CEP Advanced Airway Management & Ventilation 4 — Questions and Answers
Question 1: A patient is intubated with an 8.0 mm ETT. The cuff pressure is measured at 35 cmH2O. What is the clinical concern?
- The cuff is underinflated and risks aspiration
- Excessive cuff pressure may cause tracheal ischemia and necrosis (Correct answer)
- The pressure is within normal limits
- The tube is too large for the airway
Correct answer: Excessive cuff pressure may cause tracheal ischemia and necrosis
Cuff pressures above 30 cmH2O can compromise tracheal mucosal perfusion, leading to ischemia, ulceration, and tracheal stenosis with prolonged inflation.
Question 2: During RSI, you administer succinylcholine. After 60 seconds, you attempt laryngoscopy and find the jaw is rigid and the mouth cannot be opened. What is the MOST likely cause?
- Laryngospasm
- Masseter muscle rigidity suggesting malignant hyperthermia (Correct answer)
- Succinylcholine apnea
- Insufficient dose of succinylcholine
Correct answer: Masseter muscle rigidity suggesting malignant hyperthermia
Masseter muscle rigidity after succinylcholine administration is an early warning sign of malignant hyperthermia, a rare but life-threatening pharmacogenetic reaction.
Question 3: A CPAP mask is being applied to a patient with acute pulmonary edema. The patient reports claustrophobia and begins to remove the mask. What is the BEST initial response?
- Sedate the patient immediately for RSI
- Start at lower CPAP pressure (5 cmH2O) and coach the patient through it (Correct answer)
- Switch to nasal cannula at 15 LPM
- Apply the mask firmly and restrain the patient's hands
Correct answer: Start at lower CPAP pressure (5 cmH2O) and coach the patient through it
Starting at lower CPAP pressure and providing coaching and reassurance increases patient tolerance and compliance, which is essential for CPAP to be effective.
Question 4: Which of the following best describes the mechanism of action of high-flow nasal cannula (HFNC) in improving oxygenation?
- It delivers 100% FiO2 by eliminating room air entrainment
- It washes out nasopharyngeal dead space and provides modest CPAP effect (Correct answer)
- It provides full positive pressure ventilation
- It stimulates hypoxic ventilatory drive
Correct answer: It washes out nasopharyngeal dead space and provides modest CPAP effect
HFNC improves oxygenation by flushing CO2 from nasopharyngeal dead space, providing a consistent FiO2, and generating a small amount of positive airway pressure (1-3 cmH2O).
Question 5: An intubated patient's ETCO2 suddenly drops from 40 mmHg to 5 mmHg with no change in ventilator settings. What is the MOST critical diagnosis to rule out first?
- Tube displacement or esophageal intubation (Correct answer)
- Metabolic acidosis
- Hyperventilation
- Bronchospasm
Correct answer: Tube displacement or esophageal intubation
A sudden drop in ETCO2 to near-zero levels in an intubated patient must immediately prompt assessment for tube dislodgement or esophageal intubation before any other cause.
Question 6: A 6-year-old requires emergent intubation. Using the length-based resuscitation tape (Broselow), the appropriate uncuffed ETT size is 5.0 mm. Which formula confirms this sizing?
- Age/4 + 3
- (Age/4) + 4 (Correct answer)
- Age/3 + 3.5
- Weight (kg)/10 + 3
Correct answer: (Age/4) + 4
The standard formula for uncuffed ETT size in pediatric patients is (age in years / 4) + 4, which for a 6-year-old gives (6/4) + 4 = 5.5, confirming approximate Broselow sizing.
Question 7: During a difficult airway situation, you attempt to use a bougie (endotracheal tube introducer). Which tactile sensation confirms correct tracheal placement of the bougie?
- Smooth passage without resistance
- A clicking or 'tracheal rings' sensation as it advances (Correct answer)
- Resistance at approximately 30 cm at the teeth
- The bougie passes freely to 45 cm depth
Correct answer: A clicking or 'tracheal rings' sensation as it advances
Correct tracheal placement of the bougie is confirmed by the tracheal clicks felt as the tip contacts the tracheal rings (hold-up at ~26-30 cm in adults also confirms bronchus entry).
CEP Advanced Airway Management & Ventilation 4
A patient is intubated with an 8.0 mm ETT.
The cuff pressure is measured at 35 cmH2O.
What is the clinical concern?