The four steps for respiratory mgmt
1. tx
ventilation
first (should problem exist)
2.
oxygenation
3.
circulation
4.
perfusion
problems at one step will adversely affect each process that follows it within sequence
External respiration
vs.
Internal respiration
External = exchange of O2 and CO2 across AC membrane
- depends on diffusion capacity of AC membrane & ventilation
Internal = exchange of O2 & CO2 across blood and tissue cells
- depends on circulation
Signs
vs.
Symptoms
Signs = Objective information
; can be seen, measured, heard, or felt
- Color, pulse, edema
Symptoms = Subjective information
- Dyspnea, pain, nausea
Steps in Assessment:
1.
Visual examination
- General appearance, sensorum, chest movement, posture, skin color
2.
Bedside exam
- BS, VS, auscultate, percussion, PMH, cap refill
3.
Lab exam
- ABG, CBC, CXR, lytes
4.
Specials
- urinalysis, gram stain, MIP, VC
Skin Appearance
- color
- condition
-
Normal:
Race specific
-
Decrease in color
= ashen, pallor ? anemia, blood loss
-
Jaundice:
? bilirubin levels ? liver failure
-
Erythema:
Redness of the skin ?
hypercarbia, COHb, inflammation
-
Cyanosis:
Bluish ? Hypoxia (this is a poor assessment of hy
Smoking history
- Calculating Pack-year
- Verifying if pt is compliant w/smoking cessation program
Pack Years =
(packs per day) x (# years smoked)
Measure pt's COHb to see if they actually are quitting smoking
COHb be levels should ? from their baseline to non-smoking normals of < 1%
Terms for Describing Sensorium/Neuro (LOC)
- Conscious
- Confused
- Disoriented
- Lethargic
- Obtunded
- Stuporous
- Comatose
-
Conscious
: alert to time, place, and person; responds appropriately
-
Confused:
can't think clearly, responds inappropriately
-
Disoriented:
disoriented to time/place; starting loss of conscience
-
Lethargic:
sleepy, but will wake; still oriented (can
Glasgow Coma Scale (GCS)
To measure level of consciousness (LOC)
Eye opening:
spontaneous 4, in response to voice 3, respond to pain 2, none 1
Verbal response:
oriented 5, confused 4, inappropriate words 3, incomprehensible words 2, none 1
Motor response:
obeys commands 6, locali
iatrogenic
of or relating to illness caused by medical examination or treatment
Jugular Vein Distension (JVD)
- Occurs with
CHF and pneumothorax
- most commonly bc of right vent fail due to chronic hypoxemia and CHF
pleurodesis
pleural space is artificially obliterated
- requires a hemostat, and 3 way stop cock
macroglossia
swelling or enlargement of the tongue
- bc of trauma, or congenital (ie Down's Syndrome)
Orthopnea
Difficulty breathing except in the upright position
- can relate to CHF
tracheal shift
- causes
Toward abnormality:
- pneumonectomy (lung removal)
- atelectasis
- lung collapse
- unilateral diaphragmatic paralysis
Away from abnormality:
- pneumothorax
- hemothorax
- pleural effusion
- lung tumor
- neck tumor
- diaphragmatic hernia
Pulsus paradoxus
vs.
Pulsus alterans
Pulsus paradoxus:
Significant reduction in pulse strength during inhalation by 10+ BPM
- could be bc status asthmaticus causing air trapping
Pulsus alterans:
Succession of strong and weak pulses, but rate doesn't change
- could be due to MI or CHF
Pectus carinatum
vs.
Pectus excavatum
Pectus carinatum:
Anterior protrusion of the sternum "pigeon-chest"
Pectus excavatum:
Depression of the sternum
Kyphosis
vs.
Scoliosis
Kyphosis
= Convex of the spine (hunchback)
Scoliosis
= lateral curve
What is considered an adverse rxn to neb tx?
?RR > 20 b/m (call nurse)
Respiratory alternans / Paradoxical breathing
vs.
Asymmetrical chest movements
Respiratory Alternans / paradoxical breathing:
alternating btwn use of diaphragm & accessory muscles to breath
- chest moves inward during inhalation instead of moving outward; and abdomen moves outward
- indicative of end-stage resp muscle fatigue
Asymme
Cheyne Stokes
vs.
Biot's Respiration
vs.
Kussmaul's
Cheyne Stokes:
Crescendo then decrescendo in rate and depth in a cycle with periods of apnea
� typical of CHF, ? ICP , drug overdose, CNS disorders
Biot's respiration:
? RR & depth w/IRREGULAR periods of apnea
� typical of ? ICP and head trauma,CNS disord
Two types of Normal Breath Sounds:
- Bronchial
- Vesicular
Adventitious (abnormal) Breath sounds:
- Diminished
- Wheezes & Stridor
- Crackles
- rhonchi
- Pleural friction rub
NORMAL BS:
�
Bronchial
l* - heard over tracheobronchial tree (tubular)
�
Vesicular
*- peripheral sites
ADVENTITIOUS BS:
�
Diminished
d*: When sound intensity is reduced
�
Wheezes
s*: narrowed LOWER airway
�
Stridor
r*: narrowed UPPER airway
- supraglottic
Lung Percussion
Normal lungs =
resonant
- low pitched sound, heard easily
Flat, Dull,
decreased resonance
= atelectasis, fluid-filled, pneumonia, or tumor
Hyperresonant, tympanic
= pneumothorax
Tactile fremitus
Vibrations created by the vocal chords echoing through the chest wall
-
Increased:
Secretions, consolidation, inflammed
-
Decreased:
Hyperinflation, pleural effusion
Crepitus
Palpating bubbles of air under the skin bc air has infiltrated areas where it shouldn't be normally
- subcutaneous emphysema
- associated with injury, tears, or insults bc the air has to go somewhere, and it gets under the skin
Sputum induction & use of Luken's Trap (sterile suction trap)
- Ultrasonic nebulizer can induce pt to cough up a sputum
- IPV (brand: MetaNeb)
- Have pt inhale bland aerosol (containing sterile water or NS) or hypertonic saline
Trapped in Luken's trap to collect specimen for C&S
Describing Sputum
- amount
- consistency
- color & interpretation
� AMOUNT:
scant, small, moderate, large, copious
� CONSISTENCY:
thin, thick, tenacious
� COLOR & INTERPRETATION:
-
Mucoid (white/gray):
Chronic bronchitis
-
Yellow:
Bacterial infections
-
Green:
Gram negative bacteria; bronchiectasis
-
Brown/dark:
Old blo
Acid-fast testing
Used after a gram stain to detect
mycobacterium TB
Anemia
vs.
Polycythemia
Anemia:
- decreased concentration of Hgb
- Give O2 support until transfusion is complete
Polycythemia:
- abnormally increased concentration of Hgb (either bc ? plasma volume or ? RBCs)
Polycythemia & anemia will have normal SpO2! What about ABG????
Hemoglobin (Hb)
vs.
Hematocrit (HCT)
Hgb:
Female: 12-16 gm%
Male: 13-18 gm%
HCT:
Female: 36-48%
Male: 39-55%
(gm% = gm/dL of blood = gm/100mL of blood)
Leukocytosis
vs.
Leukopnea
-
Leukocytosis
= Excessive WBC
-
Leukopnea
= Deficient WBC
Complete Blood Count (CBC) lab
- White Blood Cell (WBC)
- Red Blood Cell (RBC)
- Platelet count
WBC = 5,000-10,000 / mm�
WBC= INCREASE bacterial infection ( Recommend antibiotics)
WBC= DECREASED Viral infection
RBC = 4-6 million/mm�
Platelets = 150,000-400,000 / mm�
Eosinophils
increase with allergic reactions & asthma
- normal = 1-6%
Electrolyte lab (BCP):
Normals for...
Blood Glucose, K?, Na?, Cl?
BCP = Blood Chemistry Profile
Blood Glucose (BGL): 70-99 mg/dL
K?: 3.5-4.5 mEq/L
- hypokalemia, hyperkalemia
Na?: 135-145 mEq/L
- hyponatremia, hypernatremia
Cl?: 95-105 mEq/L
- hypochloremia, hyperchloremia
Creatinine
- normal values
- what is it
- abnormal values indicates...
0.6-1.5 mg/dL
� waste product of muscle metabolism
� direct relation to amount of muscle mass (? men have higher levels)
�
best measurement of KIDNEY f(x)
*(better test for renal failure than BUN)
� ? levels show chronic renal insufficiency or obstruction
Blood urea nitrogen (BUN)
- normal values
- what is it
- abnormal values indicates...
7-20 mg/dL
� RECALL: the liver converts ammonia (toxic) ? urea (nontoxic), which is then excerted by kidneys
�
BUN is used to assess KIDNEY f(x)
� however, BUN can increase w/dehydration or GI bleed as well...
Troponin
- normal values
- what is it
- abnormal values indicates...
Comes in troponin T & I
Troponin T = 0-0.1 �g/L
Troponin I < 10 �g/L
� it's a
cardiac protein
, which is
released when there is damage to the heart
�
Most specific biomarker for MYOCARDIAL INFARCTION ? high levels mean increased risk for MI or death!
Albumin
- normal values
- what is it
- abnormal values indicates...
3.4-5.4 g/dL
�
? levels indicate CHRONIC LIVER injury
ry *bc albumin is made in the liver
� albumin transports hormones & meds in the blood stream & maintains oncotic pressure (to pull H2O back into vessels)
�
? albumin means drugs are more free floating
Prothrombin time and partial thromboplastin time (PPT)
vs.
International Normalized Ratio (INR)
vs.
Activated Partial Thromboplastin Time (APTT)
PPT:
Tests coag time of clots forming w/heparin
- Normal = 12-15 sec
INR:
Tests coag time of clots forming w/warfarin (coumadin)
APTT:
Tests coag time of clots forming w/heparin
- Normal = 24-32 sec
Normal urine output
1 L/day
(~40 mL/hr)
Compliance
vs.
Elastance
CL = ?volume/?pressure
(how stretchable lungs are)
Elastance = ?pressure/?volume
(how lungs recoil back)
Compliance (CL)
- normal static vs dynamic
- equations for
static vs dynamic
Cst = Vt exhaled/(Plat - PEEP)
= 70-100 ml/cmH2O
Cdyn = Vt exhaled/(PIP - PEEP)
= 40-70 mL/cmH2O
Airway Resistance (RAW)
- what is it
- normal
- equation
- what happens to pressures when RAW ?
Frictional force that must be overcome during breathing
RAW = (PIP-Pplat) / flow
� Normal =
0.5-2.5 cmH2O/L/sec
� When RAW ?...
PIP ? but Pplat remains constant
� Very similar equation to PS (PIP-Pplat) bc PS is supposed to help overcome RAW
Qs/Qt
- what is it
- normal amount of shunt
- abnormal amounts
- equation
- shunt disorders
Shunt =
perfusion w/out ventilation
� Qs = shunted perfusion
� Qt = total perfusion
� Normal Anatomical shunt = 2-5%
� Normal Physiologic shunt = 5-10%
� Acceptable shunt < 20%
� Abnormal significant pulmonary disease > 20%
� Life threatening > 30%
Shunt
VD/VT
- what is it
- equation
- normal / abnormal values
Deadspace Ventilation
(ventilation s perfusion):
Bohr Equation =
(PaCO2 - PeCO2) / PaCO2
Normal: 20-40%
-
Anatomical Vd = 1 mL/lb of IBW
Acceptable: ? 60% for ventilator pts
Unacceptable: > 60%
Anatomical Deadspace
vs.
Alveolar Deadspace
vs.
Mechanical Deadspace
�
Anatomical Deadspace
*= Amount of the inspired VT that does not enter the alveoli
�
Alveolar Deadspace
*= Amount of alveolar ventilation that has no blood perfusion
�
Mechanical Deadspace
e* = Also amount of VT that doesn't make it to alveoli bc of exce
Alveolar Volume (VA)
vs.
Alveolar Minute Ventilation (V�A)
Example: Calculate VA and V�A if pt weighs 130 lbs IBW. There's 20 mL of added mechanical Vd. Pt's Vt is 300 mL with Ftot of 15.
Alveolar Volume (VA) = Vt - VDmech - VDanatomic
300 - 20 - (130) =
150 alveolar flow
� bc 1 lb of IBW = 1 VDanatomical
Alveolar Ventilation (V�A) = VA x RR
150 x 15 =
2250 mL/min alveolar ventilation
Blood Pressure drugs / Three Pronged Method to tx Heart Failure:
- heart
- blood/fluid
- vessels
Heart, blood/fluid, vessels are 3 factors that ctrl BP... Three Pronged method to tx heart failure...
Heart:
- Chronotropic drugs (Atropine) to ?HR
- ? blockers/? antagonsits (end in "lol") block vasoconstriction & anti-rhythmic
-
positive inotropes to ?
ECG: Tachycardia
HR ?150 BPM
If symptoms persist...
- Adenosine if narrow QRS
- sedate & synchronized cardioversion
- ?-blocker or Calcium channel blocker
- Vagal maneuvers
ECG: Bradycardia
HR < 50 BPM
If symptoms persist...
- Atropine
- Trancutaneous pacing
- Dopamine IV
- Epinephrine IV
ECG: 1st degree heart block
Long PR intervals
tx: Antiarrhythmics
- Procainamide
- Amiodarone
- Sotalol
ECG: 2nd degree heart block (Mobitz type 1 / Wenckebach)
PQ gets longer and longer until QRS is dropped
tx: Antiarrhythmics
- Procainamide
- Amiodarone
- Sotalol
ECG: 2nd degree heart block (Mobitz type 2)
Long PR interval of equal length with random QRS dropped
tx: Antiarrhythmics
- Procainamide
- Amiodarone
- Sotalol
ECG: 3rd degree heart block
P and QRS waves are completely disjointed; P waves has its own rhythm and so does QRS
tx: Antiarrhythmics
- Procainamide
- Amiodarone
- Sotalol
ECG: Atrial flutter
Sawtooth; distinct QRS though
ECG: Atrial fibrillation
P wave quivers randomly; less sawtooth; distinct QRS though
ECG: Premature ventricular contractions (PVC)
Random big lumps
- can be unifocal or multifocal
tx: Antiarrhythmics
- Procainamide
- Amiodarone
- Sotalol
ECG: Ventricular tacycardia (Vtach)
Pulse present:
Sedate & synchronized cardiovert @ 100J (for wide & regular)
Pulseless:
Defibrilate, CPR
- Epinephrine 1mg, Amiodarone 300 mg then 150 mg
ECG: Ventricualr fibrillation (Vfib)
ALWAYS PULSELESS
Defibrillate, CPR
- Epinephrine 1 mg, Amiodarone 300 mg then 150 mg
ECG: Asystole
Confirm in 2 leads first & check gains
- CPR, Epinephrine
ECG: Pulseless Electrical Activity (PEA)
Can be any rhythm on the monitor, even NSR (normal sinus rhythm). But PULSELESS! meaning heart is exceptionally weak & not circulating blood at all.
- CPR, epinephrine
Cardioversion
vs.
Defibrillation
vs.
Transcutaneous Pacing
Cardioverting:
-
Shock is delivered on the R wave
of ECG for
tachycardia w/pulse
- Make sure synchronizing switch is on before cardioverting; and if Vfib occurs, don't forget to turn it off
Defibrillation:
- for
PULSELESS Vtach or Vfib
and not synchronize
Pulmonary artery catheter (PAC)
- Purposes
- Where should the PAC transducer & stop-cock be placed for accurate measure of pressure?
Purposes:
- used to measure CVP, PAP, PCWP
- used to provide fluids or meds
Transducer should be @
Phlebostatic axis
(at level of right atrium)
when pt is in supine position
- if lower than axis ? causes erroneous high pressure reading (bc added hydrostat
Central Venous Pressure (CVP)
vs.
Pulmonary Artery Pressure (PAP)
vs.
Pulmonary Artery Capillary Wedge pressure (PAW, PCWP)
CVP Normal = 2-6 mmHg
- measures
right atrial pressure
via PAC
- if CVP is low, there could be ? venous return (ie ? intrathoracic pressure)
- reflects: right venticular fail, filling pressure, right pumping efficiency
PAP Normal = 15-25/8-15 mmHg
- 15 mm
Right Arterial Pressure
vs.
Right Ventricular Pressure
Right Arterial Pressure = 2-6 mmHg
Right Ventricular Pressure = 15-25/0-5 mmHg
Left Arterial Pressure
vs.
Left Ventricular Pressure
Left Arterial Pressure = 5 mmHg
Left Ventricular Pressure = 120/0 mmHg
Blood Pressure
- Normal
- Hypertension stage 1 & 2
Normal = 90/60 - 120/80
HTN Stage 1: > 140/90
HTN Stage 2: > 160/100
Mean Arterial Pressure (MAP)
vs.
Mean Pulmonary Arterial Pressure (MPAP)
- normal
- equation
MAP is related to Arterial Blood Pressure range of 90/60 to 120/80.
MAP Normal = 70-105 mmHg
MAP =
(sys + 2diastolic)/3
MPAP is related to Pulmonary Artery Pressure range of 15/8 to 25/15 (systolic/diastolic).
MPAP Normal = 15 mmHg
MPAP = same equation as
Pulse Pressure (PP)
- normal
- equation
Normal = 40 mmHg
PP = Systemic - diastolic
(120-80 = 40)
Systemic Vascular Resistance (SVR)
vs.
Pulmonary Vascular resistance (PVR)
!!!!!!
SVR = 80-1600 dynes x sec x cm??
PVR = 20-200 dynes x sec x cm??
What to do when there's abnormal heart sounds?
Recommend echocardiogram (echo)
Electrophysiology of the heart
SA node (pacemaker): Atrial depolarization
QRS complex: Ventricular depolarization & Atrial Repolarization
T wave: Ventricular Repolarization
Ischemia
vs.
Infarction
Ischemia = Reduced blood flow to the tissue
, which can lead to pain
� EXAMPLE: Myocardial Ischemia (MI) = heart attack
- Inverted T-wave
- Injury is indicated w/elevated ST segment
- Infarction w/significant Q waves
- Right axis deviation (RAD)
- Occurs
Sublingual nitroglycerin
for chest pain due to coronary artery disease
Ways to measure Cardiac Output (CO)?
1.
Thermodilution
2.
Green Dye Method
3.
Fick's Equation
� the only one of the three that CALCULATES Qt
� Qt = [VO2 / (CaO2-CvO2)] x 100
� Normal: 4-8 LPM
Cardiac index
- Equation
- Normal
- Why important?
CI =
CO / body surface area
= (SV x HR) / BSA
Normal =
2.5-4.0 L/min/m�
� this is a more accurate measure than CO bc takes into account body size
CaO2
vs.
CvO2
Arterial oxygen content (CaO2)
� Normal CaO2 =
17-20 vol%
%* (20)
CaO2= (Hb x 1.34 x SaO2) + (PaO2 x 0.003)
� 1st part of equation: O2 in RBC
� 2nd part of equation: O2 in plasma
Venous oxygen content (CvO2)
� Normal CvO2 =
12-16 vol%
%* (15)
� CvO2 and S
Ca-vO2
Arterial minus venous oxygen content
C(a-v)O2 = CaO2 - CvO2
- normal = 4-5 vol%
- greater difference when CvO2 is decreasing ? indicating a ? CO
- plays a part in calculating VO2
Oxygen Consumption (VO2)
vs.
Carbon Dioxide Production (VCO2)
Oxygen Consumption:
VO2 = Qt x (Ca-vO2)
-
normal = 250 mL/min
- ? VO2 = ? metabolism or CO
Carbon Dioxide Production:
-
normal = 200 mL/min
Respiratory quotient (RQ) !!!!
RQ = VCO2/VO2
Normal: 0.8 ????
Range: 0.67-1.3
Perinatal history
- what should be taken
- gravidity vs parity vs abortus
Pregnancy hx, age, smoking & EtoH abuse, nutrition, infection, HTN/toxemia
�
Gravidity
*= # of times pregnant, regardless of whether made it to term
�
Parity
*= carried to viable gestational age
�
Abortus
s* = pregnancies lost for any reason
Gestational age
- normal gestation
- preterm, post-term dates
- viability of life
� After 42 weeks = Post-term
�
38-42 weeks = Term gestation
� Before 38 weeks = Preterm
Viability of life @ 22-24 wks
(bc Type II cells develop ? surfactant begins to be made)
L/S Ratio
Amount of Lecithin (dipalmitoyl phosphatidylcholine) sphingomyelin found in the amniotic fluid / surfactant
2:1 or higher = Mature lungs
(more lecithin)
� less than 2:1 shows increased risk of RDS
Dubowitz and Ballard method of determining Gestational age
Assess 7 physical & 6 neurological criteria:
Normal maturity rating = 40
< 35 pre-term
> 45 post-term
APGAR Score
Airway, pulse, grimace, appearance and response for NEONATES
� taken @ 1, 5 min (& 20 min if necessary)
� > 7-10 normal: Monitor
� 4-6 abnormal: Stimulate, O2, and assist vent
� 0-3 emergency: Resuscitate CPR
You are assessing the one minute APGAR score for a newborn.
She is pink all over and has a pulse of 130. As you dry her off she begins to cry vigorously and kick her legs. Her APGAR score is? 10
A neonatal patient has a pink color, a pulse rate of 102, an
10
Newborn ABG: normal
pH: 7.20-7.30
PaCO2: 45-55
PaO2: < 60
HCO3: 20-24
pH is typically resp acidotic & ?O2. Typically
takes 1 hr to be the low side of normal.
.* And 24 hrs to normalize completely. While bicarb is born normal.
Infant normal values:
- HR
- RR
- Temp
- BP
- blood glucose level (BGL)
HR = 110-160
RR = 30-60
Temp = 36.5 - 37.5? C
BP = 70/45
BGL > 30
(apnea periods LESS than 10 sec are considered normal)
(converting Celsius to Fahrenheit: 1.8 C = F - 32)
Infant Weight
- Full-term
- Pre-term
Full term >3000g
Pre-term 1000g (< 28 weeks)
LOW Birth weight is ? 2500 gm (high respiratory problems risk)
Normal CXR
� Hemidiaphragms rounded (dome-shaped)
� Right hemidiaphragm is higher than left bc of liver on right
� Trachea midline
� Sharp costophrenic angles
� Head of clavicles should be level!
Low density tissue =
radiolucent
= black
- Air
High density tissue =
r
Radiograph exposure
- under exposure
- over exposure
� Underexposed: Visualize the interverterbral discs
� Over exposed: Image will show very black lung
Abnormal CXR terminology
- infiltrate
- consolidation
- hyperlucency
- vascular markings
�
infiltrate:
*any ill-defined radiodensity (ie atelectasis, fluid)
�
consolidation:
:* solid white area (ie pneumonia, pleural effusion)
�
hyperlucency:
:* extra pulmonary air (ie COPD, asthma, pneumo)
�
vascular markings:
*lymphatics, vessels, lung tiss
CXR Views
- posterior anterior (PA) view
- anterior posterior (AP) view
- lateral view
- lateral decubitus view
�
posterior anterior (PA) view:
(hands on hips & elbows out w/max inhalation while
standing
g*)
- more crisp image (preferred view)
- to see pleural effusion
�
anterior posterior (AP) view:
- heart is magnified
- more hazy than PA view, but used when pt i
Tracheal deviation
- If pathology occurs INSIDE the lung: Deviation TOWARD pathology
- if pathology occurs OUTSIDE the lung: Deviation AWAY from pathology
Position of endotracheal (ETT) or tracheostomy on CXR
� Below the vocal chords
�
3-6 cm above carina
� At the level of the aortic aortic arch
�
T2-T4
Head-tilt chin lift
vs.
Jaw Thrust
Both methods used to open an airway for CPR
But Jaw thrust is used when there's a suspected neck or spinal fracture
Oral Pharyngeal Airway (OPA)
vs.
Nasal Pharyngeal Airway (NPA)
OPA:
- Unconscious patients
- Inserted upside down to back of throat then rotated
- measured from tip of nose to corner of jaw
NPA:
- Conscious patients
- Changed every 24 hrs. (to prevent epitaxis)
- insert with lubricant
- measured from tip of nose to t
Sellick maneuver
Push on cricoid to decrease risk of aspiration & to help visualize the vocal cords when intubating
Laryngoscope blade sizes
Pre-term: 0
Term infant: 1
Pediatric: 2
Adult: 3
Endotracheal tube sizes
Pre-term infants: 2.5-3.0
Full-term infants: 3.0-3.5
Adult males: 8.0-8.5
Adult females: 7.0-7.5
Evidence of difficult airway
- Short receding mandible
- Enlarged tongue (macroglossia)
Magill forceps
Used for nasal intubation
If the light on the laryngoscope doesn't work, what should you do?
- Tighten bulb (some bulbs are on the handle rather than the blade)
- Change blades
- Check batteries
Endotracheal tube changers
????? is this the actual name
Airway exchange catheter
A small diameter that acts as a stylet
Laryngeal mask airway
A supraglottic airway device
- allow for blind insertion
- reduces gastric distention
- alternative to BVM ventilation
Carlen's tube
!!!!!!!!!
Double lumen endotracheal tube
Endobronchial tube
A tube with two independent lumens used for double ventilation of both lungs
Combitube
A blind insertion airway device to provide an airway for mechanical ventilation
???? why important?
King airway
!!!!
Supraglottic airway device that uses two seals that creates a patent seal at the esophagus and pharynx
???? why important?
Tube distance & size for...
- Oral intubation
- Nasal intubation
Oral intubation:
� FEMALE = 7.0-8.0 ? 19-23 cm
� MALE = 7.5-8.5 ? 20-25 cm
Nasal intubation = 26-29 (high 20's)
Assessment of tube position after intubation
1. Look for bilateral chest expansion
2. Fogging in the ETT
3. Easy bagging
4. Use EtCO2 colorimetry detector "Easy Cap" turn purple (problem) ? yellow (yes)
5. CXR shows ETT 3-6cm above carina or at the aortic knob/notch (best indicator)
Cuff pressure
- don't exceed what pressure
- Minimum Leak Technique (MLT) vs. Minimum Occlusion Technique (MOT)
Do NOT exceed...
20-25 mmHg
27-34 cmH2O
Minimum Occlusion Technique (MOT):
- while listening over suprasternal notch or lateral neck, inflate cuff just until no leak is heard at end-inspiration
Minimum Leak Technique (MLT):
- same as MOT but then remove a
Vacuum pressure for suction
Adult: 100-150 torr
Child: 80-100 torr
Infant: 60-80 torr
Continuous aspiration of subglottic secretions (CASS) tubes
Sxn tube incorporated just above the cuff
( ie: Hi-Low Device)
- used to prevent VAP
- intermittent sxn @ -20 torr
Nasal suctioning hazards
� Trauma to mucosa (most common) ? Lubricate catheter, be gentle
� Contamination ? Use aseptic technique
� Hypoxemia ? Leading to tachycardia, arrhythmias (most severe)
� Vagal response ? Sudden bradycardia
Suctioning troubleshooting
� Check catheter for patency
� Is vacuum on?
� Change/empty a full collection bottle
� Check all tubing connections
Coude tip catheter
Angled to help suction the left main stem bronchus
Drugs that can be administered through an ETT
NAVEL:
Narcan (Narcotic overdose)
Atropine (bradycardia)
Valium/Versed/Vasopressin (sedative, low BP)
Epinephrine (Asystole)
Lidocaine (numb, arrhythmia???)
Tracheostomy
- reasons for gettings a trach ???? (slide somewhere?)
- pros & cons
- when should it be changed
- substance to clean trachs with
PROS & CONS:
- Reduced WOB bc of ? VD compared to ETT
- Greater mortality rate
- Greater expense
- Improved mobility
When it should be changed:
1.
obstructed
(unable to pass sxn catheter) ? Remove tube, BVM, and insert new tube
2.
punctured cuff
Clean tra
Nasogastric tubes (NG)
Positioned in the stomach 2-5 cm below the diaphragm
Neuromuscular blocking agents - Paralytics
Causes paralysis of skeletal muscle
Depolarizing:
succinylcholine ? short acting; used for rapid sequence intubation
Non-depolarizing:
Pancuronium (Pavulon)
Vecuronium (Norcuron)
Rocuronium (Zemuron)
Drugs for anxiety / agitation / sedation
to relieve anxiety; titrated to RASS 0 to -1
Propofol [Diprivan] (for pain and sedation)
Dexmedetomidine [Precedex]
Alprazolam [Xanax]
Midazolam [Versed]
Lorazepam [Ativan]
Diazepam [Valium]
Ketamine [Ketalar] (for pain and sedation)
Drugs for Pain Anesthetics / Opioid Analgesics
Reduce sensation of pain
Morphine (reversed by Narcan)
Codeine
Fentanyl
Remifentanyl [Ultiva]
Hydromorphone [Dilaudid]
Ketamine [Ketalar] (for pain and sedation)
Pulmonary edema
- CXR
- General S&S
- cardiogenic vs noncardiogenic
- tx
CXR: Kerley B lines or septal lines, "bat wing" or "butterfly" pattern, diffuse fluffy infiltrates, maybe cardiomegaly
S&S: ????
- cardiogenic or noncardiogenic (caused by altered AC membrane permeability or ? plasma oncotic pressure)
TX: lasix
Types of noncardiogenic pulmonary edema
acronym: NOT CARDIAC
- Near drowning
- O2 toxicity
- Transfusion or Trauma
- CNS disorder
- ARDS, Aspiration, or Altitude sickness
- Renal issue or Resuscitation
- Drugs
- Inhaled toxins
- Allergic alveolitis
- Contrast or Contusion
Atelectasis
- CXR
- S&S
- tx
CXR: patchy infiltrates, plate-like, crowded pulmonary vessels, scattered
S&S: diminished BS, WOB
TX: Lung expansion therapy (SMI, IPPB, CPAP, PEEP, lung recruitment maneuver), good lung down for better perfusion
- first ? PEEP for alveolar recruitment ra
CXR: Alveolar disease
???? elaborate
Infiltrates, air bronchograms
CXR: CHF
????
Increased vascular markings
Increased heart size
Acute Respiratory Distress Syndrome (ARDS)
- CXR
- S&S
- tx
CXR: ground glass, honeycomb pattern, diffuse bilateral radiopacity
S&S: refractory hypoxemia, WOB, tachypnea, tachycardia
tx: APRV, ARDS net ? low Vt or PIP, high PEEP, high RR, high FiO2,
prone pt
t*, allow permissive hypercapnia
Tuberculosis (TB)
- CXR
- S&S
- tx
- diagnosis
CXR: cavity formation (often in upper lobes)
S&S: hemoptysis, ?????
tx: antitubercular agent
diagnosis: Manatoux test????
Pleural Effusion
- CXR
- S&S
- tx
CXR: blunting of costophrenic angle, basilar infiltrates w/meniscus, possible mediastinal shift to unaffected side
S&S: WOB ????
tx: thoracentesis ? chest tubes, antibiotics, steroids
Pneumonia
- CXR
- S&S
- tx
CXR: consolidation & atelectasis
S&S: yellow/green sputum, dyspnea
tx: antibiotics, good lung down for better V/Q match
COPD
- normal ABG
- tx
- breathing techniques
ABG shows
compensated chronic respiratory acidosis with hypoxemia and elevated HCO3
(example: 7.36,62,58,36)
Allow for permissive hypercapnia w/ nasal cannula O2 @ 1-3LPM
Breathing techniques:
- Pursed lip breathing
- Diaphragmatic breathing training
Pulmonary Embolism (PE)
- CXR
- S&S
- At risk pts
- diagnosis
- tx
CXR: may be normal or atelectasis, rarely see westermark's sign (dilation of pulm arteries close to PE)
S&S: sudden refractory hypoxemia & WOB, sudden ? in EtCO2 but ? PaCO2, tachycardia, hyperpnea, ? Vd
Pts at risk: Post op, bedridden, DVT Hx, 3rd trimes
Thrombolytic agents
Streptokinase, tissue plasminogen activator (tPA), reteplase, anistreplase, urokinase
(ends in "-kinase" or "-plase")
Pneumothorax
- CXR
- S&S
- tx
CXR: visible visceral pleural edge seen as very thin, sharp line (but no lung markings are seen peripheral to this line), tracheal deviation AWAY, radiolucent; vascular markings absent, heart/mediastinum shifts AWAY from injury if tension pneumothorax
S&S
Transillumination
Done when pneumothorax is suspected
If + for pneumo, a light halo will appear around the point of contact
Peak Expiratory Flow Rate (PEFR)
- measuring how fast air comes out of the lungs when you exhale forcefully after inhaling fully
- to assess if there is increased RAW (ie PEFR daily for asthma ctrl)
- Measure best of 3
- Measured with a peak flow meter (Wright)
Normal =
80% of predicted
Spirometry
Measures FVC and FEV1
- if spiratory efforts are all over the place, this means effort was inconsistent!
-
very pt dependent
- can be bedside (pic) or in PFT lab
Components of a NORMAL Spirogram
- Vital capacity (VC)
- Inspiratory Capacity (IC)
- Total Lung Capacity (TLC)
- Functional Residual Capacity (FRC)
- Residual Volume (RV)
- Inspiratory Reserve Volume (IRV)
- Expiratory Reserve Volume (ERV)
Two volumes make up a capacity!
Normal TLC = 6 L
Normal VC (FVC, SVC) = 4.8 L
Normal RV = 1.2 L
Normal IC = 3.6 L
But these values
vary according to age, height, & gender.*
Components of PFT indicating an Obstructive Disease
-
normal or increased TLC
(bc of air trapping)
-
increased RV
(bc of air trapping) ?
increased FRC
-
VC should be ~normal
Best indicator of obstructive disease in PFT is ? FEV1 < 80% but should have ~normal VC & FEV1/FVC < 70%
%* (where FEV1/FVC is also r
Components of PFT indicating a Restrictive Disease
Think baby lungs, everything is decreased
-
decreased TLC
-
decreased RV
Best indicator of restrictive disease in PFT is ? VC & ? FEV1 < 80% and FEV1/FVC ? 70%
Spirometry: Normal Values
- FEV1
- FVC
- FEV1/FVC (also referred to as FEV1%)
- PEFR
- FEV?????
FEV1 Normal
? 80%
%* of predicted
FVC Normal
? 80%
%* of predicted
FEV1/FVC Normal
> 70%
of predicted
... so if normal FVC = 4.8L
... then normal FEV1 = 3.4L
PEFR Normal > 80% of predicted
- for
large airways
FEV????? Normal > 80% of predicted
- for
small
Pre and post bronchodiator testing
Measures the reversibility of an obstructive pattern
- All bronchodilator therapy should be held 8 hours prior to testing
-
post must increase 12% from pre-values OR +200mL in FEV1
Classification of spirometry results
Normal: 80-100% of predicted
Mild disorder: 60-79% of predicted
Moderate disorder: 40-59% of predicted
Severe disorder: <40% predicted
(Same classifications as hypoxemia going by 20's)
Quality assurance of spirometry
the best trial is the one with the largest sum of FVC + FEV1
????
Pre-op IC
vs.
Post-op IC goals
Pre-op IC = 2600mL
Post-op IC = Half of pre-op goal = ~1300
If patient doesn't reach goal, lower it, and re-evaluate daily
???? we talking IS
Obstructive Disease
vs.
Restrictive Disease
OBSTRUCTIVE
= issues getting air
OUT
due to airways (FACE B-itis)
- Foreign body obstruction
- Asthma
- Cystic fibrosis
- Emphysema (& bronchitis ? COPD)
- Bronchiectasis
- Ends in "-itis" for inflammation [Laryngotracheobronchitis (LTB or croup), Epiglot
Maximum inspiratory pressure (MIP, NIF, NIP)
vs.
Maximum Expiratory Pressure (MEP)
MIP Normal
= -80 to -120 cmH2O
-
Critical Care = 0 to -20 cmH2O
- Used to assess the readiness to wean pt off vent
MEP Normal
= 160 cmH2O
- the greatest pressure of expired air achieved after a full inspiration
DLCO
- function
- normal
- describe test
To measure diffusion capacity
� Normal = 25 mL/min/mmHg
1. pt takes a big breath of known [CO]
2. hold 10 sec
3. exhales through CO analyzer ? missing CO = diffused CO
Plethysmography
measures FRC based on Boyles Law PV = PV
� where V = FRC
� pt pants lightly ? ?P around pt can be used to calculate FRC
6 Minute walk test (6MWT)
vs.
Exercise Titration w/Oxygen
6MWT:
Simply tests the distance pt walked in 6 min
Exercise Titration w/O2:
- Measuring sats while walking to see if need home O2
- Used for patients with severe COPD
Oxygenation index (Oxygen Index)
- purpose
- equation
- normal
!!!!!
Helps determine if patient needs ECMO
- ECMO recommended if OI > 40 in infants
OI = 100(FIO2 x Mpaw) / PaO2
Normal < 10%
PaO2/Fio2 ratio (P/F)
- Purpose
- Normal
- ALI
- ARDS
Clinical indicator of Hypoxemia
� Normal 400-500 torr
� Moderate dysfunction 300-400 torr
- 5-15% shunt
� ALI 200-300 torr
- 15-20% shunt
� ARDS < 200 torr
- with greater than 20% shunt
Alveolar Air Equation P(A-a)O2
- purpose
- equation
- normal & abnormal values
- A-a for age equation
Helps in diagnosing the source of hypoxemia
P(A-a)O2 = [PAO2] - PaO2
P(A-a)O2 = [(Pbatm-PbH2O)FiO2 - (PaCO2 x 1.25)] - PaO2
- Pbatm in KC = 760 torr
- PbH2O in KC = 47 torr
A-a for age = 10 + 4[(age-20)/10]
-
CANNOT be negative!
�
Normal
*= < 50 torr on 1
Partial Pressure of Inspired Oxygen (PiO2)
PiO2 = (Pb - PbH2O)FiO2
- Pbatm in KC = 760 torr
- PbH2O in KC = 47 torr
Partial Pressure of Oxygen in the Arteries PaO2
- normal
- abnormal values
80-100 = Normal
If PaO2 < 80 with FiO2 > 60%
- indicates, shunting, refractory hypoxemia, venous admixture
- start to CPAP or ? PEEP
Partial Pressure of Carbon Dioxide in the Arteries PaCO2
- normal
- abnormal values
35-45 = Normal
> 45 means pt is NOT ventilating
� initiate ventilation or increase current settings
� remove/decrease mechanical deadspace
� if PaCO2 is high but pH is compensated, pt is most likely a CO2 retainer w/COPD. That's fine.
< 35 means pt is ove
Ventilation/perfusion scan
Two nuclear scan tests to measure breathing (ventilation) and circulation (perfusion) in all areas of the lungs
Maximum voluntary ventilation (MVV)
Measures the muscular mechanics of breathing
- in and out fast and deep for 15 seconds
- test is extremely effort dependent
- tests for neuromuscular disorder
Computed (axial) tomography (CT) scan
vs.
Ultrasonography
vs.
Positron Emission Tomography (PET)
vs.
Magnetic Resonance Imaging
CT Scan (CAT Scan):
� Cross-sectional chest imaging
� Can visualize great detail and minuscule structures
� DX: bronchiectasis, PE, lung cancer
Sonography: uses high frequency sound waves
PET:
� 3D images w/the use of fluoroscopy
� used to diagnose cancer
Pulmonary angiography
- Used when there's high suspicion for pulmonary embolism (PE)
- Used when there's an Inconclusive V/Q scan and/or CT scan
Bronchograms
Injection of radiopaque contrast medium into the tracheobronchial tree
- rarely used bc made obsolete by use of CT scan & bronchoscopy
Bronchoscopy:
Diagnostic Purposes
vs
Therapeutic Purposes
Diagnostic purposes:
FBAO, malignancy, bronchial washings, hemoptysis, locating the bleed, biopsy collect samples
Therapeutic purposes:
FBAO, secretion removal, bronchial lavage, airway stenosis, atelectasis
Bronchoscopy:
- rigid vs flexible
- hazards
- contraindications
Rigid:
Preferred scope for therapeutic indications, preformed in OR with patient under general anesthesia
Flexible:
Preferred scope for diagnostic indications
Contraindications:
- Refractory hypoxemia
- Bleeding disorders
- Cardiovascular instability
- St
Bronchoscopy:
preparation for non-ventilated pt
vs.
preparation for ventilated pt
Non-ventilated patient:
1. Admin local (topical) anesthetic to ctrl cough/gag reflex ? Lidocaine, Benzocaine, Cetacaine, Cetacaine, Novocain
2. Admin sedative ? Midazolam (Versed), Diazepam (Valium), Lorazepam (Ativan)
3. Admin antitussive: Morphine
Venti
Mantoux test
a test for immunity to tuberculosis using intradermal injection of tuberculin
Tensilon Test
uses the drug Tensilon (edrophonium) to diagnose
myasthenia gravis
- it prevents break down of Ach
- positive test = stimulation of mucles in person w/MG & their muscles get stronger after injected
CSF spinal tap
for Guillane Barre
Electroencephalography (EEG)
- Measures electrical activity of the brain
- Evaluation of sleep disorders
- diagnoses seizures, coma, brain death
(NOT TO BE CONFUSED W/EKG or echocardiogram/echo)
Thoracentesis
- what is it
- most common cause for procedure
- CXR findings
- procedure
(MOVE)
- needle inserted into chest to remove fluid or air from the space btwn pleura and chest wall
- Most common cause for procedure is pleural effusion
- CXR findings: Use Lateral decubitus; blunting of costophrenic angles
- Procedure: 100-300 mL of pleural f
Analysis of pleural fluid
!!!!
(MOVE)
Transudate fluid (serous fluid) is usually clear; associated with CHF
Exudate: Cloudy or opaque; infection would produce yellow or milky fluid; Bloody (hemothorax, erosanguineous)
Pleural fluid pH <7.30 is considered significant for an extudate
Intracranial pressure (ICP)
- normal values
- abnormal pressures
- therapies to reduce ICP
Normal value: 5-10 mmHg
Compression of capillary bed & compromise microcirculation when ICP >15-20 mmHg
RECOMEND TX:
�
Hyperventilation:
*Target PaCO2= 25-30 torr
�
Treat JVD:
*HOB elevated ?30?; minimize straining or coughing
�
Sedation and analgesia:
*N
Cerebral perfusion
- normal pressures
Normal: 70-90 mm Hg
Brain natriuretic peptide (BNP) !!!!
Normal: <100
???? units
Elevated levels indicate CHF
Sleep apnea studies (Polysomnography)
Central Sleep Apnea
vs.
Obstructive Sleep Apnea
vs.
Mixed of both
Central:
Apnea due to a loss of ventilation effort
� Nasal flow decreases AND respiratory effort decreases (no pleural pressure oscillations)
� tx w/Bi-level
Obstructive:
Apnea due to blockage of UA
� Nasal flow decreases, but there are still respiratory
Apnea hypopnea index (AHI)
????
Mild: 5-15
Moderate: 15-30
Severe: >30
Apnea of prematurity
- tx
- indications for infant apnea monitoring
- apnea monitoring
tx: Caffeine
Indications: sibling of a SIDS baby (sudden infant death syndrome)
Monitoring: Alert docx of reoccurring apnea, bradycardia, and/or hypoxemia
NIPPV: Contraindications
- Cardiac or respiratory arrest
- Upper airway obstruction
- Unable to protect airway (aspiration risk, dysphagia)
- Unable to clear secretions
- Facial/head trauma or surgery
Continuous Positive Airway Pressure (CPAP)
- Purpose
- troubleshooting
- Improves oxygenation; supports oxygenation at lower FiO2
- nasal CPAP is useful w/neonates bc they are OBLIGATE NOSE BREATHERS
Troubleshoot:
- Loss of pressure: Leak, insufficient flow
- Increased pressure: Obstruction, if excessive pop-off valve ventin
Bilevel Continuous Positive Airway Pressure (BiPAP)
- Initial settings
IPAP: 8-12 (affects CO2 / ventilation)
EPAP: 4-6 (affects O2 / oxygenation)
Bronchial hygiene
- indications
� Accumulated or retained secretions
� Ineffective cough
� Ciliary dysfunction
� Cystic fibrosis
� Bronchiectasis
Bronchial Hygiene
vs.
Hyperinflation therapy
Bronchial Hygiene:
(? airway clearance)
- CPT, Vest
- Cough Assist
- Oscillatory/Vibrating PEP devices on expiration ? flutter, acapella, quake, coronet
Hyperinflation Therapy:
(? lung vol for good VC & atelectasis)
- Positive Airway Pressure (PAP) on ins
Positive Airway Pressure Devices (PAP devices)
vs.
Positive Expiratory Pressure Devices (PEP devices)
PAP devices
- hyperinflation therapy ????
- for inspiratory or expiratory
- includes CPAP, PEP devices, threshold resistors to help strengthen diaphragm
PEP devices
- bronchial hygiene therapy & decreases hyperinflation ????
- positive pressure applied as
Chest Physiotherapy (CPT) positions
Postural drainage
- use when pt doesn't tolerate vest
Intermittent Positive Pressure Breathing (IPPB)
- changing settings to accomplish certain goals
- troubleshooting
Bird Mark 7 is pneumatically powered
pressure cycled
machine or use the Vortran
� ? pressure to ? volume
� ? flow to ? volume (bc increases I-time)
� ? flow to ? volume (bc more turbulance causes breath to cycle off faster bc pressure is reached)
Troubles
Body Positions
- describe
- benefit
�
Prone:
:* lying flat, face down
- beneficial for ARDS & improve V/Q mismatch
�
Supine:
:* lying flat on back
�
Fowlers/semi fowlers:
*sitting 90� to 45�
- beneficial for hypoxic, obese, dyspnea, post-op, pulmonary edema, prevent VAPs
�
Trendelenburg
*(p
Huff Cough
vs.
Quad Cough
Huff Cough
= Coughing with an open glottis
- forced expiratory technique to move secretions
Quad Cough
= cough assist
- similar to Heimlich maneuver; therapist applies pressure to pt's abdomen during exhalation
Manual resuscitation bag /BVM (self inflating)
- flow needed
- FiO2
- troubleshoot if bag fills rapidly and collapses easily on minimal pressure
BVM: Provides 95-100% O2 @ 15 Lpm
If bag fills rapidly & collapses easily, check the inlet valve
- if there's a problem, do not attempt to fix, find another form of ventilation
Low Flow Devices
vs.
High Flow Devices
- liter flow
- FiO2
- miscellaneous
- humidity
Low Flow Devices:
variable FiO2 @
< 40 LPM
inspiratory flow
1.
Nasal cannula
(1-6 LPM)
- for every liter = 4% ? FiO2 from 21% ? up to ~40% FiO2
2.
Simple Mask
(6-10 LPM; up to 50% FiO2)
- MUST BE ? 6 LPM to ? rebreath CO2
3.
"High flow" nasal cannula
(5-1
Ways to create high flow for pts with high flow demand and potential high RR
1. GIN
- uses two flowmeters
2. Large Volume Neb (LVN) w/bleed in ???? ask chad?
- if FiO2 desired < 60% ? hook LVN to air & bleed in O2
- if FiO2 desired > 60% ? hook LVN to O2 & bleed in air
- if FiO2 desired 100% ? hook both to O2
3. Tandem using 2 LVN
Transtracheal Catheter
- insertion
- FiO2 & flow
- delivers up to 35% FiO2 with 0.25-4 LPM flow (LOW FLOW)
- inserted into trachea btwn 2nd & 3rd tracheal rings to ~3 cm above carina
- no need for humidifier
Nasal cannula
- indications
- troubleshoot
Indications:
for mild hypoxemia; initial device for COPD & stable RR & VT
- Delivered FiO2: 24-41% (4% rule)
- Flow: 1-6 L/min
Troubleshoot:
- No gas flow felt from device? Check connection
- Skin irritation?: Place cushions on irritated areas
- Mouth bre
Non-rebreather mask (NRB)
- FiO2 & flow
- Indications
Delivered FiO2: 21-100%
Flow: 10-15 LPM to keep bag inflated
Indications: for moderate hypoxemia,
mixed gas therapy
(Heliox or CO2/O2), suspected
CO poisoning
Has 2 one-way valves to prevent rebreathing
T-piece (Brigg's adapter)
- FiO2
- troubleshooting w/aerosol
Delivered FiO2: 0.21-1.0
Troubleshoot:
If aerosol disappears...
- increase flow / set up a device to provide more flow if already maxed (ie blender, tandem set-up, high flow flowmeter)
- add more reservoir tubing
- set up a device to provide more flow
???
Gas Injected Nebulizer (GIN)
- uses two flowmeters
- and if each normal flowmeter is 15... then ~30 LPM
- but if using high flow flowmeter each at 60 LPM then theoretically 120 LPM... ???? ask Chad?
Magic Box
- calculation
- 1:1 ratio
- example question
Used to
calculate TOTAL flow in an entrainment
device (ie AP neb)
- whereas for the GIN you have 2 flowmeters you can just look at the #s and add
KNOW that
1:1 Air:O2 ratio is ~60% FiO2
� If
FiO2 < 60%, then AIR will be larger #
� If FiO2 > 60%, then O2 w
Oxygen hood
Flow range: 7-14 L/min to prevent CO2 buildup
use O2 analyzer to measure FiO2 closest to baby
Bubble humidifier
- indications
- troubleshooting
Indications:
- when > 4 LPM
Troubleshooting:
- If no sound occurs: Leak
- If whistling occurs: Oxygen flow is excessively high or kinking in tubing
What to do if there are thick secretions?
- use ultra sonic neb (USN) for thick secretions
- humidify to help mobilize
Special Equipment for certain drugs
- SPAG
- Altera Neb
- Pari Neb
- Respiguard II
� Small particle aerosol generator
(SPAG) ? for RSV
RSV* respiratory syncytial virus
�
Altera Neb ? Aztreonam (Cayston)
n) *for mgmt of Pseudomonas in CF pts
�
Pari Neb ? Tobramycin
in *for mgmt of Pseudomonas in CF pts
�
Respiguard II ? Pentamidine
ne *f
Metered dose inhaler (MDI)
vs.
Dry Power Inhaler (DPI)
MDI:
- Must be able to understand and cooperate or use spacer
- watch counter
- store upright & not lying down
DPI:
- keep dry & avoid caking or clumping
- must generate enough suck
Calculating duration of cylinder flow
- tank factors (E, H) for O2
- example question
Minutes cylinder will last = (Gauge pressure) x (tank factor/liter flow)
� E cylinder: 0.28 L/psi (0.3)
� H cylinder: 3.14 L/psi (3.0)
? Remember to convert min to hrs
Example: The gauge on an H cylinder reads 1500 psi. About how long would this last if t
Exhaled nitric oxide (FEno) testing
- NO is released from epithelial cells of the bronchial wall during inflammation
- ? FEno = ? in airway inflammation
- ? FEno can suspect asthma when other evidence is lacking
Carbon Monoxide (CO)
- normal
- abnormal S&S
- half-life of CO
- tx options
�
Normal COHb: 0-1%
�
COHb for smokers: 2-12%
- Mild poisoning S&S: nausea, headache, blurred vision, ? cerebral function
- can measure COHb in blood to see if pt is complying w/smoking cessation program
-
exhaled carbon monoxide (FEco)
testing for non-sm
Capnography normals (end tidal)
- normal
- what does increase / decrease indicate?
- label parts of capnography waveform
PetCO2 is similar to PaCO2 = 40 torr
? PetcO2: ? ventilation
� inadequate MV (hypoventilating), sepsis, resp depressant drugs
? PetCO2: ? ventilation or ? perfusion (ie PE, hypovelemia)
� If sudden loss of EtCO2 ? disconnect or obstruction
� If gradual lo
What values are CALCULATED and NOT directly measured in an ABG analyzer?
SaO2
HCO3?
BE
(NOTE: SaO2 is calculated from PaO2; while HbO2 is actually measured using co-ox; they are different!)
Severinghaus electrode (hydrolysis) ? TcPCO2
vs.
Clark electrode (Polargraphic) ? TcPO2
vs.
Sanz electrode ? pH
Severinghaus electrode:
noninvasively measures PCO2 ?
TcPCO2
� will
read +7-10 higher
*bc heat ? metabolic rate & ?VCO2
� uses basis of Hydrolysis (CO? + H?O ? HCO? + H?)
�
heat probe to 42�-45�C
�C* to produce capillary vasodilation ? change site Q4 hrs
Normal ABG values
pH: 7.35-7.45
PaCO2: 35-45 mmHg
PaO2: 60-100 mmHg
HCO3: 22-26 mEq/dL
PaO2
vs.
SaO2
vs.
SpO2
vs.
HbO2
PaO2 = pressure the
dissolved oxygen
exerts on the artery
- units: mmHg (torr)
- will detect hyperoxemia
SaO2 = % saturation of O2 on Hb as
CALCULATED
from measured PaO2
- units: %
- since it is calculated, it assumes there is no abnormal forms of Hb (ie
ABG analyzer: In control situation
All the values are within 2 standard deviations of the mean ? GOOD!
ABG analyzer: Random errors / Imprecision errors
Random Errors / Imprecision Errors
one sporadic data point out of 2 standard deviation range, but rest is ok
- indicates errors of imprecision
- ignore it
ABG analyzer: Systemic errors / Bias
occurs when there is a abrupt shift or trending of data points down/up but within acceptable 2 standard deviations
ABG analyzer: Out of control situation
Steadily increasing or decreasing trend that is moving outside the standard deviation range
- this indicates
electrode needs to be recalibrated or replaced
- if there is Bias & Imprecision, then also requires corrective action
Physiologic effects of hypoxia & hypercapnia
Leads to pulmonary vasoCONSTRICTION
- bc wants to shunt blood to better perfused areas to improve V/Q mismatch
- in neonates, this is beneficial bc it allows more blood to shunt through PDA so goes from pulmonary artery ? aorta to get to body
But causes s
Different types of Hypoxia
- HASH
Hypoxemic hypoxia
: caused by low PiO2 (inspired)
- shunt or venous admixture, Qs/Qt
- poor ventilation, Vd/Vt
- AC diffusion defect
- hypoventilation
Anemic hypoxia
: caused by low or loss of Hgb
- Hb changes prohibiting O2 binding (ie MetHb or COHb)
Sta
Oxygen Hemoglobin Dissociation Curve (OHDC):
- Left shift
- Right shift
Left Shift ? Lock O2
bc
increased affinity
y*, but deprives tissues
- Increase: pH (basic)
- Decrease: PaCO2, temp, 2-3 DPG
- HbF, HbM, COHb
- Polycythemia
Right Shift ? Release O2
easily bc decreased affinity, but
prevents reloading
at alveoli;
"appears
4 Primary variables during mechanical ventilation
1)
Trigger
2)
Control or Target
3)
Limit
: est a max value that a variable can reach during inspiration (pressure, volume, time, flow)
4)
Cycling
Indications for Mechanical Ventilation
� Apnea
� Acute ventilatory failure/ acute respiratory failure ? Insufficient spontaneous ventilation
� VC <1000
� MIP <20
� PaCO2 >45
IBW calculation in Adults
Male = 50+2.3(ht in inches - 60)
Female = 45.5+2.3(ht in inches - 60)
Initial settings for adult mechanical ventilation
�
Tidal volume:
*6-10 mL/kg IBW
�
Minute ventilation (Ve):
:* 5-10 LPM
�
Pressure Ctrl:
*start at 10-15 cmH2O, adjust to get desired Vt & Pplat < 35
�
Pressure Support:
*set to transairway pressure (PIP-Plat), adjust to get desired Vt
�
f:
*12-18 bpm
�
Tr
Initial settings for infant mechanical ventilation
� VT: 4-6 mL/kg
� PIP: 20-30 cmH2O
� f: 20-30 b/m
� FiO2: 40-60%
� PEEP: 2-4 cmH2O with 8 max
Ventilator alarms:
- High/Low pressure
- Minimum exhaled pressure
- Oxygen
- RR
- Vt
-
High/ Low pressure:
10 cmH2O � PIP (low P is the most important alarm!)
-
Minimum exhaled pressure:
100 mL below exhaled Vt (2nd most important alarm)
-
Oxygen:
5% � set FiO2
-
RR:
10 � spontaneous
-
Vt:
10% � Vt exhaled
Ventilator alarms: Troubleshooting
- troubleshooting Low pressure
- troubleshooting High pressure
- troubleshooting Low exhaled volume
Troubleshooting Low pressure:
- Patient disconnect
- Leak in the circuit
- Insufficient flow
- ET/Trach cuff leak
Troubleshooting High pressure:
- pt obstruction (ET-tube, pneumo, Raw, secretions, condensation can also read high fspont)
- Equipment obstru
Peak Inspiratory Pressure (PIP)
vs.
Plateau Pressure (Pplat)
PIP
= Pressure required to get a volume of air into the lungs, fighting RAW & CL
-
WITH airflow
- measures CL and RAW
Pplat
= Measures the compliance the entire lung
WITHOUT airflow
-
does not include resistance
- Use End inspiratory pause button
Mean airway pressure (Paw)
- equation
- normal
- factors which directly affect MAP
MPAW = [(f x Ti)/60] x [(PIP-PEEP) + PEEP]
Normal = 5-10 cmH2O (w/normal CL & RAW)
Factors which directly affect MAP:
PIP, f, IT, PEEP, VT
Spontaneous breaths
vs.
Assisted breaths
vs.
Mandatory breaths
Spontaneous breaths:
pt triggers & pt finishes the breath w/their own [Vt or P]
Assisted breaths:
pt triggers & vent finishes the rest of the breath to achieve set [Vt or P]
- NOTE:
assisted breaths are very different from pressure support
... PSV only he
Assist Control (AC)
or
Continuous Mandatory Ventilation (CMV)
Can be AC/VC (volume) or AC/PC (pressure), which is basically the same as PC/CMV or VC/CMV
USES
: for when sedated & you want full ctrl of their breathing; for
MANDATORY & ASSISTED
� Pt will receive set [Vt or P] and minimum set RR
� Pt can breathe above
Synchronized Intermittent Mandatory Ventilation (SIMV)
Can be PC/SIMV or VC/SIMV
USES:
for weaning purposes, if pt can trigger their own breaths & have decent volumes, to "exercise" lungs; for
SPONTANEOUS, ASSISTED, & MANDATORY
breaths
� pt can breath spontaneously at any time, but pt will get a min # of set
Pressure Support Ventilation (PSV)
� Overcomes resistance of vent circuit and ETT during
SPONTANEOUS
*breathing
�
can be set in SIMV & CPAP
*mode to help decrease WOB
� Set PSV by
calculating transairway resistance
*(PIP-Pplateau)
�
PSV is different from Assisted Breaths!
*bc PSV only help
Conventional Ventilator:
How to normalize a low PaCO2
vs.
How to increase a low PaO2
Normalizing low PaCO2:
� evaluate the cause (hypoxemia, pain, fever, anxiety)
�
? f
�
? VT or PIP
Normalizing low PaO2:
1.
? FiO2
*by 5-10% (up to 60%)
2.
? PEEP
*5, 8, 10 then by 2's until 20 until acceptable or unacceptable side effects occur (ie: ? CL,
Estimating PaO2 based on FiO2
PaO2 ~= FiO2 x 5
(ie pt breathing 100% FiO2 should have PaO2 500)
Desired MV-PaCO2 equation
desired (PaCO2)(MV) = known (PaCO2)(MV)
Desired FiO2-PaO2 equation
(desired FiO2)/(known FiO2) = (desired PaO2)/(known PaO2)
High frequency ventilation (HFOV)
- function
- changing settings to accomplish ABG goals
Improves oxygenation in patients with severe lung injury (ie ARDS, RDS, pneumothorax)
�
?P (amplitude)
controlled by
Power knob
nob*, increase to have adequate chest wiggle to thighs
-
??P to ? CO2
(it's like getting a
bigger Vt
er Vt*)
�
MAP
is set to th
Amplitude
vs.
frequency measured in Hertz (Hz)
Amplitude = how high the wave is
Frequency = how often the wave cycles
� 1 Hz = 60 breaths/min
Recruitment maneuvers
� Increase PIP to 40 and PEEP to 20 for for 40 seconds
� Increase CPAP to 30-40 for 40 seconds
� Sighs technique (inspiratory hold)
� If SpO2 rises then falls consider repeating maneuver
Waveform: Auto-PEEP & Air trapping
Expiratory flow fails to return to the baseline
Waveform: Ineffective/wasted effort
Patient inspiratory effort fails to trigger vent.
Waveform: Flow starvation
Caused by discomfort, fatigue, or dyspnea
Scooping or distortion instead of a smooth rise in the pressure curve
Waveform: Active expiration
High and variable expiratory flow pattern
Waveform: Airway secretions
Sawtooth pattern
Waveform: Auto cycling
When RR increases suddenly without patient input (exhaled volume and minute ventilation decrease)
Typically occurs due to a leak
Waveform: Double triggering
Caused by patient flow or volume demand exceeding ventilator settings
Continued patient inspiratory effort through the end of delivered breath
Loop graphics: Spontaneous breath
oval
- pt starts and finishes breath
Loop graphics: Assisted breath
fish tail
- pt starts inspiration
- machine finishes breath
Loop graphics: Mandatory breath
leaf
- machine starts and finishes breath
Loop graphics: overdistension
beak
represents overdistension as too much volume is delivered
Loop graphics: Adjusting PEEP level
PEEP is set at 0
Normalized by increasing the PEEP
Loop graphics: Adjusting PIP and/or VT
Overdistention "duck bill"
Normalized by reducing the VT or PIP
- "belly" line of the duck is inspiration; "back" is expiration
- mandatory breath bc there is no negative inflection
- PEEP is present
Loop graphics: Evaluating/treating lung compliance problems
Low compliance (ARDS, pneumonia, pulmonary edema)
Normalized by increasing PEEP
Loop graphics: Evaluating/treating airway resistance problems
High airway resistance/decreased expiratory flow (Bronchospasm, secretions, other obstructions)
Normalize by suction or bronchodialator
Loop graphics: Evaluating/treating an air leak problem
Leak
Normalize by fixing the leak
Loop graphics: Evaluating/treating tubing compensation
Water is present in the circuit
Drain condensate from tubing using water traps
Scalar graphics: Evaluating/treating air trapping (auto-PEEP)
Expiratory flow does not return to baseline
Scalar graphics: Patient ventilator asynchrony/dyssyncrony
Causes: Auto-PEEP, inappropriate trigger setting, weak patient effort
Correct: Adjust trigger setting
Scalar graphics: Auto trigger (auto-cycle)
Causes: Leak in circuit or airway, inappropriate trigger setting (too sensitive), condensation in circuit, Bounding pulse or cardiac movement causing ventilator to trigger
Correct: Recognize and adjust trigger sensitivity
Scalar graphics: Flow asynchrony (Flow starvation mismatch)
Cause: Flowrate does not meet patients inspiratory flow demands
Correct: Increasing flow, decreasing I-time, Increasing E-time
Spontaneous breathing trials
- different types
- how long
- when can you extubate pt
- failed spontaneous breathing trial ? DC
Can use SIMV, or T-piece, or CPAP w/PSV
- for minimum of 30 min to draw ABG
- when weaning parameters are good; original airway issue resolved (ie mucus plugging, glottic swelling down); can extubate pt on SIMV @ pressure of 8 ????
Failed Spontaneous brea
Measurements for Weaning Purposes:
- Vital capacity (VC)
- Maximum inspiratory pressure (MIP, NIF, NIP)
- Rapid Shallow Breathing Index (RSBI)
VC Normal = 70 ml/kg
IBW ? ~ 4.8 LPM
-
Muscle weakness ? 10-15 ml/kg
- Preformed with a respirometer (gauge that measures vol) or spirometry
MIP Normal = -80 to -120 cmH2O
- BUT
MIP Normal for WEANING should be ? -20 cmH2O
*(more negative)
RSBI < 100
-
RR
Supraglottic swelling
vs.
Subglottic swelling
SUPRAglottic swelling = Epiglottitis
- drooling & difficulty swallowing
- thumb print sign on CXR
- fever (bc typically bacterial origin)
SUBglottic swelling = Croup
- NO drooling & NO difficulty swallowing
- barking cough & hoarseness
- no fever (bc typi
Extubation procedure
1. sxn below & above cuff
2. prepare O2
3. remove tube holding device
4. deflate cuff, instruct pt to cough as you remove tube
5. silence alarm
6. sxn again
What to do with Extubation complications
-
mild distress w/stridor, sore throat
? humidity, O2, racemic epi
-
moderate distress/stridor
? O2, cool mist aerosol, racemic epi, heliox
-
severe respiratory distress w/marked inspiratory stridor
? reintubate pt!
Helium/oxygen therapy (Heliox)
- Indications
- Acceptable Concentrations
- Actual Flow
- How is it delivered
Indications: ? flow resistance via more smooth laminar flow around an airway obstruction
� Post extubation stridor
� Status asthmaticus
� Obstructive tumors or FBAO in general
� Partial vocal chord paralysis
Concentrations & Flow Correction Factor:
� 80%
Inhaled nitric oxide (iNO)
- Indications
- Dosage
- Side Effects
- DC
Indications: for pulmonary HTN bc
iNO is a vasodilator!
Dosage =
20-40 ppm
???? slide said 5-20 ppm?
� < 20 ppm when weaning
� When high calibrating, the expected value is 45 ppm
Side Effects: Methmoglobin (MetHb) levels may increase
DC:
� To avoid reboun
Chest tubes:
Pneumothorax
vs.
Hemothorax or Pleural Effusion or empyema
Pneumothorax:
� <10% may not require tx unless pt shows significant distress
� to drain air, place 14-16 needle gauge in
2nd intercostal space (just above 2nd rib) mid-clavicular line
e*, then put in chest tube afterwards
Hemothorax or Pleural Effusion or
Chest Tubes:
Three bottle water-seal suction drainage system
- Collection Chamber
- Waterseal Chamber
- Suction Control Chamber
Right to Left:
Collection chamber
: collects fluid
� if no bubbles or continuous bubbles, could indicate air leak
Waterseal chamber
: one-way valve allowing air to escape but not re-enter chest cavity
� bubbles here indicates air leak!
� but tidaling is G
Chest tubes: Removing
Just before removing the tube, the patient takes a
deep breath
, exhales and preforms a
valsalva maneuver
(exhaling w/the nostrils & mouth closed to ? pressure in middle ear & chest; typ used to equalize ear pressure)
Palliative care
Control of pain and other symptoms
Maximizing the psychological, social, and spiritual well-being
Disinfection
vs.
Sterilization
�
Disinfection
*= Destroying PATHOGENIC microbes except for spores (ie chemical disinfection, pasteurization)
�
Sterilization
*= Killing ALL microbes (good & bad) (ie autoclave, flash sterilization, low temp sterilization)
CHEMICAL method of disinfection and sterilization
� Ethylene oxide = Sterilizes
� Alkaline glutaraldehyde (Cidex & Sonacid) = Disinfection and sterilization
- for reusable plastics & bronchoscopes
� Bleach = Used to clean blood spills
PHYSICAL methods of disinfection and sterilization
�
Autoclave
e* = Steam under extreme pressure @ 15psi @ 121�
�
Flash Sterilization
*= rapid penetration of steam
�
Pasteurization
n* = Type of disinfection using moderate temperatures
- used for high level disinfection of nondisposable ventilator tubing
�
Preventing ventilator-associate pneumonia (VAP):
- cause
- prevention
Secretions that pool above airway cuff are aspirated through small folds in the cuff; accidental lavage of condensation
Prevention:
� Closed Sxn w/regular oral hygiene
� HOB 30-45�
�
DON'T often change vent circuits
� drain vent condensation
� MDI instead
Home care: Clean equipment
Soak in
white distilled vinegar (acetic acid)
solution for 20 min.
Dry carefully
Oxygen concentrators
- If bubbles are present, device is working correctly
- after oxygen concentrator has been installed, RT's job is to
change the filters
as maintenance procedure
Liquid bulk O2 systems
- If it spills let it evaporate
- Can cause frostbite
- will leak over time if not used
- can store more of it compared to gas O2
- 1 cu ft of liquid O2 = 860 cu ft of gaseous O2
Units for Pressures (general trend)
cmH2O ? anything related to the vent (like PIP or CL)
mmHg ? anything related to blood (like ABG's PaCO2 or PaO2)