Half of the resuscitation domain, the largest on the CFRN outline and 40 questions on both. The questions take basic airway skills for granted and test the decisions around them: whether to secure the airway before departure, how to prepare, and how to keep a tube and a ventilator working in a vehicle.
Pre-intubation optimization: oxygenation and hemodynamics before induction.
Airway management and complications, including the failed airway.
Pharmacologic assisted intubation (the CTRN outline says rapid sequence induction) and post-intubation management, drugs included.
Invasive and noninvasive ventilation; the CTRN adds oxygenation and the assessment and packaging of the patient for transport.
Why transport changes the airway decision
In a hospital an airway can be revisited at any time. In a helicopter cabin or the back of an ambulance, a second attempt competes with space, light, noise and motion, so stems often ask whether a borderline airway should be secured before the doors close. The physiology behind cuff and ventilator changes at altitude is on flight physiology; airway injuries of the face and neck are on trauma in transport.
15 airway and ventilator decisions
0 of 15 attempted · 0 correct · 0 missed
Airway and mechanical ventilation
Before RSI at a scene, the transport nurse performs a LEMON assessment on a patient. Which finding identifies a predicted difficult laryngoscopy under the 3-3-2 rule?
Answer and why, all 4 options
Three fingerbreadths between hyoid and chin is the normal mandibular space, so it predicts room to displace the tongue.
Fewer than three fingerbreadths from hyoid to chin means a small mandibular space, so the tongue cannot be displaced and the glottis is hard to see.
Three fingerbreadths of mouth opening is the normal value and predicts adequate access for the blade.
Two fingerbreadths from the floor of the mouth to the thyroid notch is the normal value for laryngeal position, not a warning sign.
Item 564273
Airway and mechanical ventilation
The transport nurse is moving a patient who took an overdose of sertraline and tramadol. The patient is agitated, with inducible clonus, muscle rigidity and diaphoresis. Temp 106.2°F (41.2°C) HR 148 beats/min BP 182/100 mmHg Benzodiazepines have not controlled the rigidity. Which intervention is MOST appropriate?
Answer and why, all 4 options
Haloperidol does not treat serotonin excess; it can impair heat loss and lower the seizure threshold, and it confuses the picture with neuroleptic malignant syndrome.
Dantrolene targets malignant hyperthermia; it has no proven benefit in serotonin toxicity, where the rigidity is centrally driven.
Acetaminophen does not work here because the heat comes from muscle rigidity, not a reset hypothalamic set point.
When benzodiazepines fail and the temperature is above 41 °C, sedation, intubation and nondepolarizing paralysis stop the muscle activity that is generating the heat.
Item 565555
Airway and mechanical ventilation
A patient in myasthenic crisis has just been intubated for a flight to a neuromuscular center, where plasmapheresis is planned. The referring nurse asks whether to give the scheduled pyridostigmine 60 mg via the orogastric tube before departure. Copious oral secretions are present. Which response is MOST appropriate?
Answer and why, all 4 options
IV neostigmine is the same drug class at a less controllable dose, so it adds the same secretion and bradycardia risks.
Giving the scheduled dose adds muscarinic secretions and bronchorrhea to a ventilated airway, while plasmapheresis is the treatment that reverses the crisis.
Doubling the dose risks cholinergic crisis and more secretions in a patient who is already weak and wet.
Once the airway is secured, anticholinesterase therapy is usually held because it worsens secretions without changing the course of the crisis; it is restarted as the patient nears extubation.
Item 1882829
Airway and mechanical ventilation
A patient with a BMI of 52 in acute hypoxemic respiratory failure requires rapid sequence intubation before transport. Which preoxygenation strategy is MOST appropriate?
Answer and why, all 4 options
A ramped, head-up position plus CPAP or NIV keeps alveoli open and extends safe apnea time, which is the main defense against rapid desaturation in obesity.
Head-down tilt pushes abdominal contents against the diaphragm and shrinks functional residual capacity, shortening safe apnea time in obesity.
The sniffing position on a flat bed does not align the airway axes in a large patient, and nasal cannula alone gives no positive pressure.
Supine positioning lets the abdomen compress the lungs, and a nonrebreather adds no positive pressure, so desaturation during apnea is fast.
Item 1882777
Airway and mechanical ventilation
A 70-kg patient with Guillain-Barré syndrome is being prepared for a 2-hour flight to a neurology center. The patient is speaking in full sentences on 2 L/min nasal cannula. Which finding MOST strongly supports elective intubation before departure?
Answer and why, all 4 options
SpO2 stays normal until late in neuromuscular failure because the problem is ventilatory pump weakness, so it is a poor trigger for intubation.
An FVC of 30 mL/kg that is stable shows adequate reserve; the usual concern begins near 20 mL/kg or with a rapid decline.
An NIF of −45 cmH2O is a strong inspiratory effort; values weaker than about −30 cmH2O are the warning sign.
A vital capacity under 15–20 mL/kg that is still falling predicts respiratory failure, and a 2-hour flight is no place to intubate a tiring patient.
Item 1882825
Airway and mechanical ventilation
A patient requires high-flow nasal cannula at 50 L/min with FiO2 1.0 for a 45-minute transport. Each full E cylinder holds about 680 L. Ignoring the reserve, what is the minimum number of full E cylinders needed?
Answer and why, all 4 options
The flight needs 50 × 45 = 2,250 L, and 2,250 ÷ 680 = 3.3, so four full E cylinders are the minimum before any reserve is added.
Three cylinders give 2,040 L, which runs out before the 45-minute transport ends; partial cylinders must be rounded up.
Seven cylinders comes from a wrong calculation; it overloads the aircraft without being the minimum asked for.
Two cylinders give 1,360 L, far short of the 2,250 L needed (50 L/min × 45 min).
Item 1882963
Airway and mechanical ventilation
An 84-year-old frail patient on non-invasive ventilation for a COPD exacerbation is being prepared for transfer. Which finding MOST strongly predicts NIV failure?
Answer and why, all 4 options
A small leak and mild discomfort are common and are fixed by adjusting the mask; they do not predict failure.
Worsening mental status on NIV signals rising CO2 and loss of airway protection, the strongest sign that NIV is failing and intubation should happen before transfer.
A rising pH after an hour shows CO2 clearance, which predicts NIV success.
A falling respiratory rate after starting NIV shows that the work of breathing is improving.
Item 1882967
Airway and mechanical ventilation
A single transport nurse is moving a ventilated patient who is hemodynamically borderline and has mild ventilator dyssynchrony. SpO2 is stable at 95%, arrival is in 15 minutes, and the transport ventilator's advanced modes are unfamiliar to the nurse. Which action is MOST appropriate?
Answer and why, all 4 options
Extubating a hemodynamically borderline patient in transport removes airway control with no way to recover it safely.
Paralysis without sedation leaves the patient aware and paralyzed, and it hides distress rather than correcting the cause of dyssynchrony.
With stable oxygenation and a short remaining time, staying in a familiar mode and treating pain and agitation fixes most dyssynchrony with the least risk.
Switching to a mode the nurse does not know, alone and in motion, adds error risk for a problem that analgesia can solve.
Item 1882977
Airway and mechanical ventilation
Before RSI of a patient with a predicted difficult airway at the scene, which preparation is MOST important?
Answer and why, all 4 options
Routine atropine for adults is not indicated; it is reserved for bradycardia or specific pediatric situations.
Repeated attempts without a limit cause swelling, bleeding and desaturation; attempts should be capped and followed by the rescue plan.
Briefing the failed-airway plan, with a supraglottic airway and a cric kit open, means the team moves to rescue without hesitation if laryngoscopy fails.
Removing spinal precautions to improve the view trades a possible cord injury for a convenience; manual in-line stabilization keeps the neck protected.
Item 1882981
Airway and mechanical ventilation
During ascent, a ventilated trauma patient's peak pressure alarm sounds. SpO2 falls to 84% and BP to 82/50 mmHg. After the patient is taken off the ventilator, the bag is very stiff, breath sounds are absent on the right, the tube is still 23 cm at the lip, and a suction catheter passes easily. What is the NEXT action?
Answer and why, all 4 options
Raising PEEP adds pressure to a chest that already cannot be ventilated and worsens a tension pneumothorax.
A stiff bag, absent breath sounds on one side, low BP and a tube that is in place and patent point to tension pneumothorax, which needs needle decompression now.
The patient was taken off the ventilator and the bag is still stiff, so the circuit is not the cause.
The tube is still at 23 cm and suction passes freely, so displacement and obstruction are already ruled out; pulling it back risks extubation.
Item 1882991
Airway and mechanical ventilation
A trauma patient intubated two days ago is being assessed before a 2-hour fixed-wing transfer. Which finding is the STRONGEST reason to keep the patient intubated for the flight?
Answer and why, all 4 options
Breathing above the set rate shows intact respiratory drive and is not a reason to keep the tube.
Following commands and a head lift show adequate neurologic and muscle strength, which support readiness to extubate.
Copious secretions with a weak cough mean the patient cannot clear the airway after extubation, so the tube should stay in for the flight.
A rapid shallow breathing index of 60 is well below 105 and predicts successful weaning.
Item 1883011
Airway and mechanical ventilation
The transport nurse is reviewing four patients awaiting transport. Which finding MOST warrants having a surgical airway kit opened and ready before any intubation attempt?
Answer and why, all 4 options
Massive midface fractures with oral bleeding distort anatomy, defeat bag-mask ventilation and block the view, so a surgical airway may be the only route.
A full stomach raises aspiration risk and is managed with RSI and suction, not by preparing a surgical airway.
A BMI of 32 with a thyromental distance of 7 cm is within normal limits; it does not predict a failed airway.
A cervical collar limits neck movement, but with normal mouth opening the collar front can be removed while manual stabilization is held.
Item 1883012
Airway and mechanical ventilation
During a helicopter flight, a deeply sedated patient on assist-control with a set rate of 14 now has a measured rate of 32 breaths/min. There is no visible patient effort, the circuit has no leak or pooled water, and ETCO2 has fallen from 38 to 29 mmHg. Which adjustment is MOST appropriate?
Answer and why, all 4 options
Breaths without patient effort point to auto-triggering: aircraft vibration and motion are read as inspiratory effort, so a less sensitive trigger stops the extra breaths and the hyperventilation.
The patient is already deeply sedated and is not triggering the breaths; more sedation adds hypotension without fixing the trigger.
The extra breaths are triggered above the set rate, so lowering the backup rate does not stop them.
Changing the mode leaves the same trigger sensitivity, so vibration keeps triggering breaths.
Item 9730026
Airway and mechanical ventilation
Three days after a surgical tracheostomy, a ventilated patient's tracheostomy tube comes out during loading into the aircraft. SpO2 is falling, and the upper airway is normal. Which action is MOST appropriate?
Answer and why, all 4 options
Blind reinsertion through an immature tract often creates a false passage in front of the trachea, which then cannot be ventilated.
Waiting leaves a desaturating patient without an airway for the whole flight.
A tract only days old has not matured, so a tube pushed back in can enter a false passage; covering the stoma, oxygenating by mouth and then intubating orally is the safe route.
A suction catheter carries too little flow to ventilate an adult and can tear the fresh tract.
Item 9730027
Airway and mechanical ventilation
A patient with suspected influenza pneumonia needs NIV during a 40-minute helicopter flight, and the crew sits within arm's length. Which setup BEST limits the crew's exposure while keeping NIV?
Answer and why, all 4 options
A vented mask releases unfiltered exhaled gas straight into the cabin, next to the crew.
Filtering the exhaled gas before it leaves the circuit traps infectious aerosol in a confined cabin while the patient keeps full NIV support.
More pressure increases leak around the mask and does nothing to filter exhaled gas.
Dropping to nasal cannula removes the support the patient needs and risks hypoxemia in flight.
Item 9730029
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Ventilator errors that recur
Tidal volume by actual weight. Lung-protective ventilation sets volume by predicted body weight, from height and sex: a target of 6 mL/kg with plateau pressure kept at or below 30 cmH2O (ARDS Network trial, 2000; ATS, ESICM and SCCM guideline, 2017).
Peak and plateau read alike. A high peak over a normal plateau means resistance in the tube or airways: kinking, secretions, bronchospasm, biting. Both pressures high point to stiff lungs or chest: pneumothorax, mainstem intubation, edema, abdominal pressure.
Hyperventilating the injured brain. The Brain Trauma Foundation's prehospital guidelines (3rd edition, 2023) target normal ventilation, an ETCO2 of 35–45 mmHg, and reserve brief hyperventilation (30–35 mmHg) for signs of active herniation.
Adult rates for children. With an advanced airway in place, AHA pediatric guidance gives one breath every 2 to 3 seconds, 20 to 30 a minute, not the adult rate.
Skipping the checklist when a ventilated patient worsens. DOPE (displacement, obstruction, pneumothorax, equipment) is the order transport crews use to look for the cause.
Yes. The CFRN outline lists it as pharmacologic assisted intubation, with pre-intubation optimization and post-intubation drugs; the CTRN outline calls it rapid sequence induction.
Do the exams cover noninvasive ventilation?
Both outlines list invasive and noninvasive ventilation. Expect questions on when noninvasive support is safe to continue for the length of a trip.