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APEX > Unit 1 - Airway Management > Flashcards

Unit 1 - Airway Management Flashcards

1
Q

exam that helps quantify the size of the tongue relative to the volume in the mouth

A

Mallampati

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2
Q

Mallampati 1

A

Pillars, Uvula, Soft palate Hard palate
(PUSH)

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3
Q

Mallampati 2

A

Uvula, Soft palate, Hard palate
(USH)

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4
Q

Mallampati 3

A

Soft palate, Hard palate (base of uvula my be seen)
(SH)

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5
Q

mallampati 4

A

Hard palate

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6
Q

importance of interincisor gap

A

affects ability to align oral, pharyngeal, and larygeal axes

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7
Q

normal interincisor gap

A

2-3 fingerbreadths (4 cm)

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8
Q

what does a smaller interincisor gap indicate

A

a more acute angle between oral and glottic openings, increasing difficulty of intubation

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9
Q

what does the mandibular protrusion test assess

A

function of TMJ

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10
Q

borders of the submandibular space

A

superior = mentum
inferior = hyoid bone
lateral = either side of neck

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11
Q

use of thyromental distance

A

helps estimate size of submandibular space, which gives an idea of how much space you have to displace the tongue during DL

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12
Q

thyromental distance that may indicate difficult DL

A

TMD < 6 cm (3 fingerbreadths) or > 9 cm

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13
Q

how does a thyromental distance > 9 cm affect DL

A

the larynx and tongue move more caudally - this shifts the glottic opening beyond the line of sight

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14
Q

how to test TMJ joint in airway assessment

A

patient asked to sublux jaw and position of lower incisors compared to position of upper incisors
(mandibular protrusion test)

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15
Q

MPT class 1

A

patient can move lower incisors past upper and bite the vermillion of lip

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16
Q

MPT class 2

A

patient can move lower incisors in line with upper incisors

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17
Q

MTP class 3

A

patient can’t move lower incisors past upper incisors

increased risk of difficult intubation

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18
Q

importance of atlanto occipital joint mobility in airway assessment

A

ability to place pt in sniffing position depends on AO joint mobility

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19
Q

what is the 3-3-2 rule

A

combines several airway tests to give accurate prediction of airway difficulty

  • interincisor gap < 3 fingerbreadths
  • thyromental distance < 3 fingerbreadths
  • thyrohyoid < 2 fingerbreadths
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20
Q

what is the Cormack and lehane score

A

helps quantify view obtained during DL

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21
Q

structures seen with grade 1 Cormach and Lehane score

A

complete or nearly complete view of glottic opening

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22
Q

structures seen with grade 2 Cormach and Lehane score

A

posterior region of glottic opening

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23
Q

structures seen with grade 3 Cormach and Lehane score

A

epiglottis only - can’t see any part of the glottic opening

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24
Q

structures seen with grade 4 Cormach and Lehane score

A

soft palate only

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25
Q

Cormack and Lehane score 2A & 2B

A

A: can see posterior region of glottig opening
B: you can only see corniculate cartilages and posterior vocal cords (no part of glottig opening)

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26
Q

Cormack & Lehane score that requires alternative approach to intubation

A

4

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27
Q

independent risk factors for difficult mask ventilation

A

BONES
- Beard
- Obese (BMI > 26)
- No teeth
- Elderly (>55)
- Snoring

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28
Q

risk factors for difficult DL & intubation

A
  • small mouth opening
  • long incisors
  • prominent overbite
  • high, arched palate
  • MP 3 or 4
  • retrognathic jaw
  • inability to sublux jaw
  • short, thick neck
  • short thyromental distance
  • reduced cervical mobility
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29
Q

risk factors for difficult SGA placement

A
  • limited mouth opening
  • upper airway obstruction
  • altered pharyngeal anatomy
  • poor lung compliance (requires inc. PIP)
  • increased airway resistance
  • lower airway obstruction
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30
Q

risk factors for difficult invasive airway placement

A
  • abnormal neck anatomy (tumor, abscess, hx radiation, etc)
  • obesity
  • short neck
  • laryngeal trauma
  • limited access to cricothyroid membrane (halo, neck flexion deformity)
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31
Q

current NPO guidelines

A

clear liquids = 2 hours
breast milk = 4 hours
milk, formula, solid food = 6 hours
fried/fatty foods = 8 hours

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32
Q

what is Mendelson syndrome

A

chemical pneumonitis / aspiration pneumonia

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33
Q

how does ingestion of clear liquids decrease risk of Mendelson syndrome

A

reduces gastric volume and increases gastric pH

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34
Q

mnemonic to remember difficult DL and intubation predictors

A

LEMON
- Look externally (shape of face, morbid obesity, pathology of head and neck)
- Evaluate 3-3-2 rule
- Mallampati score
- Obstructions (upper and lower airway)
- Neck mobility

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35
Q

mnemonic to remember predictors of difficult SGA placement

A

RODS
- Restricted mouth opening
- Distorted airway
- Stiff lungs or cspine

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36
Q

mnemonic to remember difficult surgical airway placement predictors

A

SHORT
- surgery (neck surgery or previous scar)
- hematoma
- obesity
- radiation or other deformities
- tumors

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37
Q

cricoid pressure applied for RSI

A

before LOC = 20 newtons or ~2 kg
after LOC = 40 newtons or ~4 kg

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38
Q

6 complications r/t cricoid pressure

A
  1. airway obstruction
  2. difficult DL
  3. impaired glottic opening
  4. difficult intubation
  5. lowered esophageal sphincter pressure
  6. esophageal rupture
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39
Q

3 congenital conditions assoc. with c spine abnormalities

A
  • Goldenhar
  • Klippel Fiel
  • Trisomy 21
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40
Q

3 causes of angioedema

A
  1. anaphylaxis
  2. ACE inhibitors
  3. hereditary
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41
Q

how can ACE inhibitors cause angioedema

A

they prevent bradykinin breakdown (genetics likely determine who is at risk)

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42
Q

treatments for angioedema from ACE inhibitors

A
  • icatbiant (bradykinin receptor antagonist)
  • ecallantide (plasma kallidrein inhibitor)
  • FFP
  • C1 esterase concentrate
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43
Q

why is FFP given for angioedema from ACE inhibitors

A

contains enzymes that metabolize bradykinin

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44
Q

why is ecallantide used for treatment of angioedema from ACE inhibitors

A

stops conversion of kininongen to bradykinin

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45
Q

what causes hereditary angioedema & how is it treated

A
  • C1 esterase deficiency
  • treat with C1 esterase concentrate, FFP, ecallantide, icatibant
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46
Q

management of patients with C1 esterase deficiency requiring upper airway surgery

A

prophylactic danazol or C1 esterase concentrate

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47
Q

what is Ludwig’s angina

A

a bacterial infection characterized by rapidly progressing cellulitis of the floor of the mouth

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48
Q

most significant concern with Ludwig’s angina

A

posterior displacement of tongue resulting in complete supraglottic airway obstruction

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49
Q

when is retrograde intubation contraindicated

A

infection above the level of the trachea
cant intubate cant ventilate

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50
Q

best way to secure airway in a patient with Ludwig’s angina

A
  • awake nasal intubation
  • awake trach
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51
Q

congenital conditions assoc. with large tongue

A

“Big Tongue”
- Beckwith syndrome
- Trisomy 21

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52
Q

congenital conditions assoc. with small/underdeveloped mandible

A

“Please Get That Chin”
- Pierre Robin
- Goldenhar
- Treacher Collins
- Cri du chat

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53
Q

congenital conditions assoc. with cervical spine anomaly

A

“Kids Try Gold”
- Klippel-Fiel
- Trisomy 21
- Goldenhar

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54
Q

airway considerations in a pt with Pierre Robin

A
  • small/underdeveloped mandible
  • tongue that falls back and down
  • cleft palate
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55
Q

airway considerations in a patient with Treacher collins

A
  • small mouth
  • small mandible
  • choanal atresia (nasal airway blocked by tissue)
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56
Q

airway considerations in Trisomy 21 patients

A
  • small mouth
  • large tongue
  • AO joint instability
  • subglottic stenosis
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57
Q

airway consideration with Klippel-Fiel pts

A

congenital cervical vertebrae fusion

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58
Q

airway considerations with Goldenhar syndrome

A
  • small/underdeveloped mandible
  • c spine abnormality
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59
Q

airway considerations with Cri du Chat

A
  • small mandible
  • laryngomalacia
  • stridor
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60
Q

optimal position for tracheal intubation

A

sniffing position - cervical flexion and AO joint extension

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61
Q

optimal positioning of obese pt for DL

A

HELP - head elevated laryngoscopy position

sternum and external auditory meatus are in same horizontal plane

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62
Q

positioning that may unload diaphragm and prolong time between apnea and desaturation in obese pts

A

reverse Trendelenburg

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63
Q

presentation of nerve damage assoc. with aggressive jaw thrust

A

affected side of face may sag, pt may drool, chewing affected

facial n. injury

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64
Q

presentation of nerve injury with face mask strap that’s too tight

A

difficulty opening and closing lips r/t impaired orbicularis oculi muscle function (buccal branch of facial n. damaged)

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65
Q

nerve that can be damaged from ETT connector resting on pt’s face

s/s injury

A

supraorbital nerve - eye pain, forehead numbness, photophobia

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66
Q

what axes are aligned when head is lying flat on the bed and extended

A
  1. pharyngeal
  2. laryngeal
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67
Q

types of oral airways designed to accomodate a fiberoptic bronchoscope and ETT

A

Williams and ovassapian

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68
Q

how to size an oral airway

A

measure from corner of mouth to earlobe or angle of mandible

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69
Q

consequences of using an oral airway that’s too short or too long

A
  • too short = obstruction from tongue against the roof of mouth
  • too long = obstruction from displacing epiglottis towards glottis
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70
Q

how to measure for a nasopharyngeal airway

A

from nare to earlobe or angle of mandible

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71
Q

how to insert nasal airway

A

gently retract tip of noce and introduce in line with nasal passage (perpendicular to face) - push cephalad

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72
Q

consequences of a nasal airway that’s too short or too long

A
  • too short = fails to relieve obstruction
  • too long = obstruction via epiglottis displacement towards glottis
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73
Q

complications of oral and nasal airway placement

A
  • laryngospasm if placed in lightly anesthetized pt
  • vomiting (if gag reflex intact)
  • dental injury
  • oropharyngeal trauma
  • ischemia
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74
Q

contraindications to nasal airway

A
  • cribiform plate injury
  • coagulopathy
  • previous transphenoidal hypophysectomy
  • previous Caldwell-Luc procedure
  • nasal fracture
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75
Q

cribiform plate injures that make nasal instrumentation contraindicated

A
  • Lefort 2 or 3 fracture
  • basilar skull fracture
  • CSF rhinorrhea
  • raccoon eyes
  • periorbital edema
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76
Q

what is the cribiform plate

A

bony structure that separates the nasal cavity from anterior cranial fossa

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77
Q

maximum ETT cuff pressure

A

25 cm H2O

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78
Q

what causes tracheal ischemia

A

ETT cuff pressure exceeds tracheal mucosal perfusion pressure

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79
Q

which ETTs use low-volume, high-pressure cuffs

A
  • red rubber tube
  • silicon tube for LMA-Fastrach
  • bronchial balloon on DLT
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80
Q

cuff compliance in low-volume high-pressure cuff vs. high-volume low-pressure cuff

A

low volume = low compliance (takes a smaller volume to increase pressure in cuff)

high volume = high compliance (takes larger volume to increase pressure in cuff)

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81
Q

benefits of a high-volume, low-pressure cuff

A

cuff pressure closely resembles the pressure exerted on the trachea - this is why it can be measured with a manometer

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82
Q

benefits of low-volume, high-pressure cuffs

A
  • better protection against aspiration
  • lower incidence of sore throat
  • easier visualization during intubation
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83
Q

risks of low-volume, high-pressure cuff

A

prolonged intubation = tracheal ischemia

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84
Q

benefits of a microthin cuff vs. standard high-volume, low-pressure cuff

A
  • lower pressure on tracheal mucosa
  • better protection against liquid aspiration
85
Q

cuff type in nearly all modern ETTs

A

high-volume, low-pressure cuff

86
Q

purpose of Murphy eye

A

provide alternate passage for air movement in case ETT tip becomes occluded or abuts tracheal wall

87
Q

advantages of ETT without murphy eye

A

positioning the cuff closer to the tip and minimizes endobronchial intubation risk

88
Q

formula for cuffed vs. cuffless ETT in pediatrics

A
  • cuffless = (age/4) + 4
  • cuffed = (age/4) + 3.5
89
Q

how to calculate pediatric ETT depth

A

internal diameter * 3

90
Q

predictors of difficult video assisted laryngoscopy

A
  • neck pathology (radiation, tumor)
  • short TMD
  • limited cervical motion
  • thin neck
  • mandibular protrusion score of 3
91
Q

examples of video assisted laryngoscopes with non-channeled design

A
  • Glidescope
  • C-MAC
  • McGrath
92
Q

acute angle video laryngoscope blades

A
  • Glidescope LoPro
  • CMac D-blade
  • McGrath Xblade
93
Q

what is a channeled video laryngoscope used for

A

integrates a channel for ETT into the device

channel automatically direct the tip of the ETT through vocal cords

94
Q

examples of a channeled video laryngoscope

A

Airtraq Avant
Pentax AWS

95
Q

greatest risk with video laryngoscopy

A

pharyngeal injury

96
Q

what do the proximal, distal, and sides of an LMA touch?

A

proximal = base of tongue
distal = upper esophageal sphincter
sides = pyriform sinuses

97
Q

max PPV pressure with an LMA

A

20 cm H2O

98
Q

max cuff pressure of an LMA

A

60mcm H2O
(target = 40-60)

99
Q

things to rule out if your LMA cuff pressure is > 60 and you still can’t get a good seal

A
  • improperly positioned LMA
  • pt inadequately anesthetized
  • laryngospasm
100
Q

why should a manometer be used if using N2O with LMA

A

N2O diffuses into the cuff and increases cuff pressure

101
Q

most common cause of nerve injury with LMA

A

cuff overinflation

102
Q

what nerves are at risk for injury with LMA

A
  • lingual n.
  • hypoglossal n.
  • RLN
103
Q

risk factors for nerve injury with LMA

A
  • cuff overinflation
  • LMA too small
  • lidocaine lubrication
  • traumatic insertion
104
Q

risks of cuff overinflation in LMA

A
  • nerve injury
  • sore throat
  • pharyngeal necrosis
105
Q

LMA size 1:
- patient size (kg)
- cuff inflation
- largest ETT that fits
- largest flexible endoscope

A
  • < 5 kg
  • cuff inflation: 4 mL
  • largest ETT: 3.5
  • largest endoscope: 2.7
106
Q

LMA size 1.5:
- patient size (kg)
- cuff inflation
- largest ETT that fits
- largest flexible endoscope

A
  • 5-10 kg pt
  • 7 mL cuff inflation
  • 4.0 largest ETT
  • 3.0 largest endoscope
107
Q

LMA size 2:
- patient size (kg)
- cuff inflation
- largest ETT that fits
- largest flexible endoscope

A
  • 10-20 kg pt
  • cuff: 10 mL
  • largest ETT: 4.5
  • largest endoscope: 3.5
108
Q

LMA size 2.5:
- patient size (kg)
- cuff inflation
- largest ETT that fits
- largest flexible endoscope

A
  • 20-30 kg pt
  • cuff inflation 14 mL
  • largest ETT: 5.0
  • largest endoscope: 4.0
109
Q

LMA size 3:
- patient size (kg)
- cuff inflation
- largest ETT that fits
- largest flexible endoscope

A
  • pt 30-50 kg
  • cuff 20 mL
  • largest ETT 6.0
  • largest endoscope 5.0
110
Q

LMA size 4:
- patient size (kg)
- cuff inflation
- largest ETT that fits
- largest flexible endoscope

A
  • 50-70 kg pt
  • 30 mL cuff inflation
  • largest ETT 6.0
  • largest endoscope 5.0
111
Q

LMA size 5:
- patient size (kg)
- cuff inflation
- largest ETT that fits
- largest flexible endoscope

A
  • 70-100 kg pt
  • cuff 40 mL
  • largest ETT: 7.0
  • largest endoscope: 5.5
112
Q

what is the max PPV for a classic LMA before seeing an air leak?

A

20 cm H2O

113
Q

purpose of LMA ProSeal

A

double lumen LMA with:
- gastric drain tube for decompression
- larger mask
- bite block

114
Q

how can stomach be decompressed with a ProSeal LMA

A

place OGT through 2nd lumen

115
Q

benefits of ProSeal vs. LMA classic

A
  • better seal
  • max pressure for PPV 30 cm H2O (vs. 20)
116
Q

what is the LMA Supreme?

A

disposable version of LMA ProSeal

117
Q

what is the LMA Fastrach

A

an intubating LMA

118
Q

type of cuff used in ETTs for Fastrach LMA

A

high pressure

119
Q

LMA useful for head and neck surgery

A

LMA Flexible

120
Q

differences in LMA Flexible vs. LMA classic

A
  • wire reinforced
  • longer than classic
  • narrower than classic (use smaller ETT/bronchoscope)
121
Q

key features of an iGel

A
  • no inflatable cuff
  • has a gastric port
  • can serve as conduit for endotracheal intubation (requires fiberoptic scope)
  • no metal parts - safe for MRI
122
Q

complications of iGel

A
  • tongue trauma
  • mucosal erosion of cricoid cartilage
  • tracheal compression
  • nerve injury
  • airway obstruction
  • regurgitation and aspiration
123
Q

which type of LMA incorporates a low-volume, high-pressure cuff

A

LMA Fastrach

124
Q

LMA contraindications

A
  • full stomach/aspiration risk
  • airway obstruction at or below glottis
  • risk for tracheal collapse (ex. tracheomalacia)
  • poor lung compliance
  • high airway resistance
125
Q

LMA tolerance requires a more or less anesthesia vs an ETT?

A

less

126
Q

what to do if you see gastric contents behind the LMA cuff

A
  • leave LMA in place
  • place in Trendelenburg and deepen anesthetic
  • 100% FiO2 via self-inflating resuscitation bag
  • low FGF and Vt
  • flexible suction catheter through LMA
  • FOB to evaluate gastric contents in trachea
127
Q

why is an LMA a better option vs ETT for asthmatics

A
  • asthmatics most likely to experience wheezing during emergence
  • since LMA sits over glottis, there’s nothing inside the trachea to stimulate it during emergence
128
Q

what is a Combitube

A

double lumen supraglottic device blindly placed in hypopharynx

129
Q

contraindications to Combitube use

A
  • intact gag reflex
  • use > 2-3 hours
  • esophageal diseaes (ex. Zenker’s diverticulum)
  • ingestion of caustic substances
  • don’t use 37 Fr in someone.< 4 ft
  • don’t use 41-F in someone < 6 ft
130
Q

Combitube can’t be used in patients under what height

A

4 ft

131
Q

how does a Combitube work

A
  • inflating oropharyngeal (proximal) cuff occludes hypopharynx
  • inflating distal cuff occludes the esophagus
132
Q

how much air should be put in oropharyngeal balloon of Combitube

A

size 37 = 40-85 mL
size 41 = 40-100 mL + option for additional 50mL

133
Q

how much air should be put in distal cuff of Combitube

A

5-12 mL

134
Q

where does the tip of the combitube typically enter?

A

esophagus

135
Q

which lumen is typically used for ventilation with Combitube

A

blue (proxima/esophageal) lumen

136
Q

which lumen is used for ventilation if the Combitube enters the trachea

A

clear (distal or tracheal) lumen

137
Q

max cuff pressures for a combitube

A

60 cm H2O

138
Q

similarities in King Laryngeal Tube and Combitube

A
  • both inserted blindly
  • both distal cuffs obstruct upper esophagus and proximal seals oral and nasal pharynxes
139
Q

how many lumens does the King Airway have for ventilation

A

one

140
Q

minimum weight for a King Airway

A

10 kg

141
Q

what is a King LTS-D

A

disposable device that includes a 2nd lumen - gastric tube can be inserted

142
Q

purpose of proximal cuff in King Airway

A

seals oral and nasal pharynxes

143
Q

roles of dominant vs. nondominant hands in fiberoptic broncoscopy

A

dominant hand holds the cord
non-dominant controls the lever

144
Q

lever movements in FOB

A
  • pushing lever up points tip down
  • pushing lever down points tip up
145
Q

absolute contraindications for FOB

A
  • uncooperative pt
  • lack of provider skills
  • near total upper airway obstruction
  • massive trauma
146
Q

moderate FOB contraindications

A
  • obstruction that might prevent successful intubation
  • lots of blood/fluid in airway
  • hypoxia
147
Q

relative FOB contraindications

A
  • concern of vocal cord damage if ETT passed over FOB
  • perilaryngeal mass
  • infectious agent that complicates scope sterilization procedures
  • allergy to LAs
148
Q

best med choices for awake fiberoptic intubation

A
  • precedex
  • remifentani
  • ketamine
  • midazolam
149
Q

use of Williams or Ovassapian airways in FOB

A
  • help FOB stay midline
  • may stimualte gag reflex in awake pt
150
Q

what is the Bullard laryngoscope

A

a rigid fiberoptic device for indirect laryncoscopy

151
Q

Bullard laryngoscope is useful for pts with:

A
  • small mandible
  • limited mouth opening (requires at least 7 mm)
  • limited cervical mobility
  • short, thick neck
152
Q

positioning consideration for Bullard laryngoscope

A

pts head & neck must stay neutral or slightly flexed

153
Q

how is glottic exposure obtained with Bullard laryngoscopt

A

handle is pulled straight up (90 degree angle to spine) - not up and caudally like DL

154
Q

how to fix ETT hanging up on right arytenoid cartilage with Bullard laryngoscope

A

cricoid pressure
lift blade anteriorly

155
Q

which causes less cervical displacement - direct video laryngoscopy or Bullard?

A

Bullard

156
Q

absolute contraindication for Bullard

A

there are none

157
Q

what is an Eschmann introducer?

A

a gum elastic bougie

158
Q

best and worst times to use a bougie

A
  • best = grade 3 view
  • next best = 2b view
  • worst = class 4
159
Q

how to use a bougie

A
  • hook angled tip under epiglottis
  • advance tip into trachea (23-25 cm)
  • placement confirmed with feeling clicks of tracheal rings
160
Q

what should you do if you dont feel tracheal clicks with bougie placement but feel that it’s in the trachea

A

look for “hold up sign” - resistance as it encouters the carina (35-40 cm)

161
Q

troubleshooting ETT catching on soft tissue of larynx with bougie use

A

rotate ETT 90 degrees counter clockwise

162
Q

indirect intubation method useful with severe oropharyngeal bleeding

A

lighted stylet

163
Q

difficult intubation situations in which a lighted stylet is not useful

A
  • super morbid obesity
  • epiglottitis
  • can’t ventilate can’t intubate scenario
164
Q

how is a lighted stylet used

A
  • blind intubation technique that transilluminates anterior neck to facilitate intubation
  • stylet in trachea = well-defined glow below thyroid prominence
  • stylet in esophagus = diffuse transillumination of neck without circumscribed glow
165
Q

when does the light in a light stylet blink

A

after 30 seconds - minimizes heat production and reminds you of elapsed time

166
Q

benefits of a lighted stylet technique

A
  • useful for anterior airway
  • useful for small mouth opening
  • requires little neck manipulation
  • less stimulating than DL
  • less sore throat vs. DL
  • useful for oral or nasal intubation
  • useful for c spine abnormality, Pierre-Robin, severe burn contractures
167
Q

disadvantages of lighted stylet

A
  • difficult when pt has a short, thick neck
  • should not be used in an emergent situation
  • blind technique - don’t use with tumor, FB, airway injury, or epiglottitis
  • do not use with traumatic laryngeal injury
168
Q

angle of Trachlight in adult vs. pediatric patients

A
  • adult: bend tip to 90 degree angle
  • children: angle 60-80 degrees (more acute) to accomadate a more cephalad glottic opening
169
Q

why are false positive results more common in peds vs. adults with lighted stylet

A

children have thinner necks - glow more prominent

170
Q

when is retrograde intubation indicated

A
  • unstable c spine
  • upper airway bleeding/difficult to visualize glottis
  • failed awake intubation
171
Q

7 contraindications to retrograde intubation

A
  • tracheal stenosis under puncture site
  • can’t access/identify cricothyroid membrane
  • pretracheal mass (goiter)
  • tumor obstructing path of wire
  • coagulopathy
  • infection at puncture site
  • neck flexion deformity
172
Q

basic steps for retrograde intubation

A
  1. puncture cricothyroid membrane with 14-18g needle
  2. aspirate for air to confirm tracheal placement
  3. pass wire through needle and advance cephalad
  4. wire should travel through vocal cords and exit through mouth
  5. load ETT over wire and advance into trachea
  6. once ETT in trachea and can’t be further advanced, withdraw wire and advance ETT to final position
173
Q

6 complications of retrograde intubation

A
  • bleeding
  • pneumomediastinum
  • PTX
  • trigeminal nerve trauma
  • breath holding
  • wire travels wrong direction
174
Q

most common use of retrograde intubation

A

unstable c spine

175
Q

how long does retrograde intubation typically take for experienced practitioners

A

5-7 min

176
Q

3 ways to create a surgical airway

A
  • percutaneous cric with transtracheal jet ventilation
  • surgical cric
  • trach
177
Q

pressure required for inspiration with jet ventilation via percutaneous cric

A

50psi or wall pressure

178
Q

why is the pt at risk for hypercapnia with jet ventilation via percutaneous cric

A

ventilation can’t be controlled

179
Q

contraindications for percutaneous cricothyroidectomy

A
  • upper airway obstruction
  • laryngeal injury
180
Q

complications of percutaneous cricothyroidectomy with airway obstruction above tip of jet ventilator

A
  • barotrauma
  • PTX
  • subcutaneous emphysema
  • mediastinal emphysema

(air can enter lungs but can’t exit)

181
Q

general complications of percutaneous cric

A
  • hemorrhage
  • aspiration
  • tracheal injury
  • esophageal injury
182
Q

ventilation with a percutaneous vs. surgical cric

A
  • percutaneous: jet ventilation
  • surgical: cuffed ETT inserted through hole for mechanical ventilation
183
Q

why is a surgical cric contraindicated in children

A
  • children have more pliable and mobile laryngeal and cricoid cartilages
  • thymoid isthmus commonly covers the mmebrane
184
Q

emergency airway of choice in kids 6 yrs and younger

A

percutaneous transtracheal ventilation (needle cric)

185
Q

contraindications to surgical cric

A
  • children 6 and under (some books say 10)
  • laryngeal fracture or neoplasm
186
Q

complications of surgical cric

A
  • tracheal stenosis
  • tracheal or esophageal injury
  • hemorrhage
  • disordered swallowing
  • subcutaneous or mediastinal emphysema
187
Q

complications of transtracheal jet ventilation

A
  • acute airway obstruction
  • tracheal stenosis
  • tracheomalacia
  • tracheal necrosis
  • trancheosophageal fistula (long term)
188
Q

complications of cricothyroidotomy

A
  • tracheal stenosis/injury
  • esophageal injury
  • hemorrhage
  • dysphagia
  • subcutaneous emphysema
189
Q

complications of tracheostomy

A
  • airway obstructin
  • hypoventilation
  • PTX
  • acute bleeding
  • tracheal stenosis/malacia/necrosis
  • tracheoesophageal fistula
190
Q

options to consider in a difficult airway in which face mask ventilation or SGA placement are adequate

A

alternative intubation approaches:
- VAL
- different DL blades
- SGA as conduit for intubation
- FOB
- lighted stylet
- blind approach

191
Q

how does the DAA define difficult laryngoscopy

A

not possible to visualize any portion of the vocal cords after multiple attempts

the difficult or failed tracheal intubation requires multiple attempts to succeed or complete failure after multiple attempts

192
Q

NMB recommended in new DAA difficult intubation guidelines

A

roc (if sugammadex available)

193
Q

when is the emergency difficult airway pathway used

A

when the patient is anesthetized but you can’t ventilate or intubate

194
Q

first step of the emergency difficult airway pathway

A

call for help

195
Q

options for emergency noninvasive ventilation

A
  • SGA
  • transtracheal jet ventilation
  • combitube
  • rigid bronch
196
Q

newly updated difficult airway algorithm suggestion for maximizing oxygenation while trying to secure a tube

A

high flow NC/transnasal humidified rapid insufflation ventilatory exchange

197
Q

The 4 plans in the difficult airway society difficult airway algorithm (DAS DAA)

A

A. facemask ventilation and tracheal intubation
B. maintain oxygenation with SGA insertion
C. facemask ventilation
D. emergency front of neck access

198
Q

in DAS DAA guidelines, what are the options with failed DL/intubation but successful SGA placement

A
  • wake pt
  • intubate via SGA
  • proceed without intubation
  • trach or cric
199
Q

first step of ASA DAA nonemergeny pathway

A

select an alternative approach to intubation (different blade, different airway device, etc)

200
Q

preventing CV and SNS stimulation with awake extubation

A
  • beta blockers
  • calcium channel blockers
  • vasodilators
201
Q

meds to decrease coughing with awake extubation

A
  • lidocaine
  • opioids
202
Q

4 techniques for extubating a difficult airway

A
  1. extubate fully awake
  2. extbuate over a flexible fiberoptic bronchoscope
  3. extubate then place LMA
  4. use airway exchange catheter
203
Q

at what stage should deep extubation occur

A

Guedel stage 3

204
Q

most common device used to manage extubation of difficult airway

A

airway exchange catheter

205
Q

what is an airway exchange catheter

A

long, thin, flexible, hollow tube that maintains direct access to airway following tracheal extubation

206
Q

when using an airway exchange catheter, what should you do if the ETT won’t advance beyond the cords?

A
  • use laryngoscope blade to displace supraglottic tissue
  • rotate 90 degrees counterclockwise before readvancing
207
Q

2 acceptable access points for wire-guided retrograde intubation

A
  1. cricothyroid membrane
  2. cricotracheal ligament
208
Q

physiologic principle that underpins the mechanism of apneic oxygenation

A

diffusion

209
Q

minimum pressure to power a hand-held jet ventialtor

A

15 psig

The hand-held jet ventilator is connected to a 50 pig oxygen source and the pressure is then set to 15 to 30 psig.

APEX (54 decks)

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