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Pulmonary: Clin Med II B > Rsp Failure > Flashcards

Rsp Failure Flashcards

1
Q

what testing evaluates oxygenation, ventilation and acid-base
disorders
one of the MC tests drawn in the ICU

A

ABG

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2
Q

what does the ABG measure?

A
  • Oxygen tension (PaO2)
  • Oxyhemoglobin saturation (SaO2)
  • Carbon dioxide tension (PaCO2)
  • Acidity (pH)
  • Bicarbonate concentration (HCO3)
  • Can also request Methemoglobin, carboxyhemoglobin and hemoglobin levels if needed
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3
Q

what test can be used to find out if blood flow to your hand is normal?
This test checks to see if both of these blood vessels are open and working correctly

A

modified allens test

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4
Q

Most of O2 that diffuses from ___ to
the ____ binds to hemoglobin

A

alveolus
pulmonary capillary

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5
Q

what is the proportion of RBCs with hemoglobin bound to O2?
Most commonly measured by pulse oximetry?

ABG

A

SaO2 - arterial oxygen saturation

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6
Q

a SaO2 level below __ is considered abnormal and needs to be below ___ to qualify for home O2

A

95%
89%

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7
Q

Best marker of oxygenation in an ABG?

A

PaO2 - arterial oxygen tension

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8
Q

What part of the ABG is the Best marker of how well a patient is ventilating

A

PaCO2 - Carbon dioxide tension

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9
Q

what are abnormal values of PaCO2? what is normal?

A

> 45mmHg or
< 35mmHg
normal = 40 mmHg

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10
Q

Carbon dioxide is an ___ gas so rapid or
deep inspiration can “blow off CO2” and
cause rapid ____

A

acidic
respiratory alkalosis

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11
Q

Most important and strongest buffer in our body

A

HCO3 - bicarbonate level

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12
Q

HCO3 can be regulated by changing the amount generated/excreted by what organ?

A

kidneys

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13
Q

normal values of HCO3?

A

22 – 26 mEq/L

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14
Q

how fast is the buffering system? (HCO3)

A

Buffers blood acidity but slower and can take
a few days (3-5) to reach full effect

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15
Q

normal value of pH?
what values are considered acidemia or alkalemia?

A

Normal pH range is 7.35 – 7.45 (7.4)
=< 7.35 is acidemia
=> 7.45 is alkalemia

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16
Q

how are [H+] and pH related

A

inversely related

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17
Q

[H+] is determined by the balance of what two levels?

A

carbon dioxide (PaCO2)
bicarb (HCO3)

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18
Q

what is the main system that regulates body pH

A

carbonic acid/bicarbonate buffering system
Carbonic acid (H2CO3) links the respiratory and
metabolic (kidneys) system

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19
Q

carbonic acid conversion is
catalyzed by an enzyme called ?

A

carbonic anhydrase

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20
Q

bicarbonate conversion requires what to convert?

A

nothing! no catalyst

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21
Q

equation Used to relate the pH of blood to the
buffering system

A

henderson hasselbalch

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22
Q

Compensatory responses help normalize the pH but usually don’t do what?

A

do not return the pH fully to normal

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23
Q

Appropriate compensatory response of acid-base disturbances requires what two things?

A

normal functioning lungs and kidneys
Failure to develop a compensatory response defines the presence of a secondary primary disorder

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24
Q

equation of the simplified A-a gradient

A

PAO2 = [150] - [PaCO2/0.8]
Normal A-a gradient increases with age:
how to calculate: (age+10)/4

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25
Q

a normal A-a gradient means what?

A

hypoventilation
low inspired O2

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26
Q

an elevated A-a gradient means what?

A
  1. V/Qmismatch
  2. Shunt
  3. Impaired diffusion
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27
Q

steps of interpreting an ABG

A
  1. Is the ABG normal? Is acidemia or alkalemia present or all levels normal range
  2. Is the cause respiratory? Look at PaCO2 (40 is ideal)
  3. assess bicarbonate level (HCO3) (24 is ideal)
  4. assess if compensation is present
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28
Q

when interpreting an ABG, this usually represents the primary disorder

A
  1. Is acidemia or alkalemia present or all levels normal range
    ◦ pH < 7.35 is acidemia
    ◦ pH > 7.45 is alkalemia
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29
Q

PaCO2 >45 means what acid-base disorder?

A

rsp acidosis

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30
Q

PaCO2 < 35 is what acid-base disorder?

A

rsp alkalosis

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31
Q

HCO3 < 22 is what type of acid-base disorder?

A

metabolic acidosis

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32
Q

HCO3 >26 is what acid-base disorder?

A

metabolic alkalosis

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33
Q

Compensation is either considered ___ or ___ depending on if it brings pH back in normal range

A

complete
incomplete

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34
Q

causes of rsp acidosis

A
  • Airway obstruction
  • Lung disease
  • Chest wall disease
  • Neuromuscular disease
  • Primary brain injury (ex. CVA, trauma), sleep apnea, drugs causing sedation like opioids.
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35
Q

causes of metabolic acidosis

A
  1. Bicarbonate loss
    - GI loss - diarrhea, biliary drainage
  2. Increased acid load
    - Lactic acidosis, DKA, ethylene
    glycol intoxication, methanol intoxication, ASA intoxication
  3. Impaired acid excretion
    - Renal failure, Type 1 renal tubular acidosis, adrenal insufficiency
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36
Q

When the primary disorder is metabolic acidosis what is the next step?

A

calculate anion gap
Often calculated when trying to find out the cause of metabolic acidosis
Measures the difference between cations (positively charged ions) and anions (negatively charged ions)

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37
Q

what is the value of a normal anion gap

A

<12
If greater = presence of anion that cannot be measured

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38
Q

MCC of high anion gaps

A

lacticacidosis, ketoacidosis, acuterenalfailure, toxicacids
MUDPILES
M- Methanol(ex.Windshieldfluid,badmoonshine)
U–Uremia(BUN>60)
D–Diabeticketoacidosis
P–Paracetamol(acetaminophen)
I–Isoniazid,iron
L–Lacticacidosis
E–Ethyleneglycol(ex.Antifreeze)
S–Salicylates(ASA)

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39
Q

causes of Non‑anion gap acidosis

A

Caused by loss of bicarb or decreased acid (H+) excretion
Common causes: Diarrhea, Renal tubular acidosis

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40
Q

Causes of metabolic alkalosis

A
  1. Volume contraction
    - Dehydration
    - Over diuresis
  2. Loss of hydrochloride
    - Vomiting
    - Gastric suction
    - Taking excessive antacids
  3. Hypokalemia
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41
Q

A term that encompasses a continuum of
clinical and radiographic changes that affect
the lungs causing respiratory failure in the
critically ill patient

A

acute lung injury (ALI)

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42
Q

ALI is Characterized by ___ (noncardiogenic pulmonary edema)

A

acute severe hypoxia that is not due to the heart

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43
Q

most common form of non cardiogenic
pulmonary edema and most severe form of
ALI
what does it cause?

A

acute respiratory distress syndrome (ARDS)
Causes hypoxemic respiratory failure

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44
Q

MC causative event to trigger ARDS

A

sepsis (1/3)

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45
Q

what is the pathogenesis that are pivotal in causing lung injury?
how does it work?

A

pro-inflammatory cytokines
Damage occurs mainly at the capillary and
alveolar cells

46
Q

diffuse alveolar damage is the pathological hallmark for ?

A

pro-inflammatory cytokines causing lung injury

47
Q

Lung injury causes excess fluid to accumulate in both the interstitium and alveoli which causes the following: (4)

A
  1. Impaired gas exchange
  2. Decreased compliance
  3. Increased pulmonary arterial pressure
  4. decreased production of surfactant
48
Q

diagnostic criteria for ARDS

A
  1. Acute onset within 1 week of known clinical insult (usually sooner)
  2. Bilateral pulmonary infiltrates
  3. Rsp failure not explained by HF or volume overload
  4. PaO2/FIO2 ratio < 300mmHg
49
Q

ARDS severity

A

Based off of level of impaired oxygenation
(PaO2/FIO2 ratio)
Mild - 200-300mmHg
Moderate - 100-200mmHg
Severe - <100mmHg

50
Q

Rapid onset of profound dyspnea
within 12-48 hours after the initiating event
SOB, tachypnea, intercostal retractions and
crackles on PE
Marked hypoxemia occurs that does not
respond to standard supplemental O2
multiple organ failure
this presentation is associated with what dx?

A

ARDS

51
Q

Many patients with ARDS demonstrate
multiple organ failure, particularly where?

A

kidneys, liver, CV system, CNS

52
Q

CXR shows diffuse / patchy bilateral
infiltrates that rapidly progress and spare the costophrenic angles
Heart size normal and small / no pleural effusions
Air bronchograms present
what are you suspicious of?

A

ARDS
Air bronchograms are seen in 80% of
pts

53
Q

with ARDS you must exclude which other ddx?

A

Cardiogenic pulmonary edema
Pneumonia

54
Q

tx for ARDS

A
  1. Treat the underlying condition
  2. Treat secondary conditions (sepsis)
  3. Supportive care to help prevent
    complications
  4. txing hypoemia
    - tracheal intubation mech vent
    - Supplemental O2 to maintain PaO2 >55mmHg
    - Efforts to keep FIO2 less than 60% ASAP - avoid O2 toxicity
  5. PEEP
  6. prone positioning
  7. Volume controlled ventilation with Low Tidal
    Volume Ventilation (LTVV)
  8. decrease O2 consumption - sedatives,
    analgesics, antipyretics

Nothing is effective at preventing ARDS

55
Q

what tx is Used to prevent alveolar collapse

A

PEEP - Positive end-expiratory pressure
The lowest levels of PEEP that is effective
Has been shown to improve hemodynamic
outcomes but not shown to improve mortality

56
Q

Auto-PEEP can develop which can cause what?

A

decrease venous return, reduce CO, hypotension, at risk for barotrauma (pneumothorax)

57
Q

what tx has resulted in 10% reduction in mortality over standard therapy

A

Volume controlled ventilation with Low Tidal
Volume Ventilation (LTVV)

58
Q

outcomes of ARDS

A
  1. Mortality 30-40%, 90% with sepsis
  2. Median survival is 2 wks
  3. Most survivors are left with chronic pulmonary sx that may improve with time (cough, dyspnea, lung fibrosis)
59
Q

Inability of the lungs to meet the metabolic
demands of the body
can be from failure of tissue oxygenation and/or CO2 elimination

A

rsp failure
a condition that occurs as a result of +1 diseases involving the lungs or other body systems

60
Q

parts of the rsp system includes:

A

CNS (Medulla)
Peripheral nervous system (phrenic nerve)
Respiratory muscles
Chest wall
Lung
Upper airway
Bronchial tree
Alveoli
Pulmonary vasculature

61
Q

Types of respiratory failure, which is MC?

A
  1. hypoxemic respiratory failure (MC) - lungs fail to provide adequate oxygenation of the blood (PaO2 <60mmHg)
  2. Defect in ventilation (CO2 elimination) - Hypoxemia is always present but PaCO2 is elevated (PaCO2>50mmHg)
62
Q

etiology of hypoxemic respiratory failure can be evaluated by what modality?

A

CXR

63
Q

causes of hypoxemic rsp failure

A

interfere with O2 exchange, but ventilation is maintained

  1. Decreased inspired O2 tension (↓PIO2)
  2. V/Q mismatch (COPD)
  3. Diffusion limitation (fibrosis)
  4. Intrapulmonary shunt
    - Pneumonia
    - Atelectasis
    - CHF
    - ARDS
  5. disorder of heart, lungs or blood
64
Q

pt with Hypoxemic Respiratory Failure has a Normal CXR
what do you consider the causes to be?

A

COPD
Intracardiac shunt (right to left)
Pulmonary embolism

65
Q

pt with Hypoxemic Respiratory Failure has Focal infiltrates on CXR
what do you consider the causes to be?

A

Atelectasis
Pneumonia

66
Q

pt with Hypoxemic Respiratory Failure has Diffuse infiltrates on CXR
what do you consider the causes to be?

A

Cardiogenic pulmonary edema
Noncardiogenic pulmonary edema (ARDS)
Interstitial pneumonitis or fibrosis
Infectious (bilateral pneumonia)

67
Q

why does the level of bicarbonate depends on the duration of hypercapnia?

A

renal response occurs over days (2-5 days)

68
Q

Causes of Hypercapnic Respiratory Failure

A
  1. Respiratory center dysfunction (medulla)
  2. Drug overdose, CVA, tumor
  3. Central Hypoventilation
  4. Neuromuscular disease
    - Polio, Myasthenia Gravis, spinal injuries, Guillain-Barre
  5. Chest wall/Pleural diseases
    - Kyphoscoliosis, pneumothorax, large pleural effusion
  6. Upper airway obstruction
    - Tumor, FB, laryngeal edema
  7. Peripheral airway disorder
    - COPD, pulmonary fibrosis
69
Q

the arterial pH of Acute Hypercapnic Respiratory Failure is ?
causes?

A

low

  1. Sedative drug OD
  2. Acute muscle weakness, ex. Myasthenia Gravis
  3. Severe lung disease
  4. Acute on chronic respiratory failure
    - Occurs with chronic CO2 retention who acutely worsen and have rising CO2 and low pH
    - Caused by rsp muscle fatigue
70
Q

s/s of hypoxemia

A

Sx: dyspnea
Signs:
- Cyanosis
- Restlessness, confusion, anxiety, delirium
- Tachypnea, tachycardia, hypertension, tremor

71
Q

s/s of hypercapnia

A
  1. Sx: Dyspnea, HA
  2. Signs:
    - Peripheral and conjunctival hyperemia
    - Tachycardia, tachypnea, hypertension
    - Impaired consciousness, papilledema, asterixis
72
Q

tx for rsp failure

A
  1. Specific therapy directed toward the
    underlying disease
    - Example: abx for pna, anticoagulants for PE, BD and corticosteroids for COPD exacerbation
  2. Rsp supportive care to maintain
    adequate gas exchange
  3. General supportive care
73
Q

The main tx goal in acute hypoxemic
respiratory failure?
how?

A

ensuring adequate oxygenation

  1. Keeping O2 sat ≥ 90% or PaO2 ≥ 60mmHg
  2. Rarely, restoring oxygenation can cause hypoventilation in pts w/ chronic hypercapnia. However, oxygen therapy should never be withheld for fear of causing progressive rsp acidosis
74
Q

7 methods of oxygen delivery methods from least/low FiO2 to most invasive/high FiO2

A
  1. Nasal cannula
  2. Nasal catheter
  3. Simple mask
  4. Partial rebreather mask
  5. Non rebreather mask
  6. Venturi mask
  7. Oxygen tent
75
Q

For every liter increase in O2, FiO2 increases about what %?

A

4%

76
Q

Common and inexpensive
Does not interfere with eating or talking, well
tolerated
Higher flow rates can dry out the nasal mucosa fast
Dependent on how much patient inhales
through the nose
what oxygen method is this

A

cannula

77
Q

low and high flow for nasal cannula

A

Low flow: 1-6 L/min (FiO2 of 24% to 44%)
High flow: up to 10 L/min

78
Q

Not used often since so uncomfortable
Inserted through the nostril with the end of the catheter resting in the oropharynx.
Needs changed to other nostril every 8 hours

what oxygen method is this

A

catheter

79
Q

Has vents on both sides to allow room air to
enter and exhaled CO2 to escape
Used when increased O2 delivery is needed
for short periods (<12 h)
what oxygen method is this

A

simple face mask

80
Q

flow rate of simple face mask

A

Delivers FIO2 of 40 to 60% at flow rates of 5 L/min to 8 L/min respectively

81
Q

why must you never use <5 L/min with simple face masks?

A

patient may rebreathe most of their own air and become hypoxemic/hypercapnic

82
Q

O2 reservoir bag allows pt to rebreathe the first 1/3 of exhaled air (dead space air)
increases FIO2 by recycling expired O2

what oxygen method is this?
flow rate?

A

partial rebreather mask
Delivers FiO2 of 35-60% at a flow rate of 6-10 L/min

83
Q

what do the Two one-way valves do on a non-rebreather mask?

A

prevents:
Entrance of room air during inspiration
Retention of exhaled gases during expiration

84
Q

flow rate of a non rebreather mask

A

Delivers the highest FiO2 possible 95% at a
flow rate of 10-12 L/min

85
Q

this oxygen method is used by mixing room air with precise amount of oxygen you can dial in the FiO2.
The size of the port and oxygen flow rate determine the FiO2
what is this method?
flow rate?

A

venturi mask
Delivers FiO2 varying from 24-60% x flow rates 4-10 L/min

86
Q

Designed for patients who cannot wear a
mask or nasal cannula (examples: facial
surgery or trauma)
what is this oxygen method?

A

face tent

87
Q

Rigid plastic dome encloses the infant’s head
what is this oxygen method

A

oxygen hood (infants)

88
Q

Plastic canopy that supplies humidified O2
what is this oxygen method?

A

oxygen tent

89
Q

first line therapy for COPD

A

Noninvasive positive airway ventilation (NPPV)
Reduces intubation rates and amount of ICU
stay

90
Q

COPD pts with hypercapnic rsp failure may use NPPV only if they have these factors:

A

Protect their own airway
Handle their own secretions
Tolerate the BPAP mask

(must be neurologically competent)

91
Q

MC used for COPD conditions causing respiratory muscle weakness and obesity hypoventilation

A

Bilevel positive airway pressure (BPAP)

92
Q

MOA of Bilevel positive airway pressure (BPAP)

A

Delivers preset inspiratory positive airway pressure (IPAP) and expiratory positive airway pressure (EPAP)

93
Q

pts must do what with BPAP machines?

A

must initiate each breath on most
machines

94
Q

Continuous level of positive airway pressure
throughout respiratory cycle
Patients must initiate all breaths
MC used in patients with sleep
apnea or cardiogenic pulmonary edema
what is this machine?

A

Continuous positive airway pressure (CPAP)
No additional pressure above the CPAP level
is provided

95
Q

when do you intubate?

A

Hypoxemia despite supplemental O2
Upper airway obstruction
Unable to protect airway or clear secretions
Acute hypercapnia that does not quickly
respond to noninvasive ventilation (CPAP or BiPAP)
Progressive fatigue, mental status changes, tachypnea, or use of accessory muscles
Apneas

96
Q

which type of intubation is preferred since
easier, faster and less traumatic than
nasotracheal

A

orotracheal intubation

97
Q

how can you verify both lungs are
being ventilated with intubation?

A

auscultating the lungs

98
Q

Position of the tip of the ET tube
should be positioned where?

A

at the level of the aortic arch and verified by CXR

99
Q

the cuff pressure during intubation should not exceed what level? why?

A

20mmHg
minimize tracheal injury

100
Q

Can fully or partially replace spontaneous
breathing
Used for acute or chronic respiratory failure
when there is insufficient oxygenation or
ventilation, or both
what type of intervention is this?

A

mech vent

101
Q

benefits of mech vent

A

Improved gas exchange
Decreased work of breathing
More precise titration of oxygen needs

102
Q

types of breaths

A
  1. Trigger
    - Ventilator-initiated breaths – preset RR triggered by a timer on ventilator
    - Patient-initiated breaths- patient effort causes flow change which initiates the breath
  2. Volume assist
    - initiated by the patient with a set inspiratory flow rate
    - Inspiration is stopped when the set tidal
    volume was delivered
  3. Volume control breaths (VC)
    - Breaths are ventilator-initiated with a set
    inspiratory flow rate
    - Inspiration is terminated once the set tidal
    volume was reached
103
Q

types of ventilation

A
  1. Continuous mandatory Ventilation (CMV) Mode
  2. Intermittent mandatory ventilation (IMV) Mode
  3. Synchronized IMV (SIMV) Mode
  4. Pressure support ventilation (PSV) mode
  5. Positive end-expiratory pressure (PEEP)
104
Q
  • Minute ventilation is determined by set RR and tidal volume
  • No pt initiation or effort
  • Pt may be on heavy sedation, pharmacologic paralysis, or coma
  • deepest form of ventilation

what type of ventilation?

A

Continuous mandatory Ventilation
CMV

105
Q

Clinician determines minimum minute
ventilation by setting the respiratory rate and tidal volume
pt can increase the minute
ventilation by spontaneously breathing
addition breaths

what type of ventilation?

A

IMV

106
Q

Variation of IMV
Ventilator breaths are synchronized with patient effort
Support can range from full support to no support at all
Better patient-ventilatory synchrony, preserves respiratory muscle function, greater control over level of support

what type of ventilation

A

SIMV

107
Q

Pt triggers each breath, no set RR
The work of breathing is inversely proportional to the pressure support level
Useful when weaning a patient from mechanical ventilation
- More comfortable mode
- pt has greater control

what type of ventilation?

A

Pressure support ventilation
PSV

108
Q

Potential Complications of Mechanical Ventilation

A
  1. Barotrauma (excessive tidal volumes, PEEP)
    - Pneumothorax
    - Subcutaneous emphysema
    - Pneumomediastinum
  2. Ventilator-associated pneumonia
  3. Trauma - tracheal stenosis, vocal cord
    dysfunction
109
Q

Most common diseases that lead to
lung transplant

A

COPD
Idiopathic pulmonary fibrosis
Cystic fibrosis
Alpha-1 antitrypsin deficiency
Idiopathic pulmonary hypertension
Coal Worker’s Pneumoconiosis
bronchiectasis

110
Q

what determines what pt gets a lung transplant and when?

A

Lung Allocation Score (LAS)
Unet computer system tracks pts and
when a lung becomes available the system
runs a donor/recipient match based on blood type, size of organ and distance from donor and recipient

111
Q

general guidelines/criteria for a lung transplant

A
  1. <65
  2. Severe lung disease that is progressive
  3. Limited life expectancy bc of their lung disease
  4. Good nutritional status and BMI <30
  5. Good support system and mentally intact
112
Q

contraindications for a lung transplant

A
  1. Active smoking (within past 6 months)
  2. Active malignancy in last 2 years
  3. Drug or ETOH dependency
  4. Significant disease of other organs including CAD and HF
  5. Untreatable pulmonary or extrapulmonary infection
  6. BMI >35
  7. Hep B, C or HIV infection

Pulmonary: Clin Med II B (10 decks)

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