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APEX > Airway Anatomy & Innervation > Flashcards

Airway Anatomy & Innervation Flashcards

(72 cards)

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1
Q

Laryngeal Muscles
INTRINSIC

A

Move vocal cords & phonation
- Cricothyroid
- Vocalis
- Thyroarytenoid
- Lateral cricoarytenoid
- Posterior cricoarytenoid
- Aryepiglottic
- Interarytenoid

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2
Q

What muscle shortens or relaxes the vocal cords?

A

Vocalis
ThyroaRytenoid = They Relax

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3
Q

What muscle elongates or tenses the vocal cord?

A

CricoThyroid = Cords Tense (SLN external innervation)

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4
Q

What muscle ABducts or opens the vocal cords?

A

Widens the glottis
Posterior CricoArytenoid = Please Come Apart

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5
Q

What muscle ADducts or closes the vocal cords?

A

Narrows the glottis
- Lateral CricoArytenoid = Let’s Close the airway
- Thyroarytenoid

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6
Q

What nerve innervates the cricothyroid?

A

Superior laryngeal nerve SEM
External branch

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7
Q

What sphincter closes the laryngeal vestibule?

A

Aryepiglottic

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8
Q

What sphincter closes the glottis posterior commisure?

A

Interarytenoid

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9
Q

Laryngeal Muscles
EXTRINSIC

A

Support the larynx & assist w/ swallowing
- Thyrohyoid
- Omohyoid
- Sternohyoid
- Digastric*
- Mylohyoid
- Stylohyoid

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10
Q

What muscles elevate the larynx?

A

Extrinsic laryngeal muscles
- Digastric (anterior & posterior)
- Mylohyoid
- Stylohyoid
- Thyrohyoid
- Omohyoid
- Sternohyoid

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11
Q

What muscles depress the larynx?

A

Extrinsic laryngeal muscles
- Thyrohyoid
- Omohyoid
- Sternohyoid

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12
Q

Trigeminal Nerve

A

Cranial nerve V
Provides sensory information to the face & head
1. Opthalmic - anterior ethmoidal nerve
2. Maxillary - sphenopalatine nerve
3. Mandibular - lingual nerve

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13
Q

V1

A

Opthalmic SENSORY
Nares & anterior 1/3 nasal septum

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14
Q

V2

A

Maxillary SENSORY
Turbinates & nasal septum

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15
Q

V3

A

Mandibular
Anterior 2/3 tongue (somatic)
Motor = mastication

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16
Q

Glossopharyngeal Nerve

A

Cranial nerve IX
Provides sensation from the oropharynx down to the anterior epiglottis - soft palate, oropharynx, tonsils, posterior 1/3 tongue, vallecula, anterior epiglottis

Gag reflex = afferent limb
Motor = swallowing & phonation

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17
Q

Vagus Nerve

A

Cranial nerve X
SLN & RLN
Innervates the larynx
SIS - internal branch
SEM - external branch

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18
Q

Superior Laryngeal Nerve
Internal Branch

A

Sensory SIS
Innervates the posterior side of the epiglottis to the vocal cords level (true vocal cords are ligaments - not innervated)

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19
Q

Superior Laryngeal Nerve
External Branch

A

Motor SEM
Innervates the CricoThyroid muscle
Cords tense

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20
Q

SLN Injury

A

RARE
Does not cause respiratory distress
Acute bilateral injury = hoarseness
- Vocal quality affected

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21
Q

Recurrent Laryngeal Nerve

A

Branches off the Vagus nerve inside the thorax
Sensory innervation below the vocal cords to the trachea
Motor innervation to ALL intrinsic laryngeal muscles except the cricothyroid

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22
Q

Unilateral RLN Injury

A

No respiratory distress
Most common nerve injury following subtotal thyroidectomy

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23
Q

Bilateral RLN Injury

A

Acute presentation w/ stridor & respiratory distress (unopposed cricothyroid muscles tensing)
- Similar presentation to laryngospasm
- EMERGENCY
- Treatment = emergent intubation or surgical airway

Chronic - no respiratory distress & typically well-tolerated

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24
Q

RLN Injury
Risk Factors

A

Overinflation ETT cuff or LMA, excessive neck stretching, neck tumor, neck surgery thyroid or parathyroid
Most common = thyroidectomy

Left side (RLN loops under the aortic arch):
PDA ligation, L atrial enlargement (mitral stenosis), aortic arch aneurysm, & thoracic tumor

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25
What areas need to be anesthetized to facilitate an awake intubation?
Tongue base Oropharynx Hypopharynx Larynx - Upper airway & vocal cords
26
Airway Blocks
1. Glossopharyngeal IX 2. Superior laryngeal 3. Transtracheal or recurrent laryngeal
27
Glossopharyngeal Block How to Perform
1. Insert the needle at the anterior tonsillar pillar (base of the palatoglossal arch) & aspirate 2. Confirm aspiration negative for air & blood 3. Depth 0.25-0.5 cm inject 1-2 mL LA 4. Repeat on the contralateral side
28
What indicates a successful glossopharyngeal block?
Soft palate, oropharynx, tonsil, posterior 1/3 tongue, & vallecula are anesthetized Glossopharyngeal nerve → afferent gag reflex
29
What risks are associated w/ the glossopharyngeal block?
5% siezure risk d/t intracarotid injection
30
Superior Laryngeal Block How to Perform
1. Inject LA at the inferior border of the greater cornu of the hyoid bone 2. Outside thyrohyoid membrane 1 mL + 2-3 mm deep to the thyrohyoid membrane 2 mL 3. Repeat on the contralateral side
31
What does air aspiration indicate when performing a superior laryngeal block?
Needle too deep
32
Transtracheal Block How to Perform
Recurrent laryngeal nerve block 1. Insert the needle through the cricothyroid membrane in the caudal direction 2. Aspirate 3. Ask patient to take deep breath before injection (cough will spray the LA upwards through the cords) 4. Inject 3-5 mL LA into the tracheal lumen
33
Adult Larynx
Provides airway protection, respiration, & phonation Anterior to C3-6
34
What components make-up the larynx?
Hyoid bone Thyrohyoid & cricothyroid ligaments Unpaired cartilages = epiglottis, thyroid, & cricoid Paired cartilages = arytenoid, corniculate, & cuneiform
35
Narrowest region in the adult airway:
Glottic opening
36
Pediatric Larynx
< 5 years old = funnel shaped Narrowest regions: - FIXED cricoid ring - Dynamic vocal cords
37
What is laryngospasm?
Sustained & involuntary laryngeal muscle contraction → inability to ventilate
38
Laryngospasm Reflex Pathway
Afferent = SLN internal branch Efferent = SLN external branch SEM - Cricothyroid elongates & tenses the vocal cords
39
Laryngospasm Causes
Airway manipulation during light anesthesia Airway secretions Surgery in the airway Hyperventilation/hypocapnia Surgical procedures in the airway Active or recent respiratory tract infection < 2 weeks Exposure to 2nd hand smoke Reactive airway disease GERD Age < 1 year old
40
Laryngospasm Prevention
Avoid airway manipulation during light anesthesia CPAP 5-10 cmH2O during inhalational induction & immediately after extubation Remove pharyngeal secretions & blood before extubation Tracheal extubation when deeply anesthetized or fully awake Laryngeal lidocaine DOA ≈ 30 minutes Lidocaine IV before extubation
41
Laryngospasm S/S
Inspiratory stidor Suprasternal & supraclavicular retractions during inspiration Paradoxical chest wall movement Increased diaphragmatic excursion Lower rib flailing Absent or altered ETCO2 waveform
42
Laryngospasm Treatment
1. 100% FiO2 2. Remove noxious stimuli 3. Deepen anesthesia 4. Larson maneuver, chin lift, and/or CPAP 5. Succinylcholine
43
Succinylcholine Laryngospasm Dose
Adult & child 0.1-1 mg/kg IV *Lower dose tends to preserve ventilation IM 4 mg/kg Children < 5 yo co-admin Atropine 0.02 mg/kg to prevent bradycardia
44
Succinylcholine Neonate & Infant Laryngospasm Dose
2 mg/kg IV IM 5 mg/kg
45
Laryngospasm Complications
Airway obstruction NPPE Pulmonary aspiration of gastric contents Cardiac dysrhythmias Cardiac arrest & death
46
Valsalva Maneuver
Exhalation against a closed glottis or obstruction Ex: Coughing, bucking, or bearing down ↑pressure in the thorax, abdomen, & brain
47
Muller Maneuver
Inhalation against a closed glottis Ex: Patient bites down on ETT & takes a deep breath Sub-atmospheric pressure in the thorax → negative pressure pulmonary edema
48
Upper Airway
Mouth & nares to the cricoid cartilage 1° functions to warm & humidify inspired air, filter particulate matter, & prevent aspiration
49
Upper Airway Obstruction
Awake patient - upper airway held open by dilator muscles that counteract the tendency for the airway to collapse when patient breathes (negative pressure gradient) Anesthetic agents reduce pharyngeal dilator muscle tone 1. Soft palate 2. Tongue 3. Epiglottis
50
Soft Palate Airway Obstruction
Tensor palatine muscle opens the nasopharynx Relaxation → obstruction
51
Tongue Airway Obstruction
Genioglossus muscle opens the oropharynx Relaxation → obstruction ***MOST COMMON***
52
Epiglottis Airway Obstruction
Hyoid muscles open the hypopharynx Relaxation → obstruction
53
What other factors contribute to upper airway obstruction?
Obesity, tongue size, tonsil & adenoid hypertrophy, & craniofacial deformities ↑soft tissue (neck) inside the box (head) Small craniofacial structure or craniofacial deformity ↓box size
54
Airway Resistance Oral vs. Nasal
Nasal passage airway resistance 2x as compared to through the mouth
55
Nasal Turbinates
3 on each side project from the lateral wall Highly vascular structures - Superior - Middle - Inferior ↑airway resistance through nasal passage
56
How to prevent nasal trauma during airway instrumentation (nasal ETT or NPA)?
Insert nasal ETT or NPA at 90° angle Direct b/w inferior turbinate & nasal cavity floor Orient bevel towards the turbinates - ensures leading edge travels along the septum to decrease injury to highly vascular turbinates risk
57
What adaptors are utilized w/ intubated patients to perform upper airway functions?
Heat & moisture exchanger HME warms & humidifies inspired air EFF cuff protects against aspiration
58
Lower Airway
Begins at the trachea & ends at the alveoli Incisors → carina ≈ 23 cm Bifurcations x23 generations ↑airways, total cross-sectional area ↓airflow velocity, cartilage, goblet cells, and ciliated cells
59
Goblet Cells
Produce mucus
60
Ciliated Cells
Clear mucus
61
Trachea
Begins at inferior cricoid cartilage border C6 Ends at the carina T4-5 2.5 cm wide 10-13 cm long 16-20 semi-circular cartilaginous rings open posteriorly Ciliated columnar epithelium Sensory innervation = Vagus
62
Carina
T4-5 (Angle of Louis) Bifurcates into the L & R mainstem bronchi Ciliated columnar epithelium
63
Mainstem Bronchi
L bronchus 5 cm 45° R bronchus 2.5 cm 25° – Mainstem more common Cuboidal epithelium
64
Pediatric Bronchi
Children up to 3 yo bronchi take off at 55° angle
65
Alveoli
Squamous epithelium Pneumocytes 1, 2, & 3 Neutrophils are present in smokers & patients w/ acute lung injury 300 million alveoli by 9 yo
66
Type 1 Pneumocytes
Provide gas exchange surface Flat squamous cells Cover 80% alveolar surface Form tight junctions
67
Type 2 Pneumocytes
Produce surfactant & type 1 pneumocytes Resistant to oxygen toxicity Able to perform cellular division
68
Type 3 Pneumocytes
Macrophages Fight lung infection Produce an inflammatory response
69
What increases as the airway birfurcates?
Number airways Total cross-sectional area
70
What decreases as the airway bifurcates?
↓airflow velocity ↓cartilage amount ↓goblet cells ↓ciliated cells
71
How many bifurcations are present?
23 generations Trachea 0 Bronchi 1-3 Bronchioles 4 Respiratory bronchioles 17 Alveolar ducts 20 Alveolar sac 23
72
What allows air movement b/w alveoli?
Pores of Kohn

APEX (18 decks)

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