Airway Management (Week 2)

Question 1

Upper Airway

Consists of (6 parts)

The _____ and _____ are also part of the upper GI tract

The ______ structures aid in preventing ______ into the trachea

Answer 1

Nose, Mouth, Pharynx, Larynx, Trachea, Mainstem Bronchi

Laryngeal, Aspiration

Question 2

Airway Anatomy

There are _____ openings to the human airway; the ____, leading to the ______ and the ____, leading to the ______

Answer 2

Two, Nose, Nasopharynx

Mouth, Oropharynx

Question 3

Pharynx

U-Shaped fibromuscular structure extending from base of the ____ to the _____ cartilage at the base of the esophagus

Answer 3

Skull, Cricoid

Question 4

Nasopharynx

Separated from the oropharynx by an _____ plane that extends posteriorly

At the base of the tongue, the _____ functionally separates the oropharynx from the laryngopharynx (or hypopharynx)

Answer 4

Imaginary

Epiglottis

Question 5

The ______ prevents aspiration by covering the _____ (the opening of the larynx) during swallowing

The _____ is a cartilaginous skeleton held together by ligaments and muscle

The Larynx is composed of nine cartilages. Name Them.

The _____ cartilage shields the _____ _____, which forms the vocal cords

Answer 5

Epiglottis, Glottis

Larynx

Thyroid, Cricoid, Epiglottic, and then in pairs: Arytenoid, Corniculate, and Cuneiform

Thyroid, Conus Elasticus

Question 6

Cranial Nerves & Sensory Function

The mucous membranes of the nose are innervated by the _____ division (VI) of the _____ nerve anteriorally, and by the ______ division (V2) posteriorly ( ___________ nerves)

The _______ nerves provide sensory fibers from the _______ nerve (V) to the superior and inferior surfaces of the hard and soft palate

Answer 6

Opthalmic, Trigeminal

Maxillary, Sphenopalatine

Palatine, Trigeminal

Question 7

Cranial Nerves & Sensory Function

The _______ nerve (I) innervates the nasal mucosa to provide the sense of ______

The ______ nerve and the _________ nerve (IX) provide general sensation to the anterior ____-____ and posterior ____-____ of the tongue

Branches of the ______ nerve (VII) and the _______ nerve (IX) provide the sensation of taste to those areas

Answer 7

Olfactory, Smell

Lingual, Glossopharyngeal

Two-Thirds, One-Third

Facial, Glossopharyngeal

Question 8

Cranial Nerves & Sensory Function

The ________ nerve (IX) also innervates the roof of the pharynx, the tonsils, amd the undersurface of the soft palate

Answer 8

Glossopharyngeal

Question 9

The Vagus Nerve

The _____ (X) cranial nerve; Provides sensation to the airway _____ the epiglottis

The _____ _____ _____ of the vagus nerve divides into an _____ (motor) nerve and an _____ (sensory) laryngeal nerve that provides sensory supply to the larynx ______ the epiglottis and vocal cords

Another branch of the vagus, the _____ _____ _____, innervates the larynx _____ the vocal cords and trachea

Answer 9

Vagus, Below

Superior Laryngeal Branch, External, Internal

Above

Recurrent Laryngeal Nerve

Below

Question 10

SLN and RLN (recap)

Sensory innervation from the mucosal lining of the larynx above the vocal folds is done by the _____ laryngeal branch of the _____ _____ _____ (X)

The _____ _____ _____, a branch of the vagus nerve (X), innervates the larynx below the vocal folds

Answer 10

Internal

Superior Laryngeal Nerve

Recurrent Laryngeal Nerve

Question 11

The external branch of the SLN innervates the ______ muscle

However, the RLN is still considered the major ______ nerve of the larynx since it supplies all other intrinsic muscles of the larynx (except for the crycothyroid muscle)

Answer 11

Cricothyroid

Motor

Question 12

The internal branch of the SLN is the major _____ nerve of the larynx, supplying laryngeal tissue from the vocal cords up, ______ the vocal cords

Answer 12

Sensory

Including

Question 13

Functions of Intrinsic Laryngeal Muscles

Discuss the “big” three…

Posterior Cricoarytenoids?

Cricothyroids?

Thyroarytenoids?

Answer 13

Abduct vocal cords (dialtes cords)

Increase vocal cord tension (tenses the cords)

Reduces cord tension (relaxes the cords)

Question 14

Vocal Cord Damage

Damage to the External Branch of SLN:

Will produce ______ and ______ in the voice, as the cords cannot be ______

The _______ muscle is paralyzed

Answer 14

Weakness and Huskiness, Tensed

Cricothyroid

Question 15

Vocal Cord Damage

Damage to the Unilateral Right RLN:

Most common injury after a ______ ___________

Characterized by _______

Also characterized by one paralyzed cord (flaccid cord) that assumes an _______ position (midway between abduction and adduction)

Answer 15

Subtotal Thyroidectomy

Hoarseness

Intermediate

Question 16

Vocal Cord Damage

Damage to the bilateral RLN’s: (Extremely Rare)

Characterized by _____ and paralyzed cords

Each paralyzed cord assumes an _______ position (midway between abduction and adduction)

The cords can flop together causing ______ _______ during ______

______ is required

Answer 16

Aphonia

Intermediate

Airway Obstruction, Inspiration

Intubation

Question 17

Vocal Cord Damage (Clinical Consideration)

_______ after thyroidectomy may result from either ________ (tensed cords due to tetany) or bilateral damage to the _______ _____ ______ (floppy cords)

Answer 17

Stridor, Hypocalcemia

Recurrent Laryngeal Nerves

Question 18

Sensory Innervation of Tongue

Responsible nerves?

Internal laryngeal branch of the _____

__________ nerve (IX)

______ nerve and ______ tympani

Answer 18

SLN

Glossopharyngeal

Lingual, Chorda

Question 19

Phonation

Involves complex _______ actions by several laryngeal muscles

Damage to the _____ nerves innervating the larynx leads to a spectrum of ______ disorders

________ denervation of a cricothyroid muscle causes very _____ clinical findings

Answer 19

Simultaneous

Motor, Speech

Unilateral, Subtle

Question 20

Phonation

Bilateral palsy of the SLN may result in ______ or ______ of the voice, but ______ control is not jeopardized

Unilateral paralysis of the RLN results in paralysis of the _______ vocal cord, causing deterioration in ______ ______

Acute bilateral RLN nerve palsy can result in ______ and _______ distress due to the unopposed tension of the cricothyroid muscles

Answer 20

Hoarseness, Fatigue

Ipsilateral, Voice Quality

Stridor, Respiratory

Question 21

Phonation

Airway problems are less frequent in _______ bilateral RLN loss due to the development of compensatory mechanisms

Bilateral injury to the ______ (X) nerve affects both the SLN and RLN. Bilateral vagal denervation produces ______, midpositioned vocal cords. Although ______ is severely impaired in these patients, ______ control is rarely a problem

Answer 21

Chronic

Vagus, Flaccid

Phonation, Airway

Question 22

Blood Supply

The blood supply of the larynx is derived from branches of the _____ ______

The ______ thyroid artery is a branch off the ______ carotid artery. The _______ artery arises from the superior thyroid artery.

Answer 22

Thyroid Arteries

Superior, External

Cricothyroid

Question 23

Trachea

The trachea begins ______ the cricoid cartilage and extends to the ______, (the point at which the right and left mainstem bronchi divide)

The trachea consists of cartilaginous rings _______

The trachea is membranous _______

Answer 23

Beneath, Carina

Anteriorly

Posteriorly

Question 24

Routine Airway Management

Airway ________

Preparation and _______ check

_______ positioning

____-oxygenation

_____ and _____ ventilation (BMV)

_______ (if indicated)

_______ of OETT placement

________ management and troubleshooting

________ (final step)

Answer 24

Assessment

Equipment

Patient

Pre

Bag and Mask

Intubation

Confirmation

Intraoperative

Extubation

Question 25

Airway assessment is the _____ step in successful airway management. Several maneuvers can be performed to estimate difficulty of ET intubation

Name these assessments (5)

Answer 25

First

Mouth opening

Upper lip bite test

Mallampati classification

Thyromental distance

Neck circumfrence

Question 26

Mouth Opening/Upper Lip Bite Test

An incisor distance of ____ or greater is desirable in an adult

The lower teeth are brought in front of the upper teeth. The degree to which this can be done estimates the ______ of ______ of the ______________ joints

Answer 26

3 cm

Range of Motion

Temporomandibular

Question 27

Mallampati Classification

Class I: The entire ____ ____, including bilateral faucial pillars, are visible down to their bases

Class II: The ____ part of the faucial pillars and most of the _____ are visible

Class III: Only the ____ and ____ palates are visible

Class IV: Only the ____ palate is visible

Answer 27

Palatal Arch

Upper, Uvula

Soft and Hard

Hard

Question 28

Mallampati Classification

Examines the size of the ______ in relation to the oral cavity

The more the tongue ______ the view of the pharyngeal structures, the more difficult ______ may be

Answer 28

Tongue

Obstructs, Intubation

Question 29

Cricoid Pressure

Answer: Kg and Newtons

Answer 29

3-5 kg of pressure (6-11 lbs)

(30 Newtons)

Question 30

Thyromental Distance/Neck Circumfrence

The distance between the ______ and the superior thyroid notch. A distance of __ ________ or more is desirable. Less than __ ________ is not reassuring

A neck circumfrence greater than __ inches is suggestive of difficulties in visualization of the ______ opening

Answer 30

Mentum

3 fingerbreadths

3 fingerbreadths

17

Glottic

Question 31

Equipment

Preparation is mandatory

___ source

____ capability

_________ (direct and video)

Several ____’s (different sizes)

Alternate airways (____, _____)

_______ equipment

Pulse _____ and ____ detector

Stethoscope

Tape

BP and ____ monitors

___ access

Answer 31

O2

BMV

Laryngoscope

OETT’s

Oral, Nasal

Suction

Oximetry, CO2

EKG

IV

Question 32

Oral & Nasal Airways

Loss of upper airway ____ tone in anesthetized patients allows tongue and epiglottis to fall back against posterior wall of the _____

_______ the head or ____ ______ is the prefered technique for opening the airway

To maintain the opening, an ______ airway can be inserted through the mouth or nose

Answer 32

Muscle

Pharynx

Repositioning, Jaw Thrust

Artificial

Question 33

Oral & Nasal Airways

Awake or lightly anesthetized patients with intact _____ reflexes may cough or even devlop _______ during airway insertion

Placement of an oral airway is sometimes facilitated by supressing airway _____, and in addition, by depressing the tongue with a _____ ______

Answer 33

Laryngeal, Laryngospasm

Reflexes, Tongue Blade

Question 34

Oral & Nasal Airways

Typical sizes?

The length of the nasal airway can be estimated as the distance from the ____ to the _____ of the _____, and should be _____ longer than oral airways

Due to risk of epistaxis, nasal airways are less desirable in _______ or _______ patients

Answer 34

Small (80 mm, #3), Medium (90mm, #4), or Large (100 mm, #5)

Nares to the Meatus of the Ear

2-4 cm

Anticoagulated or Thrombocytopenic

Question 35

Oral & Nasal Airways

Nasal airways and NG tubes should be used in caution for patients with _____ _____ fractures

All tubes inserted through the nose should be ______ before being advanced along the floor of the nasal passage

Answer 35

Basilar Skull

Lubricated

Question 36

The Face Mask

Can facilitate the delivery of ____ or an ______ ____

Transparent masks allow observation of ______ humidified gas and immediate recognition of ______

Answer 36

Oxygen, Anesthetic Gas

Exhaled, Vomitus

Question 37

The Face Mask

If the mask is held with the ____ hand, the ____ hand can be used to generate positive pressure ventilation by squeezing the AMBU bag

The mask is held against the face with ______ pressure which is exerted with the left _____ and _____ finger

The ____ and ____ fingers grasp the mandible to facilitate extension of the __________ joint

Answer 37

Left, Right

Downward, Thumb, Index

Middle, Ring

Atlantooccipital

Question 38

The Face Mask

Finger pressure should be placed on the bony _____ and not on the _____ ______ supporting the base of the tongue, which may obstruct the ______

The _____ finger is placed under the angle of the jaw and used to _____ the jaw anteriorly; this is the most important manuever to allow ______ to the patient

Answer 38

Mandible, Soft Tissues, Airway

Pinky, Thrust, Ventilation

Question 39

The Face Mask

In difficult situations, _____ hands may be needed to provide adequate jaw thrust and to create a mask ___. An assistant may be needed to squeeze the bag

The _____ hold the mask down and the _____ or _____ displace the jaw forward

Obstruction during ______ may be from excessive ______ ______ from the mask

Answer 39

Two, Seal

Thumbs, Fingertips or Knuckles

Expiration, Downward Pressure

Question 40

The Face Mask

It is often difficult to form an adequate mask ____ with the cheeks of ______ patients

_______-pressure ventilation using a mask should be normally limited to ____ cm H2O to avoid _____ inflation

Answer 40

Fit, Edentulous

Positive, 20, Gastric

Question 41

The Face Mask

Mask ventilation for long periods may result in pressure injury to branches of the _____ or _____ nerves

Bc of abscence of _____ airway pressures during _______ ventilation, only minimal _______ force on the face mask is required to create an adequate seal

Answer 41

Trigeminal, Facial

Positive, Spontaneous, Downward

Question 42

Positioning

Alignment of oral and pharyngeal axes is achieved by having patient in a “______” position

When _____ spine pathology is suspected, the head must be kept in a ______ position during all airway manipulations

__-_____ stabilization of the neck must be maintained during airway management in these patients, unless appropriate films have been reviewed/cleared by radiologist or surgeon

Answer 42

Sniffing

Cervical, Neutral

In-Line

Question 43

Positioning

Patients with morbid obesity should be positioned on a ___ degree _____ ramp

Obese patients have a decreased _____ _____ _____ (FRC), leading to deterioration in the _____ position

Answer 43

30, Upward

Functional Residual Capacity

Deterioration

Question 44

Preoxygenation

Preoxygenation with a face mask should precede all _____ mgmt interventions

Oxygen is delivered via mask for _____ minutes prior to induction

Due to this, the _____ _____ _____ (the patient’s oxygen reserve) is purged of _____

Answer 44

Airway

Several

Functional Residual Capacity, Nitrogen

Question 45

Preoxygenation

The preoxygenated patient may have a __-__ minute oxygen reserve

Conditions that increase oxygen _____ (sepsis, pregnancy) and conditions that decrease ____ (morbid obesity, pregnancy) reduce the tolerated apneic period before _______ occurs

Answer 45

5-8 minute

Demand, FRC, Desaturation

Question 46

Bag and Mask Ventilation

BMV is the first step in airway mgmt in most cases, with the exception of patients undergoing _____ ______ intubation

In emergent situations, BMV precedes intubation attempts in effort to oxygenate patient, however, with that there is a risk of ______

If the airway is _____, squeezing the bag will result in a rise of the _____

Answer 46

Rapid Sequence

Aspiration

Patent, Chest

Question 47

Bag and Mask Ventilation

If ventilation is ineffective, (no chest rise, no ETCO2, no mist in clear mask), ___ and ____ airways can be placed to relieve airway ______

Difficult mask ventilation is often found in patients with ______, ______, and craniofacial _______

Answer 47

Oral, Nasal, Obstruction

Obesity, Beards, Deformities

Question 48

Supraglottic Airway Devices

SADS are used with both _____ and _____ patients during anesthesia

Can aid ET ______ when BMV and OETT placement have failed

These devices occlude the _____, reducing gas ____ of the stomach

____ offer the protection from _____ that is offered by a properly seated, _____ OETT

Answer 48

Spontaneously breathing, Ventilated

Intubation

Esophagus, Distention

None, Aspiration, Cuffed

Question 49

Laryngeal Mask Airway

The deflated cuff is inserted ______ into the ________ so that once inflated, the cuff forms a ___-pressure seal around the entrance to the larynx

This requires _____ depth and ______ relaxation slightly greater than that required for insertion of oral airway

Although insertion is simple, attention to _____ will improve the success rate

Answer 49

Blindly, Hypopharynx

Low-Pressure

Anesthetic, Muscle

Detail

Question 50

Laryngeal Mask Airway

An ideally positioned cuff is bordered by the base of the ____ superiorly, the _____ sinuses laterally, and the upper esophageal _____ laterally

If the ______ lies within the rim of the cuff, gastric _____ and ______ become possible

If an LMA is not a proper fit, most practicioners will try one size _____ or one size _____

Answer 50

Tongue, Pyriform, Sphincter

Esophagus, Distention, Regurgitation

Larger, Smaller

Question 51

Laryngeal Mask Airway

Contraindications:

Patients with _____ pathology (ex, abcess)

_____ obstruction

Full ____ (ex, pregnancy, hiatal hernia)

Low _____ compliance (restrictive airway disease) requiring peak insp. pressure >30 cm H20

Answer 51

Pharyngeal

Pharyngeal

Stomach

Pulmonary

Question 52

Laryngeal Mask Airway

Traditionally, the LMA has been avoided in patients with bronchospasm or high airway resistance, but new evidence suggests that because it is not placed in the _____, use of an LMA is associated with less bronchospasm than an _____

Answer 52

Trachea, OETT

Question 53

Laryngeal Mask Airway

A life saving temporary measure for patients with _____ airways due to its ease of insertion (95-99% success rate)

Can be used as a _____ for an intubating stylet or small ETT

Insertion can be performed under _____ anesthesia or bilateral SLN _____ blocks

Answer 53

Difficult

Conduit

Topical, Nerve

Question 54

Laryngeal Mask Airway

___ ___ is a common side effect following use

Correct device ____, avoidance of cuff _____, and ____ movement of jaw during placement may reduce likelihood of such injuries

Injuries to the _____, ______, and _____ have been reported

Answer 54

Sore Throat

Sizing, Hyperinflation, Gentle

Lingual, Hypoglossal, and RLN

Question 55

Esophageal-Tracheal Combitube

Has two fused tubes and usually inserted _____ through the mouth and advanced until two ____ ____ on the shaft lie between the upper and lower teeth

The ETC has two inflatable cuffs, a ___mL proximal cuff and a ___ mL distal cuff, both which should be fully inflated after placement

Answer 55

Blindly, Black Rings

100 mL, 15 mL

Question 56

Esophageal-Tracheal Combitube

Distal lumen usually lies in the _____ 95% of the time so that ventilation through the longer blue tube will force gas out of the side perforations into the larynx

The _____ clear tube can be used for ______ ________

Alternatively, if the Combitube enters the ______, ventilation through the clear tube will direct gas into the trachea

Answer 56

Esophagus

Shorter, Gastric Decompression

Trachea

Question 57

King Laryngeal Tube

Consists of tube with a small _____ balloon and a larger balloon for placement in the ________. Both tubes inflate through ____ inflation line

A suction port distal to the esophageal balloon is present, permitting _______ of the stomach

If ventilation is difficult, the KLT is likely inserted too ____. Slightly _____ the tube until compliance improves

Answer 57

Esophageal, Hypopharynx, One

Decompression

Deep, Withdraw

Question 58

Endotracheal Intubation

The shape and rigidity of the ETT can be altered by inserting a _____

The patient end is beveled to aid in ______ and insertion through the vocal cords

Resistance to airflow depends primarily on ______, but is also affected by tube _____ and _____

Answer 58

Stylet

Visualization

Diameter, Length, Curvature

Question 59

Endotracheal Intubation

Choice of tube ______ is always a compromise between maximizing _____ with a larger size or minimizing _____ _____ with a smaller size

The ____ in the ETT prevents air loss after cuff inflation

The _____ balloon provides a _____ indication of cuff ______

By creating a tracheal ____, ETT cuffs permit _____ pressure ventilation and reduce likelihood of _______

Answer 59

Diameter, Flow, Airway Trauma

Valve

Pilot, Gross, Inflation

Seal, Positive, Aspiration

Question 60

Endotracheal Intubation

For Infants and Children: ______ ONLY

Formula to calculate size?

Uncuffed tubes are often used in infants and young children to ______ the risk of pressure injury and post intubation _____, but in recent years, cuffed peds tubes have been favored

Answer 60

(Age + 16)/4 = ETT Size

Minimize, Croup

Question 61

Endotracheal Intubation

Two types of cuffs: ____ pressure (low volume) ____ pressure (high volume)

High pressure cuffs are associated with more _____ damage to the tracheal _____ and are less suitable for intubations of long _____

Low pressure cuffs may increased likelihood of ____ ____, ______, spontaneous _____, and ______ insertion (floppy cuff)

____ pressure cuffs prefered secondary to reduced chance of mucosal damage

Answer 61

High, Low

Ischemic, Mucosa, Duration

Sore Throat, Aspiration, Difficult

Low

Question 62

ETT Pressure

Cuff Pressure depends on several factors:

_____ volume

______ of the cuff in relation to the trachea

_____ and _____ compliance

____-____ pressure (cuff pressures increase when coughing)

Answer 62

Inflation

Diameter

Tracheal, Cuff

Intra-Thoracic

Question 63

Specialized ET Tubes

Specialized tubes that resist ____ may be valuable in some ____ and ____ surgical procedures or in the ____ patient

Preformed ____ tubes may be helpful for ____ and ____ intubation in ____ and ____ surgery

Answer 63

Kinking, Head and Neck

Prone

Curved, Nasal, Oral

Head and Neck

Question 64

Laryngoscopes

An instrument used to examine the larynx and to facilitate _______ of the trachea

The handle usually contains batteries to a light bulb on the _____ tip

Prefered type of blade depends on personal preference and patient _______

Remember: MAC = ______ and Miller = ______

Answer 64

Intubation

Blade

Anatomy

Valeculla, Epiglottis

Question 65

Video Laryngoscope

There is a video chip or a lens/mirror at the tip of the intubation _____ to transmit a view of the ______ to the operator

These are great for ______ airways or to minimize manipulation of the _____

Video intubating _____ have a video capability and light source.

Answer 65

Blade

Glottis

Difficult, Neck

Stylets

Question 66

Flexible Fiberoptic Bronchoscopes (FOB)

Patients with ______ cervical spines, poor range of _____ of the __________ joint, or certain congenital or acquired _____ airway abnormalities– _______ may be undesirable or impossible

A flexible FOB allows ______ visualization of the larynx in such cases, or in any situation in which ______ intubation is planned

Answer 66

Unstable, Motion of the Temporomandibular, Upper

Laryngoscopy

Indirect, Awake

Question 67

Flexible Fiberoptic Bronchoscopes (FOB)

Bronchoscopes are constructed of coated glass fibers that transmit light and images _____ reflection (light beam becomes trapped within a fiber and exits unchanged at the opposite end)

______ channels allow suctioning of secretions, insufflation of oxygen, or installation of a local ______

Answer 67

Internal

Aspiration, Anesthetic

Question 68

Intubation Indications

Inserting a tube into the trachea is one way of delivering a _____ _____

An OETT is also placed to _____ the airway and for airway access

An OETT is placed in patients that are at risk for ______

Also for those undergoing surgical procedures involving body ____ or the ____ and ____

Answer 68

General Anesthetic

Protect

Aspiration

Cavities, Head and Neck

Question 69

Direct Laryngoscopy Preparation

Preparation includes checking _____ and properly _____ the patient

The OETT should be examined; The tube’s _____ _____ _____ can be tested by _____ the cuff using a ___mL syringe

Maintenance of cuff pressure ____ detaching the syringe ensures proper cuff and valve function

Answer 69

Equipment, Positioning

Cuff Inflation System, Inflating, 10 mL

After

Question 70

Direct Laryngoscopy Preparation

The ____ should be pushed firmly into the tube to decrease the likelihood of disconnection

If a _____ is used, it should be inserted into the OETT, which is then bent to resemble a hockey stick

The desired ____ is locked onto the laryngoscope handle, and ____ function is tested. _____ intensity should remain constant, even if the bulb is jiggled

Answer 70

Connector

Stylet

Blade, Bulb

Light

Question 71

Direct Laryngoscopy Preparation

An extra _____, _____, _____ (one size smaller than the anticipated size), and _____ should always be immediately available

A functioning _____ unit is needed to clear airway in case of unexpected secretions, blood, or emesis

Answer 71

Handle, Blade, OETT, Stylet

Suction

Question 72

Direct Laryngoscopy Preparation

Often depends on correct ______ positioning

Patient’s head should be _____ with the CRNA’s waist or higher to prevent ____ strain

Direct laryngoscopy displaces ______ soft tissues to create a direct line of vision from the mouth to the _____ opening

Head elevation __-__ cm above the surgical table and extension of the ________ joint place the patient in desired ______ position

Answer 72

Patient

Level, Back

Pharyngeal, Glottic

5-10 cm, Altantooccipital, “Sniffing”

Question 73

Direct Laryngoscopy Preparation

Preparation for induction and intubation also involves _______

Giving 100% oxygen provides an extra ____ of _____ in case the patient is not easily _____ after induction

Preoxygenation can be omitted in patients who object to the ____ ____, however, failing to preoxygenate increases the risk of rapid _______ following apnea

Anesthesia removed the protective _____ reflex, so the eyes are usually ____ shut to prevent corneal abrasions

Answer 73

Pre-oxygenation

Margin of Safety, Ventilated

Face Mask, Desaturation

Corneal, Taped

Question 74

Orotracheal Intubation

The laryngoscope is held in the ____ hand

With the patient’s mouth open, the blade is introduced into the ____ side of the oropharynx, avoiding the ____

The tongue is then swept to the ____ and ____ into the floor of the pharynx by the blade’s flange

Successful “______” of the tongue ______ clears the view for OETT placement

Answer 74

Left

Right, Teeth

Left, Up

Sweeping, Leftward

Question 75

Orotracheal Intubation

The curved blade is usally inserted into the ______, and the straight blade tip covers the ______

With either blade, the handle is raised ____ and ____ from the patient in a plane _________ to the patient’s mandible to expose the vocal cords

Do not trap the patient’s ___ between the teeth or use the teeth for ______

Answer 75

Vallecula, Epiglottis

Up and Away, Perpendicular

Lips. Leverage

Question 76

Orotracheal Intubation

The OETT is taken with the ____ hand and passed through the _____ vocal cords

The “_____, _____, _____ ,_____ (BURP) manuever applied externally, moves an _____ positioned glottis _____ to facilitate visualization of the glottis

The OETT cuff should lie in the upper _____, but beyond the ______

Answer 76

Right, Abducted

Backward, Upward, Rightward, Pressure

Anteriorly, Posteriorly

Trachea, Larynx

Question 77

Orotracheal Intubation

The cuff is inflated with the ____ amount of air necessary to create a seal during positive pressure ventilation to minimize the pressure transmitted to the ______

Over inflation beyond ____ mmHg may inhibit _____ blood flow, injuring the trachea

Compressing the ____ ______ with the finger is NOT a reliable method of determining whether cuff pressure is sufficient or excessive

Answer 77

Least, Mucosa

30, Capillary

Pilot Balloon

Question 78

Orotracheal Intubation

After intubation, the _____/______ are immediately auscultated and ______ tracing monitored

_____ will not be produced if there is no cardiac output

____ through the tube and visualization of the tracheal ____ and ____ will likewise confirm correct placement

The persistent detection of ___ by a capnograph is the best confirmation of ______ placement of an OETT, but it cannot exclude ______ intubation

Answer 78

Chest/Epigastrium, Capnograph

ETCO2

FOB, Rings and Carina

CO2, Tracheal, Bronchial

Question 79

Orotracheal Intubation

The earliest evidence of ______ intubation is often an increase in _____ ______ pressure

Proper tube location can also be confirmed by ______ the cuff in the ______ notch while ______ the pilot balloon with the other hand

The cuff should not be felt above the level of the ______ cartilage, as this may result in postop hoarseness and increases risk of accidental _______

Answer 79

Bronchial, Peak Inspiratory

Palpating, Sternal, Compressing

Cricoid, Extubation

Question 80

Orotracheal Intubation

Tube position can also be confirmed by chest _____

If there is doubt as to whether the tube is in the _____ versus the _____, repeat the laryngoscopy to confirm placement

A _____ intubation should not be followed by identitcal ____ attempts

Answer 80

XRAY

Esophagus, Trachea

Failed, Repeated

Question 81

Orotracheal Intubation

______ must be made to increase the likelihood of success, such as _______ the patient, _____ pressure, _____ the tube size, adding a _____, selecting a different _____, using an indirect _______, attempting a _____ route, or requesting _______ from another anesthesiologist

Answer 81

Changes

Repositioning

Cricoid

Decreasing tube size

Adding Stylet

Different Blade

Indirect Laryngoscope

Nasal Route

Requesting assistance

Question 82

Orotracheal Intubation

If the patient is also difficult to ventilate with a ____, alternative forms of airway management must be _____ pursued

(LMA, Combitube, Cricothyrotomy, Tracheostomy)

Answer 82

Mask, Immediately

Question 83

Nasotracheal Intubation

Tube is advanced through the nose and nasopharynx into the _____ before laryngoscopy

The nostril through which the patient breathes most _____ is selected in advance and prepared with _______ nose drops (0.5% or 0.25%)

to _____ vessels and _____ mucous membranes

If the patient is awake, local ______ ointment, _____, and _____ blocks can be utilized

Answer 83

Oropharynx

Easily, Phenylephrine

Vasoconstrict, Shrink

Anesthetic, Spray, Nerve Blocks

Question 84

Nasotracheal Intubation

A lubricated ETT is introduced along the floor of the nose, below the inferior turbinate, at an angle ______ to the face. The tube’s bevel should be directed _____ away from the turbinates

The tube is gradually advanced until its tip can be seen in the _______

Laryngoscopy will reveal the abducted _____ _____

The distal end of the ETT can usually be advanced into the _____ without difficulty

Nasal passage of ETT’s, airways, or NG tube catheters carries greater risk in those with severe ___-_____ trauma due to risk of _______ placement

Answer 84

Perpendicular, Laterally

Oropharynx

Vocal Cords

Trachea

Mid-Facial, Intracranial

Question 85

Flexible Fiberoptic Intubation

FOI is routinely performed in ____ or ____ patients with ______ airways

FOI is ideal for:

A ____ mouth opening

Minimizing _____ spine movement in trauma or RA

_____ airway obstruction (angioedema, tumor mass)

Facial _____ or _____

Answer 85

Awake, Sedated

Small

Cervical

Upper

Deformities, Trauma

Question 86

Flexible Fiberoptic Intubation

Can be performed ____ or ____ and by ____ or ____ routes

Awake FOI: Predicted inability to _____ by mask, ____ airway obstruction

Asleep FOI: _____ intubation, desired for minimal _____ movement in patients who refuse awake intubation

Oral FOI: ____ or ____ injuries

Nasal FOI: A ____ mouth opening

Answer 86

Awake or Asleep, Oral or Nasal

Ventilate, Upper

Failed; C-Spine

Facial or Skull

Poor (Small)

Question 87

Flexible Fiberoptic Intubation

Airway is anesthetized with local _____ spray

____ nostrils are prepped with ______ drops

Identify the nostril through which patient breathes more _____

Shaft of FOB inserted into the ETT lumen. It is important to keep shaft of bronchoscope _____

As the tip of the FOB passes through the distal end of the ETT, the _____ or _____ should be visible

Answer 87

Anesthetic

Both, Vasoconstrictive

Easily

Straight

Epiglottis or Glottis

Question 88

Flexible Fiberoptic Intubation

Having an assistant thrust the jaw _____ or apply _____ pressure may improve visualization in difficult cases

Once in the trachea, the FOB is advanced within sight of the _____

The presence of tracheal ____ and the ____ is proof of proper positioning

Proper ETT position is confirmed by viewing the tip of the tube __ cm above the carina before the FOB is withdrawn

Answer 88

Thrust, Cricoid

Carina

Rings, Carina

3 cm

Question 89

Difficult Airway (Children)

1. Obtain ____
2. Second attempt to ____
3. Place ____
4. _____ Intubation or ______ Intubation
5. Proceed with ____ as airway, ____ airway, or ____ patient up

Answer 89

Help

Intubate

LMA

Lightwand, Fiberoptic

LMA, Surgical, Wake

Question 90

Surgical Airways

“_____” airways are required when the “can’t _____, can’t ____” scenario arises

Surgical _______

Catheter or needle ______

Trans-tracheal catheter with ____ ventilation

______ intubation

Answer 90

Invasive, Can’t Intubate-Can’t ventilate

Cricothyrotomy

Cricothyrotomy

Jet

Retrograde

Question 91

Surgical Airway Techniques

A 14g or 16g IV cannula is attached to a syringe and passed through the _____ toward the carina, then ____ is aspirated

Use short __ second bursts of oxygen to ventilate patient

Sufficient outflow of _____ air must be assured to avoid ______

Patients ventilated in this manner may develop ______ ______ and may become ______ despite adequate oxygenation

Answer 91

CTM, Air

1 Second

Expired, Barotrauma

Subcutaneous Emphysema, Hypercapnic

Question 92

Surgical Airway Techniques

Transtracheal jet ventilation will usually require _____ to a surgical airway or _____ intubation

If jet ventilation system is not available, a __mL syringe can be attached to the catheter with the syinge plunger removed. A 7.0mm ETT connector can be inserted into the _____ and attached to breathing circuit

Even still, adequate ______ must occur to avoid ______

Answer 92

Conversion, Tracheal

3mL, Syringe

Exhalation, Barotrauma

Question 93

Retrograde Intubation

A ____ is passed via a catheter placed in the ____

The _____ end of the wire is secured with a clamp to prevent it from passing through the ____

The wire can then be threaded into an ___ with a loaded ETT to facilitate and confirm placement

Also, a small ____ can be guided by the wire into the _____. Once placed, the wire is removed.

Answer 93

Wire, CTM

Distal, CTM

FOB

OETT’s, Trachea

Question 94

Problems Following Intubation

Anesthesia staff must _____ that the tube is correctly placed with ____ ventilation _____ following placement

Detection of ETCO2 remains the ____ standard for verification

Answer 94

Confirm, Bilateral, Immediately

Gold Standard

Question 95

Problems Following Intubation

Should the ETCO2 suddenly ____, ___ thrombus or venous ___ _____ should be considered

Other causes of sudden decline in cardiac output or a leak in the _____ should be considered

A rising ETCO2 may be secondary to ______ or increased CO2 production as occurs with ______ ______, ______, a depleted ____ absorber, or breathing circuit ________

Answer 95

Decline; Pulmonary, Air Embolism

Circuit

Hypoventilation, Malignant Hypothermia, CO2, Malfunction

Question 96

Problems Following Intubation

Increases in airway pressure may indicate an _____ or _____ ETT or _____ pulmonary compliance

The ET tube should be _____ to confirm that it is patent and the lungs _______ to detect signs of ______, pulmonary _____, _______ intubation, or _______

Decreases in airway ______ can occur secondary to ____ in the breathing circuit or ______ extubation

Answer 96

Obstructed, Kinked, Reduced

Suctioned, Auscultated, Bronchospasm, Edema, Endobroncial, Pneumothorax

Pressure, Leaks, Inadvertent

Question 97

Techniques of Extubation

Extubation should be performed when a patient is deeply _____ or ____

In either situation, adequate recovery from _____ ______ agents must be established prior to _______

Answer 97

Anesthetized, Awake

Neuromuscular Blocking

Extubation

Question 98

Techniques of Extubation

Extubation during a ____ plane of anesthesia (state between deep and awake) is avoided due to risk of _______

The distinction between deep and light anesthesia is apparent during ______ suctioning. Any reaction to suctioning (_____ holding, _____) signals a light plane of anesthesia. No reaction is characteristic of a ____ plane

____ opening or _____ movements imply that the patient is sufficiently awake for extubation

Answer 98

Light, Laryngospasm

Phargyngeal

Breath, Coughing, Deep

Eye, Purposeful

Question 99

Techniques of Extubation

Extubating an ____ patient is usually associated with _____ (bucking) on the ETT. This reaction increases ____ ____, _____, aterial ____, _____, Intra-____ pressure, and intra-_____ pressure

It may also cause wound _______ and increased ______

The presence of an ETT in an awake _____ patient may trigger _______

Answer 99

Awake, Coughing

Heart Rate, CVP, BP, ICP, Intra-Abdominal, Intra-Ocular

Dehiscence, Bleeding

Asthmatic, Bronchospasm

Question 100

Techniques of Extubation

The likelihood of these adverse events may be alleviated by giving 1.5 mg/kg of IV _____, 1-2 minutes before _____ and ______

Extubation during _____ anesthesia may be _____ in patients who cannot tolerate these effects (provided such patients are not at risk for aspiration and do not have airways that may be difficult to control post ETT removal)

Answer 100

Lidocaine, Suctioning and Extubation

Deep, Preferable

Question 101

Techniques of Extubation

The patient’s _____ should be thoroughly _____ before extubation to decrease the potential for _____ of _____ and ______

Patients should be ventilated with ____ oxygen in case it becomes difficult to establish an ______ after the ETT is removed

The ETT is withdrawn and a ____ ____ is applied to deliver O2

O2 delivery by face mask is maintained during the period of _______ to the _____

Answer 101

Pharynx, Suctioned

Aspiration of Blood and Secretions

100%, Airway

Face Mask

Transportation, PACU

Question 102

Complications of Largyngoscopy

Name 5

These complications can occur _____ laryngoscopy and _____, while tube is in _____, or following ______

Answer 102

Hypoxia

Hypercarbia

Dental/Airway Trauma

Tube Malpositioning

Physiological response to airway instrumentation or ETT malfunction

During, Intubation, Place, Extubation

Question 103

Airway Trauma

_____ damage is a common cause of ______ claims. A range of complications can occur from ____ _____ to ______ stenosis

This is due to prolonged ______ pressure on sensitive _____ structures

When these pressures exceed the _____-_____ blood pressure (approx 30 mmHg), _____ _____ can lead to a sequence of ______, _______, _______, and _______

Answer 103

Tooth, Malpractice

Sore Throat, Tracheal

External, Airway

Capillary-Arteriolar, Tissue Ischemia, Inflammation, Ulceration, Granulation, Stenosis

Question 104

Airway Trauma

Inflation of an ETT cuff to the _____ pressure that creates a ____ during routine ______-pressure ventilation (Usually at least ___ mmHg) reduces tracheal blood flow by ____ at the cuff site. Further cuff _____ can totally eliminate _____ blood flow

Answer 104

Minimum, Seal

Positive, 20 mmHg, 75%

Inflation, Mucosal

Question 105

Airway Trauma

Post intubation ____ cause by glottic, laryngeal, or tracheal _____ is serious in _____

Vocal cord paralysis from ____ ______ or other trauma to the _____ results in _____ and increases risk for _____

Incidence of post extubation hoarseness seems to be increased with _____, _____ ______, and anesthetics of long _____

Answer 105

Croup, Edema, Children

Cuff Compression, RLN, Hoarseness, Aspiration

Obesity, Difficult Intubations, Duration

Question 106

Airway Trauma

Smaller tubes (___ in women and ___ in men) are associated with fewer complaints of postop ____ ____

Repeated attempts at _____ during a difficult intubation may lead to _______ _____, and the inability to _____ with a face mask, thus turning a bad situation into a ____-______ one

Answer 106

6.5mm women, 7.0 mm men

Sore Throat

Laryngoscopy, Periglottic Edema, Ventilate

Life Threatening

Question 107

ETT Positioning Errors

Be aware of unrecognized ______ intubation

Need to directly _____ the tip of the ETT passing ____ the vocal cords with careful _______ for the presence of _____ breath sounds and the abscence of _____ _____ while ventilating through the ETT

Analysis of exhaled gas for ____ content is most _____ method

Also Chest ____ or use of an ____ is sufficient for confirmation

Answer 107

Esophageal

Visualize, Through, Auscultation, Bilateral

Gastric Gurgling

CO2, Reliable

XRAY, FOB

Question 108

ETT Positioning Errors

Even if confirmed that ETT is in trachea, it may not be _____ positioned

Overly ____ insertion usually results in intubation of the ____ mainstem bronchus due to the less acute angle in relation to the trachea

Answer 108

Correctly

Deep, Right

Question 109

ETT Positioning Errors

Clues to bronchial intubation may include ____ breath sounds, unexpected ____ with pulse ox, Inability to ______ the ETT cuff in the ____ notch, and ______ breathing bag compliance

Inadequate insertion ____ will position the cuff in the _____, predispositioning the patient to _____ trauma. This may the case if the ETT cuff can be palpated over the _____ cartilage

Answer 109

Unilateral, Hypoxia, Palpate

Sternal, Decreased

Depth, Larynx, Laryngeal

Thyroid

Question 110

ETT Positioning Errors

Minimal testing should include: chest _______, routine _______, and occasionally cuff _____

If the patient is _____, tube placement must be _______

At no time should excessive ____ be applied during intubation

Esophageal intubations can result in ______ _____ and ______

Answer 110

Auscultation, Capnography, Palpation

Repositioned, Reconfirmed

Force

Esophageal Rupture, Mediastinitis

Question 111

Physiological Response to Airway Instrumentation

Airway manipulation violates the patient’s _____ airway reflexes and predicatably leads to _____ and ______ when performed under ____ planes of anesthesia

Hemodynamic changes can be attenuated by IV ______, ______, or _____ blockers, or _____ planes of anesthesia in the minutes before ________

______ _____ may occur during intubation, indicating _____ plane of anesthesia

Answer 111

Protective, Hypertension, Techycardia

Light

Lidocaine, Opioids, Beta Blockers, Deeper

Laryngoscopy

Cardiac Arrythmias, Light

Question 112

Laryngospasm

Forceful, involuntary spasm of the laryngeal musculature caused by _____ stimulation of the _____

Triggers may include ______ ______ or passing an ETT through the larynx during ______. This can usually be prevented by _____ patients either _____ asleep or fully _____

Treatment: Providing gentle ____ pressure ventilation with anesthesia bag and mask using ____ O2

Answer 112

Sensory, SLN

Pharyngeal Secretions, Extubation, Extubating

Deeply, Awake

Positive

100%

Question 113

Laryngospasm

Giving _____ (1.0-1.5 mg/kg)

If laryngospasm continues and hypoxia develops, _______ (0.25-0.5 mg/kg) may be required (perhaps in combo with small doses of _____ or another anesthetic) to relax the laryngeal muscles and allow ______ ventilation

Answer 113

Lidocaine

Succinylcholine

Propofol

Controlled

Question 114

Laryngospasm

The large _____ intrathoracic pressures generated by a struggling patient during laryngospasm can result in development of ______-_____ pulmonary edema, even in healthy patients

______ may result from abnormally ____ reflex

______ may result from _____ of laryngeal reflexes following prolonged intubation and general anesthesia

Answer 114

Negative

Negative-Pressure

Laryngospasm, Sensitive

Aspiration, Depression

Question 115

Bronchospasm

Another reflexive response to ____ and most common in ____ patients

This can also sometimes be clue to ______ intubation

Answer 115

Intubation, Asthmatic

Bronchial

Question 116

Tracheal Tube Malfunction

Polyvinyl Chloride tubes may be _____ by _____ or laser in an ______/______ enriched environment

Valve or cuff damage is uncommon but should be ____ prior to insertion

ETT obstruction can result from ____, foreign body _____, or thick _____ in the lumen

Answer 116

Ignited, Cautery

Oxygen/Nitrous

Excluded

Kinking, Aspiration, Secretions