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Intro Nurse Anesthesia > Airway lecture > Flashcards

Airway lecture Flashcards

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1
Q

Nasal passages includes, function, innervation

A

Includes

1) Septum
2) Turbinates
3) Adenoids

Function
-accounts 2/3 airway resistance
Humidifies
Filter
Warm

Innervation
-Trigeminal nerve (CN V)

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2
Q

Oral Cavity includes…

A

Teeth, tongue, hard palate, soft palate

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3
Q

Innervation of trigeminal nerve

A

Hard/soft palate

Anterior 2/3 tongue

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4
Q

Innervation of glossopharyngeal

A

Posterior 1/3 tongue
Soft palate
Oropharynx

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5
Q

Nasopharynx

A

Border is soft palate

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6
Q

Oropharynx

A

Border is epiglottis. INcludes tonsils/uvula

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7
Q

3 divisions of upper airway

A

Nasopharynx, oropharynx, hypopharynx/laryngopharynx

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8
Q

Innervation of pharynx

A

Glossopharyngeal and vagus

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9
Q

Larynx location in adult (c level>)

A

C4-C6 in adult

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10
Q

Function of larynx

A

Airway protection
Respiration
Phonation

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11
Q

Name the 3 paired cartilages of larynx

A

Arytenoid
Corniculate
Cuneiform

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12
Q

3 unpaired cartilages in larynx

A

Thyroid
Cricoid
Epiglottis

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13
Q

Where is a cricothotomy done?

A

Cricothyroid ligament

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14
Q

Thyroid cartilage

A

Large and most prominent

Anterior attachment for vocal cords

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15
Q

Epiglottis

A

Covers opening to larynx during swallowing

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16
Q

Cricoid cartilage

A

Only complete ring

Narrowest point of pediatric airway

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17
Q

Arytenoid cartilage

A

Posterior attachment for vocal cords

Falsely id’ed in anterior airway

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18
Q

Corniculate

A

Posterior portion of aryepiglottic fold

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19
Q

Cuneiform

A

Not always present. Lateral to corniculates

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20
Q

Vocal cords

A

Appear pearly white
Formed by thyroarytenoid ligaments
Attached anteriorly to thyroid cartilage and posteriorly to arytenoid cartilages

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21
Q

Glottis Opening

A

Triangular fissure b/w cords

Narrowest point of adult airway

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22
Q

Lateral Cricoarytenoid muscle

A

Addictive vocal cords

Let’s close airway. Glottis opening

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23
Q

Posterior cricoarytenoid muscle

A

Only vocal cord abductors. Pull cords open. GLottic opening

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24
Q

Arytenoid muscles

A

ADDUCTS vocal cords.

Consists of oblique arytenoid s and transverse arytenoids

Controls glottis closure

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25
Q

Laryngeal muscles for vocal cord length

A

Cricothyroid, thryoarytenoid, vocalis

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26
Q

Cricothyroid muscle

A

Tenses/elongates vocal cords

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27
Q

Thyroarytenoid muscle

A

Relaxes/shortens vocal cords

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28
Q

Vocalis muscle

A

Relaxes/shortens vocal cords

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29
Q

Cricothyroid muscle innervation by

A

External branch of superior laryngeal nerve branch of vagus nerve

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30
Q

All laryngeal muscles besides cricothyroid muscle are innervation by…

A

Recurrent laryngeal nerve branch of vagus nerve

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31
Q

Suprahyoid group consists of and does what to larynx?

A

Stylohyoid
Mylohyoid
Geniohyoid
Digastric

Raises larynx cephalad

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32
Q

Infrahyoid group consists of what and does what to larynx?

A

Sternothyroid,
Sternohyoid
Thyrohyoid
Omohyoid

Moves larynx caudad

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33
Q

Lower airway consists of

A 
Trachea, 
Carina
Bronchi
Brochioles
Terminal bronchioles
Respiratory bronichioles
Alveoli
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34
Q

Trachea

A

Begins at level of cricoid cartilage and extends to carina.
10-15 cm in length in adult. Diameter of 22mm in adult
16-20 c shaped cartilaginous rings that open poseriorly.

Posterior side has no cartilage
Bifurcated at T4- carina

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35
Q

Carina

A

T4 BIFURCATION

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36
Q

Airway assessment

A 
General appearance
- head, neck size, fullness
ROM
Dentition
Mouth - tongue, lips, gums
Mouth opening 2-3 fingers (30-40mm)
Body habit us
Mallampati
Thyromental distance
Mandibular protrusion test (bite lip with bottom teeth)
Hx previous difficult airway
Diagnosis
Planned sx
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37
Q

Assessment of mallampati

A 
- correlates oropharynx earl space with ease of DL and tracheal intubation
Assessment-
Pt sits upright
Head neutral
Mouth open
Tongue maximally protruded
NO AHH!
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38
Q

Class I mallampati

A 
PUSH 
Pillars
Uvula(entire)
Soft palat
Hard palate
39
Q

Class II mallampati

A

Uvula tip masked by tongue
Soft palate
Hard palate

40
Q

Class III mallampati

A

Soft palate
Hard palate
(Uvula base only)

41
Q

Class IV mallampati

A

Hard palate only

42
Q

Cormack and Lehane score

A

Laryngoscopic view of glottis

43
Q

Grade I cormack and lehane

A

Most of glottis visible

44
Q

Grade II cormack an lehane

A

Posterior portion of glottis visible

45
Q

Grade III Cormack and Lehane

A

Only epiglottis visible

46
Q

Grade IV Cormack and Lehane

A

No airway structures visible

47
Q

THyromental distance

A

Distance from lower border of mandible to thyroid notch with neck fully extended.
Normal 6-6.5 cm or 4 fingerbreadths.

If <3 fingers, receding mandible and possible difficult airway

48
Q

Mandibular protrusion test

A

Ability to align teeth

49
Q

Class A mandibular protrusion test

A

Lower incisors can be protruded anterior to upper incisors

50
Q

Class B MPT

A

Lower incisors brought edge to edge

51
Q

Class C MPT

A

Lower incisors cannot be brought edge to edge with upper incisors

52
Q

What do you need to prepare for induction?

A 
Ms. MAIDS
Monitors on and settings appropriate
Suction on and at HOB
Machine checked, +pressure ventilation
Airway
IV
Drugs
Special equipment
53
Q

What is preoxygenation and how do you achieve it?

A

Goal is to increase O2 concentration and “wash out” nitrogen in the FRC with oxygen.

Takes 3-5 min “tight mask” with normal tidal breathing with 100% Fio2 at >6L/min flow= 10 minutes of safe apnea time

4 vital capacity breaths within 30 seconds at 100% fio2 >6l/min= 5 minutes safe apnea time

8 breaths over 60 seconds will >effectiveness over 4 br/30 sec

ET concentration oxygen >90% maximizes apnea time. High metabolic rate needs more time

54
Q

When are you at increased risk for aspiration?

A 
Loss of AW reflexes 
High risk:
-full stomach
-symptomatic GERD
-Hiatal hernia
-Presence of NG tube
-morbid obesity
- DM
-Gastroparesis
-Pregnancy
55
Q

What do you need for airway setup?

A 
LOST SEAL?
Laryngoscopes +2 blades
Oral airway
S suction
T -tape and tongue depressor
S- syringe and styled
E- ETT tube +2 sizes
A- ambu bag
L-LMA w lube
56
Q

What can make a difficult mask fit?

A 
Beard
Edentulous
Short mandible
OSA
Males
BMI <30
Mallampati III or IV
AGE >55
57
Q

How do you know you are mask ventilating well?

A

Effectiveness determined by chest rise, exhaled TV, pulse ox, capnography

TV need to be achieved with peak inspiratory pressure <20

Higher pressures can cause gastric insufflation

58
Q

Common obstruction during mask ventilation?

A

Tongue and epiglottis! D/t relaxation of genioglossus muscle

59
Q

Oral airways

A

2 types- German and Guedes. Guedel has hole down center

Measure from corner of pt mouth to angle of jaw or earlobe

60
Q

Compilation/precautions in oral airways?

A 
Laryngospasm
Bleeding
Soft tissue damage
Lingual nerve palsy
Damage to teeth
Worsening obstructions
61
Q

Nasal airway

A

Nose—> pharynx beneath relaxed and obstructing tongue

Estimate distance nares to meatus of ear

Lubricate!
Can dilate with smaller sizes

62
Q

Complications/ precautions of NPA

A

Epistaxis
Nasal/nasal skull fractures
Adenoid hypertophy
Anticoags

63
Q

What is a Laryngospasm

A

Provoked by glossopharyngeal or vagal stimulation attributable to airway instrumentation or vocal cord irritation, in the settting of light anesthesia.

-can also be precipitated by other noxious stimuli and can persist well after removal of stimulas

64
Q

Treatment of laryngospasm

A 
Removal of airway irritants
Deepening of anesthetic
Admin NMB (sucks)
Treatment CPAP 100% O2
BiLATERAL pressure at laryngospasm notch (b/w condyle of mandible and mastoid process)
65
Q

What is a bronchospasm

A

Irritation of lower airway by foreign substance.

Activates a vagal reflex- mediated constriction of bronchial smooth muscle.

66
Q

Treatment of bronchospasm

A

Depending anesthetic with proposal/volatile agent

Admin b2 agonist or anticholinergic

67
Q

Potential hazards to advanced airway management

A
  • dental damage
  • soft tissue injury
  • laryngospasm
  • bronchospasm
  • vomiting/aspiration
  • hypoxemia and hypercarbia
  • SNS stimulation
  • esophageal intubation

Dentist injured Larry’s bright veneer, he sued everyone

68
Q

Predictors of difficult intubation

A
  • long upper incisors
  • prominent overbite
  • inability to protrude mandible
  • small mouth opening
  • mallampati III or IV
  • high, arched palate
  • short thyromental distance
  • short, thick neck
  • limited cervical mobility
69
Q

MAC

A

Generally chosen with adults
Less likely to cause dental damage. Grabs vallecula

3 is average size adults

70
Q

Miller

A

Straight blades generally used in kids
Also good to use for people with short thyromental distance
Grabs epiglottis

2-average size adults

71
Q

What are absolute indications for ETT?

A 
Full stomach
High risk aspiration
Critically ill
Sig lung abnormalities
Sx requiring lung isolation
ENT sx where SGA interferes with sx access
Failed SGA placement

Other

  • NMBDs
  • positioning that does not allow access to AW
  • predicted difficult airway
  • prolonged procedures
72
Q

Common features of ETT

A

Standard 15 mm adapter
High volume- low pressure cuff to protect against gastric aspiration
Beveled tip passes through vocal cords easily
Murphy eye has back-up in case of occlusion
Pilot balloon with one way valve for cuff inflation 4-5 cc fine, Air leak 20-25 cm H20

73
Q

Ideal position for ETT based on ETT size? M/F?

A

Id X3= APPROXIMATE depth

Generally 6.5-7 for female, 7.5-8 for male

74
Q

Ideal position of ETT inside trachea

A

4 cm above carina, 2 cm below vocal cords

75
Q

Optimal intubating position

A

Sniffing position. Align 3 axis
Oral axis
Pharyngeal axis
Laryngeal axis

76
Q

LMA purposes?

A

A Supraglottic airway (SGA) that can be used as

1) primary AW device,
2) rescue device,
3) or conduit for ett

77
Q

Appropriate size LMA?

A 
Based on weight
30-50 kg—> LMA 3
50-70 KG—> LMA 4
70-100 kg —> LMA 5
>100 LMA 6
78
Q

Amoung airway pressure we can ventilate LMA with?

A

20 cm H2O

79
Q

Inserting LMA

A

Adequate anesthesia depth is critical
Deflate cuff and lub posterior aspect
Inflate with min volume air (target cuff pressure 40-60 cm h2o)
Confirm with gentle PPV, Cagnography, auscultation
- leak audible at inspiratory pressure 18-20cmH2O

80
Q

Advantages of LMA over ETT

A
  • increased speed and ease of placement by inexperienced personnel
  • improved hemodynamics stability at induction and emergence
  • reduced anesthetic requirement
  • lower frequency of coughing during emergence
  • lower incidence of sore throats
81
Q

Disadvantages of LMA over ETT

A
  • not a definitive aw
  • lower seal pressure (can’t use higher pp)
  • higher frequency of gastric insufflation
  • does not maximally protect against aspiration
  • no protection against laryngospasm
82
Q

What is the common cause of airway obstruction during induction?

A

Obstruction by tongue and epiglottis due to relaxation of genioglossus muscle

(Genie cause your blue, since you’re not breathing= blue tongue= genioglossus)

83
Q

What can you do to improve obstruction in airway for induction?

A

Cervical flexion, head extension (sniffing)

Jaw thrust

Still obstructed—> OPA/NPA

84
Q

How do you measure nasal airway trumpet?

A

Distance from nares to meatus of ear.

Diameter French size 24-36

85
Q

What is the length and angle of right bronchi?

A

2.5 cm long and angle of 25

86
Q

What is the length and angle of left bronchi?

A

5 cm with an angle of 45 degrees

87
Q

What are average size LMA for adult man and woman?

A

5LMA- man

4LMA- woman

88
Q

Two types of oral

A

Bergman (BOA) and Guedel

89
Q

Classic vs Supreme LMA

A

Supreme and pro seal handles PPV put o 30 cmH2o

Also has integrated bite block. Regular LMAs need additional bite block.

90
Q

What are the intrinsic laryngeal muscles of glottis opening?

A

Lateral Cricoarytenoid
Arytenoid muscles
Posterior cricoarytenoid

91
Q

Intrinsic laryngeal muscles that control vocal cord length?

A

Cricothyroid
Thyroarytenoid
Vocalis

92
Q

When might you have good ETT placement but not have ETCO2 waveform

A

Severe bronchospasm
Equipment malfunction
Cardiac arrest
Hemodynamic collapse that may prevent appearance of capnogram tracing

93
Q

When is mask ventilation contraindicated?

A

Risk regurgitation increased
SEVERE facial trauma
Pt where head and neck manipulation must be avoided.

94
Q

What are basic questions to ask during airway assessment?

A 
Radiation or burn to head/neck
C-spine pain or LROM
TMJ pain
Rheumatoid arthritis
Anklylosing spondylitis
Abscess or tumor
Prior intubation or tracheotomy
Snoring or sleep apnea
Dysphagia or stridor

Intro Nurse Anesthesia (5 decks)

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