A 73 years old woman is brought to the Emergency Room with dyspnea and sudden onset unconsciousness. Her cardiac monitor fixed in the emergency room shows a heart rate of 100 per minute with occasional ventricular ectopic beats. Her Blood Pressure is measured to be 160/95 mmHg. From her history it is found that she is a known diabetic and hypertensive on treatment. Her pulse oximeter is showing a falling oxygen saturation of less than 70%.

1. Cervical spondylosis
2. Edentulous
3. Gastro intestinal bleed
4. Uncontrolled blood pressure

Answer: The answer is (a). Cervical spondylosis can interfere with positioning of the neck for intubation. If the woman is edentulous or has a gastrointestinal bleed it does not acutely interfere with intubation. Uncontrolled blood pressure is not a contraindication to endotracheal intubation.

The choice of orotracheal versus nasotracheal intubation in this woman would depend on:

1. Oropharyngeal anatomy
2. The underlying condition causing the airway difficulty
3. Edentulous
4. Comorbid conditions such as diabetes.

Answer: The answer is (a). The only condition, which would decide whether this woman needs an orotracheal or nasotracheal intubation, is the oropharyngeal anatomy. None of the other factors require any consideration while deciding whether to use naso or orotracheal intubation.

An orotracheal airway is obtained and secured. The proper tube positioning can be confirmed by the following method except:

1. Direct visualisation through a laryngoscope
2. Fibreoptic bronchoscopic visualisation
3. Use of an End tidal carbon di oxide monitoring
4. Indirectly through the monitoring of PaO2.

Answer: The answer is (d). The methods used to confirm the positioning of the endotracheal tube include, direct laryngoscopic visualisation, fibreoptic bronchoscopic visualisation, use of end tidal CO2 monitoring and X ray to check the position of the tube in relation to the carina. Indirect monitoring through the PaO2 is not advisable.

She is intubated and put on a mechanical ventilator. Her Chest x-ray shows bilateral fluffy infiltrates. A nitrate infusion is stared to control her blood pressures. Despite good control of her blood pressure over the next one hour her demand for inspiratory oxygen remains high and her oxygen saturation remain poor. The reason for her fluffy chest infiltrates is

1. Refractory pulmonary edema
2. Acute lung injury
3. Penumoconiosis
4. Aspergillosis

Answer: The answer is (b). Acute Lung Injury (ALI) or Acute Respiratory Distress Syndrome (ARDS) is a clinical condition where there is injury to the pulmonary alveolo capillary membrane due to a variety of reasons and this leads to fluffy infiltrates in the lungs due to congestion of protein rich inflammatory fluids in the alveoli. The clue that the infiltrates are persistent despite blood pressure lowering treatment and mechanical ventilation points out to this condition.

What is the mode of ventilation that would help in this woman's condition the most?

1. Assist Control Mode of Ventilation (ACMV)
2. Positive End Expiratory Pressure Ventilation (PEEP)
3. Control Mode Ventilation (CMV)
4. Pressure Cycled Ventilation

Answer: The answer is (b). The positive end expiratory pressure helps to maintain the airways open during the end of expiration. This helps to clear the secretions in the alveoli and the small airways and makes the air exchange process better.