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Critical Thinking

PICU quiz
1. In pressure-regulated volume control (PRVC) mode, D. Increase respiratory rate
the peak inspiratory pressure is kept at the lowest level E. Increase positive end-expiratory pressure (PEEP).
possible by altering the: 5. A hemodynamically stable 14-year-old boy (68 kg) is
A. Peak flow and tidal volume being mechanically ventilated for acute respiratory
B. Plateau pressure and peak flow distress syndrome (ARDS) with following settings: tidal
C. Peak flow and inspiratory time volume 400 ml, respiratory rate 18/min, FiO2 0.80,
D. Plateau pressure and inspiratory time I:E1:2, and PEEP 8. Arterial blood gas (ABG) shows
E. Peak and airway resistance. Pa O2 50 mmHg, Pa CO2 40 mmHg, and pH 7.42. The
2. Which of the following best describes the mode of most appropriate change in ventilator settings would
ventilation in which mandatory breaths and pressure be:
support levels are changed automatically depending on A. Increase FiO2
the breathing pattern of the patient to achieve a preset B. Increase PEEP
minute ventilation C. Increase tidal volume
A. Automatic tube compensation D. Increase ventilator rate
B. Volume ventilation plus E. Increase I:E ratio.
C. Adaptive support ventilation 6. What should be the adjustment when you see this
D. Volume-assured pressure support pressure volume loop on ventilator?
E. Proportional assist ventilation.
3. What should you not do when you see a capnogram
like this

A.Decreased metabolic rate

B.Decreased body temperature
C.Esophageal intubation
D.Hyperventilation
E.Malfunction of end-tidal carbon dioxide ( ETCO2 )
analyzer.
A. Check expiratory valve
4. What is the diagnosis of the interpretation of this
B. Increase expiratory time
capnogram? C. Increase inspiratory flow
D. Decrease tidal volume
E. Increase respiratory rate.
7. A young asthmatic (55 kg) patient was admitted with
severe respiratory distress. He was in altered sensorium,
and his ABG showed pH 7.25, Pa CO2 85 mmHg, and
Pa O2 60 mmHg. He was intubated and placed on
volume control ventilation with following settings: FiO2
A. Reduce tidal volume 50%, tidal volume 350 ml, respiratory rate 14/min,
B. Reduce respiratory rate and PEEP 5 cm H2O. His flow time ventilator graph
C. Increase tidal volume is shown below. What is the next appropriate step?

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Sharma and Khilnani: PICU quiz

B. 10–15 cm H2O
C. 15–20 cm H2O
D. 20–25 cm H2O
E. 25–30 cm H2O.
9. In all except one of the following conditions, peak
inspiratory pressure will increase, but plateau pressure
will remain the same:
A. High peak inspiratory flow
B. Endobronchial migration of the tube
C. Partial kinking of the endobronchial tube
D. Bronchospasm
E. Excessive secretions in the tube.
10. The following are clinical applications of capnometry
A.
Increase respiratory rate to 20/min
B.
Increase tidal volume to 400 ml except
C.
Decrease respiratory rate to 10/min A. Confirm the diagnosis of pulmonary embolism
D.
Change to pressure-controlled mode with same B. Assessment of the adequacy of cardiopulmonary
ventilator settings resuscitation (CPR)
E. Increase FiO2 60%. C. Return of spontaneous circulation during CPR
8. The recommendation for maximum cuff pressure D. Prediction of likelihood of successful resuscitation
of endotracheal (ET) tube in patients undergoing during CPR
mechanical ventilation is: E. Confirmation of the correct placement of the ET
A. 5–10 cm H2O tube.

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Sharma and Khilnani: PICU quiz
EXPLANATIONS
1. C: The PRVC mode is used primarily to achieve
preset tidal volume while keeping the peak inspiratory
pressure at the lowest level possible. This is achieved
by altering peak flow and inspiratory time in response
to the changing airway or lung compliance
2. C: Adaptive support ventilation is closed loop,
controlled ventilation mode designed to achieve preset
minute ventilation with minimal work of breathing.
The control variables are pressure and maximum
plateau pressure. This mode can deliver both pressure
control and pressure support breaths. This mode can
be used as a full support mode or partial support mode
during the weaning phase
3. E: There is a progressive increase in the baseline of
ETCO2 in the above diagram suggestive of rebreathing,
which can be caused by faulty expiratory valve, partial
rebreathing circuits, inadequate inspiratory flow,
insufficient expiratory time, or malfunction of a
CO2 absorber system. Increasing respiratory rate will
increase rebreathing
4. C: A normal capnogram is the best available evidence
that ET tube is correctly positioned and that proper
ventilation is occurring. When the ET tube is placed in
the esophagus, either no CO2 is sensed, or only small
transient waveforms are present. A malfunctioning
CO2 analyzer will show a sudden drop in ETCO2 to
zero
5. B: Since the patient is having acceptable pH and Pa CO2
levels, there is no need to change the tidal volume or
respiratory rate. His tidal volume should not be raised
as in ARDS, low tidal volume ventilation is shown to
have lung protection and has shown mortality benefits
in studies. To improve oxygenation, PEEP should be
increased, as it helps in the reopening of collapsed
alveoli and opposes alveolar collapse, thus improving
V/Q matching. PEEP should be increased at least to
a level that achieves adequate oxygenation with a safer
FiO2
6. A: This loop is consistent with overdistension of alveoli
as seen by the beaking of the loop. Tidal volume should
be reduced in this patient
7. C: In the waveform, expiratory flow has not
reached baseline, and the next breath is initiated,
w h i ch i n d i c a t e s a i r t r a p p i n g a n d d y n a m i c
Journal of Pediatric Critical Care | Volume 7 | Issue 3 | May-June 2020
hyperventilation. In severe attacks of asthma,
there is a severe limitation to expiratory flow of
gases, and the goal of mechanical ventilation is to
minimize auto-PEEP and limit pressures and not
normalization of Pa CO2 levels. It can be done by
reducing the respiratory rate, tidal volumes, and by
keeping low I:E ratios
8. E: The main purpose of the cuff around the
ET tube is to prevent aspiration in the lung by
creating a seal between the trachea and ET tube.
Prolonged duration of high cuff pressure may
also cause injury tracheal mucosa by reducing
local perfusion. The cuff should be inflated just
enough to prevent the leakage of gases around
the cuff. In practice, it may be difficult to achieve
balance, and hence, the use of a device to measure
cuff pressures should be used. The recommended
is 25–30 cm H 2O.
9. B: Peak inspiratory pressure is a function of airway
resistance, and it will be raised if there is airway
diameter reduction or high flow rate of gases.
Endobronchial migration of the tube will increase
both peak and plateau pressures
10. A: During the initial phase of the cardiac arrest, CO2
production continues, but that is not delivered to
the lungs to absent blood circulation. When CPR is
initiated, CO2 delivery to the lungs is mainly dependent
on the cardiac output produced by chest compressions.
ETCO2 correlates well with cardiac output, if ventilation
is kept relatively constant during CPR and thus with
adequacy of CPR. A return of spontaneous circulation
and hence increased cardiac output is indicated by a
sudden rise in ETCO2 . It can also be used for prognosis
during CPR, as it has been found that all patients
who had ETCO2 levels of <10 mmHg during CPR
were successfully revived. A low ETCO2 in intubated
patients after 20 min of CPR can be used as one of the
factors to determine when to terminate resuscitation.
ETCO2 will decrease in ETCO2 massive pulmonary
embolism, but a drop in ETCO2 cannot differentiate
pulmonary embolism from other conditions such as
endobronchial migration of ET tube or pulmonary
edema.
Financial support and sponsorship
Nil.
155
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Sharma and Khilnani: PICU quiz

Conflicts of interest
There are no conflicts of interest.
Pradeep Kumar Sharma, Praveen Khilnani1
Department of Pediatric Critical Care and Pulmonology, Sri Balaji
Action Medical Institute, 1Department of Pediatric Critical Care
and Pulmonology, Rainbow Children Hospital, New Delhi, India
This is an open access journal, and articles are distributed under the terms of the Creative
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Address for correspondence: Dr. Pradeep Kumar Sharma,

Department of Pediatric Critical Care and Pulmonology, Sri Balaji Action DOI:
Medical Institute, New Delhi, India. 10.4103/JPCC.JPCC_54_20
E-mail: drsharma025@gmail.com

How to cite this article: Sharma PK, Khilnani P. PICU quiz. J Pediatr Crit
Received: 12-04-2020 Accepted: 18-04-2020
Care 2020;7:153-6.
Published: 25-05-2020

156 Journal of Pediatric Critical Care | Volume 7 | Issue 3 | May-June 2020