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Health Assessment > Airway Assessment (Exam 2) > Flashcards

Airway Assessment (Exam 2) Flashcards

1
Q

What are the (7) airway structures?

A
  • Nose
  • Internal Nasal Cavity
  • Mouth
  • Pharnyx
  • Larynx
  • Laryngeal Cartilage
  • Trachea
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2
Q

What are the (3) parts of the Internal Nasal Cavity:

A
  • divided by septum
  • Cribriform plate
  • Turbinates
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3
Q

Name the (2) main parts of the mouth

A
  • Roof
  • Floor
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4
Q

Name (4) structures that make up the Roof of the mouth?

A
  • Maxilla and palatine bones
  • Hard palate
  • soft palate
  • teeth
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5
Q

Name the (3) structure that make up the Floor of the Mouth?

A
  • Tongue
  • Mandible
  • Teeth
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6
Q

The Heard palate is formed by parts of the ________ and _______ _______. It makes up __/__ of the roof of the mouth?

A
  • Maxilla and palatine bones
  • 2/3rds
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7
Q

Name the Job of the Pharynx?

A
  • Maintain airway patency
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8
Q

What is the primary cause of upper airway obstruction during anesthesia? And how do you prevent this?

A
  • Loss of Pharyngeal muscle tone.
  • Chin lift
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9
Q

What and Where is the Pharynx?

A
  • Muscular Tube
  • Base of the skull to lower boarder of cricoid cartilage.
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10
Q

Name the (3) Parts of the Pharynx?

A

From Top to Bottom
* Nasapharynx
* Oropharynx
* Hydropharynx

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11
Q

Where does the Nasopharynx end?

A
  • Soft Palate
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12
Q

Where does the Oropharynx start and end?

A
  • Starts: Soft Palate
  • Ends: Epiglottis
    *occupied by the tongue
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13
Q

Where does the Hypophaynx start and end?

A
  • Epiglottis to cricoid cartilage
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14
Q

Name (3) reasons why is the Larynx Important?

A
  • Inlet to trachea
  • Phonation
  • Airway Protection
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15
Q

Where does the Larynx start and end?

A
  • Epiglottis
  • lower end of cricoid cartilage. @ C6**
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16
Q

Name (2) places the Vocal Cords are Attached?

A
  • arytenoid
  • Thyroid notch (laryngeal prominence)
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17
Q

Name the (3) Unpaired Laryngeal Cartilage.

A
  • Thyroid
  • Cricoid – complete ring
  • Epliglottis
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18
Q

Name the (3) Paired Laryngeal Cartilage.

A
  • Arytenoid
  • Corniclate
  • Cineiform
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19
Q

What is the largest of the cartilages and what does it support?

A
  • Thyroid Cartilage
  • Supports most of the soft tissue.
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20
Q

How long is the trachea and what is it’s shape?

A
  • 10 to 15 cm (adults)
  • C-shaped cartilage
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21
Q

What closes the trachea posteriorly and what is the trachea anteriorly bound?

A
  • longitudinal trachealis muscle
  • bound by tracheal rings
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22
Q

What is the only difference between lethal injection and General Anesthesia?

A
  • GA does not bolus potassium.
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23
Q

What do people die of the most with anesthesia?

A
  • lack of ventilation
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24
Q

What question chould you ask yourself before initiating anesthesia in any person?

A
  • Can I ventilate/intubate this patient?
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25
Q

What should you do if you are not able to ventilated/intubate a patient?

A
  • Maintain spontaneous ventilation
  • Use awake endotracheal intubation
  • Create a surgical airway
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26
Q

What is more valuable than any pre-surgical test?

A
  • Complete Patient History
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27
Q

What are the best ways to obtain a good history for your patient?

A

** Direct questioning of the patient. **
* Review of anesthesia and surgical records

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28
Q

Name (6) RED flags in a patient’s anesthesia history?

concerns

A
  • Past difficult intubation
  • Report of excessive sore throat
  • Report of cut lip/broken teeth
  • Recent onset of hoarsness
  • History of OSA
  • Lesions intra-orally…. base of tonguelingual tonsils
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29
Q

What is the most predictive factor in a patient’s history that will indicate difficult airway management? What might be some clues to this in their history?

A

Past difficult intubation
* Pt remembered the intubation
* Was awake for the intubation
* accessory devices were used
* Multuiple attempts were documented.

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30
Q

Name (6) criterias we are looking for while completing an airway evaluation?

A
  • visual of face and neck
  • mouth opening
  • eval oropharyngeal anatomy and dentition.
  • neck ROM
  • submandibular space
  • ability of pt to slide mandible anteriorly.
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31
Q

What findings concern us when we do a visual inspection?

A
  • Facial deformites
  • head/neck cancers
  • burns
  • goiter
  • short/thick necks > 43 cm
  • receding mandible
  • beards
  • c-collar
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32
Q

What is more predictive to a difficult intubation than a high BMI?

A
  • Short/thick neck
  • > 43 cm
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33
Q

Describe a normal Inter-incisor distance

A
  • Prefer > 6 cm
  • 3 finger breadths (patients)
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34
Q

What intercisor distance is indicative of a difficult intubation?

A
  • < 3cm
  • or 2 fingerbreaths
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35
Q

What pathologic characterisics will contribute to a difficult airway?

A

Abnormal Oropharyngeal Anatomy
* Tumor
* Palate deformities (high arched palate, cleft palate)
* Macroglossia

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36
Q

During your dental assessment, what can indicates problem during intubation?

A
  • long upper incisiors
  • poor dentition/loose teeth
  • cosmetic work
  • edentulousness
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37
Q

What accounts for 25% of all insurance claims against anesthesia providers? And what percentage of them occur during tracheal intubation?

A
  • Dental Injuries
  • 75% during tracheal intubation
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38
Q

Name (5) common causes of Dental Injuries?

A
  • Laryngeal blade
  • Rigid suction catheters
  • Oropharyngeal airway placement
  • Rigourus removal of airways
  • Biting down on ETT/LMA/airways during emergence.
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39
Q

Your patient is freaking out and labored breathing against an inflated ETT. What would this causes and how should you treat it?

A
  • Negative Pressure Pulmonary Edema
  • Deflate the balloon on the ET cuff.
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40
Q

What are the 2 most injured teeth during intubation? and what side?

A

* Left Anterior Maxillary centrals (47%) and lateral incisors (20%).
* Laryngeal blade is on the left side.

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41
Q

What is the sniffing position and why do we use the postion?

A
  • Cervical flexion and atlanto-occipital extension
  • Aligns oral, pharnygeal and laryngeral axis.
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42
Q

In the sniffing postition, where should your ear be in relation to the sternum?

A
  • Ear should be at the level of the sternal notch.
43
Q

What is the Sternomental Distance?

A
  • Distance between sternal notch and chin.
    *** > 12.5 cm preferred.
44
Q

How do you measure the sternomental distance?

A
  • Head in full extension
  • Mouth Closed
45
Q

What does the Thyromental distance evaluate? What is the prefered Distance?

A
  • Submandibular compliance
    * >6.5 cm (3 fingers breadths)
  • Tip of chin to thyroid notch
46
Q

How do we assess Prognathic ability?

A
  • Upper lip bite test
  • Extension of lower incisors beyond upper incisors
47
Q

How would you instruct a patient to complete a mallampati test?

A
  • Sit upright with head in neutral postion
  • Mouth open
  • Tongue protruded
  • No phonation
48
Q

Describe the Mallampati Test

A
  • Visibility of oropharyngeal structures
  • Class I -IV
  • Comparing tongue to oropharyngeal space
49
Q

Mallampati Class I

A
  • Fauces
  • pilars
  • entire uvular
  • soft palate
50
Q

Mallampati Class 2

A
  • Fauces
  • portion of uvula
  • soft plate
51
Q

Mallampati Class 3

A
  • Base of the uvula
  • soft palate
52
Q

Mallampati Class 4

A

Only hard palate

53
Q

Laryngeal Manipulation: BURP

A

External manipulation and backward, upward, rightward pressure

54
Q

Laryngeal Manipulation: OELM

A

Optimal External Laryngeal Manipulation
* Use of the right hand to guide the position and pressure is exerted by an assistant’s hand on the larynx

55
Q

Cormack-lehane Classifiction

A
  • Classification of laryngeal view
  • Grade I-IV
  • Trying to achieve the best view during DL
56
Q

CL -Grade 1

A
  • Entire glottis
  • 68- 74% of patients
  • <1 % difficulty
57
Q

CL- Grade 2

A

* only the posterior portion of the glottis
* can be corrected by lifting blade or preforming laryngela postioning.

58
Q

CL- Grade 3

A

* No part of the glottis and only epiglottis
* 1.2 - 1.6 % of patients
* 80-87.5% difficult intubation

59
Q

CL- Grade 4

A
  • Epiglottis cannot be seen
  • Very rare
60
Q

Criteria Associated with difficult mask ventilation: OBESE-M

A

OBESE - M
* Obesity (BMI > 30)
* Beard
* Edentulous (no teeth)
* Snorer, OSA
* Elderly, male (>55 yo)

  • Mallampati 3 or 4
61
Q

Predicting The Difficult Airway: BOOTS- I

A

BOOTS
* Beard - gel (NIRL)
* Obesity
* Older
* Toothless
* Sounds - snoring, stridor
* Inability to maintain O2 > 90% w/ BVM

62
Q

Difficult Intubation: LEMON

A

LEMON
* Look (abn face, trauma, unusual anatomy)
* Evaluate (3-2-2)
* Mallampati score
* Obstructions/obesity
* Neckmobility

63
Q

Difficult airways: 3-2-2 Rule

A
  • 3 finger mouth opening, fingers along the floor of the mandible
  • 2 fingers between the space between the superior notch of the thyroid cartilage
  • 2 fingers between neck/mandible junction
64
Q

Criterial Associated with difficult airway

Test question

A
  • Large Upper Incisors
  • Strong overbite
  • Inability to pertrude mandible
  • Small inter-incisiors distance
  • Mallampati 3/4
  • Large tongue
  • Narrow, high arch palate
  • Short Thyromental distance
  • Excessive manibular soft tissue
  • Short, thick neck
  • Decreased cervical ROM
65
Q

Difficult Airway Algorithm: When would you chose between an awake or post-induction airway?

A
  • Suspected difficult laryngoscopy
  • Suspected difficult ventilation with face mask/supraglottic airway
  • Significant increased risk of aspiration
  • Increased risk of rapid desaturation
  • Suspected difficult emergency invasive airway

Answer YES to 4 = awake intubation

66
Q

During Intubation we should…….

A
  • Optimize oxygenation throughout
  • Limit attempts, consider calling for help
  • Limit attempts and consider awakening the patient.
  • Limit attempts and be aware of the passage of time.
  • WHEN IN DOUBT, CALL FOR A FRIEND.
67
Q
A
  • The patient will compensate until they can’t.
  • If something doesn’t work, try something else.
  • Try an LMA
  • Phone a friend.
  • Be proactive and not reactive.
  • Always have a plan B.
68
Q

Difficult Airway Simplication

Per Dr Cornelius

A
  1. Evaluate all your patients
  2. Figure out the difficult patients
  3. Have a plan B and C for difficult intubations
  4. General Anesthesisa w/ ETT
  5. Superglottic airway (LMA) and ventilation
  6. Call for help
  7. Video Laryngoscope
69
Q

Patient that can’t be intubated or ventilated will end up with a …….?

A

Surgical cricothyroidotomy

70
Q

Decision to Intubate: Intubate Early

A
  • Dynamic Situation
  • Bullets: Neck trauma
  • Snake Bites: Anaphylaxis/angioedema
  • Burns: Thermal and Caustic airway injuries.
71
Q

Decision to Intubate: Airway Complications

A
  • Mouth and Neck infections
  • Tumors
  • Foreign bodies
  • bleeds
72
Q

Decision to Intubate: Airway (Examples)

A
  • Stridor
  • Phonation
  • Swallowing
  • secretions
  • dysnpnea
73
Q

Decision to Intubate: Breathing

A
  • Failure of oxygenation or ventilation
  • After trying NIV
74
Q

Decision to Intubate: Circulation

A
  • supporting tissue oxygen delivery by unloading muscle of respiration
  • Ex: Sepsis
75
Q

Decision to Intubate: Disability

A
  • CNS catastrophes
  • CNS depression
  • Ongoing seizures
  • weakness

assess ability to swallow and handle secretions -

76
Q

Decision to Intubate: Expected Course

A
  • Anticipate decline
  • tranfer to radiology
  • transfer to another institution
77
Q

Decision to Intubate: Feral

A
  • Need for prompt, aggressive sedation
  • Protection for the patient
  • Protection for others
78
Q

When should you RSI over Awake Intubation?

A
  1. Urgency = quick
    * ** peri-arrest
    * dynamic airway**
  2. Difficult airway features
    * Known easy airway
    * normal anatomy
  3. Vomiting Risk
    * Upper GI bleed
    * bowel obstruction
    * vomiting in ED
79
Q

When should you Awake Intubate vs RSI?

A
  1. Urgency = slow, not a fast procedure
    * stable GI bleed for endo
    * slowly progressing neuromuscular weakness requiring transfer
  2. Difficult airway feacture
    * fixed deformity of the neck
    * cannot open mouth.
80
Q

Awake Technique

A
  • Glycopyrolate 0.2 mg or Atropine 0.1 mg/kg
  • suction and dry mouth with gauze
  • Nebulized with Lidocaine – NO EPI
  • Atomized Lidocaine to oropharynx
  • Viscous Lidocaine – w/ tongue depressor
  • Lightly sedate w/ Versed 2-4 mg or Ketamine 20 mg q 2 min
  • intubate awake/pass bougie while awake
  • Paralyze, then pass tube.
81
Q

Local Anesthesia for Intubation

A
  • dry
  • nebulize
  • atomize
  • topicalize
82
Q

IV sedation for Intubation

A
  • **KETAMINE: High Secretions
  • Versed
  • fentanyl
  • Dexmedetomidine
83
Q

Laryngoscopy: Steps to prepare

A
  • Position patient
  • find the epiglottis
  • optimize the head: sniff and head tilt
  • seat the blade
  • optimize the larynx– intubated
  • FAILED: ventilate, change something, use a bougie
84
Q

Bougie

A
  • self- confirming
  • intubate epilglottis-only views
  • leave laryngoscope in
  • lubricate tube,pull back and rotate if you get stuck
  • black strip is 25 cm ( @ lip, mid trachea in an adult male)
85
Q

If you are unable to intubate a patient, what is the best device to ventilate?

A

LMA

86
Q

Why would we NOT use etomidate for intubation?

A
  • Adrenal suppression
  • lower’s seizure thresholds
87
Q

Reasons to use Ketamine for Intubation

A
  • Reactive airway changes
  • IM RSI
  • Hypotension
  • Sepsis
88
Q

Reason to NOT use Ketamine for Intubation

A
  • Hypertension/tachycardia
  • high ICP
89
Q

What will wear off faster during an RSI: Propofol or Parlaytic?

A

Propofol

90
Q

Can I use a half -dose paralytic during Intubation?

A

NO

91
Q

Absolute Contraindications w/ Succinylcholine

A
  • Rhadomyolysis
  • hyperkalemia
  • MS/ALS
  • Muscular dystrophy
  • denervating >72 hours old
  • crash injuries > 72 hours old
  • sever infections >72 hours
  • immobilization
  • Predisposition to MH
  • bradycardia
  • fasciculations – increased ICP
92
Q

Succinycholine Duration

A

5 - 10 minutes

93
Q

Rocuronium Duration

A

30 - 90 minutes

94
Q

What are Physiologic Killers?

A
  • Hypotension
  • Hypoxemia
  • Metablic Acidosis
95
Q

What IV access do you need to have before attempting to intubate anyone?

A
  • 2 peripheral IVs (atleast)
  • or IO if unable to obtain IV access.
  • bonus points for bolus of IV fluids to maintain SBP > 140 mmHg
96
Q

What is the induction agent and paralytic agent of choice for Shock patients?

A
  • ketamine (0.5 mg/kg)
  • Rocuronium (1.6mg/kg)
97
Q

What are our push dose pressors?

A
  • Epinephrine
  • Phenylephrine
  • Vasopressin
    always dilute
98
Q

What should you do if your patient is combative/uncooperative and needs intubated?

A
  • Precedural sedation for preoxygenation
  • Ketamine 0.5 - 1mg/kg
99
Q

When should you avoid giving Bicarb?

A
  • Patient is already tachypneic
  • increasing circulating CO2 could worsen acidosis leading to arrythmias.
  • High CO2 levels, Bicarb breaks down into H2O and CO2
100
Q

You have a trauma patient that needs intubated, but you can’t get a good view, what should you do?

A
  • Mobilize the neck
  • EXCEPTION IS WITH A DIAGNOSIS OF OR OBVIOUS CERVICAL SPINE INJURY.
101
Q

In what situations do you have a Higher Aspiration Risk during intubation?

A
  • Upper GI Bleed
  • Bowel Obstruction
  • Pre-induction vomiting
102
Q

What interventions should you do during a High Risk for Aspiration Intubation?

A
  • NGT prior to intubation
  • Intubation in semi-upright position
  • Bag early, but less.
103
Q

Oxygenation while securing ETT:

A
  • NC @ 15 LPM + NRB @ 15 LPM
  • Keep PEEP Valve closed –> alveoli recruitment
  • SPO2 not > 95%: think Lung Shunt physciology
  • Can use APL as PEEP valve on vent
104
Q

How do you convert a nasal airway to ETT (French to CM)

A
  • 4cm: 1 Fr

Health Assessment (7 decks)

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