Question 1

A physician is concerned about the potential for tracheal damage due to tube movement in a patient who recently underwent tracheotomy and is now receiving 40% oxygen through a T tube (Briggs adapter). Which of the following would be the best way to limit tube movement in this patient?
A) Give a neuromuscular blocker to prevent patient movement.
B) Secure the T tube delivery tubing to the bed rail.
C) Tape the T tube to the tracheostomy tube connector.
D) Switch from the T tube to a tracheostomy collar.

Accepted Answer

If the tracheostomy patient requires oxygen therapy, tracheostomy collars are preferred to T tubes or Briggs adapters.

Question 2

After removal of an oral endotracheal tube, a patient exhibits hoarseness and stridor that do not resolve with racemic epinephrine treatments. What is most likely the problem?
A) Vocal cord paralysis
B) Tracheoesophageal fistula
C) Glottic edema or cord inflammation
D) Tracheomalacia

Accepted Answer

Vocal cord paralysis is likely in extubated patients with hoarseness and stridor that does not resolve with treatment or time.

Question 3

A patient has been receiving positive-pressure ventilation through a tracheostomy tube for 4 days. In the past 2 days, there is evidence of both recurrent aspiration and abdominal distention but minimal air leakage around the tube cuff. What is most likely cause of the problem?
A) Paralysis of the vocal cords
B) Underinflated tube cuff
C) Tracheoesophageal fistula
D) Tracheoinnominate fistula

Accepted Answer

Diagnosis can be made by a history of recurrent aspiration and abdominal distention as air is forced into the esophagus during positive-pressure ventilation.

Question 4

An alert patient with a long-term need for a tracheostomy tube (because of recurrent aspiration) is having difficulty communicating with the intensive care unit staff. Which of the following would you recommend to help this patient communicate better?
1) Use a letter, phrase, or picture board.
2) Consider switching to a fenestrated tracheostomy tube.
3) Consider a "talking" tracheostomy tube.
A)1 and 2 only
B)1 and 3 only
C)2 and 3 only
D)1, 2, and 3

Accepted Answer

Using a letter, phrase, or picture board can help the patient communicate effectively even without a talking tracheostomy tube. A "talking" tracheostomy tube is an option, but it may not be necessary in this case as the patient is alert and able to use other means of communication. Switching to a fenestrated tracheostomy tube may improve the patient's ability to speak but it may not completely solve the communication issue. Therefore, options 1 and 3 would be the best choices.

Question 5

Tracheal stenosis occurs in as many as 1 in 10 patients after prolonged tracheostomy. At what sites does this stenosis usually occur?
1) Cuff site
2) Tip of the tube
3) Stoma site
A)1 and 2 only
B)1 and 3 only
C)2 and 3 only
D)1, 2, and 3

Accepted Answer

Tracheal stenosis can occur at multiple sites after prolonged tracheostomy, including the cuff site, the tip of the tube, and the stoma site.

Question 6

Soon after endotracheal tube extubation, an adult patient exhibits a high-pitched inspiratory noise, heard without a stethoscope. Which of the following actions would you recommend?
A) STAT-heated aerosol treatment with saline
B) STAT racemic epinephrine aerosol treatment
C) Careful observation of the patient for 6 hr
D) Immediate reintubation via the nasal route

Accepted Answer

Stridor is often treated with epinephrine (2.25% racemic solution or levoepinephrine 1:1000) via aerosol.

Question 7

To ensure adequate humidification for a patient with an artificial airway, inspired gas at the proximal airway should be 100% saturated with water vapor and at which of the following temperatures?
A) 32° to 35° C
B) 37° to 40° C
C) 30° to 32° C
D) 40° to 42° C

Accepted Answer

These devices can provide saturated gas to the airway at temperatures between 32° and 35° C.

Question 8

An adult man on ventilatory support has just been intubated with a 7-mm oral endotracheal tube equipped with a high-residual-volume, low-pressure cuff. When sealing the cuff to achieve a minimal occluding volume, you note a cuff pressure of 45 cm H₂O. What is most likely the problem? A) The tube chosen is too small for the patient. B) The cuff pilot balloon and line are obstructed. C) The tube is in the right main stem bronchus. D) The cuff has herniated over the tube tip.

Accepted Answer

High pressures may be caused by the need to overinflate the cuff to seal the airway. This problem is common if the tube chosen is too small for the patient's trachea, positioned too high in the trachea or if the patient has developed tracheomalacia which is softening of the tracheal tissue.

Question 9

Which of the following techniques or procedures should be used to help minimize infection of a tracheotomy stoma?
1) Regular aseptic stoma cleaning
2) Adherence to sterile techniques
3) Regular change of tracheostomy dressings
A)1 and 2 only
B)1 and 3 only
C)2 and 3 only
D)1, 2, and 3

Accepted Answer

Regular aseptic stoma cleaning, adherence to sterile techniques, and regular change of tracheostomy dressings are all essential practices to minimize infection of a tracheotomy stoma.

Question 10

Repeated connecting and disconnecting of a cuff pressure manometer to the pilot tube of a cuffed tracheal airway will do which of the following?
A) Increase cuff pressure.
B) Not affect cuff pressure.
C) Decrease cuff pressure.
D) Rupture the cuff.

Accepted Answer

Attaching the measurement system to the pilot tube evacuates some volume from the cuff (and lowers its pressure). For this reason, you should always adjust the pressure to the desired level, never just measure it.

Question 11

Which of the following injuries are seen with tracheostomy tubes?
1) Tracheomalacia
2) Tracheal stenosis
3) Glottic edema
4) Vocal cord granulomas
A)1 and 2 only
B)2 and 4 only
C)3 and 4 only
D)1, 2, and 3 only

Accepted Answer

Tracheostomy tubes can cause tracheomalacia (softening of the tracheal cartilage) and tracheal stenosis (narrowing of the trachea), but typically do not cause glottic edema or vocal cord granulomas.

Question 12

Which of the following techniques may be used to diagnose injury associated with artificial airways?
1) Laryngoscopy or bronchoscopy
2) Physical examination
3) Air tomography
4) Pulmonary function studies
A)1 and 2 only
B)1 and 3 only
C)2, 3, and 4 only
D)1, 2, 3, and 4

Accepted Answer

The answer of Which of the following techniques may be...

Question 13

When checking for proper placement of an endotracheal tube in an adult patient on chest radiograph, it is noted that the distal tip of the tube is 2 cm above the carina. Which of the following actions would you recommend?
A) Withdraw the tube by 2 to 3 cm (using tube markings as a guide).
B) Withdraw the tube by 7 to 8 cm (using tube markings as a guide).
C) Advance the tube by 2 to 3 cm (using tube markings as a guide).
D) Advance the tube by 7 to 8 cm (using tube markings as a guide).

Accepted Answer

If the tube is malpositioned, you should remove the old tape and reposition the tube, using the centimeter markings as a guide.

Question 14

Compared with traditional surgical tracheostomy, which of the following are true about percutaneous dilatational tracheostomy?
1) Percutaneous dilatational tracheostomy has a lower incidence of complications.
2) Percutaneous dilatational tracheostomy is faster than traditional tracheostomy.
3) Percutaneous dilatational tracheostomy can be performed at the bedside.
4) Percutaneous dilatational tracheostomy does not require anterior neck dissection.
A)1 and 3 only
B)1, 2, and 3 only
C)3 and 4 only
D)2, 3, and 4 only

Accepted Answer

Percutaneous dilatational tracheostomy has been found to have a lower incidence of complications, is faster than traditional tracheostomy, and can be performed at the bedside. It does not require anterior neck dissection. Therefore, options 1, 2, and 3 are correct, while option 4 is incorrect.

Question 15

Which of the following is likely to increase the likelihood of damage to the tracheal mucosa?
A) Maintaining cuff pressures below 20 to 25 mm Hg
B) Using the minimal leak technique for inflation
C) Using a low-residual-volume, low-compliance cuff
D) Monitoring intracuff pressures every 1 to 2 hr

Accepted Answer

In the past, high-pressure tracheal tube cuffs were a major cause of airway damage. Since the 1970s, high-residual-volume, low-pressure cuffs have become the norm (see Figure 36-34).

Question 16

Tracheal airways increase the incidence of pulmonary infections for which of the following reasons?
1) Lower levels of humidification
2) Increased aspiration of pharyngeal material
3) Contaminated equipment or solutions
4) Ineffective clearance through cough
A)1 and 3 only
B)1, 2, and 3 only
C)3 and 4 only
D)2, 3, and 4 only

Accepted Answer

Tracheal airways can lead to increased aspiration of pharyngeal material, use of contaminated equipment or solutions, and ineffective clearance through cough, all of which contribute to a higher risk of pulmonary infections.

Question 17

A patient is being evaluated for tracheal damage sustained while having undergone prolonged tracheostomy intubation approximately 3 months earlier. The flow-volume loop demonstrates a fixed obstructive pattern. What is the most likely cause of the problem?
A) Tracheomalacia
B) Laryngeal web
C) Cord paralysis
D) Tracheal stenosis

Accepted Answer

Tracheal stenosis will appear as a fixed obstructive pattern, with flattening of both the inspiratory and expiratory limbs of the flow-volume loop

Question 18

What is the maximum recommended range for tracheal tube cuff pressures?
A) 15 to 20 mm Hg
B) 20 to 25 mm Hg
C) 25 to 30 mm Hg
D) 30 to 35 mm Hg

Accepted Answer

The goal is to keep cuff pressures below the tracheal mucosal capillary perfusion pressure, estimated to range between 20 and 25 mm Hg to help minimize aspiration.

Question 19

When checking for proper placement of an endotracheal tube or a tracheostomy tube on a chest radiograph, how far above the carina should the distal tip of the tube be positioned?
A) 1 to 2 cm
B) 2 to 4 cm
C) 3 to 6 cm
D) 6 to 8 cm

Accepted Answer

The tube tip should be approximately 3 to 6 cm above the carina in adults, or between the second and fourth tracheal rings.

Question 20

What is the most common sign associated with the transient glottic edema or vocal cord inflammation that follows extubation?
A) Difficulty in swallowing
B) Wheezing
C) Orthopnea
D) Hoarseness

Accepted Answer

The primary symptoms of glottic edema and vocal cord inflammation are hoarseness and stridor.

Quiz 36: Airway Management

A physician is concerned about the potential for tracheal damage due to tube movement in a patient who recently underwent tracheotomy and is now receiving 40% oxygen through a T tube (Briggs adapter) . Which of the following would be the best way to limit tube movement in this patient?

After removal of an oral endotracheal tube, a patient exhibits hoarseness and stridor that do not resolve with racemic epinephrine treatments. What is most likely the problem?

A patient has been receiving positive-pressure ventilation through a tracheostomy tube for 4 days. In the past 2 days, there is evidence of both recurrent aspiration and abdominal distention but minimal air leakage around the tube cuff. What is most likely cause of the problem?

Tracheal stenosis occurs in as many as 1 in 10 patients after prolonged tracheostomy. At what sites does this stenosis usually occur? 1) Cuff site 2) Tip of the tube 3) Stoma site

Soon after endotracheal tube extubation, an adult patient exhibits a high-pitched inspiratory noise, heard without a stethoscope. Which of the following actions would you recommend?

To ensure adequate humidification for a patient with an artificial airway, inspired gas at the proximal airway should be 100% saturated with water vapor and at which of the following temperatures?

An adult man on ventilatory support has just been intubated with a 7-mm oral endotracheal tube equipped with a high-residual-volume, low-pressure cuff. When sealing the cuff to achieve a minimal occluding volume, you note a cuff pressure of 45 cm H₂O. What is most likely the problem?

Which of the following techniques or procedures should be used to help minimize infection of a tracheotomy stoma? 1) Regular aseptic stoma cleaning 2) Adherence to sterile techniques 3) Regular change of tracheostomy dressings

Repeated connecting and disconnecting of a cuff pressure manometer to the pilot tube of a cuffed tracheal airway will do which of the following?

Which of the following injuries are seen with tracheostomy tubes? 1) Tracheomalacia 2) Tracheal stenosis 3) Glottic edema 4) Vocal cord granulomas

Which of the following techniques may be used to diagnose injury associated with artificial airways? 1) Laryngoscopy or bronchoscopy 2) Physical examination 3) Air tomography 4) Pulmonary function studies

When checking for proper placement of an endotracheal tube in an adult patient on chest radiograph, it is noted that the distal tip of the tube is 2 cm above the carina. Which of the following actions would you recommend?

Which of the following is likely to increase the likelihood of damage to the tracheal mucosa?

Tracheal airways increase the incidence of pulmonary infections for which of the following reasons? 1) Lower levels of humidification 2) Increased aspiration of pharyngeal material 3) Contaminated equipment or solutions 4) Ineffective clearance through cough

A patient is being evaluated for tracheal damage sustained while having undergone prolonged tracheostomy intubation approximately 3 months earlier. The flow-volume loop demonstrates a fixed obstructive pattern. What is the most likely cause of the problem?

What is the maximum recommended range for tracheal tube cuff pressures?

When checking for proper placement of an endotracheal tube or a tracheostomy tube on a chest radiograph, how far above the carina should the distal tip of the tube be positioned?

What is the most common sign associated with the transient glottic edema or vocal cord inflammation that follows extubation?