Airway management 4 Flashcards
When compared to the LMA classic, benefits of the ProSeal include
a better seal
max pressure for PPV <30 cmH2O (LMA classic is <20 cmH2O)
The iGel is a
supraglottic airway that’s an alternative to the LMA
With the iGel there is no
inflatable cuff which can contribute to a poor seal
Can the iGel be used in MRI?
Yes, it doesn’t contain metal parts
The iGel has a
gastric port
The iGel can serve as a conduit for
endotracheal intubation (the lumen has a larger diameter and there are no aperture bars)
Complications of the iGel include
tongue trauma
mucosal erosion of the cricoid cartilage
compression of the trachea
nerve injury
airway obstruction
regurgitation and aspiration
All of the following are contraindications to a laryngeal mask airway EXCEPT:
a. gastroparesis
b. asthma
c. tracheal tumor
d. hiatal hernia
b. asthma
What is the device in a can’t intubate, can’t ventilate scenario?
LMA
The LMA should not be used in the following situations:
risk of gastric regurgitation and aspiration (full stomach, hiatal hernia, small bowel obstruction)
airway obstruction at the level of the glottis or below the glottis
poor lung compliance
high airway resistance
In patients with _____________, the LMA is preferred over a standard ETT assuming there are no contraindications to the LMA
reactive airway disease
Compared to tracheal intubation, the LMA is less likely to
activate the SNS
The risk of aspiration can be minimized with an LMA by
selecting the appropriate use based on the surgical procedure and position as well as the patient’s history (e.g. no history of GERD)
maintaining a deep enough plane of anesthesia to prevent swallowing as this can produce gastric insufflation
removing the LMA at the first sign of rejection during emergence
avoid using too much or too little air in the cuff
using the correct size device (not under-sizing)
minimizing inflation pressure (no higher than 20 cm H2O with a classic LMA)
epigastric auscultation can be used to assess for gastric insufflation
If you observe gastric contents inside the airway tube of the LMA, then you should perform the following interventions:
Leave LMA in place
Place in Trendelenburg (30 degrees) & deepen anesthesia
Give 100% oxygen via a self-inflating resuscitation bag (if gastric contents are in the breathing circuit)
use a low FGF and low Vt
use a flexible suction catheter to suction around the LMA
use a FOB to evaluate the presence of gastric contents in the trachea- consider intubation and aspiration protocols
The tendency of airway device placement to activate the SNS (from most to least stimulating):
combitube
DVL
fiberoptic intubation
LMA
If you’re going to use an LMA for a laparoscopic procedure, then the following guidelines should be observed:
select an LMA that allows for gastric drainage
use in patients with normal BMI
observe traditional NPO fasting guidelines
avoid light anesthesia
be an experienced LMA user
Follow the “15” rule: use <15 degree tilt, <15 cmH2O intraabdominal pressure, and <15 minutes of insufflation
Identify the contraindications to the combitube: (select 3)
a. full stomach
b. Zenker’s diverticulum
c. obesity
d. intact gag reflex
e. Klippel-Feil
f. prolonged use
b. Zenker’s diverticulum
d. intact gag reflex
f. prolonged use
The combitube is a
supraglottic, double lumen device that is blindly placed in the hypopharynx
The patient’s __________ determines which size Combitube is used:
height
A size 37 combitube is suitable for
4-6 ft
A size 41 combitube is suitable for
> 6 ft.
A size __________ combitube is suitable for <4 ft
no size available
Benefits of a Combitube include
provides a secure airway (aspiration protection)
ability to decompress the stomach
useful for the obese population
minimal training required
Contraindications for a Combitube include
intact gag reflex
esophageal disease (zenker’s diverticulum)
ingestion of caustic substances
prolonged use (>2-3 hours) due to the risk of ischemia from the oropharyngeal balloon
What is the difference between the King laryngeal tube and the combitube?
King laryngeal tube: single lumen for ventilation and a single inflation port
child sizes are available
The ________ is a disposable device that includes a second lumen that allows you to pass a gastric tube to suction the stomach
King LTS-D
How much volume should be instilled in the oropharyngeal balloon of the combitube size 37?
40-85 mL
How much volume should be instilled in the oropharyngeal balloon of the Combitube size 41?
40-100 mL + option for additional 50 mL
The volume that should be instilled in the distal cuff of the combitube is
5-12 mL air (this is the second cuff that is inflated)
Cuff pressures of the combitube should not exceed
60 cmH2O
Overinflation of the cuffs of the combitube can
rupture the esophagus
Regarding the operation of the flexible fiberoptic bronchoscope: (select 2)
a. the oral, pharyngeal, and laryngeal axes must align
b. pushing the lever down points the tip up
c. the non-dominant hand controls the lever
d. mask ventilation is impossible while the scope is in place
b. pushing the lever down points the tip up
c. the non-dominant hand controls the lever
The gold standard for managing the difficult airway for the awake, spontaneously ventilating patient is
the flexible fiberoptic bronchoscopy
The flexible fiberoptic bronchoscope is used for _________________ in awake or asleep patients
indirect laryngoscopy
The absolute contraindications to fiberoptic bronchoscopy include
wild, uncooperative patient
lack of provider skills
near total upper airway obstruction (unless using FOB for diagnostic purposes)
massive trauma (unless used in conjunction with retrograde intubation)
The relative contraindications to fiberoptic bronchoscopy include
hypoxia, bleeding, and lack of patient cooperation
Before insertion of the flexible fiberoptic bronchoscope, remember to use a
defogger, antisialagogue and a vasoconstrictor
Which hand should hold the lever of the fiberoptic scope?
non-dominant hand
To move the scope horizontally,
the FOB is rotated in either direction
Other indications for using the flexible fiberoptic bronchoscope is
C-spine limitation: severe cervical stenosis, cervical fracture, Chiari malformation, vertebral artery insufficiency
Limited mouth opening: TMJ disease, facial burns, mandibular-maxillary fixation
Drugs that can be used in conjunction with awake fiberoptic intubation include
dexmedetomidine, remifentanil, ketamine, and midazolam
The ____________ helps the FOB stay midline, although they may stimulate the gag reflex in the awake patient
Williams or Ovassapian airway
Identify the statements that BEST describe the Bullard scope: (select 2)
a. the oral, pharyngeal, and laryngeal axes must align
b. it lacks disposable components
c. it requires a minimum mouth opening 7 millimeters
d. it is useful in the patient with Pierre Robin syndrome
c. it requires a minimum mouth opening of 7 mm
d. it is useful in the patient with Pierre Robin syndrome
The Bullard laryngoscope is a
rigid, fiberoptic device used for indirect laryngoscopy
With the Bullard laryngoscope, there’s a disposable tip extender which is useful for
tall patients; recover it after you’re done
Compared with DVL, the Bullard causes
less cervical spine displacement
Other types of rigid, fiberoptic devices include
the WuScope and UpsherScope
The Bullard is recommended for patients with
small mouth openings
impaired cervical spine mobility
short thick necks
congenital airway syndromes (e.g. Treacher Collins or Pierre Robin)
Contraindications for using the Bullard Laryngoscope include
no absolute contraindications but learning curve is high
Compared to FOB, intubation with the Bullard is
usually faster
Compared with DVL, the Bullard causes less
cervical spine displacement
Sometimes the endotracheal tube hangs up on the right arytenoid cartilage with the Bullard scope, but you can fix this with
cricoid pressure and/or lifting the blade anteriorly
With the bullard scope the head and neck must
stay in a neutral or slightly flexed position- any extension will make glottic visualization more difficult
What is an absolute contraindication for the use of the Bullard?
there are no absolute contraindications
