VALLEY: AIRWAY MANAGEMENT Flashcards
**Describe the method and rationale for denitrogenation (pre-oxygenation) of the airway.
With a tight mask seal, provide 100% oxygen at a flow rate high enough to prevent rebreathing ( l0-12 L/min). Slight head up position has been recommended. Denitrogenation allows the patient’s functional residual
capacity (FRC) to be filled with approximately 90% oxygen, thus lengthening the apnea time without desaturation and improving safety.
What is the pressure limit for positive- pressure facemask ventilation? why?
Positive-pressure ventilation via a facemask should normally be limited to 20 cm H10 to avoid stomach inflation.
***How is an oropharyngeal airway sized?What problems may be seen with their usage?
Measure from the corner of a patient’s mouth to the angle of the jaw or earlobe. Poorly sized oral airway devices can actually worsen the obstruction.
Other complications include lingual nerve palsy and damage to teeth.
***Name 4 types of supraglottic airways.
- Laryngeal mask airways (i.e. LMA classic, LMS ProSeal, LMA Supreme),
- Perilaryngeal sealers (air-Q SP)
- Cuffless preshaped sealers (i-gel)
- Cuffed pharyngeal sealers {Combitube and King LTS)
***Describe the advantages and
of supraglottic airways.
Ease and speed of placement, reduced anesthetic requirements
and the resulting hemodynamic stability, less airway manipulation,
less dental trauma, LESS COUGHING ON EMERGENCE, and less risk of bronchospasm
***Describe disadvantages supraglottic airways
Disadvantages include ineffective ventilation when higher airway pressures are required, no protection from laryngospasm, and no protection from gastric aspiration, though newer models ofSGA devices have been designed to reduce this risk.
List five functions of the laryngeal mask
airway (LMA).
- an airway rescue device;
{2) partial protection of the larynx from pharyngeal (but not laryngeal) secretions
(Morgan and Mikhail);
(3) handfree ventilation {it is not necessary to use one hand constantly to support the face mask on the mandible);
(4)an alternative to ventilation through a facemask
{5) a conduit for tracheal intubation.
List four situations for which the laryngeal mask airway (LMA) is appropriately used.
l) as a substitute for the classic mask airway to
eliminate the presence of a relatively large mask and practitioner’s hand
that may interfere with surgical access; (2) to establish an emergency airway in awkward settings for intubation such as the lateral or prone positions;
(3) to establish an airway in the patient in whom either mask ventilation or tracheal intubation is difficult; (4) to provide a conduit to facilitate fiber-optic or blind oral tracheal intubation
Can a supraglottic airway be used in
place of an endotracheal tube during the
administration of anesthesia?
No. The supraglottic airway (SGA) is clearly not a replacement for the endotracheal tube. The SGA provides an alternative to ventilation through a facemask or endotracheal tube
The laryngeal mask airway (LMA) can
be used with up to how many cm H20
pressure?
Peak airway pressures ofless than 20 cm H20 are indicated to avoid stomach inflation.
The cuff pressure of the laryngeal mask
airway (LMA) should not exceed what
value?
The initial cuff pressure will vary with the patient, LMA size, head position, and anesthetic depth, but should not exceed approximately 60 cm H10 particularly in prolonged surgery. The use of N 20 can be attributed to an increase cuff pressure and potential sore throat
**Describe the benefits of alternative LMs,
including the i-gel and air-Q.
The i-gel is a cuffless LM. Its advantages include a simplified insertion and easy positioning. The air-Q device has a self-pressurized cuff that eliminates overinflation. Both alternative supraglottic devices reduce the
incidence of sore throat.
***List four (4) features that distinguish the
Fastrach LMA from a classic LMA.
The Fastrach LMA, or intubating LMA (ILMA), was specifically designed for use in difficult airway situations. The primary distinguishing features of the Fastrach LMA are: (I} an anatomically curved rigid airway tube; (2} an
integrated guiding handle; (3} an epiglottic elevating bar; and, (4} a guiding ramp built into the floor of the mask aperture
What advantage does the epiglottic elevating bar afford the ILMA (Fastrach LMA)?
The 2 bars at the aperture of the LMA classic are replaced in the ILMA by a single, moveable epiglottic elevating bar that pushes the epiglottis out of the way allowing smooth and unobstructed passage of the endotracheal tube as it emerges from the distal end of the ILMA’s metal shaft
What are the advantages of the integrated guiding handle on the Fastrach LMA {ILMA)?
The integrated handle at the proximal end of the barrel of a Fastrach LMA is used for insertion, repositioning, and removal. The position of the device can be optimized by lateral and anterior-posterior manipulation by using the integrated handle, an action called the Chandy maneuver.
What is the maximum endotracheal tube diameter that can be passed through an intubating laryngeal mask
airway {ILMA/Fastrach)?
The intubating laryngeal mask airway (ILMA/Fastrach) can accept an endotracheal tube as large as 8.0 mm in diameter.
The laryngeal mask airway is (LMA) contraindicated in four (4) conditions. Identify these four conditions.
(1) who are at risk for aspiration including gross or morbid obesity, pregnancy, multiple or massive injury, acute abdominal or thoracic injury, any abdominal condition
associated with delayed gastric emptying, or use of opioid medication prior to fasting, or patients who have not fasted;
(2) with fixed decreased pulmonary compliance, such as pulmonary fibrosis, because it forms a low
pressure seal around the larynx;
(3) With long-term mechanical ventilatory support;
( 4) with intact upper airway reflexes, as the reflexes may
cause laryngospasm.
***What is the “RODS” mnemonic?
"RODS" is used to identify difficult extraglottic device situation. Restricted mouth opening Obstruction Distorted airway or disrupted airway Stiff lung or stiff cervical spine.
***What is the most common adverse effect reported with the use of the laryngeal mask airway (LMA)?
Sore throat with an incidence of 10% is the most common adverse effect of using an LMA. The sore throat is most often related to over inflation of the cuff
***You decide a laryngeal mask airway (LMA) is appropriate for the airway management of the 9-kg patient, but a 1.5 LMA is not available; will you use a
size l or a size 2 LMA?
LMA size selection is critical to its successful use, and to the avoidance of minor as well as more significant complications. The manufacturer recommends
that the clinician choose the LARGEST size that will fit comfortably in the oral cavity, and then inflate to the minimum pressure that allows ventilation to 20 cm H10 without an air leak
Accordingly, a size___LMA classic is appropriate for
the 9-kg patient
2 LMA
***Pediatric: Weight (kg) LMA size
<5 kg
1.
***Pediatric: Weight (kg) LMA size 5- 10kg
1.5.
***Pediatric: Weight (kg) LMA size
10-20kg
2.
***Pediatric: Weight (kg) LMA size
20-30kg
2.5.
***Pediatric: Weight (kg) LMA size
30-50kg
3.
What is the purpose of the second lumen
on an LMA ProSeal?
The LMA ProSeal was the first double-lumen supraglottic airway. The second lumen is used for: (1) diagnosis of malposition, (2) passive emptying • of the stomach, and (3) active emptying of the stomach (OGT insertion).
The LMA Supreme is a single-use version of the ProSeal.
When choosing an LMA ProSeal, should you use the same size, size up, or size down from the appropriate LMA classic size?
When selecting an LMA ProSeal, you should size down from the appropriate LMA classic size
***List indications for using an Esophageal- Tracheal Combitube {ETC).
Indications for an ETC include supraglottic obstruction, morbid obesity, vomiting, regurgitation, massive airway or upper gastrointestinal bleeding, and acute bronchospasm. Airway reflexes should NOT be intact during ETC use.
The ETC requires minimal training for proper placement
***Describe the functions of the Air-Q perilaryngeal tube?
The Air-Q is an SGA device. It acts as a conduit for blind, or more likely, fiberoptic placement of an ETT
***How is the King LT positioned for proper
ventilation?
The King laryngeal tube has a small esophageal cuff and a larger hypopharyngeal cuff, with an opening between the 2 cuffs. When properly placed, the esophageal cuff is seated in the esophagus, with the opening positioned over the larynx. Both cuffs are then inflated simultaneously by injecting air in just one inflation port. This will provide a sealed method for ventilation. If ventilation is inadequate, the device is likely inserted too deep.
Describe removal of a supraglottic device.
Properly timing the removal of an SGA is critical. The patient should either be deeply anesthetized, or awake enough to open mouth on command. Removing the device during the excitation phase of emergence can result in Iaryngospasm. The cuff remains inflated to lessen the amount of secretions left behind and dropping into the airway.
***Describe the passing of the ETT and the depth of its insertion in the adult.
The tracheal tube should be observed while passing through the vocal cords and then advanced 2 cm past the glottic opening. This should result
in placement halfway between the vocal cords and the carina, with an approximate depth of 21-23 cm at the teeth
***Describe the Cormack- Lehane laryngeal view scoring system –> Grade I
Grade l- view of entire glottic opening;
**Describe the Cormack- Lehane laryngeal view scoring system Grade 2-
view of only posterior glottis opening
***Describe the Cormack- Lehane laryngeal view scoring system Grade 3
view of only the tip of the epiglottis;
***Describe the Cormack- Lehane laryngeal view scoring system Grade 4
view of only the soft palate.
***What is BURP?
A “BURP” is a maneuver to place backward-upward-rightward pressure on the thyroid cartridge to improve laryngeal view during direct laryngoscopy
**Describe the Mallampati Grading Syste: Class I
Faucial pillars, uvula and soft palate are visible
**Describe the Mallampati Grading System: Class II
Base of uvula and soft palate visible
***Describe the Mallampati Grading System : Class III
Soft palate and hard palate visible
***Describe the Mallampati Grading System: Class IV
Only hard palate visiable
