Apex- Airway Management Flashcards
What does the mallampati exam evaluate?
The size of the oropharyngeal space
- The more space the tongue occupies, the less space there is to work
What airway exam assesses how easy or difficult it will be to align the oral, pharyngeal, and laryngeal axes?
Inter-Intercisor gap
(Normal = 2-3 fingerbreaths ~4cms)
*long incisors reduce the gap
Mallampati score > ____ is associated with a more difficult intubation
3-4; but by itself is a poor predictor- got to look at other stuff too
What is visibile with Mallampati
1:
2:
3:
4:
1: Pillars, Uvula, Soft palate, Hard palate
2: Uvula, Soft and Hard palates
3: Soft and Hard palates
4: Hard palate
PUSH!
Identify oropharynx structures
You know the hard and soft palates and uvula
- The empty space is fauces
- the tonsilar pillar you automatically think of is the posterior one
- and the most forward structure = anterior tonsilar pillar
What is this patient’s mandibular protrusion test classification? (enter a number)
3
What does the thyromental distance help estimate the size of?
The submandibular space
AKA: where you will need to displace the tongue in order to get a view of the glottic opening
A Thyromental distance < ___cm or > ___cm correlates with an increased risk of difficult intubation
<6cm
>9cm
The ability to place the pt in the sniffing position is highly dependent on the mobility of what?
The alanto-occipital joint
3 main conditions that can impair atlanto-occipital joint mobility, making it difficult to get the patient into a sniffing position
(5 other ones that may affect it)
- Arthritic disease
- Trauma
- Downs Syndrome
Normal Atlanto-Occipital Joint extension = ____ degrees
DL will be difficult if < ____degrees
normal = 35 degrees
difficult = 23 degrees
-okay so 23 bronchial generation splits and 23 degrees difficult intubation
Normal AO flexion and extension
90-165 degrees
3-3-2 rule includes what
inter-incisor gap >3FB
TMD >3FB
Thyohyoid > 2FB
Only the epiglottis can be visualized during DL. What’s the patient’s cormack and lehane score?
3
Cormack and Lehane score 2A vs 2B
2A = better > can see posterior region of the glottic opening
2B = worse > can only see corniculates and the posterior vocal cords but cant see glottic opening
What can’t you see with a grade 2 view?
Anterior commisure
Can you see any part of the larynx with a Grade 4 view? What can you see?
No - soft palate only
What are the BEST predictors of difficult mask ventilation (select 3)
- Mallampati 3
- Old age
- Edentulous
- Small mouth opening
- High, arched palate
- Presence of a Beard
Beard, old age, edentulous
Mnumonic for predictors of diffuclt mask ventilation
BONES
- Beard
- Obese (BMI > 26)
- No teeth
- Elderly (>55)
- Snoring
5 things you should ask yourself before providing airway management:
- Can I mask ventilate (BONES)
- Can I intubate (LEMON)
- Can I place an SGA (RODS)
- Can I place a surgical airway (SHORT)
- How fast must I secure the airway (2-4-6-8)
Most current recommendations for preop fasting guidelines
2: clear liquids
4: breast milk
6: regular milk, infant formula, solid food
8: fried or fatty foods
How can clear liquids 2 hours before surgery be benificial?
It actually has been shown to reduce gastric volume and increase gastric pH
(decreases risk for mendelson syndrome [gastric pH < 2.5, volume >25ml (0.4ml/kg)]
Risks for difficult SGA placement + mneumonic
Cricoid pressure:
The esophagus is compressed by applying pressure to the cricoid ring agisnt which vertebra?
C6
C5 = adult glottis
C6 = cricoid
C7 = Vertebral prominens
Cricoid pressure is applied (before/after) the patient loses consciouness and maintained until when?
before they lose consciousness and maintained until intubation is confirmed
20newtons>40
Cricoid pressure prior to LOC:
Cricoid pressure after LOC:
before LOC: 20 newtons ~ 2kg
after LOC: 40 newtons ~ 4kg
What congenital conditions are associated with C-Spine anomalies (select 2):
- Treacher Collins
- Klippel-Fiel
- Goldenhar
- Pierre Robin
Goldenhar
Klippel-Feil
+Trisomy 21
3 key causes of angioedema
- Anaphylaxis
- ACE inhibitors
3. C1 esterase deficiency
How would you treat angioedema caused by anaphylaxis vs ACE inhibitors or C1 esterase deficiency
Anaphylaxis:
- Epi
- Antihistamines
- Steroids
ACE inhibitors or C1 esterase deficiency:
- icatibant (bradykinin receptor antagonist)
- ecallantide (plasma kallidrein inhibitor - stops the conversion of kininogen to bradykinin)
- FFP (contains enzymes that metabolize bradykinin)
- C1 esterase conentrate
What is ludwig’s angina?
What is your most significant concern with this?
A bacterial infection characterized by a rapidly progressing cellulitis in the floor of the mouth
-concen for posterior displacement of the tongue which can result in complete, supraglottic airway obstruction
(also, inflammation and edema can compress the submandibular spaces)
Best way to secure the airway in someone with Ludwig’s angina
AWAKE NASAL INTUBATION
Or AWAKE TRACH
Angioedema is the result of increased ___________ that can lead to swellign of the face, tongue, and airway.
increased vascular permeability
What is Icatibant and what is it used for?
It is a bradykinin receptor antagonist
-it is used to treat angioedema (increased bradykinins and were blocking the receptor they bind to)
What is Ecallantine and what is it used for?
it is a plasma kallidrein inhibitor
- stops the converstion of kininogen to bradykinin*
- used for angioedmea (bradykinin excess)
When someone asks you why would you give FFP to an angioedema patient what would you say?
Bc it contains enzymes that break down bradykinins
What is the enzyme people are deficient in that can lead to angioedema?
C1 esterase
Retrograde intrubation is contraindicated in patietns with an infection where?
Above the level of the trachea
(so no retrogrades for ludwigs angina)
2 congential conditions that have a large tongue
BT - Big Tongue
Beckwicks syndrome
Trisomy 21
T/F - Micrognathia and mandibular hypoplasia can be used interchangably
True
What is glossoptosis
a tongue that falls back and downward
(Pierre robin)
What is choanal atresia and what congential condition is associated with it?
a nasal airway blocked by tissue (choanal atresia)
Treacher collins
What is congential fusion of the cervical vertebrae that leads to neck rigidity called?
Klippel-Feil
Optimal positioning for the obese patient is achieved when what 2 landmarks are in alignment?
- Sternum
- External auditory meatus
When you go into steep trendelenburg, are you more at risk for endobronchial intubation or extubation?
endobronchial intubation bc the abdominal contents shift up towards the chest, reducing thoracic volume
Which nerve is being compressed by this excessive traction at the angle of the mandible?
What 3 symptoms may this pt present with?
- stretching of the facial nerve (mandibular i think)
- saggy face on that side
- drooling
- unable to chew
What facial nerve is being compressed here?
How would this patient present?
buccal branch of the facial nerve
-difficulty openign and closing lips (impaired function of the orbiculares oris)
An ETT extender laying on the patient’s face can compress what nerve?
-pt presentation? (3)
supraorbital nerve
-eye pain, forehead numbness, photophobia
What 3 axes are aligned in the sniffing position?
Oral
Pharyngeal
Laryngeal
What axes are aligned when the head is lying flat on the bed and extended?
Pharyngeal
Laryngeal
Contraindications to the use of a nasopharyngeal airway include: (select 2):
- Dental trauma
- coagulopathy
- Pierre Robin syndrome
- Le Fort 2 Fracture
Coagulopathy and Le Fort 2 fracture
Which 2 types of fractures can disrupt the cribiform plate, creating a direct line of communication between the nasal and cranial cavities?
What are s/s of this? (3)
-Le Fort 2 and 3 fractures
S/S: raccoon eyes, periorbital edema, and/or CSF leak in the nose or ears
How to size an OPA vs NPA?
OPA: corner of the mouth to the earlobe or angle of the mandible
NPA: nare to the earlobe or angle of the mandible
What is this structure and what does it do?
Cribiform plate
-Seperates the nasal cavity from the anterior cranial fossa.
Idenify each type of oral airway
Top Left:
- Williams (Blind orotracheal intubation or fiberoptic)
Top Right:
- Ovassapian (Fiberoptic intubation)
Bottom Left:
- Guedel (DH)
Bottom Right:
- Berman (LGH)
3 types of fractures that can injure the cribioform plate
LeFort 2, 3 & Basilar skull fracture
Tracheal cuff pressure should be less than what
25cm H20
What’s the BURP manuver and when would you use it?
Backward, Upward and Rightward pressure on the thyroid cartilage
-if glottic visualization is difficult during DL
With an ETT, tracheal ischemia can occur if the cuff pressure exceeds what
tracheal mucosal perfusion pressure
(keep <25cm H20)
Purpose of the Murphy eye
to provide an alternate passage for air movement in the case that the tip of the ETT gets occluded
Sizing a pediatric endotracheal tube:
-Uncuffed:
-Cuffed:
-Depth Placement:
-Uncuffed: (age/4) + 4
-Cuffed: (age/4) + 3.5
-Depth Placement: internal diameter x 3
What 2 things does cuff inflation allow for of an ett?
- PPV & protection from aspiration of gastric contents
Is an LMA-Fastrach ETT a low-volume, high pressure cuff or a high volume, low pressure cuff?
low volume, high pressure
What findings are MOST strongly associated with difficult video-assisted laryngoscopy (select 2):
- history of neck radiation
- mallampati 4
- mandibular protrusion score of 3
- obesity
- history of neck radiation
- mandibular protrusion score of 3
Predictors of difficult VAL (5)
- neck pathology (radiation, tumor, surgical scar)
- short TMD
- class 3 upper lip bite test
- limited cervical motion
- thick neck
*if multiple factors present, then consider awake fiberoptic
Match the LMA region with the anatomical border it touches: proximal end, distal end, sides
- pyriform sinuses
- upper esophageal sphincter (cricopharyngeus muscle)
- base of the tongue
- Proximal end: base of the tongue
- Distal end: upper esophageal sphincter
- Sides: pyriform sinuses
Max PPV through an LMA
20cm H20
Maximum LMA cuff pressure
60cm H20 (compared t o 25 for ETT)
target = 40-60cm H20
What 3 nerves are at risk from overinflation from an LMA cuff?
- CN 5, V2- lingual
- CN 12- hypoglossal
- RLN’s (CN X)
Suppose the LMA cuff pressure is already >60cm H20 and you cant get a good seal; list 3 differental diagnoses
- improperly placed
- pt is inadequately anesthetized
- partial or complete laryngospasm
KG, inflation, and largest ETT that fits an LMAs
For Kg; try to remember: 5 increments x 2 then double
- <5 (5)
- 5-10 (5)
- 10-20 (10)
- 20-30 (10)
- 30-50 (20)
- 50-70 (20)
- 70-100 (30 for the big boy)
For cuff inflation:
- of your normal sized LMAs just think
3(0) - 10 = 20mls
4(0) - 10 = 30mls
5(0) - 10 = 40mls
For 1-2 i think your just gonna have to memorize 4, 7, 10, 14
- you can think 7 + 7 = 14 for the halfs
- if only 1 was 5mls then we could do 5+5 = 10
For largest ETT that fits:
- start at 3.5 and continue halfing up until the jump from 2.5-3
3 & 4 = 6
5 = 7
Match each LMA with its unique feature:
LMA flexible:
LMA ProSeal:
LMA Fastrach:
-gastric drain, deisgned for intubation, wire-reinforced airway tube
LMA flexible: wire-reinofrced airway tube
LMA ProSeal: gastric drain
LMA Fastrach: designed for intubation
Max PIP for LMA ProSeal vs Classic
Proseal <30 cm H20
Classic < 20cm H20
What is the disposible verson of the LMA ProSeal called?
LMA supreme
LMAs should not be used in what 4 situations
- Risk of aspiration (full stomach, HH, SBO)
- Airway obstruction at the level of or below the glottis
- Poor lung compliance (need higher pressures to ventilate)
- High airway resistance (need higher pressures to ventilate)
T/F- less anesthesia is needed to tolerate an LMA compared to a ETT
True
T/F: you should remove the LMA at the first sign of rejection during emergence
True- don’t wait until the patient is fully awake and able to follow commands- increases risk of gagging/apsiration
T/F- undersizing an LMA can result in increased risk of aspiration
True!
- tell that to like everyone who uses 4’s for everybody or 3’s just bc they a female
- sizing too small not only can increase risk of aspiration but it can also increase risk of nerve injury
What should you do if you see gastric contents inside the airway tube of the LMA (6)
- LEAVE IT IN PLACE
* there might be gastric contents behind the LMA cuff and removing it can worsen it - T-BURG
- Deepen anesthetic if needed; you want to be in control of this situation, if they are awake with +reflexes, they will gag and likely increase regurgitant volume
- If you think well they have + reflexes so they can protect their airway if I pull it out, NO - pulling it out may fling any gastric contents behind the cuff into the airway
- Give 100% FIO2 via self inflating bag
* if gastric contents are in the tube, postive pressure from you will push it into the lungs genius - Use a low FGF and low Vt
- Place a flexible suction cath to suction through the LMA
- Can use a fiberoptic to evaluate the presence of gastric contents in the trachea; if + - consider intubation and aspiration protocols
T/F: LMA is contraindicated in pts with GERD
True
HA!
Sort the order from least stimulating to most
DL, Combitube, LMA, fiberoptic
Least stimulating = LMA
Fiberoptic
DL
Combitube = most stimulating (just think, an inexpereinced provider just shoved this thing down my gullet)
Select 3 contraindications to this device:
- Full stomach
- Zenker’s Diverticulum
- Obesity
- Intact gag reflex
- Klippel Feil
- Prolonged Use
What other 2 contraindications
- Intact Gag
- Prolonged use
- Zenker’s diverticulum
<4’ tall
ingestion of caustic substances
What is a supraglottic, double lumen device that is placed blindy in the hypopharynx?
Combitube
What determines the size of a combitube?
Pt.height
T/F: A combitube provides a secure airway and aspiration protection
True
Why do they have to exhange out a combitube?
Risk of ischemia from the oropharyngeal balloon
What is the difference from a king tube vs combitube?
king tube only has a single lumen for ventilation and a single inflation port
+ kid sizes
How much air should be put in the oropharyngeal balloon vs distal cuff of a comitube and which one gets inflated first?
Orophayngeal balloon first
- Size 37= 40-85mls
- Size 41 = 40-100mls + option for additional 50mls
Distal cuff second:
-Both sizes = 5 - 12ml of air
T/F: thre are no absolute contraindications to fiberoptic bronchosocpy
True
relative contraindications = hypoxia, bleeding, lack of cooperation
Gold standard for managing the difficult airway
Fiberoptic bronchosocpy in the awake, spontaneously ventilating patient
Identify the statements that BEST describe the device in the image (select 2)
- the oral, pharyngeal, and laryngeal axes must align
- it lacks disposable components
- it requires a minimum out opening of 7mm
- it is useful in pt with Pierre Robin syndrome
What is this crazy looking thing anyway?
- it requires a minimum out opening of 7mm
- it is useful in pt with Pierre Robin syndrome
The Bullard Laryngoscope
Two other names for the gum elastic bougie
- eschmann introducer
- intubating stylet
When using the bougie, what should you do if you don’t feel the tracheal rings but think you are in the trachea?
Keep advancing it to assess for the “hold up” sign, AKA you are meeting resistance at the carina
-if no hold up sign, your in the esophagus
T/F - you should remove the laryngoscope after placing the ETT
- false, if you remove it before placing the ETT, the pharyngeal soft tissue will displace the EI and ETT posteriorly
How for should the eschmann introducer be advanced into the trachea?
23-25cm
Indications for the lighted stylet include (Select 3):
- super morbid obesity
- severe oropharyngeal bleeding
- mandibular hypoplasia
- epiglottitis
- cant intubate/ventilate scenario
- microstomia
- microstomia
- mandibular hypoplasia
- severe oropharyngeal bleeding
who shouldn’t you use a lightwand in? (4)
- short/thick neck
- emergency- cant intubate/cant ventilate
- tumor, foreign body obstruction, epiglottitis
- traumatic laryngeal injury
T/F- retrograde intubation is an viable option for the cant intubate/cant ventilate situation
false- takes too long
2 scenarios where retrograde intubation would be appropriate
- unstable C-spine
- upper airway bleeding
Contraindications to retrograde intubation (4)
tracheal stenosis
poor anatomy
coagulopathy
infection
Which nerve is at risk with retrograde intubation?
Trigeminal
T/F - pneumomediastinum and pneumothroax are potential complications with retrograde intubation
true
A cricothyroidotomy cannot be done in a patient younger than ___.
six years old
T/F- upper airway obstruction is a contraindication for transtracheal jet ventilation
True
-bc transtracheal jet fentilation requires high-pressure o2 (50psi) during inspiration and expiration is passive, so an upper airway obstruction can prevent exhalation (risk of barotrauma)
T/F- there are NO absolute contraindications for tracheostomy
True
3 ways to create a surgical airway
- percutaneous cricothyroidotomy with transtracheal jet ventilation (emergent)
- surgical cricothyroidotomy (emergent)
- tracheostomy (controlled)
3 thoughts other than “fuck” when you encounter a can’t intubate, can’t ventilate situation
- call for help
- LMA
- wake up the patient (but need to try and secure airway in the meantime until the drugs wear off)
if an LMA does not solve your “cant intubate/can’t ventilate” situation, what should be considered next?
emergency airway “cric”
What is the first step in the emergency pathway of the ASA difficult airway algorithm?
Call for help!
2 risks associated with deep extubation
- airway obstruction
- aspiration
What is the BEST technique to manage the patient at high risk of failed extubation?
A. Eschmann introducer
B. Airway exchange catheter
C. Nasal airway
D. Shikani stylet
B. Airway exchange catheter
(different than a bougie, which is apparently only used during intubation…still not sure why you couldnt use it as an airway exchange catheter)
difference between bougie and airway exchange catheter
airway exchange catheter is hollow and can:
- measure etco2
- provide a means for jet ventilation
- insufflate o2
…so I guess if your just exchanging tubes and its NOT a difficutl airway, you could just use a bougie, but if it was a difficult airway, use the exchange catheter
How long can an airway exchange catheter remain in place?
up to 72 hours
if you need to replace the ETT with the patient with an airway exchange cath in place, how should you proceed?
you have to DL to displace the supraglottic tissue
how should you proceed if your ett is getting hung up on the arytenoids?
roate 90 degees counter clockwise before advancing
T/F- you can suction through an airway exchange catheter
false
What is the STRONGEST contraindication to an LMA?:
A. Tracheomalacia
B. Prone position
C. Laproscopic Surgery
D. Pt is a professional singer
Tracheomalacia
*risk for tracheal collapse and LMA will not prevent this
Which two agents are the best drugs to provide sedation during a fiberoptic awake intubation?
- Diazepam
- Remifentanil
- Dexmedetomidine
- Hydromorphone
-Remi & Dex
*drugs with SHORT DOAs
-ketamine and midaz are still good options but remi is better than midaz in this question bc it is shorter acting
What is the STRONGEST contraindication to awake fiberoptic intubation?
A. Perilaryngeal mass
B. Ccoagulopathy
C. Lack of provider skill
D. Blood in the airway
C. Lack of provider skill!
The GlideScope has what degree of anterior bend?
- 60
- 100
- 40
- 80
-60 degrees
