management of difficult airway

Question 1

Definition of cannot ventilate

Answer 1

Fully trained Anesth ist cannot cause a life-sustaining amount of gas exchange to occur with a jaw thrust and/or OPAW/NPAW

Question 2

Definition of cannot intubate

Answer 2

Fully trained anesthetist cannot place ETT through the cords within a life-sustaining period

Question 3

Causes of inability to ventilate

Answer 3

Laryngospasm (nerve injury/light anesthesia)
Supraglottic soft-tissue relaxation leading to obstruction
Chest wall rigidity
Pathological, glottis, subglottic (like foreign body, edema, infection, vocal cord palsy, stenosis, compression)
Equipment failure (like if your check valves are stuck)

Question 4

Info about an intubating LMA/aka Fastrach LMA

Answer 4

The ETT fits down into an LMA and can be exchanged - allows for ventilation during intubation attempts

Sizes 3,4,5 - can take up to size 8.0 ETT (but it is a specific tube that goes with the LMA)

Question 5

Glidescope (what is it and uses)

Answer 5

Video laryngoscope with integrated high res camera

Uses:

• known difficult airway
• rescue
• anterior larynx
• poor neck mobility

Question 6

Fiber optic intubation indications

Answer 6

Known difficult airway 
Patient with c-spine precautines
Assessment of double lumen ETT placement
Airway evaluation
If you want to keep them awake with their airway reflexes intact

We often use the peds bronchoscope for adult patient because it fits nicely into the internal diameter of the ETT

Question 7

Fiber optic intubation reasons for failure

Answer 7

Need more drugs
Laryngospasm/bronchospasm
Obscured view by blood/secretions/edema
Inexperienced provider is the MOST COMMON reason for failure

Question 8

Disadvantages of a fiber optic scope

Answer 8

Fragile
Expensive
Requires more time and experience
Blood/secretions can obscure view

Question 9

Bullard scope “rigid scope”

Answer 9

Anatomically shaped scope with fiber optic bundle and eyepiece extending at 45deg angle from handle

Rarely used now

Expensive, slow learning curve

Question 10

Wu Scope

Answer 10

Also a rigid scope with fiber optic capabilities

Allows for O2 and suctioning during intubation

Slow learning curve and requires assembly

Question 11

Upsher scope

Answer 11

Rigid scope in form of oropharynx
Attached eyepiece

Slow learning curve

Question 12

Bougie

Answer 12

Eschmann introducer

15fr, 60cm long, end angled at 40deg

Used for poor view because you can feel the tracheal rings when you are in the right space, even if you can’t see that you are there

Question 13

Lightwand

Answer 13

Transillumination of the neck to guide ETT

Larynx not directly visualized - you looked for the lllumination of the neck to guide the placement

Question 14

Combitube

Answer 14

Supraglottic airway device used in emergency airway

Two lumens so it can function whether it is place in the esophagus or the trachea

Question 15

Transtracheal jet ventilation

Answer 15

Used with needle crichothyrotomy

Need high pressure O2 source (about 50psi)

Tidal volume dependent on
I:E ratio
Chest wall and lung compliance

Question 16

What airflow velocity do you need during TTJV with a 14g catheter

Answer 16

1600 ml/s

Question 17

What airflow velocity do you need during TTJV with a 16g catheter

Answer 17

500 ml/s

Question 18

Complications of TTJV

Answer 18

Tracheal mucosa damage, and thickened secretions blocking the airway, resulting from inadequate humidification of inspired gases MOST COMMON
Pneumothorax, pneumomediastinum, subQ emphysema, barotrauma
Tracheal and esophageal rupture
Hematoma
Failure to adequately ventilate
Inadequate delivery of gases

Question 19

Retrograde intubation

Answer 19

Puncture cricothyroid membrane with 18g needle directed cephalon at 45deg angle

Thread j-wire thru needle and out through mouth

Follow ETT over wire guide into trachea

Question 20

Circhothyrotomy

Answer 20

12-14g needle
3ml syringe - no plunger
15mm ETT adaptor from 7.0 ETT
Breathing circuit
TTJV

Question 21

Airway management pearls

Answer 21

Take a careful airway history
Perform a detailed airway exam
Carefully plan for intubation, extubation, and backup plans
Learn and repeatedly practice all airway management skills
First view is the best view - and you cannot beat a good view
Call for help if you need it!
Don’t take away the patient’s ventilation if you have doubts! Keep them breathing

“Plan for the worst and hope for the best”