MacIntyre: Mechanical Ventilation, 2nd Edition

Chapter 1: Classification of Mechanical Ventilators

Test Bank

MULTIPLE CHOICE

1. A mechanical ventilator that is connected to a 50 psig gas source, and uses an electrically powered solenoid valve to control the respiratory frequency and I:E ratio can be described as   _________________________.
A. pneumatically powered
B. electrically powered
C. flow cycled
D. open-loop controlled

ANS: C
A. Correct response: Pneumatically powered ventilators operate via a 50 psig gas source and generally incorporate a high-pressure reducing regulator to reduce the high source pressure to a lower working pressure. The solenoid is electrically powered to perform certain ventilator functions, but electricity is not the power that is used to perform the work of ventilating the patient.
B. Incorrect response: Electrically powered ventilators employ alternating current of 110 to 115 volts. This electrical power is reduced and converted to direct current for the purpose of depositing air into the lungs of patients.
C. Incorrect response: A flow-controlled ventilator maintains a constant flow throughout the inspiratory phase despite changes in lung compliance and airway resistance.
D. Incorrect response: Open-loop ventilation refers to systems that are unintelligent and require the clinician to make ventilator adjustments when certain conditions change. Closed-loop systems are described as intelligent because they can sense a change in input, and respond accordingly to render a different output. 
DIF: Cognitive Level: Recall
REF: page 3

2. Which factor(s) in the equation of motion remain constant?
I. time
II. elastance
III. flow 
IV. airway resistance
A. II only
B. I, III only
C. II, IV only 
D. III, IV only

ANS: C
I. Incorrect response: Pressure, volume, and flow are variables that change over time in the equation of motion.
II. Correct response: Elastance, defined as a change of pressure divided by a change of volume, is the reciprocal of compliance, and is one of the two factors that remain constant in the equation of motion.
III. Incorrect response: Elastance and airway resistance are the factors that remain constant in the equation of motion. The equation of motion is as follows:
Pventilator + Pmuscles = (elastance × volume) + (resistance × flow) 
IV. Incorrect response: Flow is a variable, and airway resistance remains constant in the equation of motion.
DIF: Cognitive Level: Recall
REF: page 4

3. How should a ventilator breath that has the following characteristics during a ventilator-assisted inspiration be classified?
I.	Pressure waveform changes when patient’s lung compliance and airway resistance change.
II.	Volume waveform remains constant despite changes in patient’s pulmonary compliance and airway resistance.
III.	Volume is measured, and used to control the volume waveform.
A. pressure controlled
B. volume controlled
C. time controlled
D. flow controlled

ANS: B
A. Incorrect response: A pressure controlled breath is a mechanical ventilator that exhibits a pressure waveform that does not change despite changes in the patient’s lung compliance and airway resistance.
B. Correct response: A breath that exhibits the following characteristics during a ventilator-assisted inspiration is classified as volume-controlled; (a) pressure waveform changes when patient’s lung compliance and airway resistance change; (b) volume waveform remains constant despite changes in patient’s pulmonary compliance and airway resistance; (c) volume is measured and used to control the volume waveform.
C. Incorrect response: A time controlled breath demonstrates altered pressure and volume waveforms as the patient’s lung compliance and airway resistance change.
D. Incorrect response: A breath that demonstrates the following features is classified as flow controlled: (a) pressure waveform changes when the patient’s lung compliance and airway resistance change; (b) volume waveform remains constant despite changes in patient’s pulmonary compliance and airway resistance; and (c) volume is not measured and used to control the volume waveform.
DIF: Cognitive Level: Recall
REF: page 6

4. Which of the following statements accurately describe closed-loop control? Closed-loop control:
I. maintains consistent inspiratory pressure, volume, or flow waveforms in the presence of changing lung compliance and airway resistance.
II. measures the output, and compares it with a reference value.
III.	lacks a stream of information from the output to generate a new input.
IV. provides a steady output in the presence of unanticipated disturbances.
A. I, IV only
B. I, II, III only
C. I, II, IV only
D. II, III, IV only

ANS: C
I. Correct response: With closed-loop control, the delivered pressure, volume, and flow can be measured and used as feedback information to control the driving mechanism. Therefore inspiratory flows, volumes, and pressures can be made to match specified input values. The advantage of closed-loop control is that the inspiratory flows, volumes, and pressures will remain constant despite alterations in patient load and minor system leaks.
II. Correct response: Closed-loop control measures the output and compares that measurement with an established reference value.
III. Incorrect response: Open-loop control does not provide for a flow or stream of information from the output to generate a new input. For example, when a tidal volume is set on a ventilator with open-loop control, the ventilator cannot ascertain a difference between the volume actually delivered and the set volume. Consequently, such a ventilator cannot respond to this difference. On the other hand, a closed-loop control ventilator measures the delivered tidal volume, compares it with the set tidal volume, and delivers a tidal volume comparable to the set value.
IV. Correct response: Ventilators having closed-loop control are often described as intelligent ventilators. Ventilators incorporating open-loop control are sometimes referred to as unintelligent ventilators.
DIF: Cognitive Level: Recall
REF: page 8

5. Which of the following terms are phase variables?
I. inspiration
II. flow
III. cycle
IV. trigger
A. I, II only
B. III, IV only
C. I, III only
D. II, IV only

ANS: B
I. Incorrect response: Inspiration and exhalation are phases of the respiratory cycle, not phase variables.
II. Incorrect response: Flow is not a phase variable. 
III. Correct response: Cycle and trigger are referred to as phase variables in the context described below. Every breath has four phases: (1) the change from exhalation to inspiration (trigger), (2) the variable that reaches a plateau before the end of inspiration, but is not responsible for terminating inspiration (limit), (3) the change from inspiration to exhalation (cycle), and (4) baseline (i.e., PEEP). 
IV. Correct response: The term trigger applies to the phase variable that causes inspiration to begin. Inspiration can be either pressure, volume, flow, or time triggered.
DIF: Cognitive Level: Recall
REF: page 13

6. The baseline pressure on a mechanical ventilator operating in the ICU has been changed from 8 cm H2O to 12 cm H2O. The trigger sensitivity had been set, and remains at 2 cm H2O. To what pressure will the circuit pressure have to decrease for inspiration to be pressure triggered? 
A. 2 cm H2O
B. 6 cm H2O
C. 10 cm H2O
D. 14 cm H2O

ANS: C
A. Correct response: The trigger sensitivity describes the sensitivity setting on the ventilator. It establishes the degree of pressure drop that the patient must generate to trigger inspiration. Trigger sensitivity is PEEP compensated. Therefore a change in baseline pressure is tracked by the sensitivity mechanism. Sensitivity remains 2 cm H2O from baseline. What this means is the pressure in the ventilator circuit will have to drop to 10 cm H2O for the breath to be triggered. Only obsolete ventilators do not have this function. 
B. Incorrect response: See explanation for choice A.
C. Incorrect response: See explanation for choice A.
D. Incorrect response: See explanation for choice A.
DIF: Cognitive Level: Application
REF: page 14

7. A patient is being mechanically ventilated with a transport ventilator as he is being moved to another hospital. The PEEP was set at 5 cm H2O with a trigger threshold of 2 cm H2O.   Immediately before the transport the baseline was raised to 10 cm H2O.  To what level will the circuit pressure need to fall for inspiration to be triggered if this ventilator is not PEEP compensated?  
A. –2 cm H2O
B. –7 cm H2O
C. –10 cm H2O
D. –12 cm H2O

ANS: B
A. Incorrect response: Generally, PEEP compensation is unavailable in transport ventilators. If this particular transport ventilator were PEEP compensated, the trigger threshold would have remained 2 cm H2O. However, triggering would be taking place at 8 cm H2O.
B. Correct response: Because this ventilator is not PEEP compensated, the patient has to develop an extraordinarily large inspiratory effort to trigger inspiration. Before the transport, the patient had to drop the pressure inside the breathing circuit to 3 cm H2O. Now the patient will breathe through the additional 5 cm H2O of PEEP and the original trigger threshold of 2 cm H2O (i.e., 5 cm H2O + 2 cm H2O = 7 cm H2O). Such a high level will significantly increase the patient’s work of breathing. Therefore the trigger threshold must be readjusted to the point where the ventilator triggers at 8 cm H2O.

C. Incorrect response: If the ventilator were PEEP compensated, the pressure would need to drop to 8 cm H2O to trigger inspiration (i.e., 10 cm H2O – 2 cm H2O = 8 cm H2O). 
D. Incorrect response: See the explanation accompanying choice C.
DIF: Cognitive Level: Application
REF: page 14

8. An ICU patient is receiving flow-triggered breaths from a mechanical ventilator.  The continuous flow in the breathing circuit is 6 L/min.  The flow trigger threshold is 2 L/min. To what level does the continuous flow in the breathing circuit need to reach for the breath to be flow triggered?  
A. 2 L/min
B. 4 L/min
C. 6 L/min
D. 8 L/min

ANS: B
A. Incorrect response: In this question, the flow trigger threshold is 2 L/min, which means that when the patient generates an inspiratory effort commensurate with a flow of 2 L/min inspiration will be triggered. 
B. Correct response: With a flow-triggered threshold set at 2 L/min, and a continuous flow of 6 L/min through the breathing circuit, the continuous flow through the circuit will need to fall to 4 L/min for inspiration to be triggered.
C. Incorrect response: A flow of 6 L/min will not trigger inspiration. A flow trigger threshold must be set.
D. Incorrect response: The flow through the breathing circuit will not achieve 8 L/min at any time before inspiration.
DIF: Cognitive Level: Application
REF: page 16

9. What is the significance of performing an inspiratory pause during mechanical ventilation?
A. It provides the opportunity to view the pressure, volume, and flow waveforms.
B. This maneuver affords the clinician the chance to ascertain the presence of auto-PEEP.
C. An inspiratory pause enables the clinician to determine the trigger variable.
D. It allows for the measurement of pulmonary mechanics.

ANS: D
A. Incorrect response: The graphics package on a mechanical ventilator generally enables the clinician to view waveforms.
B. Incorrect response: An expiratory hold maneuver, along with ventilator graphics, provides the clinician with the means to determine the presence of auto-PEEP.
C. Incorrect response: The clinician determines the trigger variable when selection of the mode of ventilation occurs at the time ventilatory support is initiated.
D. Correct response: Performing an inspiratory pause provides for the determination of the plateau pressure, which can be used to determine the pressure generated to overcome airway resistance and calculate lung compliance.
DIF: Cognitive Level: Application
REF: page 21

10. What defines a spontaneous breath, as compared with a mandatory breath?
A. Inspiration is initiated by time, and is terminated by the patient’s pulmonary mechanics.
B. Inspiration is initiated by the patient’s own ventilatory drive.
C. Inspiration is initiated by the patient’s lung mechanics, and expiration is initiated by the patient’s ventilatory drive.
D. Inspiration is initiated by the patient’s ventilatory drive, and is terminated by the patient’s lung mechanics.

ANS: D
A. Incorrect response: See the algorithm on page 25, Figure 1-16 in the textbook for a complete description of a spontaneous and mandatory breath.
B. Incorrect response: This choice listed only one criterion of the two essential components of a spontaneous breath. See the explanation in choice above.
C. Incorrect response: Expiration does not enter into the definition of a spontaneous breath.
D. Correct response: For a breath to be spontaneous, inspiration must meet both of the following criteria: (1) inspiration must be initiated by the patient’s ventilatory drive, and (2) inspiration must be terminated by either the patient’s lung mechanics or the patient’s ventilatory drive.
DIF: Cognitive Level: Recall
REF: page 25

11. Which of the following classifications matched the volume-controlled, continuous mandatory ventilation (VC-CMV) mode?
A. pressure-controlled, time-triggered, volume-limited, volume-cycled
B. volume-controlled, pressure-triggered, pressure-limited, flow-cycled
C. volume-controlled, time-triggered, flow-limited, time-cycled
D. volume-controlled, pressure-triggered, flow-limited, pressure-cycled

ANS: C
A. Incorrect response: Volume controlled-continuous mandatory ventilation (VC-CMV) cannot be pressure-controlled. In pressure-controlled, continuous mandatory ventilation (PC-CMV), pressure is the control variable, which implies that both spontaneous and mandatory breaths are available. Pressure control also implies that the mandatory breaths are either pressure-triggered (patient-cycled) or time-triggered. 
B. Incorrect response: VC-CMV is volume-controlled and may be either pressure- or time-triggered. Pressure is not a limit variable, and the cycle variable is not flow.
C. Correct response: VC-CMV is (1) volume-controlled; (2) either pressure- or time-triggered, (3) flow-limited, and (4) time-cycled.
D. Incorrect response: VC-CMV is not pressure-cycled.
DIF: Cognitive Level: Application
REF: page 29

12. Which of the following air compressors are commonly used inside ventilators?
I. fluidic
II. piston and cylinder
III. turbine
IV. bellows
A. I, III only
B. II, IV only
C. I, III, IV only
D. II, III, IV only

ANS: D
I. Incorrect response: Control circuits can be fluidic, not compressors. Fluidic circuits are analogs of electronic logic circuits. Fluidic circuits use small amounts of gas flow to generate signals that operate timing systems and pressure switches.
II. Correct response: Piston and cylinder is one of three types of small compressors used inside certain ventilators.
III. Correct response: Turbine compressors are another type of compressor used inside some ventilators.
IV. Correct response: Bellows compressors are a third type of compressor housed inside some older-generation ventilators.
DIF: Cognitive Level: Recall
REF: page 29

13. Which of the following devices are output control valves used to regulate the flow of gas to the patient?
I. rack and pinion poppet valves
II. proportional valves
III. electromagnetic poppet valves
IV. pneumatic poppet valves
A. I, II only
B. III, IV only
C. I, II, III only
D. II, III, IV only

ANS: D
I. Incorrect response: The electric motor/rack and pinion is a ventilator drive mechanism. The drive mechanism of a ventilator produces the force needed to deposit gas into the lungs of the patient.
II. Correct response: A proportional valve resembles a solenoid valve. It is operated via an electric motor whose rotation can be controlled in discrete arcs, or steps. Proportional valves change the size of their openings, thus influencing the shape of the flow-time waveform during inspiration. In fact, because the size of the opening can vary significantly, a variety of waveforms can be produced. 
III. Correct response: The electromagnetic poppet valve is the same as a solenoid valve. It uses magnetism created by an electric current to control pneumatic pressure.
IV. Correct response: The pneumatic poppet valve uses small pneumatic pressure to control large pneumatic pressure. 
DIF: Cognitive Level: Recall
REF: page 32

14. Which of the following terms describe the configuration of a ventilator waveform?
I. hyperbolic
II. sinusoidal
III. rectangular
IV. exponential
A. II, III only
B. I, II, IV only
C. I, III, IV only
D. II, III, IV only

ANS: D
I. Incorrect response: None of the ventilator waveforms is hyperbolic.
II. Correct response: The most common types of waveform produced by mechanical ventilators are:
•	Rectangular
•	Ramp
•	Exponential
•	Sinusoidal
III. Correct response: See explanation II.
IV. Correct response: See explanation II.
DIF: Cognitive Level: Recall
REF: page 23

15. If a rectangular (square) pressure waveform is generated during pressure-controlled ventilation, what type of waveforms will develop for volume and flow?
A. volume waveform: exponential rise; flow waveform: exponential decline
B. volume waveform: exponential decline; flow waveform: exponential rise
C. volume waveform: sinusoidal; flow waveform: ascending ramp
D. volume waveform: descending ramp; flow waveform: rectangular

ANS: A
A. Correct response: A rectangular pressure waveform is accompanied by an exponentially rising volume waveform and an exponentially decaying (declining) flow waveform. The volume rises exponentially to a value equal to the product of the lung compliance and the difference between the PIP and the PEEP. That is,
volume = CL  (PIP – PEEP)
			     L = L/cm H2O (cm H2O)
The inspiratory flow declines exponentially from its peak level, which is equal to the difference between change in airway pressure multiplied by the airway resistance. Hence,
			 flow = Raw × (PIP – PEEP)
 L/sec = cm H2O/L/sec × (cm H2O)

B. Incorrect response: The choice has the waveforms opposite of what they actually are. 
C. Incorrect response: When the pressure waveform is sinusoidal, the volume and flow waveforms are also sinusoidal.
D. Incorrect response: See explanation for choice A above.
DIF: Cognitive Level: Application
REF: pages 36-37

16. Based on the volume and flow waveforms depicted below, determine the cycle and limit variables.

A. limit variables: pressure and volume; cycle variable: flow
B. limit variables: volume and flow; cycle variable: time
C. limit variables: volume and time; cycle variable: flow 
D. limit variables: volume and flow; cycle variable: volume

ANS: B
A. Incorrect response: The flow waveform cannot be the cycle variable because the flow is held constant throughout inspiration. Flow does not terminate when it reaches a preset limit. It maintains that preset limit throughout the inspiratory phase. 
B. Correct response: Notice how both the volume and flow waveforms reach a limit and plateau at that level while inspiration continues. Based on that fact, the variable time serves as the cycle variable (i.e., the variable responsible for terminating inspiration).
C. Incorrect response: Limit variables include (1) flow, (2), volume, and (3) pressure. Time is not a limit variable, but can be a cycle variable (terminates inspiration).
D. Incorrect response: Both volume and flow are limit variables in this example because they both plateau during inspiration when they achieve their peak levels. Because volume is a limit variable, it cannot be a cycle variable. Because volume is held constant for a period during inspiration, it cannot cause inspiration to terminate.
DIF: Cognitive Level: Synthesis
REF: pages 21

17. The therapist enters the ICU, and hears the high-pressure alarm sounding on a mechanical ventilator.  Which of the following considerations need to be taken into account as possible causes of this alarm situation?
I. Auto-PEEP may have developed.
II. The cuff on the patient’s endotracheal tube has deflated.
III. The patient may be experiencing increased lung secretions.
IV. The flow waveform has converted from a square configuration to that of a descending ramp.
A. I, III only
B. II, III only
C. I, II, IV only
D. II, III, IV only

ANS: A
I. Correct response: Auto-PEEP is the inadvertent retention of air in the lungs at the end of exhalation. Dynamic hyperinflation (air trapping develops because of incomplete emptying of the lungs. Patients (COPD and status asthmaticus) whose lungs are characterized by long time constants are susceptible to this problem. Other causes include:
•	High minute ventilation (<10 to 20 L/min)
•	Small ID endotracheal tube
•	Bronchospasm
•	Increased lung secretions
•	Mucosal edema
•	Short expiratory time
•	Inverse ratio ventilation
II. Incorrect response: A deflated endotracheal tube cuff would not activate the low-pressure alarm. It would stimulate a low-pressure alarm, a low-volume alarm, low minute ventilation alarm, or an apnea alarm.
III. Correct response: Any condition that increases airway resistance and interferes with lung emptying can cause auto-PEEP.
IV. Incorrect response: Changing the flow waveform configuration from square (rectangular) to a descending ramp pattern does not influence lung emptying or cause auto-PEEP.
DIF: Cognitive Level: Synthesis
REF: page 43

18. What type of drive mechanism would produce the pressure, volume, and flow waveforms illustrated below?

A. spring-loaded bellows
B. proportional solenoid valve
C. piston attached to a rotating crank
D. electric motor/rack and pinion

ANS: C
A. Incorrect response: Spring-loaded bellows, such as a linear-driven piston, produces a square (rectangular) flow waveform, a linear ascending ramp volume waveform, and an ascending ramp pressure waveform.
B. Incorrect response: A proportional solenoid valve is not a drive mechanism. It is a flow control valve. Flow control valves ensure the precise flow of gas to patients as the gas flows from high-pressure sources.
C. Correct response: A piston attached to a rotating crank is a drive mechanism that provides output waveforms that are sinusoidal for pressure, volume, and flow.
D. Incorrect response: A linear drive piston, as with an electric motor/rack and pinion drive mechanism, produces an output of a rectangular flow, ascending ramp volume, and a linear ascending ramp pressure waveform. These ventilators are only of historical interest.
DIF: Cognitive Level: Recall
REF: pages 36-37

Questions 19 and 20 refer to the same patient and data.

19. A patient is receiving PC-CMV with a target tidal volume of at 750 ml. The average peak inspiratory pressure is 30 cm H2O, and the compliance factor for the breathing circuit is 3 ml/cm H2O. Calculate the volume compressed in the ventilator tubing. 
A. 250 ml
B. 90 ml
C. 25 ml
D. 10 ml

ANS: B
A. Incorrect response: See the calculation associated with choice B.
B. Correct response: The compressible volume is defined as the volume that remains in the patient’s breathing circuit at the end of inspiration. This compressed volume can be calculated as follows:
compressed volume = peak inspiratory pressure × tubing compliance factor
Vcompressed = PIP × Ctubing
Vcompressed = 30 cm H2O × 3 ml/cm H2O
Vcompressed = 90 ml
C. Incorrect response: See explanation associated with choice B.
D. Incorrect response: See explanation associated with choice B.
DIF: Cognitive Level: Application
REF: page 42

20. What tidal volume would the therapist need to set on the ventilator to achieve the desired tidal volume of 750 ml? 
A. 760 ml
B. 775 ml
C. 840 ml
D. 1000 ml

ANS: C
A. Incorrect response: See the explanation associated with choice C.
B. Incorrect response: See the explanation associated with choice C.
C. Correct response: Because 90 ml of volume are compressed in the patient’s breathing circuit at the end of inspiration, the therapist must add 90 ml to the original tidal volume, which was set at 750 ml. Therefore the therapist needs to reset the tidal volume to 840 ml to compensate for the 90 ml “lost” in the tubing. That is,
set VT – Vcompressed = patient tidal volume
840 ml – 90 ml = 750 ml
D. Incorrect response: See the explanation associated with choice C.
DIF: Cognitive Level: Application
REF: page 42