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Week 1 Flashcards

1
Q

Anatomical functions of the nose

A
  • Inhaled air warmed by conchae and septum
  • Filtration and obstruction of foreign particles
  • Assist with phonation and sensation of smell (CNI)
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2
Q

Anatomical structure of pharynx

A
  • Connects nose, mouth, larynx and middle ear.

- Posterior oral structure.

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3
Q

Macintosh blade

A

Curved blade
Indirectly grabs/lifts epiglottis
-Vallecula is space anterior to the epiglottis at root of tongue. Where blade is place

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4
Q

MIller Blade

A
  • Straight blade

- Directly grabs the epiglottis

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5
Q

Function of pharynx and tonsils

A
  • assists phonation
  • initiates deglutition (swallowing)
  • defense against infectious pathogens
  • enlarges with inflammation and tumor
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6
Q

Waldeyer’s Rings

A
  • ringed arrangement of lymphoid tissue in pharynx

- includes palatine tonsil (what we normally think of tonsils) and lingual tonsil (at back of tongue)

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7
Q

Mallampati classification

A
  • used to predict ease of endotracheal intubation
  • Class 1-4
  • Class 1-2: easier intubation
  • Class 3-4 harder intubation
  • Class 1: full view of uvula, tonsils pillars, and soft palate
  • Class 2: partial view of uvula or uvular base, partial view of tonsils, soft palate
  • Class 3: soft palate only
  • Class 4: hard palate only
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8
Q

Glossoptosis

A

Collapse of oropharynx, tongue dropping posteriorly

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9
Q

Macroglossia is

A

Large tongue

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10
Q

Micrognathia

A

Small jaw, mandible

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11
Q

Prognathism

A

Protruding jaw, mandible

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12
Q

Microgenia

A

Small chin

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13
Q

Microstomia

A

Small mouth

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14
Q

Malocclusion

A

Upper protrusion “buck teeth”, overbite

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15
Q

Difference in anatomic location of larynx in adults vs children

A
  • Adults: located anterior to 3rd-6th cervical vertebrae

- At birth: level at C3-4

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16
Q

Function of the Larynx

A
  • Airway protective sphincter
  • Closes off airway during swallowing
  • Supports vocal cords
  • modulates speech
  • provides autoPEEP
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17
Q

What is the narrowest portion of the adult upper airway

A

Rima glottidis

-This is the opening between the true vocal cords and the arytenoid cartilages of the larynx

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18
Q

What are the 3 compartments of the larynx?

A

Supraglottis compartment: above vocal cords

 - Epiglotis
 - False vocal cords

Glottis (Ventricle): at cords

 - True vocal folds
 - Rima glottidis

Infraglottis Compartment: below cords

 - Cricoid cartilage
 - Trachea
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19
Q

Arytenoid cartilage

A

Allows the vocal folds to be tensed, relaxed, or approximated

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20
Q

Extrinsic muscles of the larynx

A
  • attach larynx to bone or pharynx

- move larynx during swallowing

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21
Q

Intrinsic larynx muscle sets

A
  • two sets of intrinsic larynx muscles
    • one set alter the size and shape of the larynx
      • innervated by the Recurrent Laryngeal Nerve (RLN)
    • other set move the true vocal cords
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22
Q

In the second set of intrinsic larynx muscles, which one is not innervated by the RLN?

A

Cricothyroid

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23
Q

What are the functions of the extrinsic muscles of the larynx

A
  • larynx moves upward during swallowing

- as the epiglottis goes down

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24
Q

3 important laryngeal membranes

A
  1. Thyroid membrane
  2. Quadrangular membrane
  3. Cricothyroid membrane
    • inferior to true vocal cords
    • emergency airway: where a cric would be completed
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25
Q

Recurrent laryngeal nerve (RLN)

A
  • Vagus new branch (CN X)
  • provides sensory innervation of infraglottis
  • motor innervation to all of larynx except cricothyroid muscle
    • Stimulation causes abduction of VC
    • damage to RLN causes VC addiction
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26
Q

Superior Laryngeal Nerve

A
  • Vagus nerve X
  • Divides into 2 nerves
    • Internal SLN: stimulation causes laryngospasm
    • External SLN: motor innervation of cricothyroid muscle
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27
Q

Vallecula

A
  • Space anterior to the epiglottis at root of tongue

- Where Mac blade indirectly lifts the epiglottis by placing pressure on the hyoepiglottic ligament

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28
Q

Epiglottis positioning

A

Breathing:
-positioned upright to allow air passage during inspiration

Swallowing

 - epiglottis covers glottis to protect airway
 - larynx raised upward by muscular contractions
 - epiglottis pressed downward by base of tongue
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29
Q

Vocal cords

A

False vocal cords

 - upper vestibular folds
 - close during swallowing

True vocal cords
-responsible for vocal sounds

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30
Q

Abduction of vocal cords

A
  • move apart
  • passive resting motion
  • abduct during inspiration
  • posterior cricoartynoid is only abductor muscle
  • RLN stimulation opens vocal folds
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31
Q

This is the only abductor muscle of the vocal cords

A

Cricoarytenoid

Innervated by RLN

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32
Q

Adduction of vocal cords

A
  • move together
  • RLN responsible for adduction of VF
  • SLN tenses the VF via the cricothyroid muscle
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33
Q

These airway structure are involved in the modification of sound

A
  • pharynx/oral cavity

- tongue/lips

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34
Q

What role do the vocal cords play in sound modification?

A
  • pitch
    • control VC tension
  • intensity
    • loudness related to force of air passing through VC
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35
Q

Sellick Maneuver

A
  • AKA cricoid pressure
  • cricoid ring is a complete ring of cartilage found between the cricothyroid membrane and trachea.
  • pressure placed on cricoid posteriorly closes the esophagus
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36
Q

What is purpose of cricoid pressure

A
  • prevents gastric regurgitation
  • aligns glottis opening during intubation
  • prevents ventilation of air into stomach
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37
Q

What is the narrowest part of upper airway in children?

A

Cricoid ring

 - cone shaped, narrowing inferiorly
 - until age 8 years

Reason why will sometimes use unruffled ETT’s in children

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38
Q

What are conduction airways?

A
  • do not participate in gas exchange, ventilation, but not perfusion.
  • portion of each breath wasted.
  • anatomical dead space, portion of each breath is wasted ventilation
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39
Q

Endotracheal tube reduces dead space in upper airway to about how much?

40
Q

What percentage of normal breath remains in airway?

41
Q

What is acinus?

A
  • includes all respiratory structures
    • respiratory bronchioles
    • alveolar ducts and sacs
    • alveoli

-site of gas exchange

42
Q

Gas exchange in the alveoli occurs by what proceeds?

A

Simple diffuse

43
Q

What are PS-CC?

A
  • pseudostratified ciliated columnar epithelium
  • move mucous blanket and trapped particles out
  • disabled by smoke
44
Q

what are goblet cells?

A
  • release mucous granules into airway lumens
  • creates mucous blanket
    • moistens air
    • traps particles
  • increases with injury and infection
45
Q

What are Clara cells?

A
  • Located in smaller bronchioles which lack goblet cells
  • produce mucus-poor, water material
    • combines with surfactant and mucus
      • assist with cleaning small airways
      • reduces surface tension in bronchioles
46
Q

What are the cell types of the alveolar wall?

A
  • Type I Pneynocyte
    • covers 95% of alveolar wall
    • designed to increase alveolar surface area
    • facilitates gas exchange
    • unable to regenerate
  • Type II Pneumocyte
    • secretes surfactant: mixes with water molecules and diminishes surface tension which reduces force necessary to inflate alveali, prevents alveolar collapse during expiration. Important in neonate.
    • regenerate type I pneumocyte
47
Q

Functions of the larynx

A
  • protect the lower airway from aspiration
  • latency between the hypopharynx and trachea
  • protective gag and cough reflexes
  • phonation
48
Q

What is the function of the bronchioles?

A

Provide humidification and warming of inspired air as it passes to the alveoli

49
Q

What is simple diffusion

A

Allows for gaseous exchange between airspace and pulmonary capillaries

50
Q

What type of cell make up 95% of the alveolar wall?

A

Type I Pneumocyte

51
Q

What are Type I Pneumocytes?

A
  • squamous epithelial Cell
  • unable to regenerate
  • increase alveolar surface area
  • control fluid movement between interstitium and airspace
  • simple diffusion takes place here
52
Q

What are Type II Pneumocytes?

A
  • secretes surfactant*
  • repairs alveolar epithelium after injury
  • regenerate PC I
53
Q

What do the intrinsic muscles for the larynx do?

A

Controls the movement of the laryngeal cartilages of the vocal cords

54
Q

Which intrinsic muscle elongates the vocal cords?

A

Cricothyroid

*this is the only intrinsic muscle innervated by the SLN

55
Q

What intrinsic muscle shortens the vocal cords?

A

Thyroarytenoid

56
Q

What intrinsic muscle abducts the vocal cords?

A

Posterior cricoarytenoid

57
Q

What intrinsic muscle adductor the vocal cords?

A

Thyroarytenoid

58
Q

What laryngeal muscle is responsible for laryngospasm reflex?

A

Cricothyroid

59
Q

The superior Laryngeal Nerve branches off of what nerve?

A

Vagus nerve

60
Q

At what level do the superior laryngeal nerve branch in the the internal and external branches?

A

At the level of the hyoid

61
Q

What is the clinical presentation of superior laryngeal nerve injury?

A

Injury to the trunk of the SLN or the external branch causes hoarseness

62
Q

What nerve does the Recurrent Laryngeal Nerve branch from?

A

Vagus nerve

63
Q

What is the clinical presentations of Recurrent Laryngeal nerve injury?

A
  • acute bilateral paralysis of vocal cord abductors
    • this pt is at risk for stride and respiratory distress
  • unilateral injury results in ipsilateral paralysis of cord abductors. Does not cause respiratory distraess
  • chronic injury is well tolerated and does not cause respiratory distress
64
Q

What can cause injury to the RLN, either side?

A
  • external pressure from ETT or LMA
  • thyroid surgery
  • parathyroid surgery
  • neck stretching
  • tumor
65
Q

What can cause RLN injury, left side only?

A
  • PDA ligation
  • alert atrial enlargement (mitral stenosis)
  • AAA
  • thoracic tumor
66
Q

What are the 3 key airway blocks?

A
  • glossopharyngeal
  • superior laryngeal
  • trantracheal
67
Q

What forms the main support of the larynx and attaches to the thyroid cartilage?

A

Hyoid bone

68
Q

What does the thyroid membrane do?

A

Attaches the larynx (specifically the thyroid cartilage) to the hyoid bone

69
Q

What does the cricothyroid membrane do?

A
  • Attached the cricoid and thyroid cartilages
  • where an emergency airway is secured
  • where the needle of a tracheal block is placed
70
Q

What are the corniculate and cuneiform cartilages?

A

The cuneiform cartilages are lateral to the corniculates

Often mistaken for the arytenoids during direct laryngoscopy (these change be seen)

71
Q

What does the epiglottis cartilage do?

A

Provides a mechanical barrier to the pharynx and laryngeal opening

-contains the vallecula, space between the base of the tongue and the anterior side of epiglottis

72
Q

What is the thyroid cartilage?

A
  • provides structure and protection to the larynx

- forms the Adam’s apple

73
Q

This is the only complete cartiginous ring in the airway

A

The cricoid

74
Q

According to apex, what are the 2 narrowest parts of the pediatric airway?

A
  • vocal cords (dynamic)

- cricoid ring (fixed)

75
Q

What is Larson’s Maneuver?

A

-the application of firm pressure to the laryngospasm notch located just behind the earlobe. Pressure is applied bilaterally towards the base of the skull. Pressure should be applied for 3-5 seconds, then released for 5-10. Repeat until laryngospasm broken

This will:

  • displace the mandible anteriorly to help open the airway
  • often breaks the laryngospasm by causing the lightly anesthetized pt to sigh
76
Q

What are pre-anesthetic risks of laryngospasm?

A
  • active or recent upper airway infection
  • exposure to second hand smoke
  • reactive airway disease
  • GERD
  • age < 1 year
77
Q

What are intra-op risks of laryngospasm?

A
  • light anesthesia with concurrent airway manipulation
  • saliva or blood in airway
  • hyperventilation
  • hypocapnia
  • surgical procedures involving the airway: tonsillectomy, adenoidectomy, nasal/sinus, laryngoscopy, bronchoscopy, palatal
78
Q

Signs of laryngospasm

A
  • inspiration stridor
  • suprasternal and supraclivicular retraction during inspiration
  • “rocking horse” appearance of chest wall
  • increased diaphragmatic excursion
  • lower rib flailing
79
Q

What factors reduce the likelihood of layngospasm?

A
  • avoidance of airway manipulation during light anesthesia
  • CPAP 5-10 cm/H2O during inhalation induction as well as immediately post extubation
  • tracheal extubation when deeply anesthetized or fully awake not in-between
  • Laryngeal lidocaine
  • IV lidocaine prior to extubation
  • hypercapnia/hypoventilation
  • PaO2 < 50mmHg
80
Q

How do you treat laryngospasm?

A
  • FiO2 100%
  • Remove noxious stimulation
  • deepen anesthesia by increasing concentration of inhalation agent or with small dose of propofol or lidocaine
  • CPAP 15-20 cm/H2O while instituting maneuvers to open the airway (head extension, chin lift, Larson’s maneuver)
  • succinylcholine IV or submental
    • children <5 should receive atropine with succinylcholine to prevent bradycardia
81
Q

What is Valsalva’s maneuver?

A
  • exhalation against a a closed glottis or obstruction

- risk: increased pressure in the thorax, abdomen, and brain

82
Q

What is Muller’s maneuver?

A
  • inhalation against a closed glottis or obstruction

- risk: subatmospheric pressure in the thorax ——-negative pressure pulmonary edema

83
Q

What are the cartilaginous structures of the larynx?

A
  • 3 unpaired
  • 3 paired

*framework of 9 structures

84
Q

What is the carina?

A

Divides the 2 bronchi

  • about 25cm from the teeth
  • at level of T5-7

*generally incubate 21-23cm at teeth

85
Q

Which bronchial main stem is straighter?

86
Q

Where does the conduction airway end?

A

Respiratory bronchiole

87
Q

What type of alveolar cell increases alveolar surface area?

A

Type 1 pneumocyte

88
Q

Up until the age of 5years, both bronchi do what?

A

Branch off from the long axis of the trachea at 55 degrees

89
Q

Things that increase as the airway bifurcates:

A
  • number or airways
  • cross-sectional area
  • muscular layer
90
Q

Things that decrease as the airway bifurcates:

A
  • airflow velocity
  • amount of cartilage
  • goblet cells (produce mucus)
  • ciliated cells (clears mucus)
91
Q

Mnemonic to remember muscles that abduct the vocal cords

A

Please Come Apart

Posterior CricoArytenoid

92
Q

Mnemonic for muscles that adduct vocal cords

A

Let’s Close Airway

Lateral CricoArytenoid

93
Q

During anesthesia, the airway can obstruct in what places?

A
  • soft palate: relaxation of the tensor palatine muscle
  • tongue: relaxation of the genioglossus muscle
  • epiglottis: relaxation of the hyoid muscles
94
Q

The carina corresponds with what anatomical landmark?

A

Angle of Louis

95
Q

Mnemonic to remember which muscles tense and relax vocal cords

A

CricoThyroid: cords tense

ThyroaRytenoid: they relax

Respiratory (4 decks)

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