Airway Management - Dr. Herring Final Review

Question 1

You need to do a needle cricothyrotomy but don’t have the standard jet ventilation set up. You only have your anesthesia machine. What pieces of equipment will you need to ventilate this patient? How would you ventilate that patient?

Answer 1

3cc syringe with a 7.5mm adapter

High Pressure, Low Frequency (8-10bpm)
25-50psi Oxygen inhalation for 1s and 3-4 seconds for passive exhalation.

You’ll probably only achieve about 250-300mL tidal volume.

Question 2

What is one of the contraindications for a needle cricothyrotomy?

Answer 2

Upper airway obstruction. Exhalation is passive; if the upper airway is obstructed, air becomes trapped.

Question 3

Contraindications for Nasal Intubations?

Answer 3

Cribriform Plate Injuries such as Basilar Skull Fx, Lefort 2 or 3 Fx, Racoon Eyes, CSF Rhinorrhea

Coagulopathy

Question 4

What psi level of oxygen does the jet ventilator have?

Answer 4

50psi

Question 5

What is your plan A if you suspect or anticipate a difficult airway for an elective procedure?

Answer 5

A. Awake intubation
B. Face Mark or LMA if ventilation is not suspected to be difficult,
C. Consider regional anesthesia or local anesthesia
D. Invasive

Question 6

What supplies would you need for an emergent invasive front-of-the-neck surgical airway?

Answer 6

Scalpel - 11 blade
Bougie Stylet
6.0-6.5 ETTube or Shiley Trach Tube
Betadine or Alcohol

Question 7

What are some things you need to do when intubating through a supraglottic airway such as the Fast Trach LMA.

Answer 7

-Ensure cuff patiency of LMA and ETT
-Water soluble lubricant
-Place LMA and confirm appropriate ventilation via etCO2 and Bilateral breath sounds before placement of ETT
- Then, either blindly or with a flexible scope, advance ETT, inflate the cuff, and attempt ventilation.

Question 8

You are utilizing trans tracheal jet ventilation; how long is it good for?

Answer 8

~35-45 minutes

Question 9

When would you want to do a retrograde intubation? What is it good for?

Answer 9

Impaired visualization of the vocal cords from blood, secretions, or anatomic anomalies.
Airway tumors, unstable cervical spine, or airway trauma

Question 10

You have a patient with rheumatoid arthritis and micronathia (small lower jaw) with a poor mallampati score. He was canceled two weeks ago because he could not be intubated. What would be your airway plan? What would not be your airway plan?

Answer 10

Awake intubation with a VL or flexible bronchoscope

Would NOT want to do a Direct VL

Question 11

You do a standard induction with DVL and you end up not being able to pass the tube, what do you do next?

Answer 11

-Call for help
-Attempt mask ventilation that is confirmed adequate by etCO2.
-Consider alternative intubation approaches

Question 12

You are doing an awake intubation; what drugs will you need?

Answer 12

IV meds:
Antisialagogue - glycopyrrolate or atropine
Precedex
Versed
Ketamine

Histamine 2 antagonist for GERD

Topical or Inflitration Nerve Block
-Lidocaine 2%, 4%,5%
-Benzocaine 20%

Lidocaine 2% for infiltration nerve block

Phenylephrine 1% for nasal

Question 13

Lidocaine recommended dose for IV

Answer 13

4-5mg/kg IV

Question 14

The lidocaine lollipop uses what % topical concentration

Answer 14

5% Topical Lidocaine Paste
Held in place for 1-2 minutes

Question 15

Toxic doses of benzocaine can result in?

Answer 15

Methemoglobinemia

Question 16

Specific branches of 3 cranial nerves need to be anesthetized before awake nasal or oral intubation

Answer 16

Trigeminal
Glossopharyngeal
Vagus

Question 17

First-generation versus second-generation SADs. What are the limits regarding positive pressure ventilation?

Answer 17

First Generation can only do up to 20cmH2O PPV.

Second Generation can do 28-30cmH2O PPV

Question 18

You appropriately apply cricoid pressure and gastric secretions are seen in the back of the airway when the airway management person goes to intubate. How could this occur?

Answer 18

1. The esophagus could be lateral to the trachea
2. Cricoid pressure can relax the lower esophageal sphincter, allowing gastric contents to come up

Question 19

You’re at the end of the case, so wake up the patient. If you had a hard time getting the tube in, what are some techniques you could use to get the patient extubated?

Answer 19

1. AEC - Airway Exchange Catheter or Bougie to remain in place in case reintubation is needed
2. Extubate fully awake with NMBA fully reversed
3. Use of SAD

Question 20

You’re going to do an awake fiberoptic intubation; part of your process is to prevent laryngospasm. What things in your process do not aim at laryngospasm prevention?

Question 21

How does the Airway Exchange Catheter (AEC) differ from the bougie?

Answer 21

The airway exchange catheter (not the Eschmann introducer) contains a lumen for measuring end-tidal CO2, jet ventilation, or oxygen insufflation.

Question 22

Pros and Cons of deep extubation

Answer 22

The advantages of deep endotracheal extubation include decreased sympathetic stimulation and decreased incidence of tachycardia, hypertension, and coughing.

However, deep extubation is performed when the patient’s airway reflexes are depressed, increasing the risk of hypoventilation, airway obstruction, and aspiration.

Answer 23

Patients with a higher risk of failed extubation include (1) those with abnormal or complicated airway issues at induction (dental damage implies a difficult laryngoscopy), (2) those in which surgical conditions create airway issues (anterior cervical discectomy and fusion), and (3) those with general risk factors (obstructive sleep apnea, especially if it is untreated; neuromuscular weakness).