Deck 44: Initiating and Adjusting Ventilatory Support

Question 1

Which of the following is the LEAST frequent cause of acute respiratory failure needing mechanical ventilation?

A)sepsis
B)postoperative respiratory failure
C)heart failure
D)aspiration

Answer 1

D

Question 2

Which of the following modes of ventilatory support would you initially recommend for a patient whose compliance or resistance is likely to change rapidly?

A)pressure-targeted continuous mandatory ventilation (CMV)
B)pressure-supported ventilation (PSV)
C)volume-targeted CMV
D)pressure-targeted intermittent mandatory ventilation

Answer 2

C

Question 3

In which of the following clinical conditions is noninvasive positive pressure ventilation (NPPV) NOT recommended?

A)management of acute exacerbation of chronic obstructive pulmonary disease (COPD)
B)management of premature extubation
C)management of cardiogenic pulmonary edema
D)management of acute respiratory distress syndrome (ARDS)

Answer 3

D

Question 4

Noninvasive positive-pressure ventilation (NPPV) should not be considered for which patients?
I)those who require an artificial airway
II)those who are prone to aspiration
III)those who have excessive secretions
IV)those who are hemodynamically unstable

A)I and III
B)I, II, and III
C)II, III, and IV
D)I, II, III, and IV

Question 5

Which of the following clinical findings is LEAST likely to be seen in a patient with acute hypoxic respiratory failure?

A)confusion
B)tachycardia
C)hypotension
D)dyspnea

Question 6

Compared with a volume-cycled strategy, what are some potential advantages of pressure-targeted ventilatory support?
I)limit and control of peak airway pressures
II)direct control over inspiratory time
III)provision of a decelerating flow pattern

A)I and II
B)II and III
C)I and III
D)I, II, and III

Question 7

To stabilize a patient during the initial application of ventilatory support, which of the following parameters must be set?
I)airway temperature
II)ventilatory support mode
III)oxygen concentration (FIO₂)IV.minute ventilation (f, V_T)

A)I and III
B)I, II, and III
C)II, III, and IV
D)I, II, III, and IV

Question 8

All the following are hazards associated with mechanical ventilation except:

A)reduced cardiac output
B)liver failure
C)increased work of breathing
D)acute lung injury

Question 9

Which of the following situations may call for a ventilator that has high flow and pressure characteristics?

A)patient with ARDS
B)patient with neuromuscular disease
C)patient with chronic obstructive pulmonary disease
D)child with croup

Question 10

What is the recommended range for the tidal volume for the initial ventilator settings in the volume control mode?

A)5 to 7 ml/kg
B)8 to 10 ml/kg
C)10 to 12 ml/kg
D)12 to 15 ml/kg

Question 11

What percentage of mechanical ventilated patients has a tracheostomy tube place at some point?

A)5%
B)15%
C)25%
D)33%

Question 12

What goal(s) does the practitioner hope to achieve when selecting initial ventilatory support settings?
I. Optimize oxygenation.
II. Optimize ventilation.
III. Maintain acid-base balance.
IV. Avoid harmful side effects.

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

Question 13

Which of the following represents a clinical situation where partial ventilatory support is commonly used?

A)patient with head trauma
B)during weaning from continuous mandatory ventilation
C)while ventilating an asthmatic
D)in a drug overdose case

Question 14

After starting volume-cycled mechanical ventilation on a patient in respiratory failure with a V_T of 10 ml/kg, you measure and obtain a plateau pressure of 45 cm H₂O. Which of the following actions would you recommend to the patient's physician?

A)Decrease the inspiratory flow.
B)Lower the delivered V_T.
C)Administer a bronchodilator.
D)Add PEEP.

Question 15

Your patient has acute ventilatory failure with hypercapnia. What findings would you expect to see?

A)headache and drowsiness
B)pale, dry skin
C)bradycardia and hypertension
D)hyperresponsiveness and dilated pupils

Question 16

If the patient is being ventilated via a mechanical ventilator via synchronized intermittent mandatory ventilation with partial ventilatory support, what would probably happen to PaCO₂ if the patient suddenly had no spontaneous breathing?

A)increase
B)decrease
C)stay the same
D)change according to FIO₂

Question 17

Compared to a pressure-controlled strategy, what is the primary advantage of volume-controlled ventilatory support?

A)provides a decelerating flow pattern
B)limits and controls peak airway pressures
C)improves patient-ventilator synchrony
D)guarantees a minimum minute volume

Question 18

What is the primary advantage of negative-pressure ventilation?

A)no need for artificial airway
B)easier to prevent bedsores
C)better cardiac output
D)portability of device

Question 19

Physiological goals of artificial ventilatory support include which of the following?
I)support or manipulate gas exchange
II)reduce or manipulate the work of breathing
III)increase lung volume

A)I and II
B)II and III
C)I and III
D)I, II, and III

Question 20

Which of the following is/are a disadvantage of negative-pressure ventilation?
I)problems with leaks
II)reduced access to patient
III)reduced patient tolerance

A)I only
B)II only
C)I and II only
D)I and III only

Question 21

Which of the following statements is NOT true regarding the use of controlled ventilation?

A)may allow the muscles of breathing to rest
B)can use larger I:E ratio and may improve oxygenation
C)requires use of paralytic agents in spontaneously breathing patients
D)therapist has little control of needed inspiratory flow and pressure

Question 22

Air-trapping is a major concern in patients with what diagnosis when using the assist-control mode?

A)pneumonia
B)chronic obstructive pulmonary disease (COPD)
C)chest trauma
D)neuromuscular disease

Question 23

A physician orders intubation and mechanical ventilation in the synchronized intermittent mandatory ventilation mode for a 170-lb adult man with neuromuscular disease. Which of the following initial settings would you recommend?

Question 24

A ventilator has separate rate and V_T controls. If you set a V_T of 850 ml and a respiratory rate of 12/min in the continuous mandatory ventilation mode, what will the minute ventilation be?

A)7800 ml/min (7.8 L/min)
B)8500 ml/min (8.5 L/min)
C)9600 ml/min (9.6 L/min)
D)10,200 ml/min (10.2 L/min)

Question 25

Which of the following remedies is NOT commonly used in patients ventilated in the assist-control mode with a high ventilatory drive to avoid hyperventilation?

A)synchronized intermittent mandatory ventilation
B)tranquilizers
C)analgesics
D)reduced inspiratory flow

Question 26

What mode of ventilation may be most useful for ventilating a patient with a bronchopulmonary fistula?

A)high-frequency jet ventilation
B)pressure-supported ventilation
C)high-frequency percussive ventilation
D)pressure-controlled ventilation

Question 27

In what scenario is pressure-controlled ventilation (PCV) most often used?

A)when limiting plateau pressure is needed
B)when a pneumothorax is present
C)when the patient has chronic obstructive pulmonary disease
D)when bilateral pneumonia is present

Question 28

A ventilator has separate rate and minute ventilation controls. A physician orders continuous mandatory ventilation with a V_T of 950 ml at a respiratory rate of 12/min. What minute ventilation would you set on this ventilator?

A)7900 ml/min (7.9 L/min)
B)8600 ml/min (8.6 L/min)
C)9400 ml/min (9.4 L/min)
D)11,400 ml/min (11.4 L/min)

Question 29

A physician orders intubation and mechanical ventilation in the synchronized intermittent mandatory ventilation mode for a 200-lb ideal body weight (IBW) adult man with normal lungs. Which of the following initial ventilator settings would you recommend?

Question 30

Which of the following statements is NOT true regarding the use of intermittent mandatory ventilation (IMV) or synchronized intermittent mandatory ventilation (SIMV)?

A)The machine breath is typically time cycled to inspiration.
B)The patient can breathe spontaneously between machine breaths.
C)SIMV is easy to apply.
D)SIMV may help maintain ventilatory muscle strength.

Question 31

On a ventilator that has separate rate and minute ventilation (V_E) controls, the rate is set at 13/min and the V_E at 11 L/min. About what V_T is the patient receiving?

A)700 ml
B)850 ml
C)1000 ml
D)1200 ml

Question 32

A physician orders intubation and mechanical ventilation in the synchronized intermittent mandatory ventilation mode for a 160-lb adult man with a history of chronic obstructive pulmonary disease. Which of the following settings would you recommend?

Question 33

What mode of ventilation will automatically vary the pressure support provided as patient effort changes to maintain a "normal" work of breathing?

A)synchronized intermittent mandatory ventilation
B)proportional assist ventilation (PAV)
C)volume-control continuous mandatory ventilation
D)assist-control volume ventilation

Question 34

When a patient is initially started on mechanical ventilation common orders from the physician in the patient's chart include all the following except:

A)FIO₂
B)mode
C)sensitivity
D)tidal volume

Question 35

Which of the following statements is NOT true regarding pressure-supported ventilation?

A)It is patient triggered, pressure limited, and flow cycled.
B)It can reduce the work of breathing during intermittent mandatory ventilation mode.
C)The usual range is 10 to 15 cm H₂O.
D)It is recommended for use in most patients in the synchronized intermittent mandatory ventilation (SIMV) mode.

Question 36

What mode of ventilation is most often applied to the intensive care unit patient needing mechanical ventilation?

A)pressure-supported ventilation
B)pressure-controlled ventilation
C)assist-control or synchronized intermittent mandatory ventilation (SIMV)
D)control mode

Question 37

Which of the following statements is NOT true regarding ventilation is the assist-control mode?

A)Every breath is supported by the ventilator.
B)Usually ensures a minimum safe level of ventilation is given.
C)Assist-control mode is typically applied using the volume control mode.
D)It is usually applied with a backup rate of 5 to 8 breaths/min.

Question 38

What will most likely result if the patient ventilated in the assist-control mode develops a high ventilatory drive?

A)respiratory alkalosis
B)respiratory acidosis
C)ventilatory failure
D)large drop in oxygenation

Question 39

A physician orders intubation and mechanical ventilation in the continuous mandatory ventilation assist-control mode for a 125-lb adult woman with normal lungs. Which of the following initial settings would you recommend?

Question 40

For adolescents in the 8- to 16-year-old age range, which of the following ranges of ventilator setting would you initially recommend? Rate

Question 41

Which of the following is false about flow triggering of spontaneous breaths during mechanical ventilation?

A)Flow triggering lowers the patient's work of breathing.
B)Flow triggering is preferred for initiating spontaneous breaths.
C)Flow triggering reduces the work of breathing due to small endotracheal tubes.
D)Flow triggering results in better patient-ventilator synchrony.

Question 42

To prevent atelectasis and improve gas exchange, most thoracic surgery patients placed on ventilatory support receive which of the following?

A)0 cm H₂O PEEP
B)5 cm H₂O PEEP
C)8 cm H₂O PEEP
D)10 cm H₂O PEEP

Question 43

In which of the following conditions is PEEP NOT likely to be useful?

A)ARDS
B)pulmonary edema
C)acute lung injury
D)neuromuscular disease

Question 44

Which of the following inspiratory flow patterns would result in the lowest peak inspiratory pressure?

A)accelerating flow pattern
B)square flow pattern
C)decelerating flow pattern
D)constant flow pattern

Question 45

In which of the following clinical situations is the incidence of auto-PEEP the greatest?
I)patients with high respiratory rates
II)intubated patients with obstructive lung disease
III)patients with low minute volumes

A)I and II
B)I and III
C)II and III
D)I, II, and III

Question 46

On some ventilators, what can a trigger setting that is too sensitive cause?

A)auto-cycling
B)flow dyssynchrony
C)barotrauma
D)increased workload

Question 47

For adults with otherwise normal lungs who are receiving ventilatory support in the continuous mandatory ventilation control or assist-control mode, inspiratory flow should be set to provide what I:E?

A)2:1
B)3:1
C)1:1
D)1:2

Question 48

When adjusting the FIO₂ setting for a patient receiving mechanical ventilatory support, what should your goal be?

A)Decrease the FIO₂ to below 0.70 as soon as possible.
B)Maintain the highest possible FIO₂ as long as needed.
C)Decrease the FIO₂ to below 0.30 as soon as possible.
D)Decrease the FIO₂ to below 0.50 as soon as possible.

Question 49

Which of the following ventilator adjustments would NOT decrease inspiratory time?

A)increase the peak flow
B)increase the tidal volume
C)change the flow pattern from a sine wave to a square wave
D)none of the above

Question 50

Immediately after cardiac arrest and resuscitation, a patient is placed on a ventilator in the continuous mandatory ventilation assist-control mode. What initial FIO₂ would you recommend?

A)1.0
B)0.8
C)0.6
D)0.4

Question 51

Which of the following trigger levels is appropriate when setting a ventilator for flow-triggering?

A)9 to 11 L/min below baseline flow
B)7 to 9 L/min below baseline flow
C)4 to 6 L/min below baseline flow
D)1 to 3 L/min below baseline flow

Question 52

Which of the following criteria represents the recommended starting point for considering the use of PEEP?

A)PaO₂ < 40-50 on FIO₂ > 0.80 - 1.0
B)PaO₂ < 50-60 on FIO₂ > 0.40-0.50
C)PaO₂ < 100 on FIO₂ of 1.0
D)PaO₂ < 50 on FIO₂ > 0.75

Question 53

A chronic obstructive pulmonary disease (COPD) patient receiving ventilatory support in the CMV assist-control mode at a rate of 14 and a V_T of 750 ml exhibits clinical signs of air-trapping. Which of the following would you recommend to correct this problem?
I. Decrease “E” time.
II. Increase the inspiratory flow rate.
III. Decrease the assist-control rate.

A)I and II
B)I and III
C)II and III
D)I, II, and III

Question 54

Which of the following is FALSE about flow-triggered ventilatory support?

A)The work of breathing with flow-triggering is less than with pressure triggering.
B)Flow-triggered systems respond to changes in flow rather than pressure.
C)Pressure-triggering on new ventilators may be as sensitive as flow-triggering.
D)Flow-triggering will decrease the work of breathing in patients with small endotracheal tubes and auto-PEEP.

Question 55

An adult patient in respiratory failure has the following blood gases on a nasal cannula at 5 L/min: pH = 7.20; PaCO₂ = 67 mm Hg; HCO₃^- = 27 mEq/L; PaO₂ = 89 mm Hg. The attending physician orders intubation and ventilatory support. What FIO₂ would you recommend to start with?

A)0.21
B)0.30
C)0.50
D)0.90

Question 56

What flow pattern is least optimal for ventilating a patient with cardiovascular instability?

A)accelerating flow pattern
B)square flow pattern
C)decelerating flow pattern
D)constant flow pattern

Question 57

Beneficial effects of using high inspiratory flows in patients with chronic airflow obstruction receiving flow-limited mechanical ventilation include which of the following?
I)decreased work of breathing
II)improved gas exchange
III)decreased auto-PEEP

A)I and II
B)I and III
C)II and III
D)I, II, and III

Question 58

Which of the following statements is NOT true regarding the use of an inspiratory pause during mechanical ventilation?

A)It may be useful in ARDS patients.
B)It may be useful when obtaining a chest radiograph.
C)It has been shown to increase effectiveness of bronchodilator therapy.
D)It will increase mean airway pressure.

Question 59

Which of the following trigger levels is appropriate when setting a ventilator for pressure-triggering?

A)0.5 to 1.5 cm H₂O above the baseline pressure
B)1.5 to 2.5 cm H₂O below the baseline pressure
C)0.5 to 1.5 cm H₂O below the baseline pressure
D)2.5 to 3.5 cm H₂O below the baseline pressure

Question 60

When starting flow-limited ventilatory support on an adult patient, which of the following inspiratory flow settings would you initially select?

A)60 L/min
B)50 L/min
C)40 L/min
D)30 L/min

Question 61

Which of the following would you assess immediately after a patient is placed on a ventilatory support device?
I)ABGs
II)patient's airway
III)patient's vital signs

A)I and II
B)I and III
C)II and III
D)I, II, and III

Question 62

Which of the following criteria should be met before considering use of a heat-moisture exchanger (HME) for a patient being placed on ventilatory support?
I. There should be no problem with retained secretions.
II. The patient should not have a fever (normothermic).
III. The patient should be adequately hydrated.
IV. The support should be short term (24 to 48 hours).

A)I, II, and III
B)II and IV
C)I, II, III, and IV
D)III and IV

Question 63

What limits should be initially set for high and low V_T values and/or minute volume alarms on a ventilatory support device?

A)±5% to 10%
B)±10% to 15%
C)±15% to 20%
D)±20% to 25%

Question 64

A patient receiving continuous mandatory ventilation in the assist-control mode develops auto-PEEP. Which of the following changes in ventilatory patterns would you consider to minimize the effects of auto-PEEP in this patient?
I)decreasing the rate or increasing V_T
II)using low-rate synchronized intermittent mandatory ventilation
III)decreasing the peak inspiratory flow
IV)lowering the V_T and letting the PaCO₂ rise

A)II and IV
B)III and IV
C)I, II, and III
D)I, II, and IV

Question 65

A dehydrated, feverish patient suffering from acute bacterial pneumonia is being intubated in order to provide mechanical ventilatory support. Which of the following devices would you select to control humidification and airway temperature for this patient?

A)unheated large-volume wick humidifier
B)heated wick humidifier with servo-control
C)large-reservoir, high-output heated jet nebulizer
D)heat-moisture exchanger

Question 66

A heat-moisture exchanger (HME) should be avoided in which of the following circumstances?
I)patients with excessive secretions
II)patients with a high FIO₂
III)patients with low body temperature

A)I only
B)I and II only
C)I and III only
D)I, II, and III

Question 67

If available, the FIO₂ alarm should be set to what percentage?

A)±3%
B)±5%
C)±8%
D)±10%

Question 68

A patient suffering from postoperative complications has been receiving mechanical ventilation for 6 days with a volume ventilator. A heat-moisture exchanger (HME) is providing control over humidification and airway temperature. Over the past 24 hours, the patient's secretions have decreased in quantity but are thicker and more purulent. Which of the following actions would you suggest at this time?

A)Replace the HME.
B)Switch over to a heated wick humidifier.
C)Administer acetylcysteine every 2 hours via the nebulizer.
D)Increase the frequency of suctioning.

Question 69

For which of the following patients requiring ventilatory support would you recommend against using a heat-moisture exchanger (HME) for airway humidification?
I)patient whose expired V_T is less than 70% of the delivered V_T
II)patient with a spontaneous minute ventilation of 14 L/min
III)patient with body temperature less than 32° C

A)I and II
B)I and III
C)II and III
D)I, II, and III

Question 70

When using a heated humidifier during mechanical ventilation, the inspired gas temperature at the airway should be set to what level?

A)29° to 31° C
B)31° to 35° C
C)35° to 37° C
D)38° to 40° C

Question 71

You have just placed a chronic obstructive pulmonary disease (COPD) patient on intermittent mandatory ventilation at a rate of 8/min, a V_T of 750 ml, and an FIO₂ of 0.40. To ensure proper equilibration between the alveolar and arterial gas tensions, how long should you wait before drawing a sample for measurement of the ABG?

A)5 minutes
B)10 minutes
C)15 minutes
D)30 minutes

Question 72

After placing a patient on a volume-cycled ventilator in the continuous mandatory ventilation assist-control mode, you note that 55 cm H₂O pressure is required to deliver the preset V_T of 950 ml. What high-pressure limit would you now set for this patient?

A)60 cm H₂O
B)70 cm H₂O
C)80 cm H₂O
D)90 cm H₂O

Question 73

After setting up a patient on a ventilatory support device, which of the following supplementary equipment would you require to be available at the bedside?
I)suction source and catheters
II)backup artificial airway
III)manual resuscitator with oxygen

A)II and III
B)I and II
C)I, II, and III
D)I and III

Question 74

A patient receiving continuous mandatory ventilation in the assist-control mode develops auto-PEEP. Which of the following general approaches would you consider to minimize the effects of auto-PEEP in this patient?
I)increasing expiratory time
II)applying PEEP
III)switching ventilating mode to synchronized intermittent mandatory ventilation

A)I and II
B)I and III
C)II and III
D)I, II, and III

Question 75

Which of the following would you initially verify in assessing the airway of a patient placed on ventilatory support?
I)cuff pressure
II)tube position
III)tube patency

A)I and II
B)I, II, and III
C)I and III
D)II and III

Question 76

When the therapist is initially setting the high-pressure alarm on the ventilator and the patient's plateau pressure is less than 30 cm H₂O, what should the high pressure alarm be set at?

A)5 to 10 cm H₂O above the peak pressure
B)10 to 20 cm H₂O above the peak pressure
C)10 to 12 cm H₂O above the plateau pressure
D)10 to 15 cm H₂O above the mean airway pressure

Question 77

Which of the following factors influence patient-ventilator interaction?
I)artificial airway
II)trigger sensitivity
III)presence of auto-PEEP

A)I and II
B)I and III
C)II and III
D)I, II, and III

Question 78

All of the following machine factors can have a major impact on adult patient-ventilator interaction except:

A)humidification system
B)PEEP valve function
C)trigger sensitivity
D)tubing compliance

Question 79

Indications for delivering sigh breaths during mechanical ventilation include all of the following except which of the following?

A)before and after suctioning
B)during chest physical therapy
C)in patients with stiff lungs
D)when small V_T values are used

Question 80

A chronic obstructive pulmonary disease (COPD) patient in respiratory failure is receiving ventilatory support in the volume-targeted intermittent mandatory ventilation mode at a rate of 6/min. You measure an auto-PEEP level of 9 cm H₂O. Which of the following would you recommend to decrease the effects of auto-PEEP in this patient?

A)Decreasing the rate and increasing V_T.
B)Lowering the V_T and letting the PaCO₂ rise.
C)Applying 4 to 6 cm H₂O PEEP.
D)Decreasing the peak inspiratory flow.