Ch. 37 Review

Placement of the endotracheal tube in the esophagus

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

Return of spontaneous circulation

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

Vocal cord paralysis

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?

Stop the bleeding and use a nasopharyngeal airway for access

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

Maximal abduction of the vocal cords

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

The tube chosen is too small for the patient

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?

Administer a racemic epinephrine treatment

An adult patient receiving cool mist therapy after extubation begins to develop stridor. What action would you recommend?

I and III only

An alert patient with a long-term need for a tracheostomy tube (because of recurrent aspiration) is having difficulty communicating with the intensive care unit staff. Which of the following would you recommend to help this patient communicate better? I. Use a letter, phrase, or picture board II. Consider switching to a fenestrated tracheostomy tube III. Consider a "talking" tracheostomy tube

II, III, and IV only

Compared with the oral route, the advantages of nasal intubation include which of the following? I. Reduced risk of kinking II. Less retching and gagging III. Less accidental extubation IV. Greater long-term comfort

I, II, and III only

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

I and III only

For which of the following purposes is a tracheal button appropriate? I. Facilitate secretion removal II. Protect the airways from aspiration III. Relieve airway obstruction IV. Aid in positive-pressure ventilation

When physical findings support the need

How often should patients be suctioned?

3 to 6 cm

Ideally, the distal tip of a properly positioned endotracheal tube (in an adult man) should be positioned approximately how far above the carina?

I, II, and III

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

Through or between the second and third tracheal rings

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

Orotracheal intubation

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

I, II, and III

The major limitations of using a laryngeal mask airway are: I. Short-term use II. Cannot provide high ventilation pressures if needed III. Aspiration not avoided

I and III only

The removable inner cannula commonly incorporated into modern tracheostomy tubes serves which of the following purposes? I. Aid in routine tube cleaning and tracheostomy care II. Prevent the tube from slipping into the trachea III. Provide a patent airway should it become obstructed

Use a closed-system multiuse suction catheter

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

Neck flexed, with head supported by towel and tilted back

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

Cool mist therapy through a jet nebulizer and aerosol mask

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

II, III, and IV only

To minimize problems associated with pharyngeal aspiration in intubated patients, which of the following could you recommend? I. Position patient in prone position II. Use of medications for stress ulcer prophylaxis, such as sucralfate III. Position of patients with head of bed elevated 30 degrees IV. Provide continuous aspiration of sub glottic secretions

Mixture of .25% phenlyephrine and 3% lidocaine

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

15 seconds

Total application for endotracheal suction in adults should not exceed what?

II, III, and IV only

Tracheal airways increase the incidence of pulmonary infections for which of the following reasons? I. Lower levels of humidification II. Increased aspiration of pharyngeal material III. Contaminated equipment or solutions IV. Ineffective clearance through cough

I, II, and III only

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

Fiberoptic laryngoscopy

What bedside method can absolutely confirm proper endotracheal tube position in the trachea?

Laryngospasm

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

Identify organisms infecting the airway

What is a reason to collect a sputum sample from a patient?

Aids feeding, oral care, suctioning, and speech

What is an advantage of oral intubation?

Retained secretions without artificial airway

What is an indication for nasotracheal suctioning?

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

What is likely to increase the likelihood of damage to the tracheal mucosa?

20 to 30 mmHg

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

Poor positioning of the tube fenestration

What is the most common problem with fenestrated tracheostomy tubes?

Hoarseness

What is the most common sign associated with the transient glottic edema or vocal cord inflammation that follows extubation?

-120 -to -150 mmHg

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 children?

-80 to -100 mm Hg

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

When a patient has a long-term need for an artificial airway

What is the primary indication for a tracheostomy?

Retention of secretions

What is the primary indication for tracheal suctioning?

To seal off and protect the lower airway

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

To minimize trauma to the tracheal mucosa during insertion

What is the purpose of a tracheostomy tube obturator?

It adds rigidity and shape to ease insertion

What is the purpose of an endotracheal tube stylet?

Ensure gas flow if the main port is blocked

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

To monitor cuff status and pressure

What is the purpose of the pilot balloon on an endotracheal or a tracheostomy tube?

15-mm external diameter

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

30 sec

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

4.5 to 5.0

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

3.0 mm

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

8 mm

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

Withdraw the tube 2 to 4 cm (using tube markings as a guide)e

When checking for proper placement of an endotracheal tube in an adult patient on chest radiograph, it is noted that the distal tip of the tube is 1 cm above the carina. What action would you recommend?

Cardiac arrest

When using capnometry or colorimetry to differentiate esophageal from tracheal placement of an endotracheal tube, what condition can result in a false-negative finding (IE: no CO2 present even when the tube is in the trachea)?

I, II, and III

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

I, II, and III only

Which of the following are potential complications of suctioning? I. Hypoxemia II. Hypotension III. Arrhythmias IV. Gastrointestinal distress

II and IV only

Which of the following can help to minimize the likelihood of mucosal trauma during suctioning? I. Use as large as a catheter as possible II. Rotate the catheter while withdrawing III. Use as rigid of a catheter as possible IV. Limit the amount of negative pressure

I, III, and IV only

Which of the following equipment is needed to perform nasotracheal suctioning? I. Suction kit (catheter, gloves, basin, etc.) II. Laryngoscopes with Macintosh and Miller blades III. Oxygen delivery system (mask and manual resuscitator) IV. Bottle of sterile water or saline solution

I, II, III, IV, and V

Which of the following factors should be considered when deciding to change from an endotracheal tube to a tracheostomy tube? I. Patient's tolerance of the endotracheal tube II. Relative risk of continued intubation versus tracheostomy III. Patient's severity of illness and overall condition IV. Length of time that the patient will need an artificial airway V. Patient's ability to tolerate a surgical procedure

I and II only

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

I and II only

Which of the following injuries can be seen with tracheostomy tubes? I. Tracheomalacia II. Tracheal stenosis III. Glottic edema IV. Vocal cord granulomas

Need for emergent surgical airway

Which of the following is an absolute contraindication for percutaneous dilation tracheostomy?

I and III only

Which of the following methods can help to reduce the likelihood of atelectasis due to tracheal suctioning? I. Limit the amount of negative pressure used II. Hyper inflate the patient before and after the procedure III. Suction for as short of a period of time as possible

I, II, and III only

Which of the following statements are true about methods used to displace the epiglottis during intubation? I. Regardless of the blade use, the laryngoscopes is lifted up and forward II. The curved (Macintosh) blade lifts the epiglottis indirectly III. The straight (Miller) blade lifts the epiglottis directly IV. Levering the laryngoscope against the teeth can aid displacement

I, II, and III

Which of the following techniques or procedures should be used to help minimize infection of a tracheotomy stoma? I. Regular aseptic stoma cleaning II. Adherence to sterile techniques III. Regular change of tracheostomy dressings

III and IV only

Which of the following types of artificial airways are inserted through the larynx? I. Pharyngeal airways II. Tracheostomy tubes III. Nasotracheal tubes IV. Orotracheal tubes

Check and replace the bulb in the Macintosh blade

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?

II, III, and IV only

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? I. Obturator II. Syringe(s) III. Resuscitator bag and mask IV. Tube stylet

Stop suctioning and immediately administer oxygen

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

10 Fr

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

14 Fr (ID x 2; then round down)

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

Intubate via the nasal route

You are assisting a physician in the emergency care of a patient with a maxillofacial injury who will require short-term ventilatory support. Which airway approach would you recommend?

I, II, and III only

You have been asked to monitor a patient who has just been extubated. Which of the following parameters should you monitor? I. Color II. Breath sounds III. Vital signs IV. Inspiratory force

Tracheoesophageal fistula

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 the cause for the problem?

Tracheal stenosis

A patient is being evaluated for tracheal damage sustained while having undergone prolonged tracheostomy intubation approximately 3 months earlier. The flow-volume loop demonstrates a fixed obstructive pattern. What is the most likely cause of the problem?

Remove the tube and provide manual ventilation or oxygenation as necessary

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?

Complete tube obstruction

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?

I, II, III, and IV

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

Partial obstruction of the tracheostomy tube

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 decrease in breath sounds. What problem is most likely?

Remove the oral tube just before tracheostomy tube is inserted

A surgical resident has asked that you assist in an elective tracheotomy procedure on an orally intubate patient. What would be an appropriate action?

I, II, and III only

Serious complications of oral intubation include which of the following? I. Cardiac arrest II. Acute hypoxemia III. Bradycardia IV. Tongue lacerations

STAT racemic epinephrine aerosol treatment

Soon after endotracheal extubation, an adult patient exhibits a high-pitched inspiratory noise, heard without a stethoscope. What would you recommend?

I, II, and III

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

I, II, and III only

Before beginning an intubation procedure, the practitioner should check and confirm the operation of which of the following? I. Laryngoscope light source II. Endotracheal tube cuff III. Suction equipment IV. Cardiac defibrillator

The patient has hyperactive airways and has developed bronchospasm.

Before the suctioning of a patient, auscultation reveals coarse breath sounds during both inspiration and expiration. After suctioning, the coarseness disappears, but expiratory wheezing is heard over both lung fields. What is most likely the problem?

Decrease cuff pressure

Repeated connecting and disconnecting of a cuff pressure manometer to the pilot tube of a cuffed tracheal airway will do what?