CRT Hint

CRT Examination Hints #1
Things to Remember:
1. Food being suctioned from the trachea will not indicate an obstruction of the endotracheal tube. It will
indicate however, that a tracheo-esophageal fistula has occurred (hole between the trachea and the
esophagus) or that food has been aspirated around the cuff.
2. The Incentive Spirometry device measures the Inspiratory Capacity of the patient.
3. The stylette should be used only for oral intubation, not nasal intubation.
4. If a patient is getting an IPPB treatment using a mouthpiece and the machine fails to cut off as the patient
exhales, the therapist should use a mask for the treatment next time.
5. If performing chest physiotherapy with postural drainage on the posterior basal segments of the lower
lobes, then the patient should be placed in a prone position (face down) in a trendelenburg position at a 30
degree angle. The area to be percussed for the lateral basal segment of the left lower lobe is over the left
lower ribs. The lower lobes are the most commonly asked about lung segments on the examination.
6. Never leave the suction catheter in the airway longer than 15 seconds.
7. Most teenagers will require a 6.0 to 7.0 mm ID endotracheal tube for intubation. The adult female may
require a 7.0 to 8.0 mm ID endotracheal tube while a adult male may require a 8.0 mm ID or greater.
8. Breath sounds are decreased when normal lung is displaced by air (emphysema or pneumothorax) or fluid
(pleural effusion). Breath sounds shift from vesicular to bronchial when there is fluid in the lung itself
(pneumonia).
9. When obtaining sputum samples for laboratory analysis normal saline should be used. A Lukens suction
trap should be used and the suction catheter should be flushed with sterile water or isotonic saline.
Bacteriostatic or hypertonic saline should not be used.
10. A Coude suction catheter is angled so that the therapist can suction the left lung.
11. To assess a patient’s orientation to time and place ask the patient the date and if they know where they are.
To assess a patient’s ability to cooperate ask the patient to follow simple commands. To assess a patient’s
emotional state ask the patient to describe their feelings.
12. In hyperkalemia, the potassium levels will exceed 5.5 mEq/L. The physiological effect often results in a
metabolic acidosis. Clinical signs may include weakness, hyperventilation, agitation, hot moist skin, and
anxiety. Cardiac changes may result in elevated and peaked T waves. Some causes of hyperkalemia include
renal failure, burns, myocardial infarction, and surgery.
13. Consolidation, radiodensity, and infiltrates will all appear white on the chest x-ray. They all indicate fluids
or solids within the lungs. Infiltrates however, usually describes scattered or patchy areas.
14. Some of the effects of high oxygen concentrations on the neonate include pulmonary edema, surfactant
decrease, and retinopathy of prematurity. Effects will not include pulmonary burns or increases in
ventilation.
15. If you are attempting to evaluate whether a patient has orthopnea or not you should ask the patient
whether he uses more than one pillow to sleep on and whether he gets short of breath when lying flat
in bed.
16. A reduced flow of gas through a Bird Mark 7 IPPB machine may be due to a blocked hose. The inlet filter or
the use of compressed air instead of oxygen would not cause a reduced gas flow.
17. Gas sterilization uses ethylene oxide to destroy bacteria. It is bactericidal and lethal for all microorganisms.
Unlike steam autoclaving, ethylene oxide gas sterilization is safe for the majority of respiratory equipment
especially plastics.
18. The patient’s pulse rate and strength is usually evaluated by palpating the radial artery although the,
femoral, and brachial arteries are also used. Normal pulse rates are between 60 and 100 for the adult
patient. Pulse rate below 60 is termed bradycardia and a pulse rate above 100 is termed tachycardia.
19. If a patient has been in a house fire and is showing "marked" use of the accessory muscles to breath with
stridor then the patient is probably developing an upper airway obstruction and should be intubated.
100% oxygen is always indicated initially for a patient suspected of carbon monoxide poisoning from
smoke inhalation. Upper airway edema and bronchospasms are common effects of smoke and hot air
inhalation.
20. If a patient’s heart rate has been increased over the past twenty-four hours while on an oxygen device, then
the patient should be checked for hypoxemia. Tachycardia is one of the first signs of hypoxemia.
21. A common adverse side effect of using aerosolized beclomethasone dipropionate (Vanceril) is upper
airway fungal infections caused by Candida albicans and Aspergillus niger.
22. The list of drugs that can be put directly down an endotracheal tube can be remembered by the mnemonic
LANE which stands for (Lidocaine, Atropine, Naloxone, and Epinephrine).
23. Increased difficulty in delivering an adequate tidal volume when using a manual resuscitator device will
indicate decreased lung compliance and/or increased airway resistance. Adequacy of ventilation is
assessed by bilateral chest movement and auscultation of breath sounds first and then arterial blood gases
and pulse oximetry.
24. When using ethylene oxide gas sterilization, the equipment must first be washed in soapy water, rinsed,
dried completely, and placed in a sealed package. If the equipment is not dried completely, the ethylene
oxide will combine with the water to form ethylene glycol, a substance found in car antifreeze.
25. Kyphosis and Scoliosis are terms that describe abnormal chest configurations. Kyphosis is a hunchback or
convex curvature of the spine where as Scoliosis is a lateral curvature of the spine that resembles a S shape
when viewed posteriorly.
Important Reminders:
Avoid eating a heavy meal before the test. The blood flow will stay in your stomach and make you feel drowsy.
On the other hand, don't take the test on an empty stomach. Your brain needs the fuel.
Things to Remember:
1. The tidal volume delivered by the ventilator should be measured at the ventilator outlet, not at the patient's
endotracheal tube.
2. Hypertonic saline solution (usually 1.8-15%) is commonly used to "induce sputum" specimen but can cause
bronchospasms as a side effect. Normal saline (0.9%) is used for obtaining a sputum specimen from an
intubated patient by thinning the secretions for suctioning. Specimens are damaged by the use of other
saline type’s especially bacteriostatic saline. Specimens are also stored in normal saline. Hypotonic saline
(0.45%) may be used to trigger a cough, liquefy secretions, and humidify the airways.
3. If a patient vomits and aspirates while lying on his back, the superior lung segments will most likely be
affected. CPT should be done with the patient lying on his stomach with a pillow under the hips.
4. Vital Capacity is also known as a Slow Vital Capacity. It is the largest volume of air that can be exhaled after
a maximal inspiration. It can be used to measure the patient’s tidal volume, inspiratory reserve volume,
expiratory reserve volume, and inspiratory capacity. It is decreased in restrictive lung disorders.
5. The Spinhaler is a dry aerosol delivery device for dispensing Intal capsules (cromolyn sodium). The device
grinds the capsule into a fine powder as the patient inhales. The Rotahaler is similar to a spinhaler and is
used for administering powdered albuterol.
6. The low-pressure alarms should be set 5 to 10 cmH20 below peak inspiratory pressure. The most common
cause of low-pressure alarms being activated is a patient disconnection from the ventilator circuit or leaks
in the ventilator setup in the circuit or the humidifier connections. The low-pressure alarm is very
important when using CPAP or for those patients without any spontaneous breathing.
7. Patients who should be placed on CPAP are those whose oxygen saturation cannot be maintained within
acceptable limits with a FI02 or 60% and who have a normal or low PaC02 level.
8. A T-E fistula (tracheoesophageal fistula) is an opening between the trachea and the esophagus caused by an
erosion of the tracheal and esophageal walls. The incidence of this complication is only 1 to 5% and may
occur from tracheal erosion from the tracheal cuff and esophageal erosion from nasogastric tubes.
9. When setting up the ventilator for a patient, the two most important controls to set first are the tidal
volume and the respiratory rate. Normal tidal volume for mechanical ventilation will be between 10 to 15
ml/kg of IBW. The respiratory rate should be set between 8 and 12 breaths per minute.
10. With Assist-control every breath is a mandatory breath even though the patient can trigger the breath at a
more rapid rate than the set machine rate. This mode allows the patient to adjust respirations to a changing
metabolic status.
11. The function of the inspiratory plateau setting (inflation hold) on the ventilator is to increase the mean
intrathoracic pressure, increase the diffusion of gases, improve oxygenation, and decrease the chance of
atelectasis. The down side is the potential for cardiovascular side effects and barotrauma.
12. To determine adequate humidification of delivered oxygen to a patient with a tracheostomy, the patient’s
sputum should be assessed for consistency. If the sputum texture is thick then the humidification is not
adequate.
13. The purpose of the nasopharyngeal airway is to provide a patent airway and an access for repeated
suctioning. It is not used for mechanical ventilation or CPAP. A nasotracheal airway is used for those
purposes.
14. be aware of the difference between an acute respiratory acidosis and an acute respiratory acidosis
superimposed on a chronic respiratory acidosis. A patient in an acute respiratory acidosis may have blood
gases similar to the following: pH 7.12, PaC02 58 torr, Pa02 52 torr, and a HC03 of 26. You may see blood
gases similar to these in drug overdoses and trauma victims. A patient in an acute respiratory acidosis on
top of a chronic respiratory acidosis may have blood gases similar to the following: pH 7.28, PaC02 68 torr,
Pa02 49 torr, and a HC03 of 34. These blood gases are found in patients with chronic pulmonary diseases
and indicate that their chronic state has suddenly become acute due to an infection, smoking, etc....
15. When performing Broncho pulmonary clearance procedures, the therapist should first administer an
aerosol treatment, and then postural drainage, percussion, and deep breathing and coughing.
16. In order for tracheal mucosal circulation to be unimpeded, the cuff pressure should be directly related to
the capillary pressure, not the brachial, pulmonary artery, or the central venous pressure.
17. The polarographic oxygen analyzer is an electrochemical analyzer that uses a Clark electrode to measure
partial pressures. It is battery operated and is affected by water, high altitudes, a torn membrane, positive
pressure, and a lack of electrolyte gel.
18. One of the most common reasons for reintubation after extubation is subglottic edema. The swelling does
not occlude the airway until the endotracheal tube is removed.
19. A FRC (functional residual capacity) value greater than approx. 120% of the predicted indicates
hyperinflation. This is often a result of an obstructive disorder such as emphysema, asthmatic or
bronchiolar obstruction.
20. To calculate a percentage change for a pre and post bronchodilator study, first subtract the predrug
measurement from the post drug measurement and divide the sum of the two by the predrug
measurement. Multiple the answer by 100 to obtain the percentage. 15% is considered a significant change.
Be aware of words like spontaneously breathing, conscious, obtunded, acute ventilatory failure, etc... These
words are clear give aways for recommended actions.
Things to Remember:
1. Double-lumen endotracheal tubes are used to allow for simultaneous independent lung ventilation and for special
procedures involving one lung such as bronchoscopy, bronchoalveolar lavage, lobectomy, and pneumonectomy.
2. Potential risks of the transtracheal procedure include bleeding, abscess, pneumothorax, bronchospasms, airway
obstruction, infection, and localized subcutaneous emphysema.
3. The Holter monitor is a portable recording device that provides24-hour continuous recording of a person's heart rate
and rhythm. Many other monitoring devices provide event monitoring only, and do not provide a continuous
recording of heart activity.
4. The Flutter Valve is a hand held device that helps break up retained secretions from the airways by providing positive
expiratory pressure (PEP) and high-frequency oscillations when exhaled into.
5. The bronchial cuff of the longer lumina of the Double-lumen endotracheal tube is a high pressure, low-volume cuff
that may require pressures ten times higher than the standard cuff pressures used. This bronchial cuff is often colored
a radiopaque blue to facilitate identification on x-ray.
6. The Bronchial Challenge Test or the Methacholine Challenge Test is used to determine the extent of bronchial
hypersensitivity. A positive test is indicated when a 20% decrease occurs in the patient's FEV1 after the inhalation of
methacholine (Provocholine®), a drug that tends to cause bronchoconstriction when inhaled.
7. The urinalysis test (UA) is done to check for urinary tract infection and for the presence of blood, sugar or protein in
the urine.
8. Common indications for using holter monitorization include symptoms like dizziness, palpitations, skipped beats or
other sensations which may occur during normal day to day activities.
9. The double-lumen endotracheal tube (DLT) is used for unilateral lung injury, thoracic surgery, whole lung lavage, and
bronchopleural fistulas.
10. Two widely used types of Double-lumen endotracheal tubes are the Carlens and White tubes. The Carlens tube is
used to intubate the left bronchus whereas the White tube is used to intubate the right bronchus.
11.While wearing a Holter monitor, the patient should be instructed to not to take a bath, shower, or go swimming, not
to take off the monitor until the time instructed to do so, and to perform their normal daily activities as usual.
12. Transtracheal oxygen catheters can provide continuous oxygen therapy with only one half to two thirds of the
oxygen used compared with the nasal cannula. The average patient has a 55% reduction of oxygen flow at rest and a
30% decrease with activity compared to oxygen delivery by nasal prongs.
13. Patients should abstain from the use of sympathomimetic drugs for 12 hours before taking the Bronchial Challenge
Test.
14. The PCWP (pulmonary capillary wedge pressure) is an important indicator of the working of the left side of the heart.
The normal blood presssure in the pulmonary veins will be between 4 and 12 mmHg.
15. The pressure (constant volume) body plethysmography operates by Boyle's law which states that the volume of gas
varies in inverse proportion to the pressure to which it is subjected (if the temperature is held constant).
16. A flow volume loop with an obstructive pattern will be shifted to the left (towards the TLC) due to hyperinflation and
air trapping (increased RV). Decreased flows will show up on the top half of the loop as having a "scooped out"
appearance.
17. The normal Cardiac Output is between 4-8 L/min. The Fick method for measuring the cardiac output is: CO = Oxygen
consumption (V02) / Ca02-Cv02. The Thermodilution cardiac output method is done by the injecting of a known
temperature solution (usually iced) through the proximal lumen of the pulmonary artery catheter.
18. The CBC (complete blood count) examines three major types of cells; red blood cells (RBCs), white blood cells
(WBCs), and platelets.
19. The primary indication for lung ventilation and perfusion imaging is the detection of acute pulmonary emboli.
20. Gram staining helps the physician select an initial antibiotic until the lab completes a full culture and sensitivity
testing of the organisms. The results of the gram stain may lead to a presumptive diagnosis of bacterial pneumonia if
large numbers are found.
21. Standard precautions are the first and most general level of isolation precaution measures. Standard precautions
should be used for all patients. Standard precautions involve the use of protective barriers such as gloves, gowns,
aprons, masks, or protective eyewear when contact with body fluids and secretions are likely. In addition, hand
washing should be done when contacting body fluids, secretions, etc. even when wearing gloves.
22. When performing the Nitrogen Washout test, the complete washout of the nitrogen normally takes less than 7
minutes. However, in patients with severe lung disease this may take up as long as 30 minutes to occur.
23. The primary indication for the Barium Swallow test is dysphagia, or difficulty in swallowing. Dysphagia can lead to a
variety of difficulties, including respiratory problems. In most cases, dysphagia is caused by gastroesophageal reflux
disease (GERD) which is especially common in cough variant asthma (asthma in which the predominant manifestation
is cough and in which there is no overt wheezing).
24. Universal precautions do not apply to feces, nasal secretions, sputum, sweat, tears, urine, and vomitus unless they
contain visible blood. Universal precautions do not apply to saliva except when visibly contaminated with blood or in
the dental setting where blood contamination of saliva is predictable.
Things to Remember:
1. To obtain a sputum specimen from a patient with an endotracheal tube in place, the lukens tube should be
placed between the suction catheter and the suction tubing. This will allow suction to be applied when
necessary and allow the easy removal of the lukens trap when the specimen is obtained. Normal saline is used
to obtain specimens.
2. If a patient who is experiencing an asthmatic attack with markedly diminished breath sounds is given a
bronchodilator treatment and begins to have wheezes, then the patient is improving. If the patient starts out
with wheezes and then develops markedly diminished breath sounds, then the patient is getting worse.
3. Desirable features of a manual resuscitator will include a
self-refilling bag, transparent mask, nonjam valve system for a minimum of 30 L/min oxygen flow, standard
16-mm/22-mm fittings, oxygen reservoir, and a no pop-off valve.
4. A lung abscess is often associated with lung cancer and are mostly caused by anaerobic bacteria.
5. Obstructive sleep apnea differs from Central sleep apnea in that central sleep apnea is neurological in origin
whereas obstructive sleep apnea is often due to upper airway obstruction. If the person has an obstructive
type of sleep apnea, respiratory efforts will be seen during the period of apnea. If the person has central sleep
apnea, no respiratory efforts will be seen during the period of apnea.
6. The needle valve on the compensated thorpe flowmeter will be between the tube and the gas outlet. Other
descriptions of the needle valve position include it being located distal to or after the float (it is located farther
away from the gas source or downstream from the thorpe tube).
7. The esophageal gastric tube airway (EGTA) differs from the esophageal obturator airway (EOA) in that the
main tube is used to insert a gastric tube into the stomach so that it can be emptied.
8. Palpable rhonchi are often indicative of heavy secretions.
9. Conditions that result in an increased peak pressures with constant plateau pressures with a mechanically
ventilated patient include increased secretions, mucous plugging, and bronchospasms. All of these conditions
result in increased airway resistance.
10. Factors that will decrease the FI02 delivered by the manual resuscitator include a large stroke volume
(volume squeezed out of the bag), inadequate refill time, fast ventilatory rate, insufficient oxygen flow rate,
and the absence of a reservoir attachment.
11.If the light fails to work on a laryngoscope blade, the therapist should first tighten the bulb. The
laryngoscope blade should only be replaced after the bulb has been tightened or replaced first.
12. The Simple oxygen mask device will deliver a FI02 of
approximately 35 to 55% at flows of 6 to 10 L/min. A minimum flowrate of 6 or 7 L/min is necessary to prevent
C02 buildup in the mask.
13. A Magills forcep is used for nasal intubation only. It is used to grasp the endotracheal tube and guide it
through the vocal cords when a nasal intubation encounters difficulty.
14. If a patient who has undergone trauma or burns to the face needs oxygen then a face tent is the ideal
oxygen device to choose. It is capable of delivering oxygen percentages up to 40%.
15. The venturi mask device is the best selection to used for a patient who has a variable tidal volume and/or
variable respiratory rate and needs a precise oxygen concentration.
16. Radiopaque and Radiodensity are the same thing. Each are descriptions of fluid or dense material showing
up on the chest x-ray as lightened areas.
17. If the reservoir tubing is missing on a T-piece Briggs adaptor setup, the delivered FI02 will decrease and the
patient may draw in room air when breathing.
18. If a patient is presenting with clinical symptoms of atelectasis, then deep breathing and coughing,
incentive spirometry or IPPB should be recommended, not bronchodilators.
19. Air-Oxygen blenders require a 50 psig source of both oxygen and air that is blended by a proportioning
valve. The valve adjusts the amount of air and oxygen concentrations. Blenders have low-pressure alarms that
sound when the pressure drops below 40 psig.
20. The Tidal volume settings for a mechanically ventilated patient should range between 10 and 15 ml/kg of
IBW.
21. An effect of giving too much oxygen to a patient with chronic C02 retention is a decrease in the patient's
respiratory rate and decreased responsiveness.
22. Dyspnea training involves controlling the breathing when performing exerting activities such as walking up
stairs. Patients are instructed on how to exhale during exertion, use energy conserving techniques to control
their dyspnea, and perform common activities of daily living without becoming short of breath.
23. Any containers of sterile water that are being used for various procedures should be used within 24 hours
of being opened.
24. A sign that improved conditioning has occurred in the pulmonary patient is when walking distance has
increased by at least 15%.
25. Anytime a question describes a patient performing a procedure or treatment and the patient experiences
sudden pain or dyspnea, the therapist should immediately stop the treatment and inform the physician.
26. A chest radiograph of a patient in pulmonary edema is
characterized by bilateral fluffy infiltrates.
27. The Trendelenburg position is indicated for a patient with very low blood pressure. In this position, the
whole body of the patient is tilted with the head downward to increase blood flow to the brain and vital
organs.
28. The patient's chart is the most appropriate method of
communicating a patient's clinical status to other members of the health team.
29. If the therapist is unable to insert a suction catheter into a patient’s airway who is intubated with a
tracheostomy tube and is experiencing breathing difficulty, the therapist should suspect that the tube has
become occluded by secretions and the inner cannula
should be removed and cleaned or replaced with another.
30. Infections that are acquired during the patient's stay at the hospital are termed Nosocomial infections.
These infections usually involve Escherichia coli, Pseudomonas, or Staphylococcus bacteria. The best
prevention of these infections is proper handwashing techniques.
31. A patient in pulmonary edema should be placed in a Fowlers position where the head of the bed is raised
18 to 20 inches and the person's knees are slightly elevated. Semi-Fowlers position does not have the knees
elevated. The Sim's position is always used as a distractor in body position questions. The Sim's position is
where the patient lies on the left side with the right knee drawn up to the chest. It is often used when the
patient is receiving enemas.
32. Tachycardia is a heart rate greater than 100 bpm, Bradycardia is a heart rate lower than 60 bpm.
33. A paradoxical pulse (pulsus paradoxus) is a pulse that varies with respirations. May be found in
hyperventilation associated with emphysema, asthma, or a pneumothorax. Pulsus alternans is when strong
heart beats alternate with weak heart beats. This may be found in patients with heart failure.
34. If a patient has atelectasis of a lung segment on the right side , he may become cyanotic when he is turned
on his right side due to increased blood flow to the underventilated lung causing increased shunting.
Therefore if the patient is receiving chest physical
therapy to the left side the patient’s oxygen saturation may drop.
35. Green and foul smelling sputum is usually indicative of a Pseudomonas infection. Yellow sputum (purulent)
indicates infection and the presence of white blood cells.
36.Bradypnea is defined as a slower than normal respiratory rate.
Hypopnea is defined as shallow respirations that are about half the normal depth along with a slower than
normal rate.
37. Hemoptysis is defined as the coughing up of blood from the respiratory tract. The blood must be from the
lungs and not from the mouth in order to be defined as hemoptysis.
38. Pulmonary oxygen toxicity is characterized by decreased surfactant production, edema, fibrosis, a
thickening of the alveolar membrane, and decreased lung compliance.
39. The best bedside measurement for determining the effectiveness of a bronchodilator is a peak expiratory
flow test, not a peak inspiratory flow test.
40. Oxygen therapy is indicated during ambulation, sleep, or exercise when SaO2 is demonstrated to fall to <
or = 88%.
41. Contraindications for the esophageal obturator airway include individuals less than 5 feet tall, conscious or
semi-conscious patients, patients with known caustic poisoning or known esophageal disease, and pediatric
patients (children under 16 years of age).
42. Lateral costal breathing exercises involve placing the hands on the patients lateral costal region of the
chest wall. Unilateral or bilateral costal breathing exercises will increase ventilation to the
lower lobes and aid diaphragmatic breathing. This can be more
effective than placing the hand on the abdomen if the stomach is
large or very tender.
43. Documented hypoxemia in adults, children and infants older than
28 days includes a PaO2 < or = 55 torr or SaO2 < or = 88% in
subjects breathing room air, or PaO2 of 56-59 torr or SaO2 or
SpO2 < or = 89% in association with specific clinical conditions
(eg, cor pulmonale, congestive heart failure, or erythro-cythemia
with hematocrit > 56).
44.Oxygen therapy during exercise should be directed at maintaining
oxygen saturations of 90% or better with exercise sesssions
lasting 20 to 30 minutes occurring three or four times a week.
Exercise should be designed to bring the heart rate up to 70% of
the maximum. If oxygen saturations of 90% cannot be maintained
during exercise then oxygen may be required during the session.
45. Restrictive disorders are characterized by reduced lung volumes
with normal flow rates and are associated with reduced
compliance, increased work of breathing, hypoxemia, and
tachypnea.
At the end of the CRT examination there are usually two or three case
studies consisting of three or four questions each. These case studies
present different situations along with a description of the patient's
condition. Arterial blood gases are often given along with mechanical
ventilation settings if the patient is intubated with the questions
revolving around the patient's situation. Some of the more common
situations presented with these case studies that you should be familiar
with are:
* Person with smoke inhalation

* Drug overdose
* Motor vehicle accident
* Patient experiencing a severe asthmatic attack
* Patient with multiple rib fractures (flail chest)
* Unresponsive patient (CPR protocol)
* Setting up a mechanical ventilator
Things to Remember:
1. The Kamen-Wilkinson tracheostomy tube uses a foam cuff where air is pulled out of the cuff before
inserting the tube. After the tube is in place, the cuff is opened to room air to expand inside the trachea.
You should never insert air into a foam cuff device.
2. Cystic fibrosis is an inherited disease that primarily affects the exocrine glands in the lungs. Asthma is also
another respiratory disorder that has strong inheritance characteristics. Alpha1-antitrypsin deficiency
disorder is a genetically inherited trait that is responsible for approximately 1 percent of emphysema cases.
3. The Hypoxic Drive effect is when a chronic lung patients primary stimulus to breath comes from hypoxemia
or decreased levels of oxygen in the blood instead of elevated carbon dioxide levels as with the normal
person. Because of chronically high PaC02 levels, these patients do not respond to PaC02 levels anymore as
a stimulus to breath. Their primary stimulus now comes from the stimulation of the peripheral
chemoreceptors. When given too much oxygen the stimulus to breath is diminished causing increasing C02
levels.
4. To determine breathlessness of the obstructed airway victim or the cardiac arrest victim, the rescuer should
place the ear over the victim’s mouth and "Look, Listen, and Feel" for air movement.
5. If you must use an endotracheal cuff pressure of 25 or above to maintain an adequate seal then you should
recommend changing to a larger size tube.
6. Tracheal malacia is a loss of cartilaginous support of the trachea while the patient is intubated. After
extubation the trachial walls collapse leading to respiratory distress.
7. The Miller laryngoscope is a straight blade is placed directly under the epiglottis to expose the glottis when
lifted up. The MacIntosh laryngoscope is a curved blade is placed in the vallecula (the area between the
lateral and medial glossoepiglottic folds at the base of the epiglottis) where the epiglottis is lifted up
indirectly.
8. If a question is given where there is a leak around the E-T tube cuff but the balloon is fully inflated then the
problem will be either that the tube is too small or the tube is not down far enough. The average distance
from the teeth to the carina is 27 cm. Taping the endotracheal tube at the 23 to 25 cm mark will place the
tube in the proper position.
9. Bronchial breath sounds that are auscultated in the lower lobes will indicate consolidation. They are
normally heard over the sternum, trachea, and main-stem bronchi.
10. Diaphragmatic breathing is taught to the COPD patient to help him to avoid using the accessory muscles
when breathing. The patient is taught to concentrate on the abdomen when breathing in order to gain
control over the rate and depth of each breath.
11. In hypokalemia, potassium levels are below the 3.5 mEq/L. The physiological effect often results in
metabolic alkalosis. Clinical signs may include muscle weakness, paresthesia, and fatigue. Cardiac changes
may result in flat or inverted T waves. Some of the causes of hypokalemia include diuretics, diarrhea, and
steroid administration.
12. The NIF negative inspiratory pressure measurement provides information about the patient’s respiratory
muscle force, not their inspiratory capacity.
13. Physical therapy exercise programs may include general conditioning exercises, posture correction, energy
conservation, chest strengthening, breathing exercises, and chest percussion and postural drainage.
14. A Fistula formation is not a common complication of an arterial blood puncture.
15. A small injection of lidocaine (2%) is sometimes injected at the site of an arterial puncture. This is to
decrease the pain of the needle stick and to reduce the possibility of vasospasm. This is not commonly done
however because it involves two needle sticks even though the lidocaine injection is done just below the
surface of the skin.
16.Differences between adult (> 8 years) and child (1 year to 8 years old) One-Rescuer CPR will include the
child being given chest compressions with the heel of one hand while placing the other hand on the childs
forehead (the adult requires two hands on the victim’s chest), the chest should be compressed 1 to 1 ½
inches (adults will require 1 ½ to 2 inches), and one breath is given to the child victim after every five chest
compressions (the adult requires two breaths after every 15 compressions). The compression rate is 80 to
100 compressions per minute, the same as the adult.
17. Conditions that result in an increased peak pressures with increased plateau pressures with a mechanically
ventilated patient include pneumonia, consolidation, pneumothorax, ARDS, atelectasis, and pulmonary
edema. All of these conditions result in decreased lung compliance.
18. In order to distinguish between a myasthenic crisis and a cholinergic crisis Tensilon is given to the patient.
If the patient's condition improves, then the person is experiencing a myasthenic crisis. If the patient's
condition worsens, the patient is experiencing a cholinergic crisis.
19. Chest trauma usually presents itself as a flail chest, pneumothorax, hemothorax, or a pulmonary
contusion. A flail chest is defined as a fracture of more than one rib in more than one location resulting in
an unstable area of the chest wall.
20. A maximum inspiratory pressure of -20 cmH20 will be approximately equal to a vital capacity of 15 ml/kg
of IBW.
21. The normal I:E ratio for the adult is 1:2. For the infant it is 1:1. An inverse I:E ratio occurs when the
inspiratory time exceeds the expiratory time. This can be corrected by decreasing the rate, decreasing the
volume, or increasing the flow.
22. A lateral neck radiograph is often used to confirm a diagnosis of epiglottis. The radiograph will generally
exhibit a thickened, flattened epiglottis known as the "thumbs sign".
23. A culture and sensitivity test on the patient’s sputum is needed to determine the best type of antibiotic to
use for a patient with a bacterial infection such as pneumonia.
24. When cleaning home respiratory equipment using acetic acid (vinegar) the equipment should first be
washed with warm water and a detergent. Next, the equipment should be rinsed and shaken dry. It should
then be soaked in the vinegar (diluted with equal parts of boiled water) for 20 minutes or so and then
rinsed and air dried.
25.If you are given a question where you are to calculate a patient's minute ventilation and the patient's
weight is 150 lbs. with a respiratory rate of 12 and a tidal volume of 500 ml DO NOT subtract the anatomic
dead space. The question is asking for minute ventilation, not alveolar minute ventilation. If you are given a
alveolar minute ventilation of 5 L/min. for the above patient and you are asked to calculate the minute
ventilation, then you should subtract the IBW of 150 ml/lb multiplied by 12 from the alveolar minute
ventilation to get the patient's minute ventilation.
26. Patients should be instructed on how to check and use the backup oxygen cylinder when using an oxygen
concentrator.
27. Patients with chronic sputum production of 30 ml or more daily may benefit from aerosol therapy with
mucokinetic agents and bronchial hygiene therapy.
28. When the patient is discharged from the hospital an assessment for ongoing care should be made by the
home care therapist of the patient’s status. This may include historical background on past illness, general
state of health, operations, injuries, allergies, current medications, diet, sleep patterns, habits such as
tobacco and alcohol, brief family and psychosocial history, and a symptom history including the chief
compliant.
29. Bronchitis can be either acute or chronic.
30. If the victim vomits during CPR they should be turned on their side and kept there until vomiting ends. The
victim’s mouth should then be wiped out with the fingers and CPR resumed after the victim has been
repositioned on their back.
31. If the pulmonary disease is not of the COPD classification, then it is a restrictive disorder. Obstructive
disorders can be remembered by the word CBABE (cystic fibrosis, bronchitis, asthma, bronchiectasis, and
emphysema).
32. A V/Q (ventilation-perfusion) scan is the definitive test for finding pulmonary emboli.
33. Pneumonia, an acute inflammation of the alveoli, can be caused by bacteria, viruses, protozoan,
mycoplasma, and fungus.
34. The gas flow to a non-rebreather (usually 8-15 L/min) should be sufficient to keep the reservoir bag
inflated regardless of whether the gas being used is oxygen or helium-oxygen (Heliox).
35. The compression: ventilation ratio for one rescuer CPR for the Infant is 5:1 at 100+ compressions per
minute. The chest should be compressed ½ inch to 1 inch with 2 to 3 fingers placed one finger width below
the imaginary line between the nipples. The brachial artery should be palpated for a pulse for
approximately 5 to 10 seconds.
You will not be allowed to take any books, calculators, papers, or any other material into the examination
room. Also, you must leave your pager and cell phone in your car. These are not allowed either. You are not
allowed to ask questions about the content of the examination during the test. You must write any
comments you have about the test on the back of the answer sheet. You must have the supervisor's
permission (person running the test center) to leave the room during the examination.
Things to Remember:
There are several major respiratory disorders that are emphasized on the CRTT examination. These are Pneumothorax,
Pneumonia, Asthma, Cardiogenic pulmonary edema, Emphysema, Atelectasis, Pleural effusion, and Chest trauma.
Today's hints will cover Chest Trauma
Definition:
Chest trauma is any injury to the chest or thorax. The key factors in managing a chest trauma is to provide an airway
(airway obstruction), assure adequate ventilation (prevent respiratory failure) and control the patient's hemodynamic
situation (prevent hemorrhage).
Chest trauma injuries are classified as:
1. Penetrating - usually are caused by knives, bullets, and metal fragments from explosives. These injuries cause massive
tissue and blood vessel damage.
2. Blunt - causes damage by tearing the tissue, breaking bones, and contusion of internal organs.
3. Combination of both
A chest trauma may manifest itself as:
1. the most common blunt thoracic injury is rib fractures.

2. Pneumothorax and Tension pneumothorax
3. Hemothorax
4. Pulmonary contusion - bronchial hemorrhage
5. Flail chest - multiple rib fractures
6. Aortic injury - rupture of the aortic artery
7. Blunt cardiac injury - myocardial contusion
8. Pericardial Tamponade - accumulation of fluid around the heart
9. Diaphragmatic Rupture
10. Laryngeal and Tracheobronchial injuries
11. Widened mediastinum - usually associated with aortic injury
Causes:
1. Automobile accidents
2. Falls
3. Gunshot wounds
Clinical characteristics:
1. Decreased ability of the chest to expand

2. Hypoxemia
3. Increased or decreased respiratory rate
4. Presence of paradoxical motion of the chest wall
5. Crepitus or subcutaneous emphysema
6. Breath sound may be anything from wheezes to rales to very diminished.
7. Airway obstruction
Radiographic characteristics:
1. Subcutaneous emphysema
2. Fractures of the ribs, clavicles, scapulae, and vertebrae.
3. Pneumothorax
4. Hemothorax
5. Consolidation
6. Abnormalities of the mediastinum
7. tamponade
8. Atelectasis
Treatment:
1. Oxygen
2. Pain medications
3. Surgery
4. Mechanical ventilation or CPAP
5. Chest tube if pneumothorax is present
6. Volume expansion with crystalloids if hypotension becomes a problem
Things to Be Aware Of:
1. Complete blood count, electrolytes, glucose, BUN, creatinine, ABGs, urinalysis, ECG, and blood type and crossmatch
should be obtained.
2. Maintaining an adequate airway is vitally important. Secretions and vomitus should always be suspected and a
suctioning device (Yankauers) should be readily available.
3. It is commonly recommended that patients with unstable chest walls be intubated and placed on mechanical
ventilation with PEEP to stabilize the chest.
4. Atelectasis, refractory hypoxemia, and ventilatory failure are not uncommon in these patients. Always start a trauma
victim out on 100% oxygen usually by a nonrebreather.
Things To Remember:
1. A dull percussion note is indicative of fluid or consolidation in the airways. Disorders that may produce a
dull percussion note include atelectasis, pleural effusion or thickening, pulmonary edema, and consolidation.
Flatness is just a more severe form of dullness and indicates a higher degree of consolidation such as
"massive" atelectasis and a "massive" pleural effusion.
2. When making a chart notation on an aerosol treatment, things to include on the chart are (1) type of
treatment, (2) medication given and what strength, (3) pulse rate before and after treatment, (4) breath
sounds, (5) productive or non-productive cough, (6) how the treatment was tolerated, and maybe (7) the
respiratory rate.
3. Chest percussion should be performed with the wrists relaxed and the hands cupped.
4. Streptococcus pneumoniae is the most common bacterial pneumonia. Other bacteria include Haemophilus
influenzae, Klebsiella pneumoniae, Legionella pneumoniae, and Pseudomonas aeruginosa.
5. The venturi mask and the non-rebreather should supply the patients tidal volume requirements when used
properly. The nasal cannula will not.
6. When a second rescuer arrives at a cardiac arrest situation, that person will take over as the compressor.
The initial rescuer will go to the patient’s head, palpate for a pulse, and deliver one breath if no pulse is
found. The second rescuer then will begin chest compressions.
7. The major difference between the Minimal Occluding volume technique and the Minimal Leak technique for
measuring cuff pressures is that in the Occluding technique, the cuff is inflated until "no leak" is heard during
peak inspiration whereas in the Leak technique the cuff is inflated until no leak is heard and then deflated to
allow a "small leak" during peak inspiration. Minimal Occluding = no leak at peak inspiration Minimal Leak =
small leak at peak inspiration.
8. The pressure setting on a pressure-cycled ventilator will determine the pressure that the inspiratory cycle
will end. The volume setting on a volume-cycled ventilator will determine the volume that the inspiratory
cycle will end. The pressure-cycled ventilator will generally sacrifice volume to reach the set pressure and
the volume-cycled ventilator will generally allow high pressures to reach the set volume (unless the pressure
alarm setting is activated).
9. If a patient in congestive heart failure is on mechanical ventilation, the blood pressure and other
hemodynamic and cardiac information should be closely monitored. One of the side effects of positive
pressure ventilation is decreased blood pressure, decreased pulmonary blood flow, and decreased venous
return.
10. An air compressor is used by the patient at home to administer nebulized bronchodilator therapy.
11. Paradoxical motion of the chest is when the chest or part of the chest moves in on inspiration and out on
expiration. This is a serious complication of a flail chest following a trauma. A flail chest is defined as the
fracture of more than one rib in more than one location that results in an unstable area of the chest wall. As
the person breaths in, the unaffected side of the chest moves out on inspiration while the flail segment of
the chest is sucked in with the reverse occurring on expiration.
12. Pancuronium bromide (Pavulon) is commonly used to maintain a patient on mechanical ventilation or to
facilitate oral endotracheal intubation. Its onset of action is several minutes and it will last up to an hour.
Pavulon can be reversed by the use of Prostigmin or Tensilon, drugs commonly used in the treatment of
Myasthenia gravis
13. Cuff pressures should be inflated to match peak inspiratory pressures. A cuff pressure set when peak
pressures are around 40 or so, should be readjusted when the peak pressure becomes lower by withdrawing
air from the cuff.
14. A patient with a FEV1/FVC that is 90% of predicted and a FVC that is 55% of predicted indicates a
restrictive disorder only. FVC is not a flow measurement but a volume measurement. Volume measurements
are most indicative of restrictive disorders.
15. Digital clubbing is defined as an enlargement of the distal phalanges (the tips of the fingers) resulting in a
loss of the angle between the fingernail and the skin of the finger above the fingernail. This angle is normally
around 160 degrees. When digital clubbing occurs, the angle will flatten out greater than 180 degrees. The
majority of clubbing results from the effects of pulmonary disease.
16. If a gas leak occurs after removing the flowmeter from the oxygen outlet, the therapist should immediately
reinsert the flowmeter back into the outlet. If that does not correct the problem, a recommendation to cut
off the zone valve that controls the oxygen supply to a particular area or floor should be made. This may be
done after the patients in that particular area or floor who are on oxygen are supplied with a backup system.
17. It is not necessary to analyze the FI02 of the oxygen when setting up oxygen using a nasal cannula.
18. Compliance is defined as volume change divided by pressure change. Elastance is defined as the pressure
change divided by volume change. Usually, lungs with high compliance have low elastance and lungs with
low compliance have high elastance.
19. Equipment that has been used by a HIV patient or one with Hepatitis should be double bagged inside the
room and gas sterilized.
20. A pneumothorax is the presence of air in the intrapleural space. This may occur from an injury or
spontaneously. The pneumothorax creates pressure around the lung area leading to chest pain, atelectasis,
and respiratory distress. Intrapulmonary shunting will occur with refractory hypoxemia if action is not taken
to relieve the pressure. A pneumothorax is usually classified as traumatic or spontaneous.
21. Racemic Epinephrine is indicated for use in croup (laryngotracheobronchitis), stridor, and post-extubation
upper airway edema. It is primarily given as a decongestant for bronchial and vascular congestion and not as
a bronchodilator. Its primary effect is on the Alpha receptors with minimal effects on the beta receptors. It
should not be given in combination with a bronchodilator.
22. The Pa02 values in an arterial blood gas sample are analyzed by the method of polaragraphy. This method
is capable of measuring oxygen partial pressures in a liquid. Paramagnetism measures oxygen partial
pressure in a gaseous medium only.
23. The Maximum voluntary ventilation (MVV) maneuver is the maximum volume of air that can be moved
into and out of the lungs in 10 to 15 seconds. This is a test for overall lung functioning and capacity. It is
decreased in both obstructive and restrictive disorders.
24. The most likely hazard of the Incentive Spirometry device is hyperventilation from breathing too fast.
Sometimes however, patients complain of a sore throat after using the device too much or too forcefully.
25. Transudative pleural effusions develop when fluid from the pulmonary capillaries move into the pleural
space. The fluid produced is thin and watery and contains very few blood cells and protein. With the
transudative pleural effusion the pleural membranes are intact and are not involved in the pathogenesis of
the fluid formation.
26. Flow rates should be set high enough to allow sufficient expiratory time to prevent air trapping in patients
with severe obstructive lung disease.
27. A normal tidal volume for a healthy individual is usually 5 to 7 ml/kg of IBW. A normal tidal volume
selection for a patient on mechanical ventilation is between 10 and 15 ml/kg of IBW. Sometimes the two
figures are confused.
28. The COPD patient who is a C02 retainer will have arterial blood gases with a compensated pH (7.35-7.45),
a elevated PaC02 (46-55 usually), and a elevated HC03 (29-36 usually). These patients should always be put
on 2 liters of oxygen, 28% FI02, or enough oxygen to keep Sa02 around 89 to 90%.
29. The Fenestrated tracheostomy tube is used to help wean the patient from a tracheostomy tube while
allowing the patient to talk and maintain the tracheostomy stoma. The tube has an opening that allows the
patient to inhale and exhale through the fenestration and around the tube when the inner cannula is
removed, the cuff is deflated, and the tracheostomy tube is occluded with a plug. This allows the patient to
breath through their natural airway passages and allows air to pass through the vocal cords enabling the
patient to talk.
30. If a patient is set up on a 30% aerosol mask but the oxygen analyzer reads 50% at the patient's mask, then
a possible cause will be water collecting in the wide-bore tubing. Collected water will cause the FI02 to
increase and decrease the flow.
The Oxyhemoglobin Dissociation Curve plots the relationship between the (1) Pa02 (2) Sa02 (3) and the
affinity of hemoglobin for oxygen at various saturation levels. A common point of reference on the O-D
curve is the P-50 mark. This is the partial pressure where hemoglobin is 50% saturated with oxygen which is
normally about 27 mmHg. The clinical importance of the O-D curve lies in the fact that the actual oxygen
delivery to the patient may be lower than the Pa02 obtained by the arterial blood gas if a right shift is
taking place.
Things to Remember:
1. If an intubated patient with a drug overdose has a respiratory acidosis with an elevated PaC02, then the minute
ventilation should be adjusted to bring the PaC02 down within 30 minutes or so since the increase was acute and not
chronic.
2. To determine if a person is having an airway obstruction you should ask the victim if they are choking.
3. To prevent the occurrence of a nosocomial infection when using a heated aerosol device the therapist should make
sure the device has been sterilized, record the date and time it was set up, and avoid touching the insides of the
device.
4. If you are given a patient's blood gases where the Pa02 and the Sa02 correlate, but the Sp02 (pulse oximetry reading)
is a lot higher you should consider carbon monoxide poisoning.
5. If the airway victim becomes unconscious, the tongue-jaw maneuver should be used to open the mouth and sweeped
with the finger as the victim’s head is turned to the side.
6. To calculate the dead space percentage (the Bohr equation) for a patient with a PaC02 of 52 torr and a PEC02 of 34
torr, you would subtract the PEC02 from the PaC02 and divide the results by the PaC02 which would give you 0.35.
7. Some of the problems associated with the use of aerosol therapy are fluid overload (in infants), bronchospasms,
secretions swelling in the airways, and nosocomial infections.
8. When setting up a mechanical ventilator, the set volume can be measured by using a test lung attached distal to the
exhalation valve.
9. The difference between the tracheal button and the Kistner button is that the Kistner button has a one-way valve on
the proximal end of the tube. When the patient inhales the valve opens but when the patient exhales the valve closes
forcing air out of the natural air passages.
10. If a mechanically ventilated patient has a fairly normal PaC02 and a fairly normal pH, but the Pa02 is in the 40’s or
50’s while on 50 or 60% FI02, then PEEP should either be added or increased.
11. A decreasing lung compliance will be indicated by increasing plateau pressures as well as increasing peak pressures.
An increasing airway resistance will be indicated by increasing peak pressures with minimal increases in plateau
pressures.
12. When the airway protective reflexes are obtunded, they are lost starting with the pharyngeal (gagging and
swallowing), the laryngeal (laryngospasm), the tracheal (coughing when irritated), and the carinal reflex (coughing
when irritated).
13. After the tidal volume and rate have been set up as the initial settings for the ventilator patient, the FI02 should be
set up next. If no arterial blood gases have been done prior to intubation, then 40% to 60% FI02 is recommended with
no PEEP as the starting point. If the patient was on oxygen prior to being put on the ventilator, the same FI02 should
be used.
14. One of the major side-effects of high PEEP levels is a decrease in the cardiac output. If this happens the therapist
should decrease the PEEP levels back to the previous level before the changes were made and increase the FI02
instead.
15. If a patient is intubated with an EOA (esophageal obturator airway), the patient should be intubated with an E-T tube
before the removal of the EOA, not after its removal.
16. If the manual resuscitation bag fills rapidly and then collapses when ventilation breaths are given, check for an
absent inlet valve or see if the valve is stuck open.
17. Auscultation of a patient's lungs who is in pulmonary edema will most likely reveal moist, crepitant rales.
18. Indications that a patient is having an adverse reaction to an IPPB treatment may include bronchospasms, marked
increase in heart rate and blood pressure, onset of hemoptysis, or symptoms of a pneumothorax.
19. The compression: ventilation ratio for one rescuer for adult CPR is 15:2 at 80 to 100 compressions per minute. The
compression: ventilation ratio for two rescuers adult CPR is 5:1 at 80 to 100 compressions per minute.
20. Mask CPAP with a 100% FI02 is a good choice for a patient in acute pulmonary edema.
Things to Remember:
1. If there is a lack of condensation in the tubing of a heated humidifier (Wick or Cascade) then the heating element is
not functioning properly. If the heating element is functioning properly the gas will become saturated with water and
rain out the excess as condensation.
2. If you are asked to calculate a patient’s FEV1/FVC ratio, then take the largest FEV1 from at least two different valid
attempts, and take the largest FVC from at least two different valid attempts and divide the FEV1 by the FVC and
multiply by 100. Obstructive disease is indicated by a ratio of less than 75%.
3. Pink/Frothy secretions are usually an indication of pulmonary edema.
4. A patient's total cycle time is obtained by dividing the respiratory rate into 60 seconds. To obtain the inspiratory time
from that, the total cycle time is divided by the I: E ratio (the two parts of the I:E ratio are added together and divided
into the total cycle time).
5. A faulty flowmeter will cause a bubble humidifier to bubble even when the flowmeter is turned off. The flowmeter
should be replaced.
6. Compensation is when the levels of bicarbonate and carbon dioxide change in order to keep the pH within normal
range. Partial compensation occurs when the bicarbonate is elevated to offset an elevated PaC02 or when the PaC02
is decreased to offset a decreased bicarbonate. This is an attempt to bring the pH back to a normal range.
7. A heart rate increase of more than 20 beats per minute during a bronchodilator treatment is indicative that the
treatment should be stopped and the physician notified.
8. A mouth-to-valve mask is the device of choice when a manual resuscitator device is not available. A one-way valve is
attached to a transparent mask to which the rescuer can provide ventilation. Exhaled gases are prevented from
coming back into the rescuer’s lungs by the one-way valve.
9. To increase the expiratory time, the flow rate should be increased in a mechanically ventilated patient.
10. A CPAP device on a neonate will lose pressure if the infant is crying.
11. The H-cylinder and the E-cylinder are the most commonly used cylinder factors for the exam. The H-cylinder factor is
3.14 L/psig and the E-cylinder factor is 0.28 L/psig. The pressure remaining in the cylinder is multiplied by the cylinder
factor with the results divided by the flow of gas in L/min. The results are in minutes and must be divided by 60 to
obtain the time in hours. Be careful to see whether the answer they want on the test is in minutes or hours.
12. For a patient suspected of CO (carbon monoxide) poisoning, a pulse oximetry should not be used since it measures
total saturated hemoglobin. The device does not distinguish between hemoglobin saturated with oxygen and
hemoglobin saturated with carbon monoxide. A co-oximetry must be used.
13. To extubate a patient, the tube should be pulled at peak inspiration. This way the patient will have the lungs fully
expanded to cough and expel any secretions that may try to fall back into the airway.
14. Croup results from subglottic (below the glottis) swelling, Epiglottis results from supraglottic (above the glottis)
swelling and is much more serious.
15. An Optimal PEEP level is that level where the patient's Pa02 is at least 60 mmHg or 90% saturated with the highest
lung compliance available along with the best Cardiac Output. However, adequate lung compliance cannot be
obtained at the expense of cardiac output levels.
16. When using the Bird Mark 7 IPPB machine and the air-mix option is turned off to obtain 100% oxygen, the flow will
be decreased. When the air-mix option is turned on, the resulting oxygen concentration will be somewhere between
40 and 80% with a resulting increase in the flow.
17. To explain the purpose of incentive spirometry to a patient without medical knowledge, tell the patient that the
procedure will help her take deep breaths and expand her lungs.
18. Orthopnea is difficulty breathing when lying down. These patients usually have some type of heart problem.
19. When assessing the mechanically ventilated patient for weaning, a NIF (negative inspiratory force) equal to or
greater than -20 cmH20 is necessary.
20. Factors that will affect the FI02 of the oxygen being delivered by a venturi mask will include the velocity of the gas
through the venturi because the velocity is determined by the jet orifice size. However, the FI02 will remain the same
if the flow is increased or decreased through the gas injector. I personally find this somewhat confusing and
misleading because I consider the velocity and flow as the same thing. They don't tell you in the question that the jet
orifice size is decreased which will increase the velocity, entrain more air, and reduce the FI02. This was on a previous
exam question so beware.
21. Isoniazid (INH), ethambutol, strepomycin, and rifampicin are drugs commonly used for the treatment of tuberculosis.
22. If the Cascade humidifier device fails to generate adequate moisture, check the water level, the tower attachment,
obstruction in the water feed system, and gas flow obstructions. Leaks can also be a common problem. Check all
connections on the humidifier and tighten.
23. The SPAG II nebulizer (small-particle aerosol generator) is a specialized nebulizer that is used to nebulize ribavirin
(Virazol) that is used to treat the respiratory syncytial virus. The device is often used with an oxyhood but can be
adapted for other systems as well.
24. A endotracheal tube must be positioned 2 to 5 cm above the carina which is approximately at the aortic knob or
above the fourth rib or at the fourth intercostal space.
25. Recommendations for a patient with a diagnosis of sleep apnea are to sleep on the side instead of supine and to use
continuous positive airway pressure (CPAP) while sleeping.
26. Before performing a peak inspiratory flow rate, the patient should inspire to TLC (total lung capacity). The peak flow
is defined as the maximum flow rate achieved during an FVC (forced vital capacity). This will be decreased in
obstructive disorders.
27. Kyphoscoliosis is a combination of Kyphosis (backward curvature of the spine) and Scoliosis (lateral curvature of the
spine) and may cause decreased thoracic compliance, decreased vital capacity, dyspnea, and tachypnea. It will not
cause increased pulmonary diffusing capacity.
28."Iatrogenic" means something caused by the therapist or physician such as iatrogenic hypoxemia which is caused by
vigorous suctioning without proper pre and post hyperoxygenation.
29. When a question asks for a compliance calculation, make sure you know which type of compliance they are asking
for, static or dynamic.
30. When checking an oxygen concentrator in the patient's home, the oxygen should be analyzed, alarms checked, flow
rate checked, and the filters changed if needed.
Sometimes the NBRC question makers will throw a boggie question on the test that doesn't make sense and doesn't
seem to have a correct answer. It’s there to see if it will get you frustrated and confused. Just make an intelligent
guess and move on the another question
Things to Remember:
1. Chronic bronchitis is strictly defined as chronic cough with sputum production most days for at least three months of
the year for at least two successive years.
2. The temperature of the gas that is delivered to a patient using an ultrasonic nebulizer is 3 to 10 degrees Centigrade
higher than room air.
3. Some of the criteria for using the HME (heat moisture exchanger) are that the patient has a normal temperature, is
adequately hydrated, does not require humidity for retained secretions, and has normal minute ventilation.
4. Proper suctioning levels are -80 to -120 for the adult, -60 to -80 for the child, and -40 to -60 for the infant. The suction
catheter should be 1/2 to 2/3 of the diameter of the endotracheal tube with 1/2 being the most acceptable.
5. The Galvanic fuel cell oxygen analyzer and the Polarographic oxygen analyzer are both affected by water on the
sensor, high system pressures, and changes in altitude.
6. Goals for pulmonary rehabilitation for the patient and family should include an improved level of daily activity,
improved exercise tolerance, holding off the progression of the disease, and energy conservation.
7. A pulse oximetry will give a falsely high oxygen saturation reading when the patient has been breathing carbon
monoxide. This is because pulse oximetry measures total bound hemoglobin, regardless of whether it is bound to
oxygen or carbon monoxide.
8. The patient and the family should be instructed in cleaning and disinfecting equipment and in the maintenance of
oxygen concentrators.
9. the most common suction catheter size for a 8.0 ET tube is a 12 French catheter. However, 14 French or even a 16
French catheter can be used, but NOT a 18 French catheter. If the question asks you for the proper action to take
when secretions are too thick to be suctioned and the suction pressure is already at the upper limit and the catheter
size is as big as allowed, then use normal saline to dilute the secretions.
10. When the pH in arterial blood decreases, then the affinity of hemoglobin for oxygen is decreased in all cases. The
presence of carbon monoxide will increase the affinity of hemoglobin for oxygen not decreases it.
11. Energy conservation for the patient should include the use of frequent rest periods, alternating light and heavy
activities, using labor-saving devices, and using proper body positioning.
12. Respiratory equipment that is to be disinfected in acetic acid (vinegar) should remain in the solution at least 20
minutes.
13. Guillian-Barre syndrome is an ascending paralytic disorder of unknown origin but is often preceded by a viral
infection.
14. The Cuirass is a negative-pressure chest respirator that consists of a plastic shell that fits over the patient's chest. An
electrical pump creates a negative extrathoracic pressure that lifts the chest wall up to create inspiration. It is often
used for paralyzed patients needing home ventilation but not needed or wanting positive-pressure ventilation.
15. If the ratio light is lighting up on the ventilator, the tidal volume can be decreased, the rate can be decreased, and
inspiratory flow can be increased to correct the problem.
16. The best indicator of patient tolerance to exercise is pulse oximetry, not the patient's subjective feelings.
17. ARDS (Adult Respiratory Distress Syndrome) is also called noncardiogenic pulmonary edema.
18. A jet nebulizer is commonly used to provide oxygen and humidification to the patient using a trach collar device.
19. Exercise sessions for the COPD patient should increase the heart rate to 70% of their maximum.
20. SIMV, pressure support, and T-piece trials are all used to wean a patient off a mechanical ventilator. PEEP however,
would not be used.
Just remember, although you have just completed a comprehensive and exhausting list of courses on every aspect of
respiratory therapy under the sun, the questions on the NBRC CRTT examination are primarily job-related. They want
to know that if you are capable of performing your job as a respiratory therapist effectively and safely.
Things to Remember:
1. Cheyne-Stokes breathing pattern is characterized by a gradual increase and decrease in the depth and rate
of respirations followed by a short period of apnea. This pattern of breathing is seen in patients with CHF,
brain injury, or drug overdose. Cheyne-Stokes should not be confused with Biot’s respirations where there is
an irregular depth and rate of breathing with short periods of apnea. The major difference between Biot’s
and Cheyne-Stokes is that Biot’s is an irregular breathing pattern whereas Cheyne-Stokes has a consistently
regular respiratory cycle.
2. A patient who hyperventilates may experience dizziness and a tingling sensation in the fingers. This may
occur during an IPPB treatment or during an Incentive breathing exercise.
3. Acetylcysteine (Mucomyst) is commonly asked about on the examination. Mucomyst is a mucolytic that
breaks up sputum and allows it to be coughed up. It is available in 10% and 20% solutions and is often used
with bronchodilators due to brochospasms as a common side effect. It is commonly used with cystic fibrosis
and bronchiectasis patients. If brochospasms occur when using Mucomyst the therapist should stop the
treatment and administer a bronchodilator. Also it smells bad!
4. the most significant factor causing tracheal stenosis (narrowing of the trachea) is endotracheal cuff
pressure.
5. The amplitude control of the ultrasonic nebulizer controls the volume of the aerosol output. The
piezoelectric transducer controls the frequency. The frequency is preset at the factory.
6. Common sensitivity levels for a patient on mechanical ventilation or using an IPPB machine are -1 and -2.
Decreasing the sensitivity means changing the sensitivity to a more negative number, for instance -3 or -4.
This increases the effort required by the patient to initiate a breath from the machine. On the other hand,
increasing the sensitivity makes it easier to cycle the machine on. However, increasing the sensitivity too
much (making the sensitivity more positive to 0 or 1), will cause the machine to "auto-cycle" where the
machine will cycle on prematurely.
7. Tubing compliance occurs when volume is lost in the ventilator circuit due to the circuit’s ability to expand
when compressed gases are being forced through it. It can be calculated by cycling the ventilator into
inspiration with the patient’s circuit wye occluded. The set tidal volume is then divided by the peak pressure
achieved. The answer, in ml/cmH20, is then multiplied by the peak pressure to arrive at the volume lost in
the circuit. Tubing compliance is of little consequence for the adult patient but can be critical for children
and infants.
8. A patient on 60% or more of oxygen but is not oxygenating well probably has a large intrapulmonary shunt.
These problems are often corrected by the use of CPAP or BiPAP before mechanical ventilation is initiated.
9. The non-rebreather is usually considered a high-flow device on the exam. A distinction is sometimes made
however, between the non-rebreather with only one flap present on the side of the mask and the non-
rebreather with two flaps on both sides of the mask. If a non-rebreather has only one flap on the side of the
mask then it would be considered a low-flow device.
10. You can determine the number of stages a pressure reducing valve has by counting the number of pop-off
valves. These valves keep pressure from building up too high.
11.If you are given arterial blood gases where the Pa02 is around 45, the Sa02 is around 75%, and the Sp02 is
around 90%, then the Sp02 (pulse oximetry) should be disregarded. A Pa02 of 45 mmHg is consistent with a
Sa02 of 75%. A person with carbon monoxide poisoning will have a normal Sp02 with an decreased Sa02 by
co-oximetry but the Pa02 will usually be elevated if the person comes into the ER with a non-rebreather
mask already on.
12. If a patient’s pulse strength decreases when the patient breaths in, it is termed pulsus paradoxus and is
not uncommon in COPD patients. If the pulse strength alternates between strong and weak pulses it is
termed pulsus alterans. If there is a difference between the auscultated pulse and the palpated pulse then
there is a pulse deficit. Both pulsus alterans and a pulse deficit may indicate left-sided heart failure. A strong
and bounding pulse may indicate hypertension or hypervolemia.
13. Some important factors that will decrease the possibility of endotracheal tube occlusion are adequate
humidification of the oxygen, consistent suctioning of secretions, and proper hydration of the patient
through fluids.
14. When intubated, a patient's secretions will tend to dry out if the absolute humidity is less than 44 mg/L
and the relative humidity is less than 100% at body temperature. If you are given an absolute humidity that
is less than 44 mg/L and a relative humidity of 100% at less than body temperature (98.6 degrees) then
these are not sufficient for proper humidification. Also, the water vapor pressure should be 47 torr with 44
mg of particulate water per liter of gas.
15. The Pin Index Safety System (PISS) is used for high pressure connections on small cylinders such as the E
cylinder. The Diameter Index Safety System (DISS) is used for low pressure connections of less than 200 psi
that are often used for respiratory equipment. The American Standard Safety System (ASSS) is use for high
pressure connections on large cylinders such as the H cylinder.
16. Increased fremitus indicates fluid in the lung. Decreased fremitus indicates sound transmission that is
obstructed by chronic obstructive pulmonary disease (COPD), fluid outside the lung (pleural effusion), or air
outside the lung (pneumothorax).
17. The rationale for using a heated Cascade humidifier for an infant's oxyhood is its low noise level and low
chance of contamination. The reasons would not include the size or concentration of the particles since the
Cascade humidifier produces little or no particles. Particles are produced by aerosol generators.
18. The SIMV mode is often used for patients who have high respiratory rates, irregular respiratory patterns,
have a history of COPD, or for patients who are being weaned off the ventilator.
19. Supplemental oxygen use can be determined in a patient when the P02 and the PC02 are added and the
results are greater than 140.
20. If all involved lung segments have responded to chest physiotherapy except one, then the therapy should
continue on that segment only and should not be stopped completely.
21. When checking an oxygen concentrator in the patient's home, the oxygen should be analyzed, alarms
checked, flowrate checked, and the filters changed if needed.
22. The Kinetic flowmeter is the same thing as the thorpe tube flowmeter except that a plunger is used instead
of a ball to indicate the oxygen flow. Like the compensated thorpe tube flowmeter, if it is shut off and
plugged into the wall the plunger indicator will jump.
23. Normal Static lung compliance for a ventilator patient is 60 to 100 ml/cmH20. Anything below 25
ml/cmH20 is critical.
24. Clinical signs of right-sided heart failure are peripheral edema and jugular vein distention. Right-sided
heart failure is also known as Cor Pulmonale although the two terms are not exactly the same and is a
common effect of long-term chronic obstructive lung disease patients.
25. The Forced Vital Capacity is the same as the vital capacity except that the air is exhaled as forcefully as
possible after a maximal inspiration. The FVC provides measurements on the FEV 0.5, 1, 2, 3 second flow
rates. It is an important test for obstructive disorders and will be decreased in obstructive diseases. The FVC
is not a flow however, but a volume. It is easy to get Vital Capacity and Forced Vital Capacity mixed up.
Take special notice of words like Unstable, Adverse, Marked, Acute, and Untreated. These words often
indicate a serious condition that may be a contraindication for a procedure or treatment.
Things to Remember:
1. A low pressure alarm is essential for a CPAP device.
2. Normally, inspired air becomes 100% saturated at body temperature by the time it reaches the carina.
3. An untreated pneumothorax is an absolute contraindication to CPT (chest physical therapy).
4. Cyanosis is technically defined as a 5 g/dl decrease in oxygenated hemoglobin or when the capillary content of
reduced Hb exceeds 5 gm/100 ml. Cyanosis is usually seen clinically as a bluish discoloration of the lips and nail beds
however severe hypoxia may exist without the presence of cyanosis.
5. Transcutaneous monitors are primarily used on neonates as a means of noninvasive monitoring of PaC02 and Pa02.
The probe is attached to the skin and heated to 42 to 44 degrees Celius to increase blood flow to the skin. Because of
this, the probe must be changed every 3 to 4 hours to prevent burning of the skin. Normal Pa02 levels in the neonate
are between 50 to 70 torr.
6. Pulmonary function interpretation will be classified as a Normal PFT (80% to 100% of predicted value), Mild disorder
(60% to 79% of predicted value), Moderate disorder (40% to 59% of predicted value), and Severe disorder (less than
40% of predicted value).
7. Low-Pressure alarms should be set 5 to 10 cmH20 below the peak inspiratory level. High-Pressure alarms should be
set 5 to 10 cmH20 above the peak inspiratory level.
8. The Sensitivity control determines the amount of effort the patient is required to make to cycle a ventilator into
inspiration. Normal sensitivity is around -2 cmH20. If it becomes harder for the patient to cycle on the ventilator, the
sensitivity should be increased (changing it from -2 to -1 for example).
9. Possible causes of gradually increasing peak pressures on a ventilator patient are decreasing compliance,
bronchospasms, and secretions.
10. To increase the mean airway pressure on a neonate receiving continuous mechanical ventilation the therapist should
increase the inspiratory time and the pressure limit.
11.Techniques that can be used to prevent nosocomial infections when administering small volume nebulizer
treatments include using unit dose medications whenever possible, recording the date and time of the set-ups, using a
different nebulizer for each patient, washing out the nebulizer medication container after each use, and washing one’s
hands before and after the procedure. If a choice can be made between a small volume nebulizer and a metered dose
inhaler, the metered dose inhaler will be the best way to avoid the spreading of infection.
12. If a conscious patient develops an abrupt upper airway obstruction, the therapist should apply strong
subdiaphragmatic compressions.
13. An obese person who is experiencing dyspnea will do best in a lateral Fowlers position so the stomach does not
interfere with the person’s breathing.
14. Late complications of tracheostomy tubes may include infection, airway obstruction from tracheal stenosis,
hemorrhage, Tracheoesophageal fistula, rupture of the innominate artery, Tracheitis, and difficulty in swallowing.
15. the most efficient way to prevent cross-contamination when using a Wright’s respirometer is to attach a one-way
valve that allows only expiratory gases to pass through the respirometer.
16. The temperature of the water and gas is the most important factor in determining the humidity output of a
humidifier. Heating the water in the humidifier will increase the capacity of the gas to carry it to the patient.
17. Contraindications for postural drainage may include a recent post-op craniotomy, severe dyspnea, or active
hemoptysis.
18. The Respirgard II nebulizer is used to nebulize the drug pentamidine isethionate (Pentam) which is commonly used
to treat pneumonia in AIDS patients. It is designed to contain the medication within the nebulizer and the patient
without allowing it to escape into the surrounding air.
19. When using older ventilators, the sensitivity control must be reset when the PEEP is adjusted.
20. If a patient is to receive incentive spirometry at home, the patient’s family should be told that the therapeutic goals
will be to decrease the chance of lung collapse. They should not be told that it will cure pneumonia, or increase the
ease of breathing by causing bronchodilation.
21. Cheyne-Stokes, Biots, and Kussmaul's breathing patterns are regular questions on the CRTT exam. On the test,
Cheyne-Stokes is usually associated with CHF (congestive heart failure), Biots is usually associated with a CNS (central
nervous system) disorder, and Kussmauls is usually associated with diabetic ketoacidosis. However, be aware that
these breathing patterns can also be associated with other disorders too.
22. The Galvanic fuel cell and the Polarographic oxygen analyzers are both electrochemical analyzers. However, the
galvanic fuel cell uses a fuel cell as a power source and the polarographic analyzer uses a battery. Both use the Clark
electrode to measure the partial pressure of oxygen.
23. If a loud hissing noise is heard when the valve is opened on an E-cylinder with a regulator attached, then the
regulator connection is either loose or the washer that is located between the regulator and the cylinder needs to be
replaced. Sometimes the washer will even be missing because it has fallen off or something.
24. The most effective ventilatory pattern for a patient with emphysema is to exhale slowly, with pursed lips if becoming
short winded. This prevents airway collapse and air trapping, common problems with patients with hyperinflated
lungs.
25. The electrical load capacity of the patient’s home should be checked when a patient is being sent home with an
oxygen concentrator since the concentrator is electrically operated.
Patient Assessment, mechanical ventilation, and gas therapy make up over 50% of the examination. Hit those areas
the hardest.
Things to Remember:
There are several major respiratory disorders that are emphasized on the CRT examination. These include
Pneumothorax, Pneumonia, Cardiogenic pulmonary edema, Emphysema, Atelectasis, Pleural effusion, and
Chest trauma. Today's hints will cover
Cardiogenic Pulmonary Edema
Definition: Cardiogenic pulmonary edema is an marked increase in the amount of fluids in the lungs due to
decreased left heart function. The result is a backup of fluid from the heart into the pulmonary capillaries
which leak into the lung tissues and alveoli. Oxygenation then becomes impossible and the patient becomes
severely hypoxic.
The two major forces maintaining the equilibrium of fluids in the capillaries are the plasma oncotic pressure
(keeps the fluid in the capillary) and the capillary hydrostatic pressure (which pushes the fluids out of the
capillary). Since the oncotic pressure is usually higher than the hydrostatic pressure, the fluid stays in the
capillaries. However, when fluid backs up into the pulmonary capillaries due to decreased left heart function,
the capillary hydrostatic pressure increases and pushes the fluids out into the interstitial spaces and into the
alveoli. The result of this massive influx of fluid into the lungs is decreased lung compliance, increased airway
resistance, and intrapulmonary shunting.
Causes:
1. Left heart failure

2. Hypervolemia
3. Myocardial infarction
4. Aortic stenosis
5. Pulmonary embolus
6. Renal failure
7. Mitral valve stenosis
8. Systemic hypertension
1. Dyspnea
2. Thin, pink, frothy secretions
3. Fine rales/crackles and/or wheezes
4. Tachypnea
5. Chest pain
6. Cyanosis - if severe
7. Diaphoresis
8. Decreased lung compliance
9. Distended neck veins
10. Pedal edema
11. Initially ABGs may show moderate to severe hypoxemia and respiratory alkalosis progressing to respiratory
acidosis
12. May have a dull note to percussion
13. Increased tactile and vocal fremitus
14. Tachycardia and possible EKG changes
1. Increased vascular markings

2. Interstitial edema
3. Enlarged heart shadow
4. Patchy alveolar filling pattern (butterfly pattern)
5. Kerly B lines - short straight markings that originate near the pleural surface of the lower regions of the
lungs.
Treatment:
1. Oxygen - often starting at 100%

2. Diuretics
3. Digitalis or other positive inotropic agents
4. Cardiac glycosides
5. Morphine
6. IPPB with ethyl alcohol - not commonly used anymore
7. BiPAP is now being widely used.
8. Mechanical ventilation with PEEP
1. Exam questions often deal with the use of 100% oxygen for these patients. They may offer choices among
different oxygen delivery devices but always choose the device that has 100% oxygen available whether it is
IPPB, BiPAP, or non-rebreather.
2. These patients may experience dyspnea when lying down (Orthopnea) or an attack of dyspnea during sleep
(Paroxysmal noctural dyspnea).
3. Patients should always be put in a Fowlers or Semi-Fowlers position.
4. May use several pillows to sleep on at night.

Things to Remember:
there were some pic's that went w this test but at the time I saved this, I couldn't save the pics--- I still added the info
that went w the pics, it could still be useful)
There are several major respiratory disorders that are emphasized on the CRTT examination. These are Pneumothorax,
Pneumonia, Cardiogenic pulmonary edema, Emphysema, Atelectasis, Pleural effusion, and Chest trauma. Today's hints
will cover Pneumonia.
Definition:
Pneumonia is an acute inflammation of the lung parenchyma caused by a reaction to bacterial, viral, fungal, or
protozoan organisms. These organisms overcome decreased airway defense mechanisms due to ineffective coughing,
obstructed airways, obtunded airway reflexes, and impaired mucociliary transport mechanism. When the organism
invades the lungs, a inflammatory reaction sets in where exudative fluid containing red blood cells and leucocytes
infiltrates the lung alveoli resulting in consolidation. The result is V/Q mismatching, intrapulmonary shunting, and
hypoxemia. Pneumonia may affect the very young as well as the very old.
Causes:
1. Bacterial - Streptococcus pneumoniae is the most common bacterial pneumonia. Other bacteria include Haemophilus
influenzae, Klebsiella pneumoniae, Legionella pneumoniae, and Pseudomonas aeruginosa.
2. Viral - Influenza virus, adenovirus, and chicken pox
3. Fungal - Coccidioides, Histoplasma capsulatum, Blastomyces dermatidis, Aspergillus fumigatus
4. Mycoplasma Pneumoniae
5. Protozoan - is usually from Pneumocystis carinii pneumonia that is commonly seen in patient's with AIDS.
6. Aspiration of gastric contents
1. Inspiratory crackles on ausculation especially in the bases. Bronchial breath sounds also.
2. Dyspnea, tachypnea, and tachycardia
3. Increased tactile and vocal fremitus
4. Decreased chest expansion over the affected side
5. Decreased resonance over affected area, Dull percussion note
6. Fever and malaise - there will be a low-grade fever (WBC less than 10,000/mm3) with a viral infection and a high-
grade fever (WBC more than 10,000/mm3) with a bacterial infection.
7. Cough, chest pain, and chills (with some types of pneumonia)
1. Consolidation (radiodensity) on the chest x-ray

2. Air bronchogram
3. Areas of consolidation are usually specific in location.
4. Alveolar pneumonia - fluffy pattern in peripheral lung fields
5. Interstitial pneumonia - dense pattern
6. Bronchopneumonia - patchy, fluffy infiltrates that follow the airways
7. Lobar pneumonia - opacification of the lobe
8. Necrotizing pneumonia - formation of cavities LUL pneumonia with volume loss Note the radio density on the left side
and the loss of heart borders and the silhouetting. The area of consolidation is narrowly located.
Dx:
Pneumococcal
Pneumonia
Treatment:
1. Antibotics if the pneumonia is bacterial

2. Analgesic agents to relieve pain
3. Supplemental oxygen if saturations are low
4. Chest physical therapy
5. Adequate hydration (fluids) and nutrition
6. Incentive spirometry
7. Tracheal suctioning if cough reflex is obtunded 8.Aerosol therapy
9. Aerosolized Pentamidine if Pneumocystis carinii is the causative factor
10.A thoracentesis may be necessary if a pleural effusion develops.
1. A sputum culture and sensitivity will be ordered to analyze the organism.

2. Chills and a productive cough with thick purulent, blood streaked, or rusty sputum is more characteristic of bacterial
pneumonia.
3. Arterial blood gases may show a respiratory alkalosis (in the early stages) with a mild to moderate hypoxemia.
Things to Remember:
1. The patient's chief complaint is the patient's reason for seeking medical care. It is often asked by the question "What
is that brought you to the hospital today?" or "What is it that is bothering you today?" The answers to the chief
complaint should be written in the patient's own words and should not be diagnostic statements or elaborations of
the patient's response.
2. The dynamic compliance calculation must be lower than the static compliance. If a question gives two figures for the
dynamic and static compliance and the dynamic compliance figure is higher, then the calculation is in error.
3. The Thorpe tube flowmeter is available as compensated and uncompensated although uncompensated flowmeters
are rarely found anymore. The reason being is that the uncompensated flowmeter is affected by back pressure in the
tube which will affect the rise of the float. When a restriction occurs, the flowmeter will read lower than what the
patient is actually receiving.
4. If the patient is having difficulties cycling the IPPB machine off then the therapist should make sure there are no leaks
around the mouthpiece or mask, all connections are tight, and the expiratory valve is not stuck.
5. A radiolucent chest radiograph appears dark on the chest x-ray. This is due to the presence of air.
6. The greatest source of infection in the hospital setting is the hospital personnel mainly due to improper hand washing
techniques.
7. If water is collecting in a large bore tubing connected to an ultrasonic nebulizer, the effects will be that the aerosol
mist will come out in puffs and not a steady stream. This is because the water will occlude the tubing until the
pressure of the air flow pushes it aside. The collecting water then falls back and obstructs the tubing again until
sufficient force of the mist flow pushes it aside again. The result is that the mist comes out in puffs.
8. To determine adequate cerebral blood flow while performing chest compressions, the rescuer should check for
pupillary reaction. To determine adequate ventilation during CPR, the rescuer should look for chest expansion.
9. The Vital Capacity is the largest volume of air that can be exhaled after a maximum inspiration. It consists of the IRV
(inspiratory reserve volume), Tidal volume, and ERV (expiratory reserve volume). It is decreased in restrictive lung
diseases. It is commonly used to assess the ability of a myasthenia gravis patient to breathe spontaneously.
10. You should be very familiar with blood gases similar to the following: 7.38 pH, 55 torr PaC02, 32 mEq/liter HC03, and
60 torr Pa02. From these arterial blood gases you should know that (1) this person has COPD (2) this person is in a
"chronic" respiratory acidosis, (3) this person is a C02 retainer, (4) and that this person should be put on no more than
two liters of oxygen or keep oxygen saturations between 89 to 92%.
11. A patient being mechanically ventilated in Status Asthmaticus will have a greater difference in their peak and plateau
pressures reflecting greater airway resistance than a patient with only low lung compliance whose peak and plateau
pressure difference will not be as great.
12. The outside diameter OD of a suction catheter should not be more than 1/2 as large as the internal ID of the
endotracheal tube or tracheostomy tube. Some review books use 2/3 as the upper limit but the NBRC has 1/2 on their
previous exam tests.
13. AIDs patients are put under Universal/Secretion isolation precautions. Patients with burns or depleted white blood
cell count such as cancer patients should be put in Reverse (protective) isolation.
14. Auto-PEEP is defined as positive end expiratory pressure that is a side effect of a mechanically ventilated breath that
occurs when the inspiratory phase begins before the expiratory phase has ended. Auto-PEEP is also called occult PEEP,
inadvertent PEEP, breath stacking, and intrinsic PEEP. Auto-PEEP can be lowered by (1) increasing the expiratory time
(decreasing the rate, increasing the tidal volume), (2) decreasing the inspiratory time (increasing the flow rate), (3)
using stiffer circuit tubing, (4) using applied PEEP below the auto-PEEP level, and (5) maintaining tracheobronchial
hygiene.
15. There are three major blood gas electrodes; the Sanz electrode measures pH, the Severinghaus electrode measures
PC02, and the Clark electrode measures P02.
16. CPR Protocol for an adult that involves one rescuer is to initially establish unresponsiveness, call for help, check for
breathing, open the airway, deliver two breaths if breathing is not present, and check for a pulse. If a pulse is present
rescue breath only, if pulse is not present begin chest compressions.
17. A clogged jet orifice and/or capillary tube will prevent aerosol particles from being produced in a mist tent. This
prevents the water from being drawn up into the gas flow which will produce the mist.
18. There may be a question where there is a need to calculate a desired frequency change. For example, a patient is
being hyperventilated with a resulting hypocapnia. You are asked to choose a rate that will bring his PaC02 within
normal limits. To calculate this change, the actual PaC02 is divided by the desired PaC02 and multiplied by the actual
frequency rate. This equation will give you the desired frequency that the patient should be on.
19. Chronic Bronchitis is strictly defined as cough and sputum production for at least 3 months of the year for more than
two consecutive years.
20. When an oxygen cylinder is "cracked" the cylinder valve is opened for a second to eliminate debris from the cylinder
valve opening.
21. Ciliary dyskinesia is an impairment of the cilia within the airways to function properly to move debris out of the
respiratory tract.
22. When using (Pavulon) pancuronium bromide, the most important ventilator alarm will be the low pressure alarm
since Pavulon is a paralytic and the patient will not be able to breathe spontaneously.
23. Anatomic dead space for a patient is 1 ml/lb of IBW. However, they may give you a patient's weight in kilograms and
if you read the question too fast you may miss the correct answer. Since one pound equals 2.2 kilograms, the
anatomic deadspace for a 75 kg person will be 165 ml.
24. HMEs (heat moisture exchangers) should not be used for patients whose minute ventilation requirements exceed 10
L/min or who have heavy secretions.
25. In a Tension pneumothorax, the trachea will be deviated away from the injured side. The chest will be hyperresonant
to percussion over the affected side. Physical examination may show decreased breath sounds at auscultation.
Subcutaneous emphysema may also be present. A chest radiograph of a pneumothorax will usually reveal an absence
of lung markings and radioluceny.
26. An inspiratory hold or plateau setting is used on the mechanical ventilator when the exhalation valve is closed at
peak inspiration holding the air in the lungs for a preset time set by the therapist. This will increase oxygenation by
increasing the diffusion of gases but will also increase intrathoracic pressures in the lungs. A one-time use of the
inspiratory hold is used when determining static compliance.
27. Oral candidiasis or (thrush) is a complication of repeated administration of (Vanceril) beclomethasone. The result is
the formation of sores within the mouth.
28. A FEV1 measurement would provide the best indicator of the effectiveness of an albuterol treatment if a peak flow
measurement is not listed as one of the answers.
29. A positive modified Allen's test indicates adequate blood flow through the ulnar artery, not the radial artery. This is a
common trick question because most people will think of the radial artery and not the ulnar. The test is positive when
the color returns to the hand within 10 seconds after the ulnar artery is uncompressed.
30. The oxygen hood (oxyhood) is the oxygen delivery device of choice for the neonate and can deliver oxygen levels up
to 100%.
Please don't underestimate the importance of the CRT examination. It provides a solid foundation for taking on the
Registry exams later on. Many students don't adequately prepare for the CRT exam and barely pass and when the
Registry exam comes along, they are woefully unprepared. They either fail the Registry or wait months and even
years before trying to pass it again. There are hundreds of people who are Registry eligible but never take the exams
even though they completed the required school courses to do so. Don't You Be One of Those People!
Things to Remember:
There are several major respiratory disorders that are emphasized on the CRTT examination. These are
Pneumothorax, Asthma, Pneumonia, Cardiogenic pulmonary edema, Emphysema, Atelectasis, Pleural effusion, and
Chest trauma. Today's hints will cover Pleural Effusion
Definition:
A pleural effusion is an accumulation of fluid in the pleural space that is bordered by the parietal and visceral pleura..
This occurs from an imbalance in the amount of fluid produced and the amount absorbed within the pleural space.
Either side of the imbalance may cause a pleural effusion. The principal function of pleural fluid is to provide a
frictionless surface between the two pleura with respiration in response to changes in lung volume. Generally, pleural
effusions are categorized as transudative or exudative effusions.
Transudative pleural effusions develop when fluid from the pulmonary capillaries move into the pleural space. The fluid
produced is thin and watery and contains very few blood cells and protein. With the transudative pleural effusion the
pleural membranes are intact and are not involved in the pathogenesis of the fluid formation.
Major causes of a transudate pleural effusion are:
1. Congestive heart failure

2. Hepatic Hydrothorax - cirrhosis of the liver
3. Peritoneal Dialysis
4. Nephrotic Syndrome
Exudate plueral effusions develop when the pleural surfaces are diseased. The fluid has high protein content and a great
deal of cellular debris. Exudate effusions are usually caused by inflammation.
Major causes of an exudate pleural effusion are:
1. Metastatic disease
2. Malignant Mesotheliomas
3. Surgery
4. Trauma
5. Pulmonary embolism
6. Pneumonias
7. Tuberculosis
8. Fungal diseases
9. due to GI diseases
10. due to Collagen Vascular diseases
Causes:
1. Infection - Pneumonia usually causes small pleural effusions. However, when pnuemonia is seen in conjunction with
lobulated effusions, it may be indicative of empyema. With tuberculosis, an effusion may be the only visible
abnormality.
2. Metastases - While pleural effusions may result from pleural metastases, these are rare on a CXR.
3. Cardiac Failure - In acute left ventricular failure, small bilateral pleural effusions are common.
4. Pulmonary Infarction - These effusions are usually small and associated with a wedge shaped pulmonary infarct
shadow.
5. Collagen Vascular Disease - A common cause of both unilateral and bilateral pleural effusions.
1. Chest pain
2. Dyspnea
3. Dullness to percussion
4. Diminished breath sounds
5. Tachypnea
6. Limited chest movement on excursion
7. Tracheal / mediastinal deviation away from affected side if pleural effusion is large
8. Pleural friction rub may be heard on inspiration
1. Blunting of the costophrenic angle (angle between the chest wall and the point at which the diaphragm touches the
chest wall laterally)
2."Meniscus sign" - fluid collects on the side of the chest wall
3. Homogeneous density in the dependent part of the hemithorax
4. Fluid will layer out on a lateral decubitus projection
Treatment:
1. Thoracentesis
2. Chest tube drainage
3. Antibotics
The lateral decubitus projection position is used for radiograph confirmation of a pleural effusion. This is when the
patient lies on their side so that the fluid moves to the dependent area of the chest. The fluid must collect at the
dependent area of the chest and spreads out and not be confined to a specific area to be diagnosed as a pleural
effusion. Usually 100 cc must be present to be seen on the chest radiograph.
1. An acceptable A-aD02 gradient on room air should be between 10 - 15 mmHg. An acceptable A-aD02 gradient on
100% oxygen should be less than 300 mmHg.
2. On receiving a new order for a respiratory treatment or procedure, the therapist should first review the patient's
chart.
3. Generally speaking, decreased flows (FEV1, FEV/FVC, FEF 25-5, FEF 200-1200, and PEFR) indicate obstructive
disorders. FVC or Forced Vital Capacity is not a flow but a volume. The FEV1 is the best indicator of obstructive lung
disease.
4. Acetylcysteine (Mucomyst) is the medication of choice for thinning secretions and liquefying mucus plugs.
Bronchospasms may be an unwanted side-effect and should be treated with bronchodilators.
5. To increase the Pa02 of a mechanically ventilated patient with hypoxemia increase the FI02 up to 50-60% and then
increase the PEEP.
6. When using the venti mask (venturi oxygen dilution device) the FI02 will increase when the internal diameter of the
jet is increased and when the air-entrainment holes are decreased in size. Increasing the flow will not increase the FI02.
7. If the relief valve (pressure pop-off valve) is going off on a humidifier device, then the problem will be with the oxygen
flow being turned up too high or an obstruction in the connecting tubing. Neither a clogged filter or the down tube (the
tube from the oxygen inlet that goes into the water) becoming obstructed will activate the alarm.
8. Endotracheal tube cuff pressures should not exceed 20 mmHg. Pressures exceeding this will obstruct venous blood
flow. Arterial tracheal blood flow is hindered at pressures above 30 mmHg.
9. Never use an Oropharyngeal airway in a conscious patient. It may stimulate the gag reflex and cause the patient to
vomit.
10. If the pressure setting on a pressure-cycled ventilator goes off, the inspiratory cycle will end and the full tidal volume
will not be delivered.
11. When inspecting a patient who is intubated and you hear a gurgling sound when the ventilator is in the inspiratory
phase, add air to the cuff to stop the noise.
12. A Helium-Oxygen mixture is sometimes used to oxygenate patients with severe upper airway obstructions and for
severe unresponsive asthmatic attacks. Since oxygen flowmeter will give an inaccurate reading of the gas because it is
lighter than pure oxygen the flowmeter reading is multiplied by a correction factor. If using a 80/20 mixture, the
flowmeter reading should be multiplied by 1.8 to get an actual flow rate. If using a 70/30 mixture, the flowmeter reading
should be multiplied by 1.6.
13. Panlobular (panacinar) involves the destruction of the primary lung lobule especially the alveoli. This type is seen in
alpha1-antitrypsin deficiency disorders.
14. To increase the oxygen concentration of a manual resuscitation bag you can turn the oxygen flow up to 15 lpm or
add a reservoir if one is not already on the device. However, using a flow rate in excess of 15 lpm may cause the valves
in the device to jam and render it useless.
15. When suctioning a patient, some of the factors that may cause the suctioning to abruptly stop will be kinked tubing,
suction reservoir becoming full, and a mucus plug in the catheter.
16. If a wick or cascade humidifier is not producing sufficient humidity for an intubated patient with thick secretions,
then the temperature should be increased, if it is not at the highest safe setting already. Removing excess water or
increasing the flow will not correct the problem.
17. Fever and malaise - there will be a low-grade fever (WBC less than 10,000/mm3) with a viral infection and a high-
grade fever (WBC more than 10,000/mm3) with a bacterial infection.
18. If a question comes up where a patient has a chest radiograph with complete opacification of the right side of the
thorax with a tracheal deviation to the right, you should suspect an atelectasis right lung.
19. Inspection of the chest is a visual observation to observe chest configuration, patient positioning, ventilatory
pattern, and accessory muscle usage.
20. Carbon monoxide poisoning is always treated with 100% oxygen and is monitored using blood oximetry from an
arterial blood gas, not pulse oximetry.
21. The purpose of expiratory grunting in the newborn who is experiencing respiratory distress is to prevent airway
closure (atelectasis). This has the same effect as PEEP or CPAP when using mechanical ventilation.
22. When ventilating the head trauma patient, high flow rates should be used to keep the inspiratory time short to avoid
high positive pressures in the airways. Also, high ventilator rates will be used to maintain the patient’s PaC02 between
25 to 30 mmHg. ICP (intracranial pressure) should be maintained below 15 mmHg.
23. With smoke inhalation injuries, upper airway injury occurs mostly as a result of thermal burns. Lower airway injury
depends on the smoke content and how long the person was exposed.
24. Chest trauma is any injury to the chest or thorax. The key factors in managing a chest trauma is to provide an airway
(airway obstruction), assure adequate ventilation (prevent respiratory failure) and control the patient's hemodynamic
situation (prevent hemorrhage).
25. To determine pulselessness in cardiopulmonary resuscitation the carotid artery should be palpated in the adult and
the brachial artery in the infant.
26. When interviewing a patient concerning sputum production, questions should include the amount, color,
consistency, and odor of the secretions. Also questions concerning the how long the productive cough has been
occurring is helpful.
27. The most reliable indicator of cyanosis will be by inspecting the mucous membranes of the mouth. They are the least
affected by perfusion, temperature, and skin pigmentation. Nail bed color, skin color, and capillary refill time are also
commonly used but are less reliable than the mouth.
28. Sigh volumes are usually set at 6 to 12 sighs per hour at 1.5 to 2 times the tidal volume. Sigh volumes are used when
the patient is receiving very low tidal volumes and atelectasis may become a problem.
29. If the patient is having difficulty in cycling the IPPB machine into an inspiratory cycle then the sensitivity should be
increased, the patient should have a good seal around the mouth piece, and all connections are tight.
30. COPD (chronic obstructive pulmonary disease) is not a disease but a classification of diseases that includes
emphysema, chronic bronchitis, asthma, bronchiectasis, and cystic fibrosis.
Don't lose your place when marking your answers. Some students like to mark their answers on the test (I'm not sure
if they will allow you to mark on their test however) and then go back and mark the answer sheet and some students
like to mark their answers on the answer sheet as soon as they pick the answer.
Things to Remember:
1. Victims that have a suspected neck injury should have their airway opened using the jaw thrust maneuver without the
head tilt. All others can have the airway opened by using the head-tilt/chin-lift method.
2. With a tension pneumothorax, the trachea is shifted to the opposite side (unaffected side) of the pneumothorax. With
a massive atelectasis, the trachea is shifted to the same side (affected side) as the atelectasis.
3. If the down tube (the tube from the oxygen inlet that goes into the water) becomes obstructed in the bubble
humidifier, neither bubbling nor the alarm will occur.
4. PEEP (positive end-expiratory pressure) increases the patient's FRC (functional residual capacity) by opening up
collapsed alveoli.
5. Bronchial breath sounds (louder and harsher than vesicular) are normal when heard over the trachea and the
mainstem bronchi. They are abnormal if heard over other areas of the lung and may be an indication of atelectasis or
consolidation.
6. Cromolyn Sodium (Intal) works as a prophylactic agent by inhibiting the degranulation of mast cells that cause allergic
reactions in the airways when broken down. It is known as a "mast cell stabilizer". Intal does not have bronchodilator
activity and should never be used in the treatment of an acute asthmatic attack. Its function therefore is as a
prophylactic agent only.
7. The Vital Capacity is made up of the Expiratory Reserve Volume, tidal volume, and the Inspiratory Reserve Volume.
8. The Bourdon gauge is not pressure compensated. Back pressure generated into the gauge will cause the gauge to
read higher than what the patient is actually receiving. Back pressure generated into an uncompensated thorpe tube
flowmeter gauge will cause the gauge to read lower than what the patient is actually receiving.
9. A Volume ventilator ends inspiration after a preset volume is delivered.
10. To ascertain proper tube placement after an endotracheal intubation, the therapist should recommend a chest x-ray.
First of all however, the chest should be inspected for bilateral chest expansion during inspiration and auscultated for
bilateral breath sounds. After that the chest x-ray should be ordered.
11. the most common type of transudative pleural effusion is congestive heart failure.
12. Anticoagulation therapy (heparin, Coumadin) is the treatment of choice for a pulmonary emboli.
13. Common arterial blood gases for a patient who is experiencing a moderate asthmatic attack will consist of a
respiratory alkalosis with hypoxemia.
14. If a patient is on a CPAP device and the pressure decreases when the patient breaths in, then the flow of gas is
insufficient.
15. If an increase in the patient's blood pressure and heart rate is noted during an aerosolized beta-agonist therapy,
then the most likely cause is from drug absorption causing systemic effects. All bronchodilators have some beta 1
response if given in sufficient dosage. Although the drug is primarily deposited in the lungs some of the drug will enter
the systemic circulation and cause a beta 1 response.
16. Common gram negative organisms include Escherichia coli, Proteus, and Klebsiella. Common gram positive
organisms include Staphylococcus and Streptococcus. A common acid-fast organism is Mycobacterium tuberculosis.
17. If the set pressure is not reached until the patient actively exhales during an IPPB treatment the problem will be a
leak in the expiratory valve. The leaky expiratory valve will prevent the set pressure from being reached because gas is
escaping through the valve during the inspiratory cycle. When the patient exhales, the pressure of the exhalation will
cause the set pressure to be reached and the machine will cycle into expiration.
18. A loss of exhaled volume from the ventilator is often due to loose connections around the humidifier, the medication
nebulizer, and the patient wye.
19. A primary goal of PEEP is to decrease physiological shunting. A shunt is when pulmonary blood by passes
underventilated alveloi and fails to pick up the oxygen needed from the lungs. Conditions that increase physiologic
shunting include pneumonia, pulmonary edema, and atelectasis.
20. The Methacholine challenge test determines the reaction of the airways to a drug (methacholine) that is known to
stimulate bronchoconstriction. The objective is to determine the minimum level of methacholine that elicits a 20%
decrease in FEV1. This is not to be confused with the before-and-after bronchodilator study where reversibility is
considered significant with an increase in flow studies of at least 15%.
21. If a whistling noise is heard after a regulator is attached to an E-cylinder, then the plastic washer is missing. The
washer allows a tighter fit between the cylinder and the regulator device.
22. To achieve the highest possible FI02 when using a manual resuscitator bag the therapist should always use a
reservoir attachment, use flowrates up to 15 lpm, allow the bag to refill after each breath, and not squeeze the bag
completely with each breath.
23. Pectus carinatum is also known as "pigeon breast" and is characterized by a projection of the xiphoid process and
lower sterum. Pectus excavatum is also known as "funnel chest" and is characterized by a funnel-shaped depression
over the lower sternum.
24. The Chest Cuirass is a type of negative pressure ventilator (extrathoracic) that fits over the chest of the patient only.
25. PEEP will not increase the patient's alveolar ventilation. Increasing the tidal volume and rate will however.
26. Arterial oxygen content is the best indicator of oxygen transport for a patient with carbon monoxide poisoning.
Neither arterial oxygen tension, A-aD02, or hemoglobin concentration is the best indicator.
27. A Simple oxygen mask delivers oxygen percentages between 35% to 55% at flowrates of 6 to 10 L/min. A minimum
flowrate greater than 5 to 6 L/min is needed to flush out the exhaled carbon dioxide.
28. If very little mist is coming out of a patient's aerosol mask that is attached to a heated nebulizer the cause could be a
plugged capillary tube, inadequate flowrate, lack of water in the nebulizer, or water collecting in the aerosol tubing.
29. If a patient demonstrates a lack of cooperation when respiratory procedures are being attempted, the patient should
be evaluated for language difficulties, the effects of medication, and for anxiety and fear.
30. A patient who is to be suctioned should be hyper oxygenated before and after the procedure.
Don't get bogged down with complex questions that take up a lot of time. Remember, the simple questions that you
know the answers to count just as much as the difficult ones that you don't know the answers to.
Things to Remember:
1. There are four major ventilator flow wave capabilities; the Sine wave, the Square wave (constant flow), the
Decelerating flow wave, and the Accelerating flow wave. The Sine wave most closely matches normal human
respirations and the Decelerating flow wave will give lower peak pressures for patients with low lung compliance.
2. Mask CPAP is recommended for a spontaneously breathing patient who is alert and cooperative and who is
experiencing refractory hypoxemia. This is usually indicated by a low Pa02 on 60% FI02 or greater. CPAP increases the
patient's FRC and gas distribution and tends to correct intrapulmonary shunting.
3. Tubing compliance or system compressibility is the amount of gas compressed in the ventilator circuit for every cm of
water pressure generated by the ventilator during the inspiratory phase. The tubing compliance is calculated by
dividing the measured volume by the measured static pressure which will give you so many ml per cmH20. The
ml/cmH20 is multiplied by the peak pressures reached during the tidal volume delivered to calculate the volume lost
in the ventilator circuit.
4. The Bourdon gauge flowmeter will read the same no matter what position the flowmeter is in.
5. Lethargic, stuporous, obtunded, and somnolent are all words that describe a patient whose level of consciousness is
decreased and unable to fully cooperate.
6. If the physician makes notations in the progress notes concerning respiratory therapy procedures, the physician's
order sheet should be checked for a corresponding order. The progress notes cannot contain the physician orders.
7. Drug anaphylaxis is a severe reaction to the administration of a drug. Reactions may include apprehension,
tachycardia, tachypnea, paresthesias, edema, choking, wheezing, low blood pressure, coughing, or a loss of
consciousness. Although the majority of aerosolized respiratory medications are safe, once in a great while a patient
will have an adverse reaction to a aerosolized bronchodilator. The most common reaction however will be an increase
in heart rate which is why it is important for the therapist to obtain a pre and post pulse rate. In anaphylactic shock
epinephrine is given immediately usually followed by aminophylline.
8. The Wrights respirometer is a hand-held device used at the patient's bedside to measure vital capacity, tidal volume,
and minute ventilation. It may be used by the patient alone or be used in-line with the ventilator. It is placed on the
expiratory side of the ventilator circuit close to the patient.
9. If the pressure reading on a CPAP system drops drastically when the patient inspires, the therapist should increase the
flow rate. This question comes up again and again on the Crtt exams.
10. Spirometry (Peak flow) before and after bronchodilator therapy is the best way to assess the effectiveness of
bronchodilators for reversing an asthmatic attack.
11. The Briggs T Adaptor is a plastic piece that fits on the end of a endotracheal tube or tracheostomy tube for the
administration of oxygen, humidity, or aerosol therapy. A piece of reservoir tubing is attached to the end of the T-tube
to prevent air entrainment during inspiration. The FI02 may decrease without the reservoir. Flow rates should be
adequate enough so that mist can be seen coming out of the reservoir tubing at all times.
12. Laryngotracheobronchitis is viral in nature while Epiglottitis is bacterial in etiology.
13. Mycobacterium tuberculosis, the causative agent of tuberculosis, is usually spread through coughing and sneezing.
14. The Cascade heated humdifier can deliver 100% body humidity or relative humidity and is the main choice for
ventilators.
15. The FRC (functional residual capacity) is the amount of air left in the lungs following a normal expiration. It equals
the ERV+RV (expiratory reserve volume + residual volume). The FRC is increased in obstructive disease and decreased
in restrictive disorders.
16. Factors that must be known to calculate the delivered minute ventilation for a patient on mechanical ventilation will
include the exhaled tidal volume, the tubing compliance factor, and the ventiatory rate. The PaC02 will not be needed.
17. The gag reflex is not important to evaluate before changing a patient from mechanical ventilation to a T-piece
because the patient will still be intubated.
18. The PaC02 for a head trauma patient should be maintained at 25 to 30 mmHg to reduce cerebral vascular swelling.
Hypocapnia in the initial stages of cerebral trauma will cause vasoconstriction.
19. Vesicular breath sounds are normal breath sounds heard over the entire chest wall. Other normal breath sounds
include bronchial, bronchovesicular, and tracheal.
20. If after giving a routine therapy to a patient (bronchodilators, CPT, IPPB, ect.) you notice an adverse change in the
patient's condition, you should notify the nurse, contact the physician if changes are needed, and record the adverse
changes in the patient's chart along with all other pertinent information.
21. Atrovent and Atropine are anticholinergics or parasympatholytic drugs. They act by blocking the cholinergic
receptors that cause bronchial constriction. Atrovent is now commonly used in combination with Albuterol (a
sympathomimetic drug). Atropine inhibits secretion production and should not be used in a patient with retained
secretions. Two sympathomimetic drugs should not be given together and such an order should be clarified by the
therapist.
22. An untreated pneumothorax and a pulmonary hemorrhage are Absolute Contraindications for IPPB therapy.
Tuberculosis, hemoptysis, and closed head injury are relative contraindications.
23. If a patient has an acute onset of wheezing while being mechanically ventilated but the arterial blood gases are
normal except for a low Pa02, then a bronchodilator is in order. Adding PEEP will not be indicated because the
hypoxemia is from the constriction of the airways, not the closure of the alveoli (a very important distinction on the
test).
24. Several hereditary lung disorders include Alpha1-antitrypsin deficiency which results in emphysema and cystic
fibrosis which affects the exocrine glands that results in the production of thick secretions. Asthma also has a strong
hereditary component.
25. A baffle is used in a nebulizer in order to break up aerosol particles into smaller ones that are uniform is size.
26. the most common organism found growing on heated nebulizers and humidifiers is Pseudomonas aeruginosa.
27. The approximate total flow coming from a 40% venturi mask at 6 L/min would be 24 L/min. A 40% venturi will
entrain air at a ratio of 3 parts air to 1 part oxygen. These are added together (3+1) and multiplied by 6 l/min to get 24.
28. When using the incentive breathing device, the patient will be performing a maximum sustained inspiration. This can
be measured by assessing the patient's inspiratory capacity. The inspiratory capacity is the measured inspired volume
from a resting tidal volume. He will not be performing a peak inspiratory flow or sustained tidal volume.
29. A contraindication for using the abdominal thrust (Heimlich maneuver) to clear the airway is a woman in advanced
pregnancy. Instead, get behind the victim and apply thrusts at the mid sternum until the object is expelled.
30. You should be very familiar with blood gases similar to the following: 7.42 pH, 34 torr PaC02, 24 mEq/liter HC03, and
44 torr Pa02. If these arterial blood gases occur with an infant and the FI02 is already 60% or above you should
consider putting the child on nasal CPAP. If these blood gases occur with an adult and the FI02 is already high, then
PEEP should be considered. If the FI02 is below 60% then the FI02 should be increased instead.
Remember, you only have to get 75% of the questions right on the exam. That’s 105 questions out of 140. The vast
majority of students pass the CRTT exam without any trouble. I'm sure that you will be one of them.

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CRT Examination Hints #1

* Person with smoke inhalation

14. A Fistula formation is not a common complication of an arterial blood puncture.

29. Bronchitis can be either acute or chronic.

Chest trauma injuries are classified as:

A chest trauma may manifest itself as:

1. the most common blunt thoracic injury is rib fractures.

1. Decreased ability of the chest to expand

Things to Be Aware Of:

3. Pink/Frothy secretions are usually an indication of pulmonary edema.

1. A low pressure alarm is essential for a CPAP device.

3. An untreated pneumothorax is an absolute contraindication to CPT (chest physical therapy).

Cardiogenic Pulmonary Edema

1. Left heart failure

1. Increased vascular markings

1. Oxygen - often starting at 100%

Things to Be Aware Of:

3. Patients should always be put in a Fowlers or Semi-Fowlers position.

4. May use several pillows to sleep on at night.

1. Consolidation (radiodensity) on the chest x-ray

1. Antibotics if the pneumonia is bacterial

Things to Be Aware Of:

1. A sputum culture and sensitivity will be ordered to analyze the organism.

Major causes of a transudate pleural effusion are:

1. Congestive heart failure

Major causes of an exudate pleural effusion are:

Things to Be Aware Of:

Things to Be Aware Of:

9. A Volume ventilator ends inspiration after a preset volume is delivered.

12. Laryngotracheobronchitis is viral in nature while Epiglottitis is bacterial in etiology.

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