* UPDATED* Chapter 37: Airway Management

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

ANS: A After extubation, check for good air movement by auscultation. Stridor or decreased air movement after extubation indicates upper airway problems. Next, assess the patient's respiratory rate, breathing pattern, heart rate, blood pressure, and oxygen saturation.

An adult man on ventilatory support has just been intubated with a 7-mm oral endotracheal tube equipped with a high-residual-volume, low-pressure cuff. When sealing the cuff to achieve a minimal occluding volume, you note a cuff pressure of 45 cm H2O. What is most likely the problem? a. The tube chosen is too small for the patient. b. The cuff pilot balloon and line are obstructed. c. The tube is in the right main stem bronchus. d. The cuff has herniated over the tube tip.

ANS: A High pressures may be caused by the need to overinflate the cuff to seal the airway. This problem is common if the tube chosen is too small for the patient's trachea, positioned too high in the trachea or if the patient has developed tracheomalacia which is softening of the tracheal tissue.

The removable inner cannula commonly incorporated into modern tracheostomy tubes serves which of the following purposes? 1. Aid in routine tube cleaning and tracheostomy care 2. Prevent the tube from slipping into the trachea 3. Provide a patent airway should it become obstructed a. 1 and 3 only b. 2 and 3 only c. 3 only d. 1, 2, and 3

ANS: A A removable inner cannula with a standard 15-mm adapter is normally kept in place within the outer cannula but can be removed for routine cleaning or if it becomes obstructed.

A patient with a tracheostomy tube is receiving positive-pressure ventilation through a volume ventilator. Over the past 5 min, the peak inspiratory pressure has risen, and the pressure limit alarm is now sounding. On quick examination, you notice a generalized decrease in breath sounds. Which of the following problems is most likely? a. Partial obstruction of the tracheostomy tube b. Complete obstruction of the tracheostomy tube c. Development of a left-sided pneumothorax d. Obstruction of the left bronchus by a mucus plug

ANS: A A spontaneously breathing patient with partial airway obstruction will exhibit decreased breath sounds and decreased airflow through the tube. If the patient is receiving volume-controlled ventilation, peak inspiratory pressures will rise, often causing the high-pressure alarm to sound; during pressure-controlled ventilation, delivered tidal volumes will fall

What is the purpose of a tracheostomy tube obturator? a. To minimize trauma to the tracheal mucosal during insertion b. To provide a patent airway should the tube become obstructed c. To help ascertain the proper tube position by radiograph d. To provide a means to inflate and deflate the tube cuff

ANS: A An obturator with a rounded tip is used for tube insertion. Prior to insertion, the obturator is placed within the outer cannula, with its tip extending just beyond the far end of the tube. This minimizes mucosal trauma during insertion.

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

ANS: A Because the tracheal button has no cuff, its use is limited to relieving airway obstruction and aiding the removal of secretions.

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

ANS: A Before beginning an intubation procedure, the practitioner should confirm the operation of suction equipment, oxygen, airway equipment, monitors, and esophageal detectors and check position of the patient.

What should be the maximum time devoted to any intubation attempt? a. 30 sec b. 60 sec c. 90 sec d. 2 min

ANS: A Do not devote more than 30 sec to any intubation attempt.

After intubation of a cardiac arrest victim, you observe a slow but steady rise in the expired CO2 levels as measured by a bedside capnometer. Which of the following best explains this observation? a. Return of spontaneous circulation b. Abnormally high c. Placement of the endotracheal tube in the esophagus d. Failure of the cuff to properly seal the airway

ANS: A Generally, expired CO2 levels increase with the return of spontaneous circulation.

When checking for proper placement of an endotracheal tube in an adult patient on chest radiograph, it is noted that the distal tip of the tube is 1 cm above the carina. Which of the following actions would you recommend? a. Withdraw the tube by 2 to 4 cm (using tube markings as a guide). b. Withdraw the tube by 7 to 8 cm (using tube markings as a guide). c. Advance the tube by 2 to 4 cm (using tube markings as a guide). d. Advance the tube by 7 to 8 cm (using tube markings as a guide).

ANS: A If the tube is malpositioned, you should remove the old tape and reposition the tube, using the centimeter markings as a guide.

After determining a patient has a complete obstruction of an oral endotracheal tube, your efforts to relieve the obstruction by moving the patient's head and neck and deflating the cuff both fail. What should be your next step? a. Immediately remove the airway. b. Suction the patient. c. Call for an emergency tracheotomy. d. Apply manual positive pressure

ANS: A If you cannot clear the obstruction by using the above techniques, you must remove the airway and replace it.

When using capnometry or colorimetry to differentiate esophageal from tracheal placement of an endotracheal tube, which of the following conditions can result in a false-negative finding (i.e., no CO2 present even when the tube is in the trachea)? a. Cardiac arrest b. Gastric CO2 diffusion c. Right main stem intubation d. Delivery of a high FiO2

ANS: A In cardiac arrest victims, however, expired CO2 levels may be near zero because of poor pulmonary blood flow, yielding a false-negative result.

A patient receiving mechanical ventilatory support accidentally displaces the endotracheal tube out of the trachea. What would be the most appropriate action at this time? a. Remove the tube and provide manual ventilation or oxygenation as necessary. b. Push the tube back into the trachea by moving the patient's neck up and down. c. Suction the oropharynx with a Yankauer (tonsillar) suction tip. d. Apply manual ventilation or oxygenation directly through the endotracheal tube.

ANS: A In these cases, completely remove the tube and provide ventilatory support as needed until the patient can be reintubated or the tracheostomy tube reinserted.

What is the maximum recommended range for tracheal tube cuff pressures? a. 20 to 30 cm H2O b. 30 to 40 cm H2O c. 20 to 30 mm Hg d. 30 to 40 mm Hg

ANS: A It is recommended to inflate the cuff to 20 to 30 cm H2O, which should prevent tracheal mucosal injury.

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

ANS: A Not shown, but included with most modern endotracheal tubes, is a radiopaque indicator that is embedded in the distal end of the tube body. This indicator allows for easy identification of tube position on radiograph.

During oral intubation of an adult, the endotracheal tube should be advanced into the trachea about how far? a. Until its cuff has passed the cords b. Just far enough so that the tube cuff is no longer visible c. Until its cuff has passed the cords by 2 to 3 in d. Until its tip has passed the cords by 2 to 3 cm

ANS: A Once you see the tube tip pass through the glottis, advance it until the cuff has passed the vocal cords.

Which of the following is an absolute contraindication for percutaneous dilation tracheostomy? a. Need for emergent surgical airway b. Children younger than 12 years of age c. Coagulopathy d. Pulsating blood vessel over tracheotomy site

ANS: A See Box 37-6.

What is the normal range of negative pressure to use when suctioning an adult patient? a. -120 to -150 mm Hg b. -100 to -120 mm Hg c. -80 to -100 mm Hg d. -60 to -80 mm Hg

ANS: A Set suction pressure 120 to150 mm Hg for adults, 100 to 120 mm Hg for children, and 80 to 100 mm Hg for infants.

What is the purpose of a cuff on an artificial tracheal airway? a. To seal off and protect the lower airway b. To stabilize the tube and prevent its movement c. To provide a means to determine tube position via radiograph d. To help clinicians determine the depth of tube insertion

ANS: A The tube cuff is permanently bonded to the tube body. Inflation of the cuff seals off the lower airway, either for protection from gross aspiration or to provide positive pressure ventilation.

After removal of an oral endotracheal tube, a patient exhibits hoarseness and stridor that do not resolve with racemic epinephrine treatments. What is most likely the problem? a. Vocal cord paralysis b. Tracheoesophageal fistula c. Glottic edema or cord inflammation d. Tracheomalacia

ANS: A Vocal cord paralysis is likely in extubated patients with hoarseness and stridor that does not resolve with treatment or time.

Which of the following injuries are seen with tracheostomy tubes? 1. Tracheomalacia 2. Tracheal stenosis 3. Glottic edema 4. Vocal cord granulomas a. 1 and 2 only b. 3 and 4 only c. 2, 3 and 4 only d. 1, 2, and 3 only

ANS: A Whereas laryngeal lesions occur only with oral or nasal endotracheal tubes, tracheal lesions can occur with any tracheal airway. These tracheal lesions are granulomas, tracheomalacia, and tracheal stenosis.

An alert patient with a long-term need for a tracheostomy tube (because of recurrent aspiration) is having difficulty communicating with the intensive care unit staff. Which of the following would you recommend to help this patient communicate better? 1. Use a letter, phrase, or picture board. 2. Consider switching to a fenestrated tracheostomy tube. 3. Consider a "talking" tracheostomy tube. a. 1 and 2 only b. 1 and 3 only c. 2 and 3 only d. 1, 2, and 3

ANS: B A better solution is a letter, phrase, or picture board. These devices allow patients to communicate by simple pointing. Large and simple drawings are particularly important for patients who cannot clearly see print. For conscious patients with a long-term tracheostomy and ventilator dependent, communication can be enhanced with a "talking" tracheostomy tube.

Compared with trans laryngeal intubation, the advantages of tracheostomy include which of the following? 1. Greater patient comfort 2. Reduced risk of bronchial intubation 3. No upper airway complications 4. Decreased frequency of aspiration 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 summary of the advantages and disadvantages of each of these three approaches appears in Table 37-1 and 37-2.

To maintain positive end expiratory pressure (PEEP) and high FiO2 when suctioning a mechanically ventilated patient, what would you recommend? a. Limit suction time to no more than 5 sec. b. Use a closed-system multiuse suction catheter. c. Limit suctioning to once an hour. d. Use the smallest possible catheter.

ANS: B Basic indications for the use of closed suction catheters can be found in Box 36-2.

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

ANS: B Compared with the traditional surgical procedure, percutaneous dilatational tracheotomy is rapid with fewer complications from the surgical site and has a better cosmetic appearance after decannulation.

To prevent hypoxemia when suctioning a patient, the respiratory care practitioner should initially do which of the following? a. Manually ventilate the patient with a resuscitator. b. Preoxygenate the patient with 100% oxygen. c. Give the patient a bronchodilator treatment. d. Have the patient hyperventilate for 2 min.

ANS: B First, preoxygenation helps minimize the incidence of hypoxemia during suctioning.

Ideally, the distal tip of a properly positioned endotracheal tube (in an adult man) should be positioned approximately how far above the carina? a. 1 to 3 cm b. 3 to 6 cm c. 7 to 9 cm d. 4 to 6 in

ANS: B Ideally, the tip of an endotracheal tube should be positioned in the trachea approximately 5 cm above the carina.

While suctioning a patient, you observe an abrupt change in the electrocardiogram waveform being displayed on the cardiac monitor. Which of the following actions would be most appropriate? a. Change to a smaller catheter and repeat the procedure. b. Stop suctioning and immediately administer oxygen. c. Stop suctioning and report your findings to the nurse. d. Decrease the amount of negative pressure being used.

ANS: B If any major change is seen in the heart rate or rhythm, immediately stop suctioning and administer oxygen to the patient, providing manual ventilation as needed.

To minimize laryngeal swelling, a physician orders "continuous aerosol therapy" after the extubation of a patient. Which of the following specific approaches would you recommend? a. Heated mist therapy through a jet nebulizer and aerosol mask b. Cool mist therapy through a jet nebulizer and aerosol mask c. Oxygen therapy through a "venti-mask" and bubble humidifier d. Racemic epinephrine or saline through a small jet nebulizer

ANS: B If humidity/aerosol therapy is indicated, most clinicians suggest a cool mist immediately after extubation.

While checking a Miller and a MacIntosh blade on an intubation tray during an emergency intubation, you find that the Miller blade "lights" but the MacIntosh blade does not. What should you do now? a. Swap the defective MacIntosh for the good Miller blade. b. Check and replace the bulb in the MacIntosh blade. c. Replace the batteries in the laryngoscope handle. d. Check and clean the laryngoscope handle electrical contact.

ANS: B If the light does not function, first check that the bulb is tight. If the scope still does not light, check the batteries or replace the bulb.

After an intubation attempt, an expired capnogram indicates a CO2 level near zero. What does this finding probably indicate? a. Abnormally high ventilation/perfusion ratio ( ) b. Placement of the endotracheal tube in the esophagus c. Placement of the endotracheal tube in the trachea d. Failure of the cuff to properly seal the airway

ANS: B If the tube is in the esophagus, CO2 levels remain near zero.

Which of the following statements are true about methods used to displace the epiglottis during oral intubation? a. Regardless of the blade used, the laryngoscope is lifted up and forward. b. The curved (MacIntosh) blade lifts the epiglottis indirectly. c. The straight (Miller) blade lifts the epiglottis directly. d. Levering the laryngoscope against the teeth can aid displacement. 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 lifting the tip of the blade, you should avoid levering the laryngoscope against the teeth, as this can damage the teeth and gums.

In the absence of neck or facial injuries, what is the procedure of choice to establish a patent tracheal airway in an emergency? a. Surgical tracheotomy b. Orotracheal intubation c. Nasotracheal intubation d. Cricothyrotomy

ANS: B Orotracheal intubation is the preferred route for establishing an emergency tracheal airway.

Which of the following are potential complications of suctioning? 1. Hypoxemia 2. Hypotension 3. Arrhythmias 4. Gastrointestinal distress a. 2 and 4 only b. 1, 2, and 3 only c. 1 and 3 only d. 1, 3, and 4 only

ANS: B Potential complications are as follows: • Hypoxemia • Cardiac dysrhythmias • Hypotension or hypertension • Mucosal trauma • Bacterial colonization of lower airway

Which of the following equipment is needed to perform nontracheal suctioning? 1. Suction kit (catheter, gloves, basin, etc.) 2. Laryngoscope with MacIntosh and Miller blades 3. Oxygen delivery system (mask and manual resuscitator) 4. Bottle of sterile water or saline solution a. 1 and 3 only b. 1, 3, and 4 only c. 2 and 4 only d. 2, 3, and 4 only

ANS: B See Box 37-1.

What is the normal range of negative pressure to use when suctioning children? a. -120 to -150 mm Hg b. -100 to -120 mm Hg c. -80 to -100 mm Hg d. -60 to -80 mm Hg

ANS: B Set suction pressure 120 to150 mm Hg for adults, 100 to 120 mm Hg for children, and 80 to 100 mm Hg for infants.

What is the purpose of an endotracheal tube stylet? a. It helps ascertain proper tube position. b. It adds rigidity and shape to ease insertion. c. It minimizes mucosal trauma during insertion. d. It protects the airway against aspiration.

ANS: B Some clinicians insert a stylet into the tube to add rigidity and maintain shape during insertion.

Which of the following is a reason to collect a sputum sample from a patient? a. Reduce the risk of accidental extubation b. Identify organisms infecting the airway c. Assess extubation readiness d. Improve mechanical venation synchrony

ANS: B Sputum samples are often collected to identify organisms infecting the airway. To obtain the sample, the suctioning procedures described previously should be followed. In addition to the usual equipment, a sterile specimen container is needed.

Soon after endotracheal tube extubation, an adult patient exhibits a high-pitched inspiratory noise, heard without a stethoscope. Which of the following actions would you recommend? a. STAT-heated aerosol treatment with saline b. STAT racemic epinephrine aerosol treatment c. Careful observation of the patient for 6 hr d. Immediate reintubation via the nasal route

ANS: B Stridor is often treated with epinephrine (2.25% racemic solution or levoepinephrine 1:1000) via aerosol.

What size endotracheal tube would you select to intubate a 1500-g newborn infant? a. 2.5 mm b. 3.0 mm c. 3.5 mm d. 4.0 mm

ANS: B Table 37-3 lists recommended orotracheal tube sizes according to patient weight or age.

What size endotracheal tube would you select to intubate a 3-year-old child? a. 3.0 to 4.0 mm b. 4.5 to 5.0 mm c. 5.5 to 6.0 mm d. 6.0 to 7.0 mm

ANS: B Table 37-3 lists recommended orotracheal tube sizes according to patient weight or age.

Before the suctioning of a patient, auscultation reveals coarse breath sounds during both inspiration and expiration. After suctioning, the coarseness disappears, but expiratory wheezing is heard over both lung fields. What is most likely the problem? a. Secretions are still present and the patient should be suctioned again. b. The patient has hyperactive airways and has developed bronchospasm. c. A pneumothorax has developed and the patient needs a chest tube. d. The patient has developed a mucous plug and should undergo bronchoscopy.

ANS: B The bronchospastic response may be particularly strong in patients with hyperactive airway disease. These patients should be assessed for the development of wheezes associated with suctioning.

Serious complications of oral intubation include which of the following? 1. Cardiac arrest 2. Acute hypoxemia 3. Bradycardia 4. Tongue lacerations a. 2 and 4 only b. 1, 2, and 3 only c. 2, 3, and 4 only d. 2, 3, and 4 only

ANS: B The most common complication of emergency airway management is tissue trauma. The most serious complications are acute hypoxemia, hypercapnia, bradycardia, and cardiac arrest. Examples include intubation of patients when the oral route is unavailable, such as maxillofacial injuries or oral surgery.

What is the standard size for endotracheal or tracheostomy tube adapters? a. 22-mm external diameter b. 15-mm external diameter c. 15-mm internal diameter d. 22-mm internal diameter

ANS: B The proximal end of the tube is attached to a standard adapter with a 15-mm external diameter.

Although different techniques are used to actually remove the endotracheal tube during an extubation procedure, all aim to ensure which of the following? a. Maximal adduction of the vocal cords b. Maximal abduction of the vocal cords c. Maintenance of the appropriate cuff pressure d. Elimination of the pharyngeal (gag) reflex

ANS: B The technique used to remove the tube should help avoid aspiration of pharyngeal secretions and maximally abduct the vocal cords.

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

ANS: B To avoid this problem, limit the amount of negative pressure used and always rotate the catheter while withdrawing.

What is the primary indication for tracheostomy? a. When a patient loses pharyngeal or laryngeal reflexes b. When a patient has a long-term need for an artificial airway c. When a patient has been orally intubated for more than 24 hr d. When a patient has upper airway obstruction due to secretions

ANS: B Tracheotomy is the preferred, primary route for overcoming upper airway obstruction or trauma and for long-term care of patients with neuromuscular disease.

To provide local anesthesia and vasoconstriction during nasal intubation, what would you recommend? a. Nasal spray of 0.25% phenylephrine b. SVN aerosol delivery of 2% lidocaine for 10 min c. Mixture of 0.25% phenylephrine and 3% lidocaine d. SVN aerosol delivery of 0.25% phenylephrine for 10 min

ANS: C A mixture of 0.25% phenylephrine and 3% lidocaine may be applied to the nasal mucosa with a long cotton tip swab to provide local anesthesia and vasoconstriction of the nasal passage.

How often should patients be suctioned? a. At least once every 2 to 3 hr b. Whenever they are moved or ambulated c. When physical findings support the need d. Whenever the charge nurse requests it

ANS: C A patient should never be suctioned according to a preset schedule.

What is the purpose of the pilot balloon on an endotracheal or a tracheostomy tube? a. To help ascertain proper tube position b. To minimize mucosal trauma during insertion c. To monitor cuff status and pressure d. To protect the airway against aspiration

ANS: C A small filling tube leads from the cuff to a pilot balloon, used to monitor cuff status and pressure once the tube is in place.

What is the average distance from the tip of a properly positioned oral endotracheal tube to the incisors of an adult man? a. 16 to 18 cm b. 19 to 21 cm c. 21 to 23 cm d. 24 to 26 cm

ANS: C As indicated in Table 37-3 the average length from the teeth (incisors) to the tip of a properly positioned oral endotracheal tube in males is between 21 and 23 cm.

Repeated connecting and disconnecting of a cuff pressure manometer to the pilot tube of a cuffed tracheal airway will do which of the following? a. Increase cuff pressure. b. Not affect cuff pressure. c. Decrease cuff pressure. d. Rupture the cuff.

ANS: C Attaching the measurement system to the pilot tube evacuates some volume from the cuff (and lowers its pressure). For this reason, you should always adjust the pressure to the desired level, never just measure it.

An adult patient receiving cool mist therapy after extubation begins to develop stridor. Which of the following actions would you recommend? a. Change from cool mist to heated aerosol. b. Re-intubate the patient immediately. c. Administer a racemic epinephrine treatment. d. Draw and analyze an arterial blood gas.

ANS: C Because laryngeal edema may worsen with time and stridor may develop, be sure that racemic epinephrine for nebulization is available.

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

ANS: C Box 37-3 lists the equipment necessary for intubation.

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

ANS: C Diagnosis can be made by a history of recurrent aspiration and abdominal distention as air is forced into the esophagus during positive-pressure ventilation.

Which of the following is likely to increase the likelihood of damage to the tracheal mucosa? a. Maintaining cuff pressures below 20 to 25 mm Hg b. Using the minimal leak technique for inflation c. Using a low-residual-volume, low-compliance cuff d. Monitoring intracuff pressures every 1 to 2 hr

ANS: C In the past, high-pressure tracheal tube cuffs were a major cause of airway damage. Since the 1970s, high-residual-volume, low-pressure cuffs have become the norm.

In a properly performed traditional surgical tracheotomy, entrance to the trachea is made through an incision in what area? a. Through or between the first and second tracheal rings b. Through the ligament between the thyroid and cricoid cartilages c. Through or between the second and third tracheal rings d. Between the cricoid cartilage and the first tracheal ring

ANS: C In the traditional surgical tracheotomy, the surgeon makes an incision in the neck over the second or third tracheal ring.

Total application time for endotracheal suction in adults should not exceed which of the following? a. 20 sec b. 15 sec c. 10 sec d. 3 sec

ANS: C Keep total suction time to less than 15 sec.

What is the most common problem with fenestrated tracheostomy tubes? a. Relative frequency of accidental extubation b. Increased likelihood of tracheomalacia c. Poor positioning of the tube fenestration d. Inability to provide mechanical ventilation

ANS: C One problem associated with this type of tracheostomy tube is malposition of the fenestration, such as between the skin and stoma, or against the posterior wall of the larynx.

After repeated nasotracheal suctioning over 2 days, a patient with retained secretions develops minor bleeding through the nose. Which of the following actions would you recommend? a. Perform a tracheotomy for better access to the lower airway. b. Discontinue nontracheal suctioning for 48 hr and reassess. c. Stop the bleeding and use a nasopharyngeal airway for access. d. Orally intubate the patient for better access to the lower airway.

ANS: C Placement of a nasopharyngeal airway can help minimize nasal trauma when repeated access is needed.

What is the normal range of negative pressure to use when suctioning infants? a. -120 to -150 mm Hg b. -100 to -120 mm Hg c. -80 to -100 mm Hg d. -60 to -80 mm Hg

ANS: C Set suction pressure 120 to150 mm Hg for adults, 100 to 120 mm Hg for children, and 80 to 100 mm Hg for infants.

Successful tube passage through the larynx during blind nasotracheal intubation is indicated by which of the following? 1. Louder breath sounds 2. Harsh cough 3. Vocal Silence a. 1 and 2 only b. 1 and 3 only c. 2 and 3 only d. 1, 2, and 3

ANS: C Successful passage of the tube through the larynx usually is indicated by a harsh cough, followed by vocal silence.

What size endotracheal tube would you select to intubate an adult female? a. 6 mm b. 7 mm c. 8 mm d. 9 mm

ANS: C Table 37-3 lists recommended orotracheal tube sizes according to patient weight or age.

When checking for proper placement of an endotracheal tube or a tracheostomy tube on a chest radiograph, how far above the carina should the distal tip of the tube be positioned? a. 1 to 2 cm b. 2 to 4 cm c. 3 to 6 cm d. 6 to 8 cm

ANS: C The tube tip should be approximately 3 to 5 cm above the carina in adults, or between the second and fourth tracheal rings.

Which of the following types of artificial airways are inserted through the larynx? 1. Pharyngeal airways 2. Tracheostomy tubes 3. Nasotracheal tubes 4. Orotracheal tubes a. 1 and 4 only b. 1, 2, and 3 only c. 3 and 4 only d. 1, 2, 3, and 4

ANS: C The two basic types of tracheal airways are endotracheal (translaryngeal) tubes and tracheostomy tubes. Endotracheal tubes are inserted through either the mouth or nose (orotracheal or nasotracheal), through the larynx, and into the trachea.

You are about to suction a 10-year-old patient who has a 6-mm (internal diameter) endotracheal tube in place. What is the maximum size of catheter that you would use in this case? a. 6 Fr b. 8 Fr c. 10 Fr d. 14 Fr

ANS: C To estimate quickly the proper size of suction catheter to use with a given tracheal tube, first multiply the tube's inner diameter by 2. Then use the next smallest size catheter.

A patient with a tracheal airway exhibits severe respiratory distress. On quick examination, you notice the complete absence of breath sounds and no gas flowing through the airway. What is most likely the problem? a. Partial tube obstruction b. Right-sided pneumothorax c. Complete tube obstruction d. Vocal cord paralysis

ANS: C With complete tube obstruction, the patient will exhibit severe distress, no breath sounds will be heard, and there will be no gas flow through the tube.

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

ANS: D Obstruction of the tube is one of the most common causes of airway emergencies. Tube obstruction can be caused by (1) the kinking of the tube or the patient biting on the tube, (2) herniation of the cuff over the tube tip, (3) obstruction of the tube orifice against the tracheal wall, and (4) mucus plugging.

What is a rare but serious complication associated with endotracheal tube extubation? a. Bradycardia b. Aspiration c. Infection d. Laryngospasm

ANS: D A rare, but serious, complication associated with extubation is laryngospasm.

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

ANS: D A summary of the advantages and disadvantages of each of these three approaches appears in Table 37-1 and 37-2

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

ANS: D A summary of the advantages and disadvantages of each of these three approaches appears in Table 37-1 and 37-2.

A surgical resident has asked that you assist in an elective tracheotomy procedure on an orally intubated patient. Which of the following would be an appropriate action? a. Remove the oral tube just before tracheostomy tube insertion. b. Remove the oral tube before the tracheotomy is performed. c. Pull the oral tube only after the tracheostomy tube is placed. d. Withdraw the oral tube 2 to 3 in while the incision is made.

ANS: D After dissection to the anterior tracheal wall, the endotracheal tube is retracted to keep the tip of the tube inside the larynx.

What is the primary indication for tracheal suctioning? a. Presence of pneumonia b. Presence of atelectasis c. Ineffective coughing d. Retention of secretions

ANS: D Airway obstruction can be caused by retained secretions, foreign bodies, and structural changes such as edema, tumors, or trauma. Retained secretions increase airway resistance and the work of breathing and can cause hypoxemia, hypercapnia, atelectasis, and infection. Difficulty in clearing secretions may be due to the thickness or amount of the secretions or to the patient's inability to generate an effective cough. RTs can remove retained secretions or other semi-liquid fluids from the airways by suctioning.

Tracheal airways increase the incidence of pulmonary infections for which of the following reasons? 1. Lower levels of humidification 2. Increased aspiration of pharyngeal material 3. Contaminated equipment or solutions 4. Ineffective clearance through cough a. 1 and 3 only b. 1, 2, and 3 only c. 3 and 4 only d. 2, 3, and 4 only

ANS: D As indicated in Box 37-7, there are several reasons why tracheal tubes increase the incidence of pulmonary infection.

Which of the following methods can help to reduce the likelihood of atelectasis due to tracheal suctioning? 1. Limit the amount of negative pressure used. 2. Hyperinflate the patient before and after the procedure. 3. Suction for as short a period of time as possible. a. 1 and 2 only b. 1 and 3 only c. 2 and 3 only d. 1, 2, and 3

ANS: D Atelectasis can be caused by removal of too much air from the lungs. You can avoid this complication by (1) limiting the amount of negative pressure used, (2) keeping the duration of suctioning as short as possible, and (3) providing hyperinflation before and after the procedure.

Which of the following techniques or procedures should be used to help minimize infection of a tracheotomy stoma? 1. Regular aseptic stoma cleaning 2. Adherence to sterile techniques 3. Regular change of tracheostomy dressings a. 1 and 2 only b. 1 and 3 only c. 2 and 3 only d. 1, 2, and 3

ANS: D Good tracheostomy care, including aseptic cleaning of the stoma with sterile normal saline or half strength hydrogen peroxide, should be carried out routinely.

What is the purpose of the additional side port (Murphy eye) on most modern endotracheal tubes? a. Protect the airway against aspiration. b. Help ascertain proper tube position. c. Minimize mucosal trauma during insertion. d. Ensure gas flow if the main port is blocked.

ANS: D In addition to the beveled opening at the tip, there should be an additional side port or "Murphy eye," which ensures gas flow if the main port should become obstructed. The tube cuff is permanently bonded to the tube body. Inflation of the cuff seals off the lower airway, either for protection from aspiration or to provide positive pressure ventilation.

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

ANS: D In patients with tracheostomy tubes, stenosis may occur at the cuff, tube tip, or stoma sites, with the stoma site being the most common.

Which of the following is an indication for nontracheal suctioning? a. Bronchospasm b. Hyperinflation c. Patient preference d. Retained secretions without artificial airway

ANS: D Nasotracheal suctioning is indicated for patients who have retained secretions but do not have an artificial airway.

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

ANS: D Once the tube is in place, stabilize it with the right hand, and use the left hand to remove the laryngoscope and stylet. Then inflate the cuff to seal the airway and immediately provide ventilation and oxygenation.

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

ANS: D Pertinent factors that should be considered in making this decision are summarized in Box 37-5.

Which of the following is an advantage of oral intubation? a. Insertion is fast b. Esthetically displeasing c. Improved ability to swallow oral secretions d. Aids feeding, oral care, suctioning, speech

ANS: D See Table 37-1.

The major limitations of using a laryngeal mask airway are: 1. Short-term use. 2. Cannot provide high ventilation pressures if needed. 3. Aspiration not avoided. a. 1 and 2 only b. 2 and 3 only c. 1 and 3 only d. 1, 2, and 3

ANS: D See Table 37-2.

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

ANS: D Techniques commonly used to diagnose airway damage include physical examination, air tomography, fluoroscopy, laryngoscopy, bronchoscopy, magnetic resonance imaging, and pulmonary function studies.

To minimize the problems associated with pharyngeal aspiration in intubated patients, which of the following could you recommend? 1. Position patients in prone position. 2. Use of medications for stress ulcer prophylaxis, such as sucralfate. 3. Positioning of patients with the head of the bed elevated 30 degrees. 4. Provide continuous aspiration of subglottic secretions. a. 1 and 2 only b. 2 and 4 only c. 1, 2, and 4 only d. 2, 3, and 4 only

ANS: D Techniques to decrease the consequences of pharyngeal aspiration include: (1) use of medications for stress ulcer prophylaxis, such as sucralfate, that maintain normal gastric pH; (2) positioning of patients with the head of the bed elevated 30 degrees or more to decrease reflux; and (3) continuous aspiration of subglottic secretions.

What is the most common sign associated with the transient glottic edema or vocal cord inflammation that follows extubation? a. Difficulty in swallowing b. Wheezing c. Orthopnea d. Hoarseness

ANS: D The primary symptoms of glottic edema and vocal cord inflammation are hoarseness and stridor.

You are about to suction a female patient who has an 8-mm (internal diameter) endotracheal tube in place. What is the maximum size of catheter you would use in this case? a. 8 Fr b. 10 Fr c. 12 Fr d. 14 Fr

ANS: D To estimate quickly the proper size of suction catheter to use with a given tracheal tube, first multiply the tube's inner diameter by 2. Then use the next smallest size catheter.

A patient is being evaluated for tracheal damage sustained while having undergone prolonged tracheostomy intubation approximately 3 months earlier. The flow-volume loop demonstrates a fixed obstructive pattern. What is the most likely cause of the problem? a. Tracheomalacia b. Laryngeal web c. Cord paralysis d. Tracheal stenosis

ANS: D Tracheal stenosis will appear as a fixed obstructive pattern, with flattening of both the inspiratory and expiratory limbs of the flow-volume loop.

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

ANS: D Weaning is accomplished by using fenestrated tubes, progressively smaller tubes, or tracheostomy buttons.

Which of the following bedside methods can absolutely confirm proper endotracheal tube position in the trachea? a. Auscultation b. Observation of chest movement c. Tube length (cm to teeth) d. Fiberoptic laryngoscopy

ANS: D With the exception of fiberoptic laryngoscopy, none of these methods can absolutely confirm proper tube placement.

You are assisting a physician in the emergency care of a patient with a maxillofacial injury who will require short-term ventilatory support. Which of the following airway approaches would you recommend? a. Intubate via the oral route. b. Insert an oropharyngeal airway. c. Perform an emergency tracheotomy. d. Intubate via the nasal route.

ANS: D With the maxillofacial injury, the oral cavity will not be accessible. Intubation via the nasal route may be required. It is a short term need so a tracheotomy will not be necessary.

To make oral intubation easier, how should the patient's head and neck be positioned? a. Neck extended over the edge of the bed, with head dangling down b. Neck extended, with head supported by towel and flexed forward c. Both the neck and head fully extended, with neck supported by towel d. Neck flexed, with head supported by towel and tilted back

ANS: D You achieve this alignment by combining moderate cervical flexion with extension of the atlantooccipital joint. Placement of one or more rolled towels under the patient's head helps. You then flex the neck and tilt the head backward with your hand (Figure 36-14)