Quiz 4 Flashcards
What is one difference between the DAS and ASA guidelines for difficult airways/intubation?
Awakening of the patient following failed intubation, and successful bag-mask ventilation
Surgical Cricothyrotomy as the last emergent intervention in both guidelines
Initial use of a supraglottic airway following failed intubation in both guidelines
Emphasis of proficient planning and airway assessment to prepare for a difficult airway
Correct Answer: B & C
Rationale
The Difficult Airway Society (DAS) and the American Society of Anesthesiologists (ASA) two guidelines provide many similarities in their framework to guide anesthesia providers during a difficult airway. The DAS indicate within their framework that the initial step to be taken towards ventilating a patient after a failed intubation is to attempt to place a supraglottic airway device such as an LMA (Elisha et al., 2023, p.449). This differs from the ASA model because the initial step in that framework is to initiate bag mask ventilation (Elisha et al., 2023). An additional difference to these two guidelines is that the DAS specifies that with failure to oxygenate and ventilate with all previous attempts and devices, a surgical cricothyrotomy should be performed. Within the ASA guidelines a direct promotion of the surgical cricothyrotomy approach is not shown (Elisha et
Which intrinsic muscles in the larynx are innervated by the recurrent laryngeal nerve? (Select all that apply)
A. Cricothyroid,
B, lateral cricoarytenoid
C. Posterior cricoarytenoid
D. Thyroarytenoid
Answer = B, C, D
Rationale: All of the intrinsic muscles of the larynx are controlled by the recurrent laryngeal nerve except the cricothyroid. The superior laryngeal nerve innervates the cricothyroid.
Which of the following is NOT a component of the 3-3-2 rule for airway assessment?
A. Mouth opening should be at least 3 fingerbreadths.
B. Thyromental distance should be at least 3 fingerbreadths.
C. Sternomental distance should be at least 2 fingerbreadths.
D. Thyroid notch to hyoid bone distance should be at least 2 fingerbreadths.
Answer: C. Sternomental distance should be at least 2 fingerbreadths
Rationale: The 3-3-2 rule assesses airway geometry for predicting difficult intubation. The correct parameters are interincisor distance of 3 fingerbreadths, a thyromental distance of 3 fingerbreadths, and a thyroid notch to hyoid bone distance of at least 2 fingerbreadths.
A patient with suspected cervical spine injury requires intubation. The safest technique is:
A) Direct laryngoscopy with head extension
B) Fiberoptic intubation
C) Nasotracheal intubation
D) Blind intubation
Correct Answer: B) Fiberoptic intubation
Rationale:
Fiberoptic intubation allows for airway control with minimal neck movement, making it the safest choice for cervical spine injuries. Trauma to the airway and limited mouth opening are other indications.
Which of the following is correct regarding the function of the superior laryngeal nerve (SLN)?
A) The internal branch of the SLN provides motor function to the cricothyroid muscle.
B) The external branch of the SLN provides sensory input to the hypopharynx above the vocal cords.
C) The internal branch of the SLN provides sensory input to the hypopharynx above the vocal cords, including the base of the tongue and epiglottis.
D) The SLN provides motor function to all muscles of the larynx except the cricothyroid muscle.
Correct Answer: C)
Rational: The internal branch of the SLN provides sensory input to the hypopharynx above the vocal cords, including the base of the tongue, epiglottis, aryepiglottic folds, and arytenoids. The external branch provides motor function to the cricothyroid muscle of the larynx. The recurrent laryngeal nerve provides motor function to all the muscles of the larynx except the cricothyroid muscle.
Which of the following statements accurately differentiates cricoid pressure from the BURP maneuver during laryngoscopy?
A) Cricoid pressure is applied to improve glottic visualization, while BURP is used to prevent passive regurgitation of gastric contents.
B) Cricoid pressure is applied to occlude the esophagus and prevent aspiration, while BURP is applied to optimize vocal cord visualization during laryngoscopy.
C) Both cricoid pressure and BURP serve the same purpose and are used interchangeably during intubation.
D) BURP is applied to compress the esophagus, while cricoid pressure is used to manipulate the thyroid cartilage for better visualization.
Correct Answer: B) Cricoid pressure is applied to occlude the esophagus and prevent aspiration, while BURP is applied to optimize vocal cord visualization during laryngoscopy.
As such, cricoid pressure, which is also known as the Sellick maneuver, has remained a mainstay of anesthetic practice, particularly in patients at risk for aspiration who receive rapid-sequence induction for general anesthesia.
When is the safest time to extubate a patient after surgery?
A. During deep anesthesia only
B. During deep anesthesia or when the patient awakens
C. During light anesthesia
D. Only when the patient awakens
Answer: B
Rationale: Extubation can safely occur either while the patient is deeply anesthetized (shown by the lack of reaction to pharyngeal suctioning) or awake (patient exhibits eye opening and purposeful movements). Attempts to extubate the patient during a light plane of anesthesia increases the risk for laryngospasm (Butterworth, 2022).
Which of the following statements describes the effects of unilateral recurrent laryngeal nerve (RNL) injury?
A. Airway obstruction and respiratory distress
B. Loss of sensory innervation above the vocal cords
C. Unilateral damage results in hoarseness but is unlikely to cause respiratory distress
D. Paralysis of the cricothyroid muscle
Answer: C
Rationale: The internal branch of the superior laryngeal nerve (SLN) provides sensory input above the vocal cords. The external branch of the SLN provides motor function to the cricothyroid muscle. The RNL nerve provides sensory innervation below the vocal cords and to all muscles of the larynx bedsides the cricothyroid muscle.
Cale Hager
Feb 14 9:49am
| Last edited Feb 14 9:49am
Reply from Cale Hager
A CRNA provides general anesthesia for a patient who is having surgery. Despite performing airway risk assessments, when intubation is attempted, attempts are unsuccessful. What next step should the provider take after successfully placing a laryngeal mask airway?
A. Wake the patient up
B. Intubate trachea via the supraglottic airway device (SAD)
C. Proceed without intubating the trachea (ventilate using LMA)
D. Perform a tracheostomy or cricothyroidotomy
E. All of these answers are possible correct actions
Answer: E. Each one of these actions can be the correct answer. Many SADs allow for tracheal intubations (TI) through the SAD, but if the SAD does not have this feature, the surgeon and CRNA must discuss the risks and benefits of performing the surgery with an LMA or whether invasive airway access (tracheostomy/cricothyroidotomy) is necessary. If neither provider is satisfied with these solutions and the procedure can be postponed, the CRNA should awaken and re-evaluate the procedure. These difficult airway guidelines were provided by the Difficult Airway Society (DAS) (Nagelhout et al., 2023, pp. 446-449).
A forceful, involuntary spasm of the laryngeal musculature (laryngospasm) has developed in your freshly extubated patient. What is the most likely cause of the laryngospasm, and how can it be effectively managed?
A. Laryngospasm is caused by sensory stimulation of the recurrent laryngeal nerve and can be effectively treated with deep tracheal suctioning and administration of a bronchodilator.
B. Laryngospasm is caused by sensory stimulation of the superior laryngeal nerve and requires immediate re-intubation as the primary intervention.
C. Laryngospasm is caused by sensory stimulation of the recurrent laryngeal nerve and can be effectively treated by manual massage of the trachea to relieve the spasm
D. Laryngospasm is caused by sensory stimulation of the superior laryngeal nerve and can be effectively treated with gentle positive pressure ventilation and intravenous lidocaine.
Correct Answer: D
Rationale: “Laryngospasm is caused by sensory stimulation of the superior laryngeal nerve. Triggering stimuli include pharyngeal secretions or passing an ETT through the larunx during extubation. Laryngospasm is usually prevented by extubating patients either deeply asleep or fully awake, but it can occur – albeit rarely – in an awake patient. Treatment of laryngospasm includes providing gentle positive pressure ventilation with an anesthesia bag and mask using 100% oxygen or administering intravenous lidocaine (1-1.5mg/kg). If laryngospasm persists and hypoxia develops, small doses of succinylcholine (0.25-0.5mg/kg) may be required (perhaps in combination with small doses of propofol or another anesthetic) to relax the laryngeal muscles and allow controlled
Which anatomical structure separates the upper airway from the lower airway?
A. Hyoid bone
B. Cricoid cartilage
C. Bronchioles
D. Epiglottis
Answer: B, Cricoid cartilage
Rationale: The cricoid cartilage is a ring-shaped cartilage located at the base of the larynx. It serves as a landmark to separate the upper and lower airways. The larynx extends from the epiglottis to the cricoid cartilage, and then the trachea begins.
While Mallampati classification would correlate to only being able to visualize the soft and hard palate?
A. Class I
B. Class II
C. Class III
D. Class IV
Answer: C, Class III
Rationale: Class I Mallampati correlates to a full view of the palatal arch including both pillars, uvula, soft and hard palates. Class II Mallampati correlates to the upper part of the pillars, most of the uvula, and the soft and hard palate. Class III correlates to only the soft and hard palate being visible. Lastly, Class IV correlates to only the hard palate being seen.
What is a way to prevent gastric aspiration for a patient who received rapid-sequence induction and intubation? The patient ate 4 hours ago and needs an emergent laparoscopic cholecystectomy.
A. Cricoid pressure
B. Glossopharyngeal nerve block
C. Superior laryngeal nerve block
D. Does not need to do anything because enough time has passed for food to be digested, and the patient will not vomit
Answer: A. Cricoid Pressure
Rationale: Cricoid pressure, also known as the Sellick Maneuver, is used in anesthesia for patients at risk for aspiration who receive rapid-sequence induction for general anesthesia. The application of pressure during rapid-sequence induction has decreased upper and lower esophageal sphincter tone.
What are some advantages of laryngeal mask airways (LMAs) when compared with tracheal intubation? (Pick 2)
A. Less dental trauma
B. Decreased risk of gastrointestinal aspiration
C. Does not require neck mobility
D. Decreased risk of gas leak and pollution
Answer: A and C
Rationale: Unlike endotracheal tubes, LMAs do not require the use of a rigid laryngoscope blade, which is a primary cause of dental trauma during intubation. LMAs can also be inserted with minimal head and neck movement, making them useful in cases with limited neck mobility. Tracheal intubation, on the other hand, often requires head extension and direct visualization of the vocal cords, which may not be possible in patients with limited neck mobility.
B is incorrect because a LMA does not seal off the trachea like a cuffed ETT, which means there is a increased risk of aspiration. D is incorrect because LMAs generally have an increased risk of gas leak compared to ETTs, especially at higher ventilation pressures.
Which of the following is the most reliable predictor of a difficult airway?
A. Thyromental distance less than 6 cm
B. Mallampati Class greater than II
C. History of previous difficult intubation
D. Prescence of facial hair
Which of the following is the most reliable predictor of a difficult airway?
A. Thyromental distance less than 6 cm
B. Mallampati Class greater than II
C. History of previous difficult intubation
D. Prescence of facial hair
Answer: C. History of previous difficult intubation
Rationale: A prior history of a difficult airway is one of the strongest predictors of future difficulties in airway management. While anatomical features like a short thyromental distance and high Mallampati class may indicate difficulty, history is the most reliable factor.
What is the most reliable indicator that the endotracheal tube has not inadvertently been placed in the esophagus?
A. Bilateral breath sounds
B. Persistent end-tidal carbon dioxide
C. Equal chest excursion (rise)
D. Condensation in the endotracheal tube
Answer: B
Rationale:
It is important to recognize that other traditional methods of confirming ETT placement, such as equal bilateral breath sounds, symmetric chest wall movement, epigastric auscultation, and observation of tube condensation, lack specificity and can be misleading.
Which of the following clinical signs can provide clues to the diagnosis of bronchial intubation?
A) Bilateral breath sounds, stable oxygen saturation, normal peak inspiratory pressures, and easy ventilation with a compliant breathing bag
B) Unilateral breath sounds, unexpected hypoxia, inability to palpate the ETT cuff in the sternal notch during inflation, and increased peak inspiratory pressures
C) Decreased peak inspiratory pressures, normal bag compliance, symmetrical chest expansion, and no changes in oxygen saturation
D) Easy palpation of the endotracheal tube (ETT) cuff in the sternal notch, equal air entry bilaterally, normal breathing-bag compliance, and no increase in peak inspiratory pressures
Answer: B) Unilateral breath sounds, unexpected hypoxia, inability to palpate the ETT cuff in the sternal notch during inflation, and increased peak inspiratory pressures
Rationale: Clues to the diagnosis of bronchial intubation include: unilateral breath sounds, unexpected hypoxia with pulse oximetry (unreliable with high inspired oxygen concentration), inability to palpate the ETT cuff in the sternal notch during cuff inflation, and decreased breathing-bag compliance due to increased peak inspiratory pressures (Butterworth et al., 2022, p. 337). Other options describe normal findings, which do not indicate bronchial intubation.
Which cartilages of the larynx are paired? (Pick 3)
A. Thyroid
B. Arytenoid
C. Cricoid
D. Corniculate
E. Cuneiform
F. Epiglottic
Answer: B, D, & E
Rationale: The larynx is a cartilaginous skeleton held together by ligaments and muscle. The larynx is composed of nine cartilages: thyroid, cricoid, epiglottic, and (in pairs) arytenoid, corniculate, and cuneiform.
