SEM2WK3 ADVANCED AIRWAY PRINCIPLES

Question 1

How to reduce insufflation in preoxygenation

Answer 1

position, seal, jaw thrust, pressure <20mmhg i.e. low pressures, breathe with them if they are spont venting, PEEP 5cmH2O

Question 2

Min time to wait for medications for induction

Answer 2

60 seconds, looking for lack of jaw tone, nil spont breathing

Question 3

What is laryngeal manipulation and how to perform

Answer 3

moving the structures more inferiorly (pushing it down and “backwards” into line of view

Question 4

describe SALAD intubation

Answer 4

• Oral suctioning with the laryngoscope blade hugging the anterior surface of the tongue (this is to avoid submersion of the blade in the regurgitation, particularly important if using a VL.) Hopefully now as you drain regurg the uvula will come into view. Keep advancing the scope in normal sequence and keep the suction at the base of the tongue.
• Use of the rigid suction catheter as a tongue depressor to permit the laryngoscope blade to perfect position
• Insertion of the suction catheter in the proximal oesophagus to continue to drain regurgitation
• Moving the suction catheter to the left side of the patient’s mouth and pinning it with the laryngoscope blade to keep it there, hands free
• Passage of the ETT

Question 5

Reasons to insert gastric tube

Answer 5

• Relieve increased gastric pressure
• Common in patients who have received APPV
• Improves ventilation by resolving diaphragmatic splinting
• Reduces aspiration risk

Question 6

common sites of impaction for gastric placement

Answer 6

• Piriform sinus
• Arytenoid cartilage
• Trachea
• Can’t pass the oropharynx

Question 7

trouble shooting techniques for gastric placement- step by step appraoch (5)

Answer 7

• Neck flexion (chin to chest, opposite of sniffing position, opens hypopharyngeal region)
• Lateral neck pressure compresses the piriform sinus and move the arytenoid cartilage medially (squeezes it closed and off to the side). Press on the side of the larynx with 3 fingers
• Reverse Sellick manoeuvre, pull the larynx (up) anteriorly with the non-dominant hand whilst advancing the tube. This closes the piriform sinus and lifts the cartilage to open the oesophagus.
• Laryngoscopy and magils forceps, direct but requires most dexterity and significant airway manipulation with potential for trauma. Use cautiously as we are manipulating the airway
• Split ETT (cut down the inside of the tube to split it. Insert it into the oesophagus, you can use this with a laryngoscope. Can use it from the start or once you are having trouble and use it as a conduit to pass the tube to your marked length. Use the split to open up around the gastric tube, then use your thumb to anchor the gastric tube against the patient’s lips to ensure it doesn’t migrate when you remove the ETT.

Question 8

Mallampatti score

Answer 8

Class I: soft palate, uvula etc visible, nil difficulty
II: as above
III: moderate difficult
IIII: only hard palate visible severe difficulty **

Question 9

Difficult laryngoscopy, LEMON

Answer 9

Look externally
Evaluate 3-3-2
Mallampatti score
Obstruction/obesity
Neck mobility

Question 10

Difficult BVMV ROMAN

Answer 10

Radiation/restriction
Obesity/obstruction
Mask seal/Mallampatti, Male
Age
No teeth

Question 11

Difficult cric SMART

Answer 11

Surgery
Mass
Access/anatomy
Radiation
Tumour

Question 12

Difficult emergency airway management HEAVEN

Answer 12

Hypoxemia
Extremes of size
Anatomic challebge
Vommit/blood/fluid
Exsangination
Neck Mobility

Question 13

Troubleshotting Head scope throat technique

Answer 13

Head- raise is higher, right lip retraction
scope- change blade, suction
Throat- bimanual/ELM, BURP