Airway page 13-24

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jaime.davenport
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250839
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Airway page 13-24
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2013-12-05 19:51:32
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anesthesia
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airway lecture page 13-24
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  1. Esophageal tracheal intubation
    indications-
    contradictions-
    • 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.
  2. double lumen tubes ( blue tube for esophagus, and white tube for trachea) are used if
    • 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
  3. Combi-tube has how many inflatable cuffs? How many cc will they hold
    • two inflatable cuffs
    • 1. proximal (blue)- labeled as #1 holds 100cc- tracheal
    • 2. distal cuff (white)- labeled as #2 holds 15 cc- esophageal
  4. Insertion of combitube
    • 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
  5. If you hear no breath sounds after insertion of combi tube what do you do
    immediately ventilate through white (distal) tube.
  6. If no breath sounds or no gastric sounds with combi tube what do you do
    • 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
  7. windex
    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
  8. 4% lidocaine
    give like a neb to numb patient airway, only lasts for about 30 minutes
  9. Fiberoptic scope is used for
    • easily recognized difficult airway
    • or unrecognized difficult airway if patient is awakened or returns to sv (spontaneous ventilation???)
  10. options for fiberoptic scope
    • 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
  11. What is the most common approach for a difficult airway
    awake fiberoptic- cant go wrong with keeping someone awake and breathing on their own.
  12. antisialogogue meds
    atropine, robanol, scopolamine-- will dry out secretions

    glycopyrrolate can also be given
  13. topicalization
    local anesthetic
  14. vasoconstriction used in management of what, give what medication
    • 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
  15. adequate sedation is
    • 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
  16. fiber optic intubation requires
    a clear visual path
  17. glycopyrrolate is an_____
    what is dose???

    What is goal
    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
  18. Goal of sedation

    what do you want to avoid
    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
  19. oversedation impedes
    good visualization as pharyngeal tissues relax
  20. how to do transtracheal block
    • 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
  21. invasive types of topicalization (3)
    • 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)
  22. non-invasive techniques of topicalization
    • nasal topicalization
    • oral and tracheal topicalization
    • **there is no single nerve that can be blocked to produce complete anesthesia of the airway
  23. invasive topicalization allows what??
    what are risks?
    • selective areas to be blocked
    • use of less drug

    Risks- close to thyroid so risk of damage
  24. non-invasive topicalization blocks what?

    advantages
    • more generalized areas
    • advantages- there are no needles, but you have to use more drug
  25. how to do glossopharyngeal nerve block

    What is mandatory???
    • 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
  26. glossopharyngeal nerve block causes profound anesthesia to which part of tongue
    posterior third of tongue
  27. How to do superior laryngeal nerve block
    • 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
  28. what does superior laryngeal nerve block topicalize?
    the internal branch of superior laryngeal nerve-provides sensory loss to both of vocal cords
  29. what does transtracheal block topicalize
    below the vocal cords
  30. nebulized 4-5% lidocaine should be given over how long?
    15-20 minutes
  31. what is nebulized lidocaine used for
    • 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.
  32. topical benzocaine and cetacaine spray can be used for topicalization of what and what is the percentage used
    oropharynx and 10%
  33. what meds do you use with atomizer
    • 2-4% lidocaine
    • -one should be available on every anesthesia cart
  34. What are the different meds you can use for nasal anesthesia
    • - 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
    • -
  35. basic approach to awake fiber optic
    • 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
  36. When using fiber optic scope you want to ensure you have a
    clean and functioning light source
  37. to prevent humidification with FO scope
    • place tip in warm water
    • use anti-fog solution on distal tip
  38. what do you use to achieve better tongue retraction and protect FO scope
    use FO airway
  39. Position when using FO scope
    • keep scope straight
    • have bed in lowest position
  40. mechanics for using FO scope
    • 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
  41. advancement of FO 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
  42. What ports does FO scope have
    • suction port
    • insufflation port for 02
    • auxillary port for additional topical anesthesia
  43. when using FO scope on anesthetized patients what should you do
    jaw thrust because it opens pharyngeal space and lifts epiglottis
  44. Insertion of lightwand
    • 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
  45. lightwands what are they and what are they used for
    • light guided intubation
    • blind displacement of lighted stylet
    • trans-illumination of the soft tissue of the neck


    ***used for difficult airways
  46. when using lightwand what indicates passage through the glottis

    what do you do when you get to this point
    • well-defined glow at the sternal notch
    • **this means you are mid trachea

    slide out stylet and verify equal breath sounds and secure ETT
  47. advantages of using lightwand
    • 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
  48. disadvantages to lightwand
    • 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
  49. never use lightwand with patients with
    vocal cord mass- need to have direct visualization of vocal cord mass and using lightwand is a blind technique
  50. when is retrograde wire used
    • inability to intubate
    • -patient must be able to spontaneous ventilate (because this technique takes time)
    • -patient can be awake or asleep
  51. basic technique of retrograde wire
    • catheter or wire passed through the cricothryoid membrane
    • -advance into oropharynx
    • -acts as a guide for ETT
  52. specific insertion steps of retrograde wire
    • -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
  53. Blind nasal is used for difficult airways when there is inability to intubate, patient must be
    breathing spontaneously with good mask airway, and can be awake or asleep (easier if awake and numb than if they are asleep)
  54. In blind nasal intubations nasal prep is essential use what meds??
    • vasoconstrictor- afrin
    • quick lubrication with nasal dilators
  55. As you go down on the size of ETT they also get
    shorter
  56. when using ETT for blind nasal make sure the bevel is faced toward
    nasal mucosa, the septal wall
  57. blind nasal diameter of ETT by
    decrease calculated size by at least one half size
  58. warming your ETT before nasal intubation makes it
    more pliable and less traumatic
  59. Endotrol ETT for blind nasal
    • ring at proximal end
    • guides distal tip anterior
  60. BAAM whistle (Beck Airway AirFlow Monitor) for blind nasal
    • 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
  61. blind nasal contradictions
    • bleeding disorder (nose bleeds)
    • -basilar skull fx
    • -CSF rhinorrhea
    • -nasal fx
    • -septal deviation or deformity
  62. when would you do a cricothyrotomy
    • inability to venitlate
    • -intubation attempts have failed
    • -other conventional adjuncts have failed
    • -pt continues to desaturate
  63. criocothryotomy is a temporary measure prior to tracheostomy to allow for ________ not  _______ in the face of severe hypoxemia
    oxygenation not ventilation
  64. non-surgical (needle) cricothyrotomy is accomplished by using what
    • 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
  65. needle cricothyrotomy set up after insertion
    • 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.
  66. advantages to surgical cricothryotomy
    • larger catheters/cannuli
    • -ventilation is possible
    • -effective with total upper airway obstruction
    • -prolonged placement
  67. disadvantages of surgical cric
    • requires an incision
    • -more time consuming
  68. surgical pre-made kits for surgical cric
    • Nu-Trake Set
    • Cook Melker Kit
  69. complications of surgical cric
    those that occur early
    those that occur later
    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
  70. transtracheal jet ventilation (TTJV)

    Equipment needed
    • 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
  71. TTJV and the anesthesia machine
    • 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)
  72. advantages to TTJV
    • quick, simple, effective
    • -provides emergent means of oxygenation
    • -temporizing maneuver
  73. disadvantages of TTJV
    • room air entrapment (50% of TV)
    • -cant ventilate optimally
    • -cant use compliant breathing circuit (this is why you use high pressure tubing)
  74. Precautions of TTJV
    • 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
  75. monitor peak inspiratory pressure closely with TTJV.
    what are depended factors of TTJV?
    • tracheal size
    • cannula size
    • lung compliance
    • degree of outflow obstruction
    • inspiratory time (avoid stacking breaths)
  76. complications of TTJV
    • barotrauma
    • SQ emphysema
    • mediastinal emphysema
    • arterial perforation
    • esophageal puncture

    ***document breath sounds, chest inflation while performing TTJV
  77. Rigid scopes are a combination of what
    rigid scope and fiberoptic
  78. popular types of rigid scopes
    • bullard scope
    • WuScope
    • upsher scope

    **rigid scopes usually used by ENT on polyps of vocal cords or tonsilectomy
  79. advantages to rigid scopes
    • allows visualization of the airway with minimal manipulation
    • -sturdy and durable
  80. disadvantages of rigid scopes
    • expensive (but can reuse)
    • -steep learning curve
    • -must be used routinely for practice
    • -often need considerable mouth opening
  81. risk for cervical trauma ***KNOW****
    • 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***
  82. difficult airway algorithm is a
    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
  83. LOOK at airway algorithms!!!!
  84. take home messages from this lecture
    • 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

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