Respiratory and Airway Management Practice Questions

Q: What is the preferred method of intubation for patients undergoing oral surgeries with bilateral temporomandibular joint (TMJ) ankylosis?

North pole RAE tube. **Explanation:** In patients with **bilateral temporomandibular joint (TMJ) ankylosis**, the primary anesthetic challenge is a "cannot ventilate, cannot intubate" scenario due to restricted mouth opening. For oral surgeries, the surgeon requires an unobstructed surgical field. **Why North Pole RAE is correct:** The **RAE (Ring-Adair-Elwyn) tube** is a pre-formed, angled endotracheal tube designed to prevent kinking and improve surgical access. The **North Pole RAE tube** is specifically designed for **nasotracheal intubation**. It features a pre-formed bend that directs the tube upward (towards the patient's head/north) after exiting the nostril. This allows the breathing circuit to be positioned away from the mouth, providing the surgeon with an unobstructed view and access to the oral cavity and TMJ. **Why other options are incorrect:** * **South Pole RAE tube:** These are designed for **orotracheal intubation**. The bend directs the tube downward (towards the feet/south) over the chin. In TMJ ankylosis, the mouth cannot open sufficiently for oral intubation, and the tube would obstruct the surgical site. * **Tracheostomy/Cricothyrotomy:** These are invasive surgical airways. While they may be used in emergencies or for long-term ventilation, they are not the "preferred" initial method for elective oral surgery if a fiberoptic-guided nasal intubation is feasible. **High-Yield Clinical Pearls for NEET-PG:** * **Gold Standard for TMJ Ankylosis:** Awake Fiberoptic Intubation (AFOI) via the nasal route is the safest approach. * **RAE Mnemonic:** **N**orth = **N**asal (for oral/dental surgery); **S**outh = **O**ral (for ENT/ophthalmic/cranial surgery). * **Magill Forceps:** Often used during nasal intubation to guide the tube into the glottis, though caution is needed in limited mouth opening.

Q: During an anesthetic procedure, what is the primary purpose of compressing the cricoid cartilage?

To help in preventing regurgitation. **Explanation:** The compression of the cricoid cartilage is known as **Sellick’s Maneuver**. It is a key component of Rapid Sequence Induction (RSI), used primarily in patients with a "full stomach" who are at high risk of aspiration. **1. Why Option B is Correct:** The cricoid cartilage is the only complete cartilaginous ring in the larynx. Applying firm downward pressure (approx. 30 Newtons) compresses the esophagus against the body of the fifth or sixth cervical vertebra. This mechanical occlusion prevents the passive regurgitation of gastric contents into the pharynx, thereby reducing the risk of pulmonary aspiration. **2. Why Other Options are Incorrect:** * **Option A:** Spinal headaches (Post-Dural Puncture Headaches) are complications of neuraxial anesthesia, managed with bed rest, hydration, or an epidural blood patch, not airway maneuvers. * **Option C:** While **BURP** (Backwards, Upwards, Rightwards Pressure) on the *thyroid* cartilage is used to improve the glottic view during intubation, the primary goal of *cricoid* pressure is aspiration prophylaxis, not visualization. * **Option D:** Bronchospasm is a reactive airway issue treated with bronchodilators or deepening the plane of anesthesia; physical compression of the airway would likely worsen the situation. **High-Yield Clinical Pearls for NEET-PG:** * **Timing:** Cricoid pressure should be applied while the patient is awake (before induction) and maintained until the ETT cuff is inflated and position is confirmed. * **Contraindications:** Active vomiting (may cause esophageal rupture), unstable cervical spine fractures, and laryngeal trauma. * **Pressure:** 10N when awake, increasing to 30N once consciousness is lost.

Q: Which of the following devices is most effective in preventing aspiration?

Proseal Laryngeal Mask Airway (LMA). **Explanation:** The **Proseal Laryngeal Mask Airway (PLMA)** is the correct answer because it is a second-generation supraglottic airway device specifically designed to improve safety compared to the classic LMA. Its primary advantage is the inclusion of a **drain tube** (gastric channel) that allows for the passage of a gastric tube to decompress the stomach and provides a bypass for regurgitated fluid, significantly reducing the risk of aspiration. Additionally, it features a larger, deeper cuff that provides a better posterior seal and allows for higher positive pressure ventilation (up to 30 cm H₂O). **Analysis of Incorrect Options:** * **Laryngeal Mask Airway (Classic LMA):** While it maintains a patent airway, it does not protect against aspiration. It sits above the glottis and lacks a gastric drain, meaning regurgitated contents can easily enter the trachea. * **Oropharyngeal Airway (OPA):** This is a simple adjunct used to prevent the tongue from obstructing the posterior pharynx in unconscious patients. It provides no protection for the lower airway against gastric contents. * **Nasopharyngeal Airway (NPA):** Similar to the OPA, this is a conduit to maintain upper airway patency. It does not seal the glottis or isolate the esophagus, offering no protection against aspiration. **High-Yield Clinical Pearls for NEET-PG:** * **Gold Standard:** The **Endotracheal Tube (ETT)** remains the absolute gold standard for preventing aspiration; however, among the *listed* supraglottic/adjunct devices, the Proseal LMA is superior. * **Second-Generation SADs:** Devices like the Proseal LMA, Supreme LMA, and I-gel are characterized by their ability to allow gastric drainage. * **Indication:** PLMA is often preferred in controlled ventilation cases where a higher seal pressure is required compared to a classic LMA.

Q: All are true about armoured endotracheal tubes except?

It has a radiopaque line like a normal ETT.. **Explanation:** Armoured endotracheal tubes (also known as **reinforced** or **anode tubes**) are specialized airways designed for specific clinical scenarios where tube patency is at risk due to positioning. **1. Why Option B is the Correct Answer (The False Statement):** Unlike standard PVC endotracheal tubes, which require a **radiopaque line** (Blue Line) for X-ray visualization, armoured tubes do not need one. The **stainless steel or nylon wire coil** embedded throughout the shaft is inherently radio-dense. Therefore, the entire length of the tube is visible on a chest X-ray, making a separate radiopaque line redundant. **2. Analysis of Other Options:** * **Option A:** This is the defining feature. The wire coil provides structural integrity while maintaining flexibility. * **Option C:** The primary clinical advantage is that they are **kink-resistant**. They are ideal for surgeries involving extreme head/neck flexion (e.g., posterior fossa surgery) or where the surgeon may lean on the tube (e.g., ENT/Maxillofacial surgery). * **Option D:** To accommodate the embedded wire coil within the silicone or PVC matrix, the outer wall is slightly thicker than a standard ETT of the same internal diameter. **High-Yield Clinical Pearls for NEET-PG:** * **The "Floppy" Nature:** While kink-resistant, these tubes are very flexible and usually require a **stylet** for intubation. * **The Danger of Biting:** If a patient bites an armoured tube, the wire coil can deform permanently, **occluding the lumen**. Unlike standard ETTs, it will not "spring back." A bite block is mandatory. * **MRI Safety:** Most modern armoured tubes use non-ferromagnetic materials, but older versions with stainless steel coils are a contraindication for MRI. * **No Shortening:** You cannot cut an armoured tube to shorten it, as this would expose the wire coil.

Q: Which of the following characterizes Mallampati class 3?

Both hard palate and soft palate visible. The **Mallampati Classification** is a clinical tool used to predict the ease of endotracheal intubation by assessing the relationship between the size of the tongue and the oral cavity. It is performed with the patient sitting upright, head in a neutral position, mouth wide open, and tongue protruded without phonation. ### **Explanation of Options** * **Correct Answer (B):** In **Class 3**, the clinician can visualize the **hard palate and the soft palate**. The base of the uvula may occasionally be seen, but the pillars and the majority of the uvula are obscured by the tongue. This indicates a potentially difficult airway. * **Option A:** This describes **Class 4**, where only the hard palate is visible. This is a strong predictor of a difficult airway. * **Option C:** This describes **Class 1**, where the soft palate, fauces, entire uvula, and anterior/posterior tonsillar pillars are all clearly visible. This usually indicates an easy intubation. ### **The Mallampati Scale Summary** * **Class 1:** Soft palate, fauces, uvula, pillars visible. * **Class 2:** Soft palate, fauces, portion of uvula visible. * **Class 3:** Soft palate and hard palate visible. * **Class 4:** Only hard palate visible. ### **High-Yield Clinical Pearls for NEET-PG** * **Samsoon and Young Modification:** The original Mallampati classification had 3 classes; the 4th class was added later by Samsoon and Young. * **Predictive Value:** Classes 3 and 4 are clinically significant predictors of **difficult laryngoscopy** (Cormack-Lehane Grade 3 or 4). * **Gold Standard:** While Mallampati is a common screening tool, the "gold standard" for assessing the glottic view is the **Cormack-Lehane classification**, performed during direct laryngoscopy. * **Mnemonic:** Remember **PUSH** (Pillars, Uvula, Soft palate, Hard palate) to recall what is visible in descending order from Class 1 to 4.

Q: During laryngoscopy and intubation procedure, all of these are true, except:

After insertion of the laryngoscope, it is levered on the upper incisors to pull up the tongue and visualize the vocal cords.. **Explanation:** The goal of direct laryngoscopy is to create a straight line of sight from the operator’s eye to the glottic opening. This requires specific maneuvers and precautions to ensure patient safety and successful intubation. **Why Option D is the Correct Answer (The Incorrect Statement):** Levering the laryngoscope on the upper incisors is a **major technical error**. Using the teeth as a fulcrum can lead to dental trauma (chipped or dislodged teeth) and limits the space available for tube passage. Instead, the laryngoscope should be lifted **upward and forward** (at a 45-degree angle away from the patient) to displace the tongue and soft tissues without touching the teeth. **Analysis of Other Options:** * **Option A:** Applying slight pressure at the cricoid cartilage (Sellick’s maneuver) or the thyroid cartilage (BURP maneuver—Backward, Upward, Rightward Pressure) is often used to improve the view of the larynx or prevent aspiration. * **Option B:** Standard laryngoscopes are designed for the **left hand**. They are introduced from the right side of the mouth to sweep the tongue to the left, clearing the midline for visualization. * **Option C:** This describes the **"Sniffing Position,"** which aligns the oral, pharyngeal, and laryngeal axes. It is achieved by flexing the lower cervical spine (using a pillow) and extending the atlanto-occipital joint. **High-Yield Clinical Pearls for NEET-PG:** * **Sniffing Position:** Flexion of the neck (C6-C7) + Extension of the head (C1-C2). * **Cormack-Lehane Classification:** Used to grade the view obtained during laryngoscopy (Grade I is full view; Grade IV is no epiglottis seen). * **Macintosh Blade:** Curved blade, tip placed in the **vallecula**. * **Miller Blade:** Straight blade, tip used to **directly lift the epiglottis**.

Question 1

Plan C of anesthetic airway management involves which of the following?

Accepted Answer

Insertion of laryngeal mask airway and fiberoptic bronchoscopy

Answer

Standard laryngoscopy and intubation

Answer

Intubation catheter guided intubation

Answer

Cancel the surgery or perform tracheostomy

Question 2

Which of the following maneuvers is NOT performed during laryngoscopy and endotracheal intubation?

Accepted Answer

The laryngoscope is lifted upwards, levering over the upper incisors

Answer

Flexion of the neck

Answer

Extension of the head at the atlanto-occipital joint

Answer

In a straight blade laryngoscope, the epiglottis is lifted by the tip

Question 3

Difficulty in laryngoscopy and intubation is seen in all except:

Accepted Answer

Modified Mallampati class 2

Answer

Cervical joint immobility

Answer

Upper lip bite test negative

Answer

Interincisor gap of <3cm

Question 4

All statements are true about modified rapid sequence induction except?

Accepted Answer

Preoxygenation is not mandatory.

Answer

Rocuronium is used as a neuromuscular blocker.

Answer

Any IV induction agent can be used.

Answer

Positive pressure ventilation with bag and mask is not performed.

Question 5

What is the preferred method of intubation for patients undergoing oral surgeries with bilateral temporomandibular joint (TMJ) ankylosis?

Accepted Answer

North pole RAE tube

Answer

South pole RAE tube

Answer

Tracheostomy

Answer

Cricothyrotomy

Question 6

During an anesthetic procedure, what is the primary purpose of compressing the cricoid cartilage?

Accepted Answer

To help in preventing regurgitation

Answer

To prevent spinal headache

Answer

To aid in intubation

Answer

To relieve reflex bronchospasm

Question 7

Which of the following devices is most effective in preventing aspiration?

Accepted Answer

Proseal Laryngeal Mask Airway (LMA)

Answer

Laryngeal Mask Airway (LMA)

Answer

Oropharyngeal airway

Answer

Nasopharyngeal airway

Question 8

All are true about armoured endotracheal tubes except?

Accepted Answer

It has a radiopaque line like a normal ETT.

Answer

These are tubes with a metal wire coil embedded in the wall of the tube shaft.

Answer

It is bend resistant.

Answer

It has a slightly thicker outer wall as compared to a normal ETT.

Question 9

Which of the following characterizes Mallampati class 3?

Accepted Answer

Both hard palate and soft palate visible

Answer

Only hard palate visible

Answer

Hard palate, soft palate, uvula and faucial pillars visible

Answer

None of the above

Question 10

During laryngoscopy and intubation procedure, all of these are true, except:

Accepted Answer

After insertion of the laryngoscope, it is levered on the upper incisors to pull up the tongue and visualize the vocal cords.

Answer

A slight pressure may be applied at the cricoid cartilage.

Answer

The laryngoscope is held in the right hand and introduced from the right side of the patient.

Answer

The neck is flexed with extension at the atlanto-occipital joint.

Respiratory and Airway Management — MCQs

Respiratory and Airway Management — MCQs

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