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Basic Principles of Anesthesia > Airway Part 2 > Flashcards

Airway Part 2 Flashcards

1
Q

Factors that may indicate an anticipated difficult airway

A

Airway exam or previous difficult airway
Neck or mediastinal pathology
Upper airway impingement by mass
Previous surgery or radiation
Unstable neck fractures
Halo devices
Small or limited oral openings
Patients in the critical care setting

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2
Q

Techniques for awake intubation

A

Video or Fiberoptic-guided

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3
Q

Steps prior to awake intubation

A

Explanation - patient must be cooperative
Desiccation - Glycopyrolate
Dilation - prepare nasal airway, BOTH SIDES oxymetazoline 1-2 sprays each nostril

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4
Q

Dose of glyco for awake intubation

A

0.2 mg IV 5-20 minutes before procedure

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5
Q

Methods for anesthetizing patient’s airway

A

Topical and nerve blocks with preferably one agent to calculate max dose

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6
Q

Maximum safe dose of lidocaine

A

5 mg/kg

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7
Q

Three areas for airway anesthesia

A

Nasal
Posterior pharyngeal wall and base of tongue
Hypopharynx and trachea

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8
Q

Three nerves for airway block

A

Trigeminal
Glossopharyngeal
Vagus

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9
Q

Lidocaine application techniques

A

Spray from container
LA soaked in ribbon gauze
Cotton applicators
McKenzie technique
Mucosal atomization technique
Inhalation of nebulized lidocaine
“Spray as you go” via epidural catheter

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10
Q

Sedation techniques for awake intubation

A

Boluses of:
Diazepam, Midazolam, fentanyl, afentanyl, morphine, clonidine, procedex, propofol, ketamine
Combo of agents:
Benzos and opioids
IV infusions:
Propofol, remifentanil, preceded
Combo of IV infusions
Most common are precedex followed by remi

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11
Q

Precedex for awake airway management

A

Bolus 1 mcg/kg IV over 10 minutes, followed by infusion of 0.3-0.7 mcg/kg/hr.
Reduce in older adults and depressed cardiac function

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12
Q

Midaz dose

A

1-2 mg IV repeated prn

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13
Q

Fentanyl dose

A

25-200 mcg IV

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14
Q

Alfentanil dose

A

500-1500 mcg iv

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15
Q

Remifentanil dose

A

Bolus 0.5 mcg/kg IV followed by infusion of 0.1 mcg/kg/min

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16
Q

Propofol dose

A

0.25 mg/kg IV in intermittent boluses or Continuous infusion of 25-75 mcg/kg/min

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17
Q

Ketamine dose

A

0.2-0.8 mg/kg IV

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18
Q

Steps for Awake FOB intubation

A

Stay midline - keep scope midline as advance toward epiglottis
Visualize - airway structures of oropharyngeal, pharyngeal, and laryngeal spaces
Insufflate - o2 through suction port - oxygenates pt and keeps optics clear
Glottic Opening - Advance tip through glottic opening until tracheal rings come into view
Advance ETT
Verify placemtn by visualization of carina

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19
Q

When are rigid or semirigid fiberoptic stylets and laryngoscopes used?

A

Difficult airway situations such as trauma or limited mouth opening
When intubation has failed
During routine airway management - limited cervical spine mobility

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20
Q

Types of semirigid fiberoptic stylets

A

Shikani optical stylet
Levitan First pass Success Scope

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21
Q

Rigid Stylets

A

Bonfills Retromolar Intubation Fiberscope
Rigid Intubation fiberscope laryngoscope (RIFL)
Bullard laryngoscope

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22
Q

When is video laryngoscopy used

A

For anticipated difficult airways.
As a rescue strategy when unexpected difficulty

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23
Q

Advantages of Video Laryngoscopy

A

Magnification of airway
Visualization of structures that cannot be seen with DL
Other clinicians can also visualize airway
Recording capabilities

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24
Q

Disadvantages of Video Laryngoscopy

A

Cost
Blood and secretions can obscure view
Pharyngeal injuries

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25
Q

When do you start viewing the LCD monitor of the glidescope

A

As soon as the blade is past the teeth

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26
Q

Where does the glidescope blade get placed

A

In the vallecula

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27
Q

How is the ETT inserted with the glidescope

A

into the right side of the mouth by direct visualization and is advanced to the oropharynx

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28
Q

What stylet do you use with glidescope

A

Accompanying rigid stylet

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29
Q

Glidescope features

A

antifog
Recording capabilities
fiberoptic capabilities

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30
Q

Karl Storz C MAC video laryngoscope features

A

Similar to standard MAC
Less sharp anterior curve than Glide
Insertion and technique similar to DL
Antifog system
Recording
Fiberoptic capable

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31
Q

McGrath Video features

A

Portable
Modification of MAC blade
Similar to Glide - distal anterior angle, semirigid or rigid stylet recommended
No antifog system but uses hydrophilic optical surface coating to minimize condensation

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32
Q

Advantage of McGrath

A

Extremely portable

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33
Q

Channel Scope devices

A

Pentax Airway Scope
Res-Q-Scope
King Vision
Airtraq

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34
Q

Features of Channel scope devices

A

Allow for preloading of ETT
Can be used in limited spine mobility, prehospital setting, during difficult airway management
Less expensive option for video
Only airtraq has antifog

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35
Q

Head Elevation Laryngoscopy Position (HELP)

A

Aligns oral, pharyngeal, and laryngeal axes
Helpful with obese patients

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36
Q

Purpose and benefits of preoxygenation

A

Delays arterial desaturation prior to the induction of anesthesia and during subsequent apneic situations.
Increases o2 content and eliminated nitrogen (nitrogen is 79% of room air) from the FRC.
Gives 8 minutes of apneic time.

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37
Q

What does not preoxygenating do?

A

Decreases the time an anesthetist has to secure the airway

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38
Q

What do you look for when preoxygenating?

A

Movement of resp bag on machine.
Well defined ETCO2
Fraction of expired o2 to be 90% or greater before laryngoscopy*

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39
Q

How do you achieve preoxygenation?

A

100% inspired O2
Tight mask seal
Pt breathes at normal TV for 3-5 minutes
If limited time, can take 8 vital capacity breaths within 60 seconds
Minimum fresh gas flow of 5 L/min

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40
Q

THRIVE (transnasal humidified rapid-insufflation ventilatory exchange)

A

Used for preoxygenation
60L/min for 3 minutes
As effective as TV preoxygenation by face mask
Median apnea time 14 minutes

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41
Q

What law is used for apneic oxygenation

A

Boyle’s Law
O2 from oropharynx/nasopharynx diffuses down into alveoli as a result of net negative alveolar gas exchange rate during apnea
O2 can be insufflated at up to 15L/min with nasal cannula
NO DESAT

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42
Q

Goal of RSI

A

Achieve optimal intubating conditions rapidly to minimize length of time between LOC and securing of the airway with a cuffed ETT

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43
Q

Features of RSI

A

Cricoid pressure after preoxygenation and before IV induction.
No positive pressure ventilation after induction drugs and before intubation
Neuromuscular blocking agents

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44
Q

Modified RSI

A

Controlled PPV through cricoid pressure if necessary
Inspiratory pressure <20cm h2o

45
Q

Cricoid Pressure/Sellick Maneuver

A

Posterior displacement of cricoid cartilage against cervical vertebrae with the patient in 20 degree head-up position

46
Q

Goal of cricoid pressure

A

Prevent regurgitation and possible aspiration during induction.

47
Q

When would you use cricoid pressure

A

Full stomach, bowel obstruction, poorly controlled GERD, nausea/vomiting

48
Q

Optimal amount of force to occlude esophagus without obstruction of trachea

A

30 to 44 newtons

Apply 10-20 N (2kg force) prior to LOC then increase to 30-40 (4 kg) after LOC.
Hold until placement of tube is confirmed

49
Q

Downsides to cricoid pressure

A

Efficacy is in question
Can interfere with visualization
Can induce relaxation of lower esophageal sphinctor
Esophagus can be lateral to cricoid ring
Holding during active vomiting may result in esophageal rupture

50
Q

Where is the preferred place to secure the ett

A

Skin of maxilla - less mobility

51
Q

Confirmation of correct placement of TT

A

Presence of a normal capnogram for at least 3 breaths is the most important and objective indicator

52
Q

What cause cuase no EtCO2 tracing even with proper TT placement

A

Severe bronchospasm
Equipment malfunction
Cardiac arrest
Hemodynamic collapse

If in doubt, confirm with flexible bronch

53
Q

Strategies for patent upper airway and effective ventilation

A

mask ventilation with appropriate mask seal w/ w/o jaw thrust.
Placement of an SAD such as LMA.
Placement of ETT into trachea
Placement of invasive airway such as cricothyrotomy tube

54
Q

Indication of difficult facemask ventilation

A

Leaks from facemask and increasing use of O2 flush valve.
Poor chest rise.
Absent or inadequate breath sounds.
Gastric air entry.
Poor co2 return and altered waveform
O2 sat <92% by pulse ox when giving 100% inspired o2
Needing an oral airway or two-handed technique

55
Q

Indications of difficult supraglottic airway placement

A

Requires multiple attempts or more than one airway practitioner
Leak pressure less than 10-15 cm H2o and a poor expired tidal volume
Leaks
Poor chest rise
Absent/inadequate breath sounds
Gastric air entry
Poor co2 return
Sat <92%

56
Q

indications of difficult laryngoscopy and tracheal intubation

A

Inability to visualize any portion of vocal cords aka Cormack Lehane grade 3 or 4 after multiple attempts using a standard laryngoscope.
Requires multiple operators.
Failed intubation

57
Q

Indications of difficulty with invasive airway device placement

A

Bleeding at site of insertion
Inability to identify correct anatomic structures
Trouble accessing cricothyroid membrane and puncturing through into the trachea

58
Q

Complications of difficult airway

A

Death
Brain damage
Emergency surgical airway placement
Unanticipated ICU admission

59
Q

What is the difficult airway algorithm

A

Guidelines that provide structure for decision making and tools for use when managing difficult airways
In anticipated and CICO situations

60
Q

Any one of these factors alone may be clinically important enough to warrant an awake intubation

A

Suspected:
Difficult laryngoscopy
Difficult ventilation with face mask/supraglottic airway
Increased risk of aspiration
Increased risk of rapid desat
Difficult emergency invasive airway

61
Q

If any one factor - intubation, ventilation, aspiration, desat risk - is “yes” what do you do

A

Proceed to intubation attempt with AWAKE intubation

62
Q

If all factor in difficult airway algorithm are no, what do you do

A

Proceed to intubation after induction of general anesthesia

63
Q

What is a priority to do through difficult airway algorithm

A

Optimize oxygenation throughout

64
Q

What do you do if you cannot intubate, you’re in trouble, but you can still ventilate the patient

A

Wake the patient up

65
Q

What do you do when you are suspicious of airway trouble

A

Intubate awake

66
Q

Cricothyrotomy

A

Cricothyroid membrane is perforated to establish airflow to the trachea
CICO scenario
Needle vs Surgical

67
Q

Needle cric

A

Not as secure
Can be used as backup if anatomy is not ideal for surgical (< 12 y/o)
18g, Ravussin needle, venous or arterial angiocath
Large bore catheter inserted through CTM in a caudad direction

68
Q

What inflates lungs using a high-pressure oxygen source and a regulating valve to control o2 flow

A

Percutaneous transtracheal jet ventilation
PTJV

69
Q

Concerns with PTJV

A

barotrauma, hyperinflation, incomplete exhalation of CO2
Avoid excessively large TV
Inspiratory pressure should remain <50 psi on regulator
I:E ratios 1:3 or 1:4
Obstruction of passive exhalation - place bilateral nasal airways or oral airway

70
Q

Complications with PTJV

A

Barotrauma
Subq emphysema
Pneumothorax
Pneumomediastinum
Hypercarbia
Esophageal puncture
Airway mucosal damage
Blood or mucus obstruction
Catheter kinking
Inadvertant removal

71
Q

Indications for a surgical cric

A

Failed airway - CICO
Traumatic injuries of maxillofacial, cervical spine, head, or neck structures that make intubation through the nose or mouth difficult to impossible or too time-consuming
Immediate relief of an upper airway obstruction
Need for a definitive airway for neck or facial surgery, assuming intubation is not possible

72
Q

Absolute contraindications to surgical cric

A

Rare/none

73
Q

Relative CI to surgical cric

A

Preexisting laryngeal or tracheal diseases - tumors, infections, abscesses in location
Distortion of neck anatomy - hematoma
Bleeding diathesis
History of coagulopathy

74
Q

Equipment for surgical cric

A

No 10 scalpel
Bougie with a coude tip
Cuffed 6mm ETT

75
Q

Serious complication of failure to do surgical cric early enough

A

Death
Brain damage

76
Q

Reasons to extubate in the periop period

A

Minimize alterations in cardiopulmonary physiology
Decrease risk of resp infection and complications
Reduce length of stay = decreased costs and resource utilization

77
Q

Extubation: Resp mechanics criteria

A

Vital capacity greater than 15 ml/kg
Max negative insp force greater than -20 cm h20
Adequate tidal volume of at least 4-5 ml/kg

78
Q

Extubation: Indicators of ability to maintain adequate oxygenation with fio2 less than 50%

A

Spo2 greater than 90%
PaO2 greater than 60 mm Hg

79
Q

Extubation: Indicator of ability to maintain adequate alveolar ventilation

A

PaCO2 less than 50 mm Hg

80
Q

Standard extubation Global criteria

A

Hemodynamic status
Normothermia
Maintain patent airway
Adequate muscular strength
Acceptable metabolic indicators
Acceptable hematologic indicators
Adequate analgesia for optimal respiratory effort

81
Q

Signs of ability to maintain patent airway

A

Return of laryngeal and cough reflexes
Appropriate level of consciousness

82
Q

Indicators of adequate muscular strength

A

Reversal of a neuromuscular blockade as indicated by TOF ratio > 0.9, tetanic response to 100 hz for 5 seconds, double burst stimulation without fade
Head lift for more than 5 seconds with constant strong hand grip

83
Q

Indicators or acceptable metabolic status

A

Electrolytes WNL
Acid-base balance WNL

84
Q

Indicators of hematologic stability

A

Hemoglobin level consistent with adequate o2 delivery

85
Q

Advantages of anesthetized extubation

A

Decreased CV stimulation
Decreased coughing and straining

86
Q

Advantages of awake extubation

A

Return of airway reflexes
Decreased risk of aspiration
Airway reflex return
Spontaneous ventilation

87
Q

Disadvantages of anesthetized extubation

A

Absent or obtunded airway reflexes
Increased risk of aspiration
Airway obstruction
Hypoventilation

88
Q

Disadvantages of awake intubation

A

Increased CV stimulation
Increased coughing and straining

89
Q

What plane of anesthesia should extubation be performed during

A

Surgical plane - Deeply anesthetized or stage 3
Fully awake

90
Q

Techniques to attenuate increased CV stimulation

A

Beta blockers
Ca channel blockers
Vasodilators

91
Q

Techniques to attenuate coughing and straining

A

Local anesthetics (IV, topical, intracuff lidocaine)
Opioids

92
Q

Extubation of a difficult airway

A

Over a flexible FOB
Followed by placement of LMA
Use of an AEC
Leave ETT is place until extubation criteria are met

93
Q

Complications of residual neuromuscular blockade

A

Upper airway obstruction from pharyngeal muscle
Hypoxemia
Increased risk of aspiration
Decreased ventilatory response to hypoxia
Unpleasant muscle weakness
Delay in tracheal extubation

94
Q

Laryngospasm is caused by

A

Tensing of cords by cricothyroid muscles (stimulated by SLN nerve)
Adduction of cords by thyroarytenoid and lateral cricoarytenoid muscles (RLN)

95
Q

Complications of laryngospasm

A

Bradycardia
Pulmonary edema
Pulmonary aspiration
Hypoxemia

96
Q

Laryngospasm is caused by

A

Airway manipulation
Noxious stimuli, blood water mucus, within the pharynx
Stimulation of the larynx during inadequate anesthetic depth

97
Q

Treatment for laryngospasm

A

Remove stimulus (suction space)
100% fio2
Open and clear airway (oral airway)
Jaw thrust - Larson maneuver or pressure on laryngospasm notch
PPV (10-30 cm h20)
Consider deeper anesthesia
Give succ (0.2-2 mg/kg Iv

98
Q

Treatment of laryngotracheobronchitis

A

Humidified o2
Racemic epi
dexamethasone
helium-o2 mixture to facilitate o2 delivery through narrowed airways

99
Q

Risk factors for dental trauma

A

Pre-existing dental pathology
One or more indicators of difficult laryngospasm and intubation

100
Q

Sites most susceptible to mechanical injury

A

Posterior half of vocal cords
Arytenoids
Posterior tracheal wall

101
Q

Development of aspiration pneumonia is dependent on

A

Type of aspirate
Volume of aspirate
Patient’s comorbidities

102
Q

Phases of aspiration pneumonitis

A

1: Direct chemical injury
2: Inflammatory mediator release

103
Q

Ways to decrease the acidity and volume of gastric contents

A

Antacids: sodium citrate 30ml, 20-30 minutes before induction
Histamine blockers: famotidine, ranitidine at least 45-60 min preop
PPI: omeprazole night before surgery
Gastroprokinetic: metoclopramide 20-30 minutes preop

104
Q

Patient related risk factors for aspiration

A

Ascites
Cardiac arrest
Emergency surgery
Full stomach
N/V
Obesity
Scleroderma
Severe hypotension
Trauma or stress

105
Q

Anesthesia related risk factors for aspiration

A

Cricoid pressure
Difficult airway management
Inadequate depth of anesthesia
Opioids

106
Q

GI related risk for anesthesia

A

Decreased esoph sphincter tone
Diabetic gastroparesis
GERD
GI obstruction
Hiatal hernia
Increased gastric pressure
Peptic ulcer disease

107
Q

Neurologic related risk for anesthesia

A

Decreased airway reflexes
Decreases LOC
Head injury
Seizures

108
Q

Presentation of endobronchial intubation

A

Increased peak inspiratory pressures
Asymmetrical chest expansion
Unilateral breath sounds
Hypoxemia

109
Q

Endotracheal tube complications

A

DOPE
Displacement
Obstruction
Pneumothorax
Equipment failure

Basic Principles of Anesthesia (3 decks)

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