Final
What is the formula for calculating % predicted SVC?
% Predicted = measured value/predicted value x 100
OXYGEN STORAGE: The liquid system consists of:
--a reservoir --a vaporizer --pressure reducing valves --pressure release valves
What are the ranges for a/A Ratio?
.90 = normal (90%) < .3 = severe hypoxemia - Hypoxic Resp Failure
What are the sizes for Miller blades?
0 - 4 with sizes 2 and 3 fitting an average adult.
What is the conversion factor for E-cylinder?
0.28 L/psig (0.3)
Atrovent: Nubulizer Dosage
0.5 mg in 3 ml
Normal Saline = ______% NaCl
0.9%
Particles which are < ___ are almost unaffected by gravity.
1
Particles which are < _____ µ are generally inhaled and exhaled without depositing in the lungs.
1
PIPING DISTRIBUTION SYSTEMS: The system consists of:
1) Main lines 2) Risers 3) Branch (lateral) lines 4) Pressure Relief Valves 5) Shut off valves
Cylinder valves consists of:
1) brass body 2) threaded inlet connector 3) stem 4) outlet connection 5) pressure-relief valve
What are the contraindications to IPPB Therapy?
1. A history of Spontaneous Pneumothorax or an acute pneumothorax without a Chest Tube in place. 2. Penumomediastimun and Subcutaneous Emphysema 3. Tracheosophageal Fistula 4. Bullous Disease 5. Hemodynamic Instability 6. Pulmonary Hemorrhage 7. Active Tuberculosis 8. Uncooperative Patient 9. Recent esophageal surgery. 10. Recent facial, oral, or skull surgery. 11. Nausea 12. Air swallowing 13. Singulation (hiccups) 14. Increased intracranial pressure (ICP) > 15 mm Hg 15. Less Invasive Therapy is Available
POWER: What is required to make the ventilator run?
1. A/C power required 2. D/C (battery) power available 3. Pneumatic power (50 psig gas source) required 4. Internal compressor available 5. 50 psig air source required 6. 50 psig oxygen source required
What are the signs for Yellow Zone on Peak Flow Meter?
1. coughing 2. wheezing 3. sneezing 4. short of breath when I try to exercise
Xopenex: Nebulization Dosage
1.25mg (adults), .63mg (infants and peds)
Jet Nebulizer: Small Volume Nebulizer (SVN) generally produce aerosol particles that range in size from ___to ___ µ in diameter.
1.5 to 7
What is the difference between Causative Agent and Compensating Factor?
1.Causative agent will usually match the pH. 2.Compensating factor will usually opposite of the pH.
Critical Thinking: What questions do we ask ourselves about the patient?
1.Need more oxygen? (Delivery vs. demand). 2.Need to breathe more? (Ventilation). 3.Have normal pH or an acid base problem? 4.Have signs, symptoms, diagnosis, or medical history that apply to the ABG results? 5.Have to WORK to maintain these ABG results...is he OK or tiring out? 6.Have a chronic disease like COPD? (What's normal for this patient?)
Liquefaction of secretion using Ultrasonic Nebulizers (USN) is a ~ ___ minute treatment.
10
OBJECTIVES FOR IPPB THERAPY: A minimum effective volume, should deliver a Vt <_____% the patient's spontaneous Vt.
10
Particles which are > _____ µ do not get past the nose. Deposited in nasal and oral cavities.
10
The flowrate is set to whatever is required to prevent the reservoir bag from collapsing during inspiration (usually > ____ lpm).
10
What are the safe pressure ranges for adults while using a suction regulator?
100 - 120 mm Hg
A gas must be ______% RH before it will carry an aerosol.
100%
Brovana: Duration
12 hrs.
Formeterol: Duration
12 hrs.
Serevent: Duration
12 hrs.
Formeterol: Onset
15 min.
How long do you wash your hands?
15 seconds
Just as suctioning with MIP, how many seconds can you occlude the adapter for?
15 seconds
OBJECTIVES FOR IPPB THERAPY: An adequate volume is _____ - _____ ml/Kg of ideal body weight.
15; 20
Spriva: Dosage
18mcg (once a day)
Air Oxygen Blender needs ___ gas sources.
2
Racemic Epinephrine: Dosage
2.25% - .25 - .50 ml's in 3 cc's NS q1 - q4hr prn
What is internal diameter sizes for endotracheal tube?
2.5 - 10 mm
Albuterol: Nebulized dosage
2.5 mg in 3 ml NS
PIPING DISTRIBUTION SYSTEMS: The pipes must be identified by labeling at least every _____ feet and at least once in each room and on each building floor.
20 Ft.
Albuterol: Peak
20 min.
What are the ranges for A - a Gradient?
20 mmHg = normal > 20 mmHg = oxygenation problem. ( 21% FiO2) Normal = FiO2 > 350 = hypoxic respiratory Failure - type I
What symptoms usually indicates a chest tube?
20% Pneumothorax
Continuous Med Nebulizers uses equal or greater than ____ ml.
200
PORTABLE, HOME HEALTH, DELIVERY SYSTEMS: Oxygen Concentrators Use either a semi-permeable membrane or molecular sieves to remove oxygen from ambient air and provide it at low flowrates (< ____ lpm).
200
What is the tank filling pressure of a cylinder?
2000 - 2200 psig
Nasal Pharyngeal Airways: Sizes
26 - 32 Fr
The pressure relief valve is typically set to sound with very small (< _____ cm H2O) increases in pressure. The most common cause of this alarm is __________ or ___________ of the oxygen supply tubing.
2; crimping or kinking
The dense mist in Ultrasonic Nebulizers (USN) is ~ ___ µ in size.
3
Jet Nebulizer: A Small Volume Nebulizer (SVN), also called a Hand Held Nebulizer (HHN), is one with a reservoir volume of < _____ ml.
30
Jet Nebulizer: Small Volume Nebs (SVN) <___ ml
30
What is the ranges of PCO2 in a Respiratory Component?
35 - 45 mmHg = normal < 40 = hyperventilation + respiratory alkalosis > 40 = hypoventilation + respiratory acidosis
At the alveolar level, under normal atmospheric pressure conditions, the temperature of the gas is at ____o C, and completely saturated with water vapor.
37 C
Jet Nebulizer: Continuous Medication Nebulizer (a HART or HOPE nebulizer) are specially designed to produce a majority of particles in the ___ to ___ µ range.
3; 5
Brethine: Duration
4 - 6 hrs.
What is the PaO2 if hypoxemia is moderate?
40 - 60 mm Hg
Serevent: Onset
5 min.
Each cylinder must be inspected and tested every ___ or ___ years.
5 or 10
What is the percentage of Carboxyhemoglobin (COHb) in smokers?
5% to 7%
A cylinder, placed in a tank of water, is filled to ________ of the normal working pressure. As the pressure is increased, the cylinder __________ (Boyle's Law). Excessive expansion indicates ___________ cylinder wall thickness and/or damage.
5/3; expands; decreased
What are suction catheter sizes for neonatal?
6 - 8 fr
Maximum flowrate for a high flow nasal cannula is ____ - ____ lpm. (depending on the device)
6; 12
Albuterol: Continuous Nebulizer Dosage
7.5 - 20 mg per hour (ER tx)
The efficiency of these devices varies between manufactures, usually producing from ____% to ____% relative humidity at temperatures of 30o or 31o C.
70%; 90%^
Medical Air is ___% Nitrogen, ___% Oxygen, is dry, and contains a minimum number of impurities.
79% Nitrogen, 21% Oxygen
A value of > _____% of predicted is considered normal in Forced Vital Capacity (FVC).
80
What are the safe pressure ranges for children while using a suction regulator?
80 - 100 mm Hg
What is the PaO2 if hypoxemia is normal?
80 - 100 mm Hg
What are the ranges for PaO2? Normal Mild Hypoxemia Moderate Hypoxemia Severe Hypoxemia Venous oxygenation
80 - 100 mmHg = normal 60 - 80 = mild hypoxemia 50 - 60 = mod hypoxemia < 50 = sever hypoxemia 40 - 45 = venous oxygenation.
Hypoxemia: Normal value in the adult is ____ - 100 mm Hg.
80 mm Hg
What are the ranges for SaO2? Normal Mild Hypoxemia Moderate Hypoxemia Severe Hypoxemia Venous oxygenation
95 - 100 % = normal 92 - 95 % = mild hypoxemia. 90 - 92 % = mod hypoxemia. < 90 % = severe hypoxemia 85 % = venous oxygenation
Carbon Dioxide when used medically, as for treating hiccups, it is usually delivered as a CO2/O2 mixture, either ___% O2 with ___% CO2, or ___% O2 with ___% CO2.
95% O2 with 5% CO2; 90% O2 with 10% CO2
MODES OF VENTILATION: Inverse I:E Ratio Ventilation (IRV) The primary goal here is to keep the SIP _____ cm H2O in an attempt to limit barotrauma to the larger airways.
< 35
What is the PaO2 if hypoxemia is severe?
< 40 mm Hg
MODES OF VENTILATION: Positive End Expiratory Pressure (PEEP) and Continuous Positive Airway Pressure (CPAP) Therapeutic PEEP/CPAP 1. This refers to PEEP/CPAP levels of ____ cm H2O 2. Used to treat ________ unresponsive to an increased FIO2. This is generally defined as the inability to maintain a PaO2 > 50 mm Hg with an FIO2 > 0.50. This is accomplished by increasing _______.
> 5; hypoxia; PEEP or FRC
What is the pH range for alkalemia?
> 7.40
A Bourdon Gauge actually measures __________.
?
A popular type of humidifier for use with ___________.
?
Advantages of MDI over SVN 1. More _______ effective 2. More _______________ for the patients 3. Less ____________ Intensive 4. Patient __________
?
Helium's primary use is in ___________ applications.
?
How often is trach care performed?
?
Oral Pharyngeal Airways: Describe the Guedel
A single airway down the middle of the tube
The ______________ promotes public perception of respiratory care as a profession
AARC
The ______ and the ________ has equal or greater than 200 L/min.
ASSS; PISS
Xopenex is a refined form of what medication?
Abuterol
Non-Steroidal Antiasthma Agents: (Zafirlukast) ( age 5-11) or 20 mg( 12 - adult) twice a day
Accolate
Pulse oximeters are _________ only if the patient heart rate matches the heart rate displayed.
Accurate
Oxygen is a drug, and as such, must be measured ___________.
Accurately
What is substitute for washing your hands?
Alcohol based lotion (but still wash your hands)
Evaluate metabolic component BE > + 2 = met ________ vs. BE < -2 = met _______.
Alkalosis; Acidosis
Evaluate respiratory component. PCO2 < 40 = resp. _______ vs. > 40 = resp. _______
Alkalosis; Acidosis
Type of receptors that causes major vasoconstriction (increases blood pressure), mild bronchoconstriction, and a small amount of increased cardiac contractility.
Alpha 1 Receptors
Used to treat cardiac amerinia; show to cause pulmonary fibrosis w/ prolonged High FIO2.
Amnioderone
Aerosolized Antinfectious Agents antifungal agents - No FDA approved aerosolized antifungal agents Indication: Treat patients at risk(i.e. CF, Lung transplant , & chronic steroid use.) from fungal infections & minimize toxic effects of systemic antifungal agents - • Dosage - no standard dose response yet.
Amphotericin B
Site: Blood Possible Causes: Anemia, hemorrhage, trauma Type of Hypoxia: __________
Anemic
What type of hypoxia has inadequate hemoglobin?
Anemic Hypoxia
Do not distinguish between oxyhemoglobin and ___________________.
Arterial
• Dosage .5 - 1 ml ( .4 mg per 1 ML injectable vial) • No MDI form
Atropine Sulfate -
What is another name for Ipratropium Bromide?
Atrovent
ALARM SYSTEMS: Master alarms should be _________ and signals should be _________ and ___________.
Audible; visual; non-cancelable
OXYGEN STORAGE: The switchover between primary and stand-by supply may be _________ or ____________.
Automatic or manual
Long acting / Control medications -" stays at home"; Inhaled Steroids (Triamcinolone acetonide), 2- puffs BID
Azmacort
Formeterol: Dosage
BID
Jet Nebulizer: _________ - cause the larger particles to be knocked out of suspension.
Baffles
Why is the pass-over humidifier more efficient than the bubble humidifier?
Because the pass-over humidifier can be heated so gas can have the carrying capacity similar to the body.
Why is it generally used in NICU and not at an adult unit?
Because the skin in a premature infant is very thin making the diffusion of gas to the skin very good. Adults already have thick skin and would not work as good.
When do you use gloves?
Before touching wet stuff; When there is ay chance your hands are going to get wet.
Fluid/gas velocity increases as it travels through a constriction resulting in a pressure drop distal to the constriction.
Bernoulli's Principle
Type of receptors that are primarily cardiac in action, increasing heart rate and contractility (strength of the heartbeat). (Not Alpha Receptors)
Beta 1 Receptors
HME consists of a honeycomb-like tubular structure, made of hygroscopic materials that allow for _____________ gas flow.
Bi-directional
BIPAP
Bipolar Intermittent Positive Airway Pressure
Color code of Nitrogen (N2):
Black
Large Volume Nebulizers (LVN) are used for "_____" therapy.
Bland
Ultrasonic Nebulizers (USN) These nebulizers are used primarily for _____ aerosol therapy for sputum inductions. They ARE NOT used to nebulize ______.
Bland; medications
CONTRAINDICATIONS FOR IPPB THERAPY: A superficial, subpleural collection of air is referred to as a _______.
Bleb
Gas law with the pressure and volume are inversely related. Temperature is constant
Boyle's Law
What is the formula is this? P1V1 = P2V2
Boyle's Law
Definition: Use of suction to remove secretions or specimens from beyond main stem bronchi
Bronchoscopy
What is Arfomoterol?
Brovana
What is the formula for Compliance?
C = change in Volume/change in Pressure
Metabolic Compensation: Give some examples of the acute problems of the metabolic compensation:
COPD chronic CO2 retention
Pulse oximeters: Each of the probes are _________ for their specific use.
Calibrated
BTPS describes the conditions at the __________.
Carina
Gas law with the temperature and volume are directly related. Pressure kept constant.
Charles' Law
What formula is this? V1/T1 = V2/T2
Charles' Law
Stimulates parasympathetic system (acetylcholine)
Cholinergic
What is this formula? P1V1/T1 = P2V2/T2
Combined Gas Law
Medications: Which patients use sedation prior to intubation? Proper sedation should be used in all.
Conscious and hemodynamically stable patients
Galvanic O2 Analyzers gives a ________ reading that cannot be turned off.
Continuous
PIPING DISTRIBUTION SYSTEMS: Use seamless _________ or _________ pipes.
Copper or brass
Aerosol Therapy Objectives: To increase _____ ______ temperature through the delivery of a heated aerosol (heated to 40 - 42o C)
Core body
Type of steroids that are natural substance found in the body that help fight inflammation. It is used to treat asthma because they reduce swelling and irritation in the walls of the small air passages and ease breathing problems. It helps prevent asthma attacks.
Corticosteroids
Fiberoptic Endotracheal Intubation: Disadvantages
Costs associated with the need for special equipment and skill
CYCLING VARIABLES: ____________ is generally used to indicate a change from the inspiratory phase to the expiratory phase (or what stops the flow of gas from the ventilator and allows the patient to exhale).
Cycling
OXYGEN STORAGE: Two general types of systems used for oxygen delivery:
Cylinders only and Cylinder/Liquid Systems
Safety System that uses low pressure (working pressure) and threads and nipple.
DISS
The ______ and the ________ has less than 200 L/min.
DISS; Quick-Connect Systems
Areas of the lung that have ___________ but no blood flow.
Deadspace
What are the 2 most common vagal responses?
Decrease HR, Decrease BP
Metabolic Compensation: Decreasing HCO3 and Base Excess levels = metabolic __________.
Decreasing HCO3 and Base Excess levels = metabolic acidosis.
Ultrasonic Nebulizers (USN) delivers a _______ mist.
Dense
A cylinder without one of these tags cannot, per _____ regulations, be transported in a vehicle.
Department of Transportation (DOT)
Gas used to study patients
Diagnostic Gases
Indexed Safety Connections: --For low-pressure connections on regulators or wall outlets. --Uses changes in different size, outlet diameter, and direction of threads. --Prone to damage from cross threading. Note: These connections should attach easily and be hand-tightened ONLY. If you have to force it or use a wrench YOU AREDOING SOMETHING WRONG!!!!!!
Diameter Index Safety System (DISS)
Air and oxygen entering the blender are first directed into two chambers on opposite sides of a __________.
Diaphragm
High-flow devices (DO/DON'T) meet the patient's total inspiratory demand.
Do
If you start modifying medical devices design you (DO/DO NOT) put your license at risk. Why?
Do; Because you are doing something that does not agree with community standards.
MEDICAL AIR SYSTEMS: Must be able to deliver ____________, ___________ air at 50 psig.
Dry; Filtered
What is the mixture of Atrovent and Albuterol in nebulizer pre mix called?
Duo Neb
Provides a valuable monitor of _____________ function.
Dynamic
The combination of the oxygen and the chemicals in the electrolyte produce an ______________ current.
Electrical
Ultrasonic Nebulizers (USN) Hazards: ______ ______ ______ -- water in the same area as electrical current.
Electrical shock hazards
Most of the analyzers in use today are__________: Either Galvanic or Polarographic.
Electrochemical
What is end-tidal?
End of exhalation
ETCO2
End tidal of Carbon Dioxide
The Capnograph is used to verify _____-_____ tube replacements. (Single breath)
End-Tidal
What is flexible suction to remove secretions from trachea - main stem Bronchi?
Endotracheal Suction
Polarographic O2 Analyzers requires ___________ to power it up by getting reaction. This is an (advantage/disadvantage) because the reaction stops when the power stops.
Energy; advantage
What is the Principle of Bernoulli and Venturi?
Entrains and accelerates gas
Cuff Pressures and Volumes: What are the Alternative Cuffs called? What is it used for?
Foam cuffs, Lanz Tube; It is used to minimize mucosal trauma.
This Bedside Pulmonary Function Test (PFT) is frequently performed as a screening measure or to evaluate the effectiveness of clinical interventions. It is frequently performed after a SVC. The presence of a significant difference between the two values may indicate an obstructive process.
Forced Vital Capacity (FVC)
How is bronchoscopy used therapeutically (Therapeutic Bronch's)
Foreign Body Obstructions (secretions/hemoptysis) Mass or Tumor (Atelectasis/Edema)
What is the "F" and "I" in the FIO2?
Fraction and Inspired
Tags must be present on all cylinders and have three tear-off sections: ________, _________, and __________.
Full, In Use, and Empty
Particles suspended in a ______.
Gas
The principle use of this gas (Nitrous Oxide) is as a ____________ ___________ during surgery (also called Laughing Gas).
General Anesthetic
As particle size and mass increase,______ ______ forces act on the particle to a greater degree, tending to remove it from suspension.
Gravitational forces
What are the 2 types of Oral Pharyngeal Airways?
Guedel Berman
PORTABLE, HOME HEALTH, DELIVERY SYSTEMS: Cylinders: Typically consist of an ____-cylinder for daily use, and an ____-cylinder for travel and emergency use.
H; E
MODES OF VENTILATION: Inverse I:E Ratio Ventilation (IRV) IRV typically requires that the patient be ______ ______ or _______.
Having sedated; paralysis
What is HIPAA?
Health Insurance Portability and Accountability Act
What is HME stand for?
Heat Moisture Exchange
Water ___________ in to the gas, increasing the humidity of the gas.
Heated
Wick humidifier is hooked up to the __________ system.
Heated
MODES OF VENTILATION: Monitoring System 1. Uses temperature-sensitive resistive elements. 2. As gas passes over the wire, it is cooled, changing its resistance. 3. The power necessary to maintain the temperature above ambient is related to the velocity of the gas flow.
Heated Wire
Wick humidifier is usually attached to a _______ ________ _________.
Heated wire tubing
The ___________ element surrounds the wick and the reservoir, ____________ the rate of evaporation.
Heating; increases
An odorless, tasteless, colorless gas that is nonflammable, is chemically inert, and does not support life.
Helium
One of the rare gases, the second lightest element.
Helium
What are the Diagnostic Gases?
Helium (He) Nitrogen (N2) Carbon Monoxide (CO)
How does oxygen help support combustion?
Helps things to burn hotter and faster; Does not explode, but can create an explosive effect.
CONTRAINDICATIONS FOR IPPB THERAPY: What is an IPPB Therapy contraindication that includes hypotension, hypovolemia, and arrhythmias. This is a relative contraindication as the positive pressure may worsen these conditions.
Hemodynamic Instability
ALARM SYSTEMS: 1. This alarm alerts the RCP that the pressure being generated by the ventilator is excessive. 2. May be a result of: a. The patient fighting the ventilator. b. Secretion in the airway. c. Pneumothorax d. Changes in flow/compliance and/or pressure/resistance. 3. To protect the patient, when this alarm is triggered: a. An audible alarm occurs. b. A visual alarm occurs. c. The inspiratory phase ends immediately.
High Pressure Alarm
Indexed Safety Connections: ____________ is any pressure above 200 psig. Any pressure below 200 psig is considered____________.
High-pressure; low-pressure
Site: Tissue Cells Possible Causes: Toxic poisoning, abnormal cells Type of Hypoxia: __________
Histotoxic
What type of hypoxia has inadequate bonding sites due to abnormal hemoglobin?
Histotoxic Hypoxia
What are the 2 types of Continuous Med Nebulizers?
Hope and Hart
Simple mask is usually used with a ___________.
Humidifier
Water that is present in a gas mixture (parcel of air) as a vapor.
Humidity
What is this formula? 44 mg/L - Specific Humidity
Humidity Deficit
Prior to use, cylinders must undergo __________________.
Hydrostatic testing
________ has a tendency to absorb water.
Hygroscopic
An increased ____.
Hyperpnea
____________ solutions will gain water from body fluids due to the greater concentration of solutes.
Hypertonic
Aerosol Therapy Indications: _____ (heated aerosol)
Hyportermia
____________ solutions will lose water since the solute concentration is less than that of body fluids.
Hypotonic
A lower than normal partial pressure of oxygen in arterial blood (PaO2).
Hypoxemia
Site: A/C Membrane Possible Causes: Interstitial edema, shunt Type of Hypoxia: __________
Hypoxic
Site: Air Possible Causes: Inadequate oxygen. High altitudes. Type of Hypoxia: __________
Hypoxic
Site: Alveoli Possible Causes: Pneumonia, pulmonary edema, emphysema, fibrosis. Type of Hypoxia: __________
Hypoxic
Site: Respiratory Pump Possible Causes: Pneumothorax, fractured ribs, muscular paralysis, other musculoskeletal disorders. Type of Hypoxia: __________
Hypoxic
Site: Upper Airway Possible Causes: Foreign body, inflammation, edema Type of Hypoxia: __________
Hypoxic
What type of hypoxia has inadequate oxygen and the most common type of hypoxia?
Hypoxic Hypoxia
Amount of time to deliver mechanical breath. Directly effects oxygenation.
I. Time
Ratio of Inspiration to Expiration. Normal > ½ used to keep ventilator in sync with patient.
I/E Ratio
Inhaled Pulmonary Vasodilators inhaled gas @ 10 - 40 parts per million • Selective Pulmonary Vasodilator • Active agent for smooth muscle relaxation = vasodilation • Combines with oxygen quickly - eliminated as Meth hemoglobin
INOmax - Inhaled Nitric Oxide
What is this formula? PV = nRT
Ideal Gas Law
How much time does the patient should pass without ventilation if the intubation is delayed? What should be done to the patient if this time period has passed?
If intubation is delayed, no more than 30 seconds should pass without ventilation.3Therefore, if intubation is not performed within this time period, the procedure should be stopped and the patient ventilated with bag-mask ventilation prior to reattempting the procedure.
When do you wear a cap?
In the O.R. (Operating Room)
When do you wear shoe covers?
In the O.R. (Operating Room)
Fiberoptic Endotracheal Intubation: Contraindications
Inability to oxygenate Major bleeding
What is the most common adverse reaction?
Increase Heart Rate and Blood Pressure
What do can you do to increase the humidity of a gas?
Increase the temperature.
Increasing the amount of time the gas is in contact with the water will (increase/decrease) humidity. Decreasing the amount of time the gas is in contact with the water will (increase/decrease) humidity.
Increase; Decrease
What are the visual signs of airway obstruction?
Increased respiratory rate Gasping Use of accessory muscles Retractions - Intercostal muscles Cyanosis Diaphoresis - stress Fear, anxiety, thrashing Unconsciousness
With the volume held constant. If the temperature increases, the pressure will ___________, and if the temperature decreases, the pressure will ___________. This gas law is _____________ Law.
Increases, Decreases, Gay-Lussac's Law
Indications for Amphtericin B:
Indication: Treat patients at risk(i.e. CF, Lung transplant , & chronic steroid use.) from fungal infections & minimize toxic effects of systemic antifungal agents -
Sputum Collection using Suction: Indication
Ineffective cough to produce secretions because of weakness or artificial airway
Influenced by flow rate. (mass x velocity)
Inertia
Mass x Velocity = ___________
Inertia
_________ are also related to particle size and mass.
Inertia
Jet Nebullizer: A slow, deep __________, followed by a brief _______ before exhalation, will increase aerosol deposition in the lungs.
Inhalation; Hold breath
Metered Dose Inhalers (MDI) takes coordination. Slow _________ with breath _________.
Inhalation; hold
The maximum amount of gas that can be inspired after a normal exhalation. ( VT + IRV)
Inspiratory Capacity (IC)
The maximum volume that can be inhaled after a normal inspiration.
Inspiratory Reserve Volume (IRV)
Jet Nebullizer: Good patient _______ and _______ can influence the effectiveness of aerosol therapy to a large degree.
Instruction; monitoring
AUTOPEEP
Intrinsic PEEP
Slow Vital Capacity (SVC) (is/is not) an "effort dependent procedure."
Is
____________ solutions will remain stable (neutral toward water absorption) since solute concentrations are similar.
Isotonic
MODES OF VENTILATION: Inverse I:E Ratio Ventilation (IRV) What happens to the upper airway and the alveoli during long inspirations? How does this affect the alveolar tidal volume and ventilation?
It allows for better stabilization or equilibration of pressure in the upper airway and the alveoli. Thus, increasing alveolar tidal volume and ventilation.
DRIVE MECHANISMS: How does the ventilator create positive pressure?
It creates positive using: 1. Weighted bellows 2. Reducing valves
Why do we use 6 LPM in a simple mask?
It ensures you flush the CO2 out of the mask.
What is the carrying capacity of a gas at 37 degrees Celsius?
It is saturated (full) at 44 mg/L
Is HME very efficient?
It is somewhat efficient
What is significant about 37 degrees Celsius?
It is the temperature pass the carina. (This is the temperature pass the carina when inhaling air regardless of the temperature.)
What is the difference between the P. Plat and the PIP represent?
It represents the resistance of the air movement
The manufacture of oxygen uses the process of Fractional Distillation of Liquefied Air, also known as the ______________ or the _________________.
Joule-Thompson effect; Joule-Kelvin Principle
Aerosol Therapy Aerosol Administration Equipment: __________ Bore Tubing Corrugated tubing, frequently provided in 200-foot rolls.
Large
Ultrasonic Nebulizers (USN) is not to be used as a ___________ __________ nebulizer.
Large Volume
Alarms: What causes Low Pressure Alarms?
Leaks
Laryngeal Mask Airways (LMA): Advantages:
Less pain and coughing than ET Tube. Much easier to insert Avoids tracheal intubation Can be used with spontaneous or artificial ventilation. Less irritation to the throat.
Why is hypoxia a hazard to endotracheal suctioning?
Loss of FRC / Increased Atelectasis
What are the classifications of oxygen delivery devices?
Low-flow (Variable Performance) Oxygen Delivery and High-Flow (Fixed Performance) Oxygen Delivery Devices.
Nasal Pharyngeal Airways: What should be used to minimize nasal airway irritation & bleeding before the airway is inserted? What position should the patient's head be in?
Lubrication; Sniffer's Position
L/T Ratio: Topical delivery to this part of the body that creates a therapeutic effect.
Lungs
Type of inhaler in gas and liquid form of medicine?
MDI
How can inhaled medications be administered?
MDI DPI Nebulizers
What are the types of inhalers?
MDI DPI Spacers Nebulizers
What are the 2 types of blades on the laryngoscope?
Macintosh (curved blade) and Miller (straight blade)
The maximum negative pressure generated when a (MIP or NIF) maximum inspiratory effort is performed against a closed glottis.
Maximum Inspiratory Pressure (MIP)
This Bedside Pulmonary Functional Test (PFT) is typically performed to evaluate the strength of the patient's diaphragm as part of the assessment for the need for mechanical ventilation. Note: This test evaluates the strength of the diaphragm, but not endurance.
Maximum Inspiratory Pressure (MIP)
Aerosol Therapy Indications: Need to deliver _____________
Medications
Clinically: Any measured CO2 in exhaled air is the result of ___________. CO2 is the major stimulus for __________.
Metabolism; breathing
Metered Dose Inhalers (MDI) delivers a ________ dose of medications with each acuation.
Metered (exact)
Jet Nebulizer: (SVN) _______-________ is a single dose medication delivery (Mini-Neb)
Micro-Nebulizer
Oxygen Analyzers are affected by __________ and ________ ________.
Moisture; High Pressure
Nonsteroidal Antiasthma Medications, break down proteins to thin secretions
Mucolytics
What are the possible complications using a nasal cannula?
Mucosal irritation, skin irritation, kinking of the connecting tubing.
Nonsteroidal Antiasthma Medications Mast Cell Stabilizers - blocks production of mucous. i.e. chronic asthma
Mucous Blockers
Air Oxygen Blenders are mostly used with _____ applications.
NICU
Patient's inspiratory effort. Weaning effort > -20 cm.
NIF
PIPING DISTRIBUTION SYSTEMS: Must follow _____ regulations.
National Fire Protection Agency (NFPA)
CONTRAINDICATIONS FOR IPPB THERAPY: What is the IPPB contraindication that increases gas in the stomach and may worsen nausea, causing uncontrolled vomiting and possible aspiration.
Nausea, Air Swallowing, and Singulation (hiccups)
Type of inhalers that gives higher doses & require less patient effort than MDI. It require a compressed gas source.
Nebulizers
NIF
Negative Inspiratory Force
Medications: What type of medications are often used to facilitate intubation?
Neuromuscular blockers
1. Gas that has been found to be a potent vasodilator, especially in the lungs, and may be partially responsible for the baseline vascular tone found in normal lungs. 2. Therapeutic use of this gas requires that special care be taken to prevent exposure of health care workers. 3. Generally administered in dosages of 2 to 80 ppm (parts per million).
Nitric Oxide (NO)
In the human body, it is produced by nitric oxide synthase enzymes.
Nitric Oxide (NO)
1. An odorless, colorless, and tasteless gas which is nonflammable but will support some combustion 2. Does not support life, so must be combined with oxygen. 3. Long-term exposure of workers has been associated with neuropathy and with feto-toxic effects, therefore, if used in surgery, exhaled gases must be collected and not vented into the room.
Nitrous Oxide (N2O)
If I make the reservoir deeper, do I get increasing humidity output? Why?
No, increasing the surface area of the gas in the reservoir increases the humidity output. Making the reservoir deeper does not increase humidity.
Ultrasonic Nebulizers (USN) Hazards: _____ ______ -- always a concern where liquids are involved.
Nosocomial Infections
CO2/O2 is (used/not used) as a therapeutic gas.
Not used
What devices are high flow nasal cannulas?
Oquinox and Vapotherm
Which endotracheal intubation technique is more commonly used?
Oral Intubation
Venturi Masks: This variability in the venture masks has to do with the total ___________ of the mask.
Output
The date of the last inspection is stamped on the ________ of the cylinder.
Outside
Also has a semi-permeable membrane that allows ___________ to pass through to the electrolyte, but prevents other gases from moving across the membrane.
Oxygen
What are the gases and medical treatment and/or diagnosis?
Oxygen, medical air, Carbon Dioxide, Helium, Nitrous Oxide (N20), Nitric Oxide (NO), Nitrogen
Partial-rebreather mask is originally designed as an __________-___________ device.
Oxygen-saving
Pressure at end of expiration, keeps lungs inflated at end expiration (FRC). Opens Alveoli, directly increased oxygenation, impedes venous return. Increases interthoracic pressures.
PEEP
Transcutaneous monitors monitor ________ and ________ levels.
PaO2; PaCO2 (TCPO2; TCPCO2)
PaCO2
Partial Pressure of Carbon Dioxide in arterial blood
A non-rebreather mask without the on-way valves. 1.
Partial-Rebreather Mast
The _________________ humidifier are very inefficient with high gas flowrates.
Pass-over
Brovana: Peak
Peak 15 minutes, Peak 30 - 60 minutes
Transcutaneous Monitor: ____________ of O2 and CO2 into the electrode causes an electrical charge that is transmitted to the recorder and reported as PaO2 and PaCO2.
Perfusion
Transcutaneous is ________ dependent.
Perfusion
A phase of Principles of Pharmacology that focuses on drug actions/effects on the body.
Pharmacodynamic Phase
A phase of Principles of Pharmacology that is focusses on time, course, and disposition of a drug. Based on: • Absorption • Distribution - Ionized ( Atrovent) vs.Non Ionized ( atropine) • Metabolism • Elimination
Pharmacokinetic Phase
Pulse Oximeters works by principle of _________.
Photoplethsmography
Ultrasonic Nebulizers (USN) The ______ ______ changes shape as an electrical current is applied to it, thus changing electrical energy into mechanical energy. This produces the _____.
Piezoelectric crystal; aerosol
Indexed Safety Connections: --For high- pressure connections on SMALL cylinders (A through E) --Uses different, which fit into holes in the yoke of the cylinder. --Each gas has a unique two-hole combination of _____ and ______ that must match for the reducing valve to attach to the yoke.
Pin Index Safety System (PISS)
O2 Analyzer that is similar in design and function to galvanic analyzers.
Polarographic Analyzers
MODES OF VENTILATION: Positive End Expiratory Pressure (PEEP) and Continuous Positive Airway Pressure (CPAP) The establishment and maintenance of an airway pressure above ambient.
Positive End Expiratory Pressure (PEEP) and Continuous Positive Airway Pressure (CPAP)
BASIC TERMINOLOGY: Graph
Positive Pressure Breathing
What are the classifications of Mechanical Ventilators?
Power Control Flow Variables Drive Mechanisms Trigger Variables Cycling Variables Modes of Ventilation Monitoring Systems
CYCLING VARIABLES: 1. Causes cycling when a preset pressure has been reached. 2. Cycles the ventilator regardless of the flow delivered, time elapsed, or volume. 3. Is frequently used as a safety backup cycling mechanism with volume cycled modes of ventilation.
Pressure
Force per unit area
Pressure
Pulse oximeters have many different _________.
Probes
A vocation or occupation requiring special, usually advanced, education, knowledge, and skill.
Profession
One engaged in one of the learned professions or in an occupation requiring a high level of training and proficiency.
Professional
What is checked and verified before using the laryngoscope?
Proper light source
___________ ____________ are used to mix gases in Air Oxygen Blenders.
Proportioning valves
Long acting / Control medications -" stays at home"; Inhaled Steroids Nebulized form of Pulmicort. • .25 to 1.0 mg in 2ml unit dose 1-2 times per day • do not mix with other inhaled medications • may be mixed with Xopenex • used for chronic Asthma to reduce use of prednisone
Pulmicort Respules
What is the nebulized form of Pumicort?
Pulmicort Respules
What are examples of nebulizers?
Pulmo-aide or Pari Neb
Food and Drug Administration (FDA) -- standards for _________.
Purity
Brovana: Dosage
Q12 BID
Safety System that uses low pressure and mixtures of other devices. It is used for efficiency and most prone to leaks.
Quick Connect Systems
Advantages of MDI over SVN Less _____ time is required to deliver medication via MDI than by SVN
RCP
RSB
Rapid Shallow Breathing index
# of set mechanical breaths directly increases ventilation.
Rate
Which zone in the Peak Flow Meter do I decide to go to the doctor or ER?
Red Zone - esp. if you've used your inhaler and you're still in the "RED" When the Plan's not working!!!!!!!
Regulators are also called _______________.
Reducing Valves
CONTRAINDICATIONS FOR IPPB THERAPY: A history of spontaneous pneumothorax is a (absolute/relative) contraindication.
Relative
CONTRAINDICATIONS FOR IPPB THERAPY: Bullae are a (absolute/relative) contraindication for IPPB Therapy
Relative
What humidity is the comparison of the actual humidity to air's carrying capacity?
Relative Humidity
What is R.A.C.E.?
Rescue, Alarm Contain, and Evacuate
1. Difficulty inhaling normal volume due to structure, musculature, and trauma/disease. 2. Decrease volumes
Restrictive Disease
Results in decreased volume. Flow rates are typically normal.
Restrictive Pulmonary Disease
Nasotracheal Suction: Indications
Retained secretions without an artificial airway
What type of bronchoscope with the hollow tube functions as airway and allows ventilation? It is the preferred method for foreign body removal form large airways.
Rigid Bronchoscope
What are the 2 types of bronchoscopes?
Rigid Bronchoscope Flexible Bronchoscope
STORAGE: Cylinders should be protected from the elements to prevent ___________ and from possible _____________.
Rusting; tampering
Combination of mechanical, spontaneous breathing. Patient vent support for weaning.
SIMV
Saturation of _______ hemoglobin with oxygen.
SaO2
Compressed Gas Association (CGA) -- standards for ________ ____________.
Safety Systems
What type of maneuver can be used to facilitate intubation and reduce the risk of aspiration?
Sellick Manneuver?
Oral Airway Suction: Hazards/Precautions
Sepsis, Trauma, Infection
What is Salmeterol Xinfoate?
Serevent
PIPING DISTRIBUTION SYSTEMS: Each _______ valve controls the gas supply to a small area of the facility. 1) Typically located just outside the supplied area. 2) Are typically inset in the wall, with a removable covering. 3) Consist of a valve with an off and an on position only. 4) Are turned off during emergencies or during repairs. 5) Turning off of _______ valves typically requires instruction from either hospital administration (during the day shift) or the Nursing House Supervisor (during evening and night shifts). 6) It is the responsibility of the RCP to know the location of the ______ valves in his/her assigned area, but not to turn off the valves unless directly ordered to do so by the proper authority.
Shut-off
Nasal Pharyngeal Airways: How do you determine diameter size of the Nasal Pharyngeal Airways?
Size of the nail bed on the little finger.
1. Used to measure VC (Volume measurement only) 2. Most useful in restrictive processes 3. ≥80% of predicted is normal.
Slow Vital Capacity (SVC)
Aerosol Therapy Possible Complications: Fluid overload Prevention/Action: If the patient is an adult, review the patient's chart for indications of decreased cardiac function. This is a concern only in two populations...._________ children and those with severe _________ disease.
Small; pulmonary
Which sizes endotracheal tubes are the easiest to insert?
Smaller size endotracheal tubes
Saturation of hemoglobin with oxygen obtained using a _______ __________. (POX).
SpO2
The Metered Dose Inhalers (MDI) are more effective when using a ______ (______ ______)
Spacer; Holding chamber
MDI (Metered Dose Inhalers) Frequently combined with a ______ or ______ ______.
Spacer; holding chamber
Advantages of MDI over SVN Medication can be delivered by SVN at home, but this requires ______ ______. The MDI can be easily carried in a pocket, backpack, or purse, and used at any time or place.
Special equipment
What is Tiotropium Bromide?
Spriva
What does Non-Steroidal Antiasthma Agents do?
Stops cascade of inflamation
National Fire Protection Association (NFPA) -- standards for ________ of cylinders.
Storage
What is the advantage of the Miller blades?
Straight blades are inserted posterior to the epiglottis, thus providing better visualization of the larynx.
What are 2 common causes of acute upper airway edema that typically indicate the use of racemic epinephrine SVN tx's?
Stridor and Extubation
Alupent: Side Effects
Stronger HR and tremor
Which intubation equipment can be inserted inside the endotracheal tube to help the tube conform to the airway and may facilitate insertion into the larynx and trachea.
Stylets
What is downside to the use of Stylet during intubation?
Stylets have been associated with pharyngeal or laryngeal trauma.
What is a water seal system to secure low pressure sealed suction - 1, 2, 3 bottle or disposable setups?
Suction Chest Drainage systems
Suction Chest Drainage systems: A chamber where a level of water determines amount of suction pressure usually 15 - 20 cm - bubbling show max suction achieved - excess air bubbles through water.
Suction Control Chamber
Tracheal Airways: How is Tracheostomy performed?
Surgically inserted into the trachea
How is bronchoscopy used diagnostically (Diagnostic Bronch's)?
Suspected Foreign Body Suspected pathology Congenital abnormality Persistent problems
What is stridor?
Swelling associated with mild trauma.
SIMV
Synchronized Intermittent Mechanical Ventilation.
Aerosol Therapy Objectives: This is still listed as an objective for aerosol therapy, although most studies indicated that ______ ______ is as effective, if not more so, at reaching this objective.
Systemic hydration
Aerosol Therapy Aerosol Administration Equipment: __-Tube (also called a Briggs Adapter) Attaches directly to the artificial airway. Usually, a short (approx. 6 inches, or one section of aerosol tubing) is placed at the outlet of the adapter to provide for a reservoir for oxygen and aerosol.
T
Transcutaneous Monitors read _______ and _______.
TCPO2; TCPCO2
FRC + IC =
TLC
An increased heart rate, usually > ____ per minute in adults.
Tachycardia
An increased ventilatory rate, usually > ____ per minute in adults.
Tachypnea
Ultrasonic Nebulizers (USN) uses ____ water and ________ disk to generate mist.
Tap; piezoelectric
What is the color code for nitric acid in a cylinder?
Teal
Bubble humidifiers cannot add heat. Therefore, it is limited by _____________.
Temperature
In humidity, the gas ____________ determines the maximum amount of humidity that can be carried by a gas.
Temperature
Increasing the _____________ of the water may increase efficiency.
Temperature
The amount of heat present (kinetic energy)
Temperature
What is temperature, PH2O, and Specific Humidity of BTPS?
Temperature = 37 C PH2O = 47 mm Hg Specific Humidity = 44 mg/L
BTPS consists of:
Temperature, PH2O, and Specific Humidity
The Standard Precautions used when setting up and/or adjusting oxygen therapy are determined by the type of disease process involved. For many patients, ___________ is sufficient. For patients in respiratory isolation, __________, __________, and __________ will be required. For patients in contact isolation, __________ and __________, and possibly __________, will be required. Check with nursing, and watch for alert signs outside the room, to determine which precautions are appropriate.
The Standard Precautions used when setting up and/or adjusting oxygen therapy are determined by the type of disease process involved. For many patients, handwashing is sufficient. For patients in respiratory isolation, masks, gowns, and gloves will be required. For patients in contact isolation, gowns and gloves, and possibly masks, will be required. Check with nursing, and watch for alert signs outside the room, to determine which precautions are appropriate.
What is the advantage and disadvantages of the Macintosh blade?
The advantage of this blade is that it minimizes trauma to teeth, does not come in contact with the epiglottis and allows more room in the oropharynx. However, with this blade the epiglottis may be in the way of visualizing the vocal cords.
How can you tell if the catheter is leaks?
The bag inflates
What clinical signs would indicate a catheter being left on the ET Tube?
The bag inflates
How do you check the cuff of the endotracheal tube before using?
The balloon should be checked by inflating 10 cc of air with a syringe. Make sure that the cuff has no leaks.
Polarographic and Galvanic Analyzers have the same disadvantages except for:
The cell is continuous for polarographic analyzers and it lasts much longer.
What is the primary indication for IPPB Therapy?
The inability of the patient to take a deep breath spontaneously.
MODES OF VENTILATION: Volume-Guaranteed Modes In these newer modes of ventilation, each inspiratory phase is monitored by the ventilator. If the patient does not inspire a set tidal volume or set minute volume, what does the ventilator do?
The ventilator assists the patient to reach that goal. If the patient meets or exceeds the goal, the ventilator allows the patient to do all of the work of breathing.
A procedure of removing the fluid from the pleural space.
Thoracentesis
What does the hygroscopic mean?
To accept and release water rapidly
What is sterile water used for while suctioning?
To clear tubing
DRIVE MECHANISMS: What do most modern ventilators use microprocessors for?
To control reducing valves and solenoids.
Describes solution concentration.
Tonicity
Which intubation tube are for long term use and requires surgery?
Tracheostomy Tubes
(True or False) O2 is never contraindicated in an emergency situation.
True
True/False: Brethine is also available in tablet form.
True
True/False: In acid base balance, failure to compensate indicates a critical situation.
True
True/False: Metabolic compensation can be complete
True
True/False: Respiratory compensation is never complete...only partially compensates.
True
True/False: Xopenex is longer acting than Albuterol
True
Aerosol Therapy Indications: ______ ______ ______ (cool aerosol)
Upper airway edema
Aerosol Therapy Objectives: To decrease work of breathing by decreasing _____ _____ ______.
Upper airway edema
STORAGE: Large cylinders should be stored__________, with the _____________, and _________________.
Upright; protective cap on; restrained from being knocked over by a chain or other restraint
What to do in case your peak flow meter results indicate a red zone?
Use your inhaler Now!!!!!! Check your self again If you are not a lot better get help
OXYGEN STORAGE: Usually have two sources, one in _____ and one on __________.
Use; stand-by
Ventilation/Perfusion Ratio
V/Q
Maximum volume patient can exhale. Weaning effort > 1.5 1
VC
IC - IRV =
VT
A nasal cannula is a (VARIABLE/FIXED) performance device?
Variable
The pressure drop distal to the constriction may be used to entrain a second fluid/gas to mix with the main flow.
Venturi's Principle
A measurement that is generally performed to assess the ability of the patient to increase minute volume to meet physiologic needs. Note: Don't confuse this with the SVC & FVC as they both narrow the assessment to specific disease processes.
Vital Capacity (VC)
The delivered Vt must exceed the patient's spontaneous _____.
Vital Capacity (VC)
CYCLING VARIABLES: Once a set volume has been delivered from the ventilator, the ventilator automatically changes to the expiratory phase. This type of cycling is very common in adult therapy, becoming more common in pediatrics and neonatology. Notice that this guarantees that the set tidal volume is delivered from the ventilator, but does not guarantee that any volume reaches the terminal bronchioles.
Volume
H2O + CO2 < - > H2 CO3 < - > HCO3 + H
Water + CO2 = Carbonic Acid = Bicarbonate
Suction Chest Drainage systems: A chamber with 2 centimeters of water and shows respiration effort (spontaneous vs. mechanical) and air leaks if bubbling.
Water Seal Chamber
Bedside PFT Measuring Devices: 1. The bench standard for all volume and flow measuring devices. 2. Uses a cylinder submerged in water. 3. Graphs are produced on paper, then flows and volumes are calculated. 4. Difficult to move from place to place.
Water Sealed Spirometer
DRIVE MECHANISMS: 1. A weight provides the necessary force to overcome the resistance to airflow during inspiration. 2. The weight may be provided by an actual weight, a spring, or gas pressure. 3. May be fixed or adjustable. 4. May become inefficient in the face of very low flow or very high pressure.
Weighted Bellows
When is a high flow nasal cannula used as an alternative to an NRB?
When a prolonged administration of FIO2 is necessary.
Nasal Pharyngeal Airways: Indications
When oral airway cannot be used: • Semiconscious or conscious patient • Unable to open jaws • Severe oral airway trauma • Assist with nasal tracheal suction
When do you wear a gown?
When there is a splash potential or if there is a chance of carrying harmful bacteria out of a patient room.
When do you wear goggles?
When there is potential for a splash
When do you wear a mask?
When you have the potential to inhale droplet matter; when you might spread illness to the patient.
How do you determine the causative agent?
Whichever component matches the pH
Occupational Safety and Health Agency (OSHA) -- standards for _______ environment safety.
Work
Aerosolized Antinfectious Agents antiinfluenza agent - antiviral - neuraminidase inhibitor Indication : treatment for high risk ( cardio - pulmonary disease) patients for influenza A+B • Binds Virus agents together to prevent spread of disease • Hazards / precautions: • Bronchospasm • Allergic reactions • Under treat of underlying bacterial infection hidden by viral infection Dosage : • Dry powder dose - 5 mg per inhalation BID x 5 days
Zanamivir ( Relenza)
Ratio of Pa & PAo2's esp. useful with vent pt's on high Fio2's > 60%
a/A Ratio
Disadvantages of MDIs MDIs are much more prone to _____ than SVNs.
abuse
A Bourdon Gauge uses a needle valve with a known restriction to calculate __________.
flow
PORTABLE, HOME HEALTH, DELIVERY SYSTEMS: Cylinders: Must be replaced __________.
frequently
Respiratory Compensation: Give some examples of the acute problems of the respiratory compensation:
lactic acidosis diabetic keto acidosis
Jet Nebulizer: Baffles are placed in the path of the gas to knock out ________ particles, producing an aerosol with particles of more uniform, desired size.
larger
A capnograph generally reads levels _______ than PaCO2 values.
lower
USE: When in use, the valve should be fully _____________.
opened
ALARM SYSTEMS: All gas distribution systems require alarms to monitor the ___________, ____________, and ______________.
operating supply, reserve supply, and pressure in the main and local supply lines.
STORAGE: Flammable gases should not be stored with_______________.
oxidizing gases
Jet Nebulizer: These nebulizers produce less uniform size _______.
particles
MDI (Metered Dose Inhalers) The use of the ______ allows MDIs to be used on younger patients with the use of a mask.
spacer
Pharyngeal Airways: Indications
to prevent obstruction of pharyngeal airway caused by: • Tongue falling back - pharyngeal airways pull the tongue forward away from posterior pharynx. • Loss of muscle tone in unconscious patient causes tongue to fall back • Can be used to secure ETT & prevent obstruction of ETT due to biting • Upper airway trauma • Assist in Bag mask Ventilation - Apnea & CPR • Assist in nasal tracheal or oral tracheal suctioning • Temporarily stabilize unusual upper airway anatomy i.e. coanal atresia - Pierre Robin syndrome • Massive secretions or hemoptysis in oral pharynx
Must be in the __________ position to read accurately.
upright
USE: Unlabeled cylinders should be returned to the _____________.
vendor
Each Thorpe Tube is designed for use with a particular gas and ____________ if used with the wrong gas.
will not read accurately
Extubation Technique: Procedure
• Assemble equipment - i.e. oxygen, bag & mask, suction, medication??? • Preoxygenate patient • Suction endotracheal tube • Suction above cuff • Deflate cuff. • Remove tube - 2 techniques • During deep inspiration • During cough - What are the risks & advantages? • Administer oxygen • Administer humidity or cool aerosol. • Assess patient ( Egan mini clinic page 690)
Closed Suction Catheter Kits: Procedure
• Assess for indications & potential risk • Assemble equipment • Pre-oxygenate or hyper ventilate. • Insert catheter • Apply suction - 10 15 seconds. Rotate during withdrawal. • Patient recover & reoxygenate • Reinsert catheter • Monitor patient
List of Anticholinergics:
• Atrovent (Ipratropium Bromide) • Spriva • Atropine Sulfate
List of Inhaled Steroids:
• Azmacort (Triamcinolone acetonide) • Aerobid (flunisolide) • Flovent(fluticasone Propionate) • QVAR/Vanceril (Beclomethasone dipropionate) • Asmanex - Mometasone furoate - "Twisthaler" • ADVAIR Discus - Servent & Flovent • Symbicort - Budesonide (Pulmicort)/Formeterol fumarte (Foradil) • Pulmicort Tubuhaler asthma attacks. • Pulmicort Respules
How to instruct patients to use Peak Flow Meters?
• Breath in Deep • Blast the air out "blow out the fire" • Green Zone - your best day • Yellow Zone - ¾ th of your best day Relax Use your rescue inhaler Check your self again in 20 minutes
Indications of Methylxanthines:
• COPD - debilitating COPD despite other treatments • Acute severe Asthma - controversial older method - not common front line therapy • Nocturnal Asthma • Apnea of prematurity - used in NICU on premature neonates to prevent apnea
Closed Suction Catheter Kits: Minimize risk of Airway Obstruction
• Check catheter is completely withdrawn • Infection - Sterile technique, closed suction, good oral suction
What is the 2 techniques done to remove the endotracheal tube from the patient?
• During deep inspiration • During cough
List of Antidiabetic Agents:
• Exubera
List of Inhaled Pulmonary Vasodilators:
• INOmax • Ventavis
Closed Suction Catheter Kits: Disadvantages
• Initial Cost is more than 1or 2 suction kits • Additional weight on ETT. • Catheter can be left in ETT= airway obstruction. • Potential leak in Ventilator circuit = vol. loss. • Less control / stiffer catheter = potential inability to reach deep into airway • Airway damage from catheter hitting same location
Oral Pharyngeal Airways: Insertion Techniques
• Inserted into mouth & over tongue • Initial insertion is with tube upside down then twisted into position as it is inserted past the tongue. (tongue may also be displaced using a tongue depressor) • Jaw Trust maneuver may also be used to assist insertion
Endotracheal Tubes: What is the advantages of Oral Intubation?
• Insertion is faster • Less trauma to nasal airway • Tolerates larger tube = decreased airway resistance ( Poiseuille's law) • Less nasal inflammation=Decreased inflammation & nasal secretions i.e. sinusitis • Easier passage of bronchoscope
Tracheostomy Tubes: Indication
• Long term artificial airway • Assist with mechanical ventilation • Chronic ineffective cough i.e. neuromuscular patients • Permanent upper airway obstruction • Radical neck surgery - i.e. cancer, trauma, burn • Emergency laryngeal edema i.e. epiglottitis
Requirements of Pnetamidine:
• MMAD 1- 2 um • "respirgard" filter on exhalation - prevent aerosol exposure • negative pressure room or isolation chamber ( Aerostar) • HEPA fit tested mask
Closed Suction Catheter Kits: Minimize risk of Atelectasis
• Minimize suction time • Minimize suction pressure
Hazards/Precautions of Methylxanthines:
• Must be in therapeutic range to be effective - 8 - 10 mg / ml ( blood level) • Above therapeutic range = toxic > 15 mg / ml • Toxic levels can cause cardiac arrhythmias • High levels can be increased by : • Hepatic metabolism disorders • Acute viral infections • Cardiac failure • Drug interaction i.e. erythromycin, cimetidine • Low levels can be caused by • Cigarette smoking • Phenobarbital ( increase liver clearance ) • Nausea, vomiting , tremors, palpitations, headaches, seizures
List of Nasal Steroids:
• Nasonex, Vancenase, Flonase
Types of doctors that treat asthma
• Primary care doctors • ER doctors • Pediatricians • Allergists • pulmonologists
Which emergency equipment should always be readily available during intubation procedures?
• Resuscitation equipment • Medications • Oxygen • Alternative airway equipment
Nasotracheal Suction: Hazards/Precautions
• Same as endotracheal • Upper airway bleeding & trauma • Contamination of lungs ( sterile) with upper airway secretions ( non-sterile)
List of Long-Acting Bronchodilators:
• Serevent (Salmeterol Xinfoate) • Foradil (Formetorol) • Brovana (Arfomoterol)
Indications of Ribaviran:
• Treat seasonal RSV ( self limiting respiratory disease in infants & children • questionable effectiveness vs. cost
Closed Suction Catheter Kits: Minimize risk of Airway Trauma
• Use Correct suction depth - don't bang on the carina • Soft catheter - i.e. red robin • Murphy hole arrangement • Correct suction setting
What does the Double Lumen tubes do?
• Used to ventilate only one lung. • Used to assist jet high frequency ventilation.
Side Effects of Colistin:
• bronchospasm - • eliminated through urinary system • Neurotoxic - and neuromuscular
Hazards/Precautions of Ribaviran:
• rashes, conjunctivitis, eyelid erythema • can effect or occlude ventilator expiratory valves or filters ( what precaution should be taken if this is nebulized inline on a vent pt?) • Small Particle Aerosol Generator ( SPAG) large volume small particle nebulizer required to deliver to small aerosol to small airways • Expiratory " respirgard" filter to minimize staff exposure • RSV patients - respiratory / aerosol isolation - mask
What is the flow rate conversion of Heliox?
1:4 to 1 L/min.
Maxair: Duration
4 - 6 hrs.
ORIFICIAL RESISTORS: Operates at any __________.
?
Securing ETT Tubes and Tracheostomy Tubes: What is proper placement of an ETT?
?
What are examples of psio-electric nebulizers?
Aeroneb or ultrasonic neb
Aerosol Therapy Aerosol Administration Equipment: __________ Masks Similar to the simple oxygen mask but with two large outlet ports to facilitate evacuation of any exhaled aerosol. These masks are specifically designed to be used with large bore tubing.
Aerosol
A/C.
Assist control mode. All mechanical positive pressure breaths.
Long acting / Control medications -" stays at home"; Inhaled Steroids Mometasone furoate - "Twisthaler" - Ped and adult doses - Q Day
Asmanex
Why are nasal cannula rated 0 LPM to 6 LPM instead of 1 LPM to 6 LPM?
Because other patients that are sensitive to Oxygen take less than 1 LPM. (Neonates)
Why are we worried so much about resistance in nasal cannula?
Because the flow rate is low.
MODES OF VENTILATION: Pressure Control Ventilation (P/C) 1. In P/S, when PIP is reached flow ____________ as long as the patient is making an inspiratory effort. 2. In P/C, when PIP is reached, flow ________.
Continuous; stop
MODES OF VENTILATION: 1. A "______ ______" is ventilator initiated, or time triggered. 2. An "_____ _____" is patient initiated, or flow/pressure triggered.
Control Breath; Assisted Breath
PORTABLE, HOME HEALTH, DELIVERY SYSTEMS: Home Liquid Oxygen Systems Users must be careful to prevent injury from the extremely ________________ at the connectors when filling the portable unit.
Cold temperatures
What is the ranges of BE in a Metabolic Component?
+ or - 2 = normal > 2 = alkalosis < -2 = academia
What value that is considered normal using MIP? A value of - _____ to -_____ cm H2O is considered normal. What value is considered to indicate a need for mechanical ventilation for MIP?
-80 to -100 cm H2O; ≤ -25 cm H2O
TRIGGER VARIABLES: 1. Becoming a more popular triggering mechanism, especially when mechanical ventilation is required for a patient with obstructive pulmonary disease. 2. Usually adjustable from 1 - 5 lpm (from a background flow of 5 - 10 lpm)
Flow
Newer models of Ultrasonic Nebulizers (USN) are used to deliver medications as it limits ______ and ______.
Flow; deadspace
High flow nasal cannulas deliver heated, humidified gas to a patients using a high flow ___________ and either a __________ or__________.
Flowmeter; heated passover humidifier; wick cartridge system
Aerosol Therapy Contraindications: _____ overload
Fluid
The total amount of volume in the lungs after a normal exhalation. (ERV + RV)
Functional Residual Capacity (FRC)
List 3 physiologic responses can occur when inserting & placing an oral airway?
Gag Reflex
Oxygen analyzers that rely on a chemical reaction as oxygen passes through a membrane to measure small amounts of current.
Galvanic O2 Analyzers
Gas Law with the temperature and pressure are directly related. Volume kept constant.
Gay-Lussac's Law
What formula is this? P1/T1 = P2/T2
Gay-Lussac's Law
Influences patient's position.
Gravity
A particle with (greater/smaller) mass, when placed in motion, will have a greater inertia than a particle with a (greater/smaller) mass.
Greater; smaller
Color code of Oxygen (O2):
Green
Color code of Carbon Dioxide (CO2):
Grey
Describes how health information can be obtained and used; Information is a "need to know" basis; must be related to the therapy you are providing.
HIPAA
All are designed to help prevent delivery of the wrong gas.
Indexed Safety Connections
PORTABLE, HOME HEALTH, DELIVERY SYSTEMS: Home Liquid Oxygen Systems The oxygen will evaporate even if the system is not in use, so this system is not a good option for ___________, or ___________ use.
Storage; stand-by
What mask is the bubble humidifier designed for? (if using less than or equal to 7 LPM).
Nasal cannula
Low-flow devices (DO/DON'T) meet the patient's total inspiratory demand.
Don't
Dosage of Methylxanthines:
Dosage - based on maintaining blood level in therapeutic range 8-10 mg / ml • 300 - 1200 mg mg / day divided by Q6 to until therapeutic range is reached
A phase of Principles of Pharmacology that is delivered to respiratory tract via aerosol. • Advantages: topical delivery vs. systemic • Lower dosages • Rapid onset • Targeted delivery • Less systemic effect
Drug Administration
In Principles of Pharmacology, The course of drug action from dose to effect comprises of what 3 phases?
Drug Administration Pharmacokinetics Phase Pharmacodynamic Phase
Endotracheal Tubes: Indications
Emergency or short term artificial airway. • Assist with mechanical ventilation • Improve effectiveness of bag ventilation • Provide stable airway in unconscious or semiconscious patient • Apnea • Foreign body obstructions • Upper airway edema - (emergency tx only) • Assist with endotracheal suction - copious secretions & pt. is unable to remove effectively
Current, disposable masks are not tight fitting and therefore do not prevent the __________ of room air
Entrainment
Fiberoptic Endotracheal Intubation: Advantages
Excellent airway visualization Minimal hemodynamic stress
The wick humidifier has an ___________ humidifier.
External
What is the risk to the patient with the suction catheter weighing down the ET Tube?
Extubation
Antidiabetic Agents inhaled human insulin • Not indicted for COPD, lung disease, or smoking patients • Bronchospastic
Exubera
True/False: You can use more than one sympathomimetic medications.
False; Never use more than one sympathomimetic
(True/False) Oxygen is contraindicated.
False; Oxygen is never contraindicated.
Jet Nebulizer: Small Volume Nebulizer (SVN) are primarily used for short-term, intermittent ______________ delivery.
medication
MDI (Metered Dose Inhalers) Because less medication is deposited in the mouth there tends to be fewer _______ side effects.
medication
Aerosol Therapy Objectives: To deliver _____ to specific areas of the pulmonary system.
medications
PORTABLE, HOME HEALTH, DELIVERY SYSTEMS: Home Liquid Oxygen Systems Are ________ versions of bulk oxygen systems, consisting of a liquid reservoir, a vaporizer coil, and pressure relief valves.
miniature
REDUCING VALVES: Each stage has a pressure relief valve. Counting the number of ______ valves helps to identify the number of stages in the reducing valve.
pressure
ALARM SYSTEMS: Most life-support equipment comes equipped with a _____________.
pressure loss alarm
Neonate ETT Size: 4 kg Tube Size (mm) Oral Tube Length at Lip (cm) Suction Tube Size (Fr)
Tube Size (mm) = 3.5 Oral Tube Length at Lip (cm) = 9.0 Suction Tube Size (Fr) = 8
The ____________ of the current is directly proportional to the amount of oxygen present.
strenght
TRANSPORT: Cylinders should be transported on _______________equipped with a _______________.
suitable carts; restraining chain
MODES OF VENTILATION: Pressure Support Ventilation (P/S) P/S is effective as a ______ tool for patients with obstructive pulmonary disease.
weaning
How do you determine the compensating factor?
whichever component opposes the pH
What results do you expect from your patient for using the peak flow meter that indicates a red zone?
½ of the patient's best day
HME is used as initial method of humidification with mechanically _____________ patients.
Ventilated
Moving _______ into and out of the lungs.
Ventilation
MODES OF VENTILATION: 1. If ______ cycled, the volume during the positive pressure breaths remains constant, but PIP varies, with changes in compliance and resistance. 2. If ______ cycled, the PIP remains constant, but volume varies, with changes in compliance and resistance. 3. The volume of the spontaneous breaths is dependent on patient's _______.
Volume; pressure; effort
BASIC TERMINOLOGY: 1. Basic definition is an injury due to excessive volume. 2. Many authors feel that it is more responsible for damage to the lungs than barotrauma, but the topic is still under discussion. 3. It causes barotrauma
Volutrauma
USE: Cylinder valves should be opened slowly to allow ______________.
dissipation of heat
Pulmicort Respules: Contraindications
do not mix with other inhaled medications
MDI (Metered Dose Inhalers) The canister is activated by pressing ______.
down
TRANSPORT: Cylinders should not be __________, ___________, or ___________ to their destination.
dragged, slid, or rolled
Disadvantages of MDIs Some patients do not respond well to the ___ medications in MDIs.
dry
The supplied gases must be filtered and ________.
dry
STORAGE: The cylinder storage area should be constructed of _______________.
fire-resistant materials
Long-term use of a non-rebreather mask will probably require some way to deliver ____________.
humidification
Aerosol Therapy Objectives: To treat/prevent a ___________ deficit.
humidity
Forced Vital Capacity (FVC) (is/is not) an "effort dependent procedure."
is
Peak Expiratory Flow Rate (PEFR) (is/is not) an "effort dependent procedure."
is
TRANSPORT: During transportation cylinder valve caps should be ___________________.
kept in place
Each cylinder must have a ___________ listing the contents.
label
What is Flunisolide? What is the dosage?
Aerobid (flunisolide), 2 puffs BID
The passive movement of molecules due to a gradient.
Diffusion
Pulse oximeters cannot differentiate between _____
O2Hb and COHb
Pulse oximeters provide continuous monitoring of ___________ saturation.
Oxygen
_____________ pressure (760 mm Hg is considered normal at sea level).
PB
Hazards/Side Effects of Pentamidine:
( similar to symptoms of PCP) • Respiratory - • Bronchial irritation & bronchospasm ( what could be done to minimize this ?) • Dizziness, nausea, rashes, metallic taste • PCP symptoms - night sweats, chills • Renal Failure • Staff exposure issues / nebulizer
How do you perform a Maximum Inspiratory Pressure (MIP) to an alert patient?
1. Disconnect the patient from the ventilator. 2. Connect the patient to the manometer. 3. Coach the patient through the procedure. 4. Repeat the procedure 3 times, if possible, recording the "best" results.
Ultrasonic Nebulizers (USN) Components include: 1. __________ 2. __________ 3. __________ 4. __________ 5. __________ 6. __________ 7. __________
1. A radio frequency generator 2. A Shielded cable 3. A Reservoir chamber 4. A Fan 5. A couplant chamber 6. A chamber for normal saline or distilled water to be nebulized 7. A Piezoelectric crystal/transducer
Adequate oxygen delivery to the __________ requires:
1. Adequate hemoglobin (Hgb) 2. Adequate cardiac output (C.O.) 3. Adequate saturation of hemoglobin with oxygen (SaO2).
EVALUATION AND PATIENT MONITORING: What do you do when there is an adverse effects in patient monitoring?
1. Always include any adverse effects noted. 2. Also include the actions taken once the adverse effect was noted.
Components of a MDI (Metered Dose Inhalers)
1. Canister 2. Propellant 3. Mouthpiece 4. Spacer (optional, but generally used in a hospital setting)
What are the important components of a Bird Ventilator?
1. Center body 2. Ceramic switch 3. Flow control 4. Pressure control 5. Sensitivity control 6. Manometer 7. Expiratory timer control 8. Circuit
Aerosol Therapy Possible Complications: 1. __________ 2. __________ 3. __________ 4. __________ 5. __________ 6. __________ 7. __________
1. Sepsis 2. Swelling of secretions 3. Thermal damage to the airway 4. Retained core body temperature. 5. Fluid overload 6. Bronchospasm 7. Caregiver exposure to droplet nuclei.
Instructions for using Spacers and Chambers (Holding vs. Mixing):
1. Shake medication 2. Blow out slowly 3. Breath in through spacer & Pump A. Holding Chamber Pump then breath in B. Mixing Chamber ( Pump after starting to breath in) 4. Hold breath for 6-10 seconds 5. "don't count a bad puff" 6. How much medicine do I have left
What is the air entrainment ratio for the following: 24% FIO2: _____ 28% FIO2: _____ 35% FIO2: _____ 40% FIO2: _____ 50% FIO2: _____ 60% FIO2: _____
24% FIO2: 25:1 28% FIO2: 10:1 35% FIO2: 5:1 40% FIO2: 3:1 50% FIO2: 1.7:1 60% FIO2: 1:1
Brethine: Dosage
25 - .50 mg - .25 - .5 Ml in 3ml NS
OBJECTIVES FOR IPPB THERAPY: An ideal volume could also be _____ ml/kg of ideal body weight.
30
Formeterol: Peak
30 - 60 min.
Gas Law that is the sum of partial pressures in a sample of gas is equal to the total pressure.
Dalton's Law
What is the diagnostic benefit of thoracentesis?
A. Clear, serous, or transudate associated w/ CHF B. Opaque, milky, cloudy, bloody or exudate fluid associated w/ infections, trauma, tumors - indicates need for cytology & chemistry testing
What are the usual adult sizes for endotracheal tubes?
Adult Female 7 - 7.5 Adult Male 8 - 8.5
Non-Steroidal Antiasthma Agents allergy tx for ages 12 & above was approved in 2003 as a new class of therapy, known as anti-IgE, for patients with moderate to severe persistent allergic asthma. IgE is an antibody that we all have and it is responsible for causing allergic problems in some people. It may reduce allergic reactions by causing free IgE to disappear from the body so that the IgE cannot attach to pollen (and other substances that are present). • Used for controlling persistent asthma - not for rescue
Accolate (Zafirlukast)
Nonsteroidal Antiasthma Medications, Mucolytics • Dose 3 ml 10% solution • May be instilled ( most effective to remove plugs) as well as nebulized • Liquefy thick secretions • Irritation to airways - not recommended for long term use • Aerosolized drug - leaves sticky film on tubing, filters, and internal ventilator sensors
Acetylcystineine - Mucomyst , Mucocil
Long acting / Control medications -" stays at home"; Inhaled Steroids (flunisolide), 2 puffs BID
Aerobid
Prior to use, oxygen analyzers must be checked for _________ functioning.
Adequate
stimulate sympathetic system (epinephrine, norepinephrine); not selective
Adrenergic
What are the basic skills in airway management?
Airway clearance • Suction - Oral Pharyngeal • Suction - Nasal Tracheal • Suction - Endotracheal Artificial Airway Insertion • Oral Pharyngeal • Nasal Tracheal • Endotracheal Assist in performing special airway procedures • Bronchoscopy
Jet Nebulizer: Continuous Medication Nebulizer (a HART or HOPE nebulizer) are designed to deliver a consistent amount of medication to the ______ over several hours (as opposed to the SVN that is used for ______ medication delivery).
Airway; intermittent
ALARM SYSTEMS: A system that is audible and visual which alert the RCP of dangerous conditions. Some may be silenced, some may not.
Alarm System
Indexed Safety Connections: --For high-pressure connections on LARGE cylinders (F through H). --Uses changes in different size, outlet diameter, shape of the gas outlet nipple, and direction of the threads.
American Standard Safety System (ASSS)
Indexed Safety Connections: What are the high pressure connections?
American Standard Safety System and Pin Index Safety System
Aerosol Therapy Indications: Presence of an ____________ airway
Artificial
Why is the nasal tubing in the nasal cannula small?
Because nasal cannula is for very low flow rates.
( comes in injectable vials) • 25 - .50 mg - .25 - .5 Ml in 3ml NS • weaker beta 1 & Beta 2 typically used in patients sensitive to other Beta 2 - i.e. Albuterol • duration 4- 6 hours ( also available in tablet form)
Brethine (terbuatline sulfate)
An odorless, tasteless, and colorless gas that is nonflammable and is not capable of supporting life.
Carbon Dioxide
What is Medical Gas that is a powerful vasodialator?
Carbon Dioxide
The tubing connecting the humidifier to the patient an have a heated wire internally to maintain ___________________.
Carrying capacity of the gas.
Nonsteroidal Antiasthma Medications (Intal, Nasalcrom); Mucous Blockers • Dosage 20 mg . 2 ml unit dose 2-4 times per day • Used for persistent asthma with secretions • MDI - QID dose
Chromolyn Sodium
Each cylinder must be painted with the proper ______________ for the cylinder contents.
Color Code
MODES OF VENTILATION: What are the modes of ventilation?
Control Ventilation Assist/Control Ventilation (A/C) Sinchronized Interminttent Mandatory Ventilation (SIMV) Pressure Support Ventilation (P/S) Pressure Control Ventilation (P/C) Inverse I:E Ratio (IRV) Positvie End Expriatory Pressure (PEE) and Continuous Positive Pressure Airway Pressure (CPAP) Bilevel Positive Airway Pressure (BiPAP)
Gas exiting from the regulator section then passes through a proportioning valve connected to the _______ ________ on the front of the blender.
Control dial
MODES OF VENTILATION: Frequently the term "______ _______" is used to indicate that the patient has not initiated a breath.
Controlled Ventilation
How do you determine the size of the Oral Pharyngeal Airways?
Corner of the mouth to the angle of the jaw
Pulse oximeters are perfusion _________. ( requires blood flow )
Dependant
The efficacy of the Metered Dose Inhalers (MDI) are patient ________.
Dependent
Jet Nebulizer: A Large Volume Nebulizer (LVN) produces a non uniform particle size that does not meet ______ needed for medication delivery.
Deposition
(True/False) Flow patterns are the same as Pressure patterns.
False Flow patterns are different from pressure patterns.
% of O2 in gas. Directly increases ventilation.
FiO2
A high flow nasal cannula is a (variable/fixed) performance device.
Fixed
Site: Bronchi Possible Causes: Chronic bronchitis, tumors Type of Hypoxia: __________
Hypoxic
VT + IRV =
IC
ALARM SYSTEMS: May include Area Alarms in such areas as ____, _____, or _____.
ICU; OR; RR
For safety, calculations are performed after subtracting a certain amount of psig from the gauge pressure. This is done for two reasons:
It gives you a small period of time before the cylinder is completely empty. Vendors prefer that cylinders be returned with some gas still present. Fully empty cylinders must undergo some testing which is not required if the cylinder is still partially full.
What is simple mask usually used for? Why?
It is usually used in recovery after the anestisia.
Jet Nebulizer: A ______ which creates an acceleration in the flow of gas, causing a local pressure drop (Bernoulli Principle)
Jet
Jet Nebulizer: As the liquid is drawn up the capillary tube, it intersects with the ______ stream, which then shatters the liquid into _______ particles, which are then carried out to the patient.
Jet; aerosol
Ratio that focuses on the efficiency of aerosol delivery to lungs • Lungs - topical delivery = therapeutic effect • GI Tract - systemic absorption from oral pharynx = side effects
L/T Ratio
The nasopharynx and oropharynx lead to the ______________.
Laryngopharynx
What is an intubation equipment that is comprised of 2 separate parts; a handle which contains a light source and a blade? These blades are ether curved or straight.
Laryngoscope
Nitrous Oxide (N2O) is also referred to as __________ gas.
Laughing
What is sterile saline used for while suctioning?
Lavage
Where are cylinder valves located?
Located on the top of the cylinder.
What cylinder flaw are we looking for if testing the cylinder using hydrostatic testing at 5/3 pressure.
Looking for expansion
Systemic Corticosteroids Indications: ( questionable results) • COPD - debilitating COPD despite other treatments • Acute severe Asthma - controversial older method - not common front line therapy • Nocturnal Asthma • Apnea of prematurity - used in NICU on premature neonates to prevent apnea Hazards / Precautions: • Must be in therapeutic range to be effective - 8 - 10 mg / ml ( blood level) • Above therapeutic range = toxic > 15 mg / ml • Toxic levels can cause cardiac arrhythmias • High levels can be increased by : • Hepatic metabolism disorders • Acute viral infections • Cardiac failure • Drug interaction i.e. erythromycin, cimetidine • Low levels can be caused by • Cigarette smoking • Phenobarbital ( increase liver clearance ) • Nausea, vomiting , tremors, palpitations, headaches, seizures Dosage - based on maintaining blood level in therapeutic range 8-10 mg / ml • 300 - 1200 mg mg / day divided by Q6 to until therapeutic range is reached
Methylxanthines : aminophylline/theophyllin - Thodur, Slo Bid
How does breaking air in to small bubbles increase the humidity output in a bubble humidifier?
More (small) bubbles increases the surface area of the gas. More bubbles creates more surface in contact with the reservoir.
The warmer the gas, the (more/less) water may be carried as a vapor. Colder gas carries (more/less) water vapor than warm gas.
More; Less
Which intubation route is used in certain emergency situations which can be used with blind insertion to secure the airway?
Nasal Intubation
Gas that is an unstable, diatomic, highly lipophilic free radical, with a faint metallic smell, which is nonflammable but will support some combustion.
Nitric Oxide (NO)
Gas that is highly reactive with oxygen and rapidly produces nitrogen dioxide which is toxic even at very low levels. Also, it is very corrosive when combined with moisture, forming nitrous and nitric acids.
Nitric Oxide (NO)
Gas that may be produced by lightning and the burning of fossil fuels, is found in cigarette smoke, and may be manufactured from a sulfur dioxide/nitric acid reaction.
Nitric Oxide (NO)
Therapeutic use is still classified as experimental at this time but is primarily used in neonate applications to treat severe cases of PPH (persistent pulmonary hypertension).
Nitric Oxide (NO)
1. The most abundant gas in the atmosphere. 2. Under normal conditions it is a colorless, odorless, and tasteless gas, which is chemically inert, nonflammable, and does not support life. 3. Medical uses include providing a zero point when calibrating certain equipment and in diagnostic testing, especially Pulmonary Function Testing (PFTs).
Nitrogen
Bland means:
No meds
Can an Oxygen Analyzer deliver a precise FIO2?
No, Air Oxygen Blender delivers a precise FIO2. Oxygen Analyzers measures precise FIO2.
Do you want to cure patients? (Purpose of HME?)
No, Because you want to make the patients strong enough to promote the healing process. (You want to make patients well enough to cure themselves).
Can you disable the safety alarm in the Air Oxygen Blender?
No, if you do, then you will be jeopardizing your license.
Reservoir bag, one-way valve between the bag and the mask, one-way valves on the exhalation ports are features in a ________________ mask
Non-rebreather
Continuous Med Nebulizers are not to be used with _______ ________ (0.9%).
Normal Saline
Tracheal Airways: Which airway tubes are inserted through the pharynx into the trachea?
Oral and Nasal Tubes
Endotracheal intubation can be performed either _______ or _________.
Orally; Nasally
Pressure to expand lungs indicates compliance "stiffness" of lungs and airway resistance.
PIP
Partial pressure of oxygen.
PO2
Set "pressure" to assist spontaneous breathing during CPAP & SIMV
PSV
The Capnograph uses a trend exhaled CO2 concentrations as a way to estimate _________.
PaCO2
Partial pressure of oxygen in ______ blood.
PaO2
PAO2
Partial Pressure of Oxygen in Alveolar Air
PH2O
Partial Pressure of water vapor (47 mm Hg)
BASIC TERMINOLOGY: 1. The highest pressure recorded on the ventilator manometer during the inspiratory phase. 2. Typically recorded in cm H2O.
Peak Inspiratory Pressure (PIP)
What is Beclomethasone Dipropionate? What is the dosage?
QVAR/ Vanceril (Beclomethasone dipropionate ) 2 puffs 1-2 times per day
Aerosol Therapy Possible Complications: Sepsis Prevention/Action: Use proper technique when ______ or ______ equipment. Change equipment per Department Policy.
Replacing; refilling
R
Respiratory Quotient (0.8, for ease of calculation use 1)
BASIC TERMINOLOGY: The number of ventilatory cycles per minute. Each cycle includes one complete inhale and one complete exhale.
Respiratory Rate (RR)
Respiratory Compensation: How Fast? What is the respiratory compensation reaction used for?
Respiratory compensation is immediate and used for short term or acute problems
Regardless of the patient's ventilatory pattern, no ________ _____ is mixed with the supplied oxygen.
Room Air
BASIC TERMINOLOGY: 1. How much effort the patient must exert to begin gas flow from the ventilator. 2. Usually a result of changes in flow or pressure. 3. If pressure is used, usually this control is adjustable from 0.5 to 2.0 cm H2O. 4. If flow is used, usually this control is adjustable to respond to a drop of 1 to 5 lpm from a base flow of 5 to 10 lpm.
Sensitivity
Long Acting Broncho-dilator adrenergic/sypathomimetic ( Salmeterol Xinfoate) 50 mcg - • alsoy available in discus or in combo with Flovent ( Advair) BID • typically used for exercise induced or nocturnal asthma • Onset 5 min , Peak - 3- 5 hours, Duration - 12hours • Associated with asthma deaths - when used as a rescue medication
Serevent
A VC measurement performed without maximum forced expiratory effort.
Slow Vital Capacity (SVC)
Things that can be seen, quantified, measured. __________ findings.
Signs (objective)
Why is Helium occasionally used to treat some cases of severe lung disease (Asthma, Stridor, ...)?
Since Helium is lighter than Nitrogen, replacing Nitrogen with Helium in inspired gas tends to produce more laminar flow. This may increase alveolar ventilation in some situations, as in severe asthma. However, this is typically a short-term form of therapy.
FLOW PATTERNS: 1. A flow pattern that is most similar to spontaneous breathing. 2. Also very difficult to produce a true sine wave. 3. Frequently not tolerated by the patient.
Sine wave
Used to mix air and oxygen to _______________ concentrations.
Specific
Long acting / Control medications -" stays at home"; Inhaled Steroids Budesonide (Pulmicort) / Formeterol fumarte (Foradil) combo - adult and pediatric doses
Symbicort
What is Budesonide (Pumicort)/Formeterol (Foradil) combined? What is the dosage?
Symbicort- adult and pediatric doses
Things that are felt/experienced by the patient. ___________ findings.
Symptoms (subjective)
Bedside PFT Measuring Devices: 1. Uses the principle of heat transfer from a hot wire to the gas flow. 2. A fine wire is placed in the gas flow. 3. The wire is heated electronically. 4. As the gas flow passes over the wire, the wire is cooled. 5. The degree of cooling is affected by the flowrate. 6. May display flowrate or volume.
Thermistors
Bedside PFT Measuring Devices: 1. Consists of an ultrasonic transmitter and receiver positioned on either side of the flow of gas. 2. An obstructing strut causes eddies (vortices) of known volumes (usually 1 cc per vortex). 3. Results may be affected by moisture and/or medication deposits. 4. Results may be displayed as flow or volume.
Vortex-Shedding Devices
Volume of gas in 1 breath. Directly increases ventilation.
Vt
Humidifier that uses hygroscopic element to increase surface contact with gas.
Wick humidifier
What are the contraindications for the nasal route intubation? What is used instead?
With known or suspected neck trauma or cervical spine instability, nasal bleeding, upper facial fractures, and certain skull fractures, the nasal route is contraindicated. Instead, spine stabilization and use of a bronchoscope with cricoid pressure is preferred.
Is HME better than a bubble humidifier?
Yes, but not nearly as good as a wick
Controls a specific location of the hospital.
Zone Valves
Non-Steroidal Antiasthma Agents: Zieluton
Zyflo
What are other uses for Carbon Dioxide?
a. As a refrigerant b. As a fire extinguisher c. For carbonation d. In water treatment e. As a plant stimulant
What are the possible complications in using the non-rebreather mask?
a. Can feel very confining to the patient. b. Must be removed for eating, etc. c. Can lead to mucosal drying and/or irritation. d. May cause skin irritation.
Carbon Dioxide is the by product of:
a. Human respiration b. Combustion of fossil fuels c. Fermentation d. The decay of animal and vegetable remains.
Pulse oximeters are perfusion-dependent, that is, they will not read ___________ when perfusion is decreased (like when the hands are very cold).
accurately
Polarographic Analyzer: Obstruction of the membrane, as with _________ droplets, can cause an erroneous reading.
aerosol
Jet Nebulizer: Fluid is then accelerated by the jet into a ______ where it is broken into an aerosol where it exits the patient ports.
baffle
What is Parasympatholitic?
block parasympathetic signals such as bronchoconstriction & bradycardia
Pulse oximeters cannot read accurately when there is massive ____loss
blood
To read the dosage, read the ________ of the ball float.
center
Instructions for DPI:
click & breath - Turbohaler, Advair, Maxair
Most Thorpe Tube Flowmeters are _____________ for backpressure, that is, they will read accurately in the presence of backpressure. There are three ways to determine if a Thorpe Tube flowmeter is backpressure compensated: --Look for a statement such as "__________ to 50 psig" printed somewhere on the flowmeter. --Look for the location of the needle valve (very difficult in most flowmeters). --Attach the flowmeter to a50-psig source of gas. If the ball float initially _______ ___ and then ______ back down to the bottom of the tube, the flowmeter is backpressure compensated.
compensated
Metered Dose Inhalers (MDI) requires proper medication mixing to deliver a ______ dose.
consistent
PORTABLE, HOME HEALTH, DELIVERY SYSTEMS: Home Liquid Oxygen Systems The stationary unit is used for ________ use.
daily
STORAGE: A definite area should be ___________ for cylinder storage.
designated
Transcutaneous Monitor uses the skin as an _________ membrane.
electrode
Continuous monitors look at the CO2 value at the ______ of exhalation, called the end-tidal CO2, or PetCO2.
end
MODES OF VENTILATION: As the SIMV rate is decreased, the workload on the diaphragm (increases/decreases).
increases
MDI (Metered Dose Inhalers) Correct use requires patient ________________ and _____________.
instruction; coordination
Disposable CO2 Detectors is a ____ measurement
qualitative
PORTABLE, HOME HEALTH, DELIVERY SYSTEMS: Home Liquid Oxygen Systems Do not require as many _________ as cylinders.
refills
Polarographic Analyzer: The fuel cell must be _________ periodically.
replaced
The (RIGHT/LEFT) main stem bronchus is less angulated from the trachea than is the left main stem bronchus (25 versus 45 degrees) and therefore is more prone to intubation if an endotracheal tube (ETT) is inserted too far.
right
Aerosol Therapy Objectives: To thin/liquefy _____.
secretions
STORAGE: Full and empty cylinders should be stored in ________________ to prevent confusion.
separate areas
Both gases must be at equal psig or a reed alarm will ________.
sound
USE: Never __________ cylinders (i.e. try to refill one cylinder from another cylinder or a bulk delivery system).
transfill
_____________ in the face of backpressure.
uncompensated
Brethine: indication
weaker beta 1 & Beta 2 typically used in patients sensitive to other Beta 2 - i.e. Albuterol
Hazards/Precautions of Prednisone:
• Edema / fluid retention- "moon face" • Petechia - small hemorrhage or blood vessel rupture near skin • Osteoporosis • Immune suppression - increase infection risk - esp. respiratory of opportunistic organisms
Closed Suction Catheter Kits: Minimize risk of Hypoxemia
• Hyper oxygenate • Maintain PEEP - avoid hand bagging, Closed suction
List of Systemic Corticosteroids:
• Prednisone • Methylxantines
What are the Asthma Plan Basics?
• Prevent attack - know my triggers • Know my signals - "signs & symptoms" - Red, yellow or green • Take my rescue medicine • Relax, relax, relax - blow out slow - "pursed lip breathing" • How am I now? - Is my plan working? • If it's not working try it again or get more help • Knowing what to do means "No Fear" = Control
Indications of Pentamidine:
• Second line therapy to prevent PCP in high risk patients ( HIV +) • Previous PCP episodes • CD4 ( T4 cell helper) lymphocyte < 200/ mm • Has been shown to be effective if given in IV form ( eliminates exposure issue with aerosol)
Pulmicort Respules: Dosage
.25 to 1.0 mg in 2ml unit dose 1-2 times per day
Alupent: Nebulizer dosage
.2cc's - .3cc's (10 -15 mg) in 3ml NS
Atropine Sulfate: Dosage
.5 - .1 ml (.4mg per 1ml injectable vial)
How long should an ET Tubes be used?
1 - 2 weeks, discuss trach option on the 4th day the patient is on ET Tube.
What are the sizes for Macintosh blades?
1 - 4, with an average adult requiring a size 3.
Particle sizes between one and five microns (____µ - ____ µ) are clinically optimal for peripheral deposition in the respiratory bronchioles.
1 - 5
Maxair: Dosage
1 -2 puffs (.20mg each) 4 - 6 hrs.
Advantages of Polarographic Analyzers
1. Also provides a continuous reading of FIO2. 2. Can also be used to analyze gas that is in motion. 3. Has an additional power source, therefore response time is faster. 4. The fuel cells last longer because the analyzer can be turned off, stopping the chemical reaction, between uses.
Why is simple mask used and not a nasal cannula in the recovery from anesthesia (post anesthetic)?
1. Because oxygen reduces the half life of the inhaled anesthetic. 2. Because it is short term care; not meant for long term care.
MODES OF VENTILATION: Positive End Expiratory Pressure (PEEP) and Continuous Positive Airway Pressure (CPAP) PEEP/CPAP is contraindicated in the presence of:
1. Bronchopleural fistula 2. Pneumothorax 3. Severe unilateral lung disease a. In this case, the contraindication is for the application of the same amount of PEEP/CPAP to both lungs. b. If the same level of PEEP/CPAP is applied to both lungs, the more compliant lung will be overdistended, while the less compliant lung will be unaffected.
Problems encountered in Transcutaneous Monitor include:
1. Burning of electrode sites. Typically, the electrode is moved every 4 to 6 hours to prevent this complication. 2. Inaccurate readings in poor perfused states.
Nasal Pharyngeal Airways: Insertion Technique
1. Determine and select the correct tube length by measuring from the tip of the nose to the earlobe. Use a tube with the largest outer diameter that will fit the patient's nostril. 2. Lubricate the tube with water, water-soluble jelly, or lidocaine jelly, which will alleviate discomfort 3. Reassure the patient and familiarize him or her with the procedure. 4. Insert the airway into the nostril up to the end of the nasal trumpet. 5. Have the patient exhale with the mouth closed. (If the tube is in the correct position, air can be felt exiting from the tube opening.) 6. Open the patient's mouth, depress the tongue, and look for the tube's tip just behind the uvula.
How do you perform a Maximum Inspiratory Pressure (MIP) to an unresponsive patient?
1. Disconnect the patient from the ventilator. 2. Connect the patient to the manometer. 3. Coach the patient to take a deep breath. 4. During exhalation or during a pause, occlude the inspiratory side of the one-way valve system. 5. Keep occluding the inspiratory side until one of the following occurs: a. You obtain consistent negative pressure readings, or b. You notice a fall in the patients SpO2 reading c. You notice a change in the rate or rhythm on the EKG monitor.
What are the possible complications for the Bedside Pulmonary Function Testing (PFTs)?
1. Dyspnea 2. Dizziness 3. Inaccurate results
What are the different probes used for the pulse oximeters?
1. Ear probes 2. Finger/Toe probes 3. Nose probes 4. Forehead probes
Pulse Oximeters: Clinical applications include:
1. Exercise studies 2. Sleep apnea studies 3. Initial evaluations 4. Continuous monitoring 5. Titration of oxygen therapy 6. Monitoring during transports
MONITORING SYSTEMS: What are the minimal parameters to be monitored?
1. Exhaled Tidal Volume 2. Total Respiratory Rate 3. PIP
A two-point calibration for oxygen analyzer, at 21% and 100%, is performed:
1. Expose the analyzer to room air. 2. Adjust the calibration to read 21% 3. Expose the analyzer to a 100% oxygen environment. a. Calibration is typically done by placing the electrode inside an exam glove and flooding the glove with oxygen. b. The oxygen source should be a wall outlet or a cylinder of oxygen. A blender is not an appropriate source as the blender itself may be inaccurate. 4. Adjust the calibration to read 100% 5. Repeat the procedure until a stable reading at both points is obtained without adjustments.
What are the contraindications for the Bedside Pulmonary Function Testing (PFTs)?
1. Extreme dyspnea. 2. Inability to follow directions. (This does not apply to the MIP measurement for an intubated patient).
EVALUATION AND PATIENT MONITORING: IPPB therapy is said to be effective when at least one of the following criteria have been met. (taken from the AARC Clinical Practice Guideline, 2003 Update).
1. For lung expansion therapy, a minimum delivered tidal volume of at least 1/3 of the predicted IC has been suggested. This corresponds to approximately 1200 ml in a 70 kg adult patient. 2. An increase in FEV1 or PEFR 3. Cough more effective with treatment. 4. Secretion clearance enhanced as a consequence of deep breathing and coughing. 5. Chest radiograph improved. 6. Breath sounds improved. 7. Favorable patient subjective response.
What Bedside Pulmonary Function Test (PFT) is frequently performed as a screening measure or to evaluate the effectiveness of clinical interventions?
1. Forced Vital Capacity (FVC) 2. Slow Vital Capacity (SVC)
Wick humidifiers consists of:
1. Gas inlet 2. Gas outlet 3. Reservoir 4. Disposable wick, usually made of very absorbent paper. 5. Heating element 6. Continuous water feed connection.
What are the standard precautions for IPPB Therapy?
1. Handwashing 2. Gloves, especially if therapy is to be administered via mask 3. Mask if the patient has a communicable pulmonary disease. 4. Other barriers as indicated by the patient's clinical condition.
What are the standard precautions for the Bedside Pulmonary Function Testing (PFTs)?
1. Handwashing 2. Masks if the patient has a communicable pulmonary disease. 3. Other precautions, including the use of negative pressure rooms, as indicated by the patient's clinical condition.
Aerosol Therapy Standard Precautions: 1. __________ 2. __________ 3. __________
1. Handwashing, of course. 2. Gloves when dealing with liquids. 3. Masks if the patient has a communicable pulmonary infection.
Aerosol Therapy Contraindications: 1. ___________ 2. ___________
1. History of reactive airway disease. 2. Fluid overload
What are the types of Hypoxia?
1. Hypoxic Hypoxia 2. Anemic Hypoxia 3. Stagnant Hypoxia 4. Histotoxic Hypoxia
What are the signs and symptoms of Hypoxia?
1. IRRITABILITY 2. Tachycardia 3. Hyperpnea 4. Dyspnea 5. CNS depression as evidenced by a change in Level of Consciousness (LOC). 6. Hypertension and vasoconstriction (sympathetic responses). 7. Cyanosis (a poor indicator). 8. Euphoria
MODES OF VENTILATION: Positive End Expiratory Pressure (PEEP) and Continuous Positive Airway Pressure (CPAP) Beneficial physiologic effects of PEEP/CPAP include:
1. Improved FRC 2. Decreased shunt fraction 3. Improved lung compliance 4. Decreased work of breathing 5. Improved a/A ratio.
MODES OF VENTILATION: Bilevel Positive Airway Pressure (BiPAP) What are the advantages of BiPAP?
1. Improved patient interface 2. Does not inhibit the patient's natural defense mechanisms 3. Allows the patient to eat and drink 4. Allow patient to expectorate secretions 5. Less costly than conventional ventilation 6. Prevention of complications associated with intubation and tracheostomy
What are the contraindications for Oxygen Therapy?
1. In emergency situations, there is never a contraindication to oxygen therapy. Oxygen is a life-saving drug and in emergencies, especially those of cardiac origin, oxygen is always administered. 2. In a VERY SMALL subgroup of patients, once the emergency situation is stabilized, the use of oxygen may be limited. This subgroup of patients will be discussed in detail during the second year of the program. For now, these patients are those with end-stage pulmonary disease, who have a chronically very high level of CO2 in their blood. In these patients, oxygen is administered with care, but again, it is never withheld in emergency situations. 3. Oxygen should be administered with caution to patients suffering from paraquat poisoning and to patients receiving bleomycin or paraquat.
CONTRAINDICATIONS FOR IPPB THERAPY: What are the alternate therapy options for IPPB Therapy?
1. Incentive Spirometry 2. Chest Physiotherapy 3. Deep breathing exercises 4. PEP therapy 5. Flutter valve therapy 6. SVN or MDI for medication delivery
The objectives of Oxygen Therapy are:
1. Increased SaO2 2. Decreased myocardial work 3. Decreased work of breathing
What are the possible complications of IPPB Therapy?
1. Increased airway resistance and work of breathing. 2. Barotrauma and possible pneumothorax 3. Nosocomial infection 4. Hemptysis 5. Hyperoxia when oxygen is the gas source. 6. Gastric distention 7. Impaction of secretions due to inadequate humidity. 8. Psychological dependence 9. Impedance of venous return 10. Exacerbation of hypoxemia 11. Hypoventilation or hyperventilation 12. Increased V/Q mismatch 13. Air-trapping 14. Overdisention of alveoli
MODES OF VENTILATION: Positive End Expiratory Pressure (PEEP) and Continuous Positive Airway Pressure (CPAP) Possible harmful effects of PEEP/CPAP include:
1. Increased barotrauma. 2. Potential for decreased venous return and cardiac output, especially in cases of higher lung compliance. 3. Increased work of breathing if over-distention occurs. 4. Increased pulmonary vascular resistance, again if over-distention occurs. 5. Increased ICP 6. Decreased renal blood flow. 7. Increased deadspace 8. Increased mean airway pressure.
Describe and demonstrate the procedure for Forced Vital Capacity (FVC) to the patient.
1. Inhale as deeply as possible. 2. Place the mouthpiece in your mouth, sealing the lips around the mouthpiece. 3. Forcefully exhale until I tell you to stop.
Describe and demonstrate the procedure for Peak Expiratory Flow Rate (PEFR) to the patient.
1. Inhale as deeply as possible. 2. Place the mouthpiece in your mouth, sealing the lips around the mouthpiece. 3. Quickly exhale, forcing the air out as hard as possible generating the greatest possible force/flow. Try to get all of the air out of your lungs in one big blast.
Describe and demonstrate the procedure for Slow Vital Capacity (SVC) to the patient.
1. Inhale as deeply as possible. 2. Place the mouthpiece in your mouth, sealing the lips around the mouthpiece. 3. Slowly exhale until I tell you to stop.
Describe and demonstrate the procedure for Maximum Inspiratory Pressure (MIP) to the patient.
1. Inhale deeply. Then exhale completely. 2. Quickly inhale as hard and as deeply as possible (Assure the patient that although it will feel odd, because no air will be inhaled, that this will only be for a single breath.)
MONITORING SYSTEMS: What parameters may also be included in the Monitoring Systems?
1. Inspiratory Tidal Volume 2. Minute Volume 3. Machine vs. Proximal airway pressures 4. FIO2 5. I-Time 6. I:E Ratios 7. Mean Airway Pressure (MAP) 8. Sighs
Why don't we use a humidifier with the simple mask?
1. It causes Significant drying of the mucosa 2. Aspiration potential
Ultrasonic Nebulizers (USN) This tap water serves two functions:
1. It completes an electrical circuit 2. It cools the piezoelectric crystal.
Why is the wick humidifier popular?
1. It is very efficient, with minimal deadspace. 2. It is easy to clean and sterilize. 3. Because so little water is in the reservoir, temperature can be adjusted quickly.
What are indications of Oxygen Therapy?
1. Known or suspected Hypoxemia/Hypoxia 2. Increased ____________ Work 3. Increased _________ of _____________ (WOB) 4. Short-term therapy or ____________ intervention (e.g. post-anesthesia recovery). 5. Severe trauma. 6. CO poisoning.
What are the indications for the Bedside Pulmonary Function Testing (PFTs)?
1. Known or suspected obstructive pulmonary disease. 2. Known or suspected restrictive pulmonary disease. 3. Known or suspected exposure to substances which may cause pulmonary disease. 4. Surgery requiring general anesthesia. (ex: open heart surgery)
Do not function well in the presence of: 1. High ____________ volumes. 2. ________ body temperature. 3. The presence of large amounts of ________ ____________.
1. Minute 2. Low 3. secretion
What are the required equipment for Maximum Inspiratory Pressure (MIP)?
1. Negative pressure manometer 2. Briggs adaptor 3. One-way valve system 4. Mouthpiece and noseclips if the patient does not have an artificial airway in place.
Ultrasonic Nebulizers (USN) Hazards of USNs
1. Nosocomial Infections 2. Electrical shock hazards 3. Bronchospasm
Disadvantages Polarographic Analyzers .
1. Obstruction of the membrane, as with aerosol droplets, can cause an erroneous reading. 2. The fuel cell must be replaced periodically replaced.
What are the disadvantages of the Galvanic O2 Analyzers?
1. Once the fuel cell is activated the chemical reaction continues until the electrolyte is exhausted. (It cannot be shutoff) 2. Because chemicals in the fuel cell are continuously being used the fuel cell must be replaced periodically. 3. Obstruction of the membrane, such as with aerosol droplets, will cause an error in the reading. 4. Readings may be affected by high pressures.
Fiberoptic Endotracheal Intubation: Technique
1. Oral route preferable 2. Topical anesthesia with 2% lidocaine on a base of the tongue, hypopharynx and vocal cords (aerosolized 10% lidocaine may also be used) 3. Sedation with midazolam (adult dose 1 to 2.5 mg IV) and fentanyl (adult dose 25-100 mcg IV) 4. "Jaw thrust" maneuver improve visualization 5. Apply oral airway or "bite block" to protect the equipment. Apply 100% oxygen via face mask (oxygen may also be delivered via bronchoscope channel) 6. After the bronchoscope is lubricated and loaded with an endotracheal tube it is introduced strictly in the midline following the base of the tongue, pass the uvula, behind the epiglottis and between the vocal cords. (see video on the left below). 7. Additional topical lidocaine is applied as necessary. 8. Once the main carina is visualized endotracheal tube is introduced by rotating movement over the bronchoscope. Proper position (3-5 cm above the carina) is evaluated and the tube secured. (see video on right below)
HMEs are popular because they: 1. Decrease provider exposure to ________ since there is no liquid water. 2. Allow for longer use of ___________ circuits since these do not get wet when HMEs are used. 3. Are more ____________ than a traditional heater and water humidification system. 4. May be used to provide humidity for patients with _________ _________ _________.
1. Organisms 2. ventilator circuits 3. economical 4. permanent artificial airways
What are the possible complications of Oxygen Therapy?
1. Oxygen Toxicity 2. Apnea secondary to CO2 retention: Hypoxic Drive
What are the types of humidifiers?
1. Pass-over Humidifier 2. Bubble Humidifier 3. Wick Humidifier
What are the required equipment for Peak Expiratory Flow Rate (PEFR)?
1. Peak Flow meter 2. Mouthpiece 3. Noseclips (optional)
MODES OF VENTILATION: Positive End Expiratory Pressure (PEEP) and Continuous Positive Airway Pressure (CPAP) What are the 2 subsets that the PEEP is generally divided into?
1. Physiologic PEEP/CPAP 2. Therapeutic PEEP/CPAP
CONTROL: What changes the ventilator from one phase to another (i.e. from inspiratory to expiratory or from expiratory to inspiratory)?
1. Pneumatic Control 2. Fluid Control 3. Electronic Control 4. Microprocessor Control 5. Combination of pneumatic and microprocessor or electronic controls (all modern ventilators are a combination of the above.)
What are the steps to perform Bedside PFTs using Forced Vital Capacity (FVC)?
1. Prepare required equipment. 2. Explain the purpose of the procedure to the patient. 3. Describe and demonstrate the procedure for the patient. 4. Coach the patient through the procedure step by step. 5. Repeat the procedure 3 times, if possible, and record the "best" result.
What are the steps to perform Bedside PFTs using Peak Expiratory Flow Rate (PEFR)?
1. Prepare required equipment. 2. Explain the purpose of the procedure to the patient. 3. Describe and demonstrate the procedure for the patient. 4. Coach the patient through the procedure step by step. 5. Repeat the procedure 3 times, if possible, and record the "best" result.
What are the steps to perform Bedside PFTs using Slow Vital Capacity (SVC)?
1. Prepare required equipment. 2. Explain the purpose of the procedure to the patient. 3. Describe and demonstrate the procedure for the patient. 4. Coach the patient through the procedure step by step. 5. Repeat the procedure 3 times, if possible, and record the "best" result.
Aerosol Therapy Indications:
1. Presence of an artificial airway 2. Need to deliver medications 3. Need to obtain sputum specimens or mobilize secretions. 4. Hypothermia (heated aerosol) 5. Upper airway edema (cool aerosol)
TRIGGER VARIABLES: What are the 2 most common forms of patient trigger?
1. Pressure 2. Flow
What are the advantages of the Galvanic O2 Analyzers?
1. Provides a continuous reading of FIO2. 2. Can be used to analyze samples of moving gas.
EVALUATION AND PATIENT MONITORING: What are the parameters to be monitored?
1. Pulse before, during, and after. 2. EKG before, during, and after, if available. 3. Repiratory rate before, during, and after. 4. Breath sounds before, during, and after. 5. Level of Consciousness (LOC) before, during, and after. 6. Spontaneous and Positive Pressure volumes. 7. Ventilator settings, especially PIP required to deliver the Vt. 8. PF and VC before and after. 9. Sputum production. 10. Cough. 11. Blood pressure, if available, before, during, and after. 12. SpO2, if available, before, during, and after. 13. ICP in patients for whom ICP is of critical importance. 14. Chest radiograph, if available. 15. Patient's subjective response to therapy: pain, discomfort, dyspnea, improved, same, worse.
Bubble humidifiers consists of:
1. Reservoir 2. DISS gas inlet 3. Gas outlet 4. Diffusing element 5. A pressure relief valve
The pass-over humidifiers consists of:
1. Reservoir 2. Gas inlet 3. Gas outlet 4. May include a float for a continuous feed system
Jet Nebulizer: Components of a Jet Nebulizer
1. Reservoir 2. Jet 3. Capillary tube
What are the Red Zone signs for the Peak Flow Meter?
1. Short of breath while not moving 2. Sucking in at neck or under sternum 3. Blue color on fingers, hands, lips, gums 4. Feeling worse after using inhaler
What are the same general characteristics of all ventilators?
1. Some way to generate a pressure gradient. 2. Some way to control how the gas flow from the ventilator. 3. Some way to deliver the gas from the ventilator to a humidifier. 4. Some way to deliver the gas from the humidifier to the patient. 5. Some way to produce an inspiratory phase and an expiratory phase. 6. Some way to return gas to the ventilator. 7. Some way to monitor what is happening. 8. Some way to change how things happen during the inspiratory and expiratory phases. 9. alarms to tell you when things have changed.
FLOW VARIABLES: What flow patterns are available?
1. Square wave 2. Decelerating wave form 3. Sine wave 4. Variable wave form
Jet Nebulizer: Baffles can be any obstruction in the path of the gas flow and include, but are not limited to:
1. Structures intentionally placed in the path of the gas flow. 2. The walls of the tubing. 3. Bends in the tubing. 4. The walls of the reservoir chamber.
What are the factors that affect humidity?
1. Temperature 2. Surface of area in contact with gas. 3. Time in contact of the reservoir and gas.
What are the 2 reasons why the efficiency of the bubble humidifier decreases?
1. Temperature decreases. Therefore, the carrying capacity of the gas decreases as well 2. Reservoir decreases in size as well as the time and contact of the gas.
What equations are used to predict FI requirements?
1. The Alveolar-Air Equation 2. A/a Ratio
What are the indications of Humidity Therapy?
1. The inhalation of significant amounts of dry gas. 2. The presence of an actual or potential humidity deficit.
What are the indications for IPPB Therapy?
1. The need to improve lung expansion. 2. The need for short-term ventilatory support as an alternative to tracheal intubation and continuous mechanical ventilation (CMV) a. Pulmonary Edema b. Acute Hypoventilation 3. The need to deliver aerosol medications. a. Severe Bronchospasm b. Fatigue due to muscle weakness c. Severe hyperinflation
The amount of water vapor added from a humidifier is dependent upon:
1. The temperature of the gas and liquid. The warmer the gas, the more water may be carried as a vapor. Colder gas carries less water vapor than warm gas. 2. The Surface Area in contact with the water. Increasing the surface area for contact will increase the humidity. Decreasing the surface area for contact will decrease the humidity. 3. The amount of time the gas is in contact with the water. Increasing the amount of time the gas is in contact with the water will increase humidity. Decreasing the amount of time the gas is in contact with the water will decrease humidity.
MODES OF VENTILATION: Pressure Control Ventilation (P/C) What are the 2 things that can happen once the flow stops and PIP is reached?
1. The ventilator cycles. (pressure cycled) 2. The ventilator maintains the pressure for a specific period of time (inspiratory pause - time cycled).
The clinical applications for the capnograph includes:
1. Titration of mechanical ventilation. 2. Identification of some disease states (particularly new pulmonary embolism). 3. An elevated baseline may indicate rebreathing of exhaled gases. 4. Correct placement of an artificial airway. 5. The effectiveness of CPR.
Clinical applications in Transcutaneous Monitor include:
1. Titration of ventilation/oxygenation support (decreased need for ABGs). 2. Non-invasive monitoring to determine shock and/or hypoxemia. 3. Monitoring of patients during transports. 4. Exercise testing. 5. Determining perfusion levels in extremities.
What are the objectives for the Bedside Pulmonary Function Testing (PFTs)?
1. To assess the impact of disease on pulmonary function. 2. To assess the progression of a disease process. 3. To assess the effectiveness of interventions. 4. To screen for possible pulmonary disease. 5. To evaluate surgical risk. 6. To evaluate the patient's ability to breathe independently.
What are the objectives for IPPB Therapy?
1. To assist the patient in taking in deeper breaths than he/she could do spontaneously (usually > the patient's spont Vt). 2. To maintain normal oxygenation and ventilation until medical interventions can correct the cause of hypoventilation. 3. To deliver medications to the lung.
What are the objectives of Humidity Therapy?
1. To prevent mucosal irritation. 2. To prevent/correct a humidity deficit.
MODES OF VENTILATION: Bilevel Positive Airway Pressure (BiPAP) What are the uses of BiPAP?
1. Treatment of obstructive sleep apnea 2. Short term treatment of acute ventilatory failure 3. Patient support after extubation from PPV 4. Treatment of respiratory failure in patients resistant to intubation.
ALARM SYSTEMS: What are the critical alarms?
1. Vent Inop 2. Disconnect Alarm 3. High Pressure Alarm
What are the required equipment for Forced Vital Capacity (FVC)?
1. Volume measuring device capable of handling high flowrates. 2. Mouthpice or mask 3. Noseclips (optional)
What are the required equipment for Slow Vital Capacity (SVC)?
1. Volume measuring device. (Wright's Respirometer, VentiComp-bag, ...) 2. Mouthpiece or mask 3. Noseclips (optional)
What are the standard (universal) precautions?
1. Wash your hands 2. Gloves 3. Masks 4. Gowns 5. Caps 6. Goggles 7. Shoe Covers 8. Sharps Containers
What are the measuring devices for Bedside PFTs?
1. Water-Sealed Spriometers 2. Fleisch Pneumotachometers 3. Thermistors 4. Turbinometers 5. Vortex-Shedding Devices 6. Strain Gauges 7. Peak Flow Meters 8. Mechanical Aneroid Manometers
If a patient is not doing good in a 12 LPM simple mask and you turn it up to flush. Stats are up and patient stabilizes, and you leave for lunch break. What are 2 things that were wrong about this?
1. You can pop the oxygen tube off the flowmeter and the patient will not have flow on going in the mask making breathing so soon, making the patient sleepy. 2. Nobody was notified of patient change of status. You have to notify somebody (Nurses, Physician) of any changes in the patient.
Ranges for Normal COPD ABG's
1.pH, 7.32 - 7.38 (compensated resp. acidosis). 2.PCO2, 45 - 65 (chronic CO2 retention). 3.PO2, 50 - 70 (chronic hypoxemia). 4.HCO3, 30 - 40 (metabolic compensation). 5.BE + 5 - 10 (metabolic compensation). 6.SaO2, 90 - 94 % 9chronic hypoxemia + reduced hypoxic drive). 7.THb, 12 - 17 (chronic hypoxemia = polycythemia "more trucks."
What are suction catheter sizes for pediatric?
10 - 12 fr
A gas must have a RH of _____% before it will carry aerosol particles of water.
100%
In clinical use, however, the FIO2 is typically reported as _____ because this is the highest FIO2 available with a non-invasive device.
100%
Jet Nebulizer: A Continuous Medication Nebulizer (a HART or HOPE nebulizer), is one with a reservoir which holds _____ to _____ cc of liquid.
100; 200
The Maximum flow rate for a simple mask is ____ to ____ LPM.
10; 12
OBJECTIVES FOR IPPB THERAPY: During Pulmonary Edema a Vt of _____ - _____ ml/kg of ideal body weight is adequate.
10; 15
Continuous Med Nebulizers: A mini-hart is ___ ml. and gives ___ hour(s) to ___ hour(s) neb treatment.
10; 1; 4
What are suction catheter sizes for adults?
12 - 14 fr
CONTRAINDICATIONS FOR IPPB THERAPY: Increased intracranial pressure (ICP) > _____ mm Hg
15
What size needle is used for evacuation in thoracentesis?
16 gauge needle
Atrovent: MDI Dosage
2 - 4 puffs (.07mg each) QID
Albuterol: MDI Dose
2 - 4 puffs (.09 mg each) Q4-6H PRN
Alupent: MDI dosage
2 - 4 puffs (.65 mg each) 4 - 6 PRN
What is external diameter sizes for endotracheal tube?
2 - 9 French
Oral Pharyngeal Airways: Describe the Berman
2 channels down each side of the airway
All analyzers require a ___ point calibration.
2 point
The required 2 pt. calibration for Oxygen Analyzers are _____% for room air and _____% to fill a plastic bag from an O2 flow meter and stick the sensor in.
21%; 100%
What size needle is used for local anesthesia before performing Thoracentesis?
22 - 23 gauge needle
What is the ranges of HCO3 in a Metabolic Component?
24 mmeq = normal (if pCO2 in 40) > 24 = metabolic alkalosis (if pCo2 = 40) >24 = metabolic acidosis ( if pCo2 = 40)
Alveolar FIO2 in a high flow nasal cannula is adjustable from ____% to ____%.
24%; 60%
Ultrasonic Nebulizers (USN) Use high frequency sound waves to produce a fine aerosol with the majority of particles in the range of ______ µ.
3
Albuterol: Duration
3 - 4 hrs.
Serevent: Peak
3 - 5 hrs.
What is the conversion factor for H-cylinder?
3.14 L/psig (3.0)
Nasal cannulas at flow rates of ≤_____ LPM, usually does not require humidification.
4
Transcutaneous Monitor: The skin under the electrode is heated to between ______ C and _______ C.
43 C; 44 C
How much water vapor is present at 37 degrees Celsius and 47 mm Hg of pressure?
44 mg/L
What is the specific humidity once it is pass the carina?
44 mg/L
At BTPS conditions, gas can carry a maximum of ____ mg/L of water vapor, which exerts a partial pressure of water vapor (PH2O) of ____ mm Hg.
44 mg/L; 47 mm Hg
What is the pressure of water vapor?
47 mm Hg
What is the PH2O at Alveolar Level?
47 mmHg
A lung volume has ___ volumes and ___ capacities.
4; 4
A Micro-Nebulizer delivers ≤ ___ ml.
5
Albuterol: Onset
5 - 10 min.
Advantages of MDI over SVN Of the medication placed in a SVN, even under the best of condition, only about ___ - ___% actually enters the patient's lungs. The other ___ -___% is wasted medication. Compare this to the MDI, which, especially when combined with a _____, results in nearly all of the dosage entering the lungs. That is why, next year when you look at typical dosages, a much larger amount of liquid medication is required to obtain the same effect as a small amount of the same medication delivered by MDI.
5%; 10%; 90%; 95%; spacer
A tank containing gas or a gas mixture under pressure (usually ______ to ______ psig when full).
50
Maximum FIO2 available for a simple mask is approximately _____%.
50
What is the standard working pressure?
50 psig
The maximum FIO2 for Large Volume Nebulizer (LVN) is ____%.
50%
Require a ___-psig source for oxygen and a ___-psig source for air.
50-psig; 50-psig
Jet Nebulizer: A Large Volume Nebulizer (LVN) can use greater than _____ ml.
500
Jet Nebulizer: A Large Volume Nebulizer is one with a reservoir volume of > ______ cc.
500
Serevent: Dosage
50mcg
Minimum flow rate of a simple mask is ____ LPM. For safety reasons the usual clinical minimum flow rate is ____ LPM.
5; 6
MODES OF VENTILATION: Pressure Support Ventilation (P/S) 1. At low levels of support, such as _____ cm H2O, P/S can remove the work required to overcome the resistance to gas flow through an artificial airway. 2. At higher levels of support, _____ can remove a portion of the work required to provide adequate ventilation. 3. At P/S levels which result in a Vt of ___ - ___ ml/kg ideal body weight, the ventilator is assuming almost all of the work of breathing.
5; Pressure Support Ventilation (P/S); 8; 10
The maximum flow rate of a nasal cannula is ____ LPM.
6
Jet Nebulizer: Small Volume Nebulizer (SVN) generally require a gas flowrate of ___ - ___ lpm to function properly.
6 - 10 LPM
Xopenex: Duration
6 - 8 hrs.
What are the safe pressure ranges for infants while using a suction regulator?
60 - 80 mm Hg
What is the PaO2 if hypoxemia is mild?
60 - 80 mm Hg
The delivered FIO2 in a non-rebreathing mask is approximately _____ to _____, depending on the patient's ventilatory pattern and the fit of the mask.
60%; 80%
OBJECTIVES FOR IPPB THERAPY: A Vt of _____ - _____ ml/Kg of ideal body weight should be sufficient in this case.
6; 8
Bubble humidifiers generally uses flows less than or equal to ______ LPM.
7
If you have a flow rate to 10 LPM going to a bubble humidifier, what is the flow rate are patients getting? Why?
7 LPM. Because bubble humidifiers are designed to use ≤7 LPM and the excess flow goes out of the pressure relief valves in the bubble humidifier due to back pressure.
A value of > _____% of predicted is considered normal in Slow Vital Capacity (SVC).
80
A value of > _____% of predicted is considered normal in a Peak Expiratory Flow Rate (PEFR). A value of < ______% of predicted is generally considered to be indicative of a bronchospastic crisis requiring further interventions in a Peak Expiratory Flow Rate (PEFR).
80; 50
OXYGEN STORAGE: One (1) cubic foot of liquid oxygen, stored at -300o F, produces ___________ of gaseous oxygen at 70o F
860 cubic feet
MODES OF VENTILATION: Positive End Expiratory Pressure (PEEP) and Continuous Positive Airway Pressure (CPAP) Physiologic PEEP/CPAP 1. This refers to PEEP/CPAP levels of ____ cm H2O. 2. In this case, the PEEP/CPAP is being used mimic the normal action of the ______, not allowing the pressure in the lungs to completely equilibrate with atmospheric pressure at the end of exhalation.
< 5; epiglottis
What is the pH range for acidemia?
< 7.40
Cuff Pressures and Volumes: What is the appropriate Cuff Pressure? Why?
<10 cc. You don't want to over inflate the cuff because it can cause tissue necrosis in the trachea.
Advantages of MDI over SVN Patients can be taught proper use of the MDI prior to discharge from the acute hospital. They can be monitored for several days, verifying their understanding of the technique. In addition, this allows time for the patient to ask questions. These sessions have been shown to result in better patient understanding, use, and compliance than trying to do a quick 10 minute teaching session just before the patient is discharged.
?
Aerosol Therapy Possible Complications: Retained core body temperature. Prevention/Action: Place a thermometer in-line to monitor temperature. Unless the indication for aerosol therapy is hypothermia, keep the delivered temperature < _____o C. This is a concern only when delivering a heated aerosol to the patient with a fever. In this case, the aerosol could eliminate one of the ways the body gets rid of excess core body temperature (i.e. through the warming and exhaling of cool gases).
?
Aerosol Therapy Possible Complications: Thermal damage to the airway Prevention/Action: Place a thermometer in-line to monitor temperature. Unless the indication for aerosol therapy is hypothermia, keep the delivered temperature < _____o C. This is only a concern if using a heated aerosol.
?
As resistance to flow increases, the flowmeter becomes ___________, reading a ___________ flowrate than that actually delivered.
?
Cuff Pressures and Volumes: What is minimal leak technique?
?
Cuff Pressures and Volumes: What is minimum occluding volume technique?
?
Cuff Pressures and Volumes: When should a cuff be inflated?
?
Inspired gas is then __________ and _____________ as it passes through the exchanger.
?
MDI (Metered Dose Inhalers) Use of the spacer provides for greater deposition of medication in the ___________, with less being deposited in the ____________.
?
MEDICAL AIR SYSTEMS: Each ____________ must be capable of delivering 100% of the calculated peak demand in the event the other ____________ fail.
?
MEDICAL AIR SYSTEMS: The location of the _____________'s ambient air intake is particularly important to help eliminate or minimize contaminants.
?
Nasal Pharyngeal Airways: What special risk is associated with topical Lidocain?
?
ORIFICIAL RESISTORS: A device that uses opening ______ to _____________ the movement of air through the device
?
ORIFICIAL RESISTORS: This device (is/is not) _____ pressure compensated
?
OXYGEN STORAGE: Cylinder/Liquid Systems This system uses cylinders as an _____________ supply only.
?
OXYGEN STORAGE: Cylinders only Generally used when demand is _____, as in _______ facilities. This system usually holds only a little more than the average daily supply.
?
OXYGEN STORAGE: Have _______ _______ between each cylinder and the header to prevent loss of gas due to a leak in a single cylinder.
?
On patient extubation, is it safe to cut the pilot balloon instead of deflating cuff?
?
PORTABLE, HOME HEALTH, DELIVERY SYSTEMS: Home Liquid Oxygen Systems The portable unit, filled from the stationary unit, is used for traveling, usually lasting ____ - ____ hours, depending on the flowrate.
?
Securing ETT Tubes and Tracheostomy Tubes: How is ETT placement confirmed?
?
Securing ETT Tubes and Tracheostomy Tubes: What are the indications an ETT is too high?
?
Securing ETT Tubes and Tracheostomy Tubes: What are the indications an ETT is too low?
?
Securing ETT Tubes and Tracheostomy Tubes: What are the risks of using adhesives?
?
The _________ of the water column affects the ________ the gas is in contact with the water.
?
The wick provides a greater ____________ ________ for the gas and water to interface.
?
What are the 3 major risks / hazards of extubation? How can these risks be minimized?
?
What are the advantages of an uncuffed trach?
?
What are the risks & advantages of a cough to remove the tube during extubation?
?
What are the signs of an obstructed ETT?
?
What is a Jackson trach?
?
Why do we administer humidity or cool aerosol after extubation?
?
What is a "Murphy Hole" in a single use suction catheter kits?
A "Murphy Hole" is the hole right above the tip of the suction catheter. Its purpose is to increase suction surface area.
Difference between the oxygen level in Alveoli and artery. Indicates level of oxygenation + diffusion problems.
A - a gradient
Serevent is associated with asthma deaths when it is used as:
A Rescue Medication
What are the risks of bronchoscopy?
A. bleeding B. edema / spasm - broncho & larygospasm C. pneumothorax D. trauma E. hypoxia
Total ventilatory support
A/C.
What equation is this? Known PAO2/Known PaO2 = Desired PAO2/Desired PaO2
A/a Ratio
End-Tidal used mostly as a "trend" value and must be correlated with an ___
ABG
Long acting / Control medications -" stays at home"; Inhaled Steroids Servent & Flovent combinations in dry inhaler Dosages 100/ 50 , 250/ 50, or 500 mcg Flovent/50 mcg Serevent
ADVAIR Discus
Safety System that is used in High Pressure and Large cylinders (H and K). Uses thread and nipple size.
ASSS
Air trapped inside lungs by ventilatory and airway collapse. Can not be seen on Press gauge. Hidden Hazard.
AUTOPEEP
CONTRAINDICATIONS FOR IPPB THERAPY: An acute pneumothorax without a chest tube is an (Absolute/Relative) contraindication to IPPB Therapy.
Absolute Note: Absolute contraindication means do not do this. Relative contraindication means to think --- do the benefits outweigh the risks?
Heliox: Indication
Acute upper airway obstruction i.e.. Foreign body, mass or tumor or severe asthma airway obstruction
What effect does each of the 4 classifications have on the Cardioplumonary system? Give one medication example of each of the 4 classifications.
Adrenergic - causes vasoconstriction by stimulating the sympathetic system; Tachycardia (Epinephrine) Antiadrenergic - prevents vasoconstriction by blocking the sympathetic system (Atrovent) Cholinergic - causes vasodilation by stimulating parasympathetic system. (Acetylcholine) Anticholinergic - prevents vasodilation by blocking the parasympathetic system; Bradycardia (Atrovent)
What is the advantage and the disadvantage of the Galvanic O2 Analyzer?
Advantage: It gives a continuous reading Disadvantage: It cannot be turned off
Continuous Med Nebulizers: Patients must be monitored when receiving continuous neb treatments for ______ ______.
Adverse reactions
Particles suspended in a column of gas.
Aerosols
Aerosols are an _____________ of water molecules.
Aggregate
What are the Therapeutic Gases?
Air Oxygen Nitric Acid He/O2 CO2/O2
Chest Tubes: What type of drainage occurs when a tube is inserted on anterior chest 2nd intercostal space at mid clavicular line?
Air Drainage
Device used to deliver a precise FIO2
Air Oxygen Blenders
CONTRAINDICATIONS FOR IPPB THERAPY: A bulla is defined as an ____ _______ in the lungs that measures > 1 cm in diameter in it's distended state.
Air Space
What are the 2 gas sources for Air Oxygen Blenders?
Air and Oxygen (O2)
How do you determine the air and fluids in an X-ray image?
Air: Dark with lung markings White: Fluid
Proventil and Ventolin is another name for:
Albuterol
• Nebulized dosage = 2.5mg in 3 ml NS ( most common Beta 2 agonist with less HR effects compared to earlier meds ( such as Bronkosol, Isuprel, & Alupent) • MDI Dose - 2- 4 puffs (.09mg each) Q4-6 hours PRN • onset - 5- 10 minutes • Peak 20 minutes • Duration 3- 4 hours • Most commonly used "Rescue medication" • Continuous Nebulizer dosage 7.5 - 20 mg per hour ( ER tx) • Can lower serum "K" potassium levels
Albuterol (Proventil, Ventolin)
What advantages are being used with the wick humidifier?
All of them. Temperature, time, surface area, and contact.
Medication that is commonly used for patients that have allergic or poor tolerance to Albuterol.
Alupent
Metaprotenol is another name for:
Alupent
• Nebulizer dosage.2 cc's - .3 cc's (10-15 mg)in 3 ml NS • MDI dosage 2-4 puffs (.65 mg each) 4-6 PRN • ( stronger HR & tremor side effects but is commonly used for patients that have allergic or poor tolerance to Albuterol ) • NEVER USE MORE THAN ONE SYMPATHOMIMETIC
Alupent ( Metaproterenol)
Venturi masks are designed to deliver a precise, consistent ___________ FIO2.
Alveolar
While Relative Humidity can be calculated for any gas temperature, provided the humidity table is available, clinically we are only interested in the RH of gas at the conditions that exist at the ___________ level.
Alveolar
__________ FIO2 is set using a blender.
Alveolar
Laryngeal Mask Airways (LMA): Indications:
Anesthesia and in emergency medicine for airway management. A patient who is trapped in a sitting positing. Patient with suspected trauma to the cervical spine When intubation is unsuccessful
Gas used for response
Anesthetic Gases
blocks sympathetic system - blocks receptor site for epinephrine
Antiadrenergic
blocks parasympathetic system - blocks receptor site for acetylcholine; Parasympatholitic
Anticholinergic
Used to treat chronic bronchitis • parasympatholitic - "block parasympathetic signals such as bronchoconstriction & bradycardia" • can be used with Sympathomimetics - "synergist effect" • may also be used if patient is using Beta Blocker ( i.e. Inderal)
Anticholinergics
Fiberoptic Endotracheal Intubation: Indications
Anticipated difficult intubation (upper airway abnormality) Endotracheal intubation when neck extension is not desirable (cervical spine injury, rheumatoid arthritis)
What is Mometasone Furoate? What is the dosage?
Asmanex - Mometasone furoate - "Twisthaler" - Ped and adult doses - Q Day
Peak Expiratory Flow Rate (PEFR) is typically performed before and after bronchodilator therapy to ________ the ____________ of therapy.
Assess; effectiveness
MODES OF VENTILATION: 1. Mechanical breaths may be patient initiated or ventilator initiated. 2. Guarantees the patient a set respiratory rate, but allows the patient to increase the minute volume in the event of physiologic changes. 3. The patient can trigger, or "assist" the ventilator at any rate above the minimum. 4. Each delivered breath is at the set tidal volume...volume is constant despite changes in compliance and resistance. However, PIP will vary with changes in compliance and resistance. 5. Volume cycled, patient or time triggered, flow limited. 6. Places a minimal workload on the diaphragm.
Assist/Control Ventilation (A/C)
(fast acting & drying) • 0.5 mg in 3 ml unit dose for nebulizer • MDI dose 2-4 puffs (.07 mg each)QID • Blocks signals that are closing the airway • Atrovent & Albuterol = "Combivent"- MDI or "Duo Neb" - nebulizer pre mix • Can dry airways - • Peanut allergy alert & Glaucoma alert
Atrovent
What is Triamcinolone Acetonide? What is the dosage?
Azmacort (Triamcinolone acetonide), 2- puffs BID
Non invasive ventilation uses mask ventilation instead of intubation tube. Similar to PSV and CPAP.
BIPAP
What is added to the inspired air through the mucus lining of a patient's airways?
BTPS (Body Temperature Pressure Saturated)
What is a croup?
Bacterial or viral
PB
Barometric Pressure (760 mm Hg)
BASIC TERMINOLOGY: 1. Basic definition is an injury due to excessive pressure. 2. Pulmonary barotrauma is defined as extra-alveolar air from lung damage secondary to changes in intrathoracic pressure.
Barotrauma
What are baffles?
Barriers
Why is Heliox actual flow higher than the set flow?
Because Heliox is low density (less dense) which gives it a higher flow.
Why does Helium need to be combined with Oxygen? What can happen if given a 100% Helium?
Because Helium does not support life. Breathing 100% Helium will rapidly cause hypoxia or death.
Why don't we use the bubble humidifiers in simple masks?
Because bubble humidifiers are designed for flow rates between 4 to 6 LPM. Simple masks are designed to handle flow rates 6 to 10 LPM. Nasal cannula is the mask to be used with the bubble humidifier.
Why can't we use sterile water to lavage or rinse the specimen?
Because it can alter the form of microorganisms in the sputum sample.
Why study Gas Laws?
Because it is an important part of the study of pulmonary physiology; Gas Laws explain how and why things work.
Why is racemic epinephrine no longer the preferred short acting aerosolized medication for the treatment of asthma?
Because it is overused in dieting by the people. It causes tachycardia.
How does the Mean Airway Pressure (MAP) benefit oxygenation to the patient?
Because it prolongs the stretch of the lungs and it improves oxygenation.
Why is "low-flow" is being replaced with the term "variable performance"?
Because the amount of room air that is mixed with the supplied oxygen varies with each breath, so the alveolar FIO2 varies with each breath.
Venturi Masks use __________, ___________, and ___________ to provide a consistent FIO2 at the patient interface.
Bernoulli's Principle; Venturi's Principle; Constant-Pressure Jet Mixing
MODES OF VENTILATION: Bilevel Positive Airway Pressure (BiPAP) Mode of ventilation that is similar to CPAP in that it maintains an elevated baseline to increase FRC but allows the addition of a PS type of assist (IPAP) to support ventilation. It can be administered with a face or nasal mask and is referred to as non-invasive positive pressure ventilation (NIPPV).
BiPAP
What are the most common units used to deliver IPPB?
Bird Mark Series Ventilators
These are typically used for intermittent therapy, but could be used for continuous mechanical ventilation, provided the proper monitors and alarms are added.
Bird Ventilators
Atrovent: Characteristics
Blocks signals that are closing the airways
Color code of Nitrous Oxide (N2O):
Blue or Light Blue
These conditions are referred to as BTPS conditions (_____ ____________ ____________ ________________).
Body Temperature Pressure Saturated
What does BTPS stand for?
Body temperature Pressure Saturated
What happens to the turbulence and resistance when flow rate increases?
Both turbulence and resistance increase.
Terbualtine Sulfate is another name for:
Brethine
Aerosol Therapy Possible Complications: Bronchospasm Prevention/Action: Review the patient's chart for indications of previous bronchospasm, reactive airways disease, or asthma. If these conditions exist, request an order for a __________________ before beginning therapy. Monitor all patients, even those without this history, for signs of bronchospasm once therapy is started.
Bronchodilator
Ultrasonic Nebulizers (USN) Hazards: __________ -- this type of nebulizer is the most likely to cause bronchospasm in individuals prone to bronchospasm. This is because these units produce a dense mist consisting of very small particles.
Bronchospasm
Long Acting Broncho-dilator adrenergic/sypathomimetic (Arfomoterol) • Bid Peak 15 minutes, Peak 30 - 60 minutes, Duration 12 hours
Brovana
Color code of Helium (He):
Brown
Type of humidifier that allows air to enter to a reservoir via a capillary tube where it picks up humidity as it moves toward the patient. The most common type of humidifier used for oxygen therapy.
Bubble Humidifier
What is the least efficient of the humidifiers?
Bubble Humidifiers
System that is used as a back-up system for facilities using liquid systems.
Bulk Gas Distribution System
PORTABLE, HOME HEALTH, DELIVERY SYSTEMS: Cylinders: Are _______, _______, and take up a lot of room in the home.
Bulky; ugly
CONTRAINDICATIONS FOR IPPB THERAPY: A pulmonary condition in which there are isolated changes with development of bullae.
Bullous disease (aka bullous emphysema)
How would you assess that the effectiveness of the Prednisone therapy?
By assessing pt. breathing.
USE: Always use the appropriate _______________ to access cylinder contents. Do not attempt to interchange regulators.
CGA connector
High flow nasal cannula is often used as a __________ alternative for neonatal care.
CPAP
MODES OF VENTILATION: Positive End Expiratory Pressure (PEEP) and Continuous Positive Airway Pressure (CPAP) The term ______ is generally used when referring to an elevated baseline with spontaneous breathing.
CPAP
Total spontaneous breathing with continuous airway pressure to keep lungs & airways open. No ventilatory support.
CPAP
Atrovent: Contraindications
Can dry airways Peanut allergy alert & Glaucoma alert
What are the possible complications using a simple mask?
Can feel very confining for the patient.; Must be removed for eating, etc.; May cause skin irritation.
Albuterol: Contraindication
Can lower potassium levels Increase HR
Siphen tube is ________ tube
Capillary
Transcutaneous Monitor: The increased surface temperature causes increased ______ _______ ________ to the area.
Capillary blood flow
Jet Nebulizer: A _______ _______ connecting the liquid in the reservoir with the area of the local pressure drop, causing the liquid to be drawn up the capillary tube (Venturi Principle).
Capillary tube
Device that measures CO2 levels inline with the patient respiration.
Capnograph
What is another name for End-Tidal CO2 Monitor?
Capnograph
The ______ (at the level of the angle of Louis, about T5) is the point of airway bifurcation, leading to the left and right main stem bronchi.
Carina
Ultrasonic Nebulizers (USN) are (expensive/cheap)
Cheap
What indications or test to know if a cylinder is aluminum?
Check with magnet (if magnetic), label, flat bottom
The capnograph monitors have a _______ _______ paper that turns different colors in the presence of different levels of CO2:
Chemically active
What is the treatment for gas or fluid in pleural space? > 20%
Chest Tubes
Aerosolized Antinfectious Agents Treatment for sensitive strains of Pseudomonas Aeruginosa ( CF) and for Acinetobacter baumanni Side effects- • bronchospasm - • eliminated through urinary system • Neurotoxic - and neuromuscular blockade - possible respiratory failure
Colistimethate Sodium - Colistin
Suction Chest Drainage systems: A chamber proximal to the patient tubing that collects pleural drainage.
Collection Chamber
Mixed gases in a cylinder are indicated by ______________.
Color Combination
The presence of the correct, required gas is verified in three ways: --By the _______ of the cylinder. --By the description of the contents as listed on the _______. --By the type of ______ __________ ________which fits on the cylinder.
Color; label; safety system
What is the gas law that combines Boyle's, Charles', and Gay-Lussac's Law?
Combined Gas Law
Medical Air can be manufactured by:
Combining oxygen and nitrogen in the appropriate concentrations (rare); Using either the Linde or the Claude Process to produce liquid air; Using compressors to provide supplies (the most common method).
What is the mixture of Atrovent and Albuterol in MDI form called?
Combivent
BASIC TERMINOLOGY: 1. A measurement of how easy or how difficult it is to change/deform an object. 2. Is the inverse of elasticity, which is defined as how easily an object returns to its original shape after having been deformed. 3. Measured in units of cc/cm H2O.
Compliance
PIP/ VT = Compliance Opposite of elasticity. Static vs. Dynamic
Compliance
Stiffness/ elasticity of lungs
Compliance
Uses the concepts of Bernoulli's and Venturi's Principles to provide for an accurate mixture of air and oxygen. The delivered FIO2 is controlled by varying the size of the jet nozzle and/or the size of the entrainment port.
Constant-Pressure Jet Mixing
Jet Nebulizer: Large volume Nebulizers (LVN) should not used to nebulize ________ _________. Why?
Continuous medication; Because they produce too many large particles that do not enter the airways.
CPAP
Continuous positive airway pressure
Jet Nebulizer: Large Volume Nebulizers are primarily used for ______, ______ aerosol therapy, nebulizing ______ water.
Continuous; bland; sterile
MODES OF VENTILATION: 1. No provision for the patient's own efforts to breathe. 2. Mechanical Breath are initiated by the ventilator. 3. Patient effort will not start a breath no matter how much effort is made.
Control Ventilation
How can you tell if a reducing valve has a single or multi-stage?
Count the number of pressure relief valves
Bubble Humidifier: 1. Gas enters the humidifier through the ______ fitting on top. 2. Gas flows down through a hollow tube to a __________ element. 3. The __________ breaks up the gas flow into small bubbles. 4. As the gas bubbles float to the surface, the water ___________ into the bubbles.
DISS; diffusing element; diffuser; evaporates
What are the Gas Laws?
Dalton's Law, Poiseuille's Law, Boyle's Law, Charles' Law, Gay-Lussac's Law, Ideal Gas Law, Combined Gas Law.
FLOW PATTERNS: 1. A flow pattern that provides better alveolar ventilation. 2. As the flowrate decelerates, flow becomes more laminar. 3. Difficult to produce a true decelerating wave form.
Decelerating wave form
Alarms: What causes High Pressure Alarms?
Decrease in lung compliance and resistance
With the temperature held constant. If the pressure increases, the volume will ___________, and if the pressure decreases, the volume will ___________. This gas law is _____________ Law.
Decrease, Increases, Boyle's
He/O2 (Heliox) has ___________ density of gas.
Decreased
Respiratory Compensation: Decreasing CO2 = ________ acid = respiratory ________
Decreasing CO2 = decreasing acid = respiratory alkalosis
Aerosol Therapy Possible Complications: Swelling of secretions Prevention/Action: Monitor the patient recently placed on aerosol therapy for ______ in condition. Encourage ______ or ______ as necessary to mobilize secretions. A concern in the patient who is dehydrated. Providing high humidity may cause _____ secretions to swell as they absorb water, and these secretions may _____ airways.
Deterioration; coughing; suction; dry; block
By adding _____________ is the only way to make the bubble humidifier more efficient.
Diffuser
A _____________ can be added to the bubble humidifier to break the air into smaller bubbles within the reservoir. What is the purpose of this?
Diffuser; small bubbles increases the surface area of the gas increasing the humidity output.
ALARM SYSTEMS: 1. Indicates that the patient is no longer being ventilated as desired. 2. May be achieved by monitoring any of the following: a. Exhaled Tidal Volume b. Exhaled Minute Volume c. PIP
Disconnect alarm
A chemically active paper that use a color change to determine the presence of CO2. (Single Breath only) It is also used to immediately verify End-Tidal tube placement.
Disposable CO2 Detectors
What are sharps containers used for?
Disposal of needles and blades to avoid needle accidents that might be contaminated.
The height of the water column does not effect humidity, only the ________ of the air/water Surface (known as the fetch)
Distance
Ultrasonic Nebulizers (USN) _______ water does not have the ions necessary to complete the electrical circuit, so the unit will not function if distilled water is used in the ______ chamber.
Distilled; couplant
Laryngeal Mask Airways (LMA): Contraindications:
Does not protect from aspiration.
Nonsteroidal Antiasthma Medications, Mucolytics (used in Cystic Fibrosis patients) • 2.5 mg unit dose 1-2 times per day • use separate nebulizer do not mix with other aerosol meds • Clone of Pancreatic Dornase - missing in CF patients • Reduces viscosity in infected secretions. • Natural enzyme with few side effects • More expensive then other mucolytics
Dornase Alfa - Pulmozyne
Dosage of Prednisone:
Dosage: (0.5 - 1.0 mg / Kg / day) • Typical dosage 5 - 50 mg per day for 10 - 14 days • Dosage is typically reduced slowly = wean patient off • Tablets - 1,5,20, & 50 mg
What are the Specialized ET Tubes?
Double Lumen Tubes
Aerosol Therapy Aerosol Administration Equipment: ______ bags Placed at a low point in the tubing, between the aerosol generator and the patient, to collect condensation (also called rainout).
Drainage
Gases must be _______ when using Air Oxygen Blenders.
Dry
High Minute Volume (VE) cause ______ and ______ of secretion.
Dryness; thickness
The capnograph ___________ measures CO2.
Dynamically
The feeling of shortness of breath (SOB). A ________ finding.
Dyspnea
All home systems have a back-up ____-cylinder.
E
PORTABLE, HOME HEALTH, DELIVERY SYSTEMS: Home Liquid Oxygen Systems Usually, at least one ____-cylinder is provided for emergency backup.
E
PORTABLE, HOME HEALTH, DELIVERY SYSTEMS: Oxygen Concentrators Require one or more ____-cylinders for travel and for emergency back up.
E
____-cylinders are typically used during in-house transports.
E
What is the formula for Elasticity?
E = change in Pressure/change in Volume
The most frequently used sizes are ____ and ____
E and H
Safety margins for commonly used cylinders: E cylinders = _____ psig H cylinders = _____ psig
E cylinders = 2200 psig H cylinders = 2200 psig
Nasal Pharyngeal Airways: How do you determine the length of the Nasal Pharyngeal Airways?
Earlobe to tip of the nose
Galvanic Analyzers has a semi-permeable membrane, which allows oxygen, but not other gases, to come into contact with the ________________.
Electrolyte
The reactions Polarographic O2 Analyzers are ___________ in nature.
Electrolytic
What are the indications for endothracheal intubation?
Endotracheal intubation is indicated in several clinical situations including • acute hypoxemic • hypercapnic respiratory failure • impending respiratory failure • This procedure is also used to protect the airway in conditions of upper airway obstruction, either mechanical or from airway pathology. • Patients at risk for aspiration, most commonly from central nervous system derangements may benefit from elective intubation. • performed for many operative procedures; at times to facilitate certain diagnostic procedures (ex. computed tomographic scan /bronchoscopy); and to aid in respiratory hygiene. • Another potential indication for EI includes the ne Endotracheal intubation is indicated in several clinical situations including • acute hypoxemic • hypercapnic respiratory failure • impending respiratory failure • This procedure is also used to protect the airway in conditions of upper airway obstruction, either mechanical or from airway pathology. • Patients at risk for aspiration, most commonly from central nervous system derangements may benefit from elective intubation. • performed for many operative procedures; at times to facilitate certain diagnostic procedures (ex. computed tomographic scan /bronchoscopy); and to aid in respiratory hygiene. • Another potential indication for EI includes the need to hyperventilate by mechanical ventilation, attempting to reduce intracranial pressure • ed to hyperventilate by mechanical ventilation, attempting to reduce intracranial pressure
Moisture and heat from the patient's ____________ _____ is absorbed into the exchanger.
Exhaled breath
The maximum volume that can be exhaled after a normal exhalation.
Expiratory Reserved Volume (ERV)
_________ the purpose of the Slow Vital Capacity (SVC) procedure to the patient.
Explain
A Large Volume Nebulizer (LVN) may have an adjustable window to adjust ______.
FIO2
Deliver a constant, or fixed, alveolar ______ regardless of the patient's ventilatory pattern.
FIO2
Fractional concentration of oxygen in inspired air.
FIO2
Used to clinically verify and adjust the __________ delivered to the patient.
FIO2
Alveolar FIO2 can only be estimated for adults using the following formula:
FIO2 = (lpm x 3%) + 21%
Alveolar FIO2 can only be estimated for adults using the following formula:
FIO2 = (lpm x 4%) + 21%
Jet Nebulizer: The design of jet nebulizers may also include a control to vary the ________ using the jet to entrain room air. The FIO2 is varied by changing the size of the _______ window.
FIO2; entrainment
Aerosol Therapy Aerosol Administration Equipment: _____ _____ Designed to be strapped under the chin, enclosing the lower part of the face. Many patients find this less confining than an aerosol mask. It is also useful for patients with facial burns.
Face Tents
PORTABLE, HOME HEALTH, DELIVERY SYSTEMS: Cylinders: Cylinders tend to make people nervous, with concerns about cylinders ________, _______ and _________....
Falling; fires; explosions
(True/False) The term "low-flow" relate to the amount of oxygen being delivered to the patient.
False
MODES OF VENTILATION: Positive End Expiratory Pressure (PEEP) and Continuous Positive Airway Pressure (CPAP) (True/False) PEEP and CPAP affects both the inspiratory and expiratory phase.
False PEEP and CPAP only affect the expiratory phase of ventilation.
True/False: Maxair is available in nebulized form.
False, Maxair is not available in nebulized form
(True/False) Polarographic O2 Analyzers cannot be shut off.
False, Polarographic O2 Analyzers can be shut off. The reaction stops when powered down.
(True/False) All HMEs are bi-directional.
False, all HMEs are uni-directional. Because it has the hygroscopic element on the one side and a filter on the other side.
(true/false) It is harder to manage the temperature in the pass-over humidifier if there is a small amount of water in the reservoir.
False, because it is actually easier to manage the temperature if the reservoir has small amounts of water.
(True/False) Salt is not a common solute.
False, salt is a common solute.
(True/False) As temperature decreases, the carrying capacity stays the same.
False, the carrying capacity of gas decreases as the temperature decreases.
True/False: Bronchoscopy can be done in the NICU.
False; Bronchoscopy is not typically done in NICU due to small airways
(True/False) This mask is used to provide CO2 rebreathing.
False; This mask is not used to provide CO2 rebreathing!!!!!!!!!
List the types of Medication (Relating to Respiratory):
Fast Acting/Rescue Medication Anticholinergics Long Acting/Control Medication Long Acting Bronchodilators (Adrenergic/Sympathomimetics) Nasal Steroids Non-steroidal Antiasthma Medications Aerosolized Anti-infectious Agents Inhaled Pulmonary Vasodilators Anti-diabetic Agents Systemic Corticosteroids Non-steroidal Anti-Asthma Agents
• Sympathomimetics - mimic rescue systems - BETA 1 & BETA 2 • Increases nerve signals to open airway - "broncho-dilator" = BETA 2 • Side effects - HR, tremors, nausea, headaches, "allergic" / rebound bronchospasm, • Underdosing or too little too late - • Overdosing - sign of loss of control of disease - • Loss of effectiveness / tolerance • Daily use > Q 4 hours indicates need for long acting medication
Fast acting / Rescue medications - "stays in your pocket"
What technique is this? • Used when the patient's neck cannot be manipulated, i.e. unstable cervical spine. • Used when it is not possible to visualize the vocal cords because a straight line view cannot be established from the mouth to the larynx. • Performed either awake or under general anesthesia • Performed on a patient who have a difficult airway. • Used as abackup technique after direct laryngoscopy has been unsuccessful. • Involve adequate planning and patient preparation.
Fiberoptic Endotracheal Intubation
PORTABLE, HOME HEALTH, DELIVERY SYSTEMS: Oxygen Concentrators Do not require refilling; only cleaning of the _________ and yearly ___________.
Filters; service checks
High-Flow (____________ Performance) Oxygen Delivery Devices.
Fixed or Specific
Venturi Masks: In clinical practice, most of these devices will function as (variable/fixed)-performance devices if the FIO2 is < 0.40, but will probably function as a (variable/fixed)-performance device at high FIO2s.
Fixed; variable
Bedside PFT Measuring Devices: 1. A bench standard for all flow measuring devices. 2. Measures a pressure created by breathing through a very low resistance. a. Flow is passed through a bundle of brass capillary tubes. b. Can measure both inspiratory and expiratory flows. 3. Results may be affected by moisture and/or medication deposits. 4. Although these directly measure flow, they may be modified to display volume.
Fleisch Pneumotachometers
What type of bronchoscope allows observation of peripheral locations in the lung & avoids mechanical distortion of the airways? It is indicated in Diagnostic Bronch's.
Flexible Bronchoscope
Long acting / Control medications -" stays at home"; Inhaled Steroids (fluticasone Propionate 44, 110, & 220, mcg dosages) 1-2 x day
Flovent
What is Fluticasone Propionate? What is the dosage?
Flovent (fluticasone Propionate 44, 110, & 220, mcg dosages) 1-2 x day
Allows vent to meet patient's inspiratory demands. Puts vent and patient in synch adjusts inspiratory time.
Flow
CYCLING VARIABLES: 1. Inspiration ends when a predetermined flow has been reached. 2. Inspiration generally ends when flow degrades to 10 - 25% of the peak flow required. 3. Requires microprocessor controls as this is typically used in modes of ventilation which allow the patient to change the flow rate for each breath.
Flow
BASIC TERMINOLOGY: 1. The amount of gas passing a specific point over a specific period of time. 2. Typically measured in LPM, but may also be measured in LPS. 3. Usually set at the lowest setting which will meet the patient's inspiratory demand.
Flow Rate
Used to accurately measure the amount of gas delivered. Generally measure gas flow in liters per minute (lpm or L/min).
Flowmeters
Jet Nebulizer: The particle size can be influenced slightly by varying the gas _______...higher flowrates tend to produce (smaller/larger) particles, while lower flowrates tend to produce (smaller/larger) particles.
Flowrate;smaller; larger
Chest Tubes: What type of drainage occurs when a tube is inserted on 4 - 5th intercostal space mid axillary?
Fluid Drainage
Ultrasonic Nebulizers (USN) Hazards: ______ ______ -- this nebulizer can nebulizer up to 6 cc per min of fluid.
Fluid overload
Long Acting Broncho-dilator adrenergic/sypathomimetic ( Formoterol) • BID- onset 15 minutes , Peak 30 - 60 minutes, duration 12 hour • Dry powder MDI only
Foradil
What is Formeterol?
Foradil
1. Measures the degree of obstruction (airway collapse) 2. ≥80% of predicted is normal. 3. FEV - amount of air out in 1 second in large airways. 4. Often performed before and after bronchodilator to measure efficacy of medication (increase of 20% SIG)
Forced Vital Capacity (FVC)
A VC measurement performed with maximum forced expiratory effort.
Forced Vital Capacity (FVC)
FIO2
Fractional Concentration of Oxygen in Inspired Air
L/T Ratio: Systemic absorption from oral pharynx and usually have side effects.
G.I. Tract
What is the contraindication of Oral Phanyngeal Airways on conscious or semi-conscious patients?
Gag Reflex
STORAGE: The cylinder storage area should have signs outside the door such as "_________________________". and "____________________."
Gas Cylinders. Remove to a safe place in case of fire; Authorized Personnel Only
The ability of gas to flow through the conductive airways depends on:
Gas viscosity Gas density The lenght and diameter of the tube The flowrate of the gas
What are the medical gases?
Gases that have been refined and purified to Food and Drug Administration (FDA) standards; Used in the diagnosis and treatment of diseases and disorders.
Disadvantages of MDIs Some patients do not feel that they "___ _____" from an MDI.
Get anything
List 3 techniques that can use you minimize upper airway bleeding and trauma?
Good lubrication Gentle steady echnique Nasal airway
____-cylinders are typically used for home oxygen therapy, or when a gas supply is required in an area without a piped-in gas supply.
H
What is the humidity deficit for a patient breathing gas at 30o C which contains 15 mg/L of water vapor?
HD = 44 mg/L - actual content HD = 44 mg/L - 15 mg/L HD = 29 mg/L The 30o C given in the above example is a distracter. If you are given the water vapor content, the temperature of the inspired gas is unimportant. This is because we are not interested in the humidity deficit as the gas enters the pulmonary system, but only when it reaches the alveoli.
A device that uses a hygroscopic element and the patient's heat and humidity from exhaled gas to humidify the next breath.
HME (Heat Moisture Exchange)
A simple device whose function can, in many instances, temporarily replace the need for a humidifier.
HME (Heat-Moisture Exchangers)
What is a high flow nasal cannula?
High flow nasal cannulas deliver heated, humidified gas to a patients using a high flow flowmeter and either a heated passover humidifier or wick cartridge system.
How can you tell if a Pass-over humidifier is a high-flow or a low flow?
High-flow Pass-over Humidifier has a bigger opening in the inlet. Low-flow Passover Humidifier has a smaller opening in the inlet.
BTPS added to the inspired air through the mucus lining of a patient's airway creates _________ ___________.
Humidity Deficit
The ________ ________ is the amount of water vapor that must be added by the body to bring the inspired gas up to BTPS conditions.
Humidity Deficit
Any air breath in at less than BTPS creates a __________ _________.
Humidity deficit
As the water in the reservoir becomes less in the bubble humidifier, what happens to humidity output?
Humidity output decreases. As my reservoir lessens, the time and contact increases so my output decreases as well.
A Large Volume Nebulizer (LVN) are used to treat _______ deficit associated with _______ airways.
Humidity; artificial
A lower than normal amount of oxygen delivered to the tissues.
Hypoxia
What will happen if the temperature of the carrier gas increases with the humidity held constant?
If the temperature of the carrier gas increases, with humidity held constant, the aerosol particles will have a tendency to evaporate into the carrier gas, thus making the particles smaller.
Pulse oximeters are _________ with cold pts, very low blood pressure, pts, and dark nail polish
Inaccurate
Increasing the surface area for contact will (increase/decrease) the humidity. Decreasing the surface area for contact will (increase/decrease) the humidity.
Increase; Decrease
With the pressure held constant. If the temperature increases, the volume will ___________, and if the temperature decreases, the volume will ___________. This gas law is _____________ Law.
Increases, decreases, Charles'
As the pressure inside the tank increases, the temperature __________ if volume is constant (Gay-Lussac's Law). The increased temperature causes the disk to ___________, releasing any excess pressure
Increases; Rupture
MODES OF VENTILATION: Positive End Expiratory Pressure (PEEP) and Continuous Positive Airway Pressure (CPAP) Maintaining an increased baseline pressure (increases/decreases) alveolar pressure and thus (increases/decreases) recruitment of alveoli.
Increases; increases
Respiratory Compensation: Increasing CO2 = _______ acid = respiratory ________
Increasing CO2 = increasing acid = respiratory acidosis
Metabolic Compensation: Increasing HCO3 and Base Excess levels = metabolic ________.
Increasing HCO3 and Base Excess levels = metabolic alkalosis.
MODES OF VENTILATION: Inverse I:E Ratio Ventilation (IRV) 1. Reverses the normal I:E Ratio so that Inspiratory Time is much longer than Expiratory Time. 2. The long inspiratory time allows for better equilibration of pressures between the upper airway and the alveoli, thus increasing alveolar tidal volumes and ventilation. 3. Used in cases of very severely decreased compliance with severe hypoxemia which has failed to respond to high FIO2 or high PEEP levels. 4. The primary goal here is to keep the SIP < 35 cm H2O in an attempt to limit barotrauma to the larger airways. 5. May be accomplished using either volume or pressure cycling modes. 6. Which parameters vary with changes in compliance and resistance is dependent on the mode used to achieve the reversed ratio. 7. Typically requires that the patient be having sedated or paralysis.
Inverse I:E Ratio Ventilation (IRV)
Maximum Inspiratory Pressure (MIP) (is/is not) an "effort dependent procedure."
Is not. (This procedure may be completed on patients who are unresponsive to verbal stimuli.)
A Bourdon Gauge flowmeter uses a gauge with a faceplate calibrated in ______ rather than in psig.
L/min
CONNECTOR SYSTEMS: Outlets include faceplates that must be _________ and ___________.
Labeled and color-coded
Metered Dose Inhalers (MDI): The spacer creates a slower and more _______ delivery
Laminar
A smooth, streamlined flow with few directional changes. This is the type of flow that predominates in the smaller airways; flow in a straight line; most desired flow characteristics.
Laminar Flow
MODES OF VENTILATION: Pressure Control Ventilation (P/C) 1. As the ventilator approaches the PIP Max the flow rate slows, thus allowing for more ______ flow. 2. Holding the pressure allows for the equalization of pressure between the _____ and _____.
Laminar; mouth; alveoli
Jet Nebulizer: A typical (small/large) volume nebulizer should not be used to deliver continuous medication because they produce too many very large ______ that do not enter the airways. Also, the ______ ______ Nebulizer should not be used to deliver bland aerosol therapy because these nebulizers are expensive and bland aerosol therapy does not require such ______ particle delivery.
Large; particles; Continuous Mediation; uniform
Which sizes endotracheal tubes have less airway resistance and allow for better suctioning and less work of breathing?
Larger size endotracheal tubes
What is considered the lowest clinical SpO2 in a pulse oximeter?
Less than 92% SpO2
______________ are used to identify the cylinder size and gas capacity.
Letter Codes
The particles may be in a state of _______ or ______
Liquid; solid
This capnograph monitor works because any measured CO2 has to come from the ________, the only source of CO2 in the body.
Lungs
"Average" or total amount of press/time that lungs are exposed to. Directly increases oxygenation. MAP increases with Press or time.
MAP
Aerosol Therapy Possible Complications: Caregiver exposure to droplet nuclei. Prevention/Action: Wear a _____ if the patient has a communicable pulmonary disease or is coughing actively. Organisms are transmitted on _____ particles, not via water in the form of a vapor.
Mask; aerosol
• 1-2 puffs ( .20 mg each) 4-6 hours • A rescue inhaler for asthma • A breath-actuated inhaler- no coordination necessary • Not available in nebulized form
Maxair(Maxair™ Autohaler™ pirbuterol acetate inhalation aerosol)
The Negative Inspiratory Force (NIF) is the same as:
Maximum Inspiratory Pressure (MIP)
This procedure is typically performed on a patient with an artificial airway in place. However, it may also be performed on a patient without an artificial airway. In this case, a mouthpiece is connected to the Briggs adapter.
Maximum Inspiratory Pressure (MIP)
Typically performed to assess muscle strength as part of the evaluation of the need for continuous mechanical ventilation.
Maximum Inspiratory Pressure (MIP)
Bedside PFT Measuring Devices: 1. Very commonly used to measure pressures. 2. Those used in Respiratory Care typically display results in cm H2O pressure. However, they can display results in any pressure measurement. 3. Most are modified Bourdon Gauges. 4. Can be used for static or dynamic measurements. 5. May be used to measure positive or negative pressures.
Mechanical Aneroid Manometers
Atmospheric air compressed and stored under pressure; Supports life and is considered nonflammable.
Medical Air
MEDICAL AIR SYSTEMS: Most hospitals use _____________, usually two or more ____________ functioning either together or separately.
Medical Air Bulk Systems; Compressors
Bureau of Medical Devices (BMD) -- standards for _________ devices.
Medical Devices (Working Pressure)
Frequently used to supply gases during transports, when small amounts of gas are required, or when specialty gases are needed.
Medical gas cylinders
Jet Nebulizer: Small Volume Nebs (SVN) are used to deliver _______.
Medications
Metabolic Compensation: How Fast? What is the respiratory compensation reaction used for?
Metabolic compensation takes time and used for chronic problems
Metered Dose Inhalers (MDI) is more effective than ______-_______with patients that are not profound SOB and can coordinate procedure.
Mini-nebulizers
The volume of air inhaled or exhaled in ____ _________ (VE).
Minute Volume
BASIC TERMINOLOGY: 1. The amount of gas inhaled or exhaled over the course of a minute.
Minute Volume (VE)
The volume of gas inspired or expired in one minute during normal, tidal breathing.
Minute Volume (Ve)
What are the 2 types of Spacers?
Mixing Chamber Holding Chamber
Transcutaneous Monitor is very widely used in ____________ units, not so much in adult units.
NICU
Transcutaneous Monitors are generally used in __________ applications only.
NICU
What are the oxygen delivery devices?
Nasal Cannula, Simple Mask, Non-Rebreather Mask, Partial Rebreather Mask, and Air Entrainment (Venturi) Mask
What are the Anesthetic Gases?
Nitrous Oxide
Is the wick humidifier more efficient than the pass-over humidifier even if it is not heated?
No (not a heated pass-over), because you still have the problem with the cups.
STORAGE: Inside the cylinder storage area warning signs such as "__________, __________, ___________, and ___________" should be posted.
No Smoking, No Open Flames or Sparks, No Oil or Grease, and No Combustible Material
Old studies, which documented the delivery of 100% oxygen, used ___-_____, _____ _____ masks.
Non-disposable, tight fitting
Uses a molecular sieve to concentrate atmospheric O2 (max 4L); must be plugged in.
O2 Concentrators
Total Respiratory Rate. Set RR and patient triggered RR.
Obs. Rate
1. Difficulty exhaling normal flowrates caused by decreasing airway lumen size. 2. Decrease flowrate
Obstructive Disease
Results in decreased flow rates. Disorders may also result in increases in RV and, therefore, FRC.
Obstructive Pulmonary Disease
Note: A comparison of FVC and SVC values is sometimes used as a quick method for assessing the presence of obstructive disease. FVC for the _________ process and the SVC for the ___________ process.
Obstructive; Restrictive
PORTABLE, HOME HEALTH, DELIVERY SYSTEMS: Oxygen Concentrators No oxygen is stored in the system, so this system is very appropriate for ________ or _________ use.
Occasional; periodic
What are the types of Airway Suctioning?
Oral Airway Suction Endotracheal Suction Nasotracheal Suction Oral Tracheal Suction
An odorless, tasteless, colorless gas that is necessary to support life; Supports combustion but is itself nonflammable; Has paramagnetic qualities; 21% of the volume of the atmosphere
Oxygen
Galvanic Analyzers rely on the chemical reaction that takes place when ___________ combines with certain electrons.
Oxygen
___________, the most commonly delivered therapeutic gas, is classified as a drug, and therefore the dosage must be measured accurately.
Oxygen
Air Oxygen Blender used with NICU applications must be in conjunction with an ________ _______.
Oxygen Analyzers
Device that is used to determine the FIO2 of a delivered gas.
Oxygen Analyzers
What is used to deliver a precise FIO2?
Oxygen Blenders
What is used to verify the oxygen sample of gas?
Oxygen analyzer
Fiberoptic Endotracheal Intubation: Complications
Oxygen desaturation Bronchospasm (inadequate local anesthesia)
Pulse oximeters use light transmitted or reflected by ___________ vs. ____________ hemoglobin at specific wavelengths (photoplesmography).
Oxygenated; Deoxygenated
What is the benefit of the Mean Airway Pressure?
Oxygenation
Pulse oximeters: CO reads as _________.
Oxyhemoglobin
What is the formula for Dalton's Law?
P1 + P2 + P3 ... = PTotal - PH2O
Partial pressure of oxygen in the ______.
PAO2
What is the range of the PCO2 for Hyperventilation (Hypocarbia)?
PCO2 <40
What is the range of the PCO2 for Hypoventilation (Hypercapnic)?
PCO2 >40
Uses "set pressure" instead of set "volume." Pressure is "plateau" constant with variable flow. Used on mechanical breaths in A/C or SIMV Modes.
PCV
MODES OF VENTILATION: Positive End Expiratory Pressure (PEEP) and Continuous Positive Airway Pressure (CPAP) The term ______ is generally used when referring to an elevated baseline with positive pressure breaths. (increases FRC)
PEEP
What are the 2 things that affect the Mean Airway Pressure (MAP) the most?
PEEP (because it is constant) I. Time
What parameters changes the Mean Airway Pressure (MAP)?
PEEP and I. Time
Partial pressure of water vapor (____ mmHg at the alveolar level).
PH2O
Partial pressure of oxygen in __________ air.
PIO2
Safety System that uses high pressure and small cylinders (E). Uses different pin pattern for each gas.
PISS
What humidifier is the least efficient design in picking up humidity?
Pass-over Humidifier
What is the simplest of all humidifiers?
Pass-over Humidifiers
What are the risks of Hyperventilation and Pre-oxygenation in suctioning the patient? What techniques can you use?
Patient becomes bradicardic, apnic, ICP; Ventilate patient normally.
MODES OF VENTILATION: Pressure Support Ventilation (P/S) P/S is a successful mode of ventilation for what type of patient?
Patient who has a smaller than optimal artificial airway (e.g. burn patients, or patients with upper airway edema).
Square Flow Patterns are used for what patients?
Patients with huge inspiratory demand and a short I. Time. Used on Transport Ventilators
Measures initial flowrate and is a good indicator of the relative dilation of large airways.
Peak Expiratory Flow Rate (PEFR)
The ______ _______ _______ _______ generated with a maximum expiratory effort after a maximum inspiratory effort.
Peak Expiratory Flow Rate (PEFR)
What is the Bedside Pulmonary Function Test (PFT) is typically performed before and after treatment therapy to assess the effectiveness of intervention and the seriousness of the patient's condition?
Peak Expiratory Flow Rate (PEFR)
Bedside PFT Measuring Devices: 1. Used for bedside and home monitoring. 2. Measure on the maximum flow rate, typically that seen at the beginning of exhalation. 3. Are typically inexpensive, and come in many designs.
Peak Flow Meters
Aerosolized Antinfectious Agents antiprotozoan agent to treat Pneumocystis carnii ( PCP) pneumonia in immune compromised patients i.e. AIDS. Indication : • Second line therapy to prevent PCP in high risk patients ( HIV +) • Previous PCP episodes • CD4 ( T4 cell helper) lymphocyte < 200/ mm • Has been shown to be effective if given in IV form ( eliminates exposure issue with aerosol) Dosage: • 300 mg powder in 6 ml sterile h20 once every 4 weeks Hazards / side effects : ( similar to symptoms of PCP) • Respiratory - • Bronchial irritation & bronchospasm ( what could be done to minimize this ?) • Dizziness, nausea, rashes, metallic taste • PCP symptoms - night sweats, chills • Renal Failure • Staff exposure issues / nebulizer requirements • MMAD 1- 2 um • "respirgard" filter on exhalation - prevent aerosol exposure • negative pressure room or isolation chamber ( Aerostar) • HEPA fit tested mask
Pentamidine Isethoionate - Nebupent
_______________ uses 2 light sources to read oxygenated blood and deoxygentated hemoglobin.
Photoplethsmography
What is the generic name for Maxair Autohaler?
Pirbuterol Acetate inhalation aerosol
Temporary monitors are used to evaluate the correct _________________ of an artificial airway following intubation.
Placement
Pressure to hold lungs open. Indicates lung static compliance PIP - Plat = airway resistance.
Plateau Press
CONTRAINDICATIONS FOR IPPB THERAPY: 1. A collection of air in the mediastinal area of the chest. 2. Diagnosed radiographically. 3. Usually not a problem in itself, but it indicates the presence of barotrauma which may worsen with positive pressure.
Pneumomediastinum
Gas law that states the resistance to flow varies directly with the length of the tube and inversely with the radius of the tube to the 4th power. For example, decreasing the radius by half increases the resistance to gas flow by 16 times.
Poiseuille's Law
What kind is commonly used in hospitals? Why?
Polarographic Analyzers, because it does not continuously use receptors.
A device similar to a Galvanic O2 Analyzer but uses its power source to increase speed of reaction.
Polarographic O2 Analyzers
What is precipitation?
Precipitation is going from a less organized matter to a more organized matter. Example: Gas to Liquid.
Systemic Corticosteroids Respiratory Indications: (suppress inflammation) • Initial assessment of COPD • Acute exacerbation of COPD • Severe chronic asthma - failure to respond to inhaled steroids or other meds. • Idiopathic Pulmonary fibrosis - bronchiolitis common Hazards / Precautions: • Edema / fluid retention- "moon face" • Petechia - small hemorrhage or blood vessel rupture near skin • Osteoporosis • Immune suppression - increase infection risk - esp. respiratory of opportunistic organisms Dosage: (0.5 - 1.0 mg / Kg / day) • Typical dosage 5 - 50 mg per day for 10 - 14 days • Dosage is typically reduced slowly = wean patient off • Tablets - 1,5,20, & 50 mg
Prednisone
Jet Nebulizer: _______ drop is used to draw up a fluid from a reservoir through a siphen tube.
Pressure
TRIGGER VARIABLES: 1. The most commonly used triggering mechanism. 2. Allows the patient to initiate the inspiratory phase by creating a minor pressure drop. 3. Usually adjustable from -0.5 - -2 cm H2O.
Pressure
What breath type is the preferred method for increasing I. Time to improve oxygenation? Why?
Pressure Control (P/C) Because it is constant Flow rate is adjusted to the patient You get a better gas distribution
PCV
Pressure Control Ventilation
MODES OF VENTILATION: Pressure Control Ventilation (P/C) 1. Sets a maximum pressure (max PIP) which may be achieved. 2. Once PIP is reached, flow stops and one of two things can happen: a. The ventilator cycles. (pressure cycled) b. The ventilator maintains the pressure for a specific period of time (inspiratory pause - time cycled). 3. This mode is different from Pressure Support Ventilation because of what happens at PIP: 4. P/C provides for better alveolar ventilation for patients with very low compliance or very high resistance. 5. PIP is constant, but volume and I-time vary with changes in compliance and resistance. 6. Is time or patient triggered, pressure or time cycled, flow limited.
Pressure Control Ventilation (P/C)
Vent gas to the atmosphere in the event the pressure in the cylinder exceeds maximum safety levels.
Pressure Relief Devices
_______________ are also called frangible disks or rupture disks.
Pressure Relief Devices
Bureau of Explosives (BOE) -- standards for the construction of safety ________ ________ valves.
Pressure Relief Valves
PSV
Pressure Support Ventilation
MODES OF VENTILATION: 1. Allows the patient to breathe at a spontaneous rate, volume, and I. time. 2. The ventilator matches the patient's effort, providing varied levels of support. 3. Flow continues even after PIP is achieved as long as the patient is making an inspiratory effort. 4. Typically, the ventilator cycles when the flow had decreased to 10 - 25% of the peak flow. 5. Places a workload on the diaphragm with every breath, the amount of work being determined by the level of support. 6. Requires that the patient have a spontaneous respiratory drive as this is a spontaneous breathing mode. 7. PIP is constant, but flow, I. time, and volume vary with patient effort and changes in compliance and resistance. 8. Is patient triggered, pressure limited, flow cycled.
Pressure Support Ventilation (P/S)
What is the "P" and "A" in PAO2?
Pressure and Alveolar
What is the "P" and "a" in PaO2?
Pressure and Arterial
What are the 2 things that control inspiration and expiration in a Bird Ventilator?
Pressure gradient and Magnetism
TRIGGER VARIABLES: What must happen to change the ventilator from the expiratory to the inspiratory phase?
Pressure, flow, time and volume are the parameters that change the ventilator from expiratory to inspiratory phase. (Note: These are also the parameters that change the ventilators from expiratory to inspiratory phase.)
CYCLING VARIABLES: What must happen to change the ventilator from the inspiratory to the expiratory phase?
Pressure, flow, time and volume are the parameters that change the ventilator from inspiratory to expiratory phase. (Note: These are also the parameters that change the ventilators from inspiratory to expiratory phase.)
OXYGEN STORAGE: The bank in use is considered to be the ________ supply and the second bank is considered the __________ supply.
Primary; Stand-by
What is the principle of operation of a jet nebulizer?
Principle of Bernoulli and Venturi
What is the principle of operation of all humidifiers?
Principle of Evaporation
1. Serve the needs of society 2. Understand the characteristics of professionalism 3. Behave in a professional manner. 4. Enhance and promote professional image
Professionalism
1. Confirm and diagnose obstructive and restrictive process. 2. Monitor Lung volumes 3. Determine the degree of obstructive airflow disease.
Pulmonary Function Test (PFT)
CONTRAINDICATIONS FOR IPPB THERAPY: The increased airway pressure may increase the bleeding, so this is a relative contraindication. However, in severe cases, IPPB may help to increase the surface area available for gas exchange (as discussed with Pulmonary Edema).
Pulmonary Hemorhage
What are Inhaled Pulmonary Vasodilators indicated for?
Pulmonary Hypertension
A perfusion monitors that measures pulsatile oxygen.
Pulse Oximeter
Device that measures the oxygen saturation in pulsatile blood. (SpO2) or the percent of oxygen attached to the hemoglobin in the capillary beds.
Pulse Oximeter
Capnograph: __________ = Problem = __________________ __________ = Think = __________________ __________ = Yes = __________________
Purple; No CO2 detected Tan; The airway may be in esophagus Yellow; the airway is in the trachea
TRANSPORT: (Push/Pull) large cylinders in carts, (push/pull) small cylinders in carts.
Push; Pull
What do you do to a patient wearing a nasal cannula have sores behind the ears?
Put a gauze, or a spongy form pillows, or tegaderm (thin plastic that adhere to the skins). As a respiratory therapist, you have to improvise and make sure the patient is comfortable wearing the mask.
Long acting / Control medications -" stays at home"; Inhaled Steroids (Beclomethasone dipropionate ) 2 puffs 1-2 times per day
QVAR/ Vanceril
Indexed Safety Connections: --For low-pressure connections on regulators or wall outlets. --A modification of the Diameter Index Safety System which allows for connection/removal with one motion. --Varies the size of the connectors, shapes, and configuration of the mating portions, rather than thread size and direction. --More convenient than the Diameter Index Safety System but also more prone to leaks.
Quick-Connect Systems
What is the relative humidity at the alveolar level for a gas at BTPS if the actual content is 25 mg/L?
RH = (actual content/total capacity) x 100 RH = (25/44) x 100 RH = 56.8% In this example, the gas is carrying 57% of the maximum amount of water vapor that it could carry under BTPS conditions.
End-Tidal used to titrate amount of support given to patients requiring ___
RPV assistance
RR / VT ( liters) > 105 = poor weaning & increased WOB
RSB
TLC - VC =
RV
of, relating to, or constituting a compound or mixture that is composed of equal amounts of dextrorotatory and levorotatory forms of the same compound
Racemic
Original Emergency treatment for Asthma. • Strong sympathomimetic - not specific • Beta 1 - increase HR - Used in ACLS to treat profound bradycardia & asystole • Beta 2 - fast acting Bronchodilator - • Onset 3-5 minutes • Peak 5-20 minutes • Duration - 0.5 - 2hours ( Beta 1 & alpha systemic effects can last longer) • Alpha effects - vasoconstriction = Increase BP & decreased topical edema • Dosage - 2.25% - .25 - .50 ml's in 3 cc's NS q1 - q4hr prn • Brand names - Vaponephrin, asthmanefrine, micronefrin & Primatene mist (over the counter inhaler) Indications: • Upper airway / laryngeal edema -
Racemic Epinephrine
What is the original tx for asthma?
Racemic Epinephrine
DRIVE MECHANISMS: 1. A standard reducing valve, but connected to one or more solenoids to control the flow of gas. 2. Outlet pressure may be as high as 50 psig or as low as a few cm H2O. 3. This is the variable flow type of drive mechanism in current ventiltors. 4. When combined with microprocessors and quick-acting, mutli-step solenoids, this type of drive mechanism can provide very fine adjustments to flowrates and volumes.
Reducing Valves
Reduce a high pressure to the standard working pressure of 50 psig; Consist of body, diaphragm, high-pressure chamber, ambient chamber, and inlet (poppet) valve May be single stage or multiple stage
Reducing Valves
A ___________ __________ sounds if there is a drop in the pressure of 1 of the gases.
Reed valve
The actual amount of water vapor present in a gas (specific humidity) divided by the water vapor capacity at a given temperature. (or, what you have divided by the most you could have).
Relative Humidity (RH)
What formula is this? Actual content/H2O vapor capacity x 100%
Relative Humidity (RH)
In pass-over humidifiers, the gas flow passes over a ______________ of water.
Reservoir
Jet Nebulizer: A _______ containing a liquid to be nebulized.
Reservoir
These operate by bubbling gas through a ____________ of water.
Reservoir
The volume of gas remaining in the lungs after a maximal exhalation.
Residual Volume (RV)
BASIC TERMINOLOGY: _____________ to ventilation is due to the anatomical structure of the conductive airways, and the tissue resistance of the lungs and adjacent structures. In clinical situations, viscosity, density, and tube length remain fairly constant, and attention is paid to airway lumen size and the flow rate of gas.
Resistance
Moving _______ across a cellular membrane.
Respiration
What is the prevention and action to Apnea secondary to CO2 retention?
Review the patient's chart for a history of a high PaCO2 (> 55 mm Hg) with a normal pH (7.35 - 7.45). Administer oxygen carefully in patients with end-stage pulmonary disease. This MAY occur in that same very small subgroup of patients with end-stage pulmonary disease discussed above and is the reason that oxygen may be administered with care.
Defines the point at which laminar flow changes to turbulent flow. A number > 2000 indicates turbulent flow.
Reynolds Number
Aerosolized Antinfectious Agents antiviral - tx. For Respiratory Syncytial Virus (RSV) Indications: • Treat seasonal RSV ( self limiting respiratory disease in infants & children • questionable effectiveness vs. cost hazards / precautions • rashes, conjunctivitis, eyelid erythema • can effect or occlude ventilator expiratory valves or filters ( what precaution should be taken if this is nebulized inline on a vent pt?) • Small Particle Aerosol Generator ( SPAG) large volume small particle nebulizer required to deliver to small aerosol to small airways • Expiratory " respirgard" filter to minimize staff exposure • RSV patients - respiratory / aerosol isolation - mask • Dosage - 6 g in 300 gm sterile h20(20mg / ml) via SPAG q 12 -18 for 3-7days
Ribaviran ( Virasol)
Water follows _______.
Salt
HME is not indicated with very thick ___________, High __________, and low _______________.
Secretion; Minute Volume (VE), Body temperature
A Large Volume Nebulizer (LVN) are used to liquefy __________.
Secretions
Ultrasonic Nebulizers (USN) are used in the liquefaction of ________.
Secretions
When speaking of mechanical ventilation, it is necessary to differentiate between:
Set RR, Spontaneous RR, and Combined RR
When speaking of mechanical ventilation it is necessary to differentiate between the various tidal volumes:
Set Vt, Delivered Vt, Exhaled Vt, and Spontaneous Vt
When speaking of mechanical ventilation, it is necessary to differentiate between:
Set minute volume, Spontaneous minute volume, and Total minute volume
HME device may be used for _____-term or _____-term therapy.
Short; long
Blood that goes from the _______ heart to the _______ heart without participating in gas exchange.
Shunt
Non-Steroidal Antiasthma Agents: (Helps to relieve a broad range of seasonal allergy symptoms for a full 24 hours • Is a seasonal allergy medicine that specifically blocks leukotrienes, an underlying cause of allergy symptoms • Is a once-a-day tablet • Is available in oral granules and cherry chewable tablets for children as young as 2 years • Is approved to help control asthma • Is not a steroid
Singulair
__________ will have a label that not only lists the gases in the cylinder, but also the percentage of each gas.
Specialty Gases
What type of humidity that gives the actual amount of water vapor?
Specific Humidity or Water Vapor
BASIC TERMINOLOGY: Graph
Spontaneous Breathing
• Once a day dose ( 18 micro grams) • Dry capsule ( Handi-haler ) only
Spriva - Tiotropium Bromide-
Aerosol Therapy Indications: Need to obtain ___________ specimens or mobilize secretions.
Sputum
Aerosol Therapy Objectives: To obtain a ______ _______ from within the lungs for either culture or for examination for possible abnormal cells.
Sputum sample
What wave patterns give the most airway resistance?
Square Flow Patterns
FLOW PATTERNS: A wave form that is commonly used. May not be the best wave form as it produces the most restrictive.
Square wave
Site: Heart Possible Causes: Heart failure, cardiac defects, shock, decreased venous return Type of Hypoxia: __________
Stagnant
Site: Systemic Possible Causes: Clots, trauma Type of Hypoxia: __________
Stagnant
What type of hypoxia has inadequate cardiac output?
Stagnant Hypoxia
PORTABLE, HOME HEALTH, DELIVERY SYSTEMS: Home Liquid Oxygen Systems Usually have a __________ unit and a __________ unit.
Stationary; portable
Medical gas cylinders are made of:
Steel, aluminum, and chrome-molybdenum
Problem: A patient receiving a FIO2 of 80% has a PaO2 of 410 mm Hg and a PaCO2 of 57 mm Hg. What FIO2 would be required to obtain a PaO2 of 85 mm Hg?
Step 1: PAO2 = FIO2(PB-PH2O) - PaCO2/R PAO2 = (0.80)(760 mm Hg - 47 mm Hg) - 57 mm Hg PAO2 = (0.80)(713 mm Hg) - 57 mm Hg PAO2 = 570 mm Hg - 57 mm Hg PAO2 = 513 mm Hg Step 2: Known PAO2/Known PaO2 = Desired PAO2/Desired PaO2 513 mm Hg/410 mm Hg = Desired PAO2/85 mm Hg (513 mm Hg)(85 mm Hg)/410 mm Hg = Desired PAO2 (43605 mm Hg)/410 mm Hg = Desired PAO2 106 mm Hg = Desired PAO2 Step 3: Plug back into the alveolar air equation PAO2 = FIO2 (PB-PH2O) - PaCO2 106 mm Hg = (FIO2)(760mmHg - 47 mm Hg) - 57 mmHg 106 mm Hg = (FIO2)(713 mm Hg) - 57 mm Hg 106 mm Hg + 57 mm Hg/713 mm Hg = FIO2 163 mm Hg/713 mm Hg = FIO2 0.23 = FIO2
Bedside PFT Measuring Devices: 1. A fine wire screen is placed in the flow of gas. 2. As the gas flow passes through the screen, it deforms the screen slightly. 3. Results may be affected by moisture and/or medication deposits. 4. May be used to measure volume or pressure.
Strain Gauges
MODES OF VENTILATION: Monitoring System 1. Responds quickly to changes in pressure. 2. Relatively insensitive to vibration and shock.
Strain gauge
Neither of these analyzers measures FIO2 directly. Both monitor a chemical reaction, and the ________ or _________of that reaction is used to determine the FIO2.
Strength; weakness
Just calibrating the analyzer to room air is inadequate. Remember that these analyzers are actually monitoring the _______ or ________ of the current produced by a chemical reaction. It requires very little ________ to produce a current that reads as 21% oxygen. However, as the electrolyte is exhausted, you may not be able to produce enough _________ to produce a reading of 100%.
Strength; weakness; electrolyte; current
CONTRAINDICATIONS FOR IPPB THERAPY: 1. May be one of the first clinical signs of an air leak. 2. In itself, this generally is pathologically insignificant, but is an indicator of a more serious problem. May become clinically significant if severe (decreased compliance). 3. Results in tactile crepitus which is very painful for the patient.
Subcutaneous Emphysema
Definition: Use of negative pressure to remove secretions from Upper airway - main stem bronchi
Suctioning
MODES OF VENTILATION: 1. Guarantees the patient a set number of positive pressure breaths, but allows the patient to breathe in a minimum manner between positive pressure breaths. 2. For each positive pressure breath, the ventilator allows a time "window," then time-triggers in to the inspiratory phase if no patient effort is detected. 3. Typically volume cycled (but newer ventilators may allow pressure cycling), may be time or patient triggered, and is flow limited. 4. Allows for a variable workload to be placed on the diaphgram. 5. May reduce the cardiovascular effects of positive pressure breathing. 6. May be used as a primary ventilator mode, or as a weaning mode.
Synchronized Intermittent Mandatory Ventilation (SIMV)
What equation is this? PAO2 = FIO2 (PB - PH20) - PaCO2/R
The Alveolar-Air Equation
Governing body that specifies grades of air, from A through J. (Medical grade is J).
The Compressed Gas Association (CGA)
As a bubble humidifier is used, what happens to the efficiency of it?
The efficiency decreases.
How is the laryngoscope used in endothracheal intubation?
The laryngoscope must be held with the left hand. The patient's mouth opened with the right hand and the blade placed into the right side of the patient's mouth, sweeping the tongue to the left. The tip of the straight blade is inserted posterior to the epiglottis, while the tip of the curved blade placed anterior to the epiglottis into the vallecula. The handle is then raised up and away from the patient without leverage until the vocal cords are visualized. The clinician's wrist should not be bent as this may cause damage to the teeth. Once the vocal cords are seen, the ETT is passed through cords with the right hand and advanced to 20-26 cm, as measured at the teeth or with the cuff just below the vocal cords. The laryngoscope is then withdrawn and the cuff is inflated.
Which intubation route is preferred for endotracheal intubation? Why?
The oral route for intubation is preferred since it can usually be performed more rapidly and provides for better visualization. In addition, the mouth can accommodate a larger tube than the nose.
How does the pass-over humidifier become most efficient in delivering gas to the patient? Why?
The pass-over humidifiers become the most efficient humidifier when a heated wire is added to the tubing. Because the heated wire maintains the temperature of the gas that also maintains the carrying capacity of the gas.
What must be done to the patient prior to oral endotracheal intubation?
The patient should be prepared by removing any dental appliances (ex. dentures). Then proper sedation (and neuromuscular blockers, if used) administered. The patient must be positioned so that easy access is obtained. The head is placed in the "sniffing position" with the lower portion of the cervical spine flexed. Preoxygenation is then performed with 100% oxygen for 2 to 3 minutes via bag-mask ventilation.
How is Sellick Maneuver performed?
The technique requires an assistant to apply pressure to the cricoid member posteriorly. The cricoid cartilage is held firmly between the finger and thumb. It is then pressed posteriorly so that the esophagus can be compressed between the horizontal portion of the cartilage and cervical spine.
Gas used for treatment
Therapeutic Gases
What are the 3 groups of medical gases?
Therapeutic gases, Laboratory gases, and Anesthetic gases
What are contraindications of Humidity Therapy?
There really are NO contraindications to humidity therapy other than patient refusal.
What is the therapeutic benefit of thoracentesis?
Thoracentesis removes fluid to reduce cardio-pulmonary stress.
Flowmeter that consists of a tapered, hollow tube, a ball float, and a needle valve.
Thorpe Tube Flowmenter
What does transcutaneous mean?
Through the skin
The volume of air inhaled or exhaled in ____ _________ (Vt).
Tidal Volume
BASIC TERMINOLOGY: 1. The amount of air moved in or out of the lungs in a single breath. 2. Typically measured as exhale volume.
Tidal Volume (Vt)
The volume of gas inspired or expired during one normal breath.
Tidal Volume (Vt)
Nonsteroidal Antiasthma Medications; Mucous Blockers Nedocromil Sodium - QID MDI
Tilade
CYCLING VARIABLES: 1. Inspiration ends when a preset time has elapsed. 2. Cycling occurs regardless of the pressure, flow, or volume delivered. 3. May also be used as a safety backup cycling mechanism in some modes of ventilation which allow for patient control of ventilation. This prevents excessively long inspiratory times when there is a leak in the system.
Time
TRIGGER VARIABLES: 1. Typically used as a time-out triggering mechanism. 2. If the patient does not initiate a breath in a specific amount of time, the ventilator initiates the breath.
Time
How is the placement of the Endotracheal tube (ETT) assessed after intubation?
To assess proper placement of the ETT, the chest and abdomen are inspected for movement. If the tube is properly placed, symmetric movement of the thorax with minimal movement of the abdomen should be seen with each ventilation. Breath sounds should first be assessed over the epigastric area and then over left and right lung fields. Equal breath sounds are typically heard bilaterally with proper endotracheal intubation. If breath sounds are heard over the epigastric area only, it is likely that an esophageal intubation has occurred. If breath sounds are heard over one hemi thorax, but are diminished or absent over the other hemi thorax, the tube should be left in place. The ETT should be withdrawn 2-3 cm and chest auscultated to check breath sounds again. A common complication of EI is right main stem intubation.9Since the right main stem bronchus has a straighter alignment with the trachea than the left main stem bronchus, an ETT advanced too far will typically enter the right main stem bronchus. In this situation, breath sounds may be heard more prominently or exclusive over the right lung field. Although a deep ETT placement is the most common case of unequal breath sounds, it is important to remember that other clinical conditions can cause unequal breath sounds including consolidation, obstruction, pneumothorax, hemothorax, and pleural effusion. ETT placement can also be confirmed by use of an end-tidal CO2monitoring. A chest radiograph should always be done in emergency intubations to confirm ETT placement since equal breath sounds can be heard in up to 60% of right main stem intubations. Fiberoptic bronchoscopy has been suggested as a more reliable means of confirming ETT position over clinical assessment.
Aerosolized Antinfectious Agents antibiotic - pseudomonas aeruginosa pneumonia Indication: - • Chronic Pseudomonas - common infection in chronic respiratory disease patients such as CF Hazards / Precautions ( Egan Box 29-5) • Cannot be mixed or nebulized with other aerosolized medications • Less side effects with aerosolized TOBI • Possible ototoxicity ( hearing damage) • Staff exposure issues - filter, thumb valve / PARI neb,& isolation mask • Fetal harm - avoid exposure to pregnant women • Bronchospasm & airway irritation Dosage: 300 mg / 5m l ampule ( adults & children > 6 ) ( 20 30 mg in NICU) BID - 28 days on & 28 days off
Tobramycin (TOBI)
_______ refers to the concentration of solutes in a solution relative to their concentrations in body fluids.
Tonicity
The total amount of gas in the lung at __________ inspiration. (VT + IRV + ERV + RV)
Total Lung Capacity (TLC)
Aerosol Therapy Aerosol Administration Equipment: _____ Masks Designed to fit over a tracheostomy tube, secured by an elastic strap around the neck. A 22-mm large bore inlet fitting accommodates the aerosol tubing, and a single large outlet port allows for evacuation of exhaled aerosol.
Trach
The ______ begins at the level of the cricoid cartilage and extends to the carina.
Trachea
CONTRAINDICATIONS FOR IPPB THERAPY: 1. A direct connection between the trachea and the esophagus. 2. May be congenital or acquired. 3. IPPB may lead to gastric insufflation and vomiting.
Tracheosophageal Fistula
A diffusion dependent monitor that reads diffusion of O2 to the skin
Transcutaneous Monitor
A monitor that uses a heated probe and diffusion to read TC CO2 and CO2 Levels.
Transcutaneous Monitor
A mixture of laminar and turbulent flow. This type of flow occurs at the bifrications in the lungs.
Transitional Flow
Department of Transportation (DOT) -- standards for the ________ of ________ on roads.
Transport of gases
Capngraph used to determine the _________ ___________ concentration in exhaled gases.
Trend CO2
TRIGGER VARIABLES: ________________ is generally used to indicate a change from the expiratory to the inspiratory phase (or what starts the flow of gas from the ventilator to the patient).
Triggering
(True/False) All analyzers must be calibrated.
True
(True/False) As temperature increases, so does the carrying capacity of gas.
True
(True/False) HME is used to treat patients because it is cost effective (cheap).
True
(True/False) If a patient thinks you are invested in them healing, then the healing goes faster.
True
(True/False) Nasal Cannula is sufficient for very low flows.
True
(True/False) Partial-rebreather mask is not used in current clinical practice.
True
(True/False) Pulse Oximeter is only accurate as much as you can verify the settings.
True
(True/False) Pulse Oximiter is considered to be 4th in the vital signs in the hospital.
True
(True/False) The wick is more efficient than the bubble even without heating it.
True
(True/False) Whenever ample gas is administered, it has to be verified.
True
MODES OF VENTILATION: Bilevel Positive Airway Pressure (BiPAP) (True/False) The contraindications and potential hazards are similar to that of PEEP/CPAP.
True
MODES OF VENTILATION: Pressure Support Ventilation (P/S) (True/False) P/S has been effective for spontaneously breathing patients who have clinical evidence of muscle weakness.
True
True/False: Albuterol is commonly used as "Rescue Medication".
True
True/False: Atrovent is fast acting and drying.
True
What is the prevention and action for Oxygen Toxicity?
Try to maintain adequate tissue oxygenation with the lowest possible % oxygen. Oxygen is necessary for life, but like many things, while a little oxygen is good, too much can be very bad. Excessive high FIO2s can lead to oxygen toxicity, basically a burning or oxidizing of the lung tissue. This in turn, can lead to the formation of scar tissue, which can interfere with the transport of oxygen across the alveolar/capillary membrane. As a general guideline, we try to keep the FIO2 at < 0.40 to prevent this complication.
Neonate ETT Size: Less than 1 kg Tube Size (mm) Oral Tube Length at Lip (cm) Suction Tube Size (Fr)
Tube Size (mm) = 2.5 Oral Tube Length at Lip (cm) = 5.5 Suction Tube Size (Fr) = 6
Neonate ETT Size: 1 kg Tube Size (mm) Oral Tube Length at Lip (cm) Suction Tube Size (Fr)
Tube Size (mm) = 2.5 - 3.0 Oral Tube Length at Lip (cm) = 6.0 Suction Tube Size (Fr) = 6
Neonate ETT Size: 2 kg Tube Size (mm) Oral Tube Length at Lip (cm) Suction Tube Size (Fr)
Tube Size (mm) = 3.0 Oral Tube Length at Lip (cm) = 7.0 Suction Tube Size (Fr) = 6
Neonate ETT Size: 3 kg Tube Size (mm) Oral Tube Length at Lip (cm) Suction Tube Size (Fr)
Tube Size (mm) = 3.0 Oral Tube Length at Lip (cm) = 8.5 Suction Tube Size (Fr) = 6
Neonate ETT Size: 3.5 kg Tube Size (mm) Oral Tube Length at Lip (cm) Suction Tube Size (Fr)
Tube Size (mm) = 3.0 - 3.5 Oral Tube Length at Lip (cm) = 9.0 Suction Tube Size (Fr) = 8
Bedside PFT Measuring Devices: 1. Measure airflow using a windmill effect. 2. May not be accurate in the face of high flowrates due to the effects of momentum and inertia, therefore are not appropriate for FVC measurements. 3. Results may be affected by moisture and/or medication deposits. 4. May display results as either flow or volume.
Turbinometers
Disorderly flow with vortices known as eddy currents. This type of flow is chaotic and occurs with sharp changes in velocity, varying radii, and rough, uneven surfaces. Gas flow in the large airways is turbulent; Increase resistance; Least desired
Turbulent Flow
Which way do you turn the cylinder valve to open the cylinder?
Turn counterclockwise to open the cylinder. Righty-tighty, lefty-loosy.
Polarographic Analyzer: The fuel cells last longer because the analyzer can be _________ _________, stopping the chemical reaction, between uses.
Turned off
MODES OF VENTILATION: Monitoring System 1. Use struts and an ultrasonic transmitter/receiver. 2. Not affected by gas viscosity, temperature, or density. 3. Functions in any position.
Ultrasonic mechanisms
What are the brand names for Racemic Epinephrine?
Vaponephrin, asthmanefrine, micronefrin & Primatene mist
A simple mask is a (VARIABLE/FIXED) performance device?
Variable
Low-flow (__________ Performance) Oxygen Delivery Devices
Variable
DRIVE MECHANISMS: Reducing valves are the _______ _______ type of drive mechanism in current ventilators. (Most common)
Variable flow
FLOW PATTERNS: 1. A flow pattern that requires sophisticated electronics and computer controls. 2. Responds to patient demands, changing wave forms as required with each breath.
Variable wave form
In most cases is probably functioning as a (variable/fixed) performance device but may, on some patients, be functioning as a (variable/fixed) performance device.
Variable; Fixed
Amount of ventilation in one minute. Rate x Vt = Ve, directly determines pCO2
Ve
ALARM SYSTEMS: 1. Indicates that some primary system of the ventilator has malfunctioned. 2. This alarm cannot be silenced.
Vent Inop
Inhaled Pulmonary Vasodilators • Administered with I-neb or Prodose nebulizer • Synthetic prostacyclin PGi = pulmonary vasodilation • Side effects - syncope , cough, and headaches
Ventavis - Iloprost
MODES OF VENTILATION: Positive End Expiratory Pressure (PEEP) and Continuous Positive Airway Pressure (CPAP) Because PEEP/CPAP is a constant pressure, it does not provide ______. For ventilation to occur there must be gas movement into and out of the lungs. For gas to move there must be a ______ gradient. PEEP/CPAP provides a constant pressure, and therefore does not create the pressure gradient necessary to have ______ ______.
Ventilation; pressure; gas flow
Air Entrainment Masks are also called ___________.
Venturi Masks
The maximum amount of gas that can be exhaled after a maximum inspiration. (VT + IRV + ERV)
Vital Capacity (VC)
In the adult, the airway is narrowest at the _____ ______ and in small children at the ______ ______ _____.
Vocal Cords; Cricoid Cartilage Ring
TRIGGER VARIABLES: Newer ventilators can be triggered when a patient inhales a specific amount of volume from the ventilator circuit.
Volume
The space a gas occupies.
Volume
The __________ humidifiers are the most heated and the most efficient.
Wick
Levalbuterol is another name for:
Xopenex
refined form of Albuterol - (Single R isomer of Racemic Albuterol) • Dosage 1.25 mg adults - .63 mg infants & peds • Longer acting 6-8 hours • Less cardiac side effects - • Possible beneficial anti-inflammatory effects • Can improve benefits in combination therapy with Atrovent & Pulmicort • More expensive • available in MDI form now.
Xopenex - Levalbuterol
What is the rigid suction tube that is used to suction above the vocal chords? (Used for suctioning the Oral airway suctioning)
Yankauer Suction
Color code of Air:
Yellow
Which zone in the Peak Flow Meter do I have to stay home?
Yellow Zone after using my inhaler
Patient might request humidifier on a 2 LPM of Oxygen. Do you give it or not?
Yes, because if a patient request it then usually you do not fight it. You don't offer it to patient unless it is 4 LPM or higher.
If a patient has a normal respiratory rate and a normal tidal volume, should 5 LPM rid the gas of CO2? What if the patient starts breathing faster?
Yes; No
Why do we do a 2 point calibration on the Oxygen Analyzers?
You need to be able to tell if you are running out of current activity.
What are the possible complications of a high flow nasal cannula?
a. Mucosal irritation b. Skin irritation c. Kinking of the connecting tubing d. Oxygen toxicity e. Apnea in oxygen sensitive patients
Disposable CO2 Detectors is a main use to verify placement of an ____
artificial airway
Aerosols are accelerated into _______ to break particles into smaller sizes.
baffles
Jet Nebulizer: Continuous Medication Nebulizer (a HART or HOPE nebulizer) are specifically designed for continuous nebulization of medication, especially _____________________.
children
USE: When not in use, the cylinder valve should be in the __________ position.
closed
_____________ of molecules in a closed container create pressure.
collisions
Polarographic Analyzer: Also provides a _________ reading of FIO2.
continuous
STORAGE: The cylinder storage area should be ___________, ___________, and _____________ (Proper ventilation prevents gas from accumulating if leaks are present).
cool, dry, and well ventilated
Evaporation a (heating/cooling) process.
cooling
MDI (Metered Dose Inhalers) Less _____ is required to effectively use the MDI when it is combined with a spacer.
coordination
USE: Petroleum-based lubricants should never be in contact with __________, __________, ____________, or ___________.
cylinder valves, regulators, high-pressure hoses, or fittings
CONNECTOR SYSTEMS: Use the same low-pressure connector systems as ___________.
cylinders
MEDICAL AIR SYSTEMS: Hospitals typically also have small, portable _____________ for temporary use in areas that do not have piped medical air.
cylinders
OXYGEN STORAGE: A liquid oxygen system supplies the _______ needs.
daily
The _________ serves as a protective mechanism for preventing aspiration by covering the opening of the larynx (i.e. the glottis) during swallowing.
epiglottis
All humidifiers work by the principle of ______________.
evaporation
Polarographic Analyzer: Has an additional power source, therefore response time is _________.
faster
Gas and water are in contact only at the ____________ of the water.
fetch
MODES OF VENTILATION: A parameter is said to be "______" if it is a parameter which cannot be exceeded but which does not cycle the ventilator.
limited
In Respiratory Care, we most frequently aerosolize ______.
liquids
Polarographic Analyzer: Can also be used to analyze gas that is in _________.
motion
MDI (Metered Dose Inhalers) Activation results in the release of a _____________ dose of medication into the mouthpiece.
null
Acid Base Balance: How do you determine the degree of compensation?
ompare complete vs. partial vs. uncompensated
Bourdon Gauge operates in any __________.
position
Metered Dose Inhalers (MDI) Must ______ inhaler if more than ½ day from last accuation.
prime
Continuous Med Nebulizers are used to give ___________ medications to patient not responding to single dose neb administration.
prolonged
Ultrasonic Nebulizers (USN) The couplant chamber is filled with _____ water.
tap
USE: Cylinders should not be exposed to _____________, _________, or ______________.
temperatures greater than 54o C, sparks, or open flames
Heliox: Delivery Percentage (%)
• 60% He & 40% O2 • 70% He & 30 % O2
What is Serevent and Flovent combined? What is the dosage?
• ADVAIR Discus • Dosages 100/ 50 , 250/ 50, or 500 mcg Flovent / 50 mcg Serevent
List of Mucolytics:
• Acetylcystineine - Mucomyst , Mucocil • Dornase Alfa - Pulmozyme
List of Fast Acting/Rescue Medications:
• Albuterol (Proventil, Ventolin) • Alupent (Metaproterenol) • Xopenex (Levalbuterol) • Brethine (Terbuatline Sulfate) • Maxair (Pirbuterol Acetate)
What are the basic steps to perform an endotracheal intubation?
• Assemble & check equipment • Position the patient • Preoxygenate the patient • Insert laryngoscope • Visualize glottis • Displace epiglottis • Insert tube • Assess position • Stabilize ETT/ confirm placement
Hazards/Precautions of Tobramycin (TOBI):
• Cannot be mixed or nebulized with other aerosolized medications • Less side effects with aerosolized TOBI • Possible ototoxicity ( hearing damage) • Staff exposure issues - filter, thumb valve / PARI neb,& isolation mask • Fetal harm - avoid exposure to pregnant women • Bronchospasm & airway irritation
What are the indications for changing a trach tube?
• Changing to smaller size - i.e. weaning patient off trach • Changing to same size - or changing to fenestrated tube • Changing tube to replace leaking cuff • Unable to repair leaking pilot balloon
List of Mucous Blockers:
• Chromolyn Sodium (Intal, Nasalcrom)
Indications of Tobramycin (TOBI):
• Chronic Pseudomonas - common infection in chronic respiratory disease patients such as CF
Closed Suction Catheter Kits: Advantages
• Decreased infection control issues - patient & staff • Reusable system - cost effective • Ventilator circuit is not opened = minimal O2 , PEEP, FRC ,heliox, or Nitric oxide loss • Easily Performed by one person • Easy to instill saline lavage • Can measure depth of catheter for insertion - color coded
Patient Assessment: What are the signs of potentially difficult airways?
• Difficulties with positioning of the neck: arthritis, trauma, or previous surgery • Anatomical variations: small mouth, large tongue, bull neck, receding lower jaw, high arched palate, marked obesity • Limitation of mouth opening • Stridor or other signs of upper airway inflammation from epiglottitis, laryngeal infection or burn • Trauma to the larynx or trachea • Congenital malformation of face, head and neck
What are the complications of endotracheal intubation?
• Esophageal Intubation • Mainstem Intubation • Perforation or laceration of upper esophagus, vocal cords, larynx • Laryngospasm or bronchospasm • Dental and soft-tissue trauma • Dysrhythmias • Hypertension/Hypotension • Aspiration of oral or gastric contents
Endotracheal Suction: Hazards
• Hypoxia: Why? = Loss of FRC / Increased Atelectasis • Vagal nerve response • Airway spasm • Bleeding • Increased ICP • Pain • Interruption of mechanical Ventilation • Infection - invasive
Endotracheal Suction: Indications
• Inability to generate an effective cough • Evidence ( x-ray ) of retained secretions • Increased PIP on VC or decreased VT on PCV • Visible or easily heard secretions in airway • Obtain Sputum specimen • Suspected aspiration of oral or gastric secretions
Tracheostomy Tubes: Hazards/Precautions
• Infection control - i.e. colonization of pathogens • Hemorrhage - erode innominate artery or airway trauma • Permanent scar • Greater expense • Persistent open stoma • Bypass upper airway humidification • Reduce airway diameter = fixed increased airway resistance
Respiratory Indications of Prednisone:
• Initial assessment of COPD • Acute exacerbation of COPD • Severe chronic asthma - failure to respond to inhaled steroids or other meds. • Idiopathic Pulmonary fibrosis - bronchiolitis common
Oral Airway Suction: Indications
• Large secretions or soft foreign body obstruction • Minimize oral secretions from pooling around cuff of ETT • Minimize oral secretions draining into lungs esp. with uncuffed ETT's ( i.e. neonate) • Minimize risk of aspiration for oral / gastric secretions into lungs • Prior to deflating cuff for ETT reposition or extubation • Good oral care minimizes need for invasive endotracheal suction
What are the benefits of Xopenex?
• Less cardiac side effects - indicated for heart patients • Possible beneficial anti-inflammatory effects • Can improve benefits in combination therapy with Atrovent & Pulmicort
Endotracheal Tubes: What is the advantages of Nasal Intubation?
• More comfortable over long term use • Less gag & retching • Easier to keep tube secured • Insertion can be performed blind (with minimal sedation) • Easier & more effective oral care • Patient cannot bite ETT - no need for oral airway
Tracheostomy Tubes: Advantages
• More comfortable over long term use - eliminates oral hygiene & pain issues. • Patient can be fed • Patient "looks" better - face is not obstructed • Easier to keep secured • Easier to reinsert or exchange - RT procedure using obturator • Can use uncuffed tubes • Patient can talk - i.e. fenestrated tubes & passey Muir speaking valves
Heliox: Delivery Method
• Non Rebreather with humidifier • Circulaire nebulizer • supplemental oxygen - a 6 l o2 nasal cannula of may be used along with Heliox
What are the alternative techniques to establish airway?
• Oral Airway • Nasal Airway • Mask Ventilation • Transtracheal Jet Ventilation • Retrograde Intubation • Laryngeal Mask Airway • Light Wand • Blind Nasal Intubation • Combitube • Emergency Cricothyrotomy Devices
List of Aerosolized Anti-infectious Agents
• Pentamidine Isethoionate • Ribaviran • Tobramycin (TOBI) • Zanamivir • Amphotericin B • Colistimethate Sodium (Colistin)
What are the ETT tube components?
• Pilot balloon • Cuff - high vol. low pressure • 15 mm adapter • tapered tip • I.D • O.D. • Centimeter marks • Murphy holes • Radiopaque indicator marks
List of Non-Steroidal Antiasthma Agents:
• Singulair • Zyflo • Accolate • Xolair
Heliox: Contraindications/Hazards
• SpO2 <92% on 6l n/c & 60% He / 40% O2 non Rebreather (discontinue Heliox and return to 100% Hi Flow O2) • Do not use inline with any Puritan Bennett ventilator • Never Use Heliox without humidity or Aerosol • Mucous plugging
What equipment is used for collecting sputum samples?
• Sputum trap ( Luken's trap or De Lee) • Saline for lavage
Extubations Technique: Indications
• Weaning patient from need of mechanical ventilation. • Removal of obstructed or suspected obstructed endotracheal tube. • Removal of endotracheal tube to be replaced with tracheostomy tube
What needs to be prepared in place prior to performing endotracheal intubation?
• all equipment • medication • emergency supplies • support staff
Pulmicort Respules: Indications
• may be mixed with Xopenex • used for chronic Asthma to reduce use of prednisone
Indications for Zanamivir:
• treatment for high risk ( cardio - pulmonary disease) patients for influenza A+B • Binds Virus agents together to prevent spread of disease • Hazards / precautions: • Bronchospasm • Allergic reactions • Under treat of underlying bacterial infection hidden by viral infection
