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Critical Care > Exam 5 Final > Flashcards

Exam 5 Final Flashcards

1
Q

define pneumothorax

A

air in the pleural space resulting in partial/complete lung collapse

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2
Q

define primary spontaneous pneumothorax

A

a pneumothorax without underlying lung disease

classically in tall, thin, young men in teens or 20s

thought to be rupture of subpleural apical blebs or bullae at unequally transmitted pressure change

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3
Q

define secondary spontaneous pneumothorax

A

a pneumothorax that results from an underlying lung disease

patients with severe COPD (FEV1 < 1L), HIV related, CF, or parenchymal disease

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4
Q

define iatrogenic pneumothorax

A

results from a medical procedure, usually involves needles

transthoracic needle, aspiration, thoracentesis, CVP placement, MV, CPR

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5
Q

define traumatic pneumothorax

A

penetrating or blunt chest trauma

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6
Q

define tension pneumothorax

A

intrapleural pressure is higher than intra-alveolar or atmospheric pressure

air continues to get into pleural space but cant exit

can cause impaired venous return, systemic hypotension, respiratory and cardiac arrest (PEA) within minutes without treatment

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7
Q

define bronchopleural fistula

A

opening between the airways and pleura that allows air to enter the pleural space

possibly by pneumonectomy, post-trauma, or infections

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8
Q

pathophysiology of pneumothorax

A
  1. air in pleural space
  2. lung collapse
  3. atelectasis
  4. chest wall expansion
  5. compression of great veins and decreased C.O. and venous return
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9
Q

etiology and epidemiology of pneumothorax

A

gas can enter the pleural space in 3 ways

  1. from lungs through perforation of visceral pleura
  2. from atmosphere through perforation of chest wall and parietal pleura
  3. from gas-forming microorganism in empyema in pleural space
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10
Q

classify general terms

closed pneumothorax

A

pleural space not in direct contact with atmosphere

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11
Q

classify general terms

open pneumothorax

A

pleural space in direct contact with atmosphere in which air moves freely in and out of opening

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12
Q

classify general terms

tension pneumothorax

A

intrapleural pressure exceeds intra-alveolar (atmospheric) pressure

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13
Q

what is the clinical manifestations of awake patient with traumatic pneumothorax

A

chest wound is painful

respiratory distress

air typically makes sucking sound

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14
Q

diagnosis of tension pneumothorax

A

clinical evaluation

requires inspecting the entire chest wall surface

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15
Q

treatment of traumatic pneumothorax

A

partially occlusive dressing followed by tube thoracostomy

immediate management to cover wound with gauze taped on 3 sides to allow air to exit

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16
Q

how does tension pneumothorax form

A
  1. air accumulates and compresses lung
  2. eventually shifts mediastinum
  3. compress the contralateral lung
  4. increases intrathoracic pressure enough to decrease venous return causing shock

this happens rapidly, typically in patients on PPV

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17
Q

signs and symptoms of pneumothorax

A
  1. increased intrathoracic pressure
  2. hypotension
  3. tracheal deviation
  4. JVD
  5. affected hemithorax is hyperresonant
  6. unilateral chest movement
  7. absent breath sounds
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18
Q

treatment for tension pneumothorax

A
  1. needle decompression (14 or 16g) into 2nd intercostal space midclavicular line
  2. tube thoracostomy immediately after
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19
Q

classification based on origin

traumatic pneumothorax

A

from penetrating wounds (knife, bullet, impaling object, crush chest injury)

pleural space in contact with atmosphere

AKA: sucking chest wound

may result in tension or closed pneumothorax

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20
Q

signs and symptoms of traumatic pneumothorax

A
  1. pleuritic chest pain
  2. dyspnea
  3. tachypnea
  4. tachycardia
  5. subcutaneous emphysema
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21
Q

diagnosis of traumatic pneumothorax

A
  1. chest x-ray
  2. ultrasonography
  3. CT
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22
Q

treatment for traumatic pneumothorax

A
  1. thoracostomy tube into 5th or 6th intercostal space anterior to midaxillary line
  2. bronchoscopy
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23
Q

describe pendeluft effect traumatic pneumothorax

A

on inspiration the air enters pleural space and shunts to the good lung

on expiration the air exits pleural space partially and shunts from good lung to bad lung

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24
Q

describe pendeluft effect tension pneumothorax

A

on inspiration air enters pleural space and shunts air to good lung

on expiration a flap closes exit from pleural space and air is exhaled normally

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25
Q

classification based on origin

spontaneous pneumothorax

A

sudden onset without underlying cause

secondary to underlying process (pneumonia, TB, COPD)

bleb or bulla rupture

often occurs in tall, thin males 15-35

acts as both a closed and tension pneumothorax

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26
Q

classifications based on origin

iatrogenic penumothorax

A

sometimes occurs during diagnostic or therapeutic procedures (biopsy, thoracentesis, intercostal nerve block, cannulation of subclavian vein, tracheostomy)

during PPMV

always a hazard

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27
Q

physical assessment findings of a pneumothorax

vital signs

A

tachypnea

tachycardia

hypertension

cyanosis

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28
Q

physical assessment findings of a pneumothorax

chest assessment

A

sharp chest pain

acute dyspnea

hyperresonant percussion note over unaffected

diminished over affected

tracheal shift “away” from affected

displaced heart sounds (PMI)

increased thoracic volume on affected side

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29
Q

physical assessment findings

tension pneumothorax

A

tracheal shift, mediastinal shift away

displaced heart sounds

increased thoracic volume on affected side

hypotension and JVD

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30
Q

what occurs in a tension pneumothorax to cause hypotension

A

compression of great veins and decreased C.O. and venous return

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31
Q

why would you see JVD with a tension pneumothorax

A

a build up in chest wall pressure decreases blood return to heart and causes JVD

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32
Q

ABG with small pneumothorax

A

acute respiratory alkalosis (alveolar hyperventilation) with hypoxemia

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33
Q

ABG with large pneumothorax

A

acute respiratory acidosis (ventilatory failure) with hypoxemia

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34
Q

how does a pneumothorax affect oxygen indicies

A 
QS/QT - increases
DO2 - decreases 
VO2 - normal
C(a-v)O2 - increases
O2ER - increases
SvO2 - decreases
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35
Q

how does pneumothorax affect hemodynamics

A 
CVP - increase
RAP - increase
PAP - increase
PCWP - decrease
CO - decrease
SV - decrease
SVI - decrease
CI - decrease
RVSWI - increase
LVSWI - decrease
PVR - increase
SVR - decrease
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36
Q

radiologic findings of pneumothorax

A

increase translucency (hyperlucency) and loss of vascular markings on affected side

atelectasis

mediastinal shift to unaffected side in tension pneumothorax

depressed diaphragm

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37
Q

general management of small pneumothorax (15-20%)

A

patient may only need bed rest or limited physical activity

resorption of intrapleural gas occurs within 30 days

38
Q

general management of large pneumothorax (>20%)

A

evacuate

suction used: negative pressure used -5 to -12 cmH2O

after re-expansion and bubbling in suction chamber ceases; CT clamped and left for 24-48 hours without suction

39
Q

general management of pneumothorax

pleurodesis

A

chemical or medication injected into chest cavity (Talc, tetracycline, bleomycin sulfate)

produces inflammatory reaction between lungs and inner chest cavity (lung adhere to chest cavity)

40
Q

where do you place a chest tube

A

anterior - 2nd intercostal space, midclavicular line directed at apex

lateral - midaxillary line between 5-7 intercostal space

41
Q

define flail chest

A

double rib fracture of at least 3 adjacent ribs, resulting in an unstable thoracic cage

42
Q

what happens on inspiration and exhalation of a flail chest

A

inspiration ribs cave in

expiration ribs balloon out

43
Q

anatomic alteration of flail chest

A
  1. double fracture of numerous adjacent ribs
  2. rib instability (tx: PEEP)
  3. lung restriction
  4. atelectasis
  5. lung collapse (pneumothorax)
  6. lung contusion (bruise)
  7. secondary pneumonia
44
Q

a flailing chest wall will result in what type respiratory failure

A

type 2 (ventilatory) due to pendeluft effect

45
Q

a lung contusion will result in what type respiratory failure

A

type 1 (oxygenation) due to diffusion defect

46
Q

etiology of flail chest

A

crush chest injury result of

  1. MVA or blunt trauma
  2. falls
  3. blast injury
  4. direct compression
  5. occupational and industrial accident
47
Q

physical assessment of flail chest

A

paradoxical movement of chest wall

paradoxical movement may not be present if patient is tense

crepitation from ends of ribs moving against each other

signs and symptoms of pneumothorax

48
Q

physical exam findings of flail chest

A

vitals - tachypnea, tachycardia, HTN

chest wall paradoxical movement

cyanosis

breath sounds diminished on effected and unaffected side

49
Q

ABG findings mild to moderate flail chest

A

acute respiratory alkalosis

50
Q

ABG findings severe flail chest

A

acute respiratory acidosis

51
Q

how does flail chest affect hemodynamics

A 
CVP - increase
RAP - increase
PAP - increase
PCWP - decrease
CO - decrease
SV - decrease
SVI - decrease
CI - decrease
RVSWI - increase
LVSWI - decrease
PVR - increase
SVR - decrease
52
Q

radiologic findings flail chest

A

increased opacity

rib fractures

increased density on affected side

53
Q

treatment in mild case of flail chest

A

pain management

routine bronchial hygiene

54
Q

treatment in severe cases of flail chest

A

VC MV with PEEP

take 5-10 days form bone to start healing

55
Q

define pleural effusion

A

any abnormal accumulation of fluid in pleura

56
Q

anatomic alterations of lung with pleural effusion

A

lung compression

atelectasis

compression of great veins and decreased C.O. and venous return

57
Q

mechanics of ventilation in pleural effusion

A

effusion causes atelectasis due to limited thoracic space resulting in restrictive PFTs

commonly dyspneic

rare to cause fibrothorax

hypoxemia causes increased P(A-a)O2

58
Q

define transudate pleural effusion

A

increased hydrostatic pressure move fluid from parietal pleura capillaries into pleural space

pleural surface not involved in production of transudate

59
Q

define exudate PE

A

fluid has high protein count and cellular debris

usually caused by inflammation and the pleural surface is diseased

roughly 70% of all PE

60
Q

Etiology of transudate PE

A

CHT (most common)

hepatic hydrothorax (Ascites)

peritoneal dialysis

pulmonary embolus

hypoalbuminemia

lymphatic obstruction

nephrotic syndrome

61
Q

what are the primary causes of transudative PE

A

abnormal hydrostatic pressure

abnormal oncotic pressure

62
Q

etiology exudative PE

A

malignant PE and mesotheliomas

bacterial pneumonias

tuberculosis

fungal disease

PE result from disease in GI tract

PE result from collagen vascular disease

postoperative

63
Q

etiology pathologic pE

A

emphyema

chylothorax - ruptured thoracic duct

hemothorax - trauma or blood vessel hemorrhage

64
Q

A lab report shows a pleura effusion protein level of 10 g/dL together with the presence of malignant cells on the cytology report. You would classify this effusion as a:

A

exudate

65
Q

Complications from a parapneumatic pleural effusion may often lead to the formation of:

A

empyema

66
Q

physical assessment of PE

A

tachycardia

tachypnea

HTN

chest pain/decresed excursion

cyanosis

dry nonproductive cough

67
Q

chest assessment of PE

A

tracheal shift

decreased tactile/vocal fremitis

dispalced heart sounds/PMI

plueral friction rub

breath sounds diminished, fine crackles

68
Q

radiologic findings of PE

A

upright PA or lateral decubitus

blunted costophrenic angles (meniscus)

depressed diaphragm

mediastinal shift - unaffected side

atelectasis

excessive pleural fluid - affected side, radiopaque

69
Q

diagnostic testing for PE

A

thoracoscopy - visualize

thoracentesis - drainage

70
Q

describe thoracoscopy

A

ideally desgined for diagnostic and therapeutic pleural procedures

allows visualization of surfaces, drainage of effusion, biopsy, and pleurodesis

perform under local anesthesia and conscious sedation

71
Q

describe thoracentesis

A

percutaneous needle aspiration of effusion sample

drainage for lung reexpansion involves placement of chest tube

72
Q

risk of thoracentesis

A

artery laceration

infection

pneumothorax

73
Q

Which of the following is considered the most sensitive procedure to assess size and location of a pleural effusion?

A

CT scan of chest

74
Q

general management of PE

A

must be individualized

exam of pleural fluid for transudate or exudate assessment

pleurodesis

chest thoracotomy tube

pleuroperitoneal shunt & pleurex catheter

75
Q

describe pleurodesis

A

chemical or medication injected into chest cavity adhereing lung to chest wall

76
Q

describe pleuroperitoneal shunt and pleurex catheter

A

for effusions refractory to all other treatments

small pump moves fluid from pleura to peritoneal cavity

pleurex catheter connects to suction at home to drain persistant effustion

77
Q

indications of pleural chest tube

A

tension pneumothorax

pneumothorax (>10-20%)

hemothorax

emphyema

pleural effusion

chylothorax

78
Q

indication for mediastinal chest tube

A

free air or blood

79
Q

indication for pericardial chest tube

A

cardiac tamponade or pneumopericardium

open-heart surgery

80
Q

goals of a chest tube

A

removal or air/fluid from space (pleural, mediastinum, pericardial)

prevent fluid/air from gaining reentry to cavity

lung re-expansion (primary goal)

81
Q

components of chest tube

A

CT tubing

flexible tubing connecting CT to drainage system

1-4 compartment drainage system (1-4 bottle, disposable drainage system)

82
Q

describe 1 bottle drain system

A

tube from patient submerged 2cm into sterile H2O (PPV +2)

tube on top allows vent to atmosphere

water-seal - air leaves and not reenter

tidalling - result of pressure change

combined water seal and collection bottle

only for air

83
Q

describe 2 bottle drain system

A

collection bottle and water seal chamber

rate and amount of drain can be measured

gravity dependent

disadvantage cant drain large leak

air and fluid

84
Q

describe 3 bottle drain system

A

collection

water seal

suction chamber

can be for air or fluid

85
Q

chest tube placement for pneumothorax

A

2-3 intercostal space midcalvicular or midaxilarry

directed at apex

86
Q

chest tube placement for hemothorax or pleural effusion

A

5-7 intercostal space midaxillary

directed inferior and posterior

87
Q

CT insertion procedure

A

instruct patient

gather equipment

set up drain system

prepare site

insert CT proper location

cover with sterile occlusive dressing

place drain system below CT

attach suction

confirm placement

88
Q

troubleshooting patient with CT

A

deterioration of condition indicated tension pneumothorax

notify physician immediately

bag on 100 Fio2 if on MV

89
Q

troubleshooting drain system of CT

tidalling and bubbling present

A

indicates patient has air leak (pneumothorax)

90
Q

troubleshooting drain system of CT

no tidalling or bubbling present

A

indicates lung re-expansion or obstruction by kinks or clots

91
Q

troubleshooting drain system of CT

no tidalling
bubbling present

A

indicates possble connection or system air leak

92
Q

troubleshooting drain system of CT

tidalling present
no bubbling

A

observed with peumonectomy or decreased lung compliance

Critical Care (4 decks)

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