Chapter 13 - Ensure Modifications are Made to the Respiratory Care Plan Flashcards Preview

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1

When 15 cm H2O PEEP is initiated, a patient's cardiac output decreases from 4 to 2 L/min. Which of the following actions would be appropriate?

  1. maintain the present settings and check the ABGs in one hour
  2. decrease the respiratory rate to extend cardiac filling time
  3. increase PEEP level slightly to reach the "optimal" PEEP
  4. decrease PEEP to 10 cm H2O and recheck the cardiac output

4

One of the most common problems with PEEP is that it adversely affects cardiac output. In this case, the fall in cardiac output is potentially life-threatening. The PEEP level must be decreased and the patient's cardiac output remeasured.

2

A physician has ordered an aerosol treatment with 4 mL acetylcysteine (Mucomyst), 20% concentration. The patient develops end-expiratory wheezes. You should:

  1. administer 10 mg beclomethasone (Vanceril)
  2. discontinue therapy and notify the physician
  3. administer the treatment as ordered
  4. change to 2.5 mg albuterol (Proventil)

2

Mucomyst is very irritating to the airways and can cause bronchospasm. It should always be given with a bronchodilator. In this case, you should stop the therapy and notify the physician—making the recommendation of adding a bronchodilator if the Mucomyst is still indicated.

3

A patient is admitted to the Emergency Department with severe upper airway trauma. Attempts to intubate the patient fail and you cannot ventilate him using a bag-mask resuscitator. Which of the following actions would you recommend at this time?

  1. surgical cricothyrotomy
  2. nasotracheal tube insertion
  3. laryngeal mask airway insertion
  4. esophageal-tracheal tube insertion

1

Supraglottic airways (LMAs, Combitubes, King tubes) are contraindicated in the presence of upper airway trauma and if the patient can’t be intubated via direct laryngoscopy, blind nasotracheal intubation is not a viable option. Whenever traumatic upper airway injuries result in a "can’t ventilate, can’t intubate situation" emergency surgical access to the trachea is indicated. This can be accomplished by either cricothyrotomy or percutaneous tracheostomy.

4

 

An 8-hour-old, 28-week gestational age neonate is being maintained in an oxygen hood with an FIO2 of 0.65. The neonatologist believes that the patient has infant respiratory distress syndrome (IRDS). Based on the following results, what should you recommend?

 

pH            7.36

PaCO2       44 torr

HCO3         24 mEq/L

BE            0 mEq/L

PaO2          46 torr

  1. increasing the O2 hood concentration to 80%
  2. beginning inhaled nitric oxide (INO) therapy
  3. administering pulmonary surfactant
  4. starting high-frequency ventilation

3

This infant’s acid-base balance is normal; hence mechanical ventilation is not warranted at this time. However, the patient has refractory hypoxemia (PaO2 < 60 with FIO2 > 0.60), probably due to shunting. With the hypoxemia due to shunting, further increases in FIO2 are not warranted. CPAP may be indicated but is not an option here. Surfactant administration is indicated for premature babies for the prevention and treatment of IRDS. Nitric oxide therapy is indicated only for persistent pulmonary hypotension of newborn (PPHN) or for hypoxic respiratory failure when conventional therapies such as mechanical ventilation are not successful.

5

Which of the following would you NOT recommend for a critically ill patient with signs and symptoms of fluid overload (overhydration)?

  1. initiate diuretic therapy
  2. restrict and closely monitor fluid intake
  3. administer steroids
  4. if renal failure, consider dialysis

3

Management of patients with fluid overload (overhydration) normally includes restriction of fluid intake, administration of diuretics and in critically ill patients insertion of a CVP catheter to closely monitor fluid balance. If heart failure is suspected, inotropic agents may be considered temporarily. If renal failure is a contributing factor, dialysis may be initiated. Corticosteroids tend to cause sodium and fluid retention.

6

Which of the following would you recommend for a patient experiencing mild post-extubation stridor?

  1. 0.5 mL racemic epinephrine via SVN
  2. 0.5 mL albuterol (Proventil) via SVN
  3. 2.5 mL ipratropium bromide by SVN
  4. 2 puffs salmeterol (Serevent) by MDI

1

An effective treatment for mild to moderate post-extubation stridor is 0.5 mL of 2.25% strength racemic epinephrine (Vaponephrine) with normals saline by SVN. This alpha adrenergic drug can help reduce tissue edema by causing vasoconstriction.

7

A physician requests a trial of SIMV for a patient being managed in the control mode with pancuronium bromide (Pavulon). Which of the following agents could be administered to reverse the effects of Pavulon?

  1. sodium thiopental (Pentothal)
  2. norepinephrine (Levophed)
  3. succinylcholine (Anectine)
  4. neostigmine (Prostigmin)

4

Since pancuronium bromide is a competitive blocking agent, its action can be reversed by giving an acetlycholinesterase inhibitor, such as neostigmine methylsulfate (Prostigmin).

8

You would recommend placement of an artificial tracheal airway to:

  1. enable negative pressure ventilation
  2. decrease auto-PEEP
  3. protect against pulmonary aspiration
  4. increase anatomic deadspace

3

There are four basic indications for artificial tracheal airways: 1) to relieve airway obstruction; 2) to facilitate secretion removal; 3) to protect the lower airways from aspiration; and 4) to facilitate application of positive pressure ventilation. Negative pressure ventilation normally requires an intact and normally functioning upper airway and tracheal airways actually DECREASE anatomic deadspace.

9

A 28-year-old 80 kg (175 lb) male trauma victim with a closed-head injury is receiving volume control A/C ventilation and has been paralyzed with a cisatracurium (Nimbex). The ventilator settings and current ABGs are as follows:

  1. raising the PEEP to 10 cm H2O
  2. increasing the tidal volume to 1.0 L
  3. raising the FIO2 to obtain an SaO2 of 100%
  4. decreasing the mandatory rate to 8/min

3

The goals of ventilatory support for patients with closed-head injuries are to (1) maximize cerebral oxygenation, (2) assure good patient-ventilatory synchrony, and (3) avoid techniques/settings that could decrease perfusion or raise intracranial pressure (ICP). In general this means aiming for an SaO2 = 100%, a PaCO2 in the 35–40 torr range (avoiding hypercapnia!), and a PIP ≤ 30 cm H2O. Thus in this case the first action would be to raise the FIO2 until SaO2 = 100%. Patient-ventilatory synchrony is not at issue here since the patient is paralyzed. Raising the PEEP might decrease cerebral perfusion. Increasing the tidal volume would result in hyperventilation (PaCO2 < 35 torr), which no longer is recommended as a maintenance strategy for these patients. Decreasing the rate would cause hypercapnia and elevate the ICP. Other therapies, including osmotic diuresis, CSF fluid drainage and sedation are used for ongoing management.

10

A patient admitted to the emergency room is spontaneously breathing but comatose due to carbon monoxide inhalation. He has a PaO2 of 87 torr and PaCO2 of 36 torr on room air. Which of the following actions would you recommended?

  1. administer as high a FIO2 as possible
  2. initiate mechanical ventilatory support
  3. administer continuous positive airway pressure
  4. initiate aerosol therapy with 40% O2

1

The objective of O2 therapy for most adults is to give sufficient oxygen to maintain the PaO2 between 60–100 torr. The exceptions are those conditions in which the O2 carrying capacity of the hemoglobin is impaired. Anemia and carbon monoxide inhalation are two conditions in which high PO2s are needed to increase dissolved O2, compensating for the deficient hemoglobin transport.

11

Data for a 78 kg (172 lb) patient receiving ventilatory support with 12 cm PEEP are as follows:

Which of the following changes would you recommend at this time?

  1. lower the VT
  2. increase the rate
  3. decrease PEEP
  4. decrease the FIO2

3

Acid-base balance is normal so no change in ventilation is indicated. In terms of oxygenation, the PaO2 is excessive and can be lowered. Either a decrease in FIO2 or a decrease in PEEP could lower the PaO2 back to normal. When two changes could achieve the same goal, always first choose the one that either will cause the least harm or best reduce potential harm to the patient. In this case, the FIO2 is at a safe level (< 0.60), but the PEEP is potentially harmful. You therefore should first recommend decreasing the PEEP.

12

A patient with emphysema receiving volume control A/C ventilation develops signs of air trapping (auto-PEEP). The doctor does not want to switch to SIMV. Which of the following actions would help resolve this problem?

  1. decrease the length of time available for exhalation
  2. increase the preset frequency of breathing by 30%
  3. increase the length of time available for exhalation
  4. increase the inspiratory time by decreasing the flow

3

Air trapping/auto-PEEP during positive pressure ventilation is most likely when insufficient time is provided for exhalation. Although I:E ratios of 1:2 or 1:3 are generally sufficient to ensure complete exhalation of patients with normal lungs, lower ratios (e.g., 1:4, 1:5) may be required in some patients with severe COPD. Alternatively, small amounts of machine PEEP (50-80% of the measured auto-PEEP level) can be used to help overcome auto-PEEP.

13

After weaning and extubation, a patient on a cool aerosol mask at 40% O2 develops moderate hypoxemia and hypercapnia, with a falling pH. Which of the following actions would you recommend at this time?

  1. increase the nebulizer oxygen concentration to 60%
  2. apply bi-level positive airway pressure via mask
  3. administer 50 mEq IV sodium bicarbonate
  4. re-intubate and apply volume control ventilation

2

Bi-level positive airway pressure (BiPAP) is a good option to help avoid reintubation of patients who develop mild to moderate hypercapnia or hypoxemia after extubation. It also is used to (1) avoid intubation of COPD patients requiring ventilatory support for acute on chronic ventilatory failure, (2) treat CHF/pulmonary edema (short term application), and (3) manage obstructive and central sleep apnea (nocturnal application).

14

To remove accumulations of subglottic secretions from above the cuff of intubated patients, you should recommend which of the following?

  1. intrapulmonary percussive ventilation (IPV)
  2. use of a tracheal tube with a suction port above the cuff
  3. aggressive tracheal suctioning with saline lavage
  4. frequent oropharyngeal suctioning with a Yankauer tip

2

A common problem in intubated patients is leakage of subglottic secretions past the tracheal tube cuff. These secretions can contaminate the lower respiratory tract and are thought to be a major contributing factor in the development of ventilator-associated pneumonia (VAP). The best way to remove these subglottic secretions in these patients is to use a tracheal tube with a suction port above the cuff and apply a low level of continuous suction to it (called Continuous Aspiration of Subglottic Secretions or CASS).

15

A doctor orders a spontaneous breathing trial (SBT) for a COPD patient receiving pressure control SIMV via a 6.5 mm endotracheal tube. Which of the following methods would you recommend for implementing the SBT on this patient?

  1. volume control SIMV
  2. CPAP with pressure support
  3. pressure support alone
  4. simple T-piece

2

Spontaneous breathing modes used in SBT weaning protocols include (1) straight T-tube breathing, (2) CPAP, (3) pressure support, or (4) CPAP with pressure support (aka BiPAP). Especially in patients with expiratory airway obstruction (as in COPD) provision of CPAP can help overcome auto-PEEP. In addition, pressure support always should be used to overcome the resistance caused by spontaneous breathing through a small artificial airway (also as in this case).

16

A patient under your care has X-ray and clinical evidence of severe unilateral right lung infiltrates. His PO2 on a non-rebreathing mask is 49 torr. The attending physician asks your advice as to how best to improve this patient's oxygenation without committing to ventilatory support. Which of the following would you recommend?

  1. place the patient on his left side (left lung down)
  2. place the patient on his right side (right lung down)
  3. turn the patient from the supine to prone position
  4. institute a regimen of inspiratory resistive breathing

1

Dependent positioning can improve the distribution of ventilation in patients with V/Q imbalances, especially those with local conditions such as unilateral pneumonias. Placing the good lung in the dependent or down position (in this case the left lung) can significantly improve oxygenation without a change in FIO2, since the 'down' lung will receive the best ventilation and blood flow.

17

For which of the following purposes would you recommend pressure support ventilation (PSV)?

  1. to help manage hypoxemic respiratory failure
  2. to control a patient's minute ventilation
  3. to increase the functional residual capacity
  4. to decrease work of breathing caused by ET tubes

4

PSV is a spontaneous breath mode and therefore cannot be used to control a patient's minute ventilation. It can however be used to (1) help overcome the imposed work of breathing caused by artificial airways; (2) boost patients' spontaneous tidal volumes during SIMV; and (3) provide ventilatory assistance to patients during spontaneous breathing trials/weaning. By itself PSV does not increase FRC so it is not useful in managing hypoxemia due to shunting.

18

A doctor wants an outpatient with idiopathic pulmonary hypertension to self-administer an inhaled pulmonary vasodilator. Which of the following drugs would you recommend?

  1. epoprostenol (Flolan)
  2. diltiazem (Cardizem)
  3. iloprost (Ventavis)
  4. bosentan (Tracleer)

3

Pulmonary vasodilators administered via the inhalation route currently include three prostacyclins: epoprostenol (Flolan), treprostinil (Tyvaso) and iloprost (Ventavis). Only treprostinil (Tyvaso) and iloprost (Ventavis) are approved for administration via the inhalation route, typically for use by outpatients. Inhaled epoprostenol (Flolan) is used off-label in the acute care setting as an alternative to inhaled nitric oxide therapy and typically administered via continuous nebulization using an IV drip into a jet nebulizer. Both diltiazem (Cardizem; a calcium channel blocker) and bosentan (Tracleer; an endothelin receptor antagonist) are used to treat pulmonary hypertension, but are administered orally.

19

An ICU patient receiving ventilatory support is suspected of having a tension pneumothorax. Which of the following would you recommend?

  1. switch to bag-valve manual ventilation
  2. perform tracheobronchial suctioning
  3. obtain arterial blood gas for analysis
  4. get chest X-ray/prepare for thoracostomy

4

Although ABGs are useful for evaluating patients' acid-base and oxygenation status, this information would not contribute to defining or resolving the immediate problem at hand. In emergency situation like this only the absolutely essential information (X-ray) should be gathered and immediate corrective actions taken, i.e. needle decompression or chest tube insertion.

20

Before giving your patient an aerosol treatment with racemic epinephrine for laryngeal edema, you check his vital signs. His pulse rate is 85/min and respiratory rate is 16/min. Five minutes into the treatment, his pulse rate climbs to 135/min and his respiratory rate rises to 29/min. What is the best action in this case?

  1. Continue the treatment as ordered to completion
  2. Switch to albuterol (Proventil) and continue the treatment
  3. Stop the treatment, monitor the patient and contact the physician
  4. Ask the nurse what action she would recommend

3

The significant rise in heart rate (> 50%) suggests that the patient is experiencing an adverse reaction to the racemic epinephrine. For this reason, the therapy should be stopped, the patient stabilized and the physician contacted.

21

You observe the following pressure-volume loop display on a patient receiving volume-control ventilation. Which of the following actions would be appropriate?

  1. Decrease the delivered volume
  2. Increase the inspiratory flow
  3. Decrease the I:E ratio
  4. Increase the PEEP level

1

This pressure-volume loop exhibits significant flattening beyond its upper inflection point, indicating overdistention of the lungs. Due to its resemblance to a bird, this is sometimes called a "beaked" pressure-volume loop. When you observe this problem, you generally can resolve it by either reducing the volume (in volume ventilation) or the pressure setting.

22

A comatose patient intermittently exhibits upper airway occlusion. You should recommend:

  1. immediately intubating and ventilating
  2. inserting an oropharyngeal airway
  3. performing a tracheostomy
  4. ventilating with 100% oxygen

2

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.

23

A physician prescribes incentive spirometry for a postoperative patient who complains of dizziness when performing five inspiratory maneuvers in a row. What action should you take?

  1. Recommend that the therapy be discontinued
  2. Coach the patient to pause before each maneuver
  3. Begin CPR on the patient
  4. Begin oxygen therapy via protocol

2

To avoid light-headedness or dizziness associated with hyperventilation, a patient using incentive spirometry should be coached to perform one or two maneuvers and then to breathe normally for 30–60 seconds before initiating another maneuver.

24

A patient is receiving mechanical ventilation in the SIMV mode. At an FIO2 of 0.65, the following arterial blood gas results are reported:


pH7.42PaCO241 torrPaO247 torrHCO325 mEq/LBE0
Which of the following actions would you recommend be taken FIRST?
  1. Increase the SIMV rate
  2. Initiate PEEP
  3. Get a new arterial blood sample
  4. Increase the FIO2 to 1.0

2

The patient's acid-base status is normal, so no change in minute ventilation is indicated. On the other hand, the 60/60 rule of thumb for oxygenation (FIO2 > 0.60; PaO2 < 60 mm Hg) indicates significant shunting that will not respond to further increases in oxygen concentrations. The solution is to initiate PEEP. PEEP will open collapsed alveoli, decrease shunting, increase PaO2 and ideally allow lowering of the FIO2.

25

A patient with congestive heart failure and pulmonary edema is being managed with bi-level positive pressure (BiPAP) ventilation via a nasal mask. The IPAP is set at 15 cm H2O, and EPAP is set at 5 cm H2O. Because of a worsening of the patient's lung compliance, the VT has decreased and the PCO2 has gone from 45 to 52 mm Hg. What changes would you recommend at this time?

  1. Switch to a full oronasal face mask
  2. Increase the IPAP pressure
  3. Add additional supplemental O2
  4. Increase the EPAP pressure

2

You need to increase the patient's tidal volume. The best way to increase the VT during BiPAP ventilation is to increase the pressure gradient between the IPAP and EPAP pressure settings. Normally, you do this by increasing the IPAP setting. In this case an increase to 20 cm H2O would be a good choice.

26

A doctor is considering weaning a patient from invasive mechanical ventilation. Which of the following approaches would you recommend to wean this patient?

  1. Airway pressure release ventilation
  2. Pressure control with PEEP
  3. Pressure support with CPAP
  4. Decreasing rate SIMV

3

Weaning is most quickly accomplished via daily application of spontaneous breathing trials (SBTs). SBTs typically are implemented via simple T-piece, CPAP or pressure support with CPAP. Incremental decreases in SIMV rate would be a consideration only if the patient were deemed ventilator-dependent; otherwise it only tends to lengthen weaning time. Pressure control (pressure-limited, time-cycled ventilation) is not used for weaning.

27

Data for a 63 kg (140 lb) patient receiving ventilatory support with 10 cm of H2O PEEP are as follows:

Which of the following changes would you recommend at this time?

  1. Lower the VT
  2. Increase the rate
  3. Decrease PEEP
  4. Decrease the FIO2

4

Acid-base balance is normal so no change in ventilation is indicated. In terms of oxygenation, the PaO2 is excessive and should be lowered. Either a decrease in FIO2 or a decrease in PEEP could lower the PaO2 back to normal. When two changes could achieve the same goal, always first choose the one that either will cause the least harm or best reduce potential harm to the patient. In this case (assuming adequate cardiovascular status), the PEEP level is no a cause for major concern, but the FIO2 is dangerously high. You therefore should first recommend decreasing the FIO2.

28

You would recommend continuous positive airway pressure (CPAP) to manage which one of the following problems?

  1. Cardiogenic pulmonary edema
  2. Status asthmaticus
  3. Hypercapnic respiratory failure
  4. Drug overdose

1

CPAP involves the application of positive pressure to the airway throughout the spontaneous breathing cycle. It is indicated for patients: (1) with CHF/cardiogenic pulmonary edema (short term application); (2) with obstructive sleep apnea (nocturnal application); and (3) with adequate spontaneous ventilation but severe hypoxemia due to shunting (e.g., ARDS, IRDS). CPAP is not indicated for patients with conditions causing hypercapnia (such as drug overdose) and/or increased work of breathing (such as status asthmaticus).

29

Due to traumatic upper airway injuries, a patient cannot be orally intubated and bag-mask ventilation fails. Which of the following actions would you recommend at this time?

  1. Nasotracheal tube insertion
  2. Laryngeal mask airway insertion
  3. Percutaneous tracheostomy
  4. Esophageal-tracheal tube insertion

3

Supraglottic airways (LMAs, Combitubes, King tubes) are contraindicated in the presence of upper airway trauma and if the patient can’t be intubated via direct laryngoscopy, blind nasotracheal intubation is not a viable option. Whenever traumatic upper airway injuries result in a "can’t ventilate, can’t intubate situation" emergency surgical access to the trachea is indicated. This can be accomplished by either cricothyrotomy or percutaneous tracheostomy.

30

An anxious patient on a 15 L/min O2 via nonrebreather frequently removes the mask, complaining of restricted breathing and being "closed-in." During these episodes his SpO2 drops from 94% to 83%. Which of the following should you recommend?

  1. Switch to a standard nasal cannula at 15 L/min
  2. Intubate and provide ventilatory support with PEEP
  3. Switch to a high flow nasal cannula at 20-30 L/min
  4. Initiate noninvasive ventilation with 50% O2

3

The significant drop in this patient’s SpO2 off the mask confirms the need for a high FIO2. With the patient experiencing claustrophobia on the mask, you should switch to a high flow nasal cannula providing an equivalent FIO2 (20-30 L/min ~ 90-95% O2). Most patients will not tolerate a standard nasal cannula at 15 L/min and there is nothing in this scenario yet justifying mechanical ventilation, either invasive or noninvasive.