Airway Management

A patient who is conscious with an intact gag reflex requires an artificial airway solely to prevent obstruction of the upper airway by the tongue. Which of the following types of airways is most suitable in this situation? A.nasopharyngeal

B.Oropharyngeal

C.Orotracheal

D.tracheostomy tube

Oral & Nasal Airways

• Oral – unconscious– Beware of gagging and vomiting– Leave unsecured

• Nasopharyngeal – conscious– Change every 24 hours

A respiratory therapist is called to see a 59-year-old man who has been in a persistent vegetative state for several months after a stroke. He is diaphoretic and has a pulse of 120/min and an SpO2 of 81% with a 28% tracheostomy collar. The therapist is unable to pass a suction catheter. Which of the following should the therapist do immediately?

A.Replace the tracheostomy tube.

B.Increase suction pressure by 20%.

C.Increase the FIO2 to 1.0.

D.Activate the emergency response system.

Replace the trach tube when…

• Tube is obstructed– Cannot pass a catheter

• Tube is too small– High cuff pressures needed to seal the airway

• Punctured cuff– Unable to seal airway

A patient with neuromuscular disease has been receiving ventilatory support for 4 months through a tracheostomy. The patient is being weaned during the day, but is still receiving full ventilatory support at night. Which of the following devices will best meet both needs of this patient?

A.tracheostomy buttonB.Kistner tubeC.cuffed, fenestrated tracheostomy tubeD.uncuffed, standard tracheostomy tube

A patient is orally intubated with a size 8.0 mm ID endotracheal tube. The respiratory therapist uses a size 14 Fr suction catheter to suction the patient's airway. The vacuum is set on 120 mm Hg. The therapist notices the patient's secretions are thick and tenacious and will not aspirate through the suction catheter. Which of the following should the therapist do?

A.Use a size 16 Fr catheter.B.Instill saline into the endotracheal tube.C.Increase the vacuum setting to 160 mm Hg.D.Apply continuous suction to the patient's airway.

Suctioning

• Pressure– Adult:– Child:– Infant:– Neonate:

• Size– Catheter size = ID size x 3

2

100 – 150 mmHg

100 – 120 mmHg

80 – 100 mmHg

60 – 80 mmHg

Which of the following should a respiratory therapist check while preparing for a nasotracheal intubation procedure?   

I. integrity of the cuff

II. availability of McGill forceps

III. presence of a stylet in the tube

IV. availability of a water-based lubricant

A.I, II, and III only

B.I, II, and IV only

C.I, III, and IV only

D.II, III, and IV only

A 22-year-old woman with asthma was brought to the hospital by EMS after she was found unconscious from a heroin overdose. She was nasally intubated and is receiving mechanical ventilation. Naloxone (Narcan) was administered. Twenty-four hours later, the patient is awake, alert, and agitated. She is motioning that she wants the endotracheal tube removed. Which of the following should the respiratory therapist recommend?

A.Gradually reduce the level of ventilatory support.B.Extubate the patient.C.Sedate the patient.D.Change to noninvasive mechanical ventilation.

Five minutes after extubating a patient, the respiratory therapist observes marked stridor, labored breathing, intercostal retractions, and a decreasing SpO2. Aerosolized racemic epinephrine has been delivered without benefit. Which of the following should the therapist recommend at this time?

A.treatment with dexamethasone (Decadron)

B.manual ventilation with bag and mask

C.a cool aerosol treatment

D.reintubation

A patient receiving mechanical ventilation has a 7 mm ID, standard high-volume, low-pressure cuffed tracheostomy tube. It has become increasingly difficult to avoid a significant cuff leak. Cuff pressure monitoring reveals values in excess of 35 cm H2O. The respiratory therapist should recommend a

A.larger tracheostomy tube.

B.nasotracheal tube.

C.fenestrated tracheostomy tube.

D.tracheostomy button.

The respiratory therapist is assisting a surgeon performing a tracheotomy on a patient who is receiving pressure-controlled ventilation. The therapist notes increased heart rate, decreased exhaled tidal volume, and distant breath sounds over the right chest. This information is most indicative of a

A.circuit leak.B.right pneumothorax.C.mucus plug.D.mainstem intubation.

Tracheostomy

• Complications– Immediate (Procedure related)

• Bleeding, ptx, air embolism, subcutaneous emphysema

– Late• Infection, Hemorrhage, obstruction, T-E Fistula

• Keep cuff deflated unless…– Eating or on PPV

A patient's tracheostomy tube is being changed due to a cuff leak. After reconnecting the ventilator to the new tube, the high pressure alarm sounds, the patient's heart rate increases to 135/min, and he is cyanotic. Crepitus and swelling are evident around his neck and upper chest. To correct this situation, the respiratory therapist should

A.increase the cuff pressure until adequate ventilation can be achieved.

B.reinsert the tube and attempt to manually ventilate the patient.

C.obtain an arterial blood gas sample to assess oxygenation.

D.increase the pressure limit on the ventilator and set the FIO2 to 1.0.

Injection of 20 mL of air into the pilot line fails to inflate an endotracheal tube cuff prior to an emergent intubation. The respiratory therapist should

A.check the cuff for tears. B.check the valve on the pilot line. C.inject another 10 mL of air. D.replace the tube.

A hospitalized patient rapidly develops ventilatory failure because of an accidental overdose of morphine sulfate for pain control. The preferred way to quickly provide a safe, secure airway is to:A.Place an oropharyngeal airwayB.Hyperextend the patient’s neckC.Place a nasal endotracheal tubeD.Place an oral endotracheal tube

After a successful CPR attempt, a patient with an oral endotracheal tube is placed on a mechanical ventilator in the ICU. The RRT notices that the exhaled CO2 monitor is appropriately changing color with each breath cycle. The patient’s breath sounds are present on the right but diminished on the left side. What is the most likely cause of this situation?:A.Left-sided pneumothoraxB.Right bronchial intubationC.Malfunctioning CO2 monitorD.Delivered Vt is too small

A 2-year-old child admitted with severe croup has just been extubated after two days with an oral endotracheal tube. The child is given oxygen and aerosolized water through a large volume nebulizer. Thirty minutes later, mild inspiratory stridor is heard over the child’s throat. What should be done first?A.Deliver nebulized racemic epinephrineB.Reintubate the childC.Perform a cricothyrotomyD.Perform a tracheostomy

The respiratory therapist is supervising a respiratory care student for a clinical rotation in the ICU. The student assesses the cuff of an endotracheal tube to comply with the minimal leak techniques. Which of the following steps are included in this process?

I. Remove all of the air from the cuff. II. Inflate the cuff with air so no leak is heard at

the end of inspiration. III.Withdraw air from the cuff so a slight leak is

heard at the peak of inspiration. IV.Measure and record the cuff pressure.

A. I, II, and III only B. I, II, and IV only C. I, III, and IV only D. II, III, and IV only

When selecting an endotracheal tube, which of the following factors should the respiratory therapist consider to minimize airflow resistance?   

I. DiameterII.presence of a cuffIII.length of the tubeIV.composition of the tube

A. I and II only B. I and III only C. II and IV only D.III and IV only

An intubated and mechanically ventilated adult patient has been returned to the long-term care unit after being transported to the Radiology Department for an abdominal radiograph examination. The RRT observes that the patient’s trachea is midline. However, the patient’s left chest area does not rise with inspiration as much as the right chest area. The endotracheal tube is at the 28-cm mark at the patient’s teeth. What should be done now?

A.Check the abdominal radiograph for signs of vomiting and aspiration

B.Pull the endotracheal tube back about 4 cmC.Check the patient’s end-tidal CO2 levelD.Deliver a large tidal volume breath to inflate the

left lung better

Tube Depth

• Oral intubation– Approximately 21 – 25 cm

• Nasal intubation– Approximately 26 – 29 cm

Which of the following is the most significant factor leading to the development of tracheomalacia?

A.cuff pressure on the tracheal wall B.trauma during intubation C.intracuff volume D.tube length

Which of the following may be used to help determine the position of an endotracheal tube:

I. End-tidal carbon dioxide monitoringII. An esophageal detection device (EDD)III.Laryngeal palpation during tube insertionIV.Neck and chest radiographsV. Observation of bilateral chest movement

A. I, III, and IVB. II, IV, and VC. I, II, III, and VD. I, II, III, IV, and V

Esophageal Detectcion Device

• Attaches to the endotracheal tube post

intubation. Resistance when drawing back on the syringe-type plunger indicates esophageal placement. When properly placed, the rigidity of the trachea allows air flow and creates no resistance when drawing back.

The End

A respiratory therapist replaces a patient’s tracheostomy tube with another one of the same size and inflates the cuff with 5 mL as was done previously. Immediately the patient has difficulty breathing, and no air can be felt coming from the tube. What could be the problem?

A.The tip of the tube has been placed into the subcutaneous tissues

B.The patient has closed her esophagus over the trachea

C.More air must be added to the cuff to form a seal

D.The tube has been placed into the esophagus by accident

For which of the following is a tracheostomy button indicated?

A.to wean a patient from ventilatory support

B.to provide an artificial airway C.to provide an access for pharyngeal

suctioning D.to maintain the stoma

Which of the following is an indication for an oropharyngeal airway?

A.prevention of upper airway obstruction in an unconscious patient

B.prevention of aspiration in an unconscious patient

C.improvement of suctioning of the trachea

D.improvement of air flow in a conscious patient

A patient who had facial burns and smoke inhalation has recovered enough to be extubated. Although the patient is receiving 40% oxygen with a bland aerosol, significant inspiratory stridor is noticed within 15 minutes. After the inhalation of a vasoconstricting medication, the patient’s breath sounds are improved. Thirty minutes later, the patient’s SpO2 is 80%, and the inspiratory stridor is more serious. The patient is very anxious and is pulling off the oxygen mask. What should the RRT recommend to best manage the pateint’s problem?

A.Draw an arterial blood gas sampleB. Increase the pateitn’s oxygen to 50%C. Intubate the patientD.Administer a sedative medication

A conscious patient is recovering from Guillain-Barre syndrome and is able to breathe spontaneously off of the ventilator for several hours. She currently has a standard 7.5-mm ID tracheostomy tube. To help her weaning process but to enable her to be ventilated at night, what should be done?

A.Remove the tracheostomy tube when she is off the ventilator

B.Substitute a speaking-type tracheostomy tube C.Replace the current tracheostomy tube with

one that is 6.0-mm IDD.Substitute a fenestrated tracheostomy tube

A patient who is postoperative and is still under the effects of anesthesia is snoring loudly. The SpO 2 has been decreasing. The respiratory therapist repositions the patient's head but the problem persists. Which of the following devices would be the most appropriate to use next?

A.laryngeal mask airwayB.endotracheal tubeC.nasal cannula D.nasopharyngeal airway

A 55-year-old, 77-kg (170-lb) male patient has been returned from the OR with a fresh tracheostomy. The RRT determines the cuff pressure on the 6.0-mm ID tracheostomy tube to be 35 mmHg. The ventilator is delivering a tidal volume of 750 mL and returning a tidal volume of 650 mL, and a leak can be heard at the tracheostomy site. What should be done?

A. Increase the Vt by 100 mLB. Increase the cuff pressure to seal the trachea to

stop the leakC.Replace the tracheostomy tube with one that is

8.5-mm IDD.Deflate the cuff enough to reduce the pressure to

15 mmHg.

Shortly after the respiratory therapist caps a patient's tracheostomy tube, the patient appears agitated, and the respiratory rate and heart rate have increased. The SpO 2 has fallen from 97% to 93%. Which of the following should the therapist do first?

A.Ask the patient to speak. B.Inflate the pilot balloon of the

tracheostomy tube.C.Remove the tracheostomy and insert

another. D.Increase the F I O 2 .

A 59-kg (130-lb.) woman must be intubated to initiate mechanical ventilation. What size tube should be used?A.6.0-mm IDB.7.0-mm IDC.8.0-mm IDD.9.0-mm ID

• CRT C

• A spontaneously breathing patient vomits during an unsuccessful emergency intubation attempt. After turning the patient's head to the side, the respiratory therapist should immediately A.perform oropharyngeal suctioning.B.insert a nasogastric tube.C.manually ventilate with 100% oxygen.D.insert an oropharyngeal airway.EXPLANATIONS: (c) A. Immediate oropharyngeal suctioning is indicated to help facilitate airway clearance of vomitus residue prior to a re-intubation attempt. (u) B. The immediate response is to suction the oropharynx. (h) C. This is potentially harmful to the patient as vomitus could be reintroduced into the lungs during manual bag-mask ventilation. (u) D. This is not the immediate response but should be considered following suctioning.

• A patient's pulse drops from 82 to 40/min immediately after a suction catheter is inserted into the trachea and before suction is applied to the airway. Which of the following is the most probable cause? A.hypoxemiaB.vagal reflexC.mucosal traumaD.hypercapniaEXPLANATIONS: (u) A. Bradycardia usually develops gradually with prolonged hypoxemia. (c) B. Stimulation of vagal receptors in the tracheobronchial tree causes abrupt reflex slowing of the heart rate. (u) C. Mucosal trauma would result in bleeding and not a decrease in the heart rate. (u) D. Hypercapnia initially causes an increased respiratory rate.

• Which of the following activities must occur as part of tracheostomy decannulation in a 3-month-old infant?   I. Document airway patency during sleep and activity. II. Place progressively smaller tracheostomy tubes.III. Explain the procedure to the infant.IV. Verify the time of last feeding. A.I, II, and III onlyB.I, II, and IV onlyC.I, III, and IV onlyD.II, III, and IV onlyEXPLANATIONS:   I. True. The ability to ventilate adequately during sleep and periods of wakefulness must be assessed and documented.  II. True. The procedure for decannulation requires the placement of progressively smaller tubes during the weaning process. III. False. A 3-month-old infant lacks the cognitive ability to understand an explanation of the procedure. IV. True. The infant's stomach must be empty to minimize the risk of aspiration during the procedure. (u) A. Incomplete and incorrect response(c) B. Correct response(u) C. Incomplete and incorrect response(u) D. Incomplete and incorrect response

• A previously healthy 30-year-old patient is hospitalized with chills and fever. A chest radiograph is consistent with right upper lobe pneumonia. Which of the following is most likely to aid in the patient's management? A.in-exsufflationB.coached coughing and deep breathingC.bland aerosol therapyD.spirometry before and after a bronchodilatorEXPLANATIONS: (u) A. In-exsufflation is used for patients with excess secretions who have neuromuscular diseases. (c) B. Coached coughing and deep breathing will assist the patient with secretion removal and help open the consolidated area. (a) C. Bland aerosol therapy may be indicated if secretions were evident at this stage of the patient's disease. (u) D. Bronchospasm is not usually associated with pneumonia.

• A patient had a tracheostomy for several weeks and was recently weaned from ventilatory support. Which of the following devices will allow decannulation of the trachea and maintain the patency of the stoma? A.transtracheal catheterB.oropharyngeal airwayC.tracheostomy buttonD.laryngeal mask airway (LMA)EXPLANATIONS: (u) A. A transtracheal catheter will not maintain a tracheostomy stoma. (u) B. An oropharyngeal airway will not maintain a tracheostomy stoma. (c) C. A tracheostomy button maintains a stoma and allows decannulation of the trachea. (u) D. An LMA is used for short-term airway management.

• A respiratory therapist is called to the emergency department to assist in the selection and placement of an artificial airway in a patient currently being resuscitated during cardiac arrest. It is anticipated that continued ventilatory assistance will be required. Which of the following is the airway of choice in this situation? A.a tracheostomy button with IPPB adapterB.an oral endotracheal tubeC.a nasotracheal tubeD.a tracheostomy tubeEXPLANATIONS: (u) A. Placement of a tracheostomy button requires a surgical procedure and would not allow efficient use of positive pressure to affect ventilation. (c) B. Insertion of an oral endotracheal tube is the most direct and efficient approach to establish an artificial airway. (a) C. Although potentially more comfortable for the patient, placement of a nasotracheal tube is more time consuming and could produce trauma and bleeding, which might complicate further cardiac therapy, including anticoagulation or thrombolytic therapy. (u) D. A tracheostomy tube requires surgery and is unnecessary for short-term airway management under these circumstances.

• Following endotracheal intubation of a patient in the emergency department, which of the following should the respiratory therapist use to confirm proper tube placement? A.galvanic analyzerB.mass spectrometerC.colorimetric capnometerD.Severinghaus electrode EXPLANATIONS: (u) A. A galvanic analyzer is used to assess oxygen concentration. (u) B. A mass spectrometer is used in oxygen analysis via oximetry. (c) C. A colorimetric capnometer is used to confirm proper tube placement by assessment of alveolar end tidal CO2 concentration. (u) D. A Severinghaus electrode is used to analyze PCO2.

• Which of the following should the respiratory therapist use to collect a sputum specimen for culture and sensitivity from an intubated patient? A.Luken's trapB.Carlen's tubeC.Yankauer catheterD.Pleur-evacEXPLANATIONS: (c) A. A Luken's trap is designed to collect sputum during suctioning. (u) B. A Carlen's tube is a double-lumen endotracheal tube. (u) C. A Yankauer catheter is only used for oral secretions. (u) D. A Pleur-evac is used to evacuate a pleural effusion.

• The endotracheal tube cuff of a patient receiving mechanical ventilation is inflated to 40 cm H2O using the minimal leak technique. One hour later, peak inspiratory pressure is 20 cm H2O. Which of the following should the respiratory therapist expect to find during assessment? A.absent leak at peak inspiration B.audible air leak around the cuffC.tube in right mainstem bronchusD.tube in esophagusEXPLANATIONS: (c) A. A peak airway pressure of 20 cm H2O exerts less pressure against the cuff during inspiration so the leak diminishes or disappears. (u) B. Lower peak airway pressures would make a cuff leak less likely. (u) C. There is no evidence that the tube has migrated into the right mainstem bronchus. (u) D. There is no evidence that the tube has migrated into the esophagus.

• Administration of racemic epinephrine after extubation is preferred over albuterol (Proventil) to A.reduce bronchospasm.B.prevent the accumulation of secretions.C.stimulate alpha-receptors.D.elicit a potent beta2-response.EXPLANATIONS: (u) A. The most likely postextubation problem is mucosal edema and not bronchospasm. (u) B. Neither drug prevents accumulation of secretions. (c) C. Racemic epinephrine stimulates the alpha-receptors and albuterol (Proventil) does not. (u) D. The desired effect is an alpha-response to prevent mucosal edema.

• An adult patient who is intubated has copious secretions, but decreased amounts of mucus are passing through the suction catheter. Which of the following are appropriate to correct this problem?   I. increasing the vacuum level to 200 mm Hg II. instilling saline into the tubeIII. checking the patency of the catheterIV. selecting a larger suction catheter A.I, II, and III onlyB.I, II, and IV onlyC.I, III, and IV onlyD.II, III, and IV onlyEXPLANATIONS:   I. False. A 200 mm Hg vacuum level may be harmful to the patient.  II. True. Instilling saline may improve secretion motility. III. True. Assuring the patency of the catheter may help facilitate mucus removal. IV. True. Selecting a larger suction catheter may help facilitate mucus removal. (h) A. Incomplete and incorrect response(h) B. Incomplete and incorrect response(h) C. Incomplete and incorrect response(c) D. Correct response

• RRT C

• The respiratory therapist determines the tip of an endotracheal tube is in the trachea below the aortic knob but 2 cm above the carina on inspection of an AP chest radiograph. The therapist reports the tube should beA.advanced.B.pulled back.C.left in place.D.replaced.EXPLANATIONS:(h) A. The position is best determined relative to the carina and advancing would increase the risk of a bronchial intubation. (h) B. The position is currently correct and pulling back may extubate the patient or an inflated cuff may damage the vocal cords.(c) C. The position is currently correct; therefore, it should be left in place.(h) D. The position is currently correct. There is no indication for replacing the tube and this could be hazardous to the patient.

• The respiratory therapist is assisting the physician with an endotracheal intubation. The therapist auscultates the chest for proper placement of the artificial airway. The therapist notes breath sounds are markedly decreased on the left side of the chest. Which of the following actions is most appropriate at this time?A.Reposition the endotracheal tube. B.Reintubate the patient. C.Monitor for exhaled CO2.D.Obtain a chest radiograph.EXPLANATIONS:(c) A. A right mainstream intubation is likely. Gradually withdrawing the tube until equal bilateral breath sounds are heard should correct the problem.(h) B. Reintubation is not necessary for this patient. See explanation A. (u) C. Exhaled CO2 will be present with either bronchial or tracheal intubation. See explanation A.(h) D. Obtaining a chest radiograph would delay corrective action and may result in potential harm. See explanation A.

• A patient with a size 8 mm endotracheal tube has been receiving mechanical ventilation for 2 weeks, but weaning efforts have failed. If there is no further improvement in ventilatory status within 48 hours, the patient will be sent to the OR for a tracheotomy procedure. The tracheostomy device will facilitate this patient's care by    I. increasing dead space.  II. decreasing airways resistance. III. decreasing upper airway trauma.IV. increasing secretion clearance.A.I and II onlyB.I and IV onlyC.II and III onlyD.III and IV onlyEXPLANATIONS:   I. False. Dead space will decrease minimally with a tracheostomy and has no clinical value.  II. False. Decreasing tubing length has a significantly less effect than tube radius in determining resistance. This would have negligible clinical value. III. True. A tracheostomy tube will reduce upper airway trauma by allowing removal of the endotracheal tube. IV. True. A tracheostomy tube facilitates the suctioning procedure by decreasing the length of the artificial airway and increasing access to the lower airway. (u) A. Incorrect response.(u) B. Incomplete and incorrect response included.(u) C. Incomplete and incorrect response included.(c) D. Correct response.

• A patient who is ventilator-dependent has an 8 mm endotracheal tube in place. Using a standard 12 Fr catheter kit, the patient requires prolonged suctioning due to profuse, thick secretions. The respiratory therapist notes the patient develops tachycardia and the oxygen saturation decreases. The therapist should recommend using a A.10 mm standard catheter.B.closed-suction system.C.12 Fr Coudé tip catheter.D.q1h suctioning frequency.EXPLANATIONS:(u) A. A smaller suction catheter would be ineffective in removal of profuse thick secretions.(c) B. A closed-suction system will allow for continuation of ventilation and oxygenation during suctioning.(u) C. Using a catheter with an angled tip would not improve secretion removal and would not address the problems being encountered.(h) D. The need for suctioning should be frequently assessed and performed as needed.

• During nasotracheal suctioning, the patient does not cough, but watery secretions are aspirated through the catheter. Which of the following should the respiratory therapist do next?A.Insert an oropharyngeal airway and repeat the procedure.B.Hyperextend the patient's neck when passing the catheter. C.Ask the patient to swallow while passing the catheter.D.Increase the suction pressure and repeat the procedure.EXPLANATIONS:(h) A. An oropharyngeal airway, which may cause vomiting and aspiration, will not assist in successfully passing the suction catheter into the trachea. (c) B. Aspiration of watery secretions would indicate catheter position in either the oropharynx or the esophagus. Hyperextending the neck will better direct the catheter to the trachea.(u) C. Swallowing will direct the catheter into the esophagus.(u) D. Increasing the suction pressure is not related to placing the catheter into the trachea.