Exam 2 Airway Assessment Flashcards
The internal nose is dived by the ______.
Septum
The internal structure of the nose is composed of what structures?
Cribriform Plate
Turbinates (Superior, Middle, and Inferior)
Turbinates are also called
Conchae
The internal nasal cavity is very vascular. What do you need to use before nasal intubation to mitigate bleeding?
Vasoconstrictors (Afrin, Coccaine)
Where is the preferred passage for a nasal airway?
**Inferior Meatus **
between inferior turbinate and the floor of the nasal cavity
The roof of the mouth consist of what four structures?
Maxilla and palatine bones
Hard palate
Soft palate
Teeth
What makes up the floor of the mouth (3 structures)?
Tongue
Mandible
Teeth
What is a muscular tube that extends from the base of the skull to the lower border of the cricoid cartilage?
Pharynx (Responsible for airway patency and a common site of airway obstruction.)
What can be performed to elongate pharyngeal muscles and maintain airway patency?
Chin lift
What are the 3 parts of the pharynx?
Nasopharynx -nose to the soft palate
Oropharynx- soft palate to the epiglottis
Hypopharynx- epiglottis to the cricoid cartilage
What makes up the anterior 2/3rds of the roof of the mouth?
the hard palate
formed by parts of the maxilla and the palatine bone
The larynx extends from the __________ to the lower end of the cricoid cartilage at the ______ cervical vertebrae.
The larynx extends from the epiglottis to the lower end of the cricoid cartilage at the 6th cervical vertebrae.
What are the functions of the Larynx?
Phonation
Airway Protection
Inlet to the Trachea
What is one of the most common causes of airway obstruction in anesthesia?
Loss of pharyngeal muscle tone
Name the unpaired Laryngeal cartilage
Thyroid cartilage (This is the largest of the three and supports most of the soft tissue.)
Cricoid cartilage - (complete ring)
Epiglottis cartilage
Name the paired Laryngeal cartilages.
Arytenoid
Corniculate
Cuneiform
A common site for airway obstruction is a region termed the ____ and is where the nasopharynx ends at the _____
Velopharynx
soft palate
The vocal cords are attached to what two cartilages?
Thyroid cartilage at the thyroid notch
posteriorly in the arytenoid cartilage.
The trachea extends from the __________ membrane to the carina.
What is the length of the trachea in an adult?
inferior cricoid
10-15 cm
The trachea anteriorly is bounded by __________ and closed posteriorly by ___________ muscle.
The trachea anteriorly is bounded by tracheal C-shape rings and closed posteriorly by longitudinal trachealis muscle.
Actions to take when you know you can not mask ventilate a patient during an airway assessment?
Maintain spontaneous ventilation
Use awake endotracheal intubation
Create a surgical airway (emergency situation)
Airway assessment should be conducted before the initiation of anesthesia in all patients thoroughly.
History concerns for airway assessment (6 factors).
What is the most predictive factor?
- Past difficult intubation (most predictive factor)
- Report of excessive sore throat
- Report of cut lip/broken tooth
- Recent onset of hoarseness - issue with vocal cords or tumor, or subglottic stenosis
- History of OSA - related to anatomy or size (STOP-BANG)
- Lesions intra-orally…. base of the tongue, lingual tonsils
Airway evaluation components (6 components).
- Visual inspection of the face and neck
- Assessment of mouth opening
- Evaluation of oropharyngeal anatomy and dentition
- Assessment of neck range of motion (sniffing position)
- Assessment of the submandibular space (between thyroid and mandible)
- Assessment of the patient’s ability to slide the mandible anteriorly
What visual inspections will indicate difficult intubation? (8)
Short or thick neck (>43 cm = difficulty w/ intubation, more predictive than high BMI)
Facial deformities
Head and neck cancers
Burns
Goiter
Receding mandible
Beard (Santa Claus)
C-collar (Don’t touch C-collar, have the MD do it, chart it.)
The ability of the pt to slide the mandible anteriorly is called the
Test of mandibular prognathism
How do you assess mouth opening?
Inter-incisor distance
Prefer > 6 cm (3 finger breadths)
What to do for an enlarged tongue from use of ACE inhibitor?
Give FFP and/or TXA
What are pathologic characteristics that can be identified during oropharyngeal anatomy assessment?
Tumor
Palate deformities (High arched palate, cleft palate)
Macroglossia - giant tongue
What do you look for during a dental assessment?
Long upper incisors - (fangs, work around them.)
Poor dentition/loose teeth
Cosmetic work
Edentulousness (lack of teeth)
Dental injuries account for _____% of closed insurance claims against anesthesia providers.
______% of dental injuries occur during tracheal intubation. A lot of these are related to difficult and emergency airway management.
25%
75%
What are the factors that can cause dental injuries (5 factors)?
Laryngoscope blade
Rigid suction catheters
Oropharyngeal airway placement
Rigorous removal of airways
Biting down on ETT/LMA/airways during emergence
What two teeth have the highest incidence of dental injuries?
Left Central Incisor (47%)
Left Lateral Incisor (20%)
What does the sniffing position evaluate?
What three axis are aligned in a perfect sniff position?
Cervical flexion and atlanto-occipital extension. How well does the head move on the neck?
Alignment of the oral, pharyngeal, and laryngeal axis (Letter C in the picture)
What disease processes put pts at higher risk for atlanto-occipital injuries?
RA and Down Syndrome
What is the position called?
‘Ramping’
The ideal ramping position is to bring the ears up to the level of the sternum so that they are leveled.
What is the sternomental distance?
What is the preferred distance?
Distance between the sternal notch and chin with head in full extension and mouth closed.
> 12.5 cm preferred
What Measurement is from the tip of the chin to the thyroid notch called?
Why do we assess it?
What is the preferred distance?
Thyromental distance
To predict submandibular compliance.
Basically, do we have a chin that is not connected to the neck?
Prefer > 6.5 cm (3 finger breadths)
How do you test prognathic ability (two movements)?
- Extension of lower incisors beyond upper incisors.
- Upper lip bite test.
Test question in ppts!
What is the Mallampati Test?
How many classes are there?
How do you perform the test?
Visibility of oropharyngeal structures
Class I - IV
The patient is seated upright with head neutral
Mouth open
Tongue protruded
No phonation (Phonation will lift the uvula up)
External airway assessment
What can be visualized in a Mallampati Class I?
Fauces (arch opening in the back of the throat)
Pillars (tonsils)
Entire Uvula
Soft palate
What can be visualized in a Mallampati Class II?
Fauces (arch opening in the back of the throat)
A portion of the Uvula
Soft palate
What can be visualized in a Mallampati Class III?
Base of the uvula and soft palate
What can be visualized in a Mallampati Class IV?
Only hard palate
What are the two types of Laryngeal Manipulation?
What is the first type of Laryngeal Manipulation?
BURP
Backward
Upward
Rightward
Pressure
What is the second type of Laryngeal Manipulation?
OELM
Optimal
External
Laryngeal
Manipulation
What is the Cormack-Lehane classification?
Classification of laryngeal view
Grade I-IV
Internal Airway assessment
What is seen with a Cormack-Lehane Grade 1 View?
Entire Glottis
What is seen with a Cormack-Lehane Grade 2 View?
Only the posterior portion of the glottis
May need to lift the blade up more, or perform laryngeal positioning
What is seen with a Cormack-Lehane Grade 3 View?
No part of the glottis and only the epiglottis
What is seen with a Cormack-Lehane Grade 4 View?
Epiglottis cannot be seen. All you see is the tongue.
Difference between adult vocal cords and pediatric cords
Adult will be white from the calcification
Peds will be the same pink color as they have not developed the calcification yet
Criteria associated with difficult mask ventilation (OBESE).
O: Obesity, BMI > 30 kg/m2
B: Beard
E: Edentulous
S: Snorer, OSA
E: Elderly, male, age > 55
Mallampati 3 or 4
What to do for a pt with a beard that is tough to get a seal on when ventilating
Go quickly to LMA or oral airway
Criteria associated with difficult airway (11 of them)- Overview Flashcard.
Difficult intubation pneumonic LEMON
Look - trauma, abnormal anatomy
Evaluate - 3-3-2 rule (3 finger mouth opening, 2 fingers between the superior notch of thyroid cart. and neck/mandible junction
Mallampati score - I-IV
Obstruction/Obesity - tumor, infection
Neck mobility
Difficult Airway Algorithm
During pre-intubation choose between ________ or ________ strategy.
During pre-intubation choose between an awake or post-induction airway strategy.
Most important factor of difficult airway algorithm
The pace or duration of time elapsed is vital
What are the 5 questions asked in the Difficult Airway Algorithm?
- 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?
Any one factor alone may be clinically important to warrant awake intubation. Minimize airway risk.
Optimize _________ throughout the difficult airway algorithm.
oxygenation
If an intubation attempt after induction of general anesthesia is a failure. What is the next step according to the difficult airway algorithm?
Limit attempts, consider calling for help
or
Limit attempts, and consider waking the patient up.
In the emergency pathway, if mask ventilation is not adequate and the supraglottic airway is not adequate, what should be considered?
Call for help for invasive access and attempt alternative intubation approaches as you prepare for an emergency invasive airway.
Intubate early in:
dynamic airways:
Bullets
Bites
Burns
Awake intubation technique
Atropine 0.1 mg/kg or Glycopyrulate 0.2 mg 15 min prior
Suction
Topical Lidocaine - Atomized, Nebulized, or Viscous
Lightly sedate - versed 2-4 mg or ketamine 20 mg
Physiologic Killers
Hypotension
Hypoxia
Metabolic Acidosis
Which special situations are a high aspiration risk?
What can be done to mitigate this risk?
Upper GI bleed
bowel obstruction
Pre-induction vomiting
Place NGT prior to intubation
