Airway Management Flashcards by Shelbie Gwinn

What is not required for an LMA

NMB agents

How well did you know this?

Not at all

Perfectly

What is not required for rapid sequence induction

Ventilation

How well did you know this?

Not at all

Perfectly

First maneuvers that can be used if patient is snoring and airway obstruction is suspected

First - chin tilt
Second - jaw thrust
Can turn head to side
And then last place oral or nasal airway

How well did you know this?

Not at all

Perfectly

Placing oral airway can stimulate what reflex

Gag reflex
CN IX - afferent (sensory)
CN X - efferent (motor)

How well did you know this?

Not at all

Perfectly

How to estimate size of oral airway for patient

Estimate by holding next to patients mouth

* Tip should rest cephalad to angle of the mandible

How well did you know this?

Not at all

Perfectly

Measurements of oral airway

8,9,10
80mm
90mm
100mm

How well did you know this?

Not at all

Perfectly

Too small of an oropharyngeal airway may cause

Tongue to kink and force part of it against the roof of the mouth, causing obstruction

How well did you know this?

Not at all

Perfectly

Too large oropharyngeal airway may cause

beyond epiglottis and displaces epiglottic posteriorly and can also traumatize larynx

How well did you know this?

Not at all

Perfectly

Purpose of oropharyngeal airway

lift the tongue and epiglottis away from posterior pharyngeal wall and prevent them from obstructing the space above the larynx.

How well did you know this?

Not at all

Perfectly

Other uses for oropharyngeal airway

With emergence to prevent biting of tube of tube and negative pressure pulmonary edema
Can be used for neuro monitoring with motor evoke potentials to prevent biting of tongue

How well did you know this?

Not at all

Perfectly

Where does nasal airway sit

o Pharyngeal end should sit below the base of the tongue and above the epiglottis (same as oral airway)

How well did you know this?

Not at all

Perfectly

Nasal airway can be preferred airway in a patient with…

poor dentition

How well did you know this?

Not at all

Perfectly

What do we want to adminster into nares before nasal instrumentation

Some type of vasoconstrictor since GA can cause vasodialtiona and engorgement which can lead to excessive bleeding

How well did you know this?

Not at all

Perfectly

Contraindications for patients to have nasal airway

Patients that are anticoagulated
Patients with basilar skull fracture
Nasal pathology
Sepsis
Deformity of the nose or nasopharynx 
History of nosebleed requiring medical treatment

How well did you know this?

Not at all

Perfectly

Sizing of nasal airway

Distance from the nares to the meatus of the ear

Should be approximately 2-4 cm longer than oral airways

How well did you know this?

Not at all

Perfectly

When inserting a nasal airway where should to tip of the bevel be

Towards the septum to avoid turbinates

How well did you know this?

Not at all

Perfectly

Can facilitate delivery of oxygen or anesthetic agent from breathing system to a patient by creating an air tight seal with the patient’s face

Face Mask

How well did you know this?

Not at all

Perfectly

Internal diameter of the face mask orofice is…

22mm

How well did you know this?

Not at all

Perfectly

Complications of head straps attached to retaining hooks of face mask

Corneal abrasions from straps close to eyes

How well did you know this?

Not at all

Perfectly

Laryngeal Mask Airway is also known as

Supraglottic airway (SAD)
ABOVE the glottis and not through the cords

How well did you know this?

Not at all

Perfectly

LMA can protects larynx from oral secretions but not…

Gastric contents

How well did you know this?

Not at all

Perfectly

Where does the LMA rest when fully inserted?

Against the upper esophageal sphincter when fully inserted (cricopharyngeus muscle)

How well did you know this?

Not at all

Perfectly

Which side of the LMA is water based lubricant placed?

Posterior

How well did you know this?

Not at all

Perfectly

Proper orientation of LMA

Midline insertion

How well did you know this?

Not at all

Perfectly

What should INTRACUFF pressure not exceed for an LMA?

60 cm H2O

What should peak ventilator pressures not exceed for LMA?

APL not to exceced 20 cm H2O

What happens when APL exceeds 20 for an LMA?

Gastric insufflation

Successful insertion of an LMA depends on

Inflation of the balloon and ventilation with no leak (meaning there is an adequate seal)

Contraindications for an LMA include...

* Pharyngeal pathology (abscess) * Pharyngeal obstruction * Full stomach * Low pulmonary compliance requiring high peak inspiratory pressures * Any procedure where patient needs to be paralyzed cannot use LMA * Also want to consider position

Sizing of an LMA is indicated by patient

Weight in kg

As size of LMA increases what else increases

Amount of air

Males usually what size LMA

5 or 6

Females usually use what size LMA

3,4,5

Part of difficult airway algorithm Assistive device for intubation – not meant to be used for duration of procedure just a conduit for which we perform intubations

LMA Fastrach

Advantages of LMA over FMV

* Hands-free operation * Better seal in bearded patients * Less cumbersome in ENT surgery * Often easier to maintain airway * Protects against airway secretions * Less facial nerve and eye trauma * Less operating room pollution

Disadvantages of LMA over FMV

* More invasive * More risk of airway trauma * Requires new skill * Deeper anesthesia required * Requires some TMJ mobility * N2O diffusion into cuff – can lead to SLN and Glossopharyngeal injury due to hyperinflation over long period of time * Multiple contraindications

Delivers anesthetic gas directly into trachea and allows most control of ventilation and oxygenation

Endotracheal tube

When inserting a stylet we do not go past what on the ETT

Murphy's eye

Murphy tubes (standard) have this to decrease risk of occlusion should the distal tube opening abut the carina or trachea

Murphy's eye

Resistance to airflow depends primarily on tube....

Diameter, but is also affected by length and curvature

Tracheal tube size is usually designated by...

Internal diameter of tube in mm

Valve on ETT prevents

Air loss after cuff inflation

Provides gross indication of cuff inflation

Pilot balloon

Cuff is more narrow so it has a smaller surface area contact within the trachea and has a higher potential for tracheal mucosal ischemia

Low volume HIGH pressure cuff

Small area contact with the trachea, but distends the trachea and distorts it to a circular shape- therefore disadvantage is higher risk of ischemic damage to tracheal wall mucosa

Low volume, HIGH pressure cuff

More volume but the cuff will contact the trachea over a larger surface area. Maintains pressure at lower seal so less potential for tracheal mucosa ischemia.

High volume, LOW pressure

* As the cuff continues to inflate, the area of contact becomes larger and cuff adapts itself to the tracheal surface conforming to tracheal lumen * Reduces the risk of significant cuff-induced complications following prolonged intubation

High volume , LOW pressure

Flexible, spiral wound, wire-reinforced TTs resist kinking and may prove valuable in some head & neck surgical procedures or in prone position

Armored tubes

Small tube diameter but still has a long or regular length.

Microlaryngeal tubes

Types of preformed tubes

RAE - nasal and oral

Placed in nose so sits in airway and top comes out of nose and over pts head.

RAE nasal airway

Preformed ETT that sits in trachea and projects downward away from face

RAE oral airway

Used for lung isolation procedures such as one lung ventilation

Double lumen endobronchial tubes

Tube that connects to special monitor to allow CO and potentially other parameters

ECOM

Tube that allows intraoperative monitoring of EMG activity of the laryngeal musculature during surgery

EMG

tube sits in trachea and vocal cords come in contact with monitoring plates •As we are doing thyroidectomy's – parathyroidectomies, anterior cervical discectomy infusions •ANYTHING in neck where we are worried about integrity of nerves, we will use a NIM tube

NIM (nerve integrity monitor)

Trachea reaches adult size at what age

Insertion depth of ETT for women

approx 21 cm at lip

Insertion depth of ETT for men

approx 23 cm at lip

Ideal internal diameter of ETT for women

7.0-8.0 mm

Ideal internal diameter of ETT for men

8.0-9.0 mm

Formula for pediatric ETT size

4 + (age/4)

Formula for pediatric ETT depth of insertion

14 + (age/2)

Advantages of LMA to Endotracheal intubation

* Less invasive * Useful in difficult intubations * Less tooth & laryngeal trauma * Less laryngospasm & bronchospasm * Does not require muscle relaxation * No risk of esophageal or endobronchial intubation

Disavantages of LMA over Endotracheal intubation

* Risk of GI aspiration * Less safe in prone or jackknife positions * Unsafe in morbidly obese * Limits maximum PPV * Less secure airway * Greater risk of gas leak & pollution * Can cause gastric distention

Instrument used to examine the larynx & facilitate intubation of the trachea

Laryngoscope

Type of curved blade

Mac

Types of straight blades

Miller, Wisconsin, Phillips

Typical size of MAC blade for adults

3 or 4

Typical MAC size blade for pediatrics

2 or 2 if really small

Preferred blade for pediatric patients

Straight blade

Miller size used for pediatric patients

0 and 1

Most frequently used Miller size blade for adults

Which side do we enter the mouth with the laryngoscope

Right side and then scoop tongue to left

Video laryngoscopy utilizes what type of blade

curved

is video laryngoscopy direct or indirect laryngoscopy

Indirect

•Illumination device and microvideo camera on laryngoscope blade oGlottic visualization- indirectly accomplished

Video laryngoscopy

How can we align the three axes in order to achieve better visualization during laryngoscopy

Place pillow under head Sniffing position May even need to reverse trendelenberg for larger patients

Gold standard to confirm placement of ETT

Visualization of placement through the vocal folds Sustained detection of exhaled CO2 •Capnography for 3 consecutive breaths

Other indicators for confirmation of proper intubation placement

``` Equal bilateral breath sounds Negative abdominal sounds Visualization of chest excursion Observation of condensation in ETT Lighted stylets Fiberoptic bronchoscope identification of tracheal rings Chest x-ray ```

What 3 things should you have in your emergency back up equipment

LMA, ambu bag, Gum elastic bougie or Eschmann stylet

60 cm in length with a 40 degree bent distal tip | oUsed with glottis opening is difficult to visualize ( Cormack and Lehane grade II-III)

Eschmann Stylet (Gum elastic bougie)

Insertion of bougie is placed..

Through glottic opening, advanced to 25cm at lip, and then held in place (by another provider), ETT inserted over stylet and advanced into trachea

With an ETT in place can you have a laryngospasm?

S/s of laryngospsm

Initially stridor then complete obstrucion

Larsons maneuver

Head tilt jaw thrust with fingers behind jaw and use significant amount of pressure to break laryngospasm

Treatment for laryngospasn

1. Remove stimulus 2. 100% O2 and positive pressure ventilation (close off APL valve >20) 3. Provide open clear airway (placement of oral airway) 4. Larsons maneuver 5. Deepen anesthesia with Propofol 4. Succs for refractory unresponsive Laryngospasm (1cc or 20mg)

Before extubation we must ensure that...

oMuscle relaxants are fully reversed oAll secretions & foreign material have been suctioned oPatient has resumed spontaneous ventilation oThe airway will remain clear and unobstructed after the ETT is removed oPatient is breathing/being ventilated with 100% O2

Bronchospasm intraoperatively is mostly due to what

Anaphylactic reaction - Epi, steroids, Pepcid, Benadryl

Treatment for bronchospasm

Bronchodilator (B2), ketamine, steroids, Epi

Negative pressure pulmonary edema usually happens in what patient population

Young muscular males

Due to forceful inspiratory effort in the presence of a closed glottis or upper airway obstruction oNegative intrathoracic pressure is transmitted to the alveoli which are unable to expand owing to the more proximal obstruction and fluid is entrained from pulmonary capillary beds

Negative Pressure pulmonary edema