Ascites
accumulation of fluid in the abdomen caused by LIVER FAILURE
Venous distention
-occurs with CHF
-seen with obstructive patients (seen in exhalation phase)
Capillary refill
-indication of peripheral circulation
-Normal < 3 seconds
Jaundice skin color
-increase in bilirubin.
-mostly in face and trunk
Bradypnea (oligopnea)
-decreased respiratory rate (<12bpm) variable depth and irregular rhythm
Hyperpnea
-increased rate, depth, with regular rhythm
Cheyne-Stokes
-gradually increasing then decreasing rate and depth in a cycle lasting from 30 - 180 secs, with apnea up to 60 secs
-increased ICP, meningitis, overdose
Biots
-increased rate and depth with irregular periods of apnea
-CNS problem, head/brain injury
Kussmaul's
-increased rate, depth, irregular rhythm, breathing sounds labored
-Raspy voice
Apneustic
prolonged gasping inspiration followed by extremely short, insufficient expiration
-respiratory center problems, trauma, tumor
cachectic
muscle atrophy/loss of muscle tone
retractions
-chest moves inward during inspiratory efforts instead of outward
-blocked airway in adults = INTUBATE
-RDS in infants
Character of cough
-dry, non-productive cough may indicate tumor in the lungs or asthma
-productive cough may indicate infection
evidence of difficult airway
-short receding mandible (chin)
-enlarged tongue (macroglossia)
-bull neck
-limited neck range-of-motion
pulsus paradoxus
-pulse/blood pressure varies with respiration. may indicate severe air trapping (status asthmaticus or cardiac tamponade)
tactile fremitus
-vibrations felt by hand on chest wall
-vocal fremitus: voice vibrations on the chest wall
-pleural rub fremitus: grating sensation due to roughened pleural spaces
-Rhonchial fremitus(palpable rhonchi): secretions in airways
Crepitus
-bubbles of air under skin that can be palpated and indicates subcutaneous emphysema
Resonant percussion
-hollow sound
-normal lungs
Flat percussion
-heard over sternum, muscles, or areas of atelectasis
Dull percussion
-heard over fluid-filled organs such as heart or liver (thudding)
-pleural effusion or pneumonia
Tympanic percussion
-heard over air-filled stomach.
-drum-like sound and when heard over lung = increased volume
Hyperresonant
-found where pneumothorax or emphysema is present.
-booming sound
vesicular breath sounds
normal sounds in lungs
bronchial breath sounds
-normal sounds over airways.
-breath sounds over lungs indicate LUNG CONSOLIDATION
Egophony
-patient instructed to say E and sounds like A.
-lung consolidation
Bronchophony / whisphered pectoriloquy
-increased intensity or transmission of the spoken voice and indicate CONSOLIDATION or PNEUMONIA
-increase in spoken voice = consolidation
-decrease in spoken voice = obstructon, pneumo, emphysema
Rales
-crackles
-secretions/fluid
Coarse rales
-rhonchi
-LARGE airway secretions
-needs suctioning
medium rales
-middle airway secretions
-needs CPT
Fine rales
-fluid in alveoli
-CHF, pulmonary edema
-IPPB, heart drugs, diuretics and O2
Wheeze
-due to bronchospasm
-bronchodilator Tx
-unilateral wheeze indicative of a foreign body obstruction
stridor
-upper airway obstruction
-supraglottic swelling (epiglottitis) (thumb sign)
-subglottic swelling (croup, postextubation) (steeple sign)
-foreign body aspiration
-Racemic epinephrine
-intubation if MARKED stridor
-Lateral neck Xray for confirmation
Pleural friction rub
-coarse grating or crunching sound
-visceral and parietal pleura rubbing together
-associated with TB, pneumonia, pulmonary infarction, cancer
-steroids and antibiotics
Heart Sound S?
-closure of the mitral and tricuspid valves at the beginning of ventricular contraction
Heart Sound S?
-closure of pulmonic and aortic valves
-occurs when systole ends; ventricles relax
Heart Sound S?
-abnormal and may suggest CHF
Heart Sound S?
-abnormal and indicative of cardiac abnormality such as myocardial infarction or cardiomegaly
Heart murmurs
-sounds caused by turbulent blood flow
-heart valve defects or congenital heart abnormalities
-can occur when blood is pushed through an abnormal opening (ASD, PDA)
Bruits
-sounds made in an artery or vein when blood flow becomes turbulent or flows at an abnormal speed.
-usually heard via stethoscope over the identified vessel (carotid artery)
Blood pressure
-systolic and diastolic pressures
-sphygmomanometer to measure cuff pressures
-?BP = cardiac stress = hypoxemia
-?BP = poor perfusion = hypovolemia, CHF
Costophrenic Angle
-angle made by the outer curve of the diaphragm and the chest wall
-obliterated by pleural effusions and pneumonia
Diaphragm
-dome shaped normally
-flattened with COPD
-hemidiaphragms may shift downward with pneumothorax
-right hemidiaphragm is level of 6th anterior rib and slightly higher than the left
-right lung: 55% and appear larger than left lung
Lateral decubitus CXR
-patient lying on affected side
-detecting small pleural effusions
End expiratory film
-taken when patient is at end-exhalation
-detecting small pneumothorax/foreign body aspiration (FBA)
Position of ET/Tracheostomy tube
-tip should be positioned below the vocal chords and no closer than 2 cm or 1 inch above the carina.
-approx same level of the aortic knob/arch
-observation and auscultation will quickly determine adequate ventilation before CXR is taken
-cuff should not
Pacemaker, catheters, Etc.
-pacemaker should be positioned in the right ventricle
-PAC should appear in right lower lung field
-central venous catheters are placed in the right or left subclavian or jugular vein and should rest in the vena cava or right atrium
-chest tubes should b
Croup (laryngotracheobronchitis)
-viral disorder
-narrowing subglottic swelling
-steeple/picket fence/pencil sign
-gradual onset
-infants
-Mist tent, O2, Racemic epi, corticosteroids
-barking cough
Epiglottitis
-bacterial infection
-supraglottic swelling with an enlraged and flattened epiglottis and swollen aryepiglottic folds
-Thumb sign
-Rapid onset
-pediatrics
-provide airway and antibiotics
Computerized Tomography (CT scan)
-X-ray through a specific plane and appear as slices of organs/body parts
-diagnosis of bronchiectasis
-spiral CT scan w/ contrast dye for PE
Magnetic Resonance Imaging (MRI)
-2D view without use of radiation
-used for determining thoracic aneurysms, congenital abnormalities of the aorta and major thoracic vessels esp. the hilar area
-able to locate precise position of tumors
V/Q scan
Ventilation scan
-Radioisotope (xenon) gas is inhaled
-and obstruction to airflow will allow little gas to enter
Perfusion scan
-albumin, tagged with radioactive iodine is injected into a peripheral vein and lodges in the pulmonary capillaries
-scanned ov
Barium swallow (esophagram)
-for diagnosing of abnormalities in the hypopharynx, esophagus, or stomach
-ingested and traced through the hypopharynx and into the esophagus via fluoroscope and xray at the end
-suspected esophageal malignancy, dysphagia, congenital defect in hypopharyn
Positron Emission Tomography (PET scan)
-for determining cancer, brain disorders and heart disease
-injected with radioactive substance
bronchography (bronchogram)
-injection of radio-opaque contrast into tracheobronchial tree
-study of OBSTRUCTING LESIONS (tumors) and BRONCHIECTASIS
-better administration of postural drainage
Electroencephalography (EEG)
-measures electrical activity in the brain
-brain tumors, traumatic brain injuries, retardation, loss of brain function, epilepsy/seizures,
-EVALUATION OF SLEEP DISORDERS
Pulmonary Angiography
-most definitive for DX of pulmonary embolism
-pressures in cardiac chambers can be measured
-inserted into the femoral vein and advanced through the right heart and into the pulmonary artery which could identify filling defects
ultrasonography of the heart (Echocardiogram)
-noninvasive for monitoring cardiac performance
-doppler color flow mapping with 2D and M-Mode achocardiography to assess overall ventricular function including LEFT VENTRICULAR VOLUME and EJECTION FRACTION
-Valvular disease or dysfunction
-myocardial dis
ICP monitoring
-track the dynamics inside the skull such as volume-pressure relationships, pressure waves, and cerebral perfusion pressures
-ICP > 20 mm Hg = hyperventilated until PaCO2 is 25-30 mmHg
CAUSES
-Intracranial tumors
-Abscesses
-Meningitis
-Cerebral Edema
-Su
3 types of ICP monitoring
-Ventricular Catheter: inserted through a burr hole (surgical opening into the skull
-Subarachnoid bolt: metal screw with sensor chip that is inserted through a hole drilled into the subdural or subarachnoid space
-Epidural Sensor: consists of placement o
Cerebral Perfusion Pressure (CPP)
-Pressure gradient that determines cerebral perfusion
-CPP = MAP - ICP
-Normal Value 70 - 90 mmHg
Exhaled Nitric Oxide (NIOX) Testing
-Measurement of nitric oxide concentration (FENO) in patient's exhaled breath
-used to monitor asthma patient's response to anti-inflammatory (corticosteroid) treatment
-decrease in FENO suggests a decrease in airway inflammation
Sputum colors
Clear = normal
Mucoid = white/gray, chronic bronchitis
Yellow = presence of WBC, bacterial infection
Green = stagnant sputum, gram neg bacteria (Bronchiectasis, pseudomonas
Brown/dark = old blood
Bright red = hemoptysis (bleeding tumor, TB)
Pink frothy =
Sputum tests
sputum culture = identify bacteria present (days)
Sensitivity = identify what antibiotics will kill bacteria
Gram Stain = whether Gram positive or negative (5mins)
Acid Fast Stain = identify mycobacterium tuberculosis
can be done on blood, urine, and pleu
Oscilloscope
-provides a continous visual image of the electrical activity of the heart on a screen
-displays rapid changes in voltage as a moving line on a phosphorescent screen
Four Critical Life Functions
-Ventilation
-Oxygenation
-Circulation
-Perfusion
Signs
-Objective information
-things that can be seen or measured
Symptoms
-subjective information
-things that the patient must tell you
Respiratory care orders
-type of treatment
-frequency
-medication dosage and dilution
-physician signature
CALL MD IF MISSING
CVP abnormalities
-decreased CVP = hypovolemia
-increased CVP = hypervolemia
Katz ADL
-Activities of Daily Living: Bathing, eating, dressing, toilet, transferring, urine and bowel continence
-patient is unable to perform or needs assistance = score of ZERO
-patient needs no direction or assistance = score of ONE
-6 = independent
-4 = impai
General malaise
-run down feeling, nausea, weakness, fatigue, headache
-ELECTROLYTE IMBALANCE
Diagnosis of Pulmonary Embolism (PE)
-Pulmonary Angiography
-V/Q Scan
-Spiral CT Scan
Chest ECG electrodes
-V1 = 4th intercostal space on right side of sternum
-V2 = 4th intercostal space on left side of sternum
-V3 = between V2 and V4 on left side
-V4 = 5th intercostal space, left mid-clavicular line
-V5 = between V4 and V6 on left side
-V6 = 5th intercostal
Estimating heart rate on ECG
-two R waves between 3-5 large boxes = normal
-two R waves closer and 3 large boxes = tachycardia
-two R waves wider than 5 large boxes = bradycardia
Sinus Bradycardia
Rate less than 60
Treat with Oxygen/Atropine
Multifocal PVC
Premature Ventricular Contraction (PVCs)
Ventricular Tachycardia (V-Tach)
Ventricular Fibrillation (V-Fib)
Asystole
1st Degree AV Block
2nd Degree AV Block
3rd Degree AV Block
Ischemia
-reduced blood flow to tissue
-indicated by a depressed or inverted T-WAVE
Injury
-indicated by an elevated ST segment
Infarction
-diagnosed by significant Q waves
APGAR Score
-1 minute will determine neonatal survival
-5 minute predicts future neurological outcome
-0-3 resuscitate
-4-6 Stimuiate (stimulate, warm, O2)
-7-10 Monitor (Routine care)
Transillumination
-Normally a small lighted halo around point of contact
-a pneumothorax or pneumomediastinum will cause the entire hemithorax to light up (LARGE HALO)
Dubowitz Method
-assessment of gestation age
- >40 = post term (meconium)
- <40 = pre term (IRDS)
New Ballard Score (NBS)
-modification of dubowitz
-score of 40 = 40 weeks
Pre and post ductal blood gas
-R to L shunt across ductus arteriousus, PaO2 from pre-ductal(right arm) often exceeds PaO2 from post-ductal(umbilical or legs)
-pre ductal is 15 torr higher than post ductal = PDA w/ R to L shunt
-echocardiogram recommended
Capnography
-PaCO2 = 40 torr/PetCO2 = 30 torr
-increase in PECO = decreased ventilation (vent failure)
-decrease in PECO = increase in ventilation (PE, hypovolemia)
-low petco2 after intubation = esophagus
-during CPR, PETCO would increase
Transcuataneous Monitoring
PO2 and PCO2 measurement
-heat to 43-45 �C
-correlates well with arterial values as long as perfusion is adequate
Pressure Transducer
-if transducer is above the catheter, readings are LOWER
-if transducer is below the catheter, readings are HIGHER
Hemodynamics
Swan-Ganz Catheter
-When the balloon is inflated, the catheter will WEDGE and the back pressure from the pulmonary capillary will be measured
-measuring PAP = balloon deflated
-double spike (dicrotic notch) is normal for PAP
-Pressure Dampening = obstructed catheter (blood
Oropharyngeal Airway
-UNCONSCIOUS PATIENT
-supports base of tongue
-Bite block
-facilitate oral suctioning
-should be left unsecured
-gagging: remove-suction-oxygen
Nasopharygeal Airway
-CONSCIOUS PATIENT
-supports base of tongue
-facilitate deep tracheal suctioning
-decrease trauma during NT suctioning
-increased airway resistance (USE LARGEST SIZE)
-inserted anatomically shaped with lubricant
NARCAN
-Narcan - Narcotic overdose
-Atropine - Bradycardia
-Valium/Versed - Sedation
-Epinephrine -Asystole
-Lidocaine - PVC
- X2 normal IV dose + 10 mL saline
Cuff Pressures
-20 mmHg / 25 CM H20
- >5 - lymphatic - edema
- >10 - vein - edema
- >20 - artery - necrosis
-Low pressure, high volume, high compliance, floppy cuff is preferred
Cricoid Pressure
-Sellick maneuver
-indicated if larynx is in an anterior location
Assessment of Tube Position
- Inspect for bilateral chest expansion
- Ausculate for bilateral breath sounds
- Capnography or CO2 detectors
- Chest X-ray 2cm or 1 inch above carina or at aortic knob/notch
Laryngoscope
-mac: into vallecula, indirectly raises epiglottis
-miller: directly under and lifts the epiglottis (infants)
-tighten bulb, check handle attachment, change blade, check batteries
Stylet
-recessed 1 cm above tip of ET tube
Laryngoscope Blade Sizes
Adult: 3
Pediatric: 2
Term infant: 1
Pre-term infant: 0
ET Tube Size
pre-term: 2.5 - 3
Full term: 3.0 - 3.5
Adult: wt in kg / 10
Adult male: 8 - 9
Adult female: 7 - 8
Tube Markings
Oral Intubation: 21-25 cm mark at patient's lips
Nasal intubation 26-29 cm mark at patient's nares
Double-Lumen ET tube
-Endobronchial/Carlen's tube
-can ventilate one lung separately
-two cuffs: distal cuff is high pressure, low volume for mainstem bronchus tube
-during pneumonectomies, lobectomies
-for bronchopleural fistulas etc
Esophageal Tracheal Combitube
-for emergency airway management
-if placed in trachea, distal balloon will seal trachea(ET tube) and clear #2 is used for ventilation
-if placed in esophagus, distal balloon will occlude esophagus
-ventilation will be provided through blue #2 longer tube
Laryngeal Mask Airway (LMA)
-positioned directly over trachea (hypopharynx)
-standard ET tube can be inserted directly through LMA into the trachea
-short term ventilation
Hi-Lo Evac Tubes
-for Continuous Aspiration of Subglottic Secretions (CASS)
-continuous suction via separate pilot tube @ 20 mmHg
-reduce VAP
Extubation
-inspire deeply
-remove tube at PEAK INSPIRATION to prevent vocal cord damage
MARKED distress/stridor = reintubate
moderate stridor = O2-Cool Mist-Racemic epinephrine
mild stridor = humidity, O2, Racemic epinephrine
Tracheostomy
-for long term ventilation
-cuff should be inflated when eating & PPV
-if obsructed = pass catheter, remove tube, ventilate and insert new tube
-clean with hydrogen peroxide
Fenestrated tube
-Used for weaning
-not for codes or emergencies
-when plugging the tube, deflate cuff, remove the inner cannula and then plug the trach tube
Tracheal button
-used to maintain stoma
-patients with sleep apnea
Jackson trach tube
-Metal trach tube
-not for resuscitation or PPV
Tracheal speaking Devices
-one way valve that attaches to trach
-cuff must be deflated
Tracheostomy Care
-clean the inner cannula by soaking it in a solution of hydrogen peroxide and water, rinse with sterile water
-clean the stoma site using cotton spplicators dipped in the water-hydrogen peroxide solution, replace gauze dressing
Laryngectomy & Laryngectomy tubes
-pt will breath through a laryngectomy tube initially
-pt cannot be orally or nasally intubated
-tube will be removed after 3-6 weeks then pt will have a permanent stoma
-tubes do NOT have an inflatable cuff
Remove Bronchopulmonary Secretions
-remove/improve mobilization of secretions
-for Bronchiectasis & CF
-not for TB, post-op, unstable pulmonary and cardiovascular system
Supine
for post-craniotomy patients
Fowlers, semi-fowlers, reverse trendelenburg
-for hypoxic, obese with dyspnea, post-op abdominal patients, and pulmonary edema
Trendelenburg
-patients with very low blood pressure
Lateral fowlers
-for very obese patients with air hunger
Lateral Flat
-best position to prevent aspiration
-if aspirating, first suction and then place in opposite position for postural drainage
unilateral consolidation
-place the affected lung up to allow it to drain and to increase perfusion to the unaffected lung
-BAD LUNG UP, GOOD LUNG DOWN
Postural Drainage Position
Left upper and right middle lobe: 15 degrees and 12-14 inches up
Lower lobes: 30 degrees and 18 inches up
Chest Percussion
-used in combination with postural drainage
not for PE, pleural effusion, tuberculosis and untreated pneumothorax
Positive Expiratory Pressure (PEP) Therapy
-applying positive pressure using a one-way inspiratory valve and a one-way expiratory resistor
-expiratory pressure from 10 - 20 cmH20 at mid-exhalation
-used for 15-20 mins 3-4x/day
-improve secretion expectoration, reduce RV (decrease hyperinflation) a
Autogenic Drainage
-primarily for CF and bronchiectasis
-breathe at low lung volumes to loosen secretions from the small airways
-helps to accumulate secretions in the middle airways
-during the last stage the patient breathes at high lung volumes
Intrapulmonary Percussive Ventilation
-Combination of high frequency pulse delivery (100-250 cycles/min of a sub-tidal colume and a dense aerosol
-percussive effect of gas delivery improves ventilation past obstructions in the airway thereby delivering more aerosol to the distal airways.
-Den
Discontinuing bronchial hygiene
-clear breath sounds and x-ray
-ambulating well
-strong cough
-afebrile for 24 hours
-hazards occur (dizziness, SOB, cyanosis, etc.)
iatrogenic hypoxemia
induced by a physician's words or therapy (used especially of a complication resulting from treatment)
can be caused by suctioning
Suction Pressures
Adult: 100 - 120 mm Hg
Child: 80 - 100 mm Hg
Infant: 60 - 80 mm Hg
Coude tip catheter
suction catheter angles to help suction the LEFT main stem bronchus
Closed system/inline suction catheter (Ballard)
-allows patient to recieve ventilation and oxygenation during suctioning
-for pt with high oxygen/PEEP requirements, pulmonary infections, frequent suctioning and hemodynamic instability
Catheter sizes
-ideal length is 20 - 22 inches
-external diameter of the suction catheter should be no greater than 1/2 the inside diameter of ET/trach tube
Lukens trap/sterile suction trap
-collect sputum specimen
-placed in an upright position between the suction catheter and the suction tubing
-flush catheter with sterile water or isotonic saline
-saline for cytology samples
Change size and type of catheter if
-difficulty removing secretions (verify appropriate size for airway)
-change to Coude Catheter for LEFT main stem bronchus
-change to closed system if pt has an infection, PEEP, or frequent desaturation
Altering negative pressure
-increase negative pressure to remove thick tenacious secretions
-do not exceed appropriate pressures
Instill irrigating solutions
-5-10 mL of normal saline to dilute secretions too thick to aspirate
-5-10 mL of 10% solution of Acetylcysteine (Mucomyst) can be used for thick tenacious secretions + bronchodilator
Troubleshooting Suctioning procedure
-check catheter for patency
-assure vacuum is working/appropriate pressure
-change or empty a full collection bottle
-check all connections
Bubble humidiifier
-incorporates pressure pop-pff valves set at 2 psig/40 mm Hg
-check by occluding or pinching the connection tubing and listen for whistling sound
-if no sound = leak
Troubleshooting bubble humidifiers
-efficiency depends of water level in the reservoir = replace or refill if non disposable
-if whistling = flow too high or obstructed tubing
Passover or blow-by humidifer
-evaporation occurs as gas passes over the water container/reservoir
-least effective in humidifying an artificial airway unless heated
-commonly used in conjunction with infant ventilators and circuits
Heat Moisture Exchanger (HME)
-should be located in the vent circuit between the wye and the patient (where deadspace is located)
-creates a small VD
-can cause increased delivery pressure = replace HME
-removed during aerosol therapy
-not as effective as humidifiers and increase/thic
Wick Humidifers
-can deliver 100% body humidity (44mg/L)
-low risk of cross contamination (nosocomial infection) because no particles are being produced
-for vents, CPAP, etc
Heated Wire Circuits
-minimizes circuit condensation
-wire like structure inside the vent circuit to maintain a set gas temperature thru the entire circuit
-can be both limbs or just inspiratory limb
Jet Nebulizers
-utilize Bernoulli's principle to create an aerosol then encounter a baffle
-creates particles within therapeutic size range (1-10 microns)
HHN/SVN
-1 to 3 second breath hold is important to enhance medication delivery
-sputtering sounds indicates that all of the solution has been nebulized
Large Volume Nebulizers
-deliver bland aerosol to upper airway
-output: 1-2 mL/min
-heating element for thick secretions
-FiO2 decreased = air entrainment is increased. lower mist density, total flow or mist output increases (vice-versa)
-increase in resistance such as water in
LVN not misting enough
-clogged capillary tube
-insufficient flow
-decrease in temperature causing condensation
-mist in short puffs = condensation = drain
-
LVN + blender
-set blender at desired FiO2
-Set LVN air entrainment @ 100%
Scavenger systems
-removes medications not inhaled by the patient
-commonly used when administering Pentamidine and Ribavirin
Ultrasonic Nebulizers
-uses vibrational energy
-highest output range
-clean with acetic acid
-for thick and tenacious secretions
increasing mist in USN (troubleshooting)
-check for low fluid
-increase amplitude (volume)
-increase blower flow and check filter
-check for water in tubing
-DO NOT adjust frequency (factory)
-not grounded
Metered Dose Inhaler
-1 to 2 inches off mouth
-inhale slowly and press once
-hold breath for 10 seconds
-if quick relief, wait one minute in between puffs, no wait with other meds
Modifying Therapy
-change type equipment (USN for thick secretions)
-change dilution of medication
-adjust temp of aerosol (jet nebulizer @ 37 C)
-modify breathing patters (slow/inspiratory hold)
-change aerosol output (tandem set up)
Alpha Response
-Vasoconstriction
-blood pressures
Beta 1 Response
-increase rate (chronotropic) and strength of contraction (inotropic) of cardiac muscle
-cardiac drugs
Beta 2 response
-Bronchodilator
If bronchospasm/wheezing persists
-increase to max dose first then increase frequency
Methylxanthines
-side door bronchodilators
-theophylline 10-20mg/mL
-theophylline is also given to increase diaphragmatic contractility and stimulate CNS in infants with apnea of prematurity.
-Serum levels are kept at 5 - 10 mcg/mL in neonates and children
Nystatin
-antifungal agent to treat thrush
-rinse mouth with water after ICS treatment
Acetylcysteine (Mucomyst)
-liquify thick tenacious secretions
-ACETAMINOPHEN OVERDOSE
-give bronchodilator prior to acetylcysteine
- 3 to 4 mL of 10 - 20%
Hypotonic Saline
-0.45% saline
-liquefying secretions and humidifying the airway
Hypertonic Saline
-15% saline
-induce sputum specimens, can irritate the airway and cause bronchospasm or secretion obstruction
Leukotriene modifiers
-Non-steroid drugs for mild to moderate persistent asthma
-Montelukast, Zafirlukast, Zileuton
Cardiac Glycosides
-for CHF (increases CO; inotropic)
-digitalis (crystodigin)
-digoxin (Lanoxin)
Lidocaine
-PVC
-pulseless v-tach/v-fib
procainamide
-Pronestyl
-Ventricular ectopic beats, v-tach, and atrial arrythmias
atrial arrhythmias
quinidine, propanolol(inderal)
verapamil
-control ventricular rates in narrow complex SVT
amiodarone
-pulseless VT and V-fib that has not responded to defibrillation
Bradycardia
-atropine
-epinephrine
Angina
-Nitroglycerin
-isordil
Vasopressors
-alpha adrenergic
-increases BP
-norepinephrine (levophed) =cardiogenic shock
-Dopamine and dobutamine
Mannitol
-Osmitrol
-for Head injuries and overdose
Nondepolarizing neuromuscular blocking agents
-results in complete paralysis
-pancuronium (pavulon
-vercuronium (norcuron)
-atracurium (tracrium)
-cisatracurium (nimbex)
ALWAYS SEDATE THEN PARALYZE
Benzodiazepines
-sedative
-alprazolam (Xanax)
-diazepam (Valium)
-Midazolam (Versed)
-lorazepam (Ativan)
-antagonist = flumazenil (Romazicon)
Modified Ramsay Scale
1 = agitated, anxious, restless
2 = calm, cooperative, oriented
3 = responds to verbal commands
4 = brisk response to touch
5 = paralyzed
sedation level 3 should be achieved
Anesthetics
-propofol (Diprivan) for anesthesia and sedation of ventilated patients
-ketamine (Ketalar)
Analgesics
-reduce sensation of pain (Opiods)
-reversed with naloxone (Narcan)
-morphine
-fentanyl
-codeine
-hydrocodone
-oxycodone (Oxycontin)
-hydromorphone (Dilaudid)
-meperedine (Demerol)
Surfactant
-prevent/treat IRDS/HMD
-prophylactic/Rescue
-adverse effect: pneumothorax, devreased vital signs
respiratory stimulants
used to treat sleep apnea
Antibiotics
-cillins = gram positive
-myacins = gram negative
-coccus = gram positive
-everything else = gram negative
-common side effect: diarrhea
-Vancomycin = MRSA
Antiviral agents
-Ribavirin = treat RSV
-RSV Immune Globulin IV (RespiGam) = prevention of RSV
-palivizumab (Synagis) = man-made antibody to RSV
pentamidine
-treat Pneumocystis Jirovecii (carinii) infections (commonly with AIDS)
-must use one way valve and bacteria filter to avoid spreading
Vaccines
-against influenza and staphylococcus pneumoniae = Pneumovax for > 60 yrs
-Children at risk for RSV should be immunize with RespiGam and Synagis
Patient Positions
-Prone = ARDS
-Fowler's = CHF
-Lateral Fowler's = obese
-good lung down for unilateral lung disease
Sustained Maximal Inspiration (SMI)
-Prevention of atelectasis
-Date, time, volume should be charted (not durations)
-must be taught before surgery
-auscultate BS before and after
-Inhale! not exhale
IPPB Indications
-Prevent or correct atelectasis in patients unable to take a deep breath
-prevent/decrease pulmonary edema
-decrease WOB
-mechanical bronchodilation
-distribute aerosols more evenly
-Hazards include: hyperventilation (breathe slower), Impeding venous retu
Bird Mark 7
-Pressure Cycled
-increase flow = decrease i-time
-Air mix off = 100% source gas, low flow rate because air not entrained, increase flow setting when air mix off
-pressure limit controls volume
-
Bird Mark 7 changes that affect FiO2
-increase pressure will increase FiO2
-decrease flow will increase FiO2
-Air mix off will give 100% FiO2
-use of nebulize will increase FiO2 on PR-II
-Use of terminal flow on PR-2 will decrease FiO2
Bird Mark 7 control changes that affect volume
-increasing pressure will increase volume
-decreasing flow will increase volume
-increasing the flow will decrease volume
Bird Mark 7 control changes that affect the I:E ratio
-increased pressure will increase i-time and change I:E
-increased flow will decrease i-time
-increased rate will decrease e-time
IPPB Troubleshooting
-Loss of pressure = leak, low flow
-Excessive pressure = obstruction, excessive flow
-fail to cycle into inspiration = sensitivity, seal around mouthpiece
-fail to cycle into expiration = leak (mouthpiece, cuff, trach tube, loose connection)
-Pressure doe
Mask CPAP
-short term, temporary use
-CO poisoning
-pneumonia
-post-op atelectasis, etc.
Nasal CPAP
-neonates since they are obligate nose breathers
-readjust nasal prongs if losing CPAP
Troubleshooting CPAP
-loss of pressure = leak, insufficient flow
-increased pressure = obstruction, excessive flow
Non-Invasive PPV (NPPV)
-avoid intubation in patients with COPD, CHF, and pulmonary edema
-long term ventilation at home
-periodic support with NMD, restrictive chest wall, sleep apneas
General Considerations of NPPV
-patient with uncomplicated obstructive sleep apnea started @ EPAP of 5-10 cmH2O
-patient started on EPAP for hypoxemia at 6-8 cmH2O and increased as necessary
-patients with NMD @ 10-15 cmH2O
-low level of EPAP (5cmH2O) prevents small airway collapse on
Capillary Samples
-should not be used to monitor oxygen therapy
-PO2 values DO NOT correlate very well with arterial blood, especially when arterial PO2 is >60 torr
Air Bubbles in ABG sample
-PaCO2 decreases toward 0 torr
-PaO2 increases to 150 torr
-pH increases
Improper cooling of ABG sample
-PaCO2 increases
-PaO2 decreases
-pH decreases
Too much heparin in ABG sample
-pH decreases towards 7.0
-PaCO2 decreases toward 0
-PaO2 increases towards room air
Severinghaus Electrode
Measures PCO2
Clark Electrode
Measures PO2
Sanz Electrode
Measures pH
Levey Jennings Charts
-detecting a machine that is out of control
-�2 Standard Deviations
-If random error = do nothing
A-a Gradient interpretations
-25-65 mmHg on 100% = Normal
-66-300 mmHg = V/Q Mismatch
->300 mmHg = shunting
each 100 mmHg = 5% shunt + 5% normal shunt
C(a-v)O2 interpretations
-CvO2 values will decrease when cardiac output decreases
-SvO2 values also decrease when cardiac output decreases
-C(a-v)O2 difference will increase when the CvO2 is decreasing and would indicate a decreasing cardiac output
PaO2/FiO2 ratio interpretations
->380 torr = normal
-<300 torr = ALI
-<200 torr = ARDS
OHDC curve LEFT
-increased oxygen affinity
-increase pH
-decrease CO2
-decrease Temp
-decrease 2-3 DPG
OHDC curve RIGHT
-decreased oxygen affinity
-decrease pH
-increase CO2
-increase Temp
-increase 2-3 DPG
Spirometers
-Measures Volumes and flow rates
Dry-rolling seal
-horizontal piston spirometer
-measures volume and time
Water-seal
-Collins, Stead-Wells spirometer
-measures colume and time
-most accurate and best to check accuracy of PFT equipment
Pneumotachometers
-measures flow
-turbine device (Wright respirometer
-measures flow and may display volume
-Pressure Differential (Fleisch) measures flow
-can continuously measure VE
Plethysmograph
-Body Box
-Measures thoracic gas volume (TGV) which is the same as FRC and also Raw
-accurately measure FRC with COPD
3L syringe
-accuracy must be �3.5%
-2.9 - 3.1
-Calibrate with flows between 2 and 12 L/sec
Galvani fuel cell
-creates electron flow as a result of the oxidation/reduction of O2 (current)
-change fuel cell
-can be affected by water on sensor, high pressures, and altitude
-must be 2% of known value
Polarographic
-similar to galvanic except for the presence of a battery used to polarize the electrodes
-change batter and check electrolyte level
-can be affected by water on sensor, high pressures, and altitude
-must be 2% of known value
SVC
-Slow Vital Capacity
-provides the important VOLUMES used to identify RESTRICTIVE DISEASES
Restrictive Disease
Decreased Volumes
Obstructive Disease
-Decreased Flows
-FEV1
-FEF 200-1200
-FEF 25-75
-PEFR
FEV1/FVC
-best indicator of obstructive disease
-FEV1 decreased but FEV1/FVC ratio is normal = restrictive disease only
-minimum acceptable: 70-75%
FEF 200-1200
-first 1000 mL after 200 mL expired
-decreased = large airway obstruction
FEF 25-75%
-mid portion of the FVC
-decreased in the early stages of obstructive disease
-small airway obstruction
Peak Expiratory Flow Rate
-sometimes used to evaluate asthmatic patients, pre & post bronchodilation
FVC
-VOLUME and should be equal to SVC
-FVC<SVC = obstructive
-FVC cant be completed in 3 seconds = obstruction
Pre and Post bronchodilator Testing
-increase of 12% and 200 mL in the FEV1 post study is significant
-bronchodilator therapy should be held 8 hours prior to testing
Flow Volume Loops
-volumes and flow rates of the FVC
-Restrictive: skinny & tall
-Obstructive: short and wide
Diseases with Decreased DLCO
-Pulmonary fibrosis
-Sarcoidosis
-ARDS
-Edema
-Emphysema (Obstructive)
Bodaii adapter
-for patients receiving CMV during a bronchoscopy
-prevent loss of: Pressure, PEEP, VT
-High Frequency Jet ventilator preferred if not tolerating during bronchoscopy
-decontaminate with Cidex
Transport Ventilators
If respiratory rate or tidal volume decreases on pneumatic transport ventilator = check cylinder pressure
Ventilator Alarms
-10 above/below pressure limit
-100 mL minimum exhaled volume
-Fio2 = 5%
Initial Vent Settings - Infants
-Mode: IMV
-PIP: 20 - 30 cmH20
-RR: 20-30
-I-time: 0.5 - 0.6 seconds
-Flow: 5-6 L/min
-FiO2: same level
-PEEP: +2 - +4 (max 8)
-VT: 4-6-8 ml/kg
DeadSpace Ventilation
-1 mL per lb of IBW
-10 mL per inch of flex tubing (5" = 50mL VD)
Controls that affect MAP
-PEEP
-PIP
-RR
-I-time
-Peak Flow
-TIdal Volume
-Inflation Hold
Assist/Control Mode
-allows patient to set the respiratory rate
-ventilator will maintain a minimum rate
-may be used with most patients in most cases
-Ventilator control tidal volume for every breath
SIMV mode
-USED FOR COPD TO NORMALIZE ABG
-USED FOR TACHYPNEA TO AVOID HYPERVENTILATION
-WEANING
-Reduce barotrauma (PEEP)
Pressure Control Ventilation
-patients requiring high FiO2 and PEEP
-High PIP
-Low PaO2 and decreased compliance
High Frequency Ventilation
-Rate = Frequency
-Volume - Amplitude
-% inspiratory time - I-time
-lower peak and mean airway pressure
-bronchopleural fistula/ARDS
-Pulmonary air leak (PIE)
-Paw is set 2-5 cmH2O above MAP on CMV
High Frequency Positive Pressure Ventilation
-HFPPV
-150 - 300
-2-5 hertz
High Frequency Jet Ventilation
-HFJV
-100-600
-1.5 - 10 hertz
High Frequency Flow Interrupter Ventilation
-HFFIV
-120-1320
-2-22 Hertz
High Frequency Oscillator Ventilation
-HFOV
-180-2200
-3-36 Hertz
Normalize a high PaCO2
-decrease or remove DEADSPACE
-Increase the tidal VOLUME
-increase the RATE
Normalize a low PaCO2
-increase the DEADSPACE
-Increase the RATE
-Decrease the tidal VOLUME
target for closed head injury patients is 25-30 torr
Normalize a high O2
-Decrease the FiO2 first at or above 60%
-once the FiO2 is below 60% then reduce PEEP/CPAP
Normalize a low O2
-increase FiO2 by 5-10% up to 60%
-Increase PEEP by 2 -5 cmH2O
Sigh Volume and rate
-Used to decrease microatelectasis
-sigh volume set at double Vt or less (1.5-2x Vt)
-Rate set at 1 -3 sighs every 4-15 minutes
Sensitivity controls
-Pressure trigger: 1-2 cmH20 below baseline
-Flow Trigger: 1-3 L/min below baseline or bias flow
PEEP/CPAP Therapy
-increase FRC
-increase compliance
-2-10 cmH2O physiologic
-11-30 cmH2O therapeutic
-lowest amount necessary = optimal
Therapeutic PEEP
-PaO2 increases
-Static compliance increases
-CO/CI increases
-Hemodynamics are stable
-stable PVO2, SVO2, A-a DO2
PEEP/CPAP too high
-PaO2 decreases
-Cstat decreases
-CO/CI decreases
-Hemodynamics increase
-decreased PVO2, SVO2
-closed head injuries or low BP, increase FiO2 instead
Vent protocols for ARDS
-VT: 4-6 mL/kg
-Pplat < 30 cmH20
Vent protocols for asthma
-VT: 4-6 mL/kg
-RR: 10-12
-permissive hypercapnea
Recruitment maneuvers
-CPAP of 30-40 cmH2O for 40 secs
-PEEP of 20 & PIP of 40
-Sustained inflation
-PCV with increased PEEP
-Increase PIP in increments of 5
-Sigh breaths
Flow-Volume Loops
-Flat is bad
-Must return to baseline
-oblique-shaped
Weaning criteria
-VT: >5 ml/kg
-VC: 1000 ml
-VE < 10 L/min
-MIP/NIF: > -20 cmH2O
-MEP: >40
-RSBI <100
-A-a DO2: <300 mmHg
-QS/QT: < 20%
-VD/VT: <60%
Lowest settings on the vent prior to extubation
-SIMV @ 4 bpm
-FiO2: 40%
-PEEP: 5 cmH2O
Weaning Methods
-T-Piece Trial
-SIMV
-PSV
-no sedatives
Summary of adverse conditions (STOP&NOTIFY)
-increased HR >20 bpm
-Change in BP by 10 - 20 mmHg
-Increased PaCO2 by >10 torr
-RR increases by >10 or >30 bpm
Head-tilt/Chin-lift
-preferred method for establishing airway during CPR
-not for trauma (Neck fracture)
Jaw Thrust
-establishing airway for patients with suspected neck fractures
Effectiveness of CPR
-Carotid pulse should be present during compressions
-Return of Spontaneous Circulation (ROSC) = abrupt increase in PETCO2
-Do not remove cervical collar - check femoral pulse
-ECG shows sinus rhythm with no pulse = Continue CPR
Hypotension
-Fluid Challenge (1-2L Normal Saline or lactated Ringer's
-Vasporessor (Dopamine, Dobutamine)
Bardycardia
-Atropine, dopamine, and epinephrine for adult
-Epinephrine and Atropine for children
-trancutaneous or transvenous pacing if no response
Ventricular Arrhythmias
PVC: O2 and Lidocaine
PVT: Defibrillate - Epinephrine - Amiodarone
V-Fib: Defibrillate - Epinephrine - Amiodarone
Cardioversion
-Midazolam(Versed) given prior
-synchronizing: ON
-delivered on R wave
-Monophasic: initial is 200 joules
-Biphasic
-Unstable A-Fib: 120-200 joules
-Unstable SVT or A-Flutter: 50-100 joules
Defibrillation
-PVT
-V-Fib
-Biphasic: 120-200 joules
-Monophasic: 360 joules
-Synchronizing: OFF
Self-Inflating Resusciation bag
-Adult: 800 mL
-Infant: 200 mL
-has Universal connector with a 22 mm OD and 15 mm ID
-pressure relief (25cmH2O) for pediatric
Troubleshooting Ambu-bag
-if bag fills rapidly and collapses easily on minimal pressure, check inlet valve
-if bag becomes difficult to compress and patient compliance is normal, patient valve may be stuck open or closed
-Excessively high flow may causes valves to jam. Use 15L/mi
Transport
-0 to 80 miles: Ambulance
-81 to 150 miles: Helicopter
->150 miles: Fixed wing Aircraft
-use HME
-If RR or VT deceases on pneumatic transport vent, check tank pressure
-PaO2 will decrease as altitude increases during air transport, whether pressurized or
Pulmonary Edema/CHF
-100% FiO2
-Digitalis (inotropy) increases CO
-Lasix/Fowlers - decrease venous return
Pulmonary Embolism
-100% FiO2
-Anticoagulant
-Thrombolytic drugs
Thoracentesis
-for Pleural Effusion
-Patient sitting up or leaning forward
-3-10 mL of 2% lidocaine with 25 AWG needle
-7th or 8th intercostal space TOP RIB
-100 to 300 mL of pleural fluid is aspirated for diagnostic with 50 mL syringe
Inductive Plethysmography
-series of elastic bands are placed around the chest to measure chest movement (Respiratory effort) and breathing frequency
CPAP Titration
-starting CPAP 3-5 cmH20 max 20 cmH20
-CPAP before BIPAP
-increased increments of 1 cmH2O every 10 minutes to decrease or eliminate obstructive respiratory events
-initiate BIPAP if not tolerated, or ineffective @ 15 cmH2O
-FiO2 if <88%
-start @ 1L +1L un
BIPAP Titration
-initial of IPAP 8-10 and EPAP 3-5
-IPAP/EPAP increased by 1-2 until relieved
-increase IPAP if obstructive hypopnea, 2% desaturation or snoring
-increase EPAP with apnea and snoring
-FiO2 if <88%
-start @ 1L +1L until >90%
Chest Tube Placement
AIR: anterior chest (2nd intercostal in midclavicular line)
FLUID: 4th or 5th intercosal in midaxillary line
TOP RIB!
Chest Drainage System
Collection - Water Seal - Suction CTRL
-suction control regulates negative pressure
-water seal prevents air from entering pleura. bubbles = leak
-if water seal breaks, submerge chest tube in water. if on vent, leave on atm air
Valsalva Maneuver
-maneuver performed during removal of chest tube.
-patient exhales then performs valsalva maneuver
BronchAlveolar Lavage
-diagnosis and treatment of alveolar filling disorders (CF, Pneumocystis Pneumonia)
-diagnostic lavage = flexible bronchoscope + saline
-therapeutic lavage = large volume of saline
-lavage for entire lung = Carlen's tube to perform one lung at a time
Nasal Cannula
-1 - 6 L/min
-stable COPD patients
Simple Mask
-6 to 10 L/min
-must be at least 6LPM to flush out CO2
Partial rebreather
-6 to 10 LPM
-no one way flap valves
Non-Rebreather
-100% O2 in emergency (CO, CHF, Heliox) + Blender
-increase flow, seal mask if bag collapses
Air Entrainment Mask
-Irregular VT and RR and breathing patterns
-FiO2 remains the same regardless of flow from O2 inlet
-FiO2 will increase as diameter of gas injector increases, increased resistance (water) in tubing
-FiO2 decreases and total flow increases as air entrainme
Briggs Adapter (T-piece)
-reservoir maintains FiO2
-if reservoir removed, FiO2 will decreases due to entrained room air
-should see aerosol on inspiration
-if aerosol disappears: increase flow, add more reservoir tubing, or tandem
Oxygen Hood
-7 to 14 LPM to prevent CO2 buildup and maintain FiO2 without sealing the infants neck around the hood
-Monitor FiO2 - O2 analyzer near infants face
-use humidifier not nebulizer
Mist Tent, O2 tent, Croupette
-controls FiO2, Temp, Filtered gas, humidity and aerosol delivery
-for pediatrics
-12 to 15 LPM to flush CO2
-if FiO2 fluctuates, tuck in tent
-Jet, ultrasonic, and Hydronamic Nebulizer
-O2 analyzer near infants face
-monitor for fluid overload (weight ga
HyperBaric Oxygen Therapy
-CO poisoning
-Decompression sickness
-tisse transpalnts
-anaerobic infections
-2 to 3 ATA
-oxygen by mask or in-chamber @ 100%
Heliox
-decrease WOB in asthma, edema, obstruction, partial vocal cord paralysis
-80%/20% or 70%/30%
-Nonrebreather
-1.8 x flow for 80% = actual flow
-1.6 x flow for 70% = actual flow
Nitric Oxide Therapy
-relaxes smooth muscle = selective pulmonary vasodilation
-primary and chronic pulmonary hypertension, PE, RDS, CHF, PPHN, fibrosis
-initial 20ppm up to 80 ppm
-can cause Methehmoglobinemia
Disinfection
Destroying vegetative pathogenic microorganisms
Sterilization
complete destruction of all microorganisms
Vegetative organism
growing organism
Pathogenic organism
disease producing microorganism
Pasteurization
Disinfection process, kills vegetative organisms
Etylene oxide sterilization
sterilizes equipment by alkylation of enzymes
-affected by exposure and aeration time
-not for sterilizing a bronchoscope
Alkaline gluteraldehyde (Cidex)
-disinfection or sterilization
-bactericidal in 10 mins
-tuberculocidal in 10-20 mins
-sporicidal in 10 hours (sterile)
-plastics (tubing, nebulizer, humidifier)
-for flexible bronchoscope
Acid Gluteraldehyde (Sonacide)
-Disinfection or sterilization
-bactericidal in 10 mins
-tuberculocidal in 20 mins
-sporicidal in 1 hour
-can be used up to 28 days
Gram Negative Organisms
-Complicated names
-green sputum
-killed by "-myacins
Gram Positive Organisms
-causes pneumonia and infections
-"-coccus"
-killed by "-cillins
Pseudomonas Aeruginosa
-thrives in water containing equipment (LVNs)
-produces pink/green sputum
-Gram Negative
HIV/AIDS and Hepatitis
-Standard Precautions unless underlying infection present
-DOUBLE BAG prior to steriliation
Prevention of VAP
-use of closed suction system
-head elevated 30-45 degrees
-drain and discard condensate
-use Heated Wire Circuits or HME
-Daily sedation vacation to evaluate weaning and extubation
Home Infection Control
-Clean equipment daily
-wash with mild detergent
-rinse well with water
-soak in acetic acid (white vinegar) for 20 mins
-rinse, drain and air dry
Criteria for home oxygen therapy
-PaO2 <55 torr on RA
-SpO2 88% or less
-exercise limitation
-frequent oximetry required
-polycythemia or cor pulmonale
Reservoir Cannula
-maintain FiO2 at lower flowrates by using a reservoir
Transtracheal Oxygen Catheters (TTO2)
-low flow oxygen directly into the airway by surgically implanter catheter
-increase duration of cylinder flow
between 2nd and 3rd tracheal rings
-if SOB and increased WOB = obstructed + remove and clean
-reduced to 1/2 to 1/3 previous flowrate
Liquid bulk oxygen
-last longer than cylinders
-can cause frostbite/skin damage
-if spilled, let it evaporate
oxygen concentrators
-electric and limited portability
-has molecular sieves
-1 to 2 LPM continuously
-if sieves are not working - analyze FiO2, check circuit breaker, fuse
Croup
-Viral
-Upper Respiratory infection
-During winter
-<3 yrs old
-Gradual Onset
-Stridor at rest
-Cool mist tent
-Dexamethasone (steroid)
-Racemic Epinephrine
-Subglottic Edema (STEEPLE/PENCIL)
Epiglottitis
-Bacterial
-No Upper Respiratory Infection
-Anytime
-3-7 Years old
-Sudden Onset
-Drooling
-Extended neck
-Suspicion of epiglottitis
-Intubation and IV Ampicillin
-Supraglottic Edema
-Thumb Sign
-Obliterated vallecula
Mycobacterium Disease - Tuberculosis
-Night Sweats
-dry cough
-consolidation, fibrosis and cavity formation
-Respiratory Isolation
-Isoniazid, ethambutol, streptomycin, rifampin
Myasthenia Gravis
-Auto-immune response
-slow, fatigue improves with rest
-Descending (Mind to Ground)
-Positive Tensilon test
-Monitor VC/MIP
-Neostigmine, Pyridostigmine(MESTINON), short term mechanical vent
Guillain Barre Syndrome
-Delayed reaction to viral infection
-URI - Present
-Acute, Sudden weakness
-Ascending (Ground to Brain)
-Spinal tap - protein in spinal fluid
-Monitor VC/MIP
-Steroids, Prophylactic Antibiotics, long term mechanical vent/trach, plasmapheresis
ER Treatment for Asthma Attack
-Oxygen Therapy
-Aerosol therapy with A&A
-Oral Steroids
-Close Monitoring
-Intubation if respiratory arrest
-Heliox