egan's
True saturation equals what?
(reduced Hb+HbO2) + HbO2 + HbCO + metHb
Why do we use Point-of-Care Testing?
**Reduces turnaround time, thus should improve care and lower costs. **Used for blood chemistry and hematology parameters. **Used increasingly in hospitals and physician offices.
What are risks of long term exposure to N2O?
**neropathy **fetal disorders **spontaneous abortion
What conditions cause an increased stretch of cardiac muscle?
*ARDS *severe sepsis *chest pain *dyspnea *pulmonary edema
what are some indications for an ABG Draw?
*acute shortness of breath *abnormal breath sounds *cyanosis *heavy use of accessory muscles *change in ventilator settings *CPR *Diffuse infiltrates on CXR
clinical signs and symptoms of inadequate airway humidification
- Atelectasis - Dry, nonproductive cough - Increased airway resistance - Increased incidence of infection - Increased work of breathing - Patient complaint of substernal pain and airway dryness - Thick, dehydrated secretions
Large Paticles
- are more susceptible to the force of gravity than smaller particles. -are more affected by the bombardment of molecules deposited by diffusion.
Electrolytes
- are positively or negatively charged ions that influence the functioning of enzymes -always must be interpreted within the context of fluid balanc
Factors Affecting Performance of SVN
-Nebulizer Design -Gas Source: Wall, Cylinder, Compressor - Characteristics of Drug Formulation
What are therapeutic Aerosol depositions influenced by?
1. Inspiratory flow rate 2. Flow pattern 3. Respiratory Rate 4. Inhaled volume 5. I:E ratio 6. Breath-holding
most commonly used devices to administer orally or nasally inhaled aerosols.
1. MDI- Metered Dose Inhaler 2. SVN- Small Volume Nebulizer 3. DPI- Dry Poweder Inhaler
Bradypnea is a respiratory rate of less than _____ breaths/min.
10
Ear oximeter invented (when?)
1974
Pulse oximeter invented (when?)
1980s
AART became AARC when?
1982
white blood cell count
4,500 - 11,500
standard precautions for all patients
-wash hands after touching blood. body fluids, & contaminated items -wear fresh clean gloves for all tacks -caution with sharps -handle soiled requirement carefully
What three elements that must be present for transmission of infection within a health care setting?
A source (or reservoir) of pathogens, a susceptible host and a route of transmission. (Egan Pg 54)
Low hematocrit reading occurs with what?
Anemia
first great biologist
Aristotle
How often should you change the site when using a transcutaneous monitor?
At least every 2 to 6 hours
What is Fractional distillation?
Atmospheric air is filtered to remove pollutants, water and CO2. Purified air is liquefied by compression & cooled by rapid expansion (Joule-Thompson Effect). Resulting mixture is heated slowly to allow nitrogen to boil off, leaving just O2 **Simplified: Air is filtered, liquefied, cooled then heated slowly resulting in pure O2.
How is Aerosol Output measured?
By collecting the aerosol that leaves a nebulizer and collects on special filters.
How do you troubleshoot bland aerosol therapy bronchospasm?
Discontinue bland aerosol therapy
Nonverbal communication includes all of the following except?
Discussion
Anticholinergic
Drug that blocks a receptor for acertylcholine.
Adrenergic
Drug that stimulated a receptor responding to a norepinephrine or epinephrine
Cholinergic
Drug that stimulates a receptor for acetylcholine
What are examples of Ultra-short catecholamine agents?
Epinephrine and isoproterenol (immediate reaction rapidly metabolized) old school drugs
T/F: When interviewing a patient, you should always ask leading questions.
F
Which of the following organs is the most sensitive to the effects of electrical shock?
Heart
Hyperinflation causes the diaphragm to be in a low, flat position. Contraction of a flat diaphragm tends to draw in the lateral costal margins instead of expanding them. This is called what?
Hoover sign
A level of high potassium levels is known as what?
Hyperkalemia (>8.0)
For whom would you use a combined anticholinergic and beta-agonist for?
For patients with COPD
Why would you use a short acting (rescue) Adrenergic Bronchodilators?
For relief of acute reversible airway obstruction
What is brand name formoterol >
Foradil, Perforomist
2 forms in which O2 is transported
Physically dissolved in plasma, Chemically bound to hemoglobin (Hb)
Streptococcus pneumoniae is a common bacterium associated with?
Pneumonia
Inhaled bronchoactive aerosols are intended for:
Local effects in the airway.
What is Thrombocytopenia?
Low platelets
What does Assay measure?
Quantity of drug
Intra-arterial (In Vivo) continuous blood gas analysis is beneficial because it provides...
Real time monitoring **Reduction in therapeutic decision making time **Less blood loss **Lower infection risk **Improved accuracy **Elimination of specimen transport
CO2 gradient
Reverse of O2 cascade gradient (HIGH) ~60mm Hg
______ (right/left) heart failure commonly occurs in patients with advanced COPD because of chronic hypoxemia.
Right
How do you prime an MDI?
Shake device and release one or more sprays into the air when MDI is new or hasn't been used for a while
What is reduction in blood flow called?
Shock/Ischemia
What is brand name tiotropium?
Spiriva
What is the brand name for Tiotropium bromide?
Spiriva
T/F: Bedside assessment is of little risk to the patient and provides the initial evidence that something is wrong.
T
T/F: Crepitus is a classic sign of barotrauma.
T
T/F: Dyspnea is a subjective experience.
T
Reporting Violations
If a licensee has knowledge that another person may be in violation of, or has violated, any of the statutes or regulations administered by the board, the licensee shall report this information to the board in writing and shall cooperate with the board in furnishing information or assistance as may be required
What is the main benefit Nitric Oxide Therapy?
Improves oxygenation without shunting
What should be worn to treat patients with tuberculosis?
N-95 mask. (Egan Pg 72)
Where do most hospital fires initially start?
Kitchen
The end product of anaerobic glucose metabolism is known as?
Lactate
What are inhaled corticosteroids?
Lipid-soluble drug that is orally inhaled preparations used for anti-inflammatory maintenance therapy of persistent asthma and severe COPD
Ideal ventilation Ratio equation
VD/VT= PaCO2-PÉCO2/PaCO2
HBO2 dissociation curve describes what?
The relationship between PAO2 and SaO2 and it's "S" Shaped
What was the reservoir cannula designed for?
To conserve oxygen and make you look like Iron Man
What is a regulator used for?
To control both pressure and flow.
What is bulk O2 used for?
To meet large O2 needs of health care facilities
Why would you prime an MDI?
To mix the drug and propellant and to ensure adequate dose is provided
What are gas cylinders used for?
To store and ship compressed or liquid medical gases.
What is the drawback of Ex Vivo blood gas analysis?
Unable to provide real-time continuous data.
What is aerosol output?
The mass (amount) of fluid or drug contained in aerosol
What is the drug administration phase?
The method by which a drug is made available to the patient
What is the process of humidity therapy?
The nose heats and humidifies gas on inspiration, while cooling and reclaiming H2O from the gas that is exhaled
What is the purpose of a BUBBLE humidifier?
Usually used unheated with oxygen delivery systems to raise the water vapor content of gas to ambient levels by breaking underwater gas stream into small bubbles
virucidal
agent that destroys or inactivates viruses
Anemia
an abnormally low RBC count.
The most common cause of JVD is: a. left heart failure b. right heart failure
b
What is the majority of the O2 in the body carried in
bound to Hemoglobin (Hb)
A condition in which the pulse is less than 60 bpm.
bradycardia
A respiratory rate less than 10 breaths/min.
bradypnea
Equipment processing definitions: sterilization
complete destruction of all forms of microbial life
What is bland aerosol?
consists of liquid particles suspended in gas (O2 or air)
Discontinuous lung sounds produced when airflow moves secretions or fluid in the airways
crackles
creatine kinase (CK) also known as
creatine phosphokinase CPK
name mast cell stabilizer (1)
cromolyn sodium (Intal)
A bluish discoloration of the tissues.
cyanosis
What are the indications for Dornase alpha?
cystic fibrosis
overhydration causes hematocrit to
decrease
What is the pharmacodynamics phase of pharmacology?
describes mechanisms of drug action by which drug molecule causes its effects in body
Geometric Standard Deviation (GSD)
describes the variability of particle sizes in an aerosol distribution set at 1 standard deviation above or below the median (15.8% & 84.13)
sporicidal
destructive to the spore from of bacteria
humidifier
device that adds molecular water to gas.
Nebulizer
device that produces an aerosol suspension of liquid particles in a gaseous medium using baffling to control particle size.
What is the medical term for sweating?
diaphoresis
Laboratory Analysis is...
discrete measurements of fluids or tissue that has been removed from patient
discovers x-ray and opens door for modern field of radiology
William Roentgen
tort
a civil wrong - basic functions of torts are to keep the peace between individuals and to substitute a remedy for personal injury instead of vengeance
Strict liability
a theory in tort law that can be used to impose liability without fault, even in situations where injury occurs under conditions of reasonable care
intentional tort
a wrong perpetrated by someone who intends to break the law
bacteriostatic
ability to restrain the growth of micro-organisms
three kinds of damages in negligence lawsuits
economic-are awarded for economic loss noneconomic-include pain, suffering, disability, disfigurement, and loss of the enjoyment of life punitive-damages that are awarded to punish wrongful conduct and deter future unlawful conduct
WBC count (>15 × 103/mcl) occurs only when..
either neutrophils or lymphocytes are responding to an abnormality
hepatits, renal disease, shock, MI, trauma, widespread carcinoma, magaloblasctic anemia
elevated L-lactate dehydrogenase
Neutrophilia
elevation of the absolute value of neutrophils.
eHealth
emerging computer applications in clinical care, diagnostics, management, education, and research
M2 cholinergic
enhances cholinergic nerve transmission, decreases heart rate, inhibits release of acetylcholine
information retrieval
enhances clinical expertise by providing information for the development of evidence-based, patient-driven protocols, and aids in clinical decisions for individual patients
increased with allergic reactions and parasitic infections
eosinophils
RBC
erythrocytes: are evaluated for size and hemoglobin content.
Interviewing serves 3 purposes. What are they?
establish a rapport between the clinician and the patient, obtain essential diagnostic information, help monitor changes in the patient's symptoms and response to therapy
How many infections do hospital-acquired HAIs account for annually?
estimated 2 million infections.(Egan Pg 54)
Deposition
estimony of a witness taken on interrogatories, either oral or in writing.
Noninvasive procedures are...
external monitoring without insertion of devices INTO the patient.
During an interview, the RT should assume a position that is _____ level with the patient.
eye
what is the formula for alveolar minute ventilation
f x (VT-VD) frequency x (Tidal Volume - Physiological Deadspace)
libel
false accusation written, printed, or typewritten or presented in a picture or a sign that is made with malicious intent to defame the reputation of a person who is living or the memory of a person who is dead, resulting in public embarrassment, contempt, ridicule, or hatred
Body temperature elevation caused by disease is called fever, and the patient is said to be ___________.
febrile
Sputum that is foul-smelling is said to be _______.
fetid
Bennett 7200
first microprocessor-controlled ventilator
Should be removed from vicinity of oxygen use
flammable material
hazzards of transcutanouse monitors
flase negative or false positive results may lead to inappropriate treatment Tissue injury (erythema, blisters, burns, skin tears, may occur at the measuring site
Name inhaled corticosteroids (3 plain, 3 combo)
fluticasone (Flovent) budesonide (Pulmicort) mometasone (Asmanex) fluticasone/salmeterol (Advair) budesonide/formoterol (Symbicort) mometasone/formoterol (Dulera)
What is the term for inanimate objects that may serve to transfer pathogens from one person to another?
fomites. (Egan Pg 55)
Bright, red blood (new blood) is said to be _______.
frank
How is He commercially produced?
from natural gas through liquefaction to purity standards of at least 99%
chemical reaction, no external power,responds more slowly,may take as long as 60 sec
galvanic fuel cells
What does NONINVASIVE monitoring mean?
gathering data EXTERNALLY
noninvasive monitoring is a means of?
gathering data externally
In neonates and infants,
given the small minute volumes and small airways with increased impaction and reduced sedimentation, deposition can be only 0.5%.
List three general barrier methods used to prevent exposure to organisms
gloves, gown and goggle/mask. (Egan Pg 68)
The use of what is part of routine care when there is skin care?
gloves. (Egan Pg 74)
Standard Precaution: Patient care equipment
handle carefully -do not reuse equipment unless cleaned -discard single use items
dornase alfa
has not been shown to produce antibodies that might cause allergic reactions, including bronchospasm
Severe electrolyte disorders
have a profound impact on pulmonary function
Patients with cystic fibrosis
have increased levels of Cl− in sweat because of an inability to reabsorb it
Patients with cystic fibrosis
have increased levels of Cl− in their sweat because of an inability to reabsorb it
Cardiac output is a function of _______ ________ and ________ _________.
heart rate, stroke volume
How should gas cylinders be stored?
in racks or chained to wall away from heat sources. No smoking signs posted and with cylinder caps in place if not in use. **Store LIQUID O2 containers in cool, well-ventilated area
interaction of ethics and the law
in respiratory care is the diversification of the field into home care and durable medical equipment supply
disinfection high-level
inactivation all microorganisms except bacterial spores (with sufficient exposure times, spores may also be destroyed)
(BCP) Basic Chemistry Panel or basic metabolic panel
includes the predominant electrolytes of: Na, K+, Cl-, CO2, and glucose.
Invasive procedures are...
insertion of a monitoring device into a patient
Invasive procedures require
insertion of the sensor or collection device into the body
List the 4 steps of the physical examination.
inspection, palpation, percussion, auscultation
humidity deficit
inspired air that is not fully saturated
hygrometer
instrument that directly measures relative humidity of the atmosphere or the proportion of water in a specific gas or gas mixture, without extracting the moisture.
Philip Drinker
inventor of Iron lung
Baffle
is a surface on which large particles impact and fall out of suspension, whereas smaller particles remain in suspension, reducing the size of particles remaining in the aerosol.
The assessment of bronchodilator therapy with an anticholinergic agent
is the same as assessment for adrenergic agent
The primary function of RBCs
is to supply oxygen to the tissues. The RBC count helps determine the ability of the blood to carry oxygen
Erythrocytes primary function
is to supply oxygen to the tissues. The RBC helps determine the ability of the blood to carry oxygen.
With a heart attack, __________ happens first, followed by _________ ___________.
ischemia, myocardial infarction
what is the formula to quantify efficiency of aerosol delivery to lungs?
item deleted via Lalim Principle of Irrelevance (LPI)
how to minimize fire hazard via toys that create a spark
keep them away from oxygen use
Karl von Linde
large-scale production of 02 developed by
Thrombocytopenia (low platelets) and thrombasthenia (abnormal platelet functioning)
lead to excessive bleeding, whereas thrombocytosis (excessive platelets) causes excessive clotting
Pulsus alternans suggest _____ sided heart failure.
left
tort
legal wrong committed on a person or property independent of contract
seen in the elderly patients with severe pneumonia that is overwhelming the immune system
leukopenia
Zafirlukast and montelukast
leukotriene receptor antagonists and are selective competitive antagonists of leukotriene receptors LTD4 and LTE4
A _______, ____________cough is associated with diseases such as bronchitis and asthma.
loose, productive
What's the most common causes of anlayzer malfunction?
low batteries, sensor depletion, electronic failure • fix: replace batteries, replace sensor, repair electronic system
In high altitudes, what inaccuracy will the oxygen analyzer read?
lower % than actual • because lower pressure in higher altitudes
Enlarged lymph nodes
lymphadenopathy
increased with viral and other infections: reduced with immunodeficiency problems
lymphocytes
What are the indications for long acting adrenergic bronchodilators?
maintenance bronchodilation in patients with obstructive lung disease
What are the 3 types of nonsteroidal antiasthma medications?
mast cell stabilizer, antileukotriens, monoclonal antibody
Sigs
mature neutrophils due to their segmented shape of their nucleus.
misallocation
may consist of ordering therapy that is not indicated, ordering therapy to be delivered by an inappropriate method, or failing to provide therapy that is indicated
Lactate dehydrogenase
moderate increases leads to myocardial infarction or hemolytic anemia.
increased with invasion of foreign material
monocytes
rule utilitarianism
moral reasoning approach based not on which act has the greatest utility, but on which rule would promote the greatest good if it were generally followed
Small volume nebulizers (SVNs)
most commonly used for medical aerosol therapy hold 5 to 20 ml of medication.
What are the four sites to measure body temperature?
mouth, axilla, ear, rectum.
three basic forms of torts
negligent torts, intentional torts, and torts in which liability is assessed regardless of fault
elevation of the absolute value of neutrophils is known as
neutrophilia
increased with bacterial infection and trauma, reduced with bone marrow disease
neutrophils
Most circulating WBCs are either
neutrophils or lymphocyte
What words should you ask the patient to repeat to assess for tactile fremitus?
ninety nine
patient placement and transport precautions
o Single occupancy room ideal o Cohorting: grouping patients with same infection o Limit transport of patients with contagious diseases o During transport: patient needs to wear appropriate barrier protection (masks, gowns, impervious dressings)
hand hygiene
o Wash hands properly o Gel in- gel out
autonomy
o acknowledges the personal liberty of patients and their right to decide their own course of treatment and follow through a plan on which they freely agree.
A low hematocrit reading
occurs with anemia
Cholinergic
of or pertaining to nerve fibers that elaborate acetylcholine at the myoneural junctions.
A more comprehensive metabolic panel would include..
other important electrolytes, such as magnesium (Mg++), phosphorus (PO4−), and calcium (Ca++)
Pulmonary and Systemic Effects Excess water can cause:
overhydration
Do anticholinergic bronchodilators use sympathetic or parasympathetic nervous system?
parasympathetic (unless combined with adrenergic bronchodilator, then both)
The sensation of tingling and numbness in the extremities that often accompanies respiratory alkalosis is called:
paresthesia
What does PaO2 represent?
partial pressure of O2 in arterial blood • result of gas exchange between lung and blood
PTT
partial thromboplastin time
What humidifiers use heat?
passover (wick-type, membrane type), HME
hydrophobic
pertaining to the property of repelling water molecules, a quality possessed by nonpolar radicals or molecules that are more soluble in organic solvents than in water.
dornase alfa side effects
pharyngitis and voice alteration, laryngitis, rash, chest pain, and conjunctivitis
Takes blood gass analysis form specialized laboratory to the patients bedside
point-of-care testing
Who is David Pierson?
prominent pulmonary physician
Respirable Mass
proportion of aerosolized drug of the proper particle size to reach the lower respiratory tract
Sputum containing pus cells is said to be ___________.
purulent
Fremitus is __________ in patients who are obese or overly muscular.
reduced
Lactic acidosis
results from either overproduction of or insufficient metabolism of lactate
An intermittent sinking inward of the skin overlying the chest wall during inspiration; occur when the ventilatory muscles contract forcefully enough to cause a large decrease in the intrathoracic pressure.
retractions
The type of precaution needed when you need to protect the patient from yourself because they have NO immunity.
reverse isolation
Spinal deformity in which the spine has a lateral curvature
scoliosis
google scholar
search engine for scholarly publications in a wide range of fields-- fast, yields wide-ranging search results and provides citation data
A reference range
sets the boundaries for any analyte (e.g., electrolyte, blood cell, protein, enzyme) that would likely be encountered in healthy subjects
Where aerosol particles are deposited in the respiratory tract depends on their
size, shape, and motion and on the physical characteristics of the airways. Key mechanisms causing aerosol deposition include inertial impaction, sedimentation, and brownian diffusion.
BNP test
this test is used to evaluate patients for heart failure, or in particular, patients who present to the emergency dept with dyspnea and pulmonary edema.
immunocompromised hosts
those highly susceptible to infections, especially infections caused by bacteria, fungi or viruses
platelets are also known as
thrombocytes
who sets required amount of CEU's required to keep license to practice?
state licensing boards
Muscarinic
stimulating the postganglionic parasympathetic receptor; pertaining to the poisonous activity of muscarin
well-designed baffling systems decrease both
the MMAD (size) and the GSD (range of sizes) of the generated aerosol.
Anatomic pathology
the analysis of tissue for diagnosing diseases.
Most hospital fires start in
the kitchen
what is the preferred site for an ABG draw?
the radial artery
without a dose counter
there is no viable method to determine remaining drug in a pMDI other manually keeping a log of every dose taken.
benevolent deception
truth is withheld for patient own good
Proximate causation or legal causation
turns on foreseeability and whether it is fair to impose damages on a defendant
Percussion over normal lung fields produces a moderately low pitched sound that can be hard easily. This sound is described as normal resonance or _________.
tympanic
The threshold for blood transfusion
typically is a hematocrit of 21% or a hemoglobin of 7.0 g/dl
An electrically powered device that uses a piezoelectric crystal to generate aerosol
ultrasonic nebulizer
a waste product of metabolism that is excreted by healthy kidneys
urea
tobramycin (Tobi)
used to treat chronic P. aeruginosa infection in CF patients
How does pulse oximeter work?
uses light absorption patterns • indicate saturation of "PULSED" arterial blood
rule utilitarianism
variation of consequentialism
What does alpha-receptor stimulation cause?
vasoconstriction and increases blood pressure (used for airway bleeding and croup/stridor)
Orthopnea (dypsnea in the reclining position) is caused by the sudden increase in _________ _______ that occurs when reclining.
venous return
VAP
ventilator-associated pneumonia
A quasimusical, adventitious lung sound.
wheeze
tissue hypoxia
when the oxygen-carrying capacity of the blood is reduced
When should ventilator circuits be changed
when visibly soiled or malfunctioning
What does PETCO2 normally average?
• 1-5 mmHG less than PaCO2 (arterial CO2) ~34-39 mmHg • PaCO2 = 40 mmHg normal
How do you calibrate an ELECTROCHEMICAL analyzer? [Clark & galvanic]
• 2-point calibration • Calibrate to known source of 21% -> use control to adjust • Then calibrate to known source of 100%
What is normal saturation for pulse oximetry?
• 97% saturation • 15 g/dL Hb -> per 100 mL of blood
[Where do we get blood gas samples?]
• peripheral artery • indwelling catheter (arterial, central venous, or PA) • capillary sampling
[What are PREANALYTIC ERRORS?]
• problems occuring BEFORE sample analysis that alter accuracy
What is a PROBLEM of pulse oximetry?
• pulse oximeter only reads REDUCED Hb and HbO2 -97% but patient still in distress. Patient has 15 g/dL but only 8 available for O2 carrying. -Thus: • patient has CO poisoning, gm/dL is HbCO
[Combining the two]
• use invasive to establish baseline • apply noninvasive for ongoing monitoring of STABLE patient • trends in change of noninvasive useful in making clinical decisions
What is HEMOXIMETRY?
• uses a hemoximeter to measure blood O2 levels and Hb saturations • a type of oximetry
What is pulse oximetry?
• noninvasive portable monitoring device
Four categories of jet SVNs include
(1) continuous nebulizer with simple reservoir, (2) continuous nebulizer with collection reservoir bag, (3) breath-enhanced nebulizer, and (4) breath-actuated nebulizer
What is Anemia?
Abnormally low RBC count
body that oversees accreditation of RC programs
CoARC
Which tests is used to check blood clotting?
Coagulation study
The general term describing the sensation of breathing discomfort.
Dyspnea
What sterilization is best suited for critical moisture sensitive of heat sensitive items
EtO
Voltage
Is power behind electrical energy
Atmosphere O2 cascade
PO2= 159 mm/hg
Auditory
Pertaining to the sense of hearing
How does contact time affect humidifiers performance?
The longer a gas remains in contact with water, the greater the opportunity for evaporation to occur
consequentialism
The viewpoint in which decisions are based on the assessment of consequences
beneficence
"do no harm" requirement to an even higher level. Beneficence requires that health care providers go beyond doing no harm and contribute actively to the health and well-being of their patients
blood samples provide a one-time
"snapshot" of processes that are constantly in flux.
What are 5 types of airway appliances?
**Aerosol mask **Face tent **T-tube **Tracheostomy mask
Is Ribavirin cost effective?
**Shrug** I dunno....
What are 3 types of HMEs?
**Simple condenser humidifier **Hygroscopic condenser humidifier **Hydrophobic condenser humidifier
What should you avoid when storing gas cylinders.
**storing with combustible material **storing flammable gases with gases that support combustion
Setting humidification levels
- At least 30 mg/L of humidity is recommended for intubated patients. - Humidifiers should provide optimal levels of humidity in the inspired gas. - Some experts recommend heating the inhaled gas to maintain airway temperatures near 35 to 37 degrees C.
Bubble humidifiers
- Breaks an underwater gas stream into small bubbles - Usually unheated - Goal is to raise the water vapor content of the gas to ambient levels.
Problems related to inhalation of dry gas
- Heat and water loss - results in structural damage if prolonged - Ciliary motility is reduced - Airways become irritable - Mucus production increases - Pulmonary secretions become thick and Inspissated
What are the goals of humidity therapy?
- Maintain normal physiological conditions in the lower airways - humidifying dry medical gases - Overcoming the humidity deficit created when the upper airway is bypassed - To manage hypothermia - Treat bronchospasm caused by cold air
Heat-moisture exchangers
- Most often a passive humidifier that has been described as an "artificial nose" - Does not add heat or water to the system - Captures exhaled heat and moisture, which is then applied to the subsequent inhalation
Which of the following statements is/are true regarding the use of oxygen?
- Oxygen accelerates the rate of combustion - Increased oxygen concentration accelerates the rate of combustion
indications for bland aerosol therapy
- Presence of upper airway edema—cool, bland aerosol - Laryngotracheobronchitis - Subglottic edema - Postextubation edema - Postoperative management of the upper airway - Presence of a bypassed upper airway - Need for sputum specimens or mobilization of secretions
Large volume jet nebulizers
- used to deliver aerosolized drugs to the lung. - particularly useful when traditional dosing strategies are ineffective in the management of severe bronchospasm.
Which of the following factors can have an impact on the outcomes of therapeutic communication between patient and practitioner?
- verbal & nonverbal components of expression - environmental factors (e.g., noise, privacy) - values & beliefs of both patient and practitioner - sensory & emotional factors (e.g., fear, pain)
Short-Acting Adrenergic Bronchodialator Agents
-Metaproterenol -Albuterol -Pirbuterol -Levalbuterol
What is the FiO2 level delivered by a nasal catheter?
0.22-0.45 (replaced by nasal cannula)
What is the normal Methemoglobin % reading
1% - 2% (Co-Oximeter Reading)
Name three infection control strategies
1) Interrupting routes of transmission 2) eliminating source of pathogens 3) specialized equipment processing
Physical principles governing humidifier function
1) Temperature - the higher the temperature of the gas, the more water it can hold. 2) Surface area - affects the rate of evaporation. 3) Contact time - evaporation increases as contact time increases.
For a claim of res ipsa loquitur to be supported, three basic conditions must be met
1) The harm was such that it would not normally occur without someone's negligence. 2) The action responsible for the injury was under the control of the defendant. 3) The injury did not result from any contributing negligence or voluntarily assumed risk on the part of the injured party
Name short acting adrenergic bronchodilators (3)
1) albuterol (Proair, Proventil, Ventolin, Accuneb) 2) levalbuterol (Xopenex) 3) metaproterenol (Alupent)
harmful effects of electrical current depend on what 3 things?
1) amount of current flowing through body 2) path current takes 3) duration to current is applied
7 major competencies need by RTs by 2015
1) diagostics 2) chronic disease state management 3) evidence based medicine and RC protocols 4) patient assessment 5) leadership 6) emergency and critical care 7) therapeutics
Name ultra short acting adrenergic bronchodilators (2)
1) epinephrine (Primitene, Adrenalin) 2) racemic epinephrine (microNephrin, Nephron)
Name anticholinergic drugs (3)
1) ipratropium bromide (Atrovent) 2) tiotropium bromide (Spiriva) 3) ipratropium/albuterol (DuoNeb, Combivent)
Ethical Decision-Making Model
1)Identify the problem or issue 2)Identify the individuals involved 3)Identify the ethical principle or principles that apply 4)Identify who should make the decision 5)Identify the role of the practitioner 6)Consider the alternatives (long-term and short-term consequences) 7)Make the decision (including the decision not to act) 8)Follow the decision to observe its consequences
two types of advance directives
1)living will-states a patient's health care preferences in writing 2)durable power of attorney for health care-allows the patient to identify another person to carry out his or her wishes with respect to health care
Infection procedures include
1. eliminating the sources of infectious agents 2. creating barriers to their transmission 3. monitoring and evaluation the effectiveness of control
What are key mechanisms of aerosol deposition?
1. inertial impaction 2. Gravimetric sedimentation 3. Brownian diffusion
How much O2 is bound to hemoglobin
1.34 ml of O2 per gram of Hb
Optimal Technique for Use of a Dry Powder Inhaler
1.Assemble the apparatus. 2.Load dose, keeping device upright. 3.Exhale slowly to functional residual capacity. 4.Seal lips around the mouthpiece. 5.Inhale deeply and forcefully (>60 L/min). A breath hold should be encouraged but is not essential. 6.Repeat the process until dose is completed. 7.Monitor adverse reactions. 8.Assess beneficial effects.
Clark response time range between?
10 and 30 seconds
What is the normal Hemoglobin in women?
11.7-15.7g/dl
What is normal CaO2?
16-20 ml per 100 ml = 16-20%
normal CaO2
16-20% vol
measurement of lung's residual volume first performed when?
1800
first water-sealed spirometer developed by John Hutchinson when?
1846
laryngoscope introduced when?
1913
O2 masks first used (when?)
1918
Iron lung introduced by Philip Drinker (when?)
1928
monocytes
2%-10% absolute value of 90-1000
Patients with COPD usually achieve a steady state with in?
20 to 30 minutes
lymphocytes
20% -45% absolute value of 900-4500
What must He be always mixed with?
20% O2
How is CO2 transported?
45-55 ml of CO2 per 1 dl blood is transported by ionized bicarb, dissolved in plasma, and plasma protein transport.
What is normal SaO2?
95-100%
How long could HMEs be used
96 hours
chloride normal
98-105
What is hypertonic NaCl solution?
<0.9%
What is the PaO for severe hypoxemia?
<40 mm Hg
Laser Diffraction
A computer is used to estimate the range and frequency of droplet volumes crossing the laser beam.
What does the complete blood count (CBC) provide?
A detailed description of the number of circulating Leukocytes (White Blood cells), Erythrocytes (Red Blood cells), and Thrombocytes (Platelets).
What is a humidifier?
A device that adds molecular H2O to gas, occurring by evaporation of H2O from a surface.
Current
A flowing or streaming movement; a flow of electrons along a conductor in a closed circuit; and electric current
What is a regulator?
A mechanism attached to the gas cylinder that steps the initial pressure down to a working pressure (50 PSIG) **Readable via gauges
What is a Metered-dose inhaler? (MDI)
A pressurized canister containing the prescribed drug in a volatile propellant combined with surfactant and a dispersing agent
neutropenia
A reduced number of circulating neutrophils
What is brand name Fluticasone/Salmeterol?
Advair
What is brand name metaproferenol?
Alupent
AARC
American Association of Respiratory Care
performed human dissections and experimented with resuscitation
Andreas Vesalius
minimum educational requirement to practice RC?
Associates degree
What is an advantage of using automatic reservoir feed systems?
Avoids need for constant checking and manual refilling.
_________ _________ is the process for interviewing & examining a patient for signs & symptoms of disease and the effects of treatment.
Bedside assessment
List methods of sampling for gas analysis.
Blood can be obtained by analysis by Percutaneous puncture of a peripheral artery From an indwelling catheter Capillary sampling
Explain the components of a blood gas analyzer.
Blood gas analyzers measure 3 values pH (Sanz electrode) PO2 (Clark electrode) PCO2 (Severinghaus electrode) All other values are calculated HCO3 BE Oxygen saturation
Severe hyperkalemia increases the likelihood of?
Cardiac arrhythmias
Basic purposes of communication include all of the following except?
Change others' values orientation
Which of the following strategies for conflict resolution represents a middle-ground strategy that combine assertiveness and cooperation?
Compromising
What is the primary means by which heat transfer occurs in fluids?
Convection
A forceful expiratory maneuver that expels mucus & foreign materials from the airways.
Cough
What is inhaled Zanamivir?
DPI indicated for treatment of uncomplicated acute illness due to the flu virus in adults and children. (Off-label H1N1 treatment)
Who described what RTs of the future will focus more on?
David Pierson
temperature
Decreased temperature (<10° C) has been shown to decrease the output of CFC pMDIs.
Integrated O2 cylinders...
Definition deleted per Lalim Principle of Non-Importance
The aim of medical aerosol therapy is to:
Deliver a therapeutic dose of the selected agent (drug) to the desired site of action.
What is the delivery route for inhaled aerosols?
Delivery to specific organ needing treatment
What is brand name Iprotropium bromide and albuterol combo?
DuoNeb, Combivent
What is a combination of Ipratropium and albuterol?
Duoneb
What is an ultrasonic nebulizer?
Electrically powered device that uses a piezoelectric crystal to generate a very fine and consistently sized aerosol.
What is brand name Fluticasone?
Flovent
What are adverse effects of newer beta 2 selective agents?
Generally safe with primary side effect being tremors
What can be done to remedy heat retention in airway enclosures?
Handled differently by each manufacturer, Maxicool uses high fresh gas flows, others may use separate cooling devices.
What does oximetry measure?
Hb saturation using spectrophotometry.
Give an example of OXIMETRY?
HbO2 absorbs LESS red light and MORE infrared light.
In Pulse Oximetry what's the difference between HbO2 and deoxygenated (reduced) Hb?
HbO2 absorbs less light and more infrared light, than deoxygenated (reduced) Hb.
HIPAA
Health Insurance Portability and Accountability Act was established in August 1996 -establishment of Standards for Privacy of Individually Identifiable Health Information
What is the importance of the Heme Molecule in Hb?
Heme molecule contains iron that transports O2 and CO2.
What is a threshold for a blood transfusion?
Hemoglobin of 7.0 g/dl Hematocrit of 21%.
Coughing up blood or blood-streaked sputum from the lungs.
Hemoptysis
known as the "father of medicine"
Hippocrates
physicians are to follow certain ethical principles called this
Hippocratic oath
What are some types of heating elements that require energy source?
Hot plate humidifier base, wraparound type, yolk/collar element, immersion-type heater & heated wire.
Acting length on bronchodilators refers to?
How long the drug lasts.... Bronchodilators typically start working instantaneously.
What is the term for inspired air that is not fully saturated at body temperature?
Humidity deficit
Acute or chronic kidney disease, addison disease, severe alcoholism, and a value of >6 mmol (Life threatening) is a condition associated with?
Hyperkalemia
What is the primary side effect of INOMax?
Hypotension
meta-analysis
Identifies, analyzes, & summarizes body of literature for specific topic being studied; EVIDENCE BASED STUDY
Where are bands located?
In the bone marrow where they continue to mature
What is the cause for abnormality for Eosinophils?
Increased allergic reactions
What is the most common route of pathogen transmission in the hospital setting?
Indirect contact
Who is responsible for approving manufacture, transport and use of gas cylinders?
Industrial standards, federal regulations and ESPECIALLY the department of transportation (DOT)
What is an assessment of drug therapy for inhaled corticosteroids?
Inform patient about the drug, encourage peak flowmeter use, assess patient for side effects.
adverse affects of inhaled aztreonam
Inhaled aztreonam can cause bronchospasm and decrease FEV1. All patients should be screened for baseline pulmonary function results and be treated with a bronchodilator before administering inhaled aztreonam. Patients have been reported to experience severe allergic reactions with injectable aztreonam. Careful observation is warranted when first using inhaled aztreonam because it could cause an allergic reaction. If any signs occur during the delivery of inhaled aztreonam, the treatment should be stopped immediately, and the health care team should be informed. The use of antibiotics in the absence of infection may lead to the development of drug-resistant bacteria. Inhaled aztreonam should not be used in patients with CF not infected with P. aeruginosa.
FiO2
Inspired fractional O2 (0.21 if value is not given)
To determine the amount of urine excreted by a pt in the 24 hours, you would go to which section of the medical record?
Intake & Output (I & O) sheet
Define invasive
Invasive procedures require insertion of a sensor or collection device into the body
What does >20 x 10³/mcl suggest?
It suggests a serious infection of an elevated WBC count; patient's immune system is generating a significant response
describes relationship between gas temperature and volume
Jacques Charles ("Charles Law")
describes his discovery of oxygen: "dephlogisticated air"
Joseph Priestley
A condition when the jugular vein is enlarged and can be seen more than 3 to 4 cm above the sternal angle.
Jugular Venous Distention
Term deleted
Lalim "I am not going to test you on this"
What side effects do fully ionized aerosol drug have?
Little or no systemic side effects (ie ipratropium bromide)
_____ grade fever typically accompanies upper respiratory tract infections, whereas a _____ fever occurs with viral influenza infection.
Low, high
Most circulating WBCs are either
Lymphocytes or neutrophils are the main that are likely to cause a major increase in the WBC count when responding to a disease.
What is the most commonly prescribed method of aerosol therapy?
MDI
How do you prevent pre-analytical errors in ABG samples?
Make sure the sample is: Obtained anaerobically Properly anticoagulated Bubbles removed Analyzed within 10 to 30 minutes
Define analysis.
Measurement of fluid or tissue that must be permanently removed from the body
Drug Signaling
Mechanisms by which a drug exerts its effect on receptors.
To find out what drugs or intravenous fluids a pt has received recently, you would go to which section of the medical record?
Medication record
Hematocrit
Men-40%-52% Women-35%-47%
What can exposure to high concentrations of NO cause?
Methemogloinemia --> tissue hypoxia
Problem-Oriented Medical Record (POMR)
Method of recording data about the health status of a patient in a problem system 4 basic parts: -database -problem list -plan -progress notes
BNP test values
Mild heart failure: >300pg/ml Moderate: >600pg/ml Severe: >900pg/ml
What controls the meter rate flow of gas in an uncompensated Thorpe Tube from a 50 PSIG source.
Needle valve
What is the outcome of pregnant patients and practitioners being exposed to Ribavirin?
No bueno
Sedimentation
Occurs when aerosol particles settle out of suspension & are deposited owing to gravity. -The greater mass of the particle the faster it settles.
moderate hypoxemia?
PaO2 = 40 - 59 mm Hg
Who are heating systems primarily used for?
Patients with bypassed upper airways and those receiving mechanical ventilation
Who is a HME Booster designed for?
Patients with minute volumes of 4-20L
What is Point-of-Care Testing?
Performing blood gas analysis at the patient's bedside.
What are the UNCOMMON side effects of SVN & DPI administration of anticholinergic aerosol agents?
Pharyngitis, dyspnea, flu-like symptoms, bronchitis, upper respiratory infections, nausea, occasional bronchoconstriction, eye pain, urinary retention
Mucus from the tracheobronchial tree that has not been contaminated by oral secretions.
Phlegm
To confirm a physician's prescription for a drug that you need to give to a pt, you would go to what section of the medical record?
Physician's orders
What is the normal range for proper collateral circulation? (time wise)
Pink in 5-10 seconds
An abnormally elevate RBC count is known as?
Polycythemia
High hematocrit reading is common with?
Polycythemia
What are drawbacks to Nitric Oxide Therapy?
Poor paradoxical response, rebound hypoxemia, pulmonary hypertension.
What does a pressure compensated Thorpe Tube do?
Prevents changes in downstream resistance, or back pressure, from affecting meter accuracy
What causes infiltrates in lung parenchyma?
Prolonged exposure to high FiO2
What are nonsteroidal antiasthma drugs used for?
Prophylactic management (control) of persistent (chronic) asthma. May be used as an alternative to steroids in patients with persistent asthma symptoms.
What does Anemia suggest?
RBC production by the bone marrow is inadequate or excessive blood loss has occured
Name 2 types of RCP credentials
RRT: registered respiratory therapist (advanced level) CRT: certified respiratory therapist (entry level)
_________ (rapid/slow) respiratory rates are associated with exertions, fever, arterial hypoxemia, metabolic acidosis, anxiety, pulmonary edema, lung fibrosis, and pain.
Rapid
What is a downfall to an O2 Tent?
Regulating cooling and FiO2 can be difficult
Side Effects Seen With Anticholinergic Aerosol Agent
SVN, MDI, and DPI (Common) -Cough, dry mouth MDI (Occasional) -Nervousness, irritation, dizziness, headache, palpitation, rash SVN DPI -Pharyngitis, dyspnea, flulike symptoms, bronchitis, upper respiratory infections, nausea, occasional bronchoconstriction, eye pain, urinary retention *Side effects were reported in a small percentage (1% to 5%) of patients. *Precautions: Use with caution in patients with narrow-angle glaucoma, prostatic hypertrophy, bladder neck obstruction, constipation, bowel obstruction, or tachycardia
Four primary forms of aerosol generator are used to deliver aerosols during mechanical ventilation
SVN, USN, VM nebulizer, and pMDI with third-party adapter
Mature neutrophils are nown as what? due to there segmented shape of their nucleus
Segs
What is brand name salmeterol?
Servent
adverse effects colistimethate sodium
Side effects seen with parenteral administration include neurotoxic events and nephrotoxicity. Because colistimethate sodium is mainly eliminated by the renal system, renal insufficiency should be considered. Neurotoxic events associated with colistimethate sodium include dizziness, confusion, muscle weakness, and possible neuromuscular blockade, leading to respiratory arrest. When using aerosolized colistimethate sodium, the most common complication seen is bronchospasm. Pretreatment with a beta agonist can decrease the potential for this complication.
What brand names of drugs do we need to know?
Singulair, Albuterol, Xopenex, Recemic epinephrine, Atropine, Atrovent, and all steroids
RBC's are evaluated for?
Size and hemoglobin content
What is a cost-effective, and safe method for diagnosing TB, Pneumocystis Carinii, pneumonia and lung cancer.
Sputum induction
What bacteria is associated with pneumonia and gram positive diplococci?
Streptococcus pneumoniae
What causes Leukocytosis?
Stress, infection, and trauma
How is a transtracheal catheter placed?
Surgically placed in trachea through neck by physician
What is an ongoing process of monitoring patients and health care personnel for acquistion of infection and/or colonization of pathogens?
Surveillance. (Egan Pg 73)
What is brand name Budesonide/Formoterol?
Symbicort
A respiratory rate greater than 20 breaths/min.
Tachypnea
What is absolute humidity?
The amount of H2O in a given volume of gas (measured in mg/L)
What can happen if Isothermic saturation boundary shifts?
The body's normal heat and moisture exchange mechanisms can be compromised.
What is the relationship between GSD and the range of particle sizes?
The greater the GSD, the wider the range of particle sizes and therefore a more heterodispersed aerosol.
What is the Thermal Mass principle in regards to humidifier function?
The greater the amount of water in the humidifier, the greater the thermal mass and capacity to hold and transfer heat to the therapeutic gas.
How does thermal mass affect humidifiers performance?
The greater the mass of water or the core element of a humidifier, the greater its capacity to hold and transfer heat
What is relative humidity?
The ratio between the amount of H2O in given volume of gas and the maximum amount it is capable of holding at that temperature.
What is a crucial component of the liver panel test?
Total bilirubin
Provides continuous, noninvasive estimates of PO2 and PCO2 using a skin sensor
Transcutaneous Monitoring
What does Geometric standard deviation (GSD) describe?
Variability of particle sizes
How is Ribavirin administered?
Via aerosol requiring use of small particle aerosol generator (SPAG)
Percent solution for drug dosage
Volume (ml)= Dosage desired (mg) / % original concentration
What must be known to determine volume of gas in liquid-filled cylinder?
Weight
What is paradoxical breathing
When inhalation causes the abdomen deflate and chest to inflate... (not normal unless you are a chick)
intuitionism
When intuition is involved in the decision-making process, the approach
How pMDI works
When the canister is inverted (nozzle down) and placed in its actuator, or "boot," the volatile suspension fills a metering chamber that controls the amount of drug delivered. Pressing down on the canister aligns a hole in the metering valve with the metering chamber. The high propellant vapor pressure quickly forces the metered dose out through this hole and through the actuator nozzle.
Hemoglobin normal reference range
Women: 11.7-15.7g/dl Men: 13.3-17.7g/dl (12-18) g/dl
hypothermia
abnormal and dangerous condition in which the temperature of the body is less than 32° C, usually caused by prolonged exposure to cold.
what is the accuracy of electrochemical oxygen analyzers?
accurate to within +- 2% of actual concentrations
What is CAPILLARY BLOOD GAS ANALYSIS?
alternative to direct arterial • used in infants and small children
intentional tort
always involves a willful act that violates another's interest
What population will increase demand for RC services and RTs?
baby boomers
severe hyponatremia may develop
confusion decreased mental alertness muscle twitching possible seizures
The force in the major arteries remaining after relaxation of the ventricles.
diastolic pressure
When was positive-pressure ventilation used originally?
during anesthesia
The output volume of pMDIs range
from 30-100mcl
What is capnography?
graphic display of CO2 levels • as they change during breathing
a low sodium level is referred to as
hyponatremia
Equipment processing definitions: high level
inactivation of all microorganisms EXCEPT bacterial spores
Blood lactate concentration
is dependent on the production of lactate in muscle cells and erythrocytes and the rate of metabolism by the liver
Total bilirubin
is produced by the liver from the breakdown of destroyed RBCs
Lactate
is the end product of anaerobic glucose metabolism
What is the most common device used for bland aerosol therapy?
large volume nebulizers
What respiratory care equipment have the greatest potential to spread infection
large volume neutralizers
what changes occur if an ABG sample is left at room temperature for >45 min?
metabolic effects will occur * raises PCO2 * lowers pH * lowers PO2
Where is a transcutaneous monitor placed on an infant?
normally over the sternum
surveillance (bacteriologic)
ongoing process designed to ensure that infection control procedures are working; involves equipment, microbiological identification, and epidemiological investigation
Briefly define Continuous Quality Improvement and state the AARC recommended goals for CQI
ongoing process to detect & correct factors hindering quality care- accredited by The Joint Commission
What is the importance of the Bohr effect on Oxygen Transport.
pH has an effect of Hemoglobin's affinity for O2 -LOW pH shifts HbO2 curve RIGHT and HIGH pH shifts the curve to the left.
What factors significantly affect O2 loading and unloading?
pH, body temperature, the amount of 2,3 DPG in RBCs
four essential fluids (Hippocratic medicine)
phlegm, blood, yellow bile, black bile
This system typically consists of a platinum cathode and a silver-silver chloride anode
polarographic (CLARK) electrode
The _______ artery is the most common site used to palpate a pulse.
radial
droplet precautions
safe gaurds designed to reduce the risk of droplet transmission of infectious agents
contact precautions
safeguards designed to reduce the risk of transmission of epidemiologically important microorganisms by direct of indirect contact
disinfection
the process of destroying at least the vegetative phase of pathogenic microorganisms by physical or chemical means
Sounds heard over the trachea that have a loud, tubular quality.
tracheal breath sounds
Vibrations created by the vocal cords during speech.
vocal fremitus
Which humidifier can deliver gas at 100% body humidity?
wick humidifier
What can help minimize condensation to reduce the risk of colonization?
wick or membrane type Passover humidifiers prevent formation of bacteria-carrying aerosols. No need to frequently change the circuit.
How are medical aerosols generated in the clinical setting?
with devices that physically disperse matter into small particles and suspend them in gas.
Depth & Penetration & desposition of a particle in the respiratory tract vary...
with size and tidal volume. - with this knowledge it may be possible to target aerosol deposition to specific areas of the lunh by using the proper particle size and breathing pattern.
[Where does analysis of gas exchange begin?]
with system inputs: • inspired O2 concentrations • CO2 concentrations
2 NBRC exams
written and clinical simulation
How does the capnometer function?
• CO2 absorbs infrared light
5 ways to improve communication
• Share information rather than telling it. • Seek to relate to people rather than to control them. • Value disagreement as much as agreement. • Use effective nonverbal communication techniques. • Be a good listener
Name six methods of sterilization.
• Steam • Ionized radiation • 100% EtO (Ethylene oxide) gas • EtO mixtures • Hydrogen peroxide gas plasma • Paracetic acid
The basic actions to evaluate an aerosol drug treatment should be followed
• Verify that the patient understands that nonsteroidal antiasthma agents are controller drugs and their difference from rescue bronchodilators (relieving agents); assess the patient's understanding of the need for consistent use of these agents (compliance with therapy). • Instruct the patient in use of a peak flowmeter to monitor baseline PEF and changes. Verify that there is a specific action plan, based on symptoms and PEF results. The patient should be clear on when to contact a physician with deterioration in PEF or exacerbation of symptoms (al 724)
What are the EFFECTS OF PRESSURE on Miniox O2 analyzer?
• Yes! Because it responds to partial pressure of O2 (not %) - changes in barometric pressure change the readings - higher altitude => lower reading
What are some disadvantages of pulse oximetry?
• finger probes not reliable in patients with SHOCK • cannot distinguish HbCO from HbO2 -> false high reading w/CO poisoning • does not measure CaO2 or PCO2 -> patients w/O2 transport issues of hypoventilation need ABG
What types of electrochemical oxygen analyzers are there?
• galvanic (fuel cell) • polarographic (Clark electrode); faster
Our clinical focus is on gas exchange between what?
• lungs and blood • blood and tissues
What are 2 techniques used in capnometry?
• mainstrem - analyzing chamber is in breathing circuit • sidestream - pump small volume of gas from circuit into analyzer (not done often)
What is CO-OXIMETRY?
• measures more than 2 types of Hb-> more wavelengths needed • 3 wavelengths measure: -Hb&HbO2, HbCO, metHb
What are the effects of TEMPERATURE on Miniox O2 analyzer?
• minimal -it has internal thermistor -varies less than 3% * Note: don't handle unnecessarily, cuz body heat can affect its accuracy!
What are the 2 most common technical errors?
• not warming site properly • squeezing of puncture site (causes venous and lymphatic contamination)
How does a Pulse Oximeter work?
• photodector placed opposite LED across arterial vascular bed • light transmitted through tissue and partially absorbed • absorption is constant except during arterial pulsation • ignores constant sources of light, concentrates on pulsatile absorption • measures intensity of light @ each wavelength
What are the 2 most common types of electrochemical O2 analyzers that analyze FIO2?
• polargraphic (Clark) electrode • galvanic fuel cell
What is TRANSCUTANEOUS BLOOD GAS MONITORING?
• skin sensor • provides continuous, noninvasive estaimates of PO2 & PCO2
The end?
• the End-tidal PCO2 (PETCO2) is used to estimate deadspace ventilation
What is the PERFUSION INDEX?
• the pulsatile signal indexed against the non-pulsatile signal • ratio: PS/NPS • should be at least 1.00 • can range from .01 to 20
What is transmission vs. reflectance oximetry?
• transmission: LED goes through tissue to detector • reflectance: LED light reflects back to detector
Standard Precaution: gowns
-to prevent skin -prevent soiling of clothing
What should the FiO2 level be at when using the nasal canula (low flow)
0.24-0.40 dependent on how much room air patient inhales in addition to O2
Does Forms:
1. Aerosol of Liquid Solutions 2. Suspensions 3. Dry Powders
What is the normal Hemoglobin in men?
13.3-17.7 g/dl
hemoglobin men
13.5 -16.5 g/dl
sodium
137-147
An arterial blood pressure persistently greater than ____/___ mmHG is called hypertenstion
140/90
A normal platelet count is
150 x 10 to the 3
aerosolized epinephrine introduced as treatment for asthma (when?)
1910
oxygen tents first used oxygen tents first used (when?)
1910
For targeting aerosols for delivery to the upper airway (nose, larynx, trachea), particles in the 5- to 20-µm MMAD range are used; for the lower airways,
2- to 5-µm particles are used; and for the lung parenchyma (alveolar region), 1- to 3-µm particles are used.
Blood pressure is a __:__ ratio.
3, 2
albumin
3.5 - 5.0
potassium normal
3.5-4.8
The average body temperature for adults is about _______ C.
37
hematocrit women
38% - 47%
What is the PaO2 for moderate hypoxemia?
40-60 mm Hg
calculation for absolute humidity
44mg/L minus absolute humidity
Normal CO2 pressure in vein
46 mm Hg (40 mm Hg after passing Alveolus [Arterial])
What is an aerosol?
A suspension of solid or liquid particles in gas
Guidelines for Use of Aerosol Devices in the Care of Infants and Children
Device Age Group SVN Neonate to all ages Valved chamber with mask Neonate/infant/toddler Valved chamber with mouthpiece >3 years pMDI alone >4 years Breath-actuated Neb >4 years DPI ≥4 years
Abnormal levels of Lactate can be found in these conditions
Diabetes mellitus, malignancies, toxic ingestion of ethanol, methanol, or salicylates
Competencies
Having suitable or sufficient skill, knowledge, and experience for the purposes of a specific task
How do you troubleshoot bland aerosol therapy noise?
You don't. These devices are noisy as hell.
What is most likely a true sample from the lung and is reflective of the infection source?
a sample with numerous pus cells and few or no epithelial cells
This condition occurs with total diaphragmatic fatigue; also occurs when the diaphragm is paralyzed.
abdominal paradox
What neurotransmitter(s) does DuoNeb/Combivent effect? How? Where?
acetylcholine, blocks M1, M2, M3 norepinephrine or epinephrine, stimulates, beta 2
Bacteria pneumonia
an increase in neutrophils is the cause of the severity of infection when present with
increased with allergic reactions
basophils
veracity
binds the health care provider and the patient to tell the truth.
[What is the definition of respiratory failure based on?
blood gas measurements
compensatory justice
calls for the recovery for damages that were incurred as a result of the action of others
Abnormal levels of lactate
can be found in diverse conditions such as diabetes mellitus; malignancies
When percussing, a decreased resonance is called ___________ or ____.
dampened, dull
Public law
deals with the relationships of private parties and the government
There is a _________ in intensity of vocal/tactile fremitus when either fluid or air collects in the pleural space.
decrease
what leads to an increased PaCO2?
decrease VA, increased VCO2, increased VD
Most bedside systems use what to measure FIO2?
electrochemical principles
what can a good capillary blood gas sample provide and reflect?
estimated arterial oxygenation and PCO2
formalism
ethical viewpoint that relies on rules and principles
When should you use transcutaneous monitoring?
in hemodynamicallly stable infants or children.
When is capnograpy used?
in patients undergoing: • general anesthesia • mechanical ventilation
What is a positive response indicated from Continuous nebulization?
increase in peak flow of >10% with a goal of at least 50%
Mycobacterium tuberculosis
is a highly communicable disease
Among respiratory care equipment what have the greatest potential to spread infection?
large-volume nebulizers. (Egan Pg 74)
absolute humidity
o Absolute humidity is the total amount of water vapour present in a given volume of air. It does not take temperature into consideration
CoARC
responsible for ensuring that respiratory therapy EDUCATIONAL programs follow accrediting standards
Causation
revolves around whether the acts of negligence were the cause in fact and the legal cause of the damages
Jugular venous pressure reflects the volume & pressure of venous blood in the _____ side of the heart.
right
Mucoactive therapy
should be used with caution in patients with severely compromised vital capacity and expiratory flow, such as in the presence of end-stage pulmonary disease or neuromuscular disorders
What is P50 in regards to the HbO2 Dissociation curve
shows what the PO2 is when the Hb is 50% saturated with O2 <27 Torr>
types of HME
simple condensers, hygroscopic condenser, hydrophobic condenser
leukocytosis results from any number of problems, such as?
stress infection trauma
When air leaks from the lung into the subcutaneous tissues, fine air bubbles product a crackling sound & sensation when palpated. This condition is known as__________. The sensation produced on palpation is called _______.
subcutaneous emphysema, crepitus
Assessment of therapy with adrenergic bronchodilators should be based on:
the indication for the aerosol agent.
Philosophy
the love of wisdom and the pursuit of knowledge concerning humankind, nature, and reality
DPIs SHOULD NOT BE USED FOR
the management of acute bronchospasm.
[Where do you put the probe?]
use a T-tube and place in circuit downstream from inspiratory tube • between output and mouth
On average a normal, healthy individual produces ______ mL of mucus per day.
100
Tachypnea is a respiratory rate of more than _____ breaths/min.
20
The normal range for diastolic pressure is ___ to ___ mm Hg.
60, 90
What does a HME booster consist of mechanically?
A T-piece containing electrically heated element
What is brand name Mometasone?
Asmanex
formerly known as SGOT ( serum glutamicoxaloacetic transaminase )
Aspartate Aminotransferase AST
In the standard approach to hospital fires, the RACE plan has been suggested. What does the letter "C" stand for in this approach?
Contain
What is the practice of grouping patients with the same infection?
Cohorting. (Egan Pg 73)
what are some contraindications for drawing an ABG?
*Negative allens test. *Arterial puncture should not be done through a lesion or distal to surgical shunt. *Femoral sites should not be done outside of hospital. *If the patient is on anti-coagulation therapy
Which of the following factors are most critical in determining when a pt can be ambulated?
- Stability of vital signs - absence of severe pain
Which of the following conditions must be met for a fire to occur?
- Temperature high enough for combustion - Presence of oxygen - Presence of flammable material
enclosures (mist tents and hoods)
- Used to deliver aerosol therapy to infants and children - Can lead to heat and CO2 buildup in tents. - High flows through the tent help "wash out" CO2 and reduce heat buildup.
What if analyzer doesn't calibrate?
-> possible low battery in polarographic (galvanic uses batter to run only alarms) -> sensor depletion (galvanic fuel cell dying; clean polarographic anode/cathodes and replace electrolyte solution) -> electronic failure
What percentage is half NaCl Solution?
0.45%
Lifting heavy objects is best done with which of the following techniques?
Straight spine, bent legs
What are bedside findings that would lead to necessity of O2 therapy?
Tachypnea, tachycardia & confusion
What do temperature and humidity do above the ISB?
Temperature and humidity decrease during inspiration and increase during exhalation
What do temperature and humidity do below the ISB?
Temperature and relative humidity remain constant (BTPS)
What happens to a solution placed in a USN?
Temperature of the solution increases
What form of patient record is most designed to succinctly report data in a time-oriented format and to decrease time needed for documentation?
Flowsheet
Anatomist who believed air had a substance vital to life
Galen
Why is the pressure compensated Thorpe Tube NOT ideal for patient transport?
Gravity dependent
What is the downfall to invasive procedures?
Greater risk
Hospital Information System
HIS- a comprehensive system for communication and information processing, supports both clinical and administrative purposes
What is often a passive humidifier that has been described as an "artificial nose?"
HME (heat-moisture exchange)
For ABG testing, patients with low platelet count or an elevated INR need to?
Have the puncture site compressed for a longer time
Can you use a USN to administer undiluted bronchodilator to patients with sever bronchospasm?
Hell freaking yes!
What types of liquid can be used in bland aerosols?
Sterile water & Sterile saline (hypotonic, isotonic and hypertonic)
What precautions are used to prevent a form of contact transmission that occurs when droplets are propelled short distances(within 3ft or less through the air)
Droplet Precautions. (Egan Pg 69)
T/F: Barrel chest is associated with COPD.
F
T/F: Hypotension is synonymous with shock.
F
T/F: Lymph nodes are tender when malignancy is the cause.
F
T/F: The RT should assume a position that is above eye level with the patient.
F
T/F: The absence of cyanosis guarantees that oxygenation is adequate.
F
what does bland aerosol therapy consist of?
liquid particles suspended in a gas (oxygen or air).
electronic health records
makes patients' medical record available across the continuum of care of geographic locations
In the later part of the 1990s
managed care strategies and other cost-containment methods adopted by most third-party payers slowed the growth of the health care industry
double effect
many helping actions inevitably have both a good and a bad effect
What is a capnometer?
measures CO2
describe the drug administrative phase
method by which a drug is made available to the body
What is body humidity?
The relative humidity at body temperature (37 degrees Celsius) expressed as a percentage. Capacity of H2O at 37 Celsius is 44 mg of H2O
what are the two types of electrochemical O2 analyzers?
polarographis(Clark) electrode glavanic fuel cell
RT role in health care
prevent, identify, and treat acute or chronic dysfunction of the cardiopulmonary system
What's the best way to avoid problems with O2 analyzers?
preventive maintenance
What is a SOAP note used for?
problem oriented medical record
What is Aging when pertaining to aerosols?
process by which the aerosol suspension changes over time.
Describe methods for blood gas monitoring.
Transcutaneous PO2 and PCO2 Intraarterial (in vivo) monitoring On Demand (ex vivo
What can you do to avoid constant refilling of humidifier reservoirs?
Use a large water reservoir and utilize a gravity feed system.
clinical decision support
systems that match the characteristics of individual patients and their clinical interventions, drugs, and diagnostic tests to databases of scientific evidence and drug calculations and generate tailored recommendations, reminders, or standing orders-- instrumental in improving clinical outcomes of patients by determining optimal drug dosages.
cochrane collaboration
website for research ensuring the effects of healthcare interventions are made available worldwide
What is Deadspace Ventilation
Ventilation in excess of perfusion
how to minimize fire hazard via ignition sources
do not allow items like cigarette lighters allowed in rooms where oxygen is in use
negligent tort
does not have to involve any action at all
Dosage equation for drug dosage
dosage = volume x original concentration
A _____, ___________ cough is typical for restrictive lung diseases such as CHF or pulmonary fibrosis.
dry, nonproductive
when to wear fresh, clean gloves
for all tasks and procedures involving potential contact with blood, body fluids, or contaminated items.
Why would you use continuous nebulization?
for treatment of refractory bronchospasm. nebulized albuterol is dosed at 5-20mg/hour
uses a gold anode and a lead cathode
galvanic fuel cells
Intrapulmonary percussive ventilation provides
high-frequency oscillation of the airway while administering aerosol particles. During intrapulmonary percussive ventilation, the aerosol generator should be placed in the circuit as close to the patient's airway as practical.
What is a USN capable of?
higher aerosols outputs and higher aerosol densities than conventional jet nebulizers
Holding Chambers vs Spacers
holding chambers produce a finer, slower moving, more "respirable" aerosol with less impaction of drug in the oropharyngeal area (1% of dose) than simple spacers
D-dimer
is a small protein fragment found in the blood when fibrin clots are dissolving
Trigger point for transfusion
is based on the hemoglobin/hematocrit measurement instead of the RBC count.
A high hematocrit reading
is common with polycythem
An anion gap greater than 16
is consistent with the presence of metabolic acidosis
Additional techniques can be used for mechanically ventilated patients because
(1) a change in the differences between peak and plateau pressures (the most reliable indicator of a change in airway resistance during continuous mechanical ventilation) can be measured, (2) automatic positive end expiratory pressure levels may decrease in response to bronchodilators (see Chapter 41), and (3) breath-to-breath variations make measurements more reliable when the patient is not actively breathing with the ventilator.70
What is Cromolyn sodium?
(Brand Name: Intal) mast cell stabilizer
Lung Availability- to- todal systematic availability ratio.
(L/T ratio) quantifies the efficiency of aerosol delivery to the lung: L/T ratio=Lung availability/(Lung+GI availability)
Air in the ABG sample?
* lowers PCO2 * raises pH * raises low PO2
At a room temperature of 22°C, air has the capacity to hold 19.4 mg/L of water vapor. If the absolute humidity in the air is 7.4 mg/L, then what is the relative humidity (RH)?
*RH = (content ÷ capacity) x 100 RH = (7.4 ÷ 19.4) x 100 RH = .38 x 100 RH = 38%
respiratory hygiene/cough etiquette
*education of health care personnel, patients & visitors *posted signs with instructions *source control, cover mouth/nose when coughing *hand hygiene *spatial separation greater than 3 feet
Why do you warm the patients heel before drawing a CBG?
*it causes dilation of underlying blood vessels *increases capillary blood flow *approximately 42*C
To decrease a pt's loss of body heat....
- Increase temperature of room - Move the patient away from cold windows
hyperglycemia
-Abnormal elevation of blood glucose -is most often the result of diabetes
Bronchoactive Agents Distinguished as Controllers or Relievers in Treating Asthma, Long-Term Control
-Inhaled corticosteroids -Cromolyn sodium -Long-acting beta-2 agonists -Inhaled: salmeterol, formoterol -Oral: sustained-release albuterol -Leukotriene modifiers -Systemic corticosteroids -Methylxanthines (theophylline
Indications of use for use for Anticholinergic Bronchodilators:
-Ipatropium & tiotropium bromide are the only inhaled anticholinergic bronchodilators available in the US. -These are indicated as bronchodilators for maintenance treatment in COPD.
Ambulation helps
-Restore and maintain normal body function -Reduce the length of hospital stay
liquids used in bland aerosol therapy
-Sterile water -Sterile saline (hypotonic, isotonic, hypertonic)
Intuitionism
-an ethical viewpoint that holds that there are certain self-evident truths, usually based on moral maxims such as "treat others fairly." -easiest way to understand intuitionism is to think of as many timeless maxims as you can, which form the basis for intuitionism. These maxims may range from "do not kill" to "look before you cross the street." As a decision-making tool, intuitionism is unhelpful in large measure because it depends on the intuitional abilities of the specific caregiver
In asthma, A long-acting bronchodilator is usually combined with:
-antiinflammatory medication for control of airway inflammation and bronchospasm.
Ipratropium bromide and tiotropium bromide
-are fully ionized compounds that are not well absorbed and distributed throughout the body -
Nozzle Size and Cleanliness
-as debris builds up on the nozzle or actuator orifice, the emitted dose is reduced.
5 major routes for transmission of pathogens
-contact -droplet -airborne -common vehicle vector airborne
Hemoglobin
-is a protein substance with the unique ability to bind with oxygen -Each healthy RBC contains 200 million to 300 million molecules of hemoglobin, for a hemoglobin level of 12 to 17 g/dl in a healthy adult
Dornase alfa
-is a proteolytic enzyme that can break down the DNA material from neutrophils found in purulent secretions -This agent has been shown to be more effective than acetylcysteine in reducing the viscosity of infected sputum
B-type natriuretic peptide (BNP)
-is a substance secreted by the heart in response to increased stretch in the cardiac muscle -The BNP test primarily is used to evaluate patients for heart failure
Aerosol generators include
-pMDIs (w/ or w/o spacers & holding chambers) -DPIs - Small and Large Volume (jet) nebulizers - Hand-Bulb atomizers -Ultrasonic Nebulizers -Vibrating Mesh Nebulizers
Standard Precaution: mask, eye face protection
-to protect mucus membrane
5 questions about future of profession according to "2015 and beyond"
1) How will patients receive health care services? 2) How will respiratory care services be provided? 3) What knowledge, skills, and attributes are needed by RTs? 4) What education and credentialing systems are necessary? 5) How can the profession transition with little impact on practicing RTs?
Two specific problems are associated with SPAG use to deliver ribavirin.
1. Caregiver exposure to the drug aerosol. 2.Drug precipitation can jam breathing valves or occlude the ventilator circuit.
What are two methods to measure medical aerosol particle distribution?
1. Cascade impaction 2. Laser diffraction
hemoglobin women
12 - 15 g/dl
Isoproterenol and Isoetharine introduced as bronchodilaors (when?)
1940s-1950s (1940 and 1951 respectively)
first suction catheter described when?
1941
when was first formal RT program offered and where?
1950, Chicago
Clark electrode first developed (when?)
1960s
Development of sophisticated mechanical ventilators expand role of RT (when?)
1960s
formal education programs for inhalation therapists begins (when?)
1960s
programs multiply and become hospital based when?
1960s
state licensure for RTs begins when?
1980
protective environment precautions
A specialized engineering approach to protect highly immunocompromised patients requires: • HEPA filtration of incoming air • directed room airflow • positive room air pressure relative to the corridor • wellsealed rooms to prevent infiltration of outside air • ventilation to provide 12 or more air changes per hour • strategies to reduce dust • prohibition of dried and fresh flowers and potted plants in rooms.
What is the mode of action for Inhaled corticosteroids?
Acts on intracellular receptors with full anti-inflammatory effects that require hours to days to take full effect (No immediate relief from dyspnea NOT A RESCUE INHALER)
What are the 2 most important factors influencing accuracy of transcutaneous measurements?
Age and perfusion status
Which of the following is/are a potential area of risk to patient's receiving respiratory care?
All of the above: - movement or ambulation - electrical shock - fire hazards
All of the following factors increase the risk of surgical patients for developing postoperative pneumonia except...
All of the above: - obesity - prolonged intubation - history of smoking
What is HEMATOLOGY?
Analyzes the cellular components of the blood
List complications of arterial punctures.
Arteriospasm Air or blood emboli Patient or sampler contamination (infection) Hematoma Hemorrhage Trauma to vessel Arterial occlusion Vasovagal response Pain Tissue trauma Peripheral nerve damage
What are other important causes of leukopenia?
Bone marrow diseases, Luukemia, Lymphoma, influenza, systemic lupus erythematosus, tuberculosis, AIDS
Possible anatomical sites for blood draws
Brachial Radial Femoral Posterior tibial Dorsalis pedis
The specific sensation of an unpleasant urge to breathe.
Breathlessness
arformoterol
Brovana
What are the indications for anticholinergic bronchodilators?
CBABE: COPD Bronchitis (chronic) Asthma Bronchiectasis Emphesema
What does capnometry measure?
CO2 in respiratory gasses **Capnometer functions on basis that CO2 absorbs infrared light proportion to amount of CO2 present.
Beta-1-receptor stimulation
Causes increased heart rate & myocardial contractility.
Alpha-Receptor Stimulation
Causes vasoconstriction & a Vasopressor effect (increased blood pressure).
What are patients who live at a high altitude and patients with chronic lung disease likely to develop?
Chronic hypoxia and secondary polycythemia
What are the names of the PO2, PCO2 and pH ABG analyzer electrodes?
Clark poloarographic electrode Severing haus electrode Ph electrode
Colistimethate Sodium
Colistimethate sodium (colistin) is an antibiotic used to treat sensitive strains of gram-negative bacilli, particularly P. aeruginosa. Colistimethate sodium is available as an inhaled formulation in Europe as Promixin; this agent is not approved for inhalation by the FDA. However, nebulization of the parenteral formulation is commonly used in patients with CF. Falagas and colleagues51 published a review of IV and aerosolized colistimethate sodium
How are cylinders marked and identified?
Color coded and marked with metal stamping on shoulder.
What are physical characteristics of "medical" CO2?
Colorless and odorless gas.
Physical characteristics of Nitric Oxide (NO)
Colorless, nonflammable, toxic (Supports combustion)
What are physical characteristics of "medical" air?
Colorless, odorless, naturally occurring gas mixture. (20.95% O2, 78.1% nitrogen & about 1% argon-helium mixture)
What are 4 physical properties of O2?
Colorless, odorless, transparent and tasteless
CoARC
Committee on Accreditation for Respiratory Care
What are four categories of Expanded Precautions?
Contact Precautions, Droplet Precautions, Airborne Infection Isolation, and Protective Environment. (Eagan Pg 68)
A critical value may be potentially life-threatening unless?
Corrective action is taken promptly
Inhaled Corticosteroids
Corticosteroids are endogenous hormones produced in the adrenal cortex, which regulate basic metabolic functions in the body and exert an antiinflammatory effect -All corticosteroids used to treat asthma and COPD are glucocorticoid
What are COMMON side effects of SVN, MDI and DPI administration of anticholinergic aerosol agents?
Cough, Dry Mouth
The 3 types of infection risk categories
Critical semi-critical noncritical
Histotoxic Hypoxia is...
Cyanide Poisoning
The Drug Administration Phase
Describe the method by which a drug is made available to the body.
Pharmacodynamic Phase
Describes the mechanisms of drug action by which a drug molecule causes it's effects in the body.
What is an Antiadrenergic drug?
Drugs that block receptors for norepinephrine or epinephrine
What is a Cholinergic drug?
Drugs that stimulate receptors for acetylcholine
What is an Adrenergic drug?
Drugs that stimulate receptors responding to norepinephrine or epinephrine
Thrombocytopenia and thrombasthenia leads to what?
Excessive bleeding
What happens in retinopathy of prematurity?
Excessive blood O2 levels cause retinal vasoconstriction & necrosis
Why would you use a long acting Adrenergic Bronchodilator?
For maintenance bronchodilator in patients with obstructive lung disease
What improves water output of bubble and Passover humidifiers?
Heat
What is the primary role of the upper airway?
Heat & moisture exchange (Specifically the nose)
What are drawbacks of utilizing enclosures?
Heat retention & CO2 build-up in tents.
What is a drawback of using heating systems?
Heating inhaled gas can expose patient to a risk of airway burns.
Does CO2 support combustion?
Hell no.
Dehydration from excessive water loss or fluid restriction or excessive administration of saline fluids can lead to what?
Hypernatremia
What are two drug signaling mechanisms?
Item Deleted due to Lalim Principle of Irrelevance (LPI)
Hypernatremia can lead to what?
Lethargy, coma, and respiratory arrest
Side affects of Acetyl Cysteine (Mucomyst)?
May cause bronchospasm and airway obstruction due to irritating side effects... plus a sh*t ton more like hydrogen sulfide stank.
Misallocation
May consist of ordering therapy that is not indicated, ordering therapy to be delivered by and inappropriate method, or failing to provide therapy that is indicated
Factors Associated With Reduced Aerosol Drug Deposition in the Lung
Mechanical ventilation • Artificial airways • Reduced airway caliber (e.g., infants and children) • Severe airway obstruction • High gas flows • Low minute volumes • Poor patient compliance or technique • Limitation of specific delivery device
Hemoglobin
Men-13.3-17.7 g/dl Women-11.7-15.7 g/dl
Red blood cell
Men-4.4-5.9 × 106/mcl Women-3.8-5.2 × 106/mcl
An anion gap greater than 16 is consistent with what ?
Metabolic acidosis
Explain the function and principles of a physical oxygen analyzer.
Oxygen analyzers are used to measure inspired oxygen concentration (FiO2)
Explain the function and principles of an electrical oxygen analyzer.
Oxygen analyzers are used to measure inspired oxygen concentration (FiO2)
Alveolar air equation (based on Dalton's law)
PAO2=FiO2 x (PB-47)-(PACO2/0.8) [do not do shortcut from slide 13]
The tapping on a surface to evaluate the underlying structure.
Percussion
How do you measure Liquid Gas cylinder contents?
Pressure does not relate to amount of liquid remaining, only weight of cylinder indicates amount of gas inside
What is brand name epinephrine?
Primitine Mist, Adrenalin
What is brand name albuterol?
Proair HFA, Proventil HFA, Ventolin HFA, Accuneb
What is the brand name for Albuterol?
Proventil (2.5 mg/Q4 hours) Pg 710
Bag-Mask Device (Ambu-Bag)
Provide 100% (in theory) O2 often during emergencies
What is Intrapulmonary percussive ventilation IPPV
Provides high-frequency oscilation of airway while administering aerosol particles
List primary site for arterial puncture.
Radial ▪ safest and most accessible ▪ located superficially ▪ collateral circulation via ulnar artery Brachial ▪ no collateral circulation Femoral ▪ no collateral circulation
What does beta 2-receptor stimulation cause?
Relaxation of bronchial smooth muscle, stimulates mucociliary activity, and has some inhibitory action on inflammatory mediator release. (THIS IS THE IDEAL SETTING FOR BRONCHODILATORS for the purposes of dilating without adverse/contradictory side effects)
Hyperkalemia, hypoalemia, phosphorus, and hypophosphatemia can lead to what?
Respiratory muscle paralysis
What are some special considerations for inhaling a corticosteroid?
Rinse mouth after taking medicine and document it that way they can avoid THRUSH (candida albicans)
What does each letter in SOAP stand for
S = Subjective (patient's complaints) O = Objective (results of physical exam, lab tests, ABGs, chest radiograph, etc.) A = Assessment (What is the problem?) P = Plan (How is the problem to be treated?)
Pediatric Asthma Score
SCORE Indicator 0 1 2 PaO2 >70 mm Hg (air) <70 mm Hg (air) <70 mm Hg (40% O2) SpO2 >94% (air) <94% (air) <94% (40% O2) Cyanosis No Yes Yes Breath sounds Equal Unequal Absent Wheezing None Moderate Marked Accessory muscle use None Moderate Marked Level of consciousness Alert Agitated or depressed Comatose
What does the STEEP portion of the HbO2 dissociation curve show
SaO2<90% Occurs in capillaries facilitating O2 unloading at tissues
What are examples of Long-acting adrenergic bronchodilators?
Salmeterol, formoterol, and arformoterol (12 hour action)
Gram staining and Sputum culture procedures can also be used for?
Samples of blood, pleural fluid, or any other body fluid.
Hemoglobin Saturation is defined as:
Saturation is the % of Hb that is carrying O2 compared to total Hb
What precautions should be taken when utilizing gas cylinders?
Secure cylinders at patients bedside, do not use flammable materials on regulators, cylinders, fittings or valves, and "crack open cylinder valve slightly to remove dust before attaching regulator. Post "NO SMOKING" sign when O2 is used
An encapsulated, lancet-shaped, gram-positive diplococci is consistent with what disease?
Streptococcal pneumonia
T/F: Vocal fremitus requires a conscious and cooperative patient.
T
What is aerosol output rate?
The mass (amount) of aerosol generated per unit of time. Varies depending on different nebulizers and inhalers used.
Emitted Dose
The mass of drug leaving the mouthpiece of a nebulizer or inhaler as aerosol
what are some contraindications for pulse oximetry?
The ongoing need for actual measurements of Ph, PaCO2, total hemoglobin, and abnormal hemoglobins may be a relative contraindication to pulse oximetry.
Precautions with anticholinergic bronchodilators (Atropine)?
There is a sh*t ton of side effects (ie Dry mouth, increased HR and increased ocular pressure) when atropine is inhaled due to its easy absorption into the bloodstream. DO NOT BE A ******* AND SPRAY IT INTO THE EYES!
What is the primary function of the RBCS or erythrocytes?
To supply oxygen to the tissues
What are cylinder safety relief valves designed for?
To vent gas to atmosphere if tank is heated.
delivers specific FIO2
Venti mask
What is a side effect of inhaled tobramycin?
Voice alteration and tinnitus
How do you measure Gas-filled cylinder contents?
Volume of gas in cylinder is directly proportional to its pressure
What is Leukopenia?
WBC count below normal that occurs when patient's immune system is overwhelmed by infection
Leukopenia
WBC count below normal that often occurs when the patient's immune system is overwhelmed by infection.
Hematocrit reference range values
Women 35-47% Men 40-52%
What is brand name Levalbuterol?
Xopenex
What is the brand name for Levalbuterol?
Xopenex (0.63 mg/Q6 hours) Pg 710
What are the indications for short acting adrenergic bronchodilators?
acute reversible airway obstruction (upper airway)
anion gap is calculated by
adding the CO2 and Cl− values and then subtracting this total from the serum Na
Hand-bulb atomizers and nasal spray pumps are used to
administer sympathomimetic, anticholinergic, antiinflammatory, and anesthetic aerosols to the upper airway, including nasal passages, pharynx, and larynx (see also Chapter 32). These agents are used to manage upper airway inflammation and rhinitis, to provide local anesthesia, and to achieve systemic effects.
Lung sounds or vibrations produced by movement of air through abnormal airways are called ____________ lung sounds.
adventitious
What is the primary hazard of aerosol drug therapy?
adverse reaction to medication
Eye irritation is caused by:
aerosol asministered via face mask which causes the drug to be deposited in the eyes.
code of ethics
an essential part of any profession that claims to be self-regulating. The adoption of a code of ethics is one way in which an occupational group establishes itself as a profession. A code may try to limit competition, restrict advertisement, or promote a particular image in addition to setting forth rules for conduct
intuitionism
an ethical viewpoint that holds that there are certain self-evident truths, usually based on moral maxims such as "treat others fairly"
Poor patient response to bronchodilator therapy often occurs because
an inadequate amount of drug reaches the airway. To determine the "best" dose for patients with moderate obstruction, the respiratory therapist (RT) should conduct a dose-response titration.
Elevation of the WBC count is usually caused by
an increase in either neutrophils or lymphocytes in response to infection
continuous quality improvement
an ongoing process to detect & correct factors hindering quality care
battery
an unconsented touching of an individual that causes injury
Aim of "2015 and beyond"
answer 5 questions about future of profession
The treatment for a fever is this type of drug.
antipyretic
appropriate airway clearance techniques should accompany
any aerosol therapy designed to help mobilize secretions.
Catecholamines
any one of a group of sympathomimetic compounds composed of a catechol molecule and the aliphatic portion of an amine.
slander
any words spoken with malice that are untrue and prejudicial to the reputation, professional practice, commercial trade, office, or business of another person
Antileukotrienes
are administered orally, and the monoclonal antibody agent omalizumab is given parenterally, but these are included as bronchoactive drugs
The heart tries to maintain adequate oxygen delivery to the tissues by increasing __________ ________.
cardiac output
If NAC is administered by?
direct tracheal instillation, tracheobronchial suction should be immediately available to maintain the airway
Nebulizers
generate aerosols from solutions and suspensions.
What is the best choice for high-level disinfection of semicritical respiratory care equipment?
glutaraldehyde. (Egan Pg 74)
cohorting
grouping individuals together who share a common characteristic such as age, gender, infection
What neurotransmitter do ultra short acting bronchodilators effect? How? Where?
norepinephrine or epinephrine, stimulates, alpha 1 (epinephrine), beta 1 (racemic epinephrine)
To avoid opportunistic oral yeast infection:
rinse the mouth after steriod use.
due to the use of endotracheal tube, mechanical ventilation increases what?
risk for VAP
Risk for Caregivers and Bystanders
risk the above hazards as a result of exposure to secondhand aerosol drugs.
When bands and segs are elevated in the CBC..
the patient is likely experiencing a more severe bacterial infection
Sole dependence on tests of expiratory airflow for assessing patient response to therapy is
unwise because not all patients can perform these maneuvers. Other components of patient assessment useful in evaluating bronchodilator therapy include patient interviewing and observation, measurement of vital signs, auscultation, blood gas analysis, and oximetry.
what is the blow-by technique?
used if patient cannot tolerate mask treatment, aerosol is directed from aerosol from nebulizer towards the patients nose and mouth from a distance of several inches from the face.
How does pulse oximetry work?
uses light absorption patterns to indicate saturation levels of the "pulsed" blood which is arterial blood
benchmarking
valuable for each of the primary functions of RC managers, including planning, organizing, directing, and evaluating
When auscultating over the lung parenchyma of a healthy person, soft, muffled sounds are heard. These normal sounds are called:
vesicular breath sounds.
hypokalemia occurs when K+-containing fluids are lost in excessive amounts, such as
vomiting diarrhea administratoin of diuretics
Hygro/Hydro prefixes both mean...
water
Briefly discuss the legal and practical aspects of recordkeeping.
• A medical record or chart provides a written picture of occurrences pertaining to a patient during his or her stay in the hospital or clinic. • Medical records are strictly confidential. • Protected by HIPAA • The records represent a legal document that could be used in court.
Describe respiratory hygiene/cough etiquette.
• Education of patients & employees • Posted signs • Source control measures (covering mouth/nose, or using surgical mask) • Hand hygiene • Spatial separation (at least 3 feet of space)
Briefly discuss evidence based medicine and the basis for its acceptance
• Evidence-based medicine is an approach to determining optimal clinical management based on several practices • In a broader context, evidence-based medicine can be thought of as understanding and using the best quality evidence available (i.e., the best-designed, most rigorous clinical trials) to support the most appropriate and correct possible clinical decisions.
What causes inaccurate readings of oxygen analyzers?
• H2O condensation (on probe) • Pressure fluctuations
What are the different forms of Hb?
• Hb (reduced hemoglobin) • HbO2 (oxyhemoglobin) • HbCO (hemoglobin carboxy hemoglobin) • metHb (methemoglobin--nitrogen hemoglobin)
Frequency of Assessment of Bronchodilator Therapy For Stable Patient
• In the hospital, PEFR should be measured initially before and after each bronchodilator administration. Thereafter, twice-daily determinations may be adequate. • In the home, PEFR ideally should be measured three or four times a day: on rising, at noon, between 4 PM and 7 PM, and at bedtime. • For a stable COPD patient at home, measuring PEFR twice a day may be adequate. • Patients with asthma should adjust the frequency of PEFR measurement according to the severity of symptoms. • PEFR levels before and after bronchodilator use, medication dose, date and time, and dyspnea score should be documented. • The patient should be reevaluated periodically for response to therapy
The following precautions are suggested with use of inhaled tobramycin
• Inhaled tobramycin should be used with caution in patients with preexisting renal, auditory, vestibular, or neuromuscular dysfunction. • Tobramycin solution should not be mixed with beta-lactam antibiotics (penicillins, cephalosporins) because of admixture incompatibility, and mixing with other drugs in general is discouraged. • Nebulization of antibiotics during hospitalization should be performed under conditions of containment, as previously described for pentamidine and ribavirin, to prevent environmental saturation and development of resistant organisms in the hospital. • Aminoglycosides can cause fetal harm if administered to pregnant women; exposure to ambient aerosol drug should be avoided by women who are pregnant or trying to become pregnant. • Local airway irritation resulting in cough and bronchospasm with decreased ventilatory flow rates is possible with inhaled antibiotics and seems to be related to the osmolality of the solution.46,47 Peak flow rates and chest auscultation should be used before and after treatments to evaluate airway changes. Pretreatment with a beta agonist may be needed. • Allergic reactions in the patient, staff, or family should be considered if exposure to the aerosolized drug is not controlled. The use of a nebulizing system with a scavenging filter, one-way valves, and thumb control could reduce ambient contamination with the drug, as previously described
Soon afterward?
• PCO2 level rises sharply and plateaus (as alveolar gas is exhaled)
transmission based (droplet) precautions
• To prevent form of contact transmission that occurs when droplets are propelled short distances, such as influenza • Generated w/ coughing, sneezing, suctioning, bronchoscopy, & cough induction • Surgical mask must be worn
Frequency of Assessment of Bronchodilator Therapy For Patient with an Acute Disorder Who is in Unstable Condition
• Whenever possible, perform a full assessment and obtain a pretreatment baseline. • Assess and document all appropriate variables before and after each treatment (breath sounds, vital signs, side effects during therapy, and PEFR or FEV1). • The frequency with which physical examination and PEFR or FEV1 are repeated should be based on the acuteness of the disorder and the severity of the patient's condition. • SpO2 should be monitored continuously, if possible. • Assessment should continue as dosages are changed to optimize patient response (e.g., if an asthmatic patient achieves 70% to 90% of predicted or "personal best" or becomes symptom-free).
What are indications for arterial sampling in patient?
• acute SOB (tachypnea) • abnormal breath sounds • cyanosis • heavy use of accessory muscle • changes in ventilator settings • CPR • diffuse infiltrates in radiograph
Why is radial artery most often used?
• collateral circulation! (confirm with Allen test) • near surface, easy to stabilize • no large veins near • relatively pain free
In high pressures, what inaccuracy will the oxygen analyzer read? And what conditions make for high pressure?
• higher % than actual • some mechanical ventilation
Which is better?
• invasive more accurate • but carries greater risk
Characteristics of Drug Fomulation
•Viscosity •Surface tension •Homogeneity
What is humidity deficit?
Normal humidity range (44 mg/H20) minus actual humidity
What are the site locations for indwelling catheters?
Normal routes are peripheral arteries (radial, brachial, pedal), femoral artery, central vein, and pulmonary artery.
What is the FiO2 relationship between Nose and Mouth breathers
Nose Breathers= Increased FiO2 Mouth Breathers= Decreased FiO2
How do we analyze gas exchange levels between blood and tissue?
O2 levels in mixed venous (pulmonary artery) blood
Oxygen desaturation when assuming the upright position.
Orthodeoxia
What must always be mixed with N2O for clinical use?
Oxygen
hygroscopic
attracting or absorbing moisture from the air.
The process of listening for bodily sounds.
auscultation
How should Heat stable critical items be sterilized
autoclave (steam sterilized)
AARC mission statement
"to encourage and promote professional excellence, advance the science and practice of respiratory care, and serve as an advocate for patients, their families, the public, the profession and the respiratory therapist"
three categories of nebulizers include
(1) pneumatic jet nebulizers, (2) USNs, and (3) VM nebulizers.
Anion gap is calculated by
(Cl)+(HCO3) - (Na)
Advantages of Treatment of The Respiratory Tract with Inhaled Aerosols:
1. Aerosol doses are usually smaller than doses for systemic administration. 2. Onset of drug action is rapid. 3. Delivery is targeted to the organ requiring treatment. 4. Systemic side effects are often fewer and less severe.
What affects the accuracy of a pulse oximetry
Accuracy affected by Perfusion (shock, hypotension, hemodynamics) Things interfering with light transmission ▪ Fingernail polish ▪ Acrylic nails ▪ Erythema ▪ Bright ambient light Patient motion
Unusual Neurotransmitter is the Parasympathetic System:
Acetylcholine
What action is triggered by anticholinergic bronchodilators?
Acts as a competitive antagonist for acetylcholine on airway smooth muscle.
a liver enzyme that increases with liver diseases such as hepatits
Alanine Aminotransferase ALT
formerly known as SGPT
Alanine Aminotransferase ALT
What is the safety indexed connector system for large cylinders and attachments designated to prevent accidental misconnections
American Standard Safety System (ASSS)
National Board for Respiratory Care (NBRC)
An independent national credentialing agency for individuals who work in respiratory care and related services; assumes the responsibility for all examination standards and policies through a standing committee
What can be used if frequent blood sampling is needed?
Arterial cannulation
Atelectasis
Collapse of distal lung parenchyma; (air sacs start sticking together)
What is a downfall of indwelling catheters?
Infection and thrombosis are more likely than intermittent punctures.
The only reliable way to determine the characteristics of an aerosol suspension is:
Laboratory measurement
Mechanics of Large-Volume jet nebulizer
Liquid particles are generated by passing gas at high velocity through small et orifice. Low pressure at jet draws fluid from reservoir up siphon tube. H2O is then shattered into liquid particles. Smaller particles leave the nebulizer through the outlet port into the gas stream.
Explain how Pulse Oximetry works
Most appropriate noninvasive technique for continuous monitoring of O2 saturations (SpO2) Utilizes Beer's Law Linear relationship between absorbency of a solution and its concentration How it works Uses a probe that passes light through a pulsating tissue bed Consists of two light sources that must be lined up correctly Light passes through tissue and measures both red and infrared wavelengths Accurate in patients with good perfusion and saturations of 70% or higher
What is an example of Inhaled Pulmonary Vasodilators?
Nitric oxide (Brand Name: INOmax)
Is O2 flammable?
No but it greatly accelerates combustion
Silent Unit is defined as:
No perfusion and no ventilation
Define noninvasive
Noninvasive is a means of gathering data externally
Do we still use Pentamindine?
Nope not so much. due to limited efficacy and side effects of cough, wheezing, dyspnea and a grip of other bad stuffs.
What are adverse effects of older adrenergic bronchodilators?
Older drugs can cause tachycardia, palpitations & nervousness
Who is at risk of Absorption atelectasis?
Patients breathing small tidal volumes with FiO2 above 0.50 are at great risk
How is WBC count differential calculated?
Percentage of WBC's under study X total WBC count
After the organism has matured and is examined microscopically to determine the sensitivity to antibiotic therapy, based off this information, allows the physician to?
Prescribe the most effective antibiotic
Macroshock
Shock from an electrical current of 1 mA or greater that is applied externally to the skin
adverse effects of inhaled tobramycin
Side effects with parenteral aminoglycosides include possible auditory and vestibular damage with potential for deafness and nephrotoxicity. Other possible effects are listed in Box 32-5. Side effects observed since the introduction of inhaled tobramycin have been minimal and include voice alteration and tinnitus in a small percentage of patients. Risk for more serious side effects with tobramycin, whether by inhaled or parenteral routes, increases with the use of other aminoglycosides, in the presence of poor renal function and dehydration, with preexisting neuromuscular impairment, or with use of other ototoxic drugs.
Mucus that comes from the lung but passes through the mouth as it is expectorated.
Sputum
What are the precautions that are to be applied to the care of all patients in all health care settings?
Standard Precautions. (Egan Pg 67)
T/F: Febrile patients often have increased heart and breathing rates.
T
What is Brownian diffusion?
The primary deposition mechanism for very SMALL particles and will deposit DEEP within the lung.
Brownian Diffusion
The primary mechanism for desposition of small particles (< 3um), mainly in the respiratory region where bulk gas flow ceases
What is the hematocrit level?
The ratio of RBC volume to whole blood
To determine any recent trends in a pt's pulse, respiration, or blood pressure, you would go to which section of the medical record?
Vital signs sheet
Other than the patients subjective response what is used for the assessment of bronchodilator therapy?
Vital signs, breath sounds, and breathing pattern evaluation (Pre and Post therapy treatment)
Streptococcus pneumoniae
a common bacterium associated with pneumonia, stains as encapsulated, lancet-shaped, gram-positive diplococc
What is the Bourdon Gauge always used in combination with
adjustable pressure-reducing valve
What are methods that kill bacteria?
bactericidal. (Egan Pg 57)
sterilization
complete destruction of all forms of microbial life
NAC is the N-acetyl derivative of the amino acid L-cysteine and is given either by nebulization or by?
direct tracheal instillation
What are small volume USNs used for?
delivery of aerosolized medications (ie bronchodilators, antibiotics and anti-inflammatory agents.)
Conditions associated with JVD include: a. left heart failure b. tension pneumothorax c. cardiac tamponade d. mediastinal tumors e. all of the above
e
COPD patients may use____________ (pursed-lip/deep) breathing during exhalation.
prused-lip
2 types of law
public law and civil law
What are drawbacks of HBO therapy?
Ear or sinus trauma (ie busted eardrum) Worsened Pneumothorax (Don't use if diagnosed) Oxygen Toxicity Fire (not spontaneous combustion)
Quality of RT Department Depends on
Education, experience, and professionalism of therapist
Explain the function and principles of an electrochemical oxygen analyzer
Electrochemical oxygen analyzer Rely on a chemical reaction to produce a flow of electrons (current) Two types: Galvanic Polarographic
What is Leukocytosis?
Elevation of WBC
leukocytosis
Elevation of the WBC count -It results from numerous problems, including stress, infection, and trauma. The degree of leukocytosis reflects the severity of infection
neutrophilia
Elevation of the absolute value of neutrophils is termed
Developed pneumatic theory of respiration in Egypt
Erasistratus
Committee on Accreditation for Respiratory Care (CoARC)
Establishes standards and oversees approval of educational programs in respiratory care
Briefly discuss the primary guiding principles in contemporary ethical decision making
Ethical theories and principles provide the foundation for all ethical behavior. Contemporary ethical principles have evolved from many sources. Although controversy exists, most ethicists agree that autonomy, veracity, nonmaleficence, beneficence, confidentiality, justice, and role fidelity are the primary guiding principles in contemporary ethical decision making.
What is the change in state of a substance from liquid to gaseous form occurring below its boiling point?
Evaporation
What is the Time of Contact principle in regards to humidifier function?
Evaporation increases as the contact time increases
Ovid
Extensive collection of web-based information resources, including databases, journals, books, and searching software. Many medical libraries and large hospitals in US purchase and use Ovid in some form.
T/F: Vocal fremitus can be assessed on a comatose patient.
F
What is methemoglobin?
Ferric iron that cannot bind with O2 & ALTERS HbO2 AFFINITY (LEFT SHIFT IN HbO2 CURVE)
What is the difference between Ferrous and Ferric Iron?
Ferrous (Fe2+) is good iron that binds to O2 Ferric (Fe3+) is bad iron, RUST
Procedure for initiating indwelling catheterization...
First sample of indwelling catheter would be a waste sample.
How many O2 receptors does Hemoglobin (Hb) have?
Four!
What produces most large quantities of Medical O2?
Fractional distillation
describes relationship between gas, temperature and pressure
Gay-Lussac
What is an O2 hood (Oxyhood)
Generally the best method for delivering controlled O2 to infants
What condition is associated with abnormally high levels of Potassium (K+)
Hyperkalemia
What condition is associated with abnormally high levels of sodium (Na+)
Hypernatremia
What is a cause of central nervous system depression?
Hypernatremia
A level of low potassium levels is known as what?
Hypokalemia (<2.0)
Nitric oxide brand name and indications
INOmax, neonates w/ hypoxic resp. failure
What do INVASIVE procedures require?
INSERTION of sensor or collection device into body
What was the AARC first called?
ITA (Inhalation Therapy Association)
ITA to AARC progression
ITA > AAIT > AART > AARC
The patient should be monitored for onset of any of the previously described adverse reactions. In addition, the following actions are recommended: (al 725) al, Kacmarek et. Egan's Fundamentals of Respiratory Care, 10th Edition. Mosby, 032012. <vbk:978-0-323-08203-7#outline(32.9.1.3)>.
If coughing and bronchospasm are present, provide a short-acting beta agonist or an anticholinergic bronchodilator such as ipratropium if present with inhaled pentamidine. • Monitor for occurrence rate of PCP and rate of long-term hospitalizations. • Monitor for presence of side effects (shortness of breath, possible pneumothorax, conjunctivitis, rash, neutropenia, dysglycemia) or appearance of extrapulmonary P. jiroveci infection. • Evaluate need for prior use of a bronchodilator if symptoms of bronchospasm or coughing occur after inhalation of pentamidine (al 725) al, Kacmarek et. Egan's Fundamentals of Respiratory Care, 10th Edition. Mosby, 032012. <vbk:978-0-323-08203-7#outline(32.9.1.3)>.
Explain temperature correction in regards to blood gas analysis.
If patient's temp is abnormal corrections should be made ▪ If patient has a fever: ▪ When analyzed CO2 & O2 will be decreased and pH will be increased (due to temperature of machine) ▪ Must correct to patient's body temp which will cause the CO2 and O2 to increase and pH to decrease ▪ If patient is hypothermic: ▪ When analyzed CO2 & O2 will be increased and pH will be decreased (due to temperature of machine) ▪ Must correct to patient's body temp which will cause the CO2 and O2 to decrease and pH to increase
Resistance
Impedance to flow in a tube or conduit; quantified as ratio of the difference in pressure between the two points
What does the FLAT portion of the HbO2 dissociation curve show
SaO2>90% Facilitates O2 loading at lungs even with low PaO2
S.O.A.P.
In a problem-oriented medical record, abbreviation for subjective, objective, assessment, and plan, the four parts of a written account of the health problem
Contraindications of trancutaneous monitoring
In patients with poor skin integrity or adhesive allergy, transcutaneous monitoring may be relatively contraindicated.
Disinfection (general)
Inactivation of most pathogenic organisms, excluding spores
What is the basic chemistry panel?
Includes the predominant electrolytes sodium, potassium, chloride, and total carbon dioxide/bicarbonate and glucose
What is elevation of the WBC count caused by?
Increase in either Neutrophils or lymphocytes in response to infection
Additional costs of Increased Ventilation
Increased WoB, Increased O2 Consumption, Higher burden of external ventilation
A deep, rapid pattern of breathing.
Kussmaul breathing
A jugular venous pressure increase during inhalation.
Kussmaul sign
Combination of kyphosis and scoliosis, which may produce a sever restrictive lung defect as a result of poor lung expansion.
Kyphoscoliosis
Explain how a co-oximetry works.
Laboratory analytical procedure requiring invasive sampling of arterial blood Utilizes light at special wavelength to measure Oxyhemoglobin Deoxyhemoglobin Carboxyhemoglobin Methemoglobin
To check on the results of a pt's recent blood work, you would go to which section of the medical record?
Laboratory sheet
What is the most common device used for bland aerosol delivery?
Large-Volume Jet Nebulizers
What are all airway appliances used with and why?
Large-bore tubing to minimize flow resistance and to prevent occlusion by the condensate.
Determined sub-atmospheric pressures inflated lungs
Leonardo da Vinci
advances his "germ theory" and suggests that some diseases were result of microorganisms
Louis Pasteur
Right-Left Shunt
Malfunction in septum that causes deoxygenated blood to travel from RIGHT atrium to LEFT atrium
What are Short-acting non-catecholamine agent examples?
Metaproterenol, pirbuterol, albuterol, and levalbuterol (4-6 hour action)
What is physical separation O2 production?
Molecular sieves absorb nitrogen, trace gasses and H2O vapor from air, O2 concentrators pull ambient air through semipermeable plastic membrane.
confidentiality
Obligates health care providers to "respect the secrets which are confided even after the patient has died."
name monoclonal antibody (1)
Omalizumab (Xolair)
How do Large-Volume Jet Nebulizers work?
Pneumatically powered and connected directly to a flow meter and a compressed gas source. Variable air-entrainment port allows air mixing to increase flow rates and to alter the FiO2
Adverse Effects (al 725)
Possible side effects with aerosolized pentamidine include cough, bronchial irritation, bronchospasm and wheezing, shortness of breath, fatigue, bad or metallic taste, pharyngitis, conjunctivitis, rash, and chest pain. Systemic effects have also been noted with inhaled pentamidine, including decreased appetite, dizziness, rash, nausea, night sweats, chills, spontaneous pneumothoraces, neutropenia, pancreatitis, renal insufficiency, and hypoglycemia. It is difficult to distinguish systemic effects caused by the drug versus the disease. Extrapulmonary infection with P. jiroveci can occur with prophylactic inhaled pentamidine.
role duty
Practitioners have a duty to understand the limits of their role and to practice with fidelity
When do you do a modified Allen's test?
Prior to radial puncture ONLY.
The Joint Commission (TJC)
Private nongovernment agency that establishes guidelines for the operation of hospitals and other health care facilities, conducts accreditation programs and surveys, and encourages the attainment of high standards of institutional medical care in the United States; formerly (JCAHO)
Ambulation
Process of helping a bedridden patient begin to sit up, stand, and walk around independently
What is brand name Budesonide?
Pulmicort
What are disorders that lead to alveolar deadspace?
Pulmonary emboli, partial obstruction of the pulmonary vasculature, destroyed pulmonary vasculature (ie COPD), and reduced cardiac output.
What is brand name Dornase alpha?
Pulmozyme
________ __________ is the difference between the systolic and diastolic pressures.
Pulse pressure
Differentiate between pluse-oximetry and co-oximetry.
Pulse-oximetry is non-invasive Co-oximetry is invasive
Which of the following methods of heat transfer requires no direct contact between the warmer and cooler substances?
Radiation
Cold air and high-density aerosols can cause:
Reactive bronchospasm and increased airway resistance.
The components of quality control are?
Record keeping (policies and procedures) Performance validation (testing a new instrument) Preventative maintenance and function checks Automated calibration and verification Internal statistical quality control External quality control (proficiency testing) Remedial action (to correct errors)
What should you do if you get a negative reading on the modified Allen's test?
Redo the test on the other hand and if you get another negative call the doctor.
Benefits of Point-of-Care Testing...
Reduces turnaround time, thus should improve care and lower costs.
How does surface area affect humidifiers performance?
The greater the surface area of contact between water and gas, the more opportunity for evaporation to occur
How does temperature affect humidifiers performance?
The higher the temperature of a gas, the more water vapor it can hold (increased capacity) or vice versa
What is the temperature principle in regards to humidifier function?
The higher the temperature of gas the more H2O it can hold.
What does O2 toxicity primarily affect?
The lungs & CNS
harm principle
The main ethical issue surrounding confidentiality is whether more harm is done by occasionally violating its mandate or by always upholding it, regardless of the consequences
evidence-based medicine
Refers to determining optimal clinical management based on evidence found in scientific literature (Best scientific evidence includes rigorous clinical trials to support most appropriate & correct clinical decisions)
A therapist who says "You seem to be anxious about you surgery" to a pt is using what interpersonal communication technique?
Reflecting feelings
cleaning
Removal of all foreign material (e.g., soil, organic material) from objects
Ribavirin (al 725)
Ribavirin (Virazole) is an antiviral agent used in the treatment of severe lower respiratory tract infections caused by respiratory syncytial virus (RSV). RSV is a common seasonal respiratory infection in infants and young children, which is usually self-limiting. The cost-effectiveness of ribavirin continues to be debated. Recommendations for use of the drug were published in a statement by the American Academy of Pediatrics.44 Administration of the aerosol requires use of a special large-reservoir nebulizer called a small particle aerosol generator (SPAG). The mode of action of ribavirin is ascribed to the similarity of the drug to guanosine, a natural nucleoside. Substitution of ribavirin for the natural nucleoside interrupts the viral replication process in the host cell.
What primary parameters does a ABG analyzer measure?
They measure pH, PCO2 and PO2
Know your terms & definitions!!
This accounted for 36 questions on Test 1!
compensatory justice
This form of justice calls for the recovery for damages that were incurred as a result of the action of others. Damage awards in civil cases of medical malpractice or negligence are examples of compensatory justice
Many types of disposable SVNs are packaged with a 6-inch (15-cm) piece of aerosol tubing to be used as a reservoir
This may increase inhaled dose by 5% to 10% or increase the inhaled dose from 10% to approximately 11% with the reservoir tube.
uses oxygen to treat various condition at Pneumatic Institute
Thomas Beddoes
describes law of diffusion for gases
Thomas Graham ("Graham's Law")
What is a flowmeter used for?
To control flow to patient
What are enclosures (Mist tents and hoods) used for?
To deliver aerosol therapy to infants and children
Briefly discuss professionalism and state at least 5 characteristics of a respiratory therapist.
To have professionalism, you must be a professional.. a professional is an individual who conforms to the technical and ethical standards of a profession (i.e., HIPAA requirements, continuing education, high standards of practice, join professional organizations, etc..)
what are some indications for pulse oximetry?
To monitor the adequacy of arterial oxyhemoglobin saturation To quantify the response of arterial oxyhemoglogin saturation to therapeutic intervention or diagnostic procedures, such as bronchoscopy To comply with mandated regulation or recommendation by authoritative groups
What is the primary purpose of grounding all electrical equipment used in the hospital setting?
To prevent the dangerous build-up of voltage in the equipment
What is a reducing valve used for?
To reduce gas pressure to a useable level.
a typical SVN is powered by
a high-pressure stream of gas directed through a restricted orifice (the jet). The gas stream leaving the jet passes by the opening of a capillary tube immersed in solution. Because it produces low lateral pressure at the outlet, the high jet velocity draws the liquid up the capillary tube and into the gas stream, where it is sheared into filaments of liquid that break up into droplets. This primary spray produces a heterodisperse aerosol with droplets ranging from 0.1 to 500 µm.
What are the indications for Mucomyst?
a need to thin mucus, Tylenol overdose
What happens with an ANATOMIC SHUNT?
a portion of cardiac output returns to the left heart without being oxygenated (perfusion in excess of ventilation)
When ribavirin or pentamidine is given, the treatment is provided in a
a private room. The room should be equipped for negative pressure ventilation with adequate air exchanges (at least six per hour) to clear the room of residual aerosols before the next treatment. HEPA filters should be used to filter room or tent exhaust, or the aerosol should be scavenged to the outside.
Ciclesonide
a prodrug, is given as an inactive compound and is converted to an active metabolite, desisobutyryl-ciclesonide, by intracellular enzymes -is available as an intranasal formulation (Omnaris) and a pressurized MDI (Alvesco
What does a central piping system do?
Used to deliver compressed gas to all areas throughout the hospital at standard working pressure (50-psi)
Describe methods for blood gas monitoring for Transcutaneous PO2 and PCO2
Uses an electrode placed directly on skin to measure skin PO2 and PCO2 Used primarily on infants because their skin is more permeable to O2 and CO2
What is the mechanisms in a Bourdon Gauge and how do they function?
Uses fixed orifice operating under variable pressures, not gravity dependent but not accurate when pressure distal to orifice changes. (Ideal for patient transport)
Describe methods for blood gas monitoring for Intraarterial (in vivo) monitoring
Uses indwelling fiberoptic photochemical sensor (optodes) Optode contains a dye at one end and the amount of light the dye absorbs, reflect or re‐emits, determines the concentration of different substances
Which of the following is an acceptable practice in medical record keeping?
Using standard abbreviations
What is Pentamindine (Brand Name: NebuPent)
Was usd for treatment of opportunistic pheumonia caused by the fungus Pneumocystis Jiroveci which is the causative agent of Pneumocystis pneumonia (PCP)
The best way to prevent the spread of infection in the ICU is to?
Wash your hands after every patient contact. (Egan Pg 54)
What is the weight of 1L of liquid O2 and how much O2 gas does it produce?
Weight= 2.5 lbs Production= 860 L of O2 gas
What questions should the RT ask patients with chronic cardiopulmonary disease?
What activities of daily living trigger the dyspnea, how much exertion is required for the patient to stop and catch their breath, whether the quality of sensation of breathing discomfort varies with different activities, when did the dyspnea first began
Ampere
What current is reported in
Ohm
What resistance is reported in
what is gravimetric sedimentation?
When aerosol particles settle out of suspension and are deposited due to the pull of gravity. Breath-holding after inhalation increases sedimentation and distribution in the lungs. the greater the mass of a particle the faster it settles
Inhaled Zanamivir
Zanamivir is an inhaled powder aerosol (DPI). Despite the availability of zanamivir and the oral antiinfluenza agent oseltamivir (Tamiflu), prophylactic vaccination against influenza is still recommended, especially in high-risk individuals with cardiovascular or pulmonary disease. Zanamivir and oseltamivir represent a new class of antiviral agents termed neuraminidase inhibitors.
Describe Standard Precautions
- Wash hands - Wear fresh, clean gloves - exercise extreme caution when handling sharps - handle soiled equipment carefully
Cross-contamination
- Water in the circuit can be a source of bacterial colonization. - Minimizing condensation is helpful to reduce risk of colonization. - Frequently changing circuit is not needed to reduce chance of nosocomial infection.
hazards of bland aerosol therapy
- Wheezing or bronchospasm - Bronchoconstriction when artificial airway is used - Infection - Overhydration - Patient discomfort - Caregiver exposure to airborne contagions produced during coughing or sputum induction - Edema of the airway wall - Edema associated with decreased compliance and gas exchange and with increased airway resistance - Sputum induction by hypertonic saline inhalation can cause bronchoconstriction in patients with chronic obstructive pulmonary disease, asthma, cystic fibrosis, or other pulmonary diseases.
pMDI is
- a pressurized canister that contains the prescribed drug in a volatile propellant combined with a surfactant and dispersing agent.
Dose Counters
- a serious limitation of pMDIs is the lack of a "counter" to indicate the number of doses remaining in the canister.
Optimal performance for each DPI occurs at
- a specific inspiratory flow rate. - The fine-particle fraction of respirable drug from existing DPIs ranges from 10% to 60% of the nominal dose. - The higher the resistance or the greater the flow requirement of a DPI device, the more difficult it is for a compromised or young patient to generate inspiratory flow sufficient to obtain the maximum dose of drug from the device.
Holding chambers with masks are available for use in the care of infants, children, and adults.
- allow effective administration of aerosol from a pMDI to patients who are unable to use a mouthpiece device (because of their size, age, coordination, or mentation). - Holding chambers are helpful in administration of pMDI steroids because deposition of the drug in the mouth is largely eliminated, and systemic side effects can be minimized.
Holding Chambers
- allow the aerosol plume to develop and reduce oropharyngeal deposition. A holding chamber also incorporates one or more valves that prevent aerosol in the chamber from being cleared on exhalation. - provide less oropharyngeal deposition, higher respirable drug dosages, and better protection from poor hand-breath coordination than simple spacers.
Which of the following is/are key factor(s) determining the extent of harm caused by an electrical current?
- duration for which the current is applied - path the current takes through the body - amount of current flowing through the body
Continuous Small Colume Nebulizers with Collection Bags
- hold the aerosol generated during exhalation and allow the small particles to remain in suspension for inhalation with the next breath, while larger particles rain out, attributed to a 30% to 50% increase in inhaled dose
A critical test value
- is a result significantly outside the reference range and represents a pathophysiologic condition -may be potentially life-threatening unless corrective action is taken promptly -communicated by telephone from the clinical laboratory to the general ward or intensive care unit where the patient is situated
exhalation into the device before inspiration can result in
- loss of drug delivery to the lung
Reservoir and feed systems
-Heated humidifiers can evaporate more than 1 L/day. -To avoid constant refilling, the devices use -Large water reservoir and/or -Gravity feed system
Breath-Enhanced Nebulizers
-nebulizers that entrain room air in direct relationship to the inspiratory flow of the patient -generate aerosol continuously, using a system of vents and one-way valves to minimize aerosol waste
Infections from aerosol generators
-nosicomial infections occur by spreading bacteria by the airborne route.
Cold Freon Effect
-occurs when the cold aerosol plume reaches the back of the mouth and the pati ent stops inhaling. -can be reduced by using a spacer or holding chamber.
Residual Drug Volume
-or dead volume, is the medication that remains in the SVN after the device stops generating aerosol and "runs dry."37 -The residual volume of a 3-ml dose can range from 0.5 to more than 2.2 ml, which can be more than two-thirds of the total dose. -Residual volume also depends on the position of the SVN.
Determinant of Desposition (where a particle of any specific size is deposited)
-particle size -inspiratory flow rate -flow pattern -respiratory rate -inhaled volume -ratio of inspiraton time to expiratory time. -breath holding.
All healthcare personnel must use "two patient identifier" before initiating care
-patient name -birth date
The most common sources of bacteria are
-patient secretions -contaminated solutions -caregiver's hands.
precise amount of drug delivered to the patient's airways can be measured in terms of:
-patient's clinical response to aerosol drug therapy including the desired therapeutic effects and any unwanted adverse effects.
Monitoring for reactive bronchospasm should include:
-peak flow measuremenrs or percentage forced expiratory volume in 1 second before and after therapy. -auscultation for for adventitious breath sounds -observation of the patient's breathing pattern and overall appearance. - most essential: communicating with the patient during therpay to determine the perceived work of breathing.
Aerosols occur in nature as:
-pollens -Spores -Dust -Smoke -Fog -Mist
Sources of Conflict
-poor communication is primary source of conflict in organizations -structural problems occur more often with larger organization and when employees have little control over their work
What will RTs of the future focus more on? (6)
-prevention -protocol administration -care plan development -disease management and rehabilitation -family and patient education -tobacco cessation counseling
Before initial use and after storage, every pMDI should be
-primed by shaking and actuating the device to atmosphere one to four times. -without the priming, the initial dose actuated from a new pMDI cansiter contains less active substance than subsequent acutations. - waste a single does when it has not been used for 4-6 hours
Libel
-printed defamation by written words, cartoons, and such representations to cause the individual to be avoided or held in contempt
The eyes should be..
-protected from drug exposure with aerosol use owing to accidental spraying from an MDI or with nebulizer-mask delivery -There is less chance of eye exposure with the MDI formulation than the SVN solution; a holding chamber is recommended with MDI use
National Fire Protection Association (NFPA)
-regulates storage of medical gases -monitoring by the Joint Commission (TJC); hospital accrediting organization
Medical Director
-responsible for clinical function of department -usually is pulmonologist or anesthesiologist -must possess both management and clinical skills
Administrative law
-second major branch of public law -consists of the countless regulations set by government agencies
Improving Communication
-share information rather than tell it -seek to relate to people rather than to control them -value disagreement as much as agreement -use effective nonverbal communication techniques
Whether aerosol particles that are inhaled into the lungs are deposited into the respiratory tract depends on:
-size -shape -motion of the particled and on the physical characteristics of the airways and breathing pattern.
Airborne transmission
-spread of airborne droplet nuclei -small particles less than or equal to 5um -special air handling, ventilation, and respiratory protection is needed N-95 respirators or higher are needed to prevent transmission
Key Elements of a Respiratory Care Protocol Program
-strong and committed medical direction -capable therapists -active quality monitoring -collaborative environment among RT's, physicians, and nurses -responsiveness of all participants to address and correct problems
Gas pressure and flow through the nebulizer affect particle size distribution and output.
-the higher the pressure or flow, the smaller the particle size, the greater the output, and the shorter the treatment time. -Too low a gas pressure or flow can result in negligible nebulizer output.
Aerosol Output
-the mass of fluid or drug contained in aerosol product by a nebulizer. -the mass of aerosol generated per unit of time
Workplace exposure to aerosol may be detectable in
-the plasma of bystanders & health care providers.
Aerosol particle size depends on:
-the substance for nebulization - method used to generate the aerosol -The environmental conditions surrounding the particle
res ipsa loquitur
-the thing speaks for itself -sometimes invoked to show that the harm would not ordinarily have happened if the individuals in control had used appropriate care. In these cases, negligence is established by inference
In licensure legislation
-there is always a clause specifying a scope of practice -The scope-of-practice statutes give general guidelines and parameters for the clinician's practice
Indication for Racemic Epinephrine
-used by: -Inhaled aerosols - Direct Lung instillation -Used to reduce airway swelling after extubation or during epiglottis, croup, or bronchoiolitis or to control airway bleeding during endoscopy.
pMDI
-used to administer bronchodilators, anticholinergics, & steroids - Are easy to use but commonly misused.
Implementation of an occupational health and safety policy could include:
-using systems that introduce less aerosol to the atmosphere -dry powder inhalers - filtering exhalation to contain aerosol -using environmental controls.
Breath-Actuated Pressurized Metered Dose Inhaler
-variation of a pMDI -incorporates a trigger that is activated during inhalation. -This trigger reduces the need for the patient or caregiver to coordinate MDI acutation with inhalaiton.
Standard Precaution : Gloves
-wash hands, before and after wearing gloves -change gloves before each task
The Practitioner as Listener
-work at being good listener -stop talking; avoid interrupting speaker -resist distractions; tune them out -keep your mind open; be objective -hear the speaker out before making evaluation -maintain composure; control emotions
Components of pMDI, including function of the metering valve
...
Determining Doses Left in the Dry Powder Inhaler
...
Differentiate between capnometry and capnography
...
Explain the procedure for arterial punctures
...
Fine-Particle Fraction
...
List the recommended equipment for arterial punctures.
...
At what temperature does all kinetic activity of matter cease?
0 degrees Kelvin
eosinophils
0% - 6 % absolute value of o-600
bands
0% - 6% absolute value of 0-600
basophile
0%-1% absolute value of 0-100
How much blood is needed for an adequate ABG sample?
0.5-1 mL of blood. (usually enough to perform two tests)
creatinine
0.7-1.3
What percentage is Isotonic (normal) NaCl solution?
0.9%
3 Categories of DPIs
1. Unit-Dose DPI 2. Multiple unit-dose DPI 3. Multiple Dose Drug Reservoir DPI
What are sub-hazards to aerosol drug therapy?
1. infection 2. airway reactivity 3. pulmonary and systemic effects of bland aerosols 4. drug concentration changes during nebulization 5. eye irritation
What are three designs for O2 delivery systems?
1. low-flow systems 2. Reservoir systems 3. High-flow systems
What are beneficial characteristics of an MDI?
1. portable 2. compact 3. easy to use
portable liquid O2 systems for long-term oxygen therapy (LTOT) in home introduced (when?)
1970s
Aerosolized steroids first used to treat acute asthma (when?)
1971
designation "respiratory therapist" becomes standard (when?)
1974
Respiratory Care Week established nationally to promote profession and importance of good lung health
1980
William MacEwen successfully applied first endotracheal tube to patient when?
1980
first microprocessor-controlled ventilators developed when?
1980s
polysomnography becomes routine when?
1980s
Ratio Solution for drug dosage
1:100= 1% percent solution
Define 2,3-DPG
2,3-Diphosphoglycerate: A highly anionic organic phosphate present in human RBCs. Binds to Deoxyhemoglobin (Hb without O2)
What is the relative value of Lymphocytes?
20%-45%
Each healthy RBC contains how many molecules of hemoglobin?
200 to 300 million
each healthy RBC contains how many million molecules of hemoglobin
200-300 million
Levalbuterol (Xopenex) introduced (when?)
2000
When did AARC, NBRC & CoARC formally express support for all RT's to seek and obtain RRT credential?
2002
When did the AARC formally encourage development of baccalaureate and graduate ed in RC?
2003
further advances in home oxygen therapy equipment occurred when?
21st century
Ventilator circuits may be used up to how many days before they need to be changed?
7. (Egan pg 68)
efficiency rating for HME
70%
Normal range for Glucose is?
70-105
glucose
70-105
the normal anion gap is
8 -16 mEq/L
Normal anion gap range
8-14 meq/L
What is a technical downfall of MDIs?
80% of the aerosol hits the back of the throat depositing the medication in the oropharynx
What is normal PaO2?
80-100 mm Hg
The normal range for systolic blood pressure is _____ to _____ mm Hg.
90, 140
Hypotenstion is a systolic blood pressure less than ___ mm Hg or a mean arterial pressure less than ____ mm Hg.
90, 65
About how many people die each year in the USA from hospital-acquired infections (HAIs)?
90,000
normal SaO2 ?
95-100 %
renal disease often leads to an abnormal elevatoin of blood urea above what level
> 20 mg/dl
What value is considered abnormal for sweat Cl- levels?
> 60 mmol/L
What is percentage Hypertonic NaCl solution?
>0.9% (10% normally)
A critical value for Blood urea nitrogen is?
>100 mg/dl
Critical value for Sodium is
>155 or <125
an anion gap greater then what is consistent with the presence of metabolic acidosis
>16
What anion gap range is consistent with the presence of metabolic acidosis?
>16 meq/L
Critical value for Potassium is
>6.0 or <3.0
Inhaled Aztreonam
Aztreonam was approved in December 1986 by the FDA as a monobactam, a synthetic bactericidal antibiotic; it is given as an IV solution. Inhaled aztreonam (Cayston) was approved in 2010 to improve pulmonary symptoms in patients with CF colonized with P. aeruginosa.50 Inhaled aztreonam is not indicated for patients younger than 7 years old or patients with Burkholderia cepacia infection. This agent has been studied only in patients with FEV1 greater than 25% or less than 75% of predicted. The agent is delivered by itself using the Altera Nebulizer System.
WBC count differential
Absolute value= %WBCs (under study) x total WBC count.
What does a Humid-Heat HME do?
Absorbs expired heat and moisture, then releases it into inspired gas.
Explain criteria for Collateral Blood Flow.
Arterial punctures may cause vessel spasm, intraluminal clotting, or bleeding with the formation of a periarterial clot (hematoma) Any of these factors may result in decreased blood flow to the tissues Collateral blood flow is an important consideration in choosing arterial puncture sites in the event of arterial obstruction
high concentratoins of this enzyme are found in patients with liver disease, such as hepatitis, or during the second day after an MI
Aspartate Aminotransferase AST
before treatment
Assess the patient's adequacy of cough and level of consciousness to determine need for treatment with mechanical suctioning or adjunct bronchial hygiene (postural drainage or percussion, positive expiratory pressure therapy) to clear the airway or if treatment is contraindicated
Cross-training
Assistive personnel involves on-the-job training of unlicensed personnel, who may not have an educational background in health care, to perform technical functions
How much gas is held in bulk O2 systems?
At least 20K cubic feet of gas (in gas or liquid form)
What is brand name Ipratropium bromide?
Atrovent
What is the brand name for Ipratropium bromide?
Atrovent
Maintaining eye contact, leaning toward the pt, and nodding your head are all good examples of what communication technique?
Attending
List criteria for site of arterial puncture.
Criteria for site of arterial puncture Collateral Blood Flow Vessel Accessibility PeriarterialTissue
adverse effects of NSAAD
Cromolyn-like agents - Considered extremely safe Antileukotriene agents - Headache, dyspepsia, liver enzyme elevation Omalizumab - Injection site reaction, viral infections, headache, sinitus, pharyngitis
What is a drawback of manual reservoir feed systems?
Cross contamination.
How does the crystal transducer in an ultrasonic nebulizer work?
Crystal transducer converts radio waves into high-frequency mechanical vibrations that produce the aerosol. Cuplent (liquid) takes vibration energy and transmits it to what is being delivered to the patient.
What is the primary factor determining the effect of an electrical shock?
Current
Gas flow formulas...
Cylinder factor (L/psig) = Cubic feet (full cylinder) x 28.3 / Pressure (Full Cylinder) in psig Duration of flow = Content/Flow --Duration of flow (min) = Pressure (psig) x cylinder factor / Gas Flow (L/min)
What is results are measured and stamped on the tank?
Cylinder leakage, expansion, and wall stress.
Increased levels of CL in the sweat because of an inability to reabsorb it is consistent with what disease?
Cystic Fibrosis
advance directives
allow a patient to give direction to health care providers about treatment choices in circumstances in which the patient may no longer be able to provide that direction
durable power of attorney
allows the patient to identify another person to carry out his or her wishes with respect to health care
Respiratory therapy consult service
an "evaluate-and-treat" program; combines specific protocols to form a comprehensive approach
Polycythemia
an abnormally elevated RBC count. It counteracts then negative side effects of reduced PO2 in the blood by increasing the oxygen carrying capacity of the blood.
The primary hazard of aerosol drug therapy is
an adverse reaction to the medication being administered. Other hazards include infection, airway reactivity, systemic effects of bland aerosols, and drug reconcentration
Monitoring is defined as...
an ongoing process by which clinicians obtain and evaluate dynamic physiological processes in a timely manner (bedside)
disease management
an organized strategy of delivering care to a large group of individuals with chronic disease to improve outcomes and reduce cost
A pressure sensation with exertion or stress, resulting from coronary artery occlusion.
angina
Drugs for nebulization that escape from the nebulizer into the atmosphere or are exhaled by the patient can be inhaled by
anyone in the vicinity of the treatment. The risk imposed by this environmental exposure is clear and is associated with a range of drugs and patients with infectious disease. Pentamidine and ribavirin were associated with health risks to health care providers even when used in conjunction with filters on exhalation ports of nebulizers, containment and scavenger systems, and high-efficiency particulate air (HEPA) filter hoods and ventilation systems (Figure 36-36).
sterilization
complete destruction of all microorganisms, usually by heat or chemical means
Civil law
concerned with the recognition and enforcement of the rights and duties of private individuals and organizations
A reservoir on the expiratory limb of the nebulizer
conserves drug aerosol
Multiple Unit-Dose DPIs
contain a case of four or eight individual blister packets of medication on a disk inserted into the inhaler.
What does CaO2 represent?
content of O2 in 100 ml of arterial bloodj • amount of Hb present and degree of saturation
What does transcutaneous monitoring provide?
continuous, noninvasive estimates of PO2 and PCO2 using a skin sensor. Also PtcO2 levels
What are the indications for nonsteroidal antiasthma medications?
control of persistent asthma
The use of intranasal steroids is used for?
control of seasonal allergic or nonallergic rhinitis
The liver is primarily responsible for
converting food into substrates essential for cellular metabolism, protein synthesis, and detoxifying substances in the body
Right sided heart failure
cor pulmonale
Patients with ________ frequently feel suffocated.
coronary heart failure
Dry or loose, productive or nonproductive, acute or chronic, occurring more frequently at certain times...these are characteristics of what symptom?
cough
various respiratory symptoms include
cough, dyspnea, pneumothorax, hemoptysis, rhinitis, sinusitis), flu syndrome, GI obstruction, hypoxia, malaise, and weight loss
occurs in the brain, skeletal muscles, and heart
creatine kinase ( CK)
a waste product that is formed by muscle metabolism and filtered out of the body by the kidneys
creatinine
NBRC role in respiratory care
credentialing body for respiratory therapists (certification and registry exam)
2 types of public law
criminal and administrative
give examples of professional malpractice situations that might affect RCPs
criminal: battery, assault, euthanasia civil: negligence or practice below reasonable standard ethical: includes violations of professional ethics and may result in censure or disciplinary actions by licensure boards.
Name the three risk categories applicable for medical equipment
critical, semi-critical, non-critical
Hospital Restructuring and Design
cross training, using unlicensed assistive staff, decentralizing services (patient focused care)
Problems with aerosol therapy
cross-contamination and infection, environmental safety, inadequate mist production, overhydration, bronchospasm, noise
Chlorofluorocarbons (CFCs)
gaseous chemical compounds that were originally used to power metered dose inmhalers but currently phased out of use
Infection control procedures 2 categories
general sanitation measures specialized equipment processing
Opportunistic infections
generally occur when these lymphocytes decrease to less than 200 × 106/L, and this information is used in making the diagnosis of AIDS
RT areas of employment (6)
hospitals (75%), clinics, physicians' offices, skilled nursing facilities, cardiopulmonary diagnostic labs, public schools
Ultrasonic nebulizer (USN)
humidifier in which an electrical signal is used to produce high-frequency vibrations in a container of fluid. The vibrations break up the fluid into aerosol particles.
COPD patients exhibit what type of resonance?
hyerresonance
Result of diabetes
hyperglycemia- abnormal elevation of blood glucose level.
occurs with a variety of ailments, such as renal disease, and tissue trauma, which causes a release of intracellular K+ into the plasma
hyperkalemia
elevation of the serum Na+ is known as
hypernatremia
occurs with renal diseases and excessive water loss
hypernatremia
oulmonary and systemic effects excess saline solution can cause
hypernatremia
When the percussion note is louder & lower than normal, the sound is said to be increased resonance or _____________.
hypertympanic
occurs with prolonged vomiting, resulting in the loss of HCL, chronic respiratory acidosis, certain renal diseases
hypochloremia
an abnormally low serum K+ level is known as
hypokalemia
may occur with diurectic therapy, diarrhea, or certain kidney problems
hyponatremia
nitric oxide adverse effect
hypotension
The _____________ plays an important role in regulating body temp.
hypothalamus
A body temperature below normal.
hypothermia
Postural hypotension is commonly caused by ___________.
hypovolemia
consequentialism
idea of judging an act to be right; an ethical viewpoint on which decisions are based on the assessment of consequences
Meta-Analysis (additional tool of EB Med)
identifies, analyzes,and summarizes body of literature for specific topic being studied
When is a sputum gram stain useful?
if a patient is suspected to have an infection in the lungs/airways.
Is it a good way to measure oxygen levels?
if good quality assurance is used -> accurate!
Servo-controlled heating system
in a humidifier, heating unit that monitors the temperature of gas delivered to the patient, adjusting the power to the heater based on the difference between the temperature setting and the temperature monitored by a thermistor probe placed downstream from the humidifier, at or near the patient airway connection.
Where should the aerosol generator be placed with IPPV?
in circuit close to patient's airway
5 factors affecting communication for both parties
internal, sensory/emotional, environmental factors, verbal, non-verbal
justice
involves fair distribution of care
Clinical biochemistry
involves the analysis of blood, urine, and other bodily fluids primarily for electrolytes and proteins; hematology analyzes the cellular components of blood
justice
involves the fair distribution of care
The most common CPK enzyme test
is CPK-2 (CPK-MB), which is released from the heart after myocardial infarction
leukopenia (or leukocytopenia)
is a WBC count below normal that often occurs when the patient's immune system is overwhelmed by infection
Hypoalbuminemia (decreased serum albumin)
is a common finding in critically ill patients and significantly reduces the anion gap
What is the significance of troponin?
is a complex protein that plays an important role which a specific test can be ordered to find if patient has heart muscle damage.
Dornase alfa (Pulmozyme)
is a genetically engineered clone of the natural human pancreatic
A Nonionized drug
is a lipid-soluble and diffuses across cell membranes and into the bloodstream
Anion gap
is a quick method to determine whether a decrease in HCO3 (bicarbonate) is caused by a disruption of normal anion balance or the presence of an abnormal acid anions.
International Organization for Standardization
nongovernment agency that sets standards for various technical equipment and procedures.
What is Tissue oximetry?
noninvasive (TCM) method of measuring saturation of hemoglobin at tissue level. **Oxygen saturation at tissue level (StO2) assesses adequacy of circulation & oxygen delivery. **Early detection of low StO2 can be used as an early detection method of tissue hypoperfusion in patients with traumatic injuries.
What is pulse oximetry?
noninvasive monitoring technique performed at bedside. **Combines principles of spectrophotometry with photoplethysmography. **Noninvasive portable monitoring device providing estimates of SaO2 **Results are reported as SpO2 **Pulse oximetry uses light absorption patterns to indicate saturation levels of "pulsed" blood (arterial blood, not venous blood) **Results are not as accurate as hemoximetry **Accurate to within ±3% to 5% of hemoximetry. **Finger probes are not reliable in patients with shock. **Cannot distinguish HbCO from HbO2, so there will be a false high [SpO2] in CO poisoning. **Does not measure CaO2 or PCO2, so patients suspected of having O2 transport issues or hypoventilation should have an ABG.
fomites
nonliving material, such as bed linens or equipment, which may transmit pathogenic organism to a person who comes into contact with the object
This type of chest pain is located in the center of the anterior chest and may radiate to the shoulder or back; dull ache or pressure feeling.
nonpleuritic chest pain
The unusual neurotransmitter in the sympathetic system:
norepinephrine -this is similar to epinephrine AKA adrenaline.
What neurotransmitter(s) do long acting bronchodilators effect? How? Where?
norepinephrine or epinephrine, stimulates, beta 2
What neurotransmitter(s) do short acting bronchodilators effect? How? Where?
norepinephrine or epinephrine, stimulates, beta 2
How good are results of pulse oximeters?
not as accurate as hemoximetry • within 3-5% of hemoximetry
Briefly discuss the cons of disposable equipment in respiratory care.
o Cost o Quality o Unable to reuse (raises significant safety concerns)
critical risk category
o Devices introduced to blood stream or other parts of body o Requires sterilization
semi-critical risk category
o Devices that directly or indirectly contact mucus membranes o Requires high level disinfection
non-critical risk category
o Devices that only touch intact skin or do not touch patient at all o Require detergent washing or low to intermediate level disinfection
PPE
o Gloves: must be sterile whenever performing invasive procedures o Masks: protect mucosal surfaces against splashes or sprays but should not be confused w/ particulate respirators o N-95 or higher-level respirator: intended for diseases that could be airborne transmitted o Gowns: provide barrier protection & can prevent contamination of clothing & exposed body areas
airborne infection isolation precautions
o Isolation techniques intended to reduce risk of selected infectious agents transmitted by "small droplets" of aerosol particles, such as M. tuberculosis o Use of N-95 respirator o Room must be negative pressured, 2 air exchanges per hour, & use HEPA filters
Briefly discuss the pros of disposable equipment in respiratory care.
o No clean up other than disposing of it o reduces risk of infection due to single use
relative humidity
o Relative humidity describes the amount of water vapor in the area as opposed to how much water vapor could be in the area. This type of humidity is basically a ratio of the absolute humidity and the potential amount of water saturation that the air could possibly hold.
beneficence
o health care providers go beyond doing no harm and contribute actively to the health and well-being of their patients
nonmaleficence
obligates health care providers to avoid harming patients and to prevent harm actively where possible
What does a greater difference between PETCO2 and PaCO2 mean?
obstructive lung disease • can't expirate CO2 • [possible acidosis]
Role Conflicts
occurs when employee is pulled in different directions by individuals with different expectations
Inertial Impaction
occurs when suspended particles in motion collide with and are deposited on a surface -this is the primary deposition mechanism for particles larger than 5um
What are physical characteristics of helium (He)
odorless, tasteless, nonflammable, chemically and physiologically inert
Agonists
of or pertaining to a chemical substance or drug that has affinity for a receptor and exerts a desired or expected effect (as opposed to an antagonist).
the smallest formed elements in the blood and are important for coagulatoin
platelets ( thrombocytes )
Dyspnea in the upright position.
platypnea
Orthodeoxia may accompany this type of dyspnea.
platypnea
This type of chest pain is usually located laterally or posteriorly, and worsens when the patient takes a deep breath; sharp, stabbing pain.
pleuritic chest pain
What is the isothermal saturation boundary
point at which inspired gas becomes fully saturated to 100% relative
Isothermic saturation boundary (ISB)
point at which inspired gas becomes fully saturated to 100% relative humidity at body temperature.
can reduce turnaround time, improve care and lower costs, there by decrease a patients LOS in hospital and emergency department
point of care testing
Every drug approved for inhalation to date has been designed for and tested in
populations of ambulatory patients with moderate disease. As patients with lung disease become acutely and critically ill, the approved label doses, frequency of administration, and devices may not be practical or effective, especially for treatment of patients requiring ventilatory support. In such cases, clinicians may explore and consider nonstandard methods (doses, frequency, and devices) for administration of approved inhaled drugs to patients in the acute care environment, known as off-label use
Concerns in the use of disposable nebulizers with compressors at home involve
possible degradation of performance of the plastic device over multiple uses
An abrupt decrease in blood pressure upon standing, often seen in hypovolemic patients.
postural hypotension
globalization of respiratory care
practice of RC originally in US and Canada now expands globally
algorithms
predetermined group of directions to solve a problem in a finite number of steps
Respiration
process of moving oxygen to tissues for aerobic metabolism & removal of CO2 (involves gas exchange @ lungs & tissues
Baffling
process of removing large water particles from suspension in a jet nebulizer so that the particles entering the patient's airways are of a uniform therapeutic size.
Describe the responsibilities and the role of a medical director.
professionally responsible for the clinical function of the department and provides oversight of the clinical care that is delivered
PT
prothrombin time
respiratory care management information systems
provide a means to organize and assign respiratory care orders, measure staff productivity, report clinical results, and execute respiratory care protocols, along with generating data to show their effectiveness via outcomes research
"snapshots"
provide the clinician with valuable but time-limited insight into cellular processe
complete blood count (CBC)
provides a detailed description of the number of circulating white blood cells (WBCs), called leukocytes
The anion gap
provides a quick method for determining whether a decrease in HCO3− is caused by a disruption of normal anion balance or the presence of an abnormal acid anion
When a patient with normal cardiopulmonary function complains of intense dyspnea or suffocation, it is known as __________ _________ __________.
psychogenic hyperventilation syndrome
assault
s any conduct that creates a reasonable apprehension of being touched in an injurious manner; no actual touching is required to prove assault
Continuous pneumatic nebulizers produce the greatest amount of
secondhand aerosol, with most (60%) of the aerosol produced passing directly into the environment. The Respirgard II (Vital Signs, Totowa, NJ) nebulizer was developed for administration of pentamidine, adding one-way valves and an expiratory filter to contain aerosol that is exhaled and not inhaled. Breath-actuated nebulizers, DPIs, and pMDIs tend to generate less secondhand aerosol.
DataArc
secured, password-protected, web-based database management system for documenting and reporting clinical educational activities for nursing and allied health professions, including respiratory care
Mature neutrophils are known as..
segs because of the segmented shape of their nucleus
How does it work?
sensor warms underlying sking to increase arerial blood flow
The patient's level of consciousness, orientation to time, place, person, and situation is called _________.
sensorium
Restlessness, diaphoresis, and tachycardia also may indicate
severity of airway obstruction but must not be confused with bronchodilator overdose
During hypothermia, the hypothalamus initiates _________ and ______________ to conserve heat.
shivering, vasoconstriction
The inadequate delivery of oxygen and nutrients to the vital organs relative to their metabolic demand.
shock
What does sputum induction involve?
short-term application of high density hypertonic saline (3%-10%) aerosols to airway.
Cleaning of holding chambers and spacers
should be cleaned regularly, typically monthly, as recommended by the manufacturer. Use of dilute liquid dishwashing soap, with or without rinsing, and allowing to air dry are recommended.
how to minimize fire hazard via flammable material
should be removed from the vicinity of oxygen use
The Respimat soft mist inhaler (Boehringer, Ingelheim am Rhein, Germany) is a
small hand-held inhaler that uses mechanical energy to create an aerosol from liquid solutions to produce a low-velocity spray (10 mm/sec) that delivers a unit dose of drug in a single actuation. To operate the device, patients twist the body of the device to load an internal spring, place the mouthpiece of the Respimat between the lips, and press a button to release the drug through a uniblock to create spray, which is released over 1.1 to 1.4 seconds, depending on the formulation configuration. The Respimat device requires hand-breath coordination on the part of the patient, as does a pMDI, but because of the longer spray time, it seems more likely to get a greater percent of emitted dose despite coordination issues. Because of the small particle size and low-velocity spray, pulmonary deposition of 40% is independent of inspiratory flows with oral deposition (40%) half the oral dose used with most pMDIs and DPIs (80%). The Respimat is currently available with several drugs in Europe and is slated for introduction with tiotropium in the United States.54
What is a characteristic of automatic reservoir feed systems
small inlet can be attached to a gravity-fed intravenous type bag and the tubing allows refilling without interruption. Floatation valve controls can be used to maintain humidifier reservoir fluid volume.
most common devices used to administer aerosol therapy
small volume nebs, MDI, DPI,
SVN
small volume nebulizer
Hospital fires occur in patient care areas and are often related to
smoking
The introduction for a patient interview is done in the ________ space, approximately _______ feet from the patient.
social, 4 to 12
the most common electrolytes reported in the chemistry panel are
sodium potassium chloride total carbon dioxide
Propellant
something that propels or provides thrust, as the propellant in a metered dose inhaler
What are the 3 elements needed for infection to spread?
source, route & host
Oximetry is the measurement of blood hemoglobin saturation using what principal?
spectrophotometry
Booths or stations should be used for
sputum induction and aerosolized medication treatments given in any area where more than one patient is treated. The area should be designed to provide adequate airflow to draw aerosol and droplet nuclei from the patient into an appropriate filtration system or an exhaust system directly to the outside. Booths and stations should be adequately cleaned between patients
Noninvasive ventilation may be administered with
standard and bilevel ventilators. Bilevel ventilators often use a flow turbine, with a fixed valve or leak in the circuit that permits excess flow to vent to atmosphere. Placement of the aerosol generator between the leak and the patient's airway seems to provide the highest aerosol delivery efficiency.74 A VM nebulizer delivers a greater fine-particle dose than an SVN during noninvasive ventilation presumably because of the lower residual drug volume and lower total flow in the circuit.
Who sets minimum educational requirements and determine competence to practice?
state licensing laws
living will
states a patient's health care preferences in writing
Methods of equiptment sterilization
steam hydrogen peroxide gas plasma 100% EtO EtO mixtures peracetic acid
What is the most common, most effective and eaisest form of sterilization?
steam under pressure
What type of water should be placed in the nebulizer?
sterile distilled water. (Egan Pg 63)
pMDI steroid aerosol impaction occurs deep in the hypopharynx, which cannot be easily rinsed with gargling for this reason...
steroid pMDIs should not be used alone but always in combination with a spacer or valved holding chamber.
What factors affect a person's perception of breathing?
the neural drive to breath, the tension developed in the respiratory muscles, the corresponding displacement of the lungs and chest wall
Passive, or patient-driven, DPIs rely on
the patient's inspiratory effort to dispense the dose.
The basic chemistry panel (BCP) or basic metabolic panel includes
the predominant electrolytes sodium (Na+), potassium (K+), chloride (Cl−), and total carbon dioxide/bicarbonate (CO2) and glucose
A significantly elevated WBC count (>20 × 103/mcl) suggests..
the presence of a serious infection and that the patient's immune system is generating a significant response
The breakdown of carbohydrates results in..
the production of serum glucose, which is metabolized by the cells for energy
the AARC recommends that when monitoring trends,
the same unit be used for a given patient and that the patient's range be reestablished if a different flowmeter is used
to measure the PCO2, this blood gas analyzer is called?
the severinghaus electrode
Obligate transmission
under natural conditions, disease occurs after transmission of the microorganism through small particles aerosols
how do ultrasonic nebulizers work? (USNs)
uses piezoelectric crystal to produce aerosol. The crystal converts electrical energy into high frequency vibrations to produce aerosol. Output is directly affected by amplitude setting
gap acidosis
usually coincides with an anion gap of 16 mmol/L or greater
If bulk O2 gas supply systems go down what should you do?
utilize individual E cylinders for immediate use until system is functional. (facilities should have back up system in effect)
Causes of anemia
vitamin deficiency or iron, HIV/AIDS, chronic inflammatory diseases as Crohn disease, sickle cell anemia, and autoimmune diseases.
What is the purpose of the central piping system main alarm?
warns of pressure drops or interruptions in flow from source.
When a small fluid leak occurs at the point where pressure is applied.
weeping edema
What is inertial impaction?
when aerosol in motion collides with and are deposited onto a surface. The greater the mass and velocity of a moving droplet, the greater the inertia and tendency of that droplet to continue moving along its set path.
Cause of a severe bacterial infection
when bands and segs are elevated
Dysoxia is...
when cells are unable to adequately utilize oxygen (Histotoxic Hypoxia)
Continuous Drug Delivery
when nebulization occurs over extended periods this is the greatest effect.
A legitimate sputum sample is
when their are few epithelial cells and numerous pus cells.
Green colored sputum is a result of the death of what types of cells?
white blood cells
In terms of breath sounds, a decrease in wheezing accompanied by an overall decrease in the intensity of breath sounds indicates
worsening airway obstruction or patient fatigue. Improvement is indicated when wheezing decreases and the overall intensity of breath sounds increases.
indications for CBG of Neonates
• ABG analysis is indicated, but arterial access is not available • Noninvasive monitor readings are abnormal • Assessment of if initiation , administration, or change in therapy is indicated • A change in patients status is detected by history or physical assessment
What other LIMITATIONS?
• can't quantify degree of hypoxemia present • Hyperbilirubinemia does NOT affect accuracy of SpO2 readings
What does the modified Allen test test for?
• collateral circulation in the ulnar artery
How does Pulse Oximeter work (con't)?
• compares light absorption with red and infrared light to yeild %HbO2 • Accuracy within 3-5% of actual • the lower the SpO2, the less accurate • <70% = unreliable • signal extraction w/adaptive filter technology -> separates arterial signal from non-arterial noise
Negative-pressure "wrap" ventilator introduced
1950s
What does Lalim think about persnickety patients?
"They are Lame"
Communication has 5 basic components:
-Sender -Message -Channel -Receiver -Feedback
Priming
-Shaking the device and releasing one or more sprays into the air when the pMDI is new or has not been used for a while. -done to mix the drug and the propellant -required to provide an adequate dose.
Short-Acting Nooncatecholamine Agents
-Short Duration (4-6 hours)- results in loss of beonchodialating effect overnight. -Lack beta-2 specificty -replace with longer acting beta-2 specific agents -more suited for maintenance therapy -Can be taken 4 times daily
Indication for Short-Acting Agents (ex: albuterol & levalbuterol)
-Short-Acting beta-2 agonists are indicated for relief of acute reversible airflow obstruction in obstructive airway diseases. -These are termed rescue agents.
Bronchoactive Agents Distinguished as Controllers or Relievers in Treating Asthma, quick relief
-Short-acting inhaled beta-2 agonists: albuterol, levalbuterol -Anticholinergic (antimuscarinic): ipratropium -Systemic corticosteroids (oral burst therapy, IV
Technique for using a SVN
-Slow inspiratory flow optimizes SVN aerosol deposition. -deep breathing and breath holding during SVN therapy do little to enhance deposition over normal tidal breathing. -As long as the patient is mouth breathing, there is little difference in clinical response between therapy given by mouthpiece and therapy given by mask
Type of Recptors in the lung
-Sympathetic (adrenergic) -Parasympathetic (cholinergic)
During Treatment and Short-Term
-Teach and then verify correct use of aerosol nebulization system, including cleaning. -Assess therapy based on indication for drug: mucolysis and improved clearance of secretions. -Monitor airflow changes or adverse effects such as a decrease in FEV1. -Assess the patient's breathing pattern and rate. -Assess the patient's subjective reaction to treatment (changes in breathing effort or pattern). -Discontinue therapy if the patient experiences adverse reactions
Factors Affecting Pressurized Metered Dose Inhaler Performance & Drug Delivery
-Temperature - Nozzle Size and Cleanliness - Priming - Timing od Actuation Intervals
two general defenses against intentional torts
-The first defense is that there was a lack of intent to harm and that only clinicians who engage in intentional conduct are liable -The second defense is that the patient gave consent to the procedure. If the patient consented to the action, knowing the risks involved, the practitioner would not be liable. Consent by the patient for both nonroutine and routine procedures should be obtained before care is rendered
Adrenergic Bronchodialators
-The largest group of drugs among the aerosolized agent. -Used for Oral inhalation.
Gas density affects both aerosol generation and delivery to the lungs.
-The lower the density of a carrier gas, the less turbulent the flow (i.e., the lower the Reynolds number), resulting in less aerosol impaction. -The lower the density of a carrier gas, the less aerosol impaction occurs as gas passes through the airways, and the greater the deposition of aerosol in the lungs.
Indications of use for Adrenergic Bronchodilators
-The presence of reversible airflow obstruction. -The most common use of this is to imporve flow rates in asthma, acute bronchitis, emphysema, bronchiectasts, cystic fibrosis, and other obstructive airway states.
Aging
-The process by which an aerosol suspension changes over time.
An inhaled aerosol distributes:
-To the Lung: by inhalation -The Stomach: through swallowing os the drug that deposits in the oropharynx
Assessment of Drug Therapy
-Verify that the patient understands that a corticosteroid is a controller agent and is different from a rescue bronchodilator (relieving agent); assess the patient's understanding of the need for consistent use of an inhaled corticosteroid (compliance with therapy). -Instruct the patient in the use of a peak flowmeter to monitor baseline peak expiratory flow (PEF) and changes. Verify that there is a specific action plan, based on symptoms and PEF results. The patient should understand when to contact a physician with deterioration in PEF or exacerbation of symptoms
adverse effects of dornase alpha
-Voice alteration -Pharyngitis -Rash -Chest pain
positive-pressure breathing devices applied to patients (when?)
1950s
Venti mask to deliver specific FIO2 introduced (when?)
1960
rapid arterial blood gas (ABG) becomes available when?
1967
low pressure cuffs for endotracheal tubes introduced when?
1970s
What are the response times for galvanic fuel cells?
60 seconds
What is the PaO2 for mild hypoxemia?
60-80 mm Hg
blood urea nitrogen
7-20
Retractions seen between the ribs.
intercostal retractions
Spinal deformity in which the spine has an abnormal AP curvature.
kyphosis
axiology
the nature, types, and criteria of values
Preliminary assessment should balance
the need versus the risk of aerosol therapy
Causation in fact
the negligent act of the caregiver caused the damages
The American Medical Association Code of Ethics
"A physician may not reveal the confidences entrusted to him in the course of medical attendance or the deficiencies he may observe in the character of patients, unless he is required to do so by law or unless it becomes necessary in order to protect the welfare of the community or a vulnerable individual." Under the requirements of public health and community welfare, there is often a legal requirement to report such things as child abuse, poisonings, industrial accidents, communicable diseases, blood transfusion reactions, narcotic use, and injuries caused with knives or guns
AARC monthly science journal name
"AARC Times"
The Problem of Drug precipitation can jam breathing valves or occlude the ventilator circuit cn be overcome by:
(1) placing a one-way valve between the SPAG and the circuit and (2) filtering out the excess aerosol particles before they reach the exhalation valve, changing filters frequently to avoid increasing expiratory resistance.
The force behind law is twofold
(1) statutory punishment, ranging from reparations and fines to licensure suspension and incarceration; and (2) civil judgments for violations of duties that cause harm to others.
Formula for approximation for FiO2 (low flow device)
(4x L/m) +20
What are the two tests that together indicate renal function?
(BUN) Blood urea nitrogen and creatine
What is Motelukast Sodium?
(Brand Name: Singulair) an antileukotriene, aka a leukotriene (the bad guy) receptor antagonist.
Which electrolyte stimulates cystic fibrosis?
(Cl-) Choloride
What is Carboxyhemoglobin?
(HbCO) Hb binds CO (Carbon Monoxide) has 200x > affinity than O2. Results in Bound O2 not being able to unload (Left shift in HbO2 curve)
Formula for figuring out how much O2 is dissolved in the plasma
(Henry's Law) Dissolved O2(ml/dl)=PO2 x 0.003
Bands
(banded shape of the nucleus) immature neutrophils.
What is Dornase Alfa?
(brand name: Pulmozyme) A Proteolytic enzyme for management of cystic fibrosis by breaking down DNA material from neutrophils found in purulent secretions.
The first American medical code of ethics
(established in 1847) was as much concerned with separating orthodox practitioners from nontraditional ones as it was with regulating behavior. Even modern codes tend to be vague regarding what is prescribed and what is to be avoided.
Inpissated
(of a fluid) thickened or hardened through the absorption or evaporation of the liquid portion, as can occur with respiratory secretions when the upper airway is bypassed
Clinicans can avoid most preanalytical errors by?
* ensuring sample is obtained anaerobically (with immediate expulsion of air bubbles) * properly anti-coagulated * analyzed within 15 minutes
Excess anticoagualant in ABG sample?
* lowers PCO2 * raises pH * raises low PO2
What are medication delivery issues for infants and children?
** Smaller airway diameter ** faster breathing rate **Nose breathing filters out large particles **lower minute volumes **spontaneous patient cooperation
What are two common uses for CO2 mixtures?
**Calibration of blood gas analyzers **Diagnostic purposes in clinical laboratory
What does Extra-arterial (Ex Vivo) blood gas analysis provide?
**Eliminates all problems associated with indwelling sensors. **Provides quick results. **Determine further justification of costs and patient benefits.
What mechanisms make up a cylinder safety relief valve?
**Flangible metal disk ruptures at specific pressure **Fusible plug melts at specific temperature **Spring loaded valve opens and vents gas at set high pressure
What are three types of flowmeters?
**Flow Restrictor **Bourdon guage **Thorpe tube
What are factors affecting duration of flow
**Gas Flow **Cylinder size **Cylinder pressure at start of therapy
How does heliox decrease work of breathing?
**Has lower density **Makes gas flow more laminar
What is the mode of action for nonsteroidal antiasthma drugs?
**Intal Stabilizes mast cells in response to allergic and nonallergic stimuli **Singulair inhibits reactions induced by exercise, cold air and allergens by reducing bronchoconstriction and mucus secretion.
What affects MDI performance and drug delivery?
**Low temperature decreases output of CFC MDI's **Debris build up on nozzle or actuator orifice reduces emitted dose
What advantages do Passover devices have over bubble humidifiers?
**Maintains saturation at high flow rates **Adds little to no flow resistance to spontaneous breathing circuits
What is a therapeutic use of He/O2 mixtures (Heliox)
**Manages severe cases of airway obstruction **Decreases WOB
What can PtO2 monitors indicate?
**Monitor brain tissue oxygen as an early sign of ischemia. **Monitor adequacy of brain perfusion in patients with traumatic brain injury.
What's wrong with that freaking compensation?
**Poses risk to patient and caregivers **Can waste a lot of H2O **Can occlude gas flow through circuit **Can be aspirated
What are the benefits of indwelling catheters? (ie. A-Line)
**Provides ready access for blood sampling. **Allow continuous monitoring of vascular pressures.
In regards to accurate ABG results what are the components of quality control?
**Record keeping (policies and procedures) **Performance validation (testing new instrument) **Preventative maintenance and function checks **Automated calibration and verification **Internal statistical quality control **External quality control (proficiency testing) **Remedial action (to correct errors)
What purposes does 5-10% CO2 mixtures (Carbogen) serve?
**Singultus management **CO2 washout prevention during cardiopulmonary bypass **Regulate pulmonary vascular pressures in some congenital heart disorders
whats the difference between spacers and holding chambers
**Spacer: valve-less just adds distance from point of discharge to the mouth **Holding chamber: has valves for holding medication
What are purposes for administering humidification?
**To administer dry medical gases at flows >4L/min **To overcome a humidity deficit created when the upper airway is bypassed (ET intubation) **To manage hypothermia **To treat cold air bronchospasm
What treatments has the FDA approved the use of NO for?
**Treatment of infants with hypoxic respiratory failure **Pulmonary hypertension
Why is the radial artery the most often used site for ABG puncture?
**near surface **Collateral circulation usually exists **No large veins nearby **Radial puncture is RELATIVELY pain free
How are gas cylinders filled (Charged) with compressed gases
**normally filled to its service pressure at 70 degrees Fahrenheit **Can be filled to 10% in excess of service pressure
Health Care Infection Control Practices Advisory Committee (HICPAC)
*A federal committee *14 external infection control experts who provide advice and guidance to CDC & Secretary of the Dept of human services *health care infection control *strategies for surveillance, prevention, control of health care associated infections *in US health care facilities
what are some precautions or complications of an ABG draw?
*Arteriospasm *Hemorrhage *Air or clotted blood emboli *Trauma to the vessel *Anaphylaxis from local anesthetic *Arterial occlusion *Patient or sampler contamination *Vasovagal response *Hematoma *Pain
High-Efficient Particulate Air/Aerosol (HEPA) filters
*filtration device *capable of 99.99% efficacy on particulate matter down to 0.3mm
standard precaution
*guidelines set by CDC *to reduce he risk of transmission of blood borne and other pathogens in hospitals *guidelines apply to blood, body fluids, non-intact skin, & mucus membranes
hospital-acquired or nosocomial infections
*infection acquired at least 72 hours after hospitalization *most often occur in surgical patients chest/abdominal *often caused by Candida Albicans, Escherichia Coli, Hepatitis viruses, Herpes Zoster Virus, Pseudomonas or Staphylococcuss
what are some indications for trancutaneous monitoring?
*to continuously monitor the adequacy of arterial oxygenation and or ventilation *to quantify the real time responses to diagnostic and therapeutic interventions, as evidence by the PtCO2 or PtCO2
Inhaled Mass
- AKA inhaled dose - the amount of drug inhaled
ultrasonic nebulizer
- An electrically powered device that uses a piezoelectric crystal to generate aerosol - The crystal transducer converts radio waves into high-frequency mechanical vibrations that produce the aerosol. - Particle size is inversely proportional to signal frequency.
Heating systems
- Heat improves the water output of bubble and passover humidifiers. - Used primarily for patients with bypassed upper airways and for those receiving mechanical ventilation - Heating the inhaled gas can expose the patient to certain risks (e.g., airway burns).
The two agents approved in the United States for oral inhalation with an effect on mucus are?
- N-acetyl-cysteine (NAC) -dornase alfa *Both agents are mucolytic, although their modes of action differ
The most critical factor in using a passive DPI is the need for high inspiratory flow.
- Patients must generate an inspiratory flow rate of at least 40 to 60 L/min to produce a respirable powder aerosol.
By which of the following means can the internal energy of a substance be increased?
- Performing work on the substance - Heating the substance
large volume nebulizers (how do they work?)
- Pneumatically powered and connected directly to a flowmeter - Liquid particles are generated by passing gas at high velocity through a small jet orifice. - The low pressure at the jet draws fluid from the reservoir up the siphon tube - The water is then shattered into liquid particles. - The smaller particles leave the nebulizer through the outlet port in the gas stream.
Condensation
- Poses risks to patient and caregivers - Can waste a lot of water - Can occlude gas flow through the circuit - Can be aspirated - Problem can be minimized with use of water traps and heated circuits.
Ambulation should begin
-As soon as the patient is stable and free from severe pain
Valved holding chambers
- protect the patient from poor hand-breath coordination, with exhaled gas venting to the atmosphere, allowing aerosol to remain in the chamber available to be inhaled with the next breath. -allow infants, small children, and adults who cannot control their breathing pattern to be treated effectively with pMDIs.
Negligence
- the failure to perform one's duties competently -may involve acts of commission or omission
Which of the following is/are TRUE of liquids?
- they are hard to compress - they exert pressure - they exert buoyant force - they conform to their containers
Dry Powder Inhaler (DPI)
- typically a breath-actuated dosing system. - patient creates the aerosol by drawing air though a dose of finely milled drug powder with sufficient force to disperse and suspend the powder in the air. - dispersion of the powder into respirable particles depends on the creation of turbulent flow in the inhaler. Turbulent flow is a function of the ability of the patient to inhale the powder with a sufficiently high inspiratory flow rate
Hazards of aerosol drug therapy
-(PRIMARY HAZARD) adverse reaction to the medication being adminitered. -infection -airway reactivity -systemic effects of bland aerosols -drug concentration -eye irritation.
Levalbuterol is available as nebulixation solution in 3 strengths:
-0.31 mg/ 3 ml - .63 mg/ 3 ml -1.25 mg/3ml
Spaulding Approach to Disinfection
-1968 -published an approach to disinfect and sterilize - based on the degree of risk
Anticholinergic Bronchodilators
-2nd method of producing airway relaxation - Effective only if bronchoconstriction exists secondary to cholinergic activity.
Equipment
-A humidifier is a device that adds molecular water to gas. -This occurs by evaporation of water from a surface.
sputum sample
-A patient who is suspected to have an infection in the lungs or airways -The purpose of such an analysis is to determine the specific microorganism causing the infection, which indicates the most appropriate antibiotic to be given
Spacer
-A spacer is a simple valveless extension device that adds distance between the pMDI outlet and the patient's mouth. -This distance allows the aerosol plume to expand and the propellants to evaporate before the medication reaches the oropharynx.
AeroEclipse
-A unique, spring-loaded, one-way valve design draws the jet to the capillary tube during inspiration and causes nebulization to cease when the patient's inspiratory flow decreases below the threshold or the patient exhales into the device. -Expiratory pressure on the valve at the initiation of exhalation moves the nebulizer baffle away from its position directly above the jet orifice, reduces the pressure, and stops aerosolization
Indications for humidification and warming of inspired gases
-Administration of dry medical gases at flows greater than 4 L/min. -Following intubation of the patient -Managing hypothermia -Treating bronchospasm caused by cold air
Potential Hazards and Side Effects of Aerosolized Corticosteroids are?
-Adrenal insufficiency -Extrapulmonary allergy -Acute asthma -HPA suppression (minimal, dose-dependent) -Growth retardation† -Osteoporosis
Agonists & Antagonists that act on receptors are given classificaitons:
-Adrenergic -Antiadrenergic -Cholinergic -Anticholinergic - Muscarinic
adverse effects of NAC
-Airway obstruction due to rapid liquefaction of secretions -Disagreeable odor due to hydrogen sulfide -Increased concentration & toxicity of nebulizer solution toward end of treatment -Nausea & rhinorrhea -Stomatitis -Reactivity of acetylcysteine with rubber, copper, iron, & cork
Other side effects that can occur include the following
-Airway obstruction secondary to rapid liquefaction of secretions -Disagreeable odor secondary to hydrogen sulfide -Incompatibility with certain antibiotics (sodium ampicillin, amphotericin B, erythromycin, tetracyclines, and aminoglycosides) if mixed in solution -Increased concentration and toxicity of nebulizer solution toward end of treatment -Nausea and rhinorrhea -Stomatitis -Reactivity of acetylcysteine with rubber, copper, iron, and cork"
polycythemia
-An abnormally elevated RBC count - It occurs most often when the bone marrow is stimulated to produce extra RBCs in response to chronically low blood oxygen levels
hypoglycemia
-An abnormally reduced serum glucose level -may be drug-induced or associated with digestive problems, inadequate dietary intake of carbohydrates, or overtreatment of diabetes with insulin
Adrenergic Bronchodialators can Stimulate one or more of the following receptors.
-Aplha-Receptor Stimulaiton -Beta-1-Receptor Stimulation -Beta-2-receptor stimulation
Assesment of long term drug therapy
-Assess severity of symptoms (coughing, wheezing, nocturnal awakenings, symptoms during exertion; use of rescue bronchodilator; number of exacerbations; missed work or school days; and pulmonary function), and modify level or dosage as recommended by NAEPP and GOLD guidelines -Assess for the presence of side effects with inhaled steroid therapy (oral thrush, hoarseness or voice changes, cough or wheezing with MDI use); use a reservoir (preferably a holding chamber) with MDI use, and verify correct technique
advantages of aerosol drugs
-Can use smaller doses as compared to the systemic route -Onset of drug is rapid -Delivery is to the specific organ needing treatment -Less systemic side effects
Sender
-Communication skills -Attitudes -Experience -Culture -Self-concept
Receiver
-Communication skills -Attitudes -Experience -Culture -Self-concepts
Professional Characteristics of a Respiratory Therapist
-Completes an accredited respiratory therapy program -Obtains professional credentials -Participates in continuing education activities -Adheres to the code of ethics put forth by his or her institution and/or state licensing board -Joins professional organizations
Pharmacokinetic Phase
-Describes the time course & disposition of a drug in the body based on it's: *Absorption *Distribution *Metabolism * Elimination.
Mydriasis
-Dialation of the pupils
long term
-Discontinue therapy if the patient experiences adverse reactions. -Monitor number and severity of respiratory tract infections and need for antibiotic therapy, emergency visits, and hospitalizations. -Monitor pulmonary function for improvement or slowing in the rate of deterioration
Potential Adverse Effects with the use of Adrenergic Bronchodialators include:
-Diziness -Hypokalemia -Loss of Bronchoprotection -Nausea -Tolerance (tachyphylaxis) -Worsening ventilation/perfusion ratio
Message
-Elements -Structure -Content -Treatment
Ultra-Short-Acting Adrenergic Bronchodialator Agents
-Epinephrine - Racemic Epinephrine
FCA
-False Claims Act -forbids making false claims against the government and provides for severe sanctions for people who do
Which of the following statements correctly describe(s) gases?
-Gases exhibit the phenomenon of flow - Molecular forces of attraction are minimal - Gases are easily compressible - Gases expand to fill their container
What effect does Body Temp(T) have on the HbO2 curve?
-HIGH T shifts curve to the LEFT (LOWER metabolic demands not requiring much O2) -LOW T shifts curve to the RIGHT (facilitates more O2 unloading to meet HIGHER metabolic demands)
Physiologic control of heat-moisture exchange
-Heat-moisture exchange is the primary role of the upper airway. -The nose is an effective humidifier/heater. -The mouth is less effective. -An artificial airway puts stress on the lower airway to provide heat and moisture.
Break down of HbO2 curve shifts:
-LEFT/Alkaline is for LESS (except when dealing with pH/O2:levels increase) for example in near drowning victims. -RIGHT/Acidic is for MORE (except when dealing with pH/O2:levels decrease) for example in COPD patients **LESS/MORE Values= Temperature & 2,3-DPG
Timing of Actuation Intervals
-Manufacturers recommended 30 sec to 1 min between actuations. -Very rapid acutation of multiple puffs per breath reduces inhaled drug per puff
NLRA
-National Labor Relations Act -NLRA provides protections to hospital workers whether they are organized into a union or not. Specifically, the NLRA provides for protection where a worker engages in actions for the benefit of all employees
adverse effects of adrenergic bronchodilators
-Older adrenergic agents such as isoproterenol commonly caused tachycardia, palpitations, and nervousness. -Newer beta 2-selective agents are safe, with tremor as the primary side effect. -Dizziness, hypokalemia, loss of bronchoprotection, nausea, & tolerance to drug may occur
Disease Management
-Organized strategy of delivering care to large groups of individuals with chronic disease to improve outcomes and reduce cost -Programs maybe developed for patients with asthma, diabetes, chronic obstructive pulmonary disease (COPD), or congestive heart failure (CHF)
P.A.S.S. - fire extinguisher training
-P, pull pin -A, aim nozzle -S, squeeze nozzle -S, sweep nozzle across base of fire
Atropine
-Poorly ionized & diffuses well. -Produces systematic side effects such as mydriasis and blurring of vision.
Internal Factors Influencing Communication
-Previous experiences -Attitudes, values -Culture heritage -Religious beliefs -Self-concept -Listening habits -Preoccupation, feeling
Respiratory Care Protocols
-Put in place to enhance appropriate allocation of respiratory care services -Represent guidelines to deliver care only when indicated, by correct method; discontinued when no longer needed
R.A.C.E - core fire plan
-R, rescue patients in immediate area -A, alert other personnel to fire -C, contain the fire; shut doors to prevent spreading of fire -E, evacuate other patients and personnel
Medical Supervision
-RTs are required by their scope of practice to work under competent medical supervision -This requirement creates not only a professional relationship but also a legal one - If the RT is employed by the physician, the physician is liable for the RT's actions. If the RT is employed by the hospital, the hospital is liable for the RT's actions
Credentialing in Respiratory Care
-RTs must graduate from a CoARC approved educational program -Graduates can then sit for certification and registry exams offered by NBRC
Beta-2-Receptor Stimulation
-Relaxes bronchial smooth muscle - Stimulates mucocilary activity -has some inhibitory action on inflammatory mediator release.
Long-Acting Adrenergic Bronchodialtor Agents
-Salmeterol -Formoterol -Arformoterol
Channel
-Seeing -Hearing -Touching -Smelling -Tasting
The mucus macromolecule consists of?
-a polypeptide (protein) chain of amino acids, to which carbohydrate side chains are attached -There is internal cross-linking between strands with disulfide (-S-S-) bonds and hydrogen bonds
Another special-purpose large volume nebulizer
-a small particle aerosol generator (SPAG) - The SPAG was manufactured by ICN Pharmaceuticals specifically for administration of ribavirin (Virazole) to infants with respiratory syncytial virus infection. -incorporates a drying chamber with its own flow control to produce a stable aerosol.
Adrenergics and antiadrenergics effects what receptors?
-adrenergic stimulates norapinephrine or epinephrine -antiadrenergic blocks norapinephrine or epinephrine
Breath-Actuated Nebulizers
-aerosol device that is responsive to the patient's inspiratory effort and reduces or eliminates aerosol generation during exhalation -generate aerosol only during inspiration. -eliminates waste of aerosol during exhalation and increases the delivered dose threefold or more over continuous and breath-enhanced nebulizers.
Key characteristics of aerosols
-aerosol output -particle size -desposition -aging
Large volume nebulizers
-also known as jet nebulizers, -hold up to 200 ml and may be used for either bland aerosol therapy or continuous drug administration.
Spacers and Valved holding Chambers
-are pMDI accessory devices designed to reduce both oropharyngeal deposition and the need for hand-breath coordination. -all spacers add distance between the pMDI and the mouth, reducing the initial forward velocity of the pMDI droplets. -reduces foul taste.
Medical Aerosols are generated with
-atomizers -nebulizers -inhalers (all are items that disperse matter into small particles & suspend them into a gas)
Providing Feedback
-attending; involves use of gestures and confirming remarks -paraphrasing; repeating others' response in one's own words -requesting clarification; should be nonjudgmental in nature -perception checking; done by confirming or disproving more subtle components of communication interaction -reflecting feeling, provide opportunity for patients to express and reflect on their emotions
With all aerosol drug therpay:
-basic vital signs should be assessed before and after treatment. -Patient's subjective reaction should be monitored. -Patient's should be instructed on the correct use of aerosol devices and correct use should be verified.
Through preliminary patient instuction
-can last 10-30 min -should include: - demonstration - Practice - Confirmation of patient performance
2 most common laboratory methods used to measure medical aerosol particle size distribution are:
-cascade impaction - laser diffraction
cholinergics and anticholinergics effect what receptors?
-cholinergic stimulate acetylcholine -anticholinergic block acetylcholine
5 basic strategies for handling conflict
-competing -accommodation -avoiding -collaborating -compromising
How aerosol ages depends on:
-composition of the aerosol -initial size of its particles -time in suspension -the ambient conditions to which it is exposed.
Nonsteroidal antiinflammatory drugs
-constitute a growing class of drugs in the treatment of asthma -These include mast cell stabilizers
common functions of computer applications in research
-data sources -data collection -statistical testing -displaying study results -managing citations and references -managing ethical considerations
Reference ranges vary from laboratory to laboratory for various reasons..
-differences in measurement techniques -the populations of healthy individuals used to establish the reference intervals -analytic imprecision when the intervals were constructed
Adrenergic Bronchodialator agents:
-diffetences in these agents determine the optimal clinical application of individual agents. -Form 3 subgroups: 1. Ultra-Short-Acting Catecholamines 2. Short-Acting Noncatechloamine Agents 3. Long- Acting Adrenergic Bronchodialators
Prevention bundle: Ventilator-associated pneumonia bundle
-elevate the head of the bed -daily sedation vacation -prevent peptic ulcer disease prophylaxis -deep venous thrombosis prophylaxis -daily oral care with chrolhexidine
Aersol particle can change size as a result of
-evaporation or -hygroscopic water absorption.
procedures to help reduce contamination and infection associated with respiratory care equipment
-nebulizers should be sterilized between patients -nebulizers should frequently be replaced with disinfected or sterile units or rinsed with sterile water (not tap water) and ait dried every 24 hours.
Humidity and temperature can affect particle size and the concentration of drug remaining in the nebulizer.
-evaporation of water and adiabatic expansion of gas can reduce the temperature of the aerosol to 10° C less than ambient temperature. -This cooling may increase solution viscosity and reduce the nebulizer output, while decreasing particle MMAD.40 -Aerosol particles entrained into a warm and fully saturated gas stream increase in size.
Diabetes is diagnosed by measuring..
-fasting blood glucose level -A blood glucose level greater than 140 mg/dl on two occasions usually indicates diabetes
3 Conditions must exist for fire to start
-flammable material must be present -oxygen must be present -flammable material must be heated above its ignition temperature
Aerocount Autohaler
-flow triggered pMDI designed to eliminate the need for hand-breath coordination by automatically triggering in response to the patient's inspiratory effort.24 To use the Autohaler, the patient cocks a lever on the top of the unit, which sets in motion a downward spring force. Using the closed-mouth technique, the patient draws through the mouthpiece. When the patient's flow rate exceeds 30 L/min, a vane releases the spring, which forces the canister down and triggers the pMDI. In the United States, the Autohaler is available only with pirbuterol, a bronchodilator similar to albuterol.
droplet transmission
-form of contact transmission -transmission occurs when infectious droplets are propelled and deposed on another person -usually less than 3 feet through the air examples are: sneezes and cough
confidentiality
-founded in the Hippocratic Oath; it was later reiterated by the World Medical Association in 1949 -It obliges health care providers to "respect the secrets which are confided even after the patient has died." Confidentiality, as with the other axioms of ethics, must often be balanced against other principles, such as beneficence -Patient information should be discussed only in private and with persons who have a legitimate reason and need to know.
Direct patient environment should be:
-free of impediments to care; beware of anything creating direct fall risk -RT's responsibility to position equipment: tubing and treatments out of way of potential risk
Ipratropium
-fully ionized quarternary ammonium compound - diffuses poorly across lipid membranes
Prevention bundles: Central Line Bundle Practices
-hand hygiene before line insertion - use max sterile barrier precaution during line placement -Chlorhexidine-based skin antisepsis at insertion site -daily review of line necessity
2 hand hygiene options and when to use
-hand washing with plain antiseptic-containing soap with water for at least 15 seconds -alcohol-based products-gels/foams use: before and after all patients, contact with body fluids
virtue ethics
-has evolved based in part on the limits of both formalism and consequentialism -founded not in rules or consequences but in personal attributes of character or virtue
Common Side Effects With inhaled agents:
-headache -insomnia -nervousness
Most modern jet nebulizers are powered by
-high-pressure air or oxygen (O2) provided by a portable compressor -compressed gas cylinder, - 50-psi wall outlet.
Indication for Long-Acting Agents (ex: salmeterol, formoterol, & arformoterol)
-indicated for maintenance bronchodialation & control of bronchospasm & nocturnal symtoms in obstructive pulmonary disease.
Key Mechanisms of aerosol desposition include:
-inertial impaction -gavimetric sedimentation -Brownian Diffusion
assault
-intentional act that places another person in fear of immediate bodily -Threatening to injure someone is considered an act of assault
atropine sulfate
-is a tertiary ammonium compound that is easily absorbed into the bloodstream -atropine produces many systemic side effects when inhaled
Procalcitonin (PCT)
-is an inactive protein of the hormone calcitonin that is released in response to bacterial infections -PCT levels are directly related with the severity of infection
ipratropium
-is not contraindicated in subjects with prostatic hypertrophy, urinary retention, or glaucoma -the drug should be used with precaution and adequate evaluation for possible systemic side effects in these subjects
The hematocrit level
-is the ratio of RBC volume to whole blood - It is determined by spinning a blood sample in a centrifuge to separate the blood cells from the plasm
Oxygen is not flammable, but:
-it can greatly accelerate rate of combustion
Poor Communication can:
-limit your ability to treat patients -work well with others -find satisfaction in your employment
core functions of EHRs
-medical records -results recording -computerized physician order entry -clinical decision support -electronic communication -channels between health care providers and patients -patient-entered data
name antileukotrienes (3)
-montelukast (Singulair) -zafirlukast (Accolate) -zieuton (Zyflo)
Breach of contract
-much rarer malpractice claim than negligence -This claim is based on the theory that when a health care professional renders care, an implicit or explicit professional-patient "contract" is established
Optimal Technique for Aerosolized Drug Delivery to Mechanically Ventilated Patients
1 Review order, identify the patient, gather equipment, and assess the need for bronchodilators. 2 Clear the airways as needed, by suctioning the patient as needed. 3 If using a circuit with heat and moisture exchanger (HME), remove HME from between the aerosol generator and the patient. 4 If using heated humidifier, do not turn off or disconnect before or during treatment. 5 Assemble equipment (tubing, nebulizer, circuit adapter). 6 Fill the nebulizer with recommended volume and medication per physician order and label. 7 Place adapter in the inspiratory limb, 6 inches from the "wye," and connect aerosol generator. 8 Turn off or minimize bias flow during treatment. 9 Connect the nebulizer to a gas or power source, as appropriate. 10a For jet nebulizer (including SVN): Use gas source on ventilator to synchronize nebulization with inspiration, if available; otherwise, set gas flow 2 to 10 L/min as recommended on nebulizer label, and adjust ventilator volume or pressure limit and alarms to compensate for added flow and volume. 10b For USN and VM nebulizer: Attach power source and cable from controller. 10c For pMDI: Shake canister and connect to spacer or adapter; actuate at beginning of inspiration. 11 Observe aerosol cloud for adequate aerosol generation during nebulization. 12 After appropriate dose is administered, remove aerosol generator from the ventilator circuit. 13 Reconnect HME, as appropriate. 14 Return ventilator settings and alarms to previous values. 15 Ensure there is no leak in the ventilator circuit. 16 Rinse the nebulizer with sterile or distilled water, shake off excess water, and allow to air dry. 17 Store aerosol device in a clean, dry place. 18 Monitor heart rate, SpO2, blood pressure, and patient-ventilator synchronization. 19 Monitor the patient for adverse response. 20 Assess the airway, and suction as needed; document findings.
Conversion Solution for drug dosage
1 ml of a 1% solution= 10mg
three classifications of malpractice
1) Criminal malpractice includes crimes such as assault and battery or euthanasia (handled in criminal court). 2) Civil malpractice includes negligence or practice below a reasonable standard (handled in civil court). 3) Ethical malpractice includes violations of professional ethics and may result in censure or disciplinary actions by licensure boards
What are 2 acute conditions for which HBO would be administered by the RT?
1. Air embolism 2. Carbon Monoxide Poisoning (>1-2%)
Three types of bulk O2-Gas supply systems are?
1. Alternating supply system (cylinder manifold system) 2. Cylinder supply system with reserve supply 3. Bulk gas system with reserve
Briefly discuss disease management and include the four essential components.
1. An integrated health care system that can provide coordinated care across the full range of patients'' needs 2. A comprehensive knowledge base regarding the prevention, diagnosis, and treatment of disease that guides the plan of care 3. Sophisticated clinical and administrative information systems that can help assess patterns of clinical practice 4. A commitment to continuous quality improvement
What are 3 examples of aerosol devices?
1. Atomizers 2. Nebulizers 3. Inhalers
What contributes to aging of aerosols?
1. Composition of aerosol 2. Initial size of particles 3. time in suspension 4. Ambient condition
What are three goals of O2 Therapy
1. Correct documented or suspected acute Hypoxemia 2. Decrease symptoms associated with chronic hypoxemia 3. Decrease workload hypoxemia imposes on cardiopulmonary system
What are three drawbacks to bland aerosol therapy?
1. Cross-contamination/infection 2. Environmental exposure 3. Inadequate mist production
The Courses of Drug Action from does to effect has 3 phases:
1. Drug Administration 2. Pharmacokinetic 3. Pharmacydynamic
List the 11 general rules for medical documentation.
1. Entries should be printed or handwritten. 2. Do not use ditto marks. 3. Do not erase. 4. Record each patient interaction and sign the entry. 5. Document patient complaints. 6. Do not leave blank lines in the chart. 7. Use standard abbreviations only. 8. Use the present tense. 9. Use proper spelling. 10. Document all important conversations. 11. Be accurate.
What are two techniques of capnometry?
1. Mainstream technique places an analysis chamber in patients breathing circuit. 2. Sidestream technique pumps small volume of gas from circuit into nearby analyzer.
What are 3 common devices used to administer inhaled aerosols.
1. Metered-dose inhaler (MDI) 2. small-volume nebulizer (SVN) 3. dry-powder inhaler (DPI)
Which patients would benefit from Nitric Oxide Therapy?
1. Patients with pulmonary hypertension **PRIMARY USE** 2. ARDS & COPD patients **Possible secondary use**
What are three types of O2 delivery masks
1. Simple Mask 2. Partial Rebreathing mask 3. Non Rebreathing mask
What are two types of Passover devices?
1. Simple reservoir type 2. Wick type: has an absorbent material that increases the surface area for dry air to interface with heated water.
Evidence-Based Medicine
1. Single case studies 2. Case series 3. Cohort studies (comparing two groups) 4. Randomized controlled trials (idea, most rigorous evidence)
Basic Concepts for spacer devices include:
1. Small volume adapters 2. Open Tube Designs 3. Bag reservoirs 4. Valved holding chambers.
What are 3 factors that determine particle size?
1. Substance being nebulized 2. Method used 3. Environmental conditions
What are the three airway receptors and neurotransmitters of the lung?
1. Sympathetic (adrenergic) and parasympathetic (cholinergic) receptors are in the lungs. 2. Norepinephrine (epinephrine) is the neurotransmitter in the sympathetic system 3. Acetylcholine is the neurotransmitter in the parasympathetic system
Disadvantages of the delivery of inhaled aerosols in treating Respiratory Disease
1. The # of variables affecting dose 2. Lack of adequate knowledge of device performance & use among patients and Caregivers
What four conditions must be met before the tort of negligence is considered a valid claim?
1. The practitioner owes a duty to the patient 2. The practitioner breaches that duty 3. The breach of duty was the cause of damages 4. Damage or harm came to the patient
What are 3 subgroups of Adrenergic Bronchodilators?
1. Ultra-short catecholamine agents 2. Short-acting non-catecholamine agents 3. Long-acting adrenergic bronchodilators
Why would you use racemic epinephrine?
1. to reduce airway swelling after extubation or with acute upper airway inflammation from croup, epiglottis, or bronchiolitis. 2. to control airway bleeding during endoscopy
Optimal Technique for Using a SVN 1-5
1.Assess the patient for need (clinical signs and symptoms, breath sounds, peak flow, %FEV1) 2.Select mask or mouthpiece delivery (nose clips may be needed with mouthpiece). 3.Use conserving system (thumb port, breath actuator or reservoir) if indicated. 4.Place drug in the nebulizer. If using a multidose vial, add saline to approved dose volume (per drug label). 5.Set gas flow to nebulizer at 6 to 10 L/min (per manufacturer label).
Optimal Technique for use of MDI steps 1-5
1.Warm the pMDI canister to hand or body temperature, and shake it vigorously. 2.Before first use of a new pMDI and when the pMDI has not been used for several days, prime the pMDI by pointing it into the air (away from people) and actuating. 3.Assemble the apparatus and uncap the mouthpiece, ensuring there are no loose objects in the device. 4. Open mouth technique*: Open your mouth wide, keeping tongue down. Hold the pMDI with the canister oriented downward and the outlet aimed at your mouth. Position the pMDI approximately 4 cm (two fingerbreadths) away from your mouth. 5.Closed mouth technique†: Place mouthpiece between lips, with tongue out of the path of the outlet.
Optimal Technique for Use of Metered Dose Inhaler With A Valved Holding Chamber
1.Warm the pMDI to hand or body temperature. 2.Assemble the apparatus, ensuring there are no objects or coins in the chamber that could be aspirated or obstruct outflow. 3.Hold the canister vertically, and shake it vigorously. Prime if necessary. 4.Place the pMDI in the holding chamber inlet, position chamber outlet in the mouth (or place the mask over nose and mouth), and encourage the patient to breathe through the mouth. Visually inspect for proper valve function. 5.With normal breathing, actuate the pMDI once and have the patient breathe through the device for three to seven breaths (three breaths for adults and seven breaths for infants).* 6.Allow 30 to 60 seconds between actuations.
How many specialty sections in AARC?
10
What are the response times for Clark electrodes?
10 - 30 seconds
Aerosol administration by a VM nebulizer has been estimated to deliver greater than
10% deposition in adults and infants without the addition of gas into the ventilator circuit. The low residual drug volume and small particle size are associated with higher efficiency. Similar to the USN, the VM nebulizer does not add gas flow into the ventilator circuit, so ventilator parameters and alarms do not need to be adjusted before, during, or after nebulization. In contrast to jet SVNs and USNs, the medication reservoir of the VM nebulizer is above the circuit and separated from the ventilator tubing by the mesh, reducing the risk of retrograde contamination of medication in the reservoir from the ventilator circuit. Because of the nature of the mesh, the reservoir can be opened and medication can be added to the nebulizer without creating a perceptible leak during ventilation.
The normal resting adult rate of breathing is ____ to ____ breaths/min.
12, 18
What is the normal range of hemoglobin in a healthy adult?
12-17 g/dl
What is the minimum recommended time for hand washing in the health care environment?
15 seconds
Hand hygiene includes both handwashing with either plain or antiseptic-containing soap and water for at least how many seconds?
15 seconds. (Egan Pg 70)
platelet count
150,000- 400.000
O2 therapy widely prescibed (when?)
1940s
technicians hauled O2 cylinders and apply 02 delivery devices (when?)
1940s
Jack Emersons develops improved version of iron lung used for polio victims (when?)
1940s-1950s
ITA founded when?
1941
Patients in the emergency department with severe exacerbation of asthma or acute bronchospasm often have been taking standard doses of their bronchodilators for
24 to 36 hours before admission without response. Giving nebulizer treatments with standard bronchodilator doses and repeating the treatments until the symptoms are relieved can require hours of staff time. Administering higher doses of albuterol in short time frames can be accomplished by nebulization of undiluted albuterol (8 to 20 breaths) or by protocol titration with a pMDI and holding chamber (up to 12 puffs).
In healthy individuals PetCO2 averages
3 to 5 mm Hg less than PaCO2, or 35 to 43 mm Hg (approximately 5% to 6% CO2)
After CBT is started, the patient is carefully assessed every
30 minutes for the first 2 hours and thereafter every hour. A positive response is indicated by an increase in PEFR of at least 10% after the first hour of therapy. The goal is at least 50% of the predicted value. For small children, improved oxygenation (oxygen saturation by pulse oximeter [SpO2] >92% on room air) with evidence of decreased work of breathing indicates a favorable response. Once the patient "opens up," intermittent SVN administration is resumed, or a pMDI dose-response assessment is conducted.
What is added by using an HME?
30-90 mL of dead space
Massive hemoptysis is when more than _____ mL of blood is expectorated within 24 hours.
300
red blood cell count for women
4.2 - 5.4 X 10^ 6
red blood cell count for men
4.6 - 6.2 X 10^ 6
A value less than __ is considered unlikely to confirm the diagnosis
40
Normal O2 pressure in vein
40 mm Hg (100 mm Hg after passing Alveolus [Arterial])
hematocrit men
40% - 54%
segmented neutrophile
40% - 75% absolute value of 1800 7500
What is the relative value of Neutrophils?
40%-75%
This range is considered borderline cystic fibrosis
40-60
Patients with healthy lungs achieve a steady state in how long?
5 minutes
What are the size of droplet nuclei?
5 μm or less. (Egan Pg 56)
The vibration created by percussion penetrates the lung to a depth of ___ to ___ cm below the chest wall.
5, 7
What percentage mixture of CO2 has therapeutic purposes?
5-10% CO2/O2 mixtures
How are gas cylinders pressurized to?
5/3 of their service pressure (PSIG)
What is a pressure compensated Thorpe Tube calibrated to?
50 PSIG instead of Atmospheric pressure **IMPORTANT**
Optimal Technique for use of MDI steps 6-11
6.Breathe out normally. 7.As you slowly begin to breathe in (<0.5 L/sec), actuate the pMDI. 8.Continue inspiration to total lung capacity. 9.Hold your breath for up to 10 seconds. Then relax and breathe normally. 10.Wait 1 minute between puffs. 11.Disassemble the apparatus, and recap the mouthpiece.
Optimal Technique for Using a SVN 6-10
6.Coach patient to breathe slowly through the mouth at normal VT. 7.Continue treatment until nebulizer begins to sputter. 8.Rinse the nebulizer with sterile water and air dry, or discard, between treatments. 9.Monitor patient for adverse response. 10.Assess outcome (change in peak flow, %FEV1).
chilled samples of ABG should be discarded after how many minutes?
60 minutes
Abnormal elevated sweat CL levels are greater than?
60 mmol/L
Quality
A characteristic reflecting a high degree of excellence, fineness, or grade
What are drug effects caused by?
A combination of drugs with matching receptors
What is a CRITICAL TEST VALUE?
A result significantly outside the reference range and represents a pathophysiologic condition
What does a Humid-Heat consist of mechanically?
A supply unit with microprocessor, water pump and humidification device
Aerosol
A suspension of a solid or liquid particles in gas
Two types of VM nebulizers, active and passive, are available commercially.
Active VM nebulizers use a dome-shaped aperture plate, containing more than 1000 funnel-shaped apertures. This dome is attached to a plate that is also attached to a piezoceramic element that surrounds the aperture plate. Electricity applied to the piezoceramic element causes the aperture plate to be vibrated at a frequency of approximately 130 kHz (or one-tenth that of a USN), moving the aperture plate up and down by 1 µm or 2 µm, creating an electronic micropump. The plate actively pumps the liquid through the apertures, where it is broken into fine droplets. The exit velocity of the aerosol is low (<4 m/sec), and the particle size can range from 2 to 3 µm (MMAD), varying with the exit diameter of the apertures (Figure 36-26). Examples of an active VM nebulizer include the Aeroneb Go, Pro, and Solo nebulizers (Aerogen, Inc, Galway, Ireland) and the eFlow (Pari, Midlothian, VA). An active VM nebulizer can provide nebulization with single drops 15 mcl of formulations containing small and large molecules, suspensions, microsuspensions, and liposomes. Passive VM nebulizers use a mesh separated from an ultrasonic horn by the liquid for nebulization. A piezoelectric transducer vibrates the ultrasonic horn, which pushes fluid through the mesh. Passive VM nebulizers include the NEU-22 (Omron, Kyoto, Japan) and the I-Neb (Philips Respironics, Murraysville, PA).
What kind of injury comes with BUN (Blood urea nitrogen)
Acute kidney injury
Inhalation Route
Administering Drugs Directly yo the Respiratory tract
Information about a pt's nearest kin, physician and initial diagnosis can be found in which section of the medical record?
Admission sheet
What is the most common route for a drug administered to a pulmonary patient?
Aerosol (MDI: meter-dose inhaler)
What does Gravimetric analysis measure?
Aerosol weight
Monodisperse
Aerosols consisting of particles of similar size (GSD less than or equal to 1.2)
What is the difference in side effects between inhaled aerosols and systemic administered drugs?
Aerosols have less systemic side effects
Licensure Statute
All RTs should know in detail the requirements of their Respiratory Care Practice Act. They should know what is expected of them in terms of obtaining licensure and in the requirements to remain licensed
Which of the following is NOT true about fires in oxygen-enriched atmospheres?
All of the above are true: - they are more difficult to put out - they burn more quickly - they burn more intensely
Which of the following diseases is transmitted primarily by airborne transmission?
All of the above- Tuberculosis, Measles, and Smallpox
Which of the following parameters should be monitored during ambulation?
All of the above: - Skin color - Breathing rate and effort - Level of consciousness
Which of the following is a method for communicating empathy to your patients?
All of the above: - Use of touch - Use of key words - Use of eye contact
PH2O
Alveolar Water Vapor Pressure (47 Torr @ 100% RH)
What is Hb measurements expressed as and what is its O2 capacity when compared to what is dissolved in plasma
Always expressed in grams/dl. dl=100 ml. The O2 capacity of Hb is 7x greater than what is dissolved in plasma.
Choosing an Aerosol Agent
An aerosol agent to treat the respiratory tract is chosen based on the indication for the agent or class of drugs and a corresponding presence of the indication in the patient.
What is Mucomyst for?
An agent for mucus control
What is Ribavirin?
An antiviral agent used in the treatment of severe lower respiratory tract infections caused by respiratory syncytial virus (RSV)
What is a Heat-Moisture Exchanger (HME)?
An often passive humidifier that is also known as an artificial nose that does not add heat or water to system. It also captures exhaled heat and moisture, which is then applied to subsequent inhalation
What is N2O clinically used for?
Anesthetic agent
Which of the following organisms is NOT destroyed by a disinfection agent?
Bacterial spores
The guiding principle of homeostasis is that the total amount of water, electrolytes, acid, and base gained each day must be?
Balanced by the total amount lost
immature neutrophils are known as what due to the banded shape of the nucleus?
Bands
Immature neutrophils are known as?
Bands because of the banded shape of the nucleus
PB
Barometric Pressure (760 Torr @ sea level)
What is non-invasive ventilation?
Bi-Pap and C-Pap (pressurized assisted ventilation)
What are secondary values to ABGs that need to be CALCULATED?
Bicarbonate (HCO3-) Base excess (BE) or deficit Hemoglobin saturation (HbO2%)
What is an Antagonist
Blocking agent (The ugly sidekick)
Interpret arterial blood gas values
Blood gas analyzers measure 3 values pH (Sanz electrode) PO2 (Clark electrode) PCO2 (Severinghaus electrode) All other values are calculated HCO3 BE Oxygen saturation
Occupational Safety and Health Administration (OSHA)
Branch of the US Department of Labor, responsible for regulation of on the job safety
What are side effects of Zanamivir?
Bronchospasm and allergic reactions!
What humidifiers do not use heat?
Bubble humidifiers
Explain the function and principles of a Galvanic O2 Analyzer
Creates a current as a result of oxidation and reduction of O2 Measures partial pressures and converts to a percentage Accuracy is affected by water on the sensor, high pressure, and altitude Can measure continuous flow 2‐point calibration required (21% and 100%) If unable to calibrate check the fuel cell Disadvantage ▪ Powered by a fuel cell which must be changed on occasion
CO2 Diffusion vs. O2 Diffusion?
CO2 Diffusion = O2 Diffusion x 20
What's with that CO2 Transport?
CO2 is ionized as bicarbonate:~80% transported as HCO3
Carbonic Acid Reaction Formula (Dissociation)
CO2+H2O<==>H2CO3<==>HCO3+H
Gas Density simplified
CO2>O2Air>He
Who does depression of ventilation occur in?
COPD patients with chronic hypercapnia
What causes RELATIVE SHUNTS?
COPD, Restrictive disorders, and any condition resulting in hypoventilation
Total O2 content of blood equation:
CaO2=(0.003 x PaO2) + (Hb x 1.34 x SaO2) NORMAL RANGE: 16-20 mL/dL
How is an UNCOMPENSATED Thorpe Tube calibrated?
Calibrated in liters per minute at atmosphere pressure (without restriction)
How can tissue O2 be measured?
Can be measured by invasive probes-Tissue Oxygen (PtO2) Monitor, inserted directly into organs, tissue, and body fluids.
How do you fix the problems due to freaking compensation?
Can be minimized with use of water traps and heated circuits, by positioning circuits so it drains condensate away from patient, and checking humidifier and nebulizer often.
What is an advantage inhaled aerosols has over systemic administration?
Can use smaller doses.
Explain capriography
Capnograph is the graphic waveform display of CO2 as a function of time Measured at bedside by infrared absorption Should correlate with PCO2 onABG Useful for tube placement on intubation and monitoring patient's ventilatory status
What is capnography?
Capnography is the graphic display of CO2 levels as they change during breathing.
What is used to measure CO2 levels in capnometry?
Capnometer
Explain capnometry
Capnometry is used to measure CO2 at the patient's airway Disadvantages Needs to be calibrated periodically Water can occlude sample lines
Review the credentialing of the respiratory therapist
Credentialing is given by NBRC after passing exam (either CRT of RRT), after CRT or RRT title is given by NBRC the state that the RT is practicing in determined licensing laws
Factors Affecting Aerosol Drug Delivery During Mechanical Ventilation
Category Factor Ventilator-related Mode of ventilation VT Respiratory rate Duty cycle Inspiratory waveform Breath-triggering mechanism Circuit-related Size of endotracheal tube Type of humidifier Relative humidity Density and viscosity of inhaled gas Device-related MDI Type of spacer or adapter used Position of spacer in circuit Timing of MDI actuation SVN Type of nebulizer used Fill volume Gas flow Cycling: inspiration vs. continuous Duration of nebulization Position in circuit Patient-related Severity of airway obstruction Mechanism of airway obstruction Presence of dynamic hyperinflation Spontaneous ventilation Disease process Drug-related Dose Aerosol particle size Targeted site for delivery Duration of action
In the body, a balance normally exists between?
Cations and anions
What are mast cells
Cells that contain histamine, causes inflammation.
A therapist who says "Please explain that to me again" to a pt. during an interview is using what type of interpersonal communication technique?
Clarifying
allows measurement of arterial PO2
Clark electrode
What is the first step in equipment processing for reuse on another patient?
Cleaning the equipment?
Differentiate between pulse-oximetry and co-oximetry.
Co-oximetry Laboratory analytical procedure requiring invasive sampling of arterial blood Utilizes light at special wavelength to measure Oxyhemoglobin Deoxyhemoglobin Carboxyhemoglobin Methemoglobin Pulse Oximetry Most appropriate noninvasive technique for continuous monitoring of O2 saturations (SpO2) Utilizes Beer's Law Linear relationship between absorbency of a solution and its concentration
What is the physical process whereby the gaseous form of a substance is changed back into its liquid state?
Condensation
Ground
Connection between the electrical circuit and the ground, which becomes a part of the circuit
What do Demand & Pulse-dose systems do?
Conserve O2 by providing flow during inspiration only
Most Commonly Used SVN
Constant output design
What is intranasal steroids used for?
Control of allergic and non-allergic rhinitis
How else does OXIMETRY work?
Each FORM of hemoglobin has own pattern of light absorption.
What is the pharmacokinetic phase of pharmacology?
Describes the time course, and disposition of drug in body based on its absorption, distribution, metabolism, and elimination.
WBC Count Differential is best interpreted by?
Determining the absolute count of each WBC
what are some hazzards of pulse oximetry?
Device limitations cause false negative results of hypoxemia or false positive results for normoxemia or hyperoxemia may lead to inappropriate treatment Factor that may affect the accuracy of the SPO2 reading include motion artifact, abnormal hemoglobings, intravascular dyes, .o2 perfusion states, skin pigmentation, nail polish
What is the term for the temperature at which the water vapor in a gas begins to condense back into a liquid?
Dew Point
What is the safety indexed connector system for Low pressure gas connectors at outlets of pressure reducing valves, outlets of central piping systems and the inlets of blenders, flowmeters and ventilators
Diameter-Index Safety System (DISS)
What is the purpose of Passover in regards to humidifiers?
Directs gas over the water surface.
In general what are common side effects to Adrenergic Bronchodilators?
Dizziness, hypokalemia, nausea and tolerance to the drug.
Syringe safety precautions...
Do NOT recap the needle without a safety device, handle with both hands, point the needle at people when not performing a puncture, bend/break/remove needles from syringes by hand or dispose of used syringes in anything but an appropriate puncture resistant sharps container.
If you make a mistake when charting a pt treatment, what should you do?
Draw a line through the mistake and write "error" above it
Antiadrenergic
Drug that blocks a receptor for norepinephrine or epinephrine.
Muscarinic
Drug that stimulates acetylcholine receptors specifically at parasympathetic nerve-ending sites.
What is an Anticholinergic drug?
Drugs that block receptors for acetylcholine
What is brand name Mometasone/Fomoterol?
Dulera
what are the constant Factors for E & H cylinders?
E cylinder = 0.28 H cylinder = 3.14
Explain problems encountered during arterial punctures as well and troubleshooting techniques.
Getting a good sample ▪ Inaccessible artery ‐ choose a different site ▪ Absent pulse ‐ choose a different site ▪ Small spurt of blood ‐ needle has gone through the artery so pull back. If redirection is needed pull out until bevel is seen then redirect ▪ If patient is in pain or has increased anxiety this will cause hyperventilation and altered results
How is Mucomyst administered?
Given by aerosol or direct tracheal instillation to reduce accumulation of airway mucus via breaking the disulfide bonds of mucus DNA (unzips the DNA)
What is the most common option for high level disinfection of semicritical respiratory care equipment?
Glutaraldehyde 20 minutes
What is the benefit to invasive procedures over noninvasive procedures?
Greater accuracy
What's up with that cross-contamination?
H2O in the circuit can be a source of bacterial colonization
What is sickle cell?
HbS- Abnormal hemoglobin that is fragile that leads to hemolysis (H2O goes in until cell ruptures) & thrombi.
Where can you draw a CBG?
Heel, earlobe, great toe, finger
What does High-Flow nasal cannulas provide?
High FiO2, High relative humidity and positive pressure
Ventricular fibrillation, Diaphragm dysfunction, and Death
High currents passing through can cause
What is the difference between high flow and low flow oxygen devices?
High flow devices provide 100% of the patient's respiratory needs without inhaling uncontrolled room air. Low flow devices DON'T.
What are examples of high flow O2 delivery systems? (Provides 100% of patient's O2 needs)
High flow nasal canula, Cascade high flow, Passover high flow, Venturie Mask, regular high flow with Aerosol mask
What can be done to remedy CO2 build-up in airway tents?
High flows of fresh gas circulating continually through tent help "wash out" CO2 build up
What is the relationship between O2 and FiO2?
Higher O2= Increased FiO2 Lower O2= Decreased FiO2
Greek physician living during the 5th and 4th centuries BC
Hippocrates
believed air contained essential substance distributed to body via heart
Hippocrates
Treprostinil
Indication for Use Treprostinil (Tyvaso) is indicated for the treatment of pulmonary arterial hypertension to increase walking distance in patients with New York Heart Association class III symptoms.60 It is administered using the Tyvaso Inhalation System, which is an ultrasonic, pulsed-delivery device. Mode of Action Treprostinil is a prostacyclin analogue that causes vasodilation of the pulmonary and systemic arterial vascular beds and inhibits platelet aggregation. Treprostinil is available in a 2.9-mL ampule, which contains 1.74 mg of treprostinil (0.6 mg/mL). It is provided as a nebulization in the Tyvaso Inhalation System. The ampule is dumped into the medication cup of the nebulizer and is used for the entire day. The patient receives the prescribed amount of drug as a nebulization in four separate, equally spaced treatment sessions per day during waking hours. Each breath delivers 6 mcg of treprostinil. The initial dose is 3 breaths (18 mcg) per treatment session. If not tolerated, the dose may be reduced to 1 to 2 breaths per session and then increased to 3 breaths. Treprostinil should be increased by 3 breaths every 1 to 2 weeks until a dose of 9 breaths (54 mcg) per treatment session is reached. Adverse Effects Treprostinil has not been studied in patients with underlying lung disease (e.g., asthma, COPD). Treprostinil may cause bronchospasm. This agent should not be mixed with any other agents.
Nitric Oxide
Indications for Use As described in more detail in Chapter 38, nitric oxide (INOmax) is indicated in the treatment of neonates (>34 weeks' gestational age) with hypoxic respiratory failure.56 The patient should have evidence of pulmonary hypertension in which nitric oxide would improve oxygenation and decrease the need for extracorporeal membrane oxygenation. Off-label uses include reducing pulmonary artery pressure in the neonate.57 Mode of Action Nitric oxide is produced by cells in the body. It relaxes vascular smooth muscle by binding to the heme group of cytosolic guanylate cyclase, activating guanylate cyclase, and increasing cyclic guanosine monophosphate. When inhaled, nitric oxide produces pulmonary vasodilation, reducing pulmonary artery pressure and improving mismatching. Adverse Effects Nitric oxide is contraindicated in neonates with dependent right-to-left shunts. Precautions include methemoglobinemia and nitric dioxide formation. The most common adverse events are hypotension and withdrawal.58
Iloprost
Indications for Use Iloprost (Ventavis) inhalation is indicated for the treatment of pulmonary hypertension.59 Iloprost inhalation is administered with the I-neb nebulizer. Mode of Action Iloprost is a synthetic analogue of prostacyclin (PGI2). This agent dilates pulmonary arterial vascular beds and affects platelet aggregation. It is unknown whether platelet aggregation plays a role in the treatment of pulmonary hypertension. Adverse Effects Syncope and pulmonary edema may occur secondary to the vasodilatory properties of iloprost. During the 12-week clinical trial, headache and increased cough were the most noted adverse reactions.
What were the first respiratory therapists called?
Inhalation therapists
indications for use of inhaled zanamivir
Inhaled zanamivir is indicated for the treatment of uncomplicated acute illness caused by influenza virus in adults and children 5 years or older who have been symptomatic for no longer than 2 days. The agents have an off-label use for treatment and prophylaxis of H1N1 influenza
Explain criteria for Vessel accessibility.
It is easier to palpate, stabilize, and puncture a superficial artery than a relatively deep one Superficial arteries are found at the distal ends of the extremities
describes his law of partial pressures
John Dalton
described properties of CO2
Joseph Black
assesment of ribavirin
Monitor signs of improvement in RSV infection severity, including vital signs, respiratory pattern and work of breathing (clinically), level of fractional inspired oxygen (FiO2) needed, level of ventilatory support, arterial blood gases, body temperature, and other indicators of pulmonary gas exchange. • Monitor the patient for evidence of side effects, such as deterioration in lung function, bronchospasm, occlusion of endotracheal tube (if present), cardiovascular instability, skin irritation from the aerosol drug, and equipment malfunction related to drug residue.
120 V
Most homes and hospitals are powered with this power source
________ sputum is clear and thick, and is commonly seen in patients with asthma.
Mucoid
N-Acetyl-L-cysteine's brand name is....
Mucomyst
What is brand name N-Acetylcysteine 10%/20%?
Mucomyst
What is the difference between multiplace and monoplace chambers
Multiplace chambers can hold 12 or more people Monoplace can only hold 1 person
Hyperbaric O2 (HBO) Therapy is administered via?
Multiplace or monoplace chamber
Explain criteria for PeriarterialTissues
Muscle, tendon, and fat are reasonably insensitive to pain; bones and nerves are very sensitive to pain Arteries surrounded by relatively insensitive tissues are desirable so that the puncture can be as free from pain as possible Arteries that are not adjacent to veins are preferable to minimize the chance of inadvertent venous puncture
Name mucoactive agents (2)
N-acetylcysteine (NAC) 10%, 20% (Mucomyst) Dornase alpha (Pulmozyme)
assumes the responsibility for all examination standards and policies through a standing committee
NBRC
the primary method of ensuring quality in respiratory care is voluntary certification or registration conducted by the
NBRC
What is capillary blood gas NOT good for?
NO VALUE in estimating PO2 (arterial oxygenation)
What are examples of low flow O2 delivery systems? (part of patient's O2 needs)
Nasal canula, regular mask, partial rebreather mask, oxymizer, non rebreather mask
NBRC
National Board for Respiratory Care
What are OCCASIONAL side effects of MDI administration of anticholinergic aerosol agents?
Nervousness, irritation, dizziness, headache, palpitation and rash
Reference range for WBC count
Neutrophils 40-75% Lymphocytes 20-45% Monocytes 2-10% Eosinophils 0-6% Basophils 0-1%
Most circulating WBCs are either
Neutrophils or lymphocytes
Significant elevation of the WBC (>15 x 10³/mcl) occurs only when either
Neutrophils or lymphocytes are responding to an abnormality
What is the name for infections that are acquired in the hospital?
Nosocomial infections. (Egan pg 54)
What's the difference between a Venturie mask and a Venti mask?
Not a damn thing Yo!
Hamburger Phenomenon
Not important but very delicious (see figure on menu)
What has a downward stepwise gradient (cascade) from normal atmospheric partial pressures to intracellular?
O2
Where are O2 related fire hazards at high risk?
O2 enriched environments & surgical suites in presence of hyperbaric O2 therapy.
clinical simulation
Objectives: -interpret data -recognize and prioritize problems -make decisions -observe consequences of decisions -develop leadership skills -develop interpersonal communication skills -develop team-building skills -use available resources -manage stress and crisis
formalism (duty-oriented reasoning)
The viewpoint that relies on rules and principles
Define monitoring.
Ongoing process by which clinician obtains and evaluates dynamic physiologic processes, "Real time"
Define surveillance
Ongoing process of monitoring patients & personnel for acquisition of infection
What is the fundamental principle of aerosol deposition?
Only a fraction of emitted aerosol will be inhaled and only a fraction of what is inhaled will make it to the lungs.
Describe methods for blood gas monitoring for On Demand (ex vivo)
Optodes are located in a sensor cassette inserted in‐line with the arterial catheter Blood is pulled into the cassette, measured, then placed back into the body
What happens when perfusion exceeds ventilation?
PHYSIOLOGIC SHUNT: capillary, absolute anatomic and relative shunts seen in disease states that diminish pulmonary ventilation
in capillary sampling which parameter provides no value in estimating arterial oxygenation?
PO2
What are determining factors for O2 toxicity?
PO2 & exposure time
What value is useless in regards to Capillary blood samples
PO2 and SaO2. (SaO2 must be evaluated via pulse oximetry.
Intracellular O2 cascade
PO2= ~5mm/hg
indications for humidified gas
PRIMARY- Overcoming humidity deficit created when upper airway is bypassed SECONDARY- Managing hypothermia, treating bronchospasm caused by cold air
What is the difference of the PT and PTT measurement tests?
PT is for the extrinsic pathway factors like vitamin K; while PTT looks at the intrinsic coagulation pathway.
What is the best number for ventilation
PaCO2
Pressure values for oxygenation
PaO2 (normal = 80-100) PaO2 60-79 mm Hg = mild hypoxemia PaO2 40-59 mm Hg = moderate hypoxemia PaO2 <40 mm Hg = severe hypoxemia SaO2 (normal = 95-100%) CaO2 (normal = 18-20 vol%)
mild hypoxemia?
PaO2 = 60 -79 mm Hg
severe hypoxemia?
PaO2 = < 40 mm Hg
What is Laboratory documentation for assessing the need for O2 Therapy?
PaO2, SaO2 & SpO2
Touching the chest wall to evaluate underlying structure & function.
Palpating
Box 32-5 Side Effects With Aminoglycosides and Tobramycin
Parenteral Administration • Ototoxicity (auditory and vestibular) • Nephrotoxicity • Neuromuscular blockade • Hypomagnesemia • Cross-allergenicity • Fetal harm (deafness) Inhaled Nebulized Tobramycin • Voice alteration • Tinnitus • Nonsignificant increase in bacterial resistance (al
Inhaled Tobramycin
Patients with CF have chronic respiratory infection with Pseudomonas aeruginosa and other microorganisms. Such chronic infection causes recurrent acute respiratory infections and deterioration of lung function. With the exception of the quinoline derivatives such as ciprofloxacin, antibiotics such as the aminoglycosides (e.g., tobramycin), which are effective against Pseudomonas organisms, have poor lung bioavailability when taken orally. Consequently, these antibiotics must be given either intravenously or by inhalation. The aminoglycoside tobramycin has been approved for inhaled administration (TOBI) and is intended to manage chronic infection with P. aeruginosa in patients with CF. Goals of therapy are to treat or prevent early colonization with P. aeruginosa and maintain present lung function or reduce the rate of deterioration. The emergence of bacterial resistance was not seen in clinical trials with inhaled tobramycin.
Which of the following statements is FALSE about patient ambulation?
Patients with intravenous (IV) lines should not be ambulated.
What is the safety indexed connector system for Small cylinders up to and including E and attachments and yoke type connection. Exact positions of pins and pinholes vary for each gas. (2 & 5 for O2; 1 & 5 for Air)
Pin-Index Safety System (PISS)
Microshock
Shock from a usually imperceptible electrical current (<1 mA) that is allowed to bypass the skin and follow a direct, low-resistance pathway into the body
Explain the function and principles of a Polorgraphic
Similar to galvanic fuel cell but requires a battery to speed up the reduction reaction ▪ Allows for a faster response time Measures partial pressure and converts to a percentage Affected by water on sensor, altitude, and pressure Calibrate same as galvanic If unable to calibrate, change the battery
What are characteristics of a manual reservoir feed system?
Simple large reservoir that is manually opened and refilled with sterile or distilled water.
What does the stamping indicate?
Size, normal filling pressure, serial number, ownership and method of manufacturer.
What are adverse effects of Ribavirin?
Skin rash, Eyelid erythema and conjunctivitis.
Adverse Effects to ribavirin
Skin rash, eyelid erythema, and conjunctivitis have been noted with aerosol administration. Important equipment-related effects during mechanical ventilation include endotracheal tube occlusion and occlusion of ventilator expiratory valves or sensors. Deterioration of pulmonary function can occur. Patients or practitioners who are pregnant should not have exposure to ribavirin.
California Respiratory Care Practice Act
Some states also require that employers make reports not only on individuals terminated for cause but also on the supervisors of the RTs
What is an Agonist?
Stimulating agents (The sexy person)
Retractions seen below the rib cage
Subcostal retractions
List indications for an arterial puncture.
Sudden, unexplained dyspnea Cyanosis Abnormal breath sounds Severe, unexplained tachypnea Heavy use of accessory muscles Changes in ventilator settings CPR Diffuse infiltrates in the CXR
Reasons for drawing an ABG
Sudden, unexplained dyspnea Acute shortness of breath / tachypnea Abnormal breath sounds Cyanosis Heavy use of accessory muscles Changes in ventilator settings CPR Diffuse infiltrates in chest radiograph New infiltrates in CXR Sudden cardiac arrhythmias Acute hypotension
What is needed for CaO2 to be adequate
Sufficient normal Hemoglobin (Hb) -If hemoglobin (Hb) is absolute low, will result in anemia
Retractions seen above the clavicles
Supraclavicular retractions
What is the Surface area principle in regards to humidifier function?
Surface area affects the rate of evaporation
What force is responsible for the spherical shape of liquid droplets and their ability to keep this shape when placed into an aerosol suspension?
Surface tension
T/F: Hemoptysis is commonly found in patients with bacterial pneumonia.
T
T/F: Respiratory alkalosis amplies the sensation of breathlessness and provokes further anxiety and increased intensity of hyperventilation.
T
What is the difference in O2 use between transtracheal catheter and nasal cannula?
TT Catheter uses 40-60% less O2 to achieve the same PaO2 as nasal canula
To see all info on these drugs visit:
Table 32-1
If you are going to administer a bronchodilator what would you do?
Test the patient with a peak flow meter before and after administration of breathing treatments to ensure/document that the treatment was effective.
A variety of booths and specially designed stations are available for delivery of pentamidine or ribavirin
The Emerson containment booth (Figure 36-37) is an example of a system that completely isolates the patient during aerosol administration. The AeroStar Aerosol Protection Cart (Respiratory Safety Systems, San Diego, CA) is a portable patient isolation station for administration of hazardous aerosolized medication. It has been used during sputum induction and for pentamidine treatment. The patient compartment is collapsible with a swing-out counter and three polycarbonate walls. Captured aerosols are removed with a HEPA filter. A prefilter is used to retain larger dust particles and to prevent early loading of the more expensive HEPA filter.
What is responsible for the color of our blood?
The Fe in Hb is responsible for the color of our blood which varies depending on the amount of O2 that is bound to it.
Who monitors the purity of O2 for medical gas
The Food and Drug Administration (FDA) ensures O2 is 99% pure
The first step in evaluating the sputum sample is?
The Gram stain
Which blood gas analyzer electrode requires a separate reference electrode?
The PH electrode
distributive justice
The United States is rapidly approaching the point at which a balance must be found between health care expenses and the revenue available to pay for them. Efforts to achieve this balance will inevitably lead to some form of rationing of the delivery of health care services
The Primary focus of respiratory care pharmacology
The delivery of bronchoactive inhaled aerosols to the respiratory tract for the diagnosis & Treatment of Pulmonary Disease.
Breath holding after inhalation of an aerosol increases.....
The residence time for the particles in the lung and enhances distribution across the lungs and sedimentaiton
What s a flow restrictor?
The simplest and least expensive flowmeter device, consists of fixed orifice calibrated to deliver specific flow at constant pressure based on the principle of flow resistance.
If the Gram stain reveals an adequate sample...
The technician prepares a portion of the sputum for culture
Determine Dose Left in Pressurized MDI with dose counters
The user should29: 1.Determine how many puffs of drug the pMDI has when full. 2.Learn to read the counter display because each dose counter has a different way of displaying doses left in the canister. 3.Check the counter display to track the pMDI actuations remaining in the canister. 4.Reorder the pMDI when there are a few days of drug remaining. 5.Dispose of the pMDI properly, after the last dose is dispensed.
Determine Dose Left in Pressurized MDI without dose counters
The user should29: 1.Read the label to determine how many puffs of drug the pMDI has when full. 2.Calculate how long the pMDI will last by dividing the total number of puffs in the pMDI by the total puffs used per day. If the pMDI is used more often than planned, it will run out sooner. 3.Identify the date that the medication will run out, and mark it on the canister or on a calendar. 4.For drugs that are prescribed to be taken as needed, track the number of puffs of drug administered on a daily log sheet and subtract them from the remaining puffs to determine the amount of medication left in the pMDI. 5.Keep the daily log sheet in a convenient place, such as taped to the bathroom mirror. 6. Refill the pMDI prescription when there are a few days of use remaining in the pMDI. 7.Dispose of the pMDI properly when the last dose is dispensed.
virtue ethics
The viewpoint that asks what a virtuous person would do in a similar circumstance
What is Hemoglobin (Hb or Hgb)
a protein (metalloprotein) with Fe+2 (ferric Iron) made up of globulin chains (2 alpha and 2 beta). Each of these chains have a central structure called the Heme molecule. Hb helps maintain the shape of the RBC. Abnormal Hb will change the shape of the RBC impeding the function and flow of the blood.
In patients with septic shock
a serum lactate level greater than 4 meq/L is associated with higher mortality
When examining a patient's face for indications of respiratory problems, the most common facial signs are: a. pursed-lip breathing b. cyanosis c. nasal flaring d. red eyes
a, b, c
What does the effectiveness of a cough depend on? a. ability of the person to take a deep breath b. elastic recoil of the lungs c. expiratory muscle strength d. being awake or asleep e. level of airway resistance
a, b, c, e
Which of the following are the purposes of interviewing: a. obtain essential diagnostic information b. monitor changes in the patient's symptoms and response to therapy c. chit chat with the patient d. establish a rapport between the clinician and the patient
a, b, d
Patients who undergo ___________ surgery are prone to development of atelectasis in the postoperative period.
abdominal
Body humidity
absolute humidity in a volume of gas saturated at a body temperature of 37° C; equivalent to 43.8 mg/L of water in the air
How are liquefied gas (O2 and N20) cylinders charged?
according to specified filling density *Filling density is ratio between weight of liquid gas put into cylinder and weight of H2O cylinder could contain if full
What neurotransmitter(s) does Spiriva effect? How? Where?
acetylcholine, blocks, at M1 and M3
What neurotransmitter(s) does Atrovent effect? How? Where?
acetylcholine, blocks, at M1, M2 and M3
The principle of autonomy
acknowledges the personal liberty of patients and their right to decide their own course of treatment and follow through a plan on which they freely agree
benevolent deception
actions in which the truth is withheld from the patient for his or her own good
what areas does criminal law protect
acts of offenses against the welfare or public safety
Acute, severe elevation of blood pressure which can cause acute neurologic, cardiac, and renal failure.
acute hypertensive crisis
What are the indications for ultra short acting adrenergic bronchodilators?
acute reversible airway obstruction
Airway appliances
aerosol mask, face tent, T-tube, tracheostomy mask (all used with large-bore tubing)
What are heterodispersed aerosols?
aerosols with particles of different sizes
What are Monodispersed aerosols?
aerosols with particles of similar sizes.
when to wash hands
after touching blood, body fluids, or contaminated items (even if wearing gloves).
The two most important factors that influence the accuracy of the transcutaneous measurements are?
age and perfusoin status
The principle of utility
aims to promote the greatest general good for most people
Large volume USNs (used mainly for bland aerosol therapy or sputum induction) incorporate
air blowers to carry the mist to the patient (see Chapter 35). Low flow through the USN is associated with smaller particles and higher mist density. High flow yields larger particles and less density. In contrast to jet nebulizers, the temperature of the solution placed in a USN increases during use. As the temperature increases, the drug concentration increases, as does the likelihood of undesired side effects.
patinets with bone marrow disease may have a marked elevatoin of serum
alkaline phosphatase ALP
The Privacy Rule
applies to all health care providers, health plan providers (with some exceptions, such as small employer plans with <50 participants administered solely by the employer), and health care clearinghouses -The basic goal of the Privacy Rule is to protect all "individually identifiable health information," commonly referred to as protected health information (PHI)
In what ways can an RT function as a PA or physician extender?
applying protocols or guidelines, ventilator adjustments, arterial line insertion and management, intubation, extubation, etc.. Various things that RTs are trained for can minimize cost and unnecessary care where an MD or PA would otherwise be needed
Cascade impactors
are designed to collect aerosols of different sizes ranges on a series of stages ot plates
systemic effects of inhaled aerosols
are due to absorbtion of the drug from the airway & gastrointestinal (GI) tract.
Laboratory tests
are employed to determine a patient's health status and aid medical decisions
Expectorants
are mucoactive but stimulate the production and clearance of airway secretions rather than cause mucolysis Examples are-guaifenesin (also known as glyceryl guaiacolate), iodinated glycerol, and saturated solution of potassium iodide (SSKI)
Enzymes
are proteins that regulate all chemical reactions occurring within cells, such as metabolism and protein synthesis
ABG
arterial blood gas
For whom would you use an anticholinergic bronchodilator?
as a maintenance bronchodilator therapy for COPD patients
With continuous or bias flow through the ventilator circuit, the delivery is reduced
as flow increases, whereas placement of a VM nebulizer near the ventilator increases delivery
why will baby boomers need RC?
as they age, more will have asthma, COPD and other cardiopulmonary diseases
Patients with ________ frequently complain of chest tightness.
asthma
At what part of the lung should you auscultate when assessing for vocal fremitus?
at the base of the lung
guiding principles in contemporary ethical decision making
autonomy, veracity, nonmaleficence, beneficence, confidentiality, justice, and role fidelity
May occur with traumatic brain injury or hypothermia, as a side effect of medication (i.e. narcotics), with severe heart attack, and drug overdose. a.tachypnea b. bradypnea
b
What would be the treatment option for a patient with angina? a. Nitric oxide b. Oxygen c. Magnesium
b
An abnormal increase in the anteroposterior diameter of the chest.
barrel chest
The CDC recommends that nebulizers
be cleaned and disinfected, or rinsed with sterile water, and air dried between uses.
WBC count doubles
because of an increase in neutrophils
veracity
binds the health care provider and the patient to tell the truth. The nature of the health care delivery process is such that both parties involved are best served in an environment of trust and mutual sharing of all information. Problems with the veracity principle revolve around such issues as benevolent deception
What is a sphygmomanometer?
blood pressure cuff
the most common tests performed to evaluate kidney function are
blood urea nitrogen creatinine
a significant reduction in the platelet count known as thrombocytopenia occurs with
bone marrow disease disseminated intravascular coagulation
Causes of Leukopenia
bone marrow diseases influenza AIDS lupus chemotherapy
secondary polycythemia reffers to
bone marrow that is stimulated to produce extra RBC in response to chronically low blood oxygen levels
Damage to these tissues can increase the serum Alkaline Phosphatase
bones, kidneys, spleen, and intestine (BoKSI)
Clinical efficacy varies according to
both patient technique and device design. For these reasons, the best approach to aerosol drug therapy is to use an assessment-based protocol that emphasizes individually tailored therapy modified according to patient response.
What is a dry powder inhaler (DPI)
breath actuated dosing system by which a patient creates the aerosol by drawing air through dose of finely milled drug powder. Dispersion of powder into respirable particles depends on creation of turbulent flow in inhaler. (THERE IS NO PROPELLANT)
double effect
brings us to the essence of the definition of the word dilemma. The word comes from the Greek terms di, meaning "two," and lemma, meaning "assumption" or "proposition."
When the expiratory component of harsh breath sound equals the inspiratory component, they are described as:
bronchial breath sounds
The effect of acetycholine on muscarinic (M3) receptors on airway smooth muscle is:
bronchoconstriciton
Small volume USNs have been promoted for administration of a wide variety of formulations ranging from
bronchodilators to antiinflammatory agents and antibiotics
Sounds that can be heard around the upper half of the sternum on the anterior chest & between the scapulae; not as loud as tracheal breath sounds, slightly lower in pitch.
bronchovesicular breath sounds
Types of humidifiers
bubble humidifier, passover, heat-moisture exchangers (HME)
How is medical-grade air produced?
by filtering and compressing atmospheric air
Weakness and emaciation (extreme weight loss and thinness).
cachexia
red blood cells (RBCs)
called erythrocytes; and platelets, called thrombocytes
Malpractice
can involve professional misconduct, unreasonable lack of skill or fidelity in professional duties, evil practice, or unethical conduct
COPD patients cannot exhale all of their inspired air (they're lungs never completely empty). Because of this, they will have high ______ levels.
carbon dioxide
How do you troubleshoot bland aerosol therapy overhydration?
careful patient selection and monitoring
Personal protective equipment is recommended when
caring for any patient with a disease that can be spread by the airborne route.84 The greatest risk is communication of tuberculosis or chickenpox.
How are DPIs categorized?
categorized by the design of their dose containers. * Unit-dose DPI *Multiple dose drug reservoir DPI
Beta 1 adrenergic
causes increased heart rate and contractibility
Alpha 1 adrenergic
causes vasoconstriction and vasopressor effect
The patient's current medical problems can be found in the _______ ___________ and _________ ___ _________ ___________ section of the medical chart.
chief complaint, history of present illness
Muscarinic & antimuscarinic distinguishes
cholinergic agents whose action is limited to parasympathetic sites.
Secondary polycythemia
chronic low blood oxygen levels.
Ignition sources should not be allowed in rooms where oxygen is in use
cigarette lighters
What situation is noninvasive methods appropriate?
clinical decisions
Physical characteristics of Nitrous Oxide (N2O)
colorless gas with slightly sweet odor and taste
Breathlessness can be triggered by: a. hypoxemia b. hypercapnia c. acidosis d. all of the above
d
Criminal law
deals with acts or offenses against the welfare or safety of the public. Offenses against criminal law are punishable by fines, imprisonment, or both
Diseases that increase lung tissue density such as pneumonia, tumor or atelectasis, or pleural spaces filled with fluid, results in a ___________ resonance when percussing the chest.
decreased
In a humid Environment the emitted dose
decreases
Failure to clean the nebulizer properly resulted in
degradation of performance because of clogging of the Venturi orifice, reducing the output flow, and buildup of electrostatic charge in the device.
What does SaO2 represent?
degree to which Hb is saturated with O2 [can have 100% saturation in low amount of blood!]
When used in conjunction with high-frequency oscillatory ventilation, administration of albuterol sulfate via a VM nebulizer placed between the ventilator circuit and the patient airway has been reported to
deliver greater than 10% of dose to both infants and adults.79,80 A pMDI with adapter placed immediately proximal to the endotracheal tube achieved similar results in adult patients ventilated via high-frequency oscillatory ventilation.81
If inhalation is not performed at the optimal inspiratory flow rate for a particular device,
delivery to the lung decreases as the dose of drug dispensed decreases and the particle size of the powder aerosol increases
What are the 3 modes of transmission of human sources of pathogens in health care
direct and indirect contact respiratory droplets airborne nuclei (repairable particles <5um)
Name five transmission routes for infection and give examples of an illness or bacteria that can be transmitted from each.
direct contact- HIV, Hep A indirect contact- HIV, Hep B, Hep C droplet- Diptheria, pertussis airborne- TB vehicle- cholera
Unit-Dose DPIs
dispense individual doses of drug from punctured gelatin capsules.
DIC
disseminated intravascular coagulation
advance directives
document in which an individual specifies what medical care he or she wishes to receive in the future, should he or she no longer be able to make decisions about medical treatment; may be in the form of living will or durable power of attorney
What are non-ionized aerosol drugs?
drug that is lipid soluble and will diffuse across cell membranes and into the bloodstream, producing systemic side effects.
DPI
dry powder inhalers
In regards to aerosol inhalers what is a solution to the problem propellant dangers?
dry-powder inhalers
Name possible fire hazards associated with the use of oxygen (3)
flammable material, ignition sources, toys that may create a spark
PubMed
free search engine of the National Library of Medicine for health information- searches several databases including Medline
SPAG
duces medical gas source from the normal 50 pounds per square inch gauge (psig) line pressure to 26 psig with an adjustable regulator. The regulator is connected to two flowmeters that separately control flow to the nebulizer and drying chamber. The nebulizer is located within the glass medication reservoir, the fluid surface and wall of which serve as primary baffles. As it leaves the medication reservoir, the aerosol enters a long, cylindrical drying chamber. Here the second (separate) flow of dry gas is entrained, reducing particle size by evaporation, creating a monodisperse aerosol with an MMAD of 1.2 to 1.4 µm. Nebulizer flow should be maintained at approximately 7 L/min with total flow from both flowmeters not less than 15 L/min. The latest model operates consistently even with back pressure and can be used with masks, hoods, tents, or ventilator circuits.
Why does Oximetry work?
each substance has its own unique pattern of light absorption. (ie each form of hemoglobin HbO2, HbCO)
What do most beside systems to measure FiO2 utilize?
electrochemical principles (O2 analyzers)
Drug Concentration: what increases solute concentrations during nebulization
eveporation heating baffling recycling of drug solutions
How often do you assess a patient on continuous nebulization?
every 30 minutes for the first 2 hours then hourly. (For adverse drug responses)
How often are safety tests conducted on gas cylinders?
every 5 or 10 years
Why does OXIMETRY work?
every substance has a unique pattern of light absorption
breach of contract
failure, without legal excuse, to carry out the terms of a legal agreement
A patient's potential genetic or occupational links to disease & current life situation can be found in this section of the medical history.
family and social/environmental history
An elevated body temperature secondary to disease. often seen with infection.
fever
The USN uses a piezoelectric crystal to
generate an aerosol. The crystal transducer converts an electrical signal into high-frequency (1.2- to 2.4-MHz) acoustic vibrations. These vibrations are focused in the liquid above the transducer, where they disrupt the surface and create oscillation waves (Figure 36-25). If the frequency of the signal is high enough and its amplitude strong enough, the oscillation waves form a standing wave that generates a geyser of droplets that break free as fine aerosol particles.
A simple albuterol dose-response titration involves
giving an initial 4 puffs (90 mcg/puff) at 1-minute intervals through a pMDI with a holding chamber. After 5 minutes, if airway obstruction is not relieved, the RT gives 1 puff per minute until symptoms are relieved, heart rate increases to more than 20 beats/min, tremors increase, or 12 puffs are delivered. The best dose is the dose that provides maximum relief of symptoms and the highest PEFR without side effects.
Spontaneous breathing in all patients, including pediatric and neonatal patients, results in
greater deposition of aerosol from an SVN than occurs with positive pressure breaths (e.g., intermittent positive pressure ventilation). This mode of ventilation reduces aerosol deposition more than 30% compared with the effect of spontaneously inhaled aerosols
respiratory care protocols
guidelines for delivering appropriate respiratory care treatments and services (i.e., treatments and services that are indicated, delivered by the correct method, and discontinued when no longer needed).
Patients with pancreatitis
have abnormal levels of the pancreatic enzymes lipase and amyla
Bland aerosols
have been found to increase secretion clearance and sputum production and cause productive coughing
Another type of off-label use involves drugs that
have not been approved for inhalation, ranging from heparin to certain antibiotics. Although physicians may order such drugs via inhalation, the risk to the patient and institution is greater when the administration of such drugs via inhalation has not been thoroughly studied. All forms of off-label use should be avoided when approved and viable alternatives exist. Likewise, off-label administration should always be backed by appropriate departmental or institutional policies and procedures.
Filters and nebulizers used in treatments with pentamidine and ribavirin should be treated as
hazardous wastes and disposed of accordingly. Goggles, gloves, and gowns should be used as splatter shields and to reduce exposure to medication residues and body substances. Staff members should be screened for adverse effects of exposure to the aerosol medication. The risks and safety procedures should be reviewed regularly.
respiratory care (respiratory therapy)
health care discipline that specializes in the promotion of optimal cardiopulmonary function and health
Pedal edema most often occurs with ______ __________.
heart failure
L lactate dehydrogenase occurs in high concentrations in what organs
heart liver skeletal muscle brain kidney RBC HLS BKR
Vomiting blood from the GI tract.
hematemesis
the ratio of RBC volume to that of whole blood is known as the?
hematocrit level
A desaturated ___________ must exist before cyanosis can be identified.
hemoglobin
Droplet size and nebulization time are inversely proportional to gas flow through the jet.
higher the flow of gas to the nebulizer, the smaller the particle size generated, and the shorter is the time required for nebulization of the full dose.
malpractice
in law, professional negligence that is the proximate cause of injury or harm to a patient resulting from a lack of professional knowledge, experience, or skill that can be expected in others in the profession or from a failure to exercise reasonable care or judgement in the application of professional knowledge, experience, or skill
Antagonists
in pharmacology, a drug that has affinity but produces no effect; an antagonist can be competitive (forms reversible bond with receptor) or noncompetitive (forms irreversible bond).
Equipment processing definitions: Intermediate-level
inactivation of all vegetative bacterial most viruses most fungi, without destruction of bacterial spores
Disinfection low-level
inactivation of most bacteria, some viruses, and fungi, without destruction of resistant microorganism
Equipment processing definitions:low level disinfection
inactivation of most bacterial some viruses most fungi, without destruction of resistant microorganisms & bacterial spores
Equipment processing definitions: disinfection
inactivation of most pathogenic organisms, excluding spores
What are common technical errors associated with capillary blood sampling?
inadequate warming and squeezing of puncture site. Squeezing the puncture site may result in venous and lymphatic contamination of sample.
atropine sulfate side effects
include the local topical effect of dry mouth, pupillary dilation, lens paralysis, increased intraocular pressure, increased heart rate, urinary retention, and altered mental state
Reciprocal patient rights
include the right to autonomous choice, the right not to be harmed, and the right to fair and equitable treatment. More specific rules can be generated from these general principles of rights and obligations, such as those included in a code of ethics
The analysis of blood and other bodily fluids
includes the subspecialties of identifying bacteria (bacteriology), viruses (virology), fungi (mycology), and parasites (parasitology). A closely related discipline involves the analysis of the immune system (immunology) focusing on autoimmune and immunodeficiency diseases. Finally, the analysis of tissue for diagnosing diseases is the purview of the anatomic pathology service
How does a Large Volume USN work?
incorporates air blowers to carry mist to patient for delivery of bland aerosol therapy or sputum induction.
dehydration causes hematocrit to
increase
When the lungs are hyperinflated or if there is a pneumothorax, there will be an _____________ resonance when percussing the chest.
increased
What is the risk of administering a bronchodilator?
increased heart rate (20 point increase HR stop treatment and call doctor)
What does a beta1-receptor stimulation cause?
increased heart rate and increased heart contractility (yeah...not really used....really...)
Vocal and tactile fremitus _____ in intensity when the lung becomes consolidated such as in pneumonia.
increases
defendant
individual accused of wrong
plaintiff
individual bringing the complaint
Vector Borne transmission
infections form insects, rats, other vermin
Health Care-Associated Infections (HAIs)
infections patients acquire during the course of medical treatment
nosocomial infections
infections that are acquired in the hospital- most nosocomial pneumonias occur in surgical patients, especially patients who have had chest or abdominal procedures. In these patients, normal swallowing and clearance mechanisms are impaired, allowing bacteria to enter and remain in the lower respiratory tract. Intubations, anesthesia, surgical pain, and use of narcotics and sedatives impair host defenses further.
What stimulates a cough?
inflammation, mucus, foreign materials, noxious gases
routes of administration for corticosteroids
inhalation, oral, IM/IV, intranasal
M3 cholinergic
inhibits release of acetylcholine, inhibits bronchoconstriction
Zileuton
inhibits the 5-lipoxygenase enzyme that catalyzes the formation of leukotrienes from arachidonic acid
What is inhaled tobramycin intended for?
intended to manage chronic infection with P. Aeruginosa in patients with cystic fibrosis.
Pentamidine isethionate (NebuPent) (al 724)
is an antiprotozoal agent that has been used in the treatment of opportunistic pneumonia caused by Pneumocystis jiroveci, which is the causative agent of pneumocystis pneumonia (PCP). PCP is seen in immunocompromised patients, especially patients with AIDS.
(CPK) Creatine phosphokinase
is an enzyme found mainly in the brain, heart, and skeletal muscle tissue.
most common cause of lactic acidosis
is anaerobic metabolism from tissue hypoxia associated with shock
The normal anion gap
is approximately 8 to 14 meq/L
Liver damage
is assessed by abnormal increases in the hepatic enzymes alanine aminotransferase, aspartate aminotransferase, alkaline phosphatas
metabolic acidosis
is caused by either the addition of nonvolatile acids or a primary loss of HCO3
Liver disease
is characterized by the inability to remove toxins from the bloodstream. One of the primary toxins associated with altered mental function in patients with liver disease is the accumulation of ammonia, which forms in the body from the breakdown of proteins
A potential problem with continuous bronchodilator therapy (CBT)
is increase in drug concentration. Patients receiving CBT need close monitoring for signs of drug toxicity (e.g., tachycardia and tremor).
Combination of anticholinergic & beta agonist
is indicated for use in patients with COPD recieving regular treatment who require additional bronchodilation for relief of airflow obstruction.
Careful, ongoing patient assessment is
is key to an effective bronchodilator therapy protocol. To guide practitioners in implementing effective bedside assessment, the AARC has published Clinical Practice Guideline: Assessing Response to Bronchodilator Therapy at Point of Care.
A fully ionized drug
is not absorbed across Lipid membranes
Ammonia
is one of the primary toxins associated with altered mental function in patients with liver disease.
An abnormally low RBC count
is referred to as anemia and suggests that either RBC production by the bone marrow is inadequate or excessive blood loss has occurred
Homeostasis
is the ability of complex organisms to maintain a dynamic balance or equilibrium in their internal environments by making constant adjustments
Homeostasis
is the ability of complex organisms to maintain a dynamic balance or equilibrium in their internal environments by making constant adjustments.
Lactate dehydrogenase
is the enzyme that catalyzes the conversion of pyruvate into lactate
(CPK-MB)
is the most common CPK enzyme tests that is released from the heart after a myocardial infarction.
Coagulation
is the process by which the blood and vascular tree form clots to stop bleeding and repair damage to the injured blood vessels
To prevent concentration of solution in the nebulizer during treatment you should?
it is suggested that the last fourth of the solution in the nebulizer be diluted with an equal volume of sterile water to prevent concentrated residue, possibly leading to airway irritatio
Electrolyte balance is controlled by
kidneys
What is hemoximetry?
laboratory analytical procedure requiring invasive sampling of arterial blood. **Measures blood oxygen levels and hemoglobin saturations using a hemoximeter. **Multiple lights pass through sample to measure multiple hemoglobin species such as HbO2, HbCO, and metHb. **If good quality assurance measures are used, measurements are very accurate!
what areas does administrative law protect against
laws regulated by government
D-dimer
levels are used to help diagnose the presence of pulmonary embolism, deep vein thrombosis, or disseminated intravascular coagulation.
What are zone valves and what are their purpose?
located throughout the system. Used to turn on/off O2 flow in emergencies (ie fire)
[What do you do with an electrochemical O2 analyzer?]
measure a patient's FiO2 • after calibration • to see if they're getting the prescribed amount
Mass Median Aerodynamic Diameter (MMAD)
measure of central tendency that describes the particle diameter in micrometers in medical aerosols and pertains to cascade impaction.
What is CAPNOMETRY?
measurement of CO2 in respiratory gases
What is OXIMETRY?
measurement of blood Hb hemoglobin saturations using SPECTROPHOTOMETRY
responsible for clinical function of department
medical director
usually a pulmonologist or anesthesiologist
medical director
Two key sources of patient data are the ______ _______ and the ________ ____________.
medical history, physical examination
A significant fever causes an increased __________ rate, an increased _________ consumption, and an __________ carbon dioxide production.
metabolic, oxygen, increased
What is brand name racemic epinephrine?
microNephrin, Nephron
patients with an inadequate hemoglobin concentration will have RBC that are smaller then normal (____) and lack normal color (_____).
microcytic hypochromic
Opportunistic transmission
microorganisms that cause disease through other routes but under certain environmental conditions may be transmitted via fine particle aerosol Example SARS
Indirect contact transmission
most frequent mode of transmission in health care, transfer of pathogen through contaminated intermediate object or person
This mechanism gradually moves mucus to the hypophyarnx (larynx).
mucociliary escalator
Practitioner demonstration followed by repeated patient return demonstration is a
must and should be done frequently, such as with each office or clinic visit.
technical direction
must ensure the equipment and the associated protocols and procedures have sufficient quality to ensure the safety, health, and welfare of the patient using the equipment.
preferential transmission
natural infection results form transmission though multiple routes but small particle aerosols predominate
prevents risk of VAP
non-invasive ventilation
American Society for Testing and Materials (ASTM)
nongovernment agency that establishes performance standards for various equipment and materials.
Adrenergic
of or pertaining to the sympathetic nerve fibers of the autonomic nervous system that use epinephrine or epinephrine-like substances as neurotransmitters; any chemical or drug that mimics the effect of these neurotransmitters. Also called a sympathomimetic drug; catecholamine
Ethics
one of the disciplines of philosophy, which include ontology (the nature of reality), metaphysics (the nature of the universe), epistemology (the nature of knowledge), axiology (the nature, types, and criteria of values), logic, and aesthetics
The ideal aerosol would distribute:
only to the airway with none reaching the stomach.
The two general formulations of aerosolized glucocorticoids are?
orally inhaled and intranasal aerosol preparations
Dyspnea that is present only when one assumes the reclining position.
orthopnea
This type of dyspnea is common in patients with CHF (coronary heart failure).
orthopnea
corporate compliance officer(CCO)
oversee the hospital's business practices and ensure that they conform to the law
Fires are especially dangerous in areas where this is being used
oxygen
A good capillary sample can provide a rough estimate of?
pH and PCO2.
Most commonly prescribed method of aerosol delivery in the US
pMDI
Smoking history is recorded in ______ years, which is determined by multiplying the number of ______ smoked per ____ by the number of _______ smoked.
pack, packs, day, years
Psychogenic hyperventitlation syndrome is associated with _______ disorders.
panic
The _______ medical history describes all past major illnesses, injuries, surgeries, hospitilizations, allergies & health-related habits.
past
History of cigarette and alcohol consumption may be found in this section of the medical history.
past medical history
Direct contact transmission
pathogen is transferred from one person to another
informed consent
patient should be allowed to make their own decisions about the health care they're given (see autonomy)
distributive justice
patients pay for their health care based on their ability to pay
What patients usually require capnometry?
patients undergoing general anesthesia or mechanical ventilation.
Abnormal protrusion of the sternum
pectus carinatum
Depression of part or entire sternum, which can produce a restrictive lung defect.
pectus excavatum
Swelling of the lower extremities.
pedal edema
Who should NOT use a HME booster?
pediatric and infant patients
What are the indications for inhaled corticosteroids?
persistent asthma and COPD
defendant
person denying the party against whom relief or recovery is sought in an action or suit; also the accused in a criminal case
plantiff
person who brings an action; a person who seeks remedial relief for an injury to his or her rights
The second step of the interview is to move into the patient's ________ space, which is _______ feet from the patient.
personal, 2 to 4
Scintigraphy
photograph showing the distribution and intensity of radioactivity in various tissues and organs after administration of a radiopharmaceutical.
When pressure is applied with a finger on a swollen extremity, an indentation mark left on the skin is called ________ ________.
pitting edema
HEPA filter place where can eliminate bacteria
placed between the machinery and the external circuit, proximal to any humidifier
Direct pMDI actuation by simple elbow adapters typically results in the least
pulmonary deposition, with most of the aerosol impacting in either the ventilator circuit or the tracheal airway. Higher aerosol delivery percentages occur only when an actuator or spacer is placed in-line in the ventilator circuit. These spacers allow an aerosol "plume" to develop before the bulk of the particles impact on the surface of the circuit or endotracheal tube. The result is a more stable aerosol mass that can penetrate beyond the artificial airway and be deposited mainly in the lung. This situation leads to a better clinical response at lower doses
combines spectrophotometry with photoplethysmograpy to obtain a noninvasive measure of blood hemoglobin saturations
pulse oximetry
All patients with acute airway obstruction should be monitored for oxygenation status with
pulse oximetry. This value can be used in conjunction with observational assessment to titrate the level of inspired O2 given to the patient (see Chapter 35). Arterial blood gases are not essential for determining patient response to bronchodilator therapy but may be needed for patients in severe distress to assess for hypercapnic respiratory failure
An alternating succession of strong and weal pulses.
pulsus alternans
A significant decrease (>10 mmHg) in pulse strength during spontaneous inhalation.
pulsus paradoxus
_________ sputum suggests a bacterial infection, and appears thick, colored and sticky.
purulent
"never an accident, always a result of intelligent effort"
quality
a high degree of excellence
quality
What is most often used?
radial artery
What is the speed of onset for inhaled aerosols?
rapid. peak onset is 15 minutes
The most accurate site for body temperature measurement, as it is closest to actual core body temperature.
rectum
NAC is indicated to?
reduce accumulation of airway secretions, with concomitant improvement in pulmonary function and gas exchange and prevention of recurrent respiratory infection and airway damage -NAC also is used to treat or prevent liver damage that can occur when a patient takes an overdose of acetaminophen
the term normal ranges is now known as..
reference ranges, biologic reference intervals, and expected value
Tail-off effect
refers to variability in the amount of drug dispensed toward the end of the life of the canister.
Beta 2 adrenergic
relaxes bronchial smooth muscle, stimulates mucoclliary activity
conventional spirometry
remains the standard for determining bronchodilator response.
Equipment processing definitions: Cleaning
removal of all foreign material from objects
Battery
represents unprivileged, nonconsensual physical contact with another person. In the classic act of assault and battery, one individual threatens and injures another
restrictive gatekeeping
requires patients to obtain prior approval from their third-party payer, usually an insurance company, before hospitalization and before certain procedures
3 types of passover humidifiers
reservoir, wick, membrane
droplet nuclei
residue of evaporated water droplets; owing to their small size(0.5-12mm) droplet nuclei can remain suspended in the air for long periods of time
Pursed-lip breathing causes __________ to airflow and creates a slight ______ ___________ in the small airways during exhalation.
resistance, back pressure
This pattern is noted by the upward motion of the diaphragm during inspiration on a series of breaths, followed by diaphragmatic contractions & inward movement of the abdominal wall on the following series of breaths.
respiratory alternans
When the muscles alternately power breathing in an attempt to give each muscle group some rest.
respiratory alternans
The _______ __ _________ part of the medical history reveals problem areas the patient forgot to mention or omitted.
review of systems
What is it capillary blood gas used for?
rough estimate of arterial pH and PCO2 • needs to be warmed
bactericidal
substances with the ability to kill micro-organisms
What is an example of a clinical problem needing O2 therapy?
suspected Carbon Monoxide poisoning
Do adrenergic bronchodilators use sympathetic or parasympathetic nervous system?
sympathetic
Medical term for fainting.
syncope
The peak force exerted in the major arteries during contraction of the left ventricle.
systolic pressure
T/F: Barrel chest is associated with ephysema.
t
A condition in which the pulse exceeds 100 bpm.
tachycardia
What is the first sign of acute diaphragmatic fatigue?
tachypnea
When vocal fremitus vibrations are felt on the chest wall.
tactile fremitus
What do cylinder safety relief valves prevent?
tank pressure from becoming too high.
cross-training
teaching activities normally performed by a specific discipline but not restricted by licensing to personnel of another discipline
Factors affecting a humidifiers performance
temperature, surface area, contact time, thermal mass
antiseptics
tending to inhibit growth and reproduction of microorganisms
The greatest occupational risk for RTs has been associated with
the administration of ribavirin and pentamidine. Conjunctivitis, headaches, bronchospasm, shortness of breath, and rashes have been reported among individuals administering these drugs.83 Patients given aerosolized ribavirin or pentamidine must be treated in a private room, booth, or tent or at a special station designed to minimize environmental contamination.
Most bands are located in..
the bone marrow where they continue to mature
with ipatropium use
the closed-mouth technique to avoiid spraying in the eyes.
hydrofluoroalkane (HFA)
the current gaseous chemical compound used to power metered dose inhalers.
Medline
the database of the National Library of Medicine of millions of references from thousands of journals related to medicine, nursing, the health care system, and science
Regardless of the device used, the clinician must be aware of
the limitations of aerosol drug therapy. First, depending on the device and patient, 10% or less of drug emitted from an aerosol device may be deposited in the lungs (Figure 36-30). As indicated in Box 36-7, additional reductions in lung deposition can occur in many clinical situations that sometimes necessitate the use of higher dosages.
What is Aerosol emitted dose?
the mass (amount) of drug leaving the mouthpiece as an aerosol
describe the pharmacodynamic phase
the mechanisms of drug action by which a drug molecule causes its effects in the body (drug effects are caused by combination of a drug with a matching receptor)
Volume Mean Diameter (VMD)
the median diameter of an aerosol particle measured in units of volume.
describe the pharmacokinetic phase
the time course and disposition of a drug in the body based on its absorption, distribution, metabolism, and elimination. (aerosols made up of medications that are fully ionized have little or no systemic side effects)
PT is defined as
the time in seconds required by plasma to form a fibrin clot after exposure to tissue factors
The guiding principle for homeostasis
the total amount of water, electrolytes, acid, and base gained each day must be balanced by the total amount lost.
telemedicine
the use of telecommunication and computer technology to promote access to diagnosis, monitoring, clinical decision support, and treatment for patients at medically underserved sites that are distant from health care providers
Slander
the verbal defamation of an individual by false words by which his or her reputation is damaged
The Greater the GSD
the wider the range of particle sizes, and the more heterodisperse the aerosol
strict liablity
theory in tort law that can be used to impose liability without fault, even in situations where injury occurs under conditions of reasonable care; the most common cases of strict liability involve the use of dangerous products or techniques
importance of surveillance
to ensure that there is no ongoing problem or to detect problems and intervene to prevent transmission of pathogens in the health care environment
This is caused by extreme negative pressure that pulls the trachea downward during inspiration.
tracheal tugging
Methods for humidifying gas for tracheostomized patients
tracheostomy mask, t-tube
Piezoelectric Crystal
transducer capable of converting electrical energy into the physical energy of high-frequency vibrations
4 categories of expanded precautions
transmission based, airborne infection isolation, protective environment, patient placement and transport
What is INOmax used for?
treatment of neonates with persistent pulmonary hypertension by relaxing the smooth muscle in pulmonary vasculature by producing pulmonary vasodilation and reducing artery pressure/ improving V/Q
When a patient sits or stands while bracing his elbows on a table, allowing for the accessory muscles to gain a mechanical advantage for breathing.
tripodding
describe the historical beginnings of ethics
• Although ethics may share common origins with the disciplines of law, theology, and economics, as an applied practice, ethics is clearly different from these disciplines. Ethics can be described philosophically as a moral principle that supplements the golden rule and can be summed up by a commitment to "respect the humanity in persons."
patient-focused care
• An attempt to organize staff and services around the need of the patients and having specific services and resources directly to the bedside
Long-Term
• Assess severity of symptoms (coughing, wheezing, nocturnal awakenings, symptoms during exertion); use of rescue medication; number of exacerbations; missed work or school days; pulmonary function), and modify level of asthma therapy (up or down, as described in the 2007 NAEPP EPR III guidelines for step therapy). • Assess for the presence of side effects with nonsteroidal antiasthma agents; refer to the particular agent and its side effects
List various general barrier methods that can be used to protect both patients and healthcare workers from the spread of infection.
• Hand washing/gelling • Gloves • Masks, eye protection, face shields • gown
How does hemoximetry work?
• INVASIVE • multiple lights pass through the sample to measure multiple Hb species (HbO2, HbCO, and metHb)
Contraindications for ABG
• Improperly functioning analyzer • An analyzer for which the performance has not been validated by quality control or proficiency testing procedures • Any specimen gathered with known or suspected pre-analytical errors ( air contamination, improper anticoagulation, improper storage or handling) • An incomplete requisition that precludes adequate interpretation and documentation of results • An inadequately labeled specimen
Precautions and or possible complications with ABG
• Infection of specimen handler from blood( HIV,hepatitis B, blood borne pathogens • Inappropriate patient medical treatment based on an improperly analyzed blood specimen, on analysis of unacceptable specimen, or on incorrect reporting of results
Briefly discuss Quality monitoring benchmarks for protocol use.
• Monitoring the correctness of respiratory care plans • Monitoring the consistency of formulating respiratory care plans among therapist evaluators • Evaluating the efficacy of algorithms or protocols • Evaluating the overall effectiveness of the protocol program
How do we analyze gas exchange between lungs and blood?
• O2 and CO2 levels in ARTERIAL blood • CO2 levels in expired air
name 3 mechanisms by which the lungs can be infected
• Obligate transmission • Preferential transmission • Opportunistic transmission
What 3 ways are there to interpret oxygenation status?
• PaO2 • SaO2 • CaO2
What type of OXYGEN ANALYZERS are there?
• Physical (Beckman: outdated but accurate) • Electrical (Mira: outdated) • Electrochemical • chemical • mass spectrometer • Blood Sampling Analyzers • Spectrophotometric (pulse oximeter)
transmission based (contact) precautions
• Private room preferred or cohorting if necessary • Hand hygiene, gown and gloves necessary • Mostly used for multi-drug resistant bacteria such as C. dif
Assessment of inhaled tobramycin
• Verify that the patient understands that nebulized tobramycin should be given after other CF therapies, including other inhaled drugs. • Check whether the patient has renal, auditory, vestibular, or neuromuscular problems or is taking other aminoglycosides or ototoxic drugs. Consider whether tobramycin should be used for the patient based on severity of preexisting or concomitant risk factors. • Monitor lung function to note improvement in FEV1. • Assess rate of hospitalization before and after institution of inhaled tobramycin. • Assess need for IV antipseudomonal therapy. • Assess improvement in weight. • Monitor for occurrence of side effects, such as tinnitus or voice alteration; have the patient rinse and expectorate after aerosol treatments. • Evaluate for changes in hearing or renal function during use of inhaled tobramycin.
What does a normal capnogram show at start?
• a PCO2 of zero at start of expiration
Define professional malpractice
• a form of negligence, can involve professional misconduct, unreasonable lack of skill or fidelity in professional duties, evil practice, or unethical conduct.
What are 2 important factors that influence accuracy of transcutaneous measurements?
• age • perfusion status
[What are some Preanalytic Errors?]
• air in sample -> visible bubbles • venous admixture • excess anticoagulant • metabolic effects -> time lag of collection
[what is the only true way to measure VENTILATION?]
• arterial CO2
How are the results reported?
• as SpO2 -> NOT SaO2! • p = pulse
Where else can arterial blood be taken?
• brachial • femoral • posterior tibial • dorsalis pedis
What is a FAULTY ASSUMPTION of pulse oximetry reading?
• everytime 97% reading = 14.5 gm/dL HbO2 -> patient may be anemic (blood has less than normal # RBC) -> pulse oximeter doesn't look at all types of Hb (may only look at reduced Hb and HbO2)
Name two infection control procedures designed to remove environmental pathogens.
• general sanitation measures • specialized equipment processing.
What are the effects of HUMIDITY on Miniox O2 analyzer?
• it DECREASES the concentration of O2 -like diluting sample with another gas! -if 100% O2 is saturated with 100% humidity, then actual O2 concentration drops to 96-97%! -> using a Humidifier
What is reduced CaO2 a result of?
• low PaO2 and SaO2 • reduced Hb level • or both
What reduces the agreement between PtcO2 and PaO2?
• low perfusion • increasing age
What are oximetry LIMITATIONS?
• motion artifact • abnormal hemoglobins (CO & met) • intravascular dyes • ambient light • low perfusion states • skin pigmentation • nail polish • inaccurate below 83%
What is characteristic of MONITORING?
• ongoing process, dynamic physiologic process in timely manner • done w/MONITOR • no removal of samples from body
What types of blood sampling analyzers are there?
• polarographic (Clark electrode) • Arterial blood gas samples • Transcutaneous monitoring
What should one do so HUMIDITY does not affect Miniox O2 analyzer?
• position sensor UPSTREAM of humidifier • Mount sensor with deflector pointing downward, so water doesn't collect (condensation)
For accurate ABG results, what are components of QUALITY CONTROL?
• record keeping (policies, procedures) • performance validation (testing new instrument) • preventative maintenance / function testing • automated calibration and verification • internal statistical quality control • external quality control (proficiency testing) • remedial action (correct errors)
What is characteristics of LABORATORY ANALYSIS?
• removed from the body • discrete measurements • made with ANALYZER
[How do you calibrate an O2 analyzer?]
• use 2 sample method • expose sensor to 100% & 21% O2
Some rules of Thumb?
• wait 20-30 min. after major change in ventilatory support before sampling • set alarm at 92%, NOT 90% • but ICUs may set alarm levels @ 90% • patients w/chronic hypoxia may be set at 88%
Actions Suggested to evaluate patient response to long-acting beta agonists:
•Assess ongoing lung function, including predose FEV1 over time and variability in peak expiratory flows. •Assess amount of rescue beta agonist use and nocturnal symptoms. •Assess number of exacerbations, unscheduled clinic visits, and hospitalizations. •Assess days of absence from school or work because of symptoms. •Assess ability to reduce the dose of concomitant inhaled corticosteroids.
Nebulizer Design
•Baffles •Fill volume •Residual drug volume •Nebulizer position •Continuous vs. intermittent nebulization •Reservoirs and extensions •Vents, valves, and gas entrainment •Tolerances in manufacturing within lots
AARC Statement of Ethics and Professional Conduct
•Demonstrate behavior that reflects integrity, supports objectivity, and fosters trust in the profession and its professionals. Actively maintain and continually improve their professional competence and represent it accurately •Perform only those procedures or functions in which they are individually competent and which are within the scope of accepted and responsible practice •Respect and protect the legal and personal rights of patients they treat, including the right to informed consent and refusal of treatment •Divulge no confidential information regarding any patient or family unless disclosure is required for responsible performance of duty, or required by law •Provide care without discrimination on any basis, with respect for the rights and dignity of all individuals •Promote disease prevention and wellness •Refuse to participate in illegal or unethical acts, and shall refuse to conceal illegal, unethical, or incompetent acts of others •Follow sound scientific procedures and ethical principles in research •Comply with state or federal laws that govern and relate to their practice •Avoid any form of conduct that creates a conflict of interest and shall follow the principles of ethical business behavior •Promote health care delivery through improvement of the access, efficacy, and cost of patient care •Encourage and promote appropriate stewardship of resources
Actions suggested to evaluate patients response to Bronchodilator Therapy: (2)
•In the long-term, monitor pulmonary function studies of lung volumes, capacities, and flows. •Instruct asthmatic patients in the use and interpretation of disposable peak flowmeters to assess severity of asthmatic episodes and provide an action plan for treatment modification. •Emphasize in patient education that beta agonists do not treat underlying inflammation and do not prevent progression of asthma, and additional antiinflammatory treatment or more aggressive medical therapy may be needed if there is a poor response to the rescue beta agonist.
Effects & Characteristics of (s)-isomer of Albuterol
•Increases intracellular calcium concentration in vitro8 •Activity is blocked by the anticholinergic atropine8 •Does not produce pulmonary or extrapulmonary beta-2-mediated effects9 •Enhances experimental airway responsiveness in vitro10 •Increases contractile response of bronchial tissue to histamine or leukotriene C4 in vitro11 •Enhances eosinophil superoxide production with interleukin-5 stimulation12 •Slower metabolism than (R)-albuterol in vivo13 •Preferential retention in the lung when inhaled by MDI (in vivo)
Actions suggested to evaluate patients response to Bronchodilator Therapy: (3)
•Instruct and then verify correct use of aerosol delivery device (SVN, MDI, reservoir, DPI). •Instruct patients in use, assembly, and especially cleaning of aerosol inhalation devices.
Actions suggested to evaluate patients response to Bronchodilator Therapy: (1)
•Monitor flow rates using bedside peak flowmeters, portable spirometry, or laboratory reports of pulmonary function before and after bronchodilator studies to assess reversibility of airflow obstruction. •Assess arterial blood gases or pulse oximetry saturation, as needed, for acute states with asthma or COPD to monitor changes in ventilation and gas exchange (oxygenation). •Note the effect of beta agonists on blood glucose (increase) and K+ (decrease) laboratory values, if using high doses, such as with continuous nebulization or emergency department treatments.
Gas Source: Wall, Cylinder, Compressor
•Pressure •Flow through nebulizer •Gas density •Humidity •Temperature
Basic Elements of a Practice Act
•Scope of professional practice •Requirements and qualifications for licensure •Exemptions •Grounds for administrative action •Creation of examination board and processes •Penalties and sanctions for unauthorized practice
the Causes of Discipline
•Substance abuse •Domestic violence •Sexual abuse •Gross incompetence
Elements of Negligence
•The practitioner owes a duty to the patient •The practitioner breaches that duty •The breach of duty was the cause of damages •Damage or harm came to the patient
6 basic purposes of communication in the health care setting
•To establish rapport with another individual •To comfort an anxious patient •To obtain information •To relay pertinent information •To give instructions •To persuade others to take action
As of June 2, 20120 the FDA suggests the following on how long-acting beta-2 agonists are used for treating asthma:
•are not to be used without a controller medication (i.e., corticosteroid). •not be used by patients who are controlled on low-dose or medium-dose inhaled corticosteroids. • should be used only if patients are not controlled with agents such as inhaled corticosteroids. • should be for short-term use only. should be discontinued when asthma is controlled. •Children should use only in conjunction with a corticosteroid. The use of a combination product is needed to increase adherence.
