Basic Airway /Advanced Airway Flashcards
1
Q
Problems that can occur in association with difficult airway
A
Dental damage pulmonary aspiration airway trauma unanticipated trach anoxic brain injury cardiopulmonary arrest
2
Q
The upper and lower airway is divided where?
A
cricord cartilage
3
Q
5 parts of upper airway
A
Nose mouth pharynx hypopharynx larynx
4
Q
6 parts of lower airway
A
Trachea Bronchi Bronchioles terminal brinchioles respiratory bronchioles alveoli
5
Q
Function of the nose
A
warm and humidify air
primary source of filtration
6
Q
Anatomy of the mouth/oral cavity
A
Hard palate soft palate tongue Uvula tonsils
7
Q
What structure of the mouth is at high risk for obstruction
A
tongue
8
Q
Parts of the pharynx
A
Nasopharynx
oropharynx
hypopharynx
9
Q
What are S/S of SLN injury, both unilateral and bilateral
A
Unilateral- minimal ( no real signs)
Bilateral- hoarseness
10
Q
What are S/S of RLN injury, both unilateral and bilateral (acute and chronic)
A
Unilateral- Hoarseness
Bilateral-
—Acute-stridor, resp distress
– Chronic- Aphonia
11
Q
3 paired cartilages that make up the larynx
A
- 2 arytenoids
- 2 corniculate
- 2 cuneiform
12
Q
Vallecula
A
Space between the epiglottis and base of the tongue
13
Q
2 types of muscles in the larynx
A
Intrinsic
extrinsic
14
Q
What do the intrinsic muscles of the larynx do
A
control of vocal cords
opening and closing of the glottis
15
Q
What do the extrinsic muscles of the larynx do
A
- connect larnyx with the hyoid bone and other structure
- adjust position of trachea for phonation, breathing, and swollowing
16
Q
How long is the adult trachea
A
10-20 cm
17
Q
What is the only cartilage with a complete ring in the trachea
A
Cricord ring
18
Q
What is pertinent to airway assessment (questions to ask or look up; not physical)
A
- prior sx or hx of intubation/trach
- pror hx of diff intubation
- Hx of OSA
- Hx of oral, pharyngeal, esophageal disease
- trauma, burns, chemicals, radiation exposure to neck
19
Q
S/S that indicate a pt has an increased risk for aspiration
A
- Loss of airway reflex
- LOC
- full stomach
- obese, pregnant, hiatial hernia
- GERD
- Decrease GI motility (DM, Trauma)
- volume > 25 ml (ph < 2.5)
20
Q
Mendelson Syndrome
A
chemical pneuminitis due to the parenchymal inflammatory reaction caused by a large volume of gastric contents in lungs from aspiration ( independent of infection)
21
Q
Ways to decrease risk of aspiration
A
- NPO
- Block histamine release (H2 blockers)
- increase gastric PH (antacids)
- Increase GI motility (reglan)
- use caution with sedationa and opiods
- ETT vs LMA
- RSI vs awake FOI
- Awake vs deep extubation
22
Q
Liter flow rates and Fi02 delivered
Nasal cannula
Simple face mask
Non-rebreather
A
NC- 1-6 LPM / 24-44%
SFM- 5-12 LPM / 30-85%
NRB- 10-15 LPM / 60-85%
23
Q
4 techniques to manipulate head, neck, and jaw for airway patency
A
- chin lift
- head tilt and chin lift
- Jaw thrust
- Hyperextension of Neck (head tilt)
24
Q
3 axis to align for maximal exposure with intubation
A
- Oral axis
- pharyngeal axis
- laryngeal axis
25
3 main types of LMAs
Classic
Proseal
Fast track
26
What is unique about the proseal LMA
-drain tube
27
What is unique about the fast track LMA
Allows you to place an OETT
| has an epiglottis flap
28
Tracheal intubation is recommended when?
- compromised airway
- long procedures
- procedures of head/neck/chest/abd
- Need for positive pressure ventilation
- inability to maintain mask ventilation
- disease of the airway
- risk of aspiration
29
What are indications for Awake FOI
- anticipated difficult airway
- unstable neck fx
- Halo
- small / limited oral opening
- critical care settings
30
What airway structures are most vulnerable to injury during intubation
arytenoids
posterior half of vocal cords
posterior tracheal wall
31
What can occur up to 3 hours post extubation
Croup
32
LMA size compared to weight and max inflation (only adult sizes)
```
LMA size Weight MAX inflate
#3 30-50kg 20 ml
#4 50-70kg 30 ml
#5 70-100kg 40 ml
#6 >100kg 50 ml
* how to remember the max inflate for test- minus 1 and add 0 to the size. ex #3 -1=2 add 0 = 20 ml
```
33
What muscle acts as a barrier to regurgitation in conscious Pts.
cricopharyngeos muscle
34
Extubation criteria
- adequate TV and rate
- open eyes to commands no diplopia
- sustained protrusion and purposeful movements of the tongue
- effective swollow
- head lift >5 sec
- effective cough
- sustained titanic response to 50 hrz for 5 sec's
- TOF > 90 ratio with NO fade
35
Whats the difference in airway resistance between the nasopharynx and oropharynx
the resistance to airflow through the nasopharynx is twice that of the oropharynx and accounts for about 2/3rds of the total airway resistance
36
Disadvantages of oropharyngeal airways
- cut lips, tongue, oral mucose
- Can cause a gag reflex
- obstruction of glottis (if to large)
- Push tongue posterior and cause obstruction (if too small)
37
Advantages of oropharyngeal airways
- air can pass around or through
| - keeps teeth/lips open
38
Advantages of nasopharyngeal airways
- better tolerated in light planes
| - prefered with pts with limited mouth openings or dental caries
39
Disadvantages of nasopharyngeal airway
nose bleeds
| -contraindicated with coagupathies and basilar skull fx
40
LMA contraindications
- pharyngeal pathology
- pharyngeal obstruction
- full stomach
- decreased pulmonary compliance (RAD), that requires > 30 cmH20 pressure
41
What LMA is designed for anticipated difficult airways situations and CPR, b/c it can facilitate continuous ventilation during intubation
Fast track
42
Which LMA is a reusable airway that has a cuff made of softer material than the classic, it is designed to conform to the hypopharynyx, although it can be used with spont breathing pts, it is designed for PPV with or without muscle relaxants
proseal
43
How do you confirm appropriate tracheal intubation
MOST RELIABLE - end tidal CO2
| PCO2 > 30 mmhg for 3-5 breaths
44
S/S ETT not olaced correctly
- no rise in CO2
- decrease O2 sat
- Unilateral breath sounds
- inability to palpate ETT cuff @ sternal notch
- Increased Peak Pressures
- Tachycardia
45
Afferent is _____ and carries nerve impulses _____?
Sensory
| carries impulses to the CNS
46
Efferent is _____ and carries nerve impulses ________?
Motor
| carries impulses away from CNS to periphery
47
Mallampatti I
```
Hard palate
Soft palate
tonsillar fauces
tonsilar pillars
uvula
```
48
Mallampatti II
Hard palate
Soft palate
tonsilar fauces
uvula
49
Mallampatti III
Hard palate
Soft palate
base of uvula
50
Mallampatti IV
Hard palate
51
Cormack and Lehane Gade I
Entire laryngeal aperature
52
Cormack and Lehane Gade II
posterior portion of laryngeal aperature only
53
Cormack and Lehane Gade III
epiglottis only
54
Cormack and Lehane Gade IV
soft palate only
55
Unilateral RLN injury causes what
hoarsness
56
NPO fasting guidelines
clear liquids -2hours
Breast milk- 4 hours
everything else @ least 6 hours
57
The antacid sodium citrate (bicitra) has what disadvantage
increased gastric volume
58
ASA Scores
I- Normal healthy adult
II- Pt with mild systemic disease
III- pt with severe systemic disease
IV- pt with severe systemic disease THAT IS A CONSTANT THREAT TO LIFE
V- morbid pt who is not suspected to live without Sx
VI- brain dead/ organ donor
59
Four Ds that make a difficult airway
dentation
distortion
disproportion
dysmobility
60
what mallampatti scores are good
I-II
61
3 single cartilages that make up the larynx
thyroid
cricoid
epiglottis
62
What does the external SLN innervate
motor fxn to cricothyroid muscle of larynx
63
What 2 things does the RLN innervate
- sensory innervation to the subglottic area and trachea
| - motor to all muscles of larynyx EXCEPT cricothyroid
64
The SLN divides into what?
Internal and external SLN
65
What does the internal SLN innervate
sensory input above the cords
66
The vagus nerve branches into what in the pharynx
Superior laryngeal nerve (SLN)
| Recurrent Laryngeal Nerve (RLN)
67
The MOTOR response of the pharynx that Results in a gag is what nerve
CN X- (Vagus nerve)
68
SENSORY response elicited when the posterior wall of pharynx is touched and stimulated are carried to the brain by what nerve
Glossopharyngeal (CN IX)
69
Difficult intubation is defined as what
3 or more attempts
| more than 10 minutes
70
Difficult mask ventilation is defined as what
inability to maintain SPO2 > 90% or signs of inadequate ventilation
71
The nasopharynx is separated from the oropharynx by what
soft palate
72
The oropharynx is separated from the hypopharynx by what
epiglottis
73
The trachea begins and ends where
C6-T5 (the carina)
74
How many horseshoe shaped cartilages make up the trachea
16-20
75
What supplies the infraglottic region and comes off of the inferior thyroid artery
Inferior laryngeal artery
76
What supplies the supraglottic region of the larynx, comes from the superior thyroid artery
superior laryngeal artery
77
What part of the oral cavity remains stationary
hard palate
78
What part of the mouth covers the posterior 3rd to half of the oral cavity, rises during eating to prevent passage of contents into the nasal passage way
soft palate
79
What part of the mouth guards the passageway from the oral cavity to the oropharynx
uvula
80
What structure of the mouth is walnut shaped and sits on both sides of the posterior opening of the oral cavity
tonsils
81
Function of the larynx
- protect airway from aspiration
- provide airflow b/t hypopharynx and trachea
- cough and gag reflex
- phanation
82
5 intrinsic muscles of the larynx
```
posterior cricoarytenoid
lateral crioarytenoid
arytenoids
cricothyroid
thyroarytenoid
```
83
Common physical assessments for airway
```
interincisor gap
thyromental distance
head and neck extension
mallampatti
body weight
```
84
what is the best/ideal way to determine a difficult airway
there isn't one dummy!!!
85
Signs that may indicate a pt will be a difficult mask ventilation
```
elderly
endentulous
obese
snores/ OSA
bearded (RTFF)
stridor
```
86
Difficult airway adjuncts
```
blades
fiberopticscope
lightwand
bullard scope
LMA
stylet
retrograde intubation
bougie
TTJV
combitube
```
87
What do the intrinsic muscles of the larynx do
control the tension of the vocal cords and the opening and closing of the glottis
88
What is the ideal BVM positioning
aligning the external auditory meatus with the sternal notch
89
How do you break a laryngospasm
- positive pressure
- anesthestic gasses
- 10-20 mg sux's
- lidocaine
- push on trigger point in sternocleido muscle
90
If not treated with positive pressure the laryngospasm can cause what
negative pressure pulmonary edema
91
Why would you never wake a pt is stage II anesthesia
will cause laryngospams
92
Per the literature what adjunctive tool is most superior for difficult airways
Awake-FOI
93
Per real life what adjunctive tool is most superior for difficult airways
the one you are most comfortable using
94
How do you prepare for a nasal intubation
- prep with astringent (afrin or neosynephrin)
- dialate nares with progressive lubricated nasal trumpets
- Introduce and advance the ETT
95
Steps for an Awake-FOI
- discuss steps with pt
- local anesthetic
- antisialogoue
- monitors, 02, sedation
- semi-fowlers or supine
- insert ETT
- advance Fiberoptic
- identify anatomy
- advance through cords
- go till you see the carina
- advance ETT over fiberoptic
- withdraw fiberoptic
- conform with ETCO2
- IV or inhalation induction
96
What is important about sedation during an awake-FOI
sedation should not obtund the protective reflexes of pt
97
Sedation choices for awake-FOI
midazolem
fentanyl
dexmetomodine
98
How should you extubate the difficult to intubate pt
```
awake and responsive
good grip/ head lift sustained
adequate reversal
NIF > 20mmhg (neg inspiratory force)
VC> 15 ml/kg (vital capacity)
```
99
Can't ventilate + can't intubate = what
sugical airway
100
What must you remember about TTJV
- MUST USE INTERMEDIATE PRESSURE 02 SUPPLY
- allow time for expiration (1:4)
- risk of barotrauma
- buys the anesthesia team time before surgical airway
101
Why do we use RSI
for pt'swho are at increased risk for aspiration requireing minimal time with an unrotected airway
102
Steps for RSI
- aspiration prophylaxis
- airway eqipment - suction
- optimize intubation conditions
- denitrogenate
- STP + Sux IV push
- proper cricord pressure
- no bag ventilation
- intubate
- on emergence- awake extubation
103
What 3 intrinsic muscles are responsible for laryngospasms
lateral cricoarytnoid
cricothyroid
thyroarytnoid
remember CAT
