Resp disorders Flashcards
what is pleural effusion
fluid in pleural space caused by transudative or exudative effusion
transudative vs. exudative effusion
transudative: increased hydrostatic pressure or low oncotic pressure from HF, cirrhosis
exudative: increase in capillary permeability from inflammation - infection, tumors, hemothorax
why are the elderly at risk for pleural effusion
- decreased elasticity of the lungs -> enlarged air spaces
- increased anteroposterior diameter, shortened thorax
- altered mobility
- decreased vital capacity (max air inhaled)
- decreased chest wall compliance
classic pleural effusion s/s
- dyspnea
- pleuritic chest pain (esp. on inspiration) referred to shoulder or abdomen
- cough: nonproductive
- decreased breath sounds, pleural friction rub
- dullness/hyperresonance when percussed
how to diagnose pleural effusion
- CXR: blunting of costophrenic angle (typically used to diagnose)
- CT scan
- thoracentesis
- ultrasound to ensure needle placement
what can rapid removal of fluids via thoracentesis cause
hypotension, hypoxemia, or reexpansion pulmonary edema
so remove 1,000 - 1,200 mLs at a time
what does diff pleural fluid mean:
- bloody
- milky
- purulent
- viscous
- clear straw colored
- bloody: trauma
- milky: effusion there a long time
- purulent: infection
- viscous: mesothelioma
- clear straw colored: normal
what is pneumothorax
trapped air in pleural space and pressure is exerted in nearby structures such as trachea and heart
closed vs. open vs. tension pneumothorax
closed: air entering remains the same
open: air circulates freely
tension: air accumulates
causes for pneumothorax
- primary: without underlying lung disease
- secondary: with lung disease
- trauma, scuba diving
what procedures puts pt at risk for pneumothroax
- central line placement
- mechanical ventilation
- tracheostomy
- bronchoscopy
- intercostal nerve blocks
- pacemaker placement
- CPR
classic signs of pneumothorax
- tracheal deviation, mediastinum shift
- JVD
- sharp pleuritic pain radiating
- hypotension, tachycardia, dyspnea
- cardiac arrest
how to diagnose pneumothorax
- ultrasound -> CXR -> CT
- EKG, cardiac enzymes
- ABG
treatment of pneumothorax
- needle decompression slow
- chest tube placement
- pain meds
PaO2 normal level
80-100 mmHg
fully compensated vs. partially compensated vs. uncompensated ABG
fully compensated: pH normal
partially compensated: all values abnormal
uncompensated: PaCO2 or HCO3 is one normal one abnormal, pH out of range
what to prepare for chest tube placement
- informed consent obtained
- sterile environment
- pt sitting up leaning across table
what is flail chest
trauma where 3+ ribs broken in at least 2 places
the chest moves independently from chest wall
s/s of flail chest
- paradoxical chest movement
- pain & splinting
- dyspnea, tachypnea
- bruising, bleeding, edema in injured area
severity of flail chest depend on which 3 factors
- pleural pressure
- extent of the flail
- movement of intercostal muscles during inspiration
what does flail segment of the chest lead to in terms of damage
hypoventilation w/ atelectasis + pulmonary contusion (bruising), which leads to edema and hemorrhage
in turn, reduces lung space
diagnosis for flail chest
CT> CXR
- ABG
treatment for flail chest
probably mechanical ventilation, but try hiflow O2, CPAP/BiPAP first
endotracheal tube
what are long-terms effects of flail chest
- permanent chest wall deformity
- exercise intolerance
- stiffened thoracic cavity
what can flail chest lead to
- resp failure
- pneumothorax, hemothorax
- pulmonary contusion
- atelectasis -> hypoventilation
what are some unexpected findings in flail chest
- tachycardia, hypotension
- hypoxia, respiratory distress
- ALOC
- increased pain
- abnormal ABG or cardiac enzymes
what is saddle embolism
a large clot that blocks the bifurcation of the main pulmonary artery
how does embolism affect BP
clot blocks blood supply -> increased pulmonary arterial pressure -> harder to pump -> dead space -> high V/Q
how does pulmonary embolism affect V/Q mismatch
high V/Q >0.8
dead space created from lack of blood flow while ventilation remains the same
serotonin released -> vessels contract -> reduced bloodflow to lungs
what ABG would you expect from pulmonary embolism
- hyperventilation attempts to compensate, leading to hypocapnia
- respiratory alkalosis
how does pulmonary embolism affect the heart
increased vascular resistance increases right ventricular afterload and causes dilation & R ventricular failure
normal V/Q value
4/5 = 0.8
shunt vs. dead space
shunt: NO ventilation, has perfusion
dead space: has ventilation, NO perfusion
how does pulmonary embolism affect ABGs
hyperventilation & inflammation leads to:
- hypoxemia
- hypocapnia
- respiratory alkalosis
what is included in Virchow’s triad
- hypercoagulability
- vessel wall injury
- venous stasis
what defines venous thromboembolism (VTE)
when pt has both pulmonary embolism & DVT
list some risk factors for pulmonary embolism
- male, black americans
- HF, A.fib, A. flutter
- indwelling venous catheter
- air pollution
- trauma, lower limb fracture -> immobilization
what are the typical s/s for pulmonary embolism
- dyspnea, cough
- chest pain
- syncope
- JVD
If more severe: - arrhythmia, right ventricle failure
- hemodynamic collapse, shock
diagnostic tests for pulmonary embolism
- troponin (0 - 0.04) & BNP (<100)
- d-dimer for clot (<0.5 normal)
- EKG, CXR, ultrasound
- lung scintigraphy (V/Q scan)
- ABG
what are the anticoagulants used for pulmonary embolism
- LMWH, fondaparinux (Atrixtra)
- dalteparin (Fragmin)
- alteplase (Activase)
what is fondaprinux contraindicated in
renal issues
what should pts taking fondaprinux avoid
NSAIDS
what are the adverse effects of alteplase
- hives
- difficulty breathing
- swelling of face
what are the 2 classifications of resp failure
hypoxemic or hypercapnic
define hypoxemic vs. hypercapnic resp failure
- hypoxemic: PaO2 <60mmHg caused by lung failure (Q) - think lung dxs, PE, COPD, asthma
- hypercapnic: PaCO2 >50mmHg caused by ventilation failure (V) - think MS, sedatives, flail chest, spinal cord injuries
what classification of resp failure is more common
hypoxemic is more common than hypercapnic
what are the 2 causes of resp failure
- V/Q mismatch - low from hypoxemia or hypercapnia
- shunt - hypoxemia even with 100% O2 inhaled from poor ventilation
acute vs. chronic resp failure
acute: developed in mins to hours
chronic: developed over several days or longer
diagnostic tests for resp failure
- thyroid function tests
- pulmonary function tests spirometry FEV1/FVC (80-100%)
- electrolytes
- CXR
- CBC
- EKG
what is FEV1/FVC test
forced expiratory volume in 1 second after full inspiration / forced vital capacity (max exp)
signs of hypoxemic resp failure
- dyspnea
- confusion
- increased HR, RR
- arrhythmia
- cyanosis, somnolence
signs of hypercapnic resp failure
- headache
- asterixis (hand flap tremor)
- warm extremities
- papilledema (optic disc swelling) -> change in vision
- coma
when should a pt w/ resp failure be put on mechanical ventilation
- RR>30
- SpO2 <90% doesn’t respond to O2
- shock symptoms
- extreme ABGs
what defines ARDS
- within 7 days after trauma
- fibrotic tissue makes lungs stiff -> increased pulmonary arterial pressure, decreased pulmonary compliance from stiffness
- inflammation increased permeability -> alveoli edema
- deadspace -> hypercapnia
- shunt -> hypoxemia
key: doesn’t respond to O2
what position to place a pt with ARDS
prone position (lying down) so affected lung can expand
common causes of ARDS
- sepsis most common
- pneumonia
- aspiration
- in ICU
impact of ARDS long-term
cognitive change from prolonged hypoxia
muscle wasting, wt loss, tracheostomy - MV
what is included in the Berlin criteria for ARDS
- onset within 7 days
- noncardiac origin
- bilateral lung infiltrates in imaging
- abnormal O2
- PaO2/FiO ratio less than 300mmHg
s/s of ARDS
- dyspnea worsening
- increased HR, RR
- crackles, rales lung sounds
- low O2 saturation
CXR tube placement should show how far down the tube is placed
20-22cm for females
22-24cm for males
what s/s could indicate inappropriate endotracheal tube placement
- asymmetrical lung sounds
- no rise of chest wall
- lung sounds in abdomen
ventilator abbreviations:
AC
assisted control
takes over if RR falls below settings
ventilator abbreviations:
HME
heat & moisture exchanger
ventilator abbreviations:
PEEP
positive end-expiratory pressure
pressure left in lungs after expiration
ventilator abbreviations:
PIP
peak inspiratory pressure
ventilator abbreviations:
PSV
pressure support ventilation
ventilator abbreviations:
SIMV
synchronized intermittent mandatory ventilation
ventilation + pt’s own efforts
not all breaths helped
ventilator abbreviations:
TV
tidal volume
air in n out
richmond agitation & sedation scale (RASS) tells you what
+4 combative —- 0 alert&calm —– -5 unarousable
while on MV
purpose of ECMO
artificial circulation where blood is pumped out to oxygenate and remove CO2 and return to the body
venoarterial or venovenous
pathophys of emphysema
alveoli damaged and eventually rupture
diffusion issue
