ORALS - AIRWAY Flashcards
How would you perform an airway assessment?
I would assess for indicators of difficult laryngoscopy, BVM or supraglottic placement or surgical airways
LEMONS (laryngoscopy)
MOAN (BVM)
RODS (supraglottic)
SMART (surgical)
MOANS -
Mask seal
Obstruction / obesity
Age
No teeth
Stiffness to ventilation
LEMONS - LOOK (externally for signs of difficult intubation)
EVALUATE (3-3-2 rule, 3 fingers in mouth, along floor of mandible, 2 fingers from floor to larynx),
MALLAMPATI
OBSTRUCTION / OBESITY
NECK MOBILITY
To ensure I have a good back up plan, I will use the RODS mnemonic to assess patient’s ability to tolerate a supraglottic device
- Restricted mouth opening
- Obstruction / obesity
- Distorted anatomy
- Stiffness
And the SMART mnemonic to assess patient for landmarking for surgical airway
- Surgery history
- Mass (presence of hematoma, abscess etc)
- Access anatomy problems (obesity, edema)
- Radiation
- Tumor
Describe an intubation
People - RT (airway cart + supplies)
- RT + the airway cart (including airway supplies)
- 2nd ERP
- ENT + anesthesia
Assess for indicators of difficulty laryngoscopy, BVM / supraglottic airway device placement or surgical airway.
Prepare (SOAPP)
- check Suction + O2 (on + working)
- Airway equipment
- Pre-oxygenate (NP, BVM + PEEP valve)
- pre-treat (hypoxia, hypotension)
- Position patient - tragus @ level of sternal notch
Given no anticipated difficulties with intubation:
- Ketamine 1.5mg/kg IV /// Etomidate 0.3mg/kg IV
- Rocuronium 1.2mg/kg IV
PLAN A - RSI approach using video laryngoscopy
PLAN B - size down + bougie
PLAN C - Another experienced provider
I would confirm position and location of ETT using
- ETCO2 (waveform capnography or color)
- Listening for breath sounds bilaterally
- Misting in tube
Post intubation I would ask for:
- Full set of vitals
- NG insertion, portable CXR
- Post intubation sedation – propofol 1-5mg/kg
Describe how you perform a difficult (but cooperative) intubation
People - RT (airway cart + supplies)
- RT + the airway cart (including airway supplies)
- 2nd ERP
- ENT + anesthesia
Prepare (SOAPP)
- check Suction + O2 (on + working)
- Airway equipment
- Pre-oxygenate (NP, BVM + PEEP valve)
- Position patient - upright
ASSESS
=> indicators indicators of difficulty laryngoscopy, BVM / supraglottic airway device placement or surgical airway.
=> assess physiologic difficulties (hypotension, hypoxia, acidosis) + pretreat
=> ability to cooperate w awake
AWAKE INTUBATION
1) double set up in event of forced to act (can’t vent, can’t ox)
=> RSI meds, surgical airway supplies (6.0 ETT, scalpel + bougie), landmark neck
2) Topicalize
=> posterior pharynx spray w 1% lidocaine + 4% viscous lidocaine via tongue depressor
=> meds: 1) ketamine 20mg IV (dissociation) 2) glycopyrrolate 0.2mg IV (reduce secretions)
3) INTUBATION
Plan A – loaded fiberoptic scope with 7.0 ETT
Plan B – smaller 6.0 ETT +/- bougie
Plan C – surgical airway
If still hypoxic despite rescue airway (LMA) – move to surgical airway
ETT pass cords = deepen sedation
I would confirm position and location of ETT using
- ETCO2 (waveform capnography or color)
- Listening for breath sounds bilaterally
- Misting in tube
Post intubation I would ask for:
- Full set of vitals
- NG insertion, portable CXR
- Post intubation sedation – propofol 1-5mg/kg
Describe how you perform a difficult (and crashing) intubation (Forced to Act)
THIS IS A FORCED TO ACT AIRWAY
People - RT (airway cart + supplies)
- RT + the airway cart (including airway supplies)
- 2nd ERP
- ENT + anesthesia
Prepare (SOAPP)
- check Suction + O2 (on + working)
- Airway equipment
- Pre-oxygenate (NP, BVM + PEEP valve)
- Position patient
FORCED TO ACT INTUBATION
- no time for full airway assessment
- try to pre-treat physiologic difficulties like hypotension, hypoxia, acidosis
1) double set up
=> RSI meds, surgical airway supplies (6.0 ETT, scalpel + bougie), landmark neck
2) INTUBATION
Plan A – single attempt with video laryngoscopy + RSI
FAILED move direct to FAILED AIRWAY PLAN
1) attemp to ventilate => reposition
2) if able to ventilate: PLAN B - bougie, switch providers
3) If unable to ventilate: surgical airway
CONTAMINATED AIRWAY
Call for help – 2nd ERP, anesthesia / ENT, RT
SOAP
(SUCTION) – 2 large bore suction 1) hypopharynx 2) in front of laryngoscope – using SALAD technique
(O2) – Ensure O2 functioning
- Apneic oxygenation + optimize airway alignment
- Attempt to pre-oxygenate
(airway cart)
- During my airway set up – I would have ongoing resuscitation with blood
- I would ensure airway has been assessed (MOANS, LEMONS, RODS, SMART)
(Position) Position patient @ 30degrees
RSI with double set up, neck prepped + landmarked
I would have the following plans:
1. Plan A – VL with standard geometry (CMAC)
2. Plan B – DL with bougie
3. Plan C – SGA + if unable to oxygenate will proceed with cricothyroidotomy (would assign this role to a 2nd EP ready to perform surgical cricothyroidotomy if indicated)
*if unable to visualize the cords => I would intubate the esophagus (cap, hub, inflate + move ETT to left)
- once an adequate view is able to achieved – confirm ETT placement and ask for an NG tube to be inserted
Between each plan – I would extubate and BVM between attempts
BURN AIRWAY MGMT
Prepare for forced to act intubation
- RSI medications to be drawn up
- surgical airway supplies open and ready (6.0 ETT, scalpel and bougie)
- neck landmarked in the event patient deteriorates during awake intubation
Cooperative patient:
If cooperative but in need of an intubation with no urgent airway – I would plan for an awake topicalized look with a RSI and double set up back up
AWAKE INTUBATION
With a stable, cooperative patient with signs of airway involvement I would take an awake and topicalized look with VL or fiber optic ETT loaded
- Facial burn
- Hoarseness
- Carbonaceous sputum
- Singed eyebrows / nasal hairs
If there is any evidence of airway compromise* I would move to intubation
- Edema
- Significant soot in the supraglottic region
- Airway burns
Uncooperative patient or Unstable patient:
With the evidence of any airway compromise* - I would follow my forced to act plan as outlined above
*airway compromise
Can’t handle secretions
Airway obstruction
Hypoxia despite 100% O2
Obtunded
Obstruction
Respiratory failure
If there is any deterioration – I would be forced to act and intubate as above
ASTHMA INTUBATION
- MGMT
=> 8puffs ventolin / atrovent Q20min x3
=> nebulized ventolin 5mg (2.5mg - peds) / atrovent 500mcg (250mcg - peds)
=> MgSO4 2g IV / 20min
=> methylpred 125mg IV (1mg/kg/day)
=> adjuncts: BIPAP, epinephrine 0.5mg => infusion
**Further adjuncts for refractory hypoxia **
=> Heliox
=> Inhaled anesthetics (isoflurane) with anesthesia
=> Paralyze and sedation
=> VV ECMO - Airway Script:
Anticipate physiologic difficulty
SOAP, call anesthesia and prepare for RSI
Preoxygenate with BIPAP 100% (3min / 8TV) and NP
Pre-treat; 1-2amps bicarb, NE
Asthma vent settings: I:E 1:4, VT 6cc/kg, RR8, high IFR, low PEEP 0-5. goal of pPLAT 30 or less.
Post intubation - consider ketamine for sedation (bronchodilation), paralyze - PEA arrest / high pressure alarm post intubation - DOPES
=>Initiate typical ACLS
=>Displaced tube - visualize ETT via DL or VL
=>Obstructed tube - suction tube for mucous plugs
=>PTX - POCUS +/- finger thoracostomy
=>Equipment check - ensure connected to O2 and on 100%
=> Stacking - manual chest compression, check vent settings (ensure decr RR and incr I:E, sedate and paralyze), disconnect and bag on 100% - Consults
ICU, admission
TROUBLE SHOOTING THE VENTILATOR
Hypoxia + Hypotensive / HD unstable
- Breath stacking
- PTX
- Massive PE
Hypoxia + HD stable
- Mechanical ETT displacement
- physiologic cause
compliance
obstruction
abdominal distension
PE
Pain
Sedation
Your RT notifies you of a high pressure alarm (or hypoxic/hypotensive pt etc), how will you address this?
I would use my DOPES mnemonic to assess causes for the high pressure alarm / hypoxia
- I would assess for equipment failure – check O2 connected to patient, assess for air leak
- Disconnect patient from the vent
In obstructive lung disease => I would consider stacking, manually decompress the chest
Signs of stacking
High intrinsic PEEP >20 – do expiratory hold maneuver
High plateau >30
Hypotension
- Check ETT position
- Place on 100% FiO2 via BVM
- Suction tube
- Adjustments with the VENT
Incr PEEP
Decr RR
- POCUS for lung sliding / AE bilaterally, pCXR
- Sedation + paralyze
- Consider ECMO
*DOPES – displacement (Check equip/positioning), obstruction (Suction ETT), PTX/PT (POCUS, Ventolin, epi), Equipment (take off vent, bag w BVM), Stacking / sedation (decompress chest, paralyze + sedate)
VENTILATOR SETTINGS
Normal / Standard / Lung protective
Mode: AC
VT 8cc/kg IBW
RR 12
IFR 60-80L/min
I:E 1:2
PEEP 5 -10
pPLAT <35cm H20
FiO2 40-100%
ASTHMA
Mode: AC / Pressure control
VT 6cc/kg IBW
RR 10
IFR: 100 L/min
I:E 1:4
PEEP 0 – 5
pPLAT <30cm H20
FiO2 100%
Permissive hypercapnia
ARDS setting
Mode: AC
VT start 8cc/kg => 6cc/kg in 4hrs
Continue reducing (1cc/kg) until pPLAT <30cm OR until 4cc/kg
RR 16-20
I:E 1:2
PEEP 5-10 (increase PRN for hypoxia / prevent atelectrauma)
FiO2 100% (SpO2 88-95%)
Ph 7.30-7.45
PEDS FOREIGN BODY
Incomplete obstruction (calm child)
- supplemental O2
- RT and anesthesia
- prespare for intubation w double set up
Incomplete obstruction (extremis)
- less than 1yr - 5 chest thrusts / back blows
- >1yr - abdo thrusts
Complete obstruction - choking sign
- direct visualization w laryngoscopy => remove FB w magill forceps
- if FB at larynx - needle cric below
- intubate + push down R mainstem
- if intubation doesn’t work + low sats => remove ETT and check if FB lodged in tube (then re-intubate)
- fail? rigid bronchoscopy
- last ditch => bilateral chest tube
follow up questions
1. How can you differentiate btwn tracheal + esophageal FB
Trachea => AP (thin), Lateral (flat)
Esophageal => AP (flat), lateral (thin)
- Complications of esophageal FB
esophageal erosion
perforation
infection
strictures
fistula - How do button batteries cause damage
pressure necrosis (KOH)
alkaline leakage
current electrolysis
Hg toxicity - How can you remove esophageal FB
fizzy drinks
consider- glucagon, nifedipine/CCB, benzos
endoscopy (float foley distal, inflate + pull up)
remove with mcgill’s forcep
Bougie - push FB into stomach
expectant mgmt (watch + wait) - Indications for surgical removal of FB
resp distress
obstruction
BB (max 2H)
high powered magnet
long >5cm, wide >2.5cm
sharp
failure to pass object
