2014 mid term
What is the most important factor contributing to the oxygen carrying capacity of the blood?
hemoglobin
There are four vital signs:
1) body temperature, 2) ventilatory rate, 3) heart rate, and 4) blood pressure.
Your patient has an ideal body weight of 90 kg (200 lbs.). What would be his initial IC goal?
12 ml/kg is recommended for the first IS goal.
What is the MAXIMUM number of seconds that suctioning of the trachea of an adult should be
15 seconds
Pulmonary complications of uncompensated humidity deficits occurring with intubated patients may occur when absolute humidity drops below ______
30mg/L.
G cylinder- 5,269 L/ 2200 psig =_______`
2.41 L/psig
By subtracting the actual amount from 44 mg/L., the humidity deficit can be calculated. For example, at 23 degrees C. the potential absolute humidity (or capacity) is ____
21 mg/L
Incentive spirometry (also referred to as Sustained Maximal Inspiration) therapy is indicated when a patient's postoperative inspiratory capacity (IC) is between____ _____of their of the preoperative IC (inspiratory capacity).
50-80%
In order for gas to be 100% saturated with water vapor at normal body temperature, it must contain how many milligrams of water per liter?
44 mg at normal conditions
Your patient has a temperature of 98.6 degrees F. In order to saturate the inhaled air, how much absolute humidity must be provided?
44 mg of water vapor per liter.
Air-oxygen blenders require a ______source of both oxygen and air, while utilizing an internal pressure balancing system to maintain equal air and oxygen pressures at a proportioning valve.
50 psig
Your patient has a flow-displacement type of IS. She is attempting to, but is unable to inhale forcibly through it. What is the most likely problem?
A pinched breathing tube is the simplest reason for the obstruction. No special flow resistance features exist on these units.
A patient has a nasal cannula and needs to be transported on a stretcher. The E-size 02 cylinder will need to be laid flat under the stretcher. What flow meter would you recommend using?
A Bourdon flow meter is the only unit that will accurately indicate the flow when it is laid horizontally. The others will read accurately only in a vertical position.
A patient has a face tent on for the delivery of aerosolized oxygen. Her secretions are still too thick to be easily coughed out (expectorated). What would you recommend?
A heated aerosol mask provides increased relative humidity which will help to reduce the humidity deficit.
What are the factors that determine whether an oxygen delivery device is a high flow or a low-flow devices?
A high flow delivery provides sufficient total flow to meet or exceed the patient's inspiratory flow rate. A low flow device does not provide all of the patient's inspiratory flow needs.
Explain the "Rule of Four" in estimating the FIO2 available with a nasal cannula.
A nasal cannula running at 5 LPM will deliver approximately 40% to the patient. To help you remember this, begin with room air (approx. 20%). For each liter of nasal 02 add 4% to this. 4L X 4% = 16% added to 20% = 36%.
Your patient's air-entrainment nebulizer (large volume nebulizer) is not putting out as much aerosol as it was a short time ago. What could be the problem?
A nebulizer will fail because of too little water in the reservoir, a clogged jet, or a clogged capillary line to the reservoir.
Which oxygen delivery device(s) will provide a stable and predictable oxygen concentration to patients whose ventilatory patterns, respiratory rates and tidal volumes are normal?
A stable & predictable FIO2 may be delivered to patients via high flow devices operated so that the total flow provided by the device meets or exceeds the patient's inspiratory flow needs
When a patient who is receiving oxygen via non rebreathing mask inhales the reservoir bag on the mask does not deflate. What is the problem?
We know that the flow is NOT the problem because the reservoir bag is inflated. or excess humidity
What 02 delivery device would you recommend for a patient who has a variable respiratory rate, I:E ratio, and Vt?
An air entrainment mask (Venturi mask) should provide enough flow of the prescribed 02 percentage at any patient rate, Vt,
On the basis of particle size and desired deposition site, what aerosol delivery device should be selected for the treatment of croup (an inflammation of the throat area in small infants).
An atomizer is the simplest aerosol generator; it has no baffles and generates large particles.
If pulmonary function results are not available, at what should the initial IS goal be set?
An initial IS goal of twice the Vt is widely accepted as a adequate starting Volume. A bedside IC may be less than when measured under laboratory conditions.
A patient complains that his breathing is more difficult after an aerosol treatment with normal saline. What could account for the patient's complaint?
Breathing may be made more difficult if/when previously dry secretions absorb water, swell, and obstruct the airways.
A comatose patient is intubated and receiving 35% 02 with aerosol through a T -piece (Brigg's adaptor). While watching the patient breathe, you notice that during each inspiration the mist disappears from the downstream (distal end) of the T -piece. What would you recommend?
Adding 100 ml (about 6 inches) of aerosol tubing as a reservoir will help to maintain the patient's inspired 02 percentage
A patient with a tracheostomy is receiving continuous aerosol with a jet nebulizer operating on 40% oxygen at 8 LPM. If the patient's secretions are extremely viscid, what would be the most appropriate action for the respiratory care practitioner to take?
Addition of a heater to the system will result in an increase in air temperature and a corresponding increase in the amount of water the warmer air can hold.
What is the oxygen:air entrainment ratio for a 50% Venturi system? What would the total flow of the system be if the oxygen flow rate is 15 lpm? Is the flow sufficient to meet the needs of a patient whose minute ventilation is 8 lpm?
Air entrainment factor for a 50% Venturi device is 1:1.6. With an oxygen flow of 15 lpm, the total flow is 15 X 2.6 or 39 lpm. Using the guess imitation that inspiratory flow is approximately equal to minute ventilation X 4, the described system would just meet the inspiratory flow needs of a patient whose minute ventilation is 8 lpm.
Important information to keep in mind when an aerosol therapy is being administered would include what?
Airway obstruction may occur when/if dried secretions are re-hydrated. Upon addition of external water, inspissated secretions can swell and cause partial or total airway obstruction.
Saturated air at body temperature would have what characteristics?
At 37 C and 760 mm Hg, each liter of gas will hold 44 mg of water vapor which exerts a vapor pressure of 47 torr.
What assessment technique provides the best clinical evaluation of the effects of Incentive Spirometry?
Auscultation will reveal changes in lung aeration resulting from sustained maximum inspiration (SMI) therapy, which is another term for incentive spirometry.
Which kind of aerosol nebulizer is dependent on the effects of gravity and on the surface tension of liquid to expose the solution to the nebulization jet?
Babbington nebulizer
Describe the ideal type of oxygen flow meter for clinical use—include discussion of flow compensation.
Back pressure compensated flow meters provide accurate readings of delivered flow rates in spite of outlet obstructions.
A pneumatic nebulizer that produces an aerosol density of 35 milligrams per liter will supply what percentage of body humidity?
Body humidity (inspired gas saturated at 37 C) is 44 mg/L. 35/44 = 80%
During an aerosol therapy treatment, the respiratory care practitioner instructs a patient to hold her breath at the end of inspiration. What beneficial effect does this produce for the patient?
Breath holding , 10 seconds is the recommended time
What are Vesicular breath sounds?
Breath sounds found over normally aerated lung fields.
The simple 02 mask is a reservoir for not only incoming oxygen, but also exhaled ____ ______ It is important to use oxygen flow rates sufficient to "flush" out exhaled ____,
C02 (carbon dioxide). C02
Explain how administration of oxygen to a COPD patient with chronic CO2 retention may cause clinical problems?
CO2 retention in some COPD patients may be exacerbated by administration of oxygen.
Incentive spirometry is ordered for a patient after abdominal surgery. What information would be most appropriate in the initial explanation of the therapy to the patient?
CPs should use language that the patient can understand; goals of therapy should be explained simply and the patient encouraged to ask questions about things that are unclear or confusing. "The purpose is to help you take deep breaths to expand your lungs" would be an example.
What information should be charted by the respiratory therapist after instructing a patient in the use of volume-oriented incentive spirometry?
Date and time of therapeutic sessions as well as volume achieved (outcomes measures) by the patient are essential components of documentation of effectiveness for IS therapy.
What is dyspnea?
Dyspnea is when the patient tells you that he/she is having difficulty breathing (i.e. a subjective complaint)
There is a formula that can be used to calculate the appropriate catheter size to use based on the size of the ET tube:
ET tube size in mm divided by 2 = external diameter of suction catheter in mm. Suction catheter size in mm X 3 = French size. Example: size 8mm ET tube/2 = 4 mm suction catheter X 3 = 12 FR catheter
You notice that water has collected at the low point of the large-bore tubing of you patient's heated aerosol system. The aerosol is "puffing" out of the end of the tubing. What should the respiratory therapist do?
Excess condensate should be drained from the tubing AWAY from the patient and collected in a manner that does not contaminate the caregiver or the environment, such as wearing gloves to drain the tubing from the tubing into a waste receptacle.
What oxygen percentage should not be exceeded in order to avoid oxygen toxicity?
FIO2 should be below 50%.
What should be done to correct the problem of water collecting in the delivery tube of a continuous aerosol delivered to a patient with an endotracheal tube who is receiving oxygen enrichment via a heated nebulizer?
Frequent draining of condensate is essential to ensure consistent delivery of a specific FIO2.
The respiratory care practitioner notices that water has collected in the circuit being used for an intubated patient. The circuit is being humidified by a heated nebulizer. What action should the practitioner take?
Frequent monitoring of the delivery tubing and regular emptying of condensate are important to proper aerosol delivery
A patient with chronic obstructive pulmonary disease (COPD) frequently sits on the edge of his bed, leaning over a bedside table and using his accessory muscles of ventilation at a regular rate of 32 breaths per minute.
He is said to be tachypneic, the normal respiratory rate is 12-20 breaths per minute
A patient is intubated and placed on a heated nebulizer system at FIO2 of 0.70. A thermometer is placed within 1 inch of the patient connection and reads 85 degrees F after 5 minutes. One hour later, the patient appears flushed and restless and complains of irritation. The respiratory care student checks the thermometer and it still reads 85 degrees F. The nurse notes that the patient's temperature has spiked from 97.9 degrees F. to 101 degrees F. What should the student do?
IMMEDIATELY REMOVE THE SOURCE OF HEAT replacing it with cool mist, until the defective heater can be replaced.
Of all of the techniques used to re-expand collapsed alveoli, which is known to most favorably augment pulmonary blood flow in a person with normal lungs?
IS therapy
How can you estimate a patient's predicted PaO2?
If one considers that the FIO2 of atmospheric air is 0.21 and a healthy person's PaO2 is near 100 torr, a factor of 5 can be derived by dividing the PaO2 by the FIO2. Multiplying the delivered FIO2 by 5 will yield an approximate predicted PaO2.
Calculate the humidity deficit if a humidifier is generating 30 mg/liter of water vapor.
In this case 44 mg/liter represents body humidity. If a humidifier generates only 30 mg/liter of humidity, it presents a deficit of 44-30 = 14 mg/liter.
Suppose a doctor orders a simple 02 mask at 2 lpm, what would be your response?
In this case the physician's orders as given are clearly not compatible with sound respiratory care practice and may be detrimental to the patient's well being.
A l6-year-old post-operative appendectomy patient has clear breath sounds and normal vital signs. What would you recommend to prevent atelectasis?
Incentive Spirometry Therapy (also known as "Sustained Maximal Inspiration" therapy), is the most reasonable treatment to prevent atelectasis at this time.
A patient who has just returned from OR has a 40% Venturi mask in use operated at 2 lpm. The respiratory care practitioner discovers that the patient's inspiratory flow exceeds the output of the apparatus. What should the RCP do to correct the problem?
Increasing the oxygen flow rate will not change the FIO2, but will increase the total output of gas to the patient.
A patient who is intubated with an 8 mm ID endotracheal tube requires suctioning. A 14 Fr catheter and sterile tray are available. The vacuum setting is at -120 torr; however, the secretions are too thick to be aspirated effectively. What should the respiratory therapist do?
Instillation of normal saline would help mobilize the secretions and make them easier to aspirate.
A patient with a tracheostomy is receiving continuous, heated bland aerosol therapy. When the delivered FIO2 is analyzed, it is found that although the air entrainment setting is 40%, the oxygen analyzer reads 60%. Describe some of the causes of this discrepancy.
Lack of frequent and regular calibration of the oxygen analyzers prior to use may result in inaccurate results.
Your patient is wearing a face tent because of recent facial surgery. It is set at 35% 02. The nurse moves the patient from an upright to a supine position in bed. What effect will this have on her respiratory status?
Lying supine may result in the Vt decreasing (due to restriction of the lungs expansion by the abdominal contents).
Which device employs a jet of compressed gas passed through a restricted orifice to create a therapeutic aerosol?
Nebulizers
What is the minimum absolute humidity that a gas delivered to a patient's upper airway should have?
No less than 12 mg/L
How often is incentive spirometry recommended to be performed by the patient?
Normal individuals average about 6 sighs per hour. IS therapy should aim to ensure a minimum of 10 SMI maneuvers each hour.
If Incentive Spirometry has been successful, what type of breath sounds can be heard in the areas where atelectasis was noted before the treatment?
Normal vesicular breath sounds indicate normal lung expansion without any atelectasis.
If a respiratory care practitioner is giving routine therapy and notes adverse changes in the patient's condition, what should you do?
Notify the nurse that is responsible for the patient, contact the physician if a change in therapy seems warranted, record the patient's reactions in the chart.
While performing incentive spirometry, a patient with two rib fractures on the right side complains of severe pain on inspiration in the area of the fractures. What should the respiratory therapist do?
Pain upon deep inspiration can be expected in a patient who has sustained rib fracture.
Two patients are receiving oxygen via nasal cannula at 3 lpm. Patient A has a tidal volume of 300ml and a respiratory rate of 10 bpm. Patient B has a tidal volume of 500 ml and a respiratory rate of 14 bpm. Which patient will receive the higher FIO2?
Patient A's minute volume is lower than Patient B's. Proportionally more of Patient A's minute volume will be comprised of oxygen from the cannula, therefore his inspired concentration of oxygen will be higher than patient B's.
Describe the proper breathing pattern a respiratory therapist would instruct his/her patient to use when performing a sustained maximum inspiration with an incentive spirometer?
Patients must be coached to begin the inspiratory maneuver from the resting level, that is the end of a normal expiration. Efforts to exhale completely before starting the sustained inspiration do not contribute to prevention or resolution of atelectasis. Forced exhalation to residual volume is ineffective, may be painful for the patient, and does nothing to add volume to the lungs.
What patient conditions are at high risk for developing atelectasis?
Patients who have difficulty in taking deep breaths without assistance include those with neuromuscular disorders, those who are heavily sedated, and those with pain. The resulting repetitive, shallow breathing can lead to alveolar collapse and atelectasis.
In what clinical situation(s) would the use of an incentive spirometer NOT be indicated?
Patients with neuromuscular disease can be expected to tire easily and should not be encouraged to perform beyond their level of endurance.
What specifications should be included by physicians in their orders for administration of oxygen to a hospitalized patient?
Physician's orders for O2 via low flow systems typically specify the device and the flow rate in lpm (cannulas, simple O2 masks)
How does an ultrasonic nebulizer work?
Plezoelectric crystals vibrate when electrically excited, creating ultrasonic waves in the liquid that generate geysers at the surface. The geysers release aerosol particles.
While setting up a nasal cannula, you insert a flow meter into the oxygen outlet (with the needle valve closed). You notice that the float JUMPS up and then falls. What conclusion can be drawn from this action?
Pressure compensated Thorpe tube flow meters will demonstrate the described phenomenon when they are engaged in a high-pressure system, such as a quick connect outlet.
How is the adequacy of oxygenation assessed "non-invasively" ?
Pulse Oximetry
While setting up oxygen via a Venturi mask, you are unable to attach a flow meter with a quick connect to the wall oxygen outlet. What is the most likely cause of this problem?
Quick connect outlets are designed to connect to specific medical gas outlets. If a quick connect device fails to "seat" or properly connect to an oxygen outlet, it may be indexed for compressed air rather than oxygen.
What is the mathematical formula relating relative humidity, absolute humidity (actual content) and maximum capacity (potential humidity)?
RH = AH/capacity
How would you modify a non-rebreathing mask to make a partial rebreathing mask?
Remove the flaps
What should be observed when an incentive breathing device is being used properly?
Slow, deep breaths, followed by breath hold is the preferred pattern of breathing to accomplish goals of SMI therapy.
During a 15 second suctioning procedure, a patient's pulse decreases from 90-50/min and her systemic blood pressure decreases from 120/80 to 80/50 torr. What is the most likely cause of these changes?
Stimulation of a branch of the vagus nerve by a suction catheter may elicit a parasympthetic relex which will result in a drop in the heart rate (and subsequently a drop in the blood pressure).
Your patient is quite weak and, despite making repeated efforts to raise the ball marker on a flow displacement type incentive spirometer, is unable to raise the ball near the goal. What would you recommend?
Switching the patient from a flow displacement to a volume displacement incentive spirometer lets her see the results of her breathing efforts. This should help to motivate her to keep trying.
What effect will a build-up of water in an aerosol hose have on the FIO2 delivery of an aerosol mask?
The air entrainment devices work on Bernoulli's principle, which basically states that as the flow rate increases, the lateral pressure drops (becomes more negative) in the area of the air entrainment port (Venturi window).
A large-volume jet nebulizer is operating on 70% 02 at 12 LPM. You observe that the aerosol comes out only intermittently and that there is a bubbling sound in the system. What would you do?
The buildup of water had created an obstruction to the flow of aerosol out of the tubing. The tubing should be drained into a waste container - NOT back into the sterile reservoir.
In what clinical situations would incentive spirometry be most appropriate?
The chief indication for IS therapy is presence of pulmonary atelectasis.
The DeVilbiss (brand name) ultrasonic nebulizer has a flashing couplant indicator light. The therapist notices that the aerosol output has decreased from what it was earlier. What is the most likely problem?
The couplant light signals that the fluid in the couplant chamber is low, without this no aerosol will be produced
What errors in operation of a Venturi mask are most likely to cause it to deliver an FIO2 higher than intended?
The most common error in the operation of a Venturi device that will result in a delivered FIO2 (FIO2) higher than intended is allowing the device to operate with an obstruction in its outflow tract
When a patient who is receiving oxygen via a non-rebreathing mask inhales, the reservoir bag on the mask does not deflate. Describe the most probable cause of this situation.
The most likely cause of this problem in a poor fit.
If pulmonary function results are not available, where should the initial incentive spirometry goal be set?
The patient's goal should be set at a minimum volume of 2 X tidal volume, according to Sill's Certification Review Guide,
What is the result when a liter of air that is fully saturated with water vapor at room temperature is warmed to body temperature?
The relative humidity will decrease because the ratio of absolute humidity to capacity has become smaller.
A patient is admitted to the emergency room with a chief complaint of shortness of breath. Arterial blood gases recorded at this time reveal the following: pH 7.35 PaCO2 60 torr PaO2 48 torr HCO3 38 mEq/L Which oxygen delivery device would you select to administer supplemental oxygen to this patient?
The safe approach would be to apply a 24% entrainment device and monitor the patient's oxyhemoglobin saturation via blood gas analysis or pulse oximetry.
Explain the relationship of excessive oxygen levels and depression of respiratory drive in certain COPD (CO retaining) patients.
These patients do not breathe because of a high PCO2 level as in a normal person. They breathe due to a lower PO2. If this "hypoxic drive" is taken away by supplying excessive levels of oxygen, they will have no physiologic reason to continue breathing.
Some COPD patients experience a reduction in respiratory drive as a result of excessive oxygenation. This patient's values suggest acute and chronic respiratory acidosis, evidenced by an elevated bicarbonate value; the acidic pH is a reflection of decompensation, as the patient's PaCO2 has risen. It is likely that this patient's blood gas values prior to the onset of illness, were as follows: pH=7.35, PaCO2=60 torr, PaO2 = 60 torr (on room air,) HCO3=32 mEq/L
These values are typical of stable COPD patients. When illness develops, the patient may experience more CO2 retention that will lower the pH. Bicarbonate value will rise over time to compensate for the pH disturbance, but the patient will be acutely acidic until full compensation occurs.
A spontaneously breathing patient in the intensive care unit has viral pneumonia and is receiving 60% oxygen. An arterial blood gas analysis reveals the results below. pH 7.58 PaCO2 24 torr HCO3 22 mEq/L PaO2 44 torr Describe the most appropriate therapy for the patient described above?
These values may be interpreted as acute respiratory alkalosis with moderate to severe hypoxemia. The most appropriate therapy suggested by these values is oxygen via non-rebreathing mask, assure a good fit and monitor outcome with repeat blood gas or pulse oximetry in 20 minutes.
An 80 kg (176 lb) patient who underwent coronary artery bypass grafting was extubated 1 hour ago. The respiratory care practitioner initiates incentive spirometry and records a volume of 600 cc. What should the respiratory therapist now recommend?
This is minimally acceptable volume for a patient who is 1 hour post extubation following CABG. He/she should be closely monitored for signs of atelectasis and coached to increase inspired volume.
Your patient has just performed several excellent IS maneuvers, when she begins to complain of tingling fingers and dizziness.
Tingling fingers and dizziness are signs of acute hyperventilation (PCO2 below 35 torr). Relaxing and breathing normally will restore the CO2 to a normal level (around 40 torr).
What does enlarging the Venturi port size on a nebulizer results in?
Total flow would be increased and the resultant FIO2 would be lower because of more room air being entrained
An asthmatic patient has an increased inspiratory flow rate of 50 LPM, and requires 28% oxygen by aerosol mask. What flow rate would you set on the oxygen flow meter?
Using the "magic box," the Venturi ratio is first calculated. Dividing the needed total flow required by the "total parts" gives 5 LPM as the required 02 flow setting.
How would you go about calculating the total flow delivered from a 40% T-piece (Brigg's adapter) running at 10 LPM?
Using the '"magic box" calculate the Venturi ratio, then calculate the total flow by multiplying the 02 liter flow X the "total parts.'"
Which oxygen delivery devices(s) provide an accurate FIO2 regardless of the patient's ventilatory pattern?
Venturi masks are classified as high flow oxygen delivery devices because they can deliver a total flow rate of gas that meets or exceeds patient's inspiratory flow needs. Multiplying the patient's minute volume by 4 needs can derive estimation of inspiratory flow.
Your patient's incentive spirometry device is a flow-displacement type. With good coaching, he is able to raise the ball requiring 900 cc/sec of inspiratory flow. He can keep it elevated for 1.5 seconds. What is his inspiratory capacity?
Volume = flow rate X inspiratory time = 900 cc/sec X 1.5 sec = 1350 cc
Suppose an ultrasonic nebulizer is putting aerosol out in short rapid puffs. What would be the most likely cause of this phenomenon?
When water accumulates in the corrugated hose (delivery tubing) the aerosol is no longer able to move freely.
A patient is admitted to the emergency room with a chief complaint of shortness of breath. Arterial Blood Gases recorded at this time reveal the following: pH = 7.33, PaCO2 = 60 torr, PaO2 = 50 torr What delivery device would you select to administer supplemental oxygen to this patient?
With no additional patient history, the most appropriate oxygen delivery device would be a nasal cannula.
The minimum inspiratory need (inspiratory flow rate) may be determined by multiplying the patient's minute ventilation______.
X 4
Which of the following devices is LEAST appropriate for a patient with an artificial airway? a Babbington-type nebulizer a heated jet nebulizer an ultrasonic nebulizer a heated cascade humidifier
a Babbington-type nebulizer a heated jet nebulizer an ultrasonic nebulizer
In any given nebulizing device, which of the following may act to baffle the aerosolized particles?
a) the surface of the water, b) the sides of the container, c) a sphere placed in path of the aerosol's flow, or d) a bend in the aerosol tubing.
The following procedures are recommended to reduce the likelihood of contamination and infection with nebulizer reservoir systems:
a) use disinfected or sterile water only, b) discard reservoir water before refilling, and c) change nebulizer and circuit every 24 hours.
When an immersion heater is used, the increase in temperature causes an increase in _______ _____. There is also an increased risk of _______ as the heater is introduced into the liquid.
absolute humidity contamination
A patient who has a history of bronchospasm has an order for ultrasonic nebulization with 0.9% NaCl solution. Before administering this treatment, what would be your suggestion to the attending physician?
adding a pre treatment aerosolized bronchodilator
The respiratory therapist is operating a jet nebulizer on the 100% oxygen setting using a flow rate of 10 LPM to "drive" the jet. If he or she were to place this nebulizer on the 40% setting what would happen?
aerosol output would increase, because more air were entrained. Total flow would increase from 10 L to 40 L (on 40% , the air:oxygen ratio is 3: 1 ).
What are some complications of aerosol therapy?
aerosol-induced bronchospasm fluid overload in the infant or elderly patient, swollen secretions (after rehydration), causing an increase in the work of breathing, possible patient contamination if the reservoir water is infected (bacteria use the aerosol particle as a "vehicle.")
In general, how do all modes of hyperinflation therapy aid in lung expansion?
aid lung expansion by increasing the transpulmonary pressure gradient.
If a massive gas leak occurs from the wall oxygen outlet when a flow meter is removed from the outlet, what should the RCP do immediately?
allay patient fears resulting from the sudden loud noise and re-insert the flow meter to stop the leak.
Incentive spirometry can be started on a patient—provided they meet certain criteria. What are these criteria?
an alert and cooperative patient, respiratory rate below 25 bpm, ability to generate adequate inspiration, eg. VC > 10 ml/kg or IC > 1/3 of the predicted value for the patient's age, height, and gender.
What is an important consideration in using an aerosol mask as the method of O2 delivery?
appropriate total flow rate of gas to the patient in order to maintain a predictable and consistent FIO2.
In what way(s) is a nasal cannula advantageous as compared with air entrainment (Venturi) devices?
are generally more comfortable than a mask. They should not be used for patients who have irregular breathing patterns
Patients with ___ _____should have medical gases delivered with 100% relative humidity at a temperature of 37 degrees (most textbooks state that 32-34 degrees C is close enough).
artificial airways
A patient who is recovering from a cholecystectomy is using an incentive spirometer. She easily reaches her goal volume of 1.0 L. What should the respiratory therapist do to encourage the patient to improve her performance?
be modified to increase the patient's IC to her pre-operative volume. The patient's technique should also be reviewed to assure sustained inspiration.
Which devices would you select to add water vapor to the delivered gas in a patient receiving oxygen via a partial re-breather mask?
bubbler
Another physician prescribes an ultrasonic nebulization treatment with a bronchodilator (0.5 cc albuterol). What would be your response to this order?
call the doctor because you can't give medication in a ultra sonic neb, the frequency will alter the composition of the drug
Sustained maximal inspiratory maneuvers performed with an incentive spirometer would be most effective in the what type of condition?
can reverse atelectasis if performed regularly and frequently. Patient instruction in maintaining a long inspiratory phase is vital to resolution of atelectasis.
Regarding the ultrasonic nebulizer, what does the term piezoelectric refer to?
ceramic transducer of the ultrasonic nebulizer. Its function is to change electrical energy to sound waves which then break up the solution into small particles of aerosol.
The ultrasonic nebulizer is NOT suitable for drug delivery because the ultrasonic sound waves will alter the ____ ____ of some drugs.
chemical structure
When explaining the therapeutic goals to the patient's family, what should the respiratory student mention?
choose language that is consistent with their level of understanding and conveys the appropriate message. Resolution or prevention of atelectasis can be explained in terms of "areas of lung collapse".
Compared with other types of humidifiers, what is a major advantage of the Cascade humidifier?
claims that this heated device is capable of delivering 100% R.H. over a wide range of temperatures and flow rates.
Activity of the respiratory ACCESSORY muscles is most indicative of problems increased work of breathing. What are some general conditions that can increase the work of breathing.
conditions resulting in increased airway resistance, decreased lung compliance, will result in the use of accessory muscles.
What should the respiratory therapist assess to determine if there is adequate humidification of the inspired gas delivered to a patient with a tracheostomy?
consistency of sputum, color and whether it is dry or not
If the water in the ultrasonic nebulizer's couplant chamber is low, or if the medication cup is empty or nearly empty, the aerosol output will _______.
decrease
A patient receiving an aerosol treatment via a hand-held nebulizer powered by air complains of dizziness. What should the respiratory care student instruct the patient to do?
decrease respiratory rate and slow deep breaths
What is the function of the air-entrainment port ("venturi window") on the large volume nebulizer?
decrease the FIO2, and to increase total flow to the patient.
A patient is connected to a circuit that is utilizing a cascade humidifier; the tower was omitted during the assembly of the equipment. The temperature at the patient connection is 37 degrees C. The following two questions are in reference to this information: What changes in the patient's condition might be associated with the omission of the tower if the temperature at the patient's connection is 25 degrees C?
decreased efficiency of the humidifier and leads to an increase in humidity deficit (difference between body's need for humidity and humidity supplied by the device). Increased humidity deficit leads to thickened secretions, mucus plugging, airway obstruction, atelectasis, hypoxia and pneumonia.
A patient with an endotracheal tube in place is receiving oxygen enrichment via a heated all-purpose nebulizer. Water is collecting in the delivery hose. What action should the respiratory therapist take?
drain the delivery hose
small compressed gas cylinder is generally the most practical oxygen-supply system to use for patient transport.
e cylinder
You notice that water has collected at the low point of the large-bore tubing of your patient's heated aerosol system. The aerosol is "puffing" out of the end of the tubing.
empty out the tubing to prevent contamination.
Wheezes are more frequently heard during the _____ phase.
expiratory
A patient has a peak inspiratory flow of 48 LPM. What is the MINIMUM flow meter setting needed to meet the patient's requirements if a 40% nebulizer is being used?
flow meter is run at 12 liters per minute, the device will deliver a total flow of 48 liters per minute. Calculate total flow as follows: 1 is to 3 as 12 is to X. Solve for X.
What can help to minimize the danger of occlusion of a patient's endotracheal tube?
giving enough humidification
What factors influence aerosol deposition and penetration?
gravity, ventilatory pattern kinetic energy
The respiratory care practitioner should assess which of the following to determine adequate humidification of the inspired gas delivered to a patient with a tracheostomy?
hardened sputum in the airway
A patient complains of dizziness, lightheadedness, and a tingling sensation of her fingers after twenty deep breaths via incentive spirometry. What could be causing these symptoms?
hyperventilation. Failure to pause between breaths can also result in hyperventilation
The physician has prescribed that incentive spirometry is to be initiated for a patient who had a cholecystectomy 8 hours ago. What is the best method for determining the patient's ability to cooperate?
if a patient can repeat what you tell him/her in his own words, or return a demonstration of your directions, this is an indication that he/she probably understand what you want them to do and will cooperate with your instructions.
You are making general rounds in the hospital when you find a patient whose reservoir tubing has fallen off his Brigg's adapter. What effect would the absence of this reservoir tubing having on the delivered FIO2?
in room air being inhaled and the overall 02 percentage decreasing.
How could you remedy the situation if a patient receiving oxygen via a simple mask at 6 LPM remains hypoxic after 2 hours?
increase the oxygen concentration delivered to the patient by applying a non-rebreathing reservoir oxygen mask
A patient who is recovering from a cholecystectomy is using an incentive spirometer. She easily reaches her goal volume of 1.0 L. What should the respiratory therapist do to encourage the patient to improve her performance?
increase the patient's inspiratory capacity (IC) to her pre-operative volume. The patient's technique should also be reviewed to assure sustained inspiration.
What is Flow-oriented Incentive Spirometry?
indicate flow during inspiration; the basic IS maneuver is essentially an inspiratory capacity maneuver followed by a 5-10 second breath hold.
A patient with COPD is receiving heated water aerosol via a jet nebulizer in order to aid in mobilizing retained secretions. While auscultating, you note an increase in rhonchi.
indicates that the secretions have been loosened, now the patient will need to cough them up. Coughing assistance and postural drainage techniques would be indicated.
How should a patient be instructed to breathe when performing a sustained maximum inspiration with an incentive spirometer?
inspiratory maneuver from the resting level, that is the end of a normal expiration. Efforts to exhale completely before starting the sustained inspiration do not contribute to prevention or resolution of atelectasis
In heated nebulizers, at what temperature should the reservoir temperatures be maintained?
intained slightly higher than body temperature so that by the time the air reaches the patient it will still be warm enough to hold sufficient moisture (32-34 C)
What effect will the accumulation of a large volume of liquid in the dependent portion of a large-bore delivery tube will have on a jet nebulizer system that is set to deliver an FIO2 of 0.40?
the FIO2 increases.
The respiratory therapist is informed of a fire in the west wing of the hospital. What is the most appropriate initial response/ recommendation to this situation?
is to ensure patient safety. Thus the respiratory therapist would shut off the oxygen zone valve to the west wing, and provide emergency oxygen for all the patients who become relocated from the west wing.
patient receiving oxygen at 6 LPM via nasal cannula complains that he does not feel any oxygen coming out. What would you do?
is to verify that there are no leaks.
When a water-collection trap is placed within an aerosol hose, it must be placed along the most gravity- dependent portion of the circuit. Why is this
it can increase the airway resistance in the tubing, thereby reducing the efficiency of the nebulizer Less room air is entrained under increased back-pressure conditions.
When breath sounds heard in the peripheral areas of the lung, where breath sounds are normally quiet what is the indication for this
it is an indication that the lung tissue is consolidated.
When performing nasotracheal suctioning, what signs are used to indicate that the catheter tip has advanced into the trachea?
it is necessary to pass the catheter blindly through the vocal cords into the trachea. When the catheter tip advances through the cords, the patient's voice will become hoarse and whispery. The cough reflex is also strongly stimulated.
Given that a gas is saturated with 100% relative humidity at 32.2 degrees C. (90 degrees F.). As the gas cools to 26.7 degrees C. (80 degrees F.), what will happen to the relative humidity?
its ability to hold water vapor decreases
Incentive spirometry is ordered for a patient after abdominal surgery. What should the respiratory therapist tell the patient during the initial explanation of the therapy to the patient?
language that the patient can understand; goals of therapy should be explained simply and the patient encouraged to ask questions about things that are unclear or confusing.
Aerosol therapy is not suitable as ______ term humidification for ventilator patients, because of the danger of fluid overload
long
Which device would be indicated when trying to assure adequate humidification of inspired gases to a spontaneously breathing patient with a tracheostomy tube?
look for one that incorporates heat and increased surface area or aerosol (because of the ability of the particles to evaporate into the tracheal gas).
Under what conditions will the water vapor pressure of humidity exert 47 torr ?
lower than 100% humidity, less than 44 mg/L and therefore exert less than 47 torr of vapor pressure.
What should the respiratory therapist do first when a Yankauer device becomes obstructed while suctioning vomitus from a patient's mouth?
make sure the lumen of the yankauer is patent
A patient requires an oxygen concentration of approximately 35% to prevent hypoxemia. The patient vomits frequently as a result of medication taken to treat his condition. Which oxygen delivery device would be safest to satisfy this patient's oxygen requirements?
nasal cannula operated at a flowrate of 4 lpm.
A physician would like to know how the ultrasonic nebulizer can adjust the particle size of the aerosol. What would be the most appropriate response?
nebulizer is determined by the frequency of the sound waves hitting the fluid and breaking it up and its not adjustable
If incentive spirometry has been successful, what type of breath sound will you hear in the areas where atelectasis was noted before the treatment?
normal breath sounds
Prior to beginning bronchodilator therapy, the respiratory care student notes that the patient has a heart rate that is elevated significantly (tachycardia). What should the student do?
notify the charge nurse of the patient's condition and do not give the treatment. A bronchodilator, due to its beta I activity may severely embarrass (compromise) the patient's heart function.
Asking a patient who he/she is, what day of the week it is, and in which hospital he is, are means of assessing the patient's _______________.
orientation to "person, time, and place." If the patient can answer these questions accurately, he/she is said to be "oriented X 3. "
The compressor delivers pressurized air not _____
oxygen
What should be done immediately for an 88 year old COPD patient who becomes lethargic and has the following ABGs while receiving O2 via a nasal cannula at 4 lpm? pH 7.32 PaCO2 70 torr PaO2 95 torr HCO3 35 mEq/L
partially compensated respiratory acidosis with normoxia. this is normal for a copd patient with acute problems
Tracheal secretions tend to dry in an intubated patient when inspired air has what characteristics?
patient when the amount of water vapor in the inspired air is insufficient to meet the needs of the body
The pop-off valve is whistling on your patient's bubble humidifier to a 28% oxygen/air entrainment mask. What could be the problem?
pinching of the small bore O2 delivery tubing causes an increase in pressure within the reservoir.
A 35 year-old patient is in no apparent distress and has clear breath sounds. What should the respiratory therapist select to prevent atelectasis in this patient?
proper application of IS therapy.
The physician asks you which 02 delivery device would be best for a patient who needs about 75% 02. What would you recommend
properly fitting non-rebreathing mask with enough flow to keep the reservoir bag inflated will deliver the highest 02 percentage of the devices available.
Which of the following is the best way to communicate a patient's clinical status to the appropriate members of the healthcare team?
recording information in the patient's medical chart
The most effective way to prevent symptoms of paresthesia such as tingling fingers, is to coach patients to
redistribute their minute volume by taking fewer but deeper breaths.
A patient is receiving 40% O2 via aerosol T-piece. Condensation of the aerosol in the tubing almost completely occludes the tubing at its lowest point. How will the PAO2 be affected?
reduces the forward pressure of gas at the outlet of the entrainment device. LESS air is drawn into the gas stream through the entrainment ports of the device, thereby RAISING the delivered FIO2
Low-pitched, continuous breath sounds caused by rapid airflow through partially obstructed airways and occurring during exhalation are best described as
rhonchi
Why should non-disposable humidifiers or nebulizers for oxygen delivery devices NOT be kept filled with water for extended periods of time?
risk of microbial contamination and subsequent growth of microbes in the system.
What is the ideal breathing pattern for maximal aerosol deposition and retention in medication delivery?
slow deep breaths and holding it at the end
What information in a patient's medical history would be most important for the respiratory care student to consider in evaluating the patient's pulmonary condition?
smoking history, employment history (occupational exposures), and pulmonary function test results (reflection of lung function).
A "_____" is a high-pitched sound during inspiration coming from the upper airway.
stridor
The efficiency of any humidifier is related to which factor(s)?
surface area time of contact and tempurature
Your patient has a flow-dependent type of incentive spirometry device. She repeatedly inhales rapidly to raise the indicators to the top of the flow chamber. What should the respiratory therapist tell the patient when this breathing pattern is observed?
tell them that they need to have slow deep breaths followed by a hold for 5-10 seconds
How does the addition of a heater to a large volume nebulizer increase in the relative humidity of the inspired gas?
the air temperature will also increase, resulting in an increase in the absolute humidity.
The tower has now been reinserted and gas is being delivered to the patient at body temperature. Which of the following statements is now correct about the delivered humidity?
the device is capable of delivering 100% relative humidity through a wide range of temperatures and flow rates.
A patient is receiving O2 via a non-rebreathing mask at 8 LPM. The respiratory care practitioner notices that the reservoir bag on the mask empties completely during inspiration. What should the practitioner do immediately to assure successful clinical outcome?
the flow rate of O2 into the bag must be increased to assure safe O2 therapy with this appliance.
Your patient has just performed several excellent incentive spirometry efforts. She complain tingling fingers and dizziness. What would be your recommendation?
the most appropriate response would be to stop the therapy for a few minutes, direct the patient to breathe quietly until she feels normal, and the re-instruct her in proper technique
Suppose that the doctor has prescribed ultrasonic nebulization with normal saline to a patient who is 5 days post-op and ambulatory (able to walk around). The respiratory therapist performs an assessment before the therapy (noting clear normal breathsounds). Following the therapy, the therapist notes that the patient is dyspneic (complains of shortness of breath) and wheezing, with a dry non-productive cough. What would you recommend to the doctor?
the treatment is causing the patient to have bronchospasms, discontinue the treatment
A physician asks you to recommend a modality for a patient who is producing small amounts of thick, purulent sputum. What would be the best advice for treatment?
the use of a ultrasonic neb
Where are bronchial breath sounds normally heard?
these are normally heard over the bronchi or trachea. They are also referred as tubular breath sounds.
While examining a patient's chest, the respiratory care student palpates vibrations on inhalation and exhalation which clear when the patient effectively coughs. What does this indicate?
these vibrations are called "tactile fremitus" and are caused by secretion buildup in the airways.
What is the major function of a baffle in a nebulizer?
to break up larger particles into smaller ones
To prevent hypoxemia when suctioning a patient who is being mechanically ventilated, what actions should the respiratory care student initially take?
to hyperoxygenate the patient with 100% oxygen , not for a copd patient though
In what situations would a T-piece be indicated?
to provide aerosol (humidity) with a precise FIO2, whereas others have one or more limitations that preclude their use
The size of the aerosolized particles that are generated by an ultrasonic nebulizer is believed to be determined by ____ ____ ____
unit ultrasonic frequency
High-pitched, continuous breath sounds caused by rapid airflow through partially obstructed airways caused by bronchospasm and mucosal edemas are best described as
wheezes
A patient's humidity deficit is going to be the smallest under which conditions?
when the inspired air temperature is near body temperature and the humidification device is heated.
You are called to draw an arterial blood sample from a patient who is wearing a 35% air-entrainment (Venturi) mask. When you enter the room, you notice that his covers are drawn up over the air entrainment ports of the mask. How would this affect the function of the mask?
will result in the patient receiving a higher 02 percentage than desired (this is because there would be less room air dilution). also less flow
What would probably result if an overeager patient achieved very large inspiratory volumes on his incentive spirometry too many times in a row WITHOUT stopping for a break?
will very likely become dizzy as a result of hyperventilation
