3H- Assist a Physician/ Provider in Performing Procedures

TMC: 4 questions

A doctor is concerned that a terminally ill patient who is scheduled for withdrawal of ventilatory support might develop stridor after extubation and that this might upset the family. To minimize the likelihood of post-extubation stridor, you would recommend premedication with:

scopolamine

vecuronium

morphine

methylprednisolone

methylprednisolone

The occurrence of noisy breathing--including stridor, gurgling or sonorous respirations--during a terminal wean/extubation procedure can be very upsetting to a patient’s family. To minimize the likelihood of post-extubation stridor, some protocols premedicate the patient with A corticosteroid, usually prednisolone. Gurgling can be minimized by suctioning the patient before extubation and raising the head of the bed. In addition, premedication with an anticholinergic like scopolamine can be used to “dry” the airway. Morphine is commonly used during terminal weaning procedures, but not to help prevent stridor. Vecuronium is a neuromuscular blocking agent (paralytic), which is contraindicated during patient withdrawal from ventilatory support.

A bronchoscopy is used to diagnose

atelectasis.

idiopathic chronic bronchitis

malignant processes.

emphysema

malignant processes.

An infant delivered at 26 weeks of gestation has an APGAR score of 3 with a HR of 88/min and no respirations. The respiratory therapist should recommend which of the following in response to an order to provide ventilatory support?

PS ventilation

Pressure regulated control ventilation (PRCV)

High frequency ventilation (HFV)

VC-SIMV ventilation

High frequency ventilation (HFV)

A patient has a fenestrated tracheostomy tube in place. To prepare the patient for speech therapy, the therapist should do which of the following prior to placing a cap on the tracheostomy tube?

ensure cuff seal with minimum leak technique

insert the inner cannula

ensure the cuff is deflated

insert the obturator

ensure the cuff is deflated

A physician has inserted a CVP line in a 78-year-old patient who has cor Pulmonale. The respiratory therapist should expect to see a placement radiograph that shows the end of the catheter positioned in which of the following areas?

pulmonary artery

right ventricle

superior vena cava

level with the aortic knob or notch

superior vena cava

CVP is determined by measuring the pressure in the superior vena cava or right atrium.

A respiratory therapist is asked to quickly assess an intubated, mechanically ventilated patient for a possible pulmonary embolism. Which of the following would be most helpful?

capnometer

pulse oximeter

multiple wave-length spectrophotometer

EZ-cap CO2 detector

capnometer

A quick way to assess for the possibility of a pulmonary embolism is to compare exhaled CO2 with arterial CO2. If these two values are very far apart, a pulmonary embolism is highly suspected. Though, it is not diagnostic, it is a quick method of assessment. An example of this would be an arterial CO2 that is 45 with an exhaled CO2 a 16. This suggests that carbon dioxide is having difficulty leaving the blood and entering the alveoli. A clot in the pulmonary vasculature, which would prevent blood flow around a large portion of alveoli, could cause this clinical outcome.

A 2nd year resident is preparing to intubate a patient admitted to the emergency department with a suspected cervical spine injury. Neither the equipment nor personnel are available to perform any special intubation procedures like fiberoptic intubation. Which of the following techniques would you recommend to the resident to minimize further trauma to the patient?

insert an oropharyngeal airway

place the patient in the sniffing position

manually immobilize the patient's head/neck

tighten the patient's cervical collar

manually immobilize the patient's head/neck

For patients with suspected cervical spine injuries, the idea approach for establishing an emergency tracheal airway is fiberoptic or video-assisted intubation. If this is not possible, and the need for airway control is urgent, the patient should be anesthetized and undergo orotracheal intubation with manual in-line stabilization (MILS) of the head and neck.This entails firmly holding the patient either side of the head with the neck in the midline and the head on a firm trolley surface. Traction is not applied and the aim is to prevent any flexion or rotation of the c‐spine when laryngoscopy is performed. To assist the resident, you would need to crouch by the bedside, slightly to one side, while intubation is performed. In addition, the cervical collar may need to be loosened or the anterior portion temporarily removed to facilitate mouth opening.

The respiratory therapist observes an ECG wave form on a patient that is consistent with atrial tachycardia. The patient is complaining of chest pain, dizziness, and nausea. The respiratory therapist should recommend

sychronized defibrillation

epinephrine

unsynchronized defibrillation

Atropine sulfate

sychronized defibrillation

Non-deadly arrhythmias, such as this one, may be addressed through cardioversion, also called synchronized defibrillation. Cardioversion is a form of defibrillation with low wattage and with the synchronization set to "active". This allows the shock to be sychronized to the R wave.

The respiratory therapist is caring for a 28-week-old gestational age infant currently receiving mechanical ventilatory support on the following settings:

PIP 30 cm H2O

FIO2 0.70

PEEP 5 cm H2O

Mandatory rate 40

A chest radiograph shows bilateral haziness.

Arterial blood gas analysis shows

pH 7.22

PaCO2 67 torr

PaO2 44 torr

HCO3- 27 mEq/L

BE +1 mEq/L

The most appropriate recommendation would be to

Increase PIP

Administer Exosurf®

Increase FIO2

Decrease mandatory rate

Administer Exosurf®

Bilateral haziness observed on the chest x-ray, in conjunction with the fact that the infant is premature, is consistent pulmonary prematurity. Pulmonary prematurity may be treated by administering pulmonary surfactant. Surfactant decreases the surface tension of the alveoli, which allows and promotes explansion and causes improved gas exchange.

While assisting in a treadmill cardiopulmonary stress test procedure, the patient complains to you that she is developing severe shortness of breath and some chest pain. Which of the following actions would you recommend at this time?

decrease the treadmill speed

terminate the procedure at once

increase the O2 flow rate

decrease the treadmill incline

terminate the procedure at once

Patient responses that justify terminating a cardiopulmonary exercise test include the following: 1) a fall in systolic blood pressure > 10 mm Hg from baseline when accompanied by other evidence of ischemia such as ECG changes; 2) a hypertensive response (systolic BP > 250 mm Hg and/or diastolic >115 mm Hg); 3) moderate-to-severe angina; 4) increasing nervous system symptoms such as ataxia, dizziness, or near-syncope; 5) signs of poor perfusion, such as cyanosis or pallor; 6) sustained ventricular tachycardia or other serious arrhythmias; 7) Major ST segment changes; 8) severe wheezing or dyspnea

An exercise test can help determine the cause of which of the following?

1. Dyspnea

2. Chronic cough

3. Wheezing

4. O2 desaturation

1, 2 and 3 only

2 and 4 only

1, 2, 3 and 4

1, 3 and 4 only

1, 3 and 4 only

A 9-year-old asthmatic patient has previously responded well to Xopenex via small-volume nebulizer. The patient is intubated and has been placed on mechanical ventilation for acute respiratory failure. The physician orders Xopenex to be delivered via SVN through the ventilator circuit. Which of the following is an important consideration for effective medication delivery?

tachycardia is more likely

an alpha I response is increased

Placement of the nebulizer can result in variation of medication delivery

particle deposition will be increased

Placement of the nebulizer can result in variation of medication delivery

In preparation for oral intubation with a double-lumen endotracheal tube for the purpose of independent lung ventilation, the respiratory therapist should

1. test the bronchial cuff

2. test the tracheal cuff

3. apply water-soluble lubricant

4. ensure both cuffs are evacuated

2 and 3 only

1 and 3 only

1, 2, 3 and 4

3 and 4 only

1, 2, 3 and 4

You are assisting a resident perform orotracheal intubation of a semiconscious adult patient in the emergency room. Despite three failed attempts by the resident to place the tube in the trachea, you still are able to provide the patient with adequate ventilation and oxygenation using a bag-valve-mask system. Which of the following would you recommend to the resident as the next course of action?

suspend intubation efforts, continue bagging the patient, consider alternatives

perform an emergency cricothyrotomy and position an ET tube in the stoma

switch to the nasal route and perform a blind nasotracheal intubation

try at least one more oral intubation attempt before abandoning the effort

suspend intubation efforts, continue bagging the patient, consider alternatives

In a "can't intubate, but can ventilate" scenario, it is best to continue bag-valve-mask ventilation with oxygen and defer intubation until either a more experienced laryngoscopist arrives, or to consider an alternative technique, e.g., placement of a laryngeal mask airway or fiberoptic intubation.

While assisting a physician who is inserting a pulmonary artery catheter, you note a changeover on the monitor from pulsatile pressures of about 32/18 mm Hg to a nonpulsatile pressures of 15 mm Hg. Which of the following has occurred?

the catheter has advanced into the pulmonary wedge or occluded position

the catheter has moved from right ventricle into the pulmonary artery

the catheter has slipped back into the right atrium and needs to be and re-inserted

the catheter is in Zone I and needs to be withdrawn and re-inserted

the catheter has advanced into the pulmonary wedge or occluded position

During insertion of a pulmonary artery catheter, pressure waveforms indicate its position. In the vena cava/right atrium (RA), pressures normally are < 10 mm Hg and barely pulsatile. As the catheter moves into the right ventricle, a changeover to pulsatile pressures occurs, normally about 25/5 mm Hg. As the catheter passes into the pulmonary artery (PA), pulsatile pressures continue, but with a raised diastolic baseline (normally about 25/15 mm Hg). In the "wedge" position (PAWP or PCWP), strong pulsations are lost, and pressures normally drop to 6-12 mm Hg. In this case, the PAWP is slightly above normal.

A doctor is concerned that a terminally ill patient who is scheduled for withdrawal of ventilatory support will have a problem with excessive secretions after extubation, and that gurgling sounds or the need for repeated suctioning might upset the family. To help avoid this problem you would recommend premedication with:

scopolamine

morphine

methylprednisolone

midazolam

scopolamine

Which of the following equipment is required for patient monitoring during a fiberoptic bronchoscopy procedure?

EEG monitor

pulse oximeter

oxygen cannula

capnography adaptor

pulse oximeter

Equipment required for monitoring during a fiberoptic bronchoscopy procedure includes a pulse oximeter, ECG leads (not EEG!) and a cardiac monitor. Capnography is not required for monitoring during bronchoscopy and an oxygen cannula is used to provide O2 therapy, not to monitor the patient.

Which of the following is a potential hazard of thoracentesis?

pulmonary emboli

liver laceration

peritonitis

barotrauma

liver laceration

A 30-week gestational age infant is difficult to ventilate with a resuscitator bag and mask. A recent chest radiogram shows haziness and a reticulogranular pattern. Which of the following would be most helpful to the patient?

Vigorous suctioning

Chest physiotherapy

Fluid distraction

Surfactant therapy

Surfactant therapy

An intubated patient undergoes fiberoptic bronchoscopy during which a transbronchial biopsy will be obtained. Which of the following complications should you be on guard for during and immediately after this procedure?

pneumothorax

pneumonia

laryngospasm

fever

pneumothorax

Acute/early complications of bronchoscopy include damage to the mouth or nose (lacerations and minor bleeding), laryngospasm, transient changes in pulmonary function, hypoxemia, cardiac arrest, and pneumothorax (more common with transbronchial biopsy). However, because the patient is intubated, laryngospasm is unlikely. Pneumonia (along with its symptoms such as fever) also is a potential complication, but would occur later (days), not immediately.

A physician has attempted on several occasions to insert a central venous catheter into the right subclavian vein of a mechanically ventilated patient. Suddenly, the ventilator's high-pressure alarm sounds off, the patient's blood pressure drops, and the SpO2 value drops from 95% to 82%. Breath sounds are greatly diminished over the right lung field. What should the respiratory therapist recommend?

Withdraw the endotracheal tube from the right mainstem bronchus to the trachea.

Insert a drainage tube into the left pleural space

Insert a drainage tube into the right pleural space

Insert a pulmonary artery catheter.

Insert a drainage tube into the right pleural space

A physician performing bronchoscopy does NOT need the ability to provide which of the following down the multi-lumen ports?

saline

lidocaine

epinephrine

albuterol

albuterol

Which interspace in the thoracic cage is most suitable for insertion of a chest tube intended to facilitate the evacuation of both air and fluid?

2nd interspace

5th interspace

8th interspace

4th interspace

5th interspace

The 2nd interspace is used to evacuate only air (gas) while the 5th interspace is most suitable to evacuate the pleural space of both air and fluid.

Which of the following equipment might a doctor request to assist her in directing an endotracheal tube between the vocal cords during nasotracheal intubation?

capnograph

light wand

Magill forceps

stylet

Magill forceps

After three failed attempts at intubation, an anesthesiologist asks for your assistance in performing a retrograde intubation. After puncturing the cricothyroid membrane with an 18 gauge angiocath, she passes a long guidewire through the angiocath sheath toward the head of the patient. At this point you should:

attach a high pressure oxygen source to the angiocath connector

insert an oropharyngeal airway and suction the patient with a Yankauer tip

use forceps to pull the guidewire out the mouth and slide the ET tube over it

apply downward pressure on the cricoid cartilage to help position the guidewire

use forceps to pull the guidewire out the mouth and slide the ET tube over it

During a retrograde intubation, the assistant should locate the guidewire and use McGill forceps to pull it out the mouth (making sure a sufficient length remain in place at the cricoid side). The assistant then can slide the endotracheal tube over the guidewire. The anesthesiologist will have the assistant hold the wire ends taught while she advances the tube over the guidewire, through the larynx and into the trachea. Once the ET tube position is confirmed, the assistant can remove the guidewire by pulling it out through the ET tube.

You are using an SIMV protocol to terminally wean a cancer patient from ventilatory support. When you decrease the rate from 6 to 3 breaths/min, you observe some agitation and labored breathing. Which of the following should you recommend?

provide an IV push of sedating agents

remove the ventilator and extubate

restore full ventilatory support

immediately decrease the rate to 0

provide an IV push of sedating agents

Common signs of distress during ventilator withdrawal include labored breathing, tachypnea, grimacing and/or agitation. If any of these signs of distress occur, you should recommend pushing the prescribed sedating agents by IV until the distress is relieved. Then the infusion rate should be readjusted to maintain relief from distress. Restoring full ventilatory support will only delay the desired outcome, while immediate withdrawal of support (rate of 0 or extubation) without additional sedation will likely only increase the intensity of the distress.

While assisting a physician in the performance of bronchoscopy, the respiratory therapist notices nothing is collecting in the in-line specimen trap even though the physician has instilled normal saline and is depressing the suction button. The therapist should recommend

replacing the specimen trap.

flushing the suction channel.

increasing suction pressure to the bronchoscope.

switching to a different bronchoscope.

flushing the suction channel.

Which of the following would be helpful during a bronchoscopy procedure to ensure adequate continuous ventilatory support for a patient who is receiving mechanical ventilation and is dependent on high levels of PEEP?

Halcinon

high frequency jet ventilation

resuscitation bag with a PEEP valve

closed in-line suction catheter

high frequency jet ventilation

You are assisting a physician performing oral intubation of a 70 kg adult male patient. Which of the following endotracheal tube sizes would you select for this patient?

9.5 mm

8.5 mm

10.0 mm

7.5 mm

8.5 mm

For an average-sized adult male patient requiring endotracheal intubation, an 8.0 to 9.0 mm ID tube is satisfactory. In general, you should always recommend selecting a tube at the larger end of this range first.

A bronchoscopy is used to diagnose

malignant processes.

emphysema

idiopathic chronic bronchitis

atelectasis.

malignant processes.

A respiratory therapist has achieved the following weaning parameters on a post-operative patient who experienced a total knee replacement. The SpO2 is 97% on 35% oxygen.

Spont VT 480 mL

VC 1600 mL

VE 7.0 L

MIP -4 cm H2O

The next best action would be to

reduce FIO2 to 0.30

check the pressure manometer for leaks

return to full mechanical ventilation

evaluate the MEF

check the pressure manometer for leaks

Most of the weaning parameters listed are very good and suggest that the patient is strong enough for weaning. The respiratory therapist should not believe the NIF result of -4 cm H2O because it is not consistent with the remainder of the results. A leak is likely present in the manometer set up.

An anesthesiologist is planning a rapid sequence induction to intubate an adult patient in the surgical ICU. In preparation for intubation, the patient is being pre-oxygenated via a non-rebreathing mask. The anesthesiologist is concerned about the potential for regurgitation and aspiration before the tube is placed. To help minimize the likelihood of aspiration you would:

apply downward pressure on the cricoid cartilage

place the patient in the lateral decubitus position

place gentle pressure on the upper epigastrium

rotate the patient's head 45 degrees to the right

apply downward pressure on the cricoid cartilage

Based mainly on case reports, pressure applied to the cricoid cartilage (aka the Sellick maneuver) may reduce the risk of aspiration during rapid sequence intubation. When used, cricoid pressure is applied immediately following induction (prior to loss of consciousness) and maintained until proper ET tube placement and cuff inflation have been confirmed. However, given that (1) regurgitation and aspiration may still occur even when cricoid pressure is used, and (2) in some cases the maneuver can obscure visualization of the glottis, impede passage of an ET tube or LMA, or prevent adequate mask ventilation, its routine use no longer is recommended. Instead, the decision to apply cricoid pressure should be based on the situation at at hand and one's judgement of its relative risks and benefits. And if judged necessary, cricoid pressure should be altered or removed to ease ET tube or LMA insertion, and/or provide for adequate ventilation and oxygenation. Ultimately, inadequate ventilation and/or oxygenation is of greater concern compared to the relatively small risk of aspiration.

A bronchoscopy is NOT used to diagnose

pathogenic involvement.

malignant processes.

foreign body obstruction.

atelectasis.

atelectasis.

Bronchoscopy is used to diagnose foreign body obstructions, active bleeding causes, pathogenic involvement (to identify organisms) and cancerous or malignant processes or areas. It may help decrease atelectasis if immobilized mucous plugs are blocking a portion of the lung from expanding, but it does not serve in the diagnosis of atelectasis.

In explaining to a terminally ill patient's family the available options for withdrawing ventilatory support from their loved one, which of the following information is essential to share?

how long they can expect the procedure to last

if and when the ET tube will be removed

how much sedation the patient will receive

how often you will monitor the patient for distress

if and when the ET tube will be removed

In explaining to a terminally ill patient's family the available options for withdrawing ventilatory support, you should outline the key steps involved, discuss whether or not the endotracheal tube will be removed, and whether or how supplemental oxygen may be used. You should also be sure the family understands that noisy breathing or gasping can sometimes occur but does not indicate that their loved one is suffering. In addition, all involved personnel should make sure the family knows that the patient’s comfort is their primary concern.