Respiratory review part 2

Question 1

s/s of hypoxemic Respiratory failure
(low oxygen)

Answer 1

pulmonary: tachypnea, adventitious breath sounds, accessory muscle use

cardiac: tachyarrhythmias (initial), bradyarrhythmias (late), hypertension or hypotension, cyanosis

neuro: anxiety, agitation

Question 2

s/s of hypercapnic Respiratory failure
(high CO2)

Answer 2

pulmonary: shallow breathing, bradypnea, lungs clear or adventitious sounds

neuro: progressive decreased LOC (lethargic, obtunded, stuporous, unresponsive)

Question 3

acute respiratory failure treatment

Answer 3

upright positioning
suction
bronchodilator (for wheezing)
noninvasive ventilation
intubation if needed
repeat ABGs
optimize oxygenation
optimize circulation

Question 4

contraindications for noninvasive ventilation

Answer 4

hemodynamic instability or life-threatening arrhythmias
copious secretions
high risk of aspiration
impaired mental status
suspected pneumothorax
inability to cooperate
PaO2 < 60

Question 5

COPD includes:

Answer 5

emphysema, asthma, and bronchitis

it is easier for air to enter the pulmonary system than to exit; inspiration easier than expiration

risks of hyperinflation and air-trapping

patient may have chronic CO2 retention

Question 6

COPD management includes:

Answer 6

titrate SaO2 with care not to overcorrect hypoxemia and decrease respiratory drive

bronchodilator - SABA (albuterol) and anticholinergic

corticosteroid

antibiotic (if pneumonia the trigger)

mechanical ventilation if necessary

Question 7

status asthmaticus progresses from___

Answer 7

respiratory alkalosis to respiratory acidosis and normal PaO2 to severe hypoxemia.

ventilator management includes:
use low rate to increase exhalation time
use low tidal volume to prevent auto-peep
increase inspiration/expiration ratio to allow for optimal exhalation

Question 8

pulmonary embolism

Answer 8

a partial or complete obstruction of the pulmonary capillary bed by a blood clot or another substance such as fat, air , amniotic fluid, or a foreign material

massive >50% occlusion
submassive < 50% occlusion
80-90% result from DVT

Question 9

the primary cause of a pulmonary embolism is ___

Answer 9

a VTE (venous thromboembolism)

strong risk factors of a VTE include:
fracture (hip or leg), hip or knee replacement, major trauma, spinal cord injury

moderate risk factors of a VTE include: arthroscopic knee surgery, central venous line, chemotherapy, HF or respiratory failure, hormone replacement therapy, malignancy, oral contraceptives, pregnancy, stroke

Question 10

Pulmonary embolism

Answer 10

s/s include:
dyspnea or tachypnea, tachycardia, chest pain, S3 or S4 heart sounds, anxiety/apprehension, cough/crackles/hemoptysis, syncope, PETECHIAE (fat emboli), respiratory alkalosis, low grade fever

massive PE s/s include: hypoxemia, hypotension, EKG changes (RBBB, peaked T waves, ST elevation), PEA

Types include: venous thromboembolism (DVT) and Fat emboli (long bone, pelvic fractures),

Diagnosis: pulmonary angiography

Question 11

Prevention and treatment of PEs

Answer 11

mechanical prevention: compression socks, SCD’s

pharmaceutical prevention: heparin, lovenox, xarelto, eliquis

treatment: maintain ABC’s, fluids, anticoagulation (heparin, lovenox, coumadin), fibrinolytic therapy, maintain cardiac output (inotropes and fluids)

Question 12

pulmonary hypertension results in ____

Answer 12

cor pulmonale and right ventricular failure

treatment should include dilators (CCB). should also consider diuretics, , oxygen, coags, digoxin, and exercise

Question 13

types of pneumonia

Answer 13

by causative agents (bacterial, viral, fungal, parasitic)

according to where it developed: hospital acquired, community acquired, ventilator associated pneumonia (VAP)

prevention of VAP includes:
drain condensate from tubing, prevent backflow of tubing condensate, mobilize patient, mouth care, aseptic technique for ETT suctioning,

Question 14

treatment of pneumonia

Answer 14

optimize oxygenation and ventilation

positioning - Good lung DOWN

I.D. organisms - cultures

antibiotics

system support - hydration, fever mgmt, nutrition

Question 15

what type of aspiration is most common?

Answer 15

oropharyngeal

Question 16

ARDS and ALI

Answer 16

noncardiogenic pulmonary edema

an acute inflammatory response resulting in an increase in the permeability of the pulmonary capillary membrane which allows transudation of proteinaceous fluid into the interstitial and alveolar spaces. Damage to TypeII Alveolar cells is one of the pathologic consequences. Since these cells produce surfactant, then massive atelectasis occurs.

“Direct injury” - aspiration, pneumonia , pulmonary contusion, fat/air embolus, O2 toxicity, inhalation injury, drowning, transthoracic radiation

“Indirect injury” - sepsis, shock, head injury, non-thoracic trauma, blood transfusion pancreatitis, burns, heart bypass, DIC

s/s: tachycardia, restlessness, increasing dyspnea, early respiratory alkalosis turning into late respiratory and metabolic acidosis, crackles, white infiltrates on chest X-ray, PaO2 of 60 on RA (late will be PaO2 of 30)

Question 17

ARDS vs ALI

Answer 17

(BOTH) ARDS & ALI:
acute onset, bilateral infiltrates/pulmonary edema, PAOP </=18mmHG

(DIFFERENCE)
ARDS: PaO2/FiO2 </= 200mmHg,
ALI: PaO2/FiO2 between 201-300mmHg

Example:
The patient is receiving 50% FiO2 and PaO2 is 90.
PaO2/FiO2 = 90/0.50 = 180 (ARDS)

Example 2
The patient is receiving 30% FiO2 and PaO2 is 110
PaO2/FiO2 = 110/0.30 = 367 (ALI)

Question 18

surfactant

Answer 18

phospholipid/lipoprotein produced by typeII alveolar cells that “keeps them open” thus increasing lung compliance and eases the work of breathing

Question 19

ARDS/ALI treatment

Answer 19

pulmonary stabilization (intubation) - limit the tidal volume to prevent volume trauma, PEEP usually 15

cardiovascular stabilization - support BP (fluids, vasopressors, treat arrhythmia)

prone positioning - helps deliver blood flow to under perfused lung units

also: monitor acid-base balance, DVT prophylaxis, stress ulcer prophylaxis, analgesia/sedation, nutrition, prevent organ failure, NO STEROIDS

Question 20

Pneumothorax types:

Answer 20

types: spontaneous/traumatic (not usually life threatening) and TENSION (LIFE THREATENING)

spontaneous/traumatic
types: open (penetrating chest trauma), closed (blunt chest trauma), iatrogenic (from a therapeutic or diagnostic procedure)
s/s include: dyspnea, tachypnea, unequal chest excursion, tracheal deviation TOWARDS the affected side, hypoxemia, absent breath sounds on affected side, mediastinum REMAINS midline (NO SHIFT)

TENSION:
air is unable to exit leading to a mediastinal shift (this leads to decreased venous return, decreased cardiac output, and decreased BP)
s/s include: tracheal deviation AWAY from the affected side, distended neck veins, MEDIASTINAL SHIFT, HYPOTENSION

Question 21

hemothorax

Answer 21

lung collapse (usually d/t trauma) with blood in the pleural or mediastinal space

dullness to percussion, tracheal deviation TOWARD affected side

Question 22

Treatment for pneumothorax

Answer 22

<20% of lung - O2 and monitor

> 20% - CHEST TUBE, O2, treat pain

Chest tube management:
close assessment of respiratory status, pain treatment, entry site care, no dependent loops in the tubing, keep collection chamber lower than chest, water seal chamber (no bubbles!), suction control (gauge or water level determines this, not wall suction), no clamping (this cuts off the negative pressure)