Chapter 15 Airway management and ventilation
The major drawback of mouth-to-mouth ventilations is:
potential exposure of the rescuer to body fluids.
Which of the following would a rise in SpO2 be an objective indicator of?
proper ET tube placement
A fine, bubbling sound heard on inspiration and associated with fluid in the alveoli and terminal bronchioles is called:
rales (crackles).
The reading obtained by the use of a pulse oximeter reflects the:
ratio of unsaturated hemoglobin to saturated hemoglobin. A pulse oximeter measures hemoglobin saturation in peripheral tissues.
The tip of the endotracheal tube for the pediatric patient should be inserted no more than ________ cm below the vocal cords.
2 to 3
A portable suction device should generate a flow rate of ______ liters per minute when the tube is open.
30
What would be the appropriate size ET tube to use for a two-year-old toddler you intend on intubating?
4 ETT size (mm) = (Age in years + 16)/4, so 2+16/4 = 4.5
Advantages of endotracheal intubation after extubation in the field include
A. it impedes gastric distention by channeling air directly into the trachea. B. it eliminates the need to maintain a mask seal. C. it isolates the trachea and permits complete control of the airway. D. all of the options are correct.
Why would you not want to administer succs during and rsi procedure on a patient who was injured when he was crushed between two pieces of heavy equipment while at work?
Because of the risk of hyperkalemia
Where does the lower airway begin?
Below the larynx
The AirTraq® laryngoscope is unique because it is a(n):
disposable video-based device
The purpose of the first step in the primary assessment of a non-cardiac arrest patient is to:
ensure a patent airway.
When intubating using a lighted stylet, you see a dim, indistinct light in the throat. You have MOST likely intubated the:
esophagus
Physiologically, the term respiration refers to the:
exchange of gases at the cellular level.
You are called to an elder care facility for a resident who has arrested. Upon arrival, you are told by the nursing staff that the patient was found in the bed in cardiac arrest, and that he has no DNR orders. You immediately note the patient has a stoma with no tracheostomy tube placed, secondary to previous neck surgery from cancer. What is the best way to manage this patient's airway and ventilatory needs?
gently insert an appropriately sized and lubricated endotracheal tube into the stoma, inflate the cuff, and begin ventilations
The bifurcation of the trachea is called the:
carina.
What type of transport ventilator allows for less patient sedation?
critical care The increased adjustability found in critical care transport ventilators allows patients to be kept more comfortable with less sedation, analgesia, and paralysis.
When using a colorimetric end-tidal carbon dioxide detector, the absence of carbon dioxide in exhaled air after six breaths indicates the endotracheal tube has been placed:
in the esophagus.
Which of the following is a relative contraindication for performance of a cricothyrotomy?
inability to identify landmarks
You have intubated and are currently ventilating a COPD patient with chronic bronchitis. During ventilations, you notice the high airway pressure alarm keeps sounding, despite your knowledge that the ET tube is placed properly and you have bilateral breath sounds. Given this, what can be done while suctioning the trachea of this patient to help extract the heavy mucus?
inject 3-5 mL of sterile water into the ET tube first
Advantages of a nasopharyngeal airway include all of the following, EXCEPT:
it isolates the trachea. Advantages of an NPA include: It can be inserted with an intact gag reflex. It can be suctioned through. It can be placed blindly and safely. It does not, however, isolate the trachea.
In order to minimize tooth breakage and soft tissue laceration during ET intubation, you should perform which of the following?
keep your wrist straight and apply gentle traction up and toward the feet with your shoulder
While ventilating your intubated patient with a BVM, you note that compliance is deteriorating. What should you do?
look for possible causes.
The hypoxic drive is stimulated by:
low PaO2
When correctly placed during RSI intubation, the tip of a straight laryngoscope blade should be:
under the epiglottis
Which of the following is not a sign of adequate ventilation?
15 cm/h2o expiratory pressure
When you are intubating a stoma site, how far beyond the distal cuff (in cm) should you insert the endotracheal tube?
1 to 2
When performing suctioning of the stoma, what should be the maximum amount of suction time?
10 seconds
When performing tracheal suctioning through an ET tube on an adult patient, what is the maximum amount of time you should apply suction prior to resuming ventilations in the patient?
10 seconds
How much air is required to inflate the distal cuff in an Esophageal Tracheal Combitube (ETC)?
10-15 mL Inflate the pharyngeal cuff with 100 mL of air and the distal cuff with 10 to 15 mL of air.
For standard transport ventilators, the oxygen concentration is usually fixed at ______ percent.
100
When airway pressure of a transport ventilator exceeds a preset level, the valve opens, venting some of the tidal volume. Typically this preset level equals:
60 cm/H2O
Open cricothyrotomy is contraindicated in children under the age of ________ because the cricothyroid membrane is small and underdeveloped.
8
What is the negative pressure that the suction unit should be set at when performing tracheal suctioning?
80 mmHg
The automatic transport ventilator is contraindicated for all of the following intubated patients except,
A 17 y/o gsw patient
The 3-3-2 rule incorrectly is
A rule to help estimate et tube size
How can auscultating the chest for signs of adequate ventilation sometimes be misleading?
Air movement into the epigastrium can sound like breathing.
For which of the following instances might digital intubation after extubation not be indicated?
Airway is blocked by foreign body
In which of the following patients would a Combitube dual-lumen airway be used with caution?
A 59-year-old male with a history of chronic alcoholism who was found in cardiac arrest at a homeless shelter
You are ventilating an intubated 68 y/o male COPD patient with a bvm. You note that while his spo2 remains stable, there is poor compliance during ventilation. What is this poor compliance likely attributable to?
COPD process
What is considered the "gold standard" for verifying proper ETT placement?
Capnography Detection of end-tidal CO2 (capnography) is the gold standard for ET tube placement confirmation.
When performing noninvasive monitoring of your patient, which of the following is true?
Capnography is a rapid detector of hypoventilation.
Which noninvasive respiratory monitory device is preferred when immediate visibility to hypoventilation is needed?
Capnometer
Progressively deeper, faster, breathing alternating gradually with shallow, slower breathing is called
Cheyene-Stokes respirations
What category of the mallampati classification system would indicate the most difficult airway?
Clads IV
What type of technique should be used when attempting to auction the trachea of a patient who is endotracheally intubated?
Sterile
There is accumulating evidence that mechanical ventilation is superior to manual ventilation except in:
Crashing patients
Applying posteriorly directed pressure on the cricoid cartilage to facilitate endotracheal intubation is also referred to as
Cricoid pressure
Which of the following is not a component of the primary assessment?
Identifying sensation and motor function threats.
Which of the following airway adjuncts requires the use of specialized equipment?
ET tube
Which of the following demonstrates a proper way to document end total carbon dioxide level if the numeric display reads 38?
ETOC2 38 mmHg
_____ May be used to facilitate nasotracheal intubation
Endotrol tube
When swallowing occurs, the structure that includes the tracheal opening to prevent aspiration of food and liquid is the:
Epiglottis
Which of the following airway adjuncts is specially designed to allow for gastric decompression after insertion?
Esophageal Tracheal Combitube
Which of the following ventilatory devices has the greatest risk of causing gastric insufflation in the patient?
FROPVD
When observing the movement of the chest wall during assessment of a patients breathing, asymmetrical movement, or paradoxical breathing, may be an indicator of
Flail chest
Transport ventilators with enhanced monitoring and alarm features are:
Generally used in critical care transport settings
Which of the following suggest an esophageal intubation during an RSI?
Gurgling sounds over the epigastrium with each ventilation delivered.
During spontaneous breathing, which of the following reflexes prevents overinflating of the lungs?
Hering-Breuer The Hering-Breuer reflex prevents overexpansion of the lungs.
Video laryngoscope is considered a
Indirect technique
Failure to properly position the head and airway when attempting positive pressure ventilation will likely lead to what problem?
Inflation of the stomach
When using a laryngoscope with a curved blade, the blade tip should be advanced
Into the vallecula
Using a laryngoscope equipped with a video camera would be considered superior to traditional intubation when a patient:
Is in cardiac arrest and in a prone position
Which of the following is true regarding the esophageal tracheal combitube?
It does not require complete removal to accommodate an ET tube insertion
Which of the following is not a disadvantage of the nasopharyngeal airway?
It isolates the trachea
Advantages of a pediatric nasopharyngeal airway include all of the following, EXCEPT:
It isolates the trachea. Advantages of a pediatric NPA include: It can be inserted with an intact gag reflex. It can be suctioned through. It can be placed blindly and safely. It does not, however, isolate the trachea.
During CQI audit of one of your PCRs, the QA officer asks you for more clarification regarding the use of sedation and paralysis on a patient with an upper airway burn. Which of the following would be the best response to this?
It was best to do the RSI so we could secure the airway prior to it swelling shut.
Explain how ET tube misting is an effective means of confirming tracheal placement
It's not
What medical procedure is performed that often results in the patient having a stoma permanently placed?
Laryngectomy
After taking standard precautions and ventilating the patient with a BVM as well as possible while preparing the equipment the next step in performing an open cricothyrotomy is:
Locate the thyroid cartilage and the cricoid cartilage
What does the "L" in LEMONS law stand for?
Look externally
Foreign body removal by direct visualization with a laryngoscope would likely also require the use of what adjuncts?
Magill forceps or auction
You arrive at the scene of a single car accident. The sole patient is lying on the ground. Slightly cyanotic with sonorous respirations and no other obvious injuries. You immediately perform the jaw-thrust procedure which seems to immediately relieve the respiratory compromise. Your partner applies a nonrebreather mask with high flow oxygen and wants you to move aside so he can apply c-collar and continue the primary exam. You should:
Maintain your position and hold in line immobilization until and alternate airway adjust can be applied
The most common indication for a surgical cricothyrotomy is
Massive facial or neck trauma
Home ventilator's high pressure alarm going off:
Mucus plugging the stoma
Reassessment of a patients airway should be conducted
On a minute by minute basis
In which of the following conditions is insertion of the nasogastric tube contraindicated?
Patient with facial fractures
A drop in BP greater then 10 torr during inspiration is called
Pulsusparadoxus
After repeated intubation attempts between you and your paramedic partner on a cardiac arrest patient, you decide to insert a rescue airway device rather than attempt intubation again. Your partner, however, does not agree with you. Select the following justification that best defends your position:
Repeated intubation attempts only delay effective ventilations and cause soft tissue trauma that will further hamper intubation at the hospital.
A peak flow meter measures
Respiratory efficacy during forced expiration
A technique for RSI intubation by passing a wire through the criocothyroid membrane cephalad through a catheter is called:
Retrograde intubation
Which of the following devices can be used as a simple mechanical airway adjunct much like an oropharyngeal airway and also as a blind endotracheal tube introducer in situations where laryngoscopy is difficult?
SALT
What is a potential result of overly aggressive or improper tube placement when performing a nasotracheal intubation?
Significant bleeding
What is visualized with a Grade 3 Mallampati score?
Soft and hard palate
Which of the following paralytics would have the fastest onset time?
Succs
All of the following are potential disadvantages of the AirTraq® laryngoscope, except:
The ET tube is directable by moving the entire device rather than just the tube.
One way to improve airway management and ventilation is to make sure that
The ear to sternal notch axis is aligned
Why have the incidences of cricothyrotomy procedures being performed in the EMS setting fallen significantly over the last decade?
The effectiveness of RSI and EGAs.
Insertion of an endnotracheal tube too far in a pediatric patient is likely to result in ventilation of:
The right lung only
When ventilating a patient via a nasal ETT, what is one advantage this has over an orally placed ETT?
The tube cannot be bitten down on.
Which of the following statements about manual airway maneuvers is TRUE?
They are often neglected by EMTs and paramedics.
Why are video laryngoscope devices anticipated to completely replace direct laryngoscopes in the future?
They have proven to be more effective and prices are dropping.
Describe the procedure for insertion of the Esophageal Tracheal Combitube (ETC) in a patient who still has a gag reflex.
This airway cannot be used in a patient with a gag reflex.
When correctly placed for a pediatric patient, the tip of a straight laryngoscope blade should be:
Under the epiglottis
You arrive at a restaurant and as you approach your 58 y/o male patient you note him sitting at a table, panicked and laboring to breathe. As you get close you hire audible stridor, and the patient is Cyanotic. You feel no movement of air from his mouth or nose. Your initial impression would be
Upper airway obstruction from food
Reversal of cyanosis following initiation of PPV is an indicator of:
adequate ventilations.
You are treating a patient who was initially complaining of shortness of breath and chest pain. After stabilizing the patient you note that the pulse ox, which initially indicated a SpO2 of 87%, has now risen to 100%. What should you do now?
adjust FIO2 to maintain SpO2 of 95-100%. Trying to fully saturate hemoglobin with oxygen can cause the formation of free radicals and result in oxidative stress. Excess concentrations of oxygen (hyperoxia) should be avoided.
Shallow, slow, or infrequent breathing, indicating severe ICP buildup and brain anoxia, is:
agonal breathing.
All of the following are indications for RSI, EXCEPT:
an anticipated difficult airway.
Tracheal intubation is particularly effective for:
anaphylaxis and airway burns.
Why may the process of endotracheal intubation in a patient with a known stroke be detrimental to their neurological outcome?
because of the risk of increased intracranial pressure
The amount of gas moved in and out of the pediatric respiratory tract in one minute is termed:
minute volume.
When using a ventilatory device such as a BVM, how can you continue to monitor technique and placement after verification?
monitor the rise and fall of the chest and breath sounds
Grade II on the Cormack and LeHane grading system of airway evaluation can be described as:
only the epiglottis and posterior glottic opening can be seen with partial view of the cords.
Which of the following is a contraindication for the insertion of an Esophageal Tracheal Combitube (ETC) airway?
patients under four feet tall
You have elected to intubate a patient for rapid clinical deterioration. You have administered the appropriate RSI medications per your protocol. Upon laryngoscopy, however, you are unsuccessful in placing the ET tube. What should be your next action?
resume mask ventilations
Although more expensive, critical care transport ventilators are preferred if your service performs long-distance transports, or:
serves a high pediatric population.
If it becomes necessary to suction a stoma, what type of procedure should be employed?
sterile
In order to digitally place an endotracheal tube, you should direct the tip of the tube with:
your middle and index finger.
During a CE class you are helping to teach at your EMS service, you notice that all of the paramedics want to practice intubation, but none want to practice with the simple mechanical airways and ventilating with a BVM because "they are basic skills." What should be your response to your colleagues' comments?
"Intubation is just one way to secure an airway. You need to remember that the whole goal is to provide effective ventilation."
Ongoing evaluation of respirations and immediate correction of respiratory deficiencies are examples of:
minute-by-minute monitoring and intervention.