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Critical Care test 2
willwallace crit care test 2
| Question | Answer |
|---|---|
| Pressure from tracheal tubes can cause what | ischemia and ulcerations |
| Friction like injuries to the trachea can be caused by what in a trached pt | airway shifting as pt’s head or neck is moved, or by tube manipulation |
| Laryngeal dysfunction can be caused by what | lack of stimulation, airflow, restricted movement secondary to equipment (trach tubes do not cause because they do not pass through) |
| What are the most common laryngeal lesions associated with endotracheal intubation | glottis edema and vocal cord inflammation |
| What is glottis edema and vocal cord inflammation | shows up after extubation-caused by pressure from ETT or trauma during intubation, swelling worsens over 24 hours symptoms are hoarsness and stridor |
| What is the main symptom of glottis edema | hoarseness |
| What is the main symptom of vocal cord inflammation | stridor, much more serious, indicates significant decrease in airway diameter, treated with racemic epi 2.25 solution aerosol, more common in children |
| What is the best way to treat pt’s who are be extubated that have been intubated for a long time or have failed prior extubation due to glottis edema | IV steroids x 24 hours and watch carefully |
| Pt has hoarseness after extubation and the symptoms resolve spontaneously, what do you suspect | laryngeal/vocal cord ulcerations |
| Several weeks or several months post extubation pt complains of difficulty swallowing, hoarseness and stridor, what do you suspect | vocal cord polyps or granulomas (severe or persistent must remove surgically) |
| Vocal cord paralysis | less common but more serious, usually in extubated pts with hoarseness and stridor that doesn’t resolve with Rx and time, if obstructive symptoms continue, pt will require trach |
| Laryngeal stenosis | a less common but more serious problem of intubation, is scar tissue replaces normal tissue of the larynx causing stricture and decreased mobility, symptoms are hoarseness and or stridor may need surgery or permanent trach |
| What are the most common tracheal lesions | granulomas, tracheomalacia and tracheal stenosis, they can occur separately or together along with other less common lesions |
| What are the signs and symptoms of tracheal granulomas | difficultly swallowing, develop slowly and cause stridor/hoarseness |
| What is tracheomalacia | aka floppy trach, softening of the cartilage rings causing collapse of the trachea during insp |
| Tracheal stenosis is | narrowing of the lumen of the trachea due to fibrous scarring causing decrease diameter of tracheal lumen, in pts who have been ETT, occurs at cuff site, trach pt’s cuff, tube tip or stoma |
| What can cause tracheal stenosis in Pt’s with trach | too large a stoma, infection of the stoma, movement of the tube, freq tube changes |
| Signs and symptoms of post extubation tracheal damage | difficulty expectorating, dyspnea, stridor, often appear acutely, often appears over several months, symptoms may not appear until airy decreased by 50 percent |
| Anastomosis | surgery to repair tracheal lesions where 3 rings are removed, sometimes when severe done as a staged repair-several surgeries to fix damage |
| Tracheoesophageal fistula | TE-fistula, small rare complication of ETT or trach where a small opening between the trach and esophagus develops, my cause sepsis, malnutrition or trach erosion, Dx endoscope, rx surgery |
| Tracheoinnominate fistula | trach tube causes erosion through the innominate artery causing massive hemorrhage and usually death, pulsing of trach tube may be only indicator, inflate cuff to slow bleed |
| What are the best ways to prevent airway trauma from ETT/Trach tubes | limit tube movement, use largest tube size possible, don’t change unless necessary, discourage unnecessary coughing and talking, limit cuff press, always use sterile techniques |
| What are the best ways to limit ETT/Trach tube movement | proper taping, sedation, swivel adaptors, O2-use trach mask instead of T |
| What are the most critical responsibilities in maintenance of artificial airways | securing tube and maintaining proper placement, providing communication, ensure adequate humidification, minimize infections, aid secretion clearance, good cuff care, troubleshoot airway emergencies. |
| What is the best way to maintain proper placement of an ETT or NT tube | tape, silk tape is ok short term, but cloth tape is best |
| What is the best way to secure a trach | trach ties, threaded through the flange and tied on pts neck with one finger slack |
| When a pt has an ETT tube and flex’s his neck (flexion), what happens to the tube | tube end moves down toward the carina |
| When a pt with an ETT tube extend his neck (extension) what happens to the tube end | pulls tube up toward the larynx |
| What is a Passy-Muir valve and what does do | one way valve that pt can breath in through so that air can then pass out over vocal cords, used for speech, good for spontaneous or vented pt, cuff must be deflated to work |
| What must be monitored following placement of a passey-muir valve | HR, RR, SpO2 |
| Our are trying out a Passy-Muir valve on a trach pt and when you remove it, a rush of air comes out, what do you suspect | air trapping |
| What are the benefits to a Passy-Muir valve | speech, better vocal cord function, better sense of smell, fewer secretion problems |
| How is humidity delivered to the airway of intubated or tached pts | heated humidifier, LVN cool or heated aerosol, HME |
| What are the S and S of infection in a intubated or trached pt | 1 changes in sputum; color, consistency, amount 2 BS wheezes, crackles, rhonchi 3 CXR, infiltrates/atelectasis 4 fever, increased HR, leukocytosis |
| What is the best way to minimize the possibility of infection to intubated/trached pts | sterile techniques in sxn, clean and sterile resp equip, hand washing, prevent secretion retention, change inner canulla, prevent aspirations |
| What is the most common cause of airway obstruction in critically ill pts | retained secretions |
| What are the 3 most common airway emergencies that can occur | tube obstruction, cuff leak, accidental extubation |
| High press alarm goes off on a vented pt, what do suspect | tube obstruction |
| Low press alarm goes off on a vented pt, what do you suspect | cuff leak |
| What clinical signs often are seen in airway emergencies | varying degrees of resp distress, decreased or changed BS, air movement through mouth, press changes in vent |
| Inability to pass a suction catheter down a pt tube suggests what | airway obstruction |
| Ability to fully pass a catheter down a pt tube might suggest what | full or partial extubation |
| Intubated pt can talk when you walk into the room might suggest what | cuff is leaking |
| What extra equipment should always be kept at bedside of an intibated pt | replacement airways, manual resuscitator with mask |
| What are the two biggest causes of tube obstructions | biting tube and mucous plugging, others are kink, herniation of cuff, jamming tube against trach wall, toys |
| Clinical signs of a partial tube obstruction are | increased HR, decreased BS, decreased airflow through tube, if on vent-increased airway press (VCV) and decreased volume (PCV) |
| Clinical signs of a complete tube obstruction are | severe distress, no BS, no gas through tube |
| If you cannot clear an obstruction in an artificial airway what action should be taken | remove the airway and oxygenate the pt |
| What is methylene blue used for | put in pt food, if it shows up in secretions, pt is aspirating |
| What is a Hi-Lo Evac tube | helps decrease chance of VAP by allowing for evacuation of the subglottic space (suctions the space just above the cuff where secretions can pool) |
| Pressure from tracheal tubes can cause what | ischemia and ulcerations |
| Friction like injuries to the trachea can be caused by what in a trached pt | airway shifting as pt’s head or neck is moved, or by tube manipulation |
| Laryngeal dysfunction can be caused by what | lack of stimulation, airflow, restricted movement secondary to equipment (trach tubes do not cause because they do not pass through) |
| What are the most common laryngeal lesions associated with endotracheal intubation | glottis edema and vocal cord inflammation |
| What is glottis edema and vocal cord inflammation | shows up after extubation-caused by pressure from ETT or trauma during intubation, swelling worsens over 24 hours symptoms are hoarsness and stridor |
| What is the main symptom of glottis edema | hoarseness |
| What is the main symptom of vocal cord inflammation | stridor, much more serious, indicates significant decrease in airway diameter, treated with racemic epi 2.25 solution aerosol, more common in children |
| What is the best way to treat pt’s who are be extubated that have been intubated for a long time or have failed prior extubation due to glottis edema | IV steroids x 24 hours and watch carefully |
| Pt has hoarseness after extubation and the symptoms resolve spontaneously, what do you suspect | laryngeal/vocal cord ulcerations |
| Several weeks or several months post extubation pt complains of difficulty swallowing, hoarseness and stridor, what do you suspect | vocal cord polyps or granulomas (severe or persistent must remove surgically) |
| Vocal cord paralysis | less common but more serious, usually in extubated pts with hoarseness and stridor that doesn’t resolve with Rx and time, if obstructive symptoms continue, pt will require trach |
| Laryngeal stenosis | a less common but more serious problem of intubation, is scar tissue replaces normal tissue of the larynx causing stricture and decreased mobility, symptoms are hoarseness and or stridor may need surgery or permanent trach |
| What are the most common tracheal lesions | granulomas, tracheomalacia and tracheal stenosis, they can occur separately or together along with other less common lesions |
| What are the signs and symptoms of tracheal granulomas | difficultly swallowing, develop slowly and cause stridor/hoarseness |
| What is tracheomalacia | aka floppy trach, softening of the cartilage rings causing collapse of the trachea during insp |
| Tracheal stenosis is | narrowing of the lumen of the trachea due to fibrous scarring causing decrease diameter of tracheal lumen, in pts who have been ETT, occurs at cuff site, trach pt’s cuff, tube tip or stoma |
| What can cause tracheal stenosis in Pt’s with trach | too large a stoma, infection of the stoma, movement of the tube, freq tube changes |
| Signs and symptoms of post extubation tracheal damage | difficulty expectorating, dyspnea, stridor, often appear acutely, often appears over several months, symptoms may not appear until airy decreased by 50 percent |
| Anastomosis | surgery to repair tracheal lesions where 3 rings are removed, sometimes when severe done as a staged repair-several surgeries to fix damage |
| Tracheoesophageal fistula | TE-fistula, small rare complication of ETT or trach where a small opening between the trach and esophagus develops, my cause sepsis, malnutrition or trach erosion, Dx endoscope, rx surgery |
| Tracheoinnominate fistula | trach tube causes erosion through the innominate artery causing massive hemorrhage and usually death, pulsing of trach tube may be only indicator, inflate cuff to slow bleed |
| What are the best ways to prevent airway trauma from ETT/Trach tubes | limit tube movement, use largest tube size possible, don’t change unless necessary, discourage unnecessary coughing and talking, limit cuff press, always use sterile techniques |
| What are the best ways to limit ETT/Trach tube movement | proper taping, sedation, swivel adaptors, O2-use trach mask instead of T |
| What are the most critical responsibilities in maintenance of artificial airways | securing tube and maintaining proper placement, providing communication, ensure adequate humidification, minimize infections, aid secretion clearance, good cuff care, troubleshoot airway emergencies. |
| What is the best way to maintain proper placement of an ETT or NT tube | tape, silk tape is ok short term, but cloth tape is best |
| What is the best way to secure a trach | trach ties, threaded through the flange and tied on pts neck with one finger slack |
| When a pt has an ETT tube and flex’s his neck (flexion), what happens to the tube | tube end moves down toward the carina |
| When a pt with an ETT tube extend his neck (extension) what happens to the tube end | pulls tube up toward the larynx |
| What is a Passy-Muir valve and what does do | one way valve that pt can breath in through so that air can then pass out over vocal cords, used for speech, good for spontaneous or vented pt, cuff must be deflated to work |
| What must be monitored following placement of a passey-muir valve | HR, RR, SpO2 |
| Our are trying out a Passy-Muir valve on a trach pt and when you remove it, a rush of air comes out, what do you suspect | air trapping |
| What are the benefits to a Passy-Muir valve | speech, better vocal cord function, better sense of smell, fewer secretion problems |
| How is humidity delivered to the airway of intubated or tached pts | heated humidifier, LVN cool or heated aerosol, HME |
| What are the S and S of infection in a intubated or trached pt | 1 changes in sputum; color, consistency, amount 2 BS wheezes, crackles, rhonchi 3 CXR, infiltrates/atelectasis 4 fever, increased HR, leukocytosis |
| What is the best way to minimize the possibility of infection to intubated/trached pts | sterile techniques in sxn, clean and sterile resp equip, hand washing, prevent secretion retention, change inner canulla, prevent aspirations |
| What is the most common cause of airway obstruction in critically ill pts | retained secretions |
| What are the 3 most common airway emergencies that can occur | tube obstruction, cuff leak, accidental extubation |
| High press alarm goes off on a vented pt, what do suspect | tube obstruction |
| Low press alarm goes off on a vented pt, what do you suspect | cuff leak |
| What clinical signs often are seen in airway emergencies | varying degrees of resp distress, decreased or changed BS, air movement through mouth, press changes in vent |
| Inability to pass a suction catheter down a pt tube suggests what | airway obstruction |
| Ability to fully pass a catheter down a pt tube might suggest what | full or partial extubation |
| Intubated pt can talk when you walk into the room might suggest what | cuff is leaking |
| What extra equipment should always be kept at bedside of an intibated pt | replacement airways, manual resuscitator with mask |
| What are the two biggest causes of tube obstructions | biting tube and mucous plugging, others are kink, herniation of cuff, jamming tube against trach wall, toys |
| Clinical signs of a partial tube obstruction are | increased HR, decreased BS, decreased airflow through tube, if on vent-increased airway press (VCV) and decreased volume (PCV) |
| Clinical signs of a complete tube obstruction are | severe distress, no BS, no gas through tube |
| If you cannot clear an obstruction in an artificial airway what action should be taken | remove the airway and oxygenate the pt |
| What is methylene blue used for | put in pt food, if it shows up in secretions, pt is aspirating |
| What is a Hi-Lo Evac tuve | helps decrease chance of VAP by allowing for evacuation of the subglottic space (suctions the space just above the cuff where secretions can pool) |
| How can accident extubation be identified | decreased BS and airflow through the tube, ability to pass catheter with hitting obstruction or getting cough, pt on vent, air through mouth, air into stomach, decreased VT and VCV, must be reintubated |
| How do we assess a pt for readiness for extubation | does reason for artificial airway no longer exists? Can pt protect his airway-gag, caugh, can pt mange secretions |
| Does successful weaning mean a pt is ready to be extubated | no, they have nothing to do with each other |
| How do we evaluate patency of the trachea | perform a cuff leak test prior to extubation (test prior to extubation-not part of extubation), deflate the cuff, occlude the tube if breathing occurs test is positive, if no, suspect trach edema |
| What are the complete weaning parameters aka respiratory parameters | pt must breath spontaneously off vent, parameters are RR, VT, VC, NIF(MIP), minute ventilation |
| RSBI | tube removal parameters aka rapid shallow breathing index less than 105 take out, above 105 stays in. RR divided by VT in liters is RSBI |
| 47 yr female with an upper GI bleed, becomes hypoxic post extubation and exhibits mild stridor, what do you suspect | glottic edema, with partial airway obstruction. Treat with cool aerosol by mask with O2, Racemic epi .5 mls of 2.25% with in 3 mls NS |
| If post extubation glottic edema is severe, what can we do to oxygenate pt | heliox 70/30 or 80/20 |
| What are the common problems of extubation | harseness and sore throat, airway obstruction, increased risk of aspiration, difficult secretion clearance and glottic edema |
| What is the major complication that is associated with extubation | laryngospasm, usually transient, last a few seconds, high fio2 and positive press, if persists may have to reintubate |
| What is a self inflating bag | bag with a one way valve on both ends and an elbow and reservoir, bag is resilient and returns to original shape after squeezed, O2 into bag at 10 lpm, fills bag then reservoir |
| What is fio2 of a self inflating bag a function of | volume of the reservoir, gas flow and rate of return of the bag |
| Mapleson bag aka flow inflating bag | an anesthesia type bag, O2 into bag inflates bag bag is manually compress and breath is delivered, 100% O2 most often with neonates, has valve so wont over inflate (17-20) |
| What is the prefeerd bag for neonatal resuscitation | mapleson or flow inflating bag, operator can feel the patients compliance |
| What is the press that neonates are ventilated at on a bag mask | 17-20 |
| Inspired air contains how much CO2 | .03-.04 % |
| Expired air contains how much CO2 | 4-6 % |
| What is transcutaneous monitoring aka TCM or T-COM | non invasive way to indirectly measure ABG, electrode on skin surface, |
| What is a capnogram wave form look like | square wave, bottom left of square is begin expiration, top right is end expiration |
| What is transcutaneous O2 monitoring aka PtcO2 | heated clark electrode, best in neonates |
| What is transcutaneous CO2 monitoring aka PtcCO2 | severinghous electrode |
| What are the advantages to transcutaneous monitoring | non-invasive of blood gas values |
| What are the disadvantages of transcutaneous monitoring | burns to skin at electrode site, not work well in adults, reposition 4-6 hours |
| What are the complications of suction | hypoxemia, arrhythmias, hypotension, lung collapse, mucosal damage |
| What is the best way to prevent hypoxemia, arrhythmias and hypotension when sxn | preoxygenation, intermittent O2 with high FIO2, limit sxn to 15 seconds, cardiac monitoring |
| Indications for nasotracheal sxn are | retained secretions but no artificial airway |
| What extra equip is needed to nasotracheal sxn | sterile water, jelly and nasal trumpet if needed |
| Nasotracheal sxn procedure | lubricate catheter, gently insert through nostril toward septum, with out suction and twist, have pt assume sniffing position to align larynx with pharynx on inspiration pass catheter through cords into larynx advance to cough |
| Arterial lines are for what | used for pts who require frequent blood draws and can also measure blood pressure |
| How do we read a tracing from an arterial blood pressure monitor | highest point is systolic, lowest is diastolic, small bump is dicrotic notch and is when aortic valve flips closed |
| Where does the transducer have to be in order for an a-line to give an accurate blood pressure | transducer has to be leveled so it sits at the 4th intercostals space at the mid axillary line |
| When placing a chest tube for a pheumothorax, what direction is the tube | up |
| When placing a chest tube for a hemothorax, what direction is the tube | tube down |
| When placing a chest tube and pt has both hemo and pneumo, which direction should the tube go in | down, drain fluid first then deal with air |
| In a 3 bottle system, what do the bottles represent | bottle 1 is collector, bottle 2 is the water seal and maintains the negative press in lungs and bottle 3 is the suction control bottle, a safety devise that keeps press down |
| What is a pleur-evac chest drainage system | basically a 3 bottle system but in one disposable unit |
| What does bottle 3 do in a 3 bottle system | the suction control bottle, a safety devise that keeps press down |
| what is the Heimlich chest drain valve | flutter chest drain valve designed for field operations |
| the larynx is a passageway from what to what | pharynx to trachea |
| the upper pair of folds are called | the false vocal cords |
| cuff pressure should be | 18-22 |
Created by:
williamwallace
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