respiratory procedures Flashcards
pulse Ox?
Reads the Color Red – refraction of light
Hypothermia – decreased peripheral circulation can cause a falsely lowered O2 saturation
Fingernail polish – light cannot penetrate through nail polish. Ear lobe is an alternate site for measurement.
Carboxyhemoglobin – the pulse oximeter cannot discriminate between oxyhemoglobin and carboxyhemoglobin (need an ABG)
CXR
Most common X-ray procedure in the US.
- Typically done with PA and lateral studies (patients hold breath after maximal inhalation). posterior –> anterior
- also done from lateral decubitus: patient on left and right side
If done correctly will allow for visualization of 9-10 ribs posteriorly and 5-6 anteriorly.
AP views for bed bound patients.
Lateral decubitus - Patient on left and right side. (used to determine effusion vs. consolidation)
Lordotic view. (good view to look at apices of lungs, lean patient back)
pneumoperitoneum
gas in abdominal cavity
how to read CXR?
RIP: rotation, inspiration, penetration of xray
- look at ribs 1 to see if they are rotated or not, if even
- heart size = transverse size of heart divided by transverse diameter of thorax should be < 0.5
- Hemi-diaphragm – right usually 1.0-1.5 cm higher than the left (d/t the liver)
- Inspiration – diaphragm to the 9-10 rib
should see vertebrae of spine just to top of heart, if you can see vertebrae through heart the xray is overpenetrated…. (if underpenetrated, won’t see shadows of vertebrae)
PA view?
standing with back to beam, takes picture from posterior to anterior
on AP view CXR view the heart shadow will be falsely enlarged because of the divergence if the x-ray beams. (i.e. pt. bed bound/in ICU)
limitations of CXR?
NL x-rays can correlate poorly with actual disease going on:
- i.e. early pneumonia, may not how infiltrate
- PE, will show normal on CXR
- Early COPD/Chronic bronchitis/Asthma may be normal: late in process see hyperinflation, loss of vascular markings, flattened, hemidiaphragms, increased PA diameter, increased retrosternal air space seen in more advance disease
- interstitial dx: pneumoconiosis & asbestosis, unless in the presence of PMF (progressive massive fibrosis)
ABG, what does it determine?
(acid-base balance and oxygen status)
- pH of blood
- Partial pressure of oxygen in the blood (PaO2)
- Partial pressure of carbon dioxide (PaCO2)
- Bicarbonate level (HCO3)
- Oxygen saturation of hemoglobin (O2 sat.)
Arterial blood is used, most common sites:
Radial artery
Brachial artery
Femoral artery
- tells acid base status and oxygenation status of the patient
why use an ABG?
- Assess for hypoxia and severity
- Evaluation of acid-base disorders
- Assess need for home O2 use (chronic patients)
- Measure carboxyhemoglobin levels in patients suffering from smoke inhalation or other exposures (with a CO – oximeter )
- Calculate arterial O2 saturation content
- Blood sample in difficult draw patients (obese)
how to calculate an O2 sat?
- The ABG machine cannot differentiate between O2 and CO hemoglobin.
- Given a separate CO measurement
Thus must take the O2 sat measured - the CO hgb measured = actual O2 saturation
O2 Saturation = 98%
CO hemoglobin = 25%
Actual O2 Saturation = 73% (very hypoxic)
contraindications of ABG?
No absolute contraindications
- Invasive procedure – bleeding, arterial laceration
- Coagulopathy, including thrombolytic therapy
- Severe PAD with poor collaterals (Allen’s test)
- Trauma or infection at draw site
- Difficult to standardize d/t factors such as: Hyperventilation Breath holding Altitude Obesity
ABG collection technique?
45 degrees yo!
- Palpate artery while resting patient’s arm on bedside table. Can support wrist with towel
- Confirm with “Allen’s Test” (release of ulnar and see if hand blanches, need to have ulnar collateral circulation if going to stick the radial)
- Cleanse area first with Iodophor than wipe once with alcohol pad
- Anesthetize area if desired
- Locate artery with index and middle finger of one hand,
**then insert needle at a 45° angle to skin bevel up. Slowly advance until artery is punctured and
Blood begins to fill syringe - Collect 2-3 ml of blood, then slowly remove needle
- Apply firm pressure over site with 2X2 gauze and hold for up to 5 minutes.
Once no bleeding occurs apply band-aid and dispose of sharp properly - Transport to lab on ice ASAP
ET/NT intubation indications?
indications:
- Respiratory failure
- Airway protection for patients at risk of compromise (loss of gag reflex, or drug OD)
- Maintenance of airway, i.e. operating room
- Help facilitate pulmonary treatments and medication
- Use positive pressure ventilation
- Maintain adequate oxygenation
CI’s:
- Operator unskilled to administer tube
- Excessive trauma to face, neck, c-spine (relative)
- Inability to extend the head and neck (Endotracheal)
how do you prepare for ET tube placement?
- determine appropriate method
- make sure equip. is functioning
- ** ensure adequate IV access (don’t put tube in before getting IV access, need to make patient unconscious before intubating)
- remove foreign bodies if present (take out dentures, food, etc.)
- Hyperventilate with high concentration of oxygen if possible: Can place temporary oropharyngeal airway if needed
- Monitor BP, pulse ox, cardiac status
- Have appropriate staff and equipment ready for CPR
size of tube should be pt’s baby finger
never move tube with cuff inflated
complete sedation for ET tube?
- Not required for the unconscious patient
- Use rapid sequence intubation for patients at risk for regurgitating or aspirating
- To sedate patients use rapid IV administration of sedative (ex. Propofol, Thiopental, midazolam) *risk is sudden drop of BP
- May also need fast acting muscle relaxant
(ex. Succinylcholine, Rocuronium) - Risk of arrhythmias and post-op myalgias
ET intubation sequence?
- Recheck all equipment is functioning
- Hyperventilate the patient.
- Cricoid pressure by assistant if needed (Sellick’s maneuver, sniffing position)
- Position patient in sniffing position, extending head at OA joint. Jaw thrust or chin lift if needed
- Place laryngoscope in right side of mouth and sweep blade to left displacing tongue. (Curved blade: tip is inserted into the vallecula) (straight blade: tip is just below epiglottis)
- Lift scope upward & forward, keep your wrist stiff, (don’t use a lever action or you break teeth)
- With cords in view, insert tip of ET tube between cords, such that tip is 2-3 cm below cords. Remove scope and inflate cuff. If stylet was used, remove this now.
