Respiratory review part 2 Flashcards
s/s of hypoxemic Respiratory failure
(low oxygen)
pulmonary: tachypnea, adventitious breath sounds, accessory muscle use
cardiac: tachyarrhythmias (initial), bradyarrhythmias (late), hypertension or hypotension, cyanosis
neuro: anxiety, agitation
s/s of hypercapnic Respiratory failure
(high CO2)
pulmonary: shallow breathing, bradypnea, lungs clear or adventitious sounds
neuro: progressive decreased LOC (lethargic, obtunded, stuporous, unresponsive)
acute respiratory failure treatment
upright positioning
suction
bronchodilator (for wheezing)
noninvasive ventilation
intubation if needed
repeat ABGs
optimize oxygenation
optimize circulation
contraindications for noninvasive ventilation
hemodynamic instability or life-threatening arrhythmias
copious secretions
high risk of aspiration
impaired mental status
suspected pneumothorax
inability to cooperate
PaO2 < 60
COPD includes:
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
COPD management includes:
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
status asthmaticus progresses from___
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
pulmonary embolism
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
the primary cause of a pulmonary embolism is ___
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
Pulmonary embolism
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
Prevention and treatment of PEs
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)
pulmonary hypertension results in ____
cor pulmonale and right ventricular failure
treatment should include dilators (CCB). should also consider diuretics, , oxygen, coags, digoxin, and exercise
types of pneumonia
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,
treatment of pneumonia
optimize oxygenation and ventilation
positioning - Good lung DOWN
I.D. organisms - cultures
antibiotics
system support - hydration, fever mgmt, nutrition
what type of aspiration is most common?
oropharyngeal
ARDS and ALI
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)
ARDS vs ALI
(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)
surfactant
phospholipid/lipoprotein produced by typeII alveolar cells that “keeps them open” thus increasing lung compliance and eases the work of breathing
ARDS/ALI treatment
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
Pneumothorax types:
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
hemothorax
lung collapse (usually d/t trauma) with blood in the pleural or mediastinal space
dullness to percussion, tracheal deviation TOWARD affected side
Treatment for pneumothorax
<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)
