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79 Cards in this Set

  • Front
  • Back
Rigid laryngeal structures
hyoid bone (lndmrk nerve blk)
thyroid cart
cricoid cart
arytenoid cart
tracheal cart
Laryngeal cart
thyroid cart
cricoid cart
arytenoid cart
Nose & nasopharynx
maxillary brch of trigeminal
Post third of tongue & oropharynx
Glossophyaryngeal nerve (can numb for diff intubation)
Laryngeal & trachea
Superior laryngeal nerve sensation from the ____ & inferior _____to vocal cords
base of tongue
(can numb, awake intub, so cords don't flap
Recurrent laryngeal nerve sensation distal to ____
vocal cords
Pediatric airway
begins @ C3-4, (C4-5 adult)
Pediatric airway
large in propotion
easily causes obstruction
Pediatric airway
narrow & angled away from axis of trach
-difficult to lift w/ tip scope
Pediatric airway
Subglottic region
narrowest at cricoid cart
Airway Eval
Hx of diff intubation w/ surg
-medicalert bracelet
-prev anesthesia & medical records
Airway Eval
Specific diseases
Rheumatoid (ROM, TMJ)
Morbid Obese (short neck, inc oral tissue, Inc fat behind neck affects axis)
Congenital syndrs
Congenital Syndromes Assoc w/ diff intubation
large tongue
small mouth
Congenital Syndromes Assoc w/ diff intubation
Manidibular hypoplasia & cervical spine abnorm (craniofacial abnorm)
Congenital Syndromes Assoc w/ diff intubation
Neck rigidity d/t cerv fusion
Congenital Syndromes Assoc w/ diff intubation
Pierre Robin
small mouth large tongue
manidibular anomaly (awake intubation) Possibly unitubatedable)
Physical Examination
Cervical Spine assess
-Mobility asses
-Have Pt flex/ext neck
-NL = 90-165 deg
-dec 20% by age 75)
Physical Examination
Temperomadibular jt
open mouth wide & stick out tongue
NL = 3 fingerbreadths
Physical Examination
Oral Cavity Assess
-In conjunction w/ TMJ assess
-Doc loose, broke, chip (crowns, caps, dentures, teeth)
-protruding teeth (difficult)
-Exam palate, tumors, clefts
Assess Class (Mallampatti)
Class 1 (easy)
soft palate, fauces, uvula & ant & post tonsillar pillars
Assess Class (Mallampatti)
Class 2 (Possible difficult)
Same as 1 except tonsillar pillars hidden by tongue
Assess Class (Mallampatti)
Class 3 (Possibly difficult)
Only base of uvula seen
Assess Class (Mallampatti)
Class (very difficult)
even uvula not visible
Mallampati Modifiers
Thyromental Distance
Mallampati Modifiers
Mobility of neck
Mallampati Modifiers
Morphological features
short thick neck (men)
dental overbite
Basic Airway management
Airway positioning
Jaw thrust (used most)
Chin lift (gentle)
Care taken not to press on soft tissue below manidble
Basic Airway management
Mask Ventilation
Tight seal
-downward pressure
-extend thumb & index
Basic Airway management
Mask Ventilation
Airway occulded
little finger used behind angle of jaw
lift jaw forward
tongue moves away from post pharynx (propofol relaxes)
Basic Airway management
Mechanical airways
Oral airway
supports relaxed tongue
-proper size
-measure beside face
-end bef angle of madible
Basic Airway management
Oral airway Insertion
Method 1
-open mouth by grasping madible
-insert oral airway w/ curve toward tongue
-1/2 in rotate 180 deg
Basic Airway management
Oral airway Insertion
Method 2
fix tongue in neutral position
insert direct curve toward hard palate
check press to tongue or lips
may cause vomiting in conscious
Basic Airway management
Nasal Airway
Passes through nose ends just bef epiglottis
-tolerated well
-risk of bleed
-risk of facial inj
-Insert (lubricate, direction of palate)
Basic Airway management
Layrngeal mask airways (LMA)
-Inflatable silcone ring
-attached diag to flexible tube
-forms oval cushion fills space behind larynx
-low press seal bet tube & trachea
-alt to mask airway, Guedel ariway or ett
Basic Airway management
Layrngeal mask airways (LMA)
-Does not protect airway
-Could possibly give pos press vent & deliver anesth
-chance epiglottis could flip and anesth to stomach
-No NMB used
Basic Airway management
Layrngeal mask airways (LMA)
-clear airway (hands free)
-replaces ETT in many pt's
-Blind insert
-useful diff ETT intubation
-eliminates NMB
-Left in place until reflexes return
-repeated use
Basic Airway management
Layrngeal mask airways (LMA)
Does not prevent regurg or aspiration
-bronchial secertions irritate vocal cords (spasm)
Sizes of LMA's
1 - up to 5kg
1.5 5-10kg
2 - 10-20kg
Sizes of LMA's (fill 30ml air
2.5 - 20-30kg
3 - Child small adults
4- nl/large adults
5 - large adults
LMA insertion
-position head as w/ ETT
-neck flex w/ one hand behind head
-insert cuff into mouth
-apreture facing but not touching tounge
-press tip against hard palate
LMA insertion
Insert w/ index finger
-press tube where joining cuff
-insert to pharynx as far as possible
-want pt to return to spont breathing after induction drugs as soon as possible
LMA insertion
-change grip to insert fully
-stop pushing w/ resist met
-black line on tube face upper lip
-inflate cuff
-bite blk
-secure LMA
LMA insertion
-fail to press up against deflated mask up against hard palate
inadequate lubrication/deflation cause mask to fold on self
LMA insertion
-When mask folds may push on epiglottis into down folded position cause obst.
LMA insertion
-If mask tip deflated forward can push down on epiglottis = obst.
-if mask inadequate deflated (may push down on epiglottis, penetrate glottis
Indications Oral intubation
Airway protection (general trach anesthesia (GETA)
-Respiratory arrest
-resp fail
-hypovent/hypercardia (PaCo2 >55mm)
-Art hypox refractory to Oxygen (PaO2 <55 RA, <70 on 100%
-Resp Acidosis
-Airway obst
Indications Oral intubation
Glascow <8
Prolong vent support
Class III or IV hemmorhage w/ poor perfusion
Severe Fail chest/pulm contus
Multi trauma, head inj, alt mental stat
Inhalation inj w/ erythema
Protect from aspiration
Contraindications for intubation
Pt w/ intact gag
likely laryngospasm to attempt
-child w/ epiglottis (ent to trach)
-Basilar skull fx (avoid naso trach intub & NG tube)
Complications of Intubation
Vocal cord damage
damage to aytenoid cart
chip/break/loose teeth
injury to lips gum, tongue
trach tear (inc mortality)
bronch intub (atelectasis, edema)
Esoph intubation
Trach stenosis (vagus nerve to trach)
Equipment Intubation
Laryngoscope (str & curved)
Endotracheal tubes w/ 10ml cuff & 15mm adaptor (attach trach tube to circuit)
10ml syringe
Ett holder/tape
magill forceps (nasal)
Equipment intubation
Yankauer suction
flexible suction cath 14&16
Bag Valve mask
CO2 detect device
M= Machine Check
S= Suction
M= Monitors
A= Airway
D= Drugs
Armored Tubes (rings in tube prevent kink, need larger flow)
Uncuffed - child
High press low residual cuff
low press high residual cuff
Pediatric ETT size estimation
(16 + age)/4
Pediatric ETT size estimation
Depth from gum to carina
(MM)= 12+age(yrs)/4

Uncuffed in child <10yrs
After 14yrs what size cuff do you typically use
Tube Sizes (Size of pt little finger)
14yrs & 46 +kg =
7.0 or 8.0 mm cuffed
Tube Sizes
Adult female
7.0 - 8.0 mm cuffed
Tube Sizes
Adult male
7.5 - 8.5 mm cuffed
Specialty ETT
Right Angle Endotrachael
Nasal RAE (tooth extract)
Oral RAE
Types of laryngoscopes
Straight or Jackson Wisconsion
Prepartation of Equipment
Assemble all equipment
Inflae cuff on ETT to test
Lubricate ETT
Insert stylet into ETT
(insert to about 1cm bef distal end)
Bend tube to gentle curve
Test Laryngoscope fuction
Prep of patient
suction airway remove foreign materials in mouth
ventilate w/ mask 100% O2
-tight seal, min 60 sec
Head position No C spine injury

Approach every airway as a difficult one
Align of
Pharyngeal axis
Laryngeal axis
Oral axis
Elevate head 10 cm on pillow
Hyperextend neck
Intubation Procedure
Suction mouth till clear
Corcoid if RSI
Scope left hand insert right side of mouth
Sweep tongue to left
Intubation Procedure
-Visual of Right tonsil
-sweep blade midline
-epiglottis in view
-maintain view
-adv blade until reaches angle bet. base of tongue & epiglottis (volecular space)
-Lift scope upwards & away from nose towards chest
-Visualize cords
-Place ETT in R hand, keep concavity of tube to R side of mouth
Intubation Procedure
Insert tube (prox end of cuff 1/2 inch -1 inch beyond cords
-manually secure
-note depth
-ventilate w/ 100%
-listen to bilat breaths
-attach to ETCO2 detect
-Secure tube
Bilat breath sounds
Size & Position of ETT
Scope view, type blade
Time of insert
Number of attempts
Completition of surg
Fail to ventilate
-fail to chest to rise
-abs breath sounds
-Esoph intubation
-malfuction equipment
-Suction orophyarynx
-oxygen pt
-turn head to side
-deflate cuff
-withdraw tube on
-insp w/ positive press
-mild CPAP
-Provide supp O2
Suction on the way out
15 sec
Oxygenate pt pre/post suctioning
Rapid sequence intubation
-simultaneous admin (sedative, induction, NMB)
-Sellicks maneuver
-Dec agitation movement
-assoc tachy/HTN
-Airway damage
Dec aspiration
Risk if difficulty airway
Contraindications of RSI
Spont breathing w/ adequate vent & oxygenation

Risk of failed intubation
-maj laryngeal trauma
-upper airway obst
-distorted facial/airway anatomy
Difficult Laryngosopy
-opptmize position of head
-replace blade in necessary
-two attempts max
-request assist
-two attempts by 2nd
-oxygentate if poss
Airway Aids
Eschmann Introducer
60cm stylet like device
5 mm external diameter
35 degree bend 2.5cm from tip
Airway Aids
Eschmann Introducer
-Bemd tip directed blindly or under reduced vison into glottic inlet
-Passed 30cm into trach
-feel clicking over trach cartilages
-Slide ett over bougie
-90 deg counterclkwise turn facilitates glottic passage by present the bevel prosterior
Failed intubation
ventilate w/ mask
call for help
remeber airway adjuncts
If unable to ventilate
- consider fasttarach LMA
- retrograde intubation
- cricothyrotomy
Optimize position
Change blade
Two attempts
Request assistance
Two attempts by 2nd
Remeber to oxygenate if possible
Trach Jet ventilation
14 / 16 g cath
cricothyroid memb
attached to high pressure O2
3-way stopcock prevents excessive pressure