Question Answer
what can airway obstruction be caused by? retained secretions, foreign bodies, structural changes (edema, tumors, or trauma)
what can retained secretions cause, besides increasing airway resistance and work of breathing? hypoxemia, hypercapnia, atelectasis, infection
what might difficulty in clearing secretions be due to? thickness/amount, patients inability to generate effective cough
how can RT’s remove retained secretions or other semiliquid fluids from the airways? mechanical aspiration or suctioning
what does suctioning involve? negative pressure (vacuum) to the airways through collecting tube (flexible catheter/suction tip)
what does the removal of foreign bodies, secretions, or tissue masses beyond the mainstem bronchi require? bronchoscopy
where can suction be performed? upper airway (oropharynx)/lower airway (trachea & bronchi)
what can be used to remove secretions or fluids from the oropharynx? rigid tonsillar, or Yankauer, suction tip
access to the lower airway is via introduction of a flexible suction catheter through where? nose (nasotracheal suctioning) or artificial airway (endotracheal suctioning)
________ suctioning through the mouth should be avoided, as it causes gagging. tracheal
(ET suctioning, step 1) a patient should never be suctioned by what? preset schedule
what suggests that suctioning is needed? abnormal breath sounds (look at O2 sats also)
what is the most common abnormal breath sound assessed? rhonchi
(ET suctioning, step 2) what is the equipment needed for ET suctioning? 1. suction source 2. sterile suction catheter 3. sterile gloves 4. goggles, mask, gown 5. sterile basin 6. sterile bulk water or saline 7. sterile saline for instillation 8. O2 delivery system (BVM or vent)
how should you set the suction pressure? low as possible, yet high enough to effectively clear secretions
adult suction pressure? -100 to -120 mmHg
children suction pressure? -80 to -100 mmHg
infant suction pressure? -60 to -80 mmHg
how long are most general-purpose suction catheters? and how are the sized? 22 inches; sized in french units
what is available to increase the likelihood of left mainstem bronchial access? a curved-tip or Coude-tip
a catheter that is too large can obstruct the endotracheal airway, how does the clinican avoid this problem? (by using the “Rule of thumb”) we should never suction a pt with a catheter whose outer diameter is greater than one half the internal diameter of the tracheal tube
how do you calculate the rule of thumb? multiply the tube’s inner diameter by 2, then use the next smallest size catheter
what type of suction catheter can be used for pt’s receiving ventilatory support? closed-system multiuse suction catheter
what is recommended not to be used before endotracheal suctioning? saline irrigation
what seems to be more effective than normal saline if the secretions are extremely tenacious? acetylcysteine or sodium bicarbonate
how do you check the level of suction pressure? by closing the catheter thumb port and aspirating some sterile water or saline from the basin
(ET suctioning, step 3) how can a clinician easily hyperinflate the patient’s lungs? with a unit bag-valve-mask or manual resuscitator
how should you hyperinflate the patient’s lungfs if they’re on a ventilator? machine breath
how do you preoxygenate the patient? give 100% O2 for at least 30 seconds
how should you apply withdraw the catheter while applying suction? using a rotating motion
how long is the total suction time? less than 10-15 seconds
(ET suctioning, step 5) how is the catheter cleared? by squeezing the saline vial and applying suction at the same time
(ET suctioning, step 6) how long should you maintain the increased FiO2? at least 1 minute
what are 5 indications for ET suctioning? 1. coarse breath sounds 2. inability to generate effective spontaneous cough 3. visible secretions in airway 4. suspected aspiration 5. deterioration of ABGs
what are 5 hazards/complications of ET suctioning? 1. hypoxia/hypoxemia 2. cardiac/resp arrest 3. cardiac arrythmias 4. pulmonary atelectasis 5. bronchoconstriction/bronchospasm
what is the assessment of outcome for ET suctioning? 1. improved breath sounds 2. decreased PIP 3. improved ABGs 4. removal of pulmonary secretions
what helps minimize the incidence of hypoxemia during suctioning? preoxygenation
besides a closed-system catheter, what else helps to reduce the incidence of hypoxemia? double-lumen catheter
what occurs mainly as a result of hypoxemia? cardiac arrythmias
what can vagal stimulation cause? bradycardia or asystole
what are the steps to avoid atelectasis? 1. limit the amount of negative pressure 2. keep the duration of suctioning as short as possible 3. provide hyperinflation before/after
what is most effective for the pt being mechanically ventilated when needing to be preoxygenated/hyperinflated? use of the ventilator
who is nasotracheal suctioning indicated for? pts who retain secretions but do not have an artificial tracheal airway
in addition to the equipment and supplies used for ET suctioning, what is needed for nasotracheal suctioning? sterile water-soluble lubricating jelly to aid catheter passage through the nose
what should be considered using to help reduce mucosal trauma in the nose of patients who require long-term nasotracheal suctioning? nasopharyngeal airway
what is the key aspect of the nasotracheal suctioning procedure? catheter insertion
as the catheter enters the lower pharynx, what position should the patient assume? “sniffing” position
advancing the catheter into the oropharynx or esophagus may cause…? gagging/regurgitation
______ _______ can occur as the catheter is passed through the upper airway. airway trauma
besides trauma in the nose, what is another complication with nasotracheal suctioning? contamination of the lungs w/ bacteria from upper airway
what are often collected to identify organisms infecting the airway? sputum samples
what are the 3 indications for nasotracheal suctioning? 1. inability to clear secretions 2. audible evidence of secretions in large airways 3. obtain sputum samples
general conditions requiring airway management are impending or actual…? 1. airway compromise 2. respiratory failure 3. need to protect the airway
what are 5 indications for management of airway emergencies? 1. apnea 2. severe bronchospasm 3. self-extubation 4. pulmonary edema 5. severe laryngospasm
what are 5 hazards/complications of emergency airway management? 1. failure to establish patent airway 2. trauma to nose, mouth, tongue 3. aspiration/infection 4. ET tube problems 5. bleeding
when is an artificial airway required? when the pt’s natural airway can no longer perform its proper functions
pharyngeal airways extend only into the ________. pharynx
artificial airways that are placed in the trachea are called _____________ ______. endotracheal tubes
the process of placing an artificial airway into the trachea is referred to as __________. intubation
when the endotracheal tube is passed through the nose first, the procedure is referred to as…? nasotracheal intubation
when the tube is passed through the mouth on its way into the trachea, the procedure is called…? orotracheal intubation
how do pharyngeal airways prevent airway obstruction? keeping the tongue pulled forward and away from the posterior pharynx
what type of patient (conscious/unconscious) should pharyngeal airways be used on? unconscious
in what kind of pt is a nasal pharyngeal airway most often placed? a pt who requires frequent nasotracheal suctioning
what type of patient (conscious/unconscious) can a nasal pharyngeal airway be used on? conscious
where are oral pharyngeal airways inserted? into the mouth and over the tongue
what type of patient (conscious/unconscious) should a oral pharyngeal airway be used on? unconscious (avoid gagging/regurgitation)
pharyngeal airways are used mainly in…? emergency life support
what are the two basic types of tracheal airways? endotracheal tubes; tracheostomy tubes
where are endotracheal tubes inserted? mouth/nose, layrnx, trachea
where are tracheostomy tubes inserted? a surgically created opening in the neck directly into the trachea
what is a radiopaque indicator? it allows for identification of tube position on the radiograph
what are 2 common specialized endotracheal tubes? double lumen; jet ventilation
when is a double lumen ET tube required? independent lung ventilation
what are the important points to consider when using double-lumen ET tubes? they are stiffer and bulkier to insert than standard tubes; rotate during insertion
what might also use a specially designed tube? high-frequency jet ventilation
the use of what tube has been reported to decrease the incidence of ventilator-associated pneumonia? subglottic suction system
an __________ with a rounded tip is used for tube insertion. obturator
what is the preferred route for establishing an emergency tracheal airway? orotracheal intubation
what is the quickest and easiest route in most cases? oral
what is the equipment needed for intubation? (SOAPME) suction equipment, oxygen, airway equipment, position the pt, monitors, esopageal detectors
what are the 2 kinds of laryngoscopes? miller (straight); macintosh(curved)
how do you position the pt to visualize the glottis? allign the patient’s mouth, pharynx, and larynx
do not devote more than ___ seconds to any intubation attempt. 30
if intubation fails, immediately ventilate and oxygenate the pt for __-__ minutes before the next attempt. 3-5
how is the epiglottis displaced with the curved or macintosh blade? indirectly by advancing the tip of the blade into the vallecula and lift the laryngoscope up and forward
how is the epiglottis displaced with the straight or miller blade? directly by advancing the tip of the blade over its posterior surface and lift the laryngoscope up and forward
ideally, the tip of an ET tube should be positioned in the trachea about __ cm above the carina. 5
what is the quickest bedside method to assess ET tube position? auscultation
what are the other bedside methods to assess the ET tube position observation of chest movement, tube length, esophageal detection device, light wand, capnometry, colorimetry, fiberoptic laryngoscopy
what is the appropriate tube size for women? tube length? 7.5-9.0; 19-21
men? 8.0-9.5; 21-23
proper tube placement in the trachea can be confirmed without a chest radiograph by using a…? fiberoptic laryngoscope
what is the most accurate way to assess position of the tube? chest x-ray
what is the most common complication of emergency airway management? tissue trauma
what are the most serious complications of emergency airway management? acute hypoxemia, hypercapnia, bradycardia, cardiac arrest
in addition to ventilation/oxygenation, what else can reduce complications and facilitate intubation in the semicomatose/combative pt? sedation/anesthesia
_________ can be used in the combative pt who cannot be controlled by sedation. paralysis
what kind of pt has no ability to compensate for hypoxemia/hypercapnea? paralyzed
what is used to describe the administration of a sedative, hypnotic medication, and a paralyzing agent? rapid sequence induction
what occurs because of the inability to open the mouth, position the pt, or unusual airway anatomy? difficult intubations
what type of intubation is more difficult than orotracheal intubation? nasotracheal intubation
what is an example of when nasotracheal intubation would be used? when oral route is unavailable, such as maxillofacial injuries or oral surgery
what are the 2 way nasotracheal intubation is performed? direct visualization; blindly
what does the direct visualization approach require? standard or fiberoptic laryngoscope
what must the patient be doing for the blind technique to work? breathe spontaneously
what is needed for local anesthesia and vasoconstriction for nasotracheal intubation? sprays of 0.25% racemic epinephrine; 2% lidocaine
what is the only difference in equipment for nasotracheal intubation than for orotracheal intubation? magill forceps
what is the avg depth of tube insertion from the external naris for men? women? 28 cm; 26 cm
what is the indication for successful passage of the tube through the larynx? harsh cough, followed by vocal silence
___________ is the procedure of establishing access to the trachea via neck incision. tracheotomy
the opening created by this procedure is called a ___________. tracheostomy
what is tracheotomy the preferred, primary route for? overcoming upper airway obstruction or trauma and for LONG TERM CARE of pts with neuromuscular disease
what is another indication for tracheotomy? continuous need for artificial airway after prolonged period of oral/nasal intubation
when is the tube size correct for a tracheotomy? when it occupies between 2/3 – 3/4 of the internal tracheal diameter
what are the most common laryngeal injuries associated with endotracheal intubation? glottic edema, vocal cord inflamation, laryngeal/vocal cord ulcerations, vocal cord polyps or granulomas
what are the less common and more serious injuries associated with endotracheal intubation? vocal cord paralysis, stenosis
what are the primary symptoms of glottic edema and vocal cord inflammation? hoarseness and stridor
______ is a more serious symptom than hoarseness, indicating a significant decrease in diameter of the airway. stridor
what is stridor often treated with? what is the goal? racemic epinephrine; reduce glottic or airway edema by mucosal vasoconstriction
what may also be added to the aerosol to further reduce inflammation? who are these techniques most commonly used in? steriod; children
when does laryngeal stenosis occur? when the normal tissue of the larynx is replaced by scar tissue
________ lesions occur only with oral or nasal endotracheal tubes, ________ lesions can occur with any tracheal airway. laryngeal; tracheal
what are the most common tracheal lesions? less common, but more serious? granulomas, tracheomalacia, tracheal stenosis; tracheoesophageal and tracheoinnominate fistulas
what is tracheomalacia? softening of cartilaginous rings, causes collapse of trachea during inspiration
what is tracheal stenosis? in pts with ET tubes, where does this type of damage most often occur? narrowing of the lumen of the trachea; cuff site
in pts with tracheostomy tubes, stenosis may occur at the cuff, tube tip, or stoma sites – which site is most common? stoma sites
what is helpful in quantifying the severity of the damage? tomography, fluoroscopy, PFT
what is a direct communication between the trachea and esophagus? tracheoesophageal fistula
when can a tracheoinnominate fistula occur? what is the result? tracheostomy tube causes tissue erosion through the innominate artery; massive hemorrhage
once hemorrhage begins, what may slow the bleeding? hyperinflation of the cuff
what is the primary cause of injury? tube movement
_________ can help keep pts comfortable and decrease the likelihood of self-extubation. sedation
__________ tubes are easier to stabilize and may move less than orotracheal tubes. nasotracheal
what can be used to minimize tube traction? swivel adaptors
what is also important during prevention of injury? correct airway size
what is the most common way to secure ET tubes? with tape
what is adequate if the period of intubation is short, such as during surgery? but is easily loosened by oral secretions? silk tape
what is one of the most frustrating aspects of caring for a pt with a tracheal tube? his/her inability to talk
what is an example of a speaking valve? the Passy-Muir Valve
when using the speaking valve, what needs to happen to the cuff? deflated, allows airflow around tube
what do artificial airways bypass? normal humidification, filtration, heating functions of upper airway
thick secretions can plug a tracheal tube and cause ___________. asphyxiation
what should be used to deliver humidity to nonventilated pts with a tracheostomy? ventilated pts? heated humidifier/LV jet nebulizer/HME; active humidifiers/HME
what may decrease the incidence of ventilator-associated pneumonia? HME
what changes is the presence of infection suggesed by? additional changes? sputum, breath sounds, and/or chest radiograph; fever, increased heart rate, leukocytosis
what are the 3 ways to guard against infection? 1. sterile technique during suction 2. sterile equipment 3. washing hands b/t pts
what are 3 signs of partial airway obstruction? 1. inability to cough 2. increasing respiratory difficulty 3. cyanosis
what are 3 signs of complete upper airway obstruction? 1. inability to talk 2. cyanosis 3. extreme panic
what is the most common cause of airway obstruction in critically ill pts? retained secretions
what is normal cuff pressure? 20-25 mmHg
which minimal technique is not recommended bc it increases the risk of aspiration? MLT
what are the 3 emergency situations that may occur? 1. tube obstruction 2. cuff leaks 3. accidental extubation
what is a common finding in airway emergencies? decreased breath sounds
what is the most common cause of airway emergencies? obstruction of the tube
what are the 4 ways tube obstruction can occur? 1. kinking/biting 2. herniation of cuff over tube tip 3. jamming of tube against tracheal wall 4. mucous plugging
who are cuff leaks a primary problem for? mechanically ventilate pts
how can partial displacement of an airway out of the trachea be detected? decreased breath sounds, decreased airflow through the tube, decreased ability to pass a catheter past the end of the tube
the process of removing an artificial tracheal airway is called __________. extubation
what is the first method to remove the tube during extubation? give large breath with manual resuscitator remove at peak inspiration
what is the second method to remove the tube during extubation? pt coughs, remove during expulsive expiratory phase
what are the most common problems that occur after extubation? cough, hoarseness, sore throat
what are the most common problems during extubation failure? aspiration, edema


Question Answer
Conditions requiring management of AW are impending or actual AW compromise Respiratory failure Need to protect AW
Indications for emergency AW managment AW EMG b/f et intubation, obstruction of AW, Apnea, coma penetrating neck trauma Cardipul arrest/unstable dysrythmias severe bronchospasm pulmonary edema narcotics foreign body obstruction choanal antresia in neonates apsiration or risk of
Contraindications for Emergency AW managment Pt is a DNR
Hazards & Complications of Emergency AW managment Failure to establish a patent AW, intuabte trachea or recognize esophogeal intubation Upper AW trauma, laryngeal & esophageal damage Aspiration C-spine trauma Unrecognized Bronchial intubation Eye injury Vocal cord paralaysis ET Tube Issues
Which pt’s need AW emergency management? Pt inability to protect AW adequately (w*w/o respiratory distress) Partial or complete obstructed AW Apnea, maybe associated with cardiac arrest Hypoxemia, hypercarbia, or acidemia Respiratory distress
PT is unable to protect AW adequately if Coma Lack of gag reflex inability to cough May or may not be associated with respiratory distress
Sings of partially obstructed AW Ineffective pt effort to ventilate Paradoxial respiration stridor Use of accessory muscles PT pointing to neck choking motions Cyanosis and distress
Signs of lower AW obstruction All listed for upper AW obstruction Wheezing
Completely obstructed AW signs Respiratory efforts w/no breath sounds or suggestion of air movement
Signs of apnea No respiratory efforts seen May be associated with Cardiac arrest
Signs of Respiratory arrest Elevated RR High or low ventilatory volumes Signs of Sypathetics nervous system hyperactivity
Monitor Clinical signs during emergency management of AW Lvl of consciousness Presence of & character of breath sounds Vent ease Symty & amt of chest movmt Skin color & character (Temp & diaphoresis) Upp AW snds (crowing, snoring, stridor) Exce secretions debris in AW Epigastric snds retractions na
Monitor Physiological variables during emergency management of AW Vent frqy, VT, and AW pressure presence of CO2 in exhaled gas HR & Rhythm P/Ox ABG values CXS
ET position accuracy check: Bilateral BS Symmetric chest movement Absence or ventil sounds of epigastrium Condensate in tube, correlates with exhalation Visualization of tube through vocal cords Esophagel detector devices Capnometry endoscopic visualization
Generally a woman is intubated with what size? No. 7 or 7.5
Generally a man is intubated with what size? No. 8 or 8.5
ET tube size and distance from incisors for infant<1kg Size 2.5 mm, Length 6.5-8 cm
ET tube size and distance from incisors for infant 1-2 kg Size 3.0 mm, Length 7-8 cm
ET tube size and distance from incisors for infant 2-3 kg Size 3.5 mm, Length 8-9 cm
ET tube size and distance from incisors for infant 4 kg Size 3.5-4.0 mm, Length 9-10 cm
ET tube size and distance from incisors for 6 months Size 3.5-4.0 mm, Length 10-11 cm
ET tube size and distance from incisors for 18 months Size 3.5-4.5 mm, Length 11-13 cm
ET tube size and distance from incisors for 3 yrs Size 4.5-5.0 mm, Length 12-14 cm
ET tube size and distance from incisors for 5 yrs Size 4.5-5.0 mm, Length 13-15 cm
ET tube size and distance from incisors for 6 yrs Size 5.5-6.0 mm, Length 14-16 cm
ET tube size and distance from incisors for 8 yrs Size 6.0-6.5 mm, Length 15-17 cm
ET tube size and distance from incisors for 12 yrs Size 6.0-7.0 mm, Length 17-19 cm
ET tube size and distance from incisors for 16 yrs or small woman Size 6.5-7.0 mm, Length 18-20 cm
ET tube size and distance from incisors for women (AVG) Size 7.5-8.0 mm, Length 19-21 cm
ET tube size and distance from incisors Size 8.0-9.0 mm, Length 21-23 cm
What blade is commonly used to intubate adults? No. 3 curved macintosh or Straight Miller laryngscope blade
Generally, where should the Orotracheal tube be initially inserted in men? 21-23 cm mark at the teeth
Generally, where should the Orotracheal tube be initially inserted in women? 19-21 cm mark at the teeth
Absolute contraindication for percutaneous dilation tracheostomy Need for emergency surgical AW
Relative contraindication for percutaneous dilation tracheostomy Children <12 yrs poor landmarks secondary to body habitus, abnormal anatomy, or occluding thyroid mass PEEP> 15 cm h20 Coagulopathy Pulsating blood vessel of trach site Limited C-spine flex Hx diff intubation infection, burn, malignancy at trach si

 

Egan’s Chapter 33 Practice Questions:

 

1. What is the primary indication for tracheal suctioning?: retention of secretions

2. What is the most common complication of suctioning?: hypoxemia

3. Complication of tracheal suctioning include all except: hyperinflation

4. How often should patients be suctioned?: when physical findings support the need. A patient should never be suctioned on a schedule.

5. What is a normal range of negative pressure to use when suctioning an adult patient?: 100-120 mm Hg

6. What is the normal range of negative pressure to use when suctioning children?: 100mm Hg, for children, limit the suction pressure to -80 to -100mm Hg.

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

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

9. To prevent hypoxemia when suctioning a patient, the respiratory car practitioner should initially do which of the following?: preoxygenate the patient with 100% oxygen.

10. To maintain positive end-expiratory pressure (peep) and high FIO2’s when suctioning a mechanically ventilated patient, what would you recommend?: use a closed system multi-use suction catheter.

11. Total application time for endotracheal suction in adults should not exceed which of the following?: keep total suction time to less than 10- 15 seconds.

12. While suctioning a patient, you observe an abrupt change in the electrocardiogram wave from being displayed on the cardiac monitor. Which of the following actions would be most appropriate?: stop suctioning and immediately administer oxygen.

13. 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.

14. 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- hyper-inflate the patient before and after the procedure. 3- suction for as short a period of time as possible.

15. Atelectasis can be caused by the 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 hyper-inflation before and after the procedure.

14. To minimize the likelihood of mucosal trauma during suctioning? To avoid this problem, limit the amount of negative pressure used and always rotate the catheter while withdrawing. absolute contraindication for nasotracheal suctioning includes which of the following?

1- epiglottis
2- croup
3- irritable airway

15. Which of the following equipment is NOT needed to perform nasotracheal suctioning?: LARYNGOSCOPE WITH MACINTOSH AND MILLER BLADES

16. 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?: Stop the bleeding and use nasopharyngeal airway for access.

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

18. 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?: The patient has hyper active airways and has developed bronchospasm.The bronchospastic response may be particularly strong in patients with hyperactive airway disease. These patients should be accessed for the development of wheezes associated with suctioning.

19. What general condition requires airway management?: AARC guide lines: 1- Airway compromise. 2- respiratory failure. 3- Need to protect the airway

20. Which of the following conditions require emergency tracheal intubation?: 1- upper airway or laryngeal edema. 2- loss of protective reflexes. 3- cardiopulmonary arrest. 4- Traumatic upper airway obstruction

21. Which of the following autonomic or protective neural responses represent potential hazards of emergency airway management: Laryngospasm

22. All of the following indicate an inability to adequately protect the airway EXCEPT: WHEEZING

23. Which of the following types of artificial airways are inserted through the larynx?

a) pharyngeal airways

b) tracheostomy tubes

c) NASOTRACHEAL TUBES

d) OROTRACHEAL TUBES

24. The two basic types of tracheal airways are endotracheal tubes (translaryngeal)and tracheostomy tubes. Endotracheal tube are inserted through either the mouth or the nose (orotracheal or nasotracheal) through the larynx and into the trachea compared with the nasal route, the advantages of oral intubation include all of the following except:

a) reduced risk of kinking.

b) LESS RETCHING AND GAGGING

c) easier suctioning.

d) less traumatic insertion.

25. Compared with the oral route, the advantage of nasal intubation include all of the following except:

a) REDUCED RISK OF KINKING

b) less ratching and gagging.

c) less accidental extubation.

d) greater long-term comfort

26. Compared with translaryngeal intubation, the advantages of TRACHEOSTOMY include all of the following except:

a)greater patient comfort.

b) reduced risk of bronchial intubation.

c) no upper airway complications.

d) DECREASED FREQUENCY OF ASPIRATIONS

27. What is the standard size for endotracheal or tracheostomy tube adapters?: 15mm external diameter.



28. What is the purpose of the additional side port (murphy eye) on most modern endotracheal tubes?: To ensure gas flow if the main port is blocked, 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.

29. What is the purpose of a cuff on an artificial tracheal airway?: to seal off and protect the lower airway.

30. What is the purpose of the pilot balloon on an endotracheal or tracheostomy tube?: to monitor cuff status and pressure.

31. Which of the following feature incorporated into most modern endotracheal tube assist in verifying proper tube placement?

a) LENGTH MARKINGS ON THE CURVED BODY OF THE TUBE

b) IMBEDDED RADIOPAQUE INDICATOR NEAR THE TUBE TIP

c) additional side port near the tube tip (murphy eye).

32. The removable inner cannula commonly incorporated into modern tracheostomy tubes serves which of the following purposes:

a) AID IN ROUTINE CLEANING AND TRACHEOSTOMY CARE

b) prevent the tube from slipping into the trachea.

c) PROVIDE A PATENT AIRWAY SHOULD IT BECOME OBSTRUCTED

33. What is the purpose of a tracheostomy tube obtruator?: to minimize trauma to the tracheal mucosal during insertion.

34. In the absence of neck or facial injuries what is the procedure of choice to establish a patent tracheal airway in an emergency?: orotracheal intubation.

35. 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?: SYRINGE, RESUSCITATOR BOG OR MASK, TUBE STYLET.

36. Before beginning an intubation procedure, the practitioner should check and confirm the operation of which of the following:

a) LARYNGOSCOPE LIGHT SOURCE

b) ENDOTRACHEAL TUBE CUFF

c) SUCTION EQUIPMENT

d) cardiac defibrillator

37. 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.

38. While checking a MILLER and 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?: Check and replace the bulb on the MacINTOSH blade

39. What size endotracheal tube would you select to intubate a 3 year old child?: 4.5 to 5.0 mm

40. What size endotracheal tube would you use to intubate a 1500g newborn infant?: 3.0mm

41. What size endotracheal tube would you use to intubate an adult female?: 8mm

42. What is the purpose of the endotracheal tube stylet?: it adds rigidity and shape

43. To make oral intubation easier how should the patients head and neck positioned?: neck flexed with head supported over towels and tilt back

44. What should be the amount of time devoted to any intubation attempt?: 30 secs

45. Which of the following statements are false 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

46. During oral intubation of an adult, the endotracheal tube should be advance into the trachea about how far?: until its cuff has passed the cords!!!

47. Immediately after insertion of an oral endotracheal tube on an adult, what should you do?: once the tube is in place, stabilize it with the right hand, and use the left hand to remove the laryngoscope and the stylet, then inflate the cuff to seal the airway and immediately provide ventilation and oxygenation

48. Ideally, the distal tip of a properly positioned endotracheal tube (in an adult man) should be positioned how far above the carina?: 3-6 CM

49. What bedside methods can absolutely confirm proper endotracheal tube position in the trachea?: fiberoptic laryngoscope

50. What is the average distance from the tip of a properly positioned oral endotracheal tube to the incisors of an adult man?: 21-23cm, and 19-21 is ideal of a female

51. When using bulb type esophageal detention device during an intubation attempt, how do you know that the endotracheal tube is in the esophagus?: the bulb fails to re-expand upon release

52. After an intubation attempt, an expired capnogram indicates a co2 levels near 0, what does this finding probably indicate?: placement of the endotracheal tube is in the esophagus

53. When using a capnometry or colorimetry to differentiate esophageal from tracheal placement of an endotracheal tube, which of the following conditions can result in false-negative finding?: CARDIAC ARREST

54. 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, what can explain this?: return of spontaneous circulation

55. What are some serious complications of oral intubation?: cardiac arrest, acute hypoxemia, bradycardia

56. You are assisting a physician in the emergency care of a patient with a maxillofacial injury who will require short-term ventilatory support, which airway approaches would you recommend?: nasal route

57. To provide local anesthesia and vasoconstriction during nasal intubation, what would you recommend?: a mixture of .25 phenylephrine and 3 lidocane may be applied to the mucosal with a long cotton tip swab to provide local anesthesia and vasoconstriction of the nasal passage

58. When performing a blind nasotracheal intubation, successful tube passage through the larynx is indicated by?: a harsh cough followed by vocal silence

59. What is the primary indication for tracheostomy?: when a patient has long-term need for an artificial airway

60. What factors should be considered when deciding to change from an endotracheal tube to a tracheostomy?: projected time the patient will need an artificial airway, patients tolerance of endotracheal tube, patients overall condition, patients ability to tolerate surgical procedure, relative risk of continued endotracheal intibation vs. tracheostomy

61. In a properly performed traditional surgical tracheotomy, entrance to the trachea is made through an incision in what area?: through or between the second and third tracheal rings

62. A surgical resident has asked that you assist in an elective tracheotomy procedure on an orally intubated patient. which of the following would be appropriate action?

a.remove the oral tube just before tracheostomy tube insertion

b. romove the oral tube just b4 the tracheostomy is performed

c. pull the oral tube only after the tracheostomy tube is in placed

d. withdraw the oral tube 2-3 inches while the incision is made

63. Compared with traditional surgical tracheaostomy , all of the following are true about percutaneous dilatational tracheaostomy except: D: precutaneous dilatational tracheostomy does not require anterior neck dissection.

64. 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

65. What is the most common sign associated with the transient glottic edema or vocal cord inflammation that follows extubation?

A)orthopnea

B)wheezing

C)hoarseness

D)difficulty in swallowing

66. 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)careful observation of the patient for 6 hours

B)STAT racemic epinephrine aerosol treatment

C) immediate reintubation via the nasal route

D)STAT heated aerosol treatment with saline

67. After removal of an oral endotracheal tube, a patient exhibits hoarseness and strider that do not resolve with racemic epinephrine treatments. What is most likely the problem?

A)glottic edema or cord inflamation

B)tracheoesophageal fistula

C)tracheomalacia

D) vocal cord paralysis

68. Which of the following injuries are NOT seen with tracheostomy tubes?

1)tracheomalacia

2)tracheal stenosis

3)GLOTTIC EDEMA

4)vocal cord granulomas

69. 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

70. 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 most likely the cause of the problem?

A)cord paralysis

B)laryngeal web

C) tracheal stenosis

D) tracheomalacia

71. 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 most likely cause of the problem?

A) tracheoesophageal fistula

B) underinflated tube cuff

C)tracheoinnominate fistula

D) paralysis of the vocal cords

72. A physician is concerned about the potential for tracheal damage due to tube movement in a patient who recently underwent tracheostomy and is now receiving 40% oxygen through a T- tube (briggs adapter). Which of the following would be the best way to limit the tube movement in this patient?

A)tape the T-Tube to the tracheostomy tube connector

B)secure the T-tube delivery tubing to the red rail

C) switch from the T-tube to a tracheostomy collar

D) give a neuromuscular blocker to prevent patient movement

73. Which of the following techniques or procedures should be used to help minimize infection of a tracheostomy stoma?

1)regular aseptic stoma cleaning

2)adherence to sterile techniques

3)regular change of tracheostomy dressings

74. When checking for proper placement of an endotracheal tube or tracheostomy tube on a chest radiograph, how far above the carina should the distal tip of the tube be positioned?

A) 3 to 6 cm

B) 2 to 4 cm

C) 6 to 8 cm

D) 1 to 2 cm

75. 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 2 cm above the carina. Which of the following actions would you recommend?

A) advance the tube by 2 to 3 cm

B) withdraw the tube by 7 to 8 cm

C) advance the tube by 7 to 8 cm

D)withdraw the tube by 2 to 3 cm

76. An alert patient with a long-term need for tarcheostomy tube 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

77. To ensure adequate humidification for a patient with an artificial airway, inspired gas at the proximal airway should be 100% saturated with water vapor and at which of the following temperatures?

A) 30 to 32 degress C

B) 37 tp 40 degress C

C) 40 to 42 degress C

D) 32 to 35 degress C

78. Tracheal airways increase the incidense of pulmonary infections for all of the following reasons except:

A) contaminated equipment or solutions

B) increased aspiration of pharyngeal material

C) ineffective clearence through cough

D)lower levels of humidification

79. Which of the following is likely to increase the likelihood of damage to the tracheal mucosa?

A) using a low residual volume low compliance cuff

B) using the minimal leak technique for inflation

C) monitoring intracuff pressures every 1 to 2 hours

D) maintaining cuff pressures below 20 to 25 mmHg

80. What is the maximum recommended range for tracheal tube cuff pressures?

A) 25 to 30 mmHg

B) 20 to 25 mmHg

C) 30 to 35 mmHg

D)15 to 20 mm Hg

81. 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) decrease cuff pressure

B) not affect cuff pressure

C) rupture the cuff

D) increase cuff pressure

Egan’s Chapter 33 Test Bank:

 

1. The AARC suggests which type of suction technique to avoid disconnecting the patient from the ventilator, which interrupts ventilation and exposes the patient to infection risk: Closed suctioning

2. After connecting the catheter to the suction source, the level of suction pressure should be checked by: Closing the catheter thumb port and aspirating some sterile water or saline from the basin

3. American Society for testing and Materials: Nongovernment agency that establishes performance standards for various equipment and materials

4. As the catheter enters the lower pharynx, what position should the patient assume: The sniffing position

5. Atelectasis can be avoided by: Limiting the amount of negative pressure used. Keeping the duration of suctioning as short as possible. Using the appropriate size suction catheter. Avoiding disconnection from the ventilator.

6. Before suctioning, delivery of 100% oxygen for _____ to _____ seconds to pediatric and adult patients, especially to patients who are at risk for hypoxemia: 30 to 60 seconds

7. Bronchoscopy: Process of passing a bronchoscope into the airways for diagnostic testing or therapeutic purposes

8. Capnometry CO₂ analysis: Assessed using exhaled carbon dioxide analysis. If tube is in esophagus CO₂ levels remain at zero. However, in patients with cardiac arrest, expired CO₂ levels may be near zero because of poor pulmonary blood flow, yielding a false negative result.

9. Closed endotracheal suction: Uses a sterile, closed, in line suction catheter that is attached to the ventilator circuit so that the suction catheter can be advanced into the patients endotracheal airway without disconnecting the patient from the ventilator

10. Colorimetric CO₂ analysis: An inexpensive alternative to capnometry. Functioning similar to pH paper, a colorimetric system has an indicator that changes color when exposed to different CO₂ levels

11. The cuff leak test is designed to: Help predict the occurrence of glottic edema or stridor after extubation

12. Decannulation: Removal of a cannula or tube that may have been inserted during a therapeutic or surgical procedure

13. Deep suctioning: When the catheter is inserted until resistance is met and then withdrawn approximately 1 cm before applying suction

14. The diameter of the catheter should be less than ______% of the internal diameter of the artificial airway in adults: 50

15. The diameter of the catheter should be less than ______% of the internal diameter of the artificial airway in infants and small children: 70

16. Difficult intubation occur because of what: Inability to open the patients mouth, inability to position the patient, or unusual airway anatomy

17. Double lumen endotracheal tube: Has two proximal ventilator connectors, two inner lumens for gas flow, two cuffs, and two distal openings

18. Endotracheal Tube: Artificial airways that are placed through the mouth or nose into the trachea

19. Endotracheal tubes: Artificial airways that pass through the oropharynx or nasopharynx into the trachea

20. Esophageal detection device: May be used to determine whether the tube is in the esophagus or the trachea. Not recommended for use in children under 1 year of age.

21. Extension of the neck moves the tube toward the: larynx

22. Extubation: Process of withdrawing a tube from an orifice or cavity of the body

23. Fenestrated: An opening into a structure

24. Fenestrated tracheostomy tube: A double cannulated tube that has a opening in the posterior wall of the outer cannula above the cuff

25. Flexion of the neck moves the tube toward _____: the carina

26. Foam Cuff: Do not inflate the cuff with air it fills with atmospheric pressure

27. The foam cuff: Designed to seal the trachea with atmospheric pressure in the cuff. Before insertion the cuff must be deflated by actively withdrawing air from the cuff with a cuff pressure device or syringe. When in position the pilot tube is opened to the atmosphere and the foam is allowed to expand against the tracheal wall. Only used in patients who have already developed tracheal injury

28. For blind nasotracheal intubation to work the patient must be ________________ breathing: spontaneously breathing

29. For the blind nasal intubation what position should the patient be in: Placed in either the supine or the sitting position

30. Generally a man is intubated with what size endotracheal tube: 8 or 8.5. Distance from incisors 21 to 23

31. Generally a women is intubated with size endotracheal tube: 7 or 7.5. Distance from incisors 19 to 20

32. High frequency jet ventilation: Uses a special endotracheal tube adapter that replaces the standard endotracheal tube adapter

33. How can these problems be minimized: By using proper technique. Providing patient with adequate ventilation and oxygenation. Strictly adhering to intubation time limits. Sedation an anesthesia can reduce complication and facilitate intubation in a semi comatose or combative patient

34. How does the Macintosh blade lift the epiglottis: The epiglottis is displaced INDIRECTLY by advancing the tip of the bade into the vallecula

35. How does the miller blade lift the epiglottis: The epiglottis is displaced DIRECTLY by advancing the tip of the blade over its posterior surface

36. How do pharyngeal airways prevent airway obstruction: By keeping the tongue pulled forward and away from the posterior pharynx.

37. How do you assess upper airway function with a fenestrated tracheostomy tube: Capping or placing a speaking valve on the proximal opening of the tubes outer cannula, accompanied by deflation of the cuff

38. How do you correct right main stem intubation: By slowing withdrawing the tube, while listening for the return of left side breath sounds

39. How do you estimate the proper size of suction catheter to use with a given tracheal tube: First multiply the tubes inner diameter by 2. Then, use the next smallest size. Example: 6 mm endotracheal tube: 2 x 6= 12, next smallest is 10 french

40. How do you select a size of an endotracheal tube: Based on the patients weight or age

41. How is a tracheoesophageal fistula diagnosed: Can be made based on history of recurrent aspiration and abdominal distention as air is forced into the esophagus during positive pressure ventilation. Diagnosis is also made by direct endoscopic examination or the trachea and esophagus. Treatment involves surgery to close the defect

42. How is weaning accomplished: By using a fenestrated tube, Progressively smaller tubes, Tracheostomy button

43. How long are most suction catheters for general purpose: 22 inches long, sufficient to reach the main stem bronchi and sized in french units

44. How often do in line suction catheters need to be changed: They need to be changed only if soiled or malfunctioning and not on a daily basis, which is more cost effective

45. How often should the nasal trumpet be changes: Every 24 hours

46. How often should tracheostomy care be performed: Every 24 hours or when they become dirty

47. How should suction pressure always be checked: By occluding the end of the suction tubing before attaching the suction catheter.

48. Hypertension during suctioning may be due to: Hypoxemia, Increased sympathetic tone secondary to stress, anxiety, pain or change in hemodynamics

49. Hypotension during suctioning may be due to: Cardiac dysrhythmias, Severe coughing episodes that decrease venous return

50. If any major change is seen in the heart rate or rhythm what should the RT do: Immediately stop suctioning, Administer oxygen, Provide ventilation as needed, Notify nurse and physician

51. If intubation fails what should be done next: Immediately ventilate and oxygenate for 3 to 5 minutes then you can attempt to intubate again

52. If the secretions are extremely tenacious instillation of ________________ or ___________ may be more effective than normal saline: Acetylcystine, Sodium Bicarbonate (2%)

53. Indications for Use of closed suctioning technique: Mechanically ventilated patients, especially neonates and patients with:, PEEP ≥ 10 cm H₂O, Mean airway pressure ≥ 20 H₂O, Inspiratory time ≥ 1.5 seconds, Fio₂ ≥ 0.60, Frequent suctioning (≥6 x a day), Hemodynamic instability associated with ventilator disconnection, Respiratory infections requiring airborne or droplet precautions, Inhaled agents that cannot be interrupted by ventilator disconnection

54. In line suction catheter is recommended for suctioning patients who require: High FiO₂ and positive end expiratory pressure: At risk for lung derecruitment, Neonates, Cross contamination is less likely with in line suction catheters

55. Intubation: Passage of a tube into a body aperture; commonly refers to the insertion of an endotracheal tube within the trachea

56. Lanz tube: Incorporates an external pressure regulating valve and control reservoir designed to limit the cuff pressure to 16 to 18 mm Hg

57. Laryngeal stenosis: Occurs when the normal tissue of the larynx is replaced by scar tissue, which causes stricture and decreased mobility. Surgical correction is usually required

58. Low Pressure Cuff: a cuff with low pressure

59. Mechanical stimulation of the airway and hypoxemia can cause _______________: Cardiac dysrhythmias

60. Mucosal trauma can be avoided by: Limiting the amount of negative pressure used. Using the shallow suctioning method

61. Murphy eye: Ensures gas flow if the main port should becomes obstructed

62. Nasopharyngeal Airway: Most often placed in a patient who requires frequent nasotracheal suctioning. May also be placed in a patient who was recently extubated after facial surgery. Helps to maintain the patency of the upper airway despite swelling

63. Nasotracheal suctioning is indicated for patients who have: Retained secretions but do not have an artificial tracheal airway

64. Obturator: Used for tracheostomy tube insertion

65. Obturator: Device used to block a passage or a canal or to fill in a space, such as the obturator used to insert a tracheostomy tube

66. Open endotracheal suction: The open, sterile technique requires disconnecting the patient from the ventilator

67. Oropharyngeal Airway: Inserted into the mouth and over the tongue. Should be restricted to unconscious patients to avoid gagging and regurgitation. Used mainly in emergency life support. These airways maintain a patent airway when the tongue would otherwise obstruct the oropharynx

68. The oxygen concentration should be increased by _____% in neonates before suctioning: 10 %

69. The percent of the cuff leak should be approximately: 15% or greater, as determined by the difference between the measured expiratory tidal volume with the cuff inflated and then deflated

70. Pharyngeal Airways: Devices that maintain the patency of the pharyngeal structure

71. The presence of infection is suggested by: Changes in the patients sputum: Breath sounds, Fever, Increased heart rate, Leukocytosis

72. Proper placement of an endotracheal or tracheostomy tune normally is confirmed by: radiograph

73. Radiopaque: Pertaining to a substance or tissue that does not readily permit the passage of x rays or other radiant energy

74. Radiopaque: Indicator that is embedded in the distal end of the tube body. This indicator allow for easy identification of tube position on the radiograph

75. Removal of foreign bodies, secretions, or tissue masses beyond the main stem bronchi is done by what type of procedure: A bronchoscopy, which is performed by a physician

76. Rule of thumb: To minimize hypoxemia ans lung de recruitment when suctioning a mechanically ventilated patient, pre oxygenate and suction the artificial airway with a closed system in line catheter to avoid disconnecting the patient from the ventilator

77. Shallow suctioning: When the catheter is advanced to a predetermined depth, which is usually the length of the airway plus the adapter

78. Shallow suction method: Used by advancing the catheter just to the end of the artificial airway

79. A spontaneously breathing patient with partial airway obstruction exhibits signs of: Decreased breath sounds. Decreased airflow through the tube. If the patient is receiving volume controlled ventilation, peak inspiratory pressures increase, often causing the high pressure alarm to sound; during pressure controlled ventilation, delivered tidal volumes decrease

80. Sputum sampling are often collected to identify what: Organisms infecting the airway

81. Stenosis: Narrowing of a valve or vessel

82. Steps for extubation: 1.Assemble needed equipment, 2. suction endotracheal tube and pharynx to above cuff, 3. oxygenate patient well after suctioning, 4.Deflate cuff, 5. Remove tube, 6. Apply appropriate oxygen and humidity therapy (cool mist), 7. Assess or reassess patient

83. Steps for Suctioning: 1. Assess Patient for Indications, 2. Assemble and Check Equipment, 3. Hyper oxygenate Patient, 4. Insert Catheter, 5. Apply Suction and Clear Catheter, 6. Re oxygenate Patient, 7. Monitor Patient and Asses Outcomes (steps 3-7 are repeated as needed until improvement)

84. Stridor is often treated with what medication: Epinephrine via aerosol, Racemic solution via aerosol, Levopinephrine via aerosol

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

86. Suction can be performed in what part(s) of the airway: Suction can be performed in either the upper airway (oropharynx) or the lower airway (trachea and bronchi)

87. Suctioning: Process of mechanically aspirating airway secretions

88. Suctioning: The application of negative pressure or a vacuum to the airways through a collecting tube (flexible catheter of suction tip)

89. Then catheter is continually advanced until what happens: Until the patient coughs or resistance is felt

90. The tip of an endotracheal tube should be positioned in the trachea how far above the carina: 3 to 6 cm

91. To obtain a sputum sample what should be done: Follow the suctioning procedure, In addition to the usual equipment, a sterile specimen container is needed, Provide good oral care to the patient to insure no oral bacteria get into the specimen

92. Total suction time should be kept to less than _____: 15 seconds

93. Tracheal stenosis: A narrowing of the lumen of the trachea, which can occur as fibrous scarring causes the airway to narrow

94. Tracheal tube cuffs are used to: Seal the airway for mechanical ventilation or to prevent or minimize aspiration

95. Tracheoesophageal Fistula: A congenital malformation or an abnormality associated with disease in which there is an abnormal tubelike passage between the trachea and the esophagus

96. Tracheoesophageal fistula: A direct communication between the trachea and the esophagus. A rare complication of both tracheotomy and endotracheal intubation

97. Tracheoinnominate Artery Fistula: A fistula, connection between the trachea and the innominate artery

98. Tracheoinnominate artery fistula: Can occur when a tracheostomy tube causes tissue erosion through the innominate artery. Only 25% of patient who develop this serious complication survive

99. Tracheomalacia: Softening of the tracheal cartilages

100. Tracheomalacia: The softening of the cartilaginous rings, which cause collapse of the trachea during inspiration

101. Tracheostomy: The opening created by a tracheotomy

102. Tracheostomy: Opening thought the neck into the trachea, through which an indwelling tube may be inserted

103. Tracheostomy Tube: Inserted through a surgically created opening in the neck directly into the trachea

104. The tracheostomy tube must always be inflated or deflated before a speaking valve is placed on the tracheostomy tube: DEFLATED

105. Tracheostomy Tubes: Artificial airways that are surgically placed directly into the trachea

106. Tracheotomy: Procedure by which an incision is made into the trachea thought the neck below the larynx to gain access to the lower airways

107. Tracheotomy: The procedure of establishing access to the trachea via a neck incision

108. Tracheotomy is the preferred primary route for what: Overcoming upper airway obstruction or trauma and for patient with poor airway protective reflexes

109. True/False: A patient should be suctioned according to a preset schedule: False; A patient should NEVER be suctioned according to a preset schedule

110. True/False: Intracranial pressure has been reported during suctioning: TRUE, these changes are transient, with values normally returning to baseline within 1 minute

111. True/False: Routine instillation of sterile normal saline to aid secretion removal before suctioning is recommended: FALSE: Routine instillation of sterile normal saline to aid secretion removal before suctioning is NOT recommended because there is insufficient evidence that this practice is beneficial, and it may increase infection risk

112. Tube obstruction can be caused by: Kinking of the tube or the patient biting on the tube, Herniation of the cuff over the tube tip, Obstruction of the tube orifice against the tracheal wall, Mucus plugging

113. What 3 skills must the RT develop in the areas of airway care: .Be proficient in airway clearance techniques, including methods designed to ensure the patency of the patients natural or artificial airway. Be able to insert and maintain artificial airways designed to support patients whose own natural airways are inadequate. Be able to assist physicians in performing special procedures related to airway management

114. What are the bedside to assess endotracheal tube position: Auscultation of chest and abdomen, Observation of chest movement, Tube length (cm to teeth), Esophageal detection device, Light wand, Capnometry, Colorimetry, Fiberoptic laryngoscopy or bronchoscopy, Video laryngoscopy

115. What are the best ways to minimize complications and adverse responses during endotracheal suctioning: Careful adherence to procedure, Pre oxygenation helps minimize hypoxemia during suctioning, Pre oxygenate and suction without disconnecting the patient from the ventilator, rather than disconnecting the patient and manually ventilating

116. What are the factors to consider in switching from endotracheal tube to tracheostomy: Projected time the patient will need an artificial airway, Patients tolerance of endotracheal tube, Patients overall condition, Patients ability to tolerate a surgical procedure, Relative risks of continued endotracheal intubation vs. tracheostomy

117. What are the indications for suctioning: Need to maintain patency and integrity of the artificial airway. Need to remove accumulated secretions. Need to obtain a sputum specimen to rule out or identify pneumonia or other pulmonary infection or for sputum cytology

118. What are the most common laryngeal injuries associated with endotracheal intubation: Glottic edema: Vocal cord inflammation, Laryngeal or vocal cord ulcerations, Vocal cord polyps, Granulomas, Less common & more sever, vocal cord paralysis, Laryngeal stenosis

119. What are the most serious complications: Acute hypoxemia, Hypercapnia, Bradycardia, Cardiac arrest by causing an extreme vagal response

120. What are the several aspects of airway maintenance must the RT attend to when a tracheal airway is in place: Securing the tube and maintaining its proper placement: Providing for patient communication, Ensuring adequate humidification, Minimizing the possibility of infection, Aiding in secretion clearance, Providing appropriate cuff care, Troubleshooting airway related problems

121. What are the signs and symptoms of post extubation problems: Difficulty with expectoration: Dyspnea, Stridor

122. What are the steps for Endotracheal Suctioning: 1. Assess Patient for Indications, 2. Assemble and Check Equipment, 3. Hyper oxygenate Patient, 4. Insert Catheter, 5. Apply Suction and Clear Catheter, 6. Re oxygenate Patient, 7. Monitor Patient and Asses Outcomes (steps 3-7 are repeated as needed until improvement)

123. What are the steps for orotracheal intubation: 1. Assemble and check equipment, 2. Position Patient, 3. Pre oxygenate and ventilate patient, 4. Insert laryngoscope, 5. Visualize glottis, 6. Displace epiglottis, 7. Inser tube, 8. Asses tube position, 9. Stabilize tube and confirm placement

124. What are the steps for Tracheostomy care: 1. Assemble and check equipment, 2. Explain procedure to patient, 3. Suction patient, 4. Clean inner cannula (if present and non disposable), 5. Clean and examine stoma site, 6. Change tie or holder, 7. Replace clean inner cannula (if present), 8. Reassess patient

125. What are the suction pressures for adults: -120 to -150 mm Hg

126. What are the suction pressures for children: -100 to -120 mm Hg

127. What are the suction pressures for neonates: -80 to -100 mm Hg

128. What are the techniques commonly used to diagnose airway damage: Physical examination, Air tomography, Fluoroscopy, Laryngoscopy, Bronchoscopy, MRI, Pulmonary function studies

129. What are the two techniques for endotracheal suctioning: Open and closed

130. What can a catheter that is to large cause: Can obstruct all or part of the airway by occupying too much of its opening

131. What can cause difficulty in clearing secretions: Thickness, Amount, Ineffective cough

132. What can cause tachycardia: Patient agitation, Hypoxemia

133. What can retained secretions cause: Increased airway resistance, Increased work of breathing, Hypoxemia, Hypercapnia, Atelectasis, Infection

134. What can too large a suction catheter combined with negative suction cause: Can quickly evacuate lung volumes and can cause atelectasis and hypoxemia

135. What can Vagal stimulation cause: Transient bradycardia, Asystole

136. What causes damage to the tracheal mucosa: Wrong size tube, Too high cuff pressure

137. What causes the need for high cuff pressures: the tube is too small, positioned to high in the trachea, development of tracheomalacia, high airway pressure generated by mechanical ventilation

138. What does decreased breath sounds and decreased chest wall movement on the left side indicate: Right main stem intubation

139. What does retained secretions cause: Increased airway resistance, Increased work of breathing, Hypoxemia, Hypercapnia, Atelectasis, Infection

140. What does the inflation of the cuff do: Inflation of the cuff seals off the lower airway, either for protection from gross aspiration of to provide positive pressure ventilation

141. What does tracheal stenosis look like on a vent: Appears as a fixed obstructive pattern, with flattening of both the inspiratory and the expiratory limbs of the flow volume loop

142. What do the length marking on the endotracheal tube indicate: The distance in centimeters from the beveled tube tip. helps to know the placement of the tube

143. What equipment is needed for direct nasal intubation: The same as for oral intubation with the addition of magill forceps

144. What hand should the RT hold the endotracheal tube in: right hand, Also used to stabilize the tube

145. What hand should the RT hold the laryngoscope in: Left hand

146. What is a more serious symptom that indicates significant decrease in diameter of the airway: Stridor

147. What is an indication for intubation through the nose: Severe facial trauma, Maxillofacial injuries, Undergoing oral surgery

148. What is a problem associated with the fenestrated tracheotomy tube: Malposition of the fenestration, such as between the skin and stoma, or against the posterior wall of the larynx

149. What is Suctioning: The Application of negative pressure (vacuum) to the airways through a collecting tube (flexible catheter or suction tip)

150. What is the absolute contraindication for nasotracheal suctioning: Epiglottitis or croup

151. What is the acceptable range for cuff pressure: 20 to 25 mm Hg, 25 to 30 mm H₂O

152. What is the external diameter of the endotracheal tube and the tracheostomy tube: 15 mm (it is universal)

153. What is the key aspect of the nasotracheal suctioning procedure: Catheter insertion

154. What is the maximum amount of time that be be devoted to suctioning a patient: 15 seconds

155. What is the maximum amount of time that should be devoted to intubation: 30 seconds

156. What is the most common complication of emergency airway management: Tissue trauma

157. What is the preferred route for establishing an emergency tracheal airway: Orotracheal intubation because the oral passage is the quickest and easiest route in most cases

158. What is the purpose of the inner cannula: To maintain a patent airway

159. What may cause an airway obstruction: Retained secretions, Foreign bodies, Structural changes; edema, tumors, of trauma

160. What may happen if cuff pressure exceeds the mucosal perfusion pressure: ischemia, ulceration, Necrosis

161. What medication is given to provide local anesthesia and vasoconstriction of the nasal passage: A mixture of .25% phenylephrine and 3% lidocaine

162. What number blade is commonly used to intubate adult patients: Either a miller number 3 or a macintosh number3

163. What occurs in most extubated patients and usually resolves quickly: Hoarseness

164. What position should the patients head be in when intubating them: In the sniffing position with rolled towels under the patients shoulders

165. What should be considered to help reduce mucosal trauma in the nose or patients who require repeated, long term nasotracheal suctioning: Nasopharyngeal airway

166. What should the RT do if any untoward response occur during suctioning: The catheter should be immediately removed, and the patient should be oxygenated

167. What should the RT do if resistance is felt during the insertion of the nasotracheal catheter: Gently twist the catheter , if twisting does not help the catheter is withdrawn and inserted through the other nostril

168. What should the suction pressure be set at: The lowest effective level

169. What suction method is used to prevent tracheal mucosal trauma, especially in infants: The shallow suction method

170. What tube size should be used for a 3 year old: 4.5 to 5, Distance from incisors 12 to 14

171. What tube size should be used for an infant weighing between 1 to 2 kg: 3, Distance from lip 7 to 8

172. What type of endotracheal tube should an RT use when unilateral lung disease occurs and independent lung ventilation may be needed: A double lumen endotracheal tube

173. What type of patient is a good candidate for a speaking valve: One who is medically stable, is able to communicate, and has a low risk of aspiration

174. When a patient is intubated and a physician is placing a trach how far should you withdraw the endotracheal tube: 2-3 inches

175. When is this type of obstruction common: In an unconscious patient as a result of a loss of muscle tone

176. When is using shallow suctioning recommended rather than deep suctioning: In infants and children

177. When is vocal cord paralysis likely: In extubated patients with hoarseness and stridor that does not resolve with treatment or time

178. When should suction be applied: Suction is applied while withdrawing the catheter

179. When the endotracheal tube tip is seen passing through the glottis, it is advanced until ________________________: the cuff is passed the vocal cords

180. Where does tracheal stenosis occur with tracheostomy tubes: Stenosis may occur at the cuff, tip or stoma site. The stoma site is the most common

181. Why do tracheal airways increase the incidence of pulmonary infection: Bypassed upper airway filtration, Increased aspiration of pharyngeal secretions, Contaminated equipment or solution, Impaired mucociliary clearance in trachea, Increased mucosal damage owing to tube or suctioning, Ineffective clearance via cough

182. Why should the patient be in the sniffing position: It helps align the opening of the larynx with the lower pharynx , making catheter passage through the larynx more likely.

183. Why should tracheal suctioning through the mouth be avoided: Because it causes gagging

184. With complete tube obstruction the patient with exhibit: Severe distress, No breath sounds, No gas flow through the tube