1. The doctor is concerned that his ARDS patient on pressure control ventilation has high plateau pressures (> 30 cm H2O) and that this may be causing further lung injury. Which of the following modes of ventilation would you consider as an alternative?
A. volume control ventilation
B. pressure support ventilation
C. airway pressure release ventilation
D. continuous positive airway pressure
Airway pressure release ventilation (APRV) is a good option to consider in patients with ARDS, especially when the plateau pressures needed to provide adequate ventilation exceed 30 cm H2O. APRV is also indicated to treat refractory hypoxemia due to collapsed alveoli and massive atelectasis.
The correct answer is: airway pressure release ventilation
2. After bronchodilator therapy, you record the following PFT data on a 67 year-old male COPD patient who reports dyspnea on exertion: FEV1/FVC = 64%; FEV1 = 66% predicted. You would characterize the stage of the patient’s COPD as:
D. very severe
Irreversible air ow obstruction is present when the FEV1/FVC ratio after bronchodilator treatment is less than 70% of predicted. e stage of COPD is then gauged by its impact on the predicted FEV1. If the FEV1 is < 80% but ≥ 50% of the patient’s predicted value and there is dyspnea on exertion, the stage is classified as moderate.
The correct answer is: moderate
3. The primary aim in treating cardiogenic pulmonary edema is to:
A. increase venous return to the heart
B. decrease right heart and systemic venous pressures
C. decrease left heart and pulmonary vascular pressures
D. increase pulmonary fluid and blood volume
The primary aim in treating cardiogenic pulmonary edema is to decrease left heart and pulmonary vascular pressures.
The correct answer is: decrease left heart and pulmonary vascular pressures
4. What is the most common arrhythmia seen with pulmonary disease?
A. sinus bradycardia
B. sinus tachycardia
C. atrial fibrillation
D. ventricular tachycardia
The most common arrhythmia seen in pulmonary disease is sinus tachycardia. Common causes of sinus tachycardia include hypoxemia, anxiety and hypotension.
The correct answer is: sinus tachycardia
5. The primary purpose of oxygen administration in the management of heart failure is to:
A. increase the force of ventricular contractions
B. decrease resistance to ventricular ejection
C. increase ventricular stroke volume
D. decrease the workload on the myocardium
O2 therapy can reduce myocardial workload in ventricular failure, especially when hypoxemia is present. Rest (either in bed or sitting in a chair) also decreases the work of the heart and promotes diuresis.
The correct answer is: decrease the workload on the myocardium
6. A doctor institutes volume control ventilation for an 80 kg ARDS patient. Which of the following is the maximum pressure you would aim to achieve in this patient?
A. 50 cm H2O peak pressure
B. 30 cm H2O plateau pressure
C. 40 cm H2O peak pressure
D. 50 cm H2O plateau pressure
According to the NHLBI Protocol, the target volume for ARDS patients is 4-6 mL/kg, with a maximum plateau (alveolar) pressure of 30 cm H2O. The ventilator rate should initially be set to match the prior VE, but can be increased as needed up to a maximum of 35/min.
The correct answer is: 30 cm H2O plateau pressure
7. You would recommend against using noninvasive positive pressure ventilation (NPPV) for a patient with:
A. secretions requiring suctioning
B. the need for moderate sedation
C. facial burns or trauma
D. FIO2 needs greater than 40%
Absolute contraindications against using NPPV include the following: need for immediate intubation, hemodynamic instability, active cardiac arrhythmias or ischemia, active upper GI bleeding, uncooperative patient, facial burns or trauma, and the need for airway protection.
The correct answer is: facial burns or trauma
8. An alert patient with emphysema and an elevated CO2 level is given 50% O2 by an air-entrainment mask. One hour later the nurse calls you to evaluate the patient. He is now very lethargic. Which of the following is the most likely cause of this?
A. respiratory muscle fatigue
B. cerebral hypoxia
D. O2-induced hypoventilation
Many patients with severe COPD are chronic CO2 retainers, characterized on blood gas analysis as a compensated respiratory acidosis. Such patients are prone to a phenomenon called O2- induced hypoventilation in which high blood PO2 levels alters the V/Q balance in the lungs, increasing deadspace ventilation and PaCO2. For these reasons, clinicians recommend titrating the FIO2 in these patients to keep their PaO2s in the 50 to 60 torr range, equivalent to an SpO2 85-90%. However, you must NEVER deprive O2 from a patient in need.
The correct answer is: O2-induced hypoventilation
9. Which of the following is a key therapeutic objective in the management of a patient who has closed head trauma and is receiving ventilatory support?
A. increase the minute ventilation
B. increase intrathoracic pressure
C. assure patient-ventilator synchrony
D. decrease cerebral perfusion pressure
The overall goal of managing patients with closed head trauma is to prevent secondary injury by maintaining adequate cerebral perfusion pressure (CPP) and brain oxygenation. Because CPP = mean arterial pressure (MAP) – intracranial pressure (ICP), ventilatory care should aim to (1) maximize arterial oxygenation and (2) avoid actions that would either increase ICP or lower MAP. Goals therefore include maintaining an SaO2 of 100%; keeping the PaCO2 between 35-40 mm Hg (hypercapnia increases ICP); keeping the PIP ≤ 30 cm H2O (minimally a ecting MAP); and assuring good patient-ventilator synchrony (helps prevent increases in intrathoracic pressure/ICP). Hyperventilation should only be considered if there is an acute deterioration in neurologic status that does not respond to standard brain trauma therapy, such as osmotic diuresis, CSF fluid drainage and sedation/neuromuscular blockage.
The correct answer is: assure patient-ventilator synchrony
10. In individuals with disorders characterized by an increase in airway resistance, such as emphysema, which of the following breathing patterns results in the minimum work?
A. deep breathing
B. slow breathing
C. shallow breathing
D. rapid breathing
An increase in airway resistance increases the frictional work of breathing, i.e. the pressure difference due to air flow. Decreasing the rate of breathing will decrease the pressure difference due to air flow. us in these patients a slow breathing pattern (decreased flows) will result in the minimum work.
The correct answer is: slow breathing
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