Chapter 53: Discontinuing Ventilatory Support

Kacmarek: Egan’s Fundamentals of Respiratory Care, 12th Edition

MULTIPLE CHOICE

1. Which of the following factors will increase ventilatory demand (workload)?

1. Severe hypoxemia
2. Pulmonary infection
3. Increased compliance
4. Bronchospasm
a. 1 and 3 only
b. 1, 2, and 4 only
c. 3 and 4 only
d. 2, 3, and 4 only
ANS: B
Factors that may increase ventilatory workload are summarized in Box 53-1.

DIF: Recall OBJ: 1

2. Ventilatory capacity is determined by which of the following?

1. Central nervous system (CNS) drive
2. Trigger level
3. Muscle strength
4. Muscle endurance
a. 1 and 3 only
b. 1, 2, and 3 only
c. 2 and 4 only
d. 1, 3, and 4 only
ANS: D
Ventilatory capacity is determined by (1) CNS drive, (2) ventilatory muscle strength, and (3)
ventilatory muscle endurance.

DIF: Recall OBJ: 1

3. Which of the following factors can reduce a patient’s ventilatory drive?

1. Respiratory alkalosis
2. Metabolic acidosis
3. Depressant drugs
4. Decreased metabolism
a. 1 and 3 only
b. 1, 2, and 3 only
c. 2 and 4 only
d. 1, 3, and 4 only
ANS: D
Box 53-2 summarizes factors that may reduce ventilatory drive.

DIF: Recall OBJ: 2

4. When is ventilator dependence likely to occur?
1. When ventilatory capacity exceeds demand
2. When arterial hypoxemia is present
3. When the patient is malnourished
4. When the cardiovascular system is unstable
a. 2 and 4 only
b. 1, 2, and 3 only
c. 3 and 4 only
d. 2, 3, and 4 only
ANS: D
Other factors that may contribute to ventilator dependence include inadequate arterial
oxygenation, poor tissue oxygen (O2) delivery, myocardial ischemia, arrhythmias, low cardiac
output, and cardiovascular instability.

DIF: Recall OBJ: 2

5. What is the most important prerequisite for weaning a patient from ventilatory support?
a. Improvement in the original problem requiring mechanical ventilation
b. Assurance that the patient’s ventilatory demand exceeds the patient’s capacity
c. Objective evidence indicating good respiratory muscle endurance
d. Ability to maintain adequate oxygenation with an FiO2 less than 0.4
ANS: A
The single most important criterion to consider when evaluating a patient for ventilator
discontinuation or weaning is whether there has been significant alleviation or reversal of the
disease state or condition that necessitated use of the ventilator in the first place.

DIF: Recall OBJ: 3

6. What is the least reliable weaning index?

a. Vital capacity (VC)
b. Maximum inspiratory capacity (MIP)
c. Minute ventilation (VE)
d. Rapid-shallow breathing index (f/VT)
ANS: A
With respect to the more traditional weaning indices, vital capacity can be highly variable,
whereas MIP, minute ventilation, respiratory rate (f), and f/VT tend to be more reliable.

DIF: Recall OBJ: 3

7. Which of the following oxygenation measures support a patient’s readiness to wean?

1. PaO2/PAO2 (a/A) = 0.45
2. PaO2/FiO2 (P/F) = 110
3. PAO2–PaO2 = 240 mm Hg
4. Physiologic shunt (Qs/Qt) = 12%
a. 1 and 3 only
b. 1, 2, and 3 only
c. 2 and 4 only
 d. 1, 3, and 4 only
ANS: D
See Table 53-1.

DIF: Analysis OBJ: 4

8. Which of the following indicate that an adult patient is ready to be weaned from ventilatory
support?
1. VC = 1.9 L
2. Spontaneous rate of 32/min
3. Qs/Qt = 8%
4. MIP = –45 cm H2O
a. 2 and 4 only
b. 1, 2, and 3 only
c. 3 and 4 only
d. 1, 3, and 4 only
ANS: D
See Table 53-1.

DIF: Analysis OBJ: 4

9. Which of the following indicate that an adult patient is ready to be weaned from ventilatory
support?
1. PAO2 – PaO2 = 430 on 100% O2
2. VD/VT = 0.55
3. MIP = –33 cm H2O
4. PO2 = 76 mm Hg on 40% O2
a. 1 and 3 only
b. 1, 2, and 3 only
c. 3 and 4 only
d. 2, 3, and 4 only
ANS: D
See Table 53-1.

DIF: Analysis OBJ: 4

10. Which of the following four adult patients receiving ventilatory support is the best candidate
for weaning?
a. VC: 12; VE: 8; MVV: 22; MIF: –22; VD/VT: 0.58
b. VC: 8; VE: 8; MVV: 22; MIF: –15; VD/VT: 0.40
c. VC: 20; VE: 12; MVV: 18; MIF: –22; VD/VT: 0.60
d. VC: 12; VE: 12; MVV: 18; MIF: –10; VD/VT: 0.40
ANS: A
See Table 53-1.

DIF: Analysis OBJ: 3

11. Which of the following patients exhibits an acceptable ventilatory demand?

 a. VE: 12; PaCO2: 60
b. VE: 10; PaCO2: 55
c. VE: 8; PaCO2: 45
d. VE: 6; PaCO2: 60
ANS: C
See Table 53-1.

DIF: Analysis OBJ: 3

12. A patient has an adequate ventilatory reserve if which of the following is true?
a. Ability to double the resting minute ventilation
b. Normal PaCO2 and minute ventilation less than 10 L/min
c. MIP = –55 cm H2O
d. VD/VT less than 0.4
ANS: A
See Table 53-1.

DIF: Analysis OBJ: 3

13. You measure the spontaneous rate of breathing and VT on four patients receiving ventilator
support. For which one is successful weaning most likely?
a. Breathing frequency: 42; VT: 250 ml
b. Breathing frequency: 22; VT: 400 ml
c. Breathing frequency: 22; VT: 350 ml
d. Breathing frequency: 20; VT: 200 ml
ANS: B
See Table 53-1.

DIF: Analysis OBJ: 3

14. A patient receiving ventilator support has a spontaneous rate of breathing of 26/min and an
average VT of 300 ml. What is this patient’s rapid-shallow breathing index?
a. 12
b. 87
c. 105
d. 66
ANS: B
See Table 53-1.

DIF: Application OBJ: 3

15. Which of the following signs observed on a mechanically ventilated patient indicate that
successful weaning is unlikely?
1. Palpable scalene muscle use during inspiration
2. Palpable abdominal tensing during expiration
3. Presence of an irregular breathing pattern
4. Patient unable to alter breathing pattern on command
a. 2 and 4 only
 b. 1, 2, and 3 only
c. 3 and 4 only
d. 1, 2, 3, and 4
ANS: D
Evaluation of patients for the presence of palpable scalene muscle use during inspiration, an
irregular ventilatory pattern, palpable abdominal muscle tensing during expiration, and
inability to alter ventilatory pattern on command can be helpful in assessment of the potential
for prolonged spontaneous ventilation.

DIF: Recall OBJ: 3

16. Which of the following are true about the P0.1 measure?
1. P0.1 correlates well with central respiratory drive.
2. P0.1 is the airway pressure measured 100 msec after occlusion.
3. P0.1 is an effort-dependent measure of respiratory drive.
4. Chronic obstructive pulmonary disease (COPD) patients with a P0.1 greater than 6 cm H2O
are difficult to wean.
a. 2 and 4 only
b. 1, 2, and 4 only
c. 1 and 3 only
d. 2, 3, and 4 only
ANS: B
Airway occlusion pressure (P0.1) is the inspiratory pressure measured 100 msec after airway
occlusion. The P0.1 is effort independent and correlates well with central respiratory drive.
Ventilator-dependent patients with COPD who have a P0.1 greater than 6 cm H2O tend to be
difficult to wean.

DIF: Recall OBJ: 3

17. Successful weaning is less likely when a patient’s work of breathing exceeds what level?
a. 4 J/min
b. 8 J/min
c. 12 J/min
d. 16 J/min
ANS: D
Successful weaning has been found to be less likely among patients with spontaneous work
levels greater than 1.6 kg/m/min (16 J/min) or 0.14 kg/m/L (1.4 J/L).

DIF: Application OBJ: 3

18. Above what pressure-time index (PTI) will most patients be unable to sustain spontaneous
breathing?
a. 0.03
b. 0.05
c. 0.10
d. 0.15
ANS: D
 A PTI greater than 0.15 to 0.18 has been associated with diaphragmatic fatigue, and a PTI
greater than 0.15 cannot be sustained indefinitely.

DIF: Application OBJ: 4

19. Which of the following metabolic factors can hinder weaning?

1. Excessive carbohydrate feeding
2. Amino acid–based parenteral nutrition
3. Calorie intake = 1.5 resting energy expenditure (REE)
a. 2 and 3 only
b. 1 and 2 only
c. 1, 2, and 3
d. 1 and 3 only
ANS: B
Excessive carbohydrate feeding can increase carbon dioxide production and may precipitate
acute hypercapnic respiratory failure. Parenteral nutrition solutions containing amino acid
formulations (arginine/lysine) can cause metabolic acidosis and thus increase ventilatory
demand.

DIF: Recall OBJ: 5

20. Which of the following indicate that a patient’s renal function is adequate for weaning?
1. Urine output = 20 ml/hr
2. No major weight gain
3. No edema present
4. Normal electrolytes
a. 1 and 3 only
b. 1, 2, and 3 only
c. 3 and 4 only
d. 2, 3, and 4 only
ANS: D
The patient ideally should have an adequate urine output (>1000 ml/day), and there should be
no inappropriate weight gain or edema.

DIF: Application OBJ: 5

21. Which of the following electrolyte imbalances can hinder weaning from ventilatory support?
1. Hypochloremia
2. Hypomagnesemia
3. Hypokalemia
4. Hyponatremia
a. 2 and 3 only
b. 1 and 2 only
c. 3 and 4 only
d. 1 and 4 only
ANS: A
Key electrolytes should be normal (magnesium, 1.8 to 3.0 mEq/L; phosphate, 2.5 to 4.8
mEq/L; potassium, 3.5 to 5.0 mEq/L).
 DIF: Recall OBJ: 5

22. Which of the following cardiovascular signs would indicate that a patient’s cardiovascular
status is unstable and that weaning should not begin at this time?
a. Cardiac index of 2.5 L/min/m2
b. Hemoglobin content of 10 g/dl
c. Heart rate of 108/min
d. Systolic blood pressure of 80 mm Hg
ANS: D
Table 53-2 provides criteria for confirming cardiovascular stability.

DIF: Application OBJ: 4

23. Which of the following health care disciplines should be involved in the care of a patient who
is considered difficult to wean?
1. Physical therapy
2. Speech therapy
3. Social services
4. Occupational therapy
a. 1 and 2 only
b. 2 and 3 only
c. 1, 2, and 4 only
d. 1, 2, 3, and 4
ANS: D
This patient should be classified as a difficult to wean patient that would benefit from a
program designed specifically for patients failing to wean. This program should systemically
evaluate all systems to determine the cause of weaning failure and include the assistance of
other health care providers, specifically physical therapy, occupational therapy, speech and
language pathology, as well as social service. Ideally this should take place in a unit
specifically designed for patients who are difficult to wean.

DIF: Recall OBJ: 5

24. Prerequisites for successful weaning include

1. psychological readiness.
2. adequate gag and swallow reflexes.
3. ability to follow instructions.
4. adequate cough.
a. 1, 2, and 3 only
b. 2 and 4 only
c. 1, 2, 3, and 4
d. 3 and 4 only
ANS: C
 Adequate central nervous system function is needed to ensure stable ventilatory drive,
adequate secretion clearance (cough and deep breathing), and protection of the airway (gag
reflex and swallow). In addition, level of consciousness, dyspnea, anxiety, depression, and
motivation can affect weaning success. The patient ideally is awake and alert, free of seizures,
and able to follow instructions.

DIF: Recall OBJ: 5

25. Which of the following must you verify when considering weaning an obtunded patient?
1. Adequate gag reflex
2. No depressant drugs
3. Adequate cough
a. 2 and 3 only
b. 1 and 2 only
c. 1, 2, and 3
d. 1 and 3 only
ANS: D
Obtunded patients should, at a minimum, have an adequate gag reflex and cough.

DIF: Recall OBJ: 5

26. Which of the following drug categories can depress ventilatory drive and hinder weaning?
1. Analgesics
2. Narcotics
3. Hypnotics
4. Antibiotics
a. 1 and 3 only
b. 1, 2, and 3 only
c. 3 and 4 only
d. 2, 3, and 4 only
ANS: B
Level of consciousness is affected by the use of narcotic, sedative, and analgesic drugs.

DIF: Recall OBJ: 5

27. Which of the following techniques can help to decrease a patient’s imposed work of breathing
during weaning from ventilatory support?
1. Use of pressure-supported ventilation (PSV)
2. Trigger breath by flow, not pressure
3. Application of small amounts of continuous positive airway pressure (CPAP) or positive
end expiratory pressure (PEEP)
4. Use of automatic tube compensation (ATC)
a. 2 and 4 only
b. 1, 2, and 3 only
c. 3 and 4 only
d. 1, 2, 3, and 4
ANS: D
 The patient’s ventilatory workload should be minimized with PSV. Flow trigger, flow-by, or
ATC also may be helpful in minimizing imposed ventilatory work. Intrinsic PEEP during
mechanical ventilation may increase trigger work, and small amounts of PEEP or CPAP can
help overcome this problem.

DIF: Application OBJ: 6

28. Common approaches used to wean patients from ventilatory support include which of the
following?
1. T tube alternating with mechanical ventilation
2. Pressure-supported ventilation (PSV)
3. Intermittent mandatory ventilation
a. 2 and 3 only
b. 1 and 2 only
c. 1, 2, and 3
d. 1 and 3 only
ANS: C
There are three basic methods of discontinuing ventilatory support: (1) spontaneous breathing
trials (usually with a T tube) alternating with mechanical ventilatory support, (2) intermittent
mandatory ventilation, and (3) PSV.

DIF: Recall OBJ: 6

29. Which of the following ventilator strategies would you consider as a good alternative to T
tube trials when using a rapid weaning protocol?
1. Continuous positive airway pressure (CPAP) with flow-by (flow triggering)
2. Low-level pressure-supported ventilation (PSV)
3. Intermittent mandatory ventilation
a. 2 and 3 only
b. 1 and 2 only
c. 1, 2, and 3
d. 1 and 3 only
ANS: B
Rather than using a T tube trial, some clinicians prefer to maintain the patient attached to the
ventilator with zero PSV and zero CPAP.

DIF: Recall OBJ: 7

30. Which method of weaning may be useful to minimize auto-PEEP?

a. Intermittent mandatory ventilation
b. Intermittent mandatory ventilation
c. Continuous positive airway pressure
d. T-piece
ANS: C
Low levels of CPAP may be useful in maintaining lung volumes and overcoming intrinsic
PEEP, if present.

DIF: Application OBJ: 7

31. A physician orders a T tube trial for a patient receiving ventilatory support in the
assist-control mode with an FiO2 of 0.4. What FiO2 would you recommend for this patient
during the spontaneous breathing period?
a. 0.3
b. 0.4
c. 0.5
d. 0.6
ANS: C
See Box 53-8.

DIF: Application OBJ: 6

32. Advantages of adding continuous positive airway pressure (CPAP) to T tube weaning include
which of the following?
1. Improved blood oxygenation
2. Decreased work of breathing
3. Compensation for auto-PEEP
4. Faster weaning or extubation
a. 1 and 3 only
b. 1, 2, and 3 only
c. 3 and 4 only
d. 2, 3, and 4 only
ANS: B
CPAP has the advantage of maintaining lung volume during the weaning phase and thus of
improving the patient’s oxygenation status. Minimal levels of CPAP may be useful in
reducing work of breathing and compensating for auto-PEEP, particularly in patients with
obstructive lung disease.

DIF: Recall OBJ: 6

33. An alert patient receiving intermittent mandatory ventilation at a rate of 8/min and VT of 600
ml has stable vital signs and satisfactory blood gases on an FiO2 of 0.45. What would you do
to initiate weaning for this patient?
a. Lengthen the automatic sigh interval.
b. Decrease the mandatory rate to 5 to 6/min.
c. Increase FiO2 to 60%.
d. Decrease the VT to 500 ml.
ANS: B
At this point, the rate is reduced in a stepwise manner until complete spontaneous breathing
can be achieved.

DIF: Application OBJ: 6

34. A physician has selected a pressure support protocol to wean a patient off ventilatory support.
Which of the following pressure levels would you recommend to begin the weaning process?
a. Pressure sufficient to obtain a VT of 3 to 5 ml/kg of predicted body weight (PBW)
b. Pressure sufficient to overcome the imposed workload
c. Pressure sufficient to obtain a VT of 4 to 8 ml/kg PBW
 d. Pressure equal to 30% of the volume-cycled peak inspiratory pressure
ANS: C
For initial ventilator setup in the pressure support mode, the beginning pressure level can be
adjusted to deliver an appropriate tidal volume, usually approximately 4 to 8 ml/kg of PBW.

DIF: Application OBJ: 6

35. A physician is using a pressure support protocol to wean a patient off ventilatory support. The
patient is now at a 5 cm H2O pressure level and has a spontaneous respiratory rate of 21/min.
Other cardiovascular and respiratory signs indicate that the patient remains stable. Which of
the following actions would you recommend at this point?
a. Switch the patient to 5 cm H2O continuous positive airway pressure (CPAP)
through the endotracheal tube.
b. Extubate the patient and provide supplemental O2.
c. Switch the patient to intermittent mandatory ventilation at a rate of 2/min.
d. Decrease the pressure support level to 3 cm H2O.
ANS: B
In general, patients who can spontaneously breathe comfortably at this level of pressure
support can be extubated without problems.

DIF: Analysis OBJ: 6

36. An alert patient receiving ventilatory support through a demand flow intermittent mandatory
ventilation system exhibits clinical signs of an increased work of breathing whenever you try
to decrease the mandatory rate below 6/min. In order to aid in weaning this patient, which of
the following would you recommend?
a. Apply a low level of pressure support.
b. Apply a high level of inspiratory pressure.
c. Increase the mandatory VT.
d. Decrease the mandatory VT.
ANS: A
With intermittent mandatory ventilation, the addition of pressure support can overcome the
work of breathing imposed during “spontaneous” breaths because of the presence of
endotracheal and tracheostomy tubes, demand-flow systems, and ventilator circuits.

DIF: Application OBJ: 6

37. Which factors lead to the development of computer-based weaning protocols?

1. Respiratory therapists are unable to successfully wean most patients using protocols.
2. Computer-based weaning protocols are relatively easy to develop.
3. Weaning is time-consuming.
4. Weaning is a labor-intensive process.
a. 3 only
b. 1, 2, and 3 only
c. 2, 3, and 4 only
d. 1, 2, 3, and 4
ANS: C
 The desire to develop computer-based weaning protocols is based on two factors. First,
weaning is a time-consuming and labor-intensive process. If computer control can expedite or
simplify this process, consider- able time and money can be saved. Second, because most
weaning decisions are based on objective data, computer-based weaning protocols are
relatively easy to develop.

DIF: Recall OBJ: 7

38. Which of the following ventilator modes can ensure delivery of a preset VT during
spontaneous breathing?
1. Volume support
2. Volume-assured pressure support
3. Mandatory minute ventilation
a. 2 and 3 only
b. 1 and 2 only
c. 1 and 3 only
d. 1, 2, and 3
ANS: B
Volume-assured pressure support is similar to volume support in that a minimum preset tidal
volume is maintained by means of automatic adjustment of the ventilator.

DIF: Recall OBJ: 7

39. Which of the following is false about noninvasive positive-pressure ventilation (NIV)?
a. NIV can support ventilation without a tracheal airway.
b. NIV should not be used with patients at risk for aspiration.
c. Patients likely to fail weaning are good candidates for NIV.
d. NIV can be used to prevent reintubation when weaning fails.
ANS: C
Patients who are likely to be unsuccessful at weaning are not good candidates for NIV.

DIF: Recall OBJ: 7

40. In most weaning protocols, what minimum blood gas parameters are needed to start the
process?
a. PaO2 greater than 70 mm Hg and PaCO2 less than 50 mm Hg on FiO2 less than 0.6
and PEEP less than 5 cm H2O
b. PaO2 greater than 70 mm Hg and PaCO2 less than 50 mm Hg on FiO2 less than 0.4
and PEEP 5 cm H2O or greater
c. PaO2 greater than 50 mm Hg and PaCO2 less than 50 mm Hg on FiO2 less than 0.6
and PEEP less than 10 cm H2O
d. PaO2 greater than 70 mm Hg and PaCO2 less than 70 mm Hg on FiO2 less than 0.6
and PEEP 5 cm H2O or greater
ANS: B
See Box 53-10.

DIF: Recall OBJ: 6

41. Which of the following weaning methods provides the best respiratory muscle strength
conditioning?
a. Pressure-supported ventilation
b. T tube
c. Intermittent mandatory ventilation
d. Volume-assured pressure support
ANS: B
See Table 53-5.

DIF: Recall OBJ: 7

42. Which of the following are disadvantages of using the T tube method for weaning?
1. More staff time required
2. Abrupt transition sometimes difficult
3. High imposed work of breathing
4. Lack of alarm systems
a. 1 and 3 only
b. 1, 2, and 4 only
c. 3 and 4 only
d. 2 and 4 only
ANS: B
See Table 53-5.

DIF: Recall OBJ: 7

43. Which of the following are disadvantages of using intermittent mandatory ventilation for
weaning?
1. Potentially high work of breathing
2. Weaning time possibly prolonged
3. Patient-ventilator asynchrony
4. Higher mean airway pressures
a. 1 and 3 only
b. 1, 2, and 3 only
c. 3 and 4 only
d. 2, 3, and 4 only
ANS: B
See Table 53-5.

DIF: Recall OBJ: 7

44. Which of the following are advantages of using pressure-supported ventilation for weaning?
1. Guaranteed VT
2. Reduced work of breathing
3. Respiratory muscle fatigue prevented
4. Better patient comfort and synchrony
a. 1 and 3 only
b. 1, 2, and 3 only
c. 3 and 4 only
 d. 2, 3, and 4 only
ANS: D
See Table 53-5.

DIF: Recall OBJ: 7

45. Which of the following cardiovascular changes would you consider a bad sign during weaning
a patient from ventilatory support?
a. Development of chest pain
b. Increase in both stroke volume and cardiac index
c. Increase in heart rate from 95 to 110/min
d. Fall in blood pressure from 143/95 to 126/88 mm Hg
ANS: A
See Table 53-7.

DIF: Application OBJ: 6

46. While monitoring a patient being weaned through a T tube protocol, signs indicating that
mechanical ventilation should be restored include which of the following?
1. Development of cardiac arrhythmias
2. Asynchronous or paradoxical breathing
3. Development of severe hypotension
4. Moderate rise in respiratory rate
a. 1 and 3 only
b. 1, 2, and 3 only
c. 3 and 4 only
d. 2, 3, and 4 only
ANS: B
See Table 53-7.

DIF: Recall OBJ: 6

47. While monitoring a patient during a T tube weaning trial, you notice the following: an
increase in heart rate from 86 to 100/min; an increase in respiratory rate from 12 to 23/min; an
increase in PaCO2 from 39 to 45 mm Hg; and a decrease in PaO2 from 82 to 73 mm Hg.
Which of the following actions would be appropriate at this time?
a. Reconnect the patient to the ventilator with prior settings.
b. Request that the patient be administered a mild sedative.
c. Suction the patient after manual hyperinflation or oxygenation.
d. Encourage the patient to relax, and continue careful monitoring.
ANS: D
See Table 53-7.

DIF: Analysis OBJ: 6

48. Which of the following changes can be expected when weaning a patient through a T tube
trial?
1. Increase in respiratory rate of 10/min
 2. Increase in heart rate of 15 to 20/min
3. 5 to 10 mm Hg rise in the arterial PCO2
4. Doubling of the minute ventilation
a. 2 and 4 only
b. 1, 2, and 3 only
c. 3 and 4 only
d. 2, 3, and 4 only
ANS: B
See Table 53-7.

DIF: Application OBJ: 6

49. While monitoring a patient during a T tube weaning trial, you notice the following: increased
patient agitation; increased heart rate (from 90 to 118/min); increased respiratory rate (from
17 to 33/min with some paradoxical motion); and premature ventricular contractions (PVCs)
increasing to an average of 5/min. Which of the following actions would be appropriate at this
time?
a. Reconnect the patient to the ventilator with prior settings.
b. Encourage the patient to relax, and continue careful monitoring.
c. Request that the patient be given a stat (immediate) bolus of lidocaine.
d. Request that the patient be given a strong sedative or hypnotic.
ANS: A
See Table 53-7.

DIF: Analysis OBJ: 6

50. Which of the following is false about artificial tracheal airways and weaning?
a. There are decreases in tube inner diameter (ID) and increases in VE increase the
work of breathing.
b. The added work due to artificial airways can increase ventilator dependence.
c. Artificial airways can increase the work of breathing nearly three-fold.
d. Tracheostomy tubes increase the work of breathing more than can endotracheal
tubes.
ANS: D
The presence of an artificial airway may increase airway resistance nearly three-fold, although
some evidence calls into question the assumption that breathing through an endotracheal tube
offers a greater work of breathing than does breathing through a natural airway
postextubation. In a study with 14 successfully extubated patients, at the end of a 2-hr
spontaneous breathing trial, there was no difference in work of breathing before and after
extubation.

DIF: Recall OBJ: 6

51. What is the best way to decrease the work of breathing imposed by an artificial airway on a
patient receiving ventilatory support?
a. Provide pressure support.
b. Decrease inspiratory flow.
c. Lower the minute ventilation.
 d. Use low rates of breathing.
ANS: A
Pressure support ventilation can be very effective in overcoming this imposed work.

DIF: Application OBJ: 6

52. What are some factors that indicate a patient’s readiness for extubation?
1. Adequate oxygenation or ventilation with spontaneous breathing
2. Minimal risk for upper airway obstruction
3. Adequate airway protection or minimal aspiration risk
4. Adequate clearance of pulmonary secretions
a. 2 and 4 only
b. 1, 2, and 3 only
c. 3 and 4 only
d. 1, 2, 3, and 4
ANS: D
See Box 53-13.

DIF: Recall OBJ: 11

53. What patients are at high risk for postextubation upper airway obstruction?
1. Those with neuromuscular disorders
2. Those who have had major neck surgery
3. Those with infectious masses or abscesses
a. 2 and 3 only
b. 1 and 2 only
c. 1 and 3 only
d. 1, 2, and 3
ANS: D
Compression of the airway due to traumatic or postoperative hematoma of the neck, infectious
masses or abscesses, and malignant tumors or compression after major head or neck surgery
can lead to upper airway obstruction after extubation.

DIF: Recall OBJ: 12

54. In considering a patient for endotracheal tube extubation, which of the following procedures
would you recommend to determine the risk of postextubation upper airway obstruction?
a. Methylene blue test
b. Pre- and post-bronchodilator
c. Cuff leak test
d. Forced vital capacity
ANS: C
The cuff leak test is recommended to detect airway obstruction before extubation.

DIF: Recall OBJ: 5

55. Which of the following patients are at high risk for severe laryngeal edema after an
endotracheal tube extubation?
 1. Pediatric burn victim
2. Patient with epiglottitis
3. Smoke inhalation patient
4. Pulmonary fibrosis patient
a. 2 and 4 only
b. 1, 2, and 3 only
c. 3 and 4 only
d. 1, 2, 3, and 4
ANS: B
Children, patients with epiglottitis or angioedema (dermal, subcutaneous, or submucosal
edema of the face or larynx), and patients who have sustained smoke inhalation are at greater
risk.

DIF: Recall OBJ: 5

56. In considering a patient for extubation, which of the following would you recommend to
minimize the risk of postextubation aspiration?
a. Perform and confirm a positive cuff leak test.
b. Discontinue (DC) tube feeding 4 to 6 hr before extubation.
c. Perform deep endotracheal suctioning before extubation.
d. Keep the cuff inflated when removing the tube.
ANS: B
Withholding feeding 4 to 6 hr before extubation and clamping feeding tubes may be prudent.

DIF: Recall OBJ: 5

57. Common causes for weaning failure include which of the following?
1. Myocardial ischemia
2. Critical illness polyneuropathy
3. Psychological dependence
4. Secondary polycythemia
a. 1 and 3 only
b. 1, 2, and 3 only
c. 3 and 4 only
d. 2, 3, and 4 only
ANS: B
Myocardial ischemia may occur frequently among ventilator-dependent patients and has been
associated with weaning failure. Critical illness polyneuropathy has been cited as a frequent
cause of neuromuscular weaning failure among critically ill patients. Unsuspected
neuromuscular disease may be an important factor in ventilator dependency. Inability to wean
can sometimes be attributed to psychological dependence, poor oxygenation status, or
cardiovascular instability (congestive heart failure or ischemia).

DIF: Recall OBJ: 13

58. A patient whom you are trying to wean below 5 cm H2O pressure support develops respiratory
muscle fatigue. Which of the following would you recommend to overcome this problem?
1. Make sure there is adequate O2 transport or cardiac output.
 2. Make sure that the patient is adequately nourished.
3. Check and replace any depleted electrolytes.
4. Clear secretions and provide bronchodilation.
a. 2 and 4 only
b. 1, 2, and 3 only
c. 3 and 4 only
d. 1, 2, 3, and 4
ANS: D
See Table 53-7.

DIF: Application OBJ: 5

59. Which of the following are useful strategies in managing the psychological problems
encountered in weaning some patients from ventilator support?
1. Secure a psychiatric consult.
2. Decrease environmental stress.
3. Avoid mental stimulation.
4. Teach relaxation methods.
a. 1 and 3 only
b. 1, 2, and 4 only
c. 3 and 4 only
d. 2 and 3 only
ANS: B
See Table 53-7.

DIF: Recall OBJ: 10

60. Who should make the decisions related to terminal weaning?

a. Patient
b. Patient’s family and patient’s physician
c. Nurse
d. Respiratory therapist
ANS: B
The decision should be made by the family in consultation with the patient’s physician and in
accordance with established ethical and legal guidelines.

DIF: Recall OBJ: 13

61. In an effort to determine a patient’s need for ventilatory support, which of the following
factors increase(s) ventilatory workload?
1. Decreased lung compliance
2. Decreased thoracic compliance
3. Increased airway resistance
4. Artificial airways
a. 1 only
b. 1 and 2 only
c. 1, 2, and 3 only
d. 1, 2, 3, and 4
 ANS: D
See Box 53-1.

DIF: Recall OBJ: 2

62. The physician has requested that the respiratory therapist determine a patient’s rapid shallow
breathing index (RSBI) before placing the patient on PSV. The patient has a respiratory rate
of 32/min and VT of 300 ml. What is the patient’s RSBI?
a. 107
b. 110
c. 112
d. 114
ANS: A
The formula for calculating RSBI is f/VT. The therapist would calculate 32/0.30 = 107.

DIF: Application OBJ: 3

63. How can esophageal pressure be used to predict performance during SBT?
a. Assess diaphragm function
b. Asses risk of aspiration during SBT
c. Assess heart function
d. Assess lung function
ANS: A
Recently the use of esophageal pressure, diaphragm ultrasound, and the diaphragmatic
electromyographic signal (EAdi) have been used to assess diaphragm function and predict
performance during SBTs.

DIF: Application OBJ: 8