Pulmonary - CCRN Flashcards
Which area of the brain controls respiration?
Medulla
Which part of the C-spine contains the phrenic nerve and therefore controls the diaphragm?
C 3,4,5
Describe the process of inspiration.
Diaphragm contracts, moves downward
Intrathoracic pressure decreases
Air flows in
O2 is exchanged at the alveolar/capillary bed
Describe expiration
Diaphragm relaxes (moves up)
Thoracic volume decreases
Intrathoracic pressure increases
Gas flows out
What factors/processes can change lung compliance?
Age - infants have increased lung compliance
Compliance decreased by:
Pulmonary edema
Pneumothorax
Atelectasis
Name 2 types of collapsed lungs and describe them.
Pneumothorax - puncture to pleural lining
Atelectasis - pleural lining intact, lung cannot expand
Causes and risk factors for a pneumothorax
-Trauma
-Spontaneously - part of the lung ruptures
More common with existing lung condition:
COPD, TB, pertussis, asthma, CF, chronic bronchitis, emphysema
Procedures - line insertion
Infection
Risk factors:
Being tall and thin
Previous hx of collapsed lung
Smoking
What are the causes of atelectasis?
Usually from a blockage of the airway:
Mucous, tumors, small objects
Can result from pressure outside the lungs
Fill in the blank:
Resistance is ______________ related to airway diameter.
Give examples
Resistance is INVERSELY related to airway diameter.
Increased in: Asthma, CF, BPD, bronchiolitis, increased secretions.
This causes a DECREASE in air that reaches the lungs.
What is BPD?
Inflammation and scarring of lung tissue during development.
Most common in premies.
Describe the affect fetal circulation has on the lungs.
In utero:
Increased pulmonary vascular resistance leads to decreased pulmonary blood flow.
On delivery the pulmonary vascular resistance drops to allow for increased pulmonary blood flow.
Explain how to look at V/Q as a ratio.
Think ventilation first.
1:1 is normal.
The lower number is the problem!
High/low refers to the first number’s relationship to the second number.
What is ventilation?
Ventilation (V)
How fast O2 and CO2 are exchanged
What is perfusion?
Perfusion (Q)
The speed at which blood flows through the lungs.
Explain a high V/Q, give an example and a cause.
High V/Q is caused by inadequate perfusion (i.e. Shock)
5:1 ratio
V - 5 is good ventilation
Q - 1 poor perfusion
Explain a low V/Q, give an example and a cause.
A low V/Q is when there is not enough O2 available.
1:5
V - 1 - poor ventilation
Q - 5 - good perfusion
What is pulmonary vascular resistance?
The amount of resistance the R ventricle has to overcome to pump blood through the pulmonary vasculature by way of the pulmonary artery.
What can cause an increase in pulmonary vascular resistance?
An decrease in surface area (i.e. CF)
An increase in blood viscosity (as seen in cyanotic heart disease)
What physiological differences exist in the lungs/thorax/upper airway of an infant/young child that increase the likelihood of respiratory distress?
- Lung volume increases x4 in the first year.
- Kids have smaller alveoli, more likely to collapse.
- Infants have cylindrical chests - the AP diameter > the transverse diameter until 3 y.o.
- Elongated epiglottis that lies high in the pharynx and is more anterior
- Obligatory nose breathers until 6 months old.
- Infants/young children have greater chest compliance.
- Infants/young children have weaker intercostal muscles that cannot stabilize the chest wall against the diaphragm - leading to retractions
What type of blade is generally used to intubate an infant? Why?
Miller blade.
An infant has a high and anteriorly placed epiglottis that is floppy - the straight blade can move the epiglottis out of the way.
What type of blade is used to intubate older children and adults?
Mac Blade
Older children/adults have stiff epiglottis’ - curved blade appropriate.
What anatomical feature is the narrowest part of the airway?
Cricoid cartilage -
Acts as a natural cuff until 8 yrs old
Theoretically children under the age of 8 should not need a cuffed tube for intubation.
What anatomical features are included in the larynx?
What is the pedestrian name for the larynx?
The larynx includes: Epiglottis Supra glottis Vocal cords Glottis Sub-glottis
Commonly called the “voice box”.
What structures does the larynx connect?
The larynx connects: Pharynx Thyroid cartilage Cricoid cartilage Trachea
TLC
Total Lung Capacity
The volume o the lungs at max inspiration
TLC = FRC + VC + RV
VC
Vital Capacity
Max volume expired with max effort
FRC
Functional Residual Capacity
Volume remaining in the lungs after normal expiration
RV
Residual Volume
Volume remaining in the lungs after forced expiration.
What compensatory mechanisms does the body employ to change the pH of the blood?
Lungs
- increased rate and depth to increase tidal volume to blow off more CO2 makes the blood more alkalotic.
- Decreased rate and depth to decrease tidal volume to retain CO2 makes the blood more acidotic.
Kidneys
- change absorption of H+ ions and bicarbonate.
- decreased absorption of H+ ions leaves more H+ ions in the blood makes the blood more acidotic.
What function does PaCO2 provide information about?
Alveolar ventilation
What numerical level defines hypercarbia?
PaCO2 > 55 mmHg
What does the PaO2 provide information on?
Oxygenation status.
What numerical level defines hypoxia?
PaO2 <60 mmHg
State high/low for each: pH, PCO2, HCO3 for
Respiratory acidosis with metabolic compensation:
pH: L
PCO2: H
HCO3: H
State high/low for each: pH, PCO2, HCO3 for
Metabolic and respiratory acidosis
pH: L
PCO2: H
HCO3: L
State high/low for each: pH, PCO2, HCO3 for
Metabolic alkalosis with respiratory compensation
pH: H
PCO2: H
HCO3: H
State high/low for each: pH, PCO2, HCO3 for
Metabolic and Respiratory Alkalosis
pH: H
PCO2: L
HCO3: H
List the causes and symptoms of respiratory acidosis and high/low for pH, PCO2 and HCO3.
Due to inadequate ventilation - CO2 builds and increases H+ ions leading to acidosis
- Inadequate ventilator settings
Symptoms:
- Tachycardia
- Tachypnea
- Atrial and ventricular dysrhythmias
- Increased ICP
pH: low
PCO2: High, >45 mmHg
HCO3: Normal or high
List the causes and symptoms of respiratory alkalosis and high/low for pH, PCO2.
pH >7.45
PaCO2 <35 - lungs blow off too much CO2
Symptoms: Diaphoresis Dizziness ST changes - dysrhythmias Muscle spasm
Causes:
- seen in adults who hyperventilate
- uncommon in children unless ventilator setting require adjusting.
List the causes and symptoms of metabolic acidosis and high/low for pH and HCO3.
pH < 7.35
HCO3 < 22
Symptoms: Tachycardia Tachypnea Vision changes H/A N/V/D
Causes:
DKA
Renal issues - acute renal injury
List the causes and symptoms of metabolic alkalosis and high/low for pH and HCO3.
pH > 7.45
HCO3 > 26
Dysrhythmias
Tachycardia
Lethargy
Muscle weakness
Causes:
Prolonged emesis or NG suctioning
When suctioning a trach how big should the catheter be?
50% of the size of the trach tube.
When suctioning a trach what should the suction pressure be?
80-100
What events lead to cardiopulmonary arrest?
Hypoxia
Hypercarbia
Bradycardia
Respiratory arrest
DOPE
If a mechanically ventilated pt suddenly deteriorates use DOPE to determine the cause:
D- displacement
O- obstruction
P- pneumothorax
E- equipment failure
When is NPPV used?
Name 2 types.
Noninvasive positive pressure ventilation is used when a pt needs to keep his airway open AND can breathe independently
Types: CPAP, BiPAP
CPAP
Continuous positive airway pressure:
Administers same constant pressure during inspiration and expiration.
BiPAP
Biphasic Positive Airway Pressure:
Difference in Pressure
Can sense inspiratory effort.
Name 2 main types of invasive ventilation/ventilators.
Volume control - Tv is controlled, but allows passive expiration
Pressure Control - Pt determines Tv
Explain positive pressure ventilation:
Positive pressure ventilation forces air into the lungs by exceeding alveolar pressure.
Mode can be spontaneous or mandatory.
Explain controlled ventilation
Predetermined number of breaths per minute is set.
Requires sedation and paralyzation.
Explain AC ventilation
Assist-Control Ventilation
Rate is set, volume/min is set
with Volume Guarantee- if pt initiates low volume breath vent will finish the breath at the set volume.
This can lead to excessive ventilation (increased minute volume)
Which can lead to respiratory alkalosis, especially if the pt respiratory rate increases for non-respiratory reasons.
SIMV
Synchronized intermittent mandatory ventilation:
R is set, Tv- min set
Additional breaths initiated by the pt are permitted but not assisted by the ventilator.
By setting a high rate you provide total respiratory support
Explain spontaneous ventilation on a ventilator.
Allows pt to take breaths on own without any vent support.
Allows for monitoring of exhaled volumes and airway pressures.
Requires slight increased WOB over T piece (must overcome resistance created by vent circuit to initiate flow).
What is PEEP?
Positive end expiratory pressure.
Applied to keep alveoli from prematurely collapsing during exhalation.
It increases compliance and V/Q matching.
When is PEEP appropriate/necessary?
Tx hypoxia from lung injury
Prevent alveolar collapse in restrictive airway when the FRC is decreased.
What ventilator modes can PEEP be applied to?
All ventilator modes.
What are complications from applying PEEP?
Increasing mean and peak airway pressures can lead to barotrauma.
High pressure in the lungs = increased intrathoracic pressure = increased RA pressure, decreased venous return (and therefore decreased RA fill) = DECREASED CO
{If CO drops but O2 increases, fluid bolus may correct CO}
PEEP (and CPAP) can also: Increase ICP Decrease renal perfusion Increase hepatic congestion (increased intrathoracic pressure) Worsen intracardiac shunts
List normal values for PIP, based on age:
Newborns: 10-12 mmHg
Older infants/Children: 12-15 mmHg
Teens/Adults: <20 mmHg
What factors determine PIP?
- Lung compliance
- I time
- Airway resistance
- Tv
What is a normal tidal volume?
4-7 mL/kg
What is dead space ventilation?
It is the 1/3 of the Tv gas that occupies the airway lumen but does not participate in gas exchange.
Explain what HFJV is and how it works.
High frequency jet ventilation.
Rate, I- time, Pressure and Peep and volume are set
Rate is 100-600 breaths/min
Passive exhalation
Tv are small 1-3mL/kg
Higher mean airway pressure but lower peak airway pressure than conventional ventilator.
The jet (small tube) is placed as low as possible into the lungs, spiraling gas stream, high velocity
What are the advantages of HFJV?
Reduced chance of barotrauma (low Tv and pressures)
Forces CO2 against walls, penetrating dead space.
What is HFJV used for?
BPD
Chronic lung disease
Pulmonary interstitial emphysema
Which uses greater pressures, the JET or the Oscillator?
Oscillator
What are the advantages of using an oscillator?
Helps expand alveoli
Decreases pulmonary vascular resistance
Improves VQ matching
Decreases risk of barotrauma
What type of conditions are tx with the use of an oscillator?
RDS
{young infants with RDS may be placed directly on oscillator, skipping a conventional vent to avoid barotrauma}
Primary Pulmonary Hypertension (PPHT) r/t:
Meconium aspiration
Air leak syndrome
Pulmonary interstitial emphysema
Congenital Umbilical hernia
Describe the general function of HFOV.
Disperses gas throughout lungs at high frequency
Constantly infuses fresh gases and evacuates old ones
Active inspiratory and expiratory phases - completely controlling pt respiratory cycle
What is ECMO?
Extracorporeal Membrane Oxygenation
Provides prolonged cardiopulmonary bypass with membrane oxygenation by pumping blood outside of the body for oxygenation with a cardiopulmonary bypass machine
Indications for ECMO:
Resolvable organ failure with potential for good neuro outcomes
Contraindications for ECMO:
Irreversible conditions
Previous head bleeds in neonates
Pulmonary hemorrhages
Contraindications to heparinization
Describe Cardiac bypass ECMO
Used in cardiac and pulmonary failure
Cannulate major artery (carotid) and a major vein (subclavian or femoral)
A-V ECMO
Describe Pulmonary Bipass ECMO
Pt must have good cardiac output
Lungs bypassed
2 major veins cannulated to divert blood from and return it to R atrium
V-V ECMO
List complications of mechanical ventilation:
VAP - ventilator associated pneumonia
VILI - ventilator induced lung injury:
- valutrauma - from high volumes
- barotrauma - from high pressures
- atelecotrauma - from alveoli being forced open and closed
Can lead to = Pneumomediastium Pneumopericardium Pneumothorax Cardiac arrest
List VAP prevention techniques:
Elevate HOB
Avoid gastric distention
Maintain closed system (no saline lavages)
Vigilant mouth care
What is a normal range for I:E ratios?
1:2 to 1:5
List 2 types of acute respiratory failure and examples of causes of each.
Hypoxic - PaO2 <60mmHg
(Ex: asthma, smoke inhalation)
Hypercarbic - high CO2, generally from increased dead space
(Ex: scoliosis)
List signs and symptoms of respiratory distress:
Tachypnea Tachycardia Nasal flaring Grunting Head bobby Retractions Prolonged expiratory phase Wheezing Stridor Diaphoresis Agitation Apnea Cyanosis Pulsus Paradoxus
List signs of impending respiratory failure:
Decreased air entry Severe retractions Cyanosis despite O2 delivery Irregular respiratory pattern/apnea Altered LOC Diaphoresis
What is the formula for determining ET tube size?
16 + age (years)/4
What is pneumonia?
What can cause it?
Pneumonia is the inflammation of the lung parenchyma
Alveoli fill with exudate = alveolar edema (good for bacterial growth)
Leads to:
Lung consolidation = decreased compliance, decreased VC and decreased TLC
Can be viral or bacterial
Viral can turn into bacterial
Can be caused by inspiration, aspiration or systemic circulation
What populations of pts are at risk for developing pneumonia?
Artificial airway
Increased risk for aspiration (neuro changes/head injury)
Chronic underlying conditions (i.e. CF)
List the s/sx of pneumonia:
Hx of URI
Hx of decreased appetite and restlessness (infants)
Fever
Cough
Respiratory distress
Abd distention (from swallowing air with increased WOB
Liver may feel enlarged (from downward displacement of diaphragm from hyper inflated lungs)
Indications of bacterial pneumonia:
Tends to be lobular
WBC count tends to be >15,000
Indications of Viral Pneumonia:
Tends to be interstitial
Hazy, diffuse x-ray
What is the definition of HAP (hospital acquired pneumonia)?
Name 2 types of bacterial HAP.
Pneumonia that develops at least 72 hrs AFTER admission.
Pseudomonas Aeruginosa - most lethal HAP
- common in chronic conditions and trach S
Klebsiella - high mortality rates
What bacteria is the most frequent cause of bacterial pneumonia?
Streptococcus Pneumonia
Gram + cocci
Incidence has decreased since introduction of heptavalent pneumonia conjugate vaccine in 2000.
Describe the pathophysiology of streptococcus pneumonia.
Usually follows URI
Protein rich fluid fill alveoli and interstitium (the space around the alveoli)
List potential complications of streptococcus pneumonia.
Pleural effusions
Supra infections
Pericarditis
What is the tx for streptococcus pneumonia?
Abx - penicillin
What are pleural effusions?
An abnormal buildup of fluid in the pleural space.
What is Hemophilus Influenzae?
Bronchial or lobar pneumonia with areas of alveolar collapse and subsequent tissue hardening.
Can appear 2-6 weeks after URI with slow onset
List potential complications of Hemopilus Influenzae.
Pleural effusions
Lung abscesses
Epiglottitis
Pericarditis
What is the standard tx for Hemophilus Influenzae?
Tx with abx:
Cephalosporins and macrolides
What age group is most susceptible to viral pneumonias?
Children <5 yrs old
Describe Mycoplasma Pneumoniae, sx, ages affected.
Pleomorphic organism.
Alters cilia function and activates inflammatory response.
Gradual onset, may appear less ill-looking than other pneumonias but can worsen quickly
Sx: Paroxysmal cough Diarrhea Low grade fever Pharyngitis Erythematic rash
What is a pleomorphic organism?
One that changes shape and size in response to the environment.
List the most common causative organisms of epiglottitis.
Strep pyogenes
Strep pneumonia
Staph Aureus
Explain the course and pathophysiology of epiglottitis.
Bacteria causes thickening of the epiglottis and surrounding folds =
Obstruction and turbulent gas flow
Life threatening - kids go from minimally sick to extremely sick very quickly
Peaks at ages 2-6 yrs
What is the tx for epiglottitis?
Vaccine to prevent occurrence
Position for comfort and minimize agitation
Abx
Intubate in ICU/OR with trach set at bedside - only get one try
Only extubate when there is an air leak
List the s/sx and course of epiglottitis.
Inspiratory stridor Muffled focalization Dysphasia High fever Wants to remain in sitting position Drooling Lateral x-ray shows thumb sign
Lasts 36-48 hours
Describe the pathophysiology of croup.
Laryngotracheobronchitis
Inflammation of mucosa in the subglottic area
With large amounts of thick secretions
Can be viral or bacterial
List the s/sx and coarse of croup.
Inspiratory/expiratory stridor - worsens at night
Barking cough (seal-like)
Hoarse focalization
Low grade or no fever
On an AP x-ray visualization of steeple sign
Lasts 3-4 days
What is the management for croup?
Cool mist humidification Racemic epinephrine - vasoconstricts the vessels but can have a rebound effect Corticosteroids use is controversial Heliox - lighter gas to decrease WOB Hydration to liquify secretions If intubating - decrease ETT by 1 size
What is acute tracheitis and what are the causative organisms?
Super infection
Similar sx to croup but doesn’t always respond to the same tx
Care is supportive
Causative organisms: Staph aureus Group B-hemolytic strep CA - MRSA H. Influenzae
How long can RSV live on hard surfaces?
On clothes and hands?
Hard surfaces - 6 hrs
Clothes and hands - 1 hr
What populations are at the most risk for developing bronchiolitis?
Preemies
Infants not breastfed
Crowded conditions
Exposure to smoke
What is the pathophysiology of bronchiolitis?
Respiratory epithelium is injured from a virus =
Inflammation of the lower respiratory tract/edema and abnormal airway secretions = blockage of airways = V/Q mismatch
What are the most common viruses to cause bronchiolitis?
RSV Influenza Parainfluenza adenovirus M. Pneumonia
List the s/sx of bronchiolitis
Hx of URI
Fever
Respiratory distress
Chest x-ray - hyper inflation or infiltrates
What is the tx for bronchiolitis?
Hospitalization for monitoring of respiratory distress
Supportive care
Consider pneumothorax if pt condition worsens.
Prevent with hand washing
What age group most commonly suffers a foreign body aspiration?
60-80% of occurrences are with children under 3 yrs.
List the s/sx and tx for foreign body aspiration and the most commonly aspirated object.
Clinical course dependent on type of object, location, available assistance and degree of obstruction the object causes.
Most common location for objects is right bronchus
40% of the time the chest x-ray is normal
Nuts are the most common object.
List the criteria for ARDS/ALI.
Acute onset Severe hypoxemia, refractory to O2 administration Bilateral infiltrates on chest x-ray Absence of L atrial HTN Pulmonary HTN present
Describe the pathophysiology of ARDS.
Progressive hypoxemia
Blood and fluid leak into alveoli of injured lungs preventing O2 from entering alveoli
Inflammation leads to scar tissue formation
List the s/sx of ARDS/ALI:
Crackles,rales, wheezes
Tachypnea with expiratory grunting
Starts with respiratory alkalosis that develops into respiratory acidosis
High O2 requirement
MODS
Diffuse infiltrates, bilaterally but cardiac vessels are normal
What is the tx for ARDS/ALI?
O2
PEEP if intubate
IV fluids - take care not to fluid overload lungs
Enteral nutrition
Prone positioning where the chest and hips are supported but the abd is not.
Why does prone positioning facilitate recovery in ARDS/ALI?
Exact reasons unknown. Thought to: Mobilize secretions Decrease V/Q mismatch Recruit alveoli Increase FRC Decrease shunting
Improvement with repositioning can generally be predicted in trend of improvement in 1st 30 minutes.
Broadly speaking, what is an acute pulmonary embolism?
What are the three types?
An acute obstruction of the pulmonary artery bed. Types: Thromboemboli Air emboli Fat emboli
Describe the pathophysiology of a pulmonary thromboemboli.
Venous status leads to the formation of venous thrombi =
Emboli travel through venous circulation to pulmonary circulation =
Emboli become trapped in pulmonary artery bed
Describe the pathophysiology of pulmonary air emboli.
Air enters the venous system = travels to the R heart and into pulmonary circulation = causes damage to pulmonary endothelium = increases capillary permeability = causes flooding of the alveoli
Describe the pathophysiology of a pulmonary fat embolus.
Fat emboli most often form from long bone fx.
Injures pulmonary endothelial lining= increased capillary permeability = flooding to alveoli
List s/sx of acute pulmonary embolism.
Decreased breath sounds Dyspnea Tachypnea Pulmonary HTN Hemoptysis Fever Tachycardia Increased pulmonary artery pressure = decreased CO = Shock CXR shows diffuse alveolar filling with pulmonary emboli
How do diagnose and treat pulmonary emboli?
Spiral CT O2 Anticoagulants (if thromboemboli) Surgery to remove emboli Early dx!
What is bronchitis and what is the tx?
Inflammation of tracheobroncial tree
Usually starts as a viral URI with hacking cough
Symptomatic treatment
What is asthma?
Chronic d/o of the airway Characterized by: Recurring sx Airflow obstruction Bronchospasm Underlying inflammation
Describe the pathophysiology of asthma.
Mediators (histamine and bradychyman) are released when IgE binds to mast cells = constriction of bronchial smooth muscle, inflammation of bronchial mucosa and thick secretions.
List the s/sx of asthma.
Wheezing Dyspnea Tachypnea Productive cough Decreased minute volume Rales Prolonged expiratory phase Tires easily
List tx options for asthma (including medications, med classes).
O2 Fluids If intubated - need longer expiratory times Meds: Beta 2 agonists Anticholinergics Magnesium sulfate Leukotriene inhibitors Aminophylline Corticosteroids Ketamine gtt
Asthma medication: Albuterol
List class, S/E, action
Inhaled beta 2 agonist Short acting Causes bronchodilation S/E: Tachycardia Increased myocardial contractility and O2 consumption
Asthma medications: Epinephrine
Class, action, efficacy
Beta 2 agonist
Bronchodilation
No proven advantages over aerosol tx
Asthma medications: Terbutaline
Class, action, efficacy
Beta 2 agonist
Bronchodilation
No proven advantages over aerosol tx
Asthma medications: Ipratropium
List name, class, mechanism of action, concurrent meds
Atrovent Anticholinergic Blocks parasympathetic receptors = bronchodilation Used wth beta 2 agonist Can be mixed wth albuterol
Asthma medications: Singulair
List class, mechanism of action, effects, efficacy
Leukotriene inhibitor
Blocks action of cysterinyl leukotriene. Cysternyl leukotriene causes:
Bronchoconstriction
Mucous secretions
Increases vascular permeability
Migration of eosinophils
Takes effect in 24 hrs - not first line tx
Asthma Medications: Methylprednisolone, PO Prednisone
List drug class, mechanism of action, effects
Corticosteroids Suppress mine response and histamine release Effects: Decreased edema Decreased secretions Decreased hyperreactivity
Asthma medications: Amnophilline
No longer first line tx: narrow window of efficacy/toxicity
Need to monitor blood levels
Weak bronchodilator
Anti inflammatory properties
Asthma medications: magnesium sulfate
Drug class, mechanism of action, administration
Calcium antagonist
Causes muscle relaxation by preventing calcium re uptake
Give IV
Monitor blood levels
Have calcium chloride on hand to reverse toxicity
What use does ketamine have in the tx of asthma?
A ketamine drip can cause bronchodilation.
What is status asthmaticus?
Acute episode that fails to respond to conventional out pt or ER treatments.
List causes of pulmonary hemorrhage.
Chest Trauma Infection Increased pulmonary vascular pressure AV malformation Pulmonary emboli Autoimmune disease Asphyxia
What is a pulmonary AV malformation?
Blood flow by passes the capillary system causing Right to Left shunting between the pulmonary artery and the pulmonary vein.
Rare occurrence
What is BPD?
Chronic lung disease with alveolar damage from inflammation and scar tissue
Occurs after mechanical ventilation with O2 dependency persisting beyond 36 weeks corrected gestational age.
What are risk factors for BPD?
Preemie
Low birth weight
RDS at birth
Need for long term ventilation or O2
What is the tx for BPD?
Surfactant
Ventilaton assistance - PEEP with Low Tv
Diuretics to decrease preload
Nutrition (poor nutrition is thought to exacerbate BPD
What is a diaphragmatic hernia?
Protrusion of abd contents into the thoracic cavity.
What are the developmental complications of a diaphragmatic hernia?
Pulmonary hypoplasia which includes decrease in size of lungs and the size and number of alveoli.
Typically affects the L side to a greater degree.
What are the s/sx of a CDH?
Congenital Diaphragmatic Hernia : Scaphoid abd Barrel - shaped chest Cyanosis Respiratory distress Altered breath sounds on the affected side Pulmonary HTN
How s CDH managed/tx?
Gastric decompression Avoid BVM ventilation Low PIP Low PEEP Rapid respirations ECMO Surgery to repair after respiratory status stabilizes
What s a Tracheoesophageal fistula and what other anomaly is commonly associated with it?
A communication between the trachea and esophagus.
Commonly associated with an esophageal atresia (esophagus ends in blind-ended pouch instead of normally in the stomach)
What are the s/sx associated with a TEF?
Coughing Cyanosis Choking Drooling Inability to Pass OGT Distended abd - TEF Scaphoid abd - EA
What is the Tx for TEF?
NPO Surgery Elevate HOB Avoid BVM IVF TPN Abx May need G tube
What is choanal atresia?
Congenital d/o where the back of nasal passage is blocked by abnormal bony or soft tissue
Unilateral or bilateral
Surgery to correct
What are the s/sx of choanal atresia?
Difficulty breathing unless crying
Respiratory distress
What is Pulmonary Hypoplastia?
Incomplete development of the lungs due to inadequate pulmonary parenchyma tissue and pulmonary blood flow.
Often associated with other malformations
What are some causes of Pulmonary Hypoplastia?
Inadequate intrathoracic space (i.e.: tumor, pleural effusions, CDH)
Prolonged oligohydramnios
Renal agensis
Absent or decreased fetal breathing movements
CNS lesions
What are the s/sx of Pulmonary Hypoplastia?
Immediate respiratory distress:
Tachypnea
Retractions
Cyanosis
Hypercarbia
AcidosisWhat is the management for pulmonary hypoplastia?
Fetal surgery
AC ventilation
HFOV
ECMO
What s tracheomalacia?
Weakness,floppiness of tracheal walls
Widening of the posterior wall = reduced anterior-posterior caliber
= tracheal collapse with coughing, crying, feeding
List 3 types of tracheomalacia:
Congenital intrinsic: resolves by 6 to 12 months
Extrinsic - vascular rings
Acquired - caused by medical interventions: prolonged intubation
Describe tracheal stenosis, list 2 types, sx and tx.
Narrowing of trachea
Types: idiopathic
Traumatic
Sx: dyspnea, stridor
Tx: bronchodilation (effects may be temporary)
Resection, reconstructionWhat is pulmonary hypertension?
Mean pulmonary artery pressure >25 mmHg
Should be less than 1/4 of systemic pressure
What is the cause of pulmonary HTN?
Increased pulmonary blood flow
Increased pulmonary vascular resistance
Primary: unknown cause
Secondary: CHD
Chronic lung disease
Phen-Phen (diet drug)
Describe the pathophysiology of pulmonary HTN:
V/Q mismatch = blood shunted to lower pressure areas Hypoxic vasoconstrictions Obliteration of pulmonary vasculature Volume overload Pressure overload
List the s/sx of pulmonary HTN:
Chest pain
Dyspnea
Fatigue, lethargy
Syncope with exertion
Right-sided heart failure
Systolic ejection murmur
Rarely: Cough
Hemoptysis
HoarsenessWhat is the management for pulmonary HTN?
O2
Calcium channel blockers (amlodipine)
Digoxin
Diuretics
Vasodilators (prostacyclin agents)
Surgery - to correct underlying problem
Transplant - heart and/or lungList 4 air leak syndromes:
Pneumothorax
Pneumomediastium
Pneumopericardium
Perivascular interstitial emphysema (PIE)
What is a pneumothorax?
Air in the pleural cavity.
List the s/sx of a pneumothorax
Hypoxia Decreased perfusion Restlessness Dyspnea Sudden respiratory distress Hypotension (increased intrathoracic pressure decreases preload) Shift of PMI
What is a pneumopericardium?
List complication/tx
Air in pericardial space
Fill of heart is compromised = can lead to cardiac tamponade
Tx with needle decompression
What is a pneumomediastinum?
Is it an emergency?
List complications.
Air between R and L pleural sacs
Can lead to a pneumothorax or pneuomediastinum
List H’s and T’s of cardiac tamponade.
Hypotension
Hypoxia
Tachypnea
Tachycardia
What is PIE?
Explain the pathophysiology of PIE.
Pulmonary Interstitial Emphysema
Over distended alveoli from increased pressure and tidal volume
=Alveolar rupture
=Air moves into interstitial tissue
=if ventilation continues air moves into the subcutaneous tissue
Why is thoracic trauma generally worse in children?
They have compliant chest walls and a mobile mediastinum = look fine with a LOT of internal injuries
What should a pt with rib fx be evaluated for?
Less than 3 y.o. = abuse
R/O: spinal injury
Liver and spleen injury
Great vessel involvement (rare)
List complications of Lung Contusions.
Hemorrhage and edema
V/Q mismatch (from blood in alveoli)
Pneumothorax/hemothorax
What can tracheal perforation result from?
Rare complication of intubation = subcutaneous emphysema
Requires IMMEDIATE surgical repair
