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Normal thyromental distance is
3-4 fingers (the patient's fingers!)
How should the patient be positioned for Mallampati?
What is a Mallampati I ?
Uvula, hard and soft palate and pillars are all visible
What is Mallampati II?
Uvula is not fully visible
What is Mallampti III?
Can't see uvula but can see hard and soft palate (kind of subjective)
What is Mallampati IV?
You can only see the hard palate
What is the sniff position?
- Neck flexed 35° on the torso
- Head extended at the antlantooccipital joint to produce a 15° angle between the facial plane and the horizontal
- The axis will all align together in this position
The three axes alignment theory is????
Looking at three axes and how the alignment best in the sniff position
How do we achieve optimal head position in the morbidly obese patient?
- by supporting and elevating the shoulders and upper torso.
- Horizontal alignment of the external auditory meatus with the sternal notch should be used as an end point for correct positioning
Do you need a pillow for proper head alignment in children?
No, they have big heads
True or false? In infants, you may need to use a shoulder roll to get proper head position
What is the MOST important skill we have?
- Bag/Mask ventilation! Ventilation is far more important than intubation
- ASA Closed Claims Review Adverse Respiratory Events showed inadequate ventilation to be the cause most of the time
When/Where do difficult airway management situations occur the most?
During induction (66%)
4 "steps" of airway managment
Describe the grades of the Cormack and Lehane – Grading System for Direct Laryngoscopy
- Grade 1 – no difficulty visualizing the VC
- Grade 2 – only the posterior VC, or arytenoid cartilage, is seen
- Grade 3 – only the epiglottis is seen
- Grade 4 – no recognizable structures
Why do we use the Cormack and Lehane – Grading System for Direct Laryngoscopy
- This classification allows interobserver comparison of the view of the glottis on direct laryngoscopy.
- This grading system is pre-written on some of our anesthesia records.
- If not, you should still note the grade in on the record.
- This grading system is in common usage and would be very valuable to the next anesthesia provider if the pt. returns for another surgery.
The prevalence of difficult laryngoscopy appears to be __________ and is higher in the obstetric than the nonobstetric population.
According to the Cormack and Lehane – Grading System for Direct Laryngoscopy, Patients of grade __ and many pt’s with grade ___ view are difficult to intubate
What are the 11 anatomical things we look for regarding a patients airway?
- 1) Length of upper incisors (long)
- 2) Relationship of maxillary and mandibular incisors during normal jaw closure (overbite)
- 3) Relationship of maxillary and mandibular incisors during voluntary protrusion of mandible
- 4) Intercisor distance (<3cm)
- 5) Visibility of uvula (Mallampti 3/4)
- 6) Shape of palate (high arch or narrow)
- 7) Compliance of mandibular space (stiff, indurated, occupied by mass, or non-resilent)
- 8) Thyromental distance (<3 fingers)
- 9) Length of neck (short)
- 10) Thickness of neck (thick)
- 11) ROM of head & neck (can't flex/extend neck well)
Why are edentulous patients harder to bag/mask?
They have sunken cheeks
What is the 3-3-2 rule?
- Mouth opening (>3 fingers)
- Hyoid chin distance (>3 fingers)
- thyroid cartilage-mouth floor distance (>2fingers)
What things could cause difficult face mask ventilation?
- Mallampati III/IV
- Limited mandibular protrusion
Conditions that predispose to a difficult airway:
- Infections (epiglottitis, abscesses, croup, bronchitis, pneumonia)
- Trauma (maxillofacial trauma, cervical spine injury, laryngeal injury)
- Endocrine (morbid obesity, diabetes mellitus, acromegaly)
- Foreign Body (blood, emesis, tissue, foreign matter)
- Inflammatory Conditions (ankylosing spondylitis, rheumatoid arthritis)
- Tumors (upper and lower airway tumors)
- Congenital Problems (choanal atresia, tracheomalacia, cleft palate, Pierre Robin syndrome, Treacher Collins syndrome, Hallermann-Streiff syndrome
- Physiologic Conditions (pregnancy, morbid obesity, edema)
How do we manage the normal airway?
- 1) actors determining IV Sedation (MAC) vs. GA (or regional)
- 2) Can the airway safely be managed via LMA? Why or why not?
- 3) Intubation – Can this patient be safely intubated? –if yes, what about blades, tube sizes, potential pitfalls
Does an LMA protect the patient from aspiration?
What is the usual size LMA?
- 5 used for large adults
- 3 used for small adults
What is scissoring?
- Thumb on lower teeth
- Middle finger on upper teeth
- Slight turn of wrist and mouth opens
Besides scissoring, what is another way to get the patient's mouth open?
If you extend the neck (tell pt to put chin up towards ceiling if they’re awake) tilt head back so jaw is up in the air and that opens the mouth.
Where do you put the tip of the MAC blade?
At the vallecula (space just in front of epiglottis)
What are the normal sizes for ETT?
The cuff of the ETT can hold about 10ml of air, how much do we usually use
3-5ml of air will usually seal it off
How do we verify tube placement?
- continuous EtCO2 monitoring
- (and auscultation)
Where do we place the blade with a Miller?
- Beyond the vallecula and epiglottis
- (Can provide a better view of glottis when the larynx is anterior) but more likely to damage teeth because the blade isn't curved
What is the BURP?
- (can help bring vocal cords into view)
When would you use the Bougie or Eschmann Stylette?
- If you only see epiglottis, and you place the stylette in the center near that, the tip will likely go up into the trachea.
- As you get better, as you advance you’ll feel clicking (your hitting the cartilage in the front)
The most commonly used awake intubation choice is to ..........
anesthetize the airway ,lightly sedate the pt, and place the ETT with a fiberoptic larygoscope
- Drying Agent -EARLY
- Appropriate Sedation
- Topical Anesthetic-Oral/Nasal
- Nerve Blocks
- Supplemental O2 / Monitor
_____________has a critical role in the management of the difficult airway, and this is apparent in the ASA difficult airway algorithm
The recommended # of attempts is___ because repeated attempt cause airway swelling and bleeding, which further compromize the airway