Difficult Airway

Question 1

Difficult Airway Algorithm

Answer 1

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

Question 2

Bougie

Answer 2

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

Question 3

Bougie Technique

Answer 3

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

Question 4

Bougie Complications

Answer 4

Failed intubation
Perforation
Vocal cord trauma

Question 5

Airway Exchange Catheters

Answer 5

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

Question 6

Cook Exchange Catheter

Answer 6

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

Question 7

Sheridan Exchange Catheter

Answer 7

Standard adult 81mm 6.0-10.0 ETT

Extended DLT 100mm 35-41Fr double lumen tube

Question 8

Airway Exchange Catheter Procedure

Answer 8

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

Question 9

Lighted Stylets

Answer 9

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

Question 10

Trachlight

Answer 10

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

Question 11

Trachlight Procedure

Answer 11

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

Question 12

Needle Cricothyrotomy

Answer 12

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

Question 13

Needle Cricothyrotomy Procedure

Answer 13

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

Landmark technique or U/S guidance

Question 14

Landmark Technique

Answer 14

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

Question 15

U/S Guided Needle Cricothyrotomy

Answer 15

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

Question 16

Retrograde Intubation Indications

Answer 16

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

Question 17

Retrograde Intubation Contraindications

Answer 17

Unfavorable anatomy
Laryngotracheal disease
Coagulopathy
Infection

Question 18

Retrograde Wire Intubation (Awake)

Answer 18

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

Question 19

Retrograde Intubation Procedure

Answer 19

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

Question 20

Retrograde Intubation Guide-Wire

Answer 20

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

Question 21

Retrograde Intubation Complications

Answer 21

Bleeding
Subcutaneous emphysema
Nerve injury
Broken wire

Question 22

Awake Intubation

Answer 22

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

Question 23

Endoscope

Answer 23

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

Question 24

Fiberoptic Bronchoscope Handle

Answer 24

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

Question 25

Fiberoptic Bronchoscope Lens

Answer 25

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

Question 26

Fiberoptic Bronchoscope Insertion Tube

Answer 26

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

Question 27

Fiberoptic Flexible Tip

Answer 27

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

Question 28

Endoscope Care

Answer 28

``` 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 ```

Question 29

Trigeminal Nerve

Answer 29

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

Question 30

Glossopharyngeal Nerve

Answer 30

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

Question 31

Vagus Nerve

Answer 31

Cranial nerve X | Superior & recurrent laryngeal nerves

Question 32

Superior Laryngeal Nerve

Answer 32

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

Question 33

Recurrent Laryngeal Nerve

Answer 33

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)

Question 34

Awake Fiberoptic Intubation Indications

Answer 34

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

Question 35

Awake Fiberoptic Intubation | Equipment & Monitoring

Answer 35

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

Question 36

Awake Fiberoptic Intubation Pre-Medication

Answer 36

``` 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 ```

Question 37

Local Airway Anesthesia

Answer 37

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

Question 38

Complete Local Airway Anesthesia

Answer 38

``` Blocks: Glossopharyngeal nerve Superior laryngeal nerve Transtracheal block Bilateral nares ```

Question 39

Glossopharyngeal Nerve Block

Answer 39

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

Question 40

Superior Laryngeal Nerve Block

Answer 40

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

Question 41

Transtracheal Block

Answer 41

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

Question 42

Awake Fiberoptic Intubation Procedure

Answer 42

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

Question 43

Awake Fiberoptic Intubation Contraindications

Answer 43

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

Question 44

Extubation

Answer 44

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

Question 45

Follow-Up

Answer 45

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