Exam 1 - Principles of Nurse Anesthesia - Airway Mgt
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| 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
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| 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?
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| Harm is created by inadequate ___________, not inadequate ___________. | ventilation, intubation
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| 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.
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| What is the definition of a “difficult airway”? | Any intubation that takes a skilled anesthetist more than three attempts or greater than 10 minutes
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| 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
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| 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
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| 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
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| In a limited time scenario, how many breaths should a patient take in order to denitrogenate/preoxygenate? | 4 vital capacity breaths
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| What is the cornerstone on which the Difficult Airway Algorithm is based? | Awake intubation
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| What are the different structures of the upper airway? | Nose, mouth, pharynx, hypopharynx, larynx
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| What is the function of the trachea? | Transport air to the bronchi
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| What structure marks the beginning of the lower airway? | Trachea
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| 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
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| 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
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| What is the primary passage through which air enters the lung? | Nose
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| How much of the total resistance to breathing is created by the nose? | 2/3
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| What two structures separate the mouth from the nasal passages? | The hard and soft palates
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| 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)
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| How does age affect the structure of the soft palate? | The soft palate stretches and becomes more mobile with age
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| During sleep or anesthesia, in what direction can the tongue fall and what structure does it block? | Falls posterior to block the larynx
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| Which cranial nerve innervates the anterior tongue? | V
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| Which cranial nerve innervates the posterior tongue? | IX
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| In addition to the posterior tongue, what other structures does cranial nerve IX innervate? | soft palate, tonsils
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| What anatomical structure represents the passage from the oral cavity into the oropharynx? | Uvula
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| The uvula hangs down at the posterior border of the (hard/soft) palate. | soft
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| Repeated swallowing of the endotracheal tube may lead to swelling of what structure? | Uvula
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| What are the 3 compartments of the pharynx? | Nasopharynx, oropharynx, hypopharynx
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| The hypopharynx is also known as the ________. | Laryngopharynx
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| What structure lies at the inferior edge of the hypopharynx? | Upper esophageal sphincter
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| What is the function of the upper esophageal sphincter? | Serve as a barrier to regurgitation
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| What is the muscular component of the upper esophageal sphincter? | Cricopharyngeus
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| Which nerve innervates the hypopharynx? | Cranial nerve X
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| Cranial nerve X is also known as the _________ nerve. | Vagus
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| What are the two branches of the vagus nerve? | Superior laryngeal and recurrent laryngeal
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| What does the vagus nerve innervate? | Hypopharynx
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| The superior laryngeal nerve divides into two separate branches. Name these branches. | Internal and external
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| 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
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| Which branch of the superior laryngeal nerve provides motor function? | External branch of the superior laryngeal nerve
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| What muscle is innervated by the external branch of the superior laryngeal nerve? | Cricothyroid muscle
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| A laryngospasm occurs when the ________________ contracts. | cricothyroid
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| Which branch of the vagus nerve innervates the posterior cricoarytenoid muscles? | Recurrent laryngeal nerve
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| Innervation of the recurrent laryngeal nerve causes (abduction/adduction) of the posterior cricoarytenoid muscles. | abduction
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| True/False: Innervation of the superior laryngeal nerve causes abduction of the posterior cricoarytenoid muscle. | False
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| What are the two branches of the recurrent laryngeal nerve? | Left and right
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| Sensory innervation of the ___________ area and ___________ is provided by the recurrent laryngeal nerve. | subglottic, trachea
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| What vascular structure does the right recurrent laryngeal nerve loop around? | Bracheocephalic
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| What is another name for the bracheocephalic artery? | Innominate artery
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| What structures receive blood from the bracheocephalic artery? | Right arm, head neck
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| What is the first arterial branch of the aortic arch? | bracheocephalic (aka. innominate artery)
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| The bracheocephalic artery further subdivides into what two arteries? | Right subclavian and right common carotid arteries
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| What anatomical structure does the left recurrent laryngeal nerve surround? | Aorta
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| Traction on the _______________ nerve during thoracic surgery can result in hoarseness or stridor. | Recurrent laryngeal nerve
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| Irritation of the recurrent laryngeal nerve can cause what type of respiratory effects? | Hoarseness and stridor
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| Irritation or injury of the superior laryngeal nerve leads to what types of symptoms? | Changes in pitch of the voice
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| Stenosis of the ____________ valve may results in hoarseness due to compression of the ___________ nerve. | mitral valve, left recurrent laryngeal
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| What is Ortner's Syndrome? | A cardiovocal syndrome caused by compression of the recurrent laryngeal nerve secondary to cardiovascular disease
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| What cardiovascular diseases increase the risk for Ortner's Syndrome? | Right atrial hypertrophy, pulmonary hypertension, patent ductus arteriosis, thoracic aneurysm
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| The recurrent laryngeal nerve is responsible for the opening and closing of the __________. | Vocal cords
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| The ______________ abducts the vocal cords, the _______________ adducts the vocal cords. | Posterior cricoarytenoid muscle, cricothyroid muscle
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| Activation of the vagus nerve can lead to what types of cardiovascular effects? | Decrease in heart rate and/or blood pressure
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| True/False: Injury to the superior laryngeal nerve does not result in respiratory issues. | True
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| Stridor occurs when air attempts to pass through adducted vocal cords during __________. | Inhalation
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| True/False: Injury to either branch of the recurrent laryngeal nerve may result in hoarseness and stridor. | True
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| How do the vocal cords compensate in a unilateral recurrent laryngeal nerve injury? | Shifting to the uninjured side
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| What can result from bilateral injury of the recurrent laryngeal nerve? | Unopposed adduction of the vocal cords
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| What is the only bone in the body that is not articulated to another bone? | Hyoid
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| What is the word hyoid derived from? | The greek word "hyoeides"
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| What does the greek word "hyoeides" mean? | "Shaped like the letter upsilon [u]"
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| In what directions is the hyoid bone anchored? | Anterior, posterior, inferior
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| What two functions does the hyoid bone aid in doing? | Tongue movement and swallowing
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| The hyoid serves as an attachment for the muscles of multiple features. What are these features? | Mouth, tongue, epiglottis, larynx, pharynx
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| What is the only complete cartilage in the tracheal tree? | Cricoid cartilage
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| What structure serves as the bulk of the anterior wall of the larynx? | Thyroid cartilage
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| What is the function of the thyroid cartilage? | Protect the airway and vocal cords
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| What are the two branches of the superior laryngeal nerve? | Interior and external
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| What is the function of the internal branch of the superior laryngeal nerve? | Sensory input of the hypopharynx above the vocal cords
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| What is the function of the external branch of the superior laryngeal nerve? | Control the cricothyroid muscle (tenses and elongates the vocal cords)
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| Where does the superior laryngeal nerve branch from? | Main trunk of the vagus nerve high in the neck
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| What does damage to the superior laryngeal nerve result in? | Changes in voice pitch and the inability to produce explosive sounds
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| 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
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| What area does the recurrent laryngeal nerve provide sensation to? | Subglottic, which includes the larynx below the vocal cords and upper esophagus
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| What does the recurrent laryngeal nerve provide motor function to? | Intrinsic muscles of the larynx, excluding the cricothyroid muscle
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| 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
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| Esophageal and lung surgery poses a high risk for injury to the (superior/recurrent) laryngeal nerve. | recurrent
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| 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
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| What area does the RLN provide sensory innervation to? | Subglottic region
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| What are the borders of the larynx? | Begins with the epiglottis and extends downwards to the cricoid cartilage
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| The larynx has ________ single cartilages and ___________ paired cartilages. | 3, 3
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| What are the intrinsic muscles of the larynx? | Posterior cricoarytenoid, lateral cricoarytenoid, arytenoids, cricothyroid, thyroarytenoid
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| What is the function of the posterior cricoarytenoid muscle? | Abduct vocal cords, open the glottis
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| What is the function of the lateral cricoarytenoid muscle? | Adduct vocal cords, close the glottis
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| What is the function of the arytenoid muscle? | Close the glottis, especially posteriorly
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| What muscle initiates closure of the glottis from the posterior direction? | arytenoid muscle
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| What is the function of the cricothyroid muscle? | Produce tension on and elongate the vocal cords by tilting the thyroid forward
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| What is the function of the thyroarytenoid muscle? | Relaxation and shortening of the vocal cords
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| What are the four extrinsic muscles of the larynx? | Sternothyroid, thyrohyoid, sternohyoid, omohyoid
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| What do the structures of the larynx serve to protect? | The airway from aspiration
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| 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
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| What serves as scientific proof of intubation? | EtCO2
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| What are the superior and inferior borders of the larynx? | Epiglottis (sup) and cricoid cartilage (inf)
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| What are the three unpaired cartilage in the larynx? | Epiglottis, thyroid, cricoid
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| What membrane connects the thyroid to the hyoid bone? | Thyrohyoid membrane
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| What happens to the pharynx and larynx during swaswallowing? | Both structures rise
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| What happens to the pharynx during swallowing? | Widens to accommodate food and drink
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| What happens to the larynx during swallowing? | Moves the epiglottis down to cover the glottis
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| The epiglottis is a type of __________. | Fibrocartilage
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| True/False: The epiglottis projects obliquely downward behind the tongue and in front of the entrance to the larynx. | False - it points upwards
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| At what C-spine level is the epiglottis positioned in adults? In children? | C5 in adults. C3 in children.
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| What does the epiglottis serve to protect? | The glottis
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| What important structure does the glottis contain? | Vocal cords
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| The space between the base of the tongue and epiglottis is known as the ____________. | Superior valecula
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| What does applying anterior pressure to the superior valecula result in? | Lifting of the epiglottis, thus revealing the glottis and vocal cords
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| The structures of the larynx contribute to what actions? | Breathing, swallowing, phonation
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| What cartilaginous structure forms the lower and posterior walls of the larynx? | Cricoid cartilage
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| True/False: The thyroid cartilage is stronger than the cricoid cartilage. | False
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| What other structures does the cricoid cartilage articulate with? | Thyroid, arytenoids
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| What are the three paired cartilages of the larynx? | Arytenoid, corniculate, cuneiform
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| The arytenoid cartilages are situated along the (posterior/anterior) cricoid and attached to the (posterior/anterior) ends of the vocal folds. | posterior, posterior
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| What is the shape and function of the arytenoids? | They are pyramidal and function to open and close the vocal cords
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| Which cartilages articulate with the arytenoids to project them backwards and medially? | Corniculate
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| The corniculate cartilage is located in the __________________ and sometimes fuse with the __________________. | Posterior aryepiglottic folds, arytenoids
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| What cartilaginous structure is on each side of the aryepiglottic fold in front of the arytenoid cartilages? | Cuneiform
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| Name the site of the emergency/surgical airway access. | Cricothyroid membrane
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| Name the membrane that connects the cricoid cartilage to the thyroid cartilage. | Cricothyroid membrane
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| What is the muscle of laryngospasm? | Cricothyroid muscle
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| What muscle arises from the front and lateral part of the cricoid cartilage? | Cricothyroid muscle
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| 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
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| Laryngospasm is total and profound closure of the __________________. | Glottis
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| What muscle arises from the posterior aspect of the cricoid to the arytenoids? | Posterior cricoarytenoid muscle
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| What muscle causes external rotation of the arytenoids, and therefore abduction of the vocal cords? | Posterior cricoarytenoid muscle
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| Which muscle aids in adduction of the vocal cords? | Interarytenoid muscle
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| The interarytenoid muscle is a single muscle which fills up the (posterior/anterior) concave surfaces of the arytenoid cartilages. | Posterior
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| What are the superior and inferior borders of the trachea? | Cricoid cartilage (sup) and carina (inf)
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| What are the benefits of cricoid pressure? | Effectively closes the esophagus and limits regurgitation and aspiration
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| What is the angle of bifurcation of the right mainstem bronchus? The left mainstem bronchus? | 25-30 degrees (right), 45 degrees (left)
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| Why is the right mainstem bronchus frequently intubated? | Lower angle of resistance compared to the left mainstem
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| What 3 axes make up the triangle of intubation? | Oral, larngeal, pharyngeal
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| Which thoracic nerves sympathetically innervate the tracheobronchial tree? | 1-5 thoracic ganglia
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| Which nerve provides parasympathetic innervation of the tracheobronchial tree? | Vagus
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| True/False: The carina is a bronchial structure with limited sensation due to a lack of sensory nerves. | False
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| 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
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| What is the most sensitive area of the tracheal tree that will trigger a cough reflex? | Carina
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| What is the role of the bronchi? | Warm and humidify air as it passes to the alveoli
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| 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
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| 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
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| What is the principle muscle of respirations? | Diaphragm
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| Where is the diaphragm located? | Between the abdominal and plural cavities
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| The diaphragm is innervated from nerves that extend from which spinal cords? | C3, C4, C5
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| Which nerves innervate the diaphragm and where do they originate from? | Phrenic nerves; originate from C3-C5
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| What does FRC stand for and what does it represent? | Functional Residual Capacity - it is the lung volume at the end of normal exhalation
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| What is the normal FRC? | Approximately 2L in a 70kg adult seated upright
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| 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
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| 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
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| 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.
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| What does the LEMONS acronym stand for? | Look externally, Evaluate 3-3-2, Mallampati, Obstruction, Neck mobility, Scene and/or Situation
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| 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)
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| 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
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| What does the acronym MOANS represent? | The 5 most predictive factors related to difficult BMV
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| Identify each section of the MOANS acronym. | Mask seal, Obesity, Aged, No teetch, Snores or Stiff lungs
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| 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).
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| What patient population has the highest incidence of airway issues? | Men ages 40-59
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| Good correlation of the 3-3-2 measurements indicates alignment of what three axes? | Pharyngeal, laryngeal, oral
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| Hyothyroid distance should be ___________. | 2 finger breadths
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| 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
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| Describe the 1st classification of the Mallampati scoring system. | Soft palate, uvula, fauces, anterior and posterior tonsilar pillars
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| Describe the 2nd classification of the Mallampati scoring system. | Soft palate, uvula, fauces
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| Describe the 3rd classification of the Mallampati scoring system. | Soft palate, base of the uvula
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| Describe the 4th classification of the Mallampati scoring system. | Hard palate only
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| A Mallampati class 1 view predicts that intubating will be _________________. | Easy
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| A Mallampati class 2 view predicts that intubating will be _________________. | Possibly difficult
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| A Mallampati class 3 view predicts that intubating will be _________________. | Probably difficult
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| A Mallampati class 4 view predicts that intubating will be _________________. | Difficult
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| Identify the differences between inspiratory and expiratory wheezing. | Inspiratory wheezing signifies upper airway obstruction. Expiratory wheezing signifies lower airway or thoracic obstruction
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| Describe the 1st grade of the Cormack-Lehane grading system. | Full view of the glottis
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| Describe the 2nd grade of the Cormack-Lehane grading system. | Partial glottic view of only the arytenoids or posterior portion of the vocal cords
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| Describe the 3rd grade of the Cormack-Lehane grading system. | Only the epiglottis is viewed
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| Describe the 4th grade of the Cormack-Lehane grading system. | No view of the glottis or epiglottis
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| Which joint is the point at which head flexion and extension occurs? | Atlanto occipital joint
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| Which two joints form the atlanto occipital joint? | C1 (atlas) and C2 (axis)
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| The atlanto occipital joint is normally capable of extension of at least _________ degrees. | 35
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| Visualization of the airway may become difficult at what decreased AO angle? | 23 degrees
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| 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
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| 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
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| Sellick's maneuver involves direct pressure on the ___________________. | Cricoid cartilage
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| The ______________ technique involves the use of an over-the-wire technique for intubating. | Seldinger
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| What are the two different methods for obtaining an emergency surgical airway? | Needle cricothyoidotomy and surgical cricothyroidotomy
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| 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
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| What type of oxygen tubing should be used with a needle cricothyroidotomy? | Non-collapsible or non-compliant tubing
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| Additional room air is supplied to the lungs during PTJV due to the _____________________ effect. | Venturi
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| PTJV has the ability to cause what unfortunate effects? | Barotrauma, pneumothorax, CO2 accumulation
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| How much pressure should be delivered via PTJV? | 25-50 psi
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| 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
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| What is the recommended i:e ratio for PTJV? | 1:2
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| True/False: Exhalation is active in PTJV. | False
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| After placement of a needle cricothyroidotomy, what should be assessed frequently and why? | Breath sounds due to risk of pneumothorax
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| Besides breath sounds, what additional assessment should be made with an emergent surgical airway? | Subcutaneous emphysema
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| What two types of devices help facilitate the exhalation of CO2 after PTJV? | OPA, NPA
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| True/False: The thyromental distance is measured with the neck fully flexed. | False
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| True/False: The thyromental distance can be measured in-line. | True
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| The thyromental distance attempts to predetermine the lining of what two axes? | Laryngeal and pharyngeal
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| 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
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| What is the optimal finger distance of the mandibulohyoid measurement? | 2 fingers
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| The entrance to the larynx is marked by the position of what structure? | Hyoid bone
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| What does the epiglottis arise from? | Thyroid cartilage
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| The epiglottis is dorsal to which bone? | Hyoid
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| Ludwig’s angina is a disease characterized by cellulitis of the tissue located in what area? | Floor of the mouth
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