Practice Companion by Oakes | ACCS Study
Resource with Reviewed Question Set
A difficult intubation is anticipated with an obese pt. The decision is made to intubate by video
laryngoscopy. Which of the following is LEAST likely to be needed:
A) Cook's Exchanger
B) Rigid Stylet
C) Cuffed Endotracheal Tube
D) Video-enabled Laryngoscope - ✔✔A) cook's exchanger
Video laryngoscopy involves use of a normal ET Tube with the addition of a rigid stylet, as well as a
video-enabled laryngoscope and other normal intubation equipment.
A Cook's Tube Exchanger is not necessary - this is used to exchange tubes already in place.
A 5'6" female has been transferred from Intermediate Care to Intensive Care in respiratory distress. She
is intubated with a silver-coated #7.0 Endotracheal tube. CXR immediately following intubation shows
Right Upper Lobe infiltrate with bibasilar atelectasis. The ET Tube is noted to be approximately 4 cm
above the carina.
The Respiratory Therapist would BEST recommend:
A) Initiation of broad-spectrum antibiotics for probably pneumonia
B) Withdraw Endotracheal tube at least 3 cm
C) Use tube exchanger to replace Endotracheal tube from silver-coated to a low-pressure/high-volume
cuffed tube
D) Immediate V/Q Scan - ✔✔Correct answer is A
This pt has gone into respiratory failure, requiring intubation. The X-ray is consistent with a possible
pneumonia diagnosis. The best option therefore is to start antibiotics.
,Withdrawing ET Tube is not indicated as 4 cm is likely adequate. Pulling back 3 cm could result in
inadvertent extubation and would cause harm to patient
Use of tube exchanger is unnecessary. A silver-coated endotracheal tube is intended to help prevent
VAP
Immediate V/Q scan is not indicated - it is a poor use of resources for what is needed right away.
You are part of Physician Rounding this morning, and consulting on a patient who is currently on APRV.
They were originally admitted with a pneumonia which developed into ARDS with a P/F ratio as low as
110. The patient was transitioned to APRV from PC due to an elevated Plateau Pressure required to
maintain VT around 4 cc/kg IBW. The patient is arousable and taking breaths on their own. The physician
has asked you what should be done to address the patient's latest ABG.
Ph 7.16
PaCo2 49
PaO2 88 torr
HCO3 19
Mode- APRV
Phigh- 24
Plow- 0
Thigh- 5.0 sec
Tlow- o.5 sec
PS- 26
FiO2- 80%
A) Increase Phigh to 28 cmH2O
B) Decrease Phigh to 20 cmH2O
C) Increase sedation
D) Increase Thigh to 6.0 sec - ✔✔Correct answer is A
, This ABG may look deceptively metabolic but is truly a mixed Respiratory and Metabolic Acidosis. The
PaCO2 has risen, slightly, as a result of the Metabolic Acidosis. The correct solution is to increase Phigh
to 28 cmH2O (increasing your delta-P to increase minute volume. Decreasing Phigh will decrease minute
volume. Increasing Thigh will increase MAP (good if oxygenation), but will also lower the number of
"releases" - which are primarily responsible for dumping CO2. Increasing sedation in a patient who is
spontaneously breathing on APRV will result in a lowered minute volume and worsening acidosis. While
controversy exists, you may also consider increasing PS if the pt is breathing spontaneously.
A 56-year old woman was admitted for rapid development of respiratory failure following a suspected
aspiration. Her past medical history includes Diabetes, medication-controlled Hypertension, and she has
a 30-pack year smoking history.
She has been intubated and placed on a Ventilator.
Patient data
Ph 7.19
PaCO2 62 mmHg
PaO2 54 mmHg
HCO3 18 mEq/L
Mode - pressure control
Set PIP- 24 cm H2O
VTE- 380 ml measured
Rate- 24/min
PEEP- 8 cm H2O
FiO2- 100
This data is MOST consistent with the following diagnosis:
A) ARDS
B) Tension Pneumothorax
C) Pulmonary Hypertension
Resource with Reviewed Question Set
A difficult intubation is anticipated with an obese pt. The decision is made to intubate by video
laryngoscopy. Which of the following is LEAST likely to be needed:
A) Cook's Exchanger
B) Rigid Stylet
C) Cuffed Endotracheal Tube
D) Video-enabled Laryngoscope - ✔✔A) cook's exchanger
Video laryngoscopy involves use of a normal ET Tube with the addition of a rigid stylet, as well as a
video-enabled laryngoscope and other normal intubation equipment.
A Cook's Tube Exchanger is not necessary - this is used to exchange tubes already in place.
A 5'6" female has been transferred from Intermediate Care to Intensive Care in respiratory distress. She
is intubated with a silver-coated #7.0 Endotracheal tube. CXR immediately following intubation shows
Right Upper Lobe infiltrate with bibasilar atelectasis. The ET Tube is noted to be approximately 4 cm
above the carina.
The Respiratory Therapist would BEST recommend:
A) Initiation of broad-spectrum antibiotics for probably pneumonia
B) Withdraw Endotracheal tube at least 3 cm
C) Use tube exchanger to replace Endotracheal tube from silver-coated to a low-pressure/high-volume
cuffed tube
D) Immediate V/Q Scan - ✔✔Correct answer is A
This pt has gone into respiratory failure, requiring intubation. The X-ray is consistent with a possible
pneumonia diagnosis. The best option therefore is to start antibiotics.
,Withdrawing ET Tube is not indicated as 4 cm is likely adequate. Pulling back 3 cm could result in
inadvertent extubation and would cause harm to patient
Use of tube exchanger is unnecessary. A silver-coated endotracheal tube is intended to help prevent
VAP
Immediate V/Q scan is not indicated - it is a poor use of resources for what is needed right away.
You are part of Physician Rounding this morning, and consulting on a patient who is currently on APRV.
They were originally admitted with a pneumonia which developed into ARDS with a P/F ratio as low as
110. The patient was transitioned to APRV from PC due to an elevated Plateau Pressure required to
maintain VT around 4 cc/kg IBW. The patient is arousable and taking breaths on their own. The physician
has asked you what should be done to address the patient's latest ABG.
Ph 7.16
PaCo2 49
PaO2 88 torr
HCO3 19
Mode- APRV
Phigh- 24
Plow- 0
Thigh- 5.0 sec
Tlow- o.5 sec
PS- 26
FiO2- 80%
A) Increase Phigh to 28 cmH2O
B) Decrease Phigh to 20 cmH2O
C) Increase sedation
D) Increase Thigh to 6.0 sec - ✔✔Correct answer is A
, This ABG may look deceptively metabolic but is truly a mixed Respiratory and Metabolic Acidosis. The
PaCO2 has risen, slightly, as a result of the Metabolic Acidosis. The correct solution is to increase Phigh
to 28 cmH2O (increasing your delta-P to increase minute volume. Decreasing Phigh will decrease minute
volume. Increasing Thigh will increase MAP (good if oxygenation), but will also lower the number of
"releases" - which are primarily responsible for dumping CO2. Increasing sedation in a patient who is
spontaneously breathing on APRV will result in a lowered minute volume and worsening acidosis. While
controversy exists, you may also consider increasing PS if the pt is breathing spontaneously.
A 56-year old woman was admitted for rapid development of respiratory failure following a suspected
aspiration. Her past medical history includes Diabetes, medication-controlled Hypertension, and she has
a 30-pack year smoking history.
She has been intubated and placed on a Ventilator.
Patient data
Ph 7.19
PaCO2 62 mmHg
PaO2 54 mmHg
HCO3 18 mEq/L
Mode - pressure control
Set PIP- 24 cm H2O
VTE- 380 ml measured
Rate- 24/min
PEEP- 8 cm H2O
FiO2- 100
This data is MOST consistent with the following diagnosis:
A) ARDS
B) Tension Pneumothorax
C) Pulmonary Hypertension
