Airway management 2
How is Rapid Sequence Induction done? - ANS -Denitrogenation vs. preoxygenation
3 maximum breaths
3-5 minutes tidal breathing
8 maximal breaths over 1 minutes superior
High oxygen flow rate, tight mask seal, patient position with HOB raised
Rapid administration of induction agent followed by muscle relaxant
Cricoid pressure held until airway secured
\How much force should the sellicks manuever be? - ANS -Should be sufficient to prevent
aspiration, but not cause airway obstruction or allow esophageal rupture in the case of vomiting
40-44 Newtons is traditionally cited
Studies have indicated lower
forces usually effective-30 N
\How should air be removed from the pilot balloon? - ANS -Withdraw air from port on pilot
balloon, case reports of VC damage with breaking off pilot balloon
\The severity of aspiration Pneumonitis is related to what? - ANS -the volume aspirated and the
pH of the aspirate
Particulate matter
\What actions are needed If Regurgitation/Aspiration Occurs? - ANS -Place in 30 degree head
down position, left lateral position if possible
Cricoid pressure unless actively vomiting Suction
Deepen anesthetic, muscle relaxation, intubate, suction prior to PPV
100% oxygen, PEEP 5-7 cm H2O
Assess fiber-optically, remove particulate matter
Consider post-op ventilation
\What are complications with nasal intubations? - ANS -nose bleed
displacement of adenoidal tissue
sub mucosal passage
\What are pharmacologic preparation to prevent aspiration? - ANS -Gastrokinetic agent,
metoclopramide
Histamine2 antagonists
Proton pump antagonists
Clear antacids( Sodium citrate 30 ml)- 10-20 min before induction.
\What are preventive strategies for Aspiration? - ANS -NPO Guidelines
Pharmacologic preparation
Choice of airway management
Rapid sequence induction technique
\What are reported causes of Negative Pressure
Pulmonary Edema (NPPE)? - ANS -Laryngospasm
Biting on ET
Biting on LMA
, Epiglottitis/laryngotracheobronchitis or abcess
Tumor or foreign body
Strangulation or trauma
Drowning
\What are s/s of endobronchial intubation? - ANS -Increased peak inspiratory pressures.
Asymmetrical chest expansion.
Unilateral breath sounds
Hypoxemia.
\What are the 2 phases of Aspiration Pneumonitis? - ANS -Phase 1 (direct chemical injury)
Phase 2 (Inflammatory mediator release)
\What are the controversial aspect of the sellicks manuever? - ANS -MRI study in awake
volunteers found majority had esophagus displaced to the side of cricoid
Can worsen laryngeal view, close cords, etc making intubation more difficult
Impede mask ventilation
Prevent proper placement of LMA, glidescope, other airway adjuncts
\What are the indications for awake extubation? - ANS -Any difficulty with mask ventilation or
intubation
Risk of aspiration
Presence of airway edema
Compromised respiratory status
\What are the management of Negative Pressure
Pulmonary Edema (NPPE)? - ANS -Correct hypoxia and decreasing fluid volume in the lungs
Almost 50% require no more than supplemental oxygen for less than 24 hours
If inadequate, intubate, and provide PPV with PEEP
Diuretic administration is controversial, consider in the case of fluid overload
Consider other causes of pulmonary edema
\What are the muscles of the Upper Esophageal Sphincter? - ANS -cervical esophagus,
cricopharyngeus, and inferior pharyngeal constrictor
\What are the pharmacological management for laryngospasm? - ANS -Give succinylcholine
unless contraindicated IV 0.1 - 1 mg/kg or 4-5 mg/kg IM.
IM 4 mg/kg Atropine unless contraindicated, particularly pedi cases
\What are the Pre-operative fasting, NPO guidelines? - ANS -Clear liquids up to 2-3 hours
pre-op
Breast milk, 4 hours
Solids, 6 hours
\What are the precipitating factors for laryngospasm? - ANS -Airway manipulation
Secretions in airway
Regurgitation/vomiting
Surgical stimulation in inadequately anesthetized patient
Moving the patient
Irritant volatile anesthetics
\What are the risk factors for laryngospasm? - ANS -Difficult intubation
Pediatrics with asthma or URI
Nasal, oral or pahryngeal surgical site
How is Rapid Sequence Induction done? - ANS -Denitrogenation vs. preoxygenation
3 maximum breaths
3-5 minutes tidal breathing
8 maximal breaths over 1 minutes superior
High oxygen flow rate, tight mask seal, patient position with HOB raised
Rapid administration of induction agent followed by muscle relaxant
Cricoid pressure held until airway secured
\How much force should the sellicks manuever be? - ANS -Should be sufficient to prevent
aspiration, but not cause airway obstruction or allow esophageal rupture in the case of vomiting
40-44 Newtons is traditionally cited
Studies have indicated lower
forces usually effective-30 N
\How should air be removed from the pilot balloon? - ANS -Withdraw air from port on pilot
balloon, case reports of VC damage with breaking off pilot balloon
\The severity of aspiration Pneumonitis is related to what? - ANS -the volume aspirated and the
pH of the aspirate
Particulate matter
\What actions are needed If Regurgitation/Aspiration Occurs? - ANS -Place in 30 degree head
down position, left lateral position if possible
Cricoid pressure unless actively vomiting Suction
Deepen anesthetic, muscle relaxation, intubate, suction prior to PPV
100% oxygen, PEEP 5-7 cm H2O
Assess fiber-optically, remove particulate matter
Consider post-op ventilation
\What are complications with nasal intubations? - ANS -nose bleed
displacement of adenoidal tissue
sub mucosal passage
\What are pharmacologic preparation to prevent aspiration? - ANS -Gastrokinetic agent,
metoclopramide
Histamine2 antagonists
Proton pump antagonists
Clear antacids( Sodium citrate 30 ml)- 10-20 min before induction.
\What are preventive strategies for Aspiration? - ANS -NPO Guidelines
Pharmacologic preparation
Choice of airway management
Rapid sequence induction technique
\What are reported causes of Negative Pressure
Pulmonary Edema (NPPE)? - ANS -Laryngospasm
Biting on ET
Biting on LMA
, Epiglottitis/laryngotracheobronchitis or abcess
Tumor or foreign body
Strangulation or trauma
Drowning
\What are s/s of endobronchial intubation? - ANS -Increased peak inspiratory pressures.
Asymmetrical chest expansion.
Unilateral breath sounds
Hypoxemia.
\What are the 2 phases of Aspiration Pneumonitis? - ANS -Phase 1 (direct chemical injury)
Phase 2 (Inflammatory mediator release)
\What are the controversial aspect of the sellicks manuever? - ANS -MRI study in awake
volunteers found majority had esophagus displaced to the side of cricoid
Can worsen laryngeal view, close cords, etc making intubation more difficult
Impede mask ventilation
Prevent proper placement of LMA, glidescope, other airway adjuncts
\What are the indications for awake extubation? - ANS -Any difficulty with mask ventilation or
intubation
Risk of aspiration
Presence of airway edema
Compromised respiratory status
\What are the management of Negative Pressure
Pulmonary Edema (NPPE)? - ANS -Correct hypoxia and decreasing fluid volume in the lungs
Almost 50% require no more than supplemental oxygen for less than 24 hours
If inadequate, intubate, and provide PPV with PEEP
Diuretic administration is controversial, consider in the case of fluid overload
Consider other causes of pulmonary edema
\What are the muscles of the Upper Esophageal Sphincter? - ANS -cervical esophagus,
cricopharyngeus, and inferior pharyngeal constrictor
\What are the pharmacological management for laryngospasm? - ANS -Give succinylcholine
unless contraindicated IV 0.1 - 1 mg/kg or 4-5 mg/kg IM.
IM 4 mg/kg Atropine unless contraindicated, particularly pedi cases
\What are the Pre-operative fasting, NPO guidelines? - ANS -Clear liquids up to 2-3 hours
pre-op
Breast milk, 4 hours
Solids, 6 hours
\What are the precipitating factors for laryngospasm? - ANS -Airway manipulation
Secretions in airway
Regurgitation/vomiting
Surgical stimulation in inadequately anesthetized patient
Moving the patient
Irritant volatile anesthetics
\What are the risk factors for laryngospasm? - ANS -Difficult intubation
Pediatrics with asthma or URI
Nasal, oral or pahryngeal surgical site
