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AS - N931 Advanced Principles of Anesthesia > Difficult Airway > Flashcards

Difficult Airway Flashcards

1
Q

Difficult Airway Algorithm

A

Plan A, B, C… Z
Anticipate potential difficult airways
Practice w/ adjuncts on normal, easy airways
Purpose to facilitate difficult airway management & reduce poor outcomes
Early supraglottic airway devices
More experienced practitioner
Do NOT try the same thing again & again

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2
Q

Bougie

A 
Portex Venn introducer
60cm
Coude tip 35-45° angle
Malleable
No lumen
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3
Q

Bougie Technique

A 
Grade III view
ETT exchange
Hook under the epiglottis
Railroad tracks
Leave laryngoscope in to visualize ETT placement
Slide ETT over
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4
Q

Bougie Complications

A

Failed intubation
Perforation
Vocal cord trauma

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5
Q

Airway Exchange Catheters

A 
Used when secure airway needs to be changed or temporarily removed but laryngoscopy difficult
Distance markings
Central lumens & side ports
 TTJV or 15mm connector adaptor
Longer & less flexible than bougies
Hollow lumen
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6
Q

Cook Exchange Catheter

A 
Peds 8Fr 45cm >3.0 ETT
Adult 11-19Fr 83cm >4.0 ETT
Blunt tip
Semi-rigid
Radiopaque
Distal & side ports
Luer lock 15mm
Distance markers
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7
Q

Sheridan Exchange Catheter

A

Standard adult 81mm 6.0-10.0 ETT

Extended DLT 100mm 35-41Fr double lumen tube

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8
Q

Airway Exchange Catheter Procedure

A

HIGH risk procedure
Plan A, B, C
Minimum 2 providers
Perform DL 1st

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9
Q

Lighted Stylets

A

Soft tissue transillumination on anterior neck to guide ETT into the trachea

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10
Q

Trachlight

A

Lighted stylet
Field hockey stick shape to enhance movement through glottic opening
Retract the wire stylet 10cm when light passes through the glottis

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11
Q

Trachlight Procedure

A

Lubricate wire stylet & flexible wand
Attach ETT & clamp proximal end to handle Bend tip 90°
Position bed low
Head neutral or slightly extended
NOT sniffing position
Insert device midline & advance along the sagittal plane
Well-defined light observed below the laryngeal prominence

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12
Q

Needle Cricothyrotomy

A

Final option on the ASA difficult airway algorithm
Rapid access to airway
Able to oxygenate but CO2 removal ineffective

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13
Q

Needle Cricothyrotomy Procedure

A

14G needle w/ angio-catheter attached to syringe w/ saline

Landmark technique or U/S guidance

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14
Q

Landmark Technique

A

Provider position on same side as patient dominant hand
Stabilize larynx w/ non-dominant hand thumb & long finger
Use index finger to identify CTM
Insert needle w/ dominant hand at 45° angle caudally
Aspirate until air noted

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15
Q

U/S Guided Needle Cricothyrotomy

A

Begin at the superior thyroid notch
Slide transducer caudally & identify CTM (air-tissue interface)
Continue caudal to hyperechoic cricoid cartilage
Then slide cephalad to CTM & mark site

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16
Q

Retrograde Intubation Indications

A

Failed intubation(s)
Urgent airway required, but unable to visualize cords
Elective based on patient condition

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17
Q

Retrograde Intubation Contraindications

A

Unfavorable anatomy
Laryngotracheal disease
Coagulopathy
Infection

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18
Q

Retrograde Wire Intubation (Awake)

A

Prepare patient
Ideal position sniffing w/ head hyper-extended
Anesthetize the airway - superior laryngeal nerve block, pharynx topicalization, glossopharyngeal nerve block, & superior laryngeal nerve block w/ nebulized anesthetic

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19
Q

Retrograde Intubation Procedure

A

Puncture either above or below the cricoid cartilage
Cricothyroid membrane 1x2cm - less bleeding (avascular), but increased chance failed intubation
Cricotracheal ligament - higher success rate, lower incidence vocal cord trauma, & increased bleeding risk
Needle passed through entry site until air aspirated
Hemostat at entry site
ETT passed over guide-wire until meets resistance in trachea

20
Q

Retrograde Intubation Guide-Wire

A

Classic - epidural catheter (silk suture tie)

  • Less railroading
  • Multiple attempts w/ one puncture
  • Ability to reintubate postop

J-wire

  • Less traumatic
  • Easier to retrieve
  • Less prone to kinking
  • Use w/ fiberoptic
  • Quicker

Introducer

21
Q

Retrograde Intubation Complications

A

Bleeding
Subcutaneous emphysema
Nerve injury
Broken wire

22
Q

Awake Intubation

A

GOLD STANDARD
Known or anticipated difficult airway
Spontaneous ventilation & airway patency maintained
Awake patients able to monitor own neurologic status
Cervical spine injury
- Adequate topicalization to reduce coughing
- Minimal sedation to maintain self-airway protection

23
Q

Endoscope

A

Instrument composed w/ over 10,000 glass fibers that transmit light & allows image visualization
Flexible endoscopes all have 3 main parts:
- Handle
- Insertion tube
- Flexible tip

24
Q

Fiberoptic Bronchoscope Handle

A 
Power source
Suction/valve
Working channel
Angulation control lever
Lens w/ focus capability
25
Q

Fiberoptic Bronchoscope Lens

A 
Eyepiece
Able to focus
Orientation notch at 12 o'clock position
- Video output adaptor
- Video screen
- Camera
26
Q

Fiberoptic Bronchoscope Insertion Tube

A

Light guide bundles
- One or two non-coherent glass fibers
- High intensity light focused at the proximal bundles
Transmit source
- Continuous glass fibers
- Sensitive to damage → black spot(s)
Angulation wires
- Delicate wires move the flexible tip in opposite directions
Working channel
- Oxygen, suction, medication, specimen collection

27
Q

Fiberoptic Flexible Tip

A

Contains charged-coupled device chips & 2nd lens that allows structure viewing
Field view approximately 75-120°

28
Q

Endoscope Care

A 
Valves & working challenges are increased risk areas for ineffective sterilization
- Sentinel patients
- Contaminated water
- Inadequate sterilization
- Repeat use brushes or cleaning fluid
- Design errors or defects
Universal precautions
29
Q

Trigeminal Nerve

A 
Cranial nerve V
Provides sensory innervation to the face
Divisions:
1. Ophthalmic V1
2. Maxillary V2
3. Mandibular V3
30
Q

Glossopharyngeal Nerve

A

Cranial nerve IX
Provides sensory innervation to posterior 1/3 tongue, oropharynx, vallecula, & anterior epiglottis
Afferent limb gag reflex

31
Q

Vagus Nerve

A

Cranial nerve X

Superior & recurrent laryngeal nerves

32
Q

Superior Laryngeal Nerve

A

Internal branch
- Sensory innervation to posterior epiglottis to vocal cord folds
External branch
- Motor innervation below the vocal cords

33
Q

Recurrent Laryngeal Nerve

A

RLN
Sensory innervation below the vocal folds & trachea
Motor innervation to all intrinsic laryngeal muscles
R loops under subclavian artery
L loops under aorta (susceptible to injury)

34
Q

Awake Fiberoptic Intubation Indications

A

Anticipated difficult mask ventilation & intubation
Difficult airway w/ comorbidities
Intubation not achieved → poor outcome(s)
Failed asleep intubation
Small mouth/opening

35
Q

Awake Fiberoptic Intubation

Equipment & Monitoring

A 
IV access
Airway cart
Oxygen delivery
Suction
EKG, SpO2, ETCO2, BP
Medications
Bronchoscope
Oral & NP airways
Flexible-tip ETT
36
Q

Awake Fiberoptic Intubation Pre-Medication

A 
Antisalagogue 15-20min prior
Glycopyrrolate 0.2-0.4mg
Atropine 0.4-0.6mg
Sedation 2mg Midazolam
Nasal 0.5% Phenylephrine mixed w/ 2-4% Lidocaine spray
37
Q

Local Airway Anesthesia

A

Local anesthesia - drops, injection, nebulizer, paste, spray

38
Q

Complete Local Airway Anesthesia

A 
Blocks:
Glossopharyngeal nerve
Superior laryngeal nerve
Transtracheal block
Bilateral nares
39
Q

Glossopharyngeal Nerve Block

A 
Blunts gag reflex
Patients assist
Move tongue medially
Apply LA on inspiration to the tonsillar pillar
Injection not recommended
Use long-cotton tipped swabs
40
Q

Superior Laryngeal Nerve Block

A

Blunts cough reflex
Locate the hyoid cornu
Brace contralateral side w/ non-dominant hand
Advance the needle until ipsilateral bone contacted
Aspirate then inject
Repeat on other side

41
Q

Transtracheal Block

A

Straddle the trachea w/ non-dominant hand
Locate the cricothyroid space then slowly advance the needle while aspirating
Stop when air freely aspirated
Instruct patient to take small breath then maximum inhalation

42
Q

Awake Fiberoptic Intubation Procedure

A 
Position patient
Hold insertion tube & ensure that fiberoptic bronchoscope remains straight
Down through oropharynx
Up toward anterior commissure
Down through the vocal cords
43
Q

Awake Fiberoptic Intubation Contraindications

A

Anesthesia provider lacking skill
Procedure requires trained assistant or ready to use equipment
Uncooperative patient
Near complete upper airway obstruction

44
Q

Extubation

A

Awake vs. deep
Clinical S/S impair ventilation
Management plan unable to maintain adequate ventilation
Short-term use airway exchanger

45
Q

Follow-Up

A

DOCUMENT
Differentiate b/w ventilation & intubation
Management techniques utilizes
Beneficial vs. detrimental
Notify patient w/ information provided to ensure proper future care & prevent complications

AS - N931 Advanced Principles of Anesthesia (17 decks)

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