Airway Management and Respiratory Conditions, Exams of Advanced Education

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Significance of stomach distension, and rapidly decreased ETCO2 after successful intubation - Correct Answer-Tube was placed into esophagus Method to RAPIDLY confirm that a stoma is clear (direct laryngoscopy, suction, removing inner cannula) * - Correct Answer-remove inner catheter to see that its clear Methods to clear tracheostomy tubes - Correct Answer-3 ml of saline and suction. "Maximum allowable time" for intubation attempts. - Correct Answer-30 seconds with oxygenation between attempts Indications and contraindications for nasotracheal intubation - Correct Answer- Indications: Breathing spontaneously but require definitive airway management. Responsive patients and patients with an altered mental status and an intact gag reflex who are in respiratory failure. Contraindications: patients that should receive orotracheal intubation, head trauma, and possible midface fractures. Differential diagnosis for emphysema, pneumonia, pleural effusion and CHF - Correct Answer--Emphysema (Pink Puffer "Polycythemia", Barrel chested) is a loss of elasticity of the alveoli of the lungs. This causes extra dead space and these patients breathe off of a hypoxic drive due to the retained CO2 in the lungs and respiratory system. -Pneumonia is going to incorporate a FEVER. Most commonly it is only a one sided issue. Productive cough. Ask about secretion color.

• Pleural effusion is air or fluid in the chest cavity "air or fluid constricts lung, making it harder to breathe" (Visceral Pleura, Parietal Pleura Space). Sharp pain made worse by deep breath. -CHF is going to have pedal edema and cough up pink frothy sputum. Exacerbated by lying flat (Orthopnea). Known by history and medications taken. left sided heart failure precedes right side heart failure. Pump problem not a pipe problem. Treatment of asthma patients depending on how they present (wheezes or not, mannerism of

speaking, distress etc) - Correct Answer-Patients who are hypersensitive- remove them from irritant Asthma patient who is dehydrated- needs hydrated Asthma patients who are wheezing- Nebulizer treatment, also consider corticosteroid and CPAP Blue Bloater (Chronic Bronchitis) - Correct Answer-Chronic Bronchitis: airway flow problem, recurrent productive cough, hypoxia, respiratory acidosis, dyspnea on exertion, high hemoglobin, 'blue bloater' increase respiratory rate, dyspnea on exertion, digital clubbing, fat finger tips, cardiac enlargement, bilateral lower extremity enlargement pink puffer - Correct Answer-Emphysema: Pursed lip breathing, barrel chested, high RR (to compensate for poor functioning lungs), high HR, 'pink puffers', pink skin caused by polycythemia which is overproduction of red blood cells Escalation of airway management in a burn patient. - Correct Answer-Be prepared to intubate. Basic airway management, nebulizer treatment. Be ready to intubate. NTG=(Nitro) - Correct Answer-vasodilator that works throughout the entire body. Decreased the work of the heart. Gives somewhere for the fluid to go. Give SL 0.4 mg q 3-5 min. Given also as 1" nitropaste Drip dose. Nitro Drip 10 mcg/min. Lasix(furosemide) - Correct Answer-40-100 mg IV/IO. (0.5-1 mg/kg). Indications=Pulmonary Edema/CHF. Double dose of prescribed dose. DO NOT GIVE IF PATIENT IS HYPOTENSIVE OR HYPOVOLEMIC. Works in the Loop of Henle in the kidneys. Moves Sodium, and also causes shift in potassium. Albuterol - Correct Answer-2.5 mg nebulized. Works on B2 receptors. Bronchodilator. Contraindications=CHF. Use caution with tachydysrhythmias. Dexamethasone - Correct Answer-Dexamethasone=Corticosteroid. 10-100 mg IV Push 1 mg/kg IV bolus. Pedi 0.25-1 mg/kg IV.IO. IM. You can have the pt drink the medication if no IV. Contraindication-Systemic Sepsis. Epinephrine - Correct Answer-Epinephrine= 0.3-0.5 mg of 1:1,000 IM ONLY!!! NO IV. No selective agent Alpha and Beta

Sympathomimetic, Vasopressor, Bronchodilator. Contraindications=Hypersensitive, hypovolemic shock, hypertension, Narrow Angle Glaucoma.Epinephrine= Ipatroprium Bromide=(Atrovent). - Correct Answer-0.5 mg Nebulized. Anticholinergic. Acts by inhibiting the interactions of ACH at the receptors (Beta-2) resulting in smooth muscle relaxation and Bronchodilation. Atropine - Correct Answer-Atropine=0.5 mg IV MAX DOSE OF 3 mg. Anticholinergic (parasympatholytic) In pediatric patients give for RSI to stop Bradycardia from happening and it also drys up secretions. (speeds up the heart). Magnesium Sulfate - Correct Answer-Electrolyte, smooth muscle relaxant, anticonvulsant. DOSE=1-2 grams over no less than 5 mg in respiratory. Can paralyze diaphragm if pushed to fast. DO NOT USE IF THE PATIENT HAS A HEART BLOCK. Metabolic Acidosis - Correct Answer-High amount of H+ Ions. More the less happens when the cells have an issue that throw off the chemical balance is the blood making you more acidic. Symtoms of this would be headaches, abdominal pain, and Kussmauls breathing. respiratory acidosis - Correct Answer-reduced rate of respirations (Hypoventilation). Increased amounts of CO2. Metabolic Alkalosis - Correct Answer-metabolic condition in which the pH of tissue is elevated beyond the normal range (7.35-7.45). This is the result of decreased hydrogen ion concentration, leading to increased bicarbonate respiratory alkalosis - Correct Answer-Increased respiration rate(Hyperventilation), Decreased amount of CO2. In other words, Hyperventilating. After intubation when is it ok to let go of the tube - Correct Answer-When the tube is secured. What types of breath sounds, and locations should you expect to hear on a patient experiencing shortness of breath with CHF (left sided heart failure) - Correct Answer-Crackles Rhonchi: - Correct Answer-coarse, low pitched breath sounds heard in patients with chronic mucus or fluid in the upper or larger lower airways.

Cracles - Correct Answer-sounds produced as fluid filled alveoli pop open during inhalation. formally called rales. Wheezes - Correct Answer-a high pitched whistling breath sound that can be heard on inhalation, expiration, or both; indicates air movement through a constricted lower airway, such as with asthma. Stridor - Correct Answer-harsh, high pitched sound produced as air moves past an obstruction within or immediately above the glottic opening; severe upper airway obstructions such as caused by laryngeal edema. Normal amount of air used to inflate the distal cuff of an ET tube - Correct Answer-5- ml of air Risks of over-inflation of the endotracheal tube cuff - Correct Answer-May cause tissue necrosis of the tracheal wall. Damage to the airway. Hierarchy of steps of airway management - Correct Answer-1.repositioning, 2.suctioning,

3. 2-person BVM, 4.adjuncts, 5.intubation, 6.cricothyrotomy. Measuring acid, PH, ALK - Correct Answer-PH - acid←- 7.35 7.45 ----> alk Resp Co2 alk←- 35 45 ----> acid Kidneys metabolic Bicarb acid←-22 26 ----> alk *C02 normal numbers 35-45 mm/hg - "The higher the number the more acidic" *HC03 (Bicarb) Normal numbers 22-26 - "if its low is acidotic if its high its Alkalotic" *Alkalosis = Base baby= PH your baby has the same last name Dosage and concentration of Epinephrine in mg and ml for patients in status asthmaticus - Correct Answer-Administer 0.3-0.5 mg of 1:1,000 Epi IM Location of base, apex (lungs and heart - they're different). - Correct Answer-Base of Heart = top Apex of heart = Bottom Base of Lungs = bottom Apex of lungs=Top Base of lungs is towards diaphragm and Apex towards trachea. Apex of the heart points to stomach and base towards trachea. Beta 2 agonist - Correct Answer-Broncho dilates

Beta 2 antagonist - Correct Answer-Broncho constricts Alpha 1 agonist - Correct Answer-Constrict the vessels Alpha 2 antagonist - Correct Answer-Dilates the vessels respiratory distress - Correct Answer-increased work of breathing; a sensation of shortness of breath Breath sounds only on the right after an intubation. Why and procedure to correct - Correct Answer-Slowly pull back on the tube a couple centimeters and readvise lung sounds. This can happen due to the tube advancing past the carina and into the right mainstem bronchus respiratory failure - Correct Answer-The reduction of breathing to the point where oxygen intake is not sufficient to support life Beta 1 agonist - Correct Answer-increases the heart's inotropic/chronotropic/ dromotropic effect respiratory arrest - Correct Answer-when breathing completely stops Beta 1 antagonist - Correct Answer-decreases the heart's inotropic/chronotropic/ dromotropic effect Ionotrope - Correct Answer-force of contraction dromotrope - Correct Answer-Increases the electrical conductivity of the heart Chronotrope - Correct Answer-Increases the speed at which your heart beats BLS of choking and airway obstruction - Correct Answer-Encourage to cough, heimlich maneuver, if this doesnt work, be ready for them to collapse, start compressions. Escalation of steps of obstructed airway relief of an unresponsive and apneic patient after chest thrusts fail - Correct Answer-Open airway, magill forceps, laryngoscopic removal, intubation pushing object in lungs Antidote for Benzodiazepine overdose - Correct Answer-Romazicon - 0.2 mg IV/IO push over 30 seconds. If not effective, administer 0.3 mg IV/IO over 30 seconds, if not effective 0.5 mg over 30 seconds, repeat until desired effect. Max dose up to 3mg.

Treatment of an unresponsive, apneic and drooling patient after swallowing bleach - Correct Answer-airway protection (RSI), Gastric tube, Contact poison control Golden method for confirming ET tube placement - Correct Answer-Visualizing the tube pass through the vocal cords, and then getting a capnography reading, along with lung sounds/rise and fall over the chest. Significance of a "shark-fin" waveform and increasingly difficult ventilations of an intubated patient. What should you do to correct? - Correct Answer-Shark fin = Bronchoconstriction, Causing BronchoSpasm making it harder to bag. treatment = Albuterol/ breathing treatment. Golden method for confirming ET tube placement - Correct Answer-Visualizing the tube pass through the vocal cords, and then getting a capnography reading, along with lung sounds/rise and fall over the chest. Treatment for relieving gastric distension after intubation - Correct Answer-IN or OG tubes to relieve distension Risks of patients with facial burns, singed nasal hairs and raspy voice. Treatment - Correct Answer-Swollen airway (Stridor). Prepare for intubation Procedure to follow after failed ventilation after placing a dual-lumen airway device - Correct Answer-Move to other Lumen. Cricoid membrane next S/S of patients presenting with epiglottitis - Correct Answer-swelling of the epiglottis, Patients look very sick, Drooling, Tripod position, Not swallowing, Muffled speech. Stridor. dysphagia - Correct Answer-difficulty swallowing dysphasia - Correct Answer-difficulty speaking Risks of overzealous, forceful ventilations of apneic patients as it might pertain to venous return to the heart and blood pressure - Correct Answer-Overzealous bagging (too much force) - decreasing preload, lowers blood pressure (starling's law) pathophysiology of PPV vs NPV - Correct Answer-PPV - excessive positive pressure in the lungs/intrathoracic cavity can slow down venous return of blood to the heart. This is because pressure is being placed on the heart. NPV - negative pressure is created in the lungs/intrathoracic cavity when the diaphragm flattens out. This pressure differential pulls air into the lungs.

What is cystic fibrosis and what are its common characteristics - Correct Answer-Cystic Fibrosis Genetic disease affecting the lungs and other organs of the body. Overproduces mucus that is abnormally thick and sticky in lungs, kidneys and pancreas. This basically causes the gas exchange in the alveoli to become hindered and for a multitude of infections to form. After years of these infections and such, scar tissue begins to form (fibrosis) which also causes cysts in the lungs. Encourage them to cough and suction. Recognition of, common causes of and treatment of pulmonary embolism - Correct Answer-Early recognition may reveal normal breath sounds with good peripheral aeration, diverting attention away from from a pulmonary pathology. A hallmark of PE is that cyanosis does not resolve with oxygen therapy. Treatment includes high flow oxygen and pain management. pneumothorax - Correct Answer-collapsing of a lung due to air accumulating in the pleural space Tension Pneumothorax - Correct Answer-result of a pneumothorax that causes life threatening pressure inside the intrathoracic cavity. This includes tracheal deviation and JVD. spontaneous pneumothorax - Correct Answer-defect in alveolar wall and visceral pleura which causes air to form a sac like blister. This can rupture spontaneously, which releases air. These sacs are called blebs. This can also occur in tall/skinny patients that can happen spontaneously. Asthma - Correct Answer-Lower airway - hypersensitivity to a trigger in the environment. attack derives from histamine releases. causes inflammation, secretions, and constriction in the lower airways. wheezing sound Hemothorax - Correct Answer-blood in the pleural space which can be caused by trauma, blood clotting defect, chest or heart surgery. signs are chest pain, low BP, rapid heart rate, shocky signs. Tracheal Disruption - Correct Answer-damage to the trachea itself caused by trauma - harmful acids/smoke/chemicals Acute respiratory distress syndrome (ARDS) - Correct Answer-severe lung condition. It occurs when fluid fills up the air sacs in your lungs. Too much fluid in your lungs can lower the amount of oxygen or increase the amount of carbon dioxide in your

bloodstream. CAUSED FROM inhaling toxic substances, such as salt water, chemicals, smoke, and vomit, developing a severe infection of the lungs, such as pneumonia, receiving an injury to the chest or head, overdosing on sedatives or tricyclic antidepressants. Low ETCO2 causes - Correct Answer-hyperventilation and poor perfusion treatments - patients that can protect their own airway - encourage them to slow down there breathing and inhale/exhale more air. be cautious of a patient that needs to hyperventilate to blow off C0 (keto acidosis) Contraindications to the insertion of a PTL airway and when should it be removed - Correct Answer-gag reflex esophageal issues (varices, cancer, etc) excessive facial trauma Pedi patients Should be removed when you have an inability to ventilate High ETCO2 causes - Correct Answer-hypoventilation and ROSC treatments - manage airway, provide adequate ventilation

• In ROSC, patients ETCO2 will go up very high and then it will start to come back down after a couple minutes. lung sounds of patients experiencing asthma - Correct Answer-wheezing lung sounds of patients experiencing Chronic Bronchitis - Correct Answer-Rhonchi lung sounds of patients Pulmonary Edema - Correct Answer-Crackles Significance of a patient taking beta 2 agonists, Singulair and antibiotics in assisting you in determining what breathing problem is occurring. - Correct Answer-Beta 2 = history of asthma, singular = history of COPD, Antibiotics = History of Pneumonia Most common life-threatening hazard of moving patients that are intubated - Correct Answer-Tube placement and airway trauma from the tube not being secured When should you perform or consider deep tracheal suctioning - Correct Answer-When your patient has tons of fluid in lungs, resistance in BVM, secretions in ET Where does cellular respiration occur? - Correct Answer-Alveoli

Valium - Correct Answer-2mg IV/IM - reduce anxiety/minor sedation Versed - Correct Answer-0.5 mg IV/IM - pain management/hypnotic effects Ativan - Correct Answer-1mg - IV/IM - minor sedation/relaxant Pulmonary Edema - Correct Answer-blockage of an artery in the lungs. caused by substance that came from elsewhere in the body. Treatment bloodthinners, surgical socks, Treatment options of hyperventilation syndrome. If medication is used what would be the typical dosages of the 3 benzodiazepines. Valium (diazepam) 5mg Ativan (Lorazepam) .25mg-1mg Versed 0.2mg - Correct Answer-Valium (diazepam) 5mg Ativan (Lorazepam) .25mg-1mg Versed 0.2mg Causes of a gradual increase of ETCO2 - Correct Answer-Lack of adequate perfusion, hypoventilation, air trapping, pneumothorax Reactive Airway Disease: - Correct Answer-a term used to describe any condition that causes hyperreactive bronchioles and bronchospasm; asthma lung sounds of patients experiencing emphysema - Correct Answer-Emphysema: crackles and wheezing cor pulmonale - Correct Answer-right-sided heart failure arising from chronic lung disease dependent edema - Correct Answer-Swelling in the part of the body closest to the ground, caused by collection of fluid in the tissues; a possible sign of congestive heart failure. Differentiate the mandible and the maxilla and how it might affect orotracheal intubation. Can it be done? Should you nasally intubate? - Correct Answer-Mandible = Jaw, do nasal intubation Maxilla = under the nose, don't do nasal intubation Complication of left sided ventricular failure as it pertains to acidosis/alkalosis, surfactant and plasma - Correct Answer-Pump problem so body will be acidotic, pulmonary edema, sputum, plasma problems

due to not being able to move blood and liquids Hyperresonance - Correct Answer-lower-pitched, booming sound found when too much air is present such as in emphysema or pneumothorax subcutaneous emphysema - Correct Answer-A characteristic crackling sensation felt on palpation of the skin, caused by the presence of air in soft tissues. What tool most accurately represents the effectiveness of a patient's respiration - Correct Answer-ETCO2, because it measures the efficiency of respirations traumatic asphyxia - Correct Answer-Perthes's syndrome caused by an intense compression of the thoracic cavity, causing venous back-flow from the right side of the heart into the veins of the neck and the brain. Recognition of Pneumothorax (tension or otherwise) and treatment - Correct Answer- watch vital signs, stabbing chest pain. only needled decompress if they are not hemodynamically stable Hypoxia - Correct Answer-Low oxygen saturation of the body, not enough oxygen in the blood hypercarbia/hypercapnia - Correct Answer-excessive level of carbon dioxide in the blood hypocarbia - Correct Answer-insufficient carbon dioxide Hyperoxia - Correct Answer-condition of excessive oxygen Effect of respiratory FAILURE on PCO2, blood plasma pH and blood plasma HCO3 - Correct Answer-PCO2 - going rise due to inadequate ventilation/respiration because of acidity rising in the body (anaerobic metabolism). Acidity will cause the body's PH to fall (below 7.35), HC03 will remain normal however after a while, body will try to compensate due to your acidotic state, this will not last because your kidneys are not being perfused. What is the driver of respirations in the late stage COPD patient. why? - Correct Answer-Chronic elevation of carbon dioxide over time leads to acid-base disorders and shift of normal respiratory drive to hypoxic drive Recognition of pulmonary embolism in a post-partum patient despite underlying respiratory problems - Correct Answer-high risk for blood clots, high risk for PE, clear lung sounds. Treatment = iv, 02, monitor, hemoptysis - Correct Answer-coughing up blood

hematuria - Correct Answer-blood in the urine hematochezia - Correct Answer-blood in stool Potential deadly upper airway infection. - Correct Answer-Laryngotracheitis Effect of Fentanyl overdose on respiratory acidosis/alkalosis. Treatment to fix both - Correct Answer-Fentanyl depresses the respiratory drive which can causes acidosis if patient continues to hyperventilate. Treatment = Narcan bronchiectasis - Correct Answer-a result of chronic inflammation compounded by an inability to clear mucoid secretions Tuberculosis - Correct Answer-caused by the bacteria called Mycobacterium tuberculosis (MTB). It is characterized by cough with blood in sputum, fever lasting for more than 2 - 3 weeks, night sweats, anorexia, and weight loss What is the cause of alveolar collapse and respiratory failure in premature infants. What is lacking? How does that affect respirations? - Correct Answer-o They do not have respiratory functionality to fully expand lungs o Have not produced enough surfactant (lubricant). o Respirations will not be getting correct gas exchange in lungs Laryngotracheitis - Correct Answer-croup, it is inflammation of the mucous membrane lining the larynx, which is located in the upper part of the respiratory tract and the trachea which may cause respiratory obstruction Correct use of a McIntosh blade - Correct Answer-- A curved blade - place distal end of the blade into the vallecular space Potential temporary effects of orotracheal intubation on the body - Correct Answer- CATACHOLINE RELEASE, swelling due to stimulation of sensitive tissue hypoxia Correct use of a Miller blade - Correct Answer-A straight blade - distal end lifts up the entire epiglottis