4.2 - CVP - PPT CVP DDX (Pulmonary Section) Flashcards
Week 4, Tuesday
Describe the muscles of inspiration
Diaphragm
External intercostals (elevates ribs)
SCM (elevates sternum)
Pec Minor (pull ribs outwards)
Describe muscles of expiration
Relaxation of diaphragm
Internal intercostals (pull ribs down)
Abdominals
QL (pulls ribs down)
Describe how each of the following would deviate the trachea
Tension pneumothorax
Pleural effusion
Space-occupying lesion
Pneumectomy
Pleural fibrosis
Atelectasis (collapse of part / all of lung)
Space-occupying lesion -> pushes trachea away
Collapse of lung -> pull trachea towards it
Contralateral:
- Tension pneumothorax
- Pleural effusion
- Space-occupying lesion
Ipsilateral:
- Pneumonectomy
- Pleural fibrosis
- Atelectasis
Describe the normal respiratory rate for adults & children
Adults 12-20
Children 18-30
Newborns 30-60
What is hyperpnea? Hypopnea?
Hyperpnea - increased breathing rate
Hypopnea - decreased breathing rate
Describe a Kussmaul breathing pattern
What causes it?
Occurs in response to acidosis (Diabetic ketoacidosis)
- When hyperglycemia >300 mL
Increased tidal volume -> to expel CO2
Describe Cheyne-Stokes respiration
When does this typically occur?
End of life
Crescendo-decresecndo breathing w/ pauses between these cycles
What are vesicular breath sounds?
Normal breath sounds
“gentle breeze”, “wind in leaves”
Describe the following adventitious breath sounds & potential causes
Crackles (rales)
Wheezes
Rhonchi
Stridor
Crackles (rales) - fluid / air bubbles in the alveoli
- Pulmonary edema, pulmonary fibrosis, infection, CHF
Wheezes - high-pitched wheezing
- Asthma
Rhonchi - continuous, low-pitched; comes from copious secretions; “snoring, gurgling, rumbling” (“snoring rhino”)
- Pneumonia, bronchitis, cystic fibrosis, COPD
Stridor - high-pitched whistling; upper airway blockage / object
- Tracheal stenosis, object obstruction
How does pneumonia often show up on a chest x-ray?
Radioopaque
How many lobes does each lung have?
R) 3 lobes
L) 2 lobes
Describe atelectasis vs pneuomothorax
Atelectasis - partial lung collapse (due to interference w/ natural forces that promote lung expansion)
- treatment: a) Deep breathing exs; b) Chest PT - postural drainage, percussion, vibration; c) time
Pneumothorax - whole lung collapse (due to collection of air or gas in intrapleural space
- Treatment: chest tube
(Jobst)
What does pulse oximetry measure?
Describe the normal range
What can cause inaccuracies with pulse ox?
Measurement of arterial oxygen saturation
Normal range: 94-100%
Inaccuracies: nail polish, anemia, low perfusion
Describe the recommendation for SpO2 during exercise
Want to maintain SpO2 >90% during exercise
If <90%, titrate oxygen according to hospital guidelines
What can be used to increase SpO2?
Position change, deep breathing, pursed-lip breathing, supplemental O2
How can anemia affect pulse oximetry readings?
Even though patient has low Hb, pulseOx only reading % of that Hb that has oxygen
May have high SpO2, but have very little O2 in blood due to deficiency in RBC or Hb
(Jobst)
Describe restrictive lung disease vs obstructive lung disease
Examples of each
Restrictive lung disease
- “Volume problem”
- Reduced expansion of lung
- Decreased total lung capacity
- Decreased forced vital capacity
- FEV1/FVC ratio is normal (“you mobilize all your air, but just don’t have much of it”)
Ex: SCI, scoliosis, pulmonary fibrosis
Obstructive Lung Disease
- “Flow problem”
- Normal total lung capacity, forced vital capacity
- Decreased FEV1/FVC ratio
Ex: COPD, chronic bronchitis, emphysema, asthma
Describe the FEV1/FVC ratio is restrictive vs obstructive lung disease
Restrictive: FEV1/FVC = normal
- Flow is fine, but less volume
Obstructive: FEV1/FVC = <0.8
- Flow is impaired
Describe each of the following lung volumes
Tidal Volume
TLC
VC
RV
ERV
IRV
FRC
Tidal volume - amount of air expired w/ each breath during quiet breathing (~500 mL)
TLC - total amount of air in lunges after maximum inspiration
VC - maximum amount of air that can be exhaled after maximum inhalation
RV - volume of air remaining in lungs after maximum expiration
ERV - additional air that can be exhaled after normal TV
IRV - additional air that can be inhaled after normal TV is inhaled
FRC - amount of air remaining in lungs after normal tidal expiration
Describe how the lung volumes / capacities change w/ restrictive & obstructive lung diseases
Restrictive - reduce lung volumes & capacities
Obstructed - “hyperinflated” lung volumes & capacities
(problem is with flow / expiration, not volume)
What is COPD?
Chronic airflow limitation caused by a mixture of small airway disease and parenchymal destruction
Describe the pathogenesis of COPD
Chronic inflammation of lung tissue –> small airway disease & parenchymal destruction –> progressive airflow limitation
Small airway disease:
- Airway inflammation
- Airway fibrosis
- Increased airway resistance
Parenchymal destruction:
- Loss of alveolar attachments
- Decreased elastic recoil
Describe the mechanisms of airflow obstruction in COPD
- Inflammation (w/in airways narrow lumen)
- Mucus (obstructs small airways)
- Scarring (in small airways)
- Collapse of airways (due to lung parenchyma no longer holding them open)
Describe the clinical presentation of COPD
Productive cough
Dyspnea on exertion (progresses to dyspnea at rest)
Hyperinflation (“barrel chest”)
Cyanosis
Nail clubbing
Difficulty w/ expiration
Hypoxemia, hypercapnia
CXR:
- Hyperinflated lungs
- Flattened diaphragms
Describe the FEV1/FVC in those w/ COPD
Clinical diagnosis of COPD: post-bronchodilator FEV1/FVC <0.70
- confirms persistent airflow limitation
What are the 2 primary subtypes of COPD?
1) Emphysema
- “Pink puffers”
2) Chronic bronchitis
- “Blue bloaters”
Describe emphysema
Describe the clinical presentation
Describe treatment
Permanent enlargement of air spaces in the alveoli, loss of elasticity
Lungs become hyperinflated
“Pink puffer”
Hyperventilation
Severe dyspnea
Accessory muscle use for breathing
Cachexic appearance (mm wasting bc using lots of energy to breathe)
Tachypnea
Barrel chest (lungs lose elastic ability)
Treatment:
- Teach energy conservation
- Teach breath control - do NOT encourage “deep breaths (they don’t have a problem getting air in); prolong exhalation phase (pursed lip breathing); pause at top of inhalation
- Infection control
Describe chronic bronchitis
Clinical presentation
Treatment
Chronic inflammation of bronchi & bronchioles; increased tracheobronchial mucus production
Clinical Presentation
- Pallor
- Cyanosis (sign of deoxygenation)
- Bloating (result of edema)
- Lots of sputum
- Dyspnea
- Recurrent infections
Treatment:
- Hydration (makes mucus thinner)
- Airway clearance techniques
- Smoking cession
- Prevent infection
What is Pancoast’s tumor?
Describe the clinical presentation
Apical tumor of lung
Clinical Presentation
Mimics thoracic outlet syndrome!
- Horner’s syndrome (sympathetic damage) - miosis, ptosis, enophthalmos
- Sharp shoulder pain, axilla, subscapular areas
- Pulmonary symptoms - dyspnea, cough, hemoptysis
PULMONARY SYMPTOMS w/ TOS or shoulder pain should be a RED FLAG
Describe asthma
Clinical presentation
Treatment
Bronchoconstriction
Obstructs passage of air through the bronchi and bronchioles
- Increased responsiveness of airway smooth muscle to various stimuli
Stimulus triggers cascade of inflammatory cells –> “Spasm, swelling, secretions”
- Bronchial muscle spasm
- Inflammation of mucosa
- Mucus overproduction
Clinical Presentation:
- Increased work of breathing
- Tachypnea
- Wheezing
- Dry cough
- Chest tightness
Treatment:
- Stop activity
- Use rescue inhaler (short-acting bronchodilator)
- Sit up
If inhaler isn’t working –> call 911 (keep using inhaler until ambulance arrives)
Asthma medications:
- Bronchodilators (beta-agonists)
- Albuterol inhaler
Describe potential side effects of bronchodilators
Bronchodilators = beta-agonists
Boosts sympathetic NS
- Bronchodilation
- Increased HR
- Increased BP
Describe potential triggers for exercise-induced bronchospasms (asthma)
Hyperventilation (due to exercise itself)
Cold air
Dry air
Prevention of EIB
- Good control of asthma
- Pre-exercise prevention (short-acting bronchodilator 20-30 min before exs)
- Gentle, intermittent warm-up
- Promote nasal breathing
- Incorporate proper cool-down of at least 10 min
- Exs in warm, humid envt
