Exam 1 Airway Anatomy, Assessment, Management Flashcards
1
Q
Sensory innervation of nasopharynx
A
Posterior - Sphenopalatine nerve (maxillary division of CN V)
Anterior - Ethmoidal nerve (opthalmic division of trigeminal nerve V)
2
Q
communication of nasal cavity + ear occurs thru
A
middle ear
3
Q
primary pathway for breathing
A
nasopharynx
4
Q
What intervention can be performed to prevent excess bleeding in nasal vasculature?
A
local anesthetic + vasoconstrictor (phenyl or epi)
5
Q
nasopharynx extends from _____ to _____
A
nares opening inferiorly to soft palate
6
Q
nasal vascular supply
A
Facial, maxillary, opthalmic artery
7
Q
Implication - nasal vasculature + Rx administration
A
extensive vascularization = uptake/distribution
*be careful: not caustic to tissue
8
Q
Paranasal air sinuses
A
4: maxillary, sphenoid, frontal, ethmoid
9
Q
only sinus not innervated by maxillary nerve
A
frontal sinus
10
Q
frontal sinus nerve innervation
A
opthalmic nerve
11
Q
largest sinus
A
maxillary
12
Q
maxillary sinus nerve innervation
A
maxillary nerve
13
Q
sphenoid sinus located
A
below optic chiasm/ant. pituitary, within sphenoid bone
14
Q
risk of ethmoid sinus operation (ethmoidectomy)
A
cribiform plate broken –> brain exposure
15
Q
ostiomeatal complex
A
cleaning sinuses (drainage of frontal/maxillary/anterior ethmoid sinuses)
16
Q
External nose: sensory nerve
A
Trigeminal Nerve (V)
17
Q
External nose: motor nerve
A
Facial Nerve (VII)
18
Q
Internal nose sensory nerves
A
Vestibule - V
Septum- V
Lateral wall + floor - V, I
19
Q
avoid nasal intubation/nasogastric tubes in which patients
A
basal skull fracture
20
Q
What must be checked during nasal endoscopic proceures
A
pupillary checks - ensure instrument has not perforated into skull
21
Q
Pharynx is divided into
A
3 parts: nasopharynx, oropharynx, laryngopharynx
22
Q
sphenoid sinus separates
A
pharynx from sella turcica (contains pituitary gland)
23
Q
sphenoid sinus is important for _____ surgery
A
important landmark for pituitary surgery
24
Q
oropharynx
A
extends from posterior aspect of nose –> base of vallecula (superior to epiglottis)
25
separated by hard and soft palate
oro and nasopharynx
26
hypopharynx is located
superior border of epiglottis to inferior border of cricoid cartilage
Between C4-C6*
27
separates hypopharynx from larynx
epiglottis
28
epiglottis location
C3 - kids
| C5 - adults
29
Oropharynx sensory innervation - hard and soft palate
palatine nerves from trigeminal (CN V) + facial (CN VII)
30
Oropharynx sensory innervation - tongue
anterior 2/3: lingual nerve (mandibular division of CN V)
| posterior 1/3: glossopharyngeal nerve CN IX
31
Oropharynx sensory innervation - tongue for taste sensation
branches of CN VII + IX
32
Larynx lies at level of
C3-6
33
larynx is composed of
3 unpaired cartilages
| 3 paired cartilages
34
larynx - 3 unpaired cartilages
thyroid, cricoid, epiglottis
35
larynx - 3 paired cartilages
arytenoid, corniculate, cuneiform
36
largest and most prominent cartilage of larynx
thyroid
37
only complete cartilaginous ring in laryngotracheal tree
cricoid cartilage
38
shaped like a signet ring
cricoid cartilage
39
connects thyroid and cricoid cartilage anteriorly
cricothyroid membrane
40
posterior attachments for vocal cords
arytenoid cartilage
41
larynx is innervated by
branches of vagus nerve (CN X)
| -superior and recurrent laryngeal nerve
42
All muscles of larynx (except cricothyroid) - motor innervation
Recurrent laryngeal nerve
43
Cricothyroid - motor innervation
Superior laryngeal nerve - External
44
Sensory innervation of epiglottis (anterior surface/vallecula)
CN IX
45
Sensory innervation - between epiglottis and vocal cords
Superior laryngeal nerve - internal
46
Sensory innervation - between vocal cords and trachea
recurrent laryngeal nerve
47
Mnemonic: larynx cartilages
The Crocodile Eats Asian Corn Cunningly
| 9 cartilages: Thyroid, Cricoid, Epiglottis, arytenoid (2), corniculate (2), cuneiform (2)
48
Mnemonic: intrinsic laryngeal muscles: function
| *SLN nerve = muscle ___ + action _____
CricoThyroids = increase vocal Cord Tension
49
intrinsic laryngeal muscles: function
| *RLN nerve = muscle ___ + action _____
Everything except cricothyroids
| PCA, LCA, thyroarytenoids
50
mnemonic: intrinsic laryngeal muscles: function
| * RLN nerve = muscle ___ + action _____
Posterior CricoArytenoids: Pulls Cords Apart (abduct)
Lateral CricoArytenoids: Lures Cords Adjacently (adduct)
ThyRoarytenoids: TRanquilizes cords (reduce cord tension)
51
mnemonic: Motor innervation of larynx
REM: Recurrent and External superior for Motor
52
mnemonic: Sensory innervation of larynx
SIR: Sensory supplied by Internal superior + Recurrent
53
mnemonic: Motor innervation of larynx, specifics
SCAR
Superior = Cricothyroid
All other = Recurrent
54
mnemonic: Sensory innervation of larynx, specifics
BRAS
Below cords = Recurrent
Above (+ At) = Superior
55
pt population prone to having laryngospasm
Young, strong, AA males (strong sternal muscles)
| *make sure deep extubation
56
SLN - Unilateral nerve injury results in
minimal effects
57
SLN - Bilateral nerve injury results in
hoarseness, tiring of voice
58
RLN - Unilateral nerve injury results in
hoarseness
59
RLN - Bilateral nerve injury results in
Acute: stridor, resp distress
Chronic: aphonia
60
Vagus Nerve - Unilateral injury results in
hoarseness
61
Vagus Nerve - Bilateral injury results in
Aphonia (looks like after Sux administration)
| airway controls fine
62
Which is worse: acute or chronic RLN injury?
acute - remaining unopposed tension of cricothyroid muscle = stridor, resp distress
chronic --> not as bad d/t compensatory mechanisms
63
Trachea begins at
opposite C6
| inferior border of cricoid cartilage - extends to carina
64
length of trachea
10-20 cm in adults
65
trachea is composed of
16-20 C-shaped cartilaginous rings
66
Why is right mainstem more common than left?
Angle of bifurcation:
R = 25-30
L = 45
67
Bifurcation to right upper lobe from carina
2.5 cm
68
bifurcation to left upper lobe from carina
5 cm
69
trachea receptors are sensitive to
mechanical + chemical stimuli
| stretch/irritant/cough receptors
70
______ is richly innervated + sensitive to sensory stimulation
carina
71
mnemonic for mallampati classification
PUSH
P- Pillars, uvula, soft/hard palate
U - tip of uvula obstructed (+pillars, soft/hard)
S- soft palate (+hard, + base of uvula) NO pillars
H - Hard palate only
72
thyromental distance
```
mental process (lower border of mandible) to thyroid notch
< 3 fingerbreadths/7 cm = difficult laryngoscopy
```
73
mouth opening
-function of TMJ
| at least 2 fingerbreadths (3 cm)
74
extension of head at least
35 degrees from A-O joint
75
flexion of head at least
80 degrees from A-O joint
76
go to intubate, can't see anything
```
BURP position (manipulation of larynx -- NOT cricoid)
sniffing position
cricoid - push straight down
```
77
factors that limit larynx visualization
```
mouth opening < 3cm
mallampati classification III/IV
neck extension < 35
thyromental distance < 6.5 cm
rigid larynx
```
78
only test proven to be predictor of difficult airway
upper bite lip test (UBLT)
79
difficult airway mnemonic - laryngoscopy
```
LEMON
Look externally
Evaluate 3:3:2
Mallampati score
Obstruction/obesity
Neck mobility
```
80
difficult airway mnemonic - extraglottic device
RODS
Restricted mouth opening
Disrupted/distorted airway
Stiff lungs/spine
81
difficult airway mnemonic - BAG-valve mask
```
MOANS
Mask seal
Obstruction/Obesity
Age >55
No teeth
Stiff lungs/sleep apnea
```
82
difficult airway mnemonic - cricothyrotomy
```
SHORT
Surgery
Hematoma
Obesity
Radiation
Tumor
```
83
Nasal Cannula - Maximum O2
FiO2 increases by 3-4% per liter of O2
| Max up to 40-50%
84
Simple mask - maximum O2
FiO2 35-65%
| O2 flow rates 6-15 L/min
85
Venturi Mask - maximum O2
air entrainment mask - delivers FiO2 up to 50%
86
Nonrebreather mask - max O2
FiO2 up to 95%
87
Partial rebreather mask - max O2
FiO2 up to 80%
88
Oral/nasal airways are useful with
- loss of muscle tone, collapse of tongue/soft palate against oropharynx when sedated
- having difficulty w/ mask ventilation
89
nasal airways are preferred over oral airways in ____
lightly anesthetized patients
90
biggest issue with nasal airways
bleeding
91
risk of oral airways
stimulate gag reflex - cough - vomit - laryngospasm - bronchospasm
92
Oral airway - use
do not leave in for long time
93
nasal airway - contraindications
coagulopathy
basilar skull fracture
nasal infxn/deformities
94
length of nasal airway
from tip of nose to meatus of ear
95
biggest complication of oral/nasal airway
if placed too deep, can block airway
96
Biggest reason for obstruction during mask/bag ventilation
poor positioning
97
mask ventilation should never go above ____ cm H2O
PPV never above 30 cm H2O
98
LMA useful for
difficult airway (unable to intubate but can oxygenate/ventilate)
99
utilize LMA in
spontaneously breathing, anesthetized patient
100
asthmatic patient should avoid
ETT
| *LMA would be useful
101
LMA not used on vent if
pressures > 20 cm H2O
102
LMA does not protect against
aspiration, regurgitation, laryngospasm
| *i.e. gastroparesis/trauma pt
103
LMA is not a ______ airway
definitive
104
Pt adult > 80 kg needs ____ size LMA
size 5 LMA
cuff volume up to 40 cc
Largest ETT 7.0
105
Average adult = what size LMA?
Size 4 LMA
up to 30 cc cuff volume
largest ETT 6.0
106
Kids/small adults > 30 kg - size LMA?
Size 3 LMA
Cuff volume 20 cc
largest ETT 6.0
107
Patient size 20-30 kg, LMA size?
2.5 LMA
up to 15 cc
largest ETT 5.0
108
Up to 20 kg, what size LMA?
2 LMA
up to 10 cc
Largest ETT 4.5
109
Patient up to 6.5 kg, what size LMA?
Size 1 LMA
up to 4 cc cuff volume
largest ETT 3.5
110
Agent of choice for LMA insertion
propofol 2.5-3.0 mg/kg
111
NMBA required, which airway is used?
Endotracheal intubation
112
Endotracheal intubation indications
- need PPV
- protection of respiratory tract from GI contents
- surgical prx of head/neck when airway cannot be supported
- nonsupine positions in which airway cannot be supported
- NMBA required
- unconscious with inability to protect airway
- protection of healthy lung from dx lung
- pulmonary toilet
- severe multisystem injury
113
procedures in ____ req ETT
chest, abdomen, cranium, intracranial HTN tx
114
objective measures of endotracheal intubation
```
RR > 35
vital capacity < 15 mL/kg (adults) 10mL/kg (kids)
PaO2 < 70 mmHg on 40% FiO2
PaCO2 > 55mmHg
Inability to generate NIF of 20 mmHg
```
115
Goal PaO2 on 40% FiO2
```
200 mmHg
(40 x 5 = 200)
```
116
Most common laryngoscope blade in adults
Number 3
117
better tolerated in awake patients
| bradycardia less likely
macintosh (epiglottis not stimulated)
118
end of the blade sit on the tip of the epiglottis
miller laryngoscope
119
end of blade sit in the vallecula
macintosh
120
ETT are numbered according to
internal diameter
121
cuff pressure of ETT
between 17-23 mmHg
122
head of bed should be at your
xyphoid process
123
more crowded space in mouth
miller blade
124
carina is at level of
T4-T6
125
Women - normal ETT size
7-7.5
126
Men - normal ETT size
7.5-8
127
Women: ____ cm lip to carina
24
128
Men: _____ cm lip to carina
28
129
Children: ____ cm lip to carina
13
130
2 year old - size ETT
4.5
(age/4) + 4
if cuffed: decrease by half --> size 4
131
newborns - size ETT
3-3.5
132
Newborn to 12 months - size ETT
3.5 - 4
133
12 to 18 months - size ETT
4.0
134
denitrogenate
100% FiO2 for 3-5 min (or 4 vital capacity breaths)
135
ETT should be advanced how far beyond vocal cords?
1/2 - 1 inch
| as long as cuff goes thru
136
must be aligned to achieve direct visualization of larynx
oral, pharyngeal, tracheal axes
137
Cormack and Lehane's grading of laryngoscopy
I-IV based on glottic view during laryngoscopy
138
Cormack + Lehane grading of laryngoscopy - each grade
I: full view of glottic opening + vocal cords
II: partial view of glottis + arytenoids
III: only can visualize epiglottis
IV: no visible structures seen
139
minimum ETCO2 tracings to watch for after intubation
3 tracings on capnograph
140
auscultate breath sounds
L then Right
141
Correct location on XRay - tip of ETT
between carina + thoracic inlet (level of aortic notch T5)
