Airway Management - Quiz 1 Flashcards
Difficult to Ventilate
When signs of inadequate ventilation cant be reversed by mask ventilation or patient’s O2 sat cant stay > 90% with mask ventilation
What is considered Difficult to Intubate
More than 3 attempts or more than 10 minutes to complete tracheal intubation
Difficult Airway
When a trained anesthetist has difficulty with mask ventilation, laryngoscopy, intubation or all three
What should anesthetist do prior to any airway manipulation?
Complete a thorough airway exam using multiple airway assesments - this will guide airway management plan
Causes of Difficult Intubation
- Inadequate pre-op assessment
- Anesthetist
- Malfunctioning equipment
- Inexperienced assistance
Basic Airway Evaluation in all patients
- LEMON law
- BONES
- 4 D’s
LEMON Law
- Look externally
- Evaluate the 3-3-2 rule
- Mallampati
- Obstruction/Obesity
- Neck mobility
What to look for externally for airway assessment
- Short muscular neck
- Obesity
- Receding jaw
- Dentures
- Buck teeth
- Macoglossia
- Stridor
- Facial trauma
- Burns
3-3-2 Rule
- 3 - Minimum distance the mouth should open - Inter incisor distance
- 3 - Distance from tip of mandible to laryngeal cartilage
- 2 - Distance from floor of mouth to prominence of laryngeal cartilage
(Distances measured in fingers)
Thyro-Mental Distance
- Upper edge of thyroid cartilage to chin with head fully extended
- Short Thyro-Mental Distance = Anterior Larynx
- > 7cm usually easy intubation
- < 6cm difficult airway
Mallampati Classification
- Class 1: Complete view of uvula, tonsilar pillars, soft palate
- Class 2: Partial view of uvula base, partial view of tonsils, soft palate
- Class 3: Only soft palate
- Class 4: Only hard plalate
Obstruction?/Obesity
- Blood
- Vomit
- Teeth
- Epiglottis
- Dentures
- Tumors
- Impacted objects
Neck Mobility
Measurement of Atlanto-Occipital (AO) Angle
Mandibular Protrusion Test
Upper lip bite test.
Assess incisor length and mobility of TMJ and subluxation
Assessing difficulty of mask ventilation
BONES
- *B**eard
- *O**besity
- *N**o teeth
- *E**lderly
- *S**noring
4 D’s of Laryngeal Visualization
- Disproportion
- Distortion
- Dismobility
- Dentition
4 D’s - Disproportion
- Achondroplasia
- Acromegaly
- Prognathism
- Pierre robin sequence - small jaw
4 D’s - Distortion
- Neurofibromatosis - generalized bumps
- Burn contracture
- Cystic hygroma - fluid sac from lymph blockage
4 D’s - Dismobility
- TM joint Ankylosis - stiff jaw
- Klippel Fiel - fusion of neck vertebra
- Advanced ankylosing spondylitis - neck stiffness
Patient conditions that make bag mask ventilation difficult?
- Seal: Beards, anatomy, NG tube
- Obstruction
- Obesity
- Age >55
- Mallampati III-IV
- No Teeth
- Stiff lungs
- Sleep apnea/snoring
Difficulty with DL or VL
- If it looks difficult, it probably is
- 3-3-2
- Mallampati
- Obstruction/obesity
- Scarring, radiation, masses
- Mobility
- Operator experience
What are things that cause Difficulty with SGA (LMA)
- Restricted mouth opening
- Obstruction
- Distortion of airway
- Stiff Lungs
What should be assessed if a difficult airway is anticipated?
Cricothyroid membrane should be identified BEFORE intervention starts
Difficulty with Cricothyroidotomy
- Neck distortion
- Obseity/short neck
- Trauma around neck
- Impediments limitng access to neck (halo, fixed flexion)
- Surgery
SHORT:
- *S**urgery
- *H**ematoma
- *O**besity
- *R**adiation
- *T**umors
Manuevers for Difficult Airway
- Positioning - Sniffing position
- Neck positioning - caution with neck disorders
- Ramping - elevate shoulders, neck, head
- Apneic oxygenation
- Cricoid pressure
ASA Difficult Airway Algorithm
Options after airway assessment
- Awake intubation
- Quick look
- Induction and paralysis
Awake Intubation
Patient needs to be awake. Big risk of complications if sedatives/muscle relaxants given before airway control
Quick Look
Patient can be sedated for attempt of direct laryngoscope WITHOUT muscle relaxant
Some risk of failed laryngoscopy, but low risk of failed mask ventilation
Induction and Paralysis
Patient can be induced and paralyzed when there is low risk of difficult laryngoscope and/or mask ventilation
How much is enough Pre-Oxygenation
Two Techniques
- Tidal Volume Breathing (TVB) of oxygen for 3-5 min
- Deep breaths (DB) 4 times in 30 secs
Both equally effective in increasing arterial oxygen tension (PaO2)
Why does Failure of airway access happen?
- No discussion with colleagues about plan
- No request for experienced help
- Exaggerated idea of personal ability
- Bad plan A or plan B
- Poor execution of Plan A or Plan B
- Trying Plan A for too long
- Starting rescue plan too late
- Not involving and preparing surgical colleagues
Development of Primary and Alternative Strategies
Difficutly Areas to Indentify
- Bag Mask Ventilation (BMV)
- Direct Laryngoscopy (DL) and Video Laryngoscopy (VL)
- Supraglottic Airway Ventilation
- Cricothyrotomy Airway Placement
What does the use of face mask, LMA anesthesia, local anesthesia infiltration, or regional block usually imply?
Mask ventilation will not be problematic
What to consider when initial intubation attempts are UNSUCCESSFUL after Induction of General Anesthesia?
- Call for help
- Returning to spontaneous ventilation
- Awakening the patient
Algorithm
Airway Tools
- LMA SGA
- Larygoscope Blades
- LMA as intubation conduit
- Fiberoptic Intubation
- Intubating Stylet
- Tube Changer
- Light Wand
- Blind oral/nasal intubation
- Invasive Airway Access
- Jet ventilation, Percutatneous Intubation, Retrograde Intubation, Surgical airway
4 Plans For Airway Access
Types of Laryngoscope Blades
Mac
MIller
Wis
Heine
SGA/LMA
- Provide ventilation above glottic opening
- Sizing - kg weight
- Slide along top of mouth, often folded w/ resistance
- Intubating LMA for difficult airway
- Combitube, King LT - Retroglottic/Infraglottic
LMA Sizing
Types of Intubation Stylets
- Trachlite
- Eschmann Stylet (Bougie)
- Cook airway exchange catheter
Types of Video Assisted Larygoscopy
Glidescope
Karl Storz C-Mac
McGrath VL
Airtraq Optical Laryngoscope
Indication for Fibertopic Intubation
- Patient awake and sedated
- Anticipated Difficult Airway
- Cervical Spine Immobilzation
- Anatomical Abnormalities of Upper Way
- Failed intubation attempt, but mask vent possible
Subglottic Interventions/ Emergency Airway Access
Needle Cricothyrotomy with Jet Ventilation
Surgical Cricothyrotomy
Retrograde Intubation
Tracheotomy
What should be used for Unexpected Difficult Airway
Difficult Airway Cart
- Larygoscope - multiple blade types and sizes
- ETTs, Combitube
- Tube Exchangers, guides, introducers, LMA
- Bougie, Stylet
- Cricoidthyrotomy tray
- Fiberoptic equipment
- Suction
- Tube Securing Device
- CO2 Detector
Difficulties - Upper Airway Obstructions
Emergency
Hoarse, muffled voice, difficulty swallowing secretions, stridor, dyspnea
Difficulties - Lower Airway Obstructions
High peak pressures, low tidal volumes, impaired ventilation
Manage by optimizing ventilation and oxygenation
Difficulties - OSA
Bring CPAP to use in PACU
Managment of Obesity Difficulties
Position, Preoxygenate, 2nd Plan, Alternate Adjuncts, Assistants
Will Desat much quicker, limit time delay
Criteria for Tracheal Extubation
- Acceptable hemodynamic status
- Normothermia
- Ability to maintain airway
- Adequate muscle strength
- Adequate respiratory mechanics
- Ability to maintain adequate oxygenation
Complications of Intubation
- Dental - most common
- Vocal cord paralysis, granuloma formation, arytenoid dislocation, subluxations
- Esophageal laceration
- Aspiration
- Esophageal (Goose) Intubation
- Endobronchial Intubation
- Kinking, biting, mucus plug of tube, cuff damage
7 P’s of Preparation
Pre-Oxygenation
Pre-Treatment
Paralysis
Protection
Positioning
Placement (with Proof)
Post-Intubation Management
