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APEX > Airway Anatomy & Innervation > Flashcards

Airway Anatomy & Innervation Flashcards

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
Q

What areas need to be anesthetized to facilitate an awake intubation?

A

Tongue base
Oropharynx
Hypopharynx
Larynx
- Upper airway & vocal cords

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26
Q

Airway Blocks

A
  1. Glossopharyngeal IX
  2. Superior laryngeal
  3. Transtracheal or recurrent laryngeal
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27
Q

Glossopharyngeal Block
How to Perform

A
  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
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28
Q

What indicates a successful glossopharyngeal block?

A

Soft palate, oropharynx, tonsil, posterior 1/3 tongue, & vallecula are anesthetized

Glossopharyngeal nerve →
afferent gag reflex

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29
Q

What risks are associated w/ the glossopharyngeal block?

A

5% siezure risk d/t intracarotid injection

30
Q

Superior Laryngeal Block
How to Perform

A
  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
Q

What does air aspiration indicate when performing a superior laryngeal block?

A

Needle too deep

32
Q

Transtracheal Block
How to Perform

A

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
Q

Adult Larynx

A

Provides airway protection, respiration, & phonation
Anterior to C3-6

34
Q

What components make-up the larynx?

A

Hyoid bone
Thyrohyoid & cricothyroid ligaments
Unpaired cartilages = epiglottis, thyroid, & cricoid
Paired cartilages = arytenoid, corniculate, & cuneiform

35
Q

Narrowest region in the adult airway:

A

Glottic opening

36
Q

Pediatric Larynx

A

< 5 years old = funnel shaped
Narrowest regions:
- FIXED cricoid ring
- Dynamic vocal cords

37
Q

What is laryngospasm?

A

Sustained & involuntary laryngeal muscle contraction → inability to ventilate

38
Q

Laryngospasm Reflex Pathway

A

Afferent = SLN internal branch
Efferent = SLN external branch SEM
- Cricothyroid elongates & tenses the vocal cords

39
Q

Laryngospasm Causes

A

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
Q

Laryngospasm Prevention

A

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
Q

Laryngospasm S/S

A

Inspiratory stidor
Suprasternal & supraclavicular retractions during inspiration
Paradoxical chest wall movement
Increased diaphragmatic excursion
Lower rib flailing
Absent or altered ETCO2 waveform

42
Q

Laryngospasm Treatment

A
  1. 100% FiO2
  2. Remove noxious stimuli
  3. Deepen anesthesia
  4. Larson maneuver, chin lift, and/or CPAP
  5. Succinylcholine
43
Q

Succinylcholine
Laryngospasm Dose

A

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
Q

Succinylcholine
Neonate & Infant Laryngospasm Dose

A

2 mg/kg IV
IM 5 mg/kg

45
Q

Laryngospasm Complications

A

Airway obstruction
NPPE
Pulmonary aspiration of gastric contents
Cardiac dysrhythmias
Cardiac arrest & death

46
Q

Valsalva Maneuver

A

Exhalation against a closed glottis or obstruction
Ex: Coughing, bucking, or bearing down
↑pressure in the thorax, abdomen, & brain

47
Q

Muller Maneuver

A

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
Q

Upper Airway

A

Mouth & nares to the cricoid cartilage
1° functions to warm & humidify inspired air, filter particulate matter, & prevent aspiration

49
Q

Upper Airway Obstruction

A

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
Q

Soft Palate Airway Obstruction

A

Tensor palatine muscle opens the nasopharynx
Relaxation → obstruction

51
Q

Tongue Airway Obstruction

A

Genioglossus muscle opens the oropharynx
Relaxation → obstruction

MOST COMMON

52
Q

Epiglottis Airway Obstruction

A

Hyoid muscles open the hypopharynx
Relaxation → obstruction

53
Q

What other factors contribute to upper airway obstruction?

A

Obesity, tongue size, tonsil & adenoid hypertrophy, & craniofacial deformities
↑soft tissue (neck) inside the box (head)
Small craniofacial structure or craniofacial deformity ↓box size

54
Q

Airway Resistance
Oral vs. Nasal

A

Nasal passage airway resistance 2x as compared to through the mouth

55
Q

Nasal Turbinates

A

3 on each side project from the lateral wall

Highly vascular structures
- Superior
- Middle
- Inferior

↑airway resistance through nasal passage

56
Q

How to prevent nasal trauma during airway instrumentation (nasal ETT or NPA)?

A

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
Q

What adaptors are utilized w/ intubated patients to perform upper airway functions?

A

Heat & moisture exchanger HME warms & humidifies inspired air
EFF cuff protects against aspiration

58
Q

Lower Airway

A

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
Q

Goblet Cells

A

Produce mucus

60
Q

Ciliated Cells

A

Clear mucus

61
Q

Trachea

A

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
Q

Carina

A

T4-5 (Angle of Louis)
Bifurcates into the L & R mainstem bronchi
Ciliated columnar epithelium

63
Q

Mainstem Bronchi

A

L bronchus 5 cm 45°
R bronchus 2.5 cm 25°
– Mainstem more common
Cuboidal epithelium

64
Q

Pediatric Bronchi

A

Children up to 3 yo bronchi take off at 55° angle

65
Q

Alveoli

A

Squamous epithelium
Pneumocytes 1, 2, & 3
Neutrophils are present in smokers & patients w/ acute lung injury

300 million alveoli by 9 yo

66
Q

Type 1 Pneumocytes

A

Provide gas exchange surface
Flat squamous cells
Cover 80% alveolar surface
Form tight junctions

67
Q

Type 2 Pneumocytes

A

Produce surfactant & type 1 pneumocytes
Resistant to oxygen toxicity
Able to perform cellular division

68
Q

Type 3 Pneumocytes

A

Macrophages
Fight lung infection
Produce an inflammatory response

69
Q

What increases as the airway birfurcates?

A

Number airways
Total cross-sectional area

70
Q

What decreases as the airway bifurcates?

A

↓airflow velocity
↓cartilage amount
↓goblet cells
↓ciliated cells

71
Q

How many bifurcations are present?

A

23 generations

Trachea 0
Bronchi 1-3
Bronchioles 4
Respiratory bronchioles 17
Alveolar ducts 20
Alveolar sac 23

72
Q

What allows air movement b/w alveoli?

A

Pores of Kohn

APEX (18 decks)

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