RT 230 final

Which of the following strategies are useful in the management of shunt? 1. Positive end expiratory pressure 2. Permissive hypercapnia 3. Control of membrane permeability a. 2 and 3 only b. 1 and 3 only c. 1, 2, and 3 d. 1 only

ANS: B The use of PEEP and control of membrane permeability accompany the management of shunt

Compliance (Static)

Norm-60-100 cmH2O Vt/plat-peep

Which of the following strategies are useful in the management of shunt? 1. Positive end expiratory pressure 2. Permissive hypercapnia 3. Control of membrane permeability a. 2 and 3 only b. 1 and 3 only c. 1, 2, and 3 d. 1 only

ANS: B The use of PEEP and control of membrane permeability accompany the management of shunt.

Which of the following symptoms are typical symptom of asthma? 1. Cough 2. Shortness of breath 3. Chest tightness 4. Chest pain a. 1 and 3 only b. 1, 2 and 3 only c. 1 and 2 only d. 1, 2, and 4 only

ANS: B The classic symptoms of asthma are episodic wheezing, shortness of breath, chest tightness, or cough.

Nerve conduction studies are most helpful in the clinical diagnosis of which of the following? a. Myasthenia gravis b. Lambert-Eaton syndrome c. Myotonic dystrophy d. Amyotrophic lateral sclerosis

ANS: B The clinical diagnosis of Lambert-Eaton syndrome is supported by the results of nerve conduction studies.

Which of the following is considered an acceptable tidal volume for mechanical ventilation? a. 3 to 5 ml/kg b. 5 to 7 ml/kg c. 4 to 8 ml/kg d. 8 to 10 ml/kg

ANS: B The currently accepted VT for mechanical ventilation in acute respiratory failure is 4 to 8 ml/kg predicted body weight (PBW).

When monitoring involves images, graphs, or waveforms the data needs to be distinguishable for which of the following? 1. Artifacts 2. Factitious events 3. Instrument drift 4. Normal variation a. 1 and 3 only b. 1, 2, and 4 only c. 3 and 4 only d. 2, 3, and 4 only

ANS: B The data provided should be accurate (reflect the true value) and precise (not vary widely when repeated). When monitoring involves images, graphs, or waveforms, the data must be easily distinguishable from artifacts, factitious events, or normal variation, and still require an understanding of the overall status of the patient to understand their significance.

What is the best measure of the efficiency of gas exchange in the lung? a. PaCO2 b. VDS/VT c. End-tidal PCO2 d. PaCO2/PETCO2

ANS: B The dead space-tidal volume ratio (VD/VT) is a measure of the efficiency of gas exchange.

At what level do the nerves that innervate the diaphragm exit the spine? a. C1-3 b. C3-5 c. C6-7 d. T1-3

ANS: B The diaphragm receives its innervation from nerve roots exiting the spinal cord at levels C3-5.

Which of the following devices is considered to be the first electrically powered negative-pressure ventilator? a. The Bird b. The iron lung c. The chest cuirass d. The rocking bed

ANS: B The first electrically powered, negative-pressure ventilator was known as the "iron lung."

What is the most common measurement of pulmonary mechanics during pulmonary function testing? a. Tidal volume b. Forced vital capacity c. Residual volume d. Inspiratory reserve volume

ANS: B The forced vital capacity is the most commonly performed test of pulmonary mechanics.

Which of the following volumes or capacities can be measured by simple spirometry? 1. Functional residual capacity (FRC) 2. Expiratory reserve volume (ERV) 3. Residual volume (RV) 4. Inspiratory reserve volume (IRV) a. 2, 3, and 4 only b. 2 and 4 c. 1 and 3 only d. 1, 3, and 4 only

ANS: B The four lung capacities are TLC, inspiratory capacity (IC), FRC, and the VC. The lung volumes that can be measured directly with a spirometer or pneumotachometer include VT, IC, IRV, ERV, and VC.

Which of the following interfaces appear to be more efficient to improve ventilation? 1. Nasal pillows 2. Full-face mask 3. Nasal mask 4. Oral mask a. 1 only b. 1 and 2 only c. 1, 2, 3, and 4 d. 1 and 4 only

ANS: B The investigators reported that the full-face mask and nasal pillows improved ventilation more than the nasal mask but that the nasal mask was better tolerated.

Which of the following are considered safe settings for a recruitment maneuver? 1. Pressures up to 50 cm H2O 2. Pressures up to 35 cm H2O 3. Pressures applied for 5 to 10 min 4. Pressures applied for 1 to 3 min a. 1 and 3 only b. 1 and 4 only c. 2 and 3 only d. 2 and 4 only

ANS: B The maximum pressure needed to recruit a given patient's lung is unknown; however, most agree that pressures up to 50 cm H2O are safe with most patients when applied for short (1 to 3 min) periods of time.

Which of the following is the most common cause of acute respiratory failure needing mechanical ventilation? a. Sepsis b. Postoperative respiratory failure c. Heart failure d. Aspiration

ANS: B The most common causes of acute respiratory failure that necessitate mechanical ventilation are listed in Table 49-2.

What is the most common cause of a chylothorax? a. Chest trauma b. Malignancy c. Pulmonary embolism d. Surgery

ANS: B The most common causes of rupture are malignancy (50%), surgery (20%), and trauma (5%).

How frequently should a clinician make changes when weaning from PEEP? a. 10 to 20 min b. 30 to 45 min c. 1 hr d. 6 to 8 hr

ANS: D Generally, PEEP is sustained at the set level until FiO2 is less than 0.5, and when PEEP is decreased, it should be decreased in increments of 2 cm H2O no more frequently than approximately every 6 to 8 hr.

When using a pressure-volume curve to identify optimal PEEP levels, what does the upper inflection point represent? a. Point of lung recruitment b. Point of lung over distension c. Optimal PEEP level d. Optimal compliance level

ANS: B The upper inflection point may indicate lung overdistention.

Anatomical dead space

1 mL/lb - 150cc normal

Normal Intrapulmonary pressures (result in lower tidal volume)

What does lower pressure of spontaneous breath similar to in SIMV mode?

- The ventilator functions as a constant pressure generator triggered through a DEMAND drive

What does pressure support do during spontaneous breathing?

Alveolar Ventilation - VA

(Amount of Vt that reaches the alveoli). Don't forget we take out anatomical deadspace (est. @ 1ml/kgof IBW or if not known use 150ml)

Which of the following interstitial lung diseases (ILDs) is not occupationally related? a. Asbestosis b. Berylliosis c. Sarcoidosis d. Silicosis

ANS: C Sarcoidosis is not an occupationally related ILD.

Vd/Vt

(PaCO2 - PECO2) / PaCO2 Range .2-.4 Intubate >.6

Alveolar minute ventilation (VA)

(VT - VD) x f

VA

(Vt - VD) x F

Manipulation of ABG's in Control Mode

***According to the NBRC Matrix never add VD except in Control unless it's your only option. Also remember - ALWAYS keep tidal volume in NORMAL range for patient's in disease state(s)

What medication is currently the most effective for the treatment of asthma? a. Corticosteroids b. Fast-acting beta-2 agonists c. Long-acting beta-2 agonists d. Nonsteroidal antiinflammatory drugs

ANS: A Corticosteroids are the most effective medication currently available for the treatment of asthma.

What are the advantages of SIMV?

*May lower MAP as compared to CMV *Physiological advantage of spontaneous breathing *Variable WOB may maintain muscle strength and reduce muscle atrophy *Used for weaning & protocols are easy to apply *May reduce alkalosis & increased WOB associated with CMV *Full or partial support can be adjusted to meet patient's needs *regulates patient's pH balance *psychological encouragement *sedation/paralysis not required

What are the disadvantages of SIMV?

*May not reduce MAP if used inappropriately *Can increase WOB *Acute hypoventilation *Weaning is prolonged

Sychronized Intermittent Mandatory Ventilation (SIMV)

*a mode of ventilatory support using periodic assisted ventilation with spontaneous breathing in between. *assisted breaths are responsive to patient demand

What does pressure support ventilation do?

*assists the patient's inspiratory efforts *can augment spontaneous volumes with minimal control of the breath *overcome the imposed WOB (pouiselle's law) *improves patient-vent. asynchrony *decreases length of CMV, VAP & mortality *patient triggered, pressure limited & flow cycled breath

What ventilator adjustments would an RT make with A/C mode to prevent air trapping?

*decrease Vt, RR *shorten Ti and allow for a longer Te

What is the initiation for pressure support?

*for minimal patient support, set PS to just overcome airway resistance (minimum of 5cmH2O) *if patient is not being weaned, set PS to obtain acceptable Vt and RR (Ve)

What are the complications for a chest tube?

*infection *bleeding from intercostal artery laceration *blood clots in tubing *extreme negative intrathoracic pressures from tube *subcutaneous emphysema

What are the causes of increased airway resistance?

*inflammation *high gas flow *bronchospasm * small ETT / obstruction * secretions *edema

What are the signs of improvement of a chest tube?

*less dyspnea, pain on inspiration, drainage *improved chest xray *return of normal respiratory status *reduced O2 requirements *adequate lung expansion on water seal

Intermittent Mandatory Ventilation (IMV)

*mode of mechanical ventilatory support in which the patient receives a preset number of machine breaths per minute set by time. *the patient can breathe spontaneously between machine breaths

What type of patients can use SIMV?

*patients who are being weaned from CMV *Difficult to wean patients *May be used in place of CMV for most patients

What are the complications for Thoracentesis?

*pneumothorax *infection *bleeding from lacerated intercostal artery

What are the indications for a chest tube?

*remove blood pus, pleural fluid or air from the pleural space *mediastinal drain post-op (CABG) *prevent cardiac tamponade post cardiac surgery *manage barotrauma *hemothorax *empyema *pneumothroax

What are the indications for Thoracentesis?

*treatment of symptomatic pleural effusions & empyema *diagnostic analysis of pleural fluid

What are the indications for pressure support?

*used with any spontaneous breath *any mode that allows spontaneous breathing *very effective mode of weaning *rebuild respiratory muscle strength *NIV BiPAP mode (essentially set a CPAP then the level of PS)

Which medication is an anticholinergic bronchodilator? a. Ipratropium bromide b. Vilanterol c. Salmeterol d. Terbutaline

ANS: A Inhaled anticholinergic agents, such as ipratropium bromide, are effective dilators of airway smooth muscles.

Pressure Trigger

-0.5 to -1.5 cmH2O

Strategies to alter ventilation

1) Usually adjust RR first 2) As long as the Vt is within the normal or accepted range for the patient lung pathology adjust the RR first 3) If the Vt is out of range then adjust it first (keep in normal range per lung process) The NBRC will give you a clue if they want you to change Vt first like atelectasis, consolidation, or an abnormal X-ray.

Inadequate respiratory muscle strength is likely when a patient's MVV is which of the following? a. Less than 2 times the resting VE b. Greater than 3 times the resting VE c. Less than 200 L/min d. Greater than 120 L/min

ANS: A See Table 45-3.

Flow trigger

1-2 L/min

RAW

1-2cm pip-plat/flow

What is the normal range for PaO2/FiO2? a. 350 to 450 b. 250 to 350 c. 150 to 250 d. 75 to 150

ANS: A See Table 45-3.

Where would an RT evacuate fluid of a chest tube?

4th or 5th intercostal space at the mid-axillary line

IBW

106x[6(h-60)]/2.2 Male 100x[5(h-60]/2.2 Female

CVP

2-6mmHg

A-a gradient

211% 10-25mmHg 100% 25-65mmHg

PAP

25/10mmHg mean 15mmHg

Where would an RT evacuate air from chest tube or needle decompression?

2nd or 3rd intercostal space at the mid clavicular line

PaCO2 range

35 - 45 mmHg

Dynamic Compliance

35-60 Vt/pip-peep

CARDIAC OUTPUT

4-8 L/min

What is the normal range for pressure support?

5 to 25cmH2O

What is the normal range of Vt for a spontaneous breathing patient?

5 to 7mL/kg IBW

PCWP

5-10mmHg

Minute Ventilation (VE)

5-6 L/min Vt x f

What is the minimum level of PS to overcome the vent and ETT resistance?

5cmH2O

What is the normal range of Vt for a ventilated patient?

6 to 8mL/kg IBW

WNL PaO2 on ventilator

60 - 100

pH range

7.35 - 7.45

Arterial oxygen pressure (MAP)

70-100mmHg

WNL PaO2 on room air

80 - 100

What is the highest Pplat an RT would want for a ventilated patient?

< 30cmH2O

Anuria

< 50ml

When to intubate MIP

<-20

Oliguria

<.46

When to intubate VC

<10

When to intubate pH

<7.20

When to intubate Ve

>10

When to intubate PaCO2

>55

What is the normal range of maximum inspiratory pressure, or MIP (also called negative inspiratory force, or NIF), generated by adults? a. -80 to -100 cm H2O b. -50 to -80 cm H2O c. -30 to -50 cm H2O d. -20 to -30 cm H2O

ANS: A See Table 45-3.

A decrease in forced expiratory volume in 1 second (FEV1) and vital capacity (VC) of greater than 20% when a patient moves from the seated to the supine position is suggestive of which of the following? a. Diaphragmatic muscle weakness b. Scalene muscle weakness c. Brainstem injury d. Internal intercostal weakness

ANS: A A decrease in FEV1 and VC of greater than 20% when a patient moves from the seated to the supine position suggests diaphragmatic muscle weakness.

Which of the following measures are useful indicators in assessing the adequacy of a patient's oxygenation? 1. PaO2-PaO2 2. PaO2-to-FiO2 ratio 3. VD/VT 4. Pulmonary shunt a. 1 and 2 only b. 3 and 4 only c. 2, 3, and 4 only d. 1, 2, and 3 only

ANS: A See Table 45-3.

Improve the patient's ventilator synchrony and helps prevent breath stacking (where the vent delivers the machine set tidal volume on top of the patients spontaneous tidal volume)

What does the SIMV mode help?

Which of the following measures taken on adult patients indicate unacceptably high ventilatory demands or work of breathing? a. VE of 17 L/min b. Breathing rate of 22/min c. VD/VT of 0.45 d. MIP of -40 cm H2O

ANS: A See Table 45-3.

What percent of the total lung capacity (TLC) does the residual volume (RV) normally represent? a. 10% b. 20% c. 30% d. 40%

ANS: B The typical normal TLC is 6.00 L. The normal RV is approximately 1.20 L and represents approximately 20% of the TLC.

To wean patients from vent and help rebuild respiratory muscles

What else can pressure support be used for?

Which of the following is the recommended tidal volume for mechanical ventilation in a patient acutely requiring mechanical ventilation? a. 4 to 8 ml/kg b. 3 to 5 ml/kg c. 6 to 10 ml/kg d. 10 to 12 ml/kg

ANS: A The currently accepted VT for all patients acutely requiring mechanical ventilation is 4 to 8 ml/kg predicted body weight (PBW).

What is the primary tool used to diagnose a pneumothorax? a. Chest radiography b. Computed tomography c. PET scan d. V/Q scanning

ANS: A The diagnosis of pneumothorax is established with chest radiography.

Recruit Alveoli

What is PEEP used for?

BiPAP

What is created when you use PEEP/PS?

Pressure Support

What is inspiratory pressure support commonly referred to?

Which of the following is a potential risk of overtightening the straps of the mask? a. Absence of an air leak b. Tissue necrosis c. Eye irritation d. Claustrophobia

ANS: B Caution must be taken not to overtighten the straps on the mask because excessive pressure on the bridge of the nose can cause tissue necrosis.

Which factor is associated with a decrease in the plasma levels of theophylline in an asthmatic patient? a. Cigarette smoking b. Heart failure c. Hepatic disease d. Viral infections

ANS: A Conditions that tend to decrease plasma levels of theophylline include cigarette smoking and the use of medications that increase hepatic clearance, such as phenobarbital. See table 25-4.

What is the predicted normal tidal volume in the adult patient? a. 300 to 450 ml b. 400 to 500 ml c. 500 to 700 ml d. 450 to 750 ml

ANS: C The normal VT is approximately 500 to 700 ml for the average healthy adult.

ABG's with CMV

ALWAYS ASSESS YOUR PATIENT FIRST AND TEND TO THE VENT/EQUIPMENT LAST!!!! - Remember do not just look at a number and values! - ALWAYS assess your patient with every ventilator change! YOU ARE TREATING A PATIENT NOT A MACHINE!!!!!!!!!

A physician orders intubation and mechanical ventilation in the synchronized intermittent mandatory ventilation mode for a 160-lb adult man with a history of chronic obstructive pulmonary disease. Which of the following settings would you recommend? a. Rate: 12 breaths/min; VT: 500 ml b. Rate: 15 breaths/min; VT: 550 ml c. Rate: 20 breaths/min; VT: 300 ml d. Rate: 16 breaths/min; VT: 500 ml

ANS: A

What are some key causes of patient-ventilator asynchrony and increased work of breathing during pressure-triggered volume-controlled continuous mandatory ventilation? 1. Improper trigger setting 2. Insufficient inspiratory flow 3. High peak airway pressures a. 1 and 2 only b. 1 and 3 only c. 2 and 3 only d. 1, 2, and 3

ANS: A

Your patient is hypoventilating. Which of the following would be likely findings? a. A normal P(A-a)O2 with a marked response to an increase in FiO2 b. An increases P(A-a)O2 with a marked response to an increase in FiO2 c. A normal P(A-a)O2 with no response to an increase in FiO2 d. A increased P(A-a)O2 with no response to an increase in FiO2

ANS: A

A vital capacity (VC) value below what value indicates significant muscle weakness? a. 10 to 15 ml/kg b. 20 to 25 ml/kg c. 30 to 40 ml/kg d. 50 to 60 ml/kg

ANS: A A VC less than 10 to 15 ml/kg indicates considerable muscle weakness, which may inhibit the ability to breathe spontaneously.

What complication associated with noninvasive ventilation (NIV) is most common? a. Aspiration b. Hypotension c. Nasal congestion d. Air leaks

ANS: D See Table 50-2.

During mechanical ventilation, a mandatory breath is defined as one that is a. initiated or terminated by the machine. b. initiated and terminated by the machine. c. initiated and terminated by the patient. d. begun according to a preset time interval.

ANS: A A mandatory breath is a breath for which the machine sets the start time and/or the tidal volume. That is, the machine triggers and/or cycles the breath.

Which of the following clinical conditions are often associated with a normal chest radiograph in the patient with pneumonia? 1. Dehydration 2. Early infection 3. Klebsiella pneumonia 4. Pneumocystis jiroveci infection a. 1, 2, and 4 only b. 2 and 3 only c. 1 only d. 3 and 4 only

ANS: A A normal chest x-ray film does not exclude the diagnosis of pneumonia. The chest radiograph may be normal in patients with early infection, dehydration, or P. jiroveci infection.

Which of the following precautions must be considered when performing pulmonary function procedures on patients with potentially infectious airborne disease? 1. Practitioners should wear sterile gloves. 2. Practitioner should wear a personal respirator or a close-fitting surgical mask. 3. Practitioners should wash their hands between testing patients and after contact with testing equipment. 4. The mouthpiece, nose clips, tubing, and any parts of the instrument that come into direct contact with a patient should be disposed, sterilized, or disinfected between patients. a. 2, 3, and 4 only b. 2 and 3 only c. 1, 3, and 4 only d. 1, 2, and 3 only

ANS: A A respiratory therapist must always wash their hands and wear gloves when dealing with patients. Additional precautions are required when a patient may have an infectious disease. Therapist should put on a respirator or close-fitting surgical mask, washing hands constantly between testing patients and touching equipment, and dispose, sterilize, or disinfect any area or instrument that the patient may have contacted.

What percentage of all cases of COPD is caused by alpha1-antitrypsin deficiency? a. 2% to 3% b. 10% to 15% c. 25% to 40% d. 50% to 75%

ANS: A Accounting for 2% to 3% of all cases of COPD, alpha1-antitrypsin deficiency is severely underrecognized by health care providers, but it affects an estimated 100,000 Americans.

Which of the following variables determine the level of support achieved with adaptive support ventilation? 1. Patient effort 2. Flow 3. Time constant a. 1 and 3 only b. 2 only c. 1 only d. 1, 2, and 3

ANS: A Adaptive support ventilation is a dual-controlled mode of ventilation in which an automated increase or decrease in ventilatory support is based on patient effort and time constants.

When the patient stabilizes on mechanical ventilation with a PEEP of 12 cm H2O and the FiO2 has been reduced to 0.40, how should the PEEP level reduce? a. In increments of 2 cm H2O every 6 hr b. In increments of 3 to 5 cm H2O every 2 hr c. In increments of 3 to 5 cm H2O every 1 hr d. In increments of 5 cm H2O every 2 hr

ANS: A After reduction of the FiO2 to 0.40, PEEP can be reduced gradually as the patient improves at a rate of 2 cm H2O every 6 to 8 hr.

Airway resistance (Raw) is usually defined as a. the pressure difference between the ends of the airway divided by the flow rate of gas moving through the airway. b. the sum of the pressures between the ends of the airway divided by the flow rate of gas moving through the airway. c. the pressure difference between the ends of the airway multiplied by the flow rate of gas moving through the airway. d. the sum of the pressures between the ends of the airway multiplied by the flow rate of gas moving through the airway.

ANS: A Airway resistance is computed as the change in pressure divided by the flow.

During volume-assured pressure-supported ventilation, if the desired VT is not reached or exceeded at the preset pressure support level, what happens? a. Flow continues at a constant rate until the desired volume is achieved. b. The breath terminates when a predetermined low flow is achieved. c. Flow decreases exponentially until the desired volume is achieved. d. Flow increases linearly until the desired volume is achieved.

ANS: A Although a minimum tidal volume is guaranteed, volume-assured pressure-supported ventilation allows tidal volume to exceed the set level according to patient demand.

What is the most common cause of hemothorax? a. Chest trauma b. Malignancy c. Pulmonary embolism d. Surgery

ANS: A Although hemothorax is seen most commonly after blunt or penetrating chest trauma, a number of medical conditions can give rise to blood in the pleural space.

Which of the following mechanisms ultimately leads to ARDS regardless of the etiology? a. Disruption of the endothelial and epithelial barriers b. Alveolar flooding c. Interstitial damage d. Increased oncotic pressure

ANS: A Although many seemingly unrelated risk factors for ARDS have been identified, all causes of ARDS evoke disruption of endothelial and epithelial barriers and typically occur under conditions associated with widespread microvascular injury to the lungs.

Among smokers with IPF, normal spirometry and lung volumes with reduced DLCO suggest the presence of coexisting a. emphysema. b. asthma. c. chronic bronchitis. d. lung carcinoma.

ANS: A Among smokers with IPF, normal spirometry and lung volumes with reduced DLCO suggest the presence of coexisting emphysema.

A patient has an expired minute ventilation of 14.2 L and a ventilatory rate of 25/min. What is the average VT? a. 568 ml b. 635 ml c. 725 ml d. 410 ml

ANS: A An alternate approach is to measure the total volume of air exhaled for 1 min (E) and then divide by the breathing frequency (f) counted during the same period. The following formula can be used to calculate the tidal volume: VT = E/f.

During an acute exacerbation of COPD, what is the role of intravenous methylprednisolone? a. It accelerates recovery as noted in FEV1. b. It causes pulmonary edema due to retention of water. c. It causes severe immunosuppression and worsens outcomes. d. It has been shown to have no effect.

ANS: A An early randomized controlled trial of intravenous methylprednisolone for patients with acute exacerbations has shown accelerated improvement in FEV1 within 72 hr.

What symptoms are most common in the patient with interstitial lung disease? a. Exertional dyspnea and nonproductive cough b. Exertional dyspnea and wheezing c. Nonproductive cough and wheezing d. Productive cough and increased sputum production

ANS: A An exertional breathlessness (dyspnea) and a nonproductive cough are the most common reasons patients seek medical attention.

To overcome increased resistance of the ETT and the ventilator circuitry

What is pressure support primarily used for?

PIP-PLATEAU/FLOW

What is the formula for RAW?

Which of the following gastrointestinal conditions are commonly associated with long-term positive-pressure ventilation (PPV)? 1. Bleeding 2. Ulceration 3. Diarrhea a. 1 and 2 only b. 2 and 3 only c. 1 and 3 only d. 1, 2, and 3

ANS: A An increase in splanchnic resistance can contribute to gastric mucosal ischemia and helps explain the high incidence of gastrointestinal bleeding and stress ulceration in patients receiving long-term PPV.

Which of the following is a rheumatologic disease that affects the spine and chest wall? a. Ankylosing spondylitis b. Myotonic dystrophy c. Amyotrophic lateral sclerosis d. Lambert-Eaton syndrome

ANS: A Ankylosing spondylitis is a rheumatologic disease that affects the spine and chest wall. Chronic joint inflammation ultimately leads to fusion of the joints of the vertebrae and ribs, typically leading to a dramatic decrease in thoracic cage compliance due to kyphosis and ankylosis (stiffness due to bone and joint fusion).

The mainstays of bronchiectasis management includes a. antibiotics and bronchopulmonary hygiene. b. beta-agonist bronchodilators and bronchopulmonary hygiene. c. beta-agonists and bronchopulmonary hygiene. d. beta-agonists and antibiotics.

ANS: A Antibiotics and bronchopulmonary hygiene are the mainstays of bronchiectasis management. Antibiotics can be given as needed or following a regularly scheduled regimen.

Your patient has bronchiectasis. Which of the following therapies is most needed? a. Antibiotics b. Bronchodilators c. Incentive spirometry d. Oxygen

ANS: A Antibiotics and bronchopulmonary hygiene are the mainstays of bronchiectasis management. Antibiotics can be given as needed or following a regularly scheduled regimen. Sputum cultures may be helpful in guiding antibiotic choice.

What percentage of mechanical ventilated patients has a tracheostomy tube place at some point? a. 5% to 10% b. 10% to 15% c. 20% to 25% d. 30% to 35%

ANS: A Approximately 5% to 10% of patients receiving mechanical ventilation have a tracheotomy performed at some point.

Temporary variation in pulmonary artery pressure readings due to movement of the hemodynamic monitoring line is an example of what type of variability? a. Artifact b. Factitious event c. Physiologic variation d. Instrument drift

ANS: A Artifacts are frequently seen, for example, when the patient or monitoring lines are moved.

In which of the following modes of ventilatory support would the patient's work of breathing be greatest? a. Continuous positive airway pressure (CPAP) b. Pressure-supported ventilation (PSV) c. Intermittent mandatory ventilation (IMV) d. Continuous mandatory ventilation (CMV)

ANS: A As the mode is changed from CPAP to PSV to synchronized intermittent mandatory ventilation to time-triggered CMV, the ventilator assumes more of the work.

Which of the following variables determine the level of support achieved with adaptive support ventilation? 1. Patient effort 2. Elastance 3. Resistance of the endotracheal tube a. 1 and 3 only b. 2 only c. 1 only d. 1, 2, and 3

ANS: A Automatic tube compensation is similar to the flow assist of proportional assist ventilation but only considers the resistance of the endotracheal tube.

What mode of pressure-controlled ventilation is designed to prevent alveoli with short-time constants from collapsing, thereby improving oxygenation? a. Pressure-controlled inverse ratio ventilation b. Pressure-controlled intermittent mandatory ventilation c. Volume-assured pressure-supported ventilation d. Bilevel positive airway pressure

ANS: A Because alveoli affected by ARDS have short-time constants, more time is allotted for inspiration and less time is allotted for expiration.

Bronchiectasis characterized by regularly and uniformly dilated airway walls is classified as a. cylindrical bronchiectasis. b. varicose bronchiectasis. c. cystic bronchiectasis. d. obstructive bronchiectasis.

ANS: A Bronchiectasis refers to the abnormal, irreversible dilation of the bronchi caused by destructive and inflammatory changes in the airway walls. Bronchiectasis has the following three major anatomic patterns 1. Cylindrical bronchiectasis: Airway wall is regularly and uniformly dilated 2. Varicose bronchiectasis: Irregular pattern, with alternating areas of constriction and dilation 3. Cystic bronchiectasis: Progressive, distal enlargement of the airways, resulting in saclike dilations

Detrimental effects of auto-positive end expiratory pressure (PEEP) include which of the following? 1. Increased work of breathing 2. Increased pulmonary barotrauma 3. Decreased pulmonary vascular resistance 4. Increased venous return a. 1 and 2 only b. 1, 2, and 3 only c. 3 and 4 only d. 2, 3, and 4 only

ANS: A By increasing FRC and alveolar pressure, auto-PEEP increases the risk and severity of barotrauma and volutrauma. Auto-PEEP also increases the work of breathing and impedes venous return, the result being a decrease in cardiac output. Auto-PEEP also can increase pulmonary vascular resistance.

Approximately how many individuals died of COPD in the United States in 2015? a. 144,000 b. 210,000 c. 550,000 d. 1,000,000

ANS: A COPD is common, with recent estimates suggesting that 30 million Americans are affected. It is the third leading cause of death in the United States, responsible for 143,560 deaths in 2015.

Moderate rises in pleural pressure during positive-pressure ventilation have a minimal effect on cardiac output in normal subjects. What are some reasons for this lack of effect? 1. Compensatory dilation of the large arteries 2. Compensatory increase in venomotor tone 3. Compensatory increase in the cardiac rate a. 2 and 3 only b. 1 and 2 only c. 1, 2, and 3 d. 1 and 3 only

ANS: A Compensatory mechanisms used to counter the decrease in stroke volume include an increased heart rate, an increase in systemic vascular and peripheral venous resistance, and shunting of blood away from the kidneys and lower extremities, which results in a consistent blood pressure.

What is the benefit of pulmonary rehabilitation in patients with moderate to severe COPD? a. Improves exercise tolerance. b. Improves FEV1. c. Improves lung function. d. Improves survival.

ANS: A Comprehensive pulmonary rehabilitation is an additional important strategy for improving functional status. Indeed, randomized controlled trials show that a pulmonary rehabilitation program including education and a progressive exercise program can enhance exercise capacity, even though lung function and survival are not improved.

For which type of pneumothorax is pleurodesis most commonly indicated? a. Iatrogenic b. Bronchopleural fistula c. Spontaneous d. Traumatic

ANS: A Considering that the patient is stable, a chest x-ray would be the most indicated procedure to determine the cause of the clinical changes in Ms. Paul.

A diagnosis of respiratory failure can be made if which of the following are present? 1. PaO2 55 mm Hg, FiO2 0.21, PB 760 mm Hg 2. PaCO2 57 mm Hg, FiO2 0.21, PB 760 mm Hg 3. P(A-a)O2 45 mm Hg, FiO2 1.0, PB 760 mm Hg 4. PaO2/FiO2 400, PB 750 mm Hg a. 1 and 2 only b. 1, 3, and 4 only c. 3 and 4 only d. 2, 3, and 4 only

ANS: A Criteria for respiratory failure based on arterial blood gases have been established by Campbell and generally define failure as a PaO2 (arterial partial pressure of oxygen) less than 60 mm Hg and/or a PaCO2 (alveolar partial pressure of carbon dioxide) greater than 50 mm Hg in otherwise healthy individuals breathing room air at sea level.

What patient population is the only group currently accepted for the use of noninvasive ventilation (NIV) in the hospital ward? a. Chronic obstructive pulmonary disease (COPD) patients with near normal pH b. Postoperative patients without pneumonia c. No-code patients d. Asthma patients with normal SpO2

ANS: A Currently, the only patient population for whom initiation and management of NIV on hospital wards are recommended is hypercapnic COPD patients with a pH of 7.30 or greater.

Which of the following types of pneumonia suggests that the patient acquired it because of the reactivation of a latent infection, often in the setting of immunosuppression? a. Cytomegalovirus b. Haemophilus influenzae c. Histoplasmosis d. Staphylococcus

ANS: A Cytomegalovirus pneumonia is an example of a latent infection that can reactivate during chronic immunosuppression, especially in solid organ and bone marrow transplant recipients.

What medication is associated with dilated and fixed pupils in the intensive care unit patient? a. Atropine b. Lidocaine c. Vanceril d. Aminophylline

ANS: A Dilated and fixed (unresponsive to light) pupils are seen in patients who have been given atropine.

An intubated, mechanically ventilated patient is suspected of developing a severe nosocomial pneumonia. The pulmonologist decides to perform a bronchoscopy. Which bronchoscopy findings would be consistent with pneumonia? 1. Alveolar collapse 2. Distal purulent secretions 3. Persistent secretions surging from distal bronchi during exhalation 4. P/F ratio less than 50 a. 2, 3, and 4 only b. 1 and 3 only c. 2 only d. 3 and 4 only

ANS: A Direct visualization by bronchoscopy of the lower airway in ventilated patients is sometimes helpful in supporting the diagnosis of VAP. In one recent study, the presence of distal, purulent secretions; persistence of secretions surging from distal bronchi during exhalation; and a decrease in the PaO2/FiO2 ratio of less than 50 were independently associated with the presence of pneumonia.

In which mode does double triggering most commonly occur? a. Volume ventilation. b. Pressure ventilation. c. CPAP. d. No mode is more susceptible.

ANS: A Double triggering is usually a result of the patients' ventilatory center wanting a larger breath or a longer inspiratory time than is set on the ventilator. This causes the patient to continue inspiration when the ventilator transitions into the expiratory phase resulting in the ventilator triggering a second time. The biggest problem with double triggering is that normally there is no exhalation after the first breath, so that the actual delivered tidal volume may be up to double what is set on the ventilator. Double triggering is most common with volume A/C because of the precise setting of the tidal volume.

Which of the following medications is known to cause drug-induced pleural disease? 1. Bleomycin 2. Amiodarone 3. Advair 4. Vilanterol a. 1 and 2 only b. 3 and 4 only c. 2, 3, and 4 only d. 1, 2, and 3 only

ANS: A Drug-induced pleural disease • Nitrofurantoin • Minoxidil • Dantrolene • Methysergide • Bromocriptine • Amiodarone • Procarbazine, bleomycin, mitomycin • Methotrexate • Practolol

Which of the following categories of medications is most closely associated with the onset of interstitial pulmonary fibrosis? a. Antiarrhythmic drugs b. Anticoagulants c. Bronchodilators d. Vasodilators

ANS: A Drugs from many different therapeutic classes can cause interstitial lung disease, including chemotherapeutic agents, antibiotics, antiarrhythmic drugs, and immunosuppressive agents.

What finding is associated with Duchenne muscular dystrophy? a. Lordosis b. Drooping eyelids c. Pedal edema d. Hepatomegaly

ANS: A Duchenne muscular dystrophy manifests early in life with proximal muscle weakness that leads to a waddling gait, exaggerated lumbar curvature (lordosis), and frequent falls.

During pressure-controlled continuous mandatory ventilation, when the patient's lung compliance increases, which of the following will occur? a. The tidal volume will increase. b. The FRC will increase. c. The peak airway pressure will increase. d. The inspiratory time will decrease.

ANS: A During pressure-controlled continuous mandatory ventilation, the pressure delivered is constant. In lung mechanics, pressure = tidal volume/lung compliance. Since pressure is constant when lung compliance increases the tidal volume also increases.

Elevation of which of the following substances is consistent with hepatic inflammation? a. Aspartate aminotransferase b. Bilirubin c. Alkaline phosphatase d. Blood urea nitrogen

ANS: A Elevated levels of aspartate aminotransferase and alanine aminotransferase suggest hepatic inflammation.

Immediately after cardiac arrest and resuscitation, a patient is placed on a ventilator in the continuous mandatory ventilation assist-control mode. What initial FiO2 would you recommend? a. 1.0 b. 0.8 c. 0.6 d. 0.4

ANS: A Examples of disease states or conditions that typically warrant an initial FiO2 of 1.0 include acute pulmonary edema, ARDS, near drowning, cardiac arrest, severe trauma, suspected aspiration, severe pneumonia, carbon monoxide poisoning, and any disease state or condition resulting in a large right-to-left shunt.

Which of the following are examples of factors that interfere with host defenses? 1. Sepsis 2. Renal failure 3. Sedative use 4. Bronchodilator use a. 1 and 2 only b. 1, 2, and 3 only c. 2, 3, and 4 only d. 3 and 4 only

ANS: A Examples of factors that interfere with host defense include the following: • Underlying illnesses such as diabetes mellitus, malignancy, chronic heart and lung disease, and renal failure • Critical illnesses such as sepsis and ARDS • Therapeutic interventions such as endotracheal intubation, tracheostomy, and administration of medications such as sedatives and corticosteroids

What time does the exudative phase of ARDS typically presents? a. Between days 1 and 7 b. After 1 week c. After 3 weeks d. After 1 month

ANS: A Exudative phase is at 1 to 7 days.

Constant Pressure Generator

What is the function when PSV is applied?

Which of the following would interfere with the collection of a good sputum sample for Gram stain? 1. Contamination of the sample with oral secretions 2. Lack of productive cough 3. Prior antibiotic therapy 4. Rinsing with mouthwash prior to sputum collection a. 1, 2, and 3 only b. 2 and 4 only c. 3 only d. 1 and 4 only

ANS: A Factors that contribute to a poor Gram stain specimen include: lack of productive cough, prior antibiotic therapy, and contamination by oral secretions as specimens contaminated with oropharyngeal epithelial cells are unsatisfactory for analysis.

In low-perfusion patients, what site would be best for monitoring SpO2? a. Finger b. Earlobe c. Nose d. Forehead

ANS: A Finger probes appear more accurate than forehead, nose, or earlobe probes during low-perfusion states.

The increased work of breathing associated with auto-positive end expiratory pressure (PEEP) during mechanical ventilation is due to: 1. Hyperinflation or impaired contractility of the diaphragm. 2. Large alveolar pressure drops required to trigger breaths. 3. Increased volume of the intrathoracic airways. a. 1 and 2 only b. 1 and 3 only c. 2 and 3 only d. 1, 2, and 3

ANS: A First, hyperinflation caused by auto-PEEP stretches the lung, and the stretching impairs the contractile action of the diaphragm. Second, in pressure- or flow-triggered breaths, the high alveolar pressure caused by auto-PEEP must be overcome before any airway pressure change can occur.

You have determined your patient receiving volume ventilation has flow asynchrony. How can this be improved? 1. Increasing peak flow 2. Decreasing inspiratory time 3. Adjusting rise time 4. Adding an inspiratory pause a. 1 and 2 only b. 1, 2, and 3 only c. 3 and 4 only d. 1, 3, and 4 only

ANS: A Flow asynchrony can be greatly improved in volume ventilation by increasing peak flow and decreasing inspiratory time. In pressure ventilation, flow asynchrony can be corrected by adjusting rise time.

In which mode does flow asynchrony most commonly occur? a. Volume ventilation. b. Pressure ventilation. c. CPAP. d. No mode is more susceptible.

ANS: A Flow asynchrony occurs when the flow from the ventilator does not match the flow demand of the patient. This can occur in any mode of ventilation but most commonly occurs in volume ventilation because the clinician sets the tidal volume, peak flow, flow waveform, and inspiratory time.

Which of the following factors are associated with a higher risk for ARDS? 1. Gastric aspiration 2. Multiple transfusions 3. Septic shock 4. Burn injury a. 1 and 3 only b. 2 and 4 only c. 1, 2, and 3 only d. 2, 3, and 4 only

ANS: A For example, gastric aspiration and septic shock (sepsis with refractory hypotension) are associated with a greater than 25% risk of ARDS, whereas the administration of multiple blood transfusions carries an ARDS risk of less than 5%.

Which of the following interfaces are most commonly used to apply noninvasive ventilation (NIV) in the acute setting? 1. Nasal or full-face mask 2. Mouthpiece 3. Endotracheal tube 4. Nasal pillows a. 1 and 2 only b. 1 and 3 only c. 1, 2, and 4 only d. 1 and 4 only

ANS: A Full-face and nasal masks are the most commonly used interfaces in the acute care setting.

Using which of the following medications carries the greatest risk of persistent memory and cognition problems in the survivors of ARDS? a. Benzodiazepines b. Beta-2 agonists c. Exogenous surfactants d. Corticosteroids

ANS: A Furthermore, evidence from survivors of ARDS has demonstrated that many experience persistent problems with memory and cognition and that these changes relate to the types of sedation that patients receive during their care in the ICU. In particular, using benzodiazepines (e.g., lorazepam or midazolam) seems to carry the greatest risk for these adverse neurocognitive effects.

Which of the following is a feature of Guillain-Barré? a. Ascending muscle weakness b. Descending muscle weakness c. Limited to lower extremities d. Limited to trunk

ANS: A Guillain-Barré syndrome can commonly show up with lower extremity weakness progressing to the respiratory muscles in one-third of patients.

What clinical finding should raise your suspicion that a patient has developed hospital-acquired pneumonia? a. A new fever b. Digital clubbing c. Diplopia d. Pedal edema

ANS: A HCAP, HAP, and VAP usually present with a new onset of fever in hospitalized or institutionalized patients.

Which of the following cause of pneumonia occur with higher frequency in patients with HIV infection? 1. Klebsiella 2. Pneumocystis jiroveci 3. Staphylococcus 4. Streptococcus pneumoniae a. 2 and 4 only b. 1, 2, and 3 only c. 1 and 3 only d. 1, 3, and 4 only

ANS: A HIV testing should be performed in patients presenting with CAP, since infection with certain pathogens - such as S. pneumoniae, H. influenzae, and P. jiroveci - occur with higher frequency in patients with HIV infection than in the average population, particularly in those with advanced disease.

What is the Glasgow Coma Scale (GCS) score that requires intracranial pressure monitoring? a. Less than 8 b. Less than 9 c. Less than 10 d. Less than 11

ANS: A Head-injured patients with GCS scores of 8 and less need monitoring of intracranial pressure.

The respiratory therapist has placed a patient on noninvasive ventilation. After 2 hr the patient showing significant improvement in her work of breathing but is experiencing nasal and oral dryness. Which of the following corrective action should be performed? a. Add heated humidifier. b. Add ultrasonic nebulizer. c. Immediately discontinue NIV. d. Intubate the patient.

ANS: A Heated humidity should always be provided with NIV to avoid nasal symptoms, the accumulation of secretions in the back of the oral pharynx and enhance patient tolerance.

What is traumatic injury to lung tissue caused by excessive pressure called? a. Pulmonary barotrauma b. Pulmonary hemorrhage c. Pulmonary infarction d. Pulmonary embolism

ANS: A High ventilation pressure has long been associated with barotrauma.

During volume-assured pressure-supported ventilation, the breath will be pressure-limited under what conditions? a. The delivered tidal volume (VT) is greater than the preset minimum VT. b. The patient's lung or thoracic compliance decreases from the baseline. c. The delivered VT is less than the preset minimum VT. d. The patient's Raw increases from baseline

ANS: A If delivered tidal volume is greater than the preset minimum tidal volume, the breath becomes a pressure-supported breath.

- Fighting the ventilator (pt. becomes out of phase (sync) with the ventilator) - Stacking of breaths (normally the pt. will sync themselves with the ventilator rate but some will not)

What are the problems with IMV mode?

What are some key causes of patient-ventilator asynchrony and increased work of breathing during pressure-triggered volume-controlled continuous mandatory ventilation? 1. Improper trigger setting 2. Insufficient inspiratory flow 3. High peak airway pressures a. 1 and 2 only b. 1 and 3 only c. 2 and 3 only d. 1, 2, and 3

ANS: A If sensitivity is set too low, such that considerable effort is necessary to trigger the ventilator, patient-ventilator asynchrony occurs. A pressure sensitivity of -0.5 to -1.5 cm H2O or flow sensitivity of 1 to 2 L/min is regarded as optimal. Inspiratory flow must be set to meet the patient's inspiratory demand. An insufficient inspiratory flow can cause patient-ventilator asynchrony and increased work of breathing. See Table 47-4.

If a ventilator, not the patient, initiates a breath, what is the trigger variable? a. Time b. Pressure c. Flow d. Volume

ANS: A If the machine initiates the breath, the trigger variable is time.

Which of the following interfaces should be used in greater than 90% of the patients with hypoventilation? a. Full-face mask b. Nasal mask c. Nasal pillows d. Oral mask

ANS: A If the problem is ventilation, the full-face mask is the interface of choice and should be used initially in greater than 90% of patients requiring noninvasive positive-pressure ventilation for acute respiratory failure.

Which of the following individuals should be immunized against influenza? 1. 65-year-old individual 2. Respiratory therapist 3. Individual with chronic heart disease 4. 2-month old individual a. 1, 2, and 3 only b. 2 and 4 only c. 1 and 3 only d. 1, 2, 3, and 4

ANS: A In 2010, the Advisory Committee on Immunization Practices (ACIP) expanded its recommendation for influenza vaccination to include all individuals older than 6 months. Immunization is particularly important for individuals older than 60 years (because it reduces the incidence of illness for this age group by half) and for those with chronic lung or heart disease in whom the morbidity of influenza may be substantial. Studies suggest that widespread immunization of healthy working adults is cost-effective because the number of sick days taken and the number of visits to a physician are reduced. Health care workers, including RTs, should be immunized annually to prevent transmission of influenza to patients

Which of the following modes of ventilatory support would you recommend for a hypoxemic patient with congestive heart failure? a. Continuous positive airway pressure (CPAP) b. Intermittent mandatory ventilation (IMV) c. Inverse-ratio pressure-control ventilation (PCV) d. High-level pressure support ventilation (PSV)

ANS: A In a systematic review of randomized trials, noninvasive positive-pressure ventilation was found to reduce intubation rates and mortality in patients with acute cardiogenic pulmonary edema. Overall, the level of evidence was noted to be similar for CPAP without significant advantages of bilevel positive-pressure ventilation over CPAP.

What is the predicted change in tidal volume by adding 6 in of tubing to a ventilator circuit? a. Decrease of 50 to 70 ml b. Decrease of 30 to 50 ml c. Decrease of 20 to 30 ml d. No change

ANS: A In general, VT reduces between 50 and 70 ml for each 6 in (15 cm) of dead space added by tubing in a circuit.

What mechanism has been found to be useful in minimizing the development of pneumonia associated with intubated patients? a. Elevation of the head of the bed b. Frequent suctioning through the endotracheal tube c. Maintaining the patient on severe fluid restriction d. Use of tracheal gas insufflation

ANS: A In intubated patients, chronic aspiration of colonized secretions through a tracheal cuff has been linked to the subsequent occurrence of pneumonia, which has led to the development of novel strategies to prevent hospital-acquired pneumonia, such as continuous suctioning of subglottic secretions in mechanically ventilated patients and elevation of the head of the bed.

Which of the following comments regarding lung cancer is true? a. In women, lung cancer surpasses breast cancer in the age group of 60 and older. b. It is the third leading cause of cancer deaths in the United States. c. The peak incidence occurred in the mid-1970s. d. Incidence has increased in women 40 to 58 years of age.

ANS: A In men, lung cancer is the leading cause of cancer-related deaths from age 40 years to the end of life. In women, lung cancer surpasses breast cancer in the age group of 60 and older.

Approximately how deep should an endotracheal tube be placed on an adult male? a. 23 cm at the teeth b. 21 cm at the teeth c. 19 cm at the teeth d. 17 cm at the teeth

ANS: A In men, the tube should be positioned approximately 23 cm at the teeth (incisors) and 21 cm in women.

In the patient suspected of having tuberculosis, what finding on Gram stain would result in the initiation of antituberculosis medications? a. Acid-fast bacilli b. Gram-negative rods c. Pleomorphic cocci d. Presence of gram-negative cocci

ANS: A In patients with suspected tuberculosis, the finding of acid-fact bacilli in stained specimens of sputum often prompts initiation of antituberculous therapy, because culture isolation of M. tuberculosis may take up to 6 weeks.

Which of the following modes of mechanical ventilation are least likely to cause asynchrony? 1. Proportional assist ventilation 2. Pressure support ventilation 3. Neurally adjusted ventilator assist 4. Volume control/assist ventilation a. 1 and 3 only b. 2, 3, and 4 only c. 2 and 3 only d. 1 and 4 only

ANS: A In pressure support only the pressure is controlled, thus of all the classic modes of ventilation the mode that is least likely if set properly to cause asynchrony is pressure support. However, as well documented in the literature, proportional assist ventilation (PAV) and neurally adjusted ventilatory assist (NAVA) are the modes of ventilation that are least likely to cause asynchrony because they do not exert any control over the patient.

Which of the following are being targeted as a primary source of new customers by tobacco companies? a. Young people and developing countries b. Women aged 21 to 35 years c. Men aged 21 to 35 years d. Men and women over 50 years of age

ANS: A In the context that a person who has not started smoking as a teenager is unlikely to ever become a smoker, the tobacco industry has focused on young people and developing countries as the primary sources of new customers.

Your patient develops a fever while being mechanically ventilated in the control mode. As a result of the fever, the patient's CO2 production increases while alveolar ventilation is unchanged. What is the probable change in ABGs? a. Increase in PaCO2 b. Decrease in PaO2 c. Decrease in PaCO2 d. All of the above

ANS: A Increases in A or decreases in CO2 result in a decrease in PaCO2, whereas increases in CO2 or decreases in A result in an increase in PaCO2.

What conclusions can you draw from the following data, obtained from a 41-year-old man who admits to "occasional smoking" but otherwise reveals no past history of pulmonary problems? ACTUAL. PRED. %PRED. ACTUAL PRED % PRED TLC 4.75 4.90 97% FVC 2.96 3.63 82% FRC 2.3 2.21 105% %FEV1 82% 78% RV. 1.28 1.20 106% FEF200-1200 4.33 5.45 79% VC. 3.48 3.63 96% FEF25%-75% 1.95. 3.37. 58% a. Results indicate small airway obstruction. b. Results indicate generalized airway obstruction. c. Results indicate a restrictive lung disorder. d. Results indicate a combined disease process.

ANS: A Interpretation of the pulmonary function report: Interpretive strategies for pulmonary function testing abound. Most computer-based pulmonary function testing systems have algorithms in their software programs for computer-assisted interpretations of the pulmonary function report. A consensus for interpreting test results is growing. Table 20-8 summarizes pulmonary function changes that may occur in advanced obstructive and restrictive patterns of lung diseases, and Figure 20-16 presents a simple algorithm to assess pulmonary function test results in clinical practice. When considering a pulmonary function report, the %FEV1/VC ratio is a good place to start, because it provides an initial focus as normal, restrictive, or obstructive impairment. When the %FEV1/FVC is less than the limit of normal (LLN), there is airway obstruction. When the %FEV1/FVC is greater than the LLN, there is no airway obstruction. The LLN %FEV1/FVC can be determined directly for various population using regression equations in Table 20-9 or simply estimated at 70%. If the %FEV1/FVC ratio is greater than the LLN or 70% and if the TLC is less than the LLN, often defined as less than 80% predicted normal, the patient has a restrictive impairment, according to this algorithm. The severity of the restriction is based on the percent predicted or on the number of standard deviations below the LLN TLC according to Table 20-2. If the %FEV1/FVC ratio is less than 70%, the patient likely has an obstructive impairment;

What finding on the chest radiograph is typical for a viral pneumonia? a. Interstitial infiltrates b. Lobar consolidation c. Patchy infiltrate surrounding one bronchus or several bronchi d. Pleural effusion

ANS: A Interstitial infiltrates, especially if diffuse, suggest viral disease, P. jiroveci, or miliary tuberculosis in patients with community-acquired pneumonia.

When using a small-bore catheter with a one-way valve such as a Heimlich valve, how can you determine definitively that there is or is not a small air leak? a. Connect to an underwater seal. b. Increase the FiO2 and note clinical changes. c. Listen for air movement. d. Watch the valve to see if it moves.

ANS: A It is difficult to determine whether a Heimlich valve has an ongoing leak unless it is placed to underwater seal. This procedure can be done in the emergency department by placing the Heimlich valve into a cup of water or by placing it in-line with a water-seal chamber to see whether an air leak is continuing after lung expansion.

Which of the following is true regarding a patient's risk of developing ARDS? 1. Severity and duration of the risk factors is key to ARDS development in patients 2. Sepsis is the most common indirect cause of ARDS 3. Non-smokers have an increased risk 4. Most patients with risk factors for ARDS will develop the full clinical syndrome a. 1 and 2 only b. 2 and 3 only c. 3 and 4 only d. 2, 3, and 4 only

ANS: A It is important to recognize that only a minority of patients with risk factors for ARDS ultimately develop the full clinical syndrome. The key factors that determine which patients will develop ARDS are the severity and duration of the risk factor, and variables that lead some patients to be more susceptible. Sepsis is the most common cause, but even among all patients with sepsis; fewer than 20% will develop ARDS. As the severity of sepsis increases, the likelihood of ARDS developing increases dramatically and can exceed 50%. Among direct insults that lead to ARDS, pneumonia is the most common. As for the susceptibility of the host to develop ARDS, important variables are increased age (i.e., age >50 years), liver disease, alcoholism, and genetic polymorphisms related to inflammatory mediators (e.g., IL-1, TNF, and surfactant). Evidence suggests that cigarette smoking may also increase susceptibility to ARDS.

What etiologic factor is associated with the onset of nocturnal asthma? a. Aspiration of gastric acid at night b. Supine position c. Variation in acetylcholine secretion at night d. Variation in the secretion of insulin at night

ANS: A It probably is due to the known physiologic decrease in the airway tone during sleep, which has been attributed to variation in catecholamine and cortisol secretion. Aspiration of gastric acid also may play a role in some patients with increased symptoms at night.

Which of the following pulmonary function improvements have been associated with lung volume-reduction surgery (LVRS) in patients with emphysema? 1. Improved exercise endurance 2. Improved FEV1 3. Improved quality-of-life 4. Improved survival a. 1, 3, and 4 only b. 2 and 4 only c. 3 only d. 2, 3, and 4 only

ANS: A LVRS can prolong survival, improve quality-of-life, and increase exercise capacity.

What size of chest tube would you use in the management of trauma-related pneumothoraces? a. Large b. Medium c. Small d. Size is immaterial

ANS: A Large-caliber chest tubes are placed for trauma-related pneumothoraces to allow exit of blood and blood clots, which can be difficult to remove through small-bore catheters.

Which of the following signs associated with COPD is considered a late manifestation? a. Accessory muscle usage b. Frequent coughing c. Shortness of breath d. Wheezing

ANS: A Late signs of COPD may include use of accessory muscles of respiration (e.g., sternocleidomastoid).

What classification of drug would the leukotriene inhibitors fall under? a. Antiinflammatory b. Corticosteroid c. Long-acting bronchodilator d. Short-acting bronchodilator

ANS: A Leukotrienes are mediators of inflammation and bronchoconstriction and are thought to play a role in the pathogenesis of asthma. Three leukotriene antagonists are currently available for the treatment of asthma.

What is the most common cause of pleural effusion that occurs due to lymphatic obstruction within the mediastinum? a. Cancer that has metastasized to the mediastinum b. Hepatic hydrothorax c. Malignant pleural effusion d. Tuberculous pleurisy

ANS: A Lymphatic obstruction within the mediastinum causes poor pleural fluid egress from the pleural space, although the pleural space is otherwise normal. The most common condition that causes this abnormality is cancer that metastasizes to the mediastinum.

When bedside work of breathing measures are unavailable, you should adjust the level of pressure-supported ventilation (PSV) to which of the following breathing patterns? a. Spontaneous rate: 20 breaths/min; VT: 6 ml/kg b. Spontaneous rate: 27 breaths/min; VT: 9 ml/kg c. Spontaneous rate: 22 breaths/min; VT: 4 ml/kg d. Spontaneous rate: 10 breaths/min; VT: 9 ml/kg

ANS: A Most clinicians increase PSV until the breathing pattern approaches normal, that is, until the spontaneous ventilatory rate is 15 to 25 breaths/min and the spontaneous tidal volume (VT) is normal (5 to 8 ml/kg).

What stimulus is most commonly used in bronchoprovocation testing in the patient suspected to have asthma? a. Acetylcysteine b. Leukotriene inhibitors c. Methacholine d. Methylprednisolone

ANS: C The most commonly used bronchoprovocative stimulus is methacholine.

Muscle involvement commonly affects which of the following in patients with myasthenia gravis? 1. Mouth 2. Foot 3. Neck 4. Leg a. 1 and 3 only b. 1, 2, and 4 only c. 2 and 4 only d. 2, 3, and 4 only

ANS: A Muscle involvement commonly affects the muscles of the mouth, neck, and especially the eyes, with a presenting complaint of diplopia (double vision) or ptosis (a drooping eyelid) in more than 65% of patients.

Which of the following is the likely cause of nonhydrostatic pulmonary edema? a. Injury to the vascular endothelium and/or alveolar epithelium b. Abnormalities in intravascular hydrostatic pressures c. An influx of polymorphonuclear neutrophils d. Medication overdose

ANS: A Nonhydrostatic pulmonary edema, also called noncardiogenic pulmonary edema, results from injury to the vascular endothelium and/or alveolar epithelium. This injury creates a loss of integrity in the barrier between the vascular and alveolar spaces.

What is the normal range for the percent of O2 consumption consumed by the respiratory muscles? a. 2% to 5% b. 5% to 10% c. 10% to 15% d. 20% to 25%

ANS: A Normal O2R is approximately 2% to 5% of total O2 consumption.

What is the normal trigger delay? a. Less than 100 msec b. Less than 150 msec c. Less than 200 msec d. Less than 250 msec

ANS: A Normally the trigger delay should be minimal, less than 100 msec. When it exceeds 150 msec, the cause should be determined. Adjusting the sensitivity, setting the tidal volume appropriately and/or applying PEEP should correct delayed triggering unless there is a true malfunction of the ventilator.

You are called to attend to an ER patient complaining of shortness of breath and severe dyspnea on exertion. Patient history is significant for a 30-year-pack smoking history, dry nonproductive cough, and occasional pedal edema. CXR findings are not remarkable except for mild cardiomegaly. You want to rule out ILD versus obstructive lung disease. Which of the following tests may help you to differentiate the diagnosis on this patient? 1. Sputum culture and sensitivity 2. High-resolution CT 3. Pulmonary function testing 4. Arterial blood gas analysis a. 2, 3, and 4 only b. 1, 3, and 4 only c. 1 and 4 only d. 3 and 4 only

ANS: A Obtaining HRCT images allows noninvasive evaluation of the ILDs and is a key element in making a confident diagnosis in the management of ILD. An ABG is useful to assess gas exchange. The presence of significant mismatching, shunt, and decreased diffusion across the abnormal interstitium is a hallmark of IDLs. Both FEV1 and FVC are diminished, and the FEV1/FVC ratio is preserved or even supranormal. Lung volumes are reduced, as is the diffusing capacity of the lung for carbon monoxide (DLCO). This reduction in diffusing capacity reflects a pathological disturbance of the alveolus-capillary interface.

It is determined that a patient has silicosis. What profession is he most likely to have worked at? a. Foundry worker b. Talc manufacturer employee c. Carpenter d. Miller

ANS: A Occupations that commonly involve exposure to silica include mining, tunneling, sandblasting, and foundry work.

When is the PEEP/CPAP level optimum? a. O2 delivery to the tissues is maximized. b. Pressures are maintained below 15 cm H2O. c. CaO2-CvO2 is maximized. d. The PaO2 is 60 to 100 mm Hg.

ANS: A Optimal or best PEEP may be defined as the PEEP that maximizes O2 delivery (DO2).

In what scenario is pressure-controlled ventilation (PCV) most often used? a. When limiting plateau pressure is needed b. When a pneumothorax is present c. When the patient has chronic obstructive pulmonary disease d. When bilateral pneumonia is present

ANS: A PCV may be used immediately upon ventilator initiation when limiting the plateau pressure is a concern and in the care of patients expected to need prolonged inspiration or an increased 1:E ratio (1:1, 1.5:1, 2:1). These patients typically have acute lung injury or ARDS.

Which of the following means starting inspiration based on a signal from the patient? a. Patient-triggering b. Machine-triggering c. Patient-cycling d. Machine-cycling

ANS: A Patient-triggering means starting inspiration based on a signal from the patient, which is independent of a machine trigger signal. Machine-triggering means starting inspiratory flow based on a signal (usually time) from the ventilator, which is independent of a patient trigger signal. Patient-cycling means ending inspiratory time based on signals representing the patient-determined components of the equation of motion (i.e., elastance or resistance) and including effects due to inspiratory effort. Flow-cycling is a form of patient-cycling because the rate of flow decay to the cycle threshold, and hence the inspiratory time, is determined by patient mechanics.

Which of the following PFT values are indications a patient can safely undergo surgical resection for lung cancer? a. An FEV1 greater than 80% predicted value or 2 L b. An FEV1 between 30% and 60% predicted value or 1.75 L c. An FEV1 greater than 70% predicted value or 1.75 L d. An FEV1 between 30% and 60% predicted value or 2 L

ANS: A Patients with an FEV1 greater than 80% predicted value or 2 L can safely undergo surgical resection for lung cancer, even if pneumonectomy is needed.

Which of the following is false about the "acute-on-chronic" form of respiratory failure? a. It usually involves patients with hypoxemic respiratory failure. b. It is most common in patients with chronic airway obstruction. c. Bacterial or viral infections are common precipitating factors. d. Mortality is associated with severity of acidosis.

ANS: A Patients with chronic hypercapnic respiratory failure (chronic ventilatory failure) are at significant risk for this, as indicated by the fact that COPD is now the fourth leading cause of death in the United States. Acute-on-chronic respiratory failure can also be the presenting manifestation of neuromuscular disease in the setting of a concurrent pulmonary infection. Most common precipitating factors include bacterial or viral infections, congestive heart failure, pulmonary embolus, chest wall dysfunction, and medical noncompliance.

How is diaphragmatic paralysis most often diagnosed? a. Chest radiography b. Pulmonary function testing c. Arterial blood gases d. Physical examination

ANS: A Patients with unilateral diaphragmatic paralysis may have a 15% to 20% reduction in vital capacity and total lung capacity in the upright position and a further reduction while supine.

In what clinical condition has pressure-controlled ventilation with a prolonged inspiratory time been shown to be helpful? a. ARDS b. Pulmonary embolism c. Bilateral pneumonia d. Severe pulmonary fibrosis

ANS: A Pressure-control ventilation with prolonged inspiratory time has been associated with improvement in PaO2 in patients with ARDS.

-2

What is the initial setup of the pressure trigger?

Which of the following modes of ventilatory support is used to help decrease airway and alveolar pressures? a. Pressure-controlled continuous mandatory ventilation b. Pressure-controlled intermittent mandatory ventilation c. Volume-controlled continuous mandatory ventilation d. Volume-assured pressure-supported ventilation

ANS: A Pressure-controlled continuous mandatory ventilation may be used to reduce airway and alveolar pressures in any ventilated patient.

What does pressure-supported ventilation consist of? a. Patient-triggered, pressure-limited, and flow-cycled breaths b. Machine-triggered, pressure-limited, and flow-cycled breaths c. Patient-triggered, pressure-limited, and time-cycled breaths d. Machine-triggered, flow-limited, and pressure-cycled breaths

ANS: A Pressure-supported ventilation is a pressure-targeted mode of ventilation that is patient-triggered, pressure-limited, and flow-cycled breaths.

Which of the following modes of ventilatory support combines the advantages of pressure-controlled and volume-controlled ventilation? a. Volume-assured pressure-supported ventilation b. Pressure-supported ventilation c. Bilevel positive airway pressure d. Airway pressure-release ventilation

ANS: A Pressure-supported ventilation with a volume guarantee is the goal of volume-assured pressure-supported ventilation.

Which of the following equations best describes the equation of motion for the respiratory system as it relates to ventilator mode classification? a. Pvent(t) = EV(t) + RV(t) b. Pvent(t) = (E - V)(t) + (R - V)(t) c. Pvent(t) = (E + V)(t) + (R ÷ V)(t) d. Pvent(t) = (E ÷ V)(t) + (R + V)(t)

ANS: A Pvent(t) = EV(t) + RV(t).

Which of the following statements is true about prone positioning of patients with ARDS? a. May be beneficial if utilized < 36 hours after intubation in patients with persistent, severe ARDS (P/F ratio < 150 for > 12 hours) b. It dramatically reduces the mortality of patients with ARDS. c. It is easy to do and after and should be done prior to the titration of PEEP. d. It does not improve gas exchange at all.

ANS: A Recent studies have demonstrated the advantages of prone ventilation (as compared to continued supine ventilation) beyond just improved oxygenation. The most successful and widely recognized of those trials, PROSEVA, was a multicenter European trial that utilized early introduction (< 36 hours after intubation) of proning in patients with persistent, severe ARDS (P/F ratio < 150 for > 12 hours). Patients received a minimum of ventilation in the prone position for a minimum of 16 hours each day until oxygenation improved enough to discontinue. Most importantly, the outcome benefits to patients in the PROSEVA trial include improved survival. As a result, at many tertiary referral centers in the U.S, prone positioning is now considered to be the standard of care for patients with sustained severe ARDS after optimization of conventional strategies for mechanical ventilation with LPV and titration of PEEP.

Pulmonary function testing in patients with neuromuscular weakness would show normal values for which of the following? a. Diffusing capacity of the lungs (DLCO) b. Vital capacity c. Forced expiratory volume in 1 second d. Total lung capacity

ANS: A Residual volume is normal or increased, and diffusing capacity corrected for alveolar volume is normal or near normal but has been reported to be decreased.

What is the primary risk factor associated with spontaneous pneumothoraces? a. Cigarette smoking b. Heavy exercise c. Obesity d. Urban living

ANS: A Results of some studies suggest that cigarette smoking is a risk factor in more than 90% of cases of primary spontaneous pneumothorax. The smoking history is typically short and smoking cessation is recommended.

Which of the following are clinical features that favor congestive heart failure over ARDS? 1. Elevated PA catheter wedge pressure 2. Asymmetric, peripheral infiltrates on chest x-ray 3. Prompt (<12 to 24 hr) and lasting response to diuretics 4. Bronchoalveolar lavage fluid low protein and minimally increased cellularity a. 1 and 4 only b. 1, 2, and 3 only c. 3 and 4 only d. 2, 3, and 4 only

ANS: A See Box 29-2.

Which of the following are ways to prevent further lung injury in an ARDS patient? 1. Avoid hyperoxia 2. Permissive hypercapnia 3. Keep plateau pressure between 30 and 40 cm H2O 4. Tidal volume ideally between 8 and 10 ml/kg IBW a. 1 and 2 only b. 1, 2, and 4 only c. 3 and 4 only d. 2, 3, and 4 only

ANS: A See Box 29-4

Which of the following is a technique for minimizing the effects of auto-PEEP? a. Secretion management b. Minimizing bronchodilator therapy c. Increasing inspiratory time d. Smaller sized endotracheal tubes

ANS: A See Box 48-4.

Which of the following is the normal range for the P100? a. -0.5 to -1.5 cmH2O b. -0.5 to -5.0 cmH2O c. -5.1 to -10 cmH2O d. More negative than -10cmH2O

ANS: A See Box 48-9.

A physician orders intubation and mechanical ventilation in volume-controlled ventilation mode for a 170-lb adult man with neuromuscular disease. Which of the following initial settings would you recommend? a. Rate: 14 breath/min; VT: 540 ml b. Rate: 20 breath/min; VT: 310 ml c. Rate: 10 breath/min; VT: 770 ml d. Rate: 6 breath/min; VT: 500 ml

ANS: A See Box 49-4.

What is the recommended initial setting for positive end-expiratory pressure (PEEP) when delivering noninvasive ventilation in the pressure triggered timed mode? a. 0 to 4 cm H2O b. 4 to 8 cm H2O c. 8 to 12 cm H2O d. 12 to 16 cm H2O

ANS: A See Box 50-7.

What is the recommended initial setting for ventilating pressure when delivering noninvasive ventilation in the pressure triggered timed mode? a. 2 to 4 cm H2O b. 4 to 8 cm H2O c. 8 to 12 cm H2O d. 12 to 16 cm H2O

ANS: A See Box 50-7.

Which of the following is equal to total lung capacity (TLC)? a. VT + ERV + IRV + RV b. IC + VT + ERV c. VC + ERV d. FRC + IRV

ANS: A See Figure 20-8.

What type of histopathologic cells is associated with large-cell carcinoma? a. Pleomorphic cells b. Glandular structures c. Stratified epithelial cells d. Pulmonary stem cells

ANS: A See Table 32-1.

A need for some form of ventilatory support is usually indicated when an adult's rate of breathing rises above what level? a. 35/min b. 30/min c. 25/min d. 20/min

ANS: A See Table 45-3.

In patients suffering from acute respiratory acidosis, below what pH level are intubation and ventilatory support generally considered? a. 7.2 b. 7.3 c. 7.1 d. 7.0

ANS: A See Table 45-3.

Leak

What is the most common cause for lower exhaled tidal volumes returned than set?

You determine that an acutely ill patient can generate an MIP of -18 cm H2O. Based on this information, what might you conclude? a. The patient has inadequate respiratory muscle strength. b. The patient has inadequate alveolar ventilation. c. The patient has an excessive work of breathing. d. The patient has an unstable or irregular ventilatory drive.

ANS: A See Table 45-3.

Beneficial physiological effects of positive end expiratory pressure (PEEP) include which of the following? 1. Increased PaO2 for given FiO2 2. Increased lung compliance (CL) 3. Decreased shunt fraction 4. Increased functional residual capacity a. 1, 2, 3, and 4 b. 3 and 4 only c. 2, 3, and 4 only d. 2 and 4 only

ANS: A See Table 47-2.

Which of the following is considered a patient-related cause of poor patient-ventilator interaction? a. Abnormal respiratory drive b. Asynchrony c. Inadequate ventilatory support d. Inadequate FiO2

ANS: A See Table 48-1.

What physiologic effect will raising the expiratory positive airway pressure have in the patient receiving noninvasive ventilation? a. Increase the functional residual capacity. b. Increase the tidal volume. c. Decrease the PCO2. d. Lower the mean airway pressure.

ANS: A See Table 50-1.

What is the normal central venous pressure reading? a. 2 to 6 mm Hg b. 5 to 12 mm Hg c. 8 to 16 mm Hg d. 12 to 22 mm Hg

ANS: A See Table 52-3.

What is the normal range for pulmonary capillary wedge pressure? a. 5 to 10 mm Hg b. 15 to 20 mm Hg c. 20 to 25 mm Hg d. 30 to 35 mm Hg

ANS: A See Table 52-3.

The respiratory therapist in the ICU is called to assess a patient with ARDS. The patient is SOB. The x-ray shows "white" chest radiograph and the PAO2 is 60 mm Hg on an FiO2 of 100%. Which of the following is indicated? a. Shunting b. Alveolar hyperventilation c. Decreased CO2 d. Perfusion impairment

ANS: A Shunt is indicated by the following: shunt usually presents with a white radiograph. ARDS is a classic example of shunting. Shunt also does not respond to high level of supplemental oxygen.

In simple coal worker's pneumoconiosis, a chest radiograph that is characterized by multiple small nodular opacities on the chest x-ray film is most likely to be associated with what clinical presentation? a. Asymptomatic b. Cough c. Crackles d. Shortness of breath

ANS: A Simple coal worker's pneumoconiosis, characterized by multiple small nodular opacities on the chest x-ray film, is asymptomatic.

What respiratory dysfunction is commonly seen in myotonic dystrophy? a. Sleep-related disorders b. Pulmonary fibrosis c. Obstructive pulmonary disease d. Pulmonary edema

ANS: A Sleep-related disorders are particularly common, even at an early age.

What antibiotic is the drug of choice for the hospitalized on ward patient with S. pneumoniae? a. Ampicillin b. Azithromycin c. Penicillin d. Vancomycin

ANS: A Table 24-8 lists empiric regimens for treatment of hospitalized adults with CAP.

Which of the following statements is true about inspiratory capacity (IC)? 1. It is reduced in restrictive lung diseases. 2. It may be reduced in obstructive lung diseases. 3. It may help determine the type of lung expansion therapy to apply. a. 1 and 3 only b. 2 and 3 only c. 1 and 2 only d. 2 only

ANS: A The IC may be normal or reduced in restrictive and obstructive lung diseases. A reduction of IC occurs in restrictive lung diseases because the patient's inhaled volume is reduced, and there is a reduction in total lung capacity. In mild obstructive lung diseases, the IC is usually normal. In moderate and severe obstructive diseases, the IC can be reduced because the resting expiratory level of the functional residual capacity has increased because of hyperinflation of the lungs. An increase in IC may occur when the patient inhales from below the resting expiratory level when the measurement is performed; athletes and musicians who play wind instruments may also have increased inspiratory capacities. Therapists use the measurement of IC in clinical protocols to decide between methods of lung expansion

Which of the following would decrease PaCO2 when ventilating a patient using intermittent mandatory ventilation with pressure support? a. Increase the level of pressure support. b. Decrease the tidal volume. c. Decrease the mechanical rate. d. Increase the FiO2.

ANS: A The PaCO2 can be decreased by increasing tidal volume, increasing PSV for spontaneous breaths, or increasing the machine rate.

What is the upper limit for plateau airway pressure that is recommended during mechanical ventilation? a. Less than 28 cm H2O b. 30 to 40 cm H2O c. 40 to 50 cm H2O d. Depends on the patient

ANS: A The Pplat ideally should not exceed 28 cm H2O because elevated Pplat increases the likelihood of developing ventilator-induced lung injury.

In which of the following conditions is total lung capacity (TLC) always reduced? a. Restrictive lung disease b. Obstructive lung disease c. Combined restrictive and obstructive disease d. Acute airways obstruction

ANS: A The TLC is always reduced in restrictive lung diseases because of a loss of lung volume; the RV and functional residual capacity are often reduced proportionately. Carbon monoxide (CO) is the gas normally used to measure the DL.

To what does the range or limit of a device's measuring ability refer? a. Capacity b. Accuracy c. Error d. Precision

ANS: A The capacity of an instrument refers to the range or limits of how much it can measure

What is the name of the period that follows the exudative phase in ARDS? a. Fibroproliferative b. Transudative c. Proliferative d. Intraalveolar

ANS: A The changes in the lung tissue in ARDS are typically separated into two phases based on the overall duration of the disease process: (1) the acute exudative phase (1 to 7 days) and (2) the fibroproliferative or also called organizing phase (3 days to weeks).

Which of the following indicates the typical chest radiographic findings of a patient with silicosis? a. Apical nodules b. Bibasilar reticulogranular appearance c. Lymphadenopathy d. Pleural plaque

ANS: A The chest radiograph commonly shows upper-lung-zone predominant abnormalities characterized by multiple small nodular opacities in the central lung tissue.

What diagnostic procedure or technique is most commonly used to diagnose the presence of a pleural effusion? a. Chest radiography b. Pleuroscopy c. Thoracentesis d. Thoracoscopy

ANS: A The chest radiograph is the most common method of detecting a pleural effusion.

Which of the following therapies should be considered as first line of therapy in patients with exacerbation of chronic obstructive pulmonary disease (COPD)? a. Noninvasive ventilation (NIV) b. Mechanical ventilation c. High-flow nasal cannula d. Systemic steroids

ANS: A The differences in reported outcome between these studies suggest that NIV should be considered standard of care for COPD patients in an acute exacerbation and offered as first-line therapy to patients in all institutions treating the COPD patient.

Which of the following therapies should be considered as first line of therapy in patients with exacerbation of chronic obstructive pulmonary disease (COPD)? a. Noninvasive ventilation (NIV) b. Mechanical ventilation c. High-flow nasal cannula d. Systemic steroids

ANS: A The differences in reported outcome between these studies suggest that NIV should be considered standard of care for COPD patients in an acute exacerbation and offered as first-line therapy to patients in all institutions treating the COPD patient.

The effects of patient circuit compliance are most troublesome during what mode of mechanical ventilation? a. Volume-controlled ventilation b. Pressure-controlled ventilation c. Pressure support ventilation d. Patient circuit compliance is not troublesome in any mode.

ANS: A The effects of patient circuit compliance are most troublesome during volume-controlled ventilation.

How does noninvasive ventilation (NIV) benefit the patient with restrictive thoracic disease? 1. It rests the respiratory muscles. 2. It lowers the PaCO2. 3. It improves lung compliance. 4. It improves pulmonary function testing. a. 1, 2, and 3 only b. 2 and 4 only c. 1, 2, and 4 only d. 1, 3, and 4 only

ANS: A The first mechanism is the ability of NIV to rest the respiratory muscles. Second, NIV lowers the PaCO2, and the decrease is believed to reset the central ventilatory controller and establish a new baseline PaCO2. The third mechanism is the improvement in lung compliance, lung volume, and dead space that result from NIV.

After a resting expiration, air still remains in the lungs. What is this volume called? a. Functional residual capacity (FRC) b. Vital capacity (VC) c. Residual volume (RV) d. Expiratory reserve volume (ERV)

ANS: A The four lung capacities are TLC, inspiratory capacity (IC), FRC, and the VC. The lung volumes that can be measured directly with a spirometer or pneumotachometer include VT, IC, IRV, ERV, and VC.

Which of the following are potential complications of continuous positive airway pressure (CPAP) therapy? 1. Barotrauma 2. Hyperventilation 3. Gastric distention 4. Hypercapnia a. 1 and 3 only b. 2 and 3 only c. 1, 3, and 4 only d. 2, 3, and 4 only

ANS: A The increased work of breathing caused by the apparatus can lead to hypoventilation and hypercapnia. In addition, because CPAP does not augment spontaneous ventilation, patients with an accompanying ventilatory insufficiency may hypoventilate during application. Barotrauma is a potential hazard of CPAP and is more likely to occur in the patient with emphysema and blebs. Gastric distention may occur, especially if CPAP pressures above 15 cm H2O are needed.

Which of the following are indications for assessing pulmonary function? 1. Screen for pulmonary disease. 2. Evaluate patients for surgical risk. 3. Assess the progression of disease. 4. Assist in diagnosing cardiac disability. a. 1, 2, and 3 only b. 2 and 4 only c. 1 and 3 only d. 2, 3, and 4 only

ANS: A The indications for pulmonary function testing are: • To identify and quantify changes in pulmonary function. The most common purposes of pulmonary function testing are to detect the presence or absence of pulmonary disease, to classify the type of disease as either obstructive or restrictive, and to quantify the severity of pulmonary impairment as mild, moderate, severe, or very severe. Over time pulmonary function tests help quantify the progress or the reversibility of the disease. • To evaluate need and quantify therapeutic effectiveness. Pulmonary function tests may aid clinicians in selecting or modifying a specific therapeutic regimen or technique (e.g., bronchodilator medication, airway clearance therapy, rehabilitation exercise protocol). Clinicians and researchers use pulmonary function tests to objectively measure changes in lung function before and after treatments. • To perform epidemiologic surveillance for pulmonary disease. Screening programs may detect pulmonary abnormalities caused by disease or environmental factors in general populations, occupational settings, smokers, or other high-risk groups. In addition, researchers have determined what normal pulmonary function is by measuring the pulmonary function of the healthy population. • To assess patients for risk of postoperative pulmonary complications. Preoperative testing can identify those patients who may have an increased risk of pulmonary complications after surgery. Sometimes the risk of complications can be reduced by preoperative respiratory care, and sometimes the risk may be so significant to rule out surgery. • To determine pulmonary disability. Pulmonary function tests can also determine the degree of disability caused by lung diseases, including occupational diseases such as pneumoconiosis of coal workers. Some federal entitlement programs and insurance policies rely on pulmonary function tests to confirm claims for financial

Which of the following interfaces that improve ventilation appears to be more tolerated? a. Nasal pillows b. Full-face mask c. Nasal mask d. Oral mask

ANS: A The investigators reported that the full-face mask and nasal pillows improved ventilation more than the nasal mask but that the nasal mask was better tolerated.

What is the primary pathologic change that occurs in interstitial lung disease? a. Alveolar-capillary membrane structures replaced by fibrotic tissue b. Bronchial submucosal gland hypertrophy c. Bronchoconstriction of medium to small airways d. Increased sputum production

ANS: A The lung must respond to the damage and repair itself. If the exposure to the causative agent persists or if the repair process is imperfect, the lung may be permanently damaged with increased interstitial tissue replacing the normal capillaries, alveoli, and healthy interstitium.

Which of the following is the primary system for removing filtered fluid and protein from the lungs? a. Lymphatic b. Renal c. Circulatory d. Respiratory

ANS: A The lung protects itself from excessive fluid accumulation by several mechanisms. The lung lymphatic drainage system is the primary system for removing filtered fluid and protein from the lungs.

Which airways are most susceptible to airway obstruction in patients with COPD? a. Small b. Medium c. Large d. Central

ANS: A The mechanisms of airflow obstruction in COPD include inflammation and obstruction of small airways (<2 mm in diameter).

What mode of ventilation is most often used for noninvasive ventilation (NIV) when a critical care ventilator is in use? a. Pressure support ventilation (PSV) b. Continuous positive airway pressure c. Intermittent mandatory ventilation d. Control

ANS: A The mode of ventilation most used for NIV on intensive care unit ventilators is PSV.

During administration of a continuous positive airway pressure flow mask to a patient with atelectasis, you find it difficult to maintain the prescribed airway pressure. Which of the following is the most common explanation? a. System or mask leaks b. Outflow obstruction c. Inadequate system flow d. Inadequate trigger

ANS: A The most common problem with positive airway pressure therapies is system leaks.

Mr. Adam is in the ICU on an FiO2 of 100%. An arterial blood gas reveals the following information: pH of 7.18, PaCO2 of 59 mm Hg, PaO2 of 65 mm Hg, HCO3 of 24 mEq/L What action would you recommend? a. Provide ventilatory support. b. Put patient on steroids. c. Give patient chest PT. d. Put patient on CPAP.

ANS: A The patient is in hypoxic (type I) and hypercapnic (type II) acute respiratory failure. Providing full mechanical ventilatory support will provide the ventilator support needed to normalize pH and improve oxygenation.

What is the primary problem in obstructive lung disease? a. Increased airway resistance b. Low lung volumes c. Increased pulmonary capillary pressure d. Reduced lung diffusion

ANS: A The primary problem in obstructive pulmonary disease is an increased airway resistance.

What is recommended in terms of fluid management of patients with ARDS? a. Conservative b. Aggressive volume replacement c. Increased dieresis d. Only administer colloids

ANS: A The results of this study strongly favor the routine use of a conservative fluid management strategy in patients with ARDS.

What is the critical alpha1-antitrypsin level below which lung elastin is attacked and broken down? a. 57 mg/dl b. 84 mg/dl c. 100 mg/dl d. 150 mg/dl

ANS: A The risk for developing emphysema for individuals with AAT deficiency increases as the serum AAT level decreases to less than 11 μmol/L or less than approximately 57 mg/dl (with normal serum levels generally 100-220 mg/dl); these levels in serum define the so-called protective threshold value, which is the serum level below which the risk for emphysema is felt to increase. Cigarette smoking markedly accelerates the rate of emphysema progression in individuals with AAT deficiency.

What type of pleural problem is most likely to develop from rupture of the thoracic duct? a. Chylothorax b. Hemothorax c. Hydrothorax d. Pneumothorax

ANS: A The thoracic duct is a lymphatic channel that runs from the abdomen through the mediastinum to enter the left subclavian vein. Disruption of the thoracic duct anywhere along its course can cause leakage of chyle into the mediastinum, which then may rupture into the pleural space and cause a chylothorax.

The term "asbestos-related pulmonary disease" may be used to encompass which of the following? 1. Asbestosis 2. Coal worker's pneumoconiosis 3. Sarcoidosis 4. Silicosis a. 1, 2, and 4 only b. 1 and 4 only c. 2 and 3 only d. 2, 3, and 4 only

ANS: A The three most common types of occupational interstitial lung disease are asbestosis, chronic silicosis, and coal worker's pneumoconiosis. Predictable clinical and radiographic abnormalities occur in susceptible patients who have been exposed to asbestos. These abnormalities include pleural changes (plaques, fibrosis, effusions, atelectasis, and mesothelioma) as well as parenchymal scarring and lung cancer. The term "asbestos-related pulmonary disease" may be used to encompass all of these entities.

Which of the following two parameters are most commonly used for bedside assessment of respiratory muscle strength? a. Vital capacity and maximum inspiratory pressure b. Vital capacity and peak flow c. Maximum inspiratory pressure and MVV d. MVV and vital capacity

ANS: A The two values most commonly used for bedside assessment of respiratory muscle strength are vital capacity (VC) and maximal inspiratory pressure (MIP).

What is the normal predicted total lung capacity (TLC) for adults? a. Approximately 6 L b. Approximately 7 L c. Approximately 8 L d. Approximately 9 L

ANS: A The typical normal TLC is 6.00 L. The normal residual volume is approximately 1.20 L and represents approximately 20% of the TLC.

What is a common complication of pleurodynia? a. Atelectasis b. Insomnia c. Pneumonia d. Pneumothorax

ANS: A The typical patient with pleurodynia has shallow respirations; deeper breaths are limited by pain. The subsequent atelectasis can cause oxygenation difficulty caused by shunting.

Why did the use of intermittent positive-pressure breathing decline in the 1980s? a. Due to a lack of scientific evidence to support its use for delivering aerosolized medication b. Due to its cost of implementation c. Due to its complexity d. Replaced by newer technology

ANS: A The use of intermittent positive-pressure breathing declined significantly in the mid-1980s when evidence showed no benefit compared to small volume nebulizers.

In what clinical scenario will a Gram stain and culture's value be diminished? a. Prior antibiotic therapy b. Presence of active pulmonary TB c. Presence of pneumococcal pneumonia d. In specimens obtained before or within 6 to 12 hours of antibiotic initiation

ANS: A The value of Gram stain and culture of expectorated sputum has been debated for years. Many patients lack a productive cough, making collection of an adequate specimen difficult. Prior antibiotic therapy reduces the yield from both tests. However, sputum culture is positive in more than 80% of cases of pneumococcal pneumonia if a good quality specimen can be obtained before or within 6 to 12 hours of antibiotic initiation.

In both the helium dilution test and nitrogen washout functional residual capacity (FRC) determinations, at what point should the patient normally be connected to the system to begin the test? a. Resting expiration b. Full forced inspiration c. Resting inspiration d. Full forced expiration

ANS: A The valve is turned to connect the patient to the breathing circuit usually at the resting expiratory level of the FRC.

Which of the following terms describes the lung injury associated with the release of prostanoids? a. Biotrauma b. Barotrauma c. Volutrauma d. Atelectrauma

ANS: A These biochemical signals cause the release of cytokines, complement, prostanoids, leukotrienes, reactive oxygen species, and proteases. The release of these substances has been called "biotrauma."

Which of the following mechanisms explains the hepatic dysfunction in patients receiving positive-pressure ventilation (PPV)? a. Decreased hepatic blood flow b. Increased portal venous pressure c. Hepatic congestion d. Increased bilirubin conjugation

ANS: A These effects appear to be directly related to the reduction in hepatic blood flow that occurs with PPV.

What is the classic radiographic finding present in many end-stage interstitial lung diseases (ILDs)? a. Cystic pattern called honeycombing b. Pleural disease uncommon c. Prominent bibasilar infiltrates d. Severe hyperinflation

ANS: A This cystic pattern, called honeycombing, reflects end-stage fibrosis and is a feature of many end-stage ILDs.

- Respiratory Rate - Minute Volume - Flow

What is the patient allowed to set on their own in SIMV mode?

When starting flow-limited ventilatory support on an adult patient, which of the following inspiratory flow settings would you initially select? a. 60 L/min b. 50 L/min c. 40 L/min d. 30 L/min

ANS: A This value corresponds to an initial peak flow setting of approximately 60 L/min with a range of 40 to 80 L/min and a down ramp or square flow waveform.`

Which of the following are associated with hypercapnic respiratory failure due to decreased ventilatory drive? 1. Brainstem lesions 2. Encephalitis 3. Hypothyroidism 4. Asthma a. 1, 2, and 3 only b. 2 and 4 only c. 3 and 4 only d. 2, 3, and 4 only

ANS: A This ventilatory drive can be diminished by various factors such as drugs (overdose/sedation), brainstem lesions, diseases of the central nervous system such as multiple sclerosis or Parkinson's disease, hypothyroidism, morbid obesity (e.g., obesity-hypoventilation), and sleep apnea.

Which of the following are typical complications of thoracentesis? 1. Infection 2. Intercostal artery laceration 3. Rib fracture 4. Pneumothorax a. 1, 2, and 4 only b. 2 and 3 only c. 3 and 4 only d. 1, 2, and 3 only

ANS: A Thoracentesis involves the following three major risks: (1) intercostal artery laceration, (2) infection, and (3) pneumothorax.

A ventilator has separate rate and VT controls. If you set a VT of 650 ml and a respiratory rate of 12/min in the continuous mandatory ventilation mode, what will the minute ventilation be? a. 7800 ml/min (7.8 L/min) b. 8500 ml/min (8.5 L/min) c. 9600 ml/min (9.6 L/min) d. 10,200 ml/min (10.2 L/min)

ANS: A Tidal volume (VT) and rate (f) determine minute ventilation (E).

When setting the tidal volume on a patient being mechanically ventilated, what criteria should be kept in mind? a. It should never cause the plateau pressure to exceed 28 mm Hg. b. It should never cause the peak pressure to exceed 35 mm Hg. c. It should result in the static pressure of less than 10 mm Hg. d. It should result in a peak pressure of no more than 25 mm Hg.

ANS: A Tidal volume usually is based on specific patient considerations but should ideally never result in a plateau pressure of 28mmHg

Which of the following ventilator adjustments would decrease inspiratory time? 1. Increase the peak flow. 2. Increase the tidal volume. 3. Change the flow pattern from a decelerating wave to a square wave. a. 1 and 3 only b. 1 only c. 2 and 3 only d. 1, 2, and 3

ANS: A To decrease inspiratory time, one may increase the peak flow, decrease the tidal volume, or change from a down ramp or sine wave to a square wave flow pattern.

How can you ensure reliability when measuring the expiratory reserve volume (ERV)? a. Have the patient perform the maneuver twice, ensure consistency, and then take the best value. b. Have the patient perform the maneuver three times, and then take the last value. c. Have the patient perform the maneuver twice, ensure consistency, and then take the mean value. d. Have the patient perform the maneuver until he or she becomes fatigued, and then take the last value.

ANS: A To ensure reliability, the ERV should be measured at least twice and the two largest measurements should agree within 5%.

What treatment strategies have improved the outcome in Guillain-Barré syndrome? a. Plasma exchange b. Corticosteroids c. Radiation therapy d. Antibiotics

ANS: A Treatment for GBS may be beneficial when started within 2 weeks of symptom onset. Intravenous immunoglobulin or plasma exchange can be used (but not both). Corticosteroids offer little if any benefit in GBS.

Which of the following modes of support provides all of the patient's minute ventilation (VE) as mandatory volume-controlled (VC) breaths? a. VC continuous mandatory ventilation b. VC intermittent mandatory ventilation c. Pressure-supported ventilation d. Continuous positive airway pressure

ANS: A VC continuous mandatory ventilation provides all of the patient's minute ventilation as mandatory breaths.

Which of the following situations is most likely to call for ventilator settings of low volume and high rate while allowing for permissive hypercapnia? a. Patient with ARDS b. Patient with neuromuscular disease c. Patient with chronic obstructive pulmonary disease d. Child with croup

ANS: A Ventilation strategies for lung protection in ARDS include a low VT, rapid respiratory rates, and permissive hypercapnia if necessary to avoid overdistention or Pplat greater than 28 cm H2O.

What causes the degranulation of mast cells in asthma patients? a. Antigens attaching to IgE molecules on the mast cell surface. b. Antigens attaching to proteins receptors on mast cell surface. c. Irritant receptors on the mast cells are stimulated by antigens. d. Infectious particles attacking the

ANS: A When a patient with asthma inhales an allergen to which he or she is sensitized, the antigen cross-links to specific IgE molecules attached to the surface of mast cells in the bronchial mucosa and submucosa. The mast cells degranulate rapidly (within 30 min), releasing multiple mediators including leukotrienes (previously known as slow-reacting substance of anaphylaxis [SRS-A]), histamine, prostaglandins, platelet-activating factor, and other mediators.

Which of the following is the explanation for the increased ratio when excessive positive end expiratory pressure (PEEP) is used? a. Diversion of blood from ventilated alveoli to hypoventilated alveoli b. Diversion of blood from hypoventilated alveoli to ventilated alveoli c. Shunt-like effect d. Hyperexpansion

ANS: A When excessive PEEP is used, blood flow is diverted from ventilated alveoli to hypoventilated alveoli; the result is an increased ratio.

What spontaneous pressure-controlled breath mode allows separate regulation of the inspiratory and expiratory pressures? a. Bilevel positive airway pressure b. Continuous positive airway pressure c. Pressure-supported ventilation d. Pressure-controlled intermittent mandatory ventilation

ANS: A With BiPAP, inspiratory positive airway pressure (IPAP or pressure-supported ventilation) and expiratory positive airway pressure (EPAP or positive end expiratory pressure) are set.

The presence of pleural calcification on the chest film is consistent with what type of interstitial lung disease (ILD)? a. Asbestosis b. Coal worker's pneumoconiosis c. Sarcoidosis d. Silicosis

ANS: A With an appropriate exposure history, the presence of radiographic pleural plaques or rounded atelectasis may indicate that asbestos as the cause of the ILD.

Which group of patients is most likely to develop pneumonia subsequent to large-volume aspiration? a. Acute respiratory distress syndrome b. Alcohol toxicity c. Diabetes mellitus d. Obstructive sleep apnea

ANS: B Certain patient populations are at risk of large-volume aspiration, such as those with impaired gag reflexes from narcotic use, alcohol intoxication, or prior stroke.

If the patient is being ventilated via a mechanical ventilator via intermittent mandatory ventilation with partial ventilatory support, what would probably happen to PaCO2 if the patient suddenly had no spontaneous breathing? a. Increase b. Decrease c. Stay the same d. Change according to FiO2

ANS: A With partial ventilatory support, if spontaneous breathing ceases or becomes inadequate, as may be the case with the development of rapid shallow breathing or apnea, alveolar ventilation may decrease, and PaCO2 may increase above an acceptable level.

On a ventilator that has separate rate and minute ventilation (VE) controls, the rate is set at 13/min and the VE at 11 L/min. Approximately what VT is the patient receiving? a. 700 ml b. 850 ml c. 1000 ml d. 1200 ml

ANS: B

While checking the accuracy of a portable spirometer for volumetric measures with a calibrated super syringe, you obtain a mean measured value of 2.7 L. What is the percent error of this instrument? a. 1% b. 10% c. 30% d. 90%

ANS: B

An asthma patient's best effort produces a PEFR of 55% of personal best. What is indicated at this time? a. Patient should lie down and try to relax. b. Patient should probably seek medical attention now. c. Patient should retry the PEFR maneuver. d. Patient should take his or her controller medications.

ANS: B A PEFR below 60% of the personal best is in the red zone and signals a medical alert, requiring immediate medical attention if the patient does not return to the yellow or green zone with bronchodilator use.

Which of the following values of VD/VT, are suitable for weaning? 1. 0.10 2. 0.20 3. 0.30Which of the following values of VD/VT, are suitable for weaning? 4. 0.60 a. 1 and 3 only b. 1, 2, and 3 only c. 3 and 4 only d. 2, 3, and 4 only

ANS: B A VD/VT ratio greater than 0.60 is predictive of lack of success at discontinuance of ventilation.

What is the American Thoracic Society standard for accuracy when measuring flows during pulmonary function testing? a. 90% accuracy or within 0.30 L/sec, whichever is greater b. 95% accuracy or within 0.20 L/sec, whichever is greater c. 97% accuracy or within 0.10 L/sec, whichever is greater d. 99% accuracy or within 0.05 L/sec, whichever is greater

ANS: B A diagnostic spirometer that measures flow should be at least 95% accurate (or within 0.2 L/sec, whichever is greater) over the entire 0 to 14 L/sec range of gas flow.

Which of the following is considered a normal spontaneous tidal volume? a. 3 to 5 ml/kg b. 5 to 7 ml/kg c. 7 to 9 ml/kg d. 10 to 12 ml/kg

ANS: B A normal spontaneous tidal volume is approximately 5 to 7 ml/kg.

What is the value of determining the lower inflection point during measurement of the pressure-volume curve? a. Best tidal volume b. Best PEEP level c. To determine best airway size d. To determine type of ventilator inspiratory flow pattern

ANS: B A recommended strategy for setting PEEP is to set a level slightly above the lower inflection point with the goal of recruitment and stabilization of dependent alveoli that would otherwise sustain injury from repetitive opening, closing, and reopening during tidal ventilation.

Which of the following modes of ventilation can inappropriately set sensitivity cause asynchrony? 1. Volume A/C 2. Pressure A/C 3. PSV 4. NAVA a. 1 and 3 only b. 1, 2, and 3 only c. 2 and 4 only d. 2, 3, and 4 only

ANS: B Across all modes of ventilation, inappropriately set sensitivity, inappropriate selection of PEEP, and the presence of auto-PEEP result in asynchrony. The one exception to this is NAVA, since NAVA is controlled by the diaphragmatic EMG signal; the presence of auto-PEEP does not affect the function of this mode.

Administration of positive end expiratory pressure (PEEP) or continuous positive airway pressure (CPAP) is associated with which of the following benefits? 1. Helps maintain open alveoli. 2. Helps with alveoli stability. 3. Helps maintain fluid-filled alveoli open. 4. Ensures surfactant-depleted alveoli remain closed. a. 1 and 3 only b. 1, 2, and 3 only c. 3 and 4 only d. 2, 3, and 4 only

ANS: B Administration of PEEP with mechanical ventilation or to a spontaneously breathing patient in the form of CPAP helps to maintain open and stabilize small, collapsed, or fluid-filled alveoli.

Administration of positive end expiratory pressure (PEEP) or continuous positive airwayA pressure (CPAP) is associated with which of the following benefits? 1. Helps maintain open alveoli. 2. Helps with alveoli stability. 3. Helps maintain fluid-filled alveoli open. 4. Ensures surfactant-depleted alveoli remain closed. a. 1 and 3 only b. 1, 2, and 3 only c. 3 and 4 only d. 2, 3, and 4 only

ANS: B Administration of PEEP with mechanical ventilation or to a spontaneously breathing patient in the form of CPAP helps to maintain open and stabilize small, collapsed, or fluid-filled alveoli.

Which of the following are advantages of Assist Control Volume ventilation? 1. Minimal safe level of ventilation achieved. 2. Patient can set breathing rate. 3. May reduce work of breathing. 4. Pressure is limited. a. 1 and 3 only b. 1, 2, and 3 only c. 3 and 4 only d. 2, 3, and 4 only

ANS: B Advantages of assist-control volume ventilation include the assurance that a minimum safe level of ventilation is achieved, yet the patient can still set his or her own breathing rate. In the event of sedation or apnea, a minimum safe level of ventilation is guaranteed by the selection of an appropriate backup rate, usually approximately 4 to 6 breaths/min less than the patient's assist rate but not less than the rate necessary to provide a minimum safe level of ventilation (e.g., a backup rate of at least 12 to 14 breaths/min). Because assist-control ventilation usually provides full ventilatory support, it may result in less WOB. In volume control ventilation, pressure is variable and not limited.

Which of the following are goals of noninvasive ventilation (NIV) in the acute care setting? 1. Avoid intubation. 2. Decrease incidence of ventilation-associated pneumonia. 3. Decrease length of stay. 4. Improve mobility. a. 2 and 4 only b. 1, 2, and 3 only c. 1 and 3 only d. 1, 3, and 4 only

ANS: B Avoiding intubation and invasive positive-pressure ventilation, improving survival, decreasing the length of ventilatory support, decreasing the length of hospitalization, and decreasing the incidence of ventilator-associated pneumonia are major goals of NIV in the acute care setting (emergency department, intensive care unit, or hospital ward).

What type of lung infection is most commonly associated with cavitating lesions on the chest radiograph? a. Community-acquired pneumonia b. Reactivation tuberculosis c. Staphylococcus aureus d. Viral pneumonias

ANS: B Cavitary infiltrates are seen in reactivation pulmonary tuberculosis; fungal pneumonias, such as histoplasmosis and blastomycosis; nocardiosis; pyogenic lung abscess; and rarely, P. jiroveci pneumonia.

Which of the following statements are true regarding the use of controlled ventilation? 1. May allow the muscles of breathing to rest. 2. Can use larger 1:E ratio and may improve oxygenation. 3. Requires use of paralytic agents in spontaneously breathing patients. 4. Therapist has little control of needed inspiratory flow and pressure. a. 1 and 3 only b. 1, 2, and 3 only c. 3 and 4 only d. 2, 3, and 4 only

ANS: B Advantages of controlled ventilation include eliminating the work of breathing and complete control over the patient's inspiratory and expiratory time, flow, and pressure. In cases in which the work of breathing is high, controlled ventilation may allow for ventilatory muscle rest, reduce the O2 consumption of the ventilatory muscles, and "free up" O2 for delivery to the tissues. Controlled ventilation may allow prolonged inspiratory times and the use of 1:E ratios greater than 1:1 in cases in which other methods have failed to improve oxygenation. Disadvantages of controlled ventilation include the need for sedatives and perhaps paralytic drugs in the care of patients with spontaneous breathing efforts. The administration of paralytic agents has been associated with the development of prolonged neuropathy in some patients. Paralytic agents have no effect on the patient's level of consciousness and should not be given without concurrent and appropriate sedation. In addition, in the care of apneic patients, ventilator malfunction or disconnection can lead to death of the patient.

Which of the following are techniques for facilitating CO2 removal during lung protective ventilation in patients with ARDS? 1. Fever control 2. ECMO 3. Neuromuscular paralysis 4. Pressure support ventilation a. 1 and 3 only b. 1, 2, and 3 only c. 3 and 4 only d. 2, 3, and 4 only

ANS: B Alternative techniques for facilitating CO2 removal during lung protective ventilation in patients with ARDS include extracorporeal CO2 removal ECMO, reduction of CO2 production by control of fever, avoidance of overfeeding, and neuromuscular paralysis.

Bilevel positive airway pressure (BiPAP) is used for which of the following purposes? 1. Nocturnal ventilatory support of chronic disease patients 2. Preventing intubation of patients with acute exacerbations of chronic obstructive pulmonary disease (COPD) 3. Treatment of obstructive sleep apnea (OSA) in the home 4. Providing ventilatory support for patients with status asthmaticus a. 1 and 3 only b. 1, 2, and 3 only c. 3 and 4 only d. 2, 3, and 4 only

ANS: B Although it was originally developed to enhance the capabilities of home CPAP systems used for management of OSA, BiPAP has since been successfully used in the home and the hospital for noninvasive ventilatory support of patients with acute and chronic respiratory failure. BiPAP has been found to be useful in the prevention of intubation in acute exacerbation of COPD.

Which of the following medications is indicated for regular use in patients with stable COPD? a. Antibiotics b. Beta-2 agonists c. Corticosteroids d. Methylxanthines

ANS: B Although the airflow obstruction from emphysema itself is irreversible, most (up to two-thirds) patients with stable COPD will demonstrate a reversible component of airflow obstruction, defined as a 12% and 200-ml rise in the post-bronchodilator FEV1 and/or FVC. For this reason, as indicated in an algorithm developed by the Global Initiative for Chronic Obstructive Lung Disease (GOLD), bronchodilator therapy is recommended for patients with COPD.

A patient receiving long-term positive-pressure ventilation support exhibits a progressive weight gain and a reduction in the hematocrit. Which of the following is the most likely cause of this problem? a. Pulmonary hemorrhage b. Water retention c. Hypovolemia d. Hyponatremia

ANS: B Among critically ill patients, water retention usually is evident when rapid weight gain occurs. In addition, such patients may have a reduced hematocrit, which is also consistent with hypervolemia due to water retention.

Which level of FiO2 and what time of exposure has been associated with oxygen toxicity? 1. FiO2 of 0.5 2. FiO2 of 0.7 3. FiO2 of 0.6 4. 24 to 48 hr a. 1 and 2 only b. 3 and 4 only c. 2 and 3 only d. 1 and 4 only

ANS: B An FiO2 of 0.5 or more for longer than 24 to 48 hr is associated with the development of oxygen toxicity.

A patient with ARDS receiving ventilatory support with PEEP through a volume-cycled ventilator has a plateau pressure of 38 cm H2O. ABGs on 55% O2 are as follows: pH = 7.44; PCO2 = 37 mm Hg; HCO3 - = 25 mEq; PO2 = 55 mm Hg; SaO2 = 88%. Which of the following would you recommend? a. Increase the PEEP level. b. Make no changes. c. Reduce the VT. d. Increase the FiO2.

ANS: B An SaO2 of 88% to 90% may be acceptable for patients who need an FiO2 of 0.80 or more for an extended time.

Which of the following occur in pressure-limited modes of ventilation? 1. The volume delivered at a given pressure must decrease as compliance falls. 2. The inspiratory flow varies with patient effort and lung mechanics. 3. Active effort by the patient against inspiration will decrease delivered volume. 4. The volume delivered at a given pressure must increase as Raw rises. a. 1 and 3 only b. 1, 2, and 3 only c. 3 and 4 only d. 2, 3, and 4 only

ANS: B An increase in resistance, active exhalation, or muscle tensing by the patient during inspiration also decreases delivered volume in pressure ventilation.

You are examining the expiratory flow tracing during the patient's forced vital capacity (FVC) maneuver. At what point during the exhalation can you generally begin to see flow from the bronchioles? a. Beyond 30% b. Beyond 50% c. Beyond 70% d. Beyond 90%

ANS: B Any flow measured in the first half of the FVC reflects on the bronchi; any flow measured beyond 50% of the vital capacity reflects on the bronchioles.

Apical growth may be associated with which of the following syndromes? a. Good pasture b. Pancoast c. Miller d. Granulomatosis

ANS: B Apical growth may lead to Pancoast syndrome.

A patient with a 10-year history of chronic bronchitis and an acute viral pneumonia exhibits the following blood gas results breathing room air: pH = 7.22; PCO2 = 67; HCO3 - = 26; PO2 = 60. Which of the following best describes this patient's condition? a. Chronic hypoxemic respiratory failure b. Acute hypercapnic respiratory failure c. Chronic hypercapnic respiratory failure d. Acute hypoxemic respiratory failure

ANS: B Assessment of the pH allows a determination of whether the problem is acute or chronic.

What test is most useful for the diagnosis of asthma in the symptom-free patient? a. Arterial blood gases b. Bronchoprovocation testing with pulmonary function tests c. Chest radiograph d. Ventilation-perfusion ratio ( ) scans

ANS: B Asthmatics evaluated in a symptom-free period may have a normal chest x-ray examination and normal pulmonary function tests. Under these circumstances, provocative testing can be used to induce airway obstruction. Bronchoprovocation is a well-established method to detect and quantify airway hyperresponsiveness.

Which of the following are true about continuous positive airway pressure (CPAP)? 1. It maintains alveoli at greater inflation volumes. 2. It holds airway pressure essentially constant. 3. It provides the pressure gradient needed for ventilation. 4. It has side effects similar to those of positive pressure ventilation. a. 1 and 3 only b. 1, 2, and 4 only c. 3 and 4 only d. 2, 3, and 4 only

ANS: B Because airway pressure does not change, CPAP does not provide ventilation.

What is the best single measure of effective ventilation in the intensive care unit patient? a. Dead space-tidal volume ratio b. PaCO2 c. End-tidal PCO2 d. Qs/Qt

ANS: B Because of the relationship between alveolar ventilation and PaCO2, the single best index of effective ventilation is measurement of the PaCO2.

Which of the following complications has been associated with the use of PEEP in patients with ARDS? a. Lung infection b. Reduced cardiac output c. Hepatic failure d. Myocardial infarction

ANS: B Because the primary goal of mechanical ventilation is to provide adequate oxygenation at safe levels of FiO2 while maintaining adequate DO2 to the body, the inverse relation between PEEP and cardiac output must be considered.

The following data are gathered during a PEEP study (FiO2 = 0.60). Based on these data, what is the optimum PEEP level? PEEP cm H2O 0 5 10 15 20 25 PaO2 mm Hg 46 54 67 73 75 74 Compliance ml/cm H2O 18 23 26 30 24 19 Systolic pressure 125 123 114 115 104 94 Diastolic pressure 90 88 83 84 76 68 a. 10 cm H2O b. 15 cm H2O c. 20 cm H2O d. 25 cm H2O

ANS: B Best PEEP has been exceeded at the point when an increase in PEEP is followed by a decrease in compliance.

A patient receiving control-mode continuous mandatory ventilation has the following ABGs on an FiO2 of 0.5: pH = 7.23; PCO2 = 61 mm Hg; HCO3 - = 26 mm Hg. The current minute ventilation (VE) is 9.2 L/min. What new VE would you recommend? a. 10.6 L/min b. 14.0 L/min c. 12.4 L/min d. 5.8 L/min

ANS: B Box 49-15 gives an example of the effect of a change in A on PaCO2.

To stabilize a patient during the initial application of ventilatory support, which of the following parameters must be set? 1. Airway temperature 2. Ventilatory support mode 3. O2 concentration (FiO2) 4. Minute ventilation (f, VT) a. 1 and 3 only b. 1, 2, and 3 only c. 2, 3, and 4 only d. 1, 2, 3, and 4

ANS: B Box 49-3 summarizes key decisions that must be made as a part of initial ventilator setup.

During mechanical ventilation, which of the following is considered one cycle of inspiratory flow followed by a matching expiratory flow? a. Limit b. Breath c. Trigger d. Baseline

ANS: B Breath delivery is one of the most basic functions a mechanical ventilator performs. A breath can simply be defined as one cycle of inspiratory flow followed by a matching expiratory flow.

Bronchiectasis characterized by irregular pattern, with alternating areas of constriction and dilation is classified as a. cylindrical bronchiectasis. b. varicose bronchiectasis. c. cystic bronchiectasis. d. obstructive bronchiectasis.

ANS: B Bronchiectasis refers to the abnormal, irreversible dilation of the bronchi caused by destructive and inflammatory changes in the airway walls. Bronchiectasis has the following three major anatomic patterns: 1. Cylindrical bronchiectasis: Airway wall is regularly and uniformly dilated. 2. Varicose bronchiectasis: Irregular pattern, with alternating areas of constriction and dilation. 3. Cystic bronchiectasis: Progressive, distal enlargement of the airways, resulting in saclike dilations.

Forty-eight hours after the chest tube insertion Ms. Paul remains on mechanical ventilation. While assessing the chest tube system, you note small bubbles in the water seal chamber generated during peak inspiration. This is an indication of which of the following: a. normal functioning of the water seal chamber. b. bronchopleural fistula. c. low water level in the chamber. d. high suction pressure from the suction chamber.`

ANS: B Bubbling in the water seal chamber is an indication of a leak in the chest tube collection system. The leak can be generated by (1) cracked or broken collection system, (2) improperly positioned chest tubes, and (3) a persistent bronchopulmonary fistula. To rule out (1) versus (2), and (3), the chest tube should be clamped by the chest level. If the leak continues, the collection system is cracked or defective. If the leak stops, the chest tube is malposition or there is a bronchopulmonary fistula generating the leak.

How much improvement is needed in the FEV1 after bronchodilator therapy before reversibility can be considered present in the patient with obstructive lung disease? a. 50 ml b. 200 ml c. 350 ml d. 500 ml

ANS: B By convention, improvement in the FEV1 by at least 12% and 200 ml following administration of a bronchodilator is considered evidence of reversibility.

What factors contribute to the development of auto-positive end expiratory pressure (PEEP)? 1. High expiratory Raw 2. High inspiratory flows 3. Inadequate expiratory time a. 1 and 2 only b. 1 and 3 only c. 2 and 3 only d. 1, 2, and 3

ANS: B By effectively increasing the time constant of the lung, high expiratory resistance prolongs exhalation to the point at which air trapping begins. Any shortening of the expiratory time aggravates the problem and increases both distal airway pressure and lung volume (auto-PEEP).

What lung disease is the most common current indication for lung transplantation? a. Adult respiratory distress syndrome b. COPD c. Pneumoconiosis d. Pulmonary fibrosis

ANS: B COPD is the most common current indication for lung transplantation.

Your patient has acute pulmonary edema from left heart failure. Which therapy should be tried first? a. Noninvasive ventilation (NIV) b. Continuous positive airway pressure (CPAP) c. Mechanical ventilation d. Positive end-expiratory pressure

ANS: B CPAP has been shown to reduce the need for intubation in patients with severe cardiogenic pulmonary edema.

Which gas normally used to measure the diffusing capacity of the lung? a. O2 b. CO c. CO2 d. He

ANS: B Carbon monoxide (CO) is the gas normally used to measure the diffusion capacity (DL) of the lung. The diffusing capacity of the lung for carbon monoxide (DLCO) is expressed in ml/min/mm Hg under standard temperature and pressure and dry conditions.

What is the primary concern when using proning to improve oxygenation in the patient with ARDS? a. Sudden increase in PaCO2 b. Displacement of tubes and lines c. Pneumothorax d. Hemodynamic compromise

ANS: B Care must be taken to ensure that endotracheal tubes, intravenous lines, and catheters are not blocked or dislodged.

Most likely SMALLER than that of the mechanical tidal volume

What is the patient's spontaneous tidal volume in SIMV?

What use, other than prognostic value, can serial pulmonary function tests provide for the management of interstitial lung disease patients? a. Determine the degree of refractory hypoxemia. b. Establish the need for lung transplantation. c. Guide the type of oxygen therapy delivered. d. Guide the type of medication therapy delivered.

ANS: B Changes in lung function over time help determine whether to continue therapy or to refer eligible patients for lung transplantation.

The most common symptom of pneumothorax that occurs in nearly every patient is: a. shortness of breath. b. chest pain. c. dizziness. d. syncope.

ANS: B Chest pain, which is typically sharp and abrupt, occurs in nearly every patient with pneumothorax.

Which complaint is most closely associated with the diagnosis of chronic bronchitis? a. Airway enlargement b. Chronic productive cough c. Dyspnea on exertion d. Hemoptysis

ANS: B Chronic bronchitis is defined in clinical terms as a condition in which chronic productive cough is present for at least 3 months per year for at least 2 consecutive years.

Types of output control valves used in modern ventilators include which of the following? 1. Pneumatic diaphragm valve 2. Proportional valve 3. Electromagnetic poppet or plunger 4. Linear screw valve a. 1 and 3 only b. 1, 2, and 3 only c. 3 and 4 only d. 2, 3, and 4 only

ANS: B Commonly used output control valves include the pneumatic diaphragm, electromagnetic poppet/plunger valve, and the proportional valve. Descriptions of these devices can be found in respiratory care equipment textbooks.

Compared with a square wave flow pattern, a decelerating flow waveform has which of the following potential benefits? 1. Reduced peak pressure 2. Improved cardiac output 3. Less inspiratory work 4. Decreased volume of dead space-to-tidal volume ratio (VD/VT) a. 1 and 3 only b. 1, 3, and 4 only c. 2 and 4 only d. 2, 3, and 4 only

ANS: B Compared with a square flow waveform, decreasing flow has been shown to reduce peak pressure, inspiratory work, VD/VT, and P(A-a)O2 without affecting hemodynamic values.

What shape of the flow-volume loop is typical for the patient with a fixed upper airway obstruction? a. Circular b. Box c. Elliptical d. Ramp

ANS: B Compared with the normal flow-volume loop, a fixed upper airway obstruction produces a curve that appears box-shaped.

What diagnostic procedure or technique is most sensitive for the identification of pleural effusion? a. Chest radiography b. Computed tomography c. Pleurodesis d. Thoracoscopy

ANS: B Computed tomography of the chest is the most sensitive study for identification of pleural effusion.

What is the most common cause of pleural effusion in the clinical setting? a. Acute renal failure b. Congestive heart failure c. Liver disease d. Lung cancer

ANS: B Congestive heart failure is the most common cause of clinical pleural effusions.

What is the most common cause of low mixed venous oxygen? a. Liver disease b. Cardiac disease c. Neuromuscular disease d. Vascular disease

ANS: B Congestive heart failure with low cardiac output is the most common cause of low mixed venous oxygen, due to increased peripheral extraction of oxygen.

Indications for delivering sigh breaths during mechanical ventilation include which of the following? 1. Before and after suctioning 2. During chest physical therapy 3. In patients with stiff lungs 4. When small VT values are used a. 1 and 3 only b. 1, 2, and 4 only c. 2 and 4 only d. 2, 3, and 4 only

ANS: B Constant, monotonous tidal ventilation at a small volume (<7 ml/kg) may result in progressive atelectasis. Sighs may be used to prevent atelectasis. Atelectasis may be caused before and after suctioning and when using small tidal volumes. CPT is also used when attempting to correct atelectasis.

In which mode does cycle asynchrony most commonly occur? a. Volume ventilation. b. Pressure ventilation. c. CPAP. d. No mode is more susceptible.

ANS: B Cycle asynchrony occurs when the ventilator ends the breath at a time different from when the patients' respiratory center wants to end the breath. It is more common in pressure than volume-targeted ventilation, but it can occur in all modes of ventilation.

By what age do most patients with Duchenne muscular dystrophy die? a. 10 years b. 20 years c. 35 years d. 50 years

ANS: B Death generally occurs by 20 years of age, as a result of complications of declining respiratory muscle strength and subsequent infection.

Which of the following problems is associated with intravenous augmentation of synthetic alpha1-antitrypsin for the patient with genetic emphysema? a. Bronchospasm b. Expense c. Headache d. Nausea

ANS: B Difficulties with intravenous augmentation therapy include the substantial expense (approximately $100,000 per year), the inconvenience of frequent intravenous infusions for life, and the infusion itself, which confers a theoretical risk of transmitting a blood-borne infection.

Disorders of the neuromuscular junction include which of the following? 1. Lambert-Eaton syndrome 2. Myasthenia gravis 3. Dermatomyositis 4. Tetanus, botulism a. 1 and 3 only b. 1, 2, and 4 only c. 3 and 4 only d. 2, 3, and 4 only

ANS: B Disorders of the neuromuscular junction include myasthenia gravis, Lambert-Eaton syndrome, and poisoning (organophosphate, tetanus, and botulism).

Which of the following could be early warning signs that a pneumothorax is enlarging? 1. Desaturation of pulse oximetry reading 2. Development of a fever 3. Increased respiratory rate 4. Mental confusion a. 1, 2, and 3 only b. 1 and 3 only c. 2 and 4 only d. 2, 3, and 4 only

ANS: B During observation, it is important to record the respiratory rate and any signs of deteriorating respiratory function. An oximetry decrease can be an early warning of pneumothorax enlargement. Any deterioration indicates that the pneumothorax must be drained.

Exacerbations of silicosis are most often treated with what medication? a. Aerosolized steroids b. Antibiotics c. Diuretics d. Positive inotropes

ANS: B Exacerbations can be frequent and are treated with antibiotics and systemic corticosteroids.

Which of the following findings are exclusion criteria for using noninvasive ventilation (NIV) in the patient with acute respiratory failure? 1. Apnea 2. Hemodynamic or cardiac instability 3. Low risk of aspiration 4. Lack of cooperation by the patient a. 1 and 3 only b. 1, 2, and 4 only c. 3 and 4 only d. 2, 3, and 4 only

ANS: B Exclusion criteria include apnea, hemodynamic or cardiac instability, lack of cooperation by the patient, facial burns, facial trauma, copious amounts of secretions, high risk of aspiration, and anatomic abnormalities that interfere with gas delivery.

The use of noninvasive ventilation (NIV) in the long-term care of patients with chronic obstructive pulmonary disease (COPD) will benefit the patient in which the following ways? 1. Better gas exchange. 2. Improved sleep quality. 3. Resetting the respiratory center to better respond to hypoxemia. 4. Unloading the respiratory muscles. a. 1 and 3 only b. 1, 2, and 4 only c. 2 and 4 only d. 2, 3, and 4 only

ANS: B First, positive inspiratory pressure may improve gas exchange and unload the respiratory muscles, allowing these muscles to recover, gain strength, and reduce fatigue. These benefits should reduce symptoms associated with hypoventilation and improve quality-of-life. Second, patients with severe COPD have poor sleep quality, shorter sleep time, and nocturnal hypoventilation.

Which of the following can increase the expiratory time constant? 1. Patient circuit compliance 2. Patient circuit resistance 3. Resistance of the exhalation valve 4. Patient endotracheal tube a. 2 and 4 only b. 1, 2, and 3 only c. 1 and 3 only d. 1, 3, and 4 only

ANS: B For both pressure- and volume-control ventilation, the patient circuit compliance and resistance, along with the resistance of the exhalation valve (in series with the patient circuit and respiratory system resistance) increase the expiratory time constant.

What is the normal range for P(A-a)O2 in a healthy 30-year-old person breathing room air? a. 0 to 10 mm Hg b. 5 to 15 mm Hg c. 10 to 20 mm Hg d. Cannot predict

ANS: B For example, a healthy person has a P(A-a)O2 of 5 to 15 mm Hg while breathing room air.

For the optimal PEEP level, what increments is PEEP typically increased? a. 0 cm H2O PEEP b. 2 cm H2O PEEP c. 3 cm H2O PEEP d. 4 cm H2O PEEP

ANS: B For the optimal PEEP level, PEEP is increased in increments of 2 cm H2O.

or the optimal PEEP level, what increments is PEEP typically increased? a. 0 cm H2O PEEP b. 2 cm H2O PEEP c. 3 cm H2O PEEP d. 4 cm H2O PEEP

ANS: B For the optimal PEEP level, PEEP is increased in increments of 2 cm H2O.

Which of the following criteria represents the recommended starting point for considering the use of PEEP? a. PaO2 less than 40 to 50 on FiO2 greater than 0.80 b. PaO2 less than 50 to 60 on FiO2 greater than 0.40 c. PaO2 less than 100 on FiO2 of 1.0 d. PaO2 less than 50 on FiO2 greater than 0.75

ANS: B Generally, the indication for PEEP or CPAP is inadequate arterial O2 with moderate to high concentrations of O2 caused by unstable lung units that are collapsed. PaO2 less than 50 to 60 mm Hg with FiO2 greater than 0.40 is a good general starting place for considering use of PEEP or CPAP. In terms of ventilator initiation, initial PEEP or CPAP levels usually are 5 to 8 cm H2O even in the absence of unstable lung units or auto-PEEP. Most experts advocate for the use of 5 cm H2O PEEP for all patients who have an artificial airway in place.

Which of the following organisms have been found to colonize the oropharynx of healthy individuals and can be aspirated during sleep? a. Coccidioides immitis b. Haemophilus influenzae c. Histoplasma capsulatum d. Mycobacterium

ANS: B Healthy individuals may aspirate periodically, especially during sleep. Aspiration of even a small volume of oropharyngeal secretions, which can be colonized with potential pathogens such as Streptococcus pneumoniae and Haemophilus influenzae, may contribute to development of CAP.

Why should a high frequency oscillator always be plugged into a red outlet at the hospital? a. The high frequency oscillator will not power on if not plugged into the red outlet b. The high frequency oscillator does not have an internal back up battery c. It is required to achieve the high tidal volumes involved d. Airway pressure will not be maintained if not plugged into the red outlet.

ANS: B High frequency oscillators do not have an internal back up battery. In the event of a power failure, the ventilator will power down. Always plug the ventilator into a red outlet. The red outlet will provide back-up generator power during an electrical outage. Portable external batteries may be purchased for use. When a portable external battery is used, plug the high frequency oscillator into the portable battery, then plug the external battery into a red power outlet.

Why was High-frequency ventilation (HFV) initially devised? a. To deliver set tidal volumes b. To minimize the hemodynamic effects of conventional mechanical ventilation c. To deliver set mean airway pressures d. To inexpensively provide a lung protective method to ventilate ARDS patients

ANS: B High-frequency ventilation (HFV) was initially devised as a method to minimize the hemodynamic effects of conventional mechanical ventilation (i.e., the large inflating pressures and volumes).

Ventilatory support strategies likely to result in auto-positive end expiratory pressure (PEEP) include which of the following? 1. Continuous mandatory ventilation (CMV) assist-control 2. Inverse ratio ventilation (IRV) 3. Low-rate intermittent mandatory ventilation 4. Low inspiratory flows a. 1 and 3 only b. 1, 3, and 4 only c. 3 and 4 only d. 2, 3, and 4 only

ANS: B High-risk ventilatory support techniques include any method that increases the I:E ratio, especially CMV at a high rate or in the assist-control mode, and approaches that purposefully shorten expiratory time, such as IRV or the use of low inspiratory flow.

The volume delivered by a pressure-limited ventilator will decrease under which of the following conditions? 1. The patient's lung or thoracic (chest wall) compliance falls. 2. Airway resistance rises (inspiratory time <3 times the time constant). 3. The patient tenses the respiratory muscles during inspiration. 4. Airway resistance rises (inspiratory time >3 times the time constant). a. 1 and 3 only b. 1, 3, and 4 only c. 3 and 4 only d. 2, 3, and 4 only

ANS: B However, if insufficient time is available for pressure equilibration, delivered volume decreases as airway resistance increases.

Which of the following ventilators is generally only used for chronic noninvasive ventilation (NIV)? a. Critical care b. Portable c. Noninvasive d. Negative pressure

ANS: B However, portable volume ventilators are generally used only for chronic NIV.

To ensure a good quality specimen can be obtained for a sputum culture, when should the specimen be obtained? a. It can only be obtained prior to antibiotic initiation b. Before or within 6 to 12 hours of antibiotic initiation c. Before or within 12 to 24 hours of antibiotic initiation d. Before or within 24 to 48 hours of antibiotic initiation

ANS: B However, sputum culture is positive in more than 80% of cases of pneumococcal pneumonia if a good quality specimen can be obtained before or within 6 to 12 hours of antibiotic initiation.

Weaning

What is the primary indication for using SIMV mode?

50 -60mmHg

What is the target CO2 range for a COPD patient?

Which of the following is another term for hydrostatic pulmonary edema? a. ARDS-related pulmonary edema b. Cardiogenic pulmonary edema c. Exudative pulmonary edema d. Fibroproliferative pulmonary edema

ANS: B Hydrostatic pulmonary edema is often also called cardiogenic pulmonary edema, due to its close association with abnormalities in intravascular hydrostatic pressures that cause edema.

What is respiratory failure due to inadequate ventilation? a. Hypoxemic b. Hypercapnic c. Compensated d. Chronic

ANS: B Hypercapnic (type II) respiratory failure describes "bellows failure" of the lungs resulting in elevated carbon dioxide levels.

What is the recommended response to a drop in PaO2 when the PEEP level is reduced in a mechanically ventilated patient? a. Increase the FiO2. b. Return the PEEP to the previous level. c. Increase the rate of mechanical breaths. d. Do nothing.

ANS: B If the PaO2 decreases after PEEP is decreased the PEEP level should be returned to its prior setting.

If a patient initiates a ventilator breath, the trigger variable could be which of the following? 1. Pressure 2. Flow 3. Time 4. Volume a. 1 and 3 only b. 1, 2, and 4 only c. 3 and 4 only d. 2, 3, and 4 only

ANS: B If the patient initiates the breath, pressure, flow, or volume may serve as the trigger variable

If a patient initiates a ventilator breath, the trigger variable could be which of the following? 1. Pressure 2. Flow 3. Time 4. Volume a. 1 and 3 only b. 1, 2, and 4 only c. 3 and 4 only d. 2, 3, and 4 only

ANS: B If the patient initiates the breath, pressure, flow, or volume may serve as the trigger variable.

During a helium (He) dilution functional residual capacity (FRC) measurement, the technologist first bleeds in 500 ml of He (He Vol) and obtains an initial reading of 4.0% (FiHe). After equilibration, the second He reading is 3.2% (FfHe). What is the patient's FRC? a. 4450 ml b. 3125 ml c. 2680 ml d. 3670 ml

ANS: B If the patient is connected to the circuit at the resting level, the FRC can be calculated with the following equation: FRC = (vol He ÷ FiHe) [(FiHe - FfHe) ÷ FfHe].

Which of the following conditions is associated with a lack of response to increased FiO2 in patients receiving positive-pressure ventilation? a. Dead space b. Shunt c. Hypoxemia d. Hypoventilation

ANS: B If the patient is receiving mechanical ventilation and has adequate alveolar ventilation, failure of the PaO2 to respond to increased FiO2 likely means that the hypoxemia is due to diffusion defect or shunt.

After placing a patient on a volume-cycled ventilator in the continuous mandatory ventilation assist-control mode, you note that 55 cm H2O pressure is required to deliver the preset VT of 950 ml. What high-pressure limit would you now set for this patient? a. 60 cm H2O b. 70 cm H2O c. 80 cm H2O d. 90 cm H2O

ANS: B If the plateau pressure is less than 28 cm H2O, the high pressure limit can be adjusted to 10 to 20 cm H2O above the peak inspiratory pressure.

When the therapist is initially setting the high-pressure alarm on the ventilator and the patient's plateau pressure is less than 30 cm H2O, what should the high-pressure alarm be set at? a. 5 to 10 cm H2O above the peak pressure b. 10 to 20 cm H2O above the peak pressure c. 10 to 12 cm H2O above the plateau pressure d. 10 to 15 cm H2O above the mean airway pressure

ANS: B If the plateau pressure is less than 28 cm H2O, the high pressure limit can be adjusted to 10 to 20 cm H2O above the peak inspiratory pressure.

What are the typical pulmonary function test results in a patient with interstitial lung disease? 1. Decreased airway resistance 2. Decreased forced expiratory volumes 3. Increased airway resistance 4. Normal to elevated FEV1/FVC a. 1, 2, and 4 only b. 2 and 4 only c. 1 and 3 only d. 2, 3, and 4 only

ANS: B In ILD, both forced expiratory volume in 1 second (FEV1) and forced vital capacity (FVC) are diminished, while the FEV1/FVC ratio is preserved or even supranormal.

What is the normal range for VD/VT? a. 0.10 to 0.20 b. 0.20 to 0.40 c. 0.30 to 0.50 d. 0.40 to 0.55

ANS: B In healthy persons who are sitting, the VD/VT ratio is 0.20 to 0.40.

What is the treatment of choice for limited-stage small-cell lung cancer? a. Surgical resection b. Chemoradiotherapy c. Radiation therapy only d. Chemotherapy only

ANS: B In limited-stage disease, combination chemotherapy with concurrent hyperfractionated radiotherapy is recommended.

Which of the following would be associated with a fatal outcome in a patient with pneumonia who is mechanically ventilated? a. Heart rate of 110 beats/min b. Multisystem organ failure c. Presence of purulent sputum d. Respiratory alkalosis

ANS: B In mechanically ventilated patients, factors associated with fatal outcome include the following: • Infection with high-risk organisms such as P. aeruginosa, Acinetobacter species, and Stenotrophomonas maltophilia • Multisystem organ failure • Non-surgical diagnosis • Therapy with antacids or H2-receptor antagonists • Transfer from another hospital or ward • Renal failure • Prolonged mechanical ventilation • Coma or shock • Inappropriate antibiotic therapy • Hospitalization in a noncardiac ICU

What underlying lung disease is most often present in a patient with secondary spontaneous pneumothorax? a. Asthma b. Chronic obstructive pulmonary disease (COPD) c. Interstitial pulmonary fibrosis d. Pneumonia

ANS: B In most cases, the underlying lung disease is COPD with some component of emphysema.

In what percentage of patients with pneumonia has no microbial agent been isolated? a. Up to 40% b. Up to 50% c. Up to 60% d. Up to 70%

ANS: B In most published series, no microbiological diagnosis is established in up to 50% of patients.

Which of the following are potential benefits of using noninvasive ventilation (NIV) during weaning? 1. Reduced length of intensive care unit (ICU) stay 2. Reduced incidence of nosocomial pneumonia 3. Reduced mortality rate 4. Reduced incidence of pulmonary embolism a. 1 and 3 only b. 1, 2, and 3 only c. 3 and 4 only d. 2, 3, and 4 only

ANS: B In one study, it was found that NIV reduced weaning time, length of ICU stay, incidence of nosocomial pneumonia, and 60-day mortality compared with conventional weaning with invasive pressure support ventilation.

An intubated patient suspected of having CAP presents with diffuse interstitial infiltrates on chest radiograph. What pathogen should be suspected? a. Chlamydia pneumoniae b. Pneumocystis jiroveci c. Mycoplasma pneumoniae d. Pneumococcal pneumoniae

ANS: B Interstitial infiltrates, especially if diffuse, suggest viral disease, P. jiroveci, or miliary tuberculosis in patients with CAP.

What ventilatory strategy has been found to be useful for avoiding barotrauma in the treatment of patients with ARDS? a. Prolonged expiratory time b. Permissive hypercapnia c. Inverse ratio ventilation d. Intermittent mandatory ventilation

ANS: B In patients with ARDS, it is desirable to maintain lower tidal volumes and thus avoid volutrauma. The goal of reducing tidal volume and controlling ventilatory rate is achieved at the expense of considerable CO2 retention in patients with ARDS. In most cases, the PaCO2 increases from 60 to 80 mm Hg and the arterial pH decreases to approximately 7.25. Subsequent metabolic compensation tends to correct the acidosis over several days. In some cases, the acidosis is more severe but appears to be well tolerated so long as tissue oxygenation is maintained. This ventilatory strategy has been designated "permissive hypercapnia."

Which of the following statements are true about the use of home care ventilators for delivering noninvasive ventilation (NIV)? 1. They operate only with pressure triggering. 2. They can operate on AC or DC power sources. 3. They can have a single-limb ventilator circuit. 4. Flow delivery pattern can be adjusted. a. 1 and 3 only b. 1, 2, and 3 only c. 3 and 4 only d. 2, 3, and 4 only

ANS: B In some, flow delivery is limited to a sine-wave flow pattern.

Strategies to reduce auto-PEEP in mechanically ventilated patients with obstructive lung disease include which of the following? 1. Use high inspiratory flows (60 to 100 L/min). 2. Apply extrinsic PEEP. 3. Use low VT values (8 to 10 ml/kg). 4. Use high respiratory rates (>25/min). a. 1 and 3 only b. 1, 2, and 3 only c. 3 and 4 only d. 2, 3, and 4 only

ANS: B In such patients, lower tidal volumes (6 to 8 ml/kg), moderate respiratory rates, and high inspiratory flow rates (70 to 100 L/min) are recommended to avoid dynamic hyperinflation.

Positive-pressure ventilation (PPV) can reduce urinary output by how much? a. 10% to 20% b. 30% to 50% c. 60% to 70% d. 80% to 90%

ANS: B In terms of direct effect, PPV can reduce urinary output as much as 30% to 50%.

Initiating noninvasive ventilation (NIV) can be done in which of the following settings? 1. Emergency department 2. Intensive care unit 3. Hospital ward 4. Nursing home a. 1 and 3 only b. 1, 2, and 3 only c. 3 and 4 only d. 2, 3, and 4 only

ANS: B In the acute care setting, NIV can be initiated in the emergency department, critical care unit, intermediate care unit, or hospital ward.

How are the effects of auto-PEEP on missed triggering improved in the presence of dynamic airway obstruction? a. Adjustment of the sensitivity setting b. The application of PEEP c. Mode change d. Administration of a bronchodilator

ANS: B In the presence of dynamic airways obstruction, the application of PEEP offsets the effect of auto-PEEP on missed triggering.

A patient is exposed a second time to an antigen and subsequently seeks medical attention with sudden shortness of breath, chest pain, fever, chills, malaise, and a cough that may be productive of purulent sputum. What is the most likely cause of this pathology? a. Acute anaphylactic shock b. Acute hypersensitivity pneumonitis c. Allergic congestive heart failure d. Bronchial asthma

ANS: B Initial exposure to the antigen ramps up the immune system. Subsequent exposure to the antigen results in the hypersensitivity response. Patients with acute hypersensitivity pneumonitis usually present to medical attention with sudden shortness of breath, chest pain, fever, chills, malaise, and a cough that may be productive of purulent sputum.

When a patient is initially started on mechanical ventilation common orders from the physician in the patient's chart include which of the following? 1. FiO2 2. Mode 3. Sensitivity 4. Tidal volume a. 1 and 2 only b. 1, 2, and 4 only c. 3 and 4 only d. 2, 3, and 4 only

ANS: B Initial ventilator settings include choice of mode, tidal volume, rate, FiO2, and PEEP. The respiratory therapist must set the trigger level, inspiratory flow or time, alarms and limits, backup ventilation, and humidification.

Which of the following are likely to cause errors in SpO2 readings? 1. Anemia 2. Deeply pigmented skin 3. Motion due to shivering 4. Significant tachycardia a. 1 and 3 only b. 1, 2, and 3 only c. 2 and 4 only d. 1, 2, 3, and 4

ANS: B Intense daylight and fluorescent, incandescent, xenon, and infrared light sources have caused errors in pulse oximetric readings. Anemia and deeply pigmented skin can affect the accuracy of pulse oximetry; however, the effect of anemia is not clinically significant until the hemoglobin level is markedly reduced.

The short-term application of inspiratory positive pressure to a spontaneously breathing patient best defines which of the following? a. Sustained maximal inspiration b. Intermittent positive-pressure breathing c. Continuous positive airway pressure d. Positive end-expiration pressure

ANS: B Intermittent positive-pressure breathing refers to the application of inspiratory positive pressure to a spontaneously breathing patient as an intermittent or short-term therapeutic modality.

What conclusions can you draw from the following data, obtained on a 32-year-old 53-kg woman admitted for elective surgery? ACTUAL. PRED. %PRED. ACTUAL. PRED. %PRED TLC 4.93 5.27 94%. FVC 3.67 3.86 95% FRC 2.41 2.43 99%. %FEV1 84% 78% RV 1.29 1.35 96%. FEF200-1200 5.66 5.74 99% VC 3.64 3.86 94% FEF25%-75%. 3.53 3.49 101% a. Results indicate a mild restrictive lung disorder. b. Results indicate normal pulmonary function. c. Results indicate a combined disease process. d. Results indicate generalized airway obstruction.

ANS: B Interpretation of the pulmonary function report: Interpretive strategies for pulmonary function testing abound. Most computer-based pulmonary function testing systems have algorithms in their software programs for computer-assisted interpretations of the pulmonary function report. A consensus for interpreting test results is growing. Table 20-8 summarizes pulmonary function changes that may occur in advanced obstructive and restrictive patterns of lung diseases, and Figure 20-16 presents a simple algorithm to assess pulmonary function test results in clinical practice. When considering a pulmonary function report, the %FEV1/VC ratio is a good place to start, because it provides an initial focus as normal, restrictive, or obstructive impairment. When the %FEV1/FVC is less than the limit of normal (LLN), there is airway obstruction. When the %FEV1/FVC is greater than the LLN, there is no airway obstruction. The LLN %FEV1/FVC can be determined directly for various population using regression equations in Table 20-9 or simply estimated at 70%. If the %FEV1/FVC ratio is greater than the LLN or 70% and if the TLC is less than the LLN, often defined as less than 80% predicted normal, the patient has a restrictive impairment, according to this algorithm. The severity of the restriction is based on the percent predicted or on the number of standard deviations below the LLN TLC according to Table 20-2. If the %FEV1/FVC ratio is less than 70%, the patient likely has an obstructive impairment; the severity of the obstruction is based on the percent predicted normal FEV1 according to Table 20-2. If the percent predicted normal DLCO is less than 80%, the patient has a diffusion impairment. Some laboratories also report the DLCO/VA ratio, which indexes the DLCO for lung volume measured during the single breath test. If the DLCO/VA ratio is also less than 80% of the indexed value, the cause of the diffusion impairment is considered within the lung, and if the DLCO/VA ratio is greater than 80% of the indexed value, the cause of the diffusion impairment is considered due to small lung volume.

What is the most effective way to prevent lung cancer? a. Vitamin E b. Beta-carotene c. Smoking prevention d. Avoidance of atmospheric pollution

ANS: C The most effective way to prevent lung cancer is to prevent smoking.

Scleroderma, rheumatoid arthritis, and systemic lupus erythematosus are all examples of what type of disease group? a. Asbestos-associated illnesses b. Connective tissue diseases c. Hypersensitivity pneumonitis d. Pneumoconiosis

ANS: B Interstitial lung disease is a well-known complication of various connective tissue diseases. The most commonly implicated disorders are scleroderma, rheumatoid arthritis, Sjögren's syndrome, polymyositis/dermatomyositis, and systemic lupus erythematosus.

Which bronchodilator is commonly used in the hospital management of acute asthma exacerbation but is not considered the first-line bronchodilator? a. Albuterol b. Ipratropium bromide c. Salmeterol d. Arformoterol

ANS: B Ipratropium also can be used in treating acute asthma when first-line bronchodilators are ineffective.

Ventricular dysfunction occurs in patients receiving positive-pressure ventilation for which of the following reasons? 1. Hypovolemia 2. Excessive tidal volume 3. Receiving more than optimal positive end expiratory pressure (PEEP) 4. Hypervolemia a. 1 and 3 only b. 1, 2, and 3 only c. 3 and 4 only d. 2, 3, and 4 only

ANS: B It appears that right or left ventricular dysfunction occurs if the patient is hypovolemic, receiving an excessive tidal volume, or receiving more than optimum PEEP.

What anatomical position is most likely to show the presence of a small pleural effusion in the upright chest radiograph? a. Apical regions b. Costophrenic angles c. Fissures d. Subdiaphragmatic region

ANS: B It is important that, if possible, the chest radiograph be obtained with the patient in an upright position to show a pleural fluid meniscus at the costophrenic angles.

Which of the following signs and symptoms is most closely associated with respiratory failure in a COPD patient? a. Bilateral wheezing b. Changes in mental status c. Dyspnea on exertion d. Excessive sputum production

ANS: B Late signs of COPD may include use of accessory muscles of respiration (e.g., sternocleidomastoid), edema from cor pulmonale, mental status changes caused by hypoxia or hypercapnia (especially in acute exacerbations of chronic, severe disease), or asterixis (i.e., involuntary flapping of the hands when held in an extended position, as in "stopping traffic").

Which of the following are typically associated with local tumor growth in the central airways? 1. Large airway obstruction 2. Cough 3. Hemoptysis 4. Fine crackles a. 2, 3, and 4 only b. 1, 2, and 3 only c. 3 and 4 only d. 1 and 2 only

ANS: B Local growth in a central location (e.g., in a main stem bronchus) can cause cough, hemoptysis, or features of large-airway obstruction.

What is the number one cause of cancer-related death in the United States? a. Leukemia b. Lung cancer c. Breast cancer d. Brain cancer

ANS: B Lung cancer is the number one cause of cancer-related death in men and women; it surpassed colon cancer in the early 1950s in men and breast cancer in the late 1980s in women. There are more deaths from lung cancer than breast, colon, and prostate cancer combined.

What is the most likely cause of a large unilateral pleural effusion in a 70-year-old patient? a. Congestive heart failure b. Malignancy c. Pneumonia d. Tuberculosis

ANS: B Malignant disease is the most common cause of large unilateral pleural effusions among persons older than 60 years.

Your patient that is receiving mechanical ventilation has a high ventilatory demand. Which of the following is the most appropriate inspiratory time? a. 0.4 sec b. 0.7 sec c. 1.0 sec d. 1.2 sec

ANS: B Many adults with moderate or high ventilatory demands desire an inspiratory time between 0.6 and 0.9 sec.

Which of the following statements are true about negative-pressure ventilation (NPV)? 1. NPV is similar to spontaneous breathing. 2. Airway (mouth) pressure during NPV is zero. 3. Expiration during NPV is by passive recoil. 4. NPV decreases pressure at the body surface. a. 2 and 4 only b. 1, 2, 3, and 4 c. 3 and 4 only d. 1, 3, and 4 only

ANS: B Mechanical NPV is similar to spontaneous breathing. NPV decreases pleural pressure (Ppl) during inspiration by exposing the chest to sub-atmospheric pressure. Negative pressure at the body surface (Pbs) is transmitted first to the pleural space and then to the alveoli (Palv). Because the airway opening remains exposed to atmospheric pressure during NPV, a transairway pressure gradient is created. Thus, gas flows from the relatively high pressure at the airway opening (zero) to the relatively low pressure in the alveoli (negative).

Which of the following modes are commonly seen on noninvasive ventilators? 1. Continuous positive airway pressure (CPAP) 2. Spontaneous (pressure assist) 3. Pressure assist 4. Volume control a. 1 and 3 only b. 1, 2, and 3 only c. 3 and 4 only d. 2, 3, and 4 only

ANS: B Modes on noninvasive ventilators usually include CPAP, pressure support (spontaneous), and pressure assist/control (timed).

What factor primarily determines the effect of positive-pressure ventilation (PPV) on the cardiac output? a. Peak airway pressure b. Mean pleural pressure c. CO2 d. Expiratory time

ANS: B More specifically, the decrease in left ventricular output corresponded to the increase in pleural pressure that occurred with PPV.

Which of the following are characteristics of most noninvasive ventilators? 1. Electrically powered 2. Blower driven 3. Microprocessor controlled 4. Double-circuit design a. 2 and 3 only b. 1, 2, and 3 only c. 2, 3, and 4 only d. 1 and 4 only

ANS: B Most noninvasive ventilators are electrically powered, blower driven, and microprocessor controlled.

What is the life expectancy of a patient diagnosed with progressive idiopathic pulmonary fibrosis? a. Less than 2 years b. Less than 4 years c. Less than 6 years d. Less than 7 years

ANS: B Most patients die of progressive fibrotic lung disease within 4 years of diagnosis.

What auscultatory finding is most consistent with the diagnosis of interstitial lung disease (ILD)? a. Coarse inspiratory and expiratory crackles b. Fine bilateral inspiratory crackles c. Monophonic expiratory wheezes d. Polyphonic expiratory wheezes

ANS: B Most patients with ILD have bilateral inspiratory, fine crackles, which usually are most prominent at the lung bases.

What is the normal range for lung compliance? a. 40 to 60 ml/cm H2O b. 60 to 100 ml/cm H2O c. 80 to 120 ml/cm H2O d. 100 to 120 ml/cm H2O

ANS: B Normal compliance ranges between 60 and 100 ml/cm H2O.

To prevent muscle fatigue or atrophy, the level of PSV should be adjusted to achieve what work load? a. 0 J/L b. 0.6 to 0.9 J/L c. 0 to 0.5 J/L d. Greater than 0.9 J/L

ANS: B Normal work of breathing is 0.6 to 0.9 J/L.

Which of the following is one of the modes of ventilation that may be considered when partial ventilatory support is indicated? a. Assist-control pressure ventilation b. Proportional assist ventilation (PAV) c. Volume-control continuous mandatory ventilation d. Assist-control volume ventilation

ANS: B Normally, when partial ventilatory support is indicated, IMV, PSV, volume support, PAV, and NAVA are the modes of choice.

A patient presents with Blastomyces dermatitis. What geographic region are they likely from? a. Central river valleys b. Upper Midwest c. Desert Southwest d. Arabian peninsula

ANS: B Occasionally outbreaks of less common pathogens occur, both locally and globally; when this happens, these pathogens must be considered among patients presenting with CAP. For instance, atypical pneumonias due to endemic fungi such as Histoplasma capsulatum (central river valleys), Blastomyces dermatiditis (upper Midwest), and Coccidioides immitis (desert Southwest) are occasionally seen in the appropriate geographic settings. Middle East respiratory syndrome (MERS) has arisen as a global health concern. First described in Saudi Arabia in 2012, this coronavirus is found within the Arabian peninsula and causes a severe respiratory illness with a 30% mortality rate.

Respiratory muscle weakness is associated with which of the following abnormalities? 1. Pulmonary embolism 2. Ventilatory insufficiency 3. Hypoxemia 4. Atelectasis a. 4 only b. 2, 3, and 4 only c. 1 and 3 only d. 1, 3, and 4 only

ANS: B Of the many neuromuscular problems causing pulmonary dysfunction, respiratory muscle weakness that leads to atelectasis, hypoxemia, and ventilatory insufficiency is among the best recognized.

Which of the following are common purposes for staging a case of lung cancer? 1. Selection of therapy 2. Assessment of extent of the disease 3. Prognosis 4. Etiology a. 2, 3, and 4 only b. 1, 2, and 4 only c. 3 and 4 only d. 1 and 2 only

ANS: B One of the major factors that determines the prognosis of lung cancer and guides the proper selection of treatment is the extent to which the cancer has spread in the lungs and throughout the body.

Which of the following is the primary reason that patients poorly interact with the ventilator? a. Mode of mechanical ventilation selected b. Change in their clinical status c. FiO2 setting d. PEEP setting

ANS: B One of the primary reasons that patients poorly interact with the mechanical ventilator is a change in their clinical status. Excessive secretions, bronchospasm, and agitation are the most common and regularly seen causes of poor patient-ventilator interaction and issues that should be assessed at every patient-ventilator assessment.

Your patient has a P(A-a)O2 of 200 mm Hg while breathing 100% O2. What is the estimated percentage shunt? a. 5% b. 10% c. 20% d. 30%

ANS: B P(A-a)O2 increases to 100 to 150 mm Hg when the person is breathing 100% O2.

What hemodynamic parameter is best useful for estimated left ventricular end-diastolic pressure? a. CVP b. PCWP c. SVR d. PVR

ANS: B PCWP is an estimate of left atrial pressure, which reflects left ventricular end-diastolic pressure.

In which of the following conditions is PEEP likely to be useful? 1. ARDS 2. Pulmonary edema 3. Acute lung injury 4. Neuromuscular disease a. 1 and 3 only b. 1, 2, and 3 only c. 3 and 4 only d. 2, 3, and 4 only

ANS: B PEEP and continuous positive airway pressure are effective techniques for improving and maintaining lung volume and improving oxygenation for patients with acute restrictive disease such as acute lung injury, pneumonia, pulmonary edema, and ARDS. A PaO2 less than 50 to 60 mm Hg with an FiO2 greater than 0.40 is a good general starting place for considering use of PEEP or continuous positive airway pressure.

Contraindications for using positive end expiratory pressure (PEEP) in conjunction with mechanical ventilation include which of the following? 1. Untreated bronchopleural fistula 2. Chronic airway obstruction 3. Untreated pneumothorax a. 1 and 2 only b. 1 and 3 only c. 2 and 3 only d. 1, 2, and 3

ANS: B PEEP is contraindicated in the presence of an unmanaged bronchopleural fistula or pneumothorax.

Primary indications for using positive end expiratory pressure (PEEP) in conjunction with mechanical ventilation include which of the following? 1. When dynamic hyperinflation occurs in chronic obstructive pulmonary disease (COPD) patients. 2. When the imposed work of breathing is excessive. 3. When acute lung injury causes refractory hypoxemia. a. 1 and 2 only b. 1 and 3 only c. 2 and 3 only d. 1, 2, and 3

ANS: B PEEP is used primarily to improve oxygenation in patients with refractory hypoxemia. PEEP may be indicated in the care of patients with COPD who have dynamic hyperinflation (auto-PEEP) during mechanical ventilatory support after other efforts to decrease auto-PEEP fail.

In myasthenia gravis, which two pulmonary function values are the most sensitive in detecting respiratory muscle weakness? 1. TLC and VC 2. PImax and PEmax 3. VC and expired volume per unit time (VE) 4. VC and tidal volume (VT) a. 1 and 4 only b. 1 and 2 only c. 3 and 4 only d. 2 and 3 only

ANS: B PImax and PEmax are more sensitive markers of early respiratory muscle weakness.

Which of the following represents a clinical situation where partial ventilatory support is commonly used? a. Patient with head trauma b. During weaning from continuous mandatory ventilation c. While ventilating an asthmatic d. In a drug overdose case

ANS: B Partial ventilatory support techniques may be especially useful for weaning patients from mechanical ventilatory support, and pressure-supported ventilation (PSV) and synchronized intermittent mandatory ventilation have been used as partial support strategies for weaning.

Which of the following means starting inspiratory flow based on a signal (usually time) from the ventilator? a. Patient-triggering b. Machine-triggering c. Patient-cycling d. Machine-cycling

ANS: B Patient-triggering means starting inspiration based on a signal from the patient, which is independent of a machine trigger signal. Machine-triggering means starting inspiratory flow based on a signal (usually time) from the ventilator, which is independent of a patient trigger signal. Patient-cycling means ending inspiratory time based on signals representing the patient-determined components of the equation of motion (i.e., elastance or resistance) and including effects due to inspiratory effort. Flow-cycling is a form of patient-cycling because the rate of flow decay to the cycle threshold, and hence the inspiratory time, is determined by patient mechanics. Machine-cycling means ending inspiratory time independent of signals representing the patient-determined components of the equation of motion.

Partial Mode of ventilation

What is the weaning mode of ventilation?

Which of the following means starting inspiratory flow based on a signal (usually time) from the ventilator? a. Patient-triggering b. Machine-triggering c. Patient-cycling d. Machine-cycling`

ANS: B Patient-triggering means starting inspiration based on a signal from the patient, which is independent of a machine trigger signal. Machine-triggering means starting inspiratory flow based on a signal (usually time) from the ventilator, which is independent of a patient trigger signal. Patient-cycling means ending inspiratory time based on signals representing the patient-determined components of the equation of motion (i.e., elastance or resistance) and including effects due to inspiratory effort. Flow-cycling is a form of patient-cycling because the rate of flow decay to the cycle threshold, and hence the inspiratory time, is determined by patient mechanics. Machine-cycling means ending inspiratory time independent of signals representing the patient-determined components of the equation of motion.

What patients are at greatest risk for auto-PEEP? 1. Those supported by spontaneous breath modes 2. Those with high airway resistance 3. Those with high expiratory flow resistance a. 1 and 2 only b. 2 and 3 only c. 1 and 3 only d. 1, 2, and 3

ANS: B Patients at greatest risk of development of auto-PEEP are those with high airway resistance who are being supported by modes that limit expiratory time.

A patient with interstitial lung disease who presents with hypoxemia due to diffusion defect would have which of the following clinical signs? 1. Fine bibasilar crackles 2. Clubbing of the finger nail beds 3. Jugular venous distention 4. Thrombocytopenia a. 1 and 2 only b. 1, 2, and 3 only c. 3 and 4 only d. 2, 3, and 4 only

ANS: B Patients may have clubbing of the nail beds. Rheumatologic manifestations may be present if the underlying cause is a connective tissue disorder. Joint abnormalities, Reynaud disease, and telangiectasia (a vascular lesion formed by dilatation of a group of small blood vessels) may be observed. The pallor of anemia can be a clue to poor gas exchange, although chronic hypoxemia may lead to polycythemia and possibly cyanosis. Pulmonary hypertension may present with signs of right heart failure such as edema, jugular vein distension, and a louder pulmonary component of the second heart sound.

Which of the following factors are associated with an increased risk for auto-PEEP? 1. Mechanical ventilation of a patient with obstructive lung disease 2. High-minute volume during mechanical ventilation 3. Acute respiratory distress syndrome (ARDS) patients 4. Pulmonary fibrosis a. 1 and 2 only b. 1, 2, and 3 only c. 3 and 4 only d. 2, 3, and 4 only

ANS: B Patients receiving mechanical ventilation for obstructive airways disease have a large degree of inhomogeneity in the emptying of lung units, and auto-PEEP can develop even at relatively low-minute ventilation. Auto-PEEP is common in mechanically ventilated patients with high-minute ventilation and thus occurs in some patients with ARDS.

Air trapping is a major concern in patients with what diagnosis when using the assist-control mode? a. Pneumonia b. Chronic obstructive pulmonary disease (COPD) c. Chest trauma d. Neuromuscular disease

ANS: B Patients with COPD are at special risk of air trapping in the assist-control mode, especially if they attempt to breathe at an increased rate.

Which of the following are indications that a patient with Guillain-Barré syndrome is at risk for respiratory failure and may need ventilatory support? 1. VC becomes less than 20 ml/kg 2. PEmax is less than 40 cm H2O 3. PImax less than 30 cm H2O 4. Cardiac output above 2.0 L/min a. 1 and 3 only b. 1, 2, and 3 only c. 3 and 4 only d. 1, 2, 3, and 4

ANS: B Patients with GBS whose vital capacity becomes less than 20 ml/kg or whose PImax is less than 30 cm H2O and PEmax is less than 40 cm H2O are at risk for respiratory failure and may need ventilatory support. Patients who meet the criteria of this "20-30-40 rule" are at high risk of decompensating, and intubation should be considered, especially if weakness is still progressing or if there is difficulty managing oral secretions.

Which of the following groups of patients with nocturnal hypoventilation respond to noninvasive ventilation (NIV)? a. Hypoxic b. Hypercapnic c. Acidotic d. Hypocapnic

ANS: B Patients with hypercapnic and nocturnal desaturation may be most likely to benefit from nocturnal NIV.

A patient with nephritic syndrome is noted to have a large right-sided pleural effusion and a small to medium-sized left-sided pleural effusion. What would explain this finding? a. The nephrosis is complicated by CHF. b. The nephrosis is complicated by pulmonary emboli. c. This is a common finding in patients with nephrosis. d. This just a complicated case of nephrosis.

ANS: B Patients with nephrosis are at increased risk of deep venous thrombosis and pulmonary emboli. In nephrosis, protein S, which keeps blood from clotting, becomes deficient from leaking into the urine. Therefore, the presence of large or asymmetric pleural effusions should raise the possibility of the presence of pulmonary emboli. Pleural effusions associated with pulmonary emboli usually are exudates and contain large numbers of red blood cells.

Patients with respiratory muscle weakness due to neuromuscular disease may initially report with which of the following symptoms? 1. Exertional dyspnea 2. Fatigue 3. Oliguria 4. Orthopnea a. 1 and 3 only b. 1, 2, and 4 only c. 3 and 4 only d. 2 and 4 only

ANS: B Patients with respiratory muscle weakness due to neuromuscular disease may initially report exertional dyspnea, fatigue, orthopnea, or symptoms of cor pulmonale.

Which of the following strategies is useful in the mechanical ventilation of a patient in status asthmaticus? 1. Allow peak inspiratory pressures to go as high as required. 2. Permissive hypercapnia. 3. Prolonged inspiratory time. 4. Small tidal volumes. a. 1, 2, and 3 only b. 2 and 4 only c. 3 only d. 2, 3, and 4 only

ANS: B Patients with severe asthma and respiratory failure (hypoxia, hypercapnia, and increased work of breathing) need ventilatory support and present special challenges. Mortality rates for these patients can be as high as 22%, and complications are common, especially barotrauma. These complications can be minimized by limiting peak inspiratory pressure to less than 50 cm H2O and by the use of small tidal volumes, allowing "permissive hypercapnia" if necessary.

Under which of the following conditions would you postpone a diffusing capacity test? 1. Just before the test, the patient smoked two cigarettes. 2. Just before the test, the patient had an episode of severe coughing. 3. Just before the test, the patient had a long wait at a busy bus stop. a. 1 only b. 1 and 3 only c. 2 and 3 only d. 1, 2, and 3

ANS: B Performing the diffusing capacity on patients who have recently smoked a cigarette or who have been exposed to environmental carbon monoxide may hinder test validity.

- Any FULL support mode - A/C - CMV

What mode can not be used with pressure support?

What are some physiological advantages of volume-assured pressure-supported ventilation? 1. Improved patient-ventilator synchrony 2. Increased pressure-time product 3. Decreased work of breathing a. 1 and 2 only b. 1 and 3 only c. 2 and 3 only d. 1, 2, and 3

ANS: B Physiological effects of volume-assured pressure-supported ventilation include improved patient-ventilator synchrony and reduced pressure-time product, which is an indicator of decreased work of breathing.

After starting volume-cycled mechanical ventilation on a patient in respiratory failure with a VT of 10 ml/kg, you measure and obtain a plateau pressure of 45 cm H2O. Which of the following actions would you recommend to the patient's physician? a. Decrease the inspiratory flow. b. Lower the delivered VT. c. Administer a bronchodilator. d. Add PEEP.

ANS: B Plateau pressure (Pplat) during mechanical ventilation reflects alveolar pressure, the best bedside clinical reflection of transalveolar pressure. Generally, the lowest possible Pplat is maintained by selecting a VT of 4 to 8 ml/kg of ideal body weight (IBW). The higher the Pplat, the smaller the VT should be. Generally, a VT greater than 10 ml/kg IBW is never indicated in critically ill patients.

If accurate sizing on a pneumothorax is desired, what diagnostic technique would be most appropriate? a. Chest radiography b. Computed tomography c. PET scan d. Ultrasonography

ANS: B Pneumothoraces are most accurately sized by the use of chest CT.

Physical assessment indicating the presence of a tension pneumothorax includes which of the following? 1. Unequal chest excursion 2. Hyperresonance upon chest percussion 3. Absent breath sounds 4. Loud breath sounds a. 1 and 3 only b. 1, 2, and 3 only c. 3 and 4 only d. 2, 3, and 4 only

ANS: B Pneumothorax is identified by observation of a decrease in chest movement, hyperresonance on percussion, and decreased or absent breath sounds over the affected side.

Which of the following are potential effects of positive-pressure ventilation on the cardiovascular system? 1. Decreased venous return 2. Decreased cranial perfusion pressures 3. Increased pulmonary blood flow 4. Decreased ventricular stroke volume a. 2 and 4 only b. 1 and 4 only c. 1, 3 and 4 only d. 2, 3, and 4 only

ANS: B Positive pleural pressure compresses the intrathoracic veins and increases central venous and right atrial filling pressures. As these pressures increase, venous return to the heart is impeded and right ventricular preload and stroke volume decrease, as does pulmonary blood flow.

Which of the following lead to an increased end-tidal PCO2? 1. Decreased effective ventilation 2. Increased metabolic rate 3. Decreased minute ventilation 4. Exercise a. 1 and 3 only b. 1, 2, and 3 only c. 3 and 4 only d. 2, 3, and 4 only

ANS: B Positive pressure ventilation (especially with PEEP), pulmonary embolism, cardiac arrest, and pulmonary hypoperfusion also may cause an increase in PaCO2 to PETCO2 gradient [P(a-ET)CO2]. Exercise and a large tidal volume can reverse the P(a-ET)CO2 gradient, the PETCO2 can actually exceed the PaCO2.

Lung expansion methods that increase the transpulmonary pressure gradients by increasing alveolar pressure include which of the following? 1. Incentive spirometry (IS) 2. Positive end-expiration pressure therapy 3. Intermittent positive-pressure breathing (IPPB) 4. Expiratory positive airway pressure (EPAP) a. 1 and 2 only b. 2, 3, and 4 only c. 1 and 3 only d. 1, 2, and 3 only

ANS: B Positive-pressure lung expansion therapies may apply pressure during inspiration only (as in IPPB), during expiration only (as in positive expiratory pressure [PEP] and EPAP), or during both inspiration and expiration (CPAP).

Which of the following are primary goals of mechanical ventilation? 1. Adequate alveolar ventilation (VA) 2. Maintaining adequate hemoglobin levels 3. Restoring acid-base balance 4. Maintaining adequate alveolar oxygenation a. 1 and 3 only b. 1, 3, and 4 only c. 2 and 4 only d. 2, 3, and 4 only

ANS: B Primary goals of mechanical ventilation are: adequate alveolar ventilation (VA), maintaining tissue oxygenation, FiO2, PEEP, and MAP, restoring acid-base balance, reducing WOB and myocardial work, providing PEEP/CPAP to recruit lung, lung protective strategy: Small VT and appropriate PEEP levels and maintaining Pplat less than 30 cm H2O.

In what age group is a primary spontaneous pneumothorax most commonly seen? a. Under 15 years b. 18 to 25 years c. 35 to 45 years d. Over 60 years

ANS: B Primary spontaneous pneumothorax usually occurs in patients in their late teenage years or early 20s.

What complication often occurs following rapid lung reexpansion due to the evacuation of air or fluid from the pleural space? a. Arrhythmias b. Pulmonary edema c. Pulmonary emboli d. Systemic hypotension

ANS: B Reexpansion pulmonary edema occurs in a lung that has been rapidly reinflated from low lung volumes, particularly when the pneumothorax has been longstanding or when the pressure gradient across the lung has become high, as might occur when there is endobronchial obstruction from cancer, mucus, or blood.

Which of the following groups of patients are considered at risk for reintubation? 1. History of previous weaning failures 2. Patients older than 45 years 3. Patients with congestive heart failure (CHF) 4. Patients with COPD a. 1 and 3 only b. 1, 3, and 4 only c. 2 and 4 only d. 2, 3, and 4 only

ANS: B Reintubation has been associated with increased mortality, longer hospital stay, and a greater need for long-term care than in patients who are initially successfully extubated. In recent studies, randomly assigned patients at risk for reintubation to NIV or standard care showed lower reintubation rates with NIV. Patients with hypercapnia gained the most benefit from NIV. Risk factors associated with extubation failure include a diagnosis of COPD or congestive heart failure, age >65 years, ineffective cough and excessive secretions, upper airway obstruction, history of previous weaning failures, and the presence of comorbid conditions.

Which of the following restrictive thoracic diseases are successfully managed with noninvasive ventilation (NIV)? 1. Postpolio syndrome 2. Neuromuscular disease 3. Spinal cord injuries 4. Severe kyphoscoliosis a. 1, 2, and 4 only b. 1, 2, 3, and 4 c. 2 and 4 only d. 2, 3, and 4 only

ANS: B Restrictive thoracic diseases successfully managed with NIV include postpolio syndrome, neuromuscular diseases, chest wall deformities, spinal cord injuries, and severe kyphoscoliosis.

Which of the following would you initially verify in assessing the airway of a patient placed on ventilatory support? 1. Cuff pressure 2. Tube position 3. Tube patency a. 1 and 2 only b. 1, 2, and 3 c. 1 and 3 only d. 2 and 3 only

ANS: B The artificial airway should be assessed for proper placement, patency, and cuff inflation. Size, position, and depth of the endotracheal tube and cuff pressure, including volume used to inflate the cuff, should be recorded.

Which of the following mechanisms explains the impaired renal function seen in patients receiving ventilatory support with positive pressure? 1. Decreased secretion of aldosterone 2. Decreased intravascular volume 3. Increased secretion of vasopressin a. 1 only b. 2 only c. 1 and 3 only d. 1, 2, and 3

ANS: B Results of more recent analysis tend to refute this explanation, instead showing that impaired renal function during positive-pressure ventilation is better associated with a decrease in intravascular volume.

Which of the following are common causes of volume overload in patients with hydrostatic pulmonary edema? 1. Renal failure 2. Hepatic failure 3. Hypoalbuminemia 4. Hyperkalemia a. 1 and 3 only b. 1, 2, and 3 only c. 3 and 4 only d. 2, 3, and 4 only

ANS: B See Box 29-1.

Mean airway pressures can be increased by which of the following factors? 1. Increasing the inspiratory time 2. Increasing compliance 3. Increasing level of PEEP 4. Changing from a square to a decelerating ramp waveform a. 1, 2, and 3 only b. 1, 3, and 4 only c. 2 and 4 only d. 1, 2, 3, and 4

ANS: B See Box 47-1.

Possible ways to correct flow asynchrony in volume ventilation include which of the following? 1. Change to decelerating flow. 2. Increase peak flow to be greater than 60 L/min. 3. Match ventilator's inspiratory time to the patient's inspiratory time. 4. Decrease peak flow to be less than 60 L/min. a. 1 and 3 only b. 1, 2, and 3 only c. 3 and 4 only d. 1, 3, and 4 only

ANS: B See Box 48-2.

Which of the following can cause trigger delay? 1. Auto-PEEP 2. Poor sensitivity setting 3. Water in the circuit 4. Ventilator malfunction a. 3 only b. 1, 2, and 4 only c. 2 and 3 only d. 1, 2, 3, and 4

ANS: B See Box 48-5.

Which of the following are associated with an increase in central venous pressure? 1. Right heart failure 2. Pulmonary valvular stenosis 3. Pulmonary embolism 4. Dehydration a. 1 and 3 only b. 1, 2, and 3 only c. 2 and 4 only d. 1, 2, 3, and 4

ANS: B See Box 52-11.

Which of the following are causes of increased airway resistance? 1. Small endotracheal tube 2. High gas flow 3. Increased secretions 4. Frequent suctioning a. 1 and 3 only b. 1, 2, and 3 only c. 3 and 4 only d. 2, 3, and 4 only

ANS: B See Box 52-7.

Which of the following is the most common type of lung cancer? a. Large cell b. Adenocarcinoma c. Squamous cell d. Small cell

ANS: B See Table 32-1.

Common bedside measures used to assess the adequacy of lung expansion include which of the following? 1. VC 2. Respiratory rate 3. VT 4. VD/VT a. 1 and 3 only b. 1, 2, and 3 only c. 3 and 4 only d. 2, 3, and 4 only

ANS: B See Table 45-3.

Which of the following indicate severely impaired oxygenation requiring high FiO2s and positive end expiratory pressure? 1. PaO2-PaO2 greater than 350 mm Hg on 100% O2 2. VC less than 10 ml/kg 3. PaO2/FiO2 less than 200 4. PaCO2 greater than 45 mm Hg a. 1 and 4 only b. 1 and 3 only c. 2 and 3 only d. 1, 2, and 4 only

ANS: B See Table 45-3.

Detrimental effects of positive end expiratory pressure (PEEP) include which of the following? 1. Increased incidence of barotrauma 2. Decreased venous return or cardiac output 3. Increased pulmonary vascular resistance 4. Increased CL a. 1 and 3 only b. 1, 2, and 3 only c. 3 and 4 only d. 2, 3, and 4 only

ANS: B See Table 47-2.

A physician orders intubation and mechanical ventilation in the continuous mandatory ventilation assist-control mode for a 125-lb adult woman with normal lungs. Which of the following initial settings would you recommend? a. Rate: 10 breaths/min; VT: 550 ml b. Rate: 14 breaths/min; VT: 400 ml c. Rate: 18 breaths/min; VT: 450 ml d. Rate: 12 breaths/min; VT: 470 ml

ANS: B See Table 49-4.

A physician orders intubation and mechanical ventilation in the continuous mandatory ventilation mode for a 200-lb predicted body weight (PBW) adult man with acute asthma exacerbation. Which of the following initial ventilator settings would you recommend? a. Rate: 12 breaths/min; VT: 550 ml b. Rate: 11 breaths/min; VT: 450 ml c. Rate: 14 breaths/min; VT: 770 ml d. Rate: 20 breaths/min; VT: 550 ml

ANS: B See Table 49-4.

Which of the following techniques are useful to avoid claustrophobia in the patient being ventilated by face mask? 1. Allow patient to hold the mask. 2. Increase the inspiratory flow. 3. Use sedation. 4. Use a larger mask. a. 1 and 3 only b. 1, 2, and 3 only c. 3 and 4 only d. 2, 3, and 4 only

ANS: B See Table 50-2.

What is the normal range for cardiac output? a. 2 to 4 L/min b. 4 to 8 L/min c. 5 to 10 L/min d. Depends on patient age

ANS: B See Table 52-1.

Which of the following clinical signs is most often associated with hypoxemia due to shunt? a. Diffuse wheezing b. "White" chest radiograph c. Stridor d. Loud P2

ANS: B Shunt usually presents with a "white" chest radiograph.

Which of the following is least likely to indicate the need for noninvasive ventilation (NIV) in the acute care setting? a. Paradoxical breathing b. Jugular venous distention c. Respiratory rate more than 25/min d. Use of accessory muscles

ANS: B Signs and symptoms of respiratory distress include use of accessory muscles, paradoxical breathing, a respiratory rate of 25 breaths/min or greater, and the presence of moderate to severe dyspnea. See Box 50-3.

What type of lung cancer usually is seen as a central lesion that may obstruct airways and lead to atelectasis? a. Adenocarcinoma b. Squamous cell c. Large cell d. Bronchogenic carcinoma

ANS: B Squamous cell carcinoma and small-cell carcinoma are more likely to grow in a central location than other cell types.

If available, the FiO2 alarm should be set to what percentage? a. 3% b. 5% c. 8% d. 10%

ANS: B Suggested initial settings for these alarms and backup ventilator settings are described in Table 49-6.

What limits should be initially set for high and low VT values and/or minute volume alarms on a ventilatory support device? a. 5% to 10% b. 10% to 15% c. 15% to 20% d. 20% to 25%

ANS: B Suggested initial settings for these alarms and backup ventilator settings are described in Table 49-6.

How much pleural fluid does a normal healthy adult have in each hemithorax? a. 5 ml b. 8 ml c. 12 ml d. 16 ml

ANS: B The average person has approximately 8 ml of pleural fluid per hemithorax.

22. In which of the following modes inspiration ends when flow decays to some preset value? a. Intermittent mandatory ventilation b. Pressure support ventilation c. Continuous mandatory ventilation d. Airway pressure release ventilation

ANS: B Suppose that the peak inspiratory flow was 100 L/min. If the flow cycle threshold is set at 25% of peak flow, then inspiration would be cycled off when flow dropped below 25 L/min. Suppose further that this resulted in an inspiratory time of 1 second. Now, if the cycle threshold was raised to 50%, inspiration would end at 50 L/min and the inspiratory time would be shorter. This is an example of patient cycling that occurs with a mode of ventilation called Pressure Support. Pressure Support delivers pressure-controlled breaths to spontaneously breathing patients.

In which of the following modes inspiration ends when flow decays to some preset value? a. Intermittent mandatory ventilation b. Pressure support ventilation c. Continuous mandatory ventilation d. Airway pressure release ventilation

ANS: B Suppose that the peak inspiratory flow was 100 L/min. If the flow cycle threshold is set at 25% of peak flow, then inspiration would be cycled off when flow dropped below 25 L/min. Suppose further that this resulted in an inspiratory time of 1 second. Now, if the cycle threshold was raised to 50%, inspiration would end at 50 L/min and the inspiratory time would be shorter. This is an example of patient cycling that occurs with a mode of ventilation called Pressure Support. Pressure Support delivers pressure-controlled breaths to spontaneously breathing patients.

What treatment is the best initial modality for patients with non-small-cell lung cancer because it offers the best prospect of long-term survival? a. Chemotherapy b. Surgical resection c. Radiation therapy d. Endobronchial laser therapy

ANS: B Surgical resection offers the best chance of cure for early-stage non-small-cell lung cancer (stages I and II).

Which of the following represents an example of atypical community-acquired pneumonia? a. Haemophilus influenzae b. Legionella pneumophila c. Staphylococcus aureus d. Streptococcus pneumoniae

ANS: B Table 24-1 lists the classification and possible causes of pneumonia.

Rapidly spreading multilobar consolidation is typical for what type of pneumonia? a. Klebsiella b. Legionella c. Pneumocystis jiroveci d. Viral

ANS: B Table 24-3 lists the radiographic patterns produced by pathogens in CAP.

In order to determine the presence of pneumonia, what diagnostic procedure might be done by a respiratory therapist? a. Bronchial biopsy b. Noninvasive sampling of expectorated sputum and tracheal aspirate c. Protected specimen brush d. Transthoracic ultrathin needle aspiration

ANS: B The 2016 IDSA/ATS VAP and HAP guidelines recommend noninvasive sampling (i.e., expectorated sputum and tracheal aspirate) with semiquantiative cultures over other methods, when possible. This recommendation is based on evidence that suggest that outcomes are similar regardless of how specimens are obtained and how microbial growth is quantified. Noninvasive sampling can be completed more quickly, with fewer complications and resources.

In which of the following conditions will you see an increase in the DLCO? a. Pulmonary emphysema b. Secondary polycythemia c. Severe anemia d. Pulmonary fibrosis

ANS: B The DLCO may be increased in patients with polycythemia, congestive heart failure (resulting from an increase in pulmonary vascular blood volume), and elevated cardiac output. Factors that can alter the DLCO above or below the normal value are summarized in Table 20-4.

Which of the following parameters are used in calculating the Murray lung injury score of a patient with acute lung injury? 1. Results of chest radiograph 2. PEEP setting 3. Lung compliance 4. Cardiac output a. 1 and 3 only b. 1, 2, and 3 only c. 3 and 4 only d. 2, 3, and 4 only

ANS: B The Murray lung injury score quantifies the injury level using four factors: chest radiographic findings, PaO2/FiO2 ratio, positive end-expiratory pressure (PEEP) setting, and compliance. See Box 52-3.

According to the National Asthma Education Project guidelines, what should be considered if the patient with asthma requires more than 3 or 4 puffs of beta-2 agonists per day? a. Add or increase the dose of anticholinergic. b. Add or increase the dose of antiinflammatory. c. Add or increase the dose of magnesium sulfite. d. Increase dose of beta-2 agonists.

ANS: B The National Asthma Education Project guidelines recommend that inhaled beta-2 agonists be used as needed. If a patient needs more than 3 or 4 puffs a day of a beta-2 agonist, additional antiinflammatory therapy should be considered.

What is the normal P(A-a)O2 range while breathing room air? a. 25 to 50 mm Hg b. 10 to 25 mm Hg c. Greater than 25 mm Hg d. Less than 10 mm Hg

ANS: B The P(A-a)O2 ranges from 10 mm Hg in young patients to approximately 25 mm Hg in the elderly while breathing room air.

Which of the following is used to determine the point at which recruitment of alveolar units begins? a. UIP b. LIP c. P/F ratio d. V/P

ANS: B The P/V curve also demonstrates a lower inflection point (LIP, point at which the lower limb shifts to the middle limb) and an upper inflection point (UIP), point at which the middle limb shifts to the upper limb). The LIP represents the point at which recruitment (i.e., opening) of alveolar units begins, and typically also the point below which alveolar units close (i.e. collapse or atelectasis) if airway pressure at end expiration drops below.

What causes the residual volume (RV) and functional residual capacity (FRC) to increase? a. Atelectasis b. Chronic obstructive lung disease c. Pneumonia d. Pneumothorax

ANS: B The RV and FRC are usually enlarged in acute and chronic obstructive lung diseases because of hyperinflation and air trapping.

How closely a device measures a certain reference value refers to what quality? a. Capacity b. Accuracy c. Linearity d. Precision

ANS: B The accuracy of a measuring instrument is how well it measures a known reference value.

What is the typical high PEEP pressure range that should be targeted when using APRV in patients with ARDS? a. 20 to 25 cm H2O b. 25 to 30 cm H2O c. 30 to 35 cm H2O d. 35 to 40 cm H2O

ANS: B The aim of APRV is to increase the mean airway pressure for alveolar recruitment while allowing the patient to spontaneously breathe. This mode generally features two levels of PEEP: a high PEEP (~25 to 30 cm H2O for 5 to 6 seconds), and a low PEEP (~0 to 5 cm H2O for 0.5 to 1 second).

Which of the following organs are commonly compromised in metastatic lung cancer? a. Brain b. Liver c. Bone d. Stomach a. 2, 3, and 4 only b. 1, 2, and 3 only c. 3 and 4 only d. 1 and 2 only

ANS: B The brain, bones, liver, and adrenal glands are most commonly involved.

What is the most common radiographic finding in the chest film of a patient with sarcoidosis? a. Bibasilar parenchymal opacities b. Bilateral hilar lymphadenopathy c. Pleural plaque with calcification d. Upper-lobe distribution of fibrotic cysts

ANS: B The most common manifestation of sarcoidosis is asymptomatic hilar adenopathy. Less frequently, the chest radiograph demonstrates parenchymal opacities in the mid-lung zone, which may be nodular, reticulonodular, or alveolar.

Which of the following is the most important advantage of noninvasive ventilators over other types of ventilators? a. Cost b. Ability to trigger and cycle appropriately when small-to-moderate air leaks are present c. Ability to remove CO2 d. Ability to oxygenate

ANS: B The most important advantage of noninvasive ventilators over other types of ventilators is the ability to trigger and cycle appropriately when small- to moderate-size air leaks are present.

Which of the following are major histopathologic types of lung cancer? 1. Adenocarcinoma 2. Squamous cell carcinoma 3. Small-cell carcinoma 4. Ciliated cell carcinoma a. 2, 3, and 4 only b. 1, 2, and 3 only c. 3 and 4 only d. 1 and 2 only

ANS: B The non-small-cell cancer category consists of adenocarcinoma (including bronchoalveolar cell carcinoma), squamous cell carcinoma, large-cell carcinoma, and variants.

What is the normal predicted vital capacity (VC) measurement in the adult patient? a. 3600 ml b. 4800 ml c. 5400 ml d. 6000 ml

ANS: B The normal value of the VC is 4.80 L and represents approximately 80% of the total lung capacity.

What is the only therapy shown to prolong life in patients with end-stage, particularly fibrotic interstitial lung disease (ILD)? a. Corticosteroids b. Lung transplantation c. Oxygen therapy d. Pulmonary rehabilitation

ANS: B The only therapy shown to prolong life in patients with end-stage, particularly fibrotic ILD, is lung transplantation.

Why is it important to know about the patient circuit as it relates to the function of the ventilator? a. Because it needs to be changed when dirty. b. Because its own compliance and resistance. c. Because it changes the arterial blood gas interpretation. d. Because it effects mode choice.

ANS: B The patient interface is the connection between the ventilator and the patient—typically a system of plastic hoses, and often called the patient circuit. From the perspective of understanding how ventilators work, the important thing to know about the patient circuit is that it contributes to discrepancies between the desired and actual ventilator output values. This is because the patient circuit has its own compliance and resistance.

Which of the following peripheral nerve disorders can cause respiratory muscle dysfunction? a. Inflammatory processes b. Vascular disorders c. Metabolic imbalances d. Fluid imbalances a. 1 and 3 only b. 1, 2, and 3 only c. 3 and 4 only d. 2, 3, and 4 only

ANS: B The peripheral nerves may be affected by toxic agents, inflammatory processes, vascular disorders, malignant diseases, and metabolic or nutritional imbalances.

What is the predicted normal forced vital capacity (FVC) for the average 20-year-old man? a. 4.5 L b. 5.6 L c. 6.2 L d. 7.0 L

ANS: B The predicted normal FVC for a 20-year-old, 180-cm man approaches 5.60 L.

What is the primary role of NIV in the palliative care setting? a. Reduce cost of care b. Relief of dyspnea c. Normalize CO2 d. Normalize O2

ANS: B The primary goal of NIV is relief of dyspnea in this setting. The goals for patients with do-not-intubate (DNI) orders are to reverse the ARF and restore health. If NIV fails to achieve those goals, it can still be used to reduce dyspnea along with other palliative measures such as sedative and anti-anxiety medications and O2 therapy.

Which of the following are considered common pulmonary consequence of neuromuscular disease? 1. Sleep apnea 2. Aspiration 3. Cor pulmonale 4. Pneumothorax a. 2 and 4 only b. 1, 2, and 3 only c. 1 and 3 only d. 1, 3, and 4 only`

ANS: B The pulmonary consequences of neuromuscular disease can include the following: hyperventilation or hypoventilation, sleep apnea, aspiration, atelectasis with resulting hypoxemia, pulmonary hypertension, and cor pulmonale.

Which of the following clinical features is often common to both ARDS and congestive heart failure (CHF)? a. BALF is proteinaceous and inflammatory. b. Diffuse alveolar and interstitial infiltrates in chest radiograph. c. Pleural effusions on chest radiograph. d. Recent history of trauma.

ANS: B The pulmonary manifestations of ARDS and CHF are summarized in Box 29-2.

What radiographic technique has the ability to better define the specific parenchymal characteristics associated with specific types of interstitial lung disease? a. Bronchograms b. High-resolution CT c. MRI d. Scans

ANS: B The ready availability of high-resolution CT (HRCT) has highlighted significant radiographic differences between diseases that have similar plain chest radiographic patterns.

The respiratory manifestations of spinal cord injury depend on: a. the type of injury b. the level of injury and extent of damage c. the time it took to repair the injury d. the patient's past medical history

ANS: B The respiratory manifestations of spinal cord injury depend on the level of injury and extent of damage. Cervical cord injuries can be functionally divided into two classes: high cervical cord lesions (C1-2) and middle to low cervical cord lesions (C3-8). The diaphragm receives innervation from nerve roots exiting the spinal cord at levels C3-5. Complete injury above this level results in total respiratory muscle paralysis and death, unless urgent intubation and ventilation are performed. Injury to the cord at C3-5 can severely reduce respiratory strength, as manifested by reductions in PEmax, PImax, FVC, and FEV1, consistent with a restrictive ventilatory defect.

Which of the following are specific clinical objectives of ventilatory support? 1. To reverse hypoxemia 2. To prevent or reverse atelectasis 3. To prevent sedation and neuromuscular blockade 4. To reverse acute respiratory acidosis a. 1 and 3 only b. 1, 2, and 4 only c. 2 and 4 only d. 2, 3, and 4 only

ANS: B The specific clinical objectives of ventilatory support are listed in Box 49-2.

Toward the end of a nitrogen washout test for functional residual capacity, the expired concentration of N2 begins rising. What does this probably indicate? a. The patient is trying too hard. b. There is a leak in the system. c. The test is nearing completion. d. N2 is being trapped in the lungs.

ANS: B The test must occur in a leak proof circuit because the presence of any air increases the measured nitrogen percentages and results in grossly elevated measurements of lung volume.

Which of the following should be considered first if medical and mechanical problems have been excluded and the patient continues to fight the ventilator or exhibit high levels of agitation or distress? a. Paralytics b. Sedatives c. Narcotics d. Anesthetics

ANS: B The use of sedation in the ICU is often necessary when invasive mechanical ventilation is used, but its use should be guided by the needs of the patients, and getting patients awake and extubated should be a daily assessment for readiness. If medical and mechanical problems have been excluded and the patient continues to fight the ventilator or exhibit high levels of agitation or distress, sedation should be considered.

During mechanical ventilation, what variable causes a breath to end? a. Limit b. Cycle c. Trigger d. Baseline

ANS: B The variable causing a breath to end is the cycle variable.

Which of the following are a required ventilator alarm for noninvasive ventilation (NIV)? 1. Loss of power 2. Circuit disconnect 3. Battery failure 4. Blender alarm a. 1 and 3 only b. 1, 2, and 3 only c. 3 and 4 only d. 2, 3, and 4 only

ANS: B The ventilator must have alarms for circuit disconnect, loss of power, and battery failure if a battery is present.

What is the most common lung volume measured during spirometry? a. Tidal volume b. Vital capacity c. Total lung capacity d. Expiratory reserve volume

ANS: B The vital capacity is the most commonly measured lung volume.

Which of the following are true statements regarding the volume of tissue nitrogen excreted during the N2 washout test for measuring functional residual capacity (FRC)? 1. It is not a factor. 2. It varies with the length of the test. 3. It varies with the weight of the patient. 4. It cannot be correct. a. 1 and 4 only b. 2 and 3 only c. 2, 3, and 4 only d. 4 only

ANS: B The volume of tissue nitrogen excreted (Vtis in milliliters) is directly related to the duration (t in minutes) of the test and weight (W in kilograms) of the patient. A correction for this extra nitrogen should be made according to the following formula:

What time line has been established to initiate antibiotic treatment in patients with pneumonia who are admitted to the hospital that will result in improved survival? a. 2 hr or less b. 4 hr or less c. 6 hr or less d. 8 hr or less

ANS: B Therapy initiated within 4 hr of hospital admission has been associated with improved survival.

Which of the following techniques are used to measure residual volume? 1. Helium dilution 2. Body plethysmography 3. Nitrogen washout 4. Flow-volume loops a. 2 and 4 only b. 1, 2, and 3 only c. 1, 2, 3, and 4 d. 1, 3, and 4 only

ANS: B There are three indirect techniques to measure residual volume and FRC. They are helium dilution, nitrogen washout, and body plethysmography.

Which of the following are global monitoring indexes? 1. APACHE 2. APS 3. TISS 4. ATS a. 1 and 3 only b. 1, 2, and 3 only c. 2 and 4 only d. 1, 2, 3, and 4

ANS: B These indices (Acute Physiology and Chronic Health Evaluation [APACHE 1, 2, 3 and 4], Acute Physiology Score [APS], Therapeutic Intervention Scoring System [TISS], and Burns Weaning Assessment Program [BWAP]) are determinations of scores from a number of monitored values obtained from snapshots of the patient's condition, usually during the first 24 hr after hospital admission.

Which of the following patients are at greatest risk for developing auto-PEEP during mechanical ventilation? a. Those with acute lung injury b. Those with COPD c. Those with congestive heart failure d. Those with bilateral pneumonia

ANS: B These patients frequently have problems with elevated airway pressure or dynamic hyperinflation (auto-PEEP), which can cause barotrauma and increased dyssynchrony between the patient and the ventilator.

Which level of positive end-expiratory pressure (PEEP) is necessary to prevent rebreathing of carbon dioxide? a. 1 to 3 cm H2O b. 3 to 5 cm H2O c. 5 to 7 cm H2O d. 7 to 9 cm H2O

ANS: B These reports suggest the use of 3 to 5 cm H2O PEEP or the use of a nonrebreathing valve to prevent rebreathing of carbon dioxide.

Primary drive mechanisms used by modern ventilators include which of the following? 1. Compressed gas 2. Hydraulic or fluidic compressor 3. Electrical motor a. 1 and 2 only b. 1 and 3 only c. 2 and 3 only d. 1, 2, and 3

ANS: B They all require energy in the form of either electricity or compressed gas to function. The energy is transmitted or transformed (by the ventilator's drive mechanism) in a predetermined manner (by the control circuit) to augment or replace the patient's muscles in performing the work of breathing (the desired output).

Patient's RR is 12 breaths/min, PaCO2 is 60 mm Hg. If a PaCO2 of 40 were desired, the RR be set at what value? a. 18 b. 23 c. 35 d. 40

ANS: B This formula predicts what RR adjustment effects will be on PaCO2, with no change in VCO2 or VDphys: PaCO2(1) f(1) (Initial) = PaCO2(2) f(2) (Desired) 60 · 12 = 40 f(2) (Initial) = Adjust rate to 18 breaths/min (Desired)

What phrase is used to describe the situation where the patient with acute lung injury is ventilated with a smaller tidal volume and the PaCO2 is allowed to increase above normal range to avoid additional lung injury? a. Physiologic ventilation b. Permissive hypercapnia c. Adjusted ventilation d. Dialed acidosis

ANS: B This technique is known as permissive hypercapnia.

Which of the following explains the basis for permissive hypercapnia as a ventilator strategy for ARDS? a. Introduction of CO2 into the breathing circuit to stimulate spontaneous breaths. b. Use of lower tidal volumes and accepting a gradual rise in PCO2 to avoid associated hazards of high Paw. c. Allow patients with ARDS to breathe spontaneously to build their respiratory muscular endurance. d. To use exhaled CO2 to increase residual volume and improve gas exchange.

ANS: B Thus, in managing patients with ARDS, the clinician must resist the urge to correct the PaCO2 value to normal. Instead, in the absence of a contraindication to hypercapnia (e.g., elevated intracranial pressure), we allow hypercapnia ("permissive hypercapnia") with a goal to maintain the arterial pH at no less than 7.15 to 7.20. Even when PaCO2 rises to a point during which pH may become dangerously low (e.g., pH <7.15), the absolute need to keep the VT at 6 ml/kg PBW remains.

A ventilator has separate rate and minute ventilation controls. A physician orders continuous mandatory ventilation with a VT of 550 ml at a respiratory rate of 12/min. What minute ventilation would you set on this ventilator? a. 5500 ml/min (7.9 L/min) b. 6600 ml/min (8.6 L/min) c. 7400 ml/min (9.4 L/min) d. 8400 ml/min (11.4 L/min)

ANS: B Tidal volume (VT) and rate (f) determine minute ventilation.

What range is now recommended for tidal volumes (VT) in a patient with ARDS who is being mechanically ventilated? a. 4 to 8 ml/kg b. 6 to 10 ml/kg c. 8 to 10 ml/kg d. 10 to 12 ml/kg

ANS: B Tidal volume (VT) in mechanical ventilation should be kept within a safe range to prevent lung injury. The size of VT most recommended is 6 (4 to 8) ml/kg of PBW (not actual body weight).

What is the recommended range for the tidal volume for the initial ventilator settings in the volume control mode in a patient with normal lungs? a. 4 to 6 ml/kg b. 6 to 8 ml/kg c. 10 to 12 ml/kg d. 12 to 15 ml/kg

ANS: B Tidal volume of 6 to 8 ml/kg of ideal body weight.

Your patient is being ventilated with a common critical care ventilator using pressure support ventilation (flow cycled) with a nasal mask. A leak is present that is preventing the appropriate termination of the inspiratory cycle. What is the best response? a. Switch to volume control mode. b. Switch to time-cycled mode. c. Switch to nasal pillows. d. Switch to full-face mask.

ANS: B Time-cycled (instead of flow-cycled), pressure-limited ventilation in the presence of air leaks markedly improves patient-ventilator synchrony and patient comfort.

Which of the following parameters are major factors in determining tissue oxygenation? 1. Arterial oxygenation 2. Tissue perfusion 3. Oxygen (O2) uptake 4. P/F ratio a. 1 and 3 only b. 1, 2, and 3 only c. 3 and 4 only d. 2, 3, and 4 only

ANS: B Tissue oxygenation depends on inspired oxygen levels (FiO2), inspired partial pressure of oxygen (PIO2), alveolar oxygen tension (PAO2), arterial oxygenation (PaO2, SaO2, oxygen content of arterial blood [CaO2]), oxygen delivery (DO2), tissue perfusion, and O2 uptake.

Which of the following pulmonary function tests are frequently used to determine tolerance to resectional surgery? 1. FEV1 2. FEF25% to 75% 3. FVC 4. DLCO a. 1 only b. 1 and 4 only G R A D E S L A B . C O M c. 2 and 4 only d. 2, 3, and 4 only

ANS: B To determine if an individual will tolerate lung resection surgery, reports of activity tolerance and pulmonary function testing are used. Although no one pulmonary function study or absolute cutoff has proven ideal, the FEV1 and diffusing capacity for carbon monoxide (DLCO) are the most frequently used measures.

Which of the following provides clinicians with measured or calculated date related to ventilatory support over time? a. Waveforms b. Trends c. Compliance d. Minute ventilation

ANS: B Trends provide clinicians with measured or calculated data related to ventilatory support over time.

What method(s) is/are used to measure O2 consumption? 1. Fick method 2. Analysis of inspired and expired gases 3. V/Q scans a. 1 only b. 1 and 2 only c. 1 and 3 only d. 1, 2, and 3

ANS: B Two primary methods are in general use: the Fick method and analysis of inspired and expired gases.

Which of the following bedside assessment of respiratory muscle strength is commonly used on ventilated patients? a. Tidal volume b. Maximal inspiratory pressure c. Minute ventilation d. Respiratory rate

ANS: B Two values commonly used for bedside assessment of respiratory muscle strength are vital capacity (VC) and maximal inspiratory pressure (MIP).

If an HIV-infected patient has an adverse reaction to the treatment of choice for Pneumocystis jiroveci pneumonia, what treatment should be instituted? a. Amphotericin B b. Pentamidine c. Trimethoprim-sulfamethoxazole d. Vancomycin

ANS: B Up to 50% of HIV-infected patients will develop fever or a rash while taking TMP-SMX. Pentamidine is an acceptable alternative. See Table 24-9.

Which of the following best describes the difference between V/Q mismatch and shunt when supplemental oxygen is administered? a. Both will respond equally well. b. V/Q mismatch will respond well but shunt will not. c. V/Q mismatch will not respond but shunt will respond well. d. Neither will respond to the administration of supplemental oxygen.

ANS: B V/Q mismatch will respond to supplemental oxygen.

Which of the following are common purposes of using ventilator graphics? 1. To detect auto-PEEP 2. To assess effects of bronchodilators 3. To determine patient ventilator synchrony 4. To determine best FiO2 a. 1 and 3 only b. 1, 2, and 3 only c. 3 and 4 only d. 2, 3, and 4 only

ANS: B Ventilator graphics clearly show many important patient-ventilator interactions, such as presence of auto-PEEP, elevated airway pressure, presence of secretions, and the general pattern and dependability of supported ventilation.

A dehydrated, feverish patient suffering from acute bacterial pneumonia is being intubated in order to provide mechanical ventilatory support. Which of the following devices would you select to control humidification and airway temperature for this patient? a. Unheated large-volume wick humidifier b. Heated wick humidifier with servo-control c. Large-reservoir, high-output heated jet nebulizer d. Heat-moisture exchanger

ANS: B We prefer an optimal humidity approach and use of a heated humidifier to deliver gas in the range of 35 to 37 C at the airway.

A patient suffering from postoperative complications has been receiving mechanical ventilation for 6 days with a volume ventilator. A heat-moisture exchanger (HME) is providing control over humidification and airway temperature. Over the past 24 hr, the patient's secretions have decreased in quantity but are thicker and more purulent. Which of the following actions would you suggest at this time? a. Replace the HME. b. Switch over to a heated wick humidifier. c. Administer acetylcysteine every 2 hr via the nebulizer. d. Increase the frequency of suctioning.

ANS: B We prefer an optimal humidity approach and use of a heated humidifier to deliver gas in the range of 35 to 37 C at the airway.

What is the American Thoracic Society standard for volumetric accuracy of spirometers? a. 1% error, or within 10 ml of the reference value b. 3% error, or within 50 ml of the reference value c. 5% error, or within 100 ml of the reference value d. 10% error, or within 500 ml of the reference value

ANS: B When measuring the vital capacity, forced vital capacity, and forced expiratory volumes, a volume-measuring spirometer should have a capacity of at least 8 L and should measure volumes with less than a 3% error or within 50 ml of a reference value, whichever is greater.

Potential effects of hyperventilation on the central nervous system include which of the following? 1. Increased O2 consumption 2. Increased cerebral vascular resistance (CVR) 3. Increased intracranial pressure (ICP) a. 1 and 2 only b. 2 and 3 only c. 1 and 3 only d. 1, 2, and 3

ANS: B When mechanical hyperventilation is used, CVR increases, and the result is decreased ICP.

Which of the following breathing patterns suggests respiratory muscle decompensation? a. Rapid and deep breaths b. Rapid and shallow breaths c. Slow and shallow breaths d. Slow and deep breaths

ANS: B When muscular strength is limited, patients tend to meet minute ventilation (E) requirements by increasing frequency (f) while decreasing tidal volume (VT).

You perform a series of pulmonary function tests on a patient with a potentially infectious disease carried via the airborne route. Which of the following infection-control procedures should you implement? 1. Wear a respirator or close-fitting surgical mask. 2. Dispose of, sterilize, or disinfect the tubing circuit after testing. 3. Clean the interior surface of the spirometer before the next test. a. 1 only b. 1 and 2 only c. 2 and 3 only d. 1, 2, and 3

ANS: B When performing procedures on patients with potentially infectious airborne diseases, practitioners should wear a personal respirator or a close-fitting surgical mask, especially if the testing induces coughing. Practitioners should always wash their hands between testing patients and after contact with testing equipment. Although it is unnecessary to routinely clean the interior surfaces of the testing instruments between patients, the mouthpiece, nose clips, tubing, and any parts of the instrument that come into direct contact with a patient should be disposed, sterilized, or disinfected between patients.

A 45-year-old patient diagnosed with pneumonia has received appropriate antibiotic therapy. Radiographic resolution is most often seen within what time period? a. 1 week b. 1 month c. 6 months d. 1 year

ANS: B Within 1 month, radiographic resolution occurs in 90% of individuals younger than the age of 50 years.

Which of the following statements is false regarding pressure-supported ventilation? a. It is patient triggered, pressure limited, and flow cycled. b. It can reduce the work of breathing during intermittent mandatory ventilation mode. c. The usual range is 10 to 15 cm H2O. d. It is recommended for use in most patients in the intermittent mandatory ventilation (IMV) mode.

ANS: C

What happens to the P(A-a)O2 with mismatch and shunt? a. It increases with V/Q mismatch and decreases with shunt. b. It decreases with both V/Q mismatch and shunt. c. It increases with both V/Q mismatch and shunt. d. It does not change.

ANS: C A V/Q mismatch and shunt both result in elevated P(A-a)O2 levels.

What is the best parameter to measure when trying to assess respiratory muscle endurance? a. FVC b. MIP c. MVV d. NIF

ANS: C A measure used to assess respiratory muscle reserve, endurance, or fatigue is MVV.

A patient is admitted to the emergency department with an acute asthma exacerbation. Based on the following blood gas results, how severe was the asthma attack? pH 7.35, PaO2 58 mm Hg, PaCO2 46 mm Hg, HCO3 - 18 mEq/L, SaO2 89% a. Mild b. Moderate c. Severe d. Normalized

ANS: C A patient suffering an acute asthma attack usually has a low PaCO2 level as a result of hyperventilation. A normal PaCO2 level in such a situation indicates a severe attack and impending respiratory failure.

During volume-controlled continuous mandatory ventilation, should either compliance decrease or airway resistance (Raw) increase, what will happen? a. The peak airway pressure will decrease. b. The inspiratory flow will increase. c. The peak airway pressure will increase. d. The inspiratory time will decrease.

ANS: C A reduction in lung compliance or an increase in resistance causes higher peak airway pressures.

The disease seen in interstitial lung disease is primarily a/an _____ process. a. airway constrictive b. obstructive c. restrictive d. supralaryngeal

ANS: C A restrictive physiologic impairment is the common finding in ILD.

Which of the following is required for noninvasive ventilators to work properly? a. Exhalation valve b. Pressure alarm c. Leak d. Blender

ANS: C A small leak is required in the circuit or patient interface for these ventilators to work properly.

During mechanical ventilation, a spontaneous breath is defined as one that: a. initiated and terminated by the machine. b. begun by the patient and ended by the machine. c. initiated and terminated by the patient. d. begun by the machine and ended by the patient.

ANS: C A spontaneous breath is a breath for which the patient decides the start time and the tidal volume. That is, the patient both triggers and cycles the breath.

What flow pattern is least optimal for ventilating a patient with cardiovascular instability? a. Accelerating flow pattern b. Square flow pattern c. Decelerating flow pattern d. Constant flow pattern

ANS: C A square or even accelerating waveform may be useful in reducing mean airway pressure in patients with severe hypotension or cardiovascular instability.

What is the hallmark finding of diaphragm paralysis? a. Rapid and shallow breathing b. Weak cough c. Abdominal paradox d. Retractions

ANS: C Abdominal paradox (inward movement of the abdomen while the thorax expands) is the hallmark of significant bilateral diaphragmatic weakness.

What percentage of patient with Guillain-Barré syndrome will develop respiratory muscle weakness requiring intubation? a. 0% b. About 10% c. About 30 % d. About 50%

ANS: C About 30% of patients with GBS will develop respiratory muscle weakness significant enough to require intubation and mechanical ventilation

To what should all spirometric values obtained under ambient conditions be converted? a. Ambient temperature and pressure, saturated (ATPS) b. Standard temperature and pressure, dry (STPD) c. Body temperature, ambient pressure, saturated (BTPS) d. Ambient temperature and pressure, dry (ATPD)

ANS: C All lung volumes and capacities must be reported under BTPS conditions.

When evaluating a forced vital capacity maneuver postbronchodilator use to determine the reversibility of any airway obstruction, what percent increase in FEV1 is needed to be able to say the treatment was effective? a. 5% b. 10% c. 15% d. 20%

ANS: C Although improvements in other measurements of pulmonary function are sometimes used, reversibility is defined as a 15% or greater improvement in FEV1.

What is the leading risk factor for the development of COPD? a. Air pollution b. Alpha1-antitrypsin deficiency c. Cigarette smoking d. Secondhand smoke

ANS: C Although many risk factors exist for COPD, the two most common are cigarette smoking (which has been estimated to account for 80% to 90% of all COPD-related deaths) and alpha1-antitrypsin deficiency.

Pleural effusions that occur secondarily to _____ are most often treated with pleurodesis. a. ascites b. congestive heart failure c. malignancy d. nephrotic syndrome

ANS: C Although pleurodesis of benign effusions, such as those occurring with CHF, nephrotic syndrome, and idiopathic chylothorax, have been performed successfully, the procedure is discouraged for pleural effusions that are not malignant.

A patient switched from pressure-controlled continuous mandatory ventilation (CMV) with positive end expiratory pressure (PEEP) to pressure-controlled inverse ratio ventilation (PC-IRV) shows a good improvement in PaO2 but a decrease in tissue oxygenation. Which of the following best explains this observation? a. High mean pressures caused by PC-IRV decreased pulmonary blood flow. b. Intrinsic PEEP caused by PC-IRV resulted in increased alveolar recruitment. c. High mean pressures caused by PC-IRV decreased cardiac output. d. Intrinsic PEEP caused by PC-IRV compressed the pulmonary capillaries.

ANS: C Although some studies have shown improvement in oxygenation with PC-IRV versus CMV with PEEP, others have shown concurrent decreases in cardiac output.

What treatment is most useful in preventing subsequent right-sided heart failure in a patient with interstitial lung disease? a. Bronchodilator b. Digoxin c. Oxygen d. Caffeine

ANS: C Although studies are limited, supplemental oxygen delivered via nasal cannula can prevent resting hypoxemia and allow greater exertion before desaturation. These benefits may improve quality-of-life and potentially ward off development of pulmonary arterial hypertension, although further studies are needed.

Which level of plateau pressure increases the likelihood of causing lung injury? a. Greater than 15 cm H2O b. Greater than 25 cm H2O c. Greater than 28 cm H2O d. Greater than 32 cm H2O

ANS: C Alveolar pressures of 28 cm H2O or greater have an increased likelihood of causing lung injury.

What is the minimum objective standard for the volume exhaled during the final 1 sec of an acceptable forced vital capacity effort? a. 0.10 L b. 0.05 L c. 0.025 L d. 0.001 L

ANS: C An end-expiratory plateau must be obvious in the volume-time curve; the objective standard is less than 0.025 L exhaled during the final second of exhalation.

For what reason do patients with interstitial lung disease most commonly seek medical care? a. Excessive mucus production b. Hacking cough resulting in chest cage pain c. Progressive exertional dyspnea d. Severe wheezing and sense of breathlessness

ANS: C An exertional breathlessness (dyspnea) and a nonproductive cough are the most common reasons patients seek medical attention.

After setting up a patient on a ventilatory support device, which of the following supplementary equipment would you require to be available at the bedside? 1. Suction source and catheters 2. Backup artificial airway 3. Manual resuscitator with O2 a. 2 and 3 only b. 1 and 2 only c. 1, 2, and 3 d. 1 and 3 only

ANS: C An extra endotracheal tube or tracheostomy tube of the correct size should be placed at the patient's bedside, and the equipment needed to replace the airway must be available and easily accessible. A clean, functioning manual resuscitator with O2 supply and suction equipment, including an appropriate supply of suction catheters, sterile water or saline solution, and sterile gloves also must be placed near the bedside.

What parameter is best used to assess left ventricular afterload? a. CVP b. PCWP c. SVR d. PVR

ANS: C An increase in systemic vascular resistance increases left ventricular afterload.

.Which of the following statements is false regarding the use of an inspiratory pause during mechanical ventilation of a COPD patient? a. It may be used for estimating plateau pressure. b. It may be useful when obtaining a chest radiograph. c. It has been shown to increase effectiveness of bronchodilator therapy. d. It will increase mean airway pressure.

ANS: C An inspiratory pause is rarely used for therapeutic purposes; it is normally used for estimating the plateau pressure. In addition to inspiratory time or flow, most ventilators have an option for setting an inspiratory pause or hold in the volume-control mode. From as assessment standpoint, an inspiratory pause may be sued. However, from the therapeutic perspective, a brief inspiratory pause (up to 10%) was been recommended in the past for improving the distribution of the inspired air and PaO2.Use of an inspiratory pause has been suggested for administration of bronchodilators to improve medication delivery. An inspiratory pause can also be used for diagnostic or assessment purposes to either determine plateau pressure or to ensure a full inspiration before a chest radiograph is obtained. However, in COPD patients, an inspiratory pause did not result in significant improvement in bronchodilator effectiveness.

What is considered to be the single best indicator of effective ventilation? a. PaO2 b. SaO2 c. PaCO2 d. pH

ANS: C Arterial PaCO2 is considered the single best index of effective ventilation.

In which of the following patients is positive end expiratory pressure (PEEP) most indicated? a. FiO2: 0.3; PaO2: 80 mm Hg b. FiO2: 0.5; PaO2: 80 mm Hg c. FiO2: 0.3; PaO2: 50 mm Hg d. FiO2: 0.5; PaO2: 50 mm Hg

ANS: C As a rule, refractory hypoxemia exists when a patient's PaO2 cannot be maintained above 50 to 60 mm Hg with an FiO2 of 0.40 to 0.50 or more.

Which of the following parameters is important in determining the optimal level of positive end expiratory pressure (PEEP) in a patient with ARDS? a. PaO2 b. SaO2 c. DO2 d. CaO2

ANS: C As with increasing PEEP, improvements in arterial oxygenation attendant to reducing PCWP must be weighed against reduced cardiac output, as reflected by the measured DO2 or other measures of systemic tissue oxygenation.

Which of the following are typically found in a patient with COPD? 1. Airway inflammation 2. Partially reversible airway obstruction 3. Progressive airway obstruction 4. Restrictive disease a. 2 and 3 only b. 1 and 4 only c. 1, 2, and 3 only d. 2, 3, and 4 only

ANS: C Chronic obstructive pulmonary disease is a common, preventable, and treatable disease characterized by persistent respiratory symptoms and airflow limitation that is due to airway and/or alveolar abnormalities, usually caused by significant exposure to noxious particles or gases. The chronic airflow limitation that is characteristic of COPD us caused by a mixture of small airways disease (e.g., obstructive bronchiolitis) and parenchymal destruction (emphysema), the relative contributions of which vary from person to person.

What is the normal average inspiratory capacity (IC)? a. 1200 ml b. 2400 ml c. 3600 ml d. 4800 ml

ANS: C The normal IC is approximately 3600 ml, with a significant variation in the normal population.

Which of the following statements are true about the incidence of asthma? 1. The prevalence has increased over the past 20 years in the United States. 2. The mortality has decreased over the past 20 years in the United States. 3. Researchers have determined the causes of asthma and are working on a vaccine. 4. Diagnosis of asthma is done in a physician's office following a physical exam. a. 1 and 3 only b. 1, 2 and 3 only c. 1 and 2 only d. 1, 2, and 4 only

ANS: C Asthma is a chronic illness that has been increasing in prevalence in the United States since 1980. The number of people with asthma in the United States grew from 20 million in 2001 to 25 million in 2010 (8% of the U.S. population). According to data from the National Health Interview Survey performed by the Centers for Disease Control and Prevention in 2016, 20.4 million adults and 6.1 million children (8.3% of American children) reported having asthma. Asthma accounted for 1.7 million emergency room visits in 2015. Asthma also accounted for 11 million outpatient visits in 2014, and approximately 3500 deaths in 2016. An analysis from 1999 to 2016 showed that asthma mortality significantly decreased, which was felt to be due to an improvement in asthma management and prevention measures. The diagnosis of asthma requires a two-pronged approach of clinical assessment supported by laboratory evaluation

At what level of intracranial pressure will venous drainage be impeded and cerebral edema develop in uninjured tissue? a. 10 to 15 mm Hg b. 20 to 30 mm Hg c. 30 to 35 mm Hg d. 40 to 45 mm Hg

ANS: C At intracranial pressure levels of 30 to 35 mm Hg, venous drainage is impeded and edema develops in uninjured tissue.

In which of the following clinical situations is the incidence of auto-PEEP the greatest? 1. Patients that are sedated on mechanical ventilation. 2. Intubated patients with COPD. 3. Intubated patients with asthma. a. 1 and 2 only b. 1 and 3 only c. 2 and 3 only d. 1, 2, and 3

ANS: C Auto-PEEP is a problem in patients with obstructive lung disease (COPD, asthma).

What pulmonary function test presents the highest risk for fainting? a. Slow vital capacity b. Tidal volume per minute c. Maximum voluntary ventilation d. Total lung capacity

ANS: C Because of the potential for acute hyperventilation and fainting or coughing during maximum voluntary ventilation testing, the patient should be seated.

Which of the following is the current recommendation for adding humidity while using noninvasive ventilation (NIV)? a. It is never recommended. b. It is recommended for short-term application (<1 day). c. It is recommended for long-term application (>1 day). d. It is always recommended.

ANS: C Because the upper airway is not bypassed during NIV, the current recommendation is no humidity for short-term applications (<1 day).

A 35-year-old man is admitted to the hospital and has been confirmed to have pneumococcal pneumonia. What test would it be wise to order at this time? a. Bronchial biopsy b. CBC and electrolytes c. HIV d. Sputum culture and sensitivity

ANS: C Both pneumococcal and H. influenzae pneumonia occur with higher frequency in HIV-infected individuals than in the general population. Occasionally, an HIV-infected patient has his or her first contact with the health care system as a result of one of these infections. New guidelines recommend that all average-risk individuals ages 15 to 65 undergo testing for HIV once in their lives and persons at higher risk for HIV infection undergo more frequent testing.

Which of the following is an advantage of Pressure Control Ventilation? a. Higher mean airway pressure can decrease venous return. b. VT varies depending on lung compliance, resistance, and patient effort. c. Improved gas distribution allows for lower VT. d. If VT or minute ventilation alarms are not set properly, alveolar hypoventilation and acidosis may not be detected.

ANS: C Box 49-5 summarizes the Advantages and Disadvantages of Pressure Control Ventilation.

Bronchiectasis characterized by progressive, distal enlargement of the airways, resulting in sac-like dilatations is classified as a. cylindrical bronchiectasis. b. varicose bronchiectasis. c. cystic bronchiectasis. d. obstructive bronchiectasis.

ANS: C Bronchiectasis refers to the abnormal, irreversible dilation of the bronchi caused by destructive and inflammatory changes in the airway walls. Bronchiectasis has the following three major anatomic patterns 1. Cylindrical bronchiectasis: Airway wall is regularly and uniformly dilated 2. Varicose bronchiectasis: Irregular pattern, with alternating areas of constriction and dilation 3. Cystic bronchiectasis: Progressive, distal enlargement of the airways, resulting in saclike dilations

Which of the following pathologies is the most common cause of pleural effusions in clinical practice? a. Hepatic disease b. Acute renal failure c. Congestive heart failure d. Cor pulmonale

ANS: C CHF is the most common cause of pleural effusions in clinical practice. The effusions can be massive, filling the entire hemithorax and compressing the lung. More commonly, they are small and bilateral.

Currently, where does COPD rank among the leading causes of death in the United States? a. First b. Second c. Third d. Fourth

ANS: C COPD is currently the third leading cause of death in the United States.

Which of the following noninvasive ventilation (NIV) settings are adequate for a patient with cardiogenic pulmonary edema? a. CPAP at 10 to 15 cm H2O with 100% oxygen b. CPAP at 10 to 15 cm H2O with 50% oxygen c. CPAP at 8 to 12 cm H2O with 100% oxygen d. CPAP at 8 to 12 cm H2O with 50% oxygen

ANS: C CPAP should be administered at 8 to 12 cm H2O with 100% oxygen.

The classic chest radiographic findings in which of the following interstitial lung disease (ILD) is calcification along the pleura? a. Asbestosis b. Berylliosis c. Idiopathic pulmonary fibrosis (IPF) d. Sarcoidosis

ANS: C Calcification along the pleura on a chest radiograph suggests previous exposure to asbestos. Although such calcified areas (called plaques) do not cause symptoms or physiologic abnormality, they can provide a clue that the cause of ILD is asbestos exposure.

Which of the following factors affect cardiac performance? 1. Preload 2. Afterload 3. Contractility 4. Cardiac output a. 1 and 2 only b. 1 and 3 only c. 1, 2, and 3 only d. 1, 2, 3, and 4

ANS: C Cardiac performance is affected by preload, contractility, and afterload, and is evaluated by the measurement of cardiac output.

Which of the following organisms is associated with a poor prognosis in the patient with ventilator-related pneumonia despite optimal therapy? a. C. pneumoniae b. Klebsiella c. P. aeruginosa d. S. pneumoniae

ANS: C Certain microorganisms, such as Pseudomonas aeruginosa and Acinetobacter species, are associated with higher rates of mortality.

A patient is exposed a second time to an antigen and subsequently seeks medical attention with sudden shortness of breath, chest pain, fever, chills, malaise, and a cough that may be productive of purulent sputum. Which of the following is the most likely source for the antigen? a. Bed b. Foundry c. Hay field d. Mine

ANS: C Common organic antigens known to cause hypersensitivity pneumonitis include bacteria and fungi, which may be found in moldy hay (farmer's lung) or in the home environment, particularly in association with central humidification systems (humidifier lung), indoor hot tubs, and animal proteins (e.g., bird breeder's lung).

When is respiratory muscle fatigue likely to occur? a. When VE exceeds 20% of the maximum voluntary ventilation (MVV) b. When VE exceeds 40% of the MVV c. When VE exceeds 60% of the MVV d. When VE exceeds 80% of the MVV

ANS: C Comparing the spontaneous minute ventilation with MVV is a helpful index as fatigue and failure are both likely to occur if the minute ventilation exceeds 60% of MVV.

A reversible impairment in the response of an overloaded muscle to neural stimulation best describes which of the following? a. Central respiratory muscle fatigue b. Transmission respiratory muscle fatigue c. Contractile respiratory muscle fatigue d. Chronic respiratory muscle fatigue

ANS: C Contractile respiratory muscle fatigue is a reversible impairment in the contractile response to a neural impulse in an overloaded muscle.

Approximately what percentage of all lung cancer is linked to smoking? a. 50% to 55% b. 70% to 75% c. 85% to 90% d. 100%

ANS: C Direct exposure to tobacco has occurred in 85% to 90% of individuals with lung cancer.

What is a common clinical finding even with small pleural effusions? a. Air bronchograms b. Arrhythmias c. Dyspnea d. Tachycardia

ANS: C Dyspnea is common with small pleural effusions, even when lung mechanics are relatively preserved.

Emphysema is defined as a. chronic productive cough. b. conducting airway enlargement. c. destruction of alveolar walls without fibrosis. d. hemoptysis associated with productive cough and alveolar-capillary membrane destruction.

ANS: C Emphysema is defined in anatomical terms as a condition characterized by abnormal, permanent enlargement of the airspaces beyond the terminal bronchiole, accompanied by destruction of the walls of the airspaces without fibrosis.

While monitoring a patient receiving +12 cm H2O flow-mask continuous positive airway pressure, you note that the pressure drops to +6 cm H2O during inspiration, but returns to +12 cm H2O during exhalation. Which of the following would likely correct this problem? a. Check and correct any mask leaks. b. Check and correct any outflow obstruction. c. Increase the system flow. d. Increase the system pressure.

ANS: C Flow is adequate when the system pressure drops no more than 1 to 2 cm H2O during inspiration.

Which of the following pulmonary function devices directly collect and measure gas volumes? 1. Water-sealed spirometer 2. Dry rolling-seal spirometer 3. Bellows spirometer 4. Pneumotachometer a. 3 and 4 only b. 1 and 2 only c. 1, 2, and 3 only d. 2, 3, and 4 only

ANS: C Flow measuring devices are commonly called pneumotachometers.

Which of the following is false about flow triggering of spontaneous breaths during mechanical ventilation? a. Flow triggering lowers the patient's work of breathing. b. Flow triggering is preferred for initiating spontaneous breaths. c. Flow triggering reduces the work of breathing due to small endotracheal tubes. d. Flow triggering results in better patient-ventilator synchrony.

ANS: C Flow triggering may not be effective in reducing work of breathing because of the presence of a small endotracheal tube or auto-PEEP.

What term is used to describe objects capable of transmitting infection through physical contact with them? a. Consolidates b. Contaminants c. Fomites d. Vectors

ANS: C Fomites are objects capable of transmitting infection through physical contact with them.

A chronic obstructive pulmonary disease (COPD) patient in respiratory failure is receiving ventilatory support in the volume-targeted intermittent mandatory ventilation mode at a rate of 6/min. You measure an auto-PEEP level of 9 cm H2O. Which of the following would you recommend to decrease the effects of auto-PEEP in this patient? a. Decreasing the rate and increasing VT. b. Lowering the VT and letting the PaCO2 rise. c. Applying 4 to 6 cm H2O PEEP. d. Decreasing the peak inspiratory flow.

ANS: C For patients with obstructive disease, ensure a short inspiratory time and long expiratory time to avoid air trapping and minimize auto-PEEP. Lower VT and rate may be necessary in acute asthma to avoid further lung overinflation.

A patient receiving continuous mandatory ventilation in the assist-control mode develops auto-PEEP. Which of the following general approaches would you consider to minimize the effects of auto-PEEP in this patient? 1. Increasing expiratory time 2. Applying PEEP 3. Switching ventilating mode to synchronized intermittent mandatory ventilation a. 1 and 2 only b. 1 and 3 only c. 2 and 3 only d. 1, 2, and 3

ANS: C For patients with obstructive disease, ensure a short inspiratory time and long expiratory time to avoid air trapping and minimize auto-PEEP. Lower VT and rate may be necessary in acute asthma to avoid further lung overinflation.

How often should a spirometer in continual use undergo volumetric calibration? a. Every 4 hr b. Every shift c. At least daily d. Weekly

ANS: C For quality control, the standards include verifying volume accuracy with a 3.0-L calibration syringe at least daily.

When titrating the FiO2 down from 50% to 21%, in what increments should it be reduced? a. All at once is acceptable. b. No more than 5%. c. 5% to 10%. d. 10% to 20%.

ANS: C For reducing O2 concentration from 50% to 21%, O2 changes should be in steps of 5% to 10% followed by oximetry or measurement of blood gases.

What would you use to determine the accuracy of a water-sealed spirometer in measuring lung volumes? a. Calibrated high-flow flowmeter b. Computer-generated flow patterns c. Calibrated 3-L syringe d. Standard subject with known volumes

ANS: C For volume measurements, standard reference values are provided by a graduated 3.0-L calibration syringe.

In interstitial lung disease, which of the following mechanisms contributes to impaired gas exchange? 1. Depression of respiratory drive 2. Diffusion defect 3. Shunt 4. Ventilation/perfusion mismatch a. 1 and 4 only b. 2 and 3 only c. 2, 3, and 4 only d. 1, 2, and 4 only

ANS: C Gas exchange is impaired owing to ventilation/perfusion mismatching, shunt, and decreased diffusion across the abnormal interstitium.

In which of the following types of ventilation is alveolar expansion during inspiration due to an increase in alveolar pressure? 1. Negative-pressure ventilation 2. Positive-pressure ventilation 3. Spontaneous ventilation a. 1 and 2 only b. 2 and 3 only c. 2 only d. 1, 2, and 3

ANS: C Gas flows into the lungs because pressure at the airway opening (Pawo) is positive and alveolar pressure (Palv) is initially zero or less positive.

What is the most common peripheral neuropathy causing respiratory insufficiency? a. Lambert-Eaton syndrome b. Amyotrophic lateral sclerosis c. Guillain-Barré syndrome d. Myasthenia gravis

ANS: C Guillain-Barré syndrome is the most common peripheral neuropathy causing respiratory insufficiency.

A patient comes into the emergency department presenting with signs and symptoms of pneumonia. While taking the patient's history, it is determined that 2 months ago the patient spent 3 days in the hospital for acute angina. Since then the patient has been stable on medication. What type of pneumonia is this patient most likely to have? a. CAP b. HAP c. HCAP d. VAP

ANS: C HCAP is defined as pneumonia occurring in any patient hospitalized for 2 or more days in the past 90 days in an acute care setting or who, in the past 30 days, has resided in a long-term care or nursing facility, attended a hospital or hemodialysis clinic, or who has received intravenous antibiotics, chemotherapy, or wound care.

What is an often-neglected but very important component of preventing transmission of pathogens between patients, particularly those who are ventilated? a. Adequate antibiotic therapy b. Brushing of teeth c. Handwashing d. Use of negative-pressure rooms

ANS: C Handwashing is an important but frequently neglected measure that can reduce transmission of nosocomial bacteria from one patient to another. It is especially important for RTs who may be caring for several ventilated patients in the ICU.

Which of the following is a benefit of high inspiratory flows during positive-pressure ventilation? a. Improved gas exchange b. Higher peak pressures c. Reduced air trapping d. Higher work of breathing

ANS: C High ventilator inspiratory flow allows more time for exhalation and reduces the incidence of air trapping.

A chronic obstructive pulmonary disease (COPD) patient receiving ventilatory support in the CMV assist-control mode at a rate of 14 and a VT of 750 ml exhibits clinical signs of air trapping. Which of the following would you recommend to correct this problem? 1. Decrease "E" time. 2. Increase the inspiratory flow rate. 3. Decrease the assist-control rate. a. 1 and 2 only b. 1 and 3 only c. 2 and 3 only d. 1, 2, and 3

ANS: C Higher flow (up to 80 L/min) may improve gas exchange in COPD patients, probably because of the resulting increase in expiratory time. See Box 49-4.

What medication would likely be the least often ordered during the emergency department management of an acute asthma attack? a. Beta-2 agonists b. Corticosteroids c. Methylxanthines d. Oxygen

ANS: C Hospital and ICU care for patients with asthma should be aggressive. The goals are to decrease mortality and morbidity and to return the patient to preadmission stability and function as quickly as possible. Management includes oxygen supplementation, frequent administration of high doses of aerosolized beta-2 agonists (limited only by tachycardia or tremor), high-dose parenteral corticosteroids (more than 0.5 to 1.0 mg/kg/day), and antibiotics if there is evidence of infection.

The most important variable affecting trigger asynchrony is: a. the mode of mechanical ventilation being used. b. the tidal volume being delivered. c. the presence of auto-PEEP. d. the patient's underlying disease process requiring mechanical ventilation.

ANS: C However, the single most important variable affecting trigger asynchrony is the presence of auto-PEEP.

Hyperventilation should generally be avoided during mechanical ventilatory support. Exceptions to this rule include: 1. Trying to calm an agitated patient. 2. Failure of other methods to reduce intracranial pressure. 3. Hypokalemia causing cardiac arrhythmias. a. 2 and 3 only b. 1 and 3 only c. 2 only d. 1 and 2 only

ANS: C Hyperventilation should be used temporarily after traumatic brain injury until other methods can be used to decrease elevated intracranial pressure.

Which of the following can cause hypoxemia? 1. Diffusion impairment 2. Alveolar hypoventilation 3. V/Q mismatch 4. Intrapulmonary shunting a. 1, 2, and 3 only b. 1, 3, and 4 only c. 1, 2, 3, and 4 d. 2, 3, and 4 only

ANS: C Hypoxemia can be caused by mismatch, shunt, alveolar hypoventilation, diffusion impairment, perfusion impairment, decreased inspired oxygen, and venous admixture.

What is the best option for the patient in respiratory failure who continues to deteriorate 30 min after the initiation of noninvasive ventilation? a. Wait another 30 min and monitor the patient. b. Begin continuous positive airway pressure. c. Intubate and begin mechanical ventilation. d. Ventilate the patient using a bag-valve-mask.

ANS: C If the patient's vital signs and blood gas values are worsening after 30 min on optimal settings, intubation should be considered.

Which of the following pulmonary function tests is most likely to be normal in the patient with interstitial pulmonary fibrosis? a. Diffusing capacity of the lungs (DLCO) b. FEV1 (forced expiratory volume in 1 second) c. FEV1/FVC d. FVC (forced vital capacity)

ANS: C In ILDs, the FEV1/FVC ratio is preserved or even supranormal.

In what category is smoking prevalence high? 1. Lower socioeconomic status 2. Higher education attainment 3. Sexual minorities 4. Older than 70 years a. 2 and 4 only b. 1, 2, and 3 only c. 1 and 3 only d. 1, 3, and 4 only

ANS: C In addition, smoking prevalence remains high in vulnerable populations (e.g. lower socioeconomic status, lower education attainment) and among sexual minorities. Cigarette smoking and other tobacco use among young people is also a major public health concern.

When titrating the FiO2 level downward from 100% to 40%, what is the maximum increment that should be applied between estimates of oxygenation? a. 5% b. 10% c. 20% d. 25%

ANS: C In either case, it is suggested that O2 levels be titrated down from 100% to 50% O2 in decrements not to exceed 20%.

In most ARDS patients, PEEP levels below __________ are generally preferred. a. 10 cm H2O b. 15 cm H2O c. 20 cm H2O d. 25 cm H2O

ANS: C In most patients with ARDS, PEEP levels below 20 cm H2O are generally preferred. Levels of PEEP greater than 20 cm H2O should not be routinely used unless the benefits of higher levels of PEEP are supported by objective end points, such as improved lung compliance or optimal alveolar recruitment.

ANS: B These patients frequently have problems with elevated airway pressure or dynamic hyperinflation (auto-PEEP), which can cause barotrauma and increased dyssynchrony between the patient and the ventilator.

ANS: C In such patients, lower tidal volumes (6 to 8 ml/kg), moderate respiratory rates, and high inspiratory flow rates (70 to 100 L/min) are recommended to avoid dynamic hyperinflation.

During initial mechanical ventilation of the chronic obstructive pulmonary disease (COPD) patient with chronic hypercapnia, what PaCO2 is most likely used as a target value? a. 30 mm Hg b. 40 mm Hg c. 55 mm Hg d. 75 mm Hg

ANS: C In the care of patients with acute exacerbation of COPD and accompanying chronic ventilatory failure, the clinician may target ventilatory support to achieve the patient's "normal" PaCO2 and pH. For COPD patients with chronic hypercapnia, this may mean a target PaCO2 of 50 to 60 mm Hg with a pH of 7.30 to 7.35.

Which of the following is the Raw of intubated patients receiving ventilatory support? a. 1 to 2 cm H2O/L/sec b. 3 to 5 cm H2O/L/sec c. 5 to 10 cm H2O/L/sec d. 10 to 20 cm H2O/L/sec

ANS: C Intubated patients receiving mechanical ventilatory support typically have a Raw of 5 to 10 cm H2O/L/sec.

Which of the following tests is recommended as part of the initial assessment of asthma? a. Arterial blood gas b. Chest radiograph c. Spirometry d. V/Q scan

ANS: C It is recommended that spirometry be performed as part of the initial assessment of all patients being evaluated for asthma, and periodically thereafter as needed.

Which of the interstitial lung diseases will in one-third of patients cause a chylothorax? a. Alveolar proteinosis b. Idiopathic pulmonary fibrosis c. Lymphangioleiomyomatosis d. Nonspecific interstitial pneumonitis

ANS: C Lymphangioleiomyomatosis (LAM) is a rare disorder of abnormal smooth muscle tissue proliferating around small airways leading to severe obstruction and destruction of alveoli with resultant thin-walled cyst formation. Unilateral or less commonly bilateral chylothorax is seen in approximately one-third of patients. This results from lymphatic obstruction by abnormal smooth muscle tissue.

Which of the following clinical signs suggest more severe hypoxemia? a. Tachycardia b. Cyanosis with polycythemia c. Central nervous system dysfunction d. Use of accessory muscles

ANS: C More severe hypoxemia can lead to significant central nervous system dysfunction, ranging from irritability to confusion to coma.

Which of the following information best helps to distinguish chronic hypercapnic respiratory failure from acute hypercapnic respiratory failure? a. Long-standing dyspnea that worsens on exertion b. Forced expiratory volume in 1 sec to forced vital capacity ratio (FEV1/FVC) of less than 75% predicted c. Kidneys retaining bicarbonate to elevate the blood pH d. Physical signs of hypoxemia, such as cyanosis and clubbing

ANS: C Most commonly, chronic hypercapnic respiratory failure accompanying COPD or obesity-hypoventilation syndrome would elicit a renal response by which the kidneys retain bicarbonate to elevate the blood pH.

In which of the following types of ventilation is alveolar expansion during inspiration due to a decrease in pleural pressure? 1. Positive-pressure ventilation (PPV) 2. Negative-pressure ventilation (NPV) 3. Spontaneous ventilation a. 1 and 2 only b. 1 and 3 only c. 2 and 3 only d. 1, 2, and 3

ANS: C NPV decreases pleural pressure (Pp1) during inspiration by exposing the chest to sub-atmospheric pressure.

What beta-2 agonist is associated with 12 to 24 hr of bronchodilation? a. Albuterol b. Metaproterenol c. Salmeterol d. Aclinidium

ANS: C Newer, longer acting (12 to 24 hr) beta-2 agonists, such as salmeterol and formoterol, are now available in the United States.

What is the normal approximate value for O2 consumption? a. 150 ml/min b. 200 ml/min c. 250 ml/min d. 300 ml/min

ANS: C Normal resting O2 consumption is approximately 250 ml/min and O2 consumption increases with activity, stress, and temperature.

How reliable is the tidal volume measurement in predicting the type of lung disease present? a. Very reliable b. Somewhat reliable c. Not reliable d. Reliable but only in certain age groups

ANS: C Normal tidal volumes are often observed in both restrictive and obstructive lung diseases. Therefore, the VT alone is not a valid indicator of the type of lung disease.

A patient has a vital capacity of 4200 ml, a functional residual capacity (FRC) of 3300 ml, and an expiratory reserve volume (ERV) of 1500 ml. What is the residual volume (RV)? a. 5700 ml b. 2700 ml c. 1800 ml d. 7500 ml

ANS: C Once these corrections are made, the RV can be calculated by subtracting the ERV from the FRC according to the following equation: RV = FRC - ERV.

What is a common cause of persistent fever in intensive care unit (ICU) patients with pneumonia? a. Congestive heart failure b. Most exudative effusions c. Parapneumonic effusions d. Transudative effusions

ANS: C Parapneumonic effusions are common causes of persistent fever among ICU patients with pneumonia. Sampling by thoracentesis is commonly performed to exclude empyema. Pleural fluid drainage can improve ventilation if the fluid volume is large.

What pathophysiologic characteristic of asthma has been most recently emphasized in the description and subsequent treatment of this disease? a. Hyperactivity of the airways b. Hyperinflation of the lung parenchyma c. Inflammation of the airways d. Mucus plugging of the airways

ANS: C Past definitions of asthma emphasized airway hyperresponsiveness and reversible obstruction; newer and more accurate definitions of asthma focus on asthma as a primary inflammatory disease of the airways, with clinical manifestations of increased bronchial hyperreactivity and airflow obstruction secondary to the inflammation.

Which of the following means ending inspiratory time based on signals? a. Patient-triggering b. Machine-triggering c. Patient-cycling d. Machine-cycling

ANS: C Patient-triggering means starting inspiration based on a signal from the patient, which is independent of a machine trigger signal. Machine-triggering means starting inspiratory flow based on a signal (usually time) from the ventilator, which is independent of a patient trigger signal. Patient-cycling means ending inspiratory time based on signals representing the patient-determined components of the equation of motion (i.e., elastance or resistance) and including effects due to inspiratory effort. Flow-cycling is a form of patient-cycling because the rate of flow decay to the cycle threshold, and hence the inspiratory time, is determined by patient mechanics. Machine-cycling means ending inspiratory time independent of signals representing the patient-determined components of the equation of motion.

Patients receiving mechanical ventilation are usually turned every 2 hr to prevent which of the following? 1. Atelectasis 2. Secretion retention 3. Pressure sores 4. Hyperoxemia a. 1 and 2 only b. 2 and 3 only c. 1, 2 and 3 only d. 1, 2, 3, and 4

ANS: C Patients receiving mechanical ventilation are turned frequently, usually a minimum of every 2 hr, unless turning is contraindicated. Turning mechanically ventilated patients help prevent atelectasis, hypoxemia, secretion retention, and pressure sores.

An adult patient in respiratory failure has the following blood gases on a nasal cannula at 5 L/min: pH = 7.20; PaCO2 = 67 mm Hg; HCO3 - = 27 mEq/L; PaO2 = 89 mm Hg. The attending physician orders intubation and ventilatory support. What FiO2 would you recommend to start with? a. 0.21 b. 0.30 c. 0.50 d. 0.90

ANS: C Patients who have undergone previous blood gas measurement or oximetry who are doing well clinically and patients with disease states or conditions that normally respond to low to moderate concentrations of O2 may begin ventilation with 50% to 70% O2.

Which of the following is often preceded by a history of upper respiratory or flulike symptoms? a. Myotonic dystrophy b. Polymyositis c. Guillain-Barré syndrome d. Amyotrophic lateral sclerosis

ANS: C Patients with Guillain-Barré syndrome often have a history of upper respiratory infections or a flulike illness that precedes the onset of symptoms and is thought to be related.

What treatment is recommended by the Centers for Disease Control and Prevention (CDC) guidelines for patients with interstitial lung disease (ILD)? a. Measles vaccine b. Mumps vaccine c. Pneumococcal vaccine d. Varicella vaccine

ANS: C Patients with ILD should receive a pneumococcal vaccine per CDC guidelines and a yearly influenza virus vaccine.

During a helium dilution test for functional residual capacity, you notice that it takes 19 min for equilibration between the gas concentrations in the spirometer and the patient's lungs. Based on this information, what can you conclude? a. The patient has restrictive lung disease. b. The spirometer is leaking helium. c. The patient has obstructive lung disease. d. Insufficient oxygen was added to the system.

ANS: C Patients with obstructive lung disease may require up to 20 min to equilibrate because of slow gas mixing in the lungs.

What type of severe lung infection may result in the development of small lung cavities called pneumatoceles? a. Community-acquired pneumonia b. Legionella pneumoniae c. Staphylococcus aureus d. Viral pneumonia

ANS: C Patients with severe staphylococcal or gram-negative pneumonias may develop small cavities called pneumatoceles.

Pneumococcal vaccines are indicated for which of the following individuals? 1. 65-year-old individual 2. Respiratory therapist 3. Individual with chronic heart disease 4. Individual with glaucoma a. 1, 2, and 3 only b. 2 and 4 only c. 1 and 2 only d. 3 and 4 only

ANS: C Pneumococcal vaccination is indicated for all individuals older than the age of 65 years and for those older than the age of 2 years who have functional or anatomical asplenia. Vaccination is also indicated in patients with chronic illnesses such as CHF, chronic lung disease, chronic liver disease, alcoholism, cerebrospinal fluid leaks, or conditions characterized by impaired immunity. Routine pneumococcal vaccination of all health care workers is not currently recommended, unless they possess one of the specific indications for vaccination outlined previously.

Which of the following clinical findings are associated with an increased risk of death in the patient with pneumonia? 1. Kidney disease 2. Heart rate of 130 beats/min 3. Respiratory alkalosis 4. Systolic blood pressure of 85 mm Hg a. 1 and 3 only b. 2 and 4 only c. 1, 2, and 4 only d. 2, 3, and 4 only

ANS: C Points are assigned for the presence of a number of variables, and cumulative point scores are used to stratify patients into one of five different risk groups with predictable mortality rates. Of the above only respiratory alkalosis is NOT associated with increased risk of death.

Which of the following adverse reactions are typically seen with pulmonary function testing? 1. Syncope 2. Cough 3. Hemoptysis 4. Chest pain a. 3 and 4 only b. 1 and 2 only c. 1, 2, and 4 only d. 2, 3, and 4 only

ANS: C Possible complications include pneumothorax, syncope, chest pain, paroxysmal coughing, and bronchospasm associated with exercise-induced asthma. Hemoptysis (cough up bloody sputum) is not a side effect of spirometry.

Compared with a volume-cycled strategy, what are some potential advantages of pressure-targeted ventilatory support? 1. Limit and control of peak airway pressures 2. Direct control over inspiratory time 3. Provision of a decelerating flow pattern a. 1 and 2 only b. 2 and 3 only c. 1 and 3 only d. 1, 2, and 3

ANS: C Pressure-control ventilation is useful in limiting airway pressure and providing a decreasing (decelerating) flow, which may improve gas distribution, patient comfort, and synchrony.

A 45 year-old patient with sarcoidosis complaints of being unable to perform his daily house chores due to shortness of breaths despite continued oxygen therapy of 2 L/min via a nasal cannula. You would recommend which of the following to the patient? a. Increase O2 to 5 L/min. b. Nebulized budesonide BID. c. Pulmonary rehabilitation. d. Lung transplantation.

ANS: C Pulmonary rehabilitation, a very important part of treating obstructive lung disease, also has proved beneficial in the management of ILD. Pulmonary rehabilitation is important in building aerobic fitness, maintaining physical activity, and improving quality of life.

Comprehensive quality assurance of pulmonary function testing consists of which of the following: 1. The accuracy and precision of the measured instrument. 2. Patient must be able to do a breath-hold between 3 and 5 sec. 3. The performance of the technologist. 4. Test results when measuring a standard. a. 2, 3, and 4 only b. 2 and 3 only c. 1, 3, and 4 only d. 1, 2, and 3 only

ANS: C Quality assurance of pulmonary function testing requires accuracy and precision of instruments, monitoring of the performance of the technologist and test results being compared to a measured standard. A patient breath hold is not required.

A 65-year-old patient with a history of exposure to metal dust comes in to the emergency department with chronic cough and exertional dyspnea. HRCT shows bibasilar, peripheral reticular abnormalities with focal honeycomb cystic changes. What is the most likely diagnosis? a. Asbestosis b. Coal worker's pneumoconiosis c. Idiopathic pulmonary fibrosis d. Sarcoidosis

ANS: C Risk factors for development of idiopathic pulmonary fibrosis include exposure to smoke, metal dust, farming dust, and hairdressing chemicals. Patients present with chronic cough and exertional dyspnea with HRCT demonstrating bibasilar, peripheral reticular abnormalities with focal honeycomb cystic change.

Your patient's clinical status abruptly changed and the alarms on the ventilator are sounding. What is/are the first step(s) you should take? a. Silence the alarms and adjust the alarm parameters. b. Perform a rapid physical examination. c. Remove the patient from the ventilator and manually ventilate. d. Check the patency of the airway.

ANS: C See Box 48-1.

Which of the following is the recommended tidal volume for mechanical ventilation in patients with COPD? a. 4 to 8 ml/kg b. 3 to 5 ml/kg c. 6 to 8 ml/kg d. 10 to 12 ml/kg

ANS: C See Box 49-11.

Your patient is being ventilated with a nasal mask to relieve dyspnea. He has a long history of chronic obstructive pulmonary disease and hypercarbia. What is the goal of noninvasive ventilation in this setting with regard to the ABGs? a. Return the PaCO2 to 40 to 45 mm Hg. b. Return the pH to near normal. c. Return the PaCO2 to less than 60 mm Hg. d. Return the bicarbonate level to near normal.

ANS: C See Box 50-5.

Which of the following conditions is associated with an increased lung compliance measurement? a. Atelectasis b. Pneumonia c. Emphysema d. Bronchial intubation

ANS: C See Box 52-7.

Squamous cell carcinoma is composed of which of the following? a. Glandular structures from lung scars b. Common pulmonary stem cells c. Flattened stratified epithelial cells d. Multicentric stratified cells

ANS: C See Table 32-1.

Breathing 100% O2, a patient has a PaO2-PaO2 of 60 mm Hg. Based on this information, what might you conclude? a. The patient has severe hypoxemia. b. The patient has an excessive work of breathing. c. The patient has acceptable oxygenation. d. The patient has inadequate ventilation

ANS: C See Table 45-3.

Ventilatory support may be indicated when the VC falls below what level? a. 45 ml/kg b. 65 ml/kg c. 10 ml/kg d. 30 ml/kg

ANS: C See Table 45-3.

Which of the following measures should be used in assessing the adequacy of a patient's alveolar ventilation? 1. PaO2 2. Arterial pH 3. PaCO2 4. HCO3 a. 2 and 4 only b. 1 and 3 only c. 2 and 3 only d. 1, 2, and 4 only

ANS: C See Table 45-3.

Which of the following are variables controlled during pressure assist/control mechanical ventilation? 1. Volume 2. Flow 3. Time 4. Pressure a. 1 and 3 only b. 1, 2, and 3 only c. 3 and 4 only d. 2, 3, and 4 only

ANS: C See Table 48-2.

Which of the following is likely to occur when decreasing the expiratory positive airway pressure in the patient being ventilated using noninvasive ventilation? a. Improved PaO2 b. Increased functional residual capacity c. Increased tidal volume d. Increased inspiratory positive airway pressure

ANS: C See Table 50-1.

What is the normal range for mean arterial pressure? a. 60 to 80 mm Hg b. 50 to 100 mm Hg c. 80 to 100 mm Hg d. 90 to 120 mm Hg

ANS: C See Table 52-1.

What is the normal mean pulmonary artery pressure? a. 5 mm Hg b. 10 mm Hg c. 15 mm Hg d. 20 mm Hg

ANS: C See Table 52-3.

Which of the following levels of albumin are consistent with severe malnutrition? a. Less than 3.0 g/dl b. Less than 2.5 g/dl c. Less than 2.2 g/dl d. Less than 4.0 g/dl

ANS: C Serum albumin concentration is the most frequently used laboratory measure of nutritional status, a value less than 2.2 g/dl generally reflecting severe malnutrition.

What are some primary uses for pressure-supported ventilation (PSV)? 1. Recruiting collapsed alveoli and improving oxygenation 2. Augmenting patient's spontaneous VT 3. Overcoming the imposed work of breathing a. 1 and 2 only b. 1 and 3 only c. 2 and 3 only d. 1, 2, and 3

ANS: C Since the first description of PSV in 1982, it has been used either to overcome the imposed resistance associated with the artificial airway or to provide ventilatory support with minimal control.

Which of the following types of pneumonia suggests that the patient acquired it through inhalation of infectious particles? a. Cytomegalovirus b. Haemophilus influenzae c. Histoplasmosis d. Staphylococcus

ANS: C Six pathogenetic mechanisms may contribute to the development of pneumonia (Table 24-2). Histoplasmosis is one of those caused by inhalation of infectious particles.

Which of the following are possible solutions to correct a large air leak during noninvasive ventilation? 1. Selecting an appropriately sized mask 2. Applying chin straps 3. Using a full-face mask 4. Decreasing the inspiratory time a. 1 and 2 only b. 2 and 2 only c. 1, 2, and 3 only d. 1, 2, 3, and 4

ANS: C Small air leaks should be expected during noninvasive ventilation. Large air leaks should be addressed immediately. Air leaks can be avoided by selecting an appropriately sized mask, changing to a full-face mask, repositioning the mask, readjusting the straps and adding a forehead spacer.

Which of the following findings on a radiologic report would indicate the presence of a tension pneumothorax? a. Bilateral inversion of diaphragm, long narrow heart, and flattened ribs b. Blunting of costophrenic angles, marked interstitial infiltrates, and apical free air c. Contralateral mediastinal shift, diaphragmatic depression, and flattening of ribs d. Ipsilateral mediastinal shift, sail-shape noted right hemithorax, and marked interstitial infiltrates right sided

ANS: C Tension pneumothorax occurs when air in the pleural space exceeds atmospheric pressure. The radiographic appearance includes mediastinal shift to the contralateral side, diaphragmatic depression, and expansion of the ribs.

Which of the following statements are true about the FEV1 measurement? 1. It is a volume measurement. 2. The recorded FEV1 must come from the same forced vital capacity (FVC) effort. 3. It is often compared to the size of the FVC. 4. It is a popular test. a. 1 and 4 only b. 2 and 3 only c. 1, 3, and 4 only d. 2, 3, and 4 only

ANS: C The FEV1 is a measurement of the volume exhaled in the first second of the FVC. To ensure validity of the FEV1, the measurement must originate from a set of three acceptable FVC trials. The first second of forced exhalation begins at the zero time point. To ensure reliability of the FEV1, the largest FEV1 and second largest FEV1 from the acceptable trials should not vary by more than 0.150 L. Consistent with its definition, the largest FEV1 (body temperature, ambient pressure, saturated [BTPS]) measured is the patient's FEV1. The largest FEV1 sometimes comes from a different trial than the largest FVC.

CMV with a tidal volume of 600 and rate of 8

What mode causes more physiological effects on the patient?

Which of the following statements are true regarding measurement of the patient's forced vital capacity (FVC)? 1. The patient can be sitting or standing. 2. Nose clips are not required. 3. It is an effort-dependent test. 4. Accurate results can be obtained without patient cooperation. a. 1 and 4 only b. 2 and 3 only c. 1, 2, and 3 only d. 2, 3, and 4 only

ANS: C The FVC is an effort-dependent maneuver that requires careful patient instruction, understanding, coordination, and cooperation. Spirometry standards for FVC specify that patients must be instructed in the FVC maneuver, that the appropriate technique be demonstrated, and that enthusiastic coaching occurs. When measuring the FVC, the therapist needs to coach the preceding inspiratory capacity as enthusiastically as the FVC. According to the standards, nose clips are encouraged, but not required, and patients may be tested in the sitting or standing position. Although standing usually produces a larger FVC compared with sitting, sitting is considered safer in case of lightheadedness. It is recommended that the position be consistent for repeat testing of the same patient. FVC should be converted to body temperature conditions and reported as liters under body temperature, ambient pressure, saturated (BTPS) conditions.

What is the normal disparity between end-tidal PCO2 and PaCO2? a. End-tidal PCO2 is 1 to 5 mm Hg less than PaCO2 b. End-tidal PCO2 is 5 to 10 mm Hg less than PaCO2 c. End-tidal PCO2 is 1 to 5 mm Hg higher than PaCO2 d. End-tidal PCO2 is 5 to 10 mm Hg higher than PaCO2

ANS: C The PETCO2 normally is 1 to 5 mm Hg less than the PaCO2.

What strategy should be used when the patient complains of nasal congestion during the use of a nasal mask for noninvasive ventilation (NIV)? a. Switch to an oral mask. b. Switch to a face mask. c. Add a heated humidifier. d. Reduce the inspiratory flow.

ANS: C The application of heated humidity relieves nasal resistance and congestion.

Which of the following is not associated with the clinical features of lung cancer? a. Local growth of tumor b. Metastasis extrathoracic or intrathoracic c. Associated pain or discomfort d. Paraneoplastic syndrome

ANS: C The clinical features of lung cancer result from the effects of local growth of the tumor, regional growth or spread through the lymphatic system, hematogenous (blood-borne) distant metastatic spread, and remote paraneoplastic effects from tumor products or immune cross-reaction with tumor antigens.

An elderly patient comes in with failure to thrive, shortness of breath, confusion, and worsening congestive heart failure. What is most likely the patient's primary problem? a. An atypical pneumonia b. Aspiration pneumonia c. Community-acquired pneumonia d. Tuberculosis

ANS: C The clinical presentation of community-acquired pneumonia in elderly patients deserves special mention because it may be subtle. Older individuals with pneumonia may not have a fever or cough and may simply present with shortness of breath, confusion, worsening congestive heart failure (CHF), or failure to thrive.

Cobb angles are used to measure the severity in which disorder of the thoracic cage? a. Ankylosing spondylitis b. Flail chest c. Scoliosis d. Pectus excavatum

ANS: C The degree of scoliosis is measured by the Cobb angle, which is determined by the intersection of lines drawn between the upper and lower limbs of the primary curve in scoliosis.

A patient has a decreased DLCO but a normal DLCO/VA ratio. The patient most likely has a. emphysema. b. pulmonary fibrosis. c. a small lung (low total lung capacity). d. secondary polycythemia.

ANS: C The diffusing capacity of the lung to effective total lung capacity ratio (DLCO/VA) differentiates between diffusion abnormalities caused by having a small lung volume compared with diffusion abnormalities caused by alveolar-capillary membrane pathologies. Patients whose only problem is small lungs will have a decreased DLCO, but their DLCO/VA ratio will be normal. Patients with pulmonary emphysema or fibrosis will have a decreased DLCO and a decreased DLCO/VA ratio.

Identify the drug whose regular use in the treatment of asthma may worsen control or even increase the risk of death by asthma. a. Anticholinergic b. Antiinflammatory c. Beta-2 agonists d. Corticosteroid

ANS: C The effectiveness of beta-2 agonists as bronchodilators is not disputed, and they remain the drug of choice for acute emergency management of asthma. However, there is concern that they may worsen asthma control if used regularly and that excessive use may increase the risk of death from asthma, which makes their role in long-term maintenance therapy questionable

Which of the following are causes of hypoxemia? 1. Ventilation/perfusion (V/Q) mismatch 2. Alveolar hypoventilation 3. Diffusion impairment 4. Increased inspired O2 a. 1 and 2 only b. 2 and 3 only c. 1, 2, and 3 only d. 1, 2, 3, and 4

ANS: C The following are causes of hypoxemia: V/Q mismatch (most common cause), shunt, alveolar hypoventilation, diffusion impairment, perfusion/diffusion impairment (rare), decreased inspired oxygen, and venous admixture.

Identify the hallmark symptom of bronchiectasis. a. Evidence of cystic spaces and tram tracks on the chest radiograph b. Hemoptysis c. Large amounts of purulent sputum d. Variable dyspnea

ANS: C The hallmark of bronchiectasis is the chronic production of large quantities of purulent sputum.

Which of the following are necessary to ensure a valid single-breath diffusing capacity of the lungs (DLCO) test result? 1. Two or more acceptable tests should be averaged. 2. Breath-hold time should be between 3 and 5 sec. 3. Corrections for hemoglobin (Hb) and COHb should be included. 4. The maneuvers should be reproducible to within 10%. a. 1, 2, and 3 only b. 2 and 4 only c. 1, 3, and 4 only d. 2, 3, and 4 only

ANS: C The mean of two acceptable tests is the DLCO that meet the repeatability requirement of either being within 3 ml of CO (STPD)/min/mm Hg of each other or within 10% of the highest value.

Which parameter is considered to be the most accurate and reliable measure of oxygenation efficiency? a. PaO2/FiO2 ratio b. P(A-a)O2/PaO2 ratio c. Qs/Qt d. PaO2/SaO2 ratio

ANS: C The most accurate and reliable measure of oxygenation efficiency is direct computation of the physiologic shunt.

What is the most common method of estimating GFR? a. Blood urea nitrogen b. Blood urea nitrogen and creatinine c. Plasma creatinine and creatinine clearance d. Urine output

ANS: C The most common method of estimating GFR (renal function) is measurement of plasma creatinine and creatinine clearance rate.

What is the most commonly used additional imaging technique to confirm lung cancer? a. Gammagraphy b. Videoscintigraphy c. Positron emission tomography d. Enhanced computed tomography

ANS: C The most commonly used additional imaging technique is positron emission tomography (PET) utilizing fluorodeoxyglucose.

The pathophysiologic mechanisms of airway obstruction in COPD include which of the following? 1. Airway remodeling 2. Inflammation and obstruction of small airway 3. Loss of elasticity 4. Active bronchospasm a. 1 and 2 only b. 1 and 4 only c. 2, 3, and 4 only d. 3 and 4 only

ANS: C The pathophysiologic mechanisms of airflow obstruction in COPD include inflammation and obstruction of small airways (<2 mm in diameter); loss of elasticity, which keeps small airways open when elastin is destroyed in emphysema; and active bronchospasm. Although traditionally considered to be characteristic of asthma, some reversibility of airflow obstruction has been observed in up to two-thirds of patients with COPD when tested multiple times with inhaled bronchodilators.

Which of the following are contraindications for continuous positive airway pressure (CPAP) therapy? 1. Hemodynamic instability 2. Hypoventilation 3. Facial trauma 4. Low intracranial pressures a. 1 and 3 only b. 2 and 3 only c. 1, 2, and 3 only d. 2, 3, and 4 only

ANS: C The patient who is hemodynamically unstable is not likely to tolerate CPAP for even a short period of time. The patient who is suspected of having hypoventilation is not a good candidate for CPAP because it does not ensure ventilation. Other problems that may indicate that CPAP is not an appropriate therapy include nausea, facial trauma, untreated pneumothorax, and elevated intracranial pressure.

What is the most common cause of interstitial lung disease (ILD)? a. Asbestosis b. Berylliosis c. Pulmonary fibrosis (IPF) d. Sarcoidosis

ANS: C The plain chest radiographic and HRCT features of IPF often are considered the classic ILD pattern, primarily because, next to sarcoidosis, IPF is the most common ILD and because several other ILDs have a similar appearance.

When used to determine functional residual capacity, the body plethysmograph operates on which of the following physical principles? a. Dalton's law b. Charles' law c. Boyle's law d. Gay-Lussac's law

ANS: C The plethysmography technique applies Boyle's law and uses measurements of volume and pressure changes to determine lung volume, assuming temperature is constant.

At what point is intrapleural pressure most negative? a. End-exhalation b. FRC c. Inspiration d. Maximal expiration

ANS: C The pleural space is under negative pressure except during forced expiration. The intact thoracic rib cage provides elastic recoil pressure outward, whereas the intrinsic recoil pressure of the lung is inward toward the lung hilum. The diaphragm further decreases the intrapleural pressure below the atmospheric pressure to allow inspiration to occur.

What is the predicted normal FEV1 for the average 20-year-old man? a. 3.3 L b. 4.0 L c. 4.7 L d. 5.2 L

ANS: C The predicted normal FEV1 for a 20-year-old, 180-cm man approaches 4.70 L.

Which of the following measure is typically increased in patients with restrictive lung disease? a. Lung compliance b. Lung volumes c. Pressure needed to expand the lung d. Airway resistance

ANS: C The primary problem in restrictive lung disease is reduced lung compliance, thoracic compliance, or both lung and thoracic compliances. Compliance is the volume of gas inspired per the amount of inspiratory effort; effort is measured as the amount of pressure created in the lung or in the pleural space when the inspiratory muscles contract. Compliance is calculated according to the following formula: C = V/P.

Which of the following is a reason for ventilator alarms? a. Alter mode when patient pulmonary mechanics change. b. To adjust and reset when preselected airway pressure is reached. c. To bring events to the attention of the clinician. d. To identify deteriorating patient status.

ANS: C The purpose of ventilator alarms is to bring events to the attention of the clinician. Events are conditions or occurrences requiring clinician awareness or intervention.

When performing a lung recruitment strategy, which of the following would cause the therapist to stop? 1. Mean blood pressure drops of 80 to 65 mm Hg. 2. Heart rate increases from 88 to 110/min. 3. Patient has a run of premature ventricular complexes. a. 1 only b. 2 only c. 3 only d. 1, 2, and 3

ANS: C The recruitment maneuver is stopped if there is a decrease in SpO2 to less than 88%, a significant change in heart rate (>140 beats/min or <60 beats/min), a significant change in mean arterial blood pressure (<60 mm Hg or decrease >20 mm Hg from baseline) or the development of cardiac arrhythmia.

You are monitoring blood pressure during mechanical ventilation of a patient with pneumonia. A temporary increase in blood pressure occurs when the patient coughs. This temporary spike in blood pressure represents what type of variability? a. Artifact b. Factitious event c. Physiologic variation d. Instrument drift

ANS: C The signal itself can exhibit a random variability related to the inherent imprecision of the signal or due to normal physiologic variability in the patient. Blood pressure, for example, changes within a certain range for many reasons.

Which of the following mechanisms is an uncommon route for the spread of pneumonia? a. Aspiration of infectious particles b. Inhalation of infectious particles c. Through the bloodstream d. Direct contact

ANS: C The spread of infection through the bloodstream from a remote site is called hematogenous dissemination. This is an uncommon cause of pneumonia, which may occur in patients with right-sided bacterial endocarditis in whom fragments of an infected heart valve break off, embolize through the pulmonary arteries to the lungs, and produce either pneumonia or septic pulmonary infarcts.

Which group of disorders is categorized together because of similarities in their clinical presentations, plain chest radiographic appearance, and physiologic features? a. Congestive heart failure b. Infant respiratory distress syndrome c. Interstitial lung diseases d. Sudden acute respiratory syndrome

ANS: C The term interstitial lung disease (ILD) refers to a broad category of lung diseases rather than to a specific disease entity. It includes a variety of illnesses with diverse causes, treatments, and prognoses. These disorders are grouped together because of similarities in their clinical presentations, plain chest radiographic appearance, and physiologic features.

Which of the following asthma medications is not typically administered during pregnancy? a. Albuterol b. Cromolyn c. Ipratropium bromide d. Theophylline

ANS: C Theophyllines, beta-2 agonists, inhaled or oral corticosteroids, or cromolyn can be used during pregnancy without significant risk of fetal abnormalities.

Which of the following are primary reasons to measure intracranial pressure (ICP)? 1. To monitor patients at risk of life-threatening intracranial hypertension 2. To monitor for evidence of infection 3. To assess the effects of therapy aimed at reducing ICP 4. To maintain the mean ICP greater than 20 mm Hg a. 1 and 4 only b. 2 and 3 only c. 1, 2, 3 only d. 2, 3, and 4 only

ANS: C There are three primary reasons to measure intracranial pressure (ICP): (1) to monitor patients at risk of life-threatening intracranial hypertension, (2) to monitor for evidence of inflection, and (3) to assess the effects of therapy aimed at reducing ICP. Also, normal mean ICP for a patient in the supine is normally 10 to 15 mm Hg, ICP. Elevations in ICP to 15 to 20 mm Hg compress the capillary bed and compromise microcirculation.

Which of the following white blood cells is most commonly implicated in the inflammatory process of ARDS? a. Eosinophils b. Monocytes c. Neutrophils d. Lymphocytes

ANS: C These investigators demonstrated that ARDS, regardless of the cause, is associated with an influx of neutrophils (PMNs) and PMN-derived inflammatory byproducts, such as neutrophil elastase and myeloperoxidase, into the lung.

What minimum size does a lesion in the lung need to be in order to be called a nodule? a. 1 cm b. 2 cm c. 3 cm d. 4 cm

ANS: C These will show a small spot (<3 cm in diameter) termed a nodule.

At what anatomic position should an 18-gauge IV catheter be placed to relieve a tension pneumothorax? a. Just inferior to the second rib b. Just inferior to the third rib c. Just superior to the second rib d. Just superior to the fourth rib

ANS: C This procedure usually is done with an 18-gauge intravenous (e.g., Jelco) catheter inserted just over the second rib on the anterior aspect of the chest in the midclavicular line.

Which of the following is not a therapeutic option for patients with lung cancer? a. Surgical resection b. Radiotherapy c. Laser d. Chemotherapy

ANS: C Three classes of treatment are used to treat non-small-cell lung cancer—surgical resection, radiotherapy, and chemotherapy.

To ensure validity of the forced vital capacity (FVC) measurement, how many attempts should the patient perform? a. Just one good one b. Two that are nearly the same c. Three that are acceptable d. At least four

ANS: C To ensure validity, each patient must perform a minimum of three acceptable FVC maneuvers.

What step must be taken to gain control of asthma in a patient that is experiencing frequent emergency department visits? a. Regular antibiotic therapy b. Regular anticholinergic therapy c. Environmental control d. Regular immunotherapy

ANS: C To prevent allergic reactions in asthma patients, environmental control measures to reduce exposure to indoor and outdoor allergens and irritants are essential.

Which of the following parameters are important in the management of patients with ARDS? 1. Keep systolic blood pressure below 90 mm Hg. 2. Keep hemoglobin saturation above 90%. 3. Ensure adequate urine output. 4. Keep mean arterial pressure above 60 mm Hg. a. 1 and 2 only b. 1 and 4 only c. 2, 3, and 4 only d. 1, 3, and 4 only

ANS: C Until such tools become available, it seems prudent to prevent hypotension (systolic arterial blood pressure at >90 mm Hg, mean arterial blood pressure at >60 mm Hg), consider augmentation of DO2 in the setting of hyperlactatemia, optimize hemoglobin saturation (>90%), and ensure adequate organ function (e.g., urine output).

A heat-moisture exchanger (HME) should be avoided in which of the following circumstances? 1. Patients with excessive secretions 2. Patients with a high FiO2 3. Patients with low body temperature a. 1 only b. 1 and 2 only c. 1 and 3 only d. 1, 2, and 3

ANS: C Use of HMEs should be avoided in the care of patients with secretion problems and those with low body temperature (<32 C), high spontaneous minute ventilation (>10 L/min), or air leaks in which exhaled tidal volume is less than 70% of delivered tidal volume.

Which of the following criteria should be met before considering use of a heat-moisture exchanger (HME) for a patient being placed on ventilatory support? 1. There should be no problem with retained secretions. 2. The patient should not have fever (normothermic). 3. The patient should be adequately hydrated. 4. The support should be short term (24 to 48 hr). a. 1, 2, and 3 only b. 2 and 4 only c. 1, 2, 3, and 4 d. 3 and 4 only

ANS: C Use of HMEs should be avoided in the care of patients with secretion problems and those with low body temperature (<32 C), high spontaneous minute ventilation (>10 L/min), or air leaks in which exhaled tidal volume is less than 70% of delivered tidal volume.

Volume-controlled (VC) modes of mechanical ventilation include which of the following? 1. VC continuous mandatory ventilation 2. VC intermittent mandatory ventilation 3. Volume-assured, pressure-controlled 4. Bilevel positive airway pressure a. 2 and 4 only b. 1, 2, 3, and 4 c. 1 and 2 only d. 1, 3, and 4 only

ANS: C VC modes include VC continuous mandatory ventilation and VC synchronized intermittent mandatory ventilation.

Which of the following modes of ventilatory support would you recommend for a severely hypoxemic patient with acute lung injury or acute respiratory distress syndrome (ARDS)? a. Continuous positive airway pressure b. High VT volume-cycled ventilation c. Pressure-controlled ventilation d. Bilevel pressure support by mask

ANS: C Volume-cycled ventilation in patients with ARDS frequently leads to high-peak airway and plateau pressures.

When using a heated humidifier during mechanical ventilation, the inspired gas temperature at the airway should be set to what level? a. 29 to 31 C b. 31 to 35 C c. 35 to 37 C d. 38 to 40 C

ANS: C We prefer an optimal humidity approach and use of a heated humidifier to deliver gas in the range of 35 to 37 C at the airway.

Which of the following trigger levels is appropriate when setting a ventilator for pressure triggering? a. 0.5 to 1.5 cm H2O above the baseline pressure b. 1.5 to 2.5 cm H2O below the baseline pressure c. 0.5 to 1.5 cm H2O below the baseline pressure d. 2.5 to 3.5 cm H2O below the baseline pressure

ANS: C With pressure triggering, the range is generally -0.5 to -1.5 cm H2O.

Normal healthy people can exhale what percentage of the forced vital capacity in 1 sec? a. 50% b. 60% c. 70% d. 80%

ANS: C] In general, individuals without airway obstruction will be able to exhale at least 70% of their vital capacity in the first second.

Mechanical Deadspace

Anything outside of the patient (such as added large bore tubing, which a 6" piece is = to 50 mL of deadspace)

Which of the following are indications to use noninvasive ventilation (NIV) in patients with acute respiratory failure? 1. PaCO2 >45 mm Hg and pH <7.35 2. More than two hospitalizations related to hypercapnic respiratory failure 3. Respiratory rate 25 breaths/min 4. PaO2/FIO2 ratio <200 a. 1, 2, and 3 only b. 2 and 4 only c. 1, 2, and 4 only d. 1, 3, and 4 only

ANS: D

Which of the following are essential components of a continuous positive airway pressure (CPAP) flow system? 1. Blended source of pressurized gas 2. Nonrebreathing circuit with reservoir bag 3. Low-pressure or disconnect alarm 4. Expiratory threshold resistor a. 3 and 4 only b. 1, 2, and 4 only c. 1 and 4 only d. 1, 2, 3, and 4

ANS: D A breathing gas mixture from an oxygen blender flows continuously through a humidifier into the inspiratory limb of a breathing circuit. A reservoir bag provides reserve volume if the patient's inspiratory flow exceeds that of the system. The patient breathes in and out through a simple valveless T-piece connector. A pressure alarm system with manometer monitors the CPAP pressure at the patient's airway. The alarm system can warn of either low (usually due to a disconnection) or high system pressure. The expiratory limb of the circuit is connected to a threshold resistor, in this case a water column (H).

In which mode of ventilatory support does the patient breathe spontaneously at an elevated airway pressure, with short, intermittent decreases in pressure to a lower level? a. Volume-assured pressure-supported ventilation b. Pressure-controlled inverse ratio ventilation c. Bilevel positive airway pressure d. Airway pressure-release ventilation

ANS: D A mode related to PC-IRV is APRV, in which the patient breathes spontaneously throughout periods of high and low applied continuous positive airway pressure.

What is considered normal for the PaO2/FiO2 ratio? a. Greater than 50 b. Greater than 150 c. Greater than 250 d. Greater than 400

ANS: D A normal PaO2/FiO2 ratio while breathing room air is approximately 400 to 500 mm Hg.

Pleural fluid with a total protein concentration of less than ____________ of the serum total protein level is one of the indications of transudative pleural effusion. a. 20% b. 30% c. 40% d. 50%

ANS: D A pleural fluid total protein concentration less than 50% of the serum total protein level and lactate dehydrogenase (LDH) values in the pleural fluid less than 60% of the serum value indicate the presence of a transudative pleural effusion.

What do we measure to determine the precision of an instrument? a. Mean measured reference value b. Difference between the mean measured and actual reference value c. Range of the mean measured reference value d. Standard deviation (SD) of the mean measured reference value

ANS: D A small SD indicates low variability and high precision.

What is a normal single-breath diffusing capacity for carbon monoxide for a young, healthy man of average size? a. 10 ml/min/mm Hg b. 20 ml/min/mm Hg c. 30 ml/min/mm Hg d. 40 ml/min/mm Hg

ANS: D A typical normal value for a 20-year-old healthy man is 40 ml/min/mm Hg.

According to the equation of motion of the respiratory system, a ventilator can control which of the following variables? 1. Volume 2. Resistance 3. Pressure 4. Flow a. 1 and 3 only b. 1, 2, and 3 only c. 3 and 4 only d. 1, 3, and 4 only

ANS: D A ventilator assists with the work of breathing by using either pressure control or volume control according to the equation of motion for the respiratory system. This equation relates pressure, volume, and flow as variables of time.

You have just placed a chronic obstructive pulmonary disease (COPD) patient on intermittent mandatory ventilation at a rate of 8/min, a VT of 550 ml, and an FiO2 of 0.40. To ensure proper equilibration between the alveolar and arterial gas tensions, how long should you wait before drawing a sample for measurement of the ABG? a. 5 min b. 10 min c. 15 min d. 30 min

ANS: D ABGs should be measured 20 to 30 min after initiation of mechanical ventilation.

When administering oxygen, which of the following should be considered regarding oxygen toxicity? 1. It is only a concern with premature infants. 2. The longer the exposure, the worse the injury. 3. The higher the FiO2, the worse the injury. 4. The target SpO2 is in the range of 88% to 95%. a. 1 and 2 only b. 2 and 3 only c. 3 and 4 only d. 2, 3, and 4 only

ANS: D Administering high levels of supplemental O2 can cause lung injury as a result of O2 toxicity. Oxygen toxicity is considered to be time and dose dependent, that is, the longer the exposure and the higher the FiO2, the worse the injury. The RT must continuously titrate the FiO2 and PEEP to keep the target SpO2 in the range of 88% to 95%.

When adjusting the FiO2 setting for a patient receiving mechanical ventilatory support, what should your goal be? a. Decrease the FiO2 to below 0.70 as soon as possible. b. Maintain the highest possible FiO2 as long as needed. c. Decrease the FiO2 to below 0.30 as soon as possible. d. Decrease the FiO2 to below 0.50 as soon as possible.

ANS: D After initiation of mechanical ventilation with an FiO2 of 1.0, the FiO2 should be reduced to 0.40 to 0.50 or less as soon as is practical to avoid O2 toxicity and absorption atelectasis.

Which of the following are factors associated with pressure and flow-related complications during noninvasive ventilation? 1. Sinus and ear pain 2. Nasal congestion 3. Upper airway dryness 4. Gastric insufflations a. 1 and 2 only b. 2 and 3 only c. 1, 2, and 3 only d. 1, 2, 3, and 4

ANS: D Air pressure and flow-related complications include nasal congestion, upper airway dryness, sinus and ear pain, eye irritation, and gastric insufflations.

Which of the following lung units would be most prone to air-trapping? a. One with high resistance and low compliance b. One with low resistance and low compliance c. One with normal resistance and low compliance d. One with high resistance and high compliance

ANS: D Air-trapping occurs with incomplete emptying of lung units. Lung units prone to air-trapping are those with long-time constants (i.e., with high resistance or high compliance).

What treatment strategy is most controversial for a patient with asthma? a. Antibiotic therapy b. Anticholinergic therapy c. Environmental control d. Immunotherapy

ANS: D Although immunotherapy is acceptable in the treatment of allergic rhinitis, its use in the treatment of asthma is not standardized and remains controversial. The role of immunotherapy in asthma is currently limited to patients with allergic asthma who are unable to achieve substantial relief of symptoms with avoidance measures and pharmacotherapy. It is hoped that future studies will define its role and efficacy more clearly.

CPAP

What mode of ventilation does the patient work the hardest?

Which of the following medications has been shown to be useful in the treatment of almost all interstitial lung diseases? a. Acetaminophen b. Aspirin c. Oxytocin d. Oxygen

ANS: D Although studies are limited, supplemental oxygen delivered via nasal cannula can prevent resting hypoxemia and allow greater exertion before desaturation. These benefits may improve quality-of-life and potentially ward off development of pulmonary arterial hypertension, although further studies are needed.

A patient with which of the following diseases will have the longest life expectancy? a. Alveolar proteinosis b. Idiopathic pulmonary fibrosis c. Nonspecific interstitial pneumonitis d. Sarcoidosis

ANS: D Although the prognosis for NSIP is better than IPF, the life expectancy is still only 7 to 10 years. Sarcoidosis often follows a benign course without symptoms or long-term consequences and may spontaneously resolve.

What treatment for patients with COPD has been shown to improve long-term survival? a. Bronchodilators b. Corticosteroids c. Mechanical ventilation d. Oxygen

ANS: D Among the available treatments for COPD, supplemental oxygen is important because, like smoking cessation and lung-volume reduction surgery in selected individuals (see below), it can prolong survival. Box 23-2 reviews the indications for supplemental oxygen, and Figure 23-6 shows the results of the American Nocturnal Oxygen Therapy Trial and the British Medical Research Council Trial of Domiciliary Oxygen, 1980-1981. Survival was improved when eligible patients used supplemental oxygen for as close to 24 hr as possible and that survival improved less for those using oxygen only 15 hr/day.

After accounting for the compressed volume loss on a stable adult patient receiving volume-controlled continuous mandatory ventilation at a preset volume of 500 ml, you still note a 150-ml difference between the expected and the actual delivered volume. Which of the following is most likely causing this problem? a. Gas absorption across the alveolar membrane b. Increase in the respiratory quotient c. Bronchopleural fistula or pneumothorax d. Leak in the patient-ventilator system

ANS: D An additional factor that can cause a patient to receive less volume than the ventilator delivers is a leak.

Your patient who is orally intubated and receiving mechanical ventilation was just repositioned by the nursing staff following their bedsheets being changed. Suddenly, airway pressures and tidal volumes rapidly decrease. Which of the following explains this finding? a. Pneumothorax. b. A dislodged mucus plug is obstructing the endotracheal tube. c. Acute bronchospasm. d. Movement of the endotracheal tube.

ANS: D Another common problem with endotracheal tubes is movement of the airway into the oral pharynx or movement into the right main stem bronchus. Both of which can be life threatening although movement into the oral pharynx, essentially extubation, is the most life threatening. In some situations the airway can be moved back into the trachea, in others reintubation is necessary. If this occurs adequate ventilation is generally impossible. Airway pressures and tidal volumes rapidly decrease and there is frequent gas leakage from the mouth and nose. It is thus important to determine at each patient-ventilator assessment the location of the endotracheal tube.

What level of urine output is considered anuria? a. Less than 500 ml/day b. Less than 250 ml/day c. Less than 150 ml/day d. Less than 50 ml/day

ANS: D Anuria is present when urine output is less than 50 ml/day.

Other causes of lung cancer include 1. asbestos. 2. arsenic. 3. chromium. 4. microwave radiation. a. 2, 3, and 4 only b. 2 and 3 only c. 1 and 4 only d. 1, 2, and 3 only

ANS: D Arsenic, asbestos, and chromium confer the highest risks.

In severe cases of pneumothorax, the mediastinum and trachea: a. remain midline. b. sink posteriorly into the chest cavity. c. are shifted toward from the side with the pneumothorax. d. are shifted away from the side with the pneumothorax.

ANS: D As pressure increases, the affected side's lung collapses and begins to compress the unaffected side. In severe cases, the mediastinum and trachea are shifted away from the side with the pneumothorax.

In which of the following modes of ventilatory support would the patient's work of breathing be least? a. Continuous positive airway pressure (CPAP) b. Pressure-supported ventilation (PSV) c. Intermittent mandatory ventilation (IMV) d. Continuous mandatory ventilation (CMV)

ANS: D As the mode is changed from CPAP to PSV to synchronized intermittent mandatory ventilation to time-triggered CMV, the ventilator assumes more of the work.

Which of the following pathologies may result in the early onset of emphysema? a. Alzheimer's disease b. Cystic fibrosis c. Asthma d. Alpha-1 antiprotease deficiency

ANS: D As the second well-recognized cause of emphysema, AAT deficiency, sometimes called genetic emphysema or alpha-1 antiprotease deficiency, is a condition that features a reduced amount of the protein alpha-1 antitrypsin (AAT), which may result in the early onset of emphysema and which is inherited as a so-called autosomal codominant condition.

1. Which of the following can be adversely affected by poor patient-ventilator interaction? 1. Gas exchange 2. Ventilatory patterns 3. Hemodynamics 4. Length of mechanical ventilation a. 1 and 3 only b. 1, 2, and 3 only c. 2 and 4 only d. 1, 2, 3, and 4

ANS: D At minimum hemodynamics, ventilatory pattern and gas exchange are adversely affected. Recent data indicates that asynchrony occurs in ALL patients receiving assisted patient-triggered ventilation, is most significant during the morning when clinician patient interaction is greatest, is present even during period of sedation, and varies from mild to very severe asynchrony4. What is most important to remember is that asynchrony has been associated with increased length of mechanical ventilation, ICU and hospital length of stay, the need for tracheostomy, and ICU and hospital mortality.

Types of damage associated with pulmonary barotrauma include which of the following? 1. Pneumoconiosis 2. Pneumomediastinum 3. Pneumothorax 4. Subcutaneous emphysema a. 1 and 3 only b. 1, 2, and 3 only c. 3 and 4 only d. 2, 3, and 4 only

ANS: D Barotrauma is categorized as pneumothorax, pneumomediastinum, pneumopericardium, and subcutaneous emphysema.

In which of the following types of ventilation can pleural pressure become positive during inspiration? 1. Positive-pressure ventilation 2. Spontaneous ventilation 3. Negative-pressure ventilation a. 2 and 3 only b. 1 and 2 only c. 1, 2, and 3 d. 1 only

ANS: D Because alveolar pressure is greater than pleural pressure (Ppl) during PPV, positive pressure is transmitted from the alveoli to the pleural space, causing pleural pressure to increase during inspiration.

Which of the following occur with positive-pressure ventilation (PPV)? 1. During inspiration, pleural pressure decreases. 2. During inspiration, pressure in the alveoli increases. 3. The pressure gradients of normal breathing are reversed. 4. During inspiration, alveolar pressure exceeds pleural pressure. a. 1 and 3 only b. 1, 2, and 3 only c. 3 and 4 only d. 2, 3, and 4 only

ANS: D Because alveolar pressure is greater than pleural pressure (Ppl) during PPV, positive pressure is transmitted from the alveoli to the pleural space, causing pleural pressure to increase during inspiration.

Because an elevated PaCO2 increases ventilatory drive in normal subjects, the clinical presence of hypercapnia indicates which of the following? 1. Inability of the stimulus to get to the muscles 2. Weak or missing central nervous system response to the elevated PCO2 3. Pulmonary muscle fatigue a. 1 and 2 only b. 1 and 3 only c. 2 and 3 only d. 1, 2, and 3

ANS: D Because an elevated PaCO2 increases ventilatory drive in healthy subjects, the very existence of hypoventilation suggests other problems with the respiratory apparatus. Specifically, the presence of acute respiratory acidosis indicates one of three major problems: (1) the respiratory center is not responding normally to the elevated PaCO2, (2) the respiratory center is responding normally, but the signal is not getting through to the respiratory muscles, or (3) despite normal neurologic response mechanisms, the lungs and chest bellows are simply incapable of providing adequate ventilation due to parenchymal lung disease or muscular weakness.

Which of the following modes of ventilatory support would result in the highest mean airway pressure? a. Volume-controlled intermittent mandatory ventilation b. (Volume-controlled intermittent mandatory ventilation) + pressure-supported ventilation c. Pressure-controlled intermittent mandatory ventilation d. Volume-controlled continuous mandatory ventilation

ANS: D Because every breath is volume controlled, mean airway pressure tends to be greater compared with the mean airway pressure with synchronized intermittent mandatory ventilation and pressure-supported ventilation, and pulmonary arterial pressure and cardiac output may be lower.

A patient receiving control-mode continuous mandatory ventilation has the following ABGs on an FiO2 of 0.4: pH = 7.51; PCO2 = 30 mm Hg; HCO3 - = 25 mm Hg. Her current minute ventilation (VE) is 7.9 L/min. What new VE would you recommend? a. 9.0 L/min b. 6.7 L/min c. 7.5 L/min d. 5.9 L/min

ANS: D Box 49-15 gives an example of the effect of a change in A on PaCO2.

Which medication is a once-daily combination of a beta-2 agonist and an inhaled corticosteroid? a. Combivent Respimat b. Advair c. Flovent d. Breo Ellipta

ANS: D Breo Ellipta is a once-daily combination medication that includes fluticasone and vilanteral. It is currently only approved for patients with COPD.

Physiological effects of adding a volume-limited inflation hold to mandatory breaths include which of the following? 1. Decreased PaCO2 2. Increased inspiratory time 3. Decreased VD/VT 4. Longer expiratory times a. 2 and 4 only b. 1, 2, 3, and 4 c. 3 and 4 only d. 1, 2, and 3 only

ANS: D By momentarily maintaining lung volume under conditions of no flow, an inflation hold allows additional time for gas redistribution between lung units with different time constants. In both animal and human studies, increasing the length of an inflation hold decreases the VD/VT, PaCO2, and inert gas washout time. Adding an inflation hold effectively increases total inspiratory time, thereby shortening the time available for exhalation.

]Approximately how many Americans are affected by COPD? a. 8 million b. 16 million c. 24 million d. 30 million

ANS: D COPD is common, with recent estimates suggesting that 30 million Americans are affected. It is the third leading cause of death in the United States, responsible for 143,560 deaths in 2015

For patients with respiratory insufficiency, pressure-supported ventilation (PSV) has all of the following advantages over spontaneous breathing except: a. decreased respiratory rate. b. increased VT. c. decreased O2 consumption. d. increased muscle activity.

ANS: D Clinical studies have shown that compared with spontaneous breathing (including that occurring during synchronized intermittent mandatory ventilation), PSV can result in a decreased respiratory rate, increased tidal volume, reduced respiratory muscle activity, and decreased oxygen consumption.

Compared with nasal masks, full-face masks are associated with all of the following, except: a. increase in dead space. b. risk of aspiration. c. claustrophobia. d. hypocapnia.

ANS: D Compared with nasal masks, full-face masks are associated with an increase in dead space, risk of aspiration, and claustrophobia.

Which of the following are extra-pulmonary manifestations for TB? 1. Hectic fever 2. Hepatomegaly 3. Bronchioectasis 4. Weight loss a. 2, 3, and 4 only b. 2 and 4 only c. 1 and 3 only d. 1, 2 and 4 only

ANS: D Complications of pulmonary tuberculosis include tuberculous empyema, bronchiectasis, extensive pulmonary parenchymal destruction, spontaneous pneumothorax, and massive hemoptysis from rupture of a Rasmussen aneurysm in the wall of a cavity. Extra-pulmonary complications may include hectic fever, wasting, and hepatosplenomegaly (enlargement of the liver and spleen). Laboratory testing may demonstrate pancytopenia (decreased cell counts in white blood cells, red blood cells, and platelets) and advanced immunodeficiency.

Which of the following is necessary to assure comprehensive quality for helium dilution and nitrogen washout testing? 1. The accuracy and precision of the volume or flow-measuring device must be assured. 2. The accuracy and linearity of the gas analyzer must be verified. 3. Leak test must be acceptable while monitoring change in volume and gas concentrations over at least a minute. 4. Corrections for hemoglobin (Hb) and COHb must be included. a. 2, 3, and 4 only b. 2 and 3 only c. 1, 3, and 4 only d. 1, 2, and 3 only

ANS: D Comprehensive quality assurance for helium dilution and nitrogen washout testing requires accuracy and precision of the volume or flow measuring device, accuracy, and linearity of the gas analyzer and leak test must be acceptable levels.

Which of the following conditions may require higher initial respiratory rates? 1. Metabolic alkalosis 2. ARDS 3. Increased intracranial pressure 4. Metabolic acidosis a. 1 and 3 only b. 1, 2, and 3 only c. 3 and 4 only d. 2, 3, and 4 only

ANS: D Conditions that may necessitate a higher initial rate include ARDS, acutely increased intracranial pressure (with caution), and metabolic acidosis.

A patient is experiencing an exacerbation of COPD. He is 65 years old, slim, and in notable distress with tachypnea, tachycardia, and an arterial blood pH of 7.29. Which of the following therapies would be most indicated? a. Intrapulmonary percussive ventilation b. Intubation and mechanical ventilation c. Nasal CPAP d. Noninvasive ventilation

ANS: D Criteria defining candidacy for noninvasive ventilation include acute respiratory acidosis (without frank respiratory arrest), hemodynamic stability, ability to tolerate the interface needed for noninvasive ventilation, ability to protect the airway, and lack of craniofacial trauma or burns, copious secretions, or massive obesity.

Which of the following is the best explanation for the decreased levels of atrial natriuretic hormone commonly observed among patients receiving positive-pressure ventilation? a. Stimulation of the pulmonary stretch receptors b. Inhibition of posterior pituitary function c. Inhibition of the cortex of the adrenal gland d. Decreased right atrial transmural pressure

ANS: D Decreased right atrial transmural pressure is primarily responsible for the decrease in atrial natriuretic hormone, which leads to sodium retention.

Which of the following mechanisms probably contribute to the beneficial effects of continuous positive airway pressure (CPAP) in treating atelectasis? 1. Recruitment of collapsed alveoli 2. Decreased work of breathing 3. Improved distribution of ventilation 4. Increased efficiency of secretion removal a. 1, 2, and 4 only b. 2 and 3 only c. 1 and 4 only d. 1, 2, 3, and 4

ANS: D Exactly how CPAP helps resolve atelectasis is unknown. However, the following factors probably contribute to its beneficial effects: (1) the recruitment of collapsed alveoli via an increase in FRC, (2) a decreased work of breathing due to increased compliance or elimination of auto-positive end expiratory pressure (PEEP), (3) an improved distribution of ventilation through collateral channels (e.g., Kohn pores), and (4) an increase in the efficiency of secretion removal.

Which of the following are associated with hypercapnic respiratory failure due to respiratory muscle weakness or fatigue? 1. Hyperthyroidism 2. Myasthenia gravis 3. Amyotrophic lateral sclerosis 4. Guillain-Barré syndrome a. 1 and 3 only b. 1, 2, and 3 only c. 3 and 4 only d. 2, 3, and 4 only

ANS: D Examples include spinal trauma, motor neuron disease where lesions of the anterior horn cells may gradually lead to progressive ventilatory failure (such as in amyotrophic lateral sclerosis, or poliomyelitis), motor nerve disorders (including Guillain-Barré syndrome and Charcot-Marie-Tooth disease), disorders of the neuromuscular junction (such myasthenia gravis and botulism), and muscular diseases (including muscular dystrophy, myositis, critical care myopathy, and metabolic disorders).

Of the following common causes of asthma, which is the least likely to cause exercise-induced asthma? a. Long distance cycling b. Running cross country c. Skiing and snowboarding d. Swimming indoors

ANS: D Exercise-induced asthma (EIA) is common in asthmatics, especially after participation in outdoor activities in cold weather. The causes are not fully understood, but heat loss from the airways appears to be one of them.

What might be indicated by failure of the patient's temperature to normalize 4 or 5 days after the start of antibiotic therapy? 1. A closed-space infection 2. Drug fever 3. A missed pathogen a. 1 and 2 only b. 2 and 3 only c. 1 only d. 1, 2, and 3

ANS: D Failure of the patient's temperature to normalize within 4 or 5 days suggests the following possibilities: a missed pathogen, a metastatic or closed-space infection (e.g., empyema), drug fever, or the presence of an obstructing endobronchial lesion.

The volume of gas actually delivered to a patient by most positive-pressure ventilation is always less than that expelled from the machine. Which of the following factors help to explain this finding? 1. Gas compression under pressure 2. Presence of built-in leaks 3. Expansion of the ventilator circuitry a. 2 and 3 only b. 1 and 2 only c. 1, 2, and 3 d. 1 and 3 only

ANS: D First, gases are compressed when delivered under pressure. Thus, the generated volume (at atmospheric pressure) occupies less space when delivered under pressure. Second, most ventilator circuits are somewhat compliant.

Which of the following is false about flow-triggered ventilatory support? a. The work of breathing with flow triggering is less than with pressure triggering. b. Flow-triggered systems respond to changes in flow rather than pressure. c. Pressure triggering on new ventilators may be as sensitive as flow-triggering. d. Flow triggering will decrease the work of breathing in patients with small endotracheal tubes and auto-PEEP.

ANS: D Flow triggering may not be effective in reducing work of breathing because of the presence of a small endotracheal tube or auto-PEEP.

For adults with otherwise normal lungs who are receiving ventilatory support in the continuous mandatory ventilation control or assist-control mode, inspiratory flow should be set to provide what 1:E? a. 2:1 b. 3:1 c. 1:1 d. 1:2

ANS: D For most adults, an initial inspiratory time of approximately 1 sec (0.8 to 1.2 sec) with a resultant 1:E ratio of 1:2 or lower is a good starting point.

For which of the following uses might you consider the use of a pneumatically powered ventilator? a. In the intensive care unit b. When delivering heliox c. When alarm conditions need monitoring d. During certain types of patient transport

ANS: D For patient transport, you must use either a pneumatically powered ventilator or one that can run solely on batteries. Always take along a manually powered bag-valve mask resuscitator, and for long transports be sure to have back-up power available (extra cylinders or batteries).

A patient receiving continuous mandatory ventilation in the assist-control mode develops auto-PEEP. Which of the following changes in ventilatory patterns would you consider to minimize the effects of auto-PEEP in this patient? 1. Decreasing the rate or increasing VT 2. Using low-rate synchronized intermittent mandatory ventilation 3. Decreasing the peak inspiratory flow 4. Lowering the VT and letting the PaCO2 rise a. 2 and 4 only b. 3 and 4 only c. 1, 2, and 3 only d. 1, 2, and 4 only

ANS: D For patients with obstructive disease, ensure a short inspiratory time and long expiratory time to avoid air trapping and minimize auto-PEEP. Lower VT and rate may be necessary in acute asthma to avoid further lung overinflation.

In which of the following disorders would an increased VD/VT ratio not be likely? a. Congestive heart failure b. Pulmonary embolism c. Acute lung injury d. Hypothalamus tumor

ANS: D Frequently the VD/VT ratio is increased in patients with congestive heart failure, pulmonary embolism, acute lung injury, or pulmonary hypertension and in patients undergoing mechanical ventilation.

Which the following are hazards associated with mechanical ventilation? 1. Reduced cardiac output 2. Liver failure 3. Ventilatory muscle dysfunction 4. Ventilator-induced lung injury a. 1 and 3 only b. 1, 2, and 3 only c. 3 and 4 only d. 1, 3, and 4 only

ANS: D Hazards of mechanical ventilation include decreased venous return and cardiac output, patient-ventilatory asynchrony (See Chapter 48), and ventilatory muscle dysfunction owing to inappropriate ventilator settings, ventilator-associated pneumonia, and ventilator-induced lung injury.

Beneficial effects of using high inspiratory flows in patients with chronic airflow obstruction receiving flow-limited mechanical ventilation include which of the following? 1. Decreased work of breathing 2. Improved gas exchange 3. Decreased auto-PEEP a. 1 and 2 only b. 1 and 3 only c. 2 and 3 only d. 1, 2, and 3

ANS: D Higher flow (up to 80 L/min) may improve gas exchange in chronic obstructive pulmonary disease patients, probably because of the resulting increase in expiratory time. See Box 49-4.

A patient with an opiate drug overdose is unconscious and exhibits the following blood gas results breathing room air: pH = 7.19; PCO2 = 89; HCO3 - = 27; PO2 = 48. Which of the following best describes this patient's condition? a. Chronic hypoxemic respiratory failure b. Chronic hypercapnic respiratory failure c. Acute hypoxemic respiratory failure d. Acute hypercapnic respiratory failure

ANS: D Hypercapnic respiratory failure ("pump failure," "ventilatory failure") is characterized by an elevated PaCO2, creating an uncompensated respiratory acidosis (whether acute or acute-on-chronic).

Hypercapnic (type II) respiratory failure is a synonym for which one of the following terms? a. Mismatching b. Shunt c. Diffusion impairment d. Ventilatory failure

ANS: D Hypercapnic respiratory failure is also known as ventilatory failure.

You have just given your patient a 0.03 mg/ml dose of methacholine to assess for asthma. The subsequent forced vital capacity (FVC) shows no change. What should you do next? a. Report to the physician that the patient does not have asthma. b. Wait 1 hr and repeat the test at the same dose. c. Have the patient return tomorrow to repeat the test. d. Double the dose and repeat the FVC maneuver.

ANS: D If a positive response does not occur, the methacholine dosage is doubled to 0.06 mg/ml, and then the FVC maneuver is repeated.

Which of the following is the consequence of decreased resistance or compliance? a. It takes more time to fill the alveoli. b. It takes more time to empty the alveoli. c. It takes less time to fill and more time to empty the alveoli. d. It takes less time to fill and empty the alveoli.

ANS: D If compliance or resistance decreases, the time constant for a given lung unit decreases, and the lung fills and empties faster.

Which of the following parameters are set when volume-supported ventilation (VSV) is used? 1. Tidal volume 2. Maximum peak pressure 3. Positive end expiratory pressure (PEEP) 4. Flow a. 1 and 3 only b. 2 only c. 1, 2, 3, and 4 d. 1, 2, and 3 only

ANS: D In VSV, a desired tidal volume, maximum peak pressure, FiO2, and PEEP are set.

Which of the following is found almost universally in patients with interstitial lung disease (ILD)? a. Airway dilation b. Bronchoconstriction c. Compensatory cytokine release d. Decreased compliance

ANS: D In almost all of the ILDs, the lungs have reduced compliance and require supranormal transpleural pressures to ventilate. This lack of compliance results in small lung volumes and increased work of breathing.

Which of the following trigger levels is appropriate when setting a ventilator for flow triggering? a. 9 to 11 L/min below baseline flow b. 7 to 9 L/min below baseline flow c. 4 to 6 L/min below baseline flow d. 1 to 2 L/min below baseline flow

ANS: D In general, for flow triggering the trigger flow should be set 1 to 2 L/min below baseline or bias flow.

In intubated patients, what do sources of increased imposed work of breathing include? 1. Endotracheal tube 2. Ventilator circuit 3. Auto-PEEP a. 1 and 2 only b. 1 and 3 only c. 2 and 3 only d. 1, 2, and 3

ANS: D In intubated patients, sources of imposed work of breathing include the endotracheal tube, ventilator circuit, and auto-PEEP due to dynamic hyperinflation with airflow obstruction, as is commonly seen in the patient with COPD.

Which of the following conditions is most closely associated with exudative pleural effusion? a. Cirrhosis of the liver b. Congestive heart failure c. Nephrotic syndrome d. Tuberculosis

ANS: D In many parts of the world, any lymphocyte-predominant exudative effusion is considered tuberculosis until proved otherwise.

What is the most common identified cause of community-acquired pneumonia? a. Coxiella burnetii b. Legionella pneumophila c. Chlamydophila pneumoniae d. Streptococcus pneumoniae

ANS: D In most studies, S. pneumoniae, also called pneumococcus, has been the most commonly identified cause of community-acquired pneumonia. Table 24-1 lists the classification and possible causes of pneumonia.

Your patient has relatively normal lungs and is receiving mechanical ventilation following surgery. You observe double triggering. What is the most likely cause? a. The termination criteria is set too low. b. The flow rate is too slow. c. Auto-PEEP. d. The inspiratory time is too short.

ANS: D In patient with relatively healthy lungs where the termination criteria is set too high or inspiratory time too short, double triggering can occur every breath. These are primarily postoperative patients or overdose patients.

What finding is usually used to confirm the diagnosis of pneumonia? a. Development of central cyanosis b. New cough or new characteristic to the cough c. New fever d. New infiltrate on chest radiograph

ANS: D In patients with a compatible clinical syndrome, the diagnosis of community-acquired pneumonia is established by the presence of a new pulmonary infiltrate on the chest radiograph.

What goals does the practitioner hope to achieve when selecting initial ventilatory support settings? 1. Optimize oxygenation. 2. Optimize ventilation. 3. Maintain acid-base balance. 4. Avoid harmful side effects. a. 1 and 4 only b. 2 and 3 only c. 1, 3, and 4 only d. 1, 2, 3, and 4

ANS: D In the selection of initial ventilator settings, the goal is to optimize the patient's oxygenation, ventilation, and acid-base balance while avoiding harmful side effects.

Which of the following would you assess immediately after a patient is placed on a ventilatory support device? 1. ABGs 2. Patient's airway 3. Patient's vital signs a. 1 and 2 only b. 1 and 3 only c. 2 and 3 only d. 1, 2, and 3

ANS: D Initial patient evaluation should include physical assessment, assessment of ventilator settings, cardiovascular assessment, oximetry, and measurement of arterial blood gases (Box 49-12).

Which of the following possesses the most significant risk for hypoventilation? a. IPPB b. IS c. IPAP/EPAP d. CPAP

ANS: D Intermittent use of CPAP for correcting atelectasis is contraindicated when certain clinical situations exist. A patient who is hemodynamically unstable is unlikely to tolerate CPAP for even a short period. For those patients who are suspected to have hypoventilation NIV is usually a better option than CPAP.

What conclusions can you draw from the following data, obtained on a 67-year-old, 76-kg man admitted for pulmonary complications arising from silicosis, ACTUAL PRED % PRED. ACTUAL PRED % PRED TLC 4.34 7.73 56%. FVC 2.86 4.74. 60% FRC 1.73 4.36 40%. %FEV1 96% 83% RV 1.45 2.63 55%. FEF200-1200 6.89 6.71 103% VC 2.89. 4.74 61%. FEF25%-75% 2.78 2.88. 96% a. Results indicate generalized airway obstruction. b. Results indicate normal pulmonary function. c. Results indicate a combined disease process. d. Results indicate a restrictive lung disorder.

ANS: D Interpretation of the pulmonary function report: Interpretive strategies for pulmonary function testing abound. Most computer-based pulmonary function testing systems have algorithms in their software programs for computer-assisted interpretations of the pulmonary function report. A consensus for interpreting test results is growing. Table 20-8 summarizes pulmonary function changes that may occur in advanced obstructive and restrictive patterns of lung diseases, and Figure 20-16 presents a simple algorithm to assess pulmonary function test results in clinical practice. When considering a pulmonary function report, the %FEV1/VC ratio is a good place to start, because it provides an initial focus as normal, restrictive, or obstructive impairment. When the %FEV1/FVC is less than the limit of normal (LLN), there is airway obstruction. When the %FEV1/FVC is greater than the LLN, there is no airway obstruction. The LLN %FEV1/FVC can be determined directly for various population using regression equations in Table 20-9 or simply estimated at 70%. If the %FEV1/FVC ratio is greater than the LLN or 70% and if the TLC is less than the LLN, often defined as less than 80% predicted normal, the patient has a restrictive impairment, according to this algorithm. The severity of the restriction is based on the percent predicted or on the number of standard deviations below the LLN TLC according to Table 20-2. If the %FEV1/FVC ratio is less than 70%, the patient likely has an obstructive impairment; the severity of the obstruction is based on the percent predicted normal FEV1 according to Table 20-2. If the percent predicted normal DLCO is less than 80%, the patient has a diffusion impairment. Some laboratories also report the DLCO/VA ratio, which indexes the DLCO for lung volume measured during the single breath test. If the DLCO/VA ratio is also less than 80% of the indexed value, the cause of the diffusion impairment is considered within the lung, and if the DLCO/VA ratio is greater than 80% of the indexed value, the cause of the diffusion impairment is considered due to small lung volume.

A 26 year-old seasonal worker from South America came to the ER with a history of a dry, hacking blood-tinged cough, fever, chills, and loss of appetite. The chest x-ray showed cavitary lesion in the right upper lobe. After a week in the hospital, the sputum culture shows the present of acid-fast stained organisms. Which of the following medications would you recommend for this patient at this time? 1. Ceftizoxime 2. Isoniazid 3. Rifampin 4. Ethambutol a. 1 and 3 only b. 2 and 4 only c. 1, 2, and 3 only d. 2, 3, and 4 only

ANS: D Isoniazid, rifampin, pyrazinamide, and ethambutol are first-line antituberculous medications. Pending antimicrobial susceptibility results, treatment with four drugs is recommended. In patients with drug-susceptible pulmonary tuberculosis, many 6- to 9-month treatment regimens have been shown to be effective, as outlined in guidelines by the ATS, CDC, and IDSA.

What disease process is associated with much higher risk of tuberculosis? a. Asbestosis b. Coal worker's pneumoconiosis c. Sarcoidosis d. Silicosis

ANS: D It is important to recognize the association of silicosis with lung cancer and active tuberculosis. Silicosis patients develop active tuberculosis 2- to 30-fold more frequently than do coal worker's pneumoconiosis without silicosis.

Which of the following terms describe the lung injury associated with the use of low tidal volumes? a. Biotrauma b. Barotrauma c. Volutrauma d. Atelectrauma

ANS: D Lung damage may also occur when ventilating at low tidal volumes, if alveoli are allowed to deflate and reinflate repeatedly with each breath. This injury is called atelectrauma.

Which of the following statements is true when comparing the pulmonary function test results of men versus women? a. Females have larger predicted volumes when corrected for height. b. Females have the same predicted values when corrected for weight. c. Males and females have the same predicted values when corrected for age. d. Males have larger predicted volumes when corrected for height.

ANS: D Male values are larger than female values when height and age are equal.

Which of the following factors would tend to increase mean airway pressure? 1. Short inspiratory times. 2. Increased mandatory breaths. 3. Increased levels of positive inspiratory pressure (PIP). 4. Increased levels of positive end expiratory pressure (PEEP). a. 1 and 3 only b. 1, 3, and 4 only c. 3 and 4 only d. 2, 3, and 4 only

ANS: D Mean airway pressure is decreased by decreasing inspiratory time, tidal volume, respiratory rate, PEEP, or PIP.

In which of the following modes are spontaneous breaths between mandatory breaths not possible? a. Continuous positive pressure ventilation b. Intermittent mandatory ventilation c. Pressure support ventilation d. Continuous mandatory ventilation

ANS: D More specifically, continuous mandatory ventilation is a breath sequence for which spontaneous breaths are not possible between mandatory breaths because every patient trigger signal in the trigger window produces a machine-cycled inspiration

Lambert-Eaton syndrome is characterized by which of the following? a. It affects mainly the limbs and eyes. b. Patients have a mean age of 40 years. c. Large-cell carcinoma is most common. d. It is commonly associated with small-cell lung cancer.

ANS: D More than 66% of cases of Lambert-Eaton syndrome are associated with cancer. Of these cancer-related cases, 50% are associated with small-cell carcinoma of the lung.

Which of the following are associated with hypercapnic respiratory failure due to increased work of breathing? 1. Asthma 2. COPD 3. Obesity 4. Kyphoscoliosis a. 1 and 2 only b. 1, 2, and 4 only c. 3 and 4 only d. 1, 2, 3, and 4

ANS: D Most commonly, this situation occurs when increased dead space accompanies COPD or elevated airway resistance accompanies asthma. Both of these obstructive airway diseases may raise respiratory work requirements excessively due to the presence of intrinsic positive end expiratory pressure. Increased workload can also result from thoracic abnormalities such as pneumothorax, rib fractures, pleural effusions, and other conditions creating a restrictive burden on the lungs. Finally, requirements for increased minute ventilation can arise when increased CO2 production accompanies hypermetabolic states, such as in extensive burns.

Synchronized Intermittent Ventilation (SIMV)

What mode of ventilation is where the mechanical breaths are synchronized with patient's spontaneous respiratory rate?

NIV should be considered in patients with which of the following? 1. Chronic neuromuscular weakness 2. Apnea associated with ALS 3. Acute neuromuscular weakness 4. Exacerbations of myasthenia gravis a. 2 and 4 only b. 1, 2, and 3 only c. 1 and 3 only d. 1, 3, and 4 only

ANS: D NIV should be considered in patients with chronic or acute neuromuscular weakness, exacerbations of myasthenia gravis, post-extubation support for patients intubated for transient respiratory failure, neuromuscular patients who also have COPD or congestive heart failure.

What does the National Asthma Education Project recommend be measured at home in patients with moderate to severe asthma? a. Pulse oximeter b. Degree of pulmonary shunt c. DLCO d. Peak expiratory flow

ANS: D National Asthma Education Project guidelines also recommend that home PEFR measurement be used for patients with moderate to severe asthma.

Which of the following are used to determine a patient's neurologic status? 1. Measuring VD/VT ratio 2. Pupillary response and eye movement 3. Corneal and gag reflex 4. Respiratory rate and pattern a. 1 and 3 only b. 1, 2, and 3 only c. 3 and 4 only d. 2, 3, and 4 only

ANS: D Neurologic examinations include evaluation of the following: mental status, pupillary response, eye movements, corneal responses, gag reflex, respiratory rate and pattern, motor evaluation, and sensory evaluation.

What is the most common treatment for patients with idiopathic pulmonary fibrosis (IPF)? a. Hyperbaric oxygen treatments b. Lung transplantation c. Penicillin d. Prednisone

ANS: D No medical therapy has proven beneficial for IPF. Immunosuppression with oral corticosteroids and cytotoxic agents such as azathioprine are most commonly used, although they appear to benefit only a minority of patients.

What does the acronym TNM mean? a. Tumor, number, mass b. Tumor, non-small, metastases c. Tracheal, number, metastases d. Tumor, lymph node, metastases

ANS: D Non-small-cell lung cancer is staged using the TNM system ("T" for extent of primary tumor, "N" for regional lymph node involvement, and "M" for metastases).

A patient develops acute hypercapnic respiratory failure due to muscle fatigue. Which of the following modes of ventilatory support would you consider for this patient? 1. Assist-control ventilation with adequate backup 2. Continuous positive airway pressure 3. Intermittent mandatory ventilation with adequate backup rate 4. Bilevel pressure support by mask a. 2 and 4 only b. 3 and 4 only c. 1, 2, and 3 only d. 1, 3, and 4 only

ANS: D Noninvasive positive-pressure ventilation can improve hypoxemia and hypercarbia by several mechanisms including but not limited to (1) compensating for the inspiratory threshold load imposed by intrinsic positive end-expiration pressure, (2) supplementing a reduced tidal volume, (3) partial or complete unloading of the respiratory muscles, (4) reducing venous return and left ventricular afterload, and (5) alveolar recruitment.

Which of the following would be the more common route for nosocomial pathogens to be transmitted? a. Directly patient to patient b. Fecal-oral route c. Aerosol route d. Via the health care worker

ANS: D Nosocomial pathogens capable of producing hospital-acquired pneumonia can be transmitted directly from one patient to another, as in the case of tuberculosis. However, transmission from health care workers (including respiratory therapists (RTs)), contaminated equipment, or fomites (objects capable of transmitting infection through physical contact with them) is more common, especially for gram-negative bacilli, S. aureus, and viruses.

Which of the following side effects is associated with the use of inhaled corticosteroids? a. Bronchospasm b. Frequent cough c. Nausea d. Oral candidiasis

ANS: D Oropharyngeal candidiasis and dysphonia are controllable with spacer use and by rinsing the mouth after each treatment.

Which of the following techniques can be used to improve oxygenation beyond increasing the FiO2 or PEEP level? 1. Proning the patient 2. Use of an expiratory pause 3. Use of inverse I:E ratio ventilation a. 1 only b. 1 and 2 only c. 2 and 3 only d. 1 and 3 only

ANS: D Other techniques that may be helpful in improving arterial O2 levels include the use of PCV with a prolonged inspiratory time, use of an inspiratory pause, inverse 1:E ratio ventilation, and prone positioning.

Which of the interstitial lung diseases is directly tied to exposure to first- and secondhand tobacco smoke? a. Alveolar proteinosis b. Idiopathic pulmonary fibrosis c. Nonspecific interstitial pneumonitis d. Pulmonary Langerhans cell histiocytosis (PLCH)

ANS: D PLCH is an interstitial lung disease found in adult smokers. Patients usually have a significant smoking history and develop cough and progressive dyspnea on exertion.

Which of the following means ending inspiratory time independent of signals? a. Patient-triggering b. Machine-triggering c. Patient-cycling d. Machine-cycling

ANS: D Patient-triggering means starting inspiration based on a signal from the patient, which is independent of a machine trigger signal. Machine-triggering means starting inspiratory flow based on a signal (usually time) from the ventilator, which is independent of a patient trigger signal. Patient-cycling means ending inspiratory time based on signals representing the patient-determined components of the equation of motion (i.e., elastance or resistance) and including effects due to inspiratory effort. Flow-cycling is a form of patient-cycling because the rate of flow decay to the cycle threshold, and hence the inspiratory time, is determined by patient mechanics. Machine-cycling means ending inspiratory time independent of signals representing the patient-determined components of the equation of motion.

Which of the following symptoms can be seen in a patient with CAP? 1. Cough 2. Pleuritic chest pain 3. Diarrhea 4. Sore throat a. 2 and 4 only b. 1, 2, and 4 only c. 1 and 3 only d. 1, 2, 3, and 4

ANS: D Patients with CAP typically have fever and respiratory symptoms, such as cough, sputum production, pleuritic chest pain, and dyspnea. Patients may also complain of hoarseness, sore throat, headache, and diarrhea. Fever, cough, and sputum production may occur in other illnesses as well, such as acute bronchitis or exacerbations of chronic bronchitis.

What are the functions of a chest tube in a patient with chest trauma that causes bleeding and pneumothorax? 1. To measure the rate of bleeding 2. To improve ventilation 3. To allow lung reexpansion 4. To allow for application of bleeding control medication a. 1 and 4 only b. 2 and 3 only c. 2, 3, and 4 only d. 1, 2, and 3 only

ANS: D The chest tube is multifunctional to allow measurement of the rate of bleeding, to allow the lung to be pulled to the parietal pleural surface to tamponade bleeding, and to allow maximum ventilation.

Which of the following are considered relative contraindications for lung volume determinations? 1. Recent cataract removal surgery 2. Unstable cardiovascular status 3. Treated pneumothorax 4. Hemoptysis of unknown origin a. 2, and 3 only b. 1 and 4 only c. 2, 3, and 4 only d. 1, 2, and 4 only

ANS: D Patients with acute, unstable cardiopulmonary problems such as hemoptysis, pneumothorax, myocardial infarction, and pulmonary embolism and patients with acute chest or abdominal pain should not be tested. Testing could be harmful, if needed treatment would be delayed. Patients who have nausea and who are vomiting should not be tested; there is a risk of aspiration. Testing for patients who have had recent cataract removal surgery should be delayed; changes in ocular pressure may be harmful to the eye.

What type of disease is associated with perfusion/diffusion impairment? a. Liver disease b. Renal disease c. Neuromuscular disease d. Vascular disease

ANS: D Perfusion/diffusion impairment is a rare cause of hypoxemia found in individuals with liver disease complicated by the hepatopulmonary syndrome.

Which of the following is true concerning pneumonia? a. Patients with community-acquired pneumonia most often require hospitalization. b. Community-acquired pneumonias are most often antibiotic-resistant strains. c. Pneumonia is the number one cause of death in the United States. d. Pneumonia is the eighth leading cause of death in the United States.

ANS: D Pneumonia is the eighth leading cause of death in the United States and the most common cause of infection-related mortality.

Which of the following are associated with a decreased end-tidal PCO2? 1. Decreased metabolic rate 2. Increase in lung perfusion 3. Rapid and very shallow breathing 4. Decreased CO2 production a. 1 and 3 only b. 1, 2, and 3 only c. 2 and 4 only d. 1, 3, and 4 only

ANS: D Positive pressure ventilation (especially with PEEP), pulmonary embolism, cardiac arrest, and pulmonary hypoperfusion also may cause an increase in PaCO2 to PETCO2 gradient [P(a-ET)CO2]. Exercise and a large tidal volume can reverse the P(a-ET)CO2 gradient, the PETCO2 can actually exceed the PaCO2.

Which of the following are true about intermittent positive-pressure breathing? 1. During inspiration, pressure in the alveoli decreases. 2. The pressure gradients of normal breathing are reversed. 3. During inspiration, alveolar pressure may exceed pleural pressure. 4. Energy stored during inspiration causes a passive exhalation. a. 1 and 3 only b. 1, 2, and 3 only c. 3 and 4 only d. 2, 3, and 4 only

ANS: D Ppl may actually exceed atmospheric pressure during a portion of inspiration.

What is the ability of a measuring device to consistently provide the same measure of the same quantity? a. Capacity b. Accuracy c. Linearity d. Precision

ANS: D Precision is synonymous with reliability of measurements and the opposite of variability.

Which of the following variables determine the level of support achieved with proportional assist ventilation? 1. Patient effort 2. Elastance 3. Resistance a. 1 and 3 only b. 2 only c. 1 only d. 1, 2, and 3

ANS: D Proportional assist ventilation is a mode of ventilation designed to vary inspiratory pressure in proportion to patient effort, elastance, and resistance.

Which of the following is a clinical condition that typically does not precipitate rapid respiratory failure in patients with significant neuromuscular weakness? a. Pulmonary edema b. Pneumonia c. Mucous plugging d. Lung cancer

ANS: D Pulmonary edema, pneumonia, and mucous plugging are examples of clinical conditions that can precipitate respiratory failure rapidly in patients with significant neuromuscular weakness. Such patients may need observation of their respiratory status when they are in the hospital with these conditions.

Which of the following is not a clinical condition that precipitates respiratory failure rapidly in patients with significant neuromuscular weakness? a. Pulmonary edema b. Pneumonia c. Mucus plugging d. Pulmonary fibrosis

ANS: D Pulmonary edema, pneumonia, and mucus plugging are examples of clinical conditions that can precipitate respiratory failure rapidly in patients with significant neuromuscular weakness.

For adolescents in the 8- to 16-year-old age range, which of the following ranges of ventilator setting would you initially recommend? a. Rate: 12 to 20 breaths/min; VT: 6 to 8 ml/kg b. Rate: 20 to 25 breaths/min; VT: 4 to 6 ml/kg c. Rate: 25 to 35 breaths/min; VT: 8 to 10 ml/kg d. Rate: 25 to 35 breaths/min; VT: 6 to 8 ml/kg

ANS: D Recommended initial tidal volume and frequency for various patient types are described in Table 49-4.

What disease process is the most common cause of interstitial lung disease (ILD) in the United States? a. Asbestosis b. Coal worker's pneumoconiosis c. Idiopathic pulmonary fibrosis d. Sarcoidosis

ANS: D Sarcoidosis is an idiopathic multisystem inflammatory disorder that commonly involves the lung. In fact, it is the most common cause of the ILD in the United States.

Which of the following is an indirect injury that can cause ARDS? a. Pneumonia b. Lung contusion c. High concentrations of oxygen d. Transfusions

ANS: D See Box 29-3.

Which of the following risk factors for ARDS is classified as a nonpulmonary cause? a. Toxic inhalation b. Gastric aspiration c. Near drowning d. Sepsis

ANS: D See Box 29-3.

During your patient-ventilator assessment you observe auto-triggering. Which of the following is a likely cause? 1. Leaks in the circuit 2. Ventilator malfunction 3. Water in the circuit 4. Inappropriately set sensitivity a. 1 and 2 only b. 1, 2, and 3 only c. 3 and 4 only d. 1, 3, and 4 only

ANS: D See Box 48-6.

Which of the following are contraindications for the use of noninvasive ventilation (NIV)? 1. Hemodynamic instability 2. Apnea 3. Copious amounts of secretions 4. Uncooperative behavior on the part of the patient a. 1, 2, and 3 only b. 2 and 4 only c. 1, 2, and 4 only d. 1, 2, 3, and 4

ANS: D See Box 50-4.

What composition of adenocarcinoma best describes its histopathology? a. Stratified epithelial cells b. Pleomorphic cells c. Polygonal cells d. Glandular structures

ANS: D See Table 32-1.

Which of the following best describes the cell characteristics in small-cell carcinoma? a. Larger than lymphocyte nucleus b. Enlarged nuclei-differentiated cells c. Keratin structures throughout lung tissue d. Develops from a common pulmonary stem cell

ANS: D See Table 32-1.

Which of the following MIP measures taken on an adult patient indicates inadequate respiratory muscle strength? a. -90 cm H2O b. -70 cm H2O c. -40 cm H2O d. -15 cm H2O

ANS: D See Table 45-3.

Which of the following are benefits of continuous positive airway pressure (CPAP) in postoperative major abdominal surgery? 1. Lower mortality 2. Lower intubation rate 3. Lower incidence of pneumonia 4. Lower rate of sepsis a. 1 and 3 only b. 1, 2, and 3 only c. 3 and 4 only d. 2, 3, and 4 only

ANS: D Several investigators have reported favorable results used NIV instead of standard O2 therapy for ARF during the postoperative period after major abdominal surgery or thoracic surgery. Positive findings include improved oxygenation, fewer infections and lower rate of intubation. Although these results are encouraging, additional randomized trials are needed to define the role of NIV in the treatment of postop ARF. At the present time, there is insufficient evidence to support routine use of NIV after major surgery.

Which of the following physical examination findings could be considered a late manifestation of interstitial lung disease (ILD)? a. Bronchial wheezing b. Increased wedge pressure c. Peripheral cyanosis d. Pulmonary hypertension

ANS: D Signs of pulmonary arterial hypertension with right ventricular dysfunction, such as lower extremity edema or jugular venous distention, may occur late in the course of any ILD and are not helpful in the diagnosis of a specific ILD.

Which of the following best defines a ventilator? a. A machine that performs respiration for a patient b. A machine designed to measure pulmonary mechanics c. A machine designed to display graphical representations of respiration d. A machine that is designed to perform some portion of the work of breathing

ANS: D Some basic knowledge of mechanics is helpful to understand how ventilators work. A ventilator is simply a machine that is designed to perform some portion of the work of breathing.

Tests of pulmonary mechanics include 1. maximum voluntary ventilation. 2. functional residual capacity. 3. forced expiratory flows. 4. forced expiratory volumes. a. 3 and 4 only b. 1 and 2 only c. 1, 2, and 3 only d. 1, 3, and 4 only

ANS: D Spirometry includes the tests of pulmonary mechanics, the measurements of forced vital capacity, FEV1, several FEF values, forced inspiratory flow (FIF) rates, and the MVV.

Describe a secondary spontaneous pneumothorax. a. Pneumothorax that occurs secondary to cardiac complications b. Pneumothorax that occurs without trauma or any underlying disease c. Pneumothorax that results from nonpenetrating chest trauma d. Pneumothorax that results from underlying lung disease

ANS: D Spontaneous pneumothoraces are of two types: (1) primary spontaneous pneumothorax, in which there is no underlying lung disease, and (2) secondary spontaneous pneumothorax, in which lung disease is present.

What alteration in respiration is typically associated with stroke involving the cerebral cortex? a. Severe hypoxemia b. Respiratory acidosis c. Mild hyperventilation d. Sleep apnea

ANS: D Stroke in these regions of the motor cortex can lead to obstructive sleep apnea or aspiration pneumonia as a result of the loss of bulbar muscle function.

Which of the following define successful application of noninvasive ventilation (NIV)? 1. Overall improvement of patient's blood gas 2. Normal blood gas 3. PaO2 increased 4. PaCO2 decreased a. 1 only b. 1, 2, and 3 only c. 1, 2, 3, and 4 d. 1, 3, and 4 only

ANS: D Successful application of NIV is easy to define: the patient's blood gases improve, PaCO2 decreases, and pH normalizes, while PaO2 increases

Which of the following are laboratory findings used to identify mortality risk in adults with community-acquired pneumonia? 1. Acidemia 2. Proteinuria 3. Azotemia 4. Hyponatremia a. 1, 2, and 3 only b. 2 and 4 only c. 1 and 3 only d. 1, 3, and 4 only

ANS: D Table 24-4 illustrates the Pneumonia Severity Index (PSI) scoring system for stratifying risk of 30-day mortality in adults with CAP. Proteinuria is not scored.

ATS guidelines suggest using which of the following antibiotics if methicillin-resistant S. aureus is a concern? a. Cefazolin b. Doxycycline c. Penicillin d. Vancomycin

ANS: D Table 24-8 lists empiric regimens for treatment of hospitalized adults with CAP.

Which of the following is the cardinal sign of increased work of breathing? a. Hyperventilation b. Retractions c. Bradycardia d. Tachypnea

ANS: D Tachypnea is the cardinal sign of increased work of breathing.

Which of the following physical findings is not consistent with starvation? a. Temporal muscle wasting b. Sunken supraclavicular fossae c. Decreased adipose stores d. Less than 50 ml/day

ANS: D Temporal muscle wasting, sunken supraclavicular fossae, and decreased adipose stores are easily recognized signs of starvation

You are called to attend to an ER patient complaining of shortness of breath and severe dyspnea on exertion. Patient history is significant for a 30-year-pack smoking history, dry nonproductive cough, and occasional pedal edema. CXR findings are not remarkable except for mild cardiomegaly. You want to rule out ILD versus obstructive lung disease. Results for pulmonary function testing are shown below. Spirometry Value %Predicted FVC (L) 2.79 63 SVC (L) 2.61 59 FEV1(L). 2.12 67 FEV1/FVC (%) 80 FEF 25% to 75% (L/min) 4.11 98 Lung volume RV (L) 1.20 100 TLC (L) 3.99 60 DLCO (ml/min/mm Hg) 11.35 28 These results are consistent with a. small airway disease. b. air trapping. c. severe obstructive disease. d. loss of alveolar capillary surface.

ANS: D The DLCO indicates a loss of alveolar capillary surface area and strongly suggests that lung destruction is occurring at the level of the alveolar-capillary membrane.

When adjusting a patient's oxygenation during mechanical ventilatory support, what should your goal be? a. SaO2 of 80% to 90% b. PaO2 of 100 to 150 mm Hg c. SaO2 of 95% to 100% d. PaO2 of 60 to 100 mm Hg

ANS: D The FiO2 is then titrated to achieve a PaO2 in the range of 60 to 80 mm Hg with an SaO2 of 90% or greater or an SpO2 of 92% or greater.

Which of the following statements about pleural fluid are true? 1. Fluid can move easily between each hemithorax. 2. Normal protein concentration is between 1.3 and 1.4 g/dl. 3. The total volume is approximately 16 ml. 4. Total protein concentration is similar to that of interstitial fluid elsewhere in the body. a. 2 and 4 only b. 1, 2, and 3 only c. 1 and 3 only d. 2, 3, and 4 only

ANS: D The average person has approximately 8 ml of pleural fluid per hemithorax. It is estimated that this pleural fluid has a total protein concentration similar to that of interstitial fluid elsewhere in the body: between 1.3 and 1.4 g/dl. In human beings, the pleural spaces surrounding each lung are completely independent, being separated by the mediastinum

What mode of mechanical ventilation is designed to increase the mean airway pressure to allow recruitment of alveoli while allowing the patient to spontaneously breathe? a. Inverse ratio ventilation b. High-frequency ventilation c. Intermittent mandatory ventilation d. Airway pressure-release ventilation

ANS: D The clinical aim of APRV is to increase the mean airway pressure to allow recruitment of alveoli while allowing the patient to spontaneously breathe.

It is not clear whether your patient has COPD or asthma. Which of the following characteristics is most closely associated with the diagnosis of asthma? a. Daily phlegm production b. Diminished vascularity on the chest radiograph c. Low diffusion capacity d. Reversal of the FEV1 after use of a bronchodilator

ANS: D The diagnosis of asthma is favored if the diminished FEV1 obtained on spirometry can be normalized after use of an inhaled bronchodilator (reversible airway obstruction

Assuming a constant rate of breathing, which of the following inspiratory-to-expiratory (I:E) ratio would tend to most greatly impair a patient's systemic diastolic pressure? a. 1:4 b. 1:3 c. 1:2 d. 1:1

ANS: D The factors of positive-pressure ventilation that may decrease the systemic diastolic pressure are high mean airway pressure, due to a high positive end expiratory pressure, high tidal volume, or long inspiratory time.

The goals of mechanical ventilatory support include which of the following? 1. Support or manipulate gas exchange. 2. Reduce or manipulate the work of breathing. 3. Restore acid-base balance. a. 1 and 2 only b. 2 and 3 only c. 1 and 3 only d. 1, 2, and 3

ANS: D The goals of mechanical ventilatory support are to maintain adequate alveolar ventilation and oxygen (O2) delivery, restore acid-base balance, and reduce the work of breathing with minimum harmful side effects and complications.

Which of the following indicators are useful in assessing respiratory muscle strength? 1. Maximum voluntary ventilation (MVV) 2. Forced vital capacity (FVC) 3. Dead space-to-tidal volume ratio (VD/VT) 4. Maximum inspiratory pressure (MIP) a. 1 and 3 only b. 2 and 4 only c. 3 and 4 only d. 1, 2, and 4 only

ANS: D The most commonly used tests to assess respiratory muscle strength at the bedside are MIP and maximum expiratory pressure (MEP), FVC, and MVV.

The chest radiograph showed the presence of a meniscus in the right chest together with a blunted right costophrenic angle. Which of the following procedures would you recommend at this point to treat Ms. Paul? a. Anterior chest tube thoracostomy b. Chest needle decompression c. Video-assisted thoracoscopy (VAT) d. Posterior chest tube thoracostomy

ANS: D The presence of a meniscus in the chest radiograph is indicative of a large pleural effusion. Large pleural effusions need to be drained either by needle aspiration during a thoracentesis for spontaneously breathing patients or by the insertion of a posterior chest tube. Anterior chest tubes are used for a pneumothorax.

Which of the following are associated with auto-PEEP? 1. Erroneous calculation of static lung compliance 2. Hemodynamic compromise 3. Barotraumas 4. Increasing mean airway pressure a. 1 and 3 only b. 1 and 2 only c. 2, 3, and 4 only d. 1, 2, 3, and 4

ANS: D The presence of auto-PEEP results in the underestimation of mean alveolar pressure when mean airway pressure is being monitored to reflect mean alveolar pressure. An increase in mean alveolar pressure due to auto-PEEP may exacerbate the hemodynamic effects of positive pressure ventilation and increase the likelihood of barotrauma in a manner similar to that seen with the application of PEEP.

Compared to a pressure-controlled strategy, what is the primary advantage of volume-controlled ventilatory support? a. Provides a decelerating flow pattern. b. Limits and controls peak airway pressures. c. Improves patient-ventilator synchrony. d. Guarantees a minimum minute ventilation.

ANS: D The primary advantage of volume-controlled ventilation is maintenance of a stable minute ventilation in the face of changing lung mechanics.

What percentage of amyotrophic lateral sclerosis patients die within 5 years of diagnosis? a. 10% b. 25% c. 50% d. 80%

ANS: D The prognosis of amyotrophic lateral sclerosis is poor, with 80% of patients dying within 5 years of the onset of the disease.

What method of chest tube removal has been associated with the lowest level of pneumothorax recurrence? a. Clamp the chest tube for 4 hr; if chest radiograph is good, remove the tube. b. Clamp chest tube for 24 hr; if clinically stable, remove the tube. c. Remove the chest tube as soon as the air leak resolves. d. Remove the chest tube 48 hr after the air leak resolves.

ANS: D The recurrence rate is near zero when chest tubes are removed 48 hr after the air leak no longer is seen in the water-seal chamber.

What agent has proved to be the most successful in pleurodesis? a. Mixture of saline and Mucomyst b. Acetaminophen in suspension c. Saline solution mixed with heparin d. Talc suspended in saline

ANS: D The success of talc pleurodesis, approximately 90%, is higher than that of all alternatives except surgical abrasion.

Which of the following are considered the main goals of mechanical ventilator support? 1. Protection 2. Partial ventilatory support during trauma 3. Safety 4. Comfort a. 3 and 4 only b. 1, 2, and 3 only c. 1 and 2 only d. 1, 3, and 4 only

ANS: D The use of the ventilator mode taxonomy allows clinicians to appropriately match the technology to the patients' needs. Clinicians must not only know what tool to use but how to use it. Knowing how to use a mode involves understanding the technological capabilities of the mode and how they serve the goals of mechanical ventilation. These goals are safety, comfort, and liberation.

During pressure-targeted modes of ventilatory support, the volume delivered depends on which of the following? 1. Set pressure limit 2. Patient lung mechanics 3. Patient effort a. 1 and 2 only b. 1 and 3 only c. 2 and 3 only d. 1, 2, and 3

ANS: D The volume delivered during pressure-controlled modes varies with changes in set pressure, patient effort, and lung mechanics.

On a chest radiograph, large-cell carcinoma is commonly seen as what type of lesion? a. Central lesion b. Well-defined mass c. Bilateral nodules d. Unilateral nodules

ANS: D These will show a small spot (<3 cm in diameter) termed a nodule.

Which of the following could cause hypercapnic respiratory failure? 1. Smoke inhalation 2. Opiate drug overdose 3. Chronic obstructive pulmonary disease 4. Hypothyroidism a. 1 and 3 only b. 1, 2, and 3 only c. 3 and 4 only d. 2, 3, and 4 only

ANS: D This ventilatory drive can be diminished by various factors such as drugs (overdose/sedation), brainstem lesions, diseases of the central nervous system such as multiple sclerosis or Parkinson's disease, hypothyroidism, morbid obesity (e.g., obesity-hypoventilation), and sleep apnea.

To describe what happens during the expiratory phase of mechanical ventilation, you must know the value of which variable? a. Limit b. Cycle c. Trigger d. Baseline

ANS: D To describe what happens during expiration, we must know what baseline variable is in effect.

Which of the following has been identified as the most common cause of occupational asthma? a. Alpha1-antitrypsin deficiency b. IgE abnormality c. Nitric oxide deficiency d. Toluene diisocyanate

ANS: D Toluene diisocyanate is the most common cause of occupational asthma and is the best studied.

What is the optimal treatment of intrapulmonary shunt? a. Increase the FiO2. b. Decrease the FiO2. c. Surgery. d. Alveolar recruitment.

ANS: D Treatment of intrapulmonary shunt must be directed toward opening collapsed alveoli or clearing fluid or exudative material before oxygen can be beneficial at below toxic levels.

Which of the following medications is generally only used if the patient still has debilitating symptoms from stable COPD, despite inhaled bronchodilator therapy? a. Antibiotics b. Beta-2 agonists c. Corticosteroids d. Methylxanthines

ANS: D Treatment with methylxanthines offers little additional bronchodilation in patients on inhaled bronchodilators, and generally it is reserved for a few patients with debilitating symptoms from stable COPD, despite optimal inhaled bronchodilator therapy

What is the drug of choice for the patient with Pneumocystis jiroveci pneumonia? a. Ampicillin b. Doxycycline c. Erythromycin d. Trimethoprim-sulfamethoxazole

ANS: D Trimethoprim-sulfamethoxazole (TMP-SMX) is the drug of choice for P. jiroveci pneumonia.

What is the predicted normal for the peak expiratory flow (PEF) in the average man? a. 5.5 L/sec b. 6.5 L/sec c. 8.0 L/sec d. 9.5 L/sec

ANS: D Typical normal values for the adult male: PEF is 9.5 L/sec.

For which of the following patients requiring ventilatory support would you recommend against using a heat-moisture exchanger (HME) for airway humidification? 1. Patient with an expired VT less than 70% of the delivered VT 2. Patient with a spontaneous minute ventilation of 14 L/min 3. Patient with body temperature less than 32 C a. 1 and 2 only b. 1 and 3 only c. 2 and 3 only d. 1, 2, and 3

ANS: D Use of HMEs should be avoided in the care of patients with secretion problems and those with low body temperature (<32 C), high spontaneous minute ventilation (>10 L/min), or air leaks in which exhaled tidal volume is less than 70% of delivered tidal volume.

Ventilator input power from which of the following sources? 1. Electrical 2. Battery 3. Pneumatic a. 1 and 2 only b. 1 and 3 only c. 2 and 3 only d. 1, 2, and 3

ANS: D Ventilators can be described in terms of their input power requirements (e.g., electrical or pneumatic) and how the input power is transformed into desired outputs of pressure, volume, and flow.

You are called to the ER to assess a 25-year-old female patient in status asthmaticus. Her PEFR results of pre- and post-bronchodilator therapy are given below: Pre-bronchodilator Post-bronchodilator 1st attempt 216 334 2nd attempt. 224 330 3rd attempt 210. 340 You should suggest to the ER physician to a. stop the bronchodilators. b. repeat the PEF measurement. c. increase the medication dosage. d. continue current therapy.

ANS: D When assessing PEFR results, the highest measurement pre and post should be used to calculate the percentage improvement (pre-post/pre 100). Any improvement of 12 percentage in the PEFR or 200 ml in the FEV1 represent a significant improvement for the bronchodilator. In this case, the patient had an improvement of 52 percentage; hence the therapy should be continued.

Which of the following statements is false regarding ventilation in the assist-control mode? a. Every breath is supported by the ventilator. b. Usually ensures a minimum safe level of ventilation is given. c. Assist-control mode is typically applied using the volume control mode. d. It is usually applied with a backup rate of 5 to 8 breaths/min.

ANS: D With assist-control mode, every breath is supported by the ventilator. Breaths are patient- or time-triggered to inspiration and may be volume or pressure limited. Inspiration may be volume, pressure, or time cycled to the expiratory phase. Assist-control ventilation typically is delivered as volume-controlled (VC) continuous mandatory ventilation. Suggested initial settings for assist-control volume ventilation in the care of adults are listed in Box 49-4. Advantages of assist-control volume ventilation include the assurance that a minimum, safe level of ventilation is achieved. Every breath is a volume breath, yet the patient can set his or her own breathing rate. In the event of sedation or apnea, a minimum, safe level of ventilation is guaranteed by the selection of an appropriate backup rate, usually approximately 2 to 4 breaths/min below the patient's assist rate, but not less than the rate necessary to provide a minimum safe level of ventilation (e.g., a backup rate of at least 12 to 14 breaths/min, depending on tidal volume set). Because assist-control ventilation usually provides full ventilatory support, it may result in a lower work of breathing than partial support modes.

Which of the following is the normal alveolar-to-arterial difference for a 56-year-old female in the emergency department? a. 12 mm Hg b. 14 mm Hg c. 16 mm Hg d. 18 mm Hg

ANS: D [P(A-a)O2] = (age/4) + 4 [P(A-a)O2] = (56/4) + 4 [P(A-a)O2] = 18 mm Hg

Via what route is tuberculosis spread? a. Direct contact b. Fecal-oral route c. Fomite d. Inhaled particles

ANS: Dc. Fomite Tuberculosis is acquired by inhalation of infectious particles is the basis for a policy whereby patients with suspected or proven tuberculosis who are coughing are placed in respiratory isolation, thereby minimizing the risk of disease transmission within the hospital setting.

To increase PaO2

Adjust FiO2, if after increase > 50% hypoxemia persists, hypoxemia is present due to physiological shunting ADD PEEP - Recruits alveoli and helps oxygenation

If adjusting the tidal volume would take it out of normal range you should adjust what?

Adjust the F (rate)

Alveolar Deadspace

Alveoli that are ventilated but not perfused

PaCO2

Best indicator of effective ventilation. Adjust by modifying: Vt, RR, or dead space (up or down)

Which mode of ventilation does the patient have the least WOB?

CMV

- Sensitivity - Exhaled Tidal Volume (up to 200 cc's below set VT) - Low Inspiratory Alarms - Apnea Alarms

What are the things you MAY have to adjust on a ventilator when switching a patient from CMV and A/C to SIMV mode?

Which mode of ventilation does the patient have the most WOB?

CPAP

what mode of ventilation are completely spontaneous?

CPAP & PSV

Yes

Can you have PEEP with PS?

- Independently - With CPAP - With SIMV - With any spontaneous ventilator mode

What can Pressure Support be used with?

If a patient being ventilated in the SIMV mode suddenly stops spontaneously breathing what would happen to their VE and PaCO2?

Decrease VE & increased PaCO2

To increase the CO2

Decrease tidal volume Decrease rate Increase the dead space

Calculations to alter the PaCO2

Desired Vt = (known PaCO2 x known Vt) / desired PaCO2 Desired F = (known PaCO2 x known F) / desired PaCO2

Adjusting PaO2

First decrease FiO2 to 60% or less (to reduce O2 toxicity) Then, if patient is stable and O2 is adequate, begin to slowly decrease the PEEP

- Patient Makes own rate - Patient Make own tidal volume - Can receive mandatory rate from ventilator - Can receive a set tidal volume from ventilator

What can occur in SIMV mode of ventilation?

How frequently should a clinician make changes when weaning from PEEP? a. 10 to 20 min b. 30 to 45 min c. 1 hr d. 6 to 8 hr

Generally, PEEP is sustained at the set level until FiO2 is less than 0.5, and when PEEP is decreased, it should be decreased in increments of 2 cm H2O no more frequently than approximately every 6 to 8 hr.

A-a gradient = [P(A-a)O2]

Gradient difference between alveolar and arterial PO2. First calculate the PAO2: PAO2 = [(PB - PH2O) x FiO2 - (PaCO2 / RQ)] Unless told otherwise PB = 760, PH20 = 47; normal RQ = 0.8 (if FiO2 is >60% omit RQ and use 1.25)

Only wean breaths in increments of 2

How are patients weaned in partial support mode of ventilation?

It waits and allows the patient to take their next breath BEFORE delivering the mandatory breath

How does SIMV mode prevent breath stacking?

Rapidly and remains at that level until spontaneous inspiratory flow rates drop to 25% of the peak inspiratory flow

How does pressure develop in the ventilator system?

PaO2 < 80 mmHg

Hypoxemia - low level of O2 in arterial blood if hypoxemic ventilator patients need FiO2 adjusted >50%, then begin adding PEEP to decrease risk of O2 toxicity

Starting at a PaCO2 of 40 mmHg

If the CO2 increases by 10 mmHg then the pH decreases by .06 If the CO2 decreases by 10 mmHg then the pH increases by .10 There is an indirect relationship. They are indirectly proportional.

Permissive Hypercapnia

In critically ill pulmonary patients, it may not be possible to protect the lungs and maintain a normal PaCO2. - Typically ALI/ARDS or status asthmaticus patients To keep Pplat <30 cm H2O, the VT may be reduced to 6 mL/kg IBW while increasing the RR (Ards Net Protocol) - With RR of 30-35 breaths/min consider using a permissive hypercapnia strategy - Allow CO2 to rise slowly over hours to days

To decrease the CO2

Increase tidal volume Increase rate Decrease dead space

Indirect relationship

Increased alveolar ventilation; decreases PaCO2 and vice versa

- Patient MUST be stable - Great for weaning patients from CMV - Allows patient to make their own RR & Tidal Volume - Allows patient to re-build their respiratory muscle strength

What patients are candidates for SIMV/IMV mode?

- Fever - Increased O2 consumption - Increased CO2 production - Increased WOB - Unstable cardiac status - Unresolved primary problems that caused patient to go on the ventilator

What patients are considered unstable?

1 to 3

What should the flow trigger be set at?

Lung volumes and capacities

Lung volumes and capacities

PECO2

Mixed expired CO2, can be collected in a sampling bag or estimated by end tidal CO2

Decrease the PaCO2

What will increasing the PS do to the PaCO2 on an ABG?

A-a gradient - subtract PaO2 from PAO2

Normal difference 10 - 15 mmHg on 21%, 20 - 65 on 100% On 100% every 50 mmHg difference equals approximately a 2% shunt. If under 300 then there is a V/Q mismatch After increasing FiO2, if (A-a) over 300 there is a shunt so add PEEP or CPAP ***V/Q mismatch responds to O2 therapy, shunts do not therefore you'll need to add PEEP

Volumes

What will you be adding to the patient if the PS is set too high?

Indexes of Oxygenation

P/F ratio = (PaO2/FiO2) Divide the PaO2 by FiO2 Normal value is >350 ALI <300 ARDS <200 100/.21 = 476 80/.40 = 200 60/.50 = 120 50/1.0 = 50 Useful in determining the extent of acute lung injury and ARDS, or normal.

PCV and PaCO2

PaCO2 can be adjusted by PC level or RR. Increasing PC level increases the delivered VT which reduces CO2 Be careful to keep pressure <30 cm H2O RR is more often increased to reduce CO2 If IT (I-time) is held constant, VT will be constant If IT% or I:E ratio are held constant, the IT will decrease, which MAY decrease VT, so be careful

Oxygenation

PaO2 normal range 80 - 100 mmHg (Acceptable for vent patients is PaO2 = 60-100)

PaO2/FiO2

PaO2/FIO2, norm 350-450mmHg Mild 300-200 Moderate 200-100 Severe <100

Airway resistance formula

Raw = (PIP - Pplat) / flow L sec

A high PaCO2

Respiratory Acidosis, hypoventilation: Patient under ventilated, retaining CO2

A low PaCO2

Respiratory Alkalosis, Patient over ventilated, losing too much CO2

Physiological Deadspace

Sum of both (Vt + Vd) Normal approximately 1/3 of Vt Range - 20 to 40% Patients on ventilator 40 - 60%

Time constant (TC)

TC = RAW x Cstat

True or False: Adding and removing dead space is for CONTROL MODE use ONLY.

TRUE

PaCO2/pH relationship

Table 13-6, Egan's pg. 306

Intermittent Mandatory Ventilation (IMV)

What mode of ventilation where the patient receives a set number of mechanical breaths from the ventilator and in between these breaths the patient can take their own spontaneous breaths at a rate and tidal volume of their choice?

- Augments the spontaneous tidal volume and decrease WOB - Supplementing volumes rather than just helping to overcome the increased resistance of the ETT tube & vent circuit

What do high levels (set greater than the RAW) of pressure support do for the patient ( can be up to 20cmH20)?

You are called to attend to an ER patient complaining of shortness of breath and severe dyspnea on exertion. Patient history is significant for a 30-year-pack smoking history, dry nonproductive cough, and occasional pedal edema. CXR findings are not remarkable except for mild cardiomegaly. You want to rule out ILD versus obstructive lung disease. HRCT shows a diffused ground glass appearance with the presence of centrilobular nodules. Together with the PFT results, HRCT finding indicates the presence of a. respiratory bronchiolitis ILD. b. chronic bronchitis. c. emphysema. d. sarcoidosis.

The presence of diffused ground glass appearance with the presence of centrilobular nodules in the HRTC is consistent with respiratory bronchiolitis ILD caused by tobacco exposure. Moreover, PFT results support this conclusion by showing a restrictive process with loss of alveolar-capillary surface area.

What is the difference between IMV and SIMV?

The ventilator will attempt to synchronize the mandatory breaths with patient's spontaneous breaths to attempt to avoid breath stacking.

To overcome WOB imposed by resistance

What do low levels (minimum amount) of pressure support do for the patient (5cmH20)?

I:E ratio calculation

Ti + Te = TCT then divide RR by 60

Manipulation of ABG's in SIMV/IMV Modes

To DECREASE the CO2 you increase the VT and rate and decrease any mechanical dead space. - For spontaneous volumes you may need to add PS - May need to increase the PS to an appropriate level

Manipulation of ABG's in SIMV/IMV Modes

To INCREASE the CO2 you decrease the VT and Rate. (SIMV/IMV) Best choice if weaning. - Patient builds up respiratory muscle strength by having to take more spontaneous breaths and relies less on ventilatory support - Never add dead space in this mode! - Decrease VT by decreasing PS - Pressure Support (PS) is nothing more than augmenting the patient's breath

Manipulation of ABG's in A/C mode

To increase CO2 - Decrease Vt (may be ineffective as patient may increase rate. Decrease frequency - Patient can increase assisting to override, if ineffective you can switch to SIMV or control mode. To decrease CO2 - increase the Vt and increase the rate above the assist rate.

Total minuted ventilation formula

Total Ve = (Vt mach x Fmach) + (Vtspont x Fspont)

On some ventilators, which of the following can occur if a trigger setting is set too sensitive on a mechanical ventilator? a. Autotriggering b. Flow asynchrony c. Barotrauma d. Increased workload

Trigger sensitivity for patient-triggered ventilation should be set at the lowest possible level to minimize trigger work while avoiding ventilator autotriggering

Increase in tidal volume

What does increased pressure of machine breaths result in SIMV mode?

- Prevents muscle atrophy - Allows patient to reach baseline ABG's -Decrease mean intra-thoracic pressure - Avoids decreased venous return - Avoids cardiac embarrassment - May avoid positive fluid balance - May give patient psychological encouragement - May allow decreased use of pharmacological agents for sedation - May be the ONLY way to correct Respiratory Alkalosis on patient who are over breathing the vent in A/C mode

What are the advantages of SIMV/Partial IMV?

Indexes of Oxygenation

Useful in telling how efficient is gas exchange and determing if there's a V/Q mismatch or shunt.

- Prevents breath stacking - Aids in patient/ventilator synchrony

What are the benefits of SIMV mode?

- May need to adjust the trigger sensitivity to prevent imposing an increased WOB

What are the considerations with the setup of SIMV/IMV mode?

Formulas

VD/VT = (PaCO2 - PECO2)/PaCO2 - Portion of Vt not participating in gas exchange 40-32/40 = 0.20 (or 20%)

Frequency

Ve/Vt

Tidal volume

Ve/f

Dead Space

Ventilation without perfusion. Example would be a pulmonary emboli - Ch. 11 pg. 245-248 in Egan's.

Static Compliance formula

Vt / (Plateau - PEEP)

Dynamic compliance formula

Vt / PIP-PEEP

How can Pplat be lowered ?

Vt, PEEP, & flow

VD/VT

Wasted ventilation per breath

Increase the Tidal Volume

What does increasing the level of PS do to the patient's tidal volume?

- Flow - Tidal Volume

When applying PS to a patient what things are we allowing the patient to create on their own?

On EXPIRATION

When exactly is PEEP applied?

On INSPIRATION

When exactly is PS applied?

On INSPIRATION only and drops so patient can passively exhale

When is pressure support delivered?

-Help patient reach baseline ABG

When placing a patient on SIMV, what does this allow the patient to do?

Pouiselle's

Who's law describes the diameter of a tube by 1/2 and increases the flow through that tube by 16 times?

Demand Valve

Why doesn't breath stacking occur in SIMV (How does SIMV work)?

why is simv is used over any other modes of ventilation

allow the patient to take a spontaneous breath between artificial breaths.

Spontaneous breath

completely spontaneous breath that is usually support with pressure support

What would happen to ventilator measurements and alarms in the event there was a leak or patient disconnect in A/C mode?

decreased peak pressure , exhaled volume & pressure alarm

What would an RT do first when a mechanically ventilated patient develops a tension pneumothorax?

immediate needle decompression

Is SIMV considered full or partial ventilator support?

partial ventilator support

When switching from CMV to SIMV, what alarm settings might need to be adjusted?

low pressure and tidal volume

Mandatory breath

machine breath with preset volume/pressure and duration

Assisted breath

machine breath with preset volume/pressure and duration that is patient triggered

What has the most compromising effect on venous return?

machine positive pressure

Pressure Support Ventilation (PSV)

mode of mechanical ventilation in which preset positive pressure is delivered with spontaneous breaths to decrease work of breathing

Where is a chest tube inserted?

pleural space between the 5th and 6th rib

What/Who triggers a PSV breath?

the patient (spontaneously breathing)

What controls the level of suction delivered by a pleural drainage system?

the water level in the suction chamber

Use low compliance ventilator circuit

to decrease dead space

Cut the ET-tube to proper length

to decrease mechanical deadspace

Removing deadspace

to decrease the PaCO2

Adding deadspace

to increase the PaCO2

How does the ventilator know to cycle at the end of inspiration ?

when gas flow ceases from the ventilator and expiratory flow begins