Airway management Flashcards
What is a Mallampati exam?
assesses the oropharyngeal space to determine how much room there is to work
helps us quantify the size of the tongue relative to the volume in the mouth
A higher Mallampati score (3 or 4) is associated with
a more difficult intubation
By itself, ______ is a poor predictor of a difficult airway
Mallampati
What is the inter-incisor gap exam?
assesses how well the patient can open his mouth which directly affects your ability to align the oral, pharyngeal, and laryngeal axes
A small inter-incisor gap creates a
more acute angle between the oral and glottic openings, increasing the difficulty of intubation
What is normal inter-incisor gap?
2-3 finger breadths (4 cm)
_________ reduce the inter-incisor gap
long incisors
___________ teeth increase the risk of dental damage
Buck
What is the mnemonic for Mallampati classification?
PUSH
What is a class 1 Mallampati entail?
Pillars, Uvula, Soft palate, Hard palate
What is a class 2 Mallampati?
Uvula, soft palate, hard palate
What is a class 3 mallampati?
soft palate, hard palate (base of uvula may be seen)
What is a class 4 mallampati?
hard palate
To perform the Mallampati exam, ask the patient to:
sit upright
extend the neck
open the mouth wide
stick out the tongue
NOT phonate
Restriction of mouth opening can be caused by
arthritis, scar tissue, temporomandibular joint disease and prior surgery
The ability to place the patient into the sniffing position is highly dependent on the mobility of the
atlanto-occipital joint
Some conditions that impair the atlantooccipital mobility include
arthritic disease, trauma, and Down syndrome
ankylosing spondylitis, trauma, surgical fixation, Klippel-Feil, diabetes
The mandibular protrusion test assesses the
function of the temporomandibular joint
_______________ mandibular protrusion test correlates with an increased difficulty of intubation.
A class 3
How is the mandibular protrusion test performed?
The patient is asked to sublux the jaw and the position of the lower incisors is compared to the position of the upper incisors
To expose the glottic opening during laryngoscopy, you must displace the tongue into the
submandibular space
If the submandibular space is too small or poorly compliant, then you may not
be able to move the tongue enough to expose the glottis
The thyromental distance helps us estimate
the size of the submandibular space
A TMD less than ______ or greater than _______ correlates with an increased risk of difficult intubation
6 cm or greater than 9 cm
The borders of the submandibular space include
superior border= mentum
inferior border= hyoid bone
lateral border= either side of the neck
TMD less than 6 cm indicates
mandibular hypoplasia
What is a class 1 mandibular protrusion test?
patient can move LI past UI and bite the vermilion of the lip (where the lip meets the facial skin)
What is a class 2 mandibular protrusion test?
Patient can move LI in line with UI
What is a class 3 mandibular protrusion test?
patient cannot move LI past UI (increased risk of difficult intubation)
Normal AO flexion and extension is between
90-165 degrees
Normal AO extension
35 degrees (laryngoscopy will be difficult if <23 degrees)
What is the 3-3-2 rule?
combines several airway tests to give us a more accurate prediction of airway difficulty
inter-incisor gap > 3 finger breadths
TMD > 3 fingerbreadths
Thyrohyoid > 2 fingerbreadths
Only the epiglottis can be visualized during direct vision laryngoscopy. What is this patient’s Cormack and Lehane score?
3
The Cormack and Lehane grading system helps us measure
the laryngoscopic view we obtain during direct vision laryngoscopy
What is a grade 1 Cormack Lehane score?
complete or nearly complete view of the glottic opening
What is a grade 2A view?
posterior region of the glottic opening
What is a grade 2B view?
corniculate cartilages and posterior vocal cords (no glottic opening)
What is a grade 3 view?
epiglottis only
What is a grade 4 view?
soft palate only
How does the Cormack and Lehane score relate to the difficulty of laryngoscopy?
Grade 1 & 2A= easier intubation
Grade 2B & 3= harder intubation (consider a bougie)
grade 4= requires an alternative approach to intubation
Identify the BEST predictors of difficult mask ventilation. (select 3)
a. mallampati class 3
b. old age
c. edentulousness
d. small mouth opening
e. high, arched palate
f. presence of a beard
b. old age
c. edentulousness
f. presence of a beard
What is the mneomic for difficult mask ventilation?
BONES
beard, obese, No teeth, elderly (age > 55 years), snoring
If the patient has a full stomach or risk factors for aspiration, then a
RSI is indicated
Complications related to cricoid pressure include:
airway obstruction
difficulty with laryngoscopy
impaired glottic visualization
difficult intubation
reduced LES tone
esophageal rupture if patient is actively vomiting
What are the five questions to ask before providing airway management?
- Can I mask ventilate
- Can I intubate?
- Can i place a supraglottic airway?
- Can I place an invasive airway?
- How fast must I secure the airway?
Risk factors for difficult laryngoscopy and endotracheal intubation:
small mouth opening
long incisors
prominent overbite
high, arched palate
MP 3 or 4
retrognathic jaw
inability to sublux jaw
short, thick neck
short thyromental distance
reduced cervical mobility
Risk factors for difficult supraglottic device placement include:
limited mouth opening
upper airway obstruction
altered pharyngeal anatomy (anything that prevents a seal)
poor lung compliance (requires excessive PIP)
increased airway resistance (requires excessive PIP)
lower airway obstruction
Risk factors for difficult invasive airway placement include:
abnormal neck anatomy
obesity
short neck
laryngeal trauma
limited access to the cricothyroid membrane
What could cause abnormal neck anatomy?
tumor, hematoma, abscess, history of radiation
Why could obesity lead to difficult invasive airway placement?
difficult to identify cricothyroid membrane (same as for a short neck)
Why might access be limited to the cricothyroid membrane?
halo
neck flexion deformity
What are the current NPO recommendations?
2 hours= clear liquids
4 hours= breast milk
6 hours= light meal, infant formula, nonhuman milk
8 hours= fried or fatty foods
The mnemonic for difficult surgical airway placement is
SHORT: surgery (neck surgery or previous scar), hematoma, obesity, radiation, tumor
The mnemonic for difficult laryngoscopy and intubation is
LEMON: look externally (shape of face, morbid obesity, pathology of head and neck), evaluate 3-3-2 rule, mallampati score, obstruction (indications for upper and lower airway obstruction), neck mobility
The mnemonic for difficult supraglottic airway placement is
RODS: restricted mouth opening, obstruction, distorted airway, stiff lungs or C-spine
Where should pressure be held for an RSI?
cricoid ring against the C5 vertebra
What is the pressure before LOC for an RSI?
2 kg or 20 Newtons
What is the pressure after LOC for an RSI?
40 Newtons or 4 kg
