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 59year-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 button
B.Kistner tube
C.cuffed, fenestrated tracheostomy tube
D.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:
100 – 150 mmHg
100 – 120 mmHg
80 – 100 mmHg
60 – 80 mmHg
• Size
– Catheter size = ID size x 3
2
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, lowpressure 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 pressurecontrolled 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 airway
B.Hyperextend the patient’s neck
C.Place a nasal endotracheal tube
D.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 pneumothorax
B.Right bronchial intubation
C.Malfunctioning CO2 monitor
D.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 epinephrine
B.Reintubate the child
C.Perform a cricothyrotomy
D.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. Diameter
II.presence of a cuff
III.length of the tube
IV.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 cm
C.Check the patient’s end-tidal CO2 level
D.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 monitoring
II.An esophageal detection device (EDD)
III.Laryngeal palpation during tube insertion
IV.Neck and chest radiographs
V. Observation of bilateral chest movement
A. I, III, and IV
B. II, IV, and V
C. I, II, III, and V
D. 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 sample
B. Increase the pateitn’s oxygen to 50%
C.Intubate the patient
D.Administer a sedative medication
A conscious patient is recovering from GuillainBarre 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 ID
D.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 airway
B.endotracheal tube
C.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 6.0mm 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 mL
B. Increase the cuff pressure to seal the trachea to
stop the leak
C.Replace the tracheostomy tube with one that is
8.5-mm ID
D.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 ID
B.7.0-mm ID
C.8.0-mm ID
D.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 reintubation 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.PleurevacEXPLANATIONS: (c) A. A Luken's trap is
designed to collect sputum during
suctioning. (u) B. A Carlen's tube is a doublelumen 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 tube
III. checking the patency of the catheter
IV. 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.