Ch. 9 Pulmonary Complications

Question 1

Respiratory alkalosis
* What is the rep system doing
* Causes

Answer 1

• breathing off too much CO2 (hyperventilation)
• Early resp failure, fever, panic disorders, severe pain, heart failure and PE (cant get enough O2), Pneumo/hemothorax, Aspiration, asthma, sepsis

Question 2

Respiratory acidosis
* What is the resp system doing
* Causes

Answer 2

• Not breathing off enough CO2, this is hypoventilation
• Late resp failure, over-sedation, drug overdose, Pulm edema (intervering w CO2 release), extreme V/Q mismatch, severe obesity, muscle weakness

Question 3

Metabolic Acidosis
* What is the body doing
* Causes
* Why is this bad

Answer 3

• Either the body is producing too much acid (uric acid) or the kidneys aren’t getting rid of it
• AKI, Diabetic Ketoacidosis, Sepsis, Lactic Acidosis, Toxins, Liver failure, Hyperkalemia, Hyperchloremia (calculate the anion gap), MUD PILES
• Methanol, Uremia, DKA, Propylene glycol, isoniazid, lactic acidosis, ethylene glycol, salicylates
• Suppresses myocardial contractility

Question 4

What is Anion Gap?
* Normal gap

Answer 4

• This is the calculated difference between positively and negatively charged electrolytes in your blood to determine if your blood is too acidic or not acidic enough
• Normal gap is <12

Question 5

Metabolis Alkalosis
* What is the body doing
* Cause
* treatmtent

Answer 5

• Too much bicarb in the blood of loss of chloride via routes like vomiting and loss of stomach acid
• NG tube to suction, vomiting/emesis, Hyopkalemia, hypochloremia, antacid abuse, inadequate renal perfusion, loop diuretics,
• Fixed with diamox which causes the release of bicarbonate

Question 6

Capnography - PEtCO2
* Normal value
* Normal waveform vs no waveform
* hypoventilation vs hyperventilation

Answer 6

• 35 - 45 mmHg
• Normal waveform increased and decreased with PaCO2, no waveform ETT may be in esophagus
• Hypoventilation = high CO2, Hyperventilation = low CO2

Question 7

Post-op Atelectasis and Pneumonia
* Do many patients have some degree of post-op resp dysfunction?
* Contributors
* What is needed for these patients

Answer 7

• Yes, most have some
• General anesthesia, lack of lung activity while on CPB, alveolar collapse, fluid shifting, lack of pain management,
• These people need pulmonary toileting, splinting with pillows, incentive spirometry, Chest PT, ambulate ASAP, CDB

Question 8

Post-op Pleural Effusions
* Definition
* Is this common
* Causes
* Treatment

Answer 8

• Fluid collection in the pleural space, can cause difficulty weaning from ventilator
• Fairly common ~40%
• Heart failure and pulm edema, pneumonia, chylothorax, hemothorax, post pericardiotomy syndrome
• Most small effusions resolve on their own, bilateral effusions may require diuretics, 25% may require thoracentesis and/or chest tube

Question 9

Phrenic Nerve Injury
* Definition
* causes
* monitor for

Answer 9

• Damage to phrenic nerve during surgery
• caused by cold cardioplegia solution, surgical injury or trauma to the phrenic nerve during surgery
• Monitor for resp compromise with diaphragmatic dysfunction, lower tidal volumes or normal tidal volumes with inability to wean from ventilator, elevated diaphragm usually resolves within a few months, at risk fior pneumonia and atelectasis

Question 10

Transfusion Associated Circulatory Overload (TACO)
* Definition
* symptoms
* Treatment

Answer 10

• CHF from excessive volume resuscitation
• Dyspnea and crackles, S3 heart sound
• Responsive to diuretics, non-invasive ventilation if needed

Question 11

Transfusion Related Acute Lung Injury (TRALI)
* Definition
* Symptoms
* Treatment, does not respond to

Answer 11

• Immune meadiated response to donor plasma antibodies resulting in inflammatory process and ARDS
• Increased oxygen needs and pulm infiltrates within 6 hours of transfusion
• Does not respond to diuretics, responds to peep, prolonged ventilation

Question 12

When increasing the PEEP you should monitor for which of the following adverse effects?
Why does lung protective ventilation allow permissive hypercapnea?

Answer 12

• Hypotension
• A lower respiratory rate with lower lung volumes will prevent ventilatory damage to the lungs and can necessitate high CO2

Question 13

ARDS Rescue strategies
(5)

Answer 13

1. Inhaled pulm vasodilators (epoprostenol, iNO)
2. Neuromuscular blockade (paralytics)
3. ECMO
4. Prone therapy
5. Steroids

Question 14

Lung Protective Ventilaton consists of
* Lower TV =
* Lower peep =
* Plateau pressure <
* P
* E***

Answer 14

• TV = 6 ml/kg
• PEEP for hypoxia
• Plateau pressure < 30 mmHg
• Prone early
• ECMO

Question 15

Should you clamp chest tubes if there is bubbling in the water seal chamber? Why or why not

Answer 15

No, because this means air is continuously leaking from the lung into the plaural space and down the chest tube

Question 16

Pneumothorax
* Definition
* Causes
* Tension pneumo def
* symptoms
* treatment

Answer 16

• This is air in the peural space causeing part of the lung to collapse d/t air taking up the space and lack of negative pressure
• Caused by direct injury to the lungs (trauma), too much PEEP (barotrauma),
• Air accumulates in the pleural space and cannot escape. This is life threatening because it will gradually increase the amount of pressure on the heart
• Increased peak airway pressures, decreased expiratory lung volumes, decreased compliance, hypotension, tracheal deviation
• Needle aspiration in 2nd intercostal space for emergent evacuation and placement of chest tube

Question 17

Pneumomediastinum
* Definition
* causes
* signs/symptoms

Answer 17

• Abnormal presence of air or another gas in the mediastinal cavity. This is rare and usually benign
• Spontaneous or secondary due to blunt thoracic trauma, endobronchial/esophageal procedures, head and neck sugery,
• Thoracic pain which is retrosternal and pleuritic in nature, subcutaneous emphysema and dyspnea, cough, fever, dysphonia, dysphagia
• Monitor, rest, oxygen administration to dissolve air, chest tube if symptomatic