Pulmonary Flashcards
1
Q
Normal pH levels
A
A: 7.35-7.45
V: 7.32-7.42
2
Q
Normal PaO2
A
A: 80-100
V: 28-48
3
Q
Normal PaCO2
A
A: 35-45
V: 38-52
Body’s natural acid
4
Q
Normal HCO3
A
A: 22-26
V: 19-25
acid buffer, soaks up acid; acts like a base
5
Q
Normal SaO2
A
A: 90-100
V: 50-70
6
Q
Acidosis
A
Low pH
High CO2
Low Bicarb
7
Q
Alkalosis
A
High pH
Low CO2
High Bicarb
8
Q
Respiratory Alkalosis
A
-high pH
-decreased PaCO2
-diaphoresis
-dizziness
-tinnitus
-dysrhythmias- ST changes
-muscle spasms
9
Q
Respiratory Acidosis
A
-inadequate pulmonary ventilation leads to increased PCO2
-low pH
-increased PaCO2
-tachypnea
-tachycardia
-dysrthythmias
-increased ICP
10
Q
Metabolic Acidosis
A
-low pH
-decreased bicarb
-tachycardia
-tachypnea
-vision changes
-HA
-decreasing LOC
-nausea, vomiting, diarrhea
seen with DKA
11
Q
Metabolic Alkalosis
A
-High pH
- increased HCO3
-dysrhythmias
-tachycardia
-lethargy
-muscle weakness
Caused by:
-loss of acid
-vomiting/emesis
-NG suctioning
-loss of stomach acid
12
Q
Measuring ventilation/perfusion CO2 levels
A
-Ventilation: End tidal of 35-45
-Perfusion: PaCO2: 35-45
13
Q
When is capnography used?
A
-Ventilation (during sedation or continuous)
-Perfusion (during CPR to measure quality of CPR, low CO = low etCO2)
-Head injuries
-PCA/sedation agents
14
Q
Hypoventilation
A
Increased end tidal CO2
Too low of RR or tidal volume
15
Q
Hyperventilation
A
Decreased end tidal CO2
Too high of RR or tidal volume
16
Q
V/Q Ratio
A
-Ventilation/Perfusion
-PaCO2 - etCO2
-Should be less than 5
17
Q
V/Q Mismatch
A
-Low etCO2 but high PaCO2
-Causes: pulmonary embolism, pneumonia, ARDS, high PEEP, ETT in main stem, mucus plug, low CO
18
Q
Oxygen causes pulmonary _____ and vasco____
A
dilation, vasoconstriction
19
Q
Adventitious Breath Sounds
A
- Crackles: fluid
-Wheezes: narrowed airways
-Rhonchi: secretions in large airways, PNA
-Stridor: harsh sounds, obstructed larynx or trachea, give nebulized epi
20
Q
Signs of Acute Respiratory Failure
A
-Acute: increased WOB, use of accessory muscles, increased RR, respiratory alkalosis
-Late: Hypercapnia/high PaCO2, respiratory acidosis
21
Q
3 main reasons for hypoxemia
A
-Hypoventilation: OSA, low Mg
-V/Q mismatch: PE, PNA, ARDS
-Poor perfusion: decreased CO, severe anemia
22
Q
Causes of asthma
A
-Bronchial constriction
-Airway hyperreactivity
-Inflammation
23
Q
Treatment for asthma
A
- Beta agonist: bronchodilators
-Corticosteroids
-Hydration is key!
-Treat hypercapnia with mechanical ventilation or BiPAP
-Give mg to produce bronchodilation
-consider heliox
-No O2
-No CXR unless suspected PNA
-No ABG
-No abx
24
Q
Bronchodilators
Onset:
Duration:
Side effects
A
Onset: <5min
Duration: 2-5hrs
Side effects: tachycardia, tremors, hyperglycemia, low K,Mg, Phos
25
Corticosteroid use for asthma
-reduces airway inflammation
-prevents relapse
-give for less than 7 days
-give IV or PO
26
Status Asthmaticus
-Medical emergency
-exposure to allergy or trigger
-continuous bronchospasm and restriction
-Results in hypoxia, hypercapnia, respiratory failure
27
Phases of Status Asthmaticus
Early bronchospasm
-inflammation
-bronchospasm
-increased capillary permeability
-increased mucus secretion
Late inflammatory
-mucus plugging
-increased airway resistance
-airway obstruction
-lung hyperinflation
-V/Q mismatch
-increased RR
28
Rescue Treatment for Status Asthmaticus
Try CPAP or BiPAP
-Continuous PEEP
-CPAP: PEEP only
-BiPAP: PIP and PEEP
Intubate for:
-cardiac arrest
-decreased LOC
-respiratory fatigue/gasping
29
COPD
-emphysema and chronic bronchitis
-constant airway obstruction
-air trapping with chronic lung hyperinflation
-patient with hypoxic drive to breathe rather than hypercapnic drive
30
Signs of COPD
-SOB
-Cough
-Barrel chest
-Prolonged exhalation
-diagnosed with pulmonary function test
31
COPD Exacerbation Treatment
-Bronchodilators
-short course steroids
-antibiotics for URI
-oxygen therapy, try not to intubate
-Intubation: low RR, prolonged expiratory phase, lower TV, monitor for intrinsic PEEP
32
Signs of PE
-tachypnea
-crackles
-tachycardia
-fever
-diaphoresis
-chest pain
-feeling of impending doom
-sudden R sided heart failure
Ventilation with NO perfusion
Diagnosed with CT angio
33
Treatment for PE
-Anticoagulants: heparin, lovenox
-Fibrinolytic: TPA
34
Pulmonary Hypertension
High pressure in pulmonary vascularature
Normal PA pressure: 25/10
PHTN: 130/80
Leads to R sided heart failure, RV dilation, systemic edema, JVD
35
Treatment of Pulmonary Hypertension
Goal is to pulmonary dilate
Meds: Sildenafil, basentan, epoprostenol
Lung transplant
Keep patients calm to promote vasodilation and adequate pulmonary perfusion
36
Bubbling in Chest Tube
-Normal for pneumo
-If not a pneumothorax then there’s a leak in the system
-if no leak, get cxr for chest tube placement
37
Hemothorax
Blood in pleural space caused by trauma or thoracic surgery
Treated with lower CT
38
Pneumothorax
Air in the plural space
Caused by trauma, too much PEEP, ruptured bleb
39
Types of Pneumothorax
Closed
-air enters but can’t escape causing tension pneumo
Tension
-life threatening, accumulation of air that collapses the lung and puts pressure on the lungs/heart
-can lead to PEA arrest
Open
-penetrating injury
-Air can enter and exit
40
Treatment for Pneumothorax
Get CXR, place CT
In an emergency, a needle decompression may be performed with a 14-16g needle
41
Lung Contusions
Due to trauma, damage to parenchyma of lung, localized edema, or hemorrhage
42
Signs of a lung contusion
Not immediate, usually 24-72hrs after
-tachypneic
-tachycardia
-hypoxemia
-crackles
-rib fractures
Diagnosed with CT scan
43
Pressure Control
-Delivers breath until pre-set pressure is reached
-pre set rate
-TV varies breath to breath
44
Pressure Support
-liberate from vent
-patient decides rate and flow
-assistance during inspiration but patient must initiate breath
45
Volume Control
-Pre set tidal volume and RR
-I- time is fixed
-PIP and pressures change
46
SIMV
Synchronized Intermittent Mandatory Ventilation
Allows patients to spontaneously breathe in between set ventilator breaths
47
Propofol for Intubation
Anesthetic, Sedative, Amnesiac
-Causes respiratory and CV depression
- 5-50mcg/kg/min
- quick onset, half life of 4 min
-monitor for hypotension and decreased CO
Propofol infusion syndrome: acidosis, cardiomyopathy, muscle myopathy
48
Precedex for Intubation
Alpha 2 Agonist
-awaken and sleep easily with no respiratory depression
-dose: 0.2-1.4mcg/kg/hr
-monitor for bradycardia, hypotension, and decreased CO/SVR
49
Low Pressure Alarm
Leak or disconnect
Check connections on vent
50
High Pressure Alarm
Secretions, water, or kink causing blockage of air into patient
Suction or unkink tube
51
Low Minute Ventilation Alarm
Decreased inhalation of the amount of air per minute
Caused by hypoventilation, leak, or disconnect
52
Pulmonary Vascular Resistance
The resistance that must be overcome to push blood through vasculature of the lungs
-main determinant of RV afterload
53
The ___ is the force that pushes blood through the pulmonary artery
Right Ventricle
Right to the lungs
54
What affects PVR?
-respirations
-lung volume:
-low: hypoxic pulmonary vasconstriction, hypoxia suppresses natural nictric oxide production
- high: increases PVR due to compression of blood vessels from distended alveoli
55
Tidal Volume
-quantity of gas delivered with each breath
-normal spontaneous volume is 4-7 ml/kg
56
Total lung capacity
Volume in lungs at maximum capacity
57
Vital capacity
Maximum expired with maximum respiration
58
Functional residual capacity
Volume remaining after normal expiration
59
Residual volume
Volume remaining after forced expiration
60
Mixed Venous Oxygen Saturation (SVO2)
Percentage of oxygen saturation in pulmonary arterial blood
-normal: 65-75%
-measures the end result of O2 consumption and delivery
- average of all venous oxygen saturations of organs and tissues
61
Low SVO2
-cardiac output not high enough to meet tissue oxygenation needs
-hgb too low
-SaO2 too low
-oxygen consumption has increased without an increase in oxygen delivery (shivering, seizure, septic)
62
High SVO2
-increased O2 delivery : increased cardiac output, increased arterial O2 content
-reduced O2 consumption (health improving)
-L to R shunt
63
As resistance increases:
A. The pt is at risk for volutrauma secondary to increased TV
B. A situation of increased alveolar ventilation occurs
C. Distribution of ventilation becomes uneven
D. The risk of barotrauma increases
C. Distribution of ventilation becomes uneven
An increase in resistance leads to a decreased and uneven distribution of ventilation as gas flows to the areas with less resistance. The pt is at increased risk for barotrauma as pressure differences occur. Since the volume may be decreased, volutrauma is not commonly seen.
64
Which of the following is the main determinant of right ventricular afterload?
A. SVR
B. PVR
C. Diuretic therapy
D. Inotropic therapy
B. PVR
The RV must work harder to push the blood into the R lung, can cause RV hypertrophy from sustained pressure
65
What test measures the amount of air inhaled and exhaled during any respiratory cycle?
A. Tidal volume
B. Vital capacity
C. Oxygen saturation
D. SVO2 monitoring
A. Tidal volume
vital capacity is the maximum expired with a maximum expiration
66
A child is reported to have an increase in the VQ ratio. Assuming that the blood gas levels were WNL prior to this increase, which of the following would reflect an increase in the VQ ratio?
A. PaCO2 of 55mHg
B. PaCO2 of 30mmHg
C. PaCO2 of 60mmHg
D. No appreciable change would be noted.
B. PaCO2 of 30mmHg
A higher VQ results when more ventilation occurs in comparison to perfusion. Increased ventilation results in additional CO2 being removed from the lungs.
67
pH: 7.26
PaCO2: 54
HCO3: 26
PaO2: 88
What is the interpretation
Respiratory acidosis
68
Sedatives for intubation
Pretreatment with Atropine: not routinely used
- less than 1yr of age if concerned with HR dropping
- less than 5 if receiving succinylcholine
Etomidate
-not to be used in septic shock due to adrenal suppression
Ketamine: releases catecholamines
-helpful with bronchospasm and sepsis (asthma)
-caution w/hypertension and increased ICP
Propofol
-causes hypotension, only for short term use
Midazolam
Fentanyl
69
Propofol Infusion Syndrome
-Infusions greater than 4mg/kg/hr for more than 48hrs
-bradycardia leading to systole
-one of the following:
-metabolic acidosis
-rhabdomyolysis
-hyperlipidemia/enlarged liver
70
Benefit of rocuronium
Short duration
71
Vecuronium is contraindicated in
liver failure
72
Succinylcholine warnings
-can lead to hyperkalemia, especially if already at risk
-contraindicated in neuromuscular disease, crushing injuries, or history of malignant hyperthermia
-can drop HR, often given w/atropine
73
Naloxone
-opioid antagonist
-complete or partial reversal
-duration 2-3 minutes
-shorter than life of medication, will need drip
74
Flumazenil
-reveral for benzes
-caution w/hx of seizures, will remove all benzodiazepines from system
75
Minute Ventilation
The amount of air inspired over a minute
Tidal volume x RR
76
Inspiratory time
-time the ventilator delivers a breath
-I:E ratio determined by inspiratory time and rate
-normally 1:2 or 1:3
-longer inspiratory time usually improves oxygenation: alveoli stay open longer --> more time for gas exchange
77
Peak inspiratory pressure
-highest pressure in lungs during a ventilator breath
-determined by: lung compliance, inspiratory time, airway resistance, tidal volume
-minimizing PIP avoids volutrauma
78
PEEP
-positive pressure applied during expiration, keeps alveoli open
-initial settings of 5-8
-improves compliance and VQ matching
-creates higher mean and peak airway pressure which may lead to barotrauma
-increases FRC, increase alveolar volume
-increases inthoracic pressure and pressure within RA which may decrease venous return and RA volume = decreased cardiac output, decreases CVP
-increase ICP
-decreases renal perfusion
-increases hepatic congestion
-can worsen intracardiac shunting: may switch direction of shunt to R to L, may suddenly have cyanosis or hypoxia
79
Intrinsic PEEP
-obstruction to exhalation leads to air trapping
-produces same effect as PEEP
-decrease I time, extend exhalation time, decreasing rate
80
High Frequency Ventilation
-High flow, short duration
-small tidal volumes
-transports CO2 out of lungs using lower pressures, reduces barotrauma
-helps expand alveoli
-decreases PVR
-improves VQ matching
-will lower BP, give fluid bolus on initiation
Oscillator
81
ECMO
Extracorporeal Membrane Oxygenation
-contraindication:
-nonreversible end organ failure
-irreversible conditions
-pulmonary hemorrhage
-contraindication to heparin
82
Veno-Arterial ECMO
-supports heart and lungs
-blood diverted from vein to oxygenator
-returned through carotid
-achieves higher PaO2
-decreases PA pressure
83
