Surgical Airway Management — MCQs
All are early complications of tracheostomy except:
Road traffic accident (RTA) with multiple fractures - initial treatment would be:
What is the most common complication occurring in tracheostomy in children? (March 2004)
Best management for an inhaled foreign body in an infant is?
What is the correct sequence of management in a patient who presents to the casualty with an RTA? 1. Cervical spine stabilization 2. Intubation 3. IV cannulation 4. CECT
Early complications of Tracheostomy are all EXCEPT
High tracheostomy is done in which one of the following conditions?
A 5-year old boy while having dinner suddenly becomes aphonic and is brought to the casualty with the complaint of respiratory distress. Immediate management should be:
What is the most reliable indicator to prevent esophageal intubation?
Identify the maneuver being performed.
Surgical Airway Management Indian Medical PG Practice Questions and MCQs
Question 1: All are early complications of tracheostomy except:
- A. Hemorrhage
- B. Pneumothorax
- C. Injury to esophagus
- D. Tracheal stenosis (Correct Answer)
Explanation: ***Tracheal stenosis*** - **Tracheal stenosis** is typically considered a **late complication** of tracheostomy, developing weeks to months after the procedure due to scar tissue formation. - It arises from chronic irritation or pressure from the tracheostomy tube, leading to narrowing of the trachea. *Hemorrhage* - **Hemorrhage** can occur intraoperatively or in the immediate postoperative period due to injury to blood vessels. - It is considered an **early complication** of tracheostomy. *Pneumothorax* - **Pneumothorax** can be an early technical complication resulting from accidental pleural injury during the tracheostomy procedure. - This typically manifests shortly after the surgery. *Injury to esophagus* - **Esophageal injury** is a rare but serious **early complication** that can occur during tracheostomy, often due to misplacement of surgical instruments. - It can lead to tracheoesophageal fistula formation if not promptly identified and managed.
Question 2: Road traffic accident (RTA) with multiple fractures - initial treatment would be:
- A. Management of shock
- B. Splinting of limbs
- C. Airway management (Correct Answer)
- D. Cervical spine protection
Explanation: ***Airway management*** - In trauma, **establishing and maintaining a patent airway** is the absolute priority, as compromised breathing can lead to rapid deterioration and death. - The **ABCs (Airway, Breathing, Circulation)** of trauma care dictate that airway intervention precedes other life-saving measures. *Management of shock* - While crucial, **managing shock (C)** follows **airway (A)** and **breathing (B)** in the primary survey of trauma care. - Addressing profound shock without a patent airway can be ineffective and leads to irreversible damage. *Splinting of limbs* - **Splinting fractures** is important for pain control, preventing further injury, and minimizing blood loss in open fractures, but it is not an immediate life-saving intervention. - This falls under the **secondary survey** or definitive management, after life-threatening issues have been addressed. *Cervical spine protection* - **Cervical spine protection** is essential in trauma to prevent further neurological injury and is performed simultaneously with airway management (often with in-line stabilization). - However, a patent airway is the **most immediate life-sustaining intervention** if the airway is compromised.
Question 3: What is the most common complication occurring in tracheostomy in children? (March 2004)
- A. Infection (Correct Answer)
- B. Difficult decannulation
- C. Difficult weaning
- D. Stenosis
Explanation: ***Infection*** - **Infection** is among the most frequent complications in pediatric tracheostomy, occurring in the immediate postoperative period and throughout the tracheostomy course. - Can manifest as **stoma infections** (cellulitis, wound breakdown), **tracheitis**, **pneumonia**, or **mediastinitis**. - The constant presence of an open wound, bypassed upper airway defenses, and need for frequent suctioning create ongoing infection risk. - **Clinical significance**: While some studies cite difficult decannulation as more common, infection remains the most clinically significant early complication requiring active management. *Difficult decannulation* - A very common complication in pediatric tracheostomy, with some studies suggesting it may be the **most frequent** long-term issue. - Children's airways are more prone to **granulation tissue formation**, **suprastomal collapse**, and **tracheomalacia**. - Occurs in **prolonged tracheostomy** cases, often requiring multiple attempts or surgical intervention. - Frequency varies by underlying indication and duration of cannulation. *Difficult weaning* - Refers to challenges in **ventilator weaning** rather than a direct tracheostomy complication. - More related to the **underlying respiratory or neurological condition** necessitating tracheostomy. - A management challenge rather than a procedural complication. *Stenosis* - **Tracheal or subglottic stenosis** is a serious **late complication** occurring in 10-15% of pediatric cases. - Results from **chronic irritation**, **granulation tissue**, cartilage injury, or improper tube size. - While severe when it occurs, its overall incidence is **lower than infection or decannulation issues**.
Question 4: Best management for an inhaled foreign body in an infant is?
- A. IPPV
- B. Tracheostomy
- C. Corticosteroids
- D. Bronchoscopy (Correct Answer)
Explanation: ***Bronchoscopy*** - **Bronchoscopy** is the definitive and most effective procedure for both diagnosing and removing an inhaled foreign body in an infant. - It allows direct visualization of the airways and the precise retrieval of the foreign object, preventing complications like **atelectasis** or **pneumonia**. *Tracheostomy* - **Tracheostomy** is an emergency procedure to create a surgical airway, usually reserved for severe upper airway obstruction that cannot be managed by less invasive means. - It is not the primary line of treatment for removing an inhaled foreign body, which is typically found further down in the **bronchial tree**. *Corticosteroids* - **Corticosteroids** are used to reduce inflammation and edema in the airways, but they do not remove the foreign body itself. - While they might be used as an adjunct in managing airway inflammation after removal, they are not the definitive treatment for the foreign body. *IPPV* - **Intermittent Positive Pressure Ventilation (IPPV)** is a method of respiratory support used for patients with respiratory failure. - It does not address the physical obstruction caused by an inhaled foreign body and may even push the object further into the airway or cause **pneumothorax**.
Question 5: What is the correct sequence of management in a patient who presents to the casualty with an RTA? 1. Cervical spine stabilization 2. Intubation 3. IV cannulation 4. CECT
- A. 2,1,4,3
- B. 1,3,2,4
- C. 2,1,3,4
- D. 1,2,3,4 (Correct Answer)
Explanation: ***1,2,3,4*** - This sequence follows the **ATLS (Advanced Trauma Life Support)** protocol, prioritizing immediate life threats in order. - **Cervical spine stabilization** is the **first action upon patient contact** to prevent secondary neurological injury in any trauma patient. - **Airway management (intubation)** is then performed **with maintained in-line c-spine stabilization** - these occur nearly simultaneously but c-spine protection is instituted first. - **IV cannulation (circulation)** follows to establish vascular access for resuscitation and medications. - **CECT (imaging)** is performed last, once the patient is stabilized after addressing immediate life threats. - This follows the **ATLS Primary Survey: Airway (with c-spine protection) → Breathing → Circulation → Disability → Exposure**. *2,1,4,3* - This incorrectly places intubation **before** cervical spine stabilization is initiated. - In ATLS, **c-spine protection must be applied immediately upon patient contact** before any airway manipulation. - Delaying IV cannulation until after CECT is inappropriate as circulatory access is critical for early resuscitation. *1,3,2,4* - While this correctly starts with cervical spine stabilization, it incorrectly places **IV cannulation before intubation**. - In the ATLS primary survey, **Airway comes before Circulation** - securing the airway takes priority over establishing IV access. - This sequence could delay critical airway management in a patient with respiratory compromise. *2,1,3,4* - This sequence places **intubation before cervical spine stabilization**, which violates ATLS principles. - **C-spine stabilization must be the first action** upon approaching any trauma patient to prevent secondary spinal cord injury. - While intubation with in-line stabilization is possible, the c-spine protection must be instituted first, not after beginning airway manipulation.
Question 6: Early complications of Tracheostomy are all EXCEPT
- A. Pneumothorax
- B. Apnoea
- C. Haemorrhage
- D. Stenosis (Correct Answer)
Explanation: ***Stenosis*** - **Stenosis** (tracheal or subglottic) is a **late complication** of tracheostomy, typically developing **weeks to months** after the procedure due to scar tissue formation - Results from **granulation tissue** at the stoma site, trauma from the tracheostomy tube, or prolonged cuff inflation - Requires long-term follow-up and may need intervention with dilation or surgical correction *Pneumothorax* - **Early and acute complication** occurring during or immediately after tracheostomy - Caused by accidental puncture of the **pleura** during incision or dissection, especially in patients with a high-riding pleura or short neck - Requires immediate recognition with chest X-ray and management (chest tube if significant) *Apnoea* - **Early complication** occurring shortly after tracheostomy placement - Particularly seen in patients with **chronic respiratory failure** and CO2 retention when there is sudden reduction in **PaCO2** - Mechanism: Removal of upper airway resistance and improved ventilation leads to rapid CO2 washout, suppressing the hypercapnic respiratory drive *Haemorrhage* - Common **early complication** occurring during the procedure or within the **first 24-48 hours** - Can range from minor oozing to severe bleeding from thyroid vessels, anterior jugular veins, or rarely the innominate artery - Early bleeding usually from small vessels; late bleeding (>48 hours) may indicate tracheo-innominate fistula
Question 7: High tracheostomy is done in which one of the following conditions?
- A. Laryngeal cancer
- B. Tracheal stenosis (Correct Answer)
- C. Severe asthma exacerbation
- D. Vocal cord dysfunction
Explanation: ***Tracheal stenosis*** - A **high tracheostomy** is performed when there is **lower tracheal stenosis** or obstruction, requiring placement of the tracheostomy stoma **above the stenotic segment**. - This approach ensures that the **tracheostomy tube** bypasses the narrowed portion of the trachea and provides a patent airway. - The level of tracheostomy is chosen based on the location of the pathology - high tracheostomy for lower pathology, and vice versa. *Laryngeal cancer* - In **laryngeal cancer**, a **low tracheostomy** is typically preferred, not a high one. - A high tracheostomy in laryngeal malignancy is generally **contraindicated** due to the risk of tumor seeding and interference with surgical planning. - The tracheostomy should be placed **away from the tumor site** and below the pathology, especially if laryngectomy is planned. *Severe asthma exacerbation* - **Severe asthma exacerbation** rarely requires a tracheostomy; endotracheal intubation and mechanical ventilation are the standard initial management. - If prolonged ventilatory support is needed, a **standard tracheostomy** (not high) would be performed. - There is no specific indication for high tracheostomy placement in asthma. *Vocal cord dysfunction* - **Vocal cord dysfunction (VCD)** involves paradoxical vocal cord movement and is typically managed with **conservative measures** including speech therapy and breathing exercises. - VCD does not cause structural obstruction requiring surgical airway intervention. - Tracheostomy, especially high tracheostomy, has no role in the management of VCD.
Question 8: A 5-year old boy while having dinner suddenly becomes aphonic and is brought to the casualty with the complaint of respiratory distress. Immediate management should be:
- A. Emergency tracheostomy
- B. Humidified oxygen
- C. Heimlich maneuver (Correct Answer)
- D. Cricothyroidotomy
Explanation: ***Heimlich maneuver*** - The sudden onset of **aphonia** and **respiratory distress** during dinner indicates **foreign body airway obstruction** (FBAO). - The **Heimlich maneuver** is the immediate, life-saving intervention for conscious individuals with complete airway obstruction. *Emergency tracheostomy* - This is an invasive surgical procedure performed when other methods to clear the airway have failed or are not possible due to severe obstruction or trauma. - It is not the **first-line intervention** for a conscious child with FBAO. *Humidified oxygen* - While supportive of respiratory function, humidified oxygen alone will not resolve an **acute foreign body obstruction** causing aphonia and severe distress. - It does not address the underlying mechanical blockage of the airway. *Cricothyroidotomy* - This is an emergency procedure to establish an airway, typically used in adults when other methods of intubation or airway clearance have failed. - It is generally **contraindicated in children under 12** due to the risk of damaging the cricoid cartilage, which is a major part of the child's airway.
Question 9: What is the most reliable indicator to prevent esophageal intubation?
- A. Oxygen saturation on pulse oximeter
- B. Direct visualization of passing tube beneath vocal cords
- C. Auscultation over chest
- D. Measurement of CO2 in exhaled air (EtCO2). (Correct Answer)
Explanation: ***Measurement of CO2 in exhaled air (EtCO2)*** - The presence of **carbon dioxide** in exhaled air confirms tracheal intubation as the esophagus does not contain CO2. - This method provides a **real-time**, objective assessment of tube placement that is highly reliable because even small amounts of CO2 are detected. *Oxygen saturation on pulse oximeter* - This indicator measures **oxygenation**, which can remain adequate for several minutes after esophageal intubation due to pre-oxygenation. - A **delayed drop in saturation** might indicate esophageal intubation, but it's not immediate and therefore not the most reliable early indicator. *Direct visualization of passing tube beneath vocal cords* - While helpful, **direct visualization** can sometimes be misleading due to difficult airways or poor visibility, where the tube might appear to pass correctly but enter the esophagus. - This method is **operator-dependent** and its reliability can vary based on the intubator's experience and the patient's anatomy. *Auscultation over chest* - **Auscultation** can detect breath sounds; however, sounds can be transmitted from the stomach or surrounding tissues, leading to false positives. - It is also very difficult to reliably distinguish between **esophageal and tracheal sounds**, especially in noisy environments or with inexperienced personnel, making it less reliable than EtCO2.
Question 10: Identify the maneuver being performed.
- A. Head tilt, chin lift (Correct Answer)
- B. Jaw thrust maneuver
- C. Head extension technique
- D. In-line manual stabilization
Explanation: ***Head tilt, chin lift*** - This maneuver is performed by placing one hand on the patient's forehead and tilting the head back while simultaneously using the fingers of the other hand to lift the chin, thereby opening the airway. - It is a primary technique to establish an **open airway** in an unconscious patient who does not have suspected cervical spine injury. *Jaw thrust maneuver* - The jaw thrust maneuvers involves placing fingers behind the angles of the patient's mandible and displacing the jaw forward, which can be done without extending the neck. - This maneuver is preferred for patients with suspected **cervical spine injuries** to open the airway while minimizing neck movement. *Head extension technique* - This term describes the **head tilt component** of the head tilt, chin lift maneuver, but it doesn't encompass the chin lift aspect, making it an incomplete description of the depicted action. - Simply extending the head without lifting the chin might not adequately open the airway by lifting the tongue off the posterior pharynx. *In-line manual stabilization* - This technique involves manually holding the patient's head and neck to prevent movement, typically used when a **cervical spine injury** is suspected. - It is a **supportive measure** often performed *in conjunction* with airway maneuvers like the jaw thrust, not an airway maneuver itself.
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