Respiratory exam Flashcards
Purpose of oxygen therapy:
use lowest fraction of inspired oxygen (FiO2) to have an acceptable blood oxygen level without causing harmful side effects
Most patients with hypoxia require an oxygen flow of:
2-4L/min via nasal cannula or up to 40% Venturi mask to achieve an oxygen saturation of at least 95%
For a patient who is hypoxemia and has chronic hypercarbia, the FiO2 delivered should be titrated to..
correct the hypoxemia to achieve generally acceptable oxygen saturations in the range of 88%-92%
Best measure for determining the need for oxygen therapy and evaluating its effects:
ABG (arterial blood gas)
Parameters to monitor for hypoxemia include:
level of consciousness
respiratory pattern and rate
pulse oximetry
Lung injury from oxygen toxicity (same as ARDS) include problems such as
dyspnea
nonproductive cough
chest pain beneath the sternum
GI upset
crackles on auscultation
Prolonged exposure to high oxygen levels can cause:
atelectasis
pulmonary edema
hemorrhage
hyaline membrane formation may form
Notify the healthcare provider when PaO2 levels become:
greater than 90 mm Hg
Nitrogen purpose:
Nitrogen in air maintains patent airways and alveoli.
Prevents alveolar collapse
What happens during atelectasis?
When nitrogen is diluted, oxygen diffuses from the alveoli into the blood and the alveoli collapse
Atelectasis is detected as
crackles and decreased breath sounds on auscultation
Monitor the patient receiving high levels of oxygen closely for indications of:
absorptive atelectasis (new onset of crackles and decreased breath sounds) every 1-2 hours when oxygen therapy is started and as often as needed thereafter
Humidify delivery system when oxygen flow rate is:
higher than 4L/min
Humidifier or nebulizer must be changed
as per agency policy which ranges from 24 hours-every 7 days
Low flow systems have a low:
fraction if inspired oxygen (FiO2)
do not provide enough oxygen to meet the total oxygen need and air volume of patient.
part of tidal volume is supplied by the patient as he or she breathes room air
High flow systems have:
a flow rate that meets the entire oxygen need and tidal volume regardless of the patient’s breathing pattern
used for critically ill patients
when delivery of precise levels of oxygen is needed
Low flow systems include:
nasal cannula
simple facemask
partial rebreather mask
non-rebreather mask
(oxygen is diluted with RA 21% oxygen, which lowers the amount actually inspired)
Nasal cannula (prongs) are used at which flow rates?
1-6L/min
Oxygen concentrations of 24% (1L/min) to 44% (6L/min) can be achieved
Nasal cannula is often used for:
chronic lung disease
any patient needing long-term oxygen therapy
Simple facemarks are used to deliver oxygen concentrations of and minimum flow rate:
40%-60% for short-term oxygen therapy or in an emergency
5L/min is needed to prevent the rebreathing of exhaled air
Partial rebreather masks provide oxygen concentrations of and flow rates:
60%-75% with flow rates of 6-11L/min
Non-rebreather masks provide/flow rate/purpose:
Highest oxygen level of the low-flow systems and can deliver an FiO2 greater than 90% depending on patient’s breathing pattern
Used with patients whose respiratory status is unstable and who may require intubation
Flow rate is kept high 10-15L/min
High flow systems include/oxygen concentrations/flow rates:
Venturi mask
Aerosol mask
Face tent
Tracheostomy collar
T-piece
oxygen concentrations from 24%-100%
8-15L/min
Which O2 therapy delivers the most accurate oxygen concentration without intubation?
Venturi masks
Noninvasive positive-pressure ventilation is used to manage:
dyspnea
hypercarbia
acute exacerbations of COPD
cardiogenic pulmonary edema
acute asthma attacks
Bronchial (tubular, tracheal) characteristics:
High pitch
Loud amplitude
Inspiration < expiration
Harsh, hollow, tubular blowing
Trachea and larynx
Bronchovesicular characteristics:
Moderate pitch
Moderate amplitude
Inspiration=expiration
Mixed quality
Located over major bronchi
Vesicular characteristics:
Low pitch
soft amplitude
Inspiration > expiration
Rustling, like the sound of the wind in the trees
Located over peripheral lung fields
Fine crackles, fine rales, high-pitched rales association: (6)
Asbestosis
Atelectasis
Interstitial fibrosis
Bronchitis
Pneumonia
Chronic pulmonary disease
Fine crackles, fine rales, high-pitched rales character:
Popping, discontinuous sounds caused by air moving into previously deflated airways
hair being rolled between fingers near ear
“velcro” sounds late in inspiration
Coarse crackles, low-pitched crackles association: (4)
Bronchitis
Pneumonia
Tumors
Pulmonary edema
Coarse crackles, low-pitched crackles character:
Lower-pitched, coarse, rattling sounds caused by fluid or secretions in large airways; likely to change with coughing or suctioning
Wheeze association: (5)
Inflammation
Bronchospasm
Edema
Secretions
Pulmonary vessel engorgement (as in cardiac “asthma”)
Wheeze character:
squeaky, musical, continuous sounds associated with air rushing through narrowed airways
may be heard without a stethoscope
arise from small airways
do not clear with coughing
Ronchi association: (4)
Thick, tenacious secretions
sputum production
obstruction by foreign body
tumors
Ronchi character:
lower-pitched, coarse, continuous snoring sounds
arise from large airways
Pleural friction rub association: (5)
Pleurisy
TB
Pulmonary infarction
Pneumonia
Lung cancer
Pleural friction character:
Loud, rough, grating, scratching sounds caused by inflamed surfaces of the pleura rubbing together; often associated with pain on deep inspirations
heard in lateral lung fields
Smoking while using drugs for nicotine replacement therapy is bad because
it greatly increases circulating nicotine levels and the risk for stroke or heart attack
Bupropion and varenicline carry a black box warning that use of these drugs can cause
manic behavior
hallucinations
may unmask serious mental health issues
Black people and others with dark skin usually show what kind of oxygen saturation
lower o2 sat (3%-5%) as measured by pulse ox
this results from deeper coloration of the nail bed and does not reflect true oxygen status
Manifestations of pneumothorax:
pain on the affected side that is worse at the end of inhalation and the end of exhalation
rapid heart rate
rapid shallow respirations
feeling of air hunger
prominence of the affected side that does not move in and out with respiratory effort
trachea slanted more to the unaffected side instead of being in the center of the neck
new onset of “nagging” cough
cyanosis
Red blood cell range:
Females: 4.2-5.4 million/mm3
Males: 4.7-6.1 million/mm3
Hemoglobin range:
Females: 12-16g/dL
Males: 14-18g/dL
Hematocrit range:
Females: 37%-47%
Males: 42%-52%
WBC range:
5,000-10,000/mm3
PaO2 range:
80-100mmHg
PaCO2 range:
35-45mmHg
pH ranges:
Up to 60 year: 7.35-7.45
60-90 year: 7.31-7.42
> 90 year: 7.26-7.43
HCO3- range:
21-28mEq/L
SpO2 range:
95%-100%
Older adults: values may be slightly lower
Factors affecting right shift:
Acidosis
Hypercapnia
Hyperthermia
Elevated DPG
Hyperthyroidism
Anemia
Chronic hypoxia
Factors affecting left shift:
Alkalosis
Hypocapnia
Hypothermia
Decreased DPG
CO poisoning
Blood transfusion
Subjective data in assessment of respiratory system:
Coughing (productive, non productive)
Sputum (type and amount)
Allergies, dyspnea, SOB (at rest or exertion)
Chest pain, hx of asthma, bronchitis, emphysema, TB
Cyanosis, pallor
Exposure to environmental inhalants (chemicals, fumes)
Hx of smoking (amount and length of time)
4 techniques for respiratory exam (IPPA)
Inspect
Palpate
Percussion
Auscultation
Tachypnea rate:
over 20 for adult!
Bradypnea rate:
Less than 10!
Absent or decreased breath sounds can occur in: (4)
Foreign body
Bronchial obstruction
Shallow breathing
Emphysema
Stridor character:
Inspiratory musical wheeze
loudest over trachea
suggests obstructed trachea or larynx
requires immediate attention
associated condition
inhaled foreign body
Medical conditions associated with decreased or absent of breath sounds:
Asthma
COPD
Pleural effusion (fluid accumulating within pleural space)
Pneumothorax (accumulation of air or gas in the pleural space)
ARDS (adult respiratory distress syndrome)
Atelectasis (lung collapses)
5 main symptoms of respiratory disease:
Cough
Breathlessness
Sputum
Wheeze
Pain
Psychosocial respiratory assessment:
Lifestyle
occupational hazards
sleep apnea
anxiety/stress
sedentary jobs
athletes
eating habits
Diagnostic lab/imaging assessments used:
Chest x-rays
CT scans
VQ scan
ABG’s
CBC
Sputum test
Noninvasive diagnostic assessment:
Pulse ox
capnometery or Capnography (measures amount of carbon dioxide present in exhaled air)
Pulmonary function test (evaluates lung volumes and capacities, flow rates, diffusion capacity, gas exchange, airway resistance, distribution of ventilation)
Exercise testing
Invasive diagnostic assessment:
Endoscopic examinations
thoracentesis (aspiration of pleural fluid or air from pleural space)
lung biopsy (obtain tissue for histologic analysis, culture, cytologic examination)
Alveoli changes in aging
Alveolar surface area decreases
Diffusion capacity decreases
Elastic recoil decreases
Bronchioles and alveolar ducts dilate
Ability to cough decreases
Airways close early
Lung changes in aging:
RV increases
vital capacity decreases
Efficiency of oxygen and carbon dioxide exchange decreases
elasticity decreases
Pharynx and Larynx changes in aging
Muscles atrophy
Vocal cords become slack
Laryngeal muscles lose elasticity and airways lose cartilage
Pulmonary Vasculature changes in aging:
Vascular resistance to blood flow through pulmonary vascular system increases
Pulmonary capillary blood volume decreases
risk for hypoxia increases
Exercise tolerance changes in aging
Body’s response to hypoxia and hypercarbia decreases
Muscle strength changes in aging:
Respiratory muscle strength, especially the diaphragm and the intercostals decreases
Susceptibility to infection changes in aging:
Effectiveness of cilia decreases
Immunoglobulin A decreases
Alveolar macrophages are altered
Chest wall changes in aging:
Anteroposterior diameter increases
Thorax becomes shorter
Progressive kyphoscoliosis occurs
Chest wall compliance (elasticity) decreases
Mobility of chest wall may decrease
Osteoporosis is possible, leading to chest wall abnormalities
Follow up care for lung biopsy:
Assess vital signs, breath sounds at least every 4 hours for 24 hours
assess for respiratory distress
report reduced/absent breath sounds immediately
monitor for hemoptysis
Respiratory distress signs:
dyspnea
nasal flaring
use of accessory muscles to breathe
Pursed-lip or diaphragmatic breathing
decreased endurance
pallor
diaphoresis
tachypnea
Hypoxemia:
low levels of oxygen in the blood
Hypoxia:
decreased tissue oxygenation
Goal of oxygen therapy:
Use lowest fraction of inspired oxygen for acceptable blood oxygen level without causing harmful side effects
Hazards and complications of oxygen therapy:
combustion
oxygen induced hypoventilation
- hypercarbia: retention of CO2
- CO2 narcosis: loss of sensitivity to high levels of CO2
Oxygen toxicity
Absorption atelectasis- new onset of crackles/decreased breath sounds
drying of mucous membranes
infection
Must assess for what with nasal cannula
latency of nostrils
changes in respiratory rate and depth
High flow oxygen delivery system can deliver:
24%-100% at 8-15L/min
Venturi mask:
delivers precise O2 concentration-best for chronic lung disease
switch to nasal cannula during mealtimes
T-Piece:
delivers desired FiO2 for tracheostomy, laryngectomy, ET tubes
ensures humidification through creation of mist
mist should be seen during inspiration and expiration
Noninvasive positive pressure ventilation (NPPV):
uses positive pressure to keep alveoli open, improve gas exchange without airway intubation
BiPAP
CPAP
CPAP:
Delivers set positive airway pressure throughout each cycle of inhalation and exhalation
opens collapsed alveoli
used for atelectasis after surgery or cardiac induced pulmonary edema, sleep apnea
Transtracheal oxygen delivery (TTO)
Long-term delivery of O2 directly into lungs
small, flexible catheter is passed into trachea through small incision
avoids irritation that nasal prongs cause, more comfortable
flow rates prescribed for rest, activity
Possible complications of tracheostomy:
pneumothrorax
subcutaneous emphysema
bleeding
infection
Prevention of tissue damage with tracheostomy:
Cuff pressure can cause mucosal ischemia
use minimal leak and occlusive techniques
check cuff pressure often
prevent tube friction and movement
prevent/treat malnutrition, hemodynamic instability, hypoxia
Causes of hypoxia in the tracheostomy:
ineffective oxygenation before, during, after suctioning
use of catheter that is too large for the artificial airway
prolonged suctioning time
excessive suction pressure
too frequent suctioning
air warming and humidification with tracheostomy:
tube bypasses nose and mouth which normally humidifies, warms, and filters air
air must be humidified
maintain proper temperature
ensure adequate hydration
Suctioning purpose for tracheostomy:
maintains patent airway, promotes gas exchange by removing secretions when the patient cannot cough adequately
done through nose or mouth
Complications of suctioning:
Hypoxia
tissue (mucosal) trauma
infection
vagal stimulation, bronchospasm
cardiac dysrhythmias from induced hypoxia
Bronchial and oral hygiene for trach patient:
turn/reposition every 1-2 hours
support out of bed activities
encourage early ambulation
cough and deep breathe
chest percussion, vibration, postural drainage promote pulmonary cure
avoid glycerin swabs or mouthwash containing alcohol for oral care
assess for ulcers, bacterial/fungal growth, infection
Nutrition with tracheostomy:
swallowing can be major problem for patients with tracheostomy tube
if balloon is inflated, can interfere with passage of food though esophagus
elevate head of bed for at least 30 minutes after eating to prevent aspiration during swallowing
Weaning from a tracheostomy tube:
gradual decrease in tube size–> ultimate removal of tube
cuff is deflated when patient can manage secretions; does not need assisted ventilation
change from cuffed to uncured tube
size of tube decreased by capping; use smaller fenestrated tube
tracheostomy button has potential danger of getting dislodged
Check the patient’s skin around the ears, back of neck and face every
4-8 hours for pressure points and signs of irritation
Ensure that mouth care is provided every
8 hours and as needed
assess for nasal and oral mucous membranes for cracks or other signs of dryness
Cleanse the cannula or mask, skin under the tubing, straps every
4-8 hours
Obtain a prescription for humidification if oxygen is being delivered at
4L/min or more
Monitor the patient receiving high levels of oxygen closely for
indications of absorptive atelectasis (new onset of crackles and decreased breath sounds) every 1-2 hours when oxygen therapy is started and as often as needed thereafter
To prevent bacterial contamination of the oxygen delivery system…
never drain the fluid from the water trap back into the humidifier or nebulizer.
When is tube dislodgment an emergency?
first 72 hours of surgery because the tracheostomy tract has not matured and replacement is difficult.
tube may end up in the subcutaneous tissue instead of in the trachea “false passage”
Tracheomalacia:
constant pressure exerted by the cuff causes tracheal dilation and erosion of cartilage
Tracheal stenosis:
narrowed tracheal lumen is due to scar formation from irritation of tracheal mucosa by the cuff
Tracheoesophageal fistula (TEF)
excessive cuff pressure causes erosion of the posterior wall of the trachea.
hole is created between the trachea and the anterior esophagus.
patient with NG tube is at highest risk
Trachea-innominate artery fistula:
malpositioned tube causes its distal top to push against the lateral wall of the tracheostomy.
continued pressure causes NECROSIS and erosion of the innominate artery
MEDICAL EMERGENCY
If a tube is dislodged on an immature tracheostomy, what do you do?
Ventilate the patient using a manual resuscitation bag and facemark while another nurse calls the rapid response team
If the skin around a new tracheostomy is puffy and you can feel a crackling sensation when pressing on the skin, what do you do?
Notify the physician immediately!!
Bleeding in small amounts from tracheotomy incision is
expected for the first few days but constant oozing is abnormal
Temperature of air entering the tracheostomy:
between 98.6- 100.4 degrees
NEVER EXCEED 104 degrees
Preoxygenate patient with ___ before suctioning
100% oxygen for 30 seconds to 3 minutes to prevent hypoxemia
do not apply suction when inserting
Never suction longer than
10-15 seconds
only suction three phases
Hyperoxygenate for ____ or until patient’s baseline heart rate and oxygen saturation are within normal limits
1-5 minutes
Never use oral suction equipment for suctioning an artificial airway because
this can introduce oral bacteria into the lungs
Assessing how a patient swallows after nasal surgery is a priority because
repeated swallowing may indicate posterior nasal bleeding
use a penlight to examine the throat for bleeding, notify surgeon if bleeding is present
Nosebleeds (epistaxis) can occur as a result of
trauma
hypertension
blood dyscrasia (leukemia)
inflammation
tumor
decreased humidity
nose blowing
nose picking
chronic cocaine use
ng suctioning
Posterior nasal bleeding is an emergency because
it cannot be easily reached and the patient may lose a lot of blood quickly
Priority action when caring for a patient with facial trauma is:
airway assessment for gas exchange
Manifestations of airway obstruction:
stridor
SOB
dyspnea
anxiety
restlessness
hypoxia
hypercarbia (elevated blood levels of CO2)
decreased O2 sat
cyanosis
loss of consciousness
OSA:
obstructive sleep apnea that lasts at least 10 seconds and occurs a minimum of 5 times an hour
most common: upper airway obstruction
Factors that contribute to OSA
obesity
large uvula
short neck
smoking
enlarged tonsils or adenoids
oropharyngeal edema
Assessment for OSA:
Epworth Sleepiness scale
Most accurate tests for sleep apnea:
EEG
ECG
EMG
Drug that is helpful for patients who have narcolepsy from sleep apnea
Modafinil (Attenace, Provigil)
Notify the rapid response team if what occurs with stridor? what will be needed?
Dyspnea
emergency endotracheal intubation or tracheotomy may be needed
Manifestations of open bilateral vocal cord paralysis include
hoarseness
a breathy, weak voice
aspiration of food
place patient in high fowler’s position to aid in breathing and proper alignment of airway structures
for patients with laryngeal injuries, check vital signs…
every 15-30 minutes
Cricothyroidotomy is
an emergency procedure
stab wound at the cricothyroid membrane between the thyroid cartilage and the cricocartilage
any hollow tube can be placed through this opening to hold this airway open until a tracheotomy can be performed
this procedure is used when it is the ONLY way to secure an airway
Endotracheal intubation is:
performed by inserting a tube into the trachea via the nose (nasotracheal) or mouth (orotracheal)
by physician, anesthesia provider or other specially trained personnel
Tracheotomy:
surgical procedure (5-10 minutes to perform)
best performed in OR
local or general anesthesia
reserved for the patient who cannot be easily intubated with an endotracheal tube
emergency tracheotomy can establish airway in less than 2 minutes
Warning signs of head and neck cancer: (5)
Pain
lump in mouth, throat or neck
difficulty swallowing
color changes in the mouth or tongue to red, white, gray, dark, brown or black
oral lesion or sore that does not heal in 2 weeks
What happens when a carotid artery leak is suspected
call the rapid response team and DO NOT TOUCH THE AREA BECAUSE ADDITIONAL PRESSURE COULD CAUSE AN IMMEDIATE RUPTURE.
If carotid artery ruptures because of drying or infection….
immediately place constant pressure over the site and secure the airway
maintain direct manual, continuous pressure on the carotid artery and immediately transport patient to the OR for carotid resection
do not leave patient
carotid artery rupture has a high risk for
stroke and death
Areas to assess with patients after laryngectomy:
respiratory status
condition of wound
psychosocial status
take patient’s temp
assess the patients understanding of illness and adherence to treatment
nutrition status
Increase humidity by:
using saline in the stoma as instructed
bedside humidifier
pans of water
houseplants
What might you notice if the patient is experiencing inadequate gas exchange as a result of upper airway problems?
Voice changes (nasal quality if the problem is above the palate, “breathy” or “whispery” if the problem is in the larynx or trachea
snoring/mouth breathing
change in level of consciousness/acute confusion
decreased O2 sat by pulse ox
skin cyanosis/pallor
cyanosis or pallor of lips and oral mucous membranes
tachycardia and dysrhythmia
Asthma:
airways overreact to common stimuli with bronchospasm. edematous swelling of the mucous membranes and copious production of thick, tenacious mucus by abundant hypertrophied mucous glands
airway obstruction is usually intermittent
Chronic bronchitis:
Infection or bronchial irritants cause increased secretions, edema, bronchospasm and impaired mucociliary clearance
inflammation of the bronchial walls causes them to thicken
this thickening, together with excessive mucus blocks the AIRWAYS and hinders GAS EXCHANGE
Which drugs can trigger asthma?
Aspirin and other NSAIDS
Common drug therapy used for Asthma prevention and treatment
Bronchodilators
Short/Long acting Beta 2 Agonist
cholinergic antagonist
Methylxanthines
anti-inflammatories
corticosteroids
2 major changes that occur with emphysema and what they result in:
loss of lung elasticity
hyperinflation of lung
result in dyspnea and need for an increased respiratory rate
air trapping caused by loss of elastic recoil in alveolar walls
Bronchitis
is an inflammation of the bronchi and bronchioles caused by exposure to irritants, especially cigarette smoke
Bronchitis ONLY affects the ____ not the ___
AIRWAYS
NOT ALVEOLI
Chronic inflammation increases:
the number and size of mucus glands, which produces large amounts of thick mucus
Chronic bronchitis impairs:
airflow and GAS EXCHANGE because mucus plugs and infection narrow the airways
as a result, PaO2 level decreases (hypoxemia) and the arterial carbon dioxide (PaCo2) level increases (respiratory acidosis)
Greatest risk factor for COPD
SMOKINGGGG!!
Complications from COPD include:
hypoxemia
acidosis
respiratory infection (this risk increases because the increased mucus and poor oxygenation)
cardiac failure
dysrhythmias
respiratory failure
(hypoxemia and acidosis occur because the pt has reduced GAS EXCHANGE)
Key features of Cor Pulmonale (right sided heart failure)
Hypoxia/Hypoxemia
Increasing dyspnea
Fatigue
Enlarged and tender liver
Cyanotic hands, feet, lips
Distended neck veins
Nonpulmonary problems of Cystic Fibrosis
pancreatic insufficiency
malnutrition- vitamin deficiencies
intestinal obstruction
poor growth
male sterility
cirrhosis of liver
osteoporosis
diabetes mellitus
GERD, rectal prolapse, foul-smelling stools, steatorrhea
2 nursing priorities before surgery are (respiratory)
teaching the patient the expected regimen of pulmonary hygiene to be used in the period immediately after surgery and assisting the patient in a pulmonary muscle strengthening/conditioning regimen
Drug therapy for pulmonary arterial hypertension
Warfarin therapy
Calcium channel blockers
endothelia-receptor antagonists
natural/synthetic prostacyclin agents
digoxin and diuretics
oxygen therapy
Critical nursing priority for a patient undergoing therapy with IV prostacyclin agents is to
ensure that the drug therapy is never interrupted.
deaths have been reported if the drug delivery is interrupted even for a matter of minutes
teach patients to always have backup drug cassettes and battery packs
Sarcoidosis
inflammation of unknown cause that can affect any organ but the lung is involved most often
develops over time noncancerous inflammatory growths (granulomas)
corticosteroids main therapy
Warning signals associated with lung cancer:
hoarseness
change in respiratory pattern
persistent cough or change in cough
blood-streaked sputum
rust colored/purulent sputum
Complications of group A streptococcal infection:
rheumatic fever
acute glomerulonephritis
peritonsillar abscess
retrophraryngeal abscess
otitis media
sinusitis
mastoiditis
bronchitis
pneumonia
scarlet fever
Acute tonsillitis key features:
sudden onset of a mild to severe sore throat
fever
muscle aches
chills
dysphagia
pain in ears
Intranasal flu spray only recommended for
healthy people up to 49 years old
Dyspnea assessment guide:
indicates the amount of shortness of breath you are having at this time by marking the line
Asthma is a condition that occurs ____ and in 2 ways:
intermittently and in 2 ways
Inflammation
Airway hyper responsiveness leading to bronchoconstriction
Pathophysiology of asthma
intermittent and reversible airflow obstruction affecting airways only, NOT ALVEOLI
Asthma etiology:
different types based on how attacks are triggered
caused by specific allergens, general irritants, microorganisms, aspirin
hyper responsiveness caused by exercise, upper respiratory infection, unknown reasons
Physical assessment/clinical manifestations of asthma:
audible wheeze, increased respiratory rate
increased cough
use of accessory muscles
barrel chest from air trapping
long breathing cycle
cyanosis
hypoxemia
Laboratory assessment of asthma:
ABG’s
arterial O2 may decrease in acute asthma attack
arterial CO2 may decrease early in attack and increase later (indicating poor gas exchange)
allergic asthma with elevated serum eosinophil count, immunoglobulin E levels
Sputum with eosinophils, mucous plugs with shed epithelial cells
Pulmonary function tests of asthma:
Most accurate with use of spirometry
forced vital capacity (FVC)
forced expiratory volume in first second (FEV1)
Peak expiratory flow rate (PEFR)
COPD includes (2)
Emphysema
Chronic bronchitis
characterized by bronchospasm and dyspnea
Tissue damage is NOT reversible and increases severity…leads to respiratory failure
Chronic Obstructive Pulmonary Disease (COPD)
Pulmonary emphysema is an ______ problem
ALVEOLAR PROBLEM
NOT AIRWAY
Chronic bronchitis:
inflammation of bronchi and bronchioles caused by chronic exposure to irritants, ESPECIALLY CIGARETTE SMOKE
Chronic bronchitis affects only
AIRWAYS….NOT ALVEOLI
production of large amounts of thick mucus
Lab assessment of chronic bronchitis
ABG
sputum samples
CBC
H&H
Serum electrolytes
Serum AAT
Chest x-ray
Pulmonary function test
Drug therapy for chronic bronchitis
Beta-adrenergic agents
cholingergic antagonists
methylxanthines
corticosteroids
NSAIDS
Mucolytics
Pulmonary manifestations of CF
Respiratory infections
chest congestion
limited exercise tolerance
cough and sputum production
use of accessory muscles
decreased pulmonary function
changes in chest x-ray result
increased anteroposterior diameter
Nonsurgical management of CF
Nutritional management
Preventive/maintenance therapy
Exacerbation
Pulmonary Arterial Hypertension (PAH) etiology
occurs in absence of other lung disorders
cause unknown
Blood vessel constrictor with increasing vascular resistance in lung
Heart fails (for pulmonale)
Without treatment, death within 2 years
Idiopathic pulmonary fibrosis:
common restrictive lung disease
highly lethal
extensive fibrosis and scarring
corticosteroids, other immunosuppressants mainstays of therapy
Major diagnostic test for CF
sweat chloride test
Bronchitis not associated with
cigarette smoke
85% of lung cancer cases are caused by
cigarette smoke!!!
A special feature of inhalation anthrax is
that it is NOT accompanied by upper respiratory manifestations of sore throat or rhinitis
Pulmonary embolism can lead to
obstructed pulmonary blood flow
leading to reduced gas exchange
reduced oxygenation
pulmonary tissue hypoxia
decreased perfusion
potential death
Major risk factors for VTE leading to PE:
prolonged immobility
central venous catheters
surgery
obesity
advancing age
conditions that increase blood clotting
hx of thromboembolism
Classic manifestations of pulmonary embolism:
dyspnea, sudden onset
sharp, stabbing chest pain
apprehension, restlessness
feeling of impending doom
cough
hemoptysis
Signs of pulmonary embolism:
tachypnea
crackles
pleural friction rub
tachycardia
S3, S4 heart sound
diaphoresis
fever-low grade
Petechiae over chest
Any patient who has SOB, chest pain, and or hypotension without an obvious cause should be assessed for _____
Pulmonary embolism and rapid response team should be notified
Management options for a massive pe (mortality rate may be as high as 65%)
CPR
Inotropic/vasopressor support; fluids
Fibrinolytic therapy
Tissue plasminogen activator (tPA)
Ateplase (Activase)
Unfractionated heparin initial treatment
PE drug therapy begins:
immediately with ANTICOAGULANTS to prevent embolus enlargement and to prevent more clotting
enoxparin (lovenox)
fondaparinux (Arixtra)
usually used unless the PE is massive or occurs with hemodynamic instability
make sure to review patient’s PTT before therapy is started
Which drugs are used for treatment of PE when specific criteria are met such as…
Fibrinolytic drugs (alteplase)
criteria such as shock, hemodynamic collapse, instability
these drugs are used to break up existing clot
Blood tests used to monitor anticoagulation therapy:
Partial thromboplastin time (PTT)
Prothrombin Tim (PT)
International normalized ratio (INR) (HIGHER THAN 4 IS BAD)
Antidote for Heparin is
protamine sulfate
antidote for warfarin
vitamin K
Antidotes for fibrinolytic therapy:
clotting factors
fresh frozen plasma
aminocaproid acid (amircar)
Indicators that the patient has appropriate clotting factors: (2)
does not have bruising or petechiae
maintains H&H, platelet count within normal range
Evidence of bleeding:
oozing
bruises that cluster
petechiae
purport at least ever 2 hours
Measure abdominal girth every ___ hrs and why
8 hours because increasing girth can indicate internal bleeding
Critical values for ARF
Partial pressure of arterial oxygen (PaO2) less than 60 mm Hg (hypoxemia/oxygenation failure)
OR partial pressure of (PaCo2) more than 45 mm Hg occurring with academia (pH < 7.35) (hypercapnia/ventilatory failure)
AND arterial oxygen sat (SaO2) less than 90% in both cases
Acute respiratory failure can be:
Ventilatory failure
oxygenation (GAS EXCHANGE) failure
combination of both ventilatory and oxygenation failure
Common causes of oxygenation failure:
Low atmospheric oxygen concentration (high altitudes, closed spaces, smoke inhalation, carbon monoxide poisoning)
pneumonia
congestive heart failure with pulmonary edema
PE
ARDS
Hallmark of respiratory failure:
dyspnea (perceived difficulty breathing)
Manifestations of hypercapnia failure: (5)
decreased LOC
headache
drowsiness
lethargy
possible seizures
Effects of acidosis can lead to
decreased LOC
drowsiness
confusion
hypotension
bradycardia
weak peripheral pulses
Acute respiratory distress syndrome features
Hypoxemia that persists even when 100% oxygen is given (refractory hypoxemia, cardinal feature)
decreased pulmonary compliance
dyspnea
noncardiac-associated bilateral pulmonary edema
dense pulmonary infiltrates on x-ray
What kind of monitoring is valuable for those with ARF:
end tidal CO2 (ETCO2 or PETCO2) monitoring
pulse ox might show adequate oxygen saturation but because of increased ETCO2 the pt may be close to resp failure
ARDS can happen after:
an acute lung injury (ALI) in people who have no pulmonary disease as a result of other conditions such as
sepsis
burns
pancreatitis
trauma
transfusion
Common causes of acute lung injury
shock
trauma
serious nervous system injury
pancreatitis
fat and amniotic fluid emboli
sepsis
The diagnosis of ARDS is established by:
a lowered partial pressure of arterial oxygen (PaO2) value (decreased gas exchange) determined by arterial blood gas measurements
The patient with ARDS often needs:
intubation and mechanical ventilation with positive end-expiratory pressure (PEEP) or continuous positive airway pressure (CPAP)
3 phases of ARDS care:
Exudative phase
fibroproliferative phase
resolution phase
Exudative phase:
early changes of dyspnea and tachypnea resulting from the alveoli becoming fluid-filled and from pulmonary shunting and atelectasis
interventions focus on supporting the patient and providing oxygen
Fibroproliferative phase:
increased lung damage leads to pulmonary hypertension and fibrosis
body attempts to repair damage and increasing lung involvement reduces gas exchange and oxygenation
interventions focus on delivering adequate oxygen, preventing complications and supporting the lungs
Resolution phase:
usually 2 weeks after
if this doesn’t occur patient dies
fibrosis may or may not occur
research shows that patients surviving ards often has neuropsychological deficits and poor quality of life scores
Most accurate way to verify ET placement:
checking end-tidal carbon dioxide levels
chest xray
If an intubated patient shows manifestations of decreased oxygenation, check for DOPE:
D: displaced tube
O: obstructed tube (most often with secretions)
P: pneumothorax
E: equipment problems
If a patient develops respiratory distress during mechanical ventilation…
immediately remove the ventilator and provide ventilation with a bag valve mask device
this action allows quick determination of whether the problem is with the ventilator or with the patient
To prevent bacterial contamination with a ventilator:
do not allow moisture and water in the ventilator tubing to enter the humidifier
Assess the area around the ET tube or tracheostomy site at least every
4 hours for color, tenderness, skin irritation and drainage and document findings
Lung problems from mechanical ventilation include: (5)
Barotrauma (damage to lungs by positive pressure)
Volutrauma (damage to lung by excess volume delivered to one lung over the other)
atelectrauma (shear injury to alveoli from opening and closing)
biotrauma (inflammatory response0mediated damage to alveoli)
Ventilator-associated lung injury/Ventilator induced lung injury
Factors that reduce the likelihood of weaning
age related changes (chest wall stiffness, reduced ventilatory muscle strength, decreased lung elasticity)
Assessment findings with tension pneumothorax include:
asymmetry of thorax
tracheal movement away from midline toward unaffected side
extreme respiratory distress
absence of breath sounds on one side
distended neck veins
Initial management of pneumothorax
NEEDLE THORACOSTOMY
then a Chet tube is placed
Simple hemothorax
blood loss of less than 100 mL into the chest cavity
Massive hemothorax:
blood loss more than 1000mL
Hemothorax is
common problem after blunt chest trauma or penetrating injuries
Open thoracotomy is needed when there is
initial blood loss of 1000 mL from chest or persistent bleeding at the rate of
150-200mL/hr over 3-4 hours
