Airway

Question 0

The end of the mac blade connects to what anatomical part?

Answer 0

Vallecula

Question 1

Mac (macintosh) vs. Miller blade

Answer 1

Mac is curved, miller is straight

Question 2

What is the epiglottis function and where is it located

Answer 2

Closes during swallowing to prevent aspiration, located at C3 (end of oropharynx, start of larynx)

Question 3

What are the functions of the nasal passages?

Answer 3

Humidify, filter, and warm

Question 3

Where is the larynx and what are its functions

Answer 3

Larynx from C3 (epiglottis) to C6 (cricoid)

Protects airway, respiration, phonation

Question 4

Nasopharynx is innervated by which nerve?

Answer 4

Trigeminal (CN5), opthalmic and maxillary divisions

Question 5

What are the 9 cartilages that make up the larynx?

Answer 5

2x arytenoid, 2x corniculate, 2x cuneiform, thyroid, cricoid, epiglottis

Question 6

Which nerve supplies the posterior 1/3 of tongue and oropharynx to vellecula?

Answer 6

CN9- Glossopharyngeal

Question 7

All intrinsic muscles of the larynx are supplied by which nerve (and which branch), except for which muscle?

Answer 7

RLN (recurrent laryngeal nerve) of Vagus Nerve (CN X)

Exception: cricothyroid muscle is SLN (superior) on external branch

Question 8

What landmark is at C6?

Answer 8

Cricoid cartilage

Question 9

Intrinsic laryngeal muscles that adduct and abduct glottis

Answer 9

lateral cricoarytenoid- adduct (close)
arytenoids- adduct (close)
posterior cricoarytenoid- abduct (open)

Question 10

intrinsic laryngeal muscles that put tension on vocal ligaments

Answer 10

cricothyroid- elongates (high pitch) vocal cords (only SLN-external!)
vocalis- shortens (low pitch) vocal cords
thyroarytenoid- shortens (low pitch) and relaxes vocal cords

Question 11

extrinsic laryngeal muscles that move hyoid bone and thyroid cartilage

Answer 11

Sternohyoid, thyrohyoid, omohyoid - move hyoid caudad (down)

Sternothyroid - move thyroid cartilage caudad

Question 12

does right or left bronchus have the smaller angle? (which are you more likely to intubate?)

Answer 12

Right bronchus

Question 13

Mallampati’s stages

Answer 13

Class 1: uvula exposed (best), we see glottic opening and vocal cords
Class 2: base of uvula visible, we see glottic opening and vocal cords
Class 3: soft palate visible, we see arytenoids
Class 4: only hard palate visible, we see epiglottis only (use miller blade)

Question 14

Normal Thyromental distance and what distance is considered a contributing factor to a more difficult intubation?

Answer 14

Thyromental distance: from lower mandible to thyroid notch, with neck fully extended, normally 6cm/ 4 fingerbreadths
difficult intubation at 3 or less fingerbreadths

Question 15

For someone who is determined to be a difficult intubation, what is the alternative to giving succinylcholine?

Answer 15

Awake intubation with airway blocks, airway block will abolish gag reflex and hemodynamic response to laryngoscopy and bronchoscopy

Question 16

Complication of putting in an oral airway

Answer 16

Laryngospasm!

Bleeding, soft tissue damage

Question 17

2 types of oral airways

Answer 17

Geudel (suction through the middle is possible)

Berman

Question 18

contraindications to nasal airway

Answer 18

basal skull fx, epistaxis, anticoagulant use

Question 19

ETT size for men vs. women?

Answer 19

women: 6.5-7
men: 7.5-8

Question 20

How far does ETT get inserted? men vs. women and proximation to carina and vocal cords

Answer 20

men: 23 cm
women: 21 cm
4 cm above carina, 2 cm below vocal cords

Question 21

Steps of induction sequence

Answer 21

1. preoxygenate, 2. sniffing position, 3. monitors on, 4. give induction agent, 5. lash reflex then test ventilation, 6. check neuromuscular blocking monitor (train of 4), 7. give paralytic, 8. tape eyes closed, 9. bag until loss of twitches, 10. larygoscopy and intubation, 11. confirm ETT placement, 12. keep bagging or turn on vent, 13. Start maintenance anesthetic, 14. tape ETT

Question 22

Sensory and motor innervation of SLN-int branch of vagus nerve?

Answer 22

sensory- above vocal cords: epiglottis, tongue, supraglottic mucosa, cricothyroid joint and thyroepiglottic joint
motor- none

Question 23

Sensory and motor innervation of SLN-ext branch of vagus nerve?

Answer 23

sensory: anterior supraglottic mucosa motor: cricothyroid

Question 24

sensory and motor of RLN branch of vagus nerve?

Answer 24

sensory- below vocal cords: subglottic mucosa muscle spindles motor- intrinsic muscles of larynx (except cricothyroid is SLN-ext)

Question 25

Which muscle ABDucts, closes the glottis?

Answer 25

Posterior cricoarytenoid

Question 26

complications of airway blocks

Answer 26

``` systemic toxicity (if drug is given to vessel, aspirate to prevent this) hematoma ```

Question 27

Transtracheal blocks which nerve, so what is blocked? (indications)

Answer 27

Blocks RLN branch of vagus which blocks sensory below the vocal cords, this will block the gag reflex and hemodynamic response to laryngoscopy

Question 28

Steps of Transtracheal block

Answer 28

1. skinwheel of local, 2. local to cricothyroid membrane, 3. advance 23g butterfly needle caudad through cricothyroid membrane while aspirating, 4. aspirate air to know you're in the correct spot, 5. instruct patient to take a deep breath, 6. inject lidocaine on inspiration, 7. pt will cough, this spreads lidocaine

Question 29

What nerve is blocked by superior laryngeal nerve block? What sensory areas are blocked? (indications)

Answer 29

SLN internal branch of vagus nerve, blocks above the vocal cords (supraglottic region), blocks gag reflex and hemodynamic response to laryngoscopy

Question 30

Steps and landmarks of superior laryngeal nerve block

Answer 30

1. palpate hyoid bone and displace toward injection site, 2. insert 23g needle perpendicular, hit hyoid bone, 3. angle needle 1/4 inch caudad and 1/4 inch medial, 4. aspirate, 5. repeat on other side Landmarks: cornu of hyoid bone

Question 31

Glossopharyngeal nerve block will block what nerves, and what sensory functions?

Answer 31

Lingual branch of glossopharyngeal nerve (CN 9), sensory to posterior 1/3 of tongue, this will also block gag reflex

Question 32

Glossopharyngeal block steps

Answer 32

1. use tongue blade to move tongue away, 2. insert 25g needle at base of palatoglossal arch, 0.5 cm deep and lateral, 3. aspirate, get nothing, 4. inject lidocaine, 5. repeat on other side

Question 33

Cricothyrotomy: indications and contraindications

Answer 33

indication: emergency airway contraindication: children under 12 and patients with laryngeal fractures

Question 34

Cricothyrotomy steps

Answer 34

1. stabilize larynx between thumb and middle finger, 2. palpate thyroid and cricoid cartilage, 3. insert 14g IV through cricothyroid membrane (1.3cm or less), angle towards carina, 4. aspirate air, 5. hook up to jet ventilator

Question 35

Cricothyrotomy complications (3)

Answer 35

esophageal perforation (to avoid this, do not let needle advance more than 1.3cm), subcutaneous emphysema, excessive bleeding (vessel rupture)

Question 36

Innervation of anterior 2/3 of tongue? Innervation of posterior 1/3 of tongue?

Answer 36

anterior 2/3: (taste is facial carried by chorda tympani) tactile is lingual nerve from mandibular division of trigeminal nerve (CN5).. Motor is hypoglossal posterior 1/3: glossopharyngeal (CN9) taste and sensory (hypoglossal motor)

Question 37

What physical assessments might you do to determine if the patient will be a difficult intubation? What history questions might you ask?

Answer 37

Physical: Mallampati, thyro-mental distance, look at surrounding tissue (burns, old trachs, mass) History: Radiation/burn to head/neck? C-spine pain? TMJ pain? Rheumatoid arthritis? Ankylosing Spondylitis? Abcess/tumor? Prior intubations or tracheotomy? Snoring or sleep apnea? Dysphagia or stridor?

Question 38

What is aligned in the "sniffing" position?

Answer 38

oral, pharyngeal, and laryngeal axis

Question 39

What does preoxygenation consist of?

Answer 39

3-5 minutes of mask breathing of 100% O2 at over 5L/min | OR 4 vital capacity breaths in 30 sec (for emergencies)

Question 40

What does the airway setup consist of?

Answer 40

Laryngoscope (2 types of blades), oral/nasal airways (several sizes), tongue depressor, ETT tube (2 sizes), suction, ambu-bag, stylet, LMA

Question 41

What do the vocal cords attach to posteriorly and anteriorly?

Answer 41

posterior: arytenoids anterior: thyroid cartilage

Question 42

List complications of tracheal intubation

Answer 42

``` Trauma to airway Esophageal intubation Endobronchial intubation Endotracheal tube ignition Sore throat Laryngospasm Croup ```