Sill's 7th edition Self-Study Questions (Chapter 10 Airway Clearance Therapy)

14. A patient with bilateral pneumonia is positioned for drainage of the lateral and medial segments of the right middle lobe. After 5 minutes in this position, the patient complains of shortness of breath. The electrocardiogram shows the patient to be having premature ventricular contractions. The most likely cause of this is: A. Hypoxemia from the position B. A full stomach is causing vagal stimulation C. Increased intracranial pressure D. Increased venous return to the heart

The correct answer is: A Hypoxemia is the only possibility for the problem from among those listed. A full stomach does not cause vagal stimulation that results in PVCs. The patient's symptoms of SOB and PVCs do not correspond with increased intracranial pressure or increased venous return to the heart.

19. IPV has been ordered for an adult patient with bronchiectasis. An aerosolized bronchodilator has also been ordered. How should the two treatments initially be delivered? 1. Bronchodilator given before the IPV 2. Low pressure setting 3. Bronchodilator with IPV 4. High pressure setting 5. Bronchodilator after IPV A. 2 and 3 only B. 1 and 2 only C. 3 and 5 only D. 4 and 5 only

The correct answer is: A IPV machines include an SVN so that a medication can be delivered with the IPV breaths. The initial settings for an IPV treatment should include a low pressure (and low rate). As the patient gains comfort with the treatment, the pressure and rate can be increased as tolerated.

21. A 12-year-old patient with cystic fibrosis had PEP therapy started at 5 cm water. After a few minutes of use the patient has a strong but unproductive cough. What should be done now? A. Increase the PEP level to 10 cm water. B. Increase the PEP level to 15 cm water. C. Change to incentive spirometry. D. Discontinue the treatment.

The correct answer is: A It is reasonable to increase the PEP level from 5 to 10 cm water. Have the patient try this moderately increased pressure for several minutes, and evaluate the effectiveness of the patient's cough effort. The PEP level should not be increased to 15 cm water unless 10 cm water has been shown to be ineffective. Incentive spirometry is indicated for atelectasis or the prevention of atelectasis. It is not indicated for secretion clearance, as is PEP therapy. It is too early in the treatment to determine that PEP therapy should be discontinued.

30. A 10-year-old male patient with cystic fibrosis has large amounts of secretions. He cannot tolerate postural drainage because of nausea when he is tipped down. He is receiving aerosolized bronchodilator and mucolytic medications. To improve his condition, which of the following could the respiratory therapist recommend? 1. OPEP therapy 2. Percussion and vibration 3. HFCWO 4. Continuous positive airway pressure A. 1 and 3 only B. 2 and 4 only C. 1, 2, and 3 only D. 1, 2, 3, 4

The correct answer is: A OPEP therapy and HFCWO have been shown to be effective at mobilizing secretions. (See Box 10-5.) CPAP is indicated to increase a patient's functional residual capacity to improve oxygenation. It has no effect on secretions. Percussion and vibration will not be helpful without postural drainage.

5. A stroke patient has been admitted and is in a coma. The physician is concerned that the patient may develop atelectasis and pneumonia. What should be recommended to help prevent these problems? A. Regular turning B. PEP therapy C. IPPB D. CPAP

The correct answer is: A Regular turning is an easy and inexpensive way to alter the patient's breathing pattern and to move the VT into different lung segments. This helps to prevent atelectasis. PEP and IPPB may be needed, but only after regular turning has been shown to be ineffective. CPAP is not indicated for the treatment of simple atelectasis from inactivity.

23. For drainage of the superior and inferior lingula segments, the patient should be positioned: 1. With the foot of the bed elevated 14 inches 2. One-fourth turn up from the front-down position on the bed 3. One-fourth turn up from the back-down position on the bed 4. With the foot of the bed elevated 30 degrees 5. Flat on his or her back A. 1 and 3 only B. 4 and 5 only C. 1 and 2 only D. 1 and 5 only

The correct answer is: A Review Fig. 10-11 for the proper position to drain the superior and inferior lingula segments.

9. A patient is positioned on the left side with the foot of the bed raised 18 inches. Which lung segment would be draining in the patient? A. Anterior basal B. Superior C. Lateral and medial lingular D. Posterior basal

The correct answer is: A Review Fig. 10-8 for the recommended position to drain the anterior basal segment of the right lower lobe.

15. The respiratory therapist is using a pneumatically powered mechanical percussor on a patient receiving CPT. The unit is powered by an E cylinder of O2 because piped-in O2 is unavailable. After a few minutes of operation, it is noticed that the percussor begins to slow down and then stops. What should be done? A. Switch to an electrically powered percussor. B. Make sure the cylinder is completely turned on. C. Check the unit's batteries. D. Check the electrical cord

The correct answer is: A Switching to an electrically powered percussor is the only workable option from among those provided. A pneumatically powered percussor does not have batteries or an electrical cord. The way that the percussor gradually lost function indicates that the tank did not have any compressed O2 with which to run the unit.

26. A patient is starting HFCWO to help mobilize secretions. Which of the following instructions should the patient be given for the initial treatment? 1. Lie on the side with secretions. 2. Sit up straight. 3. Set the controls at a low pressure. 4. Set the controls at a high pressure. 5. Set the unit for nebulization. A. 2 and 3 only B. 1 and 3 only C. 2, 4, and 5 only D. 1, 3, and S only

The correct answer is: A The patient must sit up straight for the procedure. To work best, the cuirass needs to have even contact with the patient's anterior chest wall. This would not happen if the patient was lying on a side. It is best to have the patient start at the lowest rate and pressure to gain confidence in the unit and not risk injury. The HFCWO unit does not have a nebulizer.

22. After several days of receiving postural drainage and percussion therapy to all lobes in the left lung, the patient's chest radiograph shows improvement except for the lateral basal segment of the left lower lobe. In what position should the patient now be placed for postural drainage? A. Right side down with the head of the bed down 30 degrees B. Right side down with the bed flat C. Left side down with the head of the bed down 30 degrees D. Supine with the bed flat and a pillow beneath the knees

The correct answer is: A To drain the lateral basal segment of the left lower lobe, the patient must be placed with the right side down on the bed and the head of the bed dropped 30 degrees. The other positions will not properly drain the left lower lobe. Review the postural drainage positions if needed. (See Fig. 10-7.)

10. A patient has been ordered to start PEP therapy. During the initial instruction and patient practice, it is noticed that the pressure is 25 cm H2O and the patient's I:E ratio is 1:5. How should the procedure be revised? A. Adjust the PEP device to have the patient exhale through a larger hole. B. Have the patient continue but coach the patient to exhale faster. C. Adjust the PEP device to have the patient exhale through a smaller hole. D. Add a bronchodilator medication to the PEP device

The correct answer is: A When the patient exhales through a larger hole, the pressure should decrease and the expiratory time should shorten. Review Box 10-8 for the steps to be followed in the PEP therapy procedure. Having the patient exhale faster or exhale through a smaller hole increases the pressure and expiratory time. A bronchodilator medication has not been ordered for the patient.

18. A patient who is being instructed in fixed-orifice PEP therapy complains that it is taking too long to breathe out. What should be done? A. Tell the patient to blow out harder. B. Change the expiratory resistance to a larger diameter orifice. C. Change the expiratory resistance to a smaller diameter orifice. D. Increase the flow of oxygen to the system.

The correct answer is: B By changing the expiratory resistance to a larger diameter orifice, the patient will be able to exhale more quickly. Telling the patient to blow out harder will increase the pressure within the system. This could increase the patient's discomfort. Changing the expiratory resistance to a smaller-diameter orifice will further increase the expiratory time, not decrease it. Although a PEP system can have oxygen added to it to power a small-volume nebulizer, there is no mention of one in the question.

13. A patient is using the Flutter and coughs productively. Later, the patient tries to use the device but finds that no air will go through it. What should be done? A. Have the patient breathe in harder. B. Check for an obstruction. C. Remove the steel ball to reduce the backpressure. D. Have the patient blow out harder.

The correct answer is: B It is likely that the patient coughed secretions into the unit. Check for an obstruction. If one is present, it must be removed. A cotton swab or warm running water should remove any secretions. The patient blows out (does not breathe in) through the Flutter valve. It is not an incentive spirometer device. Removing the steel ball from the device will prevent it from working as intended. If the patient blows out hard, the obstruction may be blown deeper into the unit.

8. Which of the following are contraindications to percussion and vibration? 1. Performing the procedure over the kidneys 2. Mobilizing large amounts of secretions 3. Performing the procedure over bare skin 4. Performing the procedure over or near a surgical site A. 1 and 2 only B. 1, 3, and 4 only C. 2, 3, and 4 only D. 1, 2, 3, and 4

The correct answer is: B Many references indicate that percussion and vibration are beneficial in mobilizing large quantities of secretions. Review Box 10-2 for contraindications for percussion and vibration.

25. A 48-year-old woman had her gallbladder removed. What is most effective in preventing postoperative atelectasis? A. MIE B. PEP therapy C. Mechanical chest percussor D. Inspiratory muscle training

The correct answer is: B PEP therapy will increase end-expiratory lung pressure. This should increase alveolar volume and prevent the development of atelectasis. MIE is indicated to help mobilize secretions in patients with neuromuscular disease. A mechanical chest percussor can be used with CPT to help mobilize secretions. However, it does not have any benefit in preventing atelectasis. Inspiratory muscle training is beneficial in patients with chronic obstructive lung disease because they are usually deconditioned. This should be part of a general conditioning program. However, inspiratory muscle training has no direct effect on atelectasis and should not be confused with use of an incentive spirometer. (See Box 10-5.)

27. A 70-year-old patient who had a stroke has aspirated and now has a fever and pulmonary secretions. The respiratory therapist notices on the anteroposterior and right lateral chest radiographs that the posterior segment of the right upper lobe is opaque. What postural drainage position should be used with this patient? A. On the right side, head down 30 degrees, one-fourth turn up from face down B. Sitting upright and leaning forward 30 degrees C. Head down 15 degrees, pillow behind the right side to turn one-fourth turn up from flat D. Head down 15 degrees, pillow behind the left side to turn one-fourth turn up from flat

The correct answer is: B The position described would be used to drain secretions from the patient's posterior segment of the right upper lobe. See Fig. 1-17 for the area of consolidation, Fig. 10-5 for all lung segments, and Fig. 10-12 for the postural drainage position.

7. A physician has ordered PEP therapy with albuterol (AccuNeb). Which of the following are needed to start the treatment? 1. Variable orifice resistor 2. Pressure manometer 3. Bedside spirometer 4. Nebulizer with reservoir A. 2 and 4 only B. 1 and 3 only C. 1, 2, and 4 only D. 1, 2, 3, and 4

The correct answer is: C A bedside spirometer is not needed because the patient's exhaled volume does not need to be measured. In addition, a spirometer cannot be connected to the unit for volume measurement. All of the other listed items are needed. The variable orifice resistor is needed to set the level of expiratory resistance. A pressure manometer is needed to determine that the expiratory pressure is kept in the 10- to 20-cm water range. An SVN with reservoir is needed to deliver the albuterol. (See Fig. 10-21, A.)

17. Which of the following can be successfully used with a 6-year-old child? 1. Autogenic drainage 2. Chest physiotherapy 3. Oscillatory positive expiratory pressure 4. ACBT 5. IPV A. 1 and 3 only B. 4 and 5 only C. 2, 3, and 4 only D. 1, 2, and 5 only

The correct answer is: C A child can usually tolerate CPT. As the child grows older, he or she can take a more active role in the therapy. Often a child of about 4 years can learn OPEP therapy. By the age of 6, ACBT can be taught. A child will usually have to be about 10 to 12 years of age to learn IPV and AD because of their complexity.

11. A respiratory therapist is reviewing a patient's chart and looking for indications for postural drainage. Which of the following would be included? 1. A patient with bronchiectasis and retained secretions 2. A patient with cystic fibrosis who has retained secretions 3. Draining of an empyema 4. Removal of an aspirated foreign body A. 1 and 4 only B. 2 and 4only C. 1, 2, and 3 only D. 1, 2, 3, and 4

The correct answer is: C Because an empyema is a collection of pus in the pleural cavity, it cannot be drained through postural drainage. The other options are all indications for postural drainage. See Box 10-1 for the indications.

28. The respiratory therapist is working with a patient who begins to expectorate blood after being positioned for drainage of the superior segment of the left lower lobe. Percussion was provided with a mechanical device. After the patient has expectorated 50 mL of blood, what should be recommended as the best action? A. Continue the treatment because the patient has not lost a great deal of blood. B. Continue the treatment on only the upper and middle lobes. C. Stop the treatment, sit the patient up, and call the physician. D. Continue the treatment with manual percussion only.

The correct answer is: C Hemoptysis indicates pulmonary trauma. The treatment should be stopped and the physician notified. No further treatment should be done until after the patient is assessed and it is found safe to proceed with the treatment. (See Box 10-3.)

32. A 27-year-old patient with an unstable T-1 spinal cord injury has been admitted for treatment of bronchitis. A bedside assessment is performed and it is found that the patient cannot cough out the secretions. Bedside spirometry reveals the patient has a peak flow of 200 L/min (3.3 L/s). What treatment should be recommended? A. HFCWO B. Chest physiotherapy C. Mechanical insufflation-exsufflation D. Positive expiratory pressure

The correct answer is: C MIE is indicated in a patient with a neuromuscular condition or spinal cord injury who has a peak cough flow (peak flow) of <270 L/min (<4.5 L/s). A patient using HFCWO or PEP should be able to perform a normal cough to clear secretions. CPT should not be performed on a patient with an unstable spinal cord injury. Further injury could be caused by changing the drainage positions.

12. The respiratory therapist has received an order to perform postural drainage, percussion, and vibration on a 23-year-old female patient. The lateral and medial segments of the right middle lobe are among those that need to be treated. How should the procedure be performed? A. Drain, percuss, and vibrate the segments. B. Drain and vibrate the segments. C. Drain but not percuss or vibrate those segments. D. Drain and use a mechanical percussor.

The correct answer is: C Neither manual nor mechanical percussion or vibration should be performed over female breast tissue. (See Box 10-2.)

1. A 15-year-old female patient with cystic fibrosis has copious amounts of secretions. She cannot tolerate postural drainage therapy because she gets a headache when tipped head-down. Aerosolized bronchodilators and mucolytic agents are ordered every 4 hours by SVN. What else should be recommended? A. Add incentive spirometry. B. Use aerosolized medications by IPPB C. Add PEP therapy. D. Avoid head-down PDT positions.

The correct answer is: C PEP therapy has been shown to help in mobilizing secretions. In addition, some PEP units can be coupled with an SVN to more efficiently deliver the medication. Incentive spirometry does not help with secretion mobilization or medication delivery. IPPB may help with medication delivery if the patient cannot properly perform the SVN treatment. However, the SVN should be tried first. The benefits of improperly positioning a patient for PDT are questionable. (See Box 10-5.)

4. When a patient's chart is reviewed, it is important to look for contraindications to CPT. These would include which of the following? 1. Increased intracranial pressure 2. Recent stroke 3. Small VC in a bedridden patient 4. A patient who has just eaten A. 2 and 3 only B. 3 and 4 only C. 1, 2, and 4 only D. 1, 2, 3, and 4

The correct answer is: C There is no reason that a bedridden patient with a small vital capacity cannot have CPT. Head-down positions place a patient with a recent stroke or known increased intracranial pressure at risk for further brain damage. A patient who has just eaten should not be placed in a head-down position because of the risk of vomiting. (See Box 10-2.)

3. How should manual vibration be performed as part of CPT? 1. On inspiration 2. At a rate of 20 to 30 cycles/s 3. On expiration 4. At a rate of 3 cycles/s 5. Throughout the breathing cycle A. 2 and 4 only B. 1 and 4 only C. 3 and 4 only D. 4 and 5 only

The correct answer is: C Vibration should be performed only on expiration. Most people cannot vibrate at a faster rate than about 3 cycles/s.

29. CPT (postural drainage, percussion, and vibration) has been performed for 5 days on a cooperative patient with bronchiectasis. During that time, the patient has been treated with antibiotics, well fed, and hydrated. The patient has produced a total of 20 mL of sputum during the past 24 hours. What should be recommended? A. Continue the current treatment program for 48 hours and evaluate the patient again. B. Add ultrasonic nebulizer treatments to the CPT to better liquefy the secretions. C. Add nasotracheal suctioning to the CPT to remove the secretions. D. Discontinue the CPT and follow the patient's progress.

The correct answer is: D According to the AARC Clinical Practice Guideline (1991), CPT (postural drainage, percussion, and vibration) should be discontinued when the patient is able to expectorate secretions without other assistance. Also, the patient is only producing 20 mL of secretions in a day. Continuing the treatment and adding procedures are not necessary and may unnecessarily add to the patient's costs.

2. To get the best patient results, manual percussion should be performed with 1. The hand cupped 2. A tight, fixed-wrist position 3. The elbows relaxed 4. The hand flat 5. The wrist relaxed A. 2 and 4 only B. 2, 3, and 4 only C. 3, 4, and 5 only D. 1, 3, and 5 only

The correct answer is: D Manual percussion should be performed with a cupped hand and relaxed wrist and elbow joints.

20. A 56-year-old patient has been in the Trendelenburg position for 10 minutes receiving percussion and vibration. Tachycardia and dyspnea develop. Which of the following actions should be taken by the respiratory therapist? A. Continue for 5 minutes with gentle percussion. B. Turn the patient to the other side. C. Give the patient oxygen. D. Have the patient sit up

The correct answer is: D The patient should sit up because tachycardia and dyspnea are definite indications of intolerance of the head-down position. It could be dangerous for the patient to continue in the head-down position for even 5 more minutes. The treatment should be stopped, and the patient should sit up rather than being turned to the other side. Give the patient supplemental oxygen only if it is determined that the patient is hypoxic after the patient sits up. (See Box 10-3.)

24. What are the clinical benefits of using vibratory PEP? 1. Increased transpleural pressure 2. Airway vibrations 3. Increased intrapleural pressure 4. Rapid variation in airway pressure A. 1 and 2 only B. 2 and 3 only C. 3 and 4 only D. 2 and 4 only

The correct answer is: D Vibratory/oscillatory PEP is designed to cause rapid airway vibrations. These vibrations result in a rapid variation in airway pressure. This results in the airways rapidly dilating and then contracting to their resting diameter. These changes seem to loosen secretions so that they can be expectorated more easily by the patient. Neither increased transpleural pressure nor increased intrapleural pressure has any effect on the mobilization of secretions.

6. An order is received to perform postural drainage, percussion, and vibration on a patient. No segments are specified. On reviewing the chest radiograph film, the respiratory therapist notices infiltrates in the lower right lung field. Which of the following segments should be treated? 1. Apical 2. Lateral basal 3. Superior 4. Medial 5. Posterior basal A. 2 and 5 only B. 3, 4, and 5 only C. 1 and 4 only D. 2, 3, and 5 only

The correct answer is: D The lateral basal, superior, and posterior basal segments are all located in the right lower lobe where the infiltrates are located. The apical segment is located in the upper lobe, and the medial segment is located in the middle lobe. (Review Figs. 10-6, 10-7, and 10-9.)

31. A 12-year-old patient does not tolerate postural drainage for secretion clearance. The physician asks the respiratory therapist for a recommendation on high-frequency airway oscillation. Which of the following options should be recommended FIRST? A. HFCWC B. OPEP C. IPV D. ACBT

The correct answer is:B OPEP is inexpensive and easy for most patients to learn to use. HFCWC and IPV are expensive and complicated technologies. ACBT is not a form of high-frequency airway oscillation.

16. A mechanical percussor is ordered to assist with secretion clearance in a patient receiving CPT. The patient is positioned to drain the posterior basal segments of both lower lobes. The percussor is activated and applied to the patient's lower back. After 1 minute, the patient complains of skin discomfort. What should the respiratory therapist do? A. Have the patient sit up. B. Apply oxygen and check the pulse oximeter value. C. Increase the speed on the percussor. D. Change to another type of pad on the percussor.

The correct answer is:D Try another type of pad on the percussor to determine if it is more comfortable for the patient. A flat one is probably best for the lower back. The patient is not having a reaction to the head-down position and does not need to sit up. There is no indication that the patient is hypoxic. Increasing the speed on the percussor is likely to increase the skin irritation.