Walsh: Perinatal and Pediatric Respiratory Care, 3rd Edition

Chapter 15: Airway Management

Answers to Assessment Questions and Clinical Scenarios

1.	B
Rationale: A patient with central apnea can be mask ventilated or provided with noninvasive positive-pressure ventilation (NPPV) or negative-pressure ventilation. The specific indications for translaryngeal intubation are numerous; however, all can be placed in one of four broad categories, which can be defined by the four “Ps”:
•	Pulmonary function
•	Provide an airway
•	Protect the airway
•	Pulmonary hygiene
2.	A
Rationale: The appropriate ETT for any child 1 year of age or older may be determined by the following formula: Internal diameter (mm) = (age [yr]  4) + 4.
3.	D
Rationale: The laryngeal mask airway (LMA) may be used in the unconscious patient to maintain an airway without having to intubate. The LMA does not provide a barrier between the esophagus and the trachea and therefore the potential for aspiration is greater than with translaryngeal intubation. It may be useful as part of a backup plan in the event that endotracheal intubation is difficult or hazardous.
4.	D
Rationale: Disadvantages of nasal intubation include a predisposition to sinusitis, pressure necrosis of the nares, and bleeding complications associated with passing the ETT through the nares and upper airway. Another disadvantage is that a higher incidence of postextubation atelectasis among very low birth weight infants has been reported.
5.	C
Rationale: When the larynx cannot be visualized with a rigid endoscope, the flexible fiberoptic bronchoscope offers several advantages for intubation. First, the flexible scope can navigate into an endolarynx that is impossible or difficult to expose with the rigid scope. This enables the clinician to pass an ETT previously placed over the flexible scope into the trachea once the flexible scope is through the cords. Second, the flexible scope facilitates nasotracheal intubation, which may be a more secure airway in certain clinical situations, such as hypopharyngeal masses, craniofacial anomalies, and muscular dystrophy. Older children or young adults with certain muscular dystrophies may have such severe contractures that their endolarynx is impossible to expose with the anterior commissure laryngoscope. In such cases the best option for a controlled intubation is with the flexible fiberoptic scope.
6.	E
Rationale: Extubation failure treatment strategies include assessing the cause of failure (pulmonary, neurologic, or airway) followed by appropriate treatment: administration of helium–oxygen mixtures, aerosolized epinephrine treatments; nasal mask ventilation; laryngotracheal reconstruction; or tracheotomy.
7.	B
Rationale: Indications for tracheotomy include the following: upper airway obstruction, long-term ventilation, craniofacial anomalies, neurological problems, poor pulmonary toilet.
8.	C
Rationale: There are three methods of decannulation: (1) immediately remove the tube; (2) downsize and cap the tube; or (3) extubate after single-stage laryngotracheal reconstruction. When severe or total stenosis of the high trachea or subglottis exists, then a partial cricotracheal resection (PCTR) is indicated instead of the traditional laryngotracheoplasty.
9.	A
Rationale: Tracheotomy tubes have a larger outside diameter compared with ETTs.
10.	A
Rationale: The two most common reasons for death of a tracheotomy-dependent child are plugging of the tube with mucus and accidental decannulation. Plugging with mucus occurs when thick, viscous mucus obstructs the lumen of the tracheotomy tube.