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What is the best predictor of a difficult airway?
Previous difficult intubation
Best predictor of difficult laryngoscopy is a previous difficult one. What are the important factors in regards to whether that would still be the case?
- Is the patient the same weight as they were the last time
- did they have some sort of thyroid goiter last time
how do you measure thyromental distance?
- distance b/w tip of the mandible and they thyroid cartilage
- pt's own fingers, 3-4 fingers
explain the 4 classifcations of mallampati
- I- you can see uvula and tonsilar pillars, you can also see soft and hard palate
- II- You have less of a view, the uvula is not fully visable
- III- uvula is NOT visable, you can see hard palate and some soft palate
- IV- only see hard palate
explain sniffing position
the neck should be flexed at 35 degrees on the torso and the head extended at the atlantooccipital joint to produce a 15 degree angle b/w the facial pane and the horizontal
- the theory is 3 axes with head in neutral position
- neck flexion aligns the pharyngeal axis and largyngeal axis
what is the extra thing you have to do with obese patietns
Horizontal alignment of the external auditory meatus with the sternal notch should be used as an end point for correct positioning.
- you have to ramp them.
- The optimal head postion in morbidly obese pt is acheived by supporting and elevating the shoulders. Often you have to build a rampe.
How do you get proper neck alignment with a baby?
With pediatric pt's you often do NOT need a pillow under the head to get proper alignment because their heads are much bigger.
what is one reason you still might have poor visualization even with good sniff position?
Large posterior tongue
what is the coremack lehane grading system
- It describes the degree of glottic exposure, it allows for intraobserver comparison of the view of the glottis on direct laryngoscopy
- always look for the previous documentation of the grade, also always document the grade view you saw.
explain the 4 grades of the Cormack and Lehane grading system
- 1- no difficulty with viscualization the vocal chords
- 2- Only posterior VC or arytenoid cartiledge, is seen
- 3- only the epiglottis is seen
- 4- no recognizable structures
- 1 & 2 are easy intubation
- 3 & 4 are difficult intubation
describe the things you assess for on an airway assessment
- - Length of upper incisors
- - relationship of maxillary and mandibular incisors during normal mouth closure
- - relationship of maxillary and mandicular incisor during voluntarry protrusion of mandible- (if pt cannot bring mandibular incisors anterior to maxillary incisors that is a bad thing)
- - interior incisor distance- should be at least 3 cm
- - compliance of mandibular space
- - thyromental distance of at least 3 fingers
- - length of neck
- - thickness of neck ( short and thick harder)
- - range of motion of the neck ( atlanto occipital rom?)
predictors of difficult face mask ventilation:
predictors of "impossible" face mask ventilation:
- - age > 55-57
- - bmi > 26-30
- - beard
- - snoring
- - lack of teeth
- - mallampati III or IV
- - limited mandibular ROM
- mallampatti III or IV
- Neck radiation changes
condition that predispose to a difficult airway:
- - infections: epiglottis, abscesses, croup, bronchitis, pneumonia
- - trauma: maxillofacial trauma, cervical spine injury, laryngeal injury
- - endocrine : morbid obesity, diabetes mellitus, laryngeal injury
- - inflammatory conditions: ankylosing spondylitis, rheumatoid arthritis
- - tumors- upper and lower airway tumors
- - congenital problems: choanal atresal, tracheomalacia, cleft palate
- physiologic conditions- pregnancy, morbid obesity, edema
anatomic abnormalities predictive of
difficult or impossible face mask ventilation
- * Standard approach to upper airway and airway opening maneuvers not possible:
- - wired jaw, facial trauma , cervical rigidity, halo
- * poor seal b/w the face and mas- facial abnormalities, facial trauma
- * airway narrowing
- - laryngospasm, upper and lower tumors,
- especially mobile, and those associated with respiratory systems, narrowed
- pharyngeal space that cannot be easily modified ( pharyngeal edema, copious
- amounts of blood, pus, or secretions), upper and / or lower airway collapse
describe proper hand positioning with face mask ventilation
thumb and fore finger grip mask putting even gentle downward pressure on face, other 3 fingers go along pt's mandible and pull mandible forward, opening the airway.
if you don't have good seal with face mask
ventilation and you have proper grip , what is one of the first things you do?
put in an oral airway
what are the normal size of LMA's for adults and pedi
4 or 5, maybe a 3 for
Pedi : 1 and 2
- adult - 4 or 5
- small adult- 3
pedi- 1 or 2
Generally what are the size ETT for men , women?
how much air can a cuff take?
10 cc, but use the minimal amount needed to decrease the risk of trauma, like 3-5 cc
how do you verify tube placement?
CO2 capnogray, breath sounds
Why might you use a miller blade?
- the miller blade can provide a better view of the glottis when you have the larynx that is anterior, for example a grade 3 sometimes a miller blade helps.
- but it provides a smaller passage way through the oral pharynx, closer to the teeth. this is why beginers often use a mac.
what is the sellick's maneuvre
what is the BURP tecnique?
backwards , upwards, right pressure.
Explain the left side of the difficult airway algorithm , where there is a recognized difficult airway.
- *proper preperation is key!
- then awake intubation choices
* awake intubation choices : successful intubation, surgical airway, failed intubation.
after failed intubation, either surgical airway , cancel case and regroup, or regional anesthesia
what if mask ventilation is not possible?
- move to emergency pathway
- LMA, combitube, transtracheal jet ventilation.
awaken, inbuation choices, surgical airway
if you do happen to get in a difficult airway what do you do next?
- Confirm placement &
- document it was a difficult airway
what is trans tracheal jet ventilation
if you cannot intubate and cannot ventilate, think about surgical airway, needle the trachea with IV like 16 gauge cath, at soft spot b/w thryroid and cricoid cartilage needle it, hook up o2 to give o2.