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2

carina

where trachea bifurcates.

Left and right sides come off at different angles. 

right bronchi is 2.5 cm long with 25 degree angle

left bronchi is 5cm long with a 45 degree angle

 

3

Pre-op airway assessment

  1. general appearance
  2. Malampati classification
  3. range of motion of neck
  4. thyromental distance
  5. dentition
  6. mouth (lips, gums, tissues)
  7. mouth oppening (2-3 fingers)
  8. teeth (missing, protrusions, overbite, bridges out)
  9. size and mobility of tongue
  10. body habitus
  11. Hx of difficult intubation

*aspiration risk (hiatal hernia, GERD, recently ate, OSA)

 

4

Mallampati score

Pt sitting upright, head neutral mouth open as wide as possible and tongue maximally protruded.  No AAAH!

  • Correlates the oropharyngeal space with the ease of direct laryngoscopy and tracheal intubation.
    • When the base of the tongue is disproportionately large, the tonge overshadows the larynx resulting in difficult exposure of the vocal cords during laryngoscopy. 

No AAAH!

 

6

Cormack and Lehane Score

Laryngoscopic view of the glottis

Grade I: most of the glottis visible

Grade II: Only the posterior portion of glottis visible

Grade III: Only epiglottis visible

Grade IV: No airway structures visualized

7

Thyromental Distance

  • Distance from lower border of mandible to thyroid notch with neck fully extended
    • Normal 4 fingerbreadths (6-6.5 cm)
  • Difficult intubation <3 fingers

8

Optimal intubating position

"sniffing"

Oral, pharyngeal, and laryngeal axis

Most optimal for visualization of vocal cords and most effective mask ventilation

9

Mallampati classes

  1. faucial pillars, entire uvula, soft and hard palates.
  2. Uvula tip masked by tongue, soft and hard palates
  3. Soft and hard palates, uvula base only
  4. Hard palate only

 

PUSH

pillars, uvula, soft palate, hard palate

10

Nasal passage includes:

  • septum
  • turbinates
  • adenoids
  • paranasal sinuses

11

just remember where all that shit is

15

Oral airways

measure from the corner of the mouth to the earlobe

  • use tongue depressor to insert
  • Complications:
    • laryngospasm
    • bleeding
    • soft tissue damage
  • 2 types: Berman (BOA) and Guedel (hollow)
    • small- BOA 80mm / Guedel 3
    • medium- BOA 90mm / Guedel 4
    • large - BOA 100mm / Guedel 5

16

Trachea

Fibromuscular

10-20 cm length, 22 mm diameter

no cartilage on posterior side

bifurcates at T-4 (carina)

17

Trachea

  • extends from inferior end of larynx into the thorax
  • teminates at the sternal angle (T4) where it bifurcates (carina) into left and right main bronchi
    • 2.5cm in diameter
    • 10-20 cm length
    • 16-20 U shaped cartilages
    • posterior side lacks cartilage
      • posterior gap is spanned by the involuntary trachealis muscle
  • innervated by the Recurrent Laryngeal Nerve of the Vagus Nerve

18

Mainstem bronchi

  • Right mainstem bronchi is 2.5 cm long with 25 degree angle
  • Left mainstem bronchi is 5 cm long and 45 degree angle

19

Lobar bronchi Left Vs right

Left has 2

Right has 3

20

General anesthesia Mask case

  • Can be used when:
    • no difficult airway
    • surgeon does not need access to head/neck
    • no airway bleeding/secretions
    • short case
    • no position changes and easy access to head
    • obstruction easily relieved with oral or nasal airway
    • no neuromuscular blocker used--spontaneous breathing

21

Tracheal intubation indications

  1. airway compromise
  2. airway inaccessible
  3. long surgical time
  4. surgery of head, neck, cheek, or abdomen
  5. need for controlled venticalion and/or PEEP
  6. Inability to maintain airway with mask/LMA
  7. aspiration risk
  8. airway/lung disease

22

General anesthesia LMA case

 

  1. surgeon does not need access to head/neck
  2. no airway bleeding/secretions
  3. case of short duration
  4. more reliable patent airway than mask
  5. want hands free
  6. no NMB needed

23

General Anesthesia ETT case use when:

  1. airway compromise
  2. airway inaccessible
  3. long surgical time
  4. alternate surgical positions
  5. surgery of head, neck, cheek, or abdomen
  6. need for controlled ventilation and PEEP
  7. inability to maintain airway with mask/LMA
  8. aspiration risk
  9. deliver predictable O2

24

What is the difficult airway algorithm?

25

What should you do if you expext problems with your airway?

  • have the difficult airway cart
  • plan a fiberoptic intubation
  • know the difficult airway algorithm

26

LMA

  • Supraglottic airway device
  • used for routine AND difficult airway management
  • can be used as conduit for ETT placement
  • sizing based on weight
    • 30-50kg--> LMA 3
    • 50-70kg --> LMA 4
    • 70-100kg --> LMA 5
    • >100 kg --> LMA 6
  • Can be used for positive pressure but is not meant for it
    • only positive pressures below 15.

27

LMA advantages over ETT

  1. increased speed and ease of placement
  2. improved hemodynamic stability at induction and emergence
  3. reduced anesthetic requirements
  4. lower frequency of coughing during emergence
  5. lower incidence of sore throats
  6. avoids "foreigh body" in trachea
  7. pt can be fully emerged before removal. (good for asthma patients)

28

LMA disadvantages

  1. lower seal pressure
  2. high frequency of gastric insufflation
  3. esophageal reflux more likely
  4. inability to use mechanical ventilation

29

What is normal cervical ROM?

30

What are the classes of the Mandibular protrusion test?

31

What are you assessing during the physical airway exam?

  • Mouth opening
    • >4cm or >2 fingerbreadths
  • size and mobility  of tongue
  • palate- high or arched?
  • any mass seen?
  • size and shape of mandible
  • TMJ/ROM
  • ability to advance lower incisors in front of upper?

32

What are you observing for when looking at the teeth?

  • poor dentitian
  • loose teeth
  • chipped teeth
  • capped 
  • removable bridges
  • dentures

33

Pre-op airway assessment

  1. general appearance- deformities, trach scars, etc
  2. Malampati classification
  3. range of motion of neck
  4. thyromental distance
  5. dentition
  6. mouth (lips, gums, tissues)
  7. mouth oppening (2-3 fingers)
  8. teeth (missing, protrusions, overbite, bridges out)
  9. size and mobility of tongue
  10. body habitus
  11. Hx of difficult intubation

*aspiration risk (hiatal hernia, GERD, recently ate, OSA)

 

34

What are some co-morbidities that may effect airway management?

  • Lesions/infections of larynxx
  • thyroid disease- compresses airway
  • Cancer- radiation
  • Diabetes
  • Obesity- diff to allign axis
  • genetic disorders
  • rheumatoid arthritis
  • musculoskeletal
  • scleroderma- thick SC tissue, difficult to open mouth
  • genetic disorder

35

What should you ask the pt regarding their airway history?

  • Have you had an anesthetic in the past?
  • were you told of any airway problems?
    • was there severe sore throat or dental damage?
    • were you advised to have an awake or fiberoptic intubation
    • did you have any records or documentation?
  • any breathing difficulties?
  • Any recent cough -irritated airway more likely to laryngospasm
  • COPD/asthma?- have inhalor ready, use before case
  • do you snore?
  • do you use CPAP?