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airwayManagement08May - Airway Management Airway Augusto...

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Unformatted text preview: Airway Management Airway Augusto Torres, MD Department of Anesthesiology MetroHealth Medical Center Outline Outline Review of airway anatomy Airway evaluation Mask ventilation Endotracheal intubation The difficult airway Airway Anatomy Airway Ab-ductor – Posterior Posterior cricoarytenoid cricoarytenoid Tensor – Cricothyroid Ad-ductors – All the rest Airway Anatomy Airway Innervation Vagus n. – Superior laryngeal n. External branch – motor External to cricothyroid m. to Internal branch – Internal sensory larynx above TVC’s TVC’s – Recurrent laryngeal n. Right – subclavian Left – Aortic arch (board Left question) question) Motor to all other Motor muscles, Sensory to TVC’s and trachea TVC’s Airway Anatomy Airway Innervation of Innervation oropharynx oropharynx – Glossopharyngeal n. Glossopharyngeal innervates tongue base and oropharynx base Airway Anatomy Airway Membranes – Thyrohyoid – Cricothryoid Cartilages – – – Hyoid Thyroid Cricoid Airway Evaluation Airway Take very seriously Take history of prior difficulty history Head and neck Head movement (extension) movement – Alignment of oral, Alignment pharyngeal, laryngeal axes pharyngeal, – Cervical spine arthritis or Cervical trauma, burn, radiation, tumor, infection, scleroderma, short and thick neck thick Airway Evaluation Airway Jaw Movement – Both inter-incisor gap and Both anterior subluxation anterior – <3.5cm inter-incisor gap <3.5cm concerning concerning – Inability to sublux lower Inability incisors beyond upper incisors incisors Receding mandible Protruding Maxillary Protruding Incisors (buck teeth) Incisors Airway Evaluation Airway Obesity – Distribution, i. e. short, Distribution, thick neck more concerning concerning – Neck circumference Airway Evaluation Airway Thyromental distance: Thyromental bony point on mentum (mandible) to thyroid notch thyroid If short (<3FB’s or If 6cm), pharyngeal and laryngeal axis off laryngeal Airway Evaluation Airway Oropharyngeal visualization Mallampati Score Sitting position, protrude tongue, don’t say Sitting “AHH” “AHH” Airway Evaluation Airway Difficulty ventilating – Age >55 – Beard – History of snoring – Lack of teeth – BMI >26 Preoxygenation Preoxygenation Replaces the nitrogen volume of the lungs Replaces (69% of FRC) with oxygen (69% Functional residual capacity (residual Functional volume and expiratory reserve volume) volume Preoxygenation with 100% oxygen via Preoxygenation tight-fitting mask for 5 minutes up to 10 min of oxygen reserve following apnea min Four vital capacity breaths over 30 Four seconds (time to desaturation quicker) seconds Patient Positioning Patient Sniffing position – Lower neck flexion – Upper neck extension – Important in obesity Mask Ventilation Mask Induction of Induction anesthesia produces upper airway relaxation and possible collapse possible Downward Downward displacement of mask with thumb and index finger finger www.aic.cuhk.edu.hk Mask Ventilation Mask Upward traction of Upward remaining fingers upward upward Fingers on bony Fingers mandible mandible Fifth digit at angle Fifth displacing mandible anteriorly anteriorly www.aic.cuhk.edu.hk Mask Ventilation Mask Oral airway Two-handed technique www.aic.cuhk.edu.hk www.haworth21.karoo.net LMA Placement LMA Carries prominent Carries position in ASA algorithm position May be held like a pencil Balloon partially inflated Directed posteriorly and Directed upwards towards the palate palate Jaw thrust and sniffing Jaw position may help placement placement www.brandianestesia.it/Images/LMA-ins.jpg LMA Placement LMA Verify placement by ventilating – Check for good chest rise, ETCO2, and Check adequate tidal volumes adequate – Check for leak – if significant leak at around Check 10cm H2O problematic 10cm – May try size larger or smaller – May try to inflate/deflate cuff to obtain better May seal seal – If difficulty passing may try inserting upside If down and then flipping around down Endotracheal Intubation Endotracheal Open the mouth with right Open hand hand – Scissor technique Gently insert Gently laryngoscope into right side of mouth pushing tongue to the left tongue Careful with insertion not Careful to hit teeth to Advance laryngoscope Advance further into oropharynx with applied traction 45 degrees Endotracheal Intubation Endotracheal Look for epiglottis – If initially not found If insert laryngoscope further further – If this maneuver does If not work slowly pull laryngoscope back laryngoscope Once epiglottis Once visualized, push laryngoscope into vallecula and apply traction at 45 degree angle to “push” epiglottis up and out of the way up www.int-med.uiowa.edu/Research/TLIRP/Bronchos Endotracheal Intubation Endotracheal Look for vocal cords or Look arytenoid cartilages and try to optimize view optimize – (i.e. lift head, apply more (i.e. traction at 45 degree angle if necessary) if Do not move once view is Do optimized! optimized! – Assistant will hand you Assistant ETT ETT Insert ETT into far right aspect Insert of mouth of – Traction of laryngoscope Traction slightly to left may assist slightly – Traction of laryngoscope at Traction 45 degrees will also help keep mouth open keep Endotracheal Intubation Endotracheal Insert ETT above and between arytenoids Insert and through vocal cords and Try to visualize the ETT passing between Try the vocal cords the – If this is not possible, then you must visualize If the ETT passing above and between the arytenoids arytenoids Endotracheal Intubation Endotracheal Common problems: – “I can’t see anything!” Make sure tongue is Make swept to the left swept You are probably too You shallow or too deep. Even with difficult intubations the epiglottis can be visualized visualized Insert laryngoscope in Insert further looking for epiglottis epiglottis Pull laryngoscope back Pull if this fails if Endotracheal Intubation Endotracheal Common problems – “I can’t see the cords!” – Epiglottis is visualized, vocal cords are not – Removing the epiglottis partly from view is Removing necessary to visualize the vocal cords below necessary – Push the end of the laryngoscope blade Push further into the vallecula and “toe up” further – Lifting the patient’s head with your other hand Lifting may improve the sniffing position and bring the vocal cords into view the Endotracheal Intubation Endotracheal Common problems – “I can see the cords. But I can’t get the tube can there!” there!” – You may not be giving yourself adequate You room in the oral cavity room – Push up and to the left with the laryngoscope Push to make sure the mouth is still fully opened and the tongue adequately swept away and – Slide the ETT in the mouth all the way to the Slide right side, perhaps even sideways right Difficult Intubation Difficult ASA Difficult Airway Algorithm ASA www.metrohealthanesthesia.com www.metrohealthanesthesia.com Fiberoptic Intubation Fiberoptic Oral or nasal routes Topicalization is key – Aerosolized lidocaine 4% – Airway blocks Thin bronchoscope inserted into trachea Other airway options Other GlideScope Needle cricothyroidotomy Conclusion Conclusion Airway management is an extremely important Airway aspect of the practice of anesthesiology and critical care critical A firm basis in airway anatomy is needed Skills such as mask ventilation, endotracheal Skills intubation, LMA placement are necessary intubation, In the case of a difficult airway, a logical In algorithm and airway equipment assist the physician in safely managing the situation physician ...
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