Anaesthesiology - Airway management Flashcards

1
Q

Modalities of airway management

Indications of airway management

A

Indications for airway management:
□ Need for airway protection, eg. upper airway obstruction, risk of aspiration, ↓consciousness
□ Need for ventilation, eg. anaesthesia with NMB, IPPV indicated (for eg. resp failure)
□ Need for oxygenation, eg. significant unrelieved respiratory distress, blood gas abnormalities

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2
Q

Outline PE for airway exam

Features of difficult airway

A

General exam:
- Anxious, sitting upright or in tripod position
- Diaphoresis
- Cyanosis
- Altered mental status
- Obesity
- Obvious head and neck pathology (e.g. massive goiter)
- Medical equipment (e.g. halo traction, neck collar)

Oro-facial exam:
- Loose teeth/ no teeth, Dentures, SIngle incisors, overbite/ buck teeth
- Beard

Respiratory exam:
- Respiratory distress: Tachypnea, SoB, Use of accessory muscles and in-sucking of ICS
- Hoarseness/ voice change
- Snoring, Stridor, Wheezes, Crackles
- Mediastinal deviation with increased resonance (tension pneumothroax)
- No chest expansion with inspiration
- Silent chest
- No perceivable airflow

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3
Q

List predictive tests for difficult laryngoscopy

A
  • Mallampati Score
  • Interincisor Distance
  • Thyromental distance
  • Cervical spine movement
  • Sternomental distance
  • Jaw protrusion

Combined test: Mallampati and Thyromental distance are more predictive than individual tests

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4
Q

Outline Mallampati Score for ease of laryngoscopy

S

A

Mallampati score: pillars visible (I), fauces visible (II), base of uvula visible (III), only hard palate visible (IV)

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5
Q

Outline Thyromental distance for ease of laryngoscopy

A
  • Distance >6.5cm is rarely associated with difficulty
  • Distance 6-6.5cm may be associated with difficult
    laryngoscopy but intubation is usually possible
  • Distance < 6 associated with difficult direct laryngoscopes
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6
Q

Define the interincisor gap and sternomental distance for ease of laryngoscopy

A

Interincisor gap
* The distance between the incisors with mouth fully open
* It is affected by TMJ and upper C spine mobility
* <3cm = intubation more difficult
* <2.5cm = SAD insertion more difficult

Sternomental distance
Sternal notch to tip of mandible
* Less than 12.5cm = difficult direct laryngoscopy

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7
Q

Define the Cervical neck movement for ease of laryngoscopy

A
  • Extension of upper cervical spine
  • Limited (less than 90 degrees)
    = Difficult direct laryngoscopy
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8
Q

List predictors of difficult mask ventilation

A
  • Obese (BMI over 26kg/m2)
  • Beard
  • Absence of teeth
  • Facial abnormalities/ craniofacial syndromes
  • Receding chin
  • Mallampati 3-4
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9
Q

List predictors of difficult supraglottic airway device

A
  • May be used as rescue plan
  • Mouth opening < 2.5cm
  • Intraoral and pharyngeal masses
  • Obesity
  • Poor dentition
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10
Q

First-line investigations for difficult airway

A
  • Nasoendoscopy
  • CT or MRI scan
  • Ultrasound
  • Plain radiographs: CXR, facial X-rays, C-spine X-ray

Monitor: SpO2, BP/P, temperature

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11
Q

List all basic airway management options

A

Simple airway maneuvers:
- Head-tilt chin-lift: when C-spine injury is NOT a concern ± combination w/ manual in-line stabilization to stabilize C-spine when jaw thrust fail to open airway
- Jaw thrust: when C-spine injury IS a concern (eg. trauma

Simple airway adjuncts:
- Oropharyngeal airway
- Nasopharyngeal airway

Basic ventilation techniques:
- Mouth-to-mouth ventilation (only if no equipment, risk of infection and poor O2 enrichment)
- Mouth-to-mask ventilation (one way valve decrease infection risk)
- Bag-valve-mask (BVM) ventilation with Ambu-Bag

Removal of underlying causes:
- Foreign body aspiration: bough, finger sweep, Heimlich maneuvers, Chest thrust, back blows
- Suction for secretions

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12
Q

Signs of successful ventilation

A
  • Chest expansion
  • Exhaled tidal volumes
  • Presence of breath sounds
  • Listen and feel for air leaks
  • Pulse oximetry reading
  • Capnography most accurate
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13
Q

Reasons for unsuccessful ventilation

Solutions for unsuccessful ventilation

A

Causes of unsuccessful ventilation:
- Poor mask seal
- Airway obstruction: partial or complete
- facial hair
- dentures, edentulous, sunken cheek
- obese patients

Solutions:
* 2 person, 2 hand technique
* Ask assistant to support soft tissues of cheek
* Optimize head position and triple maneuver
* Ensure no leak/occlusion in equipment/circuit
* Facial hair: aqueous gel, occlusive dressing
* Considering leaving dentures in place
* Use of oropharyngeal/nasopharyngeal airway
* Supraglottic airway device

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14
Q

Complications of bag mask ventilation

A
  • Aspiration
  • Lip and dental trauma
  • Ocular pressure injury
  • Facial injury
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15
Q

Nasopharyngeal airway

  • Indications
  • Contraindications
  • Selection
  • Insertion
A

Indications: when OPA is difficult/ contraindicated
* Can be rapidly and easily inserted blindly
* presence of gag reflex
* oral trauma
* teeth clenched

Contraindications:
Absolute
- base of skull fracture
- nasal, midface fracture
Relative
- coagulopathy
- large nasal polyps
- recent nasal surgery
- suspected epiglottitis

Selection: tip of nose to angle of mandible
Insertion: coated w/ lubricant/anaesthetic jelly beforehand → inserted along floor of naris into posterior pharynx behind tongue → rotate slightly if resistance is encountered

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16
Q

Oropharyngeal airway

  • Indications
  • Contraindication
  • Selection
  • Insertion
A

Indications:
* For use in patients without gag reflex
* Easy to insert
* Can be rapidly inserted
* Serves as a bite block
* Facilitates suction of the pharynx

Contraindications:
* Awake with gag reflex
* Oral trauma

Selection: from incisor to angle of mandible
Insertion: either insert w/ airway curving upward and turn 180o inside posterior pharynx OR insert w/ tongue depressor

17
Q

List advanced airway management options

A

Supraglottic approach
o Supraglottic airway devices
o Endotracheal intubation

Infraglottic approach
o Cricothyroidotomy (needle, surgical)
o Tracheostomy

17
Q

Endotracheal intubation
- Indications
- Positioning
- Correct insertion

A

Indication:
- Controlled ventilation and oxygenation
- Airway protection
- High pressure ventilation
- Prolonged postoperative intubation or mechanical ventilation

Position:
- “Sniffing” position: Flexion of the neck, extension of head, head on 7 - 9 cm pillow/firm surface, horizontal alignment of external auditory meatus and sternal notch

Insertion:
→ Tip of ETT at midpoint of trachea ≥2cm above carina → Proximal end of cuff ≥2cm below vocal cord
→ Marking at mouth 20-22cm (F) or 22-24cm (M)

18
Q

Preparation for endotracheal intubation

A

Preparation:
* Correctly sized endotracheal tube: Generally size 8 for male adults, 7 for female
* Laryngoscope
* Oxygen source for pre-oxygenation
* Suctioning equipment
* Tapes to secure ETT, syringe to inflate cuff
* Equipment for ventilation
* Skilled assistant
* Other airway equipment to assist intubation

Assess potential difficulties (LEMON)
- 3-2-1 rule: thyromental distance <3 finger-breadths, mouth opening <2 finger-breadths, anterior jaw subluxation <1 finger-breadth
- Mallampati score

Pre-oxygenate w/ 100% O2 for ~3-5min
- Increase O2 reserve of body to increase duration of apnea without desaturation (6-7 mins)

Sedation: induction followed by paralysis
→ Induction: IV anaesthetic, eg. propofol
→ Paralysis: IV fast-acting NMB, eg. suxamethonium

19
Q

Grade of laryngeal view via direct laryngoscopy

A
20
Q

Signs to confirm ETT position and correct intubation

A

Direct visualization: ETT between the vocal cords or fibreoptic visualization of the tracheal rings and carina

Sustained detection of normal etCO2 on waveform capnograph (Most reliable)

Clinical signs:
* symmetrical chest rise and fall with ventilation
* breath sounds in the axillary chest wall
* absence of breath sounds over stomach
* condensation in the ETT

21
Q

Complication of ETT

A

Complications: can occur during intubation, while tube is in place, and after
extubation

  • Malpositioning: esophageal intubation, bronchial intubation, laryngeal trauma
  • Physiological responses: Hypertension, tachycardia, laryngo-/bronchospasm, Intracranial/ intraocular hypertension, Negative pressure pulmonary edema
  • Airway trauma: Dental damage/ dislodgement, sore throat, lacerations, dislocated mandible, laryngeal/tracheal edema and stenosis, vocal cord paralysis (hoarseness/ aspiration)
  • Tracheal tube malfunction: Cuff perforation/ damage, obstruction by kinking or thick secretions, fire (polyvinyl chloride tube ignition)
22
Q

Supraglottic airway device

  • Uses
  • Insertion
  • Predictors of difficult SAD insertion
  • Complications
A

Uses:
* For airway rescue after failed intubation and mask ventilation
* Alternative to ETT
* As a conduit for tracheal intubation eg. intubating LMA, use of flexible scope through LMA to guide ETT

Insertion:
→ Adequate depth of anaesthesia to avoid coughing, gagging etc.
→ Lubricate LMA cuff
→ Hold LMA with glottis opening facing forward
→ press cuff upward against hard palate then go backward and downward along palate until resistance is encountered
→ Inflate cuff to ~40 cmH2O

Difficult SGA insertion:
* Small mouth opening ˂ 2.5cm
* Intraoral/pharyngeal masses
* Poor dentition
* Obese

Complications:
- Dry mouth/ sore throat
- Laryngeal trauma
- Dysphonia
- Hypoglossal/ lingual nerve damage
- Pulmonary aspiration
- Gastric insufflation
- Laryngospasm

23
Q

Front of neck airway access

Indications
Techniques
Limitations
Complications

A

Indications:
* Emergency: Can’t intubate, can’t ventilate
* Acute upper airway obstructions
* severe anatomical deformity

Techniques:
* Needle cricothyroidotomy
* Surgical cricothyroidotomy

Limitations:
- Poor CO2 elimination
- limited to ~30min use, need surgical tracheostomy afterwards

Complications:
* Prolonged execution time
* Aspiration, subcutaneous emphysema
* False placement: oesophagus, pneumothorax
* Catheter issues: Tube obstruction, infection, hemorrhage
* Barotrauma
* Late: Dysphonia, subglottic stenosis

24
Q

Closed face mask

  • Uses
A
  • Bag-mask ventilation
  • Pre-oxygenation prior to general anaesthetic induction
  • Non-invasive ventilation for respiratory failure
  • Inhalational induction of general anaesthesia
  • Maintenance of general anaesthesia
25
Q

Bag-valve-mask ventilation with Ambu bag
- Uses
- Ventilation
- How to apply

A

Uses:
* High flow oxygen and high FiO2
* Controlled positive inspiratory pressure
* Provide positive end expiratory pressure
* Augmentation of spontaneous ventilation

Ventilation rate: 8-10/min if cardiac arrest and 10-12/min if respiratory arrest
O2 enrichment W/o reservoir bag: 5-6L/min O2 can achieve FIO2 ~50%
O2 enrichment W/ reservoir bag: 5-10L/min O2 can achieve FIO2 ~80%

Useage: Adequate mask seal achieved by E-C grip; Ensure patent airway by use of airway maneouvers or airway adjuncts

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32
Q

Difference between RSI and routine induction for ETT

A

→ RSI: NMB immediately after induction → apply cricoid pressure3 **but do NOT do BVM **→ ETT insertion AFTER onset of NMB (~30s)

→ Routine: IV anaesthetic induction → BVM to establish ability to ventilate → IV NMB given for paralysis → BVM again to establish ability to ventilate → ETT insertion (if failed, can do BVM)

33
Q

Outline factors that influence the choice of advanced airway

A

Considerations for ETT insertion:
□ If emergency (arrested or agonal state) OR unconscious, do direct intubation w/o giving drugs

□ If airway NOT predicted to be difficult, do intubation w/ rapid sequence induction (RSI)

□ If difficult airway predicted, choose a method that can maintain adequate oxygenation
→ RSI if rapid deterioration of condition
→ Attempt BVM or LMA if these are predicted to be more successful

□ If failed intubation
→ Consider alternative (eg. BVM, LMA, laryngoscopy-guided intubation) if still can oxygenate
→ One attempt at LMA and BVM ventilation if cannot oxygenate
→ NEEDLE CRICOTHYROTOMY if all else fail