Egan's Chapter 36

An adult patient receiving cool mist therapy after extubation begins to develop stridor. Which of the following actions would you recommend?

Administer a racemic epinephrine treatment

A patient exhibits persistent stridor after a fiberoptic bronchoscopy procedure. Which of the following would you recommend?

Aerosol therapy with racemic epinephrine

A patient with a tracheal airway exhibits signs of tube obstruction. Which of the following are possible causes of this obstruction? 1. The tube cuff has herniated over the tip of the tube. 2. The tube is obstructed by a mucus plug or secretions. 3. The tube is kinked, or the patient is biting the tube. 4. The tube orifice is impinging on the tracheal wall.

All

A physician has requested your assistance in extubating an orally intubated patient. Which of the following should be done before the tube itself is removed? 1. Suction the orolaryngopharynx 2. Preoxygenate the patient 3. Suction the endotracheal tube 4. Confirm cuff inflation

All

Immediately after insertion of an oral endotracheal tube on an adult, what should you do? 1. Stabilize it with your right hand. 2. Inflate the tube cuff. 3. Provide ventilation or oxygenation.

All

Key points to consider in planning fiberoptic bronchoscopy include which of the following? 1. Equipment preparation 2. Premedication 3. Airway preparation 4. Monitoring

All

The major limitations of using a laryngeal mask airway are: 1. It should not be used in conscious or semicomatose patients. 2. Gastric distention may occur if ventilating pressures greater than 20 cm H2O are needed. 3. It does not provide absolute protection against aspiration of gastric contents.

All

Therapeutic indications for fiberoptic bronchoscopy include which of the following? 1. Inspect the airways. 2. Retrieve foreign bodies. 3. Obtain specimens for analysis. 4. Aid endotracheal intubation.

All

To minimize the problems associated with pharyngeal aspiration in intubated patients, which of the following could you recommend? 1. Position patients in semi-recumbent position. 2. Use a cuff on all ET tubes. 3. Suction above the tracheal tube cuff. 4. Provide continuous aspiration of subglottic secretions.

All

Tracheal stenosis occurs in as many as 1 in 10 patients after prolonged tracheostomy. At what sites does this stenosis usually occur? 1. Cuff site 2. Tip of the tube 3. Stoma site

All

What general condition requires airway management? 1. Airway compromise 2. Respiratory failure 3. Need to protect the airway

All

Which of the following approaches may be used in "weaning" a patient from a tracheostomy tube? 1. Using progressively smaller tubes 2. Using a fenestrated tube 3. Using a tracheostomy button

All

Which of the following are appropriate orders before an elective fiberoptic bronchoscopy procedure scheduled for the next morning? 1. Have patient take nothing by mouth (NPO) after midnight. 2. Establish vascular access. 3. Premedicate with a benzodiazepine.

All

Which of the following are goals of airway preparation before conducting fiberoptic bronchoscopy? 1. To decrease cough and gagging 2. To decrease pain 3. To prevent bleeding

All

Which of the following autonomic or protective neural responses represent potential hazards of emergency airway management? 1. Hypotension 2. Bradycardia 3. Cardiac arrhythmias 4. Laryngospasm

All

Which of the following conditions require emergency tracheal intubation? 1. Upper airway or laryngeal edema 2. Loss of protective reflexes 3. Cardiopulmonary arrest 4. Traumatic upper airway obstruction

All

Which of the following equipment would you gather before assisting in extubation of a patient? 1. Suctioning apparatus 2. Oxygen or aerosol therapy equipment 3. Manual resuscitator and mask 4. Nebulizer with racemic epinephrine 5. Intubation tray

All

Which of the following factors should be considered when deciding to change from an endotracheal tube to a tracheostomy tube? 1. Patient's tolerance of the endotracheal tube 2. Relative risks of continued intubation versus tracheostomy 3. Patient's severity of illness and overall condition 4. Length of time that the patient will need an artificial airway 5. Patient's ability to tolerate a surgical procedure

All

Which of the following techniques may be used to diagnose injury associated with artificial airways? 1. Laryngoscopy or bronchoscopy 2. Physical examination 3. Air tomography 4. Pulmonary function studies

All

When using capnometry or colorimetry to differentiate esophageal from tracheal placement of an endotracheal tube, which of the following conditions can result in a false-negative finding (i.e., no CO2 present even when the tube is in the trachea)?

Cardiac arrest

While checking a Miller and a MacIntosh blade on an intubation tray during an emergency intubation, you find that the Miller blade "lights" but the MacIntosh blade does not. What should you do now?

Check and replace the bulb in the MacIntosh blade.

A patient with a tracheal airway exhibits severe respiratory distress. On quick examination, you notice the complete absence of breath sounds and no gas flowing through the airway. What is most likely the problem?

Complete tube obstruction

A patient exhibits persistent mild hypoxemia after a fiberoptic bronchoscopy procedure. Which of the following would you recommend?

Continue oxygen therapy and reassess in 4 hr.

To minimize laryngeal swelling, a physician orders "continuous aerosol therapy" after the extubation of a patient. Which of the following specific approaches would you recommend?

Cool mist therapy through a jet nebulizer and aerosol mask

What is the purpose of the additional side port (Murphy eye) on most modern endotracheal tubes?

Ensure gas flow if the main port is blocked

Which of the following bedside methods can absolutely confirm proper endotracheal tube position in the trachea?

Fiberoptic laryngoscopy

What is the most common complication of suctioning?

Hypoxemia

During fiberoptic bronchoscopy, a patient receiving intravenous fentanyl exhibits signs of respiratory depression. Which of the following would you recommend?

Immediately administer naloxone (Narcan).

What is the purpose of an endotracheal tube stylet?

It adds rigidity and shape to ease insertion.

What is a rare but serious complication associated with endotracheal tube extubation?

Laryngospasm

Although different techniques are used to actually remove the endotracheal tube during an extubation procedure, all aim to ensure which of the following?

Maximal abduction of the vocal cords

To provide local anesthesia and vasoconstriction during nasal intubation, what would you recommend?

Mixture of 0.25% phenylephrine and 3% lidocaine

To make oral intubation easier, how should the patient's head and neck be positioned?

Neck extended, with head supported by towel and tilted back

In the absence of neck or facial injuries, what is the procedure of choice to establish a patent tracheal airway in an emergency?

Orotracheal intubation

A patient with a tracheostomy tube is receiving positive-pressure ventilation through a volume ventilator. Over the past 5 min, the peak inspiratory pressure has risen, and the pressure limit alarm is now sounding. On quick examination, you notice a generalized decreased in breath sounds. Which of the following problems is most likely?

Partial obstruction of the tracheostomy tube

After an intubation attempt, an expired capnogram indicates a CO2 level near zero. What does this finding probably indicate?

Placement of the endotracheal tube in the esophagus

What is the most common problem with fenestrated tracheostomy tubes?

Poor positioning of the tube fenestration

To prevent hypoxemia when suctioning a patient, the respiratory care practitioner should initially do which of the following?

Pre-oxygenate the patient with 100% oxygen

What does a positive cuff leak test indicate?

The patient is at minimal risk for upper airway obstruction.

An adult man on ventilatory support has just been intubated with a 7-mm oral endotracheal tube equipped with a high-residual-volume, low-pressure cuff. When sealing the cuff to achieve a minimal occluding volume, you note a cuff pressure of 45 cm H2O. What is most likely the problem?

The tube chosen is too small for the patient

In a properly performed traditional surgical tracheotomy, entrance to the trachea is made through an incision in what area?

Through or between the second and third tracheal rings

What is the purpose of a tracheostomy tube obturator?

To minimize trauma to the tracheal mucosal during insertion

What is the purpose of a cuff on an artificial tracheal airway?

To seal off and protect the lower airway

A patient has been receiving positive-pressure ventilation through a tracheostomy tube for 4 days. In the past 2 days, there is evidence of both recurrent aspiration and abdominal distention but minimal air leakage around the tube cuff. What is most likely cause of the problem?

Tracheoesophageal fistula

During oral intubation of an adult, the endotracheal tube should be advanced into the trachea about how far?

Until its cuff has passed the cords

To maintain positive end expiratory pressure (PEEP) and high FiO2 when suctioning a mechanically ventilated patient, what would you recommend?

Use a closed-system multi-use suction catheter.

Which of the following is likely to increase the likelihood of damage to the tracheal mucosa?

Using a low-residual-volume, low-compliance cuff

After removal of an oral endotracheal tube, a patient exhibits hoarseness and stridor that do not resolve with racemic epinephrine treatments. What is most likely the problem?

Vocal cord paralysis

How often should patients be suctioned?

When physical findings support the need

A surgical resident has asked that you assist in an elective tracheotomy procedure on an orally intubated patient. Which of the following would be an appropriate action?

Withdraw the oral tube 2 to 3 in while the incision is made

What is the normal range of negative pressure to use when suctioning an adult patient?

-100 to -120 mmHg

What is the normal range of negative pressure to use when suctioning infants?

-80 to -100 mm Hg

For which of the following reasons is atropine often used during fiberoptic bronchoscopy? 1. To dry the patient's airway 2. To decrease vagal responses 3. To provide topical anesthesia

1,2

Which of the following features incorporated into most modern endotracheal tubes assist in verifying proper tube placement? 1. Length markings on the curved body of the tube 2. Imbedded radiopaque indicator near the tube tip 3. Additional side port (Murphy eye) near the tube tip

1,2

Which of the following injuries are seen with tracheostomy tubes? 1. Tracheomalacia 2. Tracheal stenosis 3. Glottic edema 4. Vocal cord granulomas

1,2

Before beginning an intubation procedure, the practitioner should check and confirm the operation of which of the following? 1. Laryngoscope light source 2. Endotracheal tube cuff 3. Suction equipment 4. Cardiac defibrillator

1,2,3

Compared with traditional surgical tracheostomy, which of the following are true about percutaneous dilatational tracheostomy? 1. Percutaneous dilatational tracheostomy has a lower incidence of complications. 2. Percutaneous dilatational tracheostomy is faster than traditional tracheostomy. 3. Percutaneous dilatational tracheostomy can be performed at the bedside. 4. Percutaneous dilatational tracheostomy does not require anterior neck dissection.

1,2,3

Compared with translaryngeal intubation, the advantages of tracheostomy include which of the following? 1. Greater patient comfort 2. Reduced risk of bronchial intubation 3. No upper airway complications 4. Decreased frequency of aspiration

1,2,3

Equipment required for patient support and monitoring during a fiberoptic bronchoscopy procedure includes which of the following? 1. Pulse oximeter 2. Oxygen cannula 3. Electrocardiographic monitor 4. Capnometer

1,2,3

Serious complications of oral intubation include which of the following? 1. Cardiac arrest 2. Acute hypoxemia 3. Bradycardia 4. Tongue lacerations

1,2,3

Which of the following statements are true about methods used to displace the epiglottis during oral intubation? 1. Regardless of the blade used, the laryngoscope is lifted up and forward. 2. The curved (MacIntosh) blade lifts the epiglottis indirectly. 3. The straight (Miller) blade lifts the epiglottis directly. 4. Levering the laryngoscope against the teeth can aid displacement.

1,2,3

You have been asked to monitor a patient who has just been extubated. Which of the following parameters would you monitor? 1. Color 2. Breath sounds 3. Vital signs 4. Inspiratory force

1,2,3

Which of the following indicate that a patient being considered for extubation can provide adequate clearance of pulmonary secretions? 1. The patient has a maximum inspiratory pressure of 73 cm H2O. 2. The patient is alert and cooperative. 3. The patient has a dead space-to-tidal volume ratio of 0.7. 4. The patient coughs rigorously on suctioning.

1,2,4

For which of the following purposes is a tracheal button appropriate? 1. Facilitate secretion removal. 2. Protect the airways from aspiration. 3. Relieve airway obstruction. 4. Aid in positive-pressure ventilation.

1,3

Lower airway anesthesia for fiberoptic bronchoscopy can be achieved via which of the following routes of administration? 1. Bronchoscopic instillation 2. Intravenous administration 3. Nebulization (aerosol delivery)

1,3

Which of the following drugs can be used to prevent bleeding during fiberoptic bronchoscopy? 1. Phenylephrine 2. Dopamine HCl 3. Epinephrine

1,3

Compared with the nasal route, the advantages of oral intubation include which of the following? 1. Reduced risk of kinking 2. Less retching and gagging 3. Easier suctioning 4. Less traumatic insertion

1,3,4

Complications of tracheal suctioning include which of the following? 1. Bronchospasm 2. Hyperinflation 3. Mucosal trauma 4. Elevated intracranial pressure

1,3,4

In which of the following conditions should fiberoptic bronchoscopy not be performed if the risks outweigh the potential benefits? 1. Uncorrected bleeding disorders 2. Presence of lung abscess 3. Refractory hypoxemia 4. Unstable hemodynamic status

1,3,4

Which of the following statements are true about the potential for aspiration in patients with cuffed tracheal tubes? 1. Periodic oropharyngeal suctioning can help to minimize aspiration. 2. Aspiration is least likely in spontaneously breathing patients. 3. The methylene blue test can help detect leakage-type aspiration. 4. Aspiration is more likely with tracheostomy tubes than with endotracheal tubes.

1,3,4

You are about to suction a 10-year-old patient who has a 6-mm (internal diameter) endotracheal tube in place. What is the maximum size of catheter that you would use in this case?

10 Fr

Total application time for endotracheal suction in adults should not exceed which of the following?

10 to 15 sec

You are about to suction a female patient who has an 8-mm (internal diameter) endotracheal tube in place. What is the maximum size of catheter you would use in this case?

14 Fr

What is the standard size for endotracheal or tracheostomy tube adapters?

15-mm external diameter

During fiberoptic bronchoscopy, a patient's SpO2 drops from 91% to 87%. Which of the following actions would be appropriate? 1. Apply suction through the scope's open channel. 2. Give oxygen through the scope's open channel. 3. Increase the cannula or mask oxygen flow.

2,3

Successful tube passage through the larynx during blind nasotracheal intubation is indicated by which of the following? 1. Louder breath sounds 2. Harsh cough 3. Vocal silence

2,3

Compared with the oral route, the advantages of nasal intubation include which of the following? 1. Reduced risk of kinking 2. Less retching and gagging 3. Less accidental extubation 4. Greater long-term comfort

2,3,4

Complications of fiberoptic bronchoscopy include which of the following? 1. Hypocapnia 2. Infection 3. Hypotension 4. Hypoxemia

2,3,4

Which of the following indicate an inability to adequately protect the airway? 1. Wheezing 2. Coma 3. Lack of gag reflex 4. Inability to cough

2,3,4

While checking a crash cart for intubation equipment, you find the following: suction equipment, oxygen apparatus, two laryngoscopes and assorted blades, five tubes, Magill forceps, tape, lubricating gel, and local anesthetic. What is missing? 1. Obturator 2. Syringe(s) 3. Resuscitator bag and mask 4. Tube stylet

2,3,4

Which of the following can help to minimize the likelihood of mucosal trauma during suctioning? 1. Use as large a catheter as possible. 2. Rotate the catheter while withdrawing. 3. Use as rigid a catheter as possible. 4. Limit the amount of negative pressure.

2,4

What should be the maximum time devoted to any intubation attempt?

20 sec

What is the maximum recommended range for tracheal tube cuff pressures?

20 to 25 mm Hg

What is the average distance from the tip of a properly positioned oral endotracheal tube to the incisors of an adult man?

21 to 23 cm

Which of the following types of artificial airways are inserted through the larynx? 1. Pharyngeal airways 2. Tracheostomy tubes 3. Nasotracheal tubes 4. Orotracheal tubes

3,4

What size endotracheal tube would you select to intubate a 1500-g newborn infant?

3.0 mm

To ensure adequate humidification for a patient with an artificial airway, inspired gas at the proximal airway should be 100% saturated with water vapor and at which of the following temperatures?

32° to 35° C

What size endotracheal tube would you select to intubate a 3-year-old child?

4.5 to 5.0 mm

What size endotracheal tube would you select to intubate an adult female?

8 mm

While suctioning a patient, you observe an abrupt change in the electrocardiogram waveform being displayed on the cardiac monitor. Which of the following actions would be most appropriate?

Stop suctioning and immediately administer oxygen.

After repeated nasotracheal suctioning over 2 days, a patient with retained secretions develops minor bleeding through the nose. Which of the following actions would you recommend?

Stop the bleeding and use a nasopharyngeal airway for access.

A physician is concerned about the potential for tracheal damage due to tube movement in a patient who recently underwent tracheotomy and is now receiving 40% oxygen through a T tube (Briggs adapter). Which of the following would be the best way to limit tube movement in this patient?

Switch from the T tube to a tracheostomy collar.

Which of the following is false about cuff inflation techniques (MOV = minimal occluding volume; MLT = minimal leak technique)?

The MLT approach negates the need for pressure monitoring

When using a bulb-type esophageal detection device (EDD) during an intubation attempt, how do you know that the endotracheal tube is in the esophagus?

The bulb fails to re-expand upon release.

To avoid the risk of aspiration after a fiberoptic bronchoscopy procedure, what would you recommend that the patient do?

Remain in a sitting position and NPO until sensation returns.

A physician asks you to assess the upper airway function of a patient with a fenestrated tracheostomy tube. How should this be accomplished?

Remove the inner cannula, plug the proximal opening, and deflate the cuff.

A patient receiving mechanical ventilatory support accidentally displaces the endotracheal tube out of the trachea. What would be the most appropriate action at this time?

Remove the tube and provide manual ventilation or oxygenation as necessary

What is the primary indication for tracheal suctioning?

Retention of secretions

After intubation of a cardiac arrest victim, you observe a slow but steady rise in the expired CO2 levels as measured by a bedside capnometer. Which of the following best explains this observation?

Return of spontaneous circulation

Soon after endotracheal tube extubation, an adult patient exhibits a high-pitched inspiratory noise, heard without a stethoscope. Which of the following actions would you recommend?

STAT racemic epinephrine aerosol treatment