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Intro to Anesthesia > Airway Anatomy, Equip., & Mgmt > Flashcards

Airway Anatomy, Equip., & Mgmt Flashcards

1
Q

What is airway management?

A

establishing and securing a patent airway

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2
Q

What structures are included in the UPPER airway?

A

nasal cavity
oral cavity
pharynx
larynx

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3
Q

Describe structures, function, and innervation of the nasal cavity

A

Includes:
Septum, Turbinates, Adenoids, Paranasal
sinuses

Function:
  Accounts for 2/3 of total upper airway 
  resistance
  Humidification and warmth
  Filter

Innervation:
Branches of the trigeminal
nerve (CN V)

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4
Q

Describe structures and innervation of the oral cavity

A 
Includes:
 Teeth
 Tongue **Predominate cause of airway
 resistance in oral cavity**
 Hard palate
 Soft palate

Innervation:
◦ Trigeminal Nerve (CN V)
Hard and Soft palate
Anterior 2/3 tongue

◦ Glossopharyngeal (CN IX)
Posterior 1/3 tongue
Soft palate
Oropharynx

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5
Q

What is the pharynx?

A

muscular tube that extends from the base of the skull down to the level of the cricoid cartilage

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6
Q

How is the pharynx divided?

A

Nasopharynx
Border is the soft palate

Oropharynx
Border is the epiglottis, tonsils, uvula

Hypopharynx/
Laryngopharynx

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7
Q

What cranial nerves is the pharynx innervated by?

A

Innervation:
◦ Glossopharyngeal (CN IX)
◦ Vagus (CN X)

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8
Q

Where is the larynx located?

A

C4-C6 (adults)

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9
Q

Name the functions of the larynx

A

Airway protection (Epiglottis)
Phonation
Respiration

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10
Q

How many cartilages make-up the larynx?

A

9 cartilages total

3 unpaired and 3 paired

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11
Q

Name the cartilages of the larynx

A

Unpaired
Epiglottis, Thyroid cartilage, Cricoid cartilage

Paired
Arytenoid, corniculates, cuneiform

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12
Q

Describe the shapes of the Arytenoid, Corniculate, Cuneiform

A

Arytenoid are pyramidal/ triangular
Corniculates are horned shaped
Cuneiform are wedge/rod shaped

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13
Q

Describe the vocal cords

A

◦ Appear pearly white
◦ Formed by the thyroarytenoid ligaments
◦ Attached anteriorly to the thyroid cartilage and
posteriorly to the arytenoid cartilages

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14
Q

Describe the glottic opening

A

◦ triangular fissure between the cords

◦ narrowest portion of ADULT airway

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15
Q

Cricoid Cartilage

A

◦Signet ring shape
◦Unique complete cartilaginous ring
◦Narrowest point of Pediatric airway
◦Inferior to thyroid cartilage-cricothyroid membrane

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16
Q

What is the role of the intrinsic laryngeal muscles?

A

◦Control the movements of the laryngeal
cartilages
◦Control the length & tension of the vocal cords; size of the glottic opening

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17
Q

Cricothyroid muscle innervated by the…

A

external branch of superior laryngeal nerve

a branch of the Vagus nerve -CN X

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18
Q

With the exception of the cricothyroid muscle, all other laryngeal muscles are innervated by…

A

recurrent laryngeal nerve

a branch of the Vagus nerve -CN X

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19
Q

posterior cricoarytenoid

A

ABDUCTS vocal cords & opens glottis

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20
Q

lateral cricoarytenoid

A

ADDUCTS glottis

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21
Q

arytenoids

A

ADDUCTS glottis (especially posterior)

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22
Q

cricothyroid

A

vocal cord tension and elongation

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23
Q

thyroarytenoid

A

vocal cord shortening and relaxation

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24
Q

Name the structures of the lower airway

A
  • Trachea
  • Carina
  • Bronchi
  • Bronchioles
  • Terminal bronchioles
  • Respiratory bronchioles
  • Alveoli
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25
Q

Describe the trachea

A

-Fibromuscular tube 10-20cm length & 22mm diameter (Adult)

-16-20 ‘U’ shaped cartilages
Posterior side lacks cartilage

-Bifurcates lower border T4-carina

-At Carina
◦ Trachea divides Rt. & Lt. mainstem bronchi
◦ Rt bronchi 2.5cm long with 25 degree angle
◦ Lt bronchi 5cm with 45 degree angle

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26
Q

Pre-op Airway Assessment

A 
General appearance- head, neck-size & fullness
Range of Motion in the Neck
Thyromental Distance
Mouth- lips, gums, tissues
Mallampati Classification
Mouth opening-usually 3-4cm or 2-3 fingerbreadths 
Dentition-Teeth missing, protruding, overbite, 
  dentures/bridges out?
Size & mobility tongue
History of Previous Difficult Airway
Body Habitus/Physical Characteristics
Diagnosis
Surgery Planned
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27
Q

Purpose of oropharyngeal A/W Evaluation -Mallampati Score?

A

Correlates the oropharyngeal space with the ease of

direct laryngoscopy and tracheal intubation

28
Q

What is the hypothesis of Mallampati?

A

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

29
Q

How do you assess the patient during the Mallampati assessment?

A

Sit upright
Head neutral
Mouth open as wide as possible
Tongue maximally protruded (No AAAH! -causes elevation of soft palate)

30
Q

Mallampati I-IV

A

P-U-S-H
Class I: faucial Pillars, entire Uvula, Soft and
Hard palates

Class II: tip of Uvula masked by tongue, Soft and
Hard palates

Class III: Uvula base, Soft and Hard palates

Class IV: Hard palate only

31
Q

Mallampati scores of _____ and _____ are considered difficult airways

A

Class III and Class IV

32
Q

Thyromental distance

A

lower border of mandible to thyroid notch with neck fully extended

  • Normal 6-6.5cm or 4 Fingerbreadths
  • Difficult intubation < 3 fingers, receding mandible; “anterior airway”
33
Q

Optimal intubation positioning

A

“Sniffing” position- aligns the 3 axis
◦ Oral axis
◦ Pharyngeal axis
◦ Laryngeal axis

-provides the most optimal visualization of the vocal cords
-Allows for the most effective mask ventilation
-Positioning is key for success especially for
the novice practitioner

34
Q

Airway Setup

A 
L   laryngoscope w/ 2 types of blades
O  oral/nasal airways
S   stylet and syringe on cuff
T   tongue depressor, tape
S   suction on and easily accessible
E   ETT 2 sizes
A   mbu-bag and machine for PPV
L    LMA &amp; facemask
35
Q

Face Masks

A

Patient characteristics may predict difficult
mask fit
◦ Examples: Beard, edentulous, short mandible

Head strap and potential nerve injuries

Technique:
◦ Hold mask in Left Hand and Reservoir Bag in Right. Thumb on upper aspect of mask, index and middle fingers on lower aspect, and 4th/5th fingers under chin for chin lift/jaw thrust

36
Q

Relaxation of the genioglossus muscle during induction can cause…

A

tongue and epiglottis to obstruct the airway

37
Q

Ensuring airway patency

A
  1. Airway Maneuvers
    ◦Head tilt/chin lift
    ◦Jaw Thrust
  2. Adjuncts
    ◦Nasopharyngeal Airway-lubricate
    ◦Oropharyngeal Airway-tongue blade
  3. 2 handed mask with bagging assistance
38
Q

Types/Sizes of oral airways

A

-Berman (BOA) & Guedel

-Adult sizes
◦ small BOA (80 mm) = Guedel #3
◦ medium BOA (90 mm) = Guedel #4
◦ large BOA (100 mm) = Guedel #5

Measure from the center of the mouth to the angle of
the jaw, or from the corner of the mouth to the earlobe

39
Q

Complications/Precautions of oral airway

A

◦ Soft tissue damage
◦ Bleeding
◦ Laryngospasm

40
Q

The nasal airway/ trumpet is used to

A

provide passageway from nose to pharynx, beneath relaxed and obstructing tongue

41
Q

Describe the nasal airway/trumpet size, measurement, insertion

A

-Diameter-French sizes 24, 26,…36; used in series small to large to dilate prior to elective nasal intubation
-Measurement estimated as distance from nares to
meatus of ear
-Lubricate!
-Usually tolerated better than oral airway during
light anesthesia

42
Q

Complications/Precautions of nasal airway

A

◦ epistaxis; anticoagulants
◦ nasal or basal skull fractures
◦ adenoid hypertrophy

43
Q

What should always be checked on laryngoscope handles? What are the types of handles?

A

Handles-> check the battery!
◦ Adult
◦ Pediatric (penlight)
◦ Stubby (short)

44
Q

What should always be checked on laryngoscope blades? What are the types of blades

A

Blades-> check the light!
◦ Macintosh (1-4)
◦ Miller (0-4)

45
Q

Macintosh blade is _________ and goes into the ________

A

Curved, Valeculla

46
Q

Miller blade is _________ and goes ___________

A

straight, under/posterior to epiglottis

47
Q

What are the ETT sizes for male and female, ideal position of tube, and measurement for depth of tube?

A

Adult ETT want 2 sizes available
◦ Female: 6.5-7.0 mm id (approximately 21 cm)
◦ Male: 7.5-8.0 mm id (approximately 23 cm)

Ideal position:
◦ 4 cm above the carina and 2 cm below the vocal
cords
ID x 3 = approximate depth

48
Q

How do you confirm placement of ETT?

A
  • bilateral chest rise
  • bilateral breath sounds
  • ETCO2 colorimetric or Capnography w/ 3 waveforms
49
Q

Murphy Eye on an ETT serves what purpose?

A

serves to provide an additional portal for ventilation should the distal end of the lumen become obstructed by either soft tissue or secretions

50
Q

The black marking on the ETT should align with the …?

A

vocal cords

51
Q

Most cuffs are ______ volume, ______ pressure.

A

High volume, low pressure

52
Q

Indications for tracheal intubation

A

◦ Airway compromise
◦ Airway inaccessible
◦ Long surgical time
◦ Surgery of head, neck, cheek, or abdomen
◦ Need for controlled ventilation and/or positive end
expiratory pressure
◦ Inability to maintain airway with mask/LMA
◦ Aspiration risk
◦ Airway/ lung disease

53
Q

What is an LMA device?

A

A supraglottic airway device used for routine and difficult airway management

Can be used as a conduit for ETT placement

54
Q

What are the appropriate sizes of LMA?

A 
Weight based sizes
◦ Adult sizes
 30-50 Kg - LMA 3
 50-70 Kg - LMA 4
 70-100 Kg -LMA 5
 >100 Kg -LMA 6
55
Q

What’s required for LMA insertion?

A

Equipment: 20 or 50 cc syringe,lubricant, suction, stethoscope, tape
◦ (lubricate posterior side only!)

Position head - neck flexed and head extended
-Hold LMA with right hand like a pen with black line facing you
-Insert LUBRICATED LMA into mouth, follow palate centrally, push into oropharynx until resistance is felt, and then stop.
-Release right hand, grasp upper aspect of LMA, and attempt
further advancement of the LMA
-Inflate the cuff (LMA will move)
-Ventilate- observe, listen (stomach, lungs)
-Secure with tape

56
Q

Advantages of LMA

A

-increased speed and ease of placement by inexperienced personnel
-improved hemodynamic stability at induction and during emergence
-reduced 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)

57
Q

Disadvantages of LMA

A
  • lower seal pressure
  • higher frequency of gastric insufflation
  • esophageal reflux more likely
  • inability to use mechanical ventilation*
58
Q

Potential Hazards of airway management

A
  • Dental damage
  • Soft tissue/mechanical injury
  • Laryngospasm
  • Bronchospasm
  • Vomiting/Aspiration
  • SNS stimulation
  • Hypoxemia/Hypercarbia
  • Esophageal/Endobronchial intubation
59
Q

Laryngoscopy injury complications

A

HTN, tachycardia, bradycardia, corneal abrasion, dental trauma, spinal cord trauma, aspiration

60
Q

Laryngospasm

A

RECOGNIZE THE EVENT!!!
Severe, sudden, sustained contraction of the glottic
opening (vocal cords) in response to a stimulus (blood,
secretions, light anesthesia) characterized by complete
airway obstruction with retractions

61
Q

Treatment of Laryngospasm

A

◦ Jaw-Lift Maneuver and placement of mask
◦ O2 w/ continuous Positive Pressure
◦Strong intermittent pressure applied manually to a bag full of oxygen can force gas effectively through the upper airway and adducted cords.

-Immediate removal of the offending stimulus
◦ Small dose of short acting Muscle Relaxant Succinylcholine
20-40 mg IV

62
Q

MAC Case

A
  • Complete Airway Setup Ready to go
  • Nasal Cannula- EVERYONE GETS O2
  • Spontaneously Breathing Patient
  • Nasal airway if snoring (partially obstructed breathing)
63
Q

General Anesthesia Mask Case

A

Use when:

  • Difficult airway not present
  • Surgeon does not need access to head/neck (BMT-ok)
  • No airway bleeding/secretions
  • Case of short duration
  • No table position changes- head available
  • Obstruction easily relieved with oral nasal airway/ chin lift
  • Patient will spontaneously breathe-no neuromuscular blocker used
64
Q

General Anesthesia LMA Case

A 
Use when:
◦ Difficult airway not present
◦ Surgeon does not need access to head/neck (?)
◦ No airway bleeding/secretions
◦ Case of short duration
◦ More reliable patent airway than mask
◦ Want hands free
65
Q

Induction of Anesthesia step 1

A 
Goal = Increase O2 concentration in functional
residual capacity (FRC) by “washing out”
nitrogen (79% in RA) in the FRC with oxygen
FRC volume of air left in the lung at end of passive expiration

3-5 minutes of “tight” mask fit during normal tidal breathing w/ 100% FiO2 at> 6L/min flow
= 10 minutes of safe apnea time

4 vital capacity breaths within 30 seconds with
100% FiO2 at >6L/min= 5 minutes of safe
apnea time

66
Q

Induction of Anesthesia

A
  1. Position patient supine in sniffing position
  2. Turn on oxygen flow
  3. Begin preoxygenation
  4. Monitors on and vital signs taken (O2 sat, BP, ECC, PNS)
  5. Suction on and ready at head-of-bed
  6. Induction agent
  7. Test lash reflex
  8. Give test mask ventilation
  9. Check neuromuscular-blocking monitor (PNS) working
  10. Paralytic drug
  11. Continue mask/bag ventilation until twitches cease/loss of twitches
  12. Tape eyes closed
  13. Laryngoscopy and intubation
  14. Confirm ETT placement—bilateral breath sounds, chest rise and fall,
    presence of ETCO2 x 3stable waveforms
  15. Continue ventilation by bag or ventilator
  16. Begin maintenance anesthetic
  17. Tape ETT
  18. Begin maintenance anesthetic
  19. Surgical case
67
Q

Basic steps of Emergence of Anesthesia

A
  1. Muscle relaxant must be fully reversed
  2. Anesthetic medications, including anesthetic gases
    and infusions, turned OFF
  3. Oropharynx is suctioned.
  4. Patient is self-maintaining an acceptable respiratory rate and depth
Respiratory Criteria*
 TV >5 mL/kg
 VC > 10 mL/kg
 RR < 30 breaths/min
 SaO2 > 90%
 ETCO2 <50
5. Assess for responsiveness / purposeful movement and/or responding to commands/ sustained 5 sec. head-lift
6. ETT is removed while a positive-pressure breath is given with the anesthesia bag to allow subsequent expulsion or secretions out of the glottis

Intro to Anesthesia (4 decks)

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