Respiratory and Airway Management Practice Questions

Q: The diagram of a correctly positioned proseal-type Laryngeal Mask Airway is provided below. Above what site is the arrow marked area of the airway positioned?

Vocal cords. ***Vocal cords*** - A correctly positioned laryngeal mask airway (LMA) forms a seal around the **laryngeal inlet**, with its tip resting in the **hypopharynx** superior to the esophagus. - The LMA cuff is designed to sit in the **piriform fossae**, sealing the entry to the esophagus, while the opening of the LMA tube is positioned over the **glottic opening**, which lies between the vocal cords. *Carina* - The **carina** is the bifurcation of the trachea into the main bronchi, which is much lower in the airway than where an LMA is designed to be positioned. - Positioning an LMA near the carina would mean it is deeply intubated into the trachea, which is not its intended use or design. *Upper end of trachea* - While the LMA provides an airway to the trachea, its cuff typically seals the laryngeal structures **above the trachea**, not within it. - The purpose of an LMA is to provide a supraglottic seal, meaning it sits above the true vocal cords and the tracheal opening. *Above esophagus* - Although the LMA's tip rests in the hypopharynx, providing a seal that prevents air from entering the esophagus, the primary target for airflow from the LMA is the **glottic opening (vocal cords)**, not simply "above the esophagus." - The device functions by sitting snugly over the laryngeal inlet, ensuring that ventilation is directed toward the trachea.

Q: The mode of ventilation shown below is used for:

Type 3 respiratory failure. ***Type 3 respiratory failure*** - The image shows a **nasal mask** providing positive pressure ventilation, often used as **Non-Invasive Ventilation (NIV)**. This mode is particularly useful for **hypoxemic respiratory failure (Type 1)** or **post-operative respiratory failure (Type 3)**, where patients may have atelectasis or reduced lung volumes. - The diagram shows a collapsed (atelectatic) alveolus, which is a common feature of **post-operative atelectasis**, a primary cause of **Type 3 respiratory failure**. NIV can help re-expand these areas and improve oxygenation. *Type 4 respiratory failure* - **Type 4 respiratory failure** refers to **shock-induced respiratory failure**, where the respiratory muscles are inadequately perfused and fail. While ventilation support might be needed, the image directly depicts a mechanism (atelectasis) more characteristic of Type 3. - Management of Type 4 failure primarily involves addressing the underlying **shock** and improving tissue perfusion to the respiratory muscles. *Tension pneumothorax with mediastinal shift* - A **tension pneumothorax** is a medical emergency requiring urgent **needle decompression** or **chest tube insertion** to relieve pressure. - **Non-invasive ventilation** is contraindicated in tension pneumothorax as it can worsen the condition by increasing intrathoracic pressure. *Interstitial lung disease* - **Interstitial lung disease (ILD)** is characterized by **fibrosis** and inflammation of the lung interstitium, leading to restrictive lung physiology. - While patients with advanced ILD may require oxygen support and sometimes ventilation, the primary issue is **stiff lungs** and impaired gas exchange due to parenchymal changes, not typically atelectasis correctable by simple NIV pressure.

Q: The following image shows:

Venturi mask. ***Venturi mask*** - The image distinctly shows a mask with a **reservoir bag** and a **jet nozzle** (often color-coded) connected to an oxygen supply, which are characteristic features of a Venturi mask. - Venturi masks are designed to deliver **precise concentrations of oxygen** by entraining room air, making them ideal for patients who require controlled oxygen therapy, such as those with COPD. *Oxygen tent* - An oxygen tent is a **large plastic canopy** placed over a bed or crib to deliver oxygen, which is clearly not depicted in the image. - It is typically used for pediatric patients or those who cannot tolerate a face mask, and it encloses the patient's head and upper body. *Nonrebreather mask* - A nonrebreather mask has a **one-way valve** between the mask and the reservoir bag and valves over the exhalation ports to prevent entrainment of room air, allowing delivery of high oxygen concentrations (up to 100%). - Although it also has a reservoir bag, the distinct Venturi jet mechanism for precise FiO2 delivery is absent in a standard nonrebreather. *Face tent* - A face tent is an **open, soft plastic dome** that fits loosely over the patient's nose and mouth, providing a humidified oxygen stream, and is not shown in the image. - It's typically used for patients who cannot tolerate a tight-fitting mask, especially those with facial trauma or claustrophobia.

Q: A patient is scheduled for emergency laparotomy for a perforated duodenal ulcer. He was administered 2 L of fluid and was wheeled into the OT. He was intubated and capnography recording shows the following recording. This indicates:

Esophageal intubation. ***Esophageal intubation*** - The capnography tracing shows **minimal and erratic CO2 waveforms**, which quickly fall to zero or near zero after a few breaths, indicating that the endotracheal tube is not in the trachea. - This pattern is characteristic of **esophageal intubation**, as there is little or no CO2 exhaled from the esophagus. *Placement of ET in right bronchus* - If the endotracheal tube is placed in the right bronchus (mainstem intubation), you would still see a **normal capnography waveform**, though often with signs of asymmetric chest rise and decreased breath sounds on the left side. - The problem would be related to **ventilation of only one lung**, not a complete absence of CO2. *Hypothermia* - While hypothermia can **decrease CO2 production** and lead to lower end-tidal CO2 values, it typically results in a **reduced but still discernible capnography waveform**, not a near absence of CO2. - The waveform morphology would remain largely normal, just shifted downwards. *Placement of ET in left bronchus* - Similar to right bronchus intubation, placement in the left bronchus would produce a **normal capnography waveform**, but with signs of unilateral lung ventilation (e.g., absent right-sided breath sounds). - The presence of a waveform indicates that the tube is in the airway, allowing for **gas exchange** and CO2 elimination from at least one lung.

Q: What is the grade of laryngeal view?

Grade I. ***Grade I*** - In a **Grade I laryngeal view**, a **full view of the glottis** (vocal cords) is achieved during laryngoscopy. - This provides optimal conditions for endotracheal intubation, as seen in the image where the entire opening to the trachea is visible. *Grade II* - A **Grade II view** means only a **partial view of the glottis** is obtained, often with only the posterior commissure visible. - The anterior portion of the vocal cords may be obstructed by the epiglottis or other structures, making intubation more challenging. *Grade III* - **Grade III** indicates that only the **epiglottis** is visible, with no part of the glottis or vocal cords being seen. - Intubation is significantly more difficult in this scenario and often requires special techniques or adjuncts. *Grade IV* - A **Grade IV view** is the most difficult, where **neither the epiglottis nor the glottis** can be visualized. - This implies that only the soft palate or base of the tongue is seen, representing a very challenging airway.

Q: What is this classification used for?

Grading for difficulty/ease of inserting ETT. ***Grading for difficulty/ease of inserting ETT*** - The image displays the **Mallampati classification**, which visually assesses the size of the **tongue relative to the oral cavity**. - This classification helps predict the **ease or difficulty of intubation** by estimating the space available for direct laryngoscopy. *Grading of temporomandibular arthritis* - **Temporomandibular arthritis** involves inflammation of the **jaw joint** and is diagnosed based on symptoms like jaw pain, clicking, and limited movement, as well as imaging. - The image shows anatomical structures of the oral cavity (uvula, soft palate, hard palate, pillars, and tongue body), not related to direct assessment of the TMJ. *Grading of trismus* - **Trismus** refers to **restricted mouth opening** and is typically measured by the interincisal distance (distance between upper and lower teeth when mouth is open). - This classification assesses the visibility of pharyngeal structures, not the degree of mouth opening. *Grading of giant cell arteritis* - **Giant cell arteritis** is a **vasculitis** affecting large and medium-sized arteries, particularly those of the head and neck. - Diagnosis involves clinical symptoms, **biopsy of the temporal artery**, and laboratory findings; it is unrelated to the anatomical features shown for airway assessment.

Q: All are correct about the image shown except:

Not influenced by tongue mobility and size. ***Not influenced by tongue mobility and size*** - The **Mallampati classification** is significantly influenced by **tongue size and mobility**, as a large or non-mobile tongue can obstruct the view of the posterior pharyngeal structures. - The classification assesses the visible structures of the soft palate, uvula, and tonsillar pillars, which can be obscured by the tongue. *Mallampati classification* - The image clearly depicts the structures observed in the **Mallampati classification** system (uvula, pillars, hard palate, soft palate, and progressively less visibility in classes 1-4). - This classification is a widely used tool for assessing airway patency. *Helps in identifying cases with difficult orotracheal intubation* - The **Mallampati classification** is a primary bedside tool used to predict the difficulty of **orotracheal intubation**. - Higher Mallampati classes (3 and 4) are associated with a greater likelihood of difficult intubation due to reduced visibility of the pharyngeal structures. *Has limited utility in patients with reduced neck extension* - Poor **neck extension** can limit the alignment of the oral, pharyngeal, and laryngeal axes, making direct laryngoscopy and intubation difficult. - The Mallampati classification primarily assesses oral cavity visualization and does not account for limitations imposed by neck mobility, thereby having reduced predictive power in such cases.

Q: In correct positioning the tip of the instrument shown in the image should lie at:

Epiglottis. ***Epiglottis*** - The image shows a **Laryngeal Mask Airway (LMA)**, which is designed to sit in the hypopharynx, with its tip resting at the **epiglottis**. - This positioning allows the LMA to create a seal around the laryngeal inlet, facilitating effective ventilation without entering the trachea. *Vocal cords* - The LMA is designed to provide a seal *above* the vocal cords, ensuring ventilation of the trachea without direct intubation of the vocal cords themselves. - Positioning the tip *at* the vocal cords would hinder proper airway sealing and could cause trauma. *Thyroid cartilage* - The thyroid cartilage is an anterior neck structure and is not the anatomical landmark for the tip of a properly placed LMA. - The LMA sits deeper in the pharynx, above the glottic opening, making the epiglottis the relevant landmark. *Above esophagus* - While the LMA sits **above the esophageal inlet**, diverting air primarily into the trachea, its *tip* specifically rests at the epiglottis, covering the laryngeal opening. - Stating "above the esophagus" is too general; the precise anatomical placement for the tip is at the epiglottis.

Q: All are correct about the airway device shown below except: (Recent NEET Pattern 2016-17)

It should remain in place till airway reflexes are regained. ***It should remain in place till airway reflexes are regained*** - The device shown is a **Laryngeal Mask Airway (LMA)**, which is typically removed once the patient shows signs of **regaining airway reflexes**, such as gagging or coughing. - Keeping it in place too long after airway reflexes return increases the risk of **laryngospasm** and patient discomfort. *Contraindicated in patients with pharyngeal abscess* - The LMA is **contraindicated** in patients with a pharyngeal abscess due to the risk of **rupturing the abscess** and causing aspiration or spreading infection. - This is a valid contraindication, so the statement is correct in its assertion. *Protects the larynx from gastric contents* - While an LMA provides **some protection** against aspiration by sealing off the larynx from the pharynx, it does not offer the same level of definitive protection as a cuffed **endotracheal tube**. - There is still a risk of **regurgitation and aspiration** of gastric contents, especially in patients with high risk factors. *Helps in passage of tracheal tube in patient with difficult airway* - The LMA can indeed be used as a conduit for **fiberoptic intubation** or with specialized catheters to facilitate the placement of an endotracheal tube in cases of a **difficult airway**. - This is a recognized use of the LMA in airway management algorithms.

Question 1

The diagram of a correctly positioned proseal-type Laryngeal Mask Airway is provided below. Above what site is the arrow marked area of the airway positioned?

Accepted Answer

Vocal cords

Answer

Carina

Answer

Upper end of trachea

Answer

Above esophagus

Question 2

The mode of ventilation shown below is used for:

Accepted Answer

Type 3 respiratory failure

Answer

Type 4 respiratory failure

Answer

Tension pneumothorax with mediastinal shift

Answer

Interstitial lung disease

Question 3

The following image shows:

Accepted Answer

Venturi mask

Answer

Oxygen tent

Answer

Nonrebreather mask

Answer

Face tent

Question 4

A patient is scheduled for emergency laparotomy for a perforated duodenal ulcer. He was administered 2 L of fluid and was wheeled into the OT. He was intubated and capnography recording shows the following recording. This indicates:

Accepted Answer

Esophageal intubation

Answer

Placement of ET in right bronchus

Answer

Hypothermia

Answer

Placement of ET in left bronchus

Question 5

All are correct about airway management shown below except:

Accepted Answer

Index finger is placed on submental soft tissues to facilitate ventilation

Answer

Continued deflation of anesthesia reservoir bag indicates substantial leak around mask

Answer

Transparent mask allows observation of exhaled humidified gas and vomitus

Answer

Face mask is contoured and conforms to varied facial features

Question 6

What is the grade of laryngeal view?

Accepted Answer

Grade I

Answer

Grade II

Answer

Grade III

Answer

Grade IV

Question 7

What is this classification used for?

Accepted Answer

Grading for difficulty/ease of inserting ETT

Answer

Grading of temporomandibular arthritis

Answer

Grading of trismus

Answer

Grading of giant cell arteritis

Question 8

All are correct about the image shown except:

Accepted Answer

Not influenced by tongue mobility and size

Answer

Mallampati classification

Answer

Helps in identifying cases with difficult orotracheal intubation

Answer

Has limited utility in patients with reduced neck extension

Question 9

In correct positioning the tip of the instrument shown in the image should lie at:

Accepted Answer

Epiglottis

Answer

Thyroid cartilage

Answer

Above esophagus

Answer

Vocal cords

Question 10

All are correct about the airway device shown below except: (Recent NEET Pattern 2016-17)

Accepted Answer

It should remain in place till airway reflexes are regained

Answer

Contraindicated in patients with pharyngeal abscess

Answer

Protects the larynx from gastric contents

Answer

Helps in passage of tracheal tube in patient with difficult airway

Respiratory and Airway Management — MCQs

Respiratory and Airway Management — MCQs

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