Airway management 6 Flashcards
Following induction of general anesthesia, initial intubation attempts are unsuccessful and face mask ventilation is not adequate. According to the ASA difficult airway algorithm, what is the NEXT immediate step?
a. place a supraglottic airway device
b. wake up the patient
c. perform a cricothyroidotomy
d. call for help
d. call for help
The ASA difficult airway algorithm includes a decision tree to help you choose between
awake intubation or airway management after anesthetic induction
If you proceed with anesthetic induction, consider
rocuronium (+ sugammadex if needed) instead of succinylcholine
Within the airway algorithm, there is a strong emphasis on
optimizing oxygenation throughout the entire airway management process
limiting attempts
being keenly aware of the passage of time and oxygen saturation
In the “can’t ventilate and can’t intubate” scenario, your primary objectives include
calling for help
placing a supraglottic airway device
possibly awakening the patient
If a supraglottic airway device does not solve a “can’t ventilate and can’t intubate” situation, then attempt
alternative intubation approaches as you prepare for an emergency invasive airway
Emergency invasive airway access options include
surgical cricothyrotomy
percutaneous cricothyrotomy with jet ventilation
rigid bronchoscopy
ECMO
Strategies for extubation in a difficult intubation include
enlisting skilled help
optimizing oxygenation
using an airway exchange catheter (in adults)
consideration of elective tracheostomy
Consider awake intubation if you anticipate difficulty with laryngoscopy or intubation coupled with any of the following:
- suspected difficult ventilation with facemask or supraglottic airway device
- significantly increased risk of aspiration
- increased risk of rapid desaturation
Deep extubation provides the MOST significant benefit in the patient with: (Select 2)
a. asthma
b. obstructive sleep apnea
c. Parkinson’s disease
d. coronary artery disease
a. asthma
d. coronary artery disease
Pros of deep extubation include:
decreased CV & SNS stimulation
decreased coughing and airway irritation
Cons of deep extubation include
ineffective airway reflexes
increased risk of airway obstruction (caution with OSA)
increased risk of aspiration (Caution with Parkinson’s)
Extubation should be performed when
the patient is deep or awake- NOT in-between
The decision of when to extubate should be
made on a patient-to-patient basis
Risks associated with awake extubation include
increased SNS stimulation
increased ICP
increased IOP
increased IAP
Techniques for extubating the difficult airway include
extubating fully awake
extubating over a flexible fiberoptic bronchoscope
extubating asleep and then placing an LMA
using an airway exchange catheter
A light plane of anesthesia is categorized by
disconjugate gaze
breath holding
unable to follow commands
To prevent coughing on awake extubation consider
lidocaine (IV or inside the ETT cuff)
opioids
To prevent CV and SNS stimulation for awake extubation consider
beta-blockers
calcium channel blockers
vasodilators
What is the BEST technique to manage the patient at high risk of failed extubation?
a. Eschmann introducer
b. airway exchange catheter
c. nasal airway
d. Shikani stylet
b. airway exchange catheter
The airway exchange catheter is a
long, thin, flexible, hollow tube that maintains direct access to the airway following tracheal extubation
If a patient requires re-intubation, the airway exchange catheter is used
as a stylet for reintubation via the Seldinger technique
The lumen of the airway exchange catheter can be used to
measure EtCO2
jet ventilate (the patient requires a patent upper airway)
insufflate O2
The airway exchange catheter can be kept in place for
up to 72 hours
Complications of the airway exchange catheter include
barotrauma/pneumothorax - if you use jet ventilation w/ a patient with an obstructed upper airway
inability to replace the ETT
Replacing the ETT with an airway exchange catheter requires
laryngoscopy to displace the supraglottic tissue
