Exam 2 - Airway Flashcards
How many turbinates are there?
Where are they located?
What is another name for turbinates?
- Inferior, middle, and superior
- lateral wall of nasal passages
- conchae
Which nasal anatomy do airway devices pass through?
- Inferior meatus, between the inferior turbinate and floor of the nasal cavity
Another name for the nasal passages?
Fossae
What is the cribriform plate?
A thin horizontal bone at the base of the skull that forms the roof of the nasal cavity
What 3 medications can be used to vasoconstrict the nasal vessels to prevent bleeding?
- Cocaine
- Phenylephrine
- Oxymetolazine
What are the three parts of the floor of the mouth?
Tongue, mandible, teeth
What two bones make up the hard palate?
Maxilla and palantine bones
What area is considered the pharynx?
- Base of skull to lower border of cricoid cartilage.
What area is indicated by 1 on the figure below?
Nasopharynx
What area is indicated by 2 on the figure below?
Oropharynx
What area is indicated by 3 on the figure below?
Hypopharynx
What structure divides the oropharynx and the hypopharynx?
- Epiglottis
Loss of pharyngeal muscle tone results in ____ .
Airway obstruction
Fill in the structures that compose the picture of the larynx below.
What structure is indicated by 1 on the figure below?
- Median glossoepiglottic fold
What structure is indicated by 2 on the figure below?
- Lateral glossoepiglottic fold
What structure is indicated by 3 on the figure below?
- Aryepiglottic fold
What structure is indicated by 4 on the figure below?
- Ventricular fold
What structure is indicated by 5 on the figure below?
- Vocal fold
What structure is indicated by 6 on the figure below?
- Trachea
What structure is indicated by 7 on the figure below?
- Corniculate Cartilage
What structure is indicated by 8 on the figure below?
- Cuneiform Cartilage
What structure is indicated by 9 on the figure below?
- Piriform Recess
What structure is indicated by 10 on the figure below?
- Tubercle of Epiglottis
What structure is indicated by 11 on the figure below?
- Epiglottis
What structure is indicated by 12 on the figure below?
- Vallecula
What vertebrae corresponds with the very bottom of the larynx?
- 6th vertebrae
What is the purpose of the larynx?
- Inlet to trachea
- Phonation
- Airway protection
The larynx is suspended from the ____ by the ____ membrane.
hyoid bone
thyrohyoid membrane
Which laryngeal cartilages are unpaired?
- Thyroid (largest, supports soft tissue)
- Cricoid
- Epiglottis
Which laryngeal cartilages are paired?
- Arytenoid
- Corniculate
- Cuneiform
What do the vocal cords attach to?
- Arytenoid muscles & cartilage
- Thyroid at thyroid notch
Which laryngeal cartiledge is a complete ring?
Cricoid
Anatomical name for the adams apple?
Laryngeal prominence
How far does the trachea span?
What supports it anteriorly and posteriorly?
- From the inferior cricoid membrane to the carina (10 - 15 cm).
- Posterior: longitudinal trachealis muscle (seperates trachea from the esophagus)
- Anterior: Tracheal rings (bougie intubation)
What airway strucutures are c-shaped?
Tracheal rings
What are the 2 basic questions that need to be answered based off an airway assessment and history?
- Can I ventilate them?
- Can I intubate them?
Is airway history or assessment more valuable?
- Airway history
What portions of patient history can be a cause for airway concern?
Which is most important?
- Previous difficult airway
- Report of sore throat
- Report of cut lip or broken tooth
- Recent onset hoarseness (subglottic stenosis)
- Hx of OSA (STOP BANG)
- Intra oral lesions
Why is assessment of the submandibular space important?
This is where tissue will be displaced with laryngoscope
What is mandible prognathism?
How is it assessed?
Ability to slide the mandible anteriorly
Upper lip bite test
What is a better indication of airway difficulty than BMI?
- Thick neck greater than 43cm
What factors that are assessed visually would give one concern for a potentially difficult airway?
- Facial deformities
- Head & neck cancers
- Burns
- Goiter
- Short/Thick neck
- Receding mandible
- Large beard
- C-collar
What inter-incisor distance is best?
- > 6cm (3 finger breadths…patients fingers not yours lol)
What are effective treatements for angioedema caused by ACEi?
FFP and TXA
High arched palates are often associated with what?
Genetic syndromes
25 % of insurance claims against anesthesia providers are because of?
Dental injuries
Which teeth are injured most often?
Why?
- left anterior maxillary central and lateral incisors
- The tongue is swept towards the left side of the mouth
What is the sniffing position?
Why does it make intubation easier?
- Cervical flexion and antlanto-occipital extension
- Aligns oral, pharyngeal, and laryngeal axes.
Make sure to elevate head on a pillow
What is the sternomental distance?
What is an indicator of a potentially difficult airway?
- Distance between sternal notch and chin with head fully extended and mouth closed.
- Less than <12.5 cm
What technique is depicted below?
Why is it used?
- Ramping: used for positioning larger patients.
What is thyromental distance measuring?
What would be preferred?
- Submandibular compliance (tip of chin to thyroid notch)
- > 6.5cm preferred
What structures should be visible in a Mallampati class I?
- Fauces
- Tonsillar pillars
- Entire uvula
- Soft palate
What should be visible in a Mallampati class II?
- Fauces, portion of uvula, and soft palate
What should be visible in a Mallampati class III?
- Base of uvula and soft palate
What should be visible in a Mallampati class IV?
- Only the hard palate
What is BURP?
- Backward, Upward, and Rightward pressure to facilitate intubation.
What is Optimal External Laryngeal Manipulation (OELM) ?
- Moving someone else’s hand over external neck until a proper view is seen.
What Cormack-Lehane view is depicted below? What is visible with this view?
- CL - 1
- Entire glottis is visible
Pediatric patients will have ____ tonsils instead of white
pink
What Cormack-Lehane view is depicted below? What is visible with this view?
- CL - 2
- Posterior of glottis is visible
What Cormack-Lehane view is depicted below? What is visible with this view?
- CL - 3
- Only the epiglottis is visible
What Cormack-Lehane view is depicted below? What is visible with this view?
- CL - 4
- Epiglottis can’t be visualized.
What is one acronym you can use to predict diffcult mask ventilation/airway?
OBESE
Obestity (BMI > 30)
Beard
Endentulous
Snorer - OSA
Elderly, male (age >55)
What is the 3-3-2 rule?
3 finger mouth opening
3 fingers along the floor of the mandible
2 fingers between the thyroid cartiledge and neck junction
What factors may warrant an awake intubation?
- Suspected difficult laryngoscopy
- Suspected difficult ventilation with face mask/supraglottic airway
- Significant increased risk of aspiration
- Increased risk of rapid desaturation
- Suspected difficult emergency invasive airway
What is the most important thing to do when you are having trouble intubating/ ventilating?
Optimize oxygenation throughout, even if only passive O2
What should you consider if you can ventilate the patient but not intubate?
Allowing the patient to wake up and postponing the case if non-emergent
Who should you intubate and intubate early?
Bullets - neck trauma
Bites - anaphylaxis, angioedema
Burns - thermal and caustic airways
What situations would you RSI vs awake intubation?
RSI: peri-arrest, deteriorating airway, known easy airway, upper GI bleed, vomiting in ED
Awake: Stable GI bleed, fixed flexion deformity of the neck, cannot open mouth
Awake intubations take 15-20 mins of premedication
What is the awake intubation technique?
Position upright
What tool can be used to intubate if you only see the epiglottis?
What does the black line indicate?
Bougie
25 cm - at lips, should be mid trachea in adult male
Why is roc preferred to sux?
Sux has a long list of contraindications and side effects where roc is mainly only allergic reactions
What do studies show with higher dose roc, 2 mg/kg?
Faster onset and better intubated conditions
Can have successful intubation within 30 seconds
What is the DOA of succ and roc?
Succ: 5-10 mins
Roc: 30-90 mins
What are the 3 physiologic killers during intubation?
- Hypotension
- Hypoxemia
- Metabolic acidosis
What can you do to mitigate hypotension related arrests from intubation?
- At least 2 IVs
- Wide open fluids
- Have push dose pressors available (epinephrine preferred)
- Intubate at a higher than normal BP before intubation (SBP >140)
In critically ill patients, what should we change about paralytic and sedation doses?
What drugs should we use?
Decrease sedative dose - Ketamine 0.5 mg/kg (shock states by themselves are powerful anesthetics)
Increase paralytic dose - Rocuronium 1.6mg/kg
What can help preoxygenate critical patients before intubation?
- Place multiple sources of oxygen (NC 15 LPM )
- Place BVM with PEEP valve over patient while spontaneously breathing
What is DSI?
When should you perform it?
Delayed Sequence Intubation - procedural sedation for the procedure of preoxygenation (0.5-1 mg/kg ketamine)
On critically ill, combative patients who are hypoxemic that need to be intubated
What is BUHE?
Back Up Head Elevated
Allows for patients who can breathe to keep at it - don’t insist on laying everyone supine
Who should you avoid intubating at all costs?
What can you do instead to help?
Acidodic patients
Trial NIPPV while attepting to correct the cause of acidemia
Why is bicarbonate therapy not adivised in acidodic patients?
Bicarb becomes CO2 - worsening tachypnea and acidosis - can lead to cardiac dysrhythmias
No controlled studies have shown improved hemodynamics or catecholamine responsiveness from bicarb infusion
What is VAPOX?
Ventilator Assisted Preoxygenation
Used to prevent apnea in acidic patients, which would increase acidosis
Procedure:
Nasal cannula @ 15 lpm
Vent on SIMV +PSV
Vt 8mL/kg of predicted body weight
FiO2 @ 100%
PS 5-10 cmH2O
PEEP 5
What should you do if someone is very high risk for aspiration?
NGT prior to intubation
Intubate semi-upright
What is important to remeber for cricothyrotomy?
If you cannot intubate or ventilate, decide early so the patient has enough reserve to allow for calm and effective execution
A good assessment, airway skils, and having a backup intubation plan can help avoid CTM - although not always
