Ventilation Flashcards
Exam 3
Anatomy:
What are the lungs protected by?
Lungs protected by thoracic cage
Anatomy:
What are the lungs attached to?
Attached at pulmonary ligament in mediastinum
Anatomy:
Right lung has how many lobes? Left?
Right lung—three lobes
Left lung—two lobes
Anatomy:
Mediastinum contains the following:
Heart, blood vessels, lymph nodes, thymus gland, nerve fibers, esophagus
Slide 4
Movement of Air Into and Out of the Lungs
How does gases move?
Movement of gases is always from an area of higher pressure to one of lower pressure
Movement of Air Into and Out of the Lungs:
What are the types of pressure?
Airway pressure
Intrapleural pressure
Intra-alveolar pressure
Transpulmonary pressure
Intrathoracic pressure
Mechanics of Ventilation
Breathing in:
When breathe in, diaphragm goes down.
Lung expands- because it gets filled with air.
Work of Breathing
In normal breathing, what occurs during inspiration and expiration?
In normal breathing muscle contract occurs during inspiration only (expiration is passive, caused by elastic recoil of lung)
Work of Breathing
Inspiration divided into three categories:
Must overcome compliance or elastic work
Must overcome tissue resistance work
Must overcome airway resistance work
Assessment of Ventilation
Minute ventilation =
volume of air inhaled and exhaled/min
Assessment of Ventilation
Dead space ventilation: Two types?
Anatomical
Physiologic
Assessment of Ventilation
Alveolar ventilation
Minute ventilation- dead space
Inversely proportional to PaCO2.
Assessment of Ventilation
Alveolar ventilation is inversely proportional to what?
Inversely proportional to PaCO2
Assessment of Ventilation
Lung compliance:
Ability of the lungs to expand and deflate.
Assessment of Ventilation
Two types of Dead Space Ventilation:
Anatomical: What is it?
Anatomical dead space or the air in the conducting airways (about 150 to 200 mL) does not participate in gas exchange but increases with intubation.
Assessment of Ventilation
Two types of Dead Space Ventilation:
Anatomical: What may cause this?
Anatomic dead space depends on body posture and disease states.
Assessment of Ventilation
Two types of Dead Space Ventilation:
Physiologic: What may cause this?
Physiologic dead space occurs when ventilation is normal but perfusion to the alveoli is reduced or absent.
Assessment of Ventilation
Two types of Dead Space Ventilation:
Physiologic: What causes Physiologic dead space?
This can occur with certain disease states, such as reduced cardiac output or pulmonary embolism.
Principles of Gas Exchange
Diffusion
Four factors affect alveolar capillary gas exchange
Perfusion
Principles of Gas Exchange
Four factors affect alveolar capillary gas exchange
- Surface wall area
- Thickness of alveolar capillary membrane
- Partial pressure of gas
- Solubility of gas
Principles of Gas Exchange
Perfusion
Flow of blood through pulmonary capillaries
Principles of Gas Exchange
Diffusion
Traveling from high concentration to low concentration.
Principles of Gas Exchange
Thickness of alveolar capillary membrane
Thickness of alveolar–capillary membrane:
Thicker it is the harder it is for gas exchange to occur.
Ventilation to Perfusion
What is the ratio?
The ventilation-perfusion ratio is the ratio between the amount of air getting to the alveoli (the alveolar ventilation, V, inml/min) and the amount of blood being sent to the lungs (the cardiac output or Q - also in ml/min).
Patient Assessment: Respiratory System
History: What two broad groups to collect?
Chief complaint
Smoking history
Patient Assessment: Respiratory System
History:
Chief complaint: What could it be?
Dyspnea
Chest pain
Sputum production
Cough
Patient Assessment: Respiratory System
History:
Smoking history: What could be collected?
Amount
For how long
Patient Assessment: Respiratory System
Physical Examination: What are you inspecting?
Head, neck, fingers, and chest
Accessory muscles, sternal retractions, nasal flaring, asymmetrical chest movements, open-mouth breathing, and gasping breaths
Patient Assessment: Respiratory System
Respiratory rate
Tachypnea: rate > 20
Bradypnea: rate < 10
Patient Assessment: Respiratory System
Respiratory rate: What should you assess about it?
Assess rate and depth and altered patterns
Patient Assessment: Respiratory System
A patient was admitted for respiratory distress. They have a productive cough. The sputum is yellowish-gree. Which of the following is the most likely cause?
A. Bacterial infection
B. Tb
C. Pulmonary infarction
D. Viral infection
A. Bacterial infection
Patient Assessment: Respiratory System
What would sputum that has large blood clots indicate?
Pulmonary infarction
Patient Assessment: Respiratory System
What would sputum that is rust colored indicate?
Tb
Patient Assessment: Respiratory System
What would sputum that has streaks of blood indicate?
Viral infection
Patient Assessment: Respiratory System
What can effect breathing?
Kyphosis or hunchback: can also affect breathing
Barrel chest can also affect breathing.
Patient Assessment: Respiratory System
Abnormal Breathing Patterns
Cheyne-Stokes
Biot’s:
Kussmaul’s:
Apneustic:
Patient Assessment: Respiratory System
Abnormal Breathing Patterns: Cheyne-Stokes
Cyclical with apneic periods
Patient Assessment: Respiratory System
Abnormal Breathing Patterns: Biot’s:
Cluster breathing
Patient Assessment: Respiratory System
Abnormal Breathing Patterns: Kussmaul’s:
deep, regular, and rapid
look at pictures!
Patient Assessment: Respiratory System
Abnormal Breathing Patterns: Apneustic
gasping inspirations
Patient Assessment: Respiratory System
Palpation: What should you evaluate?
Tactile fremitus
Subcutaneous emphysema (air leak)
Thoracic expansion during respiration
Trachea alignment
Patient Assessment: Respiratory System
Percussion: What should you evaluate?
Resonance:
Dullness:
Flatness:
Hyperresonance:
Tympany:
Patient Assessment: Respiratory System
Percussion: Resonance- what is it?
normal lung sound
Patient Assessment: Respiratory System
Percussion: Dullness- what is it?
denser than normal tissue
Patient Assessment: Respiratory System
Percussion: Flatness- what is it?
Air is absent
Patient Assessment: Respiratory System
Percussion: Hyperresonance- what is it?
increased amount of air
Patient Assessment: Respiratory System
Percussion: Tympany- what is it?
air-filled area
Patient Assessment: Respiratory System
Auscultation: What is it?
Assess breath sounds, presence of adventitious lung sounds (extra lung sounds), voice sounds
Patient Assessment: Respiratory System
Auscultation: What kind of approach do you take?
Quiet environment
Systematic approach
Patient Assessment: Respiratory System
Breath Sounds: What does it include?
Normal
Adventitious sounds
Patient Assessment: Respiratory System
Breath Sounds: What are normal breath sounds?
Bronchial
Bronchovesicular
Vesicular
Patient Assessment: Respiratory System
Breath Sounds: What are adventitious breath sounds?
Crackles
Rhonchi
Wheezes
Pleural friction rub
Stridor
Patient Assessment: Respiratory System
Arterial Blood Gases: What measurements are included?
Oxygen measurement
Ventilation measurement
Measure pH
Patient Assessment: Respiratory System
Arterial Blood Gases: What measurements are for oxygen?
PaO2 and SaO2
Patient Assessment: Respiratory System
Arterial Blood Gases: What measurements are for ventilation?
PaCO2
Patient Assessment: Respiratory System
Arterial Blood Gases: pH measures for what?
Acids
Base
Patient Assessment: Respiratory System
Arterial Blood Gases: What are the three possible results?
Respiratory acidosis
Respiratory alkalosis
Metabolic acidosis
Metabolic alkalosis
Patient Assessment: Respiratory System
Arterial Blood Gases: Respiratory acidosis- What is it?
PaCO2 greater than 45 mm Hg and pH less than 7.35
Patient Assessment: Respiratory System
Arterial Blood Gases: Respiratory alkalosis- What is it?
PaCO2 less than 35 mm Hg and pH greater than 7.45
Patient Assessment: Respiratory System
Arterial Blood Gases: Metabolic acidosis- What is it?
HCO3 less than 22 mEq/L and pH less than 7.35
Patient Assessment: Respiratory System
Arterial Blood Gases: Metabolic alkalosis- What is it?
HCO3 greater than 26 mEq/L and pH greater than 7.45
Patient Assessment: Respiratory System
Arterial Blood Gases:
What is the normal PaO2 level? What is a normal SaO2?
The normal PaO2 is 80 to 100 mm Hg at sea level
The normal SaO2 ranges between 93% and 97%.
Patient Assessment: Respiratory System
Arterial Blood Gases:
What is normal PaCO2, HCO3 and pH?
pH: 7.35 to 7.45
PaCO2: 35 to 45 mm Hg
HCO3: 22 to 26 mEq/L
Patient Assessment: Respiratory System
ABG Interpretation
Steps of evaluation include:
Determine pH-acidosis or alkalosis
CO2 abnormalities
HCO3 abnormalities
Determine compensation
Patient Assessment: Respiratory System
Compensation #1:
What kind of response to metabolic-based pH imbalances?
Respiratory response metabolic-based pH imbalances
Patient Assessment: Respiratory System
Compensation #1:
Respiratory response metabolic-based pH imbalances: Metabolic acidosis
Increase respiratory rate and depth
Patient Assessment: Respiratory System
Compensation #1:
Respiratory response metabolic-based pH imbalances: Metabolic alkalosis
Decrease respiratory rate and depth
Patient Assessment: Respiratory System
Compensation #1:
What is the response to respiratory-based pH imbalances?
Renal system response to respiratory-based pH imbalances
Patient Assessment: Respiratory System
Compensation #1:
Renal system response to respiratory-based pH imbalances: Respiratory acidosis
Increase hydrogen secretion and bicarbonate reabsorption
Patient Assessment: Respiratory System
Compensation #1:
Renal system response to respiratory-based pH imbalances: Respiratory alkalosis?
Decrease hydrogen secretion and bicarbonate reabsorption
Respiratory Diagnostic Studies
What is included?
Chest radiograph (CXR)
Ventilation–perfusion scan (VQ scan)
Pulmonary angiography
Bronchoscopy
Thoracentesis
Sputum culture
Pulmonary function tests
Patient Management: Respiratory System
Bronchial Hygiene Therapy (BHT): What is the goal of it?
Goal to improve ventilation and diffusion
Patient Management: Respiratory System
Bronchial Hygiene Therapy (BHT): Goal to improve ventilation and diffusion -How?
Mobilize and remove secretions.
Improve gas exchange.
Patient Management: Respiratory System
Bronchial Hygiene Therapy (BHT): Who is it used on?
Hospitalized patients at risk for pulmonary dysfunction
Pneumonia, atelectasis, inability to cough and deep breath, COPD, cystic fibrosis, pulmonary fibrosis, quadriplegia, etc.
Patient Management: Respiratory System
Bronchial Hygiene Therapy (BHT):
What are the positions?
A. Face lying
B. Lying on the left side
C. Back lying
D. Sitting upright or semireclining
D. Lying on the right side
Patient Management: Respiratory System
Bronchial Hygiene Therapy (BHT):
Positions: Face lying- What is the position and what is the purpose?
Hips elevated 16-18 inches on pillows, making 30-45 degree angle
Purpose: to drain the posterior lower lobes
Patient Management: Respiratory System
Bronchial Hygiene Therapy (BHT):
Positions: Lying on the left side- What is the position and what is the purpose?
Hips elevated 16-18 inches on pillows
Purpose: to drain the right lateral lower lung segments
Patient Management: Respiratory System
Bronchial Hygiene Therapy (BHT):
Positions: Back Lying- What is the position and what is the purpose?
Hips elevated 16-18 inches on pillows
Purpose: to drain the anterior lower lung segments
Patient Management: Respiratory System
Bronchial Hygiene Therapy (BHT):
Positions: Sitting upright for semireclining- What is the position and what is the purpose?
Purpose: to drain the upper lung field and allow more forceful coughing
Patient Management: Respiratory System
Bronchial Hygiene Therapy (BHT):
Positions: Lying on the right side- What is the position and what is the purpose?
Hips elevated on pillows forming a 30-45 degree angle.
Purpose: to drain the left lower lobes
Patient Management: Respiratory System
Treatment of Bronchospasm:
What is bronchospasm present in?
Present in asthma and COPD
Patient Management: Respiratory System
Treatment of Bronchospasm:
What is pharmacological therapy aimed at?
Pharmacologic therapy aimed at reducing inflammation, treating acute symptoms, and maintaining short- and long-term therapy
Patient Management: Respiratory System
Treatment of Bronchospasm:
Pharmacologic therapy aimed at reducing inflammation, treating acute symptoms, and maintaining short- and long-term therapy
What is included?
Anticholinergics
Methylxanthines
anti inflammatories (corticosteroids, leukotriene receptor antagonists)
abx
Patient Management: Respiratory System
Treatment of Bronchospasm:
Pharmacologic therapy aimed at reducing inflammation, treating acute symptoms, and maintaining short- and long-term therapy
How is the treatment delivered?
Delivery by propellant inhalers using MDI and dry powder inhalers (DPIs)
Patient Management: Respiratory System
Bronchodilator: What are the three categories of this?
B2-adrenergic agonists (albuterol)
Anticholinergic (ipatropium)
Methylxanthines (theophylline)
Patient Management: Respiratory System
Bronchodilator: B2-adrenergic agonists (albuterol)
What does this med do?
Stimulation of receptors in lung bronchial smooth muscle and decrease release of mediators from mast cells and basophils
Patient Management: Respiratory System
Bronchodilator: B2-adrenergic agonists (albuterol)
What is an example?
Salmeterol first long-acting (12-hours)
Patient Management: Respiratory System
Bronchodilator: Anticholinergic (ipatropium)
What does it do?
Reduces intrinsic vagal tone to the airways
Patient Management: Respiratory System
Bronchodilator: Methylxanthines (theophylline)
What does it do?
Anti-inflammatory activity (third- or fourth-line treatment)
Patient Management: Respiratory System
Chest Tubes: What do they do?
Remove air, fluid, or blood from the pleural space
Restore negative pressure
Reexpand collapsed lung
Prevent reflux of drainage back into the chest
Patient Management: Respiratory System
Assessment and Management—Chest Tubes
What should you maintain?
Maintain patency and function of chest tube system.
Patient Management: Respiratory System
Assessment and Management—Chest Tubes
How do you prevent kinks?
Coil tubing loosely on bed to prevent kinks in dependent loops.
Patient Management: Respiratory System
Assessment and Management—Chest Tubes
What should never be done with a chest tube?
Never raise above the chest.
Patient Management: Respiratory System
Assessment and Management—Chest Tubes
What should be checked frequently?
Check drainage, suction, and water seal levels frequently.
Patient Management: Respiratory System
Assessment and Management—Chest Tubes
What should you assess for?
Assess for air leaks.
Patient Management: Respiratory System
Assessment and Management—Chest Tubes
How should you secure connections?
Secure connections with tape.
Patient Management: Respiratory System
Assessment and Management—Chest Tubes
How should you position patient?
Position semi-Fowler’s; turn every 2 hours to enhance air and fluid evacuation.
Patient Management: Respiratory System
Assessment and Management—Chest Tubes
What kind of bubbling is normal and abnormal?
You will see bubbling: it is pulling out air. But if bubbling is constant- that is bad because air is leaking from somewhere.
Patient Management: Respiratory System
Chest tubes: Complications
Clamping of chest tubes is recommended in only two situations:
- To locate the source of an air leak if bubbling occurs in the water seal chamber (clamping is only momentary)
- To replace the chest tube drainage unit (clamping is only momentary)
Patient Management: Respiratory System
Chest tubes: Complications
If chest tube is clamped, how long?
Momentarily
Patient Management: Respiratory System
Chest tubes: Complications
If the tube must be clamped, what is used and why?
If the tube must be clamped, padded hemostats are used to avoid lacerating the vinyl chest tube.
Patient Management: Respiratory System
Ventilatory Support: Why is it used?
Unable to maintain a patent airway
Inadequate gas exchange
Respiratory failure—the inability to maintain adequate respiration
Patient Management: Respiratory System
Chest tubes: Complications
What must be done is patient is being transported?
Continuous monitoring while transporting the patient
Patient Management: Respiratory System
Ventilatory Support: How is it measured?
Measured by arterial blood pH, PaCO2, and PaO2
Patient Management: Respiratory System
Ventilatory Support: Hypoxemic respiratory failure
Hypoxemic respiratory failure
PaO2 < 60
Patient Management: Respiratory System
Ventilatory Support: Hypoxemic hypercapnic failure
PaO2 < 60 and PaCO2 > 55
Patient Management: Respiratory System
Mechanical Ventilation—Positive-Pressure
What are the types?
Volume ventilators
Pressure ventilator
High-frequency ventilator
Patient Management: Respiratory System
Mechanical Ventilation—Positive-Pressure
Volume ventilators:
Preset volume delivered with each breath
Patient Management: Respiratory System
Mechanical Ventilation—Positive-Pressure
Volume ventilators: How is pressure?
Preset pressure is sustained throughout inspiration.
Patient Management: Respiratory System
Mechanical Ventilation—Positive-Pressure
Volume ventilators: How is rate, volume and inspiratory time?
Rate and inspiratory time are preset; volume varies.
Patient Management: Respiratory System
Mechanical Ventilation—Positive-Pressure
High-frequency ventilator:
Small tidal volumes (1-3mL/kg) at frequencies > 100 breaths/minute
Patient Management: Respiratory System
Ventilator Modes—Volume Modes
What are the two types?
Assist-control mode
Synchronized intermittent mandatory ventilation
Patient Management: Respiratory System
Ventilator Modes—Volume Modes
Assist-control mode: How is rate and volume?
Rate and volume preset
Patient Management: Respiratory System
Ventilator Modes—Volume Modes
Assist-control mode: How are spontaneous breaths?
Spontaneous breaths: full volume is delivered.
Patient Management: Respiratory System
Ventilator Modes—Volume Modes
Synchronized intermittent mandatory ventilation: How is rate and volume?
Rate and volume are preset.
Patient Management: Respiratory System
Ventilator Modes—Volume Modes
Synchronized intermittent mandatory ventilation: How are Spontaneous breaths?
Volume is determined by the patient’s effort.
Patient Management: Respiratory System
Ventilator Modes—Pressure Modes
Pressure support ventilation (PSV) mode
Pressure-controlled ventilation (PCV) mode
Patient Management: Respiratory System
Ventilator Modes—Pressure Modes
Pressure support ventilation (PSV) mode: What does it assist with?
Assists spontaneous breathing
Patient Management: Respiratory System
Ventilator Modes—Pressure Modes
Pressure support ventilation (PSV) mode: What does it deliver?
Delivers preset pressure throughout the inspiratory phase
Patient Management: Respiratory System
Ventilator Modes—Pressure Modes
Pressure support ventilation (PSV) mode: What does it decrease? What is it used for?
Decreases work of breathing, used for weaning
Patient Management: Respiratory System
Ventilator Modes—Pressure Modes
Pressure-controlled ventilation (PCV) mode: What is it used for?
Used to control plateau pressures when compliance is decreased (ARDS)
Patient Management: Respiratory System
Ventilator Modes—Pressure Modes
Pressure-controlled ventilation (PCV) mode: What is preset?
Preset pressure, rate, I:E ratio
Patient Management: Respiratory System
Ventilator Modes—Pressure Modes
Pressure-controlled ventilation (PCV) mode: What is usually indicated for this?
Sedation or NMB is usually indicated.
Patient Management: Respiratory System
Tracheostomy: What are indications for it?
Long-term mechanical ventilation
Frequent suctioning
Protecting the airway
Bypass an airway obstruction
Reduce WOB
Patient Management: Respiratory System
Tracheostomy: Where is it preformed?
Performed in the operating room or bedside (percutaneous)
Patient Management: Respiratory System
Tracheal Suctioning
Suction as indicated by assessment: like what?
Visible secretions
Coughing
Rhonchi
High PIP on ventilator
Ventilator alarm
Patient Management: Respiratory System
Tracheal Suctioning
What are the types of suctioning?
Conventional versus closed suction
Patient Management: Respiratory System
Tracheal Suctioning: What is the procedure to suction?
Hyperoxygenate throughout procedure
Avoid normal saline instillation
Patient Management: Respiratory System
Tracheostomy Complications:
Ventilator-Associated Pneumonia (VAP)
Immobility
DVT/PE
Patient Management: Respiratory System
Tracheostomy: Pharmacologic Therapy
Antibiotics, if indicated
Bronchodilators and mucolytics
IV corticosteroids
Nitric oxide
Sedation
Neuromuscular blocking agents
Patient Management: Respiratory System
Sedation Assessment:
Why is sedation meds given?
Sedation medication is given to reduce anxiety; dose adjusted based on tools or scales
Patient Management: Respiratory System
Sedation Assessment:
Sedation medication is given to reduce anxiety; dose adjusted based on tools or scales like?
Richmond Agitation-Sedation Scale (RASS)
Ramsey Sedation Scale (Ramsey)
Sedation-Agitation Scale (SAS)
Patient Management: Respiratory System
Sedation Assessment:
What is important about using scales for assessment?
Inter-observer agreement in assessment using various scales is important
Patient Management: Respiratory System
Sedation Assessment:
What tool is considered the gold standard?
No tool is considered the gold standard
Patient Management: Respiratory System
Sedation Assessment:
What is the goal?
Goal is calm, easily arousable patient
Patient Management: Respiratory System
Neuromuscular Blockade for mechanically ventilated patients
What is it used for?
used clinically to facilitate endotracheal intubation and to provide skeletal muscle relaxation during surgery.
Also used in conditions of high metabolic rate, i.e. ARDS.
Patient Management: Respiratory System
Neuromuscular Blockade for mechanically ventilated patients
How does it work?
Compete with acetylcholine -> interfere with the transmission of nerve impulses -> resulting in skeletal muscle relaxation.
Patient Management: Respiratory System
Neuromuscular Blockade for mechanically ventilated patients
How are they classified?
Based on their mechanism of action, neuromuscular blocking agents are classified as either depolarizing or non-depolarizing.
Patient Management: Respiratory System
Neuromuscular Blockade for mechanically ventilated patients
Assessment and Management
Endotracheal tube care
Tube cuff pressure monitoring
Discharge planning and patient teaching
Nutritional support
Eye care
Oral care
Psychological care
Facilitating communication
Caring for the family
