NUR 729 2024 Airway Assessment Canvas (1).pptx

NUR-729: The Anesthesia Airway Assessment Stacey Schlesinger, DNP, MBA, CRNA Updated 2024 Airway Assessment History General Appearance NPO Status Airway Screening Tests Mouth Opening Dental Assessment Inter-incisor Distance Mallampati Score Thyromental distance (TMD) Mandibular mobility (ULBT) Atlan...

NUR-729: The Anesthesia Airway Assessment Stacey Schlesinger, DNP, MBA, CRNA Updated 2024 Airway Assessment History General Appearance NPO Status Airway Screening Tests Mouth Opening Dental Assessment Inter-incisor Distance Mallampati Score Thyromental distance (TMD) Mandibular mobility (ULBT) Atlantooccipital Function LEMON Assessment Hyoid-Mental Distance Mandibular Protrusion Test Upper Lip Bite Test 2 Challenge s ahead… A C D B E F Should I anticipate difficulty with… 2022 Airway Management 4 Airway A&P Upper Respiratory Tract: Includes nose, mouth, pharynx, hypopharynx, larynx and cricoid cartilage ------------------------------------Lower Respiratory Tract: All structures below the cricoid cartilage Includes trachea, bronchi, bronchioles, terminal bronchiole, respiratory bronchioles and alveoli 2024 Airway Assessment 5 The Larynx Complex structure of cartilage, muscles and ligaments Inlet to trachea Involved in phonation and airway protection Consists of 3 single and 3 paired cartilages Single: epiglottis, thyroid and cricoid Paired: corniculate, cuneiform, arytenoids 2024 Airway Assessment 6 The Anesthesia View Source: Miller’s Anesthesia, p. 1377 Tonsillar Enlargement & Adenoid Hypertrophy The Anesthesia View Cartilages of the Larynx 2024 Airway Management 10 History: Congenital Abnormalities Pierre-Robin Goldenhar’s Syndrome Klippel-Feil Down Syndrome Mucopolysacchari dosis Treacher-Collins 2024 Airway Assessment 11 Congenital Conditions: Trisomy 21 (Down Syndrome) Micrognathia (small jaw) Macroglossia (large tongue) Narrow palate Large and thick lip Flattened nose Small ears Cervical spine abnormalities Small subglottic diameter Obstructive sleep apnea Dental anomalies Macroglossia: Enlarged tongue Congenital Conditions: Treacher Collins Syndrome Mandibular hypoplasia (micrognathia) Facial bone hypoplasia Choanal Atresia Cleft palate Congenital Conditions: Goldenhar Syndrome Hemifacial Microsomia Mandibular hypoplasia Cervical spine abnormality Vertebrae may be incomplete, fused or missing Congenital Conditions: Mucopolysaccharidosis Coarse facial features Flat nasal bridge Thick lips Macroglossia Short stature Odontoid hypoplasia Dental abnormalities Sleep Apnea Congenital Conditions: Pierre Robin Syndrome Anterior positioning of Maxilla/Mandible (retrognathia) Undersized jaw (micrognathia) Downward displacement of the tongue (glossoptosis) Macroglossia Cleft palate Congenital Conditions: Klippel-Feil Syndrome Short Neck Fusion of two or more cervical vertebrate Limited ROM Congenital Conditions: Turner Syndrome Reduced neck mobility Neck webbing High arched palate Mandibular hypoplasia Short stature Delayed puberty TMJ contracture Short trachea Acquired Conditions Obesity Obstructive Sleep Apnea Infection Ludwig Angina Oral and Retropharyngeal Abscesses Epiglottitis Croup Laryngeal Papillomatosis Angioedema Benign masses Airway tumors Radiation therapy Face/ Neck/ Airway trauma Acquired Conditions: Obesity BMI Classification 25-29.9 kg/m2 Overweight 30-34.9 kg/m2= Class I obesity 35-39.9 kg/m2 Class II obesity > 40 kg/m2Class III obesity Nurse Anesthesia (Nagelhout)-6th editio GLP-1 Agonist Medications and Anesthesia Ozempic (semaglutide) ® Trulicity® (dulaglutide) Used for treatment of Type-II DM, weight loss GI side effects: nausea or vomiting, delayed gastric emptying, increased residual gastric contents Further research needed! ASA suggests withholding the medication before elective surgery Hold GLP-1 agonists day of the procedure/surgery for patients on daily dosing Hold GLP-1 agonists 1 week prior to the procedure/surgery for patients on weekly dosing Consider delaying procedure if patient is experiencing GI symptoms severe nausea/vomiting/retching abdominal bloating abdominal pain If medication not held and patient has no GI symptoms, treat as full stomach or do gastric US Acquired Conditions: Obstructive Sleep Apnea order characterized by “periodic, partial, or complete obstruction of the upper airway d aphy is considered gold standard for diagnosis Screening Questionnaire Do you snore loudly enough to be heard through closed doors? you often feel tired, fatigued, or sleepy during the day? d: Has anyone observed you stop breathing during your sleep? Do you have or are you being treated for high blood pressure? kg/m2 umference > 40 cm Male f OSA: Yes to 3 or more questions OSA: Yes to less than 3 questions isk of difficult or failed intubation Obstructive Sleep Apnea: Pediatrics your child appear restless when sleeping or have difficulty with breathing? your child have night terrors, sleep in unusual positions, or have new-onset enuresis? ur child difficult to arouse at normal awake hours? ur child overly aggressive or does he or she have trouble concentrating? Notes: Not necessarily associated with obesity and snoring! Often manifests as behavioral problems, poor school performance, learning difficulties, attention issues Often caused by enlarged tonsils and adenoids OSA: Anesthetic Considerations Airway!!! Airway!!! Airway!!! Review previous anesthetic records Assess for comorbidities: HTN, cardiovascular disease, DM Consider regional techniques when possible Adequate reversal of neuromuscular block Awake extubation Utilize non-opioid adjuncts Postoperative pain management= respiratory depression Postop monitoring/ Overnight observation vs. outpatient? Will patient be able to use CPAP postoperatively? Inspire mplanted stimulator device onitors breathing and stimulates hypoglossal nerve events tongue from blocking the airway utpatient procedure Acquired Conditions: Acromegaly aka Gigantism Caused by excess secretion of growth hormone from pituitary gland Increased risk of airway difficulties Macroglossia (large tongue) Prognathism (protrusion of mandible) Vocal Code Swelling Enlarged face and hands Enlarged nose and lips Acquired Conditions: Rheumatoid Arthritis Chronic, inflammatory autoimmune disease Characterized by joint erosion MANY AIRWAY ABNORMALITIES!! Small mouth opening due to TMJ ankylosis (abnormal stiffening) Hypoplastic mandible Limited cervical range of motion Cricoarytenoid arthritis (stridor) May see nodules on DL Subluxation of cricoarytenoid joint Cervical spine instability Acquired Conditions: Ankylosing Spondylitis aka Axial Spondylitis Inflammatory rheumatologic disorder Chronic inflammation leads to fusion of vertebrate and cervical spine ankylosis (abnormal stiffening) Limited atlanto-occipital extension Limited mouth opening Hunched forward positioning Inability to lie supine Decreased chest expansion Acquired Conditions: Trauma Cervical spine trauma Facial trauma Airway Trauma Burns GENERAL APPEARANCE 31 Look under the mask! 2022 Airway Management 32 Incidental Findings… C A B D E MOUTH OPENING MOUTH OPENING and INTERINCISOR GAP Patient is asked to open their mouth as wide as possible Place fingers between upper and lower incisors to determine inter-incisor gap Normal value is > 5 cm (3 fingerbreadths) Inter-incisor gap of < 3 cm (2 fingerbreadths) is a predictor of a difficult intubation Inter-incisor gap of 6 cm < 6 cm (3 fingerbreadths), may be associated with difficult intubation > 9 cm, may also indicate potential difficulty MANDIBULAR PROTRUSION Ask the patient to extend their lower incisors beyond their upper incisors UPPER LIP BITE TEST (ULBT) Ask the patient to bite the top lip with their bottom teeth (ULBT) ATLANTO-OCCIPITAL JOINT EXTENSION Atlanto-occipital joint extension is needed for sniffing position Patient is seated upright Ask patient to extend head back as far as possible Measure angle between occlusal (chewing) surfaces of teeth Normal: 35 degrees If < 23 degrees, it may be difficult to visualize glottic structures PRAYER SIGN Indicates possible stiff joints associated with arthritis, diabetes (cervical immobility) Patient is asked to press the palmar surfaces of the hands together with the fingers extended Abnormal-Positive: There is gap between palms Normal-Negative: There is no gap between palms Sternomental Distance (SMD) Measures from sternal notch to the lower border of the chin with the mouth closed SMD < 12.5 cm is a predictor of difficult DL/Intubation Mandibulohyoid Distance (MHD) Measurement of the vertical distance from the angle of the mandible to the hyoid bone Assessed on Xray A long TMD and long MHD indicates that the glottic opening may be situated more caudally (and thus not visible on DL) Palm Print The palm of the hand is painted with blue or black ink, the patient then presses the hand firmly against a white paper placed on a hard surface ◦Grade 0: Complete palm print ◦Grade 1: Deficiency in the interphalangeal areas of the 4th and 5th digits ◦Grade 2: Deficiency in the interphalangeal areas of the 2nd to 5th digits ◦Grade 3: Only the tips of the digits INDIVIDUAL AIRWAY ASSESSMENT TECHNIQUES ARE POOR AND UNRELIABLE PREDICTORS OF AIRWAY DIFFICULTY 3-3-2 RULE Measures upper airway geometry Evaluates ORAL ACCESS MANDIBULAR LENGTH (TMD) THYROID NOTCH TO HYOID (modification of MHD) 3-3-2 RULE LEMON ASSESSMENT L: Look externally for facial trauma, large incisors, beard or mustache, large tongue E: Evaluate the 3-3-2 Rule Incisor distance 3 fb Hyo-mental distance 3 fb Thyroid to hyoid distance 2 fb M: Mallampati O: Obstruction Presence or evidence of injuries or conditions affecting epiglottis N: Neck mobility or limits Proceed with Caution! Nurse Anesthesia (Nagelhout)-6th edition MRI, CT AND ULTRASOUND MRI and CT can be used to further evaluate the airway in complex, nonemergent situations POCUS (Point of Care Ultrasound)can provide bedside imaging of airway anatomy; use as an airway assessment tool is not yet established 2022 Airway Management 50 Should I anticipate difficulty with… Bag Valve Mask (BVM) Ventilation Direct Laryngoscopy and Intubation Supraglottic Airway Ventilation Cricothyrotomy Airway Placement 2022 Airway Management 51 Predictors of Difficult Mask Ventilation BOOTS Predictors of Difficult Mask Ventilation OBESE and MOANS The Obese (BMI > 26 kg/m2) The Bearded The Elderly The Snorers The Edentulous Difficulty with SGA Placement RODS Restricted mouth opening Obstruction of upper airway Distortion of upper airway anatomy Stiff Lungs / Spine Difficulty with FONA: SHORT Surgery Hematoma Obesity Radiation or other distortion Tumor PROCEDURAL CONSIDERATIONS 2022 Airway Management 56 Positioning the Obese Patient Ramping Elevate Shoulders, Neck & Head to Optimize Patient Positioning. Cormack and Lehane Grading System Objective assessment of the pharyngeal structures, glottic structures and glottic opening during laryngoscopy Cormack & Lehane Grading System Percentage of Glottic Opening (POGO) Cormack and Lehane Grading System Grade I: Full view of the glottic opening, including the anterior commissure and posterior laryngeal cartilages Cormack and Lehane Grading System Grade II: Partial view of vocal cords; anterior commissure not seen Cormack and Lehane Grading System Grade III: Only the epiglottis can be visualized; no portion of the glottic opening can be seen Cormack and Lehane Grading System Grade IV: Epiglottis cannot be visualized; no portion of the glottic opening can be seen. Cormack & Lehane Grading System Updated in 1998 to better define Grade II views Grade IIa: Partial view of the vocal cords (anterior commissure not seen) and full view of posterior laryngeal cartilages. Grade IIb: Only the posterior portion of the glottic opening can be visualized Confirm ETT Placement Observe ETT passing thru vocal cords Condensation/ fog in the tube Bilateral chest expansion Bilateral breath sounds ETCO2 waveform Laryngospasm Laryngospasm is an exaggerated manifestation of the gag reflex. Provoked by airway instrumentation/vocal cord irritation Treatment: Remove irritants Deepen anesthetic Continuous positive pressure ventilation Bilateral pressure at the laryngospasm notch NMBA (neuromuscular blocking agents) Questions?