Airway Management Flashcards
What are some conditions that impair AO mobility?
DJD
RA
Ankylosing spondylitis
Trauma
Surgical fixation
Klippel-Feil
Down syndrome
DM
What is the 3-3-2 rule?
Inter-incisor gap > 3 finger Breaths
Thyromental distance > 3 finger breaths
Thyrohyoid > 2 finger breaths
What is a grade 1 Cormack and Lehane view?
Complete view of glottic opening
What is a grade 2 Cormack and Lehane view?
Posterior region of the glottis opening (loss of anterior commissure)
What is a grade 3 Cormack and Lehane view?
Epiglottis only (loss of any part of the glottic opening)
What is a grade 4 Cormack and Lehane view?
Soft palate only (loss of any part of the larynx)
What is a grade 2b Cormack and Lehane view?
You can only see the corniculate cartilages and posterior vocal cords (no glottic opening)
What are the risk factors to a difficult mask?
BONES
B: beard
O: obese
N: no teeth
E: elderly (> 55years)
S: snoring
What are some risk factors to difficult intubation?
Small mouth opening
Long incisors
Overbite
High arched palate
Mallampati class 3/4
Retrognathic jaw
Short thick neck
Short TMD
Reduced cervical mobility
What are some risk factors for LMA placement?
RODS
R: restricted airway
O: obstruction
D: distorted airway
S: stiff neck or C-spine
What are some risk factors for surgical airway placement?
SHORT
S: surgery (previous scar)
H: hematoma
O: obesity
R: radiation
T: tumor
What pressure should be given before loss of consciousness during RSI? What about after?
Before: 2 kg (20 newtons)
After: 4 kg (40 Newtons)
Angioedema r/t anaphylaxis?
Cause: triggering agent
Tx: epi, antihistamine, steroids
Angioedema r/t ACE Inhibitors
Cause: prevent bradykinin breakdown
Tx: discontinue ACE, Icatibant/Ecallantide, FFP, C1 esterase concentrate
Angioedema r/t genetics
Cause: genetics/hereditary
Tx: C1 inhibitor concentrate, FFP, ecallantide/icatibant
What is Ludwig’s angina?
Bacterial infection that causes cellulitis of the floor of the mouth ~ edema and inflammation compress airway structure ~ airway obstruction
What is the best way to secure an airway for someone with Ludwig’s Angina?
Nasal intubation
Awake trach
What are syndromes with large tongues?
Big Tongue
B: beckwith syndrome
T: trisomy 21
What are syndromes with underdeveloped mandibles?
“Please Get That Chin”
P: pierre Robin
G: goldenhar
T: treacher collins
C: cri du Chat
Which two oral airways are designed to accommodate a fiberoptic bronchoscope or ETT?
Williams and Ovassapian
What are contraindications to a nasal airway?
Lefort 2or 3 fx
Basilar scull fx
CSF rhinorrhea
Raccoon eyes
Periorbital edema
Coagulopathy
Previous transsphenoidal hypophysectomy
Nasal fx
How do you size a pediatric tube without a cuff?
(Age/4) +4
How do you size a pediatric tube with a cuff?
(Age/4) + 3.5
How do you determine depth placement?
ID x 3
What is a non-channeled design? In terms of video laryngoscopes.
It’s a device used to expose glottic structures BUT the ETT is passed separate from the laryngoscope
McGrath, glide, C-MAC
What is a channeled design? In terms of video laryngoscopes.
Interstates a channel for the endo trachea tube into the device
What are some predictors of a difficult video laryngoscopy?
Radiation
Tumor
Scar
Short TMD
Limited cervical motion
Thick neck
class 3 upper lip bite test
Where does the proximal end of the PMA sit?
Near the base of the tongue
Where do the sides of the LMA sit?
Piriform sinuses
Where does the distal end of the LMA sit?
Along the upper esophageal sphincter
What is the max PPV pressure on an LMA?
20 cm H2O
What is the max cuff pressure of an LMA?
20 cm H2O
What size LMA is appropriate for a pt < 5 kg?
What is the mL for inflation?
What is the largest size ETT it can fit?
LMA 1
4 mL
3.5 ETT
What size LMA is appropriate for a pt 5-10kg?
what volume should be used for the cuff?
What is the largest ETT used to fit?
LMA 1.5
7 mL
4.0 ETT
What size LMA should you use for a pt 10 kg- 20kg?
How much mL can you inflate the cuff?
What is the largest ETT that can fit inside?
LMA 2
10 mL
4.5 ETT
What is the appropriate size LMA for a patient 20kg-30kg?
How much cuff volume is accurate?
What is the largest size ETT it can accommodate?
LMA 2.5
14 mL
5.0 ETT
What is the appropriate size LMA for a patient of 30-50kg?
How much mL is used to insert the cuff?
What is the largest ETT it will accommodate?
LMA 3
20 mL
ETT 6.0
What is the appropriate LMA size for a patient of 50-70kg?
How much volume in the cuff?
What size ETT can it accommodate?
LMA size 4
30 mL
6.0 ETT
What size LMA for a patient of 70-100kg?
How much volume in the cuff?
What is the largest ETT it can accommodate?
LMA 5
40 mL
7.0 ETT
What is the LMA ProSeal?
Adaption of LMA classic. Double lumen
Gastric drain tube (for easy gastric decompression) ~ must place an OG first
Larger mask
Biteblock
Better deal
Increased max pressure (< 30 cm H2O)
What is the LMA Fastrach and how does it differ?
Intubating LMA
Metal handle
Specifically designed ETT (high pressure cuff)
Tube pusher
Epiglottic elevating bar
What is the LMA C-Trach?
C-Trach is similar to the Fastrach, but includes a camera.
What is the LMA flexible?
Flexible
Wire-reinforced (not suitable for MRI)
Longer use than the LMA classic
Narrower than the LMA classic (must use a smaller ETT or bronchoscope)
Useful for head and neck surgery
What is the iGel?
It’s an alternative to the LMA
No inflatable cuff
There is a gastric port
It can serve as a conduit for ETT intubation
Save for use in MRI
Complications:
Tongue trauma
Mucosal erosion of the cricoid ring
Compression of the trachea
Nerve injury
Airway obstruction
Regurgitation and aspiration
When should an LMA not be used?
Risk of regurgitation and aspiration (full stomach, hiatal hernia, small bowel obstruction, symptomatic GERD, delayed gastric emptying)
Airway obstruction
Tracheomalacia or external trachea compression
Poor compliance
High airway resistance
What do you do if you observe gastric contents in the LMA?
Leave LMA in place
Tberg
100% FiO2
Use low FGF and low Vt
Use a flexible suction catheter
FOB evaluation gastric contents in trachea…if present, consider intubation.
What airway devices are the most to least stimulating?
Combitube > DVL > Fiberoptic > LMA
What is the combitube?
Supra glottic, double lumen device that is blindly inserted into the hypopharynx
(Usually pre-hospital settings)
What is the size of combitube for a 4-6 ft person?
Size 37
What is the size combitube for a patient > 6 ft
Size 41
Where does the proximal and distal cuff sit with a combitube?
Proximal cuff (40-100 mL)sits: hypopharynx
Distal cuff (5-12 mL) sits: esophagus (usually)
What are the benefits to the combitube?
Secure airway
Decompress the stomach
Use in obese
Blind insertion technique (min training)
No neck extension
High vent pressures (< 50)
Doesn’t need to be taped
What are some contraindications to the combitube?
Gag reflex
Prolonged use
Zenker’s diverticulum
Ingestion of caustic substances.
What is the King Laryngeal tube?
Similar to combitube
Like: can insert blindly, distal cuff obstructs esophagus and proximal obstructs hypopharynx
Diff: one lumen, only one inflation port, child sizes available.
What is hand placement for fiberoptic?
Non-dominant: moves the lever
Dominant: holds the cord
How do you move the camera in a fiberoptic?
Lever down = tip up
Lever up = tip down
What is the gold standard for managing difficult airways?
Fiberoptic bronchoscopy in the awake pt.
What are absolute contraindications to fiberoptic use?
Uncooperative patient
Lack of provider skills
Near total upper airway obstruction
Massive trauma
What is a Bullard Laryngoscope?
It is a rigid, fiberoptic device used for indirect laryngoscopy
What are some indications for a Bullard scope?
Small mouth opening
Impaired cervical mobility
Short, thick neck
Treacher Collins
Pierre Robin
What are the contraindications to the Bullard scope?
There are none, but learning curve is high
What is another name for the Eschmann introducer?
Bougie or intubating stylet
When is the best time to use a bougie?
Class IIb or class 3
Worst time to use is during a class 4!!!
When is the best time to use a lighted stylet?
Anterior airways
Small mouth opening
Cervical spine abnormality
Pierre-Robin syndrome
Burn contractures
When should you not use a lighted stylet?
Short, thick neck
Can’t ventilate, can’t intubate
Should be used if there is a tumor, foreign body, airway injury or epiglottitis
Do NOT use the lighted stylet in a patient with traumatic laryngeal injury
What are the indications for a retrograde intubation?
Unstable cervical spine
Upper airway bleeding
Failed awake intubation.
What are the contraindications to a retrograde intubation?
Inability to identify or access the Cricothyroid membrane
Pretrachial mass
Laryngotracheal disease
Tumor
Coagulopathy
Infection at puncture site
What are the 3 ways to create a surgical airway?
Percutaneous cricothyroidotomy
Surgical cricothyroidotomy
Tracheostomy
What psi pressure do you need for a percutaneous cricothyroidotomy?
50 psi
What are some contraindications to a percutaneous cricothyroidotomy?
Upper airway obstruction
Laryngeal injury
What are the contraindications for a surgical cricothyroidotomy?
Not for children < 6yrs
Laryngeal fx/neoplasm
