Airway (Exam II) Flashcards
How many turbinates are there?
What is another name for turbinates?
Three (also known as meatus)
- 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-afrin, neosynephrine)
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 vertebrae corresponds with the very bottom of the larynx?
6th vertebrae
What is the purpose of the larynx?
- Inlet to trachea
- Phonation
- Airway protection
Which laryngeal cartilages are unpaired?
- Thyroid (largest, supports soft tissue)
- Cricoid
- Epiglottis
Which laryngeal cartilages are paired?
- Arytenoid
- Corniculate
- Cuneiform
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 (c-shaped, bougie intubation)
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
- Aligns oral, pharyngeal, and laryngeal axes.
What technique is depicted below?
Why is it used?
Ramping: used for positioning larger patients.
Ear to sternal notch
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
What is thyromental distance measuring?
What would be preferred?
- Submandibular compliance (tip of chin to thyroid notch)
- > 6.5cm preferred
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
comparing tongue to oropharyngeal space
What should be visible in a Mallampati class II?
- Fauces
- Portion of uvula
- Soft palate
What should be visible in a Mallampati class III?
- Base of uvula
- Soft palate
What should be visible in a Mallampati class IV?
Only the hard palate
What is BURP?
Backward, Upward, and Rightward Pressure on larynx 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 forms the medial wall of each nasal passage (fossae)?
Nasal Septum
What forms the hard palate of the mouth?
Part of maxilla and palantine bone
2/3 of anterior roof of mouth
What’s one manuevar you can do to prevent pharyngeal muscle airway collapse?
Chin lift with mouth closure
What area is considered the larynx?
Epiglottis to lower end of cricoid cartilage
inlet to trachea
How do you assess mandibular prognathism?
Have pt slide mandible anteriorly
What is edentulousness?
Having no teeth
Difficult mask ventilation
What teeth are most likely to get injured?
Anterior maxillary center and lateral incisors
Why are teeth more frequently knocked out on the left?
The blade
Position for laryngoscopy
ear to sternal notch
suction ready
Class I
Class II
Class III
Class IV
What is Cromack-Lehane classification?
Classification of laryngeal view
Criterial associated w/difficult mask ventilation
O: Obesity
B: Beard
E: Edentulous
S: Snorer, OSA
E: Elderly, male
& Mallampati 3/4
What does BOOTS stand for?
B: Beard
O: Obesity
O: Older
T: Toothless
S: Sounds - snoring, stridor
Indicators of difficult airway
What does LEMONS stand for?
L: Look (abnormal face, trauma, unusual anatomy)
E: Evaluate 3-3-2 rule
M: Mallampati score
O: Obstruction/Obesity
N: Neck mobility
All criteria associated with difficult airway
Large upper incisiors
Strong overbite
Inability to protrude mandible
Small inter-incisor distance (<6 cm)
Mallampati 3/4
Large tongue
Narrow or high-arched palate
Short thyromental distance (<6.5 cm)
Excessive mandibular soft tissue
Short, thick neck
Decreased cervical range of motionap
How is adequate mask ventilation assessed?
CO2
What are 5 things you will consider when deciding on awake intubation or intubation after induction?
- Suspected difficult laryngoscopy
- Suspected difficult ventilation
- Significant increased risk of aspiration
- Increased risk of desaturation
- Suspected difficult emergency invasive airway
If yes to any of the above = awake intubation
If you fail at an attempted awake intubation what do you do?
Consider other options
If you fail an attempted awake intubation and fail at “other options” what do you do?
Postpone case
What is your first step after failed intubation attempt following induction?
Consider calling for help
Limit attempts
After failed intubation following induction you are not able to adequately mask ventilate, what do you do now?
Consider supraglottic airway
What is one thing you do with both awake and induced intubation?
Optomize oxygenation throughout
You have induced, failed to intubate, failed to bag, but successfully placed a supraglottic airway. Now what do you do?
Limit attempts, consider waking patient and consider other options
Non-emergent pathway
You induced, failed to intubate, failed to bag, failed to place a supraglottic airway… now what do you do?
- Call for help
- Limit attempts & beware of time
- Consider invasive access
Emergency pathway because you suck at anesthesia
3 B’s of dynamic airways
Bullets
Bites
Burns
RSI or Awake
Known easy airway
Normal anatomy
RSI
RSI or Awake
Upper GI bleed
RSI
RSI or Awake
Bowel obstruction
RSI
aspiration
RSI or Awake
Stable GI bleed requiring endo and slow progressive neuromuscular weakness requiring transfer
Awake
RSI or Awake
Flixed flexion deformity of the neck, cannot open mouth
Awake
If you fail to intubate what should you do?
Change something, don’t try again without adjusting
Where is the black line on the bougie?
25 cm
Which patients can’t you use SUX on?
Rhabdo
Hyperkalemia
ALS, MS
Stroke/spinal injury > 72hrs old
Burns > 72hrs old
Tetanus, botulism, severe infection
Immobilization
MH
Bradycardia
Fasciculation
Masseter spasm
Contraindications to ROC
- Allergy
- Longer DOA
- Suggamadex not avalible
DOA SUX
5-10 min
DOA ROC
30-90 min
Intubation is not a cause of death but what physiologic killers surounding intubation are?
Hypotension
Hypoxia
Metabolic acidosis
Resuscitate before you intubate!
Induction agent of choice in shock patients & dose
Ketamine
1-2 mg/kg
reduce to 0.5 mg/kg in shock pts
Paralytic agent of choice in shock patients & dose
ROC
1.6 mg/kg
longer safe apnea time
Push dose pressor of choice
Epinephrine
Alpha & Beta
Intervention 1 (hypoxia)
NC 15 LPM
BVM 15 LPM
PEEP 5-15 cmH2O
Intervention 2 (hypoxia)
- DSI (delayed sequence intubation)
- procedural sedation for preoxygenation
ketamine 1mg/kg -> preoxygenate -> paralyze -> apneic oxygenation -> intubate
Intervention 3 (hypoxia)
BUHE (back up head elevated) intubation
Intervention 1 (acidosis)
Bicarb
make sure you’re ventilating well
Intervention 2 (acidosis)
VAPOX - ventilator assisted pre-oxygenation
