Advanced Respiratory Flashcards
What 7 things put people at risk for losing their airway?
- decreased CNS- Surgery, anesthetic, alcohol, drugs-benzos
- Trauma- Skidoo-hyperextended neck, etc.
- Infections
- Latronergic-d/t medical procedure
- Foreign Bodies- kids and intellectually impaired
- tumors- anywhere in the body
- Angioedema- allergy, anapylaxis
What do you see with a complete airway obstruction?
See-saw chest movements. Attempted respirations but no air entry
What do you see with a partial airway obstruction?
- Stridor:airway swelling, compression by hematoma
- Secretions: saliva, blood
- Snoring; tongue relaxation
- Smash: risk of teeth/blood in the airway
What 2 kinds of patients, would you anticipate a future airway obstruction?
Inhalation injury/burn: since, carbonaceous sputum
Swelling neck: compression from expanding hematoma or neck mass
What in an Endotracheal tube used for?
When someone is unable to protect/maintain their own airway: trauma, cardiac arrest, ventilatory compromise/failure,
Short term solution
placement can be determined by equal air entry on both sides of the tube
What is End-tidal Co2?
Measures Co2 as it leaves the endo tube
It can tell placement
Normal: 35-45 mmHg
ETCO2 is 55mmHg, is the patient hyperventilating or hypoventilating?
HYPOventilation
ETCO2 is 28mmHg, is the patient hyperventilating or hypoventilating?
HYPERventilating
What is a tracheostomy used for?
NOT an emergency
Long term ventilation, airway obstruction, airway protection, management of secretions.
Used for those who are totally unstable, coma, trauma, head injury
Also used for quadriplegic or paraplegic
What can go wrong with a trach?
Tube obstruction d/t Dry mucous membranes
Tube Dislodgment
Hemorrhage-when bleeding is uncontrolled, can be early or late
What are the best practice guidelines for suctioning a trach?
Suction only when necessary/agency policy
Use appropriate size of suction catheter
Use the lowest, most effective suction pressure (80-120)
Insert the catheter no further than the carina
Suction no longer than 15 seconds,
Suction continuously, not intermittently
AVOID saline lavage
Provide hyperoxygenation before and after the suction procedure
What do you want to know about a new patient’s trach?
Date of insertion: tube type, size, cuff status (inflated or deflated)
Secretions: type, amount, color, odor,
frequency of suctioning, patient response to suctioning
Last time:
1. Inner cannula was changed
2. Entire trach was changed
3. Tube was suctioned
What NEEDS to be at the bedside for a patient with a trach?
- Trach insertion tray, until established (2 weeks after initial change)
- Bag valve mask, working oxygen and suction
- suction catheter and yankeur suction device
- trach tube obturbator (in a plastic bag taped to the head of the bed)
- Spare tracheostomy tubes, of the same SIZE and TYPE, and one tube of one size smaller and type
- 10ml for inflating/deflating cuff (if trach is cuffed)
- PPE, clean and sterile gloves
- Humidification supplies (trach mask, corrugated tubing, humidity bottles, sterile water).
Adventitious sounds: Fine crackles
-Sound, mechanism,
Sound: short crackling/popping
Mechanism: previously dilated airways pop open
Never normal
eg. CHF, COPD
Adventitious sounds: course crackles
-Sound, mechanism,
Sound: Bubbling, gurgling, velcro
Mechanism: Air collides with secretions
eg. pulmonary edema, pneumonia, pulmonary fibrosis
Adventitious sounds: High pitched wheeze
-Sound, mechanism,
Sound: polyphonic, musical, squeaking
Mechanism: Air squeezed through airways compressed from swelling, secretions, tumors. Diameter of the airway is diminished.
eg. diffuse airway obstruction, asthma, emphysema
Adventitious sounds: Low pitched wheeze
-Sound, mechanism,
Sound: Monophonic, musical snoring
Mechanism: Air squeezed through airways compressed from swelling, secretions, tumors. Diameter of the airway is diminished.
eg. single bronchus obstruction, bronchitis
Adventitious sounds: Stridor
-Sound, mechanism,
Sound: Often inspiratory
Mechanism: partially obstructed airway. Swelling or obstruction
eg. croup, foreign body, epiglottis
Adventitious sounds: Pleural Friction Rub
-Sound, mechanism,
Sound: inspiratory and expiratory
Mechanism: Caused by inflamed pleural linings rubbing together
eg. pleurisy, pneumonia
How can you tell if you are hearing a pleural rub of pericardial rub?
Ask the patient to hold their breath, if it continues it is probably pericardial
Disorder: Pneumonia. What would percussion and auscultation sound like?
Percussion: dull over consolidation
Auscultation: Bronchial breath sounds over consolidation, crackles
Disorder: Atelectasis. What would percussion and auscultation sound like?
Collapsed alveoli pop open
Percussion: Dull over affected area
Auscultation: faint or no breath sounds
Disorder: Pneumothorax. What would percussion and auscultation sound like?
Percussion: Hyper-resonant or tympanic
Auscultation:breath sounds decreased or absent
Disorder: Asthma. What would percussion and auscultation sound like?
Percussion: Resonant to hyper-resonant
Auscultation: Breath may be obscured by wheezes, decreased or no breath sounds if not moving air
Disorder: Acute COPD. What would percussion and auscultation sound like?
Percussion: Hyper-resonant
Auscultation: Crackles/wheezes
What does respiratory distress look like?
Resp-rate, O2 SAT, Words, work of breathing
Resp-rate: increasing dyspnea, tachypnea >20
O2 SAT:
What is ventilation?
Done by the lungs, it is the air that reaches the alveoli,
What is perfusion?
Done by the blood, blood that reaches the alveoli,
Pulmonary capillary perfusion
What should the ventilation perfusion ratio be?
1:1
For every 1 02, there should be 1 blood
If the ventilation perfusion ratio (VQ) is less than 1, is this a ventilation problem or perfusion?
Ventilation
If the ventilation perfusion ratio (VQ) is greater than 1, is this a ventilation problem or perfusion?
Perfusion
Will a X-ray alone diagnose a pulmonary embolus?
No, as a perfusion problem will not show up on a CXR..
We also need a VQ scan as it will show the lung tissue not taking up dye d/t blockage. The 02 is there but there is nothing to pick it up
What are 4 causes of hypercapnic respiratory failure? (ventilation failure)
- airways/alveoli (asthma, emphysema)
- Decreased CNS (narcotics, head injury)
- Decreased chest wall expansion (trauma, kyphoscoliosis, obesity)
- Decreased Neuromuscular (MS, Guillain-Barre)
What are the two pleural membranes in the pleural space and what are they attached to?
- Parietal: attached to the chest wall and pulled outwards
- Visceral: attached to the lungs and pulled inwards
Why do our lungs stay inflated?
The pressure in the pleura (surrounding the lungs-intra-plerual) is less than the pressure within the lungs (intrapulmonary).
What two pressures are ALWAYS greater than the intrapleural (negative) pressure?
Intra-pulmonary and atmospheric
What is the purpose of chest tubes?
To try to re-establish negative pressure in the pleural space.
It is a CLOSED system for this reason
What is a tension pneumothorax?
Something is invading the lung-air can get in but not out.
What is a closed pneumothorax?
This occurs when air, either from the lungs or outside the body, enters the pleural space that is normally occupied by the lung. It is called a “closed pneumothorax” when the chest wall is intact.
What is an open pneumothorax?
a free communication between the atmosphere and the pleural space either through the lung or through the chest wall.
Rib Fractures: Clinical findings and goals of treatment
Most common injury from chest trauma, most often ribs 5-10 are broken d/t least protection
Clinical findings: chest pain-especially on inspiration, person may develop atelectasis, splintered or displaced ribs may puncture the pleura, shallow breathing
Goals of Treatment: Treat pain with nerve blocks, narcotics, NSAIDS, teach patient to deep breath, cough, manage pain
What is a flail chest?
A segment of the thoracic cage is separated from the rest of the chest wall. Usually at least two fractures per rib, to produce a free segment.
The flail portion is unable to contribute to lung expansion.
Paradoxical breathing occurs
What is paradoxical breathing?
The separated chest segment moves independently and separate from the rest of the chest. The move in opposite directions.
What is the standard therapy for flail chest?
Pain control (PCA, Epidural) Aggressive pulmonary hygiene Positive pressure therapy Frequent chest therapy (chest wall percussion, deep breathing, and coughing exercises). Mechanical ventilation may be required. Surgical intervention is not routine.
What is a pleural effusion?
A condition in which excess fluid builds up around the lung.
Can be transudative or exudative
Transudate pleural effusion
Due to pressure change in the vessels
- Can be d/t decreased oncotic pressure : less protein (fluid shift out), cirrhosis, ESRD
- Can be d/t increased hydrostatic pressure (heart failure)
Exudate pleural effusion
Due to inflammatory process
Both leaky fluid and protein are in the effusion as vessels leaky enough to allow protein out ( pneumonia, lupus)
What is a open thoracotomy?
Large incision, gives the surgeon a wide operative field (posterolateral or anterolateral)
Usually in the area of the 5th or 6th rib
The ribs are spread apart, allowing the surgeon to look directly into the patient’s chest
Video Assisted Thoracoscopic Surgery (VATS)
Minimally invasive, uses a small camera that is introduced into the patient’s chest viz a scope.
Large incision is avoided
Decreased pain, quicker recovery
What is a pneumonectomy?
Removal of the whole lung
What is a lobectomy?
A lobe of the lung is removed
What is a wedge resection?
A triangle shaped slice of tissue is removed.
Minimal tissue and clean margins.
What is the post op care problems of chest surgery?
Pain Breathing Re-expansion General post-op Chest tubes to maintain, re-establish (-) pressure
How is pain controlled following a thoracotomy?
Regional: epidural, blocks
Systemic: analgesic (opiates, acetaminophen, timing and route). Opiates can cause N&V and other SFx
Inflammation: Ibuprofen
Nerve: Gabapentin
Why is a thoracotomy one of the most painful procedures?
Bone, cartilage and muscle are cut, large incision, chest tubes, all moving 20 times/minute
