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155 Cards in this Set
- Front
- Back
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What are the components of the Nasal Cavity
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Superior, Middle and Inferior Turbinates, Hard and Soft Palates
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The components of the Nasopharynx are...
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Tonsils, Adenoids and Uvula
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What are the components of the Oropharynx
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Tongue
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What is the other name for the Laryngopharynx and what are the components
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The HYPOPHARYNX...the components of which are the Vallecula and Epiglottis
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What are the components of the Larynx....
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The Esophagus and the Trachea
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Place the ff in sequential order from superior to inferior positions: Thyroid gland, cricothyroid membrane, vocal cords, cricoid cartilage, glottic opening, thyroid. cartilage,
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First is the glottic opening, then the vocal cords, the thyroid cartilage, cricothryroid membranne, cricoid cartilage and then the thyroid gland
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How many different cartilages are there in the Larynx
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There are 9. The single ones are Thyroid, Cricoid and Epiglottis Cartilages. The paired are the Arythenoid, Cornicula and the Cuneiform
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Describe the trachea (location, rings, etc)
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Begins at the 6th cervical vertebra and extends to the carina. It is 10-15cm long and supported by 16 to 20 horseshoe cartilages that are 20-25mm in diameter.
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Is the cricoid a part of the trachea?.....Where is it located.
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The cricoid is the most cephalad cartilage and is the only one that has a full ring structure. Shaped like a signet ring- wider in the cephalocaudal dimension posteriorly
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Describe the sections of the Bronchial Tree Branches starting with the Trachea
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Trachea; Primary Bronchi, Secondary Bronchi, Tertiary Bronchi, Bronchioles, Terminal Bronchioles, Respiratory Bronchioles, Alveolar Ducts, Alveolar Sacs, Alveoli
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Generally, which nerve innervates the Nasopharynx
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Trigeminal Nerve
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Generally, which nerve innervates the Oropharynx....and what other areas does it innervate
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The Glossopharyngeal nerve; innervates the Roof of Pharynx, the Tonsils and undersurgace of the soft palate.
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Which two nerves innervate the tongue
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The Lingual nerve (provides sensation to the anterior 2/3rd) and the Glossopharyngeal nerve (sensation to the posterior 3rd of the tongue)
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Generally, which nerve innervates the Hypopharyngeal or Laryngopharynx
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The VAGUS nerve- provides sensation to the airway below the epiglottis.
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The superior laryngeal branch of the vagus divides into ....
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An external (MOTOR) nerve and an internal (SENSORY) laryngeal nerve that provides sensory supply to the larynx btw the EPIGLOTTIC and the VOCAL CORDS.
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Which nerves innervates the larynx below the vocal cords and the trachea
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The RECURRENT LARYNGEAL NERVE
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Which muscles ABDUCT the vocal cords...
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The POSTERIOR CRICOARYTENOID muscles ABDUCT the vocal cords
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Which muscles ADDUCT the vocal cords....
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LATERAL CRICOARYTENOID muscles.
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The posterior cricoarytenoid muscle is innervated by...
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The RECURRENT LARYNGEAL NERVE
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The lateral cricoarytenoid muscle is innervated by the ...
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THE RECURRENT LARYNGEAL NERVE
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What is the function of the Thyroarytenoid muscle and what innervates it...
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The THYROARYTENOID RELAXES TENSION OF THE VOCAL CORDS, and is innervated by the RECURRENT LARYNGEA. NERVE
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What is the function of the CRICOTHYROID MUSCLE..and what is it innervated by.....
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Cricothyroid muscle functions as TENSOR of Vocal Cords, and is innervated by the external superior laryngeal nerve.
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What is the narrowest portion of the Adult airway......
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The Glottic opening (aka Vocal cords opening) is the narrowest portion of the adual airway.
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The narrowest part of a child airway is .....
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The Cricoid Cartilage
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What are absolute indications for intubation
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a. Inability to Oxygenate
b. Inability to Ventilate c. Inability to Protect Airway d. Deteriorating Airway |
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What are some signs of poor ventilation
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Poor or absent breathsounds
Paradoxical Chest Movements Stridor (90% occlusion) |
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What are some evidences of poor airway protection
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Painful Swallowing (#1)
Drooling Aspiration Glascow <8 |
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What are some RELATIVE indications for intubation...
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1. Combative pts(controversial)
2. Inability to Clear Secretions 3. Anticipate Airway Edema/Injury 4. Anticipate Deteriorating Lung Function, and 5. Anticipate Respiratory Fatigue |
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What are some nonassuring findings of the preoperative airway physical examination as it relates to : Incisor length, interincisor distance, shape of palate, thyromental distance
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Nonassuring findings include;
1. incisors relatively long 2. interincisor distance <3cm 3. Palate highly arched or very narrow 4. Thyromental distance <6.5cm. |
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Unassuring findings on the pre-op exam as it relates to the LENGTH OF THE NECK, THICKNESS OF THE NECK, ROM OF THE HEAD AND NECK, VISIBILITY OF THE UVULA include
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A SHORT neck, THICK neck; if pt can not touch the tip of the chin to the chest or cannot extend the neck( poor ROM); uvula not visible when the tongue is protruded with the pt in the sitting position (Mallampati class higher than II)
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Describe the process of assessing a pt using the mallampati scale...
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With the patient at eye level, the patient holds the head in a neutral position, opens the mouth maximally, and protrudes the tongue without phonating.
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What does the Mallampati classification scale correlate?
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The oropharyngeal space and how it correlates to the ease of direct laryngoscopy and tracheal intubation.
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The Mallampati class in which there is no soft palate visible is called...
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Class IV (class four)
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Which structures are visible in Class II of Mallampati
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The soft palate, fauces, and uvula are visible
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Decribe Class I of Mallampati
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The soft palate, facues, uvula and tonsillar pillars are visible.
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Describe Class III of Mallampati...
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The soft palate and base of the uvula are visible.
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What are the 2 primary functions of laryngoscopy
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1. Align Airway Axes
2. Move the tongue out of the way to be able to visualize the vocal cords (tongue is the biggest obstacle) |
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The alignment of which axis facilitates finding the glottic opening....
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the 3 axis, the oral, pharyngeal and laryngeal axis (OA, PA & LA) (pt's head is resting on a pad which flexes the neck on the chest with concomitant extension of the head on the neck, bringing all 3 axes into alignment (sniffing position) pg 226 in Basics of Anesthesia 6th edition
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What is the Thyromental distance, and what is it used to determine...
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It is the distance from the mentum to thyroid cartilage and less than 6-7cm (or <6.5cm) correlates with a poor laryngoscopic view.
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Which patients do you expect to see an unacceptable tyromental distance in...
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pts with short necks or pts with receding mandible.
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Why is a short thyromental distance important?
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Because a thyromental distance of <6.5cm creates a more ACUTE angle btw the oral and pharyngeal axes and limits the ablilty to bring them into alignment.
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What should the sternomental distance measure?
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It shd measure more than 12.5 to 13.5cm.
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What is the submandibular space.
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submandibular space is the area into which the soft tissues of the pharynx must be displaced to obtain a line of vision during direct laryngoscopy
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Why is submandibular compliance important.....list factors that attribute to decrease in this compliance.
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Anything limiting the size of the submandibular space or compliance of the tissue will decrease the amt of anterior displacement that can be achieved in the pharyngeal soft tissues.....Ludwig's angina, tumors, radiation scarring, burns and previous neck surgery are all conditions decreasing submandibular compliance.
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What is the process of locating the cricoid membrane from top to bottom?
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1st locate the thyroid cartilage and then skide the finger down the neck to the membrane which lies just below.
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Process of finding the cricoid membrane from lower to upper neck?
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Start at the sternal notch and slide the fingers up the neck until a cartilage that is wider and higher (cricoid cartilage) than those below is felt
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In epiglottitis, what is the difficulty that arise with intubation?
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Laryngoscopy may worsen obstruction
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Croup, bronchitis and pneumonia cause what difficulty in AM (airway management)
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Airway irritability with a tendency for cough, laryngospasm, and bronchospasm
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Tetanus presents what difficulty in AM.
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Trismus renders oral tracheal intubation impossible
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Radiation presents what difficulty in AM...
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Fibrosis may distort the airway or make manipulation difficult
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Ankylosing spondylitis presents what difficulty in AM
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Fusion of the cervial spine may render direct laryngoscpy impossible
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Obesity presents what difficulty in AM
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Upper airway obstruction with loss of consciousness....Tissue mass makes successful facemask ventilation difficult
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Thyomegaly presents what difficulty in AM
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Goiter may produce extrinsic airway compression or deviation
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Diabetes mellitus poses what difficulty in airway management (AM)
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May have decreased mobility of the atlanto-occipital joint.
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Per statistics, what is more difficult to do Intubate or Ventilate?
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Intubate (3-18%) DIFFICULTY TO INTUBATE
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Per the Stats, what is the percentage of DIFFICULT VENTILATION that lead to pt's demise?
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1-3% (difficult to ventilate)
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What is the Natl' Failure to Intubate rate?
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1-3% National 'Failed Intubation' rate
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What percentage of pts could not be Ventilated or Intubated
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0.01 - 2%- Unable to ventilate and intubate
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What is the Airway Manager's worst nightmare....
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Failure to Ventilate coupled with Failure to Intubate (CV/CI)
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The three most important things to know when intubating include?
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1. Ablility to IDENTIFY when you have established an airway
2. Ability to SALVAGE: if the ett tube is in the esophagus- no sweat- get it out and place it in the trachea. 3. SUCCESS |
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List some problems with airway management as it relates to the mouth, mandible, maxilla, tongue, position, neck
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SMALL mouth, RECEDING mandible, PROTUBERANT maxilla (overbite) LARGE tongue, NO SNIFFING position, SHORT neck, NECK MASS
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What congenital anomalies are red flags that are potential for problematic airway management
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Morquio syndrome
Klippel-Feil Syndrome Spondyloepiphyseal Dysplasia Dysproportionate Dwarfism Osteogenesis Imperfecta Neurofibromatosis |
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What difficulty does Trisomy 21 present in airway management?
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Large tongue, small mouth makes laryngoscopy difficult; small subglottic diameter is possible and Laryngospasm is very common.
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In which congenital anomaly is neck rigidity secondary to cervical vertebral fusion present.
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Klippel-Feil syndrome
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What difficulty does Turner Syndrome present in airway management
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High likelihood of difficult tracheal intubation
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What diseases complicate Airway Management
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Rheumatoid Arthritis
Still's Disease Ankylosing Spondylitis Psoriatic Arthritis Enteropathic Arthritis Reiter's Syndrome |
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Describe Class I of the ULBT (upper lip bite test)
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The lower incisors can bite above the vermilion border of the upper lip
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Describe Class II of the ULBT....
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Lower incisors cannot reach vermilion border
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When the lower incisors cannot bite the upper lip, this denotes which class in the ULBT?
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Class III
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What aligns the laryngeal and pharyngeal axes...
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Flexion of the neck, by elevating the head approximately 10cm aligns these axes.
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List the 5 major factors contributing to Difficult Mask Ventilation
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Obese
Bearded Elderly >55 Snorers Edentulous |
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What are some other factors that contribute to difficult mask ventilation
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BMI >26kg/m2
Malllampati III & IV Limited Jaw Protrusion Thyromental Distance <6cm Neck Circumference Facial Trauma Multiple intubation Attempts |
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What should the Ventilating pressures (during bag-mask ventilation) be limited to and why...
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Shd be less than 20cm to avoid insufflation of the stomach
pg 227 Basics of Anes |
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When masking a pt, pressure should be avoided in which area and why?
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pressure on the submandibular soft tissue should be avoided b/c it can cause airway obstruction.
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Which hand should be controlling the mask?
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LEFT HAND
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Where are the thumb and index fingers located in mask ventilation
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they are used in a C position to apply downward pressure on the mask body
m&m pg 95 |
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Where is the small finger located in mask ventilation
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Pinky is located on the Angle of the Mandible (from notes)- or Under the angle of the jaw and used to thrust the jaw anteriorly , the most important manuever to allow ventilation to the patient...pg 95 M&M
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What is the role of the middle and ring fingers during mask ventilation; Role of the index and thumb
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They grasp the mandible to facilitate extension of the atlantoocipital joint. Pressure on the submandibular soft tissue should be avoided b/c it can cause airway obstruction; The INDEX AND THUMB apply counter pressure on the facemask. Mandibular displacement, atlanto-occipital joint extension, chin lift, and jaw thrust combine to maximize the pharyngeal space.
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During mask ventilation, what can contribute to Gastric Inflation
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1. Large tidal Volumes
2. Rapid Delivery of Volume |
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Describe the quality of PIP that should be administered during Mask Ventilation
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PIP should be less than 20. Flow should be gentle, smooth and laminar
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In the bronchial tree, what is the sole purpose of existence for the first 16 generations...What is that portion of the bronchus called?
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Called the Conducting Airway; No gas exchange occurs here, it is solely responsible for moving air in and out
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What the different kinds of LMAs
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They included the
Reusable LMA Disposable LMA ProSeal LMA Fastrach LMA |
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Describe the Proseal LMA
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It has an orifice through which a nasagastric tube can be inserted and that facilitates positive-pressure ventilation
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Can the Arythenoid cartilage be visualized during direct intubation
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No
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From generation 17 on down the bronchial tree what occurs?
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Called the Exchange Airway; it is where alveolar gas exchange starts to occur
(notes/lecture) |
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What is the role of the Epiglottis?
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It functionally separates the oropharynx from the laryngopharynx (or hypopharynx). It prevents aspiration by covering the glottis (opening of the larynx) during swallowing
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The blood supply of the larynx is derived from branches of the
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THYROID ARTERIES
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What are the different sizes of an adult airway?
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Small- 80mm (guedel No. 3)
Medium- 90mm(guedel No. 4) Large-100mm (guedel No.5) |
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Decribe the ideal positioning of an LMA placement
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The cuff is bordered by the
1.base of tongue superiorly 2.the pyriform sinuses laterally 3.upper esophageal sphincter inferiorly |
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What is the primary cause of failed LMA placement...
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Down-folding of the epiglottis or distal cuff accounts for many failures.
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The TT used in pediatric patients are cuffed/uncuffed- why?
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Uncuffed--- b/c the cricoid cartilage is the narrowest part of their airway.
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What occurs structurally in airway obstruction and what can be done to rectify that...
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In the Oropharynx, the Jaw and Base of the Tongue relax and occlude the airway.
Rx: Chin Lift, Jaw Thrust, Oral Airway Nasal Trumpet |
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What is the correct technique for placement of an Oral Airway?
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Using a blade to depress the tongue, place the oral airway curve side down in the mouth and towards the back of the throat. do not turn 180 as you advance into the back.
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What can occur if a pt is awake during oral airway placement...
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An awake or lightly anesthetized pt may cough or even develop laryngospasm during airway insertion if laryngeal reflexes are intact.
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How do you measure for a nasal airway?
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Measure from the Nares to the Meatus of the ear (shd be approx 2-4cm longer that oral airways)
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What is the correct method for advancing a Nasal Airway.
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The NA shd be lubricated and advanced along the FLOOR OF THE NASAL PASSAGE toward the APEX of the nasal passage to avoid traumatizing the turbinates or the roof of the nose.
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Which is better tolerated in a lightly anesthetized pt; Nasal or Oral airways...
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Nasal Airways are better tolerated.
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What are some signs of Inadequate Mask Ventilation?
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1. Absent / Inadequate Chest Movement or Breath Sounds
2. Auscultory Signs of Obstruction 3. Cyanosis 4. Gastric Dilatation 5. Low SpO2 6. Low CO2 7. Low Spirometric Measures of Exhaled Gas 8. Hemodynamic Changes Associated with Hypoxemia or Hypercarbia |
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List the factors that can contribute to a Difficult Intubation (DI)
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Hx of Prior difficult intubation
Mallampati >3 TMD <6.5 (thyromental distance) SMD < 12.5(sternomental distance) Small Mouth Opening BMI >30 Upper lip bite test Multiple Attempts |
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Why is neck circumference important in intubation?
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Neck circumference >45cm indicates redundant tissue and anatomical pathology
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What are 8 essential questions to ask when considering intubating someone?
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1. Is this pt a full stomach?
2. Ease of intubation? 3. Ease of ventilation? 4. Pt's pulmonary reserve 5. Pt's hemodynamic status 6. Pt's volume status 7. Pt's cardiac reserve? 8. Other issues(c-spine, ICP?) |
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What are the two KEY things to remember with intubation?
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1. The only bad esophageal intubation is the UNRECOGNIZED ESOPHAGEAL INTUBATION
and IT IS HARD TO KILL A SPONTANEOUSLY BREATHING PATIENT |
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List several factors that determine cuff pressure
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Inflation volume
cuff diameter r/t trachea tracheal & cuff compliance intrathroracic pressure (cuff pressures increase during coughing) |
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How can Nitrous Oxide affect the cuff....
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Cuff pressure may rise during general anesthesia as a aresult of the diffusion of nitrous oxide from the tracheal mucosa into the TT cuff
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What is an armored tube and what happens if it kinks off?
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It is a flexible, spiral wound, wire-reinforced TT that resists kinking- valuable in some head & neck surgical procedures/ or prone patients: if kinked it will remain occluded and will need replacement.
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What is a common feature in all TTs?
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An embedded line that is opaque on radiographs to allow visualization in situ.
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What are the most popular straight and curved laryngoscopes?
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Straight: Miller
Curved: Macintosh |
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What are the 2 new laryngoscopes developed in the past 15 years that aid in difficult airway intubations? Describe them....
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The Wu and the Bullard. Have fiberoptic light sources and curved blades with elongated tips/ designed to help see the glottic opening in pts with large tongues or whose glottic opening is very anterior.
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What is the advantage of a flexible fiberoptic bronchoscope
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Allows indirect visualization of the larynx in pts with congenital or acquired upper airway anomalies when an awake intubation is planned
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What do blinking lights and fadings lights on the laryngoscope indicate?
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Blinking: Poor electrical contact
Depleted Batteries |
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Describe correct patient positioning as it relates to the CRNA and the pts ariway...
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Pt's head shd be level with the CRNA waist or higher to prevent backstrain
Moderate head elevation of 5-10cm above the surgical table and extension of the atlantooccipital joint = sniffing position. C-spine is flexed by resting head on pillow. |
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How does general anes affect corneal reflexes...
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Abolishes it, therefore take care not to injure pt's eye . Tape eye shut after applying petroleum-based ophthalmic ointment.
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Describe the sequence of orotracheal intubation after checking and positioning pt...
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With LEFT hand, intro blade into RIGHT SIDE of mouth and sweep tongue to LEFT side & UP into the floor of the pharynx. Handle is raised UP & AWAY from pt in a place PERPENDICULAR to pt's mandible to expose wocal cords. With RIGHT HAND tube is passed through the abducted VC; TT shd lie in upper trachea but beyond the larynx. Remove laryngoscope & inflate cuff with least amt of air (20mm Hg) needed to create seal during +pressure vent to minimize pressure to the tracheal. mucosa. Immediately auscultate the RIGHT chest then the left, and then epigastrium and obtain a CAPNOGRAPHIC tracing to ensure intratracheal location
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Is a persistent detection of CO2 by a capnograph a definitive confirmation of intratracheal intubation?
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NO!. it can not exclude BRONCHIAL INTUBATION
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What is the earliest manifestation of bronchial intubation?
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An increase in PEAK INSPIRATORY PRESSURE (pip)
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What is the risk of intralaryngeal intubation and how can it be detected?
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May result in POSTOPERATIVE HOARSENESS and increased risk of ACCIDENTAL INTUBATION. Can be detected if the cuff is palpated above the level of the CRICOID cartilage.
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Where can the cuff of a properly place ETT tube be felt?
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Shd be palpated In the STERNAL NOTCH while compressing the pilot balloon.
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What does RSI stand for and what are the considerations when thinking of using it?
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RAPID SEQUENCE INTUBATION: pt has to be intubated; can be intubated &/or ventilated; and if pt has a full stomach (ie, pregnant, gastric emptying disorder, DM, GERD, abd.compartment syndrome, etc)
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Define RSI
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RAPID SEQUENCE INDUCTION: Is the customary approach to induction of general anesthesia in the pt at risk for pulmonary aspiration of gastric acid using cricoid pressure to obstruct any potential flow of gastric content into the pharynx and trachea
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What is a glidescope
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An anatomically shaped, fixed angle (60 degree) laryngoscope blade made of medical-grade plastic. Has a miniature fog-resistant video camera embedded in the undersurface of the blade that transmits the digital image to a high-resolution monitor (can be mounted on a pole.) (Basics pg 236)
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What are the different intubation procedures that can be used to prevent aspiration?
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Awake intubation (Fiberoptic and direct laryngoscopy); Rapid Sequence Intubation (cricoid pressure and antacid admin- Only Bicitrate shd be used-does not have precipitates); Sitting Position
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What percent of the population does not have the esophagus behind the Cricoid Ring?
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52%
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How is cricoid pressure executed? and what is the other name for it?
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By exerting downward pressure with the thumb and index finger on the cricoid cartilage (3-5kg pressure) so that the cricoid ring is displaced posteriorly and the esophagus is compressed against the underlying cervial vertebrae. This is also called the SELLICK'S manuever and shd prevent spillage of gastric contents in the pharynx during the period from induction of anes (unconsciousness) to placement of the cuffed ETT.
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Is cricoid pressure really effective and what is the statistic of success?
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The efficacy of cricoid pressure is not clear.
90% of the time cricoid pressure results in a lateral displacement of the esophagus rather than resulting in compression of the esophagus. |
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If applying cricoid pressure, when can the assistant release pressure?
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1.During active vomiting (don't want to rupture the esophagus from the force of vomiting)
2. After confirming ETT location is correct with ETCO2 and auscultation. |
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What is the order of RSI
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Mitigate aspiration sequela
Pre Oxygenate(3-4 vital capacity breaths) Use ultra fast Agents (propafor, STP, Etomidate, Ketamine) and paralytics (Succinylcholine and Rocuronium) Cricoid Pressure No ventilation (disclaimer- pls 2x check notes about this- was not too clear about sequence in lecture) |
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What are some other ways to confirm intubation?
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End tidal CO2 (gold std- continuous wave form:electronic- or colorimetric:portable)
Auscultation Condensation Chest Excursion 02 Saturation Visualization Radiography (cxr, etc) Self inflating bulb FOB Chest radiograph Bougie |
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What are the caveats of LMA usage?
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no protection against aspiration
Easier to insert LMA with hyperextension of the neck Pharyngeal/Laryngeal pathologies that cause mask ventilation failures will also cause LMA failures Very high pressure ventilation = poor LMA fxn Unusually positions is controversial Light anesthesia |
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If you can not ventilate nor intubate your pt and they are dying, what are the two choices you have?
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Only Subglottic Approach : A Percutaneous Cricothyrotomy or Surgically open "Cut the neck"
Cric can be done in <30mins- establishes a definitive airway that can be used up to 72hrs (VC distension/ subglottic stenosis with >72hr use)- If cuffed tube used, pulmonary compliance less of an issue and aspiration protection better. |
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What are the dimensions of the cricothyroid membrane?
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9mm X 30mm : located btw the thyroid cartilage and the cricoid cartilage
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Discuss Combitubes
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Is a Double Lumen Device the fxns as either an Endotracheal Device or Esophageal Obturator (2 sizes available 37Fr(pts <180cm); 41Fr (pts >180cm)
Passed Blindly without force Oropharyngeal cuff is inflated first (syringe on blue port)- this seats/anchors the device. Distal cuff inflated last and ventilation done through the BLUE lumen; if no bs= device in too deep- pull back and reventilate |
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Discuss the Alternate Approaches to Intubation when faced with a difficult airway
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1. Switching blade (rarely)
2. Bougie (often an answer) 3. Blind Nasal Intubation (unless pt spontaneously breathing it's rarely an ans) 4. Intubating LMA (Fastrach) 5. FOB 6. Fiberoptic Assisted Laryngoscope (Glidescope, bullard, etc) 7. Lightwand 8. Retrograde Intubation 9.Tracheostomy |
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What are other names for the bougie and what are the benefits of using it?
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AKA gum elastic bougie; introducer; introducing stylet, the ETT introducer
1. Lo tech 2. Small Profile 3. Secures Airway without commitment to a specific size ETT 4. Easier to Manuever 5. When in the trachea the tube can not be advanced further (in the esophagus the tube can be buried into the stomach) |
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Discuss nasotracheal intubation Risks
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1. Possibility of breaking turbinates
2. Increased risk of sinusitis 3. Bleeding 4. Shd use the clearer nostril 5. Vomiting 6. Intracranial placement in pts with basilar skull fx |
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Describe intubating LMAs
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Modified LMA
90 degree Bend Intubation Guide (I-LMA or Fastrach LMA) |
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Discuss Flexible Fiberoptic Intubation
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1. Expensive
2. Fragile 3. Time Consuming (pt prep with Local anes & Sedation) 4. Route- Oral/Nasal 5. Pt has to be hemodynamic stable and cooperative |
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Risks of Flexible Fiberoptic INtubation include
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1. technique failure (inexperienced, lack of prep)
2. bleeding 3. major distortions 4. ER Use = only in very experienced hands |
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The combitube is sized based on what?
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height. There are 2 sizes 37fr and 41fr. The 37fr is used in pts 180cm or smaller and the 41fr in pts <180cm.
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When is the combitube used? Visualization of the cords is required for combitube placement (true/false)
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In situations of emergency and difficult airways. False; it can be inserted without the need for visualization in the OROPHARYNX, and it usually enters the esophagus.
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Describe the cuff functions of the combitube.
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There is a distal cuff (at the tip- 15ml of air- white pilot balloon) and a larger proximal cuff (85ml of air- blue pilot balloon) If the tube is in the trachea, ventilation is achieved through the distal lumen. If in the esophagus, ventillation is through multiple proximal apertures situated above the distal cuff (both the proximal and latter cuffs are inflated in this situation to prevent air from escaping through the esophagus or back out of the oro and nasopharynx).
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Which device is preferable to manage a difficult airway, the combitube or the LMA
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The LMA has surpassed the combitube as a preferred device to manage a diffcult airway.
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List the different kinds of LMAs
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Reusable; Disposable LMA; Proseal LMA (has an orifice thru which a ngt can be inserted and that facilitates postitive pressure ventilation; Fastrach LMA (facilitates intubating pts with difficult airway).
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List the stages of LMA placement
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1. Choose appropriate size and check for leaks
2.Leading edge of deflated cuff shd be wrinkle-free and facing away from the aperture 3. Lubricate only back side 4. Ensure adequate anesthesia (nerve block or general) Propafol with opioids gives superior results compared to sodium thiopental. 5. Head in SNIFFING POSITION 6.Use INDEX FINGER to guide cuff along hard palate and into hypopharynx. The LONGITUDINAL BLACK LINEshould ALWAYS be pointing directly cephalad (that is FACING THE PT'S UPPER LIP) 7. Inflate with appropriate amount of air 8. Obstruction after insertion is usually due to a DOWN FOLDED EPIGLOTTIS or TRANSIENT LARYNGOSPASM. 9. Avoid pharyngeal suction, cuff delfation or LMA removal UNTIL PT IS AWAKE (IE- opening mouth to command). |
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Which results in more bronchospasm, ETT placements or LMA placement
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ETT placement. Evidence suggests that b/c the LMA is not placed in the trachea there is LESS bronchospasm associated with its use.
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Mask ventilation for extended periods can result in what kind of injury......to where? What can you do to avoid this...
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Results in PRESSURE injury to the TRIGEMINAL OR FACIAL NERVES. Use minimal downward force on the face during spontaneous ventilation or change mask position regularly if using straps to prevent injury.
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what are the different LMA sizes and which pts do they correlate with? (Mask Size; pt size, wgt in kg and cuff volume)
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1-infant <6.5kg - 2-4ml cuff vol
2-child 6.5-20kg up to 10 ml 2.5 child 20-30kg up to15 ml 3 small adult >30kg up to 20ml 4 norm adult <70kg up to 30ml 5 larger adlt >70kg up to 30ml |
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where does the LARYNGEAL AIRWAY MASK SIT WHEN PLACED? What kind of ventilation does it support, spontaneous or mechanical?
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In the PHARYNX. Subsequently known also as a PERIPHARYNGEAL SEALER. It supports both mechanical and spontaneous ventilation.
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Describe the use of a light wand
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Passed blindly
Preloaded with an ETT Requires a darken Room Transillumination occurs |
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What are the two possible approaches to tracheostomies
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PERCUTANEOUS and OPEN APPROACHES
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List complications associated with tracheostomies
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BLT - CaPES
BLEEDING LOSS of AIRWAY TRACHEO-INNOMINATE FISTULA CANNULATION OF FALSE PASSAGE PNEUMOTHORAX SUBCUTANEOUS EMPHYSEMA |
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What are some complicating factors of tracheostomy
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OBESITY
EDEMA RADIATION/FIBROSIS COAGULOPATHY MASSES TRACHEAL DEVIATION |
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Decribe open tracheotomy ; aka tracheostomy
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An incision is made just above the sternal notch. Just below the thyroid, the membrane covering the trachea is divided and the trachea itself is cut. A cross incision is make to enlarge the opening and the tube is placed.
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what are the anatomic considerations to be made when a tracheostomy placement is being considered?
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THE THYROID GLAND and
VESSELS (inferior thyroid artery) |
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due to the significant morbidity and mortality associated with emergency tracheostomies, what approach is usually preferred in dire emergencies?
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CRICOTHYROTOMY (CRICOTHYROIDOTOMY)
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If a FOB fails, what is a subglottic approach that can be used to obtain an airway with less invasive means than tracheostomy or cricothyroidotomy
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RETROGRADE INTUBATION (RTI)-
1. First preoxygenate the pt 2. Spray posterior pharynx with local anesthetic 3. Prep skin overlying the cricothyroid membrane 4. If pt awake, treat glottic lumen with lidocaine 5. stabilize the thyroid cartilage and introduce the needle into the inferior portion of the cricothyroid membrane- avoid superior portion b/c this is where the cricothyroid artery branches are. angle needle cephalad- remove syringe- thread wire through needle- remove needle and retrieve wire through mouth. thread ett through mouth over wire and intubate- pull wire out completely. |
