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671A - Anesthesia I > Week 12 - Basic Airway > Flashcards

Week 12 - Basic Airway Flashcards

1
Q

Which airway exam is most indicative of a difficult or non difficult airway?

A

NONE –> Not a single exam should be used alone. These all need to be used in conjunction with one another

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2
Q

What are the four areas of airway management that we assess patients individually for to recognize difficulty in these categories?

A
  1. Bag mask ventilation
  2. Direct laryngoscopy and video laryngoscopy –> Each of these including ETT delivery and tracheal intubation
  3. Supraglottic airway ventilation
  4. Cricothyrotomy airway placement
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3
Q

In addition to the airway exam, what is another strong indicator of a difficult airway?

A

Patient with a history of a difficult airway –> Anesthetic history should be included in airway examiniations

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4
Q

What are some clues that may indicate a history of a difficult airway?

A

Chipped/broken teeth, previous sore throat after general surgery, bruised lips…

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5
Q

How can weight loss or gain influence the airway?

A

Can make intubation harder (generally with weight gain) or easier (generally with weight loss) than noted in the past

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6
Q

What does it mean if the patients thyromental distance is 2 finger breadths?

A

Difficult airway

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7
Q

What does a interincisor distance of 4 finger breadths indicate?

A

Easier airway

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8
Q

How should a mask be positioned on a patient?

A

Left thumb and index finger wrapping around the mask making a C. The middle and ring fingers are placed on the bony parts of the mandible to help compress the mask and raise the patients chin. The fifth finger (pinky) is then used the provide anterior jaw thrusting maneuver placed at the angle of the mandible.

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9
Q

What should occur if bag mask ventilation is believed to be inadequate? 6 steps

A
  1. Place the patient into a sniffing position
  2. Use an OPA (oropharyngeal airway)
  3. Use another provider to help seal the mask onto the patients face better. One using both hands to compress the mask onto the patients face while the other operates the anesthesia bag
  4. Placement of a supraglottic device may be warranted while considering waking the patient
  5. Consider laryngoscopy, using DL or VL with tracheal intubation if not attempted yet
  6. If all else fails, circothyrotomy
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10
Q

What would you see while bag mask ventilating a patient who you suspect is receiving inadequate ventilation?

A

Minimal to no chest movement, inadequate or deficient EtCO2, reduced or absent breath sounds, decreased O2 saturation (less than 92)

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11
Q

What positioning technique can be implemented to improve bag mask ventilation?

A

Ramping –> Elevating the patients head, shoulders, and neck.

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12
Q

What are some factors associated with difficulty bag mask ventilating a patient?

A

Mask seal impediments (facial hair, altered facial anatomy, lack of teeth, NG tube), upper airway obstructions, obesity, elderly, Mallampati III or IV, short thyromental distance, snoring (OSA), and poor lung compliance

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13
Q

Why are upper airway obstructions considered an emergency?

A

Because of their potential to become total airway obstructions –> Hallmark signs include:
Hoarse or muffled voice, difficulty swallowing secretions, stridor, and dyspnea

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14
Q

What are some manifestations with lower airway obstructions?

A

High peak airway pressures, low tidal volumes, and impaired ventilation

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15
Q

What considerations should be made for a patient with OSA in the postoperative period?

A

Instruct patient to bring their positive pressure device so it can be used in the PACU

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16
Q

A BMI of _________ or greater has been associated with difficult BMV

A

30 kg/m^2 –> Excessive weight from both the chest and abdominal tissues causing compression of the lungs, especially in supine or head down positions

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17
Q

What are some causes of upper airway obstructions?

A

Burns, congenital abnormalities, trauma

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18
Q

What are some causes of lower airway obstructions?

A

Angioedema, aspirated foreign bodies, hematoma, hemorrhage, and tumors or lesions.

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19
Q

Why may pregnant patients be difficult to BMV?

A

Because the gravid uterus can compress the lungs, increasing airway resistance.

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20
Q

What patient population generally has decreased lung functional residual capacities (FRC) –> the volume of air present in the lungs at the end of passive expiration?

A

Obese patients –> This predisposes them to to desaturate more quickly

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21
Q

Time to desaturation should be considered in the ______________ _____________ _____________ _____________

A

Overall airway management plan –> Any time delay after induction can result in significant hypoxia, especially in the obese population.

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22
Q

Why can excessive soft tissue in the oropharyngeal and pharyngeal cavity be problematic?

A

Can lead to difficulty with BMV because it can cause resistance to airflow in positive pressure ventilation.

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23
Q

What is apneic oxygenation?

A

Oxygenating the patient during times of apnea –> Even without lung movement, the alveoli will continue to receive oxygen if a higher O2 gradient exists in the upper airway –> 250 mL/min of O2 diffuses from the alveoli to the bloodstream during apnea.

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24
Q

Although apneic oxygenation can sustain a patient for significant amounts of time, what happens if spontaneous breaths aren’t delivered within a reasonable amount of time?

A

Acidosis and hypercarbia

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25
Q

What is required for providing apneic oxygenation during intubation?

A

A patent upper airway –> This allows O2 to drive into the hypopharynx (laryngopharynx) and become entrained into the trachea

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26
Q

How should apneic oxygenation be given prior to intubation?

A

NC at 15 L per min –> These high flows can be utilized for short periods without causing tissue damage
This allows O2 to drive into the hypopharynx (laryngopharynx) and become entrained into the trachea

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27
Q

At what age is associated with difficult BMV?

A

55 years or older –> Contributes to missing teeth, patients who are edentulous (causes airway soft tissue to sink inward) –> This causes a poor mask seal

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28
Q

Why might it be appropriate to leave dentures in prior to BMV?

A

Helps facilitate a better seal by preserving facial structure. (Can only be done if dentures are easily removable)

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29
Q

What is direct laryngoscopy (DL)?

A

Using a laryngoscope and having the laryngeal opening and supporting structures within line of sight.

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30
Q

What is video laryngoscopy (VL)?

A

Indirect procedure where the laryngeal opening is viewed via a camera on the tip of the laryngoscope.

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31
Q

How is tracheal intubation preformed?

A

Via direct laryngoscopy or video laryngoscopy

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32
Q

What is the primary goal during the airway assessment?

A

Determine factors that predispose a patient to difficulty with direct laryngoscopy, video laryngoscopy, and tracheal intubation.

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33
Q

What are some of the most commonly used airway assesments?

A

Modified Mallampati, TMD, interincisor gap distance, atlantooccipital joint mobility…

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34
Q

What does the Mallampati tool assess?

A

Mouth opening, size of tongue, size of the oral pharynx, and posterior oropharyngeal structures

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35
Q

How should the patient be positioned to preform the Mallampati assessment?

A

Sit upright, extend the neck, open the mouth as much as possible, protrude the tongue and avoid phonation

36
Q

What class Mallampati is associated with difficulty in intubation?

A

Class III and Class IV

37
Q

What are the 4 Mallampati classes?

A
38
Q

What is the Cormack and Lehane grading system?

A

It offers an objective assessment of the pharyngeal structures, glottic structures, and glottic opening during the laryngoscopy

39
Q

What grade on the Cormack and Lehane system would a partial view of the glottic opening get?

A

Grade IIa or IIb

40
Q

What grade on the Cormack and Lehane system would a view of only the epiglottis get?

A

Grade III

41
Q

What would a 0% percentage of glottic opening indicate? What about 100%?

A

0% –> No portion of the glottic opening is seen
100% –> Full view of the glottic opening is seen

42
Q

What grades on the Cormack and Lehane system are associated with easier intubation?

A

Grade I, IIa, and IIb

43
Q

What are the Cormack and Lehane grades?

A
44
Q

What is the TMD measuring?

A

Measurement of thyromental space –> Measured from the notch of the thyroid notch to the lower boarder of the mentum (chin) WHEN the patients head is extended and the mouth is closed.

45
Q

What is considered a good TMD score?

A

6 cm or 3 finger breadths –> Indicates easier intubation

46
Q

What tongue size would someone with a small thyromental distance have?

A

Smaller tongue

47
Q

What are some conditions that could diminish the thyromental space?

A

Radiation and pathologic factors like a tumor.

48
Q

What is Mandibular Hypoplasia?

A

Another condition affecting tongue placement is mandibular hypoplasia –> This causes difficult intubation because the tongue can’t be displaced into the submandibular space during direct laryngoscopy.

49
Q

What is an anterior larynx?

A

Tongue is obstructing the view of the larynx because the larynx is tucked underneath it –> Little can be done with DL if you can’t get the tongue out of this space, will need to use VL
Patients with short TMD can have this (less than 6 cm)

50
Q

What is the thyromental space?

A

It is a pliable compartment directly anterior to the larynx –> Tongue can be displaced here during laryngoscopy so the glottic opening can be viewed

51
Q

What does a TMD of 9 cm or greater indicate?

A

Could indicate a potentially difficult laryngoscopy and intubation.

52
Q

What is the 3-3-2 rule?

A

3 fingers for interincisor gap, 3 fingers for TMD, and 2 fingers for the modified MHD which measures the distance between the thyroid notch to the hyoid bone.

53
Q

What does a modified MHD of greater than 2 finger breadths indicate? Less than 2?

A

Greater than 2 –> Larynx may be positioned too far down the neck for direct visualization
Less than 2 –> Larynx may be tucked under the tongue (anterior airway)

54
Q

What is the sternomental distance (SMD)?

A

Measured from the sternal notch to the lower boarder of the mentum (chin) with the mouth closed and the head extended –> Normal is 12.5 - 15 cm

55
Q

What does a sternomental distance of less than 12.5 cm indicate?

A

Predictor of difficult laryngoscopy and intubation –> Poor head and neck extension

56
Q

What test is helpful in determining the length of the head and neck extenstion?

A

sternomental distance (SMD) –> This is measured once in a neutral position and again with the neck extended, the difference is subtracted. Should be greater than 5 cm

57
Q

What does a head extension of less than 5 cm indicate?

A

Difficult intubation and laryngoscopy

58
Q

What does the interincisor gap test assess?

A

Ability of the patient to open their mouth –> 3 finger breadths or more in good indication of ease of laryngoscopy and intubation

59
Q

What two things can increase the risk of dental damage when intubating?

A

Patient who has buck teeth or prominent incisors

60
Q

What joint offers the highest degree of mobility in the neck?

A

Atlantooccipital joint

61
Q

Normal full range of neck flexion and extension?
How much flexion does the atlantooccipital joint provide?

A

90 - 165 degrees –> decreases by 20% between ages 16 - 75 years olds
35 degrees (10ish flexion, 20ish extension)

62
Q

Why is proper atlantooccipital joint mobility helpful when intubating?

A

Allows the patient to be placed in the sniffing position. This improves DL views by promoting displacement of the tongue by better aligning the oral, pharyngeal, and laryngeal axes.

63
Q

How do you assess atlantooccipital joint mobility?

A

Patient seated in an upright neutral face forward position. The patient is asked to lift the head back with the chin up as far as possible.

64
Q

What is anticipated if the patient shows atlantooccipital joint mobility of 23 degrees or less (down syndrome, trauma patients, diabetics potentially)?

A

Visualization via DL for intubation may be difficult –> VL has been show to be effective in patients with limited cervical spine mobility as well as fiberoptic scope

65
Q

What is the mandibular protrusion test?

A

Upper lip bite test –> Assesses the patients ability to extend the mandibular incisors anterior past the maxillary incisors.
This assesses the patients temporomandibular joint function and forward subluxation of the jaw.

66
Q

What are the classes of the mandibular protrusion test?

A

Class A, B, and C –> Class A indicates relative ease while class C is more indicative of a difficultly with the laryngoscope.

67
Q

What is an example of a supraglottic airway?

A

LMA

68
Q

When may a supraglottic airway be implemented?

A

As a primary means of ventilation during surgery or as a rescue source of ventilation in the event that a face mask ventilation isn’t sufficient

69
Q

What two assessments could indicate ease or difficultly with inserting a supraglottic airway?

A

Interincisor gap assessment and atlantooccipital joint mobility

70
Q

What types of obstructions would not indicate the use of a supraglottic airway (LMA)?

A

Lower airway obstructions –> Obstruction of the larynx, trachea, or below

71
Q

Why may it not be ideal to use a supraglottic airway in patients presenting with a bronchospasm or ARDS?

A

These conditions require higher ventilatory pressures –> ET tube placement is preferred

72
Q

Can a supraglottic airway protect against aspiration of stomach contents?

A

NO –> Only ET tube

73
Q

What are the absolute contradictions to preforming a circothyrotomy?

A

NONE –> There are conditions that will make this more difficult but this is a last resort means of providing the patient with adequate oxgenation/ventilation.

74
Q

What are some conditions that will make preforming a circothyrotomy more difficult?

A

SHORT –> Surgery, hematoma, obesity, radiation, and tumors

75
Q

What should be done preoperatively in patients who may indicate a difficult cricothyrotomy?

A

Cricothyroid membrane should be marked PRIOR to surgery so in the advent that a cricothyrotomy needs to be preformed it can be done so quickly.

76
Q

What imaging tool is gold standard for ruling out fractures of the cervical spine?

A

CT Scan

77
Q

Difference in imaging of MRI and CT

A

CT –> Can look at bones and soft tissue
MRI –> Can only look at soft tissue

78
Q

How can ultrasonography be used in assessment of the airway?

A

Can help indicate a difficult laryngoscopy if patients show excessive pre tracheal soft tissue.
Also used to find the cricothyroid membrane in obese individuals.

79
Q

How long can a functional FRC theoretically oxygenate a healthy individual?

A

8 minutes –> Pre oxygenation is required though!

80
Q

What should be done to pre oxygenate a patient?

A

100% FiO2 with a tight mask seal for 3-5 minutes of normal tidal volumes, providing a minimum of FGF of 5 L per min

81
Q

How to pre oxygenate a patient when time is limited?

A

Patient takes 8 vital capacity breaths within 60 seconds before the induction of anesthesia.

82
Q

How should a curved MAC (Macintosh) laryngoscope be used?

A
  1. Place the tip of the blade in the vallecula
  2. Apply tension to the hyoepiglottic ligament using a gentle lifting force which promotes indirect elevation of the epiglottis
83
Q

How should a straight Miller laryngoscope be used?

A
  1. Place the tip of the scope posterior to the epiglottis
  2. Apply gentle force to directly lift the epiglottis
84
Q

When should levering action of the laryngoscope be applied to the patients dentition?

A

NEVER

85
Q

What technique helps improving the visualization of the vocal cords?

A

BURP –> Backwards-upwards-rightwards, pressure

86
Q

What are some signs of adequate pre oxygenation?

A

Respiratory bag which moves with each inspiration and expiration, a well defined EtCO2 waveform, and a fraction of EXPIRED oxygen over 90%

87
Q

Aligning the patients sternum with the tragus of the ear may aid in what?

A

May help in intubation with patients potentially difficult to intubate.

671A - Anesthesia I (22 decks)

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