Pulmonary Flashcards
What are the general parts of pulmonary anatomy?
- upper respirator tract
- lower respiratory tract
- alveoli
- primary inspiratory muscles
- primary expiratory muscles
What does the upper respiratory tract consist of?
- nasal cavity
- oral cavity
- larynx
- pharynx
What is the function of the upper respiratory tract?
- warm, humidify, and filter inspired air
- mucocilliary escalator
What does the lower respiratory tract consist of?
- trachea
- bronchi
- bronchioles
- alveoli
What is the function of the lower respiratory tract?
- houses immune cells
- complete pulmonary defense
What should be noted about the R mainstem bronchus?
it is more vertically aligned than the L and is more likely to be the site of aspiration
What is the function of alveoli?
primary site of gas exchange
Name the primary inspiratory muscles
- diaphragm
- external intercostals
- accessory muscles (SCM, scalenes, pecs, traps)
Name the primary expiratory muscles
- rectus abdominus
- external obliques
- internal obliques
- internal intercostals
What are the parts and normal values of V/Q ratio
V - ventilation
Q - perfusion
Normal value: 0.8
What affects V/Q ratio?
- concentration gradient
- surface area
- thickness of membrane
When does dead space occur?
- decreased perfusion (Q)
- example: pulmonary embolism
When does shunting occur?
- decreased ventilation (V)
- example: atelectasis, COPD, pneumothorax
What are the types of lung volumes?
- VC: vital capacity
- TV: tidal volume
- IC: inspiratory capacity
- ERV: expiratory reserve volume
- RV: residual volume
Define vital capacity
- the greatest volume of air that can be expelled from the lungs after taking the deepest possible breath
Define tidal volume
- the amount of air that moves in or out of the lungs with each respiratory cycle (quiet breathing)
Define inspiratory capacity
- the max volume of air that can be inspired after reaching the end of a normal, quiet expiration
Define expiratory reserve volume
- the amount of extra air, above a normal breath, exhaled during a forceful breath out
Define residual volume
the volume of air remaining in the lungs after maximum forceful expiration
Name the types of breathing patterns (13)
- apnea
- biot’s respirations
- bradypnea
- cheyne-stokes respirations
- hyperpnea
- hyperventilation
- hypoventilation
- kussmaul respirations
- orthopnea
- paradoxic ventilation
- sighing respirations
- tachypnea
- hoover’s sign
Define apnea and its causes
- lack of airflow to the lungs for >15 seconds Causes: - airway obstruction - cardiopulmonary arrest - alterations to the respiratory center - narcotic overdose
Define Biot’s respirations and its causes
- constant increased rate and depth of respiration followed by periods of apnea of varying lengths
Causes: - increased ICP
- meningitis
Define bradypnea and its causes
- ventilation rate <12 breaths per minute Causes: - sedatives - narcotics - alcohol - neurologic or metabolic disorders - excessive fatigue
Define Cheyne-Stokes respirations and its causes
- increasing depth of ventilation followed by a period of apnea Causes: - increased ICP - CHF - narcotic overdose
Define hyperpnea and its causes
- increased depth of ventilation Causes: - activity - pulmonary infections - CHF
Define hyperventilation and its causes
- increased rate and depth of ventilation resulting in decreased PCO2 Causes: - anxiety - nervousness - metabolic acidosis
Define hypoventilation and its causes
- decreased rate and depth of ventilation resulting in increased PCO2
Causes: - sedation/somnolence
- neurologic depression of respiratory centers
- overmedications
- metabolic alkalosis
Define Kussmaul respirations and its causes
- irregular rate and depth of respirations
Causes: - diabetic ketoacidosis
- renal failure
Define orthopnea and its causes
- dyspnea that occurs in a flat supine position; relief occurs with more upright sitting or standing
Causes: - chronic lung disease
- CHF
Define paradoxic ventilation and its causes
- inward abdominal or chest wall movement with inspiration and outward movement with expiration Causes: - diaphragm paralysis - ventilation muscle fatigue - chest wall trauma
Define sighing respirations and its causes
- the presence of a sigh 2-3x/minute Causes: - angina - anxiety - dyspnea
Define tachypnea and its causes
- ventilation rate >20 breaths per minute Causes: - acute respiratory distress - fever - pain - emotions - anemia
Define Hoover’s sign and its causes
- the inward motion of the lower rib cage during inhalation
Causes: - flattened diaphragm
–> often related to decompensated or irreversible hyperinflation of the lungs
What are the arterial blood gasses (ABGs)?
- acid-base balance (pH)
- ventilation (CO2)
- oxygenation (O2)
What are ABGs used for?
to guide medical or therapeutic interventions such as mechanical ventilation settings or breathing assist techniques
What might disturbances in acid-base balance be caused by?
- pulmonary dysfunction
- metabolic dysfunction
In what order are ABGs typically written?
pH / PaCO2 / PaO2 / HCO3
What is PaCO2?
partial pressure of dissolved CO2 in plasma
What is PaO2?
partial pressure of dissolved O2 in plasma
What is HCO3?
the level of bicarbonate in the blood
What is the difference between PaO2 and SaO2?
- PaO2 is the partial pressure of dissolved O2 in plasma
- SaO2 is a percentage of the amount of hemoglobin sites filled(saturated) with O2 molecules
Define air trapping
retention of gas in the lung as a result of partial or complete airway obstruction
Define bronchospasm
smooth muscle contraction of the bronchi and bronchiole walls resulting in a narrowing of the airway lumen
Define consolidation
transudate, exudate, or tissue replacing alveolar air
Define hyperinflation
over-inflation of the lungs at resting volume as a result of air trapping
Define hypoxemia
a low level of oxygen in the blood
- PaO2 <60-80mmHg
Define hypoxia
a low level of oxygen in the tissues available for cell metabolism
Define respiratory distress
the acute or insidious onset of dyspnea, respiratory muscle fatigue, abnormal respiratory pattern and rate, anxiety, and cyanosis related to inadequate gas exchange
- this clinical presentation usually precedes respiratory failure
Define Acute Respiratory Distress Syndrome (ARDS)
acute inflammation of the lungs associated with
- aspiration
- drug toxicity
- inhalation injury
- pulmonary trauma
- shock
- systemic infection
- multi organ failure
Describe the sequelae and treatment for ARDS
- variable latent pulmonary sequelae (none to mild exertional dyspnea to mixed obstructive-restrictive abnormalities)
- prone positioning in ICU
- -> facilitates improved aeration to dorsal lung segments, improves VQ matching, and secretion drainage
Define pleural effusion and describe its causes and treatment
- fluid in the pleural space (transudate or exudate) which can be unilateral or bilateral Causes: - compressive atelectasis Treatment: - fluid must be drained
Define pneumothorax
- air in the pleural space which can be open or closed
What can pneumothorax cause? (VQ)
decreased ventilation = shunting
Define hemothorax
blood in the pleural space
Define cystic fibrosis
a genetic anomaly in which there is an issue with sodium channels that results in an excessive amount of fluid in the lungs (mild to severe cases)
Define atelectasis and what it may cause
- collapsed alveoli
- May cause decreased ventilation = shunting
Define flail chest and what it may lead to
- a case in which you have a double fracture of 3+ adjacent ribs which separates the chest from the rib cage
- this leads to paradoxical breathing patterns and can lead to atelectasis if not treated quickly
Define subcutaneous emphysema
bubbles popping under the skin from the presence of air in subcutaneous tissue
Name the different breath sounds
- bronchial breath sounds
- bronchovesicular breath sounds
- bronchial breath sounds in place of vesicular sounds
- decreased/diminished breath sounds
- absent breath sounds
- extrapulmonary sounds
- whispered pectriloquy
- bronchophony
- egophony
Describe bronchial breath sounds
- a pause between inspiration and expiration
- inspiratory and expiratory phases are equal
Describe bronchovesicular breath sounds
- no pause between inspiration and expiration
- inspiration longer and louder than expiration
Describe bronchial breath sounds in place of vesicular sounds
- fluid or secretion consolidation that could occur with pneumonia
Describe decreased/diminished breath sounds
- hypoventilation
- severe congestion
- emphysema
Describe absent breath sounds
- pneumothorax
- lung collapse
Describe extrapulmonary sounds
- from dysfunction outside of lung tissue
- most common: pleural friction rub
Describe whispered pectriloquy
patient whispers 1,2,3
+ Consolidation: phrases are clearly audible
+ Hyperinflation: phrases less audible in distal lung fields
Describe bronchophony
patient repeats 99
+ Consolidation: phrases are clearly audible
+ Hyperinflation: phrases less audible in distal lung fields
Describe egophony
patient repeats the letter ‘e’
+ fluid in air spaces: ‘e’ sounds like an ‘a’ in the distal lung fields
Name the different types and subtypes of adventitious breath sounds
Continuous breath sounds - wheeze - stridor - rhonchi Discontinuous breath sounds - crackles
Describe wheezing
caused by airway obstruction, more common with expiration
Continuous breath sound
Describe stridor
a high-pitched wheeze on inspiration and expiration
Continuous breath sound
Describe rhonchi
low-pitched, caused by airway obstruction
Continuous breath sound
Describe crackles
bubbling and popping sounds from fluid/secretions or sudden opening of closed airway
Discontinuous breath sounds
What is mediate percussion and why is it performed?
- place palmar surface of index and middle fingers flatly against chest wall within intercostal spaces; strike the distal 1/3 of fingers with tips of other fingers; proceed in cephalocaudal, side to side pattern
- evaluates tissue densities within the thoracic cage
What are the different sounds heard from mediate percussion?
- resonant
- hyperresonant
- tympanic
- dull
- flat
What do resonant sounds indicate?
normal lung tissue
What do hyperresonant sounds indicate?
tissue with emphysema or pneumothorax
What do tympanic sounds indicate?
gas bubbles in the abdomen
What do dull sounds indicate?
increased tissue density or decreased air
What do flat sounds indicate?
dense tissue
sound like extreme dullness
What are the different types of pulmonary pharmacologic agents?
- glucocorticoids
- antihistamines
- bronchodilators
- leukotriene modifiers
- mast cell stabilizers
- nebulizer treatments optimally active 15-20mins after administration
Name the goals of PT treatment for pulmonary patients
- promote independent functional mobility
- maximize gas exchange
- increase aerobic capacity
- increase respiratory muscle endurance
- patient education about condition
Name general interventions for pulmonary PT
- breathing retraining exercises
- secretion clearance techniques
- positioning
- functional activities
- exercise
- patient education
- monitoring VS
Name some more specific interventions for pulmonary PT
- improve endurance
- improve strength
- improve functional mobility
- use positioning to promote hemodynamic stability
- work on breathing techniques
- airway clearance with effective coughing
- energy conservation techniques
- ROM to stimulate alveolar ventilation
- postural drainage and manual techniques
- suctioning
What are appropriate outcome measures for pulmonary patients?
- CPAx
- 2MWT
- 6MWT
- AM-PAC 6 Clicks
- DEMMI
- FSS-ICU
What is the purpose of mechanical ventilation?
to maintain homeostasis between gas concentrations of O2 and CO2
When is mechanical ventilation indicated?
- airway protection
- cardiac arrest
- management of ICP
- airway obstruction
- surgery/trauma
What are the different values PTs need to know for mechanical ventilation?
- FiO2
- tidal volume
- PEEP
- O2 flow
- RR
What is FiO2?
fraction of inspired oxygen
- shown as %
What is tidal volume?
normal amount of air ventilated at rest
- shown as mL
What is PEEP?
positive end expiratory pressure
- shown as cmH2O
What is O2 Flow?
how fast the oxygen is flowing
- shown as L/min
What is RR?
respiration rate
- shown as breaths/min
Name the types of mechanical ventilation (11)
- invasive mechanical ventilation
- non-invasive mechanical ventilation
- tracheostomy
- volume control (VC)
- pressure control (PC)
- assist control (AC)
- pressure regulated volume control (PRVC)
- synchronous intermittent mandatory ventilation (SIMV)
- pressure support ventilation (PSV)
- volume support (VS)
- CPAP
What is invasive mechanical ventilation and what does it consist of?
- intubation of artificial ariway into trachea
- endotracheal tube
- nasotracheal tube
- tracheostomy
What is non-invasive mechanical ventilation? What is key about it?
- BiPAP or CPAP
- KEY: the last step before intubation
When is a tracheostomy indicated?
- when a patient is unable to be weaned from the ventilator
- difficulty intubating patient (severe morbid obesity)
- airway blocked or obstructed (tumor, traumatic injury)
What is VC and what are its characteristics and indications?
- preset tidal volume delivered at a set respiratory rate
Indication: - pt with no spontaneous breathing
Characteristics: - peak pressure can vary depending on pts lung compliance and resistance
What is PC and what are its characteristics and indications?
a predetermined amount of pressure at a set rate
Indication:
- pt with no spontaneous breathing
Characteristics:
- ventilator determines inspiratory time
- PEEP used to increase arterial O2 and improve lung compliance
What is AC and what are its characteristics and indications?
delivers a specific amount of tidal volume Indications: - pt can initiate breaths Characteristics: - forces air into lungs - pt or vent initiates breaths - high level of respiratory support
What is PRVC and what are its characteristics and indications?
combines PC and VC ventilation
- a preset tidal volume is delivered at a set rate but with the lowest possible pressure
Indications:
- prevent barotrauma
What is SIMV and what are its characteristics and indications?
allows pts to breathe in between each machine assisted breath and delivers a certain number of breaths in coordination with respiratory effort of pt
Indications:
- pts with some but not sufficient breathing
- weaning
Characteristics:
- increased work of breathing
What is PSV and what are its characteristics and indications?
a small, specific amount of pressure occurs on inspiration
Indications:
- pt can initiate all breaths
Characteristics:
- ventilator assists pt with spontaneous breaths
- pt regulates RR and TV
What is VS and what are its characteristics and indications?
tidal volume and PEEP are set Indications: - pt can initiate all breathing Characteristics: - vent delivers support in proportion to pt's inspiratory effort and target volume
What is CPAP and what are its characteristics and indications?
continuous pressure is maintained in the airways to prevent collapse
Indications:
- pt regulates all other respiratory functions
What medications are used with mechanical ventilation?
- propofol
- precedex
- fentanyl
What are causes of red alarms with mechanical ventilation?
- apnea
- disconnection
- high pressure
What are causes of yellow alarms with mechanical ventilation?
- low tidal volume
- high respiratory rate
- low minute ventilation
- low inspiratory pressure
What does weaning off mechanical ventilation mean?
- a process of decreasing or discontinuing mechanical ventilation
- a condition that led to ventilation support needs to be resolved
What factors should be considered during weaning?
- respiratory demand and ability of NM system to cope with O2 demand
- oxygenation
- cardiovascular performance
- psychological factors
- adequate rest and nutrition
What are signs of distress during weaning?
- tachypnea (>30 breaths/min)
- decreased pH (<7.25-7.30 with increased PaCO2)
- paradoxical breathing patterns
- O2 Saturation <90%
- HR change of >20bpm
- BP change > 20mmHg
- agitation
- panic
- diaphoresis
- cyanosis
- angina
- arrhythmia
What are contraindications to PT for mechanical ventilation?
- comatose
- unresponsive
- does not follow commands
- severe agitation/combativeness
- PEEP >10cmH2O
- FiO2 > 0.6 or 60%
- uncontrolled active bleeding
What are complications of mechanical ventilation?
- skin breakdown
- joint contractures
- deconditioning
