TESTBANK FOR STOELTING’S ANESTHESIA AND CO-EXISTING DISEASE, 9TH EDITION
,TABLE OF CONTENTS
Stoelting’s Anesthesia and Co-Existing Disease, 9th Edition
Complete Original Test Bank | 32 Chapters | 960 Questions
Section 1 — Respiratory & Sleep-Related Disorders
1. Sleep Related Breathing Disorders
2. Anesthetic Considerations for Obstructive Lung Disease
3. Restrictive Respiratory Diseases and Lung Transplantation
Section 2 — Cardiovascular Disease
4. Ischemic Heart Disease
5. Valvular Heart Disease
6. Congenital Heart Disease
7. Abnormalities of Cardiac Conduction and Cardiac Rhythm
8. Systemic and Pulmonary Arterial Hypertension
9. Heart Failure and Cardiomyopathies
10.Pericardial Disease and Cardiac Trauma
11.Vascular Disease
Section 3 — Neurologic, Spinal, Peripheral & Aging
12.Diseases Affecting the Brain
13.Disorders of the Spine and Spinal Cord
14.Diseases of the Autonomic and Peripheral Nervous Systems
15.Diseases of Aging
Section 4 — Hepatic, Metabolic, Nutritional, Renal & Endocrine
16.Diseases of the Liver and Biliary Tract
17.Inborn Errors of Metabolism
18.Nutritional Diseases: Obesity and Malnutrition
19.Fluid, Electrolyte, and Acid Base Disorders
20.Renal Disease
21.Endocrine Disease
Section 5 — Hematologic, Musculoskeletal, Infectious, Immune & Malignant Disease
22.Hematologic Disorders
23.Skin and Musculoskeletal Diseases
24.Infectious Diseases
25.Diseases Related to Immune System Dysfunction
26.Cancer
Section 6 — Psychiatric & Substance Use
27.Psychiatric Disease, Substance Use Disorder and Drug Overdose
28.Anesthetic Considerations for Adults with Substance Use Disorder or Acute Intoxication
Section 7 — Pediatric, Pregnancy & Chronic Pain
29.Pediatric Diseases
30.Medical Disorder in Pregnancy
, 31.Chronic Pain
Section 8 — Critically Injured Patient / Trauma
32.The Critically Injured Patient
Test Bank Structure
Feature Coverage
Total Sections 8
Total Chapters 32
Questions per Chapter 30
Total Original Questions 960
Answer Options A–D
Correct Answers One Best Answer
Detailed Rationales
Why Other Options Are Incorrect
Anesthesia Pearls
Exam Strategies
Clinical Tables & Data Panels
Graphs & Trend Interpretation
Clinical Algorithms & Decision Chains
Calculations & Quantitative Questions
Word-Compatible Clinical Diagrams
Section 1 — Respiratory & Sleep-Related Disorders
Chapter 1 — Sleep Related Breathing Disorders
,Visual 1 — OSA Pathophysiology: Word-Safe Mermaid-Style Flow
PERIOPERATIVE VULNERABILITY
Question 1.
During natural sleep, repetitive episodes occur in which inspiratory effort continues but airflow stops because the pharyngeal
airway collapses.
Which mechanism best identifies the disorder?
A. Loss of central respiratory drive without inspiratory effort
B. Fixed intrathoracic tracheal stenosis
C. Recurrent upper-airway obstruction despite ongoing respiratory effort
D. Primary impairment of pulmonary diffusion
ANS: C
Rationale: Obstructive sleep apnea is characterized by repetitive upper-airway narrowing or collapse during sleep while
respiratory effort persists. Reduced pharyngeal dilator muscle tone during sleep allows a susceptible airway to collapse.
Why the other options are less appropriate:
• A: Absent airflow plus absent respiratory effort characterizes central rather than obstructive apnea.
• B: OSA is dynamic and sleep dependent rather than a fixed tracheal lesion.
• D: Diffusion impairment does not produce repetitive obstructive apneas.
Anesthesia Pearl: General anesthetics, sedatives, and opioids can reproduce or intensify several mechanisms that normally
promote obstruction during sleep.
Exam Strategy: Airflow absent + effort present = obstructive apnea.
,Question 2.
An anesthesia plan is being developed for a patient with untreated severe OSA who will require postoperative analgesia.
Which complication deserves particular attention?
A. Opioid- and sedative-associated worsening of upper-airway obstruction and ventilatory depression
B. Complete resistance to respiratory depressant drugs
C. Guaranteed postoperative hypertension without airway problems
D. Reduced susceptibility to hypoxemia
ANS: A
Rationale: OSA patients are susceptible to postoperative upper-airway obstruction, hypoxemia, and respiratory
depression, particularly when opioids and sedating medications reduce arousal responses and ventilatory drive. SASM
educational guidance specifically emphasizes judicious use of opioids and respiratory depressants in this population. (SASM)
Why the other options are less appropriate:
• B: Respiratory depressants are a major concern rather than an ineffective class.
• C: Cardiovascular consequences may occur, but airway/ventilatory complications are central perioperative risks.
• D: OSA increases rather than decreases hypoxemic vulnerability.
Anesthesia Pearl: Postoperative respiratory risk often reflects the interaction of OSA severity + opioids + residual
anesthesia + sleep.
Exam Strategy: OSA + opioid = think obstruction and hypoventilation.
Question 3.
Polysomnography reports an apnea-hypopnea index of 42 events/hour.
How should this OSA severity generally be classified?
A. Normal
B. Mild
C. Moderate
D. Severe
ANS: D
Rationale: Common adult sleep-medicine categories classify OSA as approximately:
• Mild: AHI 5–14.9/hour
• Moderate: AHI 15–29.9/hour
• Severe: AHI ≥30/hour
An AHI of 42 therefore represents severe OSA. (AASM)
Why the other options are less appropriate:
• A: An AHI of 42 is markedly abnormal.
• B: Mild disease is below 15/hour.
• C: Moderate disease is below 30/hour.
Anesthesia Pearl: AHI is useful, but perioperative risk also depends on hypoxemic burden, comorbidity, PAP use, opioid
requirement, and postoperative environment.
Exam Strategy: Remember the anchors: 5, 15, 30.
Visual 2 — STOP-BANG Screening Table
Question 4.
Preoperative screening produces the following findings:
, STOP-BANG Element Finding Point
S — Snoring Loud nightly snoring 1
T — Tired Daytime fatigue 1
O — Observed apnea Yes 1
P — Pressure Treated hypertension 1
B — BMI >35 kg/m² BMI 39 1
A — Age >50 yr Age 47 0
N — Neck >40 cm 44 cm 1
G — Male Female 0
TOTAL 6/8
Which interpretation is most appropriate?
A. OSA is excluded because the patient is female
B. The patient screens as high risk for OSA
C. The score establishes central sleep apnea
D. No perioperative precautions are necessary until polysomnography is completed
ANS: B
Rationale: This patient scores 6/8, which is a high-risk STOP-BANG result. SASM material describes 5–8 positive responses
as high risk, 3–4 as intermediate, and 0–2 as low risk. (SASM)
Why the other options are less appropriate:
• A: Female sex contributes zero points but does not exclude OSA.
• C: STOP-BANG screens for obstructive sleep apnea, not central apnea.
• D: A high-risk screen should influence anesthetic and postoperative planning even before formal confirmation.
Anesthesia Pearl: Screening is useful because many surgical patients have clinically important but undiagnosed OSA.
Exam Strategy: STOP-BANG ≥5 = strong perioperative warning signal.
Question 5.
Repeated nocturnal obstructive events produce intermittent hypoxemia, hypercapnia, and frequent arousals.
Which chronic physiologic consequence is most strongly associated with this pattern?
A. Persistent parasympathetic dominance
B. Suppression of catecholamine release
C. Recurrent sympathetic activation contributing to cardiovascular stress and hypertension
D. Permanent reduction in systemic vascular resistance
ANS: C
Rationale: Repetitive airway obstruction causes hypoxemia, hypercapnia, intrathoracic pressure changes, and arousal.
These provoke recurrent sympathetic surges that contribute to systemic hypertension, arrhythmias, and other cardiovascular
consequences.
Why the other options are less appropriate:
• A: Sympathetic rather than parasympathetic activation is prominent.
• B: Catecholaminergic activity increases.
• D: Chronic OSA does not characteristically produce persistent low SVR.
Anesthesia Pearl: OSA is not simply “snoring”—it can be a cardiovascular stress disorder.
Exam Strategy: OSA chain: obstruction → hypoxia/arousal → sympathetic surge.
,Question 6.
Medication and equipment reconciliation shows that a patient with established OSA uses CPAP every night and has good
adherence.
Which perioperative plan is generally appropriate?
A. Discontinue CPAP for several days after surgery
B. Encourage continuation/resumption of the patient's prescribed PAP therapy during appropriate perioperative sleep periods
C. Replace CPAP routinely with supplemental oxygen alone
D. Use PAP only if cardiopulmonary arrest develops
ANS: B
Rationale: Patients who routinely use PAP should generally continue or resume therapy perioperatively when feasible.
SASM materials specifically recommend perioperative access to CPAP for known OSA patients and emphasize identifying
barriers when established users are nonadherent. (SASM)
Why the other options are less appropriate:
• A: Withdrawal removes an effective airway therapy.
• C: Oxygen does not splint open the upper airway.
• D: PAP is preventive/supportive therapy, not merely a resuscitation intervention.
Anesthesia Pearl: Asking a patient to bring their PAP device can be a meaningful part of perioperative planning.
Exam Strategy: Established effective therapy → do not unnecessarily remove it.
Question 7.
Airway examination documents severe OSA, BMI 42 kg/m², a large tongue, crowded oropharynx, and neck circumference of 46
cm.
Which anesthetic concern should be anticipated?
A. Potentially difficult mask ventilation and tracheal intubation
B. Guaranteed impossible supraglottic-airway placement
C. Absence of airway obstruction during sedation
D. Reduced need for preoxygenation
ANS: A
Rationale: OSA and the anatomic factors that predispose to pharyngeal collapse frequently overlap with predictors of
difficult mask ventilation and difficult laryngoscopy. SASM perioperative guidance explicitly recommends anticipating difficult
airway management in OSA. (SASM)
Why the other options are less appropriate:
• B: Difficulty is increased but not guaranteed.
• C: Sedation may worsen airway collapsibility.
• D: Preoxygenation is especially important in high-risk patients.
Anesthesia Pearl: The anatomy that obstructs the airway during sleep may also complicate airway management when the
patient is unconscious.
Exam Strategy: OSA should trigger both a respiratory-risk plan and an airway plan.
Question 8.
A patient with severe OSA is undergoing knee replacement.
Which postoperative analgesic strategy most effectively reduces respiratory risk while still treating pain?
A. High-dose continuous opioid infusion
B. Benzodiazepine plus opioid PCA without monitoring
,C. Avoid analgesia completely
D. Multimodal opioid-sparing analgesia, incorporating regional techniques when appropriate
ANS: D
Rationale: Opioid-sparing multimodal analgesia reduces exposure to respiratory depressants while maintaining effective
pain control. Regional analgesia, acetaminophen, NSAIDs when suitable, and other multimodal options can reduce systemic
opioid requirements.
Why the other options are less appropriate:
• A: Continuous opioids may exacerbate respiratory depression.
• B: Combining sedatives and opioids magnifies risk.
• C: Severe untreated pain is harmful and can itself impair respiratory recovery.
Anesthesia Pearl: The goal is less opioid—not less analgesia.
Exam Strategy: OSA analgesia question → look for multimodal + regional + opioid sparing.
Visual 3 — Airway Positioning Sketch
Question 9.
The airway team compares two induction positions for a patient with severe obesity and OSA.
approximately aligned with
Which position is generally preferable?
A. Trendelenburg
B. Ramped or head-elevated positioning
C. Extreme neck flexion
D. Flat supine positioning in every case
ANS: B
Rationale: Head-elevated/ramped positioning in obese patients can improve upper-airway alignment, preoxygenation, and
respiratory mechanics. SASM educational recommendations specifically identify head-elevated laryngoscopy positioning and
adequate preoxygenation as important OSA strategies. (SASM)
Why the other options are less appropriate:
• A: Trendelenburg may worsen respiratory mechanics.
• C: Extreme flexion can impair airway alignment.
• D: Flat positioning may reduce FRC and worsen oxygen reserve.
Anesthesia Pearl: Positioning is one of the few airway interventions that improves conditions before any drug is
administered.
Exam Strategy: Obesity + OSA airway → ramp early.
,Visual 4 — Desaturation Trend Graph
Question 10.
Two patients are adequately preoxygenated before induction. After apnea begins, the following illustrative trend occurs:
Seconds of apnea
Patient Y has severe obesity and OSA.
Which explanation best accounts for the more rapid desaturation?
A. Increased functional residual capacity
B. Decreased metabolic oxygen consumption
C. Reduced oxygen reserve from decreased FRC combined with relatively increased oxygen consumption
D. Complete inability of hemoglobin to bind oxygen
ANS: C
Rationale: Obesity reduces FRC, especially after induction and in the supine position. At the same time, oxygen
consumption is often increased. The combination reduces the size and duration of the pulmonary oxygen reservoir, producing
faster desaturation during apnea.
Why the other options are less appropriate:
• A: FRC commonly decreases.
• B: Oxygen consumption is not generally reduced.
• D: Hemoglobin binding remains intact unless another disorder is present.
Anesthesia Pearl: Difficult intubation becomes much more dangerous when the patient's safe apnea time is short.
Exam Strategy: Obesity → smaller tank + faster oxygen use.
Question 11.
At the end of surgery, an OSA patient has received a nondepolarizing neuromuscular blocker.
Which extubation condition is most appropriate?
A. Awake, appropriately responsive, adequately ventilating, with complete neuromuscular recovery
B. Deeply anesthetized with significant residual blockade
, C. Immediately after the final opioid dose regardless of ventilation
D. Before reversal is assessed
ANS: A
Rationale: Residual neuromuscular blockade can impair upper-airway muscle function and ventilation. An OSA patient
should generally have reliable reversal, adequate spontaneous ventilation, and protective airway responses before tracheal
extubation.
Why the other options are less appropriate:
• B: Residual anesthetic and neuromuscular effects increase obstruction risk.
• C: Opioid exposure can worsen ventilatory depression.
• D: Objective recovery should be confirmed.
Anesthesia Pearl: Small amounts of residual weakness can have a large effect on an already collapsible pharyngeal airway.
Exam Strategy: OSA extubation = awake + strong + fully reversed.
Question 12.
Once safely extubated, which postoperative positioning principle is useful for an OSA patient when surgical circumstances
permit?
A. Mandatory steep Trendelenburg
B. Flat supine position throughout recovery
C. Prone positioning in every case
D. Head-elevated or nonsupine positioning when feasible
ANS: D
Rationale: Supine positioning can promote gravitational narrowing of the upper airway. Head elevation or
lateral/nonsupine positioning can improve upper-airway patency and respiratory mechanics in selected OSA patients.
Why the other options are less appropriate:
• A: Trendelenburg may worsen upper-airway and respiratory mechanics.
• B: Supine sleep commonly worsens OSA.
• C: Prone positioning is not universally required or practical.
Anesthesia Pearl: Postoperative airway management includes position as well as equipment and medications.
Exam Strategy: OSA recovery → avoid unnecessary flat supine positioning.
Question 13.
PACU recovery has been uncomplicated, but a patient with severe untreated OSA will continue receiving systemic opioids
overnight.
Which disposition is most appropriate?
A. Unmonitored waiting-room chair
B. A postoperative environment providing appropriate continuous respiratory monitoring based on risk
C. Immediate discharge simply because SpO₂ is normal while awake
D. No monitoring once the patient falls asleep
ANS: B
Rationale: Higher-risk OSA patients—especially those receiving opioids or demonstrating postoperative respiratory
events—may require monitored care. SASM protocols describe continuous oximetry and enhanced monitoring for high-risk
patients after PACU discharge. (SASM)
Why the other options are less appropriate:
• A: This does not provide adequate surveillance.
• C: Awake saturation does not predict sleep-related obstruction after opioids.
,TABLE OF CONTENTS
Stoelting’s Anesthesia and Co-Existing Disease, 9th Edition
Complete Original Test Bank | 32 Chapters | 960 Questions
Section 1 — Respiratory & Sleep-Related Disorders
1. Sleep Related Breathing Disorders
2. Anesthetic Considerations for Obstructive Lung Disease
3. Restrictive Respiratory Diseases and Lung Transplantation
Section 2 — Cardiovascular Disease
4. Ischemic Heart Disease
5. Valvular Heart Disease
6. Congenital Heart Disease
7. Abnormalities of Cardiac Conduction and Cardiac Rhythm
8. Systemic and Pulmonary Arterial Hypertension
9. Heart Failure and Cardiomyopathies
10.Pericardial Disease and Cardiac Trauma
11.Vascular Disease
Section 3 — Neurologic, Spinal, Peripheral & Aging
12.Diseases Affecting the Brain
13.Disorders of the Spine and Spinal Cord
14.Diseases of the Autonomic and Peripheral Nervous Systems
15.Diseases of Aging
Section 4 — Hepatic, Metabolic, Nutritional, Renal & Endocrine
16.Diseases of the Liver and Biliary Tract
17.Inborn Errors of Metabolism
18.Nutritional Diseases: Obesity and Malnutrition
19.Fluid, Electrolyte, and Acid Base Disorders
20.Renal Disease
21.Endocrine Disease
Section 5 — Hematologic, Musculoskeletal, Infectious, Immune & Malignant Disease
22.Hematologic Disorders
23.Skin and Musculoskeletal Diseases
24.Infectious Diseases
25.Diseases Related to Immune System Dysfunction
26.Cancer
Section 6 — Psychiatric & Substance Use
27.Psychiatric Disease, Substance Use Disorder and Drug Overdose
28.Anesthetic Considerations for Adults with Substance Use Disorder or Acute Intoxication
Section 7 — Pediatric, Pregnancy & Chronic Pain
29.Pediatric Diseases
30.Medical Disorder in Pregnancy
, 31.Chronic Pain
Section 8 — Critically Injured Patient / Trauma
32.The Critically Injured Patient
Test Bank Structure
Feature Coverage
Total Sections 8
Total Chapters 32
Questions per Chapter 30
Total Original Questions 960
Answer Options A–D
Correct Answers One Best Answer
Detailed Rationales
Why Other Options Are Incorrect
Anesthesia Pearls
Exam Strategies
Clinical Tables & Data Panels
Graphs & Trend Interpretation
Clinical Algorithms & Decision Chains
Calculations & Quantitative Questions
Word-Compatible Clinical Diagrams
Section 1 — Respiratory & Sleep-Related Disorders
Chapter 1 — Sleep Related Breathing Disorders
,Visual 1 — OSA Pathophysiology: Word-Safe Mermaid-Style Flow
PERIOPERATIVE VULNERABILITY
Question 1.
During natural sleep, repetitive episodes occur in which inspiratory effort continues but airflow stops because the pharyngeal
airway collapses.
Which mechanism best identifies the disorder?
A. Loss of central respiratory drive without inspiratory effort
B. Fixed intrathoracic tracheal stenosis
C. Recurrent upper-airway obstruction despite ongoing respiratory effort
D. Primary impairment of pulmonary diffusion
ANS: C
Rationale: Obstructive sleep apnea is characterized by repetitive upper-airway narrowing or collapse during sleep while
respiratory effort persists. Reduced pharyngeal dilator muscle tone during sleep allows a susceptible airway to collapse.
Why the other options are less appropriate:
• A: Absent airflow plus absent respiratory effort characterizes central rather than obstructive apnea.
• B: OSA is dynamic and sleep dependent rather than a fixed tracheal lesion.
• D: Diffusion impairment does not produce repetitive obstructive apneas.
Anesthesia Pearl: General anesthetics, sedatives, and opioids can reproduce or intensify several mechanisms that normally
promote obstruction during sleep.
Exam Strategy: Airflow absent + effort present = obstructive apnea.
,Question 2.
An anesthesia plan is being developed for a patient with untreated severe OSA who will require postoperative analgesia.
Which complication deserves particular attention?
A. Opioid- and sedative-associated worsening of upper-airway obstruction and ventilatory depression
B. Complete resistance to respiratory depressant drugs
C. Guaranteed postoperative hypertension without airway problems
D. Reduced susceptibility to hypoxemia
ANS: A
Rationale: OSA patients are susceptible to postoperative upper-airway obstruction, hypoxemia, and respiratory
depression, particularly when opioids and sedating medications reduce arousal responses and ventilatory drive. SASM
educational guidance specifically emphasizes judicious use of opioids and respiratory depressants in this population. (SASM)
Why the other options are less appropriate:
• B: Respiratory depressants are a major concern rather than an ineffective class.
• C: Cardiovascular consequences may occur, but airway/ventilatory complications are central perioperative risks.
• D: OSA increases rather than decreases hypoxemic vulnerability.
Anesthesia Pearl: Postoperative respiratory risk often reflects the interaction of OSA severity + opioids + residual
anesthesia + sleep.
Exam Strategy: OSA + opioid = think obstruction and hypoventilation.
Question 3.
Polysomnography reports an apnea-hypopnea index of 42 events/hour.
How should this OSA severity generally be classified?
A. Normal
B. Mild
C. Moderate
D. Severe
ANS: D
Rationale: Common adult sleep-medicine categories classify OSA as approximately:
• Mild: AHI 5–14.9/hour
• Moderate: AHI 15–29.9/hour
• Severe: AHI ≥30/hour
An AHI of 42 therefore represents severe OSA. (AASM)
Why the other options are less appropriate:
• A: An AHI of 42 is markedly abnormal.
• B: Mild disease is below 15/hour.
• C: Moderate disease is below 30/hour.
Anesthesia Pearl: AHI is useful, but perioperative risk also depends on hypoxemic burden, comorbidity, PAP use, opioid
requirement, and postoperative environment.
Exam Strategy: Remember the anchors: 5, 15, 30.
Visual 2 — STOP-BANG Screening Table
Question 4.
Preoperative screening produces the following findings:
, STOP-BANG Element Finding Point
S — Snoring Loud nightly snoring 1
T — Tired Daytime fatigue 1
O — Observed apnea Yes 1
P — Pressure Treated hypertension 1
B — BMI >35 kg/m² BMI 39 1
A — Age >50 yr Age 47 0
N — Neck >40 cm 44 cm 1
G — Male Female 0
TOTAL 6/8
Which interpretation is most appropriate?
A. OSA is excluded because the patient is female
B. The patient screens as high risk for OSA
C. The score establishes central sleep apnea
D. No perioperative precautions are necessary until polysomnography is completed
ANS: B
Rationale: This patient scores 6/8, which is a high-risk STOP-BANG result. SASM material describes 5–8 positive responses
as high risk, 3–4 as intermediate, and 0–2 as low risk. (SASM)
Why the other options are less appropriate:
• A: Female sex contributes zero points but does not exclude OSA.
• C: STOP-BANG screens for obstructive sleep apnea, not central apnea.
• D: A high-risk screen should influence anesthetic and postoperative planning even before formal confirmation.
Anesthesia Pearl: Screening is useful because many surgical patients have clinically important but undiagnosed OSA.
Exam Strategy: STOP-BANG ≥5 = strong perioperative warning signal.
Question 5.
Repeated nocturnal obstructive events produce intermittent hypoxemia, hypercapnia, and frequent arousals.
Which chronic physiologic consequence is most strongly associated with this pattern?
A. Persistent parasympathetic dominance
B. Suppression of catecholamine release
C. Recurrent sympathetic activation contributing to cardiovascular stress and hypertension
D. Permanent reduction in systemic vascular resistance
ANS: C
Rationale: Repetitive airway obstruction causes hypoxemia, hypercapnia, intrathoracic pressure changes, and arousal.
These provoke recurrent sympathetic surges that contribute to systemic hypertension, arrhythmias, and other cardiovascular
consequences.
Why the other options are less appropriate:
• A: Sympathetic rather than parasympathetic activation is prominent.
• B: Catecholaminergic activity increases.
• D: Chronic OSA does not characteristically produce persistent low SVR.
Anesthesia Pearl: OSA is not simply “snoring”—it can be a cardiovascular stress disorder.
Exam Strategy: OSA chain: obstruction → hypoxia/arousal → sympathetic surge.
,Question 6.
Medication and equipment reconciliation shows that a patient with established OSA uses CPAP every night and has good
adherence.
Which perioperative plan is generally appropriate?
A. Discontinue CPAP for several days after surgery
B. Encourage continuation/resumption of the patient's prescribed PAP therapy during appropriate perioperative sleep periods
C. Replace CPAP routinely with supplemental oxygen alone
D. Use PAP only if cardiopulmonary arrest develops
ANS: B
Rationale: Patients who routinely use PAP should generally continue or resume therapy perioperatively when feasible.
SASM materials specifically recommend perioperative access to CPAP for known OSA patients and emphasize identifying
barriers when established users are nonadherent. (SASM)
Why the other options are less appropriate:
• A: Withdrawal removes an effective airway therapy.
• C: Oxygen does not splint open the upper airway.
• D: PAP is preventive/supportive therapy, not merely a resuscitation intervention.
Anesthesia Pearl: Asking a patient to bring their PAP device can be a meaningful part of perioperative planning.
Exam Strategy: Established effective therapy → do not unnecessarily remove it.
Question 7.
Airway examination documents severe OSA, BMI 42 kg/m², a large tongue, crowded oropharynx, and neck circumference of 46
cm.
Which anesthetic concern should be anticipated?
A. Potentially difficult mask ventilation and tracheal intubation
B. Guaranteed impossible supraglottic-airway placement
C. Absence of airway obstruction during sedation
D. Reduced need for preoxygenation
ANS: A
Rationale: OSA and the anatomic factors that predispose to pharyngeal collapse frequently overlap with predictors of
difficult mask ventilation and difficult laryngoscopy. SASM perioperative guidance explicitly recommends anticipating difficult
airway management in OSA. (SASM)
Why the other options are less appropriate:
• B: Difficulty is increased but not guaranteed.
• C: Sedation may worsen airway collapsibility.
• D: Preoxygenation is especially important in high-risk patients.
Anesthesia Pearl: The anatomy that obstructs the airway during sleep may also complicate airway management when the
patient is unconscious.
Exam Strategy: OSA should trigger both a respiratory-risk plan and an airway plan.
Question 8.
A patient with severe OSA is undergoing knee replacement.
Which postoperative analgesic strategy most effectively reduces respiratory risk while still treating pain?
A. High-dose continuous opioid infusion
B. Benzodiazepine plus opioid PCA without monitoring
,C. Avoid analgesia completely
D. Multimodal opioid-sparing analgesia, incorporating regional techniques when appropriate
ANS: D
Rationale: Opioid-sparing multimodal analgesia reduces exposure to respiratory depressants while maintaining effective
pain control. Regional analgesia, acetaminophen, NSAIDs when suitable, and other multimodal options can reduce systemic
opioid requirements.
Why the other options are less appropriate:
• A: Continuous opioids may exacerbate respiratory depression.
• B: Combining sedatives and opioids magnifies risk.
• C: Severe untreated pain is harmful and can itself impair respiratory recovery.
Anesthesia Pearl: The goal is less opioid—not less analgesia.
Exam Strategy: OSA analgesia question → look for multimodal + regional + opioid sparing.
Visual 3 — Airway Positioning Sketch
Question 9.
The airway team compares two induction positions for a patient with severe obesity and OSA.
approximately aligned with
Which position is generally preferable?
A. Trendelenburg
B. Ramped or head-elevated positioning
C. Extreme neck flexion
D. Flat supine positioning in every case
ANS: B
Rationale: Head-elevated/ramped positioning in obese patients can improve upper-airway alignment, preoxygenation, and
respiratory mechanics. SASM educational recommendations specifically identify head-elevated laryngoscopy positioning and
adequate preoxygenation as important OSA strategies. (SASM)
Why the other options are less appropriate:
• A: Trendelenburg may worsen respiratory mechanics.
• C: Extreme flexion can impair airway alignment.
• D: Flat positioning may reduce FRC and worsen oxygen reserve.
Anesthesia Pearl: Positioning is one of the few airway interventions that improves conditions before any drug is
administered.
Exam Strategy: Obesity + OSA airway → ramp early.
,Visual 4 — Desaturation Trend Graph
Question 10.
Two patients are adequately preoxygenated before induction. After apnea begins, the following illustrative trend occurs:
Seconds of apnea
Patient Y has severe obesity and OSA.
Which explanation best accounts for the more rapid desaturation?
A. Increased functional residual capacity
B. Decreased metabolic oxygen consumption
C. Reduced oxygen reserve from decreased FRC combined with relatively increased oxygen consumption
D. Complete inability of hemoglobin to bind oxygen
ANS: C
Rationale: Obesity reduces FRC, especially after induction and in the supine position. At the same time, oxygen
consumption is often increased. The combination reduces the size and duration of the pulmonary oxygen reservoir, producing
faster desaturation during apnea.
Why the other options are less appropriate:
• A: FRC commonly decreases.
• B: Oxygen consumption is not generally reduced.
• D: Hemoglobin binding remains intact unless another disorder is present.
Anesthesia Pearl: Difficult intubation becomes much more dangerous when the patient's safe apnea time is short.
Exam Strategy: Obesity → smaller tank + faster oxygen use.
Question 11.
At the end of surgery, an OSA patient has received a nondepolarizing neuromuscular blocker.
Which extubation condition is most appropriate?
A. Awake, appropriately responsive, adequately ventilating, with complete neuromuscular recovery
B. Deeply anesthetized with significant residual blockade
, C. Immediately after the final opioid dose regardless of ventilation
D. Before reversal is assessed
ANS: A
Rationale: Residual neuromuscular blockade can impair upper-airway muscle function and ventilation. An OSA patient
should generally have reliable reversal, adequate spontaneous ventilation, and protective airway responses before tracheal
extubation.
Why the other options are less appropriate:
• B: Residual anesthetic and neuromuscular effects increase obstruction risk.
• C: Opioid exposure can worsen ventilatory depression.
• D: Objective recovery should be confirmed.
Anesthesia Pearl: Small amounts of residual weakness can have a large effect on an already collapsible pharyngeal airway.
Exam Strategy: OSA extubation = awake + strong + fully reversed.
Question 12.
Once safely extubated, which postoperative positioning principle is useful for an OSA patient when surgical circumstances
permit?
A. Mandatory steep Trendelenburg
B. Flat supine position throughout recovery
C. Prone positioning in every case
D. Head-elevated or nonsupine positioning when feasible
ANS: D
Rationale: Supine positioning can promote gravitational narrowing of the upper airway. Head elevation or
lateral/nonsupine positioning can improve upper-airway patency and respiratory mechanics in selected OSA patients.
Why the other options are less appropriate:
• A: Trendelenburg may worsen upper-airway and respiratory mechanics.
• B: Supine sleep commonly worsens OSA.
• C: Prone positioning is not universally required or practical.
Anesthesia Pearl: Postoperative airway management includes position as well as equipment and medications.
Exam Strategy: OSA recovery → avoid unnecessary flat supine positioning.
Question 13.
PACU recovery has been uncomplicated, but a patient with severe untreated OSA will continue receiving systemic opioids
overnight.
Which disposition is most appropriate?
A. Unmonitored waiting-room chair
B. A postoperative environment providing appropriate continuous respiratory monitoring based on risk
C. Immediate discharge simply because SpO₂ is normal while awake
D. No monitoring once the patient falls asleep
ANS: B
Rationale: Higher-risk OSA patients—especially those receiving opioids or demonstrating postoperative respiratory
events—may require monitored care. SASM protocols describe continuous oximetry and enhanced monitoring for high-risk
patients after PACU discharge. (SASM)
Why the other options are less appropriate:
• A: This does not provide adequate surveillance.
• C: Awake saturation does not predict sleep-related obstruction after opioids.
