Airway part I

Question 1

Airway evaluation

Answer 1

If airway is:

• Critical- do immediate intervention
• OK or mildly compromised- no real hurry
• Moderately compromised- consider intervention, but must also monitor very closely

Question 2

Airway management

Answer 2

Least invasive to most
Cont’d observation, O2, pulse oximeter, ECG
Pt re-positioning, airway devices, jaw thrust
LMA, other devices
Endotracheal intubation
Tracheotomy or cricothyrotomy

Question 3

How to assess pt airway

Answer 3

Quick observation: resp effort/apnea, air moving, cyanosis, retraction, dyspnea, air hunger, resp. rate, obtunded, M-S weakness
Acute obstruction (blood, vomitus, secretions, foreign body, trauma); or hx of chronic airway or pulm condition (pt normally impaired)
Auscultation: wheeze, rales, rhonchi, stridor, air movement

Question 4

What does the lemon law stand for?

Answer 4

Look externally
Examine (3-3-2)
Mallampati grade
Obstruction (Obesity)
Neck mobility

Question 5

Air hunger

Answer 5

Dyspnea with great discomfort

Question 6

Retrognathia

Answer 6

Jaw is behind

Nearly impossible to do standard intubation

Question 7

3-3-2 rule

Answer 7

Assess oral opening- 3 fingers
Measure the mandible- 3 fingers
Position of larynx- 2 fingers

Question 8

Assessing the oral opening

Answer 8

Should be able to accommodate 3 fingers

Question 9

Measuring the mandible

Answer 9

Should be able to fit 3 fingers between the mentum and the hyoid bone

Question 10

Assessing the position of the larynx

Answer 10

Should get 2 fingers between the thyroid cartilage and the mandible
Do not extend head all the way when using this rule

Question 11

Mallampati classification

Answer 11

Ranges from classes I-IV
Class I is most patent, IV is most obstructed
III- only top part of uvula is seen
Class I- can see hard palate, soft palate, uvula, pillar

Question 12

What are causes of obstruction?

Answer 12

Obstruction can result from both external compression or internal blockage (foreign body, tumor, etc.)

Question 13

Stridor

Answer 13

A high-pitched, harsh sound occurring during inspiration
It is a sign of upper airway obstruction
May be caused by laryngospasm, epiglottitis, foreign body, aspiration, airway trauma

Question 14

Neck mobility

Answer 14

Not every pt will come in with neck brace, must ask pt about neck
Intubation requires neck extension

Question 15

Airway management caveats

Answer 15

First, do no harm
Get help and monitor pt
Continue to observe during tx efforts
Less invasive is safest- don’t over-treat
Pt directives and informed consent: DNI or DNR should be followed
If algorithms or pathways are available, follow them, but-
1st branch of algorithm tree is more impt: obstructed airway (crisis) or lung problem

Question 16

3 big indications for E-T intubation

Answer 16

Pt’s inability to maintain and protect patent (open, unobstructed) airway
Failure/insufficiency of oxygenation or ventilation
Anticipated need that is based on clinical course or tx requirements- airway, pulmonary, cardiac, neurologic, sepsis/shock, pending surgery with general anesthesia

Question 17

Who are the airway experts?

Answer 17

Anesthesiologists
EMTs
Intensivists/pulmonologists
ICU/CCU/ER staff
Resp therapists

Question 18

Why to defer to the airway experts

Answer 18

They have more experience with, and are better at:

• The airway evaluation
• Use of less invasive devices (nasal/oral airways)
• LMA devices, laryngoscopes
• Have access to expensive non-standard equipment
• Better able to recognize/anticipate complications

Question 19

Where does airway obstruction most commonly occur?

Answer 19

Above epiglottis, at oropharynx; the tongue and/or soft palate touch posterior pharyngeal wall which occludes airway (as in sleep apnea)
Why jaw thrust works

Question 20

What airway devices are available?

Answer 20

Ambu bag and mask
Oral airways
Nasal airways
LMAs
Oral tubes (combitube, King device)
E-T tubes
Crico-thyrotomy devices
Tracheotomy

Question 21

Nasal airway

Answer 21

Also called “nasal trumpet” due to shape
Made of latex or silastic; different sizes
Should always be lubricated before insertion (and warm)
Many pts have deviated septum- don’t force

Question 22

LMA

Answer 22

Used a lot in anesthesia, more comfortable than NG tube

Doesn’t seal off airway- don’t use in conscious pts

Question 23

Intubating LMA

Answer 23

ET tube is specifically designed to fit through LMA
Designed to not only assist with achieving an airway, but also to facilitate intubation
LMA can be removed over the ET tube once it is placed properly

Question 24

BVM

Answer 24

Purpose- To provide positive-pressure ventilation for non-intubated ventilation
Device has one-way valve to prevent rebreathing and port to add oxygen flow
Various mask sizes
May be difficult, requires expertise
Use the least pressure needed for given pt (to prevent gastric insufflation)

Question 25

BVM ventilation difficulties

Answer 25

Mask fit Mask seal- more problematic for obese pt, or those with facial hair -Lube can help with seal Airway patency- may need airway assist devices Gastric insufflation- common if high pressures used for mask ventilation Frequently requires 2 ppl

Question 26

What does JAWS stand for?

Answer 26

Jaw thrust Airways (oral/nasal) Work together Slow, small squeeze

Question 27

How to solve the mask leak problem in a BVM

Answer 27

Elevate head, extend neck, leave dentures in Pull mandible up to mask, don't push chin down For facial hair, apply goop Change mask size, inflate mask cuff, use 2 hands

Question 28

How to solve the airway failure/obstruction problem in a BVM

Answer 28

Use airways, mandible lift/jaw thrust, decongestants

Question 29

How to solve the esoph/stomach insufflation, vomiting problem in a BVM

Answer 29

Minimize bag pressure, have suction available | Realize that morbidly obese pt require much higher airway pressure to successfully ventilate

Question 30

What are the two main problems with BMV?

Answer 30

Insufficient ventilation- not enough airflow in and out of lungs, resulting in rising CO2 and falling O2 saturation (commonly air leak around mask or gastric insufflation) Airway isn't protected (lungs not sealed off) from secretions, blood, stomach contents, etc.

Question 31

CIs and precautions of airway instrumentation

Answer 31

``` Laryngeal trauma Bleeding Someone more adept is available Anticipated difficult intubation -A failed attempt at intubation almost always makes further attempts more difficult Contraindication to needed meds ```

Question 32

Potential intubation complications

Answer 32

Anatomic issues: trauma, tumor, edema, bleeding, difficult anatomy Physiological issues: Pharmacologic side effects, coughing, vomiting, stress/CV effects Psychological issues: over or under sedation, pt's wishes Ethical: should you intubate- futile care; directives

Question 33

Complications of intubation attempt

Answer 33

Failed intubation- worsened airway/ventilation Iatrogenic airway trauma, more difficult intubation Vomiting with or without aspiration Respiratory depression from medication Hypoxia and/or hypercarbia Hypotension (drugs) hypertension (manipulation) Cardiac effects- tachycardia, arrhythmia Trauma (post intubation)- teeth, neck extension, glottis, soft tissue

Question 34

Intubation/airway tools and equipment

Answer 34

Laryngoscopes (from least to most expensive) -Direct: MIller and MacIntosh blades -Fiberoptic -Video ET tubes, stylette; bougie; syringe for ETT cuff, mask, LMA Suction, gloves, lubricant, topical anes. gel Assorted nasal and oral airways Ventilation Always pretest equipment for failure

Question 35

Age and ET tube sizing

Answer 35

``` Measured by internal diameter in mm -LBW neonates: 2.5-3.0 mm -Avg neonates: 3.0-3.5 mm Ages 1-15: age in (yrs/4) + 3.5 or 4 mm (uncuffed tube up to age 7-8 yo; then cuffed, bc cricoid is tightest in young children) Adults: -Females: 7-7.5 mm -Males: 7.5-8.5 mm ```

Question 36

Direct laryngoscope blade sizes (Miller or MacIntosh)

Answer 36

Size 0 for neonates Size 1 for infants Size 2 for children Size 3 for small adults Size 4 for large adults Miller (straight): tip goes underneath epiglottis, is used to lift up tip of epiglottis out of the way MacIntosh (curved): tip goes in front of epiglottis into vallecula, where it tilts and retracts epiglottis out of the way

Question 37

Tube cuffs

Answer 37

Smaller pediatric tubes (4.5 or smaller) don't have cuffs 6.0 or larger do have cuffs 5.0 and 5.5 are available with and without cuffs Cuffs are filled by syringe attached to pilot tube Try cuff 1st to make sure it's not leaking

Question 38

Mnemonic for tracheal intubation preparation

Answer 38

Suction Tools for intubation Oxygen source for preoxygenation and ongoing ventilation Positioning Monitors, including ECG, pulse ox, BP, end-tidal CO2, and esophageal detectors Assistant IV access Drugs

Question 39

Sniffing position

Answer 39

Atlanto-occipital joint is extended, C7 is flexed

Question 40

Goals of intubation

Answer 40

Try to predict a difficult rel airway based on clinical criteria rather than be surprised by it Plan for appropriate action in the difficult airway Initiate appropriate plans of attack with confidence in the can't ventilate/can't intubate situation Become informed about some new (and not so new) airway options out there

Question 41

Meds for ET intubation

Answer 41

Sedation (intubation hurts, triggers cough reflex) -Propofol, etomidate, ketamine -Sedative (midazolam) and/or narcotic (fentanyl, morphine) Muscle relaxants The two categories of meds either cause resp depression or paralyze the pt; improperly used, will make everything much worse if pt can't be ventilated Topical anesthetics: gel for devices, liquid or spray for pt application

Question 42

Purpose of RSI

Answer 42

Can increase success of ET intubation by using sedation/anesthesia for pt comfort and paralyzing agents to facilitate intubation by giving musculoskeletal relaxation

Question 43

CIs for RSI

Answer 43

Difficulty or failure with mask ventilation Inadequate time to prepare (crashing or hypoxic pt) Known or anticipated difficult intubation

Question 44

Preparation for RSI

Answer 44

Time to evaluation pt ascertain no emergency Not likely difficult intubation No CIs Gather equipment Check equipment Assemble personnel Prepare meds for administration, monitors, environment, permit

Question 45

Meds for pretreatment- RSI

Answer 45

O2 (preoxygenation 4-5 min, perhaps other meds)

Question 46

Meds for after pretreatment- RSI

Answer 46

Induction (sedation); quickly followed by paralysis | Paralysis takes 15-30 secs after infusions

Question 47

Pretreatment for RSI

Answer 47

Preoxygenate- high flow O2, 4-5 min Consider: -Narcotic (fentanyl 1-3 mcg/kg) to blunt stress response -Atropine (0.01-0.02 mg/kg) to blunt bradycardia, decrease secretions -Defasciculating dose (0.01 mg/kg vecuronium) to prevent muscle pain from paralytic drug -IV lidocaine (1.5 mg/kg) blunts increase in HR, BP, and ICP -midazolam (Versed 0.02 mg/kg) amnestic/anxiolytic

Question 48

Sedation for RSI

Answer 48

Etomidate (0.3 mg/kg)- CV stability, rapid onset, short duration, may be cerebro-protective Propofol (2 mg/kg)- rapid onset, short duration, may be cerebro-protective, but drops BP and CO Ketamine (1-2 mg/kg)- bronchodilator, may increase HR, and BP, has analgesic effects, longer duration, dissociative effects may cause dysphoria Midazolam is sedative/anxiolytic/amnestic, but not an induction agent (requires big dose-long duration)

Question 49

Paralysis for RSI

Answer 49

Depolarizing- succinylcholine (2 mg/kg) -Quickest onset (20-50 secs), shortest duration (8-10 mins); causes fasciculation of muscles and myalgia; may worsen hyperkalemia; may increase intra-ocular pressure; rarely, prolonged duration Non-depolarizing: rocuronium (1-1.2 mg/kg- a big dose) -Slower onset (60-75 secs), longer duration (30-50 min), no fasciculation; not best choice for difficult intubation, but good if prolonged paralysis is indicated (status epilepticus, etc)

Question 50

Effects of sedatives and paralyzing agents for RSI

Answer 50

Removing pt's protective reflexes for the airway (cord closure, cough) You are rendering the pt absolutely unable to breathe (apneic)

Question 51

RSI advantages

Answer 51

``` Pt comfort- sedated or amnestic Easier intubating conditions If done properly and quickly- minimizes risk of vomiting and aspiration Less airway trauma If done quickly- shorter period of apnea ```

Question 52

RSI disadvantages

Answer 52

Polypharmacy Med side effects Requires time for implementation If intubation fails, can lead to catastrophe of can't ventilate/can't intubate

Question 53

Verification of correct ET tube placement

Answer 53

Always auscultate chest and epigastrum Chest- listen for equal bilat breath sounds; not quality (wheeze, stridor, etc) Epigastric auscultation: absence of insufflation sound OK; if present, the tube is in esophagus CXR the gold standard for correct placement CO2 detection devices handy if available

Question 54

Factors associated with difficult intubation

Answer 54

Obesity, facial hair, short neck, large tongue Retrognathia, buck teeth, unstable or fixed neck Bleeding, secretions, vomiting

Question 55

Alternatives to ET intubation

Answer 55

BVM Fiberoptic scopes Nasotracheal intubation Cricothyrotomy