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Apex > Unit 1 Respiratory 1: Airway Anatomy > Flashcards

Unit 1 Respiratory 1: Airway Anatomy Flashcards

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1
Q

What are the intrinsic muscles of the larynx used for?

A

Phonation and/or vocal cord movement

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2
Q

What are the extrinsic muscles of the larynx used for?

A

Support the larynx inside the neck

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3
Q

Where do the true vocal cords attach anteriorly and posteriorly?

A

Anteriorly: to the thyroid cartilage
Posteriorly: to the arytenoid cartilage

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4
Q

Cricothyroid:
Function
Primary outcome of muscle contraction
Innervation

A

Function: adjusts length (tension) of the vocal ligaments
Primary outcome of muscle contraction: elongates (tenses)
Innervation: SLN (external)

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5
Q

Vocalis:
Primary outcome of muscle contraction
Innervation

A

Function: adjusts length (tension) of vocal ligaments
Primary outcome of muscle contraction: shortens (relaxes)
Innervation : RLN

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6
Q

Thyroarytenoid:
Primary outcome of muscle contraction
Innervation

A

Function: adjusts length (tension) of vocal ligaments AND glottic diameter
Primary outcome of muscle contraction: shortens (relaxes) AND adducts vocal folds (narrows glottis)
Innervation: RLN

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7
Q

Lateral cricoarytenoid:
Function
Primary outcome of muscle contraction
Innervation

A

Function: glottic diameter
Primary outcome of muscle contraction: adducts vocal folds (narrows glottis)
Innervation : RLN

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8
Q

Posterior cricoarytenoid
Function
Primary outcome of muscle contraction
Innervation

A

Function: glottic diameter
Primary outcome of muscle contraction: abducts vocal folds (widens glottis)
Innervation: RLN

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9
Q

Sphincter function of aryepiglottic? Interarytenoid?

A

Aryepiglottic: closes laryngeal vestibule - RLN
Interarytenoid: closes posterior commisure of glottis - RLN

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10
Q

What 6 extrinsic muscles elevate the larynx in the neck for breathing and swallowing?

A 
Stylohyoid
Geniohyoid
Mylohyoid
Thyrohyoid
Digastric
Stylopharyngeus
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11
Q

What 3 extrinsic muscles depress the larynx within the neck for breathing and swallowing?

A

Omohyoid
Sternohyoid
Sternothyroid

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12
Q

What nerve does the SLN branch off of and where?

A

SLN branches off of the vagus nerve just beyond the jugular foramen at the skull base

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13
Q

At what level does the SLN divide? What does it divide into?

A

At the level of the hyoid, the SLN divides into the internal and external branches

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14
Q

What does the internal branch of the SLN penetrate?

A

The thyrohyoid membrane between the greater Cornu of the hyoid bone

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15
Q

Where does the external branch enter?

A

The cricothyroid muscle

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16
Q

What does the RLN branch off of and where?

A

The RLN branches off of the vagus nerve inside the thorax

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17
Q

Both the right and left RLNs make loops before ascending tracheoesophageal groove to joint larynx, where do each loop?

A

Right RLN: loops under the subclavian artery

Left RLN: loops under the aortic arch

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18
Q

Which RLN is more susceptible to injury and why?

A

Due to its location in the thorax the left RLN is more susceptible to injury

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19
Q

What 4 nerves provide sensory innervation of the airway?

A

Trigeminal (CN V)
Glossopharyngeal (CN IX)
Superior laryngeal
Recurrent laryngeal

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20
Q

Describe Trigeminal (CN V) sensory innervation of the airway

A

V1: ophthalmic (anterior ethmoidal) - nares & anterior 1/3 of nasal septum
V2: maxillary (sphenopalatine) - turbinates & septum
V3: mandibular (lingual) - anterior 1/3 of tongue

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21
Q

Describe the glossopharyngeal (CN IX) sensory innervation of the airway

A 
Soft palate
Oropharynx
Tonsils
Posterior 1/3 of tongue
Vallecula
Anterior side of epiglottis
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22
Q

What is the afferent limb of the gag reflex?

A

Glossopharyngeal (CN IX)

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23
Q

Describe the superior laryngeal nerve sensory innervation of the airway

A

Internal branch: posterior side of the epiglottis to level of the vocal cords

The external branch provides motor only, not sensory innervation

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24
Q

Describe the recurrent laryngeal nerve sensory innervation of the airway

A

Below level of vocal cords to trachea

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25
Describe the superior laryngeal nerve motor innervation of the larynx
External branch: cricothyroid muscle - tense vocal cords Internal branch provides sensory innervation only
26
Describe recurrent laryngeal nerve motor innervation of the larynx
All intrinsic muscles except cricothyroid
27
SLN injury causes what?
Hoarseness because the vocal cords can’t be tensed
28
Injury to the RLN causes what?
Depends on unilateral or bilateral injury: Unilateral - results in paralysis of the ipsilateral (same side) vocal cord abductors and does not cause respiratory distress Bilateral - results in bilateral paralysis of the vocal cord abductors, tensing action of the cricothyroid muscles act unopposed -> stridor and respiratory distress
29
What about chronic injury of the RLN?
Well tolerated and does not cause respiratory distress
30
Name 6 things that can cause RLN injury to either side
``` External pressure from ETT tube External pressure from LMA Thyroid surgery Parathyroid surgery Neck stretching Tumor ```
31
Name 4 things that can cause injury to the right RLN only
PDA ligation Left atrial enlargement (mitral stenosis) Aortic arch aneurysm Thoracic tumor
32
Name the 3 infiltration airway blocks
Glossopharyngeal block Superior laryngeal block Transtracheal block
33
Glossopharyngeal block: Needle insertion site Aspiration Injected amount
Needle insertion site: at the base of the palatoglossal arch (anterior tonsillar pillar) at a depth of 0.25 - 0.5 cm Aspiration: air - too deep; blood - withdrawal and redirect medically (carotid is very close) Injected amount: 1 - 2 mL of LA on both sides
34
SLN block: Needle insertion site Aspiration Injected amount
Needle insertion site: inferior border of the greater Cornu of the hyoid bone Aspiration: air - too deep Injected amount: 1 mL injected above the thyrohyoid membrane then 2 mL injected 2 - 3 mm beneath it
35
Transtracheal block: Needle insertion site Aspiration Injected amount
Needle insertion site: advance needle in a caudal direction as it penetrates the cricothyroid membrane Aspiration: before injection ask patient to take a deep breath Injected amount: during inspiration 3 - 5 mL, cough sprays LA up through the cords
36
The adult larynx extends from what level to?
C3 - C6
37
What are the 3 paired and 3 unpaired cartilages of the larynx?
paired: corniculate, aryteniod, cuneiform unpaired: epiglottis, thyroid, cricoid
38
What forms the main support of the larynx and attaches to the thyroid cartilage via the thyrohyoid ligament?
Hyoid bone
39
What attaches the larynx (specifically the thyroid cartilage) to the hyoid bone?
The thyrohyoid membrane
40
What attaches the cricoid and thyroid cartilages? What significance does this have in an airway emergency?
Cricothyroid membrane. This is punctured during cricothyroidotomy to emergency secure an airway. This is also where the needle for a Transtracheal block is placed.
41
What cartilages provide structure to the aryepiglottic folds? Which are lateral to the other?
Corniculate and cuneiform. | The cuneiform are lateral to the corniculates.
42
What often is misidentified as arytenoids during DVL?
Corniculate and cuneiform. You can not see the arytenoids on DVL.
43
The base of each arytenoid cartilage articulates with the cricoid cartilage to form a ball and socket joint that allows the arytenoids to rotate, pivot, and glide; what may cause airway obstruction in relation to this synovial joint?
The movement of the arytenoids can be significantly restricted by RA and systemic lupus erythematosus -> airway obstruction
44
What provides a mechanical barrier between the pharynx and the laryngeal opening?
Epiglottis
45
What is the space between the base of the tongue and the anterior side of the epiglottis?
Vallecula
46
What ligament connects the epiglottis to the thyroid cartilage?
Thyroepiglottic ligament
47
What cartilage provides structure and protection to the larynx?
Thyroid
48
What is the largest cartilage in the larynx?
Thyroid
49
What forms the Adam’s apple?
Thyroid cartilage
50
What is the most caudal part of the larynx?
Cricoid cartilage
51
What is the narrowest part of the adult airway? Pediatric?
Adult: vocal cords Pediatric: Vocal cords (dynamic), cricoid (fixed)
52
Laryngeal shape in the adult? Pediatric?
Adult: cylinder Pediatric: funnel
53
Define laryngospasm. What can it lead to?
Sustained and involuntary contraction of the laryngeal musculature that results in the inability to ventilate. Often outlasts the stimulus. May result in complete airway obstruction, negative pressure pulmonary edema, gastric aspiration, cardiac arrest, and death
54
In what population is laryngospasm more common?
Children, especially < 1 year of age
55
List 5 pre-anesthetic risks for laryngospasm:
``` Active or recent URI (< 2 weeks) Exposure to second hand smoke Reactive airway disease GERD Age < 1 year ```
56
List 5 in the OR risks for laryngospasm:
``` Light anesthesia particularly with concurrent airway manipulation Saliva or blood in the upper airway Hyperventilation Hypocapnia Surgical procedures involving the airway ```
57
``` Reflex pathway of laryngospasm: Afferent limb Efferent limb Tensions of the vocal cords Adduction of the vocal cords ```
Afferent limb: SLN internal branch Efferent limb: SLN external branch and RLN Tensions of the vocal cords: cricothyroid Adduction of the vocal cords: lateral cricoarytenoid and thyroarytenoid
58
Signs of laryngospasm:
Inspiratory stridor Suprasternal and supraclavicular retractions during inspiration “Rocking horse” appearance of the chest wall Increased diaphragmatic excursion Lower rib flailing
59
8 factors that reduce the likelihood of laryngospasm
Avoidance of airway manipulation during light anesthesia CPAP 5 - 10 cmH2O during inhalation induction and post extubation Remove pharyngeal secretions and blood before extubation Deep extubation or fully awake - no in-between Laryngeal lidocaine - DOA ~ 30 min IV lidocaine before extubation Hypercapnia/hypoventilation PaO2 < 50 mmHg
60
6 interventions for laryngospasm
1. FiO2 100% 2. Remove noxious stimuli 3. Deepen anesthesia 4. CPAP 15 - 20 cmH2O while instituting airway maneuvers - head extension, chin lift, Larson’s maneuver) 5. IV Sux: 2 mg/kg (neonate or infant) or 1 mg/kg child or adult IM Sux: 5 mg/kg (neonate or infant) or 4 mg/kg child or adult 6. Children < 5 years old should receive atropine 0.02 mg/kg with Sux to prevent bradycardia
61
Where will IM sux produce the fastest onset?
Submental
62
Define Larson’s maneuver. What are the 2 goals? How long should it be applied?
Application of firm pressure bilaterally to the laryngospasm notch (behind the earlobes) towards the skull base. It displaces the mandible anteriorly to help open the airway. It often breaks larngospasm by causing the lightly anesthetized patient to sigh. Apply for 3 - 5 seconds, release for 5 - 10 seconds and repeat.
63
What is valsalva’s maneuver? What risk is associated with it?
Exhalation against a closed glottis or obstruction. | Risk: increased pressure in the thorax, abdomen, and brain
64
What is Muller’s maneuver? What risk is associated with it?
Inhalation against a closed glottis or obstruction. | Risk: subatmospheric pressure in thorax -> negative pressure pulmonary edema
65
What are the 3 borders of the larngospasm notch?
Posterior: mastoid process Anterior: ramus of the mandible Superior: skull base
66
The upper airway extends from?
Mouth/nares to cricoid cartilage
67
Tensor palatine muscle relaxation will most likely cause airway obstruction at which level?
Soft palate | Tensor palatine opens the nasopharynx
68
Genioglossus muscle relaxation will most likely cause airway obstruction at which level?
Tongue | Genioglossus opens the oropharynx
69
Hyoid muscle relaxation will most likely cause airway obstruction at which level?
Epiglottis | Hyoid muscles open the hypopharynx
70
The lower airway begins where?
At the trachea and ends at the alveoli
71
``` Trachea: Begins/ends Width Length Epithelium ```
Begins/ends: begins at C6 and ends at T4-5 the carina Width: 2.5 cm Length: 10 - 13 cm Epithelium: ciliated columnar epithelium
72
What provides the sensory innervation of the trachea?
Vagus nerve
73
What arteries provide blood supply to the trachea?
Inferior thyroid a. Superior thyroid a. Bronchial a. Internal thoracic a.
74
Where is the carina? What level does it correspond with? What type of epithelium is there?
T4-5 Angle of Louis Ciliated columnar epithelium
75
Mainstem Bronchi: Right length and angle Left length and angle Epithelium present
Right 2.5 cm long; 25 degree take off Left 5 cm long; 45 degree take off Cuboidal epithelium
76
How many alveoli does one have by age 9 year?
300 million
77
What type of epithelium are the alveoli?
Squamous epithelium
78
What allows air movement between the alveoli
Pores of Kohn
79
Name the 3 types of pneumocytes and their functions
Type I cells: provide surface for gas exchange - flat squamous cells - cover ~ 80% of alveolar surface - form tight junctions Type II cells: produce surfactant - resistance to oxygen toxicity - capable of cell division - can produce type I cells Type III cell: are macrophages - fight lung infections - produce inflammatory response
80
What type of cells are present in the alveoli in smokers and patients with acute lung injury?
Neutrophils
81
Distance from incisors to larynx?
13 cm
82
Distance from larynx to the carina?
13 cm
83
Distance from incisors to carina?
26 cm
84
How do the bronchi angles change in children up to 3 years old?
Both bronchi take off 55 degrees from the long axis of the trachea
85
What 3 things increase as the airway bifurcates?
Number of airways Cross-sectional area Muscular layer
86
What 4 things decrease as the airway bifurcates?
Airflow velocity Amount of cartilage Goblet cells Ciliated cells

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