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SRNAHealthAssessment > Leo- Eval of Airway > Flashcards

Leo- Eval of Airway Flashcards

1
Q

What are the 3 unpaired larynx cartilages?

A

Cricoid
Thyroid
Epiglottis

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2
Q

What are the 3 paired larynx cartilages?

A

Arytenoids
Cuneiforms
Corniculate

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3
Q

What is the function of the PosteriorCricoArytenoids muscle?

A

Pull Cords apart (PCA) ***

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4
Q

Cricothyroid

A

Lengthen and stretch

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5
Q

VOCALIS (vocal ligament)

A

part of muscle that help with voice

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6
Q

Larynx all nerves come from

A

Vagus

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7
Q

***Most of motor function comes from the

A

Recurrent LARYNGEAL nerve

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8
Q

➢ Difficult mask ventilation

A

“Not possible for the unassisted anesthesiologist to prevent or reverse signs of inadequate ventilation during positive pressure mask ventilation

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9
Q

➢Difficult intubation

A

The proper insertion of an endotracheal tube using conventional laryngoscopy requires more than 3 attempts, or greater than 10 minutes”

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10
Q

➢Failed airway is defined as

A

⚫ 3 failed attempts at orotracheal intubation by a skilled provider
⚫ Failure to maintain acceptable saturations (> 90%) in otherwise normal individuals

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11
Q

ASA Closed Claims Database: single most important factor leading to fail airway

A

“Failure to evaluate the airway and predict difficulty is the single most important factor leading to a failed airway”

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12
Q

Incidence of Difficult Intubation by Rigid Laryngoscopy

⚫ Failed intubation 1 in 280

A

➢ Parturient 2.7%

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13
Q

Parturient and intubation

A

Almost 10x greater than in the nonparturient patient

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14
Q

➢ Major cause of injury in anesthetic practice

A 
➢ Inadequate ventilation—largest class of adverse
events
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15
Q

_____is especially important in patients at high risk for aspiration

A

Anticipation

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16
Q

Factors preventing a snug mask fit,

A

interfering with positioning of head and neck, limited opening of mouth, and narrow or distorted airway

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17
Q

Difficult Intubation Predictors:➢ External anatomic features

A
  • ↓ Head/neck movement (atlanto-occipital joint)
  • Jaw movement (temporo-mandibular joint), mouth opening, and subluxation of the mandible
  • Receding mandible
  • Protruding maxillary incisors
  • Obesity
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18
Q

More Predictors o difficult airway

A

Thyromental distance <6cm or 3 fingerbreaths.
• Sternomental distance
• Visualization of the oropharyngeal structures
• Anterior tilt of the larynx
• Radiographic assessment

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19
Q

Mouth opening (distance between incisors) limited to

A

3.5 cm or less will contribute to difficult intubation

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20
Q

Mouth opening is limited by

A 
Limited by:
⚫ TMJ dysfunction
⚫ Congenital or surgical fusion of the joints/ vertebrae
⚫ Trauma
⚫ Tissue contracture around the mouth
⚫ Trismus (lock jaw)
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21
Q

Protruding maxillary incisors can interfere with

A

laryngoscope placement and ETT passage

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22
Q

Mouth opened maximally normal

A

normal opening 5-6cm

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23
Q

➢ Class II–

A

base of tongue obscures tonsillar pillars, posterior pharyngeal wall visible below soft palate, uvula

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24
Q

➢ Class III–

A 
only soft palate visualized (7.58 x
greater chance of difficult intubation than class I)
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25
Q

➢ Class IV–

A

essentially nothing visualized, not even soft palate (11.2x greater chance of difficult intubation than class I)

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26
Q

Don’t Forget . . .

A

➢ Overbite
➢ Mobility of and ability to displace mandible
– can patient push jaw to place lower teeth
past the top teeth

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27
Q

⚫ May not be able to pull mandible forward far

enough to see larynx - TMJ

A

➢ Tongue Size
➢ Loose, chipped, or missing teeth, or dental
work

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28
Q

Micrognatia

A

No room to displace the tongue and epiglottis forward

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29
Q

➢ Anterior airway associated wtih ______

A

Micrognatia ; with the laryngoscope, the structures will be anterior to your field of view

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30
Q

Neck ➢ Limited Mobility -

A

Neck touch chin to chest, both shoulders, and extend back (normal 55 degrees) Harder to push tongue and epiglottis forward

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31
Q

➢ Neck circumference

A

> 27 inches is suggestive of difficult management

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32
Q

Neck: With trachea check

A

➢ Trachea mobility and alignment

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33
Q

➢ TM Less than

A

3 fingerbreadths is considered a receding mandible and may contribute to difficulty with intubation

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34
Q

➢ Rigid laryngoscopy may be impossible if

A

<6cm

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35
Q

➢ TM Measured with the

A

head fully extended,
between the bony part of the mentum of
the mandible and the thyroid notch

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36
Q

➢ TM Measured with the

A

head fully extended, between the bony part of the mentum of the mandible and the thyroid notch

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37
Q

Atlanto-occipital Mobility

A

Alignment of the oral, pharyngeal, and laryngeal axis required for visualization of the glottis during rigid laryngoscopy

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38
Q

Head has to be above the

A

Breast

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39
Q

What is responsible for the sensory and motor innervation of the larynx?

A

The vagus nerve (cranial nerve X), via the superior and recurrent laryngeal nerve, is

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40
Q

Has the highest density of touch receptors

A

The posterior half of the vocal cords

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41
Q

During bedside evaluation of Atlanto occipital mobility?

A

Bedside evaluation: have the patient sit straight and extend their head while maintaining a neutral cervical spine

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42
Q

With Atlanto occipital mobility ↓ degree of head extension indicate→

A

↑ possibility

for difficult intubation

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43
Q

Axis alignment

A

Elevation of the head about 10 cm with pads below to occiput with the shoulders remaining on the table aligns the laryngeal and pharyngeal axis

44
Q

Head extension at the atlanto-occipital joint

serves to

A

create the shortest distance and most nearly straight line from the incisor teeth to glottic opening

45
Q

Difficult bag-mask-ventilation: MOANS

A 
➢ M: Mask seal
➢ O: Obese
➢ A: Aged
➢ N: No teeth
➢ S: Snores or stif
46
Q

Difficult laryngoscopy and intubation: LEMON

A 
L: Look externally
➢ E: Evaluate 3-3 (3 fingers between teeth, 3
fingers chin-neck to thyroid notch)
➢ M: Mallampati class
➢ O: Obstruction
➢ N: Neck mobility
47
Q

Radiography: Not routine but To confirm vertebral damage and reveal degree of airway compression

A

⚫ Lateral C spine
⚫ MRI
⚫ CT

48
Q

Predictors of a Difficult Airway

A 
➢ High Mallampati Classification
➢ Small mouth opening
➢ Prominent Incisors
➢ Thyromental Distance <6 cm
➢ Decreased neck extension
➢ Neck Circumference
49
Q

Predictors of Difficult FACE MASK VENTILATION

ABBSMLL

A 
➢ Age >55 y.o.
➢ BMI >26-30 kg/m2
➢ Beard
➢ Snoring
➢ Lack of teeth
➢ Mallampati III or IV
➢ Limited mandibular protrusion
50
Q

Single most important predictor for both Difficult mask

ventilation and difficult intubation

A

Limited mandibular protrusion

51
Q

Predictors of Impossible Face Mask Ventilation

A 
➢ Male
➢ Beard
➢ Obstructive Sleep Apnea
➢ Mallampatie III or IV
➢ Neck radiation changes
52
Q

Many of the airway tests such as Mallampati and thyromental distance have limitations

A

Interobserver variability, low to modest sensitivity, inability to assess for base of tongue pathology

53
Q

Categories of Difficult Airway

A

➢ Known or expected difficult airway
➢ Probable difficult airway
➢ Unexpected difficult airway

54
Q

Mouth opening & proper position of the

Head & Neck adversely affected by:

A

➢ Tissues of head/neck, oral cavity, pharynx, & larynx fixed by tumor, surgical scars, or radiation fibrosis
➢ Supra-epiglottic mass may limit mobility of Epiglottis → complete airway obstruction after induction

55
Q

➢ Rheumatoid arthritis→ pathologic changes

➢ May involve any joint

A

⚫ Cervical spine
⚫ Temporomandibular joint
⚫ Cricoarytenoid joint

56
Q

➢ may indicate laryngeal involvement

A

Change in voice, dysphasia, dysarthria, stridor,

or sense of fullness in oropharynx

57
Q

Progressive cervical spondylosis (degeneration) can lead to

A

severe flexion deformity

58
Q

Should be the technique of choice if there is any reason to believe that maintaining a patent airway after induction of
anesthesia may be difficult

A

Awake intubation

59
Q

______________ in patients with an unstable neck should be done with extreme caution.
➢ Avoid movement that can cause spinal
cord compression and damage

A

Tracheal intubation

60
Q

Awake fiberoptic intubation can be performed without

➢ Any head and neck stabilizing device can be left in place to prevent movement of c-spin

A

atlanto-occipital extension

61
Q

Predictors of difficult video laryngoscopy

A 
Scarring
➢ Radiation
➢ Masses
➢ Large neck circumference
➢ TMD < 6 cm
➢ Limited neck mobility
➢ Operator experience
62
Q

➢ Airway assessment should be performed with

the patien

A

in a sitting position as well as supine.

63
Q

➢ Respiratory function and airway patency can be

greatly changed with

A

position changes.

64
Q

What may interfere with spontaneous respirations?

A

➢ Chest compliance and vital capacity change

65
Q

➢ Even with local or regional anesthesia, work of

breathing may be

A

Excessive and require ventilatory support

66
Q

For mobid Obesity create an Create an angle where the
____
Why? •

A

head and neck are above the thorax, so gravity will pull the weight away from airway
helps view and gives room for laryngoscope handle

67
Q

The higher incidence of (3 conditions) found in obese

patients, place these patients at a higher risk for aspiration of gastric contents

A

hiatal hernia
low gastric pH ( < 2.5),
low FRC

68
Q

For obese patient, to minimize the risk of

aspiration, what is performed?

A

a RSI is commonly performed

69
Q

Safe and logical approach for morbid obese patients?

A

Securing the airway in morbidly obese patients before induction of anesthesia

70
Q

2 studies show no correlation between

A

obesity and difficult intubation

71
Q

Morbid Obesity Weight distribution and consideration

A

Abdomen & hip area less important than if weight is

also in upper body;

72
Q

Fat in upper body lead to Cervical spine fat pads interfere with

A

laryngoscopy

73
Q

Rapid desaturation during apnea 2o to

A

↓ FRC limits time for intubation

74
Q

➢ Life threatening infection

A

Epiglottitis

75
Q

Epiglottis is what kind of infection?

A

Bacterial

➢ Lasts 2-4 days

76
Q

Epiglottis onset and progression

A

➢ Rapid onset and progression→ urgent dx and tx

77
Q

4 Ds of Epiglottis

A

Dysphagia, dysphonia, dyspnea, drooling

78
Q

S & S of airway injury

A

Subcutaneous emphysema
Hoarseness
Stridor,
Tracheal deviation

79
Q

Trauma Patient

Examine for

A

➢ Examine for cervical spine injuries
⚫ Cervical collar & axial traction during intubation
⚫ Limited range of motion

80
Q

Congenital Syndromes most often accompanied by aberrations of the upper airway (4)

A

⚫ Crouzon’s
⚫ Goldenhar’s
⚫ Pierre Robin’s
⚫ Treacher Collins

81
Q

Congenital syndromes: These children may also have a shortened trachea and should have

A

ETT positioned fiberoptically

82
Q

Crucial to assess

A

mouth size and opening, size of tongue, and neck movement, as well as feeling the neck under the mandible

83
Q

Intrathoracic Lesions

➢ IT lesions can compromise the airway through

A

compression of the tracheobronchial tree or by invasion of the trachea or bronchi

84
Q

➢ Anterior mediastinal tumors can completely

A

block the airway when a patient is placed in a

supine position

85
Q

➢ If flow-volume loop deterioration occurs in the

supine position,

A

the patient should not be anesthetized or paralyzed

86
Q

Cormack-Lehane laryngeal grading system
➢ View during direct laryngoscopy
➢ III

A

III—epiglottis

87
Q

Cormack-Lehane laryngeal grading system
➢ View during direct laryngoscopy
➢ I—

A

entire glottic opening

88
Q

Cormack-Lehane laryngeal grading system

➢ View during direct laryngoscop II—

A

posterior glottic structures

89
Q

Cormack-Lehane laryngeal grading system

➢ View during direct laryngoscopy➢ IV

A

soft palate only

90
Q

Anteriorly Tilted Larynx
➢ Degree of thyroid cartilage tilt can be
related to

➢

A

difficulty of laryngeal exposure

w/ Mac blade

91
Q

Anteriorly Tilted Larynx Reduced exposure

A

by depression of the thyroid cartilage

92
Q

Anteriorly Tilted Larynx Increased exposure by

A

cricoid pressure

93
Q

Unexpected Difficult Airway

A

Hyperplasia of the lingual tonsils, a lingual thyroid nodule/cyst, and an asymptomatic epiglottic cyst can contribute to a failed intubation or ventilation.

94
Q

Anatomical Features Associated with unanticipated Difficult Intubations

A 
Anterior larynx (most common)
➢ Abnormal neck anatomy (poor mobility, short)
➢ Decreased mouth opening
95
Q

The KEY to successful awake intubation

A

Topical anesthesia

96
Q

Most conservative approach when difficult airway is

known or suspected

A

Awake intubation

97
Q

During awake intubation, Important to use

A

glycopyrrolate to dry mucous membranes prior to topical LA (at least 20 min before)

98
Q

When deciding on awake vs. asleep airway management:

A

➢ If difficulty w/ ventilation by both mask &
supraglottic airway device is anticipated.
➢ Consider presence of at least 3 factors
predictive of difficult or impossible to mask
ventilate

99
Q

Preexisting Airways

A 
➢ Endotracheal or tracheal
➢ Indication
➢ Date of Placement
➢ Ease of Placement
➢ Size
➢ Presence of cuff
➢ Vent settings
➢ Recent ABG
100
Q

Difficult intubation is a

A

life-threatening situation
➢ Even the most experience provider seeks
help

101
Q

Unexpected failed intubation/ventilation may be

due to

A

Supraglottic mass or lingual tonsillar

hyperplasia

102
Q

Incidence of tracheal stenosis after emergency

tracheostomy is

A

high (FO evaluation prior to intubation is suggested)

103
Q

When in doubt, secure airway with the patient

A

awake and spontaneously breathing

104
Q

are the major airway management problems in

pediatrics

A

Infection related and congenital airway compromise

105
Q

➢ In adults, stridor at rest=

A

serious obstruction w/ cross sectional opening less than 4mm

106
Q

Should always be available

A

➢ Emergency airway management cart

107
Q

➢ Important for pt w/ difficult airway to get

A 
MedicAlert
bracelet (make sure to document on record)

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