SEM2WK1 ADVANCED AIRWAY AX Flashcards
Systematic approach to the ax of respiratory pt components
Inspection
Rhythm
Position
Palpation
Percussion
Auscultation
Most common abnormalities found in the inspection phase of resp pts
rate depth and rhythm
Hyperpnea vs hyponoea respirations
hyper - rapid and deep
hypo- shallow impending respiratory failure
Why doe some pts do pursed lip breathing
Pursed lip breathing acts like a physiological PEEP and works to increase intra-airway pressure thereby preventing expiratory airway closure and maximising perfusion by decreasing RR and increasing arterial oxygenation.
define orthopnoea
dyspnoea that is aggravated by lying flat
causes of tracheal shift (2)
Increase in the volume of the contralateral lung and/or pleural space (pneumothorax or pleural effusion) OR decrease in the volume of the lung on the same side, usually result of atelectasis.
What is fremitus and what can it indicate
palpable thrill made by the patient’s voice. Provides information on sound transmission and disease processes can alter fremitus. Becomes more pronounced when consolidation present.
Bronchial vs Bronchiovesicular vs Vesicular sounds on auscultation
- Bronchial: harsh, loud, high-pitched sounds that are found over the larynx and trachea. Classified as abnormal lung sounds if heard over the peripheral lung fields. This can be due to consolidation or fibrosis which alter lung density and increase transmission of sound. Can be heard in patients with pulmonary oedema.
- Bronchovesicular: moderately pitched, can be heard equally over insp/exp and is normally heard over the major bronchi where fewer alveoli are found.
- Vesicular: soft, low pitched and heard throughout inspiration continuously until the last third of expiration
A vs B vs C lines
A line (horizontal) = reverberation of healthy tissue, air moving within the lung
B lines (vertical) = presence of fluid in the lungs, you can tell how much fluid is present based on how many b lines there are
C lines (curved horizontal line)= indicative of pneumonia or damage to the lung
Key things to assess for CXR for good technical quality
RIPE
-ROTATIONassessment of rotation, we want the patient to be midline, the thoracic vertebrae should be equidistant from each clavicle
-INSPIRATION inspiratory effort, good inspiratory effort will demonstrate the anterior aspect of at least 6 ribs above the diaphragm
-PROJECTION, is it AP or PA
-EXPOSURE, assessment of penetration, is the image under or over exposed?
Lung anatomy in CXR, zones
- Upper = upper two ribs
- Mid = ribs 2-4
- Lower = ribs 4 and below
Right lobe upper middle and lower silhouettes
RUL - medial pleura of r medistinum
RML- R heart border
RLL - right hemidiaphragm
Left lobe upper middle and lower silhouettes
LUL- aortic knuckle and left heart border
LLL- left hemidiaphragm
opacity vs lucency CXR
the denser tissue the whiter it will appear
an area with increased density can be referred to as an opacity
area of decreased density is lucency
ie air is black and bone is white
ABCDE method of CXR
- AIRWAY, trachea should be located centrally, or slightly deviated to the right. The carina should be clearly visible and the divisions of the right and left main bronchus should be seen
- BREATHING, the lungs should be divided into zones and compared bilaterally. The pleura should NOT be seen in healthy lungs but may be visible and further medial than if a normal if a pneumothorax is present.
- CARDIAC, the heart should occupy no more than 50% of the thoracic width (AP films exaggerate heart size and cardiac size should not be interpreted from these)
- DIAPHRAGM, the right hemidiaphragm will usually be higher than the left due to the presence of the liver. The stomach underlies the left hemidiaphragm and can be identified from the gastric bubble within it.
- EVERYTHING ELSE, the visible bones should be examined for fractures. You may be able to view medical equipment here in some patients too.
ETT placement CXR
- An ETT should be placed between the vocal cords and the carina, ideally around 4cm proximal to the carina
- If an ETT is placed too deep it tends to migrate down the right main bronchus, which has less of an angle at the carina when compared to the left.
Gastric tube assessment and position CXR
- Ideal position will have the tip positioned around 10cm further than the gastro-oesophageal junction
- This junction is midline at the level of T10, generally easily identifiable as most patients have 12 ribs.
- Generally poor position will involve the tube curling up in the pharynx or oesophagus or uncommonly but accidently inserted into the airways
Pleural effusion CXR
- Inner visceral and outer parietal membranes
- In the erect position the effusion will collect on the lateral costophrenic angles
in comparison, supine positioning, they will spread out over an entire field
Pneumothorax CXR
- Will demonstrate a visible visceral pleural edge which can be seen as a thin sharp white line.
- No lung markings will be seen after this line, while the peripheral space being radiolucent compared to the adjacent lung
Consolidation CXR
- Consolidation results in homogenous airspace opacity = cotton wool type opacification with little to no volume loss
COPD CXR
- Chronic changes include pulmonary hyperinflation and narrowed mediastinum
- more than the usual 6 ribs can be visible above the diaphragm – this is due to the chronic hyperinflation that can occur in COPD
- The mediastinum in COPD can be pulled inferiorly by ongoing hyperinflation. As a result the diameter of the mediastinum and cardiac silhouette will narrow
Hypoxia vs Hypoxaemia
Hypoxia (low oxygen at tissue level)
Hypoxemia (low oxygen in arterial blood)
Causes of Hypoxemia (5)
Hypoventilation
Right to left shunt (mixing of deoxygenated blood in systemic circulation)
VQ mismatch
Diffusion impairment
low inspired oxygen (high altitude)
acute compensatory mechanisms for hypoxaemia
initial increase in Mv
* Pulmonary arterial vasoconstriction decreases perfusion to hypoxic alveoli
* This balances ventilation and perfusion to restore arterial oxygenation it may also cause acute right side heart failure and is ineffective with diffuse lung disease
* Sympathetic tone increases and improves oxygen delivery by increasing cardiac output and increasing heart rate
chronic compensatory mechanisms for hypoxaemia
red blood cell mass and decreased tissue oxygen demands
Hypercapnia cause
alveolar hypoventilation and is defined as a PaCO2 >45mmhg
(rapid shallow breathing, small tidal volumes, reduced respiratory drive, never arises from an increase in CO2 production alone)
Management of hypercapnia
Increasing the Mv by either increasing the RR or VT or often both
**needs to be dx via ABG or ETCO2
Most common causes of pleural effusion
HF, pneumonia and cancer
exudatuve vs transudative effusion
- Exudate effusions result from pleural disease
- Transudative effusions result from imbalance between hydrostatic and oncotic pressure.
