Alternative Airway Devices
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Questions and Answers

What are limitations of using LMA in airway management?

  • It can lose its fit with position change (correct)
  • Airway is not protected - aspiration risk (correct)
  • It is suitable for patients with laryngospasm
  • It can be used for patients with high airway pressures

    • What is the primary difference between modified RSI and RSI?

  • Modified RSI verifies the ability to ventilate before giving a muscle relaxant (correct)
  • RSI uses a muscle relaxant before laryngoscopy
  • Modified RSI does not use cricoid pressure
  • RSI uses a different type of induction agent

    • What is the most treacherous time of airway management?

  • Preoxygenation
  • Laryngoscopy
  • Extubation (correct)
  • Intubation

    • What is the maximum recommended cuff pressure for LMA?

    <p>60 cmH2O</p> Signup and view all the answers

    What is the advantage of using a hyperangulated blade in video laryngoscopy?

    <p>It enables the visualization of anterior airway structures</p> Signup and view all the answers

    What is the definition of difficult airway?

    <p>Clinical situation in which a trained anesthetist experiences difficulty with facemask ventilation, laryngoscopy, intubation, or all of these</p> Signup and view all the answers

    What is the primary advantage of using a Laryngeal Mask Airway (LMA) over an Endotracheal Tube (ETT)?

    <p>It is less stimulating and causes less coughing and bucking</p> Signup and view all the answers

    What is the primary contraindication for using a nasal airway?

    <p>Basilar skull fracture</p> Signup and view all the answers

    What is the primary purpose of cricoid pressure/Sellick maneuver during a rapid sequence intubation (RSI)?

    <p>To reduce the risk of aspiration</p> Signup and view all the answers

    What is the primary advantage of using a microlaryngeal tube?

    <p>Smaller diameter, longer length for head and neck procedures</p> Signup and view all the answers

    What is the primary complication associated with the use of a LMA?

    <p>Aspiration risk</p> Signup and view all the answers

    What is the gold standard for managing the difficult airway in an awake, spontaneously breathing patient?

    <p>Flexible fiberoptic bronchoscope</p> Signup and view all the answers

    What is the recommended duration of preoxygenation with 100% FiO2?

    <p>3-5 minutes</p> Signup and view all the answers

    What is the primary feature of a RAE tube?

    <p>Preformed bend to prevent kinking</p> Signup and view all the answers

    What is the purpose of the 'hold-up' sign during Bougie use?

    <p>To indicate the Bougie has reached the carina</p> Signup and view all the answers

    What is the primary complication of using a RAE tube that is too deep?

    <p>The tip can rest at or below the carina</p> Signup and view all the answers

    What is the recommended management for laryngospasm after LMA extubation? select 2

    <p>Suction if secretions are visualized</p> Signup and view all the answers

    What is the minimum force required for cricoid pressure during a rapid sequence intubation (RSI)?

    <p>30 Newtons</p> Signup and view all the answers

    What is a unique feature of the Fastrach LMA?

    <p>It has a handle, making it helpful in CICV situations</p> Signup and view all the answers

    What is the primary difference between direct and indirect nasal intubation? (select 2)

    <p>The patient's ability to spontaneously breathe</p> Signup and view all the answers

    What is the primary indication for using an armored ETT?

    <p>When extreme angles are needed, but pt can occlude tube if they bite down</p> Signup and view all the answers

    What is the primary indication for rapid sequence intubation (RSI)?

    <p>Increased risk of aspiration</p> Signup and view all the answers

    What is the purpose of the 'SOAP' mnemonic in airway management?

    <p>To ensure preparation of essential equipment (suction, oxygen, airway/ancillary equipment, pharmacy/drugs)</p> Signup and view all the answers

    What is the primary purpose of using a NIM tube?

    <p>For intraoperative nerve monitoring of vocal cords</p> Signup and view all the answers

    What is the main difference between a nasal RAE tube and an oral RAE tube?

    <p>The direction of the pre-formed bend - nasal is up while oral is down</p> Signup and view all the answers

    Blind nasal intubations require a spontaneously breathing patient

    <p>True</p> Signup and view all the answers

    What is a key difference between nasal intubation and orotracheal intubation?

    <p>Nasal intubation requires the use of a vasoconstrictor and nasal trumpets prior to intubation</p> Signup and view all the answers

    When are RAE (Ring-Adair-Elwyn)tubes used and what is important to check?

    <p>Used to facilitate surgical access (cleft palate repair, tonsillectomy, UVPP, procedures of upper eye or face)</p> Signup and view all the answers

    What is unique about the ETT used in laser surgery?

    <p>It is designed to decrease the risk of airway fire</p> Signup and view all the answers

    What is the primary purpose of using double lumen tubes in anesthesia?

    <p>To isolate lung ventilation for thoracic procedures</p> Signup and view all the answers

    In which Le Fort fractures is it contraindicated to use nasal airways?

    <p>Le Fort 2 and 3</p> Signup and view all the answers

    Double lumen tubes are contraindicated in pediatrics for extended use

    <p>True</p> Signup and view all the answers

    What is a bronchial blocker?

    <p>An inflatable balloon passed through a separate channel on a specially designed ETT or through the regular lumen of an ETT, used as an alternative to DLT</p> Signup and view all the answers

    VL has a similar risk of trauma as DL

    <p>True</p> Signup and view all the answers

    What is the most widely used video laryngoscope (VL)?

    <p>GlideScope</p> Signup and view all the answers

    What are examples of channeled video laryngoscopy (VL) devices?

    <p>Airtraq and King Vision</p> Signup and view all the answers

    When is a bougie typically used in airway management?

    <p>When the glottic opening is difficult to visualize</p> Signup and view all the answers

    What is the difference between a King Airway and a Combitube in terms of their uses in difficult airway management?

    <p>A King Airway has 1 lumen with 2 cuffs while a combitube has 2 lumens</p> Signup and view all the answers

    What are contraindications to LMA use?

    <p>All of the above</p> Signup and view all the answers

    What acronym is used for difficult SGA placement?

    <p>RODS - restricted mouth opening, obstruction, distorted airway, stiff lung/spine</p> Signup and view all the answers

    What is the primary purpose of the aperture bars in a Laryngeal Mask Airway (LMA)?

    <p>To prevent the epiglottis from obstructing the airway</p> Signup and view all the answers

    LMAs are less stimulating than ETT

    <p>True</p> Signup and view all the answers

    What is the result of the distal tip of an LMA folding over?

    <p>Airway occlusion</p> Signup and view all the answers

    What is unique about the LMA Flexible?

    <p>It can be repositioned during shared airway cases and ET procedures</p> Signup and view all the answers

    What is unique about the Ambu Auragain?

    <p>It can ventilate with higher pressures and be used as a conduit for intubation</p> Signup and view all the answers

    What types of LMAs can be used to intubate through?

    <p>Both Fastrach and Air-Q</p> Signup and view all the answers

    What is unique about the I-gel LMA?

    <p>It is a single-use LMA that uses gel to seal the inner cuff</p> Signup and view all the answers

    The Air-Q LMA has no aperature bars and can be used to intubate through

    <p>True</p> Signup and view all the answers

    What is a consequence of LMA cuff over-inflation?

    <p>All of the above</p> Signup and view all the answers

    When using a Laryngeal Mask Airway (LMA), what should peak pressures be limited to?

    <p>&lt;20 cm H2O</p> Signup and view all the answers

    What is the purpose of airway exchange catheters?

    <p>All of the above</p> Signup and view all the answers

    What is unique about the technique used with a flexible fiberoptic bronchoscope?

    <p>The scope is held with the dominant hand while manipulating the lever with the non-dominant hand.</p> Signup and view all the answers

    When is a rigid bronchoscope indicated?

    <p>All of the above</p> Signup and view all the answers

    When is awake intubation indicated?

    <p>When patients have difficult airway features but are not at risk for aspiration</p> Signup and view all the answers

    What medications are commonly used in the awake intubation technique?

    <p>Local anesthetics and sedatives</p> Signup and view all the answers

    Tracheostomy is typically an elective surgical airway that can take up to 30 mins to perform

    <p>True</p> Signup and view all the answers

    What are the indications for an emergency cricothyrotomy?

    <p>CICV, maxillofacial trauma, upper airway obstruction</p> Signup and view all the answers

    What are relative contraindications for cricothyrotomy?

    <p>All of the above</p> Signup and view all the answers

    What type of ventilation is used when a needle cricothyrotomy is performed?

    <p>Jet ventilation</p> Signup and view all the answers

    What size ETT can accommodate a surgical airway?

    <p>6</p> Signup and view all the answers

    What are the indications for retrograde intubation when you can ventilate?

    <p>All of the above.</p> Signup and view all the answers

    How is retrograde intubation performed?

    <p>Threading a ETT through a wire first inserted through a surgical airway</p> Signup and view all the answers

    Study Notes

    Difficult Airway

    • A difficult airway is a clinical situation where a trained anesthetist experiences difficulty with facemask ventilation, laryngoscopy, intubation, or all of these.
    • Difficult laryngoscopy is the inability to visualize any portion of the vocal cords.
    • Difficult endotracheal intubation is the inability to intubate despite multiple attempts.
    • Failed intubation occurs in about 1 in 2000 patients in an elective setting.

    Airway Plan

    • Must consider patient factors and procedure factors.
    • Preop airway assessment findings include:
      • Anticipated difficulties.
      • Aspiration risk.
      • Awake vs. Asleep.
      • Airway devices.
      • Backup Plan if Plan A fails.
      • Preparation.
    • ASS: Ambu, suction, stethoscope.
    • SOAP: suction, oxygen, airway/ancillary equipment, pharmacy.
    • MSMAIDS: machine, suction, monitor, airway, IV drugs, special.

    Preoxygenation/Denitrogenation

    • 100% FiO2, 10-12 L/min for 3-5 minutes.

    Patient Positioning

    • Head extended, neck flexed.
    • Align OA, PA, LA axes.
    • Higher height might be better -- bed between xiphoid and nipple.

    Intubation Procedures

    • Standard intubation procedure:
      1. Preoxygenation.
      2. Administer Induction Agent.
      3. Verify loss of consciousness.
      4. Attempt PPV.
      5. Administer muscle relaxant.
      6. Continue PPV while waiting for muscle relaxant effect.
      7. Laryngoscopy.
      8. Intubation.
      9. Verify ETT Placement.
    • RSI (Rapid Sequence Induction):
      1. Preoxygenation.
      2. Administer Induction Agent AND muscle relaxant.
      3. CRICOID PRESSURE (aka Sellick maneuver) at 30 Newtons.
      4. Verify loss of consciousness.
      5. NO PPV.
      6. Laryngoscopy.
      7. Intubation.
      8. Verify ETT Placement.
      9. Release Cricoid Pressure AFTER placement is confirmed.
    • Modified RSI:
      1. Preoxygenation.
      2. Administer Induction Agent.
      3. CRICOID PRESSURE.
      4. Verify loss of consciousness.
      5. Attempt PPV to confirm ability to ventilate.
      6. Administer muscle relaxant.
      7. Laryngoscopy.
      8. Intubation.
      9. Verify ETT Placement.
      10. Release Cricoid Pressure AFTER placement is confirmed.

    Specialized Airway Management

    • Microlaryngeal tubes:
      • Used for head and neck procedures.
      • Smaller diameter, longer length to give more room in oral cavity.
      • More proximal adult-sized cuff.
    • RAE Tubes:
      • Preformed bend to prevent kinking.
      • Used to facilitate surgical access in facial procedures, oral procedures, mandibular procedures.
      • Check bilateral breath sounds.
    • Nasal Intubation:
      • Direct Nasal Intubation Procedure:
        • Standard induction.
        • Vasoconstrictor bilateral nares.
        • Slowly, sequentially insert lubricated nasal trumpets of increasing size to dilate nares.
        • Introduce nasal ETT and gently insert past turbinates.
        • DL method - Insert laryngoscope with or without forceps and visualize ETT passing through cords.
      • Nasal Intubation Indirect Intubation Procedure:
        • Main difference is that pt is spontaneously breathing.
        • Administer vasoconstrictors.
        • Sedate pt.
        • Anesthetize posterior oropharynx, pharynx, larynx.
        • Slowly, sequentially insert nasal trumpets.
        • Gently insert NETT until past turbinates.
        • Listen for breath sounds while advancing.

    Other Airway Devices

    • Armored ETT:
      • Reinforced tubes with embedded coiled metal or plastic wire.
      • Useful when extreme angles are needed.
      • Can be occluded if pt bites down.
    • NIM (Neural Integrity Monitor) Tubes:
      • Used for intraoperative nerve monitoring of vocal cords.
      • Precise tube placement is critically important -- use VL.
    • Laser Surgery:
      • Special tubes designed to decrease risk of airway fire.
      • Cuff filled with saline or methylene blue to allow for prompt detection of cuff rupture.
    • Double Lumen Tubes:
      • One tube with 2 lumens, bronchial and tracheal.
      • Ability to isolate lung ventilation for thoracic procedures i.e. one lung ventilation.
      • Size based on height.
      • Not appropriate for children or for extended postop use.

    Video Laryngoscopy (VL)

    • Channeled = integrated place where you pass an ETT through a channel.
    • Non-channeled = pass ETT separately i.e. not through a channel e.g. Glidescope, McGrath.
    • Disadvantages:
      • Cost.
      • Blood, secretions, and fog can obscure view.
      • Risk of dental and pharyngeal injury by hyper-focusing on screen.

    Supraglottic Airway Devices (SGA)

    • Laryngeal Mask Airway (LMA):
      • Used as a primary airway device and rescue device.
      • Used with or without muscle relaxation.
      • Less coughing and bucking on emergence/removal.
      • Preserved laryngeal competence and mucocilliary function.
      • Less laryngeal trauma and less stimulating than ETT.
      • Less likely to cause bronchospasm than ETT, but you can still have laryngospasm.
      • Has aperature bars to prevent the epiglottis from blocking the airway.
      • Sizing 3 female adults, 4-5 male adults.
      • Disadvantages:
        • Aspiration risk.
        • Non-supine position.
        • Obesity, pregnancy.
        • Long surgical duration.
        • Intraabdominal or airway procedures.
        • Procedures involving insufflation.
    • King Laryngeal Tube:
      • Single lumen with 2 cuffs.
    • Combitube:
      • Have 2 lumens (esophageal and trachea).
    • I-gel vs regular LMA.
    • Coiled vs regular LMA.
    • LMAs designed for intubating through e.g. Fastrach LMA and Air-Q.

    Airway Management Challenges

    • Laryngospasm after LMA extubation:
      • Suction if secretions are visualized.
      • PPV.
      • Consider succs and reintubate.
    • One lung ventilation in children:
      • Just purposefully mainstem or use fiber optic guidance.
    • One lung ventilation options on adults:
      • Use double lumen tubes or bronchial blockers.
    • Factors associated with difficult VL:
      • Neck immobility.
      • Restricted mandibular protrusion.
      • Restricted mouth opening, jaw mobility, and oropharyngeal space.
      • Obesity.

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    Description

    Learn about the challenges of airway management in anesthesiology, including difficult laryngoscopy, intubation, and ventilation.

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