question

Decide on the technique w/ back-up plan (A<B<C) based on

answer

Complete airway hx & PE Ventilation challenges Indications for intubation Risks for aspiration Risks of failed airway

question

Respiratory quotient (RQ) =

answer

ratio of total CO2 production to O2 consumption

question

Normal VCO2 is

answer

is 200 ml/min

question

Normal VO2 is

answer

250 ml/min for resting awake adults, 3-4 ml/kg/min, and 6-7 ml/kg/min in children

question

So if you are struggling w/ the airway for 6 minutes, apnea, what is the Rate of rise of CO2:

answer

6 mmHg during first minute 3-4 mmHg for each subsequent minute 60 Seconds: PaCO2 rise from 40 to 46 mmHg 120 Sec: 4649 mmHg 180 Sec: 49 53 mmHg 240 Sec: 53 57 mmHg 300 Sec: 57 61 mmHg 360 Sec: 61 65 mmHg

question

Hypoxemia

answer

Anaerobic ventilation, H & lactate - acidosis

question

Cellular membranes in the brain and other hypoxia intolerant tissue beds begin to fail as ___ is consumed.

answer

ATP

question

How much ATP is made with aerobic v. anaerobic respiration?

answer

Aerobic- 38 mol ATP per 1 mol glucose. Anaerobic- 2 mol ATP per 1 mol glucose.

question

Organ specific responses to hypoxemia for heart

answer

Initial Excitatory & vasoconstrictive HR, SV, contractility increase Late Depressed & vasodilatory Blood pressure down, HR down, shock develops, fibrillation, asystole

question

Physical Exam Steps DL worried about

answer

aiway, small mouth, micrognathia, head/neck pathology, large toungue, high pallet, large teeth, obesity

question

Physical Exam Steps mask ventilation worried about

answer

airway, large tongue, endentulous or no teeth, obesity, OSA

question

Previous intubation questions

answer

Does the pt know they were difficult? Scar on their neck? Sore throat, dental injury or lacerated lip?

question

does patient have Co-morbidities that increase probability such as?

answer

Previous head & neck surgery/radiotherapy RA, cervical disease, TMJ "locked jaw" Uncontrolled DM Genetic/congenital syndromes, such as Down syndrome, Autoimmune dz

question

PEs lead to many false positives

answer

Specificity 40-75%

question

how many difficult airways not predicted

answer

25%

question

Using__ methods increases predictive value

answer

≥ 2

question

Mallampati exam positioning is

answer

Sitting upright Tongue extended No "ah"

question

Mallampati classes and scoring

answer

PUSH Class 1 Soft palate Fauces Uvula Pillars Class 2 Soft palate Fauces Uvula Class 3 Soft palate Base of uvula Class 4 Hard palate only

question

Upper Lip Bite Test is Lower Incisors to

answer

Class I Vermillion border Class II Mid upper lip Class III Don't touch upper lip

question

Wilson Risk Sum Score: 5 factors Predictive Factors

answer

Weight Head & neck movement Mouth opening Jaw development Prominence of upper incisors

question

Wilson Risk score

answer

one or two points for each mark hit: weight 90, 110kg h/n movement 90, <90 degrees jaw movement IG<5, slux 0; IG<5, slux 3 = 75%, >4 predicts 90% difficult airway

question

Interincisor Gap aka

answer

aka Mouth Opening Opens mouth as wide as possible

question

Interincisor gap assessment

answer

< two FB or 3 cm=difficult DL Miller NETT AFOI

question

Thyromental Distance or, Patil's test, assessed by

answer

Extend head Distance from thyroid notch & submentum Not hyomental which is 3cm

question

Thyromental Distance results mean

answer

6.5cm easy, 6cm difficult, <6 very difficult/impossible

question

Head & Neck ROM assess by

answer

Flexion-extension < 90 ° = decreased ability to align axis including: Oral Pharyngeal Tracheal

question

CRNA Natl. Avg. does 880 cases/yr Difficult mask: unable to keep O2Sat >90 in __% Difficult Intubation: more than 3 attempts or more than 10 minutes in _% Failed intubation in _%

answer

0.07% Up to 5%,6-44/yr 1.1% Up to 8.5%,10-75/yr 0.01-0.03%, 1-3 in 10,000, every 5-11 yrs

question

Mask Ventilation steps

answer

Right size- Over nose first, Base midway between lip & mental prominence Head at xiphoid process Sniffing position C index & thumb E fingers- Bony prominences only. Avoid submandibular soft tissue Pull to mask-don't push

question

Difficult Mask Fit broad indicators

answer

Bearded patients Edentulous patients Very large patients Very small patients Airway/facial anomalies

question

Difficult Mask Ventilation, DMV, 6 criteria

answer

Age >55 yrs Body mass index >26 kg/m2 Beard Edentulous History of snoring OSA 2+ factors = high likelihood of DMV Ltd. mandibular protrusion DMV & DTI

question

DMV Corrective Actions

answer

Reposition mask Reposition patient Place oral airway Place nasal airway Still can't ventilate 2nd nasal airway Call for help 2 handed mask/ assistant ventilates Still difficult=definition of DMV

question

Airway Adjuncts allow Air passage between tongue & posterior pharyngeal wall. Why is this important?

answer

Loss of upper airway muscle tone in anesthetized patients allows tongue to fall back against posterior wall of pharynx.

question

Oral Airways Benefits

answer

Maintains patent airway Prevents patient from biting/occluding ET tube Prevents patient from biting tongue Allows path for suctioning pharynx Allows placement of (OG) tube

question

Oral Airways Contraindications

answer

Awake patient- stims gag Intact airway reflexes Inability to open mouth Poor dentition

question

oral airway Sized by distance (mm) from flange to tip Peds size? adult size? Landmarks used?

answer

peds 3.5cm-11cm adult 40mm-100mm, typical is S80, M90, L100 tragus to corner of mouth, Too short equals airway obstruction

question

Types of Oral Airways

answer

Berman Open channel Guedel Inner channel Fiberoptic- Williams, Ovassapian, Berman Intubating Airway

question

Oral Airway Insertion

answer

Insert airway about half way down or until you approach posterior pharynx, then gently turned 180 degrees.

question

oral airway limitations and Disadvantages

answer

Disadvantages Aspiration Trauma & necrosis May elicit laryngospasm & vomiting Loss of teeth Limitations Anatomy of patient Existing trauma & lesions Intact reflexes Awake pts can't tolerate

question

Nasal Airways

answer

Indications Dilate nares prior to nasal intubation Oral airway adjunct Oral airway not appropriate Lighter planes of anesthesia Oral surgeries

question

Adult & pediatric

answer

Adult 26-34 Fr Peds 12-24 Fr

question

Nasal Airways Insertion Technique

answer

Lubrication some use 4 % lidocaine jelly Slow downward pressure parallel to nasal floor Bevel facing the septum (Why?)

question

Laryngeal Mask Airway (LMA) Insertion is independent of

answer

Mallampati class In-line traction / Cervical collar Cricoid pressure (+/-)

question

Proper LMA Positioning

answer

Tip of cuff rests in inferior recess of hypopharynx above esophageal sphincter Sides of cuff face into pyriform fossa Upper borders rest against the base of the tongue Aperture bar lies over the laryngeal inlet

question

lma is Face mask alternative for elective surgical procedures

answer

Less than 2-3 hours Short duration when intubation is not necessary

question

Does not protect the airway from the effects of regurgitation or aspiration. full stomachs are

answer

Non-fasted Pregnancy Trauma or severe pain Acute abdomen Thoracic injury Chronic opioid use Autonomic neuropathy

question

LMA Insertion Prepare LMA by

answer

Lubricate posterior surface prior to insertion

question

LMA Insertion

answer

Induction Sniffing position/jaw thrust Standard insertion technique Aim toward your umbilicus May finger sweep tip

question

LMA PEARLS

answer

Test the cuff before use Don't lubricate anterior surface of the mask Only when adequate anesthetic depth obtained Displace jaw out and up Maintain adequate anesthetic depth during surgery Don't disturb patient during emergence Prime pt for removal while awake Keep the cuff inflated during LMA removal

question

ETT Indications

answer

Not required for all GA Not risk-free Aspiration risk Definitive airway Routine GA Procedures w/ abdominal insufflation Need for PPV> 20 mm H2O Impaired gas exchange Neurologic impairment Untoward surgical positioning Prolonged surgical time >2Hr

question

Inflation Valve/Port

answer

Connects to syringe May leak Attached syringe Can damage valve Can injure patient's eye May prevent excess volume/pressure build up

question

Pilot Balloon/Inflation Lumen

answer

Indicates whether cuff is inflated or not Does not measure cuff pressures Fails if damaged, will not Deflate Inflate

question

Av. Tracheal diameter is ___ mm

answer

21-27

question

how much air does ett cuff hold ___ ml average

answer

2-10

question

Cuff pressure should not exceed___ cmH20

answer

Cuff pressure should not exceed 20-25 cmH20 25-30 mmHg tracheal mucosa perfusion pressure

question

High Volume Low Pressure cuffs (HVLP)

answer

also LPHV. good Pressure dispersed over greater surface area

question

Implant tested to ensure nontoxicity

answer

Marked I.T. or Z-79

question

ETT Features

answer

Machine end standard 15 mm

question

Murphy eye allows for ventilation in case

answer

beveled end of tube lies against tracheal mucosa. Murphy hole lessens the risk of complete tube occlusion.

question

ETT Clinical Implications Resistance & work of breathing. Varies inversely with internal diameter, ID, r/t which physics law?

answer

Pouseille's Law 1 mm decrease increases WOB by 35 - 150%

question

Mendelson's Syndrome

answer

Inhalation of highly acidic or particulate aspirate Gastric volume > 25cc Gastric pH < 2.5

question

non airway methods to protect from aspiration

answer

Gastrointestinal stimulants Gastric acid secretion blockers Antacids Antiemetics

question

Rapid Sequence Induction (RSI)

answer

Used for patients at risk for aspiration Only when a difficult airway is not identified It is a sequence of events planned to flow rapidly

question

Rapid Sequence Induction

answer

Preoxygenation with 100% O2 for 4-5 min - insure nitrogen wash out Vital capacity breaths can be used for True RSI no anxiolytics or narcotics Application of cricoid pressure Successive IV administration of a hypnotic & muscle relaxant No positive pressure mask ventilation An endotracheal tube is inserted in the trachea

question

Esophagus should be occluded to prevent passive regurgitation of stomach contents w/ ___ lbs of downward pressure on cricoid cartilage

answer

9 lbs

question

Nasal Intubation awake? asleep? blind?

answer

Awake Nasal- Difficult airway in a patient who will need post-op ventilation Asleep Nasal- Elective procedure with surgical implications Blind Nasal- SV patient, failed intubation, no DL

question

Most common is

answer

asleep nasal intubation w/ direct visualization

question

Nasal Intubation Determine most patent nare

answer

left preferable because of shape of nasal ET

question

Nasal Intubation

answer

Induction Lubricated nasal airways - 6.5-8.0 or 28-34 Fr Sequentially place lubricated nasal airways to dilate & lubricate the nare Insert ETT into nare (same as nasal airway) until tip is in pharynx above epiglottis

question

Nasal Intubation Contraindications

answer

Intranasal abnormalities Tumors, fractures, deviations Extensive facial trauma Basilar skull fracture Coagulopathies Cerebrospinal fluid leak

question

Confirming ETT Placement Auscultation

answer

Auscultation Apices equal volume Axilla Bilateral lung bases, equal volume & expansion Epigastric area

question

Confirming ETT Placement

answer

Expired CO2 (end-tidal) Gold Standard Palpate balloon cuff at sternal notch Compress pilot balloon Pulse oximetry Humidification in the ETT

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