Respiratory Care: Artificial Airways, Mechanical Ventilation, and Chest Tubes

Course #38800 - $15 • 3 Hours/Credits


Self-Assessment Questions

    1 . Inadvertent slipping of an endotracheal tube into the esophagus will result in
    A) epiglottitis.
    B) pneumothorax.
    C) gastric dilatation.
    D) complete obstruction.

    TYPES OF ARTIFICIAL AIRWAYS

    Immediately after intubation, the lung fields should be auscultated and an x-ray ordered to determine if the tube is placed properly. Because the right bronchus is straighter than the left, the tube may be improperly inserted into the right mainstream bronchus, permitting aeration of the right lung only. If the end of the endotracheal tube rests on the carina (i.e., the area where the trachea bifurcates into the left bronchus and right bronchus), partial or complete obstruction results. Inadvertent slipping of the tube into the esophagus will result in gastric dilatation [1,4].

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    2 . After a tracheotomy tube is removed, the opening usually closes within
    A) 2 hours.
    B) 24 hours.
    C) 2 days.
    D) 5 days.

    TYPES OF ARTIFICIAL AIRWAYS

    Prior to removal of a tracheotomy or laryngectomy tube, the patient should be ventilated, oxygenated, and suctioned to remove tracheal and pharyngeal secretions. The cuff is deflated, and the patient is again suctioned. The tube is then removed, and a dressing is placed over the stoma. Normally, the opening closes within five days [5,6].

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    3 . Excessive pressure on the trachea from the cuff of endotracheal tubes
    A) will prevent tissue necrosis.
    B) will increase blood supply to the area.
    C) may lead to tracheal stenosis or a tracheoesophageal fistula.
    D) All of the above

    POSSIBLE COMPLICATIONS OF ARTIFICIAL AIRWAYS

    Excessive pressure on the trachea from the endotracheal tube cuff can decrease blood supply to the area and cause tissue necrosis. This may lead to tracheal stenosis or a tracheoesophageal fistula.

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    4 . Which of the following is NOT a type of positive-pressure ventilator?
    A) Time-cycled
    B) Volume-cycled
    C) Pressure-cycled
    D) Provider-cycled

    MECHANICAL VENTILATION

    There are basically three types of positive-pressure ventilators: time-cycled, pressure-cycled, and volume-cycled machines.

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    5 . Intermittent mandatory ventilation (IMV)
    A) provides air in synchronization with the patient's own ventilation efforts.
    B) facilitates diffusion of more oxygen from the alveoli into the pulmonary capillaries.
    C) delivers air for individuals who are apneic (e.g., those who have suffered damage to the brain stem).
    D) delivers a preset tidal volume at a specific rate while also providing a continuous flow of air for spontaneous breaths.

    MECHANICAL VENTILATION

    IMV delivers a preset tidal volume at a specific rate while also providing a continuous flow of air for spontaneous breaths. IMV was originally introduced for the purpose of gradually weaning individuals from ventilators, but the use of this type of ventilation has expanded, and it has become popular for patients who require mechanical ventilation but are able to initiate some inspiratory effort on their own, such as patients with chronic obstructive pulmonary disease. IMV cannot be used for individuals who are apneic (e.g., those who have suffered damage to the brain stem). An advantage of IMV ventilation is that it allows the patient to use respiratory muscles, which prevents atrophy [2,3,5,6].

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    6 . Which of the following physiologic changes occurs with the administration of positive end-expiratory pressure (PEEP)?
    A) Increased cardiac output
    B) An increase in intrathoracic pressure
    C) An increase in the venous return of blood to the heart
    D) Decreased production of antidiuretic hormone (ADH)

    MECHANICAL VENTILATION

    Physiologic changes occur with the administration of PEEP. PEEP causes an increase in intrathoracic pressure, which decreases the venous return of blood to the heart. The baroreceptors in the thoracic aorta interpret the decreased venous return as hypovolemia and stimulate an increase in production of antidiuretic hormone (ADH). Increased ADH can lead to the development of hypovolemia, which results in decreased cardiac output. Another potential problem encountered is the development of a pneumothorax [2,6].

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    7 . Patients who are "out of phase with the ventilator"
    A) should not be pharmacologically sedated.
    B) will not improve with altered inspiratory flow rates.
    C) are only able to spontaneously inhale, but not exhale.
    D) attempt to actively exhale while the ventilator is still delivering the inspired volume.

    MECHANICAL VENTILATION

    Patients will occasionally "fight" the ventilator, also referred to as "being out of phase with the ventilator." In these cases, the patient attempts to actively exhale while the ventilator is delivering the inspired volume. This conflict should be corrected because it results in decreased volume delivery and excessively high airway pressures. A bag-valve mask may be used to increase volume delivery gradually and decrease the respiratory rate. Altered inspiratory flow rates may be ordered for the ventilator to correct the situation, or medication may be prescribed to sedate the patient and allow the ventilator to function more efficiently [2,7].

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    8 . What measurement is used to determine whether a patient's chest expansion is sufficient to produce a negative alveolar pressure and stimulate a deep inspiration?
    A) Tidal volume
    B) Expiratory reserve volume
    C) Maximum inspiratory effort
    D) Residual inspiratory volume

    MECHANICAL VENTILATION

    If the patient is receiving PEEP, it should be no higher than 5 cm; otherwise, it will interfere with the patient's independent inspiratory efforts. Vital capacity should be greater than 15 mL/kg of body weight, as this indicates that the patient is able to move enough air. This measurement can be obtained using a respirometer attached to the end of the patient's endotracheal or tracheotomy tube. Maximum inspiratory effort should also be assessed to determine whether the patient's chest expansion is sufficient to produce negative alveolar pressure and stimulate a deep inspiration. The greater the patient's ability to inhale, the more negative the inspiratory pressure will be. This is assessed by attaching a pressure gauge to the end of the endotracheal or tracheotomy tube and instructing the patient to take in a deep breath. The patient is considered to be ready for weaning with a pressure of -25 to -30 cm. Respiratory rate and minute volume measurements should be taken. The respiratory rate should be at least 12 breaths per minute, but no greater than 20 breaths per minute [6,7]. Additional criteria for weaning include a stable chest wall, an acceptable chest x-ray, adequate cardiac output, normal body temperature, adequate nutritional status, and a generally well-rested condition.

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    9 . The major objective of nursing care for patients with chest tubes is to
    A) facilitate emergency access to the trachea.
    B) prevent the spread of pulmonary infection.
    C) support patients' wishes with regards to body image issues.
    D) facilitate drainage of fluid and air, fostering lung re-expansion.

    CHEST TUBES

    The major objective of nursing care for patients with chest tubes is to facilitate drainage of fluid and air, fostering lung re-expansion. After insertion of the chest tube, a dressing is applied using sterile technique. Gauze or a hydrocolloid dressing is wrapped around the insertion site, and wide tape is applied to provide an occlusive dressing. This prevents air from entering the intrapleural space. Although the chest tube is sutured in place, further care should be taken to secure the tube when applying the tape. If drainage is present on the dressing, the physician should be notified [7].

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    10 . Which of the following should be included in patient teaching for individuals with chest tubes?
    A) Movement such as turning, coughing, and deep breathing should be discouraged.
    B) Patients should be discouraged from verbalizing fears, which could increase anxiety.
    C) Patients should be informed that the tube is not secured and may easily become dislodged.
    D) Patients should be told that pain medication can be given to decrease discomfort during breathing exercises.

    CHEST TUBES

    Patients with chest tubes may restrict their breathing and movement not only to minimize pain, but because they fear they may dislodge the tube. They should be informed that the tube is secured with sutures and tape. Movement such as turning, coughing, and deep breathing should be encouraged, as this will facilitate re-expansion of the lung. The patient should be told that pain medication is available to decrease discomfort during breathing exercises. Opioids, however, should be avoided or administered judiciously because they can depress the respiratory rate [7].

    The collection receptacle should also be explained to the patient. If suction is necessary, patients should be aware that bubbling and some noise are expected. Patients and family members should be given the opportunity to verbalize fears and ask questions regarding the procedure and equipment. Be aware that chest tubes may seem more frightening to visitors than other sorts of tubes, and be prepared to reassure patients that it is the visitor's lack of knowledge, not the patient's situation, that has caused the reaction [7].

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