Airway Management (Week 2) Flashcards by Lindsay Reynolds

Upper Airway

Consists of (6 parts)

The _____ and _____ are also part of the upper GI tract

The ______ structures aid in preventing ______ into the trachea

Nose, Mouth, Pharynx, Larynx, Trachea, Mainstem Bronchi

Laryngeal, Aspiration

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Airway Anatomy

There are _____ openings to the human airway; the ____, leading to the ______ and the ____, leading to the ______

Two, Nose, Nasopharynx

Mouth, Oropharynx

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Pharynx

U-Shaped fibromuscular structure extending from base of the ____ to the _____ cartilage at the base of the esophagus

Skull, Cricoid

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Nasopharynx

Separated from the oropharynx by an _____ plane that extends posteriorly

At the base of the tongue, the _____ functionally separates the oropharynx from the laryngopharynx (or hypopharynx)

Imaginary

Epiglottis

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The ______ prevents aspiration by covering the _____ (the opening of the larynx) during swallowing

The _____ is a cartilaginous skeleton held together by ligaments and muscle

The Larynx is composed of nine cartilages. Name Them.

The _____ cartilage shields the _____ _____, which forms the vocal cords

Epiglottis, Glottis

Larynx

Thyroid, Cricoid, Epiglottic, and then in pairs: Arytenoid, Corniculate, and Cuneiform

Thyroid, Conus Elasticus

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Cranial Nerves & Sensory Function

The mucous membranes of the nose are innervated by the _____ division (VI) of the _____ nerve anteriorally, and by the ______ division (V2) posteriorly ( ___________ nerves)

The _______ nerves provide sensory fibers from the _______ nerve (V) to the superior and inferior surfaces of the hard and soft palate

Opthalmic, Trigeminal

Maxillary, Sphenopalatine

Palatine, Trigeminal

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Cranial Nerves & Sensory Function

The _______ nerve (I) innervates the nasal mucosa to provide the sense of ______

The ______ nerve and the _________ nerve (IX) provide general sensation to the anterior ____-____ and posterior ____-____ of the tongue

Branches of the ______ nerve (VII) and the _______ nerve (IX) provide the sensation of taste to those areas

Olfactory, Smell

Lingual, Glossopharyngeal

Two-Thirds, One-Third

Facial, Glossopharyngeal

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Cranial Nerves & Sensory Function

The ________ nerve (IX) also innervates the roof of the pharynx, the tonsils, amd the undersurface of the soft palate

Glossopharyngeal

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The Vagus Nerve

The _____ (X) cranial nerve; Provides sensation to the airway _____ the epiglottis

The _____ _____ _____ of the vagus nerve divides into an _____ (motor) nerve and an _____ (sensory) laryngeal nerve that provides sensory supply to the larynx ______ the epiglottis and vocal cords

Another branch of the vagus, the _____ _____ _____, innervates the larynx _____ the vocal cords and trachea

Vagus, Below

Superior Laryngeal Branch, External, Internal

Above

Recurrent Laryngeal Nerve

Below

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SLN and RLN (recap)

Sensory innervation from the mucosal lining of the larynx above the vocal folds is done by the _____ laryngeal branch of the _____ _____ _____ (X)

The _____ _____ _____, a branch of the vagus nerve (X), innervates the larynx below the vocal folds

Internal

Superior Laryngeal Nerve

Recurrent Laryngeal Nerve

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The external branch of the SLN innervates the ______ muscle

However, the RLN is still considered the major ______ nerve of the larynx since it supplies all other intrinsic muscles of the larynx (except for the crycothyroid muscle)

Cricothyroid

Motor

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The internal branch of the SLN is the major _____ nerve of the larynx, supplying laryngeal tissue from the vocal cords up, ______ the vocal cords

Sensory

Including

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Functions of Intrinsic Laryngeal Muscles

Discuss the “big” three…

Posterior Cricoarytenoids?

Cricothyroids?

Thyroarytenoids?

Abduct vocal cords (dialtes cords)

Increase vocal cord tension (tenses the cords)

Reduces cord tension (relaxes the cords)

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Vocal Cord Damage

Damage to the External Branch of SLN:

Will produce ______ and ______ in the voice, as the cords cannot be ______

The _______ muscle is paralyzed

Weakness and Huskiness, Tensed

Cricothyroid

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Vocal Cord Damage

Damage to the Unilateral Right RLN:

Most common injury after a ______ ___________

Characterized by _______

Also characterized by one paralyzed cord (flaccid cord) that assumes an _______ position (midway between abduction and adduction)

Subtotal Thyroidectomy

Hoarseness

Intermediate

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Vocal Cord Damage

Damage to the bilateral RLN’s: (Extremely Rare)

Characterized by _____ and paralyzed cords

Each paralyzed cord assumes an _______ position (midway between abduction and adduction)

The cords can flop together causing ______ _______ during ______

______ is required

Aphonia

Intermediate

Airway Obstruction, Inspiration

Intubation

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Vocal Cord Damage (Clinical Consideration)

_______ after thyroidectomy may result from either ________ (tensed cords due to tetany) or bilateral damage to the _______ _____ ______ (floppy cords)

Stridor, Hypocalcemia

Recurrent Laryngeal Nerves

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Sensory Innervation of Tongue

Responsible nerves?

Internal laryngeal branch of the _____

__________ nerve (IX)

______ nerve and ______ tympani

SLN

Glossopharyngeal

Lingual, Chorda

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Phonation

Involves complex _______ actions by several laryngeal muscles

Damage to the _____ nerves innervating the larynx leads to a spectrum of ______ disorders

________ denervation of a cricothyroid muscle causes very _____ clinical findings

Simultaneous

Motor, Speech

Unilateral, Subtle

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Phonation

Bilateral palsy of the SLN may result in ______ or ______ of the voice, but ______ control is not jeopardized

Unilateral paralysis of the RLN results in paralysis of the _______ vocal cord, causing deterioration in ______ ______

Acute bilateral RLN nerve palsy can result in ______ and _______ distress due to the unopposed tension of the cricothyroid muscles

Hoarseness, Fatigue

Ipsilateral, Voice Quality

Stridor, Respiratory

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Phonation

Airway problems are less frequent in _______ bilateral RLN loss due to the development of compensatory mechanisms

Bilateral injury to the ______ (X) nerve affects both the SLN and RLN. Bilateral vagal denervation produces ______, midpositioned vocal cords. Although ______ is severely impaired in these patients, ______ control is rarely a problem

Chronic

Vagus, Flaccid

Phonation, Airway

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Blood Supply

The blood supply of the larynx is derived from branches of the _____ ______

The ______ thyroid artery is a branch off the ______ carotid artery. The _______ artery arises from the superior thyroid artery.

Thyroid Arteries

Superior, External

Cricothyroid

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Trachea

The trachea begins ______ the cricoid cartilage and extends to the ______, (the point at which the right and left mainstem bronchi divide)

The trachea consists of cartilaginous rings _______

The trachea is membranous _______

Beneath, Carina

Anteriorly

Posteriorly

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Routine Airway Management

Airway ________

Preparation and _______ check

_______ positioning

____-oxygenation

_____ and _____ ventilation (BMV)

_______ (if indicated)

_______ of OETT placement

________ management and troubleshooting

________ (final step)

Assessment

Equipment

Patient

Pre

Bag and Mask

Intubation

Confirmation

Intraoperative

Extubation

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Airway assessment is the _____ step in successful airway management. Several maneuvers can be performed to estimate difficulty of ET intubation Name these assessments (5)

First Mouth opening Upper lip bite test Mallampati classification Thyromental distance Neck circumfrence

Mouth Opening/Upper Lip Bite Test An incisor distance of ____ or greater is desirable in an adult The lower teeth are brought in front of the upper teeth. The degree to which this can be done estimates the ______ of ______ of the ______________ joints

## Footnote 3 cm Range of Motion Temporomandibular

Mallampati Classification Class I: The entire ____ \_\_\_\_, including bilateral faucial pillars, are visible down to their bases Class II: The ____ part of the faucial pillars and most of the _____ are visible Class III: Only the ____ and ____ palates are visible Class IV: Only the ____ palate is visible

## Footnote Palatal Arch Upper, Uvula Soft and Hard Hard

Mallampati Classification Examines the size of the ______ in relation to the oral cavity The more the tongue ______ the view of the pharyngeal structures, the more difficult ______ may be

## Footnote Tongue Obstructs, Intubation

Cricoid Pressure Answer: Kg and Newtons

## Footnote 3-5 kg of pressure (6-11 lbs) (30 Newtons)

Thyromental Distance/Neck Circumfrence The distance between the ______ and the superior thyroid notch. A distance of __ \_\_\_\_\_\_\_\_ or more is desirable. Less than __ \_\_\_\_\_\_\_\_ is not reassuring A neck circumfrence greater than __ inches is suggestive of difficulties in visualization of the ______ opening

## Footnote Mentum 3 fingerbreadths 3 fingerbreadths 17 Glottic

Equipment Preparation is mandatory \_\_\_ source \_\_\_\_ capability \_\_\_\_\_\_\_\_\_ (direct and video) Several \_\_\_\_'s (different sizes) Alternate airways (\_\_\_\_, \_\_\_\_\_) \_\_\_\_\_\_\_ equipment Pulse _____ and ____ detector Stethoscope Tape BP and ____ monitors \_\_\_ access

O2 BMV Laryngoscope OETT's Oral, Nasal Suction Oximetry, CO2 EKG IV

Oral & Nasal Airways Loss of upper airway ____ tone in anesthetized patients allows tongue and epiglottis to fall back against posterior wall of the \_\_\_\_\_ \_\_\_\_\_\_\_ the head or ____ \_\_\_\_\_\_ is the prefered technique for opening the airway To maintain the opening, an ______ airway can be inserted through the mouth or nose

## Footnote Muscle Pharynx Repositioning, Jaw Thrust Artificial

Oral & Nasal Airways Awake or lightly anesthetized patients with intact _____ reflexes may cough or even devlop _______ during airway insertion Placement of an oral airway is sometimes facilitated by supressing airway \_\_\_\_\_, and in addition, by depressing the tongue with a _____ \_\_\_\_\_\_

## Footnote Laryngeal, Laryngospasm Reflexes, Tongue Blade

Oral & Nasal Airways Typical sizes? The length of the nasal airway can be estimated as the distance from the ____ to the _____ of the \_\_\_\_\_, and should be _____ longer than oral airways Due to risk of epistaxis, nasal airways are less desirable in _______ or _______ patients

## Footnote Small (80 mm, #3), Medium (90mm, #4), or Large (100 mm, #5) Nares to the Meatus of the Ear 2-4 cm Anticoagulated or Thrombocytopenic

Oral & Nasal Airways Nasal airways and NG tubes should be used in caution for patients with _____ \_\_\_\_\_ fractures All tubes inserted through the nose should be ______ before being advanced along the floor of the nasal passage

## Footnote Basilar Skull Lubricated

The Face Mask Can facilitate the delivery of ____ or an ______ \_\_\_\_ Transparent masks allow observation of ______ humidified gas and immediate recognition of \_\_\_\_\_\_

## Footnote Oxygen, Anesthetic Gas Exhaled, Vomitus

The Face Mask If the mask is held with the ____ hand, the ____ hand can be used to generate positive pressure ventilation by squeezing the AMBU bag The mask is held against the face with ______ pressure which is exerted with the left _____ and _____ finger The ____ and ____ fingers grasp the mandible to facilitate extension of the __________ joint

## Footnote Left, Right Downward, Thumb, Index Middle, Ring Atlantooccipital

The Face Mask Finger pressure should be placed on the bony _____ and not on the _____ \_\_\_\_\_\_ supporting the base of the tongue, which may obstruct the \_\_\_\_\_\_ The _____ finger is placed under the angle of the jaw and used to _____ the jaw anteriorly; this is the most important manuever to allow ______ to the patient

## Footnote Mandible, Soft Tissues, Airway Pinky, Thrust, Ventilation

The Face Mask In difficult situations, _____ hands may be needed to provide adequate jaw thrust and to create a mask \_\_\_. An assistant may be needed to squeeze the bag The _____ hold the mask down and the _____ or _____ displace the jaw forward Obstruction during ______ may be from excessive ______ \_\_\_\_\_\_ from the mask

## Footnote Two, Seal Thumbs, Fingertips or Knuckles Expiration, Downward Pressure

The Face Mask It is often difficult to form an adequate mask ____ with the cheeks of ______ patients \_\_\_\_\_\_\_-pressure ventilation using a mask should be normally limited to ____ cm H2O to avoid _____ inflation

## Footnote Fit, Edentulous Positive, 20, Gastric

The Face Mask Mask ventilation for long periods may result in pressure injury to branches of the _____ or _____ nerves Bc of abscence of _____ airway pressures during _______ ventilation, only minimal _______ force on the face mask is required to create an adequate seal

Trigeminal, Facial Positive, Spontaneous, Downward

Positioning Alignment of oral and pharyngeal axes is achieved by having patient in a "\_\_\_\_\_\_" position When _____ spine pathology is suspected, the head must be kept in a ______ position during all airway manipulations \_\_-\_\_\_\_\_ stabilization of the neck must be maintained during airway management in these patients, unless appropriate films have been reviewed/cleared by radiologist or surgeon

Sniffing Cervical, Neutral In-Line

Positioning Patients with morbid obesity should be positioned on a ___ degree _____ ramp Obese patients have a decreased _____ \_\_\_\_\_ _____ (FRC), leading to deterioration in the _____ position

## Footnote 30, Upward Functional Residual Capacity Deterioration

Preoxygenation Preoxygenation with a face mask should precede all _____ mgmt interventions Oxygen is delivered via mask for _____ minutes prior to induction Due to this, the _____ \_\_\_\_\_ _____ (the patient's oxygen reserve) is purged of \_\_\_\_\_

## Footnote Airway Several Functional Residual Capacity, Nitrogen

Preoxygenation The preoxygenated patient may have a \_\_-\_\_ minute oxygen reserve Conditions that increase oxygen _____ (sepsis, pregnancy) and conditions that decrease ____ (morbid obesity, pregnancy) reduce the tolerated apneic period before _______ occurs

## Footnote 5-8 minute Demand, FRC, Desaturation

Bag and Mask Ventilation BMV is the first step in airway mgmt in most cases, with the exception of patients undergoing _____ \_\_\_\_\_\_ intubation In emergent situations, BMV precedes intubation attempts in effort to oxygenate patient, however, with that there is a risk of \_\_\_\_\_\_ If the airway is \_\_\_\_\_, squeezing the bag will result in a rise of the \_\_\_\_\_

## Footnote Rapid Sequence Aspiration Patent, Chest

Bag and Mask Ventilation If ventilation is ineffective, (no chest rise, no ETCO2, no mist in clear mask), ___ and ____ airways can be placed to relieve airway \_\_\_\_\_\_ Difficult mask ventilation is often found in patients with \_\_\_\_\_\_, \_\_\_\_\_\_, and craniofacial \_\_\_\_\_\_\_

## Footnote Oral, Nasal, Obstruction Obesity, Beards, Deformities

Supraglottic Airway Devices SADS are used with both _____ and _____ patients during anesthesia Can aid ET ______ when BMV and OETT placement have failed These devices occlude the \_\_\_\_\_, reducing gas ____ of the stomach \_\_\_\_ offer the protection from _____ that is offered by a properly seated, _____ OETT

## Footnote Spontaneously breathing, Ventilated Intubation Esophagus, Distention None, Aspiration, Cuffed

Laryngeal Mask Airway The deflated cuff is inserted ______ into the ________ so that once inflated, the cuff forms a \_\_\_-pressure seal around the entrance to the larynx This requires _____ depth and ______ relaxation slightly greater than that required for insertion of oral airway Although insertion is simple, attention to _____ will improve the success rate

## Footnote Blindly, Hypopharynx Low-Pressure Anesthetic, Muscle Detail

Laryngeal Mask Airway An ideally positioned cuff is bordered by the base of the ____ superiorly, the _____ sinuses laterally, and the upper esophageal _____ laterally If the ______ lies within the rim of the cuff, gastric _____ and ______ become possible If an LMA is not a proper fit, most practicioners will try one size _____ or one size \_\_\_\_\_

## Footnote Tongue, Pyriform, Sphincter Esophagus, Distention, Regurgitation Larger, Smaller

Laryngeal Mask Airway Contraindications: Patients with _____ pathology (ex, abcess) \_\_\_\_\_ obstruction Full ____ (ex, pregnancy, hiatal hernia) Low _____ compliance (restrictive airway disease) requiring peak insp. pressure \>30 cm H20

Pharyngeal Pharyngeal Stomach Pulmonary

Laryngeal Mask Airway Traditionally, the LMA has been avoided in patients with bronchospasm or high airway resistance, but new evidence suggests that because it is not placed in the \_\_\_\_\_, use of an LMA is associated with less bronchospasm than an \_\_\_\_\_

## Footnote Trachea, OETT

Laryngeal Mask Airway A life saving temporary measure for patients with _____ airways due to its ease of insertion (95-99% success rate) Can be used as a _____ for an intubating stylet or small ETT Insertion can be performed under _____ anesthesia or bilateral SLN _____ blocks

## Footnote Difficult Conduit Topical, Nerve

Laryngeal Mask Airway \_\_\_ ___ is a common side effect following use Correct device \_\_\_\_, avoidance of cuff \_\_\_\_\_, and ____ movement of jaw during placement may reduce likelihood of such injuries Injuries to the \_\_\_\_\_, \_\_\_\_\_\_, and _____ have been reported

## Footnote Sore Throat Sizing, Hyperinflation, Gentle Lingual, Hypoglossal, and RLN

Esophageal-Tracheal Combitube Has two fused tubes and usually inserted _____ through the mouth and advanced until two ____ \_\_\_\_ on the shaft lie between the upper and lower teeth The ETC has two inflatable cuffs, a \_\_\_mL proximal cuff and a ___ mL distal cuff, both which should be fully inflated after placement

## Footnote Blindly, Black Rings 100 mL, 15 mL

Esophageal-Tracheal Combitube Distal lumen usually lies in the _____ 95% of the time so that ventilation through the longer blue tube will force gas out of the side perforations into the larynx The _____ clear tube can be used for ______ \_\_\_\_\_\_\_\_ Alternatively, if the Combitube enters the \_\_\_\_\_\_, ventilation through the clear tube will direct gas into the trachea

## Footnote Esophagus Shorter, Gastric Decompression Trachea

King Laryngeal Tube Consists of tube with a small _____ balloon and a larger balloon for placement in the \_\_\_\_\_\_\_\_. Both tubes inflate through ____ inflation line A suction port distal to the esophageal balloon is present, permitting _______ of the stomach If ventilation is difficult, the KLT is likely inserted too \_\_\_\_. Slightly _____ the tube until compliance improves

## Footnote Esophageal, Hypopharynx, One Decompression Deep, Withdraw

Endotracheal Intubation The shape and rigidity of the ETT can be altered by inserting a \_\_\_\_\_ The patient end is beveled to aid in ______ and insertion through the vocal cords Resistance to airflow depends primarily on \_\_\_\_\_\_, but is also affected by tube _____ and \_\_\_\_\_

## Footnote Stylet Visualization Diameter, Length, Curvature

Endotracheal Intubation Choice of tube ______ is always a compromise between maximizing _____ with a larger size or minimizing _____ \_\_\_\_\_ with a smaller size The ____ in the ETT prevents air loss after cuff inflation The _____ balloon provides a _____ indication of cuff \_\_\_\_\_\_ By creating a tracheal \_\_\_\_, ETT cuffs permit _____ pressure ventilation and reduce likelihood of \_\_\_\_\_\_\_

## Footnote Diameter, Flow, Airway Trauma Valve Pilot, Gross, Inflation Seal, Positive, Aspiration

Endotracheal Intubation For Infants and Children: ______ ONLY Formula to calculate size? Uncuffed tubes are often used in infants and young children to ______ the risk of pressure injury and post intubation \_\_\_\_\_, but in recent years, cuffed peds tubes have been favored

## Footnote (Age + 16)/4 = ETT Size Minimize, Croup

Endotracheal Intubation Two types of cuffs: ____ pressure (low volume) ____ pressure (high volume) High pressure cuffs are associated with more _____ damage to the tracheal _____ and are less suitable for intubations of long \_\_\_\_\_ Low pressure cuffs may increased likelihood of ____ \_\_\_\_, \_\_\_\_\_\_, spontaneous \_\_\_\_\_, and ______ insertion (floppy cuff) \_\_\_\_ pressure cuffs prefered secondary to reduced chance of mucosal damage

## Footnote High, Low Ischemic, Mucosa, Duration Sore Throat, Aspiration, Difficult Low

ETT Pressure Cuff Pressure depends on several factors: \_\_\_\_\_ volume \_\_\_\_\_\_ of the cuff in relation to the trachea \_\_\_\_\_ and _____ compliance \_\_\_\_-\_\_\_\_ pressure (cuff pressures increase when coughing)

Inflation Diameter Tracheal, Cuff Intra-Thoracic

Specialized ET Tubes Specialized tubes that resist ____ may be valuable in some ____ and ____ surgical procedures or in the ____ patient Preformed ____ tubes may be helpful for ____ and ____ intubation in ____ and ____ surgery

## Footnote Kinking, Head and Neck Prone Curved, Nasal, Oral Head and Neck

Laryngoscopes An instrument used to examine the larynx and to facilitate _______ of the trachea The handle usually contains batteries to a light bulb on the _____ tip Prefered type of blade depends on personal preference and patient \_\_\_\_\_\_\_ Remember: MAC = ______ and Miller = \_\_\_\_\_\_

## Footnote Intubation Blade Anatomy Valeculla, Epiglottis

Video Laryngoscope There is a video chip or a lens/mirror at the tip of the intubation _____ to transmit a view of the ______ to the operator These are great for ______ airways or to minimize manipulation of the \_\_\_\_\_ Video intubating _____ have a video capability and light source.

## Footnote Blade Glottis Difficult, Neck Stylets

Flexible Fiberoptic Bronchoscopes (FOB) Patients with ______ cervical spines, poor range of _____ of the __________ joint, or certain congenital or acquired _____ airway abnormalities-- _______ may be undesirable or impossible A flexible FOB allows ______ visualization of the larynx in such cases, or in any situation in which ______ intubation is planned

## Footnote Unstable, Motion of the Temporomandibular, Upper Laryngoscopy Indirect, Awake

Flexible Fiberoptic Bronchoscopes (FOB) Bronchoscopes are constructed of coated glass fibers that transmit light and images _____ reflection (light beam becomes trapped within a fiber and exits unchanged at the opposite end) \_\_\_\_\_\_ channels allow suctioning of secretions, insufflation of oxygen, or installation of a local \_\_\_\_\_\_

## Footnote Internal Aspiration, Anesthetic

Intubation Indications Inserting a tube into the trachea is one way of delivering a _____ \_\_\_\_\_ An OETT is also placed to _____ the airway and for airway access An OETT is placed in patients that are at risk for \_\_\_\_\_\_ Also for those undergoing surgical procedures involving body ____ or the ____ and \_\_\_\_

## Footnote General Anesthetic Protect Aspiration Cavities, Head and Neck

Direct Laryngoscopy Preparation Preparation includes checking _____ and properly _____ the patient The OETT should be examined; The tube's _____ \_\_\_\_\_ _____ can be tested by _____ the cuff using a \_\_\_mL syringe Maintenance of cuff pressure ____ detaching the syringe ensures proper cuff and valve function

## Footnote Equipment, Positioning Cuff Inflation System, Inflating, 10 mL After

Direct Laryngoscopy Preparation The ____ should be pushed firmly into the tube to decrease the likelihood of disconnection If a _____ is used, it should be inserted into the OETT, which is then bent to resemble a hockey stick The desired ____ is locked onto the laryngoscope handle, and ____ function is tested. _____ intensity should remain constant, even if the bulb is jiggled

## Footnote Connector Stylet Blade, Bulb Light

Direct Laryngoscopy Preparation An extra \_\_\_\_\_, \_\_\_\_\_, _____ (one size smaller than the anticipated size), and _____ should always be immediately available A functioning _____ unit is needed to clear airway in case of unexpected secretions, blood, or emesis

## Footnote Handle, Blade, OETT, Stylet Suction

Direct Laryngoscopy Preparation Often depends on correct ______ positioning Patient's head should be _____ with the CRNA's waist or higher to prevent ____ strain Direct laryngoscopy displaces ______ soft tissues to create a direct line of vision from the mouth to the _____ opening Head elevation \_\_-\_\_ cm above the surgical table and extension of the ________ joint place the patient in desired ______ position

## Footnote Patient Level, Back Pharyngeal, Glottic 5-10 cm, Altantooccipital, "Sniffing"

Direct Laryngoscopy Preparation Preparation for induction and intubation also involves \_\_\_\_\_\_\_ Giving 100% oxygen provides an extra ____ of _____ in case the patient is not easily _____ after induction Preoxygenation can be omitted in patients who object to the ____ \_\_\_\_, however, failing to preoxygenate increases the risk of rapid _______ following apnea Anesthesia removed the protective _____ reflex, so the eyes are usually ____ shut to prevent corneal abrasions

## Footnote Pre-oxygenation Margin of Safety, Ventilated Face Mask, Desaturation Corneal, Taped

Orotracheal Intubation The laryngoscope is held in the ____ hand With the patient's mouth open, the blade is introduced into the ____ side of the oropharynx, avoiding the \_\_\_\_ The tongue is then swept to the ____ and ____ into the floor of the pharynx by the blade's flange Successful "\_\_\_\_\_\_" of the tongue ______ clears the view for OETT placement

## Footnote Left Right, Teeth Left, Up Sweeping, Leftward

Orotracheal Intubation The curved blade is usally inserted into the \_\_\_\_\_\_, and the straight blade tip covers the \_\_\_\_\_\_ With either blade, the handle is raised ____ and ____ from the patient in a plane _________ to the patient's mandible to expose the vocal cords Do not trap the patient's ___ between the teeth or use the teeth for \_\_\_\_\_\_

## Footnote Vallecula, Epiglottis Up and Away, Perpendicular Lips. Leverage

Orotracheal Intubation The OETT is taken with the ____ hand and passed through the _____ vocal cords The "\_\_\_\_\_, \_\_\_\_\_, _____ ,\_\_\_\_\_ (BURP) manuever applied externally, moves an _____ positioned glottis _____ to facilitate visualization of the glottis The OETT cuff should lie in the upper \_\_\_\_\_, but beyond the \_\_\_\_\_\_

## Footnote Right, Abducted Backward, Upward, Rightward, Pressure Anteriorly, Posteriorly Trachea, Larynx

Orotracheal Intubation The cuff is inflated with the ____ amount of air necessary to create a seal during positive pressure ventilation to minimize the pressure transmitted to the \_\_\_\_\_\_ Over inflation beyond ____ mmHg may inhibit _____ blood flow, injuring the trachea Compressing the ____ \_\_\_\_\_\_ with the finger is NOT a reliable method of determining whether cuff pressure is sufficient or excessive

## Footnote Least, Mucosa 30, Capillary Pilot Balloon

Orotracheal Intubation After intubation, the \_\_\_\_\_/\_\_\_\_\_\_ are immediately auscultated and ______ tracing monitored \_\_\_\_\_ will not be produced if there is no cardiac output \_\_\_\_ through the tube and visualization of the tracheal ____ and ____ will likewise confirm correct placement The persistent detection of ___ by a capnograph is the best confirmation of ______ placement of an OETT, but it cannot exclude ______ intubation

## Footnote Chest/Epigastrium, Capnograph ETCO2 FOB, Rings and Carina CO2, Tracheal, Bronchial

Orotracheal Intubation The earliest evidence of ______ intubation is often an increase in _____ \_\_\_\_\_\_ pressure Proper tube location can also be confirmed by ______ the cuff in the ______ notch while ______ the pilot balloon with the other hand The cuff should not be felt above the level of the ______ cartilage, as this may result in postop hoarseness and increases risk of accidental \_\_\_\_\_\_\_

## Footnote Bronchial, Peak Inspiratory Palpating, Sternal, Compressing Cricoid, Extubation

Orotracheal Intubation Tube position can also be confirmed by chest \_\_\_\_\_ If there is doubt as to whether the tube is in the _____ versus the \_\_\_\_\_, repeat the laryngoscopy to confirm placement A _____ intubation should not be followed by identitcal ____ attempts

## Footnote XRAY Esophagus, Trachea Failed, Repeated

Orotracheal Intubation \_\_\_\_\_\_ must be made to increase the likelihood of success, such as _______ the patient, _____ pressure, _____ the tube size, adding a \_\_\_\_\_, selecting a different \_\_\_\_\_, using an indirect \_\_\_\_\_\_\_, attempting a _____ route, or requesting _______ from another anesthesiologist

## Footnote Changes Repositioning Cricoid Decreasing tube size Adding Stylet Different Blade Indirect Laryngoscope Nasal Route Requesting assistance

Orotracheal Intubation If the patient is also difficult to ventilate with a \_\_\_\_, alternative forms of airway management must be _____ pursued (LMA, Combitube, Cricothyrotomy, Tracheostomy)

## Footnote Mask, Immediately

Nasotracheal Intubation Tube is advanced through the nose and nasopharynx into the _____ before laryngoscopy The nostril through which the patient breathes most _____ is selected in advance and prepared with _______ nose drops (0.5% or 0.25%) to _____ vessels and _____ mucous membranes If the patient is awake, local ______ ointment, \_\_\_\_\_, and _____ blocks can be utilized

## Footnote Oropharynx Easily, Phenylephrine Vasoconstrict, Shrink Anesthetic, Spray, Nerve Blocks

Nasotracheal Intubation A lubricated ETT is introduced along the floor of the nose, below the inferior turbinate, at an angle ______ to the face. The tube's bevel should be directed _____ away from the turbinates The tube is gradually advanced until its tip can be seen in the \_\_\_\_\_\_\_ Laryngoscopy will reveal the abducted _____ \_\_\_\_\_ The distal end of the ETT can usually be advanced into the _____ without difficulty Nasal passage of ETT's, airways, or NG tube catheters carries greater risk in those with severe \_\_\_-\_\_\_\_\_ trauma due to risk of _______ placement

## Footnote Perpendicular, Laterally Oropharynx Vocal Cords Trachea Mid-Facial, Intracranial

Flexible Fiberoptic Intubation FOI is routinely performed in ____ or ____ patients with ______ airways FOI is ideal for: A ____ mouth opening Minimizing _____ spine movement in trauma or RA \_\_\_\_\_ airway obstruction (angioedema, tumor mass) Facial _____ or \_\_\_\_\_

## Footnote Awake, Sedated Small Cervical Upper Deformities, Trauma

Flexible Fiberoptic Intubation Can be performed ____ or ____ and by ____ or ____ routes Awake FOI: Predicted inability to _____ by mask, ____ airway obstruction Asleep FOI: _____ intubation, desired for minimal _____ movement in patients who refuse awake intubation Oral FOI: ____ or ____ injuries Nasal FOI: A ____ mouth opening

## Footnote Awake or Asleep, Oral or Nasal Ventilate, Upper Failed; C-Spine Facial or Skull Poor (Small)

Flexible Fiberoptic Intubation Airway is anesthetized with local _____ spray \_\_\_\_ nostrils are prepped with ______ drops Identify the nostril through which patient breathes more \_\_\_\_\_ Shaft of FOB inserted into the ETT lumen. It is important to keep shaft of bronchoscope \_\_\_\_\_ As the tip of the FOB passes through the distal end of the ETT, the _____ or _____ should be visible

## Footnote Anesthetic Both, Vasoconstrictive Easily Straight Epiglottis or Glottis

Flexible Fiberoptic Intubation Having an assistant thrust the jaw _____ or apply _____ pressure may improve visualization in difficult cases Once in the trachea, the FOB is advanced within sight of the \_\_\_\_\_ The presence of tracheal ____ and the ____ is proof of proper positioning Proper ETT position is confirmed by viewing the tip of the tube __ cm above the carina before the FOB is withdrawn

## Footnote Thrust, Cricoid Carina Rings, Carina 3 cm

Difficult Airway (Children) 1. Obtain \_\_\_\_ 2. Second attempt to \_\_\_\_ 3. Place \_\_\_\_ 4. _____ Intubation or ______ Intubation 5. Proceed with ____ as airway, ____ airway, or ____ patient up

## Footnote Help Intubate LMA Lightwand, Fiberoptic LMA, Surgical, Wake

Surgical Airways "\_\_\_\_\_" airways are required when the "can't \_\_\_\_\_, can't \_\_\_\_" scenario arises Surgical \_\_\_\_\_\_\_ Catheter or needle \_\_\_\_\_\_ Trans-tracheal catheter with ____ ventilation \_\_\_\_\_\_ intubation

## Footnote Invasive, Can't Intubate-Can't ventilate Cricothyrotomy Cricothyrotomy Jet Retrograde

Surgical Airway Techniques A 14g or 16g IV cannula is attached to a syringe and passed through the _____ toward the carina, then ____ is aspirated Use short __ second bursts of oxygen to ventilate patient Sufficient outflow of _____ air must be assured to avoid \_\_\_\_\_\_ Patients ventilated in this manner may develop ______ \_\_\_\_\_\_ and may become ______ despite adequate oxygenation

## Footnote CTM, Air 1 Second Expired, Barotrauma Subcutaneous Emphysema, Hypercapnic

Surgical Airway Techniques Transtracheal jet ventilation will usually require _____ to a surgical airway or _____ intubation If jet ventilation system is not available, a \_\_mL syringe can be attached to the catheter with the syinge plunger removed. A 7.0mm ETT connector can be inserted into the _____ and attached to breathing circuit Even still, adequate ______ must occur to avoid \_\_\_\_\_\_

## Footnote Conversion, Tracheal 3mL, Syringe Exhalation, Barotrauma

Retrograde Intubation A ____ is passed via a catheter placed in the \_\_\_\_ The _____ end of the wire is secured with a clamp to prevent it from passing through the \_\_\_\_ The wire can then be threaded into an ___ with a loaded ETT to facilitate and confirm placement Also, a small ____ can be guided by the wire into the \_\_\_\_\_. Once placed, the wire is removed.

## Footnote Wire, CTM Distal, CTM FOB OETT's, Trachea

Problems Following Intubation Anesthesia staff must _____ that the tube is correctly placed with ____ ventilation _____ following placement Detection of ETCO2 remains the ____ standard for verification

## Footnote Confirm, Bilateral, Immediately Gold Standard

Problems Following Intubation Should the ETCO2 suddenly \_\_\_\_, ___ thrombus or venous ___ \_\_\_\_\_ should be considered Other causes of sudden decline in cardiac output or a leak in the _____ should be considered A rising ETCO2 may be secondary to ______ or increased CO2 production as occurs with ______ \_\_\_\_\_\_, \_\_\_\_\_\_, a depleted ____ absorber, or breathing circuit \_\_\_\_\_\_\_\_

## Footnote Decline; Pulmonary, Air Embolism Circuit Hypoventilation, Malignant Hypothermia, CO2, Malfunction

Problems Following Intubation Increases in airway pressure may indicate an _____ or _____ ETT or _____ pulmonary compliance The ET tube should be _____ to confirm that it is patent and the lungs _______ to detect signs of \_\_\_\_\_\_, pulmonary \_\_\_\_\_, _______ intubation, or \_\_\_\_\_\_\_ Decreases in airway ______ can occur secondary to ____ in the breathing circuit or ______ extubation

## Footnote Obstructed, Kinked, Reduced Suctioned, Auscultated, Bronchospasm, Edema, Endobroncial, Pneumothorax Pressure, Leaks, Inadvertent

Techniques of Extubation Extubation should be performed when a patient is deeply _____ or \_\_\_\_ In either situation, adequate recovery from _____ \_\_\_\_\_\_ agents must be established prior to \_\_\_\_\_\_\_

## Footnote Anesthetized, Awake Neuromuscular Blocking Extubation

Techniques of Extubation Extubation during a ____ plane of anesthesia (state between deep and awake) is avoided due to risk of \_\_\_\_\_\_\_ The distinction between deep and light anesthesia is apparent during ______ suctioning. Any reaction to suctioning (\_\_\_\_\_ holding, \_\_\_\_\_) signals a light plane of anesthesia. No reaction is characteristic of a ____ plane \_\_\_\_ opening or _____ movements imply that the patient is sufficiently awake for extubation

## Footnote Light, Laryngospasm Phargyngeal Breath, Coughing, Deep Eye, Purposeful

Techniques of Extubation Extubating an ____ patient is usually associated with _____ (bucking) on the ETT. This reaction increases ____ \_\_\_\_, \_\_\_\_\_, aterial \_\_\_\_, \_\_\_\_\_, Intra-\_\_\_\_ pressure, and intra-\_\_\_\_\_ pressure It may also cause wound _______ and increased \_\_\_\_\_\_ The presence of an ETT in an awake _____ patient may trigger \_\_\_\_\_\_\_

## Footnote Awake, Coughing Heart Rate, CVP, BP, ICP, Intra-Abdominal, Intra-Ocular Dehiscence, Bleeding Asthmatic, Bronchospasm

Techniques of Extubation The likelihood of these adverse events may be alleviated by giving 1.5 mg/kg of IV \_\_\_\_\_, 1-2 minutes before _____ and \_\_\_\_\_\_ Extubation during _____ anesthesia may be _____ in patients who cannot tolerate these effects (provided such patients are not at risk for aspiration and do not have airways that may be difficult to control post ETT removal)

## Footnote Lidocaine, Suctioning and Extubation Deep, Preferable

Techniques of Extubation The patient's _____ should be thoroughly _____ before extubation to decrease the potential for _____ of _____ and \_\_\_\_\_\_ Patients should be ventilated with ____ oxygen in case it becomes difficult to establish an ______ after the ETT is removed The ETT is withdrawn and a ____ \_\_\_\_ is applied to deliver O2 O2 delivery by face mask is maintained during the period of _______ to the \_\_\_\_\_

## Footnote Pharynx, Suctioned Aspiration of Blood and Secretions 100%, Airway Face Mask Transportation, PACU

Complications of Largyngoscopy Name 5 These complications can occur _____ laryngoscopy and \_\_\_\_\_, while tube is in \_\_\_\_\_, or following \_\_\_\_\_\_

Hypoxia Hypercarbia Dental/Airway Trauma Tube Malpositioning Physiological response to airway instrumentation or ETT malfunction During, Intubation, Place, Extubation

Airway Trauma \_\_\_\_\_ damage is a common cause of ______ claims. A range of complications can occur from ____ \_\_\_\_\_ to ______ stenosis This is due to prolonged ______ pressure on sensitive _____ structures When these pressures exceed the \_\_\_\_\_-\_\_\_\_\_ blood pressure (approx 30 mmHg), _____ \_\_\_\_\_ can lead to a sequence of \_\_\_\_\_\_, \_\_\_\_\_\_\_, \_\_\_\_\_\_\_, and \_\_\_\_\_\_\_

## Footnote Tooth, Malpractice Sore Throat, Tracheal External, Airway Capillary-Arteriolar, Tissue Ischemia, Inflammation, Ulceration, Granulation, Stenosis

Airway Trauma Inflation of an ETT cuff to the _____ pressure that creates a ____ during routine \_\_\_\_\_\_-pressure ventilation (Usually at least ___ mmHg) reduces tracheal blood flow by ____ at the cuff site. Further cuff _____ can totally eliminate _____ blood flow

## Footnote Minimum, Seal Positive, 20 mmHg, 75% Inflation, Mucosal

Airway Trauma Post intubation ____ cause by glottic, laryngeal, or tracheal _____ is serious in \_\_\_\_\_ Vocal cord paralysis from ____ \_\_\_\_\_\_ or other trauma to the _____ results in _____ and increases risk for \_\_\_\_\_ Incidence of post extubation hoarseness seems to be increased with \_\_\_\_\_, _____ \_\_\_\_\_\_, and anesthetics of long \_\_\_\_\_

## Footnote Croup, Edema, Children Cuff Compression, RLN, Hoarseness, Aspiration Obesity, Difficult Intubations, Duration

Airway Trauma Smaller tubes (\_\_\_ in women and ___ in men) are associated with fewer complaints of postop ____ \_\_\_\_ Repeated attempts at _____ during a difficult intubation may lead to _______ \_\_\_\_\_, and the inability to _____ with a face mask, thus turning a bad situation into a \_\_\_\_-\_\_\_\_\_\_ one

## Footnote 6.5mm women, 7.0 mm men Sore Throat Laryngoscopy, Periglottic Edema, Ventilate Life Threatening

ETT Positioning Errors Be aware of unrecognized ______ intubation Need to directly _____ the tip of the ETT passing ____ the vocal cords with careful _______ for the presence of _____ breath sounds and the abscence of _____ \_\_\_\_\_ while ventilating through the ETT Analysis of exhaled gas for ____ content is most _____ method Also Chest ____ or use of an ____ is sufficient for confirmation

## Footnote Esophageal Visualize, Through, Auscultation, Bilateral Gastric Gurgling CO2, Reliable XRAY, FOB

ETT Positioning Errors Even if confirmed that ETT is in trachea, it may not be _____ positioned Overly ____ insertion usually results in intubation of the ____ mainstem bronchus due to the less acute angle in relation to the trachea

## Footnote Correctly Deep, Right

ETT Positioning Errors Clues to bronchial intubation may include ____ breath sounds, unexpected ____ with pulse ox, Inability to ______ the ETT cuff in the ____ notch, and ______ breathing bag compliance Inadequate insertion ____ will position the cuff in the \_\_\_\_\_, predispositioning the patient to _____ trauma. This may the case if the ETT cuff can be palpated over the _____ cartilage

Unilateral, Hypoxia, Palpate Sternal, Decreased Depth, Larynx, Laryngeal Thyroid

ETT Positioning Errors Minimal testing should include: chest \_\_\_\_\_\_\_, routine \_\_\_\_\_\_\_, and occasionally cuff \_\_\_\_\_ If the patient is \_\_\_\_\_, tube placement must be \_\_\_\_\_\_\_ At no time should excessive ____ be applied during intubation Esophageal intubations can result in ______ \_\_\_\_\_ and \_\_\_\_\_\_

## Footnote Auscultation, Capnography, Palpation Repositioned, Reconfirmed Force Esophageal Rupture, Mediastinitis

Physiological Response to Airway Instrumentation Airway manipulation violates the patient's _____ airway reflexes and predicatably leads to _____ and ______ when performed under ____ planes of anesthesia Hemodynamic changes can be attenuated by IV \_\_\_\_\_\_, \_\_\_\_\_\_, or _____ blockers, or _____ planes of anesthesia in the minutes before \_\_\_\_\_\_\_\_ \_\_\_\_\_\_ _____ may occur during intubation, indicating _____ plane of anesthesia

## Footnote Protective, Hypertension, Techycardia Light Lidocaine, Opioids, Beta Blockers, Deeper Laryngoscopy Cardiac Arrythmias, Light

Laryngospasm Forceful, involuntary spasm of the laryngeal musculature caused by _____ stimulation of the \_\_\_\_\_ Triggers may include ______ \_\_\_\_\_\_ or passing an ETT through the larynx during \_\_\_\_\_\_. This can usually be prevented by _____ patients either _____ asleep or fully \_\_\_\_\_ Treatment: Providing gentle ____ pressure ventilation with anesthesia bag and mask using ____ O2

## Footnote Sensory, SLN Pharyngeal Secretions, Extubation, Extubating Deeply, Awake Positive 100%

Laryngospasm Giving _____ (1.0-1.5 mg/kg) If laryngospasm continues and hypoxia develops, _______ (0.25-0.5 mg/kg) may be required (perhaps in combo with small doses of _____ or another anesthetic) to relax the laryngeal muscles and allow ______ ventilation

## Footnote Lidocaine Succinylcholine Propofol Controlled

Laryngospasm The large _____ intrathoracic pressures generated by a struggling patient during laryngospasm can result in development of \_\_\_\_\_\_-\_\_\_\_\_ pulmonary edema, even in healthy patients \_\_\_\_\_\_ may result from abnormally ____ reflex \_\_\_\_\_\_ may result from _____ of laryngeal reflexes following prolonged intubation and general anesthesia

## Footnote Negative Negative-Pressure Laryngospasm, Sensitive Aspiration, Depression

Bronchospasm Another reflexive response to ____ and most common in ____ patients This can also sometimes be clue to ______ intubation

## Footnote Intubation, Asthmatic Bronchial

Tracheal Tube Malfunction Polyvinyl Chloride tubes may be _____ by _____ or laser in an \_\_\_\_\_\_/\_\_\_\_\_\_ enriched environment Valve or cuff damage is uncommon but should be ____ prior to insertion ETT obstruction can result from \_\_\_\_, foreign body \_\_\_\_\_, or thick _____ in the lumen

## Footnote Ignited, Cautery Oxygen/Nitrous Excluded Kinking, Aspiration, Secretions