Midterm Airway Flashcards
You receive a call for a 49-year-old woman who passed out. The patient’s husband tells you that they were watching TV when the incident occurred. No trauma was involved. The patient is semiconscious and has cyanosis to her lips. After opening her airway with the head tilt-chin lift maneuver, you should:
A: begin ventilation assistance.
B: insert an oropharyngeal airway.
C: insert a nasopharyngeal airway.
D: assess her respiratory effort.
C: insert a nasopharyngeal airway.
Reason:
In the absence of trauma, open the patient’s airway with the head tilt-chin lift maneuver. To help maintain airway patency, a nasopharyngeal airway should be inserted. Your patient is semiconscious, not unconscious, so she will likely gag if you attempt to insert an oropharyngeal airway; this may result in aspiration if she vomits. Remember, you must first open the patient’s airway and, if needed, suction any secretions from the mouth. Next, insert an airway adjunct and assess respiratory effort. The method of oxygenation you provide depends on the adequacy of the patient’s breathing.
In what position would you expect a patient with severe dyspnea to be in? A. Prone B: Supine C: Lateral recumbent D: Fowler’s
D: Fowler’s
The preferred position of comfort for most patients with respiratory distress is the Fowler’s position (sitting up). A prone, supine, or lateral recumbent position would make it more difficult for the patient to breathe. If a patient with severe dyspnea is willing to lie flat, the EMT should take this as an ominous sign and should be prepared to assist the patient’s ventilations.
When ventilating an apneic patient, you note decreased ventilatory compliance. This means that:
A: the upper airway is blocked.
B: you meet no resistance when ventilating.
C: the lungs are difficult to ventilate.
D: fluid is occupying the alveoli.
C: the lungs are difficult to ventilate.
As it applies to artificial ventilation, compliance is the ability of the lungs to expand during ventilation. Increased ventilatory compliance means that no resistance is met when you ventilate the patient; you can ventilate the lungs with ease. Decreased ventilatory compliance means that significant resistance is met when you ventilate the patient; the lungs are difficult to ventilate. Conditions such as upper airway obstruction, widespread bronchospasm, fluid in the alveoli (eg, pulmonary edema), and COPD can all cause decreased ventilatory compliance.
A 50-year-old man, who fell approximately 20 feet and landed on a hard surface, is semiconscious. You should:
A: check for a carotid pulse if the patient is breathing rapidly.
B: stabilize his head while performing the jaw-thrust maneuver.
C: begin positive-pressure ventilations with a bag-mask device.
D: gently tilt the patient’s head back to assess for breathing.
B: stabilize his head while performing the jaw-thrust maneuver
Because of the significant mechanism of injury (fall of greater than 15 feet), spinal injury should be assumed. The first step in managing this patient is to manually stabilize his head in a neutral position and open his airway with the jaw-thrust maneuver, both of which can be performed simultaneously. After the patient’s airway is open, assess the rate and quality of his breathing and treat accordingly. The head tilt-chin lift maneuver should not be used on a patient with a possible spinal injury unless the jaw-thrust maneuver does not adequately open his or her airway. The patient in this scenario is semiconscious; therefore, he has a pulse (pulseless patients are unresponsive). If an uninjured patient is found to be unresponsive, you should quickly assess for breathing by visualizing the chest. If the patient is not breathing or only has agonal gasps, you should check for a carotid pulse.
Which of the following patients obviously needs positive-pressure ventilation assistance?
A: Semiconscious; respiratory rate of 14 breaths/min and good chest rise
B: Responsive to pain only; respiratory rate of 8 breaths/min and shallow
C: Combative; respiratory rate of 24 breaths/min and deep
D: Restless; respiratory rate of 12 breaths/min with adequate tidal volume
B: Responsive to pain only; respiratory rate of 8 breaths/min and shallow
Any patient with a decreased level of consciousness should be assessed for inadequate breathing (eg, fast or slow respiratory rate, reduced tidal volume [shallow breathing]). Of the patients listed, the patient who is responsive to pain only and has shallow respirations of 8 breaths/min clearly needs positive-pressure ventilation assistance. Slow, shallow respirations will not produce the minute volume needed to support adequate oxygenation of the blood.
Which of the following is the MOST correct technique for ventilating an apneic adult who has a pulse?
A: Deliver each breath over 1 second at a rate of 10 to 12 breaths/min.
B: Ventilate at a rate of 15 breaths/min and look for visible chest rise.
C: Deliver each breath over 1 second at a rate of 8 to 10 breaths/min.
D: Hyperventilate at a rate between 20 and 24 breaths/min.
A: Deliver each breath over 1 second at a rate of 10 to 12 breaths/min
When ventilating an apneic adult who has a pulse, deliver each breath over a period of 1 second, at a rate of 10 to 12 breaths/min (one breath every 5 to 6 seconds), while observing for visible chest rise. A ventilation rate of 8 to 10 breaths/min (one breath every 6 to 8 seconds) is appropriate for infants (except newborns), children, and adult patients in cardiac arrest after an advanced airway device (eg, ET tube, multilumen airway, supraglottic airway) has been inserted. Do NOT hyperventilate the patient; doing so may impede blood return to the heart, thus reducing cardiac output, secondary to hyperinflation of the lungs. Hyperventilation also increases the incidence of gastric distention, regurgitation, and aspiration.
A nonrebreathing mask is MOST appropriate to use on patients who:
A: are semiconscious and breathing shallowly.
B: are breathing less than 12 times per minute.
C: have an adequate rate and depth of breathing.
D: are cyanotic and have a low oxygen saturation.
C: have an adequate rate and depth of breathing.
With the oxygen flow rate set at 15 L/min, the nonrebreathing mask can deliver an oxygen concentration of 90% or greater. Unlike the bag-mask or pocket mask devices, which deliver oxygen via positive pressure, the nonrebreathing mask delivers oxygen passively; therefore, the patient must have an adequate rate and depth (tidal volume) of breathing in order to open the one-way valve in the nonrebreathing mask and inhale oxygen from the reservoir bag. Shallow (reduced tidal volume) breathing, bradypnea (slow breathing), cyanosis, a low oxygen saturation, and a decreased level of consciousness are signs of inadequate breathing, and should be treated with some form of positive-pressure ventilation assistance
During your assessment of a trauma patient, you note massive facial injuries, weak radial pulses, and clammy skin. What should be your MOST immediate concern?
A: Applying 100% supplemental oxygen
B: Potential obstruction of the airway
C: Internal bleeding and severe shock
D: Providing rapid transport to a trauma center
B: Potential obstruction of the airway
Reason:
Any trauma patient with severe maxillofacial trauma is at an extremely high risk of airway compromise. The airway can be compromised by either mandibular fractures, in which the tongue may occlude the airway, or severe oral bleeding, in which blood clots can obstruct the airway. Correct ANY airway problems immediately upon discovery, ensure adequate ventilation and oxygenation, assess for and treat other life-threatening injuries, and prepare for rapid transport.
If an adult patient presents with a respiratory rate of 26 breaths/min, your initial action should be to:
A: evaluate his mental status and the depth of his respirations.
B: apply oxygen via a nonrebreathing mask and take his vital signs.
C: apply the pulse oximeter and assess his oxygen saturation.
D: begin assisting his ventilations with a bag-mask device.
A: evaluate his mental status and the depth of his respirations.
Reason:
The normal respiratory rate for an adult at rest is 12 to 20 breaths/min. If a patient presents with a respiratory rate outside of the normal range, you should immediately assess him or her for other signs of inadequate breathing, such as a decreased level of consciousness, shallow breathing (reduced tidal volume), brief inhalations followed by prolonged exhalations, and cyanosis. If the patient is conscious, alert, and has adequate tidal volume (eg, his or her chest rises adequately with each breath), supplemental oxygen via nonrebreathing mask or nasal cannula would be appropriate, depending on his or her chief complaint and oxygen saturation. However, if the patient’s mental status is decreased and his or her tidal volume is reduced (eg, shallow breathing), some form of positive-pressure ventilation should be initiated (eg, bag-mask or pocket face mask ventilations). It is important to note that breathing adequacy is not determined solely by the patient’s respiratory rate; you must assess all aspects of breathing (rate, regularity, depth) as well as the patient’s mental status. A patient can be breathing at a “normal” rate; however, if his or her tidal volume is reduced, minute volume will decrease and some form of positive-pressure ventilation may be required.
Which of the following clinical findings is MOST consistent with a chronic respiratory disease?
A: Use of accessory muscles
B: Altered mental status
C: An irregular pulse
D: A barrel-shaped chest
D: A barrel-shaped chest
Reason:
In certain lung diseases (eg, emphysema, asthma), air is gradually and continuously trapped in the lungs in increasing amounts; this increases the anterior-posterior (front to back) diameter of the chest, causing the chest to assume a barrel shape. A barrel-shaped chest indicates a chronic respiratory disease. Accessory muscle use and an altered mental status in a patient with respiratory distress should be assumed to be acute findings. An irregular pulse could be the result of a primary cardiac problem, or a cardiac problem secondary to chronic hypoxemia in patients with various respiratory diseases.
When ventilating an apneic patient with a pocket mask device, each breath should be delivered over:
A: 4 seconds.
B: 1 second.
C: 3 seconds.
D: 2 seconds.
B: 1 second
Reason:
When ventilating any apneic patient, each breath should be delivered over a period of 1 second—just enough to produce visible chest rise. Excessive ventilation duration and/or volume increases the likelihood of gastric distention—especially if the patient’s airway is not secured with an advanced device (ie, ET tube, multilumen airway, supraglottic airway)—and may result in increased intrathoracic pressure, decreased venous return to the heart, and decreased cardiac output.
A young woman who overdosed on heroin is unresponsive with slow, shallow breathing. As you attempt to insert an oropharyngeal airway, she begins to gag. You should:
A: suction the patient’s oropharynx as you insert a nasopharyngeal airway.
B: remove the oropharyngeal airway and be prepared to suction her mouth.
C: place her on her side until she stops gagging and then suction her mouth.
D: make sure you are using the most appropriate size of oropharyngeal airway.
B: remove the oropharyngeal airway and be prepared to suction her mouth.
Reason:
Although uncommon, an unresponsive patient may have an active gag reflex. If an unresponsive patient begins to gag as you are attempting to insert an oropharyngeal airway, you must remove the airway immediately and be prepared to suction if vomiting should occur. Turn the patient on his or her side to facilitate drainage of secretions. Once the airway has been cleared, a nasopharyngeal airway, which is better tolerated in patients with a gag reflex, should be inserted.
If the level of carbon dioxide in the arterial blood increases:
A: the respiratory rate slows significantly.
B: the respiratory rate and depth decrease.
C: the respiratory rate and depth increase.
D: a reduction in tidal volume will occur.
C: the respiratory rate and depth increase.
Reason:
Special receptors, called chemoreceptors, sense the levels of oxygen and carbon dioxide in the arterial blood. The central chemoreceptors are located in the brain; the peripheral chemoreceptors are located in the aorta and carotid arteries. The level of carbon dioxide in the arterial blood stimulates the healthy patient to breathe (primary respiratory drive). If the carbon dioxide level rises above normal, the chemoreceptors send messages to respiratory centers in the brain, resulting in an increase in respiratory rate and depth (tidal volume). Conversely, if the level of carbon dioxide is too low, respiratory rate and depth decrease accordingly.
A patient with a mild foreign body airway obstruction:
A: has a low oxygen saturation.
B: presents with a weak cough.
C: is typically not cyanotic.
D: has progressive difficulty breathing.
C: is typically not cyanotic.
Reason:
Patients with a mild (partial) airway obstruction are able to move adequate amounts of air, but will have varying degrees of respiratory distress. The patient can cough forcefully, although you may hear wheezing in between coughs. Because the patient is able to move air effectively, the level of oxygen in his or her blood remains adequate; therefore, cyanosis is typically absent. By contrast, the patient with a severe (complete) airway obstruction cannot move air effectively and cannot speak. If a cough is present, it is weak and ineffective. As the level of oxygen in the blood falls, cyanosis develops, oxygen saturation falls, and the patient’s level of consciousness decreases. A foreign body airway obstruction, mild or severe, is an acute event that presents with an acute onset of difficulty breathing. Progressive (gradually worsening) difficulty breathing is more consistent with diseases such as congestive heart failure and pneumonia.
A 60-year-old female is found unresponsive. She is cyanotic, is making a snoring sound while she breathes, and has a slow respiratory rate. You should:
A: suction her airway for 15 seconds.
B: manually open her airway.
C: insert an airway adjunct.
D: ventilate her with a bag-mask device.
B: manually open her airway.
Reason:
Before you can assess and manage a patient’s breathing, you must ensure that his or her airway is open first; this patient’s airway is not open! Snoring respirations indicate partial blockage of the airway by the tongue. Manually open her airway, using the head tilt-chin lift or jaw-thrust maneuver, and ensure that her airway is clear of secretions. If needed, suction her oropharynx for up to 15 seconds. After manually opening her airway and removing any secretions with suction, insert an airway adjunct (eg, oral or nasal airway) to assist in maintaining airway patency. Slow respirations and cyanosis in an unresponsive patient are obvious signs of inadequate breathing; assist the patient’s ventilations with a bag-mask device and high-flow supplemental oxygen.
Prior to your arrival, a woman experiencing an asthma attack took two puffs from her prescribed inhaler without relief. After administering supplemental oxygen, you should:
A: administer one more puff from her inhaler.
B: provide immediate transport to the hospital.
C: contact medical control for further advice.
D: perform a detailed secondary assessment.
C: contact medical control for further advice.
Reason:
Before assisting a patient with any medication other than oxygen, the EMT must ensure that the medication is prescribed to the patient and then obtain authorization from medical control. In this case, the physician probably will allow you to help the patient take one more puff from her inhaler. Generally, up to three puffs from an inhaler are delivered in the field. It is important for you to ask the patient how many puffs were taken from the inhaler before you arrived. The EMT must correct any airway and/or breathing problems as quickly as possible. After doing so, a secondary assessment can be performed.
The MOST appropriate treatment for a semiconscious patient with slow, shallow respirations includes:
A: an oropharyngeal airway and assisted ventilation with a bag-mask device.
B: an oropharyngeal airway and high-flow oxygen via a nonrebreathing mask.
C: a nasopharyngeal airway and assisted ventilation with a bag-mask device.
D: a nasopharyngeal airway and high-flow oxygen via a nonrebreathing mask.
C: a nasopharyngeal airway and assisted ventilation with a bag-mask device.
Reason:
Semiconscious patients are not fully able to protect their own airway and require an airway adjunct. The nasopharyngeal airway is indicated for semiconscious patients because they often have an intact gag reflex; the oropharyngeal airway is contraindicated in any patient with an intact gag reflex. Slow, shallow respirations will not provide the minute volume needed to support adequate oxygenation and should be treated with positive-pressure ventilation assistance (eg, bag-mask device, pocket face mask).
A properly placed oropharyngeal airway:
A: keeps the tongue off of the posterior pharynx.
B: will not stimulate a conscious patient’s gag reflex.
C: prevents aspiration if the patient regurgitates.
D: eliminates the need to perform a head tilt-chin lift.
A: keeps the tongue off of the posterior pharynx.
Reason:
The oropharyngeal (oral) airway is an artificial adjunct used to keep the tongue away from the posterior pharynx (back of the throat), thus preventing it from blocking the upper airway. It is used in conjunction with, not in lieu of, the head tilt-chin lift or jaw-thrust maneuver to maintain patency of the airway. The oral airway will not prevent aspiration if the patient regurgitates because it does not occlude the esophagus or protect the trachea. The oral airway is contraindicated in conscious patients and in all patients, even those who are unconscious, who have an intact gag reflex. Stimulation of the gag reflex may cause vomiting and aspiration.
When ventilating an unresponsive apneic adult with a bag-mask device, you should ensure that:
A: the pop-off relief valve is manually occluded.
B: you are positioned alongside the patient.
C: an airway adjunct has been inserted.
D: ventilations occur at a rate of 20 breaths/min.
C: an airway adjunct has been inserted.
Reason:
When ventilating an unresponsive apneic patient with a bag-mask device, you should ensure that an oral or nasal airway adjunct is inserted, which will keep the tongue off of the posterior pharynx. When ventilating a patient with a bag-mask device, it is best for you to be positioned at the patient’s head to allow for better control of the head. Ventilations in the apneic adult with a pulse (ie, not in cardiac arrest) should be provided at a rate of 10 to 12 breaths/min (one breath every 5 to 6 seconds). Generally, only pediatric sized bag-mask devices have pop-off relief valves, which should NOT be occluded, because they help prevent overinflation of the patient’s lungs.
When suctioning copious secretions from a semiconscious adult’s airway, you should:
A: avoid touching the back of the airway with the suction catheter.
B: apply suction as you carefully insert the catheter into the mouth.
C: suction for up to 20 seconds while withdrawing the catheter.
D: use a flexible catheter because it will remove the secretions faster.
A: avoid touching the back of the airway with the suction catheter.
Reason:
When suctioning a patient’s airway, especially if he or she is semiconscious, you should avoid touching the back of the airway with the suction catheter. Inserting the catheter too far may stimulate the gag reflex, cause vomiting, and increase the risk of aspiration. Rigid (tonsil-tip) catheters are best for removing large amounts of fluid from the airway. Flexible (whistle-tip) catheters are used in situations in which rigid catheters cannot be used, such as with a patient who has a stoma, patients whose teeth are clenched, or if suctioning the nose is necessary. Apply suction while you are withdrawing the catheter. In the adult, suction for no longer than 15 seconds (10 seconds in children, 5 seconds in infants); suction not only removes secretions from the airway, it also removes oxygen.
During the inhalation phase of breathing:
A: air passively enters the lungs as pressure within the thorax increases.
B: the diaphragm and intercostal muscles contract and ascend.
C: the muscles in between the ribs relax, which lifts the ribs up and out.
D: pressure within the thorax decreases and air is drawn into the lungs.
D: pressure within the thorax decreases and air is drawn into the lungs.
Reason:
Inhalation is the active, muscular part of breathing. During inhalation, the diaphragm and intercostal muscles contract. When the diaphragm contracts, it moves down (descends) slightly and enlarges the thoracic cage from top to bottom. Contraction of the intercostal muscles, the muscles in between the ribs, causes the ribs to move up and out. As we inhale, the combined actions of these structures enlarge the thorax in all directions. The air pressure outside the body, called the atmospheric pressure, is normally higher than the air pressure within the thorax. As we inhale and the thoracic cage expands, the air pressure within the thorax decreases, creating a slight vacuum. This draws air in through the trachea and into the lungs, a process called negative-pressure ventilation.
Oxygen that is administered through a nasal cannula would be of LEAST benefit to a patient who:
A: is in need of long-term oxygen therapy.
B: breathes through his or her mouth.
C: has COPD and an oxygen saturation of 94%.
D: is breathing greater than 12 times per minute.
B: breathes through his or her mouth.
Reason:
A patient who breathes through the mouth or has a nasal obstruction will get little or no benefit from a nasal cannula. Many patients with COPD (eg, emphysema, chronic bronchitis) require long-term, low-flow oxygen therapy; the nasal cannula is ideal in this situation. Considering their chronic respiratory problem, an oxygen saturation of 94% in a COPD patient is good; in fact, many COPD patients maintain an oxygen saturation lower than 94%, even with supplemental oxygen. A nasal cannula is appropriate to use in patients breathing greater than 12 times per minute, provided they have adequate tidal volume and are not significantly hypoxemic. Regardless of the oxygen delivery device used, you should maintain a patient’s oxygen saturation at greater than 94%.
Prior to applying a nonrebreathing mask on a patient with difficulty breathing, you should:
A: prefill the reservoir bag to ensure delivery of 100% oxygen.
B: insert a nasopharyngeal airway to maintain airway patency.
C: set the flow rate to no more than 10 liters per minute.
D: perform a complete exam to assess the degree of hypoxia.
A: prefill the reservoir bag to ensure delivery of 100% oxygen.
Reason:
After attaching the nonrebreathing mask to the oxygen source, the flowmeter should be set to between 12 and 15 L/min. The reservoir bag is then prefilled with oxygen, which will allow the delivery of high-flow oxygen. Unless the patient has a decreased level of consciousness, a nasopharyngeal airway is not required before applying a nonrebreathing mask. The need for supplemental oxygen should be determined early in your assessment; do not perform an in-depth exam before deciding to administer oxygen.
An elderly woman with COPD presents with a decreased level of consciousness, cyanosis to her face and neck, and labored respirations. Her pulse is rapid and weak and her oxygen saturation is 76%. You should:
A: insert a nasal airway and give her oxygen via a nonrebreathing mask.
B: apply oxygen via nasal cannula and reassess her respiratory status.
C: avoid high-flow oxygen because this may cause her to stop breathing.
D: assist her ventilations with a bag-mask device and high-flow oxygen.
D: assist her ventilations with a bag-mask device and high-flow oxygen.
Reason:
The patient in this scenario is experiencing an exacerbation (worsening) of her COPD. Her decreased level of consciousness; cyanosis; weak, rapid pulse; low oxygen saturation (SpO2); and labored breathing clearly indicate that she is not breathing adequately. Therefore, you should assist her ventilations with a bag-mask device and high-flow oxygen; if you don’t, she will continue to deteriorate, possibly to the point of cardiac arrest. If needed, insert a nasal airway adjunct to help keep her airway open. Regardless of the patient’s history of COPD, you must NOT withhold oxygen from her. Respiratory depression in COPD patients who receive high-flow oxygen is highly uncommon. Death due to hypoxia, however, is very common.
During your initial attempt to ventilate an unresponsive apneic patient, you meet resistance and do not see the patient’s chest rise. You should:
A: suction the airway for no longer than 15 seconds.
B: reposition the head and reattempt to ventilate.
C: assume that a foreign body is blocking the airway.
D: begin CPR, starting with chest compressions
B: reposition the head and reattempt to ventilate.
Reason:
If your initial attempt to ventilate a patient is met with resistance and/or does not make the chest visibly rise, you should reposition the patient’s head and reattempt to ventilate. In many cases, this simple action will open the airway and enable you to ventilate the patient. However, If both of your breaths are met with resistance and/or do not make the chest visibly rise, you should assume that a foreign body is obstructing the airway and begin chest compressions. The airway should be suctioned if secretions are present in the mouth; if oral secretions are not present, do not suction
An unresponsive 60-year-old male is apneic and has a weak, rapid pulse. His oxygen saturation reads 79%. You should:
A: mildly hyperventilate him until his oxygen saturation improves.
B: ventilate at a rate of 8 to 10 breaths/min, ensuring visible chest rise.
C: use a pocket face mask to deliver 12 to 20 breaths/min.
D: deliver one breath over 1 second every 5 to 6 seconds.
D: deliver one breath over 1 second every 5 to 6 seconds.
Reason:
When ventilating an apneic adult with a pulse, deliver one breath every 5 to 6 seconds (10 to 12 breaths/min). A ventilation rate of 12 to 20 breaths/min (one breath every 3 to 5 seconds) is appropriate for infants and children. Regardless of the patient’s age or ventilation device you are using (eg, bag-mask device, pocket face mask), each breath should be delivered over a period of 1 second (enough to produce visible chest rise). Do not hyperventilate any patient, even mildly, as this may cause a decrease in venous return to the heart secondary to hyperinflation of the lungs. Hyperventilation also increases the risks of gastric distention, regurgitation, and aspiration. After an advanced airway device has been inserted (eg, ET tube, multilumen airway, supraglottic airway) in a cardiac arrest patient, you should no longer perform “cycles” of CPR; the compressor delivers compressions at a rate of at least 100/min and the ventilator delivers 8 to 10 breaths/min (one breath every 6 to 8 seconds). This ventilatory rate during cardiac arrest applies to all age groups, except the newborn.
After an initial attempt to ventilate an unresponsive apneic patient fails, you reposition the patient’s head and reattempt ventilation without success. You should next:
A: perform continuous chest compressions until ALS personnel arrive.
B: turn the patient onto his side and deliver 5 to 10 back slaps.
C: administer 5 to 10 abdominal thrusts and reattempt to ventilate.
D: perform chest compressions, open the airway, and look in the mouth.
D: perform chest compressions, open the airway, and look in the mouth.
Reason:
If you are unable to ventilate an unresponsive, apneic patient after two attempts, you should assume that he or she has a severe (complete) foreign body airway obstruction. Immediately perform 30 chest compressions (15 compressions if two EMTs are present and the patient is an infant or child). Next, open the patient’s airway and look inside the mouth. If you can see the object, attempt to remove it with your finger (never perform blind finger sweeps of the mouth). If you cannot see the object, continue chest compressions. If you are able to remove the object, reattempt to ventilate. Unless paramedics are nearby, begin transport while continuing chest compressions, opening the airway and looking in the mouth, and attempting to ventilate (if you can remove the object). Abdominal thrusts are indicated for responsive children and adults with a severe airway obstruction. Back slaps are indicated for a responsive infant with a severe airway obstruction.
Medications such as albuterol (Ventolin) relieve respiratory distress by:
A: contracting the smaller airways in the lungs.
B: dilating the large mainstem bronchi of the airway.
C: constricting the bronchioles in the lungs.
D: relaxing the smooth muscle of the bronchioles.
D: relaxing the smooth muscle of the bronchioles.
Reason:
Medications such as albuterol (Ventolin) and metaproterenol (Alupent) are in a class of drugs called bronchodilators. They relax the smooth muscle found within the bronchioles in the lungs, which causes them to dilate. This effect opens the air passages and improves the patient’s ability to breathe.
A 22-year-old male has a shard of glass impaled in his cheek. You look inside his mouth and see minor bleeding. The patient is conscious and alert with adequate breathing. You should:
A: be prepared for severe bleeding as you carefully remove the shard of glass.
B: carefully stabilize the shard of glass and allow him to suction his own mouth.
C: carefully remove the shard of glass in the same direction that it entered.
D: remove the shard of glass and place gauze in his mouth to control the bleeding.
B: carefully stabilize the shard of glass and allow him to suction his own mouth.
Reason:
It remains true that you should remove an impaled object if it compromises the airway or impedes your ability to manage the airway. However, neither is the case with this patient because he has an adequate airway. He is conscious and alert and has only minor bleeding in his mouth. The safest approach, and most practical given the situation, would be to carefully stabilize the shard of glass in place; consider wrapping the exposed glass with gauze to protect yourself from getting cut. Since the patient is conscious and alert and has only minor oral bleeding, it would not be unreasonable to hand him the suction catheter and allow him to use it as needed. Be sure to instruct the patient to use the suction and not to swallow any blood. Keep in mind that if you attempt to remove the shard of glass, you risk cutting yourself and causing further injury to the patient.
Signs of inadequate breathing in an unresponsive patient include:
A: warm, moist skin.
B: cyanotic oral mucosa.
C: an irregular pulse.
D: symmetrical chest rise.
B: cyanotic oral mucosa.
Reason:
Signs of inadequate breathing in both responsive and unresponsive patients include a respiratory rate that is too slow (less than 12 breaths/min) or too fast (greater than 20 breaths/min); shallow (reduced tidal volume), irregular, or gasping respirations; asymmetrical (unequal) chest rise; abnormal respiratory sounds, such as wheezing, stridor, or gurgling; and abnormal skin color and condition (ie, cool or cold skin, pallor, diaphoresis, cyanosis). An irregular pulse indicates a cardiac dysrhythmia.
Clinically, reduced tidal volume would MOST likely present with respirations that are:
A: shallow.
B: eupneic.
C: slow.
D: deep.
A: shallow
Reason:
Tidal volume is the amount of air, in milliliters, that is breathed into or out of the lungs in a single breath. Shallow respirations (minimal chest rise) indicates that negative-pressure ventilation, and therefore tidal volume, is inadequate. Deep respirations (hyperpnea) would cause an increase in tidal volume. Slow respirations, especially if accompanied by a shallow depth of breathing, would lead to a reduction in minute volume. Eupnea is the medical term for normal breathing; therefore, eupneic respirations are of adequate rate, depth, and regularity.
A woman presents with acute shortness of breath. Her breathing appears labored and her skin is pale. You should:
A: place her supine and assist her ventilations with a bag-mask device.
B: administer high-flow oxygen and assess the quality of her breathing.
C: deliver humidified oxygen and administer an inhaled bronchodilator.
D: ensure that her oxygen saturation does not fall below 85 percent.
B: administer high-flow oxygen and assess the quality of her breathing.
Reason:
Patients with acute respiratory distress and labored breathing need high-flow oxygen. You should then assess the patient for signs of inadequate ventilation and provide ventilatory assistance if needed. Patients with labored breathing will probably not allow you to place them in a supine position as this will make it more difficult for them to breathe. An inhaled bronchodilator is indicated if you hear wheezing when auscultating the patient’s lung sounds, which you have not done at this point. You should administer oxygen in a concentration sufficient to maintain an oxygen saturation that is equal to or greater than 94 percent.
A 33-year-old female presents with acute respiratory distress. She is conscious but anxious, and tells you that she has a history of asthma. She took two puffs of her albuterol inhaler prior to your arrival, but states that it did not help. Her oxygen saturation reads 89% and you hear diffuse wheezing while auscultating her lungs. You should:
A: ventilate her with a bag-mask device until her oxygen saturation is at least 94% and rapidly transport her to the closest appropriate medical facility.
B: assist her with a third albuterol treatment, contact medical control for further advice, give her high-flow oxygen, and transport her to the hospital.
C: give her 100% humidified oxygen to dilate her bronchioles, monitor her oxygen saturation, and transport her to an appropriate medical facility.
D: administer high-flow oxygen, contact medical control to request permission to assist her with another albuterol treatment, and prepare for transport.
D: administer high-flow oxygen, contact medical control to request permission to assist her with another albuterol treatment, and prepare for transport.
Reason:
Despite two albuterol treatments, the patient is still experiencing respiratory distress. Furthermore, the presence of wheezing indicates continued bronchospasm. After administering high-flow oxygen via a nonrebreathing mask, you should contact medical control and request permission to assist the patient with a third albuterol treatment. Drugs such as albuterol (Proventil, Ventolin) and metaproterenol (Alupent) stimulate beta-2 receptors in the lungs, resulting in bronchodilation. Up to three bronchodilator treatments are typically given in the prehospital setting. In most EMS systems, EMTs are not allowed to assist patients with their medication without medical control authorization. After assisting the patient with a third albuterol treatment, reassess her breath sounds and oxygen saturation and transport her promptly.
You receive a call for a 49-year-old woman who passed out. The patient’s husband tells you that they were watching TV when the incident occurred. No trauma was involved. The patient is semiconscious and has cyanosis to her lips. After opening her airway with the head tilt-chin lift maneuver, you should:
A: begin ventilation assistance.
B: assess her respiratory effort.
C: insert a nasopharyngeal airway.
D: insert an oropharyngeal airway.
C: insert a nasopharyngeal airway.
Reason:
In the absence of trauma, open the patient’s airway with the head tilt-chin lift maneuver. To help maintain airway patency, a nasopharyngeal airway should be inserted. Your patient is semiconscious, not unconscious, so she will likely gag if you attempt to insert an oropharyngeal airway; this may result in aspiration if she vomits. Remember, you must first open the patient’s airway and, if needed, suction any secretions from the mouth. Next, insert an airway adjunct and assess respiratory effort. The method of oxygenation you provide depends on the adequacy of the patient’s breathing.
To ensure you deliver the highest concentration of oxygen with a nonrebreathing mask, you should:
A: securely fasten the mask to the patient’s face.
B: cover the flapper valves on the oxygen mask.
C: set the flow rate to at least 10 to 12 L/min.
D: make sure that the reservoir bag is preinflated.
D: make sure that the reservoir bag is preinflated.
Reason:
To ensure delivery of high-flow (greater than 90%) oxygen to your patient with a nonrebreathing mask, you must first set the flowmeter to 15 L/min and then preinflate the reservoir bag. When the patient inhales, pure oxygen is inspired directly from this bag. The valves on the sides of the mask close during inhalation, which prevents outside carbon dioxide from mixing with the oxygen in the reservoir; they open during exhalation, which allows the patient to eliminate carbon dioxide. Following inflation of the reservoir, apply the mask to the patient and ensure that it is secured so as to prevent as much air leakage as possible.
Which of the following signs or symptoms is indicative of cerebral hypoxia?
A: Decreased level of consciousness
B: Diffuse wheezing on exhalation
C: Heart rate greater than 120 beats/min
D: Chief complaint of dyspnea
A: Decreased level of consciousness
Reason:
Dyspnea, a feeling of shortness of breath, is a symptom of a condition that can cause cerebral hypoxia (eg, CHF, COPD); however, dyspnea itself does not indicate cerebral hypoxia. Wheezing, a whistling sound that indicates bronchospasm, is a sign; like dyspnea, it indicates the presence of a condition that can cause cerebral hypoxia (eg, asthma). Tachycardia can occur for many reasons; cerebral hypoxia is but one. Of the choices listed, a decreased level of consciousness is most indicative of cerebral hypoxia. As oxygen levels in the brain decrease and carbon dioxide levels increase, the patient’s mental status deteriorates.
Which of the following processes occurs during cellular/capillary gas exchange?
A: The capillaries give up oxygen to the cells.
B: The cells receive carbon dioxide from the capillaries.
C: The cells give up oxygen to the capillaries.
D: The capillaries give up carbon dioxide to the cells.
A: The capillaries give up oxygen to the cells.
Reason:
At the cellular level, oxygen passes across the capillary bed from the arterioles and into the cell, which is facilitated by a process called diffusion, in which oxygen (as with any gas) moves from an area of higher concentration to an area of lower concentration. At the same time, carbon dioxide crosses the capillary bed and enters the venules, where it is transported back to the lungs for reoxygenation.
A 60-year-old woman is experiencing severe respiratory distress. When you ask her a question, she can only say two words at a time. Treatment for her should include:
A: applying a nasal cannula set at 2 to 6 L/min.
B: assisted ventilation with a bag-mask device.
C: insertion of a nasopharyngeal airway.
D: applying a nonrebreathing mask set at 15 L/min.
B: assisted ventilation with a bag-mask device.
Reason:
Because the patient is only able to speak in minimal word sentences (two-word dyspnea) and is experiencing severe respiratory distress, it is unlikely that she is ventilating adequately. Therefore, you should assist her ventilations with a bag-mask device. If her breathing continues as it is, she will become increasingly hypoxic and may lose consciousness. Because this patient is conscious, you must explain to her that every time she takes in a breath, the bag-mask device will be squeezed so that an adequate volume of air can be delivered. Clearly, this can cause the patient great anxiety, so your reassurance during this procedure is important. If the patient will not tolerate your attempts to assist her ventilations, apply a nonrebreathing mask and monitor her closely.
You are assessing a 66-year-old man who has emphysema and complains of worsened shortness of breath. He is confused, has a heart rate of 120 beats/min, and an oxygen saturation of 89%. Which of the following assessment findings should concern you the MOST?
A: Confusion
B: Tachycardia
C: Worsened shortness of breath
D: Low oxygen saturation
A: Confusion
Reason:
All of your assessment findings in this patient are significant. Worsened shortness of breath in a patient with a preexisting respiratory disease could indicate exacerbation of his or her condition or a new problem. Tachycardia and a low oxygen saturation (SpO2) are signs of hypoxemia, a low level of oxygen in arterial blood. Of all the patient’s assessment findings, the fact that he is confused should concern you the most. A decreased level of consciousness in a patient with respiratory distress indicates that the brain is not getting enough oxygen and that carbon dioxide is accumulating in the blood. It is important to recognize the signs of hypoxemia and begin immediate treatment (eg, high-flow oxygen via a nonrebreathing mask, assisted ventilation) in order to prevent hypoxia, a dangerous condition in which the body’s cells and tissues do not receive enough oxygen. Left untreated, hypoxia may cause permanent brain damage or death.
Tidal volume is defined as:
A: volume of air moved in and out of the lungs each minute.
B: volume of air inhaled or exhaled per breath.
C: total volume of air that the lungs are capable of holding.
D: volume of air that remains in the upper airway.
B: volume of air inhaled or exhaled per breath.
Reason:
Tidal volume (VT) is the amount of air that is inhaled or exhaled per breath; it is normally 500 mL in a healthy adult male. Tidal volume is assessed by noting the depth of a patient’s breathing. Shallow breathing, for example, indicates a reduced tidal volume. The volume of air that remains in the upper respiratory tract (eg, larger bronchi, trachea) is called dead space volume (VD); it is approximately 30% of the adult male’s tidal volume and does not participate in pulmonary gas exchange. The volume of air that moves in and out of the lungs each minute, and does participate in pulmonary gas exchange, is called alveolar minute volume (VA). It is calculated by multiplying the tidal volume (minus the dead space volume) and the respiratory rate. Therefore, if an adult male has a tidal volume of 500 mL and a respiratory rate of 18 breaths/min, his alveolar minute volume is 6,300 mL (500 mL [VT] - 150 mL [VD] × 18 [breaths/min] = 6,300 mL [VA]). The maximum volume of air that the lungs are capable of holding is called the total lung capacity (TLC); it is approximately 6 L in the healthy adult male.
Which of the following would MOST likely occur if an adult patient is breathing at a rate of 45 breaths/min with shallow depth?
A: The lungs would become hyperinflated, potentially causing a pneumothorax.
B: The volume of air that reaches the alveoli would increase significantly.
C: Most of his or her inhaled air will not go beyond the anatomic dead space.
D: Alveolar minute volume would increase due to the rapid respiratory rate.
C: Most of his or her inhaled air will not go beyond the anatomic dead space.
Reason:
Alveolar minute volume, the amount of air that reaches the alveoli per minute and participates in pulmonary respiration, is affected by tidal volume, respiratory rate, or both. If the respiratory rate decreases, tidal volume must increase in order to maintain adequate alveolar minute volume. Conversely, if tidal volume decreases, the respiratory rate must increase accordingly. However, if the respiratory rate is extremely fast, especially if the depth of breathing is shallow (reduced tidal volume), most of the inhaled air will only make it to the anatomic dead space (ie, trachea, larger bronchi) before it is promptly exhaled. As a result, alveolar minute volume would decrease, resulting in inadequate pulmonary respiration and hypoxia. For this reason, patients with rapid, shallow breathing often require ventilation assistance. Pulmonary hyperinflation would not be an issue in a patient with exceedingly fast breathing and reduced tidal volume because very little air is actually reaching the lungs.
Occasional, irregular breaths that may be observed in a cardiac arrest patient are called:
A: Cheyne-Stokes respirations.
B: agonal gasps.
C: Biot respirations.
D: ataxic respirations.
B: agonal gasps.
Reason:
Occasional, irregular breaths, called agonal gasps, may be observed in some patients shortly after their heart stops beating. They occur when the respiratory center in the brain sends stray signals to the respiratory muscles. Agonal gasps are not adequate because they are infrequent and result in negligible tidal volume. Biot respirations are characterized by an irregular pattern, rate, and depth of breathing with intermittent periods of apnea; they are commonly associated with severe brain trauma. Ataxic respirations are ineffective, irregular breaths that may or may not have an identifiable pattern; they are also commonly associated with severe brain trauma. Cheyne-Stokes respirations are characterized by a crescendo-decrescendo pattern of breathing with a period of apnea between each cycle (fast, slow, apnea). Cheyne-Stokes respirations may occur in healthy people during certain phases of the sleep cycle; however, if they are grossly exaggerated or occur in a patient with a head injury, they are an ominous sign.
To obtain the MOST reliable assessment of a patient’s tidal volume, you should:
A: look at the rise of the chest.
B: listen for airway noises.
C: assess for retractions.
D: count the respiratory rate.
A: look at the rise of the chest.
Reason:
Tidal volume is the amount of air, in milliliters, breathed into or out of the lungs in a single breath. The most effective (and practical) way to assess tidal volume is to evaluate the rise of the patient’s chest. If the patient’s chest rises minimally during inhalation, his or her respirations are shallow; shallow respirations reflect a reduced tidal volume.
An inaccurate pulse oximetry reading may be caused by:
A: heat illnesses, such as heat stroke.
B: a heart rate greater than 100 beats/min.
C: excessive red blood cell production.
D: severe peripheral vasoconstriction.
D: severe peripheral vasoconstriction.
Reason:
A pulse oximeter measures the percentage of hemoglobin that is saturated with oxygen. Under normal conditions, a patient’s oxygen saturation (SpO2) ranges between 95% and 100% while breathing room air. Although no definitive threshold for normal SpO2 values exists, an SpO2 that is less than 95% in a nonsmoker may indicate hypoxemia. Of the factors listed, several peripheral vasoconstriction (ie, hypothermia, cigarette smoking, chronic hypoxia) would be the most likely to produce an inaccurate SpO2 reading. When the peripheral vasculature constricts, blood is shunted to the core of the body; in such cases, the pulse oximeter would likely yield a falsely low reading (or no reading at all). Other factors that can cause inaccurate readings include dark or metallic nail polish, dirty fingers, and abnormal hemoglobin binding (ie, carbon monoxide [CO] poisoning). It is important to note that the pulse oximeter is designed to detect gross abnormalities, not subtle changes, and should be used in conjunction with a thorough clinical assessment of the patient.
