RT-240, Final Exam good questions to go over
Vent Discontinuance: Modes for weaning: SIMV
"Gradual reduction in ventilator controlled RR as supported by ABG and patient assessment."
Vent Discontinuance: Modes for weaning: CPAP
Delivers positive pressure to reduce WOB and compensate for auto-PEEP during weaning phase. As patient condition improves, CPAP is reduced to zero and patient is monitored using alarm functionality of the ventilator.
Describe the purpose of the DME
Durable Medical Equipment. Equipment that is deemed medically necessary...i.e. O2 concentrator, nebulizers, & CPAP equipment..
What is indicated by an elevated ST segment? Depressed ST segment?
Elevated: Myocardial Infarction Depressed: Ischemia
ETT sizes for neonates and pediatrics
Equation: 16 + age / 4 Neonates: < 1000 mg = 2.5 mm; 1-2 kg = 3.0 mm; 2-3 kg = 3.5 mm; > 3 kg = 4.0 mm
What is Biot's respiration?
Breathing marked by several short breaths followed by long, irregular periods of apnea. It is seen in patients with increased intracranial pressure.
Describe the disease process, diagnosis, Radiograph, and treatment for the following: BPD
Bronchopulmonary Dysplasia: Pre-term infants have decreased alveolar recruitment due to atelectrauma and damaged lung tissue due to overinflation, i.e. volutrauma. "Prolonged hyperoxia begins a sequence of lung injury that leads to inflammation, diffuse alveolar damage, pulmonary dysfunction, and death." Clinical Manifestation: Typically 2-3 weeks into life, the preterm infant begins to digress into pulmonary distress. Previously not requiring O2 and mechanical ventilation, the infant now requires both. If preterm infant has pneumonia and sepsis, very high levels of O2 and mechanical ventilation may be required. X-ray: Atelectasis, emphysema, and fibrosis diffusely intermixed throughout the lung. The best treatment for BPD is PREVENTION. - Establish FRC without over-stretching the lungs - Avoid large Vt - Early administration of surfactant - Prevent pulmonary hypertension and cor pulmonale -- CPT, Antibiotics, Supplemental O2, Bronchodilators to reduce airway resistance, Steroid therapy for short-term improvement (use with caution). NO therapy is controversial.
When to use CPAP vs BiPAP and the common settings for both
CPAP works primarily by splinting the upper airway open. - CPAP settings: 7.5-12.5 cm H2O
Describe the disease process, diagnosis, Radiograph, and treatment for the following: CDH
Congenital Diaphragmatic Hernia of the neonate: Manifests as severe respiratory distress - Lung hypoplasia, decreased alveolar count, decreased pulmonary vasculature, pulmonary hypertension, and unusual anatomy of the Inferior Vena Cava. - Typically diagnosed in utero via ultrasound, postpartum via X-ray. - Surgery is required for repair.
Describe the disease process, diagnosis, and treatment for the following: CF
Cystic Fibrosis: A buildup in thickened mucus in the airways, intestinal, and exocrine cells. Caused by a mutation in the CF transmembrane conductance regulator protein. CFTR provides an apical chloride channel for free movement of chloride which regulates water content in secretions. There are over 1600 known CFTR mutations. If both parents have a deleterious CFTR mutation, there is a 1 in 4 chance the child will have CF. Diagnosis: - Sweat Chloride Test (> 60 mEq/L) Treatment: - Airway Clearance Therapy (the Vest, percussion, postural drainage, PEP) MEDS used: Albuterol, Dornase Alfa, 7% Hypertonic Saline, and Tobramycin
Vent Discontinuance: Commonly used weaning indexes: Volume Control
- "Inspiration is initiated by the patient. During the inspiratory phase, the pressure is regulated to a value that is based on the previous breath's pressure-volume relationship as compared with a target Vt. The pressure-support level is automatically adjusted by up to +/- 3 cm H2O from one breath to the next to maintain the target Vt." "As the patient's spontaneous Vt improves, the level of pressure support is automatically reduced."
Ventricular Tachycardia
- > 100 bpm. Typically much higher. - Represented by a run of 3 or more PVCs - Often progresses to V-fib TREATMENT: Lidocaine: 1-1.5 mg/kg of body weight IV
APGAR scoring
- A system for evaluating an infant's physical condition at birth. The infant's heart rate, respiration, muscle tone, response to stimuli, and color are rated at 1 min, and again at 5 min after birth. Each factor is scored 0, 1, or 2; the maximum total score is 10. Interpretation of scores: 7 to 10, good to excellent; 4 to 6, fair; less than 4, poor condition. A low score at 1 min is a sign of perinatal asphyxia and the need for immediate assisted ventilation. Infants with scores below 7 at 5 min should be assessed immediately to see if they require resuscitation.
Define GRUNTING:
- An abnormal sound heard during labored exhalation that indicates a need for high chest pressures to keep the airways open. It is caused by closing of the glottis at the end of expiration. PATIENT CARE A grunting patient is laboring to breathe and may soon suffer respiratory failure without intervention to improve respiratory status.
Describe the disease process, diagnosis, Radiograph, and treatment for the following: Apnea of Prematurity
- Apnea of Prematurity: Marked by repeated episodes of apnea lasting longer than 20 sec. The diagnosis of AOP is one of exclusion, arrived at when no treatable cause can be found. Increased frequency of apneic episodes directly relates to the degree of prematurity. AOP is not an independent risk factor for sudden infant death syndrome. Apneic episodes may result in bradycardia, hypoxia, and respiratory acidosis. - Tactile stimulation of the newborn is often successful if apneic spells are very mild and promptly recognized. When gentle stimulation does not produce a response, bag and mask ventilation is initiated. Methylxanthines such as caffeine are helpful. Caffeine infusions may be stopped when newborns have no significant interruption in breathing for five days and reach 33 weeks of postmenstrual age. - PATIENT CARE Care includes maintenance of a neutral thermal environment, avoidance of prolonged oral feedings, use of tactile stimulation early in the apneic episode, and ventilatory support as needed. The infant who has experienced and survived an episode of apnea is maintained on cardiac and respiratory monitoring devices. Before discharge, parents are taught cardiopulmonary resuscitation, use of monitoring equipment, and how to recognize signs of medication toxicity if medications are used.
Measuring outcomes of a Rehab Program
- Changes in exercise tolerance - Before and after 6- or 12- minute walking distance - Before and after pulmonary exercise stress test - Review of patient home exercise logs - Strength measurement - Flexibility and posture - Changes in symptoms - Frequency of cough, sputum production - Activities of daily living changes - Frequency and duration of respiratory exacerbations - Frequency and duration of hospitalizations - Frequency of ER visits - Return to productive employment
Myocardial Infarction
- Complete obstruction of coronary artery - Causes death of heart tissue (necrosis) - Elevated ST segment on EKG
Structures of the Kidney: Loop of Henle
- Descending Loop is where water is reabsorbed (osmolarity increases due to higher concentration of Na+ and Cl-) - Ascending Loop is where Na+ and Cl- is reabsorbed (osmolarity is decreased due to water not being reabsorbed)
Define REPOLARIZATION
- Diastole. Relaxation (filling of atria and ventricles occur) - of Ventricles is the T wave
Describe the disease process, diagnosis, Radiograph, and treatment for the following: Epiglottitis
- Life-threatening Supraglottic inflammation causes by a bacterial infection. - Thumb Sign on X-ray - Presents with high fever, sore throat, stridor, and labored breathing - Treatment: Steroids and Antibiotics, Intubation under sedation, Tracheostomy (if required)
Premature Ventricular Contraction (PVC)
- Occurs when ectopic beats originate in the ventricles - Result from hypoxia, electrolyte imbalance, and acid-base disorders - QRS complex is wide and has no preceding P wave TREATMENT: Lidocaine: 1-1.5 mg/kg of body weight IV
Structures of the Kidney: Glomerulus
- One of the capillary networks that are part of the renal corpuscles in the nephrons of the kidney. Each is surrounded by a Bowman's capsule, the site of renal (glomerular) filtration, which is the first step in the formation of urine.
What are the normal PR and QRS intervals?
- PR interval normal is not > 0.2 second -- Longer indicates 1st degree heart block - QRS complex normal is 0.12 second
Development stages: 8-10 years old
Approx. 470 million mature alveoli formed
Rehab program monitoring
- Patient's response to progressive and general reconditioning exercises in conjunction with breathing techniques - O2 requirements at rest and with exercise - Knowledge and skills acquisition - Patient's subjective comments - Progress in achieving goals - Patient appearance - Vital signs - Cardiac telemetry - Perceived exertion and dyspnea (Modified Borg scale)
Contraindications for weaning
- Pt is unable to protect airway - RSBI > 105 - pH < 7.30 - Persistent tachycardia - Decrease in SpO2 <= 90% - RR >= 35 bpm - PaCO2 increase > 10 mm Hg - Decreased cardiac index - Angina - Anxiety
Indications for use of Inhaled Nitric Oxide and common PPM settings
- Pulmonary vasodilation - 20 Parts Per Million (PPM) is common, starting dosage
Atrial Flutter
- Represented by a Saw-tooth shaped QRS - Rapid atrial depolarization from ectopic focus (250-300/min) - Caused by wide variety of disorders (Rheumatic heart disease, Coronary Heart disease, renal failure, stress, and hypoxemia) TREATMENT: Cardioversion, vagal maneuvers, beta blockers, Anti-coagulants to prevent clot formation
Indications for weaning
- Resolution of the disease state or condition - Hemodynamic stability - Absence of sepsis - Adequate oxygenation status with a decreased FiO2 and decreased PEEP or CPAP - Adequate ventilatory status and PaCO2 - Pt is able to protect airway
Describe the disease process, diagnosis, Radiograph, and treatment for the following: Croup
- Subglottic Inflammation caused by a viral infection. - Steeple sign on X-ray - Caused by the Parainfluenza Virus - Treatment: Racemic Epi, Cool Mist, Supplemental O2, Corticosteroids to reduce swelling
Define DEPOLARIZATION
- Systole. Contraction of the atria and ventricles occur. - of Atria is the P wave - of Ventricles is the QRS complex
Ventricular Fibrillation
- The inferior chambers of the heart shake (ineffective contraction). Typically precedes asystole. - Cardiac Output drops to 0. - Represented by zigzag pattern TREATMENT: Epinephrine: 1 mg IV or intraosseous (IO) 1:10,000 solution; repeat every 3-5 min - Amiodarone: 300 mg IV or IO after dose of epinephrine if no initial response to defibrillation; repeat 150 mg IV in 3-5 min
Structures of the Kidney: Nephron
- The structural and functional unit of the kidney, consisting of a renal (malpighian) corpuscle (a glomerulus enclosed within Bowman capsule), the proximal convoluted tubule, the loop of Henle, and the distal convoluted tubule. These connect by arched collecting tubules with straight collecting tubules. Urine is formed by filtration in renal corpuscles and selective reabsorption and secretion by the cells of the renal tubule. - There are approx. one million nephrons in each kidney.
Atrial Fibrillation
- The superior chambers of the heart shake (ineffective contraction) - Ventricular rate may be slow and irregular - Decreases Cardiac Output and may lead to clot formation in the atria TREATMENT: Cardioversion, vagal maneuvers, beta blockers, Anti-coagulants to prevent clot formation
Define DECELERATIONS
- Typically occur during the delivery phase as the neonate passes through the birth canal...the heart rate may fluctuate
Surgical options for OSA/CSA?
- Uvulopalatopharyngoplasty (UPPP): Portions of the soft palate, uvula, and additional redundant tissue are removed - Less than 50% success rate - Maxillofacial surgery
Ventilator Management: HFOV
- Ventilation: Hertz (1 hz = 60 breaths) - Amplitude: Affects Vt
Vent Discontinuance: Modes for weaning: T-Piece
100% patient initiated breaths. No alarm support from the ventilator. Patients must be closely monitored for increased WOB and stress.
Development stages: Canalicular
16-26 weeks gestation. 16-17th week: Respiratory bronchioles and immature acini (basic gas-exchanging unit of the lung) begin to form. 20-24th week: Type 1 and Type II pneumocytes begin to appear and replicate. 24-26th week: Pulmonary capillaries develop on surface of acinus, immature surfactant begins to appear in lung fluid.
Development stages: Embryonic
20-22 days to 5th week
Development stages: Terminal Saccular
26th week to Birth - Type I and II pneumocytes continue to multiply - Surfactant production increases - Extrauterine life is possible with support
Development stages: Alveolar
32-40th week - Immature alveoli begin to form and increase in number - Surfactant production matures - @ 40th week, 50 million immature alveoli formed
Development stages: Pseudoglandular
6-16th week - Diaphragm is completed - Terminal bronchioles and associated pulmonary vessels form
What is Cheyne-Stokes respiration?
A breathing pattern marked by a period of apnea lasting 10 to 60 sec, followed by gradually increasing depth and frequency of respirations (hyperventilation). It occurs in dysfunction or depression of the cerebral hemispheres, (as in coma), in basal ganglia disease, and occasionally in congestive heart failure. It often indicates a grave prognosis in adults but may be a normal finding in children.
What is Kussmaul's respiration?
A very deep, repetitive, gasping respiratory pattern associated with profound acidosis, e.g., diabetic ketoacidosis. It may be a sign of impending death. Metabolic Acidosis DEONTAE!!
Sleep Apnea: Central
Apnea that occurs during sleep when the respiratory center of the brainstem does not send normal periodic signals to the muscles of respiration. Observation of the patient shows no respiratory effort (no movement of the chest, and no breath sounds).
Sleep Apnea: OSA
In obstructive sleep apnea, vigorous respiratory efforts are present during sleep but the flow of air in and out of the airways is blocked by upper airway obstruction.
Describe the disease process, diagnosis, Radiograph, and treatment for the following: Patent Ductus Arteriosus
PDA: Ductus Arteriosus fails to close after typical 5-7 day period post birth. - Shunting may be right to left (pulmonary pressure greater than aortic) or left to right (aortic pressure greater than pulmonary) - Treatment: Indomethacin or surgical ligation
Describe the disease process, diagnosis, Radiograph, and treatment for the following: MAS
Meconium Aspiration Syndrome: "Aspiration of meconium into the central airways of the lung. It is usually associated with perinatal depression and asphyxia." 3 primary problems: Pulmonary obstruction, lung tissue damage, and pulmonary hypertension. Treatment: Suction via ETT. Have blowby 100% O2 during procedure. Complete multiple ETT/Suction passes until there is no longer evidence of meconium. CPAP is indicated if hypoxemia is noted. CPAP helps overcome the ball-valve effect (air in but not out, i.e. air trapping) Use of HFV and surfactant aid in MAS resolution. iNO aids in reduction of persistent pulmonary hypertension.
Apnea-Hypopnea Index
Mild: 5-15 AHI Moderate: 15-30 AHI Severe: > 30 AHI
Vent Discontinuance: Commonly used weaning indexes: NIF
Negative Inspiratory Force If -20 or less (more negative), successful weaning indicated
Define FLARING
Nostrils dilate to aid in air movement/flow - Indicates an increased Work of Breathing
Rehab and Alt Sites: Components of a Rehab program
Open or Closed format. - Open: No set time-frame. Completion over weeks or months. Good for self-directed patients or patients with scheduling difficulties. Patients who require individual attention. LACKS GROUP SUPPORT. - Closed: Set time frame and amount of sessions approved by insurance or Medicare (36 initial sessions). Classes usually last 2 hours. Schedule determines program completion rather than objectives. - PLANNED follow-up is a must. - Groups should be organized based on capability. - 3 to 10 participants per class is ideal
Describe the disease process, diagnosis, Radiograph, and treatment for the following: RDS
Respiratory Distress Syndrome: Also known as Hyaline Membrane Disease. Major factors in pathophysiology: "Qualitative surfactant deficiency, decreased alveolar surface area, increased small airways compliance, and presence of a ductus arteriosus." X-ray: Diffuse, hazy, reticulogranular densities with the presence of air bronchograms with low lung volumes. Treatment: CPAP and PEEP, HFV and Surfactant Replacement Therapy
Vent Discontinuance: Commonly used weaning indexes: Rapid Shallow Breathing Index (RSBI)
RR / Vt < 105 indicates successful weaning (Most MDs prefer RSBI around 50)
Describe the disease process, diagnosis, Radiograph, and treatment for the following: ROP
Retinopathy of Prematurity: "An abnormal eye condition that occurs in some premature or low-birth weight infants who receive supplemental O2 for extended periods of time. Excessive blood O2 levels cause retinal vasoconstriction, which leads to necrosis of the blood vessels. In response, new vessels form and increase in number. Hemorrhage of these delicate new vessels causes scarring behind the retina. Scarring often leads to retinal detachment and blindness." - O2 greater than 50% for more than 24 hours leads to RoP.
Cardiac Anatomy and Structures
Right Atria - Receives deoxygenated blood from Inferior and Superior Vena Cava Left Atria - Receives oxygenated blood from the lungs via the pulmonary vein. Right Ventricle - Receives deoxygenated blood from the right atria (tricuspid valve separates the two chambers). Pumps deoxygenated blood to the lungs. Left Ventricle - Receives oxygenated blood from the left atria (bicuspid or mitral valve separates the two chambers). Pumps blood through the aortic valve to the body.
List the structure and functions of the conduction pathways of the heart.
SA Node - Electrical conductor of the heart. Known as the "Pacemaker". AV Node - Backup electrical conductor of the heart. Bundle of HIS - Conduction fibers between the left and right ventricles. Initiates ventricular contraction. Purkinje Fibers - A cardiac muscle cell beneath the endocardium of the ventricles of the heart. These extend from the bundle branches to the ventricular myocardium and form the last part of the cardiac conduction system.
Cardiac Output
Stroke Volume x Heart Rate - Normal is 5-6 Liters per minute
Describe the disease process, diagnosis, Radiograph, and treatment for the following: SIDS
Sudden Infant Death Syndrome: An infant who dies of SIDS typically is: - Preterm - African American - Male - Born to a poor mother who received inadequate prenatal care - Mother < 20 years old, Cigarette smoker, Narcotic use, Previous fetal loss - Prone sleeping increases risk for SIDS. - Infants who die of SIDS typically have repeated episodes of hypoxemia or ischemia.
Rehab program exercises
Target Heart Rate is computed as follows: [(MHR-RHR) x 0.6] + RHR - Lower extremity (leg) aerobic exercises - Timed walking (6- or 12- minute walk) - Upper extremity (arm) aerobic exercises - Ventilatory muscle training (progressive resistance)
Describe the disease process, diagnosis, Radiograph, and treatment for the following: Tetralogy of Fallot
ToF: Obstruction of right ventricular outflow (pulmonary stenosis), Ventricular Septal Defect, Dextroposition of the aorta, & Right Ventricular Hypertrophy - History of infant squatting or entering a knee-chest position - Corrected by surgery
Describe the disease process, diagnosis, Radiograph, and treatment for the following: TTN
Transient Tachypnea of the Newborn: Often called Type II RDS. Caused by delayed clearance of fetal lung liquid (Cesarean birth or incomplete development of lymphatic vessels [reabsorption]). Clinical Manifestation: During first few hours of life, infants begin breathing rapidly. Cap Blood Gas is usually normal. X-ray: Hyperinflated lungs secondary to air-trapping and perihilar streaking (lymphatic engorgement). - Pleural effusions may be evident in costophrenic angles and interlobar fissures. Treatment: - Low FiO2 delivered via O2 hood or Nasal Cannula - CPAP may be used on those requiring higher FiO2. - Frequent body position changes to encourage movement of fluids
Ventilator Management: Conventional Modes: mL/Kg for Neonates/Pediatrics
Vt: 6-8 ml/kg RDS: Vt: 4-6 ml/kg
Define RETRACTIONS
sub-Sternal depression to increase negative pressure required to overcome resistance/obstruction