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N936 Speciality Techniques > Week 1a Anesthetic Considerations of the Difficult Airway > Flashcards

Week 1a Anesthetic Considerations of the Difficult Airway Flashcards

1
Q

What is the most common cause of adverse respiratory events for patients undergoing anesthesia?

A

difficult tracheal intubation

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2
Q

LEMONS

A 
Look externally
Evaluate the mandibular space
mallampati classification
obstructions
neck mobility
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3
Q

BONES

A 
beard
obesity
no teeth 
elderly (>55yrs)
snores
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4
Q

MOANS

A 
Mask seal
obesity
Age >55
no teeth
stiff lungs
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5
Q

What has decreased instances of difficult airways?

A

Video laryngoscopes

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6
Q

What is the most severe difficult airway emergency?

A

can’t intubate can’t ventilate

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7
Q

Failed intubation and failed ventilation accounts for what percentage of all anesthesia related deaths?

A

25%

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8
Q

Using the ASA Difficult airway algorithm, how do you arrive at the Emergency Pathway?

A

The emergency pathway occur when you can’t mask ventilate and the supraglottic airway is not adequate (LMA)
OR fail or deteriorating ventilation

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9
Q

Using the ASA Difficult airway algorithm, describe the emergency pathway?

A

limit attempts and be aware of the passage of time
call for help/ invasive access
Attempt to intubate approaches as you prepare for emergency invasive airway

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10
Q

Describe Cormack-Lehane Grade 1 View

A

most or full view of the glottic opening

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11
Q

Describe Cormack-Lehane Grade 2a View

A

only the posterior portion of the glottic opening can be visualized anterior commissure not seen; partial view of the glottis

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12
Q

Describe Cormack-Lehane Grade 2b View

A

arytenoids or posterior part of the vocal cords only just visible

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13
Q

Describe Cormack-Lehane Grade 3 View

A

only the epiglottis can be visualized; no portion of the glottic opening can be seen

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14
Q

Describe Cormack-Lehane Grade 4 View

A

epiglottis cannot be seen only view of soft palate

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15
Q

What are distinguishing features of a bougie?

A

long 60cm
coude tip (35-40 degree bend)
malleable, yet firm
NO LUMEN FOR INSUFFLATION

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16
Q

Can you ventilate with a bougie?

A

NO

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17
Q

The Bougie

A

portex venn introducer

cheap reliable and familiar tool many anesthesia providers utilize

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18
Q

Indications for a Bougie

A 
unable to pass ETT
grade 3 or 4 view
ETT exchange
digital intubation
adjunct to invasive techniques
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19
Q

Describe how to use a bougie

A 
obtain the best possible view
hold bougie like a pencil with Coude tip anterior
advance and "hook" under epiglottis
anticipate "clicking"
DO NOT remove laryngoscope
Slide ETT over bougie
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20
Q

Pearls of the Bougie

A

LEAVE the laryngoscope IN PLACE during procedure
Rotate ETT 90 degrees counter clockwise
use flexible- tip tube
capnography

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21
Q

Tip to utilizing a Standard Tube with a Bougie

A

pull the tube back 2 cm then rotate counter clockwise and re-inserted to advance

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22
Q

Complications of Bougie Placement

A

failed intubation
perforation
vocal cord trauma

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23
Q

When are airway exchange catheters commonly used?

A

when a secure airway should be changed or temporarily removed, but laryngoscopy is likely difficult

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24
Q

Common Features of an airway exchanger include:

A

distance markings
central lumen and/or side ports
adapter for TTJV or 15mm connection

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25
Q

In relation to a Bougie, Airway exchanger catheters are

A

longer, less flexible and have a hollow lumen

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26
Q

Pediatric size of a Cook Catheter

A

8Fr, 45cm >3.0 ID ETT

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27
Q

Adult sizing of a Cook Catheter

A

11,14,19 Fr 83cm >4.0, 5.0, 7.0 ID ETT

blunt tip, semi-rigid

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28
Q

Describe Cook Airway Exchange Catheter

A

radiopaque
distal and side ports
rapi-fit adapter: Luer Lock 15mm
Distance markers

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29
Q

Standard Adult Sizing of an Sheridan Exchange Catheter

A

Standard
81mm
6-10 ETT

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30
Q

Extended Adult Sizing of an Sheridan Exchange Catheter

A

for DLT exchange
100 mm
35-41 Fr DLT

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31
Q

Other Airway Exchange Catheters include:

A

Frova Intubation Introducer
Endotracheal tube Introducer
Parker Flex-It Directional Stylet

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32
Q

Frova Intubation Introducer

A

similar to bougie, but with a hollow lumen that allows for O2 delivery
Pediatric version is available

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33
Q

Endotracheal tube Introducer

A

similar to a bougie, but 10 cm longer and stiffer

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34
Q

Parker Flex-It Directional Stylet

A

allows provider to elevate tip of ETT from proximal end

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35
Q

Pearls of Airway Exchange Catheters

A 
HIGH risk procedure
Have a Plan A, B and C
two providers minimum
review to all previous airway and intubation notes/history
perform a direct laryngoscopy first
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36
Q

Lighted Stylets

A

use the principle of transillumination of soft tissues of the anterior neck to guide the tip of the ETT into the trachea

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37
Q

Indications for a lighted Stylet

A

routine intubation (studies show high success rates and lower airway trauma)
patients with difficult airways
can be used to locate tip of ETT when performing a percutaneous tracheotomy
can be used with laryngoscopy, LMA or Bullard and during retrograde intubation

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38
Q

A trachlight tip needs to be bend to form a

A

field hockey stick

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39
Q

What does the field hockey stick formation of a trachlight do?

A

enhances the movement through the glottic opening

once the light passes through the glottis the wire stylet is retracted 10cm

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40
Q

How do you prep a trachlight?

A

lubricate wire stylet
lubricate the flexible wand
attach ETT, clamp proximal end to handle
Bend tip 90 degrees like a field hockey stick

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41
Q

How do you position a patient for a trachlight?

A

bed in the low position
head neutral or slightly extended
do not place the patient in the sniffing position

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42
Q

Explain the technique of using a trachlight

A

Device is inserted mid-line and advanced along the sagittal plane
when the illumination of the light is noted below the laryngeal prominence, retract the wire stylet 10cm
advance the wand (without the wire stylet) until glow disappears below the sternal notch (this is about 5cm above the carnia)
unclamp ETT from handle and advance

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43
Q

Pearls of a trachlight

A

full muscle relaxation is recommended
jaw thrust or mandible lift
insert device mid-line
when a faint glow is seen above the larynx, lifting the jaw or tongue will raise the epiglottis and facilitates the wand toward the vocal cords
when the wand enters the glottic opening a well defined light will be observed below the laryngeal prominence
if resistance is met when attempting to advance ETT, rotate it 90 degrees

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44
Q

Needle Cricothyromtomy

A

final option is ASA difficult airway algorithm
provides rapid access to the airway
ability to oxygenated, but CO2 removal ineffective
can be performed either using landmark technique or with ultrasound-guidance

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45
Q

Equipment needed for a Needle Cricothyromtomy

A

14 gauge needle with angiocatheter attached to a syringe partially saline-filled

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46
Q

Landmark technique of Needle Cricothyromtomy

A

provider positioned on the same side as the patient’s dominant hand
larynx stabilized with non-dominant hand; thumb and long finger
index finger to identify CTM
needle inserted with dominant hand at a 45 degree angle CAUDALLY
needle aspirated until presence of air noted

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47
Q

TACA Technique for Needle Cricothyromtomy

A

begin at the thyroid notch
slide transducer caudally and identify CTM/ air tissue interface
continue caudal to the hypoechoic cricoid cartilage
slide cephalad to CTM/ air tissue interface and mark CTM

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48
Q

Indications for Retrograde intubation

A

failed intubations

urgent airway required, but cords cannot be visualized

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49
Q

Contraindications to retrograde intubation

A

unfavorable anatomy
laryngotracheal disease
coagulopathy
infection

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50
Q

Preparation for Retrograde Intubation

A

positioning
skin preparation
anesthesia
entry site

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51
Q

What is the ideal patient position for retrograde intubation?

A

sniffing position with head and neck hyper-extended

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52
Q

Awake Retrograde Intubation

A

if possible the airway should be anesthetized

53
Q

What blocks should be performed for an Awake Retrograde Intubation

A

trans-laryngeal with superior laryngeal nerve block
trans-laryngeal with topicalization of the pharynx
glossopharyngeal nerve block with nebulized anesthetic

54
Q

Entry Site of Retrograde Intubation

A

puncture can occur either above or below the circoid cartilage

55
Q

Cricothyroid Membrane vs Cricotracheal ligament for Retrograde Intubation

A

cricothyroid membrane- less bleeding, greater chance of failed intubation
cricotracheal ligament - higher success rate, lower incidence of vocal cord trauma and greater risk of bleeding

56
Q

Cricothyroid Ligament

A

attaches from the inferior border or the thyroid cartilage to the upper border of the cricoid cartilage
it measures approximately 1 cm in height and 2cm in width
avascular

57
Q

Guidewire Technique of Retrograde Intubation

A

Classic Epidural Catheter
J-wire
J-wire/Introducer

58
Q

Guide Wire Technique of Retrograde Intubation

A

A: needle with catheter is passed through entry site until air is aspirated
B: guidewire is threaded through needle until it passes through the oropharynx or nasopharynx
C: a hemostat clamps the guide-wire at the trachea insertion site
D: endotracheal tube is passed over guide wire until it meets resistance in larynx

59
Q

FOB Technique for Retrograde Intubation

A

Guide wire passed through trachea in normal fashion
guide wire passed through suction port of FOB allowing for straight path to vocal cords
ETT can be passed over FOB through vocal cords
continuous O2 can be delivered

60
Q

Pull Through Technique for Retrograde Intubation

A

epidural catheter is passed as previously described
silk suture tied to epidural catheter extending from pharynx
catheter pulled through tracheal incision site with silk suture
catheter removed. ETT tied to cephalad end of suture
hold slight pressure, ETT is passed until it abuts against the cricothyroid membrane

61
Q

Pearls of Retrograde Intubation

A

CTM associated with less bleeding, lower success rate

use a smaller ETT (6.5-7mm)

62
Q

Pearls with Silk Pull Through Retrograde Intubation

A

less railroading, can perform multiple attempts with one puncture, ability to re-intubate postoperatively

63
Q

Pearls with J-Wire Retrograde Intubation

A 
less traumatic
easier to retrieve
less prone to kinking
can be used with FOB
takes less time to perform
64
Q

Complications of Retrograde Intubation

A

bleeding
subcutaneous emphysema
nerve injury
broken wire

65
Q

Awake Intubation is

A

the gold standard for the management of difficult airway

66
Q

Why is Awake intubation the gold standard?

A

patient spontaneously breathes
airway patency maintained
larynx does not move into anterior position

67
Q

When is awake intubation commonly used?

A

Cervical spine injury
adequate topicalization to reduce coughing
judicious sedation for self airway protection

68
Q

What sedation is utilized for awake intubation?

A

precedex because it maintains spontaneous ventilation

69
Q

What is the leading cause of mortality and morbidity ASA closed claims analysis?

A

Airway management failure

70
Q

When does a difficult airway occur?

A

routine induction/ intubation sequence
awake intubation with known/ anticipated difficult airway
as part of the ASA difficult airway algorithm

71
Q

What is an endoscope?

A

an instrument composed of over 10,000 glass fibers that transmits light and allows for visualization of images

72
Q

Three main parts of a flexible endoscope?

A

handle
insertion tube
flexible tip

73
Q

What are the parts of the FOB handle?

A 
power source
suction/valve
working channel
angulation control lever
lens with focus capability
74
Q

All lenses of the FOB have

A

an eyepiece that can be focused

75
Q

How do you orient yourself in the lens of a FOB?

A

a visible block notch in the eyepiece at the 12oclock position aids in orientation

76
Q

New FOB lens systems may have (3)

A

video output adapter
video screen
camera

77
Q

What are the four components inside the insertion tube?

A

light guide bundles
transmit light source
angulation wires
working channel

78
Q

What are light guide bundles?

A

light is transmitted by one or two non-coherent glass fibers

high intensity light is focused at the proximal bundles

79
Q

What is a transmit source in the FOB?

A

continuous glass fibers run the length of the insertion tube, transmitting images

80
Q

What does a black spot represent in a FOB image?

A

damage to the fibers

81
Q

Purpose of Angulation Wires

A

move the flexible tip in opposite directions

two wires course along the sagittal plane of the bronchoscope

82
Q

How long is the working channel?

A

runs the length of the insertion tube

83
Q

What can the working channel provide?

A

oxygen
suction
medication portal
specimen collection

84
Q

What is contained in the flexible tip?

A

charged coupled devices (CCD) chip and second lens that allows viewing of structures

85
Q

What is the field of view for the flexible tip?

A

approximately 75-120 degrees

86
Q

Has there ever been a documented case of infection or cross contamination by fiberoptic intubation?

A

no

87
Q

What are the most likely ares for ineffective FOB sterilization?

A

valves and working channels

88
Q

What are other sources of contamination for a FOB?

A 
sentinel patients
contaminated water
inadequate sterilization technique
repeated use of brushes or cleaning fluid
FOBs with design errors or defects
89
Q

Care of the Endoscope includes:

A

universal precautions are mandatory

disinfection can take up to an hour

90
Q

After using the FOB:

A

inspect for any damage
dissemble moving parts, pass a cleaning brush through working port
nondisposable parts are placed in an approved cleaning solution
after sterilization time, bronchoscope washed and rinsed with water
working port must be dried with 70% alcohol and compressed air

91
Q

How and what sterilization is required for endoscopes?

A

ethylene oxide sterilization for 24 hours may be required after use in patients

92
Q

Successful airway anesthesia requires:

A 
trigeminal nerve block (nasal intubation)
glossopharyngeal nerve (GPN) block
laryngeal nerve blocks
93
Q

Orotracheal airways are innervated by

A

cranial nerve V (trigeminal)
Cranial nerve IX (glossopharyngeal)
Cranial nerve X (vagus)

94
Q

Trigeminal nerve

A

provides sensory innervation to the face

95
Q

What are the three divisions of the trigeminal nerve?

A

opthalamic (v1)
maxillary (v2)
mandibular (v3)

96
Q

Glossopharyngeal Nerve

A

provides sensory innervation to posterior 1/3 of tongue, oropharynx, vallecula, anterior epiglottis
Afferent limb of the gag reflex

97
Q

internal branch of superior laryngeal nerve

A

sensory innervation to posterior epiglottis to vocal cord folds

98
Q

external branch of superior laryngeal nerve

A

motor innervation below the vocal cords

99
Q

Sensory innervation of the recurrent laryngeal nerve

A

innervates below the vocal folds and trachea

100
Q

Motor innervation of the recurrent laryngeal nerve

A

all intrinsic laryngeal muscles

101
Q

Recurrent Laryngeal Nerve branches off the vagus

A

in the thorax

102
Q

Right RLN loops under

A

the subclavian artery

103
Q

What recurrent Larygneal nerve is susceptile to injury?

A

left

104
Q

L RLN loops under

A

the aorta

105
Q

What is included in the FOB cart?

A

bronchoscopes
ancillary equipment
local anesthetics
emergency airway equipment

106
Q

What is included in the Ancillary Equipment?

A 
swivel adapters
endoscopy masks
intubating oral airways
nasopharyngeal airways
endo tracheal tubes
107
Q

Advantages to an intubating oral airway

A

protects the bronchoscope
shields FOB from tongue, tissues
allows for passage of ETT (up to 9.0mm)

108
Q

Nasal Pharyngeal Airways

A

cut laterally along the length of the airway

can serve as a conduit for oxygen adminstration

109
Q

Swivel adapter

A

used mostly for bronchoscopy

allows for continuous ventilation without an airway leak

110
Q

Flexible Tip ETT vs regular PVC ETTs can get caught on what structure?

A

arytenoids

111
Q

Awake Fiberoptic Intubation Indications

A

anticipated difficult mask ventilation and intubation
difficult airway with comorbidites likely to result in poor outcome if intubation is not achieved
failed asleep intubation
small mouth

112
Q

Equipment and monitoring for Awake Fiberoptic Intubation

A 
IV access
FOB cart and airway cart (test FOB for light and movement)
oxygen delivery system
two suctions
monitors (SpO2 is mandatory)
medications
113
Q

Psychological Preparation for Awake Fiberoptic Intubation

A

explain and re-assure patient in a professional manner

114
Q

What should you include in patient prep for Awake Fiberoptic Intubation

A

benefits of FOB
probably amnesia
local airway anesthetic administration
patient assistance during the procedure

115
Q

Pre-medication for Awake Fiberoptic Intubation

A

antisialagogue 15-20 minutes prior (glycopyrrolate/ atropine)
Sedation
Induction agents
Nasal drops

116
Q

What are the doses for the antisialagogue?

A

glyco 0.2-0.4mg

atropine 0.4-0.6mg

117
Q

How can you perform local airway anesthesia for Awake Fiberoptic Intubation?

A 
drops
injection
nebulizer
paste
spray as you go
118
Q

Complete local airway anesthesia requires

A

glossopharyngeal block
superior laryngeal block
transtracheal block
nasal (both sides)

119
Q

Glossopharyngeal Block

A

patient may be required to assist
tongue moved medially
local anesthetic applied on inspiration to the tonsillar pillar
injection of the area with local anesthetic is not recommended
commonly applied with long cotton tipped swabs

120
Q

How to perform a Superior Laryngeal Nerve Block

A

local the hyoid cornua with non dominant hand brace the contralateral side
advance needle until ipslateral bone is contacted
aspirate then inject
repeat other side

121
Q

How to perform a transtracheal block

A

straddle the trachea with the non-dominant hand
locate the cricothyroid space, slowly advance the needle while aspirating
stop when air is freely aspirated
instruct patient to take a small breath, then maximum exhalation

122
Q

Awake Fiberoptic Intubation Procedure

A

position patient
an assistant to help with airway
hold insertion tube so that FOB remains straight
FOB is passed in a down up down motion

123
Q

Explain down up down technique with FOB

A

down- through oropharynx
up- toward anterior commissure
down through vocal cords

124
Q

preparation for Routine Fiberoptic Intubation

A

nasal drops
antisialgogue pre-operatively
standard induction

125
Q

Unsuccessful Awake Fiberoptic Intubation

A

reinstitute face mask ventilation

giver more anesthetics prior to second attempt

126
Q

Contraindications for FOB

A 
lack of skill by anesthesia provider
lack of trained assistant or ready to use equipment
wild, uncooperative patient
near total upper airway obstruction
another technique
127
Q

Extubation and the DAW

A

have a strategy

128
Q

Facts to consider for Extubation and the DAW

A

awake vs deep
clinical symptoms that will impair ventilation
management of plan if unable to maintain adequate ventilation
short term use of an airway exchanger

129
Q

Follow Up care of the DAW

A

document presence and nature of difficulty
differentiate between ventilation and intubation
description of managemnet techniques used
provide patient information for future care

N936 Speciality Techniques (3 decks)

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