When called to the bedside of a patient in ICU receiving volume control SIMV, you note the low volume and pressure alarms sounding and hear gurgling around the endotracheal tube cuff. After confirming the integrity of the cuff, which of the following would you do NEXT?
- increase the set tidal volume to compensate for the volume loss
- add air to the cuff until the pressure is between 20-30 cm H2O
- increase the mandatory (machine) rate to maintain minute ventilation
- lower the low pressure and volume alarms until they stop sounding
The problem is a leak around the ET tube and the initial solution would be to inflate the cuff to a pressure between 20 to 30 H2O and reassess the patient. Cuff pressures below 30 H2O not only can cause leaks but also may allow for aspiration and contribute to VAP. Pressures above 30 cm H2O can cause tissue ulceration and necrosis. Sometimes leakage around the cuff may still occur, even at the high end of the recommended pressure range. This occurs most often when high peak pressures are required (typically above 40–50 cm H2O). Cuff leakage due to high peak pressures is acceptable as long as adequate ventilation can be maintained.
A physician asks you to assess the upper airway function of a patient with a fenestrated tracheostomy tube. How should this be accomplished?
- replace the inner cannula, plug the outer, inflate the cuff
- remove the inner cannula, plug the outer, inflate the cuff
- replace the inner cannula, plug the outer, deflate the cuff
- remove the inner cannula, plug the outer, deflate the cuff
A fenestrated tracheotomy tube is a double cannulated tube that has an opening in the posterior wall of the outer cannula, above the cuff. Removal of the inner cannula opens the fenestration. Plugging of the proximal opening of the tube's outer cannula (with the cuff deflated) allows for assessment of upper airway function. Removal of the plug allows access for suctioning. If the need for mechanical ventilation occurs, the inner cannula can be reinserted.
To avoid leaks while manually bagging a patient with a laryngeal mask airway (LMA) in place, you should:
- add more air to the mask cuff
- inflate the lungs quickly
- keep volumes above 10 mL/kg
- keep pressures below 30 cm H2O
To avoids leaks during positive pressure ventilation (PPV) with a LMA, you should use slow inflation, keep peak inspiratory pressures less than 20-30 cm H2O, and limit delivered tidal volume to no more than 8 mL/kg. Leaks during PPV most likely are due to upward displacement of the mask. If a leak occurs: (1) ensure that the airway is securely taped in place, (2) readjust the position of the airway by pressing the tube downward, and (3) resecure the airway in its new position. Do not simply add more air to the cuff (this can worsen the leak by pushing the cuff away from the larynx).
Which of the following airway management techniques can help decrease the incidence of ventilator-acquired pneumonia (VAP)?
- aspirating subglottic secretions
- using the nasal route for intubation
- inflating the ET tube cuff to 35 cm H2O
- using an uncuffed endotracheal tube
Airway management techniques that can help decrease the incidence of VAP include: (1) avoiding intubation when possible (using noninvasive ventilation instead); (2) intubating via the oral (as opposed to nasal) route; (3) maintaining proper ET tube cuff pressures (20–30 cm H2O); (4) aspirating subglottic secretions; and (5) using only sterile water or saline to flush suction catheters.
After an intubated patient successfully completes a 90 minute trial of spontaneous breathing on a ventilator (CPAP with pressure support), the attending doctor requests that he be extubated. Which of the following would you want to confirm before agreeing to remove the patient's ET tube?
- That the likelihood of aspiration is minimal: No; That the risk of upper airway obstruction is low: No; That secretion clearance can be assured: Yes
- That the likelihood of aspiration is minimal: Yes; That the risk of upper airway obstruction is low: No; That secretion clearance can be assured: Yes
- That the likelihood of aspiration is minimal: Yes; That the risk of upper airway obstruction is low: Yes; That secretion clearance can be assured: Yes
- That the likelihood of aspiration is minimal: No; That the risk of upper airway obstruction is low: Yes; That secretion clearance can be assured: Yes
Extubation should be considered only if the patient 1) can maintain acceptable ABGs during a spontaneous breathing trial; 2) can pass a cuff leak test (indicating minimal risk for upper airway obstruction); 3) is at minimal risk for aspiration (e.g., has positive gag reflex; can raise head on command); and 4) can adequately clear pulmonary secretions (e.g., exhibits deep cough on suctioning and/or has an MEP > 60 cm H2O).
Which of the following represents the proper sequence for use of an airway exchange catheter (AEC) for exchanging a patient's ET tube?
- extubate patient > introduce AEC into pharynx > thread new tube over AEC > remove AEC
- insert AEC inside old ET tube > remove old tube > thread new tube over AEC > remove AEC
- insert AEC next to old ET tube > remove old tube > thread new tube over AEC > remove AEC
- extubate patient > insert AEC inside new ET tube > intubate with new ET tube > remove AEC
An airway exchange catheter (AEC) is designed to allow exchange of one ET tube for another without losing airway access. Were you to extubate the patient before exchange (options A and B here) you might lose airway access. And the only way to ensure that the AEC is properly positioned to make the exchange is to first insert it inside existing (old) properly placed ET tube.
Which of the following is associated with difficult intubation via direct laryngoscopy?
- large tongue/small oropharynx
- small neck circumference
- small tongue/large oropharynx
- large mouth opening
The LEMON mnemonic can help the clinician predict difficult intubation. LEMON stands for Look externally, Evaluate external anatomy, Mallampati classification, Obesity/Obstruction, and Neck mobility. If the patient cannot fully cooperate with the oral inspection needed to assign a Mallampati, one should at least attempt to assess the size of the tongue relative to the oropharynx. A large tongue/small oropharynx indicates difficult intubation.
You insert a #4 (red) King LT airway in a 5-foot, 8-inch tall adult female. After insertion and preliminary positioning, you would inflate the cuff
- with 30 mL air
- to 25 cm H2O
- with 90 mL air
- to 60 cm H2O
A #4 (red) King LT airway is the proper size for use on a 5-foot, 8-inch patient. Recommended King LT cuff inflation volumes vary by both device and patient size. The manufacturer recommends a cuff inflation volume of 60–80 mL for the #4 (red) King LT. However, to ensure that the cuff is not overinflated, you initially should adjust cuff pressure to 60 cm H2O or to "just seal" volume. This guideline applied to all five sizes of the King LT.
A hospitalized patient with a laryngectomy and tracheoesophageal voice prosthesis who being treated for pneumonia requires tracheobronchial suctioning. To suction this patient you would
- insert the catheter via the nasotracheal route
- insert the catheter directly into the stoma
- insert the catheter through the voice prosthesis
- insert the catheter via the oral route
In patients with a laryngectomy, there is no connection between the stoma and upper airway. For this reason all airway management (ventilation, oxygenation, intubation, suctioning, aerosol drug delivery, etc.) must be via the stoma, not via the oral or nasal route. And were your to insert a catheter through the voice prosthesis, it would end up in the esophagus.
Which of the following conditions represent the minimum humidification requirements for patients with artificial tracheal airways?
- Relative humidity of at least 50%
- Temperature between 30 to 32 degrees Celsius
- Vapor pressure of at least 25 torr
- Absolute humidity of at least 33 mg/L
For patients with bypassed upper airways, inadequate humidification can cause damage to the tracheal mucosa and impair mucociliary clearance. For these patients, therapy gas should be warmed to 34–41 degrees Celsius and fully saturated with water vapor, i.e., 100% relative humidity. These conditions will provide absolute humidity in the range of 33-44 mg/L water vapor content. Therefore, a minimum of 33 mg H2O/L has been recommended for patients with an artificial airway.
A laryngectomy patient with a double cannula laryngectomy tube exhibits signs of complete airway obstruction. After you call for the rapid response team, you remove the inner cannula but cannot pass a suction catheter. You next action should be to:
- pull the laryngectomy tube, insert a ET tube into the stoma and bag the patient via the ET tube
- plug the laryngectomy tube, insert a laryngeal mask airway and bag the patient via the LMA
- pull the laryngectomy tube and bag the patient via a pediatric face mask applied over the stoma
- orally intubate the patient, plug the laryngectomy tube and bag the patient via ET tube
If a laryngectomy patient with a double cannula laryngectomy tube exhibits signs of complete airway obstruction, first remove the inner cannula and try to pass a suction catheter. If you cannot pass the catheter, remove the laryngectomy tube and provide bag-valve ventilation and oxygenation via a pediatric face mask or LMA applied over the stoma. Only if this method fails to provide adequate ventilation and oxygenation should you consider intubating the stoma with an ET tube.
During an attempt to insert a nasopharyngeal airway in a patient, you encounter an obstruction to further movement. What is the most appropriate action at this time?
- Use a stylet to force the nasopharyngeal airway in place
- Attempt to pass the airway through the opposite naris
- Insert the nasopharyngeal airway through the oral cavity
- Use a tongue depressor to push the airway posteriorly
If an obstruction is felt while inserting a nasopharyngeal airway, the most likely cause is a deviated nasal septum. In this case, one should simply attempt passage through the other naris.
To minimize the risk of aspiration of glottic secretions or cord damage during removal of an oral endotracheal tube, you should:
- have the patient cough while you quickly pull the tube
- provide 100% oxygen for 1-2 minute before extubation
- keep the tube cuff pressure below 25-30 cm H2O
- fully occlude the ET tube while you quickly it out
Having the patient cough while you quickly pull out an endotracheal tube has two benefits: (1) it minimizes the risk of aspiration of glottic secretions; and (2) it helps prevent damage to the vocal cords (abducted during a cough).
Which of the following factors are associated with difficult airway during manual bag-valve-mask ventilation?
- lack of facial hair
The MOANS mnemonic can help the clinician predict difficult bag-valve-mask ventilation. MOANS stands for Mask seal, Obesity/Obstruction, Aged, No teeth (edentulousness), and Stiff lungs. Excessive facial hair/beards can create a problem with the mask seal. Neither malnutrition nor sinusitis are associated with difficult airway during BVM ventilation.
A patient has been supported by a mechanical ventilator using a heat and moisture exchanger (HME) for the last 3 days. Suctioning reveals an increase in the amount and tenacity of secretions. Which of the following actions are indicated?
- Switch the patient to a large volume heated humidifier
- Switch the patient to continuous ultrasonic nebulization
- Reassess the patient's secretions over the next 24-48 hours
- Replace the heat and moisture exchanger with a new one
HMEs can be used to warm and humidify the inspired gas in ventilator circuits of patients who are normothermic, adequately hydrated, and do not require therapeutic humidity for retained secretions. HMEs are contraindicated in patients with thick or bloody secretions and those with high tidal/minute volumes. If these conditions occur, a conventional large volume heated humidifier should be employed.
To help minimize the risk of ventilator-associated pneumonia in patients receiving invasive ventilatory support you would:
- use an HME or humidifier with heated wire circuit
- keep the airway temperature above 45 degrees Celsius
- change the ventilator circuit every 24-48 hours
- drain any circuit condensate back into the humidifier
To minimize the risk of ventilator-associated pneumonia, you should (1) only change circuits when soiled or malfunctioning; (2) maintain a ‘closed‘ circuit by minimizing disconnections and using an in-line/closed suction system; (3) as appropriate for the patient, consider an HME or heated wire circuit to eliminate circuit condensate; (4) if condensate cannot be eliminated, prevent its accumulation by draining it away from both the patient and humidifier and avoiding contamination during its disposal.
You can blindly insert an ET tube into the trachea through which of the following supraglottic airways?
You can blindly insert an ET tube through a laryngeal mask airway (LMA). A 6.0 mm ID ET tube can be passed through a # 3 or #4 LMA, while a 7 mm ID ET tube can be passed through a #5 LMA. A variant of the standard LMA (LMA Fastrach) is designed specifically for use as a guide for intubation of the trachea. You can also blindly insert an ET tube through a King LT airway.
You are assisting a physician in exchanging the ET tube of a patient using a fiberoptic bronchoscope (FOB) as the re-intubation guide. You would remove the old tube:
- immediately upon insertion of the FOB into the pharynx
- only after confirming the FOB tip is just above the carina
- prior to insertion of the FOB into the pharynx
- only after the new tube is positioned in the trachea
During fiberoptic assisted ET tube exchange, a small (pediatric size) bronchoscope is "pre-loaded" or ensleeved with a new ET tube. Using the scope for visual guidance, the tip of the new tube is positioned in the laryngopharynx. Then the tip of the scope is passed through the glottis and into trachea alongside the existing tube (requires deflation of the old tube cuff). Only after the scope tip is confirmed to be in proper position (just above the carina), should the old tube be removed. Once the old tube is removed, the physician threads the new tube over the bronchoscope into the trachea.
Which of the following positions would you use to position a patient for orotracheal intubation?
- neck hyperextended
- head extension with neck flexion
- head hyperextended
- head flexion with neck extension
For oral intubation, the patient's head should be placed in the "sniffing," i.e., head extension with neck flexion and pillow or towel under the head. This helps align the larynx and posterior pharynx for easier tube insertion. Note that this position is contraindicated in patients with suspected C-spine injury, for which manual inline stabilization is recommended.
A comatose patient intermittently exhibits upper airway occlusion. There is no evidence of secretion retention. Which of the following actions would you take to help prevent this problem?
- immediately intubate and ventilate
- insert an oropharyngeal airway
- recommend a tracheotomy
- place the patient in the prone position
In comatose patients airway obstruction is often due to the tongue obstructing the posterior pharynx. In this instance, the insertion of an oropharyngeal airway would help overcome this problem. If insertion of an oropharyngeal airway provokes a gag reflex, consider a nasopharyngeal tube.
You are performing intubation on an average-sized adult male. Which of the following endotracheal tube size ranges would you select for this patient?
Choose one answer.
- 6.0 - 7.0 mm
- 7.0 - 8.0 mm
- 8.0 - 9.0 mm
- 9.0 - 10.0 mm
For an average-sized adult male patient requiring endotracheal intubation, a tube in the 8.0 - 9.0 mm ID range would be satisfactory.
When using a disposable CO2 indicator to confirm ET tube placement, a false negative (absence of color change even with tracheal positioning) can occur
- with metabolic acidosis
- during cardiac arrest
- with mainstem bronchial intubation
- during bag-valve ventilation
With disposable CO2 indicators, a failure to change color can occur even with proper tube position (false negative) if there is no blood circulation through the lungs, as during cardiac arrest. On the other hand, color change can occur with improper tube placement if the ET tube is in the mainstem bronchus (a false positive).
You are reviewing the chest x-ray of a 26-year-old female patient who has an oral endotracheal tube in place. You can confirm proper placement of the tube by determining that its tip is located:
- even with the carina
- 4 to 6 cm above the carina
- at the sixth intercostal space
- level with the 5th cervical vertebra
Proper placement of an endotracheal or tracheostomy tube normally is confirmed by X-ray. The tube tip should be about 4 to 6 cm above the carina or between thoracic vertebrae 2 and 4 (T2-T4).
Immediately after insertion of a #4 laryngeal mask airway (LMA) in a 70 kg adult, you should inflate the cuff to:
- 60 cm H2O pressure
- 10 mL volume
- 30 cm H2O pressure
- 60 mL volume
In general, regardless of the size of the LMA, you should inflate the cuff to 60 cm H2O, while at the same time keeping the maximum inflation volume within that specified by the manufacturer. For a #4 LMA, the maximum recommended cuff inflation volume is 30 mL.
The most important safety consideration in providing tracheostomy care is to:
- always use hydrogen peroxide for cleaning
- always change the tube ties/holder
- always make sure the tube is secure
- always keep the inner cannula in place
Assuring that the trach tube is always secure is the most important safety consideration during provision of trach care. You do this by: (1) carefully removing the old dressing, making sure the tube stays in tube in place; (2) using a second person to hold the tube in place when changing the tube ties or holders; (3) never tying tube in place with a bow (always use a square knot instead); and (4) not leaving the bedside until you are sure that the tube is secured in proper position.
Which of the following are indications for changing a tracheostomy tube?
1. the need for different size tube
2. a blown/damaged tube cuff
3. a soiled stoma dressing
- 1 and 2 only
- 1 and 3 only
- 2 only
- 1, 2 and 3
A tracheostomy tube change is indicated if the cuff is damaged and cannot be inflated or if the physician wants to switch to a different size or different type tube, e.g., a fenestrated tube.
You should select an active water heated humidifier when initiating mechanical ventilation instead of a heat and moisture exchanger (HME) under all of the following circumstances except:
- patient has thick secretions
- patient receiving large tidal volumes
- patient was intubated via the nasal route
- patient-ventilator system has large leaks
You should start mechanically ventilated patients on a heated humidifier whenever one or more contraindications exist against using an HME. HME contraindications include thick or bloody secretions, hypothermia (< 32° C), large tidal volumes (> 1000 mL) and large system leaks.
Which of the following would indicate that a patient may not be ready to extubate?
- a positive gag reflex
- a negative cuff leak test (no leakage)
- a successful spontaneous breathing trial
- a deep cough on suctioning
In considering a patient for extubation, first assure adequate oxygenation and ventilation during a spontaneous breathing trial. To assess for upper airway obstruction, perform a cuff leak test (deflate the cuff and occlude the tube at its outlet). If leakage occurs (a "positive" test), then the airway most likely is patent. A positive gag reflex and the ability to raise the head off the bed indicate adequate airway protection. Last, the ability to clear secretions is evident if the patient is alert, coughs deeply on suctioning and can generate a maximum expiratory pressure (MEP) > 60 cm H2O.
Which of the following is true for the airway management of a patient with a laryngectomy?
- these patients should never be orally or nasally intubated
- these patients will always need a laryngectomy tube in place
- laryngectomy tubes used by these patients should be cuffed
- no special precautions are needed when these patients shower
Because there is no connection between the stoma and upper airway of laryngectomy patients, neither oral nor nasal intubation can provide access to the trachea/lungs. Not all patients with a laryngectomy need a laryngectomy tube; however if a tube is used is must be uncuffed. To prevent aspiration, laryngectomy patients should use a protective cover when showering or bathing.
You are assisting with the oral intubation of an adult patient. After the ET tube has been placed, you note that breath sounds are decreased on the left compared with the right lung. The most likely cause of this observation is:
- the cuff of the endotracheal tube has been over-inflated
- the tip of the tube is in the right mainstem bronchus
- the endotracheal tube has been inserted into the esophagus
- the tip of the tube is in the left mainstem bronchus
Because the right mainstem bronchus is more in line with the trachea than the left, mainstem intubation is more common on the right side. A classic finding in this instance is significantly decreased breath sounds on the left side. This is confirmed with a chest X-ray and corrected by withdrawing the ET tube until it is 4 to 6 cm above the carina.