3F- Utilize Evidence-Based Practice

TMC: 6 questions

A patient is receiving mechanical ventilatory support with volume-controlled ventilation in the A/C mode. Over the last several days plateau pressures have been increasing and are currently hovering around 30 cm H2O with peak pressures reaching 51 cm H2O. A P/F ratio is determined to be 280. Which of the following should be anticipated by the respiratory therapist?

a changed to pressure-controlled ventilation

a ventilation/perfusion study

eventual use of high-frequency jet ventilation.

a switch to APRV mode

a changed to pressure-controlled ventilation

A plateau pressure of 30 cm H2O is excessive and indicates significant decrease in pulmonary compliance. A PF ratio less than 300 suggests acute lung injury. This could easily advance to a state consistent with ARDS. Use of pressure-controlled ventilation is indicated.

A patient who suffered a closed head injury approximately 4 months ago has developed microatelectasis bilaterally. The patient is breathing spontaneously, but does not respond to verbal commands. Which of the following would be the most appropriate treatment for this patient?

incentive spirometry

albuterol (Proventil) via MDI

mechanical insufflation-exsufflation

intermittent CPAP via mask

intermittent CPAP via mask

A patient receiving volume-controlled ventilation in SIMV mode has a total respiratory rate of 26/min and is showing signs of increased labor of breathing. The mandatory rate is 14/min. Which of the following would most likely help the patient?

Increase PEEP

Switch to pressure control ventilation

Increase the machine flow rate

Use of pressure support

Use of pressure support

During ventilator weaning, a patient must maintain a moderately low respiratory rate, an adequate sized tidal volume, and low work of breathing. In this case, the patient is experiencing increased labor of breathing and an increase in respiratory rate. This is likely due to a reduced spontaneous tidal volume. Although this data is not shown, this condition can be assumed. The solution for a low spontaneous tidal volume and increased work of breathing during weaning is to provide pressure support.

A patient in distress has a chest radiograph that shows diffuse alveolar infiltrates while breath sounds reveal moist rales. The following data is available:

CVP 13 mm Hg

Right-side preload 14 mm Hg

mPAP 28 mm Hg

PCWP 22 mm Hg

C.I. 1.7 L/min/m2

The respiratory therapist should administer

diuretics

Xopenex

inhaled nitric oxide

Priscoline

diuretics

A female patient weighing 150 lbs is receiving mechanical ventilation in the SIMV, volume-cycled mode. Set tidal volume is 500 mL. Returned volumes for mechanical breaths are 490 mL. The respiratory therapist should

add air to the cuff.

continue current therapy.

check the circuit for leaks.

increase the set VT to 510 mL

continue current therapy.

A respiratory care supervisor is reviewing a prospective protocol for incentive spirometry. Under the section related to assessment of effectiveness, the supervisor should expect to see which of the following observations?

1. an increase followed by a reduction in secretion expectoration

2. improvement of air movement by auscultation

3. clearing chest radiograph

4. improvement in FEV1

1, 3, and 4 only

1 and 2 only

1, 2 and 4 only

1, 2, and 3 only

1, 2, and 3 only

Incentive spirometry, also called sustained maximal inspiration, is most helpful at preventing post-operative complications. Specifically, it is helpful in preventing the development of secretions in the lungs and avoiding infection. In this case, it should promote expectoration of secretions and therefore will result in an increase of secretions followed by a reduction. The chest radiograph would also show improvement.

A negative effect of mechanical PEEP is reduced

atelectasis

A-aDO2

FIO2

venous return

venous return

PEEP results in greater intrathoracic pressure. It causes difficulty for the cardiovascular system to function properly. Our natural negative pressure ventilation is thought to aid in venous return. Positive pressure would have the opposite effect, making it more difficult for blood to return to the right atrium.

A doctor orders postural drainage therapy for a post-operative patient who has a history of gastroesophageal reflux. You assessment of the patient indicates possible bilateral basal atelectasis but no excessive secretions. Which of the following would you recommend?

scheduling the postural drainage at least 2 hours before/after meals

combining early mobilization with lung volume expansion therapy

waiting at least 24 hours until the patient recovers from surgery

providing the postural drainage only, without any percussion or vibration

combining early mobilization with lung volume expansion therapy

Because postural drainage therapy has proved ineffective in treating postoperative atelectasis (being used primarily for patients with documented excessive secretions), it is not indicated for this patient. Instead you should recommend therapies proven to help prevent or treat atelectasis, including early mobilization and ambulation, perhaps supplemented with lung volume expansion therapy (CPAP or incentive spirometry). Were secretions to be a problem, directed coughing might also be considered. If assessment indicates that pain may hinder treatment, you also should consider coordinating therapy with prescribed pain medication.

A respiratory therapist is preparing to initiate a rehabilitation program on a COPD patient with a 75 pack-year history of smoking. During the initial visit, the patient reports having to take rescue medication (Albuterol) 4 times a day but otherwise feels healthy. Appropriate goals for the first week should include which of the following?

1. assess base exercise tolerance

2. review of activities of daily living

3. obtain normal pulmonary function results

4. educate about the long-term affects of smoking

1, 2, 3, and 4

1 and 4 only

1, 2, and 4 only

2 and 3 only

1, 2, and 4 only

The laboratory results of a sputum culture and sensitivity have returned for a patient who has bilateral bacterial pneumonia. The culture reveals streptococcus, a gram-positive bacteria. The medical records indicates the patient is allergic to penicillin. Which of the following should the respiratory therapist recommend?

Amoxicillin

Methacillin

Nafcillin

Cephalexine (Keflex)

Cephalexine (Keflex)

Normally gram-positive bacteria may be killed by penicillin-type antibiotics. But, because the patient is allergic to penicillin, a suitable drug is cephalexine. Nafcillin and methacillin are suitable antibiotics when a patient is penicillin-resistant but not when they are allergic.

A patient who is breathing room air and in a coma as a result of acute carbon monoxide poisoning has a PaO2 of 95 torr and PaCO2 of 30 torr. Which of the following changes in the treatment plan should be recommended?

administer mask CPAP

administer 100% oxygen

initiate mechanical ventilation

start bronchodilator therapy

administer 100% oxygen

A COPD patient who receives 2 lpm continuous oxygen therapy by nasal cannula is exercising in conjunction with a monitored pulmonary rehabilitation program. The patient has begun breathing quickly and deeply. To ensure consistent arterial oxygenation, the respiratory therapist should

use a partial rebreathing mask

decrease oxygen flow to 1 L/min

increase oxygen flow rate

use a nonrebreathing mask

increase oxygen flow rate

A premature infant being mechanically ventilated with an FIO2 of 0.65 and 10 cm H2O PEEP exhibits intercostal retractions and tachypnea. The X-ray shows bilateral dense infiltrates with air bronchograms and the SpO2 is 78%. Which of the following would you recommend for this infant?

indomethacin (Indocin)

ribavirin (Virazole)

beractant (Survanta)

indomethacin (Indocin)

beractant (Survanta)

In response to an Asthma action plan, the patient has attempted to contact their physician after determining peak flow measurement is less than 50% of the patient's usual baseline value. The physician is not responding to the call. According to NAEP guidelines, the patient should NEXT

take a short-term bronchodilator, check peak flow in 1 hour

take a short-term bronchodilator and contact a different physician

report to the hospital or call an ambulance

take a corticosteroid inhaler and check again in 20 minutes

report to the hospital or call an ambulance

According the national asthma guidelines, a self monitored peak flow of 50% of baseline is an indication to contact one's physician. However, if one's physician is not available, the patient should report to the hospital or to the emergency room or call an ambulance.

An adult patient experiences an adverse cardiac and blood pressure reaction to 0.25 mL Albuterol when administered by small volume nebulizer. The respiratory therapist should

change to 0.31 mg Xopenex.

switch to unit dose Atrovent (ipratropium bromide).

change to unit dose budesonide (Pulmicort).

continue therapy as this adverse reaction is often normal.

change to 0.31 mg Xopenex.

When a patient experiences an adverse reaction, the offending agent should first be discontinued and modification of therapy, due to the patient’s response, is required. In this case, Atrovent is a suitable replacement. Although Xopenex would also be suitable, the dose of 0.31 mg is a pediatric dose and would be sub-therapeutic for the patient.

A doctor institutes volume control ventilation for a 70 kg ARDS patient with a targeted tidal volume of 420 mL. To maintain adequate ventilation with this tidal volume, you would allow a machine respiratory rate as high as:

30/min

35/min

20/min

25/min

35/min

According to the NHLBI Protocol, you begin ventilation of ARDS patients with an initial tidal volume of 8 mL/kg IBW, then reduce it by 1 mL/kg every 2 hrs until you achieve a VT of 6 mL/kg (minimum of 4 mL/kg). 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.