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Anesthesia Concepts-Cassie > Airway > Flashcards

Airway Flashcards

0
Q

The oral cavity is innervated by what nerve? (try to use topical anesthesia but very hard to obliterate the gag reflex, does not work as well as with nasal)

A

Glossopharyngeal nerve

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1
Q

This is very responsive to transmucousal anesthesia (ex: lidocaine)

A

Nasal Passage

*does not work well in oral cavity

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2
Q

In the oral cavity~

  • This structure is stationary?
  • This structure can stretch?
A
  • Hard palate

* Soft palate

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3
Q

Use OPA on induction to help control? (2)

A

Tongue & Soft palate

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4
Q

The nasal passage to the _____ is generally considered upper airway. The nasal passage is innervated by this nerve?

A 
Cricoid cartilage (C6) 
Trigeminal nerve (5th cranial nerve)
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5
Q

Upper Airway:

Nose to cricoid cartilage?
large turbinates or adenoids will obstruct view of this

A

Pharynx

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6
Q

The space (depression) in front of the epiglottis?

A

Vallecula

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7
Q
  • This blade will slip into vallecula? When you pull the epiglottis forward you will see the vocal cords.
  • This blade actually picks up the epiglottis and you will see the vocal cords?
A
  • MAC blade (curved)

* Miller blade (straight)

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8
Q

Back part of cricoid cartilage is what you use to compress the ____ (bone on bone, cricoid on vertebrae)

*cricoid cartilage is unique, has a front and back, looks like a ring

A

esophagus

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9
Q

Front of vocal cords attached to the? (inside vocal cords can see the trachea)

A

Thyroid

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10
Q

This functions to protect the airway, respiration and phonation?
*In adults, at level of C3-C6 (includes the epiglottis to the cricoid cartilage).

A

Larynx

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11
Q

Protects our airway by closing over the inlet of the vocal cords. Allows us to phonate, respiration as they open and close, protects from aspiration.

A

Epiglottis

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12
Q

Muscles and Ligaments of the Larynx include? (4)

*Have paired cartilages. Muscles grouped together based on function, abduct (pull away vocal cords), adduct (bring cords back together). Regulators of tension (lengthen or shorten larynx as a whole).

A
  • thyroid
  • cricoid
  • epiglottis
  • arytenoids
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13
Q

Protects the airway from contents of the GI tract?

*@ level?

A

Larynx

*C3-C6

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14
Q

Vocal cords - pearly white ligament.

  • Attach anteriorly to the ____.
  • Attach posteriorly to the ____.
A
  • Thyroid cartilage (angles of the thyroid)

* Arytenoid cartilage

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15
Q

Triangular fissure between vocal cords, this is the narrowest portion of the adult airway (6-9 mm). Choose tube size based on gender, height and weight.

A

Glottic Opening

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16
Q

Patients in steep trendelenburg position, abdominal contents can come up toward the lungs, will use a large tube with this patient.

A

Davinci Robotics

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17
Q

Corniculate and cuneiform cartilages which articulate with the?

A

Arytenoids

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18
Q

Larynx has 9 cartilages.

  • 3 Paired?
  • 3 Unpaired?
A
  • Arytenoid, corniculate, cuneiform

* Thyroid, cricoid, epiglottis

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19
Q

3 Basic functions of the Muscle and Cartilages of the Larynx?

A

Abduct, adduct, regulate tension

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20
Q

Cartilage in the larynx:

Have very little function other than the fact that they articulate with the arytenoids. Serve as an aide to pull the arytenoids backwards.
*Located in the post arytenoid epiglottic fold, usually fused with the arytenoids, difficult to see.

A

Corniculate and Cuneiform cartilage

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21
Q

Larynx: Paired Cartilages

1) Posterior attachment to vocal cords (airway may be only thing visible)
2) Usually articulates with the arytenoids
3) Found in the small epiglottic fold

*2 & 3 do not play prominent role in laryngoscopic appearance or function.

A

1) Arytenoids
2) Corniculate
3) Cuneiform

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22
Q

Larynx: Unpaired Cartilages

Largest and most prominent part of the larynx.
Vocal cords anterior attachment (anterior = protective housing of the vocal cord mechanism, large shield that sits in front, used to protect vocal cords).

A

Thyroid Cartilage

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23
Q

Larynx: Unpaired Cartilages

Covers opening to larynx during swallowing

A

Epiglottis

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24
Q

Larynx: Unpaired Cartilages

Cartilaginous Signet-shaped ring. Sits inferior to the thyroid cartilage (cricothyroid membrane).
Uncomfortable to press down on - do not do this until patient is asleep.

*Narrowest part of pediatric airway

A

Cricoid Cartilage

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25
Q

Laryngeal Muscles - Intrinsic
Concerned with movements of the laryngeal parts, making alterations in length and tension of the vocal cords and in the size and shape

*All Intrinsic Muscles of the Larynx are supplied by the _____, which is a branch of the ____.

A 
Recurrent Laryngeal Nerve 
Vagus Nerve (CN 10)
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26
Q

Intrinsic Laryngeal Muscles are supplied by the Recurrent Laryngeal Nerve.
***Except the ______, which is supplied by the _____.

A

Cricothyroid muscle

External branch of the Superior Laryngeal Nerve

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27
Q
  • Nerve going to nasopharynx, responsive to transmucousal local anesthetic (nose, back of nose)?
  • Nerve that supplies the back 1/3 of the tongue and the oropharynx?
  • Nerve has the RLN & SLN (these nerves are very important to airway anatomy)?
A
  • Trigeminal nerve (CN 5)
  • Glossopharyngeal nerve (CN 9)
  • Vagus nerve (CN 10)
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28
Q

Intrinsic Laryngeal Muscles:

  • Those that open and close the glottis
    1) Adductors
    2) The ONLY VC ABductor

~the nerve responsible for this opening and closing movement is the Recurrent Laryngeal Nerve

A

1) Arytenoids & Lateral Cricoarytenoid

2) Posterior Cricoarytenoid

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29
Q

Intrinsic Laryngeal Muscles:

Muscles that put tension on vocal ligaments
(shorten or lengthen the vocal cords)

1) Elongates vocal cords
2) Shortens vocal cords
3) Shortens and relaxes the vocal cords

Gets nerve supply from?

A

1) Cricothyroid
2) Vocalis
3) Thyroarytenoid

  • SLN-1
  • RLN-2 & 3
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30
Q

These muscles move parts of the larynx?

These muscles move the larynx as a whole (move up or down)?

A

Internal muscles

External muscles

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31
Q

Extrinsic Muscles of the Larynx~moves the larynx up or down (4)?

  • # 1-3: Moves hyoid bone caudad?
  • # 4: Moves thyroid cartilage caudad?
A

1) Sternohyoid
2) Omohyoid
3) Thyrohyoid
4) Sternothyroid

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32
Q

Main purpose is induction of air and gas exchange?

  • Bifurcation of right and left lung - 5th thoracic vertebrae?
  • Sits opposite of the 6th cervical vertebrae?
A

Lower airway

  • Carina
  • Trachea
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33
Q 
Fibromuscular tube (10-20 cm long, 22 mm diameter on adult)?
16-20 U-shaped cartilages, no cartilage on posterior side (flat)

*This bifurcates at the lower border of T4?

A

Trachea

*Carina

34
Q

Carina: Trachea divides into right and left mainstem bronchi.

  • 2.5 cm long at 25 degrees or less
  • 5 cm long at 45 degrees or less
A
  • Angle of right bronchus

* Angle of left bronchus

35
Q

Always listen to ___ first. Tube wants to go into right bronchus (smaller angle-25 degrees).

*Airway pressures will be high if just in right side (____ mismatch, ____ will drop).

A

Left side first

  • V/Q mismatch (ventilation/perfusion)
  • Sats
36
Q

The gold standard to tell you your tube is in. However, this will not tell you if it is in correctly (Ex: right bronchus)?

A

End tidal tracing

37
Q

If they have a trach scar can develop?

*A size 7 tube will not go through the airway, will need to get a smaller tube.

A

Tracheal stenosis

38
Q

When the base of the tongue is disproportionately large, the tongue overshadows the larynx resulting in difficult exposure of the vocal cords during laryngoscopy?

A

Mallampati’s Hypothesis

39
Q

Mallampati’s Classification:
*One of the most sensitive indicators for a difficult airway

The less part of the ___ we see the more difficult the intubation will be (make sure they have one). *No AAAH

A

Uvula

40
Q

With this class should think of using fiberoptic scope or awake intubation?

A

Class 4

41
Q

*If only see epiglottis will probably want to use this blade?
(then you could pick up the epiglottis and maybe see the vocal cords)

A

Miller Blade

42
Q

Cricothyroid membrane injection (saw in video). Cough after injection to spread the local anesthetic below the vocal cords. Put more local anesthetic above the cords as well - so there is innervation above and below the cords.

A

Transtracheal Block

43
Q

Distance from lower border of mandible to thyroid notch?

  • Normal 6-6.5 cm or 4 fingers
  • Difficult intubation:
    1) < ________
    2) receding ____

~If patient only has one finger means the trachea has moved forward. Patient has very anterior airway, not likely to see vocal cords.

A

Thyromental Distance

  • 3 Fingers
  • Receding mandible
44
Q

If you get secretions on vocal cords, vocal cords will close.
Profound closure of vocal cords is known as?

*Can break this by administering ______ - ventilator, or using _____.

A

Laryngospasm

  • Positive pressure
  • Succinylcholine
45
Q

Optimal intubating position?
*Aligns the 3 axes?

  • Provides for the most optimal visualization of the vocal cords. Allows for effective mask ventilation.
  • Positioning is of the utmost importance for successful intubation.
A

Sniffing Position

1) Oral
2) Pharyngeal
3) Laryngeal

46
Q

Goal is increased oxygen concentration in FRC; decreased nitrogen in FRC (79% in RA)?

*3-5 minutes of “tight” face mask fit, normal breathing of 100% oxygen, >5L/min flow. Healthy patient can tolerate up to ____ of apnea.

A

Pre-oxygenation

*10 minutes

47
Q

4 Vital Capacity breaths in 30 seconds (occasionally have to do test ventilation this way). Healthy patient can tolerate up to ______ of apnea.

  • Patient takes 4 breaths, then give induction drugs, put cricoid pressure and intubate.
  • Do this with emergent aneurysm, crash C-section-uterine rupture, or if patient does not like the mask on their face).
A

5 minutes

48
Q

Goal of _______ is to fill the FRC with 100% oxygen for about 5 minutes (do this as we are getting monitors on, getting supplies etc). Do _______ after this. Give ________ (wait 90 seconds). Bagging patient while keeping FRC at 100%. Now will try to intubate patient. FRC at 100% buys you some time while you attempt to intubate (patient not receiving oxygen while intubating).

A
  • Pre-oxygenation
  • Test ventilation
  • Muscle relaxant
49
Q

Airway Set up:

  • Every case needs this? Bridge airway, allows you to place a #6 ETT through the LMA.
  • This will allow you to place a #8 ETT?
A
  • # 4 LMA

* Intubating LMA

50
Q
  • The tongue and other soft tissues are forward, allowing an unobstructed air passage?
  • The tongue and epiglottis fall back to the posterior pharyngeal wall, occluding the airway?
A
  • Normal airway

* Obstructed airway

51
Q

Posterior 1/3 of the tongue innervated by ______. If patient is not sedated and you try to apply oral airway, patient will have ______. Gag reflex present, secretions will cause this.
*Be careful of plane and depth patient is in

A
  • Glossopharyngeal nerve

- Laryngospasm

52
Q

Nasal Airways aka Nasal Trumpet:

Used to provide passageway, _____ to ____ beneath the relaxed and obstructing tongue.

Make sure you ______!

A

Nose
Pharynx

Lubricate

53
Q

Complications/Precautions of Nasal Airways/Nasal Trumpet:

  • Epistaxis
  • _____ or _____ fractures
  • _____ hypertrophy
  • Anticoagulants
A
  • Nasal or basal skull fractures

- Adenoid

54
Q

Nasal Airway/Trumpet:

  • Very well tolerated. Usually better tolerated than oral airway during light anesthesia.
  • Make sure you use the smallest one possible and lubricate it.
  • Make sure patient does not have a lot of _______.
  • Do not take ETT out to soon.
A

*Nasal obstruction

55
Q

Important Numbers:

*Desirable position for ETT is ____above _____ & _____ below the ____.

Males approximately?
Females approximately?

A
  • 4 cm above the carina
  • 2 cm below the vocal cords
Males = 23 cm
Females = 21 cm
56
Q

Look at ____ = gold standard for ETT placement verification. Tells us if ETT is in the lungs and not in the esophagus. Will not tell you if you are in the right or left stem bronchus.

A

End tidal CO2

57
Q

With this block you spread the lidocaine by coughing?

A

Transtracheal Block

58
Q

If patient has ____ ____ will not do intubation asleep, will need to have an awake intubation.

A

Severe Rheumatoid Arthritis

59
Q
  • Getting sensory innervation above the vocal cords?

* Getting sensory innervation below the vocal cords?

A
  • Internal branch of Superior Laryngeal Nerve

* Recurrent Laryngeal Nerve

60
Q

Bring patient in, _____, give induction drug, perform ____ - test for unconsciousness, _____, then do laryngoscopy.

A
  • Pre-oxygenate
  • Lash reflex
  • Test ventilate
62
Q

Sensory Innervation: Larynx

1) Posterior 1/3 of tongue and oropharynx to vallecula?
2) Supplies sensory to vocal cords and above (branch of Vagus)?
3) Supplies mucosa below vocal cords (branch of Vagus)?

A

1) Glossopharyngeal (CN 9)
2) Internal Superior Laryngeal
3) Recurrent Laryngeal

63
Q

Motor Innervation of Larynx:
*Remember not taking away motor, only sensory

1) Supplies cricothyroid muscle - puts tension on vocal cords?
2) Supplies ALL intrinsic muscles of larynx EXCEPT cricothyroid muscle?

A

1) External Branch of Superior Laryngeal

2) Recurrent Laryngeal

64
Q

We have to ____ the airway to prevent noxious stimuli (HTN, tachycardia, ischemia, MI, laryngospasm).

  • Important prior to manipulating airway block is done or patient is sedated
  • If HR becomes elevated when blade is in, take blade out and give more propofol (make sure patient is asleep!)
  • ______ (give versed) then perform block to block sensory innervation.
A
  • Numb

- Awake Intubation

65
Q

Placed for awake intubation on patients whose anatomy dictates an awake endotracheal intubation.
*suspected difficult airway patients

A

Airway blocks

66
Q

Airway Blocks (placed for awake intubation):

-Need firm support under head to prevent patient’s natural withdrawal reflex upon injection
-Need to consider ____ prior to placing blocks.
(This is minimal want patient to continue breathing on their own.)

A

Sedation

67
Q

General Indication for Airway Blocks:

1) To abolish or blunt _____
2) To provide patient comfort and airway anesthesia during the performance of these procedures

A

1) reflexes

68
Q

Complications of Airway Blocks:

1) From local anesthetic (lots of vascular structures in neck, give anesthetic on accident in artery)?
2) Can go through vessel and patient will bleed. Make sure you are always aspirating the needle! If you see blood, take needle out immediately and hold pressure - not in right site.

A

1) Systemic Toxicity

2) Hematoma Formation

69
Q

The ____ supplies mostly motor, except for the ____ (gives motor to cricothyroid muscle). However, ____ also has sensory (just so we know).

A

Recurrent Laryngeal Nerve
External branch of the SLN
Recurrent Laryngeal Nerve

70
Q

This block results in anesthesia of the trachea below the vocal cords?

A

Transtracheal Block

71
Q

Transtracheal Block:

  • Block the ____ for awake intubation, fiberoptic and/or retrograde intubation.
  • Abolition of the _____ or hemodynamics responses to laryngoscopy or bronchoscopy.
A
  • Recurrent Laryngeal Nerve

- Gag reflex

72
Q

Transtracheal Intubation:

  • Inject local anesthetic into _____?
  • Continuously ____ while injecting needle through membrane in caudad direction.
  • Visualize ____ in syringe to verify placement in tracheal lumen.
A
  • Cricothyroid membrane
  • Aspirate
  • Air bubbles
73
Q

Transtracheal Block:

  • Instruct patient to take a deep breath and inject lidocaine on _______.
  • This will simulate _____ (spread lidocaine). Keep your needle steady!
A
  • Inspiration

- Cough reflex

74
Q

Superior Laryngeal Nerve Block:

1) Blocks the ?
2) Blocks the _____ region

A

1) Internal branch of SLN

2) Supraglottic region

75
Q

Superior Laryngeal Nerve Block:
*Hyoid bone palpated and displaced ____ side to be injected.
*Inferior border of cornu palpated (23 G, 1.75 cm needle) inserted ____ to the skin (1/4 inch caudad and medial).
*1-2 cc of LA _____ the thyrohyoid membrane aspirating.
(if air you are deep in pharynx, should not get anything back, just feel a little resistance)

A
  • towards
  • perpendicular
  • ABOVE and below
76
Q

Glossopharyngeal Nerve Block:

1) Blocks? (supplies sensory to the back of the tongue)
2) Also do this when _____ is not effective.

A

1) Lingual branch of glossopharyngeal nerve

2) topical application

77
Q

Superior Laryngeal Block:

Displace hyoid bone towards the side you are injecting (hoping to bring hyoid bone toward side where needle is, use tip of hyoid bone to walk off into membrane ). Once you feel hyoid bone, go medially and caudally so you can inject into _____. Will feel a ___ when you inject.
** Do not want air and/or blood in this block

A
  • Thyrohyoid membrane

- Pop

78
Q
  • This is a bilateral block.
  • This block is rarely used. Usually will have patient’s nebulized with 4% lidocaine instead of albuterol. Have patient breathe in and out nebulized lidocaine.
A

Glossopharyngeal Block

79
Q

*Use tongue blade to move tongue to opposite side of mouth (form a gutter). Insert needle into palatoglossal arch (0.5 cm deep and lateral to tongue base).
*Aspirate before injecting
____ = too deep
____ = withdraw and redirect needle medially

*Can have ____ if you use too much local anesthetic.

A
  • Air
  • Blood

-Systemic Toxicity

80
Q

Adductor muscles? (4)

A

1) Arytenoids
2) Lateral cricoarytenoid
3) Interarytenoid
4) Cricothyroid (tensor, adductor)

81
Q

Internal Superior Laryngeal Nerve supplies sensory innervation to? (5)

A

1) Epiglottis
2) Base of tongue
3) Supraglottic mucosa
4) Thyroepiglottic joint
5) Cricothyroid joint

82
Q

External Branch of the Superior Laryngeal nerve supplies sensory innervation to?

A

Anterior subglottic mucosa

83
Q

Recurrent Laryngeal Nerve supplies sensory innervation to? (2)

A

Subglottic mucosa

Muscle spindles

84
Q

Recurrent Laryngeal Nerve supplies motor innervation to? (4)

1) Shortens and relaxes the vocal cords?
2 & 3) Adducts the vocal cords?
4) Only VC abductor?

A

1) Thyroarytenoid
2) Lateral cricoarytenoids
3) Interarytenoids
4) Posterior cricoarytenoid

Anesthesia Concepts-Cassie (4 decks)

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