ACCS Technological and Procedural Proficiency 2 — Questions and Answers
Question 1: When performing a bronchoscopy-guided percutaneous tracheostomy, which landmark is most critical to identify before dilation?
- Cricothyroid membrane
- Tracheal rings 1-2 interspace
- Tracheal rings 2-3 interspace (Correct answer)
- Carina
Correct answer: Tracheal rings 2-3 interspace
The 2-3 tracheal ring interspace is the preferred insertion site for percutaneous tracheostomy to avoid damage to the cricoid cartilage and subglottic stenosis.
Question 2: A patient on volume-controlled ventilation develops a sudden increase in peak airway pressure with unchanged plateau pressure. What is the most likely cause?
- Pneumothorax
- Increased secretions or bronchospasm (Correct answer)
- ARDS progression
- Auto-PEEP
Correct answer: Increased secretions or bronchospasm
An isolated rise in peak pressure with stable plateau pressure indicates increased airway resistance, most commonly due to secretions or bronchospasm rather than parenchymal changes.
Question 3: During placement of a pulmonary artery catheter, the waveform transitions from a right ventricular trace to a pulmonary artery waveform. Which change confirms this transition?
- Loss of diastolic dip
- Appearance of a dicrotic notch and elevated diastolic pressure (Correct answer)
- Decrease in systolic pressure
- Widening of pulse pressure
Correct answer: Appearance of a dicrotic notch and elevated diastolic pressure
The pulmonary artery waveform shows a dicrotic notch and a higher diastolic value than the RV, confirming passage through the pulmonic valve.
Question 4: Which ventilator setting is MOST directly associated with ventilator-induced lung injury (VILI) in ARDS patients?
- FiO2 > 0.6
- Tidal volume > 8 mL/kg IBW (Correct answer)
- PEEP < 5 cmH2O
- Respiratory rate > 20 breaths/min
Correct answer: Tidal volume > 8 mL/kg IBW
Volutrauma from excessive tidal volumes (>8 mL/kg IBW) is the primary driver of VILI; ARDSNet protocols target 6 mL/kg IBW to reduce stretch injury.
Question 5: An ICU patient's arterial line waveform shows marked respiratory variation in pulse pressure (>13%). What does this most likely indicate?
- Cardiac tamponade
- Fluid responsiveness in a mechanically ventilated patient (Correct answer)
- Aortic regurgitation
- Peripheral vascular disease
Correct answer: Fluid responsiveness in a mechanically ventilated patient
Pulse pressure variation >13% during mechanical ventilation correlates strongly with preload dependence and predicts fluid responsiveness.
Question 6: During continuous renal replacement therapy (CRRT), a sudden rise in transmembrane pressure (TMP) most likely indicates:
- Filter clotting (Correct answer)
- Catheter kinking
- Electrolyte imbalance
- Air embolism
Correct answer: Filter clotting
Rising TMP signals increasing resistance across the hemofilter membrane, most commonly caused by clot formation in the filter.
Question 7: When using ultrasound to place a central venous catheter in the internal jugular vein, which maneuver best distinguishes the vein from the carotid artery?
- Color Doppler flow direction
- Applying gentle probe compression to collapse the vessel (Correct answer)
- Measuring vessel diameter
- Identifying pulsatility
Correct answer: Applying gentle probe compression to collapse the vessel
Gentle probe compression collapses the compliant vein but not the pulsatile, high-pressure carotid artery, reliably distinguishing the two.
ACCS Technological and Procedural Proficiency 2
When performing a bronchoscopy-guided percutaneous tracheostomy, which landmark is most critical to identify before dilation?