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.