Resp airway management Flashcards by Bryan Groff

Mallampati mnemonic

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Normal incisor gap? What does this tell you?

2-3 finger breadths or 4cm

Ability to align the oral, pharyngeal, and laryngeal axes

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Normal thyromental distance? What does this tell you?

Helps to estimate the size of the submandibular space

6-9 cm

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How many cm is one finger breadth?

1 finger breadth = 2cm

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Mandibular protrusion test? (Upper bite test)

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What is the atlanto-occipital joint mobility? What is normal?

Ability to place patient in the sniffing position

Normal 90-165 degrees

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What conditions impair the AO mobility?

RA
Ankylosing spondylitis
Trauma
Klippel Feil
Down syndrome
Diabetes

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Cormack and Lehane score

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Easy or difficult intubation for Cormack score;

Grade 1
Grade 2A
Grade 2B
Grade 3
Grade 4

Grade 1+ 2A - Easy
Grade 2B + 3 - Hard (use bougie)
Grade 4 - Requires alternative approach

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You see a Cormack score of 4, should you attempt to intubate?

No - use alternative approach

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mnemonic for difficult mask?

BONES

Beard
Obese
No teeth
Elderly (over 55)
Snoring

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Does a high arched palate predict a difficult intubation or masking?

Difficult intubation

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NPO status

Clear
Breast milk
Nonhuman milk / solid food / formula
Fried or fatty foods

-Clear - 2 hours
-Breast milk - 4 hours
-Nonhuman milk / solid food / formula - 6 hours
-Fried or fatty foods - 8 hours

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What cervical level does the cricoid ring reside? (cricoid pressure)

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Cricoid pressure in newtons and kg before and after LOC?

Before LOC - 20 newtons or 2kg
After LOC - 40 newtons or 4kg

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What are three causes of angioedema?

Anaphylaxis (remove triggering agent and give Epi)

ACE inhibitors (D/C ACEI and give FFP or C1 esterase)

Hereditary angioedema (Give FFP or C1 esterase)

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What is Ludwig’s Angina? How to intubate?

Bacterial infection of cellulitis on the floor of the mouth

Awake nasal or awake trach

DO NOT use retrograde due to do infection

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Large tongue syndrome mnemonic?

Big Tongue

Beckwith syndrome
Trisomy 21

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Small/underdeveloped mandible syndrome mnemonic?

Please Get That Chin

Pierre Robin
Goldenhar
Treacher Collins
Cri du Chat

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Cspine anomaly syndrome mnemonic?

Kids Try Gold

Klippel-Feil
Trisomy 21
Goldenhar

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What position is used for tracheal intubation on a normal adult? What about an obese adult?

Normal - Sniffing
Obese - HELP

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An aggressive jaw thrust, or a mask strapped too tight may injure what nerve?

Facial nerve (CN 7)

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Oral airways

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How is an oral airway measured? What about nasal?

Corner of the mouth to mandible or earlobe

Nasal - Nare to mandible or earlobe

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LeFort fractures

Which two oral airways can be used to fiberoptic intubate through?

Williams and Ovassapian

Can a nasal airway be used in a LeFort 1 fracture?

Yes

Where does the tip of an LMA sit?

Upper esophageal sphincter

What is the most common cause of a nerve injury with an LMA?

Cuff overinflation

Benefits to an iGel?

Gastric Port MRI safe Can intubate through

Which LMA's have a gastric port?

ProSeal Supreme iGel

If you notice gastric contents in the LMA, what position should the patient be placed in?

Trendelenburg and deepen anesthetic Give 100% O2 with a mask Use low FGF and Vt

Most stimulating airway device?

1. Combitube 2. DL 3. Flexible fiberoptic 4. LMA

Combitube sizing?

4-6 feet; size 37 >6 feet; size 41

Inflating the distal balloon occludes what with a Combitube?

Distal cuff - esophagus

Inflating the proximal balloon occludes what with a Combitube?

Proximal cuff - hypopharynx

The blue lumen on the Combitube is what?

Tracheal

The blue lumen on the Combitube is what?

Esophageal

How much air goes into each balloon of the Combitube?

Proximal 70mL Distal 10mL

Contraindications for the Combitube?

- Prolonged use over 2 hours - Intact gag - Zenker's diverticulum

Can a combitube be used with a full stomach and/or a neck injury?

Yes

What is a Bullard laryngoscope good for?

-Small mouth opening < 7mm -C spine issues -Short thick neck -Treacher Collins and Pierre Robin

Do all Axes need to be aligned for the Bullard? Are there any Absolute contraindications?

NO NO Faster than fiberoptic

Best views to use a Eschmann introducer (bougie)?

Grade 3 then Grade 2B

Should you feel clicks or see the holdup sign when using a Bougie?

Yes - you are feeling the tracheal rings

Should a lighted stylet be used in a cant intubate scenario? What about with traumatic laryngeal injury?

No NO

When using the lighted stylet in Peds, should the stylet be bent at a more or less acute angle?

More of an acute angle (60-80 degrees) Adults use 90 degrees The light will be brighter in kids and will also be seen sooner

Best times to use retrograde intubation?

Unstable C spine Upper airway bleeding Takes time so not useful in can't intubate scenario

What PSI is required for a jet ventilator?

50 Psi

What is the youngest age someone can be surgically cricothyroidotomy

6 and under

Are there any absolute contraindications to a trach?

What should be used if suspected failed extubation is likely?

Airway exchange catheter

What else can an airway exchange catheter be used for?

Jet ventilation End tidal measurement Oxygenation insufflation

The glidescope has a bend of what degree?

60 degrees

What are the first two steps in the emergency pathway?

1. Call for help 2. Attempt ventilation with a supraglottic device

Does the PNS cause bronchoconstriction or dilation?

Bronchoconstriction

Does Beta2 stimulation increase or decrease cAMP? How does this affect Ca?

It increases cAMP which decreases Ca

How do anticholinergics help with Bronchodilation?

M3 antagonism which decreases IP3 which decreases Ca

What measures the ability for gas Exhange?

DLCO - based on Ficks law of diffusion 17-25 m:/min/mmHg

Does mild or moderate asthma increase the risk of postoperative pulmonary complications?

Albumin < then what indicates a risk factor for postop pulmonary complications?

< 3.5 * Indicates poor nutritional status

How long does it take PFT to return after the cessation of smoking?

At least 6 weeks

Does short term smoking cessation reduce pulmonary complications?

When does the P50 return to normal after smoking cessation? what about carbon monoxide levels?

P50 - 12 hours Carbon Monoxide - 6 hours

What is the best alveolar recruitment maneuver to reduce atelectasis?

PIP 40cm H20 for 8 seconds then apply PEEP Use lowest FiO2 to prevent absorption atelectasis

With an intrathoracic obstruction, can you move air in or out?

You can move air In INtra = IN

With an extra thoracic obstruction, can you move air in or out?

You can move out Extra = out Can't move air in - something on the outside blocking air from coming in

A patient with asthma bronchospasms right after intubation, what most likely causes this?

Vagal stimulation M3 receptor - bronchoconstriction

Is asthma an obstructive or restrictive disease?

Obstructive

What is the common ABG seen with asthma?

Respiratory alkalosis with hypocarbia

What type of beta blockers should be avoided in asthma?

nonselective because they can bronchoconstrict

Which nerve block should be avoided in COPD? Why?

ISB because the phrenic nerve will be blocked which innervates the diaphragm

Is neuraxial anesthesia good for COPD patients?

Yes ! But must avoid any blockade higher than T6

Which gas is the least likely to cause irritation to the airway?

Sevo

Do volatile agents inhibit the hypoxic pulmonary constriction?

Yes but only at a MAC level > 1.5

Can nitrous produce a pneumothorax in COPD patients?

Yes

What is an immediate treatment for dynamic hyperinflation of the lungs?

Disconnect the circuit

What I:E ratio helps with COPD and auto peeping?

1:2 or 1:3 Longer expiratory phase Also reducing the RR helps

What is a good I:E ratio for restrictive diseases?

1:1 (longer inspiratory time)

Is pulmonary edema a restrictive or obstructive disease?

Restrictive

Do PPI's reduce the incidence of ventilator pneumonia?

No - actually increases

What is Mendelson's syndrome?

Chemical aspiration pneumonitis

What are the two risk factors for Mendelson's syndrome?

Gastric pH < 2.5 Gastric volume >25mL

What must be D/C if a pneumothorax is suspected?

Nitrous

Where does the 14g needle need to be placed for a pneumothorax?

2nd intercostal space mid clavicular line

Two best indicators of a venous air embolism?

Air observed on TEE Mill wheel murmur

How is a venous air embolism treated?

100% FiO2 Flood surgical field with saline Left lateral decubitus position Aspirate air from CVC

How does PEEP affect PVR?

Increases

How does acidosis affect PVR?

Increases

How does increase PaO2 affect PVR?

Decreases

How does ketamine affect PVR?

Increases

How does nitrous affect PVR?

Increases

Hyperbaric is indicated If CoHgb exceeds what percent

25%

100% FiO2 should be administered until CoHgb is less than?

What is used instead of a DLT in children under 8?

Bronchial blocker

DLT sizes?

Female < 160cm - 25 French Female>160cm - 37 French Male<170 - 39 French Male>170 - 41 French

Absolute indications for OLV?

Infection Hemorrhage Bronchopleural fistula Unilateral cyst or bulla Unilateral pulmonary lavage

Two most common complications of a mediastinoscopy?

1. Hemorrhage 2. Pneumothorax

Where should a BP cuff and pulse ox be placed during a mediastinoscopy?

BP cuff - L arm Pulse ox - R arm (incase the innominate artery is compressed)

What are the two types of ARDS?

Pulmonary - pneumonia, COVID, aspiration, smoke inhalational, drowning Extra-pulmonary - Sepsis, burns, shock, TRALI, TACO

What are the three stages of ARDS?

1. Exudative 2. Proliferative 3. Fibrotic

What type of ventilator settings should be used in ARDS?

Low tidal volume PEEP Keep Plateau <30

Most common pulmonary cause of ARDS? What about extra pulmonary?

1. Pneumonia 2. Sepsis

4 pathologic features of ARDS?

1. Protein rich pulmonary edema 2. Loss of surfactant 3. Hyaline membrane formation 4. Long term injury

Best vent setting for ARDS?

Pressure control

O2 goal for ARDS?

PaO2 = 55- 80 SaO2 = 88-95 Permissive hypercapnia may be required