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Respiratory Flashcards

1
Q

What is the definition of weaning delay

A

Failing more than three spontaneous breathing trials
Needing greater than 1 week of mechanical ventilation following the first SBT
Need for more than 2 weeks of ventilation without a resp factor prevention delay or for 3 weeks -> failure

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2
Q

What are the principles behind a successful wean

A 
Adequate rest
Gradual reductions in support
Sprints 
Downsizing of tranchoestomies 
Periods of cuff down deflation
Optimising sedation holidays / breaks
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3
Q

Describe an obstructive flow loop

A

Dipping pattern to expiratory loop with prolonged expiratory phase

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4
Q

Describe a restrictive flow loop

A

Reduces volume with a grossly normal shape

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5
Q

Describe a fixed upper air ways obstruction flow loop

A

Flattened inspiratory and expiratory traces

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6
Q

What are the causes of interstitial lung disease

A

Inhaled- asbestosis, hypersensitivity pneumonitis (dust), silicosis

Drugs- amiodarone, methotrexate

Connective tissues - RA, SLE

Infection- TB, PCP, atypical infection

Malignancy- Radiotherapy, lymphagitis carcinomatosis

Idiopathic- sarcoidosis, IPF, interstitial pneumonia

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7
Q

Pharmacological Treatment options for a PE

A

Low molecular weight heparin
Unfractionated heparin
Fondaparinux

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8
Q

Features suggestive of massive PE

A

Blood pressure <90
Or a drop of >40 mmhg
For at least 15mins with no other cause (arrhythmia/ low GCS/ shock)

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9
Q

What is the oxygen index equation

A

Fio2 x 100 x mean airways pressure / pao2

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10
Q

Life threatening asthma fees

A 
Altered consciousness
Arrhythmia 
Hypotension
Cyanosis 
Silent chest 
Poor rr effort
pefr <33%
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11
Q

Treatment of asthma

A 
Oxygen 94-98% sats 
Beta 2 agonists 
Ipratropium bromide
Steroids 
Mgso4
Aminophylline
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12
Q

Ventilation strategies for dynamic hyperinflation

A 
Reducing the tidal volume
Shortening of the Inspiratory time -> increase I:e ratio 
Reduced RR
Reduce extrinsic PEEP
Disconnection and manual decompression
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13
Q

What is the purpose curb65

A

To assess severity and predict mortality

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14
Q

What parameters are in the curb 65

A

Confusion mini mental <9
Urea >7
Rr > 30
Bp systolic <90 or diastolic <60

> 65 yrs

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15
Q

What are the 3 different types of effusion

A

Uncomplicated - sterile
Complicated - bacteria without pus PH <7.2
Empyema - ph >7.2

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16
Q

What are the indications for niv in acute exacerbation of copd

A

Ph <7.35
And
Pco2 > 6.5
After medical management

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17
Q

Contraindications to NiV

A 
Not indicated
Patient refusal
Facial deformities 
Facial burns / injuries 
Fixed upper air ways obstruction
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18
Q

Complications of NIv

A 
Nasal bridge ulceration 
Mucosal drying 
Gastric distension
Sinusitis
Anxiety
Pneumothorax 
Hypotension 
Raised icp
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19
Q

What is the basic preparation for spirometery

A

No smoking 24 hours
Avoid exercise and large meal prior to the test
Record patients: age, ethnicity, height, weight

Prepare the one way mouth piece, nose clip and bacterial and viral filters and spirometer

Reconfirm consent. Tell the patient to sit, breath in to maximal inspiration and create a tight seal around the mouthpiece.
Blow into the device as forcibly as possible and as long as possible.

3/8 acceptable readings and best result recorded.

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20
Q

What is FVC

A

Forced vital capacity - total exhaled volume during a forced maximal expiration from maximal inspiration.

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21
Q

What is the meaning of fev1/ fvc?

A

The proportion of the forced vital capacity that is expired in 1 second

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22
Q

What is the clinical relevance of DLCO

A

Lung diffusion capacity for carbon monoxide is a surrogate estimate of the ability for oxygen to pass from the alveolar to the red blood cell

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23
Q

What is the meaning of the tlc

A

Total lung capacity is vital capacity and residual volume

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24
Q

How is copd graded

A

Gold 1: FEv1 ≥ 80% predicted

Gold 2 : FEV1 50-79%predicted

Gold 3 : FEV1 30< 49% predicted

Gold 4 : FEV1 < 30% predicted

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25
What is vital capacity
Tidal volume Insp reserve volume Expiratory reserve volume
26
What factors used in judging if someone ready for extubation.
``` Lung pathology resolved Cough Low o2 and settings Haemodynamic stability Alert Chest wall strength ```
27
What is rsbi
Rr/ tidal volume in l
28
What rsbi suggests ready for extubation
<105 80% chance successful
29
Describe the anatomical boarders of the triangle of safety
Lateral boarder pec major Lateral boarder lat dorsi 5th intercostal space/nipple line Axilla base
30
Where do you insert an apical chest drain
Second intercostal space mid clavicular line
31
What is a flail chest
fractures or 2 or more adjacent ribs - 2 or more places - paradoxical chest movement
32
What causes and increase in plateau pressure
Reduction in compliance
33
What causes an increase in peak airway pressure but bit plateau pressure
Airways resistance increase
34
In volume support ventilation what triggers the end of the breath
Reduction in inspiratory flow by a present proportion
35
What is lights criteria
Pleural protein to serum >0.5 Pleural ldh to serum >0.6 Pleural LDH > 2/3 normal
36
How is pleural albumin concentration used to determine transudate or exudate
Serum albumin - pleural albumin < 1.2 g = exudate
37
Empyema ph on pleural fluid
<7.2
38
What is the definition of compliance
Change in lung volume per unit change in pressure
39
What is the definition of static compliance
The compliance when there is no gas flow- end Inspiratory hold manoeuvre
40
What is the definition of dynamic compliance
Measured during breathing cycle Tidal volume / Peak pressure - peep
41
Which should be high dynamic or static compliance
Static compliance is higher than dynamic This is because you hold the insp cycle and normally your peak is higher than plateau pressure therefore it will be lower value
42
BTs severe asthma features
Pefr 33-50 Rr >25 Hr >110 No complete sentences
43
Bts life threatening
``` Altered consciousness Exhaustion Arrhythmia Silent chest Sats 92% Po2 <8 Normal co2 Pefr <33% ```
44
What is the oxygen content equation
Do2 (oxygen delivery) = cardiac output X arterial content of o2 Arterial content of o2= (Hb x sats x 1.39) + (0.003 x pa02)
45
What is dead space
Part of the respiratory tract that does not contribute to gas exchange- anatomical or physiological (blocked or underperfused alveolar )
46
What is the Berlin criteria
Timing : within a week of an insult Imaging: bilateral opacification in keeping with oedema Origin of oedema: not be explained by cardia failure Moderate to severe hypoxia: PF ratio with peep 5 giving PF of < 26.6
47
Mechanism of inhalationary injuries
Heat - oedema, erythema and ulceration Toxin- chloride, ammonia etc causing damage with pH or free radicals Hypoxia- environmental consumption of oxygen.
48
Pathophysiology of inhaled lung disease
Exudative phase - neutrophil influx macrophage activation increase permeability decreased surfactant Fibrotic phase - collagen deposit and fibroid get alveolitis
49
Carbon monoxide inhalation mechanism hypoxia
250 time binding affinity to Hb than o2 Left shift Cytochrome oxidase system is inhibited - tissue hypoxia
50
Cyanide inhalation pathophysiology
Cyanide binds to ferric ion on cytochrome oxidase blocking aerobic metabolism Therefore lactic acidosis
51
Trratment cyanide inhalation
Hydroxycobalamin Amyl nitrate Sodium thiosulphate
52
Define asthma
Chronic disease of the airways associate with hyper reactivity and inflammation. Mucosal oedema Increased sputum Bronchospasm Widespread airflow obstruction.
53
How can you quantify dynamic hyperinflation from asthma
Quantify the intrinsic peep by an expiratory hold - enabling the expiratory alveolar pressure to equilibriate with the upper air pressure Measured pressure - Peep delivered = intrinsic peep
54
Define HAp
Pneumonia acquired more that 48 hours following admission More likely to be gram negative organisms with higher rates of resistance Psa, Kleb e.coli
55
Common bacteria in cap
Strepto pneumonia Haem influenza Mycoplasma Legionella
56
What is in curb 65
``` Confusion Urea > 7 Resp rate > 30 bp < 90 Age > 65 ```
57
Transudate pleural effusion Protein level And cause
Protein < 30 Increased hydrostatic pressure Heart, liver and kidney failure Hypothyroid
58
Exudate pleural effusion Protein level And cause
> 30 ``` Increased capillary permeability Pulmonary infection Malignancy Connective tissues - RA SLE Pancreatitis ```
59
Aetiology broncopleural fistula
``` Post pulmonary surgery Post pneumonia Cancer (bronchial) Trauma Ards ```
60
Management bronchopleural fistula
``` Ventilation strategy: Avoid positive pressure Oscillation Ecmo Dlt ``` ``` Closure: Stent Glue Bronchial blocker Lobectomy ```
61
Define copd
Progressive inflammatory lung disease, characterised by expiratory airflow limitation due to obstructive bronchiolitis and or parenchymal destruction.
62
Spirometery needed to define copd
Post dilator FEV1/ FVC < 0.7
63
Indications for ITU in copd
Persistent worsening of hypoxia with Ph < 7.25 despite o2 and NIV
64
Which patients should be considered for LToT
Stable chronic copd and pao2 <7.3 Or <8 and oedema/ polycythemia / pulmonary hypertension
65
Consequences of intrinsic peep on physiology
Decreased venous return Increased pulmonary vascular resistance Barrotrauma
66
Define ICU acquired weakness
Clinically detected weakness where there is no other aetiology Spectrum of critical illness myopathy, critical illness polyneuropathy or critical illness neuromyopathy
67
Features of ICU acquired weakness
Symmetrical flaccid tetraparesis with sparing of the Facial muscles
68
In the Cim and CIPN of ICU acquired weakness what do the nerve conduction studies show
Cim : normal | CIPN: decrease compound muscle action potentials and sensory action potential, normal velocity
69
Anatomical changes post pneumonectomy
``` Space fills with air Often ICD but not on suction Raised hemidiaphragm Mediastinum shifts towards space Hyperinflation remaining lung 4months- complete opacification Lung volume and dlco reduce < 50% ```
70
Complications post pneumonectomy
``` Haemothorax Chylothorax Pulmonary oedema Bronchopleural fistula Post pneumonectomy syndrome - sob, infection, Stridor ```
71
What is cpet and what is a bad scores
Quantification of cardio respiratory reserve by determining the anaerobic threshold Cycle, measure inspired and expired gasses BP and ecg AT < 11 is associated with adverse risk
72
Considerations is obesity in critical care
``` Increase in difficult airway Perc trache difficult Raised HD, reduction frc Reduced chest wall compliance IV Access BP cuff Increased VTE Insulin resistance Increased volume of distribution ```
73
What is the stop bang
Snore loudly Tired in the day Observed you chocking in sleep Pressure BP high Bmi Age > 50 Neck large Gender - male
74
What is the mallampati score
``` 1-4 1- entire uvula 2- uvula masked by tongue 3-only soft palate 4- only hard palate ```
75
What is the interinsisor | Gap
Distance in cm between the upper and lower incisor | Less than 3.5 cm is poor
76
What is thyromental distance
Chin to Adam’s Apple with full extension and mouth closed | Below 6 cm is difficult to fit blade in.
77
What is the upper lip bite test and jaw protrusion.
Upper lip bite test 1-3 (3 unable to bite) | Jaw protrusion grade a- c (c can’t meet upper teeth)
78
What sternomental distance indicates difficult airway
< 13cm
79
Lobes of the left lung
Left main bronchus - left upper and left lower Left upper has 2 divisions - upper (which had posterior and anterior) and lower ( inferior and superior) Left lower has 3 divisions- superior, anterior and posterior.
80
Lobes of the right lung
Right upper has 3 segments (anterior, apical, posterior) Right main bronchus becomes bronchus intermedius Right middle has 2 ( medial and lateral) Right lower has 1 superior and 4 basal
81
What strategies for ARDS have evidence
Proning - 16hrs 5/7 decreases mortality Low TV with 6mls/kg and pp<30 decrease mortality Ecmo decreased mortality in mod/ severe Paralysis- possibly in moderate ards High peep - > 15 decreases at electro trauma
82
Define primary pneumothorax
< 50 Non smoker No underlying lung disease
83
Treatment of primary pneumothorax
Aspirate if > 2cm abs SOB | Send home if < 2cm
84
Treatment of secondary pneumothorax
1-2 cm - aspirate Consider HF for 1cm > 2 or breathless then ICD
85
Define massive PE
Acute pe with Hypotension. < 90 for 15mins Pulseless Or Brady
86
Treatment options of PE
Anticoagulation with UFh Reperfusion - thrombolysis embolectomy
87
Anatomical and physiological dead space definition
Anatomical - air ways, trachea and proximal bronch Physiological- vq miss match
88
How does HFNC meet inspiratory needs
The high. Flow rates exceed patients Inspiratory flow and therefore entrain less air and deliver the intended fio2
89
Components of high flow
``` Gas blender Flow meter Corrugated tubing Sterile water Heated breathing circuit Canula Heater and humidifier ```
90
Starting pressure NIv
iPap 10 Epap 4 rR 12
91
Define double lumen tube
Bifurcated tube with separate tracheal and endobronchial lumens
92
Size of double lumen tube
37 female | 39 male
93
How to size a double lumen tube
12+ height /10cm
94
Indications double lumen tube
Prevent damage or contamination of healthy lung Control distribution of ventilation Facilitate one lung lavage Surgical access
95
Insertion of double lumen tube
``` Check cuffs Lubricate Insert stylet Watch with laryngoscopy beyond vocal cord Remove stylet Turn 90 degrees Hit resistance or desired depth ```
96
Confirmation of double lumen tube position
``` Inflate tracheal Ventilate-> co2 / auscultation Clamp tracheal Inflate bronchial -> ventilation Release clamp ``` Bronch to confirm
97
What is the triangle of safety
Lateral edge of pec major Lateral edge lat Dorsi 5th intercostal space Base axilla

Icm (16 decks)

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