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1,230 terms

Review for CRT

Review for CRT
STUDY
PLAY
Ventilation
Breathing air in and out of the lungs
Oxygenation
Getting Oxygen into the blood
Circulation
Moving the blood through the body
Perfusion
Getting Blood and Oxygen into the tissues
Ventilation
Respiratory Rate, Tidal Volume, Chest Movement Breath Sounds, PaCO2
Oxygenation
Heart Rate, Color, Sensorium, PaO2
Circulation
Pulse Heart Rate and Strength. Cardiac Output
Perfussion
Blood Pressure, Sensorium temperature, Urine Output hemodynamics
When you have an emergency what comes first?
1st is Ventilation (establish an open airway and breathe 2nd. Oxygenation (Increase FIO2) 3rd is Circulation (Chest compressions defibrillate, give heart drugs Most Common problem is Oxygenation
What is on a Patient Evaluation?
l) Admission Notes include: Admitting diagnosis History of Present Illness (chief complaint) and past medical history2) Signs and Symptoms things you can see Color, Pulse Edema, Blood Pressure Symptoms Patient must tell you: dyspnea, pain neasea muscle weakness Occupation or Employment History Allergies, Prior Surgeries Illness or Injury Vital Signs, RR, Pulse, BP, Temp Physical Exam of Chest inspection, palpation, purcussion and auscultation
What is smoking history?
Patients number of pkg per day times number of years smoked
What is an Advance Directive?
DNR: Do Not Resuscitate
What is On the Respiratory Care Orders?
Type of treatment, frequency, medication dosage and dilution Physican Signature
What goes on a Patients Progress Notes and Lab Reports
Respirator Notes Date, times Reactions Nursing Notes check patient status boats Reports ABG Pulmonary Function testing Image Reports Xrays Ct, MRI, PET
What are the basic lab Assessments?
CBC, electrolytes, urine analysis, pleural fluid Intake and Output: Normal l liter a day Sensible water loss-urine, vomiting Insensible water loss Lungs and Skin If intake exceeds output could cause: Weight gain, electrolyte imbalance Increased homodynamic pressures... Decreased Lung Compliance
What do you check for bedside interview?
Determine Level of Consciousness Alert and responsive is Norma) Lethargic somnolent sleepy could be COPD Overdose or Sleep Apnea stuporous confused, respond inappropriate could be Drug Overdose, Intoxication Semi Comatose responds only-to painful Stimuli Coma does not respond to painful stimuli Obtunded drowsy state may have decreased cough or gag Check Orientation to time and place and person Assess emotional State Check activities of daily living: Eating, dressing, walking, bathing
What are some subjective symptoms?
Orthopnea difficulty breathing upright CHF General Malaise: electrolyte imbalance Dyspnea Grade I normal dys pnea occurs. after unusual exertion Grade II breathless after going up hills or stairs Grade 111 dyspnea while walking abnormal speed Grade IV dyspnea slowly walking short distances Grade V dyspnea at rest, shaving dressing
What is pain and some signs?
Reaction of specific nervous tissue, BP up and HR also
Whet are some symptoms of Nose and throat?
Excessive nasal secretions Itching and burning of nose and throat Dysphagia difficulty swallowing and hoarseness
What does the Respiratory Care Plan consist of?
Case Management Plan Therapy protocols Disease management Patient and family educational needs
What is a patents physical environment?
Ramps, doorways. stairs
What are open ended questions?
Questions that ask a Patient to describe they provide more detail.
How do you assess a patnent's learning need?
Knowing possible barriers Language Age Education Emotional barriers
Assessment by Inspection What Can you see?
General Appearance age height, weight sex, nourishment Peripheral Edema Caused by CHF and Renal Failure Clubbing of fingers Chronic hypoxemia Venous distention CHF Seen during exhalation COPD Capillary refill indication of peripheral circulation noninvasive and quick Diaphoresis heavy sweating Heart failure Fever infection TB night-sweats Cachectic Muscle Wasting
What do you look at for skin Color?
Normal is pink,tan,brown, black Abnormal is a decrease in color anemia or blood loss Vasoconstriction will cause a change by reducing blood flow Jaundice Increase in bilirubin 17 blood tissue face and trunk Erythema Redness of skin capillary congestion and inflammation Cyanosis blue or blue gray Hypoxia from increased amount of reduced hemoglobin.
What are the chest Configurations?
Normal is normal A-P diameter Kyphosis is hunch back or convex spine curve Scoliosis is lateral curvature of-the Spine Kyphoscoliosis combination hunchback and lateral curvature Barrel chest result of chronic air trapping C0PD increased AP diameter
What is the normal movement of the Chest?
Symmetrical Both sides of chest move at same Time Abdomen moves out due to diaphram dropping chest moves outward and upward
What is Asymmetrical ?
Asymmetrical is an unequal movement of chest Underlying pathology could include Chronic lung disease Atelectasis Pneumotorax Flail Chest Paradoxical Intubated patient with endotacheal tube in one lung
What are some breathing patterns?
Eupnea Normal RR depth and rhythm Tachyphnea Increased RR > 20 Bpm Fever, Hypoxia, Pain, CNS problem Bradypnea Oliaopnea Decreased RR < 8bpm variable depth and Rhythm Apnea is cessation of breathing Cheyne-Stokes Increased and Decreased Rate and Depth with periods of Apnea Caused by increased intracranial pressure meningitis, drug overdose
What is accessory muscle activity?
Muscles used to increase ventilation during times of stress are Diaphragm-intercostals scalene, sternocleidomastoid and abdominal
What is muscle Condition?
Muscle wasting atrophy is loss of muscle tone and occurs in paralysis Increase in muscle size hypertrophy occurs in C0PD patients
What are retractions?
Intercostals and or sternal retractions occur when the chest moves inward during inspiratory efforts instead of outward This is due to a obstructed airway A sign of respiratory distress in infants
What is nasal flaring?
Flaring of the nostrils during inspiration. A sign of respiratory distress in infants Expiratory grunting and retractions occur in newborns to prevent atelectasis
What is the character of a cough?
Strong, moderate or weak. Productive or non productive Frequent or infrequent, tight or moist A dry or nonproductive cough may indicate a tumor in the lungs. A productive cough may indicate an infection.
What is the pulse?
Normal 60-100 bpm Tachycardia >100 bpm indicates hypoxemia anxiety, stress Bradycardia <60bpm indicates heart failure shock code emergency
When is heart rate a cause for concern?
Increased heart rate > 2Obpm is an adverse reaction, stop therapy, notify nurse and doctor Any change in rhythm is indication for further monitoring
What is paradoxical pulses pulse paradoxus?
Pulse blood pressure varies with respirations May indicate severe airtrapping as m status asthmatics tension pneumothorax
What is tracheal deviatlon?
Pulled to Abnormal side? Pulmonary Atelectasis Pulmonary Fibrosis Pnemonectomydiaphragmatic paralysis
Whet is percussion ?
Percussion is done by placing the middle finger between two ribs and tapping the middle fingers first joint with the middle fingertip of your opposite hand Resonance Normal filled air filled lungs\ This gives a hollow sound. Flatness heard over Sternum muscle on area of atelectasis Dullness heard over a loud filled organs such as heart or liver pleural effusion or pneumonia will give this thudding sound Tympany heard over air filled stomach) This is a dreamlike sound and when heard over the lungs indicates increased volume Hyperresonance found in areas of the lung where pnemothorax or emphysemas are present this is a booming sound
What are breath sounds?
Normal breath sounds vesicular Bronchial breath Sounds normal sounds heard over tracheal on bronchi Over the lung would indicate lung Consolidation
Abnormal Breath Sounds
Rates crackles secretion fluid
Coarse rales rhonchi Large Airways Secretions
Patient needs suctioning
Medium Rales
Middle airways secretions Patient needs chest physical therapy
Fine Rales mass crepitate rates
Abrader fluid Patient has cHF pulmonary edema Patient needs IPPB heart drugs diuretics and oxygen
What is wheeze due to?
Broncho spasm, patient needs bronchodilator Unilatenatal Wheeze indicative of a foreign body obstruction, Mucus plug
What is stndor?
Due to upper airway obstruction Supraglottic swelling epiglottis Subglottic swelling croup post extubation Foreign body aspiration solids or fluids
What is Pleural Friction Rub?
Coarse grating or crunching sound visceral and parietal pleura rubbing together
What are normal Heart Sounds)
SI and S2
What are abnormal heart sounds?
S3 and S4 heart sounds You need an Echocardiogram
What is normal blood pressure?
120180 mmHg using a sphygmomanometer Increased Blood Pressure indicates cardiac stress-hypoxemia Decreased blood pressure indicates poor perfusions shock<
What is the position of the endothachial tube?
Below the vocal cords and no closer than 2 cm or I inch above the carina
What are some of the anatomical landmarks?
Trachea seen as a dark area midline Costophrenic angles, Angle made by the outer curve of diaphragm and the chest wall Angles are obliterated by Pleural Effusions Diaphragm Dome Shaped normally Flattened with COPD Vascular Markings are Blood Vessels lymphatics,lung tissue
What are the positions and projections on the chest x-ray?
"AP projection-anterior, posterior
Lateral decubitus position-Patient lying on affected side-valuable for detecting small pleural effusion"
What is normal chest x-ray?
Both hemidiaphragms are frounded (dome-shaped) The right hemidiaphragm is slightly higher than the left, liver pushes it up. The right hemidiaphragm is at the level of the sixth anterior rib.
What are the position of tubes and catheters?
Chest tubes should be located in the pleural spaace surrounding the lung. Nasogastric tubes and feeding tubes should be positioned in the stomach and small bowel below the diaphragm. Central Venous catheters are placed in the right or left subclavian or jugular vein and should rest in the vena cava or right atrium of the heart.
What is a valuable diagnostic tool for an upper airway obstruction in children ? Croup and Epiglottitus
Lateral neck x-ray
What is the classic x-ray sign for croup(larynotrachebronchitis)
Viral disorder , the xray will reveal tracheal narrowing in a classic pattern called steeple sign, pencil point , picket fence all meaning pointing
What is Epiglottitis and what x-ray sign helps identify it?
Epiglottitis is a potentially life-threatening inflammaaton of the supraglottic airway caused by a bacterial infection. A lateral neck x-ray shows supaglottic narrowing showing a thumb sign.
What is Radiolucent?
Dark pattern, air seen on X-ray normal for lungs
What is Radiodense?
White pattern, solid , fluid normal for bones, organs.
What is an Infilttrate?
Any ill-defined radiodensity as in Atelectasis.
What is Consolidation?
"Solid white area, such as Pneumonia(inside)
Pleural effusion (outside)"
What is hyperlucency?
Extra pulmonary air as seen in COPD, asthma attack, pneumothorax.
What are Vascular markings?
"Lymphatics, vessels,lung tissue
Increased with CHF
Absent with Pneunmothorax"
What is Diffuse meaning on X-ray?
Spread throughout as in Atelectasis /Pneumonia
What is Opaque meaning on X-ray?
Fluid , solid as in consolidation
What is Bilateral and what is unilateral?
"Bilateral means on both sides
Unilateral means on one side"
"What are Fluffy infiltrates?
What are Butterfly/Batwing pattern?"
Diffuse whiteness and infiltrate in shape of butterfly as seen with Pulmonary Edema
What are patchy infiltrates and platelike infiltrates?
Scattered densities and thin-layered densities as seen in Atelectasis
What is Ground Glass Appearance and Honeycomb Pattern?
Reticulogranular and Reticulonodular as seen in ARDS/IRDS
What is an Air Bronchogram?
Pneumonia
What are peripheral-wedge-shaped Infiltrate?
Pulmonary Embolus
"What are Concave superior inerface/border?
What are Basilar infiltrates with meniscus?"
Pleural effusion
What is Bronchography?(bronchograms)
Injection of radio-opaque contrast that outlines the airways it allows study of obstruction lesions(tumors) and bronchiectasis.
What is a V/Q scan?
Two scans ventilation and perfusion if the results indicate a normal ventilation scan but abnormal perfusion scan= Pulmonary Emboli
What type of equipment do you need for a MRI?
Manual resuscitation equipment should have detachable non-rebreathing valves made of non-ferrous(non-metallic) materials.
What is an Electroencephalography? (EEG)
Electrical activity of the brain. Indications for brain tumors, injuries, retardation, epilepsy, seizuries, sleep disorders.
What is normal ICP?(intracranial pressure)
5-10 mm Hg
When should ICP be treated?
"If ICP> 20 mmHg
Patient should be hyperventilated until PaCo2 is 25-30 mmHg"
What is Ultrasonography of the Heart? Echocardiogram (ECG)
"Non invasive method for monitoring cardiac performance.
More S1 or S2"
What is the normal RBC? red blood cell count
"Normal value
4-6 mill/cu mm"
What is normal Hemoglobin? Hb
"Normal value
12-16 gm/dl"
What is normal hematocrit?Hct
"Normal value
40-50%"
What is normal White blood cell ? WBC
"Normal WBC
5,000 to 10,000 per cu mm"
What is leukocytosis?
Increased WBC over 10,000 is bacterial infection
What is leukpenia?
Decreased WBC count under 5,000 mean viral infection
What are Electrolytes and their clinical application of imblance?
"K+, Na+, Cl-, HCO3-(CO2 content) are elements required by the body for normal metabolism.
Electroyle imbalance cause muscle weakness, soreness, nausea, mental changes such as lethargy, dizziness and drowsiness - general maliase"
What is the normal value for K+ Potassium?
"Normal = 3.5 - 4.5 range Important for acid-base balance
CO2 +"
What is Hypokalemia?
"Low K+ low potassium, metabolic alkalosis, excessive excretion , renal loss, vomiting
Flattened T waves on EKG"
What is Hyperkalemia?
"High K+ potassium , kidney failure, metabolic acidous
Spiked T wave on EKG"
What is the normal value for Na+ sodium?
"Normal Na+ Sodium is 140mEq/L (135-145 range)
CO2+"
What is hyponatremia?
"Low Na+ low sodium
fluid loss from diuretics, vomiting, diarrhea, fluid gain from: CHF,IV therapy"
What is hypernatremia?
"High Na+ high sodium
Dehydration"
What is the normal value for Cl- Chloride?
"Normal values for Cl- Chloride 90 mEq/L (80-100 range)
Pa-"
What is hypochloremia?
"Low Cl- chloride
metabolic alkalosis"
What is hyperchloremia?
"High Cl- chloride
metabolic acidosis"
"What is normal HCO3?
Bicarbonate (total CO2 content)"
"Normal HCO3 24mEq/L
22-26 range"
What do you look at in Sputum analysis?
"Amount of sputum teaspoons, tablespoon.
Consistency-thin,thick, tenacious
Color"
What does the color of sputum tell you?
"Clear-normal
Mucoid-White/gray, chronic brochitis
Yellow presence of WBCs bacterial infection
Green- stagnant sputum, gram negative bacteria (Bronchiectasis, pseudomonas)
Brown/dark- old blood
Bright red - hemoptysis(bleeding tumor, TB)
Pink frothy- pulmonary edema"
What does the sputum culture tell you?
Identify the bacteria present and what antibiotics will kill the bacteria
What is the difference between the Gram and Acid fast stain?
"Gram stain identifies whether it is gram positive or negative this is a fast test less than 1 hour.
Acid fast stain indicates tuberculosis takes longer to get result"
What is an Oscilloscope?
Oscilloscope is a moniter that is at the head of the bed that provides the visual image of the ECG
What is the Electrocardiograph?
"It is the printed version of recording the electrical activity of the heart.
Always Look at Lead II"
What is a Holter Monitor?
Portable version of an electrocardiograph that is worn under clothes for 24-48 hours continually
What is an Electrode?
Electrode is a sticker placed on the skin to conduct electric current
What is a lead?
A positive and negative electrode that allows electrical current to flow.
How many leads and electrodes are there in a 12 lead?
There are 12 leads and 10 stickers (electrodes)
What lead do you moniter?
"Moniter Lead II
Left leg positive, Right Arm Negative"
What is distintive about the AVR lead?
AVR is the only limb lead that produces an upside down (neg) pattern
What leads give dimension of right heart and where are they placed ?
"V1 - 4th intercostal space on right side of sterum
V2 - 4th intercostal space on left side of sterum"
What leads give dimension of Ventricular septum and where are they placed?
"V3- between V2 and V4 on left side
V4 - 5 th intercostal space, left mid clavicular line"
What leads give dimension of left heart and where are they placed?
"V5- between V4 and V6 on the left side
V6-5th intercostal space, left mid-axillary ling"
What is normal heart rate?
60-100 bpm
What is bradycardia?
<60bpm
What is tachycardia?
>100bpm
What is flutter?
>200bpm
What is fibrillation?
Too fast to count
How do you measure heart rate on a strip?
"You measure the distance between the two R waves and divide 300 by it.
If the two R waves are between 3 and 5 large blocks the the rate is normal 60-100
If the two R waves are closer than 3 large blocks then the rate is greater than 100-tachycardia
If the two R waves are wider than 5 large blocks than the rate is less than 60 - bradycardia"
How do you treat Sinus Rhythm?
Normal rate, no skips, or extra beats, treat other symptoms
How do you treat Sinus Tachycardia?
"Sinus rhythm > 100
Treat with Oxygen"
How do you treat Sinus bradycardia?
"Sinus rhythm <60
Treat with Atropine, Oxygen"
How do you treat PVC's?
"Premature ventricular contractions (PVC)
Absent of P wave
Treat with Oxygen, Lidocaine, Suctioning"
How do you treat V tach?
"Ventricular tachycardia
Ventricular rhythm with rate>100
Treat with Defibrillate (If No Pulse)
Lidocaine and Cardiovert (If Pulse Present)
Oxygen"
How do you treat V-fib?
"Ventricular fibrillation, completely irregular ventricular rhythm
Treat-Defibrillate"
How do you treat Multifocal PVC's?
"Premature ventricular contractions
No P wave , Large QRS
Treat with Oxygen, Lidocaine (this reduces the irritibility of heart)"
How do you treat Asystole?
Confirm in 2 leads first, then Epinephrine, Atropine , 100% Oxygen and CPR
What does the axis of an ECG measure?
Axis measures the direction of all the electricity through the heart during contraction
What do you assess for a perinatal history?
Mother's History: History of pregnancy, age, smoking and substance abuse, nutrition, infecton , previous pregnancies/outcomes. Hypertension, toxemia diabetes ( diabetes prone to have problems with premature babies)
What is the gestation Age of infant?
"Time since the estimated date of conception.
Term-38 to 42 weeks
Preterm(premature) less than 38 wks
Post- more than 42 wks"
What are the five factors for evaluating infant and when are they done?
"APGAR routinely done at 1 and 5 minutes
A isAppearance (Color) Good is 2 completely pink Bad is 1 Body pink , extremities blue, Real Bad is 0 blue all over, pale
Pulse Good(2) is >100 minute
Bad(1) is <100 minute
Real Bad (0) is absent no pulse
Grimace(Reflex irritability) Good(2) cough or sneeze
Bad(1) grimace
Real Bad(0) No response
Activity Good(2) Active motion
Bad(1) some flexion of extremities
Real Bad (0) Limp No movement
Respiratory effort Good(2) Regular, strong cry
Bad(1) slow, irregular weak cry
Real bad(0) Absent no cry"
What action do you take based on APGAR score?
"0-3 RESUSCITATE
4-6 SUPPORT stimulate, warm , administer O2
7-10 MONITOR routine care"
What is a transillumination?
"Bright fiberoptic light placed against the infant's chest in a darkened room
Normally a lighted halo is seen around the point of contact
A Pneumothorax or pneumomediastinum will cause the entire hemithorax to light up"
What are the vital signs of an infant?
"Normal pulse rate 110-160bpm
Respirations normal 30-60breaths per minute(higher in preterm babies)
Blood Pressure Normal term Infant 60/40mmHg
Preterm 50/30 mmHg
Birth Weight Normal Term>3000gm 3kg
28wks 1000gm"
What are some signs of Respiratory Distress in Infants?
"Cyanosis bluish all over
Acrocyanosis is bluish extremities not true cyanosis
Retractions intercostal sucostal substernal or supraclavicular retractions
Nasal Flaring dilation of nasal openings (breathing through nose)
Capillary refill How long it takes for normal color to return -longer than 3 seconds may indicate a decreased cardiac output"
What are some methods of measuring gestional age?
Dubowitz Method and New Ballard Score
What are pre and post ductal blood gas studies and what do they mean/
If the pre-ductal (right radial artery Pao2 is 15 mmHg highter than the post-ductal (umbilical artery) PaO2 , then the patient has a paten ductus arteriosus with a right to left shunt. Needs a Echocardiogram
What are the normal Blood glucose levels in infants?
"Hypoglycemia
Term infants >30 mg/dL
Preterm > 20 mg/dL"
What is L/S ratio and what does it mean?
"Lecithin/sphingomyelin , a ratio
of 2:1 or highter is good. It measures lung maturity.
A ratio less than 2:1 indicates high risk of hyaline membrane disease (HMD) or Infant respiratory distress syndrome (IDS) approaches zero"
What is PG?
Most reliable indicator of pulmonary maturity even with diabetes. Phosphatidylglycerol
What is capnography and what is the normal range?
Measuring exhaled carbon dioxide content using infrared absorption. ETCO2 normal value is 3-5%
What does an increase in Capnograph (PECO2 or PetCO2% ) indicate?
"An increase indicates a decrease in ventilation (ventilatory failure)
Increase Tidal Volume"
What does an decrease in the capnograph indicate?
Decrease indicates an increase in ventilation or decreased perfusion (deadspace disease: pulmonary embolism, hypovolemia
What does low PetCO2 reading immediately following intubation indicate?
"ET tube is in the esophagus
If patient already on ventilator and you get low or 0 reading then reconnect patient to ventilator"
What does the PetCO2 do during CPR?
The PetCO2 should increase during CPR
What are the examples of color change for PCO2?
"Purple=poor
Yellow=normal
False readings may occur in patients who have been without CPR for a period of time"
What is a non-invasive method of monitoring oxygen saturation?
Pulse oximetry measures SaO2 or SpO2 and pulse
What effects accuracy of pulse ox?
Perfusion, shock and hypotension, conditions that interfere with the light transmission, fingernail polish bright ambient lights, erytherma (redness of skin due to capillary dialation)
What will make a pulse ox measure higher?
Carbon Monoxide poisoning
What accurately measures COHb?
"Co-oximeter/hemoximeter
Used to diagnose carbon monoxide poisoning.>20% COHb"
What is normal COHb reading and abnormal?
"Normal COHb is 1-3%
COHB for smokers 5-10%
Heavy Smokers 10-15%"
What is an invasive and non-continuous measurement of O2Hb?
ABG but is this is calculated and the Co-oximetry are directly measured
What are transcutaneous PO2 and PCO2 measurement?
Continuous non-invasive measurement by electrodes placed on the skin instead of ABG
What improves Transcutaneous PO2 and PCO2 measurment?
Heating the skin to 43-45C improves the capillary blood flow (perfusion) and enhances gas movement through the skin.
How long should electrode site be changed for transcutaneous measurement?
Every four hours. If redness or blistering every 3 hrs.
What is hemodynamics?
Hemodynamics is monitoring the blood pressures . circulation and perfusion
What is the physiology of blood pressures?
"Without sufficient blood pressure the tissue will not receive the oxygen and nutrients it needs to survive.(perfussion)
High blood pressure causes strain on the heart and willeventually cause heart failure.
There are three factors that control blood pressures: Heart, Blood and Vessels"
How do changes in the heart affect blood pressure?
"Increase in the heart rate / strenght will increase the blood pressure
Decrease in the heart rate/ strength will decrease the blood pressure-contractility"
How does the blood affect the blood pressured?
"Excessive fluids increase pressures so give diuretics
Loss of fluids decrease pressures so give fluid"
How does the condition of the vessels change blood pressures/
"Vessel constriction increase pressures so give sodium nitro(Nipride)
Vessel dilation decrease pressures give dopamine"
How do you calculate mean arterial pressures (MAP)?
"MAP= 1 x systolic + 2 x diastolic / 3
Normal value is 120/80mmHg
Normal = 90mmHg"
What is the normal blood pressure?
120/80 or 90mmHg
What is the normal value for Central Venous Pressure ?
"2-6 mmHg
4-12 cmH2O
Mean right atrial pressure.
If low also give fluids and drugs"
What is the Pulmonary Artery Pressure (PAP)?
25/8mmHg or 14mmHg
What is the Wedge Pressure (PWP)?
"4-12mmHg
Estimates left ventricle filling
(preload)
Equal to left atrial pressure"
What is the flow of blood through the body?
Left ventricle through the aortic valve into the systemic arterial system to the capillary then the systemic veins back to right heart through right atria through the tricuspid valve to right ventricle through the pulmonic valve into the pulmonary artery through the lungs then to the pulmonary veins into the left atria through the mitral valve into the left ventricle again.
When will CVP be increased/
Right Heart Failure, Cor pulmonale (tricusid valve) The CVP will be up
When will PAP be increased?
Lung disorders, Pulmonary embolism, Pulmonary hypertension, Air Embolism , Hypoxcemia
When will PCWP be increased?
Left heart failure Mitral valve stenosis CHF/pulmonary edema High PEEP effects
What happens with Hypervolemia (fluid overload)?
Every value is up
What happens with Hypovolemia (fluid decreased)?
Every value is down
What is pulse pressure and the normal?
"The difference between the systolic and diastolic pressure
The normal value is 40 mmHg"
What is Cardiac Output equation?
"Fick equation =
QT=VO2/Ca-v)o2 (10)
QT= heart rate x stroke volume
Normal Value 4-8L/min"
How do you calculate Cardiac Index (Cl)?
"Cardiac Index is the cardiac output (QT) divided by the body surface area (BSA) in meters squared(m2)
Cl= QT/BSA
normal is 2.5-4L /min/m2
half of QT normal"
"What is the Systemic Vascular Resistance( SVR)?
<20 mmHg/L/min or 1600Dynes/sec/cm-5"
"The pressure gradient across the systemic circulation divided by the cardiac output
SVR=MAP-CVP/Cardiac output x 80 for dynes/sec/cm-5"
How may SVR change?
SVR is increased with systemic hypertension and or vasoconstriction(especially due to Alpha Type drugs) SVR may change with changes in cardiac output or index if other values remain constant
"What is Pulmonary Vascular Resistance(PVR)?
Normal <2.5mmHg/L/min or 200Dynes/sec/cm-5"
"The pressure gradient across the pulmonary circulation divided by the cardiac output.
PVR=(MPAP-PCWP) / Cardiac Output x 80"
How is Pulmonary Vascular Resistance increased?
PVR is increased with hypoxia, pulmonary hypertension and lung disease
What is the formula for calculating resistance?
R= Change in Pressure /Flow
What are the three sights for obtaining an arterial blood gas?
Radial, Brachial, Femoral
What should Not be used to monitor oxgen therapy and why?
Capillary gases should not be used as PO2 values do not correlate very well with actual arterial blood.
What artery is the first choice to draw a ABG and why?
Radial artery is first choice because of accessibility and collateral blood flow.
What test is used to assess collateral blood flow?
Modified Allen's Test and you release the ulnar artery to test for collateral blood flow.
What does Blood Gas Analyzers Measure?
"PCO2 (severinghaus electrode)
PO2(Clark electrode)
PH(Sanz electrode)
All other values are calculated"
What is point of care testing?
Monitoring done at the bedside
What is the Alveolar Air Equation? PAO2
"PAO2 calculates the partial pressure of oxygen in the alveoli.
PAO2= (7 x FIO2)-(PaCO2 + 10)"
"What is the A-aDO2 or the
A-a gradient?"
"A-a gradient measures the difference between alveolar and arterial PO2.
Best done after patient has been on 100% oxygen for 20 minutes."
What can be evaluated by the A-a gradient (A-aDO2)?
Therapy to improve distribution of ventilation can be evaluated(IPPB, IS )
What are the values of the A-a gradient?
"Normal 25-65 mmHg on 100%
V/Q mismatch 66-300mmHg
Shunting >300mm Hg"
What is CaO2 and it's normal?
"CaO2 is the best measurement of oxygen delivered to the tissues, or best index of oxygen transport Oxygen in RBC + Oxygen in Plasma
Normal is 17-20 vol %(mL/dL)"
What is the CaO2 formula?
"CaO2= (Hb x 1.34 x SaO2)
If SaO2 above 90% then don't use it"
What is CvO2 and it's normal?
"CvO2 is total amout of oxygen carried in the mixed venous blood.
Normal is 12-16vol%
Blood is drawn from Pulmonary Artery by swan-ganz catheter"
What is the C(a-v) O2?
"C(a-v)O2 is the arterial minus the venous oxygen content It measures oxygen consumption of the tissues
CaO2-CvO2
Normal 4-5vol%
Short Cut Take SaO2-SvO2 x 2 and put in decimal"
What happens when QT cardiac output decreases?
CvO2 and SvO2 decreases and C(a-v)O2 increases
What is the PaO2/FIO2 ratio and what are the normals and what is it used for?
"PaO2/FIO2 measures the efficiency of oxygen transfer across the lung and used in deternimation of ALI or ARDS
Normal is 380 mmHg or >
Less than 300mmHg is ALI
Less than 200mmHg is ARDS"
What does C(a-v)O2 equal?
C(a-v)O2 = (SaO2- SvO2) x 0.2
What is the QS/QT?
"The portion of the cardiac output that is shunted
Normal value is 3-5%
(PAO2-PaO2( first number from A-a + 1 ) x 5"
What is the relationship of PaO2 to SaO2?
SaO2 =PaO2 + 30
What is VD /VT?
"Dead space to Tidal Volume ratio Ventilation without Perfussion
VD/VT=
PaCO2-PECO2/PaCO2"
How do you calculate VD?
VD/VT x VT= VD
How do you determine a desired VE?
(VE (known) x PaCO2 (known) /Desired PaCO2
How do you determine a Desired FIO2?
PaO2(desired) x FIO2(known) /PaO2 (known)
How do you determine a desired rate?
Current rate x PaCO2(known) / Desired PaCO2
What are the normal blood gas ranges?
"PCO2 35-45 torr
PO2 80 - 100 torr
pH 7.35 - 7.45
HCO3 22 - 26 mEq/L
SO2 95-100% Venus 70-75%"
What are the blood gas interpretations?
"CO2 to Ventilation
35-45torr normal
Above 45 Patient Not Ventilating Ventilate Pt or Increase Tidal Volume or Rate
Below 35 Pt Is Ventilating too much Add Deadspace if PO2 acceptable
Abnormal PCO2 with normal pH Pt COPD don't change ventilation"
What are the normal oxygen values and responses/
"PaO2 FIO2 Interpretation
80 -100 on ,21 Normal
<80 on .21-.59 Hypoxemia due to Poor ventilation High PCO2 INcrease ventilation
V-Qmismatch normal PCO2 Increase FIO2 up to 0.60
Below 80 on .60+ Shunting, Venus Admixture Start CPAPif Pt breathing on own
Start PEEP if Pt on ventilator
Above 100 (hyperoxemia) if on .22-1.0 Over Oxygenation Decrease the FIO2 first if at or above .60 Once FIO2 is<60 then reduce PEEP/CPAP and decrease ventilation if lowPCO2"
What are the exceptions to the rule for ABG interpertations?
"TYPE 1 ABG looks good / Pt looks and feels bad / CO poisoning /100% oxygen treatment /Anemia Low Hb , pt maybe hypoxic PVC's , tachycardia, distress, CBC low/ give oxygen until transfusion is complete / Pulmonary Embolus (increased dead space)Sudden increased rate and depth of breathing/Anticoagulat therapy support ventilation.
COPD type 2 also could have given too high an oxygen flow"
What are some types of Spirometers?
"Water -seal Collins measures volume and time and are most accurate. Pneumotachometers measure flow like the Turbine Wright respirometer, Pressure differential Fleish and can continuously measure VE.
Peak flow meters can measure at the bedside they have a resistor and moveable indicator, resistance is provided by utilizing a narrow orifice"
What is the plethysmograph?
It's the body box , it measures airway resistance difference in pressure between the mouth and the alveoli and it will more accurately measure FRC in COPD patients
What are some recording devices?
"Kymograph is a rotating drum which maneuver is recorded on graph paper it plots volume (y-axis) against time (x-axis)
The X-Y recorder plots volume(x-axis) against flow(y-axis) Advantage over kymograph is it allows for recording of flow-volume loops"
How is equipment tested for accuracy?
Volume calibration and leak tests by using a large volume syringe , normally 3.0 liters. If a leak occurs recalibrate.
What is a gas analyzer?
Galvanic fuel cell that produces a current measures partial pressure , displays FIO2 as percent. Accuracy can be affected by water on the sensor, high system pressures and changes in altitude, if unable to calibrate , change fuel cell.
What is a polarographic?
Similar to a galvanic fuel cell except it has a battery . If unable to calibrate change the battery and check electrolyte level. Trouble shooting recalibrate analyzer and recheck equipment
What is the VC, SVC?
"Vital Capacity pt takes maximal inspiration followed by a maximal exhalation without force.
The SVC will provide the important Volumes used to measure Restrictive Disease"
What are the volumes and capacities measured in pulmonary diagnostic testing?
"VT tidal volume normal breathing
IRV inspiratory reserve volume
ERV expiratory reserve volume
IC inspiratory capacity (IRV+VT)
VC Vital capacity (IRV+VT+ERV"
What is the best indicator of Restrictive lung disease?
Decreased Vital Capacity
What is FVC forced vital capacity?
The volume that can be expired as forcefully and as rapidly as possible after a maximum inspiration. It provides important flow rates to measure obstructive disease
What is the best indicator of Obstructive disease?
"Decreased FEV1/FVC
If the FEV1 is decreased but the FER1/FVC ratio is normal then the patient is restrictive only.
Most individuals can exhale all of their air in about 2 seconds"
What is the forced expiratory flow 200-1200?
FEF200-1200 is average flow during the first 1000ml after 200ml expired decreased values are associated with large airway obstruction. (begining of breathe)
What is forced expiratory flow 25-75?
FEF25-75 decreased values are associated with small airway obstruction. (middle of breathe)
What is PEFR?
Peak expiratory flow rate effort dependant sometimes used to evaluate asthmatic patients , pre and post bronchodilation.
What is MVV?
Maximum voluntary ventilation the largest volume and rate that can be breathed per minute by voluntary effort.12-15 seconds. Measures the muscular mechanics of breathing preOp patients.
What is pre and post bronchodilator PFT testing?
Used to measure the reversibility of an obstructive pattern . increase of 12% or 200mL in the FEV1 post test is considered significant
How do you measure FRC?
FRC (RV,TLC) is measured by either the He dilution (closed method) or N2 wash out (Open method)
What are flow volume loops?
Displays the volumes and flow rates of the FVC. Flow rates are measured on the vertical axis. Expiratory flows are above the base line. Inspiration is below the line.Volume is measured directly on the horizontal axis. Restrictive is a skinny and tall loop . Obstructive is short and wide loop
What is the evaluation of pulmonary function tests?
"Values predicted on age, height, and sex
80-100% of predicted=normal
60-79%of predicted=mild disorder
40-59% of predicted=moderate
<40% of predicted=severe"
How can PFT tell the difference between Obstructive and Restrictive disease?
"Restrictive only decreased Volumes, VC or FVC
Obstructive only decreased flows, FEV1, FEV1/FVC
Both obstructive and restrictive decreased flows and decreased volumes"
What is a bronchoscopy?
A procedure that allows the therapist to visualize the trachea and bronchi.
What are the types of bronchoscopy and what is the difference in use?
"There is a flexable bronchoscopy used for diagnostic reasons and a ridgid bronchoscopy used for therapeutic reasons in the OR for foreign-body obstruction atelectasis.
Also used for intubation in patients with a suspected neck fracture use a flexable fiberoptic bronchoscopy"
What is the first procedure before inserting the bronchoscopy?
"Topical anesthetic is administered to control the gag/cough reflex and prevent laryngospasm. Lidocaine , cetacaine, novacaine.
Patients receiving continuous ventilation need a special adaper Bodaii for introduction of the scope and Increase FIO2 and Increase high pressure alarm setting. Be sure to reset after procedure."
What is partial obstruction?
Inspiratory stridor, cough/gurgling or unilateral wheeze
What is complete obstruction/
"Marked inspiratory efforts without air movement inability to speak
Marked, sternal, intercostal and epigastric retractions. Marked distress and marked attempts to ventilate"
What is the cause of upper airway obstruction?
Tongue/soft tissue obstruction most common
What are the methods of establishing a patent airway and the contraindications?
"Head-tilt / Chin -lift Opens airway and pulls tongue back
Contraindications: fractured neck
Jaw Thrust / Modified Jaw Thrust Allows for establishing a patent airway in patients with suspected neck fractures"
When do you preform a Abdominal thrust?
When complete airway obstruction is indicated. Contraindications; Obese victims, Advanced pregnancy, Infants
When do you preform a chest thrust?
Used instead of abdominal thrust on obsese victims, infants and pregnant women
When do you use a oral pharynegal airway?
"Unconscious patient Patient has bite block as in seizure facilitate oral suctioning
Complications: Airway to be left uncecured."
When do you use a nasal pharygneal airway?
"On a conscious patient to facilitate deep tracheal suctioning and decrease nasal trauma
Complications; Trauma to mucosa -lubricate water soluble"
What is the size determination and insertion techniques of oral and nasal techniques?
"Size of oral -Lenght should be equal to distance formangle of jaw to just past corner of mouth. Insert upside down and twist into position.
Nasal- Length of airway is from tip of earlobe to center of nostrils. Inserted the way it is anatomicallly shaped with water soluble lubricant."
What is the purpose of oral and nasal intubation?
"Patent airway
Access for suctioning
Means for mechanical ventilation
Protect airway (aspiration, obstruction)
Direct instillation of medication."
What is NAVEL?
"Narcan-Narcotic Overdose
Atropine-Bradycardia
Valium-Versed-Sedative
Epinephrine_Asystole
Lidocaine-PVC's"
What are some complications of intubation?
"Infection, fever,secretions
Cuff pressures, Larynogospasm most serious
Right mainstem intubation>25cm marking deep
VAP Ventilator acquired pneumonia"
What is cuff pressure related to?
"Cull pressure is directly related to capillary pressures. It should be equal to or less than 20 torr or mmHg or 25cmH2O
>5mmHg is the lymphatic vessel resulting in edema
>10mmHg is vein resulting in edema
> 20mmHg is the artery resulting in necrosis"
What is the procedure for ventilation?
Position patients head in sniffing position. Adequately hyperoxygenate(resuscitation bag with FIO2 100% for 2 minutes) Hold laryngoscope in left hand, ET tube in right hand Insert b lade down reght side of mouth Advance blade, lift epiglottis, visualize cords (curve blade tip into vallecula, straight blade tip under epiglottis) have suction available Insert tube, inflate cuff, assess tube position, ventilate, and oxygenate
How do you assess the position of the tube?
"Look for bilateral chest expansion during inspiration
Auscultation, breath sounds should be heard on both sides
Capnography or CO2 dectectors
Chest x-ray - tip of tube should be 2 cm or 1 inch above carina or at the aortic notch"
What do you preform for tube maintenance?
"Suctioning maintain patency
Humidification prevent dehydration of tissue (100% Humidity @ 37 C best way to prevent obstruction
Cuff pressure minimal leak
minimal occluding volume
use high volume/low pressure cuff (equal to or < 20 mm Hg pressure"
What equipment do you use for intubation?
"Laryngoscope, Handle , Always held in left hand, holds batteries for light,
Blades, Curved MacIntosh fits into vallecula, indirectly raises epiglottis
Straight Miller blade fits directly under epiglottis (preferred for infants)"
What do you check for troubleshooting upon intubation?
"If light does not work
tighten bulb
check handle attachment
change blades
check batteries"
What are the blade and endotracheal tube sizes used/
"Blade sizes: Adult Size 3
Pediatric Size 2
Term Infant Size 1
Pre-term Size 0
Tube Sizes
Full term Infant 3 -3.5
Adult males 8 - 9mm
Adult females 7-8 mm
Adult (wt in kg ? 10 = approximate size"
When do you use Magill forceps?
Only to aid nasal intubation
What are the tube markings and cuff types used in intubation?
"Oral intubation-21-25cm mark
Nasal Intubation 26-29cm mark
Cuff types: Low pressure, high volume, high compliance , floppy cuff
Cuff pressure should not exceed 20mmHg or 25cmH2O"
What is the MOV and MLT?
"Minimal occluding volume -stop inflating at no leak via trach or endotracheal tube
Minimal leak technique slowly inject air during inspiration until leak stops then small amount of air is removed to allow a sling leak during inspriation"
What is a DLT?
"Double lumen endotracheal tube /Carlen's tube : A tube with two independent lumens of different lengths; the longer lumen is inserted into either right or left mainstem and shorten end into trachea above the carina to independent lung ventilation (two ventilators) Unilateral lung disease, used in surgery during a pneumonectomy , lobectomy, esophageal resecton and aortic aneurysm
To provide airway protection in preventing blood or secretions from entering the unaffected lung"
What is a LMA?
Laryngeal Mask Airway used fmost frequently during anesthesia Inflatable mask positioned directly over the opening into the trachea (hypopharynx) Indicated for short term intubation or facial or nasal injuries. Or and Emergency Dept , EMTs
When would an endotracheal tube be inserted into the trachea?
If patient was eating or had a heart attack and no time.
What is the proper extubation technique?
"Suction the airway below then above the cuff
Deflate the cuff
have patient inspire deeply
Pull the tube out at peak inspiration to prevent vocal cord damage
Have patient cough to clear any remaining secretions, speak
Administer oxygen and humidity if as indicated
Observe for any complications:
Laryngeal edema - strider
Respiratory obstruction"
What do you do for complications and management of extubation?
"Severe respiratory distress and/or Marked inspiratory stridor--REINTUBATE the patient
Moderate distress/stridor-Oxygen, cool mist aerosol and racemic epinephrine to reduce swelling
Mild distress/stridor /Sore throat--Provide humidity, oxygen and/or racemic epinephrine as necessary"
What are the indications and advantages of Tracheostomy?
"Preferred method for long-term ventilation
When upper airway obstruction prevents intubation/child epigloltisis
Patient is able to eat and speak with takling trach tubes"
When should the cuff be deflated on a trach tube?
The cuff should be kept deflated unless the patient is eating or on positive pressure ventilation and the tube should not be changed more than once a week .
When do you replace a trach tube?
When the tube is obstructed and unable to pass a suction catheter, then you must pull tube out, ventilate and insert new tube. If the tube is too small , change to larger tube .5 size larger as you will have too high cuff pressure >20mm Hg . Also change if punctured cuff , unable to seal trach
What types of trach tubes are there?
"Standard trach tubes may have an inner cannula for easy cleaning, Often have an oberator to reduce trama during insertion.
Fenestrated tubes has opening in outer cannula above the cuff for weaning and temporary mechanical ventilation with inner cannula and can be used for phonation you must deflate cuff for this
Tracheal Button used to maintain stoma, for multiple intubations."
What other types of trach tubes are there?
"Jackson trach tube , silver or metal comes with inner cannula , no cuff, not for resuscitation (you need cuff )
Lamen-Wilkinson Foam/Bivona Cuff Foam filled cuff in which air is evacuated prior to insertion, Pilot is open to the atmosphere and foam expands to seal treachea(has no pilot balloon) Do not inflate the cuff with a syringe"
What tracheal speaking devices are there?
One way valve that attaches to tracheostomy tube. Cuff should be deflated
What is a laryngectomy and larngectomy tube?
Surgical removal of the patient's larynx, patient will breathe through a laryngectomy tube initially , patient cannot be orally or nasally intubated it has no cuff, Laryngectomy tube will be removed after 3-6 weeks then patient will have a permanent stoma . Laryngectomy tubes are designed to maintain a patent airway after a laryngectomy has been performed
What is postural drainage and percussion(vibration) done for?
Purpose is for improve mobilzation of secretions , prevent accumulation of secretions and improve ventilation, the indications is accumulated or retained secretions ineffective cough examples are bronchiectasis, CF lots of secretions.
What are the body positions for postural drainage?
"Bed is flat-Upper lobes
Head of bed down 15 degrees Middle lobes
Head of bed down 30 degrees Lower Lobes
If patient aspirates while in a particular body position,first suction and then place in opposite position for drainage
If patient has unilateral consolidation affected side up to drain and increase perfusion to unaffected lung"
For how long do you percuss for and what do you do for sensitive patients?
Percuss for 5 minutes in every position and use mechanical percussors or percussion cups for sensitive patients
How and when do you perform vibration?
After every segment you put hand over hand compress and vibrate with exhalation to move secretions to larger airways
What are some alternative airway clearance techniques?
"Positive Expiratory (PEP) Therapy The expiratory flow resistor prevents end-expiratory pressures from falling to zero
Flutter Valve Devices Combines positive expiratory pressure therapy with high-frequency oscillations at the airway. (PEP)"
What is Autogenic Drainage?
Breathing exercises utilized to improve mucus clearance, primarily in patients with cystic fibrosis and bronchiectasis. Patients are insturcted to breathe at low lung volumes to loosen secretions from the small airways. Patients then increase their volume by breathing in the normal tidal volume range , but exhaling at low range , during last stage patient breathes at high lung volumes
What are external percussive devices?
High frequency chest wall compression devices , oscillatory , vests
What is intrapulmonary percussive ventilation?
IPV is for bronchial clearance is a combination of high frewuency pulse delivery of a sub tidal volume and a dense aerosol , delivering more aerosol to the distal airways and coughing helps facilitate removal of retained secretions
Why would you modify chest physical therapy?
Consideration for pediatrics and neonates, size of thorax , fear and positioning , goal 5 minutes but must listen to patient. Presence of chest tubes, fractures and treatments (IPPB, IS, bronchdialator) must be scheduled and coordinated with CPT
How do you evaluate if CPT is working?
"Assessment of bronchial hygiene is preformed by
Ascultation /improved BS
Inspection/color, chest expansion
Chest x-ray improved pattern"
When would you discontinue bronchial hygiene?
When you have clear breath sounds and xray , Ambulating Well, Strong cough , Afebrile 24 hrs, Hazards occur (dizziness, SOB, cyanosis
What is the purpose, indications and hazards of suctioning?
"Purpose patent airway,specimen collection, stimullate cough
Indications accumulated secretions
Obstructed airway, depressedf cough , inability to swallow
Hazards Trauma to mucosa (most common) Lubricate catheter(nasal-tracheal suctioning) use gentle technique
Contamination use aseptic technique
Hypoxemia leading to trachcardia, arrhythmias (most severe)
Bradycardia from vagal nerve stimulation"
What is the procedure of suctioning?
100% O2 pre and post suctioning is required. Oxygenation should be for at least 1-2 minutes.
What is some of the equipment used in suctioning?
"Vacuum regulators Used to adjust vacuum pressure
Adjust with tubing occluded and a built in shut off device in the collection bottle prevents aspirated secretions from entering the regulator and vacuum system when bottle is full"
What are the suction pressures for patients?
"Adult 100- 120 mm Hg
Child 80 - 100 mm Hg
Infant 60 - 80 mm Hg"
What type of suction catheters and specimen collectors?
"Coude tip catheter is angled to help suction the left main stem bronchus
A closed system suction catheter the Ballard (inline suction) allows the patient to receive ventilation and oxygenation during suctioning. Indicated for patients with high oxygen and or PEEP"
What and how are the sizes of catheters determined?
"The ideal catheter length is 20 -22 inches.
Catheter size is listed in French Units
The external diamenter of the suction catheter should be no greater than 1/2 the Inside diameter (ID) of endo or trach tube
Catheter Size = ID size x 3 / 2"
What is an oral suction device?
Yankauer , tonsil suction device , used to suction the mouth and throat, using aseptic technique
What is a suction trap?
Lukens trap , used to collect a sputum specimen
How do you modify suctioning?
"Change size and type of catheter If having difficulty removing secretion , verify the appropriate catheter size for patients endotracheal tube
Change to a Coude catheter is used to suction the left mainstem bronchus
Change to a closed system suction(Ballard) catheter.
Alter negative pressure/ suctioning should be stopped if hazards occur reduce level of vacuum or do in less time, increase negative pressure to remove thick tenacious secretions. Instill to dilute secretions 5-10cc normal saline or Mucomyst (Acetylcysteine) Alter duration of suctioning no longer than 15 seconds If cardiac arrhythmias Stop and decrease time in airway"
What do you do to troubleshoot suctioning?
"Check catheter for patency
Assure vacuum system is working
Change or empty a full collection bottle
Check all connections"
What are the hazards of aerosol therapy (continuous nebulization)?
"Bronchospasm treat with bronchodilator
Secretion swelling and airway obstrution treat with suctioning
Fluid overload ( CHF, renal failure and especially infants) treat by monitoring intake and ooutput and weight
Cross contamination(especially large volume, heated aerosol devices) heated humifier to treat"
How do you check a bubble humidifier alarm?
"Occluding or pinching the connecting tubing and listening for the whistling alarm
If no alarm occurs there is a leak
If alarm sounds without occlusion oxygen flow is excessively high or obstruction or kinking of tubing"
What is a heat moisture exchanger/
"An artificial nose humidifier, must be removed during aerosol therapy and some may not be as effective as Heated Humidifiers and may increase or thicken secretions, if this occurs change to a heated humidifier
Ideal use is for patient transport and short term ventilation"
What is the preferred heat humidifier?
The Wick is preferred , it can deliver 100 % body humidity (44mg/L) It has a low risk of cross contamination (nosocomial infection) because no particles are being produced.
What is a heated wire circuits?
"Used in conjunction with ventilator humidification systems to minimize circuit condensation.
Condensation (rainout) is minimized"
What are some Aerosol Devices/
"Pneumatic nebulizers-gas
Jet nebulizers gas also hand held small volume nebulizer (SVN) are used to nebulize small doses of medications A 1-3 second breath hold is important to enhance medication delivery"
What are Large volume nebulizers used for/
"LVN are used to deliver bland aerosols to the upper airway to decrease the chances of edema or humidity deficit
For thick secretions a heating element can be added.
Heated jet nebulizers have a much higher output of water vapor and aerosolized solution than non-heated nebulizers"
How do flow and FIO2 interact in a LVN?
As the FIO2 is decreased on the nebulizers , air entrainment is increased , the density of the mist decreases and the total flow or output of the mist increases
How do you trobleshoot a LVN?
"Not enough mist: often due to clogged capillary tube , insufficient flow , a decrease in the temperature or insufficien water level
Changes in FIO2: Any increase in resistance (such as water collecting in the tubing) will cause less air to be entrained causing the FIO2 to increase
The best way to verify adequate aerosol flow is to observe the aersol comming out the end of the tubing during inspiration. (turn up flow or add another neb) Flow >50% add two Nebs"
What is a SPAG?
Small particle aerosol generator nebulizer specifically designed to deliver Ribavirin (anti viral) for treating RSV (bronchiolitis) used with a scavenger evacuation system
What is a electric nebulizer?
Ultrasonic nebulizer has the highest output range of aqueous solution without heating
What is a DPI?
"Dry powder inhaler medications are in powder form and do not require a propellant
Inhale through the DPI with more force than when using an MDI"
What is a MDI?
"Metered dose inhaler shake canister first. Patient inhales slowly while squeezing cartridge. Hold breath briefly to allow distribution. Patient must be able to understand and cooperate
Spacers improves the efficacy of MDI and can be used to overcome coordination difficulties"
What is the Drug Calculation?
"Drug % x 10 = #mg/mL
#mg/mL x dosage ordered =number of mg of drug"
What is Clark's Rule?
"Clark's Rule=
wt(lb) x normal adult dose/ 150"
What are Sympathomimetics Drugs?
"Front door Bronchodilators
Alpha, beta1 and beta2 adrenergic recptor agonist"
What are Parasympatholytics drugs?
"Back Door Bronchodilator
Anticholinergics drugs act by blocking cholinergic parasympathetic receptors"
What are Xanthine drugs?
"Side door bronchodilators
This inhibitor indirectly increases the amount of cAMP within the smooth muscle this increased amount of cAMP causes bronchodilation"
What are wetting agents?
Substances to liquefy secretions and as diluent for medications.
Name some wetting agents
"Water given orally is the best mucolytic
Saline solution .45% hypotonic saline
0.9 Saline normal saline same as body tissue
1.8 - 15% hypertonic saline , commonly used to induce sputum specimens, and also cause bronchospasm or secretion obstruction"
What is an asthmatic prophylactic agents?
"Inhibit histamine release
Cromolyn Sodium (Intal) donot give during asthma attack only in prevention of bronchospasm
Nedocromil(Tilade) donot give during acute asthma attack"
What are corticosteroids?
"Anti inflammatory,immunosuppressive agent Status asthmaticus and asthmatic bronchitis
(end in one)
Predisone
Methyleprednisolone(Solu-Medrol)
Dexamethasone(Decadron)
Beclamethasone(Vanceril/Beclovent)
Triamcinolone(Asmacort)
Funisolide(Aerobid)
Fluticasone(Flovent)
Pulmicort(budesonide)
to prevent thrush rinse with water"
What are decongestants?
"Alpha effect which causes vasoconstriction and reduces blood flood and mucosal edema
Racemic Epinephrine(vaponephrine)"
What are Leukotriene modifiers?
"Non steroid drugs that have been approved for use in cases of mild to moderate asthma
Montelukast(Singulair)"
What are anti inflammatory /long acting brochodilator combinations?
Combination of fluticasone(anti inflammatory) and salmeterol(long acting bronchodilator)--Advair Indicated for asthma
What are some beta bronchodilators?
"Albuterol-0.5mL normal 2.5mg/Side effect Tremors
Metaproterenol(Alupent or Metaprel) dosage 0.3mL q4
Terbutaline(Brethine or Bricanyl) 0.5mL
Bitolterol(Tornalate) 1.25QID
Pirbuterol(maxair)0.2mg/puffQ4-6hr
Saimeterol(Serevent)21ug/puffBID
Formelterol"
What are some of the side effects of beta adrenergic bronchodilators?
"Tachycardia
Palpitations
Hypertension/hypotension
Headache
Tremors
Paradoxical hypoxemia
Nausea vomiting"
What are some anticholinergic bronchodialators?
"Atropine Sulfate
Ipratropium Bromide (Atrovent)
Tiotropium(Spiriva)"
What are some Adrenergic/Anticholinergic bronchodilators?
"Combination of beta adrenergic and anticholinergic agents.
Ipratropium Bromide and Albuterol(Combivent, DuoNeb)"
What are some Xanthine drugs?
"Theophylline (Aminophylline)
Theophylline(Theo-Dur)
Oxytriphylline(Choledyl)
Caffine also"
What are the safe blood levels of theophylline and signs of toxicity?
"Therapeutic blood levels of theophylline are 10-20/ug/mL
Blood levels are important to monitor in asthmatic patients
Signs of toxicity are
tremors nausea and vomiting
nervousness
tachycardia and other arrhymias"
What is given for mucus plugs, CF?
"Acetylcysteine(mucomyst) dissolves disulfide bonds used for liquefaction of thick tenacious secretions
Always give bronchodilator first"
What is a mucolytic agent other than mucomyst?
"Dornase Alpha(pulmozyme)
digests extracellular DNA
treat viscous secretions CF"
What are Cardiac Glycosides and what are they used for?
"Increases the strength of contraction
Treatment of CHF
Digitalis(Crystodigin)
Digoxin (Lanoxin)"
What are anti-arrhythmic agents?
"Used for arrhythmias-
Atrial arrhymias Quinidine, Propranolol (Inderal)
Ventricular arrhythmias Lidocaine control of PVC's, pulseless ventricular tachycardia, or ventricular fibrillation"
What is Amiodarone used for?
Treatment of pulseless ventricular tachycardia and ventricular fibrillation that has not responded to defibrillation
What do you treat bradycardia with?
Atropine, Epinephrine
What do you treat angia with?
"Nitroglycerin (vasodilation)
Isordil
Relief of pain (angina pectoris) is almost immediate"
What are the vasodilator drugs and what do they treat?
"Vasodilator drugs used to decrease BP. (Nitro)
Diuretics-Thiazides
Chlorthiaside(Diuril)
Hydrochlorothiazide(Hydrodiuril)
Sympatholytics are Methyldopa (aldomet)blocks sympathetic neurotransmission
Propranolol(Inderal) bloks over reactive sympathetic neurons
Metoprolol(Lopressor) B1 blockade(slow down the rate)"
What are direct vasodilators?
"Diazoxide(Hyperstat IV)
Sodium Nitroprusside(Nipride)light sensitive
Nipride lowers blood pressure and decreases ventricular preload"
What are vasopressers and what do they do?
"Vasopressors are a adrenergic and raise blood pressure.
Dopamine used to maintain BP
Norepinephrine(Levophed ) used in cardiogenic shock"
What are some diuretics, what do they do and what effects do they have?
"Loop diuretics- furosemide(lasix)
Used for pulmonary edema, liver and kidney disease, CHF
Adverse effects:hyplkalemia, hypochloremia, metabolic alkalosis"
What do you use for drug over dose?
Narcotic Antagonist: Naloxone(narcan) reverses narcotics.
What is an antiviral agent?
"Used to treat respiratory syncytial virus (RSV)
Delivered via a smalll particle aerosol generator SPAG
Deliver Ribavirin(Virazole)"
What are some artificial surfactants and how used and delivered/
"Used to prevent and treat IRDS/HMD(hylan membrane disease)
Route of administration directly into trachea, immediately after birth or once RDS has been diagnosed
Survanta Infasurf, Curosurf"
What is used to treat Central sleep apnea
"Doxapram(Dopram)
Medroxyprogesterone(hormone)
Aminophylline/Theophylline, caffine used to treat Apnea of Prematurity"
What is nicotine therapy and some treatments?
"Used to help patients quit smoking
Nicotine gum(NIcorette)
Patch (Nicotrod, NicoDerm)
Nicotine nasal spray (Nocotrol NS)
Nicotine inhaler"
What are some antibiotics?
Penicillin-effective especially for gram postive organasims all the coccus (strep, diplo etc)
What are good for broad spectrum therapy?
Carbenicillin, Amoxicillin, Ampicillin
What are some penicillnase resistant drugs?
Methacillin. oxacillin and nafcillin
What is a broad spectrum drug?
"Cephalosporins :effective on gram+ and gram- and can be given to patients allergic to penicillin
Cephalothin(Keflin)
Cephaloridine(Loridine)
Cephalexin(Keflex)
Erythromycin and for mhycoplasm pneumoniae infections"
What are Aminoglycosides?
"Good for gram- E. Coli, Pseudomonas
the mycins
Streptomycin
Gentamycin
Tobramycin
Vacomycin"
What are the antituberculin drugs?
"Used to treat TB
Isoniazid(INH)
Rifampin
Streptomycin
Ethambutol
Combination therapy usuall will continue for 2 yrs (3 drug combination0
Chemoprophylaxis for TB - 1yr of Isoniazid (INH) if exposed and no alchol"
What is the ideal breathing pattern?
"Slow, deep inspriation(from resting exhalation)
Inspiratory pause/hold (1-3 seconds)"
What is IS and how is it preformed?
"Indications: Prevention of atelectasis ,treatment of atelectasis. Encourage patients to take a deep breath.
IS should be performed hourly for 10 breaths
Date, time and Volume (IC) should be charted
Increase or decrease volume goals based upon patient's performance. Half of pre op goal
Volume-oriented:Patient inspires until preset measured volume of gas in inhaled.
Flow-oriented Patient's inspiratory flow rate causes a ball or float to rise"
How do you troubleshoot IS?
"Patient's must be reminded to inhale not exhale into device
In flow spiromenter ,a slow inspiration may not generate sufficient flow to raise the float/ball :may need to switch to a volume type spirometer"
What are the indications of IPPB therapy?
Prevent or correct atelectasis in patients unable to take a Deep Breath
What are the hazards of IPPB therapy/
"Hyperventiation-dizziness, tingling of fingers (have pt slow down respirations)
Impeding venou return-results in decreased cardiac output
increased intracranial pressure (keep pressure low)"
What is pressure-cycled ventilators?
"IPPB therapy - Bird Mark 7
Pressure cyclec : inspiration ends if you don't reach preset pressure
Flow rate ; Increasing flow will increase the E-time
Decreasing flow will increase the I time"
What are appropriate ventilators for IPPB home therapy?
Bennett AP-4 and AP-5 ventilators ,electrically powered
What changes on IPPB will effect the FIO2/
"Increase pressure will increase FIO2
Decrease flow (increased inspiratory time) will increase the FIO2"
What changes on IPPB will change the volume?
"Increasing the pressure will increase the volume
Decreasing the flow will increase the volume (increased inspiratory time)
Increasing th flow will increase turbulence and decrease volume (decreased inspiratory time)"
What changes the effect on the I:E ratio on IPPB ?
"Increased pressure(increase tidal volume) will increase the inspiratory time
Increased flow will decrease expiratory time"
How do you troubleshoot IPPB?
"Loss of pressure means leak or not enough flow
Excessive pressure means Obstruction or too much flow
Failing to cycle into inspiration mean adjust sensitivity or tight seal around mouthpiece
Failing to cycle off means a Leak, mouthpiece/mask seal
Cuff leaking
Fenestrated trach tube open
Loose equipment connection
If pressure does not rise normally =not enough flow"
What are the indications for non-invasive positive pressure ventilation NPPV?
"To avoid intubation , in patient who is DNI
To facilitate long-term ventilation at home
Assist a patient in early respiratory failure/COPD
Contraindications -poorly fitting mask"
What is BiPAP ventilation?
"Non invasive
Provides two levels of CPAP
One during inspiration(IPAP)
One during expiration(EPAP)
IPAP (ventilation) should be greater than EPAP (oxygenation)
An I:E ratio of 1:2 is preferred
Contraindicated for patients with dysphagia (trouble swallowing)"
What is a negative pressure ventilators , extrathoracic?
"Negative pressure (suction) is applied to the outside of the chest.
This causes the chest to rise and expand(inspiration)
Ventilation is controlled by adjusting the length of inspiration andt the amount of suction (time cycled ventilation
Indicated for intermittent use , home care(central sleep apnea) and patients with neuromuscular strength"
What do you troubleshoot for in negative pressure ventilators?
"Chest cuirass is hissing and unable to reach pressure means check for leaks
Patient is breathing faster than the rate setting on the machine means increase the rate on the machine"
What are some of the negative effects of positive pressure ventilation?
"Decreased venuous return
Increased intrathoracic pressures
Increased intracranial pressures
Decreased cardiac output"
What are the types of positive pressure ventilation?
"volume cycled-pressure is applied until a preset volume is delivered, inspiration ends
Airway pressure will increase and decrease with changes in patient's compliance or airway resistance.
Pressure Cycled- ventilation is (VT) adjusted by increasing or decreasing the pressure limit Inspiration ends when preset pressure is reached. Although peak pressure will remain constant , the volume will change as lung compliance and or airway resistance change
This type of ventilator is best for intermittent therapyIPPB or continuous ventilation for patients with normal lungs (Bird Mark 7, Bennett PR-2) Inspiration ends when time is reached .
Also used for infant ventilation"
What type of ventilators are used for home/
"Examples of negative pressure-Cuirass or shell and Body Wrap or poncho
Positive vents Intermed Bear33
Life Care PLV 100 and 102
Aequitron LP 6 and LP10
Puritan Bennett companion 2801
A backup vent should be provided for any pt who requires ventilation the majority of the time"
What are the qualities of a transport ventilator?
"Should be portable and lightweight
Duration of flow must be considered when using an oxygen tank to power vent
If respiratory rate or tidal volume decreases on pneumatic transport vent-check the tank pressure-may be running out of gas"
When should you change a vent circuit and how?
Every seven days and manual ventilation with a resuscitation bag will be necessary while the new circuit is attached and tested by another person
What are the common alarms for a ventilator?
"High pressure limit (set 10-15 cmH2O above peak airway pressure)
Minimum exhaled volume(set 100mL below exhaled tidal volume)
Low pressure limit (set 10 cmH2O below peak airway pressure)"
What does a low pressure alarm on the ventilator mean?
"Consider :
Leak in the ventilator circuit
Insufficient flow
Endotracheal/tracheostomy tube cuff leak"
What does a high pressure alarm on the ventilator mean?
"Consider:
Equipment obstruction(ventilator circuit)
Patient obstruction (endotracheal tube, pneumothorax, increased airway resistance , secretions etc.)"
What does low exhaled volume alarm mean?
"Consider;
Equipment disconnect(ventilator circuit)
Low spontaneous tidal volume"
What are time cycled pressure limited ventilators?
"Inspiration begins and ends according to preset inspiratory time
Maintains preset pressure limit using pressure popoff (pressure relief valve)
Volume delivered demands close monitoring because it varies with EVERYTHING
Pressure limit, flowrate, inspiratory time, compliance, airway resistance patient effort during spontaneous breathing, CPAP or PEEP changes"
What are the dtime cycled pressure limited settings for infants?
"Mode-SIMV
Peak Inspiratory Pressure(PIP)- 20-30 cmH2)
Respiratory Rate 20-30 breaths
Inspiratory time- 0.5-0.6 seconds
Flow- 5-6 L/min
FIO2 40 -60% or set at same level prior to ventilation
PEEP 2-4 cmH20
Change in increments of 2 cm H2O and not above 8 cm H2O"
What are the three phases of mechanical ventilation?
"Phase 1 initiating mechanical ventilation (when, settings)
Phase 2 caring for the patient receiving mechanical ventilation(changes)
Phase 3 weaning a patient off mechanical ventilation (when, method, monitoring)"
What are the indications for continuous mechanical ventilation?
"Apnea(not breathing) observation
Acute ventilatory failure not breathing enougnh (one ABG)
Impending respiratory failure rising PaCO2 (serial ABGs) neuromuscular, VC, MIP
Oxygenation last reason for ventilator, used to reduce work of breathing(Oxygen, CPAP)"
What are the clinical data for mechanical ventilation?
"Patient Assessment
Arterial Blood Gases , PH 7.35-7.45.mmHg PCO2 35-45mmHg
PO2 80-100mmHg
Bedside pulmonary function
Tidal Volume(VT) >5mL/kg
Vital capacity(VC) >10mL/kg or 2 x Vt
Respiratory rate(f) 8-20 bpm
Minute ventilation(VE) <10L/min
Maximun inspiratory pressure(MIP) -20 cmH2O measures muscle strength (NIF)
Maximum expiratory pressure(MEP) 40cmH2O
Physiological assessment/calculations
A-a DO2(21%O2) 5-10mmHg
A-aDO2(100%O2)25-65mmHg Acceptable66-300mmHg
Qs/Qt(% shunting) <5% Acceptable <20%
VD/VT(%deadspace) 20-40% Acceptable<60%
Cst(static compliance)60-100mL/cmH2O Acceptable>25mLcmH2O
Qs/Qt(%)"
What is the set-up of a continuous ventilator?
"Mode, VT, RR,FIO2, and PEEP
Mode:Control, assist/control, IMV/SIMV
Tidal volume and Rate two most important controls and should be set first
Tidal volume(VT) set at 10mL/kg of ideal body weight Range 8-12 set at 10 mL/kg and go 100mL up and down to get range
Respiratory rate 8-12breaths
FIO2 and PEEP once the ventilation has been set (VT and f ) then the next life function oxygenation should be set, Oxygenation begins with FIO2 setting if no information about prior O2/ABGs or patient on room air(21%) then Oxygen at 40-60% and no PEEP therapy
Patient was on oxygen prior to ventilation then same FIO2 and or/PEEP
PEEP 0-10 cmH2O"
What measurements are taken with patient OFF the ventilator?
"Tidal Volume(using respirometer)
Respiratory Rate (f)
Vital capacity(VC)
Maximum inspiratory pressure(MIP)
Maximum expiratory pressure(MEP)"
What are measurements are taken with patient ON the ventilator?
"Exhaled tital volume(VT)= (VE /f)
Respiratory rate(f)
Minute ventilation(VE)=(VT x f)
Inspiratory flow (I:E ratio)
Alveolar ventilation VA=Tidal volume -weight x 10"
What is the formula for static compliance and what is the normal value?
"Stactic Compliance = Exhaled volume/Plateau pressure -PEEP
Normal is 60 - 100 cm H2O"
What are some of the reasons for increasing pressures on a ventilator?
"Increasing airway resistance(Raw) obstructive disease
Peak inspiratory pressure(PIP) increases
Plauteau pressure(Ppl) REMAINS SAME - compliance
Raw can be estimated;PIP-Plp
Common causes are secretions in airway
Bronchospasm
Treatment /suction and
bronchodilator
Decreasing lung compliance(CL) restrictive
Peak inspiratory pressure(PIP)
Increases
Plateau pressure (Ppl)Increases Complance down
Common causes:
atelectasis, pulmonary edema
ARDS, pneumonia
Treatment: Increase PEEP ,
treat underlying cause for decreased compliance"
What is the mean airway pressure(Paw) what controls affect it ?
"Paw is the average pressure transmitted to the airway from the beginning of one breath to the beginning of the next.
Controls that affect Paw
peak inspiratory pressure(PIP)
rate(f)
inspiratory time(IT)
PEEP most influence on Paw inspiratory and expiratory
Peak Flow
Tidal Volume
Inflation hold"
What are the typical mean airway pressure values(Paw)?
"Patients with normal compliance and resistance 5-10 cmH2O
Obstructive patients 10-20 cm H2O
ARDS patients 15-30cm H2O"
What does Control mode on ventilator indicated for?
Head trauma/surgery patients, status asthmaticus, flail chest, does not allow patient to initiate breaths. Change it
What is the assist/control mode?
"Ventilator gives Tidal volume everytime patient inhales
Patient may hyperventilate if in pain"
What is the SIMV mode usually used for?
"Spontaneously breathing patient
Ventilator provides a miniumum minute ventilation
Used with COPD patients to normalize ABGs
Used with tachypnea(>mo bpm) to avoid hypervention(pulmonary emboli)
Used for weaning patients
Used instead of assist/control to reduce barotrauma
Used with PEEP to reduce barotrauma"
What is pressure control ventilation used for (PCV)?
"Used when peak inspiratory pressures(PIP) are very high(>50 cm H2O
Recommended for patients requiring high FIO2's(>60%) and PEEP (>15 cm H2O)
High PIP(>50 cm H2O)
Low PaO2's and decreased compliance (ARDS)"
What do you do to normalize a high PaCO2?
"Increase the tidal volume(8-12mL/kg)
Increase the respiratory rate
Remove the deadspace"
What do you do to normalize a low PaCO2?
"Decrease the tidal volume Target PaCO2 for head injury should be 25-30mm Hg
Decrease respiratory rate"
What do you do to increase a low PaO2?
"First increase FIO2 by 5-10%(up to 60%)
Then Increase PEEP levels by 5cm H2O until: Acceptable oxygenation is achieved or unacceptable side-effects occure (decrease compliance, decrease cardiac output, barotrauma)"
What do you do to decrease a high PaO2?
"First decrease FIO2 to less than 60%
Then decrease PEEP"
What is High Frequency Ventilation and when do you use it?
"Positive pressure ventilation with breathing rates in excess of 150 bpm and low tidal volumes(<5mL/kg) 1-3mL/kg
Used for ARDS, pulmonary interstitial emphysema and infants"
What are the primary controls used to adjust ventilation and control gas exchange?
"1) Rate control/frequency
2) Amplitude/drive pressure regulator(volume)
3) % inspiratory time (I:E ratio)"
What are the types of HFV?
"High Frequency Positive Pressure Ventilation HFPPV
Rate150-300 Hertz 2-5
High Frequency Jet Ventilation HFJV
Rate100-600 Hertz1.5-10
High Frequency Flow Interruper Ventilation HFFIV
Rate 120-1320 Hertz 2-22
High Frequency Oscillator Ventilation HFOV
Rate 60-3000 Hertz >50"
What do you adjust in Volume control to change the I:E ratio?
"Flow rate
Increasing the flow rate will increase the time for exhalation"
What do you adjust to change Inspiratory Plateau and why?
"The inflation hold, the purpose is to increase diffusion of gases (improve distribution) and to decrease microstelectasis formation.
Not to be used with head injury patients and hypotensive patients"
How should the patient be positioned for mechanical ventilation?
"Patient should initially be placed in a supine position.
If patient stable Low or semi Fowlers"
Why should you adjust pressure support?
"To help patient overcome the resistance of breathing thorough the ventilator circuit
Pressure support can be adjusted above the airway resistance , PIP , Plateau"
What is normal PEEP/CPAP and when is it theraputic?
"PEEP/CPAP normal is 2-10cm H2O is considered physiological
PEEP/CPAP therapy 10-30 cm H2O"
When is PEEP/CPAP improving patients status?
"PO2 increases
Static Compliance increases(corrected plateau pressures decrease)
Cardiac output/Cardiac Index stabel or increases
Hemodynamic pressures are stable(PAP, PWP0
Increased PVO2,SVO2, stable or decreased A-aDO2"
When is PEEP/CPAP too high?
"PO2 decreases
Static Compliance decreases(corrected plateau pressures increase)
Cardiac Output.cardiac index decreases
Hemodynamic pressures increase(PAP, PWP)
Decreased PVO2 , SVO2,stable or increased A-aDO2
For patient with head injuries, increase the FIO2 instead of increasing or adding PEEP
Hypotensive pts also"
What is the sign volume and rate set at and why?
"Usually in Assist Control
Used to decrease microatelectasis
Sign volume set at double the VT or less (1.5 2 times VT)
Rate set at 1-3 sighs every 4-15 minutes"
How do you calculate minimum flowrate?
Flowrate= (Tidal volume x Rate) x (I + E)
What does a spontaneous volume/pressure loop look like?
Skinny Oval
What does a assisted volume/pressure loop look like?
Fish tail , with tail over pressure line
What does a controlled volume/pressure loop look like?
Football
What does Poor compliance too low a PEEP look like on loop graph?
"Football is flat on bottom, starts at 0 and is flat till 10 or whatever
If PEEP is optimual football starts at 10 or whatever is optimual for that PEEP"
What does the loop look like on the volume/pressure in overdistension of the lung?
"Beak of duck
To improve reduce tidal volume in volume control
or change to pressure control and limit PIP"
What does the loop look like on the volume/pressure with low compliance?
"Lazy line, just above the pressure line slanting down
such as in ARDS, IRDS,pneumonia, pulmonary edema,)
Improve with PEEP therapy, surfactant therapy"
What does the loop look like on the flow/volume loop with high airway resistance (decreased flow)?
"Laying flat above and below 0 line
This can occur with bronchospasms, secretions and other forms of obstruction
Therapy: Bronchodilator therapy , suctioning"
What does the loop look like on the flow/volume loop with leak?
"The loop will be broken , not at 0 in both flow/volume and volume/pressure
Example of leaks: Cuff, curcuit,chest tube bubbles in water chamber 2"
How do you evaluate air trapping (auto PEEP ) problems ?
Flow / time graph and expiratory flow does not return to th zero baseling before next breath starts. square pattern
What are the ideal drug characteristics for patients receiveing mechanical ventilation?
"Potent respiratory depressant
Minimal cardiovascular effects
Euphoric effects (makes being conscious tolerable)
Analgesic effects(alleviate pain)
Easily reversible"
What are the pharmacological agents used for mechanically ventilated patients?
"Morphine sulfate is a narcotic analgesic and causes a decrease in respiratory rate and tidal volumes in high doses.
Valium/Versed /ativan /Conscious sedation procedure
Anti-anxiety , sedative, anticonvulsant, Acts on CNS for anxietry, relieves fear
Pavulon(Pancuronium Bromide)Non-depolarizing neuromuscular blocking agent
Causes total muscle relaxation
Takes 2-3 min , no cardiovascular effects. Reversed by anticholinesterase dreu Edrophonium Chloride(Tensilon)
Curare(d-Tubocurarine)Non-depolarizing neuromuscular blocking agent, causes muscle paralysis, Reversed by Neostigmine and Atropine(Neostigmine destroys acetylcholinesterase) Check for complete reversal by asking patient to move
Norcuron(Vecuronium bromide) Non-depolarizing neuromuscular blocking agent, more potent than Pancuronium Bromide, less likely to cause histamine release, onset 2.5 -3min, duration 25-40min
Anectine(succinylcholine chloride) Sucostoran, given primarily for intubation, Fast acting drug last 3-10minute"
What do you assess for weaning from vent?
"1) Verify that underlying disease process has been reversed
2) Aterial Blood Gases should show adequate ventilation and oxygenation(PCO2, PO2, pH)
Bedside pulmonary function:
VT>5mL/kg
VC>10mL/kg
f 8-20bpm
MIP/NIF >-20cm H2O
MEP>40cm H2O
RSBI<100 (RR/Vt(L) rapid shallow breathing index
Clinical measurements
A-aDO2<300mm Hg
Qs/Qt <20%
VD/VT<60%
Pulse and blood pressure normal"
What methods are used for weaning?
"Traditional method/Trial and error/T-piece trial. Patient is taken completely off the ventilator.
IMV/SIMV decreasing the ventilator rate and allowing the patient to breathe spontaneously. Pressure Support Ventilation(PSV) IPAP to support inspiration when the patient is having difficulty with weaning. PSV can be used with IMV/SIMV
Drugs that suppress ventilation should be stopped
The patient should be aware of what is happening"
What do you assess during weaning from vent?
"Heart and Lungs , if heart rate increases 20 beats or more from baseling, then stop weaning and resume mechanical ventilation.
If the heart rate increases less than 20 beats, continue weaning and observe closely, you may increase the FIO2 while off the ventilator
BP,RR, VT,VC should be checked every 20 minutes for any problems.
Sensorium: Patient should be alert and responsive . Any chance in mental status or level of consciousness would indicate the need to resume mechanical ventilation.
Other assessments: ABG should be drawn after 20 -30 minutes off the ventilator to assess ventilation and oxygenation
Summary of adverse conditions to Resume mechanical ventilation
Increase in HR by>20 bpm
Change in BP by 10-20 torr
Increased PaCO2 by >10 torr
RR increases by >10 or is >30 BPM"
What are the steps in basic life support (BLS)?
"1) Determine unresponsiveness- tap and shout
2) Call for help-do not leave paient
3) Establish airway- position patient, elevate chin(head tilt-chin lift or modified jaw thrust)
4) Check for breathing-watch for chest movement,listenand feel air flow(no more than 10 seconds)
5) Give two breaths-(if unable to ventilate , reposition head)
6) Check for pulse, carodid artery
7) If pulseless:begin chest compressions-chech hand postion
8)Provide 100% oxygen and draw arterial blood gas
9)Even with proper CPR (30:2) can only establish about 30% of the patient's original cardiac output"
What are the two most common complications of basic life support?
"Number One Complication of artificial respirations is Gastric distention.
Number One Complication of external cardiac compression is Rib fractures"
What are the differences in performing CPR on adult , child, infant and newborn?
"IN establishing airway the same for Infant under 1yr to Adult use the head tilt-chin lift or Modified jaw thrust
Except in the Newborn Birth to 1 month Just Head slightly Extended
Breathing Rate 8yrs to Adult:10-12breaths/min or every 5-6seconds
Child and Infant under 1 to 8yrs 12 -20 breaths/min
Newborn birth to 1 month 40 -60 breaths/min
Compressions 8yrs to Adult Use heel of bottom hand
Child 1 to 8yrs Use heel of 1 hand
Infant to 1 month Use 2 or 3 fingers
Birth to 1 month Use 2 fingers or thumbs
Position of hands or fingers Infants to Adult -Lower half of sternum
Newborn birth to 1 month Use Lower Third of Sternum
Depth 8yr to Adult 1 1/2 - 2inches
Child 1 to 8yrs 1 to 1 1/2inch
Infant under 1 yr 1/2 to 1 inch
Newborn birth to1 month 1/2 to 3/4 inch
Rate 100/min except for Newborn is 90/min
Compression to Ventilation Ratio 8yr - Adult 30:2 both one and two rescurer
Child Under 1 to 8 yrs 15:2 two rescurer
Newborn 3:1 both one and two rescuer
For Under 1 to 8yr call 911 after 1 min or 20 cycles
Newborn birth to 1 month Begin chest compressions if HR is < 60 despite 30 sec. of ventilation .Only newborn has pulse and you still start compressions"
What is Hypotension and how do you treat it?
"Characterized by low blood pressure, poor capillary refill,weak thready pules.
Treated with fluid challege, dopamine, dobutamine"
What is Bradycardia and how treated?
"Characterized by heart rate < 60 in an adult and heart rate<100 in an infant
Treated with atropine, dopamine and epinephrine for adult
Epinephrine and atropine for children
Also treated with external pacemaker"
What are Ventricular arrhythmias and how are they treated?
"PVC:treat with Oxygen and LIdocaine
Pulseless Ventricular Tachycardia treat with defibrillation at 360 joules
If defibrillation unsuccessful, start CPR and administer:Epinephrine, amiodarone or lidocaine
Ventricular fibrillation treat with Defibrillation at 360 joules, if defibrillation unsuccessful, start CPR and administer Epinephrine, amiodarone or lidocaine
Special considerations: if the patient has a metabolic acidosis(documented by ABG) administer sodium bicarbonate."
What is asystole and how is it treated?
"No activity , straight line
1st Confirm in two leads
Treat with Epinephrine, Atropine, DO NOT DEFIBRILLATE
CPR, intubate , IV pacing"
What is cardioversion?
"Therapeutic procedure (non-emergency) involves low voltage (50-100Joules) current to heart to attempt to convert dysrythmia to normal sinus rhythm. The electric current is synchronized with patient's rhythm. (Shock to R wave)
Atrial fibrillation , atrial flutter and venticular tachycardia with pulse. If ventricular fibrillation occurs , check pulse first, then turn off synchronizing switch , increase to 200 joules and defibrillate
Madazolam(Versed) is a strong short acting sedative given prior to cardioversion"
What is dibrillation and when is it used?
"Similar to cardioversion ,except used when emergency (lethal) cardiac dysrhymias are present.
Pulseless Ventricular Tachycardia
Ventricular Flutter
Ventricular Fibrillation
Normally 360 Joules
Life threathing, unsynchronized"
What is the criteria for the ideal resuscition bag?
"Self -inflating
Good mask design, will fitting, shapeable and transparent
Reservoir to give 95-100% oxygen at 15 L/min with a quick attachment (not bulky)"
How do you troubleshoot a resuscitation bag?
"If bag fills rapidly and collapes easily on minimal pressure then check inlet valve.
If bag becomes difficult to compress with normal patient compliance , patient valve maybe stuck open or closed.
Too high flow may cause valves to jam. Use 15 L/min.
If these are not the problem use another form of ventilation"
What are the advantages of mouth to valve mask ventilation?
"Head tilt is applied , mask is placed on the face of patient, (an oropharyngeal airway maybe inserted if needed)
This eliminates direct contact with patient and eliminates exposure to exhaled air.
Easy to preform and supplemental oxygen can be administered"
What equipment is needed for patient transport?
"Intubation equipment
Portable oxygen
Resuscitation device
Transport vent if patient on vent
Pulse oximeter
Appropriate medications
portable ECG monitor
Stethoscope and spirometer, for tidal volume assessment"
What is Pulmonary Edema ?
Congestive Heart Failure/Left ventricular failure and lung reaction. Excessive fluids accumulate in the lungs that affect ventilation and especially oxygenation
What are the signs of Pulmonary Edema?
"Assessment:
Orthopnea,pitting edema, distended neck veins and increased respiratory distress.
Pink/frothy/watery secretions
Fine crepitant audible rales ore crackles"
What is the treatment of Pulmonary Edema/ Congestive Heart Failure(CHF)?
"Improve gas exchange-give 100% O2 via non-rebreather, IPPB wigh 100% o2 and ethanol, PEEP, CPAP if necessary.
Increase strength of heart contraction(Inotropy)- give digitalis
Decrease venous return-give lasix(diuretic) body position(Fowlers)"
What is Pulmonary Emboli?
Deadspace disease(ventlation without perfusion) Caused by blood clots in the lungs and will affect oxygenation and circulation.
What are some of the signs of Pulmonary Emboli?
"Assessment:
Sudden onset of dyspnea, tachypnea
Patient appears to be hyperventilating but is not (ABG's show normal PaCO2)
Anxious, chest pain
Wedge shaped x-ray
Ventilation/Perfusion (V/Q) scan-shows no perfusion with ventilation=deadspace disease"
What is the treatment of Pulmonary Emboli?
"Anticoagulation therapy(heparin and coumadin)
Oxygen therapy
Thrombolytic drugs/screens/surgery"
What is a Pneumothorax/
Presence of gas in the pleural space that can seriously affect ventilation
What are some of the signs of Pneumothorax?
"Assessment:
Sudden onset of dyspnea with decreased breath sounds and tracheal shift away from the affected side
Decreased vocal fremitus, percussion is hyperresonant or tympanic.
X-ray shows hyperlucency without vascular markings and a flattened diaphragm."
What is the treatment for Pneumothoraxx?
"Give 100% O2 via non-rebreathing mask
Immediate chest tube/ thoracentesis, or relieve pressure with needle and tubing inserted into a glass of water"
What is CO poisoning?
The inability of hemoglobin to bind with oxygen due to the binding of carbon monoxide. This can serously arrect oxgenation.
What are the symptoms of CO poisoning?
"Assessment:
History of present illness will be important. (fireman, smoke filled room, burning building etc.)
Redness of skin
Breathing labored and deep (tachypnea, hyperpnea)
Tachycardia with normal ABGs
Increase COHb on co-oximeter>20%
Do not rely on pulse oximetry(SpO2)"
What is the treatment of CO poisoning?
"100% O2 via non-rebreathing mask, CPAP mask
Hyperbaric Oxygen"
What is Status Asthmaticus?
Sustained asthma attack, unrespinsive to bronchodilator therapy. Will have marked affect on ventilation and oxygenation
What are the symptoms of Status Asthmaticus?
"Assessment:
Diagnosis made by history
Retractions and pulsus paradoxus
ABG's indicating respiratory acidosis or respiratory failure(PCO2>45)"
What is the treatment of Status Asthmaticus?
"100%O2 therapy via a non-rebreathing mask
Subcutaneous epinephrine x 3
Mechanical ventilation-sedate,paralyze,control if necessary
Bronchodilator therapy and steriods"
What are some examples of trauma?
Head,chest, neck,burns and near drowning
How do you treat trauma?
"Always start with airway,breathing and circulation
Administer 100% O2
Administer drugs and/or fluids based upon bedside and laboratory assessment
Remainder of treatment is based upon careful patient assessment."
What is a thoracentesis and the most common disorder that requires it?
Diagnostic and/or therapeutic procedure in which a needle is inserted into the chest to remove air/fluid from the pleural space. Most commonly used for pleural effusion
How is a thoracentesis preformed?
Patient is sitting up and leaning forward, 3 to 10 mL of licocaine is used to anesthetize the skin with a 25 gauge needle. A larger and longer needle is then used to anesthetize the thickness of the chest wall. The needle is inserted until the fluid level is reached. This is established when fluid can be withdrawn. 100 to 300 of pleural fluid is aspirated for diagnostic purposes with a 50 mL syringe
What does the pleural fluid appearance mean?
"A clear fluid that has a light straw color is called a transudate (serous fluid) and is associated with Congestive Heart Failure
A cloudy or opaque fluid (more cells) is empyema and is an exudate as is infections that produce yellow or milky exudate fluid.
Purulent or pus filled is an exudate also chyle containing lymphatic exudative fluid
Mucopurulent is an exudate containing mucus and pus
Bloody effusions (hemothorax, serasanguineous) may suggest malignancy of cancer
Loculated means very thick
Pleural fluid pH can be measured and a ph < 7.30 is considered significant (Exudate)"
What is a Polysomnography?
Sleep Apnea Study
What is sleep apnea and what are the 3 types?
"Sleep apnea is a condition in which the patient has apnea during sleep for periods of 10 seconds or longer.
There are 3 types:
Central:apnea due to loss of ventilation effort/chest stops moving
Obstructive;apnea due to blockage of the upper airway/chest still moves
Mixed:a combination of central and obstructive"
What does Polysomnography use to confirm the diagnosis and assess the severity of sleep apnea?
"Chest motion detectors to measure respiratory effort
Flow dectectors to measure nasal flow
Oximetry to measure oxygen desaturation(SpO2) during apneic periods
If nasal flow decreases and respiratory effort decreases(chest rise) then desaturation is a result of central problem
If nasal flow decreases but respiratory effort increases(chest rise) then desaturation is a result of an obstructive pattern."
What are the treatments for Sleeep Apnea?
"Weight loss
Surgery
Respiratory stimulants for Central Apnea
Tracheostomy
Nasal mask CPAP and/or BiPAP therapy"
What conditions require a chest tube?
"Pneumothorax air enters the pleural space with little or no fluid If this air that enters the pleural space is not allowed to escape it will not only collapse the lung but also affect the mediastinum by pushing it away from the effected side. This is a tension pneumothorax
Hemothorax or pleural effusion is fluid that enters the pleural cavity with no air. Immediate action should be taken to insert a large bore needle to relieve the pressure. Then insert a chest tube and apply the most appropriate chest tube drainage system."
Where is the chest tube placed?
"One , two or more chest tubes may be inserted into the pleural space. If the tube is to drain Air (A-anterior) from the pleural space it is placed in the anterior chest (second interspace in the midclavicular line)
If the tube is to drain Fluid from the pleural space 1st is placed between the fourth and fifth interspace in the midaxillary line(fluid under arm)"
How do water seal suction drainage systems work?
"One collection (bottle) system bottle should be lower than pt.
Three bottle collection system
1st bottle is collection bottle from patient (blood drained)
2nd bottle is Water seal bottle with 2cm of water in it if bubbles in this the 2nd bottle patient still has a leak
3rd bottle is the suction control bottle it has 20cm of water and has gentle bubbles when system is on"
What are the Low Flow Devices to deliver Oxygen ?
"1) Low flow - provide ONLY part of total inspired volume
a) Cannula: Delivered FIO2: 0.24 - 0.45 / Flow 1-6LPM
To approximate FIO2 : for every 1LPM increase FIO2 increases by 4%
Most appropriate initial oxygen device for COPD patients with stable respiratory rates and tidal volumes.
b) Oxygen Conservation Cannulas
Reservoir cannula- Designed to maintain FIO2 at lower level by using a reservoir. The flowrate may be reduced without affecting the FIO2
Used commonly in the homecare setting to reduce costs.
c)Transtracheal Oxygen Catheters(TTO2)
Amethod of delivering long-term low flow oxygen therapy directly into the airway by a surgically implanted catheter
If the patient becomes SOB or has increased WOB ith a TTO2 device the catheter could be obstructed with secretions and you would need to flush catheter.
d) Simple mask
Delivered FIO2 : 0.40- 0.55
Flow 6-10LPM
Flow MUST be greater than 5LPM to flush out exhaled CO2
e) Partial rebreather mask
Delivered FIO2 : 0.60 - 0.65
Flow 6-10LPM/ Has NO one-way flaps"
What is the rule for oxygen deliervy for COPD patients?
"COPD Patients
1 - 2 LPM = 24 to 28% FIO2
Theraputic 30 to 60% FIO2
Emergency Situation 100% FIO2"
What are the high flow devices to deliver oxygen?
"1) High Flow Devices provides patient's entire inspired volume(100%)
a) Non-rebreather mask
1) Delivered FIO2: 0.21 to 1.0
2) Used to deliver 100% O2 in an emergency (Pneumothoras, CO Poisoning, CHF,Burns,etc)
He/O2, CO2/O2 mixtures
3)Ideally has THREE one-way valves
4) Troubleshooting
a) Flow rates must be sufficient to keep the bag from collapsing. If bag collapes, increase the flow
b) If patient inhales and bag does not contract
1)Mask is not tight, seal mask
2) Nonrebreathing valve is stuck, replace mask
b)Air-Entrainment Mask/Venturimask
1) Precise FIO2 concetrations available (ideal for patients with COPD)
2)Ideal for patients with irregular tidal volumes, rates and breathing patterns
c)Brigg's adapter (T-piece)
1)Delivered FIO2 : 0.21-1.0 depends upon the aerosol source
2)Turn up flow, add tubing after the patient
d)Aerosol masks, trach collars(masks) and face tents
1)Delivered FIO2 : 0.21-1.0 depends upon the aerosol source and nebulizer output"
What is an Oxygen Hood?
"1)Clear plastic device of various sizes that completely encloses the head of the infant for the administration of oxygen and high humidity
2)Flow range 7-14L/min to prevent CO2 buildup and allow controllled FIO2 without sealing the infants neck around the hood.
3)Monitor temperature:
a) Overheating can cause dehydration and apnea
b) Underheating can increase O2 consumption
4)Monitor FIO2 -Preferred method is to analyze O2 continuously near the infant's face. Oxygen may ""layer"" with higher FIO2 in the lower layers"
What environmental control devices are there for oxygen delivery?
"1)Mist Tent, Oxygen Tent, Croupette
a)Indicated for patients requiring a controlled environment
b)Environmental factors controlled:
1) Oxygen concentration
2)Temperature(less than room temperature
3)Filtered gas
4)Humidity and aerosol delivery
c)Used mostly for neonatal and pediatric patients
d)Run flow at 12-15L/min to wash out CO2
FIO2 variable at 0.40-0.50 and hard to control
f) If FIO2 is fluctuating-make sure tent is tightly tucked in. Increase flow
2)Incubators (Isolette)
a)Indications
1)Filtered gas
2)Temperature control-will maintain a neutral thermal environment
Ideal for non-stressed newborns
3)Radiant warmers(Open incubator
a)Ideal for code emergency and for easy access.
b)Provides a neutral thermal environment but will not decrease insensible water loss in premature infants due to evaporation.
4)Troubleshooting
1) As eith most circuits, LOSS OF PRESSURE indicates
a)Leak
b) Insufficient flow
INCREASED PRESSURES indicates
a) Obstruction
b)Faulty exhalation/CPAP/PEEP valve
c)With excessive flow, a continuous venting of the pop-off valve will occur"
What is Hyperbaric Oxygen Therapy?
"1) Means of increasing the PO2 by increasing the barometric pressure
2) Diseases/disorders frequently treated by hyperbaric O2 therapy
a) CO poisoning
b) Tissue transplants/grafts
c) Anaerobic infections(gas gangrene)
d) Decompression sickness (bends)"
What is Helium/Oxygen Therapy (He/O2)?
"1)Purpose-decreases the patient's work of breathing by delivering low density gas(most important property) that can easily maneuver around obstructions. Used for patients with increased airway resistance, edema, foreign object obstruction, or partial vocal cord paralysis
2) Concentrations used:80%He/20%O2 or 70%He/30%O2 mixtures
3) Considerations
a)Therapy given with non-rebreather
b) Use 1.7 for both concentrations =1.7 x Liter /min"
What is Nitric Oxide Therapy?(NO)
"1)The physiologic effects of nitric oxide are due to its ability to relax smooth muscle. This improves blood flow to alveoli to improve ventilation/perfusion mismatch, decreases pulmonary vascular resistance, decreases pulmonary pressures and improves oxygenation
2)Indications for nitric oxide therapy include:
a) primary and chronic pulmonary hypertension
b) Pulmonary fibrosis
c) Pulmonary embolism
d) Respiratory distress syndrome(ARDS)
e) Congenital heart defects
f) Persistent pulmonary hypertension of the newborn
g) Chronic lung disease
h) Heart and lung transplant
i) Sepsis
j) Sickle cell disease
3)Effective dose is in the range of 2 - 20ppm (parts per million)
4) Recommended starting dose is 20ppm. Doses up to 40 ppm can be sdministered without major side effects
5) Nitric oxide is most commonly delivered via mechanical ventilation. (I-NO delivery system) but can be delivered through a nasal cannula to spontaneously breathing patients as well
6) I - NO-Vent is a machine that is attached to vent to deliver NO Therapy
7) When nitric oxide is exposed to oxygen it can forem nitrogen dioxide(NO2) Levels of nitrogen dioxide greater than 10 ppm can result in cellular damage, pulmonary edema and death
9) Other adverse effects include:
a)poor/and or paradoxical response
b) methmeglobimenia/ hemoglobin ability to carry oxygen
c) rebound hypoxemia and /or pulmonary hypertension
d) increased left ventricular filling pressure
e) platelet agglutination(cells clump together
10)Discontinuing therapy
a) Must be done carefully to prevent a rebound effect
b) The nitric oxide level dhould be decreased to the lowest possible dose, usually 5 ppm or less
c) The patient should be able to maintain a good oxygenation level on an FIO2 of 0.4 or less
d) Before withdrawing the nitric oxide always hyperoxygenate the patient"
What do you do to troubleshoot an oxygen cylinder?
"Troubleshooting:
a) If tank is leaking, check and tighten all connections, check outlet for debris and check/replace washer
b) If patient states that no flow is sended from the cannula, the patient should be insturcted first to verify the flow by inserting the cannula into a glass of water and checking for bubbles"
What is the Formula for finding the duration of flow for a tank?
"Formula of Duration (in min)
Tank factors
E cylinder= 0.3
H cylinder= 3.0
duration= tank psi x tank factor/ Liters running at"
What is a pulsed-dose oxygen delivery system?
"1) Used in place of a flowmeter with low flow oxygen devices(nasal cannula, reservoir cannula and transtracheal catheters) and connected to a 50 psi gas source
2) Device senses the start of inspiration and delivers oxygen only during inspiration"
What is an Air-Oxygen Proportioners (Blenders)?
"1) Purpose:
a) To control the mixing of air and oxygen to obtain a specific FIO2
2) Can be used with a non-rebreather mask to achieve a precise FIO2"
What is an Air Compressor?
"1) Used as an alternative means for providing air to patient without using an air cylinder
2) Can be used in a hospital, out-patient clinic or in the home setting
3) Can be used to power a hand-held nebulizer for a COPD patient in the home setting"
Why are Total Flow and Oxygen Percentage calculations used?
"These calculations are necessary when:
a) A patient's inspiratory peak flow exceeds the output of the delivery device. (normal peak flow is approximately 40-60 L/min
b) blenders are unavailable for achieving specific FIO2"
What are the air-oxygen entrainment ratios?
"Total Flow = Flowmeter setting x Factor
Factors are;
FIO2 28%Ratio10:1= 11Factor
FIO2 40% Ratio 3:1 = 4 Factor
FIO2 60%Ratio 1:1=2 Factor"
What is the terminology for disinfection and sterilization techniques?
"Terminology:
1) Disinfection-the process of destroying vegetative pathogenic organisms
2) Sterile-lack of any life organism
3) Vegetative organisms-growing microorganisms
4) Pathogenic organisms-disease producing.
5) Contaminated-the introduction of disease causing microorganisms.
6) Static-growth is inhibited
7) Cidal-microorganisms are killed.
8) Spore-a resistant form of certain species of bacteria."
What is the first thing that should be done before the disinfection process?
All equipment should be adequately cleaned by removing organic soil and disassembled prior to the disinfection process.
What are the physical methods of disinfection and sterilization?
"1) Steam under pressure (steam autoclave)
a) Conditions for sterilization- 121C at 15psi for 15 min.
b) This method will not be used for plactics or other heat sensitive items.(rubber)
c) Items must be wrapped in penetrable packaging
d) All air must be evacuated and steam must be allowed to penetrate all parts of the load.
e) Heat sensitive tapes and/or biological indicators are used to assure that the conditions sterilization have been met.
2) Pasteurzation -disinfection processes using moderate temperatures to kill vegetative organisms.
a) Items are first washed then completely submersed in a hot water bath at 63-70C for 30minutes (plastics, rubber)
b) Items must be completely dried then assembled and packaged
3) Incineration-the best method of treating contaminated disposable items and supplies.
4) Irradiation-gamma rays are used to sterilze pre-packaged equipment
a) Items that have been gamma radiated should not be re-sterillzed with ethylene oxide."
What are the chemical methods of disinfection and sterilization?
"1) Ethylene oxide sterilization (ETO) sterlizes equipment by alkylation of enzymes.
a) Factors influencing the ETO process:
1) Temperature of the chamber
2) Concentration of ETO: 800-1000 mg/L
3) 50% relative humidity enhances the effectiveness of ETO
4) Exposure time
5) Aeration time
6) Can't get water out
b) Biological indicators(Attest) are necessary to verify that the conditions for sterility have been met.
c) Examples:Bird Mark VII, Electric Incentive Spirometry device, and a non-disposable resuscitation bag removed from a HIV patient's room
d) Not recommended for sterilizing a bronchoscope"
What is Alkaline gluteraldehyde?
"Cidex - disinfection or sterilization process
a) The pH of Cidex is 7.5-8.5
b) Cidex is :
1) bactericidal in 10 minutes
2)tuberculocidal in 10-20 minutes
3) sporicidal in 10 hours(to sterilize)
c) Equipment must be rinsed, dried and packaged after each soaking
d) Cidex once activated will be fully potent for 14 days.
e) Appropriate method for resuable plastics(mouthpiece, tubing aerosols, etcl)
f) Appropriate method for a bronchoscope"
What is Acid guteraldehyde?
"Sonacide-disinfection/sterilization processl
a) Sonacide's pH is 2.5-3-5
Sonacide is :
1) bactericidal in 10 minutes
2) tuberculocidal in 20 minutes
3) sporicidal in 1 hour
c) Equipment must be rinsed, dried and packaged after exposure to Sonacide
d) Sonacide remains potent for 28 days"
What is the Alcohol disinfection process?
"Alcohol disinfection process:
a) Ethyl and isopropyl alcohol are most effective in 70 - 90% solutions
b) Alcohol wipes are not sporicidal although it is bactericidal and fungicidal"
Are soaps and detergents used as disinfects?
"Not antimicrobial agents but will be used as cleaners
a) Agents are surfactants that will reduce surface tension"
What are some common respiratory pathogens?
"Gram + Cocci-pneumonia , respiratory track infections
All the Cocci- Staphylococcus
Streptococcus, Diplococus, Pneumococcus
2) Gram Negative cause pneumonia and respitatory tract infections Grow in water and found in GI tract. Spread by poor hand washing .
a) Pseudomonas aeruginosa -produces green sputum (most common)
b) Haemophilus influenza
c) Serratria marcescens
d) Escherichia coli
e) Proteus
f) Klebsiella
3) Acid fast bacilli
a) Mycobacterium tuberculosis-TB
4) Pathogenic fungi
a) Candida- Candidiasis
b) Histoplasma capsulatum-Histoplasmosis
c) Coccidioides immitis-Coccidiomycosis
5) Viruses commonly cause respiratory infections, flu-like symptoms and viral pneumonia
a) Adenovirus
b)Influenza
c) Cytomegalovirus (CMV)
d) Respiratory Syncytial Virus (RSV)"
What are nosocomial infections?
Dirct contact, airborne, droplet, and indirect transmission are common routes for infectious organisms to be transmitted. Hospital accwuir
What is Acid guteraldehyde?
"Sonacide-disinfection/sterilization processl
a) Sonacide's pH is 2.5-3-5
Sonacide is :
1) bactericidal in 10 minutes
2) tuberculocidal in 20 minutes
3) sporicidal in 1 hour
c) Equipment must be rinsed, dried and packaged after exposure to Sonacide
d) Sonacide remains potent for 28 days"
What is the Alcohol disinfection process?
"Alcohol disinfection process:
a) Ethyl and isopropyl alcohol are most effective in 70 - 90% solutions
b) Alcohol wipes are not sporicidal although it is bactericidal and fungicidal"
Are soaps and detergents used as disinfects?
"Not antimicrobial agents but will be used as cleaners
a) Agents are surfactants that will reduce surface tension"
What are some common respiratory pathogens?
"Gram + Cocci-pneumonia , respiratory track infections
All the Cocci- Staphylococcus
Streptococcus, Diplococus, Pneumococcus
2) Gram Negative cause pneumonia and respitatory tract infections Grow in water and found in GI tract. Spread by poor hand washing .
a) Pseudomonas aeruginosa -produces green sputum (most common)
b) Haemophilus influenza
c) Serratria marcescens
d) Escherichia coli
e) Proteus
f) Klebsiella
3) Acid fast bacilli
a) Mycobacterium tuberculosis-TB
4) Pathogenic fungi
a) Candida- Candidiasis
b) Histoplasma capsulatum-Histoplasmosis
c) Coccidioides immitis-Coccidiomycosis
5) Viruses commonly cause respiratory infections, flu-like symptoms and viral pneumonia
a) Adenovirus
b)Influenza
c) Cytomegalovirus (CMV)
d) Respiratory Syncytial Virus (RSV)"
What are nosocomial infections?
Dirct contact, airborne, droplet, and indirect transmission are common routes for infectious organisms to be transmitted. Hospital accquired
What are isolation procedures and techniques?
"1) Once the organisms have been identified, attempts are made to isolate the microorganism and prevent its spread.
2) Type of isolation is dependent upon how organism is spread.
a) Universal/Secretion precautions
1) Gloves are worn by personnedl having contact with secretions. Mask and gowns are optional
2) Used eith acquired immunosuppressed deficiency syndrome(AIDS)
b) Respiratory Isolation-Airborne transmission
1) Patients must have private rooms and closed doors.
2) Masks and gloves are worn when working with the patient, gowns are not necessary.
3) Diseases requiring respiratory isolation: Measles,Rubella, Mumps, Pertussis, Meningitis and Suspected Tuberculosis patients.
4) Paatients should wear a mask when persons are in the room.
c) Strict/complete isolation
1) Gloves, masks and gowns must be worn by all personnel and visitors.
2) Staphylococcus aureus and group Patients with streptococcus pneumonia must by isolated by this method.
d) Protective(reverse) isolation procedures must be followed
1) Strict isolation procedures must be followed.
2) Used with burn, transplant, or cancer patients and immunosuppressed individuals.
e) Enteric/Blood isolation
1) Gowns are used, gloves necessary only when having direct contact with the patient and infected blood/fecal material
f) Wound and skin isolation
1) Gloves are worn by personnel having contact with infected areas.
2) Mask and gowns are optional."
What does home care infection control consist of?
"1) Flu shots/immunizations
2) Clean equipment daily
a) Wash with mild detergent
b) Remove all soap by rinsing well with water
c) Soak in white distilled vinegar (acetic acid) solution for 20 min.--Pseudomonas
d) Rinse, drain, dry without wiping
e) Air dry on a clean towel"
What different types of home oxygen delivery systems are there and what are some of their safety measures?
"1) Cylinders
a) Indicated for patients who use small amouts of oxygen intermittently (Prn)
b) They can be stored indefinitely but Do Not store in the trunk of a car.
2) Liquid bulk oxygen systems
a) Last longer than cylinders, used often in the home
b) Non-electrical, portable units are easily filled for trips
3) Oxygen concentrators
a) Principle of operation:
1) Run on electricity and have limited portability
2) Utilize a molecular sieve that removes nitrogen and other gases from room air to concentrate the oxygen.
3) If molecular sieve beds are not working-analyze the FIO2, check circuit breaker/fuse
b) Safety:
a) Instruct patients to routinely check and change filters
2) A properly grounded electrical outlet is required.
3) A backup system (tank or liquid ) must be used in case of a power failure"
What Is Chronic Obstructive Disease?
"1) Description: characterized by dyspnea on exertion with significant hypercapnea
2) Terminology used commonly to describe a COPD patient -chronic ventilatory failure patient, chronic hypercapnic patient, increased compliance patient, a loss of elastic recoil patient and CO2 retainer.
C-BABE- Cystic Fibrosis , Chronic Bronchitis,Asthma, Bronchiectasis, Emphysema"
What are the assessments for COPD?
"Assessment COPD:
a) Expiratory wheeze, barrel chest, clubbing and cyanosis
b) Percussion notes-resonant or hyper-resonant
c) Hyperlucency, hyperinflaton, increased A-P diameter on chest X-ray
d) Compensated respiratory acidosis wht hypoxemia and hypercapnea
e) Pulmonary functions- decreased flows(FEV1)"
What is the treatment for COPD?
"a) Aerosol therapy-low flow O2
b) Medications-bronchodilators, (give with compressed air) expetorants, corticosteroids and diuretics
c) Rehab therapy (purse lip breathing), proper nutrition and monitor fluid intake
d) If a COPD pt. comes into ER in a full arrest-resuscitate with 100% O2"
What are two acute obstructive diseases?
Croup and Epiglottitis
What is the etiology , symptoms and treatment of Croup?
"Croup is caused by the Parainfluenza (85%) Viral , it is an Upper Respiratory Infection , usually strikes in the Winter children less than 3 years old, the Onset is Gradual and Admission Criteria is Stridor At Rest
Treatment and Drugs: Cool mist tent, Dexamethasone (Steroid) and Racemic Epinephrine Aerosol
Lateral Neck X-Rays revel :
Subglottic edema, Steeple or pencil sign"
What is the etiology, symptoms and treatment of Epiglottitis?
"Epiglottitis is caused by Hemophilus Influenza (Bacterial) There is no upper respiratory infection it is usually between 3-7 years old the onset is Sudden , there is fever ,drooling and retraction, and a toxic appearance
Admission Critera is Drooling Extended neck and a Suspicion of epiglottitis
Treatment and drugs are Intubation, IV Antibiotics (Ampicillin)
Lateral Neck X-Rays revel Supraglottic edema, Thumb or thumbprint sign and Obliterated vallecula"
What is a mycobacterium disease ?
Tuberculosis - caused by acid-fast , rod-shaped bacteria, spread by inhalation
What is the Assessment of Tuberculosis?
"Assessment:
a) Night sweats(nocturnal diaphoresis), weight loss and weakness
b) Dry couch with or without hemoptysis and pleural pain
c) Two positive test are required from-TB test, bacteriological studies, sputum culture
d) X-rays will show consolidation, fibrosis and cavity formation"
What is the treatment for Tuberculosis?
"a) Isolate-Respiratory isolation
b) Drugs-Isoniazid(INH) , ethambutol, streptomycin, rifampin"
What is an infectious disease?
Pneumonia , infectious bacteria or virus enters the lung via inhalation or aspiration
What are some assessments of Pneumonia?
"Assessments of Pneumonia:
a) Chills, fever, cough, purulent sputum, dyspnea, cyanosis, rales and rhonchi on auscultation
b) White blood cell count (WBC) increased in bacterial, decreased in viral
c) Scattered patchy opacity/ consolidation on x-ray"
What is the treatment of Pneumonia?
"Treatment of Pneumonia:
a) Oxygen therapy if needed (pulse oximetry , ABG)
b) Bronchial hygiene
c) Antibiotics-penicillin for gram positive infections(stap &streptococcus), streptomycin, gentamycin and tobramycin for gram negative infections(serratia, klebsiella, haemophilus, pseudomonas, E.coli, proteus)
d) Mechanical ventilation if PCO2>45mmHg and PaO2<60mmHg"
What is pleural effusion, assessment of and treatment for?
"1) Description: Fluid in the pleural space
2) Assessment:
a) Dyspnea, chest pain, decreased breath sounds and dry non-productive cough
b) Mediastinal shift to the unaffected area(away from the affected area)
c) Lateral decubitus x-ray- obliteration of the costophrenic angle, unilateral basilar infiltrate with meniscus formation
3) Treatment:
a) Thoracentesis/or chest tube drainage system
b) Antibiotics"
What is Acute Respiratory Distress Syndrome (ARDS)?
(ARDS) is a series of reactions leading to inflammation, resulting in a decrease in lung compliance, shunting, hypoxemia
What are the assessments of ARDS?
"Assessment for ARDS:
a) Respiratory distress with tachypnea and cyanosis
b) Refractory hypoxemia, increased A-a DO2 gradient and work of breathing
c) X-ray -shows diffuse alveolar infiltrates in honeycomb/ground glass pattern
d) Decreased FRC, shunting and respiratory failure"
What are the treatments for ARDS/
"Treatment for ARDS:
a) O2 therapy-adequate arterial oxygenation without high FIO2
b) CPAP/PEEP therapy- to increase FRC and to decrease work of breathing
c) Titrate PEEP and FIO2 such that the FIO2 can be reduced below .60 (decrease FIO2 first then PEEP
d) Use IMV/SIMV with PEEP
e) Consider pressure control ventilation"
Name two neuromuscular diseases?
Myasthenia Gravis and Guillain Barre Syndrome
What is the etilolgy , signs, symptoms , tests and treatment of Myasthenia Gravis?
"Etiology of Myasthenia Gravis is it is an Auto-immune response , No URI
Signs and Symptoms:
Onset is slow, fatigue improves with rest
Paralysis is descending(Mind to Ground)
Diagnostic tests are : postive tensilon test and monitoring of VCand MIP
Drugs and treatment is Neostigmine,Pyridostigmine
Intubation /mech vent -short term"
What is the etilogy ,signs, symptoms, tests and treatment of Guillain Barre Syndrome?
"Etilolgy of Guillain Barre Syndrome is a Delayed reaction to a viral infection
URI is present
Signs/Symptoms are Acute , sudden weakness
Paralysis is Ascending(Ground to Brain)
Diagnostic Tests are spinal tap revels protein in spinal fluid and you Monitor VC/MIP
Drugs/treatments are Steroids, Prophylactic Antibiotics
Mech vent/trach-long term
Plasmapheresis"
What is the treatment plan for Asthma?
"Zone Green Peak Flow(80-100%) Level 1
No symptoms of an asthma episode /Able to perform usual activities/No coughing, wheezing or chest tightness
Status is stable/Action plan is continue with medications in daily treatment plan /Use preventative (anti-inflammatory medicine(steroids)
Yellow Peak Flow (50-80%) Level 2
Increased need for inhaled quick relief medicine
Increased asthma symptoms upon awakening
Awakening at night with asthma symptoms
Status is increase in symptoms
Action plan is Preventative(anti-inflammatory) inhaler
ADD:
Quick relief(short-acting bronchodilator) inhaler (Albuterol)
Begin/increase treatment with oral steroids.
Call doctor
Return to Level 1 when symptoms improve
Red/Level 3 /Peak Flow (less than 50% Or No improvement after increasing treatment according to Zone 2 )
Very short of breath
Increased symptoms longer than 24 hours
Limited daily activities
Status : No improvement Or Increase in symptoms
Action: Quick relief(bronchodilator) inhaler
Begin /increase treatment with oral steroids
Call Doctor
Danger Signs: Status/ Difficulty walking and talking due to shortness of breath
Lips or fingernails are blue
Go To Hospital or Call 911
Call Doctor if:
Asthma symptoms worsen while taking oral steroids
Or
Inhaled bronchodilator treatments are not lasting 4 hours
Or
Peak flow drops despite following treatment plan"
What is the Cardiac Output equation?
QT= heart rate x stroke volume
What is pulse pressure?
Pulse pressure=systolic-diastolic
What is Stroke volume?
Stroke volume=CO/Heart rate
What is ejection fraction?
Ejection fraction=Stroke volume/End Diastolic Volume
What is QT?
QT=VO2/C(a-v)O2 (10)
What is VO2?
"Oxygen consumption=
VO2=QT x C(a-v)O2 x 10"
What is Alveolar ventilation equation?
"VA=(VT-VD)f
use ideal body weight for VD"
What are the Hemodynamic's Values?
"CVP is 2-6 mmHg or 4-12H2O
PAP is 25/8 is 13mmHg
PCWP is 4-12mmHg
MAP is 120/80 or 90mmHg
Cardiac Output is 4-8L/m
Cardiac Index is 2-4 L/m"
What is an easy way to remember pulmonary function?
"FVC is Restrictive <80%
FEV1 is Obstructive <80%"
What do you do to increase ventilation on a ventilator?
"To increase ventilation:
High Jet Frequency Increase Driving Pressure
Bi-Pap Increase IPAP
Osculation Increase Amplitude
Pressure Control Increase PIP
Volume Control Increase Tidal Volume"
What is the shortcut for Shunt Equation?
Take the first number from the A-aDo2 add a 1 and x it by 5
What is the number for normal Resistance?
".6-2.4 cmh2o/l/min
PIP - Plateau
Plateau -PEEP if PEEP given"
Urine output
Minimum 40 mL/hour
Range 40-60 mL/hour
Adult heart rate
60 - 100/min
Intracranial Pressure (ICP)
5 - 10 mm Hg
Diagnostic Chest Percussion
Resonant
Breath sounds
Vesicular
Heart sounds
S1, S2
Adult Blood pressure
120/80 mm Hg
Range 90/60 - 140/90 mm Hg
Cerebral Perfusion Pressure (CPP)
70 - 90 mm Hg
Red blood cell count (RBC)
4 - 6 Mill/mm3
Hemoglobin (Hb)
12 - 16 gm/100 mL blood
Hematocrit(Hct)
40 - 50%
White Blood Cells
5,000 - 10,000 per mm3
Potassium (K+)
4.0 mEq/L
Range 3.5 - 4.5 mEq/L
Sodium (Na+)
140 mEq/L
Range 135 - 145 mEq/L
Chloride (Cl-)
90 mEq/L
Range 80 - 100 mEq/L
Bicarbonate (HCO-3)
34 mEq/L
Range 22 -26 mEq/L
Creatinine
0.7 - 1.3 mg/dL
Blood Urea Nitrogen (BUN)
8 - 25 mg/dL
Clotting Time
Up to 6 minutes
Platelet Count
150,000 - 400,000/mm3
Activated Partial Thromboplastin Time (APTT)
24 - 32 seconds
Prothrombin Time (PT)
12 - 15 seconds
Trombin Time
7 - 12 seconds
Term Infant (Gestational Age)
38 - 42 weeks
APGAR
Activity, Pulse, Grimace, Appearance, Respiration
APGAR score
7 - 10
Infant Temperature
36.5 degrees Celsius
Infant Heart Rate
110 - 160/min
Infant Respiratory Rate
30 - 60 breaths/min
Infant Blood Pressure
60/40 mm Hg
Term Infant Birth Weight
3000 g
Dubowitz Score
40
Define Dubowitz Score
A method of clinical assessment in the newborn from birth until five days old that includes neurological criteria for the infant's maturity and other physical criteria to determine gestational age.
New Ballard Score (NBS)
40
Term Infant Blood Glucose
> 30 mg/dL
L/S Ratio
2:1 or higher
Capnography (ETCO2)
30 torr
range 3 - 5%
Pulse Oximetry (SpO2)
93% - 97%
Carboxyhemoglobin
1 - 3%
Mean Arterial Pressure (MAP)
93 - 94 mm Hg
Right Atrial Pressure
2 - 6 mm Hg
4 - 12 cm H2O
Right Ventricular Pressure
25/0 mm Hg
Pulmonary Artery Pressure (PAP)
25/8 mm Hg
Mean 13 - 14 mm Hg
Pulmonary Capillary Pressure
8 - 10 mm Hg
Pulmonary Capillary Wedge Pressure (PCWP)
4 - 12 mm Hg
Left Atrial Pressure
2 - 6 mm Hg
Left Ventricle Pressure
120/0 mm Hg
Cardiac output
4 - 8 L/min
Cardiac Index
2 - 4 L/min/m2
Pulse Pressure
40 mm Hg
Systemic Vascular Resistance (SVR)
< 20 mm Hg/L/min
1600 dynes/sec/m-5
Pulmonary Vascular Resistance (PVR)
< 2.5 mm Hg/L/min
200 dynes/sec/cm-5)
Endotracheal Tube Cuff Pressure
< 20 mm Hg
< 25 cm H2O
Pre-term Infant ET Tube Size
2.5 - 3.0 mm
Term Infant ET Tube Size
3.0 - 3.5 mm
Adult Male ET Tube Size
8.0 - 9.0 mm
Adult Female ET Tube Size
7.0 - 8.0 mm
Adult ET Tube Markings for Oral Intubation
21 - 25 cm at lips
Adult ET Tube Markings for Nasal Intubation
26 - 29 cm at nares
Body Humidity
44 mg/L or 47 mm Hg at 37 degrees Celsius
PAO2
Varies directly with patient's FIO2
A-a DO2
5 - 10 mm Hg on 21% O2
25 - 65 mm Hg on 100% O2
CaO2
17 - 20 vol%
CvO2
12 - 16 vol%
C(a-v)O2
4 - 5 vol%
PaO2/FiO2
380 torr or >
SaO2
98%
Range 95 - 100%
Vd/Vt Ratio
20 - 40%
PaCO2
40 torr
Range 35 - 45 torr
PaO2
97 torr
Range 80 - 100 torr
pH
7.40
Range 7.35 - 7.45
Newborn PaCO2
< 50 torr
Newborn PaO2
> 60 torr
Spirometry Calibration Syringe
3.0 liters
Range 2.895 - 3/105 L (+ 3.5%)
Maximum Inspiratory Pressure (MIP)
- 80 cm H2O
Maximum Expiratory Pressure (MEP)
+ 160 cm H2O
Spirometry Vital Capacity (VC)
5 - 6 liters Typical or 80% of predicted or higher
Spirometry FEV1
3.5 - 4.0 liters Typical or 80% of predicted or higher
Spirometry FEV1/FVC
70% or greater
Spirometry FEF 200-1200
8 L/sec or 480 L/min typical or 80% of predicted or higher
Spirometry FEF 25-75%
6 L/sec or 360 L/min typical or 80% of predicted or higher
Spirometry Peak Expiratory Flowrate (PEFR)
10 L/sec or 600 L/min typical or 80% of predicted
Spirometry Airway Resistance
0.6 - 2.4 cmH2O/L/sec
Spirometry DLco
25 mL CO/min/mm Hg (STPD)
Tidal Volume (Vt)
5 - 8 mL/kg
Vital Capacity (VC)
65 - 75 mL/kg or 10 x Vt
Respiratory Rate
12 - 20 breaths/min
Minute Ventilation (VE)
5 - 6 L/min
Static Lung compliance
60 - 100 mL/cmH2O
Mean Airway Pressure (Paw) for patients with normal compliance and resistance
5 - 10 cm H2O
Mean Airway Pressure (Paw) for patient with ARDS
10 - 20 cm H2O
Mean Airway Pressure (Paw) for patients with obstructive disease
15 - 30 cm H2O
Adult CPR Breathing Rate
10 - 12 breaths/min or every 5 - 6 seconds
Child CPR Breathing Rate
12 - 20 breaths/min
Infant CPR Breathing Rate
12 - 20 breaths/min
Newborn CPR Breathing Rate
40 - 60 breaths/min
Adult CPR Compression to Ventilation Ratio
30:2 both one and two rescuer
Child CPR Compression to Ventilation Ratio
15:2 two rescuer
Infant CPR Compression to Ventilation Ratio
15:2 two rescuer
Newborn CPR Compression to Ventilation Ratio
3:1 both one and two rescuer
A patient has a peak expiratory flow rate (PEFR) of 4.7 L/sec before bronchodilator treatment and 5.1 L/sec after treatment. What percent change in PEFR occurred?
9%
24%
5%
18%
9%
calculation %change= post-pre/pre x 100
A patient breathing 100% at sea level has a PaO2 of 350 torr and a PaCO2 of 48 torr. What is her A-a gradient or P(A-a)O2?
363 torr
313 torr
663 torr
563 torr
313 torr
PAO2= Fio2(PB-47) - 1.25 x PaCo2
P(A-a)o2= PAo2- Pao2
A patient receiving volume-limited ventilation with a tidal volume of 600 mL and 10 cm H2O PEEP has a peak pressure of 45 cm H2O and a plateau pressure of 30 cm H2O. What is her static compliance?
30 mL/cmH2o
13 mL/cmH2o
15 mL/cmH2o
20 mL/cmH2o
30 mL/cmH2o
CLT = VT ÷ (Pplat-PEEP) 600 / (30-10) = 30 mL/cm H2O
What inspiratory flow is needed for a patient receiving volume-limited ventilation at a rate of 15/min, I:E ratio of 1:3, and tidal volume of 600 mL?
36 L/min
48 L/min
27 L/min
9 L/min
...
A patient has a TLC of 5500 mL a VC of 4000 ml and IC of 3000 ml what is his FRC?
2500
TLC - IC = FRC
What is changed when a pat is on PV?
Change the set pressure increased or decreased to adjust Vt
What equation is used to reduce PaCo2 on a pat vented with VC ventilation when the rate is needing to be changed due to volume being high enough?
Desired F= known F X PaCo2/desired PaCo2
What is the equation to find desired Vt in VC ventilation?
Desired Vt= known Paco2 X Known Vt/desired PaCo2
What is increased to increase Vt with a PVC time cycled ventilation?
With pressure control ventilation PCV the set pressure is generally increased to obtain the targeted Vt. PCV is Time cycled If It is short increasing it will increase volume delivery without increasing pressure.
What do you change if Vt and pressure plateu are already high to improve PaCo2?
frequancy
What will need to be changed on a ventilated pat on VC and PV to decrease the PaCo2?
minute volume Ve
What are the causes of respiratory acidosis in a nonventilated patient?
pulmonary edema
pneumonia
asthma
chest wall abnormalities
neuromuscular disorders
central nervous system problems
What two values are effected if patient has respiratory acidosis and Va is not adequante on volume ventilation and pressure ventilation?
PaCo2 elevated above >45mmhg and pH decreased <7.35
What two things can be adusted when a patient is on PCV with respiratory acidosis?
Inspiratory time set pressure reaches alveolar level if this doesnt work set pressure increased to improve volume
What change in ventilation is made to ventilator to correct respiratory alkalosis or acidosis?
Vt or rate
What change is made right away when a patient is on mechanical ventilatio?
minute volume Ve
What should a therapist do if the heart rate increased during suctioning?
immediately stop suctioning and provide 100% O2
For above the cuff suctioning, what pressure is left on to continuously suction?
20mmHg
What is the correct size of catheter used to suction?
1/2 the size of the ET tube. equation for a size 8 ET tube 3x8=24 24/2=12Fr Size 12Fr is used
A patient with CHF has what type of secretions?
Thin white or pink frothy secreations but won't block the airway
What is the normal ratio of Vd to Vt (Vd/Vt)?
0.2 to 0.4
Where does the contraction start of the ventricle?
Starts at Q
What is pip?
Peak inspiratory pressure, this is the peak at which the flow is given at an inspiration
What is SpO2?`
Saturation of O2 on the Hb
What is an HME?
artificial nose humidity, filter,warms
What is slope (aka rise)?
Inspiratory rise time, it slows or speeds the rate at which pressure and flow exit the ventilator for a specific period of time
What is trigger?
The sensativity set too low can also cause auto peep
What is FIO2?
% of O2 to improve Oxygenation. A way to measure O2 to the tissues. Check ABG's to keep PaO2 ath 60-90mmHg below 0.4 to 0.5
What is minimal occluding volume?
volume of air measured to seal the cuff at 1 to 2%
What is minimal leak?
It allows a small amount of air to leak out of cuff
How do we check for the level of consciouness?
wake up the patient (if arousable) check for alertness, sleep, etc.
How does CPAP effect a patient on a ventilator?
It provides FiO2, inspiratory flow, peep, inflates alveoli
How is peep used to detect level of optimal peep?
static compliance, prevents atelectasis
What is plateau pressure
measures pressures needed to keep lungs extended less or equal to 35cmH2O
What wave does ventricular repolarization start?
T wave
What level is PIP set to on an alarm?
10cmH2O above and below
What is Ve set to on an alarm?
low Ve= 10% below
highVe= 10% above
What is the equation for MAP?
(PIPxIt) + (peepx Et)/total seconds
What is VC?
IRV, Vt, ERV
What is IC?
IRV, Vt
What is TLC?
IRV, Vt, ERV, RV
What is FRC?
ERV, RV
What is predicted FVC, FEV1, FEV1% for a restrictive patient?
<80% predicted FVC, normal or <80% predicted FEV1, > or equal to predicted FEV1%
What is predicted FVC, FEV1, FEV1% for obstructive patient?
normal or <80% predicted FVC, <80% predicted FEV1, <predicted FEV1%
What is a patients trigger, target and cycle? VC
trigger=time, target=flow, cycle=volume
What is a patients trigger, target, and cycle? VA
trigger=effort, target=flow, cycle=volume
What is a patients trigger, target, and cycle? PC
trigger=time, target=ins, cycle=time
What is a patients trigger, target, and cycle? PS
trigger=effort, target=ins, cycle=flow
What is a ptients trigger, target, and cycle? spontaneous
trigger=effort, target=ins, cycle=effort
What is one cuase of increased dead space?
pulmonary embolism or low cardiac output resulting in low pulmonary perfusion
What is the ABG values with mexed acid bases?
pH increased, PaCo2 increased, PaO2 increased, HcO3 increased
What are the two sure signs of metabolic acidosis on and ABG?
pH 7.45 to 7.70 and bicarbonate 26 to 48
What are the causes of metabolic acidosis
ketoacidosis
uremic acidosis (renal failure)
diarrhea
toxins ingested
What is decreased on VC when patient is breathing spontaneously?
switch ventilator to SIMV mode
or PS
could possibly sedate but a last resort if patient is anxious
On a PV what should be decreased to improve ventilation?
frequancy, and set the pressure second
To correct respiratory alkalosis in a vented patient, what should be decreased to correct ventilation on a VV vented patient?
frequancy first then Vt
What are the causes of respiratory alkalosis?
hypoxia with compensated hyperventilation
pneumonia
pulmonary edema
medications
mechanical ventilation
central nervous system disorders
anxiety
metabolicd problems
What is the normal value for body temperature?
Adult- 98.6 F, 37C, Child- 37.5C, Infant-37.5
What is the normal pulse for a human?
Adult-60-100, Child-80-120, infant-90-170
What is the normal Respiratory Rate for a human?
Adult-12-20, child-20-25,infant- 35-45
What is the normal Blood Pressure for a human?
Adult-<120/80 mmHg, Child- 94/52, Infant- 84/52
What is a normal value range for Pulse oximetry?
>92%
What are the Red Blood Cells (RBC) normal values?
M 4.6-6.2 x 10-6/mm3
F 4.2-5.4 x 10-6/mm3
What is the monitoring threshold for Maximum Inspiratory Pressure/ Negative Inspiratory Force (MIP/NIF)?
-20 to -25 cm H2O
What is the monitoring threshold for Respiratory Rate?
12-20 breaths/min
What is the monitoring threshold for minute volume (VE)?
5-7 L/min (amount of air exhaled in one minute)
What does Barrel Chest imply?
COPD
What does Kyphoscoliosis imply?
Severe restrictive lung defect
What does it mean if patients are using their accessory muscles to breathe?
An increased work of breathing, loss of normal diaphragm function
What does it it mean if the patient has Abdominal paradox?
Diaphragmatic fatigue, increased work of breathing.
What does it mean if the patient has retractions?
The patient has a reduced lung volume, low lung compliance, increased work of breathing.
If a patient has clubbing in their fingers or toes what could that mean?
Bronchogenic carcinoma, COPD, chronic cardiovascular disease.
What does a prolonged exhalation imply?
Expiratory obstruction (asthma, COPD)
What does a prolonged inspiration imply?
Upper airway obstruction (croup, epiglottitis)
What does it likely mean if a patient is breathing rapid and shallow?
A loss of lung volume (atelectasis, pulmonary fibrosis, ARDS or acute pulmonary edema)
What does it mean if a patient is breathing in a Kussmaul breathing pattern(deep and fast)?
Diabetic Ketoacidosis
What does it mean if a patient is breathing in Biot's breathing pattern (irregular with periods of apnea)?
Increased intracranial pressure
What does it mean if a patient is breathing in a Cheyne Stokes pattern (waxing and waning)?
Central Nervous System (CNS) diseases or severe congestive heart failure (CHF).
What conditions is associated with Clear/White (thick or thin) sputum? (Also known as Mucoid)
Asthma
What conditions is associated with Clear to yellowish (thick) sputum? (Also known as Mucopurulent)
Chronic Bronchitits, cystic fibrosis, pneumonia (blood streaked)
What conditions is associated with yellow to green, thick sputum? (also known as purulent)
Aspiration pneumonia, bronchiectasis (fetid/foul smelling, may separate into layers if left standing), lung abscess (fetid/foul smelling, may separate into layers if left standing)
What conditions is associated with pink to red/dark red, thin (unless coagulated) sputum? (also known as bloody)
TB (red), lung cancer (red), pulmonary infarction (red), pulmonary edema (pink,watery, frothy)
What conditions does an acute cough (<3 wks) imply?
Postnasal drip, allergies, and infections (especially common cold, bronchitis, laryngitis)
What conditions does a Chronic (>3 wks) or recurrent cough imply?
Postnasal drip, asthma, GERD, chronic bronchitis, bronchiectasis, COPD, TB, lung tumor, Angiotensin Converting Enzyme (ACE) inhibitors, left heart failure
What conditions does a recurrent cough in children imply?
Viral bronchitis, asthma, allergies
What conditions does a barking cough imply?
Epiglottitis, croup, influenza, laryngotracheal bronchitis
What conditions does a brassy or hoarse cough imply?
Laryngitis, laryngeal paralysis, laryngotracheal bronchitis, pressure on laryngeal nerve, mediastinal tumor, aortic aneurysm
What conditions does a wheezy cough imply?
Bronchospasm, asthma, cystic fibrosis, bronchitis
What conditions does a dry cough imply?
Viral infections, inhalation of irritant gases, interstitial lung diseases, tumor, pleural effusion, cardiac conditions, nervous habit, radiation or chemotherapy
What conditions does a dry to productive cough imply?
Atypical pneumonias, Legionnaires' disease, pulmonary embolus, pulmonary edema, lung abscess, asthma, silicosis, emphysema (late phase), smoking, AIDS
What conditions does a chronic productive cough imply?
Bronchiectasis, chronic bronchitis, lung abscess, asthma, fungal infections, bacterial pneumonias, TB
What conditions does a Paroxysmal (especially at night) cough imply?
Aspiration, asthma, left heart failure
What conditions does a positional (especially when lying down) cough imply?
Bronchiectasis, left heart failure, chronic postnasal drip or sinusitis, GERD with aspiration
What conditions does cough associated with eating or drinking imply?
Neuromuscular disease of the upper airway, esophageal problems, aspiration
To develop an effective program for teaching a patient to use a small volume nebulizer, a respiratory therapist should evaluate the patient's what?
Language skills, mental status and manual dexterity, not visual acuity
To demonstrate significant post-bronchodilator improvement, a patient's FEV1 must increase by a minimum of what percentage?
12%
A patient has the lung volume results below:
VC 3600 mL
FRC 6000 mL
ERV 1000 mL
8600 ml (FRC+VC)-ERV)
Which condition results in an abnormal elevation of the left hemidiaphragm?
left lower lobe atelectasis
While the patient is breathing normally a respiratory therapist measures the volume of 1 exhalation. What is the therapist measuring?
tidal volume
A patient has Guillain-Barre syndrome. Which results of bedside pulmonary function testing most strongly indicates the need for ventilatory assistance?
Vital capacity equal to the tidal volume
With an FiO2 of 0.70, a 27-week gestational age neonate who weighs 950 g has the following umbilical artery blood gas results:
pH
7.38
PaCO2 - 42
PaO2 - 38
HCO3- 24 mEq/L
BE - -2 mEq/L
A physician has decided to intubate the infant. What should the therapist recommend to continuously monitor the infant's oxygenation?
pulse oximetry
What is the best index of oxygen transport for a patient who has been resuscitated after carbon monoxide poisoning?
Arterial oxygen content
A RT needs to place a cap on the end of a patient's fenestrated tracheostomy tube so that the patient can breathe through her upper airway and speak. Before applying the cap to the tube what does the RT need to do?
Remove the inner cannula and deflate the cuff
A RT is checking a jet nebulizer with an entrainment setting of 35%. A properly calibrated oxygen analyzer measures the concentration at 45%. What explains this finding?
Water in the tubing
A physician has ordered an FiO2 of 0.40 by oxyhood and blender for an infant. When analyzing the oxygen concentration, a RT notes the FiO2 is 0.30, and the flowmeter is set at 10 L/min. The nebulizer's entrainment port is set at 50% and the blender is set at an FiO2 of 0.40. What does the RT need to do to correct the problem?
Set the nebulizer's entrainment port to 100%
After 30 minutes of oxygen delivery by nasal cannula at 6 L/min, a patient with sever fibrotic lung disease has a PaO2 of 45 torr. What should the RT recommend?
A non-rebreathing mask
A 2-year-old child is receiving oxygen by an aerosol tent. the RT is unable to maintain a consistent FiO2 inside the canopy. What should the therapy do?
increase the oxygen flow
The aerosol from an ultrasonic nebulizer is being produced in short, rapid puffs. What does the RT need to do to correct the problem?
Clear the water from the delivery tube
A pt with severe COPD is receiving O2 by nasal cannula at 4 L/min. The pt is lethargic and his respirations are shallow at a rate of 20/min. The pulse oximeter is reading 94%. What should a RT recommend?
Change to a 28% air-entrainment mask
An infant in a oxyhood is receiving 24% oxygen by a large volume nebulizer at a flow of 10 L/min. The infant is restless. The SpO2 is 97%. To calm the infant what should the RT do?
replace the nebulizer with a blender
A patient with hepatitis coughs into a spirometer. What process should be used to disinfect the non-disposable mouthpiece before it is used again?
pasteurization
Quality control results using a 3.0 L calibration syringe spirometer are as follows:
Volume 1 - 2.67 L
Volume 2 - 2.70 L
Volume 3 - 2.68 L
According to ATS Standards, the spirometer is considered what?
is inaccurate
A RT is calibrating a helium analyzer. What should the analyzer read when calibrated with air?
0%
A 201-kg (442-lb) pt who underwent a gastric bypass and tracheotomy 2 weeks ago remains in the ICU receiving volume-controlled ventilation. After the patient is rolled to the supine position, the ventilator high-pressure alarm sounds with each breath. The suction catheter can be passed only 10 cm into the tracheostomy tube and no secretions are evident. What should the RT do?
Reposition the tracheostomy tube into the trachea.
Which of the following should be used to provide adequate humidity for a spontaneously breathing patient with a tracheostomy tube?

1 air-entrainment nebulizer
2 spinning disk nebulizer
3 heated wick humidifier
4 heat moisture exchanger
air-entrainment nebulizer
heated wick humidifier
heat moisture exchanger
During a routine ventilator check, a respiratory therapist measures endtracheal tube cuff pressure at 45 mm Hg. Air passes around the cuff at peak airway pressure. What is the therapists most appropriate action?
Recommend changing the endotracheal tube
A patient has been intubated for 4 days. When suctioning, a RT notices that the secretions are becoming tenacious. What is the best solution?
Ensure proximal airway temperature is 35 degrees C
A patient receiving a nebulizer treatment with 3% saline complains of shortness of breath. What should a RT do?
Discontinue therapy and notify the physician
When should tracheal suctioning be terminated?
bradycardia
What of the following provides the best clinical evaluation of the effects of incentive spirometry?
...
A. arterial blood gas analysis after treatment.
B. Peak flow before and after treatment.
C. Auscultation of the chest before and after treatment.
D FEV1 measurement before and after treatment
Auscultation of the chest before and after treatment
A RT decreases the inspiratory flow during volume-controlled ventilation. If the patient's total rate does not change, which of the following will decrease?
A. tidal volume
B. end-expiratory pressure
C. expiratory time
D. mean airway pressure
Expiratory time
A 65-year old male with a history of COPD is brought to the emergency department because of respiratory distress. The patient is receiving oxygen by a simple mask at 5 L/min. A respiratory therapist notes the patient has shallow breathing and is difficult to arouse. Which of the following should the RT do?
A. Initiate pulse oximetry
B. Request a chest radiograph
C. Intubate and initiate mechanical ventilation
D. Perform an arterial blood gas analysis
Perform an arterial blood gas analysis
A 26-year-old patient is receiving volume ventilation due to status asthmaticus. Current ventilatory settings yield with an I:E of 1:2 and a PaCO2 of 51 torr. Which of the following should a respiratory therapist decrease?
Inspiratory time
An adult patient with intermittent needs for bilevel ventilation has a 4.0 mm ID single cannula tracheostomy tube. Which of the following is true?
A. The tracheostomy cuff should be fully inflated to allow speech
B. The tracheostomy cuff should be fully inflated during bilevel ventilation.
C. the inner cannula should be removed during speech.
D. The inner cannula should be inserted for bilevel ventilation.
The tracheostomy cuff should be fully inflated during bilevel ventilation
An attending physician writes an order for the administration of 80%/20% heliox to a patient with airways obstruction. What piece of equipment should a RT use to administer the therapy?
nonrebreathing mask
A patient is receiving noninvasive positive pressure ventilation. Pulmonary compliance has increased over the past 4 hours. To maintain the patient's tidal volume, is would be appropriate to do what?
decrease the IPAP
A patient with dyspnea is breathing 60% oxygen through a T-piece and reservoir system. A heated air-entrainment nebulizer is connected to a flowmeter set at 12 L/min. The aerosol mist disappears from the reservoir outlet during each inspiration. What should a RT do?
Add a second nebulizer
An adult patient who is being mechanically ventilated has high airways resistance to inspiratory flow. What could be implemented to improve the distribution of ventilation?
inspiratory plateau
A patient receiving receiving beta-adrenergic aerosol therapy is taking slow, deep breaths with a pause at the end of each inspiration. Five minutes into the treatment, the patient complains of lightheadedness, dizziness, and tingling in the fingers. What should a respiratory therapist do?
Have the patient pause every 1-2 minutes during treatment
A patient with known reversible airway disease administers two puffs from his MDI. After the treatment a RT measures the patient's peak flow and notices that it has only increased marginally from pre-administration. A RT should do what?
Add a spacer to the MDI
What drug could be recommended to reduce systemic arterial blood pressure and reduce ventricular preload?
Sodium nitroprusside (Nipride)
A patient demonstrates refractory hypoxemia while receiving oxygen by a non-rebreathing mask. What should a respiratory therapist recommend to improve arterial oxygenation?
CPAP therapy
CRT
capillary refill time
CSF
cerebrospinal fluid
CT
computed tomography or chest tube
CVA
cerebrovascular accident or costovertebral angle
CVP
central venous pressure
CXR
chest x-ray
dc
discontinue
D/C
discontinue
D&C
dilation and curettage
DIC
disseminated intravascular coagulation
diff
differential or differential blood count
dil
dilute or diluent
DKA
diabetic ketoacidosis
dl
deciliter
DM
diabetes mellitus or diastolic murmur
DNR
do not resuscitate
DOE
dyspnea on exertion
DSD
dry sterile dressing
DTR
deep tendon reflex or deep tendon reflexes
DVT
deep vein thrombosis
DW
daily weight
D5W
5% dextrose in water
dx
Diagnosis
DX
diagnosis
EC
enteric-coated
ECF
extracellular fluid
ECG
electrocardiogram
EKG
electrocardiogram
ECT
electroconvulsive therapy
EDB
estimated date of birth
EDD
estimated date of delivery
EEG
electroencephalogram
EGD
esophagogastroduodenoscopy
elix
elixir
EMG
electromyogram
ENT
ear, nose and throat
EOM
extra-ocular movements
ER
extended release or Emergency Room
ESR
erythrocyte sedimentation rate
ESRD
end-stage renal disease
ESRF
end-stage renal failure
ET
enterostomal therapist
ETOH
ethyl alcohol (ethanol)
F
Fahrenheit
Fe
iron
FeSO4
iron sulfate
FHR
fetal heart rate
FSBS
fingerstick blood sugar
f/u
follow up
FUO
fever of unknown origin
fx
...
Fx
fracture or fractional urine test
g
...
gm
...
Gm
gram
GERD
gastroesophageal reflux disease
GI
gastrointestinal
gr
grain
grav I
II, III, etc,gravida (pregnancy) 1, 2, 3, etc.
GSW
gunshot wound
gtt
drop or drops
GTT
glucose tolerance test
GU
genitourinary
GYN
...
Gyn
gynecological
h
hour
H+
hydrogen ion
H/A
headache
H/H
hemoglobin and hematocrit
H&P
history and physical examination
HAV
hepatitis A virus
Hb
...
Hgb
hemoglobin
HBAg
hepatitis B antigen
HBV
hepatitis B virus
HCO3-
bicarbonate
Hct
...
HCT
hematocrit
HCV
hepatitis C virus
HEENT
head, eyes, ears, nose and throat
HD
hemodialysis
Hg
mercury
HHNS
hyperglycemic hyperosmolar nonketotic syndrome
HIPAA
Health Insurance Portability and Accountability Act
HIV
human immunodeficiency virus
h/o
history of
H2O
water
HOB
head of bed
HOH
hard of hearing
HR
heart rate
hs
at bedtime
HTN
hypertension
I&D
incision and drainage
I&O
intake and output
ICD
implantable cardiac defibrillator
ICF
intracellular fluid
ICP
intracranial pressure
ICU
intensive care unit
Alveolar Air Equation (PAO2)
(Pb-PH2O)FiO2 - PaCO2 x 1.25 / or
(760-47)FiO2 - PaCO2/.08
Normal: Varies with FiO2
A-a Gradiant (A-a DO2)
PAO2-PaO2 or P(A-a)O2
Normal: 5-10% mm/Hg on 21% O2
25-65% mm/Hg on 100% O2
Arterial O2 Content (CaO2)
(Hbx1.34xSaO2) - (PaO2x.003)
(Oxygen in RBC) - (Oxygen in Plasma)
Normal: 17-20 vol%
Mixed Venous O2 Content (CvO2)
(Hbx1.34xSvO2) - (PvO2x.003)
(Oxygen in RBC) - (Oxygen in Plasma)
Normal: 12-16 vol%
Arterial-Venous O2 Difference
C(a-v)O2
CaO2-CvO2
Normal: 4-5 vol%
Cardiac Output (Qt)
VO2 / C(a-v)O2 x (10)
Normal: 4-8 L/min
Shunt Equation (Qs-Qt)
(A-aDO2)(.003) /
(A-aDO2)(.003)+ C(a-v)O2
Normal: 98%
Deadspace to Tidal Volume Ratio (Vd/Vt)
PaCO2-PECO2/PaCO2 x 100
Normal: 20-40%
Desired FiO2 or PaO2
FiO2d x PaO2d = FiO2c x PaO2c
d=desired and c=current
Exhaled Tidal Volume (Vt)
(Ve-f)
Alveolar Minute Ventilation (Va)
(Vt-Vd) x f
**Use 1ml per lb of ideal body weight for estimated Vd
Normal 4-6 L/min
Ideal Body Weight (IBW)
Male: 106lbs + 6lbs for every inch over 6ft
Ht(in) -60 x2.3 +50
Female: 100lbs + 5lbs every inch over 6ft
Ht(in) -60 x2.3 +45.5
Minute Ventilation (Ve)
Vt x f
Normal 5-10 L/min
Dynamic Compliance (Cdyn)
Vt/PIP-PEEP
Normal 40-70 mL/cm H2O
Static Compliance (Cstat)
Vt/Plat-PEEP
Normal 70-100 mL/H2O
Airway Resistance (RAW)
Peak Pressure - Plateau Pressure
PIP-Plat/Vt
Normal 0.5-2.5 cm/H2O
Compliance (C)
^V/^P
(change in volume/change in pressure)
Normal 70-100 mL/cm H2O
Work of Breathing
^P x ^V
(change in pressure x Change in Volume)
Minimum Flow Rate
(VtxRate) + (I+E)
Rapid Shallow Breathing (RSBI)
Respiratory Rate/Vt in liters
Normal =<100
I:E Ratio
Ve/60 = seconds for each breath
i time usually a 1
Potassium (K+)
3.5-4.5 mEq/L
Sodium (Na+)
135-145 mEq/L
Chloride (Cl-)
80-100 mEq/L
BiCarbonate (HCO3-)
22-26 mEq/L
Creatinine
0.7-1.3 mg/dL
Blood Urea Nitrogen (BUN)
8-25 mg/dL
Carboxy Hemoglobin (CoHb)
0-1.5% - non smoker
4%-5% - light smoker
6%-8% - heavy smoker
Erythrocytes (RBC)
4-6 mill/mm3
Number of cells available to carry O2/CO2
Hemoglobin (Hb)
12-16 gm/100mL of blood
Carries O2 in the Blood
Hemacrit (Hct)
40%-50%
Percent of blood volume occupied by RBC's
Leukocytes (WBCs)
5,000-10,000 per mm3
Blood cells that fight infection in the body
Capnography (ETCO2)
30 torr or 3%-5%
Pulse Oximetry (SpO2)
93%-97%
Co-Oximetry
1%-3%
Mean Arterial Pressure (MAP)
Formula: BPsys-BPdia/3
Normal:93-94 mm/Hg
Right Arterial Pressure (CVP)
2-6 mm/Hg
4-12 cm/H2O
Pulmonary Artery Pressure (PAP)
25/8 mm/Hg
Mean Pumonary Artery Pressure (MPAP)
13-14 mm/Hg
Pulmonary Capillary Wedge Pressure (PCWP)
4-12 mm/Hg
Cardiac Output (Qt)
Normal: 4-8 L/min
Formula: SVxHR
Cardiac Index (CI)
2-4 L/min
Formula: Qt/BSA (body surface area)
Pulse Pressure (PP)
BPsys-BPdia
Normal 20-80 mm/Hg
BP difference, Systolic-Diastolic
Pulmonary Vascular Resistance (PVR)
(MPAP-PCWP/Qt) x80
Normal: <2.5 mm/Hg/L/min
200 Dynes/sec/cm3
Systemic Vascular Resistance (SVR)
(MAP-CVP/Qt) x80
Normal: <20 mm/Hg/L/min
1600 Dynes/sec/cm3
Saturation of Arterial O2 (SaO2)
PaO2 + 30
Normal: 98%
Duration in Flow (O2 Tank)
(in minutes)
gauge pressure (psi) x tank factor/liter flow
Tank Factors (O2 tanks)
E cylinder = .28L/psi (0.3)
H cylinder = 3.14L/psi (3.0)
Total flow = factor x flow
Arterial Blood Gas (ABG)
normal values
pH: 7.35-7.45
PaCO2: 35-45
PaO2: 80-100
HCO3-: 22-26
Right Heart Failure
Cor Pulmonale
Tricuspid Valve Stenosis
CVP's = Increased
PAP & PCWP = Decrease or Normal
Cardiac Output = Normal
Lund Disorders
Pulmonary Embolism
Pulmonary Hypertension
Air Embolism
CVP's = Increased
PAP = Increased
PCWP = Decreased/Normal
Cardiac Output = Normal
Left Heart Failure
Mitral Valve Stenosis
CHF - Congestive Heart Failure
High PEEP Effects
CVP's = Normal
PAP & PCWP = Increased
Cardiac Output = Decreased
Hypervolemia
CVP/PAP/PCWP/Qt all Increased
Hypovolemia
CVP/PAP/PCWP/Qt all Decreased
Beta2 Adrenergic Bronchodilators
(Front Door Bronchodilators)
Activates B2 receptors in bronchial smooth muscle.
Albuterol/Ventolin or Proventil
Levabuterol/Xopenex
Terbutaline/Brethine or Brethaire
Pirbuterol/Maxair
Long Acting Beta2 Agonists
Maintenance/Long Term Control
Relaxes bronchial smooth muscle
,Salmeterol/Serevent
Formoterol
Arfomoterol/Brovana
Parasympatholytics
(Anticholinergics)
(Back Door Bronchodilators)
Competitivelt blocks all muscarinic receptors
Atropine Solfate
Ipatropium Bromide/Atrovent
Tiotropium Bromide/Spiriva
Oxitropium Bromide/Oxivent
Methylxanthines
(Phosphodiesterase Inhibitors)
(Side Door Bronchodilators)
Relaxes bronchial smooth muscle
Theophyline/Aminophyline
Theo-Dur
Oxitriphyline/Choledyl
Theoair
Caffeine
Cortocosteroids
(Anti-Infamitory or Immunosuppressive Agents)
Direct/Indirect Bronchodilators
Causes vasoconstriction
Fluticasone/Flovent
Beclomethasone/Beclovent Vanceril Qvar
Budesonide/Pulmicort
Flunisolide/Aerobid Aerobid M
Triamcinolone/Azmacort
Prednisone, Methylprednisone, Solumedrol
Adrenergic & Anticholinergic
(Combining Medications)
Ipatropium Bromide & Albuterol:
Combivent or Duoneb
Anti-Imflamitory & Long Acting Bronchodilators (Combining Meds)
Advair: Fluticasone & Salmeterol
Symbicort: Budesonide & Formoterol
Mucolytics (for secretions)
Acetylcysteine/Mucomyst
DNAse/Pulmozyme
Leukotreine Modifiers
(non-steroid drugs for asthma)
Montelukast/Singulair
Zafirlukast/Accolate
Zileyton/Zyflo
IgE Blocker
Omalizumab/Xolair
Mast Cell Stabilizers
Inhibits degranulation of mast cells and prevents the release of histamines
Cromolyn Sodium/Intal, Aarane
Nedocromil Sodium/Tilade
Eupnea
Normal Respiratory Rate, Depth & Rhythm
Normal Respiratory Rate is 12-20/min
Tachypnea
Increased Respiratory Rate (> 20/min)
ie: hypoxia, fever, pain, CNS problem
Bradypnea (Oligopnea)
Decreased Respiratory Rate (<12/min)
Variable Depth & Irregular Rhythm
ie: sleep (normal), drugs, alcohol, metabolic disorders
Apnea
Cessation of Breathing
(delay in breathing)
Hyperpnea
Increased Respiratory Rate & Depth
Regular Rhythm
ie: metabolic disorder, CNS disorders
Cheyne-Stokes
Gradually increasing/decreasing rate/depth
cycles lasting 30-180 sec, apnea 60 sec
ie: increased ICP's, Meningitis, drug OD
Biots
Increased Respiratory Rate/Depth w/ Irregular periods of Apnea (same depth)
ie: CNS Problems
Kussmaul's
Increased Respiratory Rate/Depth, Irregular Rhythm, Breath Sounds Labored
ie: metabolic acidosis, renal failure, diabetic ketoacidosis
Apneustic
Prolonged Gasping Inspiration, followed by Extreme Short, Insufficient Expriration
ie: problem w/ respiratory center, trauma or tumor
Tactile Fremitus
Vibrations that are felt by the hand on the chest wall during breathing (tactile=touch/fremitus=vibrations)
Vocal Fremitus
Voice Vibrations on the chest wall.
Pleural Rub Fremitus
A grating sensation felt on the chest wall due to roughened pleural surfaces rubbing together.
Rhonchial Fremitus
(palpable rhonchi)
Secretions in the airway
Crepitus
Bubbles of air under the skin, can be palpated, indicates the presence of subcutaneous emphysema
Percussions
Done by placing the middle finger between two ribs & tapping the middle finger's first joint with the middle finger tip of your opposite hand.
Resonant Percussion
Normal air filed lung, gives a hollow sound.
Flat Percussion
Heard over the sternum, muscle or areas of atelectasis.
Dull Percussion
Heard over fluid-filled organs (heart/liver). Pleural Effusion or Pneumonia will give this thudding sound.
Tympanic Percussion
Heard over air-filled stomach, a drum-like sound, when heard over lungs indicates increased volume.
Hyperresonant Percussion
Found in area of lungs with Pneumothorax or Emphysema is present, this is a booming sound.
Rales or Crackles
Secretions or Fluid
Coarse Rales (rhonchi)
Large airway secretions.
Patient needs suctioning.
Medium Rales
Middle airway secretions.
Patient needs chest physical therapy
Fine Rales (moist crepitant rales)
Alveoli/Fluid
Patient has CHF/Pulmonary Edema
Pt needs IPPB/heart meds/diurectics/O2
Wheeze
Broncho Spasms
Pt needs Bronchodialtors
Unilateral Wheeze
Indicative of foregn body obstruction
Pt needs Bronchoscopy
Stridor
Upper airway obstruction
Supraglottic/Subglottic swelling
ie: epiglottitis, croup, post estubation
Foreign body aspiration (solids/fluids)
Pt needs Racemic Epinephrine, maybe suctioning or bronchoscopy
Plueral Friction Rub
Coarse grating or crunching sound.
Inflamed surface or visceral & parietal pleura rubbing together.
Associated w/ TB, pneumonia, cancer, pulmonary infarction.
Pt needs steroids and antibiotics.
Endotracheal/Tracheostomy Tubes
Tip should be positioned below the vocal cords, 2-3 inches above the Carina.
approx. level of Aortic Knob/Aortic Arch
Pacemaker
Normally positioned in the Right Ventricle
Pulmonary Artery Catheters
Should appear in the right lower lung field
Central Venous Catheter
Placed in the right/left subclavian or jugular vein and should rest in the vena cava or right atrium of the heart
Chest Tubes
Should be located in the pleural space surrounding the lung
Nasogastric Feeding Tubes
Positioned in the stomach, 2-3 cm below the diaphragm
Radiology Terminology:
01. Radiolucent
02. Radiodense/opacity
03. Infiltrate
04. Consolidation
05. Hyperlucency
06. Vascular Markings
07. Diffuse
08. Opaque
09. Bilateral
10. Unilateral
Radiology Interpretation:
01. dark pattern, air
02. white pattern, solid, fluid
03. any ill-defined radiodensity
04. solid white area
05. extra pulmonary air
06. lymphatics, vessels, lung tissue
07. spread throughout
08. fluid, solid
09. on both sides, in both lungs
10. on one side, right or left lung
Pulmonary Edema X-Ray
Fluffy infiltrates, diffuse whitness
Butterfly/Batwing, infiltrates in butterfly or batwing shape
Atelectasis X-Ray
Patchy Infiltrates, scattered densities
Platelike Infiltrates, thin-layered densities
ARDS/IRDS X-Ray
Ground glass appearance, reticulogranular
Honeycomb Pattern, reticulogranular
Diffuse bilateral radiopacity
Pneumonia X-Ray
Pulmonary Edema X-Ray
Air bronchogram
Peripheral wedge-shaped infiltrate
Pleural Effusion X-Ray
Concave superior interface/border
Basilar infiltrates with meniscus
Platelet Count
Normal 150,000-400,000
Blood constituent for clotting
Neutrophils
Granular Leukocyte having a nucleus with 3-5 lobes connected by chromatin, cytoplasm containing very fine granules
40-75%
Lymphocytes
Mononuclear, nongranular Leukocyte having a deeply staining nucleus containing dense chomatin and a pale-blue staining cytoplasm
20-45%
Monocytes
Mononuclear phagocytic Leukocyte with an ovoid or kidney shaped nucleus and azurophilic cytoplasmic granules
2-10%
Eosinophils
Granular Leukocyte having a nucleus with two lobes connected by a thread of chromatin, and cytoplasm containing coarse round granules of uniform size
1-6%
Basophils
Any structure, cell, or histologic element staining readily with basic dyes
0-1%
Lung Volumes
TLC =
VC + RV =
IC (IRV + VT) + FRC (ERV + RV) =
IRV + VT + ERV + RV
Asthma
>RR, >expiration, dyspnea, >accessory muscle use, nasal flaring, orthopnea, > A-P diameter
Atelectasis
>RR, dyspnea, <chest expansion (same side), cyanosis(?), tracheal deviation (same side)
Chronic Bronchitis
>RR, > expiration, dyspnea, >accessory muscle use, fat or stocky, >A-P diameter, chronic cough, <diaphragm movement
Emphysema
>RR, >expiration, dyspnea, orthopnea, pursed-lip breathing, hypertrophy of accessory muscles, thin, >A-P diameter, <chest & diaphragm movement
Large Mass
Usually normal
Pleural Effusion
>RR, dyspnea, <chest movement (same side), tracheal deviation (opposite side), cyanosis
Pleural Thickening
<chest movement (same side)
Pneumonia
>RR, dyspnea, cough, <chest movement (same side), pleuritic pain(?), cyanosis (?), fever
Pneumothorax
>RR, dyspnea, <chest movement & expanded if closed, tracheal deviation (same side), other side if tension), cyanosis
Pulmonary Edema
>RR, dyspnea, orthopnea, >accessory muscle use, pale or cyanosis
Pulmonary Embolism
>RR, dyspnea, >HR, apprehension, cough, sharp chest pain, hemotysis
Pulmonary Interstitial Fibrosis
Rapid, shallow breathing, >accessory muscle use, dyspnea on exertion cyanosis (late), clubbing (?)
Tidal Volume (Vt)
Volume of gas moved in or out of the lungs ina normal resting breath
Inspiratory Reserve Volume (IRV)
Maximum volume of gas inspired from end-tidal inspiration
Inspiratory Capacity (IC)
Maximum volume of gas inspired from resting expiratory level (Vt + IRV)
Expiratory Reserve Volume (ERV)
Maximum volume of gas expirted from resting expiratory level
Vital Capacity (VC)
Maximum volume of gas expired after a maximum inspiration (IC + ERV)
Residual Capacity (RC)
Volume of gas in the lungs at the end of a maximum expiration
Total Lung Capacity (TLC)
Volume of gas in the lungs at the end of maximum inspiration
RV/TLC
Residual volume expressed as a percent of total lung capacity
Functional Residual Capacity (FRC)
Volume in lungs at resting expiratory level (ERV + RV)
Thoratic Gas Volume (Vtg)
Volume of gas in entire thoratic cavity at resting expiratory level whether or not in communicates with the airways
Restriction
Most all values are << proportionately, especially VC, TLC
normal flows
...
Obstruction
>>: TLC, RV, FRC, RV/VC, RV/TLC
<<: VC and flows
Helium (He) Dilution
Measures RV and FRV
Nitrogen (N2) Washout
Measures RV and FRC
Body Plethysmography
Measures Vtg(FRV) + RAW
SPIRIVA
(TIOTROPIUM BROMIDE)
CLASS:BRONCHODILATOR BACK DOOR
ADULT DOSE DPI INHALER ----Q DAY
EXOSURF
CLASS ARTIFICIAL SURFACTANT
IMMATURE NEONATAL LUNGS
SURVANTA
CLASS: ARTIFICIAL SURFACTANT
IMMATURE NEONATAL LUNGS
DOPRAM
(DOXAPRAM)
CLASS RESPIRATORY STIMULANT
USE TO TREAT CENTAL SLEEP APNEA
MEDROXYPROGESTERONE
(HORMONE)
CLASS RESPIRATORY STIMULANT
USED TO TREAT CENTRAL SLEEP APNEA
RIBAVIRIN
(VIRAZOLE)
CLASS ANTIVIRAL
DELIVER WITH SPAG UNIT OR PARTICLE SCAVENGER DEVICE
USE TO TREAT RSV
(RESPIRATORY SYNCYTIAL VIRUS)
PENTAMADINE
(NEBUPENT)
CLASS ANTIPNEUMOCYSTIS AGENT
USE TO TREAT
PNEUMOCYSTIS CARINII
(MOSTLY SEEN IN AIDS)
CARBENICILLIN
AMOXICILLIN
AMPICILLINE
CLASS PENICILLIN TYPE ANTIBOTIC
USED TO TREAT
GRAM POSITIVE BACTERIAL INFECTIONS
(STAPHYLOCOCCUS, STREPTOCOCCUS, ETC)
METHACILLIN
OXACILLINE
NAFACILLIN
CLASS PENICILLIN RESISTANT TYPE ANTIBOTIC
USED TO TREAT
GRAM POSITIVE BACTERIAL INFECTIONS THAT ARE RESISTANT TO NORMAL PENICILLIN
CAPHALOTIHIN (KEFLIN)
CEPHALORIDINE (LORIDINE)
CAPHALEXIN (KEFLEX)
CLASS NON -PENICILLIAN TYPE ANTIBOTIC
USED TO TREAT
BRAM POSITIVE BACTERIAL INFECTIONS
FOR PATIENTS ALLERGIC TO PENICILLIN
ERYTHROMYCIN
CLASS NON PENICILLIAN TYPE ANTIBOTIC
USE
FOR PATIENTS ALLERGIC TO PENICILLIN
OR MYCOPLASMA PNEUMONIA
AMIONPHYLLINE FOR NEONATES
(ALSO CALLED THEOPHYLLINE
CLASS RESPIRATORY STIMULANT
USED TO TREAT
CENTRAL SLEEP APNEA
FOR
NEONATES
NICORETTE
CLASS STOP SMOKING ASSISTANCE
USE TO
CURB ADDICTION TO NICOTINE
NICODERM
CLASS STOP SMOKING ASSISTANCE
USE TO
CURB ADDICTION TO NICOTINE
(DERMAL PATCH)
NOCOTROL NS
CLASS STOP SMOKING ASSISTANCE
USE TO CURB ADDICTION TO NICOTINE
ASPIRIN
IBUPROFEN (MOTRIN
ADVIL)
NAPROXEN (NAPROSYN, ALEVE),CLASS NON STEROID ANTI-INFLAMMATORY
USE TO TREAT
GENERAL INFLAMMATION
ETHAMBUTOL
CLASS: ANTITUBERCULLIN
USE TO TREAT
TUBERCULOSIS
RIFAMPIN
CLASS ANTITUBERCULIN
USE TO TREAT
TUBERCULOSIS
** USED WITH ISONIAZID
ISONIAZID
(INH)
CLASS ANTITUBERCILLIN
ONE YEAR USE
USE TO TREAT
TUBERCULOSIS
** USED WITH RIFAMPIN
TETRACYCLINE
CLASS BRAOD SPECTRUM ANTIBIOTIC
USED TO TREAT
ROCKY MOUNTAIN SPOTTED FEVER
MYCOPLASMA PNEUMONIA
CHRONIC BRONCHITIS
GENTAMYCIN
CLASS ANTIBIOTIC
USED TO TREAT
GRAM NEGATIVE INFECTIONS
(PSEUDOMONAS, E. COLI)
TOBRAMYCIN
CLASS ANTIBIOTIC
USED TO TREAT
GRAM NEGATIVE INFECTIONS
(PSEUDOMONAS, E.COLI
STREPTOMYCIN
CLASS ANTIBIOTIC
USED TO TREAT
GRAM NEGATIVE INFECTIONS
ALSO USED WITH TUBERCULOSIS
HYPERTONIC SALINE
(1.8 - 15% SALINE
CLASS WETTING AGENT
MAY CAUSE IRRITATION AND BRONCHOSPASM
FOR
SPUTUM INDUCTION
INTAL
(CROMOLYN SODIUM)
CLASS ASTHMA PROPHYLAXIS
DO NOT GIVE WHEN WHEEZING PRESENT
NOT A RESCUE MEDICATION
FOR
INHIBIT HISTAMINE RELEASE
PREVENT BRONCHOCONSTRICTION
HYPOTONIC SALINE
(0.45% SALINE)
CLASS WETTING AGENT
MAY CAUSE IRRITATION AND BRONCHOSPASM
FOR
THICK SECRETIONS
SODIUM BICARBONATE
CLASS SURFACE ACTIVE AGENT
TREAT
THICK SECRETIONS
LOWERS PH
SOLU-MEDROL
(METHYLPREDISOLONE)
CLASS CORTICOSTEROID
FOR
ANTI-INFLAMMATORY
OF AIRWAYS
DECADRON
(DEXAMETHASONE)
CLASS CORTICOSTEROID
FOR
ANTI-INFLAMMATORY OF AIRWAYS
PREDNISONE
CLASS CORTICOSTEROID
FOR
ANTI-INFLAMMATORY
OF AIRWAYS
NEDOCROMIL
(TILADE)
CLASS ASTHMA PROPHYLAXIS
DO NOT GIVE WHEN WHEEZING PRESENT
DOSE MDI 2 PUFFS QID
FOR
PREVENT BRONCHOCONSTRICTION
ROBINUL
(GLYCOPYRROLATE)
CLASS BRONCHODILATOR BACK DOOR
LONG TERM BRONCHODILATION
&
DRYING AGENT
OXIVENT
(OXITROPIUM)
CLASS BRONCHODILATOR BACK DOOR
MDI ONLY
FOR
LONG TERM BRONCHODILATION
MUCOMYST
(ACETYLCYSTEINE)
CLASS MUCOLYTIC AGENT
ADULT DOSE 2-4 CC OF 10-20% STRENGTH
TREAT
THICK SECRETIONS
PULMOZYME
(DORNASE ALPHA)
CLASS MUCOLYTE AGENT
ADULT DOSE 2.5MG OR 2.5 ML
TREAT
PREVENT INFECTION IN
CYSTIC FIBROSIS
CHOLEDYL
OXYTRIPHYLLINE)
CLASS BRONCHODILATOR SIDE DOOR
FOR
LONG TERM BRONCHODILATION
ATROVENT
(IPRATROPIUM BROMIDE)
CLASS BRONCHODILATOR BACK DOOR
TREAT
WHEEZING
ESPECIALLY GOOD FOR EMPHYSEMA
THEOPHYLLINE
(AMINOPHYLLINE & THEO-DUR)
CLASS BRONCHODILATOR SIDE DOOR
THERAPEUTIC BLOOD LEVEL 10-20 UG/ML
FOR
LONG TERM BRONCHODILATION
ATROPINE
(SCH 1000)
CLASS BRONCHODILATOR BACK DOOR
CARDIAC STIMULANT
TREAT
WHEEZING, BRADYCARDIA
OR REVERSE CHOLINERGIC CRISIS
AS SEEN IN MYASTHENIA GRAVIS
SALMETEROL
(SEREVENT)
CLASS BRONCHODILATOR FRONT DOOR
ADULT DOSE MDI 2 PUFF BID
TREAT
WHEEZING
PIRBUTEROL
(MAXAIR)
CLASS BRONCHODILATOR FRONT DOOR
ADULT DOSE MDI 2 PUFFS Q6 HR
TREAT
WHEEZING
BITOLTEROL
(TORNALATE)
CLASS BRONCHODILATOR FRON DOOR
ADULT DOSE 1.25 MG QID
TREAT
WHEEZING
TERBUTALINE
(BRETHINE)
CLASS BRONCHODILATOR FRONT DOOR
ADULT DOSE 0.5 ML
GIVEN BY TABLET
TREAT
WHEEZING
ALUPENT
(METAPROTERENOL)
CLASS BRONCHODILATOR FRONT DOOR
ADULT DOSE 0.3 ML
MAIN SIDE EFFECT : TACHYCARDIA
TREAT
WHEEZING
ALBUTEROL
CLASS BRONCHODILATOR FRONT DOOR
ADULT DOSE 0.5 ML
MAIN SIDE EFFECT : TREMORS
TREAT
WHEEZING
XOPENEX
(LEVALBUTEROL)
CLASS BRONCHODILATOR FRONT DOOR
ADULT DOSE 0.63 MG TID
TREAT
WHEEZING
PULMICORT
(BEDESONIDE)
CLASS CORTICOSTEROID
FOR
ANTI-INFLAMMATORY
OF AIRWAYS
RACEMIC EPINEPHRINE
(S2 OR VAPONEPHRINE)
CLASS DECONGESTANT
MUCOSAL VASOCONSTRICTOR
FOR
ACUTE EPIGLOTTITIS
STRIDOR FOLLOWING EXTUBATION
ZYFLO
(ZILEUTRON)
CLASS LEUKOTRIENE MODIFIER
NOT A RESCUE MEDICATION
ALTERNATIVE TO CORTICOSTEROIDS
ACCOLATE
(ZAFIRLUKAST)
CLASS LEUKOTRIENE MODIFIER
NOT A RESCUE MEDICATION
FOR ALTERNATIVE TO
CORTICOSTEROIDS
BECLAMETHASONE
(BECLOVENT OR VANCERIL)
CLASS CORTICOSTEROID
FOR
ANTI INFLAMMATORY
OF AIRWAYS
AZMACORT
(TRIAMCINOLONE)
CLASS CORTICOSTEROID
FOR
ANTI-INFLAMMATORY
OF AIRWAYS
FLOVENT
(FLUTICASONE)
CLASS CORTICOSTEROID
FOR
ANTI-INFLAMMATORY
OF AIRWAYS
AEROBID
(FLUNISOLIDE)
CLASS CORTICOSTEROID
FOR
ANTI-INFLAMMATORY
OF AIRWAYS
QUINDINE OR PROPRANOLOL
(INDERAL)
CLASS CARDIAC GLYCOSIDE
FOR ATRIAL ARRHYTHMIAS
PRONESTYL
(PROCAINAMIDE)
CLASS ANTI-ARRHYTHMIC AGENT
FOR
ATRIAL ARRHYTHMIAS
&
VENTRICULAR TACHYCARDIA
VERAPAMIL
CLASS ANTI-ARRHYTHMIC AGENT
FOR
CONTROL VENTRICULAR RATE
(SUPRAVENTRICULAR TACHYCARDIA)
AMIODERONE
CLASS ANTI-ARRHYTHMIC AGENT
FOR
PULSELESS V-TACH AND V-FIB
NON RESPONSIVE TO DEFIBRILLATION
SINGULAIR
(MONTELUKAST
CLASS LUEKOTRIENE MODIFIER
FOR
ALTERNATIVE TO CORTICOSTEROIDS
ADVAIR
(FLUTICASONE AND SALMETEROL)
CLASS BRONCHODILATOR
COMBINED LONG AND SHORT TERM
FOR BRONCHOCONSTRICTION
DIGOXIN
(LANOXIN)
CLASS CARDIAC GLYCOSIDE
FOR
INCREASE CARDIAC CONTRACTILITY
CHF, LEFT HEART FAILURE
DIGITALIS
(CRYSTOGDIGIN)
CLASS CARDIAC GLYCOSIDE
FOR
INCREASE CARDIAC CONTRACTILITY
(CHF, LEFT HEART FAILURE)
DOPAMINE
CLASS VASOPRESSOR
USE TO
INCREASE BLOOD PRESSURE
OSMITROL
(MANNITOL)
CLASS DIURETIC
FOR
CEREBRAL EDEMA
DRUG OVERDOSE
DIAMOX
(ACETAZOLAMIDE)
CLASS DIURETIC
FOR
PERIPHERAL EDEMA
CEREBRAL EDEMA
LASIX
(FUROSEMIDE)
CLASS DIURETIC
FOR
CHF, PULMONARY EDEMA
FLUID OVERLOAD
LIDOCAINE
CLASS ANTI-ARRHYTHMIC AGENT
FOR
PVCS
PULSELESS V-TACH
V-FIB
NITROGLYCERINE
CLASS ANTI-ANGINA
FOR
ANGINA PECTORIS
(CHEST PAIN)
NIPRIDE
(SODIUM NITROPRUSSIDE)
CLASS VASODILATOR
FOR
LOWER BLOOD PRESSURE
DECREASED VENTRICULAR PRELOAD
LEVOPHED
(NOREPINEPHRINE)
CLASS VASOPRESSOR
FOR
INCREASE BLOOD PRESSURE
(CARDIOGENIC SHOCK
SECONAL
(SECOBARBITAL)
CLASS SEDATIVE BARBITURATE
USE TO
PROVIDE SEDATION
CUROSURF
CLASS ARTIFICIAL SURFACTANT
USE FOR
IMMATURE NEONATAL LUNGS
INFASURF
CLASS ARTIFICIAL SURFACTANT
USE FOR
IMMATURE NEONATAL LUNGS
ATIVAN
CLASS BENZODIAZEPINE
USE TO
REDUCE ANXIETY
RESTORIL
CLASS BENZODIAZEPINE
USE TO
REDUCE ANXIETY
XANAX
CLASS BENZODIAZEPINE
USE TO
REDUCE ANXIETY
HALCINON
CLASS BENZODIAZEPINE
USE TO
REDUCE ANXIETY
DEMORAL
(MEPERIDINE)
CLASS NARCOTIC ANALGESIC
USE TO
PROVIDE SEDATION AND PAIN RELIEF
(DO NOT USE ON COPD)
MORPHINE
CLASS NARCOTIC ANALGESIC
USE TO
PROVIDE SEDATION AND PAIN RELIEF
(DO NOT USE ON COPD)
CODEINE
CLASS NARCOTIC ANALGESIC
USE TO
PROVIDE SEDATION AND PAIN RELIEF
(DO NOT USE ON COPD)
NARCAN
CLASS NARCOTIC AGONIST
USE TO
REVERSE NARCOTIC INFLUENCE
PHENOBARBITAL
(LUMINAL)
CLASS SEDATIVE BARBITURATE
USE TO
PROVIDE SEDATION
PENTABARBITAL
(NEMBUTAL)
CLASS SEDATIVE BARBITURATE
USE TO
PROVIDE SEDATION
VERSED
(MIDAZOLAM)
CLASS SEDATIVE MINOR TRANQUILIZERS
USE TO
PROVIDE SEDATION
VALIUM
(DIAZEPAM)
CLASS SEDATIVE MINOR TRANQUILIZERS
USE TO
PROVIDE SEDATION
NOCTEC
(CHLORAL HYDRATE)
CLASS SEDATIVE NON-BARBITURATE
USE TO
PROVIDE SEDATION
DALMANE
(FLURAZEPAM)
CLASS SEDATIVE NON-BARBITURATE
USE TO
PROVIDE SEDATION
QUAALUDE
(METHAQUALONE)
CLASS SEDATIVE NON-BARBITURATE
USE TO
PROVIDE SEDATION
greenhouse effect
gases in the atmosphere absorb thermal energy and radiate it back to earth
atmosphere
mixture of gases surrounding the earth
nitrogen
70% of the atmosphere
oxygen
21% of the atmosphere
wind
movement of gases as a result of air pressure differences
troposhpere
layer of the atmosphere closest to the earth where gases mix
thermosphere
highest layer of the atmosphere where temperatures are very high
stratosphere
layer of the atmosphere above the troposphere where gases are in layers
mesosphere
layer of the atmosphere below the thermosphere where temperatures are very cold
air pressure
measure of how hard gases are pushing down on the earth
convection
transfer of thermal energy by circulation
radiation
transfer of thermal energy by electromagnetic waves
conduction
transfer of energy through a material
ozone layer
a layer in the stratosphere that contains a concentration of ozone sufficient to block most ultraviolet radiation from the sun
relative humidity
ratio of actual amount of water in the air to the potential amount it could hold
saturation
relative humidity is 100%
tilt of the earth
primary reason there are seasons
sun
primary source of all energy on earth
humidity
the actual amount of water in the air
dew point
the temperature at which a gas condenses
condensation
change of state from gas to liquid
evaporation
change of state from a liquid to a gas
precipitation
any form of water that falls from the sky to the earth
prevailing winds
affect the amount of precipitation a region gets
photosynthesis
plants use the sun to make and store energy
cyclone
low pressure area where winds spiral to the center
anticyclone
high pressure area where winds spiral out
anemometer
measures wind speed
barometer
measures air pressure
sun angle
determines atmospheric heating
What is the normal value for body temperature?
Adult- 98.6 F, 37C, Child- 37.5C, Infant-37.5
What is the normal pulse for a human?
Adult-60-100, Child-80-120, infant-90-170
What is the normal Respiratory Rate for a human?
Adult-12-20, child-20-25,infant- 35-45
What is the normal Blood Pressure for a human?
Adult-<120/80 mmHg, Child- 94/52, Infant- 84/52
What is a normal value range for Pulse oximetry?
>92%
What are the Red Blood Cells (RBC) normal values?
M 4.6-6.2 x 10-6/mm3
F 4.2-5.4 x 10-6/mm3
What is the monitoring threshold for Maximum Inspiratory Pressure/ Negative Inspiratory Force (MIP/NIF)?
-20 to -25 cm H2O
What is the monitoring threshold for Respiratory Rate?
12-20 breaths/min
What is the monitoring threshold for minute volume (VE)?
5-7 L/min (amount of air exhaled in one minute)
What does Barrel Chest imply?
COPD
What does Kyphoscoliosis imply?
Severe restrictive lung defect
What does it mean if patients are using their accessory muscles to breathe?
An increased work of breathing, loss of normal diaphragm function
What does it it mean if the patient has Abdominal paradox?
Diaphragmatic fatigue, increased work of breathing.
What does it mean if the patient has retractions?
The patient has a reduced lung volume, low lung compliance, increased work of breathing.
If a patient has clubbing in their fingers or toes what could that mean?
Bronchogenic carcinoma, COPD, chronic cardiovascular disease.
What does a prolonged exhalation imply?
Expiratory obstruction (asthma, COPD)
What does a prolonged inspiration imply?
Upper airway obstruction (croup, epiglottitis)
What does it likely mean if a patient is breathing rapid and shallow?
A loss of lung volume (atelectasis, pulmonary fibrosis, ARDS or acute pulmonary edema)
What does it mean if a patient is breathing in a Kussmaul breathing pattern(deep and fast)?
Diabetic Ketoacidosis
What does it mean if a patient is breathing in Biot's breathing pattern (irregular with periods of apnea)?
Increased intracranial pressure
What does it mean if a patient is breathing in a Cheyne Stokes pattern (waxing and waning)?
Central Nervous System (CNS) diseases or severe congestive heart failure (CHF).
What conditions is associated with Clear/White (thick or thin) sputum? (Also known as Mucoid)
Asthma
What conditions is associated with Clear to yellowish (thick) sputum? (Also known as Mucopurulent)
Chronic Bronchitits, cystic fibrosis, pneumonia (blood streaked)
What conditions is associated with yellow to green
thick sputum? (also known as purulent),Aspiration pneumonia, bronchiectasis (fetid/foul smelling, may separate into layers if left standing), lung abscess (fetid/foul smelling, may separate into layers if left standing)
What conditions is associated with pink to red/dark red
thin (unless coagulated) sputum? (also known as bloody),TB (red), lung cancer (red), pulmonary infarction (red), pulmonary edema (pink,watery, frothy)
What conditions does an acute cough (<3 wks) imply?
Postnasal drip, allergies, and infections (especially common cold, bronchitis, laryngitis)
What conditions does a Chronic (>3 wks) or recurrent cough imply?
Postnasal drip, asthma, GERD, chronic bronchitis, bronchiectasis, COPD, TB, lung tumor, Angiotensin Converting Enzyme (ACE) inhibitors, left heart failure
What conditions does a recurrent cough in children imply?
Viral bronchitis, asthma, allergies
What conditions does a barking cough imply?
Epiglottitis, croup, influenza, laryngotracheal bronchitis
What conditions does a brassy or hoarse cough imply?
Laryngitis, laryngeal paralysis, laryngotracheal bronchitis, pressure on laryngeal nerve, mediastinal tumor, aortic aneurysm
What conditions does a wheezy cough imply?
Bronchospasm, asthma, cystic fibrosis, bronchitis
What conditions does a dry cough imply?
Viral infections, inhalation of irritant gases, interstitial lung diseases, tumor, pleural effusion, cardiac conditions, nervous habit, radiation or chemotherapy
What conditions does a dry to productive cough imply?
Atypical pneumonias, Legionnaires' disease, pulmonary embolus, pulmonary edema, lung abscess, asthma, silicosis, emphysema (late phase), smoking, AIDS
What conditions does a chronic productive cough imply?
Bronchiectasis, chronic bronchitis, lung abscess, asthma, fungal infections, bacterial pneumonias, TB
What conditions does a Paroxysmal (especially at night) cough imply?
Aspiration, asthma, left heart failure
What conditions does a positional (especially when lying down) cough imply?
Bronchiectasis, left heart failure, chronic postnasal drip or sinusitis, GERD with aspiration
What conditions does cough associated with eating or drinking imply?
Neuromuscular disease of the upper airway, esophageal problems, aspiration
To develop an effective program for teaching a patient to use a small volume nebulizer
a respiratory therapist should evaluate the patient's what?,Language skills, mental status and manual dexterity, not visual acuity
To demonstrate significan postbronchodilator improvement
a patient's FEV1 must increase by a minimum of what percentage?,12%
A patient has the lung volume results below:
VC 3600 mL
FRC 6000 mL
ERV 1000 mL
8600 ml (FRC+VC)-ERV)
Which condition results in an abnormal elevation of the left hemidiaphragm?
left lower lobe atelectasis
While the patient is breathing normally a respiratory therapist measures the volume of 1 exhalation. What is the therapist measuring?
tidal volume
A patient has Guillain-Barre syndrome. Which results of bedside pulmonary function testing most strongly indicates the need for ventilatory assistance?
Vital capacity equal to the tidal volume
With an FiO2 of 0.70
a 27-week gestational age neonate who weighs 950 g has the following umbilical artery blood gas results:
pH - 7.38
PaCO2 - 42
PaO2 - 38
HCO3- 24 mEq/L
BE - -2 mEq/L

A physician has decided to intubate the infant. What should the therapist recommend to continuously monitor the infant's oxygenation?,pulse oximetry
What is the best index of oxygen transport for a patient who has been resuscitated after carbon monoxide poisoning?
Arterial oxygen content
A RT needs to place a cap on the end of a patient's fenestrated tracheostomy tube so that the patient can breathe through her upper airway and speak. Before applying the cap to the tube what does the RT need to do?
Remove the inner cannula and deflate the cuff
A RT is checking a jet nebulizer with an entrainment setting of 35%. A properly calibrated oxygen analyzer measures the concentration at 45%. What explains this finding?
Water in the tubing
A physician has ordered an FiO2 of 0.40 by oxyhood and blender for an infant. When analyzing the oxygen concentration
a RT notes the FiO2 is 0.30, and the flowmeter is set at 10 L/min. The nebulizer's entrainment port is set at 50% and the blender is set at an FiO2 of 0.40. What does the RT need to do to correct the problem?,Set the nebulizer's entrainment port to 100%
After 30 minutes of oxygen delivery by nasal cannula at 6 L/min
a patient with sever fibrotic lung disease has a PaO2 of 45 torr. What should the RT recommend?,A non-rebreathing mask
A 2-year-old child is receiving oxygen by an aerosol tent. the RT is unable to maintain a consistent FiO2 inside the canopy. What should the therapy do?
increase the oxygen flow
The aerosol from an ultrasonic nebulizer is being produced in short
rapid puffs. What does the RT need to do to correct the problem?,Clear the water from the delivery tube
A pt with severe COPD is receiving O2 by nasal cannula at 4 L/min. The pt is lethargic and his respirations are shallow at a rate of 20/min. The pulse oximeter is reading 94%. What should a RT recommend?
Change to a 28% air-entrainment mask
An infant in a oxyhood is receiving 24% oxygen by a large volume nebulizer at a flow of 10 L/min. The infant is restless. The SpO2 is 97%. To calm the infant what should the RT do?
replace the nebulizer with a blender
A patient with hepatitis coughs into a spirometer. What process should be used to disinfect the non-disposable mouthpiece before it is used again?
pasteurization
Quality control results using a 3.0 L calibration syringe spirometer are as follows:

Volume 1- 2.67 L
Volume 2 - 2.70 L
Volume 3 - 2.68 L

According to ATS Standards
the spirometer is considered what?,is inaccurate
A RT is calibrating a helium analyzer. What should the analyzer read when calibrated with air?
0%
A 201-kg (442-lb) pt who underwent a gastric bypass and tracheotomy 2 weeks ago remains in the ICU receiving volume-controlled ventilation. After the patient is rolled to the supine position
the ventilator high-pressure alarm sounds with each breath. The suction catheter can be passed only 10 cm into the tracheostomy tube and no secretions are evident. What should the RT do?,Reposition the tracheostomy tube into the trachea.
Which of the following should be used to provide adequate humidity for a spontaneously breathing patient with a tracheostomy tube?

1 air-entrainment nebulizer
2 spinning disk nebulizer
3 heated wick humidifier
4 heat moisture exchanger
air-entrainment nebulizer
heated wick humidifier
heat moisture exchanger
During a routine ventilator check
a respiratory therapist measures endtracheal tube cuff pressure at 45 mm Hg. Air passes around the cuff at peak airway pressure. What is the therapists most appropriate action?,Recommend changing the endotracheal tube
A patient has been intubated for 4 days. When suctioning
a RT notices that the secretions are becoming tenacious. What is the best solution?,Ensure proximal airway temperature is 35 degrees C
A patient receiving a nebulizer treatment with 3% saline complains of shortness of breath. What should a RT do?
Discontinue therapy and notify the physician
When should tracheal suctioning be terminated?
bradycardia
What of the following provides the best clinical evaluation of the effects of incentive spirometry?

A. arterial blood gas analysis after treatment.
B. Peak flow before and after treatment.
C. Auscultation of the chest before and after treatment.
D FEV1 measurement before and after treatment
Auscultation of the chest before and after treatment
A RT decreases the inspiratory flow during volume-controlled ventilation. If the patient's total rate does not change which of the following will decrease?

A. tidal volume
B. end-expiratory pressure
C. expiratory time
D. mean airway pressure
C. expiratory time
A 65-year old male with a history of COPD is brought to the emergency department because of respiratory distress. The patient is receiving oxygen by a simple mask at 5 L/min. A respiratory therapist notes the patient has shallow breathing and is difficult to arouse. Which of the following should the RT do?

A. Initiate pulse oximetry
B. Request a chest radiograph
C. Intubate and initiate mechanical ventilation
D. Perform an arterial blood gas analysis
Perform an arterial blood gas analysis
A 26-year-old patient is receiving volume ventilation due to status asthmaticus. Current ventilatory settings yield with an I:E of 1:2 and a PaCO2 of 51 torr. Which of the following should a respiratory therapist decrease?
Inspiratory time
An adult patient with intermittent needs for bilevel ventilation has a 4.0 mm ID single cannula tracheostomy tube. Which of the following is true?

A. The tracheostomy cuff should be fully inflated to allow speech
B. The tracheostomy cuff should be fully inflated during bilevel ventilation.
C. the inner cannula should be removed during speech.
D. The inner cannula should be inserted for bilevel ventilation.
The tracheostomy cuff should be fully inflated during bilevel ventilation
An attending physician writes an order for the administration of 80%/20% heliox to a patient with airways obstruction. What piece of equipment should a RT use to administer the therapy?
nonrebreathing mask
A patient is receiving noninvasive positive pressure ventilation. Pulmonary compliance has increased over the past 4 hours. To maintain the patient's tidal volume
is would be appropriate to do what?,decrease the IPAP
A patient with dyspnea is breathing 60% oxygen through a T-piece and reservoir system. A heated air-entrainment nebulizer is connected to a flowmeter set at 12 L/min. The aerosol mist disappears from the reservoir outlet during each inspiration. What should a RT do?
Add a second nebulizer
An adult patient who is being mechanically ventilated has high airways resistance to inspiratory flow. What could be implemented to improve the distribution of ventilation?
inspiratory plateau
A patient receiving receiving beta-adrenergic aerosol therapy is taking slow
deep breaths with a pause at the end of each inspiration. Five minutes into the treatment, the patient complains of lightheadedness, dizziness, and tingling in the fingers. What should a respiratory therapist do?,Have the patient pause every 1-2 minutes during treatment
A patient with known reversible airway disease administers two puffs from his MDI. After the treatment a RT measures the patient's peak flow and notices that it has only increased marginally from pre-administration. A RT should do what?
Add a spacer to the MDI
What drug could be recommended to reduce systemic arterial blood pressure and reduce ventricular preload?
Sodium nitroprusside (Nipride)
A patient demonstrates refractory hypoxemia while receiving oxygen by a non-rebreathing mask. What should a respiratory therapist recommend to improve arterial oxygenation?
CPAP therapy
What is changed when a pat is on PV?
Change the set pressure increased or decreased to adjust Vt
What equation is used to reduce PaCo2 on a pat vented with VC ventilation when the rate is needing to be changed due to volume being high enough?
Desired F= known F X PaCo2/desired PaCo2
What is the equation to find desired Vt in VC ventilation?
Desired Vt= known Paco2 X Known Vt/desired PaCo2
What is increased to increase Vt with a PVC time cycled ventilation?
With pressure control ventilation PCV the set pressure is generally increased to obtain the targeted Vt. PCV is Time cycled If It is short increasing it will increase volume delivery without increasing pressure.
What do you change if Vt and pressure plateu are already high to improve PaCo2?
frequancy
What will need to be changed on a ventilated pat on VC and PV to decrease the PaCo2?
minute volume Ve
What are the causes of respiratory acidosis in a nonventilated patient?
pulmonary edema
pneumonia
asthma
chest wall abnormalities
neuromuscular disorders
central nervous system problems
What two values are effected if patient has respiratory acidosis and Va is not adequante on volume ventilation and pressure ventilation?
PaCo2 elevated above >45mmhg and pH decreased <7.35
What two things can be adusted when a patient is on PCV with respiratory acidosis?
Inspiratory time set pressure reaches alveolar level if this doesnt work set pressure increased to improve volume
What change in ventilation is made to ventilator to correct respiratory alkalosis or acidosis?
Vt or rate
What change is made right away when a patient is on mechanical ventilatio?
minute volume Ve
What should a therapist do if the heart rate increased during suctioning?
immediately stop suctioning and provide 100% O2
For above the cuff suctioning
what pressure is left on to continuously suction?,20mmHg
What is the correct size of catheter used to suction?
1/2 the size of the ET tube. equation for a size 8 ET tube 3x8=24 24/2=12Fr Size 12Fr is used
A patient with CHF has what type of secretions?
Thin white or pink frothy secreations but won't block the airway
What is the normal ratio of Vd to Vt (Vd/Vt)?
0.2 to 0.4
Where does the contraction start of the ventricle?
Starts at Q
What is pip?
Peak inspiratory pressure, this is the peak at which the flow is given at an inspiration
What is SpO2?`
Saturation of O2 on the Hb
What is an HME?
artificial nose humidity, filter,warms
What is slope (aka rise)?
Inspiratory rise time, it slows or speeds the rate at which pressure and flow exit the ventilator for a specific period of time
What is trigger?
The sensativity set too low can also cause auto peep
What is FIO2?
% of O2 to improve Oxygenation. A way to measure O2 to the tissues. Check ABG's to keep PaO2 ath 60-90mmHg below 0.4 to 0.5
What is minimal occluding volume?
volume of air measured to seal the cuff at 1 to 2%
What is minimal leak?
It allows a small amount of air to leak out of cuff
How do we check for the level of consciouness?
wake up the patient (if arousable) check for alertness, sleep, etc.
How does CPAP effect a patient on a ventilator?
It provides FiO2, inspiratory flow, peep, inflates alveoli
How is peep used to detect level of optimal peep?
static compliance, prevents atelectasis
What is plateau pressure
measures pressures needed to keep lungs extended less or equal to 35cmH2O
What wave does ventricular repolarization start?
T wave
What level is PIP set to on an alarm?
10cmH2O above and below
What is Ve set to on an alarm?
low Ve= 10% below
highVe= 10% above
What is the equation for MAP?
(PIPxIt) + (peepx Et)/total seconds
What is VC?
IRV, Vt, ERV
What is IC?
IRV, Vt
What is TLC?
IRV, Vt, ERV, RV
What is FRC?
ERV, RV
What is predicted FVC
FEV1, FEV1% for a restrictive patient?,<80% predicted FVC, normal or <80% predicted FEV1, > or equal to predicted FEV1%
What is predicted FVC
FEV1, FEV1% for obstructive patient?,normal or <80% predicted FVC, <80% predicted FEV1, <predicted FEV1%
What is a patients trigger
target and cycle? VC,trigger=time, target=flow, cycle=volume
What is a patients trigger
target, and cycle? VA,trigger=effort, target=flow, cycle=volume
What is a patients trigger
target, and cycle? PC,trigger=time, target=ins, cycle=time
What is a patients trigger
target, and cycle? PS,trigger=effort, target=ins, cycle=flow
What is a ptients trigger
target, and cycle? spontaneous,trigger=effort, target=ins, cycle=effort
What is one cuase of increased dead space?
pulmonary embolism or low cardiac output resulting in low pulmonary perfusion
What is the ABG values with mexed acid bases?
pH increased, PaCo2 increased, PaO2 increased, HcO3 increased
What are the two sure signs of metabolic acidosis on and ABG?
pH 7.45 to 7.70 and bicarbonate 26 to 48
What are the causes of metabolic acidosis
ketoacidosis
uremic acidosis (renal failure)
diarrhea
toxins ingested
What is decreased on VC when patient is breathing spontaneously?
switch ventilator to SIMV mode
or PS
could possibly sedate but a last resort if patient is anxious
On a PV what should be decreased to improve ventilation?
frequancy, and set the pressure second
To correct respiratory alkalosis in a vented patient
what should be decreased to correct ventilation on a VV vented patient?,frequancy first then Vt
What are the causes of respiratory alkalosis?
hypoxia with compensated hyperventilation
pneumonia
pulmonary edema
medications
mechanical ventilation
central nervous system disorders
anxiety
metabolicd problems