board exam preparation written exams crt and rrt

Board Exam Board Exam PreparationPreparationWritten ExamsWritten Exams

CRT and RRTCRT and RRT

Be Prepared!Be Prepared!

WHAT to studyWHAT to study WHERE to studyWHERE to study WHEN to studyWHEN to study HOW to studyHOW to study

What to StudyWhat to Study

Know Your Enemy: The Board ExamsKnow Your Enemy: The Board Exams You must understand the You must understand the structure and structure and

contentcontent of the board exams and apply this of the board exams and apply this knowledge to your study plan.knowledge to your study plan.

REVIEW THE MATRIX FOR THE CRT, REVIEW THE MATRIX FOR THE CRT, RRT, CSERRT, CSE

ALL FOUND ON WWW.NBRC.ORGALL FOUND ON WWW.NBRC.ORG

The EXAMThe EXAM

Part one: Study all content, take plenty of Part one: Study all content, take plenty of practice exams, schedule your CRT practice exams, schedule your CRT exam and layout a study planexam and layout a study plan

After completing the CRT schedule your After completing the CRT schedule your Written RRT and Clinical Simulation Written RRT and Clinical Simulation exam. You may take both the same day exam. You may take both the same day or seperateor seperate

Exam StructureExam Structure

CRTCRT 160 questions160 questions

140 actual test questions140 actual test questions 20 additional questions that 20 additional questions that

are NOT scoredare NOT scored 3 hours3 hours Passing score 75% (105 Passing score 75% (105

correct)*correct)*

RRT WrittenRRT Written 115 questions115 questions

100 actual test questions100 actual test questions 15 additional questions 15 additional questions

that are NOT scoredthat are NOT scored 2 hours2 hours Passing score 70% (70 Passing score 70% (70

correct)*correct)*

•Computer based testingComputer based testing•No calculators allowedNo calculators allowed•A pencil and paper will be provided for youA pencil and paper will be provided for you

Exam StructureExam Structure

CSE (Clinical Simulation Exam)CSE (Clinical Simulation Exam) PART 2 of the RRTPART 2 of the RRT Consists of 11 scenarios (only 10 are Consists of 11 scenarios (only 10 are

graded)graded) Covers all areas from the CRT and WRRTCovers all areas from the CRT and WRRT Typically you will get disease management Typically you will get disease management

scenarios for: COPD, Trauma, scenarios for: COPD, Trauma, Cardiovascular disease, Neuromuscular, Cardiovascular disease, Neuromuscular, Peds, Neonates, and others (page 450)Peds, Neonates, and others (page 450)

Exam ContentExam Content

Content OutlineContent Outline Candidate HandbookCandidate Handbook www.nbrc.orgwww.nbrc.org All items on the exam are developed All items on the exam are developed

from these outlinesfrom these outlines Categorized by cognitive levelCategorized by cognitive level

RecallRecall ApplicationApplication AnalysisAnalysis

Recall: the ability to recall or recognize specific information

FactsFacts DefinitionsDefinitions Normal valuesNormal values PrinciplesPrinciples Equations…Equations…

RecallRecall

Involves remembering memorized Involves remembering memorized informationinformation

You either know it or you don’tYou either know it or you don’t If you don’t know the answer, eliminate If you don’t know the answer, eliminate

answers that you think are impossible, answers that you think are impossible, and then guess from the remaining and then guess from the remaining options.options.

Recall ExampleRecall Example

An otherwise healthy An otherwise healthy 25-year-old male 25-year-old male patient who took an patient who took an overdose of sedatives overdose of sedatives is being supported on a is being supported on a ventilator. Which of the ventilator. Which of the following measures of following measures of total static compliance total static compliance would you expect in would you expect in this patient?this patient?

A.A. 100 mL/cmH2O100 mL/cmH2OB.B. 10 mL/cmH2O10 mL/cmH2OC.C. 1 mL/cmH2O1 mL/cmH2OD.D. 0.1 mL/cmH2O0.1 mL/cmH2O

Answer AAnswer A To evaluate and monitor a patient, you need To evaluate and monitor a patient, you need

to know what is normal and what is abnormal. to know what is normal and what is abnormal. This item tests your ability to recall normal This item tests your ability to recall normal static compliance. It also separately static compliance. It also separately assesses your ability to differentiate the assesses your ability to differentiate the common bedside units used for this measure common bedside units used for this measure (mL/cmH2O) from that typically employed in (mL/cmH2O) from that typically employed in a pulmonary lab (L/cmH2O).a pulmonary lab (L/cmH2O).

Application: Application: the ability to the ability to comprehend or apply knowledge comprehend or apply knowledge to new or changing conditionsto new or changing conditions

Tests your understanding of principles, Tests your understanding of principles, practices, and procedures involved in practices, and procedures involved in respiratory carerespiratory care

Application ExampleApplication Example

An adult patient receiving An adult patient receiving volume-oriented volume-oriented assist/control ventilation assist/control ventilation has a corrected tidal has a corrected tidal volume of 700 mL, a peak volume of 700 mL, a peak pressure of 50 cmH2O, pressure of 50 cmH2O, and a plateau pressure of and a plateau pressure of 40 cmH2O and is receiving 40 cmH2O and is receiving 5 cmH2O of PEEP. What 5 cmH2O of PEEP. What is the patient’s static is the patient’s static compliance?compliance?

A.A. 200 mL/cmH2O200 mL/cmH2O

B.B. 20 mL/cmH2O20 mL/cmH2O

C.C. 2 mL/cmH2O2 mL/cmH2O

D.D. 0.2 mL/cmH2O0.2 mL/cmH2O

Answer BAnswer B This item tests your ability to apply a This item tests your ability to apply a

formula to a clinical situation (most formula to a clinical situation (most formula-type questions are at the formula-type questions are at the application level). To answer it correctly, application level). To answer it correctly, you need to “plug” the correct data into you need to “plug” the correct data into the formula for computing static the formula for computing static compliance Vt/(Ppl-PEEP)compliance Vt/(Ppl-PEEP)

AnalysisAnalysis: the ability to analyze : the ability to analyze information, to put information information, to put information together to arrive at solutions, together to arrive at solutions, and/or to evaluate the usefulness of and/or to evaluate the usefulness of the solutionsthe solutions

They begin the question with facts that you need to They begin the question with facts that you need to analyze and interpret to come to a conclusion. analyze and interpret to come to a conclusion.

They may ask what is wrong, or they may ask what do They may ask what is wrong, or they may ask what do you want to do about it.you want to do about it.

Analysis: 10% of the exam. analyze or interpret Analysis: 10% of the exam. analyze or interpret information in order to solve a problem. information in order to solve a problem.

Analysis ExampleAnalysis Example

A patient is receiving A patient is receiving volume cycled mechanical volume cycled mechanical ventilation in the control ventilation in the control mode. The following ABG mode. The following ABG data were obtained:pH data were obtained:pH 7.56, PaCO7.56, PaCO22 25 torr, PaO 25 torr, PaO22

93 torr, HCO93 torr, HCO33- 22 mEq/L- 22 mEq/L

Which ventilator Which ventilator adjustments should be adjustments should be made at this time?made at this time?

A.A. Institute 5 cmH20 PEEPInstitute 5 cmH20 PEEP

B.B. Increase the FiO2Increase the FiO2

C.C. Increase the tidal Increase the tidal volumevolume

D.D. Decrease the ventilatory Decrease the ventilatory raterate

Answer DAnswer D This item assesses your ability to analyze monitoring This item assesses your ability to analyze monitoring

data and apply this information to recommend a data and apply this information to recommend a treatment approach for this patient. First, youmust treatment approach for this patient. First, youmust analyze the data, which should reveal that the patient analyze the data, which should reveal that the patient has uncompensated respiratory alkalosis. Second, has uncompensated respiratory alkalosis. Second, you need to recognize that this can be due to over-you need to recognize that this can be due to over-ventilation. Last, you need to apply this data and your ventilation. Last, you need to apply this data and your knowledge of mechanical ventilation to recommend knowledge of mechanical ventilation to recommend the correct course of actionthe correct course of action

The “NBRC Hospital”The “NBRC Hospital”

Treat the exam matrix as the policy Treat the exam matrix as the policy manual for the NBRC hospitalmanual for the NBRC hospital Focus on the things that you do Focus on the things that you do notnot typically typically

do at your clinic sitedo at your clinic site As you study, identify things that are As you study, identify things that are

different that what you typically dodifferent that what you typically do

Do not be afraid to use your independent Do not be afraid to use your independent judgement.judgement.

The “NBRC Hospital”The “NBRC Hospital”• You “enter” the NBRC hospital every time you take an NBRC You “enter” the NBRC hospital every time you take an NBRC

exam.exam.• This hospital may or may not function the same as the clinical This hospital may or may not function the same as the clinical

site or sites you are at, it represents an idealized institution.site or sites you are at, it represents an idealized institution.• The NBRC RC department always relies of generally The NBRC RC department always relies of generally

accepted knowledge based on various practice guidelinesaccepted knowledge based on various practice guidelines• Their “procedure manual” is based upon broad national Their “procedure manual” is based upon broad national

agreement among clinicians and educators as to what agreement among clinicians and educators as to what common skills the average therapist performscommon skills the average therapist performs

• So upon entering the NBRC hospital, you may be expected to So upon entering the NBRC hospital, you may be expected to know and do different things from those you were trained to know and do different things from those you were trained to do.do.

Your TextbookYour Textbook

Bold Topic HeadingsBold Topic Headings Evaluate the patient’s general Evaluate the patient’s general

appearance (Code: IB1a) [Difficulty: appearance (Code: IB1a) [Difficulty: ELE: R, Ap; WRE: An)ELE: R, Ap; WRE: An)

The code refers to a section of the matrixThe code refers to a section of the matrix ELE: entry level examELE: entry level exam WRE: written registry examWRE: written registry exam R: recall, Ap: Application, An: AnalysisR: recall, Ap: Application, An: Analysis

Your Text BookYour Text Book

Read xv through xxiRead xv through xxi For every chapter take the pre-test (answers For every chapter take the pre-test (answers

and explanations are at the end of each and explanations are at the end of each chapter) and review the content areas specific chapter) and review the content areas specific for the examfor the exam

Use the Jones and Bartlett Learning Use the Jones and Bartlett Learning companion websitecompanion website

REVIEW THE TEST TAKING TIPS AND REVIEW THE TEST TAKING TIPS AND TECHNIQUES APPENDIX page 511TECHNIQUES APPENDIX page 511

Where and When to Where and When to StudyStudy

Choose a quiet, distraction free Choose a quiet, distraction free environmentenvironment

Establish and follow a strict study Establish and follow a strict study scheduleschedule

How to StudyHow to Study Prepare yourself mentally and physicallyPrepare yourself mentally and physically Be organizedBe organized

Organize your resourcesOrganize your resources Create a “battle plan”Create a “battle plan” Create a list of problem areas to focus onCreate a list of problem areas to focus on

Use reflections to help with this!Use reflections to help with this!

Get psyched!Get psyched! Create and maintain a positive attitude toward Create and maintain a positive attitude toward

test preparation and test takingtest preparation and test taking http://dus.psu.edu/academicsuccess/studyskills.htmlhttp://dus.psu.edu/academicsuccess/studyskills.html

Test Taking TipsTest Taking Tips

Pace yourselfPace yourself So that you have time to get through all So that you have time to get through all

questionsquestions ““bookmark” questionsbookmark” questions Do not leave any blanksDo not leave any blanks

Completely read each questionCompletely read each question Determine what you are really being askedDetermine what you are really being asked

Test Taking Tips cont.Test Taking Tips cont.

Separate the important informationSeparate the important information From that which is not importantFrom that which is not important

Do not read beyond the questionDo not read beyond the question Use only what is given to youUse only what is given to you

Carefully read each answerCarefully read each answer Pick the best answer offeredPick the best answer offered

Even if you don’t like itEven if you don’t like it


Multiple multiplesMultiple multiples1.1. Find an option that you know is incorrect Find an option that you know is incorrect

and cross off any of the answers that and cross off any of the answers that contain itcontain it

2.2. Find an option that you know to be correct Find an option that you know to be correct and cross off any answers that do not and cross off any answers that do not contain itcontain it

3.3. Find the remaining answerFind the remaining answer


Again, answer every questionAgain, answer every question Take practice examsTake practice exams

Evaluate your strengths and weaknessesEvaluate your strengths and weaknesses Use reflection to help with this!Use reflection to help with this!

Spend time studying your weak areasSpend time studying your weak areas

Maximize Exam Prep Maximize Exam Prep TimeTime

Spend the Majority of your time studying the Spend the Majority of your time studying the most heavily tested areas:most heavily tested areas: Mechanical Ventilation of the AdultMechanical Ventilation of the Adult Patient AssessmentPatient Assessment

Bedside and AdvancedBedside and Advanced

Arterial Blood GasesArterial Blood Gases Oxygen and Medical Gas TherapyOxygen and Medical Gas Therapy PharmacologyPharmacology Airway ManagementAirway Management

Maximize Exam Prep Maximize Exam Prep Time cont.Time cont.

Review the exam hints in all chaptersReview the exam hints in all chapters ABG interpretation is a must!ABG interpretation is a must!

In order to answer mechanical ventilation In order to answer mechanical ventilation and oxygen therapy questionsand oxygen therapy questions

Mechanical ventilation of the adult is the Mechanical ventilation of the adult is the most heavily questioned content.most heavily questioned content. You MUST understand mechanical You MUST understand mechanical

ventilation to do well on the examsventilation to do well on the exams

Taking the Test!Taking the Test!

Know What to Expect When Know What to Expect When Reporting to the Testing Reporting to the Testing CenterCenter

Arrive earlyArrive early Relax before the examRelax before the exam If you are more than 15 minutes late you If you are more than 15 minutes late you

will have to reschedulewill have to reschedule Bring two forms of IDBring two forms of ID You may only bring your wallet and keys You may only bring your wallet and keys

into the testing centerinto the testing center You will be provided with a pencil and You will be provided with a pencil and

scratch paperscratch paper

Know What to ExpectKnow What to Expect

There will be a short practice testThere will be a short practice test Once you begin, you cannot ask Once you begin, you cannot ask

questionsquestions You are allowed to take breaksYou are allowed to take breaks Break time counts against your exam Break time counts against your exam

timetime Take the practice tests on-line at Take the practice tests on-line at

www.nbrc.org

During the TestDuring the Test

Get comfortableGet comfortable Answer all questionsAnswer all questions Budget your timeBudget your time

Monitor your paceMonitor your pace Answer easy questions firstAnswer easy questions first Bookmark difficult item and return to them Bookmark difficult item and return to them

laterlater Use all the available timeUse all the available time

Test PreparationTest Preparation

“… “… the most valuable the most valuable resource you possess resource you possess is your own ability is your own ability and determination to and determination to succeed.”succeed.”Malley, W., Malley, W., Clinical Blood Gases: Application and Noninvasive AlternativesClinical Blood Gases: Application and Noninvasive Alternatives , W.B. , W.B. Saunders Co., Philadelphia, PA, 1990.Saunders Co., Philadelphia, PA, 1990.

Elements of an NBRC Elements of an NBRC Multiple-Choice QuestionMultiple-Choice Question

Scenario: Brief description of the clinical Scenario: Brief description of the clinical situationsituation

Stem: The statement that asks the Stem: The statement that asks the question or specifies the problemquestion or specifies the problem

Options: Possible answers to the Options: Possible answers to the question or solutions to the problemquestion or solutions to the problem

Keyed response: The correct answerKeyed response: The correct answer Distracters: Wrong answersDistracters: Wrong answers

An 80 kg adult male patient with aspiration pneumonia An 80 kg adult male patient with aspiration pneumonia receiving volume-oriented SIMV has the following ventilator receiving volume-oriented SIMV has the following ventilator settings and blood gas results:settings and blood gas results:

Mode SIMVMode SIMV pH 7.29pH 7.29Vt 500 mLVt 500 mL PaCO2 52 mmHgPaCO2 52 mmHgRate 12Rate 12 HCO3- 25 mEq/LHCO3- 25 mEq/LFiO2 0.50FiO2 0.50 PaO2 63 mmHgPaO2 63 mmHgPEEP 5 cmH2OPEEP 5 cmH2O SaO2 91%SaO2 91%

The respiratory therapist should do which of the following The respiratory therapist should do which of the following first?first?

A. Increase the FiO2A. Increase the FiO2B. Increase the tidal volumeB. Increase the tidal volumeC. Add pressure supportC. Add pressure supportD. Increase PEEPD. Increase PEEP

The ScenarioThe Scenario• Briefly describes a clinical situation that you need to assess.Briefly describes a clinical situation that you need to assess.• Thoroughly review the scenario before even looking at the stem or optionsThoroughly review the scenario before even looking at the stem or options• Sometimes the scenario and stem are combined and must be reviewed togetherSometimes the scenario and stem are combined and must be reviewed together• Look for the following critical informationLook for the following critical information• Look for the following information:Look for the following information:• The location or setting (ICU, outpatient clinic, patient’s home)The location or setting (ICU, outpatient clinic, patient’s home)• The available resources (equipment being used or at hand) The available resources (equipment being used or at hand)

• Ventilator capable of volume SIMVVentilator capable of volume SIMV• The patient’s general characteristics (age, size, disease process, mental status)The patient’s general characteristics (age, size, disease process, mental status)

• Adult, male, 80kg, aspiration pneumoniaAdult, male, 80kg, aspiration pneumonia• Relevant objective data (ABG, PFT…)Relevant objective data (ABG, PFT…)

• Vt may be low for weightVt may be low for weight• FiO2 is on higher end of safe rangeFiO2 is on higher end of safe range• Respiratory acidosisRespiratory acidosis• Low but adequate Po2Low but adequate Po2

• Relevant subjective data (signs and symptoms)Relevant subjective data (signs and symptoms)

The StemThe Stem• Asks the question or directs your attention.Asks the question or directs your attention.• Often contains key words or phrases that may help Often contains key words or phrases that may help

you choose the correct answeryou choose the correct answer• Priority: first, initially, best, priority, safest, most, Priority: first, initially, best, priority, safest, most,

leastleast• Put a value on each option and place them in Put a value on each option and place them in

rank orderrank order• Sequence: before, after, nextSequence: before, after, next

• Apply procedural knowledge or logic to place Apply procedural knowledge or logic to place options in proper sequenceoptions in proper sequence

• Absolutes: always, neverAbsolutes: always, never• Find the only option that would be correct in Find the only option that would be correct in

every case every timeevery case every time

The StemThe Stem• Negative polarity: not, except, contraindicated, unacceptable, avoidNegative polarity: not, except, contraindicated, unacceptable, avoid

• Switch from being concerned with what is correct or true to what is falseSwitch from being concerned with what is correct or true to what is false• Verbal associations: word or phrase in the stem that is identical or similar to a Verbal associations: word or phrase in the stem that is identical or similar to a

word in the correct answerword in the correct answer• Select the option that includes wording similar to that found in the stemSelect the option that includes wording similar to that found in the stem

• What is the key word in the sample question?What is the key word in the sample question?• FirstFirst• A priority clue directing you to choose the action most immediately neededA priority clue directing you to choose the action most immediately needed• The primary/most severe problem is respiratory acidosisThe primary/most severe problem is respiratory acidosis• Keyed option B increase tidal volumeKeyed option B increase tidal volume

Do not overanalyze!Do not overanalyze! The simplest interpretation is generally the correct one.The simplest interpretation is generally the correct one.

Anticipate the answerAnticipate the answer Before looking at the options availableBefore looking at the options available

OptionsOptions Every question has 4 optionsEvery question has 4 options

The StemThe Stem

Do not overanalyze!Do not overanalyze! The simplest interpretation is generally the correct The simplest interpretation is generally the correct

one.one. Anticipate the answerAnticipate the answer

Before looking at the options availableBefore looking at the options available OptionsOptions Every question has 4 optionsEvery question has 4 options

The StemThe Stem

Stem Wording AStem Wording A

Which of the following Which of the following assessment assessment procedures would help procedures would help determine proper determine proper positioning of an positioning of an endotracheal tube in endotracheal tube in the patient’s trachea?the patient’s trachea?

Stem Wording BStem Wording B

Which of the following Which of the following assessment assessment procedures would help procedures would help confirm proper confirm proper positioning of an positioning of an endotracheal tube in endotracheal tube in the patient’s trachea?the patient’s trachea?

• A tiny variation in wording makes a huge differenceA tiny variation in wording makes a huge difference• A: breath sounds, capnography, tube insertion A: breath sounds, capnography, tube insertion

length, esophageal detection device, CXR…length, esophageal detection device, CXR…• B: CXRB: CXR

• Do not overanalyze!Do not overanalyze!• The simplest interpretation is generally the correct one.The simplest interpretation is generally the correct one.

• Anticipate the answerAnticipate the answer• Before looking at the options availableBefore looking at the options available

OptionsOptions

Every question has 4 optionsEvery question has 4 options When you are sure of the correct When you are sure of the correct

response, select it and move onresponse, select it and move on Do not panic when you encounter Do not panic when you encounter

questions that appear difficult or questions that appear difficult or unfamiliar to youunfamiliar to you

• All exam candidates encounter dozens of these questionsAll exam candidates encounter dozens of these questions

• Instead of getting flustered, get resourceful and use some of the following option Instead of getting flustered, get resourceful and use some of the following option selection strategiesselection strategies

• Always look for the best option not just the correct oneAlways look for the best option not just the correct one

• Two or more options may be correct but one likely is most correct in the Two or more options may be correct but one likely is most correct in the particular circumstances or with the specific patient describedparticular circumstances or with the specific patient described

• When you are unsure of the correct option, switch from finding the right When you are unsure of the correct option, switch from finding the right answer to finding the wrong answer(s)answer to finding the wrong answer(s)

• Eliminate options you know to be incorrect; each time you eliminate a Eliminate options you know to be incorrect; each time you eliminate a distracter, you increase your chances of answering the question correctlydistracter, you increase your chances of answering the question correctly

• When in doubt, give each option a “true-false” test as compared with the When in doubt, give each option a “true-false” test as compared with the stem (the true statement is usually the best answer)stem (the true statement is usually the best answer)

• Be wary of options that are totally unfamiliar to you; more often than not Be wary of options that are totally unfamiliar to you; more often than not unfamiliar options are distractersunfamiliar options are distracters

• If you encounter a “double negative” in a stem and option, remember that If you encounter a “double negative” in a stem and option, remember that it creates the equivalent positive statementit creates the equivalent positive statement

• Avoid impulsively selecting an option simply because it provides correct Avoid impulsively selecting an option simply because it provides correct information as an option can provide correct information but still be the information as an option can provide correct information but still be the wrong choice because it does not answer the question askedwrong choice because it does not answer the question asked

• Let’s look at some more specific strategies…Let’s look at some more specific strategies…

Which of the following is true regarding Which of the following is true regarding patients in the early stages of an asthmatic patients in the early stages of an asthmatic attack?attack?

A. They all exhibit respiratory alkalosisA. They all exhibit respiratory alkalosis

B. They always have moderate hypoxemiaB. They always have moderate hypoxemia

C. They have decreased expiratory flowsC. They have decreased expiratory flows

D. They never respond to beta adrenergicsD. They never respond to beta adrenergics

AbsolutesAbsolutes• Correct answer: CCorrect answer: C• Always, never, all, every, none, onlyAlways, never, all, every, none, only• These key words indicate that the option has no exceptionsThese key words indicate that the option has no exceptions• More often than not, options that use absolutes are falseMore often than not, options that use absolutes are false• Generally you should avoid choosing an option that must be true Generally you should avoid choosing an option that must be true

or false every time without exceptionor false every time without exception• You do not see this very frequently in the board examsYou do not see this very frequently in the board exams• Some absolutes , especially this efounded in rules or standards, Some absolutes , especially this efounded in rules or standards,

may be a correct optionmay be a correct option• “ “ you must always properly identify the patient before you must always properly identify the patient before

treatment” holds without exceptiontreatment” holds without exception

A patient’s advance directive:A patient’s advance directive:

A. Is usually obtained at the time of A. Is usually obtained at the time of admissionadmission

B. Can be found in the doctor’s progress B. Can be found in the doctor’s progress notesnotes

C. Represents a guideline, not a legal C. Represents a guideline, not a legal requirementrequirement

D. Cannot be altered after it is written and D. Cannot be altered after it is written and signedsigned

QualifiersQualifiers

• Correct answer ACorrect answer A

• A qualifier is the opposite of an absoluteA qualifier is the opposite of an absolute

• Usually, probably, often, generally, may, Usually, probably, often, generally, may, frequently, seldomfrequently, seldom

• Options that contain qualifiers usually Options that contain qualifiers usually represent good choicesrepresent good choices

• The NBRC minimizes its use of qualilfiersThe NBRC minimizes its use of qualilfiers

An intubated patient is receiving volume control An intubated patient is receiving volume control ventilation. The patient’s condition has not ventilation. The patient’s condition has not changed, but you observe higher peak changed, but you observe higher peak inspiratory pressures than before. Which of inspiratory pressures than before. Which of the following is t he most likely cause of this the following is t he most likely cause of this problem?problem?

A. There is a leak in the patient-ventilator systemA. There is a leak in the patient-ventilator system

B. The endotracheal tube cuff is deflatedB. The endotracheal tube cuff is deflated

C. The endotracheal tube is partially obstructedC. The endotracheal tube is partially obstructed

D. The endotracheal tube is displaced into the D. The endotracheal tube is displaced into the pharynxpharynx

Equally Plausible OptionsEqually Plausible Options• Correct answer CCorrect answer C• You will often see question that contain two options You will often see question that contain two options

that are very similar to equivalent to each otherthat are very similar to equivalent to each other• Options A and B are equivalent because they both Options A and B are equivalent because they both

represent a leak in the systemrepresent a leak in the system• Usually when two items are very similar or Usually when two items are very similar or

equivalent, they are distracters and should be equivalent, they are distracters and should be eliminatedeliminated

Over a 3 hour period, you note that a Over a 3 hour period, you note that a patient’s plateau pressure has remained patient’s plateau pressure has remained stable, but her peak pressure has been stable, but her peak pressure has been steadily increasing. Which of the steadily increasing. Which of the following is the best explanation for this following is the best explanation for this observation?observation?

A. The patient’s airway resistance has A. The patient’s airway resistance has increasedincreased

B. The patient is developing atelectasisB. The patient is developing atelectasis

C. The patient’s compliance has decreasedC. The patient’s compliance has decreased

D. The patient is developing pulmonary D. The patient is developing pulmonary edemaedema

Equally Plausible OptionsEqually Plausible Options


• B,C, and D all represent decreases in B,C, and D all represent decreases in compliance thus are equivalentcompliance thus are equivalent

• The “odd man out” is the correct answerThe “odd man out” is the correct answer

You are assisting with the oral intubation of an You are assisting with the oral intubation of an adult patient. After the ET tube has been adult patient. After the ET tube has been placed, you note that breath sounds are placed, you note that breath sounds are decreased on the left compared with the right decreased on the left compared with the right lung. What is the most likely cause of this?lung. What is the most likely cause of this?

A. The tip of the tube is in the right mainstem A. The tip of the tube is in the right mainstem bronchusbronchus

B. The cuff of the endotracheal tube has been B. The cuff of the endotracheal tube has been overinflatedoverinflated

C. The endotracheal tube has been inserted into C. The endotracheal tube has been inserted into the esophagusthe esophagus

D. The tip of the tube is in the left mainstem D. The tip of the tube is in the left mainstem bronchusbronchus

Opposite OptionsOpposite Options• Correct answer ACorrect answer A• In general, when you encounter two In general, when you encounter two

options that are opposites, chances are options that are opposites, chances are the correct choice is one of the twothe correct choice is one of the two

• A and D are opposites, one of them is A and D are opposites, one of them is most likely the correct answermost likely the correct answer

• There are exceptions to this strategyThere are exceptions to this strategy

A patient receiving long-term positive-A patient receiving long-term positive-pressure ventilatory support exhibits a pressure ventilatory support exhibits a progressive weight gain and a reduction progressive weight gain and a reduction in the hematocrit. Which of the following in the hematocrit. Which of the following is the most likely cause if this problem?is the most likely cause if this problem?

A. LeukocytosisA. Leukocytosis

B. Chronic hypoxemiaB. Chronic hypoxemia

C. Water retentionC. Water retention

D. LeukocytopeniaD. Leukocytopenia

Opposite OptionsOpposite Options

• Correct answer CCorrect answer C

• A and D are opposites but in this case A and D are opposites but in this case they are distractorsthey are distractors

In reviewing the PFT results of a 67-year-In reviewing the PFT results of a 67-year-old smoker with an admitting diagnosis of old smoker with an admitting diagnosis of emphysema and chronic bronchitis, you emphysema and chronic bronchitis, you would expect which of the following would expect which of the following general findings?general findings?

A. Increased airway resistance and A. Increased airway resistance and decreased lung compliancedecreased lung compliance

B. Increased airway resistance and B. Increased airway resistance and increased lung complianceincreased lung compliance

C. Decreased airway resistance and C. Decreased airway resistance and decreased lung compliancedecreased lung compliance

D. Decreased airway resistance and D. Decreased airway resistance and increased lung complianceincreased lung compliance

Duplicate Facts in OptionsDuplicate Facts in Options• Correct answer BCorrect answer B• This question’s options contain two contrasting This question’s options contain two contrasting

statements: increased/decreased resistance and statements: increased/decreased resistance and increased/decreased compliance.increased/decreased compliance.

• Identify any statement that you know is either true or Identify any statement that you know is either true or false.false.

• If you know that patients with emphysema and If you know that patients with emphysema and chronic bronchitis typically have increased airway chronic bronchitis typically have increased airway resistance you can eliminate options C and D.resistance you can eliminate options C and D.

When instructing a patient how to breathe When instructing a patient how to breathe during a small-volume nebulizer drug during a small-volume nebulizer drug treatment, the respiratory therapist treatment, the respiratory therapist coaches the patient to hold his breath at coaches the patient to hold his breath at the end of inspiration. The purpose of the end of inspiration. The purpose of this maneuver is to improve:this maneuver is to improve:

A. Drug deliveryA. Drug delivery

B. Particle stabilityB. Particle stability

C. Aerosol penetrationC. Aerosol penetration

D. Inertial impactionD. Inertial impaction

Global OptionsGlobal Options


• A is the most general or global alternativeA is the most general or global alternative

• B, C, and D are all factors that fall under B, C, and D are all factors that fall under the broader concept of enhanced drug the broader concept of enhanced drug delivery, making option A the best delivery, making option A the best choice.choice.

You obtain an SpO2 measurement on a You obtain an SpO2 measurement on a patient of 80%. Assuming this is an patient of 80%. Assuming this is an accurate measure of hemoglobin accurate measure of hemoglobin saturation, what is the patient’s saturation, what is the patient’s approximate PaO2?approximate PaO2?

A. 40 torrA. 40 torr

B. 50 torrB. 50 torr

C. 60 torrC. 60 torr

D. 70 torrD. 70 torr

Options Constituting a RangeOptions Constituting a Range• Correct answer BCorrect answer B• Item writers often try to mask the correct Item writers often try to mask the correct

choice by placing it within a set of higher and choice by placing it within a set of higher and lower values. lower values.

• Consider eliminating the highest and lowest Consider eliminating the highest and lowest values and choosing an option in the middle.values and choosing an option in the middle.

• ““40-50-60/70-80-90”40-50-60/70-80-90”

A portable spirometer requires that you A portable spirometer requires that you enter the patient’s height in centimeters enter the patient’s height in centimeters in order to derive normal values. The in order to derive normal values. The patient tells you that she is 5 feet 6 patient tells you that she is 5 feet 6 inches tall. What value would you enter inches tall. What value would you enter into the device?into the device?

A. 26 cmA. 26 cm

B. 66 cmB. 66 cm

C. 168 cmC. 168 cm

D. 186 cmD. 186 cm

Math ProblemsMath Problems• Correct answer CCorrect answer C• 66 in x 2.5466 in x 2.54• Or approximately 2 x 66 + ½ 66 = 66+66+33 = 168Or approximately 2 x 66 + ½ 66 = 66+66+33 = 168• 66/2.54 = 26 answer choice A is a good distracter66/2.54 = 26 answer choice A is a good distracter

• Use scratch paperUse scratch paper• Ste up the problem properlySte up the problem properly• Try estimating the answer without calculatingTry estimating the answer without calculating

• Do your computation twice to confirm the Do your computation twice to confirm the answeranswer

• Many distracters are based on common Many distracters are based on common formula or computation errors, do not formula or computation errors, do not immediately select an answer that immediately select an answer that matches your calculationmatches your calculation

• If you absolutely do not know choose If you absolutely do not know choose from the answers in the middlefrom the answers in the middle

During postural drainage of the left lower During postural drainage of the left lower lobe, a patient complains of acute chest lobe, a patient complains of acute chest pain. Which of the following would you pain. Which of the following would you do?do?

A. Give the patient supplemental oxygenA. Give the patient supplemental oxygen

B. Continue the treatment with the bed flatB. Continue the treatment with the bed flat

C. Ask the nurse to administer pain C. Ask the nurse to administer pain medicationmedication

D. Discontinue the treatment and monitor D. Discontinue the treatment and monitor the patientthe patient

The Triple S RuleThe Triple S Rule

• Correct answer DCorrect answer D

• If a patient gets worse while you are If a patient gets worse while you are giving therapy…giving therapy…• Stop, stabilize, stayStop, stabilize, stay

• Stop what you are doingStop what you are doing• Stabilize the patient Stabilize the patient • Stay with the patientStay with the patient

A 45-year-old patient with asthma is prescribed A 45-year-old patient with asthma is prescribed 0.3 mL of albuterol (Proventil) in 3 mL normal 0.3 mL of albuterol (Proventil) in 3 mL normal saline via small-volume nebulizer. Before saline via small-volume nebulizer. Before initiating therapy, you note from chart review initiating therapy, you note from chart review that the patient is severely hypertensive and that the patient is severely hypertensive and has been experiencing episodes of has been experiencing episodes of supraventricular tachycardia. You should do supraventricular tachycardia. You should do which of the following?which of the following?

A. Administer the treatment as orderedA. Administer the treatment as orderedB. Postpone the treatment and notify the B. Postpone the treatment and notify the

physicianphysicianC. Dilute the albuterol with extra normal salineC. Dilute the albuterol with extra normal salineD. Decrease the amount of albuterol D. Decrease the amount of albuterol

administeredadministered

The Triple S Rule (part 2)The Triple S Rule (part 2)

• Correct answer BCorrect answer B

• A corollary to the triple S rule is to never A corollary to the triple S rule is to never start therapy if the patient is exhibiting start therapy if the patient is exhibiting abnormal signs ir symptoms that could abnormal signs ir symptoms that could be worsened by your actionbe worsened by your action

A patient is admitted to the emergency A patient is admitted to the emergency department comatose with suspected department comatose with suspected smoke inhalation. After confirming smoke inhalation. After confirming airway patency, which of the following airway patency, which of the following should you do should you do firstfirst??

A. Measure the SpO2A. Measure the SpO2

B. Initiate 100% OxygenB. Initiate 100% Oxygen

C. Obtain an arterial blood gasC. Obtain an arterial blood gas

D. Request a STAT chest X-rayD. Request a STAT chest X-ray

Act First, Ask Questions LaterAct First, Ask Questions Later


• Obtaining additional information is Obtaining additional information is important but given that the patient is important but given that the patient is suspected of smoke inhalation 100% suspected of smoke inhalation 100% oxygen should be administered oxygen should be administered immediatelyimmediately

You are called to the bedside of a patient by her You are called to the bedside of a patient by her ICU nurse to check the attached volume ICU nurse to check the attached volume ventilator. You note that both the low-volume ventilator. You note that both the low-volume and high-pressure limit alarms are sounding on and high-pressure limit alarms are sounding on each breath, Your first action should be to:each breath, Your first action should be to:

A. Disconnect patient and manually ventilate with A. Disconnect patient and manually ventilate with 100% oxygen100% oxygen

B. Call the attending physician for further patient B. Call the attending physician for further patient informationinformation

C. Check the patient’s chart for the original C. Check the patient’s chart for the original ventilator ordersventilator orders

D. Ask the nurse about how recently the patient D. Ask the nurse about how recently the patient was suctionedwas suctioned

Act First, Ask Questions LaterAct First, Ask Questions Later


• B,C, and D nay help you evaluate the B,C, and D nay help you evaluate the problem but they waste precious time.problem but they waste precious time.

• Your priority os patient safetyYour priority os patient safety

A 60-kg (132-lb) COPD patient is receiving A 60-kg (132-lb) COPD patient is receiving SIMV with a Vt of 500 mL at a rate of SIMV with a Vt of 500 mL at a rate of 9/min with an FiO2 of 0.35. Blood gases 9/min with an FiO2 of 0.35. Blood gases are as follows: pH = 7.36; PaCO2 = 61 are as follows: pH = 7.36; PaCO2 = 61 torr; HCO3- = 36 mEq/L; PaO2 = 64 torr. torr; HCO3- = 36 mEq/L; PaO2 = 64 torr. Which of the following changes would Which of the following changes would you recommend at this time?you recommend at this time?

A. Increase the IMV rateA. Increase the IMV rate

B. Increase the FiO2B. Increase the FiO2

C. Maintain settingsC. Maintain settings

D. Increase the VtD. Increase the Vt

If It Ain’t Broke, Don’t Fix It!If It Ain’t Broke, Don’t Fix It!


A 30-kg (66-lb) child is being mechanically A 30-kg (66-lb) child is being mechanically ventilated in the SIMV mode. The following ventilated in the SIMV mode. The following data are available: Ventilator settings: FiO2 data are available: Ventilator settings: FiO2 0.45; mandatory rate 18; total rate 23; Vt 350 0.45; mandatory rate 18; total rate 23; Vt 350 mL; PEEP 12 cmH2O. Blood gases: pH 7.38; mL; PEEP 12 cmH2O. Blood gases: pH 7.38; PaCO2 42 toor; PaO2 110 torr; HCO3- 23 PaCO2 42 toor; PaO2 110 torr; HCO3- 23 mEq/L, BE 0 mEq/L. Based on these data, mEq/L, BE 0 mEq/L. Based on these data, which of the following should you do?which of the following should you do?

A. Decrease the tidal volumeA. Decrease the tidal volume

B. Reduce the PEEPB. Reduce the PEEP

C. Decrease the rateC. Decrease the rate

D. Lower the FiO2D. Lower the FiO2

Back Off Bad!Back Off Bad!


The following data are available for a patient:The following data are available for a patient:Blood Gas AnalyzerBlood Gas Analyzer Co-OximeterCo-OximeterpH 7.35pH 7.35 OxyHb 97%OxyHb 97%PaCO2 28 torrPaCO2 28 torr CarboxyHb 1%CarboxyHb 1%HCO3- 14 mEq/LHCO3- 14 mEq/L MetHb 1%MetHb 1%BE -10 mEq/LBE -10 mEq/L Hb 18.8 g/dlHb 18.8 g/dlPaO2 40 torrPaO2 40 torrSaO2 73%SaO2 73%You should do which of the following?You should do which of the following?A. Report the SaO2 value at 73%A. Report the SaO2 value at 73%B. Report the SaO2 value as 97%B. Report the SaO2 value as 97%C. Recommend administration of bicarbonateC. Recommend administration of bicarbonateD. Recalibrate the instruments and repeat the D. Recalibrate the instruments and repeat the

analysisanalysis

Data Just Don’t JiveData Just Don’t Jive


• Large discrepancy between PaO2, SaO2 Large discrepancy between PaO2, SaO2 and OxyHb and OxyHb

The results of an arterial blood gas The results of an arterial blood gas analysis for a patient who is breathing analysis for a patient who is breathing 100% oxygen are below: pH 7.27; PaCo2 100% oxygen are below: pH 7.27; PaCo2 44 torr; HCO3- 23 mEq/L; BE +1; PaO2 44 torr; HCO3- 23 mEq/L; BE +1; PaO2 598 torr; SaO2 100%. Which of the 598 torr; SaO2 100%. Which of the following is the likely problem?following is the likely problem?

A. Respiratory acidosisA. Respiratory acidosis

B. Large physiologic shuntB. Large physiologic shunt

C. Metabolic acidosisC. Metabolic acidosis

D. Laboratory errorD. Laboratory error

Errors, Errors, Everywhere!Errors, Errors, Everywhere!• Correct answer DCorrect answer D• When ever you have laboratory error as When ever you have laboratory error as

an option, always check the numbersan option, always check the numbers• PaO2 is normal (use alveolar air equation)PaO2 is normal (use alveolar air equation)• Acid base status is impossible based on Acid base status is impossible based on

theHenderson-Hasselbach equationtheHenderson-Hasselbach equation

A doctor asks you to assess if a 75-kg (165-lb) A doctor asks you to assess if a 75-kg (165-lb) patient with a neuromuscular disorder being patient with a neuromuscular disorder being mechanically ventilated in the SIMV mode is mechanically ventilated in the SIMV mode is ready for weaning. You obtain the following ready for weaning. You obtain the following data during a bedside ventilatory assessment: data during a bedside ventilatory assessment: spontaneous Vt 250 mL; Minute ventilation 10 spontaneous Vt 250 mL; Minute ventilation 10 L/min; Vital Capacity 750 mL; MIP -28 cm2O. L/min; Vital Capacity 750 mL; MIP -28 cm2O. Based on thus information, which of the Based on thus information, which of the following would you recommend?following would you recommend?

A. Begin a spontaneous breathing T-piece trialA. Begin a spontaneous breathing T-piece trialB. Postpone weaning and reevaluate the patientB. Postpone weaning and reevaluate the patientC. Begin weaning using a pressure support C. Begin weaning using a pressure support

protocolprotocolD. Begin weaning by decreasing the SIMV rateD. Begin weaning by decreasing the SIMV rate

Don’t Know What You’re Missing!Don’t Know What You’re Missing!• Correct answer BCorrect answer B• VC and MIP are borderline adequateVC and MIP are borderline adequate• But Vt and VE suggest a major problemBut Vt and VE suggest a major problem• Spontaneous rate = 10 L/min / 250 mL/breath Spontaneous rate = 10 L/min / 250 mL/breath

= 40 breaths/ minute= 40 breaths/ minute• RSBI = 40/0.25 – 160RSBI = 40/0.25 – 160• Review the numbers to see what is missing!Review the numbers to see what is missing!

A surgeon orders an increase in PEEP from 6 to A surgeon orders an increase in PEEP from 6 to 10 cmH2O for a post-op patient receiving 10 cmH2O for a post-op patient receiving mechanical ventilation. After you adjust the mechanical ventilation. After you adjust the PEEP setting, you note a rapid fall in the PEEP setting, you note a rapid fall in the patient’s arterial blood pressure and a rapid patient’s arterial blood pressure and a rapid rise in her heart rate. Which of the following rise in her heart rate. Which of the following actions would you recommend to the surgeon?actions would you recommend to the surgeon?

A. Increase the FiO2 by 10%A. Increase the FiO2 by 10%

B. Administer a vasopressorB. Administer a vasopressor

C. Return The PEEP to 6 cmH2OC. Return The PEEP to 6 cmH2O

D. Obtain a STAT blood gasD. Obtain a STAT blood gas

Jump Back, Jack!Jump Back, Jack!• Correct answer CCorrect answer C• When things go bad, many times your action When things go bad, many times your action

immediately preceded things going badimmediately preceded things going bad• The best course of action is the reverse course and The best course of action is the reverse course and

undo what you have just doneundo what you have just done• One of the adverse effects of PEEP is decreased One of the adverse effects of PEEP is decreased

cardiac outputcardiac output• Due to increased pleural pressure and decreased Due to increased pleural pressure and decreased

venous returnvenous return

Manual ventilation of a patient with a self-Manual ventilation of a patient with a self-inflating bag-valve-mask device fails to inflating bag-valve-mask device fails to inflate the patient’s chest adequately. inflate the patient’s chest adequately. You should do which of the following?You should do which of the following?

A. Intubate and mechanically ventilate the A. Intubate and mechanically ventilate the patientpatient

B. Switch to a gas-powered resuscitator B. Switch to a gas-powered resuscitator with maskwith mask

C. Reposition the patient’s head, neck, and C. Reposition the patient’s head, neck, and maskmask

D. Insert a laryngeal mask airway (LMA)D. Insert a laryngeal mask airway (LMA)

KISS It!KISS It!


• The simplest and should be tried before The simplest and should be tried before moving on to more aggressive optionsmoving on to more aggressive options

When checking a ventilator, you discover When checking a ventilator, you discover that the set PEEP level cannot be that the set PEEP level cannot be maintained. Which of the following might maintained. Which of the following might be causing this problem?be causing this problem?

I. Leak in the tubingI. Leak in the tubingII. Faulty exhalation valveII. Faulty exhalation valveIII. Leak around the airway cuffIII. Leak around the airway cuffIV. Loose humidifier connectionIV. Loose humidifier connection

A. I and IIA. I and IIB. I and IIIB. I and IIIC. II and IVC. II and IVD. I, II, III, and IVD. I, II, III, and IV

Gas Goes In, Gas Goes In, Gas Comes OutGas Comes Out

• Correct answer DCorrect answer D• You will be asked questions that ask you You will be asked questions that ask you

to differentiate between a leak and an to differentiate between a leak and an obstructionobstruction

• Leaks prevent pressure buildupLeaks prevent pressure buildup• Obstructions cause pressure buildupObstructions cause pressure buildup

At the bedside of a patient receiving At the bedside of a patient receiving volume-oriented mechanical ventilation, volume-oriented mechanical ventilation, you suddenly observe that simultaneous you suddenly observe that simultaneous sounding of the high-pressure and low-sounding of the high-pressure and low-volume alarms. Which of the following is volume alarms. Which of the following is the most likely cause of this problem?the most likely cause of this problem?

A. A leak in the ET tube cuffA. A leak in the ET tube cuff

B. A mucous plug in the ET tubeB. A mucous plug in the ET tube

C. Ventilator circuit disconnectionC. Ventilator circuit disconnection

D. Development of pulmonary edemaD. Development of pulmonary edema

Gas Goes In, Gas Goes In, Gas Comes OutGas Comes Out

• Correct answer BCorrect answer B• Obstructions can be more difficult to identify Obstructions can be more difficult to identify

because they can either be partial or completebecause they can either be partial or complete• High pressure/low volume = obstructionHigh pressure/low volume = obstruction• Low pressure/low volume = leakLow pressure/low volume = leak• B and D both cause obstruction but the one that B and D both cause obstruction but the one that

would arise would arise suddenlysuddenly is the mucus plug is the mucus plug

Which of the following would facilitate Which of the following would facilitate clearance of pulmonary secretions in a clearance of pulmonary secretions in a patient with cystic fibrosis?patient with cystic fibrosis?

I. MucomystI. Mucomyst

II. Flutter valveII. Flutter valve

III. AtropieneIII. Atropiene

IV. DNaseIV. DNase

A. I and IIIA. I and III

B. II and IVB. II and IV

C. I, II, and IVC. I, II, and IV

D. II, III, and IVD. II, III, and IV

Love Those Multiple Multiples!Love Those Multiple Multiples!


During a short pause from resuscitation of a child During a short pause from resuscitation of a child in the emergency department, you cannot in the emergency department, you cannot palpate a carotid pulse but observe the palpate a carotid pulse but observe the following rhythm on the ECG monitor (next following rhythm on the ECG monitor (next slide)slide)

Which of the following actions should you take at Which of the following actions should you take at this time?this time?

A. Resume cardiac compressions and ventilationA. Resume cardiac compressions and ventilation

B. Discontinue compressions and monitor the B. Discontinue compressions and monitor the patientpatient

C. Recommend cardioversion at 100 JoulesC. Recommend cardioversion at 100 Joules

D. Recommend epinephrine administrationD. Recommend epinephrine administration

Treat the Patient,Treat the Patient,Not the Monitor!Not the Monitor!

• Correct answer ACorrect answer A• They will give you scenarios where the patient and They will give you scenarios where the patient and

monitor data conflictmonitor data conflict• Pulse oximetry dataPulse oximetry data• ECGECG

• PEAPEA• Remember the ECG only represents electrical activity Remember the ECG only represents electrical activity

and a patient with no pulse requires resuscitationand a patient with no pulse requires resuscitation

A physician has ordered albuterol A physician has ordered albuterol (Proventil) and deoxyribonuclease (Proventil) and deoxyribonuclease (DNase) by aerosol for a cystic fibrosis (DNase) by aerosol for a cystic fibrosis patient who also receives postural patient who also receives postural drainage 3 times a day. You should drainage 3 times a day. You should administer these therapies in which of the administer these therapies in which of the following sequences?following sequences?

A. DNase, postural drainage, albuterolA. DNase, postural drainage, albuterol

B. Albuterol, DNase, postural drainageB. Albuterol, DNase, postural drainage

C. Postural drainage, albuterol, DNaseC. Postural drainage, albuterol, DNase

D. DNase, albuterol, postural drainageD. DNase, albuterol, postural drainage

Keeping OrderKeeping Order

• Correct answer B Correct answer B

• Open ‘em upOpen ‘em up

• Thin ‘em downThin ‘em down

• Clear ‘em outClear ‘em out

A 90-kg (198-lb) patient is being ventilated in the A 90-kg (198-lb) patient is being ventilated in the postanesthesia care unit (PACU) following upper postanesthesia care unit (PACU) following upper abdominal surgery. Ventilator settings and arterial abdominal surgery. Ventilator settings and arterial blood gas date are as follows: blood gas date are as follows:

Ventilator Settings:Ventilator Settings: Blood Gases:Blood Gases:Mode SIMVMode SIMV pH 7.51pH 7.51Vt 800 mLVt 800 mL PaCO2 31 torrPaCO2 31 torrSet rate 14/minSet rate 14/min HCO3- 24 mEq/LHCO3- 24 mEq/LTotal rate 14/minTotal rate 14/min BE +1BE +1FiO2 0.40FiO2 0.40 PaO2 115 torrPaO2 115 torrPEEP 5 cmH2OPEEP 5 cmH2O SaO2 99%SaO2 99%You should recommend which of the following?You should recommend which of the following?A. Increase the FiO2A. Increase the FiO2B. Decrease the rateB. Decrease the rateC. Decrease the tidal volumeC. Decrease the tidal volumeD. Discontinue PEEPD. Discontinue PEEP

Give me a V; Give me an O!Give me a V; Give me an O!


• You must be able to interpret blood You must be able to interpret blood gasesgases

• You must be able to differentiate You must be able to differentiate between an ventilation problem versus between an ventilation problem versus an oxygenation probleman oxygenation problem

A 45-year-old 70-kg (154-lb) male with a diagnosis of A 45-year-old 70-kg (154-lb) male with a diagnosis of bilateral pneumonia is receiving volume-controlled bilateral pneumonia is receiving volume-controlled ventilation in the SIMV mode. Ventilator settings and ventilation in the SIMV mode. Ventilator settings and blood gas data are below:blood gas data are below:

Ventilator Settings:Ventilator Settings: Blood Gases:Blood Gases:Mode SIMVMode SIMV pH 7.35pH 7.35Vt 700 mLVt 700 mL PaCO2 345 torrPaCO2 345 torrSet rate 6/minSet rate 6/min HCO3- 23 mEq/LHCO3- 23 mEq/LTotal rate 10/minTotal rate 10/min BE -1BE -1FiO2 0.65FiO2 0.65 PaO2 55 torrPaO2 55 torrPEEP 5 cmH2OPEEP 5 cmH2O SaO2 83%SaO2 83%Which of the following shoud be recommended?Which of the following shoud be recommended?A. Increase PEEPA. Increase PEEPB. Increase the rateB. Increase the rateC. Increase the FiO2C. Increase the FiO2D. Add an inspiratory plateauD. Add an inspiratory plateau

Give Me a V; Give Me an O!Give Me a V; Give Me an O!


• Hypoxemia is present so both A and C would Hypoxemia is present so both A and C would helphelp

• Use the 60/60 ruleUse the 60/60 rule• PaO2 > 60 & FiO2 < 0.60 maldistribution of PaO2 > 60 & FiO2 < 0.60 maldistribution of

ventilation = increase FiO2ventilation = increase FiO2• PaO2 < 60 & FiO2 > 0.60 physiologic shunting = PaO2 < 60 & FiO2 > 0.60 physiologic shunting =

add/increase PEEP/CPAPadd/increase PEEP/CPAP

A nurse tells you that his patient is A nurse tells you that his patient is scheduled to start chest physiotherapy scheduled to start chest physiotherapy four times a day this morning and that he four times a day this morning and that he would like you to get started before she would like you to get started before she goes to radiology for a CT scan. Which goes to radiology for a CT scan. Which of the following should you do first?of the following should you do first?

A. Auscultate and percuss the patient’s A. Auscultate and percuss the patient’s chestchest

B. Initiate therapy after reviewing the X-rayB. Initiate therapy after reviewing the X-ray

C. Interview the patient to obtain a historyC. Interview the patient to obtain a history

D. Confirm the doctor’s order in the chartD. Confirm the doctor’s order in the chart

Who’s in Charge Here?Who’s in Charge Here?


GOOD LUCK!GOOD LUCK!

ResourcesResources

Scanlan et. Al. Scanlan et. Al. Certified Respiratory Certified Respiratory Therapist Exam Review Guide.Therapist Exam Review Guide. 2010. 2010. Jones and Bartlett.Jones and Bartlett.

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