User:Mzimmer33/Advanced airway management

User:Mzimmer33/Advanced airway management

Sandbox for Advanced airway.

Changes to be made:


 * improve discussion of tracheal intubation methods section with greater organization
 * orotracheal
 * direct laryngoscopy
 * blade types, indications, risks
 * video laryngoscopy
 * types, indications, risks, benefits
 * fiberoptic
 * indications, benefits
 * nasotracheal
 * indications
 * equipment
 * McGill
 * RAE tube
 * methods
 * phenylephrine and tolazone
 * lubrication
 * lubrication of ETT
 * use of McGill forceps
 * add citation for nasotracheal intubation with additional information discussing McGill forceps and technique
 * add section discussing management of difficult airway

Methods
Classically, tracheal intubation has been performed utilizing laryngoscopy to obtain direct visualization of the vocal cords. There are multiple different laryngoscope blade styles, shapes and lengths from which to choose based on patient anatomy and clinician preference. In North America, the Macintosh blade is the most commonly used curved blade while the Miller blade is the most common straight blade. Many modern laryngoscopes are equipped with a fiberoptic light source to aid in visualization. Regardless of blade shape, direct laryngoscopy technique involves passage of the laryngoscope through the mouth and into the back of the throat. Manipulation of the neck and lifting of the tongue allow for direct visualization of the larynx and vocal cords by the operator. Following visualization, the endotracheal tube can be passed along the blade, through the vocal cords, and into the trachea.

Multiple intubation tools are now available with built-in video technology. A Glidescope utilizes a curved laryngoscopic blade with an integrated camera connected to a large external monitor. The McGrath model has a compact design with a small display directly attached to the blade. The operator introduces the video laryngoscope through the mouth with a technique similar to direct laryngoscopy. The larynx and vocal cords are visualized via the camera and the operator is able to pass the endotracheal tube through the vocal cords and into the trachea. Studies have shown that when compared to direct laryngoscopy, video laryngoscopy resulted in fewer failed intubation attempts, especially in patients with known difficult airways.

In patients with known difficult airways, fiberoptic intubation can be considered. This technique involves the use of a flexible fiberoptic bronchoscope for visualization of the vocal cords. The bronchoscope can be passed directly into the trachea and the endotracheal tube can be threaded over the bronchoscope into position. This technique has various advantages over direct laryngoscopy and video laryngoscopy techniques. The fiberoptic scope is flexible and can be directed by the operator, allowing it to traverse the upper airway with minimal manipulation of the patient's neck. The operator can manipulate the device around obstructions in the upper airway, making the technique advantageous for patients with cancer or swelling in the upper airway. The device is relatively small compared to a laryngoscope and can therefore be implemented in patients with small mouth openings. Lastly, the fiberoptic scope can be passed through the nostril to provide visualization for a nasotracheal intubation.

Confirming placement
The gold standard for confirming successful placement of an endotracheal tube is direct visualization of the tube passing through the vocal cords. Secondary methods of confirmation include capnography, oxygen saturation, chest x-ray, or equal chest rise and breath sounds heard on both sides of the chest.

Pediatric considerations


Many advanced airway techniques may be applied to children. In the fields of pediatric anesthesiology, pediatric critical care, and pediatric emergency medicine, a clear passage between the lungs and the environment is essential.

Children have numerous anatomic differences from adults which present unique challenges when implementing advance airway techniques. Neonates and infants have overall smaller airway anatomy including a shorter trachea and smaller nasal openings. Additionally, they have proportionally larger tongues and heads. As a result, infants are obligate nasal breathers until the age of 5 months. Given their overall smaller airway diameter, children are more susceptible to airway obstruction from swelling. Given the rapid growth throughout childhood, care must be taken to choose the proper sized airway device for every individual. Broselow tape is a tool used to help facilitate rapid and accurate equipment sizing decisions in pediatric emergency situations.

Supraglottic airway devices, direct laryngoscopy, indirect video laryngoscopy, and fiberoptic intubation are all techniques which can be used to secure the pediatric airway. In the event that these techniques can not adequately ventilate the patient, a surgical airway may be required. Surgical help should be requested for invasive access, however, in scenarios in which a pediatric surgeon is not available, a needle cricothyrotomy is an emergency alternative. Pediatric

Pediatric considerations:

- mechanical difficulty

- tonsillar tissue bradycardia peer review:

Overall this is a very well written discussion of bradycardia. It is clear that this topic is of great importance to the community. This talk page is incredibly active.


 * 1) I believe that your changes to the first paragraph do a lot to set the tone of the article and clear up common misconceptions. (bradycardia being physiologic in young athletes but less likely physiologic in older adults. The subsequent discussion of symptoms that can be associated with bradycardia is appropriate and further helps outline why bradycardia may be problematic to the patient.
 * 2) Your discussion of normal cardiac conductance is essential to the discussion of bradycardia. Your section does a great job of describing the system in understandable terms. One suggestion I have for this section would be to add an image of the heart with the conduction system labeled.
 * 3) The discussion of sinus bradycardia further clarifies the difference between sinus bradycardia in young athletes vs older adults.
 * 4) A small suggestion, but I believe that the causes section would benefit from being divided under sub headings for cardiac and non cardiac causes.
 * 5) Diagnosis section would benefit from extended discussion of the use of ECG in diagnosis
 * 6) The management section should be expanded to discuss long term management of symptomatic bradycardias

Overall, this is a very info packed, well written discussion. The above editors contributions added significant clarity to the discussion and addressed concerns of individuals within the talk page.