Respiratory and Airway Management Practice Questions

Q: Endotracheal tube in the esophagus is best assessed by:

CO2 Exhalation. ***CO2 Exhalation*** - Measuring **CO2 exhalation** (capnography) is the most reliable method to confirm endotracheal tube placement, as CO2 is present in the trachea but not in the esophagus. - A persistent **waveform on the capnograph** indicates proper tracheal intubation. *Direct laryngoscopy* - While helpful for initial visualization during intubation, **direct laryngoscopy** cannot confirm continuous tracheal placement after the tube is advanced. - It only confirms the tube passing through the vocal cords, not its final position in the trachea versus esophagus. *Auscultation* - **Auscultation** can be misleading because stomach sounds can be transmitted to the chest, and breath sounds can be heard in the epigastrium even with esophageal intubation. - It relies on subjective interpretation and is less definitive than capnography. *Chest wall movement* - Observing **chest wall movement** is not a definitive sign, as the chest can still rise with esophageal intubation due to air entering the stomach. - This method is unreliable and can be mistaken for proper ventilation, leading to dangerous delays in correcting tube misplacement.

Q: During rapid sequence intubation in a child after taking brief history and clinical examination next step is:

Administer oxygen. ***Administer oxygen*** - Pre-oxygenation with 100% oxygen is critical before **rapid sequence intubation (RSI)** to maximize **oxygen reserves** and extend the safe apnea time. - This step helps prevent **hypoxemia** during the intubation procedure, especially in children who have lower functional residual capacity. *Analgesic injection with Fentanyl* - While fentanyl is often used in RSI for its **analgesic** and **sedative properties**, it typically follows pre-oxygenation and is administered as part of the **induction phase**, often concurrently with a paralytic. - Administering fentanyl alone without prior oxygenation or other induction agents would not be the immediate next step in a structured RSI protocol. *Preanaesthetic medication with atropine and lignocaine* - **Atropine** may be used in children to prevent **bradycardia** during intubation, particularly in infants, but it's not the immediate next step after initial assessment; pre-oxygenation is more critical. - **Lidocaine** can be used to blunt the sympathetic response to intubation or to suppress cough, but it's not universally required and comes after pre-oxygenation and other induction medications. *IV anesthetic Diazepam/Ketamine* - **Diazepam** and **ketamine** are **induction agents** that cause sedation and loss of consciousness, but they are administered after pre-oxygenation and often just before the paralytic agent. - Administering an induction agent without adequate pre-oxygenation would increase the risk of **hypoxemia** during the subsequent apnea.

Q: Effective adjuvant in attenuating hypertension and tachycardia associated with laryngoscopy and intubation?

Fentanyl. ***Fentanyl*** - **Fentanyl**, a potent **opioid**, effectively blunts the **sympathetic response** associated with **laryngoscopy** and **intubation**, thereby reducing **hypertension** and **tachycardia**. - Its rapid onset and short duration of action make it a suitable **adjuvant** for this purpose. *Suxamethonium* - **Suxamethonium** is a **depolarizing neuromuscular blocker** used to facilitate intubation, not to attenuate the hemodynamic response. - It does not directly impact **blood pressure** or **heart rate** in a way that would mitigate the stress response. *Ketamine* - **Ketamine** can cause **sympathomimetic effects**, including **increased heart rate** and **blood pressure**, which would worsen rather than attenuate the hemodynamic response to intubation. - It is often used for its **dissociative anesthetic** properties, not for blunting the stress response. *Atracurium* - **Atracurium** is a **nondepolarizing neuromuscular blocker** used for muscle relaxation during intubation and surgery. - It does not directly affect **blood pressure** or **heart rate** in a manner that would attenuate the hypertensive and tachycardic response to laryngoscopy.

Q: A patient is admitted following a road traffic accident. He has sustained significant blunt injury to his head, chest and abdomen and has a Glasgow Coma Scale score of 8/15. His saturations are poor at 89% on 15 L of oxygen a rebreathing mask. You note bruising around both eyes and blood-stained fluid issuing from his left ear, which forms concentric circles when dripped on a white sheet. You wish to support his airway to improve oxygenation. The first choice of airway adjunct would be

Oropharyngeal airway. ***Oropharyngeal airway*** - An **oropharyngeal airway (OPA)** is the most appropriate initial airway adjunct in a patient with a **depressed GCS (8/15)** and poor oxygenation, as it helps to relieve **upper airway obstruction** caused by the tongue falling back. - Given the potential for a **basal skull fracture** (bruising around eyes, blood-stained fluid from ear forming concentric circles), a **nasopharyngeal airway (NPA)** is contraindicated due to the risk of intracranial insertion. *Nasopharyngeal tube* - A **nasopharyngeal airway (NPA)** is contraindicated in this patient due to signs suggestive of a **basal skull fracture**, which include **raccoon eyes (periorbital bruising)** and **Battle's sign (bruising behind the ear)**, as well as the **halo sign (concentric circles of blood and CSF)** from the ear. - Inserting an NPA in such a scenario risks inadvertently entering the **cranial cavity**, leading to further neurological damage or infection. *Intubation* - While **intubation** may eventually be necessary given the patient's low GCS and poor oxygenation, it is not the *first choice* of airway adjunct. - The immediate priority is to establish a **patent airway** quickly and safely, which an OPA can achieve while preparations for definitive intubation are made. *Laryngeal mask* - A **laryngeal mask airway (LMA)** could be considered for airway management, but it is typically a more advanced adjunct than an OPA. - Its insertion requires a certain level of skill and might be more time-consuming than an OPA, which is crucial in an emergency setting.

Q: On doing laparoscopic cholecystectomy patient developed wheezing. Which of the following is used in the treatment?

Administration of beta agonist. ***Administration of beta agonist*** - **Wheezing** during surgery suggests **bronchospasm**, which is effectively treated by **beta agonists** administered via inhalation to relax airway smooth muscles. - In a laparoscopic cholecystectomy, increased **intra-abdominal pressure** and **CO2 absorption** can trigger bronchoconstriction, making a rapid bronchodilator essential. *IV ketamine* - **Ketamine** has **bronchodilatory effects** and can be used in severe cases, but it's not the first-line treatment for acute wheezing due to its psychoactive and cardiovascular effects. - It would typically be considered if inhaled bronchodilators are insufficient or if there's an associated **anaphylactic reaction**. *IV lignocaine* - **Lignocaine** (lidocaine) can suppress airway reflexes and has some bronchodilatory properties, but it is primarily used as a **local anesthetic** or for treating arrhythmias. - Its role in acute **bronchospasm** is limited and not a primary treatment for wheezing. *Deepen the plane of anesthesia* - While light anesthesia can sometimes trigger bronchospasm, simply deepening the anesthetic plane may not be sufficient or safe if the wheezing is due to other causes like **allergy** or **CO2 retention**. - Without addressing the underlying cause directly, increasing anesthetic depth could lead to **hemodynamic instability**.

Q: Helium is used along with oxygen instead of plain oxygen because

It decreases turbulence. ***It decreases turbulence*** - **Helium** is a very low-density gas, which makes the mixture of helium and oxygen significantly less dense than air or pure oxygen. - This lower density reduces **turbulent flow** in constricted airways, promoting laminar flow and decreasing the work of breathing, especially beneficial in conditions like **asthma** or **C.O.P.D**. *For analgesia* - **Helium** itself does not possess significant analgesic properties, even at high concentrations. - While some anesthetic gases provide analgesia, **helium** is not used for pain relief in respiratory therapy. *It decreases the dead space* - **Helium-oxygen mixtures** do not directly alter or decrease the anatomical or physiological dead space in the lungs. - Dead space is primarily determined by lung anatomy and ventilation-perfusion matching, not the inhaled gas composition. *It increases the absorption of oxygen* - The primary mechanism by which **helium-oxygen mixtures** improve oxygen delivery is by reducing the work of breathing, allowing for better ventilation and oxygen access to **alveoli**. - It does not directly enhance the **absorption coefficient** or diffusion rate of oxygen across the alveolar-capillary membrane.

Q: WHAT IS THE TYPE OF LARYNGOSCOPE SHOWN BELOW ?

MILLER. ***MILLER*** - The Miller laryngoscope is a type of **straight blade** often used in infants and small children. - Its straight design allows it to directly lift the **epiglottis** to visualize the glottis. *BULLARDS* - A **fiberoptic laryngoscope** that uses a curved, rigid blade and an eyepiece for indirect viewing, which is not what is shown. - Primarily used for difficult airways where direct laryngoscopy is challenging. *MC INTOSH* - The Macintosh blade is a **curved blade** that is typically used in adults. - It works by displacing the **epiglottis indirectly** by fitting into the vallecula. *MC COY* - The McCoy laryngoscope is a **modified Macintosh blade** featuring a hinged, movable tip. - This movable tip is levered by a finger trigger to elevate the epiglottis, making intubation easier in some difficult cases.

Q: Which of the following is the most common postoperative complication related to intubation:

Sore throat. ***Sore throat*** - **Sore throat** is a very common and usually minor complication that occurs after intubation, due to irritation of the pharyngeal mucosa by the endotracheal tube. - The incidence can be as high as 60% and is often considered a **nuisance complication** rather than a serious one. *Abductor Paralysis* - **Abductor paralysis** of the vocal cords is a rare but serious complication, often resulting from injury to the **recurrent laryngeal nerve**. - This can lead to **stridor** and **airway obstruction**, requiring further intervention. *Bleeding* - Significant **bleeding** related to intubation is uncommon but can occur if there is trauma to the pharynx, larynx, or trachea, especially in the presence of **coagulopathy** or difficult intubation. - Minor epistaxis can occur if a **nasal intubation** is performed. *Malposition* - **Malposition** of the endotracheal tube, such as **esophageal intubation** or **mainstem bronchial intubation**, is a critical complication that can lead to severe hypoxemia or lung collapse. - While serious, it is usually recognized and corrected immediately during or shortly after intubation, making it less frequently a *postoperative* symptom compared to sore throat.

Q: Intraocular pressure rises in ?

Intubation & laryngoscopy. ***Intubation & laryngoscopy*** - The **stress response** to laryngoscopy and intubation causes an increase in **arterial blood pressure** and venous pressure, which can transiently elevate intraocular pressure. - This effect is mediated by sympathetic stimulation, leading to **increased choroidal blood volume** and consequently higher intraocular pressure. *Infusion of IV propofol* - **Propofol** is known to **decrease intraocular pressure** by reducing blood pressure and relaxing extraocular muscles, making it a favorable induction agent for patients at risk of elevated IOP. - Its mechanism involves a reduction in **aqueous humor production** and an increase in **uveoscleral outflow**. *LMA* - The use of a **Laryngeal Mask Airway (LMA)** generally produces **less hemodynamic stress** and a smaller increase in intraocular pressure compared to tracheal intubation. - While some mild elevation can occur, it is significantly **less pronounced** than with direct laryngoscopy. *Bag and mask ventilation* - **Bag-mask ventilation** without intubation typically causes **minimal change** or even a slight decrease in intraocular pressure, provided there is controlled ventilation and no excessive positive pressure. - If excessive pressure is used or if the patient strains, a transient, mild elevation could occur, but it is not a direct and consistent cause of IOP rise as seen with intubation.

Q: The Blade of the laryngoscope used in intubation of newborn is

Straight blade with uncuffed tube. ***Straight blade with uncuffed tube*** - A **straight blade** (e.g., Miller blade) is preferred in neonates because their **epiglottis is U-shaped** and relatively long, making it easier to lift directly with a straight blade. - **Uncuffed endotracheal tubes** are used in newborns and young children because their cricoid cartilage is the narrowest part of the airway, providing a natural seal and reducing the risk of **subglottic stenosis** from cuff pressure. *Straight blade with Cuffed tube* - While a **straight blade** is appropriate for neonates, a **cuffed tube** is generally avoided due to the higher risk of tracheal damage and the natural anatomical seal provided by the cricoid cartilage in this age group. - The cuff can cause **pressure ischemia** and lead to **post-extubation stridor** or subglottic stenosis in small airways. *Curved blade with uncuffed tube* - A **curved blade** (e.g., Macintosh blade) is typically used in older children and adults to indirectly lift the epiglottis by placing it in the vallecula, which is less effective in neonates due to their more anterior and U-shaped epiglottis. - Although an **uncuffed tube** is correct for neonates, the curved blade choice is generally inappropriate. *Curved blade with cuffed tube* - Both a **curved blade** and a **cuffed tube** are generally unsuitable for neonatal intubation. - The curved blade is less effective for the neonatal airway anatomy, and the cuffed tube carries a significant risk of **airway compromise** and injury in this population.

Question 1

Endotracheal tube in the esophagus is best assessed by:

Accepted Answer

CO2 Exhalation

Answer

Direct laryngoscopy

Answer

Auscultation

Answer

Chest wall movement

Question 2

During rapid sequence intubation in a child after taking brief history and clinical examination next step is:

Accepted Answer

Administer oxygen

Answer

Analgesic injection with Fentanyl

Answer

Preanaesthetic medication with atropine and lignocaine

Answer

IV anesthetic Diazepam/Ketamine

Question 3

Effective adjuvant in attenuating hypertension and tachycardia associated with laryngoscopy and intubation?

Accepted Answer

Fentanyl

Answer

Suxamethonium

Answer

Ketamine

Answer

Atracurium

Question 4

A patient is admitted following a road traffic accident. He has sustained significant blunt injury to his head, chest and abdomen and has a Glasgow Coma Scale score of 8/15. His saturations are poor at 89% on 15 L of oxygen a rebreathing mask. You note bruising around both eyes and blood-stained fluid issuing from his left ear, which forms concentric circles when dripped on a white sheet. You wish to support his airway to improve oxygenation. The first choice of airway adjunct would be

Accepted Answer

Oropharyngeal airway

Answer

Nasopharyngeal tube

Answer

Intubation

Answer

Laryngeal mask

Question 5

On doing laparoscopic cholecystectomy patient developed wheezing. Which of the following is used in the treatment?

Accepted Answer

Administration of beta agonist

Answer

IV ketamine

Answer

IV lignocaine

Answer

Deepen the plane of anesthesia

Question 6

Helium is used along with oxygen instead of plain oxygen because

Accepted Answer

It decreases turbulence

Answer

For analgesia

Answer

It decreases the dead space

Answer

It increases the absorption of oxygen

Question 7

WHAT IS THE TYPE OF LARYNGOSCOPE SHOWN BELOW ?

Accepted Answer

MILLER

Answer

BULLARDS

Answer

MC INTOSH

Answer

MC COY

Question 8

Which of the following is the most common postoperative complication related to intubation:

Accepted Answer

Sore throat

Answer

Abductor Paralysis

Answer

Bleeding

Answer

Malposition

Question 9

Intraocular pressure rises in ?

Accepted Answer

Intubation & laryngoscopy

Answer

Infusion of IV propofol

Answer

LMA

Answer

Bag and mask ventilation

Question 10

The Blade of the laryngoscope used in intubation of newborn is

Accepted Answer

Straight blade with uncuffed tube

Answer

Straight blade with Cuffed tube

Answer

Curved blade with uncuffed tube

Answer

Curved blade with cuffed tube

Respiratory and Airway Management — MCQs

Respiratory and Airway Management — MCQs

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