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A1 > Respiratory APEX > Flashcards

Respiratory APEX Flashcards

1
Q

Intrinsic muscles (larynx)

A

Chubby tired leprochauns piss terrible venom
Cricothyroid
Thyroaryetnoids
Lateral cricoaryetnoids
Posterior cricoaryetnoids
Traverse/ aryepiglottc / Inter aryetnoids
Vocalis

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2
Q

Cricothyroid pneumonic

A

Cords tense (elongate)

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3
Q

ThyroaRyetnoids pneumoic

A

They Relax

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4
Q

Lateral vs posterior cricoarytenoids

A

Lateral- Adduct cords
Posterior- Abduct cords (ABs at the POSTERIOR of a work out)

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5
Q

External muscles (larynx)

A

HYOID
Omohyoid
Sternohyoid
Sternothyroid
Mylohyoid
Stylohyoid
Thryohyoid
Digastric (anterior and posterior)

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6
Q

What is the role of the intrinsic vs extrinsic muscles of the larynx?

A

Intrinsic- phonation, vocal cords
Extrinsic- Swallowing

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7
Q

What innervates the muscles (motor) of the larynx?

A

RLN- all except cricothyroid
SLN (EB)- cricothryoid

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8
Q

Airway innervation nerves (4)

A

Trigeminal (CN5)
Glossopharyngeal (CN9)
SLN (CNX)
RLN (CNX)

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9
Q

SLN IB ranges from ___ to ___

A

Posterior epiglottis to the top of the vocal cords

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10
Q

What does the SLN EB sense?

A

Nothing, motor only

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11
Q

Trigeminal Nerve branches

A

TRI- 3 branches
V1 Opthalmic nares and anterior 1/3 septum
V2 Maxillary Turbinates and posterior 2/3 septum
V3 Mandibular anterior 2/3 tongue

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12
Q

CN9 sensory

A

Posterior 1/3 tongue
Oropharynx
Valeculla
Anterior epiglottis

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13
Q

Afferent vs Efferent limb of gag reflex

A

CN9
CN10

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14
Q

What cranial nerve serves the epiglottis

A

CN9- anterior
CNX SLN- posterior

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15
Q

Which RLN is more susceptible to injury and why?

A

Left bc it loops around the aortic arch instead of the subclavian

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16
Q

Risk factors for L RLN injury

A

PDA ligation
LA enlargement (from mitral stenosis)
Aortic arch aneurysm
Thoracic tumor

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17
Q

Risk factors for RLN injury to either side

A

Pressure from ETT or LMA
Thyroid or parathyroid surgery
Neck stretching
Neoplasm

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18
Q

Which branch of X is high risk for emergency if injured?

A

Biltateral RLN (makes sense, its most of the muscles motor)

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19
Q

What cranial nerve is for chewing?

A

CN5, branch V3, mandibular (lingual)

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20
Q

Cranial nerves of airway innervation

A

5
9
10

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21
Q

Landmark for SLN block

A

Superior Greater
Greater cornu of hyoid bone

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22
Q

What nerves must be blocked from airway? (3)

A

Glossopharyngeal (9)
SLN
RLN

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23
Q

Landmark for glossopharyngeal block

A

Palatoglossal arch

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24
Q

Glossopharyngeal block aspiration of air vs blood

A

Air- too far
Blood- in carotid artery

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25
Q

How much anesthetic for glossopharyngeal, SLN, RLN

A

1-2 ml
2ml
3-5 ml

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26
Q

Where does RLN block go?

A

Cricothyroid membrane

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27
Q

Larynx position C spine

A

C3-C6

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28
Q

Paired vs unpaired cartilages of larynx

A

Paried- aryetnoids, corniculate, cuneiform
Unpaired- epiglottis, cricoid, thyroid

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29
Q

2 instances when you would need to place a needle thru the cricothyroid membrane

A

Transtracheal block for RLN
Cricothyroidotomy

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30
Q

What ligament pulls the epiglottis via the vallecula?

A

Thyroepiglottic

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31
Q

Narrowest airway in adults and children

A

Adults- glottis
Children- glottis dynamic, cricoid fixed

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32
Q

Manuever of laryngospasm

A

LARSONS - firm pressure to laryngospasm notch just behind earlobe , breaks spasm by causing a lightly anesthetized patient to sigh, also opens airway as a jaw thrust
Hold for 3-5 seconds an released for 5-10 seconds

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33
Q

Signs of laryngospasm

A

Rocking horse chest wall movement
Inspiratory stridor
Absent etco2

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34
Q

Risk factors for laryngospasm

A

Recent URI
Second hand smoke exposure
GERD
<1yr
Light anesthesia
Saliva/blood in airway
hypocapnia
Procedures of the airway

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35
Q

Laryngospasm interventions/ prevention

A

Avoid airway manipulation during light anesthesia
CPAP 5-10 during induction and extubation
Remove secretions before extubation
Extubation when deep or awake, not inbetween
Lidocaine (laryngeal or iv)

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36
Q

Laryngospasm treatment

A

Fio2 100%
Deepen anesthetic
CPAP 15-20
Larsons
SUCC IV 1mg/kg or 2mg/kg for infants
SUCC IM 4mg/kg or 5mg/kg for infants
Atroping 0.02 for children under 5

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37
Q

Valsalva vs Mullers

A

Opposites
Exhalation against closed glottis- coughing, bucking
Inhalation against closed glottis- pulmonary edema, bites ett and breathes in

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38
Q

Which nmb can be given IM?

A

Succ 4mg/kg adults, 5mg/kg kids
Roc

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39
Q

Where can the upper airway obstruct and what muscle will cause it?

A

Soft palate- tensor palatine
Tongue- genioglossus
Epiglottis- hyoid

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40
Q

Trachea C spine location

A

C6-T5

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41
Q

Degree of L and R mainstem bronchus

A

L- 45 degrees, also 2.5 cm from carina
R- 25 degrees, 5cm from carina

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42
Q

Alveoli cell type

A

Squamous epithelium

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43
Q

Distance from teeth to carina

A

13cm from teeth to larynx
13cm from larynx to carina
26cm total

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44
Q

Bronchi angle on children

A

55 degrees for both for children under 3

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45
Q

Goblet vs ciliated cells

A

Goblet- mucus production in large airways, decrease as airway bifurcates
Ciliated- clears mucus in carina
BOTH decrease with airway bifurcation, lungs start to only focus on gas exchange

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46
Q

What is the angle of louis and where is it C spine

A

Correspond with the carina
T5

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47
Q

What are pores of Khon?

A

Air movement between alveoli

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48
Q

What is an example of Boyles law?

A

Contraction of the inspiratory muscles reduces thoracic pressures and increases thoracic volume

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49
Q

Muscles of inspiration

A

Sternocleidomastoid (accessory)
Scalenes (accessory)
EXternal intercostals
Diaphragm

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50
Q

Conducting, transitional, and respiratory zones

A

No gas exchange, dead space
Dual funciton of air conduit and gas exchange via the respiratory bronchioles
Gas exchange

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51
Q

Muscles of expiration

A

I let the air out of my TIRE
Transverse abdominus
Internal intercostals
Rectus abdominus
External obliques

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52
Q

Transplural pressure, example of it

A

Alveolar pressure-Interplueral pressure
If positive, stays open, if negative, airway collapses
0-(-5)= 5
Should always be positive

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53
Q

When is alveolar pressure more and less positive

A

More positive (barely) on expiration
Less positive (or negative) on inhalation

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54
Q

When is interpleural pressure positive and negative?

A

Always negative to keep lung inflated
Can become positive during forced exhalation

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55
Q

Where does gas exchange end and begin?

A

Ends at the terminal bronchioles
Starts right after at respiratory bronchioles

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56
Q

Normal dead space (Vd) in percentage and weight based

A

33%
2ml/kg

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57
Q

Alveolar ventilation equation

A

(Vt-Vd)xrr
Primary determinant of CO2 elimination, not Ve

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58
Q

What can increase Paco2-etco2 ? Decrease?

A

Things that increase deadspace
Neck extension
PPV
Hypotension by reducing pulmonary bloodflow
Bronchodilators increase conducting zone to increase deadspace
Decreease- ETT,LMA, neck flexion

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59
Q

What is physiologic deadspace?

A

Alveolar + anatomic deadspace

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60
Q

What is the most common cause of increased deadspace under GA? How would it present?

A

Reduction in CA
Decrease in ETCO2

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61
Q

What increases deadspace

A

Apparatus like facemask, HME, PPV
Anticholinergics open conducting zone
Old age sigh longer
Neck extension opens airway
Decreased CO, COPD, PE
Sitting

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62
Q

What decreases deadspace

A

ETT, LMA, Trach
Neck flexion
Supine, trend

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63
Q

HPV minimizes ____

A

shunt

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63
Q

Most common cause of hypoxemia in the PACU

A

VQ mismatch

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64
Q

Treatment of VQ mismatch in the PACU

A

O2
Deep breathing, mobility, spirometry

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65
Q

When is surfactant produced?

A

Starts at 26 weeks
Completion at 36

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65
Q

Law of laplace formula

A

tension= pressure x radius
alveoli, blood vessels

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66
Q

What can be used to hasten fetal lung maturity?

A

Corticosteroids

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67
Q

Shunts not in the lungs

A

Thesbian
Pleural
Bronchiolar

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68
Q

West zone is associated with hypotension?

A

1
Not enough blood flow causes deadspace

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69
Q

Alveolar oxygen formula

A

fio2 x (pb-h2o [47]) - (paco2/RQ[.8])

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70
Q

RQ formula

A

CO2 production/ O2 Consumption
200/250= 0.8

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71
Q

5 causes of hypoxemia

A

VQ mm (most common, increased Aa)
Shunt (increased Aa)
Diffusion limitation (increased Aa)
Hypoxic mixture (normal Aa)
Hypoventilation (normal Aa)

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72
Q

What are things that increase Aa

A

Aging
Vasodilators (prevent HPV)
Diffusion limitation ()
RL shunt (atelectasis are basically closed)
VQ mm- copd, 1LV

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73
Q

Estimation of shunt

A

1% for every 20mmHg of Aa gradient
5% normally

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74
Q

TLC, VC, IC, FRC

A

5.8L
4.5L
3.5L
2.3L

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74
Q

IRV, Vt, ERV, RV

A

3L
.5L
1.1L
1.2L

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75
Q

What reduces FRC

A

Obesity
pulmonary edema

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76
Q

How is FRC measured?

A

Nitrogen washout
Helium washin
Body pleth

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77
Q

Formula to determine how long FRC will last

A

FRC (in O2) / VO2
FRC if 100% oxygen is 2300ml
FRC if .21 O2 is 483
Vo2 always 250

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78
Q

Closing capacity vs closing volume

A

CC- The absolute volume in the lungs when airways begin to collapse
CV- The volume above RV where small begin to collapse
CC=CV+RV

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78
Q

What is the relationship between FRC and CC?

A

FRC should always be bigger, otherwise airways will close during normal breathing

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79
Q

What is the consequence of CC>FRC?

A

Shunting
Hypoxemia

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80
Q

How can you treat CC>FRC?

A

PEEP open the airways

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81
Q

How does aging effect FRC, CC, RV, and VC?

A

Increase all except VC decreases

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82
Q

The relationship of age, anesthesia and CC

A

At 30, CC=FRC when under GA (supine)
At 44, CC=FRC when supine (awake)
At 66, CC=FRC when standing (awake)

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83
Q

CaO2, DO2, VO2 formula

A

(1.34xhgbxsao2) + (pao2x.003)
Cao2 x 10 co
Cao2-cvo2 x 10 x co

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84
Q

How does HgF, methemoglobin and carboxyhemoglobin affect oxyhemoglobin dissociation curve?

A

All shift left

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85
Q

Effect of 2,3 DPG on oxyhemoglobin dissociation curve

A

Increase- right shift
Decrease- left shift

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86
Q

Glycolysis, krebs cycle, oxidative phosphorylation ATP production

A

2,2,34
All aerobic

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87
Q

What does glycolysis turn into, and then what does that turn into? (anaerobic and aerobic)

A

Glycolysis (2 atp) always turns into pyruvic acid
In anaerobic- this turns into lactic acid, then 2 atp
In aerobic, it turns into acetyl CoA, then goes to the krebs cycle (2 atp) and oxidative phosphorylation / electron transport (34 atp)

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88
Q

How much atp from pyruvate/ lactic acid pathway?

A

2

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89
Q

For what process is the hamburger shift?

A

Co2 + H2o-> H2CO3-> h HCO3
The HCO3 goes into plasma, and the Cl- goes into RBC

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89
Q

How is CO2 transported in the blood?

A

HCO3- 70%
HGB- 23%
Plasma- 7%

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90
Q

What enzyme is needed to convert CO2 + H2o into H2CO3?

A

Carbonic anhydrase

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91
Q

Haldane vs Bhor pneumonic

A

Haldan holds CO2- left
Bhor Byeeeeee O2- right

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92
Q

What things increase CO2 production?

A

Shivering
MH
Overfeeding
Seizures
Burns
Thyriod storm
Sepsis

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93
Q

What decreases CO2 elimination?

A

Hypoventilation
Airway obstruction
Increased Vd
ARDS
COPD

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94
Q

CO2 effect on heart and lungs

A

Myocardial depressant
However, it also stimulates SNS which should offset
Increases PVR (unlike SVR)

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95
Q

How much does 10mmHg CO2 decrease PH?

A

0.08 (1 for memory purposes)
Less for chronic CO2 holders- 0.03

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96
Q

Effects of K and Ca by increased CO2

A

Increases both

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97
Q

What drugs left shift CO2 ventilatory curve? R shift?

A

Aspirin
Norepi
Aminophylline
Doxapram
—-
Opioids
Volatile anesthetics
NMB

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98
Q

Do you want a left or right shift apneic thershold?

A

Left! will stimulate u to breathe sooner
Right shift will not make u breathe until co2 is higher like 75

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99
Q

What is the pace maker for breathing?

A

Old- DRG
New- (pre-botzinger) in the VRG

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100
Q

Location of Pneumotaxic and Apneic centers

A

Upper and low pons

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101
Q

Location of DRG and VRG

A

Medulla for both
Nucleus tractus solitarus
Nucleus ambigous and retro ambiguous

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102
Q

DRG vs VRG

A

Active during inspiration (rate and rhythm)
Active during expiration (important for exercise or stress)

103
Q

Pneumotaxic vs apneic

A

Pneumo- ihibits a pneumo (stops DRG)
Apneic- prevent apnea (stimulates DRG)

104
Q

What does the central and peripheral chemoreceptors respond to?

A

Central- CO2 via H influence on PH in CSF
Peripheral- Pao2 <60

105
Q

Location of central and peripheral chemoreceptors

A

Ventral side of medulla (in between DRG and VRG)
Carotid bodies, aortic arch

106
Q

Can Co2 or H diffuse the BBB?

A

Co2 only, then forms carbonic acid, the disassociates into h and hco3, then h influences central chemoreceptors

107
Q

What impairs hypoxic ventilatory response?

A

Carotid endarectomy
0.1MAF

108
Q

Where does herings nerve branch off? what is it for?

A

CN9 hypoglossal
Breathe! via the peripheral chemoreceptors

109
Q

Herin breuer inflation vs deflation reflex

A

Inflation- stops breathe 1.5L above FRC
Deflation- stops ehalation and causes deep breathes

110
Q

What stimulates J receptors

A

Tachypnea
Pulmonary embolism
CHF

111
Q

What agents increase shunt? How so?

A

MAC 1-1.5
Vasodilators
Vasoconstrictors
Hypervolemia
Excessive PEEP
NOT TIVA
Prevent HPV

112
Q

Hemmorhage effect on Paco2/etco2

A

Increases!
Think about hemmorhage bleeding out to a space without alveoli, thats deadspace!

113
Q

Boyles law pneumonic

A

Breathes in far and says “boyyyyyyy!!!” when really angry

114
Q

Wheres does dead space begin in the circuit?

A

at the y piece
If the unidirectional valve become incompetent, then the whole limb of the circuit become deadspace

115
Q

When ERV decreases, you get ___

A

shunt!
Decreases FRC which decreases air

116
Q

Vagus pathway on lungs

A

ACH
M3
IT3
PLC
(increased ca)
CONTRACTION

117
Q

Catecholamines pathway on lungs

A

B2
(AC- ATP to cAMP
Decrease Ca)
PKA
RELAX

118
Q

Respiratory drug classes

A

Bronchodilators- albuterol, anticholinergics
Anti inflammatories- steroids, leukotrine antagonists, cromolyn
Methylxanthines- aminophylline, theophylline

119
Q

Most sensitive test of small airway disease (obstruction)

A

FEF 25-75 aka MMEF

120
Q

Test to differentiate OLD vs RLD

A

FEV1:FRC
Normal with RLD
<70% in OLD

121
Q

MMV normal range

A

80-180L in one minute

122
Q

FVC normal

A

4.8L men (VC= tlc-rv)
3.8L women

123
Q

Risk factors for PPC

A

Age >60
ASA >2
CHF
COPD
Smoker
Aortic-thoracic- abdomen- nuero
GA
2h surgery
Albumin <3.5

124
Q

Smoking effects on respiratory and cardiovascular systems

A

Decreased mucus clearance
Airway hyperreactivity
Vasoconstriction
Decreased DO2

125
Q

How long of cessation in smoking before improvements in PPC?

A

6 weeks

126
Q

How to give an ARM

A

Alveolar recruitment maneuver
40cm H2o for 8 seconds
Apply peep to keep alveoli open

127
Q

Extra vs intrathoracic obstruction

A

Extra is extra worse bc u cant get anything in
So, flat on bottom but normal exhalation
Intra opposite

128
Q

Asthma triggers

A

Aspirin NSAIDS Beta blockers
URI
Cold air
Physical activity
Environment

129
Q

ABG of asthmatics

A

Respiratory alkalosis
If acidotic, impending respiratory failure

130
Q

Bad drugs for asthmatics intraoperatively

A

Histamine releasing drugs- sux, atracurium, morphine, meperdine
Ketorolac increases airway resistance
H2 blockers can cause bronchospasms- ranitidine, famotidine
Beta blockers- esmolol is best choice bc short half life and b1 specificity
Carboprost bronchoconstriction
Anticholinesterases can be negated with anticholinergics

131
Q

Treatment and doses for bronchospasm

A

1.0 fio2
Deepen anesthetic
Albuterol
Apratropium
Epi 1mcg/kg
Hydrocortisone 2-4mg/kg iv for prevention
Aminophylline
Heliox

132
Q

When I say alpha 1 antitrypsin deficiency you say

A

Emphysema
Liver disease

133
Q

Bronchitis vs emphysema

A

B- blue bloater- hypertrophied bronchioles from cigarettes smoke
E- pink puffer- pink panther- enlargement and destruction of distal airways- increased Vd,

134
Q

What level of the c spine is the cut off for regional blocks

A

Dont go above T6- impairs cough and expiratory muscle function

135
Q

Halogenated agents and bronchioles

A

Bronchodilators

136
Q

Which gasses are best and worst for airway irritation

A

Des is worst, thats why its not used for induction
Sevo is good

137
Q

Potential risk of N2o

A

Pneumothorax d/t rupture of pulmonary blebs

138
Q

Inhibition of HPV by volatile agents can be treated by

A

Increasing Fio2 to treat small shunts

138
Q

What are some things that can cause air trapping?

A

COPD- need more time to exhale
Reduced outflow/ increased resistance- secretions, bucking vent, inflammation
Large Vt, high RR

139
Q

How does air trapping affect cardiac and respiratory system?

A

C- The same as high peep- decreased venous return, hypotension
R- Barotrauma, pneumo

140
Q

Tx of air trapping

A

Disconnect circuit
Increase IE ratio (1:3 instead of 1:1)
Reduce RR
Suctioning

141
Q

RLD examples by class

A

Increased abdominal pressure- obesity, pregnancy, ascites
Acute intrinsic pulmonary edema- Aspiration, reversal of opioids, cocaine OD, re-expansion of lung
Chronic intrinsic lung disease- sarcoidosis, drug induced PF
Chest disease- Neuromuscular disorders GB AS, kyphoscoliosis, pneumo, pleural effusion,

142
Q

How do you treat RLD on vent?

A

1:1 ie (decreased)
Low Vt, rapid rate

143
Q

What is Mendelson syndrome

A

Aspiration pna
25ml
2.5 PH

144
Q

Cricoid vs thyroid pressure

A

C- controversial, lowers LES tone (below big thryoid)
T- BURP (adams aple)

145
Q

Tx for aspiration pneumonitis

A

Tilt head down, suction upper airway
PEEP to reduce shunt
Bronchodilators
IV lidocaine reduces neutrophil response
NO steroids, NO abx until and if WBC rises and fever

146
Q

Which aspiration patients can go home?

A

If they don’t experience these for 2 hours- new cough or wheeze, cxr evidence of injury, spo2 drop of 10%, Aa>300

147
Q

Hallmark sign of aspiration pneumonitis

A

Hypoxemia

147
Q

Most common bacteria in VAP

A

Pseudomonas aeruginosa
Staph aureus

148
Q

Hallmark sign of tension pneumo

A

Sudden hypoxia

149
Q

Where does trachea go in tension pneumo?

A

Opposite side

150
Q

Where to NCD for tension pneumo

A

2ICS mid clavicular
OR
4/5 IC anterior axillary

151
Q

How fast can N2O increase a pneumo size?

A

Double in 10 minutes

151
Q

What can cause a pneumo

A

Subclavian CVC
Supraclavicular, interscalene, and intercostal blocks
Neck, shoulder, chest, kidney surgeries
Barotrauma, high peep
Lung cysts, bullae

152
Q

What causes a hemothorax?

A

Bleeding of intercostal vessels

153
Q

Indications for a thoracotomy

A

Hemothorax >1L total blood loss, >200ml/hr

154
Q

Thoracotomy vs VATS indications

A

Thoracotomy >200ml/hr, initial drainage 1L
VATS when patients are stable <150ml/hr blood

155
Q

Where does lymph drain?

A

L subclavian

156
Q

Flail chest causes and presentation

A

Trauma
Paradoxical movement

157
Q

Chylothorax ____
Pyothorax ____
Fibrothorax

A

Lymph
Pus
Blood clot

158
Q

Signs of VAE

A

Air on TEE (gold standard diagnosis)
Mill wheel murmur on doppler (2nd place)
Decreased ETCO2- say it blocks the whole lung, you only get end tidal from 1 lung

159
Q

Tx of VAE

A

Durants maneuver (L lateral)
Flood surgical field with saline
Fio2 100%
Aspirate from CVC
STOP Insufflation

160
Q

PH is mean PAP over ___

A

25mmHg

161
Q

What causes PH?

A

COPD
LH dysfunction/ mitral disease
Congenital heart disease

162
Q

PVR formula and range

A

(mean PAP- PCWP )/ CO x80
Normal 150-250 d/s/cm

163
Q

What drugs increase PVR?

A

Ketamine
N2O
Des

164
Q

Epidural vs spinal time

A

Epidural is slow
Spinal is fast???

165
Q

What can cause a patent foramen ovale?

A

Elevated RA pressure (possibly from PH)
Leads to RL shunt

166
Q

Order of volatile agents that produce the most to the least CO

A

DES
Iso
Sevo

167
Q

When is methylene blue used? (not for septic shock)

A

Methemoglobinemia

168
Q

How does CO poison effect ATP production?

A

Prevents oxidative phosphorylation (34atp)
Causes metabolic acidosis

169
Q

CO poison apearance

A

CHERRY RED
NOT cyanotic

170
Q

Tx for CO poison

A

1.0 fio2 for 6h (1/2 life of co is 1-1.5 hour)
1.0 fio2 until cohgb is <5%
Hyperbaric oxygen if COHGB >25% or symptomatic

171
Q

Soda lime is hydrated to ____

A

15%, when it dries (desiccates), sevo forms compound a, which increases fire risk

172
Q

NAVEL

A

Drugs u give thru ETT
Narcan
Atropine
Vasopressin
Epi
Lidocaine

173
Q

Strong indicators for intubation
VC, Inspiratory force, PaO2, Aa, Paco2, RR

A

<15, <25, <55, >55, (<200, >450 if fio2 1.0), >60, >40

174
Q

Pillars of PPC

A

DLCO <40% (bad gas exchange)
FEV1 <40% (bad airflow)
VO2 MAX <15ml/kg/min (cardiopulmonary reserve, normal is 30-40)- if patient can climb 2 flights of stairs, then they are fine

175
Q

Indications for OLV

A

Infection prevention
Massive hemmorhage
Bronchopleural fistula
Life threatening hypoxemia
Relative- Pneumonectomy, thoracic aortic aneurysm, thoracoscopy, lobectomy,

176
Q

DLT sizes and depth from men and women, kids

A

35,37,39,41
27, 29 cm
Kids 8-9- 26, 10+-28-32

177
Q

How much fio2 in OLV?

A

Common practice is 1.0, however, .8 can prevent absorption atelectasis

178
Q

How do you confirm DLT placement?

A

FOB

179
Q

How to handle hypoxemia during OLV

A

fio2 1.0
FOB placement check
Check for cardiac output, bronchospasm, mucus plug, pneumo of dependent lung
CPAP to non-dependent lung- reduces shunt flow to top lung
PEEP to dependent lung
—-
Intermittently reinflate top lung
Clamp pulmonary artery to non dependent lung
Eliminate drugs that prevent HPV (switch to tiva)
2 lung ventilation

180
Q

What CANT the bronchial blocker do that the DLT can?

A

Prevent infection- balloon easily slides up and blocks/ contaminates both lungs
Ventilate the isolated lung
Suction secretions

181
Q

Bronchial blocker names

A

EZ
Cohen
Arndt
Uniblocker

182
Q

What is a mediastinoscopy used for? What are complications of it? Contraindications?

A

To diagnose lung cx
Hemmorhage (many vessels near)
Pneumo
Previous mediastincoscopy d/t scarring, tracheal deviation, thoracic aortic aneurysm, SVC obstruction

183
Q

Where to place pulse ox and nibp during mediastinoscopy?

A

R finger (assesses for r innominate artery injury)
LUE- maintains accurate reading even if innominate vein is compressed

184
Q

ARDS criteria

A

Within 1 week respiratory symptoms
Bilat infiltrates with no cardiac cause
PF ratio <100 = severe, 100-200= moderate, 200-300=mild

185
Q

Some causes of ards (pulmonary vs non)

A

PNA, covid, aspiration, smoke inhalation, drowning
Sepsis, trali/taco, shock, burns, bypass

186
Q

3 effects from chronic bronchitis

A

cor pulmonale from PH from HPV from low PAo2
Polycythemia (blue bloaters)
Decreased airway diameter from hypertrophy

186
Q

3 stages of ards and when

A

Exudative- 6-72h to 7 days (cap leak, hyaline membrane, alveolar destruction)
Proliferative- 7-21 days (new surfactant, new T1PC, recovery although cxr is worse still)
Fibrotic- Pt who dont recover from prolif phase, fibrosis occurs

187
Q

PH effect on PCWP

A

NORMAL
Only increases PAP

188
Q

What to do IMMEDIATELY after aspiration

A

Oral and pharynx suction (not deep bc its too late)
PEEP
Lidocaine reduces free radical production, inhibits neutrophil chemtaxis
ABX after wbc and fever

189
Q

Hypoventilation effect on NMB

A

Enhances it

190
Q

How much fluid can a pt have who is on OLV?

A

<3L in 24h

191
Q

PUSH stands for

A

Posterior pillars (tonsillar)
Uvula
Soft palate
Hard palate

192
Q

Normal inter incisor grap

A

2-3 fingers (4-6cm)

193
Q

When is mouth opening restricted? (what diseases)

A

Arthritis, TMJ disease, scar tissue, prior surgery

194
Q

Mandibular protrusion test numbers

A

1 is good (overbite)
3 is bad (underbite)

195
Q

Ideal thyromental distance

A

6-9cm

196
Q

What causes short or long TMD

A

Short- mandibular hypoplasia, small submandibular space
Long- caudal larynx

197
Q

AO joint extension degrees

A

35, hard if less than 23

198
Q

Conditions that impair AO mobility

A

Degen joint disease
Arthritis
Ankylosing spondylitis
Trauma
Klippel feil
Down syndrome
DM

199
Q

Cormack scores

A

1- complete view of glottic opening
2- partial glottis- no anterior commissure
(2a- posterior region of glottis, 2b- corniculate but not glottic opening)
3- epiglottis only
4- soft palate only

200
Q

When to use bougie?

A

Cormack sb and 3

201
Q

BONES

A

Beard
Obesity (BMI >26)
No teeth
Elderly (>55)
Sleep apnea

202
Q

LEMON

A

Difficult laryngoscopy and intubation
Look at airway (obesity, fat neck, shape of face)
Evaluate 332
Mallampati
Obstruction
Neck mobility

203
Q

RODS

A

LMA
Restricted mouth opening
Obstructed mouth airway
Distorted airway
Stiff lungs

204
Q

SHORT

A

Difficult surgical airway
Surgery prior
Hematoma
Obesity
Radiation
Tunor

205
Q

How much force for cricoid pressure

A

20N awake
40N anesthetized

206
Q

Anaphylaxis angioedema tx

A

Epi
Antihistamines
Steroids

207
Q

Ace I angioedema tx

A

DC ace i
Icatibant (bradykinin blocker)
Ecallantide (kallikrein blocker which stops bradykinin production)
FFP (metabolizes bradykinin)
C1 esterase concentrate

208
Q

Hereditary angioedema tx

A

C1 blocker concentrate prophylaxis
Similar to ace i- ffp, ecallantide, icatibant

209
Q

What is ludwigs angina?

A

Bacterial infection of the floor of the mouth
Concern of tongue displacement resulting in complete obstruction
Use awake nasal intubation or awake trach to secure airway
retrograde intubation is Cx bc u push bacteria around

210
Q

Large tongue
Small jaw
C spine anomaly

A

Big Tongue- beckwith, trisomy 21
Please get that chin- pierre robin, goldenharr, treacher collins, cri du chat
Kids try gold and gave spine abnormality- klippel feil, trisomy 21, goldenhar

211
Q

Sniffing position

A

Cervical flexion
AO extension

212
Q

HELP lines up ___ and ___

A

Sternum
External auditory meatus

213
Q

Which nerve do you damage when you jaw thrust aggressively? S&S?

A

CN7 Facial
Drooling
Chewing affected
Affected side will sag

214
Q

Which nerve is damaged when face mask is too tight?S&S?

A

CN7 facial (buccal branch)
Difficulty opening and closing lips

215
Q

What nerve is injured if ETT lays on PT face? S&S?

A

CN5 Trigeminal V1 opthalmic nerve (Supraorbital branch)
Forehead numbness, photophobia, eye pain

216
Q

Oropharyngeal airways

A

Geudel
Berman (common)
Williams (FOB)
Ovassapian (FOB)

217
Q

Nasopharyngeal airway contraindications

A

Cribiform plate injury (lefort 2 or 3, basilar fx, csf rhinorrhea, raccoon eyes, periorbital edema)
Coagulopathy, previous transsphenoidal hypophysectomy, previous caldwell luc, nasal fx

218
Q

Max pressure of ett cuff

A

25cm H2o

219
Q

What is the murphy eye?

A

A small extra opening on the end of an ett incase the ett becomes occluded
FOB, forceps, and tube exchangers can get stuck in murphys eye

220
Q

How to size ETT for peds

A

Cuffed- age/4+3.5
Uncuffed- (age/4)+4
Depth- id x 3

221
Q

Channeled vs non channeled ETT

A

Channeled- has a place to place ett
Non channeled examples- airtraq avant, pentax, king vision has both options

222
Q

Max PPV and cuff pressure for LMA

A

20cm H2O
60cm H2O (goal 40-60)

222
Q

LMA size and cuff inflation

A

1-4
1.5-7
2-10
2.5-14
3-20
4-30
5-40

223
Q

Proseal LMA/ supreme

A

Gastric tube- seals off the airway for protection

224
Q

LMA fastrach

A

Intubating
Metal handle- not suitable for mri

225
Q

LMA C trach

A

You can C (see)
has camera- like glidescope

226
Q

LMA flexible

A

More flexible- useful for head/ neck surgery

227
Q

iGel

A

Gastric port
No seal
Conduit for intubation w FOB
Safe for MRI

228
Q

LMA should not be used when:

A

Risk of regurg (full stomach, hiatal hernia, sbo, gerd, delayed gastric empty)
Obstruction
Poor lungs
High airway resistance

229
Q

What to do if patient aspirates with LMA?

A

Leave it in
Trend
fio2 1.0
Low fgf/vt
Suction thru lma
FOB

230
Q

How to minimize LMA aspiration

A

Keep sedation deep
Remove LMA as soon as pt rejects during emergence

231
Q

Least stimulating airway devices

A

Nasal airway, oral airway, LMA, FOB, DVL, comitube

232
Q

Comitube

A

Blindly placed ETT
100c in proximal pharyngeal cuff, distal only 15 cc
Sizes 37 or 41
2 lumens- esophageal and tracheal

233
Q

King laryngeal tube

A

Similar to comitube
Blind ETT
Only 1 lumen
kid sizes available

234
Q

FOB indications

A

Gold standard for difficult airway
C spine limitation- cervical stenosis, cervical fx, chiara malformation, vertebral artery insufficiency
Limited mouth opening- TMJ disease, facial burn, mandibular maxillary fixation

235
Q

Cx to FOB

A

Some say none
Wild, uncooperative pt
Lack of skills
Massive trauma/ complete obstruction

236
Q

Bullard/wu laryngoscope indications

A

Small mouth opening (minimum 7mm)
Suction
Impaired c spine
Short thick neck
Treacher collins
Pierre robin
Similar toL wuscope and upsher scope)

237
Q

Best and worse time for bougie

A

Best- 3, then 2b
Worst- 4, becomes a blind attempt

238
Q

How far to advance bougie

A

23-25 cm
If you dont feel clicks, you feel the hold up sign at 35-40cm at the carina

239
Q

When is retrograde indicated? not?

A

unstable c spine, upper bleeding, failed awake intubation
NOT for emergency as it takes long- its not a cric, cant see cric, mass, tumor, coagulopathy, infection in neck

240
Q

When is lighted stylet indicated and not?

A

Good when u can mask but not DL , anterior airway, small mouth opening
NOT for emergency, thick neck

241
Q

3 invasive airways

A

Percutaneous Cric/jet vent- under 50psi, upper airway must be patent for exhalation
Surgical cric- contraindicated in <6yr olds
Trach- 2/3 tracheal ring, fire risk, no cx,

241
Q

How to retrograde intubate

A

14-18g needle into cricothyroid
Aspirate for air to confirm
Place wire thru and cephalad

242
Q

When is deep extubation indicated? not?

A

Asthma-decreased airway irritation
and
CAD-Decreases SNS stimulation
NOT good for sleep apnea. or parkinsons (aspiration)

243
Q

How to prevent complications of awake extubation (meds)

A

BB< CCB, vasodilators prevent SNS stim
Lidocaine and opioids prevent coughing

244
Q

What to use for patient at high risk of failed extubation?

A

Airway exchange - pt maintains airway for 72 hours post extubation- think of it as a place holder
AEC= etco2, jet ventilation, oxyhem insufflation

245
Q

Glidescope degree

A

60

246
Q

First step once ur in the emergency pathway of difficult airway

A

Call for help

247
Q

If LMA fails, whats next step

A

Sniffing position

248
Q

Fastest onset anesthetic for awake intubation

A

Benzocaine- 1 minute
Lidocaine- 15 minutes

249
Q

What is oxymetolazine

A

Vasoconstrictor for FOB nasal intubation

250
Q

What is the ring adair elwyn tube?

A

RAE
Used to keep circuit out of the way of the surgical field

251
Q

How big of an ett can an lma take? Fastrach?

A

7
8.5

252
Q

Troop elevation pillow

A

Used with HELP for obese to help breathing

253
Q

1st vs 2nd sga

A

2nd have gastric drain

254
Q

What sits on top of the aryetnoids

A

Corniculates

255
Q

Contraindications for cricoid pressure

A

Active vomiting
C spine fx
Laryngeal fx

256
Q

What size tube for a full term infant

A

3 cuffed
3 uncuffed for preme

A1 (122 decks)

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