Airway page 13-24

• usually used by paramedics or EMT prior to arriving to hospital
• indications- failure to intubate or ventilate
• contradicitons- intact gag reflex, known esophageal disease, ingestion of causative substance

**usually blind intubation, just open mouth and insert, two balloons on this devise, make sure correct one is inflated, if in esophagus blow up both, if in trachea only have to blow up small one at the bottom of the tube.

• patient has hemothorax trauma, tumor, etc..
• these are used if going to let one lung go and they will isolate and ventilate good tube.. These patients are usually dying.

** notes say not to worry much about this  just know basics because we will not use these much

• two inflatable cuffs
• 1. proximal (blue)- labeled as #1 holds 100cc- tracheal
• 2. distal cuff (white)- labeled as #2 holds 15 cc- esophageal

• usually blind technique
• lubricate with H2O soluble lubricant
• most of the time tube is going to end up in esophagus
• advance until teeth lie between two black bands
• inflate blue (proximal cuff) first
• make sure cuff is in trachea before inflating white (distal cuff)
• ***ventilate through blue (proximal) lumen

immediately ventilate through white (distal) tube.

• tube is advanced to far
• deflate #1 proximal (blue) cuff and move tube back 2-3 cm.
• reinflate #1 balloon and ventilate through the same port #1 proximal port.
• ***can pull it back and reinsert

mixture of lidocaine  and prilocaine. Use suction tubing and put hole in it, and spray back of patient throat. Use prongs to spray in sections and get further down each time

give like a neb to numb patient airway, only lasts for about 30 minutes

• easily recognized difficult airway
• or unrecognized difficult airway if patient is awakened or returns to sv (spontaneous ventilation???)

• nasal versus oral
• awake versus asleep- deep sedation but still breathing
• **if patient awake may give something for nerves, if patient morbidly obese use it while completely awake

awake fiberoptic- cant go wrong with keeping someone awake and breathing on their own.

atropine, robanol, scopolamine-- will dry out secretions

glycopyrrolate can also be given

local anesthetic

• if using nasal approach, it helps decrease the risk of nosebleeds
• --give afrin (oxymetazoline)  in pre-op if this may be a possibility when inducting patient

• individualized when inducting patient
• may have to hold hand and reassure patient when intubating if they are not a candidate for any type of relaxant

a clear visual path

antisialogogue and is a drying out agent

**can be given 0.2 mg IM one hour prior to surgery or 0.2 mg iv immediately prior to surgery

Goal is to dry out mucosa prior to topicalization

to produce a cooperative and relaxed patient

• avoid apnea!!!
• -incremental titration to achieve drowsiness or slurred speech
• -midazolam, fentanyl, and propofol are popular
• -narcotics blunt cough reflex, and this is bad because you want patient to breath

good visualization as pharyngeal tissues relax

• use 20 gauge angiocath at 90 degree angel and slightly caudad
• pierce cricothyroid membrane and confirm air aspiration
• use 4cc of 2-4% lidocaine and inject on inspiration
• **aspirate the whole time while doing this, may see a little drop of blood

• intraoral glossopharyngeal block- usually done by md (see other notecard for more info)
• superior laryngeal nerve blocks (see other note card for more info)
• transtracheal block (see other notecard for info)

• nasal topicalization
• oral and tracheal topicalization
• **there is no single nerve that can be blocked to produce complete anesthesia of the airway

• selective areas to be blocked
• use of less drug

Risks- close to thyroid so risk of damage

• more generalized areas
• advantages- there are no needles, but you have to use more drug

• use 10% benzocaine spray to optimize exposure
• use tongue blade or miller to view tonsils
• 22g or 23g tonsilar needle used, inject at base if spinal pillar
• 5cc of 2% lidocaine into base of anterior tonsilar pillar (lower 1/3 of height) bilaterally
• ASPIRATION IS MANDATORY BEFORE INJECTING

posterior third of tongue

• find superior border of lateral wing of thyroid cartilage
• gently pierce thryo-hyoid membrane with 22 gauge needle
• aspirate (carotid sheath)
• inject 2-3 cc of 2% lidocaine

the internal branch of superior laryngeal nerve-provides sensory loss to both of vocal cords

below the vocal cords

15-20 minutes

• topicalization of nose and carina--but can be unpredictable
• -can loose up to 50% of solution to room air
• good for obese patients with obscure anatomy in the neck.

oropharynx and 10%

• 2-4% lidocaine
• -one should be available on every anesthesia cart

• - progressive nasal dilation with 2% lidocaine jelly
• -10% benzocaine spray (spray this in back of throat and not in nose)
• -2 cc of 4% lidocaine to each naris with 18g iv catheter (this is going to burn their nose)
• -mix 1 cc neosynephrine 1% with 4 cc viscous lidocaine and dribble down each nare while patient sniffs
• -

• use mild sedation
• antisialogogue- dry out secretions 
• 10% spray of cetacaine and benzocaine to posterior pharynx and side to side
• 2% viscous lidocaine to posterior tongue via tongue blade
• transtracheal block
• **if obese, use aerosolized 4% lidocaine and or spray as you go, b/c this may cover more tissue

clean and functioning light source

• place tip in warm water
• use anti-fog solution on distal tip

use FO airway

• keep scope straight
• have bed in lowest position

• keep ETT on scope
• -small changes with lever for up and sown
• slight turn of wrist for side to side changes
• distal hand should hold scope at patient mouth
• **little notch on scope is at 12:00, start at 12:00 when looking in scope

• after carina is visualized advance scope
• if visual field lost, pull back scope until familiar structures appear
• **often takes slight turns to advance past arytenoids

• suction port
• insufflation port for 02
• auxillary port for additional topical anesthesia

jaw thrust because it opens pharyngeal space and lifts epiglottis

• lubricate stylet and insert into ETT
• shape at 90 degree angle (like hockey stick)
• neutral or slight extension of the head
• turn off lights
• insert into corner of mouth
• turn to midline of mouth
• advance gently with a rocking motion along an imaginary arc
• use light glow as guide

• light guided intubation
• blind displacement of lighted stylet
• trans-illumination of the soft tissue of the neck

***used for difficult airways

• well-defined glow at the sternal notch
• **this means you are mid trachea

slide out stylet and verify equal breath sounds and secure ETT

• requires minimal cervical spine manipulation
• prevents dental and soft tissue damage
• less stimulating than direct laryngoscopy
• good for small mouth openings- because you don't have to worry about getting on teeth

• learning curve
• trauma to upper airway with blind technique
• reliance on trans illumination---may not be able to see well on obese patients and dark skinned patients

vocal cord mass- need to have direct visualization of vocal cord mass and using lightwand is a blind technique

• inability to intubate
• -patient must be able to spontaneous ventilate (because this technique takes time)
• -patient can be awake or asleep

• catheter or wire passed through the cricothryoid membrane
• -advance into oropharynx
• -acts as a guide for ETT

• -LTA lidocaine if possible
• -crycothyrotomy with 18 gauge iv catheter
• -pass guide wire up through mouth- magil forceps may be needed to grab it
• -then pass wire through murphy eye (slit on side of ETT) from outside to in and out the top of the ETT.
• - slide ETT down wire through larynx
• -ETT stops advancing approximately 2 cm below the cords
• -hold ETT securely
• -pull out guide wire from below
• -advance ETT down trachea
• -verify placment

breathing spontaneously with good mask airway, and can be awake or asleep (easier if awake and numb than if they are asleep)

• vasoconstrictor- afrin
• quick lubrication with nasal dilators

shorter

nasal mucosa, the septal wall

decrease calculated size by at least one half size

more pliable and less traumatic

• ring at proximal end
• guides distal tip anterior

• 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

• bleeding disorder (nose bleeds)
• -basilar skull fx
• -CSF rhinorrhea
• -nasal fx
• -septal deviation or deformity

• inability to venitlate
• -intubation attempts have failed
• -other conventional adjuncts have failed
• -pt continues to desaturate

oxygenation not ventilation

• a small needle that is passed through the cricothryoid membrane
• -10-14 gauge angiocath is inserted at a 90 degree angle and slightly caudad
• ** technique is similar to transtracheal block

• connect directly to a jet ventilator (luer lock connection)
• -connect to a homemade breathing apparatus
• --7.5 ETT adapter
• --3 cc syringe
• --10-14 g IV catheter
• --use oxygen flush valve to provide oxygenation***you have to make sure patient is exhaling to avoid barotrauma.  This is only temporary to oxygenate patient. Surgical intervention may be required after this.

• larger catheters/cannuli
• -ventilation is possible
• -effective with total upper airway obstruction
• -prolonged placement

• requires an incision
• -more time consuming

• Nu-Trake Set
• Cook Melker Kit

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, TEF, voice changes

• provides a mean of oxygenation following cricothyrotomy (venturi principle)
• -temporizing measure prior to surgical cricothyrotomy

• equipment needed- large bore catheter (10-14g)
• 50psi oxygen source
• non-compliant tubing

• disconnect common gas outlet
• connect high pressure tubing with 15mm (7.5 ETT) adapter at one end and a luer lock at the other end
• -depress the O2 flush valve (50 psi)

• quick, simple, effective
• -provides emergent means of oxygenation
• -temporizing maneuver

• room air entrapment (50% of TV)
• -cant ventilate optimally
• -cant use compliant breathing circuit (this is why you use high pressure tubing)

• avoid use with complete obstruction above the cords
• -gas must escape from the mouth- to avoid barotrauma

I:E ration must be increased 1:3 or 1:4, this allows time for passive exhalation

• tracheal size
• cannula size
• lung compliance
• degree of outflow obstruction
• inspiratory time (avoid stacking breaths)

• barotrauma
• SQ emphysema
• mediastinal emphysema
• arterial perforation
• esophageal puncture

***document breath sounds, chest inflation while performing TTJV

rigid scope and fiberoptic

• bullard scope
• WuScope
• upsher scope

**rigid scopes usually used by ENT on polyps of vocal cords or tonsilectomy

• allows visualization of the airway with minimal manipulation
• -sturdy and durable

• expensive (but can reuse)
• -steep learning curve
• -must be used routinely for practice
• -often need considerable mouth opening

• in-line cervical counter traction
• cervical instability
• -trauma, fx
• -rheumatoid arthritis-in children or elderly

• **some patients more at risk than others
• -downs syndrome
• -old ladies

don't crank head back**be careful***

systematic approach to managing an airway

-developed by ASA in 1990

• -plots primary and alternative airway strategies for emergent and non emergent airways
• -begins with thorough preoperative airway evaluation

• if your suspicious of trouble, secure the airway awake
• -if you get into trouble wake the patient up immediately
• -think ahead with plan B,C,D immediately available
• -intubation choices--do what you do best!!!
• -always have a back up plan available in the room