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Basics
Airway
| Question | Answer |
|---|---|
| Name the three compartments and levels of the pharynx. | 1. Naso (c1) 2. Oro (C2 & C3) 3. Hypo (C4 & C5) |
| Functions of the laryngeal cartilages | -protect the airway from aspiration -provide airflow between the trachea and and hypo pharynx -provide cough/gag reflex -phonation |
| Larynx | begins at the epiglottis (C4) and extends to the cricoid cartilage(C6), composed of cartilage, muscles, and connected by ligaments and membranes |
| Name the cartilages of the larynx | Single: Epiglottis, thyroid, cricoid Paired: Arytenoid, Corniculate, Cuneiform |
| Thyroid Cartilage | made of 2 laminae that fuse anteriorly to form the laryngeal prominence (adams apple), inferior horns articulate with cricoid cartilage at the cricothyroid joint |
| Cricoid Cartilage | only complete (ring) cartilage, smallest diameter in a child's airway |
| The epiglottis | attaches inferiorly to the thyoid cartilage, located anterior to the glottic opening, closes during swallowing |
| Superior Vallecula | space between the epiglottis and base of tongue, this is where you place you MAC blade |
| Arytenoid Cartilages | -sit on top of the posterior portion of the cricoid -any movement of the arytenoids will effect the vocal cords -they tense, relax, and swing the vocal cords -allow breathing, coughing, swallowing and phonation |
| Corniculate Cartilages | -cone shapesd -attach to the apex of the arytenoids |
| Cuneiform Cartilage | -attach to the posteriod arytenoids |
| Cricothyroid Membrane | -from upper margin of the cricoid cartilage to back of the thyroid cartilage anteriorly (this is where trachs are placed) |
| Thyrohyoid Membrane | Extends from upper border of thyroid cartilage to greater wing of the hyoid bone |
| Instrinsic Muscles of the Larynx | -aid in respiration and vocalization -control tension of the vocal cords and open/close glottis |
| Extrinsic Muscles of the Larynx | -connect the larynx to the hyoid -adjust the position of the trachea and other structures during phonation, breathing, and swallowing |
| The Trachea | -begins at inferior cricoid and extends to carina -10-20cm in adults -made of 16 to 20 c-shaped rings -cricoid cartilage is the only complete ring -posterior aspect has open side of ring to allow swallowing |
| Bronchi | -at the carina the trachea splits into R & L mainstem bronchi -function to provide humidification and warmth -R main is shorter, wider, and angles 25-30degress -L main angles at 45 degrees |
| Alveoli | -final branches of the resp tree -primary gas exchange units of the lung -gas/blood barrier between the alveolar space and pulmonary capillaries is thin to allow rapid gas exchange |
| Mallampati Classification | -examine tongue size in relation to oral cavity - pt seated upright, neutral head, mouth opened max, tongue protrudes max (phonation will falsify findings) |
| Components of the Airway Assessment | 1. Mallampati Classification 2. "3-3-2 Rule " 3. Atlanto-occipital joint extension 4. Dental Exam |
| Atlanto-Occipital Joint Extension | -have patient extend neck at much as possible-full extension (greater than 35 degrees) aligns the oral, pharyngeal, and laryngeal axes (sniffing position) - 2/3 decrease atlanto-occiptal joint extension is assoc with grade III or IV laryngoscopic view |
| 3-3-2 Rule | -no scientific data to support it -helps ensure relative geometry of upper airway is assessed -Oral Access: 3 Fingers -Thryomental Distance: 3 Fingers -Mandibulohyoid: 2 fingers |
| Indications for Intubation | 1. Provide patent airway 2. Prevent aspiration 3. Frequent Suctioning 4. Positive Pressure Vent 5. Inadequate ventilation or oxygenation 6. Position other than supine 7. Surgical site near airway 8. Airway maintenance diff by mask 9. Upper Airway disease |
| Face mask | -delivery of 02 or gas via breathing system -conforms to face and creates airtight seal -held in left hand and right hand used to generate positive pressure with bag |
| Artifical Airways | anesthetized patients lose upper airway muscle tone allowing the tongue and epiglottis to fall against the posterior wall of the pharynx, an oral or nasal airway can be placed to maintain space and allow airflow |
| Nasal Airway | -length is estimated as distance from nare to meatus of ear -lubricate tube and advance along floor of bare |
| Contraindications for Nasal Airway | -anticoagulation -children with prominent adenoids -patients with basilar skull fracture -severe maxillofacial fracture -known or suspected nasal obstruction (polyps) -inadequate operator skill |
| Guidelies for ETT size | Infants: ID 3.5, length 12 Children: age/4 + 4 (go down .5 for cuff tube), length 14 + age/2 Adult Female: 7.0/7.5 length 24 Adult Male: 7.5-9.0 length 24 |
| Laryngoscope | used to examine the larynx and facilitate intubation, Mac and Miller blades |
| Confirmation of ETT placement | -ETCO2 is most reliable (>30 x 3-5 breaths) -Presence of bilateral breath sounds and movement -absence of gastric gurgling -condensation in the tube (not reliable) |
| Complications During Laryngoscopy & Intubation | -Dental trauma -Hypertension & tachycardia -Posterior pharyngeal or lip bruises/lacs -Dislocated mandible -Tube malfunction -Cardiac arrest & brain damage -Malpositioning (esophageal/bronchial) -Laryngeal Cuff position (inadequate depth) |
| Complications while ETT in place | -malposition (accidental extubation, bronchial, cuff position) -Airway trauma (mucosal inflammation/ulceration, nasal excoriation) -Tube Malfunction (obstruction of the ETT by secretions or kink) -Fire |
| Airway Fire | -Prevent: do not use 100% oxygen or nitrous with tonsil surgery -surgeon will remove the ETT and flood the field with saline |
| Complications after Tracheal Extubation | -Layngospasm: extubate asleep or awake, not in between -Inhalation of gastric contents -Airway Trauma (edema/stenosis or hoarseness) -Negative pressure pulmonary edema (bite tube) -Tracheal mucosal damage w/ prolonged intubation |
| Damage of the Tracheal Mucosa | -major complication of prolonged intubation -may progress to destruction of the cartilage rings and scar formation -can cause tracheal stenosis (symptomatic when lumen is decreased to 5mm) |
| Asleep Extubation | -100% 02 and agent -wait until patient is breathing spent -suction (dont want them to respond) -deflate balloon and if no response then extubate |
| Alternative to Orotracheal Intubation | Blind: use stylet such as bougie Nasal: blind or layrgoscopy Supraglottic Device: LMAs Surgical Airway: cricothyrotomy and tracheostomy |
| Complications of Nasal Intubation | -epistaxis -dislodgement of pharyngeal tonsils (adenoids) -maxillary sinusitis -bacteremia -gastric distension |
| LMA | -supraglottic device as alternative to intubation (or as aid) -Use when: intubation is difficult or impossible, less invasice alternative to intubation is desired, serve as guide for fiberoptic intubation -insert to base of hypo pharynx |
| Disadvantages of LMA | -placement may not be possible in patients with limited cervical spine mobility/mouth opening -principle disadvantage is lack of airtight seal around larynx - does not protect against aspiration of gastric contents |
| LMA Proseal | -has conduit to provide access to the esophagus to minimize risk of aspiration -lacks mask aperture bars and has deeper bowl making migration of the epiglottis into the lumen less likely -has built in bite block -flexible wire-reinforced to minimize kinks |
| Combitube (CBT) | -double lumen airway with 2 balloons and traps glottis in-between -8 hour placement -can be inserted with head and neck in neutral and from variety of angles -offers some protection against gastric aspiration |
| Laryngeal Tube (LT) | -two balloons (esophagus & oropharynx) only 1 lumen -high volume, low pressure cuffs -less aspiration protection than ETT -intracuff pressure can climb to 15cm H20 w/ nitrous -req mouth opening of 23mm -cannot be uses if anatomic distortion of airway |
Created by:
MegPRN86
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