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APEX > Airway Assess & Equipment > Flashcards

Airway Assess & Equipment Flashcards

1
Q

Mallampati I

A

Class 1
Pillars, uvula, soft palate, & hard palate

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2
Q

Mallampati II

A

Class 2
Uvula, soft palate, & hard palate

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3
Q

Mallampati III

A

Class 3
Soft & hard palate ± partial uvula

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4
Q

Mallampati IV

A

Class 4
Only hard palate

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5
Q

Inter-Incisor Gap

A

Normal 4-6 cm

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6
Q

What factors contribute to limited mouth opening?

A

Buckteeth
Arthritis
Scar tissue
Temporomandibular joint disease
Prior surgery

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7
Q

Thyromental Distance

A

Helps to estimate the submandibular space
Normal > 6 cm
Submandibular space borders = mentum (superior), hyoid bone (inferior), & neck (lateral)

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8
Q

Mandibular Protrusion Test

A

Upper lip bite test
Temporomandibular joint function

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9
Q

Mandibular Protrusion Test
Class 1

A

Patient can move lower incisor past upper incisor & bite the lip vermilion

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10
Q

Mandibular Protrusion Test
Class 2

A

Patient able to move lower incisor inline w/ upper incisor

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11
Q

Mandibular Protrusion Test
Class 3

A

Patient cannot move lower incisor past the upper incisor (indicates potential difficult intubation)

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12
Q

Atlanto-Occipital Joint Mobility

A

Ability to place patient in the sniffing position

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13
Q

What conditions impair atlanto-occipital mobility?

A

Degenerative joint disease, arthritis, RA
Ankylosing spondylitis
Trauma or surgical fixation
Down syndrome
Klippel-Feil
Diabetes mellitus

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14
Q

Cormack & Lehane
Grade 1

A

Complete or near complete view of the glottic opening

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15
Q

Cormack & Lehane
Grade 2

A

Posterior region of the glottic opening
Unable to see the anterior commissure

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16
Q

Cormack & Lehane
Grade 3

A

Epiglottis only
Unable to see any part of the glottic opening

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17
Q

Cormack & Lehane
Grade 4

A

Soft palate only
Unable to see any part of the larynx

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18
Q

When to consider a bougie?

A

Grade 2B or 3

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19
Q

Difficult Mask-Ventilation Indicators

A

BONES
- Beard (mask seal)
- Overweight/obese BMI > 26 kg/m^2
- No teeth (edentulous)
- Elderly > 55 yo
- Sleep apnea OSA

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20
Q

Difficult Laryngoscopy & ETT Intubation Indicators

A

LEMON
Small mouth opening
Long incisors
Prominent overbite
High, arched palate
Mallampati class 3 or 4
Retrognathia
Inability to sublux jaw
Short, thick neck (obesity)
Reduced cervical mobility
Short thyromental distance

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21
Q

Difficult Video Laryngoscopy Indicators

A

Neck pathology - radiation, tumor, or previous surgery
Short thyromental distance
Limited cervical ROM or mouth opening
Class 3 upper lip bite test

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22
Q

Difficult Supraglottic Airway Placement Indicators

A

Limited mouth opening
Upper airway obstruction
Altered pharyngeal anatomy
C-spine

Poor lung compliance
↑airway resistance
Lower airway obstruction

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23
Q

Difficult Invasive Airway Placement

A

Abnormal neck anatomy - tumor, hematoma, abscess, radiation history
Surgery or previous scar
Obesity
Short neck
Laryngeal trauma
Limited access to the cricothyroid membrane (Halo or neck flexion deformity)

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24
Q

NPO Guidelines

A

Clear liquids 2 hours
Breastmilk 4 hours
Non-human milk, infant formula, or solid food 6 hours
Fried or fatty foods 8 hours

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25
Q

Mendelson Syndrome

A

Gastric content aspiration → pneumonia
Risk factors include gastric volume > 25 mL or 0.4 mL/kg + pH < 2.5

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26
Q

RSI Cricoid Pressure

A

Apply pressure to the cricoid ring C5 vertebrate

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27
Q

How much pressure to apply during RSI?

A

Before LOC 20 Newtons or ≈ 2 kg
After induction 40 Newtons or ≈ 4 kg

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28
Q

What are cricoid pressure complications?

A

Airway obstruction
Difficult DL and/or intubation
Impaired glottic visualization
↓LES pressure
Esophageal rupture (w/ active vomiting)

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29
Q

Angioedema

A

↑vascular permeability → face, tongue, & airway swelling
1° concern = upper airway obstruction

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30
Q

Angioedema Cause

A

Anaphylaxis
ACEi prevent bradykinin breakdown
Hereditary C1-esterase inhibitor deficiency

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31
Q

Angioedema Treatments

A
  1. Anaphylaxis mast-cell mediated → Epi, antihistamines, & steroids
  2. Discontinue ACEi → bradykinin receptor antagonist, plasma kallikrein inhibitor, FFP, & C1 esterase concentrate
  3. C1-esterase inhibitor deficiency → C1 inhibitor concentrate, FFP, & prophylaxis prior to upper airway procedures or tracheal intubation
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32
Q

Ludwig’s Angina

A

Bacterial infection characterized by rapidly progressing cellulitis in the floor of the mouth
Inflammation & edema compress the submandibular, submaxillary, & sublingual spaces

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33
Q

What’s the 1° concern w/ Ludwig’s angina?

A

1° concern = posterior tongue displacement resulting in complete, supraglottic airway obstruction

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34
Q

How to secure the airway in a patient w/ Ludwig’s angina?

A

Best way to secure the airway = AWAKE nasal intubation or tracheostomy
Retrograde intubation contraindicated in patients w/ an infection above the trachea***

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35
Q

What congenital conditions are associated w/ difficult airway management?

A

Beckwith syndrome
Trisomy 21
Pierre Robin
Goldenhar
Treacher Collins
Cri du chat
Klippel-Feil

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36
Q

What nerve injury can result from an aggressive jaw thrust or excessive traction at the mandibular angle?

A

Facial nerve stretch

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37
Q

What nerve injury can result from face straps being too tight?

A

Facial nerve 7
- Buccal branch

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38
Q

What nerve injury can result from an ETT connector resting on the patient’s face?

A

Supraorbital nerve compression

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39
Q

How does facial nerve stretch present?

A

Affected side sagging, drooling, & mastication affected

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40
Q

How does facial nerve compression to the buccal branch present?

A

Patient has difficulty opening & closing lips
Orbicularis oris muscle function impaired

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41
Q

How do OPA & NPAs function?

A

Open the airway by displacing the tongue & epiglottis from the posterior wall

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42
Q

How to measure OPAs:

A

Measure from the mouth corner to the earlobe or mandibular angle
The flange should protrude outside the lips & the pharyngeal end should rest at the tongue base

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43
Q

OPA Types

A
  • Guedel
  • Berman
  • Williams
  • Ovassapian
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44
Q

How to measure NPAs:

A

Measure from the are to the earlobe or mandible angle

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45
Q

What are contraindications to NPAs?

A

Cribiform plate injury
- LeFort 2 or 3 fracture
- Basilar skull fracture
- CSF rhinorrhea
- Raccoon eyes
- Periorbital edema
Coagulopathy
Previous trans-sphenoid hypophysectomy
Previous Caldwell-Luc procedure
Nasal skull fracture

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46
Q

BURP Maneuver

A

Backward
Upward
Rightward
Pressure

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47
Q

High-Volume, Low-Pressure Cuff

A

High cuff compliance
Manometer to measure internal pressure
Easy to pass things around the cuff (esophageal stethoscope, OT tube, temp probe)
Less protection against aspiration

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48
Q

Low-Volume, High-Pressure Cuff

A

Low cuff compliance
Better protection against aspiration
Lower sore throat incidence
Easier visualization during intubation
Prolonged intubation → tracheal ischemia

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49
Q

Pediatric ETT Equations

A

Cuffed ETT = [Age (years) / 4] + 3.5
Uncuffed ETT = [Age (years) / 4] + 4

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49
Q

Video Laryngoscopy Types

A

Non-channeled
Channeled
Acute-angle blade

50
Q

Non-Channeled Video Laryngoscopes

A

Glidescope
C-MAC
McGrath

51
Q

Channeled Video Laryngoscopes

A

Airtraq avant
Pentax AWS
King vision

51
Q

Acute-Angle Blade Video Laryngoscopes

A

Glidescope LoPro
C-MAC D-blade
McGrath X-blade

52
Q

LMA Types

A

Classic
ProSeal or Supreme
Fastrach
C-Trach
Flexible
iGel

53
Q

Classic LMA
Max Pressures

A

MAX PIP pressure = 20 cmH2O
MAX cuff pressure = 60 cmH2O

54
Q

What most commonly causes nerve injury w/ LMAs?

A

Cuff overinflation
Also increases sore throat & pharyngeal necrosis risk

55
Q

What nerves are at risk for injury w/ LMA use?

A
  • Lingual
  • Hypoglossal
  • RLN
56
Q

What do the aperture bars on LMAs prevent?

A

2 aperture bars prevent the epiglottis from obstructing the airway

57
Q

LMA Anatomical Borders

A

Superior = tongue base
Lateral sides = piriform sinus
Inferior = upper esophageal sphincter

58
Q

LMA 1

A

< 5 kg
Cuff 4 mL
ETT 3.5 mm
Flexible endoscope 2.7 ID mm

59
Q

LMA 1.5

A

5-10 kg
Cuff 7 mL
ETT 4.0 mm
Flexible endoscope 3.0 ID mm

60
Q

LMA 2

A

10-20 kg
Cuff 10 mL
ETT 4.5 mm
Flexible endoscope 3.5 ID mm

61
Q

LMA 2.5

A

20-30 kg
Cuff 14 mL
ETT 5.0 mm
Flexible endoscope 4.0 ID mm

62
Q

LMA 3

A

30-50 kg
Cuff 20 mL
ETT 6.0 mm
Flexible endoscope 5.0 ID mm

63
Q

LMA 4

A

50-70 kg
Cuff 30 mL
ETT 6.0 mm
Flexible endoscope 5.0 ID mm

64
Q

LMA 5

A

70-100 kg
Cuff 40 mL
ETT 7.0 mm
Flexible endoscope 5.5 ID mm

65
Q

LMA ProSeal

A

Double lumen LMA
Gastric drain tube, large mask, & built-in bite block
Max PIP < 30 cmH2O
LMA supreme = disposable version

66
Q

LMA Fastrach

A

Intubating LMA w/ specially designed ETT (uses high-pressure cuff)
Metal handle
Tube pusher
Epiglottic elevating bar

67
Q

LMA C-Trach

A

Similar to Fastrach but includes a camera

68
Q

LMA Flexible

A

Flexible airway tube
Wire-reinforced
Longer & narrower than LMA classic
Used w/ head & neck surgery

69
Q

iGel

A

Supraglottic airway alternative to the LMA
No inflatable cuff
Gastric port
No aperture bars
MRI safe

70
Q

iGel Complications

A

Tongue trauma
Cricoid cartilage mucosal erosion
Trachea compression
Nerve injury
Airway obstruction
Regurgitation & aspiration

71
Q

Most to least stimulating airway device placement & SNS stimulation

A
  1. Combitube (most)
  2. DVL
  3. Fiberoptic intubation
  4. LMA (least)
72
Q

LMAs + Laparoscopy

A

Select an LMA that allows gastric drainage
Normal BMI
Avoid light anesthesia
< 15° tilt < 15 cmH2O intraabdominal pressure < 15 minutes insufflation

73
Q

Combitube

A

Supraglottic double lumen device
Blindly placed in the hypopharynx

74
Q

Combitube Cuffs

A

Proximal oropharyngeal cuff (blue port) occludes the hypopharynx 50-85 mL
Distal cuff (white port) occludes the esophagus 5-15 mL air INFLATE 1st!

75
Q

Combitube Sizing

A

Based on patient height
4-6’ = size 37
> 6’ = 41

76
Q

Combitube Benefits

A

Provides a secure airway (aspiration protection)
Ability to decompress the stomach
Useful in the obese population
Does not require neck extension
Allows high ventilatory pressures
Does not need to be taped

77
Q

Combitube Contraindications

A

Intact gag reflex
Use > 2-3 hours (ischemia risk from the oropharyngeal balloon)
Esophageal disease = Zenker diverticulum
Caustic substances ingestion

78
Q

King Laryngeal Tube

A

Similar to Combitube
Inserted blindly
Single ventilation lumen
Child-size devices are available
- Minimum weight 10 kg
King LTS-D (disposable) 2nd lumen allows gastric tube to suction the stomach

79
Q

King Laryngeal Tube Cuffs

A

Only one inflation port
Simultaneously inflates both the proximal & distal cuffs

80
Q

Flexible Fiberoptic Bronchoscope

A

Difficult airway gold standard = awake fiberoptic
Non-dominant hand = holds the scope near the proximal end & thumb controls the lever
Dominant hand = holds the cord
Pushing the lever ↓down flexes the tip ↑UP
Pushing the lever ↑up extends the tip ↓DOWN
Rotation L or R allows to control the scope in the horizontal plane

81
Q

What are the best drug choices to facilitate awake fiberoptic bronchoscopy?

A

Short DOA and/or minimal respiratory depression
Midazolam
Dexmedetomidine
Ketamine
Remifentanil

82
Q

Bullard Laryngoscope

A

Rigid fiberoptic device
Indirect laryngoscopy
Adult & pediatric patients
Disposable tip extender available (tall patients)

Maintain head in neutral or slightly flexed position
Lubricate the stylet
Lift handle to straight up (90° angle to the spine) to expose the glottic opening

83
Q

What patients are ideal candidates to use the Bullard laryngoscope?

A

Small mouth openings (minimum 7 mm)
Impaired cervical spine mobility - do not need to align OPL axes
Short, thick neck
Congenital airway syndromes (Pierre Robin or Treacher Collins)

84
Q

What are absolute contraindications to the Bullard Laryngoscope?

A

NONE

85
Q

Rigid Fiberoptic Laryngoscopes

A

Bullard
WuScope
UpsherScope

86
Q

Intubating Stylet

A

Eschman introducer
Gum elastic BOUGIE
Coudé angled tip

87
Q

When to use bougie?

A

Cormack & Lehane 2B or 3 view

88
Q

How to confirm bougie placement?

A

Tracheal rings

Advance the tip into the trachea 23-25 cm

89
Q

What does encountering resistance w/ the bougie indicate?

A

Hold-up sign at the carina
35-40 cm

90
Q

Lighted Stylet

A

BLIND intubation technique
Illuminates the anterior neck

91
Q

Lighted Stylet (+) Pros

A

Anterior airway
Small mouth opening
Minimal neck manipulation
Less stimulating than DVL
Sore throat less common
Cervical spine abnormality
Pierre Robin
Severe burn contractures

92
Q

Lighted Stylet (−) Cons

A

Difficult to use in patients w/ short, thick neck
Obese patients ↑adipose tissue
More false positive possible in children
NOT an emergency airway technique
Blind technique - do not use w/ tumor present, foreign body, airway injury, or epiglottitis
Traumatic laryngeal injury

93
Q

What angle should be used w/ a lighted stylet for pediatric patients?

A

60-80°

94
Q

Retrograde Wire Intubation

A

Blind procedure

95
Q

Retrograde Intubation STEPS

A
  1. Puncture the cricothyroid membrane w/ 14-18 G needle
  2. Aspirate 3 cc syringe w/ air to confirm placement in the tracheal lumen
  3. Pass a wire through the needle & advance it cephalad
  4. Wire should travel b/w vocal cords & exit via the mouth
  5. Secure the wire at the cricothyroid membrane w/ clamp
  6. Load the ETT over the wire & advance it into the trachea
    Withdraw the wire & advance the ETT into position
96
Q

Retrograde Intubation Indications

A

Unstable cervical spine
Upper airway bleeding (unable to visualize the glottis)
*Possible to perform on awake patient

97
Q

Retrograde Intubation Contraindications

A

Poor anatomy - neck deformity or mass
- Unable to access the cricothyroid membrane
- Severe obesity
- Pretracheal mass (thyroid goiter)
Laryngotracheal disease
- Tracheal stenosis
- Tumor that obstructs wire path
Coagulopathy
Infection (pre-tracheal abscess)

98
Q

Retrograde Intubation Complications

A

Bleeding
Pneumothorax
Trigeminal nerve trauma

99
Q

Surgical Invasive Airways

A

Percutaneous cricothyroidotomy
Cricothyroidotomy
Tracheostomy

100
Q

Percutaneous Needle Cricothyroidotomy

A

EMERGENT surgical airway
- Insert large-bore needle through the cricothyroid membrane
- Ventilate w/ jet & high-pressure oxygen source ≈ 50 psi

101
Q

How does expiration occur w/ percutaneous needle cric?

A

PASSIVE

102
Q

What conditions limit or prevent exhalation w/ percutaneous needle cric?

A

Upper airway obstruction limits or prevents exhalation → barotrauma, pneumothorax, subcutaneous emphysema, and/or mediastinal emphysema
Unable to control ventilation → hypercapnia

103
Q

Percutaneous Needle Cricothyroidotomy Complications

A

Hemorrhage, aspiration, tracheal injury, & esophageal injury

104
Q

Cricothyroidotomy

A

EMERGENT surgical airway
- Small horizontal incision made through the cricothyroid membrane
- Insert cuffed ETT via hole

105
Q

Cricothyroidotomy Contraindications

A

Children < 6-10 years old more pliable & mobile laryngeal/cricoid cartilages
Laryngeal fracture or neoplasm

106
Q

Cricothyroidotomy Complications

A

Tracheal stenosis, tracheal or esophageal injury, hemorrhage, dysphagia, subcutaneous or mediastinal emphysema

107
Q

Tracheostomy

A

Usually controlled surgical airway
Requires more time than cricothyroidotomy
Chosen when a patient requires a definitive airway (failure to wean from mechanical ventilation)

  • Incision made b/w 2nd & 3rd tracheal rings
  • Pull back ETT when surgeon enters the trachea (ensure not to puncture the cuff)
108
Q

Tracheostomy ABSOLUTE Contraindications

A

NONE

109
Q

Tracheostomy Complications
Acute

A

Airway obstruction, hypoventilation, pneumothorax, & bleeding

110
Q

Tracheostomy Complications
Long-Term

A

Tracheal stenosis, tracheomalacia, tracheoesophageal fistula, & tracheal necrosis

111
Q

Difficult Airway Algorithm

A
  1. Pre-airway management decision-making
  2. Awake airway management
  3. Airway management after anesthesia induction
    a. Able to ventilate → non-emergent pathway
    b. Unable to ventilate → emergent pathway HELP!!!
112
Q

Guedel Anesthesia Stages

A
  1. Awake - airway reflexes intact
  2. Light anesthesia - airway reflexes are hyperreactive
  3. Deep anesthesia - airway reflexes are attenuated
113
Q

Extubation AWAKE (+) Pros

A
  • Airway reflexes intact
  • Ability to maintain airway patency
  • ↓aspiration risk
114
Q

Extubation AWAKE (−) Cons

A

↑CV & SNS stimulation
↑Coughing
↑ICP/IOP
↑intra-abdominal pressure

115
Q

How to prevent complications associated w/ awake extubation?

A

β blockers, Ca2+ channel blockers, & vasodilators to minimize cardiovascular & SNS stimulation
Lidocaine IV or inside the ETT cuff & opioids to minimize coughing

116
Q

Extubation DEEP (+) Pros

A

↓CV & SNS stimulation
↓coughing

117
Q

Extubation DEEP (−) Cons

A

Airway reflexes are ineffective
↑airway obstruction risk
↑aspiration risk

118
Q

Extubation Risk Factors

A

Difficult airway
Aspiration risk
OSA
Obesity
Cardiopulmonary disease
Neuromuscular disease
Metabolic abnormalities including acidosis, electrolyte imbalance, hypothermia

119
Q

Airway Exchange Catheter

A

Long, thin, flexible, & hollow tube that maintains direct access to the airway following tracheal extubation
- Able to measure ETCO2
- Provide jet ventilation via Luer-lock adaptor
- Oxygenation insufflation via 15 mm adaptor

120
Q

How to use an airway exchange catheter?

A
  1. Insert the airway exchange catheter into the ETT
  2. Keep the distal end in the trachea ≈ 25-26 cm at the lip
  3. Remove ETT
  4. Maintain airway exchange catheter in place up to 72 hours
121
Q

Airway Exchange Catheter Complications

A

Jet ventilation w/ obstructed upper airway → barotrauma/pneumothorax

APEX (18 decks)

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