(Obesity) Emergency Airway management Article (josh)

Question 1

Calculation for BMI

Answer 1

BMI= weight (KG) / Height (meters squared)

Question 2

BMI classification
Overweight
Class I Obesity
Cass II obesity (formerly Morbid obesity)
Class III obesity (formerly Severe obesity)

Answer 2

Overweight- 25.0-29.9
Class I Obesity- 30.0- 34.9
Cass II obesity- 35.0-39.9
Class III obesity- > or= to 40

Question 3

Physiologic and Anatomic Changes:

Both __1___ consumption and __2____ production are increased

Answer 3

1-Oxygen consumption

2-CO2 production

Question 4

Physiologic and Anatomic Changes:

both the increased O2 consumption and CO2 production are a result of what?

Answer 4

metabolic activity in excess adipose tissue and from increased work required of supportive tissue

Question 5

Physiologic and Anatomic Changes:

do to the increased O2 consumption and CO@ production, what occurs to the “safe apnea period” in obese pts

Answer 5

decreases

Question 6

Physiologic and Anatomic Changes:

what happens to Airway resistance?

Answer 6

increases

Question 7

Physiologic and Anatomic Changes:

what is different about the diaphragm?

Answer 7

abnormally elevated

Question 8

Physiologic and Anatomic Changes:

what happens to “work of breathing”?

Answer 8

Increases

Question 9

Physiologic and Anatomic Changes:

Why do obese pt’s have an increased work of breathing?

Answer 9

secondary to abnormal chest wall elasticity and resistance to caudad excursion of diaphragm.

Question 10

Physiologic and Anatomic Changes:
Due to the increased airway resistance, abnormally elevated diaphragm, and increased work of breathing in obese pt’s, what is the affect on there respiratory pattern? (AKA what do their respiration’s look like)

Answer 10

Shallow and rapid

with limited ventilatory capacity

Question 11

Physiologic and Anatomic Changes:

what is a common upper airway anatomical problem with obese pts?

Answer 11

pharyngeal wall collapse

Question 12

Physiologic and Anatomic Changes:

what causes Pharyngeal wall collapse?

Answer 12

increased fat deposition in pharyngeal tissues

Question 13

Physiologic and Anatomic Changes:

Obesity puts pt’s at an increased risk for other health related complication. give ex of these health care issues

Answer 13

atherosclerosis
HTN
DM
Cardiomyopathy
Arrhythmias

Question 14

Physiologic and Anatomic Changes:

Obese pt’s have an increased risk for aspiration pneumonitis due to what?

Answer 14

Excess volume of gastric acid

increased intraabdominal pressures

Question 15

Metabolism & Pharmacokinetics:

What type of drugs have a larger Vd

Answer 15

Lipophilic drugs (since Vd is dependent upon the amount of adipose tissue)

Question 16

Metabolism & Pharmacokinetics:

what happens to GFR?

Answer 16

increases

Question 17

Metabolism & Pharmacokinetics:

What happens to renaly excreted drugs in obese pt’s?

Answer 17

shorter 1/2 lives ( since their elimination is directly proportional to creatinine clearance)

Question 18

Metabolism & Pharmacokinetics:

What effect does obesity have on Heapaticly eliminated drugs?

Answer 18

none

Question 19

Airway Assessment:
the goal of airway assessment is to identify clinical features that predict difficulty in 3 main areas of emergency airway management. What are those 3 main areas?

Answer 19

1) Ventilation (w/bag mask pr extraglottic device)
2) Laryngoscopy & ETT intubation
3) Surgical Airway performance

Question 20

Airway Assessment:

Obesity my complicate all 3 areas/task, thus airway management in the obese pt’s should always be considered what?

Answer 20

Potentially difficult

Question 21

Airway Assessment: Bag Mask Ventilation

why is bag mask more difficult? (3 reasons)

Answer 21

Increased Airway resistance
Difficulty maintaining seal
Target O2 saturation difficult to obtain

Question 22

Airway Assessment: Bag Mask Ventilation

What causes the increased Airway resistance?

Answer 22

redundant airway soft tissue

Increased body mass

Question 23

Airway Assessment: Bag Mask Ventilation

what causes Difficulty in maintaining a seal?

Answer 23

requirement for higher pressures

Question 24

Airway Assessment: Bag Mask Ventilation

what causes the Target O2 saturation to become difficult to obtain?

Answer 24

O2 consumption is increased

Question 25

Airway Assessment: Tracheal intubation | what makes ETT placement difficult?

Answer 25

altered upper airway anatomy- resulting in poor view of glottis

Question 26

Airway Assessment: Surgical airway | What makes surgical airways difficult in the obese?

Answer 26

excessive soft tissue in the anterior neck - limits access to cricothyroid membrane - Difficult to identify anatomic landmarks

Question 27

Airway Management: Bag-Mask Ventilation | what is the best method for bag-mask ventilation w/ the obese pt?

Answer 27

two-person tech w/ oropharyngeal AND nasapharyngeal airways in place (yes it says AND nor or)

Question 28

Airway Management: Bag-Mask Ventilation | what position of bed is best for bag-mask ventilation?

Answer 28

angled w/ head uo and feet down (AKA reverse trendelenburg)

Question 29

Airway Management: Bag-Mask Ventilation | Why is reverse trendelenburg position good?

Answer 29

- Reduces pressure from abdominal contents on diaphragm | - Shifts weight of chest wall INFERIORLY (thus improving chest wall diaphragm excursion)

Question 30

Airway Management: Tracheal Intubation | what position is best for ETT placement?

Answer 30

- Reverse trendelenburg (upright position) - Ramped or head elevated position (extrenal auditory meatus and sternal notch horizontally aligned) *** traditionally sniffing position has been recommended to optimize glottic view during DL, but the ramped position appears to be more effective in obese pt's***

Question 31

Airway Management: PreOxygenation | this is the essential aspect of _____ intubation

Answer 31

RSI

Question 32

Airway Management: PreOxygenation | what are some techniques to optimize preOxygenation?

Answer 32

1) Administer highest possible concentration of O2, via the best available means 2) remember NRB-mask gives 70% O2, a properly placed Bag-Mask unit gives 90-100% w/o assistance 3) Place in upright Position 4) use lubricated, BILATERAL nasal trumpets when needed

Question 33

Airway Management: PreOxygenation | how long should you pre-Oxygenate

Answer 33

3-5 min

Question 34

Airway Management: PreOxygenation | what is a way to aide in keeping O2 saturation up during the Apneic Phase of RSI

Answer 34

Nasal cannula in 5 LPM | thought this was cool

Question 35

Medication Dosing: | How should induction drugs be dosed?

Answer 35

LBW

Question 36

Medication Dosing: | how should rocuronium and Vecuronium be dosed?

Answer 36

IBW

Question 37

Medication Dosing: | How should SCh be dosed

Answer 37

TBW

Question 38

Medication Dosing: | What happens to Thiopental and Benzodiazepines effects?

Answer 38

prolonged (due to their lipophilicity and large Vd)

Question 39

Medication Dosing: | what happens to Propofol and Opiods effects?

Answer 39

no real changes very similar to non-obese

Question 40

Specific Equipment: | what type of equipment can make intubation easier

Answer 40

Short Laryngoscope handle Larger Laryngoscope blades ETT introducer (AKA bougie)

Question 41

Specific Equipment: | What are some devices for airway management?

Answer 41

``` Optical or video Laryngoscope (glide scope) LMA and Laryngeal tubes Intubating LMAs Combitube (i always think of dwayne w/this) ETTI (bougie) Lighted stylet Fiberoptic stylet Flexible Fiberoptic ```

Question 42

Thats it for fatties and airways article next slide is summary

Answer 42

FAT PEOPLE = Difficult airway | could have done this all in one slide