Midterm Study Tips Flashcards
O2 Transport Chain
Inspired O2 and quality of ambient air airways lungs and chest wall diffusion perfusion myocardial function peripheral circulation tissue extraction and use of O2 return of desat blood and CO2 to the lungs
O2 Transport: Airways
become smaller and branch out
lined with smooth mm, cilia, mucus
O2 transport: lungs and chest wall
contraction of diaphragm creates (-) intrapleural pressure to inflate the lungs and bring air in
need good compliance
O2 transport: diffusion
O2 from alveoli -> pulm capillaries
O2 transport: perfusion
gravity dependent
V/Q ratio ideally is 0.8
O2 transport: myocardial function
need a coordinated conduction system, strong forceful contraction
O2 transport: peripheral circulation
neural stimulation of arteriole smooth mms contract or relax and let more/less blood through
O2 transport: tissue extraction and use of O2
rate of O2 extraction by cells depends on the O2 demand of those cells
O2 transport: return
CO2 eliminated by diffusion into alveoli
Practice Pattern A
Primary Prevention/Risk Reduction for Cardio/Pulm Disorders
Practice Pattern B
Impaired aerobic capacity/endurance associated with deconditioning
Practice Pattern C
Impaired ventilation, resp/gas exchange, and aerobic capacity/endurance associated with Airway Clearance Dysfunction
Practice Pattern D
Impaired ventilation, resp/gas exchange, and aerobic capacity/endurance associated with Cardiovascular pump dysfunction or failure
Practice Pattern E
Impaired ventilation, resp/gas exchange, and aerobic capacity/endurance associated with Ventilatory pump dysfunction or failure
Practice Pattern F
Impaired ventilation, resp/gas exchange, and aerobic capacity/endurance associated with Respiratory Failure
Practice Pattern G
Impaired ventilation, resp/gas exchange, and aerobic capacity/endurance associated with Respiratory failure in the neonate
Practice Pattern H
Impaired circulation and anthropometric dimensions associated with lymphatic system disorders
preload
amount of blood that fills ventricles in diastole
decreased = decreased CO
afterload
amount of BP (resistance) heart has to push against to eject blood out
(Increased = decreased CO)
Signs and Sx of Unstable patient
hypotension acute altered mental status signs of shock ischemic chest discomfort acute heart failure
4 pieces to the complicated patient
dysrythmia
heart failure
thrombosis
damage to heart structure
3rd spacing
the space where fluids build up in the interstitum of the lungs
hydrostatic pressure (water)
higher in capillaries and tends to PUSH fluid OUT into the interstitum
oncotic pressure
high in the capillaries and PULLS fluid IN to the capillaries
oncotic > hydrostatic - net flow of fluid IN
if hydrostatic is high enough (CHF) it will push fluid out
Shunt
alveolus not ventilated but normal flow through the capillary
dead space
alveolus is normally ventilated but no blood flow through the capillary
silent
alveolus is unventilated and capillary no perfusion
conducting divisions
1-16 of bronch*
respiratory divisions
> 16
more SA however narrower lumen therefore easier to clog
Risk Factors for Atelectasis
smoking hx DOE, PND, CHF, orthopnea, dependent edema, angina PaO2 60mmHg, PaCO2 > 50 mmHg bed rest for 36+ hours FIM <3-4 abdominal and or cardio thoracic surgery/traume impaired cognitive status low tidal volumes/breaths retained secretions
Risk Factors for pneumonia
smoking, alcoholism, obesity underlying disease trauma prior viral illness altered consciousness immunosuppression surgery invasive procedures (mech vent) Meds -
compliance
ease of which lungs are inflated during inspiration
Decreased compliance due to…
lung fibrosis, alveolar edema, dec surfactant, rib injury, intercostal mm tightness/fibrosis
Inc WOB
Heart Failure Signs and Sx
BNP >100
chest x-ray - cardiomegaly
ST elevation or depression on EKG
NYHA Class I/ Class A Heart Failure
cardiac dz; no limits with daily activity
unrestricted physical activity
NYHA Class II/ Class B Heart Failure
Cardiac dz; comfortable at rest, ordinary activity causes fatigue, palpation, angina, SOB
no severe or competitive sports
NYHA Class III/ Class C Heart Failure
marked limits of physical activity, still comfortable at rest
moderate restrictions on ordinary activity and no strenuous efforts
NYHA Class IV/ Class D heart failure
symptoms at rest - activity causes discomfort
Ordinary activity restricted
Class E - complete rest
Zone of Apposition
part of the diaphragm that lines up against the inside of the lower rib cage. D/t line of pull brings rib cage up and out with inspiration
If diaphragm is flat ZofA will be less and therefore less lung expansion
MIP - Maximum inspiratory pressure
negative value
max inspiration after a max expiration
MEP - max expiratory pressure
max expiration after max inspiration (Positive value)
Arterial Blood Gas Levels (ABGs)
Hyperventilation - alkalosis pH >7.45
Hypoventilation - Acidosis pH < 7.35
hypercapnia pCO2 >45 mmHg
Ventilation and gravity
ventilation inc from apex to bass regardless of position. Lower alveoli are more compliant
Perfusion and gravity
changes with position. More perfusion in the dependent areas of the lungs
V/Q ratio and gravity
decreases as you move from apex to base
Chest Xray Basics
PA and later views Look at all 4 corners Heart size and contour (1/2 width of chest) L/R pulmonary arteries and main bronchi trachea compare lung 1/3s domes of hemi-diaphragms costophrenic angles gastric air bubbles post ribs are horizontally aligned, ant ribs angled inferiorly
pneumo-peritoneum
air gets between diaphragm and live-stomach, looks paper thin on xray
Auscultation
S1 - closure of mitral and tricuspid valves. Beginning of systole
S2 - closure aortic and pulmonic valves. Beginning of diastole
S3 - ventricular gallop - low pitched sound caused by rapid filling of ventricules - compliant ventricle walls or in high out put conditions
S4 - soft, low pitched sound via vibration of atrial contraction, caused by hypertroph of ventricles
Contraindication to activity
CHF (overt) MI or extension of MI 2nd or 3rd degree heart block HTN resting BP or hypo >10-15 PVCs per minute at rest severe aortic stenosis unstable angina with recent changes in sx dissecting aortic aneurysm uncontrolled metabolic diseasse psychosis or other unstable psych condition
Diuretics
Bumex
Positive Ionotropes
milrinone
Sedativess
Popofol
Beta 2 agonists for Bronchodilation
albuterol
anticholinergics for bronchodilation
Spiriva
inhaled corticosteroids
azmacort
negative chronotopes/beta blockade
metropolol - beta blocker for angina and HTN
causes slowed heart rate
PSV
patient controls frequency, tidal vol, inspiratory volume. When initiated, triggers preset inspiratory support until min pressure reached
high patient compliance
CMV
controlled mandatory ventilation
patient does 0 work; no spontaneous breathing
AC
assist control or “partial support” - patient receives set volume, frequency and flow rate however pt can trigger machine on their own
no spontaneous breathing?
IMV
intermittent mandatory ventilation
set to give number of breaths per min. Patient can breathe on own in between - no coordination b/n machine and patient
SIMV
synchronized mandatory ventilation - synchronizes machine delivered breaths with pts spontaneous breaths
if no insp. effort machine will begin
PEEP
positive end expiratory pressure - keeps pressure positive so it never goes to zero to keep the alveoli from closing
CPAP
contunuous positive airway pressure - alveoli kept open constantly to take some work off skeletal mm
done with spontaneous breathing patient
Delirium
acute, fluctuating change in mental status, with inattention and altered level of consciousness
RASS
Level of consciouness scale
+4 combative - violent
+3 very agitated - removes tubes
+2 agitated - nonpurposeful mvmt, fights vent
+1 restless - non aggressive
0 alert and calm
-1 drowsy - eye opens to voice
-2 light sedation - awake to voice <10 s
-3 moderate sedation - mvmt to voice no eyes
-4 deep sedation - no response to voice, only to tactile
-5 - unarousable
CAM - ICU
confusion assessment method
1. acute change or fluctuating course of mental status AND
2. inattention + 3. altered level of consciousness
Or
4. disorganized thinking
=delirium (+)
triad factors of asthma
mucus production - blocks airways
inflammation - can damage airways
bronchospasm - increases resistance to flow
RDS
rapid breathing
air hunger
low O2 sat in blood
SBTs
spontaneous breathing trials
avoid prolonged mechanical ventilation
SATs
spontaneous awakening trials - interrupted sedation to avoid acute brain injury from delirium
poor air quality causes
inflammation, destroys lung tissue, weakens lung defenses
LFT
liver function test
dysfunction of liver can be life threatening - metabolizes carbs and proteins and detoxifies blood
test: amylase, alkaline, phosphotase, bilirubin
BUN/Cr
kidney function. 10-20:1 is normal
<10:1 = renal damage
D-dimer
molecule present in blood after clot has been degraded by fibrinolysis - indicative of thrombus
Cardiac markers
troponin and CPX - elevated = infarct
CBC - if decreases = diminished O2 transport
FRC
functional residual capacity
amount of air left in lungs at end or NORMAL respiration.
FRC = residual vol + expir. reserve volume
higher is better
greater in standing than sitting
FEV1
forces expiratory volume in 1 second - amount of air vol forcibly exhaled from lungs in 1 sec
Lung issues FEV1 is < 1L
FEV1/FVC %
anything <70% = airway problems
RV
volume of air in lungs after forced expiration
closure of airways (atlectasis) causes inc RV
TLC
total lung capacity
vol after forced inspiration
dec compliance = dec TLC
FVC
amt of air can fully get out o flungs
dx with obstructive/restrictive dz
DLCO
diffusion capacity of the lung for CO2
O2 passes from alveoli into blood
low - less O2 into blood and less CO2 out
MVV
maximal voluntary ventilation
time takes for VMP to dec to 1/2 its peak ventilation, when breathing in and out as much and as fast as possible
measure of VMP power/fatigue
PC-20 Methacholine
dx airway hyperresponsiveness
measure amount of methacholine (bronchoconstrictor) have to give the person for there to be a 20% change in FEV1
>16 mg/mL dose is normal, 1-4 mg/mL is mild hyperresponsiveness, <1 severe
DVT Signs and Sx
swelling, pain/tenderness, inc warmth and redness
PE Signs and Sx
sudden onset tachypnea, radiating chest pain, anxiety
MAP
(1/3 SBP) + (2/3 DBP)
<60 mmHg blood isnt getting to internal organs enough = cell death
normal 65-90 mmHg
CVP
central venous pressure monitoring - direct measure of BP in right atrium and vena cava
good for assessing right ventricular function and systemic fluid status
INC with Heart Failure
