Deck 13: Airway Management

Question 1

The therapist is about to perform endotracheal intubation on a 2-year-old infant. What size endotracheal tube needs to be used?

A) 3.5 mm ID
B) 4.0 mm ID
C) 4.5 mm ID
D) 5.0 mm ID

Answer 1

C
Using the following formula, the therapist can calculate the approximate size endotracheal tube to use to intubate a 2-year-old infant:
Internal diameter (mm) = (age [yr] ÷ 4) + 4
= (2 yr ÷ 4) + 4
= 0.5 + 4
= 4.5 mm IDs

Question 2

How should the therapist confirm proper placement of an endotracheal tube?

A) Presence of end-tidal CO₂ one breath after intubation
B) Pulse oximetry >88%
C) Presence of end-tidal CO₂ for at least five breaths after intubation
D) Presence of vapor in the ETT

Answer 2

C
The presence of vapor in the ETT is not an accurate test for proper ETT placement. Proper endotracheal, and not esophageal, placement of the endotracheal tube is confirmed with sustained presence of end-tidal CO₂. Capnography via a monitor is preferred over a single-use end-tidal device (Pedi-Cap; Nellcor, Boulder, Colorado). End-tidal CO₂ should be monitored for at least five breaths after intubation. Even endotracheal tubes placed in the esophagus may have transient detection of CO₂ due to the presence of CO₂ in the stomach (which can occur due to bag-mask ventilations).

Question 3

Where in the upper airway of an infant should the laryngoscope straight blade be placed to expose the glottis during endotracheal intubation?

A) The epiglottis is directly lifted with the tip of the laryngoscope blade.
B) The tip of the laryngoscope blade is placed in the vallecula.
C) The tip of the laryngoscope blade is placed in the uvula.
D) The laryngoscope blade is used to sweep the tongue to the left.

Answer 3

A
When a straight blade is used, the epiglottis is lifted with the tip of the blade and pressed against the base of the tongue.

Question 4

Prolonged exposure to increased tracheostomy cuff pressure may cause which of the following disorders?

A) Tracheomegaly
B) Tracheomalacia
C) Tracheal granulomatosis
D) Tracheal bleeding

Question 5

Which of the following conditions is considered a disadvantage of nasotracheal intubation in neonates?

A) Postextubation atelectasis among very low-birth weight infants
B) Pressure necrosis of the nares
C) Deformation of the nasal turbinates
D) Olfactory nerve damage

Question 6

Which of the following conditions are considered contraindications for nasotracheal intubation?
I) Bleeding diathesis
II) Facial trauma
III) Temporal skull fracture
IV) Choanal atresia

A) I and II only
B) I, II, and IV only
C) I, III, and IV only
D) II, III, and IV only

Question 7

Which of the following conditions associated with upper airway obstruction may cause respiratory failure and require an artificial airway?
I) Laryngotracheobronchitis
II) Pneumonia
III) Epiglottitis
IV) Subglottic stenosis

A) I and III only
B) II and IV only
C) I, II, and III only
D) I, III, and IV only

Question 8

What is considered the best predictor of a readiness for extubation?

A) An oxygen saturation > 95%
B) A respiratory rate < 35 breaths per minute
C) A cuff leak < 25 cm H₂O
D) Improvement in the disease process that initially mandated intubation

Question 9

What is the purpose of placing a small towel under the occiput of a 4-year-old patient who is undergoing oral intubation?

A) To prevent unnecessary pressure from being exerted on the occiput
B) To enable the clinician to more easily move the patient's tongue to the left
C) To obtain a better alignment and visualization of the airway
D) To assist in maintaining the patency of the upper airway

Question 10

A child orally intubated because of laryngotracheal stenosis has an air leak at 25 cm H₂O. What action does the therapist take now?

A) The therapist should recommend that a tracheotomy be performed.
B) The therapist needs to insert an oral ETT smaller than the one in place.
C) The therapist must insert an oral ETT large enough to stop the leak.
D) The therapist should do nothing because this situation is acceptable for this type of patient.

Question 11

The therapist is measuring the intracuff pressure of a pediatric ETT. Where should the pressure be maintained to avoid complications?

A) 5 to 10 cm H₂O
B) 10 to 20 cm H₂O
C) 20 to 25 cm H₂O
D) Not greater than 30 cm H₂O

Question 12

The therapist is trying to confirm the proper placement of an endotracheal tube of an infant. Auscultation reveals breath sounds over both the stomach and the chest wall. What should the therapist do?

A) Advance the ETT until breath sounds are not heard over the stomach.
B) Pull the ETT at least 4 cm until breath sounds are not heard over the stomach.
C) Leave it in place because breath sounds over the stomach are simply transmitted from the lungs.
D) Pull the ETT because it is most probably in the esophagus.

Question 13

How should the therapist determine the depth of insertion of an endotracheal tube marked with three rings in an infant during the intubation procedure?

A) Just when the Murphy eye clears the vocal cords and enters the trachea
B) At the location where the second double-ring mark just passes the glottis
C) At the point where the first heavy black line just moves beyond the glottis
D) Just after the distal third of the tube passes into the trachea past the glottis

Question 14

Which of the following criteria are used to define ventilatory and hypoxemic dysfunction in patients who may need intubation?
I) PaO₂ < 80 mm Hg with FiO₂ > 0.60
II) PaCO₂ > 50 to 60 mm Hg
III) pH < 7.3
IV) PaO₂/ FiO₂ > 250

A) I and III only
B) II and III only
C) I, II, and III only
D) I, III, and IV only

Question 15

Which of the following techniques should be considered when intubating neonates with craniofacial syndromes?

A) Nasotracheal intubation
B) Routine orotracheal intubation
C) Fiberoptic laryngoscopy
D) Finger intubation of the trachea

Question 16

Where should the therapist secure a 4.0-mm endotracheal tube after the intubation procedure?

A) 8 cm at the lip
B) 9 cm at the lip
C) 10 cm at the lip
D) 12 cm at the lip

Question 17

Which of the following statements describes the laryngeal mask airway (LMA)?

A) The LMA should be used only with conscious patients.
B) The potential for aspiration is lower than with translaryngeal intubation.
C) The LMA is a good alternative as an emergency airway when positive-pressure ventilation is needed.
D) The LMA is placed into the larynx immediately above the epiglottis.

Question 18

A 5-year-old child is brought to the emergency department in severe respiratory distress with a diagnosis of epiglottitis. What measures must be performed to secure the child's airway?

A) The child should be immediately intubated orally in the emergency department.
B) A tracheotomy needs to be performed in the emergency department.
C) The child is in urgent need of transport to the operating room to be intubated.
D) Nebulized 2.2% racemic epinephrine needs to be given via face mask every 10 minutes.

Question 19

Which of the following anatomic differences between the larynx of an infant and that of an adult makes blind nasal intubation of the infant more difficult?

A) The larynx of an infant is more cephalad and anterior.
B) The upper airway in the laryngeal area is smaller in an infant.
C) The cricoid cartilage in an infant acts as a partial airway obstruction.
D) The upper airway structures in an infant are more pliable and compliant.

Question 20

Prior to 2005, why were endotracheal tubes (ETTs) without cuffs routinely recommended for children less than 8 years of age?

A) Because some lung volumes are so small cuffs are unnecessary
B) Because in some infants the ETT creates a seal against the cricoid cartilage
C) Because less airway resistance develops without a cuff, promoting lower ventilation pressures
D) Because ETTs without cuffs enable pressure venting when an infant cries

Question 21

What are the most common causes of death in tracheotomy-dependent children?

A) Hemorrhage
B) Sepsis/infection
C) Significant leaks
D) Mucous plugging

Question 22

Which of the following are considered common mixtures of Heliox?
I) 80% helium-20% oxygen
II) 70% helium-30% oxygen
III) 80% oxygen-20% helium
IV) 70% oxygen-30% helium

A) I and II only
B) I and III only
C) II and IV only
D) III and IV only

Question 23

Ideally, how many hours after last feeding should a therapist consider before changing a tracheostomy tube to minimize the risk of vomiting and aspiration?

A) At least 2 hours
B) At least 4 hours
C) At least 6 hours
D) At least 12 hours

Question 24

What conditions should be met before considering decannulation?
I) Original indication for tracheostomy has resolved.
II) Tolerance of a Passey-Muir valve most of the day.
III) No need for suctioning.
IV) Absence of fever.

A) I, II, and III only
B) I and III only
C) III and IV only
D) II, III, and IV only

Question 25

Which of the following are considered indications for tracheostomy in children?
I) Congenital upper airway obstruction
II) Pulmonary toilet
III) Prolonged ventilatory support
IV) Severe bronchospasms

A) III only
B) I and III only
C) I, II, and III only
D) III and IV only

Question 26

Where is the tracheostomy tube usually placed in children?

A) Between the second and fourth tracheal rings
B) Between the fourth and fifth tracheal rings
C) Between the cricoid and the thyroid cartilage
D) Between the first and second tracheal rings