Airway

Question 1

Nasal Passages - cricoid cartilate

Answer 1

septum, turbinates UPPER AIRWAY
trigeminal nerve CN X
nasal passage very responsive to transmucosal anesthesia (lidocaine, afran)

Question 2

Oral cavity

Answer 2

teeth, tongue, hard palate, soft palate
posterior 1/3 tongue back,
glossalpharyngeal nerve
hard to eliminate gag reflex, not as responsive to transmucosal

Question 3

pharynx

Answer 3

nose to cricoid cartilage
nasopharynx - seperates soft palate
oropharynx - tonsils, uvula, epiglottis c2-c3

Question 4

cricoid cartilage

Answer 4

c6

Question 5

larynx

Answer 5

c3-c6
airway protection
respiration
phonation

Question 6

tube size

Answer 6

6.5-7 female
7-7.5 male
8-8.5 long term intubation
pressure of tube against cords can cause swelling therefore try for smallest possible

Question 7

3 paired cartilages

Answer 7

arytenoid
corniculate
cuneiform

Question 8

3 unpaired cartilages

Answer 8

thyroid
cricoid - external superior laryngeal
epiglottis

Question 9

cricoid

Answer 9

complete signet shaped ring of cartilage
external external superior laryngeal
narrowest point of pediatric airway (in adults, glottal opening)

Question 10

intrinsic laryngeal muscles

open and close glottis

Answer 10

all innervated by recurrent laryngeal 
 (AB and AD)
lateral cricoarytenoid (ADD)
arytenoids (ADD)
posterior cricoarytenoid (only ABD)

Question 11

intrinsic laryngeal muscles
tension on vocal ligament
elongate and shorten

Answer 11

cricothyroid - elongates (external superior laryngeal)
vocalis - shortens
thyroarytenoid - shorten and relax

Question 12

Extrinsic laryngeal muscles

Answer 12

sternohyoid
thyrohyoid
omohyoid
sternothyroid

Question 13

carina

Answer 13

5th thoracic vertebrae

Question 14

lower airway

Answer 14

main function - conduction of air and gas exchange
trachea, carina, bronchi, bronchioles, terminal bronchioles, resp bronchioles, alveoli

innervated by superior laryngeal

Question 15

trachea

Answer 15

sits opposite 6th cervical vertebrae
flattened in back
16-20 horse shoe cartilages
10-20 cm length and 22 mm diameter
R 2.5cm long 25 degree angle
L 5cm long 45 degree angle

Question 16

class I airway

Answer 16

faucil pillars
soft palate
uvula
full vocal cords

Question 17

class II airway

Answer 17

uvula masked by tongue

Question 18

class III airway

Answer 18

soft palate
uvula base
maybe just arytenoid (post attachement vocal cords)

Question 19

class IV airway

Answer 19

only hard palate

epiglottis

Question 20

thyromental distance

Answer 20

lower border mandible to thyroid notch with neck fully extended
normal 6-6.5cm or 4 finger breadths
less than 3 is difficult airway

Question 21

optimal intubating position

Answer 21

“sniffing” position
oral
pharyngeal
laryngeal

Question 22

preoxygenation

Answer 22

increased O2 conc in FRC. decreased nitrogen in FRC (79% in RA)
3-5 min tight mask tidal breathing of 100% O2 over 5L/min flow (healthy person tolerates up to 10 min apnea)
4 vital capacity breaths in 30 sec (healthy person tolerates up to 5 min apnea)

Question 23

airway setup

Answer 23

laryngoscope/ 2 blade types
oral/nasal airway
tongue depressor
ETT tubes 2 sizes
suction
ambu bag
stylet
LMA (difficult airway)

Question 24

nasal airways/trumpets

Answer 24

provide passageway (nose to pharynx) beneath obstructing tongue
length estimate dist from nare to meatus of ear
complications - epistaxs, nasal/basal skull fx, adenoid hypertrophy, anticoagulants???? bleeding

Question 25

laryngoscopes and blades

Answer 25

macintosh (curved, behind velicula) 1-4 | miller (straight, pick up epiglottis) 0-4

Question 26

Adult ETT sizes

Answer 26

6. 5, 7 females | 7. 5, 8 males

Question 27

how far does ETT go?

Answer 27

4cm above carina 2cm below vocal cords males approx 23 cm females approx 21 cm

Question 28

order of events

Answer 28

``` preoxygenate induction drug lash reflex test vent muscle rela laryngoscopy ```

Question 29

sensory innervation of airway

Answer 29

``` glossal pharyngeal internal branch superior laryngeal (above cords) recurrent laryngeal (below cords) ```

Question 30

motor innervation of airway

Answer 30

external branch superior branch laryngeal | recurrent laryngeal

Question 31

glossal pharyngeal CN IX

Answer 31

sensory o posterior 1/3 tongue and oropharynx to vallecula

Question 32

interior superior laryngeal (sensory)

Answer 32

branch of vagus, sensory to vocal cords and above ``` epiglottis base of tongue supraglottic mucosa thyroepiglottic joint cricothyroid joint ```

Question 33

recurrent laryngeal (sensory)

Answer 33

branch of vagus, mucosa below vocal cords | muscle spindles

Question 34

external branch superior laryngeal (motor)

Answer 34

motor to cricothyroid (adductor | tension on vocal cords)

Question 35

recurrent laryngeal (motor)

Answer 35

ALL intrinsic muscles of larynx (except for cricothyroid muscle) thyroarytenoid lateral cricoarytenoid interarytedoid (add) post arytenoid (ABD)

Question 36

external branch superior laryngeal (sensory)

Answer 36

anterior subglottic mucosa

Question 37

responses to tracheal intubation

Answer 37

cv - HTN, tachy, MI, resp - laryngospasm, bronchospasm trauma, esophageal intubation, et ignition, sore throat, croup

Question 38

induction sequence

Answer 38

1) preoxygenation 2) position in sniffing 3) monitors on/working 4) induction agent 5) lash reflex 6) test vent 7) check NM blocking monitor working 8) paralytic 9) tape eyes closed 10) continue bag/mask vent until paralytic drug takes effect (loss of twitches) 11) laryngoscopy and intubation 12) confirm ETT placement - bilat breath sound, chest rise, etco2 13) cont vent bag or ventilator 14) begin maintenance anesthetic 15) tape ETT

Question 39

indications for airway blocks

Answer 39

abolish or blunt reflexes | provide comfort and airway anesthesia during performance of these procedures

Question 40

complication of airway blocks

Answer 40

``` systemic toxicity (metal taste, seizure) hematoma formation ```

Question 41

transtracheal block

Answer 41

block recurrent laryngeal nerve - cricothyroid membrane (sensory but not motor) for awake laryngoscopy, riberpotic and/or retrograde intubation abolition of gag reflex, hemodynamic response results in anesthesia of trachea below vocal cords, cough stimulus spreads to upper continuously aspirate, caudad direction, visualize air bubbles, instruct to take deep breath, inject lidocaine on inspiration cough sill spread (SLN above VC)

Question 42

superior laryngealblock

Answer 42

internal (sensory) branch SLN blocks supraglottic region, abolition gag and hemodynamic respons palpate hyoid, displace toward side to be injected, inferior border cornu 23 g 1/75cm needle perpendicular into skin, 1/4 caudal, 1/4in medial 1-2cc LA 1-2cc above and helow thyrohyoid membrane, aspiration, if air, you are deep in pharynx repeat on other side... dont want air or blood

Question 43

glossopharyngeal nerve block

Answer 43

lingual branch GPH nerve sensory to back of tongue abolition gag and hemodynamic when topical application ineffective move tongue with blade, form gutter, 25g spinal needle at base of palatoglossal arch .5 cm deep and .5 cm lateral to tongue base aspirate before inn 1-2cc lidocaine air - too deep blood - withdraw and redirect needle medially