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Respiratory > Apex- Airway Anatomy > Flashcards

Apex- Airway Anatomy Flashcards

1
Q

Match the intrinsic muscle of the larynx with its action on the vocal cords

Thyroidarytenoid
Lateral cricoarytenoid
Cricothyroid
Posterior cricoarytenoid

Shortens
Elongates
Abducts
Adducts

A

Thyroidarytenoid
>Shortens “THey Relax”

Lateral Cricoarytenoid
>Adducts “Leaves Cords Alone”

Cricothyroid
>elongates “Cords Tense”

Posterior cricoarytenoid
>Abducts “Pulls Cords Apart”

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2
Q

The RLN innervates all of the intrinsic laryngeal muscles except what?

What is that innervated by?

A

The cricothyroid muscle

  • the external branch of the SLN
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3
Q

All laryngeal muscles are classified as intrinsic or extrnisic, which are each responsible for?

A

Intrinsic- phonation (tension and position of cords)

Extrnsic- support the larynx and assist with swallowing

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4
Q

The vocal cords attach to the __________anteriorly, and the _________posteriorly.

A

thyroid anteriorly

arytenoids posteriorly

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5
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11
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12
Q

What does the vocalis do?

A

Shorten (relaxes) the vocal cords

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13
Q

Which laryngeal muscle has 2 functions and what are they?

A

Thyroarytenoid

  1. THey Relax > shortens (relaxes) VCs
  2. ADDucts (in ADDition to relaxing, they adduct the VCs) [close the glottis]
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14
Q

What kind of muscles end in “-hyoid?”

A

Extrinsic muscles of the larynx

*Except digastiric

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15
Q

What muscles tense/relax the vocal cords?

A

Tense = CricoThyroid “Cords Tense”

Relax = THyro aREtenoid “THey RElax”

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16
Q

Which muscles Abduct vs Adduct the vocal cords?

A

Abduct = Posterior CricoAretynoids “Pulls Cords Apart”

Adduct = Lateral CricoAretynoids “Leaves Cords Alone”

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17
Q

The SLN innervates (select 2):

  • Cricothyroid muscle
  • Trachea
  • Posterior third of the tongue
  • Underside of the epiglottis
A
  • Cricothyroid
  • Underside of the epiglottis
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18
Q

What 4 nerves innervate the airway?

A
  1. Trigeminal (CNV)
  2. Glossopharyngeal (CNIX)
  3. SLN (internal and external)
  4. RLN
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19
Q

What does the internal vs external branches of the SLN innervate?

A

internal branch = sensory

posterior side of epiglottis > top of the vocal cords

NO MOTOR

external branch = motor

cricothyroid muscle

NO SENSORY

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20
Q

CN9 (GP) provides sensation from where to where

A

oropharynx down to the anterior side of the epiglottis

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21
Q

What gives rise to the SLN?

A

Vagus (X)

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22
Q

Trigeminal subsets and function:

V1:

V2:

V3:

A

V1: (opthalmic): SENSORY to nares and anterior 1/3 nasal septum

V2: (Maxillary): SENSORY to turbinates and nasal septum; anterior 2/3 tongue - sensory

V3: (Mandibular): muscles of mastication MOTOR

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23
Q

What gives rise to the RLN and what does the RLN provide sensation to if anything?

A

Vagus nerve gives rise to RLN

sensation BELOW the elvel of the cords > trachea

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24
Q

Most common cause of RLN injury (either side) and 3 other potential causes

A

*Thyroidectomy* (neck surgery)

  1. overinflation of ETT or LMA cuff
  2. tumor
  3. excessive neck stretching
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25
Q

What 4 things can cause injury to the LEFT RLN?

A
  1. PDA ligation
  2. Left atrial enlargement (Mitral stenosis)
  3. aortic arch aneurysm
  4. Thoracic tumor
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26
Q

What closes the laryngeal vestibule?

A

Aryepiglottic fold? sphincter?

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27
Q

What closes the posterior commisure of the glottis?

A

Interarytenoid

(RLN)

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28
Q

Which extrinsic muscles depress the larynx? (3)

A

SOS

Stern oyhoid

Omohyoid

_Stern_othyroid

(all other extrinsic muscles “-hyoid” elevate the larynx + the digastric)

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29
Q

What kind of nerve damage would result in one of the vocal cords being unable to abduct?

A

RLN damage

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30
Q

T/F: injury to b/l SLN’s constitutes a respiratory emergency

A

FALSE

  • B/L RLN -neither cord can abduct
  • stridor/resp distress
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31
Q

Laryngospasm is a forceful, involuntary spasm of the laryngeal muscles caused by stimulation of what nerve?

A

the INTERNAL branh of the SLN

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32
Q

Sensory vs motor innervation for a laryngospasm

A

Sensory (afferent) innervation = internal branch of the SLN

Motor (efferent) innervation = external branch of the SLN (cricothyroid, cords tense)

AND RLN (Lat. cricoaretenoids & thyroaretynoids = adduct cords)

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33
Q

Hoarseness would be injury to SLN or RLN

A

RLN

-hoaRness

(SLN = Softness)

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34
Q

What 3 cranial nerves are responsible for innervation of the airway?

A
  1. Trigeminal nerve (V)
  2. Glossopharyngeal (IX)
  3. Vagus (X)

>SLN, RLN

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35
Q

Trigeminal V1, V2, V3 matching:

Lingual nerve

Anterior ethmoidal nerve

Sphenopalantine nerve

A

V1 = anterior ethmoidal

V2 = sphenopalantine

V3 = lingual nerve

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36
Q

What serves as the afferent nerve of the gag reflex

efferent nerve?

A

CN IX - glossopharyngeal (Sensory = affernt)

X = efferent limb/motor resposne of gagging

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37
Q

What provides motor innervation to the muscles of mastication (chewing)

A

V3 division of CNV

)

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38
Q

What provides motor inneration to the tongue?

A

CN 12 - hypoglossal nerve

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39
Q

CN 9 (GP) provides sensory innervation from the oropharynx to the anterior side of the epiglottis. What 6 structures are included?

A
  1. Soft palate
  2. Oropharynx
  3. Tonsils
  4. Posterior 1/3 of tongue
  5. Vallecula

6. Anterior side of the epiglottis

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40
Q

CN 5 is mostly sensory, what is the exception?

A

Muscles of mastication innervated by V3 Mandibular/linguial nerve

(sensory of this is anterior 2/3 of tongue)

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41
Q

CN 9 is mostly sensory, what are the 2 exceptions?

A

swallowing and phonation

42
Q

At the level of the ______, the SLN divides into internal and external branches

A

hyoid

43
Q

The internal branch of the the SLN penetrates what membrane and between what two structures?

A

Thyohyoid membrane

Between the greater cornu of the hyoid bone

& the superior horn or the thyroid cartilage

44
Q

The RLN branches off the vagus where?

A

inside the thorax

45
Q

What does the right vs left RLNs loop under

A

right - loops under subclavian

left- loops under aortic arch

46
Q

What landmark is identified for a SLN block?

A. Greater cornu of the hyoid bone

B. Suprior horn of the thyroid cartilage

C. Circothyroid membrane

D. Palatoglossal arch

A

A. Greater cornu of the hyoid bone

47
Q

What 3 nerves must be blocked for an awake intubation?

A
  1. Glossopharyngeal (B/L) (base of palatoglossar arch/anterior tonsillar pillar)
  2. SLN (B/L) (inferior border greater cornu hyoid)
  3. RLN (cricothyroid membrane)
48
Q

Which block involves injecting the needle at the base of the palatoglossal arch?

AKA

depth

mls

5% risk of what?

A

Glossopharyngeal block

AKA anterior tonsillar pillar

0.25-0.5cm

1-2mls

5% risk of seizure from intracarotid injection

49
Q

How to do a transtracheal block

What nerves are you trying to anesthesize?

A

insert needle through cricothyroid membrane in a caudal direction

ask pt to take a deep breath

inject 3-5mls of LA into the tracheal lumen

RLN

50
Q

If your doing a glossopharyngeal nerve block and aispirate air, what does that mean?

A

too deep

51
Q

If your doing a glossopharyngeal nerve block and aispirate blood, what does that mean?

What should you do?

A

withdraw needle and redirect medially (close to the carotid artery)

52
Q

The adult larynx lies anterior to what spinal segments?

A

C3-C6 = Larynx

53
Q

What is the only bone in the body that does not articulate with another bone?

A

Hyoid bone

54
Q

What is the most caudal part of the larynx?

A

The criocid

55
Q

What is the narrowest part of the ariway in the infant vs adult

A

infant = cricoid = narrowest “fixed” region; vocal cords = narrowest “dynamic region”

adult = glottis

56
Q

3 paired vs unpaired cartlidges of the larynx

A

3 unpaired:

  • epiglottis
  • thyroid
  • criocid

3 paired:

  • arytenoids
  • cornicutlates
  • cuniforms
57
Q

What is a laryngospasm?

A

Sustained, involuntary contraction of the laryngeal muscles, vocal cords slam shut and cant be opened

58
Q

S/S of someone having a laryngospasm? (6)

A
  1. Inspiratory stridor
  2. Suprasternal or supraclavicular retraction during inspriation
  3. “Rocking horse” apparence of chest wall (paradoxical movement)
  4. Increased diaphrgamatic excursion
  5. Low rib flailing
  6. Absent or altered ETCO2
59
Q

What are some things that can cause laryngospasm? (5)

A
  1. manipulating the airway during light anesthesia
  2. airway surgery
  3. airway secretions
  4. active or recent resp infection <2 weeks
  5. Age < 1yo
60
Q

5 steps in treating laryngospasm

A
  1. 100% FIO2
  2. Remove stimulus
  3. Deepen anesthesia
  4. Larson’s maneuver, chin lift, and positive pressure (CPAP 15-20)
  5. Sux
61
Q

What is exhalation agaisnt a closed glottis called

A

valsalva’s maneuver

62
Q

What is muller’s manuver?

A

INHALATION against a closed glottis

(where as valsava is EXHALATION agaisnt a closed glottis)

63
Q

What would it be called if a patient bites down on the ETT and takes a deep breath?

Risk?

A

Muller’s maneuver

Risk= supatmospheric pressure in the thorax > negative pressure pulmonary edema

64
Q

T/F: hypocapnia/hyperventillation increases risk for laryngospasm

A

True!

65
Q

DOA of laryngeal lidocaine

A

30 minutes

66
Q

IV dosing of SUX for adult or child vs infant or neonate

IM?

A

IV

adult 1-1.5
Kids 1.5-2

infant or neonate = 2-3mg/kg

IM

adult or child = 4mg/kg

infant or neonate = 5mg/kg (2+3 = 5)

67
Q

What IM route of administration provides the fastest onset of sux to break a layngospasm?

A

Submental ….

68
Q

you need to break a laryngospasm in a kid without an IV and has a contraindication to sux….now what?

A

ROC is the only other NMB that can be given IM

69
Q

When adminsitering sux to kids < _____, what should you administer with it, how much, and why?

A

kids <5yo

Atropine 0.02mg/kg

prevent bradycardia

70
Q

What borders the laryngospasm notch:

Anterior:

Posterior:

Superior:

A

Anterior: Ramus of the mandible

Posterior: Mastoid process

Superior: Skull Base

71
Q

T/F: Laryngospasm notch is located jsut behind the earlobe

How should pressure be applied

A

True

Apply pressure BILATERALLY , TOWARDS the skull base (UP)

72
Q

How long should you apply pressure to the laryngospasm notch?

A

3-5 seconds, release for 5-10 seconds and repeat until it breaks

KISS - 5 sec on, 5 sec off

73
Q

Which maneuver puts the patient at risk for negative pressure pulmonary edema? Valsalva or Mullers?

A

Mullers- forced experation against a closed glottis

74
Q

Tensor palatine muscle relaxation will MOST likely cause airway obstrution at which level?

A. Hard palate

B. Soft palate

C. Epiglottis

D. Tongue

A

B. Soft palate

75
Q

Relaxation of the hyoid muscles contributes to upper airway obstruction from what structure?

A

The epiglottis

76
Q

Relaxation of the genioglossus muscle contributes to upper airway obstruction from what structure?

A

The tongue

it’s a genius!

77
Q

The upper airway extends from where to where?

A

mouth and nose > cricoid cartilage

78
Q

Airway resistance is ___x higher in the nasal passage compared to the mough

A

2x

79
Q

Primary functions of the upper airway (3)

A
  1. warming and humidfying inspired air
  2. filtering particulate matter
  3. preventing aspiration
80
Q

How can you reduce the risk of airway trauma when instrumenting the nasal cavity?

A

direct the device between the inferior turbinate and the floor of the nasal cavity

&

orient the bevel towards the septum

81
Q

What muscle opens the:

Nasopharnyx:

Oropharnyx:

Hypopharnyx:

A

Nasopharnyx: Tensor Palatine

Oropharnyx: Genioglossus

Hypopharnyx: Hyoid muscles (epiglottis)

82
Q

When compared to the trachea, which factor is GREATER in the terminal bronchioles?

A. Total cross-sectional area

B. Airflow velocity

C. Amount of cartilage

D. Quantity of goblet cells

A

A. Total cross-sectional area

83
Q

Where does the lower airway begin and end?

A

Begins at the trachea > alveoli

84
Q

Where does the trachea begin and end?

A

beings at the inferior border of the cricoid cartilage and ends at the carina (T4-5)

85
Q

What spine processes does the carina correlate with?

What is this called?

A

T4-T5

The Angle of Louis

(just think when you tickle that carina those cardiac acclerates (T4) go wild as the pt starts coughing and carrying on) - dumb idk

-tickle Louis’s carina

86
Q

Does neck flexion make the distance from the mouth to the carina longer or shorter?

A

Shorter *rember tube follows the nose , felxed neck = more likely to come out

87
Q

Length and projections of:

Left bronchus vs Right bronchus

A

Left bronchus:

5cm

45 degree takeoff

Right bronchus:

2.5cm

25 degree take off

88
Q

in children up to ___yo, both bronchi take off at ____degrees

A

3 years old

55 degrees

89
Q

Type 1 vs Type 2 pneumocytes

A

Type 1 provide surface for gas exchange

Type 2 produce surfactant and type 1 pneumocytes

90
Q

The trachea is ____cm wide

& _____cm long

A

2.5cm wide

10-13cm long

91
Q

Sensory innervation to the trachea

A

Vagus

92
Q

Match:

Trachea, Mainstem bronchi, Alvoli

Cuboidal epithelium, ciliated columnar epithelium, squamous epithelium

A

Trachea = ciliated columnar (duh, it’s got the cilia to keep shit out)

Mainstem = cuboidal

Alveoli = squamous

93
Q

What allows for air movement between the alveoli?

A

Pores of Kohn

94
Q

What are type 3 pneumocytes responsible for?

A

fighting infection and eliciting an inflammatory response

95
Q

The lower airway begins as a single tube (the traceha) but the ncontinues to bifurcate along ____ generations/divisions

A

23 (bitrhday bronchioles! yay0

96
Q

What 2 things increase as the airway bifurcates?

A
  1. # of airways
  2. Total cross-sectional area

*everything else decreases: airflow velocity, amount of cartilage, goblet cells (produce mucous), ciliated cells (clear mucus)

97
Q

What vertebral level corresponsds with the adult trachea?

A

C6

lower airway STARTS at C6

98
Q

Which structures are anesthetized by injecting lidocaine at the base of the palatoglossal arch (select 2)

  • Posterior side of the epiglottis
  • Anterior 2/3 of the tongue
  • Oropharynx
  • Vallecula
A

-Oropharynx & Vallecula

This is a CN9 block- anesthesizes soft palate, oropharynx, tonsils, posterior 1/3 of tongue, vallecula, and anterior side of the epiglottis

Anterior 2/3 of the tongue is innervated by the mandibular branch (V3) (lingual nerve) of the trigeminal nerve (CN 5)

The posterior side of the epiglottis is innervated by the internal branch of the superior laryngeal nerve

99
Q

Contraction of which muscles widens the glottic aperture:

Cricothyroid

Thyroarytenoid

Vocalis

Posterior cricoarytenoid

A

Posterior cricoarytenoid

“Pulls Cords Apart”

100
Q

Calculate the dose of IM sux for a 12kg patient

A

kids and adults IM = 4mg/kg

4x12 = 48mg

101
Q

A patient bites down on the ETT during emergence. Pink frothy sputum is noted inside the breathing circuit. Which maneuver explains the pathphys of this complication?

A. Valsalva

B. Muller

C. Larson

D. Beck

A

B. Muller

Respiratory (5 decks)

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