Respiratory and Airway Management Practice Questions

Q: Which statement is false regarding endotracheal tube cuffs?

The cuff is meant to keep the tube firmly in the trachea.. **Explanation** The primary purpose of an endotracheal tube (ETT) cuff is to provide an **airtight seal** between the tube and the tracheal wall. This seal facilitates positive pressure ventilation and protects the lower airway from aspiration of gastric contents or secretions. **Why Option B is False:** The cuff is **not** designed to anchor or fix the tube in place. Securing the tube is achieved using adhesive tapes or ties around the patient’s mouth or neck. Relying on the cuff for stabilization would require excessive inflation, leading to tracheal mucosal ischemia. **Analysis of Other Options:** * **Option A:** Traditionally, infant ETTs were uncuffed because the narrowest part of a child's airway is the cricoid cartilage, which acts as a natural anatomical seal. While cuffed tubes are now increasingly used in pediatrics, the classic teaching for exams remains that infants typically use uncuffed tubes to prevent subglottic stenosis. * **Option C:** The capillary perfusion pressure of the tracheal mucosa is approximately **25–30 cm H₂O**. If cuff pressure exceeds this (ideally kept between 20–30 cm H₂O), it causes ischemia, which can lead to tracheal stenosis or tracheomalacia. * **Option D:** This is a core function of the cuff; it prevents air leaks during inspiration and prevents aspiration. **High-Yield Clinical Pearls for NEET-PG:** * **Cuff Type:** Most modern ETTs use **High-Volume Low-Pressure (HVLP)** cuffs to distribute pressure over a larger area, reducing the risk of mucosal damage. * **Microaspiration:** HVLP cuffs can form longitudinal folds that allow microaspiration; newer tapered-shaped cuffs (e.g., Lanz) aim to minimize this. * **Monitoring:** Cuff pressure should be monitored using a dedicated manometer, especially during prolonged surgeries or ICU stays.

Q: If a satisfactory laryngeal view is not achieved during laryngoscopy, which maneuver is performed?

Backward-upward-rightward pressure. **Explanation:** The correct answer is **D. Backward-upward-rightward pressure (BURP maneuver)**. **1. Why BURP is correct:** When the laryngeal view is suboptimal (e.g., Cormack-Lehane Grade 2 or 3) during direct laryngoscopy, the **BURP maneuver** is the standard technique used to improve visualization. It involves an assistant applying manual pressure on the thyroid cartilage in three specific directions: **B**ackward (against the cervical vertebrae), **U**pward (superiorly), and **R**ightward. This maneuver displaces the larynx into the line of sight of the laryngoscopist, significantly improving the view of the glottis. **2. Why other options are incorrect:** * **A. Neck should be flexed:** While the "sniffing position" involves lower cervical flexion and upper cervical extension, further flexion of the neck *during* laryngoscopy usually obstructs the view rather than improving it. * **B & C. Chin lift and Jaw thrust:** These are basic airway maneuvers used to open the airway in a spontaneous breathing patient or during bag-mask ventilation to relieve soft tissue obstruction. They are not used to improve the laryngeal view once the laryngoscope is already in the mouth. **Clinical Pearls for NEET-PG:** * **BURP vs. SELLICK:** Do not confuse BURP with the **Sellick Maneuver** (Cricoid pressure). Sellick is used to prevent gastric regurgitation, whereas BURP is specifically to improve the laryngeal view. * **Cormack-Lehane Classification:** This system grades the laryngeal view (Grade 1: Full view; Grade 4: No epiglottis seen). BURP is most effective in converting a Grade 3 view to a Grade 2. * **OELM:** Optimal External Laryngeal Manipulation (OELM) is a variation where the intubator moves the larynx with their own right hand to find the best view, then has an assistant maintain that position.

Q: What is the approximate pressure that should be applied during cricoid pressure application?

30 N. **Explanation:** Cricoid pressure, also known as **Sellick’s Maneuver**, is a technique used during Rapid Sequence Induction (RSI) to prevent the regurgitation of gastric contents into the pharynx, thereby reducing the risk of aspiration. **1. Why 30 N is correct:** The recommended force for effective cricoid pressure is **30 Newtons (N)**, which is approximately equivalent to 3 kg of pressure. This force is sufficient to occlude the esophagus against the body of the sixth cervical vertebra (C6) without causing airway obstruction or significant trauma. In clinical practice, it is recommended to apply **10 N** while the patient is awake/during pre-oxygenation and increase it to **30 N** once the patient loses consciousness. **2. Analysis of Incorrect Options:** * **20 N (Option A):** This force is often considered insufficient to reliably occlude the esophagus in an unconscious patient, increasing the risk of aspiration. * **40 N (Option C):** Applying force greater than 30 N is excessive. It can lead to airway distortion, making tracheal intubation difficult, and may cause esophageal rupture if the patient is actively vomiting. * **5 N (Option D):** This is negligible pressure and provides no clinical benefit in preventing regurgitation. **Clinical Pearls for NEET-PG:** * **Anatomical Landmark:** The cricoid cartilage is the only **complete cartilaginous ring** in the larynx. * **Contraindications:** Suspected cricoid/laryngeal fracture, active vomiting (risk of esophageal rupture), and unstable cervical spine injuries. * **Complications:** If applied incorrectly, it can cause laryngeal view distortion (Grade 3 or 4 Cormack-Lehane view) and difficulty in passing the endotracheal tube.

Q: Which supraglottic airway device offers the maximum airway seal during positive pressure ventilation?

Laryngeal mask airway ProSeal. **Explanation:** The **Laryngeal Mask Airway (LMA) ProSeal** is a second-generation supraglottic airway device (SAD) specifically designed to provide a superior seal compared to its predecessors. It features a larger, redesigned silicone cuff and a posterior bolster that pushes the mask forward, ensuring a tighter fit against the periglottic tissues. This allows it to withstand higher airway pressures (up to **30 cm H₂O**), making it the gold standard for positive pressure ventilation (PPV) among SADs. **Analysis of Options:** * **LMA Classic (Option B):** A first-generation device with a lower seal pressure (typically <20 cm H₂O). It lacks a gastric drainage channel and is prone to leaks during high-pressure ventilation. * **i-gel (Option C):** A second-generation, non-inflatable device made of thermoplastic elastomer. While it is easy to insert and provides a good seal (approx. 24–26 cm H₂O), it generally does not reach the high seal pressures achieved by the ProSeal. * **Laryngeal Tube (Option D):** A double-lumen tube that seals the esophagus and oropharynx. While effective, it is associated with higher mucosal pressure and is less commonly used than the ProSeal for routine high-pressure ventilation. **High-Yield Clinical Pearls for NEET-PG:** * **Gastric Channel:** The ProSeal has a dedicated drainage tube that allows for the passage of a Ryle’s tube to decompress the stomach, reducing the risk of aspiration. * **Second-Generation SADs:** Defined by the presence of a gastric drainage port and improved seal mechanisms (e.g., ProSeal, Supreme, i-gel). * **Indications:** ProSeal is often preferred in obese patients or laparoscopic surgeries where higher inspiratory pressures are required.

Q: What is the name of the curved blade of a laryngoscope as depicted?

Macintosh blade. ***Macintosh blade*** - The **Macintosh blade** is the standard **curved laryngoscope blade** designed with a gentle curve to follow the natural anatomy of the tongue and oropharynx. - It is placed in the **vallecula** (the space between the base of tongue and epiglottis) to indirectly lift the epiglottis for vocal cord visualization. *McCoy blade* - The McCoy blade is a **modified Macintosh blade** with a **hinged tip** that can be flexed to improve glottic view in difficult airways. - While it has a curved design, it is specifically distinguished by its **articulating tip mechanism**, not just being "curved." *Miller's blade* - The **Miller blade** is a **straight laryngoscope blade** designed for direct lifting of the epiglottis. - It is commonly used in **pediatric intubation** and provides better visualization in patients with **anterior larynx** positioning. *Wisconsin blade* - The **Wisconsin blade** is also a **straight blade** similar to Miller but with a slightly different tip design and curve. - It is **straight in configuration**, not curved, making it unsuitable as the answer for a curved blade.

Q: In a patient with Le Fort II, Le Fort III, and nasoethmoid fractures, what is the choice of intubation?

Submental. **Explanation:** The management of a complex maxillofacial trauma involving **Le Fort II, Le Fort III, and nasoethmoid (NOE) fractures** presents a unique airway challenge. In these cases, the goal is to secure the airway while allowing the surgeon to establish proper dental occlusion (intermaxillary fixation) and repair midface fractures. **Why Submental Intubation is the Correct Choice:** Submental intubation involves passing an endotracheal tube through the floor of the mouth. It is the preferred choice here because: 1. **Surgical Access:** Unlike oral intubation, it keeps the oral cavity clear, allowing the surgeon to check dental occlusion. 2. **Safety:** Unlike nasal intubation, it avoids the risk of **accidental intracranial tube placement** or worsening of CSF rhinorrhea, which are high risks in Le Fort II/III and NOE fractures due to potential disruption of the **cribriform plate**. 3. **Avoidance of Tracheostomy:** It serves as a safer, less invasive alternative to a short-term tracheostomy. **Analysis of Incorrect Options:** * **Oral (A):** While safe, it interferes with the surgical requirement of achieving intermaxillary fixation (IMF) to align the jaw. * **Nasal (C):** Absolutely contraindicated in suspected base-of-skull or cribriform plate fractures (common in Le Fort II/III/NOE) due to the risk of intracranial insertion. * **Oral and Nasal (B):** Incorrect as both have the specific contraindications mentioned above. **Clinical Pearls for NEET-PG:** * **Absolute Contraindication for Nasal Intubation:** Fractures of the base of the skull, CSF rhinorrhea, and severe midface trauma. * **Submental Intubation Indication:** When long-term ventilation is not needed, but both oral and nasal routes are unsuitable due to surgical or anatomical reasons. * **Gold Standard for Long-term Airway:** If the patient requires prolonged mechanical ventilation post-surgery, **Tracheostomy** remains the definitive choice.

Question 1

A 72-year-old man has multiple injuries and an altered sensorium after a high-speed motor vehicle collision. He is intubated for his decreased mental status. During intubation, a large amount of gastric contents are noted in the posterior pharynx and he aspirates. What is the appropriate initial treatment?

Accepted Answer

Bronchoscopy for aspiration of particulate matter

Answer

Steroids

Answer

Prophylactic antibiotics

Answer

Inhaled nitric oxide

Question 2

Which statement is false regarding endotracheal tube cuffs?

Accepted Answer

The cuff is meant to keep the tube firmly in the trachea.

Answer

Infant endotracheal tubes do not have cuffs.

Answer

Lateral pressure should not exceed 30 cm H2O.

Answer

The cuff provides an airtight seal and facilitates controlled ventilation.

Question 3

If a satisfactory laryngeal view is not achieved during laryngoscopy, which maneuver is performed?

Accepted Answer

Backward-upward-rightward pressure

Answer

Neck should be flexed

Answer

Chin lift

Answer

Jaw thrust

Question 4

What is the approximate pressure that should be applied during cricoid pressure application?

Accepted Answer

30 N

Answer

20 N

Answer

40 N

Answer

5 N

Question 5

Which supraglottic airway device offers the maximum airway seal during positive pressure ventilation?

Accepted Answer

Laryngeal mask airway ProSeal

Answer

Laryngeal mask airway Classic

Answer

i-gel

Answer

Laryngeal tube

Question 6

Which of the following statements is true about the laryngeal mask airway?

Accepted Answer

It provides full protection from aspiration.

Answer

It can be used in patients with a full stomach.

Answer

It is used as an alternative to endotracheal intubation.

Answer

A difficult airway is an indication for its use.

Question 7

What is the name of the curved blade of a laryngoscope as depicted?

Accepted Answer

Macintosh blade

Answer

McCoy blade

Answer

Miller's blade

Answer

Wisconsin blade

Question 8

In a patient with Le Fort II, Le Fort III, and nasoethmoid fractures, what is the choice of intubation?

Accepted Answer

Submental

Answer

Oral

Answer

Oral and nasal

Answer

Nasal

Question 9

What is the landmark for superior laryngeal nerve block?

Accepted Answer

Greater cornu of hyoid bone

Answer

Angle of mandible

Answer

C7 transverse process

Answer

Cricoid cartilage

Question 10

Which of the following conditions is NOT an indication for securing the airway?

Accepted Answer

A patient with a large tumor in the oral cavity

Answer

Difficult intubation

Answer

Cardiopulmonary resuscitation

Answer

A child undergoing elective eye surgery

Respiratory and Airway Management — MCQs

Respiratory and Airway Management — MCQs

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