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931: Advanced Principles of Anesthesia I > Difficult Airway > Flashcards

Difficult Airway Flashcards

1
Q

The most common cause of adverse respiratory events is

A

difficult tracheal intubation

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2
Q

Describe the distinguishing feature of a bougie.

A 
long- 60 cm
Coude tip (35-40 degree bend)
malleable yet firm
no lumen for insufflation
cheap, reliable, and familiar
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3
Q

A bougie is most useful in a grade

A

3 view

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4
Q

Indications for a bougie include

A

unable to pass ETT, grade 3 view, ETT exchange, digital intubation, adjunct to invasive techniques

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5
Q

Technique for using the bougie is

A 
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
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6
Q

Pearls for using the bougie include

A

LEAVE laryngoscope IN PLACE during procedure
rotate ETT 90 degrees counter clockwise
use a flexible tip tube
capnography

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7
Q

Complications of using a bougie include

A

failed intubation
perforation
vocal cord trauma

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8
Q

Airway exchange catheters are used when

A

a secure airway should be exchanged or temporarily removed but laryngoscopy is likely difficult

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9
Q

Common features of airway exchangers include

A

distance markings
central lumen and/or side ports
adapter for TTJV or 15 mm connector

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10
Q

In relation to a bougie, an airway exchange catheter is

A

longer, less flexible, hollow lumen

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11
Q

Examples of airway exchangers include

A 
a cook catheter
sheridan exchange catheter
Parker flex-it directional stylet
Frova Intubation inducer
Endotracheal tube introducer
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12
Q

A Frova intubation introducer is

A

similar to a bougie but with hollow lumen that allows for O2 delivery

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13
Q

An endotracheal tube introducer is

A

similar to a bougie but 10 cm longer and stiffer

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14
Q

The Parker Flex-it directional stylet allows

A

provider to elevate tip of ETT from proximal end

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15
Q

Pearls for airway exchange catheters:

A 
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
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16
Q

Lighted stylets use

A

the principle of transillumination of soft tissue at the anterior neck to guide the tip of the ETT into trachea

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17
Q

Indications for lighted stylets include

A

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

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18
Q

The tip of the trachlight is

A

bent to form a “hockey stick”

which enhances movement through the glottic opening

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19
Q

Preparing the trachlight includes

A

lubricate wire stylet
lubricate the flexible wand
attach ETT, clamp proximal end to handle
bend tip 90 degrees like a hockey stick

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20
Q

With patient positioning when using a trachlight,

A

bed should be in the low position
head neutral or slightly extended
DO NOT place patient in the sniffing position

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21
Q

Pearls when using a trachlight include

A

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

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22
Q

A needle cricothyrotomy provides the ability to

A

oxygenation, but CO2 removal is ineffective

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23
Q

Describe the landmark technique for needle cricothrotomy.

A

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

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24
Q

The ultrasound technique for needle cricothyrotomy is shown to be

A

more effective than landmark

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25
Q

When performing the needle cricothyrotomy technique using ultrasound, the steps include

A

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
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26
Q

Indications for retrograde intubation include:

A

failed intubations
urgent airway required, but cords cannot be visualized
elective based on patient condition

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27
Q

Contraindications for retrograde intubation include

A

unfavorable anatomy
laryngotracheal disease
coagulopathy
infection

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28
Q

Preparation for retrograde intubation is to

A

place the patient in the sniffing position with the head hyperextended

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29
Q

When performing a retrograde intubation, the airway should be

A

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

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30
Q

The entry site for retrograde intubation is

A

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

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31
Q

Describe the retrograde intubation guidewire technique

A

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

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32
Q

Describe the fiberoptic technique for retrograde intubation.

A

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

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33
Q

Describe the pull through technique for retrograde intubation.

A

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

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34
Q

Describe PEARLS associated with retrograde intubation

A

CTM associated with less bleeding, lower success rate

use a smaller ETT (6.5-7)

35
Q

Describe the benefits of the silk pull through technique

A

less railroading, can perform multiple attempts with one puncture, ability to reintubate postoperatively

36
Q

Describe the benefits of the J wire technique

A

less traumatic, easier to retrieve, less prone to kinking, can be used with FOB, takes less time to perform

37
Q

Complications of retrograde intubation include:

A

bleeding, subcutaneous emphysema, nerve injury, broken wire

38
Q

The gold standard for the management of difficult airway is

A

awake intubation

39
Q

Benefits of awake intubation include

A

spontaneous ventilation is maintained
airway patency is maintained
larynx does not move into an anterior position
awake patients can monitor own neurologic status

40
Q

The leading cause of morbidity and mortality in ASA closed claim analysis is

A

airway management failure

41
Q

The universally accepted Gold standard for awake, sedated, and difficult to intubate patients is

A

fiberoptic

42
Q

What is an endoscope?

A

an instrument composed of over 10,000 glass fibers that transmits light and allows for visualization of images

43
Q

All flexible endoscopes have three main parts:

A

handle, insertion tube, flexible tip

44
Q

The FOB handle contains the following parts:

A

power source, suction/valve, working channel, angulation control lever, lens with focus capability

45
Q

The ability to orient the FOB is via the

A

visible notch at the 12 o’clock position

46
Q

Newer fiberoptic systems may also have

A

video output adapter, video screen, camera

47
Q

The four components inside the insertion tube of the FOB include

A

light guide bundles, transmit source, angulation wires, working channel

48
Q

The fibers of the fiberoptic system are

A

very sensitive to damage

damage to the fibers result in a “black spot” within the image

49
Q

Describe what angulation wires are.

A

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

50
Q

Describe the working channel

A

runs the length of the insertion tube

it can be used to provide: oxygen, suction, medication portal, and specimen collection

51
Q

The flexible tip of the FOB contains

A

charged-coupled device chip and a second lens that allows viewing of structures
the field of view is approx 75-120 degrees

52
Q

The most likely areas for ineffective FOB sterilization is

A

valves and working channels

53
Q

Sources of contamination for the FOB include:

A

sentinel patients, contaminated water, inadequate sterilization technique, repeated use of brushes or cleaning fluid, FOBs with design errors or defects

54
Q

When caring for the endoscope,

A

universal precautions are mandatory

disinfection can take up to one hour

55
Q

After using the FOB,

A

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

56
Q

Successful airway anesthesia techniques requires:

A

trigeminal nerve block (nasal intubation)
glossopharyngeal block
laryngeal nerve blocks (vagus nerve)

57
Q

Prior to performing any awake fiberoptic intubation anesthesia is needed to

A

prevent discomfort, decrease psychological stress, minimize hemodynamic changes, and increase patient cooperation
have all supplies & equipment available
appropriate monitors

58
Q

The orotracheal airway structures are innervated by

A

cranial nerve V (trigeminal)
cranial nerve IX (glossopharyngeal)
cranial nerve X (vagus)- superior & recurrent laryngeal nerve

59
Q

The trigeminal nerve provides

A

sensory innervation to the face via the three divisions ophthalmic, maxillary, mandibular

60
Q

The glossopharyngeal nerve provides sensory innervation to

A 
posterior 1/3rd of the tongue
oropharynx
vallecula
anterior epiglottis
afferent limb of the gag reflex
61
Q

The vagus nerve branches into the

A

superior laryngeal nerve (SIS & SEM)

recurrent laryngeal nerve

62
Q

The recurrent laryngeal nerve provides sensory innervation

A

below the fold cords and trachea

motor innervation to all intrinsic laryngeal muscles

63
Q

The ______ nerve is more susceptible to injury because it wraps around and under the aorta

A

left recurrent laryngeal nerve

64
Q

Advantages to an intubating oral airway include

A

protect the bronchoscope, Shield FOB from tongue & tissues, allows for passage of ETT (up to 9.0)

65
Q

An intubating oral airway can be used in patients who are

A

unconscious or have anesthetized oropharynx

66
Q

The swivel adaptor is used mostly for

A

bronchoscopy

allows for continuous ventilation without an airway leak

67
Q

The parker flex tip ETT is beneficial for

A

preventing the bevel from catching on anything

68
Q

Steps for FOB awake intubation include

A

indications, equipment and monitoring, psychological preparation, pre-medication, local airway anesthesia, procedure

69
Q

Indications for fiberoptic intubation include

A

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

70
Q

Equipment and monitoring for FOB intubation includes

A

IV access, FOB cart & airway cart (test light), oxygen delivery system, two suctions, monitors, medication

71
Q

When preparing the patient psychologically for fiberoptic intubation

A

explain and reassure the patient with benefits of FOB, probable amnesia, local airway anesthetic administration, patient assistance during the procedure

72
Q

Premedication for FOB includes

A

antisialogogue 15-20 minutes prior
sedation- midazolam preferred
nasal drops possible with phenylephrine 0.5% mixed with lidocaine spray 2-4%

73
Q

Local airway anesthesia for FOB includes

A

drops, injection, nebulizer, paste, spray as you go

74
Q

Complete local airway anesthesia requires:

A

glossopharyngeal nerve block, superior laryngeal nerve block, transtracheal block

75
Q

For follow-up care of the difficult airway,

A

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

76
Q

When extubating a difficult airway, factors to consider include

A

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

77
Q

Contraindications for FOB include:

A

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

78
Q

When there is an airway emergency,

A

approach must be sped up, assume full stomach, use cricoid pressure, intubation should be attempted by most experienced provider

79
Q

When performing a FOB, the FOB is passed in a

A

“down, up down” motion
down- through oropharynx
up toward anterior commissure
down through vocal cords

80
Q

If a patient is gagging during FOB it is because of

A

glossopharyngeal nerve

81
Q

If a patient is coughing during FOB it is because of

A

superior laryngeal nerve

82
Q

When performing a transtracheal block,

A

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

83
Q

Describe the superior laryngeal nerve block.

A

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

84
Q

When doing a glossopharyngeal block,

A

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

931: Advanced Principles of Anesthesia I (22 decks)

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