Medical and Surgical Interventions Flashcards
Buproprion (Zyban)
Smoking cessation med
Antidepressant
Helps with withdrawal side effects
Varenincline (Chantix)
Partial nicotine receptor agonist
Helps prevent nicotine from stimulating receptors in the brain
Helps with withdrawal
Medications to Manage Secretions
Antitussives
Antihistamines
Decongestants
Mucolytics and Expectorants
Antitussives
Manages secretions
Cough medication
Suppresses cough reflex
Opioids also suppress this
Ex. hydrocodone, codeine... Could be in OTC cough suppressant meds Can be addictive Can build a tolerance Keep in mind that we need to get stuff out (minimize retainment of this)
Antihistamines
Manages secretions
Blocks histamine receptor
Some of these meds can cross BBB, so you can see CNS SEs (sedation, fatigue)
Ex. diphenhydramine (benadryl), cetirizine (zyrtec), loratadine (claritin)
Claritin
Decreases nasal decongestion
Decreases mucosal irritation
Zyrtec and Claritin
Don’t cross BBB
Decongestants
To manage secretions
Stimulates vasoconstriction in nasal vasculature
Often classified as alpha receptor agonists
Method of delivery affects side effects
Need to be aware of cardiovascular side effects
Ex. epenephrine (primatene), pseudoephedrine (sudafed)…
HA
Nausea
Nervousness
Can affect cardiac beta-1 receptors (arrhythmias, palpitations)
Mucolytics
Break up mucus in airway
Makes you want to cough
Expectorants
Facilitate mucus secretion and clearance
Makes you actually cough
Examples of Mucolytics and Expectorants
Mucomyst
Pulmozyme
Guaifenesin (Mucinex)
Beta-2 agonists
SHORT and LONG acting
Cause bronchodilation, relaxation of smooth mm by activating Beta 2 receptors and inhibit respiratory smooth mm contraction
Usually taken orally or inhaled (nebulizer, metered dose inhaler)
Albuterol
Salmetrol
Bronchodilators
Beta-2 agonists
Theophylline
Anticholinergics
Theophylline
Relaxes airway smooth mm, some anti-inflammatory effects
Usually taken orally, but can be injected
Xanthine derivative
Anticholinergics
Decrease ACh activity at various sites in the body, including the lungs… so inhibition of this facilitates bronchodilation
Limited use as not specific to the pulmonary system - may be used in combination with a beta-2 agonist
Atrovent
Spiriva
Anti-inflammatory medication
Corticosteroids - glucocorticoids
Leukotriene Modifiers
Cromones
Corticosteroids - glucocorticoids
Oral = prednisone, methylprednisone
Inhaled = triamcinolone (Asmacort), Flovent
Very effective at treating inflammation
Very useful in treatment of asthma
Steroid side effects
Steroid myopathy HTN Gastric ulcers Exacerbation of DM Steroid induced DM Glaucoma Adrenal gland suppression Osteoporosis Skin breakdown May have cushingoid look to face
Leukotriene Modifiers
Impact how leukotrienes work
Ex. Montelukast (singulair)
Leukotrienes
Lipid compound produced within cells lining respiratory mucosa that tend to augment the inflammatory response
Cromones
Help prevent inflammation in airway by inhibiting release of inflammatory mediators from cells in respiratory mucosa
Need to take BEFORE exposure to allergen/irritant
Help with prevention of an attack
Ex. Cromolyn (nasalcrom)
Cardiac affects in PT
Theophylline and beta-agonists
Corticosteroid effects PT
Thinning of skin and weakening of bones
Wedge resection
Remove a triangular-shaped tissue
Lung tumor removal
Bullectomy
Taking out bullae from emphysema patients
Lobectomy
Taking out one lobe of a lung
Pneumectomy
Removal of an entire lung
Lung Volume Reduction (LVRS)
Used to improve breathing in patients with severe emphysema
Lung transplant candidacy
Idiopathic pulmonary fibrosis COPD Cystic fibrosis Emphysema due to alpha-1-antitripsin deficiency Pulmonary arterial HTN Bronchiolitis obliterans Restrictive lung disease Pulmonary vascular disease
Absolute Criteria Lung Transplant
Normal other organ function
No malignancy for 2-5 years
Severe obstructive or restrictive disease
Limited life expectancy
No C/I to immunosuppressants
Ineffective or unavailable medical therapy
Relative criteria
Case by case basis
No resistant organisms
Ambulatory with rehab potential
No current alcohol, smoking, substance abuse
Absolute C/I Lung Transplant
Recent malignancy
Active infection with HEP B or C
Active/recent cigarette smoking, drug, or alcohol abuse
Severe psychiatric illness
Noncompliance with medical care
Absence of consistent and reliable social netowrk
Relative C/I Lung Transplant
HIV infection
Significant extrapulmonary organ dysfunction
Obesity/underweight
Nutritional status
Age
Other co-morbidities
Lung Transplant Complications
Primary Graft dysfuncton
Airway complications (bronchial stenosis)
Infection
Acute rejection
Chronic allograft dysfunction due to bronchiolitis obliterans (edema within 72 hrs of transplant)
Lung Transplant Anti-Rejection Meds
Tacrolimus (Prograf) - causes tremors
Mycophenolate mofetil (MMF)
Glucocorticoids
Lateral thoracotomy
Nipple line to scapula
Latissimus NOT incised, but retracted
Serratus and intercostals incised
Wedge resections, lobectomies
Anterolateral thoracotomy
Pec major
Wedge resections
Posterolateral thoracotomy
From spine of 4th vertebrae to 5th or 6th IC space at the anterior axillary line
Serratus anterior divided close to the attachment
Lobectomies or wedge resections
Axillary thoracotomy
Apical bleb resections
Median sternotomy
Most commonly used for cardiothoracic surgery
Sternum close with stainless steel sutures
Thoracoabdominal incision
For diaphragm and other major organs
Affects... Rectus femoris Obliques Latissimus dorsi Serratus anterior
Clamshell/transverse sternotomy
For large-scale thoracic surgeries
Chest tubes
To drain the intrapleural space or the mediastinum
Water seal
Suction seal
Pleurodesis
Pleural space artificially obliterated
Performed to prevent recurrence of pneumothorax or recurrent pleural effusion
Generally avoided in CF population because lung transplantation becomes more difficult following this procedure
Pleurocentesis/thoracocentesis
Drainage of cavity
PT implications of surgical procedures
Watch the tubing, pleurevac, etc
Look at breathing pattern and determie what you can do to improve it
Early mobilization
Breathing exercises
Indications for O2 therapy
Hypoxemia
Increased work of breathing
Increased myocardial work
Decreased ex/activity tolerance for patients who desaturate with ex/activity
Oxygen toxicity
Increased production of free radicals
Can damage cell membrane, proteins, and DNA
Can lead to cell death and loss of organ function
In lungs…this may lead to airway inflammation, increased alveolar permeability, or pulmonary edema
Keep FiO2
Aerosol mask
Used to administer medications
Often a nebulizer at 10-12 L/min
FiO2 0.35-1.0
Venturi mask
Mixes O2 with RA - creates high-flow enriches O2 of a CONTROLLED concentration
Low flow O2
Nasal cannula
Face mask
High flow O2
Aerosol mask Venturi mask Non-rebreather Manual resuscitator Optiflow
Non-rebreather
Face mask with a reservoir which prevents pt from re-breathing any expired air
FiO2 is 100%
Manual resuscitator
Ambubag
Delivers 100% O2
Can be used to ambulate ventilated patients or for manual hyperinflation
Optiflow
Can adjust flow and FiO2 separately
Can wear for transfers, but recommend Venti mask for ambulation
Reasons for intubation
Airway obstruction
Inability to protect the lower airway from aspiration
Inability to clear secretions from the lower airways
Need for positive pressure ventilation (apnea or ventilatory failure)
Oral endotracheal tube
Mouth to trachea
Nasal endotracheal tube
Nose to trachea
Tracheostomy
Incision in neck to allow for breathing
Tracheostomy tube
Directly to trachea via tracheostomy just below vocal cords
Parts…
Outer cannula
Inner cannula
Obturator
Fenestrated trach
Has holes
Positive Pressure Ventilator
Delivers a positive pressure
This is opposite of normal negative pressure ventilation
Negative Pressure Ventilator
Iron lung
Frequency
Number of breaths per minute
Flow rate
The speed at which the ventilator breath is delivered
Spontaneous breath
Breathing through the ventilator circuit without assistance
Trigger
Variable that causes a breath to be delivered
Controlled Mechanical Ventilation (CMV)
Ventilator delivers ALL breaths at a preset frequency and flow rate
Usually at set volume and/or pressure
Pt usually is sedated and paralyzed
Pt can NOT take a spontaneous breath or trigger the machine
Assist/Control (AC)
Volume targeted mode (pt receives a preset volume)
Pressure targeted mode (pt receives a preset pressure)
Frequency
Machine senses pt initiated breath by sensing negative pressure and then starts to supply a positive pressure breath
If pt does not initiate breath, the machine will supply a breath
ALL breaths are machine delivered
Problem with volume modes
As lung compliance decreases, need to increase pressure to supply the same volume
Intermittent Mandatory Ventilation (IMV)
Machine delivers set frequency and volume or pressure
The pt can take spontaneous breaths in between
Synchronized Intermittent Mandatory Ventilation (SIMV)
Mechanical and spontaneous breaths
Available in volume or pressure modes
Used for weaning
Pressure support (PS)
Pressure stays constant, but the volume needed to reach the pressure may vary depending on lung compliance, resistance, and patient effort
Pt determines rate of breathing
Machine will NOT deliver a breath without a pt trigger
Recruitment
Opening of previously collapsed airway (alveoli)
Derecruitment
Collapsing of previously opened alveoli
Positive End Expiratory Pressure (PEEP)
Maintains set pressure at the end of expiration to prevent airway collapse
Continuous Positive Airway Pressure (CPAP)
Spontaneous breathing with an elevated baseline airway pressure – helps keep airway open
Indicated for oxygenation
Tells you mode/pressure/FiO2
BiPAP
Bilevel Positive Airway Pressure
Indicated for ventilation - helps to blow off CO2
Can set inspiratory and expiratory pressures
Can set FiO2 and PEEP
Mobilize with NIV?
NIPPV and BiPAP
Yes, but source of O2 may limit distance
Have RT around when mobilizing
Both require tight fitting mask
Some pts are not indicated for this - thoracic pts, esophagectomy pts
Ventilator screen
TV
Breath type
RR
Pressure support
FiO2
Alarms
C breath type
Control
S breath type
Spontaneous
High pressure vent alarm
Check for secretions or airflow obstruction
May need to suction or use ambubag
Low pressure vent alarm
May be a leak in the circuitry or poor connection to pt
Apnea vent alarm
Pt did not trigger the machine to deliver a breath
Disconnection vent alarm
Usually low pressure alarm
Volume vent alarm
If not maintaining minute ventilation (pt may be fatiguing)
Suctioning
Need to maintain a STERILE FIELD
Low vacuum setting (
Nicotine Replacement Therapy
Start with higher doses and wean down
It’s a way to attenuate someone’s need for nicotine
It can affect someone’s cardiac system
