Airway Management in Children — MCQs
Laryngeal mask airway [LMA] is contraindicated in?
Child with aspiration risk needs emergency surgery. Best induction sequence is:
Identify the instrument shown in the image:
What is the MOST clinically significant anatomical difference between pediatric and adult airways?
A child presents with high grade fever, inspiratory stridor and develops swallowing difficulty with drooling of saliva since last 4-6 hours. Which of the following treatment is recommended apart from general airway management?
In infant (full term) diameter (mm) length (cm) of ETT used are –
All of the following statements about laryngomalacia are true, except for:
Endotracheal tube in the esophagus is best assessed by:
During rapid sequence intubation in a child after taking brief history and clinical examination next step is:
What is the primary purpose of Sellick's maneuver?
Airway Management in Children Indian Medical PG Practice Questions and MCQs
Question 1: Laryngeal mask airway [LMA] is contraindicated in?
- A. Ocular surgeries
- B. Pregnant female (Correct Answer)
- C. Difficult airways
- D. In CPR
Explanation: ***Pregnant female*** - **Pregnant patients** are at an increased risk of **gastric reflux and aspiration pneumonitis** due to decreased lower esophageal sphincter tone and increased intra-abdominal pressure. - The LMA does not provide a secure airway seal against aspiration, making it contraindicated in cases where **aspiration risk is high**, such as pregnancy or full stomach. *Difficult airways* - The LMA is often considered a **rescue device** in difficult airway algorithms when tracheal intubation fails. - It can be used as a conduit for **fiberoptic intubation** or as a temporary airway while preparing for a definitive airway. *Ocular surgeries* - LMAs are generally suitable for ocular surgeries as they provide a stable airway without the use of a mask, which can obstruct the surgical field. - They tend to cause **less coughing and straining** upon insertion and maintenance compared to endotracheal tubes, which is beneficial in preventing increases in intraocular pressure. *In CPR* - The LMA can be an effective airway device during **cardiopulmonary resuscitation (CPR)** when endotracheal intubation is not immediately feasible. - It provides a relatively quick and easy way to establish an airway, facilitate ventilation, and reduce the risk of gastric insufflation during chest compressions.
Question 2: Child with aspiration risk needs emergency surgery. Best induction sequence is:
- A. Preoxygenation-ketamine-succinylcholine
- B. Sevoflurane-propofol-succinylcholine
- C. Midazolam-propofol-rocuronium
- D. Preoxygenation-propofol-succinylcholine (Correct Answer)
Explanation: ***Preoxygenation-propofol-succinylcholine*** - This sequence describes a **rapid sequence intubation (RSI)**, which is the preferred method for patients at high risk of aspiration, including children needing emergency surgery with an unknown fasting status. - **Preoxygenation** provides an oxygen reserve during the apneic period, **propofol** offers rapid induction with good hemodynamic stability, and **succinylcholine** provides fast-onset, short-acting neuromuscular blockade, crucial for preventing aspiration. *Preoxygenation-ketamine-succinylcholine* - While preoxygenation and succinylcholine are appropriate for RSI, **ketamine** may not be the optimal choice for a child with aspiration risk due to its potential to increase secretions and maintain laryngeal reflexes, which could complicate intubation. - Ketamine can also cause **emergence delirium** in some children, making it less favorable for a smooth anesthetic course compared to propofol. *Sevoflurane-propofol-succinylcholine* - **Sevoflurane** is an inhaled anesthetic often used for mask induction in children due to its non-pungent odor and rapid onset. However, it is generally **not suitable for RSI** in patients with aspiration risk as it has a slower induction time compared to intravenous agents and can cause coughing or laryngospasm. - Using both sevoflurane and propofol for induction in an RSI scenario is redundant and prolongs the induction phase, increasing aspiration risk. *Midazolam-propofol-rocuronium* - **Midazolam** is a benzodiazepine used for anxiolysis and sedation but has a **slower onset** and longer duration of action compared to propofol for rapid induction. - **Rocuronium** is a non-depolarizing neuromuscular blocker with a slower onset of action than succinylcholine, making it less ideal for RSI where immediate paralysis for intubation is critical to prevent aspiration.
Question 3: Identify the instrument shown in the image:
- A. Nasogastric tube
- B. Uncuffed endotracheal (ET) tube (Correct Answer)
- C. Oropharyngeal tube
- D. Tracheostomy tube
Explanation: ***Uncuffed endotracheal (ET) tube*** - This image displays a transparent, flexible tube with a distinct connector at one end and no inflated cuff near the distal tip, which is characteristic of an **uncuffed endotracheal tube**. - Uncuffed ET tubes are commonly used in **pediatric patients** where a cuff could potentially damage the narrower, cone-shaped trachea. *Nasogastric tube* - A nasogastric tube typically has a much **smaller diameter** and a distinctly different tip design, often with multiple side ports for fluid aspiration or administration. - It does not feature the large, universal connector seen on endotracheal tubes. *Oropharyngeal tube* - An oropharyngeal (Guedel) airway is a **rigid, curved device** inserted into the mouth to maintain an open airway, and it looks distinctly different from the flexible tube shown. - It does not extend into the trachea like an ET tube. *Tracheostomy tube* - A tracheostomy tube is typically shorter, often with a curved neck flange for securement to the neck, and frequently made with an outer and inner cannula, which are absent in the image. - While it helps maintain an airway, its design is specific for insertion directly into a tracheostomy stoma, unlike the longer tube for oral/nasal intubation.
Question 4: What is the MOST clinically significant anatomical difference between pediatric and adult airways?
- A. Funnel-shaped vs cylindrical airway shape
- B. Proportionally larger tongue
- C. Larynx in higher position
- D. Narrowest part is cricoid cartilage (Correct Answer)
Explanation: ***Narrowest part is cricoid cartilage*** - In **pediatric airways**, the **cricoid cartilage** is the narrowest point, making it the **most critical consideration** for endotracheal tube sizing and intubation. - This contrasts with adults where the **glottic opening** (vocal cords) is typically the narrowest. - This difference is **clinically crucial** as it determines tube selection, risk of subglottic stenosis, and why uncuffed tubes were traditionally preferred in children. *Proportionally larger tongue* - Pediatric patients indeed have a **proportionally larger tongue** relative to their oral cavity, which can contribute to airway obstruction [1]. - While this is a true anatomical difference, it is **less critical** for intubation decisions than the cricoid narrowing. *Funnel-shaped vs cylindrical airway shape* - Pediatric airways are **funnel-shaped** with narrowing at the cricoid, whereas adult airways are more **cylindrical**. - This morphological difference is a **consequence** of the cricoid being the narrowest point, not a separate primary consideration. *Larynx in higher position* - The **larynx** in infants and young children is positioned more **superiorly** (C3-C4 vs C4-C6 in adults). - While this affects intubation technique and angle, it is **less directly relevant** to airway sizing than the cricoid narrowing.
Question 5: A child presents with high grade fever, inspiratory stridor and develops swallowing difficulty with drooling of saliva since last 4-6 hours. Which of the following treatment is recommended apart from general airway management?
- A. IV ceftriaxone (Correct Answer)
- B. Anti-diphtheria toxin
- C. Corticosteroids
- D. Nebulized racemic epinephrine
Explanation: ***IV ceftriaxone*** - The symptoms (high-grade fever, inspiratory stridor, swallowing difficulty with drooling, rapid onset) are highly suggestive of **acute epiglottitis**, a life-threatening emergency. - **Empiric intravenous antibiotics** like ceftriaxone are crucial for treating the bacterial infection (commonly *Haemophilus influenzae* type b or *Streptococcus pneumoniae*) causing epiglottitis. *Anti-diphtheria toxin* - This treatment is specific for **diphtheria**, which causes a pseudomembrane and can lead to airway obstruction, but the clinical picture here is more consistent with epiglottitis due to its rapid and severe presentation without mention of a pseudomembrane. - Diphtheria typically has a more gradual onset and is characterized by a **grayish pseudomembrane** in the throat, unmentioned in this case. *Corticosteroids* - While corticosteroids are used in other forms of upper airway obstruction (like **croup**), their role in acute epiglottitis is controversial and not a primary life-saving measure; antibiotics and airway management are paramount. - Their primary benefit lies in reducing inflammation, but they do not address the acute bacterial cause of epiglottitis directly and are secondary to antibiotics. *Nebulized racemic epinephrine* - This treatment is primarily used for **laryngotracheobronchitis (croup)**, which presents with a barking cough and stridor, but typically lacks the high fever and severe drooling seen in epiglottitis. - Nebulized racemic epinephrine helps to reduce subglottic edema in croup but would not be effective against the severe supraglottic swelling of epiglottitis, nor would it treat the underlying bacterial infection.
Question 6: In infant (full term) diameter (mm) length (cm) of ETT used are –
- A. 3.5,12 (Correct Answer)
- B. 7,12
- C. 3.5,16
- D. 7, 10
Explanation: ***3.5, 12*** - For a full-term infant requiring endotracheal intubation, the recommended internal diameter (ID) of the endotracheal tube (ETT) is typically **3.5 mm**. - The appropriate insertion length of the ETT at the lip for a full-term infant is approximately **12 cm**. *7, 12* - An ETT with an internal diameter of **7 mm** is generally used for older children or adults, not for full-term infants. - While **12 cm** might be the correct insertion length, the ETT diameter is incorrect for an infant. *3.5, 16* - While **3.5 mm** is the appropriate ETT internal diameter for a full-term infant, an insertion length of **16 cm** is too long and would likely lead to right mainstem bronchus intubation. - This length is typically seen in older children or adults. *7, 10* - Both the internal diameter of **7 mm** and the insertion length of **10 cm** are incorrect for a full-term infant. - An ETT of 7 mm is too large, and an insertion length of 10 cm is generally too short, risking accidental extubation.
Question 7: All of the following statements about laryngomalacia are true, except for:
- A. It is associated with an omega shaped epiglottis
- B. Surgical Tracheostomy is the treatment of choice (Correct Answer)
- C. It is the most common congenital anomaly of the larynx
- D. Stridor is increased on crying and relieved on lying prone
Explanation: ***Surgical Tracheostomy is the treatment of choice*** - While laryngomalacia is the most common cause of **stridor** in infants, most cases are **mild and self-limiting**, resolving spontaneously by **12 to 18 months of age**. - **Surgical tracheostomy** is reserved for severe cases with significant **airway obstruction**, **failure to thrive**, or **life-threatening apneic spells** after failed conservative management and supraglottoplasty. *It is the most common congenital anomaly of the larynx* - This statement is **true**; laryngomalacia is indeed the most frequent congenital anomaly of the larynx, affecting approximately **60% of all congenital laryngeal anomalies**. - It is the most common cause of **inspiratory stridor** in infants. *It is associated with an omega shaped epiglottis* - This statement is **true**; the characteristic finding in laryngomalacia is the collapse of the **supraglottic structures** during inspiration. - This often includes a **long, curled, 'omega-shaped' epiglottis**, which contributes to the airway obstruction. *Stridor is increased on crying and relieved on lying prone* - This statement is **true**; the inspiratory stridor in laryngomalacia is typically **worsened by agitation, crying, feeding, or supine positioning**. - Lying **prone** or **side-lying** positions can help relieve the stridor by allowing the supraglottic tissues to fall forward and open the airway.
Question 8: Endotracheal tube in the esophagus is best assessed by:
- A. Direct laryngoscopy
- B. Auscultation
- C. CO2 Exhalation (Correct Answer)
- D. Chest wall movement
Explanation: ***CO2 Exhalation*** - Measuring **CO2 exhalation** (capnography) is the most reliable method to confirm endotracheal tube placement, as CO2 is present in the trachea but not in the esophagus. - A persistent **waveform on the capnograph** indicates proper tracheal intubation. *Direct laryngoscopy* - While helpful for initial visualization during intubation, **direct laryngoscopy** cannot confirm continuous tracheal placement after the tube is advanced. - It only confirms the tube passing through the vocal cords, not its final position in the trachea versus esophagus. *Auscultation* - **Auscultation** can be misleading because stomach sounds can be transmitted to the chest, and breath sounds can be heard in the epigastrium even with esophageal intubation. - It relies on subjective interpretation and is less definitive than capnography. *Chest wall movement* - Observing **chest wall movement** is not a definitive sign, as the chest can still rise with esophageal intubation due to air entering the stomach. - This method is unreliable and can be mistaken for proper ventilation, leading to dangerous delays in correcting tube misplacement.
Question 9: During rapid sequence intubation in a child after taking brief history and clinical examination next step is:
- A. Administer oxygen (Correct Answer)
- B. Analgesic injection with Fentanyl
- C. Preanaesthetic medication with atropine and lignocaine
- D. IV anesthetic Diazepam/Ketamine
Explanation: ***Administer oxygen*** - Pre-oxygenation with 100% oxygen is critical before **rapid sequence intubation (RSI)** to maximize **oxygen reserves** and extend the safe apnea time. - This step helps prevent **hypoxemia** during the intubation procedure, especially in children who have lower functional residual capacity. *Analgesic injection with Fentanyl* - While fentanyl is often used in RSI for its **analgesic** and **sedative properties**, it typically follows pre-oxygenation and is administered as part of the **induction phase**, often concurrently with a paralytic. - Administering fentanyl alone without prior oxygenation or other induction agents would not be the immediate next step in a structured RSI protocol. *Preanaesthetic medication with atropine and lignocaine* - **Atropine** may be used in children to prevent **bradycardia** during intubation, particularly in infants, but it's not the immediate next step after initial assessment; pre-oxygenation is more critical. - **Lidocaine** can be used to blunt the sympathetic response to intubation or to suppress cough, but it's not universally required and comes after pre-oxygenation and other induction medications. *IV anesthetic Diazepam/Ketamine* - **Diazepam** and **ketamine** are **induction agents** that cause sedation and loss of consciousness, but they are administered after pre-oxygenation and often just before the paralytic agent. - Administering an induction agent without adequate pre-oxygenation would increase the risk of **hypoxemia** during the subsequent apnea.
Question 10: What is the primary purpose of Sellick's maneuver?
- A. Prevention of hypertension
- B. Prevention of alveolar collapse
- C. Prevention of aspiration of gastric contents (Correct Answer)
- D. Prevention of bradycardia
Explanation: ***Prevention of aspiration of gastric contents*** - **Sellick's maneuver**, also known as **cricoid pressure**, involves applying pressure to the cricoid cartilage. - This pressure occludes the **esophagus**, thereby preventing the regurgitation and aspiration of gastric contents into the airway, especially during rapid sequence intubation. *Prevention of alveolar collapse* - **Alveolar collapse** (atelectasis) is typically prevented by maintaining positive end-expiratory pressure (PEEP) or using lung recruitment maneuvers during mechanical ventilation. - Sellick's maneuver has no direct role in maintaining **alveolar patency**. *Prevention of hypertension* - **Hypertension** during intubation can be managed with specific medications like opioids or beta-blockers, or by optimizing anesthetic depth. - Sellick's maneuver does not influence **blood pressure regulation**. *Prevention of bradycardia* - **Bradycardia** can occur during intubation due to vagal stimulation and is often managed with anticholinergic drugs like atropine. - Sellick's maneuver does not affect **heart rate** directly.
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