Midterm review

Question 1

A patient with extensive infiltrates throughout the right lung should be placed in which of the following positions to improve oxygenation?

Answer 1

Left lung down laterally

To improve oxygenation without uneven distribution of PEEP to the normal lung, the patient should be placed with the “good lung” down.

Question 2

Thirty minutes after intubation and initiation of mechanical ventilation, a patient’s PaO2 = 55 mm Hg and the FIO2 = 0.5. To what should the FIO2 be set to obtain a PaO2 of 80 mm Hg?

Answer 2

.75

Pa02/Fi02 (Desired) = Pa02/Fi02 (Known)

Question 3

What is the estimated shunt equation?

Answer 3

Qs/Qt = (P(A-a)02 x 0.003)
———————————————
(C(a-v)02 + [P(A-a)02 x 0.003)]

Question 4

A patient is being ventilated with a PEEP of 10 cm H2O and an FIO2 of 0.4. The arterial blood gas results show that the patient remains hypoxemic, and the respiratory therapist increases the PEEP to 18 cm H2O, maintaining the FIO2 at 0.4. The patient’s static compliance changes from 28 mL/cm H2O to 22 mL/cm H2O just after this change. The respiratory therapist should do which of the following?

Answer 4

Decrease PEEP to 15 cm H2O and measure static compliance.

Question 5

Regardless of the procedure used to establish an appropriate PEEP level, ventilating pressures should not be allowed to exceed which of the following?

Answer 5

Upper inflation point on the inspiratory limb (UIPi)

Regardless of the procedure used to establish an appropriate PEEP level, ventilating pressures should not be allowed to exceed the UIP on the UIPi, because injury to lungs can occur if the lungs become overstretched. The appearance of the UIP on the graphic display may be influenced by the type of recruitment procedure used. For example, in one study, when the VT was set low (5 to 6 mL/kg), the UIP was 26 cm H2O.

Question 6

In which ventilator mode should a patient receiving a sustained inflation technique be placed?

Answer 6

CPAP/spontaneous

To perform the sustained inflation technique, the ventilator needs to be set in the CPAP/spontaneous mode, because no mechanical breaths should be given during the procedure. The patient also requires sedation and short-term paralysis during this procedure.

Question 7

“Loose atelectasis,” or compression atelectasis, is most often associated with _____________.

Answer 7

anesthesia

Compression atelectasis, the result of gravitational pressure from lung and heart tissue, often occurs with anesthesia.

Question 8

A pneumonia that was not incubating at the time of admission (intubation) is one that develops a minimum of how many hours after admission?

Answer 8

48 hours

Question 9

A patient was intubated in the emergency department just after arrival at the hospital from home. This patient develops VAP 36 hours after intubation. What type of pneumonia is this considered?

Answer 9

Non–hospital-acquired pneumonia

Question 10

The mortality rate for VAP associated with prolonged hospital stays is which of the following?
  5% to 25%
  15% to 40%
  25% to 50%
  45% to 75%

Answer 10

25-50%

Question 11

Sixty percent of all VAP infections are caused by which of the following?

Answer 11

Aerobic gram-negative bacilli

Aerobic gram-negative bacilli have accounted for nearly 60% of all VAP infections. The most common of these are Pseudomonas aeruginosa, Klebsiella pneumoniae, Escherichia coli, and Acinetobacter sp.

Question 12

The most common gram-positive bacterium that causes ventilator-associated pneumonia is which of the following?
Streptococcus pneumoniae
Enterococcus faecalis
Methicillin-resistant Staphylococcus aureus
Pseudomonas aeruginosa

Answer 12

Methicillin-resistant Staphylococcus aureus

Question 13

The incidence of ventilator-associated pneumonia for all intubated patients is ___________.

Answer 13

8-28%

Question 14

When an alarm is activated on a ventilator, the respiratory therapist’s first priority is to ______________.

Answer 14

ensure adequate ventilation and oxygenation.

Question 15

Reduction of preload and afterload is important in the management of which of the following?

Answer 15

Cardiogenic pulmonary edema

Cardiogenic pulmonary edema and heart failure often can be managed successfully with medications that reduce preload, increase contractility, and reduce afterload; such medications include furosemide (Lasix), digoxin (Lanoxin), enalaprilat (Vasotec), and morphine.

Question 16

An increased arterial-to-end-tidal partial pressure CO2 gradient can help identify which of the following?

Answer 16

Pulmonary embolism

Capnographic findings can provide a clue to the presence of a PE. A decrease in the end-tidal carbon dioxide (PetCO2) value compared with previous readings and a widening of the arterial-to-end-tidal partial pressure CO2 gradient (P[a-et]CO2) may suggest the presence of an embolus.

Question 17

What ends inspiration in pressure support ventilation?

Answer 17

Flow

Question 18

Which mode of ventilation delivers the exact amount of pressure required to overcome the resistive load imposed by the ET tube for the flow measured at the time?

Answer 18

ATC

ATC reduces the work of breathing associated with increased ET tube resistance. ATC is designed to deliver exactly the amount of pressure required to overcome the resistive load imposed by the ET tube for the flow measured at the time. In a sense, this is providing variable PSV with variable inspiratory flow compensation. Volume-targeted PSV maintains a target volume by varying the pressure support level. PSV provides an operator-selected set pressure for every spontaneous breath. The automode can switch between time-triggered mandatory breaths and patient-triggered, volume-targeted, pressure-limited breaths as long as the patient is breathing spontaneously.

Question 19

The closed loop mode used for weaning from mechanical ventilation is which of the following?

Answer 19

Adaptive support ventilation

ASV is a patient-centered method of closed loop mechanical ventilation that increases or decreases ventilatory support based on monitored patient parameters.

Question 20

A 46-year-old male patient (IBW = 85 kg) who was injured in a motor vehicle accident has been receiving invasive mechanical ventilation for 24 hours. The patient is awake and alert and looks comfortable on these settings: VC-SIMV with pressure support of 5 cm H2O; set rate = 8 breaths/min; set VT = 500 mL; FIO2 = 0.4; PEEP = 5 cm H2O. A 10-minute spontaneous breathing trial (SBT) yields this information: f = 30 breaths/min, RSBI = 145, P0.1 = 10 cm H2O. What should the respiratory therapist suggest to the physician during patient rounds?

Answer 20

Continue with the current ventilator settings.

The RSBI is at a level that suggests the patient is not ready for weaning. An RSBI below 105 suggests that weaning is likely to be successful. The P0.1 is a measurement of the drive to breathe. The patient achieved 10 cm H2O, which indicates a high drive to breathe and suggests that weaning from mechanical ventilation is not likely to succeed. This information is a strong indicator that the patient should not begin active weaning at this time and should be continued on the original settings, because the patient was comfortable on those settings.

Question 21

In which patient would continued use of an artificial airway be necessary?

Answer 21

A patient with upper airway burns and no peritubular leak

A patient with upper airway burns may have upper airway inflammation that could obstruct the upper airways. The fact that the patient does not have a peritubular leak means that the airway caliber is not adequate. Extubation of this patient at this time would not be successful.

Question 22

A patient is extubated and placed on a cool, bland aerosol with 30% oxygen. Twenty minutes postextubation, the respiratory therapist is called to assess the patient, who has shortness of breath. The respiratory therapist observes intercostal retractions, accessory muscle use, and a respiratory rate of 38 breaths/min. Stridor can be heard without a stethoscope, and the SpO2 has dropped from 97% to 85%. The patient is given an aerosolized racemic epinephrine treatment and reassessed. Accessory muscle use continues, intercostal retractions decrease slightly, and stridor is heard on auscultation. The patient’s respiratory rate is 30 breaths/min, and the SpO2 is 88%. What should the respiratory therapist recommend?

Answer 22

Heliox therapy and steroid administration

The racemic epinephrine treatment improved the patient’s clinical status, as evidenced by a decrease in intercostal retractions, decrease in respiratory rate, and increase in SpO2. The patient’s stridor now is heard only on auscultation, whereas it was audible without a stethoscope before the racemic epinephrine. Heliox therapy would reduce the patient’s WOB further and allow time for the steroids to take effect. Because the patient improved, reintubation would only increase the risk of nosocomial pneumonia and is not warranted at this time. Increasing the FIO2 may help improve the patient’s SpO2, but it does not address the patient’s upper airway obstruction. A nonrebreather mask with 15 L/min oxygen would not help relieve the patient’s upper airway obstruction.

Question 23

If increases in alveolar ventilation do not correct respiratory acidosis, what can be the cause?
3 common causes

Answer 23

Pulmonary embolism, low pulmonary perfusion, or increased dead space

Question 24

If increases in alveolar ventilation do not correct respiratory acidosis, what can be the cause?
3 common causes

Answer 24

Pulmonary embolism, low pulmonary perfusion, or increased dead space

Question 25

PEEP should be increased in increments of what?

Answer 25

3-5