Airway Management Flashcards
Why is rapid sequence induction done?
To minimise chance pulmonary aspiration in high risk individuals eg pregnancy
Name 6 features associated with difficult mask ventilation
BONESS
Beard
Obesity
No teeth
Extremes of age
Sleep apnea/ snoring
Severe prognathia, receding mandible, other facial deformities
Name 2 features associated with difficult insertion of laryngeal mask
• Limited access to mouth (inter-incisor distance <2,5 cm)
• intra-oral pathology eg Intra oral tumours
Name 4 features associated with difficult crico-thyroidotomy and tracheostomy
• Fixed flexion of neck eg ankylosing spondylitis, scaring
• deviation larynx and trachea
• Tissue overlying cricothyroid membrane and trachea eg fat, goitre, sepsis
• Devices overlying trachea eg surgical collar
Name 8 pre-operative clinical tests that can predict the ability of a successful laryngoscopy
- Inter-incisor gap ( <3 cm difficult)
- Protrusion of mandible- inability to protrude lower incisors in front of upper (retrognathia) - difficult.
- Mallampati score
- Flexion and extension craniocervical junction: > 90 degrees should be possible
- Thyromental distance (Patil’s test): <6 cm difficult.!
- Sternomental distance (Savva’s test): < 12,5 cm. difficult
- Mandibular space
- Neck circumference - thyromental distance (patil) ratio: obese >5 difficult
What must be done if high likelihood mask ventilation and direct laryngoscopy will be difficult?
Awake fibreoptic intubation
Name the steps of RSI ( 6)
- Preoxygenation with mask and 100% oxygen 3-5 minutes at high flow 6L/min, tight fitting mask
- Iv induction with drug with fast onset action eg propofol, sodium thiopental, ketamine
- As soon as patient loses consciousness, apply cricoid pressure on cricoid ring to occlude oesophagus posterior to it. (Sellick’s maneuver) (BURP - BACK UP RIGHT PRESSURE)
- Administer fast acting muscle relaxant. Either suxamethonium (30s) 1-1,5 mg/kg or rocaronium (60s) 0,6-1 mg/kg (modified RSI)
- Perform laryngoscopy, intubate trachea, inflate ETT cuff
- Verify correct position of ETT and then only stop cricoid pressure
Name 5 indications for RSI
- Emergency operation
- Unfasted patient
- Delayed stomach emptying: acute abdomen, hiatus hernia (regurgitation), pyloric stenosis, trauma
- Pregnancy
- Autonomic neuropathy: renal failure, diabetes mellitus, etc.
(All these = risk aspiration)
Name 7 indications intubation in surgical procedures
• Protect airway
• maintain airway
• controlled ventilation (relaxants)
• surgery on head and neck (access)
. Longer procedures > 180 minutes
. Babies and small children
• non-supine positions
Name 6 ways correct placement of endotracheal tube can be checked
• See tube passing through cords
• 5 point auscultation
• bilateral chest movement
• press on chest and listen
• oximetry desaturation (late sign)
• capnography
Name 6 complications intubation
• sore throat
• incorrect placement
• trauma
• regurgitation/aspiration
• bronchospasm
• stress response - tachycardia, hypertension
Name 3 complications face mask air way management and SGA LMA
• Inflation stomach
• obstruction airway and for some, regurgitation
• pulmonary aspiration
Name 3 advantages to using face mask airway management
• inflatable cuff to make it fit better
• warm humid air easily seen to check if patient breathing
• foreign material can be seen easily
Name 4 indications facemask airway management
• Oxygenate hypoxic patient
• preeoxygenate before induction anaesthesia
• assisted manual ventilation during induction
• spontaneous or assisted ventilation for short procedures eg D and c, myringotomy insertion
Name 7 contraindications SGA LMA
Rroodds
• regurgitate and aspirate risk
• reach airway difficult/unable during surgery eg head and neck surgery
• other position than supine
• opening mouth restricted - inter-incisor distance <2.5cm
• Distorted upper airway eg tumour
• disrupted upper airway
• stiff lungs and must be ventilated during procedure
Optimal position for tracheal intubation?
Flex base of neck with pillow, extend at c1 c2
After excluding neck injury!
Name 4 clinical features predicting difficult intubation
4 D’s
Disproportion
Distortion eg micrognathia
Dysmobility
Dentition
Hair piece, obesity
Describe mallampati classification
• Class 1: uvula, faucal pillars, soft palate visible
• class 2: faucial pillars and soft palate visible
. Class 3: soft and hard palate visible
• class 4: hard palate visible only
Name the 3 types of supraglottic air ways
• First generation: classic LMA (simple airway conduit)
• second generation: proseal LMA (reduce risk aspiration)or combitube - has suction port
• intubating LMA:fastrach (conduit for placement ett)
Name device in picture 57
First generation SGA: Classic LMA
Name device in picture 58
Second generation SGA: proseal supreme LMA or combitube
Name device in picture 59
Intubating LMA:fastrach
Minimum oxygen concentration is FGF mixture shouldn’t be less than?
30%
Classify picture 70
Cormack lehane grade 1: full view of glottis
Classify picture 71
Cormack Lehane grade 2: partial view of glottis or arytenoids
Classify picture 72
Cormack Lehane grade 3: only epiglottis visible
Classify picture 73
Cormack Lehane grade 4: neither glottis nor epiglottis visible
What is classification on picture 74 called?
Cormack Lehane
Dose of suxamethonium for RSI?
1-1,5 mg/kg
Dose of rocaronium for RSI?
0,6-1 mg/kg
Define respiratory failure in terms of PAO2
<60 mmHg
How is front of neck access (fona) achieved as a last resort for airway management
Cricothyroidotomy (surgical or needle) with tracheostomy
How do pre-oxygenation? (4)
• Tight fitting mask
• 100% oxygen
• 3-5 minutes
. High FGF (fresh gas flow)
Normal end tidal co2?
35-45 mm hg
When use intubating LMA?
Emergency, allows blind intubation. Especially when intubation difficult eg C spine injury
Useful between attempts of intubation and before intubation to have airway
Classify picture 78
Mallampati class 1: uvula, faucial pillars, soft palate visible.
Classify picture 79
Mallampati class 2: faucial pillars, soft palate visible
Classify picture 80
Mallampati class 3: soft and hard palate visible
Classify picture 81
Mallampati class 4: only hard palate visible
Label picture 95
See picture 96
Label picture 97
See picture 98
How should extubation be performed in patient at high risk aspiration? (2)
• Fully awake, MAC < 0,3
• extubate fully reversed if used rocaronium - tof 0,9 or 90%
How calculate fi02 from Pa02?
Pa02= fi02 x 500
Describe how to assess airway difficulty (5)
Lemon
. Look externally: bones
• evaluate: 3-3-2
- can pt fit 3 fingers between incisors
-Is mandible length 3 fingers from the mentum to the hyoid
- distance from hyoid to thyroid 2 fingers
• mallampati
• obstruction or obesity: epiglottis, tumours, Ludwig’s angina, neck haematoma,foreign body, thermal injury can compromise airway management
• neck mobility: ability to extend, affected by trauma cervical collar, elderly, arthritis
Name 9 risk factors for bronchospasm
• Atopy
• smoking, COPD
• occupational exposure: fumes, chemicals, smoke
• recent lower respiratory tract infection
• use of iv contrast media.
• use cholinergic drugs eg neostigmine
• use of histamine releasing drugs eg atracurium, morphine
• iatrogenic airway irritation and trauma
• use of beta blockers for other chronic conditions
Name 8 classes pharmacological agents that may be useful in treating bronchospasm
• Beta 2 stimulants: salbutamol
• corticosteroids
• volatiles
• NMDA receptor antagonists: ketamine, mgs04
• anti-muscarinics
• methylxanthines: aminophylline
• leukotriene antagonists
• lignocaine (sodium channel blocker)
