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!!!!! Advanced Anesthesia I !!!!! > Difficult airways > Flashcards

Difficult airways Flashcards

1
Q

First four steps of the dificult airway algorythm

(stop at the algorithm)

A
  1. Asssess the likelyhood of basic management problems
    • Difficult ventilation
    • Difficult intubation
    • Difficulty with consent or cooperation
    • Difficult tracheostomy
  2. ​Deliver supplimental oxygen throughout
  3. Consider merits and feasible management choices:
    1. Awake vs intubation after general anesthesia
    2. Non-invasive vs invasive technique to intubation
    3. Preservation vs Ablation of spontaneious ventilation
  4. ​Develop primary and alternative strategies
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2
Q

Develop primary and alternative strategies

Side A

A
  1. Awake intubation
    • invasive or non-invasive approach to intubation
  2. If this FAILS
    • Cancel case
    • consider feasibility of other options
    • if you attempted a non-invasive approach - you can attempt an invasive approach
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3
Q

Develop primary and alternative strategies

Side B

Non-emergency pathway

A
  1. The initial intubation was unsucessful
  2. Consiter from here on:
    1. Calling for help
    2. Returning to spontaneous ventilation
    3. awakening the pateint
  3. ​If you are ABLE to mask ventilate it is the NON-EMERGENCY pathway
    • ​this means the intubation failed but ventilation is adequate
  4. ​​Alternate approaches to intubation
    • ​​try a different blade
    • use the LMA as a conduit
    • Use and intubating stylet
    • Retrograde intubation
    • Light Wand
    • Blind oral/nasal intubation
  5. ​Still fail after multiple attempts
    • ​Consider invasive airway access (tracheostomy, cricothyrotomy)
    • Consider other feasible options
    • Awaken the patient
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4
Q

Develop primary and alternative strategies

Side B

Emergency pathway

A
  1. The initial intubation was unsucessful
  2. Consiter from here on:
    • Calling for help
    • Returning to spontaneous ventilation
    • awakening the pateint
  3. If facemask ventilation is not adequate
    • Consider/Attempt an LMA
  4. ​If the LMA is not feasible and you are UNABLE to mask ventilate it is the EMERGENCY pathway
    • ​this means the intubation failed unable to provide adequate ventilation
  5. ​​​CALL FOR HELP!!!
  6. Emergency NON-Invasive airway ventilation
    • ​Rigid bronchoscope
    • Esophageal-tracheal combitube ventilation
    • Transtracheal jet ventilation
  7. ​If this fails go to INVASIVE airway ventilation
    • ​tracheostomy
    • cricothyrotomy
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5
Q

Difficult Airway Management

Pink one

A
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6
Q

ASA Difficult Airway Algorythm

A
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7
Q

Radiological studies have shown this maneuver is the most improtant to maintain space between the pharyngeal soft tissues

A

Head extension

(it stretches the anterior neck structures and move the hyioid bone and attached structures anteriorly)

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8
Q

Four principals central to the prevention of complications during tracheal intubation

A
  1. Maintinence of oxygenation
  2. Trauma must be prevented
  3. Must have a sequence of backup plans before staarting the primary technique
    • sometimes the safest plan is to stop attempts, awaken the patietn and postpone the surgery
  4. Call for help as soon as difficult tracheal intubation is experienced
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9
Q

Five predictors of difficult mask

A
  1. Age
  2. Facial hair
  3. Snore (Apnea)
  4. Edentulous (No teeth)
  5. BMI >26
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10
Q

Four things you can do if you are having difficulty initially

A
  1. Pull back
  2. ventilate
  3. re-group
  4. change positions
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11
Q

Two techniqes for preoxygenation.

What does this do?

A
  1. Tidal volume breathing
  2. Four deep breaths within 30 seconds

(both increase arterial oxygen tension, and provide a longer time to desaturation)

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12
Q

What is the goal of preoxygenation?

A

TO fill the FRC(alveoli), arterial compartment and tissue compartment to increase the duration of safe apnea time

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13
Q

What is the barrier between the upper and lower airway?

A

Glottis

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14
Q

Normal mouth opening distance

A

3 - 4 cm (2-3 FB)

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15
Q

Precautions for nasal airways

A

Epistaxis and anticoagulants

Nasal and basilar skull fractures

Adenoid hypertrophy

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16
Q

Big caution with oral airways

A

LARYNGOSPASM

bleeding

soft tissue damage

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17
Q

What should we remember to do before placing a nasal airway?

A

Lube that sucker up

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18
Q

When is a mask case ok?

A
  1. Pt doesn’t have difficult airway
  2. Airway obstruction is easily relieved with oral/nasal airway or chin lift
  3. Short case duration
  4. Surgeon doesn’t need access to head/neck (exception to the rule: bilateral myringotomy tubes)
  5. Head will be accessible for the entire case
  6. No airway bleeding/secretions
  7. No table position changes
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19
Q

When in the induction sequence can an LMA be placed?

A

After loss of lash reflex and confirmation of mask ventilation

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20
Q

Who should not have an LMA placed?

A

Anyone considered a full stomach

(non-fasting, parturients 34+ weeks, uncontrolled GERD, trauma, acute abdomens, diabetics d/t autonomic neuropathy, low pulmonary complience)

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21
Q

LMA advantages

A
  • ↑ speed & ease of placement by inexperienced personnel
  • Improved hemodynamic stability at induction & during emergence
  • ↓ anesthetic requirements for airway tolerance
  • Lower frequency of coughing during emergence
  • Lower incidence of sore throats in adults (10% vs 30%)
    • Avoids “foreign body” in the trachea
  • Patient can be fully emerged prior to removal of LMA → good for asthmatic patients
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22
Q

LMA disadvantages

A
  • Lower seal pressure
  • Higher frequency of gastric insufflation → risk for aspiration
  • Esophageal reflux more likely
  • Inability to use mechanical ventilation at higher pressures
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23
Q

LMA - when do you deflate the cuff

A

Keep the cuff inflated until the patient is awake → DO NOT DEFLATE at END OF CASE

Keeps secretions from getting on vocal cords

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24
Q

ETT indications

A
  1. Airway compromise
  2. Airway inaccessible
  3. Long surgical time
  4. Surgery of head, neck, chest, or abdomen
  5. Need for controlled ventilation & positive end-expiratory pressure
  6. Inability to maintain airway with mask/LMA
  7. Aspiration risk
  8. Airway disease
  9. Pregnancy
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25
Q

How far to insert the ETT

A

males - 23 cm

females 21 cm

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26
Q

RSI Sequence of Events

A
  1. Adjuncts → aspiration prophylaxis
    • Bicitra, reglan, protonix
  2. Monitors, suction on & placed at head of bed
  3. Supine “sniffing” position
  4. Sedation (Versed) if applicable
  5. Pre-Oxygenate 5 minutes or Minimum 4-5 VC Breaths!
  6. Sellick’s Maneuver = Cricoid pressure
  7. Induction agent followed by succinylcholine
    • Wait 60 seconds → watch the clock NOT the block!
  8. Attempt Laryngoscopy → visualize vocal cords → place ETT inflate cuff
  9. Confirm tracheal tube placement:
    • Chest rise
    • BBSE
    • Confirm presence of EtCO2
  10. Give assistant permission to release cricoid pressure
  11. Ventilate
  12. Start inhaled anesthetic or anesthetic infusion
  13. Ventilator on
  14. Secure ETT/tape eyes
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27
Q

Potential Hazards in Airway Management

A
  • Dental damage
  • Soft tissue/mechanical injury
  • Laryngospasm
  • Bronchospasm
  • Vomiting/Aspiration
  • Hypoxemia/Hypercarbia
  • SNS stimulation
  • Esophageal/Endobronchial intubation
  • Endobronchial intubation evident by → high airway pressures, unilateral chest rise & breath sounds, ↓ O2 saturation
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28
Q

Extubation Criteria

A
  • TV: >6 mL/kg
  • VC: >10 mL/kg
  • RR:
  • If >30 could mean pain or anxious
  • SaO2: >90%
  • ETCO2:
  • If EtCO2 is too low → can ↓ RR or ↓ VT
  • Sustained tetanic contraction
  • Closed grip fist for 5 seconds
  • Sustained head lift for 5 seconds
29
Q

Laryngospasm interventions

A
  • Jaw-Lift Maneuver
    • Forward displacement of the mandible with O2 administered by mask with positive pressure
  • Administration of O2 with continuous positive pressure
    • Strong intermittent pressure applied manually to a bag full of O2 can force gas effectively through the upper airway & adducted cords
  • Immediate removal of the offending stimulus
  • Small dose of short acting muscle relaxant succinylcholine 20-40 mg
30
Q

when is it allowed not to test-ventilate a patient before insertion of the ETT/LMA?

A

in RSI

31
Q

Nasal Tracheal Intubation: Asleep Sequence of Events

A
  • Phenylephrine to nose (AFRIN) or consider Anticholinergic/Antisialogogue (glycopyrrolate)
  • Monitors, Supine “sniffing” position, Sedate (Versed)
  • Pre-Oxygenate
  • Induction Agent
  • Confirm loss of consciousness
  • Attempt ventilation if able to ventilate →
  • Muscle Relaxant
  • Consider dilation of nare with sequential sizes of nasal airways → choose nare that is easily able to breathe through in preop
    • Consider induction agent may be wearing off
  • Insert LUBRICATED ETT through nare (that was dilated)
  • Continue to ventilate
  • Attempt direct visual laryngoscopy → visualize VC → use Magill forceps to pick up end of ETT & advance through cords
  • Inflate cuff
  • Confirm tracheal tube placement:
    • Chest rise
    • BBSE in all lung fields & over stomach
    • Confirm presence of EtCO2
  • Ventilate
  • Start inhaled anesthetic or anesthetic infusion
  • Ventilator On
  • Secure ETT/tape eyes
32
Q

Extubation guidelines

A
  • Nearly fully awake extubation is performed when the patient has
    • Purposeful movement
    • ready to maintain & protect his/her own airway
  • Muscle relaxant must be fully reversed & confirmed with PNS
  • Anesthetic medications, including anesthetic gases & infusions, turned OFF
  • Oropharynx is suctioned
  • The patient is self-maintaining an acceptable respiratory rate & depth (see respiratory extubation criteria*)
  • Assess for responsiveness / purposeful movement &/or responding to commands
    • A sustained (5 second) head lift is an excellent way to assess clinically adequate reversal
  • ETT is removed while a positive-pressure breath is given with the anesthesia bag to allow subsequent expulsion or secretions away from the glottis
33
Q

This is the only muscle that ABDUCTS the vocal ligaments

A

Posterior cricoarytenoid muscles

34
Q

What is the most narrow part of the adult and pediatric airways?

A

Pediatric - cricoid cartilage

Adults - glottis (6 - 9 mm)

35
Q

Posterior cricoarytenoid

what do they do

who innervates it

A

Only abductor of the cords!! Opens the glottis

Recurrent laryngeal nerve

intrinsic muscle

36
Q

Lateral cricoarytenoid

function

nerve

A

Adducts the cords

Recurrent laryngeal nerve

intrinsic muscle

37
Q

Arytenoids

function

nerve

A

Closes the glottis (esp the posterior)

Recurrent laryngeal nerve

intrinsic muscle

38
Q

Crycothyroid

function

nerve

A

Produces tension and elongates the cords

superior laryngeal nerve

39
Q

Thyroarytenoid & Vocalis

A

Shortens and relaxes the cords

recurrent laryngeal nerve

40
Q

Sensory and Motor Function of the Superior Laryngeal Nerve (Internal branch)

A

Sensory only!!

Base of tongue

Epiglottis

Supraglottic mucosa

2 joints (thyroepiglottic and cricothyroid joints)

41
Q

Sensory and Motor Function of the Superior Laryngeal Nerve (External branch)

A
  • Sensory:
    • Anterior subglottic mucosa
  • Motor:
    • Cricothyroid muscle (adductor/tensor)
42
Q

Sensory and Motor Function of the recurrent laryngeal nerve

A
  • Sensory
    • Subglottic mucosa
    • Muscle spindles
  • Motor
    • Thyroarytenoid
    • Lateral cricothyroid
    • Interarytenoid
    • Posterior arytenoid
43
Q

Proper Snifing position

A

pillow under the head (not soulders)

35° neck flexion and 15° head extension (angles relative to horizontal planes)

44
Q

Difficult Airway Management

Pink one

A
45
Q

ASA Difficult Airway Algorythm

A
46
Q

Ten airway assesment concerns,

A
  1. Length of Upper Incisors → Long
  2. Relation of maxillary & mandibular incisors during normal jaw closure → Prominent Overbite
  3. Interincisor distance → Less than 3 cm (2 FB)
  4. Visibility of uvula → Mallampati > II
  5. Shape of palate → Highly arched or very narrow
  6. Compliance of mandibular space → Stiff, occupied by mass, non-resilient
  7. Thyromental distance → Less than 3 ordinary finger breadths
  8. Length of neck → Short
  9. Thickness of neck → Thick
  10. Range of motion of head & neck → Cannot touch chin to chest or extend neck
47
Q

What is the 3-3-2 Rule

A
  • 3 fingers fit in mouth → Inter incisor distance
  • 3 fingers fit from mentum to hyoid
  • 2 fingers fit from the floor of the mouth to top of thyroid cartilage
48
Q

Thyro-Mental Distance significance

A
  • Measure from upper edge of thyroid cartilage to chin with the head fully extended
    • A short thyromental distance = anterior larynx
    • > 7 cm is usually = easy intubation
    • < 6 cm = difficulty airway
49
Q

Medical History and potential difficult airway considerations

Thyroid disease

A
  • Does the patient have goiter or enlarged thyroid mass?
  • Check for tracheal deviation
  • possible tracheomalacia
    • which would be more problematic for extubation criteria rather that intubation.
50
Q

Medical History and potential difficult airway considerations

Cancer

A
  • Head and Neck cancer
    • may involve previous surgical intervention or medical intervention for chemo and radiation.
  • Radiation to neck is known to cause tissue to become fibrotic
    • leading to stiff neck structures internally and externally.
51
Q

Medical History and potential difficult airway considerations

Asthma

A
  • If moderate to severe = want to optimize respiratory status before surgery.
  • Be prepared for laryngospasm
  • ​choose anesthetic drugs that would not cause reactivity
    • ie. Histamine releasing drugs or Beta 2 antagonists
    • think about your muscle relaxants and induction agents
52
Q

Medical History and potential difficult airway consderations

GERD

A

Consider

  1. rapid sequence intubation
  2. pre-treat with prokinetics
  3. non-particulate antacids.
53
Q

Medical History and potential difficult airway considerations

Diabetes

A
  1. Stiff joint syndrome
    • can patient do the “prayer’s sign”
    • 1:4 adolescent diabetics present with this.
    • Due to Glycosylation of collagen tissues.
    • Joints involved TMJ, antlantooccipital joint, cervical spine
    • results in limitation of head and neck mobility
  2. Autonomic Neuropathy secondary to DM
    • occurs in approx 1:10 diabetics → this increases 4-5 fold in patients with coexisting HTN.
    • Anhydrosis (failure of sweat glands)
    • Gastroparesis→ predispose patients to N/V, GERD, and aspiration
    • impotence, urinary retention, early satiety.
54
Q

Medical History and potential difficult airway considerations

Obesity

A
  1. redundant tissue
    • upon induction can cause obstruction
    • may make mask ventilation difficult or impossible.
55
Q

Medical History and potential difficult airway considerations

Genetic Disorders

A
  1. Down’s syndrome, Treacher collins
    • maxillofacial malformations = large tongues, small mouth, receding chin
    • antlantooccipital joint instability
56
Q

Medical History and potential difficult airway considerations

Rheumatoid Arthritis

A
  1. antlantooccipital joint instability
    • need to keep neck in neutral position
    • may NOT be able to align axis’ as well.
57
Q

Medical History and potential difficult airway considerations

Sclerodema

A
  • Connective tissue disorder
    • stiff TMJ may make mouth opening difficult
58
Q

Medical History and potential difficult airway considerations

Hypothyroidism

A
  • Large tongue
  • Abnormal soft tissue (myxedema)
  • May be difficult to ventilate and intubate
59
Q

Medical History and potential difficult airway considerations

Pierre Robin Syndrome

A

Airway management usually requires awake fiberoptic intubation; patients usually present with:

  • Micrognathia
  • Small mouth/Large tongue
  • U-shaped cleft palate (50% of patients)
  • Airway Obstruction secondary to glossoptosis
60
Q

Surgical History and potential difficult airway considerations

tracheaostomy

A
  • potential for traceheal stenosis
  • may require smaller ETT
61
Q

Surgical History and potential difficult airway considerations

Neck Dissection

A
  • patient may have had radiation therapy
  • they may present with fibrotic/stiff tissue
62
Q

Surgical History and potential difficult airway considerations

Uvulopalatopharyngoplasty (UVPP)

A

uvulopalatoplasty for sleep apnea

  • may present with
    1. large tongue
    2. large/short neck
    3. obesity.
  • More emergence issues
63
Q

Surgical History and potential difficult airway considerations

Cervical Neck Instrumentation

A
  • usually secondary to cervical stenosis and depending on level of surgical intervention may present with decreased extension
64
Q

What are some potential airway obstructions to be concerned about?

What are some assement signs of obstruction?

A

Potential airway obstructions:

  • Tongue
  • Blood
  • Vomitus
  • Dentures
  • Tumors
  • Epiglottis
  • Foreign Object?

Assessment signs of Obstruction = could be difficutlt AW

  • stridor when they breathe = likely could be a difficult airway
  • Hoarseness
  • Recurrent papilloma
  • Epiglottis cyst
  • Lingual tonsil hyperplasia
65
Q

The most frequent timing of poor outcomes in the operative period

A
  1. At induction! When we have controll
    • ​they also resulted in brain damage or death
  2. Additionally Nearly ALL difficult airway claims that happen in non-OR or PACU result in brain damage or death!
    • can’t ventilate/can’t inubate
66
Q

5 Questions Before You Even Touch the Patient regurding airway management

A
  1. Does the airway have to be managed? or is Regional appropriate?
  2. Will DVL be difficult? Mallampati
    • Class 1 (85% NOT DIFFICULT),
    • Class 2 (9%)
    • Class 3 (5%)
    • Class 4 (1%)
  3. Is Supraglottic airway use possible? Mask or LMA?
    • Ask the ? Before injecting induction drug → What if I am wrong, will I be able to ventilate?
  4. Stomach empty?
    • even though you think it is empty, may be very nervous and increased secretions
  5. Can the patient tolerate apnea?
67
Q

Five predictors of difficult mask-

A
  1. Age
  2. Facial hair
  3. Snore
  4. Edentulous
  5. BMI >26
68
Q

BURP Maneuver

A

To help visualize the airway on DVL

  1. Backward
  2. Upward
  3. Right Pressure

!!!!! Advanced Anesthesia I !!!!! (9 decks)

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