Airway Management

Miller Anesthesia, Chapter 42

1. True or false?
The principal impediment to air flow in the nasopharynx is the inferior turbinates.

2. True or false?
The principal impediments to air flow in the oropharynx are the prominent tonsillar lymphoid structures.

3. In adults, the cricoid cartilage usually lies at the level of

• C3
• C4
• C5
• C6
• None of the above

4. In infants, the cricoid cartilage usually lies at the level of

• C3
• C4
• C5
• C6
• None of the above

5. In adults, where is the narrowest segment of the laryngeal opening?

6. In small children, where is the narrowest segment of the laryngeal opening?

7. Name the muscles that are the only effective abductors of the vocal cords. How are they innervated?

8. You are performing a mask induction using N20, 02, and halothane on a 2 year old who presents for tonsillectomy and adenoidectomy. The child is unconscious, breathing spontaneously and all appears to be going well. Suddenly the pulse oximeter begins to alarm. You turn off the N20, turn up the 02 and halothane, and begin to assist the child's respiration. His chest wall and abdomen appear to be moving. The pulse oximeter continues to alarm (sats 80% now on 96% FIO2) and the patient appears somewhat cyanotic. Describe your next steps to evaluate and treat this patient.

9. You are performing a narcotic-based induction of a 68 year-old vasculopath who presents for an bilateral fem-fem bypass and right fem-pop bypass. All is going well until the patient begins to desaturate. You tell the very somnolent patient to breath, and she takes a long, snoring inspiration. Describe how you will manage the patient's airway.

10. You are working as the PAR dog (aaaaaaaaaagh!) and are asked to emergently intubate a patient on 4C. You sprint to the MICU, resuscitation equipment in hand, and find the patient obtunded and making respiratory efforts (chest retractions, "rocking" abdomen). He is mildly cyanotic. He has a history of polycythemia and was admitted for an apparent MI. He has been on a beta-blocker, IV morphine, and heparin since admission earlier in the day. The medicine residents are clamoring for you to "put him to sleep and intubate him." Indicate what your first step in managing this patient will be. Will you comply with their request?

11. True or false?
The epiglottis covers the laryngeal inlet and is essential for airway protection.

12. You are performing a general inhalational anesthetic on a 3 year old who presents for dilation of the rectum. You have elected to do this as a "mask" case as the patient is a same-day admit who is to be discharged later today, and the surgeons have warned you that the case will likely last only a few minutes. All is going well until shortly after the surgeons begin their procedure. Suddenly you can no longer ventilate the previously spontaneously breathing patient. What may have happened and how will you deal with it?

13. You are asked to anesthetize a 19 year old patient for ORIF of a fractured distal radius. Before seeing the patient, you suggest that an axillary block might be a good anesthetic option. The orthopod informs you that the patient is unlikely to be able to cooperate as she has Down's syndrome with severe developmental delay. Describe in detail your evaluation of the patient's airway and your plans for managing her anesthetic.

14. You are asked to anesthetize a 30 year old patient with a history of Pierre-Robin syndrome for a D & C. How will you approach her anesthetic and her airway?

15. You are asked to anesthetize an obese 42 year old male for I and D of sacral decubitus ulcers. The patient is s/p MVA in 1992 and is a T6 paraplegic. He also had cervical injuries as a result of his accident and has undergone an anterior cervical fusion. He tells you that following his original injury, he was intubated and mechanically ventilated for several weeks. You note what appears to be the scar from a previous tracheostomy in the folds of his neck. His voice is somewhat soft and a bit hoarse. On further exam, he has no upper teeth and only a few remaining lower teeth (most of them isolated). The horizontal length of his mandible is 10 cm. Sitting, with his mouth open, tongue protruding, without phonation, you are able to visualize the soft palate and base of the uvula. Describe your airway management plan.

16. You are asked to assist Dr. Belani in evaluating and intubating a child with Hurler's syndrome, s/p bone marrow transplant. Describe your evaluation, preparations, and major concerns.

17. You are asked to anesthetize a 20 year old 140 kg defensive tackle for the Gopher football team who has an apparent acute appendicitis. On exam, he has a neck which is roughly the same thickness as his thigh and which appears to be approximately 6 cm long. He has a profound overbite, which the accompanying coach cautions you not to comment on as the man's childhood peers teased him mercilessly about it, and as such it became one of the things that motivated this young athlete to build himself up to his current size. Thyro-mental distance is 2 finger breadths (yours, not his) and with the patient supine, tongue extended, moaning (him, not you), only his soft palate can be visualized. Describe your anesthetic/airway management plan. If you choose to do an "awake" intubation, will you include transtracheal and/or superior laryngeal blocks as part of your preparation? Why/why not?

18. List the elements of a "rapid sequence" induction according to Miller.

19. True or false? Lidocaine ointment used to lubricate the ETT tip reduces the incidence of sore throat postop.

20. You are called to the ER to manage the airway of a trauma victim. You arrive to discover that the patient has been involved in an MVA (auto vs. pedestrian--he was the pedestrian). Obvious injuries include an open right tib-fib fracture, a substantial hematoma (? fracture) of the right upper arm, and abrasions and a substantial area of swelling over the right ramus of the mandible. The patient is a 38 year old hemophiliac with a history of polydrug abuse. He is HIV positive. He is belligerent, has reportedly been spitting on ER personnel, and has been maintaining a constant stream of profanity. He smells like ETOH, but no one has been able to get an ethanol level. The junior surgery resident on-call ask you to induce and intubate this patient to insure his cooperation with a CT scan to determine the extent of the man's injuries. Will you? How will you manage this patient's airway?

21. You are performing a routine induction on a 68 year old patientwith arthritis for total knee arthroplasty. On preop exam the she wasnoted to be mildly obese with good dentition, a mallampati class 2-3airway with a thyro-mental distance of nearly 2 finger breadths, and slightly reduced neck extension. On your initial attempt to intubate the patient, you are unable to visualize the cords. You are able to mask ventilate her with relative ease. How will you proceed?

22. You are asked to anesthetize a patient with a known difficult airway for an elective procedure. The patient has a history of rheumatic fever and hypothyroidism. You plan an awake nasal intubation with a fiber optic scope, as this was successful for his last surgery and there are no contraindications to nasal intubation. What medications will you include as part of your preparations for this procedure and how will you proceed?

23. You are the PAR dog (it's like something from No Exit) and one of your colleagues has done you the favor of bringing the patient from #22 to the PAR intubated. It's time to extubate. How you gonna do it?

24. You are planning to intubate an otherwise normal 7 year old after induction of general anesthesia for closed (possible ORIF) reduction of a Colles fracture. What size/type endotracheal tube will you use.

25. True or false? Inadvertent left mainstem intubation is just as likely as right mainstem intubation in newborns.