1 Larynx

The larynx, which lies at the level of the third through sixth cervical vertebrae, serves as the organ of phonation and a valve to protect the lower airways from the contents of the alimentary tract. The structure consists of muscles, ligaments and a framework of cartilages. These include the thyroid, cricoids, arytenoids, corniculate, cuneiform and the epiglottis (fig. 3). The epiglottis, a fibrous cartilage, has a mucous membrane covering that reflects as the glossoepiglottic fold onto the pharyngeal surface of the tongue. On either side of this field are depressions called valleculae. The epiglottis overhangs the laryngeal inlet. The laryngeal cavity extends from the epiglottis to the lower level of the cricoid cartilage. The inlet is formed by the epiglottis, which joins to the apex of the arytenoid cartilage on each side by the aryepiglottic fold. Inside the laryngeal cavity one encounters the vestibular folds, which are narrow bands of fibrous tissue on each side. These extend from the anterolateral surface of each arytenoid to the angle of the thyroid where the latter attaches to the epiglottis. These folds are the false vocal cords and are separated from the true cords by the laryngeal sinus or the ventricle. The true vocal cords are pale white ligamentous structures that attach to the angle of the thyroid cartilage and to the arytenoids. The triangular opening formed by the true vocal cords is called the glottis. The muscles of the larynx may be classified into abductors, adductors, and regulators of tension. The Anatomy of the Airway The larynx consists of nine cartilages, including the thyroid, cricoid, epiglottis, corniculate, cuneiform, and arytenoid cartilages. These cartilages are covered by folds of mucosa, connective tissue, and muscle; laryngeal tissue folds define the glottis. The superior, inferior, and recurrent laryngeal nerves innervate the larynx. Supraglottic sensation is mediated by the superior laryngeal nerve, and infraglottic sensation is mediated by the inferior laryngeal nerve. The recurrent laryngeal nerve provides most laryngeal motor innervation. Only the cricothyroid muscle is innervated by the superior laryngeal nerve. The airway is lined with ciliated and squamous epithelium that is highly vascular and overlies a rich network of lymphatic vessels. Laryngeal innervation a. Superior laryngeal nerve (internal division) supplies the epiglottis, base of the tongue, supraglottic mucous, thyroepiglottic joint, and cricothyroid joint. b. Superior laryngeal nerve (external division) gives sensory supply to anterior subglottic mucosa and motor to cricothyroid muscle (adductor, tensor). c. Recurrent laryngeal nerve gives sensory innervation to the subglottic mucosa and muscle spindles, and motor innervation to thyroarytenoid, lateral cricoarytenoid, inter arytenoids and posterior cricoarytenoid. The larynx maintains the airway and functions as a valve to occlude and protect the lower airway from the alimentary tract. It is also an organ for phonation. With the exception of the anterior nasal passages, the laryngeal inlet is the narrowest portion of the entire airway system in the adult. The cricoid cartilage forms a complete ring, protecting the upper airway from compression. On the other hand it is vulnerable to stenosis, since the mucosal edema can only occur inwards, diminishing the lumen. In the infant this edema may produce severe obstruction, whereas the same degree of swelling in adults may cause no more than mild discomfort. Ischemic mucosal edema may cause symptoms of upper airway obstruction and if severe enough, subsequent fibrosis and subglottic stenosis. Physiology of airway protection The pharynx, epiglottis, and vocal cord play a major role in protecting the lower airway from aspiration of foreign bodies and secretions. Although the epiglottis covers the laryngeal inlet, it is not absolutely essential for airway protection. Most vital in the protective function is the glottis closure reflex, which produces protective laryngeal closure during deglutition. The physiological exaggeration of this reflex, laryngospasm, is counterproductive to respiration. Laryngospasm is a prolonged intense glottic closure in response to direct glottic or supraglottic stimulation from inhaled agents, secretions, or foreign bodies. Stimulation from the periosteum, celiac plexus, or dilatation of the rectum may also precipitate the problem reflexly. This reflex tends to persist in spite of removal of the stimulus causing it. Treatment of severe spasm may require the use of muscle relaxants. However, forward displacement of the mandible, together with oxygen administered by mask under pressure, is often effective. Developmental Airway Considerations

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The anatomy of the pediatric airway differs from the adult airway until it reaches mature position at approximately 8 to 14 years of age. The major differences between the pediatric and the adult airway are size, shape, and position in the neck. Because the diameter of the pediatric trachea is small, relatively small compromise in trachael radius can significantly increase resistance to airflow and work of breathing. Resistance to airflow is inversely related to the fourth power of the radius during quiet breathing, when airflow is laminar, but is inversely related to the fifth power of the radius when airflow is turbulent. When respiratory distress is present, providers should attempt to keep the child as quiet as possible, minimizing agitation to reduce turbulent flow, airway resistance, and work of breathing. The anatomic differences particular to children are these: 1. Higher, more anterior position of the glottic opening. (Note the relationship of the vocal cords to the chin/neck junction.) 2. Relatively larger tongue in the infant, which lies between the mouth and glottic opening. 3. Relatively larger and more floppy epiglottis in the child. 4. The cricoid ring is the narrowest portion of the pediatric airway versus the vocal cords in the adult. 5. Position and size of the cricothyroid membrane in the infant. 6. Sharper, more difficult angle for blind nasotracheal intubation. 7. Larger relative size of the occiput in the infant. Anatomic differences between adult and pediatric airways

Anatomy

Clinical significance

Tongue occupies relatively large portion of High anterior airway position of the glottic opening the oral cavity. compared with that in adults High tracheal opening (relative to cervical vertebrae): Straight blade preferred over curved blade to push C1 in infancy distensible anatomy out of the way to visualize the C3 to C4 at 7 years of age larynx C4 to C5 in the adult Sniffing position opens the airway. The larger occiput actually elevates the head toward the sniffing Large occiput may cause flexion of the position in most infants and children (neck must be airway, and large tongue can fall against extended). A towel may be required under the posterior pharynx when child is supine. shoulders to elevate torso relative to head in small infants. Uncuffed tubes may provide adequate seal, as they Cricoid ring is the narrowest portion of the can fit snugly at the level of the cricoid ring. child's trachea (vocal cords are the Selection of correct tube size is essential because narrowest portion in the adult). use of excessively large tube may cause mucosal injury. Consistent anatomic variations with age, Age-related with fewer anatomic abnormal variations <2 years: High related to body habitus, arthritis, and 2-8 years: chronic disease. >8 years: Small adult anterior variations: airway Transition

Large tonsils and adenoids may bleed. Blind nasotracheal intubation not indicated in More acute angle between epiglottis and children. laryngeal opening makes endotracheal May cause failure of attempted nasotracheal intubation difficult. intubation. Small cricothyroid membrane. Needle cricothyrotomy difficult; surgical cricothyrotomy is impossible in infants and small children.

Trachea The trachea is a tubular structure lying opposite the sixth cervical vertebra at the level of the cricoid cartilage.

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It is flattened posteriorly and supported along its 10 to 15cm length by 16 to 20 horseshoe shaped cartilages until bifurcating into right and left main bronchi at the level of the 5th thoracic vertebra. The trachea contains a number of receptors that are sensitive to mechanical and chemical stimuli. The muscles of the posterior tracheal wall contain slowly adapting stretch receptors that are involved in the regulation of the rate and depth of breathing. They also produce dilation of the upper airway by decreasing vagal efferent activity. Other rapidly adapting irritant receptors are found all around the tracheal circumference. They are usually considered to be cough receptors, although the other reflex action consists of bronchoconstriction. Coughing is the mechanism for expelling secretions and foreign bodies from the lower respiratory tract. It consists of three events. A deep inspiration to attain a high lung volume comes first and allows attainment of high expiratory flow rates. Then a tight closure of the glottis follows with contraction of the expiratory muscles. Intrapleural pressure rises to above 100 cm of H2 O so that during the final or expiratory phase, sudden expulsion of air occurs as the glottis opens. There is a significant narrowing of the airway lumen during coughing. The significance is that the decreased airway caliber increases the linear velocity of gas flow and improves cough effectiveness. Conclusion Over a century and a half of development of the science of anaesthesia, the anaesthesiologist has learned to use the above understanding of the airway to protect our patients in many ways. We now assess the integrity of the airway before embarking on anaesthesia so that we are not caught unawares. We have learnt to avoid prolonged nasotracheal intubation when possible. We now understand the danger of the collapsible pharyngeal airway and the risk of resultant respiratory obstruction. Thanks to this understanding, many people with obstructive sleep apnoea sleep comfortably at night aided by continuous positive airway pressure (CPAP), and go through general anaesthesia with less risk. We use artificial warming and humidification of inspired gases when we are forced to bypass the nose for prolonged periods of time. We treat the larynx with respect now and take measures to avoid the trauma of tight fitting endotracheal tubes. Paediatric anatomy and physiology Respiratory Anatomy and Physiology Babies have a relatively larger head with a prominent occiput. The head needs to be stabilised for intubation. The neck is short and the tongue large. The airway is prone to obstruction. The relatively large head with little hair leads to greater heat loss. The head should be covered. Infants and neonates breathe mainly though their noses. Their nostrils are small and easily obstructed. The larynx is more anterior and is situated at a higher level relative to the cervical vertebrae (C3 to C4 at birth) compared to an adult(C6). The epiglottis is relatively longer, leaflike and U shaped. The inexperienced anaesthetist may find the baby more difficult to intubate. The trachea is short and the right main bronchus is angled less than the left. Right main bronchus intubations are more likely. With most infants, if the 10 cm mark on the endotracheal tube is at the gums, the tip of the tube will be just above the carina. In older children the length of the endotracheal tube may be estimated by (age/2) + 12 cm. Always listen to both lungs to check that the endotracheal tube is not in one lung. Because the length of the trachea is short, a small movement of the tube may move it to the wrong position. The tube should be secured to the maxilla rather than the mandible, which is mobile. The narrowest part of the upper airway is the cricoid ring in the pre-pubertal child. After puberty, the narrowest part of the airway is at the level of the vocal cords. One of the most serious complications of endotracheal intubation is mucosal oedema and post extubation stridor due to pressure from the external surface of the endotracheal tube. The diameter of the trachea in the newborn is 4 to 5 mm. Just 1 mm of oedema can cause serious harm. Children before puberty should have an uncuffed tube and there should be a slight air leak with positive pressure ventilation. It is important to select the correct size endotracheal tube. Their ribs are more horizontal and any increase in the volume of the thorax is due to downward movement of the diaphagm. A distended abdomen or surgical retraction can easily reduce ventilation.

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Oxygen consumption in neonates may be greater than 6 ml/kg/min, i.e twice the oxygen consumption of adults. In infancy a gradual change towards the adult rate (3.5 ml/kg) occurs. A higher oxygen consumption means that neonates and infants will rapidly consume their oxygen reserves and become cyanotic if they are apnoeic. The anaesthetist must be skilled at maintaining a clear airway and intubation. Attempts at intubation must not exceed 30 seconds. Higher oxygen consumption leads to a higher carbon dioxide production, which requires increased ventilation to remove it. The increased ventilation is mainly achieved by a higher respiratory rate (newborn 35 to 40 breaths/minute). The tidal volume/kg is similar for adults and children. Peripheral airways are narrower and airway resistance is relatively higher in babies. In the newborn or the preterm baby the brain control of respiration is immature. Pre- mature and ex-premature babies up to 52 weeks post conceptual age are at risk of apnoea after general anaesthesia. They must be very closely observed for at least 24 hours. Cardiovascular Anatomy and Physiology Cardiac output in the neonate might be 200 to 400 ml/kg/min compared to 70 to 80 ml/kg/min in the adult because of the higher metabolic rate and oxygen requirement in the neonate. Stroke volume is relatively fixed in the newborn due to the poorly compliant ventricular muscle. Stroke volume in the newborn is 5 to 7 ml/kg compared to 1 to 2 ml/kg in adults. Therefore, an increase in cardiac output is achieved by an increase in heart rate. The newborns resting heart rate is much higher than that of the adult (130 to 140/min in the neonate, 70/min in the adult) and it is not until about the age of ten that it reaches adult rates. Blood pressure is lower in children than adults because of low peripheral resistance. Blood volume in the neonate is about 80 ml/kg compared to 70 ml/kg in the adult. The sympathetic nervous system is not well developed. Infants can easily become bradycardic. Atropine premedication will reduce the incidence of bradycardia and reduce secretions. (Intravenous or intramuscular dose is 0.01 to 0.02 mg/kg). Maximum dose should be less than 0.06 mg/kg. Haemoglobin at birth is high (18 g/dl) and falls to a low at 3 to 6 months of about 11 g/dl. The change is due to a decrease in foetal haemoglobin. Foetal haemoglobin is not able to deliver oxygen to the tissues as efficiently as adult haemoglobin. A haemoglobin of less than 13 g/dl in the newborn and less than 10 g/dl in the first 6 months of life may be significant. Renal System and Fluid Balance Neonates have a greater total body water (70 to 75% of body weight) compared to adults (60% ofbody weight). There is a larger extracellular compartment (ECF) and smaller intracellular compartment (ICF). By the first year of age the proportions are the same as for adults (ECF 45%, ICF 55% of total body water). The increased metabolic rate of infants results in a faster turnover of extracellular fluid.An interruption of the normal fluid intake can therefore rapidly lead to dehydration and the anaesthetist must take care with fluid management. The anaesthetist must estimate replacement fluid, maintenance fluid and ongoing fluid losses. Children have a relatively small blood volume. A 5kg infant will have a blood volume of only 400 ml. Blood loss of only 40 ml is a 10% decrease in blood volume and 80 ml a 20% loss of blood volume. A soaked swab will contain at least 5 ml and a small pack at least 20 ml of blood. Urine output should be at least 0.5 ml/kg/h. The neonate has decreased glomerular filtration and tubular function. The ability to excrete a fluid load is initially poor but this function rapidly increases in the first month of life. The ability to produce concentrated urine is also initially poor and improves rapidly in the first two months reaching adult levels by two years of age. Temperature The newborn is at a greater risk of cooling when exposed to a cold environment because the ratio of body surface area to body weight is double that of older patients. Skin and subcutaneous fat is thinner, providing less insulation and leading to greater heat loss. Heat production is low and the ability to shiver is not well developed. Temperature regulation is immature. The environmental temperature range in which oxygen consumption is minimal (thermoneutral range) is narrow. A decrease in environmental temperature of two degrees Celsius may double the oxygen consumption of a newborn. Infants must be kept warm. The operating theatre should be heated and the infant kept covered. Try to warm intravenous fluids.

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Hepatic Physiology Liver metabolism may be poor in the newborn but develops rapidly in the first few weeks. Drugs such as opioids, benzodiazepines and barbiturates may not be metabolised as rapidly in neonates. Paediatric Pharmacology The differences in physiology of the infant will alter the effect of some drugs. All opioids and central nervous system depressants must be given with caution in neonates unless the patient is being ventilated and closely monitored. Morphine clearance in neonates is one quarter that of adults so that the elimination half time will be four times that of adults. The immature respiratory centre makes the neonate more sensitive to the respiratory depressive effects of morphine. The proportion of cardiac output going to the brain is greater in the neonate than in older children. The dose of intravenous induction agents should be reduced in neonates. Decreased renal and liver function results in certain drugs being excreted more slowly. The dosing interval should be increased to avoid toxicity. Neonates and infants require a greater dose suxamethonium (2 mg/kg) than adults (1 mg/kg). The MAC of inhalational agents is greater in the young and decreases with increasing age, however neonates require lower concentrations than infants do. There may be nearly a 30% greater anaesthetic requirement for inhalation agents but there is a smaller margin of safety between adequate anaesthesia and cardiovascular and respiratory depression in infants compared with adults. Both induction and recovery from inhalation agents is more rapid in children than adults. Physiology of Spinal Anaesthesia Local anaesthetic solution injected into the subarachnoid space blocks conduction of impulses along all nerves with which it comes in contact, although some nerves are more easily blocked than others. There are three classes of nerve: motor, sensory and autonomic. Stimulation of the motor nerves causes muscles to contract and when they are blocked, muscle paralysis results. Sensory nerves transmit sensations such as touch and pain to the spinal cord and from there to the brain, whilst autonomic nerves control the calibre of blood vessels, heart rate, gut contraction and other functions not under conscious control. Generally, autonomic and sensory fibres are blocked before motor fibres. This has several important consequences. For example, vasodilation and a drop in blood pressure may occur when the autonomic fibres are blocked and the patient may be aware of pressure or movement and yet feel no pain when surgery starts. Practical implications of physiological changes. The patient should be well hydrated before the local anaesthetic is injected and should have an intravenous infusion in place so that further fluids or vasoconstrictors can be given if hypotension occurs. Anatomy

The spinal cord usually ends at the level of L2 in adults and L3 in children. Dural puncture above these levels is associated with a slight risk of damaging the spinal cord and is best avoided. An important landmark to remember is that a line joining the top of the iliac crests is at L4 to L5. Remember the structures that the needle will pierce before reaching the CSF (figure 1).

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The skin. It is wise to inject a small bleb of local anaesthetic into the skin before inserting the spinal needle. Subcutaneous fat. This, of course, is of variable thickness. Identifying the intervertebral spaces is far easier in thin patients. The supraspinous ligament that joins the tips of the spinous processes together. The interspinous ligament which is a thin flat band of ligament running between the spinous processes. The ligamentum flavum is quite thick, up to about 1cm in the middle and is mostly composed of elastic tissue. It runs vertically from lamina to lamina. When the needle is within the ligaments it will feel gripped and a distinct "give" can often be felt as it passes through the ligament and into the epidural space. The epidural space contains fat and blood vessels. If blood comes out of the spinal needle instead of CSF when the stylet is removed, it is likely that an epidural vein has been punctured. The needle should simply be advanced a little further. The dura. After feeling a "give" as the needle passes through the ligamentum flavum, a similar sensation may be felt when the needle is advanced a further short distance and pierces the dural sac. The subarachnoid space. This contains the spinal cord and nerve roots surrounded by CSF. An injection of local anaesthetic will mix with the CSF and rapidly block the nerve roots with which it comes in contact

An ulnar claw, also known as claw hand, is an abnormal hand position that develops due to a problem with the ulnar nerve. A hand in ulnar claw position will have the 4th and 5th fingers drawn towards the back of the hand at the first knuckle and curled towards the palm at the second and third knuckles. Some sources refer to the ulnar claw as a "hand of benediction"[1]. However, the term "hand of benediction" more commonly refers to a similar hand position which is caused by damage to the median nerve[2][3] and is only present when the patient is asked to make a fist. Wrist drop, also known as radial nerve palsy, or Saturday night palsy, is a condition where a person cannot extend their wrist and it hangs flaccidly. To demonstrate wrist drop, hold your arm out in front of you with your forearm parallel to the floor. With the back of your hand facing the ceiling (i.e. pronated), let your hand hang limply so that your fingers point downward. A person with wrist drop would be unable to move from this position to one in which the fingers are pointing up towards the ceiling. The median nerve is a nerve in humans and other animals. It is in the upper limb. It is one of the five main nerves originating from the brachial plexus. The median nerve is formed from parts of the medial and lateral cords of the brachial plexus, and continues down the arm to enter the forearm with the brachial artery. It originates from the brachial plexus with roots from C5, C6, C7, C8, & T1. The median nerve is the only nerve that passes through the carpal tunnel, where it may be compressed to cause carpal tunnel syndrome