Respiratory (Exam #3)

Adventitious Lung Sounds

1. Crackles: Soft, high-pitched, discontinuous popping sounds that occur during inspiration. "Coarse" where fluid is. "Fine" heard in the bases. - Best heard posteriorly! 2. Wheezes: continuous high-pitched musical sound heard mainly on expiration (asthma) or inspiration (bronchitis). -From airway constriction. 3. Sonorous wheezes (rhonchi): Deep, low-pitched rumbling sounds heard primarily during expiration; loud, sometimes heard without stethoscope - Due to secretions or tumor 4. Pleural rub: Harsh, crackling sound, like two pieces of leather being rubbed together - Difference between pleural rub and pericardial rub: have them hold their breath if it goes away it is pleural

Diffusion

Traveling from an area of higher concentration to lower. Example: O2 crosses semi-permeable membrane into blood from alveolar sacs

Normal V:Q Ratio

1:1 equal and adequate ventilation and perfusion

Pleura

2 kinds 1. Parietal (lines the chest cavity) 2. Visceral (covers the lung itself) Note: Too much fluid = _______ effusion. Too little fluid = a stitch!

HCO3 (Bicarbonate)

22-26 mEq/L low = acidic high = alkaline

Diaphragmatic Excursion

A form of Thoracic Palpation/Percussion Assess the position and motion of the diaphragm. The nurse instructs the patient to take a deep breath and hold it while the maximal descent of the diaphragm is percussed.

Respiratory Excursion

A form of Thoracic Palpation/Percussion Estimation of thoracic expansion and movement. Assesses the patient for range and symmetry of excursion.

PaCO2 (Carbon Dioxide)

35-45 mmHg low = alkaline high = acidic

pH Normal Value

7.35-7.45 low = acidic high = alkaline

PaO2 (arterial pressure of OXYGEN)

80 - 100 mmHg

What is important to know about CONTINUOUS Pulse Oxymetry Monitoring?

A PHYSICIAN'S ORDER IS REQUIRED!

Tactile Fremitus

A form of Thoracic Palpation/Percussion A tremulous vibration of the chest wall during inspiration that is palpable on physical examination. Put hand of their chest and say 99 over and over again. Percussion can be used to assess location and pathology in underlying tissue and structures Dull sound over consolidation or fluid, determines location of liver.

How is cardiogenic shock related to ARDS??

ARDS leads to Right sided heart failure because blood flow to lungs (filled with inflammation) becomes backed up. Left side will also eventually fail. ARDS will LEAD to cardiogenic shock! (note: this will be on tests AND FINAL!)

Silent Unit

Absence of both ventilation and perfusion. Causes: pneumothorax, severe ARDS

Arterial Blood Gases

Aid in assessing the ability of the lungs to provide adequate oxygen and remove carbon dioxide, which reflects ventilation, and the ability of the kidneys to reabsorb or excrete bicarbonate ions to maintain normal body pH, which reflects metabolic states. ● Allen's test: to determine perfusion through ulnar artery Includes: ○ pH: 7.35-7.45 (down = acidic, up= alkaline) ○ PaCO2: 35-45 mmHg ○ HCO3: 22-26 mEq/L ○ PaO2: 80 - 100 mmHg Note: "ROME" (Resp Opposite, Met Equal)

Functional Sleep Apnea

Apneas occur repeatedly during sleep, secondary to transient upper airway blockage, snoring. Is neurological! Accounts for <5% of apneas.

Pulmonary Function Test

Assess respiratory function, extent of dysfunction and response to therapy. Used with Asthma and COPD, prior to surgery.

Pulmonary Embolism

Assessment and Diagnostics: ● D-dimer blood test - shows % of risk for developing DVT, Is an indirect measurement ● CAT scan - most common. detects clots in the lung circulation. easy, quick and cost effective ● V/Q scan- Compares the movement of air in and out of the lungs with the movement of blood through the lung circulation. Time consuming test. Requires inhalation of a substance under fluoroscopy to determine if there are any areas of the lung that don't get air movement, then injection of a substance while under fluoroscopy to determine of there are any areas of the lung circulation that don't get blood moving through them. ○ Normal is 1:1, high vq = impaired blood; low vq = impaired air movement

Pulmonary Embolism

At home prevention ● Drink water ● Avoid sitting for long periods of time, or sitting with legs crossed ● Long road trips especially postpartum: Get out of car periodically to walk about ● In plane - stay hydrated, lower legs exercises Who is at risk? ● Travel 4 or more hours in the past month either in car or airplane flight ● Sitting for long periods ● Surgery past 3 months ● Smoking ● Malignancy ● Central venous instrumentation past 3 months - ie picc placement

Cultures

Best gotten in the early AM, after respiratory treatments. The secretions will have mobilized!

What is the #1 cause of loss of lung compliance?

COPD

Acute Respiratory Distress Syndrome (ARDS)

Caused by: ● Aspiration of stomach contents: Pneumonitis ○ Low pH burns the lungs and cause inflammatory process ● Chemical inhalation ● Severe Pneumonia ● Sepsis, septic bacteremia ● Pregnancy ● Fat embolisms ● Major surgery ● Drug overdoses ● DIC- disseminated intravascular coagulopathy ● Shock ● LOW V/Q ratio!! → ventilation is down ...eventually ZERO and perfusion is normal so unoxygenated blood is shunted to the right side of the heart.... The big problem is that this is always bilateral! -Due to fluid immobilization. No air to keep alveoli open - they collapse

Pulse Oximetry

Checks % of Hgb with Oxygen attached. ● Easiest way for the nurse to monitor the patient's oxygenation status. NO order needed! ● Considered the 6th vital sign ○ Should be > 92% ● When in doubt, administer O2 therapy and then obtain order ● NEED PHYSICIAN'S ORDER FOR CONTINUOUS MONITORING!! ● Must take into account the patient's hematologic studies (hemoglobin and hematocrit) in order to ascertain validity of reading. ● Problems with assessment: -Movement: hold them still -. Perfusion: warm up the hand, put in dependant position -. Nail polish: often can't read thru it

Pulmonary Embolism

Clinical Manifestations: ● Most frequent symptom - dyspnea (shortness of air) ● Most frequent sign - tachypnea (breathing fast) ● Tachycardia: heart increases rate to cont to generate an appropriate blood pressure, clot may be large enough to prevent the forward flow of blood through the pulmonary bed ● Anxiety, apprehension: associated with hypoxia, more severe as hypoxia worsens ● Chest pain can be non descript or severe Note: Depends on size and area involved ○ if small: chest pain, cough, mild apprehension - may be easily missed ○ If large: symptoms may be sudden such as severe dyspnea, alarm, seizures with rapid progression to death, ○ If pt presents with seizures - may be treated for seizure disorder ○ If presents with chest pain - may be treated evaluated for MI

High V:Q Ratio

DEAD SPACE. Ventilation exceeds perfusion. Ventilation adequate, perfusion compromised. ■ Causes: PE, pulmonary infarction, cardiogenic shock. ■ The alveoli do not have an adequate blood supply for gas exchange to occur ■ Deoxygenated blood goes back to the left side of the heart → not okay!

Metabolic Acidosis

Decrease in pH, Decrease in HCO3 ○ S&S: N/V/D, restlessness, Dysrhythmias, Slow respirations, Muscle twitches, Headache, hallucinations, encephalophy ● Kussmaul's Respirations (DKA) Causes: Diarrhea (electrolyte imbalance), aspirin OD, renal failure, DKA, shock TX: Bicarb IV, Dialysis

Respiratory Acidosis

Decrease in pH, Increase in CO2 ○ D/t Rapid shallow resp./Dyspnea/Apnea ○ Retain CO2 ○ S &S: Disorientation ○ Causes: inadequate ventilation, airway obstruction, pulmonary edema, chest trauma, drug OD ○ TX: Improve ventilation, bronchodilators, suctioning, adequate hydration

Pulmonary Embolism

Discharge instructions: ○ Educate pt on medication ○ Monitor pt/inr ○ Teach injection if going home on lovenox ○ Cont coumadin until dr says you can stop ○ Avoid increasing foods high in Vit k - such as green leafy veg ■ Antibiotics kill off gut bacteria that synthesize vitamin K ○ Report blood in urine and increased bruising

Auscultating Lung Sounds

Done on every patient every time! Assessing airflow through bronchial tree and lungs. ● Normal sounds: top to bottom (Tracheal, Bronchial, Bronchovesicular, Vesicular) ● Abnormal/Adventitious: (Crackles, Wheezes, Rhonchi, Pleural Rub

External Respiration

Exchange of gases in lungs ■ Air w/ oxygen comes thru mouth and nose into lungs and alveolar sacs. -Oxygen-poor and CO2-rich blood from the right side of the heart and pulmonary circulation surrounds alveolar sacs. There is a difference in the concentrations between the blood and the sacs. -Diffusion → things cross semipermeable membrane from area of high to low concentration. CO2 in lungs is going to diffuse across the alveolar membrane into the alveolar sacs. O2 is going to diffuse at the same time across the alveolar membrane into the blood because its oxygen poor. Then blood heads to the left side of the heart and throughout the body.

Internal Respiration

Exchange of gases in the tissue. ■ When oxygen-air gets to the capillary beds. -One side oxygen-rich, one side oxygen-poor. Oxygen will move into tissue and CO2 will move into the tissue.

Function of the Respiratory System

Exchange of oxygen and CO2 by diffusion in alveolar sacs. Includes Internal and External Respiration.

Decongestants

For nasal obstruction. Note: At the pharmacy need an ID, because it is used to make meth

Normal Lung Sounds

From top to bottom. ● Tracheal: Inspiratory and expiratory sounds are about equal. ○ Very loud and harsh. Relatively high. Over the trachea in the neck. ● Bronchial: Expiratory sounds last longer ○ Loud and relatively high pitched ● Broncho vesicular: Inspiratory and expiratory sounds are about equal. ○ Often in the 1st and 2nd interspaces anteriorly and between the scapulae ● Vesicular: Inspiratory sounds last longer, soft sound ○ Entire lung field except over the upper sternum and between the scapulae. Fluttery.

Perfusion/ventilation scan (V/Q scan)

Gives the ratio of ventilation to perfusion. Given for Pulmonary Embolisms!

Resistance and lung compliance

Governs ease of ventilation. ○ Resistance increases, so does effort of breathing -Resistance increased by asthma, pneumonia, fluid in lungs... ○ Lung Compliance goes down, effort of breathing goes up Air hunger signs: use of accessory muscles, Nasal flaring.

Metabolic Alkalosis

High pH, High HCO3 ○ Disorientation, Muscle twitches, tetany ○ Tingling in fingers & toes ○ Change in LOC, encephalopathy→ delirium Causes: loss of gastric juices (NG tube suctioning, vomiting), overuse of antacids TX: restore and dilute fluid volume with NaCl

COPD and Breath Control

If person has been exposed to chronic high levels of CO2 as in COPD, the respiratory drive changes to the partial pressure of O2 in the blood. These people will have an increased sensitivity to supplemental oxygen. ○ Give them too much O2 their body will shut down Resp. Effort ○ Be careful with people in hypobaric chamber with COPD or chronic bronchitis because CO2 has been chronically high O2 is their drive to breathe ○ Watch their respirations, if they get low turn O2 down!

Respiratory Alkalosis

Increased pH, decreased PaCO2 ○ d/t Rapid breathing ○ S&S: Confusion, seizures ○ Causes: hyperventilation (excessive blowing off of CO2),, anxiety, high altitudes ○ TX: attempt to calm pt, breath into paper bag- Easiest to fix!

Respiratory Physical Assessment

Includes: ● Nose: nares are patent, septum midline, no erosion, drainage? color → clear = viral, color: bacterial ● Sinuses: pressure, tap tap tap with = pain, pressure in ears, earaches, post nasal drip ● Oropharynx: pink, moist, no pockets of infection, uvula midline, tonsils normal size, finger sweep for oral cancer especially hx of smoking/tobacco use, lesions are typically painless ● Trachea: midline, any deviation could indicate mass or pneumothorax but be careful palpating ● Chest configuration: Normal ratio A/P: lateral is 2:1 a. Barrel chest: increased A / P diameter 1:1 due to chronic over inflation → COPD b. Funnel chest: depression in the lower portion of the sternum. May compress the heart. c. Pigeon chest: displacement of the sternum d. Kyphoscoliosis: sign of severe osteoporosis a. Careful when transferring → high risk for fractures

Bronchodilators

Includes: Albuterol, the rescue inhaler. It's for ACUTE ATTACKS! Affects Beta 2 receptors in Bronchiole tree.

Breathing Patterns

Includes: ● Eupnea: Normal ● Bradypnea: Slower ● Tachypnea: Rapid ● Hypoventilation: Shallow, irregular ● Hyperventilation: Increased rate and depth ● Apnea: Period of cessation ● Cheyne-Stokes: Regular cycle of rate and depth increase, decrease, then apnea ● Biot's respiration: Periods of normal breathing, then apnea ● Orthopnea: shortness of breath when lying flat ● Functional sleep apnea: apneas during sleep ● Obstructive sleep apnea (OSA): morbid obesity tissue block

Lung Volume and Capacity

Includes: ● Tidal volume: volume of air inhaled + exhaled each breath ● Inspiratory reserve volume: Max volume of air that can be inhaled normally ● Expiratory reserve volume: Max volume of air that can be exhaled forcibly normally ● Residual volume: Volume of air remaining in the lungs after a maximum exhalation ● Vital capacity: Max volume of air exhaled from the point of maximum inspiration ● Inspiratory capacity: Max volume of air inhaled normally ● Functional residual capacity: Volume of air remaining in the lungs normally ● Total lung capacity: Volume of air in the lungs after a maximum inspiration

Cough Suppressants

Includes: Codeine Suppresses a nagging cough, shuts down reflex in the brain (Medulla Oblangata)

Mucolytics

Includes: Guaifenesin/Mucinex Available without a prescription and is used to promote removal of secretions by breaking up thick mucus. Mobilizes secretions to expectorate! Note: drink lots of water!

Expectorants

Includes: Robitussin (Guaifenesin) Thins the secretions to be coughed up!

Antitussives

Includes: Tessalon pearls (Benzotanate) Given to stop coughing!

Hyperventilation

Increased rate and depth of breathing that results in decreased PaCO2 level. Inspiration and expiration nearly equal in duration. Associated with exertion, anxiety, and metabolic acidosis - body is trying to compensate! Note: Called Kussmaul's respiration if associated with diabetic ketoacidosis or renal origin

Acute Respiratory Distress Syndrome (ARDS)

Key characteristics: 1) refractory arterial hypoxemia → no gas exchange no matter how much O2 they are on 2) bilateral infiltrates/hx of toxic fumes, stomach contents, bloodborne infection, septic Put them on antibiotics, corticosteroids, lots of surfactant, Put them in medical Coma to reduce metabolic demands Maintain BP with alpha-adrenergic blockers that decrease vascular resistance once lungs fill up with fluid you then have symptoms of cardiogenic shock... It kills people, Rapid onset, Life threatening→ 60% mortality rate. Inflammatory process that results in pulmonary edema

Acute Respiratory Distress Syndrome (ARDS)

Key characteristics: 1. Unresponsive/refractory arterial hypoxemia (even with high FiO2) (no matter how much O2 you supplement PaO2 does not increase) 2. Diminished alveolar dilation 3. Tachypnea 4. Increased PaCO2 Bilateral infiltrates (both lungs affected) ■ Onset 12-48 hrs after insult ■ Severe dyspnea ■ Intercostal retractions ■ Crackles

Arterial Blood Gases

Levels are obtained through an arterial puncture at the radial, brachial, or femoral artery or through an indwelling arterial catheter.

Obstructive Sleep Apnea

Majority of people with sleep apnea have this kind; usually associated with morbid obesity. Tissue blocks the airway. Adipose tissue blocks nasal passageways and oropharynx. 95% of apneas.

Antibiotics

Many different kinds are used in Respiratory issues, so don't need to know any specifics. Just know use a wide array of these!

Eupnea

Normal breathing at 14-20 breaths/min

Pulmonary Embolism

Obstruction of a pulmonary artery or one of its branches by a thrombus ○ other types of emboli: air, fat, amniotic fluid, and septic (from bacterial invasion of the thrombus). ● Usually in the leg (DVT) but can also occur in arms and large deep veins such as iliac and femoral veins. Thrombus risks: ● Venous stasis (hence ambulating after surgery) ● Hypercoagulation ● Injury to intima of vein: Platelets continue to clump forming a clot ● Vasoconstriction of surrounding capillaries

Expiration

One of the 2 phases of Ventilation. Is a PASSIVE process! Diaphragm and intercostals relax and air moves out. Lungs spring back to normal shape. ■ Gas exchange occurs during the first third of ________ Note: This is why pursed lipped breathing works for COPD and SOA so well because it extends __________ (increases amount of time for gas exchange)

Inspiration

One of the 2 phases of Ventilation. Is an ACTIVE process! Takes muscle contraction to work. Diaphragm and intercostals contract causing thoracic cavity to expand causing a drop in pressure in thoracic cavity. Air moves in to equalize pressure.

The lab test used to monitor coumadin is?

PT/INR

Nose

Part of the Upper Respiratory Tract. Filters and warms the air. The body wants to breathe thru this! - If Anxious, breathing thru ______ can help! COPD and asthmatics breathing thru _______ can help prevent bronchospasm via cold air. Contains Cranial Nerve I (Olfactory)

Parasinal Sinusus

Part of the Upper Respiratory Tract. Includes: frontal, maxillary, ethmoidal, sphenoidal ○ Green mucus= paranasal infection ○ Infection indicated by pressure in forehead and earaches -Turbinate bones (conchae): increased surface area to warm and humidify air, trap dust and allergens

Pulmonary Embolism

Pathophysiology: ● Increased platelet clumping on valves in deep veins, Clot forms , Small piece of clot breaks off, Moves through right heart, Occludes pulmonary artery or its branches ● Alveolar dead space is increased...HIGH V/Q RATIO...although continuing to be ventilated, receives little or no blood flow

Apnea

Period of cessation of breathing; time duration varies. May occur briefly during other breathing disorders. Life-threatening if sustained.

Biot's Respiration

Periods of normal breathing (3-4 breaths) followed by a varying period of apnea (usually 10-60 s) Also called ataxic breathing; associated with complete irregularity Associated with respiratory depression resulting from drug overdose and brain injury, normally at the level of the medulla

Acute Respiratory Distress Syndrome (ARDS)

Physiology: 1. Inflammatory process in the lungs 2. Hypoventilation (lungs lose elasticity) 3. Obstructed blood flow through the lungs 4. Left ventricular failure (NOW heart is involved DUE to this disease process) Lower Respiratory Tract Anatomy ■ Bronchi and Bronchioles: alveoli are surrounded by the pulmonary capillaries. This is where gas exchange takes place. The damage occurs here! Pathophysiology: ■ Inflammatory trigger such as aspirating chemicals- causes inflammation ■ Initiates release of cellular and chemical mediators and fluid is drawn to the area of injury ■ Alveolar capillary membrane injured - gas exchange is impaired ■ Alveolar collapse occurs after they fill with fluid and collapse. Fluid builds up in the interstitial space ■ Lung compliance decreases. Lungs become "stiff" - because surfactant is destroyed - surfactant allows the alveoli to be elastic ■ Severe hypoxemia occurs and this process progresses quickly to respiratory failure ■ These pts are critically ill - in the ICU - on ventilators

The nurse knows Lovenox can affect which lab value?

Platelet count

Pulse Oximetry

Probe or sensor is attached to the fingertip, forehead, earlobe, or bridge of the nose to measure the oxygen saturation of hemoglobin in the blood.

Antihistamines

Provides a "drying out" effect. Anticholinergic side effects are WANTED in this case! Administered for sneezing, pruritus, and rhinorrhea.

Tachypnea

Rapid, shallow breathing >24 breaths/min Associated with pneumonia, pulmonary edema, metabolic acidosis, septicemia, severe pain, or rib fracture

Cheyne-Stokes

Regular cycle where the rate and depth of breathing increase, then decrease until apnea (usually about 20 s) occurs. Duration of apnea may vary and progressively lengthen; therefore, it is timed and reported. Associated with heart failure and damage to the respiratory center (drug induced, tumor, trauma) Near end-of-life!

Respiratory Rate

Respiration consists of a single inspiration and a single expiration. Normal breathing at 14-20 breaths/min. Factors that affect ______________: ● Age: respirations go up as compliance decreases (older people breathe more often) ● Sex: Males have larger lungs and breathe fewer times ● Position: any position that compresses lungs will increase rate (best is tripod position- backwards in chair, elbows up) ● Exercise: respirations go up ● Temperature: respirations go up ● Drugs: respirations go up or down (Narcotics and scheduled will decrease) ● Emotions: respirations go up ● Pain/ physical conditions : respirations go up or down

ROME

Respiratory = Opposite Metabolic = Equal Note: In relation to the normal value of pH!

Control of Breathing

Respiratory center in the medulla oblongata at base of brain stem! ○ Triggered by the partial pressures of CO2 in the blood: increased CO2 levels stimulate an increase in rate and depth of respirations → receptors in carotid artery and aortic arch ● Usually controlled by the autonomic nervous system but can be overridden by choice Note: If person has been exposed to chronic high levels of CO2 as in COPD, the respiratory drive changes to the partial pressure of O2 in the blood.

Pulmonary Embolism

Risk Factors: ● Venous Stasis (need to ambulate!) ● Hypercoagulability due to release of tissue thromboplastin after injury/surgery (most common knee and hip) ● TOO MUCH ACTIVITY before therapeutic INR is reached!! Check INR at beginning of shift! ● Venous Endothelial Disease ○ PICC line can cause blood clot ● Certain Disease States (heart disease, trauma, postoperative, DM, COPD, Cancers) ● Other Predisposing Conditions: advanced age, obesity, pregnancy, Estrogen oral contraceptive use, constrictive clothing, long air travel

Low V:Q Ratio

SHUNT → perfusion exceeds ventilation. Ventilation is compromised and perfusion is adequate. ■ Blood bypasses the alveoli without gas exchange occurring, leading to hypoxia ■ Causes: obstruction of the distal airways, pneumonia, atelectasis, tumors, mucus plug, ARDS. Causes shunting ■ Post -op Atelectasis may lead to pneumonia, prevent it with incentive spirometry, deep breath and cough

Hypoventilation

Shallow, irregular breathing

Orthopnea

Shortness of breath that occurs when lying flat, many don't sleep in beds, just a recliner

Bradypnea

Slower than normal rate (<10 breaths/min), with normal depth and regular rhythm Associated with increased intracranial pressure, brain injury, and drug overdose

Acute Respiratory Distress Syndrome (ARDS)

The effects of hypoxia on the major organ systems: Cardiovascular ● Arrhythmias ● Ischemia ● Myocardial depression - all leads to low blood pressure and worsens oxygen delivery to the tissues ● Will cause Cardiogenic Shock because the heart is not getting oxygenated blood (this is why cardiac is combined with respiratory!) Neuro ● Increased confusion leading to coma ● Cerebral perfusion affected - brain cells die... no anaerobic metabolism Renal ● If the MAP is less than 80 - glomerular filtration decreases - causing acute renal failure/acute kidney disease ● Kidneys unable to function - urine output decreases ● Not enough blood to filter. Accumulates BUN and Creatine

Perfusion

The filling of the pulmonary capillaries with unoxygenated blood from the right side of the heart.

Ventilation

The flow of gas in and out of the lungs.

Vital Capacity

The maximum volume of air exhaled from the point of maximum inspiration

Inspiratory Capacity

The maximum volume of air inhaled after normal expiration.

Expiratory Reserve Volume

The maximum volume of air that can be exhaled forcibly after a normal exhalation. END OF TIDAL VOLUME- HOW MUCH IS LEFT. Is decreased with restrictive conditions, such as obesity, ascites, pregnancy.

Inspiratory Reserve Volume

The maximum volume of air that can be inhaled after a normal inhalation

Residual Volume

The volume of air remaining in the lungs after a maximum exhalation HIGH with COPD = problem getting air out not in! Due to loss of compliance! Can expand but will not contract.

Total Lung Capacity

The volume of air in the lungs after a maximum inspiration.

Tidal Volume

The volume of air inhaled and exhaled with each breath

Functional Residual Capacity

Volume of air remaining in the lungs after a normal expiration.

Corticosteroids

inhaled for maintenance only. NOT for "rescue" (aka acute attacks) Note: Have them rinse out their mouth to prevent thrush

Pulmonary Embolism

● Anticoagulation - DO ASAP! ○ Lovenox: most commonly used anticoagulant for _______; Dose is 1mg/kg BID ○ Coumadin - will be started at same time as Lovenox - give daily dose to get INR 2 - 3, then can stop the Lovenox and cont to monitor PT/INR to maintain anticoagulation, must cont for 3-6 months if first event - if second event then will be lifelong ○ Heparin - IV infusion, must monitor the PTT, Heparin is given based on weight and hospitals' heparin protocols that are followed. Heparin may be used if patient has large one ● Thrombolytics ○ Only given in severe cases - dissolve the clot... huge risk for systemic bleeding (GI, kidneys, gums) ○ Contraindications to thrombolytic therapy include a cerebrovascular accident (CVA) within the past 2 months, other active intracranial processes, active bleeding, surgery within 10 days of the thrombotic event, recent labor and delivery, trauma, or severe hypertension ● Surgery ○ Embolectomy (rare) - using a wire cage to snare the clot and remove it ○ Open heart surgery - to open pulmonary artery and remove clot ○ Greenfield filter - may be place for those with _____ who have DVT and may not be able to tolerate long term anticoagulation (allergies, or non-compliance, Hx of hemorrhagic stroke)- Works like an umbrella in inferior vena cava

Lower Respiratory Tract

● Bronchi and Bronchioles: branch off from trachea. Right is straighter and bigger than left (If someone aspirates, it most often ends up in right lung) ● Alveoli: lung is made up of about 300 million alveoli arranged in clusters of 15 to 20. Surface area of 2 tennis courts. They secrete surfactant to help keep open. Note: preemies have problem because last thing to develop are cells that develop surfactant.

Endoscopic Procedures

● Bronchoscopy: direct inspection and examination of the larynx, trachea, and bronchi through either a flexible fiberoptic bronchoscope or a rigid bronchoscope ○ Look for lesions and take biopsies ● Thoracoscopy: pleural cavity is examined with an endoscope and fluid and tissues ● Thoracentesis: aspiration of fluid and air from the pleural space ○ Also: biopsy; and instillation of medication into the pleural space. ○ Used regularly for pt's with pleurisy ○ Pt position: Sitting on the edge of the bed with the feet supported and arms on a padded over-the-bed table, inform them to stay still ● Biopsy: Lung biopsy: obtain tissue for examination when other diagnostic testing indicates potential interstitial lung disease, such as cancer, infection, or sarcoidosis. ○ Pleural biopsy: when there is pleural exudate of undetermined origin or when there is a need to culture or stain the tissue to identify tuberculosis or fungi

Imaging Studies

● Chest x-ray ● Computer tomography (CT): further examination of something seen on CXR ● Magnetic Resonance Imaging (MRI): ● Fluoroscopic studies: checks blood flow ● Pulmonary Angiography: checks blood flow

Pulmonary Embolism

● Emergency: ○ If present severe distress will give O2, may need to be intubated ○ Insert a large bore IV - to infuse fluids ○ CT scan of chest ○ ABGs: evaluation for hypoxemia ○ May need pressors (dobutamine, dopamine, or norepinephrine) to support BP if blood flow is cut off through the lungs ○ Pain meds: Small doses of IV morphine or sedatives are administered to relieve patient anxiety, to alleviate chest discomfort, to improve tolerance of the endotracheal tube, and to ease adaptation to the mechanical ventilator, if necessary

Acute Respiratory Distress Syndrome (ARDS)

● Is not cardiogenic in nature! (NOT caused BY heart failure- but CAN CAUSE cardiogenic shock!) ● Initially insult to lungs→ inflammatory process in the lungs from: smoke, near-drowning, toxins, severe pneumonia, sepsis, urosepsis, bacteremia, aspiration of stomach contents. ● Damage is to the lung itself but will soon LEAD to cardiogenic shock ● Alveolar sacs fill with fluid → Big problem with VENTILATION (not profusion)! NOTE: MOST IMPORTANT THING TO DO: get them INTUBATED!

Lower Respiratory Tract

● Lungs: paired elastic structures enclosed in the thoracic cage, an airtight chamber with distensible walls. -Thoracic cavity: Airtight - if air is getting in another way called pneumothorax = big problem ● Pleura: Parietal (lines the chest cavity) and Visceral (covers the lung) ● Pleural cavity: space between the pleural linings with a small amount of lubricating fluid to reduce friction.. Infection is this space called pleurisy.. ● Lobes: Each lung is divided up into lobes. 2 on left and 3 on right

Upper Respiratory Tract

● Nose: Filters and warms the air ● Paranasal sinuses: frontal, maxillary, ethmoidal, sphenoidal. Can get infected. -Turbinate bones (conchae): increased surface area to warm and humidify air, trap dust and allergens ● Pharynx, tonsils and adenoids: → get edematous with URTI. Many people still have them now! ● Larynx: voice box ● Epiglottis: guards entrance to larynx (Prevents aspiration) ● Trachea: windpipe composed of smooth muscle with C-shaped rings of cartilage at regular interval (If you palpate do it gently! smooth muscle)

Pulmonary Embolism

● Use SCDs, compression stockings such as TEDS, leg exercises = avoid venous stasis, no crossing legs, or constrictive clothing ● Hydration, avoid bed rest, up in chair for meals, early/frequent ambulation, prophylactic anticoagulation with lovenox ● Medication ○ Monitor platelet count for Lovenox ○ Monitor PT/INR for coumadin ○ Monitor ptt for heparin drip ○ All - monitor for bleeding such as bruising, blood in urine, bloody sputum, place pressure over lab draws for at least 5 minutes, pressure dressing won't do it - you need to apply direct pressure to make sure pressure is over puncture site ● Pain ○ Morphine is usually best choice because it is quickly effective and dilates the pulmonary bed helping to improve gas exchange ● Airway ○ Semi-Fowler's position provides a more comfortable position for breathing. ● Breathing- Assess lung sounds, Resp rate, O2 sats, Titrate oxygen ● Circulation

Ventilation/Perfusion V/Q Ratio

● Ventilation is the flow of gas in and out of the lungs ● Perfusion is the filling of the pulmonary capillaries with unoxygenated blood from the right side of the heart Includes: ○ Normal V:Q ratio: 1:1 equal and adequate ventilation and perfusion ○ Low V:Q ratio: SHUNT → perfusion exceeds ventilation. ○ High V:Q ratio: DEAD SPACE → ventilation exceeds perfusion. ○ Silent unit: absence of both ventilation and perfusion.

Geriatric Respiration

● Vital capacity decreases (loss of chest wall mobility, which restricts the tidal flow of air, sometimes can't hear air in bases of lungs) ● Loss of strength in the respiratory muscles: intercostals and diaphragm is weakened so doesn't expand as much ● Loss of compliance of lungs: At approximately 50 years of age, the alveoli begin to lose elasticity. ● Decreased ability to move air in and out of the lungs: small breaths → diminished breath sounds in bases is expected ● Musculoskeletal changes: kyphosis ● Poor ventilation of the bases of the lungs