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Critical Care > Pulmonary > Flashcards

Pulmonary Flashcards

1
Q

Parietal Pleura

A
  • lines chest wall
  • slides back and fourth with breath
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2
Q

Visceral pleura

A
  • lines the lung parenchyma
  • protective layer
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3
Q

How much vacuum pressure prevents lungs from collapsing?

A

-5cm h2o

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4
Q

Alveoli

type II cells

A
  1. produce surfactant
  2. decrease surface tension
    Makes it easier to inflate during inspir
    Prevents collapse during expiration
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5
Q

Ventilation

A

air in and out of lungs

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6
Q

Perfusion

A

movement of blood

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7
Q

Diffusion

A

gas exchange
1. high concentration to low concentration

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8
Q

Alveolar diffusion is affected by
(4)

A
  1. Surface area
  2. Thickness of alveolar capillary membrane
  3. Partial pressure of gasses
  4. Solubility of the gas (co2 diffuses 20x faster than o2)
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9
Q

VQ
Normal Unit

A

things are working correctly

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10
Q

VQ
Shunt Unit

A
  • Perfusion over ventilation
  • Blood passes without gas exchange
    pneumonia, atelectasis, tumor, mucous plug
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11
Q

VQ
Deadspace unit

A
  • Ventilation over perfusion
  • Does not participate in gas exhcange
  • pulmonary embolism, pulmonary infarction
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12
Q

Oxygenation

A
  1. (Sa02) bound to hemoglobin saturation of arterial blood
  2. (Pa02) dissolved in plasma
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13
Q

Clinical manifestations of hypoxemia

A
  • Tachypnea
  • Hyperventilation
  • Dyspnea
  • Abd breathing
  • C’s (cool, clammy, cyanosis)
  • Tachycardia, HTN, palp, angina, dysrhythmia
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14
Q

PaCO2 tells us about what status?

A

Ventilation

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15
Q

PaCO2 High vs Low

A
  • High = hypoventilation
  • Low = hyperventilation
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16
Q

Clinical manifestions of hypercapnia (High PaCO2)

A
  • Drowsiness (difficult to arose)
  • Flushed
  • Headache

very similar to hypoxysemia becuase HIGH PaCO2 means HYPOventilation

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17
Q

pH normal values

A

7.4 absolute
7.35-7.45

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18
Q

PaO2 normal values

A

80-100mm Hg

hypoxemia

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19
Q

SaO2 normal values

A

93-99%

hypoxia

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20
Q

PaCO2 normal values

A

35-45 mm Hg

this is an ACID
respiratory parameter of the lungs

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21
Q

HCO3 normal values

A

22-26 mEq/L

Metabolic parameter regulated by the kidneys (SLOWER)

this is a BASE

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22
Q

Compensation of pH

A

other system changes to bring pH back to normal

Ex: respiratory is acidic = pH acidic, kidneys will become more basic to correct

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23
Q

Partial vs Full compensation

A

Partial = pH unchanged
Full = pH is now normal

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24
Q

Alkalosis

A

too much HCO3
too little CO2

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25
Q

Acidosis

A

too much CO2
too little HCO3

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26
Q

Mixed Disorder

A

All BASIC or ALL ACIDODIC

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27
Q

Goal of oxygen therapy

A

Deliever the LEAST amount necessary

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28
Q

Nasal canula

A
  1. 1-6L/min
  2. 21-44% FiO2
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29
Q

High - flow nasal canula

A
  1. 1-60L/min
  2. 21-100% FiO2
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30
Q

Acute Respiratory Failure

Etiology

A

Inadquate gas exchange
secondary to disorder
problem with oxygenation or CO2 elimination
ABGs –> hypoexmia/ hypercapnia

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31
Q

Acute Respiratory Failure

Causes

A

Intrapulmonary
1. Lower airways
2. alveoli, capillary membrane, pulmonary embolism
Extrapulmonary
1. Upper airway
2. CNS injury, neuromuscular disorders, thorax, pleura

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32
Q

Acute Respiratory Failure

Treatment

A
  • Improve oxygenation/ventilation
  • Non-invasive or intubation
  • Treat cause
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33
Q

Non-invasive Ventilation

A

uses a mask to fit over nose and mouth
PAPs

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34
Q

BiPAP

A

Positive pressure on inspiration and experiation
IPAP (bumps inspiration –> in deep= out deep)
EPAP (maintain pressure/recruit more)

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35
Q

CPAP

A

Continuous positive airway pressure
Inspir/Expir is the same

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36
Q

Acute Respiratory Failure

Nursing interventions

A
  • airway protection (prevent aspiration) (note emesis)!
  • nutrition/hydration
  • oral/skin care
  • communication –> write
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37
Q

Intubation

Placement (verification), color?, coughing presence?

A
  • Placed in trachea 2-3cm above carina
  • CXRAY for verification
  • ETCO2 goes from purple to yellow
  • Coughing indicated suctioning / inproper placement
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38
Q

Intubation

Nursing Interventions

A
  • Prep equipment
  • Monitor time, pulse ox/BP
  • Sedative then paralytic
  • Secure/note placement
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39
Q

Goals of Mechanical Ventilation

A
  1. Improve ventilation
  2. Decrease work of breathing
  3. Correct inadequate breathing patterns
  4. Improve oxygenation
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40
Q

Ventilation (PaCO2) components

A
  • Rate
  • Tidal Volume
  • Pressure support
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41
Q

Oxygenation (PA02/SaO2) components

A

FiO2
PEEP

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42
Q

Tidal volume

A

Size of each breath
(larger breath in, larger breath out)

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43
Q

Rate

A

number of breaths per minute
(easiest to change)

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44
Q

Tidal volume (Vt) and Rate (f) affect (1) and indirectly affect (2).

A
  1. PaCO2
  2. pH
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45
Q

Assist Control (A/C)

Ventilation modes

A

Ventilation delievers tidal volume at preset rate
Patient will never get fewer but can get more
Patient can trigger aditional breath THEN vent will kick in and delivers full tidal volume

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46
Q

Synchronized Intermittent Mandatory Ventilation (SIMV/IMV)

Ventilation modes

A

Preset volume at preset rate
Patient can breath spontaneously with pressure support (may not be a good quality tidal volume)

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47
Q

Advantages of SIMV

A
  • Respiratory muscles are active/coordinated
  • Can be used as weaning mod
  • If pt stops breathing, they will still recieve preset volume
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48
Q

Pressure Support

Ventilation modes

A

used for breathing trial/weaning
vent gives a a boost to trig spontaenous volume making inspiration easier

overcomes increased airway resistance afford by ETT (less work to initiate breath)

49
Q

Fraction of Inspired Oxygen

Fi02

A

percentage of oxygen delivered via the ventilator
30-100%

50
Q

Positive End Expiratory Pressure

PEEP

A

Positive pressure applied t the end of expiration
Increases oxygenation and prevents collapse of alveoli (recruits more)

Set at 5cm H20
If 100% FiO2,
peep will increase
cause better gas exchange
potentially lower o2

51
Q

Complications of PEEP

A

hemodynamic compromise d/t decreased venous return
Volutrauma/Barotrauma
damage alveoli/decrease venous return –> hypotension

52
Q

Elevated PaCO2 on ABG means on vent you need to

A

increase rate

53
Q

Low PaCO2 on ABG means on vent you need to

A

increase Fi02

54
Q

Complications of Mechanical Ventilation

A
  • Aspiration
  • Barotrauma
  • Pneumonia
  • Decrease CO
  • Decrease fluid balance
55
Q

ABCDEF bundle

A

breaks cycle of over sedation

assess pain
both spontaneous awakenoing trials wakening trials
choice of pain meds/sedation
delirium
early mobility
family engagement

decrease vent time

56
Q

ICU delirium nonpharm intervention

A

Monitor/manage pain (FACE, FLACC, CPOT)
Ortient –> axo, whiteboards
Sensory aids
Sleep –> encourage as much as possible

57
Q

Ventilation Pharmacologic management

A

Analgesics with short half-lives to be able to tirtate to orientation
Fentanyl most popular

58
Q

Propofol (diprivan)

A

Anesthetic agent (short-acting)
CNS depression/hypotension warning
tubing/bottle change q12h

59
Q

Propofol Contraindication

A

egg, soybean, peanut allergy

60
Q

Propofol complication

A

pancreatits
infusion syndrome

61
Q

Dexmedetomidine (Precedex)

A

Sedative (alpha 2 agonist)
continuous iv
Bradycardia/hypotension
DOES NOT cause respiratory depression
Can maintain when extubated d/t no withdrawal
Titrate no frequent than q30min

62
Q

Benzodiazepines

A

Anxiolytics
Alc abuse or unable to use precedex/propofol
LONG ACTING, RESPIRATORY DEPRESSION

precipitate delirium, prolong ventilation

63
Q

Benzodiazepine reversal agent

A

Flumazenil
Romazicon

64
Q

RASS assessment

A

sedation scale

65
Q

Neuromuscular blocking agents (NMBA)
Cisatracurium, Rocuronium,

A

PARALYTIC!! NEED SEDATION FIRST
decreases oxygen demand
post op, therapeutic hypothermia
BIS/train of four

66
Q

Bispectral Index Monitoring

A

measures sedation level
0-100
40-60 general anesthesia goal
80 is light/mod sedation

67
Q

Peripheral Nerve Stimulator – Train of Four

A

check before NMBA

68
Q

Nursing considerations for NMBA

A

SAFETY: airway in place, ambu bag at bedside
infuse only after sedated
eye/skin care
once d/c, continue til TOF is 4/4

69
Q

Ventilator-Associated Pneumonia

Etiology

A

Risk when on mech vent for over 48 hours, bacteria enters through aspiration/leakage around ET cuff

70
Q

Aspiration prevention

A

maintain ETT cuff pressure of 20-25 mmHG

70
Q

Oral care VAP

A

brush teeth/gums/tongue twice a day using soft toothbrush

71
Q

VAP oropharyngeal suctioning

A

suction before deflating cuff
with each oral care/turn

72
Q

Removal of subglottic secretions

A

-10 to -20cm continous suction through dorsal lumen above cuff

73
Q

VAP aspiration prevention

A

HOB 30-45 degrees
use sedation sparingly
verify TF placement
swallow eval after prolonged intubation

74
Q

Suction ETT

A

no greater than 120mmHg
limit passes to 10-15sec 3 sets

watch vs, hyperoxygen, no lavage

75
Q

Vent considerations

A

Ulcer prophylaxis
DVT prophylaxis
Communication
Psychological care
Fam
Nutrition

76
Q

Troubleshooting vent alarms
High vs Low

A

High –> obstruction
Low –> leak

77
Q

Guidelines for weaning from short-term ventilation

A
  1. Hemodynamically stable
  2. Sa02 >90 on Fi02 less than 50 and peep less than 8
  3. ABG WNL
  4. Adequate pain management
  5. No neuromuscular blockade
78
Q

Spontaneous Breathing Trials

A

“CPAP”
pressure support, peep/fi02
no tidal volume
enteral feeds hold
minimize sedation
monitor patient response

79
Q

Criteria for stopping SBT

A

RR > 35
SaO2 < 90%
Decreased tidal volumes
Increased work of breathing
Increased anxiety and/or diaphoresis
HR > 140
SBP > 180 or < 90

80
Q

Extubation Criteria

A

ABGs WNL for the patient
Respiratory rate < 30
NIF > -20 cm water
Negative Inspiratory Force
(-30 is better, -10 is worse)
Patient alert/following commands
Adequate cough/gag reflex to protect airway
Occlusion test (if concerned for tracheal swelling) – gurgling test if deflate cuff

81
Q

Extubation Procedure

8 steps

A
  1. Elevate HOB and instruct pt
  2. Suction ETT/oropharynx
  3. Deflate cuff and remove
  4. Cough
  5. Suction
  6. Oxygen administration
  7. Assess edema/ability to talk
  8. Monitor VS
82
Q

Which setting provides patient with a tidal volume?

A

AC
(rate/tidal volume)

83
Q

Which setting augument spontaneous breath by decreasing resistance?

A

Pressure support (bump!)

84
Q

*

Which vent setting increases to improve oxygenation?

A

PEEP

85
Q

Tracheostomy tubes

Uses

A

Long-term intubation
trauma, tumors, spinal cord injury

86
Q

Terminal vent weaning/withdrawal

Reasons

A

poor prognosis, requests, interventions are now futile

87
Q

Terminal vent weaning/withdrawal

Nursing interventions

A

Establish a time, expectations and goals
NMBA should be discontinued and cleared
Opioids and sedatives (morphine and benzodiazepines)
Create a calm environment
After comfort achieved, vent settings are reduced

88
Q

Acute Lung Injury

Etiology

A
  • Pulmonary manifestation of MODS
  • Non-cardio pulm edema
  • Disruption of alveolar-capillary membrane
  • ARDS
89
Q

Acute Respiratory Distress

Direct causes

A
  • Aspiration
  • Infection pneumonnia
  • Lung contusions
  • Toxic inhalations
90
Q

Acute Respiratory Distress

Indirect causes

A
  • Sepsis
  • Burns
  • Trauma
  • Blood transfusion
91
Q

ARDS

Pathophysiology

A
  • reduce blood flow to lungs
  • platelet aggregation
  • increases permeability
  • fluid to interstitial space
    alveoli collapse decreasing gas exchange and lung compliance (lungs are now stiff)
    Refractory hypoxemia is end resul correct with high Fi02/PEEP
92
Q

Clinical Manifestations of ARDS

A
  • Tachypnea/tachycardia
  • Clear then crackles
  • restless, agitated, lethargic
  • accessory muscles
  • Hypoxemia non respondent to treatment
93
Q

Pa02:Fi02 ratio

A

normal = >350
ALI < 300
ARDS < 200

94
Q

What would refractory hypoxemia look on an xray?

A

diffuse “white out”

95
Q

Management of ARDS

A
  • Prevention/detection
  • High Fi02/PEEP
  • Pressure-controlled ventilation
  • NMBA’s
  • Antibiotics/steroids
  • Continuous lateral rotation
  • Pronation
96
Q

Pneumothorax

A

air in pleual space with lung collapse

97
Q

Open/closed pneumothorax

Assessment

A
  • Short of breath
  • Hyperresonance
  • Pain
  • Subq emphysema
  • Respiratory distress
98
Q

Open chest trauma

Management

A
  1. Chest tube
  2. Cover site with 3 sided occulsive dressing
99
Q

Tension Pneumothorax

Etiology

A

one-way pneumo (air can enter but cannot escape)

100
Q

Tension Pneumothorax

Clinical manifestations

A
  • displacement of mediastinum and trachea to uneffected side
  • PMI displaced
  • Neck vein distention
101
Q

Tension Pneumo

Treatment

A
  1. needle aspiration
  2. chest tube
102
Q

Hemothorax

Etiology

A

blood in pleural space with collapse of lung

103
Q

Hemothorax

Assessment findings

A
  • Hypotension
  • Hypovolemic shock
    * Dullness
104
Q

Hemothorax

Causes

A
  • chest trauma
  • rib fracture
  • CVC placement
  • anticoagulation therapy
105
Q

Flail Chest

Etiology

A

multiple rib fractures causing unstable wall

106
Q

Flail chest

Clinical manifestations

A
  • Paradoxical chest expansion
  • decreased negative pressure
  • decreased tidal volume
  • pain
107
Q

Flail chest

Treatment

A
  • oxygenation/vent
  • pain control
108
Q
A
109
Q

Chest tubes

A

inserted in pleual space
remove fluid or air
restore negative intrapleural pressure
RE-expand lung

110
Q

Chest tube

Nursing interventions

A
  • Monitor amount and drainage
  • Assess for air leak/subq emphysema
  • Patency
  • Suction (-27cm)
111
Q

How would a nurse assess for air leaks?

A
  1. If lung chamber is bubbling
  2. Clamp tube
  3. If stops –> tube
  4. If doesnt stop its a leak
112
Q

Pulmonary Embolus

Etiology

A

VTE in pulmonary vasculature
90-95% DVT

113
Q

Pulmonary Embolus

Assessment

A
  • Tachypnea/cardia
  • Apprehension
  • Chest pain
  • Hemoptysis
  • Syncope
  • Crackles
    *** DVT evidence **
114
Q

Pulmonary Embolus

Risk factor

A

POST OP!!!
no prophylaxis
birth control/pregnancy
smoking

115
Q

PE diagnostics

A
  • d-dimer
  • CTA (CT angiography)
116
Q

When a DVT more concerning

A

Above the knee!

117
Q

Pulmonary Embolus

Pathophysiology

A
  • Deadspace = bronchoconstriction
  • hypoxemia
  • 40% < occulded is MASSIVE
118
Q

Pulmonary Embolus treatment

A
  • Anticoagulation (acute/longterm)
  • Thrombolytic therapy
  • Hemodynamic support (+ inotropic agents)
  • Embolectomy
  • ICV filter

Critical Care (9 decks)

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