation of vagal nerve, and in this scenario we give epinephrine to increase the heart rate. May be the sedative was too much that’s why dropped the heart rate
How many attempts for the first intubation?
2
The two lines in the Ett should be how?
One line below the vocal cords and one line above
If not chest rise when using Ett
Either the tube is not in trachea
Either it is in the right main stem(if not bilateral)
Either the the patient has a baro trauma, or pneumothorax that’s why no chest rise!!
What happens if no chest rise when OPA is inserted
Means the patient is having pneumothorax….which can be due to flow inflating bag or self inflating bag….even if noticed it too quickly. Becuz with OPA it is impossible it is in the main right main stem or to be in the esophagus…so what’s left?? The size…if short it can obstruct and be of no benefit!!
So think about the reasons quickly…no chest rise!! Why?? Is the OPA too short?? Or is it because I am blowing the air too fast and caused a barotrauma or pneumothorax.
Benefit of cricoid pressure?
2 benefits
To prevent aspiration
To prevent from air entering esophagus and stomach from BVM
From when to when the cricoid pressure should be applied
From the time pt is unconscious until Ett is in place…..sometimes the intubator will say to release pressure
True or false.
Cricoid pressure blocks vomits
False, it doesnot prevent vomit from occuring. If that happens, let it go means release the pressure and log roll the patient to avoid vomiting from entering into stomach and then suction immediately.
What is BURP?
Cricoid pressure is just pushing down with thumb and middle finger,
But BURP is applying pressure backwards, upwards and towards right and pressure of the thyroid cartilage or larynx by the assistant and the operator.
Burp is for better visualization of glottis opening, where as cricoid is for preventing aspiration
Signs of difficult intubation when you look externally
C-spine- positioning due to limited mobility for sniffing position
Beard- BVM, we cannot form a seal.
Denture or tooth too long or loose teeth- laryngoscopy and Ett
Scar tissue from previously trach/cric/ thyroid surgery patient- ett is difficult to pass.
Sometimes a patients trachea is stitched to the skin and that patient always breathes through the hole which is opening from the outside—> tracheostomy stoma.
LEMON
LEMON- to rule out if we can see the glottis? Is it going to be difficult intubation or not? Alll before intubation!!!
Look- BVM(beard), laryngoscopy(scarring), difficult airway(c-spine)
Evaluate- 3-3-2- for ease of laryngoscopy
3-mouth opening
3- thyromental space
2- thyroid cartilage to hyoid bone(start of the neck)
Tip—> when u evaluate the 3-3-2 rule, same time see Mallampati classification for uvula.
Mallampati- to check the size of the mouth opening, tongue and oropharynx, class 1 and 2 accepted, 3 and 4 difficult intubation
O- obstruction of upper airway is an indicator of difficult airway.
Signs such as stridor, drooling, kneeling forward—>immediately it is epiglotitis (need to go to OR), difficult swallowing, muffled voice—. All these are signs of epiglottitis and are under difficult intubation due to upper airway obstruction
FBO, Laryngeal trauma, airway burns/swelling and tumor are other examples of obstruction. If patient met an accident, assume difficult intubation
N- neck mobility is the ability to place in sniffing position and optimal visualization of glottis. Such as, degenerative cervical arithritis, morbid obesity, facial or neck burn scarring, cervical trauma, fractures, thoracic kyphosis, hydrocephalus…..pt with c-spine issues, kyphoscholosis and hydrocephalus we can never put them in neutral position.
True or false,
Orotracheal intubation is preferred route due to ease and speed of compared to nasal route.
True
Can we place a pillow or towel to obtain a sniffing position?
Yes, you just have to make sure that the oral, pharyngeal and laryngeal axes are aligned.
The blade should never touch the upper teeth and the lips aswell….true or false?
True
How much volume should we inflate the cuff with?
7ml, 7cc….and pressure is <20cmh2o
When is cricoid pressure recommended?
Only if the patient has had a positive pressure ventilation prior to intubation and applied correctly.
