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614 General Principles Of Anesthesia > Week 3- Airway & Airway Equipment > Flashcards

Week 3- Airway & Airway Equipment Flashcards

1
Q

in a person with normal lungs, breathing can be performed exclusively by

A

the diaphragm

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2
Q

in an adult, the orotracheal tube moved how much with head and neck flexion/extension

A

3.8 cm but as much as 6.4 cm

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3
Q

movement of the orotracheal tube in infants and children

A

displacement of even 1 cm can move the tube above the vocal cords or below the carina

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4
Q

a. length of adult mainstem bronchus before branching into lobar bronchi?
b. name some variations from that normal

A

a. 2.5 cm
b. 10% adults right upper bronchus departs from right main stem bronchus < 2.5 cm below carina & 2-3% of adults, the right upper lobe bronchus opens directly into the trachea, above carina

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5
Q

when lung compliance is reduced, what does the body do to achieve the same tidal volume (Vt)

A

large changes in pleural pressure

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6
Q

why is spontaneous respiratory effort the most sensitive clinical index of lung compliance

A

patients with low lung compliance breathe with smaller Vt and more rapidly

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7
Q

at what PaO2 values are carotid and aortic bodies stimulated

A

60-65 mmHg

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8
Q

T or F: the response of peripheral receptors will reliably increase the ventilatory rate or minute ventilation to herald the onset of hypoxemia during general anesthesia and recovery

A

F… it does not reliably do that

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9
Q

3 etiologies of hyperventilation

A
  • arterial hypoxemia
  • metabolic acidemia
  • central etiologies
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10
Q

examples of illnesses that may cause hyperventilation

A

intracranial HTN, hepatic cirrhosis, anxiety, pharmacological etiologies

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11
Q

increases in dead space affect:
increases in physiologic shunt effects:

A

CO2 elimination
arterial oxygenation

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12
Q

alveolar to dead space ratio:

a. positive pressure ventilation
b. spontaneous ventilation

A

a. 1:1

b. 2:1

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13
Q

why should minute ventilation during mechanical vent support be greater than during spontaneous ventilation

A

to achieve same PaO2 because the ratio of alveolar to dead space is 2:1 and during positive pressure ventilation, the ratio of alveolar to dead space is 1:1

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14
Q

what causes the difference between PaCO2 anD PETCO2

A

Due to dead space ventilation and the most common cause is decreases cardiac output

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15
Q

calculating shunt fraction tells you

A

the lungs efficiency in oxygenating the arterial blood

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16
Q

what takes into account the contribution of mixed venous blood to arterial oxygenation

A

index of oxygenation

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17
Q

what happens when functional lung capacity is reduced

A

lung compliance falls (causing tachypnea) and venous admixture increases, creating arterial hypoxemia

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18
Q

when should preoperative pulmonary tests be administered

A

to ascertain the presence of reversible pulmonary dysfunction (bronchospasm) or to define severity of advanced pulmonary disease

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19
Q

how long before surgery should smokers be advised to quit and why

A

2 months, the decrease postop pulmonary complications (PPCs)

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20
Q

what body area causes the highest risk for PPCs

A

nonlaparoscopic upper abdominal operations and lower abdominal and intrathoracic operations

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21
Q

most important postoperative prevention of PPCs

A

early ambulation

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22
Q

describe the thorax

A

shape: truncated cone
sternal angle at horizontal plane and passes thru vertebral column at T4 and T5

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23
Q

what does the horizontal plane of chest separate

A

superior and inferior mediastinum

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24
Q

during ventilation, where do the predominant changes in thoracic diameter occurs

A

in the anterioposterior direction in the upper thoracic region and in lateral or transverse direction of lower thorax

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25
Q

what fatigues the muscles of ventilation

A

inadequate oxygen, poor nutrition, increased work secondary to COPD with gas trapping and airway resistance

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26
Q

ventilatory muscles

A

diaphragm
intercostal muscles
abdominal muscles
cervical strap muscles
sternocleidomastoid muscles
large back and intervertebral muscles of the shoulder girdle

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27
Q

what happens when work of breathing increases

A

ab muscles assist with rib depression and increase intra-abdominal pressure to facilitate forced exhaustion causing the “stitch” feeling

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28
Q

what is a “side stitch caused by”

A

forced exhalation during increased work of breathing

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29
Q

during an increased work of breathing, what muscles assist and what do they do

A

cervical strap muscles elevate the sternum and upper portions of the chest to optimize the dimensions of the thoracic cavity

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30
Q

when you are at Vmax of breathing what muscles assist

A

large back and paravertebral muscles of shoulder girdle

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31
Q

most powerful muscles of expiration

A

abdominal wall muscles

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32
Q

the muscle that assists with =coughing

A

abdominal

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33
Q

what do fatique-resistant fibers of lungs do

A

50% of diaphragmatic muscle fibers
endurance phenomenon- slow twitch response to electrical stimulation requiring enough force to generate subatmospheric pressure in intrapleural space

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34
Q

the unique dual function of lungs

A

endurance and explosive

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35
Q

in lung fibers, what creates endurance units

A

high oxidative capacity of the fibers

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36
Q

the most important inspiratory accessory muscle

A

cervical strap muscles

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37
Q

what is an example of when the cervical strap muscles may become to primary inspiratory muscles

A

c-spine cord transection

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38
Q

why do the visceral and parietal pleurae oppose each other

A

create a potential intrapleural space where the pressure decreases when diaphragm descends and rib cage expands

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39
Q

the air is left after passive expiration Is called

A

functional residual capacity (FRC)

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40
Q

subambient pressure at FRC

A

-2 to -3 mmHg

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41
Q

the 3 lung parenchyma categories and what they do

A
  1. conductive airways- gas transport NO gas exchange (trachea, mainstem bronchi, bronchioles)
  2. transitional airways- gas movement &limited gas diffusion and exchange
  3. smallest airways- gas exchange
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42
Q

the # of alveoli by age 8 or 9 vs at birth

A

300 million vs 24 million

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43
Q

the surface area in the lungs for gas exchange

A

70 m^2

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44
Q

compare right vs left mainstem

A

right= > diameter than left, 25 degree angle from the trachea
left= < in diameter and 45 degree angle from trachea

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45
Q

the angle of the right and left mainstem in kids < 3 years old

A

55 degrees

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46
Q

in a supine patient, why is aspiration most likely it RUL bronchus

A

RUL bronchus dives almost directly posteriorly at ~ 90-degree angle from the right main stem

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47
Q

left main stem bronchus length before branching the LUL and lingula

A

5 cm

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48
Q

last airway component that is incapable of gas exchange and its size?

A

1 mm and terminal bronchioles

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49
Q

first site of gas exchange when descending airway

A

respiratory bronchioles

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50
Q

describe the final division of the alveolar ducts

A

they terminate in alveolar sacs that open into alveolar clusters

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51
Q

two functions of the alveolar-capillary membrane

A
  • transport respiraoptyr gases (O2 & CO2)
  • production of a variety of local and humoral substances
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52
Q

the alveolar capillary membrane produces ________ and is responsible for ____________

A

surfactant

electrolyte balance

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53
Q

why do we need surfactant

A

so lung doesn’t collapse

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54
Q

2 major circulatory systems involving the lungs

A

pulmonary vascular system

bronchial vascular system

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55
Q

the pulmonary vascular system delivers_________ blood from the ___________ to the ___________ via ___________

A

mixed-venous
right ventricle
pulmonary capillary bed
two pulmonary arteries

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56
Q

describe what happens after the gas exchange in the pulmonary capillary bed

A

blood returned to left atrium via 4 pulmonary veins

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57
Q

what system provides metabolic and oxygen needs of alveolar parenchyma

A

Pulm. capillary system

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58
Q

what system provides oxygen to the conductive airways and pulmonary vessels

A

bronchial arterial system

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59
Q

a “normal” shunt of 2-5% total cardiac output occurs where

A

anatomic connections between bronchial and pulmonary venous circulations

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60
Q

the response of the lungs to external forces is governed by what two things?

A
  1. ease of elastic recoil of the chest wall
  2. resistance to gas flow in airways
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61
Q

the FRC represents what about gas volume in the lungs

A

the gas volume in lungs when outward forces= inward forces

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62
Q

in an upright adult, the difference in intrapleural pressure from top to bottom of lung

A

7 cm H2O

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63
Q

what is the “simplified” difference between restrictive lung disease and obstructive lung disease

A

R: trouble getting air in
O: trouble getting air out

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64
Q

decreased lung complaince in restrictive pulmonary diseases results in ________ FRCs

A

smaller

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65
Q

what would the graph of the sum or pressure-volume relationships of the thorax and lung look like

A

sigmoidal curve

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66
Q

T or F: CPAP cannot increase the FRC

A

F- It Can! :)

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67
Q

most common examples of diseases with high lung compliance `

A

Chronic obstructive lung disease and acute asthma

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68
Q

what happens to FRC and Vt in restrictive disease

A

less FRC and less Vt– think about it… cant get air in!

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69
Q

in restrictive lung disease, how does the body compensate for changes in FRC and Vt

A

increases RR

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70
Q

what happens to FRC in obstructive lung disease and why

A

increases because lacking elastic recoil

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71
Q

how can compliance and inspiratory elastic work be measured

A

via a single breath

by measuring airway pressure (Paw), intrapleural (Ppl) pressure and Vt

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72
Q

t/f: there is laminar flow but no turbulent flow in respiratory tract

A

F: there is both in the respiratory tract

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73
Q

the velocity of laminar flow and what it sounds like

A

zero at wall and max at center

usually inaudible

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74
Q

flow that is usually audible

A

turbulent flow

75
Q

in laminar flow, relationship between resistance and gas flow rate

A

inversely proportional

76
Q

4 conditions that change laminar flow to turbulent flow

A
  1. high gas flow
  2. sharp tube angles
  3. branching in tube
  4. decreased tube diameter
77
Q

in turbulent flow, the relationship between resistance and gas flow rate

A

resistance increases in proportion to flow rate

78
Q

things that can increase airway resistance (name 6)

A
  1. bronchospasm
  2. mucosal edema
  3. mucous plug
  4. epithelial desquamation
  5. tumors
  6. foreign bodies
79
Q

changes in the aging lung and chest wall

A
  • decreased lung recoil creating increased residual volume and FRC
  • chest wall compliance diminishes this increasing work of breathing
  • decreased muscle mass
80
Q

respiratory muscle strength decreases with aging and is strongly correlated with

A

nutritional status and cardiac index

81
Q

with aging, what happens to the respiratory centers in the CNS

& in what situations would their ventilatory response be diminished

A

decreases sensitivity to hypoxemia and hypercapnia

HF, airway obstruction, pneumonia

82
Q

define breathing

A

act of inhaling and exhaling

83
Q

define ventialtion

A

movement of gas in and out of lungs

84
Q

________ occurs when energy is released from organic molecules

A

respiration

85
Q

Humans breath to __________ and __________ to _____________

A

ventilate
ventilate
respire

86
Q

Define eupnea

A

continuous inspiration and expiration movement without ionterruption

87
Q

define apnea

A

no breathing, no ventilatory effort

88
Q

define apneustic ventilation and give an example

A

cessation of ventilatory effect with lungs filled to total lung capacity–> example is when harvesting lungs for donation, will fill lungs to capacity and then clamp to remove

89
Q

define BIOT

A

ventilatory gaps interposed between periods of ventilation aka agonal breathing

90
Q

where where the most basic ventilatory control centers in brain

A

medulla oblongata

91
Q

the inspiratory centers that reside in the __________ are located in the _________

A

dorsal respiraotyr group (DRG)

dorsal medullary reticular formation

92
Q

the source of ventilatory rhythmicity/ the pacemaker of the respiratory system

A

DRG

93
Q

the expiratory coordinating center

A

ventral respiratory group (VRG)

94
Q

where is the VRG located

A

ventral medullary reticular formation

95
Q

what do the peripheral chemoreceptors vs the CNS receptors respond to

A

PC: lack of O2

CNS: changes in PCO2, pH, acid-base disturbaces

96
Q

what are the peripheral chemoreceptors composed of and where are they located

A

carotid and aortic bodies

cartoid= bifurcation of the common carotid artery (predominantly ventilatory effects)
aortic= scattered about aortic arch and branches (predominantly circulatory effect)

97
Q

how does neural output from the carotid bodies reach the central respiratory centers

A

the afferent glossopharyngeal nerves

98
Q

carotid bodies are stimulated by ____________ and stimulate the central receptors to increase ___________

A

decrease in PaO2 and pHa (NOT saturation)

minute ventilation

99
Q

80% of ventilatory response to inhaled CO2 originates where

A

central medullary centers

100
Q

acid-base regulation is related primarily to

A

chemosensitive receptors in the medulla

101
Q

what is a normal PFT

A

depends on size/height of individual

102
Q

why do we put a patient on 100% oxygen prior to intubation

A

to de-nitrogenate them. this buys time when you have a difficult airway

103
Q

what is VQ

A

ventilation and perfusion–> how well its working

104
Q

what is tidal volume (Vt)
&
What are normal values

A

volume of gas that moves in/out of lungs during quiet breathing

6-8 mL/kg

105
Q

what happens to Vt when there is decreased lung compliance

A

Vt decreases due to reduced ventilatory muscle strength

106
Q

what is vital capacity?
&
what are the normal values

A

correlates with deep breathing and effective coughing

60 mL/kg

107
Q

what happens to vital capacity in restrictive lung diseases

A

decreased

108
Q

examples when vital capacity may be reduced

A

pleural effusion, pneumothorax, pregnancy, large ascites, ventilatory muscle weakness

109
Q

what is the inspiratory capacity?
&
what happens to it in the presence of extrathoracic airway obstruction?

A

largest volume of gas that can be inspired from the resting expiratory level

decreased

110
Q

what is residual volume

A

gas remaining within the lungs at end of forced maximal expiration

111
Q

the resting expiratory volume of the lung and is the primary determining of oxygen reserve in humans when apnea occurs

A

FRC

112
Q

diseases that reduce FRC and lung compliance

A
  • Pulm. fibrotic processes
  • Acute lung injury
  • Pulmonary edema
  • Atelectasis

-pregnancy
-obesity
-pleural effusion
- posture

PAPA & POPP reduce FRC

113
Q

what happens to FRC when a healthy patient is supine

A

decreases 10%

114
Q

what is forced vital capacity (FVC)

A

volume of gas that can be expired as forcefully and rapidly as possible after maximal inspiration

115
Q

what happens to FVC in restrictive and obstructive lung diseases

A

decreased in both

116
Q

FVC values associates with PPCs

A

< 15 mL/kg

117
Q

why is FEVt a meaure of flow

A

records volume of gas expired over time

118
Q

what is forced expiratory volume (FEVt)

A

forced expiratory volume of gas over a given time interval during the FVC maneuver

119
Q

what happens to FEVt values in obstructive/restrictive lung diseases

A

decreased in both

120
Q

what is forced expiratory flow (FEF25-75%)

A

average forced expiratory flow during the middle half of the FEV maneuver

121
Q

another name for the FEF25-75% test

A

maximum mid-expiratory flow rate

122
Q

normal vakue for FEF25-75% for healthy 70 kg man

A

4.7 L/sec (or 280 L/min)

123
Q

what is included in the upper airway

A

nasal and oral cavities
pharynx
larynx
trachea
principle bronchi

124
Q

what is included in the laryngeal skeleton

A

3 paired and 3 unpaired (9 total) cartilages

125
Q

what contains the vocal cords

A

laryngeal skeleton

126
Q

what are the 2 muscle groups of the larynx and what do they do

A

extrinsic- move larynx as a whole
intrinsic- move the various cartilages

127
Q

what nerve innervates the larynx

A

superior and recurrent laryngeal nerves, which are branches of the vagus nerve

128
Q

the recurrent laryngeal nerves suplly all of the _____________ muscles of the larynx… with the exception of __________

A

intrinsic

cricothyroid muscle

129
Q

trauma to what nerve group can result in vocal cord dysfunction

A

recurrent laryngeal nerves

130
Q

unilateral damage to the recurrent laryngeal nerve can cause…

A

causes hoarseness makes aspiration more likely and could cause airway obstruction

131
Q

bilateral injuiry to recurrent laryngeal nerves can cause:

A

complete airway obstruction d/t fixed cord adduction–> could be surgical emergency

132
Q

where is the cricothyroid membrane

A

1-1.5 finger breaths below the laryngeal prominence (thyroid notch)

133
Q

how would you place a cricothyrotomy

A

inferior 1/3 and directed posteriorly

134
Q

describe the trachea of an adult

A
  • 15 cm
  • 17-18 C-shaped cartilages w/ a membranous posterior aspect overlaying esophagus
  • 1st ring is anterior to the 6th cervical vertebra
135
Q

what spinous process lines up with the carina

A

T5

136
Q

lt airway management accounts for what % of anesthetic deaths

A

2.3-16.6%

137
Q

is it safe for a patient to chew gum before surgery? why or why not

A

chewing gum increases hydrochloric acid secretion which increases gastric content and if that ends up in the lungs, it can cause a chemical pneumonitis

138
Q

what is the 3-3-2 rule

A

3 fingers between incisors
3 fingerbreadths from thyroid to mentum

139
Q

several minutes of 100% O2 may support _____ minutes of apnea before desaturation would occur

A

8

140
Q

explain mallampati classifications

A

class I- uvula, pillars, soft palate
class II- pillars, soft palate
Class III- soft and hard palate
Class IV- only hard palate

141
Q

most common reason for not achieving FiO2

A

loose fitting mask

142
Q

what is a laryngospasm

A

reflex closure of the vocal folds as a result of:
- foreign body
- saliva
- blood
- vomitus touching glottis
- light plane of anesthesia

143
Q

non-cariogenic pulmonary edema is the result of

A

spontaneous breath against a closed glottis

144
Q

how to treat laryngospasms

A
  • remove the offending stimulus
  • continuous positive airway pressure
  • deepening of anesthesia
  • succinylcholine
145
Q

what should cuff of the supraglottic airway be blown up to

A

to create a seal that allows positive pressure ventilation up to 20 cm of H2O pressure

146
Q

how to decide what size LMA

A

the largest size that will fit in the mouth comfortably

147
Q

T or F: The LMA protects the trachea from regurgitation

A

F- it does not

148
Q

high risk for aspiration with LMA

A
  • obese
  • trendelenberg
  • upper abdomen surgery
  • intraperitoneal insufflation
  • positive pressure ventilation > 20 mmHg
  • full stomach
  • GERD
  • Bowel obstxn
149
Q

when should SGA be pulled

A

either fully awake or deeply anesthetized NOT in between (could spasm)

150
Q

what two things MUST you have to intubate

A

suction and oxygen

151
Q

provides sensory innervation from the level of the vocal cords to the underside of the epiglottis

A

the finternal branch of the superior laryngeal nerve (branch of vagus)

152
Q

stimulation of the internal branch of the superior laryngeal nerve (branch of the vagus) can cause

A

vagal response: laryngospasm, bradycardia, HTN

153
Q

when is the miller blade considered a better option

A

pt with small mandibular space, large incisors, and large epiglottis

154
Q

when is macintosh blade considered better option

A

when there is little room to pass the tube

155
Q

placement of a Mac blade and what is the shape

A

in vallecula and curved

156
Q

what can you do to confirm ETT placement

A
  • visualize ETT thru cords
  • listen to breath sounds (left first)
  • check EtCO2
  • is there condensation in the tube
  • is there chest rise
  • could listen to belly too
157
Q

what size ETT for:
a. women
b. men

A

a. 7
b. 8

158
Q

extubation criteria

A
  • return of consciousness
  • spontaneous respiration
  • resolution of NM blockade- 5 sec
  • follows commands
  • 5-sec head lift
  • sustained hand grasp
  • spontaneous Vt > 6 cc/kg
  • negative inspiratory pressure > 20 cm H20
159
Q

define difficult airway per ASA

A

the situation in which the conventionally trained anesthesiologist experiences difficulty with intubation, mask ventilation, or both

160
Q

evaluation of a difficult airway directs the clinician to enter the ASA algorithm at what 2 points

A

awake intubation
or
intubation attempts after induction of general anesthesia

161
Q

if a difficult airway, when would you consider regional

A
  • superficial surgery
  • minimal sedation needed
  • anesthetic may be provided with local infiltration
162
Q

if a difficult airway, when would you NOT consider regional anesthesia

A
  • cavity-invading surgery
  • significant sedation needed
  • extensive neuraxial local anesthesia required
  • risk of intravascular injection/ absorption is high
  • poor airway access
  • surgery cannot be stopped once begun
163
Q

6 steps of awake airway management

A
  1. explain why to pt
  2. explain the procedure
  3. sedation for decreased anxiety (benzo)
    - may administer lidocaine or cocaine to decrease gag reflex
  4. anti-sialagogues (decrease saliva)
  5. vasoconstrict nasal passage
  6. supplemental O2 during
164
Q

airway medication prep that may cause methemoglobinemia and what is it treated with

A

cetacaine spray (benzocaine + tetracaine, butyl aminobenzoate, benzalkonium chloride, and cetydimethyl ammonium bromide)

treat with methylene blue

165
Q

nerves of nasal cavity

A

greater and lesser palatine nerves and anterior ethmoidal nerve (branches of trigeminal nerve (CN V))

166
Q

nerves of oropharynx

A

branches of vagus, facial, and glossopharyngeal nerves

167
Q

nerves of the hypopharynx, larynx, trachea

A

superior laryngeal nerve block

168
Q

contraindications to fiberoptic bronchoscopy

A
  • hypoxia
  • excessive airway secretions (that you cant fix)
  • upper/lower airway bleeding (that you cant fix)
  • local anesthetic allergy (for awake attempts)
  • inability to cooperate (for awake attempts)
169
Q

in fiberoptic bronchoscopy, which route is easiest: oral or nasal

A

nasal

170
Q

glidescope laryngoscope blade angle

A

60 degrees

171
Q

complications of retrograde wire intubation

A
  • bleeding
  • subQ emphysema
  • pneumomediastinum
  • breath-holding
  • catheter traveling caudad
  • trigeminal nerve trauma
  • pneumothroax
172
Q

can you use an LMA to pass an ETT

A

yes, a 7.0 ETT can pass thru #5 LMA

173
Q

Can’t intubate, can’t ventilate situation– last resort option

A

percutaneous emergency airway access (PEAA)

174
Q

Ventilatory muscles include

A
  • The diaphragm
  • The intercostal muscles
  • Abdominal muscles
  • cervical straps
  • sternocleidomastoid muscle
  • Large back and intervertebral muscles of shoulder girdle
    -endurance muscle
175
Q

When you have a C-spinal cord transaction, the __________ muscles become your primary inspiratory muscles.

A

Cervical strap

** diaphragm function is impaired

176
Q

C-pine injury patients can still breath but they can’t _________.

A

Cough out secretions

**they end up with pneumonia. They can’t do the work of breathing that a normal healthy person could.

177
Q

The _____________ muscles, active even during restful breathing, are the most important inspiratory ACCESSORY muscles.

A

Cervical strap

178
Q

In an intact respiratory system, the expandable lung tissue fills the ______________.

A

Pleural cavity

179
Q

The volume of gas remaining in the lungs at passive end-expiration.

A

Functional residual capacity

180
Q

Lung Parenchyma can be subdivided in 3 categories:

A
  • Conductive airways
  • Transitional airways
  • Respiratory airways
181
Q

Compliance and inspiratory elastic work can be measured by:

A

Airway pressure (Paw)
Tidal volume (TV)
Intrapleural (Ppl)

182
Q

Primary determinant of O2 reserve when apnea occurs

A

FRC

183
Q

May be used to quantify the degree of pulmonary restriction

A

FRC

614 General Principles Of Anesthesia (14 decks)

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