Session 3: Airway Management - LCC Flashcards
how many axis’ does the airway have
3
types of airway axis
oral (OA)
pharyngeal (PA)
laryngeal (LA)
axis’ alignments laying flat on back
unaligned
problems with laying pt flat on back
do not have a clear path for ventilation
potentially harder to breath
tongue falls against back of throat - obstruct airway
snoring obstruction type
partial obstruction
sleep apnea obstruction type
total obstruction
which pts typically struggle breathing on backs?
obese pts due to unaligned axis and more soft tissue mass in airway
methods to align airway axis’
- sniff position
- head tilt/chin lift
how to maximally align airways
sniff position and neck extension
sniff position benefits
better passage for air
less likely to obstruct
easier to ventilate
better view of vocal cords
anesthesia drugs will do either of these 2 things
make pt stop breathing
cause airway to obstruct
how can we breathe for pts?
breathing bag
ventilator
4 types of airway obstruction
- soft tissue (tongue) obstruction
- laryngospasm
- bronchospasm
- airway swelling
soft tissue (tongue) obstruction
- most common type of airway obstruction
- tongue falls against back of pharynx
- obese pts more prone to severe obstruction
laryngospasm
can occur with every extubation
bronchospasm
causes
- most common cause is too lightly anesthetized
- can also occur w/anaphylaxis
airway swelling
seen following trauma, burn injury, pregnancy , etc
soft tissue obstruction situations
- MAC anesthesia
- right after GA induction before LMA/ETT inserted
- after extubation if pt is not quite awake
treatments for soft tissue obstruction
chin lift
jaw thrust
oral airway
nasal airway
chin lift
can relieve airway obstruction by aligning the 3 axis’ of the airway
indicated for minor airway obstruction
jaw thrust
opens airway
stimulates respirations (Painful)
try after chin lift
push HARD
oral airways
- more likely to cause gagging in awake pts
- dental injuries
nasal airways
- better tolerated in conscious pts
- can cause nosebleeds
- contraindicated in pts w/facial fractures and blood thinners
how do oral/nasal airways work?
relieve airway obstruction by lifting tongue off posterior pharynx
laryngospasm
sudden muscle spasm and closure of vocal cords
life threatening medical emergency - pt cannot ventilate
what triggers laryngospasm
stimulation of the superior laryngeal nerve
stimulation of vocal cords during stage II (light) anesthesia
causes of laryngospasm stimulation
- ETT during extubation
- airway secretions
stage 2 anesthesia
pt half awake/half asleep
never extubate during stage
2
can you laryngospasm in stage 1
unlikely because pt has airway protection from cough/talk reflexes
can pt laryngospasm in stage III
unlikely because laryngeal muscles are deeply anesthetized
diagnosis of laryngospasm after extubation
- absence of ventilation
- difficult providing positive pressure ventilation after extubation
diagnosis of laryngospasm during procedure w/o intubation
- pt too lightly anesthetized
- sudden loss of end tidal CO2 and inability to ventilate
laryngospasm treatment
- high jaw thrust behind ear w/positive pressure breathing
- propofol
- relaxes vocal cords
- takes pt to stage III
- succinylcholine
- muscle relaxant
- IM dose 4-6 mg/kg
bronchospasm
narrowing of the bronchioles that is caused by inflammation/constriction
can occur if lungs get irritated
what type of pts are more prone to bonchospasm
smokers
asthmatics
causes of bronchospasm
- endotracheal tubes
- light anesthesia
- emergence
- Desflurane
- Anaphylaxis
how do ETTs cause bronchospasm
lungs/trachea/airway are always irritated by tube
how does light anesthesia cause bronchospasm
ETT will irritate airway making pt cough if not anesthetized enough
how does emergence cause bronchospasm
as pt emerges, they notice the ETT and will typically cough
how does desflurane cause bronchospasm
- most pungent/irritating volatile agent
does anaphylaxis cause bronchospasm
- rare but possible
diagnosis of bronchospasm
sudden difficult to ventilate due to increase resistance to lung expansion
difficult to squeeze bag
high pressure in lungs
most likely observed during light anesthesia
treatment for bronchospasm cause by light anesthesia
give propofol and/or higher concentrations of volatile agent to anesthetize more deeply
treatment for bronchospasm caused during emergence
give albuterol inhaler via ETT
albuterol is a beta 2 agonist/bronchodilator
treatment for bronchospasm caused by anaphylaxis
give bronchodilators:
1) epinephrine
- (300 mcg IM)
2) beta 2 agonists
- albuterol inhaler
- subcutaneous
terbutaline injection
(0.25mg)
3) volatile agent
- isoflurane or
sevoflurane
prevention of coughing on ETT
- anesthetize trachea w/lidocaine jelly or LTA kit
- keep patient paralyzed or deeply anesthetized
LTA Kit
device that allows you to spray 4% lidocine into the trachea during laryngoscopy and prior to intubation
anesthetizes trachea
can reduce coughing during procedure and during emergence
treatment of coughing on endotracheal tube
- turn off ventilator
- dose muscle relaxant or deepen anesthetic w/narcotics or volatile gases
edema
swelling
vasodilation induced edema
when blood vessels vasodilate, they become leaky and allow more blood to leak into interstitial space
increased fluid in interstitial space causes edema
common causes of vasodilation induced edema
injury
anaphylaxis
causes of airway swelling
- burns
- traumatic intubation / multiple laryngoscopies
- pregnancy
- allergic rxn / anaphylaxis
traumatic intubation swelling
consider leaving pt intubated until swelling decreases
extubation in presence of significant airway swelling could be catastrophic
regurge
passive reflux
cause of regurge
reduction in tone of the lower esophageal sphincter (LES)
prevention of regurge
cricoid pressure
(sellicks maneauver)
benefits of cricoid pressure
- occludes the esophagus
- improves intubation view
vomiting
active reflux
vomiting treatment
suction pt
place in trendelenburg with head tilted to side
aspiration
gastric contents entering trachea/lungs
aspiration treatment
intubation
send to ICU
potentially prophylactic antibiotics and/or steroids
