Airway Management

Question 1

3 Axis of airway

Answer 1

Oral/Pharyngeal/Laryngeal

Question 2

Airways aligned

Answer 2

Sniff and Neck Extension

Question 3

Problems with bad alignment

Answer 3

1. Don’t have clear path for ventilation

2. Soft tissue can fall back and cause apnea in severe cases (obese patients)

Question 4

Good airway looks like…

Answer 4

Nose above abdomen

Question 5

Advantages of aligning the airway (3)

Answer 5

1. Airway “more open” and easier to breathe
2. Easier to ventilate the patient
3. Better view of the vocal cords

Question 6

4 Types of Airway Obstruction

Answer 6

1. Soft Tissue (tongue/obese patients)
2. Airway swelling (Edema/trauma/burn patients/pregnancy)
3. Laryngospasm (risk every time in extubated)
4. Bronchospasm (risk is patients are intubated “lightly”)
   
   • Patient still has reflex to protect the airway

Question 7

Soft Tissue Obstruction

Answer 7

tissue falls against the pharynx (sedated/unconscious)

Question 8

Soft Tissue Ob cases (3)

Answer 8

1. MAC anesthesia (sedated patients)
2. Right after induction of GA (before LMA/ETT inserted)
3. After extubation (still not awake)

Question 9

Is soft tissue obstruction a problem during GA?

Answer 9

No, LMA or ETT will be placed and tube will bypass the tongue.

Question 10

Soft Tissue Treatment (4)

Answer 10

1. Chin lift
2. Jaw thrust
3. Nasal Airway
4. Oral Airway

Question 11

Chin Lift

Answer 11

• indicated for minor airway obs.

- aligns the 3 axis’

Question 12

Jaw Thrust

Answer 12

• opens airway by lifting soft tissue off the pharynx
• stimulates respirations with pain
• behind mandible

Question 13

Double handed jaw thrust

Answer 13

best opportunity to get a good mask seal and the best opportunity to mask ventilate the patient (requires a 2nd provider to squeeze bag)

Question 14

Oral/Nasal Airways

Answer 14

lift tongue off posterior pharynx

Question 15

Oral airway

Answer 15

unconscious patients only, can cause gagging

Question 16

Nasal airway

Answer 16

• tolerated better in awake patients

- contraindicated with patients on blood thinners/facial fractures

Question 17

Proper sizing of oral airway

Answer 17

One end at the lips/ the other end at the angle of mandible

Question 18

Proper sizing of Nasal Airway

Answer 18

• distance from the nares to the meatus of ear

- diameter of the patient’s smallest finger

Question 19

Anaphylaxis

Answer 19

allergic reaction that can cause severe swelling within the airway

Question 20

Swelling causes (5)

Answer 20

1. Traumatic intubation/multiple laryngoscopies
2. Anaphylaxis
3. Burned patient
4. Fluid overload
5. Pregnancy

Question 21

Swelling Treatment (4)

Answer 21

1. Steroids (Decadron)
2. Diuretics
3. Leave the patient intubated
4. Epinephrine (if anaphylaxis is the cause)

Question 22

Laryngospasm

Answer 22

vocal cords snap shut

Question 23

Causes of laryngospasm

Answer 23

1. ETT during extubation
2. Airway secretions (mucus, saliva, blood)
   - Vocal cords must be stimulated during “light anesthesia” (stage II)
   - CANNOT occur when patient is deep asleep.
   - Stimulation of superior laryngeal nerve (branch of vagus nerve)

Question 24

When will a patient most likely experience a laryngospasm?

Answer 24

Stage II (half asleep)

Question 25

Is extubating a patient during stage II anesthesia a good idea?

Answer 25

No, pulling tube out during this time will stimulate the vocal cords.

Question 26

Laryngospasm Treatments (4)

Answer 26

1. High jaw lift at laryngospasm notch (breaks larnygospasm when combined with positive pressure) 2. Positive airway pressure with bag and mask (Double handed jaw thrust w/ bag squeezing/only to 20 cmH20, protects air from going into esophagus) 3. Propofol (relaxes vocal cords by taking patient from stage II to stage III. 4. Succinylcholine

Question 27

Bronchospasm

Answer 27

narrowing of the bronchioles caused by inflammation or constriction if lungs become irritated. (smokers and asthmatics more susceptible)

Question 28

Causes of bronchospasm (5)

Answer 28

1. ETT irritating the lunch if patient not anesthetized deeply enough 2. Emergence from anesthesia 3. Desflurane (most pungent volatile agent) 4. Anaphylaxis 5. Aspiration

Question 29

Treatment for bronchospasm caused by light anesthesia

Answer 29

- give more propofol and/or give more volatile agent--> put them more to sleep - ETT need to be paralyzed or deeply anesthetized

Question 30

If patient is in emergence from anesthesia, how would you treat a bronchospasm?

Answer 30

Give albuterol (best 2 agonist/bronchodilator) inhaler via the ETT (60 mL syringe)

Question 31

How would you treat a patient with a bronchospasm caused by Anaphylaxis?

Answer 31

Give bronchodilators (3) 1. Epinephrine (~300 mcg IM) 2. Best 2 agonists - albuterol inhaler - subcutaneious terbutaline (0.25mg) 3. Volatile agent (isoflurane or sevoflurane)

Question 32

Coughing Prevention on ETT

Answer 32

1. Lidocaine jelly or LTA kit (more effective/releases in 360 degrees) 2. patient paralyzed or deeply anesthetized

Question 33

Coughing treatment on an ETT

Answer 33

1. Turn off ventilator (can resume once cause of coughing is treated) 2. Dose muscle relaxant (Zemuron) or deepen anesthetic (narcotics or higher conc of volatile anesthetic)

Question 34

Regurge (Passive Reflux

Answer 34

reduction in tone of the lower esophageal sphincter (LES).

Question 35

How can regurge (passive reflux) be prevented?

Answer 35

Sellick's maneuver: applying cricoid pressure to prevent reflux through the esophagus. This also improves intubation view.

Question 36

Is vomiting an active or passive reflux?

Answer 36

Active: patient is treated with aggressive suctioning and them in Trendelenburg with their head tilted to the side. (Cricoid pressure controversial due to esophageal ruptures.)

Question 37

Aspiration

Answer 37

Gastric contents enter the trachea/lungs.

Question 38

What should you do if a patient aspirates?

Answer 38

Patient should be intubated and sent to the ICU. Could be placed on prophylactic antibiotics and possibly steroids.