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Basics of Anesthesia > Week 3 - Airway Management > Flashcards

Week 3 - Airway Management Flashcards

1
Q

What main three nerves supply sensory innervation to the upper airway?

A

Trigeminal (eyebrows to upper lip)

Glossopharyngeal (upper lip to chin – naso and oro pharynx)

Vagus (larynx) – pharyngeal nerve = branch (posterior/lateral wall of laryngopharynx)

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2
Q

What is the nose entirely innervated by?

A

The Trigeminal Nerve

  • septum and anterior parts of the nasal cavity are affected by the anterior ethmoidal nerve (a branch of ophthalmic nerve)
  • rest of nasal cavity is innervated by the greater and lesser palatine nerves (branches of the maxillary nerve)
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3
Q

What are the branches of the trigeminal nerve?

A

Ophthalmic nerve

Maxillary nerve

Mandibular nerve – innervate the mouth and include the greater and lesser palatine nerves (sensation to hard/soft palate, and tonsils) and lingual nerve (sensation to anterior 2/3 of tongue)

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4
Q

What does the glossopharyngeal nerve innervate?

A

the whole oro-nasal pharynx

posterior third of tongue

vellecula

tonsils

epiglottis

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5
Q

What does the superior laryngeal nerve, internal division innervate?

A 
Sensory to: 
epiglottis
base of tongue
supraglottic mucosa
thyroepiglottic joint
cricothyroid joint
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6
Q

What does the superior laryngeal nerve, external division innervate?

A

Sensory to anterior subglottic mucosa

Motor to cricothyroid membrane

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7
Q

What does the recurrent laryngeal nerve innervate?

A

Sensory to subglottic mucosa and muscle spindles

Motor to:

  • Thyroarytenoid membrane
  • Lateral cricoarytenoid membrane
  • Interarytenoid membrane
  • Posterior cricoarytenoid membrane
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8
Q

List the nerves and branches that supply the upper airway

A

V1: ophthalmic division of trigeminal nerve (anterior ethmoidal nerve)
V2: Maxillary division of trigeminal nerve (sphenopalatine nerves)
V3: Mandibular division of trigeminal nerve (lingual nerve

IX: Glossopharyngeal nerve

X: Vagus nerve

  • Superior laryngeal branch
  • Internal laryngeal nerve
  • Recurrent laryngeal nerve
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9
Q

What should you assess for when doing an airway assessment?

A

Assess the likelihood and clinical impact of basic management problems

  • Difficult mask
  • Difficult intubation
  • Difficulty with patient cooperation or consent
  • Difficult tracheostomy
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10
Q

What are independent variables associated with Difficult Mask ventilation?

A
  • Age >55
  • Edentulous
  • BMI >26
  • Beard
  • History of snoring
  • Repeated attempts at laryngoscopy
  • MP III to IV
  • Neck radiation
  • Male gender
  • Limited ability to protrude mandible
  • BONES: beard, obese, no teeth, elderly, snoring
  • MOANS: male, mallampati, mask seal, obesity, obstruction, age, no teeth, stiff, snoring
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11
Q

What can you do to help difficult intubation with direct visualization?

A

Alignment of the oral pharyngeal and laryngeal axis

Proper positioning

*May have physical limitations – limited mouth opening, limited neck mobility, short neck/chin

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12
Q

What is the 3-3-2 rule for airway assessment?

A

Inter-incisor distance in fingers (3)

Hyoid mental distance in fingers (3)

Thyroid to floor of mouth in fingers (2)

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13
Q

What should you ask yourself if you have a predicted difficult airway?

A

Does the pt have to be intubated?
-neuraxial anesthesia or peripheral nerve block or use of SGA

Do you need to do the intubation awake?

  • Yes: if you predict difficult to mask and placement of SGA would be difficult or impossible – awake fiberoptic intubation
  • No: if you think you can mask ventilate and placement of SGA would be easy – asleep fiberoptic intubation w/ spont breathing, intubate through SGA, use video laryngoscopy, have bougie available
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14
Q

What is the difference between a bougie and intubating catheters/airway exchanger?

A

Bougie has no means to provide O2 and designed to slide under the epiglottis

Airway exchangers are designed to aid intubation through an SGA or an ETT

*Both indispensable pieces of equipment for difficult and advanced airway management

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15
Q

What is low frequency (manual) Jet Ventilation?

A

High pressure gas source is applied through a small bore catheter

  • a hand operated valve connected to 100% O2 and a pressure-limiting device to deliver gas to the patient at 50 psi or less with a RR of 10 to 14 breaths/min
  • chest rise and fall is observed to allow for proper expiratory time
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16
Q

What is supraglottic jet ventilation?

A

A true Venturi type of ventilation and the tidal volume is the sum of injected and entrained air

  • observe chest rise and fall to avoid air trapping
  • Venturi Effect - gas flow at a constriction speeds up causing a pressure drop and entrainment
17
Q

What is retrograde intubation?

A

One of several alternative maneuvers for securing the difficult airway

Insert guide wire through the cricothyroid membrane and feed it back up through the mouth. then feed ETT over the wire into the airway

18
Q

Describe Melker Technique for cricothryotomy

A
  • Palpate the membrane with non-dominant hand
  • Attach needle with the flexible catheter to a syringe with saline and insert through the membrane caudally at a 45 degree angle, aspirating as you advance until you see bubbles
  • Advance the catheter, remove the needle and syringe
  • Thread the guidewire through the catheter
  • Remove the catheter
  • Make small incision at the skin with provided #15 scalpel
  • Thread the trach kit with the grey tipped dilator over the guidewire and into the trachea and advance the airway catheter to the hub until it is flush with the skin
  • Remove guidewire and dilator
  • Secure the kit with “trach tape”
19
Q

What are the considerations when doing a blind nasal intubation?

A
  • Does the pt have a deviated septum or breathe out one side of the nostril better than the other?
  • Prep nose with vasoconstrictor (Afrin or phenylephrine)
  • Numb nasal passage and airway with aerosolized lidocaine
  • Pass NP airway to verify pathency
  • Pass ETT into nose and down pharynx, listening to breath sounds through ETT (may have a whistle attachment)
20
Q

What are contraindications for i-gel use?

A
  • Non-fasted patients for routine and emergency anesthetic procedures
  • Trismus, limited mouth opening, pharyngo-perilaryngeal abscess, trauma or mass
  • Don’t allow peak airway pressure of ventilation to exceed 40cmH2O
  • Don’t use excessive force to insert the device
  • Inadequate levels of anesthesia may lead to coughing, bucking, salivation, retching, laryngospasm, or breath holding
  • Do not leave in for more than 4 hours
  • Do not reuse or attempt to reprocess the i-gel
  • Use on a conscious/semi-conscious pt in an emergency setting
21
Q

What are the advantages and disadvantages of facemask airway technique?

A

Advantages: simple and quick

Disadvantages: Difficult for prolonged positive pressure ventilation, occupies your hands, no airway protection

22
Q

What are the advantages and disadvantages of SGA airway technique?

A

Advantages:

  • Simple
  • Frees your hands
  • Some airway protection

Disadvantages:

  • May be appropriate for longer periods of positive pressure ventilation
  • May dislodge with position changes
  • Peak pressures shouldn’t exceed 20cmH20
  • Pt may still laryngospasm
23
Q

What are the advantages and disadvantages of ETT airway technique?

A

Advantages:

  • Frees your hands
  • May ventilate with higher than 20 peak pressures
  • Protects lungs from aspiration

Disadvantages:

  • Requires training and time
  • Damage to teeth/airway
  • Bronchospasm

*reasons to intubate: high risk for aspiration, need for paralysis, respiratory failure/issues

24
Q

Where is the larynx in the adult and child?

A

Adult Larynx = C4-5

Infant Larynx = C3-4

*as the child grows to about 10 years of age, the airway starts to resemble the adults

25
Q

What can you do to improve the airway position of an child?

A

Shoulder roll

  • have large occiput causing flexion of the neck
  • proper positioning of a towel under a child’s shoulders to counter neck flexion
26
Q

What kind of cuffed ETT should be used in a child?

A

Low pressure, High volume

  • seal with as little as 10 cmH2O
  • *monitor cuff pressures with manometer
27
Q

How do you chose the correct ETT size for pediatric patients?

A

(Age + 16) / 4 = correct uncuffed ETT size —> use 0.5 size smaller with cuffed ETT

28
Q

What should the depth of anesthesia be for safe extubation?

A

Patient needs to be either deeply anesthetized of fully awake (follows commands)

  • extubation during light anesthesia (stage II) increases risk for laryngospasm
  • reaching for ETT may just be a localizing response to an irritant, not demonstration of consciousness
  • don’t extubate deep if it was difficult to intubate or airway is not dry
29
Q

What should occur prior to extubation of a patient?

A
  • Assure pt is fully reversed (TOF>0.9)
  • Spontaneous respirations with 100% oxygen (good tidal volumes? good respiratory effort?)
  • If awake: no breath-holding, eyes midline, responds to commands, expired volatile agent low to zero, entropy/BIS 100
  • If deep: breathing spontaneously, no breath holding, no response to suctioning, jaw thrust or ETT movement, expired volatile at least 1.5 MAC
  • Have mask by head and oral/NP immediately available
  • Suction
  • Let air out of cuff
  • Pull ETT, place mask on face and be ready to provide positive pressure
30
Q

What are the indications for fiberoptic intubation?

A
  • Difficult Airway – not just difficult intubation but also difficult mask
  • *known or predicted

-Cervical Spine Fractures – unstable C-spine or neurological symptoms with neck movement

31
Q

When would you do an awake fiberoptic intubation vs asleep fiberoptic intubation?

A

If you think you can’t mask or intubate the pt you shouldn’t make the patient apneic — Awake

Most sedating drugs cause respiratory depression and can lead to apnea

If you think you can mask the patient or place LMA, consider asleep fiberoptic

32
Q

What should the view during fiberoptic intubation be when the provider is standing at the head of the bed vs being in front of the patient?

A

Head of Bed – epiglottis is at the top of the view

Front of Pt – epiglottis is at the bottom of the view

Basics of Anesthesia (35 decks)

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