Respiratory Flashcards
Define Hypoxia
- Less than normal levels of 02 in the body tissues
Define Hypoxemia
less than normal levels of 02 in the blood
Pa02 <80mmHg (<60mmHg significant hypoxaemia)
Define Hypercapnia
- Greater than normal levels of C02
- PaC02 > 45mmHg
Define Hypocapnia
- Less than normal levels of C02
- PaC02 < 35mmHg
What is the normal range of PaC02?
35-45mmHg
What is the normal range of Pa02 levels?
75-100mmHg
What is the normal range of Arterial Oxygen?
75-100mmHg
What are 12 signs and symptoms of hypoxaemia?
- Changes in the colour of your skin
- Confusion
- Restlessness
- Anxiety
- Increased heart rate
- Increased respiration rate
- Shortness of breath
- Sweating
- Wheezing
- Use of Accessory muscles
- Flaring of nostrils or pursed lips
- Decreased oxygen saturation levels
What are 8 clinical manifestations that a person would experience with COPD?
- Frequent chest infections
- Persistent wheezing
- Persistent chesty cough which can be dry or with sputum
- Difficulty breathing
- Dyspnea
- Decreased energy levels
- Tightness of the chest
- Swelling in the lower extermities
What is efficient gas exchange dependent on?
Adequate Ventilation and Perfusion
What is shunting?
When blood flow can be redirected from poorly ventilate alveolus (one air sac) to a well-ventilated alveolus through vasoconstriction
What is a dead space?
Poor perfusion and a well ventilated alveolus
What is a silent unit?
Poor ventilation AND Poor perfusion (no air moving through the lungs)
What are the two areas of Gas Exchange Insufficiency?
Mechanical
Functional
What are the three areas of Mechanical Insufficiency of gas exchange?
- Structural damage
- Airway obstruction
- Medication
Describe how structural damage impacts on gas exchange
- Nervous system (spinal injury high up, anything that impacts the nerve pathways)
- Intercostal Muscles
- Diaphragm (injury which impacts taking a deep breath to expel CO2 effectively, or on
inspiration with the intake of O2) - Abdominal muscles (Pushing diaphragm out to push the air out)
Describe airway obstruction for gas exchange
- Physiological and foreign objects (asthma, mucous)
Describe how medication can impact on gas exchange
CNS Depressants (Alcohol, benzodiazepines, sedatives. Anything which effects the
respiration rate)
What functional factors can impact on gas exchange?
- Cardiac Compromise (Poor venous return)
- Pulmonary Embolism (Block off blood vessels and lungs - ventilated but not perfused)
- Tumour (blockage which effects perfusion)
- Hb (Haemoglobin) (Not enough Haemogolbin = not enough red blood cells to carry
enough oxygen as Haemogolbin has 4 oxygen particles) - Infection (pus, anything in the lungs which block the perfusion in the lungs)
- COPD
- Compliance (the ability for the lungs to inflate and recoil)
- Resistance
- Surface area (hold the alveolus open, if you lose this, the alveoli might collapse more
easily as the surface area will be reduced - smoking)
What are 4 problems with ventilation (air in/out)?
- Inflammation of Bronchial walls causing epithelial oedema = decrease air entry, decrease gas exchange
- Exudate in lower airways causing obstruction to air flow = decrease air entry, decrease gas exchange
- Exudate in alveoli causing increased diffusion distance = decrease gas exchange
- Inflammation in alveolar wall causing increased diffusion distance = decreased gas exchange
What are 2 problems with perfusion (blood to lungs and body)?
- Partial or complete obstruction to pulmonary artery (could be a clot and partially close off the artery) causing reduced blood flow = decreased gas exchange
- Ineffective functioning alveoli (from exudate or oedema) causing vasoconstriction of surrounding pulmonary capillaries = further decrease gas exchange
What clinical presentations are we observing with the respiratory rate?
- Tachypnoea/bradypnoea (fast and slow breathing)
- Orthopnoea (have trouble breathing lying down, but can breathe normally when sitting up
heart not pumping efficiently) - Dyspnoea (subjective feeling of breathing, reporting they are struggling to breath)
- Rhythm and depth (are they breathing in a normal rhythm? Gasping? Breathing shallow?)
What clinical presentations are we observing with breath sounds?
- Wheeze
- Crackles
- Stridor (usually on inspiration, sounds like a barking type sound. Inflammation or
obstruction of the airway) - Reduced Air entry
- Cough
What accessory muscles are we observing for within the clinical presentation?
- Sternocleidomastoid
- Scalenes
- Trapezius
- Pectoralis minor/major
- Abdominals (on expiration)
What clinical presentation are we observing for the patient’s positioning?
- Upright
- Tripod (leaning forward, supporting upper body with hands on knees/similar)
- Chest symmetry
What are body tissues?
a group of cells that have similar structure and that function together as a unit.
Which usually comes first? Hypoxia or Hypoxaemia?
Hypoxaemia.
We can assess and use interventions to prevent this from going to hypoxia hence preventing cell death
What is a common cause of Hypocapnia?
Hyperventillation.
Taking in too much O2, and not being able to balance this with CO2
What is the cause of Hypoxia?
Often caused secondary to Hypoxaemia.
Which is caused by any condition that reduces the amount of oxygen in your blood or restricts blood flow can cause hypoxia. People living with heart or lung diseases such as COPD, emphysema or asthma, are at an increased risk for hypoxia
What are the medical causes of Hypoxaemia?
ventilation-perfusion (V/Q) mismatch, diffusion impairment, hypoventilation, low environmental oxygen and right-to-left shunting.
What is Ventilation/perfusion mismatch?
Ventilation-perfusion mismatch is mismatched distribution of ventilation (airflow) and perfusion (blood flow)
When does ventilation/perfusion mis match occur?
Ventilation-perfusion (V/Q) mismatch occurs when either the ventilation (airflow) or perfusion (blood flow) in the lungs is impaired, preventing the lungs from optimally delivering oxygen to the blood
What does VQ ratio stand for?
ventilation/perfusion ratio
What is vasoconstriction?
Vasoconstriction is the narrowing (constriction) of blood vessels by small muscles in their walls. When blood vessels constrict, blood flow is slowed or blocked
What is an alveolus?
a small air-containing compartment of the lungs in which the bronchioles terminate and from which respiratory gases are exchanged with the pulmonary capillaries.
What are bronchioles?
A tiny branch of air tubes in the lungs
WOB: 5 signs of respiratory distress
DiapHRaGM
- Diaphoresis (excessive sweating) different to normal sweating, clammy al over dripping in sweat and they feel cold. increased metabolic effort. hypocapnia
- Hypoxia (less than normal level of 02 in the cells
- Respiratory rate
- Gasping associated with running out of breath, RR starts to drop and they start gasping, rhythm changes too)
- Accessory muscle
Need to intervene quickly or they can go into respiratory arrest
what we can measure: RR, depth and pattern
can be measured but a degree of subjectivity depending on how it is calculated
what we can measure: Work of breathing
- accessory muscle use
nasal flaring/ pursed lip breathing - speaking long/short sentences, single words only, not speaking
- intercostal indrawing
what we can measure: peak flow measurement
- measurement of maximal forced exhaled air flow (L/min)
- baseline and to measure effectiveness of interventions
- useful for people with asthma
- used to keep an eye on maximal force
what we can measure: specialist tests
- CXR (chest X-ray)
- spirometry
- CT/MRI
- ABG (arterial blood gas)
Airway assessments
patency is it open and is it fully open, partial obstruction?
- is the airway patent
- partial obstruction- snoring, stridor, you can hear something
- complete obstruction- silence, no extra sounds
- under threat?
- what your assessing for, patency, expecting to find the airway patent, or patent and concern that it is under threat.
possible cause of obstruction
- tongue
- vomit
- epiglottis
- uvulitis
- secretions
- inflammation
- neurological impairment
- foreign body
What is the rationale for “Sitting’ the patient up to increase lung expansion”
In doing this we are increasing ventilation hence increasing gas exchange in the lungs.
What are the 7 things that we can clinically observe when thinking about a patient with a respiratory issue?
Respiratory rate
Breath sounds
Accessory muscles
Positioning
Neurological changes
Skin
Sputum
What are we observing in terms of the Respiratory rate when we are assessing a patient?
Tachypnoea/bradypnoea
Orthopnoea
Dyspnoea
and
Rhythm & Depth
What is Tachypnoea?
abnormally rapid breathing.
What is bradypnoea?
abnormally slow breathing.
What is orthopnoea?
Orthopnea is the sensation of breathlessness that affects a person when they are lying down and subsides in other positions, such as standing or sitting up.
What is Dyspnoea?
difficult or laboured breathing that is self reported by the patient
If we notice cyanosis what is an important factor to assess?
Cyanosis is the blue tinging of the skin so assess capillary refill of peripherals.
What is a peak flow measurement test?
Peak flow is a simple measurement of how quickly you can blow air out of your lungs. Normal adult peak flow scores range between around 400 and 700 litres per minute
What can we use a peak flow measurement for?
as a baseline and to measure the effectiveness of interventions (useful for diagnosing asthma)
What are clinical presentations of neurological changes?
Anxiety
Agitation
Confusion
Drowsiness
Pain
What are clinical presentations of Skin?
Diaphoresis
Pallor
Cyanosis
Flushing
What are clinical presentations of Sputum?
Colour
Odour
Haemoptysis
Airway interventions:
Positioning:
- maintaining head and neck alignment (chin tilt/jaw thrust)
- Consider elevating head of bed/side positioning in OSA
- Recovery position
Clear secretions:
- Encourage airway clearance with coughing
- Consider suctioning (Yankeur/suction catheter)
- Promote hydration to thin secretions for expectoration
Breathing assessments:
General appearance:
Work of breathing
Rate, depth and pattern
Accessory muscle use
Nasal flaring/pursed lips
Cough
Colour
Skin moisture
Positioning:
Supine/erect
Tripod
Pillows to support
Level of activity:
What is your patient doing?
Chest:
AP measurement
Symmetry
Paradox
Drains?
Supplemental oxygen use:
Nasal cannula
Airvo (humidified O2)
CPAP/BiPAP machine
Posterior chest auscultation:
Air entry
Quality of breath sounds
Wheeze
Crackles
Adventitious sounds
Percussion:
Resonance
Hyper resonance
Dullness
Breathing interventions:
Positioning:
Sit the patient upright
Support with pillows if required
Mobilise as able
Regular turns/repositioning
Cough techniques:
Huff coughing
Incentive spirometry
Deep breathing
Administer prescribed medications:
Bronchodilators (inhalers with spacer
Oxygen
Physiotherapy referral:
Education
Loosen secretions
Secretions:
Promote hydration to thin secretions
Consider humidification of O2
Anxiety reduction:
Education and reassurance to reduce respiratory effort and SNS response
Circulation assessments:
General appearance:
Skin colour
-Flushed
-Cyanotic
Temperature
-Raised (core)
-Peripherally cool
Capillary refill time
Diaphoresis
Heart rate:
Tachycardia/bradycardia
Rhythm (regular/irregular)
Quality (weak/bounding)
Blood pressure:
Hypertension
Normotension
Hypotension
Renal function:
Urine output
eGFR
Fluid balance
Circulation interventions:
Hydration:
Oral
Intravenous fluid as prescribed
Administer prescribed medication:
Consider DVT prophylaxis
Mobilising:
Foot pedalling
Frequent mobilisation as able
Regular repositioning
Disability assessments:
Level of consciousness:
AVPU
Orientated to time, person & place?
Restlessness/agitation (hypoxaemia)
Anxiety:
Breathlessness
Fear of dying
Dyspnoea
Increased work of breathing
Mood
SNS response
Pain:
COLDSPA
Pleuritic pain will contribute to alveolar hypoventilation (decreasing gas exchange)
Opioid analgesia causing ↓ RR and LOC
Disability interventions:
Pain management:
Select appropriate analgesia
Administer analgesia as prescribed
Anxiety reduction to reduce SNS response:
Patient education
Communication of plan
Involve family/whānau
Not “reassure patient” – what does this mean?!
Environment assessment:
Patient risk assessment:
Falls
Braden
Smoking
Past medical/surgical history:
Previous respiratory issues (COLDSPA)
Medications
Drug reactions
Allergies
Early Warning Score:
Trends
Action required?
Other assessments:
Occupation (hazards)
Living situation
Family/whānau supports
Self-management of health issues
Alcohol and drug use
Cultural needs
Spiritual needs
