Ch. 4 Management of The Airway (Test 2)

Question 1

Main Causes of Upper Airway Obstruction

Answer 1

1. Tongue falling back against the posterior wall of
   the pharynx, which is caused by unconsciousness or central nervous system (CNS) abnormality; patients with macroglossia (enlarged tongue) are at greater risk
2. Edema, or postextubation inflammation and swelling of the glottic area
3. Bleeding
4. Secretions
5. Foreign substance
   - Foreign bodies
   - False teeth
   - Vomitus
   6.Laryngospasm

Question 2

Signs of Partial Upper Airway Obstruction

Answer 2

1. Crowing, gasping sounds on inspiration (stridor)
2. Inability to cough (with a slight obstruction, the patient may be able to cough)
3. Increasing respiratory difficulty
4. Good to poor air exchange (depending on the severity of the obstruction)
5. Exaggerated chest and abdominal movement without comparable air movement
6. Cyanosis

Question 3

Signs of Complete Upper Airway Obstruction

Answer 3

1. Inability to talk
2. Increased respiratory difficulty with no air
   movement
3. Cyanosis
4. Sternal, intercostal, and epigastric retractions
5. Use of accessory muscles of the neck and chest
6. Extreme panic
7. Unconsciousness and respiratory arrest if obstruction is not removed

Question 4

Treatment of Airway Obstruction

Answer 4

1. If the patient is conscious and has a partial airway obstruction, the patient should be monitored closely and allowed to try to relieve the obstruction on his or her own.
2. If the patient is conscious and has a complete airway obstruction caused by food or a foreign object, abdominal thrusts must be performed until the object is dislodged.
3. If the patient is unconscious and has a partial or complete airway obstruction that is most likely caused by the tongue, the head tilt and chin lift maneuver will help relieve the obstruction by moving the tongue forward.

Question 5

Oropharyngeal Airway

Answer 5

• This airway maintains a patent airway by lying between the base of the tongue and the posterior wall of the pharynx, preventing the tongue from falling back and occluding the airway.
• This airway must only be used on the unconscious patient because a conscious patient would gag on the airway, potentially leading to aspiration.

Question 6

Proper insertion of the oropharyngeal airway:

Answer 6

a. Measure the airway from the corner of the lip to the angle of the jaw to ensure proper length.
b. Remove foreign substances from the mouth.
c. Hyperextend the neck.
d. Using the cross-finger technique, open the
patient’s mouth, and insert the airway with the
tip pointing toward the roof of the mouth.
e. Observe the airway passing the uvula, and
rotate the airway 180 degrees.

Question 7

Nasopharyngeal Airway

Answer 7

This airway maintains a patent airway by lying between the base of the tongue and the posterior wall of the pharynx.

Question 8

How do you select the proper size for a nasopharyngeal airway

Answer 8

Select the proper size by measuring the airway
from the tip of the nose to the earlobe. The outside diameter of the airway should be equal to the inside diameter of the patient’s internal nares.

Question 9

Can a nasopharyngeal airway tolerated by the conscious patient and still allows the patient to eat, drink, and speak?

Answer 9

Yes

Question 10

Nasopharyngeal airways is most commonly used to facilitate nasotracheal suctioning.

Answer 10

Know

Question 11

Hazards of Nasopharyngeal airways

Answer 11

a. An airway that is too small may be aspirated.
b. Nasal irritation may result. To prevent nasal irritation, alternate nostrils daily.

Question 12

Laryngeal Mask Airway (LMA)

Answer 12

The LMA is designed to be used as an alternative to a face mask for achieving and maintaining control of the airway during surgery when tracheal intubation is not necessary, or in emergencies when ET intubation cannot be accomplished after several attempts.

Question 13

Indications for LMA

Answer 13

a. Difficult face mask fit
b. Unsuccessful intubation and difficulty ventilating with bag mask
c. Unavailability of personnel trained in ET
intubation
d. Elective surgical procedures

Question 14

Contraindications for LMA

Answer 14

a. Health care provider not trained in the use of the LMA
b. If risk of aspiration exists

Question 15

Advantages of the LMA

Answer 15

a. This airway can be quickly inserted to provide ventilation when bag-mask ventilation is not adequate and ET intubation cannot be accomplished.
b. VT delivered may be greater when the LMA is used as opposed to bag-mask ventilation.
c. There is less gastric insufflation than with bag-mask ventilation.
d. The LMA ventilates equally as well as an ET tube.

Question 16

___________ airways are made of hard plastic and have a groove down either side to guide a suction catheter to the glottic area.

Answer 16

Berman

Question 17

Guedel airways are made of a

Answer 17

a soft, pliable material that has an opening through the middle to allow the passing of a suction catheter into the glottic area.

Question 18

How do you properly measure a nasopharyngeal airway

Answer 18

from the tip of the nose to the earlobe.

Question 19

For a nasopharyngeal airway the flanged end should rest against the nose, and the distal tip should rest behind the uvula.

Answer 19

Know

Question 20

Disadvantages of LMA

Answer 20

• Does not provide protection agains aspiration
• Cannot be used if the mouth cannot be opened more than 0.6 inches

Question 21

Esophageal Tracheal Combitube is a

Answer 21

double-lumen tube. The tubes run parallel to each other

Question 22

Indications for the ETC

Answer 22

a. Difficult face mask fit
b. Unsuccessful intubation and difficulty ventilating with bag mask
c. No one available that has been trained in ET intubation

Question 23

Contraindications for the ETC

Answer 23

a. Patient with an intact gag reflex
b. Patient with known or suspected esophageal
disease
c. Patient known to have ingested a caustic substance
d. Suspected upper airway obstruction
because of laryngeal foreign body or
pathology
e. Patient less than 4 feet tall

Question 24

Advantages of the ETC

Answer 24

a. Minimal training and retraining required
b. Visualization of the upper airway or use
of special equipment not required for insertion

Question 25

Disadvantages of ETC

Answer 25

a. Proximal port may be occluded with
secretions
b. Difficulty in determining proper tube
location resulting in ventilation through
wrong tube
c. Soft tissue trauma because of rigidity of the
tube
d. Cannot suction the trachea if the tube is in
the esophagus
e. Esophageal trauma from poor insertion
technique

Question 26

The King Airway is similar to

Answer 26

the ETC but is a single-lumen tube rather than a double- lumen tube. This airway is placed in difficult-to- intubate patients to provide for adequate ventilation.

Question 27

King Airway sizes

Answer 27

Three sizes are available, and the appropriate size is based on the patient’s height: #3 tube for patients 4 to 5 feet tall, #4 tube for patients 5 to 6 feet tall, and #5 tube for patients over
6 feet tall.

Question 28

This is a visual observation made as the patient opens his or her mouth and sticks out the tongue. It determines the ease with which intubation can be accomplished. May also be helpful in determining the likelihood of obstructive sleep apnea (OSA).

Answer 28

Mallampati classification

Question 29

Class I

Answer 29

full visibility of tonsils, uvula, and soft palate

Question 30

Class 2

Answer 30

visibility of hard and soft palates, upper part of tonsils, and uvula

Question 31

Class 3

Answer 31

soft and hard palates and base of uvula are visible

Question 32

only hard palate is visible

Answer 32

Class 4

Question 33

The curved blade (Macintosh) should be inserted between the epiglottis and the base of the tongue (vallecula). With a forward and upward motion, raise the epiglottis to expose the glottis and vocal cords.

Answer 33

KNOW

Question 34

The straight blade (Miller) should be placed under the epiglottis and lifted upward and forward to expose the cords.

Answer 34

know

Question 35

If the tube is inserted too far it will enter the

Answer 35

right mainstream bronchus

Question 36

Never exceed 15 to 20 seconds per intubation at- tempt. The blade and tube in the back of the throat may stimulate the vagus nerve, which may lead to bradycardia. Remove the blade and tube and use bag-mask ventilation until cardiac status has stabilized.

Answer 36

KNOW

Question 37

End-tidal CO2 levels are generally around ___%

Answer 37

6%

Question 38

If the tube is in the esophagus, the end-tidal CO2 reading will remain

Answer 38

near zero

Question 39

The carina is seen on radiographs at the

Answer 39

fourth rib or at the fourth thoracic vertebra.

Question 40

Complications of ET tubes

Answer 40

a. Poorly tolerated by conscious or semiconscious
patients
b. Difficult to stabilize because of the movement
of the tube
c. Stimulates oral secretions
d. Gagging caused by tube irritation
e. More difficult to pass suction catheter as a result of the curvature of the tube and poor stabilization
f. Harder for the patient to communicate
g. Harder to attach equipment to a poorly stabi-
lized ET tube
h. Patient may bite the tube, occluding air flow
and setting off the ventilator high-pressure
alarm, which ends inspiration prematurely
i. Erodes corners of patient’s mouth

Question 41

Insert tracheostomy tubes through an incision (stoma)
made between the

Answer 41

second and third tracheal rings.

Question 42

Indications for tracheostomies

Answer 42

a. To bypass upper airway obstruction
b. To prevent problems posed by oral or nasal ET
tubes
c. To allow patient to swallow and receive nourishment
d. For long-term airway care (ET tubes should be left in no longer than 3 to 4 weeks)

Question 43

Immediate complications of tracheostomy tubes occurring within the first 24 hours and associated with the tracheotomy procedure: (4)

Answer 43

a. Pneumothorax
b. Bleeding
c. Air embolism from tearing of pleural vein
d. Subcutaneous emphysema

Question 44

Late complications of tracheostomy tubes
occurring more than 2 days after the tracheotomy: (9)

Answer 44

a. Hemorrhage
b. Infection
c. Airway obstruction
d. Tracheoesophageal fistula
e. Interference with swallowing
f. Rupture of innominate artery
g. Stomal stenosis
h. Tracheitis
i. Tracheal malacia

Question 45

If, after changing a tracheostomy tube, you observe subcutaneous emphysema and respiratory distress and can auscultate little or no air movement, the tube is malpositioned and must be removed immediately; ventilate the patient with bag and mask.

Answer 45

know

Question 46

Fenestrated tracheostomy tube is used to aid

Answer 46

in weaning the patient from a tracheostomy tube and to allow the patient to talk.

Question 47

Passy-Muir valve

Answer 47

speaking valve that is placed on the proximal end of the tracheostomy tube (with a 15-mm adapter).

Question 48

THE CUFF MUST BE DEFLATED WITH A PASSY-MUIR VALVE

Answer 48

KNOW

Question 49

Tubes should employ high-volume, low-pressure cuffs only because less occlusion to tracheal blood flow occurs as a result of the application of less pressure. They are also called floppy cuffs. If excessive air is placed in the cuff, it acts as a high-pressure cuff.

Answer 49

Know

Question 50

minimal leak technique

Answer 50

The cuff is slowly inflated to a point where only a slight leak is heard at maximal inspiration with a stethoscope over the vocal cords.

Question 51

MLT is not recommended because it may lead to silent aspiration of pharyngeal secretions, resulting in lower airway bacterial contamination, increasing the risk
of VAP.

Answer 51

know

Question 52

minimal-occluding-volume technique:

Answer 52

This is accomplished by slowly inflating the cuff to the point where no leak is heard.

Question 53

Cuff pressures must be kept below tracheal mucosal capillary perfusion pressure, which is approximately

Answer 53

20 to 30 cm H2O or 15 to 22 mm Hg

Question 54

If the cuff is inflated above 30 cm H2O and a leak is still heard, continue inflating the cuff using the minimal-occluding-volume technique. It may be that the ET tube is too small and that more air must be taken into the cuff to adequately seal the airway. In this case the cuff pressure does not relate to the pressure on the tracheal wall. To be safe, what should be done

Answer 54

replace the ETT with a larger one

Question 55

The suction catheter should not occupy more
than one half of the internal diameter of the
tube. (Suction catheters are sized by Fr units.)

Answer 55

know

Question 56

To estimate the proper catheter size, multiply the internal diameter of the
ET x 3 /2

Answer 56

Know

Question 57

Suction catheters come in the following sizes:

Answer 57

61⁄2 Fr, 8 Fr, 10 Fr, 12 Fr, 14 Fr, 16 Fr.

Question 58

Although the manufacturers recommend changing the closed suction system daily, studies show that the system may be changed

Answer 58

once per week.

Question 59

Yankauer suction is used to

Answer 59

suction the oropharynx

Question 60

Hazards of tracheal suctioning

Answer 60

• Hypoxemia
• Arrythmias
• Hypotension
• Atelectasis
• Tissue trauma

Question 61

Coude suction catheter:

Answer 61

angled-tip catheter used to suction the left mainstem bronchus

Question 62

Indications for tracheal suctioning (3)

Answer 62

a. To remove retained secretions that the patient
cannot mobilize
b. To maintain patency of artificial airways
c. To obtain sputum for culture and sensitivity testing

Question 63

Appropriate suction levels:
Adults

Answer 63

-100 to -120 mm Hg (-150 mm Hg maximum)

Question 64

Appropriate suction levels:
Children

Answer 64

-80 to -100 mm Hg (-120 mm Hg max)

Question 65

Appropriate suction levels:
Infants

Answer 65

-60 to -80 mm Hg (-100 mm Hg max)

Question 66

When do you withdraw the tube out while extubating?

Answer 66

Peak inspiration

Question 67

Complications of Extubation

Answer 67

• Laryngospasm
• Glottic edema

Question 68

Inspiratory stridor is the major clinical sign, caused by (4)

Answer 68

a. Traumatic intubation
b. Insertion with oversized ET tube
c. Poor ET tube maintenance
d. Allergic response to material in the
ET tube

Question 69

Stridor should be treated with:

Answer 69

A. Vasoconstrictor such as racemic epinephrine via handheld nebulizer to constrict mucosal blood vessels and reduce swelling
b. Corticosteroids such as dexamethasone (Decadron) to reduce swelling
c. Intubation or reintubation is necessary when severe or marked inspiratory stridor is present

Question 70

A patient has just been intubated, and the CO2 detector placed on the proximal end of the endotracheal (ET) tube reads 1.5%. The respiratory therapist should suspect which of the following?

A. The tube is in the trachea.
B. The tube is in the right mainstem bronchus and should be withdrawn 4 cm.
C. The tube is in the esophagus.
D. The tube is at the level of the carina and should be withdrawn 2 cm.

Answer 70

The tube is in the esophagus

If the ET tube is in the trachea, the CO2 detector should read approximately 5% to 6%. A level of only 1.5% indicates that the tube cannot be in the trachea but is in the esophagus.

Question 71

Which of the following statements is true regarding the King Airway?

A. It is a double-lumen tube placed in the esophagus to ventilate difficult-to-intubate patients.
B. The airway can be used only on patients at least 5 feet tall.
C. The airway utilizes one cuff, which is inflated with 45 to 90 mL of air to block off the oropharynx.
D. Because of the length of the airway, it is unlikely that the trachea can be intubated inadvertently.

Answer 71

Because of the length of the airway, it is unlikely that the trachea can be intubated inadvertently

The King Airway is a single-lumen esophageal airway that can be used on patients 4 to 6 feet tall. It is shorter in length than the Combitube, making it unlikely to be accidentally placed in the trachea.

Question 72

Magill forceps are used during which of the following procedures?

A. Nasotracheal intubation
B. Oral intubation
C. Tracheotomy
D. Insertion of an esophageal tracheal Combitube (ETC

Answer 72

Nasotracheal intubation

Magill forceps are a curved instrument used to grasp the ET tube and advance it through the vocal cords during nasotracheal intubation.

Question 73

The physician wants to begin weaning a patient from a tracheostomy tube. How can this best be accomplished?

A. Deflate the cuff every 2 hours.
B. Change to a fenestrated tracheostomy tube.
C. Keep the cuff inflated and remove the inner cannula.
D. Change to a tracheostomy tube with a foam cuff.

Answer 73

Change to a fenestrated tracheostomy tube.

Question 74

You are called to a patient’s room because a ventilator alarm is sounding. You hear an audible leak around the patient’s ET tube during a ventilator breath and notice the exhaled volume reading is 150 mL less than the set VT. You check the cuff pressure and find that it is 12 cm H2O. Which of the following is the appropriate action to take?

A. Maintain the current cuff pressure and increase the patient’s VT to compensate for the leak.
B. Instill enough air to maintain a cuff pressure of 30 mm Hg.
C. Instill air into the cuff to a pressure of 20–30 cm H2O.
D. Instill enough air until only a slight audible leak is heard.

Answer 74

Instill air into the cuff to a pressure of 20–30 cm H2O.

Question 75

You want to pass a suction catheter into the patient’s left lung to obtain a sputum specimen. What is the most appropriate method of accomplishing this?

A. Have the patient turn his or her head to the left.
B. Have the patient turn his or her head to the right.
C. Use a coude suction catheter.
D. Use a catheter that is one half the internal diameter
of the patient’s airway.

Answer 75

Use a coude suction catheter.

Question 76

The respiratory therapist is using a 12-French (Fr) suction catheter to suction a female patient who is intubated with a 7.0-mm ET tube and is having difficulty removing the thick secretions. The suction pressure used is -120 mm Hg. Which of the following should be recommended to correct this problem?

A. Increase the suction pressure to -140 mm Hg.
B. Instill 5 mL of normal saline down the ET tube.
C. Change to a 14-Fr suction catheter.
D. Change to a coude-tipped suction catheter.

Answer 76

Increase the suction pressure to -140 mm Hg.

It is permissible to use suction pressures of up to -150 mm Hg in order to remove thick, tenacious secretions, although a range of -80 to -120 mm Hg should be tried first. The 12-Fr suction catheter is appropriate for the 7.0-mm ET tube, with a 14-Fr catheter being too large. A method for determining the proper size catheter is to multiply the ET tube size by 2 and drop down to the next number that would be a catheter size. Instilling saline is not recommended due to the potential of washing bacteria from the proximal end of the tube down into the airway. Also, studies indicate that instilling saline does not effectively thin secretions to improve mobilization.

Question 77

The respiratory therapist is called to pediatric ICU to suction a 6-year-old ventilator patient with pneumonia who is intubated with a 5.0-mm ET tube. Which of the following represents the most appropriate catheter size and suction pressure to use on this patient?

A. 8-Fr catheter, -100 mm Hg
B. 10-Fr catheter, -60 mm Hg
C. 8-Fr catheter, -60 mm Hg
D. 10-Fr catheter, -100 mm Hg

Answer 77

8-Fr catheter, -100 mm Hg

To determine the proper size suction catheter, one that occupies no more than one half the internal diam- eter of the ET tube, multiply the ET tube size by 2 (5.0 x 2 =10) and drop down to the next lowest number that represents a catheter size, in this case an 8-Fr. The appropriate suction level for a pediatric patient is -80 to -100 mm Hg, although a maximum of -120 mm Hg may be used if necessary.

Question 78

Which of the following will increase the possibility of the ET tube cuff causing tracheal mucosa damage?

1. Maintaining intracuff pressure of 38 cm H2O
2. Using minimal leak technique
3. Using a low-volume, high-pressure cuff
4. Using minimal occluding volume technique

Answer 78

1 and 3

Cuff pressures of more than 30 cm H2O and high- pressure cuffs will both increase the incidence of dam- age to the tracheal wall.

Question 79

An intubated patient begins exhibiting severe respiratory distress, and the respiratory therapist auscultates no breath sounds and determines that there is no gas flow passing through the end of the ET tube. The high-pressure alarm is sounding on the ventilator. Which of the following should the therapist do at this time?

A. Instill 5 mL of saline down the ET tube and suction.
B. Extubate and manually ventilate the patient.
C. Obtain an arterial blood gas.
D. Recommend a stat chest x-ray.

Answer 79

Extubate and manually ventilate the patient.

When taking the NBRC exams, be alert for adjectives such as mild, moderate, and severe or marked, since these will often dictate the necessary course of action. In this question, the patient is in severe respiratory distress and no gas is flowing out the end of the tube. This patient is not getting ventilated; therefore the tube must be removed in order to ventilate the patient.

Question 80

The average distance from the teeth to the carina is 27 CM in males and 25 CM and females

Answer 80

Know

Question 81

On average How many breaths before we get color change on the colorimetric

Answer 81

6 breaths