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931: Advanced Principles of Anesthesia I > Difficult Airway > Flashcards

Difficult Airway Flashcards

1
Q

The most common cause of adverse respiratory events is

A

difficult tracheal intubation

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2
Q

Describe the distinguishing feature of a bougie.

A 
long- 60 cm
Coude tip (35-40 degree bend)
malleable yet firm
no lumen for insufflation
cheap, reliable, and familiar
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3
Q

A bougie is most useful in a grade

A

3 view

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4
Q

Indications for a bougie include

A

unable to pass ETT, grade 3 view, ETT exchange, digital intubation, adjunct to invasive techniques

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5
Q

Technique for using the bougie is

A 
obtain best possible view
hold bougie like a pencil with Coude tip anterior
advance & hook under epiglottis
anticipate clicking
do not remove laryngoscope
slide ETT over bougie
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6
Q

Pearls for using the bougie include

A

LEAVE laryngoscope IN PLACE during procedure
rotate ETT 90 degrees counter clockwise
use a flexible tip tube
capnography

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7
Q

Complications of using a bougie include

A

failed intubation
perforation
vocal cord trauma

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8
Q

Airway exchange catheters are used when

A

a secure airway should be exchanged or temporarily removed but laryngoscopy is likely difficult

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9
Q

Common features of airway exchangers include

A

distance markings
central lumen and/or side ports
adapter for TTJV or 15 mm connector

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10
Q

In relation to a bougie, an airway exchange catheter is

A

longer, less flexible, hollow lumen

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11
Q

Examples of airway exchangers include

A 
a cook catheter
sheridan exchange catheter
Parker flex-it directional stylet
Frova Intubation inducer
Endotracheal tube introducer
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12
Q

A Frova intubation introducer is

A

similar to a bougie but with hollow lumen that allows for O2 delivery

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13
Q

An endotracheal tube introducer is

A

similar to a bougie but 10 cm longer and stiffer

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14
Q

The Parker Flex-it directional stylet allows

A

provider to elevate tip of ETT from proximal end

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15
Q

Pearls for airway exchange catheters:

A 
this is a HIGH-RISK procedure
Have a Plan A, B, & C
two providers minimum
perform a direct laryngoscopy first
review all previous airway & intubation/history notes
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16
Q

Lighted stylets use

A

the principle of transillumination of soft tissue at the anterior neck to guide the tip of the ETT into trachea

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17
Q

Indications for lighted stylets include

A

routine intubations (high success rates with lower airway trauma)
patients with difficult airways
can be used to locate tip of ETT when performing a percutaneous tracheotomy
can be used with laryngoscope, LMA, Bullard, and during during retrograde intubation

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18
Q

The tip of the trachlight is

A

bent to form a “hockey stick”

which enhances movement through the glottic opening

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19
Q

Preparing the trachlight includes

A

lubricate wire stylet
lubricate the flexible wand
attach ETT, clamp proximal end to handle
bend tip 90 degrees like a hockey stick

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20
Q

With patient positioning when using a trachlight,

A

bed should be in the low position
head neutral or slightly extended
DO NOT place patient in the sniffing position

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21
Q

Pearls when using a trachlight include

A

full muscle relaxation is recommended
jaw-thrust or mandible lift
insert device mid-line
when a faint glow is seen above the larynx, lifting the jaw or tongue will raise the epiglottis and facilitate the wand towards the vocal cords
when the wand enters the glottic opening a well-defined will be observed below the laryngeal prominence
if resistance is met when attempting to advance ETT, rotate it 90 degrees

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22
Q

A needle cricothyrotomy provides the ability to

A

oxygenation, but CO2 removal is ineffective

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23
Q

Describe the landmark technique for needle cricothrotomy.

A

provider positioned on the same side as the patient’s dominant hand
larynx stabilized with non-dominant hand; thumb and long finger. Index finger used to identify CTM
needle inserted with dominant hand at a 45 degree angle caudally
needle aspirated until presence of air noted

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24
Q

The ultrasound technique for needle cricothyrotomy is shown to be

A

more effective than landmark

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25
When performing the needle cricothyrotomy technique using ultrasound, the steps include
TACA technique - begin at the superior thyroid notch - slide transducer caudally & identify CTM/Air-tissue interface - continue caudal to the hypoechoic cricoid cartilage - slide cephalad to CTM/air-tissue and mark the CTM
26
Indications for retrograde intubation include:
failed intubations urgent airway required, but cords cannot be visualized elective based on patient condition
27
Contraindications for retrograde intubation include
unfavorable anatomy laryngotracheal disease coagulopathy infection
28
Preparation for retrograde intubation is to
place the patient in the sniffing position with the head hyperextended
29
When performing a retrograde intubation, the airway should be
anesthetized if possible, translaryngeal with superior laryngeal nerve block translaryngeal with topicalization of the pharynx glossopharyngeal nerve block and superior laryngeal nerve block with nebulized anesthetic
30
The entry site for retrograde intubation is
puncture can occur either above or below the cricoid cartilage cricothyroid membrane- less bleeding, greater chance of failed intubation cricotracheal ligament- higher success rate, lower incidence of vocal cord trauma, greater risk of bleeding
31
Describe the retrograde intubation guidewire technique
needle with catheter is passed through entry site until air is aspirated guide-wire is threaded through needle until it passes through oropharynx or nasopharynx a hemostat clamps the guidewire at the trachea insertion site the endotracheal tube is passed over guidewire until it meets resistance in larynx
32
Describe the fiberoptic technique for retrograde intubation.
guide-wire passed through the trachea in normal fashion guidewire passed through suction port of FOB, allowing for straight path to vocal cords ETT can be passed over the FOB through vocal cords continuous O2 can be delivered
33
Describe the pull through technique for retrograde intubation.
epidural catheter is passed through nasopharnx or oropharynx silk suture tied to epidural catheter extended from the pharynx catheter pulled through incision site with silk suture catheter removed, ETT tied to cephalad end of suture hold slight pressure, ETT is passed until it abuts against the cricothyroid membrane
34
Describe PEARLS associated with retrograde intubation
CTM associated with less bleeding, lower success rate | use a smaller ETT (6.5-7)
35
Describe the benefits of the silk pull through technique
less railroading, can perform multiple attempts with one puncture, ability to reintubate postoperatively
36
Describe the benefits of the J wire technique
less traumatic, easier to retrieve, less prone to kinking, can be used with FOB, takes less time to perform
37
Complications of retrograde intubation include:
bleeding, subcutaneous emphysema, nerve injury, broken wire
38
The gold standard for the management of difficult airway is
awake intubation
39
Benefits of awake intubation include
spontaneous ventilation is maintained airway patency is maintained larynx does not move into an anterior position awake patients can monitor own neurologic status
40
The leading cause of morbidity and mortality in ASA closed claim analysis is
airway management failure
41
The universally accepted Gold standard for awake, sedated, and difficult to intubate patients is
fiberoptic
42
What is an endoscope?
an instrument composed of over 10,000 glass fibers that transmits light and allows for visualization of images
43
All flexible endoscopes have three main parts:
handle, insertion tube, flexible tip
44
The FOB handle contains the following parts:
power source, suction/valve, working channel, angulation control lever, lens with focus capability
45
The ability to orient the FOB is via the
visible notch at the 12 o'clock position
46
Newer fiberoptic systems may also have
video output adapter, video screen, camera
47
The four components inside the insertion tube of the FOB include
light guide bundles, transmit source, angulation wires, working channel
48
The fibers of the fiberoptic system are
very sensitive to damage | damage to the fibers result in a "black spot" within the image
49
Describe what angulation wires are.
two angulation wires course along the sagittal plane of the FOB these move the flexible tip in opposite directions attempting to move the tip while still in the ETT can break the wires
50
Describe the working channel
runs the length of the insertion tube | it can be used to provide: oxygen, suction, medication portal, and specimen collection
51
The flexible tip of the FOB contains
charged-coupled device chip and a second lens that allows viewing of structures the field of view is approx 75-120 degrees
52
The most likely areas for ineffective FOB sterilization is
valves and working channels
53
Sources of contamination for the FOB include:
sentinel patients, contaminated water, inadequate sterilization technique, repeated use of brushes or cleaning fluid, FOBs with design errors or defects
54
When caring for the endoscope,
universal precautions are mandatory | disinfection can take up to one hour
55
After using the FOB,
inspect it for any damage dissasemble moving parts, pass a cleaning brush through working port non-disposable parts are placed in an approved cleaning solution after sterilization time, bronchoscope washed and rinsed with water working port must be dried with 70% alcohol and compressed air
56
Successful airway anesthesia techniques requires:
trigeminal nerve block (nasal intubation) glossopharyngeal block laryngeal nerve blocks (vagus nerve)
57
Prior to performing any awake fiberoptic intubation anesthesia is needed to
prevent discomfort, decrease psychological stress, minimize hemodynamic changes, and increase patient cooperation have all supplies & equipment available appropriate monitors
58
The orotracheal airway structures are innervated by
cranial nerve V (trigeminal) cranial nerve IX (glossopharyngeal) cranial nerve X (vagus)- superior & recurrent laryngeal nerve
59
The trigeminal nerve provides
sensory innervation to the face via the three divisions ophthalmic, maxillary, mandibular
60
The glossopharyngeal nerve provides sensory innervation to
``` posterior 1/3rd of the tongue oropharynx vallecula anterior epiglottis afferent limb of the gag reflex ```
61
The vagus nerve branches into the
superior laryngeal nerve (SIS & SEM) | recurrent laryngeal nerve
62
The recurrent laryngeal nerve provides sensory innervation
below the fold cords and trachea | motor innervation to all intrinsic laryngeal muscles
63
The ______ nerve is more susceptible to injury because it wraps around and under the aorta
left recurrent laryngeal nerve
64
Advantages to an intubating oral airway include
protect the bronchoscope, Shield FOB from tongue & tissues, allows for passage of ETT (up to 9.0)
65
An intubating oral airway can be used in patients who are
unconscious or have anesthetized oropharynx
66
The swivel adaptor is used mostly for
bronchoscopy | allows for continuous ventilation without an airway leak
67
The parker flex tip ETT is beneficial for
preventing the bevel from catching on anything
68
Steps for FOB awake intubation include
indications, equipment and monitoring, psychological preparation, pre-medication, local airway anesthesia, procedure
69
Indications for fiberoptic intubation include
small mouth, failed sleep intubation, anticipated difficult mask ventilation and intubation, difficult airway with comorbidities likely to result in poor outcomes if intubation is not achieved
70
Equipment and monitoring for FOB intubation includes
IV access, FOB cart & airway cart (test light), oxygen delivery system, two suctions, monitors, medication
71
When preparing the patient psychologically for fiberoptic intubation
explain and reassure the patient with benefits of FOB, probable amnesia, local airway anesthetic administration, patient assistance during the procedure
72
Premedication for FOB includes
antisialogogue 15-20 minutes prior sedation- midazolam preferred nasal drops possible with phenylephrine 0.5% mixed with lidocaine spray 2-4%
73
Local airway anesthesia for FOB includes
drops, injection, nebulizer, paste, spray as you go
74
Complete local airway anesthesia requires:
glossopharyngeal nerve block, superior laryngeal nerve block, transtracheal block
75
For follow-up care of the difficult airway,
it is necessary to document presence and nature of difficulty -differentiate between ventilation and intubation description of management technique used provide patient with information for future care
76
When extubating a difficult airway, factors to consider include
awake vs. deep extubation clinical symptoms that will impair ventilation management plan if unable to maintain adequate ventilation short-term use of an airway exchanger
77
Contraindications for FOB include:
most important is lack of skill by provider lack of trained assistant or ready to use equipment wild, uncooperative patient near-total upper airway obstruction another technique
78
When there is an airway emergency,
approach must be sped up, assume full stomach, use cricoid pressure, intubation should be attempted by most experienced provider
79
When performing a FOB, the FOB is passed in a
"down, up down" motion down- through oropharynx up toward anterior commissure down through vocal cords
80
If a patient is gagging during FOB it is because of
glossopharyngeal nerve
81
If a patient is coughing during FOB it is because of
superior laryngeal nerve
82
When performing a transtracheal block,
straddle the trachea with the non-dominant hand locate the cricothyroid space, slowly advance the needle while aspirating stop when air is freely aspirated instruct patient to take a small breath, then maximum exhalation
83
Describe the superior laryngeal nerve block.
locate the hyoid cornua with non-dominate hand brace contralateral side advance needle until ipsilateral bone is contacted aspirate, then inject repeat on the other side
84
When doing a glossopharyngeal block,
patient may be required to assist tongue is moved medially local anesthetic is applied on inspiration to the tonsillar pillar injection of the area with local anesthetic is not recommended common to apply local with long-cotton tipped swabs

931: Advanced Principles of Anesthesia I (22 decks)

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