Question 1

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

Accepted Answer

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?

Accepted Answer

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?

Accepted Answer

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?

Accepted Answer

Prolonged exposure to increased pressure can lead to tracheal dilation, or tracheomegaly. Careful management of the tube size and cuff may prevent this complication. Cuff pressure should be checked regularly and adjusted as needed.

Question 5

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

Accepted Answer

Disadvantages to nasal intubation include a predisposition to sinusitis, pressure necrosis of the nares, and bleeding complications associated with passing the ETT through the nares and upper airway.

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

Accepted Answer

The major contraindications to nasotracheal intubation are a bleeding diathesis, such as thrombocytopenia, abnormal clotting times, facial trauma, suspected basilar skull fracture, and abnormal anatomy such as choanal atresia.

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

Accepted Answer

Upper airway obstruction may also cause respiratory failure. Examples that are included in this category are diseases such as laryngotracheobronchitis (i.e., croup), epiglottitis, laryngeal papillomatosis, and severe subglottic stenosis.

Question 8

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

Accepted Answer

The most important question to consider when evaluating a patient for extubation is whether there has been improvement in or reversal of the disease process that initially mandated the 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?

Accepted Answer

The occiput of babies and infants is larger than that of older children. A small roll placed under the shoulders of these younger patients facilitates view of the vocal cord during laryngoscopy. Direct laryngoscopy may be facilitated by placing a roll under the shoulders of any patient lying on a soft mattress.

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?

Accepted Answer

Children with laryngotracheal stenosis who do not have a tracheotomy may require intubation. The severity of the stenosis may dictate the approach used to access the airway. Plain magnified soft tissue radiographs may show subglottic narrowing or long-segment tracheal stenosis. In cases of mild subglottic stenosis, the patient may be intubated orally, but it would be essential to start with an endotracheal tube size at least one smaller than the age-appropriate tube, and air leakage must be checked. A leak between 10 and 20 cm H₂O during the time of intubation is necessary so that further damage is not incurred. If the air leak is greater than 20 cm H₂O, a smaller tube should be placed. In cases of severe laryngotracheal stenosis, an LMA may be used, or occasionally an emergency tracheotomy may be performed as an alternative.

Question 11

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

Accepted Answer

Positive pressure applied through the ETT should produce an audible escape of air, or leak, at less than or equal to 20 cm H₂O. The larynx should be auscultated to confirm the leak. Intracuff pressures are maintained at less than 20 to 25 cm H₂O because higher pressures are associated with ischemia and necrosis of the tracheal mucosa and can lead to tracheal stenosis.

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?

Accepted Answer

The chest is auscultated after intubation as a method for assessing whether the ETT is in the trachea. Breath sounds should be heard bilaterally over the lateral chest wall. If breath sounds are auscultated over both the stomach and the chest wall, the ETT is in the esophagus and should be pulled. It should be noted that auscultation is not the most accurate method of assessing proper ETT placement.

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?

Accepted Answer

The tip of the ETT is advanced through the glottic opening so that the single black ring is just distal to the opening of the glottis. If the ETT is marked with three rings, the ETT should be inserted until the double black ring is distal to the glottic opening.

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

Accepted Answer

The need for intubation, due to a lack of pulmonary function, results from deficits in oxygenation, ventilation, or both taken in concert with the patient's clinical condition. Acute ventilatory dysfunction can be defined as an arterial partial pressure of carbon dioxide (PaCO₂) greater than 50 to 60 mm Hg with a pH less than 7.3. Pulmonary dysfunction due to hypoxemia is defined as an arterial partial pressure of oxygen (PaO₂) less than 60 mm Hg with a fraction of inspired oxygen (FiO₂) greater than or equal to 0.60. These definitions assume that there is no intracardiac right-to-left shunt resulting from a congenital cardiac defect.

Question 15

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

Accepted Answer

Children with craniofacial syndromes (e.g., Treacher Collins syndrome or Pierre Robin syndrome) are assumed to have a difficult airway, even if they have undergone jaw advancement. Acquired causes of a difficult airway include limited mouth opening due to decreased temporomandibular joint mobility (as may occur in rheumatoid arthritis or muscular dystrophy), orofacial trauma, trauma to the neck, hematoma of the neck, and infections either of the anterior neck or the epiglottis. Patients with a history of burns or radiation to the face or neck are very difficult to intubate. The clinician should always have additional options available to secure the airway in the event that orotracheal intubation is not successful. An LMA should be readily available during intubation attempts. The Glidescope is a fiberoptic laryngoscope that greatly facilitates intubation of patients with a difficult airway. It is best to learn how to use the Glidescope on patients with a normal airway prior to using this device on patients with an abnormal airway.

Question 16

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

Accepted Answer

The proper depth of the endotracheal tube can be estimated based on the size of the endotracheal tube used. Multiply the internal diameter of the endotracheal tube by three and tape the ETT at that centimeter mark at the lip . This formula cannot be used in children weighing more than 3 kg.

Question 17

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

Accepted Answer

If endotracheal tube placement is unsuccessful, placement of an LMA can be used as a temporizing measure. It is essential to realize that the LMA does not provide a secure airway and that it may permit aspiration of gastric or oral secretions. The lubricated LMA is placed by itself into the pharynx above the epiglottis and can be used for gentle (<20 cm H₂O) positive-pressure ventilation. The deflated mask is manually inserted into the patient's mouth and guided blindly along the hard palate. It is advanced until resistance is encountered (the distal tip of the LMA rests against the upper esophageal sphincter at this point).

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?

Accepted Answer

The child with clinical manifestations of epiglottitis (drooling, stridor, and respiratory distress) should not undergo a visual examination in the emergency department. The child should not be stimulated and should be kept as calm as possible. If the patient is stable, a soft tissue lateral neck radiograph (refer to Figure 13-8 in the textbook) can be performed. Radiologic findings include thickening of the epiglottis and aryepiglottic folds and the classic "thumbprint" sign. If the patient is not stable or if the diagnosis of epiglottitis has been made, the patient should be immediately transported to the operating room to be managed by an ENT surgeon and an anesthesiologist.

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?

Accepted Answer

The larynx of an infant or small child is anterior and cephalad, making intubation more difficult in general. This anatomic difference between adults and children makes attempts at blind nasal intubation almost uniformly unsuccessful. Wisdom dictates that attempts at a blind nasal intubation be vigorously discouraged because of the potential for damaging the airway. Mechanically generated damage and subsequent bleeding would make further intervention and attempts at intubation more difficult and dangerous.

Question 20

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

Accepted Answer

Because the cricoid cartilage is the narrowest portion of the pediatric airway until about 8 years of age, use of an uncuffed ETT was traditionally recommended until that time. In 2005, the American Heart Association's Pediatric Advance Life Support program (PALS) stopped recommending uncuffed tubes because there was no evidence to support one over the other. Today it is left up to the clinician to determine whether a cuff is needed for patients less than 8 years of age.

Quiz 13: Airway Management

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

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

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

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

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

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

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

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

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

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

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

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?

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

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

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

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

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

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?

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?

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

Quiz 13: Airway Management

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

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

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

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

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

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

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

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

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

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

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

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?

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

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

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

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

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

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?

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?

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

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

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