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2-General Anesthesia Exam 1 > Airway Assessment > Flashcards

Airway Assessment Flashcards

1
Q

Airway assessment: Should be conducted in a _______ and ______ fashion

A

thorough and systematic fashion

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2
Q

What does evidence say about airway exam techniques?

A

No single examination has emerged that has a consistently high sensitivity and specificity with minimal false positive or false negative reports

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3
Q

Research advocates for the use of __________

A

multiple airway tests

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4
Q

What does the mallampati classification allow us to determine? (2)

A
  • Serves as a rough estimate of the tongue size relative to the oral cavity
  • Provides an estimate of the relative visibility of the pharyngeal structures
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5
Q

Mallampati classification: A __________ may hinder the view of the larynx

A

disproportionately large tongue base

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6
Q

Describe how you should instruct the patient on how to preform the mallampati classification.

A
  • Perform with patient in sitting position.

- Instruct patient to open mouth as wide as possible and stick their tongue out.

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7
Q

What should be avoided during the mallampati assessment?

A

Avoid phonation

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8
Q

What is the Intraclass Correlation Coefficient ICC?

A

Used to describe the degree to which individuals with a fixed degree of relatedness (e.g. siblings, anesthesia providers, etc.) resemble each other in terms of a quantitative trait.

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9
Q

What is sensitivity?

A

is the ability of a test to correctly identify those with the disease (true positive rate)

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10
Q

What is the specificity?

A

is the ability of the test to correctly identify those without the disease (true negative rate)

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11
Q

What is the Intraclass Correlation Coefficient (ICC) of the mallampatic?

A

0.31

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12
Q

Mallampati: Sensitivity _____%; Specificity _______%

A

Sensitivity 49%; Specificity 86%

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13
Q

When is the hard palate immobile?

A

Immobile during mastication, breathing and swallowing

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14
Q

What is the function of the soft palate? (3)

A

1) Prevents food from entering nasal passages; 2) With age the soft palate stretches and becomes more pliable; 3) the soft palate relaxes and may cause upper airway obstruction

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15
Q

What are the characteristics of the Mallampati Class I (3)?

A

Exposure of the:

  • Soft palate
  • Faucial pillars
  • Entire uvula
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16
Q

What are the characteristics of the Mallampati Class II (3)?

A

Exposure of the:

  • Soft palate
  • -Faucial pillars
  • Portion of the uvula
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17
Q

What are the characteristics of the Mallampati Class III (3)?

A

Exposure of the:

  • Soft palate
  • Base of the uvula
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18
Q

What are the characteristics of the Mallampati Class IV?

A

Exposure of the: Hard palate only

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19
Q

Practice examples

A

Slide 44

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20
Q

What is the airway opening assessment?

A

Defined as the maximal mouth opening and measured by the distance between upper and lower incisors

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21
Q

The airway opening should be at least __________.

A

3cm (2 full finger breadths)

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22
Q

What is the Intraclass Correlation Coefficient (ICC) of the oral opening?

A

0.93, excellent correlation

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23
Q

Oral opening: Sensitivity _____%; Specificity _______%

A

Sensitivity 46%; Specificity 89%

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24
Q

What is the thyromental distance assessment?

A

Defined as the distance from the mentum to the thyroid notch

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25
Q

What would be considered a challenging airway according to the thyromental distance?

A
  • If less than 6cm (3 finger breadths) anticipate a challenging airway
  • May also be challenging if >9cm
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26
Q

What is the Intraclass Correlation Coefficient (ICC) of the thyromental distance?

A

0.74

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27
Q

Thyromental distance: Sensitivity _____%; Specificity _______%

A

Sensitivity 20%; Specificity 94%

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28
Q

What is the Prognathism/Mandibular Protrusion Test?

A

Ability to protrude the lower jaw beyond the upper incisors (ULBT)

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29
Q

How many classifications of the Prognathism/Mandibular Protrusion Test

A

3

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30
Q

What is a normal Prognathism/Mandibular Protrusion Test?

A

Patient can protrude lower incisors anteriorly past the upper incisors and can bite the upper lip above the vermilion border

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31
Q

What is a intermediate Prognathism/Mandibular Protrusion Test?

A

Patient can move lower incisors in line with the upper incisors and bite the upper lip below the vermilion border, but cannot protrude lower incisors beyond

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32
Q

What is a abnormal Prognathism/Mandibular Protrusion Test?

A

Lower incisors cannot be moved in line with the upper incisors, and cannot bite the upper lip*

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33
Q

What is the Intraclass Correlation Coefficient (ICC) of the Prognathism/Mandibular Protrusion Test?

A

0.66

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34
Q

What is the Atlanto-Occipital Extension?

A

Measurement of patient angles in the sniffing position

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35
Q

What is the desirable result of Atlanto-Occipital Extension?

A

A greater degree of extension is desirable, normal head extension is 35 degrees

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36
Q

What is the Intraclass Correlation Coefficient (ICC) of Atlanto-Occipital Extension?

A

0.67

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37
Q

What does the Profile Classification/Mandibular Hypoplasia measure?

A

Measurement of retrognathia

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38
Q

What is the Intraclass Correlation Coefficient (ICC) of Profile Classification/Mandibular Hypoplasia?

A

0.58

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39
Q

What is ramus length?

A

Length of the jaw

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40
Q

What is the Intraclass Correlation Coefficient (ICC) of ramus length?

A

0.53

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41
Q

What is the oropharyngeal best view?

A

The best Mallampati view obtained using any and all means

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42
Q

What is the Intraclass Correlation Coefficient (ICC) of oropharyngeal best view?

A

0.49

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43
Q

What is the sternomental distance?

A

Less than 12.5cm my indicate difficults

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44
Q

What is sternomental distance reliability?

A

Poor indicator

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45
Q

Review additional factors:

A

Slide 50

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46
Q

What are some advantages of the artificial airways?

A

Creates a patent airway after loss of upper airway tone secondary to relaxation of the genioglossus muscle

47
Q

What are the disadvantages to oral airways (2)?

A
  • Awake or lightly anesthetized patient at risk for laryngospasm
  • Nasal airways trauma may lead to epistaxis
48
Q

What are some contraindications to artificial airway? (3)

A
  • Contraindicated in anticoagulated patients
  • Children with prominent adenoids
  • Basilar skull fracture
49
Q

What is an absolute contraindication to artificial airways?

A

Basal skull fracture, can end in brain

50
Q

Nasal airway: How do you measure the device?

A

on the patient, Device should reach from the patient’s nostril to the earlobe or angle of the jaw

51
Q

What should be done before inserting the nasal airway tube?

A

thoroughly lubricate the length of the device to minimize soft tissue trauma

52
Q

How do you determine the appropriate diameter of the nasal airway device?

A

Examine patient’s nostrils

53
Q

How is the nasal airway inserted?

A

Insert the airway perpendicular to the nostril with gentle pressure. If unable to pass, attempt placement through other nostril

54
Q

How is an oral airway chosen?

A

Correct size is chosen by measuring the device against the patient’s head from the earlobe to the corner of the mouth

55
Q

Why is measuring for the oral airway important?

A

Measuring is important. The flared ends of the airway must rest securely against the oral opening in order to remain secure

56
Q

What are two methods for inserting an oral airway?

A
  • Place oral airway in the mouth. Once contact is made with the back of the throat, rotate the airway 180 degrees.
  • Use a tongue depressor to hold the tongue down and insert the airway right side up. This is the preferred method
57
Q

What can happen with the 180 degree rotating airway method for inserting oral airway?

A

May cause trauma to roof of mouth

58
Q

How does the head tilt and chin lift help with insertion?

A

Obtain an extended position

59
Q

What is the components of the jaw thrust?

A

Grasp the angles of the lower jaw and lift with both hands on each side moving the jaw forward

60
Q

Mastering the art of ________ is a hallmark of the anesthesia provider

A

mask ventilation

61
Q

What is required for effective ventilation?

A

requires a tight seal and patent airway

62
Q

What is the incidence of difficult BMV? Impossible BMV?

A

Incidence of difficult BMV has been described between 0.9% and 7.8% and the incidence of impossible BMV as 0.15%

63
Q

What is the hand position for face mask ventilation?

A

C and E

64
Q

What are some characteristics that can be indicative of a difficult BMV? (10)

A
  • Mask seal impediments: facial hair, altered facial anatomy, edentulous, -NGT
  • Upper airway obstructions
  • Obesity: BMI >30kg/m2
  • Pregnancy, esp. third trimester
  • Elderly patients
  • Mallampati scores of III or IV
  • Short thyromental distance
  • Snoring/OSA
  • Poor lung compliance
65
Q

What is the goal of the ASA closed claims projects?

A

The goal of the American Society of Anesthesiologists (ASA) Closed Claims Project is to identify major safety concerns, patterns of injury and strategies for prevention to improve patient safety.

66
Q

The project consists of an in-depth investigation of approximately ______ closed insurance claims resulting from anesthetic mishaps

A

10,000

67
Q

How is ASA data gathered for ASA closed claims?

A

Data is gathered in the form of detailed case summaries collected by ASA member anesthesiologists from insurance company claim files.

68
Q

Most cases are from mishaps resulting in _______, as files in these cases contain the most extensive information

A

lawsuits

69
Q

Review the database of the ASA closed claims.

A

Slide 68

70
Q

What are the top three sentinel events associated with ASA closed claims?

A

Permanent brain damage (867), airway injury (581), difficult intubation (466)

71
Q

Esophageal intubations have declined significantly since the adoption of _____________.

A

end tidal capnography

72
Q

Inadequate oxygenation and ventilation have also declined with the adoption of _________ as a standard intra-operative monitor

A

pulse oximetry

73
Q

ASA review: How many claims were reviewed

A

179 claims

74
Q

ASA review: What was the setting of these claims?

A

87% of claims occurred in peri-operative setting; 13% occurred at outside locations

75
Q

ASA review: Who was more likely to be subjects of claims outside the OR? (3)

A

more likely to be female, ASA I-II, and pts undergoing general, ortho or gyn/urologic surgery

76
Q

________ or ________ occurred in more than half of the peri-op claims and ALL of the claims outside of the operating suite.

A

Death or brain damage

77
Q

Review indications for intubation.

A

Slide 72

78
Q

What are the characteristics of inability to oxygenate or ventilate?

A

SpO2 <90%, PaO2 <55mmHg, rising PaCO2, respiratory acidosis, mental status changes

79
Q

What are the key steps to intubation preparation? (4)

A
  • Assemble and check all equipment
  • Calculate correct doses of medications and draw up medications
  • Ensure appropriate IV access and flush fluid
  • Optimize your intubating condition
80
Q

What blade is most commonly used to learn intubation technique?

A

Macintosh

81
Q

What blade had advantageous for anterior intubations?

A

Miller

82
Q

What is the is the rule of thumb for determining ETT size in pedicatrics?

A

(Age/4) + 4 (uncuffed) OR (Age/4) + 3.5 (cuffed)

83
Q

What is the equation for determining length of insertion of ETT?

A

Length of insertion = 3 x ID

84
Q

What size ETT is appropriate for a premature neonate?

A

2.5-3.0 mm ID @ 8cm

85
Q

What size ETT is appropriate for a FT neonate?

A

3.0 mm ID @ 10cm

86
Q

What size ETT is appropriate for a 1-6 months?

A

3.5 mm ID @ 11cm

87
Q

What size ETT is appropriate for a 6-12 months ?

A

4 mm ID @ 12cm

88
Q

What size ETT is appropriate for a age 2 years old?

A

4.5 mm ID @ 13cm

89
Q

What size ETT is appropriate for a 4 years old ?

A

5.0 mm ID @ 14cm

90
Q

What size ETT is appropriate for a 6 years old ?

A

5.5 mm ID @ 15 cm

91
Q

What size ETT is appropriate for a 8 years old ?

A

6.5 mm ID @ 16 cm

92
Q

What size ETT is appropriate for an adults ?

A

7.0-8.0 mm ID

93
Q

What is the optimal bed height for intubation?

A

Ensure bed is at a comfortable height – HOB at xiphoid process

94
Q

What is the optimal patient position for intubation?

A

Patient aligned without lateral deviation of head or neck, Shoulders, head and neck supported, Extremities supported and secure

95
Q

What does the sniffing position do?

A

Aligns the laryngeal, oral and pharyngeal axes

96
Q

Most pediatric patients are, by virtue of their anatomy, already in the _______ .

A

sniffing position.

97
Q

How do you preform the sniffing position?

A
  • Neck flexed approximately 15 degrees
  • Head hyperextended to maximum comfortable degree (may be done after induction)
  • Elevate the patient’s head and extend the atlanto-occipital joint
  • Allows for optimal visualization of the glottic opening
98
Q

What is another name for sellick’s maneuver?

A

“cricoid pressure”

99
Q

How do you instruct someone to preform the sellick maneuver?

A

Thumb and index finger of assistant apply downward pressure to the cricoid cartilage
“BURP (back upward right pressure)”

100
Q

When do you apply cricoid pressure?

A

Begin applying pressure prior to administration of induction agents

101
Q

When do you release cricoid pressure?

A

Do not release pressure until receiving confirmation that the airway has been secured

102
Q

When is cricoid pressure usually used?

A

Used during rapid sequence induction (RSI)

103
Q

What are the steps for RSI?

A
  • Preoxygenate patient
  • Assortment of blades and ETT prepared prior to induction
  • Sellick’s maneuver applied by assistant
  • Administration of induction agents, including rapid acting muscle relaxant (succinylcholine vs rocuronium)
104
Q

Why is the sellick’s maneuver applied?

A

to avoid potential aspiration of gastric contents

105
Q

RSI: Mask ventilation is ______

A

avoided

106
Q

How are pts preoxygenated in RSI?

A

100% high flow (8-12 L) not bag mask

107
Q

What is important to know about cricoid pressure in clinical practice?

A

literature suggest controversy over this benefits out weigh risks

108
Q

What could happen if a patient vomits during cricoid pressure?

A

cricoid could rupture

109
Q

In the pediatric population less than ________, the cricoid cartilage is the narrowest portion of the airway*

A

5 years

110
Q

An ETT that passes thru the glottic opening may still have difficult passing the _________

A

cricoid cartilage

111
Q

What can mucosal trauma from forcing the ETT lead to postop? 4

A

edema, stridor, croup or airway obstruction

112
Q

Due to the chance of mucosal trauma from forcing the ETT into a pediatric patient, it is recommended for uncuffed ETTs or not inflating a cuffed ETT in peds ________.

A

< 5 years

113
Q

What can external manipulation of the cricoid during intubation do the the vocal cords?

A

can alter the view of the vocal cords in both pediatrics patients and adults

2-General Anesthesia Exam 1 (7 decks)

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