Intubation and Anatomy of the Airway

Question 1

What do we have to check for and prepare with a tracheal intubation?

Answer 1

• Prepare for Success: A BASIC MAD POSTER

o Airway assessment
o Bag-valve mask
o Airways: OPA and NPA
o Suction
o IV access established
o Capnometry: ETCO2 monitoring
o Monitors: pulse oximeter, ECG, BP cuff
o Audible tone setting on SaO2 monitor
o Drugs: prepared and labeled
o Positioning: optimize for intubation
o Oxygen: preoxygenation
o Stylet: position within the ETT
o Tape
o ETT and laryngoscope
o Rescue: back-up airway plan, resuscitation drugs

Question 2

What is the procedure for tracheal intubation?

Answer 2

1. Position the patient
2. Open the patient’s mouth
3. Perform laryngoscopy
4. Insert ETT through vocal cords and remove laryngoscope
5. Confirm correct ETT placement and secure ETT

Question 3

When we position the patient for tracheal intubation, what is the procedure?

Answer 3

o The patient’s head should be at the height of the physician’s umbilicus
o Sniffing position: cervical flexion, atlantooccipital extension
 Lines the axes of the mouth, pharynx, and larynx in a common plane
 The external auditory meatus should be aligned along the same horizontal plane as the
sternal notch
o Consider optimizing position with a Troop pillow to increase thoracic spine flexion

Question 4

When we position the patient for tracheal intubation, where should the patient’s head be at?

Answer 4

The patient’s head should be at the height of the physician’s umbilicus

Question 5

When we position the patient for tracheal intubation, what is the sniffing position? How do we accomplish this?

Answer 5

o Sniffing position: cervical flexion, atlantooccipital extension
 Lines the axes of the mouth, pharynx, and larynx in a common plane
 The external auditory meatus should be aligned along the same horizontal plane as the
sternal notch

Question 6

When we position the patient for tracheal intubation, how can we optimize the position and how does it do this?

Answer 6

o Consider optimizing position with a Troop pillow to increase thoracic spine flexion

Question 7

When we perform laryngoscopy for tracheal intubation, what do we have to remember?

Answer 7

o Remember to avoid a stooped position as this actually limits visibility of the vocal cords

Question 8

When we insert ETT through the vocal cords and remove laryngoscope for tracheal intubation, how can we improve invisibility of the vocal cords?

Answer 8

o BURP maneuver: improve visibility of the vocal cords with backward, upward, and rightward
pressure on the thyroid cartilage (this is different than the cricoid pressure maneuver)

Question 9

When we insert ETT through the vocal cords and remove laryngoscope for tracheal intubation, before we remove the laryngoscope, what do we need to check?

Answer 9

o Note the ETT depth at the teeth before removing the laryngoscope
 Normal male: 21-24 cm
 Normal female: 18-22 cm

Question 10

When we insert ETT through the vocal cords and remove laryngoscope for tracheal intubation, after we insert it, what do have to remember?

Answer 10

o Remember to inflate the ETT cuff

Question 11

Once we confirm correct ETT placement and secure the ETT, what are procedures?

Answer 11

o Visualize the ETT passing through the vocal cords
o Note ETCO2 returning with every respiration
o Bronchoscope
o Auscultate the lung apices and epigastrium
o Observe chest rise and fall with PPV
o Observe condensation within the ETT lumen
o Palpation or ETT cuff ballottement

Question 12

What are the complications of laryngoscopy and intubation?

Answer 12

• Dental damage
• Airway trauma
• Vocal cord injury
• Laryngospasm
• Recurrent laryngeal nerve damage
• Arytenoid dislocation
• Edema of hypopharyngeal and glottic tissues

Question 13

What is laryngospasm that can happen with laryngoscopy and intubation?

Answer 13

o Stimulation of the superior laryngeal nerve can cause muscle spasms that close the vocal cords

Question 14

How do we manage laryngospasm?

Answer 14

 Gentle PPV (pulse pressure variation), suction of secretions, forceful jaw thrust, deeper anesthesia, succinylcholine

Question 15

What are the indications for tracheal intubation?

Answer 15

The 8 Ps

• PaO2 < 60 mmHg
• PaCO2 > 60 mmHg
• pH < 7.20 in COPD patients with respiratory acidosis (i.e., don’t worry about their PaCO2 > 60 mmHg)
• Puffing (RR > 35 in adults; otherwise patient suffers muscle fatigue)
• Protect against aspiration or impending airway obstruction (e.g., burn victim)
• Provide an airway during airway obstruction
• PPV
• Pulmonary toilet (allow for passage to suction secretions)

Question 16

How do we manage a difficult airway during tracheal intubation?

Answer 16

• Four Levels of Airway Management
  1. BMV (bag-mask ventilation)
  2. LMA (Laryngeal mask airway)
  3. ETT (endotracheal tube)
  4. Surgical airway (i.e., cricothyroidotomy, percutaneous tracheostomy)

Question 17

How do we manage a difficult intubation?

Answer 17

• BURP maneuver
• McCoy laryngoscope (distal articulating tip may deflect obstructive tissue)
• Bougie
• LMA
• Lighted stylet (placement relies on visualizing the light through the neck skin, not laryngoscopy)
• Video laryngoscope (e.g., Glidescope)
• Fiberoptic bronchoscope and awake intubation

Question 18

What are the reasons for opting for tracheal intubatino with laparoscopic procedures?

Answer 18

• Muscle relaxation is required
• Abdominal insufflation impairs spontaneous ventilation
• CO2 insufflation and absorption requires increases minute ventilation to maintain a normal pH

Question 19

What are the drugs that we can administer through an endotracheal tube?

Answer 19

• Naloxone
• Atropine
• Ventolin
• Epinephrine
• Lidocaine

Question 20

What are the indications for tracheal extubation?

Answer 20

- CNS
o Regained gag reflex
o Purposeful movement
- Respiratory
o Spontaneous breathing
o TV > 5 ml/kg
o VC > 15 mg/kg
o NIF > -25 cmH2O
- Neuromuscular
o 5 second head lift
o Train-of-four stimulus
- Cardiovascular
o Hemodynamic stability

Question 21

Which patients are not suited for laryngeal mask airway device?

Answer 21

• Patients with risk factors for gastric aspiration
• Patients with oropharyngeal or retropharyngeal pathology, or foreign bodies
  in the hypopharynx
• Patients with limited mouth opening
• Patients requiring PPV with airway pressures > 20 cmH2O (e.g., restrictive
  or obstructive lung disease, laparoscopy, Trendelenburg position)

Question 22

How do we determine laryngeal mask airway size?

Answer 22

LMA Size Based on
Patient Weight

1 - Neonates < 5 kg
1.5 - 5-10 kg
2 - 10-20 kg
2.5 - 20-30 kg
3 -  30-50 kg
4 -  50-70 kg
5 - 70-100 kg
6 > 100 kg