INI-CET 2015 — Anesthesiology

Q: What is the next best step in patient with the following capnography tracing?

Check for position of endotracheal tube. ***Check for position of endotracheal tube*** - The "curare cleft" or re-curarization pattern on the capnography indicates that the patient is spontaneously breathing against the ventilator, suggesting the effects of **muscle relaxants are wearing off**. - This pattern can also indicate a partially obstructed or dislodged endotracheal tube, where the patient's spontaneous breaths against the obstruction cause a dip in the expiratory plateau. Therefore, checking the **endotracheal tube position** is a critical immediate step. *Check for connections of anesthesia machine* - While machine connections are important for proper ventilation, this specific **"curare cleft" pattern** is more indicative of patient respiratory effort or tube issues rather than a primary machine connection problem. - A machine connection issue would typically manifest as a **loss of waveform** or an abnormal overall shape, not specifically a dip in the expiratory plateau. *Change the soda lime canister* - A depleted soda lime canister causes an **elevation of the baseline** (inspire CO2 not zero) and a rise in end-tidal CO2, as CO2 is not effectively reabsorbed. - This capnography tracing does not show an elevated baseline, making a depleted soda lime canister an **unlikely cause** of the observed "curare cleft." *Give skeletal muscle relaxant* - While the "curare cleft" can indicate that the effects of muscle relaxants are waning and the patient is beginning to spontaneously breathe, the **immediate next step** is to ensure airway patency and security. - Administering a muscle relaxant without first checking the **airway and tube position** could mask a serious issue. Re-dosing relaxants might be considered after ensuring the airway is secure and the tube is correctly positioned if the patient's spontaneous breathing is detrimental. [Practice more Anesthesiology PYQs on OnCourse]

Q: The diagram of a correctly positioned proseal-type Laryngeal Mask Airway is provided below. Above what site is the arrow marked area of the airway positioned?

Vocal cords. ***Vocal cords*** - A correctly positioned laryngeal mask airway (LMA) forms a seal around the **laryngeal inlet**, with its tip resting in the **hypopharynx** superior to the esophagus. - The LMA cuff is designed to sit in the **piriform fossae**, sealing the entry to the esophagus, while the opening of the LMA tube is positioned over the **glottic opening**, which lies between the vocal cords. *Carina* - The **carina** is the bifurcation of the trachea into the main bronchi, which is much lower in the airway than where an LMA is designed to be positioned. - Positioning an LMA near the carina would mean it is deeply intubated into the trachea, which is not its intended use or design. *Upper end of trachea* - While the LMA provides an airway to the trachea, its cuff typically seals the laryngeal structures **above the trachea**, not within it. - The purpose of an LMA is to provide a supraglottic seal, meaning it sits above the true vocal cords and the tracheal opening. *Above esophagus* - Although the LMA's tip rests in the hypopharynx, providing a seal that prevents air from entering the esophagus, the primary target for airflow from the LMA is the **glottic opening (vocal cords)**, not simply "above the esophagus." - The device functions by sitting snugly over the laryngeal inlet, ensuring that ventilation is directed toward the trachea. [Practice more Anesthesiology PYQs on OnCourse]

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What is the next best step in patient with the following capnography tracing?

The diagram of a correctly positioned proseal-type Laryngeal Mask Airway is provided below. Above what site is the arrow marked area of the airway positioned?

INI-CET 2015 - Anesthesiology INI-CET Practice Questions and MCQs

Question 1: What is the next best step in patient with the following capnography tracing?

A. Check for position of endotracheal tube (Correct Answer)
B. Check for connections of anesthesia machine
C. Change the soda lime canister
D. Give skeletal muscle relaxant

Explanation: ***Check for position of endotracheal tube*** - The "curare cleft" or re-curarization pattern on the capnography indicates that the patient is spontaneously breathing against the ventilator, suggesting the effects of **muscle relaxants are wearing off**. - This pattern can also indicate a partially obstructed or dislodged endotracheal tube, where the patient's spontaneous breaths against the obstruction cause a dip in the expiratory plateau. Therefore, checking the **endotracheal tube position** is a critical immediate step. *Check for connections of anesthesia machine* - While machine connections are important for proper ventilation, this specific **"curare cleft" pattern** is more indicative of patient respiratory effort or tube issues rather than a primary machine connection problem. - A machine connection issue would typically manifest as a **loss of waveform** or an abnormal overall shape, not specifically a dip in the expiratory plateau. *Change the soda lime canister* - A depleted soda lime canister causes an **elevation of the baseline** (inspire CO2 not zero) and a rise in end-tidal CO2, as CO2 is not effectively reabsorbed. - This capnography tracing does not show an elevated baseline, making a depleted soda lime canister an **unlikely cause** of the observed "curare cleft." *Give skeletal muscle relaxant* - While the "curare cleft" can indicate that the effects of muscle relaxants are waning and the patient is beginning to spontaneously breathe, the **immediate next step** is to ensure airway patency and security. - Administering a muscle relaxant without first checking the **airway and tube position** could mask a serious issue. Re-dosing relaxants might be considered after ensuring the airway is secure and the tube is correctly positioned if the patient's spontaneous breathing is detrimental.

Question 2: The diagram of a correctly positioned proseal-type Laryngeal Mask Airway is provided below. Above what site is the arrow marked area of the airway positioned?

A. Carina
B. Upper end of trachea
C. Vocal cords (Correct Answer)
D. Above esophagus

Explanation: ***Vocal cords*** - A correctly positioned laryngeal mask airway (LMA) forms a seal around the **laryngeal inlet**, with its tip resting in the **hypopharynx** superior to the esophagus. - The LMA cuff is designed to sit in the **piriform fossae**, sealing the entry to the esophagus, while the opening of the LMA tube is positioned over the **glottic opening**, which lies between the vocal cords. *Carina* - The **carina** is the bifurcation of the trachea into the main bronchi, which is much lower in the airway than where an LMA is designed to be positioned. - Positioning an LMA near the carina would mean it is deeply intubated into the trachea, which is not its intended use or design. *Upper end of trachea* - While the LMA provides an airway to the trachea, its cuff typically seals the laryngeal structures **above the trachea**, not within it. - The purpose of an LMA is to provide a supraglottic seal, meaning it sits above the true vocal cords and the tracheal opening. *Above esophagus* - Although the LMA's tip rests in the hypopharynx, providing a seal that prevents air from entering the esophagus, the primary target for airflow from the LMA is the **glottic opening (vocal cords)**, not simply "above the esophagus." - The device functions by sitting snugly over the laryngeal inlet, ensuring that ventilation is directed toward the trachea.