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difficult airways Flashcards

1
Q

A difficult airway is:

A
    1. Difficulty with mask ventilation or ventilation with SGA
    1. difficulty with endotracheal intubation (difficult DL)
    1. Or both
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2
Q

must investigate

A

a flat capnograph

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3
Q

if mask ventilation and SGA ventilation fail, should exclude

A

laryngospasm

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4
Q

trachea begins at

A

level of C6 and extends to about T5

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5
Q

Ophthalmic (V1) nerve

A

sensory:

  • anterior ETHMOID
  • anterior MUCOUS MEMBRANES
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6
Q

Maxillary (V2) nerve

A

Sensory:

  • sphenopalatine
  • POSTERIOR mucous membranes
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7
Q

Mandibular Nerve (V3)

A

Sensory:

  • anterior 2/3rds of tongue

Motor:

  • muscles of mastication
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8
Q

Glossopharyngeal Nerve (CN9)

A

sensnory:

  1. Roof of pharynx
  2. tonsils
  3. under surface of palate
  4. Posterior 1/3 of tongue
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9
Q

Superior Laryngeal Nerve (SLN)

A

Superior Laryngeal Nerve (SLN)

External -

sensory:

  • ​Below epiglottis

motor:

Cricothyroid muscle (cords tense)

Superior Laryngeal Nerve (SLN)

internal -

sensory:

  • to laryngeal mucosa - blocked in awake intubation
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10
Q

SLN sensory innervation:

A

external branch: below epiglottis

internal branch: laryngeal mucosa

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11
Q

Recurrent Laryngeal Nerve

A

Recurrent Laryngeal Nerve

Sensory:

  • below vocal cords

Motor:

  • all INTRINSIC muscles of the larynx except cricothyroid muscles (“cords tense” -> SLN”)
  • includs posterior cricoarytenoid.
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12
Q

Injury to SLN

A
  • voice hoarseness
  • motor: cricothyroidarytenoid “cords tense”
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13
Q

Injury to RLN

A
  • unilateral: hoarseness
  • bilateral: r/f partial or total occlusion of vocal cords
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14
Q

Hypoglossal N (CN12)

A

motor:

  • all intrinsic and extrinsic muscles of the tongue
  • except PALATOGLOSSUS (vagus)
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15
Q

Complications r/t Pierre-Robin Syndrome

A

Complications r/t Pierre-Robin Syndrome

  • micrognathia
  • macroglossia
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16
Q

Treacher-Collin’s Syndrome Airway Effects

A

Treacher-Collin’s Syndrome

  1. auricular defects
  2. ocular defects
  3. malar/manidublar hypoplasia
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17
Q

Goldenhar’s Syndrome Airway Effects

A

Goldenhar’s Syndrome Airway Effects

  1. Auricular defects
  2. ocular defects
  3. malar/mandibular hypoplasia
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18
Q

Down’s syndrome airway effects

A

Down’s syndrome airway effects

  1. Poorly developed or absent bridge of nose
  2. macroglossia
  3. Small mouth
  4. atlanto-axial instability
  5. small subglottic diameter - subglottic stenosis
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19
Q

Klippel-Feil Syndrome Airway Defects

A

Klippel-Feil Syndrome Airway Defects

  1. congenital fusion of a variable number of cervical veretebrae - cervical spine abormality
  2. limited ROM
  3. small-underdeveloped mandible
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20
Q

Turner Syndrome Airway Effects

A

Turner Syndrome Airway Effects

​- frequent/complex abnormality affecting women.

  1. short neck
  2. maxillary/mandibular hypolasia
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21
Q

epiglottitis

A
  • bacterial infection of epiglottis,
  • may lead to emergent airway,
  • potentially life threatening.
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22
Q

Croup

A
  • viral mediated inflammation
  • may see “steeples sign” on CXR
  • laryngeal edema
  • airway irritabiltiy
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23
Q

Ludwig’s Angina

A
  • Abcess in the floor of the mouth under the tongue
  • edema/obstruction/distortion of airway/trismus
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24
Q

Acromegaly Airway Considerations

A
  1. macroglossia
  2. hypertrophy of laryngeal tissue
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25
Q

Hemtoma an airway risk with

A
  1. thyroidectomy
  2. tonsillectomy
  3. neck dissection
26
Q

short thyromental distance

A

<6 cm = anterior airwa, difficult intubation

27
Q

class IIa is associated with

A

4.3-13.4% risk of difficult intubation

28
Q

class IIb is associated with

A
29
Q

class III is associated witih

A

80-87% chance of difficult intubation

30
Q

glossopharyngeal nerve block abolishes

A

airway reflexes

31
Q

Glossopharyngeal Nerve Block Anesthetizes

A

Glossopharyngeal Nerve Block Anesthetizes

  1. the posterior 1/3 of the tongue
  2. oropharynx
  3. laryngopharunx up to the valleculae
  4. anterior surface of epiglottis
  5. ABOLISHES GAG REFLEX.
32
Q

Glossopharyngeal Block

intra-oral approach

A

Glossopharyngeal Block

intra-oral approach

  • block at the base of the palatoglossus and palatopharyngeal folds
  • need sufficient mouth opening
  • need 25 g needle, position INFERIOR to tonsillar pillars
  • 1-2 mls of 2% lidocaine
33
Q

Glossopharyngeal Nerve Block

Peristyloid Approach:

A

Glossopharyngeal Nerve Block

Peristyloid Approach:

  • posterior to styloid process (external)
  • close proximity to INTERNAL carotid
  • 5-7 mL of 2% lidocaine

“peristyloid approach aims to infiltrate LA just porior to the styloid process where the glossopharyngeal nerve lies”

34
Q

Superior Laryngeal Nerve Block

anesthetizes

A

Superior Laryngeal Nerve Block

  • anesthetizes
    • external SLN: sensory below epiglottis above vocal cords
    • internal: laryngeal mucosa
35
Q

SLN block approach

A
36
Q

Direct RLN blocks are

A

not performed as these would result in bilateral vocal cord paralysis and airway obstruction as botht motor and sensory fibers run together.

37
Q

Upsher laryngoscope blade

A
  • is for adults only
  • fits 7-8 ETT
  • fixed curve with lighted channel
  • good for small mouth openings (15 mm)
  • requires MINIMAL head manipulation
  • can be used for awake intubation
  • insert horizontal then turn vertical
  • RIGID, fiberoptic laryngoscope
38
Q

criteria for “difficult mask” ventilation

A
  1. inability for one anesthesia provider to maintain saO2 >92%
  2. Significant gas leak around mask
  3. Need for >4L of gas flow
    • or need of FGF button more than 2x
  4. No perceptible chest rise
  5. Two handed mask required
  6. >20-25 cm H2O pressure to inflate the lungs
  7. Change of operator required

“Incidence of DMV varies from 0.08 to 0.15%, varies due to absence of universally accepted defintion of DMV”

  • varies due to absence of accepted defintition, provider experience, reporting, diverse populations
39
Q

Risk factors for DMV

A
  1. prence of beard
  2. edentulous
  3. Higher BMI
  4. Male gender
  5. Age >55
  6. Hx of snoring/OSA
  7. Increased neck circumferences
  8. Hx of difficult intubation
  9. Mallampati 3/4
  10. severely limited jaw portrusion
40
Q

combitube

“king tube”

A
  • ONLY for ADULTS
  • twin lumen device designed for emergency situations and difficult airways (EMTs in field)
  • Can be inserted without the need for visualization into the oropharynx
  • Usually enters the esophogus
  • Low volume inflatable distal cuff
  • Much larger proximal cuff designed to occlude the oro-pharynx
  • If the tube has entered the trachea, ventilation is achieved through distal lumen.
  • Enters the esophogus and ventilation is achived through multiple proximal aperatures situated above the distal cuff-proximal and distal cuffs have to be inflated to prevent air from esacping through the esophogus or back out of the oro and nasopharynx.
  • Does not allow for long term airway control
41
Q

combietube sizes

A
  1. 37F: patient below 5’
  2. 41F: patient above 5’
42
Q

combitube balloons

A
  1. distal, small, 15 mLs of air - WHITE
  2. proximal (blue), large, 85 mLs of air
43
Q

Insertion of combietube

A
  1. pt supine with neutral head alignment
  2. use left hand for chin life and insert the combietube until the upper incisors are between the two black lines
  3. Inflate the distal (white) cuff with 12 mLs of air.
  4. attempt to ventilate, if breath sounds - tracheal
  5. no breath sounds, inflate proximal cuff, 50-75 ml of iar
  6. listen for breath sounds
  7. confirm with capnography
44
Q

Complications of combietube

A
  1. sore throat
  2. dysphagia
  3. upper airway damage
  4. esophogeal rupture (rare)
  5. increased stress response
  6. needs to be replaced with ETT to fully protect airway
45
Q

Relative Contraindications to Emergent Airways

A
  1. fracture to larynx
  2. Laryngotracheal disruptions
  3. Transection of the trchea
  4. Young children <12
46
Q

Transtrachel jet ventilation

A
  • connect to O2 osurce, to DISS not machine
  • open flow regular 1/2 turn
  • adjust pressure regulator to 20-20 PSI
  • attach catheter airway device,
  • 15-20 breaths perminute, 1:3 or 1:4 ratio
47
Q

Increased extubation complications associated with

A
  1. Paradoxical Vocal Cord movement
  2. Thyroid surgery
  3. Tracheomalacia
  4. Diagnostic Laryngoscopy
  5. Uvulopalatoplasy
  6. Sleep apnea
  7. Maxillofacial trauma
  8. parkinson’s disease
  9. RA
  10. inadequate protective airway reflexes
  11. prolonged prone or trendelenberg
  12. anaphylaxis
48
Q

extubation criteria

A
  1. vital capacity >10mL/kg
  2. peak negative IF -20 cm H2O
  3. Tidal volume > 6mL/kg
  4. TOF ratio >70%
  5. Aa gradient <350
49
Q

retrograde intubatino is C/I in pts

A

with infection above the level of the trachea

50
Q

syndromes with macroglossia

A
  • big -> Beckwith
  • tongue -> Trisomy 21
51
Q

Syndromes with small mandibles

A

Micrognathic:

  • “Please” - Pierre-Robin
  • “Get” - Goldenharr
  • “That” - Treacher Collins
  • “Chin” - Cru di chat
52
Q

Syndromes with Cervical Spine Anomaly

A
  • “kids” - Klippel-Fiel
  • “Try” - trisomy 21
  • “Gold” - Goldenhar
53
Q

Complicatoins r/t Treacher Collins

A
  • micrognathia - manidublar hypoplasia
  • small mouth
  • nasal airway is blocked - choanal atresia
    • ocular and auricular anomalies
54
Q
A
55
Q

Cri du Chat airway effects

A
  • small, underdeveloped mandible, mandibular hypoplasia
  • laryngomalacia
  • stridor
56
Q

Max PPV pressure with LMA

A

20 cm H2O

57
Q

Max LMA cuff pressure

A

40-60 cmH2o

58
Q

tendency of airway device placement to activate the SNS

A
  1. combitube (most likely)
  2. DVL
  3. Fiberoptic intubation
  4. LMA
59
Q

when to use a bougie

A
  1. with grade III CL view - best time
  2. with grade IIb CL view - next best time

Should NOT use bougie wiht grade IV CL view - success rate is unacceptably low

60
Q

palattoglossus muscle is innervated by

A

vagus nerve

61
Q
A

Advanced Principles (8 decks)

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