Pulmonary

Question 1

What is a normal minute ventilation and how is it calculated? What does it mean if you increase your minute ventilation?

Answer 1

Normal 5-8L/minute
Tidal volume x RR
Increase work of breathing

Question 2

What is the clinical indicator of ventilation? How do you know your patient is ventilating normally?

Answer 2

The PaCO2

Question 3

What is the primary muscle of ventilation? What conditions affect this muscle?

Answer 3

Diaphragm

Deconditioning, hypoxemia, acidosis, hypophosphatemia

Question 4

What is alveolar dead space? What condition increases it?

Answer 4

Alveolar dead space is pathologic and is the area of non-perfused alveoli

PE increases alveolar dead space- no blood flow past the alveoli in the area of the pulmonary circulation

Question 5

What is pulmonary perfusion? What conditions affect perfusion?

Answer 5

It’s a movement of blood through the pulmonary capillaries.
PE, low cardiac output- any decrease in blood flow past the alveoli will affect the ventilation/perfusion ratio and gas exchange.

Question 6

What is a normal Ventilation/ Perfusion (VQ) ratio?

Answer 6

4L ventilation/min/ 5L perfusion/min

Ideal lung unit =0.8

Question 7

A patient is experiencing a large right lung PNA. What side should the patient lay on to prevent hypoxia?

Answer 7

“You want the GOOD lung down”

Turn pt to left side

Question 8

What is V/Q mismatch? What causes it and how do you treat a V/Q mistmatch?

Answer 8

Is when there is excessive blood flow in relation to ventilation OR ventilation with decreased perfusion

Causes: ARDS( shunting), PNA,mucus plugging

Treatment: give O2 and identify and treat the underlying cause

With shunting even providing 100%FiO2 will not correct the hypoxemia

Question 9

What are the effects of PEEP?

Answer 9

• prevents expiratory pressure from returning to zero by keeping the expiratory pressure positive
• decreases surface tension of thr alveoli (preventing atelectasis)
• increases alveolar recruitment
• increases driving pressure- extending the time of gas transfer, allows for a decrease in FiO2

Question 10

What is the PaO2? What is the normal?

Answer 10

Arterial oxygen. Normal 80 - 100mmHg on RA.

Less than 80 = hypoxemia

Question 11

What is the SaO2, normal and relevance?

Answer 11

Saturation of arterial oxygen
95- 99% on RA
Direct relationship with PaO2: amount of hemoglobin combined with O2

Question 12

What is an SvO2, normal, relevance?

Answer 12

Mixed venous o2 saturation
60-75%
Most sensitive indicator of oxygenation at the cellular level

Question 13

What is CaO2, normal and relevance?

Answer 13

Oxygen content
15-20ml/100 ml blood
Severe anemia may result in hypoxia

Question 14

What is DO2, normal, relevance?

Answer 14

Oxygen delivery
900 to 1,100 ml/min
Pump problem ❤ will decrease the DO2

Question 15

What is the alveolar arterial gradient (A-a)?

Answer 15

<10mmHg
Calculates the difference between the alveolar oxygen and the arterial oxygen. Indicates whether the gas transfer is normal and if not how bad the VQ mismatch or shunt is

Question 16

According the oxyhemoglobin dissociation curve, what clinical conditions shift the curve to the left?

Answer 16

“Left is aLkaLosis, coLd, Low Bad for patients; SaO2 is high but the O2 is stuck to the Hgb”

Alkalosis
Low PaCO2
Hypothermia
Low 2,3 DPG

Question 17

According the oxyhemoglobin dissociation curve, what clinical conditions shift the curve to the right?

Answer 17

” Good for tissues; SaO2 is low but the O2 is easily released to the tissues”

Acidosis
High PaCO2
Fever
High 2,3 DPG

Question 18

What clinical conditions causes a decreased affinity of 2,3 DPG?

Answer 18

Multiple blood transfusions of banked blood
Low phosphate
Hypothyroidism

Results in less O2 available to tissues

Question 19

What clinical conditions causes an increased affinity of 2,3 DPG

Answer 19

Chronic hypoxemia ( prolonged time spent at high altitudes, chronic CHF)
Anemia
Hyperthyroidism

Results in more O2 availability to tissues

Question 20

A patient is experiencing carbon monoxide poisoning, their carboxyhemoglobin (COHb) level is approx. 50%. They are losing consciousness along with Cheyne stokes respiration. What nursing intervention are required for this patient?

Answer 20

100% FiO2 until symptoms resolve and COHb levels are less than 10%

Hyperbaric o2 chamber is available

Question 21

What is static compliance?

Answer 21

Measurement of elastic properties of the LUNG

increase in plateau pressures will decrease compliance

Tidal volume ÷ plateau pressures (minus PEEP)

Normal 45 to 50

Question 22

What is dynamic compliance?

Answer 22

Measurement of elastic properties if the AIRWAY

Tidal volume ÷ peak inspiratory pressure

An increase in PIP will decrease compliance

Normal 45 to 50

Question 23

What are problems that can lead to metabolic acidosis/increase the anion gap?

Answer 23

M ethanol P ropylene glycol
U remia. I soniazid
D ka. L actic acidosis(shock,hypoxemia)
E thylene glycol
S alicylates

Question 24

What are clinical symptoms of hypoxemic respiratory failure?

Answer 24

Tachypnea, adventitious breath sounds,use of accessory muscles, cyanosis ( central- lips and ear lobes)

Question 25

What are signs of hypercapnic respiratory failure?

Answer 25

Shallow breathing, bradypnea, lungs may be clear or adventitious Neuro- progressive LOC

Question 26

What is the treatment for acute respiratory failure?

Answer 26

1. Maintain airway and improve ventilation (bronchodilators if wheezing, positioning, ABGs) 2. Optimize O2 (Decrease FIO2 to 50 or less) 3. Optimize cardiac output and circulation (manage hypotension and arrhythmias) 4. identify cause 5. Provide emotional support

Question 27

What are contraindications for NIV?

Answer 27

1. Hemodynamic instability 2. Copious secretions 3. High risk for aspiration 4. Impaired mental status 5. Suspected pneumothorax 6. Life threatening refractory hypoxemia (PaO2<60 with FIO2 at 100%)

Question 28

A patient complaining of worsening dyspnea, sputum production and hypoxemia comes in. It appears as though they are experiencing a COPD exacerbation. What line of treatment is indicated for the patient? Are they a candidate for NIV? A. Yes, provide O2 and sit them up B. No d/t increasing sputum production C. No. Titration O2 to PaO2 > 60, bronchodilators, corticosteroids and abx if indicated D. No. Titration O2 until reach SaO2 of 100% give bronchodilators and corticosteroids

Answer 28

C ( bronchodilators - inhaled short acting beta agonists ie albuterol, inhaled anticholinergic) Do not over correct the hypoxemia as it will decrease their respiratory drive

Question 29

A patient presents with chest tightness, wheezing bilaterally, elevated WBC, eosinophils, and pulsus paradoxus (greater than 15mmHg) and CXR reveals a flatten diaphragm. What is the diagnosis for this patient and how do you manage them?

Answer 29

Status Asthmatics Bronchodilators ( short acting beta 2 agonist albuterol) Anticholinergic(atrovent) Corticosteroids (systemic) Hydration to prevent thickened secretions

Question 30

When should you intubate a patient with status asthmaticus?

Answer 30

Ominous signs- respiratory acidosis, severe hypoxemia, silent chest, change in LOC

Question 31

Your patient with a hx of status asthmaticus is intubated, they are causing a high pressure alarm on the vent and are dysynchronous with the ventilator. Should you paralyze the pt to aid in ventilator synchrony? What is causing thr high pressure alarm?

Answer 31

No paralytics! Because paralytics combined with steroids increase the incidence of neuropathy. The high pressure alarm indicates- water or kink in the tube or secretions

Question 32

What settings are recommended for an incubated patient with status asthmaticus?

Answer 32

Low rate to increase exhalation time Low Tidal volume to prevent auto peep Increase IE ratio ( inhalation/ exhalation) 1:3-4 to allow time for optimal exhalation and prevent auto peep

Question 33

What are signs and symptoms of a PE?

Answer 33

``` Dyspnea, tachypnea Tachycardia, chest pain Right sided S3 or S4 heart sound Cough, hemoptysis, crackles Petechiae (fat embolism) Low grade fever Respiratory alkalosis ```

Question 34

What are S/S of a massive PE?

Answer 34

Hypoxia Hypotension EKG changes - RBBB, Tall peaked P waves in lead II, ST elevation in V1 and V2 Cardiopulmonary arrest

Question 35

What is the treatment and diagnosis of a PE?

Answer 35

Gold standard- pulmonary angiography Treatment: - maintain airway, ventilation and oxygenation -fluids -anticoags( heparin and Coumadin on first day treatment if able) - fibrinolytic therapy for pt with low risk for bleeding - maintain CO ( inotropes and fluids) - pain management

Question 36

Pulmonary HTN | Mean pulmonary artery pressure, PAOP, signs and symptoms

Answer 36

Mean PAP > 25mmHg PAOP less than 16 mmHg at rest with secondary right heart failure S/S: exertions dyspnea lethargy and fatigue due to an inability to increase cardiac output with activity syncope with exertion, hepatic congestion causing anorexia and abd pain Increased intensity of pulmonary component of s2 heart sound RV hypertrophy Ortner's syndrome ( cough, hemoptysis, hoarseness)

Question 37

Treatment for Pulmonary HTN

Answer 37

Treat underlying cause All regimens should consider: diuretics, O2, AC, digoxin and exercise training Use dilators: Ca channel blockers and phosphodiesterase-5 inhibitors ( viagra, cialis, remodulin)

Question 38

What are 4 factors that need to be evaluated to diagnose ARDS?

Answer 38

1. Acute onset with precipitating factors 2. Bilateral infiltrates consistent with pulmonary edema 3. PaO2/FiO2 less than or equal to 200mmHg regardless of the level of PEEP 4. PAOP less than or equal to 18 mmHg

Question 39

P/F ratios - PaO2/FiO2

Answer 39

Examples: Pt is receiving 50% fio2 and pao2 is 90 90 ÷ .5= 180 Pt is on 100% fio2 and pao2 is 95 95 ÷ 1= 95

Question 40

What is the treatment for ARDS?

Answer 40

1. *pulmonary stabilization - PEEP 15 or greater but monitor for barotrauma and decrease in CO - limit plateau pressure to 30cm H2O or less - low Tidal volume 5-6 ml/kg prevent volutrauma 2. Cardiovascular stabilization - support BP with fluids and pressure - monitor for arrhythmias 3. Prone 4. Prevent and identify organ failure

Question 41

What are the ventilator guidelines for a pt with ARDS?

Answer 41

``` Plateau (static) pressure <30cm Low Tidal volume (5-6 ml/kg) High PEEP (15-20 cm) ```

Question 42

Criteria for weaning from a ventilator

Answer 42

Resting minute ventilation (ideally <10L/min) Spontaneous Tidal volume >5ml/kg NIF > -25 cm H2O Rapid shallow breathing index (RR/Vt) <105 breaths/min/L Vital capacity ( above 10ml/kg body weight) ABG/oxygenation acceptable with FiO2 50% or less