Airway indications CC

Question 1

Supraglottic airways (laryngeal mask airways or LMAs) indications

Answer 1

• Alternative to ET intubation (not as a replacement) or mask ventilation
• Rescue device in expected/unexpected difficult airway
• Conduit for intubating stylet, flexible fiberoptic bronchoscopy/intubation (FOB), or small diameter ETT

Question 2

Contraindications to supraglottic airways

Answer 2

• Pharyngeal pathology
• Obstruction
• High aspiration risk
• Low pulmonary compliance (need PIP >20 cm H2O)
• Long surgeries

Question 3

Flexible fiberoptic bronchoscopes indications

Answer 3

• Potentially difficult laryngoscopy/mask ventilation
• Unstable cervical spines
• Poor cervical range of motion
• TMJ dysfunction
• Congenital/acquired upper airway anomalies

Question 4

Awake flexible fiberoptic intubation indications

Answer 4

• Cervical spine pathology
• Obesity
• Head & neck tumors
• Hx of a difficult airway
• Presence of anterior mediastinal mass

Question 5

Indications of fiberoptic bronchoscopy in intubated patients

Answer 5

• Obtain lower respiratory tract secretions for diagnosis of pneumonia
• Clearing of secretions that are not adequately cleared by more conservative methods
• Persistent atelectasis that fails to respond to conservative treatment
• Assess upper airway patency
• Assess hemoptysis
• Determine the location and extent of injury from toxic inhalation or aspiration
• Perform difficult intubation
• Remove aspirated foreign body

MCQs

Question 6

Indications for tracheal intubation

Answer 6

• Upper airway obstruction
• Emergency drug delivery in cardiac arrest (epinephrine, atropine, lidocaine, naloxone)
• Respiratory failure
• Shock or hemodynamic instability
• Neuromuscular weakness with progressive respiratory compromise
• Absent protective airway reflexes (cough, gag)
• Inadequate respiratory drive
• Need to maintain normocarbia in pt with increased ICP
• GCS <8 for trauma pt

Question 7

Endotracheal intubation in COPD indications

Answer 7

• PaO2 < 55-60
• Increasing PaCO2
• Decreasing pH
• High RR
• Respiratory fatigue
• Change in MS
• Hemodynamic instability

Question 8

Nasotracheal intubation indications

Answer 8

• Intraoral, facial/mandibular procedures

Question 9

Contraindications to nasotracheal intubation

Answer 9

• Basilar skull fx
• Nasal fx
• Polyps or tumors
• Underlying coagulopathies
• Upper airway foreign body obstruction

Question 10

Rapid sequence intubation indications

Answer 10

• Pt at high risk for aspiration
• Full stomach
• Pregnant
• GERD
• Morbidly obese
• Bowel obstruction
• Delayed gastric emptying—pain/diabetic gastroparesis

Question 11

Transtracheal procedures indications

Answer 11

• Emergency tracheal access when an airway cannot be secured via nasal/oral route

Question 12

Contraindications to transtracheal procedures

Answer 12

• Pt <6 yr old (upper part of trachea not fully developed) → incision through cricothyroid membrane increase the risk of subglottic stenosis

Question 13

Tracheotomy indications

Answer 13

• Prolonged tracheal intubation
• Neurologic impairment
• Congenital airway malformations
• Craniofacial syndromes
• Vocal cord paralysis

Question 14

Cuff-leak test indications

Answer 14

• Traumatic intubation
• Intubation >6 days
• Large endotracheal tube
• Those who have been repeatedly reintubated and extubated
• Women

Question 15

Readiness for a Spontaneous Breathing Trial (SBT) indications

Answer 15

• Underlying cause of respiratory failure has improved
• Hemodynamically stable: systolic BP >90 mm Hg without vasopressor support
• Ventilator parameters: PaO2/FiO2 > 200, PEEP ≤ 5 cmH2O, FiO2 ≤ 40%, Rapid Shallow Breathing Index (RSBI: f/Vt) < 105 breaths/min/L
• No administration of neuromuscular blocking agents
• Minimal secretions with an adequate cough
• Stable mental status: successful daily awakening trial (off sedation, able to follow commands)
• No severe acidosis: arterial blood pH ≥ 7.25
• Sufficient cough strength and ability to swallow

Question 16

Success in SBT indicators

Answer 16

• Patient can maintain a spontaneous breathing trial for at least 30-120 minutes, with a ventilator setting of either a T-piece, CPAP ≤ 5cm H2O or PS ≤ 8cm H2O with FiO2 ≤ 40%
• Respiration rate of less than 35/min
• Maintaining oxygen saturation (SpO2) ≥ 90% and/or PaO2 ≥ 60 mmHg
• No signs of respiratory distress, diaphoresis, anxiety or agitation
• Spontaneous tidal volumes > 5 mL/kg of predicted body weight
• No evidence of myocardial ischemia or significant arrhythmias
• Hemodynamic stability without a requirement for increasing vasopressor medication
• No new significant EKG changes or worsening arrhythmias

Question 17

Indications of capnography in the ICU

Answer 17

• Confirmation of ET intubation
• Noninvasive monitoring of ventilation (esp. during positional changes)
• Assessment of CO
• Prognosis when CPR is required
• Prediction of outcome during resuscitation for trauma
• Confirmation of needle placement during percutaneous dilatational tracheostomy