Final Exam Flashcards
How much O2 in atmosphere?
21% O2
Nasal Cannula
-24-44% o2
-1-6L
Reservoir Cannula
-conserve o2, stored in reservoir
-100% o2 in each breath
-retains exhhaled air
High Flow Cannula
-1-15L w/ humidification
-24-75% o2
-not harsh on nose
Simple O2 Mask
-6-10L
-30-70%
-6L minimum to brevent rebreathing
Face Tent
-for mouth breathers or facial trauma
-8-15L
-21-40%
Aerosol Mask
-liquid medicatitons into mist
-must be able to see mist
-8-15L
-21-60%
Venturi Mask
-rroom air mixed with specific concentration
-color coded
Nonrebreathing Mask
-highest 02
-75-100%
-8-15L
-bag must be 1/3-1/2 full
-might be close to intubation
Tracheostomy Mask
-straight into tracheostomy tube
-35-60%
-10-15L
High Flow humidification Systems
-up to 60L
-up to 100% o2
-humidified and warmed air
Mechanical Ventilation
-meet physiological needs of pulmonary system
- Rrespiratory failure
- Protection of airway and lung
- Relief of upper airway obstruction
- Improvement of ulmonary toilet (unable to clear airways)
Paradoxical Breathing
-diaphragm fatigued from working hard
-must be inubated
Ventilator Settings to Know
-mode of ventilation
-FiO2: o2 concentration being administered (>60 concern)
-PEEP
Ventilator Patient Data to Know
-Minute ventilation
-respiratory rate
PEEP
-Positive End Expiratory Pressure
-resisdual pressure in alveoli after exhalation
-pressure required to inflate alveoli and prevent collapse
Low PEEP 3-5: normal
Moderate PEEP 5-15: treat refractory hypoxemia
High PEEP >15: severe lung injury
-put pressure on IVC and decreased CO
Mode of Ventilation
-how breath is delivered
- Assist-Control
- SIMV and Pressure Support
- Pressure Support
Assist-Control
-non weaning: breathing for patient
-rate and tidal volume pre-set
-patient can trigger breaths with pre-set tidal volume
SIMV
-synchronized intermittent Mandatory Ventilation
-Weaning mode: starting to take them off
-rate and tidal volume pre-set
-patient can trigger breaths with pressure support instead of pre-set tidal volume
Pressure Support Ventilation
-weaning mode: 0-30cmH20 (10 normal)
-applies to spontaneous breaths
-tidal volume not pre-set
-NOT air, only pressure
CPAP
-constant positive pressure applied in airways
-noninvasive ventilation
BIPAP
-Bi-level pulmonary airway pressure
-noninvasive ventilation
Hypoxia
O2 concentration of tissues
Hypoxemia
O2 concentration of blood
Right Shift in O2 Concentration
-reduced affinity for for O2, higher po2 will result in lower hemoglobin concentrations
-high temp, high acidity
Left Shift in O2 concentration
-increased affinity for O2, lower po2 will result in higher hemoglobin concentrations
-low temp, basic environment
Ventilation to Perfusion Ratio (V/Q)
-blood flow to alveoli must match ventilation or =hypoxemia
-changes with posture
-Norm: 0.8
Reduced: decreased ventilation to perfusion, blood shunted to other parts of the lung, vasoconstriction at arterioles to reduce BV, corrected with O2
Increased: increased ventilation to perfusion, vasodilation to increase BV, dead space
Arteriole Vasoconstriction
-alpha receptors
Shunt blood to muscles, from skin and mesenteric
Arteriole Vasodilation
-induced by increased vessel stretch
-induced by low O2 or high H+, CO2, metabolites
Beta Receptors
-increased blood flow to Skeletal muscle
-increase ventilation and alveolar perfusion
Most common cause of pulmonary congestion
-heart failure
-mostly right side affected
Pulmonary Embolism
-lung infarction due to decreased BV
-increased pulmonary hypertension
-increases load to right side of heart
-presence of ascities, bilateral LE edema and jugular vein distension
-increases V/Q ratio
Pulmonary Hypertension
-risk for cardiac disease
->20mmHg
-increased R ventricle work (Swangan’s Catheter)
Respiratory Cycle
Inspiration: 1/3, faster and louder
Expiration: 2/3, slower and softer
Vesicular Breath Sounds
-most of lung area
-inspiratory longer than expiatory
-soft
Brocho-Vesicular Breath Sounds
-near midline around upper spine and sternum
-inspiratory equal expiatory
Bronchial Breath Sounds
-above manubrium
-loud
-inspiratory shorter than expiatory
Chest Tubes
-placed to suction air or fluid
-avoid pulling out, dont tip over, treat as drainage tube
-encourage upright positions, ambulation and deep breathing
Anesthesia
-restrictive
-depresses breathing and diaphram contractions (intubation)
-decreases TLC, FRC, RV, lung compliance
-can cause collapse, shunting, atelectasis
-consider time under and O2 given during procedure
-airway obstructions from tubes/fluids
FRC
-causes alveolar collapse in supine
PT Intervention Goal
-prevent bedrest issues
-weightbearing activites
-ADLs
-pulmonary toilet/normal breathing
-o2
-family support
Incentive Spirometry
-ball rises as patient inspires
-helps inflate the lungs
Positive Expiratory Decives: Acapella
-vibratory PEP therapy
-exhale through device and vibrations looses secretions
-10x followed by huffs and a cough
Inspiratory Muscle Training
-use if pt can diaphragmatically breath w/o accessory muscles
-90-90-90 positioon, nose clippped, back supported
-lower pressures= weakness
Maximal Inspiratory Pressure:
-expire fully then maximal inspire
-can be used with sniff pressure
Maximal Expiratory: inspire fully then perfoorm maximal expiratory
IMP Endurance
-15-20% MIP
-30min/day
IMP Strength
-50-60% MIP
-train to failure 25-35 breaths
High Frequency Chest Wall Oscillation
-vibration of chest wall to remove secretions
Bed Rest Effects
Cardio:
-increased resting HR, risk of DVT
-decreased max HR, Vo2max
Respiratory:
-decreased vital capacity, inpaire toilet, increase V/Q mismatch
Abnormal Response to Exercise
-HR increase 20-30 or drop below resting
-SBP increase 20-30 or drop by 10
-Spo2 drop
-High RR, accessory muscles
Coronary Artery Bypass Graft
-CABG
-open heart surgery
-place another vessel from one spot to bypass blockage (radial arteries, saphenous veins, mammary arteries)
On pump: extensive, machine pumps for heart
Off pumo: minimally invase
Check:
-hemoglobin, hemocrit, xrays, nurses and drs, temporary pacemakers
Sternal Precautions
-limit movement for 6-8 weeks
-gentle coughing
-move “in the tube”: keep arms to the side
-infection control/incision
Intra Aortic Balloon Pump
-severe heart failure; shock
-restore CO and perfusion
-inserted in femoral (bedrest) and axillary (might be allowed to exercise) to ascending aorta
-balloon inflates and deflates to increase CO by 40%
Complications: dissectiono, perforation, ischemia, emboli
Mechanical Circulatory Support Steps
Bridge to recovery: allow organ to regain function
Bridge to Decision: determine if transplant candidate
Bridge to transplant: keep paitents alive before transplant
Destination Therapy: prolong survival and quality of life
Fried Frailty Phenotype
-weight loos, low PA, slow gait, exhaustion, weakness
Impella Device
-cathater based ventricular assist device (hook)
-increased blood flow from LV to aorta 2.2-6.2 L/min
ECMO
-Veno-Arterial Ecmo: supports heart and lungs
-Veno-venous Ecmo: supports lungs
-cannot be turned off by PT
LVAD
-Left ventricular assist device
-pump blood from LV to aorta
-has outer controller
-3-10L/m (drop in flow could be pump failure)
-Speed usually fixed (abnormal condition)
-10 Watts
-Pump Index (higher is better LV function
Complications:
-bleeding, infection, MAP
Heart Transplant
Indications:
-CHF, Cardiomyopathy, low prognosis
Post op:
-infections, low response to activity, sternal precautions
Denervated heart:
-no ischemic pain
-higher RHR >90
-slower HR changes
-orthostatic HTN
Lung Transplant
Single:
-Thoracotomy
Double:
-clamshell
Complications:
-pneumothorax, plural effusion, hypoventilation, phrenic n injury
Denervated Lungs:
-decreased cough reflex, ciliary mmt
-Increased infection risk, edema, mucous
Chest Wall Excursion Skills
-Direct Technique
-Tape Measure
Chest Wall Examination SKills
-Bronchohony
-Egophony
-Whispered Pectoriloquy
-Mediate Percussion
-Diaphragmic Excursion
Trachial Deviation
-determine if trachea is in midline position
Lower Lateral Costal Breathing
Explain: I’m going to show you how to focus on your ribs movements as you breathe to make sure you get enough air in, i will be palcing my hand on the sides of your lower ribs
-position Pt < palpate lower ribs < instruc Pt to “breathe into my hands”
Abnormal Breathing
- inward motion of abdomen during inhalation
-upper chest moves excessively
-excessive use of accessory muscles
Diaphragmatic Breathing
-ease breathing in a controlled manner
-in all positions
Explain: I’m going to teach you a breathing technique tha focuses on using your diaphragm so you can do less work to breathe
Position patient upright < palpate diaphram and place Pt hand on it and upper chestt < instruct them to breath in through the nose and slowly through their mouth < encourage them to feel it more in their belly than chest
Segmental Breathing
Explain: I’m going to teach hhow to focus on expanding different parts of your belly and chest as you breathe so we can decrease the amount of work your body has to do
-i will be palcing my hand on your chest and belly
-place hand in diaphragm scoop < instruct to breathe into hand < place other hand low on sternum < instruct to breathe into hand < place first hand into upper sternum < instruct to breath into hand
Scoop Diahragmatic Breathing
-allows Pt to feel the breathing in their diaphragm as they do it by following the scoop motion, self cues
-“i will be palcing my hand on the front of your stomach”
-position patient up right < palpate breathing pattern < scoop diaphragm instruct to “breathe into hand” < scoop upward during exhalation < after some breaths place Pts hand there
-CHANGE POSITION IF NEEDED
Sniffing Breathing Technique
-Pt with weak diaphragm or controlled doesn’t work
-sit patient up with bent knees
Intruct:
-3 small sniffs, let it out slowly
-2 small sniffs, let out slowly
-1 long sniff, let out slowly
Pursed Lip Breathing
-used with emphysema Pt
-slows down exhalation and maintains pressure in airways
-makes it easier for next breath
Relax mouth < inhale < purse lips and exhale slowly
DONT USE IF ACUTELY SOB
Basic Ventilatory Strategies for Inhalation
-trunk extension
-shoulder flexion, abduction, ER
-against gravity
Basic Ventilatory Strategies for Exhalation
-trunk flexion
-shoulder extension, adduction, IR
-into gravity
Posture Strategies for Ventilation
-Butterfly technique (w/ rotation)
-Modified PNF Bilateral UE (flx/ext)
-Lateral Costal Expapnsion
-Diaphragmatic Cues
-Segmental Breathing
Thoracic Mobility Exercises to Enhance Inspiration
Explain: I’m going to teach you an exercise to help you expand your ribcage to take larger breaths
Butterfly:
Patient sitting < hands behind your head in a slouched position < bring elbows out as you inhale deeply < exhale normally through mouth as you come back to start
Home exercise:
Patient sitting < hands down by feet in a slouched position < bring arms and chest up as you inhale deeply < exhale normally through mouth as you come back to start
-to expand one side abduct ipsi arm and SB to contra
Thoracic Mobility Exercises to Enhance Expiration
Explain: I’m going to teach you an exercise to help you close your posture to take release breaths out
Butterfly:
Patient sitting < hands behind your head in a slouched position during inhale normally through the nose < bring elbows down by your ears as you exhale with PURSED LIPS < inhale normally through nose as you come back to start
Home exercise:
Patient sitting < inhale trough nose normally < hands down by feet in a slouched position as you exhale through PURSED LIPS < inhale normally through nose as you come back to start
-to expand one side abduct ipsi arm and SB to ipsi too force out air
Postural Drainage
Prone (head down): superior lobes, posterior basal
Sidelying (head down a little): lateral lobes
Supine: anterior lobes, middle lobe
Forward Lean: posterior and superior lobes2
Percussion
Explain: To loosen and remove secretions i’m going to do some cupping and precussion, Show on leg
Position to help gravity drain into larger areas < cup hands and percusses for 15-30s < reasses vitals < repeat 3x < add vibration on exhale < reasses vitals
CONTRAINDICATIONS:
-hemmorage, emoblism, new babies with respiratory issues, subcutaneous emphysema, pneumothorax, bone issues, osteoporosis
-COPD: can cause spasms, pursed lip exhalation, more secretions
Vibration
-used on chest wall during exhalation
-can be used when percussion not tollerated
CONTRAINDICATIONS:
-hemmorage, emoblism, new babies with respiratory issues, subcutaneous emphysema, pneumothorax, bone issues, osteoporosis
-COPD: can cause spasms, pursed lip exhalation, more secretions
Special Considerations for Airway Clearance with COPD
Percussion can cause spasms, pursed lip exhalation, more secretions
-avoid forced exhalation
-head down might not be tolerated
Coughing
Explain: I’m going to teach you how to prepare and to cough to best clear the lungs of secretions
Position: upright with towel <Teach Thoracic Expansion < hold on inspiration < Recruit abdominals by tightening muscles like preparing for a punch < hunch over and cough into napkin
CONTAINDICATIONS:
-surgical incisions, aortic aneryism, hemmorage, wounds, tolerance
Huffing
Explain: I’m going to teach you another technique when coughing isn’t working. It is more of a forced breath like fogging up your glasses
Sit patient upright with towel < segmental thoracic expansion < hold on inspiration < recruit abs < open mouth on an “O” and huff while flexing trunk
-good for noneffective coughs, COPD less forced exhale
Active Cycle Breathing Technique
Explain: We will combine deep breathing, huffing, and coughing
Relaxed diaphragmatic breathing < gradually breathing deeper (note crackles early are large airways and late are small airways) < Add thoracic expansion < inspire and hold 3s < relaxed exhalation in sigh < 1-2 huffs < if felt in upper airways cough gently < relax breathing
Autogenic Breathing
-self drainage to control mucus
Explain: Self drainage to control mucus
-breathe normally, breath diaphragmatically for 3-4 breaths, exhale completely, inhale maximally, let me know when you feel secretions
Level 1: Unsticking of mucus
-avoid coughing < exhale completely < inhale a small breath and hold 1-3s < repeated until crackles are heard
Level 2: Collecting the mucus
- avoid coughing < slighly larger breath < hold for 1-3s < slight exhale < repeat until crackles heard at the end of exhale < continue for 2-3 more breaths
Level 3: Evacuating mucus
-slow deep breath < hold 1-3s < exhale forcefully in a < spit out secretion < if not, do 2-3 large huffs
Patient Paced Diaphragmatic Breathing (Emphysema)
-allows for ambulation, prevents dypnea, helps with management of dypnea
Explain: I’m going to teach you how to breathe properly during different activities to conserve your energy while we move.
-you will inhale normally and exhale through pursed lips
Supine < Palpate diaphragm and tell to breathe into hand < exhale and PURSE LIPS during transitional mmt (roll to sit) < put on gait belt < show relief position if needed (bend over and breathe into belly) < reminder to pace themselves < walk and guard
Diaphragmatic Breathing (Obstructive/Emphysema))
-ease breathing in a controlled manner
-in all positions
Explain: I’m going to teach you a breathing technique tha focuses on using your diaphragm so you can do less work to breathe
Position patient upright < palpate diaphram and place Pt hand on it and upper chest < instruct them to breath in through the nose REGULARLY and slowly through their mouth with PURSED LIPS < encourage them to feel it more in their belly than chest
Emphysema
-COPD
-Obstructive
-red skin, skinny, pursed lips
-working hard to exhale air, can still oxygenate
-hypercompliant lung balloons alveoli trapping air
-O2 desaturation during exercise
Panacinar: alveoli only, genetic
Centrilobular: bronchioles only, progression of bronchitis
Chronic Bronchitis
-COPD
-obstructive
-inflamation of bronchioles obstructing/narrowing airway and increasing mucous/cough
-“blue bloater”
S/S:
-Cor pulmonale, jugular vein distension, edema, decreased FEV1
Segmental Thoracic Expansion
-place hand in diaphragm under constal angle < instruct to breathe into hand < place other hand low on sides of ribs < instruct to breathe into hand < place first hand into upper ribs; apical (not sternum) < instruct to breath into hand
CONTRAINDICATIONS:
-pneumothorax, hemmorage
Tracheal Tickling Technique
-if effective cough cannot be produced
-apply digital pressure to trachea, right above sternal notch, move side to side
Tongue out Technique
-if effective cough cannot be produced
-deep breath and stick toungue out before cough
Chest Wall Excursion: Direct Technique
Explain: I’m to place my hands on your shoulders, chest and mid back to see how it expands on each side
-Breathe normally, looking for symmetrical movement
-inhale maximally
Apixal:Palms at upper trap, thumbs meet at clavicles
Middle: palms below nipple line, thumb meet at middle
Posterior Lobe: behind Pt, palms under 10th rib
Chest Wall Excursion: Tape Measure
Explain: I’m to meaure your chest and mid back to see how it expands on each side when breathing
-Breathe normally 1st
-inhale maximally 2nd round
-measure at 3 and average (8.5cm)
Upper: 4th costal cartilage
Middle: xiphoid process
Lower: 9th constal cartilage
Bronchophony
Explain: I’m going to listen your lungs and see how equal the sounds are on both sides while you repeat certain sounds
-chest wall examination using stethoscope
-listen for increased (consolidation) or decreased sounds
-say “Blue moon” and listen to changes in each lobe
Egophony
Explain: I’m going to listen your lungs and see how equal the sounds are on both sides while you repeat certain sounds
-chest wall examination using stethoscope
-listen for increased (consolidation) or decreased sounds
-say “eeeee” and check for shifting sounds to “aaaaa”
Whispered Pectoriloquy
Explain: I’m going to listen your lungs and see how equal the sounds are on both sides while you repeat certain sounds
-chest wall examination using stethoscope from top to bottom and side to side
-listen for increased (consolidation) or decreased sounds
-Whisper “99” and check for differences
Mediate Percussion
Explain: I’m going be tapping my fingers along your chest and back to see if the sounds change from side to side
-strike finger at intercostal spaces anterior and posterioly over each lobe
Expectations:
Resonant (low longer) sounds over the lungs; filled with air
Dull: (higher pitched and shorter) indicate more dense structures/fluid, consoldation
Hyper-resonant: very low pitched and long; decreased tissue (emphysema)
Flat: muscle
Tympanic: high pitched, hollow structures
Diaphragmatic Excursion
Explain: I’m going to tap several parts of your back to listen to how your diaphragm is moving as you breathe
-inhale and hold your breath
-Exhale and hold your breath
-tap down back from T7 and listen to where the resonant sound stops both time
-measure disance (3-5cm norm)
-repeat on other side
Restrictive Lung Diseases
-decreased in vital capacity
-lung compliance reduced and stiffness limits expansion
-lower ventilation
Ex: pneumonia, collapsed lung
Diaphragmatic Breathing (Restrictive)
-ease breathing in a controlled manner
-in all positions
Explain: I’m going to teach you a breathing technique tha focuses on using your diaphragm so you can do less work to breathe
Position patient upright < palpate diaphram and place Pt hand on it and upper chest < instruct them to take a DEEP breath in through the nose and slowly through their mouth in a SIGH < encourage them to feel it more in their belly than chest
Right Bronchial Tree
-more vertical/short, more chance of asperation pneumonia
Diffusion
-Co2 diffuses 4x faster than O2
-co2 sensitive to changes in ventilation
-o2 sensitive to changes in ventilation and diffusion
-need blood flow, air, close to capillary wall, sufficient o2
-takes 1/2 time RBC is in capillary to diffuse
CO2:
-Co2 (capillary) 46 + C02 (alveloi) 40 = co2 goes into alveoli
-Co2 (capillary) 40 + C02 (tissue) 46 = co2 goes into vein
O2:
-O2 (capillary) 40 + O2 (alveloi) 100 = O2 goes into capillary
-O2 (capillary) 100 + O2 (tissue) 40 = O2 goes into tissue
Hypercapnic
-increased Co2
-hypoventilation: increases Co2, lowers pH
>45 PaCo2
Hypoxemia
-decreased blood o2
<80% PaO2
Diaphragm
-right sits higher
-tends to go upward with surgery and obesity
Hypercompliant Lung
-stretches excessively without returning to normal during exhalation
-increased FRC, PaCo2, airway resistance
-Decreased PaO2, intrathoracic pressure
-COPD, Obstructive
Hypocompliant Lung
-does not expand or contrac correctly
-decreased VC and RV
-increased work and pressure
-restrictive, obesity, surgery
Tidal Volume
-500ml
-amount of air moved in and out in each breath
Inspiratory Reserve Volume
-3000ml
-max inspiration after normal inspiration
-decrease with restrictive
Expiratory Reserve Volume
-1100ml
-max one can expire after normal exhale
Residual Volume
-1200ml
-volume of air left in lungs after max exhale
-FRC-ERV=RV (cannot be measured)
Functional Residual Capacity
-volume of air in lungs after normal expiration
-RV + ERV
(cannot be measured)
-balances lung and chest wall forces
Inspiratory Capacity
-max volume one can inspire
-TV+ IRV
-decrease with restrictive
Vital Capacity
-max volume one can exchange in a respiratory cycle
-IRV+TV+ERV
-decrease with restrictive
Total Lung Capacity
-air in lungs during full inflation
-IRV+TV+ERV+RV
-RV+VC=TLC
(cannot be measured)
-decrease with restrictive, increase obstructive
FEV1
-forced expiratory volume in 1 sec
-80% of predicted/max
-based on age, gender, race, height
FVC
-forced vital capacity
-how much can you force out and in
FEV1/FVC
-percentage of vital capacity exhaled in 1 sec
->70% norm
Dynamic Airways Resistance
-increases as lung volumes dec
-forced exhalation increases resistance
Obstructive: longer exhale, more air out
Restrictive: faster exhale, less air out
Ventilation to Perfusion Ratio (V/Q)
-blood flow to alveoli must match ventilation or =hypoxemia
-changes with posture
-Norm: 0.8
Reduced: shunt, decreased ventilation to perfusion, blood shunted to other parts of the lung, vasoconstriction at arterioles to reduce BV, corrected with O2
Increased: dead space, increased ventilation to perfusion, vasodilation to increase BV, dead space
Control of Respiration
-increased CO2 increases ventilation and breathing drive
-Decreased O2 weakly stimulates (<60)
PaO2/Co2
-partial pressure of arterial O2 (80-100) /Co2 (35-45)
SaO2
-o2 sat of arterial hemoglobin (>90%)
HCO3-
Bicarbonate ion concentration (22-26)
pH
-<7.4 acidic
->7.5 alkaline
7.35-7.45
Hgb
-hemoglobin (12-16)
Hypocapnia
-Hyperventilation: raises pH, reduces Co2
-PaCo2 <35
Acid Base Regulation
-kidneys can extrete or retain HCO3 (slowly)
Increased Ecretion: low pH, metabolic acidosis
Decreased Extrcetion/Increased Retention: high pH, metabolic alkalosis
-respiratory
Hyperventilation: raises pH, reduces Co2, respiratory alkalosis
Hypoventilation: increases Co2, lowers pH, respiratory acidosis
Respiratory Acidosis
-excess CO2, low pH
Causes:
-CNS depression
-ashyxia/hypoventilation
Compensation:
-high HCO3-
S/S:
-sweating, headache, tacycardia, restlessness
Respiratory Alkalosis
-low CO2 (excretion), high pH
Causes:
-hyperventilation
-respiratory stimulation
-bacteria
Comensation:
-low HCO3-
S/S:
-rapid breathing, parasthesia, light headedness, twitching
Metabolic Alkalosis
-HCO3- retention (acid loss), high pH
Causes:
-renal disease
-vomiting
-decreased K
Compensation:
-high CO2
S/s:
-shallow breathing, confusion, twitching, restlessness
Metabolic Acidosis
-HCO3- loss (excretion), low pH
Causes:
-kidney disease
-hepatic disease
-endocrine disorders
-high K
Compensation:
-low CO2
S/s:
-rapid breathing (kuzmals), fatigue, fruity breath, headache
Acid Base Values
-pH, PaCO2, HCO3
Ventilation Values
-PaCO2
Oxygenation Values
-PaO2, SaO2, Hbg
Evaluate ABG Results
- pH
-high= alkalosis
-Low= acidosis - CO2
-high: resp acidosis (with low pH)
-low: res alkalosis (with high pH) - HCO3
-high: metabolic alkalosis (with high pH)
-low: metabolic acidosis (with low pH) - Compensatory
ABG Short Cut
Metabolic: look @ pH and HCO3- same (look at co2 for compensations-must be same)
Respiratory: look @ pH and CO2-different (look at HCO3 for compensations-must be same as CO2)
Obstructive Disorders
-airway obstruction, reduce flow rates
-asthma, COPD, cystic fibrosis
-FEV1/FVC= <70%
Restrictive Disorders
-reduction in vital capacity
-pulmonary or neuro
Acute:
-atelectasis, pneumothorax, pneumonias, respiratory distress syndrome, Pleural effusion, ascities, LVAD
Chronic:
-BPD, pulmonary fibrosis, SLE, scleroderma, cancer, skeletal issues, neuromuscular issues
GOLD COPD Scale
1-4
-Mild (FEV1 >80)
-Moderate (FEV1 50-80)
-Severe (FEV1 30-50)
-Very Severe (FEV1 <30)
or number x exacerbation history A-D
Asthma
-Obstructive
-bronchospasm/increased thickness and airway narrowing due to increased irritants
Irritants: allergens and enviornment or exercise
Brochiectasis
-obstructive
-dilation of bronchial walls due to scar tisue or stretched from coughing
-reain secretions
Atelectasis
-most common restrictive
-partial collapse of alveoli
Microatelectasis: alveolar collapse
Obstructive Atelectasis: occluded bronochus
Causes:
-inadequate pressure, chest wall deformity
Pneumonias
-restrictive
-bacterial, chemical, aspiration
Bronchial:
-infection
-little consolidation
-wet cough
Lobar:
-infection
-consolidation
-dry cough
Acute Respiratory Distress Syndrome
-restrictive
-life threatening (multy system organ failure)
-damage to alveoli cells
-fluffy look on xray
Causes:
-injury
-pneumonia
-embolism
SNS Increasing Medications
-good for pulmonary sys
PNS Increasing Meds
-bad for pulmonary sys
Bronchoconstriction
-smooth muscle contraction
-in most obstructive pathophysiology
-Normal: balance between SNS and PNS activity
Pulmonary Med Categories
-bronchodilation
-mucociliary clearance
-alveolar ventilation
-control of breathing
Sympathomimetic Agents
-mimic SNS, increase HR and BP
Cause:
-anaphylaxis and asthma
Action:
-activate Beta 2 adrenergic receptors to bronchodilate
-epinephrine for emergent situations
Beta 2 Agonists
-bronchodilation
Short acting:
-3-5 mins for 4-6 hours
-rescue inhalers
S/e: cough, high HR, tremors
Selective Beta 2 Agonist (SABA):
-long or short time
-treat bronchospasms for COPD
-rol ending
Long Lasting Beta 2 (LABA):
-12+ hours
-used for maintenance and COPD sleep
Epinephrine
-for emergencies to bronchodilate
-non selective
s/s: increase BP, dizziness, tremors, increase HR
Decongestants
-stimulate alpha-adrenergic vasoconstriction of capillaries in nasal mucosa
-reduction of fluid
S/s: dizziness, HTN, nausea, cardio irregularities
Parasympatholytic Agents
-mimic PNS, bronchodilation
-Vagus: PNS input to lungs
-Acetylcholine: nicotitnic and muscarinic receptors
Muscarinic Antagonists
-for heart when bradycardic
-lung bronchodilation
Atropine (MC)
-reduces secretions
-used to paralyze respiriatory sys due to poisoning
-not for asthma
Methylxanthines
-promote increases in cAMP by stoping the breakdown by phosphoodiesterase
-cAMP is precursor to epinephrine
-promote bronchodilation and vasodilation of peripheral arteriole
-enhance epi and stop prostaglandins
-improve contractility of diaphragm
s/s: fast HR, CNS effects, RR, chest pain, dizziness, increase in urine
Corticosteriods
-indirectly bronchodilate via immune system
-reduces swelling in mucosa
-immuno supressant
s/s: edema, hyperglycemia, osteoporosis, infections, atrophy, hypokalemia, clots
Delivery Methods
Meter Dosed Inhaler:
-specific amount of aerosol meds per short burst from device
Nebulizer:
-mist inhaled into lungs
-compressed air/o2
Respiratory Stimulants
-inhance CNS activity in respiratory centers
-sympathomimetics and methylxanthines
Analeptics: increase activity, convulsions
Dopram: chemorecepters in carotid, medulla
Respiratory Depressants
-sedatives, tranqs, narcotics
-avoid witth pulmonary diseases
-supresses ventilator drive
-controls abnormal breathing patterns, anxiety
DVT Locations
Proximal: worse, closer to bigger vessels
-popliteal & sup femoral (MC), proximal veins
Distal: smaller vessels
-Calf DVT extends proximally 30%
Proximal Deep Vein Thrombosis
-PDVT
-most dangerous lower extremity because it can move
Role of PT in DVT
Prevention:
-mobility, screen risk, education, compression, know signs, recommend testing
Post-DVT:
compression, verify anticoagulants, mobility, consult with team, screen for fall risk
Test Risk of DVT
-Pauda Prediction Score
-Pt history and risk factors
Test of Having DVT
-Wells DVT
-probablity of DVT
-Current symptoms
Lab Test to Determine DVT
D-Dimer Test:
-reflects amount of degradation of a clot
-followed by ultra sound
PT Prothrombin Time:
-time it takes to clot, prothrombin to thrombin
->25 high risk for bleeding
PTT Partial Thromboplastin Time:
-22-32s
-heparin makes the value 2x higher
V/Q Scan:
-diagnose PE
-air is white and bad
-black is good and perfused
Inferior Vena Cava Filter
-filter in IVC to catch blood cloths
Exercise Considerations: Mild Lung Disease
-80 of predicted values but <70% of FEV1/FVC
-does well with exercise
s/s: SOB, cough
Exercise Considerations: Moderate Lung Disease
<80 FEV1
-limited exercise tolerance
-consider meds being taken
-vitals
s/s:
-SOB with mild acivity, modify ADLs
-decreased respiiratory capacity
Exercise Considerations: Severe Lung Disease
FEV1 <50
-limited walking
-need for O2, elevated CO2
Exercise Considerations: Poor Oxygenation
-limits exercise capacity
s/s: SOB, decreased SaO2, secretions, cyanosis
Treat:
-postural drainage, huffing, coughing, percussion, O2, bronchodilators
Exercise Considerations: Pump Dysfunction/Failure
Dysfunction
-weakness of diaphragm or fatigue
-reliance of accessory muscles and costal retraction
s/s: SOB, drop in O2
-Treat:
-breathing, positioning, supplementarry O2 (not too much or decrease in breathing drive), exercise training
Failure
-advancement of dysfunction
-further decline
-Mechanical dysfunction: obstruction of lungs, increased effort, accessory muscles (paradoxical breathing= hoover’s sign)
-Muscle Dysfunction: diaphragm ineffective
-Control Dysfunction: brainstem of breathing control
-Treat: leaning forward, urse liped
Exercise Considerations: Pulmonary Hypertension
->20mmhg at rest and 30 during exercise
-40-50 stop exercise
-increased O2 demand, vasodilators, Ca blockers
s/s: hypoxia, dizziness, LOC
- PAH
- Left Heart Disease
- Lung Disease
- Chronic PE
- Insidious
Exercise Considerations: Downward Spiral of Dyspnea Deconditioning
-Dyspnea during exercise
-less exercise: avoidance
-deconditioning: type 1 fibers then 2
-dysnea in early exercise…ADLs
Exercise Considerations: Chronic Bronchitis
-hypersecretion of mucus
-low endurance, dyspnea, obesity, muscle fatigue
-reduced FEV1/FVC and FEV1
Exercise Considerations: Emphysema
-decreased gas exchange
-hyperinflation
-low endurance
-accessory msucle use
-muscle wasting
-reduced FEV1/FVC and FEV1
Exercise Considerations: Asthma
-wheezing, chest tightness, SOB
-low FEV1/FVC
Predicted Percentage of Static Lung Volumes
<80% = Restricted Lung disease
>120%= obstructive lung disease
Exercise tests for Muscle Strength
-if minute ventilation and max volume of inhalation are withing 70%= lungs were cause of end of exercise
-look for low dyspnea with high SpO2
Dyspnea Scale
-1-5
COPD Inspiratory Muscle Training
-<60% predicted
-diaphragmatic breathing
-facilitate expiration
-start at 30%
Abnormal Breath Sounds
-bronchial sounds
-Decreased/diminished
-Absent
Adventitious Sounds
-Crackles or rales: discontinuous sounds; airway obstruction or restrictive lung diseases
-wheezing: smaller airways, asthma
-stridor: crowing sound, uper airway obstruction
-Pleural rub: rubbing inflamed pleural surfaces agains lung
Diagnosis of Sounds
Pleural Effusion: conta traacheal dev, decreased sounds, dull percussion (stuff)
Consolidation: increased fremitus and pectoriloquy, decreased breath sounds, dull percussion, bronchial sounds
Emphysema: decreased fremitus, hyper resonant percussion, decreased pectoriloquy, crackles
Tension Pneumonthorax:
-contra tracheal dev, hyper resonant percussion, decreased breath sounds
Mucus Plug w/ Collapse: ipsi tracheal dev, decreased everything, dull percussion
