Airway Assessment

Question 2

carina

Answer 2

where trachea bifurcates.

Left and right sides come off at different angles.

right bronchi is 2.5 cm long with 25 degree angle

left bronchi is 5cm long with a 45 degree angle

Question 3

Pre-op airway assessment

Answer 3

1. general appearance
2. Malampati classification
3. range of motion of neck
4. thyromental distance
5. dentition
6. mouth (lips, gums, tissues)
7. mouth oppening (2-3 fingers)
8. teeth (missing, protrusions, overbite, bridges out)
9. size and mobility of tongue
10. body habitus
11. Hx of difficult intubation

*aspiration risk (hiatal hernia, GERD, recently ate, OSA)

Question 4

Mallampati score

Answer 4

Pt sitting upright, head neutral mouth open as wide as possible and tongue maximally protruded. No AAAH!

• Correlates the oropharyngeal space with the ease of direct laryngoscopy and tracheal intubation.
  
  • When the base of the tongue is disproportionately large, the tonge overshadows the larynx resulting in difficult exposure of the vocal cords during laryngoscopy.

No AAAH!

Question 6

Cormack and Lehane Score

Answer 6

Laryngoscopic view of the glottis

Grade I: most of the glottis visible

Grade II: Only the posterior portion of glottis visible

Grade III: Only epiglottis visible

Grade IV: No airway structures visualized

Question 7

Thyromental Distance

Answer 7

• Distance from lower border of mandible to thyroid notch with neck fully extended
  
  • Normal 4 fingerbreadths (6-6.5 cm)
• Difficult intubation <3 fingers

Question 8

Optimal intubating position

Answer 8

“sniffing”

Oral, pharyngeal, and laryngeal axis

Most optimal for visualization of vocal cords and most effective mask ventilation

Question 9

Mallampati classes

Answer 9

1. faucial pillars, entire uvula, soft and hard palates.
2. Uvula tip masked by tongue, soft and hard palates
3. Soft and hard palates, uvula base only
4. Hard palate only

PUSH

pillars, uvula, soft palate, hard palate

Question 10

Nasal passage includes:

Answer 10

• septum
• turbinates
• adenoids
• paranasal sinuses

Question 11

Answer 11

just remember where all that shit is

Question 15

Oral airways

Answer 15

measure from the corner of the mouth to the earlobe

• use tongue depressor to insert
• Complications:
  
  • laryngospasm
  • bleeding
  • soft tissue damage
• 2 types: Berman (BOA) and Guedel (hollow)
  
  • small- BOA 80mm / Guedel 3
  • medium- BOA 90mm / Guedel 4
  • large - BOA 100mm / Guedel 5

Question 16

Trachea

Answer 16

Fibromuscular

10-20 cm length, 22 mm diameter

no cartilage on posterior side

bifurcates at T-4 (carina)

Question 17

Trachea

Answer 17

• extends from inferior end of larynx into the thorax
• teminates at the sternal angle (T4) where it bifurcates (carina) into left and right main bronchi
  
  • 2.5cm in diameter
  • 10-20 cm length
  • 16-20 U shaped cartilages
  • posterior side lacks cartilage
    
    • posterior gap is spanned by the involuntary trachealis muscle
• innervated by the Recurrent Laryngeal Nerve of the Vagus Nerve

Question 18

Mainstem bronchi

Answer 18

• Right mainstem bronchi is 2.5 cm long with 25 degree angle
• Left mainstem bronchi is 5 cm long and 45 degree angle

Question 19

Lobar bronchi Left Vs right

Answer 19

Left has 2

Right has 3

Question 20

General anesthesia Mask case

Answer 20

• Can be used when:
  
  • no difficult airway
  • surgeon does not need access to head/neck
  • no airway bleeding/secretions
  • short case
  • no position changes and easy access to head
  • obstruction easily relieved with oral or nasal airway
  • no neuromuscular blocker used–spontaneous breathing

Question 21

Tracheal intubation indications

Answer 21

1. airway compromise
2. airway inaccessible
3. long surgical time
4. surgery of head, neck, cheek, or abdomen
5. need for controlled venticalion and/or PEEP
6. Inability to maintain airway with mask/LMA
7. aspiration risk
8. airway/lung disease

Question 22

General anesthesia LMA case

Answer 22

1. surgeon does not need access to head/neck
2. no airway bleeding/secretions
3. case of short duration
4. more reliable patent airway than mask
5. want hands free
6. no NMB needed

Question 23

General Anesthesia ETT case use when:

Answer 23

1. airway compromise
2. airway inaccessible
3. long surgical time
4. alternate surgical positions
5. surgery of head, neck, cheek, or abdomen
6. need for controlled ventilation and PEEP
7. inability to maintain airway with mask/LMA
8. aspiration risk
9. deliver predictable O2

Question 24

What is the difficult airway algorithm?

Answer 24

Question 25

What should you do if you expext problems with your airway?

Answer 25

• have the difficult airway cart
• plan a fiberoptic intubation
• know the difficult airway algorithm

Question 26

LMA

Answer 26

• Supraglottic airway device
• used for routine AND difficult airway management
• can be used as conduit for ETT placement
• sizing based on weight
  
  • 30-50kg–> LMA 3
  • 50-70kg –> LMA 4
  • 70-100kg –> LMA 5
  • >100 kg –> LMA 6
• Can be used for positive pressure but is not meant for it
  
  • only positive pressures below 15.

Question 27

LMA advantages over ETT

Answer 27

1. increased speed and ease of placement
2. improved hemodynamic stability at induction and emergence
3. reduced anesthetic requirements
4. lower frequency of coughing during emergence
5. lower incidence of sore throats
6. avoids “foreigh body” in trachea
7. pt can be fully emerged before removal. (good for asthma patients)

Question 28

LMA disadvantages

Answer 28

1. lower seal pressure
2. high frequency of gastric insufflation
3. esophageal reflux more likely
4. inability to use mechanical ventilation

Question 29

What is normal cervical ROM?

Answer 29

Question 30

What are the classes of the Mandibular protrusion test?

Answer 30

Question 31

What are you assessing during the physical airway exam?

Answer 31

* Mouth opening * \>4cm or \>2 fingerbreadths * size and mobility of tongue * palate- high or arched? * any mass seen? * size and shape of mandible * TMJ/ROM * ability to advance lower incisors in front of upper?

Question 32

What are you observing for when looking at the teeth?

Answer 32

* poor dentitian * loose teeth * chipped teeth * capped * removable bridges * dentures

Question 33

Pre-op airway assessment

Answer 33

1. general appearance- deformities, trach scars, etc 2. Malampati classification 3. range of motion of neck 4. thyromental distance 5. dentition 6. mouth (lips, gums, tissues) 7. mouth oppening (2-3 fingers) 8. teeth (missing, protrusions, overbite, bridges out) 9. size and mobility of tongue 10. body habitus 11. Hx of difficult intubation \*aspiration risk (hiatal hernia, GERD, recently ate, OSA)

Question 34

What are some co-morbidities that may effect airway management?

Answer 34

* Lesions/infections of larynxx * thyroid disease- compresses airway * Cancer- radiation * Diabetes * Obesity- diff to allign axis * genetic disorders * rheumatoid arthritis * musculoskeletal * scleroderma- thick SC tissue, difficult to open mouth * genetic disorder

Question 35

What should you ask the pt regarding their airway history?

Answer 35

* Have you had an anesthetic in the past? * were you told of any airway problems? * was there severe sore throat or dental damage? * were you advised to have an awake or fiberoptic intubation * did you have any records or documentation? * any breathing difficulties? * Any recent cough -irritated airway more likely to laryngospasm * COPD/asthma?- have inhalor ready, use before case * do you snore? * do you use CPAP?