Chapter 35: Humidity and Bland Aerosol Therapy

1. What is the point in the respiratory track where inspired gas reaches body temperature,

ambient pressure, saturated (BTPS) conditions?

a. point of thermal equilibrium

b. hygroscopic saturation boundary

c. thermal inversion boundary

d. isothermic saturation boundary

As inspired gas moves into the lungs, it achieves BTPS conditions (body temperature, 37° C;

barometric pressure; saturated with water vapor [100% relative humidity at 37° C]). This

point, normally approximately 5 cm below the carina, is called the isothermic saturation

boundary.

2. Which of the following is FALSE about the isothermic saturation boundary (ISB)?

a. Below the ISB, temperature and relative humidity remain constant.

b. Above the ISB, temperature and humidity increase during exhalation.

c. The ISB is normally located just below the larynx (vocal cords).

d. Above the ISB, temperature and humidity decrease during inspiration.

This point, normally approximately 5 cm below the carina, is called the isothermic saturation

boundary (ISB). Above the ISB, temperature and humidity decrease during inspiration and

increase during exhalation.

3. Which of the following factors cause the isothermic saturation boundary (ISB) to shift farther

down into the airways?

1. decreased ambient temperature

2. increased tidal volume (VT)

3. endotracheal intubation

a. 1 and 2

b. 2 and 3

c. 1 and 3

d. 1, 2, and 3

The ISB shifts distally when a person breathes through the mouth rather than the nose; when

he or she breathes cold, dry air; when the upper airway is bypassed (breathing through an

artificial tracheal airway); or when the minute ventilation is higher than normal.

4. What is the primary goal of humidity therapy?

a. decrease airway reactivity to cold

b. maintain normal physiologic conditions

c. deliver drugs to the airway

d. reduce upper airway inflammation

The primary goal of humidification is to maintain normal physiological conditions in the

lower airways.

5. Indications for warming inspired gases include all of the following except:

a. treating a patient whose airways are reactive to cold

b. providing humidification when the upper airway is bypassed

c. treating a patient with a low body temperature (hypothermia)

d. reducing upper airway inflammation or swelling

6. Administration of dry gases at flows exceeding 4 L/min can cause which of the following?

1. structural damage

2. heat loss

3. water loss

a. 1 and 2

b. 2 and 3

c. 1 and 3

d. 1, 2, and 3

Administration of dry medical gases at flows greater than 4 L/min to the upper airway causes

immediate heat and water loss and, if prolonged, causes structural damage to the epithelium.

7. Inhalation of dry gases can do which of the following?

1. increase viscosity of secretions

2. impair mucociliary motility

3. increase airway irritability

a. 1 and 2

b. 3

c. 1 and 3

d. 1, 2, and 3

As the airway is exposed to relatively cold, dry air, ciliary motility is reduced, airways

become more irritable, mucous production increases, and pulmonary secretions become

inspissated (thickened due to dehydration).

11. Clinical indications for delivering cool humidified gas include which of the following?

1. post-extubation edema

2. upper airway inflammation

3. croup (laryngotracheal bronchitis)

4. epiglottitis

a. 2, 3, and 4

b. 1, 2, and 3

c. 1, 2, 3, and 4

d. 2 and 3

The delivery of cool humidified gas is used to treat upper airway inflammation resulting from

croup, epiglottitis, and post-extubation edema.

12. What device adds molecular water to gas?

a. agitator

b. humidifier

c. nebulizer

d. atomizer

A humidifier is a device that adds molecular water to gas.

13. Factors affecting a humidifier’s performance include all of the following except:

a. surface area

b. temperature

c. time of contact

d. outlet size

The following four variables affect the quality of a humidifier’s performance: (1) temperature,

(2) surface area, (3) time of contact, and (4) thermal mass.

14. What is the most important factor determining a humidifier’s performance?

a. surface area

b. temperature

c. time of contact

d. gas flow

Temperature is an important factor affecting humidifier performance.

15. The greater the temperature of the gas, the:

a. more water vapor it can hold

b. less water vapor it can hold

c. less efficient the humidifier is

d. more water vapor is lost

The greater the temperature of a gas, the more water vapor it can hold (increased capacity). 27. The relief valve on a bubble humidifier serves which of the following functions?

1. It indicates when flow has been interrupted.

2. It protects the device from pressure damage.

3. It warns you when the water level is low.

a. 1 and 2

b. 2 and 3

c. 1 and 3

d. 1, 2, and 3

The relief valve on a bubble humidifier serves to warn of flow-path obstruction and to prevent

bursting of the humidifier bottle.

32. What are some types of passover humidifiers?

1. simple reservoir

2. membrane

3. wick

a. 1 and 2

b. 2 and 3

c. 1 and 3

d. 1, 2, and 3

37. Heat-moisture exchangers (HMEs) are mainly used to do what?

a. warm and humidify gases delivered to the trachea via ventilator circuits

b. humidify therapeutic gases delivered at high flows to the lower airway

c. provide extra humidity for a patient with thick or retained secretions

d. warm and humidify dry therapeutic gases delivered to the upper airway

Traditionally, HME use has been limited to providing humidification to patients receiving

invasive ventilatory support via endotracheal or tracheostomy tubes

78. For which of the following patients would you NOT recommend bland aerosol therapy

administration?

1. patient with a history of airway hyperresponsiveness

2. patient with a bypassed upper airway

3. patient with active bronchoconstriction

a. 1, 2, and 3

b. 2 and 3

c. 1 and 2

d. 1 and 3

79. Hazards and complications of bland aerosol therapy include all of the following except:

a. bronchospasm

b. overhydration

c. infection

d. hemoconcentration

82. Which of the following would indicate that administration of a bland water aerosol to a patient

with post-extubation upper airway edema was having the desired effect?

1. decreased work of breathing

2. improved vital signs

3. decreased stridor or dyspnea

4. improved oxygen saturation

a. 1, 2, and 3

b. 1, 2, 3, and 4

c. 3 and 4

d. 1, 2, and 4

87. Which of the following nebulizers uses a piezoelectric transducer to generate liquid particle

aerosols?

a. hydrodynamic nebulizer

b. ultrasonic nebulizer

c. jet nebulizer

d. centrifugal nebulizer

An ultrasonic nebulizer is an electrically powered device that uses a piezoelectric crystal to

generate aerosol. 97. A physician orders bland water aerosol administration to a patient with a tracheostomy.

Which of the following airway devices could you use to meet this goal?

1. tracheostomy mask

2. face tent

3. T-tube

4. aerosol mask

a. 2 and 4

b. 1, 2, and 3

c. 1 and 3

d. 2, 3, and 4

Chapter 36: Aerosol Drug Therapy

1. Which of the following best defines an aerosol?

a. suspension of liquid droplets in a gas

b. suspension of particulate matter in a gas

c. molecular water dispersed throughout a carrier gas

d. suspension of liquid or solid particles in a gas

An aerosol is a suspension of solid or liquid particles in gas.

2. With which of the following devices are therapeutic aerosols generated?

1. atomizers

2. nebulizers

3. humidifiers

a. 1 and 2

b. 1 and 3

c. 2 and 3

d. 1, 2, and 3

In the clinical setting, medical aerosols are generated with atomizers, nebulizers, or inhalers.

3. The mass of aerosol particles produced by a nebulizer in a given unit time best describes

which quality of the aerosol?

a. stability

b. density

c. output

d. deposition

Aerosol output is defined as the mass of fluid or drug contained in aerosol produced by a

nebulizer generated per unit of time.

4. Which of the following describes the mass of drug leaving the mouthpiece of a nebulizer as

aerosol?

a. single dose

b. emitted dose

c. multiple dose

d. output dose

For drug delivery systems, emitted dose describes the mass of drug leaving the mouthpiece of a nebulizer or inhaler as aerosol. 9. What is the retention of aerosol particles resulting from contact with the respiratory tract mucosa called?

a. stability

b. density

c. penetration

d. deposition

When aerosol particles leave suspension in gas they deposit on (attach to) a surface. 10. Which of the following factors affect pulmonary deposition of an aerosol?

1. size of the particles

2. shape and motion of the particles

3. physical characteristics of the airways

a. 1 and 2

b. 1 and 3

c. 2 and 3

d. 1, 2, and 3

Whether aerosol particles that are inhaled into the lung are deposited in the respiratory tract

depends on the size, shape, and motion of the particles and on the physical characteristics of

the airways and breathing pattern.

24. What is the process by which aerosol suspension changes over time?

a. evaporation

b. deposition

c. aging

d. sublimation

The process by which an aerosol suspension changes over time is called aging. 27. What is the primary hazard of aerosol drug therapy?

a. untoward drug reactions

b. pulmonary infection

c. airway reactivity

d. drug reconcentration

The primary hazard of aerosol drug therapy is an adverse reaction to the medication being

administered.

29. All of the following drugs or drug categories have been associated with increased airway

resistance and bronchospasm during aerosol administration except:

a. steroids

b. albuterol

c. acetylcysteine

d. antibiotics

33. What is the preferred method for delivering bronchodilators to spontaneously breathing and

intubated, ventilated patients?

a. dry powder inhaler

b. small-volume jet nebulizer

c. metered-dose inhaler

d. hand-bulb atomizer

Pressurized metered-dose inhalers often are the preferred method for delivering bronchodilators to spontaneously breathing patients as well as those who are intubated and undergoing mechanical ventilation. 41. Before inspiration and actuation of a metered-dose inhaler, the patient should exhale to which of the following?

a. total lung capacity

b. residual volume

c. functional residual capacity

d. expiratory reserve volume

42. To ensure delivery of the proper drug dosage with a metered-dose inhaler, which of the

following must be done before its use?

1. The canister valve stem should be cleaned with a pin.

2. The canister should be warmed to hand or body temperature.

3. The canister should be vigorously shaken.

a. 1 and 2

b. 1 and 3

c. 2 and 3

d. 1, 2, and 3

Chapter 4: Principles of Infection Prevention and Control

1. About how many people die each year in the United States from hospital-acquired infections

(HAIs)?

a. 5,000

b. 25,000

c. 99,000

d. 250,000

HAIs account for an estimated 1.7 million infections; $4.5 billion in costs, and 99,000 excess

deaths annually.

2. Approximately what percent of patients receiving mechanical ventilation develop pneumonia

as a complication?

a. 1%

b. 10%

c. 15%

d. 25%

Approximately 25% of patients undergoing mechanical ventilation develop pneumonia.

3. Which of the following is considered the primary source of infection in the health care

setting?

a. medical equipment

b. humans

c. food and water

d. carpet

Humans (patients, personnel, or visitors) are the primary source for infectious agents in the

health care setting

4. How do endotracheal tubes increase the risk of infection?

a. impeding local host defenses

b. providing surfaces for biofilms to develop

c. by reducing neutrophil effectiveness

d. both A and B

Endotracheal tubes allow pathogens to increase the risk of infection by impeding local host

defenses and providing biofilms that may facilitate adherence of pathogens. 5. All of the following factors increase the risk of surgical patients for developing postoperative

pneumonia except:

a. obesity

b. prolonged intubation

c. history of smoking

d. strong cough

Patients at highest risk include elderly persons, the severely obese, those with chronic

obstructive pulmonary disease (COPD) or a history of smoking, and those having an artificial

airway in place for long periods. Strong cough mechanism actually helps to prevent atelectasis

and pneumonia

6. What is the most common route of pathogen transmission in the hospital setting?

a. indirect contact

b. droplet transmission

c. airborne transmission

d. surgical transmission

Indirect contact transmission is the most frequent mode of transmission in the health care

environment

8. If you are caring for a patient who is suspected of having SARS, at what distance from the

patient is it recommended to wear an effective filtration mask?

a. 6 feet

b. 10 feet

c. 12 feet

d. 15 feet

Current HICPAC guidelines state it may be prudent to don a mask when within 6 feet of the

patient or upon entry into the room of a patient who is on droplet isolation.

9. Which of the following diseases is transmitted primarily by airborne transmission?

a. tuberculosis

b. measles

c. smallpox

d. all the above

The pathogens transmitted by the airborne route include Mycobacterium tuberculosis,

varicella-zoster virus (chickenpox), and rubeola virus (measles). Airborne transmission of

variola (smallpox) has been documented and airborne transmission of SARS, monkeypox, and

the viral hemorrhagic fever virus has been reported, although not proved conclusively.

10. What techniques are used by most hospitals to reduce host susceptibility to infection?

a. immunization

b. chemoprophylaxis

c. surveillance

d. both A and B

Hospital efforts to decrease host susceptibility focus mainly on employee immunization and

chemoprophylaxis.

11. What vaccination does OSHA require hospital employers to provide?

a. tuberculosis

b. smallpox

c. hepatitis B

d. Streptococcus pneumoniae

13. What is the first step in equipment processing for reuse on another patient?

a. drying the equipment

b. cleaning the equipment

c. disinfecting the equipment

d. sterilizing the equipment

Cleaning is the first step in all equipment processing.

15. What should be used to wipe down the surface of devices that cannot be immersed in water?

a. 70% ethyl alcohol

b. warm soapy water

c. strong detergent

d. bleach

The surface of the device should be disinfected using a 70% ethyl alcohol solution or the equivalent. 17. What solution should be used to disinfect the surfaces of the room of a patient who was infected with C. difficile?

a. 70% ethyl alcohol

b. 5.25% sodium hypochlorite

c. 1% sodium benzoate

d. 5% iodine solution

Because C. difficile may form spores that are resistant to commonly used surface

disinfectants, the CDC recommends the use of 1:10 dilution of 5.25% sodium hypochlorite

(household bleach) and water for routine environmental disinfection in the rooms of patients

with C. difficile

25. Which of the following is the most common source of patient infections?

a. large-volume nebulizers

b. small-volume nebulizers

c. internal circuits of a ventilator

d. oxygen therapy devices

Large-volume nebulizers are the worst offenders.

What are three goals of O2 Therapy

1. Correct documented or suspected acute Hypoxemia2. Decrease symptoms associated with chronic hypoxemia3. Decrease workload hypoxemia imposes on cardiopulmonary system

What is Laboratory documentation for assessing the need for O2 Therapy?

PaO2, SaO2 & SpO2

What are bedside findings that would lead to necessity of O2 therapy?

Tachypnea, tachycardia & confusion

What is an example of a clinical problem needing O2 therapy?

suspected Carbon Monoxide poisoning

Who does depression of ventilation occur in?

COPD patients with chronic hypercapnia

What happens in retinopathy of prematurity?

Excessive blood O2 levels cause retinal vasoconstriction & necrosis

Who is at risk of Absorption atelectasis?

Patients breathing small tidal volumes with FiO2 above 0.50 are at great risk

Where are O2 related fire hazards at high risk?

O2 enriched environments & surgical suites in presence of hyperbaric O2 therapy.

What are three designs for O2 delivery systems?

1. low-flow systems2. Reservoir systems3. High-flow systems

What are examples of low flow O2 delivery systems? (part of patient's O2 needs)

Nasal canula, regular mask, partial rebreather mask, oxymizer, non rebreather mask

What are examples of high flow O2 delivery systems? (Provides 100% of patient's O2 needs)

High flow nasal canula, Cascade high flow, Passover high flow, Venturie Mask, regular high flow with Aerosol mask

What should the FiO2 level be at when using the nasal canula (low flow)

0.24-0.40 dependent on how much room air patient inhales in addition to O2

What is the main benefit Nitric Oxide Therapy?

Improves oxygenation without shunting

Which patients would benefit from Nitric Oxide Therapy?

1. Patients with pulmonary hypertension*PRIMARY USE*

2. ARDS & COPD patients*Possible secondary use*

What are drawbacks to Nitric Oxide Therapy?

Poor paradoxical response, rebound hypoxemia, pulmonary hypertension.

What are 4 physical properties of O2?

Colorless, odorless, transparent and tasteless

Is O2 flammable? No but it greatly accelerates combustion

Who monitors the purity of O2 for medical gas

The Food and Drug Administration (FDA) ensures O2 is 99% pure

What are physical characteristics of helium (He)

odorless, tasteless, nonflammable, chemically and physiologically inert

What is a therapeutic use of He/O2 mixtures (Heliox)

**Manages severe cases of airway obstruction**Decreases WOB

Physical characteristics of Nitric Oxide (NO)

Colorless, nonflammable, toxic (Supports combustion)

What can exposure to high concentrations of NO cause?

Methemogloinemia --> tissue hypoxia

What treatments has the FDA approved the use of NO for?

**Treatment of infants with hypoxic respiratory failure**Pulmonary hypertension

Physical characteristics of Nitrous Oxide (N2O)

colorless gas with slightly sweet odor and taste

What is N2O clinically used for?

Anesthetic agent

What must always be mixed with N2O for clinical use?

O2

How are cylinders marked and identified?

Color coded and marked with metal stamping on shoulder.

What does the stamping indicate?

Size, normal filling pressure, serial number, ownership and method of manufacturer.

How often are safety tests conducted on gas cylinders?

every 5 or 10 years