133 Questions
What is the recommended action for patients on daily dosing of GLP-1 agonists before elective surgery?
Hold the medication on the day of the procedure/surgery
What is the gold standard for diagnosing Obstructive Sleep Apnea?
Polysomnography
What is the risk factor for difficult or failed intubation?
Obstructive Sleep Apnea
What is the criterion for diagnosing Obstructive Sleep Apnea in adult patients when using the STOP-BANG questionnaire?
Yes to 3 or more questions on the screening questionnaire
What is the recommended action for patients on weekly dosing of GLP-1 agonists before elective surgery?
Hold the medication for 1 week prior to the procedure/surgery
What is the characteristic of Obstructive Sleep Apnea in pediatric patients?
Not necessarily associated with obesity and snoring
What is the function of the cricoid cartilage in the upper respiratory tract?
To separate the upper and lower respiratory tracts
Which of the following congenital conditions is associated with hemifacial microsomia, mandibular hypoplasia, incomplete/fused/missing vertebrae and cervical spine abnormalities?
Goldenhar Syndrome
What is the term for the downward displacement of the tongue in Pierre-Robin Syndrome?
Glossoptosis
Which of the following medications can increase the risk of delayed gastric emptying and nausea or vomiting?
Ozempic (semaglutide)
What is the term for the distance between the hyoid bone and the chin?
Hyoid-Mental Distance
Which of the following is a characteristic feature of Down Syndrome?
All of the above
Which obesity-related complication can increase the risk of anesthesia-related complications?
Obstructive sleep apnea
What is the classification of obesity with a BMI of 35-39.9 kg/m2?
Class II obesity
Which of the following is NOT a component of the upper respiratory tract?
Trachea
What is the primary purpose of the Cormack and Lehane Grading System?
To objectively assess the pharyngeal and glottic structures during laryngoscopy
What is the characteristic of a Grade IIb view in the Cormack and Lehane Grading System?
Only the posterior portion of the glottic opening can be visualized
Which of the following is NOT a sign of correct ETT placement?
Unilateral chest expansion
What is the primary mechanism underlying laryngospasm?
An exaggerated manifestation of the gag reflex provoked by irritation or obstruction
What is the first step in treating laryngospasm?
Remove irritants
What is the term for the abnormal stiffening of the TMJ, leading to a small mouth opening?
TMJ ankylosis
Which of the following conditions can cause limited atlanto-occipital extension?
Ankylosing spondylitis
What is the normal value for inter-incisor gap?
> 5 cm
What is the purpose of the upper lip bite test (ULBT)?
To determine the presence of difficult airway secondary to maxilla and mandibular movement
What is the measurement of the vertical distance from the angle of the mandible to the hyoid bone?
Mandibulohyoid distance
What is the purpose of the prayer sign?
To determine the presence of stiff joints
What is the term for the abnormal fusion of the vertebrate and cervical spine?
Ankylosing spondylitis
What is the 3-3-2 rule used to evaluate?
Upper airway geometry (oral access, TMD, Thyroid to hyoid)
What is a common cause of OSA?
Enlarged tonsils and adenoids
What is a characteristic of Acromegaly?
All of the above except a
What is a benefit of using regional techniques for OSA patients?
Reduced risk of respiratory depression
What is the primary function of the Inspire implanted stimulator device?
Stimulation of the hypoglossal nerve and prevents tongue from blocking airway
Why is postoperative monitoring important for OSA patients?
Risk of respiratory depression
What is a characteristic of Rheumatoid Arthritis?
Chronic inflammatory autoimmune disease
What is the primary purpose of the LEMON assessment in airway assessment?
To identify potential airway difficulties and guide further evaluation
What is the primary indicator of difficult mask ventilation?
Obesity
What is the characteristic of Treacher-Collins syndrome affecting the airway?
All of the above
What is the primary indication for using regional anesthesia in patients with Obstructive Sleep Apnea (OSA)?
To reduce the risk of respiratory complications
What is the purpose of the thyromental distance measurement in airway assessment?
To measure the anterior mandibular space
What is a benefit of using regional techniques for OSA patients?
Reduced risk of respiratory depression
What are the structures of the upper respiratory tract?
Nose, mouth, pharynx, hypopharynx, larynx, and cricoid cartilage
What structures comprise the lower respiratory tract?
Trachea, bronchi, bronchioles (terminal, respiratory), alveoli
What separates the upper airway structures from the lower airway structures?
Cricoid cartilage
The larynx serves as the inlet to what structure?
Trachea
What are the three paired cartilages in the larynx?
Arytenoid, Corniculate, and Cuneiform
What are the three unpaired (single) cartilages in the larynx?
Epiglottis, thyroid, cricoid
What is micrognathia?
A condition characterized by an abnormally small jaw
What is macroglossia?
Enlargement of the tongue
What are the characteristic airway structure features in patients with Down's syndrome?
All of the above
What are the characteristics of Treacher Collins syndrome as it relates to airway structures?
Mandibular hypoplasia (micrognathia), facial bone hypoplasia, choanal atresia, cleft palate
What is hypoplasia?
Underdevelopment or incomplete development of a tissue or organ.
What are the characteristics of Goldenhar syndrome as it relates to airway structures?
hemifacial microsomia, mandibular hypoplasia, cervical spine abnormalities, vertebrae incomplete/fused/missing
What are the characteristics of Pierre Robin syndrome as it relates to airway structures?
Micrognathia, retrognathia, glossoptosis, macroglossia, cleft palate
What is glossoptosis?
Downward tongue displacement
What is retrognathia?
A condition where the lower jaw (mandible) is positioned further back than the upper jaw (maxilla
What are the characteristics of Klippel-Feil syndrome as it relates to airway structures?
Fusion of C2 and C3 vertebrae, causing limited neck mobility and ROM
What is choanal atresia?
A congenital anomaly causing blockages of the nasal passages
What are the characteristics of rheumatoid arthritis as it relates to airway structures?
Mouth opening limitation secondary to TMJ stiffness, hypoplastic mandible, limited cervical spine movement/instability, cricoarytenoid arthritis, sublaxation of cricoarytenoid joint
What can cricoarytenoid arthritis cause?
Stridor
What are the characteristics of ankylosing spondylitis as it relates to airway structures?
Limited atlantooccipital extension, limited mouth opening, hunched forward positioning, inability to lie supine, decreased chest expansion
What is ankylosing spondylitis?
A type of inflammatory rheumatoid disorder that causes chronic inflammation that can lead to vertebral fusion and ankylosis
What is ankylosis?
Abnormal stiffening
How does acromegaly affect the airway?
It causes tissue enlargement, leading to macroglossia, prognathism, vocal cord swelling, enlarged face/hands/nose/lips
What causes acromegaly?
Excess growth hormone production from the pituitary gland
During DL, you may see nodules in patients that have RA
True
Rheumatoid arthritis causes many airway abnormalities
True
What is rheumatoid arthritis?
A chronic autoimmune disease that causes inflammation of the joints and joint erosion
How does Ludwig's angina affect the airway?
It causes trismus making it difficult to open mouth
What is Ludwig's angina?
A bacterial infection of the submandibular space
What is the atlantooccipital angle and its relation to mobility?
The angle formed by the junction of the atlas and the occipital bone, extension needed to place patient in sniffing position
What does extension at the atlanto-occipital joint provide for the airway?
Increased mouth opening facilitating better visualization of the airway
Mallampati is the gold standard for identifying difficult intubations
False
What items are assessed in the Mallampati test?
Mouth opening, size of tongue, size of oropharynx and visualization of posterior oropharyngeal structures
What does the PUSH acronym mean as it relates to the Mallampati test?
P: Pillars, U: Uvula, S:Soft palate, H: Hard palate
You can visualize the patient's soft palate only. What is the patient's Mallampati score?
III
How is the Mallampati test performed?
The patient is seated upright with their head in a neutral position, and then asked to open their mouth as wide as possible with tongue protruded
Phonation is is the last part of the Mallampati test
False
When you can see a patient's facial pillars, uvula, and palate, what is the patient's Mallampati score?
Class I
What are the components of the LEMON assessment in airway evaluation
Look externally, Evaluate 3-3-2 Rule, Mallampati, Obstruction, Neck mobility
What does the 'O' in the LEMON assessment stand for?
Obstruction - presence of injuries or conditions affecting epiglottis
What is the purpose of the sniffing position?
To facilitate tracheal intubation by aligning the oral, pharyngeal, and laryngeal axes via neck flexion with upper cervical extension
What is the purpose of ramping in achieving the sniffing position?
To elevate shoulders, neck, and head to optimize patient positioning for DL
What does the thyromental distance (TMD) measure?
The distance from the thyroid cartilage to the mental protuberance (anterior mandibular space)
How do you assess the thyromental distance?
Measure the distance from the thyroid notch to the mentum with patient's head extended and mouth closed
What thyromental distance is indicative of potentially difficult intubating?
< 6 cm and >9cm
What does the thyromental distance reflect?
Neck mobility and degree of retrognathia
In the upper lip bite test, what score indicates the least mobility?
3 - unable to bite upper lip
A patient is able to bite the vermillion border of upper lip with their lower incisors. What would be the ULBT score?
2
How do you perform the mandibular protrusion test?
Ask the patient to thrust their jaw forward as far as possible
The patient is able to place their lower teeth in alignment with the upper teeth while performing the Mandibular Protrusion Test. What is their grade?
B
The patient is unable to place lower teeth in alignment with upper teeth. What is their Mandibular Protrusion grade?
C
What is a normal atlanto-occipital joint angle?
35 degrees
An atlanto-occipital joint less than ___ indicates difficulty visualizing glottic structures
23
What does the sternomental distance (SMD) measure?
The distance from the sternal notch to the mentum (chin) with mouth closed
A SMD of less than ___ cm is a predictor of difficulty intubating
12.5
What are the components of the 3-3-2 rule?
3 fingerbreadths for oral access, 3 fingerbreadths for TMD, 2 fingerbreadths for thyroid-hyoid notch
The TMD is also known as the ___ length
Mandibular length
What acronym is used to predict difficult mask ventilation?
BOOTS
BOOTS = Bearded, Obese, Old, Toothless, Snoring
True
In positioning obese patients, try to align the ear with the sternal notch
True
What is a normal BMI range?
18.5-24.9
What BMI is considered overweight?
25-29.9
What BMI is considered Class 1 obesity?
30.0-34.9
Class 2 obesity corresponds to what BMI?
35-39.9 kg/m2
A BMI greater than 40 is considered what class of obesity?
Class 3 obesity
What acronym is used to predict difficulty with supraglottic airway placement?
RODS
What does RODS stand for in predicting difficulty with SGA placement?
Restriction, Obstruction, Distortion, Stiff lungs/spine
What does FONA stand for in anesthesia?
Front-of-Neck Access
What acronym is used to predict difficulty with FONA?
SHORT
What does SHORT stand for in predicting difficulty with FONA?
Surgery, Hematoma, Obesity, Radiation/distortion, Tumor
What is the purpose of the Cormack and Lehane grading system?
To assess the pharyngeal and glottic structures during laryngoscopy
Most of the glottis can be seen during DL. What is the patient's Cormack and Lehane Grade?
I
The vocal cords can be partially seen during DL. What is the patient's Cormack and Lehane Grade?
II
Only the epiglottis can be seen during DL. What is the patient's Cormack and Lehane Grade?
III
The epiglottis cannot be seen during DL. What is the patient's Cormack and Lehane Grade?
IV
What does POGO stand for in anesthesia?
Percentage of Glottic Opening
What are the 3 POGO scores?
100, 33, 0
A POGO score of 100 indicates
entire glottic structures are visible
A POGO score of 33 indicates
Only lower third of vocal cord and arytenoid visible
How do you confirm ETT placement?
Observation of tube passing through vocal cords, condensation in tube, bilateral chest expansion, bilateral breath sounds, ETCO2 waveform
What are the methods to treat laryngospasm?
Remove irritants, deepen anesthetic, PPV, bilateral pressure at laryngospasm notch, NMBA
Short length of upper incisors can indicate difficulty managing airway
False
Palm mobility is not associated with overall joint mobility
False
Patients with a high risk of OSA answer yes to 2 or more questions in the STOP-BANG questionnaire
False
STOP-BANG = Snoring, Tired, Observed, Pressure (HTN), BMI>35, Age>50, Neck>40, Gender - male
True
Regional techniques should be used in when possible with patients with OSA
True
What is the preferred method of extubation in OSA patients?
Awake extubation
Apert syndrome is a congenital condition characterized by underdevelopment of the tongue, maxilla, and mandible resulting in upper airway obstruction
True
How does angioedema affect the airway?
It leads to swelling of the airway, which can cause obstruction.
What separates the larynx from the pharynx?
Epiglottis
What parts comprise the larynx?
Epiglottis, Glottis, and Vocal folds
What is the primary difference between acromegaly and gigantism?
Age of onset of excessive growth hormone production
What Mallampati score indicates the potential for difficulty in airway management?
III and IV
Study Notes
Airway Assessment
- Airway screening tests assess difficult airways, but most difficult airways are unanticipated.
- Mouth opening: normal value > 5 cm (at least 3 fingers).
- Dental assessment: assess for any chipped or broken teeth that could end up in the lung.
- Inter-incisor distance: assess for potential airway issues.
- Mallampati: assess mouth opening, size of tongue, size of oropharynx, and visual of posterior oropharyngeal structures.
- Thyromental distance: measure of anterior mandibular space; normal is 6 cm.
- Mandibular protrusion test: assess for airway mobility.
- Upper lip bite test: assess for upper lip mobility.
- Atlanto-occipital joint extension: assess for neck mobility.
- LEMON assessment: Look, Evaluate 3-3-2 rule, Mallampati, Obstruction, Neck mobility.
Airway Anatomy
- Upper respiratory tract: nose, mouth, pharynx, hypopharynx, larynx, cricoid cartilage.
- Larynx: 9 cartilages, 3 paired and 3 single.
- Lower respiratory tract: everything beneath the cricoid cartilage; trachea, bronchi, bronchioles, alveoli.
Congenital Abnormalities
- Pierre-Robin: underdevelopment and recessed chin.
- Goldenhar's syndrome: hemifacial macrosomia, mandibular hypoplasia, cervical spine abnormality.
- Klippel-Feil: fusion of 2+ cervical vertebrae, short/no neck.
- Treacher-Collins: mandibular hypoplasia, micrognathia, choanal atresia, cleft palate, facial bone hypoplasia.
- Down syndrome: micrognathia, macroglossia, narrow palate, large and thick lip, flattened nose, small ears, cervical spine abnormalities, small subglottic diameter, OSA.
Acquired Conditions
- Obesity: be familiar with BMI calculation, GLP-1 agonists, and anesthesia considerations.
- Obstructive Sleep Apnea: increased risk for difficult or failed intubation, STOP-BANG questionnaire, polysomnography diagnosis.
- TMJ: causes trismus, ankylosing spondylitis, and rheumatoid arthritis.
- Infections: Ludwig's angina, oral and retropharyngeal abscesses, epiglottis, croup, laryngeal papillomatosis.
- Angioedema: rapid swelling of mucosa, lips, and tongue.
Airway Management
- Predictors of difficult mask ventilation: pick one to memorize.
- Ramping: align airway for direct laryngoscopy.
- Cormack and Lehane Grading System: assess intubation difficulty.
- Difficulty with BVM: poor mask seal, airway obstruction, obesity, age > 55, no teeth, stiff lungs, sleep apnea, or snoring.
Respiratory Mechanics
- Resistance: 8 x length x (viscosity/π) x radius^4.
- Laminar flow: function of viscosity of gas.
- Turbulent flow: function of density of gas.
- Reynold's number: > 2000 = turbulent.
Lung Volumes and Capacities
- Spirometry: can give all volumes except FRC, TLC, RV.
- Respiratory Mechanics: preop tests correlate with post-thoracotomy outcomes; FEV1, FVC, Max minute ventilation, RV/TLC, DLCO.
- DLCO: best test for determining surface area for gas exchange.
Pre-op Assessment
- Goal: plan implementations to improve outcomes.
- Functional assessments: respiratory mechanics, gas exchange, cardiopulmonary interaction, quality of life, exercise tolerance, and pulmonary function testing when indicated.
Assess your knowledge of airway assessment tests and procedures in anesthesia, including the LEMON assessment, Mallampati score, and more. This quiz is ideal for nurse anesthetists and anesthesia students.
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