Airway Management Study Guide PDF

Airway Management Induction Prepare equipment and supplies Appropriately sized mask, oral and nasal airways Laryngoscope o Check handle and blade connection and adequate light source o Extra handle and blades ETT size with cuff tested and 10ml syringe connected...

Airway Management Induction Prepare equipment and supplies Appropriately sized mask, oral and nasal airways Laryngoscope o Check handle and blade connection and adequate light source o Extra handle and blades ETT size with cuff tested and 10ml syringe connected o Stylet inserted and shaped in “hockey stick” position o Extra ETT usually one size smaller Other airway equipment, per plan Suction available Prepare patient Patient positioned to optimize airway Head at level of waist or higher “Sniffing” position Ramped if needed Sniffing position with Pharyngeal, Oral and Laryngeal axis in alignment Pre-oxygenation with 100% FiO2 Washes out Nitrogen (79% in room air)- requires mask seal! Increases safety margin from 3-5 minutes to 10-12 minutes Creates 100% concentration of O2 in the patient’s FRC Induction of General Anesthesia after Pre-oxygenation Protect eyes by taping shut and applying ointment Prevents corneal abrasions (Common complications) Check ability to mask ventilate (+ETCO2) Use additional adjuncts (oral airways, nasopharyngeal airways, etc) as needed If intubating, give paralytic and ventilate with volatile to maintain anesthetic depth When the paralytic has taken effect, intubate (+ETCO2) If difficulty intubating, try different methods/adjuncts, mask ventilating between attempts If not intubating, insert supraglottic airway or continue mask airway management management (+ETCO 2) Rapid Sequence Induction (RSI) is used when patient is high-risk for aspiration. RSI Technique: Apply cricoid pressure Anesthesia induction with Propofol Neuromuscular blockade with Succinylcholine Immediately after induction Direct laryngoscopy and intubation is performed without mask ventilation ”Modified” RSI- may include 1-2 mask ventilation breaths prior to NMB to assure ventilation in a possible difficulty airway. ▪ Modified approach is used when you have concerns about a patient’s airway. This approach allows you to attempt ventilation before inducing paralysis (safer approach) Cricoid Pressure / Sellick Maneuver: Posterior displacement of the cricoid cartilage against the cervical vertebrae to prevent regurgitation and possible aspiration. 30 and 44 Newtons of pressure required (6-10 lbs) ** Know these numbers for Exam and Boards Risks May induce vomiting Airway obstruction Difficult glottic visualization Decreases upper/lower esophageal sphincter tone Cricoid pressure should not be released until successful intubation has been confirmed Mask Ventilation Equipment Orifice: 22mm ID opening connects to breathing circuit Hooks: allow for mask strap to be attached (Hooks) Body: Transparent masks allow for observation of exhaled “mist” and recognition of vomitus Rim/Cushion: can be inflated or deflated with a 10cc syringe to provide a good fit Sizes: X-Lg Adult (6), Lg Adult (5), Adult (4), Sm Adult/Child (3),Toddler (2) Infant, Infant (1), Neonatal (0) Mask Ventilation Technique One-handed mask technique “EC” technique using left hand Thumb and index finger on left hand are placed on mask (creates a “C”) These fingers hold mask to face and prevent leaks- slight downward pressure; You do not need to apply heavy pressure, rather you should lift the face into the mask Middle and 4th finger are placed under mandible Care is taken to prevent compressing soft tissue (can cause obstruction) Lifting mandible into the mask 5th finger is placed under angle of jaw (finishing the “E)” Lifts jaw anteriorly to open airway Head strap can be used to hold mask firmly on the face for short procedures or to free up your hands during induction Pressure from mask straps can injure underlying nerves Readjust during case to prevent excessive pressure Avoid pressure of mask on eyes Some mask straps are made of latex- check before using on latex allergy patient Criteria for difficult Mask Ventilation “It is not possible to provide adequate ventilation (e.g., confirmed by end-tidal carbon dioxide detection), because of one or more of the following problems: inadequate mask seal, excessive gas leak, or excessive resistance to the ingress or egress of gas.” -Steps if Difficult BMV Suspected- Prepare patient with proper positioning – “sniffing” position Attempt ventilation with head strap available Place OPA early if difficult first attempt Move to 2-hand mask ventilation Consider SGA device Move to intubation if unable to ventilate→ awaken patient if unsuccessful Emergency cricothyrotomy if necessary 2- Hand technique -Oral Airways- Oral pharyngeal Airways (OPAs) Prevents airway obstruction by lifting the tongue from posterior pharynx Decreases the work of breathing during spontaneous ventilation Not well tolerated in awake patient Proper placement Sized by distance between angle of mandible to the corner of mouth Adults sizes should be 80-100mm 80-90 for women and 90-100 for men typically Insert with a tongue blade and sliding along base of tongue Alternatively invert OPA and rotate once around or behind the tongue -Nasal Airways- Nasal Pharyngeal Airway (NPA) Lifts tongue off posterior surface of pharynx and provided a patent passageway to just above the epiglottis Better tolerated in the awake patient Can trigger laryngospasm if not sized correctly and touches epiglottis/vocal cords Proper placement Lubricated with water soluble lube Consider Neo nasal spray to reduce bleeding Size by distance from nasal opening to tragus of ear (36, 32 or 28fr for most adults) Upward and posterior gentle placement Bevel placed against the septum If resistance met then switch nares or use smaller size Performing Direct Laryngoscopy Steps for Laryngoscopy Hold laryngoscope in left hand Open mouth by “scissoring” or head tilt with right hand Place blade along right side of mouth- AVOID TEETH Release scissor-mouth will stay open Advance blade while sweeping tongue to left If using MaCblade advance to valleCula space and lift epiglottis If using MiLLer blade advance to epigLottis is seen and lift under epiglottis Raise up the handle and avoid applying pressure to teeth Take endotracheal tube in right hand and advance into laryngeal inlet If using a stylet, have an assistant withdraw it before advancing from inlet to trachea A = Miller Blade B= Mac Blade Cormack and Lehane Grading System Grade I Full view of glottic opening Grade II Posterior glottic opening without a view of the anterior commissure Grade III Epiglottis is visible without the glottic opening Grade IV Epiglottis is NOT visible, and the view is of the soft palate ONLY Optimizing Laryngoscopy View – Sniffing position (C) and “ramping” (B) BURP maneuver may help to improve view of vocal cords→ Hand on thyroid cartilage External backward (posterior), upward (superior), and rightward pressure with right hand -Supraglottic Airway Devices- If using a reusable LMA check for: Visual inspection- discoloration, broken aperture bars, cracks, cuff herniation, misshaped (tip should flip back to original shape) Kink test- classic/unique LMA *Discard after 40 uses* Deflate/inflate- look for complete deflation of cuff o Inflate to the recommended volume o Cuff should stay inflated if no leak present Lubricate dorsal surface just prior to use o DO NOT use Lidocaine ointment/gel -Insertion- Open mouth by head tilt or lifting mandible o Can be facilitated with use of a tongue blade Hold LMA as if it were a pen Gently slide along the hard palate applying constant pressure toward the posterior pharynx Stop advancing when resistance is felt o If not completely advanced tip may have folded over→ withdraw and reinserted Properly placed against hypopharyngeal floor with tip entering upper esophageal opening and anterior portion facing glottic opening After inserted, inflate the cuff to approximately 60 cm H2O pressure LMA 3: 30 ml LMA 4: 45 ml LMA 5: 60 ml Apply manual breath and listen for a leak 20 cmH20 with LMA classic Up to 30 cmH20 with LMA Proseal E&E states up to 40-45cm H2O Observe for ETCO2 and listen for breath sounds If a leak is heard: -LMA may not be seated well -The tip of LMA may be folded over -Epiglottis may be downfolded or -Laryngospasm/bronchospasm  Patients who shouldn’t get an LMA or will be a difficult insertion Acronym: RODS “Remember because the LMA is like a rod you shove in” Restricted mouth opening Obstruction in the airway Distortion of the normal anatomy Stiff Lungs: Patients who require high pressures to ventilate (Asthmatics, COPD, Morbidly Obese) ▪ Because you cannot deliver high pressures with an LMA without compromising the seal Fastrach (Intubating LMA) -More commonly used by EMS- Improved features from Classic LMA Handle→ single handed insertion from any position No fingers in airway Wider→ accepts #8 cuffed ETT Reinforced tube Epiglotic elevating bar (EEB) Increased success rate overall compared with Classic LMA Three sizes (3, 4, 5), All accept #8.0 ETT Insertion Lubrication on hard palate is essential Circular motion Pressure on hard palate using handle Intubation through Fastrach: Lubrication essential Look for 15cm depth marker Lift handle 2-5 cm as ETT is advanced Use specialized ETT with Fast-trach kit Removal: Advantage of Fastrach over Classic LMA Can remove LMA keeping ETT in place Technique Remove ETT connector Fully deflate LMA cuff Insert stabilizing rod onto ETT Slide LMA completely out of mouth Remove stabilizing rod Intubating Bougie or Eschmann Stylet A flexible, long, semi-rigid device used to facilitate difficult intubations. Acts as a guide for placing an ET Tube into the trachea when direct visualization of the cords is challenging or impossible. Used when the glottis or vocal cords are partially visible (Cormack-Lehane grade 2-3) during laryngoscopy. The “J” shape at the tip aids in maneuvering around the epiglottis and through the vocal cords. Once advanced into the trachea the bougie can serve as a “tactile guide” since the angled blunt tip allows the operator to feel the tracheal rings (a “clicking” sensation) which distinguishes it from the smooth walls of the esophagus. ET Tube is then threaded over the bougie and advanced into the trachea, followed by removal of the bougie. Bougies are particularly useful in patients with small or distorted airway due to trauma, anatomic abnormalities or swelling. Standard length is around 60-70 cm -Video Laryngoscopy- Improved view of the vocal cords Indirect view Sharp angle around pharyngeal structures Axis alignments is not required Midline approach similar to Mac May require the use of a rigid stylet Steps for Video Laryngoscopy Scissor jaws and insert under direct visualization Look at screen; advance to glottic view Insert tube into mouth under direct visualization Look at screen; advance ETT through glottic opening The Glidescope has radically altered our approach to difficult airways. Using a form of video-assisted intubation has been demonstrated in meta-analysis to improve Cormack-Lehane views from grades 3 & 4 to 1 & 2 about 77% of the time (ASA guidelines, 2013). The ability to circumvent redundant retropharngeal tissues improves the view and success rate of intubation in patients that are difficult to intubate. Since the view with the scope is indirect, it is very important to use the scope as it is intended to be used by the manufacturer with the provided stylet, approaching from the side of the mouth with the stylet in view to prevent traumatizing airway tissues. Lightwand -Light-guided intubation- Blind placement of lighted stylet Transillumination of the soft tissue of neck Insertion Lubricate stylet and insert into ETT Shape to a 90° angle Neutral or slight extension of head Turn off lights Insert into corner of mouth and turn to midline Advance gently in a rocking motion along an imaginary arc Use light glow as guide Well-defined glow at the sternal notch Indicates passage through the glottis Mid-trachea Slide out stylet Verify bilateral breath sounds Secure ETT -Blind Nasal- Endotrol ET Tube Ring at proximal end Guides distal tip anterior- pull ring to bend the tube B.A.A.M whistle (BAAM) Small disposable whistle attached to ETT Produces a whistle when near airflow Pitch changes with respiratory cycle Loud enough to hear in an ambulance or helicopter Fiberoptic Indicated when there is early recognized difficulty or when difficulty arises during an intubation attempt; patient may be awakened and then attempt awake fiberoptic intubation Options for FOI include: nasal vs. oral & awake vs. asleep Awake fiberoptic intubation (AFOI) is the most common approach to a known difficult airway Principles of management: Antisialogogue (a medication to decrease secretions such as glycopyrrolate) Topicalization Vasoconstriction Select appropriate sedation Fiberoptic Pearls Ensure a clean, functioning light source and use anti-fog solution on the distal tip Use FO airways Williams, Ovassapian & Berman airways Retracts tongue Protect FO scope Basically an OPA that has a hole for the scope to pass through Positions Patient’s right side, facing patient and patient sitting Keep the scope straight; use step stool if needed Mechanics Keep ETT on scope Small changes with lever for up and down (up = down & down = up) Slight turn of the wrist for side-to-side changes Distal hand should hold FO scope at patient’s mouth Advancement After carina is visualized Pull scope back until familiar structures appear if visual field lost Often takes slight turns or clockwise/counterclockwise motions to pass arytenoids Minimize space between scope and ETT Optimize conditions by utilizing the suction port Insufflation port for oxygen and auxiliary port for additional topical local anesthesia Anesthetized patients often require a jaw thrust Opens pharyngeal space and lifts epiglottis Use the tracheal rings to help orient you to which was in anterior/posterior, this will then allow you to distinguish between which direction is left vs right Infraglottic Airway Access -Emergent Airway- Application in the Difficult Airway: Inability to intubate OR ventilate… Available adjuncts exhausted… Patient desaturating… -Needle Cricothyrotomy- Accomplished using a small catheter passed through the cricothyroid membrane. 10-14 gauge angiocath inserted at 90° and slightly caudad (vessels) This technique is similar to a transtracheal block Oxygen injected using jet ventilator Percutaneous Cricothyrotomy Surgical pre-made kits Nu-Trake Set #4.5, 6, 7.2 mm I.D. airways Cook Melker Kit #3.5, 4 mm I.D. airways Cricothyroid membrane punctured with angiocath or needle Wire advanced, introducer removed Scalpel used to enlarge the hole Introducer/dilator forced down wire to dilate tissue, then removed leaving cricothyroid airway (like a small trach) Surgical Cricothyrotomy Cricothyroid membrane located Midline skin incision, followed by manual dissection Scalpel used puncture cricothyroid membrane, then a handle or finger is used to enlarge the hole 6.0 ETT (± Eschmann Stylet) inserted through the hole Cricothyrotomy Adverse Effects Early Hemorrhage Improper tube placement Failure to gain airway, SQ emphysema, pneumothorax, Vocal cord injury, Aspiration Laryngeal disruption Later Tracheal and subglottic stenosis Aspiration, Swallowing dysfunction, Transesophageal Fistula (TEF) voice changes Transtracheal Jet Ventilation (TTJV) Oxygenation by Venturi principle after needle cricothyrotomy. Temporary measure prior to surgical cricothyrotomy emergent tracheostomy Equipment needed Premade kits preferable Large bore catheter (10-14g) 50 psi oxygen source Non-compliant tubing If commercial kit is unavailable you can use: #7.5 ETT adaptor 3 cc syringe (for leur-lock) 10-14 gauge IV catheter Use oxygen flush valve to provide oxygenation Multiple studies now demonstrate that rigged kits have a lower success rate and a higher likelihood of injuring a patient. Whenever possible use a cricothyrotomy needle kit and breathing circuit connection kit, but if there are not other options these techniques could be assistive. Advantages Acceptable TTJV ventilating systems Quick, simple, effective Oxygen DISS connector (wall/tank) Provides emergent means of oxygenation High pressure tubing Temporary maneuver (20 mins!) Luer-lock connector Disadvantages Pressure gauge Room air entrainment (50% of TV) Can’t ventilate optimally Can’t use compliant breathing circuit -Precautions- Avoid use with complete obstruction above the cords Gas MUST escape through the mouth I:E ratio should be increased 1:3 or 1:4 Allows time for passive exhalation Peak Inspiratory Pressure Must be Monitored; Dependent factors for increased pressure: Tracheal size Cannula size Lung compliance Degree of outflow obstruction Inspiratory time (avoid stacking breaths) Complications -Barotrauma -SubQ emphysema -Mediastinal emphysema -Arterial perforation. -Esophageal puncture ** Document breath sounds, and chest inflation while performing TTJV **