Mod 2 Difficult Airway Management Flashcards
4 Types of Assessments for a Difficult Airways?
- Difficult Bag Mask (Roman)
- Difficult Laryngoscopy and Intubation (Lemon)
- Difficult Extraglottic Device (Rods)
- Difficult Cricothyotomy (smart)
Why is difficult Bag Mask Ventilation important?
- Ventilates patient
- Oxygenation; buys time for other treatments
What is classified as a Failed Airway?
Failure to maintain oxygen sats during or after 1 or more laryngoscopy attempts (C.I.C.O)
- CICO = Can’t intubate, Can’t oxygenate
What are 3 main stays/signs for a failed airway?
- CICO (bagging no longer viable)
- 2 failed attempts at orotracheal intubation by exp person
- Single best attempt at intubation fails in the forced to act situation
What are 3 golden rules for Bag Mask Ventilation (BMV)?
Edit don’t like this card
- Manual vent skills w/proper equipment
- Anybody can be oxygenated and ventilated w/bag and mask (usually)
- Bagging should be mastered before intubation
What does successful Bag Mask Ventilation (BMV) largely depend on? (3)
- Patent airway
- Adequate mask seal
- Proper ventilation
Indicators of difficult Bag Mask Ventilation?
MOANS or ROMAN (updated version of MOANS)
What does the abbreviation ROMAN assess?
Difficulty of airway management
- R: Radiation/Restriction
- O: Obesity/Obstruction/OSA (triple O)
- M: Mask seal
- A: Age
- N: No teeth
What type of “O” categories would cause airway management to be difficult? (Roman)
O in Roman measures obstruction level, factors that would affect quality of oxygenation and ventilation would be:
- Increased weight of chest
- Decreased diagrammatic excursion
- Increased resistance secondary to swelling or adipose tissue
What “Radiation or Restriction” considerations would cause airway management to be difficult?
- Radiation would involve burns?
- Restrictions would involve resistance to ventilation, high vent pressures (restrictive disease), or hyperinflation (obstructive disease)
What considerations could affect the mask seal?
Trauma or beards
What age group is considered harder to intubate?
Older than 55
- Floppier airways
should dentures be taken out or left in during intubation?
Left in because the face will cave in without the structure of teeth or dentures
- would this apply to BMV or Intubation?
How does LEMON assess a difficult airway?
- L: Look externally
- E: Evaluate 332 rule
- M: Mallampati score
- O: Obstruction/obesity
- N: Neck mobility
When “looking externally” at the neck and mouth. what should be assessed? (5)
- DCAP BLS TIC
(Deformities, contusions, abrasions, penetrations, burns, lacerations, swelling, tenderness, instability, crepitus) - Excessive Bleeding
- Tracheal Deviation
- JVD
- Obvious Masses
Caudad vs Saudad?
- Probably not important to know?
- Saudad towards the head
- Caudad towards the tail bone
What does the Mallapati score assess?
It grades the view of how much of the back of the mouth can be seen
- The tonged and the pharynx are the main objects of comparison
- has 4 grades, 3&4 are potential difficulty airways
- inset pic from slide 14
What are the 4 cardinal signs of airway obstruction?
- Muffled (hot potato voice)
- Difficulty swelling secretions
- Stridor; insp particularly
- Sensation of dyspnea
How is Neck Mobility assessed?
C Spine is measures the distance between the lower border of mandible to thyroid notch at full neck extension
- Distance should be greater than 4 fingers in adults at full extension
What does extraglotitis mean?
Airways outside of the epiglottis
What does RODS assess?
Difficulty with extraglottic devices
- R- Restriction (Like in ROMAN)
- O- Obesity/Obstruction
- D- Disrupted or Distorted Airway
- S- Short Thyromental distance (less than 6 cm indicates potential difficulty)
What does SMART assess?
Difficult Cricothyrotomy
- S- Surgery or other airway disruption (Eg. Radical neck/jaw etc.)
- M- Mass (hematoma and/or infection, abscesses)
- A– Access/Anatomy (inability to access or assess the structures/landmarks )
- R- Radiation distortion (scar tissue)
- T- Tumors
Why aren’t Cricothrytomies typically performed on kids?
There isn’t enough access via the cricoid
- trachestomies are still performed, just usually not via cricoid.
- Access in “smart” also refers to kids
Why are Cricothyrotomies performed if tracheostomies are used for the same if not similar function?
To provide oxygen and ventilation, its a rescue technique.
- performed if no other access is available
What does the Cormack and Lebanese Laryngeal view grades assess?
How much of the glottis opening you can see with a laryngoscope blade
- 4 grades
- insert image from slide 23
How do you know if you have a difficult airway?
- Can’t ventilate, can’t oxygenate
- Cormack and Lebanese laryngeal view
DAM Cart?
Difficult Airway Management Cart
How many kinds of artificial airways are there?
slide 2
What is the function of Pharyngeal Airways?
Used to elevate the tounge off the posterior pharyngeal wall and away from the hard/soft palates
- Establishes patent airway by allowing spontaneous ventilation
- basically facilitates flow
- OPA and NPA
How many types of tracheal airways are there?
4
- orotracheal
- Nasotracheal
- Cricothyrotomy
- Tracheostomy
What are 2 extraglottic airway types
Supraglottic and Infraglottic
Where do Oropharyngeal Airways (OPAs) rest?
Keeps the passage open at the mouth.
- Sits distal to the tongue above the glottis opening
- insert slide 4
Indications for Oropharyngeal Airways (OPA)
- Used in pts w/decreased submandibular tone
- When manually ventilating
- Used as aid for deep suctioning
- Bite block
- Some can facilitate intubation
- Bilateral Choanal Atresia in neonates
What would causes of decreased submandibular tone be?
- solution?
Use a OPA to address problem. Causes would be:
- Obtunded secondary to central causes of airway obstruction
- Anaesthesia
- Deep sedation
Contraindications for OPA use?
Patients with obvious oral trauma or awake/semi awake
- can cause gagging/vomiting
- It pt is awake enough to shut or tongue the device, they’re too awake from this OPA
What are some complications with OPA use?
May cause trauma to lips, mouth, and/or teeth
- May cause pressure necrosis
- Difficult to perform mouth care
- May cause gagging and vomiting
Where do Nasopharyngeal Airways (NPAs) rest?
Tip lays distal to the tongue above the glottis opening
- length is more critical than diameter
- measure corner of out to jaw angle (roughly 2 cm)
Indications for NPAs?
Pt is intolerance to OPA
- Can facilitate deep suctioning
- Pierre-Robin Syndrome in neonates (micrognathia, mandibular hypoplasia)
Contraindications for NPA?
Obvious nasal trauma or deformities of the nose
- Basal skull fractures (raccoon eyes or battle signs)
- Coagulation disorders
What is Littles area?
- Keissel becks plexus?
Area where nose bleeds happen most often
- stay away from the septum if you’re inserting something in the nose, it could cause bleeding.
- guide it to the outside of the nose
Complications of NPA use
If too long, it could enter esophagus causing gastric distension and hypoventilation
- could cause vomiting and laryngospasm in semi awake pt
- injury of nasal mucosa w/bleeding
- sinusitis and otitis media
- occlusion of airway be secretions
- tissue necrosis
General indications for use for Extraglottic airways?
As an airway rescue when BMV is difficult and intubation has failed (seal on the inside, over the glottis rather than over the face with a mask) i.e beard.
- In preparation for another device bc CICO aka failed airway
- alt to endotracheal intubation (i.e if procedure is short, don’t risk damaging the vocal cords)
- Can guide endotracheal intubation
Supraglottic vs Infraglottic (retroglottic)
- Supraglottic = above the glottis
- Infraglottic = behind/beyond the glottis (intended to be placed in the esophagus)
What are common Supraglottic airways?
- LMA classic
- LMA FastTrach
- LMA Proseal
- Perilaryngeal Airway
- iGel
How does the “classic” Laryngeal Mask Airways work (LMA)
Closes off the opening so air can’t go into the stomach and can’t escape into the mouth. ‘
- Placed in posterior pharynx, seals region of base of tongue and laryngeal opening
- Air can only go into the mouth
- Similar to ETT w/small mask and inflatable circumferential cuff
Contraindications of LMAs?
Establish airways, but don’t protect the airways. so the following are affected:
- Pts with full stomachs
- Pts w/hiatal hernia (abdominal contents pushing into the chest aka bulging)
- Pts more than 14 weeks pregnant
- Trauma patients
Classic LMA sizes?
insert image 20
What are advantages of LMAs?
Good for short procedures requiring anesthesia or deep sedation. and they’re simple and easy to use (easy to insert).
- Does not require airway manipulation or extreme head positioning
- Hands free airway mana magnet
- some protection of airway from aspiration
- can aid in difficult intubation
- Provides route for fibre optic laryngoscopy or bronchoscope
What is a main drawback of LMA use?
Does not prevent aspiration completely
- Pressures > 20 cmH2O can lead to ventilation volume loss and gas leak around mask/cuff
- Expensive and sizing may not be correct
Complications of LMA use?
Gag reflexes that are intact will cause coughing, straining, and spasm (solved by anesthesia)
- Regurgitation and aspirations
- insert image of others
What is a Fastrach?
A intubating LMA (ILMA)
- combines the high insertion and ventilation success rate of other LMAs w/specifically designed features to facilitate blind intubation
- An epiglottis elevating bar
- A rigid guide channel that directs an ETT anteriorly into the larynx
How does a igel LMA differ from other extraglottic devices like proseals?
They use a gel material and has a non inflatable cuff.
- reduces trauma and easier to insert
- has a gastric channel, beside the connector
- has a bite block, so the pt can’t deflate it
How do you know if you’re in the esophagus or the trachea with a infra(retro)glottis airway (Combitube)
Depends on which tube you can ventilate with and if you get chest rise.
- First tube is number 1 (blue) = sitting in the esophagus
- Second tube is clear/white = in the trachea
What purpose does the second lumen/connector serve if the infraglottic airway is confirmed to be in the esophagus?
It can be used to insert a ng tube
What is the difference between a combitude vs easy tube?
- both are infraglottic airways?
EasyTube has a non-latex distal cuff or lumen
what is a Biannual laryngoscopy?
Involves manipulated the BURP technique (from the intubators perspective)
- involves manipulating the assistings hands
What can you do if basic laryngoscopy is difficult (assuming direct laryngoscopy is the only method available)?
- BURP
- McCoy Blade (laryngoscopy blade that flexes at the tip)
- Gum Elastic Bougie (place ETT over it)
What is the benefit of using a McCoy Blade?
Allows greater lift of the hypoepiglottic ligament
- Lifts epiglottis further out of your field of view
What does a blind nasal intubation require if performed?
Patient needs to be spontaneously breathing
Start reviewing and reading in slide 34
What would you choose a Proseal LMA?
Why is an independent open drain tube desirable?
The opening at the upper esophageal sphincter does provides an escape route for any inadvertently inspired gas, thus preventing gastric insufflation
- Allows drainage of gastric fluids and access to GI tract
- protects the pt against regurgitation and prevents aspiration
- allows blind insertion
What is the primary function of infraglottic (retro) airways?
Allows blind insertion into the esophagus, but still provides an airway inserted into trachea
- 3 types
- Double lumen
What are the 2 categories for endotracheal intubation?
- Visualization (direct or indirect)
- Blind
What is direct visualization technique for endotracheal intubation?
A direct line of sight between the vocal cords and your eyes
What is indirect visualization intubation technique?
Using a instrument to provide the view of the cords
- Fiberoptics (bronchoscope or stylet)
- Video Laryngoscope (glidescope)
- Optically enhanced laryngoscope (Airtraq)
What are the benefits of using Flexible fiberoptics via bronchoscope or stylet?
Can be used for both oral and nasal routes
- Can visualize laryngeal structures prior to intubation
- Can confirm tracheal position
What type of device is a Aintree Catheter?
Flexible fiberoptic bronchoscope
What kind of device is a Airway RIFL?
Fiberoptic Stylet
What are 2 types of Optically enhanced laryngoscopes?
AirTraq and King Vision video laryngoscope
What kind of device is a glidescope?
A laryngoscope with a fiberoptic camera
What is transillumination?
A visualization technique for intubation that involves a lighted stylet and a trach light
- Not in practice anymore
- Don’t worry about this slides
What are 3 blind indirect indicators for intubation placement?
- Transillumination of the neck
- Bind nasal intubation (listen and feel air movement)
- Feel structures of the oropharynx via Tactile digital intubation
What is the purpose of evac tube?
Have a port that opens above the cuff to remove secretions above the cuff
- Reduces ventilator acquired pneumonia
- Port connected to 20-30 mmHg suction
What is the suction pressure of the EVAC tube?
30 mmHg suction
What is a anode tube and when is it used when in place of a ETT?
Has metal rings inside the tube that allows blind of tube w/o occlusion aka armoured tube
- Used during surgery
- Available in different sizes, cuffed and uncuffed
What are advantages of Anode Tubes?
Prevents kinking and collapse of tube under external pressure
Disadvantage of Anode Tubes?
Once kinked it does not rebound to original shape
What are Endotrol Tube (Trigger tube)?
Has a small trigger to angle end of tube anterioly during intubation
- Particularly well suited for blind nasal intubation or w/c spine precautions
- Has a small ring that wraps around the pinky
What are Rae Tubes?
Intended for facial surge; has 2 types
- Can be difficult to pass a suction through tight bends
- Has a preformed curve that directs airway connection away from surgical field w/o kinking tube
- 2nd type is a nasal type
Double Lumen Endotracheal Tube (DLET)
Designed to be inserted into either the right or left main bronchus (or main stem as well ofc)
- Has a distal and bronchial cuff
- Has 2 connectors; each lung can be attached to separate ventilators (1 lung is sicker than the other)
Why do you want smaller tubes when considering evac tubes?
The outer diameters are bigger, so you want to go down half a size
When is DLET used?
When it is desirable to isolate 1 lung such as thoracic surgery
- Independent lung ventilation
- Lug lovage for thick tenacious secretions (alveolar proteinosis)
What conditions or pathophysiologies would benefit from DLET?
- Necrotizing pneumonia
- Lung abscess
- Pulmonary embolus
- Lungs with markedly different compliance and resistance (such as single lung transplant)
What are Laser Tubes
Used for upper airway laser surgery where conventional ETTs may ignite or cuff may be perforated
- Metal Tubes
- cuffs inflated w/water or saline to reduce fire hazard, not air
- Has 2 cuffs in series in case 1 perforates
How do you know if a laser tube has perforated?
Some cuffs have blue markers to indicate perforation
What are some disadvantages to Laser Tubes?
Stiff, bulky, and less stable
- They’re more likely to cause tissue damage when inserted
What is a Bronchial Blocking Tube
Single lumen tube with extra channel fused along its length containing a separate directable bronchus blocking cuff to isolate a lung.
- Blocker cuff can be advanced or retracted on its separate tube which has both pilot and suction channels
- used during surgery when 1 lung is collapsed while other is maintained for oxygenation and ventilation
- Has a stylet that can move around
What are some advantages of Bronchial Blocking Tubes?
Allows for active lung deflation by syringe or suction on blocker lumen
- Can be used to maintain oxygenation and ventialtion if 1 lung collapses
- Allows greater visualization and less movement within the operative hemithorax
- Can be used to block/isolate sections like hemoptysis (ruptured pulmonary artery) so repairs can be made
What is a disadvantage of Bronchial Blocking Tubes?
Increased risk of CO2 retention compared to DLET because it blocks sections of the lungs
What are Jet Tubes?
Allow for Jet ventilation
- Has a monitoring/irrigation lumen that enters tube at the tip
- 3rd port allows for ventilation?
- See if RSV12 has more info
What are additional ports could ETT potential have?
- Medication ports
- Ports to provide supplemental O2 or measure distal airway pressures
When would you use a medication port in the ETT?
Emergencies where vascular access no established
- meds can be instilled w/o interrupting ventialtion
What are Foam Cuff tubes?
- not commonly used or current
Similar to ETT; Have a foam ball in the inside of the cuff; Self sealing, self regulating (supposed to)
- is not reliable to keep a good cuff pressure and does not reliably protect from aspirations
- Is gentle tho
