Midterm study guide: Pulmonary Flashcards
FiO2
measure of how much oxygen we breathe in compared to the other gases in the air.
*ex: if you breathe in air with an FiO2 of 0.21, it means that about 21% of what you’re breathing is oxygen.
*Room air is 21%.
*Max is 100%.
*We start getting more concerned when FIO2 is 60% or higher
*You can extubate on 40% fiO2 because it could be very small volumes we were doing → get them off vent and on NC
PEEP: Positive End Expiratory Pressure.
(when to be concerned and why? PEEP for obese pts?)
*How much air or pressure is in the lungs just after a breath out. Like a diastolic reading for BP, but for the lungs’ pressure at rest.
*Normally lowest is a 5 cause we have to make up for the pressure the vocal cords would keep in the lungs if the pt didn’t have an ETT blocking it.
*Concerning is 10 or above
*Too high? = decreased cardiac output cause there is more physical pressure on the heart.
*PEEP and vasopressors can be increased together
*Increased PEEP could be good if patient has a higher BMI
Respirations
(can indicate…, what is hypervent? What if tidal vol is too low?
*Can indicate pain
*Patient can still initiate breaths so looking and taking RR’s can be important
*Hyperventilation = blowing off too much CO2
*If trauma happens and you lower your tidal volume… you then have to increase the respirations in order to get the same amount of air in and out of the lungs per minute
Oxygenation vs Ventilation
*ventilation: CO2 (inhalation and exhalation)
*Oxygenation: O2 (getting o2 to the tissue level)
Tidal volume:
Vol of air normally displaced between inhalation and exhalation (how big of a breath you’re taking)
PIP: Peak Inspiratory Pressure
(what + goal PIP)
the max volume/amount of pressure in your lungs when you take a breath in
*goal PIP: <40 cm H2O
Plateau pressure
(what is it? what does it measure? what is the goal?)
*pressure at the end of inspiration inside your lungs measured after a brief pause in the delivery of air during mechanical ventilation
*measures the compliance of the airway
*goal <30 cm H2)
Ventilation: who is initiating the breath?
(control, support, SIMV)
*control: vent is initiating the breath
*support: pt is initiating the breath
*SIMV: mix of both
Ventilators: Volume
Volume is the constant and pressure varies
*vent adjusts the pressure to ensure the flow
*increase the TV and the required pressure increases
Volume Control: pros and cons
Pro: ensures adequate ventilation
Con: risk of barotrauma (happens when there is a fast change in pressure)
Pressure control: pros and cons
pro: decreased risk of barotrauma
con: server hypercapnia (too much CO2) can occur
ARDS: def
your lungs become inflamed and filled with fluid, making it difficult for oxygen to get into your bloodstream.
ARDS: etiology
(2)
non-cardiogenic PE and disruption of the alveolar-capillary membrane.
ARDS: factors that precipitate it/lead to it (15 possible, name 5)
*aspiration (30-40% of cases)
*near drowning
*Toxic inhalation
*Pulmonary contusion
*Pneumonia
*Oxygen toxicity
*Transthoracic radiation
*Sepsis
*Non-thoracic trauma
*Hypertransfusion
*Cardiopulmonary bypass
*Severe pancreatitis
*Embolism-air, fat, amniotic fluid
*DIC
*Shock states
Standardized criteria used to dx ARDS: (4)
(when does it start? 3 criteria)
*Acute onset (w/in 1 week of known clinical insult or new or worsening respiratory symptoms)
*Bilateral infiltrates on CXR (complete white-out)
*Pulmonary edema (not explained by HF or fluid volume overload)
*Ratio of PaO2 to FiO2 is ≤ 200 mmHg regardless of PEEP level (60/0.25 = 240 or 60/0.80 = 75)
Patho ARDS (4)
injury/infamm -> increased permeability -> difficult gas exchange -> breathing difficulty
ARDS Medical and Nursing Management: 3
- optimize o2 and ventilations
- provide comfort and emotional support
- maintaining surveillance
ARDS Medical and Nursing Management: optimize o2
(oxygen 3 + 1 other)
- oxygen:
*Goal is to maintain o2 sats (90% using lowest o2 level, preferably < FiO2 of 0.050)
*pts will be intubated and ventilated by this time
*may use ECMO when conventional therapy failing - PEEP (usually high PEEP)
Positive reasons to use high PEEP for ARDS pts (4)
*opens collapsed alveoli
*stabilizes flooded alveoli
*decreases intrapulmonary shunting
* increases compliance
Negative reasons to use high PEEP for ARDS pts (2)
*Decreases CO
*Barotrauma - gas escaping into the surrounding spaces d/t alveoli rupture
ARDS Medical and Nursing Management: optimizing ventilation -> “who will be initiating breaths”
Ventilator so the lungs can rest
ARDS Medical and Nursing Management: optimizing ventilation -> “Is volume or pressure control better for this pt?”
*Volume so less likely to have problems
*Pressure less risk of barotrauma
ARDS Medical and Nursing Management: optimizing ventilation -> “is ventilation or oxygenation the problem?”
both
ARDS Medical and Nursing Management: optimizing ventilation -> “how do we fix it?”
Prone position
ARDS Medical and Nursing Management: tissue perfusion (4)
- Keep adequate CO and Hgb levels
- Manipulate HR, preload, and contractility to keep wedge 5-8
- Use fluid restrictions and diuretics to minimize fluid leakage
- Use vasoactive and inotropic meds to keep CO up
ARDS Medical and Nursing Management: the other P’s (4)
- Positioning
- Prone
- Preventing desaturation
- Promoting secretion clearance
ARDS Medical and Nursing Management: maintaining surveillance for complications (7)
- Encephalopathy (not enough O2 to brain)
- Cardiac dysrhythmias
- DVT
- GI bleed
- Barotrauma
- Volutrauma (too much volume)
- O2 toxicity
Pulmonary Embolus (PE): def
occurs when a clot or other matter lodges in the pulmonary arterial system, disrupting the blood flow to the lungs.
PE: what causes?
Biggest is DVTs
PE: predisposing factors (virchow’s triad)
*hypercoagulability
* injury to vascular endothelium (inner layer of cells lining surface of blood vessels)
*Venous stasis
PE classification: massive (4)
*acute PE
*sustained HoTN (<90 SBP for >15 min)
*need for inotropes (help heart pump more effectively) not based on other causes
*signs of shock
PE classification: Submassive (3)
*acute PE
*Evidence of R ventricular dysfunction
*myocardial necrosis
PE classification: Low risk (2)
*Acute PE
*non of the other conditions
Patho of PE: (12)
- large blockage of a lobar or larger artery causing occlusion of >40% of pulmonary vascular bed
- lungs receiving vent but not able to perfuse -increase work of breathing 3. body compensates with bronchoconstrictors d/t hypocarbia, hypoxia
- constrictions occur
- increased airway resistance
- unaffected area of lungs try to compensate
- heart receives blood without gas exchange
- congestion results in pulmonary HTN
- R ventricle failure
- decreased L vent preload
- decreased CO and BP
- shock
PE: S/S (7 total, name 4)
- most common: tachycardia and tachypnea
*apprehension
*dyspnea/crackles/wheezing
*Pleuritic chest pain
*cough/ Hemoptysis (bloody cough)
*DVT
*syncope
PE: lab studies (ABG) 3
- ABG:
*low PaO2: hypoxemia
*low PaCO2: hypocarbia (caused by tachypnea)
*high pH: alkalosis
PE Lab studies: D-dimer
*elevated D-dimer
PE: diagnostic procedure (1)
*EKG: Sinus Tachy/T wave inversion
How to differentiate a PE from other illnesses (5)
think diagnostics
*VQ scan
*pulmonary angiogram
*DVT studies
*Spiral CT
*Transthoracic/ transesophageal echo
PE RN management: optimize oxygenation
*o2 therapy: start w/ NC but likely work up to intubate
*intubate pt: if unable to maintain PaO2
PE RN management: optimize ventilation (who’s initiating breaths, vol or pressure used, oxy or vent prob, how to fix)
*Vent initiating breaths
* both pressure and volume used for this pt
*both a ventilation and oxygenation problem
*will fix by using anticoagulants, thrombolytics, inferior vena cava filter
PE: what meds are we using if pt can have anticoags(4)
*anticoagulants
*eliquis
*xarelto
PE: what meds if pt cannot have anticoags (4)
*thrombolytics
*Bronchodilators
*inotropic agents
*sedatives
PE: anticoagulants (5)
*heparin/coumadin/lovenox
*Prevents further cotting but doesn’t affect existing clot
*adjust heparin to keep PTT 2-3 times the control
*Maintain INR 2-3
*Coumadin is continued for 3-12 mon
PE: eliquis (3)
*multiple dosing requirements
* no meal requirements/ food restrictions
*no INR monitoring
PE: Xarelto dosing regimens (2)
*10 mg dose w/ or w/o food
*15mg and 20mg should be taken w/ food at the same time each day
PE: xarelto contraindications
*If pt has an artificial heart valve
* antiphospholipid syndrome
PE: xarelto (do you monitor INR)
No
PE: thrombolytics (4)
*reserved for pt w/ huge PE and are hemodynamically unstable (massive PE)
*can use up to 14 days from onset of s/s
*most benefits w/i 48hrs of s/s
*EKOS (directly delivers meds to clot) catheter
PE: bronchodilators (2)
*relaxes smooth muscle
*opens up airway
PE: inotropic agents (2)
*what: reverse pulmonary HTN
*increase contractility and CO
PE: sedatives (2)
*for high anxiety/sense of impending doom
*if anxious, there is and increase demand for o2 which we want to avoid
PE: analgesics (3)
*highly painful
*increased anxiety w/ pain
*increased anxiety means increased 02 demand which we can’t have rn
PE: IV fluids (3)
*increase RV preload
*stretches the R ventricle and increases contractility
*hydrates blood so RBCs don’t coagulate
PE: the other Ps (3)
*positioning
*prevent desatting, *promote secretion clearance
PE: other Nursing interventions (non meds) (3)
- antiembolic stockings applies
- ROM
- Progressive ambulation
PE Complications (2)
- Monitor for bleeding: gums, skin, urine, stool, emesis. Watch PT, PTT, and INR levels
- ARDS
Criteria for meeting ecmo (3)
*age
*comorbidities
*how many failing systems
hyperventilation
20-30 bpm
RSB
Rapid shallow breathing: not effective gas exchange
RSV
too increased metabolism and RR leading to decreased o2 a
Volume:
How deep we breath
Dependent on Way/mode we are giving breath
PIP goal
25
Platue pressure
when we are giving a breath, how much pressure is given
Most important oxygenation issues to tx
*FiO2: need >60%
*PEEP
*Diffusion: +5
