During VC-CMV, a change in ____ or rate is needed to correct for respiratory alkalosis or acidosis.
1. inspiratory time
3. pressure limit
During mechanical ventilation of a CHF patient, the PaCO2 = 28 mm Hg and the f = 16/min. If the desired PaCO2 is 40, then the f must be changed to ____.
During mechanical ventilation of a head injury patient, the PaCO2 = 48 mm Hg and the f = 12/min. If the desired PaCO2 is 30, then the f must be changed to ____.
During PC-CMV, a change in ____ or rate is needed to correct for respiratory alkalosis or acidosis.
2. inspiratory time
3. Either A or B
4. pressure limit
Either A or B (Vt or inspiratory time)
Common causes of respiratory alkalosis include the following except ____.
1. mechanical ventilation
3. medications (salicylate, xanthines, analeptics)
4. opiates for pain management
opiates for pain management
Head injury that results in a high minute ventilation and hyperventilation is sometimes difficult to control, regardless of the mode selected. Some patients with brain injury have a tendency to breath with a high tidal volume and rate, which is due to a central nervous system lesion and cannot be corrected.
Common causes of metabolic alkalosis include all of the following except ____.
1. loss of gastric fluid and stomach acids (vomiting, nasogastric suctioning)
2. acid loss in the urine (diuretic administration)
3. mechanical ventilation
4. acid shift into the cells (potassium deficiency)
In the presence of fever, burns, multiple trauma, sepsis, hyperthyroidism, muscle tremors or seizures, agitation, and multiple surgical procedures, it is not unusual for metabolism to be high. In these situations the elevated ____ is due to the increased metabolic rate.
2. mean airway pressure
Hyperventilation may be needed for brief periods when acute neurological deterioration is present and ICP is elevated. Mild hyperventilation (PaCO2 30 - 35 mm Hg) may be used for longer periods in situations where increased ICP is refractory to standard treatment.
A deliberate limitation of ventilatory support to avoid lung overdistention and injury is termed ____.
1. protective hyperresonance
2. permissive hypoxemia
3. permissive hypercapnea
4. permissive hypocapnea
The time spent suctioning is brief and must not exceed 15 seconds. Suction is applied intermittently rather than continuously, and the catheter is rotated as it is withdrawn.1. False
The intent of saline lavage is to loosen secretions; however, saline does not thin secretions, and instilling saline may increase the risk of dislodging bacteria from the endotracheal tube, causing them to enter the patient's airway and potentially leading to nosocomial pneumonia.
During mechanical ventilation of a patient with COPD, the PaO2 = 58 mm Hg and the FIO2 = 0.50. If the desired PCO2 is 65, then the FIO2 must be changed to ____.
During mechanical ventilation of a patient with CHF, the PaO2 = 38 mm Hg and the FIO2 = 0.60. If the desired PCO2 is 60, then the FIO2 must be changed to ____.
During mechanical ventilation of a patient with CHF, the PaO2= 48 mm Hg, the FIO2 = 0.60, and the PEEP is 5 cm H2O. If the desired PCO2 is 60, then the FIO2 must be changed to ____.
It is important to try and keep FIO2 below 0.4 to 0.5 to prevent the complications of O2 toxicity, while keeping the partial pressure of O2 in the arteries (PaO2) between 60 and 90 mm Hg and the CaO2 near normal (20 mL/dL).
Factors that increase Paw during PPV include all of the following except ____.
1. increased f
2. increased FIO2
3. increased total PEEP
4. increased PIP
Atelectasis is the partial or complete collapse of previously expanded areas of the lung, producing a shrunken, airless state. It may be caused by all of the following except ____.
1. alveolar hyperinflation
2. blockage of air passages
3. shallow breathing with increased FIO2
4. surfactant deficiency
The positive pressure employed with CPAP or PEEP is commonly applied to the airway with all of the following devices except ____.
1. esophageal obturator
2. a tight fitting mask
3. endotracheal tube
4. nasal prongs
A(n) ____ is a device that provides a constant pressure throughout expiration regardless of the rate of gas flow or ventilation (i.e., flow independent).
1. isothermal resistor
2. threshold resistor
3. electrical resistor
4. flow resistor
The level of PEEP set must be balanced against producing profound cardiopulmonary side effects such as decreased venous return, decreased cardiac output, decreased blood pressure, increased shunting, increased VD/Vt barotrauma, and volutrauma.
The use of PEEP allows for the reduction of FIO2 because PEEP improves oxygenation and helps to avoid the complications associated with a high FIO2 in certain disorders. Specific clinical disorders that may benefit from the use of PEEP include all of the following except ____.
1. bilateral diffuse pneumonia
2. cardiogenic pulmonary edema
3. ALI or ARDS
4. carbon monoxide poisoning
carbon monoxide poisoning
Patients' clinical conditions that indicate that PEEP or CPAP therapy be started as soon as possible include all of the following conditions except ____.
1. pathological conditions with FIO2 values ³0.5
2. pathological conditions with high compliance
3. pathological conditions that damage pulmonary cells (types I and II)
4. high peak pressures (>35 cm H2O)
pathological conditions with high compliance
A clinician is asked to reduce the PEEP that the patient has been receiving from 10 to 5 cm H2O, using an older-generation ventilator. After the adjustment is made, the ventilator begins initiating inspiration spontaneously (auto-cycling). Which of the following best explains this malfunction?
1. The sensitivity control needed to be reset after PEEP was adjusted.
2. The peak flow control is probably not adjusted properly.
3. The respiratory rate should have been reset after PEEP was adjusted.
4. The pressure limit was not reset after PEEP was adjusted.
The sensitivity control needed to be reset after PEEP was adjusted.
A patient is receiving 10 cm H2O PEEP with an FIO2 of 0.40. The patient is hypoxemic and the clinician decides to increase the PEEP to 15 cm H2O and maintain the FIO2. The subsequent cardiac output measurement shows a change from 4.5 to 2.7 L/min. The most appropriate action is to ____.
1. apply PEEP at 20 cm H2O and maintain the FIO2 at 0.40
2. discontinue PEEP, set the FIO2 at 1.0, and obtain an ABG sample in 30 minutes
3. apply PEEP at 10 cm H2O and increase the FIO2 to 0.50
4. apply PEEP at 5 cm H2O and maintain the FIO2 at 0.40
apply PEEP at 10 cm H2O and increase the FIO2 to 0.50
If cardiac output is low, O2 transport may be enhanced by all of the following methods except ____.
1. slightly reducing the PEEP level
2. using beta-blocking agents
3. using volume loading (administration of fluids)
4. using inotropic agents
using beta-blocking agents
Despite risk, it is still important to use PEEP, since it can prevent alveolar collapse during exhalation and reopening even when a low Vt setting is used. It is now theorized that it is important to use the pressure-volume loop to set PEEP ____.
1. at the peak inspiration point detected during inflation of the lung
2. at the lower inflection point detected during inflation of the lung
3. at the upper inflection point detected during inflation of the lung
4. above the upper inflection point detected during deflation of the lung
above the upper inflection point detected during deflation of the lung
In primary ARDS (direct), lungs are mostly consolidated. In secondary ARDS (indirect), alveolar collapse is predominant. A lung recruitment maneuver is less likely to improve oxygenation and compliance of the lung in secondary ARDS.
Several types of recruitment maneuvers are currently being used in the clinical setting. These include a sustained high pressure in the CPAP mode, PCV with a single high PEEP level imposed, PCV with progressive increases in PEEP level, and sigh maneuvers.
The ARDS Network trial and other studies provide strong evidence in support of using VT of 6 mL/kg and a Pplateau <30 cm H2O when ventilating patients with ARDS. The differences in survival are significant when these settings are used compared with using a VT of 12 mL/kg.
Relaxation of smooth airway muscle in the presence of reversible airflow obstruction is a general indication for the use of:
1. Antiinfective agents
3. Adrenergic bronchodilators
Ipratropium agents may be indicated to treat:
1. Nonallergic rhinitis
2. The common cold
3. Allergic rhinitis
4. All of the above
The common cold
***All of the above***
The most common side effect of anticholinergic bronchodilators is:
1. Increased heart rate
4. Dry mouth
Possible side effects of aerosolized Atrovent include which of the following?
I. Flulike symptoms
III. Cardiac arrest
IV. Dry mouth
1. I, II, IV, and V only
2. I, II, and III only
3. I, II, III, IV, and V
4. I, II, and IV only
I, II, IV, and V only
Disease states that could benefit from the use of adrenergic bronchodilators include which of the following?
V. Pleural effusion
I, II, III, and IV only
Racemic epinephrine comes in what percent solution?
The keyhole theory indicates that the larger the side-chain attachment to a catechol base, the:
1. Shorter the duration of action
2. More easily it is metabolized
3. More easily it is broken down by COMT
4. Greater the b2 specificity
Greater the b2 specificity
Albuterol is available in which of the following forms?
II. Nebulizer solution
III. Metered dose inhaler (MDI)
IV. Oral tablets
V. Dry powder inhaler (DPI) capsules
1. I, II, and V only
2. I, II, III, IV, and V
3. II and III only
4. III, IV, and V only
I, II, III, IV, and V
Inhalation is the preferred route of administering catecholamines for which of the following reasons?
I. Rapid onset of action
II. Smaller dosage used
III. Reduced side effects
IV. Drug is delivered to target organ
V. Safe and painless route
1. I, III, and V only
2. I, II, III, IV, and V
3. III and IV only
4. I and II only
I, II, III, IV, and V
You receive an order to administer 5 ml of albuterol by small volume nebulizer (SVN). You would:
1. Give 0.5 ml of medication because that is probably what the doctor meant to write
2. Confirm the order on the chart and administer as directed
3. Call the physician to confirm the medication dose
4. Have your supervisor administer the treatment
Call the physician to confirm the medication dose
A patient with glottic edema is in mild distress. Which of the following medications would be of benefit in this situation?
1. Ipratropium bromide
3. Racemic epinephrine
Ipratropium bromide can be delivered by which of the following methods?
V. Nasal spray
1. II only
2. I, III, and IV only
3. II, IV, and V only
4. I, II, and IV only
II, IV, and V only
Sedation is frequently required for mechanically ventilated patients for agitation and sleep deprivation, which can result from all of factors below except ____.
2. adverse drug effects
3. flail chest and paradoxical breathing
4. extreme anxiety and delirium
flail chest and paradoxical breathing
Sedation may be required for mechanically ventilated patients who are being treated with non-conventional modes of ventilation including all of the following except ____.
1. inverse I:E ventilation
2. high-frequency ventilation
3. permissive hypercapnia
4. pressure support ventilation for weaning
pressure support ventilation for weaning
Benzodiazepines have been the drugs of choice for the treatment of anxiety in critical care.
Drugs that produce anxiolytic, hypnotic, muscle relaxation, anticonvulsant, and anterograde amnesic effects are ____.
Propofol (Diprivan) is an intravenous, general anesthetic agent that possesses sedative, amnesic, and hypnotic properties at low doses, although it has no analgesic properties.
An appropriate depolarizing agent for use during intubation is ____.
NMBAs should not be used with sedatives for patients on mechanical ventilation.
A fresh postoperative patient displaying ventilator dysynchrony should first be treated with ____.
The most potent analgesic agent is ____.
1. Demerol HCl
3. morphine sulfate
Nondepolarizing agents resemble acetylcholine in their chemical structure. These drugs induce paralysis by binding to acetylcholine receptors and causing prolonged depolarization of the motor end plate.
Regardless of the NMBA used, it is important to understand that these drugs do not possess sedative or analgesic properties and must, therefore, be used in conjunction with adequate amounts of sedatives and analgesics to ensure patient comfort.
NMBAs are commonly used in mechanically ventilated patients when ____.
1. cardiac arrhythmias are present
2. the patient is in severe pain
3. patient anxiety results from ICU psychosis
4. patient-ventilator dysynchrony cannot be corrected
patient-ventilator dysynchrony cannot be corrected
A patient exhibits delirium characterized by disorganized thinking and unnecessary motor activity after being on a ventilator in the ICU for 4 days. The drug type appropriate to treat this condition is a(n) ____.
Fentanyl exerts significant effects on the cardiovascular system but does not cause histamine release like morphine.
Fentanyl citrate (Sublimaze) is a synthetic opioid that is approximately 100 to 150 times more potent than morphine.
Morphine is a potent opioid analgesic agent that is the preferred agent for analgesic intermittent therapy for mechanically ventilated patients because of ____.
1. its ability to alter the control of breathing
2. its effects on the central nervous system
3. its benign cardiac effects
4. its longer duration of action
its longer duration of action
Although the primary pharmacological action of opioids is to relieve pain, these drugs can also provide significant secondary sedative and anxiolytic effects, which are mediated through two types of opioid receptors: µ and ê receptors.
Reversal of opioid side effects can be accomplished with the opioid antagonist ____.
2. propofol (Diprivan)
3. naloxone hydrochloride (Narcan)
4. the butyrophenone haloperidol
naloxone hydrochloride (Narcan)
Observing the patient's skeletal muscle movements and respiratory effort can provide an easy method to determine if the patient is paralyzed with NMBAs; however, more sophisticated electronic monitoring is typically required to determine the depth of paralysis.
____ is a rare but potentially fatal disorder that is characterized by sustained skeletal muscle depolarization.
2. Malignant neoplasm
3. Malignant hyperthermia
4. Hypotensive neuralgia
Vecuronium bromide (Norcuron) is an intermediate duration nondepolarizing aminosteroid NMBA that does not possess the vagolytic properties of pancuronium.
It has been known for several decades that PPV decreases cardiac output. This phenomenon can be understood in part by comparing intrapleural (intrathoracic) pressure changes that occur during normal spontaneous negative pressure breathing and intrapleural (intrathoracic) pressure changes that occur during positive pressure ventilation.
PEEP with assist/control decreases cardiac output less than when PEEP is used with IMV/SIMV or CPAP alone.
During spontaneous breathing, the fall in intrapleural (intrathoracic) pressure that draws air into the lungs during inspiration also draws blood into the major thoracic vessels and heart. This phenomenon increases ____.
1. right ventricular afterload
2. right ventricular preload
3. systemic vascular resistance
4. P capillary resistance
right ventricular preload
During inspiration with high Vt or when high levels of PEEP are used, the pulmonary capillaries that interlace the alveoli are stretched and narrowed. As a result PEEP ____.
1. increases right ventricular afterload
2. decreases right ventricular afterload
3. decreases left ventricular afterload
4. increases right ventricular preload
decreases right ventricular afterload
Left ventricular output may also be decreased when high Vts are used during PPV, because the heart is compressed between the expanding lungs. This is known as ____.
1. cardiac hypertrophy
3. cardiac tamponade
In addition to reduced venous return and alteration in ventricular function, lower cardiac output may be due to myocardial dysfunction associated with ____ and the resultant myocardial ischemia.
1. reduced renal blood flow
2. reduced portal blood flow
3. reduced carotid blood flow
4. reduced coronary blood flow
reduced coronary blood flow
Systemic hypotension commonly occurs in hemodynamically normal individuals receiving positive pressure ventilation.
It is unusual to see a reduction in cardiac output in normovolemic patients when low levels of PEEP are used (i.e., 5 to 10 cm H2O of PEEP).
Patients with very stiff lungs, such as those with ARDS or pulmonary fibrosis, receiving positive pressure ventilation are ____.
1. more likely to experience hemodynamic changes with high pressures
2. less likely to transmit alveolar pressure to the intrapleural space
3. more likely to have higher intrapleural pressures
4. less likely to have decreased lung compliance
less likely to transmit alveolar pressure to the intrapleural space
Maintaining the lowest possible mean airway pressure helps to minimize the reductions in cardiac output that can occur during mechanical ventilation.
Positive pressure ventilation and PEEP can be beneficial for patients with left ventricular dysfunction and elevated filling pressures for all of the following reasons except ____.
1. reductions in venous return decrease the preload to the heart and thus improve length-tension relationships and improve the stroke volume
2. PEEP decreases the transmural coronary artery pressure, changing myocardial perfusion
3. PEEP may improve cardiac function by raising the PaO2 and improving myocardial oxygenation and performance
4. PPV raises the intrathoracic pressure, decreases the transmural LV systolic pressure and, thus, the afterload to the left heart
PEEP decreases the transmural coronary artery pressure, changing myocardial perfusion
With normal I:E ratios, the majority of pulmonary perfusion and gas exchange occurs during ____.
1. expiratory time
2. coughing maneuvers
3. ventricular systole
4. inspiratory time
Inflation hold is now used almost exclusively to measure plateau pressure in order to calculate static compliance, not to improve the distribution of alveolar gas.
Increased amounts of PIP may be needed to ventilate patients with elevated Raw, but this increased pressure will not all reach the alveoli. This is true in all of the following conditions except ____.
1. mucus plugging
2. mucosal edema
4. lobar pneumonia
The most serious management complications associated with PPV include all of the following except ____.
1. alterations in cardiac function
2. respiratory alkalosis
3. interference with gas exchange
4. increased risk of lung injury from over-distension
When severe, uncontrollable increased intracranial pressure is present, patients may be mechanically hyperventilated to reduce intracranial pressure by ____.
1. lowering PaCO2 to 25 to 30 mm Hg
2. raising PaCO2 to 45 to 50 mm Hg
3. lowering PaCO2 to 15 to 20 mm Hg
4. lowering PaCO2 to 10 to 13 mm Hg
lowering PaCO2 to 25 to 30 mm Hg
It has been known for nearly half a century that pressurized breathing can induce reductions in renal function and urine output. These effects include ____.
1. renal responses to increased FIO2 administration
2. renal responses to diuretic administration
3. renal responses to increased IV fluid administration
4. renal responses to hemodynamic changes resulting from high intrathoracic pressures
renal responses to hemodynamic changes resulting from high intrathoracic pressures
Although urinary output stays fairly constant over a wide range of arterial pressures, it becomes severely reduced as the glomerular capillary pressure decreases below 75 mm Hg.
In the seriously ill mechanically ventilated patient, administering positive pressure increases all of the following except ____.
1. renal blood flow
2. weight gain
3. water and sodium retention
4. pulmonary edema
renal blood flow
PPV increases splanchnic resistance, decreases splanchnic venous outflow, and may contribute to gastric mucosal ischemia. This last change is one of the factors leading to increased incidence of ____, which are frequently seen in critically ill patients.
1. liver metastases
2. tracheal malacia
3. portal blood flow increases
4. gastrointestinal bleeding and gastric ulcers
gastrointestinal bleeding and gastric ulcers
Barotrauma implies trauma associated with pressure. Examples of barotraumas resulting from mechanical ventilation include all of the following except ____.
1. subcutaneous emphysema
2. subcutaneous edema
Prolonged alveolar over-distention from mechanical ventilation leads to the release of inflammatory mediators from the lungs that can cause failure of other organs of the body. This response has been termed ____.
More recent evidence demonstrates that the repeated opening and closing of lung units generates shear stress, with direct tissue injury at the alveolar and pulmonary capillary level as well as the loss of surfactant from these unstable lung units. This injury is now termed ____.
The term ____, in general, is used when referring to lung injury occurring in humans that has been identified as a consequence of mechanical ventilation.
A condition that can be accelerated by mechanical ventilation is ____. It can be detected by a hyperresonant percussion note and absence of breath sounds on the affected side of the thorax.
1. ejectate injury
3. pneumococcal pneumonia
____ occurs when an alveolus that is normally expanded is adjacent to one that is collapsed (atelectasis) and unstable. As airway pressure increases during inspiration, the normal alveolus inflates, but the collapsed unit does not.
1. Absorption injury
4. Shear stress
Chemical mediators produced in the lung during ventilator mismanagement can leak into the blood vessels. The pulmonary circulation then carries these stimulating substances to other areas of the body and sets up an inflammatory reaction in other organs such as the kidneys, gut, and liver.
Mechanical ventilation is not benign and may cause lung injury. Treating patients with lung-protective strategies includes all of the following except ____.
1. low FIO2
2. low Vt
3. permissive hypercapnea
4. therapeutic PEEP
It is generally considered important in mechanical ventilation of patients with ALI and/or ARDS to open alveoli with a recruitment maneuver and keep them open with an appropriate level of PEEP.
The positive effects of PEEP in ALI and ARDS include all of the following except ____.
1. improved oxygenation
2. improvement of the V/Q relationships of the lungs
3. decreased CVP and right ventricle preload
4. FRC is increased when collapsed alveoli open up
decreased CVP and right ventricle preload
Ventilator-associated pneumonia (VAP) refers specifically to a pneumonia acquired by a patient receiving mechanical ventilation 48 hours after intubation.
Strategies for reducing the risk for colonization and VAP include all of the following except ____.
1. saline instillation into the ET tube during suctioning.
2. semirecumbent positioning of patient
3. handwashing and use of accepted infection control procedures and practices and use of closed suction catheters and sterile suction technique
4. continuous aspiration of subglottic secretions
saline instillation into the ET tube during suctioning.
The easiest way to detect air trapping or auto-PEEP is to evaluate ____.
1. the manometer PIP
2. the volume-time curve on the ventilator graphic
3. the flow-time curve on the ventilator graphic
4. the pressure-time curve on the ventilator graphic
the flow-time curve on the ventilator graphic
Management of patient-ventilator asynchrony begins with several specific steps. The initial step is to ____.
1. analyze the FIO2
2. check low pressure alarm setting
3. disconnect the patient from the ventilator and perform manual ventilation
4. decrease the peak flow setting
disconnect the patient from the ventilator and perform manual ventilation
As opposed to a ventilator-related problem, patient-related problems include all of the following except ____.
2. increased patient circuit rainout
3. artificial airway problems
increased patient circuit rainout
Rupture of the innominate artery can occur and is most often noticed with ____.
1. pulmonary artery lines
2. heated wire patient circuits
3. endotracheal tubes
4. tracheostomy tubes
Causes of airway problems that can lead to sudden distress include all of the following except ____.
1. cuff inflated to 24 mm Hg
2. endotracheal tube kinking
3. migration of the endotracheal tube above the vocal cords
4. migration of the endotracheal tube into the right mainstem bronchus
cuff inflated to 24 mm Hg
The sudden onset of dyspnea can be visually recognized by the physical signs of distress, which include all of the following except ____.
2. nasal flaring
4. no accessory muscle use noted
no accessory muscle use noted
If a tension pneumothorax is strongly suspected and death is imminent, the appropriate next step is to ____.
1. confirm the finding with a chest radiograph
2. insert a 14- or 16-gauge needle into the second intercostal space at the midclavicular line
3. obtain a 7 Fr trocar and establish a pleural drainage tube
4. use a Heimlich chest drainage valve with chest tube placement
insert a 14- or 16-gauge needle into the second intercostal space at the midclavicular line
Wheezing associated with increased Raw from airway reactivity, such as occurs with asthma, is treated with all of the following except ____.
1. inhaled bronchodilators
2. parenteral corticosteroids
3. peak flows above 2 L/sec
4. increased expiratory time
peak flows above 2 L/sec
Abdominal distention during mechanical ventilation can be caused by ____.
1. excessive nasogastric suction
The occurrence of low pressure, low volume, and low VE alarms indicates that ____ is causing the problem.
2. a leak
4. pulmonary embolism
Leaks rarely result from a patient disconnection in the modern ICU.
During ventilation with VC-CMV, pleural leaks can sometimes be compensated for by increasing the ____.
1. Vt setting
2. peak flow
3. pressure limit
4. number of chest tubes
Auto-PEEP may interfere with the ventilator's ability to detect patient efforts. This is corrected by decreasing the sensitivity setting.
During volume ventilation, a concave appearance on the inspiratory pressure curve indicates active inspiration with inadequate flow.
Asynchronous breathing may occur when patients with COPD are ventilated with PSV. These patients are known to have an active short inspiration. If the patient begins to actively exhale during the inspiratory phase of PSV, this can be corrected by ____.
1. switching to a ventilator with adjustable pressure-cycling characteristics
2. switching to a ventilator with adjustable flow-cycling characteristics
3. switching to PRVC
4. switching to VC-CMV
switching to a ventilator with adjustable flow-cycling characteristics
Conditions leading to high pressure alarms can be divided into all of the following categories except ____.
1. airway problems
2. leaks associated with the ventilator or patient circuit
3. changes in lung characteristics or patient-related conditions
4. obstructive problems related to the ventilator or patient circuit
leaks associated with the ventilator or patient circuit
The ventilator alarms that are most likely to occur include all of the following except ____.
1. low exhaled volume alarm
2. ventilator inoperative alarm
3. low ET cuff volume alarm
4. low pressure alarm
low ET cuff volume alarm
Although invasive ventilation is effective and often necessary to support alveolar ventilation, it has many associated risks that often result in increased mortality, morbidity, and financial cost.
NPPV is considered a life-saving application that offers a number of benefits over IPPV. Least significant among these is the avoidance of intubation.
Endotracheal intubation is associated with all of the following complications except ____.
1. choanal atresia
2. nosocomial pneumonia
3. airway trauma and increased risk of aspiration
4. patient discomfort requiring the use of sedatives
The physiological goal of NPPV in acute respiratory failure is to improve gas exchange by ____.
1. decreasing the effect of conducting airway secretions
2. increasing alveolar ventilation and resting the respiratory muscles
3. decreasing FRC
4. increasing right ventricular preload
increasing alveolar ventilation and resting the respiratory muscles
When compared with patients with COPD receiving only conventional medical therapy (such as bronchodilators, antiinflammatory agents, oxygen, and antibiotics), patients with COPD receiving NPPV have shown significant improvement in vital signs, pH and blood gas values, respiratory rate, and breathlessness within the first hour of application.
A number of studies have found that NPPV is currently considered a standard of care to treat ____ in selected patients.
1. hypoxemic respiratory failure/ARDS
2. COPD exacerbations
3. asthma exacerbations
4. community-acquired pneumonia
When NPPV was compared with CPAP in the treatment of CPE, patients treated with NPPV had more rapid improvements in PaCO2 and pH, but mortality rates and intubation rates were not significantly different.
NPPV can be useful in chronic cases as supportive therapy for all the following clinical disorders except ____.
1. nocturnal desaturation and poor sleep quality
2. metabolic disorders leading to acidosis
3. chronic hypoventilation
4. respiratory muscle fatigue
metabolic disorders leading to acidosis
Disorders associated with nocturnal hypoventilation that generally benefit from NPPV include all of the following except ____.
1. pulmonary fibrosis
2. obesity hypoventilation syndrome
3. central sleep apnea
4. obstructive sleep apnea combined with COPD or CHF
Symptoms of chronic hypoventilation that may be indications for NPPV include all of the following except ____.
1. daytime anxiety
2. fatigue and morning headache
3. daytime hypersomnolence
Symptoms and selection criteria for NPPV in acute respiratory failure include all of the following except ____.
1. respiratory rate >24 breaths/min
2. purse-lipped breathing
3. paradoxical breathing
4. accessory muscle use
NPPV can be used after extubation in patients who exhibit fatigue. NPPV in this setting reduces work of breathing and maintains adequate gas exchange as effectively as invasive ventilation.
Physiological criteria for commitment to NPPV include all of the following except ____.
1. pH <7.35
2. SaO2 <92%
3. PaO2/FIO2 <200
4. PaCO2 >45 mm Hg
Mask discomfort is the most frequently occurring complication of NPPV. The most common problem is ____.
1. mask strap pressure leads to increased ICP
2. air leaks around the mask often result in eye irritation
3. pressure sores may occur over the forehead
4. nasal masks are not well tolerated
air leaks around the mask often result in eye irritation
All of the following factors will increase ventilatory demand (workload) except:
1. increased compliance
2. severe hypoxemia
4. pulmonary infection
Ventilatory capacity is determined by all of the following except:
1. trigger level
2. muscle endurance
3. central nervous system (CNS) drive
4. muscle strength
All of the following factors can reduce a patient's ventilatory drive except:
1. respiratory alkalosis
2. depressant drugs
3. decreased metabolism
4. metabolic acidosis
When is ventilator dependence likely to occur?
I. when ventilatory capacity exceeds demand
II. when arterial hypoxemia is present
III. when the patient is malnourished
IV. when the cardiovascular system is unstable
1. II and IV
2. II, III, and IV
3. I, II, and III
4. III and IV
II, III, and IV
All of the following indicate that an adult patient is ready to be weaned from ventilatory support except:
1. MIP = -33 cm H2O
2. VD/VT = 0.55
3. PAO2 - PaO2 = 430 on 10O2
4. PO2 = 76 mm Hg on 4O2
PAO2 - PaO2 = 430 on 100% O2
Which of the following five adult patients receiving ventilatory support is the best candidate for weaning?
Which of the following patients exhibits an acceptable ventilatory demand?
A patient has an adequate ventilatory reserve if which of the following is TRUE?
ability to double the resting minute ventilation
You measure the spontaneous rate of breathing and VT on four patients receiving ventilator support. For which one is successful weaning most likely?
A patient receiving ventilator support has a spontaneous rate of breathing of 26/min and an average VT of 300 ml. What is this patient's rapid-shallow breathing index?
Which of the following signs observed on a mechanically ventilated patient indicate that successful weaning is unlikely?
I. palpable scalene muscle use during inspiration
II. palpable abdominal tensing during expiration
III. presence of an irregular breathing pattern
IV. patient unable to alter breathing pattern on command
1. III and IV
2. I, II, III, and IV
3. I, II, and III
4. II and IV
I, II, III, and IV
Which of the following is false about the P0.1 measure?
1. Chronic obstructive pulmonary disease (COPD) patients with a P0.1 greater than 6 cm H2O are difficult to wean.
2. P0.1 is the airway pressure measured 100 ms after occlusion.
3. P0.1 is an effort-dependent measure of respiratory drive.
4. P0.1 correlates well with central respiratory drive.
P0.1 is an effort-dependent measure of respiratory drive.
Successful weaning is less likely when a patient's work of breathing exceeds what level?
1. 16 J/min
2. 8 J/min
3. 4 J/min
4. 12 J/min
Above what pressure-time index (PTI) will most patients be unable to sustain spontaneous breathing?
Which of the following electrolyte imbalances can hinder weaning from ventilatory support?
1. II and III
2. I and II
3. I, II, and III
4. I and III
II and III
Which of the following cardiovascular signs would indicate that a patient's cardiovascular status is unstable and that weaning should NOT begin at this time?
1. heart rate of 108/min
2. cardiac index of 2.5 L/min/m2
3. systolic blood pressure of 80 mm Hg
4. hemoglobin content of 10 g/dl
systolic blood pressure of 80 mm Hg
Of the following adult patients receiving ventilatory support, which has a stable enough cardiovascular profile to consider weaning?
Systolic blood pressure (mm Hg) Hemoglobin (g/dl)
Which of the following must you verify when considering weaning an obtunded patient?
I. adequate gag reflex
II. no depressant drugs
III. adequate cough
1. II and III
2. I and III
3. I and II
4. I, II, and III
I, II, and III
Common approaches used to wean patients from ventilatory support include which of the following?
I. T-tube alternating with mechanical ventilation
II. pressure-supported ventilation (PSV)
III. intermittent mandatory ventilation
1. I and II
2. I, II, and III
3. I and III
4. II and III
I, II, and III
Which method of weaning may be useful to minimize auto-PEEP?
1. synchronized intermittent mandatory ventilation
3. intermittent mandatory ventilation
4. continuous positive airway pressure (CPAP)
continuous positive airway pressure (CPAP)
An alert patient receiving intermittent mandatory ventilation at a rate of 8/min and VT of 600 ml has stable vital signs and satisfactory blood gases on an FIO2 of 0.45. What would you do to initiate weaning for this patient?
1. Decrease the mandatory rate to 5 to 6/min.
2. Lengthen the automatic sigh interval.
3. Increase FIO2 to 60%.
4. Decrease the VT to 500 ml.
Decrease the mandatory rate to 5 to 6/min.
A physician is using a pressure support protocol to wean a patient off ventilatory support. The patient is now at a 5 cm H2O pressure level and has a spontaneous respiratory rate of 21/min. Other cardiovascular and respiratory signs indicate that the patient remains stable. Which of the following actions would you recommend at this point?
1. Switch the patient to intermittent mandatory ventilation at a rate of 2/min.
2. Switch the patient to 5 cm H2O continuous positive airway pressure (CPAP) through the endotracheal tube.
3. Decrease the pressure support level to 3 cm H2O.
4. Extubate the patient and provide supplemental O2.
Extubate the patient and provide supplemental O2.
An alert patient receiving ventilatory support through a demand flow intermittent mandatory ventilation system exhibits clinical signs of an increased work of breathing whenever you try to decrease the mandatory rate below 6/min. In order to aid in weaning this patient, which of the following would you recommend?
1. Apply a low level of pressure support.
2. Decrease the mandatory VT.
3. Increase the mandatory VT.
4. Apply a high level of inspiratory pressure.
Apply a low level of pressure support.
Which of the following ventilator modes can ensure delivery of a preset VT during spontaneous breathing?
I. volume support or VERSUS (Siemens Servo Ventilator 300)
II. volume-assured pressure support or VAPS (Bird 8400ST)
III. augmented minute ventilation or MMV (Bear 1000)
1. I, II, and III
2. II and III
3. I and II
4. I and III
I and II
Limitations of noninvasive positive-pressure ventilation include all of the following except it:
1. limits access to the airway
2. causes mask-related problems
3. prevents speech or swallowing
4. requires patient cooperation
prevents speech or swallowing
Advantages of noninvasive positive-pressure ventilation include all of the following except it:
1. eliminates risk of aspiration
2. allows speech or swallowing
3. allows intermittent use
4. preserves airway defenses
eliminates risk of aspiration
In most weaning protocols, what minimum blood gas parameters are needed to start the process?
1. PaO2 greater than 70 mm Hg and PaCO2 less than 70 mm Hg on FIO2 less than 0.6 and PEEP 5 cm H2O or greater
2. PaO2 greater than 70 mm Hg and PaCO2 less than 50 mm Hg on FIO2 less than 0.6 and PEEP less than 5 cm H2O
3. PaO2 greater than 50 mm Hg and PaCO2 less than 50 mm Hg on FIO2 less than 0.6 and PEEP less than 10 cm H2O
4. PaO2 greater than 70 mm Hg and PaCO2 less than 50 mm Hg on FIO2 less than 0.4 and PEEP 5 cm H2O or greater
PaO2 greater than 70 mm Hg and PaCO2 less than 50 mm Hg on FIO2 less than 0.4 and PEEP 5 cm H2O or greater
All of the following are disadvantages of using the T-tube method for weaning except:
1. abrupt transition sometimes difficult
2. lack of alarm systems
3. more staff time required
4. high imposed work of breathing
high imposed work of breathing
All of the following are disadvantages of using intermittent mandatory ventilation for weaning except:
1. potentially high work of breathing
2. higher mean airway pressures
3. patient-ventilator dyssynchrony
4. weaning time possibly prolonged
higher mean airway pressures
All of the following are advantages of using pressure-supported ventilation for weaning except:
1. better patient comfort and synchrony
2. respiratory muscle fatigue prevented
3. guaranteed VT
4. reduced work of breathing
While monitoring a patient being weaned by intermittent mandatory ventilation, you notice the following: total minute ventilation = 12 L/min; set (machine) minute ventilation = 5 L/min; set rate = 10/min; total rate = 20/min. What is the patient's average spontaneous VT?
1. 800 ml
2. 600 ml
3. 500 ml
4. 700 ml
Which of the following cardiovascular changes would you consider a bad sign during weaning a patient from ventilatory support?
1. development of chest pain
2. increase in both stroke volume and cardiac index
3. fall in blood pressure from 143/95 to 126/88 mm Hg
4. increase in heart rate from 95 to 110/min
development of chest pain
While monitoring a patient being weaned through a T-tube protocol, signs indicating that mechanical ventilation should be restored include all of the following except:
1. asynchronous or paradoxical breathing
2. development of cardiac arrhythmias
3. moderate rise in respiratory rate
4. development of severe hypotension
moderate rise in respiratory rate
Which of the following changes can be expected when weaning a patient through a T-tube trial?
I. increase in respiratory rate of 10/min
II. increase in heart rate of 15 to 20/min
III. 5 to 10 mm Hg rise in the arterial PCO2
IV. doubling of the minute ventilation
1. II and IV
2. III and IV
3. I, II, III, and IV
4. I, II, and III
I, II, and III
While monitoring a patient during a T-tube weaning trial, you notice the following: increased patient agitation; increased heart rate (from 90 to 118/min); increased respiratory rate (from 17 to 33/min with some paradoxical motion); and premature ventricular contractions (PVCs) increasing to an average of 5/min. Which of the following actions would be appropriate at this time?
1. Reconnect the patient to the ventilator with prior settings.
2. Request that the patient be given a strong sedative or hypnotic.
3. Request that the patient be given a stat (immediate) bolus of lidocaine.
4. Encourage the patient to relax, and continue careful monitoring.
Reconnect the patient to the ventilator with prior settings.
Which of the following is FALSE about artificial tracheal airways and weaning?
1. The added work due to artificial airways can increase ventilator dependence.
2. Artificial airways can increase the work of breathing nearly threefold.
3. There are decreases in tube inner diameter (ID) and increases in VE increase the work of breathing.
4. Tracheostomy tubes increase the work of breathing more than can endotracheal tubes.
Tracheostomy tubes increase the work of breathing more than can endotracheal tubes.
What is the best way to decrease the work of breathing imposed by an artificial airway on a patient receiving ventilatory support?
1. Lower the minute ventilation.
2. Use low rates of breathing.
3. Provide pressure support.
4. Decrease inspiratory flow.
Provide pressure support.
In considering a patient for endotracheal tube extubation, which of the following procedures would you recommend to determine the risk of postextubation upper airway obstruction?
1. forced vital capacity
2. methylene blue test
3. pre- and post-bronchodilator
4. cuff leak test
cuff leak test
Which of the following patients are at high risk for severe laryngeal edema after an endotracheal tube extubation?
I. pediatric burn victim
II. patient with epiglottitis
III. smoke inhalation patient
IV. pulmonary fibrosis patient
1. I, II, and III
2. II and IV
3. III and IV
4. I, II, III, and IV
I, II, and III
Common causes for weaning failure include all of the following except:
1. myocardial ischemia
2. critical illness polyneuropathy
3. secondary polycythemia
4. psychological dependence
All of the following are useful strategies in managing the psychological problems encountered in weaning some patients from ventilator support except to:
1. secure a psychiatric consult
2. avoid mental stimulation
3. decrease environmental stress
4. teach relaxation methods
avoid mental stimulation
Who should make the decisions related to terminal weaning?
1. respiratory therapist
4. patient's family and patient's physician
patient's family and patient's physician