Session 2: Direct Laryngoscopy Flashcards
LEMON Score
preoperative assessment for difficult airway
L
Look extermally
facial trauma
lg incisors
beard/moustache
large tongue
E
Evaluate the 3-3-2 rule
incisor distance - 3 finger
hyoid-mental dist - 3 finger
thyroid-to-mouth distance- 2 finger breadths
M
Mallampati Score >= 3
O
obstruction
presence of any condition like:
epiglottitis
peritonsillar abscess
trauma
N
Neck mobility
limited neck mobility
Mallampati Class 1
complete visualization of soft palate, uvula, fauces, pillars
Mallampati Class 2
complete visualization of the soft palate, uvula, and fauces
Mallampati Class 3
only partial view of soft palate and uvula
Mallampati Class 4
soft palate not visible
only hard palate/tongue
Mallampati conditions
patient sitting upright
open mouth wide
stick tongue out
epiglottitis
severely inflamed airway
airway emergency
upper incisor nonreassuring sign
large/protruding
occlusion (bite) nonreassuring sign
overbite
mandibular protrusion nonreassuring sign
cannot protrude mandible incisors beyond maxillary incisors
mouth opening (interincisal distance) nonreassuring sign
less than 3 cm
mallampati score nonreassuring sign
score of 3 or 4
hard palate shape nonreassuring sign
high/arched/narrow
mandibular soft tissue nonreassuring sign
tense/radiated/deviated
neck size nonreassuring sign
short/thick
range of motion nonreassuring sign
limited degree of flexion or extension
nonreassuring sign
what you do not want to see in preoperative assessment (potential for difficult airway)
congenital conditions that impair laryngoscopy
Goldenhar
Klippel-Feil
Pierre Robin
Treacher Collins
Turner
Trisomy 21
Pathological states that impair laryngoscopy
Epiglottitis
Abscess/Ludwig Angina
Croup/Bronchitis
Papillomatosis
Tetanus
Traumatic Foreign Body
Cervical Spine Injury
Basilar skull fracture
maxillary/mandible injury
Laryngeal Fracture
Laryngeal edema
Soft tissue neck injury
Upper airway tumor
Lower airway tumor
Radiation therapy
Rheumatoid Arthritis
Ankylosing spondylitis
TMJ
Scleroderma
Sarcoidosis
Angioedema
Acromegaly
Diabetes mellitus
Hypothyroid
Thyromegaly (Goiter)
Obesity
Sensitivity
prediction of positive assessment
specificity
prediction of negative assessment
Cormack Lehane grade 1
full view of glottis / vocal cords
Cormack Lehane grade 2
Partial cords are visible
Cormack Lehane grade 3
only epiglottis visible
no cords visible
Cormack Lehane grade 4
no glottis structure visible (no cords visible)
Laryngoscopy indications
(PPALADINS)
Paralytics/laparoscopy
Poor lung physiology
Airway mx
Lack of access
Aspiration prevention
Diffucult ventilation/PPV needed
Ill (critically)
Non supine positioning
Suctioning frequently
Laryngoscopy tools
laryngoscope w/blade
stylets (lube)
bougie
pillow
ETT
suctioning
syringe
PPV
monitors to confirm
macintosh
beginner curved blade
less likely to break teeth
miller
straight blade
more potential for damage
potentially better view
syringe and cuff
10mL syringe (adults)
test cuff for integrity prior to insertion
deflate cuff fully after test
sniff postion
aligns axis
provides LOS
OA
PA
LA
sniffing position setup
place pillow under occiput
Extend atlanto-occipital joint
elevate the head
correctly placed pillow
aligns the PA and LA axis
Laryngoscopic Process (Macintosh)
- sniff postion
- elevate bed (pts nose to xiphoid cartilage)
- ensure asleep w/max muscle relaxation
- scissor mouth open
- insert blade right
- sweep tongue left to midline
- adv blade elevating the handle to view epiglottis
- adv blade tip into vallecula
- elevate handle to extend hyoepiglottic ligament (visualize glottic opening)
- right hand to lift head
- visualize glottis and ask for ETT
- adv ETT into glottic opening
- ask for stylet removal once ETT past vocal cords
- adv ETT until cuff no longer seen (twist if catching)
- gently remove blade
- inflate cuff
- confirm correct placement
- secure with holder or tape
securing ETT
courtesy tabes
taped low to mouth
avoid vermillion border
clean skin (mastitol)
tube/trach tie
ETT tie
useful if patient is dirty
oily skin/makeup
keep wrap/tie close to mouth
tight knot
ETT holder
most often used in ICU/ED
can be adjusted if swelling occurs
lung isolation or keeping pt intubated in post op
Intubation confirmation
Capnography
- gold std
sustained CO2
- stomach wont have
sustained CO2
Chest rise
- not specific
Auscultation over chest v abdomen
- not specific
Fog in ETT
- not specific
Feel of bag
- not specific
Capnography
the noninvasive measurement of the partial pressure of carbon dioxide (CO2) in exhaled breath expressed as the CO2 concentration over time.
gold std to confirm tube placement
Intubation Verbalize
- testing eyelid reflex
- masking pt
- scissoring mouth open
- inserting blade
- sweeping tongue
- adving blade into vallecula
- lifting
- I have a grade __ view, I can see_________.
- please provide cricoid pressure (if needed)
- please hadn me tube
- tip of tube through cords
- please remove stylet
ramping
used if pillow didnt help
positions pt into forced sniffing position
aligns 3 axis
Laryngoscopic intubation complications
(ATEDIOUS)
- dental damage
- oral/laryngeal soft tissue damage
- tracheal/cord damage
- aspiration
- incorrect location of cuff on cords
- scraping ETT on cords
- endobronchial intubation
- unnoticed esophageal intubation
common intubation failure reasons
improper pt height
improper sniff posn
minimal neck extension
not sweeping tongue
rocking blade back
not verbalizing needs
