Endotracheal Intubation and Advanced Airway Placement - NREMT Paramedic Level

1. What is the recommended initial airway maneuver to improve laryngoscopic view without moving the neck?

   External laryngeal manipulation (e.g., BURP). Applies targeted pressure to align laryngeal structures, enhancing glottic visualization while maintaining cervical spine stability.

2. What is the primary confirmation method for correct endotracheal tube placement in the field?

   Continuous waveform capnography (ETCO$2$ waveform). Offers continuous, objective monitoring of exhaled CO2 to confirm tracheal placement and detect complications like dislodgement.

3. What is the preferred method to secure an endotracheal tube after confirmation?

   Commercial tube holder or tape with documented depth. Prevents accidental extubation by stabilizing the tube at a measured depth, ensuring consistent tracheal positioning.

4. What is the primary risk of excessive ventilation rate after advanced airway placement?

   Decreased venous return and reduced cardiac output. Causes positive intrathoracic pressure, impeding preload and potentially leading to hypotension in critically ill patients.

5. What is the most common cause of sudden loss of ETCO$2$ waveform after confirmed intubation?

   Tube dislodgement or disconnection. Often results from patient movement or transport, interrupting the capnography circuit and requiring immediate reassessment.

6. What is the corrective action for suspected right mainstem intubation?

   Withdraw ETT slightly and reassess breath sounds and ETCO$2$. Repositions the tube above the carina to achieve bilateral lung ventilation, confirmed by equal breath sounds.

7. Which device is typically used to guide an endotracheal tube when only the epiglottis is seen?

   Bougie (tracheal tube introducer). Facilitates blind or semi-blind intubation by providing a flexible guide that follows anterior tracheal anatomy in limited views.

8. Which finding most strongly suggests right mainstem intubation after ETT placement?

   Absent or markedly decreased left breath sounds. Occurs due to the tube advancing into the right bronchus, bypassing the left lung and causing unilateral ventilation.

9. Which patient positioning is preferred to optimize laryngoscopy in most adults?

   Head-elevated laryngoscopy position (ear-to-sternal notch). Aligns the oral, pharyngeal, and tracheal axes to improve glottic exposure and reduce intubation difficulty in non-obese patients.

10. Which supraglottic airway is generally considered a rescue option when intubation fails?

    Supraglottic airway (e.g., i-gel, King, LMA) per protocol. Provides an alternative extraglottic ventilation pathway, bypassing glottic visualization challenges in failed intubation attempts.

11. What is the most appropriate response if you see the tube pass through the cords but ETCO$2$ is absent?

    Reassess, ventilate, and re-confirm; consider displacement. Addresses potential discrepancies between visual and capnographic confirmation, prioritizing re-evaluation to ensure proper placement.

12. What is the purpose of preoxygenation before intubation?

    Increase oxygen reserve and delay desaturation. Replaces alveolar nitrogen with oxygen, extending safe apnea time during laryngoscopy and intubation attempts.

13. Which technique is used to reduce aspiration risk during bag-mask ventilation before intubation?

    Two-person BVM with good seal and appropriate tidal volume. Enhances mask seal and controls volume to minimize gastric insufflation and regurgitation during pre-intubation ventilation.

14. What ETCO$2$ finding most strongly suggests esophageal intubation in a perfusing patient?

    Absent or rapidly decaying ETCO$2$ waveform. Reflects lack of CO2 detection from the lungs, distinguishing esophageal from tracheal placement in patients with adequate perfusion.

15. Which laryngoscopic view grade indicates full visualization of the vocal cords?

    Cormack-Lehane Grade I. Represents the optimal view where the entire glottic opening is visible, facilitating easier endotracheal tube passage.

16. What is apneic oxygenation during intubation?

    Nasal cannula oxygen left on during apnea. Delivers passive oxygenation via nasal prongs to maintain oxygen diffusion into alveoli during apneic periods.

17. After advanced airway placement in cardiac arrest, what ventilation rate is typically recommended?

    1 breath every 6 seconds (10 breaths/min) with continuous CPR. Supports adequate oxygenation without interrupting chest compressions, aligning with resuscitation guidelines for arrested patients.

18. What is the contraindication to placing an oropharyngeal airway (OPA)?

    Intact gag reflex. Indicates patient consciousness, risking airway obstruction or aspiration from gag-induced vomiting upon insertion.

19. Which laryngoscopic view grade indicates no glottic structures are seen?

    Cormack-Lehane Grade IV. Denotes the most difficult view with no identifiable laryngeal anatomy, predicting high intubation failure risk.

20. What is the major contraindication to nasopharyngeal airway (NPA) placement?

    Suspected basilar skull fracture or severe facial trauma. Increases risk of cribriform plate penetration or intracranial insertion due to disrupted facial and cranial anatomy.

21. Which positioning is preferred for suspected cervical spine injury during airway management?

    Manual in-line stabilization with neutral alignment. Minimizes cervical motion to prevent secondary spinal injury while allowing airway access in trauma patients.

22. What is the best immediate action when you cannot ventilate and cannot intubate?

    Perform emergency cricothyrotomy per protocol. Establishes a definitive surgical airway in life-threatening can't-intubate, can't-ventilate situations to restore oxygenation.

23. What is the most appropriate immediate action when the laryngoscopic view is obscured by secretions?

    Suction the oropharynx (SALAD approach as needed). Clears contaminants to restore visualization, with SALAD technique optimizing suction during ongoing airway management.

24. What is the key tactile sign that a bougie is in the trachea rather than the esophagus?

    Tracheal ring "clicks" or distal "hold-up". Provides haptic feedback confirming tracheal entry, as the esophagus lacks rigid rings and distal obstruction.

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