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Principles II > airway management techniques > Flashcards

airway management techniques Flashcards

1
Q

what are indications for a LMA?

A
  • use instead of mask
  • facilitate ventilation, intubation with difficult airway
  • ventilate for flexible bronchoscopy
  • avoidance of airway manipulation (with RAD)
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2
Q

what are contraindications for LMA use?

A
  • pharyngeal pathology, obstruction
  • full stomach, fasting not confirmed, GERD
  • low pulmonary compliance (PIP > 30 cmH2O)
  • irritable airway (COPD, emphysema) with increased PIP
  • leaks at 20 cmH2O
  • grossly or morbidly obese (while lying supine, if tip of stomach is over line of trachea; but still used sometimes)
  • more than 14 wks pregnant
  • multiple or massive injuries (potential to code, intubate)
  • acute abdomen, lap chole (need NMB)
  • thoracic injury (decreased compliance)
  • any delayed gastric emptying (opioid therapy)
  • pts. who are not profoundly unconscious (maximize airway, intubate)
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3
Q

what are the advantages of LMA when compared to mask?

A
  • allows hands free, less fatigue
  • better seal, esp. with beard or no teeth
  • allows operating (ENT, esp. nose and eys)
  • easier to maintain airway
  • protects against nasal secretions (not gastric!)
  • less facial nerve and eye injury (place gauze under mask straps)
  • less OR pollution
  • no neck manipulation
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4
Q

what are disadvantages of LMA when compared to mask?

A
  • more invasive
  • airway trauma potential
  • different skill
  • deeper anesthesia required
  • TMJ must be mobile
  • N2O can diffuse into cuff
  • contraindications: laryngeal pathology, obstruction
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5
Q

what are potential complication with a LMA?

A
  • aspiration (2: 10,000)
  • sore throat (10%)
  • hypoglossal nerve injury
  • tongue cyanosis
  • vocal cord paralysis (poor insertion technique; over-inflation of cuff)
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6
Q

describe insertion technique for LMAs

A
  • choose appropriate size
  • deflate cuff, lubricate back side of cuff
  • anesthesia (propofol 2.5-3.0 mg/kg) or local anesthesia or SLN block
  • press mask against the hard palate (the black line should be pointing directly cephalad)
  • press LMA into pharynx along the curve of the palate using the index finger
  • grasp the LMA with the opposite hand and withdraw the inserting finger
  • press downward on the LMA until resistance is met
  • inflate cuff with appropriate amount of air and visualize the LMA displace out slightly
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7
Q

what are the common sizes of LMAs for adult males and females?

A

adult female: 4

adult male: 5

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8
Q

where should the tip of the LMA be?

A

over the esophagus

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9
Q

what is the appropriate LMA size for a 30-50 kg (small) adult and appropriate max volume to inflate cuff?

A
  • LMA size 3
  • max volume 20 cc
  • largest ETT mm: 6.0 cuffed
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10
Q

what is the appropriate LMA size for a 50-70 kg adult and its max cuff volume? what’s the largest ETT size that can be used with the LMA?

A
  • LMA size 4
  • 30 cc
  • 6.0 cuffed ETT
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11
Q

what is the appropriate LMA size for a 70-100 kg adults and max cuff volume? what is the largest ETT size that can be used?

A
  • LMA size 5
  • 40 cc
  • 7.0 ETT cuffed
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12
Q

what size LMA is used for adult pts. > 100kg, what is the max cuff volume and what is the largest ETT size that can be used?

A
  • LMA size 6
  • 50 cc
  • 7.0 cuffed ETT
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13
Q

what are ways to intubate through a LMA

A
  • use fiberoptic to visualize cords (need to have ETT threaded on before inserting)
  • blindly insert smaller ETT (6.0) through LMA
  • use intubating LMA (Fastrach) to insert larger ETT (not to be left in place)
  • inserting intubating stylet
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14
Q

describe Fastrach LMAs

A
  • advanced LMA for tracheal intubation
  • handle allows one hand insertion, removal
  • comes in sizes 3, 4, 5 with max air 20cc, 30cc, and 40 cc respectively
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15
Q

describe ProSeal LMAs

A
  • has a separate lumen through which a gastric tube can be inserted to evacuate contents from the stomach
  • allows for positive pressure ventilation (studies show higher airway leak pressure)
  • studies show that PIP are lower with the ProSeal b/c it has a smaller leak
  • can use higher PIP with better seal and lower leak
  • if air is introduced to stomach, has a way to get out
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16
Q

describe ventilation with the LMA

A
  • spontaneous ventilation: assisted ventilation to maintain EtCO2 (beware with opioids and inhalation agents which can cause shallow breathing and allow CO2 build up; EtCO2 may read low d/t shallow expiration)
  • CPAP- 3 cm pressure: reduces work of breathing
  • pressure support with CPAP: lower EtCO2, slower RR, lower WOB, lower esophageal pressure, higher expired TV
  • no difference in SaO2, MAP, HR with LMA ventilation
17
Q

how should LMAs be cleaned and sterilized?

A
  • wash in 10% sodium bicarbonate solution
  • detergent: Endozime
  • steam autoclave only (deflate cuff prior) to a temp of 275 degrees F (135 C); don’t want cuff to inflate and burst
  • avoid: germicides, disinfectants, gluteraldehyde, ethylene oxide, phenol-based cleaners, iodine-containing cleaners, ,or quaternary ammonium compounds (all can be absorbed)
18
Q

describe the esophageal-tracheal combitube

A
  • alternative emergency airway
  • allows ventilation whether the tip enters the esophagus or the trachea (usually goes to esophagus)
  • only 1% of times goes into trachea
  • two balloons, one 100cc in the oropharynx and one smaller 15cc near the tip
  • two lumens- one straight used if tip in trachea; one with side perforations used if tip in the esophagus
19
Q

describe fiberoptic intubation

A
  • indirect visualization using a flexible fiberoptic bronchoscope
  • considered the Gold Standard for management of expected difficult airway (although not frequently used)
20
Q

what are clinical indications for fiberoptic intubation?

A
  • airway tumors
  • infections
  • cervical spine fractures, instability
  • cervical spine fixation (immobility; down syndrome; cant extend neck)
  • very limited TMJ mobility
  • conscious intubation
  • difficult intubation
21
Q

what should pt. be pretreated with prior to fiberoptic intubations?

A

-glycopyrrolate and neosinephrine (nasal vasoconstriction) to decrease oral secretions and nasal bleeding

22
Q

describe an awake, oral fiberoptic procedure

A
  • nebulize lidocaine 4% (gets above and below cords)
  • cetacaine spray to posterior pharynx
  • lidocaine gel oral prep (gargle and spit out)
  • insert special oropharyngeal airway to prevent biting (protects tubes)
  • lubricated ETT inserted 4-5 cm into airway
  • fiberoptic scope is threaded into ETT
  • *view: uvula, epiglottis and vocal cords
  • advance scope into mid trachea (have propofol ready and hooked up, push when carina is seen, give before threading ETT)
  • thread ETT over scope tip
23
Q

describe nasal fiberoptic intubation

A
  • causes less gagging
  • patient cannot bite the scope
  • insert warmed (more pliable), lubricated ETT into vasoconstricted (neosinephrine, afrin, manually stretch), anesthetized nasal passage
  • suction oropharynx
  • insert scope through ETT, straight shot, into glottis
  • thread ETT over the scope
  • be careful of epistaxis
24
Q

describe an asleep fiberoptic intubation

A
  • must interrupt to ventilate patient
  • results when a failed intubation occurs unexpected
  • can maintain cricoid pressure
  • compared to awake pts., these have greater chance of tongue and epiglottis blocking cords
25
Q

describe a glidescope

A
  • video laryngoscope
  • digital camera in the blade tip
  • 60 degree curvature
  • can be used with patient in neutral cervical position
  • stylet needed (make sure stylet angle matches angle of glidescope)
  • indirect method of visualization of vocal cords
26
Q

how does glottic view with glidescope use in pts. with cervical collar compare to direct laryngoscopy with a Mac?

A
  • 93% pts. had an improved view with the glidescope
  • average time to intubation: 38 sec.
  • no complication, including dental trauma
27
Q

describe technique for glidescope use

A
  • look into the mouth as you insert midline into mouth
  • look at the monitor as you lift up to see the epiglottis and glottic opening (may lift as the Mac or use to directly lift epiglottis)
  • look into mouth as you guide the tube with the stylet toward the tip of the scope
  • look back at the monitor to complete the insertion of the ETT into the glottic opening
28
Q

describe the bullard laryngocope

A
  • rigid laryngoscope with fiberoptic capability
  • can view cords without sniffing position
  • indicated for cervical immobility or instability
  • suction channel used for suctioning, insufflating O2, or injecting local anesthesia
  • light source can be laryngoscope handle or fiberoptic light source
29
Q

describe insertion technique for the bullard laryngoscope

A
  • load ETT onto stylet
  • prepare pt. with antisialagogue
  • blade inserted midline with handle parallel to pts. body
  • slide blade down into laryngopharynx as the handle comes to vertical
  • lower the blade to pick up the epiglottis to visualize the cords
  • slide the ETT off the stylet into the trachea
30
Q

describe light wand technique

A

-lighted stylet which transilluminates the neck
-used for routine and difficult intubations
technique:
-insert stylet into ETT
-bend ETT proximal to cuff to 90 degree angle
-induction of anesthesia
-pull tongue forward
-insert ETT with light wand stylet
-visualize light as it advances down trachea
*if dims or disappears, the ETT has entered the esophagus
*once light is below cricoid cartilage, stylet withdrawn to allow insertion of the ETT into the trachea

31
Q

describe retrograde intubation

A
  • insertion of a guide wire through the crciothyroid membrane, through the mouth over which the ETT is inserted
  • most common complication is bleeding
32
Q

describe technique for retrograde intubation

A
  • topical anesthesia to oropharynx, larynx, and trachea
  • needle (18g) attached to syringe containing lidocaine 2% inserted through cricothyroid membrane
  • aspirate air to confirm placement
  • guide wire is threaded into the pharynx back into mouth and retrieved (once passed through mouth, hook something at neck to prevent from pulling out)
  • a guide is passed over wire, through the cords
  • ETT passed over guide; can use fiberoptic scope
33
Q

describe jet ventilation

A
  • temporary oxygenation
  • 14g or larger IV catheter inserted through the cricothyroid membrane (12 g better)
  • oxygen source to deliver flow at 30 psi and 15 L/min
  • ventilate 6-8 breaths/min
  • I:E 1:4, long expiratory phase to allow emptying
  • may need to employ airway techniques, positioning or jaw thrust to allow exhalation (verify emptying to avoid barotrauma)
34
Q

describe cricothyrotomy

A
  • the cricothyroid membrane is surgically cut and an ETT is placed into the trachea
  • risks higher than a cricothyroid puncture

Principles II (18 decks)

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