18 CEN: respiratory

Question 1

What are Kussmaul respirations? What condition causes it?

Answer 1

Rapid and deep breathing from DKA

Question 2

What is the difference b/w dyspnea and orthopnea?

Answer 2

dyspnea is labored breathing, orthopnea is when it occurs laying down

Question 3

What is stridor and what can cause it?

Answer 3

Upper airway obstruction

→croup LTB, epiglottitis, anaphylaxis

Question 4

Where does wheezing occur? Causes?

Answer 4

Lower airway bronchial obstruction

→asthma, bronchiolitis

Question 5

Why does NIPPV require the pt to be alert and hemodynamically stable?

Answer 5

Using CPAP and BiPAP decreases venous return to the heart.

Pt needs to be alert and able to swallow d/t aspiration risk.

Question 6

What drugs are used in drug-assisted intubtion (DAI)?

Answer 6

→Succinylcholine: neuromuscular blocker

→Fentanyl: may cause chest wall rigidity

→Etomidate: short acting, doesn’t affect BP (so it’s a good choice for Trauma!)

→Propofol: lowers MAP

→Ketamine: increases secretions

Question 7

When is succinylcholine contraindicated?

Answer 7

As a neuromuscular blocker, it should not be given to pts w/ Hx of malignant hyperthermia, conditions that precipitate hyperkalemia (burns, CRUSH INJURIES, renal failure), neuromuscular disorders like Guillain Barre, MS, myasthenia gravis.

Question 8

How is ETT placement confirmed?

Answer 8

Auscultate epigastric first, then four lung fields, pulse ox, ETCO2, CXR

Question 9

If a pt decompensates in mechanical ventialtion, what should the RN do?

Answer 9

manually ventilate.

DOPES:
Displaced? -
Obstruction?
Pneumothorax?
Equipment issue?
Stacked breaths?

Question 10

Interpret ABGs.

Answer 10

1. Look at pH
   →if outside 7.35-7.45, uncompensated.
   →if in range, normal or compensated
2. Look at pH
   →acidic or alkalosis
3. Look at CO2
   →if pH and CO2 are opposite directions it is a respiratory issue (pH <7.35, CO2 >45 Resp acidosis) OR
   (pH >7.45, CO2 <35 Resp alkalosis)
4. Look at HCO3
   →if pH and HCO3 are in equal direction it is a metabolic issue
   →pH <7.35, HCO3 <22 Metabolic acidosis
   →pH >7.45, HCO3 >26 Metabolic alkalosis

Question 11

Causes of metabolic acidosis?

Answer 11

-DKA, SHOCK
-alcoholic acidosis (high anion gap from ethylene glycol poisoning),
-renal disease
-diarrhea
-salicylate poisoning (vomiting, tinnitus, confusion, hyperthermia, respiratory alkalosis, metabolic acidosis, and multiple organ failure)

Question 12

When is risk for aspiration highest? How should the HOB be?

Answer 12

Obese, HEAD INJURY, intoxication, advanced pregnancy

HOB 30-45°

Question 13

What is asthma?

Answer 13

CHRONIC reactive airway dz → airway hyper reactivity, inflammation, and bronchial constriction

Triggered by environmental factors like exercise, allergies, and seasonal changes

Question 14

S/S of asthma?

Answer 14

chest tightness, dyspnea, TACHYPNEA, ↓ SpO2, ↑ WOB, cough, PROLONGED EXPIRATORY TIME, repiratory alkalosis to acidosis, WHEEZING EARLY TO SILENT CHEST.

Question 15

What are the ominous signs of asthma?

Answer 15

1. pulsus paradoxus (an exaggerated fall in a patient’s blood pressure during inspiration by greater than 10 mmHg)
2. silent chest

Question 16

Which medications tx asthma?

Answer 16

1. Albuterol (short-acting beta agonist) q20min x3- to relax smooth muscles (s/e tachycardia)
2. Anticholinergics (Ipratropium) -to limit secretions of mucus and inhibit bronchial muscle contraction
3. Corticosteroids- inhaled or oral to reduce inflammation
4. Magnesium- inhibit bronchial muscle contraction

–Tx effective if ↑ in peak flow

Question 17

Pt education for asthma.

Answer 17

Use spader or nebulizers to ↑ medication delivery, avoid allergens and NSAIDS, pretreat with meds before exercise, stop smoking

Question 18

If an asthmatic needs to be intubated, which is best induction agent?

Answer 18

Ketamine b/c it is a bronchdilator.

Question 19

What should inspiration:expiration (I:E ratio) be on the vent for asthmatic?

Answer 19

increase from 1:2 to 1:3-4

Question 20

What is emphysema? S/S?

Answer 20

COPD- (Decreased lung capacity)
-Destruction of alveoli from toxins or alpha-1 antitrypsin deficiency

S/S: “pink puffer” (pink face from short, fast breaths), thin body, BARREL CHEST (A:P diameter larger), pursed-lip breathing, lung over inflation and low diaphragm on XR

Question 21

What is chronic bronchitis? S/S?

Answer 21

COPD- (Decreased lung capacity)
-hacking cough with sputum production for at least 3 mo during 2 consecutive years

S/S: PURSED LIP BREATHING, ↑ WOB, “Blue bloater” (d/t ↓ O2), stocky build, polycythemia (thicker blood and ↑ Hgb leads to clots), Cor pulmonale (pulmonary HTN), enlarged heart on XR, rhonchi, and wheezes

Question 22

How are COPD conditions treated?

Answer 22

1. oxygen via NC or venturi mask (goal 88-92%, reduce O2 if RR ↓ )
2. BiPAP
3. bronchodilators
4. Sit on edge of bed leaning forward with feet dangling

Pt should sleep upright, and get PNA immz

Question 23

What does pulmonary HTN cause?

Answer 23

Cor pulmonale - Right sided HF d/t enlarged RV
→HF d/t lung condition

Question 24

What are S/S of pulmonary HTN? Treatment?

Answer 24

S/S: exertional dyspnea and fatigue, peripheral edema, hepatomegaly

Tx: oxygen, vasodilators like phosphodiesterase inhibitors (sildenafil or tadalafil), diuretics, anticoagulants, and DIGOXIN TO ↑ CONTRACTILITY

Question 25

How is pulmonary HTN diagnosed?

Answer 25

ECHO: RV hypertrophy
ECG: RBBB

Question 26

What is acute bronchitis?
S/S? Dx? Tx?

Answer 26

Acute bronchitis - Viral inflammation due to Influenza A or B, RSV, etc.

S/S: Non-productive DRY COUGH FOR > 5 days and worse at night, airway hyper reactivity, pleuritic chest pain, sore throat, stuffy nose, fatigue, low-grade fever.

DX: Chest x-ray to rule out pneumonia.

TX: Cough medication, bronchodilators, corticosteroids, NO ANTIBIOTICS needed.

Question 27

What is Bronchiolitis?
S/S? Dx? Tx?

Answer 27

Viral infection, usually RSV in premature infants, producing COPIOUS NASAL SECRETIONS (rhinitis)

“S/S: Respiratory distress, WHEEZING, CRACKLES, grunting, poor feeding.

DX: Nasopharyngeal culture to rule out influenza and chest x-ray.

TX: SUCTION NARES, bronchodilators, admission if RR > 70 breaths/min.

D/C education: Teach hand hygiene to reduce spread of RSV since most spread through direct contact.

Question 28

What is Epiglottitis?
S/S? Dx? Tx?

Answer 28

Epiglottitis - bacterial infection decreased since HIB vaccine.

• S/S: Triad of Drooling, Dysphagia, and Distress; ABRUPT ONSET OF HIGH FEVER; tripod position; “turtle sign” (extend neck) to open airway. HOT POTATO VOICE

dX: thumbprint sign on lateral neck x-ray;

• TX: Keep in caregiver’s arms and KEEP CHILD CALM (no IV or labs) and consult expert to secure airway STAT. →→”If they cry, they die.”

Question 29

What is Croup LTB? Age group?
S/S? Dx? Tx?

Answer 29

croup (Acute Laryngotracheobronchitis - LTB) - viral infection 6 months - 3 years

S/S: Gradual onset of URI; barky, seal-like cough; low-grade fever;
Dx: steeple sign on chest x-ray.
TX: Racemic nebulized epinephrine (wears off leaving rebound effect, so consider hospital admission), and dexamethasone.

Question 30

What is Pneumonia?
S/S? Dx? Tx?

Answer 30

Pneumonia - Viral or bacterial (faster onset) infection; community or hospital-acquired

S/S: Fever, chills, malaise, pleuritic CP, productive cough, egophony, increased fremitus (vibration) over the affected area with decreased breath sounds.

DX: Increased WBC, chest x-ray, blood cultures.

TX: Antibiotics, bronchodilators, oxygen, and fluids as indicated, pneumococcal vaccine recommended for under age 2 and above age 65.

Pleural effusion - same S/S. Thoracentesis to remove purulent empyema.

Question 31

S/S of Pleural effusion? Tx?

Answer 31

Pleural effusion - same S/S as PNA
S/S: Fever, chills, malaise, pleuritic CP, productive cough, egophony, increased fremitus (vibration) over the affected area with decreased breath sounds.

Thoracentesis to remove purulent empyema.

Question 32

When is intubation necessary immediately with inhalation injuries?

Answer 32

if oral burns, stridor, and/or carbonaceous sputum. 

Question 33

Why is SpO2 not reliable if pt has inhalation injury from smoke?

Answer 33

Combustible fumes from malfunctioning furnace, exhaust, etc. - CO poisoning - shifts the oxyhemoglobin dissociation curve to the left, impairing the ability of hemoglobin to release 02, so SpO, is 100% (unreliable); arterial PaO, reliable.

Question 34

Inhalation injuries. S/S? Dx? Tx?

Answer 34

S/S: headache, confusion, nausea/vomiting, cherry-red skin, ST segment depression on ECG due to hypoxia.

DX: Carboxyhemoglobin (COHb) level and airway evaluation.

TX: 100% oxygen until carboxyhemoglobin < 10%, Hyperbaric oxygenation (HBO) for pregnant female since fetus most vulnerable.
→Perform escharotomy if circumferential chest burn, and unable to ventilate.

Question 35

For what populations does Spontaneous Pneumothorax typically occur?

Answer 35

Spontaneous Pneumothorax - most common in males 20-40, COPD, pulmonary fibrosis, smokers, Marfan’s.

Question 36

Spontaneous Pneumothorax S/S? Tx?

Answer 36

S/S: dyspnea, decreased or absent breath sounds on affected side, pleuritic chest pain, hyperresonance on percussion, subcutaneous emphysema if large pneumothorax.

TX: High-fowler position, supplemental oxygen, potential chest tube placement at 5-6th ICS, mid-axillary line (> 15% pneumothorax typically).

Question 37

What are causes of Non-cardiogenic Pulmonary Edema/Acute Respiratory Distress Syndrome (ARDS)?

Answer 37

1. Causes: submersion injury, rapid ascent while scuba diving, HAPE (high altitude pulmonary edema), inhalation of toxic gases, heroin overdose.

Question 38

What are S/S of Non-cardiogenic Pulmonary Edema/Acute Respiratory Distress Syndrome (ARDS)?

Answer 38

S/S: severe dyspnea, tachypnea, cough, crackles, wheezing, PINK FROTHY SPUTUM, skin cool pale and

TX: NIPPV or intubation/ ventilation with LOW TIDAL VOLUMES (6 ml/kg due to sick lungs) and add PEEP to decrease chance of ARDS, IV NTG, diuretics.

Question 39

What is Acute Respiratory Distress Syndrome (ARDS) and what is the Tx?

Answer 39

ARDS (acute respiratory distress syndrome) - severe hypoxemia that is refractory to high concentrations of oxygen, and loss of surfactant.

TX: Mechanical ventilation and prone positioning.

Question 40

How can a pulmonary embolus occur?

Answer 40

1. Blood clot from DVT (Risk factors - Virchow triad of immobility, damage, or hypercoagulopathy),
2. air emboli from diving, or
3. amniotic fluid emboli.

Question 41

When do fat emboli typically present? Hallmark sign?

Answer 41

Fat emboli typically seen 12-48 hours post long-bone fracture

“hallmark sign” is chest and axilla petechiae, sudden onset of altered mental status, and hypoxia.


Question 42

What is Dx and Tx for PE?

Answer 42

DX: elevated D-dimer; new RBBB and right axis deviation, peaked P waves and cressed I waves on ECCa scan,
***pulmonary angiography definitive test,
ABG - low PaO, and low CO, - respiratory alkalosis and hypoxemia.

TX: Oxygen is the priority, anticoagulants and/or fibrinolytics (r-TPA) as indicated, embolectomy.

Question 43

What are conditions post chest trauma?

Answer 43

Rib fractures
Pulmonary contusion
Flail chest

Question 44

If there is an Impaled object like knife or ice pick, what should you do?

Answer 44

LEAVE IT IN PLACE

Question 45

What are 1st or 2nd rib fractures associated with?

Answer 45

great vessel (aortic dissection - widened mediastinum and obscured aortic knob on chest x-ray) and/or pneumothorax.

Question 46

Which ribs are most often fractured? What is risk?

Answer 46

4th to 9th ribs most often fractured -

risk is pulmonary contusion and blunt chest injury, so decrease IVF rate.

Question 47

What are 9th to 12th rib fractures associated with?

Answer 47

spleen (L) and liver (R) injury,
renal injury if posterior.

Question 48

Rib fractures in Peds vs Geriatrics?

Answer 48

Rib fractures demonstrate significant injury in pediatrics (pliable ribs) so suspect maltreatment and in geriatrics due to lack of pulmonary reserves.

Question 49

What is the Tx for rib fractures?

Answer 49

Pain management with NSAIDs, lidocaine patches, intercostal nerve blocks.
Aggressive pulmonary care cough and deep breath and incentive spirometry to prevent atelectasis

Question 50

What is pulmonary contusion?
S/S? Dx? Tx?

Answer 50

Lung injury and edema from chest trauma or barotrauma 24-48 hours after event.

S/S: Respiratory distress, chest wall bruising, increased work of breathing, restlessness, crackles, wheezes.

DX: Chest x-ray may not reveal infiltrates until 12 hours or later**

TX: Oxygen is the priority, patient in semi-fowlers position, NIPPV to intubation/mechanical ventilation, judicious use of fluid administration (euvolemia) to prevent ARDS (refractory hypoxemia).

Question 51

What is flail chest and the tx?

Answer 51

→Typically seen in high-speed MVC, sternal fracture from airbag.
→Two or more adjacent ribs fractured in two or more places resulting in a free-floating unstable segment with paradoxical chest wall motion (asymmetry) during respiration, muscle spasm obscures failing initially.

TX: Oxygen, intubation/ventilation with PEEP, prepare for surgery for rib fixation, judicious fluid administration since causes pulmonary contusion, monitor for associated pneumothorax or hemothorax (breath sounds, percussion).

Question 52

What are the S/S of a Simple pneumothorax (Air-leak syndrome)? Tx?

Answer 52

• S/S: Decreased or absent breath sounds on affected side, hyperresonance (tympanic) to percussion, tachypnea, tachycardia.
• TX: High-fowlers position, oxygen, potential small-bore chest tube or catheter placement at 5-6”h ICS, mid-axillary line (ML) for > 20% pneumothorax.

Question 53

What is an Open pneumothorax? Tx?
What if a tension pneumo develops?

Answer 53

Sucking chest wound from penetrating trauma, visible open chest wound with sucking sound and BUBBLING OF BLOOD around wound, with SQ emphysema.
*If impaled object like an ice pick still in chest, stabilize it in place.

TX: Cover wound with 3-SIDED OCCLUSIVE (non-porous) dressing AT END-EXHALATION and prepare for chest tube (ask patient to exhale fully).

***Remove dressing if tension pneumothorax develops (decreasing 02 saturation, tracheal deviation).

Question 54

What is a Tension pneumothorax? Tx?

Answer 54

LIFE-THREATENING pneumothorax with severe respiratory distress, absent or decreased breath sounds, jugular vein distention, hypotension due to impaired venous return to heart, and TRACHEA DEVIATED TO UNAFFECTED SIDE (→late sign along with cyanosis). X-ray shows mediastinal shift.

TX: Immediate needle decompression with 14-16-gauge 7 cc needle at 2nd ICS over 3rd rib (or 4-5th ICS), and immediate chest tube insertion. Treatment is effective if assisted ventilation become easier after decompression.

Question 55

What is a Hemothorax?
S/S? Dx? Tx?

Answer 55

Accumulation of blood in pleural space from tear of internal mammary artery.

S/S: Severe SOB, dullness to percussion, S/S of hemorrhagic shock (tachycardic, delated capillary refill, cool and clammy skin, hypotension).

DX: FAST bedside ultrasound.

TX: Two large-bore IVs, transfuse blood products, large-bore 32-36 Fr chest tube placement at 5-6th ICS, emergent surgery if initial drainage > 1500 ml, or 200 ml/hour over next 2-4 hours.

Consider autotransfusion for blunt injury less than 4-6 hours ago.
Advantages: Fresh, warm, whole blood without risk of transfusion reaction

Contraindicated if lower chest injury (risk of bowel injury) or ruptured diaphragm. Increased risk of contamination with penetrating injury.

Chest drainage system - tape all connections, keep upright below the level of the chest, no dependent loops, tidaling is normal.

Question 56

What occurs with a Ruptured diaphragm?
S/S? Tx?

Answer 56

Abdominal contents herniate into chest and compress the lungs, heart, and vessels, most on the left side from lateral impact MVC, unable to breathe.

S/S: Dyspnea, “gurgling” peristaltic sounds in lower left chest with progressive scaphoid abdomen (sunken in), abdominal pain radiating to left shoulder (KEHR’S SIGN), elevated left diaphragm on chest x-ray.

TX: ABC’s, prepare to intubate, emergent exploratory laparotomy.

Question 57

What is a Tracheobronchial Injury?
S/S? Tx?

Answer 57

Direct blow to neck (karate blows) or all-terrain vehicle (ATV) or snowmobile driver into suspended cable “clothesline injury”.

S/S: Dyspnea, dysphagia (difficulty swallowing), odynophagia (painful swallowing), SQ emphysema, Hamman’s crunch synchronized with heartbeat, anterior neck pain, hemoptysis, hematoma.
-Fractured Larynx - dysphonia (hoarse voice), seen with tracheobronchial injury.
-Esophageal injury - food particles in chest tube, seen with tracheobronchial injury.

TX: Increase head of bed 30-45 degrees, fiberoptic bronchoscopy for intubation and prepare for surgery, positive pressure ventilation may worsen subcutaneous air.