l1

Airway Assessment Notes

Today's Objectives

• How to perform an airway assessment

• BVM (Bag-Valve-Mask)

• Supraglottic airway management

• Intubation techniques

• Understanding recognition of a compromised airway

• Quick review of airway anatomy

Airway Anatomy Overview

• Natural Openings:   - Nose/Nasopharynx   - Mouth/Oropharynx

• These passages are separated anteriorly by the palate but join posteriorly in the pharynx.

• The pharynx is a U-shaped structure that extends from the base of the skull to the larynx.

Compromised Airway Considerations

• Assess for factors that can lead to a compromised airway.

• Categorize these factors into groups:
    - Patients requiring means of "Oxygenation/Ventilation"   - Patients needing means of "Airway protection/patency"   - Patient's anticipated clinical course

• Compromised airway definition: deficiencies in the ability to move respirable gas through the respiratory tract.

Assessment Goals and Priorities

• Goals of airway management:
    - Oxygenation
    - Ventilation
    - Patency & Protection

• Key indicators for assessment:   - Oxygenation:
      - Color
      - SpO2 levels
    - Ventilation:
      - Auscultation     - Minute ventilation     - Airway reflexes     - PaCO2 & pH balance     - PaO2

Airway Assessment Criteria

• A-B-C's of Assessment:
    - Airway: Patency/Protection
      - Assess appearance and patient history
      - Evaluate ability to talk/cough/gag
      - Listen for abnormal sounds such as "hot potato voice" and stridor
    - Breathing: Oxygenation & Ventilation
      - Respiratory rate & volume     - Differentiate supported vs unsupported breathing
    - Circulation:
      - V/Q (Ventilation/Perfusion) matching
      - Vital signs & perfusion assessment   - Note: Without adequate circulation, tissue oxygen becomes depleted, and waste products accumulate.

Importance of Airway Assessment

• Identify potential problems early in the airway management process.

• Mode of airway management is dictated by:
    - Cause and severity of the patient's condition
    - Environment factors
    - Clinician skill level

Upper Airway Anatomy

• Components include:
    - Mouth
    - Nose
    - Paranasal sinuses
    - Tonsils, adenoids, teeth
    - Uvula
    - Palate (hard/soft)
    - Tongue

Upper Airway Problems

• Nasopharynx Issues: Fractures can lead to:
    - Cerebrospinal rhinorrhea
    - Cerebrospinal otorrhea

• Indicators of Basal Skull Fracture:
    - Battle Sign   - Raccoon Eyes

Oropharynx Issues

• Fractures or avulsions of teeth may result in:
    - Aspiration Risk

• Conditions affecting the tongue:   - Flaccidity when supine can cause upper airway obstruction.

• Tonsils and Adenoids: Swelling/infection may lead to obstruction.

Middle Airway Anatomy

• Components:
    - Transition mark from upper to lower airway
    - Thyroid cartilage (Adam's apple)
    - Cricoid cartilage (cricoid ring)
    - Cricothyroid membrane (site for cricothyrotomy)

• Middle Airway Problems:   - Abnormal masses/anatomy issues   - Deviations   - Laryngospasm   - Epiglottitis

Lower Airway Anatomy

• Includes:
    - Left & right mainstem bronchi
    - Lobar (secondary) bronchi
    - Segmental (tertiary) bronchi
    - Terminal bronchi
    - Respiratory bronchioles
    - Alveoli

• Problems of Lower Airway:   - Obstruction
    - Collapse
    - Disease/injury

Neural Innervation

• Superior Laryngeal Nerve:   - A branch of the Vagus Nerve (CN X)   - Controls functions of the upper larynx's sensation and protective reflexes (coughing, swallowing)
    - At risk during surgeries like thyroidectomy.

• Recurrent Laryngeal Nerve:   - Another branch of the Vagus Nerve (CN X)   - Controls most laryngeal muscles enabling vocal cord movement and providing sensation below the cords.

Case Study: Emergency Assessment

• Case Details:
    - 56-year-old male, home oxygen patient (3 L/min)   - Smoking in his apartment   - HR: 110 bpm, NIBP: 156/78   - SpO2: 100% on non-rebreather   - Audible wheezing/stridor, RR: 4-6/min   - Level of Consciousness: Drifting

• Concerns:
    - Documented previous airway management
    - Evaluating altered cardio-respiratory physiology
    - Difficulty in bag-mask ventilation
    - Difficulty in placing supraglottic airway
    - Intubation challenges
    - Aspiration risk assessment
    - Ease of extubation

Airway Management Strategies

• BVM Assessment – Mnemonic:
    - BONES:     - Beard     - Obstruction/O obese/Old     - Neck stiffness/mass     - Edentulous (no teeth)

• Considerations for mask seal integrity:   - Facial hair, trauma, abnormal anatomy, and equipment choice.

Supraglottic Airway Management

• RODS Assessment – Mnemonic:
    - R: Restricted mouth opening   - O: Obstruction (airflow impediments)   - D: Distorted anatomy   - S: Stiff lungs/neck

• Supraglottic airways may not guarantee airflow; watch for increased ventilation pressures.

Intubation Assessment

• LEMON Assessment – Mnemonic:
    - L: Look externally (facial features, obesity, trauma)   - E: Evaluate anatomical distances using 3-3-2 rule
      - 3 finger opening of the mouth
      - 3 finger distance from the chin to hyoid
      - 2 finger distance from hyoid to thyroid cartilage
    - M: Mallampati Score (Class I-IV)     - Class I: Complete visualization of soft palate
      - Class II: Visualization of uvula
      - Class III: Base of uvula only
      - Class IV: Soft palate not visible
    - O: Identify obstructions (foreign bodies, swelling)
    - N: Assess neck mobility

Summary Mnemonics

• Difficult Intubation Features:
    - L: Look externally
    - E: Evaluate 3-3-2
    - M: Mallampati Classification
    - O: Obstruction/Obesity
    - N: Neck Mobility

• Difficult LMA Features:
    - R: Restricted mouth opening
    - O: Obstruction   - D: Distorted anatomy
    - S: Stiff Lungs/Neck

• Difficult Cricothyrotomy Features:
    - S: Surgery
    - H: Hematoma, infection
    - O: Obesity
    - R: Radiation
    - T: Trauma/Tumor