RRT Boards Exam Review Questions & Answers Rated 100% Correct!! | Exams Nursing | Docsity (2024)

Download RRT Boards Exam Review Questions & Answers Rated 100% Correct!! and more Exams Nursing in PDF only on Docsity! RRT Boards Exam Review Questions & Answers Rated 100% Correct!! ABG measures what? What is Calculated? Answer- Measured: - pH - PaCO2 - PaO2 Estimated: - HCO3 What are the four life functions and what order do they go in to fix an issue? Answer- - Ventilation - Oxygenation - Circulation - Perfusion Out of the four life functions, which one is the most common problem? Answer- Oxygenation What does HPI stand for? Answer- History of Present illness What is the pack years equation? Answer- # of packs per day X number of years smoked How many pack years are significant and usually indicate possible COPD? Answer- 20 pack years Calculate the pack years: 4 packs per day 10 years of smoking Answer- 4 packs x 10 yeas = 40 pack years If a patient has a change in prognosis, what should you look for? Answer- Change in orders (To start new methods of treatment) What is a normal urine output? Answer- 40 mL/hr (approximately 1 Liter/day) Difference between CVP Swan Ganz catheter and Central line? Answer- CVP Swan Ganz = 2-6 mmHg CVP Central Line = 4-12 cmH20 What does Medication Reconciliation mean? Answer- To check whether or not the medications that a patient is on match the ones they use at home if possible If carbohydrates are increased, how does that affect the RQ (Respiratory Quotient)? Answer- ↑ Carbohydrates = ↑ RQ = ↑ CO2 Rapid weight loss vs Rapid weight gain? Answer- Rapid weight loss = Cancer Rapid weight gain = Fluid overload Recommended diet for COPD patient? Answer- Recommended Diet: ↑ Proteins ↑ Fats ↓ Carbohydrates Peripheral Edema shows what? Answer- Excessive fluid in the tissue How is Peripheral Edema Rated? Answer- +1, +2, +3, etc. the higher the number, the greater the swelling What causes Peripheral Edema? Answer- - CHF (Congestive Heart Failure) - Renal Failure What does Ascites mean? Answer- Accumulation of fluid in the abdomen (Usually caused by Liver failure) Clubbing of fingers is caused by? Answer- Chronic Hypoxemia Chronic hypoxemia is defined as? Answer- ↓ PaO2 for a long period of time Venous Distention is usually seen in what patients and when should you look for it? Answer- CHF (Seen during exhalation in obstructive air trapping patients) How do you test for peripheral circulation? Answer- Using Capillary Refill by blanching the hand and waiting for color to return What is a normal Capillary Refill? Answer- ≤ 3 seconds = normal What does Diaphoresis mean? Answer- Profuse/heavy Sweating What patient usually has Diaphoresis during the night? Answer- Tuberculosis (Night Sweats) Retractions are usually seen in what type of patients? Answer- - Severe airway obstruction - Respiratory Distress What is the most two most common signs of respiratory distress in infants? Answer- - Nasal Flaring - Grunting If an asthmatic is not well controlled, what is a good indicator? Answer- Dry non- productive cough Dry non-productive cough can indicate? Answer- Possible tumor in lungs What does Macroglossia mean? Answer- Enlarged Tongue What score is used to visualize the soft palate, uvula, and fauces? Answer- Mallampati Score What is the purpose of the Mallampati score and how is it measured? Answer- To see if a patient will be difficult to intubate or not Measure from I-IV (The higher the number the harder the intubation) If a Mallampati score is III or IV, what device do we need to use to intubate? Answer- Fiberoptic bronchoscope What is a normal pulse for an adult? Answer- 60-100 bpm What drug is used to treat bradycardia? Answer- Atropine A change in _____ bpm indicates an adverse reaction? Answer- 20 bpm or more increase means we need to stop the treatment What does Paradoxical pulse/pulsus paradoxus mean? Answer- Pulse/blood pressure varies with respiration > 10mmHg drop in systolic blood pressure during inspiration Paradoixcal pulse/Pulsus paradoxus may indicate? Answer- Severe air trapping How to tell which way the trachea will deviate? Answer- Inside the lung = Toward Outside the lung = Away Examples: Inside: - Atelectasis - Pneumonia Outside: - Pneumothorax - Pleural effusion - Tumor or mass What is Tactile fremitus? Answer- Vibrations that are felt by the hand on the chest wall Fremitus shows? Answer- Patient has secretions What does Crepitus mean? Answer- Extra pulmonary air under the skin What patient shows Crepitus? Answer- Subcutaneous emphysema What do each of these breath sounds mean: - Resonant - Flat - Dull - Tympanic - Hyperressonant Answer- Resonant = Normal air filled lungs (Hollow sound) Flat = Fluid filled or bone Dull = Fluid filled Tympanic = Air filled stomach (Increased volumes) Hyperresonant = Extra air filled Hyperresonant can indicate unilateral or bilateral lung issues, what is shown with each? Answer- Unilateral = Pneumothorax Bilateral = Emphysema What does Vesicular mean? Answer- Normal breath sounds What does Adventitious mean? Answer- Abnormal breath sounds Bronchial breath sounds are normal and are heard where? Answer- Over the trachea and bronchi If bronchial breath sounds are heard over the periphery, this would indicate? Answer- Lung consolidation = Pneumonia What does Egophony mean? Answer- Patient is instructed to say "E" but it sounds like "A" this indicates consolidation of the lung Coarse crackles (rhonchi that clear with a cough) show what? Answer- Large airway secretions If a patient has coarse crackles, what should we do? Answer- Suction them Fine crackles/rales indicates? Answer- Alveoli are full of fluid - CHF - Pulmonary Edema If a patient has fine crackles/rale, what should we do? Answer- - Positive pressure - Positive inotropic agents - Diuretics What is the most common breath sounds heard from a bronchospasm? Answer- Wheeze Unilateral vs Bilateral wheeze? Answer- Unilateral = Indicates Aspiration/foreign body obstruction Bilateral = SABA needed Stridor indicates? Answer- Upper airway obstruction (high pitched or crowing inspiratory sound) What are some things that commonly cause stridor? Answer- - Supraglottic swelling (Epiglottis) - Subglottic swelling (Croup/post extubation) How do we treat stridor? Answer- - Humidified O2 - Racemic Epinephrine - Corticosteroid - Heliox What does Stertor sound like? Answer- Noisy breathing during inhalation (Low pitched snoring type of sound arises from vibration of fluid) What does Pleural friction rub sound like? Answer- A coarse grating, raspy, or crunching sound What is Pleural friction rub usually indicated in? Answer- - Pleurisy - Tuberculosis - Pneumonia (Possibly) What does Pleurisy mean? Answer- Inflammation of the lining of the lungs What is a heart murmur? Answer- abnormal heart sound is typically due to a leaky valve To detect foreign body aspirations we use inspiratory/expiratory radiographs, these allow us to use what device to help remove them? Answer- Bronchoscope What does Infiltrate mean and what is shown on an Xray? Answer- Ill defined radiodensity (Atelectasis) What does Consolidation mean and what is shown on an Xray? Answer- Solid white area (Fluid or Solid) (Pneumonia/Pleural effusion) What does Hyperlucency mean and what is shown on an Xray? Answer- Extra pulmonary Air (COPD, Asthma attack, Pneumothorax) What does Vascular Markings mean and what is shown on an Xray? Answer- Lymphatics, Vessels, Lung tissue (↑ with CHF, Absent with Pneumothorax) If Vascular marking are increased it shows? Answer- CHF If Vascular Marking are decreased it shows? Answer- Pnuemothorax What does Diffuse mean and what is shown on an Xray? Answer- Spread throughout (Pneumonia/Atelectasis) What Xray sign is shown with Pulmonary Edema? Answer- - Fluffy infiltrates - Batwing - Butterfly What Xray sign is shown with Atelectasis? Answer- - Patch infiltrates - Platelike infiltrates - Crowded pulmonary vessels - Crowded air bronchograms What Xray sign is shown with ARDS? Answer- - Groundglass appearance - Honeycomb pattern - Diffuse bilateral radiopacity What Xray sign is shown with Pleural Effusion? Answer- - Blunting/obliteration of costophrenic angles - Basilar infiltrates with meniscus - Concave superior interface/border What Xray sign is shown with Pneumonia? Answer- Air bronchogram What Xray sign is shown with Pulmonary Embolus? Answer- Peripheral Wedge- shaped infiltrate What Xray sign is shown with Tuberculosis? Answer- - Cavity Formation - Hilar Nodule What should you do first when interpreting Xrays? Answer- Look for the ET tube first What is another name for a CT scan? Answer- CAT scan What is the best order to see if a patient has a Pulmonary Embolism? Answer- 1 = Spiral CT with Contrast 2 = VQ scan 3 = Pulmonary Angiogram What is the first and second choice for best test to see if a patient has Bronchiectasis? Answer- 1 = Spiral CT with contrast 2 = Bronchogram What patients are prone to developing Bronchiectasis from retained secretions? Answer- Cystic Fibrosis What is the biggest advantage to an MRI? Answer- No radiation is used What type of ventilator must be used during an MRI? Answer- - Non-electric/gas powered (The magnetic field would disrupt the electronic devices in the ventilator if an electrical one was used) What type of gas cylinders can you take to an MRI? Answer- - Non-ferrous (Aluminum gas cylinders are used instead of Steel) What is the best type of cylinder used during an MRI? Answer- Aluminum (Because it is non-ferrous) What gas does a Ventilation/Perfusion Scan use (VQ scan)? Answer- Xenon gas What does the V/Q mean in VQ scan? Answer- V = Ventilation Q = Perfusion A normal ventilation with abnormal perfusion scan indicates? Answer- Pulmonary Embolism (They are ventilating fine, but the blood flow is blocked by a clot) What test is used to diagnose abnormalities in the hypopharynx, esophagus, or stomach? Answer- Barium Swallow (Esophogram) What is another name for a Barium Swallow? Answer- Esophagram What is the number one indicator for a Barium Swallow? Answer- Dysphagia (Difficulty Swallowing) What is the main purpose/advantage a PET scan has over MRI/CT? Answer- It detects diseases earlier Why is a bronchogram the second choice and not first when comparing to CT scan? Answer- It is dangerous because you are injecting a radiopaque contrast into the tracheobronchial tree, which could cause impairment of ventilation or allergic reaction What is the main indication to perform a Bronchogram? Answer- Bronchiectasis EEG stands for? It measures what? Answer- Electroencephalogram Measures Brain waves Pulmonary Angiogram is used to test for? Answer- Pulmonary Embolism ECG stands for? It measures what? Answer- Electrocardiogram Measures cardiac performance (Overall Cardiac Function and Left Ventricular volume and Ejection Fraction) What is the purpose for a Cardiac Catheterization? Answer- To find a possible narrowing so we can place a stint to open it up What is a normal Intracranial Pressure (ICP)? Answer- 5-10 mmHg When should you treat Increased Intracranial Pressure (ICP)? Answer- > 20 mmHg What are the two times we use Hyperventilation? Answer- 1 = Patient just got into ER 2 = In unit on ventilator and random spike of ICP (Temporarily decreases PaCO2 because CO2 is a Cerebral Vasodilator, so we blow more off to constrict it) If a patient has High ICP and we need to help them oxygenate more what can we do? Answer- Increase the FiO2, but increasing the PEEP would worsen the problem because of more pressure What is the major intracellular cation, extracellular cation, and Major extracellular anion? Answer- Intracellular Cation = K+ Extracellular Cation = Na+ Extracellular Anion = Cl- What is a normal Chloride (Cl-) range? Answer- 80-100 mEq/L What is a normal Bicarbonate (HCO3-) range? Answer- 22-26 mEq/L Most of the CO2 in the blood is carried as HCO3- so that changes in total CO2 content can reflect how? Answer- HCO3 = TCO2 = 22-26 mEq/L H+ = CO2 What is a normal Creatinine (Cr-) range? Answer- 0.7-1.3 mg/dL What is a normal Blood urea nitrogen (BUN) range? Answer- 8-25 mg/dL Gram + vs Gram - Stain color and what drugs to use? Answer- Gram + = Purple - Use "cyllin" - Usually ends in Occocus Gram - = Red - Use "Mycin" - Usually hard to spell or pronounce Green sputum usually shows what kind of infection? Answer- Gram - Bacteria What are the benefits/disadvantages of the following: Sputum Culture Sensitivity Gram Stain Acid Fast Stain Answer- Sputum Culture: - 48-72 hours - Identifies Bacteria present Sensitivity: - 48-72 hours - Identifies what antibiotics kill bacteria Gram Stain: - 1 hour - Identifies whether + or - bacteria Acid fast: -Only identifies Tuberculosis What is a normal Clotting time? (Time it takes for the body to stop bleeding) Answer- 6 minutes What is a normal Platelet (Plt) Value? Answer- 150,000-400,000 mm3 Why are platelets important? Answer- They help blood clot (Stop bleeding) Activated Partial Thromboplastin Time (APTT) vs Prothrombin Time (PT) and purpose? Answer- Used to measure time it takes to clot APTT = Heparin Therapy PT = Warfarin (coumadin) What is the purpose of Troponin? Answer- Protein found in myocardial cells and indicates damage to the heart muscle What is a normal Troponin level? Answer- Troponin normal = 0.01 ng/mL (If increases places patient at higher risk for death from a myocardial infarction) What is a normal Brain Natriuretic Peptide (BNP) Value? Answer- < 100 pg/mL Why is Brain Natriuretic Peptide (BNP) important? Answer- It is secreted by the cardiac muscle when heart failure develops or worsens What are the Brain Natriuretic Peptide (BNP) levels used to determine how bad a patient has potential heart failure? Answer- > 300 pg/mL = mild heart failure > 600 pg/mL = moderate heart failure > 900 mg/mL = Sever heart failure (CHF) What test is used to determine if a patient has Tuberculosis? Answer- Mantoux test/PPD (PPD = Purified protein derivative) Oscilloscope or ECG monitor is also known as? Answer- Telemetry What is a Holter Monitor? Answer- A portable ECG monitor What is the pace maker of the heart? Answer- Sinoatrial Node (SA Node) P wave, QRS complex, and T wave show what? Answer- P wave = Atrial Depolarization QRS = Ventricular Depolarization T wave = Ventricular Repolarization Small box vs Large box on ECG? Answer- Small = 0.04 seconds Large = 0.20 seconds 1 millivolt is _______ mm on an ECG? Answer- 1 millivolt = 10 mm (Ten boxes vertically Y-axis) What does axis mean when talking about electrophysiology of the heart? Answer- Average direction of impulse (electrical flow) What is the normal impulse/axis of electrical flow? Answer- Down and to the left What are the two factors that affect electrical impulse/axis? Answer- Hypertrophy = increased electrical activity, Axis will shift toward hypertrophy (Toward) Infarction = Dead tissue, no electrical activity, axis will shift away from the infarction (Away) If there is an axis deviation on an ECG, this show? Answer- Abnormal Finding There are 12 leads on an ECG and 10 electrodes, where are they? Answer- 6 on chest 1 on each arm 1 on each leg 10 total What are the limb leads for Lead I, Lead II, and Lead III? Answer- Lead I: Right arm - Left Arm + Lead II: Right arm - Left leg + Lead III: Left arm - Left leg + What are the limb leads for AVR, AVL, AVF? Answer- AVR = Right arm (Away) AVL = Left arm (Toward) AVF = Left foot (Toward) (So impulse is down and to the left so the impulse is toward except on Right arm because it is not down and to the left) - Some flexion of extremities - Slow irregular weak cry 0: - Blue or pale all over - Absent - No response - Limp no movement - Absent no cry Transillumination is used to see what in infants? Answer- Pneumothorax If there is no light on the left side while using a Transilluminator on a infant, there could be? Answer- Diaphragmatic hernia Normal Heart rate for infant? Answer- 110-160 bpm Normal Respiratory Rate for infant? Answer- 30-60 breaths per minute If apnea is longer than _______ it is considered abnormal for an infant? Answer- 20 seconds Normal Blood pressure for term and preterm infants? Answer- Term = 60/40 mmHg Preterm = 50/30 mmHg What is a normal birth weight for an infant? Answer- 3000g or 3 kg Acrocyanosis means what? Answer- Bluish extremities and it is not true cyanosis What is the Silverman Score used for and how is it measured? Answer- 0-10 and it is used for assessment of respiratory distress in infants (Higher the score the Worse the distress) Dubowitz or Ballard Score is measured how and is used to do what? Answer- Used to assess gestational age Normal = 40 corresponding to 40 weeks > 40 = Post-term (Suction + ETT) < 40 = Pre-term (Surfactant) New Ballard score is used when and why? Answer- Estimates gestational age in low birth weight infants SGA = Small gestational age If the pre-ductal (right radial artery) PaO2 is 15 mmHg higher than the post-ductal (umbilical artery) PaO2 then this shows? Answer- Patent Ductal Arteriosus suspected get an ECG Blood glucose is important to monitor in infants, what is the normal for term and Pre- term infants? Answer- Term = > 30 mg/dL Pre-Term = 20mg/dL What is Lecithin/Sphingomyelin (L/S) ratio? Why is it important? Answer- It indicates if an infant is at higher risk of developing Hyaline membrane disease (HMD) or Infant Respiratory Distress Syndrome (IRDS) What is a normal Lecithin/Sphingomyelin (L/S) ratio? What does it mean if it is low? Answer- 2:1 or higher ratio is good If low it indicates higher risk of HMD/IRDS When looking at the Lecithin/Sphingomyelin (L/S) ratio which number should always be higher in the ratio? Answer- First number should always be higher Example: 2:1 Phosphatidylglycerol (PG), Phosphatidylcholine (PC), or Dipalmitoylphosphatidylcholine (DPPC) are all used to evaluate? Answer- Indicator for lung maturity in infants and will increase as lungs mature (If present this is good) Capnography measures what? Answer- Exhaled carbon dioxide (CO2) content using infrared absorption How does Capnography work? Answer- Infrared absorption ECO2, ETCO2, and PETCO2 are known as? Answer- Capnography Normally Capnography (PETCO2) is usually lower than arterial PCO2 by how much? Answer- PaCO2 = 40 Torr PETCO2 = 35 Torr USually 5 less What is a normal ETCO2 %? Answer- 3-5 % Increase vs Decrease in PETCO2% shows? Answer- Increased = Decrease in Ventilation (Ventilatory Failure) Decrease = Increase in Ventilation or Decrease in Perfusion (Pulmonary Embolism/Hypovolemia) Deadspace disease is also known as? Answer- Pulmonary Embolism Low PETCO2 readings after intubation indicate the ET tube is where? Answer- In the esophagus If a capnograph measure 0 mmHg, what is the problem? Answer- Leak or disconnect (CO2 in the atmosphere is 1% so the reading is 0 mmHg because it is such a low %) Capnograph should show what color if good or bad? What is the rule to remember it? Answer- Yellow = Mellow Purple = Poor (ETT in esophogus) What are some other names for Capnography devices? Answer- - EZ cap - Colormetric devices How is a Capnograph calibrated? Answer- 0% room air 5% CO2 concentration Compared with PCO2 from ABG at time of Capnograph sampling and should be 5 mmHg less Normal range for Pulse Oximeter? Answer- 93-97% At what % should an ABG be drawn if a Pulse Oximeter is lower than? Answer- > 80% = accurate < 80% = ABG needed to confirm Pulse oximeter has no affect on what patients/problems? Answer- Jaundice, Anemia, Dark skin = No effect Blue, green, black nail polish = Poor signal What is a normal Venous saturation? Answer- 70% Co-oximeter/hemoximeter are used to diagnose? Answer- Carbon Monoxide poisoning (CO) What is a normal COHb? Answer- 0-1% COHb is elevated in what type of patient and to what range usually? Answer- Smokers = 2-12 COHb Carbon Monoxide (CO) poisoning is considered at what %? What do we use to treat it? Answer- 20% = CO poisoning Treat with 100% O2 Hyperbaric Chamber What drugs are used to treat MetHb Poisoning? Answer- Methylene Blue Vitamin C (Ascorbic Acid) Vitamin C is known as? Answer- Ascorbic Acid - Air Embolism Give some examples of PCWP being high? Answer- - Left Heart Failure - Mitral valve Stenosis (BCV) - CHF If all values are high or low when monitoring hemodynamics is shows what two things? Answer- All increased = Hypervolemia All decreased = Hypovolemia Pulse pressure equation? Answer- Systolic - Diastolic = Pulse Pressure What is a normal Pulse pressure? Answer- 40 mmHg If a pulse pressure is greater than 40mmHg it shows? If lower it shows? Answer- > 40 mmHg = ↑ CO < 40 mmHg = ↓ CO What is the equation for Mean Arterial Pressure? Answer- MAP = (Diastolic x 2) + Systolic / 3 (This is because of 2/3 of the blood is free falling during the rapid filling phase of the ventricles) What does cardiac output measure? Answer- Output of the left ventricle to the systemic arterial circulation What are the 3 ways to measure Cardiac output? Answer- - Fick equation = CO = VO2/C(a-v)O2 x 10 - Stroke Volume = CO = SV x HR - Thermal Dilution What is a normal Cardiac Output? Answer- 4-8 L/min What is the Cardiac Index equation? Answer- CI = CO/BSA (Usually 1/2 the Cardiac Output) What is a normal Cardiac Index (CI)? Answer- 2.5-4.0 L/min/m2 Systemic Vascular Resistance (SVR) and Pulmonary Vascular Resistance (PVR) represent what? Answer- SVR = LV PVR = RV What is the equation for Systemic Vascular Resistance (SVR) ? Answer- SVR = MAP - CVP / CO x 80 What is a normal Systemic Vascular Resistance (SVR)? Answer- < 1600 Dynes/sec/cm^-5 What is the equation for Pulmonary Vascular Resistance (PVR)? Answer- PVR = MPAP - PCWP / CO x 80 What is a normal Pulmonary Vascular Resistance (PVR)? Answer- < 200 Dynes/sec/cm^-5 Oropharyngeal airways should only be used on? Answer- Unconscious patients How do you insert an Oropharyngeal airway? Answer- Inserted opposite of its anatomical shape (Upside down) to back of throat then rotate into correct position Nasopharyngeal airway is for? Answer- Conscious Patients What must be used with a Nasopharyngeal Airway? Answer- KY jelly or water soluble lubricant (To prevent Trauma to the mucosa) What does Epistaxis mean? Answer- Nose bleed How is a Nasopharyngeal Airway inserted? Answer- Inserted the way it is anatomically shaped with lubricant What is the preferred method of establishing an airway during CPR? Answer- Head- tilt/Chin-lift Why would you not perform a Head-tilt/Chin-lift? Answer- Cervical Injury (Use modified Jaw thrust) How do you tell the difference between a mild/severe airway obstruction? Answer- Mild = Can Vocalize Severe = Can Not Vocalize How do you treat Severe airway obstruction in infants? Answer- - 5 back blows Turn over then - 5 chest thrusts (If infant becomes unresponsive then activate emergency response system) What are some options that are bad to pick during your clinical simulations? Answer- - Blind finger sweep - STAT ABG - STAT Xray - Repeat ABG If a pregnant woman needs help with a Severe Airway Obstruction, how do you perform the Heimlich? Answer- Chest thrusts by sternum A Manual resuscitation bag (Self-inflating) is set to what liter flow? Answer- 15 Lpm When using a Manual resuscitation bag (Self-inflating), where does the PEEP valve go? Answer- Attach to the expiratory side of patient valve If a Manual resuscitation bag (Self-inflating) fills rapidly and collapses easily on minimal pressure, where should you check? Answer- Inlet Valve A Flow-Inflating Resuscitation (Anesthesia) bag is used on what type of patients? Answer- Neonates When does a Flow-Inflating Resuscitation (Anesthesia) bag inflate? Answer- When the gas source is turned on and opening of bag is seal (Mask placed tightly on neonates face) When would you instill medication down an Intubation tube? Answer- If no IV access is avaliable When administering medication down the ET tube, you must? Answer- - Double the normal IV dose - Flush with 10mL of saline - Hyperventilate for 30 seconds What does the acronym VANE stand for? Answer- V = Valium/versed = Sedative A = Atropine = Bradycardia N = Narcan = Narcotic Overdose E = Epinephrine = Asystole Why would a patient have a less effective cough with an ET tube in? Answer- It is holding the glottis open (glottis needs to close and contract when we cough) How do you measure mmHg vs cmH2O when determining cuff inflation? Answer- mmHg = Pressure Manometer cmH2O = Cufflator What is the most serious complication of Intubation with an ET tube? Answer- Laryngospasm What is a Laryngospasm? Answer- Spasm of the Larynx (Vocal cords) What should cuff pressure be inflated to? Answer- 20-25 mmHg 25-35 cmH2O What does a rapid sequence intubation mean? Answer- You do NOT know the last time the patient ate something What items are needed for an intubation? Answer- - Neuromuscular blocking agent (Succinylcholine) - Hyperoxygenation before and after (2 minutes) What is the purpose of a Double-Lumen endotracheal tube (DLT)/Endobronchial tube/Carlens tube? Answer- Independent unilateral lung ventilation When is a Double-Lumen endotracheal tube (DLT)/Endobronchial tube/Carlens tube used? Answer- - Lung Abscess - Surgery (Pneumonectomy, esophageal resection, aortic aneurysm repair) - Bronchopleural fistulas If someone is persistently bleeding during surgery, what tube would we use? Answer- Double-Lumen endotracheal tube (DLT)/Endobronchial tube/Carlens tube What is the purpose of an Esophageal Tracheal Combitube? Answer- Pre-hospital emergency airway management (If one port is blocked or you do not hear breath sounds, use the other port) Esophageal Tracheal Combitube is only used for what? Answer- Short term emergencies (Want to pull and put in Et tube ASAP) Laryngeal Mask Airway (LMA) has what advantages? Answer- - Size 6 ET tube can be inserted directly through the LMA into the trachea - Can NOT cause VAPS because above the vocal cords - Emergency situations when trauma to the face or nasal route has happened What is the main purpose of the Laryngeal Mask Airway (LMA)? Answer- Short term ventilation for face or nasal trauma King LT is another type of what tube? Answer- Supraglottic Airway (Want to pull ASAP and insert ET tube) What is the purpose of an Airway exchange catheter/Gum Elastic Bougie? Answer- To replace damaged ET tubes A patient can not _______ through a Gum Elastic Bougie? Answer- Oxygenate or Ventilate (Only used to change damaged ET tubes) How do you perform an Extubation? Answer- - Suction airway above and below the cuff - Deflate the cuff (Listen for leak) - Have the patient inhale deeply - Remove tube at peak inspiration to prevent vocal cord damage - Give O2 and humidity as indicated (Vocal cord is open during inhalation) If a patient is extubated then has Marked inspiratory stridor or Severe Respiratory distress, what should you do? Answer- Reintubate the patient ASAP What is the preferred method of providing an airway for patients who require long term ventialtion? Answer- Tracheostomy At what day should you give a Ventilator patient a Tracheostomy according to the NBRC? Answer- 8 days Why is a Tracheostomy used compared to a ET tube for long term ventilation? Answer- - Fewer hazards - Less RAW (Airway resistance) What are some immediate (Within 24hrs) complications from a Tracheostomy? Answer- - Bleeding (Major hazard) - Pneumothorax - Air embolism - Subcutaneous Emphysema What are some late (After 24hrs) complications from a Tracheostomy? Answer- - Infection - Hemorrhage (Tracheoinnominate artery fistula) - Obstruction - Tracheo-Esophageal (T-E) fistula When should the cuff to a Tracheostomy tube be inflated? Answer- - Patient is eating - Positive pressure ventilation (To prevent aspirations) When should a stoma be close? Answer- Never, it will either shut by itself or not (NEVER SUTURE A STOMA) If a tracheostomy is obstructed what should you do first? Answer- Remove the inner cannula Fenestrated tubing means? Answer- It is a hole in tube in case of obstruction If a patient can not tolerate a Passy Meir, what tube can be used? Answer- Fenestrated tube What are the types of Tracheostomy tubes? Answer- - Standard Tracheostomy tube - Fenestrated Tube - Tracheal Button - Extended Tracheostomy Tube - Jackson Trach tube - Foam Cuff (Kamen-Wilkinson, Bivona) - Tracheal Speaking devices (Passy Meir/Kisner Valve) Purpose of Tracheal Button? Answer- - To maintain stoma (Keep it open) - Used in some patients with OSA (Obstructive sleep apnea) Disadvantage of tracheal button? Answer- Uncuffed = can NOT use for resuscitation (Need to use ET tube) Purpose of Extended Tracheostomy tubes? Answer- Designed to accommodate variation in the distance from the skin to the trachea Silver is used because it is a? Answer- Natural Anti microbial (Microbes have a hard time forming on it) Jackson trach tube is made of? Answer- Metal (Silver) Disadvantages to a Jackson Trach tube? Answer- - No cuff - Not for resuscitation or Positive Pressure Ventilation How does a Foam cuff (Kamen-Wilkinson, Bivona) Trach tube work? Answer- Pilot tube is left open to the atmosphere and foam expands to seal trachea When using a speaking valve for a trach patient, what must always be done? Answer- Cuff MUST be deflated What do you clean the inner cannula with? Answer- Hydrogen peroxide and sterile water If a patient has a Laryngectomy (Removal of vocal cords), how long will the tube be in and what happens afterwards? Answer- 3-6 week, when tube is removed there will be permanent stoma Laryngectomy tubes do NOT have what? Answer- Inflatable cuff You can NOT replace a Laryngectomy tube with a Trachea tube, you must use what? Answer- Endotracheal Tube What is the most serious complications of suctioning a patient? Answer- Hypoxemia (leads to Tachycardia) What are the routes for suctioning? Answer- - Endotracheal - Nasotracheal - Oropharyngeal What device do we use to suction infants? Answer- Bulb syringe What kind of Ventilator is the Mark 7? Answer- - Pneumatically powered - Pressure cycled (Set a pressure and once it is reached it cycles into exhalation) If there is loss of pressure when using an IPPB what is the issue? Answer- - Leak - Insufficient flow If there is Excessive pressure when using an IPPB what is the issue? Answer- - Obstruction - Excessive flow If it fails to cycle into inspiration when using an IPPB what is the issue? Answer- - Adjust sensitivity - Tight seal around mouthpiece If it fails to cycle off when using an IPPB what is the issue? Answer- - Mouthpiece/Mask seal - Cuff leaking - Fenestrated trach tube open - Loose equipment connection What is the purpose of Bronchial Hygiene Therapy? Answer- Improve mobilization of secretions (Prevent accumulation of secretions) What types of patients use Bronchial Hygiene therapy the most? Answer- - Cystic Fibrosis - Bronchiectasis What are some hazards/contraindications for Bronchial hygiene therapy? Answer- - Unstable cardiovascular system - Unstable pulmonary system - Unstable post-operative status - Untreated tuberculosis Good lung is always placed down unless? Answer- Lateral Decubitus is performed Postural Drainage Positions: - Flat - Down 15° - Down 30° What is being drained? Answer- Flat = Upper lobes Down 15° = Middle lobes Down 30° = Lower lobes What is the purpose of chest percussion? Answer- Mechanically dislodge secretions What is the absolute contraindication for chest percussion? Answer- Tension pneumothorax What is the purpose of Vibration for patients? Answer- To move secretions to larger airways When is Vibration performed? Answer- On Exhalation ONLY What are the cough control techniques? Answer- - Serial Coughs - Huff Coughing - Splinting - Quad Cough What is Serial Coughs? Answer- Small breath and cough then large breath and cough then deep breath and hard cough What is Huff coughing? Answer- coughing with an open glottis ( More effective in patients with COPD or head trauma to prevent increased intracranial Pressures (ICP)) What is Splinting? Answer- Press pillow over incised area to enhance better cough (Used for Post op patients mostly) What is Quad coughing? Answer- Therapist applies pressure to the patients abdomen during exhalation How does a Positive expiratory pressure (PEP) therapy work? Answer- One way inspiratory valve and a one way expiratory flow resistor are used Expiratory flow resistor prevents end-expiratory pressures from falling to zero What should the expiratory pressure range from? Answer- 10-20 cmH2O mid exhalation What are some names for PEP therapy devices? Answer- - Flutter valve - Acapella - Quake (Great for post op patients) What is Autogenic Drainage? Answer- Breathing exercises utilized to improve mucus clearance What is another name for External Percussive devices? Answer- High Frequency Chest Wall Compression Devices (HFCWCD) (The vest) What is the therapeutic range for HFCWO (Vest)? Answer- 5-25 Hz (300-1500 cycles min) 30 minutes (1-6 times a day) What does IPV stand for? Answer- Intrapulmonary percussive ventilation How does IPV work? Answer- Combination of high frequency pulse delivery (100- 250 cycles/min) of a sub-tidal volume and a dense aerosol (percussive effect of gas delivery improves ventilation past obstructions in the airway) Advantage of IPV? Answer- Can be administered to patients who are unconscious or cannot follow directions (Use Mask on the patient) Insufflation/Exsufflation devices are also known as? Answer- Manually Assisted Coughing (MAC) When would you use a Insufflation/Exsufflation device? Answer- Patients with neurological problems or muscles weakness to force them to cough How does a Manually Assisted Coughing (MAC) device work? Answer- Attach to mask/ET tube/Trach Deliver deep inspiration by positive pressure followed by 1-2 second breath hold then negative pressure exsufflation to create a cough 44mg/L at 37C is known as? Answer- Water Vapor Content 47 mmHg is known as? Answer- Water Vapor Pressure When is a bubble humidifier most commonly used? Answer- Anytime flow greater than 4 L/min (Low flow device) If a whistling noise is heard from a Bubble Humidifier, what can the problem be? Answer- - Oxygen flow is excessively high - Obstruction or kink in tubing If the jabber (Spike in the plastic spin on top) does not pierce or make a hole in the plastic, what can happen? Answer- The pop off alarm would not sound properly (Clogged inlet) What is the advantage vs disadvantage of a DPI? Answer- Advantage: Medications are in powdered form and do not require propellant Disadvantage: Have to be able to suck in hard enough for it to work properly Always change from SVN to ____ and _____ if possible? Answer- MDI or DPI What is the desired FiO2 for COPD patients? Answer- 24%-28% 1-2 L What is the therapeutic oxygen range? Answer- 30%-60% Nasal Cannula can deliver how much flow and at what % FiO2? Answer- Flow = 1-6 Lpm FiO2 = 0.24-0.45 What is the best rule to determine Liter flow on a nasal cannula? Answer- 1 L = 24% 2L = 28% 3L - 32% 4L = 36% 5L = 40% 6L = 44% Simple Mask can deliver how much flow and at what % FiO2? Answer- Flow = 6-10 Lpm FiO2 = 0.40-0.55 (Flow must be at least 6Lpm to flush out exhaled CO2) Partial Rebreather Mask can deliver how much flow and at what % FiO2? Answer- Flow = 6-10 Lpm FiO2 = 0.60-0.65 (Has no one way flap valves) What are the low flow devices? Answer- - Nasal Cannula - Simple mask - Partial Rebreather Non-Rebreather Mask can deliver at what % FiO2? Answer- 0.21-1.0 If the bag collapses on a Non-Rebreather, what should you do? Answer- Increase the flow If the patient inhales and the bag does not slightly contract when using a Non- Rebreather, what should you do? Answer- - Mask is not tight so seal it better - Non-Rebreather valve is stuck so replace the mask T-Piece (Briggs Adapter) can deliver how much FiO2 %? Answer- 0.21-1.0 If aerosol disappears while using a T-piece, what can you do? Answer- - Increase the flow - Add more reservoir tubing - Setup a device to provide more flow (Blender, Tandem setup, change flowmeter) When using an Aerosol Mask, Trach Collar, and Face tent, room air will not enter the devices exhalation ports as long as the devices flow _______ the patients inspiratory flow? Answer- Exceeds (> 40L/min) High flow nasal cannula can deliver flow rates up to _____ and almost ______ humidity? Answer- 40 L/min 100% body humidity Why is it important to make sure we use humidity when either a patient complains of dry nose or over 4Lpm? Answer- It can cause Epistaxis (Nose bleeds) When using an Oxygen hood for an infant, what flow range do we use and why? Answer- 7-14 Lpm to prevent CO2 buildup and maintain FiO2 without sealing the infants neck around the hood What is the preferred method for analyzing O2 when using an Oxygen hood? Answer- Continuously monitor the O2 near the infants Face What is the advance of using an Isolette (Incubator) Answer- Temperature control will maintain a neutrothermal environment (Constant temperature maintained) Before attaching a regulator, what should you do to the cylinder valve? Answer- Open the cylinder valve slowly to discharge gas then close (This cracking of the tank valve prevents debris from entering the regulator) What is the location called where a flow meter is inserted? Answer- Zone Valve What is the duration of flow equation? Answer- Tank Factor X PSI/Lpm Example: E cylinder = 0.28 PSI = 2200 Flow = 10 0.28 X 2200 = 616 616/10 = 61.6 61.6 = 1 hour and 1 minute (Could also divide 61.6/60 to get the answer in minutes) What are the Tank factors? Answer- D = 0.16 E = 0.28 H/K = 3.14 What is the Total Flow equation? Answer- Total Flow = 100-FiO2/FiO2-21 Example: FiO2 = 28% Flow = 5 Lpm 100-28/28-21 = 72/7 72/7 = 10.2 10/1 = Air to O2 ratio (For every 10 parts air, there is 1 part O2) 10/1 = 11 11 x Flow 11 x 5 = 55 Lpm A patient requires a total flow of 45Lpm, What flowrate should the therapist select if the dilution control is set to deliver 40% Oxygen? Answer- O2 flow = Total flow/Factor O2 Flow = 45/4 = 11.25 Lpm What are the FiO2 Air to oxygen ratios for .28, .40,and .60? Answer- .28 = 10:1 = 11 Factor .40 = 3:1 = 4 Factor .60 = 1:1 = 2 Factor What is the accuracy precision on Air-Oxygen Proportioners (Blenders)? Answer- +/- 3% What is another name for the Oxygen Analzyers? Answer- Galvanic Fuel Cell Polargraphic Clark Oxygen Analzyers (Galvanic Fuel Cells) are affected by what? Answer- - Water on the sensor - High System pressures - Changes in Altitude What does Intravenous infusion mean? Answer- Used to administer medications or blood products or supplemental nutrition and fluids continuously to patients Where can Intravenous infusion be performed? Answer- Any central Vein: - Femoral - Jugular - Subclavian Vessel - Peripheral Vessels Where is the most commonly used Intravenous infusion performed? Answer- In the peripheral vessels of the hand or arm What is the Alveolar Air equation? Answer- PAO2 = ( Pb - pH20 ) FiO2 - PaCO2/RQ What is the purpose of the Alveolar Air equation? Answer- Calculates the partial pressure of oxygen (PO2) in the alveoli What is the equation for the Respiratory Quotient (RQ)? Answer- VCO2/VO2 Usually 200/250 = 0.8 CO2 vs O2 consumption What is another term for Respiratory Quotient? Answer- Respiratory Exchange Ratio If WBC increase when a patient has a line in, what should you check for? Answer- Suspected infection What is the formula for the A-a Gradient? Answer- PAO2-PaO2 What are the interpretation values for PF ratio vs A-a gradient? Answer- PF ratio: > 380 = normal 200-380 = VQ < 200 = Shunting A-a gradient: 25-65 = Normal 66-300 = VQ > 300 = Shunting How do we treat VQ mismatch vs Shunting? Answer- VQ = Give O2 Shunting = PEEP When using the PF ratio, what values define Normal, ALI, ARDS? Answer- Normal = 380 ALI = < 300 ARDS = < 200 What is the PF ratio equation? Answer- PaO2/FiO2 What is the Arterial Oxygen Content Equation? Answer- CaO2 = (Hb x 1.34 x SaO2) + (PaO2 x 0.003) What is a normal CaO2? Answer- 17-20 Vol % (mL/dL) What is a normal CvO2? Answer- 12-16 Vol% (14 Vol%) How are CvO2 and SvO2 affected when Cardiac Output is Decrease? Answer- CvO2 ↓ = CO ↓ SvO2 ↓ = CO ↓ What is the equation for Arterial-Venous Oxygen Content Difference? Answer- C(a- v)O2 = CaO2 - CvO2 What is a normal C(a-v)O2? Answer- 4-5 Vol % What is the purpose of the Arterial-Venous Oxygen Content Difference (C(a-v)O2)? Answer- To measure oxygen consumption of the tissues C(a-v)O2 will increase if? Answer- - CvO2 is ↓ - CO ↓ - Too much PEEP What is the modified Fick Equation? Answer- CO = VO2/C(a-v)O2 x10 How can the modified Fick equation be rearranged to find O2 consumption? Answer- VO2 = CO x C(a-v)O2 x 10 What equations can be used to set minimum flow for ventilator patient? Answer- TV x RR x (I + E) or MV x (I + E) What is the shunt equation? Answer- Qs/Qt = (A-aDO2)(0.003) / C(a-v)O2 + (A- aDO2)(0.003) What is a normal shunt value? Answer- 3-5 % What is the shortcut for the shunt equation to determine % shunt? Answer- A-a gradient, for each 100 Torr add 5% then add 5% for normal anatomical shunt Example: A-aDO2 = 300 torr C(a-v)O2 = 3.6 Vol % 300 torr = 15% shunt + 5 % anatomical shunt = 20% shunt What is the purpose of SaO2? Answer- Percentage of hemoglobin that is bound by oxygen What is the best way to measure SaO2? Answer- Hemoximeter How can you estimate PaO2 vs SaO2? Answer- 4,5,6,7,8,9 rules PaO2: 40 50 60 SaO2: 70 80 90 (Remember "P" (PaO2) comes before "S" (SaO2) in the alphabet) What is the equation for Oxygen index? Answer- Paw x FiO2/PaO2 x 100 Example: Mean airway pressure = 35 cmH20 FiO2 = 70% Goal PaO2 = 80 torr 35 x .70/80 x 100 = 0.31 x 100 = 31 What is a normal value for Oxygen index Answer- OI = < 10 What is the purpose of the Oxygen Index? Answer- To measure the amount of ventilatory support required to support the level of oxygenation When should you recommend ECMO for infants based on Oxygen Index (OI) values? Answer- ECMO recommended for newborns with OI > 40 What is the formula for Deadspace to Tidal Volume Ratio? Answer- VD/VT = PaCO2-PECO2/PaCO2 x 100 What is a normal Deadspace to Tidal Volume Ratio? Answer- 20-40% What does a Pneumotachometer do? Answer- Measures flow and converts to a volume Wright respirometer is a form of a what device? Answer- Pneumotachometer What are the normal Peak Expiratory Flow rate ranges? Answer- 80-100% = Green 50-79% = Yellow < 50% = Red What is a normal PEFR? Answer- 10 L/sec or 600 L/min Thoracic gas volume is another term that also means? Answer- FRC (Functional Residual Capacity) A Body Box (Plethysmography) uses what law? Answer- Boyles Law What is boyles law? Answer- P1V1 = P2V2 (Temperature is always constant) (Boyle = Temperature his name sounds like boiling, which is a great way to remember temperature is always constant) What can be used to calibrate a body box? Answer- - Mouth pressure transducer (Water or mercury barometer) - Box pressure transducer (Sine wave rotary pump) What should the quality control for the body box be in what range? Answer- +/- 5% of the volume of the lung model How is quality control performed for a Body box? Answer- Isothermal Lung model used with the following items: - Glass bottle - Rubber stopper - Mouthpiece connection - Rubber squeeze bulb What should the Body box be calibrated with each day and in what range? Answer- 3L super syringe Accuracy +/-3.5% (2.895-3.105 L) Flow calibration is calibrated using a? Answer- Rotameter The Helium Analyzer uses what device inside of it? Answer- Wheatstone bridge When calibrating a Helium Analyzer you should use a multi-point precise gas concertation to establish? Answer- Linearity (Straight line of dots plotted) Nitrogen Analyzer is calibrated how? Answer- Calibrate to 0 with 100% Oxygen (0% N2) and a known concentration CO2/CO/CH4 (Methane) analyzers are calibrated how? Answer- Calibrate to room air (0%) and known concentration (0.3% CO) then re-zero Is a CO2/CO/CH4 (Methane) analyzer affected by partial pressure in altitude? Answer- No A water manometer or barometer is used to measure? Answer- Pressure (Atmospheric) MIP/MEP devices are used to measure? Answer- Maximum pressures (Readiness to wean in ventilator patients) What is a normal MIP? Answer- 80 cmH20 < 20 cmH20 = inspiratory muscle weakness What is MEP used for? Answer- To see if patient has the ability to maintain an airway and clear secretions (Ability to cough effectively) What is a normal MEP? Answer- 160 cmH20 < 40 cmH20 = poor ability to clear airway secretions Max inspiration followed by max exhalation without force is known as? Answer- Slow Vital Capacity Decreased Vital capacity is the best indicator for? Answer- Restrictive lung disease If FVC is smaller than SVC it indicates? Answer- Obstructive Disease FEV1/FVC vs FVC determines? Answer- FEV1/FVC = Obstructive FVC = Restrictive Forced Expiratory flow 200-1200 FEF shows? Answer- Large airway obstructions - Tumors - Vocal cord paralysis Forced Expiratory Flow 25%-75% FEF shows? Answer- Small airway obstructions - Asthma - COPD Pre and Post bronchodilator therapy should have an increase in FEV1 by _____% or ______mL to show obstruction is reversible? Answer- FEV1 = 12% increase or increase of 200 mL On a flow volume loop the inspiratory vs expiratory flow goes in which direction? Answer- Expiratory is above base line Inspiratory is below base line By looking at the shape of a flow volume loop what can be determine by these: - Skinny - Concave - Egg shaped Answer- Skinny = Restrictive Concave = Obstructive Egg shaped = Obstruction What are the Restrictive Values to interpret PFT's? Answer- > 80% = Normal 79-70 = Mild 60-69 = Moderate 50-59 = Moderate Severe 35-50 = Severe < 35 = Very Severe What are the Obstructive Values to interpret PFT's? Answer- > 70% = Normal 60-69 = Mild 50-59 = Moderate 35-50 = Severe < 35 = Very Severe SVC maneuver should be at least ________ Seconds? Answer- 6 seconds SVC should be performed how for quality assurance? Answer- - 3 acceptable attempts - 6 seconds minimum FVC should be performed how for quality assurance? Answer- - 3 acceptable attempts - Not differ more than 5% or 200mL How do you determine the best test from a FVC manuever? Answer- whichever test has the largest FVC + FEV1 sum Spirometer are used to measure? Answer- Volumes What is the minimum amount of volume a spirometer must be able to measure? Answer- 8 Liters How long should Pneumotachometers be able to measure SVC, FVC, FEV1? (Flows) Answer- SVC = 30 seconds FVC = 14 seconds What is administered during a Bronchoscopy to control cough/gag reflex? Answer- Topical Anesthetic: - Lidocaine - Benzocaine - Cetacaine - Novocaine "Caines" = numbing agent What is a bad side affect of using topical anesthetics that end in "Caine"? Answer- They raise MetHb Levels What are some common sedatives used? Answer- - Midazolam (Versed) - Diazepam (Valium) - Lorazepam (Ativan) "Lam/Pam" (The drugs that make people not care about what is being performed) What do we give for analgesic problems? Answer- Morphine (analgesic = Pain medications) If a sudden drop in HR is observed during a bronchoscopy, that means? Answer- Vagal nerve stimulation, too close to the carina What is the minimum size for a flexible bronchoscope for a ventilator patient? Answer- 8.0 mm ID What is the adaptor called that allows a patient to still receive positive pressure ventilation during a bronchoscopy? Answer- Bodai Adaptor What should the bronchoscope be put in after a procedure? Answer- Alkaline glutaraldehyde (Cidex) How long does it take to disinfect vs sterilize? Answer- Disinfect = 20 minutes Sterilize = 10 hours (Cidex for bronchoscope) What are the 4 primary variables during positive pressure mechanical ventialtion? Answer- - Trigger Variable - Control/Target Variable - Limit Variable - Cycling Variable What is the parameter that starts the inspiratory phase? Answer- Trigger Variable What are the 5 ways the Trigger Variable can be initiated? Answer- - Pressure - Flow - Volume - Time - Manual Which is preferred, Pressure or Flow triggering? Answer- Flow is preferred What is the limit variable? Answer- Maximum value that a variable can reach during inspiration Which primary variable creates a plateau? Answer- Limit Variable What is the biggest advantage of Volume cycled ventilation? Answer- Minute volume will remain constant to provide stable blood gases What is the biggest disadvantage of Volume cycled ventilation? Answer- Lung compliance or airway resistance worsen (PIP and PLP ↑) (May result in Barotrauma) What is the cycling variable used during IPPB? Answer- Pressure Cycled What is the cycling variable during pressure control ventilation? Answer- Time Cycled What are 3 types of breathes the Ventilator can be used with? Answer- - Spontaneous (All patient) - Mandatory Breath (Ventilator controls all) - Assisted (Patient initiates the breath then ventilator controls all) What do you set the following Ventilator alarms at: High Pressure Minimum Exhaled Volume Low pressure Answer- High Pressure = Set 10 cmH2O above PIP Minimum Exhaled Volume = Set 100 mL below exhaled TV Low Pressure = Set 10 cmH2O below PIP When troubleshooting a ventilator, you should always do what first? Answer- Provide manual ventilation then troubleshoot (Also start at the patient then go towards the machine) What are the 3 phases for Mechanical Ventilation? Answer- Phase 1: - Recommend/initiate Mechanical Ventilation - Recommend/initiate initial ventilator settings Phase 2: - Monitor the patient receiving mechanical ventilation - Recommend/initiate changes to the ventilator settings - Identify and correct problems with patient/ventilator Phase 3: - Assess patient's readiness for weaning - Implement weaning procedures - Monitor the patient during weaning What is the absolute indication for mechanical ventilation? Answer- Apnea What are the two main indications for mechanical ventilation besides apnea? Answer- - Acute ventilatory failure/Acute respiratory failure - Impending ventilatory failure What is a normal Vital Capacity (VC)? Answer- 65-75 mL/kg (10 x TV) What is an acceptable Vital Capacity (VC)? Answer- ≥ 10 mL/kg (2 x TV) What is a normal, acceptable, and unacceptable MIP? Answer- Normal = 80 cmH2O Acceptable = 20 cmH2O Unacceptable = < 20 cmH2O What is a normal, acceptable, and unacceptable Respiratory rate? Answer- Normal = 12-20 bpm Acceptable = 8-20 bpm Unacceptable = > 20 bpm or < 8 bpm What is a normal, acceptable, and unacceptable Spontaneous Tidal Volume (TV)? Answer- Normal = 5-8 mL/kg Acceptable = ≥ 5 mL/kg Unacceptable = < 5 mL/kg What is a normal, acceptable, and unacceptable Minute Ventilation (VE)? Answer- Normal = 5-6 L/min Acceptable = < 10 L/min Unacceptable = > 10 L/min What is a normal, acceptable, and unacceptable MEP? Answer- Normal = 160 cmH2O Acceptable = 40 cmH2O Unacceptable = < 40 cmH2O What is a normal, acceptable, and unacceptable VD/VT (Deadspace)? Answer- Normal = 20-40% What are some controls that directly affect Mean Airway Pressure (PAW)? Answer- - PIP - RR - I-time - PEEP (Most influence) - Peak flow - TV - Inflation Hold What has the largest influence on Mean Airway Pressure (PAW)? Answer- PEEP What does not affect Mean Airway Resistance at all? Answer- FiO2 What are normal Mean Airway Pressures for the following: - Patients with normal compliance and resistance - Patients with Obstructive Disease - Patients with ARDS Answer- Patients with normal compliance and resistance = 5- 10 cmH2O Patients with Obstructive Disease = 10-20 cmH2O Patients with ARDS = 15-30 cmH2O How is work of breathing calculated? Answer- Change in Pressure X change in Volume (ΔP x ΔV) What is a normal Work of breathing value? Answer- 0.5 +/- 0.2 Joules/L When is Inverse Ratio Ventilation (IRV) recommended for patients? Answer- - High FiO2 (>60%) - PEEP (>15 cmH2O) - High PIP (>50 cmH2O) - Low PaO2 with decreased compliance - PLP > 30 cmH2O What is the starting ratio for Inverse Ratio Ventilation (IRV)? Answer- 2:1 or greater What is another name for Airway Pressure Release Ventilation (APRV)? Answer- Bi-Level APRV must always be? Answer- Spontaneous What is Pressure Regulated Volume Control (PRVC)? Answer- A form of ventilation that keeps pressure at the lowest level by providing automatic breath-to-breath pressure regulation while providing a preset volume (Volume control) What are the 4 Inspiratory Flow patterns and what are they associated with? Answer- Constant (Square) (Volume) Decelerating (Pressure) Accelerating Sinusoidal (Spontaneous) What patient does decelerating inspiratory flow help with the most? Answer- COPD (Less air trapping) When is High Frequency Oscillatory Ventilation (HFOV) chosen or used? Answer- Last chance option 1 Hz is equal to how many cycles per minute? Answer- 1 Hz = 60 cycles per minute (1 cycle per second) Frequency and volume are ________ related? Answer- Inversely Frequency and I-time are _______ related? Answer- Inversely What is a normal respiratory rate in Hz for HFOV? Answer- 3-15 Hz What are the primary and secondary controls used during HFOV for: PaCO2 PaO2 Answer- Primary PaCO2: - Amplitude (Power, ΔP) Secondary PaCO2: - Frequency in Hz (Also affects I-time) (Lower the frequency the Higher the TV) Primary PaO2: - Mean Airway Pressure (PAW) If there is High PaCO2 during HFOV, how should you change the following: - Frequency - Amplitude - I-time Answer- Frequency = Decrease Amplitude = Increase I-time = Increase If there is Low PaO2 during HFOV, how should you change the following: - Mean Airway Pressure Answer- Mean Airway Pressure (PAW) = Increase What is the ARDSnet protocol? Answer- - TV = 8mL/kg IBW then reduce to 6 mL/kg IBW - Maintain PLP < 30 cmH2O - Consider Permissive hypercapnea and subsequent respiratory acidosis - Switch from VC to PC (Low compliance and high ventilation pressures) Purpose of a Recruitment Maneuver? Answer- To increase pressure in lungs to open as many collapsed alveoli as possible What is the most common setup for a Recruitment Maneuver? Answer- - Increase to high level of PEEP for short period of time - Increase PEEP to 40 cmH2O for 40 seconds - Increase CPAP o 20 cmH2O for 20 seconds (if not intubated) Prone positioning a patient may increase PaO2 by how much, and decrease shunting by how much? Answer- PaO2 increased by 10-50 torr Shunting decreased by 12-25% Prone positioning a patient should be considered for ARDS/ALI when? Answer- FiO2 60% and PEEP > 15 cmH2O or if Recruitment Maneuver has failed When Prone positioning a patient you should do this before and after due to transient oxygen desaturation and hemodynamic instability for a short time? Answer- Pre and Post hyperoxygenation What does Auto PEEP mean? Answer- Incomplete exhalation and air is trapped in the lungs (Insufficient Expiratory time) What are other terms also known as Auto PEEP? Answer- - Intrinsic PEEP - Occult PEEP - Dynamic Hyperinflation How can you tell the difference for spontaneous, Assisted, and Mandatory breathes with a graphic loop? Answer- Spontaneous = Oval shape on both sides of volume line Assisted = Jesus fish Mandatory = Oval shape all above 0 on pressure line What is the purpose of the inflection point? Answer- Critical opening pressure to inflate alveoli (Set PEEP here) Over distention looks like what on a graphic loop? Answer- Bird beak Not enough PEEP looks like what on a graphic loop? Answer- Flat line across bottom of oval on pressure line (Point should just touch pressure line to make an oval) What are some usual causes of irreversible ventilator dependence? Answer- - High spinal cord injury - ALS (Lou Gehrig Disease) When should NIPPV be used over a ventilator if possible? Answer- - Acute exacerbation of chronic respiratory failure (COPD) - CHF/Pulmonary Edema - DNI/ DNR What are some advantages of NIPPV? Answer- - Avoids Ventilator associated pneumonia (VAP) - Avoids complications of artificial airway - Avoids complications of mechanical ventilation What are the initial settings for BiPAP? Answer- IPAP = 8-12 cmH2O EPAP = 4-6 cmH2O 10/5 = average How do you fix a Ventilation problem on BiPAP? Answer- Increase IPAP How do you fix an Oxygenation issue on BiPAP? Answer- Increase IPAP and EPAP IPAP vs EPAP? Answer- IPAP = Ventilation EPAP = Oxygenation Purpose of Hyperbaric Oxygen Therapy (HBO)? Answer- To increase the PaO2 by increasing the barometric pressure Most HBO is conducted between _____ to _____ ATM? Answer- 2-3 atmosphere (Chamber can go between 2-6 ATM) What are the two concentrations of Heliox used? Answer- 80% He / 20% O2 = 1.8 70% He / 30 % O2 = 1.6 How do you calculate actual flow? Answer- Actual flow = Indicated flow X Factor Example: Indicated flow = 10 Lpm Factor = 1.8 10 x 1.8 = 18 Lpm Nitric Oxide is used as a? Answer- Pulmonary Vasodilator Advantage of Nitric Oxide? Answer- Only affects pulmonary Blood pressure and not systemic Indications for Inhaled Nitric Oxide? Answer- - Pulmonary Hypertension - Refractory Hypoxemia related to increased PAP - Increased PVR - Cor pulmonale/RHF What is the standard dosage of Nitric Oxide? Answer- 20-40 ppm (DO NOT EXCEED 80ppm) What are some side affects of Nitric Oxide? Answer- - MetHb Increases - Nitrogen Dioxide (NO2) increase and are toxic to the body (> 10 ppm = toxic) - Rebound pulmonary hypertension (Occurs when Nitric Oxide is discontinued too rapidly) What should you do before with drawing Nitric Oxide? Answer- Hyperoxygenate the patient What is the most common pleural disorder that requires a thoracentesis? Answer- Pleural Effusion Where do you insert a large bore needle for a thoracentesis? Answer- 7th-8th ICS above the rib at maximal sight of dullness (Make sure to use local anesthetic (lidocaine) before) What is the normal range for diagnostic fluid aspirated from a pleural effusion? Answer- 100 mL - 300 mL (Performed with a 50 mL syringe) Transudate fluid is associated with what patient? Answer- Congestive Heart Failure (CHF) What does transudate fluid look like? Answer- Clear and has a light straw color What is another name for transudate fluid? Answer- Serous fluid Exudate is defined how? Answer- pH = < 7.30 Pleural fluid protein to serum protein = > 0.5 Loculated/Very thick What type of patient can show Exudate? Answer- - Emphyema/pyothorax - Bloody effusions (Hemothorax) - Purulent (Pus) - Chyle (Lymphatic exudative fluid) What are the 3 types of sleep apnea disorders and how are they defined? Answer- - Obstructive Sleep Apnea (OSA) = apnea due to blockage of upper airway - Central Sleep Apnea (CSA) = Apnea due to loss of ventilation effort - Mixed Sleep Apnea = Combination of Central and Obstructive types Inductive plethysmography is also known as? Answer- Chest motion (Bands that go on chest to detect movement) What parameters are monitored during a sleep study? Answer- - Inductive Plethysmography - Nasal Air flow - Pulse oximetry - Number of Apnea (Cessation of breathing) - Number of Hypopneas (Shallow or slow breathing) How do you calculate the Apnea Hypopnea Index (AHI)? Answer- Apneas + Hypopneas / Hours of sleep What are the values for Mild, Moderate, and Severe for the Apnea Hypopnea Index (AHI)? Answer- Mild = 5-15 Moderate = 16-30 Severe = > 30 Central Sleep Apnea vs Obstructive Sleep Apnea? Answer- CSA = No Effort with decreased Nasal Flow OSA = Effort with decreased Nasal Flow What PEEP level is the start for being considered High pressure? Answer- 15 PEEP What should CPAP therapy be started at? Answer- 3-5 cmH2O When should a patient be switched from CPAP to BiPAP? Answer- - They can NOT tolerate high pressures on CPAP - They are continued Obstructive respiratory events when CPAP reaches 15 cmH2O If a patient has a 20 pound weight gain or loss since starting CPAP/BiPAP, what must be done? Answer- Update the pressures needed currently (If they weigh less it could require less pressure) When is supplemental oxygen added to a patient in a sleep study? Answer- - SpO2 ≤ 88% while in the supine position breathing room air (Should start at 1 L and be titrated by 1 L increments until SpO2 > 90% What is a pneumothorax? Answer- Air in the pleural space with little or no fluid If a pneumothorax is < 10% do we need to fix it? Answer- Not until 20% or greater, because it could fix itself What is the advantage the Mini-BAL procedure has? Answer- It utilizes a protected catheter to prevent specimen contamination When is an Infant Apnea Monitor indicated? Answer- - If an infant may be at risk of periods of apnea > 20 seconds - One or more ALTE - SIDS (Sudden infant death syndrome) - Preterm infants with significant apnea periods - Snoring in infants ALTE stands for? Answer- Apparent Life-Threatening Event When an infant is sent home while needing an apnea monitor, the parents must know? Answer- CPR When can you discontinue an apnea monitor for infants? Answer- - 2 months free of events - No monitor alarms on apnea settings > 20 seconds and heart rate < 60 bpm When is Cardioversion indicated? Answer- - Non-life threatening arrhythmias - Unstable A-fib - Unstable A-Flutter - Stable Ventricular Tachycardia How do you know if a patient is unstable? Answer- They are symptomatic Cardioversion is delivered at: - Joules - Synchronized Switch - Delivered when Answer- Cardioversion: - 50-100, then 200 if unsuccessful J (Monophasic) - Synchronized to R wave (ON) (Usually atrial issues) When is Defibrillation indicated? Answer- - Pulseless Ventricular Tachycardia - Ventricular Fibrillation Defibrillation is delivered at: - Joules - Synchronized Switch - Delivered when Answer- Defibrillation: - 360J - Ventricular Problems - Unsynchronized (OFF) When is a Automated External Defibrillator (AED) indicated? Answer- ONLY when a patient has the following: - No response - No breathing - No pulse Intra-Hospital transport vs Inter-Hospital Transport? Answer- Intra-Hospital = In the hospital Inter-Hospital = Between Hospitals (For different levels of care/Different types of equipment at certain hospitals) How do you determine if a patient needs, Ambulance, Helicopter, Fixed Wing Aircraft? Answer- Ambulance = 0-80 miles Helicopter = 81-150 miles Fixed Wing Aircraft = > 150 miles How will oxygen partial pressure be affected even if an aircraft has a pressurized or non-pressurized cabin? Answer- It will decrease Cuff pressures and Volume vary with? Answer- Changes in altitude What is the equation for the respiratory Quotient? Answer- RQ = VCO2/VO2 CO2 consumed to Oxygen consumed (Normal is usually 200mL/250 mL = 0.8) What is a normal range for Respiratory Quotient? Answer- 0.67-1.3 How do Carbohydrates, Fats, and Proteins affect the Respiratory Quotient? Answer- Carbohydrates = 1.00 Fats = 0.71 Proteins = 0.82 (In general, molecules that are more oxidized (e.g., glucose) require less oxygen to be fully metabolized and, therefore, have higher respiratory quotients. Conversely, molecules that are less oxidized (e.g., fatty acids) require more oxygen for their complete metabolism and have lower respiratory quotients.) (The ratio of carbon dioxide output to oxygen usage is called the respiratory quotient, so the respiratory quotient for carbohydrates is 1.0.) (Diet high in carbohydrates would produce excess CO2 which would Increase the Work of breathing) What is indirect Calorimetry? Answer- Method of calculating resting energy expenditure (REE) by measuring the whole body VO2 and VCO2 How is Indirect calorimetry performed? Answer- Gas exchange measurements are obtained over 15-30 minutes and extrapolated to 24 hours Respiratory Quotient > 1.1 vs < 0.7? Answer- > 1.1 = Over feeding < 0.7 = Under feeding Total daily energy expenditure (TEE) is equivalent to? Answer- Resting energy expenditure (REE) in normal patients In hypermetabolic patients the _____ can be up to _____% higher than extrapolated _____? Answer- In hypermetabolic patients the TEE can be up to 40% higher than extrapolated REE? Palliative care means? Answer- Comfort measurement to control pain and other symptoms (Terminally ill Patients) Hospice care means? Answer- Comfort measurements to control pain or other symptoms without curative intent How do you perform an apnea test for brain death determination? Answer- - Disconnect patient from ventilator while administering 100% O2 and monitoring SpO2 - Observe patient for any chest/abdominal movement to produce adequate TV - Absence of respiratory effort supports diagnosis - Diagnosis is completely confirmed by cerebral perfusion scan (Cerebral angiogram) How do you treat tachypnea or dyspnea when withdrawing someone from life support? Answer- - Benzodiazepines - Barbiturates (or low dose morphine) When a patient is an organ donor how do we treat their body? Answer- Maintain: PaCO2 = 35-45 mmHg PaO2 > 100 mmHg SaO2 > 95% (Mainly all normal values with increased PaO2)