Ch. 8 Test, Initial Pt Assessment Flashcards

1
Q

The first step in the assessment and documentation of patient-ventilator interaction following the placement of a patient on a mechanical ventilator is which of the following?

a. Verifying physician’s orders
b. Verifying a passing operational verification procedure
c. Checking the integrity of the ventilator circuit and the humidifier system
d. Assessment of the patient’s vital signs, breath sounds, and level of consciousness

A

ANS: A
The first step in the process of assessment and documentation of patient-ventilator interaction after a patient has been placed on a mechanical ventilator involves the respiratory therapist verifying the physician’s orders. The second step is to verify that the ventilator passed an operational verification procedure (OVP). The OVP involves checking the integrity of the ventilator circuit and the humidification system. The patient assessment is performed during the patient-ventilator system check.

DIF: 1 REF: pg. 125

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2
Q

The operational verification procedure (OVP) involves checking the ventilator circuit for leaks. Ventilator settings that could be used to perform this procedure include which of the following?

a. Tidal volume (VT) = 500 mL, Flow rate = 60 L/min, High pressure limit = 50 cm H2O
b. VT = 1000 mL, Flow rate = 20 L/min, High pressure limit = maximum
c. VT = 500 mL, Flow rate = 20 L/min, High pressure limit = maximum, Inspiratory pause = 2 seconds
d. VT = 200 mL, Flow rate = Maximum, High pressure limit = 50 cm H2O, Inspiratory pause = 1 second

A

ANS: C
To check for leaks in the ventilator circuit the operator should set the tidal volume to 500 mL, the gas flow low (e.g., 20 L/min), the maximum pressure limit high (e.g., 100 to 120 cm H2O), and an inspiratory pause of 1 to 2 seconds.

DIF: 1 REF: pg. 125

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3
Q

How often should the fractional inspired oxygen (FIO2) of an adult be measured with an oxygen analyzer?

a. Twice daily
b. Continuously
c. Every patient-ventilator system check
d. Every other patient-ventilator system check

A

ANS: C
The fractional inspired oxygen (FIO2) for a ventilated adult should be measured during each patient-ventilator system check.

DIF: 1 REF: pg. 125

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4
Q

How long after beginning mechanical ventilation on a patient should an arterial blood gas sample be drawn?

a. 5 minutes
b. 10 minutes
c. 15 minutes
d. 20 minutes

A

ANS: C
An arterial blood gas sample should be obtained about 15 minutes following the initiation of mechanical ventilation. This is vital for the evaluation of the effectiveness of ventilation and oxygenation.

DIF: 1 REF: pg. 126

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5
Q

A female patient who is 5’7” tall and weighs 68 kg is being mechanically ventilated with volume-controlled continuous mandatory ventilation (VC-CMV), set rate 12, patient trigger rate 25 bpm, tidal volume (VT) 500 mL, set flow rate 60 L/min, fractional inspired oxygen (FIO2) 40%, positive-end-expiratory pressure (PEEP) 5 cm H2O. The patient is currently in distress using accessory muscles of inspiration. A patient-ventilator system check is performed by the respiratory therapist. The flow-time waveform shows a failure of the expiratory flow to return to zero before the next breath is triggered. The most appropriate action for the respiratory therapist to take includes which of the following?

a. Sedate the patient.
b. Switch to pressure-controlled continuous mandatory ventilation (PC-CMV).
c. Decrease set rate to 8 bpm.
d. Switch to volume-controlled synchronized intermittent mandatory ventilation (VC-SIMV).

A

ANS: D
There are two clues to the fact that this patient is having problems because of unintended positive-end-expiratory pressure (auto-PEEP): the patient’s trigger rate of 25 bpm and the flow-time curve not returning to zero before the next breath is triggered. Sedating the patient is not the most appropriate action to take in this situation. Sedating and paralyzing the patient is reserved as a last resort for respiratory distress from patient-ventilator asynchrony. Switching to pressure-controlled continuous mandatory ventilation (PC-CMV) will most likely not change the situation too much, unless the pressure is markedly reduced to reduce the tidal volume. Decreasing the set rate to 8 bpm will not affect the patient’s trigger rate and therefore will not change the situation. Switching to a mode where there is more spontaneous breathing is an acceptable strategy for dealing with auto-PEEP.

DIF: 3 REF: pgs. 128, 129

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6
Q

Calculate the volume delivered to the patient when the tubing compliance (CT) is 2.5 mL/cm H2O, the tidal volume (VT) at the exhalation port is 550 mL, and the peak inspiratory pressure (PIP) is 28 cm H2O.

a. 70 mL
b. 330 mL
c. 480 mL
d. 620 mL

A

ANS: C
Volume Lost = PIP × CT and Delivered VT = measured VT – volume lost

DIF: 2 REF: pgs. 129, 130

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7
Q

A 6’2” male patient is being ventilated in the volume-controlled continuous mandatory ventilation (VC-CMV) mode with a set tidal volume (VT) of 650 mL. There is 40 mL of mechanical dead space. Calculate the final alveolar ventilation.

a. 432 mL
b. 445 mL
c. 510 mL
d. 535 mL

A

ANS: A
Volume of anatomical dead space (VDanat) = 1 mL/lb ideal body weight (IBW);
IBW = 106 + 6 (ht inches – 60); tidal volume (VT)  volume of mechanical dead space (VDmech)  VDanat

DIF: 2 REF: pg. 130

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8
Q

An increasing PIP may indicate which of the following?

a. Decreasing lung compliance
b. Decreasing airway resistance
c. Leak in the ventilator circuit
d. Increasing dynamic compliance

A

ANS: A
Compliance is equal to tidal volume divided by peak inspiratory pressure (PIP). If the PIP is rising the compliance is decreasing. Therefore, the answer is “A.” An increasing PIP would be caused by a rise in airway resistance and decreased dynamic compliance. A leak in the system would be indicated by a decreased PIP.

DIF: 1 REF: pg. 131

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9
Q

A pathophysiologic condition that causes an increase in peal inspiratory pressure (PIP) while transairway pressure (PTA) remains the same is which of the following?

a. Acute respiratory distress syndrome (ARDS)
b. Asthma
c. Emphysema
d. Chronic Bronchitis

A

ANS: A
An increase in peak inspiratory pressure (PIP) with a constant transairway pressure (PTA) is due to an increase in plateau pressure (Pplateau). The most common reason for a rise in Pplateau is acute respiratory distress syndrome (ARDS). The three other choices are all obstructive diseases that would cause an increase in the PTA with no significant change in Pplateau.

DIF: 1 REF: pg. 131

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10
Q

During the course of several patient-ventilator system checks a respiratory therapist notices that the patient’s peak inspiratory pressure (PIP) is rising, while the plateau pressure (Pplateau) has remained the same. This most likely indicates which of the following?

a. Decrease in dynamic compliance
b. Increase in airway resistance
c. Decrease in static compliance
d. Increase in elastic recoil of alveolar walls

A

ANS: B
The difference between the peak inspiratory pressure (PIP) and plateau pressure (Pplateau) readings (PIP - Pplateau) is the transairway pressure (PTA). PTA is the amount of pressure required to overcome airway resistance (Raw) (Raw = PTA/Flow). Notice that PTA includes the resistance of the endotracheal tube (ET). A higher than expected difference between PIP and Pplateau suggests an increased Raw.

DIF: 2 REF: pg. 131

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11
Q

The data on the following ventilator flow sheet for a patient being ventilated in the volume-controlled continuous mandatory ventilation (VC-CMV) mode demonstrates which of the following?

Time   	PIP Pplat PEEP Exh.VT  Flow rate
0800	35	30	5 	1000	60
1000	39	34	5   	1000	60
1100	45	39	5 	1000	60
1130	50	44	5 	1000	60

a. Airway resistance is increasing.
b. Lung compliance is decreasing.
c. Dynamic compliance is increasing.
d. Water is accumulating in the patient circuit.

A

ANS: B
This ventilator flow sheet shows that while the peak inspiratory pressure (PIP) and plateau pressure (Pplateau) are both increasing over the course of the 3 hours, the transairway pressure (PTA = PIP  Pplateau) has remained almost unchanged (either 5 cm H2O or 6 cm H2O). This means that there has been little change in airway resistance between 0800 and 1130. What is demonstrated is that there is an increase in the Pplateau and that reflects an increase in the elastic resistance of the alveolar walls and thoracic cage against the volume being delivered. This is due to decreasing lung compliance or stiffening of the lungs. The other answers would cause an increase in the PTA.

DIF: 2 REF: pg. 131

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12
Q

A patient’s transairway pressure (PTA) is rising while the plateau pressure (Pplateau) remains unchanged. The treatment plan that could correct this problem includes which of the following?

  1. Administer a bronchodilator.
  2. Insert a chest tube.
  3. Increase extrinsic positive-end-expiratory pressure (PEEPE)
  4. Suction airway secretions.
    a. 2 only
    b. 2 and 4 only
    c. 1 and 4 only
    d. 1 and 3 only
A

ANS: C
An increase in the transairway pressure (PTA) reflects the need for an increased amount of pressure to overcome airway resistance (Raw). Raw most often increases when the patient`s airway needs suctioning, the patient is biting on the tube, the tube is kinked, or the patient has mucosal edema or bronchospasms (or both). Bronchospasm is treated with the administration of a bronchodilator, and retained airway secretions may be removed by suctioning. The presence of a pneumothorax requiring a chest tube would manifest an increase in plateau pressure (Pplateau) along with other signs not present in this scenario. If the Pplateau had been increased or if there was intrinsic positive-end-expiratory pressure (PEEPI), increasing extrinsic positive-end-expiratory pressure (PEEPE) might be a viable solution.

DIF: 3 REF: pg. 132

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13
Q

The respiratory therapist is evaluating the following ventilator flow sheet. The recommendation that is most appropriate in this situation is which of the following?

Time PIP	Pplat PEEPE Exh.VT Flow rate
0800  35	30	5	     1000		60
1000  39	34	5	     1000	        60
1100  45	39	5	     1000      	60
1130  50	44	5	     1000		60

a. Increase extrinsic positive-end-expiratory pressure (PEEPE).
b. Suction the airway.
c. Switch out the heat moisture exchanger (HME).
d. Administer a bronchodilator.

A

ANS: A
What is demonstrated here is that there is an increase in the plateau pressure (Pplateau) and this reflects a decreasing lung compliance or stiffening of the lungs. Adding extrinsic positive-end-expiratory pressure (PEEPE) to this patient could result in a decrease in the Pplateau. Since the transairway pressure (PTA) has remained stable over the 3.5 hours, there is no increase in airway resistance and no need to suction the airway, switch out the heat moisture exchanger (HME), or administer a bronchodilator.

DIF: 3 REF: pg. 132

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14
Q

Following initiation of volume-controlled continuous mandatory ventilation (VC-CMV) ventilation, the patient’s average peak inspiratory pressure (PIP) is 23 cm H2O. The high pressure limit alarm should be set at which of the following?

a. 28 cm H2O
b. 33 cm H2O
c. 38 cm H2O
d. 43 cm H2O

A

ANS: B
The high pressure limit alarm should be set to about 10 cm H2O.

DIF: 1 REF: pg. 133

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15
Q

A 31-year-old woman is admitted to the emergency department following a motor vehicle accident. The paramedics brought her into the ER in respiratory distress. She was intubated in the field and started on mechanical ventilation as soon as she arrived. Breath sounds were clear on the left and absent on the right. Percussion revealed resonance on the left and hyperresonance on the right. The patient’s trachea was shifted to the left. The most likely cause of this patient’s clinical presentation is which of the following?

a. Acute respiratory distress syndrome (ARDS)
b. Flail chest
c. Pneumothorax
d. Pleural effusion

A

ANS: C
Absent breath sounds on the right side with hyperresonance means there is excessive air in the pleural cavity on the right side. A tracheal shift to the left indicates that there is either a right- sided pneumothorax or left-sided atelectasis. The presence of the hyperresonance with the tracheal shift and absent breath sounds points to the pneumothorax.

DIF: 2 REF: pg. 133

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16
Q

A 46-year-old male patient is 2 days post-op for surgery to repair and aortic aneurysm. He is currently receiving mechanical ventilation. Auscultation of the anterior and posterior chest reveals bilateral late inspiratory crackles. Percussion is dull in both lower lobes. A STAT radiograph reveals bibasilar infiltrates. The most likely cause of this patient’s clinical presentation is which of the following?

a. Asthma
b. Pneumonia
c. Pneumothorax
d. Pleural effusion

A

ANS: B
Late inspiratory crackles and infiltrates on the chest x-ray are indicative of consolidation due to pneumonia. A patient having an asthma exacerbation would present with wheezing, hyperresonance on percussion, and increased radiolucency on x-ray. A patient with a pneumothorax would have unilateral absence of breath sounds, hyperresonance on percussion over the affected area, and lack of vascular markings over the affected area on x-ray. A pleural effusion manifests itself on x-ray as a blunting of the costophrenic angle on the affected side, a pleural friction rub just above the fluid level, and dullness to percussion over the pleural effusion.

DIF: 2 REF: pg. 135

17
Q

The respiratory therapist is performing a physical assessment of a patient receiving pressure support ventilation. The patient is short of breath, has a respiratory rate of 28 breaths per minute, a dull percussion note over the right base that becomes resonant over the right upper lobe, and resonance over the left lung. Chest movement on the right side is decreased. The STAT chest x-ray reveals a blunting of the right costophrenic angle. The pulmonary disorder that is causing this clinical presentation is which of the following?

a. Acute respiratory distress syndrome (ARDS)
b. Emphysema
c. Pneumothorax
d. Pleural effusion

A

ANS: D
The dullness over the right base along with the resonance over the right upper lobe means that there is something either in or around the right lower lobe that is causing the dullness. The blunting of the right costophrenic angle along with the dull percussion over the right base points to a right side pleural effusion.

DIF: 2 REF: pg. 135

18
Q

To reduce the risk of tracheal damage associated with overinflated tube cuffs, intracuff pressures should not exceed what range of pressures?

a. 10 – 15 mm Hg
b. 15 – 20 mm Hg
c. 20 – 25 mm Hg
d. 25 – 30 mm Hg

A

ANS: C
Intracuff pressures should not exceed 20 to 25 mm Hg (27 to 34 cm H2O).

DIF: 1 REF: pgs. 136, 137

19
Q

The respiratory therapist is monitoring the cuff pressure of a tracheostomy tube inserted in a patient who is receiving mechanical ventilation. The cuff pressure is measured at 41 cm H2O. The respiratory therapist should immediately do which of the following?

a. Inject more air through the pilot balloon.
b. Release some of the air from the cuff.
c. Insert a new tracheostomy tube.
d. Do nothing; everything is acceptable.

A

ANS: B
The measured intracuff pressure is more than the acceptable range of pressure. Some air from the cuff should be released to bring the cuff pressure down to below 34 cm H2O.

DIF: 3 REF: pgs. 136,137

20
Q

A 49-kg female patient intubated with a size 7 mm ID endotracheal tube is being mechanically ventilated in the volume-controlled continuous mandatory ventilation (VC-CMV) mode. During patient rounds, both the low pressure and low volume alarms are sounding persistently on the ventilator. Upon observation of the patient, the respiratory therapist hears murmuring from the patient, with audible sounds during inspiration. The cause of this condition is which of the following?

a. Circuit leak
b. Endotracheal tube (ET) cuff leak
c. Circuit disconnection
d. Incorrect ET tube size

A

ANS: B
If a leak is present during a positive pressure breath, air can be heard escaping from the patient’s mouth. If there is a large enough leak, the ventilator’s low pressure and low volume alarms will sound. A circuit leak or disconnection would cause the low alarms to sound but not cause the leak around the endotracheal tube cuff. An incorrect endotracheal tube may cause a leak around the cuff. However, a size 7 mm ID is appropriate for this particular size patient.

DIF: 2 REF: pg. 138

21
Q

An 87-kg male patient, orally intubated with a size 7.5 mm inner diameter (ID) endotracheal tube, is being mechanically ventilated in the pressure-controlled continuous mandatory ventilation (PC-CMV) mode. During patient rounds, both the low pressure and low volume alarms are sounding persistently on the ventilator. Upon observation of the patient, the respiratory therapist hears murmuring from the patient, with audible sounds during inspiration. The respiratory therapist notes the position of the endotracheal tube is 21 cm at the gum line, measures the cuff pressure, and adds 3 mL of air to the cuff. To make an appropriate seal, it requires 44 cm H2O. The respiratory therapist should do which of the following?

a. Change to a larger size endotracheal tube.
b. Add air to the cuff and clamp the pilot tube.
c. Check the position of the endotracheal tube.
d. Reposition the endotracheal tube in the mouth.

A

ANS: A
The endotracheal tube (ET tube) used with this patient is too small. This is evident from the fact that it is requiring 44 cm H2O to seal the airway and also because a size 7.5 mm ET tube should be used for a small adult female. This patient should have at least a size 8 mm ET tube. The placement of the tube is appropriate for the size, being 21 cm at the gum line, so repositioning is not necessary. Since the respiratory therapist has already added, measured, and noted that the airway can be sealed, but with a higher than normal pressure, we know that there is no problem with the pilot balloon.

DIF: 3 REF: pgs. 136-138

22
Q

During intracuff measurement with a three-way stopcock, manometer, and syringe, the amount of cuff volume/pressure lost in the connecting tube should be minimized by which of the following?

a. Using a four-way stopcock
b. Overinflating the cuff prior to measurement
c. Simultaneously inflating the cuff and manometer
d. Pressurizing the manometer to 25 mm Hg prior to use

A

ANS: D
Pressurizing the manometer to 25 mm Hg before measuring the cuff pressure will ensure that the pressure/volume in the cuff will not be lost into the connecting tubing. Once pressurized, the three-way stopcock, syringe, and manometer system can be inserted into the pilot. With all three ways open, the cuff can be inflated or deflated while the pressure is being measured.

DIF: 1 REF: pg. 136

23
Q

The flow sheet below, for a patient on pressure-controlled continuous mandatory ventilation (PC-CMV), demonstrates which of the following?

Time PIP PEEP Exhaled VT
0800 28 8 575
1000 28 8 558
1200 28 8 500

a. Lung compliance is increasing.
b. Dynamic compliance is decreasing.
c. Airway resistance is decreasing.
d. There is a leak in the ventilator circuit.

A

ANS: B
During pressure-controlled continuous mandatory ventilation (PC-CMV), a decrease in volume delivered is characteristic in a decreased dynamic compliance. If lung compliance increased or airway resistance decreased, the exhaled tidal volume would have increased. A leak in the ventilator circuit would also drop the peak inspiratory pressure (PIP).

DIF: 2 REF: pg. 140

24
Q

The normal airway resistance range is which of the following?

a. 0.6 to 2.4 cm H2O/L/sec
b. 16 to 24 cm H2O/L/sec
c. 26 to 34 cm H2O/L/sec
d. 70 to 100 cm H2O/L/sec

A

ANS: A
Normal Raw ranges from 0.6 to 2.4 cm H2O/L/sec.

DIF: 1 REF: pg. 142

25
Q

A patient’s transairway pressure (PTA) is rising while the plateau pressure (Pplateau) remains unchanged. The treatment plan that could correct this problem includes which of the following?

  1. Administer a bronchodilator.
  2. Insert a chest tube.
  3. Measure unintended positive-end-expiratory pressure (auto-PEEP).
  4. Suction airway secretions.
    a. 2 only
    b. 2 and 4 only
    c. 1 and 4 only
    d. 1 and 3 only
A

ANS: C
Airway resistance can be estimated for a ventilated patient using transairway pressure (PTA). When the PTA rises, the airway resistance is rising. When plateau pressure (Pplateau) is constant, this means that the static compliance has not changed. In this question the PTA is rising while the Pplateau remains the same. This is due to an increase in Raw and can be corrected by administering a bronchodilator and/or suctioning the airways. An increase in Pplateau could occur from a pneumothorax, which would require the insertion of a chest tube and also from dynamic hyperinflation, which can be measured as unintended positive-end-expiratory pressure (auto-PEEP).

DIF: 2 REF: pg. 132

26
Q

In a patient receiving mechanical ventilation with a constant tidal volume, an airway resistance increase is indicated by which of the following?

a. Increased peak inspiratory pressure (PIP) and transairway pressure (PTA)
b. Increased static compliance
c. Increased plateau pressure (Pplateau) and stable PIP
d. Decreased dynamic compliance

A

ANS: A
Airway resistance can be estimated for a ventilated patient using transairway pressure (PTA). When peak inspiratory pressure (PIP) increases and plateau pressure (Pplateau) remains relatively unchanged, there is an increase in PTA. An increased Pplateau and a stable PIP indicates a decrease in static compliance.

DIF: 2 REF: pg. 142

27
Q

The pressure at which large numbers of alveoli are recruited in a patient with acute respiratory distress syndrome (ARDS) is located on the static pressure-volume curve at which of the following?

a. Upper inflection point
b. Lower inflection point
c. Peak inspiratory pressure
d. Between the lower and upper inflection points

A

ANS: B
The lower inflection point marks a significant change in the slope of the curve and may indicate the pressure at which large numbers of alveoli are recruited.

DIF: 1 REF: pg. 140

28
Q

The pressure at which large numbers of alveoli become overinflated in a patient with acute respiratory distress syndrome (ARDS) is located on the static pressure-volume curve at which of the following?

a. Upper inflection point
b. Lower inflection point
c. Peak inspiratory pressure
d. Between the lower and upper inflection points

A

ANS: A
The upper inflection point indicates a point at which large numbers of alveoli are becoming overinflated.

DIF: 1 REF: pg. 144

29
Q

To help prevent inflated alveoli from collapsing and reexpanding with each breath, the positive-end-expiratory pressure (PEEP) level should be set at which point on the deflation part of the loop?

a. Above the upper inflection point
b. Below the upper inflection point
c. Above the lower inflection point
d. Below the lower inflection point

A

ANS: C
Setting positive-end-expiratory pressure (PEEP) above the lower inflection point on the deflation part of the loop may help prevent inflated alveoli from collapsing and reexpanding with each breath.

DIF: 1 REF: pg. 144

30
Q

The flow sheet below, for a patient on pressure-controlled continuous mandatory ventilation (PC-CMV), demonstrates which of the following?

Time PIP PEEP Exhaled VT
0800 28 8 435
1000 28 8 493
1200 28 8 500

a. Overinflated endotracheal tube
b. Lung compliance is decreasing.
c. Airway resistance is decreasing.
d. Dynamic compliance is worsening.

A

ANS: C
During pressure-controlled continuous mandatory ventilation (PC-CMV), increased tidal volume (VT) delivery with the same pressure indicates an improvement in compliance and/or a decrease in airway resistance (Raw).

DIF: 2 REF: pg. 140

31
Q

The low pressure and low tidal volume alarm is sounding on a mechanically ventilated patient. Measurement of the cuff pressure reveals 18 cm H2O. What action should be taken?

a. Replace the endotracheal tube with a larger size.
b. Add enough air to the cuff to maintain the cuff pressure at 34 cm H2O.
c. Increase the set pressure to increase the tidal volume and compensate for the leak.
d. Add air until a slight leak is heard while auscultating the larynx, then measure pressure.

A

ANS: D
The minimum leak technique (MLT) should be used whenever possible to avoid tracheal necrosis associated with cuff overinflation. The size of the tube and patient is not given so one cannot say whether or not the endotracheal (ET) tube is too small. 34 cm H2O is the maximum pressure that should be in a cuff. However, since all airways are different, the most effective way to minimize the risk of tracheal problems is to use MLT.

DIF: 3 REF: pg. 134