Airway

Question 1

What is the barrier between the upper and lower airway?

Answer 1

Glottis

Question 2

This is the only muscle that ABDUCTS the vocal ligaments

Answer 2

Posterior cricoarytenoid muscles

Question 3

What is the most narrow part of the adult and pediatric airways?

Answer 3

Pediatric - cricoid cartilage

Adults - glottis (6 - 9 mm)

Question 4

Normal mouth opening distance

Answer 4

3 - 4 cm (2-3 FB)

Question 5

Precautions for nasal airways

Answer 5

Epistaxis and anticoagulants

Nasal and basilar skull fractures

Adenoid hypertrophy

Question 6

Big caution with oral airways

Answer 6

LARYNGOSPASM

bleeding

soft tissue damage

Question 7

Posterior cricoarytenoid

what do they do

who innervates it

Answer 7

Only abductor of the cords!! Opens the glottis

Recurrent laryngeal nerve

intrinsic muscle

Question 8

Lateral cricoarytenoid

function

nerve

Answer 8

Adducts the cords

Recurrent laryngeal nerve

intrinsic muscle

Question 9

Arytenoids

function

nerve

Answer 9

Closes the glottis (esp the posterior)

Recurrent laryngeal nerve

intrinsic muscle

Question 10

Crycothyroid

function

nerve

Answer 10

Produces tension and elongates the cords

superior laryngeal nerve

Question 11

Thyroarytenoid & Vocalis

Answer 11

Shortens and relaxes the cords

recurrent laryngeal nerve

Question 12

Sensory and Motor Function of the Superior Laryngeal Nerve (Internal branch)

Answer 12

Sensory only!!

Base of tongue

Epiglottis

Supraglottic mucosa

2 joints (thyroepiglottic and cricothyroid joints)

Question 13

Sensory and Motor Function of the Superior Laryngeal Nerve (External branch)

Answer 13

• Sensory:
  
  • Anterior subglottic mucosa
• Motor:
  
  • Cricothyroid muscle (adductor/tensor)

Question 14

Sensory and Motor Function of the recurrent laryngeal nerve

Answer 14

• Sensory
  
  • Subglottic mucosa
  • Muscle spindles
• Motor
  
  • Thyroarytenoid
  • Lateral cricothyroid
  • Interarytenoid
  • Posterior arytenoid

Question 15

What should we remember to do before placing a nasal airway?

Answer 15

Lube that sucker up

Question 16

When is a mask case ok?

Answer 16

1. Pt doesn’t have difficult airway
2. Airway obstruction is easily relieved with oral/nasal airway or chin lift
3. Short case duration
4. Surgeon doesn’t need access to head/neck (exception to the rule: bilateral myringotomy tubes)
5. Head will be accessible for the entire case
6. No airway bleeding/secretions
7. No table position changes

Question 17

When in the induction sequence can an LMA be placed?

Answer 17

After loss of lash reflex and confirmation of mask ventilation

Question 18

Who should not have an LMA placed?

Answer 18

Anyone considered a full stomach

(non-fasting, parturients 34+ weeks, uncontrolled GERD, trauma, acute abdomens, diabetics d/t autonomic neuropathy, low pulmonary complience)

Question 19

LMA advantages

Answer 19

• ↑ speed & ease of placement by inexperienced personnel
• Improved hemodynamic stability at induction & during emergence
• ↓ anesthetic requirements for airway tolerance
• Lower frequency of coughing during emergence
• Lower incidence of sore throats in adults (10% vs 30%)
  
  • Avoids “foreign body” in the trachea
• Patient can be fully emerged prior to removal of LMA → good for asthmatic patients

Question 20

LMA disadvantages

Answer 20

• Lower seal pressure
• Higher frequency of gastric insufflation → risk for aspiration
• Esophageal reflux more likely
• Inability to use mechanical ventilation at higher pressures

Question 21

LMA - when do you deflate the cuff

Answer 21

Keep the cuff inflated until the patient is awake → DO NOT DEFLATE at END OF CASE

Keeps secretions from getting on vocal cords

Question 22

ETT indications

Answer 22

1. Airway compromise
2. Airway inaccessible
3. Long surgical time
4. Surgery of head, neck, chest, or abdomen
5. Need for controlled ventilation & positive end-expiratory pressure
6. Inability to maintain airway with mask/LMA
7. Aspiration risk
8. Airway disease
9. Pregnancy

Question 23

How far to insert the ETT

Answer 23

males - 23 cm

females 21 cm

Question 24

RSI Sequence of Events

Answer 24

1. Adjuncts → aspiration prophylaxis
   
   • Bicitra, reglan, protonix
2. Monitors, suction on & placed at head of bed
3. Supine “sniffing” position
4. Sedation (Versed) if applicable
5. Pre-Oxygenate 5 minutes or Minimum 4-5 VC Breaths!
6. Sellick’s Maneuver = Cricoid pressure
7. Induction agent followed by succinylcholine
   
   • Wait 60 seconds → watch the clock NOT the block!
8. Attempt Laryngoscopy → visualize vocal cords → place ETT inflate cuff
9. Confirm tracheal tube placement:
   
   • Chest rise
   • BBSE
   • Confirm presence of EtCO2
10. Give assistant permission to release cricoid pressure
11. Ventilate
12. Start inhaled anesthetic or anesthetic infusion
13. Ventilator on
14. Secure ETT/tape eyes

Question 25

Potential Hazards in Airway Management

Answer 25

* Dental damage * Soft tissue/mechanical injury * Laryngospasm * Bronchospasm * Vomiting/Aspiration * Hypoxemia/Hypercarbia * SNS stimulation * Esophageal/Endobronchial intubation * Endobronchial intubation evident by → **high airway pressures**, unilateral chest rise & breath sounds, ↓ O2 saturation

Question 26

Extubation Criteria

Answer 26

* TV: \>6 mL/kg * VC: \>10 mL/kg * RR: * If \>30 could mean pain or anxious * SaO2: \>90% * ETCO2: * If EtCO2 is too low → can ↓ RR or ↓ VT * Sustained tetanic contraction * Closed grip fist for 5 seconds * Sustained head lift for 5 seconds

Question 27

Laryngospasm interventions

Answer 27

* Jaw-Lift Maneuver * Forward displacement of the mandible with O2 administered by mask with positive pressure * Administration of O2 with continuous positive pressure * Strong intermittent pressure applied manually to a bag full of O2 can force gas effectively through the upper airway & adducted cords * Immediate removal of the offending stimulus * Small dose of short acting muscle relaxant succinylcholine 20-40 mg

Question 28

Proper Snifing position

Answer 28

pillow under the head (not soulders) 35° neck flexion and 15° head extension (angles relative to horizontal planes)

Question 29

when is it allowed not to test-ventilate a patient before insertion of the ETT/LMA?

Answer 29

in RSI

Question 30

Nasal Tracheal Intubation: Asleep Sequence of Events

Answer 30

* Phenylephrine to nose (AFRIN) or consider Anticholinergic/Antisialogogue (glycopyrrolate) * Monitors, Supine “sniffing” position, Sedate (Versed) * Pre-Oxygenate * Induction Agent * Confirm loss of consciousness * Attempt ventilation if able to ventilate → * Muscle Relaxant * Consider dilation of nare with sequential sizes of nasal airways → choose nare that is easily able to breathe through in preop * Consider induction agent may be wearing off * Insert LUBRICATED ETT through nare (that was dilated) * Continue to ventilate * Attempt direct visual laryngoscopy → visualize VC → use Magill forceps to pick up end of ETT & advance through cords * Inflate cuff * Confirm tracheal tube placement: * Chest rise * BBSE in all lung fields & over stomach * Confirm presence of EtCO2 * Ventilate * Start inhaled anesthetic or anesthetic infusion * Ventilator On * Secure ETT/tape eyes

Question 31

Extubation guidelines

Answer 31

* Nearly fully awake extubation is performed when the patient has * Purposeful movement * ready to maintain & protect his/her own airway * Muscle relaxant must be fully reversed & confirmed with PNS * Anesthetic medications, including anesthetic gases & infusions, turned OFF * Oropharynx is suctioned * The patient is self-maintaining an acceptable respiratory rate & depth (see respiratory extubation criteria\*) * Assess for responsiveness / purposeful movement &/or responding to commands * A sustained (5 second) head lift is an excellent way to assess clinically adequate reversal * ETT is removed while a positive-pressure breath is given with the anesthesia bag to allow subsequent expulsion or secretions away from the glottis