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Principles Exam 3 > Awake nasal+ difficult intubation > Flashcards

Awake nasal+ difficult intubation Flashcards

1
Q

What may contribute to difficult extubations?

A

Obese sleep apnea, obstetrical, oral/neck surgeries

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2
Q

Indications for awake blind nasal intubations?

A
  1. questionable airway (obesity- can’t lay down, anatomical difficulty,patient unable to open mouth due to trauma, wired jaw, pain, etc.)
  2. oral and maxillofacial procedures where patient is unable to open his mouth
  3. spontaneously breathing patient in respiratory distress (patients on the wards, ICU, ER, PAR) (MOST COMMON)
  4. cervical fracture
  5. neuro injury
  6. trismus or fractured jaw
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3
Q

Contraindications for awake nasal intubations?

A
  1. nasal fracture
  2. nasal obstruction
  3. coagulopathy or bleeding disorder (Liver dx)
  4. acute infectious process (sinusitis, mastoiditis)
  5. basilar skull fracture
  6. intra-nasal or pharyngeal abscess tumors
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4
Q

Advantages to awake nasal intubations?

A
  1. same as for asleep nasal (more stable tube fixation, less chance of tube kinking, greater comfort in the awake patient, away from the site for oral surgery
  2. better tolerated by patient
  3. less equipment used
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5
Q

Disadvantages to awake nasal intubations?

A
  1. same as for asleep nasal (smaller tube size therefore resistance, additional equipment needed (vasoconstrictor), ↑incidence of bleeding)
  2. may be more difficult to direct NET than under direct visualization
  3. patient cooperation mandatory
  4. very stimulating for patient
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6
Q

Which nostril should be used for nasal intubations?

A

Question patient regarding which nostril they breathe easiest through (if no difference, use right)

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7
Q

Why is right nostril preferable for nasal intubations?

A

right is preferable because the bevel of most tracheal tubes when introduced through the right nare will face the flat nasal septum, reducing damage to the turbinates.

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8
Q

After determining which nostril what should you do next for awake nasal intubations?

A

2 .Explain the procedure to the patient and talk to patient throughout the procedure.

  1. Carefully sedate.
  2. Apply vasoconstrictor to both nares.
  3. Insert a well lubricated NPA into nare.
  4. Position the head in a an amended or “sniffing” position (stand on right side of patient)
  5. Remove NPA and insert well lubricated NET (size 7 or 8) along the floor of the nose into the pharynx where you will feel a loss of resistance.
  6. Proceed slowly and gently. Keep talking to the patient.
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9
Q

What vasoconstrictors are often used for nasal intubations?

A

Nasal spray:Affrin, cocaine

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10
Q

Why do you insert NPA intro nostril?

A

spread local and assess patency

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11
Q

What type of tube is used for awake nasal?

A

Size 7 or 8 Regular nasal tube or Endotrol (good option)

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12
Q

What should you always do prior to inserting any tube into the nose?

A

lube it

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13
Q

What to you assess to help determine if you are in the right spot for an awake nasal intubation?

A

Listen, feel and watch the distal (machine end) of the tube for breath sounds. Continue to advance the NET as long as breath sounds are maximal and tubular in quality.

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14
Q

What should you do if breath sound are diminished or cease through nasal ET tube when doing awake nasal intubation?

A

re-direct NET towards glottis. If an endotrol tube is used, you can direct the tip of the tube anteriorly to facilitate insertion.

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15
Q

What does coughing indicate when trying to do a blind awake nasal intubation?

A

usually indicates correct positioning of the tube; continue to advance the tube through the vocal cords.

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16
Q

If tube does not go into trachea what should you do (blind awake nasal)?

A

Pull back until BS heard maximally again and redirect tube

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17
Q

Once in what should you do (blind awake nasal)

A

secure and document should be at approx 27cm

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18
Q

Causes of epistaxis?

A
  1. too large tube
  2. insufficient lubrication
  3. rough or vigorous instrumentation
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19
Q

Possible non-tracheal postions of tube during awake nasal intubations?

A
  1. in the vallecula
  2. on the anterior commissure
  3. against closed glottis during laryngospasm
  4. esophagus
  5. pyriform sinus
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20
Q

How many intubations is considered to make a person a skilled anesthetist?

A

50

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21
Q

What is the definition of a difficult airway?

A

-difficulty with face mask ventilations
-difficulty with tracheal intubations or both
(any intubation that takes a skilled anesthetist more than three attempts or greater than 10 minutes and or difficult bag mask ventilations)

22
Q

What is the mainstay of the difficult airway algorithm?

A

Awake airway management

23
Q

What are the ratio of failed intubations in the OR, OB, and ER?

A 
OR= 1:2000
OB= 1:300
ER= 1:50-100
24
Q

What should you do during difficult intubations if one way isn’t working?

A
  • examine head position and laryngoscopy technique. (different blade, amended position ramp patient, pressure externally.) Don’t keep doing the same thing
  • if unsuccessful, the patient should be allowed to awaken or an attempt at an awake intubation. If NDMR used, the patient should be ventilated until reversal is possible.
25
Q

When should you use a glidescope or fiber optic during a difficult intubation?

A

attempt before the field is obscured with blood, secretions and edema

26
Q

When is a difficult airway even more emergent?

A
  • much more emergent if the patient can not be manually ventilated by mask nor intubated (if short-acting drugs administered, spontaneous respirations should return before life threatening hypoxia supervenes) -
  • tracheostomy takes longer than it takes for CNS damage to occur
27
Q

What is one of the first things the difficult algorithm tells you to do if you are having trouble with intubation?

A

Get help

28
Q

What is a bimanual laryngoscopy or BURP maneuver?

A

Cricoid pressure that brings airway into line of vision?

BURP maneuver (backward-upward-rightward pressure)
B backward against the cervical vertebrae
U superiorly as possible
R slightly laterally to the right; using exteral pressure over the cricoid cartilage

29
Q

When is it best to use an awake fiberoptic technique?

A

***Non-emergent and non-bloody

30
Q

Indications for awake fiber optic?

A
  • anatomical airway difficulty predicted
  • upper airway mass, swelling
  • mask ventilation difficult or impossible
31
Q

What is the technique for awake fiber optic intubation?

A
  1. when the tip of the scope emerges from the end of the obturator, the epiglottis should be in view (vocal cords may be seen at this time also), once the tip of the fiber optic bronchoscope is positioned well into the trachea, but above the carina, it is used as a guide over which the endotracheal tube is advanced.
  2. verify position of the tube prior to removing the bronchoscope.
  3. Induce anesthesia (IV)
32
Q

What can help with a fiber optic intubation?

A

ovasapian oral airway and maybe a little sedation

33
Q

What may help with a nasal fiber optic intubation?

A

Step stool and superior laryngeal block

34
Q

What is a Leforte fracture and how do you intubate?

A

Skull fracture when skull is dropped? Awake trach is airway of choice

35
Q

How would you intubate an patient with fixed traction of head (spinal cord patient) in sniffing position?

A

Awake nasal if emergent (if time fiber optic)

36
Q

What needle and angle is used for a retrograde emergency intubation?

A

18 gauge needle with bevel directed cephalad (towards head) at 45 angle.

37
Q

How do you confirm if needle is in trachea with retrograde intubation?

A

Aspiration of air

38
Q

What is used to thread the ET in a retrograde intubation?

A

Insert a .025-.035 cm guidewire 110-150 cm long thru the needle and threaded through the vocal cords into the pharynx and out of the mouth.

39
Q

How do you withdraw the guidewire after successful retrograde intubation?

A

Through the mouth

40
Q

What is pierced with an 18 gauge needle in a retrograde intubation?

A

the cricothyroid membrane

41
Q

When is a cricothyroidotomy used?

A
  • Lifesaving measure usually last resort
  • When can’t vent via mask and cannot intubate
  • Not recommended for under 12 y/o (it is the narrowest part of airway until this age)
42
Q

What is the technique for cricothyroidotomy?

A
  1. Place a 14-16 gauge over the needle catheter through the cricothyroid membrane.
  2. Aspirate air (indicates catheter in the trachea) remove the stylet, advance the catheter, aspirate, catheter connected to O2 source.
43
Q

How can you connect the needle in cric to O2 source?

A
  1. Inserting a 3mm endotracheal tube adapter into the catheter hub permits attachment of the anesthesia circuit or a resuscitation bag.
    or
  2. Insert the adapter from a 7mm ETT into the barrel of a 3cc syringe from which the plunger has been removed.
44
Q

How do you ventilate with transtracheal ventilation (cricothyroidotomy)?

A

Jet ventilation is the most effective means of reliable ventilation. Noncompliant tubing is attached (O2 under pressure)

45
Q

How does transtracheal ventilated patient get rid of CO2?

A

upper airway if able then converted to surgical emergent cric or trach

46
Q

What is a light wand stylet?

A
  • ultilzed to assist with blind intubation techniques; light the trachea can be seen with lights dimmed
47
Q

What is a Aintree Intubating Catheter (bougie)?

A
  • Put in LMA to ventilate
  • use fiberoptic bronchoscope with aintree through it
  • insert Aintree into trachea then exchange ET over catheter
48
Q

What is a AirTraq or Glidescope

A

May be first choice for difficult intubations

  • lighted hand held laryngoscope/camera
  • magnified, angular view of the larynx
  • useful in any position (go straight down middle of tongue when inserting unlike MAC/Miller)

(Airtraq is poor mans glidescope used before glidescope no screen just eye whole)

49
Q

What can help facilitate a better view with a glidescope?

A

Robinol to decrease secretions

50
Q

What stylet should you use with glidescope?

A

The rigid one that comes with it manipulate from top (like stick shift) (don’t use other ones) Will need a 2nd person to pull stylet

51
Q

When can a tube changer also be used other than exchanging ET tube?

A
  • Difficult extubations and leave in place

- Also can ventilate through it

Principles Exam 3 (3 decks)

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