Airway - LMA

Question 1

4 indications for LMA

Answer 1

• Use instead of mask
• Facilitate ventilation, intubation with difficult airway
• Ventilate for flexible bronchoscopy
• Avoidance of airway manipulation

Question 2

what is important concept to know regarding LMAs and contraindications?

Answer 2

NOT an occlusive airway, will have leak so potential for aspiration

Question 3

some advantages of LMA over mask?

Answer 3

hands free, better seal, easier to maintain, less facial nerve/eye injury

Question 4

some disadvantages of LMA vs mask airway?

Answer 4

more invasive so more trauma, deeper anesthesia, TMJ has got to be mobile

Question 5

5 potential complications of LMA?

Answer 5

Aspiration 1-2:10,000
Sore Throat (10%)
Hypoglossal nerve injury
Tongue cyanosis
Vocal cord paralysis

Question 6

what causes vocal chord paralysis with LMA use?

Answer 6

overinflating cuff, bad positioning

Question 7

how much prop would you give for an LMA vs ETT

Answer 7

2.5 to 3, have to increase to surpress airway reflexes

Question 8

what is obstruction after insertion of lma typically from?

Answer 8

down-folded epiglottis or transient laryngospasm

Question 9

describe proper position of LMA

Answer 9

tip in esophagus, opening over trachea

the cuff occupies the entire hypopharynx and lies immediately behind the cricoid cartilage, anterior to the second to seventh cervical vertebrae

Question 10

4 Complications of Malpositioned Supraglottic Airway Devices (LMAs)

Answer 10

ventilatory failure
airway trauma
nerve trauma
difficulties using LMA as intubation conduit

Question 11

LMA size, cuff volume, ETT size for 30-50 kg pt

Answer 11

3
20 cc
6.0

Question 12

LMA size, cuff volume, ETT size for 50-70 kg pt

Answer 12

4
30 cc
6.0

Question 13

LMA size, cuff volume, ETT size for 70-100 kg pt

Answer 13

5
40 cc
7.0

Question 14

LMA size, cuff volume, ETT size for >100 kg

Answer 14

6
50 cc
7.0

Question 15

4 ways to intubate through LMA?

Answer 15

Use fiberoptic to visualize cords
Blindly insert smaller ETT (6.0) through LMA
Use intubating LMA (Fastrach) to insert larger ETT
Insert intubating stylet

Question 16

Advanced LMA for tracheal intubation
Handle allows one hand insertion, removal
Comes in sizes 3, 4, 5 with max air volumes of 20, 30, and 40 ml respectively

Answer 16

Fastrach lma

[has the metal]

Question 17

Has a separate lumen through which a gastric tube can be inserted to evacuate contents from the stomach

Answer 17

proseal lma

Question 18

This lma allows for pos pressure ventilation and allows for lower PIP

Answer 18

Proseal lma

Question 19

4 different ways to ventilate with LMA?

Answer 19

-spont ventilation
-cpap 3 cm
-pressure support with cpap
all showed no difference in sa02, map, bp

Question 20

what does pressure support with cpap look like with lma

Answer 20

Lower ETCO2, slower respiratory rate, lower WOB, lower esophageal pressure, higher expired tidal volume

Question 21

what should you avoid when cleaning lma’s?

Answer 21

basically everything but sodium bicarb solution and endozime

Question 22

Two balloons, one 100cc in the oropharynx and one smaller (15cc) near the tip.
Two lumens – one straight used if tip in trachea; one with side perforations used if tip in the esophagus.

Answer 22

Esophageal-tracheal combitube

Question 23

Alternative emergency airway

Allows ventilation whether the tip enters the esophagus or the trachea.

Answer 23

Esophageal-tracheal combitube

Question 24

Considered Gold Standard for management of expected difficult airway

Answer 24

Fiberoptic intubation

Question 25

why Fiberoptic intubation?

Answer 25

``` Airway tumors Infections Cervical spine fractures, instability Cervical spine fixation Conscious intubation Difficult intubation ```

Question 26

what is an important step NOT to skip with fiberoptic intubation?

Answer 26

make sure to thread ETT over fiberoptic tube

Question 27

why is nasal fiberoptic int better than oral?

Answer 27

straight shot to glottis less gagging cannot bite scope

Question 28

compared to awake patients, asleep fiberoptic intubation patients

Answer 28

have greater chance of tongue and epiglottis blocking cords.

Question 29

60o curvature Can be used with patient in neutral position Stylet needed

Answer 29

glidescope

Question 30

Ideal when the 3 axis can’t be aligned.

Answer 30

glidescope

Question 31

difference in inserting glidescope and mac/miller blade

Answer 31

insert glidescope at midline and others on right side

Question 32

Rigid laryngoscope with fiberoptic capability Can view cords without sniffing position. Indicated for cervical immobility or instability

Answer 32

bullard laryngoscope

Question 33

Lighted stylet which transilluminates the neck. | Used for routine and difficult intubations

Answer 33

light wand technique

Question 34

Insertion of a guide wire through the cricothyroid membrane, through the mouth over which the ETT is inserted.

Answer 34

retrograde intubation

Question 35

what is jet ventilation?

Answer 35

Temporary oxygenation | 14g or larger IV catheter inserted through the cricothyroid membrane

Question 36

what is important to remember with jet ventilation?

Answer 36

Ventilate 6-8 breaths/min; I:E 1:4 and long expiratory phase to allow emptying

Question 37

describe oxygenation/ventilation with jet ventilation

Answer 37

good oxygenation, bad ventilation

Question 38

what does increase in intrathoracic pressure with jet ventilation cause

Answer 38

decreased venous return, decreased cardiac output, increased intracranial pressure

Question 39

Complications jet ventilation

Answer 39

air entrapment, pneumothorax, bleeding, thyroid gland puncture, esophageal perforation, subcutaneous emphysema

Question 40

most important thing Dr C said to remember about difficult airway?

Answer 40

call for help, no more than 2 more passes