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Principles II > Airway management techniques and blocks > Flashcards

Airway management techniques and blocks Flashcards

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1
Q

What are the primary indications for LMA use?

A

Difficult mask ventilation, difficult airway, bronchoscopy ventilation, avoid neck manipulation

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2
Q

Why should LMAs not be used in non-fasting patients?

A

Risk of aspiration due to unprotected airway

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3
Q

What makes LMAs easier to manage than face masks during surgery?

A

Hands-free once placed and better seal (especially with beards)

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4
Q

Name major limitations of LMA use

A

More invasive than a mask

Does not protect against aspiration

Requires deeper anesthesia than a mask

Cuff complications: hypoglossal nerve injury, overinflation risks

Skill-dependent (placement, troubleshooting)

Cannot be used when airway pressures are high or gastric emptying is delayed

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5
Q

Why is deep anesthesia required before inserting an LMA?

A

To prevent gagging, laryngospasm, or discomfort

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6
Q

What are some contraindications to LMA use?

A

Full stomach / aspiration risk (e.g., not NPO, pregnant >14 weeks, GERD)

Airway obstruction (pharyngeal mass, stridor, anatomy issues)

Poor lung compliance (e.g., ARDS, obesity, PIP >30 cmH₂O)

Morbid obesity or acute abdomen

Thoracic trauma or multiple injuries

Not deeply anesthetized (can trigger laryngospasm or gag)

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7
Q

What are some advantages of LMA over the mask?

A

Hands-free once placed (no need to hold like a mask)

Better seal than face mask—especially helpful with beards

Less facial trauma compared to mask

Avoids neck manipulation

Easier than intubation for trained providers

Reduces OR pollution from gas leakage

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8
Q

What should be done to the LMA cuff before insertion?

A

Deflate* the cuff, and lubricate the back side of the cuff

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9
Q

What should you use to anesthetize for LMA insertion?

A

Small amount of propofol, or local anesthesia, or SLN block (the one where you poke right next to the carotid)

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10
Q

How should the LMA be inserted into the mouth?

A

Press along the hard palate and into the pharynx using the index finger, then press downward until resistance is met

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11
Q

What is a common cause of obstruction after LMA insertion?

A

Down-folded epiglottis or transient laryngospasm

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12
Q

Where should the distal tip of the cuff be?

A

The cuff should rest against and block the upper esophageal spinchter

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13
Q

What are is a serious complication of a malpositioned LMA?

A

Ventilatory FAILURE which can be from insufficient tidal volume, air leak, and airway obstruction

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14
Q

What size LMA would you use for a 30-50 kg (small adult)? How much volume would you put in the cuff? What is the largest ETT for this person?

A

3 LMA

20 cc
6.0 cuffed

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15
Q

What size LMA would you use for a 50-70 kg? How much volume would you put in the cuff? What is the largest ETT for this person?

A

4 LMA

30 cc
6.0 cuffed

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16
Q

What size LMA would you use for a 70-100 kg? How much volume would you put in the cuff? What is the largest ETT for this person?

A

5 LMA

40 cc
7.0 cuffed

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17
Q

What size LMA would you use for a >100 kg? How much volume would you put in the cuff? What is the largest ETT for this person?

A

6 LMA

50 cc
7.0 cuffed

You would likely just intubate this person and not use an LMA, because obesity is a contraindication for LMA

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18
Q

What additional feature does the ProSeal LMA have?

A

Has an extra/separate lumen through which a gastric tube can be inserted and you can suction stomach contents

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19
Q

What advantage does ProSeal LMA offer for ventilation?

A

ProSeal LMA allows for positive pressure ventilation with higher leak pressures (26-28 cm H2O)

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20
Q

Why is the ProSeal considered safer for aspiration risk than a standard LMA?

A

It provides gastric drainage and improved seal

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21
Q

What type of LMA is used for tracheal intubation?

A

Fastrach LMA

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22
Q

What size ETT can be blindly inserted through a classic LMA?

A

6.0 ETT, if you need a larger ETT then use the Fastrach to insert it

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23
Q

What tool allows visualization of the cords during LMA-assisted intubation?

A

Fiberoptic scope to visualize the cords

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24
Q

What type of ventilation should you have when using an LMA?

A

The patient should able to do spontaneous ventilation

However you still may need to assist with ventilation to maintain ETCO2 (assist every 3rd breath was Terri’s tip)

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25
What is the role of CPAP with LMA use?
Using 3 cm pressure will reduce the WOB
26
How does pressure support + CPAP affect ventilation with an LMA?
Lowers ETCO2, slower RR, lower WOB, lower LES pressure, HIGHER expired tidal volume
27
Is there a difference in SaO₂ or HR between spontaneous breathing and CPAP with LMA?
Nope! No significant difference
28
What is the Combitube and when is it used?
A dual-lumen emergency airway used when standard intubation fails or is not possible
29
How often does the Combitube enter the esophagus instead of the trachea?
~99% of the time!
30
What are the balloon volumes for the Combitube?
100 cc in the oropharynx, and a 15 cc at near the tip
31
If the Combitube enters the esophagus, which lumen do you ventilate through?
The proximal lumen with side holes (pharyngeal opening)
32
If the Combitube enters the trachea, which lumen do you use?
The distal straight lumen
33
What is the gold standard technique for expected difficult airways?
Fiberoptic intubation
34
Name indications for fiberoptic intubation.
Airway tumors Infections Cervical spine issues (fractures, fixation, instability) Conscious intubation Difficult intubation
35
What’s a key difference between awake vs asleep fiberoptic intubation?
Asleep=greater chance of tongue and epiglottis blocking blocking cords Awake = safer, maintains airway reflexes and cricoid pressure
36
What topical agents are commonly used for awake fiberoptic?
4% lidocaine (spray or gel), Cetacaine spray
37
What should you do if the patient coughs during topicalization?
That’s good! It means the anesthetic is hitting the right spot.
38
Name the steps of doing an awake fiberoptic
1. Anesthetize with something 2. Insert an oropharyngeal airway to prevent biting 3. Lubricate ETT and instert 4-5 cm into airway 4. Thread the scope into ETT 5. View the vocal cords 6. Advance the scope into mid trach 7. Thread the ETT over the scope
39
What are benefits of a nasal fiberoptic?
Causes less gagging, and the patient can't bite the scope
40
What do you need to be cautious of any time you're doing any type of nasal intubation? Fiberoptic included
Be careful of epitaxis, use oxymetazoline (Afrin)
41
What is the Bullard laryngoscope and when is it used?
Rigid, fiberoptic laryngoscope used in patients with limited neck mobility or cervical spine precautions Terri said this isn't really used anymore
42
When is the one time you do what the sylet to protude from the end of the ETT?
With the Bullard you load the ETT onto the sylet and allow for it to protrude out the end of ETT
43
What accessory feature does the Bullard include?
Suction channel for suctioning, insufflating oxygen, or injecting local anes.
44
Do you need an antisialagogue with a Bullard?
Yes!
45
How would you insert the Bullard?
Start midline and parallel to patient's body, and then slide the blade down until it's vertical. At this point you'll see the cords, then slide the ETT off the stylet.
46
How does the lightwand aid intubation?
It transilluminates the neck
47
When is the lightwand technique used?
For difficult AND routine
48
What does dim or absent light suggest when using a lightwand?
Esophageal placement
49
When is the lightwand especially useful?
Cervical spine injury, facial/neck burns, or congenital airway problems
50
What is a Glidescope and how does it help with intubation?
A video laryngoscope with a 60° curved blade that allows visualization of the glottis even when axes are not aligned
51
When should you look at the monitor when using a Glidescope?
Look at the monitor as you lift up the blade to see the epiglottis, and look at the monitor to complete the insertion of the ETT
52
When do you look into the mouth when using a Glidescope?
Look into the mouth as you insert the GS midline into the mouth, and when you guide the tube with the stylet toward the tip of the scope Basically look at the mouth anytime you're putting something into it
53
What’s one clinical advantage of the Glidescope over traditional laryngoscopy?
Provides better glottic view, 93% of patients had an improved view with the Glidescope
54
What is a cricothyrotomy?
When you surgically cut the cricothyroid membrane and place an ETT directly into the trachea
55
When is cricothyrotomy indicated?
In "cannot intubate, cannot oxygenate" (CICO) situations as a last-resort airway
56
What is the difference between surgical and percutaneous cricothyrotomy?
Surgical = scalpel and tracheal hook Percutaneous = needle + cannula or kit (faster, bedside-friendly) Find where the kits are at your clinical sites
57
What are complications of cricothyrotomy?
Bleeding, subcutaneous emphysema, esophageal perforation, thyroid injury, infection
58
What is jet ventilation?
A high-pressure oxygen delivery technique through a catheter placed in the trachea
59
What gauge needle is typically used for jet ventilation?
14g of larger IV cath into the cricothyroid membrane
60
What pressure and flow settings are used in jet ventilation?
O2 source to deliver 30 psi and 15 L/m, ~6–8 breaths/min, I:E ratio 1:4
61
What is the major limitation of jet ventilation?
GOOD OXYGENATION AND POOR VENTILATION
62
What are complications of jet ventilation?
Biggest thing is barotrauma, but others are air entrapement, pneumothorax, bleeding, thyroid gland puncture, esophageal perf, subcutaneous emphysema
63
What must you ensure during jet ventilation to prevent barotrauma?
That exhalation is passive and unobstructed, may need to position properly or jaw thrust to allow this
64
What are physiological effects of jet ventilation?
The increased intrathoracic pressures result in decreased venous return and decreased cardiac output and increased intracranial pressure
65
What is the purpose of a glossopharyngeal nerve block?
When topical anesthesia doesn't completely obliterate the gag reflex
66
What landmark helps locate the glossopharyngeal nerve for blockade?
The palatopharyngeal fold (posterior tonsillar pillar)
67
What side do you stand on when doing a glossopharyngeal nerve block?
Contralateral side of the side to be blocked
68
What’s the technique for glossopharyngeal nerve block?
Displace the tongue medially with a tongue blade → insert 25g spinal needle at the base of the cul-de-sac near the floor of the mouth → aspirate → inject 2 mL of 1% lidocaine into the tonsillar pillar
69
What is a major precaution with the glossopharyngeal nerve block?
Paralysis of pharyngeal muscles may obstruct the airway—do this block LAST if combining with SLN block
70
What’s a common complication of glossopharyngeal block?
It is painful, and may result in a persistent hematoma
71
What does the internal branch of the superior laryngeal nerve innervate?
Sensation above the vocal cords (epiglottis, arytenoids)
72
What is the landmark for a superior laryngeal nerve block?
Greater cornu of the hyoid bone (palpated just below the angle of the mandible)
73
Describe the SLN block technique.
Palpate hyoid → displace toward the side being blocked → insert 22 or 23g needle just inferior to the hyoid and “walk off” the bone caudad → inject 2 mL of 2% lidocaine between the thyrohyoid membrane and pharyngeal mucosa, then 1 mL when withdrawing the needle
74
What is a precaution for the SLN block in full-stomach patients?
Loss of protective airway reflexes may increase aspiration risk
75
What are complications of an SLN block?
Hematoma and local toxicity
76
What’s the first step in the “Topical Thunder” method for airway anesthesia?
Atomize 2 mL of 4% lidocaine into the oropharynx and allow the patient to cough
77
What is a “lidocaine lollipop”?
5% lidocaine paste applied to a tongue blade and placed on the posterior tongue for ~1 minute
78
What is the final step of full airway topicalization before intubation?
Spray 2–3 mL of 4% lidocaine directly onto the cords and into the trachea via scope
79
What serious (but rare) complication can occur with topical anesthetics like lidocaine?
Methemoglobinemia—treat with methylene blue
80
What’s the max safe dose of lidocaine for tracheal topicalization?
4 mg/kg

Principles II (4 decks)

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