BLOCK 6: RESPIRATORY EMERGENCIES Flashcards
who first described pneumonia
Hippocrates in 400BCE
what is one of the most common fatal illnesses in developing countries
pneumonia
intrinsic respiratory disease factors
genetics, cardiac disease, stress
extrinsic respiratory disease factors
smoking, environmental pollutants
what airway structure acts as a pathway for air exchange
trachea
American College of Chest Physicians recommend transition to tracheostomy by ___
3 weeks
where does the tracheal cartilage bifurcate
carina
where is the carina located
5th intercostal space
where do ET tubes advanced too far and aspirated foreign bodies usually go and why
right main stem bronchus because it branches at a less acute angle than the left
all airways that do not participate in gas exchange represent what
dead space
where is gas transfer most efficient
alveoli
what structures make up the lung parenchyma
terminal bronchioles and alveoli
bronchodilator medications have little effect below the ____
subsegmental level
which number branches are the terminal bronchioles
16-24
what is the area in the middle of the chest between the lungs with the heart and large blood vessels called
mediastinum
what is pneumomediastinum
mediastinum widening with blood from a ruptured aorta or trapping air from a traumatic injury
which part of the lung has a greater number of capillaries and therefore has more gas exchange
the bases have more than the apices
what happens to the blood in patients with chronic lung disease or hypoxia
generate surplus of RBCs making their blood thick
what happens to the blood in patients with polycythemia
viscous blood
what is cor pulmonale
right-sided heart failure that occurs because of chronic lung disease
which patients have an impaired ability to transport oxygen and CO2
anemic (low hemoglobin level) and hypovolemic
which sided heart failure progresses much faster than the other
left-sided is faster (AMI)
the right side of the heart does what? the left side?
right side: pumps blood to lungs
left side: receives blood from lungs and pumps to body
what is the body’s immediate response to mild hypoxemia vs severe hypoxia
mild: increased HR/tachycardia
severe: bradycardia
what is the amount of air moved each minute called
minute ventilation
kidneys receive approximately how much of cardiac output
25%
3 conditions that cause upper airway obstruction
foreign body obstruction, infection, trauma
4 conditions that cause lower airway obstruction
trauma, obstructive disease, increased mucus production, airway swelling
4 conditions that cause chest wall impairment
pneumothorax, flail chest, pleural effusion, restrictive disease (scoliosis, kyphosis)
what is pH
how many free hydrogen ions are present in a solution
patients who are hypoventilating usually have what
respiratory acidosis
as CO2 levels go up, what happens to pH level
drops
how to measure oxygenation
how to measure ventilation
pulse oximetry (oxygen to tissues)
capnography (eliminating CO2 from body)
what groups of conditions cause patients to hypoventilate
conditions that impair lung function, impair mechanics of breathing, impair neuromuscular apparatus, and reduce respiratory drive
what is obesity hypoventilation syndrome and what is it also known as
respiratory compromise caused by morbid obesity
Pickwickian syndrome
serious injury to spinal cord above which vertebra may block nerve impulses to stimulate breathing
above C5
which nerve controls the diaphragm and breathing
phrenic nerve
what is Guillain-Barre syndrome
progressive muscle weakness and paralysis starting from feet and moving up body, can lead to ineffective breathing if paralysis reaches diaphragm
what is amyotrophic lateral sclerosis also known as and what is it
(ALS) Lou Gehrig disease
causes progressive muscle weakness, causes death from respiratory failure as muscles lose strength to ventilate
what is botulism
food poisoning or giving infants raw honey which may be contaminated with spores of bacterium that can cause muscle paralysis and is fatal when it reaches respiratory muscles
respiratory drive vs hypoxic drive
respiratory: stimulated by chemoreceptors detecting increased CO2
hypoxic: stimulates breathing from low oxygen levels
hypoventilation crisis most commonly seen by medics is what
acute heroin OD
what is the result of hyperventilation
alkalosis (increased pH) and low CO2 levels
what is breathing off more CO2 than normal triggered by emotional distress or a panic attack called
hysterical ventilation or hyperventilation syndrome
hyperventilation not caused by some metabolic crisis is usually what
self-limiting
what does respiratory alkalosis result in
numbness/tingling in hands/feet and mouth, ultimately carpopedal spasm
what is carpopedal spasm
hands and feet become clenched into a claw-like position from hyperventilating
what should NOT be done for hyperventilating patients
rebreathing carbon dioxide
how does the body attempt to compensate for acidosis
hyperventilation or Kussmaul respirations
hyperventilation is a diagnosis of ___, meaning what
exclusion, cannot presume hyperventilation syndrome until all other medical causes have been ruled out
wear a gown if patient is suspected of having what
MRSA (transmitted in their sputum)
most common complaint of patients with respiratory disease
dyspnea
the most common cause of dyspnea
hypercapnia
what is hypercapnia
too much CO2 in the blood
what is paroxysmal nocturnal dyspnea
dyspnea that comes on suddenly in middle of night and is an ominous sign of left-side heart failure
immunity by the pertussis vax lasts how long
5-10 years
what is the classic presentation of a patient with emphysema
barrel chest, muscle wasting, pursed-lip breathing, tachypneic
typically do not present with profound hypoxia and cyanosis
tall, thin young adults are predisposed to what
spontaneous pneumothorax
women who smoke and take oral contraceptives are predisposed to what
pulmonary embolus
patients with chronic bronchitis usually present how
in a chair or recliner sleeping in an upright position with a lot of things they need around them (urinal, meds, cigs)
what is Hickam’s advice
patients can have as many disease as they damn well please
increased work of breathing or hypoxia can trigger a sympathetic nervous system response which is characterized by what
tachycardia, diaphoresis, and pallor
what movement is an ominous sign of imminent decompensation
head bobbing
after intubation, true capno reading comes after the ___ breath
sixth
what patients usually get bony retractions with accessory muscle breathing
infants and small children
what patients usually get soft-tissue retractions with accessory muscle breathing
adults
what is pulsus paradoxus and in what conditions is it usually seen in
increased intrathoracic pressure can make peripheral pulse weak during inspiration
seen with cardiac tamponade and severe asthma
what are bony retractions
sternum or ribs retract into the chest during inhalation
what are soft-tissue retractions
soft tissue drawn in around bones during inhalation
what is tracheal tugging
thyroid cartilage is drawn upward and area just above sternal notch is pulled in during inhalation
what is paradoxical respiratory movement
epigastrium is pulled in as the abdomen is pushed out, creating a seesaw effect as the two move in opposite directions during inhalation
why do respiratory patients grunt
exerts a small amount of pressure that helps keep the alveoli open
what is the formula for minute volume
respiratory rate x tidal volume
many pathologic conditions are dependent on what meaning what
gravity, meaning most affect lung basees
wheezing is typically distributed how
diffuse and spread throughout lung fields
wheezing confined to only one spot may indicate what
foreign body or tumor
where to listen to the base of the lungs and the apex of the lungs
base: back
apex: anterior chest
best place to listen to confirm ET tube placement
mixaxillary line
how are breath sounds made
turbulent airflow in large airways
sound moves better through ___ than ___
fluid, air
what is lung consolidation
fluid accumulation makes the lungs firm
signs of lung consolidation
bronchophony, egophony, whispered pectoriloquy
what does it indicate if the patient’s words are audible while auscultating lung sounds
patient has consolidation from pneumonia or atelectasis
sound if single bronchus is vibrating vs many bronchi are vibrating
single: monophonic
many: polyphonic
how to test for bronchophony
when patient says “99”, if its consolidated you can understand the 99, if its a normal lung it sounds like a hum
how to test for egophony
the patient says “eeee” and you hear “aaaay”. sound may be heard particularly well over pleural effusion
how to test for whispered pectoriloquy
patient whispers while you are auscultating and you can understand what they said
what is “death rattle”
low-pitched gurgling sound when patient becomes unable to clear secretions
for ICP patients, titrate EtCO2 to what range
30-35
snoring respirations indicate what
partial obstruction of upper airway by tongue
gurgling respirations indicate what
fluid in the upper airway
stridor respirations indicate what
narrowing as a result of laryngeal edema
quiet tachypnea is indicative of what
possible shock
how does hydration affect thickness of sputum
dehydration makes sputum thicker
what is frothy, pink sputum caused by
heart failure
what is thick sputum caused by
dehydration or antihistamine use
what is purulent sputum caused by
(milky/pus-like) infectious process (pus contains dead WBCs)
what is yellow, green, brown sputum caused by
older secretions in various stages of decomposition
what is clear or white sputum caused by
bronchitis
what is blood-streaked sputum caused by
tumor, TB, pulmonary edema, trauma from coughing
what is the classic presentation of pneumonia
increased sputum production coupled with fever and chills
why does ICP affect breathing
squeezes the medulla
what is eupnea
normal breathing
what does sighing do
forces open alveoli that routinely close from time to time
Cheyne-Strokes breathing if what two criteria are met
- three consecutive apneas separated by crescendo/decrescendo with cycle length of at least 40secs
- five or more apneas per hour over minimum of 2hrs
what does polio infection do
attacks nerves that supply respiratory muscles
what does myasthenia gravis do
weaken respiratory muscles
what is the hemoglobin level in healthy adults
12-14g/dL
how much hemoglobin becomes desaturated before cyanosis becomes apparent
5g/dL
how does cyanosis present in patients with light, yellow, and darker skin tone
light: blue
yellow: gray-green
darker: ashen or grey
what causes dark brown skin
high methemoglobin levels from nitrates and toxic exposures
what causes pallor
release of catecholamines like epi or norepi
asthma with fever that responds to treatment but flares up again is usually caused by what
underlying infection such as pneumonia or bronchitis
sloping downward of plateau (phase III) on capno shows what
history of emphysema
why do some patients present with significant pulmonary edema after a trip
not wanting to take diuretics while traveling
why do you receive increase of respiratory related calls when weather changes
bacteria, mold, and fungi grow in heating ducts or AC units during their off season and then are released when turned out due to change of weather
what is curare cleft
visible inhalation in the middle of the plateau
sedation is wearing off and patient is fighting intubation
what do antihistamines do
dry out secretions
what do antitussives do
suppress cough
what do expectorants do
thin out pulmonary secretions so they can be coughed up
what do the most common OTC bronchodilators consist of
attenuated (diluted) forms of epi
what does decline in PaO2 manifest as
restlessness, confusion, and progresses to combative behavior
what does increase in PaCO2 manifest as
sedative effects
what often accompanies a hypoxic effect or cardiac arrest
seizure
what can cause JVD
cardiac tamponade, pneumothorax, heart failure, COPD
which is concerning?
A. grossly distended jugular veins despite BP of 80/40 in a trauma patient
or
B. JVD in a 20-year-old lying flat
A
what is a classic late sign of tension pneumothorax
tracheal deviation
what is hepatomegaly
distended liver
what is hepatojugular reflux
distention of jugular veins when liver is gently pressed
how to assess for hepatojugular reflux
press gently on liver while patient is in semi-Fowler position (45 degree angle)
what is tactile fremitus and what causes it
obvious vibrations from large-airway secretions
hemothorax or pneumothorax in chest will have what kind of percussion
hypertympanic
a chest tumor will have what kind of percussion
dull
what is a sign of chronic hypoxia
digital clubbing
what three things are ominous signs of impending arrest in patients with respiratory diseases
bradycardia, hypotension, falling respiratory rate
what is the relationship between hemoglobin and oxygen saturation
inverse
(low hemoglobin, high oxygen - high hemoglobin, low oxygen)
people who live in an industrial society have a carbon monoxide level of ___
smokers have one of ____
1-2%
3-4%
what is the oxyhemoglobin dissociation curve illustrate
relationship between oxygen saturation and amount of oxygen dissolved in the plasma (PaO2)
what is peak flow
max rate at which a patient can expel air from the lungs
normal peak flow values
350-700L/min
peak flow under what value is considered inadequate and signals significant distress
less than 150L/min
at what percent is oxygen safe to administer to almost anyone
50%
what did the physician Paracelsus observe
it’s the dose of a substance, not its composition, that makes it poisonous
most nebulizers need a gas flow of at least ___LPM to generate optimal particle size
6
respiratory acidosis
-oxygen level
-respirations
-BP level
-what patient feels
-what it can cause
-what causes it
hypoxic
rapid, shallow respirations
decreased BP
headache, dyspnea, drowsiness/dizziness
hyperkalemia, dysrhythmias
decreased respiratory stimuli (OD) COPD, pneumonia, atelectasis
respiratory alkalosis
-respirations
-BP level
-what patient feels
-what it can cause
-what causes it
deep, rapid breathing
decreased or normal BP
numbness/tingling, lethargy, lightheaded, nausea/vomiting
hypokalemia, tachycardia, seizures
hyperventilation from anxiety or improper mechanical ventilation
why are spacers used on meter dosed inhalers
collects medication as it’s released from canister allowing more to be delivered to lungs and less to be lost to environment
why should you rinse your mouth after using corticosteroid inhaler
residual corticosteroid in the pharynx can predispose patients to thrush (an annoying fungal infection of pharynx or mouth)
an example of dry-powder inhaler medication
tiotropium (Spiriva) - anticholinergic med for COPD management
what are leukotrienes
bronchoconstricting chemicals released in some patients during an allergic response
example of leukotriene blocker
montelukast (Singulair)
what is IV magnesium sulfate used for
side effect?
severe asthma attacks to encourage smooth muscle relaxation
hypotension if given too quickly
what are corticosteroids used for
reduce bronchial swelling
what can long-term use of corticosteroids cause and what is it characterized by
Cushing syndrome and rapid BGL changes
classic moon face and generalized edema
how must corticosteroids be discontinued
gradually
three components of asthma triad
bronchospasm, airway edema, increased mucus production
treatment for pulmonary edema
promoting vasodilation
what is used to help reduce BP and maintain fluid balance in patients with heart failure
diuretics
what diuretics are most commonly used in emergencies
loop (Bumex and furosemide)
diuretics cause the loss of fluid and what?
potassium
do not give diuretics to which patients
with pneumonia and dehydrated patients
how is CPAP outcome related to patient’s respiratory rate
inversely
if resp rate increases, therapy is likely to fail
if resp rate decreases, therapy is likely to succeed
conscious patients require up to ___L/min of flow to breathe comfortably, but most transport vents are permanently set to deliver ___L/min. what does that mean?
150, 40
making it inadequate for a spontaneously breathing patient
patients with asthma are susceptible to what when intubated
pneumothoraces
what is laryngotracheobronchitis
inflammation of the larynx, trachea, and bronchi
what is a common cause of croup
acute form of laryngotracheobronchitis
what is croup
characterized by stridor, hoarseness, and barking cough mostly in infants and small children
what is the Poiseuille law
as diameter of tube increases, resistance to flow increases exponentially
is croup caused by bacteria or virus
viral
what is asthma also referred to as
reactive airway disease
what is a severe prolonged asthmatic attack that cannot be stopped with conventional treatment
status asthmaticus
how to treat bronchospasm
bronchodilators, magnesium sulfate, epinephrine
how to treat bronchial edema
anticholinergics (Ipratropium) and corticosteroids
how to treat excessive mucus secretions
improve hydration and mucolytics
what is COPD mainly comprised of
emphysema and chronic bronchitis
examples of restrictive lung disease
severe kyphosis, scoliosis
how is chronic bronchitis defined
sputum production most days of the month for 3 or more months out of year for more than 2 years
what is cardiac asthma
diffuse wheezing with acute left-sided heart failure
what is bronchiolitis obliterans with organizing pneumonia
“BOOP”
inflammation and plugging of the bronchioles resulting in pneumonia distal to the blockages
when is lung cancer usually identified
when tumors in the large airways bleed causing hemoptysis (coughing up blood in the sputum)
what is a common cleaning error that can make someone sick
mixing drain cleaner and chlorine bleach which makes chlorine gas
what is ammonia
highly water soluble, acute upper airway irritation
what is chlorine
moderately water soluble, effects depend on concentration and amount ranging from coughing to chemical burns
what is phosgene
minimally water soluble, delayed onset of pulmonary edema
two classifications of pulmonary edema
high pressure (cardiogenic)
high permeability (non-cardiogenic)
where does air collect in a pneumothorax
between visceral and parietal pleura
what are blebs
weak spots that can rupture under stress causing a spontaneous pneumothorax
what produces a pleural effusion
fluid collecting between the visceral pleura and parietal pleura (from a pneumothorax)
what is thoracentesis
draining of large effusions
what is the classic presentation of a pulmonary embolism
sudden dyspnea and cyanosis that does not resolve with oxygen therapy, pinpointed pain in the chest
what is the Homan sign
calf pain during dorsiflexion of the foot caused by thrombophlebitis in the leg
what patients are at high risk for pulmonary embolism
patients with thrombophlebitis (inflammation of veins in the legs)
where do pulmonary emboli often originate
greater saphenous vein or other large veins of the leg
what is a saddle embolus
exceptionally large pulmonary embolus lodged at the bifurcation of the right and left pulmonary arteries
what is cape cyanosis and what is it caused by
usually caused by saddle embolus
deep blue color of face, neck, chest, and back despite good CPR and ventilation
