Difficult Airway Flashcards
What is the difficult airway algorithm?
How do you identify where you would do a cricothyroidotomy?
What can you do in advance if you anticipate a cricothyroidotomy being difficult on your patient?
- If you anticipate difficulty, you can palpate the neck and identify and mark the cricothyroid membrane before any intervention
What 5 questions should you address before you even touch the patient?
- Does the airway have to be managed, or would regional be appropriate?
- Do you expect DVL to be difficult? Masking?
- Is a supraglottic (mask or LMA) possible?
- Is stomach empty?
- Can patient tolerate apnea?
What should you always give before you do a fiberoptic airway?
Glyco
What is some of the equipment used for difficult airways?
- Intubating LMA
- bougie
- light wand
- optical stylet
- Alternative laryngoscopes
- Upsher, airtraq, Bullard
When is the Upsher laryngoscope useful?
- Helpful with visualization when you are unable to align the oral, pharangeal, and laryngeal axes
- anterior larynx
- unstable cervical spine fx
- upper body burns
- trauma
- TMJ immobility
- micrognathia
- Must have mouth opening of 15 mm
- Only for oral intubations
- OK with RSI
- No pediatric version
When is the Bullard Laryngoscope good to use?
- All the same reasons as the Upsher
- Can be used for oral AND nasal intubations
- Can be used with a mouth opening of 6 mm
- OK for RSI
- Available in pediatric sizes
What is important to know about the Airtraq?
- It is single use
- allows view of glottic opening without aligning the axes
- requires a minimal mouth opening of 16-18 mm
- LED must be turned on 30 seconds prior to use
Who is the combitube used in?
- Adults only; often in the ER
- Can be inserted without visualization
- known esophageal disease is a contraindication
What are the different kinds of video laryngoscopes?
- Glidescope
- C-MAC
- Mcgrath series 5
- Mcgrath Mac
- “channeled scopes”
- Airtraq
- The Airway Scope
What is Retrograde Endotracheal Intubation?
- A wire or plastic stylet is passed through the cricothyroid membrane and is then coughed out of the larynx into the oropharynx
- The ETT is then inserted into the larynx over the wire
How is a percutaneous cricothyrotomy done?
- A 14 gauge angiocath is inserted through the cricothyroid membrane angled caudally
- The correct position is confirmed by aspirating air
- Attach a standard ETT connector to the syringe and then must use the jet ventilator
What I:E ratio do you use with a Jet ventilator through an angiocath?
1:3-4
How do you use the cricothyrotomy kits?
What are the benefits of awake intubation?
- Maintain spontaneous respiration
- patient can cooperate
- maintain esophageal sphincter tone and decrease aspiration risk
- can test neurological function post intubation
What praparation should be done for an awake intubation?
- Patient education
- sedatives
- antisialogogue med
- If nasal, vasoconstriction (cocaine/ neosynephrine)
- Aspiration prophylaxis if high risk
- supplemental O2
How is a glossopharyngeal nerve block done?
- Use a tongue blade to move the patient’s tong to the opposite side of the mouth
- Inject LA using a 25g spinal needle inferiorly to pilars
- 1-2 ml 2% lidocaine
- OR Spray cetacaine or hurricaine spray to inferior border of pillars
- OR use cetacaine, hurricaine, lidocaine soaked gause and place it at inferior border of pillars
- Lidocaine gargle
How is a superior Laryngeal Nerve Block done?
- Pts head extended with clinician standing on side to be blocked
- Identify hyoid bone
- displace hyoid bone toward clinician
- Use 23g 1.75 cm needle inserted directly inferior to border of the cornu perpendicular to skin
- insert 1/4 inch caudad and 1/4 inch medial until eld to pass through the thyrohyoid ligament (approx 1-2 cm)
- Aspirate
- inject 1-2 ml of LA above and 1-2 ml of LA below the thyrohyoid membrane
How is a transtracheal block done?
- Use a 23 g butterfly needle attached to a syringe to inject 5 ml of 2% lidocaine through the cricothyroid membrane
- continuously aspirate while advancing needle through membrane in a posterior direction perpendicular to the floor
- air bubbles verify placement in the tracheal lumen
- Instruct pt to exhale fully prior to injection–inject on inspiration
- pt will cough and will spread lidocaine
- make sure to hold needle/syringe steady
What are the common reasons for failure of fiberoptic intubation? (7)
- lack of provider experience
- failure to adequately dry the airway
- failure to adequately anesthetize the airway
- nasal cavity bleeding
- obstructing base of tongue
- ETT/scope diameter ratio too large
- flexible scope fogging
What should you take into consideration when trying to decide to extubate a pt with a difficult airway?
- type and length of surgery
- condition of pt
- skills and preference of anesthetist
- evaluation of clinical factors that may cause adverse impact on ventilation after extubation
- back up plan if pt is unable to maintain adequate ventilation
What follow-up should you do for a patient with a difficult airway?
- inform patient and family of difficult airway
- meticulous documentation to help with future procedures
- registration with an emergency notification service to decrease adverse airway related outcomes
