Airway (Exam II) Flashcards
How many turbinates are there?
What are their names?
Three
- Inferior
- Middle
- Superior
Which turbinate does the endotracheal tube pass through during a nasal intubation?
- Inferior turbinate
What is necessary for bleeding reduction during nasal intubation?
- Vasoconstrictors (ex. oxymetazoline)
What area is considered the pharynx?
- Base of skull to lower border of cricoid cartilage.
What area is indicated by 1 on the figure below?
Nasopharynx
What area is indicated by 2 on the figure below?
Oropharynx
What area is indicated by 3 on the figure below?
Hypopharynx
What structure divides the oropharynx and the hypopharynx?
- Epiglottis
Loss of pharyngeal muscle tone results in _________ _________.
Airway obstruction
Fill in the structures that compose the picture of the larynx below.
What structure is indicated by 1 on the figure below?
- Median glossoepiglottic fold
What structure is indicated by 2 on the figure below?
- Lateral glossoepiglottic fold
What structure is indicated by 3 on the figure below?
- Aryepiglottic fold
What structure is indicated by 4 on the figure below?
- Ventricular fold
What structure is indicated by 5 on the figure below?
- Vocal fold
What structure is indicated by 6 on the figure below?
- Trachea
What structure is indicated by 7 on the figure below?
- Corniculate Cartilage
What structure is indicated by 8 on the figure below?
- Cuneiform Cartilage
What structure is indicated by 9 on the figure below?
- Piriform Recess
What structure is indicated by 10 on the figure below?
- Tubercle of Epiglottis
What structure is indicated by 11 on the figure below?
- Epiglottis
What structure is indicated by 12 on the figure below?
- Vallecula
What is the purpose of the larynx?
- Inlet to trachea
- Phonation
- Airway protection
Which laryngeal cartilages are unpaired?
- Thyroid cartilage (largest, supports soft tissue)
- Cricoid cartilage
- Epiglottis cartilage
Which laryngeal cartilages are paired?
- Arytenoid cartilage
- Corniculate cartilage
- Cuneiform cartilage
What do the vocal cords attach to?
- Arytenoid muscles & cartilage
- Thyroid at thyroid notch
How far does the trachea span?
What supports it anteriorly and posteriorly?
- From the inferior cricoid membrane to the carina (10 - 15 cm).
- Posterior: longitudinal trachealis muscle
- Anterior: Tracheal rings
Is airway history or assessment more valuable?
- Airway history
What portions of patient history can be a cause for airway concern? Which is most important?
- Past difficult airway
- Report of sore throat
- Report of cut lip or broken tooth
- Recent hoarseness
- Hx of OSA
What is a better indication of airway difficulty than BMI?
- Thick neck greater than 43cm
What factors that are assessed visually would give one concern for a potentially difficult airway?
- Facial deformities
- Head & neck cancers
- Burns
- Goiter
- Short/Thick neck
- Receding mandible
- Large beard
- C-collar
What inter-incisor distance is best?
- > 6cm (3 finger breadths)
What is the sniffing position?
Why does it make intubation easier?
- Cervical flexion and antlanto-occipital extension, ear to sternal notch
- Aligns oral, pharyngeal, and laryngeal axes.
What technique is depicted below?
Why is it used?
- Ramping: used for positioning larger patients.
What is the sternomental distance?
What is an indicator of a potentially difficult airway?
- Distance between sternal notch and chin with head fully extended and mouth closed.
- Less than 12.5 cm = potentially difficult
What is thyromental distance measuring?
What would be preferred?
- Submandibular compliance (tip of chin to thyroid notch)
- > 6.5cm preferred (3 finger breadths)
How is prognathic ability measured?
- Upper lip bite test (assesses how much lower incisors can extend beyond upper incisors)
What structures should be visible in a Mallampati class I?
- Fauces
- Tonsillar pillars
- Entire uvula
- Soft palate
What should be visible in a Mallampati class II?
- Fauces, portion of uvula, and soft palate
What should be visible in a Mallampati class III?
- Base of uvula and soft palate
What should be visible in a Mallampati class IV?
- Only the hard palate
What is BURP?
External laryngeal manipulation- Backward, Upward, and Rightward pressure to facilitate intubation.
What is Optimal External Laryngeal Manipulation (OELM) ?
- Moving someone else’s hand over external neck until a proper view is seen.
What Cormack-Lehane view is depicted below? What is visible with this view?
- CL - 1
- Entire glottis is visible
What Cormack-Lehane view is depicted below? What is visible with this view?
- CL - 2
- Posterior of glottis is visible
What Cormack-Lehane view is depicted below? What is visible with this view?
- CL - 3
- Only the epiglottis is visible
What Cormack-Lehane view is depicted below? What is visible with this view?
- CL - 4
- Epiglottis can’t be visualized.
What criteria can suggest difficulty with mask ventilation?
Obesity (BMI>30)
Beard
Edentulous (no teeth)
Snorer (OSA)
Elderly (>55)
What does LEMON evaluate in terms of difficult intubation?
Look (unusual anatomy)
Evaluate (3-3-2 rule)
Mallampati score
Obstruction/obesity
Neck mobility
What to do: failed GA intubation but able to mask ventilate adequate as confirmed by CO2?
Non-emergent pathway: limit attempts, consider awakening patient. Consider alternative approaches.
What to do: failed GA intubation and unable to mask ventilate adequate?
consider/attempt supraglottic airway
What to do: failed supraglottic airway (cannot intubate, cannot ventilate)
Emergency pathway: call for help, attempt alternatives while preparing for emergency invasive airway.
What criteria would suggest considering an awake intubation?
- Suspected difficulty with mask ventilation or supraglottic
- high risk of aspiration
- high risk rapid desaturation
- suspect difficult emergency invasive airway
What factors would express a dynamic changing airway?
- neck trauma (bullet)
- anaphylaxis/angioedema
- thermal/caustic injury (burns)
When considering awake intubation, what options could you use to manage secretions?
*glycopyrolate 0.2mg (takes 15 min onset)
*suction and pad dry with gauze
If you fail laryngoscopy what options should you consider?
- help
- glidescope
- bougie
- positioning
- LMA
Why might you avoid using etomidate for intubation?
- adrenal suppression
- lowers seizure threshold
What might ketamine be a drug of choice for?
- hypotensive
- asthmatics (bronchodilation effects)
What are some key contraindications for succinylcholine? (5)
- rhabdo
- hyperkalemia
- Neuromuscular disorders (MS, ALS)
- Malignant Hyperthermia hx
- Burns
What is the duration of action of succinycholine?
5-10 min
What is the duration of action of rocuronium?
30-90 min
What are the 3 main physiologic killers (as discussed in lecture)
- Hypotension
- Hypoxemia
- Metabolic Acidosis
What are the main purposes of sedation when intubating?
blunt sympathetic surge and provide amnesia
What might be a good drug of choice for shock? Why?
Ketamine
-gives simultaneous sympathetic surge
What are your two main amnestic agents?
ketamine and versed
How would you make push-dose Epi from a code stick?
Code stick: 1mg/10mL (0.1mg/mL) = 100mcg/mL => dilute 1mL Epi with 9mL = 10mcg/mL
10mcg pushes
What options would you have with intubating a trauma pt with possible cervical injury?
- Fiberoptic, glidescope to avoid movement
- Helper holding C-spine
What options would you have for intubating a high risk aspiration pt?
- sit up (gravity)
- NGT - suction
- RSI
Conversion from french to mm?
usually 4:1
28fr = 7.0mm
What does Ventilator Assisted Pre-Oxygenation (Vapox) treatment for acidosis entail?
NC 15 LPM
SIMV+PSV
- VT 8mL/kg
- FiO2 80%
- Pressure support 5-10cmH2O
- PEEP- 5
What makes up the anterior 2/3 of the roof of the mouth? What bones does this consist of?
- Hard palate
- maxilla & palatine bone
Where does the nasopharynx end? What is another term for nasopharynx?
- soft palate
- velopharynx
What area does the hypopharynx span?
epiglottis to the cricoid cartilage
