Airway Part II Flashcards
What are available airways to the nurse anesthetist?
(ISRAEL-FRCT)
- Intubating Stylets
- Specialized Stylets
- Rigid Fiberoptic Laryngoscopes
- Airway Exchange Catheters
- Esophageal Airways
- Laryngeal Mask Airways
- Flexible Fiberoptic Laryngoscopes
- Retrograde Intubation
- Cricothyrotomy Devices
- Transtracheal Jet Ventilation
Techniques For Difficult Intubation
(FLAIL-BVS)
- Fiberoptic Intubation
- Laryngoscope blades of assorted design and size
- Awake intubation
- Intubating stylet or tube changer
- Light Wand
- Blind intubation (Oral or nasal)
- Videolaryngoscope
- Supraglottic airway as an intubating conduit
Techniques For Difficult Ventilation
(I-RIOTS)
- Intratracheal Jet stylet
- Rigid ventilating bronchoscope
- Invasive airway access
- Oral and nasopharyngeal airways
- Two-person mask ventilation
- Supraglottic airway
Ideal positioning for intubation
- Head resting on pad, flexion of the neck
- Neck extension
- Oral axis, laryngeal axis, and pharyngeal axis are aligned
Whare some consideration with Rapid Sequence Induction (RSI)?
- Used for aspiration prophylaxis, time permitting
- Awake extubation should be done on emergence
- It is controversial in children
Sequence of events with Rapid Sequence Induction?
- Airways equipment- SUCTION
- Optimize intubating conditions
- De-nitrogenate (Pre-oxygenate)
- IV induction agent + Succinylcholine IV Push (DO NOT VENTILATE WHEN WAITING FOR DRUG EFFECT)
- Cricoid pressure, 40 Newtons for adult, 4 Newtons for children
- NO BAG VENTILATION
- Intubate
What is the next option after a patient cannot be ventilated and cannot be intubated
Surgical Airway!
The 3 types of surgical airways?
- Cricothyrotomy
- Retrograde Intubation
- Tracheotomy
What history questions would you ask pertaining to airway ?
Have you had hospitalizations requiring intubation?
Did you have a difficult intubation, is there a medic alert record?
Do you have sleep apnea?
Do you have oral pharyngeal esophageal, (ie cancer, surgeries) disease?
Have you ever had trauma, burns, chemical radiation?
Why do we care about esophageal disease or esophageal varies?
Will update when I find the answer, but I think partly b/c of excessive bleeding
Why do we obtain history and review previous history pertaining to airway
Detects medical, surgical, and anesthetic factors that may indicate the presence of a difficult airway
How do you complete an airway assessment?
Examine multiple airway features
What other additional evaluation tools can be used to obtain information regarding airway examination?
Guided by the history and physical examination you may examine diagnostic exams.
CT scans, MRI, X-rays
What are ASA recommendations for evaluation of the Airway?
Length of upper incisors
Relationship of maxillary and mandibular incisors during normal closure, during voluntary protrusion of mandible
Inter-incisor distance, visibility of uvula, shape of palate, compliance of mandibular space, thyromental distance, length of neck, length of neck, thickness of neck, range of motion of head and neck.
What are categories of difficult airway?
Known or suspected -
history of difficult or failed intubation, conditions associated with difficult airway.
Potential difficult airway -
Limited neck extension, limited mouth opening, receding mandible Mallampati Class III or IV, short thyromental distance
Unexpected difficult airway - Unknown mass in the airway Missed evidence of difficult airway Poor preoperative evaluation Ignoring presence of evidence
What are conditions that predispose to a difficult airway?
FIT PETS InC
Foreign Body - Blood, emesis, tissue, foreign matter.
Infections - Epiglottitis, abscesses, croup, bronchitis, pneumonia
Trauma - Maxillofacial trauma, cervical spine injury, laryngeal injury.
Physiologic Conditions - Pregnancy, morbid obesity, edema.
Endocrine - Morbid obesity, diabetes mellitus, acromegaly.
Tumor - Upper and lower airway tumors.
Inflammatory Conditions - Ankylosing spondylitis, rheumatoid arthiritis.
Congenital Conditions - Choanal atresia, tracheomalasia, cleft palate, Pierre Robin, Syndrome, Treacher Collins, Syndromes, Hallerman-Streiff Syndrome
FOUR D’s THAT suggest a difficult airway.
Dentition
Prominent upper incisors, receding chin.
Distortion
Edema, blood, vomitus, tumor, infection.
Disproportion
Short chin-to-larynx distance, bull neck, large tongue, small mouth.
Dysmobility
TMJ and cervical spine
Two options for management of Difficult Ventilation
- Establish an airway with the patient awake:
Sedation may be necessary.
Anesthetize the airway.
- Initiate an inhalation induction of anesthesia with Sevoflurane:
If airway remains patent as anesthesia progresses then an LMA or intubation can be done.
If airway obstruction occurs and not relieved by an oral airway then stop the Sevoflurane.
Establish an airway with the patient awake.
Management of a Difficult Intubation
Failed first intubation:
- reposition the head and neck
- use external laryngeal manipulation
- more muscle relaxant prn
- BVM ventilation PRN
Second intubation attempt:
- use straight laryngoscope blade or specialized blade.
- use neck hyperflexion
- use bougie
- BVM PRN
Third intubation attempt:
1.failed 3rd intubation attempt or inability to BVM ventilate
= failed airway algorithm.
What is the purpose of the ASA Difficult Airway Algorithm
The purpose of the guidelines is to facilitate the management of the difficult airway and reduce the likelihood of adverse outcomes
Difficult Airway adverse outcomes.
Death Brain injury Cardiopulmonary arrest Unnecessary surgical airway Airway trauma Damage to teeth
The Difficult Airway Algorithm 1
Difficult Airway under general anesthesia (+/-paralysis):
If unplanned, call for help EARLY!!
Maintain spontaneous ventilation if possible
If no spontaneous ventilation:can you mask ventilate?
If YES = GOOD
If NOT SO MUCH:
Reposition
Insert oral and/or nasal airways
Jaw thrust (2-handed/2-person technique)
The Difficult Airway Algorithm 2
Cannot Intubate, Can Ventilate:
Consider other intubation choices: LMA as ETT conduit (Air-Q, Fast-track LMA) Glidescope Fiberoptic intubation Blind Nasal Retrograde Wire
Consider providing GA via mask airway
A circumstance where “it is NOT possible for the unassisted anesthesiologist to prevent or reverse signs of inadequate ventilation during positive pressure ventilation”.
Difficult Ventilation
A circumstance in which “the proper insertion of an endotracheal tube using conventional laryngoscopy requires more than 3 attempts, or greater than 10 minutes”.
Difficult Intubation
According to closed claims analysis, the highest percentage of difficult airway claims occurred during this perioperative period.
Upon induction (67%)
According to the closed claims analysis of difficult airway claims during the perioperative period _____% occurred during surgery, _____% occurred during extubation, and ______% occurred during recovery? The period of greatest complication was during induction at _____%.
15% during surgery
12% at extubation
5% during recovery
67% upon induction
The Difficult Airway Algorithm
“Cannot Intubate, CANNOT Ventilate”
- Attempt LMA
- Consider awakening the patient
-Emergency non-invasive airway ventilation
(Combitube, King tube, rigid brochoscope, transtracheal jet ventilation)
-Emergency Surgical Airway
(Percutaneous tracheostomy or cricothyrotomy)
Assessing the Difficult Airway
RODS- Difficult supraglottic device
R: Restricted mouth opening
O: Obstruction in upper airway
D: Disrupted or distorted airway
S: Stiff lungs or c-spine
Assessing the Difficult Airway
SHORT- Difficult cricothyrotomy or surgical airway
S: Surgery/disrupted airway H: Hematoma or infection O: Obese or access problem R: Radiation T: Tumor
ASA Recommendations for Basic Preparation
- Difficult Airway cart
- Inform the patient of the special risk and procedures
- Make sure you have help
- Make sure you adequately preoxygenate your patient
- Actively deliver supplemental oxygen during the management of a difficult airway
- Nasal Canula
- Facemask
- LMA
- Insufflation
- Blow-by
Difficult Airway Cart Contents
- Rigid laryngoscope blades of alternate design and size from those routinely used; this may include a rigid fiberoptic laryngoscope
- Videolaryngoscope
- Tracheal tubes of assorted sizes
- Tracheal tube guides (semirigid stylets, ventilating tube-changer, light wands, and forceps designed to manipulate the distal portion of the tracheal tube)
- Supraglottic airway (LMA or ILMA of assorted sizes)
- Flexible fiberoptic intubation equipment
- Equipment suitable for emergency invasive airway acess
- An exhaled carbon dioxide detecter
Persistent intubation attempts lead to?
Persistent intubation attempts led to outcomes of death and brain damage!
What are the Airway Desktop Essentials?
- Cuffed Endotracheal tubes
(2 available sizes)
Laryngoscope blades & handles
(Make sure working properly, check lightbulb and flashlight) - Face mask of adequate fit, back up AMBU
- Suction
(No suction, No induction) - Machine check and ability to deliver (+) pressure
- Laryngeal mask airways available
- Nasal and oral airways with tongue blade
Difficult airway cart
(Know location and contents)
Assessment of the Airway includes?
- Patients history, ie, TMJ
- Physical examination
- Mallampati
- Atlanto-occipital joint extension
- Thyromental distance
- Inter-incisor distance
- Neck circumference
Airway physical exam initial observation at a distance includes?
- General appearance, stature, anomalies, defects, external fixators, trauma
- Ease of respiration
- Voice quality
- Supplemental O2
Focused Airway physical exam involves?
- Face, jaw, mouth
- Oropharynx, posterior pharynx
- Neck, larynx
- Chest
