Airways B Midterm Flashcards
What actions are most likely to cause iatrogenic retropharyngeal abscesses?
Failed NGT placement
What is the age for end of development in humans?
7 years old
What is the age for peak incidence of foreign body aspiration?
2-3 years old
How should you examine and evaluate the airway of patients who have undergone radiation?
Manual exam of the larynx with swallowing
How should you manage the airway of a patient with Ludwig’s angina?
Nasal intubation
How should you induce anesthesia in patients with LeFort fractures?
RSI w/ great preO2
What airway adjuncts do you NOT use in patients with a LeFort II fracture?
NAW, NETT, NGT
What airway adjuncts do you NOT use in patients with a LeFort III fracture?
Anode ETT
What muscle of the tongue depresses and protrudes it?
Genioglossus
What anatomical structures make up Waldeyer’s ring?
Adenoids, lingual, nasopharyngeal, and palatine tonsils
What anesthetic should you use for management of tonsillar abscess drainage?
GETA with short-acting IV anesthetic, sevo or des, and short acting NMB
What airway adjunct should you consider for management of tonsillar abscess drainage?
Anode tube
What auscultatory sound is caused by an orificial airway lesion?
Stridor
What auscultatory sound is heard in patients with asthma?
Wheezes
What are complications associated with nasotracheal intubation?
Epistaxis, abrasion, hemorrhage, infection, perichondritis, chondritis, sinusitis
What is a primary tracheostomy?
Tracheostomy done within 24 hours of intubation
What is the function of the atlanto-occipital joint?
To provide flexion and extension of the head
Does hoarseness occur more in males or females?
Females
What lab values should you check following a parathyroidectomy?
Ca2+
What is the most common cause of stridor in 2 year olds?
Laryngomalacia
What should the FiO2 be kept under when the surgeon is lasering the airway?
30%
Where is squamous cell carcinoma most commonly found on the body?
In the mouth, orally
Why do obese patients desaturate more quickly?
They have a lower FRC
What can interrupt function of the right RLN and cause hoarseness?
Aortic aneurysm
What surgeries often use McIvor mouth gags?
Pharynx surgeries, i.e. tonsils
What vocal cord injury is associated with being intubated for over 72 hours?
Ulceration
What vocal cord injury is associated with being intubated for 3-21 days?
Granulomata
What vocal cord injury is associated with being intubated for more than 2 weeks?
Cicatricial stenosis
What is the position of the vocal cords immediately following interruption of the RLN?
Paramedian
How do you manage the airway of a patient presenting with facial burns, including lips and nasal hairs
Oral intubation
For repair of a lower lip laceration under MAC, so long as oxyhemoglobin saturation remains satisfactory (>94%), what is the safest FiO2 to provide the patient?
21% room air
At the conclusion of a general anesthetic for total laryngectomy, how should the patient be breathing/supported?
Spontaneous
How would you select an oral airway size for an acromegalic patient?
Increase size
Would you use a nasal airway for an acromegalic patient?
No
How would you select a laryngoscope for an acromegalic patient?
Increase size
How would you select an ETT for an acromegalic patient?
Use the regular size
If hoarseness is due to arthritis of a joint, which joint is most likely involved?
Cricoarytenoid
An increase in lung water would produce which breath sounds?
Rales
What is the surgical requirement for postop airway safety after a tracheostomy?
A stay suture in place to ensure access to trach
How do you calculate time to hypoxia/desaturation time?
FRC/VO2
What is the incidence of postop hoarseness?
3%
What is the resolution for postop hoarseness?
Usually resolves on its own in 1-3 days
What is a secondary tracheostomy?
A tracheostomy that takes place more than 24 hours after intubation
What are the increased risks with a secondary tracheostomy?
Bleeding and infection
What are the causes of postop stridor?
Supraglottic edema, RLN injury (rare), hypocalcemia (rare)
What position should a gravid patient be in for airway examination?
Supine
What is the proper management for ulceration of vocal cords?
Strict voice rest and observation
What is the proper management for cicatricial stenosis?
Surgery
How do you calculate oxygen consumption?
Kg^0.75 x 10
What is the appropriate ETT position for the McIvor mouth gag?
Midline on the tongue (on spatula/groove) and between the tongue and flange
What do rales sound like?
Crackling, high pitched
What do rhonchi sound like?
Vibrating, low pitched
What does stridor sound like?
Shrill, high pitched
Is wheezing high-pitched or low-pitched?
High pitched
Hoarseness persisting more than 2 weeks requires what action?
Otolaryngoscopy
What is the most frequent laryngeal malignancy?
Squamous cell carcinoma
What is the flow-volume loop of a patient with thyroid disease?
Extrathoracic, inspiratory plateau
What airway device should be used for a patient with a laryngectomy?
Laryngoflex
What are the functions of the larynx?
Protection, effort closure, phonation, air passage
What is the vertebral level of the hyoid bone?
C3
What is overjet?
Upper teeth jet over the bottom teeth horizontally
What is the etiology of otitis media with nasotracheal intubation?
Misplaced nasal tube in the eustachian tube
What is the concentration of heliox most commonly used in hospitals?
80/20
What is secreted from the parotid glands?
Saliva
What is the hallmark for laryngomalacia?
Inspiratory stridor
Which tracheal rings are involved in an elective tracheostomy?
2nd or 3rd
How does gastric pressure change in a gravid patient with 1 child?
Increases by 7-17cmH2O
How does gastric pressure change in a patient pregnant with twins?
Increases by 7-40cmH2O
How does gastric pressure change with a gravid patient in the lithotomy position?
Increases by 7-24 cmH2O
Who is the main manufacturer of tracheostomy tubes?
Shiley
What are the intermediate and long-term risks of a tracheostomy?
Ischemia, necrosis, erosion, dilation, stenosis
What gas can produce significant ischemic lateral-wall injury?
Nitrous oxide
Which trach tube has a foam-filled cuff and an adjustable flange?
Kamen-Wilkinson trach
What are the 2 critical considerations for proper placement of a trach tube?
1) No traction on trach
2) Optimum cuff pressure
Which trach tubes are all metal and can come with or without a cuff?
Jackson trach
What piece of equipment maintains stomal patency for future access?
Trach button
Which trach tube maintains stomal patency for suctioning and permits speech?
Kistner trach
Which trach tube is also known as the “talking trach”?
Fenestrated trach
What is the proper end-of-case management for a laryngectomy?
A laryngectomy tube (NOT TRACH TUBE) sutured to skin with patient spontaneously breathing
What airway device has a laryngeal limb that provides airflow, a tracheal limb that serves as a stent, and an exposed limb that allows for PPV?
Montgomery T-Tube
How should you manage the airway of a patient with retropharyngeal abscess?
Oral ETT with or without FFOB
Which laser is used for cuts and cauterizing of more superficial tissue?
CO2
Which laser is used on deeper tissue and can be transmitted by cornea?
YAG
Where is the glottis in infants?
C3-C4
How are the vocal cords situated in infants?
Horizontal and concave
How does the epiglottis differ in infants?
Longer, omega shape, stiffer, horizontal
What are the branches of the facial nerve superior to inferior? (two zombies butchered my cat)
- Temporal
- Zygomatic
- Buccal
- Mandibular
- Cervical
How do you determine the type of anode ETT tube you should use?
Depends upon surgery and direction of ETT and circuit (cephalad or caudad)
What is the long-term complication associated with flexible fiberoptic bronchoscopy?
Infection
What are the only three possible FFOB directional movements?
- Longitudinal
- Rotational
- Angulation
What does the longitudinal movement of the FFOB allow?
Allows you to enter and leave the airway
What does the rotational movement of the FFOB allow?
To move through approximately 180 degrees either clockwise or counterclockwise
What does the angulation movement of the FFOB allow?
Flexion and extension of the tip from 90 degrees to 180 degrees
What are the size measurements of the Aintree catheter?
4.7mmID x 6.5mmOD x 56cm L
With which sized ETT tubes can Aintree catheters be used?
7.0 and above
What structure must you see before sliding an ETT introducer into the larynx?
Tip of the epiglottis
What are the complications associated with ETT introducers?
Tracheal abrasion, hemorrhage, hematoma, infection, abscess, mediastinitis
What length ETT introducer is used with a 6.0 ETT?
66cm
What length ETT introducer is used with a 7.0 ETT?
70cm
What does HPOV stand for?
High-pressure oxygenation and ventilation
What does RGW stand for?
Retrograde guide wire-assisted endotracheal intubation
What is the minimum length of a J-wire required for RGW-assisted intubation?
60cm
What is the primary purpose of HPOV?
To oxygenate (not ventilate)
Which type of airway obstruction is HPOV used for?
Ball-valve obstruction
What type of airway obstruction will not be helped with HPOV?
Complete upper airway obstruction
In which direction should the 3-way stopcock be turned for HPOV assembly?
All ports open
What is the long-term complication associated with HPOV?
Barotrauma
What is the name of the conventional ETT with an integrated bronchial blocker?
Univent
What is the name of the bronchial blocker that has a specialized connector?
Ardnt endobronchial blocker (Cook)
What device is required for Ardnt endobronchial blocker placement?
FFOB
Which bronchial blocker has 2 distinct proximal balloons and bifurcated distal extensions?
Rusch EZ-blocker endobronchial blocker
What is the leading cause of obstetric anesthetic mortality?
AIRWAY - failure to secure and aspiration
What are the airway risk factors associated with pregnancy?
- Failure to intubate
- Aspiration
- Hypoxemia
What factors can cause a decrease in gastric emptying of pregnant patients?
- Progesterone
- Labor (stress)
- Narcotic
What contributes to increased gastric acidity in pregnant patients?
Gastrin
Does NPO status eliminate risks in pregnant patients?
No
What factors can decrease gastro-esophageal sphincter tone?
- Reflux patients
- Anticholinergics
- Narcotics
- NG tube
What are 3 contributing factors of intubation failure?
- Upper airway edema
- Adiposity of head/neck/trunk
- Breast enlargement
How is FRC changed in pregnant patients?
Decreased by 20%
How is oxygen consumption changed in pregnant patients who have carried to term?
Increased by 20%
How is oxygen consumption changed in patients who are in active labor?
Increased by 60%
How is Cimetidine administered for pregnant patients?
300mg IV 60 minutes prior to surgery
How is Metoclopramide administered for pregnant patients?
10mg IV 30 minutes prior to surgery
How is sodium citrate administered for pregnant patients?
30ml PO immediately prior to surgery
How does Cimetidine work to decrease airway complications in pregnant patients?
Histamine H2 antagonist that decreases stomach acid production and decreases risk for aspiration
How does Metoclopramide work to decrease airway complications in pregnant patients?
Helps with stomach emptying and GERD
How does sodium citrate work to decrease airway complications in pregnant patients?
Neutralizes acid in the GI system
At what age are patients considered an increased airway risk due to their age?
80 or older
What comorbidity do many geriatric patients have that would hinder mouth opening and C-spine motion?
Arthritis
How is thoracic compliance changed in the majority of geriatric patients?
Decreased
How is vital capacity changed in the majority of geriatric patients?
Decreased
How is FRC changed in the majority of geriatric patients?
Unchanged
What aspects of the geriatric airway can indicate a difficult BMV?
Edentulous and loose facial skin
How is the ability to cough and protect the airway changed in the majority of geriatric patients?
Decreased
What airway adjuncts could be used to improve BMV of elderly patients?
Oral airway and face mask strap
How does an increased prevalence of osteoporosis in geriatric patients pose an airway risk?
Increased fracture risk
According to Dr. Hall, what class of drugs should be avoided in patients over 70 unless they’re visibly stressed or anxious?
Benzodiazepines
What are the divisions of the thyroid gland?
Right lobe, left lobe, isthmus
How many parathyroid glands do humans have?
4
Which laryngeal nerves are contiguous with the thyroid gland?
RLNs
What monitoring is very important during thyroid surgeries?
Nerve testing and NMB monitoring
What are the airway and surgical risks during the maintenance phase of thyroid surgeries?
Hemorrhage
Where does the left side of the vagus cross under?
Aortic arch
Where does the right side of the vagus cross under?
Subclavian
Which cranial nerve is protected in the larynx by thyroid cartilage?
Vagus
What muscle is the only vocal cord abductor?
Posterior cricoarytenoid
What is the overall effect of RLN INJURY?
Vocal cord adduction
What are the acute effects of unilateral RLN injury?
Affected vocal cord will move to median position, opposed by the normal VC
What are the long term effects of unilateral RLN injury?
Affected vocal cord may force the normal cord away from midline
What are the acute effects of bilateral RLN injury?
Upper airway obstruction
What are the long term effects of bilateral RLN injury?
Resolution of edema, no problems
What is the overall effect of RLN INTERRUPTION?
Paramedian vocal cord position
What are the acute effects of bilateral RLN interruption?
Upper airway open
What are the long term effects of bilateral RLN interruption?
Aspiration and dyspnea
What are the 2 lobes of the parotid glands?
Superficial and deep
How many parotid glands do humans have?
2
What is another name for the parotid duct?
Stenson’s duct
Which cranial nerve transverses the parotid gland?
Facial
What makes up the majority of parotid gland diseases?
Adenoma (benign tumors)
What is the name for parotid inflammation?
Parotitis
How should electrodes be placed to optimize NMB monitoring?
- Maximum current density
- Minimal current dispersion
- Close to the nerve
When should the sensory threshold be tested during facial NMB monitoring of parotid surgeries?
Before induction - watch facial expression
When should the motor threshold be tested during facial NMB monitoring of parotid surgeries?
After induction, before the muscle relaxant
What is a supramaximal stimulus?
Stimulus that activates all muscle fibers served by the stimulated nerve without directly stimulated the muscle fibers
What is the empiric setting for NMB monitoring?
25mA above motor threshold, so 40mA (25mA+15mA)
What is the end point for neuromuscular blockade reversal?
TOF 4/4 –> sustained tetanus –> TOF ratio > 0.9
What type of anesthesia should be used for a patient for peritonsillar abscess surgery?
General
What airway device should be used for a patient with a peritonsillar abscess?
Anode ETT tube
What induction drugs should be selected for a surgery on a peritonsillar abscess?
Short-acting IV anesthetic and short-acting muscle relaxant
How should the airway of a patient undergoing surgery for a peritonsillar abscess be managed post-operatively?
Careful oral suctioning with flexible catheter, patient awake and alert
What is trismus?
Inability to open the mouth fully
What is the airway management plan for a patient undergoing surgery for Ludwig’s angina?
FFOB NETT sedation
How should induction proceed for a patient undergoing surgery for Ludwig’s angina?
IV induction AFTER intubation is complete and confirmed
How should the airway of a patient undergoing surgery for Ludwig’s angina be managed postoperatively?
The patient will remain intubated
What is angina ludovici?
Cellulitis of the floor of the mouth
What does angina mean in greek?
Strangling
What is the airway management plan for a patient undergoing surgery for acute epiglottitis?
Oral ETT
How should the airway of a patient undergoing surgery for acute epiglottitis be managed postoperatively?
Patient will remain intubated
What causes acute epiglottitis?
An infection by H. flu
What anticholinergic and dose should be considered for a patient presenting with acute epiglottitis?
Atropine 10mcg/kg IV
What signs would indicate the resolution of acute epiglottitis?
Decreased WBCs, fever abates, air leak develops
What airway devices are used during surgery for chronic recurrent tonsilitis?
McIvor retractor and anode oral ETT
What is a major periop risk of surgery for chronic recurrent tonsilitis?
Hemorrhage
What obscures the DL view in patients presenting with kissing tonsils?
Significant lymphoid tissue
Are thermal airway injuries more prevalent in males or females?
Males
What are the primary goals of managing an airway affect by thermal injury?
Maintain airway patency and oxygenation
What is the projected status of patients presenting with facial, oral, or nasal burns?
Rapid loss of airway patency due to laryngeal edema
In order of best to least, what airway devices are best to manage an airway of a patient with thermal injury?
Oral ETT > Nasal ETT > Tracheostomy
What are the risks associated with nasal intubation in patients with thermal injury?
Infection - sinusitis, otitis, sepsis
What are the risks associated with tracheostomies in patients with thermal injury?
Wound and mediastinal infection
How can you simply evaluate the need for continuing or discontinuing airway support in patients with thermal injury?
Cuff-leak test
What is the acceptable leak in the cuff-leak test that will indicate airway support can be safely discontinued in patients with thermal injury?
5-10cmH2o
What are unacceptable leaks in the cuff-leak test that will indicate airway support cannot be safely discontinued in patients with thermal injury?
Greater than 20cmH2o
What chemical associated with fire and chemical accidents produces pulmonary edema?
Acrolein
What accidents can cause the accumulation of carbon monoxide?
Fires and incomplete combustion
What chemical is released upon polyurethane conflagration?
CN (cyanide)
What chemical is released upon PVC conflagration?
HCl
What is caused by exposure to HCl from PVC conflagration?
Severe mucosal burns in airway
What is spondylitis?
Vertebral inflammation
What anatomical characteristics are associated with Klippel-Feil Syndrome?
Vertebral fusion of the C-spine
What anatomical characteristics are associated with Arnold-Chiari Malformation?
Small posterior fossa, caudal displacement, hydrocephalus
What is Juvenile Rheumatoid Arthritis?
An inflammatory, multiple-organ disease that affects the C-spine, TMJ, and cricoarytenoid joint
What are the body proportions of an achondroplastic dwarf?
Normal trunk, shortened extremities, enlarged forehead
What is achondroplastic dwarfism?
Developmental disorder with decreased proliferation of growth plate cartilage
What anatomical differences of an achondroplastic dwarf will increase the difficulty of their airway management?
- Large head
- Short maxilla
- Large mandible
- Cervical instability
What movement should you avoid when positioning an achondroplastic dwarf ?
Hyperextension
What is polyarthropathy?
Synovial inflammation and granulation
What are the signs and symptoms of polyarthropathy?
Morning stiffness, PIP stiffness, pain, swelling
What is spondyloarthopathy?
Progressive arthritis of spine and pelvis
What effect of spondyloarthopathy can severely hinder airway management?
Fixed cervical spine
What is DJD?
Degenerative joint disease
What is DJD of the TMJ?
Degeneration of articular cartilage
What are the symptoms of DJD of the TMJ?
Limited inflammation and pain with use
What are the symptoms of DJD of the cervical spine?
Limited inflammation, pain, paresthesias, motor involvement
If suction is inadvertently applied to the lungs by an NG tube that enters the trachea beside a cuffed ETT, what action should be taken following removal of the NGT?
Give continuous positive pressure and hold
What is the perfusion pressure of tracheal mucosa?
25cmH2O (18mmHg)
What is the narrowest part of the airway in patients 7 and younger?
Cricoid cartilage
What is the narrowest part of the airway in adults?
Glottis
What is the action of the cuneiform cartilage?
Stiffens aryepiglottic folds to help reopen glottis
What is ankyloglossia?
Stiff tongue
What does abnegation mean?
Denial or refusal
What is innervated by the motor branch of the SLN?
Cricothyroid muscle
How does heliox compare to O2?
Increased heat capacity, increased viscosity, decreased density
What drug/dose is used for nasal vasoconstriction?
2000mcg phenylephrine
What is the action of the posterior cricoarytenoid?
Abduct vocal cords
What is anisocoria?
Unequal pupil size
What type of cartilage makes up cricoid, arytenoid, and thyroid cartilages?
Hyaline
What type of cartilage is the epiglottis and cuneiform/corniculate cartilages?
Elastic
When does an acute airway complication occur?
During performance of a procedure, administration of a drug, etc.
When does an intermediate airway complication occur?
During the existence of a drug or device in a patient
When does a long-term airway complication occur?
After elimination of a drug or removal of a device from a patient
Which laser type can cause severe retinal damage?
YAG
Which laser type can cause severe heat injury to the anterior eye?
CO2
