109: U5: Critical Resp Problems

Question 1

Pulmonary Embolus Definition

Answer 1

Obstruction of blood flow in part of the pulmonary vascular system by an embolus.

Question 2

Pulmonary Embolus Pathophys

Answer 2

Clot (DVT) breaks loose -> thru vena cave and right side of heart -> lodges in smaller vessel off pulmonary artery -> platelets collect -> serotonin and thromboxane A2 released -> vasoconstriction and pulmonary HTN -> impaired ventilation & perfusion -> hypoxia -> possible death.

Question 3

Pulmonary Embolus Etiology

Answer 3

Immobilization - long term
Surgery, fractures
Obesity
Advancing age
Hypercoagulability
H/O thromboembolism
Smoking, pregnancy, estrogen tx, CHF, CVA
CA, tumor cells
Fat, oil, air
Amniotic fluid
Foreign objects, injected particles

Question 4

Pulmonary Embolus Common S/S

Answer 4

Dyspnea and mild to moderate hypoxemia with low PaCo2.. Symptoms may begin slowly or suddenly.

Question 5

Pulmonary Embolus Other S/S

Answer 5

Cough
Pleuritic chest pain
Hemoptysis
Crackles
Fever
Loud pulmonic heart sound
Sudden change in mental status (secondary to hypoxemia)

Question 6

Pulmonary Embolus Medium Sized Emboli

Answer 6

Pleuritic chest pain
Dyspnea
Slight fever
Productive cough for blood streaked sputum
Tachycardia

Question 7

Pulmonary Embolus Massive Emboli

Answer 7

Abrupt hypotension
Pallor
Severe dyspnea
Hypoxemia
Chest pain

Question 8

Pulmonary Embolus Dx

Answer 8

VQ Scan (Ventilation-Perfusion)
Pulmonary angiography MRI
Spiral CT
D-Dimer
ABG
Venous Doppler

Question 9

Pulmonary Embolus Tx

Answer 9

Prevention!
Oxygen
Anticoagulation (Heparin, Coumadin, Lovenox)
Thrombolytics
Embolectomy
Vena Cava filter
Mechanical Ventilation

Question 10

Pulmonary Embolus PCs

Answer 10

Hypoxemia
Pulmonary Infarction
Acute Cor Pulmonale
Death

Question 11

Chest Trauma/Pneumothorax Definition

Answer 11

Accumulation of atmospheric air in the pleural space.

Question 12

Chest Trauma/Pneumothorax Pathophys

Answer 12

Injury -> atmospheric air in pleural space -> increased intrathroacic pressure and decreased vital capacity -> lung collapses

Question 13

Chest Trauma/Pneumothorax Etiology

Answer 13

Open-air enters pleural space through opening in chest wall - stabs, GSW, surgery.
Closed - no association with external wound. Bleb rupture, ventilation, central line, broken ribs.
Ruptured bleb d/t COPD, CF or smoking (chronic inflammation damages lung lining).

Question 14

Chest Trauma/Pneumothorax S/S

Answer 14

If small - Increased HR and dyspnea
Decreased breath sounds on affected side
Hyperresonance
Prominence of involved side, which moves poorly with respirations
Pleuritic pain
Tachypnea
Crepitus (SubQ Emphysema)
Cough
Dyspnea, air hunger, decreased O2 sats

Question 15

Chest Trauma/Pneumothorax Tension Pneumo S/S

Answer 15

Rapid accumulation of air with tension on heart and blood vessels, lung collapses with mediastinal and tracheal shift. Decreased cardiac output.

Question 16

Chest Trauma/Pneumothorax Dx

Answer 16

CXR - air on affected side

Question 17

Chest Trauma/Pneumothorax Tx

Answer 17

Chest tubes

Heimlich valves

Question 18

Chest Trauma/Pneumothorax Tension Pneumo Tx

Answer 18

Large bore needle to release trapped air

Question 19

Chest Trauma/Pneumothorax PCs

Answer 19

Hypoxemia

Question 20

Hypoxemic Respiratory Failure Definition

Answer 20

Oxygenation failure.

Not a disease - occurs secondary to something else.

Question 21

Hypoxemic Respiratory Failure Pathophys

Answer 21

Thoracic pressure changes are normal, lungs can move air sufficiently but cannot oxygenate the pulmonary blood properly.
Inadequate O2 transfer between alveoli and pulmonary capillary bed.
PaO2 60%

Question 22

Hypoxemic Respiratory Failure Etiologies

Answer 22

VQ mismatch
Secretions in alveoli
Bronchospasm
Alveolar collapse
Mucus plug in bronchioles
Clot in pulmonary capillary
Thickened alveolar-capillary membrane
Restrictive lung disease
Toxic inhalation
Pneumonia
Shock
Low atmospheric oxygen

Question 23

Hypoxemic Respiratory Failure S/S

Answer 23

Tachypnea
Restlessness, confusion, agitation, combativeness
Prolonged expiration
Nasal flaring
Retractions
Use of accessory muscles
Paradoxic chest or abdominal wall movement
Decreased SpO2 (<80%)
Unable to speak full sentences without pausing to breathe
Cyanosis (late)

Question 24

Hypercapnic Resp Failure Definition

Answer 24

Ventilatory Failure

Not a disease, it occurs secondary to something else.

Question 25

Hypercapnic Resp Failure Pathophys

Answer 25

Thoracic pressures can't be changed sufficiently to permit adequate air movement in and out of lungs -> insufficient O2 to alveoli and increased CO2 PaCO2 >48mmHg with pH <7.35

Question 26

Hypercapnic Resp Failure Etiologies

Answer 26

``` Air trapping with asthma, COPD, CF CNS: suppressed drive to breathe, defect in respiratory control center in brain Impaired function of respiratory muscles Chest wall abnormalities Neuromuscular conditions ```

Question 27

Hypercapnic Resp Failure S/S

Answer 27

``` Low RR or High & shallow RR Morning headache Muscle weakness Decreased DTR's Pursed lip breathing Tripod position Progressive somnolence ```

Question 28

S/S to BOTH Hypoxemic & Hypercapnic Resp Failure

Answer 28

``` Dyspnea Disorientation HTN Tachycardia Coma (late) ```

Question 29

Hypoxemic & Hypercapnic Resp Failure Interventions

Answer 29

``` Treat underlying cause! O2 to correct hypoxemia: use lowest concentration possible to maintain PaO2 90% Positioning: side lying (good side down), Elevate HOB 45 degrees. Ventilation: PPV (positive pressure ventilation; CPAP (continuous positive airway pressure); BiPAP (Bilevel positive airway pressure, higher inspiratory, lower expiratory); ETT with mechanical vent Chest PT Suctioning Cough/Deep breathe Hydration and Humidification Pulmonary meds Maintain cardiac output Maintain Hg Energy conservation Nutrition Monitor for complications ```

Question 30

Hypoxemic & Hypercapnic Resp Failure PCs

Answer 30

Hypoxia O2 toxicity (in intubated patients, increased O2 for >48 hours) Respiratory arrest Death