ABCDE

Question 1

Airway obstruction can be described by the level at which it affects e.g. …

Answer 1

oral, supraglottic, laryngeal, mid tracheal, lower tracheal or bronchial obstruction

may be multilevel in e.g. oedema

Question 2

main causes of airway obstruction?

Answer 2

• reduced GCS
• vomit/blood contaminating the airways from regurgitation of stomach contents or trauma
• foreign body
• oedema due to burns
• inflammation or anaphylaxis and laryngeal spasm
• Lower airway obstruction may also be caused by excessive bronchial secretions, bronchospasm and pulmonary oedema.

Question 3

Signs of partial airway obstruction?

Answer 3

• inspiratory stridor
• expiratory wheeze
• gurgling
• snoring
• crowing

Question 4

signs of complete airway obstruction?

Answer 4

• paradoxical chest and abdominal movements
• see-saw breathing - no sound from mouth/upper airway
• use of accessory muscles – neck and shoulder muscles, recession of intercostal and subcostal muscles; tracheal tug

Question 5

The most basic respiratory measurement is minute volume (VM) - what is this?

Answer 5

= tidal volume (VT) x respiratory rate (RR)

Question 6

what is the alveolar ventilation?

Answer 6

the portion of the minute volume that takes part in gas exchange.

Each tidal volume contains a proportion of gas which is wasted, either because it remains in the large airways or goes to parts of the lung where there is ineffective gas exchange (dead space)

Question 7

V/Q

In the healthy lung: V/Q = ?

In the diseased lung, 2 types of V/Q mismatching may occur

1. Shunt: Q ? V
2. Dead space: V ? Q

Answer 7

1 (ventilation and perfusion are well matched and respiratory gas exchange is efficient)

1. Shunt: Q > V wasted perfusion
2. Dead space: V > Q wasted ventilation

Question 8

Elimination of CO2 from the blood via the lungs basically depends on ____ ____, which removes CO2 from the alveoli and maintains a concentration gradient for more CO2 to move from the blood to the alveoli.

Answer 8

alveolar ventilation

Thus, if effective alveolar ventilation falls for any reason, the level of CO2 in the blood will rise.

Question 9

1. anatomical vs
2. physiological dead space?

Answer 9

1. tidal volume that remains in the large airways, doesn’t participate in gas exchange
2. In disease e.g. emphysema, areas of the lung may be ventilated, but not perfused

Question 10

As total dead space (wasted ventilation) increases, there is a relative reduction in effective ____ ____, thus impeding ___ elimination. This increase in wasted ventilation is initially compensated for by an increase in overall minute volume, particularly by ____.

Answer 10

1. alveolar ventilation
2. CO2
3. tachypnoea

Question 11

why does shunt have much less impact on CO2 elimination than a reduction in overall alveolar ventilation?

Answer 11

lungs compensate better for shunt

• in the diseased lung, if some blood flow to the lungs bypasses ventilated regions (shunt) more CO2 will be removed in the remaining ventilated part, again due to the concentration gradient from blood to alveoli.
• This compensates for the poorly ventilated region.
• Therefore, arterial concentration of CO2 is largely determined by effective alveolar ventilation over the whole of the lungs.

Question 12

T/F: unlike CO2 elimination, arterial oxygenation is very sensitive to shunt and patients with significant shunt will become hypoxic.

Answer 12

This is because

• Oxygen is carried in blood almost exclusively bound to Hb, so there’s a limit (set by the Hb concentration) on how much oxygen can be carried in each ml
• Therefore, increasing alveolar ventilation cannot compensate for an area of shunt with poor oxygenation since the blood leaving the well ventilated area cannot have greater than 100% Hb O2 saturation.

Question 13

If total dead space increases sufficiently to cause effective alveolar hypoventilation, then hypoxia will result, largely due to an increase in alveolar ____ levels.

Answer 13

CO2

a patient apparently moving large volumes of air may still have effective alveolar hypoventilation if they have a large dead space.

Question 14

name some causes of respiratory failure with CO2 retention which occur with

1. normal / increased
2. reduced

respiratory drive

Answer 14

1. Acute pathologies: pulmonary oedema, contusion, pneumonia, lung collapse, pneumothorax, (airflow resistance and mechanical failure) (eg, due to rib fractures) can increase dead space (wasted ventilation). The onset of hypercapnia (paCO2) may signify the patient is becoming exhausted/ unable to compensate further
2. Opioid analgesics (commonest cause), Type II respiratory failure with chronic CO2 retention (uncommon, predisposed individuals e.g. COPD: ‘blue bloaters’

Question 15

what is ‘the oxygen cascade’?

Answer 15

• describes what happens to the partial pressure of oxygen as it moves from the atmosphere to mitochondria in cells.
• Decreases during each step

Question 16

What is hypoxia?

The causes of hypoxia can be divided into which 4 groups?

1. arterial pO2 < 12kPa
2. normal arterial pO2 but the amount of available Hb for O2 carriage is low e.g. anaemia, carbon monoxide poisoning
3. normal arterial pO2 and Hb but reduced blood flow to the tissues – may be due to a reduction in cardiac output or a interruption to the blood flow to the tissues e.g embolus
4. normal arterial pO2, normal Hb level and normal blood flow to the tissues but the tissues are unable to utilise the oxygen e.g. cyanide poisoning, carbon monoxide poisoning

Answer 16

Hypoxia = reduced amount of oxygen available for tissue respiration

1. hypoxic hypoxia (hypoxaemia)
2. anaemic hypoxia
3. stagnant (ischaemic) hypoxia
4. histotoxic (cytotoxic) hypoxia

Question 17

The hypoxic hypoxia division can be further subdivided into which 4 main causes?

Answer 17

1. hypoventilation
2. diffusion limitation
3. shunt
4. ventilation – perfusion inequality

Question 18

causes of hypoventilation?

Answer 18

• central respiratory depression (drugs, intracranial pathology, hypocapnia, metabolic disturbance (metabolic aklalosis), hypothermia, sleep apnoea
• impaired peripheral mechanism of breathing (respriatory disease, airway obstruction, restricted chest wall movement, muscular weakness, nerve lesions, NM junction impairent
• increased dead space (embolism or anaesthetic apparatus)

Question 19

what is diffusion limitation/impairment?

Answer 19

occurs when the membrane over which oxygen is required to diffuse is altered, increasing the diffusion time e.g. pulmonary fibrosis, connective tissue disease.

Question 20

In the healthy lung only a very small proportion of blood (1-2%) bypasses the alveoli.

Large increases in this shunt can occur with any acute pulmonary pathology e.g.

Answer 20

pulmonary oedema, contusion, pneumonia, pneumothorax and large (lobar or segmental) airway collapse

Question 21

1. T/F: Ventilation – perfusion mismatch is normal in the average individual
2. However, if for some reason this mismatch should increase then hypoxia is more likely to ensue. There are a wide variety of reasons that mismatch can occur including …

Answer 21

1. True - with alveolar ventilation being slightly less than perfusion.
2. PE, pulmonary oedema, pneumonia, decreased cardiac output.

Question 22

Failure of the circulation and pulmonary perfusion can also cause gas exchange problems by interfering with ventilation / perfusion matching.

Examples of when this can occur?

Answer 22

• disturbance of the pulmonary circulation (pulmonary emboli - thrombus, fat, amniotic fluid)
• systemic hypotension secondary to hypovolaemia, sepsis, vasodilation or pump failure which is generally accompanied by pulmonary hypotension.
• These all cause increased dead space, shunt and hypoxia

Question 23

‘shunt’ = ‘wasted perfusion’

‘dead space’ = ‘wasted ventilation’

Answer 23

ok

Question 24

what is meant by the ‘triple airway manoeuvre’?

Answer 24

head tilt, chin lift and jaw thrust

(perform if there is evidence of airway obstruction)

Question 25

which Ix are essential in respiratory failure?

Answer 25

chest x-ray and arterial blood gas

Question 26

Oxygen delivery devices can be divided into Fixed and Variable Performance devices.

Difference?

Answer 26

• Fixed performance e.g. Venturi masks: deliver a fixed Oxygen concentration (FiO2) independent of patient’s respiratory effort
• Variable performance: vary with the patient’s respiratory effort and other factors such as patient size and mask fit.

Question 27

If you want to know the FiO2 you are giving a patient, you need to use a fixed performance device e.g. a ___ mask

Answer 27

venturi

Question 28

There are 4 basic options for O2 delivery on the ward and in the ED

Name these, stating whether they are fixed or variable performance

Answer 28

1. Nasal Cannulae (VP)
2. Hudson Mask (VP)
3. Non-rebreathe reservoir mask aka ‘Trauma mask’ (VP)
4. The Venturi Mask (FP)

Question 29

Nasal Cannulae (NC)

1. Useful for which patients
2. Benefits?
3. Flow rate?
4. The FiO2 delivered is dependent on what factors

Answer 29

1. Ideal for patients on long term O2 and those with a low O2 requirement.
2. They allow patients to eat and drink and are usually well tolerated and less bulky leading to better compliance.
3. 2-4 l/min (FiO2 of 0.28-0.36) - Higher flow rates can be uncomfortable for the patient leading to poor complicance.
4. Patient’s respiratory effort as well as the O2 flow rate

Question 30

Hudson Mask Cheap

1. benefits?
2. T/F: The FiO2 can be changed by altering the O2 flow rate without changing the mask.
3. They have a small reservoir which means the patient inhales a mixture of what?
4. What impact can hyperventilation have on patients wearing these?
5. Flows less than 4L are not recommended - why?
6. With a normal respiratory pattern, a flow rate of 4l/min will typically give an FiO2 of around ____
7. T/F: These masks are not recommended for patients whose ventilation depends on a hypoxic drive

Answer 30

1. Simple and comfortable- most commonly used in the hospital
2. true
3. O2 from the mask and ambient air on tidal ventilation.
4. The normal expiratory pause is essential for the mask to refill with O2 and eliminate expired gases - hyperventilation can lead to rebreathing, lowering FiO2.
5. because of the potential for rebreathing (at these lower flows nasal cannulae are preferable)
6. 0.4
7. true - e.g. some COPD patients

Question 31

Non rebreathe reservoir mask aka ‘Trauma mask’

1. Basically a hudson mask but with a 1litre reservoir bag attached to the O2 supply. What is the purpose of this adaptment?
2. The reservoir should be inflated before applying to the patient and high flow rates are needed of _____l/min to achieve ____% FiO2.
3. T/F: If a patient is receiving 80% FiO2, their PaO2 should be at least 12kPa

Answer 31

1. When the patient inspires, O2 is drawn from the reservoir and expired gases are expired and eliminated through one way valves in the side of the mask.
2. 10-15, 60-80
3. false - if a patient is receiving 80% FiO2 and their PaO2 is 12kPa they have a major V/Q mismatch and you should contact your senior

Question 32

ABGs should always be interpreted in the context of the FiO2

As a rough guide PaO2 breathing air should be ____kPa, and PaO2 should be roughly kPa less than the FiO2 in healthy patients breathing supplemental oxygen.

Answer 32

1. 10-13
2. 10

Question 33

The Venturi Mask (fixed performance)

1. Useful in what patients?
2. They are colour coded depending on FiO2 delivered and range from __% to __%. Printed on the mask is the FiO2 delivered and the flow of O2 that should be set on the O2 flowmeter (up to 15l/min for 80% FiO2)
3. T/F: Different masks are needed to change the FiO2

Answer 33

1. Those who rely on their hypoxic drive for ventilation i.e. some COPD patients. Also when weaning O2 therapy.
2. 24 - 80
3. true - in contrast to the hudson where only the O2 flow rate needs to be altered.

Question 34

T/F: Hypoxia is more common and more rapidly fatal than CO2 retention

Answer 34

true

Question 35

what is ‘shock’?