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AFN Assessment > Airway Assessment 1 > Flashcards

Airway Assessment 1 Flashcards

1
Q

Single most important factor in safe and satisfactory anesthesia & resuscitation

A

Airway management

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2
Q

3 High Risk Themes

A

Communication failure: CRNA, surgeon, nurses, pt, etc. tx of care
Failure to comply w/ AANA standards: read through the list
Errors in judgment: fatigue/stress

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3
Q

Improvement in airway risk

A

implementation of systems for prevention/detection of errors, quality improvement, airway assessment tools, difficult airway algorithm, better equipment, drug safety, improvements in operating systems (time outs, etc)

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4
Q

People do not die from lack of intubation, they die from a lack of ventilation!!!

A
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5
Q

Examples of anesthesia complications

A

aspiration
obstruction
resp failure
high spinal
local anesthetic toxicity
anaphylaxis
sedative overdose

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6
Q

How many breaths of Positive CO2 is needed on monitor to confirm ETT placement?

A

6

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7
Q

Minor morbidity

A

Moderate distress w/o prolonging hospital stay
No permanent complications (PONV)

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8
Q

Intermediate morbidity

A

Serious distress prolonging hospital stay.
No permanent complications (dental injury, aspiration, spasm)

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9
Q

Major Morbidity

A

permanent disability or complication (anoxic brain injury, spinal injury)

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10
Q

Airway types

A

Routine, anticipated difficult, unanticipated difficult, failed

Most difficult airways are unanticipated - usually due to inflamed or swollen lingual tonsils undetected on assessment.

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11
Q

Considerations for airway mgmt

A

Thorough airway history/exam
Consideration of ease of intubation
Form mgmt plan for mask ventilation or supraglottic airway
Estimate relative risk of periods of apnea
Aspiration risk

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12
Q

Review the Difficult Airway Algorithm

A
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13
Q

Induction Mgmt Plan

A

provide oxygen the entire time!! (new).
Patient can tolerate a longer apneic period if you’re oxygenating the whole time

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14
Q

Consideration in induction Mgmt Plan

A

Aspiration risk
Likeliness to obstruct
Difficulty in masking
Difficulty with SGA/intubation
Toleration of apneic period
Comorbidities
Anesthesia history

Make extubation part of your plan. Unless you decide to leave ETT in.

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15
Q

Nose & Nasopharynx (Turbinates)

A

Large surface area, very vascular
Relevant for placement of nasal trumpet
Risk for bleeding increases if enlarged.

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16
Q

Nose Bleeds

A

Inc vascularity with pregnancy, allergies, and prolonged prone positioning

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17
Q

_________ stimulation usually constricts blood vessels, but we block that with anesthesia

A

Sympathethic

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18
Q

Where do 90% of nose bleeds occur?

A

Anterior (littles area): ICA/ECA branches

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19
Q

How should you stop nose bleeds

A

hold pressure on cartilaginous part of nose, not on nasal bone! (many branches of anterior ethmoid artery here)

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20
Q

Tx of Posterior Nose bleed

A

hard bleed to treat (may require embolization, surgery, silver nitrate, ballooning, packing), further back, profuse, sphenopalatine artery, greater risk of airway compromise, blood in both nostrils & posterior pharynx.

Apply pressure, gauze, neo on gauze. If doesn’t stop → CALL ENT

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21
Q

What causes a person to be more susceptible to nose bleeds?

A

allergies, dryness, chemical exposure, prone position, blood thinners, broken nose

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22
Q

Location of the Oropharynx

A

Starts at the mouth and meets the nasopharynx posteriorly. Soft palate → epiglottis, contains the palatine & lingual tonsils

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23
Q

Tongue

A

Large muscle, relaxes when it falls back

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24
Q

Soft Palate

A

Raises during swallowing

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25
Q

Uvula

A

protects passageway from oral cavity to nasopharynx

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26
Q

What happens to the oropharynx with increasing age?

A

With increased age (>50), muscle tissues stretch/relax → increases obstruction

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27
Q

Enlargement of the pharyngeal adenoids tonsils can cause obstruction of what structure in the nasopharynx?

A

Eustachian tubes

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28
Q

T/F: Palatine tonsils which are located in the oropharynx can cause enlargement w or w/o infection?

A

True

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29
Q

What are the most common cause of enlargement and are compensatory mechanisms after tonsillectomy or with auto-immune disorders. These are also located on posterior ⅓ of tongue.

A

Lingual Tonsils

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30
Q

Lingual Tonsil enlargement

A

CANNOT see with airway assessment; unanticipated difficult airway!!!

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31
Q

Laryngeal skeleton

A

3 unpaired cartilage (thyroid, cricoid, epiglottis)

3 paired cartilages (arytenoid, corniculate, cuneiform)

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32
Q

Hyoid bone

A

chief support for the larynx

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33
Q

Fxn of the Larynx

A

Protect patency between hypopharynx (part of throat that lies behind the larynx; entrance to the esophagus) & trachea
Phonation
Gag/cough reflexes

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34
Q

Location of Larynx in adults

A

C4-C6

35
Q

Location of Larynx in infants

A

C3-C4 & more anterior

36
Q

Differences b/w Male and Female Vocal Cords

A

Male vocal folds are longer (17mm-25mm) - deeper voice

Female vocal folds are shorter (12.5-17.5) - higher pitch voice.

37
Q

Review Netter’s plates 54, 60, 70-74 for airway anatomy

A
38
Q

Thyroid cartilage

A

Largest of the 9 cartilages

Superior cornu attaches to lateral thyrohyoid ligament
Inferior cornu attaches to cricoid cartilage

39
Q

Cricoid Cartilage

A

Anatomical lower limit of the larynx
Wraps completely around larynx (only complete ring in upper airway!)
Narrowest part of larynx in a child
Attaches to the thyroid cartilage by the cricothyroid membrane (1-1.5 cm past laryngeal prominence)

40
Q

Cricoid Pressure

A

Used in RSI, controversial. Apply light pressure until they fall asleep, then firmer. If vomiting, let go

41
Q

Epiglottis anatomy

A

Unpaired leaf-shaped projects obliquely upward (free extremity is broad & rounded with a stem connected to the thyroid cartilage),

42
Q

Epiglottis fxn

A

protect the glottis from aspiration (when swallow, it folds backward)

43
Q

Vallecula

A

pouch-like area found between the median & lateral folds of epiglottis

44
Q

Epiglottis attachments

A

INFERIORLY to posterior aspect of thyroid cartilage
SUPERIORLY into the hypopharynx
POSTERIORLY is free & visualized with laryngoscopy
ANTERIOR attached the hyoid bone

45
Q

What are the paired cartilages of larynx?

A

Artyenoids
Cuneiform
Corniculate

46
Q

Arytenoids

A

pyramidal shaped, attached to posterior portion of vocal cords, articulates with the cricoid cartilage forming a synovial joint (problem w rheumatoid arthritis- vocal cord fatigue)

47
Q

Cuneiform & Corniculate

A

connected to the arytenoids by laterally placed aryepiglottic ligaments & folds, embedded in the aryepiglottic folds, reinforce & support the aryepiglottic folds & may help the arytenoids move

48
Q

Vocal Cords & Glottis

A

Fibromembranous folds attached anteriorly to the thyroid cartilage and posteriorly to the arytenoids, alteration in tension on the vocal cords determines the pitch of the voice

49
Q

Intrinsic muscles

A

TENSION of vocal cords control the glottic opening, moves the cartilages in relation to each other

50
Q

Extrinsic muscles

A

move the larynx as a whole, connects larynx, hyoid, & neighboring structures, adjusts the POSITIONING of the larynx

51
Q

Pharyngeal Muscles

A

Posterior Cricoarytenoids- abduction
Lateral Cricoarytenoids - adduction

52
Q

In an awake patient muscle tension is maintained by…

A

Tensor palatini m (nasopharynx)
Genioglossus m (oropharynx)
Hyoid m (laryngopharynx)

53
Q

Importance with correction of sleep apnea

A

Many surgeries to correct: hyoid suspension, genioglossal advancement, upper airway stimulators)

54
Q

Motor innervation of the tongue

A

CN XII Hypoglossal N
CN IX Glossopharyngeal N

55
Q

Complications of CN XII Hypoglossal N

A

Risk of injury during vigorous manipulation of airway
Risk of nerve palsy with LMA/use of nitrous oxide. Complications can lead to Dysphagia

56
Q

CN IX Glossopharyngeal

A

Sensory innervation to: vallecula, base of the tongue, roof of the pharynx, tonsils, undersurface of soft palate)

57
Q

Stimulation of CN IX Glossopharyngeal N will result in what?

A

Gag reflex and increased coughing

58
Q

Glossopharyngeal Nerve Block

A

Anesthetize the tongue with topical anesthesia
Inject in the gutter where tongue meets palatoglossal arch using a 23 or 25g needle →
Inject 1-2 cc lido on both side
MUST ASPIRATE! Risk of intracarotid injection!

59
Q

Which nerves share nuclei in the medulla?

A

Glossopharyngeal, vagus, & spinal accessory nerves

60
Q

Gag reflex MOA

A

stimulation such as suctioning back of oropharynx sends afferent impulse via CN IX to medulla → vagus nerve sends efferent impulse for all muscles to contract → GAG

61
Q

Innervation of the Larynx

A

CN X Vagus nerve

Supplies sensory & motor innervation, 2 main branches

62
Q

What nerve supplies sensory innervation above the VC (supraglottic)?

A

Superior Laryngeal N (2 Branches)

63
Q

What are the 2 branches of the SLN?

A

Internal Branch
External Branch

64
Q

What does the External branch of the SLN do?

A

Motor innervation to cricothyroid muscles
Tenses the VC

65
Q

T/F: Unilateral injury to the larynx indicates an immediate need for repair.

A

False: usually no treatment, over time the VC will move medial, changes in voice or voice tiring

66
Q

Bilateral injury to the larynx

A

(rare) aspiration risk
Possible need for tracheostomy
Loss of sensation above cords (inability to adduct-close)
Floppy cords

67
Q

Route of the Recurrent Laryngeal N

A

Right RLN loops around Brachiocephalic innominate artery; Left RLN wraps around Aorta

68
Q

Sensory innervation for the Recurrent Laryngeal N

A

Sensory below VC (Subglottic)

69
Q

Motor innervation for the Recurrent Laryngeal N

A

Motor innervation to all intrinsic muscles EXCEPT cricothyroid

Motor innervation to the cricoarytenoids (ONLY ABDUCTORS of VC)

70
Q

Unilateral damage to the RLN will cause what?

A

Hoarseness

71
Q

Bilateral injury to the RLN will cause what?

A

* worst scenario

Unopposed adduction by the cricothyroid via the SLN → inability of the cords to abduct
Aphonia
Stridor can lead to death
IMMEDIATE REINTUBATION & laryngoscopy to evaluate cord function

72
Q

Damage to either the SLN or the RLN may cause the larynx to become incompetent with a potential for _________ or _____________!!

A

Aspiration or Airway obstruction

73
Q

Superior Laryngeal Nerve Block

A

→sensory above vocal cords, supraglottic region

Find the hyoid bone & greater cornu of hyoid bone at angle of mandible
Walk off hyoid bone to thyrohyoid membrane
Inject a small amount of local
Go 2-3mm deep & inject 2 mL lido
Repeat on the other side

74
Q

What risk is associated with a Transtracheal Block?

A

Risk of tearing mucosa with needle

This block is contraindicated if aspiration risk

75
Q

Transtracheal Block Procedure

A

Find cricothyroid membrane & find middle
Do a skin wheel of local 22g angiocath w 5mL syringe attached
Add about 3-5 mL of lidocaine
Aspirate constantly (want air bubbles)
When get bubbles, remove needle while advancing catheter & inject lido
Tell patient to take a deep breath while injecting → cough spreads local

76
Q

What are the laryngeal muscles?

A

Vocal cords
Glottis

77
Q

Vocal cords movement

A

Lengthened by cricothyroid muscles (tension)
Shortened by thyroarytenoid muscles (relaxation)

78
Q

Glottis movement

A

Abducted by posterior cricoarytenoid (opens) - “Pulls Cords Apart”
Adducted by lateral cricoarytenoids (closes )

79
Q

How many cartilaginous rings are located in the trachea?

A

15-20 rings

80
Q

The last ring produces the bronchial bifurcation also known as what?

A

Carina

Lies at the angle of louis formed by the articulation of the manubrium with the body of the sternum

81
Q

Why are the tracheal rings incomplete?

A

Allow for esophageal expansion

82
Q

The length from the VC to carina is about________

A

10-15cm

83
Q

Right mainstem bronchi

A

Diverges from trachea at 20 degree angle, 2 cm long

84
Q

Left mainstem bronchi

A

Diverges from trachea at 45 degree angle, 5 cm long

AFN Assessment (7 decks)

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