Principles I - Airway Management

Front 1

airway injuries are 4th

Back 1

most commonly litigated - behind death, spinal cord injury/paralysis, and brain damage

Front 2

number one reason for anesthesia related morbidity and mortality

Back 2

improper airway management (broken teeth, airway trauma, unexpected tracheostomy, brain injury, and cardiopulmonary arrest)

Front 3

of litigated airway damage - 87% were due to

Back 3

injury to the larynx - vocal cord paralysis, hematoma, arytenoid dislocation, granulomas

Front 4

of laryngeal injuries, what % were considered difficult airways

Back 4

17% - 80% were considered non-difficult

Front 5

ontoward outcomes related to difficult airways

Back 5

death (46%), brain damage (11%), airway injury (34%), and aspiration (7%)

Front 6

success at airway competence and management depends on

Back 6

knowledge of A&P, proper assessment, skill, appropriate use of devices, and application of difficult airway algorithm (our ability to assess, develop a plan,and alternate plans, and the skill makes us different)

Front 7

the upper airway is divided from the lower airway at the

Back 7

cricoid cartilage

Front 8

upper airway consists of

Back 8

nose, mouth, nasal and oral pharynx, and larynx

Front 9

purpose of the nose

Back 9

to warm and humidify inspired air

Front 10

what do the nasal turbinates do

Back 10

cause directional change in the air allowing for filtering of the air

Front 11

what arteries supply the nasal mucosa

Back 11

maxillary (sphenopalatine branch), opthalmic, and facial (septal)

Front 12

resistance in the nasal passage is

Back 12

twice that of the mouth

Front 13

what breaks in some head trauma cases to allow access to the cranium

Back 13

the cribiform plate

Front 14

positive pressure ventilation in patients with skull fractures can cause

Back 14

bacteria and foreign material to be pushed through fracture in cribiform plate into the cranium causing sepsis and meningitis

Front 15

avoid what with skull fractures

Back 15

nasal airways, nasogastric tubes, and nasaltracheal intubation

Front 16

what types of skull fractures should you avoid nasal things with

Back 16

basilar skull fractures, LaFortes II + III (others too but those 3 are the worst)

Front 17

the nasal cavity blood supply is through what artery

Back 17

the trigeminal nerve and its branches

Front 18

the anterior third of the nasal septum and the lateral wall is supplied by what nerve

Back 18

the anterior ethmoidal nerve which is a branch of the ophthalmic division of the trigeminal nerve

Front 19

the posterior two thirds of the septum and the lateral wall is supplied by what nerve

Back 19

the maxillary division of the trigeminal nerve via the sphenopalatine ganglion

Front 20

sympathetic innervation causes what in the nose

Back 20

vasoconstriction and shrinkage of the nasal mucosa

Front 21

why is there a tendency for engorgement of blood vessels in the nose with general anesthesia?

Back 21

depression of the sympathetic system by general anesthetic and the dry air that's delivered

Front 22

what can you give to decrease bleeding and engorgement of the nose during surgery

Back 22

phenylephrine drops

Front 23

the oral cavity is separated from the nasal cavity by

Back 23

the hard and soft palates

Front 24

soft palate characteristics are

Back 24

posterior third of the oral cavity, rises during eating to prevent food and liquid going into the nose

Front 25

factors that affect movement of soft palate

Back 25

age, obesity, paralytics

Front 26

sleep apnea is frequently caused by

Back 26

soft palate falling back against the nasal passage and blocking air movement - also tongue relaxing and falling back causing airway obstruction

Front 27

the #1 cause of upper airway obstruction

Back 27

tongue (soft palate a close 2nd)

Front 28

what other anatomical features of the airway can cause obstruction

Back 28

uvula, tonsils

Front 29

tonsils are partially protected by

Back 29

the anterior and posterior tonsilar pillars and are partially buried in the soft tissue at the base of the tongue

Front 30

another name for the laryngopharynx

Back 30

hypopharynnx

Front 31

the pharynx is divided into the

Back 31

oropharynx, nasopharynx, and laryngopharynx

Front 32

the nasopharynx lies

Back 32

anterior to C1

Front 33

what is found in the nasopharynx

Back 33

the eustachian tubes and the adenoids

Front 34

the oropharynx lies

Back 34

at C2 and C3 between the soft palate and the epiglottis

Front 35

the laryngopharynx lies

Back 35

between the epiglottis and the cricoid cartilage

Front 36

the cricoid cartilage lies at

Back 36

C5 - C6 levels in adults

Front 37

what acts as a barrier to regurgitation in conscious patients

Back 37

the esophageal sphincter - it sits at the junction of the opening of the esophagus and the lower edge of the hypopharynx

Front 38

the esophageal sphincter is controlled by

Back 38

the cricopharyngeal muscle - a horizontal band of muscle encircling the neck

Front 39

the larynx cartilages are

Back 39

6 cartilages - 3 paired and 3 unpaired

Front 40

the 3 unpaired cartilages of the larynx are

Back 40

the thyroid cartilage, the cricoid cartilage, and the epiglottis

Front 41

the cricoid cartilage is shaped like

Back 41

a signet ring

Front 42

characteristics of the thyroid cartilage

Back 42

shield shaped, thyroid notch, rises on the side called the cornu, "adam's apple", the largest unpaired cartilage

Front 43

the epiglottis is shapes like

Back 43

a leaf

Front 44

the function of the epiglottis is

Back 44

to invert allowing food and liquid into the esophagus and to protect the vocal cords and airway during swallowing

Front 45

the space between the end of the tongue and the epiglottis is called

Back 45

the vallecula

Front 46

damaging the epiglottis can cause

Back 46

bleeding, edema, airway obstruction

Front 47

the three paired cartilages of the airway are

Back 47

corniculate, cuneiform, and arytenoid

Front 48

the arytenoids function is

Back 48

a connecting place for the vocal cords allowing opening and closing of the vocal cords for respiration and voice - should not be able to visualize arytenoids

Front 49

cuneiform and corniculate functions

Back 49

is unknown

Front 50

location of cuneiform and corniculate cartilages

Back 50

the coons are on the corn

Front 51

be able to label all anatomical diagrams handed out in class

Back 51

be able to label all the diagrams handed out in class

Front 52

what happens if the vocal cords close completely

Back 52

get a laryngospasm

Front 53

nerves involved in the innervation of the larynx

Back 53

the recurrent laryngeal, the internal and external branches of the superior laryngeal nerve (all these nerves are derived from the vagus nerve)

Front 54

motor innervation of the larynx is by

Back 54

the recurrent laryngeal nerve except for the cricothyroid muscle that is supplied by the external branch of the laryngeal nerve (only supplies the one muscle)

Front 55

sensory innervation of the laryngeal tissue from the vocal cords up (including the vocal cords) is through the

Back 55

internal branch of the superior laryngeal nerve

Front 56

sensory innervation of the laryngeal mucosa inferior to the vocal cords is

Back 56

the recurrent laryngeal nerve

Front 57

the left recurrent laryngeal nerve is located

Back 57

separates from the vagus and loops around the aortic arch

Front 58

the right recurrent laryngeal nerve

Back 58

loops around the subclavian artery

Front 59

injury to one side of the recurrent laryngeal nerve results in

Back 59

a hoarse voice with 1 floppy vocal cord

Front 60

injury to both sides of the recurrent laryngeal nerve results in

Back 60

paralyzed, taut vocal cords that cannot breathe through - so don't pull the ETT.

Front 61

what muscle abducts the vocal cords and opens the glottis

Back 61

the posterior cricoarytenoid

Front 62

what muscle closes the glottis

Back 62

the lateral cricoarytenoid, and the transverse and oblique arytenoids

Front 63

what muscle shortens and relaxes the vocal cords

Back 63

the thyroarytenoid

Front 64

damage to the external branch of the superior laryngeal nerve causes

Back 64

huskiness and weakness of voice because the cricothyroid muscle cannot produce tension or is completely paralyzed

Front 65

unilateral right recurrent laryngeal nerve damage is common after

Back 65

subtotal thyroidectomies

Front 66

laryngospasm occurs when

Back 66

there is stimulation in teh supraglottic region resulting in protective closure of the glottis

Front 67

afferent neurons are

Back 67

sensory neurons

Front 68

efferent neurons are

Back 68

motor neurons

Front 69

the efferent branch of what nerve is stimulated in a case of laryngospasm

Back 69

recurrent laryngeal nerve

Front 70

the afferent branch of what nerve is stimulated in a case of laryngospasm

Back 70

internal branch of the superior laryngeal nerve

Front 71

blood supply to the larynx

Back 71

external carotid and the subclavian arteries

Front 72

the splitting point where the left and right bronchus branch from the trachea is the

Back 72

carina

Front 73

the carina is located at

Back 73

T5

Front 74

how long is the trachea in adults

Back 74

10 - 20 cm

Front 75

the only cartilage of the trachea that is a complete ring is

Back 75

the cricoid cartilage

Front 76

how many C shaped rings in the trachea

Back 76

16 - 20

Front 77

the back of the trachea is open to the esophagus except for

Back 77

a membrane separating the two - allows for swallowing of larger food stuffs

Front 78

the right bronchus branches at how many degrees and is how long

Back 78

25 degrees and 2.5 cm

Front 79

the left bronchus branches at how many degrees and is how long

Back 79

45 degrees and 5 cm

Front 80

cartilage rings continue in the bronchus until a size of

Back 80

0.6 mm in size - where the bronchioles begin

Front 81

most common aspiration pattern is

Back 81

right upper lobe aspiration because of less acute angle

Front 82

which bronchus is most likely to be main stem intubated

Back 82

the right because of the less acute angle (in adults - children different)

Front 83

what do you ask for a good airway history

Back 83

previous surgeries
airway difficulties previously
comorbidities (c spine fx)
anomalies
change in body habitus (significant weight change)

Front 84

what are the predictors of difficult bag valve mask ventilation

Back 84

OBESE -
Obese (BMI > 26)
Bearded
Elderly
Snorers
Edentulous

Front 85

things to look at for airway assessment

Back 85

length on upper incisors, overbite or underbite with natural closure and protrusion of lower jaw, interincisor distance, visibility of the uvula, shape of palette, compliance of the mandibular space, thyromental distance, length of neck, thickness of neck, and range of motion of head and neck

Front 86

what is the 3-3-2 rule

Back 86

3 fingers between the teeth, 3 fingers under the chin, and 2 fingers between the floor of the mandible and the thyroid notch

Front 87

a good thyromental distance is

Back 87

over 6.5 cm

Front 88

a thyromental distance of less than what means a nearly impossible intubation

Back 88

6.0 cm

Front 89

the thyromental distance is from where to where

Back 89

the tip of the jaw to the thyroid notch with the head extended

Front 90

a proper Mallampati score is conducted in what position

Back 90

observer at eye level, patient is sitting, head is neutral, opens mouth all the way, and protrudes tongue without saying AHHH

Front 91

A class I Mallampati characteristics includes visualization of

Back 91

the soft palate, the opening (or fauces), the uvula, and the tonsilar pillars

Front 92

a class II Mallampati score visualizes

Back 92

the soft palate, fauces, and uvula - but not the tonsilar pillars

Front 93

a class III Mallampati score visualizes

Back 93

the soft palate and the base of the uvula

Front 94

a class IV Mallampati score visualizes

Back 94

not even the soft palate

Front 95

what classes of Mallampati are classified as difficult airways

Back 95

Classes III and IV

Front 96

preoxygenation is more accurately described as

Back 96

denitrogenation

Front 97

a 90% sat is the same as a PaO2 of

Back 97

60

Front 98

in healthy patients, 5 minutes of 100% O2 can lead to

Back 98

10 minutes of oxygen reserve - instead of usual room air 2 minute depletion

Front 99

most common reason for not achieving a high FRC FiO2 is

Back 99

a non-fitting mask - very important to have a nice tight fit

Front 100

alternative to 5 minutes of tight mask 100% oxygenation is

Back 100

have patient take 4 deep breaths over 30 seconds, or 8 deep breaths over 60 seconds (will buy you some more time, but not the full 10 minutes)

Front 101

hypoxemia is defined as

Back 101

not enough oxygen delivered to meet the tissue demands

Front 102

maximum FiO2 of a simple mask is

Back 102

60%

Front 103

nasal cannula calculation of O2%

Back 103

4% for every additional L over 20%

Front 104

FiO2 for simple mask at 5-6 L/min

Back 104

40%

Front 105

FiO2 for simple mask at 6-7 L/min

Back 105

50%

Front 106

FiO2 for simple mask at 7-8 L/min

Back 106

60% (and anything above 8 L)

Front 107

maximum FiO2 delivered by nasal cannula

Back 107

44%

Front 108

minimum flow rate for simple mask

Back 108

5L - to prevent CO2 from accumulating

Front 109

Maximum FiO2 for NRB is

Back 109

80%

Front 110

80% FiO2 achieve on a NRB at flow rates of

Back 110

8 and higher

Front 111

Flow rates of 6L and 7L on a NRB have FiO2 of

Back 111

60% and 70% respectively

Front 112

If the NRB bag is pulled flat with inspiration then

Back 112

remove venting diaphragm on the side of the mask to allow room air entrainment

Front 113

examples of low flow devices are

Back 113

nasal cannulas, simple masks, and NRB

Front 114

examples of high flow devices are

Back 114

venturi masks, t-pieces, and ambu bags (manual resuscitation bags)

Front 115

an ambu bag can deliver up to

Back 115

>90% O2 and 800 ml tidal volume

Front 116

PEEP valves should be uses on

Back 116

patient requiring more than 5 cm O2 PEEP

Front 117

what is the most important skill an anesthesia provider can obtain

Back 117

bag-mask ventilation - buys you time in a crisis to make the next move

Front 118

#1 reason students are not successful at intubation and ventilation is

Back 118

improper positioning

Front 119

face masks increase

Back 119

dead air space

Front 120

big concern with face masks

Back 120

ocular trauma

Front 121

most common method of O2 delivery in apneic pts prior to intubation

Back 121

face mask (bag mask) ventilation

Front 122

partial airway obstruction sounds like

Back 122

snoring, crowing, stridor

Front 123

complete airway obstruction sounds like

Back 123

no sound, no air movement, retractions, no chest expansion

Front 124

causes of soft tissue upper airway obstruction include

Back 124

loss of pharyngeal muscle tone due to anesthesia, stroke, trauma, coma
space occupying lesions like tumors, edema, abscesses, hematomas
foreign substances like teeth, vomit, foreign bodies

Front 125

causes of laryngeal obstruction is most likely

Back 125

increased muscle activity from a reaction to sputum or vomit, or presence of a foreign body, tumor, or swelling

Front 126

snoring is typical of a partial occlusion in the

Back 126

oral or nasal pharynx

Front 127

stridor or crowing suggests an obstruction

Back 127

in the glottic laryngeal area or laryngospasm on inspiration

Front 128

possibly associated with laryngospasm

Back 128

hypoxia, hypercarbia, and desaturation

Front 129

methods of opening the airway

Back 129

head tilt/chin lift, jaw thrust, sniffing position

Front 130

the sniffing position is described as

Back 130

raising the head 1-4 inches, 8-10 cm above the shoulders and extending the neck

Front 131

the sniffing position lines up

Back 131

the laryngeal and pharyngeal axis

Front 132

the jaw thrust is preformed by

Back 132

lifting the hyoid bone and tongue away from the posterior pharynx wall by subluxating the mandible forward onto the sliding part of the temporormandibular joint

Front 133

adult sizes in oral airways are

Back 133

80 mm, 90 mm, and 100 mm (Guedels 3, 4, and 5)

Front 134

estimate the size of the oral airway by

Back 134

the distance between the tragus of the ear to the corner of the mouth

Front 135

proper placement of an oral airway

Back 135

is by using a tongue blade to move the tongue forward

Front 136

common problems with the oral airway

Back 136

pushing the tongue posteriorly, improper sizes, broken teeth, traumatized oral pharynx, necrosis, nerve damage, and laryngospasm (under light sedation)

Front 137

to use an oral airway the patient

Back 137

must be unconscious

Front 138

do not do what with an oral airway

Back 138

insert upside down and twist

Front 139

nasal airways are measures from

Back 139

the nares to the meatus (tragus) of the ear

Front 140

nasal airways should not be used in

Back 140

anticoagulated patients, basal skull fractures, children with prominent adenoids

Front 141

method for nasal airway insertion

Back 141

lubricate, insert at angle perpendicular to the face,bevel towards the septum, the twist as slides into place

Front 142

the 3 airway axis are

Back 142

laryngeal axis, pharyngeal axis, and oral axis

Front 143

the oral axis is most affected by

Back 143

extension of the neck

Front 144

the pharyngeal and laryngeal axis line up in

Back 144

sniffing position

Front 145

over extension of the neck can cause

Back 145

worsening view of the airway, a hurt neck

Front 146

ramping is

Back 146

when you prop up obese people to let gravity help you out - to keep some of the weight falling out of your way when you try to intubate

Front 147

the FRC of obese people is

Back 147

nonexistant - or even a negative value - so preoxygenate sitting up to get you as much time as able for a difficult airway

Front 148

intubation is (characteristics)

Back 148

the definitive and most secure airway and is used to protect and assure access to the airway. Also helps protect lungs from aspiration

Front 149

intubation is recommended for

Back 149

aspiration risks, body cavity procedures, head and neck surgeries, and lengthy cases

Front 150

benefits of intubation include

Back 150

patent airway, protection against blood and aspiration, PPV, removal of tracheal secretions, decreases anatomical dead space, controlled oxygen delivery, and route for emergency drugs

Front 151

the most important piece of equipment to have at bedside during intubation is

Back 151

suction!!!!

Front 152

Equipment to gather before intubating

Back 152

suction, positioning stuff, laryngoscope, ETTs, circuit and masks, oral and nasal airways, tongue blade, drugs, and alternate airway prep

Front 153

remember to check what before induction

Back 153

circuit and suction

Front 154

"Stubby" laryngoscope handle is good for

Back 154

obese patients so you don't get stuck on their extra tissue

Front 155

long and skinny laryngoscope handles is good for

Back 155

peds - better maneuverability with the smaller blade

Front 156

Always check what when organizing equipment before intubating

Back 156

that the blades fit with the handle, that the batteries on the scope are fine