Exam 2 Material Flashcards by Krista Walls

Incidence of difficult mask ventilation ranges from ___

0.07-5%

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Adverse outcomes result from failure to (3)

Ventilate/oxygenate
Prevent aspiration
Both

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Does intubation usually cause an adverse outcome?

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What is the most common claim with airway management?

Dental damage

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What is a more common airway management complication?

Laryngospasm

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How do you treat a laryngospasm?

Remove offending stimulus
Positive airway pressure
Deepen anesthetic state
Rapid acting muscle relaxer

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To generate pressure on the anesthesia machine during a laryngospasm, what would you do?

Close APL valve, put it to 10, squeeze bag

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Starred portion of the difficult airway algorithm:

Face mask ventilation inadequate– move to SGA being adequate or not feasible

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A key overlooked step on the difficult airway algorithm is:

Place a SGA if you can’t ventilate/intubate

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Resistance to airflow through the nose is ___ compared to the mouth

2x more

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Larynx lies between the ___ and ___ cervical vertebrae

3rd and 6th

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Trachea lies ___ vertebrae to ___ which is at ___

Trachea is at C6 to carina (T4)

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The Angle of Louis is the joint between the ___ and ______ ______

Manubrium and sternal body

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Trachea is ____cm long
How many horseshoe rings?
What is the most cephalad ring?

10-15cm long
w/ 17-18 horseshoe shaped rings and 1 complete, cephalad cricoid

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____ to the carina is the most important to us

Larynx

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What does the larynx do? (2)

Modulate sound
Separate trachea from esophagus during swallowing

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What shields the larynx anteriorly?

Thyroid cartilage

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Larynx is composed of muscles, ligaments and cartilages. Name them (4)

Cricoid, arytenoids, corniculates, epiglottis

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_______ ligaments form the vocal cords

And what is special about it?

Thyroarytenoid

Narrowest part of the adult airway

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Movement is controlled by 2 muscle groups:

Extrinsic and intrinsic

Extrinsic muscles move larynx as a whole
Intrinsic muscles move various cartilages in relation to one another

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Nerve that provides sensory for posterior 1/3 tongue, soft palate, oropharynx

Glossopharyngeal

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Nerve(s) that provides sensory for larynx (below the epiglottis) (2)

Superior laryngeal (internal) epiglottis to cords
Recurrent laryngeal- below cords and trachea

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Nerve(s) that provide motor for larynx (2)

Recurrent laryngeal
EXCEPT for cricothyroid muscle = superior laryngeal (external MOTOR)

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What is the most important component in preoxygenation?

What is preoxygenation also known as

Mask seal is MOST IMPORTANT

Preoxygenation is also called denitrogenation

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If a patient is claustrophobic, you should ___

Let the patient hold the mask

A healthy patient without oxygen for 1-2 min on RA would have an O2 sat of ___, compared to a patient that is preoxygenated for several min with 100% O2 with good facemask seal could maintain adequate oxygen for ____ minutes

< 90% 8 minutes

GOLD standard for confirmation of proper device placement is

ETCO2 with 3-5 SUSTAINED (key word) breaths

Airway management begins with (3)

Airway relevant h&p exam Airway history Anatomic features

What is the best option for airway assessment?

Combination of exams

What score correlates with ease of direct laryngoscopy and intubation at eye level?

Mallampati

Which class Mallampati score correlates with soft palate, fauces, uvula, tonsillar pillars visible?

Class I

Which Mallampati score correlates with soft palate not visible? And is this a concern?

Class IV (yes-- it is a concern)

Which Mallampati score correlates with soft palate and base of uvula visible?

Class III

Which Mallampati score correlates with soft palate, fauces, uvula visible?

Class II

What is the sniffing position?

Puts the 3 axis in optimal alignment for direct visualization of larynx during laryngoscopy

What three landpoints do we want aligned in the sniffing position?

OA, PA and LA **OA= oral axis PA =pharyngeal axis LA = laryngeal axis

_____ of the neck is elevating the head approximately 10cm

Cervical flexion

How many cm are in one inch?

2.54

Cervical flexion is achieved at what degree angle?

Atlanto-occipital extension of the head is achieved at what degree angle?

15 **Remember occiput= base of skull and atlas = C1

TROOP pillow is used in what pt population to elevate head for the laryngoscopy position?

Obese

What is the desirable incisor distance in an adult?

3cm or >

What distance is a predictor of poor laryngoscopic view?

Thyromental distance < 6-7cm = 3 fingerbreadths

Thyromental means

Mentum to thyroid cartilage

At what BMI do you air on side of caution for potentially difficult airway?

BMI 30 kg/m2 or greater

What neck circumference is worrisome for potential difficult airway?

> 17 inches

Ultrasound for airway examination is especially beneficial in ____

Identifying cricothyroid membrane during emergent cricothyroidotomy

Most important thing to do after induction:

Bag and mask machine, AMBU

What type of fiberoptic do we usually use to intubate?

Pediatric

What should be available to you before intubating (but does not need to be present during all routine intubations)?

Flexible fiberoptic bronchoscope

What can fall against the posterior wall of the pharynx and obstruct the airway and what should you keep beside you to aid in assistance if this were to happen?

Tongue and epiglottis can fall ALWAYS HAVE AN ORAL AIRWAY BESIDE YOU

What airway can induce a gag reflex if awake and what is generally well-tolerated in an awake patient?

Oral airway = gag Nasal airway = well tolerated

Where do we measure for a nasal airway?

Nares to meatus of ear

Where do we measure for an oral airway?

Mouth to angle of mandible

How should you insert a nasal airway? Do you use lubricant?

Advance along the floor of the nasal passage (perpendicular to face) **AVOID TURBINATES OF LATERAL NASAL CAVITY YES-- alway use lube

Should you apply constant pressure while placing a nasal airway?

Yes

What are 3 contraindications to the nasal airway?

Coagulation or platelet abnormalities Basilar skull fractures Children with prominent adenoids

The sides of a facemask should seal ___

Just lateral to nasolabial folds

True or false: The face mask should fit over the bridge of the nose with the upper border aligned below the pupils

False -- needs aligned WITH the pupils

The bottom of the facemask should seat ____ and the _____

Between the lower lip and the mentum (chin)

What kind of masks allow for visualization of fogging and lips, as well as regurgitation? And what signs can this show us?

Clear masks show signs of air exchange

What hook allows you to attach a head strap to help hold mask in place/maintain seal?

Retaining hook around the 22mm fitting (it accepts the anesthesia circuit)

What masks have a fruity smell and what are they designed to do?

Pediatric masks and they also minimize dead space

What technique is best to denitrogenate?

3 minutes of TV breathing of 100% O2 (high FGF)

Ideal oxygenation/denitrogenation will allow a normal patient to maintain an O2 sat of > ____ for ____ minutes

>90% for ~8 minutes

O2 is entrained into alveoli from pharynx/trachea after induction is referred to as ____

Apneic oxygenation

To counterbalance apneic oxygenation, you should _____

Continue O2 with a seal during apnea

Oxygen molecules go to the ____ w/o ventilation d/t....

Oxygen molecules go to the alveoli w/o ventilation d/t apneic oxygenation

True or false: When performing the head/chin tilt, jaw thrust maneuver.... you place jaw toward floor

FALSE-- Jaw goes toward ceiling

What is the most important maneuver to allow ventilation?

Head/chin tilt, jaw thrust maneuver

What should ventilation pressure be?

< 20 cm H2O

Should we leave dentures in to adequately bag them?

Yes, then remove right before intubation

Incidence of difficult mask ventilation ranges from 0.9% to _____

7.8%

What complication can arrive from prolonged mask ventilation?

Pressure injury to trigeminal or facial nerves

True or false: Eyes should be taped after ventilation

False-- BEFORE ventilation *check reflexes, then tape

Accurate hand positioning on mask: Downward pressure on mask with ____ and ____ of ____ hand

Downward pressure on mask with thumb and index finger of left hand

In accurate hand positioning, what do you do with your middle and ring finger? What are we extending?

Middle and ring finger grasp the mandible to facilitate extension Extension of the atlanto-occipital joint

If you add pressure to the soft tissue instead of the mandible... what will it do?

Obstruct the airway

What do you do with your pinky to lift the jaw anteriorly?

Place it under angle of jaw and lift toward ceiling **lift mandible up into mask

Right hand typically used to _____

Generate positive pressure on bag for ventilation

If ventilation is difficult, you should consider what technique?

Two handed technique, thumbs hold mask in place, other fingers perform jaw thrust

Top 4 predictors for difficult facemask ventilation:

Age > 55 years BMI > 26-30 Beard Edentulous

Facemask fun facts: 3

Common in peds Must have empty stomach Short duration of cases

Where does a laryngeal mask airway sit?

Supraglottic airway (SGA) Above cords/above glottis

True or false: LMA is used more frequently than older techniques of mask anesthesia

True

Is a LMA designed to protect from aspiration/regurgitation?

Where does the tip of the LMA sit?

Above esophagus

Inserting a LMA requires ____ anesthesia than an oral or nasal airway

Deeper

Which airway is placed blindly into hypopharynx: head neutral and KEY IS

LMA = NO NECK EXTENSION

LMA cuff is bordered by ____ superiorly ____ laterally ____ inferiorly

LMA cuff bordered by Base of tongue superiorly Piriform sinuses laterally Upper esophageal inlet inferiorly

At what pressure do LMAs usually leak?

@ 20 cm H2O airway pressure ***limit airway pressure to < 20 cm H2O

What position would you place pt in if you suspect aspiration with an LMA in place? What other considerations?

Trendelenburg position LEAVE LMA IN PLACE w/ 100% oxygen, suction

What is the maximum cuff inflation pressure for a LMA?

60cm H2O

LMA size recommended & their volumes for a 30-50kg patient

LMA size 3 with a cuff volume of 30, max cuff volume of 20

LMA size recommended & their volumes for a 50-70kg patient

LMA size 4 with a cuff volume of 45, max cuff volume of 30

LMA size recommended & their volumes for a 70-100 kg patient

LMA size 5 with a cuff volume of 60, max cuff volume of 40

LMA size recommended & their volumes for a > 100 kg patient

LMA size 6 with a cuff volume of 75, max cuff volume of 50

What is the max ETT you can put down with a LMA 3?

6 CUFFED

What is the max ETT you can put down with a LMA 4?

6 CUFFED

What is the max ETT you can put down with a LMA 5?

7 CUFFED

What is the max ETT you can put down with a LMA 6?

7 CUFFED