Exam 2 Flashcards
what is ventilation
the movement of air btw atmosphere and the alveoli-by inhalation/exhalation, higher to lower pressure
minute ventilation
volume inhaled/exhaled per minute = 7500ml at rest
alveolar ventilation
volume of fresh gas entering respiratory zone available for gas exchange per minute
if rapid breathing, how are PaCO2 and alveolar ventilation impacted
alveolar vent is increased and CO2 decreases
diffusion
exchange of O2 and CO2 b/w pulmonary capillaries and the alveoli
what impacts diffusion (4)
- Affected by surface area available for diffusion
- Affected by thickness of alveolar-cap membrane
- partial pressure of gas across the membrane
- and solubility and molecuar characteristics of the gas
perfusion
flow of blood through the pulmonary capillary bed
what is transport
Oxygen and co2 being circulated in the blood and to and from the cells
how is o2 transported
RBCs - hemoglobin (97%)
Dissolved in blood (3%)
how is co2 transported
Dissolved in blood (10%)
Attached to hemoglobin (30%)
Bicarbonate in bloodstream (60%)
What drugs can go down ET tube because they are metabolized in lung tissue?
Lidocaine
Epi
NARCAN
Atropine
conducting airways
No actual gas exchange takes place here (anatomic dead space)
Nasopharynx warms, humidifies and filters air
Includes naso and oropharynx, trachea, bronchi, bronchioles, and terminal bronchioles
respiratory airways
Respiratory bronchioles, alveolar ducts, and alveolar sacs
Surrounded by smooth muscle
type 1 alveolar cells
responsible for gas exchange
type 2 alveolar cells
secrete surfactant
Macrophages present to remove foreign substances
what is the v/q relationship
Ventilation/perfusion (V/Q) relationship
Measure of how well someone is ventilating vs perfusing
what is the normal v/q
Normal is 0.8 - 1 (4L/minute of ventilation to 5L / minute of perfusion)
what 5 things influence V/Q
- anatomical dead space
- alveolar dead space
- anatomical shunt
- physiological shunt
- silent unit
anatomical dead space
Conducting airways
*Tubing from ET tube back to ventilator - adds dead space
High V/Q ratio (alveolar dead space)
-Normal or good ventilation with decreased or no perfusion
-When regions in respiratory airways are ventilated but not perfused
-ex: pulmonary embolism, cardiogenic shock (amount of o2 in alveoli is so low)
shunt
blood bypasses alveoli w/o picking up O2
anatomical shunt
Patent ductus arteriosus
ASD
VSD
Patent foramen ovale
Mixing of oxygenated and deoxygenated blood → dilutes oxygen to tissue
physiological shunt (low VQ)
low ventilation, normal perfusion
decreased gas exchange
d/t obstruction like a mucus plug in the tube
physiological shunt (high VQ)
High VQ (good ventilation) but poor perfusion = alveolar dead space
I.e. PE, cardiogenic shock
silent unit
low / no perfusion and low/no ventilation
(ex: pneumothorax, patient with ARDs)
normal PaO2: FiO2
normal > 300
what does a PaO2: FiO2 of 200-300 mean
one of the mismatches is happening → 15 - 20% shunting
what does a PaO2:FiO2 of 100 mean?
100 > 20 % shunting
four cardinal symptoms of respiratory distress
Dyspnea
Chest pain
Sputum production
Cough
crackles
rales - high pitched brief popping sound heard during inspiration
Fluid in smaller airways / alveoli trying to open and not opening or terminal airways that are collapsed
Classic in CHF, pneumonia
Sounds like hair being rubbed together
rhonchi
Deep low pitched rumbling
Snore, gurgle
Can be expectorated
Noise comes from sputum in airways
Bronchitis, pneumonia
wheeze
Asthma, COPD
High pitched
friction rub
Same as pericardial rub
Usually heard on inspiration
Two surfaces with fluid are rubbing together
Sounds like sandpaper
Hear in heart beat - pericardial effusion
Cardiac or respiratory?
Would go with rate - either HR or RR
stridor
High pitched inspiratory sound
Crowing
When we have air passing through constricted trachea
Constriction, obstruction
Medical emergency
Need to be intubated or intubated
Croup in pediatrics
3 goals of O2 therapy
Correct hypoxemia
Decrease work of breathing
Decrease myocardial workload
if you patient has a problem with oxygenation, what do they need
more FiO2
if your patient has a problem with ventilation, what do they need
more flow (bipap, cpap or additional breaths)
what is effective O2 therapy
lowest FiO2 and lowest amount of oxygen - to achieve normal SaO2 or normal PaO2 on pulse ox
6 factors affecting success of supplemental O2
medical history
LOC
patent airway
RR
depth of breathing (tidal volume)
hgb level
5 complications of supplemental o2
Skin breakdown
Drying of mucous membranes
Epistaxis
Infection of the sinuses
Oxygen toxicity
who can get CPAP
Can only be used on patients breathing spontaneously - just o2 issues, not ventilation issues
5As for treating smoking use and dependence
Ask about tobacco use - at every visit
Advise to quit
Assess willingness to make attempt to quit
Assist in attempt at quitting - offer medication, provide counseling or referral
Arrange follow up
pulmonary function test
Measures lungs ability to move air in and out of alveoli
CT scan (PE protocol)
Need large bore IV, know kidney functions
Contrast - hold metformin for 48 hours after to avoid lactic acidosis
Check lab results
*Contrast dye is nephrotoxic
what can a chest x ray be used for
Sees tubes/drains/catheter placements
Pulmonary edema, pleural effusion
pneumothorax
Can see bones
See infiltrates
Cardiomegaly → muscle has gotten thicker/hypertrophied → means EF is low
bronchoscopy
direct visualization of tracheobronchial tree/larynx
Can remove foreign objects
Can do biopsies
Can stop bleeding
Can be done while patient is ventilated
thoracentesis
Can remove fluid during pleural effusion → decreased surface area for o2 and co2 exchange → SOB, DOE
Can be diagnostic or therapeutic
Therapeutic = symptom mgmt
Diagnostic - send drainage to lab and get diagnosis - (i.e. WBC, cancer cells, etc)
end tidal co2 monitoring
Measures maximal partial pressure of CO2 obtained at the end of an exhaled breath
capnography
continuously monitors the PaCO2 in the airway during inhalation and exhalation and provides a written tracing
normal paCO2 values
35-45 mmhg
normal HCO3 - values
22-26 meq/l
normal PaO2
80-100 mm hg
what is an anion gap and what is the normal level
specialized blood tests that lets us know about metabolic acidosis
Look at difference b/w sodium + potassium on one side and Cl and HCO3 on the other
Less than 12 = normal
BNP
Want to know if someone has pulmonary edema d/t HF → will impact oxygenation
Increases as HF worsens
normal BNP level
less than 100
BNP of 100-300
mild volume overload of some kind
BNP of over 600
moderate HF, pulmonary edema
BNP of over 1000
severe pulmonary edema
BNP over 5000
kidney problems
D Dimer and normal level
indicates Degradation of certain fibrin molecules in the blood
Normal = less than 0.50
what meds are important with COPD exacerbation (4)
Bronchodilators, mucolytics, corticosteroids, oxygen
what meds are important with pulmonary edema?
diuretics, oxygen
which med is most important with CHF or pulmonary edema
diuretics
how to get ABG sampling
-Radial, brachial or femoral site (no tourniquet needed)
-Wipe with chlorhexidine, 20G needle, heparinized syringes, insert 30 - 45 degrees with bevel up right below where you feel the pulse → 3-5ml → hold pressure for 3-5 minutes on artery → put sample it on ice and to the lab (ice to reduce oxygen metabolism and give more accurate reading)
allen’s test
if using radial approach for ABG sampling
Testing patency of other vessel supplying hand - ulnar artery
Positive test = ulnar is patent
uncompensated ABGs
ph and 1 PaCO2 OR HCO3- are going to be abnormal
partially compensated ABGs
ph is still abnormal and both PaCO2 and HCO3 are abnormal
fully compensated ABGs
ph is normal but PaCO2 and HCO3 are not normal
indication for chest tubes
To drain fluid or air from the thoracic cavity, in the pleural space
-Hemothorax
-Pneumothorax
-Tension pneumothorax
-Pleural effusion
hemothorax
Blood collects b/w chest wall and lungs in pleural cavity
Can cause lung to collapse if volume buildup is so high
s/s of hemothorax (4)
Chest pain
Difficulty breathing
Reduced breath sounds on affected side
Rapid heart rate
pneumothorax
Air leaks into space b/w lung and chest wall
can be closed, open or tension
tension pneumothorax
air in pleural space increasing and unable to escape
Pressure is so great that lung pushes up and becomes non functioning
Everything is pushed (trachea, heart) to unaffected side
Breath sounds will be absent on affected side
tx for tension pneumothorax
needle decompression w/ large bore needle into 2nd intercostal space in midclavicular line
pleural effusion
Fluid between pleural space, 2 pleural linings
s/s of pleural effusion
SOB,
chest pain especially when breathing in deeply,
activity intolerance,
DOE,
cough
tx for pleural effusion
drained with thoracentesis or chest tube
3 chambers of drainage systems for chest tubes
Collection
Water seal chamber
Suction apparatus
what is normal finding in drainage system
Tidaling - normal finding subtle up and down of water in under water seal chamber (usually middle chamber)
normal finding in chest tube drainage system for spontaneous breathers
Should rise a little with inspiration because you are getting more negative
Should fall during expiration when patient is breathing spontaneously
normal finding in chest tube drainage system for mechanical ventilation
Fall during inspiration because you are putting positive pressure into lungs
Should rise during expiration when positive pressure is pumped out
how often do you check VS and CV/pulm for patient with chest tube
q2
how often do you mark and monitor drainage for chest tubes
q15, q 30, q1, q4,q8
what does a sudden increase in drainage mean?
could be internal bleeding
More than 150-200 ml when its been going down → need to let someone know
what does it mean if the chest tubes suddenly stop draining
expect its a clot
assess for air leaks and that connections are sealed
how will patient breathe with chest tube
they’ll be in pain so more shallow breathing –> can lead to atelectasis
pt should splint with pillow towel and be medicated
subq emphysema
When you palpate - feels like rice krispies = air is escaping from lungs
Happens if chest tube moves → air will escape into sub q tissue
Looks like edema
Long time to reabsorb back in
what is another complication of chest tubes
tension pneumo
what do you do if there is a dislodgement or accidental removal of chest tube
Petroleum gauze with DSD and occlusive tape: occludes the opening
paO2
Measures oxygen levels in arterial blood
No acid base role
Indicates hypoxemia when low
SaO2
Represents % of hemoglobin molecules that are bound with O2 in arterial blood
normal level of SaO2
93-97%
what can cause resp acidosis
May be result of inefficient pulmonary function or excessive production of CO2
CNS depression
Decreased ventilation
Pulmonary edema
causes of resp alkalosis (6)
Anxiety
Fear
Hypoxia
Pain
Head injury
Mechanical ventilation
causes of metabolic acidosis (4)
Diarrhea
GI losses
Renal failure
DKA / ketoacidosis (Ketones are produced when body is forced to use fat to create injury because lack of insulin that is converting glucose to energy
Fat is turned into ketones = acids → accumulate in bloodstream)
causes of metabolic alkalosis (4)
Vomiting
Diuretics
High NG output
Antacids
what is the normal amount of drainage in the drainage system
typically less than 100 cc/hr
what does excessive bubbling in the air leak monitor mean
can mean air leak
what does intermittent bubbling in the air leak monitor mean
pt might have pneumothorax (expected)
if chest tube becomes dislodge, what do you do?
Sterile dressing
Tape on 3 sides - allows air to escape and prevent pneumo
Notify MD
steps for chest tube removal
-Done at bedside by physician
-Gather supplies - sterile gloves, suture removal kit
-Teach valsalva’s maneuver - deep breath, exhale and bear down during removal – prevents air entering pleural space during removal
-Pre-medicate for pain
-Position semi fowler’s
-Monitor respiratory status, lung sounds, drainage, chest rising, dyspnea
-chest x ray to assess lung
6 goals of intubation
-Maintain alveolar ventilation appropriate for the patient’s respiratory & metabolic needs
-Correct hypoxemia and maximize oxygen transport
-Protect the airway
-Alleviate respiratory distress
-Prevent or reverse atelectasis
-Acid/base balance
