Airway Assessment (Exam 2) Flashcards
(104 cards)
1
Q
What are the (7) airway structures?
A
- Nose
- Internal Nasal Cavity
- Mouth
- Pharnyx
- Larynx
- Laryngeal Cartilage
- Trachea
2
Q
What are the (3) parts of the Internal Nasal Cavity:
A
- divided by septum
- Cribriform plate
- Turbinates
3
Q
Name the (2) main parts of the mouth
A
- Roof
- Floor
4
Q
Name (4) structures that make up the Roof of the mouth?
A
- Maxilla and palatine bones
- Hard palate
- soft palate
- teeth
5
Q
Name the (3) structure that make up the Floor of the Mouth?
A
- Tongue
- Mandible
- Teeth
6
Q
The Heard palate is formed by parts of the ________ and _______ _______. It makes up __/__ of the roof of the mouth?
A
- Maxilla and palatine bones
- 2/3rds
7
Q
Name the Job of the Pharynx?
A
- Maintain airway patency
8
Q
What is the primary cause of upper airway obstruction during anesthesia? And how do you prevent this?
A
- Loss of Pharyngeal muscle tone.
- Chin lift
9
Q
What and Where is the Pharynx?
A
- Muscular Tube
- Base of the skull to lower boarder of cricoid cartilage.
10
Q
Name the (3) Parts of the Pharynx?
A
From Top to Bottom
* Nasapharynx
* Oropharynx
* Hydropharynx
11
Q
Where does the Nasopharynx end?
A
- Soft Palate
12
Q
Where does the Oropharynx start and end?
A
- Starts: Soft Palate
- Ends: Epiglottis
*occupied by the tongue
13
Q
Where does the Hypophaynx start and end?
A
- Epiglottis to cricoid cartilage
14
Q
Name (3) reasons why is the Larynx Important?
A
- Inlet to trachea
- Phonation
- Airway Protection
15
Q
Where does the Larynx start and end?
A
- Epiglottis
- lower end of cricoid cartilage. @ C6**
16
Q
Name (2) places the Vocal Cords are Attached?
A
- arytenoid
- Thyroid notch (laryngeal prominence)
17
Q
Name the (3) Unpaired Laryngeal Cartilage.
A
- Thyroid
- Cricoid – complete ring
- Epliglottis
18
Q
Name the (3) Paired Laryngeal Cartilage.
A
- Arytenoid
- Corniclate
- Cineiform
19
Q
What is the largest of the cartilages and what does it support?
A
- Thyroid Cartilage
- Supports most of the soft tissue.
20
Q
How long is the trachea and what is it’s shape?
A
- 10 to 15 cm (adults)
- C-shaped cartilage
21
Q
What closes the trachea posteriorly and what is the trachea anteriorly bound?
A
- longitudinal trachealis muscle
- bound by tracheal rings
22
Q
What is the only difference between lethal injection and General Anesthesia?
A
- GA does not bolus potassium.
23
Q
What do people die of the most with anesthesia?
A
- lack of ventilation
24
Q
What question chould you ask yourself before initiating anesthesia in any person?
A
- Can I ventilate/intubate this patient?
25
What should you do if you are not able to ventilated/intubate a patient?
* Maintain spontaneous ventilation
* Use awake endotracheal intubation
* Create a surgical airway
26
What is more valuable than any pre-surgical test?
* Complete Patient History
27
What are the best ways to obtain a good history for your patient?
***** Direct questioning of the patient. *****
* Review of anesthesia and surgical records
28
Name (6) **RED** flags in a patient's anesthesia history?
| concerns
* Past difficult intubation
* Report of excessive sore throat
* Report of cut lip/broken teeth
* Recent onset of hoarsness
* History of OSA
* Lesions intra-orally.... base of tonguelingual tonsils
29
What is the most predictive factor in a patient's history that will indicate difficult airway management? What might be some clues to this in their history?
**Past difficult intubation**
* Pt remembered the intubation
* Was awake for the intubation
* accessory devices were used
* Multuiple attempts were documented.
30
Name (6) criterias we are looking for while completing an airway evaluation?
* visual of face and neck
* mouth opening
* eval oropharyngeal anatomy and dentition.
* neck ROM
* submandibular space
* ability of pt to slide mandible anteriorly.
31
What findings concern us when we do a visual inspection?
* Facial deformites
* head/neck cancers
* burns
* goiter
* short/thick necks > 43 cm
* receding mandible
* beards
* c-collar
32
What is more predictive to a difficult intubation than a high BMI?
* Short/thick neck
* > 43 cm
33
Describe a normal Inter-incisor distance
* Prefer > 6 cm
* 3 finger breadths (patients)
34
What intercisor distance is indicative of a difficult intubation?
* < 3cm
* or 2 fingerbreaths
35
What pathologic characterisics will contribute to a difficult airway?
Abnormal Oropharyngeal Anatomy
* Tumor
* Palate deformities (high arched palate, cleft palate)
* Macroglossia
36
During your dental assessment, what can indicates problem during intubation?
* long upper incisiors
* poor dentition/loose teeth
* cosmetic work
* edentulousness
37
What accounts for 25% of all insurance claims against anesthesia providers? And what percentage of them occur during tracheal intubation?
* Dental Injuries
* 75% during tracheal intubation
38
Name (5) common causes of Dental Injuries?
* Laryngeal blade
* Rigid suction catheters
* Oropharyngeal airway placement
* Rigourus removal of airways
* Biting down on ETT/LMA/airways during emergence.
39
Your patient is freaking out and labored breathing against an inflated ETT. What would this causes and how should you treat it?
* Negative Pressure Pulmonary Edema
* Deflate the balloon on the ET cuff.
40
What are the 2 most injured teeth during intubation? and what side?
*** Left Anterior Maxillary centrals (47%) and lateral incisors (20%).**
* Laryngeal blade is on the left side.
41
What is the sniffing position and why do we use the postion?
* Cervical flexion and atlanto-occipital extension
* Aligns oral, pharnygeal and laryngeral axis.
42
In the sniffing postition, where should your ear be in relation to the sternum?
* Ear should be at the level of the sternal notch.
43
What is the Sternomental Distance?
* Distance between sternal notch and chin.
*** > **12.5 cm preferred.**
44
How do you measure the sternomental distance?
* Head in full extension
* Mouth Closed
45
What does the Thyromental distance evaluate? What is the prefered Distance?
* Submandibular compliance
*** >6.5 cm (3 fingers breadths)**
* Tip of chin to thyroid notch
46
How do we assess Prognathic ability?
* Upper lip bite test
* Extension of lower incisors beyond upper incisors
47
How would you instruct a patient to complete a mallampati test?
* Sit upright with head in neutral postion
* Mouth open
* Tongue protruded
* No phonation
48
Describe the Mallampati Test
* Visibility of oropharyngeal structures
* Class I -IV
* Comparing tongue to oropharyngeal space
49
Mallampati Class I
* Fauces
* pilars
* entire uvular
* soft palate
50
Mallampati Class 2
* Fauces
* portion of uvula
* soft plate
51
Mallampati Class 3
* Base of the uvula
* soft palate
52
Mallampati Class 4
Only hard palate
53
Laryngeal Manipulation: BURP
External manipulation and backward, upward, rightward pressure
54
Laryngeal Manipulation: OELM
**Optimal External Laryngeal Manipulation**
* Use of the right hand to guide the position and pressure is exerted by an assistant’s hand on the larynx
55
Cormack-lehane Classifiction
* Classification of laryngeal view
* Grade I-IV
* Trying to achieve the best view during DL
56
CL -Grade 1
* **Entire glottis**
* 68- 74% of patients
* <1 % difficulty
57
CL- Grade 2
*** only the posterior portion of the glottis**
* can be corrected by lifting blade or preforming laryngela postioning.
58
CL- Grade 3
*** No part of the glottis and only epiglottis**
* 1.2 - 1.6 % of patients
* 80-87.5% difficult intubation
59
CL- Grade 4
* Epiglottis cannot be seen
* Very rare
60
Criteria Associated with difficult mask ventilation: OBESE-M
OBESE - M
* Obesity (BMI > 30)
* Beard
* Edentulous (no teeth)
* Snorer, OSA
* Elderly, male (>55 yo)
* Mallampati 3 or 4
61
Predicting The Difficult Airway: BOOTS- I
BOOTS
* Beard - gel (NIRL)
* Obesity
* Older
* Toothless
* Sounds - snoring, stridor
* Inability to maintain O2 > 90% w/ BVM
62
Difficult Intubation: LEMON
LEMON
* Look (abn face, trauma, unusual anatomy)
* Evaluate (3-2-2)
* Mallampati score
* Obstructions/obesity
* Neckmobility
63
Difficult airways: 3-2-2 Rule
* 3 finger mouth opening, fingers along the floor of the mandible
* 2 fingers between the space between the superior notch of the thyroid cartilage
* 2 fingers between neck/mandible junction
64
Criterial Associated with difficult airway
## Footnote
Test question
* Large Upper Incisors
* Strong overbite
* Inability to pertrude mandible
* Small inter-incisiors distance
* Mallampati 3/4
* Large tongue
* Narrow, high arch palate
* Short Thyromental distance
* Excessive manibular soft tissue
* Short, thick neck
* Decreased cervical ROM
65
Difficult Airway Algorithm: When would you chose between an awake or post-induction airway?
* Suspected difficult laryngoscopy
* Suspected difficult ventilation with face mask/supraglottic airway
* Significant increased risk of aspiration
* Increased risk of rapid desaturation
* Suspected difficult emergency invasive airway
Answer YES to 4 = awake intubation
66
During Intubation we should.......
* Optimize oxygenation throughout
* Limit attempts, consider calling for help
* Limit attempts and consider awakening the patient.
* Limit attempts and be aware of the passage of time.
* WHEN IN DOUBT, CALL FOR A FRIEND.
67
* The patient will compensate until they can't.
* If something doesn't work, try something else.
* Try an LMA
* Phone a friend.
* Be proactive and not reactive.
* Always have a plan B.
68
Difficult Airway Simplication
## Footnote
Per Dr Cornelius
1. Evaluate all your patients
2. Figure out the difficult patients
3. Have a plan B and C for difficult intubations
4. General Anesthesisa w/ ETT
5. Superglottic airway (LMA) and ventilation
6. Call for help
7. Video Laryngoscope
69
Patient that can't be intubated or ventilated will end up with a .......?
Surgical cricothyroidotomy
70
Decision to Intubate: Intubate Early
* Dynamic Situation
* Bullets: Neck trauma
* Snake Bites: Anaphylaxis/angioedema
* Burns: Thermal and Caustic airway injuries.
71
Decision to Intubate: Airway Complications
* Mouth and Neck infections
* Tumors
* Foreign bodies
* bleeds
72
Decision to Intubate: Airway (Examples)
* Stridor
* Phonation
* Swallowing
* secretions
* dysnpnea
73
Decision to Intubate: Breathing
* Failure of oxygenation or ventilation
* After trying NIV
74
Decision to Intubate: Circulation
* supporting tissue oxygen delivery by unloading muscle of respiration
* Ex: Sepsis
75
Decision to Intubate: Disability
* CNS catastrophes
* CNS depression
* Ongoing seizures
* weakness
assess ability to swallow and handle secretions -
76
Decision to Intubate: Expected Course
* Anticipate decline
* tranfer to radiology
* transfer to another institution
77
Decision to Intubate: Feral
* Need for prompt, aggressive sedation
* Protection for the patient
* Protection for others
78
When should you **RSI** over Awake Intubation?
1. Urgency = quick
* ** peri-arrest
* dynamic airway**
2. Difficult airway features
* Known easy airway
* normal anatomy
3. Vomiting Risk
* Upper GI bleed
* bowel obstruction
* vomiting in ED
79
When should you **Awake** Intubate vs RSI?
1. Urgency = slow, not a fast procedure
* stable GI bleed for endo
* slowly progressing neuromuscular weakness requiring transfer
2. Difficult airway feacture
* fixed deformity of the neck
* cannot open mouth.
80
Awake Technique
* Glycopyrolate 0.2 mg or Atropine 0.1 mg/kg
* suction and dry mouth with gauze
* Nebulized with Lidocaine -- NO EPI
* Atomized Lidocaine to oropharynx
* Viscous Lidocaine -- w/ tongue depressor
* Lightly sedate w/ Versed 2-4 mg or Ketamine 20 mg q 2 min
* intubate awake/pass bougie while awake
* Paralyze, then pass tube.
81
Local Anesthesia for Intubation
* dry
* nebulize
* atomize
* topicalize
82
IV sedation for Intubation
* **KETAMINE: High Secretions
* Versed
* fentanyl
* Dexmedetomidine
83
Laryngoscopy: Steps to prepare
* Position patient
* find the epiglottis
* optimize the head: sniff and head tilt
* seat the blade
* optimize the larynx-- intubated
* FAILED: ventilate, change something, use a bougie
84
Bougie
* self- confirming
* intubate epilglottis-only views
* leave laryngoscope in
* lubricate tube,pull back and rotate if you get stuck
* **black strip is 25 cm** ( @ lip, mid trachea in an adult male)
85
If you are unable to intubate a patient, what is the best device to ventilate?
LMA
86
Why would we NOT use etomidate for intubation?
* Adrenal suppression
* lower's seizure thresholds
87
Reasons to use Ketamine for Intubation
* Reactive airway changes
* IM RSI
* Hypotension
* Sepsis
88
Reason to NOT use Ketamine for Intubation
* Hypertension/tachycardia
* high ICP
89
What will wear off faster during an RSI: Propofol or Parlaytic?
Propofol
90
Can I use a half -dose paralytic during Intubation?
NO
91
Absolute Contraindications w/ Succinylcholine
* Rhadomyolysis
* **hyperkalemia**
* **MS/ALS**
* **Muscular dystrophy**
* denervating >72 hours old
* crash injuries > 72 hours old
* sever infections >72 hours
* immobilization
* Predisposition to MH
* bradycardia
* fasciculations -- increased ICP
92
Succinycholine Duration
5 - 10 minutes
93
Rocuronium Duration
30 - 90 minutes
94
What are Physiologic Killers?
* Hypotension
* Hypoxemia
* Metablic Acidosis
95
What IV access do you need to have before attempting to intubate anyone?
* 2 peripheral IVs (atleast)
* or IO if unable to obtain IV access.
* bonus points for bolus of IV fluids to maintain SBP > 140 mmHg
96
What is the induction agent and paralytic agent of choice for Shock patients?
* ketamine (0.5 mg/kg)
* Rocuronium (1.6mg/kg)
97
What are our push dose pressors?
* Epinephrine
* Phenylephrine
* Vasopressin
*always dilute*
98
What should you do if your patient is combative/uncooperative and needs intubated?
* Precedural sedation for preoxygenation
* Ketamine 0.5 - 1mg/kg
99
When should you avoid giving Bicarb?
* Patient is already tachypneic
* increasing circulating CO2 could worsen acidosis leading to arrythmias.
* High CO2 levels, Bicarb breaks down into H2O and CO2
100
You have a trauma patient that needs intubated, but you can't get a good view, what should you do?
* Mobilize the neck
* EXCEPTION IS WITH A DIAGNOSIS OF OR OBVIOUS CERVICAL SPINE INJURY.
101
In what situations do you have a Higher Aspiration Risk during intubation?
* Upper GI Bleed
* Bowel Obstruction
* Pre-induction vomiting
102
What interventions should you do during a High Risk for Aspiration Intubation?
* NGT prior to intubation
* Intubation in semi-upright position
* Bag early, but less.
103
Oxygenation while securing ETT:
* NC @ 15 LPM + NRB @ 15 LPM
* Keep PEEP Valve closed --> alveoli recruitment
* SPO2 not > 95%: think Lung Shunt physciology
* Can use APL as PEEP valve on vent
104
How do you convert a nasal airway to ETT (French to CM)
* 4cm: 1 Fr
