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what are indications for a LMA?

-use instead of mask
-facilitate ventilation, intubation with difficult airway
-ventilate for flexible bronchoscopy
-avoidance of airway manipulation (with RAD)


what are contraindications for LMA use?

-pharyngeal pathology, obstruction
-full stomach, fasting not confirmed, GERD
-low pulmonary compliance (PIP > 30 cmH2O)
*irritable airway (COPD, emphysema) with increased PIP
*leaks at 20 cmH2O
-grossly or morbidly obese (while lying supine, if tip of stomach is over line of trachea; but still used sometimes)
-more than 14 wks pregnant
-multiple or massive injuries (potential to code, intubate)
-acute abdomen, lap chole (need NMB)
-thoracic injury (decreased compliance)
-any delayed gastric emptying (opioid therapy)
-pts. who are not profoundly unconscious (maximize airway, intubate)


what are the advantages of LMA when compared to mask?

-allows hands free, less fatigue
-better seal, esp. with beard or no teeth
-allows operating (ENT, esp. nose and eys)
-easier to maintain airway
-protects against nasal secretions (not gastric!)
-less facial nerve and eye injury (place gauze under mask straps)
-less OR pollution
-no neck manipulation


what are disadvantages of LMA when compared to mask?

-more invasive
-airway trauma potential
-different skill
-deeper anesthesia required
-TMJ must be mobile
-N2O can diffuse into cuff
-contraindications: laryngeal pathology, obstruction


what are potential complication with a LMA?

-aspiration (2: 10,000)
-sore throat (10%)
-hypoglossal nerve injury
-tongue cyanosis
-vocal cord paralysis (poor insertion technique; over-inflation of cuff)


describe insertion technique for LMAs

-choose appropriate size
-deflate cuff, lubricate back side of cuff
-anesthesia (propofol 2.5-3.0 mg/kg) or local anesthesia or SLN block
-press mask against the hard palate (the black line should be pointing directly cephalad)
-press LMA into pharynx along the curve of the palate using the index finger
-grasp the LMA with the opposite hand and withdraw the inserting finger
-press downward on the LMA until resistance is met
-inflate cuff with appropriate amount of air and visualize the LMA displace out slightly


what are the common sizes of LMAs for adult males and females?

adult female: 4
adult male: 5


where should the tip of the LMA be?

over the esophagus


what is the appropriate LMA size for a 30-50 kg (small) adult and appropriate max volume to inflate cuff?

-LMA size 3
-max volume 20 cc
*largest ETT mm: 6.0 cuffed


what is the appropriate LMA size for a 50-70 kg adult and its max cuff volume? what's the largest ETT size that can be used with the LMA?

-LMA size 4
-30 cc
-6.0 cuffed ETT


what is the appropriate LMA size for a 70-100 kg adults and max cuff volume? what is the largest ETT size that can be used?

-LMA size 5
-40 cc
-7.0 ETT cuffed


what size LMA is used for adult pts. > 100kg, what is the max cuff volume and what is the largest ETT size that can be used?

-LMA size 6
-50 cc
-7.0 cuffed ETT


what are ways to intubate through a LMA

-use fiberoptic to visualize cords (need to have ETT threaded on before inserting)
-blindly insert smaller ETT (6.0) through LMA
-use intubating LMA (Fastrach) to insert larger ETT (not to be left in place)
-inserting intubating stylet


describe Fastrach LMAs

-advanced LMA for tracheal intubation
-handle allows one hand insertion, removal
-comes in sizes 3, 4, 5 with max air 20cc, 30cc, and 40 cc respectively


describe ProSeal LMAs

-has a separate lumen through which a gastric tube can be inserted to evacuate contents from the stomach
-allows for positive pressure ventilation (studies show higher airway leak pressure)
-studies show that PIP are lower with the ProSeal b/c it has a smaller leak
*can use higher PIP with better seal and lower leak
*if air is introduced to stomach, has a way to get out


describe ventilation with the LMA

-spontaneous ventilation: assisted ventilation to maintain EtCO2 (beware with opioids and inhalation agents which can cause shallow breathing and allow CO2 build up; EtCO2 may read low d/t shallow expiration)
-CPAP- 3 cm pressure: reduces work of breathing
-pressure support with CPAP: lower EtCO2, slower RR, lower WOB, lower esophageal pressure, higher expired TV
*no difference in SaO2, MAP, HR with LMA ventilation


how should LMAs be cleaned and sterilized?

-wash in 10% sodium bicarbonate solution
-detergent: Endozime
-steam autoclave only (deflate cuff prior) to a temp of 275 degrees F (135 C); don't want cuff to inflate and burst
*avoid: germicides, disinfectants, gluteraldehyde, ethylene oxide, phenol-based cleaners, iodine-containing cleaners, ,or quaternary ammonium compounds (all can be absorbed)


describe the esophageal-tracheal combitube

-alternative emergency airway
-allows ventilation whether the tip enters the esophagus or the trachea (usually goes to esophagus)
-only 1% of times goes into trachea
-two balloons, one 100cc in the oropharynx and one smaller 15cc near the tip
*two lumens- one straight used if tip in trachea; one with side perforations used if tip in the esophagus


describe fiberoptic intubation

-indirect visualization using a flexible fiberoptic bronchoscope
-considered the Gold Standard for management of expected difficult airway (although not frequently used)


what are clinical indications for fiberoptic intubation?

-airway tumors
-cervical spine fractures, instability
-cervical spine fixation (immobility; down syndrome; cant extend neck)
-very limited TMJ mobility
-conscious intubation
-difficult intubation


what should pt. be pretreated with prior to fiberoptic intubations?

-glycopyrrolate and neosinephrine (nasal vasoconstriction) to decrease oral secretions and nasal bleeding


describe an awake, oral fiberoptic procedure

-nebulize lidocaine 4% (gets above and below cords)
-cetacaine spray to posterior pharynx
-lidocaine gel oral prep (gargle and spit out)
-insert special oropharyngeal airway to prevent biting (protects tubes)
-lubricated ETT inserted 4-5 cm into airway
-fiberoptic scope is threaded into ETT
**view: uvula, epiglottis and vocal cords
-advance scope into mid trachea (have propofol ready and hooked up, push when carina is seen, give before threading ETT)
-thread ETT over scope tip


describe nasal fiberoptic intubation

-causes less gagging
-patient cannot bite the scope
-insert warmed (more pliable), lubricated ETT into vasoconstricted (neosinephrine, afrin, manually stretch), anesthetized nasal passage
-suction oropharynx
-insert scope through ETT, straight shot, into glottis
-thread ETT over the scope
-be careful of epistaxis


describe an asleep fiberoptic intubation

-must interrupt to ventilate patient
-results when a failed intubation occurs unexpected
-can maintain cricoid pressure
-compared to awake pts., these have greater chance of tongue and epiglottis blocking cords


describe a glidescope

-video laryngoscope
-digital camera in the blade tip
-60 degree curvature
-can be used with patient in neutral cervical position
-stylet needed (make sure stylet angle matches angle of glidescope)
*indirect method of visualization of vocal cords


how does glottic view with glidescope use in pts. with cervical collar compare to direct laryngoscopy with a Mac?

-93% pts. had an improved view with the glidescope
-average time to intubation: 38 sec.
-no complication, including dental trauma


describe technique for glidescope use

-look into the mouth as you insert midline into mouth
-look at the monitor as you lift up to see the epiglottis and glottic opening (may lift as the Mac or use to directly lift epiglottis)
-look into mouth as you guide the tube with the stylet toward the tip of the scope
-look back at the monitor to complete the insertion of the ETT into the glottic opening


describe the bullard laryngocope

-rigid laryngoscope with fiberoptic capability
-can view cords without sniffing position
-indicated for cervical immobility or instability
-suction channel used for suctioning, insufflating O2, or injecting local anesthesia
-light source can be laryngoscope handle or fiberoptic light source


describe insertion technique for the bullard laryngoscope

-load ETT onto stylet
-prepare pt. with antisialagogue
-blade inserted midline with handle parallel to pts. body
-slide blade down into laryngopharynx as the handle comes to vertical
-lower the blade to pick up the epiglottis to visualize the cords
-slide the ETT off the stylet into the trachea


describe light wand technique

-lighted stylet which transilluminates the neck
-used for routine and difficult intubations
-insert stylet into ETT
-bend ETT proximal to cuff to 90 degree angle
-induction of anesthesia
-pull tongue forward
-insert ETT with light wand stylet
-visualize light as it advances down trachea
*if dims or disappears, the ETT has entered the esophagus
*once light is below cricoid cartilage, stylet withdrawn to allow insertion of the ETT into the trachea


describe retrograde intubation

-insertion of a guide wire through the crciothyroid membrane, through the mouth over which the ETT is inserted
*most common complication is bleeding


describe technique for retrograde intubation

-topical anesthesia to oropharynx, larynx, and trachea
-needle (18g) attached to syringe containing lidocaine 2% inserted through cricothyroid membrane
-aspirate air to confirm placement
-guide wire is threaded into the pharynx back into mouth and retrieved (once passed through mouth, hook something at neck to prevent from pulling out)
-a guide is passed over wire, through the cords
-ETT passed over guide; can use fiberoptic scope


describe jet ventilation

-temporary oxygenation
-14g or larger IV catheter inserted through the cricothyroid membrane (12 g better)
-oxygen source to deliver flow at 30 psi and 15 L/min
-ventilate 6-8 breaths/min
-I:E 1:4, long expiratory phase to allow emptying
*may need to employ airway techniques, positioning or jaw thrust to allow exhalation (verify emptying to avoid barotrauma)


describe cricothyrotomy

-the cricothyroid membrane is surgically cut and an ETT is placed into the trachea
*risks higher than a cricothyroid puncture