02-Airway Management

1. A major difference between the adult and neonatal airway is that the
  * A. Neonate’s larynx is located more superiorly in the neck
  * B. Neonate’s epiglottis is angled more superiorly
  * C. Narrowest segment of a neonate’s upper airway occurs at the level of the vocal cords
  * D. Neonate is at lower risk of postextubation stridor compared to the adult

2. The narrowest segment of a 14-day-old child’s upper airway is located at the
  * A. Hyoid bone
  * B. Thyroid cartilage
  * C. Vocal cords
  * D. Subglottic region

3. Airway obstruction in Pierre Robin syndrome most likely occurs
  * A. Between the tongue and pharyngeal wall
  * B. At the level of the glottis
  * C. In the subglottic trachea
  * D. At the bronchial level

4. Airway management in Klippel–Feil syndrome is most likely to be challenging because of
  * A. Micrognathia
  * B. Macroglossia
  * C. Subglottic stenosis
  * D. Cervical spine fusion

5. One of the following statements regarding airway management in patients with congenital syndromes is most accurate:
  * A. Laryngoscopy is often challenging in Turner syndrome because of a high frequency of laryngeal distortion
  * B. Airway management in Treacher Collins syndrome is complicated by a high incidence of cervical spine instability
  * C. Intubation in patients with Goldenhar syndrome is often challenging due to a high rate of subglottic stenosis
  * D. Airway management of patients with trisomy 21 is complicated by a high incidence of cervical spine instability

6. A healthy 2-year-old male is scheduled to undergo a laparoscopic inguinal hernia repair. His airway was managed uneventfully with mask ventilation
followed by direct laryngoscopy and intubation with a 4.5-mm uncuffed endotracheal tube (ETT). Manual ventilation produces an air leak in the oropharynx
beginning at a peak pressure of 20 cm H2O. The best next step in the anesthetic management is to
  * A. Continue current management
  * B. Replace the ETT with a smaller-sized uncuffed tube
  * C. Replace the ETT with a larger-sized uncuffed tube
  * D. Replace the ETT with a 4.0-mm cuffed ETT

7. A 4-year-old patient scheduled for laparoscopic gastrostomy tube placement undergoes induction of general anesthesia and endotracheal intubation
with a 4.5-mm cuffed endotracheal tube. The tube is taped 14 cm at the gumline, and the patient is placed on volume-control ventilation. The most likely
first sign of a right main stem intubation is
A. Arterial desaturation
B. Hypercapnia
C. Increased peak inspiratory pressures
D. Hypotension

8. A 6-year-old patient scheduled for laparoscopic bilateral inguinal hernia repair undergoes inhalational induction and intubation with a 5.0-mm cuffed
endotracheal tube. The tube is secured with the 15-cm mark at the patient’s gumline. Auscultation reveals equal breath sounds bilaterally. Inflation of the
pilot balloon results in palpation of the inflated tube cuff just above the cricoid cartilage. A leak test reveals leak of air into the oropharynx at a positive
pressure of 20 cm H2O. The next best step in management is
A. No change in anesthetic care is indicated
B. The tube cuff should be deflated until a leak is present starting at 15 cm H2O of positive pressure
C. The tube cuff should be deflated and the tube advanced until the cuff, when inflated, is palpable below the cricoid cartilage
D. The tube cuff should be deflated and the tube withdrawn until ventilator peak pressures decrease

9. A 4-year-old boy with autism and failure-to-thrive undergoes a gastrostomy tube placement. At the completion of the operation, the patient remains
unresponsive but is breathing spontaneously and has a mild gag response to oral suctioning. The anesthesiologist extubates the patient and immediately
shuts off the volatile agent. The anesthesiologist then inserts an appropriately sized oropharyngeal airway and places a face mask connected to the
ventilator circuit over the patient’s face, allowing the patient to breathe 100% oxygen. Despite providing a chin lift, jaw thrust, and positive-pressure
breaths, the anesthesiologist notes that the ventilator shows no end-tidal carbon dioxide. Auscultation over the sternal notch reveals no air movement.
The pulse oximeter reading then rapidly drops to 70% from 100%. The next best step in management is
A. Administration of albuterol
B. Insertion of a nasal trumpet
C. Endotracheal reintubation
D. Administration of succinylcholine

10. In the scenario above, if the patient’s postextubation condition is left untreated, the patient will most likely experience
A. Aspiration
B. Bronchospasm
C. Pulmonary edema
D. Croup

11. A 2-year-old child weighing 13 kg is scheduled for inguinal hernia repair. She is at the 55th percentile for height for her age. An appropriately-sized
cuffed endotracheal tube for this patient will have an internal diameter of
A. 3.0 mm
B. 4.0 mm
C. 5.0 mm
D. 6.0 mm

12. The superior surface of the epiglottis is innervated by the
A. Hypoglossal nerve
B. Recurrent laryngeal nerve
C. Internal branch of the superior laryngeal nerve
D. External branch of the superior laryngeal nerve

13. Tactile sensation from the anterior third of the tongue is carried by fibers of the
A. Trigeminal nerve
B. Facial nerve
C. Glossopharyngeal nerve
D. Hypoglossal nerve

14. A 48-year-old female patient with temporomandibular joint dysfunction and associated limited mouth opening is scheduled for a thyroidectomy for goiter.
Due to concern for challenging laryngoscopy, the anesthesiologist elects to perform an awake fiberoptic intubation. In order to anesthetize the posterior
third of the tongue, the anesthesiologist should perform a nerve block of the
A. Cranial nerve V
B. Cranial nerve VII
C. Cranial nerve IX
D. Cranial nerve XII

15. A patient who suffers acute, bilateral denervation of the external branch of the superior laryngeal nerve will most likely present with
A. No symptoms
B. Hoarseness
C. Stridor
D. Aspiration

16. To anesthetize the supraglottic laryngeal mucosa, the local anesthetic should be injected into one of the following areas:
A. The base of the anterior tonsillar pillar
B. Medial to the lesser cornu of the hyoid bone
C. Superior to the superior cornu of the thyroid cartilage
D. Through the cricothyroid membrane

17. The efferent limb of the glottic closure reflex, which is involved in laryngospasm, primarily involves the
A. Internal branch of the superior laryngeal nerve
B. Hypoglossal nerve
C. Recurrent laryngeal nerve
D. Glossopharyngeal nerve

18. A 65-year-old woman undergoes a thyroidectomy for papillary thyroid cancer. Immediately after emergence and extubation, she is aphonic and has
minimal chest movement, despite spontaneously moving her limbs and head. Auscultation reveals lack of breath sounds over the chest. There is no
evidence of a surgical site hematoma. The anesthesiologist provides a jaw thrust and positive-pressure breaths, which slightly improve the patient’s
oxygenation and ventilation. The surgeon suggests a bilateral block of both the internal and external branches of the patient’s superior laryngeal nerve. If
performed this block would likely result in
A. Worsening of the patient’s respiratory distress and no change in her aphonia
B. Improvement of the patient’s respiratory distress and no change in her aphonia
C. No change in the patient’s respiratory distress and improvement of her aphonia
D. No change in the patient’s respiratory distress and no change in her aphonia

19. A 48-year-old woman with temporomandibular joint dysfunction and limited mouth opening is scheduled for thyroidectomy for goiter. Due to concern for a
difficult laryngoscopy, the anesthesiologist elects to perform an awake oral fiberoptic intubation. To reliably blunt the afferent limb of the cough reflex, the
anesthesiologist should perform a bilateral block of the
A. Superior laryngeal nerve and the recurrent laryngeal nerve
B. Glossopharyngeal nerve and internal branch of the superior laryngeal nerve
C. Glossopharyngeal nerve and external branch of the superior laryngeal nerve
D. Internal and external branches of the superior laryngeal nerve

20. If an adult patient were to suffer an acute, bilateral transection of cranial nerve X, awake laryngoscopy would most likely reveal
A. Fully adducted vocal cords
B. Fully abducted vocal cords
C. Vocal cords in a partially adducted position with 2 to 3 mm of space between them
D. Vocal cords oscillating between adducted and abducted position

21. Several hours after undergoing repair of an ascending aortic dissection, a 65-year-old male patient is extubated in the intensive care unit. All of the arch
vessels were preserved during the operation. After extubation, the patient’s voice is noted to be hoarse. Awake fiberoptic laryngoscopy would most likely
show the following during inspiration:
A. Vocal cords in a fully abducted position
B. Vocal cords in a fully adducted position
C. Left vocal cord in an adducted position and right vocal cord fully abducted
D. Left vocal cord in an abducted position and right vocal cord fully adducted

22. An awake tracheostomy would be facilitated by a regional block of the
A. Trigeminal nerve
B. Glossopharyngeal nerve
C. Superior laryngeal nerve
D. Recurrent laryngeal nerve

23. One of the following statements regarding the innervation of airway structures is most correct:
A. The afferent limb of the gag reflex is primarily carried by fibers of the recurrent laryngeal nerve
B. Trigeminal nerve block would facilitate awake nasotracheal intubation
C. The superior surface of the epiglottis is primarily innervated by the glossopharyngeal nerve
D. Tactile sensation from the posterior one-third of the tongue is carried by the hypoglossal nerve

24. A nasal trumpet would be most appropriate for management of anesthetic-induced upper airway obstruction in one of the following patients:
A. A 25-year-old passenger ejected out of a motorcycle now with Glasgow Coma Scale of 13 and some periorbital bruising
B. A 32-year-old term parturient, otherwise healthy except for gestational thrombocytopenia, who requires emergent cesarean section under general
anesthesia
C. A 45-year-old female with temporomandibular joint syndrome and breast cancer scheduled for bilateral mastectomy
D. A 65-year-old male with a mechanical mitral valve on therapeutic anticoagulation undergoing emergent coronary catheterization for unstable angina

25. A 55-year-old woman with severe anxiety and rheumatoid arthritis is scheduled for thyroidectomy for medullary thyroid cancer. Her airway exam in the
upright position is notable for a nonvisible uvula with the tongue protruded, a 2 fingerbreadth mouth opening, a thyromental distance of 2.5 fingerbreadths,
and neck range-of-motion at the atlanto-occipital joint of about 70 degrees. Examination of her neck reveals an enlarged, fixed, and nonmobile mass that
appears to be contiguous with the thyroid gland when the patient swallows. The trachea cannot be palpated. The patient is highly anxious and tells you
that under no circumstance will she let you insert a “breathing tube inside my airway while I’m awake.” The next best step in anesthetic management is
A. Induction of general anesthesia followed by fiberoptic bronchoscopy
B. Induction of general anesthesia followed by rigid bronchoscopy
C. Induction of general anesthesia followed by laryngeal mask airway placement
D. Cancel the case

26. After rapid sequence induction of general anesthesia, a patient is unable to be intubated. Subsequent attempts at ventilation by face mask and a
supraglottic airway device are also unsuccessful. One of the following statements regarding transtracheal jet ventilation and surgical cricothyrotomy in this
situation is most correct:
A. Transtracheal jet ventilation does not require a patent natural airway
B. Ventilation through a surgical cricothyrotomy allows both inhalation and exhalation to occur
C. The development of laryngospasm during ventilation through a cricothyrotomy would rapidly cause pulmonary overinflation and barotrauma
D. Transtracheal jet ventilation can be continued for a longer period of time than can ventilation via a cricothyrotomy

27. Use of a laryngeal mask airway would be most appropriate for airway management in the following patient:
A. An obese patient with acute appendicitis who, after rapid sequence induction, cannot be intubated
B. An elderly patient with restrictive lung disease scheduled for inguinal hernia repair
C. An obese male patient with a hiatal hernia and GERD scheduled for umbilical hernia repair
D. A full-term parturient brought to the OR for emergent cesarean section because of fetal bradycardia

28. After undergoing an uneventful operation, one of the following patients would be the best candidate for “deep extubation”:
A. A 23-year-old woman with asthma who has just undergone an exploratory laparotomy for small bowel obstruction
B. A 65-year-old man with gastroesophageal reflux who has just undergone an inguinal hernia repair
C. An 18-year-old patient with scoliosis who has just undergone a 6-hour posterior thoracolumbar spinal instrumentation and fusion
D. A 64-year-old female with coronary artery disease who has just undergone a total hip arthroplasty under general anesthesia

29. One of the following is a primary risk factor for difficult mask ventilation:
A. Limited mouth opening
B. Thyromental distance less than 3 fingerbreadths
C. High arched palate
D. Inability to bring mandibular incisors anterior to the maxillary incisors

30. An otherwise healthy patient with a history of daytime sleepiness and snoring from laryngeal papillomatosis undergoes polysomnography and
spirometry, which shows dynamic inspiratory obstruction. The flow–volume loop that would be most consistent with this patient’s condition is
Figure 2-1
A. Figure 2-1A
B. Figure 2-1B
C. Figure 2-1C
D. Figure 2-1D