2-1: Respiratory Flashcards by Emily Tyner

Which nerve innervates the diaphragm and where does it originate?

the phrenic nerve, originating at C3-C5

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What are factors that can affect oxygen’s affinity for hemoglobin?

oxygen levels
carbon dioxide levels
temp
2, 3 - DPG
pH

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What does 2, 3 - DPG do to the oxygen?

it encourages it to offload from the hemoglobin

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What does a left shift in the ODC mean for oxygen delivery?

hgb holds tighter to oxygen and there is less oxygen released to the tissues

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What does a right shift in the ODC mean for oxygen delivery?

hgb releases oxygen easier resulting in more oxygen released to the tissues

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What is the V/Q ratio and what does a V/Q mismatch most commonly cause?

the balance between ventilation in the lungs and perfusion in the body
mismatch is the most common cause of respiratory failure

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What does a low V/Q look like?

poor ventilation
there is adequate blood flow, but the alveoli aren’t inflated to capacity to exchange gas

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What does a high V/Q look like?

good ventilation
poor blood flow to alveoli makes them less able to get rid of what they need to get rid of

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What is FiO2?

the concentration of oxygen in the gas mixture

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What is PEEP?

Positive end-expiratory pressure (PEEP) is the alveolar pressure above atmospheric pressure that exists at the end of expiration. There are two types of PEEP:

●Extrinsic PEEP – PEEP that is provided by a mechanical ventilator is referred to as applied PEEP

●Intrinsic PEEP – PEEP that is secondary to incomplete expiration is referred to as intrinsic PEEP or auto-PEEP

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What is the normal tidal volume for an adult?

400-500 mL

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What are the indications for using oxygen?

saturation of <92%
known or expected anemia (trauma, GI bleed)
altitude sickness
paraquat/diquat, CO, or cyanide
abruptio placenta or prolapsed cord

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What is COPD

a condition which results in a decreased forced expiratory volume per second

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COPD - Chronic Emphysema
what happens physiologically and what can happen?

permanent enlargement of the air spaces that are distal to the terminal bronchioles
- destruction of the alveolar walls
- partial collapse of terminal
  bronchioles
- loss of elastic recoil of the lungs

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What are some abnormalities associated with emphysema?

increased air trapping
loss of recoil
loss of alveolar surface area due to alveolar and capillary destruction
bullae formation
increased dead space
increased work of breathing

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What might you hear upon auscultation of a pt with emphysema?

distant, diminished breath sounds and diffuse wheezing

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What will the radiograph of a pt with emphysema show?

flattened, low diaphragm
hyperlucent lung fields
wide intercostal spaces
long, narrow heart shadow

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What is the clinical definition of chronic bronchitis?

the presence of a productive cough for three months out of the year for two years in a row.

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What is the pathophysiology of chronic bronchitis?

chronic irritation results in hyperplasia of the tracheobronchial mucus glands and goblet cells
this results in an increase in mucus production

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What will you hear when listening to the chest of someone with chronic bronchitis?

course crackles, wheezing over smaller airways, ronchi over larger airways

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What circumstances will cause hyperglycemia in a pt with chronic bronchitis? What will cause hypoglycemia?

hyperglycemia:
- stress response/elevated cortisol levels
- use of B-agonists/corticosteroids

hypoglycemia:
- increased work
- poor stores

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When should you consider RSI for your COPD patient?

respiratory failure
fatigue
AMS
worsening respiratory acidosis
hypoxemia refractory to supplemental O2 administration

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What are your vent settings for a COPD patient?
TV:
Rate:
Mode:
FiO2:

TV: 5-8 mL/kg
Rate: 12-18/min
Mode: VC or PRVC
FiO2: 1.0 (1.0 means 100% oxygen, 0.8 means 80% oxygen, and so on…)

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How long do corticosteroids such as methylprednisolone take to have effect?

6-8 hours

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what does AMS in the asthma patient indicate?

severe hypoxia and impending respiratory arrest

What might you hear when listening to the lungs of an asthma patient?

diffuse wheezing ronchi may be heard if mucus present "silent chest" ominous finding

Treatment for an asthma patient is similar to that for a COPD patient EXCEPT?

- asthmatics don't require antibiotics - mag sulfate used more in asthma

What is pulmonary arterial hypertension?

the pulmonary arteries have a higher-than-normal pressure, causing an increased workload for the right side of the heart.

What are factors that can cause PAH?

- decreased prostacyclin - increased thromboxane - vasoconstriction ---> thrombosis

less severe PAH patients can be managed with what medications (3)?

calcium channel blockers, endothelin antagonists, and phosphodiesterase inhibitors

More severely ill PAH patients require what kind of therapy? What are some other meds?

prostacyclin therapy flolan veletri (epoprostinol) remodulin (treprostinil) ventavis (Iloprost)

What two things should you NEVER do when transporting a patient with PAH on a med pump?

- NEVER titrate infusion without med control - NEVER flush the IV line in which the med is being administered

What is the second most common cause of sudden unexpected natural death at any age?

pulmonary embolus (second to CAD)

What is a pulmonary embolism?

the occlusion of the pulmonary artery or one of its branches by an embolus carried by the bloodstream.

What type of V/Q mismatch do we see in patients with a PE?

- blood flow decreased to the alveoli - ventilation unaffected

What does a PE do to the RV afterload?

increases it

What are the most common symptoms of a PE?

- dyspnea - pleuritic chest pain - cough - hemoptysis

What is the most important diagnostic tool in the investigation of a pulmonary embolism?

the history

What is the gold standard diagnostic test for identifying a PE?

CT scan or CT angiography

What do the early and late radiographs of a PE show?

early: initially normal late: - atelectasis - westermark sign (pulmonary vessel dilation and a sharp cutoff) - pleural effusion

How do we feel about using ABGs in the setting of a PE?

don't use em, they can be unreliable

What are the most common EKG abnormalities seen with PE?

- sinus tachycardia - non-specific ST changes the ABSENCE of EKG abnormalities doesn't mean anything in the setting of a PE

What can happen if you give fluids to someone with a massive PE?

a drop in BP

What is the priority after securing the airway and ensuring adequate ventilation in someone with a massive PE?

eliminating the clot and preventing further thrombosis

What can cause ARDS?

any condition that produces a systemic inflammatory response: - increased ICP - sepsis (most common) - COVID - prolonged hypotension/shock - and more

Is ARDS an inflammation process or an infection process?

inflammation

How might you describe the lungs in the acute phase of ARDS?

congested and heavy

Which study findings will point towards a clinical diagnosis of ARDS?

gas exchange values and radiograph

Is a radiograph reliable for distinguishing ARDS?

No, don't know if the bilateral infiltrates are from ARDS or cardiogenic pulmonary edema

What happens if the vented ARDS pt is positioned laying supine and why?

the ventral alveoli are over-inflated and the dorsal alveoli are collapsed under the weight of the fluid in the lungs.

Why are vented ARDS patients put in the prone position?

gravity causes the fluid to shift into the ventral aspect of the lungs, which doesn't affect as many of the lung fields more alveoli are recruited

What are the two types of pneumonia?

1. community-acquired 2. hospital-acquired

What are some risk factors associated with aspiration pneumonia?

- stroke with deficits - esophageal motility/swallowing disorders - seizures/syncope - intubation

What are some risk factors associated with bacteremia pneumonia?

indwelling devices: - vascular devices - GI/GU devices - intrathoracic devices

What will auscultation of the pneumonia pt sound like?

crackles, ronchi, diminished breath sounds

The head of the bed should be elevated ____ degrees for pneumonia patients?

What does iatrogenic mean?

illness caused by a medical treatment or procedure

What things might cause a spontaneous and iatrogenic pneumothorax?

- PPV - mechanical ventilation - central line placement - NG tube placement - tracheostomy - bronchoscopy - CPR

What disease is most commonly associated with spontaneous pneumothorax?

COPD

What is the pathophysiology of a pneumothorax

- air in the intrapleural space - there are negative pressures in the intrapleural space and greater pressures in the alveoli - in a pneumo, air moves from the alveoli into the pleural space - as the lung collapses, the pneumo increases

How do young and healthy people usually tolerate a pneumothorax?

"quite well" with mild tachycardia and tachypnea

Which types of patients are at risk for developing a simple pneumothorax?

- mechanically ventilated patients - patients flown at altitude

What diagnostic studies are required for the dx of tension pneumo?

none

what is the immediate treatment of a tension pneumothorax?

needle decompression

What is a tube thoracostomy used for?

removal of abnormal accumulations: - blood - air - fluid

What position should the head of the bed be raised for a stable patient receiving a tube thoracostomy?

30 - 60 degrees

Where is a tube thoracostomy placed when the goal is air removal? what size tube?

2nd intercostal space at the midclavicular line - 16-20 Fr

Where is a tube thoracostomy placed when the goal is fluid removal? What size tube?

4th/5th intercostal space at the midaxillary line - 20-36 Fr

If unsure of the patient's anatomy, it is better to place a thoracostomy tube ______ (high or low). Why?

High too low may result in: - injury to the diaphragm - intra-abdominal placement

what are the contraindications to tube thoracostomy?

none in the unstable trauma patient

What is the valve in a tube thoracostomy called and why is it used?

Heimlich valve - one way valve allows for flow outside of the chest, prevents air from entering the chest

What is the mnemonic for assessing the drainage unit of a chest tube?

FOCAL F- fluctuation (height of fluid level in drainage tube fluctuates with respiration) - Absence of fluctuation indicates that the system is blocked or the lung is fully expanded O- output (assess amount and consistency) C- color A- air leak (if present, repair) L- levels Ensure adequate water levels in the chambers and proper negative pressure levels

What are some ways you can troubleshoot a tube thoracostomy

- look/listen for air leak - make sure all connections are tight - make sure all distal fenestrations of the tube are within the thorax - tape connections where a leak is possible - clamp tube to the chest

What is the difference between anaphylaxis and anaphylactoid

Anaphylaxis is immune-mediated (by Ig-E) and anaphylactoid is a similar reaction but is not immune-mediated

What is a normal inspiration to expiration (I:E) ratio?

1:2 - expiration is 2x as long as inspiration

what is characterized by increased air trapping secondary to bronchiole collapse and loss of recoil and reduction of total alveolar-capillary membrane surface area secondary to alveolar and capillary destruction?

Chronic emphysema

Which disease is characterized by cyanosis and peripheral edema, giving rise to the "blue bloater" phrase?

chronic bronchitis

What are three pathological changes that contribute to airflow obstruction in the asthmatic

- mucous plugging - bronchospasm - airway inflammation and edema

What is the number 1 cause of ARDS?

Sepsis

What skills do prehospital providers do that may result in an iatrogenic pneumothorax?

- CPR - PPV - NG tube placement

What are the s/s of a pneumo in a mechanically vented patient?

- fighting the vent - tachycardia - hypotension - hypoxia - acute increase in the inspiratory and/or static airway pressure - cardiovascular collapse

what methods can be used to confirm chest tube placement?

- drag a finger along length of tube as finger is removed from pleural space - observe condensation in the tube - free flow of blood or fluid - ability to rotate tube freely - pt is improving - auscultation of lung sounds - chest radiograph

Will a vented COPD patient require higher or lower vent rates and why?

lower, to prevent breath stacking

What is the reason for death occurring in a tension pneumothorax?

due to decreased preload leading to decreased cardiac output

What is the typical amount of wall suction required for a chest tube?

20 cmH2O