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Advanced Anesthesia Fall Semester > Airway Review > Flashcards

Airway Review Flashcards

1
Q

What is the barrier between the upper and lower airway?

A

Glottis

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2
Q

This is the only muscle that ABDUCTS the vocal ligaments

A

Posterior cricoarytenoid muscles

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3
Q

What is the most narrow part of the adult and pediatric airways?

A

Pediatric - cricoid cartilage

Adults - glottis (6 - 9 mm)

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6
Q

Normal mouth opening distance

A

3 - 4 cm (2-3 FB)

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7
Q

Posterior cricoarytenoid

what do they do

who innervates it

A

Only abductor of the cords!! Opens the glottis

Recurrent laryngeal nerve

intrinsic muscle

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8
Q

Lateral cricoarytenoid

function

nerve

A

Adducts the cords

Recurrent laryngeal nerve

intrinsic muscle

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9
Q

Arytenoids

function

nerve

A

Closes the glottis (esp the posterior)

Recurrent laryngeal nerve

intrinsic muscle

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10
Q

Crycothyroid

function

nerve

A

Produces tension and elongates the cords

superior laryngeal nerve

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11
Q

Thyroarytenoid & Vocalis

A

Shortens and relaxes the cords

recurrent laryngeal nerve

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12
Q

Sensory and Motor Function of the Superior Laryngeal Nerve (Internal branch)

A

Sensory only!!

Base of tongue

Epiglottis

Supraglottic mucosa

2 joints (thyroepiglottic and cricothyroid joints)

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13
Q

Sensory and Motor Function of the Superior Laryngeal Nerve (External branch)

A
  • Sensory:
    • Anterior subglottic mucosa
  • Motor:
    • Cricothyroid muscle (adductor/tensor)
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14
Q

Sensory and Motor Function of the recurrent laryngeal nerve

A
  • Sensory
    • Subglottic mucosa
    • Muscle spindles
  • Motor
    • Thyroarytenoid
    • Lateral cricothyroid
    • Interarytenoid
    • Posterior arytenoid
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15
Q

Precautions for nasal airways

A

Epistaxis and anticoagulants

Nasal and basilar skull fractures

Adenoid hypertrophy

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16
Q

Big caution with oral airways

A

LARYNGOSPASM

bleeding

soft tissue damage

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25
Q

What should we remember to do before placing a nasal airway?

A

Lube that sucker up

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26
Q

When is a mask case ok?

A
  1. Pt doesn’t have difficult airway
  2. Airway obstruction is easily relieved with oral/nasal airway or chin lift
  3. Short case duration
  4. Surgeon doesn’t need access to head/neck (exception to the rule: bilateral myringotomy tubes)
  5. Head will be accessible for the entire case
  6. No airway bleeding/secretions
  7. No table position changes
27
Q

When in the induction sequence can an LMA be placed?

A

After loss of lash reflex and confirmation of mask ventilation

28
Q

Proper Snifing position

A

pillow under the head (not soulders)

35° neck flexion and 15° head extension (angles relative to horizontal planes)

29
Q

Who should not have an LMA placed?

A

Anyone considered a full stomach

(non-fasting, parturients 34+ weeks, uncontrolled GERD, trauma, acute abdomens, diabetics d/t autonomic neuropathy, low pulmonary compliance)

30
Q

LMA advantages

A
  • ↑ speed & ease of placement by inexperienced personnel
  • Improved hemodynamic stability at induction & during emergence
  • ↓ anesthetic requirements for airway tolerance
  • Lower frequency of coughing during emergence
  • Lower incidence of sore throats in adults (10% vs 30%)
    • Avoids “foreign body” in the trachea
  • Patient can be fully emerged prior to removal of LMA → good for asthmatic patients
31
Q

LMA disadvantages

A
  • Lower seal pressure
  • Higher frequency of gastric insufflation → risk for aspiration
  • Esophageal reflux more likely
  • Inability to use mechanical ventilation at higher pressures
32
Q

LMA - when do you deflate the cuff

A

Keep the cuff inflated until the patient is awake → DO NOT DEFLATE at END OF CASE

Keeps secretions from getting on vocal cords

33
Q

ETT indications

A
  1. Airway compromise
  2. Airway inaccessible
  3. Long surgical time
  4. Surgery of head, neck, chest, or abdomen
  5. Need for controlled ventilation & positive end-expiratory pressure
  6. Inability to maintain airway with mask/LMA
  7. Aspiration risk
  8. Airway disease
  9. Pregnancy
34
Q

How far to insert the ETT

A

males - 23 cm

females 21 cm

35
Q

RSI Sequence of Events

A
  1. Adjuncts → aspiration prophylaxis
    • Bicitra, reglan, protonix
  2. Monitors, suction on & placed at head of bed
  3. Supine “sniffing” position
  4. Sedation (Versed) if applicable
  5. Pre-Oxygenate 5 minutes or Minimum 4-5 VC Breaths!
  6. Sellick’s Maneuver = Cricoid pressure
  7. Induction agent followed by succinylcholine
    • Wait 60 seconds → watch the clock NOT the block!
  8. Attempt Laryngoscopy → visualize vocal cords → place ETT inflate cuff
  9. Confirm tracheal tube placement:
    • Chest rise
    • BBSE
    • Confirm presence of EtCO2
  10. Give assistant permission to release cricoid pressure
  11. Ventilate
  12. Start inhaled anesthetic or anesthetic infusion
  13. Ventilator on
  14. Secure ETT/tape eyes
36
Q

Potential Hazards in Airway Management

A
  • Dental damage
  • Soft tissue/mechanical injury
  • Laryngospasm
  • Bronchospasm
  • Vomiting/Aspiration
  • Hypoxemia/Hypercarbia
  • SNS stimulation
  • Esophageal/Endobronchial intubation
  • Endobronchial intubation evident by → high airway pressures, unilateral chest rise & breath sounds, ↓ O2 saturation
37
Q

Extubation Criteria

A
  • TV: >6 mL/kg
  • VC: >10 mL/kg
  • RR: < 30 breaths/min
    • If >30 could mean pain or anxious
  • SaO2: >90%
  • ETCO2: < 50
    • If EtCO2 is too low → can ↓ RR or ↓ VT
  • Sustained tetanic contraction
    • Closed grip fist for 5 seconds
  • Sustained head lift for 5 seconds
38
Q

Laryngospasm interventions

A
  • Jaw-Lift Maneuver
    • Forward displacement of the mandible with O2 administered by mask with positive pressure
  • Administration of O2 with continuous positive pressure
    • Strong intermittent pressure applied manually to a bag full of O2 can force gas effectively through the upper airway & adducted cords
  • Immediate removal of the offending stimulus
  • Small dose of short acting muscle relaxant succinylcholine 20-40 mg
40
Q

when is it allowed not to test-ventilate a patient before insertion of the ETT/LMA?

A

in RSI

41
Q

Nasal Tracheal Intubation: Asleep Sequence of Events

A
  • Phenylephrine to nose (AFRIN) or consider Anticholinergic/Antisialogogue (glycopyrrolate)
  • Monitors, Supine “sniffing” position, Sedate (Versed)
  • Pre-Oxygenate
  • Induction Agent
  • Confirm loss of consciousness
  • Attempt ventilation if able to ventilate →
  • Muscle Relaxant
  • Consider dilation of nare with sequential sizes of nasal airways → choose nare that is easily able to breathe through in preop
    • Consider induction agent may be wearing off
  • Insert LUBRICATED ETT through nare (that was dilated)
  • Continue to ventilate
  • Attempt direct visual laryngoscopy → visualize VC → use Magill forceps to pick up end of ETT & advance through cords
  • Inflate cuff
  • Confirm tracheal tube placement:
    • Chest rise
    • BBSE in all lung fields & over stomach
    • Confirm presence of EtCO2
  • Ventilate
  • Start inhaled anesthetic or anesthetic infusion
  • Ventilator On
  • Secure ETT/tape eyes
42
Q

Extubation guidelines

A
  • Nearly fully awake extubation is performed when the patient has
    • Purposeful movement
    • ready to maintain & protect his/her own airway
  • Muscle relaxant must be fully reversed & confirmed with PNS
  • Anesthetic medications, including anesthetic gases & infusions, turned OFF
  • Oropharynx is suctioned
  • The patient is self-maintaining an acceptable respiratory rate & depth (see respiratory extubation criteria*)
  • Assess for responsiveness / purposeful movement &/or responding to commands
    • A sustained (5 second) head lift is an excellent way to assess clinically adequate reversal
  • ETT is removed while a positive-pressure breath is given with the anesthesia bag to allow subsequent expulsion or secretions away from the glottis
43
Q

Innervation of the nasopharynx, oropharynx and larynx

A

Trigeminal (CN V)

  • From the pterygopalatine ganglion via the maxillary division of the trigeminal nerve (CN 5)
  • innervates the posterior two thirds of the nasal septum and the turbinates.

Glossopharyngeal (CN IX)

  • Base of the tongue and oroparynx
  • Lingual branch - Innervates the posterior one third of the tongue, vallecula, and anterior surface of epiglottis
  • Pharyngeal branch - Innervates the lateral and posterior walls of the pharynx
  • Tonsillar branch - Innervates the tonsillar pillars and soft palate

Vagus (CN X)

  • structures beyond epiglottis
  • superior laryngeal nerbe
  • Recurrent laryngeal nerve

Advanced Anesthesia Fall Semester (10 decks)

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