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N936 Specialty Techniques > Difficult Airway Lecture; Dr. Pitman > Flashcards

Difficult Airway Lecture; Dr. Pitman Flashcards

1
Q

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

A

difficult tracheal intubation

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2
Q

What is the common anatomic change in unanticipated difficult airways?

A

anatomic variances of the “middle column”- pharynx behind the tongue

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3
Q

What % of difficult airway events are unanticipated?

A

75%

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4
Q

What is LEMON

A 
Look at neck
Evaluate thyromental distance / assessment
Mallampati
Old age >55?
Neck anomalies

Difficulty with intubation

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5
Q

What is BONES

A 
Beard / Mask seal
Obesity / Obstructions
No teeth / Neck
Elderly / Edentulous
Snores
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6
Q

Failed intubations account for what percent of anesthesia related deaths?

A

25%

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7
Q

What is Grade 1, 2, 3, 4 views?

A
  1. everything
  2. see posterior portion of glottic opening
  3. see epiglottis
  4. see nothing
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8
Q

What is a bougie?

5 things

A

feels for tracheal rings “click”

LONG - 60cm
Coude tip: 35-40d bend
Malleable, yet firm

**NO LUMEN FOR INSUFFLATION (cannot ventilate through)

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9
Q

What is the other name for a bougie?

A

Portex Venn Introducer

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10
Q

What are 5 indications for the bougie?

A
  1. unable to pass ETT
  2. Grade 3-4 view
  3. ETT exchange
  4. digital intubation??
  5. adjunct to invasive technique
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11
Q

How do you hold the bougie?

A

like a pencil, with coude tip anterior

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12
Q

How do you place/advance a bougie?

A 
hold like a pencil
coude tip anterior
"hook" epiglottis
advance & feel "clicks"
DO NOT REMOVE laryngoscope
slide ETT over bougie
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13
Q

What maneuver can you do if the ETT is difficult to advance through the glottic opening?

A

use counter-clock turn

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14
Q

What are 4 PEARLS of using the bougie?

A
  1. leave the laryngoscope in place during procedure
  2. rotate the ETT 90d counter-clockwise if needed
  3. use a flexible tip tube
  4. capnography
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15
Q

What is the ETT that has less chance of catching on the glottic opening when using a bougie?

A

Parker Flex-Tip Tube

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16
Q

What are 3 complications of using a bougie?

A
  1. failed intubation
  2. perforation
  3. vocal cord trauma
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17
Q

When should airway exchange catheters be used?

A

an already secure airway needs to be changed out or temporarily removed, but laryngoscopy is likely to be difficult

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18
Q

What are 3 common features of an airway exchange catheter?

A
  1. cm distance markings
  2. central lumen or side ports (can deliver O2 through)
  3. adapter for TTJV or 15mm connector (to circuit)
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19
Q

How does an airway exchange catheter relate to a bougie? 3 ways

A
  1. longer than a bougie
  2. less flexible than a bougie
  3. hollow lumen
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20
Q

What is a big difference between a bougie and an airway exchange catheter (specifically COOK)

A

airway exchange catheters come in pediatric sizes

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21
Q

4 characteristics of a COOK airway exchange catheter

A
  1. radiopaque
  2. distal AND side ports
  3. rapi-fit adapter: luer lock 15mm
  4. distance markers
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22
Q

What are the 2 sizes of the Sheridan exchange catheter?

A
  1. Adult standard: 81mm, 6-10.0 ETT

2. Adult extended (DLT exchange): 100mm, 35-41F Double Lumen ETT

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23
Q

What airway exchange catheter can be used with a double lumen ETT?

A

Sheridan

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24
Q

How is a Frova Intubation Introducer different from a bougie?

A
  1. Hollow lumen to allow for O2 delivery

2. Pediatric versions are available

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25
Q

How is an Endotracheal tube Introducer different from a bougie?

A

10cm longer & stiffer

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26
Q

What does a Parker Flex-It Directional Stylet allow for?

A

allows provider to elevate the tip of the ETT from the proximal end

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27
Q

What are 5 PEARLS of using an airway exchange catheter?

A
  1. HIGH-RISK procedure
  2. have plan A, B, C…
  3. TWO providers minimum
  4. review all previous airway & intubation notes/history
  5. perform a direct laryngoscopy FIRST!
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28
Q

What is a lighted stylet?

A

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

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29
Q

If a lighted stylet is placed into the esophagus, what will happen?

A

the light will disappear

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30
Q

What are 4 indications for use of a lighted stylet?

A
  1. routine use (research shows less trauma?)
  2. difficult airway
  3. can locate tip of ETT when performing a percutaneous tracheotomy
  4. can be used with laryngoscope, LMA, bullard & during retrograde intubation
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31
Q

What is special about the preparation of equipment before using a lighted stylet?

A

BEND IT INTO A HOCKEY STICK!!

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32
Q

What are 4 key preparation steps when using a lighted stylet?

A
  1. lubricate the wire stylet
  2. lubricate the flexible wand
  3. attach ETT, clamp proximal end to handle
  4. BEND TIP 90d like a field-hockey stick
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33
Q

How is a patient positioned when using a lighted stylet?

A

LOW!!

and you are HIGH!!

**do not place the patient in sniffing position!

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34
Q

What do you NOT do when using a lighted stylet?

A

place the patient in sniffing position

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35
Q

When using a lighted stylet, when do you retract the wire stylet?

A

when the light is noted below the laryngeal prominence

retract it 10cm

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36
Q

How much do you retract the wire stylet when the light of the lighted stylet is noted below the laryngeal prominence?

A

10cm

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37
Q

After retracting the wire stylet of the lighted stylet, what do you do?

A

advance the wand until glow disappears below the sternal notch (this is about 5 cm above the carina)

then unclamp the ETT and advance

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38
Q

What are 6 PEARLS of using the trachlight?

A
  1. full muscle relaxation is recommended
  2. Jaw-thrust or mandible lift
  3. insert device midline
  4. when a faint glow is seen above the larynx, lifting the jaw or tongue will raise the epiglottis and facilitate the wand towards the vocal cords
  5. when the wand enters the glottic opening, a well-defined light will be observed below the laryngeal prominence
  6. if resistance is met when attempting to advance ETT, rotate it 90d
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39
Q

When do you perform a needle cricothyrotomy?

A

CAN’T INTUBATE, CAN’T VENTILATE

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40
Q

How long is a needle cric good for?

A

10min

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41
Q

The moment you decide to needle cric, what do you do?

A

CALL FOR SURGICAL AIRWAY

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42
Q

Where is needle cric in the ASA difficult airway algorithm?

A

the FINAL OPTION

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43
Q

What does the needle cric do?

A

provides rapid access to the airway, able to provide O2 but you cannot remove CO2 through it (ineffective)

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44
Q

What equipment do you need to perform a needle cric?

A
  1. 14G needle
  2. 3-way stop-cock
  3. 3mL syringe with some saline in it
  4. oxygen source/ adapter from a 7.5ETT
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45
Q

What are the 2 techniques of performing a needle cric?

A
  1. landmark technique

2. ultra-sound guided

46
Q

What MUST you remember after performing a needle cric?

A

you must allow for passive exhalation

alternate O2 delivery and passive exhalation

47
Q

How is the needle inserted when performing a needle cricothyrotomy?

A

needle is inserted with dominant hand; 45d angle caudally (towards the patient’s feet)

aspirating while inserting until bubbles are noted then STOP

48
Q

What are 3 indications for retrograde intubation?

A
  1. failed intubations
  2. urgent airway required, but cords CANNOT be visualized
  3. elective based upon patient condition
49
Q

What are 5 contraindications for retrograde intubation?

A
  1. unfavorable anatomy
  2. laryngotracheal disease
  3. coagulopathy
  4. infection
  5. mass
50
Q

What equipment is needed to perform a retrograde intubation?

A
  1. sedation or local anesthesia
  2. cleaning solution
  3. wire
  4. needle driver
  5. needle
  6. syringe
51
Q

What is the ideal patient position for performing a retrograde intubation?

A

sniffing position with the head HYPER-EXTENDED to improve access to the neck

52
Q

How is anesthesia done for a retrograde intubation?

A

AWAKE

  • anesthetize the airway
    1. translaryngeal & superior laryngeal nerve block (greater cornua of the hyoid bone)
    2. translaryngeal with topicalization of the pharynx
    3. glossopharyngeal nerve block with superior laryngeal nerve block with nebulized anesthetic
53
Q

Where does the puncture site occur during a retrograde intubation?

A

can occur above or below cricoid cartilage

54
Q

What is the benefit/downside of puncturing the cricothyroid membrane during retrograde intubation?

A

less bleeding but greater chance of failed intubation

55
Q

What is the benefit/downside of puncturing the cricotracheal ligament during retrograde intubation?

A

higher success rate & lower incidence of vocal cord trauma, but higher risk of bleeding

56
Q

What is the size of the cricothyroid membrane?

A

1cm tall

2cm wide

57
Q

What becomes insignificant moving from lateral to medial cricothyroid membrane?

A

the cricothyroid artery

58
Q

What are the 3 techniques of retrograde intubation?

A
  1. classic - epidural catheter
  2. J-wire
    3 J-wire / introducer
59
Q

What is the most important step when performing a retrograde intubation?

A

CLAMP the distal end of the wire with hemostats once the proximal end has exited via the naso- or oro-pharynx

60
Q

How is the fiberoptic retrograde intubation technique different from the wire technique?

A 
once the wire has been placed, 
the proximal (face) end is threaded through the suction port of the fiberoptic scope allowing for a direct pathway to the vocal cords

ETT is passed over the fiberoptic scope into the glottic opening

**continuous O2 can be delivered through the fiberoptic scope during the procedure

61
Q

What is one advantage to using the fiberoptic scope during retrograde intubation?

A

O2 can be delivered throughout the procedure

62
Q

What are 3 PEARLS of retrograde intubation?

A
  1. CTM is associated with less bleeding but a lower success rate
  2. use a smaller ETT (6.5-7.0)
  3. J-wire technique:
    • less traumatic
    • easier to retrieve
    • less prone to kinking
    • can be used with fiberoptic
    • takes less time to perform
63
Q

What are 4 complications of retrograde intubation?

A
  1. bleeding
  2. subcutaneous emphysema
  3. nerve injury
  4. broken wire
64
Q

What is the GOLD STANDARD for management of a difficult airway?

A

Awake fiberoptic intubation

65
Q

What are 4 benefits of awake fiberoptic intubation?

A
  1. spontaneous ventilation is maintained
  2. airway patency is maintained
  3. larynx does not move into an anterior position
  4. awake patients can monitor own neurologic status
66
Q

What is the leading cause of patient M&M in the ASA closed claims analysis?

A

airway management failure

67
Q

What is the universally accepted “gold standard” in the awake, sedated, or anesthetized difficult to intubate patient?

A

awake fiberoptic intubation

68
Q

What are the 3 main parts of the endoscope?

A
  1. handle
  2. insertion tube
  3. flexible tip
69
Q

What are the 5 parts of the fiberoptic handle?

A
  1. power source
  2. suction/valve
  3. working channel
  4. angulation control lever
  5. lens with focusing capability
70
Q

At what position is the black “notch” located on the fiberoptic scope?

A

12 o’clock

71
Q

What are the 4 components inside of the fiberoptic insertion tube?

A
  1. light guide bundles
  2. transmit source
  3. angulation wires
  4. working channel
72
Q

What kind of fibers run the length of the fiberoptic insertion tube?

A

glass

73
Q

How many glass fibers from the fiberoptic scope can fit into a human hair?

A

20

74
Q

What happens when a glass fiber of the fiberoptic scope is damaged?

A

a “black spot” will appear in the image

75
Q

How many angulation wires are in a fiberoptic insertion tube?

A

2

76
Q

In what plane do the angulation wires run in the fiberoptic insertion tube?

A

the sagittal plane

77
Q

The working channel of the fiberoptic insertion tube can provide what 4 things?

A
  1. oxygen
  2. suction
  3. medication portal
  4. specimen collection
78
Q

What does the flexible tip of the fiberoptic scope provide?

A

it contains the charged-coupled device (CCD) chip and a second lens

79
Q

What is the field of view of the fiberoptic scope?

A

75-120d

80
Q

What are the 4 reasons anesthesia is required before performing an awake fiberoptic?

A
  1. prevent discomfort
  2. decrease psych stress
  3. minimize hemodynamic changes
  4. increase pt cooperation
81
Q

Successful airway anesthesia includes what 3 blocks?

A
  1. trigeminal nerve block (nasal intubation/scope)
  2. glossopharyngeal nerve block (GPN)
  3. laryngeal nerve blocks
82
Q

What CN is the trigeminal nerve?

A

5

83
Q

What CN is the glossopharyngeal nerve?

A

9

84
Q

What CN is the vagus nerve?

A

10

85
Q

The trigeminal nerve provides sensory innervation to:

A

the face

  • ophthalmic
  • maxillary
  • mandibular
86
Q

The glossopharyngeal nerve provides sensory innervation to, what?

A
  • posterior 1/3 of the tongue
  • oropharynx
  • vallecula
  • anterior epiglottis

*AFFERENT branch of the gag reflex

87
Q

If you want to eliminate the gag reflex, which cranial nerve should you target?

A

CN 9, the glossopharyngeal nerve

88
Q

What are the 2 branches of the Vagus nerve important to the larynx?

A

Recurrent laryngeal nerve
Superior Laryngeal nerve
- Internal branch
- External branch

89
Q

What does the internal branch of the superior laryngeal nerve innervate?

A

sensory innervation from the posterior epiglottis to the vocal cord folds

90
Q

What does the external branch of the superior laryngeal nerve innervate?

A

motor innervation below the vocal cords

91
Q

What does the recurrent laryngeal nerve innervate?

A

Sensory innervation below the vocal folds & trachea

Motor innervation to ALL intrinsic laryngeal muscles

92
Q

Where does the recurrent laryngeal nerve branch off of the Vagus nerve?

A

in the thorax

93
Q

What does the recurrent laryngeal nerve loop around?

A

the right side loops under the subclavian artery

the left side loops under the aorta

94
Q

What are the advantages to using an oral airway during fiberoptic intubation?

A

protects the bronchoscope

allows passage of ETT up to 9.0

95
Q

What is a swivel adapter?

A

allows for continuous ventilation without an airway lead (can put a scope, etc down the ETT with the ventilator attached)

96
Q

Using a flexible-tip ETT protects what anatomic structure?

A

the arytenoids

97
Q

What are 4 indications for awake fiberoptic intubation?

A
  1. anticipated difficult mask ventilation/intubation
  2. difficult airway w/ comorbidities likely to result in poor outcome if intubation not achieved
  3. failed asleep intubation
  4. small mouth
98
Q

What 6 pieces of equipment are needed to perform an awake fiberoptic intubation?

A
  1. IV access
  2. FOB cart & airway cart (test light and movement)
  3. O2 delivery system
  4. TWO suctions
  5. Monitors (SpO2 is MANDATORY)
  6. Medications
99
Q

When explaining a FOB intubation to a patient, what should be included?

A
  1. benefits of FOB
  2. probable amnesia
  3. local airway anesthetic administration
  4. patient assistance during the procedure
100
Q

What 3 types of medication should be given to patients for an awake fiberoptic intubation?

A
  1. Antisialagogue
  2. Sedation
  3. Nasal Drops
101
Q

What type of antisialagogue mediation should be given to patients for an awake fiberoptic intubation and when?

A

Glycopyrolate 0.2-0.4mg
Atropine 0.4-0.6mg

15-20 minutes before procedure

102
Q

What type of sedation medication should be given to patients for an awake fiberoptic intubation and when?

A

dexmedetomidine to maintain spontaneous ventilation gold standard

103
Q

What type of nasal medication should be given to patients for an awake fiberoptic intubation?

A

Phenylephrine 0.5% mixed with Lidocaine 2-4% spray

*used to vasoconstrict

104
Q

Complete local airway anesthesia requires: (4)

A
  1. glossopharyngeal nerve block (GPN)
  2. superior laryngeal nerve block (SLN)
  3. Transtracheal block
  4. Trigeminal / nasal block
105
Q

What nerve innervates the gag reflex?

A

glossopharyngeal nerve

106
Q

What nerve innervates the cough reflex?

A

superior laryngeal nerve

107
Q

What is the motion of the FOB when intubating?

A

“down, up, down”

down - through oropharynx

up - toward anterior commissure

down - through vocal cords

108
Q

What is the most important contraindication for using the FOB for intubation?

A

lack of skill by the anesthesia provider

109
Q

What are contraindications for performing an awake FOB intubation?

A
  1. lack of skill by the anesthesia provider
  2. lack of trained assistant or equipment
  3. wild, uncooperative patient
  4. near-total upper airway obstruction (retrograde wire preferred)
110
Q

If there is a near-total upper airway obstruction, what type of intubation procedure is preferred?

A

retrograde wire intubation

111
Q

What are 4 considerations when extubating a difficult airway patient?

A
  1. awake vs deep
  2. clinical symptoms that will impair ventilation
  3. management plan if unable to maintain adequate ventilation
  4. short-term use of an airway exchanger
112
Q

What are 3 parts of follow up documentation for the patient with a difficult airway?

A
  1. differentiate between difficult ventilation and difficult intubation
  2. description of management techniques used; what was beneficial vs detrimental
  3. provide the patient with information for future care/cases
    • letter
    • medical alert bracelet?

N936 Specialty Techniques (4 decks)

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