Difficult Airway Flashcards
Difficult Airway Algorithm
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
Bougie
Portex Venn introducer 60cm Coude tip 35-45° angle Malleable No lumen
Bougie Technique
Grade III view ETT exchange Hook under the epiglottis Railroad tracks Leave laryngoscope in to visualize ETT placement Slide ETT over
Bougie Complications
Failed intubation
Perforation
Vocal cord trauma
Airway Exchange Catheters
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
Cook Exchange Catheter
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
Sheridan Exchange Catheter
Standard adult 81mm 6.0-10.0 ETT
Extended DLT 100mm 35-41Fr double lumen tube
Airway Exchange Catheter Procedure
HIGH risk procedure
Plan A, B, C
Minimum 2 providers
Perform DL 1st
Lighted Stylets
Soft tissue transillumination on anterior neck to guide ETT into the trachea
Trachlight
Lighted stylet
Field hockey stick shape to enhance movement through glottic opening
Retract the wire stylet 10cm when light passes through the glottis
Trachlight Procedure
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
Needle Cricothyrotomy
Final option on the ASA difficult airway algorithm
Rapid access to airway
Able to oxygenate but CO2 removal ineffective
Needle Cricothyrotomy Procedure
14G needle w/ angio-catheter attached to syringe w/ saline
Landmark technique or U/S guidance
Landmark Technique
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
U/S Guided Needle Cricothyrotomy
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
Retrograde Intubation Indications
Failed intubation(s)
Urgent airway required, but unable to visualize cords
Elective based on patient condition
Retrograde Intubation Contraindications
Unfavorable anatomy
Laryngotracheal disease
Coagulopathy
Infection
Retrograde Wire Intubation (Awake)
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
Retrograde Intubation Procedure
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
Retrograde Intubation Guide-Wire
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
Retrograde Intubation Complications
Bleeding
Subcutaneous emphysema
Nerve injury
Broken wire
Awake Intubation
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
Endoscope
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
Fiberoptic Bronchoscope Handle
Power source Suction/valve Working channel Angulation control lever Lens w/ focus capability
Fiberoptic Bronchoscope Lens
Eyepiece Able to focus Orientation notch at 12 o'clock position - Video output adaptor - Video screen - Camera
Fiberoptic Bronchoscope Insertion Tube
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
Fiberoptic Flexible Tip
Contains charged-coupled device chips & 2nd lens that allows structure viewing
Field view approximately 75-120°
Endoscope Care
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
Trigeminal Nerve
Cranial nerve V Provides sensory innervation to the face Divisions: 1. Ophthalmic V1 2. Maxillary V2 3. Mandibular V3
Glossopharyngeal Nerve
Cranial nerve IX
Provides sensory innervation to posterior 1/3 tongue, oropharynx, vallecula, & anterior epiglottis
Afferent limb gag reflex
Vagus Nerve
Cranial nerve X
Superior & recurrent laryngeal nerves
Superior Laryngeal Nerve
Internal branch
- Sensory innervation to posterior epiglottis to vocal cord folds
External branch
- Motor innervation below the vocal cords
Recurrent Laryngeal Nerve
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)
Awake Fiberoptic Intubation Indications
Anticipated difficult mask ventilation & intubation
Difficult airway w/ comorbidities
Intubation not achieved → poor outcome(s)
Failed asleep intubation
Small mouth/opening
Awake Fiberoptic Intubation
Equipment & Monitoring
IV access Airway cart Oxygen delivery Suction EKG, SpO2, ETCO2, BP Medications Bronchoscope Oral & NP airways Flexible-tip ETT
Awake Fiberoptic Intubation Pre-Medication
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
Local Airway Anesthesia
Local anesthesia - drops, injection, nebulizer, paste, spray
Complete Local Airway Anesthesia
Blocks: Glossopharyngeal nerve Superior laryngeal nerve Transtracheal block Bilateral nares
Glossopharyngeal Nerve Block
Blunts gag reflex Patients assist Move tongue medially Apply LA on inspiration to the tonsillar pillar Injection not recommended Use long-cotton tipped swabs
Superior Laryngeal Nerve Block
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
Transtracheal Block
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
Awake Fiberoptic Intubation Procedure
Position patient Hold insertion tube & ensure that fiberoptic bronchoscope remains straight Down through oropharynx Up toward anterior commissure Down through the vocal cords
Awake Fiberoptic Intubation Contraindications
Anesthesia provider lacking skill
Procedure requires trained assistant or ready to use equipment
Uncooperative patient
Near complete upper airway obstruction
Extubation
Awake vs. deep
Clinical S/S impair ventilation
Management plan unable to maintain adequate ventilation
Short-term use airway exchanger
Follow-Up
DOCUMENT
Differentiate b/w ventilation & intubation
Management techniques utilizes
Beneficial vs. detrimental
Notify patient w/ information provided to ensure proper future care & prevent complications
