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Airway (2) Flashcards

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1
Q

What are the components of the internal nasal cavity?

A

Divided by septum
Cribriform plate
Turbinates

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2
Q

What can be used to vasoconstrict vessels in the nose?

A

Phenylephrine
Afrin
Lidocaine jelly

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3
Q

What makes up the roof of the mouth vs the floor of the mouth?

A

Roof:
Maxilla and palatine bones
Hard palate
Soft palate
Teeth

Floor:
Tongue
Mandible
Teeth

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4
Q

What is one of the primary causes for upper airway obstruction during anesthesia?

A

Loss of pharyngeal muscle tone

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5
Q

What is the pharynx?

A

Muscular tube (AKA throat)

Base of skull to lower border of cricoid cartilage

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6
Q

What are the different sections that the pharynx is divided into?

A

Nasopharynx
→Ends at soft palate

Oropharynx
→Soft palate to epiglottis

Hypopharynx
→Epiglottis to cricoid cartilage

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7
Q

Larynx is the gateway to the trachea and stretches from ___________ to lower end of _______ __________.

A

Epiglottis, Cricoid cartilage

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8
Q

Which laryngeal cartilages are unpaired?

A

Thyroid
Cricoid - complete ring
Epiglottis

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9
Q

Which laryngeal cartilages are paired?

A

Arytenoid
Corniculate
Cuneiform

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10
Q

Which laryngeal cartilage is the only one to have complete ring?

A

Cricoid cartilage

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11
Q

Trachea extends from ________ _______ _________ to ________

A

Inferior cricoid membrane, carina

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12
Q

The average adult trachea is _____cm

A

10-15 cm

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13
Q

How is tracheal cartilage shaped?

A

C-shaped
→Closed posteriorly by longitudinal trachealis muscle
→Anteriorly bounded by tracheal rings

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14
Q

What might you consider if you are worried you wont be able to adequately ventilate the patient?

A

Awake intubation

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15
Q

What is the most valuable part of patient pre assessment in regards to airway assessment?

A

Patient history: ask direct questions

Hx of difficult airway may report as: sore throat/jaw from prior anesthesia

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16
Q

What things would be concerning when asking patient history?

A

Past difficult intubation – most predictive factor

Report of excessive sore throat

Report of cut lip/broken tooth

Recent onset of hoarseness: subglottic stenosis

History of OSA

Lesions intra-orally…. base of tongue, lingual tonsils

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17
Q

Why is it important to assess submandibular space?

A

That is where the tissue is displaced when intubating

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18
Q

If the patient can slide their mandible _______, then its a good sign for intubation.

A

anteriorly (bottom teeth over top lip)

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19
Q

Neck circumference greater than ______ is a concern for difficult intubation.

A

> 43cm

Better predictor than BMI

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20
Q

Inter-incisor distance of ____ suggests possibility of difficult intubation.

A

2 finger breadths (<6cm)

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21
Q

What is the ideal inter-incisor distance we want to see?

A

> 6cm (3 finger-breadths)

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22
Q

Which common drug could cause airway issues and difficulty with intubation? How can this be treated?

A

ACE inhibitors–angioedema, massive tongue

Treat with FFP/TXA

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23
Q

What is macroglossia?

A

Enlarged tongue

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24
Q

What’s a consideration for patient that dont have teeth?

A

Difficult mask ventilation

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25
25% of closed insurance claims against anesthesia providers are from ________ injuries
Dental
26
When do dental injuries commonly occur during anesthesia delivery?
75% occur during tracheal intubation Difficult or emergency airway management Laryngoscope blade Rigid suction catheters Oropharyngeal airway placement Rigorous removal of airways Biting down on ETT/LMA/airways during emergence
27
What is the Sniffing position? What the purpose?
Cervical flexion and atlanto-occipital extension Aligns oral, pharyngeal, and laryngeal axis
28
What is being measured when assessing head/neck mobility with sternomental distance? What distance is preferred?
Distance between notch and chin Head in full extension, mouth closed >12.5cm preferred
29
What is thyromental distance? What is the preferred distance?
Measuring from tip of chin to thyroid notch--looking at submandibular compliance >6.5cm (3 finger-breadths) preferred
30
What is prognathic ability measuring?
Extension of lower incisors beyond upper incisors (bitting upper lip)
31
What is the gold standard of airway tests?
Mallampati Test--external airway eval visibility of oropharyngeal structures
32
What position is the patient in for the mallampati assessment?
Pt seated upright Mouth open, tongue protruded No phonation
33
How many mallampati classes are there?
1-4: 4 is the hardest airway
34
What is visualized in Mallampati class 1?
Fauces, pillars, entire uvula, and soft palate
35
What are fauces?
Arched opening at the back of the mouth leading to the pharynx
36
What structures are visualized with mallampati class 2?
Fauces, portion of the uvula, and soft palate
37
What structures are visualized with mallampati class 3?
Base of uvula and soft palate
38
What is seen with mallampati class 4?
Only hard palate
39
What mallampati class is this?
Class 1
40
What mallampati class is this?
Class 2
41
What mallampati class is this?
Class 3
42
What mallampati class is this?
Class 4
43
What is BURP laryngeal manipulation?
External pressure B: backward U: upward R: rightward P: pressure
44
How is optimal external laryngeal manipulation (OELM) achieved?
One person guiding the position of the tube and assistant to put pressure on the larynx
44
How is the Cormack-Lehane classification different from mallampati?
Cormack lehane: internal airway eval--laryngeal view
45
How many grades are involved with cormack-lehane classification?
Grade 1-4
46
CL-Grade 1:
Visualization of the entire glottis
47
How do pediatric airways differ from adults?
Vocal cord tissue in kids do not have calcification and will be same color as surrounding tissue (pink)
48
CL- grade 2:
Can only see the posterior portion of the glottis
49
CL-grade 3:
Can only visualize epiglottis, no part of the glottis is visible
50
CL_grade 4:
Epiglottis cannot be seen
51
CL Statistics
52
Criteria associated with difficult mask ventilation:
"OBESE" O: Obesity (BMI > 30 kg/m2) B: Beard E: Edentulous S: Snorer, OSA E: Elderly, male (Age > 55) & Mallampati 3 or 4
53
Predicting a difficult airway:
"BOOTS" Beard--may need LMA Obesity Older Toothless – “gather” cheek, 2 people Sounds – snoring, stridor
54
What is the 3-3-2 rule?
3 finger inter-incisor distance 3 finger thyro-mental distance 2 finger between superior notch and thyroid cartilage
55
What does the mallampati score relate mouth opening to?
Size of tongue
56
Assessment to identify difficult intubation:
"LEMON" L- Look – abnormal face, trauma, unusual anatomy Evaluate – 3-3-2 rule Mallampati score – I-IV, relates mouth opening to size of tongue Obstruction/obesity – tumor, infection Neck mobility
57
List of things associated with difficult airway
58
What factors may be clinically important to warrant an awake intubation?
- Suspected difficult laryngoscopy - Suspected difficult ventilation with face mask/supraglottic airway - Significant increased risk of aspiration - increased risk of rapid desturation - suspected difficult emergency invasive airway
59
Optimize ____ throughout the difficult airway algorithm
oxygenation
60
If an intubation attempt after induction of general anesthesia is a failure, what is the next step according to the difficult airway algorithm?
Limit attempts, consider calling for help or Limit attempts, and consider waking the patient up.
61
In the emergency pathway, if mask ventilation is not adequate and the supraglottic airway is not adequate, what should be considered?
Call for help for invasive access and attempt alternative intubation approaches as you prepare for an emergency invasive airway
62
What are the important features of a bougie?
- Strategically designed deflection at the tip - self-confirming - can intubate epiglottis-only views - leave the laryngoscope in - lubricate the tube, pull back and rotate if you get stuck - black stripe is 25 cm- at lips, mid trachea in an adult male
63
When would you want to use ketamine for intubating?
- Reactive airways - IM RSI - hypotension/sepsis
64
When would you want to avoid using ketamine for intubating?
- If hypertension/tachycardia undesirable - contraindication in high ICP (slowly dissolving)
65
What patients would you not want to use Sux?
- rhabdomyolosis - existing hyperkalemia - multiple sclerosis/ALS - muscular dystrophies/inherited myopathies - denervating injuries > 72 hours old - burns > 72 hours old - crush injuries > 72 years old - tetanus, botulism, and other exotoxin infections - severe infections > 72 hours old - immobilization (patients found down)
66
What are some other problems from using Sux?
- predisposition to malignant hyperthermia - bradycardia - fasciculations - increased ICP, myalgias, hastened desaturation - masseter spasm
67
What is the duration of action for sux and roc?
Sux: 5-10 minutes Roc: 30-90 minutes
68
What are physiologic killers in intubation?
Hypotension Hypoxemia Metabolic acidosis
69
What can you do to prevent fatal hypotension?
- have at least 2 PIVs or IO if unable to get PIV - judicious bolus of IVF wide open or vasopressor support (push dose pressors) - shoot for a higher than normal BP before intubating if possible (BP rarely goes up with emergent intubation)
70
What is the induction agent of choice in shock patients and why?
Ketamine - gives sympathetic surge and pain control *shock itself is a powerful anesthetic
71
What is the paralytic of choice for shock patients and why?
Rocuronium - gives a longer safe apnea time
72
What meds can you use as push dose pressors?
- Epi* - Phenylephrine - Vasopressin
73
What is delayed sequence intubation? When would you use it?
Procedural sedation for preoxygenation In critically ill, agitated patients who are hypoxemic that need to be intubated
74
What can you do to prevent a patient from desaturating while trying to secure a tube?
- NC at 15 LPM + BVM at 15 LPM - PEEP valve at 5 cm H2O
75
What would you consider if you are preoxygenating and can't get the sats >95%?
Lung shunt physiology (pulmonary edema, pneumonia, etc.)
76
What does intervention three - back up head elevated mean?
If they can breathe in that position, leave them there. Not everyone has to lay supine
77
What is the first intervention to correct acidosis?
Bicarbonate therapy may not be as beneficial as we think→ giving bicarb would potentially increase CO2 levels and making things worse or causing arrythmias Need to be able to blow off CO2 with adequate ventilation
78
What is the second intervention to correct acidosis?
Vapox - ventilator associated pre-oxygenation - start with NC at 15 LPM - then SIMV+PSV - Vt 8 ml/kg, 100% FiO2, PS 5-10 cm H2O, PEEP 5
79
What situations are a high aspiration risk and what can you do to prevent it?
Upper GI bleeding, bowel obstruction, pre-induction vomiting NGT prior to intubation, intubate in semi-upright position, bag early, but slightly less early
80
Initiate rescue maneuvers such as ventilation and cricothyrotomy ____ so that the paitnet has enough reserve to allow for calm and effective execution
Early
81
What are considered "dynamic airways"?
- Bullets (neck trauma) - Bites (anaphylaxis/angioedema) - Burns (thermal and caustic airway injuries)
82
A) Epiglottis B) Supraglottis C) Vocal Cords D) Glottis E) Subglottis F) Esophagus G) Trachea H) Larynx
83
A) Trachea B) Corniculate Cartilage C) Cuneiform Cartilage D) Epiglottis E) Vallecula

Health Assessment (27 decks)

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