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NU 568

Exam 1 - Principles of Nurse Anesthesia - Airway Mgt

What are the 9 steps in the progression of airway management? 1)Chin lift 2)OPA/NPA 3)Mask ventilation 4)Mask w/OPA/NPA 5)LMA 5)DL 6)Glidescope 7)FOI 8)Surgical
What unfortunate result did closed claims analysis of patient’s with difficult airways reveal? What unfortunate result did closed claims analysis of patient’s with difficult airways reveal?
Harm is created by inadequate ___________, not inadequate ___________. ventilation, intubation
What is the definition of a “difficult ventilation”? The inability of a trained anesthetist to maintain oxygen saturation >90% using a face mask and 100% FiO2.
What is the definition of a “difficult airway”? Any intubation that takes a skilled anesthetist more than three attempts or greater than 10 minutes
How long with the FRC last in a “can’t ventilate-can’t intubate” situation when a patient has not been denitrogenated/preoxygenated? 2.5 minutes
How long with the FRC last in a “can’t ventilate-can’t intubate” scenario when a patient has been appropriately denitrogenated/preoxygenated? 12 minutes
Describe the adequate denitrogenation/preoxygenation procedure? Have the patient wear a face mask with a good seal. The patient should breathe normal tidal volumes for 3-5min with an oxygen flow of no less than 5L/min. The bag should move with each inspiration/expiration with good EtCO2 waveform
In a limited time scenario, how many breaths should a patient take in order to denitrogenate/preoxygenate? 4 vital capacity breaths
What is the cornerstone on which the Difficult Airway Algorithm is based? Awake intubation
What are the different structures of the upper airway? Nose, mouth, pharynx, hypopharynx, larynx
What is the function of the trachea? Transport air to the bronchi
What structure marks the beginning of the lower airway? Trachea
What are the 6 structures of the lower airway from top to bottom? 1)Trachea 2)bronchi 3)bronchioles 4)terminal bronchioles 5)respiratory bronchioles 6)alveoli
What is the function of the nose and through what passages does it achieve this function? Humidify and warm inspired air through the turbinates and sinuses
What is the primary passage through which air enters the lung? Nose
How much of the total resistance to breathing is created by the nose? 2/3
What two structures separate the mouth from the nasal passages? The hard and soft palates
What is the difference between the hard and soft palates? The hard palate is stationary while the soft palate is mobile (i.e. moves to cover the glottis while swallowing)
How does age affect the structure of the soft palate? The soft palate stretches and becomes more mobile with age
During sleep or anesthesia, in what direction can the tongue fall and what structure does it block? Falls posterior to block the larynx
Which cranial nerve innervates the anterior tongue? V
Which cranial nerve innervates the posterior tongue? IX
In addition to the posterior tongue, what other structures does cranial nerve IX innervate? soft palate, tonsils
What anatomical structure represents the passage from the oral cavity into the oropharynx? Uvula
The uvula hangs down at the posterior border of the (hard/soft) palate. soft
Repeated swallowing of the endotracheal tube may lead to swelling of what structure? Uvula
What are the 3 compartments of the pharynx? Nasopharynx, oropharynx, hypopharynx
The hypopharynx is also known as the ________. Laryngopharynx
What structure lies at the inferior edge of the hypopharynx? Upper esophageal sphincter
What is the function of the upper esophageal sphincter? Serve as a barrier to regurgitation
What is the muscular component of the upper esophageal sphincter? Cricopharyngeus
Which nerve innervates the hypopharynx? Cranial nerve X
Cranial nerve X is also known as the _________ nerve. Vagus
What are the two branches of the vagus nerve? Superior laryngeal and recurrent laryngeal
What does the vagus nerve innervate? Hypopharynx
The superior laryngeal nerve divides into two separate branches. Name these branches. Internal and external
Which branch of the superior laryngeal nerve provides sensory input to the area of the hypopharynx above the vocal cords? Internal branch of the superior laryngeal nerve
Which branch of the superior laryngeal nerve provides motor function? External branch of the superior laryngeal nerve
What muscle is innervated by the external branch of the superior laryngeal nerve? Cricothyroid muscle
A laryngospasm occurs when the ________________ contracts. cricothyroid
Which branch of the vagus nerve innervates the posterior cricoarytenoid muscles? Recurrent laryngeal nerve
Innervation of the recurrent laryngeal nerve causes (abduction/adduction) of the posterior cricoarytenoid muscles. abduction
True/False: Innervation of the superior laryngeal nerve causes abduction of the posterior cricoarytenoid muscle. False
What are the two branches of the recurrent laryngeal nerve? Left and right
Sensory innervation of the ___________ area and ___________ is provided by the recurrent laryngeal nerve. subglottic, trachea
What vascular structure does the right recurrent laryngeal nerve loop around? Bracheocephalic
What is another name for the bracheocephalic artery? Innominate artery
What structures receive blood from the bracheocephalic artery? Right arm, head neck
What is the first arterial branch of the aortic arch? bracheocephalic (aka. innominate artery)
The bracheocephalic artery further subdivides into what two arteries? Right subclavian and right common carotid arteries
What anatomical structure does the left recurrent laryngeal nerve surround? Aorta
Traction on the _______________ nerve during thoracic surgery can result in hoarseness or stridor. Recurrent laryngeal nerve
Irritation of the recurrent laryngeal nerve can cause what type of respiratory effects? Hoarseness and stridor
Irritation or injury of the superior laryngeal nerve leads to what types of symptoms? Changes in pitch of the voice
Stenosis of the ____________ valve may results in hoarseness due to compression of the ___________ nerve. mitral valve, left recurrent laryngeal
What is Ortner's Syndrome? A cardiovocal syndrome caused by compression of the recurrent laryngeal nerve secondary to cardiovascular disease
What cardiovascular diseases increase the risk for Ortner's Syndrome? Right atrial hypertrophy, pulmonary hypertension, patent ductus arteriosis, thoracic aneurysm
The recurrent laryngeal nerve is responsible for the opening and closing of the __________. Vocal cords
The ______________ abducts the vocal cords, the _______________ adducts the vocal cords. Posterior cricoarytenoid muscle, cricothyroid muscle
Activation of the vagus nerve can lead to what types of cardiovascular effects? Decrease in heart rate and/or blood pressure
True/False: Injury to the superior laryngeal nerve does not result in respiratory issues. True
Stridor occurs when air attempts to pass through adducted vocal cords during __________. Inhalation
True/False: Injury to either branch of the recurrent laryngeal nerve may result in hoarseness and stridor. True
How do the vocal cords compensate in a unilateral recurrent laryngeal nerve injury? Shifting to the uninjured side
What can result from bilateral injury of the recurrent laryngeal nerve? Unopposed adduction of the vocal cords
What is the only bone in the body that is not articulated to another bone? Hyoid
What is the word hyoid derived from? The greek word "hyoeides"
What does the greek word "hyoeides" mean? "Shaped like the letter upsilon [u]"
In what directions is the hyoid bone anchored? Anterior, posterior, inferior
What two functions does the hyoid bone aid in doing? Tongue movement and swallowing
The hyoid serves as an attachment for the muscles of multiple features. What are these features? Mouth, tongue, epiglottis, larynx, pharynx
What is the only complete cartilage in the tracheal tree? Cricoid cartilage
What structure serves as the bulk of the anterior wall of the larynx? Thyroid cartilage
What is the function of the thyroid cartilage? Protect the airway and vocal cords
What are the two branches of the superior laryngeal nerve? Interior and external
What is the function of the internal branch of the superior laryngeal nerve? Sensory input of the hypopharynx above the vocal cords
What is the function of the external branch of the superior laryngeal nerve? Control the cricothyroid muscle (tenses and elongates the vocal cords)
Where does the superior laryngeal nerve branch from? Main trunk of the vagus nerve high in the neck
What does damage to the superior laryngeal nerve result in? Changes in voice pitch and the inability to produce explosive sounds
What muscle tenses the vocal cords when innervated and what cranial nerve is it innervated by? cricothyroid muscle, external branch of the superior laryngeal nerve
What area does the recurrent laryngeal nerve provide sensation to? Subglottic, which includes the larynx below the vocal cords and upper esophagus
What does the recurrent laryngeal nerve provide motor function to? Intrinsic muscles of the larynx, excluding the cricothyroid muscle
Where do the different branches of the RLN originate from? Right originates from the inferior portion of the right subclavian artery and travels cephalad and posteriorly, left originates from the aortic arch and travels cephalad and posteriorly
Esophageal and lung surgery poses a high risk for injury to the (superior/recurrent) laryngeal nerve. recurrent
True/False: The RLN supplies motor function to all the muscles of the larynx. False, the external branch of the SLN supplies motor function to the cricothyroid muscle
What area does the RLN provide sensory innervation to? Subglottic region
What are the borders of the larynx? Begins with the epiglottis and extends downwards to the cricoid cartilage
The larynx has ________ single cartilages and ___________ paired cartilages. 3, 3
What are the intrinsic muscles of the larynx? Posterior cricoarytenoid, lateral cricoarytenoid, arytenoids, cricothyroid, thyroarytenoid
What is the function of the posterior cricoarytenoid muscle? Abduct vocal cords, open the glottis
What is the function of the lateral cricoarytenoid muscle? Adduct vocal cords, close the glottis
What is the function of the arytenoid muscle? Close the glottis, especially posteriorly
What muscle initiates closure of the glottis from the posterior direction? arytenoid muscle
What is the function of the cricothyroid muscle? Produce tension on and elongate the vocal cords by tilting the thyroid forward
What is the function of the thyroarytenoid muscle? Relaxation and shortening of the vocal cords
What are the four extrinsic muscles of the larynx? Sternothyroid, thyrohyoid, sternohyoid, omohyoid
What do the structures of the larynx serve to protect? The airway from aspiration
The structures of the larynx combine to perform what 5 functions? 1)airway protection from aspiration 2)provide airflow between the hypopharynx and trachea 3)cough and gag reflexes 4)phonation 5)swallowing
What serves as scientific proof of intubation? EtCO2
What are the superior and inferior borders of the larynx? Epiglottis (sup) and cricoid cartilage (inf)
What are the three unpaired cartilage in the larynx? Epiglottis, thyroid, cricoid
What membrane connects the thyroid to the hyoid bone? Thyrohyoid membrane
What happens to the pharynx and larynx during swaswallowing? Both structures rise
What happens to the pharynx during swallowing? Widens to accommodate food and drink
What happens to the larynx during swallowing? Moves the epiglottis down to cover the glottis
The epiglottis is a type of __________. Fibrocartilage
True/False: The epiglottis projects obliquely downward behind the tongue and in front of the entrance to the larynx. False - it points upwards
At what C-spine level is the epiglottis positioned in adults? In children? C5 in adults. C3 in children.
What does the epiglottis serve to protect? The glottis
What important structure does the glottis contain? Vocal cords
The space between the base of the tongue and epiglottis is known as the ____________. Superior valecula
What does applying anterior pressure to the superior valecula result in? Lifting of the epiglottis, thus revealing the glottis and vocal cords
The structures of the larynx contribute to what actions? Breathing, swallowing, phonation
What cartilaginous structure forms the lower and posterior walls of the larynx? Cricoid cartilage
True/False: The thyroid cartilage is stronger than the cricoid cartilage. False
What other structures does the cricoid cartilage articulate with? Thyroid, arytenoids
What are the three paired cartilages of the larynx? Arytenoid, corniculate, cuneiform
The arytenoid cartilages are situated along the (posterior/anterior) cricoid and attached to the (posterior/anterior) ends of the vocal folds. posterior, posterior
What is the shape and function of the arytenoids? They are pyramidal and function to open and close the vocal cords
Which cartilages articulate with the arytenoids to project them backwards and medially? Corniculate
The corniculate cartilage is located in the __________________ and sometimes fuse with the __________________. Posterior aryepiglottic folds, arytenoids
What cartilaginous structure is on each side of the aryepiglottic fold in front of the arytenoid cartilages? Cuneiform
Name the site of the emergency/surgical airway access. Cricothyroid membrane
Name the membrane that connects the cricoid cartilage to the thyroid cartilage. Cricothyroid membrane
What is the muscle of laryngospasm? Cricothyroid muscle
What muscle arises from the front and lateral part of the cricoid cartilage? Cricothyroid muscle
What effect does cricothyroid muscle contraction have on the larynx? Causes the larynx to shift downward and in turn, stretches and increases tension on the vocal cords leading to vocal cord adduction
Laryngospasm is total and profound closure of the __________________. Glottis
What muscle arises from the posterior aspect of the cricoid to the arytenoids? Posterior cricoarytenoid muscle
What muscle causes external rotation of the arytenoids, and therefore abduction of the vocal cords? Posterior cricoarytenoid muscle
Which muscle aids in adduction of the vocal cords? Interarytenoid muscle
The interarytenoid muscle is a single muscle which fills up the (posterior/anterior) concave surfaces of the arytenoid cartilages. Posterior
What are the superior and inferior borders of the trachea? Cricoid cartilage (sup) and carina (inf)
What are the benefits of cricoid pressure? Effectively closes the esophagus and limits regurgitation and aspiration
What is the angle of bifurcation of the right mainstem bronchus? The left mainstem bronchus? 25-30 degrees (right), 45 degrees (left)
Why is the right mainstem bronchus frequently intubated? Lower angle of resistance compared to the left mainstem
What 3 axes make up the triangle of intubation? Oral, larngeal, pharyngeal
Which thoracic nerves sympathetically innervate the tracheobronchial tree? 1-5 thoracic ganglia
Which nerve provides parasympathetic innervation of the tracheobronchial tree? Vagus
True/False: The carina is a bronchial structure with limited sensation due to a lack of sensory nerves. False
What is the carina? A cartilaginous ridge that runs antero-posteriorly between the two primary bronchi at the site of tracheal bifurcation in the lower end of the trachea
What is the most sensitive area of the tracheal tree that will trigger a cough reflex? Carina
What is the role of the bronchi? Warm and humidify air as it passes to the alveoli
What are the signs of endobronchial intubation? (6) 1)Increased PIP 2)Uneven chest excursion 3)Decreased LS to one side 4)Decreased ETCO2 5)Tachycardia 6)Hypoxemia
How can endobronchial intubation be managed? Without removing the ETT from the trachea, deflate the cuff and pull back on the ETT until B breath sounds are heard
What is the principle muscle of respirations? Diaphragm
Where is the diaphragm located? Between the abdominal and plural cavities
The diaphragm is innervated from nerves that extend from which spinal cords? C3, C4, C5
Which nerves innervate the diaphragm and where do they originate from? Phrenic nerves; originate from C3-C5
What does FRC stand for and what does it represent? Functional Residual Capacity - it is the lung volume at the end of normal exhalation
What is the normal FRC? Approximately 2L in a 70kg adult seated upright
What are 4 considerations to make in assessing the difficult airway in relation to the ASA Difficult Airway Algorithm? 1)Awake v. Asleep 2)Emergent v. Nonemergent 3)Supra- v. Sub- glottic 4)Surgical v. Nonsurgical
What are some causes of failed preparation in airway management? (6) 1)Exaggerated sense of personal ability 2)Not requesting for help 3)No team discussion prior to intubation 4)Poor plan w/no backup plan 5)Continuing w/a failed plan and delaying rescue management 6)Failure to notify the surgical team of a difficult airway
What is the difference between the Mallampati and Cormack-Lehane classification systems? The Mallampati is based on the the level of visualization with maximal mouth opening while the Cormack-Lehane involves the level of visualization under direct laryngoscopy.
What does the LEMONS acronym stand for? Look externally, Evaluate 3-3-2, Mallampati, Obstruction, Neck mobility, Scene and/or Situation
What is the maximum number of points in the LEMONS scale and what does it represent? 9. A score of 9 represents that all measures were assessed to be suboptimal for all sections of the LEMONS grading system (up to 4 points possible in the Look category)
What are the 5 most predictive factors of the difficult airway? 1)Obesity 2)Decreased head and neck movement 3)Decreased mouth opening 4)Overbite 5)Short mandible
What does the acronym MOANS represent? The 5 most predictive factors related to difficult BMV
Identify each section of the MOANS acronym. Mask seal, Obesity, Aged, No teetch, Snores or Stiff lungs
Describe each measurement in the 3-3-2 portion of the LEMONS acronym? The first 3 measures mouth opening. The second 3 measures mandibular length (hyomental). The 2 assesses laryngeal positioning (hyothyroid).
What patient population has the highest incidence of airway issues? Men ages 40-59
Good correlation of the 3-3-2 measurements indicates alignment of what three axes? Pharyngeal, laryngeal, oral
Hyothyroid distance should be ___________. 2 finger breadths
How is the Mallampati exam performed? The structures of the mouth are evaluated with the patient seated upright, maximal mouth opening and tongue extrusion, and no phonation
Describe the 1st classification of the Mallampati scoring system. Soft palate, uvula, fauces, anterior and posterior tonsilar pillars
Describe the 2nd classification of the Mallampati scoring system. Soft palate, uvula, fauces
Describe the 3rd classification of the Mallampati scoring system. Soft palate, base of the uvula
Describe the 4th classification of the Mallampati scoring system. Hard palate only
A Mallampati class 1 view predicts that intubating will be _________________. Easy
A Mallampati class 2 view predicts that intubating will be _________________. Possibly difficult
A Mallampati class 3 view predicts that intubating will be _________________. Probably difficult
A Mallampati class 4 view predicts that intubating will be _________________. Difficult
Identify the differences between inspiratory and expiratory wheezing. Inspiratory wheezing signifies upper airway obstruction. Expiratory wheezing signifies lower airway or thoracic obstruction
Describe the 1st grade of the Cormack-Lehane grading system. Full view of the glottis
Describe the 2nd grade of the Cormack-Lehane grading system. Partial glottic view of only the arytenoids or posterior portion of the vocal cords
Describe the 3rd grade of the Cormack-Lehane grading system. Only the epiglottis is viewed
Describe the 4th grade of the Cormack-Lehane grading system. No view of the glottis or epiglottis
Which joint is the point at which head flexion and extension occurs? Atlanto occipital joint
Which two joints form the atlanto occipital joint? C1 (atlas) and C2 (axis)
The atlanto occipital joint is normally capable of extension of at least _________ degrees. 35
Visualization of the airway may become difficult at what decreased AO angle? 23 degrees
What are the 6 steps to be considered in the management plan of an anticipated difficult airway? 1)discussion with colleagues in advance 2)equipment testing 3)senior help 4)definite initial plan for ventilation and intubation 5)definite plan for awake intubation if necessary 6)surgical team on standby
What are different techniques to manage the unexpected difficult airway? (5) 1)laryngeal manipulation 2)NPA/OPA 3)Different blade 4)Intubating stylet 5)Supraglottic device
Sellick's maneuver involves direct pressure on the ___________________. Cricoid cartilage
The ______________ technique involves the use of an over-the-wire technique for intubating. Seldinger
What are the two different methods for obtaining an emergency surgical airway? Needle cricothyoidotomy and surgical cricothyroidotomy
In what age group is needle cricothyroidotomy the emergency surgical airway of choice and why? Children <12yo because of the small tracheal diameter on which an open cricothyrotomy is virtually impossible
What type of oxygen tubing should be used with a needle cricothyroidotomy? Non-collapsible or non-compliant tubing
Additional room air is supplied to the lungs during PTJV due to the _____________________ effect. Venturi
PTJV has the ability to cause what unfortunate effects? Barotrauma, pneumothorax, CO2 accumulation
How much pressure should be delivered via PTJV? 25-50 psi
How many ml of oxygen can be delivered through a 20G PIV at 50 psi? 16G PIV? 14G PIV? 400ml O2/sec; 500ml O2/sec; 1600ml O2/sec
What is the recommended i:e ratio for PTJV? 1:2
True/False: Exhalation is active in PTJV. False
After placement of a needle cricothyroidotomy, what should be assessed frequently and why? Breath sounds due to risk of pneumothorax
Besides breath sounds, what additional assessment should be made with an emergent surgical airway? Subcutaneous emphysema
What two types of devices help facilitate the exhalation of CO2 after PTJV? OPA, NPA
True/False: The thyromental distance is measured with the neck fully flexed. False
True/False: The thyromental distance can be measured in-line. True
The thyromental distance attempts to predetermine the lining of what two axes? Laryngeal and pharyngeal
What does a short thyromental distance (< 3 finger widths) signify? The laryngeal axis makes a more acute angle with the pharyngeal axis, making it difficult to achieve alignment with less space to displace the tongue
What is the optimal finger distance of the mandibulohyoid measurement? 2 fingers
The entrance to the larynx is marked by the position of what structure? Hyoid bone
What does the epiglottis arise from? Thyroid cartilage
The epiglottis is dorsal to which bone? Hyoid
Ludwig’s angina is a disease characterized by cellulitis of the tissue located in what area? Floor of the mouth
Created by: philip.truong