airway

Previous difficult intubation

• Is the patient the same weight as they were the last time
• did they have some sort of thyroid goiter last time

• distance b/w tip of the mandible and they thyroid cartilage
• pt's own fingers, 3-4 fingers

• I- you can see uvula and tonsilar pillars, you can also see soft and hard palate
• II- You have less of a view, the uvula is not fully visable
• III- uvula is NOT visable, you can see hard palate and some soft palate
• IV- only see hard palate

the neck should be flexed at 35 degrees on the torso and the head extended at the atlantooccipital joint to produce a 15 degree angle b/w the facial pane and the horizontal

• the theory is 3 axes with head in neutral position
• neck flexion aligns the pharyngeal axis and largyngeal axis

• you have to ramp them. 
• The optimal head postion in morbidly obese pt is acheived by supporting and elevating the shoulders.  Often you have to build a rampe.

Horizontal alignment of the external auditory meatus with the sternal notch should be used as an end point for correct positioning.

With pediatric pt's you often do NOT need a pillow under the head to get proper alignment because their heads are much bigger.

Large posterior tongue

• It describes the degree of glottic exposure, it allows for intraobserver comparison of the view of the glottis on direct laryngoscopy
• always look for the previous documentation of the grade, also always document the grade view you saw.

• 1- no difficulty with viscualization the vocal chords
• 2- Only posterior VC or arytenoid cartiledge, is seen
• 3- only the epiglottis is seen
• 4- no recognizable structures

• 1 & 2 are easy intubation
• 3 & 4 are difficult intubation

• - Length of upper incisors
• - relationship of maxillary and mandibular incisors during normal mouth closure
• - relationship of maxillary and mandicular incisor during voluntarry protrusion of mandible- (if pt cannot bring mandibular incisors anterior to maxillary incisors that is a bad thing)
• - interior incisor distance- should be at least 3 cm
• - compliance of mandibular space
• - thyromental distance of at least 3 fingers
• - length of neck
• - thickness of neck ( short and thick harder)
• - range of motion of the neck ( atlanto occipital rom?)

• difficult
• - age > 55-57
• - bmi > 26-30
• - beard
• - snoring
• - lack of teeth
• - mallampati III or IV
• - limited mandibular ROM

• impossible
• male
• beard
• osa
• mallampatti III or IV
• Neck radiation changes

• - infections: epiglottis, abscesses, croup, bronchitis, pneumonia
• - trauma: maxillofacial trauma, cervical spine injury, laryngeal injury
• - endocrine : morbid obesity, diabetes mellitus, laryngeal injury
• - inflammatory conditions: ankylosing spondylitis, rheumatoid arthritis
• - tumors- upper and lower airway tumors
• - congenital problems: choanal atresal, tracheomalacia, cleft palate
• physiologic conditions- pregnancy, morbid obesity, edema

• * Standard approach to upper airway and airway opening maneuvers not possible:
• - wired jaw, facial trauma , cervical rigidity, halo
• fixation
• * poor seal b/w the face and mas- facial abnormalities, facial trauma
• * airway narrowing

• - laryngospasm, upper and lower tumors,
• especially mobile, and those associated with respiratory systems, narrowed
• pharyngeal space that cannot be easily modified ( pharyngeal edema, copious
• amounts of blood, pus, or secretions), upper and / or lower airway collapse

thumb and fore finger grip mask putting even gentle downward pressure on face, other 3 fingers go along pt's mandible and pull mandible forward, opening the airway.

put in an oral airway

• adult - 4 or 5
• small adult- 3

pedi- 1 or 2

• Men- 8
• Women- 7

10 cc, but use the minimal amount needed to decrease the risk of trauma, like 3-5 cc

CO2 capnogray, breath sounds

• the miller blade can provide a better view of the glottis when you have the larynx that is anterior, for example a grade 3 sometimes a miller blade helps. 
• but it provides a smaller passage way through the oral pharynx, closer to the teeth. this is why beginers often use a mac.

cricoid pressure

backwards , upwards, right pressure.

• *proper preperation is key!
• then awake intubation choices

* awake intubation choices : successful intubation, surgical airway, failed intubation.

after failed intubation, either surgical airway , cancel case and regroup, or regional anesthesia

• move to emergency pathway
• LMA, combitube, transtracheal jet ventilation.

awaken, inbuation choices, surgical airway

• Confirm placement &
• document it was a difficult airway

if you cannot intubate and cannot ventilate, think about surgical airway, needle the trachea with IV like 16 gauge cath, at soft spot b/w thryroid and cricoid cartilage needle it, hook up o2 to give o2.