APEX: AIRWAY MANAGEMENT and Review exam Flashcards
1
Q
Mallampati score measure what?
A
Size of the tongue relative to the volume of the mouth
2
Q
Mallampati exam helps predict
A
Difficulty of ET intubation
3
Q
Mallampati exam perform with the patient
A
Sit upright
Extend neck
Open mouth
Stick out tongue
4
Q
Class I airway you can visualize the
A
Tonsillar pillars
5
Q
The more space the tongue occupies,
A
The less space is there to work
6
Q
Higher mallampati score
A
More difficult intubation
7
Q
is mallampati a good predictor?
A
By itself mallampati is a poor predictor of a difficult airway.
8
Q
Mnemonic to remember Mallampati Class
A
PUSH
9
Q
Class I Mallampati you can see
A
Pillars , Uvula, Soft palate, Hard palate
10
Q
Class II Mallampati you can see
A
Uvula, Soft palate, Hard Palate
11
Q
Class III Mallampati you can see
A
Soft palate and Hard palate
12
Q
Class IV Mallampati you can see
A
Hard palate
13
Q
What affects your ability to align the axes
A
Patient’s ability to open the mouth
14
Q
What are the axes you are trying to align?
A
Pharyngeal
Oral
Laryngeal
15
Q
Small inter-incisor gas creates
A
Acute angle between the oral and glottic opening increasing the difficulty of intubation
16
Q
what is a normal inter-incisor GAP
A
2-3 fingerbreaths or 4cm
17
Q
Longer incisors and the inter-incisor gap
A
Reduce the gap
18
Q
What increase the risk of dental damage
A
Buck teeth.
19
Q
Mandibular protrusion test assesses the function of
A
the TMJ
20
Q
When performing the mandibular protrusion test, the patient is asked to
A
SUBLUX THE JAW and the position of the lower incisors is compared to the position of the upper incisors
21
Q
A class 3 mandibular protrusion meaning
A
More difficult laryngoscopy
22
Q
To expose the glottic opening you must
A
Displace the tongue into the Submandibular space (radiation, tumor make this more difficult)
23
Q
What are the border of the submandibular space:
A
Superior
Inferior
Lateral
24
Q
Superior border of the submandibular space is
A
Mentum
25
Inferior border of the submandibular space is
Hyoid
26
Lateral border of the submandibular space is
Either side of the neck.
27
How is the thyromental distance helpful?
Estimate the size of the submandibular space.
28
Where is the thyromental distance measured?
Thyroid cartilage to the TIP of the mentum
29
Thyromental distance less than ________ or greater than makes laryngoscope more difficult
6 cm ( 3 fingerbreaths) and greater than 9cm
30
TMD less than 6cm seen with
Mandibular hypoplasia
| Small submandibular space
31
TMD more than 9cm seen with
Larynx is more caudal
32
Mandibular protrusion test is a
Upper lip bite test.
33
MPT class I
Patient can move lower incisors past upper incisors and bite the vermillion of the lip (where lip meets facial skin)(
34
MPT CLass II
Patient can move Lower incisors in line with upper incisors.
35
MPT Class III
Patient cannot move lower incisors past upper incisors. Indicating difficult intubation
36
The ability to place the patient in a sniffing position is highly dependent on the mobility of what joing?
Atlanto-occipital joint
37
What is a normal atlanto occipital joint flexion and extension ?
90-165 degrees
38
Normal Atlanto occipital joint extension
35 degrees
39
At what degree of extension of the atlanto-occipital joint is laryngoscopy difficult?
< 23 degrees
40
What are top conditions affecting Atlanto-occipital joint mobility?
```
Degenerative joint disease
RA
Ankylosing spondylitis
Trauma
Surgical fixation
Klippel-feil
Down syndrome
DM (joint glycosylation)
```
41
Cormack and lehane grading if you can only see the EPIGLOTTIS
3
42
Cormack and lehane grading: Grade I what can you see
Complete or nearly complete view of the glottic opening
43
Cormack and lehane grading: Grade II what can you see
Posterior region of the glottic opening seen
44
Cormack and lehane grading: Grade III what can you see
Epiglottis opening
45
Cormack and lehane grading: Grade IV
Soft palate only
46
Grade II BCormack and lehane grading:
corniculate cartilages and posterior vocal cords. ( if you see arytenoids pick that if corniculate is not an answero
47
Grade indicating easier intbuation Cormack and lehane grading?
I & IIA
48
Grade indicating harder intubation Cormack and lehane grading?
Grade IIB & III
49
Grade indicating alternative approach to intubation Cormack and lehane grading?
Grade IV
50
Best predictors of Difficult mask ventilation?
| BONES
```
Beard
Obese (BMI >26)
No teeth (edentulous)
Elderly
Snoring
```
51
5 Questions to answer before providing airway management?
1. Will you be able to mask ventilate
2. Will you be able to intubate
3. Will you be able to place a supraglottic airway
4. Will you be able to place invasive airway
5. HOw fast must you secure the airway
52
Mouth opening and incisors, overbite with intubation, what makes difficult
Small mouth opening,
Long incisors
Prominent overbite
53
Palate and mallampati, what makes intubation difficult?
```
High arches palate
Mallampati class III or IV
```
54
Jaw and difficult intubation, what makes it difficult
Retrognathic jaw
| Inability to sublux jaw
55
Neck and difficult intubation
Short, thick neck
Short thyromental distance
Reduce cervical mobility
56
Risk factors for difficult supraglottic device placement? Mouth opening and upper airway implications
Limited mouth opening
Upper airway obstruction (anything that prevent the passage of the airway to the pharynx)
Altered pharyngeal ANATOMY (preventing a seal)
57
Risk factors for difficult supraglottic device placement? lung and Upper and lower airway implications
Poor lung complinace (requiring excessive PIP)
Increase airway resistance( Requiring excessive PIP)
lower airway obstruction
58
Risk factors for difficult invasive airway placement?
| neck anatomy
Abnormal neck anatomy (tumor, radiation, abscess)
| Short neck
59
Risk factors for difficult invasive airway placement?
| Weight
Obesity (cant see cricothyroid membrane)
60
Risk factors for difficult invasive airway placement?
| Larynx
Laryngeal trauma
61
Fasting guidelines Clear liquid
2 hours
62
Fasting guidelines breastmilk
4 hours
63
Fasting guidelines nonhuman milk, infant formula solid food
6 hours
64
Fasting guidelines Fried and fatty food
8 hours
65
Clear liquid 2 hours before surgery does what?
Reduces gastric volume and increases gastric pH
66
Mendelson syndrome risk factors
Gastric ph<2.5
| Gastric volume > 25 ml
67
RSI , different because
pt is not ventilated
Esophagus compressed by applied pressure to cricoid ring (applied before the patient loses consciousness and maintained until tracheal intubation is confirmed.
68
Pressure before LOC
2kg
69
Pressure after LOC
4kg
70
RSI avoid if patient is
actively vomiting
71
RSI and LES pressure
reduce
72
Complications of RSI
AID
Airway obstruction
Difficulty with laryngoscopy
Difficult intubation
73
Congenital associated with cervical spine abnormalities?
Goldenhar
Klippel-Feil
Trisomy 21 (down syndrome)
74
What is angioedema?
Results in vascular permeability leading to swelling of the face, tongue, and airway. Acute obstruction is a concern>
75
2 main causes of Angioedema
ACEI
| Hereditary
76
ACEI angioedema treatment
Epinephrine
Antihistamine
Steroids
77
Hereditary angioedema caused by
C1 esterase deficiency
78
Hereditary angioedema treatment
C1 esterase concentrate or FFP
79
For hereditary angioedema , does ACEI angioedema treatment work?
No
80
What is ludwig's angina?
bacterial infection, rapidly progressive cellulitis in the floor of the mouth.
81
Ludwig's angian affect
Submandibular
Submaxillary
Sublingual spaces
82
Most significant concern with Lugwig's angina
Displacement of the tongue resulting in complete, supraglottic airway obstruction.
83
With Ludwig's angina, The best way to secure the airway is with the patient
Awake (Awake nasal intubation, awake tracheostomy )
84
Contraindicated in patients with an infection above the level of the trachea
Retrograde intubation
85
Congenital abnormality: Large tongue (BIG TONGUE (BT)
```
Beckwith syndrome
Trisomy 21 ( Down syndrome)
```
86
Congenital abnormality: Small under developed mandible (PGTC)
```
Please GET THAT CHIN
Pierre Robin
Goldenhar
Treacher collins
Cri du chat
```
87
Congenital abnormality: Cervical Spine anomaly (KTG)
Kids TRY GOLD '
Klippel - Feil
Trisomy 21
Goldenhar
88
Congenital abnormality subglottic stenosis
Trisomy 21 (down syndrome)
89
What is choanal atresia?
Nasal airway is blocked by tissue
90
Pierre ROBIN tongue
Falls back and downwards (GLOSSOPTOSIS)
91
Terms that indicate small underdeveloped mandible
Micrognathia
| Mandibular hypoplasia
92
What is the optimal position for tracheal intubation?
Cervical Flexion and atlanto-occipital joint extension
93
Sniffing position maximizes the probability of successful tracheal intubation by aligning the
oral
Pharyngeal
laryngeal axes
94
2 key elements of sniffing position
Cervical flexion
| Atlanto-occipital joint extension: Extends the head on the neck
95
Best position for direct vision laryngoscopy
sniffing position
96
Best position for obese patient is HELP
HELP means HEAD ELEVATED laryngoscopy position
97
Optimal position is achieve for sniffing when
Sternum and EXTERNAL AUDITORY MEATUS are in the same horizontal plane,
98
Why is putting the bed in reverse trendelenburg positio help?
prolongs the time between apnea and desaturation?
99
How does the head position affect the ETT after intubation
The tube goes where the NOSE goes
100
Nose to chest pushes tip of ETT
Towards the carina 2cm
101
Nose away from chest pushes tip of ETT
away from carina 2cm
102
Lateral rotation of the head moves the tip of ETT
Away from carina 0.7cm
103
Steep Tredelenburg position causes
Abdominal content to shift towards the chest. This reduces thoracic volume and increases the risk of ENDOBRONCHIAL INTUBATION
104
Position increases the risk of endobronchial intubation>
Steep Tredelenburg
105
Contraindications of nasopharyngeal airway
Coagulopathy
| Le Fort II or III fractures
106
What can LeFort fracture can cause that affect airway?
Can disrupt the cribiform place, direct line of communication with nasal and cranial cavities. Placing a nasal airway , nasal ETT and NGT could be catastrophic.
107
Signs of cribiform plate injury include
Raccoon eyes,
Periorbital edema
CSF leak in the nose or ears
108
Most common used oral airway
Berman
109
How do you size oral pharungeal airway (OPA)
Measured from the corner of the mouth to the EARLOBE or Angle of the mandible
110
If OPA too short what can happen?
Obstruct the airway by causing tongue to kink against roof of the mouth
111
OPA too long can
Obstruct the patien'ts ariway by displacing the epiglotiss towards the glottis.
112
How do you size the Nasopharyngeal airway (NPA)
From the nare to the earlobe or the angle of the mandible.
113
Do not do this with NPA
Do not push towards the brain, it can traumatize the turbinates.
114
NPA too short will
fail to relieve the obstruction
115
NPA too longs will
obstruct the airway but displacing the epiglottis towards the glottis. may also cause trauma
116
Complications of OPA and NPA and anesthesia
Placing an airway into a lighly anesthesized patient can precipitate laryngospasm. Nasal ariway is better tolerated in this situation
117
NPA contraindication
```
le Fort II and III fracture
Basilar skull fracture
CSF rhinorrhea
Racoon eyes
Periorbital edema
Coagulopathy
```
118
NPA contraindication if they've had this surgery
Transphenoidal hypophysectomy
Caldwell-luc procedure
Nasal fracture.
119
Which intervention demonstrates the MOST accurate understanding of inflating the cuff on the ETT ?
Attaching a manometer to the PILOT BALLOON is the best way to determine the pressure inside the cuff.
120
When can tracheal ischemia occur?
If the cuff pressure exceed tracheal mucosal perfussion pressure
121
What should the ETT cuff pressure be
Less than 25 cm H2O
122
What is the purpose of inflating the ETT cuff
occlude trachea because it Create a seal that permits PPV and protects the lung from aspiration of gastric contents.
123
2 types of cuffs
Low volume and high pressure
| High volume, low pressure.
124
Types of cuff with low volume and high pressure
Red rubber tube
| Silicone tube for LMA fastrach
125
Can you measure inside the cuff pressure with red rubber tube or LMA fasttrach
no
126
Way to minimize cuff pressure
Use manometer after intubation
Fill cuff with the same gas mixture you will use during the case
Fill cuff with saline or water.
127
What is the murphy eye?
small hole on the opposite side of the bevel
| Provide and alternate passage for air movement in case the tip of the ETT becomes occluded
128
What is the murphy's law?
A fiberoptic scope, forceps or tube exchanges can get stuck in the murphy eye
129
How do you calculate size for ETT for kids: ETT without cuff?
(Age/4)+ 4
130
How do you calculate size for ETT for kids: ETT with cuff?
(Age/4) +3.5
131
Depth of placement for pediatric ETT
ID x 3
132
For LMA, where does the distal end ends?
Upper esophageal sphincter (cricopharyngeus muscles)
133
For LMA, where does the sides of the LMA lie?
Pyriform sinuses
134
For LMA, where does the proximal end of the LMA lie?
Base of the tongue
135
Most commonly used supraglottic airway
LMA
136
LMA and tracheal intubation
May be used as a conduit for tracheal intubation
137
Inflating the LMA cuff creates
Seal over the larynx which allows for PPV
138
Max PPV pressure with LMA
20 cm H2O
139
Max cuff pressure
60 cm H2O
140
Most common cause of nerve injury for LMA
Cuff overinflation
141
Nerve injuries associated with LMA
Lingual
Hypoglossal
RLN
142
LMA size 1 weight _____Cuff inflation ___ largest ETT to fit
<5kg; 4 ml ; 3.5
143
LMA size 1.5 weight _____Cuff inflation___
5-10 kg; 7ml ; 4.0
144
LMA size 2 weight _____Cuff inflation___
10-20kg; 10ml ; 4.5
145
LMA size 2.5 weight _____Cuff inflation___
20-30; 14 ml; 5.0
146
LMA size 3 weight _____Cuff inflation___
30-50; 20ml; 6.0
147
LMA size 4 weight _____Cuff inflation___
50-70; 30ml; 6.0
148
LMA size 5 weight _____Cuff inflation___
70-100 kg; 40 ml ; 6.0
149
Which LMA is designed for Intubation
LMA fastrach
150
LMA designed for gastric drain
LMA proseal
151
LMA designed for Wire-reinforced airway tube
LMA flexible.
152
Double lumen LMA is the _____-
Proseal
153
Feature of the double lumen LMA proseal?
Gastric drain tube (for easy gastric decompression)
Larger mask
Bite block
154
What not to do with LMA proseal ?
Do not place suction directly to the drain tube. Instead you must pass an OGT through the tube to decompress the stomach
155
comparing classic LMA to proSeal.?
Better seal
| Max pressure for PPV< 30cm H2O
156
Special features of the fastrach LMA
Metal handle
Tube pusher
Epiglottic elevating bar
157
The LMA flexible has an airway tube that is
Flexible
| longer than classic LMA
158
When do you use the LMA flexible?
Useful for head and neck surgery, where the airway tube of the LMA classic would limit access to the surgical site.
159
Is the LMA suitable for asthma?
Yes because it produces less airway irritation and making it a suitable choice in asthmatic patient.
However, the PROVIDE A SECURE AIRWAY
160
LMA contraindicated in
Airway obstruction at or below the level of the glottis (tracheal tumor)
161
4 main situation where you should use an LMA (RAPH)
Risk of gastric regurgitation and aspiration; (full stomach, hiatal hernia, SBO, symptomatic GERD, delayed gastric emptying
Airway obstruction at the level of the glottis of below the glottis
Poor lung compliance
High airway resistance
162
In the event of CVCI , should you use an LMA with full stomach?
LMA can be lifesaving and should be use, even if the patient is at risk of aspiration. In that situation, hypoxemia is the greatest risk to the patient.
163
What if mid-case you notice gastric contents inside the tube of the LMA?
Leave the LMA in place
Place the patient in Trendelenburg position
Deepen the anesthetic
Give 100% via abu
Use Low FGF and low VT
use flexible suction catheter through the LMA
164
Even though an LMA does not provide a truly secure airway, it does
Shield the glottic openin g
165
Direct vision laryngoscopy and SNS
intensely stimulating procedure that can lead to increase catecholamines, tachycardia, HTN, dysrhythmias, bronchospasm
166
What is the least stimulating airway disease?
LMA
167
The tendency of airway device placement to activate the SNS (MOST to LEAST stimulating)
Combitude
DVL (direct visual laryngoscopy)
Fiberoptic
LMA
168
If you're using an LMA for laparoscopy follow this rule: 15 rule
use < 15 degree tilt
< 15 cm H2O intraabdominal pressure
< 15 minutes of insufflation
avoid light anesthesia
169
VA action and pulmonary reflexes
decrease the sensitivity of pulmonary reflexes.
170
Contraindications for the combitube : gag reflex
Intact gag reflex is a contraindications
171
This disease is a contraindication to the combitube use
Zencker's Diverticulum
172
What is the combitube?
Supraglottic double lumen device BLINDLY placed in the hypopharynx
173
How long can you use a combitube for?
2-3 hours max
174
Combitube useful alternative for patient with
Full stomach
175
Does the placement of combitube need hyperextension? what is the significance of that?
No; May be use for patient with joint disease such as Klipper feil syndrome
176
Combitube sizing is based on
Height
177
Combitube size for < 4 ft
None
178
Combitube size for patients height 4-6ft
Size 37
179
Combitube size for patients height > 6ft
Size 41
180
Combitube: what are the 2 balloons and what do they occlude?
Proximal Oropharyngeal balloon, occludes the hypopharynx
| Distal Esophageal balloon occlude the esophagus
181
With the combitube with balloon is inflated first
Oropharyngeal balloon
182
Inflation volume for oropharyngeal balloon for both sizes
Size 37 = 40-85
| Size 41 = 40 -100ml + option for additional 50ml
183
The distal cuff of both sizes for the combitube both get inflated with
5-12ml of air
184
Combitude, you should attempt ventilation in which lumen? why
BLUE Proximal (esophageal lumen) : the tip usually enters the esophagus
185
Describe parts of the combitube
```
Double lumen: Tracheal and esophageal
Oropharyngeal balloon
Distal cuff
Tracheal lumen: open
Esophageal lumen: Closed
Perforation in the esophageal lumen
```
186
If the tip of the combitube enters the trachea, where do you ventilate?
Through the CLEAR, distal tracheal lumen
187
For combitube, cuff pressure should not exceed
60cm H2O
188
Combitube benefits for stomach
Ability to decompress the stomach
189
Combitube allow ventilation pressure up to
50 cm H2O
| Uses a blind insertion techniques (min training needed)
190
What is Zencker's diverticulum?
diverticulum (pouches) for in the pharyngeal mucosa
191
What is the GOLD STANDARD for managing the difficult airway?
Flexible Fiberoptic Bronchoscopy in the awake, spontaneously ventilating patient
192
FOB under GA downsides
Loss of pharyngeal tone
| Upper airway obstruction
193
You're doing a Flexible FOB, if the patient require PPV what can you do?
A special adapter can be placed between the mask and the y-piece. This allows PPV while FOB is in the patient's airway
194
FOB, describe hand position
The dominant hand holds the cord
| The non-dominant hand holds the scope near the proximal end where the thumb controls the lever.
195
FOB, pushing the lever down
Points the tip up
196
FOB pushing the lever up,
points the tip down
197
FOB rotating the scope left and right allows you to
control the score in the horizontal plane.
198
The working channel port of the FOB allows
Insufflation
Suction
or injection
199
Other indications for FOB
C-spine limitation, severe cervical stenosis, CHIARI MALFORMATION, Lmited mouth opening, TMJ disease, facial burn, mandibular-maxillary fixation.
200
Relative contraindication for FOB
```
Hypoxia
Secretions not relieved by antisialagogue
Hemorrhage impairing vision
Uncooperative patient
LA allergy (For awake attempt)
```
201
What should be applied to the tip of the FOB
Anti-fog solution
202
What should be given with FOB to minimize secretions
Antisialogogue (Glyco 0.2 mg IV)
203
FOB for nasal approach use
Vasoconstrictors to minimize epistaxis
204
FOB extra airway equipment
Williams or Ovassapian airway, help FOB stay midline but may stimulate gag reflex in the away patient.
205
FOB second provider may do this
Grab tongue anteriorly with a 4x4 gauze
206
What can be use in conjunction with the FOB
LMA
207
During the FOB use, if the bevel of the ETT hangs up on the right arytenoid what should the provider do?
Pull back
rotate the ETT 90degrees counterclockwise
and advance ETT again
208
If the FOB get stuck in the Murphy eye,
Remove the FOB and the ETT and repeat the procedure
209
What is the BULLARD laryngoscope?
rigid, fiberoptic device used for indirect laryngoscopy
210
BULLARD laryngoscope, useful for
Small mandible
Limited mouth opening (requires 7mm opening)
Limited cervical mobility .
211
Compared to DVL, the BULLARD causes
Less cervical spinal displacement
212
Compared to FOB intubation with BULLARD is
Faster
213
The Eschmann introducers provides the most signifcant benefit when you obtain a
Grade III view during laryngoscopy
| Grade IIb view
214
3 names for the Eschman introducer
Eschman introducer
Intubating stylet
Gum elastic bougie
215
The eschman introducer tip
Coude angled tip to facilitate a very anterior glottis
216
WORST time to use the Eschman introducer
GRADE IV view, change of intubation is low
217
How to use the Eschmann introducer? What confirms placement?
Hook the angled tip under the epiglottis (grade III view)
Advance the tip into the trachea, lubricate EI to facilitate passing ETT over it
Feeling the click of the tracheal rings confirm placement.
218
IF you don't feel the click
Look for the hold up sign, (EI meet resistance at the carina 35-40 cm)
219
To summarize the EI tube insertion
If you feel click, you're in the trachea
| If you dont feel the click, youre in the esophagus
220
Lighted stylet useful for 2 conditions
Microsotomia
Mandibular Hypoplasia
Severe oropharyngeal bleeding
221
With lighted stylet Esophageal placement
Diffuse transillumination of the neck
222
With lighted stylet Tracheal placement
Well defined circumscribed glow
223
Lighted stylet benefits
Anterior airway
Cervical spinal abnormality
Pierre Robin syndrome
Severe burn contractures.
224
Can you use a lighted stylet with a traumatic laryngeal injury? CVCI situation?
NO; NO
225
Trachlight in the adult should be bent
90 degrees
226
Trachlight in the pediatric Angle should be
60-80 degrees to accommodate cephalad glottis opening
227
What is the bronchial blocker?
Alternative to the double lumen tube.
228
The bronchial blocker cannot
Prevent contamination from contralateral lung infection
Provide ventilation to the isolated lung
Be used to suction secretion from the isolated lung,.
229
Unlike the bronchial blocker the DLT cannot
Provide lung separation in children < 8- 10 years old
| Provide lung separation for the patient requiring nasotracheal intubation
230
Similarity DLT and bronchial blocker allow you to
insufflate oxygen into the isolated lung.
231
HOw can you provide single lung ventilation
with a bronchial blocker and a single lumen ET tube.
232
Bronchial Blocker placmenet
Insert lumen ETT
Insert the bronchial blocker into the single lumen ETT.
After in the correct position, inflate the ballon to isolate the lungs
233
With the bronchial blocker which lung is ventilated?
opposite side of the bronchial blocker
| same side of the bronchial blocker not ventilated
234
Bronchial blockers are indicated for
children less than 8
Requires nasotracheal intubation
Have a tracheostomy
Have a single lumen ETT in place
235
A bronchial block is not the best choice for what situation?
When lung is isolated for concerns of contamination
236
Retrograde intubation requires you to penetrate the
Cricothyroid membrane
237
Needle size for a retrograde intubation
14-18 Ga needle
238
Retrograde intubation steps
Insert needle
Aspirate for air to confirm proper placement inside the tracheal lumen
Pass wire thorugh the needle and advance in a cephalad direction.
239
MOST COMMON Indications for retrograde intubation
UNSTABLE SPINE
240
3 percutaneous airway management
Transtracheal Jet ventilation
Cricothyroidotomy
Tracheostomy
241
Absolute contraindication for transtraceal jet ventilation
Upper airway obstruction / laryngeal injruy
242
Absolute contraindication for cricothyroidotomy
Patient age less than 6 years
243
Absolute contraindication for tracheostomy
No absolute contraindications.
244
Describe Transtracheal Jet ventilation
Large bore needle inserted in the cricothyroid membrane
A jet ventilatior is used to ventilated the patient
Inspiration requires high pressure oxygen (50psi)
245
Why is the Transtracheal jet ventilation needs high pressure
Because airway diameter is narrow
246
Using transtracheal jet ventilation put the patient's at risk for what?
Hypercapnia
247
What is a cricothyroidotomy
Crease a small, horizontal incision through the cricothyroid membrane, and then inserted a cuffed ETT through the hole.
248
Why is cricothyroidotomy not performed in children why?
Because the thyroid isthmus commonly covers the cricothyroid membrane
249
What is the emergency surgical airway of choice for children 6 or younger? (some books say less than 10)
Percutaneous transtracheal ventilation , needle cric
250
Where is the incision made for the tracheostomy?
2nd and 3rd tracheal rings
251
Complications of tracheostomy acute
Airway obstruciton
Hypoventilation
Pneumothorax, and bleeding
252
Complications of tracheostomy long term
Tracheal stenosis and necrosis
Tracheomalacia
TEF
253
Pros of deep extubation inclde
Decrease CV and SNS stimulation (desirable with CAD)
| Decreased coughing and airway irritation (desirable with asthma)
254
Cons of deep extubation
Ineffective airway reflexes
Increase risk of airway obstruction
Increased risk of aspiration
255
Extubation should be performed when
DEEP or awake
256
What are the stages of anesthesia?
Awake
Light anesthesia
Deep anesthesia
257
Guedel stage II is _____anesthesia
Light
258
Guedel Stage III is _________ anesthesia
Deep
259
Airway reflexes and anesthesia: Stage II
Airway reflexes are hyperreactive -> Increase risk of laryngospasm
260
Airway reflexes and anesthesia: Stage III
Airway reflexes attenuated
261
Pros of extubating awake: as far as airway reflexs
Airway reflexes intact
ability to maintain airway patency
Decrease risk of aspiration
262
CONS of extubating awake
Increase CV and SNS stimulation
Increase coughing
Increase intracranial pressure, intraoccular pressure and intraabdominal pressure
263
Preventing complications of AWAKE extubation do 2 things?
CV and SNS stimulation: BBlockers, CCBs and vasodilators
| Coughing; lidocaine (IV or inside th ETT cuff and opioids)
264
3 questions to determine possible difficult intubation?
Was the airway abnormal of difficult during induction
Did anything change during surgery that would make the airway difficult to manage
Does the patient have risk factors for increase extubation risk.
265
What is the best technique to manage the patient at high risk for failed extubation
Airway Exchange catheter
| Another best choice is a nasal airway
266
How long can you use the Airway Exchange catheter?
up to 72 hours.
267
Does the AEC provide the patent airway?
No its just a placehold, in case patient requires re-intubation the AEC is used as a stylet for re-intubation via the seldinger techniques.
268
Nonhuman milk how long do you wait?
6 hours
269
Which upper airway can precipitate laryngospasm?
Oropharyngeal in light anesthesia patient.
270
the 2 most reliable signs of ETT tube placement
Visualizing ETT between cords
Fiberoptic visualization
ETCO2 for 3 breaths
271
For LMA If you put 60cm H2O, and no seal what does that indicated?
LMA is improperly placed
272
Adequacy of LMA is based on MOSTLY
Sizing and correct placement
273
WHy is nitrous bad with LMA
Cuff pressure is increase and must be monitored
274
Best intubation for UNSTABLE cervical spine
Blind nasal intubation
| Fiberoptic bronchoscopy
275
Airway Fire how to treat?
Remove ETT
Stop flow of all airway gases
Remove all material from airway
Pour saline on the airway
276
How do you do the post tetanic count?
Use 5 second tetanic stimulation followed by TOF 3 seconds
277
Intense blockade and response to tetanic count?
No response
278
When intense block start going way, and before 1st TOF appears
First response to post tetanic twitch stimulation
279
At a minimum you must have PTC TOF of less than
2
280
You can't repeat PTC TOF for a minimum of
6 minutes
281
PTC TOF 1-2 How much sugammadex do you administer?
4mg/kg
282
PTC of 1 means TOF
Of 1 within 30 minutes
283
3 questions to ask and answering yes to any would indicate difficult intubation?
Was airway abnormal or difficult during induction
| Did anything chane druign
