Difficult Airway Flashcards
The most common cause of adverse respiratory events is
difficult tracheal intubation
Describe the distinguishing feature of a bougie.
long- 60 cm Coude tip (35-40 degree bend) malleable yet firm no lumen for insufflation cheap, reliable, and familiar
A bougie is most useful in a grade
3 view
Indications for a bougie include
unable to pass ETT, grade 3 view, ETT exchange, digital intubation, adjunct to invasive techniques
Technique for using the bougie is
obtain best possible view hold bougie like a pencil with Coude tip anterior advance & hook under epiglottis anticipate clicking do not remove laryngoscope slide ETT over bougie
Pearls for using the bougie include
LEAVE laryngoscope IN PLACE during procedure
rotate ETT 90 degrees counter clockwise
use a flexible tip tube
capnography
Complications of using a bougie include
failed intubation
perforation
vocal cord trauma
Airway exchange catheters are used when
a secure airway should be exchanged or temporarily removed but laryngoscopy is likely difficult
Common features of airway exchangers include
distance markings
central lumen and/or side ports
adapter for TTJV or 15 mm connector
In relation to a bougie, an airway exchange catheter is
longer, less flexible, hollow lumen
Examples of airway exchangers include
a cook catheter sheridan exchange catheter Parker flex-it directional stylet Frova Intubation inducer Endotracheal tube introducer
A Frova intubation introducer is
similar to a bougie but with hollow lumen that allows for O2 delivery
An endotracheal tube introducer is
similar to a bougie but 10 cm longer and stiffer
The Parker Flex-it directional stylet allows
provider to elevate tip of ETT from proximal end
Pearls for airway exchange catheters:
this is a HIGH-RISK procedure Have a Plan A, B, & C two providers minimum perform a direct laryngoscopy first review all previous airway & intubation/history notes
Lighted stylets use
the principle of transillumination of soft tissue at the anterior neck to guide the tip of the ETT into trachea
Indications for lighted stylets include
routine intubations (high success rates with lower airway trauma)
patients with difficult airways
can be used to locate tip of ETT when performing a percutaneous tracheotomy
can be used with laryngoscope, LMA, Bullard, and during during retrograde intubation
The tip of the trachlight is
bent to form a “hockey stick”
which enhances movement through the glottic opening
Preparing the trachlight includes
lubricate wire stylet
lubricate the flexible wand
attach ETT, clamp proximal end to handle
bend tip 90 degrees like a hockey stick
With patient positioning when using a trachlight,
bed should be in the low position
head neutral or slightly extended
DO NOT place patient in the sniffing position
Pearls when using a trachlight include
full muscle relaxation is recommended
jaw-thrust or mandible lift
insert device mid-line
when a faint glow is seen above the larynx, lifting the jaw or tongue will raise the epiglottis and facilitate the wand towards the vocal cords
when the wand enters the glottic opening a well-defined will be observed below the laryngeal prominence
if resistance is met when attempting to advance ETT, rotate it 90 degrees
A needle cricothyrotomy provides the ability to
oxygenation, but CO2 removal is ineffective
Describe the landmark technique for needle cricothrotomy.
provider positioned on the same side as the patient’s dominant hand
larynx stabilized with non-dominant hand; thumb and long finger. Index finger used to identify CTM
needle inserted with dominant hand at a 45 degree angle caudally
needle aspirated until presence of air noted
The ultrasound technique for needle cricothyrotomy is shown to be
more effective than landmark
When performing the needle cricothyrotomy technique using ultrasound, the steps include
TACA technique
- begin at the superior thyroid notch
- slide transducer caudally & identify CTM/Air-tissue interface
- continue caudal to the hypoechoic cricoid cartilage
- slide cephalad to CTM/air-tissue and mark the CTM
Indications for retrograde intubation include:
failed intubations
urgent airway required, but cords cannot be visualized
elective based on patient condition
Contraindications for retrograde intubation include
unfavorable anatomy
laryngotracheal disease
coagulopathy
infection
Preparation for retrograde intubation is to
place the patient in the sniffing position with the head hyperextended
When performing a retrograde intubation, the airway should be
anesthetized if possible,
translaryngeal with superior laryngeal nerve block
translaryngeal with topicalization of the pharynx
glossopharyngeal nerve block and superior laryngeal nerve block with nebulized anesthetic
The entry site for retrograde intubation is
puncture can occur either above or below the cricoid cartilage
cricothyroid membrane- less bleeding, greater chance of failed intubation
cricotracheal ligament- higher success rate, lower incidence of vocal cord trauma, greater risk of bleeding
Describe the retrograde intubation guidewire technique
needle with catheter is passed through entry site until air is aspirated
guide-wire is threaded through needle until it passes through oropharynx or nasopharynx
a hemostat clamps the guidewire at the trachea insertion site
the endotracheal tube is passed over guidewire until it meets resistance in larynx
Describe the fiberoptic technique for retrograde intubation.
guide-wire passed through the trachea in normal fashion
guidewire passed through suction port of FOB, allowing for straight path to vocal cords
ETT can be passed over the FOB through vocal cords
continuous O2 can be delivered
Describe the pull through technique for retrograde intubation.
epidural catheter is passed through nasopharnx or oropharynx
silk suture tied to epidural catheter extended from the pharynx
catheter pulled through incision site with silk suture
catheter removed, ETT tied to cephalad end of suture
hold slight pressure, ETT is passed until it abuts against the cricothyroid membrane
Describe PEARLS associated with retrograde intubation
CTM associated with less bleeding, lower success rate
use a smaller ETT (6.5-7)
Describe the benefits of the silk pull through technique
less railroading, can perform multiple attempts with one puncture, ability to reintubate postoperatively
Describe the benefits of the J wire technique
less traumatic, easier to retrieve, less prone to kinking, can be used with FOB, takes less time to perform
Complications of retrograde intubation include:
bleeding, subcutaneous emphysema, nerve injury, broken wire
The gold standard for the management of difficult airway is
awake intubation
Benefits of awake intubation include
spontaneous ventilation is maintained
airway patency is maintained
larynx does not move into an anterior position
awake patients can monitor own neurologic status
The leading cause of morbidity and mortality in ASA closed claim analysis is
airway management failure
The universally accepted Gold standard for awake, sedated, and difficult to intubate patients is
fiberoptic
What is an endoscope?
an instrument composed of over 10,000 glass fibers that transmits light and allows for visualization of images
All flexible endoscopes have three main parts:
handle, insertion tube, flexible tip
The FOB handle contains the following parts:
power source, suction/valve, working channel, angulation control lever, lens with focus capability
The ability to orient the FOB is via the
visible notch at the 12 o’clock position
Newer fiberoptic systems may also have
video output adapter, video screen, camera
The four components inside the insertion tube of the FOB include
light guide bundles, transmit source, angulation wires, working channel
The fibers of the fiberoptic system are
very sensitive to damage
damage to the fibers result in a “black spot” within the image
Describe what angulation wires are.
two angulation wires course along the sagittal plane of the FOB
these move the flexible tip in opposite directions
attempting to move the tip while still in the ETT can break the wires
Describe the working channel
runs the length of the insertion tube
it can be used to provide: oxygen, suction, medication portal, and specimen collection
The flexible tip of the FOB contains
charged-coupled device chip and a second lens that allows viewing of structures
the field of view is approx 75-120 degrees
The most likely areas for ineffective FOB sterilization is
valves and working channels
Sources of contamination for the FOB include:
sentinel patients, contaminated water, inadequate sterilization technique, repeated use of brushes or cleaning fluid, FOBs with design errors or defects
When caring for the endoscope,
universal precautions are mandatory
disinfection can take up to one hour
After using the FOB,
inspect it for any damage
dissasemble moving parts, pass a cleaning brush through working port
non-disposable parts are placed in an approved cleaning solution
after sterilization time, bronchoscope washed and rinsed with water
working port must be dried with 70% alcohol and compressed air
Successful airway anesthesia techniques requires:
trigeminal nerve block (nasal intubation)
glossopharyngeal block
laryngeal nerve blocks (vagus nerve)
Prior to performing any awake fiberoptic intubation anesthesia is needed to
prevent discomfort, decrease psychological stress, minimize hemodynamic changes, and increase patient cooperation
have all supplies & equipment available
appropriate monitors
The orotracheal airway structures are innervated by
cranial nerve V (trigeminal)
cranial nerve IX (glossopharyngeal)
cranial nerve X (vagus)- superior & recurrent laryngeal nerve
The trigeminal nerve provides
sensory innervation to the face via the three divisions ophthalmic, maxillary, mandibular
The glossopharyngeal nerve provides sensory innervation to
posterior 1/3rd of the tongue oropharynx vallecula anterior epiglottis afferent limb of the gag reflex
The vagus nerve branches into the
superior laryngeal nerve (SIS & SEM)
recurrent laryngeal nerve
The recurrent laryngeal nerve provides sensory innervation
below the fold cords and trachea
motor innervation to all intrinsic laryngeal muscles
The ______ nerve is more susceptible to injury because it wraps around and under the aorta
left recurrent laryngeal nerve
Advantages to an intubating oral airway include
protect the bronchoscope, Shield FOB from tongue & tissues, allows for passage of ETT (up to 9.0)
An intubating oral airway can be used in patients who are
unconscious or have anesthetized oropharynx
The swivel adaptor is used mostly for
bronchoscopy
allows for continuous ventilation without an airway leak
The parker flex tip ETT is beneficial for
preventing the bevel from catching on anything
Steps for FOB awake intubation include
indications, equipment and monitoring, psychological preparation, pre-medication, local airway anesthesia, procedure
Indications for fiberoptic intubation include
small mouth, failed sleep intubation, anticipated difficult mask ventilation and intubation, difficult airway with comorbidities likely to result in poor outcomes if intubation is not achieved
Equipment and monitoring for FOB intubation includes
IV access, FOB cart & airway cart (test light), oxygen delivery system, two suctions, monitors, medication
When preparing the patient psychologically for fiberoptic intubation
explain and reassure the patient with benefits of FOB, probable amnesia, local airway anesthetic administration, patient assistance during the procedure
Premedication for FOB includes
antisialogogue 15-20 minutes prior
sedation- midazolam preferred
nasal drops possible with phenylephrine 0.5% mixed with lidocaine spray 2-4%
Local airway anesthesia for FOB includes
drops, injection, nebulizer, paste, spray as you go
Complete local airway anesthesia requires:
glossopharyngeal nerve block, superior laryngeal nerve block, transtracheal block
For follow-up care of the difficult airway,
it is necessary to document presence and nature of difficulty
-differentiate between ventilation and intubation
description of management technique used
provide patient with information for future care
When extubating a difficult airway, factors to consider include
awake vs. deep extubation
clinical symptoms that will impair ventilation
management plan if unable to maintain adequate ventilation
short-term use of an airway exchanger
Contraindications for FOB include:
most important is lack of skill by provider
lack of trained assistant or ready to use equipment
wild, uncooperative patient
near-total upper airway obstruction
another technique
When there is an airway emergency,
approach must be sped up, assume full stomach, use cricoid pressure, intubation should be attempted by most experienced provider
When performing a FOB, the FOB is passed in a
“down, up down” motion
down- through oropharynx
up toward anterior commissure
down through vocal cords
If a patient is gagging during FOB it is because of
glossopharyngeal nerve
If a patient is coughing during FOB it is because of
superior laryngeal nerve
When performing a transtracheal block,
straddle the trachea with the non-dominant hand
locate the cricothyroid space, slowly advance the needle while aspirating
stop when air is freely aspirated
instruct patient to take a small breath, then maximum exhalation
Describe the superior laryngeal nerve block.
locate the hyoid cornua
with non-dominate hand brace contralateral side
advance needle until ipsilateral bone is contacted
aspirate, then inject
repeat on the other side
When doing a glossopharyngeal block,
patient may be required to assist
tongue is moved medially
local anesthetic is applied on inspiration to the tonsillar pillar
injection of the area with local anesthetic is not recommended
common to apply local with long-cotton tipped swabs
