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Lindsays Flashcardlet > RE1: Chapter 23: Airway Management II > Flashcards

RE1: Chapter 23: Airway Management II Flashcards

0
Q

Upper airway consists of

A

nose, mouth, pharynx, hypopharynx and larynx

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1
Q

Difficult ventilation is the inability of a trained anesthetist to maintain the O2 sat > _______% using a facemask for ventilation and ________FiO2 provided pre-op sats was w/in normal range.

A

92%

100%FiO2

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2
Q

The nose provides almost ______ of the resistance to breathing?

A

2/3

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3
Q

What 3 arteries supply blood to the nasal mucosa?

A

Maxillary (sphenopalatine),
Ophthalmic, &
Facial

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4
Q

Parasympathetic innervation to the nose arises from _______________ & _______________.

A

7th CN (Facial) and pterygopalatine ganglion

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5
Q

Sympathetic innervation to the nose is derived from ____________

A

superior cervical ganglion

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6
Q

At day _____, is the development of the pharyngeal arches.

A

22

6 arches develop from 5 structures (1-4 & 6 develop airway structures and 5 dissapears)

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7
Q

What separates the mouth from the nasal passages?

A

Hard and soft palate

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8
Q

The soft palate covers the posterior ____ to ____ of the oral cavity

A

1/3 to 2/3

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9
Q

The pharynx is divided into what 3 compartments?

A

Nasopharynx, oropharynx and hypopharynx

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10
Q

The nasopharynx lies anterior to ____

A

C1

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11
Q

The oropharynx lies anterior to ______. It is bounded superiorly by the ________ and inferiorly by the _______.

A

C2-C3

Soft palate

Epiglottis

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12
Q

The hypopharynx lies posterior to the larynx at ______ level. It is bounded superiorly by the _______ and inferiorly by the __________.

A

C5-C6

Epiglottis

Cricoid cartilage

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13
Q

What separates the upper and lower airway?

A

Cricoid cartilage

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14
Q

The larynx lies anterior to _______. It begins with the ______ and extends to the _______.

A

C3-C6 (Begins at C3-C4 & ends at the cricothyroid muscle at C6 in adults)

Epiglottis

Cricoid cartilage

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15
Q

The larynx is composed of three single cartilages and three paired cartilages. What are they?

A

Single

  • Epiglottis
  • Thyroid
  • Cricoid

Paired

  • Arytenoids
  • Corniculates
  • Cuniforms
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16
Q

What acts as a barrier to regurgitation in the conscious pt?

A

Cricopharyngeus muscle

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17
Q

What arises from the cricopharyngeus muscle?

A

Upper esophageal spincter

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18
Q

What is the role of the intrinsic muscles in the larynx?

A

Control tension of vocal cords and the opening and closing of the glottis

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19
Q

What does the posterior cricoarytenoid do?

A

Separates the vocal cords and opens the glottis (abducts)

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20
Q

What does the lateral cricoarytenoid muscles do?

A

Closes the cords (adducts)

“Lets Close Airway”

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21
Q

What does the cricothroid muscles do?

A

Tenses the vocal cords

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22
Q

What does the thyroarythenoid muscles do?

A

Relaxes the vocal cords

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23
Q

What nerves innervates all the muscles of the pharynx, larynx and soft palate?

A

Glossopharyngeal (afferent stimuli)
Vagus (efferent response - gag reflex)
Spinal accessory nerve

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24
Q

What two branches of the vagus nerve innervate the hypopharynx?

A

SLN and RLN

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25
Q

What does the SLN divide into?

A

Internal and external branches

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26
Q

What does the internal branch of the SLN provide?

A

Sensory innervation ABOVE the vocal cords

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27
Q

What does the external branch of the SLN provide?

A

Motor fnx to the CRICOTHYROID MUSCLE of the larynx

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28
Q

What does the RLN provide?

A

Sensory intervention BELOW the vocal cords

Motor intervention to all muscles of the larynx EXCEPT the cricothyroid muscle

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29
Q

Where does the right RLN travel?

A

Right RLN loops around the innominate artery

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30
Q

Where does the left RLN travel?

A

Left RLN loops around the aorta

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31
Q

What does unilateral injury to the RLN do? Bilateral injury?

A

Unilateral - hoarseness
Bilateral - Acute: respiratory distress or death
Chronic: develops comp. mechanisms, gruff/husky speech

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32
Q

What consists of the lower airway?

A

trachea, bronchi, bronchioles, terminal bronchioles, & resp bronchioles

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33
Q

What develops from the foregut and becomes the primitive lung bud?

A

Laryngotracheal groove

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34
Q

What day doe the lung bud divide into R and L bronchial buds?

A

28

35
Q

What day does the bronchopulm. segments appear?

A

42

36
Q

During _____ weeks, cuboidal cells of the terminal sacs differentiates into __________ and secretion of _________ begins.

A

16-26th weeks

Alveolar type II cells

Surfactant

37
Q

During _______ weeks, alveoli develops and capillaries proliferate.

A

24-36th

38
Q

By _____ week, a blood-gas barrier is developed.

A

26th

39
Q

By _____ week, there are mature alveoli.

A

36th

40
Q

The trachea originates at the _______ and extends to the _______.
What is the approx length?
How many C-shaped rings are there?

A

Cricoid cartilage and extends to the carina

10-20cm

16-20 C-shaped rings

41
Q

The cartilaginous rings continue until bronchi reach _____ mm in size.

A

0.6-0.8mm

42
Q

What is the R mainstem bronchus angle and distance from the carina?

A

25-30 degrees

2.5cm

43
Q

What is the L mainstem bronchus angle and distance from the carina?

A

45 degrees

5cm

44
Q

What is the sympathetic and parasympathetic innervation of the tracheobronchial tree?

A

Sympathetic: 1-5th thoracic ganglia
Parasympathetic: vagus

45
Q

What are the most prominent physical factors associated with a difficult intubation?

A

Obesity, decreased head and neck movement, decreased jaw movement, receding mandible and buck teeth

46
Q

What three axis are you aligning in the sniffing position?

A

oral, pharyngeal, and tracheal axis

47
Q

Incisor distance should be at least?

Thyromental distance should be at least?

A

4cm

less than 6cm or 3 fingerbreaths

48
Q

What joint is capable of extending the head/neck up to 35degrees?

A

Atlantooccipital joint - provides the highest degree of mobility in the neck (should be able to touch tip of chin to the chest)

49
Q

What is considered full range of motion?

How much does it decrease between ages 16 - 75 years?

A

90-165 degrees

20%

50
Q

Mallampati classification is an indirect method of relating _____ to _____.

A

tongue to the oral cavity

Class 1: soft palate, fauces, uvula, tonsillar pillars
Class 2: same as 1 except tonsillary pillars
Class 3: only base of uvula seen
Class 4: even the uvula is not visulalized

51
Q

What are the components of the Lemon Law?

A
  • Look externally
  • Evaluate 3-3-2 (3FB b/t incisors,3FB b/t chin & hyoid bone & 2FB b/t thyroid notch
  • Mallampati
  • Obstruction
  • Neck Mobility
52
Q

What are the 4 endpoints of the difficult airway algorithm?

A

Intubation awake or asleep
Intubation emergent or nonemergent
Approach supraglottic or subglottic
Airway access surgical or nonsurgical

53
Q

Difficult airway is defined as any intubation that takes a skilled anesthetist more than ______ attempts or greater than _____ minutes.

A

3 attempts

10 minutes

54
Q

What is the purpose of pre-oxygenating the patient?

A

Increase O2 content and eliminate nitrogen (79% of room air) from the FRC

55
Q

With adequate pre-O2, the FRC has enough O2 to last almost ____ minutes.

A

12 minutes

Without pre-O2, the O2 reserve in the FRC will last approx 2-5minutes in a difficult airway situation.

56
Q

With adequate pre-O2, the patient should breath normal VT for ____ minutes with FGF no less than ____L and have a tight mask fit.

With a fast-track patient, pre-O2 where the patient take _______ breaths in _______ seconds.

A

3-5 minutes & 5L

4 VC breaths over 30 seconds

57
Q

What situations should awake FO intubation be used?

A

Unstable neck fx
Halo device
Small or limited oral openings
Intubation of awake pts in the ICU

58
Q

What is most commonly used to anesthetize the airway for FO awake intubations?

When is the peak serum levels?

A

2% Lidocaine in a nebulizer

30 minutes

59
Q

Describe a superior laryngeal nerve block.

A

-Provides a dense block of the supraglottic region
-Locate hyoid bone and displace it towards side bring injected
-Palpate inferior border of cornu, insert needle perpendicular to skin
(site where SLN pierces the thyrohyoid membrane)
-Deposit 1-2mL of LA ABOVE membrane and 2mL of LA BELOW membrane
-Repeat on opposite site

60
Q

Describe a transtracheal block.

A
  • Inject LA through the cricothyroid membrane
  • Attach a 23G needle w/5mL of 2% lidocaine
  • With CONSTANT aspiration, advance needle in a CAUDAD direction
  • When air bubbles are visualized, tip of needle is in tracheal lumen
  • Inject LA into lumen on INSPIRATION (pt will cough spraying LA onto vocal cords)
61
Q

Describe a glossopharyneal block.

A
  • To block the lingual branch of this nerve, have pt open mouth and displace tongue to opposite side to create a gutter.
  • Where the gutter meets base of the palatoglossal arch, insert 26G needle 1/4 inch deep.
  • If air is obtained, needle is too deep
  • If blood is obtained, withdraw needle and reposition
  • Inject 1-2ml of 2% lidocaine and repeat on opposite side
62
Q

What is BURP?

A

Backward, Upward, Rightward & Pressure

63
Q

To prevent aspiration, cricoid pressure must be applied before or after loss of consciousness.

A

BEFORE

64
Q

What is the recommended force of cricoid pressure needed prior to loss of consciousness and on loss of consciousness?

A

Prior to loss of consciousness: 20N or 2kg of pressure

On loss of consciousness: 44N or 4kg of pressure

65
Q

When should cricoid pressure by released?

A

AFTER placement of ETT is verified

66
Q

Where is an LMA positioned in the airway?

A

Positioned in the hypopharynx below the base of the tongue and above the epiglottis

67
Q

What should you keep the positive pressure below with an LMA to avoid inflating the stomach?

A

20 cmH20

68
Q

How does a pro-seal LMA differ from a traditional LMA?

A
  1. Pro-seal LMA has a second tube to pass a OG with passing through the hypopharynx
  2. Pro-seal LMA provides a seal against the posterior wall of the pharynx allowing positive inspiratory pressures of up to 30 cmH2O
69
Q

What is the confirmation of placing in bougie blindly?

A

Confirmation of proper placement is made by feeling the stylet bounce along the tracheal rings as it is advanced.

70
Q

What are the limitations of a FO laryngoscope?

A
  1. Can become fogged
  2. Broken/damaged FO strands
  3. Vision can be obstructed by secretions or blood
71
Q

Instillation of ____L flow provides the pt with up to ____% O2 and keeps debris from collecting on the port or lens of the FO laryngoscope.

A

2-4L

26%

72
Q

What scopes do NOT require the sniffing position?

A
  1. Airtraq Optical laryngoscope

2. Bullard scope

73
Q

With transtracheal jet ventilation, the delivery pressure of 50psi, a 20G catheter delivers approx ____mL of O2 per second.
16G delivers approx ____mL of O2 per second
14G delivers approx ____mL of O2 per second

A

20G - 400mL
16G - 500mL
14G- 1600mL

74
Q

What is a sufficient inspiratory pressure with jet ventilation?

A

25psi

75
Q

What gauge IV catheter or Cook needle is needed for a retrograde intubation?

Is this an emergent process?

A

14 to 18G catheter or Cook needle

NOT an emergent process and can be completed in 5-7 min
(An EMERGENT method of ventilation is percutaneous dilated cricothyrotomy)

76
Q

Where is a tracheotomy placed?

A

Performed at the level of 4th-5th tracheal rings BELOW the isthmus of the thyroid gland.

NOT PERFORMED BY A CRNA

77
Q

What are the signs of a esophageal intubation?

A
  1. Absence of BS over lung fields
  2. Gurgling over epigastrium w/progressive distention of abd
  3. Lack of sustained ETCO2
78
Q

What are signs of endobronchial intubation?

A
  1. Increased PIPs
  2. Uneven chest rise
  3. Decreased BS on the unventilated side
  4. Drop in ETCO2 conc.
  5. Tachycardia
  6. Hypoxemia
79
Q

What are most susceptible to injury during a ETT placement?

A

Arytenoids, posterior half of vocal cords and posterior tracheal wall

80
Q

What can an obstruction of an ETT lead to?

A

Negative pressure pulmonary edema (NPPE)

Caused by movement of fluid from interstitial space of lung into the plural cavity

Treatment: diuretics and positive pressure ventilation

81
Q

What is the most common post-op complaint following intubation?

What are the risk factors?

A

Sore throat

Risk Factors:

  1. ETT size
  2. Difficulty with intubation
  3. Use of NG/OG tube
  4. Female gender
  5. History of smoking
82
Q

What is a laryngospasm and what is the sensory stimulation?

A

Forceful, involuntary spasm of the laryngeal muscles

Occurs through sensory stimulation of the SLN and afferent response from the RLN

83
Q

What are the 2 phase mechanisms with laryngeal spasms?

A

Shutter mechanism - results in PARTIAL airway obstruction
Treatment: positive pressure ventilation with 100% FiO2 (10-20cm H2O). If condition persists, give partial dose of succ 0.1mg/kg IV

Ball-valve mechanism - COMPLETE airway obstruction
Treatment: intubating dose of succ 1-2mg/kg IV or 4mg/kg IM

84
Q

What is the treatment for croup?

A

Aim is reducing the swelling of the glottis / subglottic region

  1. Inhalation of cool, moist O2
  2. Inhalation of racemic epi
  3. Dexamthasone (0.1-0.5mg/kg)

Lindsays Flashcardlet (27 decks)

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