Airway Management II: Lecture 8 - ENT Flashcards
(33 cards)
Patient Evaluation: Upper Airway Pathology
Supraglottic lesions
Benign and malignant tumors
infection
laryngomalacia
Glottic abnormalities
Vocal cord palsy
Papillomatosis
neoplasm
edema
Subglottic disease
Tumor
stenosis
tracheomalacia
Just use a videoscope
Patient Evaluation “Sounds”
Stridor
Produced by partial airway obstr. at the level of the larynx or trachea
Inspiratory – supraglottic or glottic lesions
Expiratory – subglottic obstruction
Hoarseness
Implies dysfunction or pathology at the level of the vocal cords
Snoring
Obstruction at the level of the pharynx
Aphonia
Complete airway obstruction
Wheezing
Bronchial obstruction
If you can hear just sitting there, could cancel, but very least albuterol nebulizer
Cough
Can be voluntary or due to mechanical, thermal, or chemical stimulation of cough receptors
Barking or croupy quality typically assoc. with subglottic pathology
Drooling
Classically associated with acute epiglottitis but also occurs in association with esophageal obstruction and organophosphate poisoning
Patient Evaluation General
Watch for presence of surgical scars
Fibrosis association with previous radiotherapy
Clinical evaluation of degree of airway obstruction and respiratory distress
Assess level of consciousness, agitation, cyanosis, respiratory rate and chest wall excursion, HR and BP, voice quality, and upper airway noise
Note location, size, and mobility of airway pathology
Otorhinolaryngology Procedures
Upper Endoscopy
Laryngoscopy
Pharynx, hypopharynx, or larynx
Microlaryngoscopy uses a microscope and possibly a laser with it
Esophagoscopy
Esophagus
Bronchoscopy
Tracheobronchial tree with bronchoscope
Laryngoscopy Overview
Microlaryngoscopy w/
suspension
Laryngoscopy
Diagnostic or therapeutic
Surgeon may need to visualize the airway prior to intubation and/or muscle relaxation
If laser to be used and intubation necessary then use special laser tube and fiO2 < 30% necessary
May need microlaryngeal tube (MLT)
Only come in sizes 4.0, 5.0, and 6.0 mm
Basically a pediatric size tube designed for adult use with adult length and cuff size
Laser Precautions
General Anesthesia Airway Options
Majority of direct laryngoscopic procedures
performed under GA w/:
Endotracheal intubation
Apneic techniques
Jet ventilation
Insufflation
If site of lesion/degree of airway obstruction not
well defined
Inhalation induction may be safer than IV induction
Airway Management: Intermittent Apnea Technique
Intermittent apnea technique
Involves hyperventilation followed by intermittent tracheal extubation for 1-5 min, during which the surgeon works
Disadvantages
Airway trauma and edema from repeated tube placement
Time consuming
Airway Management: THRIVE
THRIVE- Transnasal Humidified Rapid-Insufflation Ventilatory Exchange
Uses high flows of nasal oxygen and cardiac oscillations to partially ventilate paralyzed patients during apnea to prolong time for the surgeon to work on the airway between periods of mechanical ventilation.
https://www.entandaudiologynews.com/development/spotlight-on-innovation/post/what-is-transnasal-humidified-rapid-insufflation-ventilatory-exchange-thrive
Airway Management: Jet Ventilation
May be necessary when an ETT cannot be used
(i.e. supraglottic and subglottic lesions)
Can use a ventilating laryngoscope or Hunsaker tube
Observe complete chest deflation between jet ventilator puffs
Jet triggered during pauses between laser firings to keep vocal cords immobile
Complete MR absolutely essential
Complications
Barotrauma, pneumothorax, and gastric distention (risk of regurgitation), and submucosal gas injection
Hindered by decreased chest wall or lung compliance
Hunsaker Jet Ventilation
Airway Management: Insufflation/Inhalational Anesthesia
Best suited to brief diagnostic examinations, especially in the pediatric population when minimal instrumentation is req., minimal bleeding is expected, and the airway is relatively unobstructed
Useful when there is a need to evaluate the dynamics of the airway during spontaneous ventilation, when a full view of the glottis is req.
Disadvantages: pollution of the OR w/ anesthetic gases, no airway protection against aspiration, gastric distention if the tip of the insufflation tube directs its flow into the esophagus
Nasal & Sinus Surgery
Includes:
Polypectomy
endoscopic sinus surgery
maxillary sinusotomy
Rhinoplasty
septoplasty
Pts may have preop nasal obstruction caused by polyps, a deviated septum, or mucosal congestion from infection
Airway Management: Septorhinoplasty
Nasal Reconstruction Overview
Rhinoplasty, Septoplasy, Nasal Fx (closed and open reduction)
GETA with oral tube
Throat pack – may be very bloody
Suction stomach
Brutal-appearing manipulation during procedure
Topical LA for vasoconstriction
Cocaine, pseudoephedrine, phenylephrine
Care at end of procedure not to put pressure on nose with mask
Face tents are great for PACU
Nasal Packing and drip sponge
Tell pt to breath through their mouth!!
Rhinoplasty
Nasal Dressings
Head & Neck Cancer Surgery
Includes laryngectomy, glossectomy, pharyngectomy, parotidectomy, hemimandibulectomy, and radical neck dissection
An endoscopic exam often precedes these
procedures
Airway Management Overview
May be complicated by an obstructing lesion or preop
radiation therapy that has further distorted pts anatomy
If in doubt
Awake direct or fiberoptic laryngoscopy (cooperative pt.)
Inhalational induction, maintaining spontaneous ventilation (uncooperative pt.)
Emergency equipment and personnel for tracheostomy immediately available
Elective tracheostomy under local anesthesia sometime performed
GETA most commonly used
Thyroidectomy
Specialized tube used (NIM tube) to assist in identification of Vagus or RLN
May also be used for carotid endarterectomy, cricopharyngeal myotomy, excision of zenker’s diverticulum, hemithyroidectomy, neck biopsy, neck dissection, parathyroidectomy, partial laryngectomy, substernal goiter
Ideally placed under videolaryngoscopic guidance
Extubate without coughing or bucking
The blue (exposed wire electrodes) must be at the level of the true vocal cords on the NIM tube
Thyroidectomy
Tonsillectomy & Adenoidectomy
