RSI, reintubation, extubation complications and difficult airway

Question 1

describe aspiration prevention

Answer 1

1) pharmacological aspiration prophylaxis
- goal: reduce amount ( 2.5 pH) of gastric contents
- liquid acid neutralizer (Bicitra)
- prokinetic agent (Reglan)
- acid secretion prevention with proton pump inhibitors (PPIs: Prilosec) and/or H2 antagonists (Pepcid/zantac)
2) preoxygenate/denitrogenate as usual
3) rapid sequence induction (RSI)
- rapid injection of propofol and succs

Question 2

describe rapid sequence induction (RSI)

Answer 2

objective: prevent pulmonary aspiration
1) decreases time b/w when protective airway reflexes are eliminated and airway protection is secured (seconds matter!) *speeds up intubation
2) attempts to protect airway when protective reflexes are eliminated by occluding gastric pathway to airway (cricoid pressure: occludes gastric pathway to block anything from coming up)

Question 3

what are RSI indications?

Answer 3

• patients at an increased risk for aspiration of gastric contents
• trauma (includes falls with fractures: once trauma occurs, digestion stops, so even if > 6 hrs consider “full stomach”)
• esophageal obstruction
• NPO guidelines not followed
• acute abdomen and bowel obstruction
• active GI bleeding or upper airway bleeding (nausea)
• pregnancy (consider “full stomach”)
• abdominal mass or ascites increasing risk of gastric content expulsion
• severe GERD (N/V)

Question 4

describe RSI prep

Answer 4

• check equipment immediately prior to induction
• be sure ETT has stylet
• ensure competent airway personnel present for cricoid pressure
• position for optimal laryngoscopy

Question 5

describe RSI procedure

Answer 5

• adequate preoxygenation/denitrogenation
• slam induction agent then immediately give paralytic
• perform cricoid pressure maneuver
• if bag mask ventilating while waiting for paralytic effect then do not exceed pressure > 20 cmH2O (introduces air into gastric cavity and gastric insufflation increases risk of aspiration)
• laryngoscopy, intubation, inflate cuff
• *verify ETT position before releasing cricoid pressure

Question 6

describe cricoid pressure procedure

Answer 6

using Sellick’s maneuver

• thumb and index finger pressing downward on the cricoid ring will compress the esophagus against the cervical vertebrae
• cricoid pressure effectiveness often debated
• RSI with cricoid pressure prevents gastric contents form exiting up through esophagus and insufflation d/t PPV forcing air into stomach
• esophagus to the right of trachea in 75% of people

Question 7

what are some complications of cricoid pressure?

Answer 7

• may produce poor view during intubation (mask ventilation NOT affected)
• increased risk for esophageal rupture if vomiting

Question 8

what are contraindications to cricoid pressure?

Answer 8

• airway trauma
• lack of properly trained assistant
• fractured larynx or cricoid
• active vomiting
• esophageal foreign body near cricoid (C6)
• esophageal disease
• cervical fracture near the cricoid (C6)
• no suspected spinal injury
• do RSI w/o cricoid pressure

Question 9

what are alternatives to RSI?

Answer 9

• regional anesthesia (*always be prepared for a tracheal intubation if regional fails or regional results in airway compromise such as a high spinal)
• awake intubation (maintains protective airway reflexes)
• tracheostomy under local
• delay in surgical procedure (if surgery is non-urgent/emergent)

Question 10

what are some complications of intubation during laryngoscopy and intubating?

Answer 10

• malpositioning: esophageal intubation, endobronchial intubation, laryngeal cuff supraglottic
• airway trauma: tooth damage, lip/tongue/mucosal laceration, sore throat, dislocated mandible, retropharyngeal dissection
• physiologic reflexes(sympathetic outflow): HTN, tachycardia, intracranial HTN, intraocular HTN, laryngospasm
• tube malfunction: cuff perforation

Question 11

what are some complications of intubation while the tube is in place?

Answer 11

• malpositioning: unintentional extubation, endobronchial intubation, laryngeal cuff position
• airway trauma: mucosal inflammation and ulceration, excoriation of nose
• tube malfunction: ignition, obstruction

Question 12

what are some complications of intubation following extubation?

Answer 12

• airway trauma: edema and stenosis (glottis, subglottic, or tracheal), hoarseness (vocal cord granuloma or paralysis), laryngeal malfunction and aspiration
• physiologic reflexes
• laryngospsasm

Question 13

describe bronchospasms

Answer 13

• occurs during intubation or extubation
• reactive airway disease (RAD) increases risks: asthmatics, bronchitis, URI
• characterize by inability to ventilate

Question 14

how are bronchospasms treated?

Answer 14

• 100% O2
• beta 2 agonist like albuterol
• lidocaine IV or ETT if intubated
• deepen volatile anesthetic if intubated or masked
• IV atropine, epinephrine, fentanyl

Question 15

describe steps for emergence

Answer 15

• establish spontaneous breathing first
• increase CO2 level to stimulate breathing (do by decreasing TV and RR)
• stimulate to awaken: verbal and physical (moving arms and calling name); noxious stimulation (ETT movement; surgical field and incision) *blocks are reducing this stimulus
• removal of agents that promote sleep: versed (remains for hours), fentanyl (may or may not remain), volatile agent (remove by ventilation), paralytic (reverse)

Question 16

describe the steps extubation

Answer 16

• can be done deep or awake depending on:
• surgery (hernia, ENT, sling, carotid endarterectomy want deep since coughing will increase pressure in areas of surgery)
• pt. history (aspiration risk, difficult intubation, OSA want light since pt. needs protective reflexes and want fully awake and breathing)
• desire smooth , atraumatic extubation
• avoidance of coughing: lidocaine, narcotic, pull deeper

Question 17

what are criteria for extubation?

Answer 17

• adequate NMBA reversal
• 4/4 TOF with sustained 5 second tetanus w/o fade
• TV and RR adequate to eliminate CO2
• strong hand grip, cough, and sustained head lift > 5 sec.
• airway reflexes: swallowing and tongue movement
• maintain oxygenation/ventilation w/o stimulation

Question 18

what are crucial questions to ask before extubating?

Answer 18

• can I maintain a patent airway post-extubation? (effectively ventilate and oxygenate)
• can I reintubate easily if needed? (don’t take tube if difficult intubation unless positive pt. is awake, following commands, and can maintain ventilation)
• are aspiration risks reduced?
• can pt. maintain oxygentation and ventilation as evidenced by adequate RR rate and TV?
• is paralytic reversed?
• have protective airway reflexes returned? (aspiration risks are reduced)

Question 19

describe extubation procedure

Answer 19

• suction the oropharyngeal cavity
• administer a positive pressure breath
• remove air from cuff and gently remove ETT while monitoring the airway for exhalation (exhalation during extubation ensures that secretions are projected away from cords)
• do not pull at the end of expiration or secretions will be sucked in on inspiration
• immediately apply supplemental O2 and PPV via facemask while maintaining seal
• listen and feel for air movement (crowing and turbulent sounds indicate air movement but partially obstructed airway; risk laryngospasm)
• PP breathing good with crowing since pushes air in

Question 20

describe laryngospasms

Answer 20

-glottic closure reflex
-more prevalent in young adults and children
causes:
-light anesthesia, stage 2 extubation (hyperirritable)
-direct glottis, supraglottic stimulation
-irritation from inhaled agents
-foreign bodies on cords (blood/secretions)
-stimulation of periosteum, celiac plexus or dilation of rectum
signs/symptoms:
-high pitched squeaking or crowing indicates some air is moving
-absence of sound indicates complete closure

Question 21

describe the treatment of laryngospasms

Answer 21

• suction all secretions from cords and mouth
• forward displacement of mandible (jaw thrust) moves tongue off posterior pharynx
• continuous PP with 100% O2
• paralytic agent: Succs 10-20 mg (1/2- 1 cc)
• IV lidocaine
• laryngospasm notch (at soft tissue just behind earlobes, push both sides firmly inward towards skull base while simultaneously pushing anterior similar to jaw thrust; should break within 1-2 breaths)
• work quickly to prevent desaturation and negative pressure pulmonary edema
• reintubate if unable to maintain oxygenation

Question 22

describe negative pressure pulmonary edema (NPPE)

Answer 22

• results when a strong inspiratory effort against a totally occluded airway generates increased negative intrathoracic cavity pressure (occluded ETT, laryngospasm)
• fluid enters the lungs resulting in pulmonary edema
• more pronounced in young, muscular patients
• light pink or white frothy foam with coughing
• unable to maintain oxygen saturation
• CXR to confirm

Question 23

how is NPPE treated?

Answer 23

• remain intubated
• Lasix
• 100% O2
• PEEP
• sedation

Question 24

describe glottic edema

Answer 24

-repeated intubation attempts resulting in trauma to laryngeal structures and glottic opening
-stridor can indicate glottic edema
-results in partial or total airway obstruction
causes:
-ETT too large and tight fitting
-excessive coughing while intubated

Question 25

what is the treatment for glottic edema?

Answer 25

- IV steroids (Decadron) - racemic epinephrine - humidified O2 - may require reintubation or tracheostomy in severe cases

Question 26

what are common complications of extubation?

Answer 26

- coughing: * increased bleeding * break incisions/sutures and hernia repairs * promote vomiting and aspiration * increase intraocular and intracranial pressure * trauma to glottic opening and arytenoids - HTN and tachycardia d/t increased SNS outflow - hypoventilation and transient hypoxemia

Question 27

what surgeries and conditions are associated with a high risk extubation?

Answer 27

- thyroid surgery: hematoma or swelling, nerve injury (RLN or ex-SLN), tracheomalacia - maxillofacial surgery - deep neck infections - cervical spine surgery - carotid endarterectomy - posterior fossa surgery - tracheal resection - preexisting airway obstruction: Parkinson's syndrome, rheumatoid arthritis, epidermolysis bullosa, pemphigus - tracheomalacia or bronchomalacia - airway instrumentation: diagnostic laryngoscopy or rigid bronchoscopy - paradoxical vocal cord motion (dysfunction)

Question 28

describe re-intubation

Answer 28

- "...potentially and fundamentally different from the original intubation" - 70% r/t anesthesia management (pulled too early) - usually urgent or emergent - pt. likely hypoxic, hypercapnic, acidotic, agitated, or hemodynamically unstable - larynx and tongue edematous - increased secretions

Question 29

what are indications of re-intubation?

Answer 29

- post-extubation airway compromise | - sustained hypoxemia and hemodynamic instability

Question 30

what is the ASA definition of a difficult intubation?

Answer 30

"the clinical situation in which a conventionally trained anesthesiologist experiences difficulty with mask ventilation of the upper airway, difficult with tracheal intubation, or both."

Question 31

in addition to what is the next step, what questions should be a concern once the initial intubation attempts have failed?

Answer 31

- can I ventilate and oxygenate? - should I use alternate airway device while considering next step? - continued amnesia- IV induction agent will redistribute. should I need to supplement inhalation agent or redoes with IV induction agent to maintain MAC amnesia? - should surgery be cancelled or postponed and pt. awakened and brought back in the future for an awake controlled intubation? (can depend on whether the surgery is urgent or elective)

Question 32

what are the two types of difficult airways?

Answer 32

- anticipated | - unanticipated

Question 33

describe an anticipated difficult airway

Answer 33

- plan and control the airway from beginning to end - safest plan is awake tracheal intubation under topical anesthesia (don't lose breathing or protective airway reflexes) - most useful equipment is the flexible fiberoptic bronchoscope - alternatives to tracheal intubation such as an LMA (not if aspiration risk or paralytic required), MAC, regional anesthesia - avoid non depolarizing NMBA b/c renders pt. unable to resume SV if intubation fails (can use Succs) - minor surgery can be potentially done with inhaled induction and mask

Question 34

describe an unanticipated difficult airway

Answer 34

- cant be prevented so be prepared! (know where difficult airway cart is) - should be skilled in alternative airway management - don't be afraid to call for help - awakening the pt. is an option - emergency situation vs. airway compromise must be weighed - LMA is an est. technique

Question 35

describe the airway approach algorithm

Answer 35

1) must the airway be managed a- yes, next question; b- no, regional 2) is there potential for a difficult laryngoscopy? a-yes, next question; b- no, proceed with it 3)can a supralaryngeal (LMA) ventilation be used? a- yes, next question; b-no, awake or SV 4) is the stomach empty? a- yes, next question; b-no, awake or SV 5) will the pt. tolerate an apneic period? a-yes, proceed with induction, SLA must be present b- no, awake or SV

Question 36

describe a cannot intubate, cannot ventilate (CICV situation

Answer 36

- can be caused by repeated unsuccessful attempts at intubation (bleeding and swelling; no patency) - non-invasive before invasive airway rescue - insertion of a supraglottic airway device can be pursued * insertion of LMA in the CICV situation has a significant failure rate (tissue edema changes airway anatomy) - cricothyrotomy is the percutaneous invasive airway choice when non-invasive techniques do not restore oxygenation and ventilation (cannula or surgical)

Question 37

describe Anectine (Succs) use in RSI and difficult intubation

Answer 37

- with RSI, used to shorten the timeframe that the airway is left unprotected by reflexes to reduce aspiration risks - in difficult airway, used to rapidly paralyze pt. to shorten time needed from induction to intubation; this way the pt. can return to SV and awaken if intubation is unsuccessful

Question 38

what would be the airway management plan be for... - 47 y/o male, 365 lbs., 6'0, - OSA, cpap at night - receding chin (thyromental distance 3 cm) - mallampati IV - doesn't tolerate lying flat - surgey: bowel resection d/t obstruction - a

Answer 38

- must airway be managed? yes - is there potential for a difficult laryngoscopy? yes - can a supraglottic device be used? no * plan: awake fiberoptic intubation * most providers will still use succs and proceed with standard oral intubation

Question 39

what would the airway management plan be for... -65 y/o, 70 kg male -CABG, 3 minute preoxygenation -3000 mcg fentanyl given -chest and abdomen become rigid -unable to effectively ventilate; sat drops next step?

Answer 39

- RSI and ventilation | - use of either non depolarizing or depolarizing NMBA to break stiff chest d/t too much fentanyl

Question 40

-78 y/o female -fell and broke hip while leaving a restaurant 8 hrs ago -ate full steak, baked potatoes and tea -surgeon want a GA routine intubation or RSI?

Answer 40

- RSI with cricoid pressure | - considered full stomach d/t fracture

Question 41

-34 y/o -fell off roof 3 hrs after eating big lunch -fractured right clavicle, C5, and femur -C-collar currently in place airway plan?

Answer 41

- RSI and cricoid pressure contraindicated - must airway be managed? yes - is there potential for a difficult laryngoscopy? yes - can supraglottic ventilation be used? no * awake fiberoptic intubation

Question 42

-24 y/o male, 6 ft, 178 lbs. -airway exam indicates no suspected difficult airway -elective hand surgery less than 2 hrs duration -no reflux -NPO > 10 hrs -surgeon want GA what is airway plan?

Answer 42

- must airway be managed? yes - is there potential for a difficult laryngoscopy? no - can supraglottic ventilation be used? yes - is stomach empty? yes - will pt. tolerate apneic period? yes, proceed * use LMA

Question 43

-47 y/o female, 5 ft 4 in., 130 lbs -airway exam indicates no suspected difficult airway -NPO 8 hrs -surgeon wants a GA -elective bunionectomy (1 hr case) airway plan?

Answer 43

- must airway be managed? yes - is there potential for a difficult laryngoscopy? no - can supraglottic ventilation be used? yes - is stomach empty? yes - will pt. tolerate apneic period? yes, proceed * surgeon wants GA, use LMA (MAC could've been good)

Question 44

- 68 y/o male, 6ft, 140lbs - h/o throat cancer, s/p radical neck dissection for cancerous tumor two yrs. ago with subsequent reconstruction and oral maxillofacial surgeries - hand surgery, one hour - NPO 12 hrs - should this be considered a high risk extubation?

Answer 44

yes! high risk extubation - use awake fiberoptic intubation - LMA contraindicated * most providers will still just use Succs and continue with standard oral intubation