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Principles of Anesthesia I > Airway Part I > Flashcards

Airway Part I Flashcards

1
Q

During intubation with an ET tube, the tip of the MAC blade sits in what anatomical area?

A

The vallecula

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2
Q

The 5 anatomical features relevant to endotracheal intubation?

A

mnemonic (VEVAT)

  • Vallecula
  • Epiglottis
  • Vocal cords
  • Arytenoids
  • Trachea
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3
Q

During direct laryngoscopy the tube is inserted at ________, then directed towards the ________, and tracheal placement is confirmed with a _________ ETC02 waveform, and esophageal waveform would be_________.

A
  • The right corner of the mouth
  • Glottis
  • Alpha/Beta square
  • Flat
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4
Q

In pediatrics the black line on the ETT should not pass how far pas the cords?:

  • <6 months
  • Up to 1 year
  • Over 1 year
A
  • 1cm
  • 2cm
  • 3-4 cm
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5
Q

Average ETT length at the interior incisors for:

  • Males?
  • Females?
A
  • 23-24cm

- 21-22cm

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6
Q

What are the complications of ETT placement? (SHUN-GMTV)

A
  • Sore throat
  • Hoarseness
  • Neurologic injury
  • “Goose” (Gastric tube in the airway)
  • Macroglossia
  • Tracheal stenosis
  • Vocal cord dysfunction
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7
Q

What instrument is used to visualize airway anatomical landmarks but cannot drive the tip of the ETT into the laryngeal inlet?

A

Bougie

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8
Q

An instrument that is always used in nasal intubation and can be used to direct a tracheal tube into the larynx or other devices into the esophagus.

A

Magill’s forceps

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9
Q

Laryngeal Mask Airways are inserted in the _______, creates a seal at the ________, and only protects from _______ secretions.

A
  • Hypopharynx
  • Larynx
  • Pharyngeal
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10
Q

Because LMAs are a __________ device, they are not considered definitive airways.

A

Supraglottic devices.

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11
Q

A supraglottic device that can protect from gastric contents.

A

Proseal LMA

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12
Q

Parameters when positive pressure ventilating with an LMA.

A
  • Limitied Tidal Volume < 8ml/kg

- Airway pressure < 20cm H20

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13
Q

LMA sizes…

A
  • 1-6
  • 1.5-2.5, 10kg intervals
  • 3-4, 20kg intervals
  • 5-6, 30kg or more intervals
    > 1, up to 5kg
    > 1.5, 5-10kg
    > 2, 10-20kg
    > 2.5, 20-30kg
    > 3, 30-50kg
    > 4, 50-70kg
    > 5, 70-100kg
    > 6, 100kg and more
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14
Q

Contraindications for LMA (DIM-HFF)

A
  • Delayed gastric emptying (Diabetic gastroparesis)
  • Intestinal obstruction
  • Morbid obesity
  • Hiatal hernia w/ GERD
  • High-risk for gastric content aspiration
  • Full stomach
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15
Q

Relative contraindications to LMA intubation (Increased risk for aspiration) (LASTPIG-NCPR-12)

A
  • Laparoscopic surgery
  • Airway obstruction (Supraglottic, glottic)
  • Supraglottic pathology
  • Trauma
  • Prone
  • Inflation pressures
  • Gastric bypass
  • Narcotics
  • Cervical pathology
  • Prolonged procedures
  • Restricted access to airway
  • 12 weeks pregnant
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16
Q

Complications FROM LMAs? (DANGBAT)

A
  • Dislodment
  • Aspiration
  • Nerve injury
  • Gastric distribution
  • Bronchospasm
  • Airway obstruction
  • Trauma
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17
Q

This is an exaggerated and prolonged response of the protective glottic closure reflex, where airflow is absent, there is no vocal sound, and the true vocal cords cannot be seen, which can be caused by inhaled anesthetics, secretions and/or foreign bodies.

A

Laryngospasm

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18
Q

what do CRNAs need to anticipate

A

.Difficult airways
.Unanticipated difficult intubations or ventilations
.Failed airways
.Patients at risk for aspiration of gastric contents
.Patients who present with airway obstruction

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19
Q

Incidence of difficult mask ventilation

A

0.09%- 51.

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20
Q

What are the four treatments for laryngospasm?

A

1) Displace the mandible by pressing against the laryngospasm notch and extend the neck
2) Open the vocal cords with forced Oxygen pressure by bag-mask.
3) If Severe - give small dose of sux 0.15-0.30 mg/kg (approx 10-20mg)
4) Intubation (last resort)

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21
Q

Used to ventilate a patients with a mask, be sure you have a tight seal and avoid the eyes because you can accidentally cause this injury?

A

orneal abrasions

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22
Q

What wasThe average settlement payment for adverse respiratory events?

A

$200,000

with a range from $1,000 to $6,000,000.

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23
Q

settlement claims for injury due to difficult tracheal intubation averaged?

A

$76,000

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24
Q

Questions to ask patient about their Airway History:

A

Prior surgery or hospitalization requiring intubation or tracheostomy?
Prior history of difficult intubation?
Difficult Intubation Medic Alert Record?
History of obstructive sleep apnea?
History of oral, pharyngeal, esophageal disease?
Trauma, burns, chemicals, radiation ?

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25
Q

ways of reducing the risk of aspiration

A
  1. NPO orders
  2. Increase gastric pH (H2 antagonists)
    Cimetidine, Ranitidine, Famotidine
  3. Increase gastric motility
    Metoclopromide
4. Caution with sedation and opioids:
 Decrease LES (Lower esophageal sphincter)
  1. Endotracheal intubation vs LMA
  2. Rapid sequence induction vs awake intubation
  3. Aspiration of gastric contents after intubation and prior to extubation
  4. Awake extubation vs deep extubation
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26
Q

What are the Four D’s that suggest a difficult airway

A

Dentition (prominent upper incisors, receding chin)

Distortion (edema, blood, vomitus, tumor, infection)

Disproportion (short chin-to-larynx distance, bull neck, large tongue, small mouth)

Dysmobility (TMJ and cervical spine)

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27
Q

what is the airway divided into?

A

upper and lower airway.

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28
Q

Upper Airway includes:

A 
Nose 
Mouth
Pharynx
Hypopharynx 
Larynx
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29
Q

Lower Airway includes:

A 
Trachea
Bronchi
Bronchioles
Terminal bronchioles
Respiratory bronchioles
 Alveoli
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30
Q

what are the functions of the nose?

A

The nose and mouth open to the respiratory tree
The nasal mucosa warms and humidifies inspired air
Provides 2/3 of resistance to breathing, Resistance is 2x that of mouth breathing

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31
Q

Blood supply to the nose?

A

The maxillary artery
Ophthalmic artery
Facial artery

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32
Q

The Spasming of the vocal cords in laryngospasm is caused by the stimulation of which nerve?

A

The Superior laryngeal nerve

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33
Q

Which stage of anesthesia is laryngospasm most commonly seen?

A

Stage 2/Excitatory Stage

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34
Q

What are the four treatments for laryngospasm?

A

1) Displace the mandible by pressing against the laryngospasm notch and extend the neck

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35
Q

Used to ventilate a patients with a mask, be sure you have a tight seal and avoid the eyes because you can accidentally cause this injury?

A

corneal abrasions

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36
Q

what are the 3 branches of the trigeminal nerve (V)?

A
  1. Anterior ethmoidal nerve - V1
    Opthalmic division
    Anterior third of the septum and lateral wall
  2. Sphenopalatine nerves - V2
    Maxillary division
    Posterior 2/3rds of the septum and lateral wall
  3. Lingual nerve - V3
    Mandibular division
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37
Q

parts of the mouth?

A
  1. The soft palate:
    Covers the posterior third to half of the oral cavity.
    Rises during eating to prevent food and liquids from passing from the mouth into the nose and decreases aspiration
    Is movable and can obstruct the airway!!!!!!!
  2. The tongue:
    A muscular organ relaxes when the patient is asleep or paralyzed causing obstruction!!!!!!!!!!!!!
  3. The uvula:
    Guards the airway, it can swell and cause obstruction
  4. The tonsils:
    Partially buried in the soft tissue and are protected by the anterior and posterior tonsillar pillars.
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38
Q

what separates the nasal passages from the mouth?

A

the hard and soft palate.

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39
Q

Functions of the Glossopharyngeal Nerve (IX)

A 
Innervates.
Posterior third of the tongue
Roof of the pharynx
Tonsils
Soft palate  
Motor fibers to the stylopharyngeal muscle
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40
Q

what are the 3 compartments of the pharynx

A

Nasopharynx

Oropharynx

Hypopharynx

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41
Q

what is the larynx?

A

is a musculocartilaginous organ at the upper end of the trachea, below the root of the tongue, lined with ciliated mucous membrane, that is part of the airway and the vocal apparatus.

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42
Q

why is it important to Identify patients that are at increased risk for aspiration of gastric contents?

A

aspiration increases M&M.

1-7:10K cases M&M = 80% morbidity & 20% mortality

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43
Q

The cricoid cartilage is at:

A

The cricoid cartilage is at:

level C4-5

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44
Q

describe the larynx

A

the larynx is a Cartilaginous structure surrounded by ligaments and muscles, it Begins with the epiglottis and extends to the cricoid cartilage

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45
Q

what is the larynx composed of

A

Composed of: NINE CARTILAGES

3 single cartilages:
Epiglottis cartilage
Thyroid cartilage
Cricoid cartilage

3 paired cartilages:
Aretynoid cartilage
Corniculate cartilage
Cuneiform cartilage

Intrinsic and extrinsic muscles

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46
Q

Functions of the Larynx:

A

Protect the airway from aspiration
Provide airflow between the hypopharynx and the trachea
Provide cough and gag reflexes
Produce phonation

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47
Q

what are some situations that increase aspiration risks?

A

Loss of airway reflexes

Altered level of consciousness,
Ie, trauma, car accident

Full stomach

Anatomy – Obesity, Pregnancy, Hiatal hernia
Gastroespohageal Reflux Disease (GERD)

Decreased GI motility: diabetes, trauma

> Risk = pH < 2.5 and volume > 25 ml!!!!!

48
Q

What is the pressure limit for mask ventilation?

A

20cm H20

49
Q

What are the advantages to anesthesia delivery via facemask?

A

Lower incidence of sore throat
Less anesthetic depth
No muscle relaxants needed

50
Q

What are the disadvantages to anesthesia delivery via facemask?

A

Your hands are tied up
Need higher flows
Need to continually assess and readjust airway
Work of breathing is greater

51
Q

Five Facial characteristics that will contribute to difficulty with Mask ventilation?

A

1) Fat
2) Emaciated, edentulous faces
3) Protruding nares
4) Flat noses
5) Receding jaws

52
Q

8 Facial characteristics that will contribute to difficult with Mask ventilation?

A

1) Male gender
2) A beard
3) Lack of teeth
4) Over the age of 55
5) Macroglossia
6) Obese
7) History of snoring
8) Increased Mallampati score

53
Q

The following are complications of ____________?Dermatitis, Nerve injury, Gastric inflation, Eye injury, Environmental pollution, Jaw pain, Cervical spine movement, Latex allergy, No correlation between arterial and ETCO2, User fatigue.

A

Face Mask Ventilation

54
Q

What are the 3 types of devices used to maintain a patent airway?

A

Oral Airways
Nasopharyngeal Airways
Laryngeal mask airway (LMA)

55
Q

What are the five contraindications for Nasopharyngeal Airways?

A

1) Pt on anticoagulation
2) A basilar skull fracture
3) Pathology
4) Sepsis
5) Deformity of the nose or nasopharynx

56
Q

What are the eight complications of airway devices?

A

1) Airway obstruction
2) Trauma
3) Tissue edema
4) Ulceration and necrosis
5) Dental damage
6) Laryngospasm and coughing!!!!!!
7) CNS trauma
8) Nerve Damage

57
Q

The size of the ETT refers to the?

A

Internal Diameter

58
Q

The sound-producing apparatus of the larynx consist of ?

A
  • The two vocal cords and the intervening space

- The Rima glottides

59
Q

A Leaf shaped lid of cartilage that protects this opening

A

epiglottis

60
Q

What muscle are Adductors of the vocal cords and CLOSES the glottis?

A

Intrinsic Muscles

-Lateral Cricoarytenoid muscle

61
Q

What muscle are Abductors of the vocal cord

and Separates the vocal cords and OPENS the glottis?

A

Intrinsic Muscles

-Posterior cricoarytenoid muscle

62
Q

What muscle is a Tensor of the vocal cord and

Produces tension and elongates the vocal cord?

A

Intrinsic Muscles

-Crycothyroid muscle

63
Q

What muscle Shortens and relaxes the vocal cord?

A

Intrinsic Muscles

-Thyroarytenoid muscle

64
Q

What muscle closes the glottis, especially the posterior?

A

Intrinsic Muscles

-Arytenoids

65
Q

Folds of the ________ play a significant role in the maintenance of the laryngeal functions of breathing and preventing food from entering the airway during swallowing.

A

Larynx

66
Q

A fold of mucous membrane covering muscle in the larynx

A

Ventricular folds (False Vocal Cords)

67
Q

The lower pair of vocal cords that enclose the lower part of the elastic membrane of the larynx, extend from inner surface of the thyroid cartilage near the median line to a process of the corresponding arytenoid cartilage on the same side of the larynx, and when drawn taut, subjected to the flow of breath produce voice

A

Vocal cords (True vocal cords)

68
Q

An opening between the true Vocal folds forms a narrow slit, called the______

A

glottis

69
Q

Trigeminal nerve (V) sensory supplies?

A
  • V1 Opthalmic
  • V2 Maxillary (sinus)
  • V3 Mandibular
70
Q

Glossopharyngeal nerve (IX) sensory supplies ?

A

Posterior third of the tongue to the uvula

71
Q

Vagus Nerve (X) sensory supplies?

A
  • Superior laryngeal

- Recurrent laryngeal

72
Q

The superior laryngeal nerve innervates?

A

1) Internal branch- SENSORY

2) External branch- MOTOR

73
Q

The recurrent laryngeal nerve innervates?

A

1) RIGHT recurrent laryngeal nerve

2) LEFT recurrent laryngeal nerve

74
Q

Vagus nerve X (also known as Cranial nerve) innervates between

A

The epiglottis and vocal cords

75
Q

Superior Laryngeal nerve (EXTERNAL BRANCH) is a MOTOR to ?

A

Crycothyroid muscle: Adductor tensor

-Tensor of the vocal cords

76
Q

Superior Laryngeal nerve (INTERNAL BRANCH) is a SENSORY nerve to?

A
  • Aryepiglottic folds
  • Arytenoids
  • Epiglottis: tongue base
  • Supraglottic mucosa (Hypopharynx)
  • Thyroepiglottic joint
  • Cricothyroid joint

Motor: NONE

77
Q

Recurrent Laryngeal nerve sensory MOTOR innervates the larynx below the vocal cords at ?

A

1) INTERARYTENOID: Posterior cricoarytenoid: Opens vocal cords

2) THYROARYTENOID: Lateral crcoarytenoid: Adduct the vocal cords
* *These muscles adduct the vocal cords and theerby close the rima glottidis, Protecting the airway!!!!!!!!!

78
Q

Superior Laryngeal nerve (External branch) is a SENSORY nerve to?

A

Anterior subglottic mucosa

79
Q

Recurrent Laryngeal nerve is a SENSORY nerve to?

A

1) Subglottic mucosa

2) Muscle spindles

80
Q

Gag Reflex sensory innervation

A

1) AFFERENT pathway is SENSORY: Glossopharyngeal nerve

2) EFFERENT pathway is MOTOR: Vagus nerve

81
Q

Results in hoarseness but does not compromise respiratory status

A

Unilateral injury to the RLN (Recurrent laryngeal nerve)

82
Q

Results in stridor, which may deteriorate into: Severe respiratory distress

A

Bilateral injury to the RLN (Recurrent laryngeal nerve)

83
Q

Usually does NOT cause respiratory distress

A

Injury to the SLN (Superior Laryngeal nerve)

84
Q

Surgical Incision made through the skin and cricothyroid membrane to establish a patent airway during certain life threatening situations

A

Cricothyrotomy

85
Q

Connects the thyroid and cricoid cartilage, located below the thyroid cartilage

A

Cricothyroid Membrane

86
Q

Trachea

A

-Suspended from the cricoid cartilage by the cricotracheal ligament
-1st tracheal ring is anterior to C6
-Trachea ends at the carina, level T5
-Tracheal length approx. 15cm (adults)
-Originates from the inferior border of the cricoid cartilage and extends to the carina
-It is 10-20cm long in adults
-Cricoid cartilage is a complete ring:
-The remainder of trachea is composed of
16-20 C-shaped cartilaginous rings
-Right mainstem bronchus:
Angle is 25-30 degrees!!!
-Left mainstem bronchus:
Angle is 45 degrees!!!!!!

87
Q

Where should you mark (measure) the ET tube after insertion?

A

At the teeth or lips after intubation, in centimeters

88
Q

When placing ET tube where should you place the marks?

A

When there are two marks, place the vocal cards between the marks when there is only one, the mark should be at the vocal cords

89
Q

What is the slant at the end of the ET tube called and why is the this important ?

A

The slant is called a bevel and when present the left facing bevel gives a better view

90
Q

What is the Murphy Eye in the ET tube?

A

If the main opening of the ET tube gets blocked gas flow can still occur via the Murphy eye
Without the Murphy eye the ET tube would be completely obstructed, if blocked in any way.

91
Q

What is the purpose of the ET tube cuff?

A

Forms a seal against tracheal wall
Prevents gases from leaking pasts the cuff
Allows positive pressure ventilation
Prevents aspiration

92
Q

How do I inflate the ET tube cuff?

A

A syringe is attached to the pilot balloon and inflated, syringe is removed, the air does not leak because it is a one way valve.

93
Q

The high volume low pressure cuffs have what effect on the trachea?

A

Less risk of tracheal ischemia

94
Q

The low volume high pressure cuffs have what effect on the trachea?

A

Higher risk of tracheal ischemia

95
Q

Why would you use a preformed RAE tube?

A

North RAE tubes and South RAE tubes allow easy access for dental and ENT surgeons

96
Q

What is special about a pediatric ET tube?

A

They are uncuffed, even if a cuffed tube is used it is not inflated to prevent damage to the trachea

97
Q

What does the reinforced ET tube prevent?

A

Kinking, used for thyroidectomy and surgery, has spiral wire embedded into the wall of the ET tube to give it strength and flexibility

98
Q

Are there special tubes for use with Laser?

A

Yes, special ET tubes resist damage by laser beams

99
Q

What safety measures are built in to ET tubes to prevent airway fires?

A

Cuff filled with methylene blue saline.

If cuff is damaged the blue color will identify rupture and saline will help prevent an airway fire.

100
Q

What are the advantages of routinely using cuffed ET tubes in adults?

A

Accurate ETCO2, TV, and compliance monitoring
Decrease aspiration
Less OR pollution
*Must use smaller diameter in children

101
Q

What are important considerations when using uncuffed tube in children

A

The tube should be large enough to provide effective ventilation
Maintain leak at 20-25 cm H2O

102
Q

When using a stylet care should be taken to avoid this?

A

Prevent stylet going through Murphy Eye and perforating the trachea

103
Q

Physical Characteristics Associated with Difficult Intubation?

A 
Obesity
Limited head and neck movement
Jaw movement
Receding mandible
Buck teeth
High mallampati score
Male sex
Age 40-59
Decreased mouth opening
Short thyromental distance
Short neck
Maxillary incisor characteristics
104
Q

Mallampati Classification descriptions?

A

Class 1: Soft/hard palates, fauces, pillars, uvula
Class 2: Soft/Hard palate, fauces, portion of uvula
Class 3: soft/hard palate, base of uvula
Class 4: Hard palate only

105
Q

Laryngeal View different Grades classification?

A

Grade 1: Full view of the glottis
Grade 2: Only the posterior commissure is visible
Grade 3: Only the epiglottis is seen
Grade 4: No epiglottis or structures visible

106
Q

How is the Thyromental Distance measured?

A

Tip of thyroid cartilage to the tip of the chin (mentum). Mandibular space length between the thyroid notch and the inner border of the mandible with the head extended.

107
Q
  1. Difficulty of Thyromental Distance >6cm?
A

3 fingerbreadths: Indicates easy intubation

108
Q
  1. Difficulty of Thyromental Distance 6.0-6.5 cm?
A

Intubation maybe difficult but may be possible

109
Q
  1. Difficulty of Thyromental Distance <6 cm?
A

Intubation maybe impossible

110
Q
  1. Airway Assessment includes?
A

A. Head and neck extension:
Range of motion.
Patient should touch the tip of the chin to the chest.
Ability to place the patient in the sniffing position
- Neck flexed on chest 35 degrees and neck extension 80 degrees
B. Body weight
C. Mallampati classification:
Relates the size of the base of the tongue to the oral cavity

111
Q

What is the Sniffing Position and the importance?

A

Proper positioning of the head is essential to facilitate success with mask ventilation and tracheal intubation.
Requires the head to be flexed forward 35 degrees and extended 80 degrees.
Allows for alignment of the oral, pharyngeal, and tracheal axis.

112
Q

Define the Lemon Law Assessment?

A
  • Look Externally: Look at the patient’s characteristics known to cause difficult laryngoscopy, intubation, and ventilation
  • Evaluate 3-3-2
    3 fingerbreadths between incisors
    3 fingerbreadths between tip of the chin and hyoid bone
    2 fingerbreadths between hyoid bone and thyroid notch
    -Mallampati score
    What class is the pt?
    -Obstruction
    Listen to respiration
    -Neck mobility
    Range of motion
113
Q

Congenital Syndromes Associated with Difficult Intubation?

A 
Trisomy 21
Goldenhar
Klippel-Feil
Pierre Robin
Treacher Collins
Turner
114
Q

Aspiration of Gastric Contents highest percentage of occurrence?

A

Induction 60%

115
Q

What’s the Sellick’s Maneuver?

A

Pressure on cartilage: pushes trachea more posterior for visualization of vocal cords intubation. Compresses esophagus to inhibit vomiting.

Principles of Anesthesia I (6 decks)

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