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Scientific Principles > Week 3 - Airway Management > Flashcards

Week 3 - Airway Management Flashcards

1
Q

What equipment is needed for manual ventilation?

A

Masks Airway Adjuncts (Oral/Nasopharyngeal airways)

Manual Ventilators (Resuscitation Devices - self inflating or non self inflating)

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2
Q

What are the steps for a non-rapid sequence general anesthesia induction?

A
  1. Pre-Anesthesia Safety Check (APSF guidelines)
  2. Apply monitors (ECG, NIBP, Pulse ox, ETCO2)
  3. Pre-oxygenation
  4. Induction Drugs (render pt unconscious and apneic and possibly paralyzed)
  5. Mask ventilation (while waiting for drugs to take effect)
  6. Airway Management Device Placement and Securement

*make sure you are able to ventilate pt prior to administration of paralytic

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3
Q

What is an essential anesthesia skill?

A

Positive Pressure Manual Ventilation – the ability to use your hands to breathe for a patient

Even more important than intubation (according to Heather)

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4
Q

APSF Prevention Focus, Back up Available: What are the basic things the ASPF says we need to have available to execute a general anesthetic induction?

A
  • Reliable delivery of O2 at any appropriate concentration up to 100%
  • Reliable means of positive pressure ventilation
  • Backup ventilation equipment available and functioning
  • Controlled release of positive pressure in the breathing circuit (able to exhale)
  • Anesthesia vapor delivery (if intended as part of the anesthetic plan)
  • Adequate suction
  • Means to conform to standards for pt monitoring
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5
Q

What are the indications for manual ventilation?

A
  • Bridge to placement of more secure airway (ETT, SGA)
  • Anesthesia machine ventilator failure or circuit malfunction
  • Excessive sedation and respiratory depression in MAC case
  • Transporting pt to ICU or from satellite anesthesia locations to PACU
  • Any emergency code situation or other loss of airway
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6
Q

What are the manual ventilation relative contraindications for GA?

A
  • Full stomach or other increased aspiration risk
  • Anticipated or known difficult airway
  • Facial trauma or anomalies of the face which would make mask ventilation difficult
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7
Q

What is the mask ventilation technique?

A
  • Optimal Ramped Position
  • Use of oral/nasopharyngeal airways
  • Correct mask size and fit
  • Jaw Thrust (push posterior angles of the mandible upward)
  • Proper hand positions

*Positioning and Jaw Thrust are VERY important

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8
Q

What is the proper ramped “sniffing” position and why is it important?

A

EAC at the sternal level

Helps alleviate upper airway obstruction and improves intubation view

*elevate head and shoulders on pillows/blankets

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9
Q

What are the steps in placing a oral airway?

A
  • Scissor mouth open
  • Pull jaw forward
  • Insert airway “upside down” and turn 180 degrees as you approach posterior pharynx (pushes tongue out of the way)
  • Flange should rest above the teeth
  • Alternatively, use a tongue blade to displace tongue and inset airway
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10
Q

How do you choose the correct size or an oral and nasopharyngeal airway?

A

Oral: flange should reach from corner of mouth to earlobe

Nasal: flange should reach from nose to earlobe

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11
Q

What is the proper fit of a mask?

A

It should sit over the bridge of the pt’s nose without putting pressure on the eyes

Sides should seal just lateral to the nasal folds with the bottom of the face mask sitting between the lower lip and chin

Proper size and fit needed to obtain a good seal — standard sizes are available (size 4 or 5 fits majority of adults; sizes 0-3 for peds)

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12
Q

When should you use an oral airway?

A
  • Edentulous patients (no teeth)
  • Down’s syndrome and pediatric pt with large tongues
  • Sleep apnea

*Never really hurts to place one, make sure pt is deep enough to avoid gag/cough reflex

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13
Q

What are the steps in placing a nasopharyngeal airway?

A

Gentle insertion with bevel towards septum, stop if resistance is felt

Insert with bevel towards septum and turn 180 degrees when NP airway is about halfway in

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14
Q

When would you use a nasopharyngeal airway? When is it contraindicated?

A

Great for when pt can’t open their mouth

Tolerated better for those with intact gag reflex

Caution with anti-coagulated pt — may cause nose bleeds

Contraindicated in basilar skull fracture

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15
Q

Describe the Jaw Thrust One Handed Technique

A
  • Place correct sized mask over nose/mouth
  • Position mask, holding body of mask between thumb and index finger
  • 3 remaining fingers support the jaw, with little finger hooked behind angle of mandible
  • Lift mandible upwards, toward and into the mask to create an air-tight seal
  • Slight head extension may improve airway patency
  • Ventilate with other hand by squeezing bag
  • Watch for bilateral chest movement, listen for leaks
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16
Q

Describe the two handed technique while using a mask

A

Use the thumbs to stabilize the mask while the index and middle fingers are used to bring the angle of the jaw forward

*Works better for smaller hands

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17
Q

What are the risk factors for difficult mask airway?

A

Facial Hair

Lack of Teeth

Obesity, OSA

Facial Anomalies

*Don’t forget the SGA option if you can’t mask or go directly to intubation

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18
Q

What is a closed reservoir self-inflating device?

A

Has a bag with a valve that will let air in if the bag becomes empty

The bag needs to be large enough to contain a tidal volume, or the balance of gas entering the bag will be air

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19
Q

What is a non-rebreathing valve?

A

Valve that ensures exhaled gas doesn’t mix with fresh gas entering the self-inflating bag and allows exhaled gas to escape into the atmosphere

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20
Q

What is a open reservoir self-inflating device?

A

Open end allows for air to enter

Some oxygen will be lost if flow is too high as it is open to the atmosphere

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21
Q

What is the oxygen reservoir on self-inflating devices?

A

Usually either bags or lengths of large bore tubing

-Allows accumulation of oxygen during the inhalation phase and release of the stored oxygen into the self-inflating bag during exhalation when the bag is refilling Increases the FiO2

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22
Q

Label the Diagram (Self Inflating Manual Ventilation Device)

A
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23
Q

What is a flow-inflating ventilation device bag inflation dependent on?

A

Bag inflation dependent on oxygen flow rate and adjustment of pressure relief valve

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24
Q

Describe the Circle Breathing Circuit

A

Happens when manually ventilating with the anesthesia machine

  • Gases flow in a circular pathway through separate inspiratory and expiratory channels
  • CO2 is removed through an absorbent
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25
Q

Label the diagram (circle breathing circuit)

A
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26
Q

What is the adjustable pressure limit (APL) or “Pop off” valve?

A
  • the only gas exit from the breathing system during spontaneous, assisted or manually controlled ventilation IF there are NO circuit leaks
  • used to control the pressure in the breathing circuit, which in turn adjusts bag filling
  • Higher gas flows will pressurize the circuit more quickly

**The breathing system bag will become a tactile monitoring device for you

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27
Q

What is the definition of general anesthesia?

A
  • Condition of having sensation (including feeling of pain) blocked or temporarily taken away — Reversible lack of awareness
  • Total lack of awareness (general anesthetic) or lack of awareness of a part of the body such as a spinal anesthetic (regional anesthetic)
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28
Q

What are the types of general anesthetic induction?

A
  • Inhalation induction (Mask)
  • IV induction (RSI or Modified RSI)
  • Combination
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29
Q

What is the main sequence of most GA inductions?

A
  1. Monitor application (look at vital signs prior to admin of drugs)
  2. Pre-oxygenation
  3. Induction agents given
  4. Airway support or management through masking, supraglottic airway or ETT placement
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30
Q

What is the effect of pre-oxygenation?

A

Increases apnea threshold by filling the FRC with oxygen

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31
Q

What are the indications for Inhalation (Mask) Induction?

A

Pediatric patient that is NPO where IV placement may be distressing

Adult patient that is NPO and are difficult IV placement or unable to cooperate with IV placement

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32
Q

What is the typical mask induction sequence?

A
  1. Monitors
  2. Nitrous/Oxygen mixture, then add Sevoflurane
  3. Gentle mask ventilation until IV placed – Pt can be susceptible to obstruction, laryngospasm, and bradycardia at this time period (delicate balance of anesthetic depth, too light can lead to laryngospasm, too deep can cause bradycardia)
  4. Intubation or airway placement after IV placed

*some GAs may be able to just mask without IV (must have back up plan – IM or intralingual drugs)

33
Q

What causes a laryngospasm?

A

Mediated by the SUPERIOR LARYNGEAL NERVE in response to irritating glottic or supraglottic stimuli (food, blood, vomit, airway sectretions)

Occurs most frequently with light anesthesia upon induction or emergence

34
Q

What is a laryngospasm?

A

False cords and epiglottic body come together firmly and allow no air flow and no vocal sound

35
Q

How do you treat a laryngospasm?

A

Forward displacement of the jaw and apply positive pressure with 100% oxygen

Severe spasm may require small doses of succinylcholine (0.1 to 1 mg/kg) and re-intubation

Laryngospasm will eventually cease as hypercarbia and hypoxia develop

36
Q

What is the general sequence of IV induction of a patient that has been NPO?

A
  1. Pre-oxygenation (Filling FRC with O2)
  2. IV induction agent
  3. Mask airway
  4. IV paralytic if ETT used (not always required) -No paralytic if SGA placed
  5. Placement of airway device and confirmation of placement
37
Q

What is a Rapid Sequence Induction (RSI)?

A

Anesthesia induction sequence that aids in securing airway with an ETT as quickly as possible – NO masking after induction agent is given

-reduces the time at risk for pulmonary aspiration and development of hypoxemia

38
Q

What are the indications for a rapid sequence induction?

A

Full stomach

Severe GERD

Anticipated possible difficult mask or intubation

39
Q

What are the steps in a rapid sequence induction?

A

Pre-oxygenation up to 5 minutes

IV anesthetic agent

Rapid-onset neuromuscular blockade (Sux)

Use of cricoid pressure

Intubation with ETT

Release of cricoid pressure after confirmation of ETT placement

40
Q

What is a modified RSI?

A

Patient is masked with gentle pressure while cricoid pressure is maintained

May be done if you need extra oxygenation or feel the need to see if the patient has a good mask airway

41
Q

What is the purpose of cricoid pressure?

A

Used to prevent pulmonary aspiration

-Hypothetical basis that pressure on the front of the cricoid cartilage is transmitted to its posterior lamina, which occludes the esophagus by compression against the vertebral bodies

42
Q

What is the technique for cricoid pressure?

A

Pressure is placed with thumb and index finger on lateral edges of cricoid cartilage (Pressure is 30N directed posterior)

  • Maintain cricoid pressure during laryngoscopy
  • DO NOT release cricoid pressure until after confirmation of successful intubation
43
Q

What are the disadvantages to cricoid pressure?

A
  • Reduce tone of lower esophageal sphincter (risk of regurgitation is increased)
  • Impair insertion of laryngoscope
  • Degrade the view of the larynx
  • Impede passage of introducer or tracheal tube
  • Cause airway obstruction
  • Application of pressure by assistant impedes external laryngeal manipulation by anesthesiologist
  • Fracture of cricoid cartilage
  • Rupture of esophagus from vomiting in presence of cricoid pressure (low levels of pressure might be safe in the presence of vomiting)
44
Q

What are complications of induction?

A

Laryngospasm – Bronchospasm

  • Induction of GA involves rendering a pt breathless and unconscious
  • In any “typical” induction involves anticipating difficulties and having a back up plan
45
Q

According to the Difficult Airway Algorithm, what do you do after initial intubation attempts are unsuccessful after induction of GA?

A
  1. Call for Help
  2. Return to spontaneous ventilation
  3. Awaken the patient (Most important thing is to wake the pt up if you can)
46
Q

According to the Difficult Airway Algorithm, when is a supraglottic airway, fiberoptic/video laryngoscope, rigid bronchoscope and/or jet ventilation used?

A

After initial intubation attempts are unsuccessful after GA:

  • Attempt to mask ventilate and use a SGA if ventilation is not adequate
  • If ventilation is still not adequate after SGA or SGA is not feasible, use fiberoptic/video laryngoscope, rigid bronchoscope and/or jet ventilation
47
Q

What is a summary of the difficult airway algorithm?

A
  • Assess airway and try to anticipate difficult intubations
  • If airway is anticipated to be difficult, consider awake fiber optic intubation or keep the patient breathing
  • If at any time you are unable to intubate a pt and unable to mask a pt, the SGA is the next line of treatment
  • Surgical airway is the end option if can’t intubate, can’t ventilate scenario
48
Q

Direct Visualization or Direct Laryngoscopy (DL) vs Fiberoptic camera (video) assisted

A

DL = laryngoscope with light source and Blade (requires some movement of head and neck)

Video = Rigid fiberoptic (version of a DL blade with a camera) or Flexible fiberoptic

49
Q

What are the different types of laryngoscope blades?

A

Straight (Miller Blade) - goes under epiglottis

Curved (Macintosh Blade) - goes in vallecula

Sizes = Neonate:0 Infant: 1 Child: 2 Most Adults: 3 Large/Tall Adults: 4

**Prior to induction check light source

50
Q

What is the direct laryngoscopy technique with MAC Blade?

A
  • Hold laryngoscope blade in left hand
  • Scissor mouth open with right thumb and 3rd finger
  • Insert blade at the right side of mouth, sweep tongue out of the way as you insert tip of blade into vallecular space
  • Make sure lip is not caught under blade on top or bottom
  • Remove fingers once blade is inserted and epiglottis is visualized

*if you don’t see epiglottis, pull blade back a little

*if epiglottis is large, use blade to lift it

51
Q

What is the direct laryngoscopy technique with Miller Blade?

A
  • Effective control of the tongue is critical for straight blade use (The small flange height prevents any ability to sweep tongue)
  • Proper position is achieved by deliberately directing the blade to the right paraglossal space
  • No tongue should be present to the right of the blade
  • Full insertion of the blade should occur through the right lateral mouth, over the molar dentition, and while the distal blade may then be directed medially, the proximal blade should never be brought back towards the midline (will hit central incisors)
  • Once epiglottis is “trapped” under the blade, bring the handle slightly more upright by a slight backward tilt
52
Q

What are rigid fiberoptic laryngoscopes?

A

Bullard or Upsher

  • use fiberoptics to transmit image from tip of device to eye piece
  • elevates jaw without the need for neck extension and useful with small mouth opening
  • ETT slides along device or through device
53
Q

What are video laryngoscopes?

A

Glidescope or Storz C-MAC or Airtraq (‘06)

  • insert blade down middle of tongue
  • use metal stylet and follow the ETT along the course of the blade
  • provides magnified wide-angle view without the need for eye piece
54
Q

What is a bougie?

A

Inserted through the ETT and clicking or bumping is felt as the tip runs along the tracheal rings

55
Q

What is the advantage of flexible fiberoptic laryngoscopes (bronchoscope)?

A

The scope can follow any anatomic space, working around obstructions AFOI “gold standard” for anticipated difficult airway

*But not without limitations

56
Q

What are the benefits of a SGA compared to an ETT?

A
  • Less invasive airway (non-irritating to bronchial tree, less anesthetic required)
  • Relatively quick and easy to insert
  • Requires no special equipment for insertion
  • Less coughing on emergence
  • If removed inflated, secretions come out with it
  • Less chance of kinking, but may be more likely to dislodge
  • Can avoid mask ventilation (4 hour max use time)
57
Q

What are the benefits of an ETT compared to SGA?

A
  • Theoretical aspiration protection (GERD, full stomach, laparoscopy)
  • More “secure” airway (less likely to move/dislodge)
  • Ability to positive pressure ventilate at higher peak pressures
  • Used if postop ventilation is required (obese, lung disease)
  • Protects against laryngospasms while in place
58
Q

Label the parts of an ETT

A
59
Q

What are the sizes of ETTs?

A

Based on the INTERNAL diameter — 2.5mm to 9.0mm

  • Adults = 7.0 - 9.0
  • Children = age divided by 4 plus 4 (compare diameter to pinky size) (For depth = ETT size x 3)

Ex: 4 yo: 4/4 + 4 = 5.0 ETT – 5 x 3 = 15 depth

*children size if for uncuffed – go down 0.5 size for cuffed

60
Q

What are the approximate cuffed ETT sizes for full term infants and children?

A

0-4 months = 3.0

4-12 months = 3.5 - 4.0

10 months - 2 years = 4.0

2-3 years = 4.5

3-5 years = 5.0

6-10 years = 5.5

10-14 years = 6.0

15-18 years = 6.5 - 7.0

61
Q

What is a microlaryngoscopy tube (MLT)

A

Small diameter, longer ETT to facilitate the view of the airway

Size 5-6mm

62
Q

Uncuffed vs Cuffed ETT

A

Uncuffed - typically used in infants since cuff can be damaging (narrowest point of infant airway is right past the vocal cords)

Cuffed - provides seal between the tube and tracheal wall to prevent pharyngeal contents from passing into the trachea and ensure no gas leaks past cuff during positive pressure ventilation

63
Q

What are the types of cuffed ETTs?

A

Low Volume, High Pressure: inflating pressure rises rapidly because compliance of cuff wall is low (better protection against aspiration, better visibility during intubation, lower incidence of sore throat) - unable to determine pressure on the trachea when inflated

High Volume, Low Pressure: (most frequently used) pressure rises only slightly until it forms a seal with the tracheal wall – thin compliant cuff wall can achieve a seal without stretching the tracheal wall - can measure intracuff pressure

64
Q

What are the different types of ETT?

A

PVC Endotracheal Tube

Microlaryngoscopy Tube

Wire Reinforced ETT (prevents kinking)

Laser Resistant ETT (PVC ETT are flammable)

Ring-Adair-Elwin (RAE) ETT

Laryngectomy/Tracheal Stoma ETT (“J Tube”)

65
Q

What is special about a Ring-Adair-Elwin (RAE) ETT and when would you use it?

A

The external portion of the oral version is bent at an acute angle so when in place, it rests on the pt’s chin – nasal version rests on pt’s forehead

Allows for connection of circuit to be away from surgical field during surgery around the head

  • Use oral RAE during tonsil surgery to keep tube out of the way
  • Use nasal RAE if oral cavity is obstructed (angioedema)
66
Q

Tips on how to insert a nasal RAE

A

Place ETT in warm saline container

Mix Afrin with 2% lidocaine jelly

Dilate nasal passage with nasal trumpets lubricated with same solution

Use McGill forceps to guide tube, but often with external laryngeal manipulation, ETT is directed naturally to go through vocal cords

67
Q

What is a laryngectomy/tracheal stoma ETT (“J Tube”)?

A

Designed to be inserted into a tracheostoma – allows the part of the tube external to the pt to be directed away from the surgical field

*Can be done awake or asleep

68
Q

What is a Laryngeal Mask Airway (LMA)?

A

Supraglottic Airway

  • Essentially a big oral airway that fills entire pharynx
  • ASA difficult airway algorithm stresses early insertion of LMA in event of difficult mask

LMA Unique = disposable (single use)

LMA Classic = reusable

69
Q

How do you insert a LMA?

A
  • Lubricate the top
  • Grasp tube portion as if it were a pen with index finger pressing on the point where the tube joins the mask
  • Follow the hard palate with the mask portion pressing with index finger pushing LMA all the way in
70
Q

What is the max cuff volume for each size of a LMA?

A

Size 1 = 4 mL

Size 1.5 = 7 mL

Size 2 = 10 mL

Size 2.5 = 14 mL

Size 3 = 20 mL

Size 4 = 30 mL

Size 5 = 40 mL

71
Q

What is a flexible LMA?

A

It is a wire-reinforced LMA

  • longer and narrower tube
  • tube can be bent to any angle without kinking
  • Less likely to be displaced during head rotation or repositioning
  • Not MRI compatible

*Designed for use with surgery on the head, neck and upper torso where classic LMA would be in the way

72
Q

What is a ProSeal LMA?

A
  • Has an esophageal drain tube
  • Shorter and smaller diameter airway tube, wire reinforced
  • Has an integrated bite block
73
Q

What is a LMA Supreme?

A
  • Has a built-in drain tube (can suction through it) and fins in the bowl to protect the airway from epiglottic obstruction
  • Gentle curve and oblong shape allows easier insertion and more stable placement
74
Q

What is a LMA Fastrach?

A

It was developed to help with intubation and to overcome some of the problems associated with intubating through the LMA-classic

75
Q

How has the original LMA evolved?

A

LMA Classic –> LMA Unique (single use) –> LMA Flexible (wire-reinforced) –> LMA Fastrach (designed for intubation) –> LMA ProSeal (esophageal drain) –> LMA Supreme (able to suction through)

76
Q

What is an i-gel?

A

Supraglottic Airway

  • designed to create an anatomical seal without an inflatable cuff
  • Has a gastric channel and bite block
77
Q

How do you insert a i-gel?

A
  • Grasp the bite block firmly positioning the device so the cuff outlet is facing the chin
  • With pt in sniffing position insert into mouth directed toward the hard palate with continuous gentle push until definite resistance is felt
  • The black line on the tip should be in line with the teeth
  • Secure the i-gel by taping up from maxilla to maxilla
78
Q

What are complications from supraglottic airways?

A

Sore throat, trauma from insertion

Nerve injury including hypoglossal nerve (vocal cord paralysis, excessive high cuff pressures, use of N2O)

Gastric distention and aspiration

Scientific Principles (16 decks)

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