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SEE/BOARD STUDY AA > AA APEX: AIRWAY ANATOMY > Flashcards

AA APEX: AIRWAY ANATOMY Flashcards

1
Q

Adducts VOCAL Cords muscle of the larynx

A

Lateral Cricoarytenoids

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2
Q

ABDUCTS VOCAL Cords muscle of the larynx

A

POSTERIOR Cricoarytenoids

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3
Q

Elongates vocal cords

A

CRICO(T)HYROID

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4
Q

Shorten Vocal cords

A

Thyroarytenoids

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5
Q

Intrinsic Muscles that tense and relax vocal cords

A

Cricothyroid - tenses

(T)hyroa(R)ytenoids_ THEY RELAX

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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
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7
Q

Extrinsic Muscles of the Larynx: DEPRESSES the larynx (SOS)

A

Omohyoid
Sternohyoid
Sternothyroid

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8
Q

Closes posterior commissure of the glottis

A

interarytenoids

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9
Q

Key players of the Laryngospasm reflex

A

Cricothyroid muscles

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10
Q

What is the ONLY intrinsic laryngeal muscles that receive motor innervation from EXTERNAL branch of the SLN

A

CRICOTHYROID muscles

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11
Q

RLN course underneath the

A

Aortic arc before ascends the trachea towards the larynx

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12
Q

What are causes of left RLN injury>

A

PDA ligation
Left atrial enlargement secondary to mitral stenosis
Aortic Arch Aneurysm
Thoracic tumor

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13
Q

The Superior Laryngal nerve innervates

A

underside of the epiglottis

Cricothyroid muscles

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14
Q

4 nerves that should come to mind with innervation of the airway

A

Trigeminal
Glossopharyngeal
SLN (external or internal)
RLN

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15
Q

The SLN branches off the

A

Vagus nerve just beyond the jugular foremen at the skull base

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16
Q

Where does the SLN divides into internal and external branches

A

At the level of they hyoid

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17
Q

The internal branch of the SLN penetrates the thyrohyoid membrane between the

A

Greater cornu of the hyoid bone

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18
Q

The internal branch of the SLN penetrates the _____while the external branch of the SLN penetrates the ________

A

Thyrohyoid

Cricothyroid

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19
Q

The recurrent laryngeal nerve branches off the

A

Vagus nerve inside the thorax

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20
Q

The right RLN loops under the ______while the left RLN loops under the

A

Subclavian artery

Aortic ARCH

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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

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22
Q

Which nerve is more likely to be injured and why?

A

The left RLN due to its location in the thorax.

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23
Q

What are the branches of the trigeminal nerve (CN V)

A

V1: Ophtalmic (anterior ethmoidal)
V2: Maxillary (sphenopalatine)
V3: Mandibular (lingual

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24
Q

V3 mandibular branch is responsible for sensory innervation of the airway of what part

A

Anterior 2/3 of tongue

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25
Q

Turbinates and septum are innervated by

A

V2 (maxillary) sphenopalatine

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26
Q

Nares and Anterior 1/3 of nasal septum innervated by

A

V1 Opthalmic (anterior ethmoidal)

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27
Q

Soft palate innervated by

A

Glossopharyngeal (CN IX)

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28
Q

Oropharynx innervated by

A

Glossopharyngeal (CN IX)

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29
Q

Tonsils innervated by

A

Glossopharyngeal (CN IX)

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30
Q

Posterior 1/3 of tongue innervated by

A

Glossopharyngeal (CN IX)

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31
Q

Vallecula innervated by

A

Glossopharyngeal (CN IX)

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32
Q

Anterior side of the epiglottis

A

Glossopharyngeal (CN IX)

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33
Q

The true vocal cords are

A

Ligaments

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34
Q

WHich innervates structure below the vocal cords?

A

RLN

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35
Q

Tuning fork for the voice

A

SLN (external branch)

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36
Q

Injury to the trunk of the superior laryngeal nerve or the external branch causes

A

hoarseness (Because the vocal cords can’t be tense)

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37
Q

RLN injury can be classified as

A

Unilateral

acute Bilateral

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38
Q

Unilateral injury of RLN results in _______ Does it cause resp distress?

A

paralysis of the ipsilateral vocal cords abductors. DOES NOT CAUSE RESP DISTRESS

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39
Q

Bilateral injury of RLN results in _______ Does it cause resp distress?

A

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

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40
Q

Procedure that put patient at risk for RLN injury on the left side

A

PDA ligation
Left atrial enlargement and mitral stenois
AA Aneurysm
Thoracic tumor

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41
Q

Procedure that put patient at risk for RLN injury on either side (R or L)

A 
External pressure on ET tube
Extern pressure on LMA
Thryroid and parathyroid surgeires
Neck stretching 
Tumor
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42
Q

What are the 3 key airway blocks

A

Glossopharyngeal
Superior Laryngeal
Transtracheal

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43
Q

To block the SLN, LA is injected where?

A

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.

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44
Q

In what block in the needle inserted at the base of the palatoglossal arch (anterior tonsillar pillar) ?

A

Glossopharyngeal block

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45
Q

You are performing a glossopharyngeal block and you aspirate air, what does that mean?

A

Needle is too deep

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46
Q

You are performing a glossopharyngeal block and you aspirate BLOOD, what does that mean?

A

Needle should be withdrawn and redirected medially (Carotid artery is very close)

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47
Q

There is a risk of _________with glossopharyngeal block which will be manifested as ______

A

Intracarotid injection

Seizure

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48
Q

Superior Laryngeal block : where is the anesthetic injected?

A

Inferior border of the greater cornu of the hyoid bone

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49
Q

You are performing a Superior Laryngeal block and you aspirate air, what does that mean?

A

Needle is too deep

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50
Q

Transtracheal block, the needle is advance in a_____as it penetrates the _______membrane

A

Caudal; cricothyroid membrane

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51
Q

During the transtracheal block, after aspiration and before injection what should the patient do? and what does the practitioner do ?

A

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

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52
Q

The adult larynx extends from

A

C3-C6

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53
Q

Larynx consists of

A

One bone, ligaments and 9 cartilages (3 paired and 3 unpaired.

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54
Q

What is the only bone in the body that does not articulate with another bone?

A

HYOID

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55
Q

Form the main support of the larynx and attaches to the thyroid cartilage via the THYROHYOID ligament

A

Hyoid

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56
Q

Anterior ligaments are the

A

Thyrohyoid membrane

Cricothyroid membrane

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57
Q

Which ligament attaches the larynx to the hyoid bone

A

Thyrohyoid membrane

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58
Q

Which ligament attaches the cricoid and thyroid cartilages

A

Cricothyroid membrane

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59
Q

What is puncture during the cricothyroidotomy ?

A

Cricothyroid membrane

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60
Q

What are the paired cartilages?

A

Arytenoid
Cuneiform
Corniculate

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61
Q

What can you not see during direct laryngoscopy ?

A

Arytenoids

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62
Q

What do the corniculate and cuneiform cartilates do?

A

provide structure to the aryepiglottic folds.

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63
Q

What cartilages shapes like 3-sided pyramids

A

Arytenoids

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64
Q

2 conditions that may impair movement of the arytenoids,

A

RA

SLE

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65
Q

Provides a mechanical barrier between pharynx and the laryngeal opening?

A

Epiglottis

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66
Q

What is the space between the base of the tongue and the anterior side of the epiglottis

A

Vallecula

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67
Q

Which ligament connects the epiglottis to the thyroid cartilage>

A

Thyroepiglottic

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68
Q

Provide structure and protection to the larynx

A

Thyroid cartilage

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69
Q

What is the largest cartilage in the larynx?

A

Thyroid

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70
Q

Forms Adam’s appled

A

Thyroid

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71
Q

Cartilage most caudal to the larynx

A

Cricoid

72
Q

What is the narrowest part of the pediatric airway ?

A

Vocal cords or cricoid ring

73
Q

What is laryngospasm ?

A

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
Q

Pre-anesthetic risk factors for laryngospasm?

A 
Active or recent URI
Exposure to 2nd hand smoke
Reactive airway disease
GERD
Age< 1 year
Hypocapnia
75
Q

INTRA OP risk factors for laryngospasm?

A 
Light anesthesia with airway manipulation
Saliva or blood in upper airway
Hyperventilation
Hypocapnia
Surgical procedure involving airway
76
Q

Explain the REFLEX PATHWAY?

A

Afferent limb : SLN INTERNAL BRANCH

EFFERENT limb: SLN EXTERNAL branch+ RLN

77
Q

What are sings of laryngospasm?

A

Inspiratory stridor
Suprasternal or supraclavicular retraction during inspiration
Rocking horse appearance of the chest wall
Increasing diaphragmatic excursion
Lower rib flailling

78
Q

Factors that reduce the likelihood of laryngospasm

A

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
Q

Treatment of Laryngospasm : In order of importance

A
  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
Q

When treating laryngospasm with succinylcholine in children less than 5 years what should they all receive

A

Atropine 0.02mg/kg with succinylcholine to prevent bradycardia.

81
Q

What is the larson’s maneuver

A

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
Q

What does the larson’s maneuver accomplisH?

A

Displaces the mandible anteriorly to help open the airway

Breaks laryngospasm by causing the lightly anesthesized patient to sigh.

83
Q

What is the Valsava’s maneuvers?

A

Exhalation against a closed glottis

example: ballon, straining, saxophone

84
Q

Risk of valsava’s maneuvers

A

Increased pressure in the Thorax, abdomen and brain

85
Q

What is the MULLER’s maneuvers?

A

Inhalation against a closed glottis

86
Q

Risk of Muller’s maneuvers

A

Subatmospheric pressure in the thorax –> Negative pressure pulmonary edema

examples: osa, holding nose and breath

87
Q

Tensor palatine muscle relaxation will most likely cause airway obstruction at which level ?

A

soft palate

88
Q

During anesthesia, where are the 3 places where the upper airway can obstruct

A

soft palate
Tongue
Epiglottis

89
Q

Relaxation of the tensor palatine muscle

A

Soft palate

90
Q

Relaxation of the GENIOGLOSSUS muscle

A

Tongue

91
Q

Relaxation of the HYOID muscles

A

Epiglottis

92
Q

Primary functions of the upper airway including

A

Warming and humidifying muscle inspired air, filtering particulate matter and preventing aspiration

93
Q

During normal inspiration, what occurs

A

Diaphragmatic contraction and chest wall expansion create a negative pressure to draw air into the lungs.

94
Q

Factors that impair airway patency

A

Condiation that reduce the diameter of the tube

Condition that reduce the size of the box

95
Q

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

A

tongue, soft palate, pharyngeal tissue and cervical spine

96
Q

What are the 3 sets of dilator muscles that prevents airway obstruction in the awake state?

A

Tensor palatine
Genioglossus
Hyoid muscles

97
Q

Function of the tensor palatine

A

Opens the nasopharynx

98
Q

Function fo teh GENIOGLOSSUS

A

Opens the oropharynx

99
Q

Function of the Hyoid muscles

A

Opens the hypopharynx

100
Q

from top to bottom

A

NOH (Naso–>oro–> Hypo) Pharynx

101
Q

Explain the 2 competing explanations for the primary cause of UPPER AIRWAY OBSTRUCTION during anesthesia and sedation

A
  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
Q

When compared to the trachea, which of the following is increased in the terminal bronchioles?

A

Cross-sectional area

103
Q

Tracheobronchial tree is a branching network of airways that includes the

A

Trachea –> Bronchi–> Bronchioles

104
Q

In terms of airway, a division is

A

where an airway divides into 2 or more smaller airways

105
Q

How many division or generation in humans

A

23-25

106
Q

At each division, the diameter of the new branches becomes_____But the cross sectional area ____

A

smaller ; increases

107
Q

At each At each division, the diameter of the new branches becomes smaller But the cross sectional area increases, this explains

A

Why airflow velocity SLOWS as you move down the tracheobronchial tree.

108
Q

The trachea contains ______And ________ while the terminal bronchioles contains________

A 
Cartilage (C-shaped rings) 
Goblet cells (mucus secretion)
109
Q

Where does the lower airway begins and ends?

A

Begins At trachea , ends at the alveoli

110
Q

Where the trachea begins and ends

A

C5 ; T4-5 at the carina

111
Q

Length of trachea; width

A

10-13 cm long

2-3 cm

112
Q

Tracheal cells

A

Ciliated columnar epithelium

113
Q

Sensory innervation of the trachea

A

Vagus

114
Q

Blood supply of the trachea (BISI)

A

Bronchial artery
Internal thoracic artery
Superior thyroid artery
Inferior thyroid artery

115
Q

At level of the CARINA_______ corresponds to _______

A

T4-T5

Corresponds to ANGLE OF LOUIS

116
Q

Right mainstem bronchus is _____; and ______degrees take off

A

2.5 cm long ; 25 degrees take off

117
Q

Left mainstem bronchus is _____; and ______degrees take off

A

5cm long; 45 degrees take off

118
Q

Mainstem bronchi types of cells

A

CUBOIDAL epithelium

119
Q

Alveoli number

A

300 million by age 9

120
Q

Alveoli tissue

A

Squamous epithelium

121
Q

Which structure allows air movement between alveoli?

A

PORES of KOHN

122
Q

Type I pneumocytes role

A

Provide surface for gas exchange

123
Q

Which type of pneumocytes cover 80% of alveolar surface?

A

Type I pneumocytes

124
Q

Type II pneumocytes role

A

Produce surfactant

125
Q

Pneumocytes resistant to Oxygen toxicity

A

Type II

126
Q

What pneumocytes can produce type I cells

A

Type II

127
Q

Pneumocytes capable of cells division

A

Type II

128
Q

Pneumocytes that are macrophages and produce inflammatory response

A

Type III

129
Q

Pneumocytes that fights lung infection

A

Type III

130
Q

What is the distance between from the incisors to the larynx is ?

A

13cm

131
Q

What is the distance between from the larynx to the carina is about

A

13 cm

132
Q

Distance from incisors to carina is

A

26cm

133
Q

Neck flexion makes distance from incisors to carina

A

ShORTER distance

134
Q

Neck extension makes distance from incisors to carina

A

Increases distance

135
Q

with NECK EXTENSION and NECK FLEXION, remember what happens to the tube?

A

The tube goes where the nose goes

136
Q

Characteristics of progressive airway division : What increase as the airway bifurcates

A

Number of airway
Cross sectional area
Muscular layer

137
Q

Characteristics of progressive airway division : What decrease as the airway bifurcates

A

Airflow velocity
Amount of cartilage
Goblet cells (produce mucus)
Cillated Cells (clear mucus)

138
Q

Order of cartilage from most superior to most inferior

ECo- ArC

A

Epiglottis
Corniculate
Arytenoids
Cricoid

139
Q

Location of infant’s larynx is

A

C2-C4

140
Q

What are the landmark for larson’s maneuver?

A

Posterior: mastoid (PM)
Superior: skull base (SS)
Anterior : Ramus of mandible (AR)

141
Q

Which muscle abduct the vocal cords?

A

Posterior Cricoarytenoids.

142
Q

The cricothyroid muscle is innervated by the

A

EXTERNAL BRANCH OF THE SUPERIOR LARYNGEAL NERVE

143
Q

The internal branch of the superior Laryngeal nerve is

A

Purely sensory

144
Q

Innervates all intrinsic muscles of the larynx

A

RLN

145
Q

Nerve that does not innervate the larynx

A

Glossopharyngeal nerve

146
Q

Posterior Epiglottis innervated by

A

SLN

147
Q

Vallecula innervated by

A

Glossopharyngeal nerve

148
Q

Anterior tongue innervated by

A

Trigeminal nerve BRANCH V3 MANDIBULAR

149
Q

Trachea innervated by

A

Vagus

150
Q

Anterior Epiglottis innervated by

A

Glossopharyngeal nerve

151
Q

Laryngeal mucosa below level of vocal cords

A

Recurrent Laryngeal nerve

152
Q

Posterior side of epiglottis to level of cords

A

Superior Laryngeal Internal branch

Below cords to trachea: RLN

153
Q

3 nerve blocks that can provide anesthesia for oral fiberoptic intubation?

A

Glossopharyngeal
Superior Laryngeal
Recurrent Laryngeal

154
Q

What nerve block is performed by injecting 1-2 ml at the tonsillar pillars bilaterally?

A

Glossopharyngeal nerve block

155
Q

The transtracheal block is performed by

A

Injecting 3-5ml through the cricothyroid membrane.

156
Q

How is the SUPERIOR LARYNGEAL NERVE BLOCK performed?

A

3 ml at the inferior aspect of the GREATER CORNU of the hyoid bone bilaterally.

157
Q

Where is the adult larynx located?

A

C3-C6

158
Q

What is the role of the TENSOR PALATINE

A

Opens Nasopharynx

159
Q

What is the role of the Hyoid muscles

A

Opens Hypopharynx

160
Q

What is the role of the genioglossus?

A

Open oropharynx

161
Q

Mnemonic to remember

OPEN NOH - TGH

A

Nasopharynx - Tensor (No tension)
Oropharynx - Genioglossus (OGod)
Hypopharynx – Hyoid (HH)

162
Q

Muller’s maneuver is (MI)

A

Inhaling against a closed glottis

163
Q

Valsava maneuver is (VE)

A

Exhaling against a closed glottis

164
Q

I actively let AIR out of my TIRE

A

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
Q

Branches of Trigeminal Nerve (CN V)

A

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
Q

True VC attaches front and back:

A

front: thryoid
back: arytenoid

167
Q

Cells in

Trachea
Alveoli
Bronchi

A

Trachea: Columnar (trachea in columns)
Alveoli: Squamous (squash alveoli when smoking)
Bronchi: Cuboidal (bronchi circles, cubes in circles)

168
Q

What muscles control inspiration?

A

Diaphragm

External intercostals

Accessory Muscles- Sternocleidomastoid & Scalene

169
Q

Effective Cough

A

VC 15/ml/kg

170
Q

Transpulmonary Pressure = difference of pressures

A

AP-IP = Transpulmonary Pressure

Alveolar Pressure: inside airway
Intrapleural Pressure: outside airway (always negative)

TPP + = Airway open
TPP - = Airway collapses

171
Q

AP is

A

a little negative during inspiration

a little positive during expiration

172
Q

NO airflow when

A

at FRC
or
end-inspiration

173
Q

Normal deadspace

A

~2 mL/kg

70 kg: 150 mL

174
Q

Increasing dead space causes

A

paco2- etco2 gradient wider

co2 retention

175
Q

How do you calculate alveolar ventilation?

A

Tidal volume- dead space x RR

directly prop: co2 production
inverse to Paco2

SEE/BOARD STUDY AA (20 decks)

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