AA APEX: AIRWAY ANATOMY Flashcards
1
Q
Adducts VOCAL Cords muscle of the larynx
A
Lateral Cricoarytenoids
2
Q
ABDUCTS VOCAL Cords muscle of the larynx
A
POSTERIOR Cricoarytenoids
3
Q
Elongates vocal cords
A
CRICO(T)HYROID
4
Q
Shorten Vocal cords
A
Thyroarytenoids
5
Q
Intrinsic Muscles that tense and relax vocal cords
A
Cricothyroid - tenses
(T)hyroa(R)ytenoids_ THEY RELAX
6
Q
Extrinsic Muscles of the Larynx: ELEVATE the larynx ( Style-GENI-MY-THY-Di- STyloP
Extrinsic=Elevate
A
Stylohoid Geniohyoid Mylohyoid Thyrohyoid Digastic Stylopharyngeus
7
Q
Extrinsic Muscles of the Larynx: DEPRESSES the larynx (SOS)
A
Omohyoid
Sternohyoid
Sternothyroid
8
Q
Closes posterior commissure of the glottis
A
interarytenoids
9
Q
Key players of the Laryngospasm reflex
A
Cricothyroid muscles
10
Q
What is the ONLY intrinsic laryngeal muscles that receive motor innervation from EXTERNAL branch of the SLN
A
CRICOTHYROID muscles
11
Q
RLN course underneath the
A
Aortic arc before ascends the trachea towards the larynx
12
Q
What are causes of left RLN injury>
A
PDA ligation
Left atrial enlargement secondary to mitral stenosis
Aortic Arch Aneurysm
Thoracic tumor
13
Q
The Superior Laryngal nerve innervates
A
underside of the epiglottis
Cricothyroid muscles
14
Q
4 nerves that should come to mind with innervation of the airway
A
Trigeminal
Glossopharyngeal
SLN (external or internal)
RLN
15
Q
The SLN branches off the
A
Vagus nerve just beyond the jugular foremen at the skull base
16
Q
Where does the SLN divides into internal and external branches
A
At the level of they hyoid
17
Q
The internal branch of the SLN penetrates the thyrohyoid membrane between the
A
Greater cornu of the hyoid bone
18
Q
The internal branch of the SLN penetrates the _____while the external branch of the SLN penetrates the ________
A
Thyrohyoid
Cricothyroid
19
Q
The recurrent laryngeal nerve branches off the
A
Vagus nerve inside the thorax
20
Q
The right RLN loops under the ______while the left RLN loops under the
A
Subclavian artery
Aortic ARCH
21
Q
After the right RLN and the Left RLN loop under the vascular structure both nerves ascend the
A
Tracheoesophageal groove to join the larynx
22
Q
Which nerve is more likely to be injured and why?
A
The left RLN due to its location in the thorax.
23
Q
What are the branches of the trigeminal nerve (CN V)
A
V1: Ophtalmic (anterior ethmoidal)
V2: Maxillary (sphenopalatine)
V3: Mandibular (lingual
24
Q
V3 mandibular branch is responsible for sensory innervation of the airway of what part
A
Anterior 2/3 of tongue
25
Turbinates and septum are innervated by
V2 (maxillary) sphenopalatine
26
Nares and Anterior 1/3 of nasal septum innervated by
V1 Opthalmic (anterior ethmoidal)
27
Soft palate innervated by
Glossopharyngeal (CN IX)
28
Oropharynx innervated by
Glossopharyngeal (CN IX)
29
Tonsils innervated by
Glossopharyngeal (CN IX)
30
Posterior 1/3 of tongue innervated by
Glossopharyngeal (CN IX)
31
Vallecula innervated by
Glossopharyngeal (CN IX)
32
Anterior side of the epiglottis
Glossopharyngeal (CN IX)
33
The true vocal cords are
Ligaments
34
WHich innervates structure below the vocal cords?
RLN
35
Tuning fork for the voice
SLN (external branch)
36
Injury to the trunk of the superior laryngeal nerve or the external branch causes
hoarseness (Because the vocal cords can't be tense)
37
RLN injury can be classified as
Unilateral
| acute Bilateral
38
Unilateral injury of RLN results in _______ Does it cause resp distress?
paralysis of the ipsilateral vocal cords abductors. DOES NOT CAUSE RESP DISTRESS
39
Bilateral injury of RLN results in _______ Does it cause resp distress?
bilateral paralysis of the ipsilateral vocal cords abductors. Danger because the TENSING action of the Cricothyroid muscles act unopposed. RISK FOR STRIDOR and RESP DISTRESS. Requires intubation or a SURGICAL AIRWAY
40
Procedure that put patient at risk for RLN injury on the left side
PDA ligation
Left atrial enlargement and mitral stenois
AA Aneurysm
Thoracic tumor
41
Procedure that put patient at risk for RLN injury on either side (R or L)
```
External pressure on ET tube
Extern pressure on LMA
Thryroid and parathyroid surgeires
Neck stretching
Tumor
```
42
What are the 3 key airway blocks
Glossopharyngeal
Superior Laryngeal
Transtracheal
43
To block the SLN, LA is injected where?
just below the border of the GREATER CORNU of the HYOID BONE.
1 ml is injected outside the thyrohyoid membrane
2ml are injected just beneath the thyrohyoid membrane.
44
In what block in the needle inserted at the base of the palatoglossal arch (anterior tonsillar pillar) ?
Glossopharyngeal block
45
You are performing a glossopharyngeal block and you aspirate air, what does that mean?
Needle is too deep
46
You are performing a glossopharyngeal block and you aspirate BLOOD, what does that mean?
Needle should be withdrawn and redirected medially (Carotid artery is very close)
47
There is a risk of _________with glossopharyngeal block which will be manifested as ______
Intracarotid injection
| Seizure
48
Superior Laryngeal block : where is the anesthetic injected?
Inferior border of the greater cornu of the hyoid bone
49
You are performing a Superior Laryngeal block and you aspirate air, what does that mean?
Needle is too deep
50
Transtracheal block, the needle is advance in a_____as it penetrates the _______membrane
Caudal; cricothyroid membrane
51
During the transtracheal block, after aspiration and before injection what should the patient do? and what does the practitioner do ?
Take a DEEP BREATH ; During that inspiration part of that deep breath, 3-5ml of LA is injected into the tracheal lumen. The PATIENT will cough , SPRAYING THE LA up through the vocal cords
52
The adult larynx extends from
C3-C6
53
Larynx consists of
One bone, ligaments and 9 cartilages (3 paired and 3 unpaired.
54
What is the only bone in the body that does not articulate with another bone?
HYOID
55
Form the main support of the larynx and attaches to the thyroid cartilage via the THYROHYOID ligament
Hyoid
56
Anterior ligaments are the
Thyrohyoid membrane
| Cricothyroid membrane
57
Which ligament attaches the larynx to the hyoid bone
Thyrohyoid membrane
58
Which ligament attaches the cricoid and thyroid cartilages
Cricothyroid membrane
59
What is puncture during the cricothyroidotomy ?
Cricothyroid membrane
60
What are the paired cartilages?
Arytenoid
Cuneiform
Corniculate
61
What can you not see during direct laryngoscopy ?
Arytenoids
62
What do the corniculate and cuneiform cartilates do?
provide structure to the aryepiglottic folds.
63
What cartilages shapes like 3-sided pyramids
Arytenoids
64
2 conditions that may impair movement of the arytenoids,
RA
| SLE
65
Provides a mechanical barrier between pharynx and the laryngeal opening?
Epiglottis
66
What is the space between the base of the tongue and the anterior side of the epiglottis
Vallecula
67
Which ligament connects the epiglottis to the thyroid cartilage>
Thyroepiglottic
68
Provide structure and protection to the larynx
Thyroid cartilage
69
What is the largest cartilage in the larynx?
Thyroid
70
Forms Adam's appled
Thyroid
71
Cartilage most caudal to the larynx
Cricoid
72
What is the narrowest part of the pediatric airway ?
Vocal cords or cricoid ring
73
What is laryngospasm ?
Sustained and involuntary contraction of the laryngeal muscles that results in the inability to ventilate, results in complete airway obstruction, Negative pressure pulmonary edema, gastric aspiration, cardiac arrest.
74
Pre-anesthetic risk factors for laryngospasm?
```
Active or recent URI
Exposure to 2nd hand smoke
Reactive airway disease
GERD
Age< 1 year
Hypocapnia
```
75
INTRA OP risk factors for laryngospasm?
```
Light anesthesia with airway manipulation
Saliva or blood in upper airway
Hyperventilation
Hypocapnia
Surgical procedure involving airway
```
76
Explain the REFLEX PATHWAY?
Afferent limb : SLN INTERNAL BRANCH
| EFFERENT limb: SLN EXTERNAL branch+ RLN
77
What are sings of laryngospasm?
Inspiratory stridor
Suprasternal or supraclavicular retraction during inspiration
Rocking horse appearance of the chest wall
Increasing diaphragmatic excursion
Lower rib flailling
78
Factors that reduce the likelihood of laryngospasm
Avoidance of airway manipulation during light anesthesia
CPAP 5-10 cm H2O during inhalation induction as well as immediately post intubation
Remove pharyngeal secretion and blood before extubation
Laryngeal lidocaine
IV lidocaine before extubation
Hypercapnia/hypoventilation
PaO2 < 50 mmHg
79
Treatment of Laryngospasm : In order of importance
1. FiO2 100%
2. Remove noxious stimulation
3. Deepen anesthesia by increasing gas concentration or with a small dose of propofol or lidocaine
4. CPAP 15-20 cm while doing maneuvers to open the airway such as the head extension, chin lift, larson's maneuver
5. If IV access Succinylcholine 2mg/kg for infant. 0.1 to 1 mg/kg for adult
If no IV , 5mg/kg for infant, 4 mg/kg for children or adult
80
When treating laryngospasm with succinylcholine in children less than 5 years what should they all receive
Atropine 0.02mg/kg with succinylcholine to prevent bradycardia.
81
What is the larson's maneuver
Application of firm pressure to the laryngospasm notch located being the EARLOBE. Pressure is applied bilaterally towards the skull base. applied pressure 3-5 seconds then released 5-10 seconds
82
What does the larson's maneuver accomplisH?
Displaces the mandible anteriorly to help open the airway
| Breaks laryngospasm by causing the lightly anesthesized patient to sigh.
83
What is the Valsava's maneuvers?
Exhalation against a closed glottis
example: ballon, straining, saxophone
84
Risk of valsava's maneuvers
Increased pressure in the Thorax, abdomen and brain
85
What is the MULLER's maneuvers?
Inhalation against a closed glottis
86
Risk of Muller's maneuvers
Subatmospheric pressure in the thorax --> Negative pressure pulmonary edema
examples: osa, holding nose and breath
87
Tensor palatine muscle relaxation will most likely cause airway obstruction at which level ?
soft palate
88
During anesthesia, where are the 3 places where the upper airway can obstruct
soft palate
Tongue
Epiglottis
89
Relaxation of the tensor palatine muscle
Soft palate
90
Relaxation of the GENIOGLOSSUS muscle
Tongue
91
Relaxation of the HYOID muscles
Epiglottis
92
Primary functions of the upper airway including
Warming and humidifying muscle inspired air, filtering particulate matter and preventing aspiration
93
During normal inspiration, what occurs
Diaphragmatic contraction and chest wall expansion create a negative pressure to draw air into the lungs.
94
Factors that impair airway patency
Condiation that reduce the diameter of the tube
| Condition that reduce the size of the box
95
Think of the pharynx as a collapsible tube that lives inside a box> this box is formed by the borders of the surrounding such as the
tongue, soft palate, pharyngeal tissue and cervical spine
96
What are the 3 sets of dilator muscles that prevents airway obstruction in the awake state?
Tensor palatine
Genioglossus
Hyoid muscles
97
Function of the tensor palatine
Opens the nasopharynx
98
Function fo teh GENIOGLOSSUS
Opens the oropharynx
99
Function of the Hyoid muscles
Opens the hypopharynx
100
from top to bottom
NOH (Naso-->oro--> Hypo) Pharynx
101
Explain the 2 competing explanations for the primary cause of UPPER AIRWAY OBSTRUCTION during anesthesia and sedation
1. Tongue obstructs the airway - Genioglossus muscle relaxes and allows the tongue to obstruct the airway
2. Soft plate obstructs the airway- The TENSOR palatine muscle relaxes and allows the soft palate to obstructs the airway
102
When compared to the trachea, which of the following is increased in the terminal bronchioles?
Cross-sectional area
103
Tracheobronchial tree is a branching network of airways that includes the
Trachea --> Bronchi--> Bronchioles
104
In terms of airway, a division is
where an airway divides into 2 or more smaller airways
105
How many division or generation in humans
23-25
106
At each division, the diameter of the new branches becomes_____But the cross sectional area ____
smaller ; increases
107
At each At each division, the diameter of the new branches becomes smaller But the cross sectional area increases, this explains
Why airflow velocity SLOWS as you move down the tracheobronchial tree.
108
The trachea contains ______And ________ while the terminal bronchioles contains________
```
Cartilage (C-shaped rings)
Goblet cells (mucus secretion)
```
109
Where does the lower airway begins and ends?
Begins At trachea , ends at the alveoli
110
Where the trachea begins and ends
C5 ; T4-5 at the carina
111
Length of trachea; width
10-13 cm long
| 2-3 cm
112
Tracheal cells
Ciliated columnar epithelium
113
Sensory innervation of the trachea
Vagus
114
Blood supply of the trachea (BISI)
Bronchial artery
Internal thoracic artery
Superior thyroid artery
Inferior thyroid artery
115
At level of the CARINA_______ corresponds to _______
T4-T5
| Corresponds to ANGLE OF LOUIS
116
Right mainstem bronchus is _____; and ______degrees take off
2.5 cm long ; 25 degrees take off
117
Left mainstem bronchus is _____; and ______degrees take off
5cm long; 45 degrees take off
118
Mainstem bronchi types of cells
CUBOIDAL epithelium
119
Alveoli number
300 million by age 9
120
Alveoli tissue
Squamous epithelium
121
Which structure allows air movement between alveoli?
PORES of KOHN
122
Type I pneumocytes role
Provide surface for gas exchange
123
Which type of pneumocytes cover 80% of alveolar surface?
Type I pneumocytes
124
Type II pneumocytes role
Produce surfactant
125
Pneumocytes resistant to Oxygen toxicity
Type II
126
What pneumocytes can produce type I cells
Type II
127
Pneumocytes capable of cells division
Type II
128
Pneumocytes that are macrophages and produce inflammatory response
Type III
129
Pneumocytes that fights lung infection
Type III
130
What is the distance between from the incisors to the larynx is ?
13cm
131
What is the distance between from the larynx to the carina is about
13 cm
132
Distance from incisors to carina is
26cm
133
Neck flexion makes distance from incisors to carina
ShORTER distance
134
Neck extension makes distance from incisors to carina
Increases distance
135
with NECK EXTENSION and NECK FLEXION, remember what happens to the tube?
The tube goes where the nose goes
136
Characteristics of progressive airway division : What increase as the airway bifurcates
Number of airway
Cross sectional area
Muscular layer
137
Characteristics of progressive airway division : What decrease as the airway bifurcates
Airflow velocity
Amount of cartilage
Goblet cells (produce mucus)
Cillated Cells (clear mucus)
138
Order of cartilage from most superior to most inferior
| ECo- ArC
Epiglottis
Corniculate
Arytenoids
Cricoid
139
Location of infant's larynx is
C2-C4
140
What are the landmark for larson's maneuver?
Posterior: mastoid (PM)
Superior: skull base (SS)
Anterior : Ramus of mandible (AR)
141
Which muscle abduct the vocal cords?
Posterior Cricoarytenoids.
142
The cricothyroid muscle is innervated by the
EXTERNAL BRANCH OF THE SUPERIOR LARYNGEAL NERVE
143
The internal branch of the superior Laryngeal nerve is
Purely sensory
144
Innervates all intrinsic muscles of the larynx
RLN
145
Nerve that does not innervate the larynx
Glossopharyngeal nerve
146
Posterior Epiglottis innervated by
SLN
147
Vallecula innervated by
Glossopharyngeal nerve
148
Anterior tongue innervated by
Trigeminal nerve BRANCH V3 MANDIBULAR
149
Trachea innervated by
Vagus
150
Anterior Epiglottis innervated by
Glossopharyngeal nerve
151
Laryngeal mucosa below level of vocal cords
Recurrent Laryngeal nerve
152
Posterior side of epiglottis to level of cords
Superior Laryngeal Internal branch
Below cords to trachea: RLN
153
3 nerve blocks that can provide anesthesia for oral fiberoptic intubation?
Glossopharyngeal
Superior Laryngeal
Recurrent Laryngeal
154
What nerve block is performed by injecting 1-2 ml at the tonsillar pillars bilaterally?
Glossopharyngeal nerve block
155
The transtracheal block is performed by
Injecting 3-5ml through the cricothyroid membrane.
156
How is the SUPERIOR LARYNGEAL NERVE BLOCK performed?
3 ml at the inferior aspect of the GREATER CORNU of the hyoid bone bilaterally.
157
Where is the adult larynx located?
C3-C6
158
What is the role of the TENSOR PALATINE
Opens Nasopharynx
159
What is the role of the Hyoid muscles
Opens Hypopharynx
160
What is the role of the genioglossus?
Open oropharynx
161
Mnemonic to remember
| OPEN NOH - TGH
Nasopharynx - Tensor (No tension)
Oropharynx - Genioglossus (OGod)
Hypopharynx -- Hyoid (HH)
162
Muller's maneuver is (MI)
Inhaling against a closed glottis
163
Valsava maneuver is (VE)
Exhaling against a closed glottis
164
I actively let AIR out of my TIRE
Active Exhalation- Happens when increase in minute ventilation or COPD Patients
Abdominal Musculature
Transverse Abdominis
Internal Oblique
Rectus Abdominis
External Oblique
Internal Intercoastals- 2ndary role
Exhalation is normally passive
165
Branches of Trigeminal Nerve (CN V)
v1= opthalamic ( anterior ethmoidal) Nares and anterior 1/2 of nasal septum
v2 maxillary (sphenopalatine) Turbinates and septum
v3 Mandibular (lingual) anterior 2/3 of tongue
O-cyrus: eyes
Max:smell
Tibu:love
166
True VC attaches front and back:
front: thryoid
back: arytenoid
167
Cells in
Trachea
Alveoli
Bronchi
Trachea: Columnar (trachea in columns)
Alveoli: Squamous (squash alveoli when smoking)
Bronchi: Cuboidal (bronchi circles, cubes in circles)
168
What muscles control inspiration?
Diaphragm
External intercostals
Accessory Muscles- Sternocleidomastoid & Scalene
169
Effective Cough
VC 15/ml/kg
170
Transpulmonary Pressure = difference of pressures
AP-IP = Transpulmonary Pressure
Alveolar Pressure: inside airway
Intrapleural Pressure: outside airway (always negative)
TPP + = Airway open
TPP - = Airway collapses
171
AP is
a little negative during inspiration
| a little positive during expiration
172
NO airflow when
at FRC
or
end-inspiration
173
Normal deadspace
~2 mL/kg
70 kg: 150 mL
174
Increasing dead space causes
paco2- etco2 gradient wider
| co2 retention
175
How do you calculate alveolar ventilation?
Tidal volume- dead space x RR
directly prop: co2 production
inverse to Paco2
