Ch. 18 Test, Troubleshooting Flashcards
When an alarm is activated on a ventilator, the RT’s first priority is
Patient safety is the foremost obligation of the respiratory therapist. Whenever an alarm activates on a ventilator, the respirator therapist first should make sure the patient is adequately ventilated and oxygenated. To do this, the respiratory therapist can assess the patient’s level of consciousness, use of accessory muscles, and chest wall movements; determine whether bilateral breath sounds are present; and evaluate the heart rate and SpO2
Removing a patient from a ventilator to ventilate manually can lead to which of the following?
- Barotrauma
- Lung derecruitment
- Increased airway resistance
- Ventilator-acquired pneumonia
a. 1, 2, and 3
b. 1, 2, and 4
c. 2, 3 and 4
d. 3 and 4
ANS: B
Removing a patient from the ventilator for manual ventilation can inadvertently cause barotrauma by using excessive pressure during ventilation (>40 cm H2O). Disconnecting a patient who is being ventilated with a high level of PEEP (15 to 25 cm H2O) can cause derecruitment of the lung. Disconnection of the ventilator can cause contamination of the patient’s airway, increasing the patient’s risk of developing ventilator-associated pneumonia.
A 68-year-old woman was admitted to the ICU with pneumonia and was intubated when she developed progressive hypoxemia. She has been on the ventilator for 5 days and has been tolerating this therapy well. The patient has suddenly become severely agitated and appears to be fighting the ventilator. The ventilator’s high pressure alarm is sounding continuously. The respiratory therapist disconnects the patient from the ventilator and begins manual ventilation with 100% oxygen and PEEP. The resuscitator bag is difficult to squeeze, breath sounds are present on the left with no adventitious sounds and absent on the right side, and percussion reveals hyperresonance over the right side. The most appropriate action to address this situation is which of the following?
a. Pull the endotracheal tube back until bilateral breath sounds are heard.
b. Administer a bronchodilator and suction the endotracheal tube.
c. Extubate the patient and reintubate with a larger endotracheal tube.
d. Insert a 14-gauge needle in the second intercostal space, midclavicular line, right side.
ANS: D
If the endotracheal tube had slipped into the right mainstem bronchus, breath sounds would be heard on the right side and not on the left. The absence of breath sounds on the right side indicates that the endotracheal tube has not slipped into the right mainstem bronchus. No adventitious breath sounds are heard over the left lung, the patient has no history of bronchospasm, and no wheezing is heard—this essentially eliminates bronchospasm as the problem. The patient had been tolerating mechanical ventilation well for 5 days; therefore, the ET tube is not too small. The presence of auto PEEP would cause hyperresonance to percussion bilaterally. The patient apparently has a pneumothorax on the right side, as evidenced by the absence of breath sounds and hyperresonance to percussion on that side.
The respiratory therapist is called to the bedside of a patient mechanically ventilated in the VC-CMV mode because the low pressure, low exhaled tidal volume, and low exhaled minute volume alarms all have activated. This situation could be caused by which of the following?
a. Patient biting the endotracheal tube.
b. Rupture of the endotracheal tube cuff.
c. Slipping of the endotracheal tube into the right mainstem.
d. Plugging of the airways by airway secretions and mucus.
ANS: B
With rupture of the ET tube cuff, volume escapes the system rather than being delivered to the patient. This activates the low pressure alarm and eventually leads to activation of the low tidal volume and low minute volume alarms. All the other options would activate the high pressure alarm.
The initial step in the management of patient-ventilator asynchrony is which of the following?
a. Lower the high pressure alarm setting.
b. Check the endotracheal tube cuff pressure.
c. Ventilate the patient with a manual resuscitator bag.
d. Check the low and high pressure alarm settings.
ANS: C
If the patient is in severe distress, the first step is to disconnect the patient from the ventilator and carefully ventilate the patient using a manual resuscitation bag.
At 1030 the respiratory therapist is called to the bedside of a patient being mechanically ventilated with VC-IMV. The patient is a 55 kg female who has been intubated with a size 8 endotracheal tube. Currently, the ET tube is located 20 cm at the gum line. During spontaneous breathing, the patient shows lack of coordinated chest wall movement, and the respiratory therapist notes some retraction of the intercostal spaces. The respiratory therapist performs a system check. The current and past few patient-ventilator system checks reveal the following information:
Time 0430 0640 0835 1030
PIP (cm H2O) 28 31 34 41
Pplateau (cm H2O) 18 21 19 20
The most appropriate action to take in this situation is which of the following?
a. Deflate the cuff and reposition the endotracheal tube.
b. Request that the patient receive haloperidol and midazolam.
c. Administer albuterol via an in-line metered-dose inhaler.
d. Switch the mode to PC-IMV and increase the rate.
ANS: C
The lack of coordinated chest wall movement, the intercostal retractions, and the increased transairway pressure (seen at 1030) indicate bronchospasm. This can be confirmed by auscultating the patient’s chest. The patient should be suctioned before receiving the bronchodilator to remove any mucus. The sudden onset rules out an insidious increase in mucus. The ET tube is properly placed at the 20 cm mark and therefore does not require repositioning. This patient is not displaying any evidence of agitation, delirium, or anxiety; therefore, administration of haloperidol and midazolam is not appropriate in this situation. There also is no evidence of a need to change from volume to pressure control or to increase the set rate at this time.
A patient with a past medical history of COPD was placed on a ventilator after upper abdominal surgery for a serious wound infection. Although the patient was medically stable, a tracheostomy was performed 2 weeks later because the patient was unable to be weaned from the ventilator. The patient is on VC-CMV, rate = 12, VT = 700 mL, FIO2 = 40%, PEEP = 5 cm H2O, with an HME. The respiratory therapist notes that the patient is assisting at a rate of 18 and has bilaterally decreased breath sounds in the bases. The respiratory therapist suctions a moderate amount of very thick, tenacious yellow sputum from the tracheostomy tube. What action should the respiratory therapist take?
a. The HME should be replaced with an active heated humidifier system.
b. No action is necessary, because there seems to be no patient problem.
c. The patient should be suctioned on a regular schedule instead of when needed.
d. PEEP and the FIO2 should be increased, and diuretic and positive inotropic agents should be administered.
ANS: A
This patient seems to have a secretion problem, as evidenced by the very thick, tenacious yellow sputum suctioned from the ET tube. The thickness of the sputum indicates drying of the secretions. To alleviate this problem, the HME should be replaced with a heated humidification system.
Reduction of preload and afterload is important in the management of which of the following?
a. Pulmonary embolism
b. Dynamic hyperinflation
c. Cardiogenic pulmonary edema
d. Noncardiogenic pulmonary edema
ANS: C
Cardiogenic pulmonary edema and heart failure often can be managed successfully with medications that reduce preload, increase contractility, and reduce afterload; such medications include furosemide (Lasix), digoxin (Lanoxin), enalaprilat (Vasotec), and morphine.
An increased arterial-to-end-tidal partial pressure CO2 gradient can help identify which of the following?
a. Pulmonary embolism
b. Dynamic hyperinflation
c. Cardiogenic pulmonary edema
d. Noncardiogenic pulmonary edema
ANS: A
Capnographic findings can provide a clue to the presence of a PE. A decrease in the end-tidal carbon dioxide (PetCO2) value compared with previous readings and a widening of the arterial-to-end-tidal partial pressure CO2 gradient (P[a-et]CO2) may suggest the presence of an embolus.
The respiratory therapist enters the room of an intubated and mechanically ventilated patient to find the low pressure, low exhaled volume, and low VE alarms active. The ventilator circuit is connected to the patient’s endotracheal tube. This situation could be caused by which of the following?
a. Improper flow rate and flow pattern.
b. Poorly responsive internal demand valve.
c. Migration of the ET tube into the upper airway.
d. The patient is continuing to actively inhale.
ANS: C
A combination of low pressure, low exhaled volume, and low VE alarms indicates a leak in the patient-ventilator system. This can be caused by migration of the ET tube into the upper airway. Because there is no longer a seal, gas does not travel into the lungs. Active inhalation may activate the low pressure alarm, but it would not activate the low volume and low VE alarms. On the contrary, there may be more volume than set on current ventilators.
A patient is intubated and set up on VC-CMV. After stabilization and suctioning of the ET tube, the peak inspiratory pressure (PIP) is 25 cm H2O. The low pressure and high pressure alarms should be set at _____________ cm H2O and _____________ cm H2O, respectively.
a. 5, 35
b. 10, 30
c. 12, 40
d. 15, 35
ANS: D
The low pressure alarm should be set 5 to 10 cm H2O below the PIP, and the high pressure alarm should be set about 10 cm H2O above the PIP. Therefore, with a PIP of 25 cm H2O, the low pressure alarm should be set at 15 to 20 cm H2O and the high pressure alarm at 35 cm H2O.
The respiratory therapist enters the room of an intubated and mechanically ventilated patient to find the high pressure, low exhaled volume, and low VE alarms active. This situation could be caused by which of the following?
a. Improper flow rate and flow pattern.
b. Migration of the ET into the upper airway.
c. The patient is out of synchrony with the ventilator.
d. The ventilator has an internal malfunction.
ANS: C
A high pressure alarm may also be triggered when a patient actively breathes out of synchrony with the ventilator. The PIP rises if the patient actively exhales while the ventilator is in the inspiratory phase, and this can activate the high pressure alarm.
DIF: 2 REF: p. 361
An apnea alarm may be activated by which of the following?
a. Secretions
b. Auto PEEP
c. Loss of PEEP
d. Active inhalation
ANS: B
In a spontaneous mode, the presence of auto PEEP can cause the patient difficulty in triggering the ventilator. As a result, the patient’s efforts can go undetected, and the ventilator misinterprets this as apnea.
DIF: 1 REF: p. 362-363
The flow-time curve shows small oscillations after the peak flow rate has been reached. The respiratory therapist can alleviate this by making which of the following ventilator adjustments?
a. Increase the set flow rate.
b. Increase the inspiratory time.
c. Decrease the inspiratory rise time.
d. Increase the inspiratory rise time.
ANS: D
The oscillations on the flow-time curve represent a phenomenon known as ringing, spiking, or overshoot. This is due to a nonsmooth breath delivery. Increasing the inspiratory rise time smoothes out the breath delivery by increasing the time it takes for the ventilator to reach the set flow rate.
DIF: 3 REF: p. 369-370
Use of an externally powered, small-volume nebulizer for aerosol delivery during partial ventilatory support with PSV may cause which of the following?
- High VT alarm activation
- Triggering difficulties
- Low pressure alarm activation
- Ventilator inoperative alarm
a. 1 and 2
b. 2 and 3
c. 3 and 4
d. 1 and 4
ANS: A
When a continuous flow nebulizer is placed between the patient and the sensing mechanism, the patient often finds it more difficult to generate the effort to trigger the ventilator. High VT delivery can occur when externally powered, small-volume nebulizers are used for aerosol delivery.
DIF: 1 REF: p. 371
