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Airway Flashcards

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1
Q

Assess difficult BMV by?

A

Mallampati score
Radiation to neck
Beard
Old >55yrs
Obese
No teeth, thyromental distance <6cm
Snorning, sleep apnoea

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2
Q

Anterior column components of airway assessment

A

Mouth opening - Mallampati
Teeth - prominent front teeth
Shortening of TMD
Size of tongue
Jaw protrusion

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3
Q

Middle column assessment of airway

A

History of stridor or hoarse voice
Nasopharyngoscopy
CT / MRI

Mainly looking for abnormality of airway passage - foreign body, tumours

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4
Q

Posterior column assessment

A

Range of neck movement
- Flexion of lower C spine
- Extension of the occipito-atlanto-axial complex

Neck circumference of > 43cm = difficult

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5
Q

Mnemonic for difficult LMA? RODS

A

Restricted mouth opening
Obesity, OSA
Distorted airway
Stiff lungs

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6
Q

Difficult intubation predictors

A

Long upper incisors
Poor jaw protrusion
Small mouth opening
Limited movement of neck
Short TMD
High MP score

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7
Q

What are the 3 cardinal signs of upper airway obstruction

A

Stridor
Difficulty swallowing
Muffled voice

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8
Q

What did the landmark trial for THRIVE show?

A

Patel’s study
- Average apnoea time of 17 mins
- Small rise in EtCO2 of 1.1mmHg per min

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9
Q

What are the risks and contraindications of high flow?

A

Contraindicated in CSF leak, oesophageal perf, BoS fracture, pneumothorax

Risks: barotrauma, gastric distention

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10
Q

How is preoxygenation achieved?

A

EtO2 >0.9
Adequate seal
3mins of TV ventilation or 8 deep breaths in 60s

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11
Q

Benefits of HFNP oxygen

A

reduces dead space, generates PEEP, and reduces work of breathing

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12
Q

What does TRHIVE stand for?

A

Transnasal humidified rapid insufflation ventilatory exchange

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13
Q

How much does EtCO2 rise per min in apnoea

A

1.8mmHg per min

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14
Q

What’s the pressure relief valve set at for Laerdal bag?

A

60cmH2o for adult
40 for children

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15
Q

What are the goals of assessing an obstructing airway

A

Nature, location and extent of the lesion causing obstruction

Urgency of airway management

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16
Q

What are the four choices of airway management in an obstructing airway?

A

Awake surgical tracheostomy
Awake intubation
Asleep SV intubation
Asleep intubation with paralysis

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17
Q

Measures to manage obstructing airway?

A

Sit upright
Apply O2 via HFNP to reduce WoB
Nebulised adrenaline 1-4mg
IV steroids
Helium O2 mixture

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18
Q

Why is inhalational induction no longer recommended for an obstructing airway?

A

In theory it maintains SV, can reverse volatile anaesthesia in failure

However, complete airway obstruction can occur, resulting in hypoxia and inability to decrease anaesthetic depth

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19
Q

Options of airway management for advanced laryngeal tumour

A
  1. Inhalational induction with double set up
    - If obstruction moderate, and intubation deemed possible on FNE.
    - 2 attempts at intubation. If failed, then surgeon to perform tracheostomy
  2. Tracheostomy under LA in severe pathology
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20
Q

Why is AFOI not used in laryngeal tumour?

A

Risk of topicalisation causing laryngeal spasm
Sedation causing complete obstruction
Airway diameter too narrow - cork in bottle
Risk of bleeding
Technical difficulty can lead to loss of airway

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21
Q

What are the newer techniques for managing advanced laryngeal tumours?

A

AFOI, in skilled operator, coaching pt through cork in bottle stage

Awake videolaryngoscopy with fiberoptic intubation - displacing the tongue for greater glottic access

SV TIVA with HFNP

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22
Q

What is Ludwig angina?

A

Bilateral bacterial cellulitis of the entire floor of mouth, usually an extension of a dental infection

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23
Q

How does Ludwig’s angina change the airway?

A

Elevation and posterior displacement of the tongue

progressive swelling of epiglottis and oropharyngeal tissue

Can cause truisms - reflex spasm of the master and medial pterygoid muscles

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24
Q

What symptoms will make AFOI difficult in patients post neck radiotherapy?

A

Usually not difficult.
However, if preop hoarseness and stridor, known to have laryngeal oedema = difficult

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25
Progression of symptoms in post thyroid neck haematoma?
Subtle voice change or hoarseness Dyspnoea and stridor are late signs
26
What's the cause of airway obstruction in post thyroidectomy haematoma?
Spread of blood in the tissue plane - direct compression of airway Compression of veins and lymphatics -> airway oedema
27
Why and when should you reopen the neck in post thyroid haematoma?
If patient is distressed and airway threatened. Unwise to attempt intubation in a symptomatic patient without opening haematoma Allows access to rapid tracheostomy
28
Airway plan for post thyroidectomy haematoma?
Open neck wound AFOI preferred - very likely to succeed. Inhalational induction IV induction + paralysis if surgeon ready to perform tracheostomy when intubation fails. Double set up to perform surgical airway
29
Symptoms and signs of acute epiglottis?
sore throat, odynophagia (pain on swallowing) fever, muffled voice, pharyngitis signs Respiratory distress
30
Why is inhalational induction the traditional approach for epiglottis?
LA could precipitate loss of airway
31
What are some key points when managing the airway of pt with acute epiglottis
Avoid LA for intubation Double set up - plan B surgical airway should intubation be impossible - Tracheostomy performed with volatile anaesthetic + SV Avoid muscle relaxant traditionally Use a smaller than usual ETT
32
What's the pathophysiology of hereditary angioemdema? How is it treated?
C1 esterase inhibitor deficiency. Treat with FFP, containing C1 esterase inhibitor
33
Why can't SAD be used in C spine injury?
High pressure against C spine may cause posterior displacement if spine is unstable
34
What are the C-spine abnormalities possible in rheumatoid arthritis
Subaxial subluxation Atlanto-axial subluxation
35
What's the radiological finding of atlanto-axial subluxation
Widening of the distance between arch of C1 and the dens of >3mm in adults in fully flexed position.
36
Cyanide poising - lab indicator? - antidote?
unexplained lactic acidosis >10mmol/L Hydroxycobalamin 5g IV over at least 15 mins Sodium thiosulphates - slower effect, give in combination with hydroxycobalamin
37
In laryngeal trauma (tracheal transection) - what is the preferred airway management technique and why?
Fibreoptic intubation under LA - Careful passage through the injured area. - BMV, or ETT passing partially transected trachea can create false passage -> complete airway obstruction In emergency, can use direct placement of a smaller ETT, with position checked with fiberoptic scope. Surgical tracheostomy is the favoured approach
38
Threatened obstructed airway in an uncooperative patient - options?
Safest = volatile induction, despite risk of gastric regurgitation. Maintain SV Double set up, as can perform tracheostomy should intubation fail
39
Airway considerations for high grade maxillary fractures?
Le Fort 3 - midface is mobile, can displace posteriorly to obstruct airway - Patient will position self to maintain airway - take note of position - Can lift bone manually Bleeding can be severe. Beware of BoS fracture - no high flow / THRIVE, or C-spine # -> need for MILS. Head injury with reduced conscious state = impaired ability to protect airway
40
Describe TIVA SV induction
Marsh model Cpt 2-3 mcg/ml starting Increase Cpt by 0.5-1 when the Ce reaches a point below Cp Continue until Ce of 5-6mcg/ml -> laryngoscopy. Spray cophenylcaine onto epiglottis, vocal cords, trachea. Suspension laryngoscopy when Ce 6-7 mcg/ml
41
Absolute contraindications to AFOI
Patient refusal Allergy to LA
42
Relative contraindications to AFOI
Blood and secretion in airway - difficult visualisation Gross airway distortion, fixed laryngeal obstruction - Cork in bottle effect Significant respiratory distress or airway compromise - LA may precipitate spasm
43
Disadvantages of nasal AFOI
epistaxis smaller tube use patient's discomfort topicalisation includes nasopharynx
44
Disadvantages of oral AFOI
natural conduit of the passage of the tube is lost - needs more advanced fibreoptic skills Patient bite on scope Can gag as scope might touch the oropharynx Holdup of tube at the cord Reduced MO = difficult
45
What's the main purpose of Berman airway?
Protect the fiberoptic scope and facilitate direct passage to larynx
46
What's the advantage of Ovassapian airway over the Berman?
Smaller size, better tolerated, easier to remove post intubation
47
Max dose of lignocaine from current recommendations?
Reasonable to use 7-9mg/kg DAS suggests not exceeding 9mg/kg
48
What does each co-phenylcaine spray contain?
5mg lignocaine, 0.5mg phenylephrine
49
What are the target nerves when topicalising for AFOI?
Trigeminal nerve - sensory to nasal cavity, anterior 2/3 of tongue Glossopharyngeal nerve - posterior 1/3 of tongue, soft palate, palatoglossal folds, lingual surface epiglottis Vagus - internal branch of superior laryngeal nerve for larynx above cord, RLN for sensory below cords
50
Aims of topicalisation in AFOI?
Ablate gag reflex - success when no response when touching pharynx anaesthetise vocal cords and trachea anaesthetise nose
51
How does a DeVilbiss atomisation device work?
Generates very small LA droplets for efficiency passage through airway and absorption via mucosa
52
What's the endpoint for airway topicalisation?
Ablation of gag reflex Change in voice
53
What is LASER?
light amplification of stimulated emission of radiation.
54
Advantages of laser surgery?
Precise cutting Low tissue reaction Simultaneously cut and cauterise - reduce bleeding
55
Disadvantages of laser surgery
Airway fire Iatrogenic burns of surrounding tissue Scarring ETT cuff rupture
56
Staff protection measures from laser?
Warning signs or locks on OR doors Protective glass Skilled operator Regular training / inservice Protection from fire - bottle of water set to douse the fire
57
Hazards of laser
eye damage, skin burns, airway burns Atmospheric contamination with laser plume - can cause laryngospasm / viral transmission Tissue perforation
58
What are the three approaches to micro laryngeal surgery?
1. Conventional low pressure ventilation with either microlaryngeal tube or laser-flex tube 2. Subglottic jet ventilation 3. no-tube technique
59
What is the crucial distinction between patients with laryngectomy vs. tracheostomy?
Tracheostomy patients have a potentially patent upper airway.
60
What is the function of an obturator in tracheostomy tube?
Fits within the trache tube, acts as an introducer, with a smooth, rounded tip to assist passage of tube.
61
What is the function of an inner cannula for tracheostomy?
Allows cleaning of build up of secretions Blocks the fenestrated holes of the outer tube
62
Steps of emergency management for tracheostomy
Apply O2 upper + trache site. Assess patency by passing suction tube down. Can't pass -> let down cuff If can't do either, remove tracheostomy If can't breath, positive pressure ventilate via either ends No improvement - intubate via stoma or orally
63
after how many days would you expect a well established stoma for tracheotomy?
7-10 days

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