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Barry U Airway lecture class 2012

Function of Nasopharynx warming and humidificationPrimary pathway for normal breathing
The Oropharynx starts where & ends where Extends from posterior aspect of nose down to the base of the tongue/vallecula, superior to the epiglottis
Key parts of the upper airway are? Pharynx: Nasopharynx, Oropharynx, Laryngopharynx (hypopharynx) & Epiglottis
What Cranial Nerves Sensory Innervate Oropharynx CN: V, VII & IX
Cervical orientation to the Larynx on an Adult C3-6
How many & What Cartilages make up the Larynx Thyroid, Cricoid, Epiglottis, 2 Corniculate, 2 Cuneiform & 2 Arytenoid
Narrowest part of adult’s airway is? vocal cords.
the only complete tracheal ring? Cricoid
the narrowest part of a child’s airway Cricoid
The Larynx is supplied by the branches of What Nerve? vagus nerve (CN X):Superior laryngeal nerve & Recurrent laryngeal nerve
The Posterior cricoarytenoids (PCA) muscles do what? PCA- abducts vocal cords (opens cords)
The Lateral cricoarytenoids (LCA); arytenoids muscles do what? Adductors of vocal cords(close cords)
The Cricothyroid muscles do what? tense the cords (phonation=making noise)
Unilateral SLN injury on voice Minimal effects
Bilateral SLN injury on voice Hoarseness, tiring of voice
Unilateral RLN injury on voice Hoarseness
Acute Bilateral SLN injury on voice Stridor, respiratory distress
Chronic Bilateral SLN injury on voice Aphonia
How long is the adult Trachea? Approx 10-20 cm long in adults
Cervical orientation to the trachea is? Begins opposite C6
Trachea is Composed of how many C-shaped cartilaginous 16-20
Angle of bifurcation of right mainstem bronchus is? 25-30 degrees
Angle of bifurcation of left mainstem bronchus is? 45 degrees
What airway HISTORY may indicate a Difficult Airway Sleep apnea (OSA), TMJ dysfunction, Arthritis (rheumatoid> osteo), Morbid obesity, Congenital syndromes, prior airway surgery/tracheostmy/cricothyrocotomy
What PHYSICAL finding may indicate dificult airway? Micrognathia, beard or large nose, Less than 3 finger oral opening, Buck Teeth, Long arched palate & narrow mouth, Large tongue, Limited TMJ mobility, Limited c-spine, Short/thick neck, Tracheal deviation, Technical factors (Casts, collars, halo, Foreign
What Pathologies can lead to airway difficulties Angioedema , trauma, swelling, Ludwig’s angina, Cervical fusion, ankylosis, RA, Endocrine problems (Obese, Acromegalic, Goiter, DM), Tonsils, infections, scarring, Bleeding, Vomiting, Congenital (Pierre Robin, Treacher Collins)
What is the Single, most reliable method of assessing airway Physical Exam
Pre-op classification based on visualized structures to estimate airway difficulty Mallampati classification
Class I Mallampati= ? Soft palate, tonsillar pillars, uvula all seen
Class II Mallampati= ? pharyngeal pillars and soft/hard palate visible, tip of uvula obstructed
Class III Mallampati= ? Soft/hard palate visible & base of Uvula, pillars obstructed
Class IV Mallampati= ? only hard palate seen
Airway grading based on laryngoscopic view after blade inserted Cormack & Lehane’s
What is the Thyromental distance measure from mental process to thyroid prominence with head in full extension, < 3 finger breadths (50mm; 7 cm), predictor of difficult laryngoscopy
What can Examination of the A-O joint tell you Neck extension < 35* and flexion < 80* may be indicative of difficult intubation
The "Sniffing Position" will align what anatomical axis Laryngeal, Pharyngeal & Oral
What Factors that limit larynx visualization/intubation Mouth opening < 3 finger or 6.5cmMallampati Class III/IVNeck extension < 35*Thyromental distance < 6.5 cm Rigid larynx
What equipment would you need on your airway cart? Suction, Oral airway &/or soft bite block, Tongue blade, Nasal airway, Ambu/mask and oxygen, Endotracheal tubes / stylets , Laryngoscope handle and blades, Difficult airway equipment
Nasal Cannula can deliver how much FiO2 FiO2 increases by 3-4% per liter of O2 given up to 40-50%
Simple mask can deliver how much FiO2 delivers O2 flow rates from 6-15 L/min, providing FiO2 of 35-65%
What are the Oral Airway Sizes? Adult sizes range from 80-100 mm (#3-5)Pediatric sizes range from 50-70 mm (#00-2)Measure correct length from corner of mouth to meatus of ear
What are the contraindications for Nasal Airways? Relative contraindications include coagulopathy, basilar skull fracture and nasal infections or deformities
What is the Adult size range for Nasal Airways? Adult sizes range from #28-34
What are some causes of obstruction when hand ventilating a patient? Poor positioningSoft tissueForeign bodyAbnormal pathologyLaryngospasm
Positive pressure ventilation greater than 20-30 cm H2o can cause what? gastric distention, interfering with ventilation by impeding diaphragmatic movement that Can lead to regurgitation
Mask anesthesia is useful for what kind of procedures? minor/fast surgeries with low aspiration risk, supine position, ECTs, lower extremity cases.
When would you want to use a Laryngeal mask airway (LMA)? LMAs used for supine position only with cases that are a little longer than mask would allow. Never use LMA with a laproscopic procedure. Never use with patients at risk for gastric aspiration.
When would you NOT want to use a Laryngeal mask airway (LMA)? Do not use with patients at risk for aspirationObese, Full stomachs, Diabetics?, Those receiving opioidsCan not utilize if controlled ventilation will require pressures > 20 cm H2O
What are some complications associated with LMA's Possibility of regurgitation and pulmonary aspirationOral and pharyngeal mucosa injuryLaryngospasm and coughing in lightly anesthetized patientNegative pressure pulmonary edema with improper placement
Will a LMA protect the airway from aspiration? NO
What size LMA is frequently used 4
What size LMA would you use on a 35kg patient 3
Tip of LMA is positioned where anatomically? Hypopharynx
What are some indications for Endotracheal Intubation Need to deliver positive pressure ventilationProtection of respiratory tract from gastric contentsSurgical procedures of the head and neck when the airway cannot be supportedNonsupine positions in which the airway cannot be supported properlyMost
Laryngoscope is held in which hand? left hand period dot end of sentence.
What is the name of the curved laryngoscope blade MAC
What is the name of the strait laryngoscope blade Miller
What blade sit between the Vallecula & tongue MAC
What is the most common MAC blade 3
what is the most common miller blade 2
Which blade is inserted & used to lift up the glottis miller
What sizes do ET tubes come in 2-10
When do you use an uncuffed ET tube typically children under 8-10
Common ET Tube size for women 7-8
Common ET Tube size for men 7.5-9
What is the formula to find correct ET tube size for children 2ys & older age/4+4
When to use Nasotracheal intubation Maxillofacial or mandibular surgeryOral / dental surgery
What are the contraindication for Nasotracheal intubation Basilar skull fractureLe Forte III fracturePresence of CSFSevere intranasal disease - tumor, sinusitisCoagulopathy (nose bleeds may be relative c/i)
What is the reason for 100% oxygen prior to starting intubation This replaces nitrogen in the FRC with 100% O2This oxygen reserve prolongs the time to development of hypoxemia with induction
What is the name of the technique used to open the mouth prior to placing the laryngoblade Scissor maneuver
How much time should you NOT exceede when attempting intubation 30 seconds
Cormack and Lehane’s Grade I = full view of glottic opening, including vocal cords
Cormack and Lehane’s Grade II = partial view of glottis and arytenoids
Cormack and Lehane’s Grade III = only can visualize epiglottis
Cormack and Lehane’s Grade IV = no visible structures seen
Confirming ETT placement consist of? Direct visualization of ETT passing through cordsObserve at least 3 ETCO2 tracings on the capnographAuscultate breath sounds first on the left then right midaxillary then over the epigastrum
When would you use RSI? Used when risk of aspiration high; to minimize gastric distention and aspirationPatients with history of recent meal, trauma, GERD, pregnancy, opioid use, diabetics (gastric paresis)
What is "Sellect Maneuver" Sellick’s maneuver= cricoid pressureOccudes esophagus, preventing gastric regurgitation and distention
What is the most common cause of upper airway obstruction Soft tissue obstruction Caused by relaxation of tongue and jaw(Can also be caused by foreign body, dentures, tumors, infective process)
How do you treat a laryngeal spasm Displace mandible and extend neckStrong manual positive pressure of O2 via mask and bag may forcefully open adducted cordsIf severe, small dose of Sux 0.15-0.30 mg/kg(10-20 mg) may be necessaryIntubation last resort
What are causes of bronchospasms Mechanical obstructionInadequate depth of anesthesiaPulmonary aspirationEndobronchial intubationPneumothoraxPulmonary embolusAcute bronchial asthma
What is the treatment for Bronchospasm Place on 100% O2Deepen the anestheticHold positive-pressure in attempt to break spasmAdminister Beta-2 agonist (Albuterol puffs/nebs, Terbutaline SQ 0.25 mg; may repeat in 15-30 min; max dose 0.5 mg in 4 hours)Epinephrine SQ 0.4 ml of 1:1000 solut
What are some complications of intubation Malpositioning, Airway trauma, Physiologic reflexes, Tube malfunction
What are some complications of long duration intubation or if TOO LARGE ET tube placed EdemaCuff pressure (vocal cord paralysis)Tracheal erosion, tracheomalacia or stenosis, vocal cord damage or granuloma
When do you extubate your patient Can be performed while the patient is deeply anesthetized or fully awakeDeep extubation performed for cases in which the surgery could be harmed if the patient coughs and bucks
How do you treat NPPE Treatment: O2 therapy; may require reintubation with CPAP and PEEP depending on severity
What is the Extubation criteria (most sensitive) Train of four 4/4 on nerve stimulator with sustained tetanusSustained head lift > 5 secondsSustained leg or arm lift > 5 secondsTongue protrusionNIF > -20 cm H2OAbility to hand grasp and follow commands
What is Negative pressure pulmonary edema (NPPE) Post extubation complication that can occur independently or after laryngospasm, aspiration, upper airway tumors, foreign bodies, bronchospasm, croup, airway trauma, strangulation, and difficult intubation
Who is typically affected by NPPE Young, muscular black males more prone to this
What is a combitube Blind airway insertion device, part of difficult airway Algorithm
Where is the Cricothyroid membrane Cricothyroid membrane is between cricoid and thyroid cartiliages.
What Are The Five Dimensions of the Difficult Airway Difficult Hand Ventilation (BMV) ?Difficult laryngoscopy ?Difficult intubation?Difficult Supra Glottic Device (LMA, I-LMA, combitube)?Difficult cricothyrotomy?
Who is the Master of the Airway YOU ARE! said Obie Wan Kenobi to all of the young Padawan's
Created by: Secret squirrel