Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

N931 Advanced Principles of Anesthesia I > Difficult Airway > Flashcards

Difficult Airway Flashcards

1
Q

What is the most common cause of adverse respiratory events for patients undergoing anesthesia?

A

difficult tracheal intubation

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

Are difficult airway scenarios anticipated?

A

no, not usually; >75% of events are unanticipated

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

incidence of failed intubation

A

1 in 2000

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

incidence of failed intubation and ventilation

A

1 in 5000-10,000

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

what percentage of anesthesia related deaths does failed intubation/ventilation account for?

A

25%

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

what is the purpose of the difficult airway algorithm

A
  • to facilitate management of the DA and reduce poor outcomes
  • primary focus = tracheal intubation for patients undergoing general anesthesia
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

grade I view

A

full view of glottic opening

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

grade II view

A

posterior portion of glottic opening and arytenoid cartilage visible

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

grade III view

A

only tip of epiglottis visible

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

grade IV view

A

soft palate visible; no recognizable laryngeal structures

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

what is another name for a bougie

A

portex venn introducer

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

distinguishing features of a bougie

A
  • long (60 cm)
  • coude tip (35-40 degree bend)
  • malleable yet firm
  • no lumen for insufflation
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

ideal view to use bougie

A

grade III view

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

indications for bougie use

A
  • unable to pass ETT
  • grade III view
  • ETT exchange
  • digital intubation
  • adjunct to invasive techniques
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

bougie insertion technique

A
  • obtain the best view possible
  • hold bougie like a pencil with coude tip anterior
  • advance and hook epiglottis
  • anticipate clicking (you can feel the tracheal rings)
  • do NOT remove laryngoscope
  • slide ETT over bougie (have an assistant)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

pearls for using the bougie

A
  • leave the laryngoscope in place during the procedure
  • rotate ETT 90 degrees counter clockwise so the tip doesn’t get stuck
  • use a flexible tip tube
  • capnography
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

potential complications of bougie

A
  • failed intubation
  • perforation
  • vocal cord trauma
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

airway exchange catheters

A
  • commonly used when a secure airway should be changed or temporarily removed, but laryngoscopy is likely difficult
  • intubating guides are different sizes, shapes, lengths, and materials
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

common features of airway exchange catheters include

A
  • distance markings
  • central lumen and/or side ports
  • adapter for TTJV or 15mm connector
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

airway exchange catheter vs a bougie

A
  • longer
  • less flexible
  • hollow lumen (so you can ventilate)
  • straight tip, not coude like bougie
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q

cook catheter

A
  • type of airway exchange catheter
  • radiopaque (lines)
  • distal and side ports
  • rapi-fit adaptor, luer lock 15mm attaches to vent
  • distance markers
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
22
Q

sheridan exchange catheter

A
  • longer
  • markings
  • can ventilate
  • standard = 81mm, 6.0-10.0 ETT
  • extended (for DLT exchange) = 100 mm, 35-41 Fr. DLT
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
23
Q

frova intubation introducer

A
  • similar to bougie but with hollow lumen that allows for O2 delivery
  • peds version available (3.0-5.0)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
24
Q

ETT introducer

A
  • similar to bougie

- 10 cm longer and stiffer

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
25
Q

parker flex-it directional stylet

A

-allows provider to elevate tip of ETT from proximal end

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
26
Q

pearls for airway exchange catheters

A
  • HIGH RISK procedure because you are manipulating a likely difficult airway (or else why would you be using the exchange catheter)
  • have plan A, B, C and ALL EMERGENCY EQUIPMENT
  • two anesthesia providers in the room at minimum
  • review all previous airway and intubation notes/history
  • perform a DVL first
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
27
Q

lighted stylet

A

use the principle of transillumination of soft tissues like the anterior neck to guide the tip of the ETT into the trachea

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
28
Q

indications for lighted stylet

A
  • routine intubations (studies show high success rates and decreased airway trauma)
  • patients with difficult airways
  • can be used to locate tip of ETT when performing and percutaneous tracheotomy
  • can be used with laryngoscope, LMA, Bullard, and during retrograde intubation
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
29
Q

trachlight

A
  • tip is bent to form a “field hockey stick” –> enhances movement through the glottic opening
  • once the light passes through the glottis, the wire stylet is retracted 10 cm
  • device inserted midline and advanced along sagittal plane
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
30
Q

how to prepare the trachlight

A
  • lubricate wire stylet
  • lubricate the flexible wand
  • attach ETT, clamp proximal end to handle
  • bend tip 90 degrees like a field hockey stock
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
31
Q

patient positioning for trachlight

A
  • bed in low position
  • head neutral to slightly extended
  • DO NOT place patient in sniffing position
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
32
Q

trachlight technique

A
  • when illumination of the light is noted below the laryngeal prominence, retract the wire stylet 10 cm
  • advance wand (without the wire stylet) until the glow disappears below the sternal notch (this is about 5 cm above the carina)
  • unclamp the ETT from the handle and advance
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
33
Q

trachlight pearls for use

A
  • full muscle relaxation 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 toward the cords
  • when wand enters the glottis opening, a well-defined light will be observed below the laryngeal prominence
  • if resistance is met when attempting to advance ETT, rotate it 90 degrees
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
34
Q

needle cricothyrotomy

A
  • final option in ASA difficult airway algorithm
  • provides rapid access to airway
  • ability to oxygenate, but CO2 removal ineffective
  • a 14-G needle with angio-catheter attached to a syringe partially saline filled
  • can be performed using either landmark technique or with ultrasound guidance
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
35
Q

needle cricothyrotomy landmark technique

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
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
36
Q

needle cricothyrotomy ultrasound guided TACA technique

A
  • shown to be more effective
  • begin at the superior Thyroid notch
  • slide transducer caudally and identify CTM/Air tissue interface
  • continue caudal to the hypoechoic Cricoid cartilage
  • slide cephalad to CTM/air-tissue interface and mark the CTM membrane
37
Q

retrograde intubation indications

A
  • failed intubation
  • urgent airway required but cords cannot be visualized
  • elective based on patient condition
38
Q

contraindications to retrograde intubation

A
  • unfavorable anatomy
  • laryngotracheal disease
  • coagulopathy
  • infection
39
Q

retrograde intubation preparation

A
  • positioning - sniffing with head hyper-extended
  • skin prep - if possible should be sterilized
  • anesthesia - should be anesthetized with airway nerve block (translaryngeal with superior laryngeal nerve block, translaryngeal with topicalization of the pharynx, glossopharyngeal nerve block and superior laryngeal nerve block with nebulized anesthetic)
  • entry site - puncture can occur either above or below the cricoid cartilage (cricothyroid membrane, cricotracheal ligament)
40
Q

retrograde intubation through cricothyroid membrane

A
  • less bleeding because relatively avascular (cricothyroid artery becomes insignificant as it moves midline)
  • greater chance of failed intubation
41
Q

retrograde intubation through cricotracheal ligament

A
  • higher success rate
  • lower incidence of vocal cord trauma
  • greater risk of bleeding
42
Q

retrograde intubation guide-wire technique

A
  • a needle with catheter is passed through the entry site until air is aspirated
  • guide-wire is threaded through needle until it passes through the oropharynx or nasopharynx
  • a hemostat clamps the guide-wire at the trachea insertion site
  • ETT is passed over guide-wire until it meets resistance in larynx
43
Q

retrograde intubation FOB technique

A
  • guide-wire passed through the trachea in normal fashion
  • guide-wire passed through a 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
44
Q

retrograde intubation pull through technique

A
  • epidural catheter is passed as previously described
  • silk suture tied to epidural catheter extending from pharynx
  • catheter pulled through tracheal 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
45
Q

retrograde intubation pearls

A
  • CTM associated with less bleeding, but lower success rate
  • use a smaller ETT (6.5-7.0 mm)
  • silk pull-through offers some benefits - less railroading, can perform multiple attempts with one puncture, ability to reintubate post-op
  • J wire - less traumatic, easier to retrieve, less prone to kinking, can be used with FOB, takes less time to perform
46
Q

retrograde intubation complications

A
  • bleeding
  • subcutaneous emphysema
  • nerve injury
  • broken wire
47
Q

awake intubation

A
  • gold standard for management of difficult airway
  • spontaneous ventilation is maintained
  • airway patency maintained
  • larynx does not move into an anterior position
  • awake patients can monitor own neurologic status
48
Q

when do you use a FOB?

A
  • routine induction/intubation sequence
  • awake intubation with known, anticipated difficult airway
  • as part of the ASA difficult airway algorithm
49
Q

what is an endoscope?

A
  • instrument composed of over 10,000 glass fibers that transmits light and allows for visulization of images
  • all flexible endoscopes have three main parts - handle, insertion tube, flexible tip
50
Q

FOB handle

A
  • power source
  • suction/valve
  • working channel - inject meds like LA
  • angulation control level - allows for manipulation of FOB tip
  • lens with focus capability
51
Q

FOB Lens

A
  • all FOB have an eyepiece that can be focused
  • a visible block notch in the eyepiece at the 12 o’clock position aids in orientation
  • newer systems may also have - video output adapter, video screen, camera
52
Q

FOB insertion tube four components

A
  • light guide bundles
  • transmit source
  • angulation wires
  • working channel
53
Q

light guide bundles of FOB

A
  • light is transmitted by one or two non-coherent glass fibers
  • high-intensity light is focused at the proximal bundles
54
Q

transmit source of FOB

A
  • continuous glass fibers run the length of the insertion tube, transmitting images
  • each fiber is approximately 20 times smaller in diameter than a human hair
  • the fibers are VERY sensitive to damage
  • damage to the fibers result in a black spot within the image
55
Q

angulation wires of FOB

A
  • two angulation wires course along the saggital plane
  • these delicate wires move the flexible tip in opposite directions
  • attempting to move the tip while still in the ETT can break the wires
56
Q

working channel of FOB

A
  • the working channel runs the length of the insertion tube

- it can be used to provide - oxygen, suction, meds, specimen collection

57
Q

flexible tip of FOB

A
  • contains the charged coupled device (CCD) chip and a second lens that allows viewing of structures
  • the field of view is approximately 75-120 degrees
58
Q

care of the endoscope/FOB

A
  • valves and working channels are the most likely areas for ineffective FOB sterilization
  • other sources of contamination include - sentinel patients, contaminated water, inadequate sterilization techniques, repeated use of brushes or cleaning fluid, FOBs with design errors or defects
  • universal precautions = mandatory
59
Q

disinfection of the FOB after use

A
  • can take up to an hour
  • inspect FOB for any damage
  • disassemble moving parts, pass a cleaning brush through working port
  • non-disposable parts placed in an appropriate cleaning solution
  • after sterilization, bronchoscope washed and rinsed with water
  • working port must be dried with 70% alcohol and compressed air
  • ethylene oxide sterilization for 24 hours may be required after use in patients
60
Q

airway anesthesia

A

prior to performing an awake fiberoptic intubation, anesthesia is needed to prevent discomfort, decrease psychological stress, minimize hemodynamic changes and increase pt cooperation

61
Q

three components of successful airway anesthesia

A
  • trigeminal nerve block (nasal intubation)
  • glossopharyngeal nerve block (GPN)
  • laryngeal nerve blocks
62
Q

neural pathways involved in airway ansethesia

A
  • trigeminal nerve (CN V)
  • glossopharyngeal nerve (CN IX)
  • vagus nerve (CN X)
63
Q

trigeminal nerve

A

provides sensory innervation to the face

64
Q

three divisions of trigeminal nerve

A
  • opthalamic (V1)
  • maxiallary (V2)
  • mandibular (V3)
65
Q

glossopharyngeal nerve

A
  • provides sensory information to…
  • posterior 1/3 of tongue
  • oropharynx
  • vallecula
  • anterior epiglottis
  • afferent limb of the gag reflex
66
Q

superior laryngeal nerve

A
  • branch of vagus nerve
  • internal branch - sensory innervation to posterior epiglottis to vocal cord folds (SIS)
  • external branch - motor innervation below the vocal cords (SEM)
67
Q

recurrent laryngeal nerve

A
  • sensory innervation below the vocal folds and trachea

- motor innervation to all intrinsic laryngeal muscles

68
Q

RLN R branch

A

loops under subclavian artery

69
Q

RLN L branch

A

loops under aorta, susceptible to injury

70
Q

intubating oral airway

A
  • patient either unconscious or anesthetized oropharynx

- advantages - protect bronchoscope, shield FOB from tongue + tissues, allows for passage of ETT up to 9mm

71
Q

nasal paryngeal airway

A
  • cut laterally along length of airway

- can serve as conduit for oxygen admin

72
Q

swivel adapter

A
  • used mostly for bronchoscopy

- allows for continuous ventilation without an airway leak

73
Q

awake fiberoptic intubation indications

A
  • anticipated difficult mask ventilation and intubation
  • difficult airway with comorbidities likely to result in poor outcome if intubation not acheived
  • failed asleep intubation
  • small mouth
74
Q

awake fiberoptic intubation equipment and monitoring

A
  • IV access
  • FOB cart and airway cart (test FOB for light and movement)
  • oxygen delivery system
  • two suctions
  • monitors - pulse oximetry is mandatory
  • medications
75
Q

awake fiberoptic intubation psychological preparation

A
  • explain and reassure the patient in a professional manner
  • benefits of FOB
  • probable amnesia
  • local airway anesthetic administration
  • patient assistance during procedure
76
Q

awake fiberoptic intubation pre-mediation

A
  • antisialogogue 15-20 min prior (glyco 0.2-0.4 mg), (atropine 0.4-0.6 mg)
  • sedation (midaz 2mg PRN)
  • nasal drops - phenyephrine 0.5% mixed with lido 2-4% spray
77
Q

awake fiberoptic intubation local anesthesia

A
  • drops
  • injection
  • nebulizer
  • paste
  • spray as you go
78
Q

what does complete local airway anesthesia require?

A
  • glossopharyngeal nerve block
  • superior laryngeal nerve block
  • transtracheal block
  • nasal (both sides potentially)
79
Q

GPN Block

A
  • patient may be required to assist
  • tongue moved medially
  • LA is applied on inspiration to the tonsillar pillar
  • injection of the area with local is NOT recommended
  • common to apply local with long cotton swabs (lido lolly pop)
80
Q

SLN block

A
  • locate hyoid cornua
  • with non-dominate hand, brace contralateral side
  • advance needle until ipsilateral bone is contacted
  • aspirate and inject
  • repeat on other side
81
Q

trans tracheal 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 the patient to take a small breath then max exhale
82
Q

fiberoptic awake intubation procedure

A
  • position patient
  • assistant to help with special airways
  • hold insertion tube so FOB remains straight
  • blocks!
  • FOB passed in a down up down motion (down - through oropharynx, up - toward anterior commissure, down - through vocal cords)
83
Q

if there is a gag what needs to be blocked

A

GPN

84
Q

if there is a cough what needs to be blocked

A

SLN

85
Q

routine fiberoptic intubation preparation

A
  • nasal drops
  • antisialgogue pre-op
  • standard induction
86
Q

routine fiberoptic intubation unsuccessful

A
  • reinstitute face-mask ventilation

- give more anesthetic prior to second attempt

87
Q

FOB contraindications

A
  • lack of skill by anesthesia provider
  • lack of trained assistant or ready to use equipment
  • wild, uncooperative patient
  • near total upper airway obstruction
  • another technique
88
Q

things to consider with DAW and extubation

A
  • have a strategy for safe extubation
  • awake vs deep
  • clinical symptoms that will impair ventilation
  • management plan if unable to maintain adequate ventilation
  • short-term use of airway exchanger
89
Q

follow-up care of DAW

A
  • differentiate between ventilation and intubation
  • description of management techniques used
  • provide patient with information for future care (dr note or medical alert bracelet)

N931 Advanced Principles of Anesthesia I (19 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2024 Bold Learning Solutions. Terms and Conditions