Chapter 22; Neonatal and Pediatric Ventilation Test Bank

Multiple Choice

1. Respiratory failure is imminent in infants who demonstrate which of the following?

a. Substernal retractions b. Tachypnea c. Grunting d. Nasal flaring

ANS: C

Infants attempt to maintain a back pressure in the lungs to preserve the functional residual capacity by narrowing the glottis and maintaining respiratory muscle activity (active exhalation). This results in vocalization during exhalation, or “grunting,” which often is mistaken for crying. Grunting, which usually can be heard without auscultation, is a useful clinical sign of impending respiratory failure.

DIF: 1 REF: pg. 461

2. The primary goals of mechanical ventilatory support in newborns and pediatric patients include all of the following except a. improving lung compliance b. eliminating airway resistance c. achieving adequate lung volume d. limiting lung injury

ANS: B

The goals of mechanical ventilatory support in newborns and pediatric patients are to (1) provide adequate ventilation and oxygenation, (2) achieve adequate lung volume, (3) improve lung compliance, (4) reduce WOB, and (5) limit lung injury. If airway resistance is a problem, it needs to be addressed; however, eliminating it is not a goal of mechanical ventilatory support.

DIF: 1 REF: pg. 462 a. Substernal retractions, PaCO2 = 65 mm Hg, PaO2 = 48 mm Hg, FIO2 = 0.4. b. Tachypnea, nasal flaring, PaCO2 = 50 mm Hg, PaO2 = 50 mm Hg, FIO2 = 0.6. c. Grunting, substernal retractions, pH = 7.20, PaCO2 = 70 mm Hg, PaO2 = 40 mm Hg, FIO2 = 0.7. d. Tachypnea, pale skin, pH = 7.32, PaCO2 = 45 mm Hg, PaO2 = 75 mm Hg, FIO2 = 0.21.

3. Anewborn with which of the following clinical manifestations should receive nasal CPAP?

ANS: B

A newborn with tachypnea, nasal flaring, a PaCO2 of 50 mm Hg, a PaO2 of 50 mm Hg, and an FIO2 of 0.6 meets the criteria for nasal CPAP.Anewborn with these findings has adequate minute ventilation, as evidenced by the PaCO2 of 50 mm Hg, but also has hypoxemia that is not being corrected by an FIO2 of 0.6. The newborn in option A (substernal retractions, PaCO2 = 65 mm Hg, PaO2 = 48 mm Hg, FIO2 = 0.4) does not have an adequate minute ventilation and requires some ventilatory assistance. Mechanical ventilation is indicated for the newborn in option C (grunting, substernal retractions, pH = 7.20, PaCO2 = 70 mm Hg, PaO2 = 40 mm Hg, FIO2 = 0.7), because this patient has respiratory acidosis and uncorrected hypoxemia. The newborn in option D (tachypnea, pale skin, pH = 7.32, PaCO2 = 45 mm Hg, PaO2 = 75 mm Hg, FIO2 = 0.21) has two of the physical indications for CPAP, but the ABG findings demonstrate adequate oxygenation.

DIF: 2 REF: pg. 463; Box 22-1 a. Cleft palate b. Choanal atresia c. Patent ductus arteriosus d. Tracheoesophageal fistula

4. Infants with which of the following problems would benefit from nasal CPAP?

ANS: C

A newborn with a patent ductus arteriosus has increased pulmonary blood flow and reduced lung compliance and FRC and therefore would benefit from the positive intrathoracic pressure produced by CPAP. The use of CPAP can be dangerous in newborns with choanal atresia, a tracheoesophageal fistula, or a cleft palate.

DIF: 1 REF: pg. 464 a. Nasopharyngeal tube b. Binasal prongs c. Nasal mask d. Endotracheal tube

5. The most common interface for infants receiving CPAP is which of the following?

ANS: B

The short binasal prongs are the most commonly used interface for infants receiving nasal CPAP. Nasal masks are slowly becoming more popular. The least popular method of administering CPAP is through nasopharyngeal or endotracheal tubes, because they are invasive.

DIF: 1 REF: pg. 464 a. cleft palate b. choanal atresia c. apnea of prematurity d. tracheoesophageal fistula

6. Nasal CPAP should be administered to a neonate with .

ANS: C

The use of CPAP can be dangerous in a newborn with choanal atresia, a tracheoesophageal fistula, or a cleft palate. CPAP can be used successfully in infants with apnea of prematurity.

DIF: 1 REF: pg. 464 a. 3 b. 5 c. 8 d. 10

7. The gas flow rate for a noncommercial bubble CPAP device should be set at L/min.

ANS: B

Gas flow in noncommercial bubble CPAP devices should be set at 5 L/min.

DIF: 1 REF: pg. 465 a. Switchto NIPPV. b. Increase the FIO2 to 0.7. c. Increase the CPAPto 6 cm H2O. d. Intubateand use ventilatorCPAP.

8. A full-term neonate shows signs of respiratory distress after delivery by cesarean section. The baby is placed on nasal CPAP at 4 cm H2O with an FIO2 of 0.6. The ABG results on these settings are: pH = 7.32, PaCO2 = 45 mm Hg, PaO2 = 48 mm Hg, SaO2 = 70%, HCO= 22 mEq/L. The respiratory therapist should recommend which of the following?

ANS: C

TheABG results show that the neonate is adequately ventilated. This eliminates the need for NIPPV because the CPAP level is not optimized at this time, and the FIO2 is set at a high level. The ABG results also show that the patient has not had an adequate response to the CPAP of 4 cm H2O with an FIO2 0.6. The CPAP can be increased in increments of 1 to 2 cm H2O until it reaches 10 cm H2O. Intubating for the use of ventilator CPAPwould not provide any benefit over noninvasive CPAP and would increase the risk of nosocomial infection.

DIF: 3 REF: pg. 466

9. Bubble CPAPshould a. bubble only on expiration b. bubble only on inspiration c. bubble on inspiration and expiration d. have a gas flow setting of 10 L/min

ANS: C

Bubble CPAP should have the lowest possible flow to maintain constant bubbling throughout the respiratory cycle.

DIF: 1 REF: pg. 465| pg. 466 a. Severe ventilatory impairment b. Persistent apnea c. After extubation d. Cleft palate

10. NIPPV can be used successfully in neonates for which of the following?

ANS: C

NIPPV can be used as an initial form of respiratory support and also after extubation from invasive mechanical ventilation.

DIF: 1 REF: pg. 467 a. Increase the CPAP to 8 cm H2O and the FIO2 to 0.7. b. Switch to nasal IMV, an inspiratory pressure of 18 cm H2O, PEEP of 4 cm H2O, and an FIO2 of 0.8. c. Continue with the current settings and monitor the patient closely. d. Intubate and use PC-IMV, an inspiratory pressure of 16 cm H2O, PEEP of 5 cm H2O, and an FIO2 of 0.8.

11. A neonate of 30 weeks’ gestation shows signs of respiratory distress after delivery, including grunting, nasal flaring, and cyanosis. The baby is placed on nasal CPAP at 6 cm H2O with an FIO2 of 0.6. The grunting and nasal flaring are alleviated, and the ABG results on these settings are: pH = 7.20, PaCO2 = 64 mm Hg, PaO2 = 48 mm Hg, SaO2 = 70%, HCO= 21 mEq/L. The respiratory therapist should recommend which of the following?

ANS: D

This neonate meets the requirements for invasive mechanical ventilation because of continued signs of respiratory distress: respiratory acidosis and a PaO2 of 48 mm Hg with an FIO2 of 0.6. Remaining in CPAP would not address the respiratory acidosis or the hypoxemia. Increasing the CPAP level and the FIO2 would not address the respiratory acidosis. This patient is showing severe ventilatory impairment (pH < 7.25, PaCO2 > 6 mm Hg) and refractory hypoxemia (PaO2 < 50 mm Hg on an FIO2 > 0.6); therefore, the patient should not be placed on NIPPV.

DIF: 3 REF: pg. 467| pg. 469 a. Volutrauma b. CO2 retention c. Oxygen toxicity d. Ventilator-induced lung injury

12. Potential harmful effects of nasal CPAPinclude which of the following?

ANS: B

CPAP can cause pulmonary overdistention, which can increase WOB and cause CO2 retention. Volutrauma and VILI are associated with invasive mechanical ventilation. Oxygen toxicity is related to the PaO2 that results from FIO2 levels higher than 0.6.

DIF: 1 REF: pg. 466 a. Barotrauma b. Alveolar overdistention c. Ventilator-induced lung injury d. Increased pulmonary vascular resistance

13. A newborn of 32 weeks’ gestation currently is receiving nasal CPAP. The respiratory therapist recently increased the CPAP level from 8 to 10 cm H2O; the FIO2 is 0.6. On the new setting, the PaO2 is 52 mm Hg and the PaCO2 increased from 48 to 55 mm Hg. The most likely cause of this is which of the following?

ANS: B

The rise in CO2 after the increase in the CPAP level is most likely due to pulmonary overdistention, which leads to increased work of breathing. The increased WOB causes CO2 retention.

DIF: 2 REF: pg. 466 a. Set flow rate above 5 L/min b. Set flow rate below 5 L/min c. Fluid in the inspiratory line d. Improperly placed manometer

14. The pressure manometer in-line with a bubble CPAP setup is reading higher than the depth of the expiratory limb in the liquid-filled bottle. This is most likely caused by which of the following?

ANS: A

The set flow rate for a bubble CPAP setup is 5 L/min. Flow rates above 5 L/min result in higher pressures than those anticipated by the submersion depth of the distal tubing. Flow rates lower than 5 L/min would not be able to maintain the bubble CPAP level needed for a given depth. Improper placement of the manometer could result in lower pressures than expected, because the manometer would not be reading pressure on exhalation. Fluid in the inspiratory line may drop the pressure reading by the manometer, because it would cause back pressure behind the fluid.

DIF: 1 REF: pg. 465| pg. 466

15. Pressure support should not be used in neonates receiving nasal IMV because of which of the following?

1. Large airway leaks

2. Ineffectiveness of triggering

3. Increased risk of volutrauma

4. Hypocapnia from excessive triggering a. 1 and 2 b. 1 and 3 c. 2 and 3 d. 4

ANS: A

Pressure support typically is not provided to assist spontaneous breaths during nasal IMV because of large airway leaks and ineffective triggering.

DIF: 1 REF: pg. 467

16. Neonatal patients are more vulnerable to rapid deterioration because of a. high chest wall compliance b. low functional residual capacity c. smaller surface area for gas exchange d. presence of fetal hemoglobin

ANS: C

Neonatal and pediatric patients have smaller lungs, higher airway resistance, lower lung compliance, less surface area for gas exchange, and lower cardiovascular reserve than do adults; all of these factors make them more vulnerable to rapid deterioration. Although neonates have high chest wall compliance, this is not the reason for their vulnerability to rapid deterioration. It is the reason for the presence of retractions when the WOB is elevated.

DIF: 1 REF: pg. 461 a. Mucus membrane color b. Skin color and tone c. Capillary refill d. Chest x-ray

17. Oxygen delivery and tissue perfusion may be evaluated clinically by which of the following?

ANS: C

Oxygen delivery and tissue perfusion can be evaluated clinically by noting the capillary refill.

DIF: 1 REF: pg. 462 a. 7.20 b. 7.25 c. 7.30 d. 7.35

18. The minimum acceptable pH for a premature or term newborn is which of the following?

ANS: B

The minimum acceptable pH for a premature or term newborn is 7.25. Values below that level are considered inadequate, especially when the PaCO2 is greater than 50 mm Hg.

DIF: 1 REF: pg. 463; Box 22-1 a. Nasal SiPAP b. NIPPV c. Nasal IMV d. Nasal HFV

19. The mode of ventilation that allows a neonate to breathe at a high and a low CPAP setting is which of the following?

ANS: A

Nasal SiPAP allows the neonate to breathe continuously at CPAP and during a sustained “sigh” breath to recruit lung units at two different lung volumes. It allows the neonate to breathe at a high and a low CPAP setting.

DIF: 1

REF: pg. 467 a. BiPAP b. Nasal HFV c. Nasal SiPAP d. Tracheostomy andCPAP

20. A 5-year-old patient diagnosed with tracheomalacia after a long intubation has had numerous failures to wean and extubate. What should the respiratory therapist recommend to help alleviate spontaneous breathing problems associated with tracheomalacia until a stent can be placed in the airway?

ANS: D

Tracheomalacia can make weaning from ventilation and extubation difficult. Atracheotomy and CPAP would be appropriate for this patient (24 hours a day) until surgery to place a stent in the airway can be performed.

DIF: 2

REF: pg. 468 a. = 10 cm H2O; frequency = 8 Hz; FIO2 = 1.0 b. = 10 cm H2O; frequency = 10 Hz; FIO2 = 0.8 c. = 6 cm H2O; frequency = 8 Hz; FIO2 = 0.8 d. = 6 cm H2O; frequency = 10 Hz; FIO2 = 1.0

21. A preterm neonate is being supported with nasal SiPAP. The baseline CPAP level is set at 6 cm H2O, the high CPAP level at 10 cm H2O, the rate is 20 “sigh” breaths, and the FIO2 is 0.8. The baby’s PaO2 on these settings has been steadily declining and is now 48 mm Hg. The physician and respiratory therapist decided to use nasal HFV before intubating and using mechanical ventilation. The initial settings for NHFV for this patient should include which of the following?

ANS: D

The initial mean airway pressure for nasal HFV usually is set to equal the previous level of CPAP, with a frequency of 10 Hz. Because the nasal SiPAP baseline level was set at 6 cm H2O, the NHFV should be set at that level. The only option with those two set parameters includes the FIO2 of 1.0, which should be titrated down when oxygenation improves.

DIF: 2

REF: pg. 467| pg. 468 a. Time b. Flow c. Pressure d. Volume

22. Newer ventilators allow neonates to use what type of trigger for better synchronization with the ventilator?

ANS: B

Patients can trigger breaths based on a pressure or flow change that is sensed by the ventilator. In neonates, flow sensing is more sensitive and allows better synchronization than pressure triggering.

DIF: 1 REF: pg. 471| pg. 472 a. Decrease the PEEP to 5 cm H2O. b. Keep the PEEP at 8 cm H2O. c. Decrease the PIP to 20 cm H2O. d. Increase the PIP to 24 cm H2O.

23. A 3-month-old, 6.4 kg infant with ARDS is receiving ventilatory support. The initial settings are: PC-CMV, PIP = 22 cm H2O, PEEP = 5 cm H2O, rate = 30 breaths/min, FIO2 = 0.6. The ABG results show a PaO2 of 48 mm Hg. The respiratory therapist increases the PEEP to 8 cm H2O. The pressure-volume loops below show the change that occurs after this increase. (Loop A(solid line) was generated from the initial settings. Loop B (dashed line) was generated from the increase in PEEP).

The respiratory therapist’s most appropriate action is which of the following?

ANS: B

The increase in PEEP to 8 cm H2O has led to an immediate rise in volume for the set pressure. According to the infant’s weight, the volume should be 32 mL. The increase in PEEP has brought the volume to that level without overdistention; this means that the PEEP of 8 cm H2O is appropriate and should be maintained. Obtaining an ABG reading at this point would be appropriate.

DIF: 3 REF: pg. 474 a. Flow b. Time c. Volume d. Pressure

24. Which type of trigger allows for better synchronization during neonatal ventilation?

ANS: A

According to the literature, in neonates, flow sensing is more sensitive and shows better synchronization than does pressure triggering. Patient triggering allows for better synchronization than does machine triggering.

DIF: 1 REF: pg. 471| pg. 472

25. The number of time constants for almost complete equilibration of alveolar pressure in a normal infant’s lungs is a. 1 to 3 b. 2 to 4 c. 3 to 5 d. 4 to 7

ANS: C

Nearly complete equilibrium of alveolar pressures occurs in 3 to 5 time constants in infant lungs with normal mechanics.

DIF: 1 REF: pg. 477 a. 0.25 sec b. 0.30 sec c. 0.45 sec d. 0.55 sec

26. The inspiratory time setting for an infant with RDS, airway resistance of 30 cm H2O/L/sec, and lung compliance of 0.002 L/cm H2O should be which of the following?

ANS: B

Raw CL = 1 time constant. This is 0.06 sec in this problem. One time constant multiplied by 5, or 0.30 sec, should be the inspiratory time setting for this patient.

DIF: 2 REF: pg. 477 a. 0.25 sec b. 0.45 sec c. 0.6 sec d. 0.9 sec

27. The inspiratory time setting for an infant with bronchopulmonary dysplasia (BPD), airway resistance of 45 cm H2O/L/sec, and lung compliance of 0.004 L/cm H2O should be which of the following?

ANS: D

Raw CL = 1 time constant. This is 0.18 sec in this problem. One time constant multiplied by 5, or 0.90 sec, should be the inspiratory time setting for this patient.

DIF: 2 REF: pg. 477 a. 0.8% b. 1.2% c. 17.8% d. 21.6%

28. Calculate the percent leak when theVTinsp is 45 mLand the VTexp is 37 mL.

ANS: C

Percent leak = [(VTinsp - VTexp)/VTinsp]/100.

DIF: 2 REF: pg. 477 a. 6% b. 12% c. 19% d. 25%

29. The maximum percent leak that may be allowed around a cuffless endotracheal tube is which of the following?

ANS: C

Most clinicians consider small leaks (<20%) acceptable and even desirable as an added safety pressure-release site and as assurance that no significant inflammation is present around the tube.

DIF: 1 REF: pg. 477 a. Increase the PS level. b. Increase the rise time. c. Decrease the PS level. d. Increase the flow cycle.

30. A pediatric patient intubated with a 3.5 mm endotracheal tube is receiving pressure support ventilation. The respiratory therapist notes patient-ventilator asynchrony and a rapid deceleration of flow that prematurely ends inspiration. The most appropriate action to alleviate this is which of the following?

ANS: B

ET tubes smaller than 4.5 mm may provide excessive resistance during PS. This can cause pressurization of the ventilator circuit before sufficient flow enters the patient’s airway. The result is a rapid deceleration of flow, which may prematurely end the inspiratory phase (premature pressure support termination [PPST]). This phenomenon does not allow the augmentation of VT, and patient-ventilator asynchrony may result. When PPST is suspected, a slower rise time can be used, which may reduce or eliminate the problem.

DIF: 3 REF: pg. 480 a. The PS setting is too high. b. The flow cycle setting is too low. c. This is the normal cycle for PS. d. Alarge leak is present around the cuffless ET tube.

31. A mechanically ventilated pediatric patient in the process of being weaned is switched to PC-IMV with PS. The respiratory therapist notes that every PS breath is being time cycled. The most likely cause of this is which of the following?

ANS: D

Failure to flow cycle can be due to leaks around the ET or tracheostomy tube. Time cycling is a backup for flow cycling.

DIF: 2 REF: pg. 480

32. Neurally adjusted ventilator assist (NAVA) is particularly useful with newborns because it a. reduces gas trapping. b. is not affected by leaks. c. decreases the development of VILA. d. is sensitive to changes in respiratory drive.

ANS: B

NAVAis not affected by leaks, because this ventilator trigger uses the electrical activity of the diaphragm.

DIF: 1 REF: pg. 483 a. Status asthmaticus b. Bronchopleural fistula c. Meconium aspiration d. Cystic fibrosis

33. The patient with which of the following conditions should be considered for HFV?

ANS: B

HFV should be considered for a patient with a bronchopleural fistula.

DIF: 1 REF: pg. 485; Box 22-7 a. High-frequency positive pressure ventilation b. High-frequency oscillatory ventilation c. High-frequency jet ventilation d. High-frequency percussive ventilation

34. Both inspiration and expiration are active in which type of high-frequency ventilation?

ANS: B

HFOV differs from other types of high-frequency ventilation in several ways; for example, both inspiration and expiration are active in HFOV.

DIF: 1 REF: pg. 487

35. During HFOV, oxygenation can be improved by making which of the following changes?

1. Increasing the FIO2

2. Decreasing the amplitude

3. Increasing the

4. Increasing the frequency a. 1 and 2 b. 1 and 3 c. 2 and 3 d. 2 and 4

ANS: B

The and FIO2 controls are used to control the patient’s oxygenation. The amplitude and frequency are used to control the patient’s ventilatory status.

DIF: 1 REF: pg. 491 a. Increase the frequency. b. Increase the c. Decrease the amplitude. d. Decrease thebias flow.

36. An 835 g newborn is receiving HFOV with the following settings: = 10 cm H2O; FIO2 = 0.6; frequency = 10 Hz; amplitude (P) = 20 cm H2O. The ABG values are: pH = 7.35, PaCO2 = 40 mm Hg, PaO2 = 40 mm Hg. Based on these data, which of the following is the most appropriate action?

ANS: B

Increasing the will improve the patient’s oxygenation status. Oxygenation also can be altered by changing the FIO2

DIF: 3 REF: pg. 489| pg. 490 a. 8 to 10 cm H2O b. 10 to 12 cm H2O c. 12 to 14 cm H2O d. 14 to 16 cm H2O

37. A pediatric patient with air leak syndrome is being ventilated with PC-CMV. The settings are: rate = 20 breaths/min, TI = 0.8 sec, PIP = 30 cm H2O, PEEP = 8 cm H2O, FIO2 = 0.8, = 14 cm H2O. The patient is to be switched to HFOV. What range is appropriate for this patient?

ANS: D

The initial usually is set at the same level as or 2 to 3 cm H2O higher than that required for conventional ventilation.

DIF: 2 REF: pg. 491 a. 4 cm H2O b. 6 cm H2O c. 8 cm H2O d. 10 cm H2O

38. A pediatric patient with a 5 mm ET tube is ready to be switched to PSV. What minimum PS level should be used for this patient?

ANS: B

The minimum PS setting for a patient with a 5 mm ET tube is 6 cm H2O.

DIF: 1 REF: pg. 491; Box 22-8 a. Draw a sample for arterial blood gas evaluation. b. Increase the target volume. c. Put the patient in the PC-CMV mode. d. Recommend surfactant replacement therapy.

39. A neonate is being ventilated with PRVC. The respiratory therapist responds to a low volume alarm.After checking the patient and the ventilator, the respiratory therapist finds no disconnects. The most appropriate action is which of the following?

ANS: B

In the PRVC mode, if the ET tube has a leak, the level of support will be reduced; this occurs because the ventilator is sensing more volume is being delivered for a given pressure, when actually the gas is escaping around the cuffless ET tube. With the alarms set properly, this problem is caught. The patient should be switched to the PC-CMV mode, in which the set pressure is not automatically altered by the ET tube leak.

DIF: 3 REF: pg. 481 a. PointA b. Point B c. Point C d. Point D

40. The pressure manometer should be placed at which point in the following CPAP system?

ANS: C

The manometer belongs near the nasal prongs on the expiratory side of the circuit.

DIF: 2 REF: pg. 466; Figure 22-5