Final

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Hazards/Side Effects of Pentamidine:

( similar to symptoms of PCP) • Respiratory - • Bronchial irritation & bronchospasm ( what could be done to minimize this ?) • Dizziness, nausea, rashes, metallic taste • PCP symptoms - night sweats, chills • Renal Failure • Staff exposure issues / nebulizer

Contraindication for Manually Assisted Coughing

(1) An increased potential for regurgitation/aspiration, as in the unconscious patient with an unprotected airway (2) Acute abdominal pathology, abdominal aortic aneurysm, hiatal hernia, or pregnancy (3) A bleeding diathesis (4) An untreated Pneumothorax (5) Osteoporosis or flail chest

Possible Complications for Bedside PFT

(1) Dyspnea (2) Dizziness (3) Inaccurate results

Monitoring before&after (Endotracheal Suctioning) via closed catheter system

(1) EKG (2) color, consistency, and volume of secretions (3) presnece of bleeding or trauma (4) cough (5) ICP (6) ventilator parameters (7) ABGs as indicated

Contraindications for Bedside PFT

(1) Extreme Dyspnea (2) Inability to follow directions

Possible Complications

(1) Hypoxemia (2) Increased ICP (3) Pulmonary hemorrhage (4) Pain/Injury to muscles, ribs, or spine (5) Vomiting and/or Aspiration (6) Bronchospasm (7) Dysrhythmias

Indications for Nasotracheal Suctioning

(1) Inability to clear secretions (2) Audible evidence of secretions (3) Inability to cough on command

4 Lung Capacities

(1) Inspiratory Capacity (IC) (2) Functional Residual Capacity (FRC) (3) Vital Capacity (VC) (4) Total Lung Capacity (TLC)

4 Lung Volumes

(1) Inspiratory Reserve Volume (IRV) (2) Tidal Volume (VT) (3) Expiratory Reserve Volume (ERV) (4) Residual Volume (RV)

Indications for Bedside PFT

(1) Known or suspected Obsturctive / Restrictive pulmonary disease (2) Known or suspected exposure to substances which may cause pulmonary disease (3) Surgery requiring general anesthesia (ex. open heart surgery)

What possible causes can relate to Restrictive Pulmonary Disease?

(1) Neuromuscular problems (2) Sturctural problems (3) Loss of compliance

Advantages for (Endotracheal Suctioning) via closed catheter system

(1) No need to disconnect the patient from the O2 or ventilator (no need to turn down PEEP) (2) Don't break open the circuit - Less exposure for caregivers - Less chance of nosocomial infection for patient (3) Less prep time & medical waste

Contraindications for Nasotracheal Suctioning

(1) Occluded nasal passage (2) Nasal bleeding (3) Acute head, facial, or neck injury (4) Coagulopathy or bleeding disorder (5) Laryngospasm (6) Irritable airway (7) Upper respiratory tract infection ABSOLUTE CONTRAINDICATION: (1) Epiglottis or Croup

(1) Difference between performing the procedure of MIP on alert patients and unresponsive patients ? (2) Why?

(1) On an unresponsive patient, during exhalation or during a pause, the inspiratory side of the one-way valve system is occluded (2) To check until one of the following occurs: - consistent negative pressure reading - fall in the patients SpO2 reading - change in the rate / rhythm on the EKG monitor

Assessment of effectiveness of IPPB

(1) PIP (2) VT exhaled (3) Vital Signs (RR, HR, breath sounds, SpO2) and more...

Contraindications for IPPB

(1) Pneumothorax without a chest tube (ABSOLUTE) (2) Uncooperative patient (3) A less invasive therapy is avaiable - Incentive Spirometry - Deep breathing exercise - Flutter valve therapy - Chest physiotherapy - PEP therapy - SVN/MDI for medication therapy (4) Pneumomediastinum & Subcutaneous Emphysema (5) Tracheosophageal Fistula (6) Ballous Disease (7) Hemodynamic Instability (8) Pulmonary hemorrhage (9) Active tuberculosis (10) Recent esophageal surgery (11) Recent facial, oral, or skull surgery (12) Nausea (13) Air swalloing (14) Hiccups (15) Increased Intracranial Pressure > 15 mm Hg

Contraindications for CPT (Reverse Trendellenburg)

(1) Presence of hypotension (2) Use of vasoactive medications

Indications for Pulmonary Clearnace Procedures

(1) Retained secretions (2) Restrictive disease and disorders (3) Aspiration (4) Prophylactic Care

Contraindications for CPT (Percussion and/or Vibration)

(1) Subcutaneous Emphysema (2) Recent epidural spinal infusion / spinal anesthesia (3) Recent skin grafts, or flaps, on the thorax (4) Burns, open wounds, and skin infections of the thorax (5) A recently placed transvenous pacemaker or subcutaneous pacemaker, especially if mechanical devices are to be used (6) Suspected pulmonary tuberculosis (7) Lung contusions (8) Bronchospasm (9) Ostemomyelitis of the ribs (10) Osteoporosis (11) Coagulopathy (12) Complaint of chest wall pain

Indications for IPPB

(1) The need to improve lung expansion - treatment of atelectasis (2) Short-term ventilatory suppport - pulmonary edema - acute hypoventilation (3) The need to deliver medication Overwhelming Indication: (1) Patient is unable to take a spontaneous deep breath

The effectiveness of coughing may be compromised...

(1) The presence of severe obstructive airway disease (2) Pain from coughing (3) Fear of pain (4) Neurologic, muscular, or skeletal abnormalities (5) The presence of an artificial airway (6) The presence of thick, tenacious sputum

Objectives for Bedside PFT

(1) To assess the impact of disease on pulmonary function (2) To assess the progression of a disase process (3) To assess the effectiveness of interventions (4) To screen for possible pulmonary disease (5) To evaluate surgical risk (6) To evaluate the patient's ability to breath independently

Objectives for Nasotracheal Suctioning

(1) To maintain a patent airway (2) To obtain a sputum specimen (3) To stimulate a cough

Objectives for Pulmonary Clearnace Procedures

(1) To remove retained secretions (2) To remove foregin objects from the lungs (3) To prevent the accumulation of secretions in the lungs

Contraindications for CPT (Trendellenburg)

(1) Uncontrolled Hypertension (2) Distended abdomen (3) Esophageal surgery (4) Recent hemoptysis related to lung cancer (5) Uncontrolled airway at risk for aspiration

(Bedside PFT) measuring devices

(1) Water-Sealed Spirometers ... volume and flow (2) Fleisch Pneumotachometers ... pressure diff to calculate flow (3) Thermistors ... temp diff to calculate flow (4) Turbinometers ... uses RPM to calculate flow (5) Vortex Shedding Devices (6) Strain Gauges ... deformation of screen (grid) to calculate flow (7) Peak Flow Meters ... measures flowrate (8) Mechanical Aneroid Manometers ... manually measure pressure

(1) Resistance (2) What Law?

(1) a measure of how difficult it is to get gas to flow into the lungs (2) Pouiselle's Law

Monitoring before & after (Endotracheal Suctioning) via traditional sunction kits

(1) breath sounds (2) EKG (3) color, consistency, and volume of secretions (4) presence of bleeding or trauma (5) cough (6) ICP (7) ventilator parameters (PIP, Vt, Graphics, FIO2) (8) ABGs as indicated

Monitoring during Nasotracheal Suctioning

(1) breath sounds (2) skin color (3) breathing pattern & rate (4) pulse rate

Monitoring before & after Nasotracheal Suctioning

(1) color, consistency, and volume of secretions (2) subjective responses (3) cough (4) oxygenation

(PEP) may be more effective when combined with other therapies...

(1) combining with IS for the treatment of Post-op atelectasis (2) combining with huff coughing (most effective) (3) combining with CPT for cycstic fibrosis patients

(1) ___ 10% of spontaneous VC or ______ ml/kg of ideal body weight = minimum effect (2) ____ - _____ ml/kg of ideal body weight = adequate volume

(1) greater or equal ; 30 (2) 15 - 20 ml/kg 10 - 15 ml/kg (pulmonary edema)

(1)SVC, FVC values (2) PEFR values (3) MIP(NIF) values

(1) greater or equal to 80 % predicted is considered normal (2) greater or equal to 80 % predicted is considered normal & less or equal to 50 % predicted is generally considered to be indicative of bronchospastic crisis requiring further interventions (3) - 80 to -100 cm H2O is considered normal & less or equal to -25 cm H2O considered to indicate a need for mechanical ventilation

Monitoring during (Endotracheal Suctioning) via traditional suction kits

(1) skin color (2) breathing pattern & rate (3) pulse rate (4) oxygenation

Monitoring during (Endotracheal Suctioning) via closed catheter system

(1) skin color (2) breathing pattern & rate (3) pulse rate (4) oxygenation (5) breath sounds (6) subjective response

Oraltracheal Suctioning

(1) uses tonsil (Yankaur) suction catheter (2) try not to trigger a gag relfex (3) may assist the patient with a productive, spontaneous cough

What can happen to a patient when he loses muscle tone in his airway? What can cause this?

(possibly due to altered mental status and neurological disorders)\n\nTongue relaxes and falls back, which causes the epiglottis to fall back and cover the entrance of the trachea. Obstructs the airway.

Possible Complications for Endotracheal Suctioning

** (1) Cardiac dysrhythmias / arrest (2) Hypoxia / Hypoxemia (3) Tissue trauma (4) Respiratory arrest (5) Pulmonary atelectasis (6) Bronchospasm (7) Infection (8) Pulmonary hemorrhage / bleeding (9) Increased ICP (10) Interruption of mechanical ventilation (11) Hypertension & Hypotension

Possible Complications for Nasotracheal Suctioning

**(1) Cardiac dysrhythmias (espically bradycardia) or arrest (2) Hypoxia / Hypoxemia (3) Trauma to the upper airway (4) Increased blood pressure (5) Hypotension (6) Respiratory arrest (7) Uncontrolled coughing (8) Gagging / vomiting (9) Laryngospasm (10) Bronchospasm (11) Pain (12) Increased Intracranial Pressure

Possible Complications for IPPB

**(1) Impedance of venous return (2) Gastric distension (3) Air-trapping (4) Over distension of alveoli (5) Barotrauma and possible pneumothorax (6) Increased airway resistance & WOB (7) Nosocomial infection (8) Hemoptysis (9) Hyperoxia if using O2 (10) Secretion impaction (11) Psychological dependence (12) Exacerbation of hypoxia (13) Hypoventilation / Hyperventilation (14) Worsening V/Q mismatch

Protection against malicious software

*-Firewall:* filter the exchange of data between the internet and local networks -verify user identification, passwords and registered internet address -restricts certain communication -update security patches -install virus scanning program and update it -discriminate email files -refrain from downloading applications from unknown sources

Obstructive Disease (characteristics)

*Airway resistance* -Diseases which impede full exhalation -Trapping of gas in the alveoli and distal airways.

Residual Volume

*Cannot be exhaled from the lungs after forced exhalation* -The amount of air that remains (cannot be exhaled from lungs) after MAXIMAL exhalation -Prevents fluctuations in gas exchange by maintaining oxygen during expiration -RV cannot be directly measured with spirometry but there are other clinical ways -Always will have air remaining in lungs even after forced expiration or else lung would collapse -RV makes it easier to make the next breath because the lung is partially inflated

membrane-type humidifiers

*Does Not* require a flow control system because it cannot overfill *Only* requires an open gravity feed sysytem

FEF25-75

*Forced mid-expiratory flow FEF25-75* Slope of the line between 75% and 25% of the total lung capacity during forced exhalation -The slope of this line indicates the volume changed by time of gas flow -Assessment of airway RESISTANCE

Helium dilution measurement

*Helps find FRC* -If a known concentration of helium is present at a known volume, the gas can be redistributed by breathing for several minutes from spirometer cylinder. -The concentration of helium is then measured at the end of the normal exhalation (FRC) and a simple proportion determines the new volume of gas between the patient and the spirometer. -By subtracting the original volume of the spirometer and the expiratory reserve volume measured during spirometery, the patient's residual volume is calculated. -FRC= Resting lung volume -RV= FRC - ERV

What is the simplest way to increase the humidity output of a humidifier?

*Increase* Water or Gas temp

Increasing the flow through an unheated bubble humidifier will ________

*Increase* the water vapor content.

The greater the temperature of the gas, the ______

*More* Water Vapor it can hold

Question 18 What is the *primary goal* of a *heated humidification system?*

*Primary goal* is to *match the output* of the humidifying *device* to the normal *inspiratory conditions* occurring at the *level of the trachea*

What is the goal of using an unheated bubble humidifier with oronasal oxygen delivery systems?

*Raise* Water vapor of gas to ambient levels

FVC measurement in Restrictive lung disease

*Reduced forced vital capacity in absence of significant neuromuscular disease* -Residual volume is often REDUCED -Total lung capacity reduced due to reduction of FVC -FEV1/FVC ratio is normal or even greater than normal -FEF25-75 has STEEP slope indicating low airway resistance to gas flow. -Patients with restrictive lung disease have difficulty getting the gas into the lung because of STIFFNESS (more elastance) of the lung or chest wall. -FEV1 is reduced because exhalation starts at a LOWER total lung capacity and reaches residual volume more QUICKLY -Gas can come out faster as lung is stiffer

FVC measurement in obstructive lung disease

*Reduction in FEV1/FVC ratio* -Less is exhaled from forced vital capacity -FEF25-75: FLAT not steep= low gas flow -Difficulty getting the gas out and have a high residual volume and increased total lung capacity -Forced vital capacity is reduced but the FEV1 is reduced far more. -Residual volume increases as less air is exhaled out. -Patients with obstructive lung disease have high *expiratory airway RESISTANCE* to gas flow.

HIS

*hospital information system -large scale multi user database* management system

List malicious software and preventative measures: worms

*self replicating malicious computer program. self contained* User does not need to do anything. *can spread to entire network* Invade computer memory, distributes copies of itself to others

Question #17 purpose bubble "pop off" valve

- Audible pressure relief, sounds 2psi limit, indicate obstruction in tubing -failure to indicate faulty valve or leak -high flow rates aerosol ^risk of infection

What two factors determine harmful effects of oxygen toxicity?

- PO2 - higher (higher FiO2 causes) - Exposer time - longer

problems associated with use of enclosures? (mist tents andhoods)

-*CO2 build up and heat retention* -CO2 build up can be reduced by having sufficient flow of fresh gas circulating through device -Heat build up may be handled by High fresh gas flow and incorporation of separate cooling device (usually electric powered refrigeration unit

Reservoir or feed systems

-*Heated humidifiers running continuously* can evaporate more than 1 L of H2O per day To avoid constant refilling many have *large reservoir or gravity feed* Ideal system should be safe, easy to set up, dependable and allow for continuity of therapy when reservoirs being filled -Large reservoir still require filling Interruption of mechanical ventilation Potential for contamination *-Gravity feed systems require constant checking and opening of valve danger system could run dry* -Membrane cartridge systems are now being used to humidify high flow nasal cannula for adults and infants

Warmed, humidified gases are used to treat?

-*Hypothermic* patient who requires an increase in core temperature -*Prevention of intraoperative hypothermia* -Patient with *exercise or cold induced bronchospasm* A scarf over the face and mouth may act as a crude heat moisture exchanger Remember when you had on that mask for infection control

Obstructive lung disease (pathophysiology)

-*Increased compliance* of the lung making it more easily distended -Alveolar spaces are dramatically increased in size as a result of the decrease in lung elastin and resultant *gas trapping* as airways close during exhalation. -Ex.) Emphysema (COPD)

Question 28 What are *five factors *associated with *condensation (rain out) in ventilator circuit?*

-*Temperature* difference between *humidifier and airway* -The *ambient temperature * -The *gas flow* -the *set airway temperature* -*Length, diameter and thermal mass of breathing circuit*

What value that is considered normal using MIP? A value of - _____ to -_____ cm H2O is considered normal. What value is considered to indicate a need for mechanical ventilation for MIP?

-80 to -100 cm H2O; ≤ -25 cm H2O

Explain the basic operation of the wick and membrane heated humidifier Membrane

-A membrane type humidifier *separates the membrane from the gas* stream by means of a hydrophobic membrane * water vapor* molecules can easily *pass* through the *membrane but liquid water cannot* -Advantages include: can maintain saturation at high flow rates Add little or no flow resistance to spontaneous breathing circuits Do not generate any aerosol / *little risk of spreading infection*

Explain the basic operation of the wick and membrane heated humidifier Membrane

-A membrane type humidifier separates the membrane from the gas stream by means of a hydrophobic membrane water vapor molecules can easily pass through the membrane but liquid water cannot -Advantages include: can maintain saturation at high flow rates Add little or no flow resistance to spontaneous breathing circuits Do not generate any aerosol / little risk of spreading infection

Retinopathy of prematurity (ROP) or Retrolental Fibroplasia

-Abnormal eye problem occurring in some premature or low birth weight infants -Excessive PaO2 levels causes retinal vasoconstriction Leads to necrosis of blood vessels New vessels form and increase in number Hemorrhage of the new vessels causes scarring behind the eye's retina, leads to retinal detatchment -affects newnates up to about 1 month -other associated problems are hypercapnia, hypocapnia, hemorrhage, infection and anemia hypothermia

cross contamination

-Aerosol and condensate from ventilator circuits are known sources of bacterial colonization -Wick and membrane type passover humidifiers prevent formation of bacteria carrying aerosols -Heated wire circuits reduce production and pooling of condensate -Higher temperatures in humidifiers is bacteriocidal -Circuit contamination usually occurs from patient to circuit

Define oxygen toxicity, its affects on the CNS and list precautions to avoid O2 toxicity.

-Affects the lungs and CNS -Pulmonary effects may occur at clinical PO2 levels -Oxygen toxicity CNS: Tremors, twitching, convulsions, symptoms are more pronounced with hyperbaric oxygen(usually aboe 1atm) -Avoiding oxygen toxicity: Limit patient exposure to 100% oxygen to less than 24 hours whenever possible. High FiO2 is acceptable if the concentration can be decreased to 70% within 2 days and 50% or less in 5 days

What effect does air dilution (air entrainment) have on aerosol output and aerosol density?

-Air dilution increases the aerosol output(total water leaving) but decreases the aerosol density(how thick it is) -Jet flow is not increased, large particles carried out by increased air entrainment flow -Aerosol density or amount of aerosol per liter of gas actually decreased with air entrainment -Aerosol output: 1 - 1.5ml/min -Particle size 55% fall into 1-5 micron range and 100% fall into 1- 10 micron range

Question #9 level ANSI set the minimum water vapor content to avoid damage to the upper airway non intubated pt(normal airway)?

-American National Standard Institute(ANSI) id 10mg/L water vapor content as minimum level of absolute humidity avoid mucosal damage to upper airway

What are the problems associated with using high FIO2 settings on an LVN?

-At higher FIO2 settings the total flow may *not be sufficient to meet patients inspiratory demand*

What are the problems associated with using high FIO2 settings on an LVN?

-At higher FIO2 settings the total flow may not be sufficient to meet patients inspiratory demand

Question # 10 clinical signs and symptoms of inadequate airway humidification?

-Atelectasis -Dry, nonproductive cough -increase airway resistance -increase infection -increase WOB -substernal pain, airway dryness -Thick, dehydrated secretion [A.D. 3I's S.T]

Question 30 What is an advantage of an automatic feed reservoir system?

-Automatic feed system avoid the need for constant checking and manual refilling of heated humidifiers

Oxygen Toxicity and O2 therapy

-Breathing up to 50% for extended periods without major damage. We attempt to keep FiO2 less than the 60% -Weigh both FiO2 and exposure time in assessing risks of high PO2 -Goal should always be to use the lowest possible FIO2 compatible with tissue oxygenation -Never withhold supplemental O2 from hypoxic patient -Toxic effects of high FIO2 can be serious -Alternative is certain death due to tissue hypoxia

What are two problems associated with the use of enclosures? (mist tents andhoods)

-CO2 build up and heat retention -CO2 build up can be reduced by having sufficient flow of fresh gas circulating through device -Heat build up may be handled by High fresh gas flow and incorporation of separate cooling device (usually electric powered refrigeration unit

Respiratory Depression

-COPD patient breathing due to hypoxic drive(chronic hypercapnia) which is high CO2 high PaCO2 -central response to carbon dioxide is blunted and the primary stimulus to breath is due to hypoxemic stimulation to the peripheral chemoreceptors -High levels of oxygen may cause hypoventilation (or worse) -Maintain PaO2 between 50 and 65 mmHg on these patients Our normal goal is 60 mmHg -High flow device and low concentrations of oxygen ideal: low flow nasal canula -If you give a person with hypoxic drive O2 they may hyperventilate and stop breathing.

Depression of ventilation

-COPD patients with chronic hypercapnia tend to ventilate less when breathing moderate to high O2 concentrations Suppression of the hypoxic drive Response to high PCO2 is blunted Primary stimulus to breathe is hypoxemia sensed by peripheral chemoreceptors

What are 3 cons of using an HME?

-Can cause Increased Delivery Pressures -Must be removed during Aerosol Therapy -May increase or thicken secretions

Question 29 What problems does condensate in a ventilator circuit pose for mechanically ventilated patient?

-Can impair gas flow through circuit May effect ventilator function -condensation may be aspirated by patient Circuits must be pointed to drain condensate away from patient Check often, excess condensate must be drained from circuit -Patients contaminate circuits within hours which becomes colonizes with bacteria and thus poses an infection risk -Breathing circuit condensate should be treated as infectious waste

What problems does condensate in a ventilator circuit pose for mechanically ventilated patient?

Minimizing Cardiopulmonary workload

-Cardiopulmonary systems compensates for hypoxemia by increasing: Ventilation and cardiac output -Hypoxemic patients breathing room air can only achive acceptable PaO2 by increasing ventilation -Increased ventilatory demand -Increased WOB -O2 therapy decreases ventilatory demand and WOB

Low flow system

-Criteria Should have ventilatory pattern that is consistent and regular Should have tidal vol in 300 to 700 ml range Should have respiratory rate that is less than 25 breaths/min -Assessment of patient Therapist assessment Laboratory measurements Patients subjective response

Cylinder transport and signage

-Cylinder carts designed for transport, small cylinder vs large -Dont let them strike orther cylinders -Dont drop them, roll them, drag them -Dont transport cylinders that are not properly labeled -Signs for gas presence Used to have signs outside patients room. Now hospitals are all non smoking so there is only a sign when entering the hospital

Differentiate between the markings and identifications found on a gas cylinder

-DOT or ICC(interstate commerce commission) marking top of tank. -Type of tank: 3A or 3AA also type as in (E tank) -PSI, serial number, ownership mark, elastic expansion -Aluminum cylinders must be hydrostatically re tested every 5 yrs. forces of water and pressure it exerts -During testing cylinders are pressurized to 5/3 of their service pressure. (determines elastic expansion, 5-10yr testing, *indicates a 10 year testing. - + sign indicates cylinder may be filled to 10% above service pressure (passed specifications or refill) ex: service pressure of 2015 can be filled to 2200psig - After testing cylinders receive internal and external visual examination.

Oxygen Toxicity Exudative phase

-Damage to alveoli and blood vessels with influx of inflammatory cells into interstitium -Low V/Q ratios -Physiological shunting -Hypoxemia -End stage Hyaline membranes form: cellualr debris and condensed plasma preteins that fill the alveolar spaces Pulmonary fibrosis Hypertension

Non rebreathing mask

-Delivers 80-95% at flow of 6-15L/min -flow must be sufficient to keep reservoir bag 2/3 full at peak inspiration -One way filter valve between mask and reservoir bag, which will not allow exhaled gases into the bag. -1 to 2 one way flutter valves are located on exhalation ports of mask to prevent room air entrainment. -Commonly used for severe hypoxemia ex: CO poisoning -used in hospital

Classify large volume nebulizers (type of flow) and define their use

-Device of choice to use with patients with artificial airways Tacheostomy collar and briggs T adaptor -Performs as a fixed performance device only when output flow meets or exceeds patients inspiratory demand. Fixed only if delivering low O2 concentrations of less than 28-100% -Do not allow easy increases in nebulizer output flow by means of an increase in O2 input. -6-15 L/min at 50 psig

two major devices used deliver a bland aerosol?

-Devices to deliver bland aerosol theapy are usually either *large volume nebulizers (LVN) or untrasonic nebulizer (USN)* -Delivery system includes: aerosol mask, face tent, trach collar, T - tube and mist tent

What are the two major devices used to deliver a bland aerosol?

-Devices to deliver bland aerosol theapy are usually either large volume nebulizers (LVN) or untrasonic nebulizer (USN) -Delivery system includes: aerosol mask, face tent, trach collar, T - tube and mist tent

Air entrainment system

-Direct high pressure oxygen source through a small nozzle or jet surrounded by air entrainment points. -Entrainment of air varies directly with port size. size - larger intake, more air entrained. velocity of oxygen - more air entrained. -Set to deliver less than 35% O2 easily meets peak inspiratory flow -above 35% difficult to main flow (FiO2 often variable) -Range 24-55% -Always provide less than 100% -More air entrained, higher total output flow, lower the delivered FiO2 -high flows only possible when deliverying low oxygen concentration -Function as true high flow system as low FiO2

Humidifiers / Passover

-Directs gas over a water surface -Three common types: simple reservoir, wick and membrane

List indications for oxygen therapy

-Documented hypoxemia as evidenced by: PaO2 less than 60 mmHg or SaO2 less than 90% in subjects breathing room air. PaO2 or SaO2 below desirable range for a specific clinical situation -Acute care situations in which hypoxemia is suspected -Severe trauma -Acute myocardial infarction -Short term therapy or surgical intervention

Differentiate between the letter designations for different size tanks

-E through AA are referred to as "small cylinders" -Most often for anesthetic gases and transportation -Easily Identifiable by their unique valve and connecting mechanism - E tank is the most used in the clinical setting to transport patient - H and K same size

Obstructive Disease (chronic)

-Emphysema: The loss of elastic tissue in emphysema decreases lung elasticity and causes collapse of airways and air trapping. The trapped air increases the RV and FRC. -Chronic bronchitis *Classic examples of chronic obstructive airway diseases*

Absorption atelectasis

-FIO2 increases 0.50 (60%) percent significant risk -O2 washes out the Nitrogen (N2) causing alveolar volume to decrease (N2 is thelargest amount of gas in alveoli and blood) Nitrogen levels decrease thus total pressure of venous gases rapidly decrease. Other gases that exist at atmospheric pressue within any body cavity rapidly diffuse into the venous blood This includes diffusion of oxygen from the alveolar region into the blood Alveolar plug complicate the problem more causing gas pressure in the alveolus to progressively decrease until collapsed and this=shunt -Risk greatest in patients: Breathing with low tidal volume Sedation, surgical pain, CNS dysfunction

Protection against malicious software

-Firewall: filter the exchange of data between the internet and local networks -verify user identification, passwords and registered internet address -restricts certain communication -update security patches -install virus scanning program and update it -discriminate email files -refrain from downloading applications from unknown sources

Estimating duration of gas flow

-For a given flow: the more gas a cylinder holds, the longer it will last. H and K cylinders are large cylinders Duration of flow is directly proportional to its contents -Conversely, the higher the flow, the shorter the emptying time. Inversely proportional to its flow

Obstructive Disease (Acute)

-Foreign body -Asthma: caused by airway inflammation and bronchoconstriction -Pulmonary (airway) edema

Question 35 Why are ventilator circuits changes less often then they once were?

-Frequent circuit changes actually increase the risk of nosocomial pneumonia -Minimal infection risks with weekly circuit changes -Many institutions no longer change circuits unless they are visibly contaminated -Less frequent changes also provide cost savings

Assessing lung function

-Gas Exchange: PaO2, SaO2, PaCO2, pHa -Lung volumes (Restrictive disease): Vital capacity -Airway gas flow (obstructive disease): Forced expiratory flows -Specialized tests: >Diffusing capacity >Functional residual capacity (FRC)

Explain the basic operation of a bubble humidifier

-Gas conducted below the surface of sterile water and allowed to bubble back up to the top diffuser causes the gas to be broken up into smaller bubbles Increased efficiency due to increase surface area for gas/water content -The goal is to raise the water vapor content of the gas to ambient levels -can provide absolute humidity of 15 - 20 mg/L -most common, to provide some humidity for patients with nasal cannula and oxygen masks -used when flow greater than 4L/min

Question #16 basic operation bubble diffuser humidifier

-Gas go below the surface water and allowed to bubble back up to the surface ~Diffuser cause gas to broken up small bubbles ~^efficency ^ area content gas/water -provide absolute humidity 15-20mg/L -most common type humidifier -simple O2 devices flow greater 4L/min -heated reservoir ^ humidity cause occulsion small bore tubing -goal rise water vapor content comfortable 4 pt (nasal cannula and O2 mask provide humidity)

Ultrasonic nebulizers

-Have been marketed as *cool mist devices* for use in *home as humidifiers* -There is some concern that the reservoirs can easily become contaminated and source of infection. should be cleaned regularly and reservoir disinfected every 6 days

Ultrasonic nebulizers

-Have been marketed as cool mist devices for use in home as humidifiers -There is some concern that the reservoirs can easily become contaminated and source of infection. should be cleaned regularly and reservoir disinfected every 6 days

Partial rebreathing mask

-High concentration but still low flow -Delivers 60-80% O2 at flow rates of 6-15L/min -Flowrate must be sufficient to keep reservoir bag at least 2/3 full at peak inspiratio -No valves on mask -First part of patients exhaled gas enters the reservoir bag which is high in O2 -Mixes with O2 in bag

Gas Cylinders

-High pressure cylinders used to store and ship compressed or liquid medical gases. -Uses: Transportation or ambulation of patients requiring oxygen. Transportation of patients on ventilators Use as O2 source for long term requirements -Made of seamless steel or aluminum

What does the *moisture output* of an *HME* tend to *fall with?*

-High volumes and high rates of breathing -High inspiratory flows and FIO2 levels

Variable affecting FIO2 of low flow oxygen system: Increases FIO2

-Higher O2 input -mouth closed breathing -low inspiratory flow -low tidal volume -slow rate of breathing -small minute ventilation

What is the difference between humidity and aerosol?

-Humidity (cant see) is simply water in the gas phase -Bland aerosol (Can see) consists of liquid particles in a gas

*warmed,* humidifiers used treat:

-Hypothermia want increase core temp. -prevention of intraoperative hypothermia -exercise or cold induced bronchospasm

Warmed, humidified gases are used to treat?

-Hypothermic patient who requires an increase in core temperature -Prevention of intraoperative hypothermia -Patient with exercise or cold induced bronchospasm A scarf over the face and mouth may act as a crude heat moisture exchanger Remember when you had on that mask for infection control

If water content is kept constant and temperature is increased, what effect will this have of relative humidity? Explain why this is true

-If a gas is cooled the capacity to hold water vapor will decrease and relative humidity will lower -If gas is warmed the capacity to hold water vapor will increase and relative humidity must increase

Question 5 If water content is kept constant and temperature is increased, what effect will this have of relative humidity? Explain why this is true

How is corrugated tubing used with large volume nebulizers

-If you add 50-150 ml(open reservoir) tubing to expiratory side of the T tube you can obtain a higher FiO2. -Humidity and Temperature combined produce particulate water to the airways. this will cause entrainment and cause lower FiO2. To fix you would need to drain the tube. Results in inaccurate FiO2

Describe reservoir devices

-Incorporate a mechanism to gather and store oxygen between patient breaths. -Draw on this reserve supply whenever their inspiratory flow exceeds the oxygen flow into the device. Air dilution is reduced. Generally provide higher FIO2s than low flow systems -3 types: Simple mask, partial rebreathing mask and nonrebreathing mask

What will a lack of O2 in arterial blood cause?

-Increased work of the heart. By correcting hypoxemia we can prevent or minimize the increased cardiopulmonary workload associated with responses to hypoxemia

What are different memory devices?

-Internal memory: immediately available to CPU -External memory: Provided by mass storage devices such as disk drives -Memory is the electronic space where computer's store data or instructions

Question #6 ISB, 4 ways make it shift deeper into the lung?

-Isothermic saturation boundary -5cm below the carina - 4 things make ISB shift deeper into the lungs: * ~breathe through your mouth instead of nose ~upper airway is bypassed ~min. ventilation higher normal ~breathe cold, dry air* [B.U.M.B]

Define and contrast low flow and high flow devices (including minimum and maximum flows) low flow

-Low flow systems: supplemental oxygen directly to the airway at flows of 8L/min or less(exception high flow n/c) -Total inspired volume or flow is not delivered by the apparatus it is mixed with room air. -*Oxygen provided always diluted with room air.* -Low and vairable FIO2: nasal cannula, nasal catheter, transtracheal catheter -*All extremely variable and unpredictable*(if hypoventilatioin you will get more, hyperventilating and you will get less

Define and contrast low flow and high flow devices (including minimum and maximum flows) low flow

-Low flow systems: supplemental oxygen directly to the airway at flows of 8L/min or less(exception high flow n/c) -Total inspired volume or flow is not delivered by the apparatus it is mixed with room air. -Oxygen provided always diluted with room air. -Low and vairable FIO2: nasal cannula, nasal catheter, transtracheal catheter -All extremely variable and unpredictable(if hypoventilatioin you will get more, hyperventilating and you will get less

Contrast low level FIO2 devices, moderate FIO2 devices and High FIO2 devices. Give a patient example for each level

-Low(<35%): Fixed= AEM, air entrainment nebulizer, blending system, isolette incubator(infact) Patient Ex:Patient who comes in who is in unstable condition and needs a low flow system. Variable: nasal cannula, nasal catheter, transtracheal catheter, Ex patient: home care patient who need long term therapy. Stable patient who needs low flow FIO2 -Moderate (35-60%) fixed: air entrainment nebulizer, blending system Patient example:Patient who an artificial airway Variable: simple mask, air entrainment nebulizer Patient example:simple mask, emergencies, short term therapy req moderate FIO2, mouth breathing patients req FIO2 -High ( greater than 60%): Fixed: Oxyhood (infant), blending system, Patient ex: Infant who needs supplemental oxygen variable: tent (child)partial, nonrebreathing patient ex: nonrebreathing, emergencies, short term needing high FIO2

Variable affecting FIO2 of low flow oxygen system: Decreases FIO2

-Lower O2 input -mouth open breathing -High inspiratory flow -high tidal volume -Fast rate of breathing -large minute ventilation

Aerosol drug therapy includes?

-MDI -DPI -Jet nebulizers both SVN and LVN -USN -Atomizers / nasal spray pumps -Vibrating mesh nebulizers

Troubleshooting AE systems

-Major problem assuring that the set FiO2 is actually delivered to the patient, few problems below 35% -Performance is affected by downstream resistance Results in inaccurate FiO2 If you Increased FiO2. If blocked patient will become air hungry and entrain more room air and the oxygen percentage may decrease

Question 25 What is the difference between a manual control and a servo control on a heated humidifier

-Manuel control to allow a therapist to regulate heat delivery to humidifier Like a knob on the stove. Higher reference number greater amount of heat available -Servo control: automatically adjust temperature level via a probe close to the patients airway Like thermostat on your furnace

List malicious software and preventative measures: Trojan horse

-Masquerades as seemingly benign and legitimate program -If activated, *may lay dormant in computer and then emerge and destroy* or remodel unsuspecting host *by erasing drive* -Can allow someone to gain control over invaded computer from remote site -*Not self replicating*

List malicious software and preventative measures: Trojan horse

-Masquerades as seemingly benign and legitimate program -If activated, may lay dormant in computer and then emerge and destroy or remodel unsuspecting host by erasing drive -Can allow someone to gain control over invaded computer from remote site -Not self replicating

List malicious software and preventative measures: spy ware

-May be legitimately installed to enhance network security -May be embedded in downloadable files or free software on the web The purpose can be *data collection for marketing via "cookies" malicious subversion of the operation of computer* May log all of users keystrokes stealing confidential information

List malicious software and preventative measures: spy ware

-May be legitimately installed to enhance network security -May be embedded in downloadable files or free software on the web The purpose can be data collection for marketing via "cookies" malicious subversion of the operation of computer May log all of users keystrokes stealing confidential information

Question 33 Explain the basic *operation* of a *heated wire circuit*

-Most use *dual controllers with two temp sensors* * One monitors the temp leaving the humidifier* * One monitors the temp near patients airway* The *controller regulates the temperature* between the humidifier and the patients airway There is less water use, less condensation, less need for drainage and less infection risk to patient or healthcare worker

Be prepared to recommend oxygen delivery device for specific patient scenarios

-Nasal cannula: good for patients who need to eat. -Simple mask: ambulatory -partial rebreathing mask: patients with moderate to severe hypoxemia -Non rebreather mask: patients with severe hypoxemia(CO poisoning) -Air entrainment(venturi mask): alert patient needing low to mod FiO2 -Aerosol mask with air entrainment nebulizer: when bypassing upper airway. -Oxygen hood: infants and newborns -Oxygen tents: primarily used on children for croup, epiglottitis and cystic fibrosis

Performance - Low flow systems

-Nasal low flow system oxygen concentration ranges Normal range 22% - 44%, max flow of .5L/min to 6L/min most common and most common and comfortable for patient 8L/min could be considered a comfortable flow for some and new high L/min nasal systems that may achieve 60% -FIO2 varies with the amount of air dilution amount of dilution is variable based on multiple factors -Impossible to determine exact O2 concentration

If the DOWN tube on a Bubble Humidifier becomes obstructed, what happens?

-No bubbling or alarm will occur -And the Compensated Flow Meter will read ZERO

FEV1/FVC in lung disease

-Normal: 0.75-0.80 -Obstructive: lower ratio (<0.75) >Can't get gas OUT -Restrictive: Normal to higher ratio >Can't get gas IN -Ratio between FEV1.0 and FVC is more important than FEV1.0 alone.

Who should use high flow nasal cannula?

-Numerous chronic lung disease improve gas exchange or reduce work of breathing -pulmonary fibrosis -unable to tolerate traditional mask: claustrophobia, burns -Unable to tolerate NIPPV, Dementia, DNR, End stage -High flow oxygen therapy should be considered as an alternative for patients with respiratory insufficiency that so not respond adequately to traditional methods of administering oxygen prior to implementation of NPPV or intubation/ mechanical ventilation

Classes of lung disease

-Obstructive -Restrictive -Diffusive

Be familiar with cylinder safety outlines

-Outlines from national Fire protection agency and compressed gas association -Racks or chain cylinders to wall -No combustibles stored next to them -Away from source heat, temperature below 125F -Store flammable gases separate from gases that support combustion - Dont take protective cylinder cap off when in storage -Store cylinder supply in 1 hour fire resistive rating area -Separate full and empty cylinders

List the hazards of oxygen therapy (including hypoxic drive)

-Oxygen toxicity -Depression from ventilation -Retinopathy of Prematurity -Absorption atelectasis -hypoxic drive

What are some problems associated with computer usage in hospital setting

-Password security -HIPAA

Oxygen Toxicity

-Patchy infiltrates (white areas on xray) -Major alveolar injury -Damages the capillary endothelium -Interstitial edema: (fluids build up in interstitial) Thickening of the alveolar capillary membrane Type I cells destroyed Type II cells proliferate

Question 23 What are the contraindications of HME?

-Patient with thick, excessive or bloody secretions. -Patients with tracheal damage -Patients with body temperature less than 32C -Patients with high spontaneous minute volumes (>than 10 L/min) -HME must be removed from breathing circuit when patient is receiving in line aerosol (drug) therapy On some devices gas flow can be bypassed from going thru HME material -Not recommended for infants since deadspace and weight on ventilator circuit may decrease effective ventilation

What are the contraindications of HME?

What is the purpose of using water traps in a ventilator circuit and where should they be placed?

-Place water traps in low points in circuit (both inspiratory and expiratory side) -Water traps should allow emptying without disrupting ventilation and not be prone to leaks -Maintaining circuit temperature with heated wire can help *prevent the formation or rain out*

Question 32 What is the purpose of using water traps in a ventilator circuit and where should they be placed?

What is the purpose of using water traps in a ventilator circuit and where should they be placed?

According to Eggan, what are the two primary indications for humidity therapy and two secondary indications for humidity theryapy

-Primary goal : Humidification of dry inspired medical gases and overcoming the humidity deficit created when the upper airway is bypassed. Secondary indication: managing hypothermia and treating bronchospasm caused by cold air

What are the *primary and secondary goals* associated *(LVN)?*

-Primary goal: To provide *humidification* to the respiratory tract either with *patients* having an *artificial airway* or with patients *complaining of dryness* while inspiring medical gas Typically used continuously -Secondary goal: *To improve bronchial(clean airway) hygiene*; usually with a heated aerosol Typically used intermittently; 10-15 min treatment QID reduce mucosal upper airway swelling usually with cool aerosol Typically following extubation of a patient who required an artificial airway

What are the primary and secondary goals associated with a large volume nebulizer (LVN)?

-Primary goal: To provide humidification to the respiratory tract either with patients having an artificial airway or with patients complaining of dryness while inspiring medical gas Typically used continuously -Secondary goal: To improve bronchial(clean airway) hygiene; usually with a heated aerosol Typically used intermittently; 10-15 min treatment QID reduce mucosal upper airway swelling usually with cool aerosol Typically following extubation of a patient who required an artificial airway

Restrictive lung disease

-Reduced lung or chest wall compliance or distensibility of the lung/chest wall -Increased STIFFNESS (elastance) -Less compliant -Problems with getting air into lungs -Acute: Interstitial pulmonary edema; Acute respiratory distress syndrome (RDS) -Chronic: Pulmonary fibrosis *Lung or chest wall problem-> Produce restriction*

List the hazards of oxygen therapy (including hypoxic drive)

-Retinopathy of Prematurity -Oxygen toxicity -Absorption atelectasis -Depression from ventilation -hypoxic drive. (ROAD H)

Compare and contrast bulk, cylinder and manifold oxygen storage systems Cylinder

-Secure at patient bedside -Do not use oil, grease, on regulators, cylinders, fittings or valves -Do not cover tanks with bedspreads, sheet or any material -Open cylinder valve slightly to remove dust and dirt before attaching regulator. This is Cracking the Tank -Do not use damaged regulators -Do not deface cylinder marking or color -Use ASSS (big) or PISS (little) cylinders

Contrast yoke connectors and treaded valve outlets

-Small cylinders use a post valve and yoke connector. -Large cylinders (F to H & K) have a threaded valve outlet.

Diameter index safety System (DISS)

-Specifications to prevent accidental interchange of low pressure (less than 200 psig) medical gas connectors. -Used to connect equipment to a low pressure gas source

Aerosol nebulizers:

-Spray water particles into a gas stream The higher the aerosol density( number of particles per volume of gas) the greater the surface area

Question 22 What are the *characteristics* of an *ideal HME?*

-Standard set by International Organization of Standards (ISO) -*Operate at 70% *efficiency or better -*Providing* at least *30mg/L water vapor* -Uses standard connections -Have a *low compliance* -*Add minimal weight* *-Add minimal dead space* *-add minimal flow resistance to a breathing circuit*

What solutions are delivered via a bland aerosol?

-Sterile water -Hypotonic Saline <(0.90)% ex: 0.45% -Isotonic Saline aka as normal saline(0.90)% -Hypertonic Saline >(0.90)% Ex: 7%

High Flow systems

-Supply oxygen concentration at flows equaling or exceeding the patients peak inspiratory flow. -Air entrainment or blending system -If flow delivered exceeds patient flow you can ensure a fixed FIO2 -To qualify for high flow device, a system should provide at least 60L/min of flow. The flow criterion is based on the fact that an average adult peak inspiratory flow during tidal ventilation is approximately 3x the minute volume.

Transtracheal Catheter

-Teflon catheter surgically inserted into the trachea. between 2nd and 3rd tracheal ring -No humidifier required -40 - 60% less O2 to achieve a given PaO2 low as .25L/min to achieve adequate oxygenation -cheaper, more mobile, smaller flow needed

Question #13 4 principles or variables that affect performance of humidifiers

-Temp -time contact -thermal mass -surface area

Question 34 When using a heated wire circuit with a neonate, where should the temperature probe be placed?

-Temp probes need to be placed outside of isolettes or radiant warmers

What are three factors that affect the performance of a humidifier?

-Temperature : increased T = increased Humidity -Surface area: Increased SA = increased humidity -Time of contact -thermal mass

three factors affect the performance of a humidifier?

-Temperature : increased T = increased Humidity -Surface area: Increased SA = increased humidity -Time of contact -thermal mass

What are five factors associated with condensation (rain out) in ventilator circuit?

-Temperature difference between humidifier and airway -The ambient temperature -The gas flow -the set airway temperature -Length, diameter and thermal mass of breathing circuit

five factors associated with condensation (rain out) in ventilator circuit?

-Temperature difference between humidifier and airway -The ambient temperature -The gas flow -the set airway temperature -Length, diameter and thermal mass of breathing circuit

If the alarm on a Bubble Humidifier sounds without an intentional occlusion, what is the cause?

-The gas flow is too HIGH -A kink in the tubing -Obstruction of the outlet

Inspiratory Reserve Volume

-The max amount of additional air that can be inhaled beyond the VT -IC (Inspiratory Capacity)-VT (Tidal Volume)= IRV -Volume of air entering the lung in going from the end of normal (tidal) inspiration to maximal inspiration -About 3.3L

Explain how both of the above are affected by the patients breathing patterns

-The more the patient breathes, the more air dilutes the delivered O2, and FIO2 is lowered -If the patient breathes less with this type of device, less air dilutes the O2 and FIO2 increases. -*A system that provides only a portion of the inspired gas always provides a variable FIO2*

Explain how both of the above are affected by the patients breathing patterns

-The more the patient breathes, the more air dilutes the delivered O2, and FIO2 is lowered -If the patient breathes less with this type of device, less air dilutes the O2 and FIO2 increases. -A system that provides only a portion of the inspired gas always provides a variable FIO2

Primary lung volumes

-Tidal volume -Inspiratory reserve volume -Expiratory reserve volume -Residual volume

Heated humidifier systems

-Traditional recommendations has been to *keep the inspired gas 100% saturated at 37C* -Reasonable approach would seem to be to provide *100% relative humidity at temperatures between 32 -34C* -*Heat improves *the *water output of bubble and passover humidifiers* Used primarily for patients with *bypassed upper airways or mechanical ventilation*

Bourdon Gauge

-Used with an adjustable pressure reducing valve -Uses a fixed orifice -Operates under varying pressures. Fixed orifice, variable pressure flow metering device -Measures pressure changes and liter flow -Use to be the best choice for patient transfers since it is not affected by gravity like flow restrictors -Best choice when you cant maintain your flowmeter in the upright position. Common during transport

List malicious software and preventative measures:virus

-Viruses: May erase files, documents or render programs inoperable *Self inflicted* * Attatch to email or downloaded from web*

List malicious software and preventative measures:virus

-Viruses: May erase files, documents or render programs inoperable Self inflicted Attatch to email or downloaded from web

Tidal Volume

-Volume at which we normal breath -Difference of lung volume from normal inspiration and expiration -Volume after one complete respiration of inspiration and expiration -VT increases when the O2 consumption rate of the body (QO2) increases

Contrast large volume nebulizers with oxygen blenders

-When large volume nebulizer cannot provide high enough O2 concentration or flow oxygen blender may be considered.You input seperate air and O2 and they are mixed. This system allows precise control over fio2 and output -Can provide flow greater than 60L/min so fixed delivery device. -Adults use aerosol mask or T tube like nebulizer or nonrebreathing system -Alarm if gas fails or pressure decreases. -especially prone to inacuracy and should be checked once per shift

List malicious software and preventative measures: worms

-Worms: self replicating malicious computer program. self contained User does not need to do anything. can spread to entire network Invade computer memory, distributes copies of itself to others

Question #14 Surface area effects the performance of humidifiers?

-^ area contact between water/gas and greater opportunity for evaporation to occur -most efficient designs. (B.A.W) bubble aerosol wick -most common method increase surface area gas through water form small bubbles

humidifiers

-add molecular water to gas -occurs by evaporation from water surface into gas

humidity therapy

-adding water vapor and sometimes heat to inspired gas -invisible moisture -water forms individual molecules in it vapor or gaseous state

What are the clinical signs and symptoms of inadequate airway humidification?

-atelectasis -dry, non productive cough -increased airway resistance -increased incidence of infection -increased work of breathing -Patient complaint of substernal pain and airway dryness -Thick. dehydrated secretions

Question #7 primary indication for humidification

-humidification of dry inspired medical gas -overcoming humidity deficit when upper airway is bypassed

Question #7 secondary indication of humidification

-manage hypothermia - treat bronchospasm caused by cold air

Basic Aim for humidification?

-meet or exceed the water vapor content found in room air -American National Standard Institute(ANSI) id 10mg/L water vapor content as minimum level of absolute humidity avoid mucosal damage to upper airway -equal to 50% relative humidity and 23C and 72F - bubble humidifier meet this level of humidification and more

O2 therapy for more stable patient

-mild to moderate hypoxia low to moderate Oxygen concentrations. Stable FIO2 not necessary nasal cannula at moderate flow or simple mask -common examples: immediate post op patients or acute MI

Therapeutic Gases

-most commonly used humidification O2 pt w/normal airway - pt need supplement humidification: systemic dehydration abnormal production secretion(COPD)

Question #14 temperature effects humidifiers performance?

-most important factor that affects level of humidity -the greater the temp. of gas the more water vapor it can hold(^ capacity) - evaporation cools the temp. of gas ability to carry water vapor. ~temp gas leaves humidifier less than room air ~humidity output less saturated air at ambient temp -simple solution heat the humidifier.

HME basic operation

-passive humidifier -artificial nose ~like nose capture exhaled moisture and heat use next inspiration ~unlike nose dont actively add heat and water -return 70% moisture - used for machenically ventilated and spontaneously breathing pt & long term use

Question # 20 wick passover humidifier

-porous water absorbent material ^ surface area -cylinder absorbent materials placed upright water reservoir surrounded by heat ~gas go into the chamber picks up moisture and leaves the chamber fully saturated with water vapor ~used on pt bypassed airway who mechanically ventilated ~no bubble or aerosol produced ~most common humidification mechanically ventilated -surface of wick ^ area contact between water/gas

*Cool,* humidifiers used to treat

-post extubation edema -airway inflammation -croup -epiglottitis -upper airway swelling -used w/ bland aerosol delivery (P.A.C.E. U.U)

humidity therapy 3 function

-primary goal maintain physiological condition of lower airway -assuring normal function of mucociliary transport -supplying increased levels of water vapor to inspired gas

aerosol nebulizers

-spray water particles into stream of gas -higher the aerosol density the greater surface area

53. According to the National Institute of Standards and Technology of the U.S. Department of commerce, a gas cylinder that is color-coded brown and green should contain which of the following?

02-He mixture

13. At what temperature does all kinetic activity of matter cease?

0° K

How long should an ET Tubes be used?

1 - 2 weeks, discuss trach option on the 4th day the patient is on ET Tube.

What are the sizes for Macintosh blades?

1 - 4, with an average adult requiring a size 3.

Maxair: Dosage

1 -2 puffs (.20mg each) 4 - 6 hrs.

You set up an Oxy-Hood with an FIO2 of 0.5 for a newborn infant. What is the maximum time that should pass before assessing this patient's PaO2 or SaO2?

1 hour

IPPB: Sensitivity should be set so that machine will begin breath at a pressure that is ___ or ___ cmH2O pressure below zero.

1 or 2

What guidelines must you follow when preparing to attempt ventilation on a conscious patient with rapid ventilations?

1) Assess adequacy of respirations\n\n2) Explain procedure to the patient\n\n3) Place mask over mouth and nose\n\n4) After sealing the mask, squeeze the bag with the patient's inhalation. Watch as the patient's chest begins to rise and deliver the ventilation with the start of patient's own inhalation. Over the next several breaths, adjust the rate so you are ventilating fewer times, but deeper.

What guidelines must you follow when preparing to attempt ventilation on a conscious patient with slow ventilations?

1) Carefully assess adequacy of respirations\n\n2) Explain procedure to the patient\n\n3) Place mask on face\n\n4) After sealing mask, squeeze the bag with every inhalation. If the rate is very slow, add ventilations in between the patient's own to obtain a rate of approx. 12/minute.

What are the signs of adequate artificial ventilation?

1) Chest rise\n\n2) Heart rate returning to normal\n\n3) Rate of ventilations is sufficient and not excessive

What steps would you follow to provide artificial ventilations to a patient with a stoma?

1) Clear any mucus plugs or secretions from the stoma\n\n2) Leave the head and neck in a neutral position, as it is unnecessary to position the airway prior to ventilations in a stoma breather.\n\n3) Use a pediatric-sized mask to establish a seal around the stoma\n\n4) Ventilate at the appropriate rate for the patient's age.\n\n5) If unable to artificially ventilate through the stoma, consider sealing the stoma and attempting to ventilate through the mouth and nose. This will not work if the trachea has been disconnected from the mouth and nose.

What are the steps to administering oxygen?

1) Explain to the patient the need for oxygen.\n\n2) Open the main valve, adjust flowmeter.\n\n3) Place an oxygen delivery device on the patient. \n\n4) Adjust flowmeter\n\n5) Secure cylinder during transfer

What special considerations must be taken into account when administering oxygen and clearing the airway?

1) Facial injuries: massive bleeding may require an airway adjunct and plenty of suctioning\n\n2) Obstructions: sometimes obstructions are so large that they must be cleared using manual techniques such as abdominal thrusts, chest thrusts, or finger sweeps.\n\n3) Dental appliances: Leave dentures and partials in place in possible since they give form to the face, but remove if they endanger the airway.

Name some events that might trigger respiratory arrest.

1) Heart attack\n2) Stroke\n3) Airway obstruction\n4) Drowning\n5) Electrocution\n6) Drug overdose\n7) Poisoning\n8) Brain injury\n9) Severe chest injury\n10) Suffocation\n11) Prolonged respiratory failure

Name the 2 primary indications for humidification therapy.

1) Humidifying dry medical gases 2) Overcoming the humidity deficit created when the upper airway is bypassed

How do you perform the jaw-thrust maneuver?

1) Keep head, neck, and spine aligned, moving patient as a unit until he is supine.\n\n2) Kneel at top of head.\n\n3) Reach forward and place one hand on each side of the patient's lower jaw, at the angles of the jaw below the ears. \n\n4) Stabilize head with forearms\n\n5) Using index fingers, push jaw forward (patient's forward, not your forward :)\n\n6) Retract lower lip with thumb if necessary\n\n7) Do not tilt or rotate head

What steps must you follow in order to use a bag-valve mask on a patient without suspected spine injury?

1) Kneeling above patient's head, open airway and insert properly sized oral or nasal airway if no gag reflex is present.\n\n2) Position thumbs over top of mask, index fingers at the bottom.\n\n3) Place mask over patient's face. Position mask over nose and lower to the chin.\n\n4) Use your middle, ring, and little fingers to bring jaw up to mask\n\n5) Connect bag to mask and have assistant squeeze bag until chest rises.\n\n6) If no rise, reevaluate head position and mask seal. \n\n7) If unable to ventilate, use another method.

Name th secondary indications for humidification therapy.

1) Managing hypothermia 2) Treating bronchospasm caused by cold air

What steps must you follow when inserting a nasopharyngeal airway?

1) Measure airway from patient's nostril to earlobe.\n\n2) Lubricate the tube with water-based lubricant.\n\n3) Gently push tip of nose upward. Keep patient's head in neutral position. Try right nostril first, and make sure that the bevel points towards the septum.\n\n4) Insert airway until flange rests against nostril. If you meet resistance, try the other nostril. DO NOT FORCE IT.

What three indications do you have of a spinal injury, even with an unconscious patient?

1) Mechanism of injury - falls, car crashes, etc.\n\n2) Location of injury - above the shoulders\n\n3) Family or bystanders

What are the four major techniques available to an EMT for providing artificial ventilation, in order of preference?

1) Mouth to mask (preferably with oxygen at 15 liters/minute)\n\n2) Two-rescuer bag-valve mask (BVM)(preferably with oxygen at 15 liters/minute)\n\n3) Flow-restricted oxygen-powered ventilation device\n\n4) One-rescuer bag-valve mask (preferably with oxygen at 15 liters/minute)

What are the appropriate flow rates for the various oxygen delivery devices?

1) Nonrebreather mask: 12-15 LPM\n\n2) Nasal cannula: 1-6 LPM\n\n3) Venturi mask: Varied, up to 15 LPM

What are the oxygen concentrations for the various oxygen delivery devices?

1) Nonrebreather mask: 80-90%\n\n2) Nasal cannula: 24-44%\n\n3) Venturi mask: 24-60%

What are the four principal procedures to treat life-threatening respiratory problems?

1) Opening and maintaining the airway\n\n2) Providing artificial ventilation to the nonbreathing patient and the patient with inadequate breathing\n\n3) Providing supplemental oxygen to the breathing patient\n\n4) Suctioning as needed

What are the medical hazards of oxygen?

1) Oxygen toxicity or air sac collapse (extremely rare in the field)\n\n2) Infant eye damage\n\n3) Respiratory depression or respiratory arrest.

What are the four steps of performing the head-tilt/chin-lift maneuver?

1) Place one hand on the forehead and the fingertips of the other hand under the bony area at the center of the patient's lower jaw.\n\n2) Tilt the head by applying gentle pressure to the patient's forehead\n\n3) Use your fingertips to lift the chin and to support the lower jaw. Move the jaw forward to a point where the lower teeth are almost touching the upper teeth.\n\n4) Do not allow patient's mouth to be closed.

What steps do you follow to insert an oropharyngeal airway?

1) Place patient on his back. Keep spinal injuries in mind.\n\n2) Perform a crossed-finger technique -- cross thumb and forefinger and push jaws open at teeth at corner of mouth.\n\n3) Position airway so tip is pointing toward roof of mouth.\n\n4) Insert airway and slide it along roof of mouth past the uvula or until you meet resistance at soft palate. Don't push tongue into pharynx. Use tongue depressor if necessary. (carefully insert the airway pointing DOWN and using a tongue depressor for children/infants)\n\n5) Gently rotate airway 180 degrees. (unless already pointing down)\n\n6) Position patient -- use maximum head tilt if no spinal injury, otherwise maintain straight and immobilized spine.\n\n7) Check to see that flange of airway is against patient's lips.\n\n8) Place mask over adjunct.\n\n9) Provide ventilations and monitor patient closely. When removing device, there is no need to rotate it.

What steps must you follow in order to provide mouth-to-mask ventilation?

1) Position yourself at the patient's head and open the airway. It may be necessary to clear the airway of obstructions. If necessary, insert oropharyngeal airway to help keep airway open.\n\n2) Connect oxygen to the inlet on the mask and run at 15 liters/minute. If oxygen isn't available, go ahead without it.\n\n3) Position mask on the patient's face so that the apex is over the bridge of the nose and the base is between the lower lip and the chin. Center port over mouth.\n\n4) Hold mask in place\n\n5) Exhale into mask -- deliver breath over one second and watch for chest rise.\n\n6) Remove mouth from port and wait for passive exhalation.

What are the nonmedical hazards of using oxygen?

1) Pressurized tanks can become explosives or missiles when damaged. They can be deadly.\n\n2) Oxygen supports combustion and makes fires burn more rapidly.\n\n3) Under pressure, oxygen and oil don't mix. When combined, they can essentially explode. DO NOT USE petroleum-based lubricants or adhesives (tape) around oxygen.

What are the steps to discontinuing oxygen?

1) Remove the delivery device\n\n2) Close the main valve

When using a FROPVD and the chest doesn't rise, what should you do?

1) Reposition head\n\n2) Check seal\n\n3) Check for obstructions\n\n4) Consider alternative methods of ventilation

What are the steps to preparing an oxygen delivery system?

1) Select desired cylinder, check for label "Oxygen U.S.P."\n\n2) Place the cylinder in upright position and stand to one side.\n\n3) Remove plastic wrapper or cap protecting the cylinder outlet.\n\n4) Keep the plastic washer (some setups)\n\n5) Crack the main valve for one second.\n\n6) Select the correct pressure regulator and flowmeter. \n\n7) Place the cylinder valve gasket on the regulator oxygen port. \n\n8) Make sure that the pressure regulator is closed. \n\n9) Tighten t-screw on pin yoke, or tighten threaded outlet with nonferrous wrench.\n\n10) Attach tubing and delivery device

What are four steps of positioning a prone patient for basic life support when you are the only rescuer present?

1) Straighten patient's legs, position the closest arm above the patient's head.\n\n2) Grasp under the distant armpit\n\n3) Cradling head and neck, move patient as a unit onto his side\n\n4) Move patient onto back and reposition the extended arm

What are some symptoms of severe hypoxia?

1) Tachycardia progressing to bradycardia (heart rate drops = trouble!)\n2) Dyspnea (poor breathing)\n3) Pale, cool skin\n4) Drowsiness\n5) Altered mental status\n6) Accessory muscle use

What are 8 symptoms of mild to moderate hypoxia?

1) Tachypnea (fast breathing)\n2) Dyspnea (poor breathing)\n3) Tachycardia (fast heart rate)\n4) Pale, cool skin\n5) Restlessness\n6) Disorientation\n7) Headache\n8) Hypertension

What are the primary rules of suctioning?

1) always use infection control measures. Gloves required, eye and face protection recommended.\n\n2) Try to limit suctioning to 15 seconds or less at a time. However, you must also continue suctioning until a patient stops vomiting. \n\n3) Place the tip where you want to begin suctioning and suction as you pull the tip out.

Name more space-efficient ways to increase the water/gas surface-area ratio.

1) bubble diffusion 2) aerosol 3) wick technologies

Hygroscopic condenser humidifiers provide higher efficiency by using what?

1) condensing element of low conductivity (paper, wool, foam) 2) impregnating material with a hygroscopic salt (calcium or lithium chloride)

Prolonged breathing of improperly conditioned gases through a tracheal airway can result in conditions?

1) hypothermia 2) inspissation of airway secretions 3) mucociliary dysfunction 4) destruction of airway epithelium 5) atelectasis

If oxygen fails to flow from the humidifier, what should you check?

1) is flowmeter turned on 2) if pre-filled, make sure the reservoir has been pierced and that gas can flow through it 3) check the outlet for obstruction 4) check the oxygen tubing for obstruction or kinks 5) replace the humidifier

What are some advantages of passover humidifiers over bubble humidifiers?

1) maintain saturation at high flow rates - unlike bubble 2) add little or no flow resistance to spontaneous breathing circuits 3) do not generate any aerosols 4)thus, minimal risk for infection

What are some values for an ideal HME?

1) should operate at 70% efficiency or better (providing at least 30 mg/L water vapor) 2) use standard connections 3) have a low compliance 4) add minimal weight, dead space, and flow resistance to a breathing circuit

Fiberoptic Endotracheal Intubation: Technique

1. Oral route preferable 2. Topical anesthesia with 2% lidocaine on a base of the tongue, hypopharynx and vocal cords (aerosolized 10% lidocaine may also be used) 3. Sedation with midazolam (adult dose 1 to 2.5 mg IV) and fentanyl (adult dose 25-100 mcg IV) 4. "Jaw thrust" maneuver improve visualization 5. Apply oral airway or "bite block" to protect the equipment. Apply 100% oxygen via face mask (oxygen may also be delivered via bronchoscope channel) 6. After the bronchoscope is lubricated and loaded with an endotracheal tube it is introduced strictly in the midline following the base of the tongue, pass the uvula, behind the epiglottis and between the vocal cords. (see video on the left below). 7. Additional topical lidocaine is applied as necessary. 8. Once the main carina is visualized endotracheal tube is introduced by rotating movement over the bronchoscope. Proper position (3-5 cm above the carina) is evaluated and the tube secured. (see video on right below)

What are the steps to perform Bedside PFTs using Slow Vital Capacity (SVC)?

1. Prepare required equipment. 2. Explain the purpose of the procedure to the patient. 3. Describe and demonstrate the procedure for the patient. 4. Coach the patient through the procedure step by step. 5. Repeat the procedure 3 times, if possible, and record the "best" result.

IPPB Administration - volume measuring devices

1. Venti-Comp 2. Wright's Respirometer 3. collection bag

What are the required equipment for Slow Vital Capacity (SVC)?

1. Volume measuring device. (Wright's Respirometer, VentiComp-bag, ...) 2. Mouthpiece or mask 3. Noseclips (optional)

What are the measuring devices for Bedside PFTs?

1. Water-Sealed Spriometers 2. Fleisch Pneumotachometers 3. Thermistors 4. Turbinometers 5. Vortex-Shedding Devices 6. Strain Gauges 7. Peak Flow Meters 8. Mechanical Aneroid Manometers

What are the signs for Yellow Zone on Peak Flow Meter?

1. coughing 2. wheezing 3. sneezing 4. short of breath when I try to exercise

special considerations in airway management?

1. facial injuries. frequent suctioning may be required for all the bleeding. consider airway adjunct or endotracheal tube. \n2. obstruction. suctioning will probably not work for larger things. use abdominal thrusts, chest thrusts or finger sweep. \n3. dental appliances - leave denture in place unless it endangers airway.

IPPB Administration - Initial Assessment

1. vitals signs 2. level of consciousness 3. patient's breathing pattern 4. breath sounds 5. VC, PF, and tidal volume per protocol 6. explain procedure to patient a) purpose of therapy b) explanation of equipment and instructions 7. check equipment function

OBJECTIVES FOR IPPB THERAPY: A minimum effective volume, should deliver a Vt <_____% the patient's spontaneous Vt.

What are suction catheter sizes for pediatric?

10 - 12 fr

What is the Constant Expiratory Pressure range in EZPAP?

10 - 20 cm H2O

Unheated bubble humidifiers have limited effectiveness at flow rates higher than what?

10 L/min

83. A physician orders 40% O2 through an air-entrainment nebulizer for a patient with a minute volume of 12 L/min. What is the minimum nebulizer input flow required to ensure the prescribed FIO2? A. 8 L/min B. 10 L/min C. 12 L/min D. 14 L/min

10 L/min 12*3=36 (100-40)/(40-21)=60/19 -> (60/19)/(19/19)= 3.15/1 ->3.15+1=4.15 -> (4X/4)=36/4 -> x=9 since 9 is not an option 10 L/min is the best selection from the choices that were provided

A physician orders 40% O2 through an air-entrainment Neb for a patient with a minute volume of 12 LPM. What is the minimum neb input flow required to ensure the prescribed FIO2?

10 LPM

When giving artificial ventilations to an adult, how many ventilations should you give per minute?

10-12 ventilations per minute

Which of the following techniques will increase aerosol deposition by sedimentation in the lungs?

10-second breath-hold

What are the safe pressure ranges for adults while using a suction regulator?

100 - 120 mm Hg

Large hospital air compressor systems must be capable of maintaining 50 pounds per square inch gauge (psig) at what flows?

100 L/min

Gas leaving an unheated humidifier at 10°C and 100% relative humidity (absolute humidity = 9.4 mg/L) would provide what relative humidity at body temperature?

20%

According to Avogadro's law, under standard conditions of temperature and pressure (0°C and 760 mm Hg), 1 mol of any gas occupies ________ L .

22.40L

A 45-year-old patient with CHF is receiving O2 through a 35% air-entrainment mask with an O2 input of 6 LPM what is the total output gas flow?

34 LPM

Question 31 What *temperature range* should be used for *heated humidifier?*

35-37C

At body temperature and pressure saturated, inspired gas is what?

37 degrees C, contains 44 mg/L of water and exerts a partial pressure of 47 mmHg and is fully saturated

In general, to deliver oxygen to the upper airway, a bubble humidifier is required only when the gas flow exceeds which of the following?

4 L/min

A lung volume has ___ volumes and ___ capacities.

4; 4

Albuterol: Onset

5 - 10 min.

What is the minimum flow setting for a simple mask applied to an adult?

5 L/min

79. A well-fitted non-rebreathing mask, adjusted so that the patient's inhalation does not deflate the bag (flows between 10 and 15 L/min), should provide inspired O2 concentrations in what range?

55-70%

39. In the lungs alveoli, there are four gases mix together: Oxygen, carbon dioxide, nitrogen and water vapor. And a normal barometric pressure of 760 mm Hg, alveolar O2 exerts a partial pressure of 100 mm Hg, Co2 40 mm Hg, and water vapor 47 mm Hg. What is the alveolar partial pressure of nitrogen?

573 mmHg -> 760mmHg - (O2=100 mmHg + CO2=40 mmHg + H2O=47 mmHg) =573 {760-187=573} PT=P1+P2+P3

What are suction catheter sizes for neonatal?

6 - 8 fr

Xopenex: Duration

6 - 8 hrs.

At what pressure level will the inspiratory pressure release valve on a FROPVD open?

60 cm of water pressure

A near-drowning patient has a recorded body temperature of 30° C. What is the equivalent temperature in degrees Fahrenheit?

86°F

An ideal heat-moisture exchanger (HME) should have an efficiency rating of at least which of the following?

90%

47. What is the U.S. Food and Drug Administration (FDA) purity standard for O2?

99%

What is the U.S. Food and Drug Administration (FDA) purity standard for O2?

99%

18. Which of the following would help to decrease a patient's loss of body heat

: Increase the temperature of the room, move the patient away from cold windows

Cuff Pressures and Volumes: What is the appropriate Cuff Pressure? Why?

<10 cc. You don't want to over inflate the cuff because it can cause tissue necrosis in the trachea.

Restrictive lung disease (Abnormalities of chest wall)

>Fibrothorax >Kyphoscoliosis >Morbid obesity

Restrictive lung disease (Weakness of the respiratory muscles)

>Myasthenia Gravis >ALS >Gullian-Barre syndrome

Restrictive lung disease (Abnormalities of the lung parenchyma)

>Pulmonary edema >Idiopathic pulmonary fibrosis (IPF) >ARDS (Acute Respiratory Distress Syndrome)

Cuff Pressures and Volumes: What is minimal leak technique?

Cuff Pressures and Volumes: What is minimum occluding volume technique?

Cuff Pressures and Volumes: When should a cuff be inflated?

Nasal Pharyngeal Airways: What special risk is associated with topical Lidocain?

Case #2

A 52 year old heavy (1 1/2 PPD) smoker presents with a history of increasing dyspnea (difficulty breathing) on excretion and shortness of breath when climbing 1 flight of stairs -A presumed diagnosis of COPD is made. -Pulmonary function tests are ordered

How is Relative Humidity measured by?

A Hygrometer

Define "nonrebreather mask."

A face mask and reservoir bag device that delivers high concentrations of oxygen. The patient's exhaled air escapes through a valve and is not rebreathed.

Define "nasopharyngeal airway."

A flexible breathing tube inserted through the patient's nose into the pharynx to help maintain an open airway.

Define "bag-valve mask."

A handheld device with a face mask and a self-refilling bag that can be squeezed to provide artificial ventilations to a patient. It can deliver air from the atmosphere or oxygen from a supplemental oxygen supply system.

The actual conent or weight of water present in a given volume of gas, is termed?

Absolute Humidity

What is the actual content or weight of water present in a given volume of gas and is expressed in mg/L?

Absolute Humidity

What is the term for the actual content or weight of water present in a given volume of air?

Absolute humidity

Non-Steroidal Antiasthma Agents allergy tx for ages 12 & above was approved in 2003 as a new class of therapy, known as anti-IgE, for patients with moderate to severe persistent allergic asthma. IgE is an antibody that we all have and it is responsible for causing allergic problems in some people. It may reduce allergic reactions by causing free IgE to disappear from the body so that the IgE cannot attach to pollen (and other substances that are present). • Used for controlling persistent asthma - not for rescue

Accolate (Zafirlukast)

Nonsteroidal Antiasthma Medications, Mucolytics • Dose 3 ml 10% solution • May be instilled ( most effective to remove plugs) as well as nebulized • Liquefy thick secretions • Irritation to airways - not recommended for long term use • Aerosolized drug - leaves sticky film on tubing, filters, and internal ventilator sensors

Acetylcystineine - Mucomyst , Mucocil

Question 26 What is the difference between an active and passive HME?

Active: External heat and water can be added to the HME Water pump to add water directly and electric heater to evaporate water into inspired air -The goal is to reach 100% body humidity at 37C -should compare favorably with heated wich and membrane systems -Possible advantages is less condensation "rainout" in ventilator circuit -Possible disadvantage is weight, complexity of system and cost

Absolute humidity

Actual content of water in a measured volume of a gas 10 mg/L

Heliox: Indication

Acute upper airway obstruction i.e.. Foreign body, mass or tumor or severe asthma airway obstruction

What should one be looking for when judging whether a patient's breathing is adequate or inadequate?

Adequate expansion on both sides of the chest

If a patient is speaking in full sentences and is alert and calm, is that patient breathing adequately or inadequately?

Adequately. If they are complaining of shortness of breath, though, provide them with a nonrebreather mask or a nasal cannula.

Respiratory therapists must ensure that any oil or dust is cleared from high-pressure medical-gas delivery systems before pressurization. Why is this action needed?

Adiabatic compression could ignite the oil or dust.

What effect does each of the 4 classifications have on the Cardioplumonary system? Give one medication example of each of the 4 classifications.

Adrenergic - causes vasoconstriction by stimulating the sympathetic system; Tachycardia (Epinephrine) Antiadrenergic - prevents vasoconstriction by blocking the sympathetic system (Atrovent) Cholinergic - causes vasodilation by stimulating parasympathetic system. (Acetylcholine) Anticholinergic - prevents vasodilation by blocking the parasympathetic system; Bradycardia (Atrovent)

What are the usual adult sizes for endotracheal tubes?

Adult Female 7 - 7.5 Adult Male 8 - 8.5

What are adequate breathing rates for children, adults, and infants?

Adults: 12-20 breaths/minute\nChildren: 15-30 breaths/minute\nInfants: 25-50 breaths/minute

Describe the advantage and disadvantage of high flow nasal cannulas

Advantages: Comfortable delivery, can eat and drink and talk, broad range of flows and O2 concentrations (flexible as patient condition changes), Improved respiratory efficiency, better secretion clearance, alternative for comfort end stage, less changing between multiple oxygen devices, increase confidence in the actual FiO2 being delivered to patient, used to wean patients for noninvasive or invasive ventilation Disadvantages: *Drying and damaging to mucosa*( high flows uncomfortable for the patient. some systems are not heated although provide humidification.) Some systems *not able to achieve liter flows greater than 15 L/min,* cost, physician buy in

Describe the advantage and disadvantage of high flow nasal cannulas

Advantages: Comfortable delivery, can eat and drink and talk, broad range of flows and O2 concentrations (flexible as patient condition changes), Improved respiratory efficiency, better secretion clearance, alternative for comfort end stage, less changing between multiple oxygen devices, increase confidence in the actual FiO2 being delivered to patient, used to wean patients for noninvasive or invasive ventilation Disadvantages: Drying and damaging to mucosa( high flows uncomfortable for the patient. some systems are not heated although provide humidification.) Some systems not able to achieve liter flows greater than 15 L/min, cost, physician buy in

Advantages and disadvantages of low flow system

Advantages: Easy and rapid set up, comfort, low oxygen concentration needs easily met, patient compliance Disadvantages: variable and limited FIO2, high flow drying and irritation, dislodging, sores from equipment, complications from nasal abnormalities, danger with patient abnormal breathing patterns

What are advantages and disadvantages of flow restrictors?

Advantages: Low cost, simple, reliable (no moving parts) -Cannot be set to incorrect flow -can be used in any position (gravity independent) Disadvantages: Different versions required for different flows -Accuracy varies with changes in source and downstream pressures -Cannot be used with high resistance equipment

A physician requests you provide a patient with exactly 45% O2 at a flow of 60 LPM. Lacking a blender you must manually mix air and O2 to achieve the desired mixture at the prescribed flow. Which of the following air and O2 flow would you select?

Air LPM (42) O2 LPM (18)

CONTRAINDICATIONS FOR IPPB THERAPY: A bulla is defined as an ____ _______ in the lungs that measures > 1 cm in diameter in it's distended state.

Air Space

Which of the following factors determine the actual O2 provided by an air-entrainment system?

Air-to-O2 ratio of the device Resistance downstream from the jet

How do you determine the air and fluids in an X-ray image?

Air: Dark with lung markings White: Fluid

What is the term for the impedance to ventilation caused by the movement of gas through the conducting system of the lungs?

Airway Resistance

What takes precedence: the spine, or airway and breathing?

Airway and breathing. If you find a non-breathing patient and suspect injury, you will probably have to provide manual stabilization and treat the breathing problem before you have time to put on a cervical collar.

What are the basic skills in airway management?

Airway clearance • Suction - Oral Pharyngeal • Suction - Nasal Tracheal • Suction - Endotracheal Artificial Airway Insertion • Oral Pharyngeal • Nasal Tracheal • Endotracheal Assist in performing special airway procedures • Bronchoscopy

All of the following drugs or drug categories have been associated with increased airway resistance and bronchospasm during aerosol administration except:

Albuterol

• Nebulized dosage = 2.5mg in 3 ml NS ( most common Beta 2 agonist with less HR effects compared to earlier meds ( such as Bronkosol, Isuprel, & Alupent) • MDI Dose - 2- 4 puffs (.09mg each) Q4-6 hours PRN • onset - 5- 10 minutes • Peak 20 minutes • Duration 3- 4 hours • Most commonly used "Rescue medication" • Continuous Nebulizer dosage 7.5 - 20 mg per hour ( ER tx) • Can lower serum "K" potassium levels

Albuterol (Proventil, Ventolin)

ASTM

American Society Testing Material - specification design and performance

Specifications covering the design and performance requirements for medical humidifiers are established by who?

American Society for Testing and Materials (ASTM)

62. What is the indexed safety system for threaded high-pressure connections between large compressed gas cylinders and their attachments?

American Standard Safety System (ASSS)

Define "patent airway."

An airway that is open and clear and will remain open and clear, without interference to the passage of air into and out of the body.

Used to treat chronic bronchitis • parasympatholitic - "block parasympathetic signals such as bronchoconstriction & bradycardia" • can be used with Sympathomimetics - "synergist effect" • may also be used if patient is using Beta Blocker ( i.e. Inderal)

Anticholinergics

Thorpe Tube

Attached to 50psig source Preset pressure reducing valve Bedside station outlet -variable orifice, constant pressure flow metering device. -Key component is a tapered transparent tube with a float Diameter increase from bottom to top -Gas flow suspends the float against the force of gravity. -Reading flow: Compare float position to an adjacent calibrated scale. Normally L/min -Compared to a bourdon gauge (which measures pressure) a Thorp tube measure flow. -Float rises, more room (like increasing the orifice) for flow to get through thus higher flow

A patient receiving ventilatoiy support is being provided with humidification using a heat-moisture exchanger (HME). A physician orders a bronchodilator drug administered through a metered-dose inhaler (MDI) via the ventilator circuit. Which of the following must be performed to ensure delivery of the drug to the patient? A. The inspiratory flow setting of the ventilator should be increased. B. The HME must be removed from the circuit during MDI use. C. The VT setting of the ventilator should be decreased. D. A heated humidifier should replace the IIME when using the MDI.

B. The HME must be removed from the circuit during MDI use.

All of the following are potential hazards of using a heated humidifier during mechanical ventilation except: A. underhydration or impaction of secretions B. hypoventilation due to increased dead space C. aerosolization of condensate during disconnection D. unintended tracheal lavage from condensate

B. hypoventilation due to increased dead space

How often should heat-moisture exchangers be inspected and replaced? A. at least every shift B. when contaminated by secretions C. at least every day D. when condensate is visible

B. when contaminated by secretions

Due to the small jet orifice causing high resistance what is the upper flow rate range for many LVN

Because a small jet is used with this type of nebulizer and a high resistance is created, the upper flow rate available through a flowmeter is 12 -15 L/min

Why is it important to keep in mind the anatomic "dead space?"

Because even when the depth and rate of breathing changes, the amount of dead space does not. So when breaths become more shallow, a greater proportion of each breath is wasted in the dead space.

Why can't we use sterile water to lavage or rinse the specimen?

Because it can alter the form of microorganisms in the sputum sample.

Why is racemic epinephrine no longer the preferred short acting aerosolized medication for the treatment of asthma?

Because it is overused in dieting by the people. It causes tachycardia.

Disadvantages of standard O2 masks include all of the following except:

Being difficult to apply to patients.

Type of IPPB Ventilator: • Same features as Mark-7 plus adjustable expiratory flow rate providing positive (PEEP)/negative (NEEP) end expiratory pressure.

Bird Mark - 8

These are typically used for intermittent therapy, but could be used for continuous mechanical ventilation, provided the proper monitors and alarms are added.

Bird Ventilators

What are the three major types of flowmeter?

Bourdon gauge (durable and useable in most situations), pressure-compensated flowmeter (accurate but delicate and must be upright), constant flow selector valve

What are the smaller branches that originate at the bronchi and bring air to alveoli in the lungs?

Bronchioles

Definition: Use of suction to remove secretions or specimens from beyond main stem bronchi

Bronchoscopy

Long Acting Broncho-dilator adrenergic/sypathomimetic (Arfomoterol) • Bid Peak 15 minutes, Peak 30 - 60 minutes, Duration 12 hours

Brovana

What is Arfomoterol?

Brovana

What is the most common of the disposable humidifiers used in Respiratory Care?

Bubble Humidifier (non-heated)

What is the most common type of disposable humidifiers used in Respiratory?

Bubble Humidifiers

Three types of humidifiers?

Bubble, passover and HME

CONTRAINDICATIONS FOR IPPB THERAPY: A pulmonary condition in which there are isolated changes with development of bullae.

Bullous disease (aka bullous emphysema)

How would you assess that the effectiveness of the Prednisone therapy?

By assessing pt. breathing.

How can one determine whether a pressure-reducing valve uses multiple stages for pressure reduction?

By noting the number of pressure relief vents.

During routine use on an intubated patient, a heated humidifier should deliver inspired at which of the following? A. temperature of 37 = 2° C, with a minimum of 44 mgfL of water vapor B. temperature of 20 + 2° C, with a minimum of 10 mg/L of water vapor C. temperature of 33 ± 2°C, with a minimum of 30 mgL of water vapor D. temperature of 30 ± 2° C, with a minimum of 24 mg/L of water vapor

C. temperature of 33 ± 2°C, with a minimum of 30 mgL of water vapor

41. The 37° C and 760 mmHg Pressure, 0.023 ml of O2 Can be dissolved in one ML of plasma, Whereas at the same temperature and pressure, 0.510 ml of CO 2 will dissolve in one ML of plasma. What explains the difference?

CO 2 is more soluble in plasma than O2

Albuterol: Contraindication

Can lower potassium levels Increase HR

What can spirometer NOT measure?

Cannot measure anything involving residual volume (cannot determine the amount of volume left in lung after ERV). Cannot measure: -Residual Volume -Functional Residual Capacity -Total Lung Capacity

27. What is the phenomenon where by a liquid in a small tube tends to move upward against the force of gravity?

Capillary action

What is the phenomenon whereby a liquid in a small tube tends to move upward against the force of gravity?

Capillary action

Which type of Humidifer is capable of producing a Body Humidity with gases at a HIGH Flow?

Cascade Humidifier

Which of the following is a common method to measure aerosol particle size?

Cascade impaction

High oxygen concentrations given over a long period of time will:

Cause intrinsic cellular damage to the alveolar epithelium

Convert Fahrenheit to Celsius

Celsius = (F-32) / 1.8

Room humidifiers work off of what principle?

Centrifugal Force (spinning). Electrically powered.

How is compliance computed?

Change in volume/change in pressure

Melting Point

Change over from solid to liquid Temp at which solids become liquids Water = 0C, 32F

What do you need to do before teaching your patient how to use the Incentive Spirometer?

Check the chart for: • Order; Admitting Dx; evidence of any recent surgery (when?; type?); evidence of any previous pulmonary problems (COPD; asthma?); Chest X-ray reports At the bedside check for: • mental status; ability to comprehend; pain level; evidence of any pulmonary problems (tachypnea &/or S.O.B.?)

How do we know if someone has an Atelectasis?

Chest X-Ray Clinical Signs Oxygenation

Nonsteroidal Antiasthma Medications (Intal, Nasalcrom); Mucous Blockers • Dosage 20 mg . 2 ml unit dose 2-4 times per day • Used for persistent asthma with secretions • MDI - QID dose

Chromolyn Sodium

What are the organelles found in cells in the trachea and lungs that help propel mucus and dirt out of the body?

Cilia

Identify and discuss the role of the federal government that regulates the design, manufacturing, transport and use of gas cylinders.

Classified and governed by the Federal Department of Transportation (DOT) according to their fabrication makeup

Nasotracheal Suctioning consider a _______ procedure using _______ technique

Clean ; Aseptic

What actions must you take when using Room Humidifiers?

Clean them regularly and change out the water in the reservoir frequently

What physical principle underlies most fluidic circuitry?

Coanda effect

44. What physical principle underlies most fluidic circuitry?

Coanda effect (the water the spoon http://www.youtube.com/watch?v=AvLwqRCbGKY )

Aerosolized Antinfectious Agents Treatment for sensitive strains of Pseudomonas Aeruginosa ( CF) and for Acinetobacter baumanni Side effects- • bronchospasm - • eliminated through urinary system • Neurotoxic - and neuromuscular blockade - possible respiratory failure

Colistimethate Sodium - Colistin

Suction Chest Drainage systems: A chamber proximal to the patient tubing that collects pleural drainage.

Collection Chamber

Spirograph (Set up)

Collins spirograph uses an inverted cylinder of gas floating in a second cylinder of water -The gas containing, floating cylinder is connected to inspiratory and expiratory tubing and a one-way valve system thru which the patient breathes -The exhaled gas is passed through a CO2 scrubber to remove CO2 before the gas enters the floating cylinder -As the patient exhales, volume in the floating cylinder increases and it floats higher in the water creating an increasing tracing on the drug recording. -When the patient inspires, gas is removed from the cylinder so it floats lower and creates a decreasing tracing on the recording.

List the characteristics of oxygen

Colorless, odorless, tasteless, transparent gas. Occurs in nature. -Components of other compounds. -Pure O2 may be combined with air, carbon dioxide, and helium. -atmospheric concentration 20.95%, - Nonflammable but accelerates combustion -Standard delivery hospital setting 50psig -Stored in high pressure cylinders or in large centralized bulk reservoirs

BASIC TERMINOLOGY: 1. A measurement of how easy or how difficult it is to change/deform an object. 2. Is the inverse of elasticity, which is defined as how easily an object returns to its original shape after having been deformed. 3. Measured in units of cc/cm H2O.

Compliance

20. What is the physical process whereby a gaseous form of a substance is changed back into a liquid state?

Condensation

Condensation - opposite of evaporation, gas to liquid Return heat to surrounding air.

16. What term is used for the transfer of heat by the direct interaction of atoms for molecules in a hot area with atoms or molecules in a cooler area?

Conduction

What extremely rugged flowmeter is gaining in popularity?

Constant flow selector.

Efficiency of a Bubble Humidifier depends on what?

Contact to the water level in the reservoir

A direct measure of the kinetic activity of water vapor molecules is _______ ______ ________.

Critical Temperature

Which of the following inspired conditions should be maintained when delivering medical gases directly into the trachea through an endotracheal tube or a tracheotomy tube? A. l00% RH at 20° to 22°C B. 95% RH 29° to 32°C C. 50% relative humidity (RH) at 20 to 22° C D. 100% RH at 32° to 35°C

D. 100% RH at 32° to 35°C

Which of the following factors cause the isothermic saturation boundary (ISB) to shift farther down into the airways? I. decreased ambient temperature II. increased tidal volume III. endotracheal intubation A.I and II B. II and III C. I and III D. I, II and III

D. I, II and III

What are some potential problems with manually refilled heated humidifier reservoirs? I. cross-contamination and infection II. variable compliance or delivered volume III. delivery of dry andlor hot gases A. II and III B. I and III C. I and II D. I, II, and III

D. I, II, and III

Where should you place the thermistor probe for a servo-controlled heated humidifier being used on a patient receiving mechanical ventilation? A. in the inspiratory limb of the circuit, as close to the "wye" as possible B. in the expiratory limb of the circuit, as close to the "wye" as possible C. in the expiratory limb of the circuit, near but not at the "wye" D. in the inspiratory limb of the circuit, near but not at the "wye"

D. in the inspiratory limb of the circuit, near but not at the "wye"

What is the name of the point in the respiratory tract where inspired gas reaches body temperature, ambient pressure, saturated (BTPS) conditions? A. hygroscopic saturation boundary B. thermal inversion boundary C. point of thermal equilibrium D. isothermic saturation boundary

D. isothermic saturation boundary

The higher the flow rate used, the less time of contact between the gas and the water, thus ____________ humidity output.

Decreases

The lower the water level in the jar, the less time of contact between the gas and the water, thus _______ the humidity ouput.

Decreases

A venti-mask set at 24% O2 has the flowmeter running at 4 LPM. Which of the following would increase the O2 concentration?

Decreasing the air entrainment port size Increasing the oxygen-orifice diameter

A patient receiving 3 LPM O2 through a nasal cannula has a measure SpO2 of 93% and no clinical signs of hypopnea. At this point what should you recommend?

Decreasing the flow to 2 LPM and rechecking the SpO2

Increasing the flow through an unheated bubble humidifier has which of the following effects?

Decreasing the water vapor content.

Gas Laws

Define the relationship among gas: pressure, temperature and volume. Mass remains constant

Know how to use the magic box

Determines O2:air ratio when FiO2 is known: a. place FiO2 in center b. subtract FiO2 from 100 and put in bottom right corner c. subtract FiO2 from 21 and put is left corner. d. divide value of b from value of c e. this represents ratio of o2 and air. f. add together to get total ratio parts

Flow Volume Loops

Differences in gas flow as lung volume changes during forced exhalation -Graph shows expiratory phase of the force ventilator cycle >Inspiratory phase would be a NEGATIVE flow moving from right to left below the y-axis baseline -Lung volume is x axis -Rate (Flow) is y axis

What type of Humidifier functions by having gas travel down a tower, through a one-way valve, into a diffusion grid. The gas then travels back up through the grid from underneath, picking up the moisture and delivering it to the patient?

Diffuser/Cascade Heated Humidifier

Nonsteroidal Antiasthma Medications, Mucolytics (used in Cystic Fibrosis patients) • 2.5 mg unit dose 1-2 times per day • use separate nebulizer do not mix with other aerosol meds • Clone of Pancreatic Dornase - missing in CF patients • Reduces viscosity in infected secretions. • Natural enzyme with few side effects • More expensive then other mucolytics

Dornase Alfa - Pulmozyne

Dosage of Prednisone:

Dosage: (0.5 - 1.0 mg / Kg / day) • Typical dosage 5 - 50 mg per day for 10 - 14 days • Dosage is typically reduced slowly = wean patient off • Tablets - 1,5,20, & 50 mg

Endotracheal Tubes: Indications

Emergency or short term artificial airway. • Assist with mechanical ventilation • Improve effectiveness of bag ventilation • Provide stable airway in unconscious or semiconscious patient • Apnea • Foreign body obstructions • Upper airway edema - (emergency tx only) • Assist with endotracheal suction - copious secretions & pt. is unable to remove effectively

Describe the general goals for the delivery of oxygen to specific patient populations. ex: emergency room, or critically ill patient with moderate to severe hypoxia

Emergency situation: *With suspected hypoxia, give as high FIO2 as possible*(nonrebreathing mask). Ideally *100% of high flow or closed reservoir system * -Highest possible blood oxygen content -hyberbaric oxygen therapy CO and cyanide poisoning may require -Critically ill patient with moderate to severe hypoxia reservoir or high flow system capable of at least 60% oxygen Changes base on assessment maintain: PaO2 above 60 mmHg and Hb saturation(SaO2 above 90%

Describe the general goals for the delivery of oxygen to specific patient populations. ex: emergency room, or critically ill patient with moderate to severe hypoxia

Emergency situation: With suspected hypoxia, give as high FIO2 as possible(nonrebreathing mask). Ideally 100% of high flow or closed reservoir system -Highest possible blood oxygen content -hyberbaric oxygen therapy CO and cyanide poisoning may require -Critically ill patient with moderate to severe hypoxia reservoir or high flow system capable of at least 60% oxygen Changes base on assessment maintain: PaO2 above 60 mmHg and Hb saturation(SaO2 above 90%

Expiratory Flows

Expiratory flows: Expiratory gas flow rate can be assessed by multiple methods -Maximum (peak) expiratory flow -Mid-expiratory flow -FEV1.0: VOLUME in first 1 second (Not a flow rate but a volume) -FEV1.0/FVC: Forced 1 second expiratory VOLUME to forced vital capacity ratio (Forced expiratory flow/Forced Vital capacity ratio) -FEF25-75: Forced expiratory FLOW during mid exhalation (25-75% of vital capacity) >Used to assess elevated airway resistance seen with OBSTRUCTIVE disease -Steepness of FEF25-75 slope line indicates high gas flow

_________ the purpose of the Slow Vital Capacity (SVC) procedure to the patient.

Explain

CPAP: What lung volume is increased as a result of the net effect of CPAP?

FRC

Spirometry data obtained

FVC, FEV1, FEV1/FVC, VC

True/False: EZPAP can only be used on responsive patients only.

False; EZPAP can also be used on nonresponsive patients as well.

True/False: EZPAP is delivered using low flow oxygen.

False; EZPAP is delivered high flow oxygen

True/False: EZPAP can be used inline with Large Volume Nebulizer treatment.

False; EZPAP is used inline with SVN tx, not LVN.

True/False: You can use more than one sympathomimetic medications.

False; Never use more than one sympathomimetic

List the types of Medication (Relating to Respiratory):

Fast Acting/Rescue Medication Anticholinergics Long Acting/Control Medication Long Acting Bronchodilators (Adrenergic/Sympathomimetics) Nasal Steroids Non-steroidal Antiasthma Medications Aerosolized Anti-infectious Agents Inhaled Pulmonary Vasodilators Anti-diabetic Agents Systemic Corticosteroids Non-steroidal Anti-Asthma Agents

What technique is this? • Used when the patient's neck cannot be manipulated, i.e. unstable cervical spine. • Used when it is not possible to visualize the vocal cords because a straight line view cannot be established from the mouth to the larynx. • Performed either awake or under general anesthesia • Performed on a patient who have a difficult airway. • Used as abackup technique after direct laryngoscopy has been unsuccessful. • Involve adequate planning and patient preparation.

Fiberoptic Endotracheal Intubation

Bedside PFT Measuring Devices: 1. A bench standard for all flow measuring devices. 2. Measures a pressure created by breathing through a very low resistance. a. Flow is passed through a bundle of brass capillary tubes. b. Can measure both inspiratory and expiratory flows. 3. Results may be affected by moisture and/or medication deposits. 4. Although these directly measure flow, they may be modified to display volume.

Fleisch Pneumotachometers

Long acting / Control medications -" stays at home"; Inhaled Steroids (fluticasone Propionate 44, 110, & 220, mcg dosages) 1-2 x day

Flovent

What is Fluticasone Propionate? What is the dosage?

Flovent (fluticasone Propionate 44, 110, & 220, mcg dosages) 1-2 x day

What type of I.S. device only display inspiratory flowrate and may attempt to estimate an inhaled?

Flow Oriented devices ( Tri flow)

BASIC TERMINOLOGY: 1. The amount of gas passing a specific point over a specific period of time. 2. Typically measured in LPM, but may also be measured in LPS. 3. Usually set at the lowest setting which will meet the patient's inspiratory demand.

Flow Rate

Name three different types of flowmeter

Flow restrictor, Bourdon gauge, Thorpe tube

Determine what flow may be necessary to meet a patients inspiratory demand

Flow should equal or exceed three times the patients minute volume. If minute vol is 10L/min it is 10 x 3=30

Chest Tubes: What type of drainage occurs when a tube is inserted on 4 - 5th intercostal space mid axillary?

Fluid Drainage

Uses a simple metal ball, enclosed in pipe-like device, to create expiratory resistance and vibrations

Flutter Valve Therapy

Cuff Pressures and Volumes: What are the Alternative Cuffs called? What is it used for?

Foam cuffs, Lanz Tube; It is used to minimize mucosal trauma.

What should one be feeling for when judging whether a patient's breathing is adequate or inadequate?

For air leaving the chest (bad sign!) or leaving the mouth and nose (good sign!)

What should one be listening for when judging whether a patient's breathing is adequate or inadequate?

For air leaving the chest (bad sign!) or leaving the mouth and nose (good sign!)

1. Measures the degree of obstruction (airway collapse) 2. ≥80% of predicted is normal. 3. FEV - amount of air out in 1 second in large airways. 4. Often performed before and after bronchodilator to measure efficacy of medication (increase of 20% SIG)

Forced Vital Capacity (FVC)

A VC measurement performed with maximum forced expiratory effort.

Forced Vital Capacity (FVC)

This Bedside Pulmonary Function Test (PFT) is frequently performed as a screening measure or to evaluate the effectiveness of clinical interventions. It is frequently performed after a SVC. The presence of a significant difference between the two values may indicate an obstructive process.

Forced Vital Capacity (FVC)

Define "artificial ventilation."

Forcing air or oxygen into the lungs when a patient has stopped breathing or has inadequate breathing. Also called positive pressure ventilation.

How is bronchoscopy used therapeutically (Therapeutic Bronch's)

Foreign Body Obstructions (secretions/hemoptysis) Mass or Tumor (Atelectasis/Edema)

Compute the oxygen percentage of a mixture of air and oxygen

Formula: %O2 = (air flow x 21) + (O2 flow x 100)/ total air Ex: An air entrainment device mixes a fixed ratio of 3 volume of air to each volume of oxygen. What is the FiO2 %? (3 x 21) + (1 x 100) = 63 + 100= 163/3+1 = 163/4 = 40%

By what means is oxygen for medical use in a hospital most commonly produced?

Fractional distillation

46. What is the most common and least expensive method for commercial production of O2?

Fractional distillation of air

Type of Atelectasis that is a blockage occurs in the airway- preventing ventilation downstream - resulting in eventual removal of remaining gas & alveolar collapse.

Gas Absorption (Reabsorption) Atelectasis

The risk of overhydration with continuous delivery of bland water aerosols is greatest among which patient group? I. Patients with fluid or electrolyte imbalances. III. Infants and small children.

I and III

Specific clinical objectives of oxygen (O2) therapy include which of the following? I. Decrease the symptoms caused by chronic hypoxemia. II. Decrease the worklod hypoxemia imposes on the heart and lungs. III. Correct documented arterial hypoxemia.

I, II, and III

To minimize problems with environmental safety when aerosol therapy is prescribed for immunosuppressed patients or those with tuberculosis, what precautions should you follow? I. Those for tuberculosis exposure II. Centers for Disease Control and Prevention (CDC) standards and contact precautions III. CDC standards and airborne precautions

I, II, and III

What are some potential problems with manually refilled heated humidifier reservoirs? I. Cross-contamination and infection II. Variable compliance or delivered volume III. Delivery of dry and/or hot gases

I, II, and III

What can properly applied O2 therapy decrease? I. Ventilatory demand II. Work of breathing III. Cardiac output

I, II, and III

Which of the following factors affect pulmonary deposition of an aerosol? I. Size of the particles II. Shape and motion of the particles III. Physical characteristics of the airways

I, II, and III

Which of the following factors determine how much of a given gas can dissolve in a liquid? I. Solubility coefficient of the gas. II. Temperature of the liquid. III. Gas pressure above the liquid.

I, II, and III

Which of the following groups of patients are most likely to have difficulty using a simple metered-dose inhaler for aerosol drug therapy? I. Patients in acute distress II. Infants and young children III. Elderly persons

I, II, and III

Which of the following is a common way to increase the surface area ratio of humidifiers? I. Generate a water droplet aerosol. II. Expose the gas to a saturated wick. III. Use a bubble or diffusion head.

I, II, and III

Which of the following is/are good clinical examples of the principle of capillary action? I. Capillary stick blood samples II. Absorbent humidifier wicks III. Certain surgical dressings

I, II, and III

Which of the following medical gases support combustion? I. O2 II. N2O III. compressed air IV. CO2

I, II, and III

Which of the following methods can be used to minimize the harmful effects of environmental exposure to ribavirin or pentamidine aerosols? I. Use an isolation booth or tent with HEPA filtered exhaust. II. Have health care personnel wear a HEPA filtered mask. III. Use a negative pressure room with adequate air exchange.

I, II, and III

Which of the following occurs when water vapor is added to a dry gas at a constant pressure? I. The volume occupied by the gas mixture increases. II. The relative humidity of the mixture increases. III. The partial pressure of the original gas is reduced.

I, II, and III

85. What are some key patient considerations in selecting O2 therapy?

I. type of airway II. severity and cause of hypoxemia III. age group (infant, child, adult) IV. stability of the minute ventilation

You increase the fill volume from 2 to 4 ml in a small-volume jet nebulizer being used to administer a bronchodilator agent with an aerosol. What effect will this have on the amount of drug delivered?

Increase

What is the most common adverse reaction?

Increase Heart Rate and Blood Pressure

What is the evidence of Atelectasis on a Chest X-Ray?

Increase opacity Reduced FRC/Lung Volume

Laryngeal Mask Airways (LMA): Advantages:

Less pain and coughing than ET Tube. Much easier to insert Avoids tracheal intubation Can be used with spontaneous or artificial ventilation. Less irritation to the throat.

A physician wants to deliver a therapeutic aerosol to the lung parenchyma (alveolar region). To help ensure maximum deposition in this area, you would select an aerosol generator with an MMAD in what range?

Less than 1 µm

When checking a patient attached to a servo-controlled heated-wire humidifier breathing circuit you notice no visible condensate anywhere in the tubing. Based on this observation you can conclude that the relative humidity of the delivered gas is which of the following:

Less than 100%

Restrictive lung disease (Characteristics)

Lung chest wall compliance decreased -Affects lungs or chest wall -More elastance/stiffness, less compliance -Diseases which restrict the full expansion of the lung -Lung distress despite normal lung tissue. -Hypoxemia from diseases caused by diffusion impairment increases significantly during periods of stress or exercise. -Abnormalities of the chest wall -Abnormalities of the lung parenchyma -Weakness of the respiratory muscles

What's an NPA?

Nasopharyngeal airway.

Physiologic Breathing

Negative Pressure Breathing (1) Respiratory muscles increase volumes in the lungs creating a "relative" negative pressure (2) Air moves in until the pulmonary pressure equals to the atmospheric pressure (3) Pulmonary muscles relax creating "relative" positive pressure

Correcting Hypoxemia

O2 therapy corrects hypoxemia by raising oxygen levels of: alveoli and blood -Hypoxemia and lung disease Relieves hypoxic symptoms associated with certain lung disorders. COPD Interstitial lung disease: Relief of dyspnea. Improve mental function of the chronically hypoxemic

When can you not use an OPA?

OPA can only be used when gag reflex not present. Gag reflex may reappear as a patient regains consciousness. But patient may be able to tolerate NPA instead.

If patient is speaking only 1-2 word sentences, is very sweaty, and is exhibiting severe anxiety, is that patient breathing adequately or inadequately?

Patient is breathing inadequately and needs assisted ventilations. Provide them with a pocket face mask (PFM), bag-valve mask (BVM), or flow-restricted oxygen-powered ventilation device (FROPVD). Assist ventilations before they stop altogether!

What types of patients will need more oxygen than a nasal cannula can provide?

Patients with chest pain, shock, hypoxia, or other more serious problems (really any patient with inadequate breathing)

Brovana: Peak

Peak 15 minutes, Peak 30 - 60 minutes

PEFR or PF

Peak Expiratory Flow Rate the peak expiratory flow rate generated with a maximum expiratory effort after a maximum inspiratory effort

(Bedside PFT) Used to evaluate need / effectivness of bronchodilator therapy & measures the peak flow

Peak Expiratory Flow Rate (PEFR / PF)

Measures initial flowrate and is a good indicator of the relative dilation of large airways.

Peak Expiratory Flow Rate (PEFR)

The ______ _______ _______ _______ generated with a maximum expiratory effort after a maximum inspiratory effort.

Peak Expiratory Flow Rate (PEFR)

What is the Bedside Pulmonary Function Test (PFT) is typically performed before and after treatment therapy to assess the effectiveness of intervention and the seriousness of the patient's condition?

Peak Expiratory Flow Rate (PEFR)

Bedside PFT Measuring Devices: 1. Used for bedside and home monitoring. 2. Measure on the maximum flow rate, typically that seen at the beginning of exhalation. 3. Are typically inexpensive, and come in many designs.

Peak Flow Meters

BASIC TERMINOLOGY: 1. The highest pressure recorded on the ventilator manometer during the inspiratory phase. 2. Typically recorded in cm H2O.

Peak Inspiratory Pressure (PIP)

Aerosolized Antinfectious Agents antiprotozoan agent to treat Pneumocystis carnii ( PCP) pneumonia in immune compromised patients i.e. AIDS. Indication : • Second line therapy to prevent PCP in high risk patients ( HIV +) • Previous PCP episodes • CD4 ( T4 cell helper) lymphocyte < 200/ mm • Has been shown to be effective if given in IV form ( eliminates exposure issue with aerosol) Dosage: • 300 mg powder in 6 ml sterile h20 once every 4 weeks Hazards / side effects : ( similar to symptoms of PCP) • Respiratory - • Bronchial irritation & bronchospasm ( what could be done to minimize this ?) • Dizziness, nausea, rashes, metallic taste • PCP symptoms - night sweats, chills • Renal Failure • Staff exposure issues / nebulizer requirements • MMAD 1- 2 um • "respirgard" filter on exhalation - prevent aerosol exposure • negative pressure room or isolation chamber ( Aerostar) • HEPA fit tested mask

Pentamidine Isethoionate - Nebupent

identify oxygen delivery devices utilized in the home care setting

Physical seperation -Smaller quantities of concentrated oxygen are produced with this method. Molecular Sieves (1st method) Used in home care (low flow concentrator) Silicate pellets absorbs nitrogen (N2) and H2O vapor from air. (provides concentration of over 90% oxygen for patient use. -Semi permeable plastic membrane Vacuum pulls and filters N2 from ambient air Oxygen and water vapor pulls through faster then nitrogen thus producing approximately 40% o2 concentration. These devices are known as oxygen concentrators seen most often in the home. Most effective long term low flow oxygen

Systemic Corticosteroids Respiratory Indications: (suppress inflammation) • Initial assessment of COPD • Acute exacerbation of COPD • Severe chronic asthma - failure to respond to inhaled steroids or other meds. • Idiopathic Pulmonary fibrosis - bronchiolitis common Hazards / Precautions: • Edema / fluid retention- "moon face" • Petechia - small hemorrhage or blood vessel rupture near skin • Osteoporosis • Immune suppression - increase infection risk - esp. respiratory of opportunistic organisms Dosage: (0.5 - 1.0 mg / Kg / day) • Typical dosage 5 - 50 mg per day for 10 - 14 days • Dosage is typically reduced slowly = wean patient off • Tablets - 1,5,20, & 50 mg

Prednisone

Indications for Endotracheal Suctioning

Presence of an artificial airway associated with ... - Course breath sounds (rhonchi) - Increased PIP - Decreased Vt - Inability to cough - Visible secretions in the airway - Changes in flow/pressure graphics - Suspected aspirations - Increased work of breathing (WOB) - Deterioration of ABG values - Radiologic changes - Need to obtain sputum samples - Pulmonary atelectasis associated with secretions

Gay-Lussac's Law

Pressure and Temperature of a gas system varies directly Volume and mass constsant P1/V1 = P2/V2 Temperature up = pressure up. Gay had tp on his shoe Application: increased pressure in a cylinder when heated, correction for blood gases/ pt temperature.

What is the first priority in Oxygen therapy and COPD

Preventing hypoxia

DISS Diameter index safety system

Prevents accidental interchange of low pressure (less than 200psig) medical gas connectors. Outlets of pressure reducing valves attached to cylinders. Wall outlets of central piping systems Inlets of flowmeters nebulizers, ventilators, and other pneumatic equipement -Externally threaded body and a mated nipple with a hex nut -Eleven indexed DISS connections plus one for oxygen -Do not manipulate to bypass safety system

Restrictive lung disease (Chronic disease)

Pulmonary Fibrosis -Result in thickening of the alveolar capillary membrane which also impairs diffusion of oxygen into the blood (chronic)

1. Confirm and diagnose obstructive and restrictive process. 2. Monitor Lung volumes 3. Determine the degree of obstructive airflow disease.

Pulmonary Function Test (PFT)

Long acting / Control medications -" stays at home"; Inhaled Steroids (Beclomethasone dipropionate ) 2 puffs 1-2 times per day

QVAR/ Vanceril

What is Beclomethasone Dipropionate? What is the dosage?

QVAR/ Vanceril (Beclomethasone dipropionate ) 2 puffs 1-2 times per day

Indications for assessment of patient's response to bronchodilator therapy include all of the following except to:

Quantify the degree of bronchial hyperresponsiveness

The term for the ration between the amount of water in a given volume of gas and the maximum amount it is capable of holding at that temperature is?

Relative Humidity

34. What is the term for the ratio of the actual water vapor present in a gas compared with the capacity of that gas to hold the vapor at a given temperature?

Relative humidity

Question 1 Given the content and capacity of water vapor in a gas be able to determine its relative humidity

Relative humidity = content / capacity x 100%

Aerosolized Antinfectious Agents antiviral - tx. For Respiratory Syncytial Virus (RSV) Indications: • Treat seasonal RSV ( self limiting respiratory disease in infants & children • questionable effectiveness vs. cost hazards / precautions • rashes, conjunctivitis, eyelid erythema • can effect or occlude ventilator expiratory valves or filters ( what precaution should be taken if this is nebulized inline on a vent pt?) • Small Particle Aerosol Generator ( SPAG) large volume small particle nebulizer required to deliver to small aerosol to small airways • Expiratory " respirgard" filter to minimize staff exposure • RSV patients - respiratory / aerosol isolation - mask • Dosage - 6 g in 300 gm sterile h20(20mg / ml) via SPAG q 12 -18 for 3-7days

Ribaviran ( Virasol)

What is Tiotropium Bromide?

Spriva

• Once a day dose ( 18 micro grams) • Dry capsule ( Handi-haler ) only

Spriva - Tiotropium Bromide-

CONTRAINDICATIONS FOR IPPB THERAPY: 1. May be one of the first clinical signs of an air leak. 2. In itself, this generally is pathologically insignificant, but is an indicator of a more serious problem. May become clinically significant if severe (decreased compliance). 3. Results in tactile crepitus which is very painful for the patient.

Subcutaneous Emphysema

How do you calculate the flow time of an oxygen tank?

Subtract the safe residual from the current pressure. Multiply the difference by the appropriate tank constant. Divide that by 10

What is a water seal system to secure low pressure sealed suction - 1, 2, 3 bottle or disposable setups?

Suction Chest Drainage systems

Suction Chest Drainage systems: A chamber where a level of water determines amount of suction pressure usually 15 - 20 cm - bubbling show max suction achieved - excess air bubbles through water.

Suction Control Chamber

Which of the following best defines an aerosol?

Suspension of liquid or solid particles in a gas.

Switch the patient to a large-volume heated humidifier.

Long acting / Control medications -" stays at home"; Inhaled Steroids Budesonide (Pulmicort) / Formeterol fumarte (Foradil) combo - adult and pediatric doses

Symbicort

What is Budesonide (Pumicort)/Formeterol (Foradil) combined? What is the dosage?

Symbicort- adult and pediatric doses

What is the advantage and disadvantages of the Macintosh blade?

The advantage of this blade is that it minimizes trauma to teeth, does not come in contact with the epiglottis and allows more room in the oropharynx. However, with this blade the epiglottis may be in the way of visualizing the vocal cords.

Define "minute volume."

The amount of air breathed in during each respiration multiplied by the number of breaths per minute.

Tidal volume (TV)

The amount of gas inspired with each breath

73. Which of the following statements is false about low-flow O2 delivery systems?

The greater the patient's inspiratory flow, the greater is the FIO2(The following are true: all low-flow devices provide variable O2 concentrations, provided O2 is diluted with air, patient's flow usually exceeds that from a low-flow device)

If you see a DECREASE in the condensation in a Cascade/Diffuser Heated Humidifier, what is this a sign of?

The heating element is not functioning adequately

When the water level is low in a Cascade/Diffuser Heated Humidifer, what happens?

The heating element shuts off

What is the u-shaped bone on the anterior aspect of the cervical region situated directly superior to the larynx?

The hyoid bone

What is the primary indication for IPPB Therapy?

The inability of the patient to take a deep breath spontaneously.

How is the laryngoscope used in endothracheal intubation?

The laryngoscope must be held with the left hand. The patient's mouth opened with the right hand and the blade placed into the right side of the patient's mouth, sweeping the tongue to the left. The tip of the straight blade is inserted posterior to the epiglottis, while the tip of the curved blade placed anterior to the epiglottis into the vallecula. The handle is then raised up and away from the patient without leverage until the vocal cords are visualized. The clinician's wrist should not be bent as this may cause damage to the teeth. Once the vocal cords are seen, the ETT is passed through cords with the right hand and advanced to 20-26 cm, as measured at the teeth or with the cuff just below the vocal cords. The laryngoscope is then withdrawn and the cuff is inflated.

Expiratory reserve volume (ERV)

The maximum volume of additional air that can be expired from the end of a normal expiration

Vital capacity (VC)

The maximum volume of air that can be forcefully expelled from the lungs following a maximal inspiration. Called a capacity because it is the sum of inspiratory reserve volume, tidal volume, and expiratory reserve volume. VC=IRV+TV+ERV=TLC-RV

What must be done to the patient prior to oral endotracheal intubation?

The patient should be prepared by removing any dental appliances (ex. dentures). Then proper sedation (and neuromuscular blockers, if used) administered. The patient must be positioned so that easy access is obtained. The head is placed in the "sniffing position" with the lower portion of the cervical spine flexed. Preoxygenation is then performed with 100% oxygen for 2 to 3 minutes via bag-mask ventilation.

Which lung is larger?

The right lung -- it has three lobes instead of two

What is the most popular type of suction tip?

The rigid pharyngeal tip, also known as the Yankauer, tonsil sucker, or tonsil tip.

With regard to surfactant and surface tension which of the following statements is correct?

The smaller the size of the alveolus, the greater the effect of surface tension

Which nasopharyngeal airway do you use in the field?

The soft flexible one, not the rigid clear plastic one.

How is Sellick Maneuver performed?

The technique requires an assistant to apply pressure to the cricoid member posteriorly. The cricoid cartilage is held firmly between the finger and thumb. It is then pressed posteriorly so that the esophagus can be compressed between the horizontal portion of the cartilage and cervical spine.

Define "dew point"

The temperature at which the water vapor in a gas begins to condense back into a liquid

Conditions that can cause temperature "overshoot" with servo-controlled heated humidifiers include

The unit is allowed to warm up without flow. Flow is decreased during normal operation. The airway temperature probe becomes dislodged.

Residual volume (RV)

The volume of air remaining in the lung after a maximal expiration. This is the only lung volume which cannot be measured with a spirometer.

Functional residual capacity (FRC)

The volume of air remaining in the lung at the end of a normal expiration. Called a capacity because it equals residual volume plus expiratory reserve volume. FRC=RV+ERV

Define hyperbaric oxygen therapy, listing indications and complications and compare and contrast two ways it is delivered.

Therapeutic use of O2 greater than 1 atm. one ata = 760 mmHg. conducted between 2 and 3 ATA -Indications: treat divers with decompression sickness, air embolism, carbon monoxide poisoning, gangrene, nonhealing wounds, refreactory osteromyelitis, radiation necrosis complications: Barotrauma which includes eye or sinus trauma, tympanic membrane rupture, pneumothorax, air embolism. oxygen toxicity which includes central nervous system roxic reaciton and pulmonary toxic reaction.fire, visual changes, claustrophobia Delivered:multiple chamber which holds a dozen and goes to 6ATA. Used for decompression or embolism. monoplace chamber

11. Which of the following statements about liquids is NOT true?

They expand to fill their container (the following are true: they exhibit the phenomenon of flow, they assume the shape of their container, they are difficult to compress)

Nonsteroidal Antiasthma Medications; Mucous Blockers Nedocromil Sodium - QID MDI

Tilade

Question #14 time contact effect humidifiers performance?

Time of contact between gas and water -longer a gas is in contact with water, greater opportunity for evaporation to occur -time contact directly related depth of water, inversely related flow rate gas through water (T.L.T)

What is the purpose of Humidification?

To "make-up" for the water that is loss when a dry gas is delivered or when the upper airway is by-passed

How is the placement of the Endotracheal tube (ETT) assessed after intubation?

To assess proper placement of the ETT, the chest and abdomen are inspected for movement. If the tube is properly placed, symmetric movement of the thorax with minimal movement of the abdomen should be seen with each ventilation. Breath sounds should first be assessed over the epigastric area and then over left and right lung fields. Equal breath sounds are typically heard bilaterally with proper endotracheal intubation. If breath sounds are heard over the epigastric area only, it is likely that an esophageal intubation has occurred. If breath sounds are heard over one hemi thorax, but are diminished or absent over the other hemi thorax, the tube should be left in place. The ETT should be withdrawn 2-3 cm and chest auscultated to check breath sounds again. A common complication of EI is right main stem intubation.9Since the right main stem bronchus has a straighter alignment with the trachea than the left main stem bronchus, an ETT advanced too far will typically enter the right main stem bronchus. In this situation, breath sounds may be heard more prominently or exclusive over the right lung field. Although a deep ETT placement is the most common case of unequal breath sounds, it is important to remember that other clinical conditions can cause unequal breath sounds including consolidation, obstruction, pneumothorax, hemothorax, and pleural effusion. ETT placement can also be confirmed by use of an end-tidal CO2monitoring. A chest radiograph should always be done in emergency intubations to confirm ETT placement since equal breath sounds can be heard in up to 60% of right main stem intubations. Fiberoptic bronchoscopy has been suggested as a more reliable means of confirming ETT position over clinical assessment.

What is sterile water used for while suctioning?

To clear tubing

Define the EMT's primary goal in one sentence.

To immediately find and correct life-threatening problems pertaining to airway, breathing, and circulation (ABC).

Objectives for Endotracheal Suctioning

To maintain a patent airway ... (1) To remove secretions (2) To improve ventilation/perfusion (V/Q) ratios (3) To obtain sputum specimen (4) To remove foreign objects / liquids (5) To improve chest x-ray results

What is the primary purpose of indexed connector systems?

To prevent inadvertent misconnections between equipment.

Define a true high flow oxygen delivery system

To qualify as a high flow device, a system should provide at least 60L/min total flow. This flow criterion is based on the fact that the average adult peak inspiratory flow during tidal ventilation is 3x the minute volume. Because 20L/min is close to the upper limit of sustainable minute volume for persons who are ill, a flow of 3 x 20, or 60L/min should suffice.

The ______ begins at the level of the cricoid cartilage and extends to the carina.

Trachea

CONTRAINDICATIONS FOR IPPB THERAPY: 1. A direct connection between the trachea and the esophagus. 2. May be congenital or acquired. 3. IPPB may lead to gastric insufflation and vomiting.

Tracheosophageal Fistula

Which intubation tube are for long term use and requires surgery?

Tracheostomy Tubes

patients upper airway is bypassed,done to ensure adequate humidification?

Traditionally *HME* have been limited to providing humidification to patient with *artificial airway who require ventilatory support*

Neonate ETT Size: 1 kg Tube Size (mm) Oral Tube Length at Lip (cm) Suction Tube Size (Fr)

Tube Size (mm) = 2.5 - 3.0 Oral Tube Length at Lip (cm) = 6.0 Suction Tube Size (Fr) = 6

Neonate ETT Size: 2 kg Tube Size (mm) Oral Tube Length at Lip (cm) Suction Tube Size (Fr)

Tube Size (mm) = 3.0 Oral Tube Length at Lip (cm) = 7.0 Suction Tube Size (Fr) = 6

Neonate ETT Size: 3.5 kg Tube Size (mm) Oral Tube Length at Lip (cm) Suction Tube Size (Fr)

Tube Size (mm) = 3.0 - 3.5 Oral Tube Length at Lip (cm) = 9.0 Suction Tube Size (Fr) = 8

Neonate ETT Size: 4 kg Tube Size (mm) Oral Tube Length at Lip (cm) Suction Tube Size (Fr)

Tube Size (mm) = 3.5 Oral Tube Length at Lip (cm) = 9.0 Suction Tube Size (Fr) = 8

Before operating a suction unit, you must have:

Tubing, suction tips, suction catheters, a collection container, and a container of clean water

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Helium Dilution (Equation)

V1 X C1 = V2 X C2 -V1: Spirometer/tubing volume -C1: Initial He concentration -Allow gas equilibrate in the system and find new volume using spirometer (can use switch to allow in/out) -V2: Initial volume plus FRC (Will need to subtract from V1 later to find out just the FRC) -C2: Final He concentration

Delivery systems that provide only a portion of a patient's inspired gas are referred to as what?

Variable-performance systems

A measurement that is generally performed to assess the ability of the patient to increase minute volume to meet physiologic needs. Note: Don't confuse this with the SVC & FVC as they both narrow the assessment to specific disease processes.

Vital Capacity (VC)

The maximum amount of gas that can be exhaled after a maximum inspiration. (VT + IRV + ERV)

Vital Capacity (VC)

In the adult, the airway is narrowest at the _____ ______ and in small children at the ______ ______ _____.

Vocal Cords; Cricoid Cartilage Ring

What is a type of I.S. device that actually measure and display the amount of air patient inhaled?

Volume Oriented Devices

Humidity

Water vapor content in air

Would a clogged inlet prevent the pop off alarm from sounding?

Yes

Which of the following is false about intermittent positive-pressure breathing? a. During inspiration, pressure in the alveoli decreases. b. The pressure gradients of normal breathing are reversed. c. During inspiration, alveolar pressure may exceed pleural pressure. d. Energy stored during inspiration causes a passive exhalation.

a. During inspiration, pressure in the alveoli decreases.

An alert and cooperative 28-year-old woman with no prior history of lung disease underwent cesarean section 16 hours earlier. Her x-ray film currently is clear. Which of the following approaches to preventing atelectasis would you recommend for this patient? a. incentive spirometry b. PEEP therapy c. deep breathing exercises d. intermittent positive-pressure breathing therapy

a. incentive spirometry

p.r.n

as required

A postoperative patient using incentive spirometry complains of dizziness and numbness around the mouth after therapy sessions. What is the most likely cause of these symptoms? a. gastric insufflation b. hyperventilation c. pulmonary barotrauma d. respiratory acidosis

b. hyperventilation

Which of the following modes of lung expansion therapy is physiologically most normal? a. continuous positive airway pressure b. incentive spirometry c. positive end-expiratory pressure d. intermittent positive-pressure breathing therapy

b. incentive spirometry

What is the primary goal of humidity therapy? a. decrease airway reactivity to cold b. maintain normal physiologic conditions c. deliver drugs to the airway d. reduce upper airway inflammation

b. maintain normal physiologic conditions

The application of gravity to achieve specific clinical objectives in respiratory care best describes which of the following? a. breathing exercises b. postural drainage therapy c. hyperinflation therapy d. directed coughing

b. postural drainage therapy

To ensure a stable FIO2 under varying patient demands, what must an O2 delivery system do? a. have a reservoir system at least equal to the VT b. provide all the gas needed by the patient during inspiration c. maintain flows that are at least equal to the patient's peak flows d. be able to deliver any O concentration from 21% to 100%

b. provide all the gas needed by the patient during inspiration

Humidifier pop-offs should provide what?

both an audible and visible alarm and should automatically resume normal position when pressures return to normal

Which of the following signs and symptoms are associated with the presence of hypoxemia? I. tachypnea II. tachycardia III. cyanosis IV. bradycardia a. II and III b. I and II c. I, II, and III d. I and IV

c. I, II, and III

Which of the following are advantages of the nasal cannula as a low-flow O2 delivery system? I. stability II. low cost III. easy application IV. disposability a. II and IV b. I, II, and IV c. II, III, and IV d. I, II, III, and IV

c. II, III, and IV

All of the following are true of heat-moisture exchangers (HMEs) except: a. Moisture output falls at high volumes and rates of breathing. b. High inspiratory flows and high FIO2 values can decrease HME efficiency. c. In-use HMEs have little effect on flow resistance to breathing. d. HMEs reduce bacterial colonization of ventilator circuits.

c. In-use HMEs have little effect on flow resistance to breathing.

During inspection of the shoulder of a compressed gas cylinder, you note a plus sign (+) next to the test date. This indicates what about the cylinder? a. It is made of spun aluminum, not steel. b. It only requires a 10-year DOT inspection. c. It can be filled to 10% above its service pressure. d. It has a high coefficient of elastic expansion.

c. It can be filled to 10% above its service pressure.

A patient with chronic hypercapnia placed on an FIO2 of 0.6 starts hypoventilating. What is the probable cause of this phenomenon? a. decreased cardiac output b. O2 toxicity c. O2-induced hypoventilation d. absorption atelectasis

c. O2-induced hypoventilation

Which type of humidifier "traps" the patient's body heat and expired water vapor to raise the humidity of inspired gas? a. membrane b. bubble c. heat-moisture exchanger d. passover

c. heat-moisture exchanger

A cooperative and alert postoperative patient taking food orally requires a small increment in FIO2, to be provided continuously. Precise FIO2 concentrations are not needed. Which of the following devices would best achieve this end? a. simple O2 mask b. air-entrainment mask c. nasal cannula d. nonrebreathing mask

c. nasal cannula

Persistent breathing at small tidal volumes can result in which of the following? a. reabsorption atelectasis b. spontaneous pneumothorax c. passive atelectasis d. respiratory alkalosis

c. passive atelectasis

Conditions that can affect airway patency and cause abnormal clearance of secretions include which of the following? I. foreign bodies II. tumors III. inflammation IV. bronchospasm a. I, II, and III b. II and IV c. II, III, and IV d. I, II, III, and IV

d. I, II, III, and IV

What are some key patient considerations in selecting O2 therapy equipment? I. type of airway (natural or artificial) II. severity and cause of the hypoxemia III. age group (infant, child, adult) IV. stability of the minute ventilation a. II and IV b. I, II, and III c. III and IV d. I, II, III, and IV

d. I, II, III, and IV

Which of the following clinical signs indicate that a patient is having a problem with retained secretions? I. lack of sputum production II. labored breathing III. development of a fever IV. increased inspiratory and expiratory crackles a. II and IV b. I, II, and III c. III and IV d. I, II, III, and IV

d. I, II, III, and IV

Which of the following factors will decrease the FIO2 delivered by a low-flow O2 system? I. short inspiratory time II. fast rate of breathing III. lower O2 input IV. large minute ventilation a. II and IV b. I, II, and III c. III and IV d. I, II, III, and IV

d. I, II, III, and IV

11. Which of the following is/are considered therapeutic gases? I. O2 II. O2-NO mixture III. O2-He mixture IV. N2O a. I and II b. II and IV c. III and IV d. I, II, and III

d. I, II, and III

Administration of dry gases at flows exceeding 4 L/min can cause which of the following? I. structural damage II. heat loss III. water loss a. I and II b. II and III c. I and III d. I, II, and III

d. I, II, and III

Specific clinical objectives of oxygen (O2) therapy include which of the following? I. decrease the symptoms caused by chronic hypoxemia II. decrease the workload hypoxemia imposes on the heart and lungs III. correct documented arterial hypoxemia a. I and II b. II and III c. I and III d. I, II, and III

d. I, II, and III

Which of the following are potential indications for incentive spirometry? I. a restrictive disorder such as quadriplegia II. abdominal surgery in a COPD patient III. presence of pulmonary atelectasis a. I and II b. II and III c. I and III d. I, II, and III

d. I, II, and III

Which of the following patient categories are at high risk for developing atelectasis? I. those who are heavily sedated II. those with abdominal or thoracic pain III. those with neuromuscular disorders a. I and II b. II and III c. I and III d. I, II, and III

d. I, II, and III

Which of the following situations is a contraindication for incentive spirometry? I. a patient whose vital capacity is less than 10 ml/kg II. a patient who cannot cooperate or follow instructions III. an unconscious patient a. I and II b. II and III c. I and III d. I, II, and III

d. I, II, and III

According to the National Institute of Standards and Technology of the U.S. Department of Commerce, a gas cylinder that is color-coded brown and green should contain which of the following? a. O2-N2 mixture b. O2-CO2 mixture c. CO2 d. O2-He mixture

d. O2-He mixture

Above the ISB, temperature & humidity during inspiration & exhalation do what?

decrease during inspiration. increase during exhalation

Why is the Pass-Over Humidifier low humidification?

decreased contact time. limited surface area

Question 36 What device could be used to monitor humidity levels in a ventilator circuit?

hygrometer

What device could be used to monitor humidity levels in a ventilator circuit?

hygrometer

Peak Expiratory Flow Rate (PEFR) (is/is not) an "effort dependent procedure."

What is the name of the point where inspired gas achieves BTPS?

isothermic saturation boundary (ISB)

The typical HME is a _________ humidifier.

passive

Who are heated humidifiers mainly used for?

patients with bypassed upper airway and those receiving mechanical ventilatory support

87. All of the following conditions can be treated with hyperbaric oxygen (HBO) therapy except:

septic shock (the following are true: carbon monoxide poisoning, air embolism, clostridial gangrene can all be treated)

define bronchoconstriction.\n\nwhen is this common?\nIs this in the upper or lower airway?

the contraction of smooth muscle that lines the bronchial passages that results in a decreased internal diameter of the airway and increased resistance to air flow. \nCommon in diseases like asthma. \nIn the lower airway.

For bubble humidifiers, what does the contact time depend on?

the depth of the water column: the deeper the column, the greater the time of contact as the bubbles rise to the surface.

Define "saturation"

the equilibrium condition in which a gas holds all the water vapor molecules that it can

Why is temperature important in a humidifier?

the greater the temperature of a gas, the more water vapor it can hold (increased capacity)

Why is contact time important?

the longer a gas remains in contact with, the greater the opportunity for evaporation to occur.

The primary goal of humidification is to maintain normal physiologic conditions in what?

the lower airways

What is Relative Humidity?

the ratio between the amount of water in a given volume of gas and the maximum amount its capable of holding at that temperature. Humidity expressed as a percentage of a gas's capacity (water content when fully saturated)

What is "Percent body humidity (BH)"

the ratio of the amount of water vapor in a volume of gas compared to the amount of the water in gas saturated at a normal body temperature of 37°C

Heat and moisture exchange is a primary function of......

the respiratory tract, mainly the nose

Why shouldn't the reservoirs of bubble humidifiers be heated?

the resulting condensate tends to obstruct the small bore delivery tubing to which they connect

The amount of heat and humidity the patient needs depends on what?

the site of gas delivery

Pharyngeal Airways: Indications

to prevent obstruction of pharyngeal airway caused by: • Tongue falling back - pharyngeal airways pull the tongue forward away from posterior pharynx. • Loss of muscle tone in unconscious patient causes tongue to fall back • Can be used to secure ETT & prevent obstruction of ETT due to biting • Upper airway trauma • Assist in Bag mask Ventilation - Apnea & CPR • Assist in nasal tracheal or oral tracheal suctioning • Temporarily stabilize unusual upper airway anatomy i.e. coanal atresia - Pierre Robin syndrome • Massive secretions or hemoptysis in oral pharynx

Helium dilution example

v1= 1o L C1= o.10 (10% He) C2= o.08 v2= 12.5 L FRC= V2-10= 2.5 L -What is the residual volume? -RV= 2.5-1= 1.5L >1 is the tabulated ERV

How does the "hydrophobic" membrane work?

water vapor molecules can easily pass through this membrane, but liquid water (and pathogens) cannot.

How may a patient reduce cold-air induced bronchospasm?

wearing a scarf over nose and mouth when outside in cold weather

What is Serevent and Flovent combined? What is the dosage?

• ADVAIR Discus • Dosages 100/ 50 , 250/ 50, or 500 mcg Flovent / 50 mcg Serevent

List of Mucolytics:

• Acetylcystineine - Mucomyst , Mucocil • Dornase Alfa - Pulmozyme

List of Fast Acting/Rescue Medications:

• Albuterol (Proventil, Ventolin) • Alupent (Metaproterenol) • Xopenex (Levalbuterol) • Brethine (Terbuatline Sulfate) • Maxair (Pirbuterol Acetate)

List of Inhaled Steroids:

• Azmacort (Triamcinolone acetonide) • Aerobid (flunisolide) • Flovent(fluticasone Propionate) • QVAR/Vanceril (Beclomethasone dipropionate) • Asmanex - Mometasone furoate - "Twisthaler" • ADVAIR Discus - Servent & Flovent • Symbicort - Budesonide (Pulmicort)/Formeterol fumarte (Foradil) • Pulmicort Tubuhaler asthma attacks. • Pulmicort Respules

Indications of Methylxanthines:

• COPD - debilitating COPD despite other treatments • Acute severe Asthma - controversial older method - not common front line therapy • Nocturnal Asthma • Apnea of prematurity - used in NICU on premature neonates to prevent apnea

Hazards/Precautions of Tobramycin (TOBI):

• Cannot be mixed or nebulized with other aerosolized medications • Less side effects with aerosolized TOBI • Possible ototoxicity ( hearing damage) • Staff exposure issues - filter, thumb valve / PARI neb,& isolation mask • Fetal harm - avoid exposure to pregnant women • Bronchospasm & airway irritation

What are the indications for changing a trach tube?

• Changing to smaller size - i.e. weaning patient off trach • Changing to same size - or changing to fenestrated tube • Changing tube to replace leaking cuff • Unable to repair leaking pilot balloon

List of Antidiabetic Agents:

• Exubera

List of Inhaled Pulmonary Vasodilators:

• INOmax • Ventavis

1st mechanical ventilator produced used for IBBP

"Bird Ventilator"

It is the LEAST invasive method and natural mechanism of clearing the airways

"Coughing"

The controlled cough designed to move secretions without creating excessive intrathoracic and/or intracranial pressure

"Huff-Coughing"

Types of Bedside PFT

(1) SVC (2) FVC (3) PEFR / PF (4) MIP / NIF

The volume of gas in the pulmonary system at the end of a normal passive exhalation is....

*Functional residual Capacity*

Compare and contrast bulk, cylinder and manifold oxygen storage systems Bulk

- Tanks are white and outside hospital and hold 22,000 cubic ft gas -Stored in liquid or gaseous form (liquid most common) -Advantages: Eliminates the inconvenience and hazard of transporting and storing of large numbers of cylinders. Regulate delivery pressures centrally Operates the gas stored at low pressures which is safer than high pressure cylinders

Question #14 thermal mass effect humidifier performance?

- the greater amount water humidifier greater thermal mass - ^ capacity hold and transfer heat to gases - Larger reservoir humidifier more consistent heat and humidification (G.I.L)

cross contamination

-*Aerosol and condensate* from *ventilator circuits* are known sources of bacterial colonization -Wick and membrane type passover humidifiers prevent formation of bacteria carrying aerosols -Heated wire circuits reduce production and pooling of condensate -Higher temperatures in humidifiers is bacteriocidal -Circuit contamination usually occurs from patient to circuit

air dilution (air entrainment) have on aerosol output and aerosol density?

-*Air dilution increases the aerosol output*(total water leaving) but *decreases the aerosol density*(how thick it is) -Jet flow is not increased, large particles carried out by increased air entrainment flow -Aerosol density or amount of aerosol per liter of gas actually decreased with air entrainment -Aerosol output: 1 - 1.5ml/min -Particle size 55% fall into 1-5 micron range and 100% fall into 1- 10 micron range

What type of heating elements possible for heated humidification?

-*Hot plate* at base of humidifier -*Wraparound* which covers humidifier chamber -*Yolk or collar element* -*Immersion type* -*Heated wire* for warming a wick or hollow fiber

The resistance across an HME can increase with?

-Absorption of water -Secretion contamination

Which type of Humidifiers delivers 100% BH?

-Cascade Humidifier -Wick Humidifier

Restrictive Lung disease (pathophysiology)

-Difficulty getting the gas into the lung because of increased stiffness of the lung tissue -Thickening of alveolar capillary membrane -*Decreased lung compliance* -Ex.) Pulmonary fibrosis

Bubble diffusion humidifiers

-Direct a stream of gas under water where it is broken up into tiny bubbles. The smaller the bubble the greater the water/air surface ration

Simple reservoir

-Directs gas over a surface of a volume of water -Limited surface area -Used with heater for mechanical ventilation -Used with room temperature fluid for nasal CPAP and BiPAP -Ex: air moving across a pan of water / boiler radiator heat

Indications for humidification

-Primary indications: Humidification of dry inspired medical gas overcoming the humidity deficit created when the upper airway is bypassed -Secondary indications: managing hypothermia, treating bronchospasm caused by cold air

3 primary types of humidifiers

-bubble -passover (three types) ~Wick, simple reservoir, and membrane -HME (two types) ~active type:actively add heat & or water device ~passive type: recycling heat and humidity from pt

hazards are greater breathing cold, dry gas with artificial airway cause?

-damage tracheal epithelium within mins - prolonged breathing cause hypothermia, thickened secretion, damage epithelium, mucociliary dysfunction and atelectasis -humidity 60% at BTPS no damage to lungs

Question #20 heated wick humidifier

-draws water like sponge honeycomb structure by capillary action - gas pass through or next wick evaporation to occur -addition of heat ,high humidity achieved 90%+

Administer a dry medical gas at flows greater than 4L/min cause?

-heat and water loss -prolonged exposure cause damage to epithelial lining - exposure to cold, dry gas cause ciliary activity decease, airway become irritable, increase in mucus production, pulmonary secretion become inspissated.

inspissated

-thicken due to dehydration(thick or congeal) -breathing dry air

......121 final......

...

Question 4 What is the normal value for water vapor pressure in mmHg or torr if a gas is 100% saturated at body temperature?

...

Pulmicort Respules: Dosage

.25 to 1.0 mg in 2ml unit dose 1-2 times per day

57. What cylinder factor is used to compute the duration of flow for a 22 cu/ft O2 E cylinder?

.28

Alupent: Nebulizer dosage

.2cc's - .3cc's (10 -15 mg) in 3ml NS

Atropine Sulfate: Dosage

.5 - .1 ml (.4mg per 1ml injectable vial)

What are the sizes for Miller blades?

0 - 4 with sizes 2 and 3 fitting an average adult.

The average compliance of the lungs and chest all combined is:

0.1 L/cmH2O

Normal lung compliance is:

0.20 L/cmH2O

What is the relationship between the pressure measurements of mmHg and torr?

1 torr = 1mmHg

What elements are used for heating bubble and passover humidifiers?

1) "hot-plate) 2) "Wraparound" type that surrounds chamber 3) yolk, or collar that sits between water reservoir & gas outlet 4) immersion-type heater, element placed in water 5) heated wire in the inspiratory limb warming a wick or hollow fiber

What are signs of inadequate artificial ventilation?

1) Chest doesn't rise and fall\n\n2) Patient's heart rate does not return to normal\n\n3) Rate of ventilation is inadequate or excessive.

What two methods are used to clear the tongue out of the airway and open the airway wide?

1) Head-tilt/Chin-lift maneuver\n\n2) Jaw-thrust maneuver (preferable when spine injury is suspected)

What 9 general rules apply to the use of airway adjuncts?

1) Use an airway on all unconscious patients that don't exhibit a gag reflex.\n\n2) Some patients that can't tolerate an oropharyngeal airway can tolerate a nasopharyngeal airway.\n\n3) Open the airway manually before using an adjunct device.\n\n4) When inserting the airway, take care not to push tongue into pharynx.\n\n5) Do not continue inserting airway if patient begins to gag.\n\n6) When an airway adjunct is in place, you MUST MAINTAIN the head-tilt/chin-lift, or jaw-thrust maneuver and monitor the airway.\n\n7) When an airway adjunct is in place, you must remain ready to suction.\n\n8) If the patient regains consciousness or develops a gag reflex, remove airway and prepare to suction immediately.\n\n9) Use infection control practices!

Name factors that can shift the ISB deeper into the lungs.

1) When a person breathes through the mouth rather than nose, the ISB shifts distally. 2) Breathing cold, dry air. 3) Upper airway is bypassed. (breathing through artificial tracheal airway) 4) Minute ventilation is higher than normal.

What safety rules must you follow when using oxygen cylinders?

1) always use gauges, regulators, and tubing intended to be used with oxygen.\n\n2) Always use nonferrous metal oxygen wrenches. These are non-spark wrenches.\n\n3) Always ensure that valve seat inserts and gaskets are in good condition. Be sure to replace disposable gaskets with every use.\n\n4) Always use medical-grade oxygen labeled "OXYGEN USP" that is less than 5 years old.\n\n5) always open oxygen valve fully then turn back a half turn to prevent others from mistakenly trying to force it open,\n\n6) always have reserve oxygen stored in a cool, dry place, securely fastened,\n\n7) Never drop a tank, always have it secured.\n\n8) never leave a tank standing upright.\n\n9) No smoking!\n\n10) no open flames!\n\n11) keep grease/oil/petroleum products away from tanks\n\n12) do not move tanks by dragging or rolling

Name the 3 types of HMEs.

1) simple condenser 2) hygroscopic condenser 3) hydrophobic condenser

Name the 3 common types of passover humidifiers.

1) the simple reservoir type 2) the wick type 3) the membrane type

Name conditions that warm, humidified gases are used to treat or prevent.

1) treatment of hypothermic patient. (raises core temperatures back to normal) 2) prevent intraoperative hypothermia 3) alleviate bronchospasm in patients who develop airway narrowing after exercise or breathing cold air

What are the contraindications to IPPB Therapy?

1. A history of Spontaneous Pneumothorax or an acute pneumothorax without a Chest Tube in place. 2. Penumomediastimun and Subcutaneous Emphysema 3. Tracheosophageal Fistula 4. Bullous Disease 5. Hemodynamic Instability 6. Pulmonary Hemorrhage 7. Active Tuberculosis 8. Uncooperative Patient 9. Recent esophageal surgery. 10. Recent facial, oral, or skull surgery. 11. Nausea 12. Air swallowing 13. Singulation (hiccups) 14. Increased intracranial pressure (ICP) > 15 mm Hg 15. Less Invasive Therapy is Available

EVALUATION AND PATIENT MONITORING: What do you do when there is an adverse effects in patient monitoring?

1. Always include any adverse effects noted. 2. Also include the actions taken once the adverse effect was noted.

What are the important components of a Bird Ventilator?

1. Center body 2. Ceramic switch 3. Flow control 4. Pressure control 5. Sensitivity control 6. Manometer 7. Expiratory timer control 8. Circuit

Nasal Pharyngeal Airways: Insertion Technique

1. Determine and select the correct tube length by measuring from the tip of the nose to the earlobe. Use a tube with the largest outer diameter that will fit the patient's nostril. 2. Lubricate the tube with water, water-soluble jelly, or lidocaine jelly, which will alleviate discomfort 3. Reassure the patient and familiarize him or her with the procedure. 4. Insert the airway into the nostril up to the end of the nasal trumpet. 5. Have the patient exhale with the mouth closed. (If the tube is in the correct position, air can be felt exiting from the tube opening.) 6. Open the patient's mouth, depress the tongue, and look for the tube's tip just behind the uvula.

How do you perform a Maximum Inspiratory Pressure (MIP) to an alert patient?

1. Disconnect the patient from the ventilator. 2. Connect the patient to the manometer. 3. Coach the patient through the procedure. 4. Repeat the procedure 3 times, if possible, recording the "best" results.

How do you perform a Maximum Inspiratory Pressure (MIP) to an unresponsive patient?

1. Disconnect the patient from the ventilator. 2. Connect the patient to the manometer. 3. Coach the patient to take a deep breath. 4. During exhalation or during a pause, occlude the inspiratory side of the one-way valve system. 5. Keep occluding the inspiratory side until one of the following occurs: a. You obtain consistent negative pressure readings, or b. You notice a fall in the patients SpO2 reading c. You notice a change in the rate or rhythm on the EKG monitor.

What are the possible complications for the Bedside Pulmonary Function Testing (PFTs)?

1. Dyspnea 2. Dizziness 3. Inaccurate results

What are the contraindications for the Bedside Pulmonary Function Testing (PFTs)?

1. Extreme dyspnea. 2. Inability to follow directions. (This does not apply to the MIP measurement for an intubated patient).

EVALUATION AND PATIENT MONITORING: IPPB therapy is said to be effective when at least one of the following criteria have been met. (taken from the AARC Clinical Practice Guideline, 2003 Update).

1. For lung expansion therapy, a minimum delivered tidal volume of at least 1/3 of the predicted IC has been suggested. This corresponds to approximately 1200 ml in a 70 kg adult patient. 2. An increase in FEV1 or PEFR 3. Cough more effective with treatment. 4. Secretion clearance enhanced as a consequence of deep breathing and coughing. 5. Chest radiograph improved. 6. Breath sounds improved. 7. Favorable patient subjective response.

What Bedside Pulmonary Function Test (PFT) is frequently performed as a screening measure or to evaluate the effectiveness of clinical interventions?

1. Forced Vital Capacity (FVC) 2. Slow Vital Capacity (SVC)

What are the standard precautions for IPPB Therapy?

1. Handwashing 2. Gloves, especially if therapy is to be administered via mask 3. Mask if the patient has a communicable pulmonary disease. 4. Other barriers as indicated by the patient's clinical condition.

What are the standard precautions for the Bedside Pulmonary Function Testing (PFTs)?

1. Handwashing 2. Masks if the patient has a communicable pulmonary disease. 3. Other precautions, including the use of negative pressure rooms, as indicated by the patient's clinical condition.

IPPB Administration - Equipment

1. IPPB machine 2. disposable circuit 3. noseclips (hard to do w/o clips, especially smokers) 4. volume measuring device (venti-comp bag)

CONTRAINDICATIONS FOR IPPB THERAPY: What are the alternate therapy options for IPPB Therapy?

1. Incentive Spirometry 2. Chest Physiotherapy 3. Deep breathing exercises 4. PEP therapy 5. Flutter valve therapy 6. SVN or MDI for medication delivery

What are the possible complications of IPPB Therapy?

1. Increased airway resistance and work of breathing. 2. Barotrauma and possible pneumothorax 3. Nosocomial infection 4. Hemptysis 5. Hyperoxia when oxygen is the gas source. 6. Gastric distention 7. Impaction of secretions due to inadequate humidity. 8. Psychological dependence 9. Impedance of venous return 10. Exacerbation of hypoxemia 11. Hypoventilation or hyperventilation 12. Increased V/Q mismatch 13. Air-trapping 14. Overdisention of alveoli

Describe and demonstrate the procedure for Forced Vital Capacity (FVC) to the patient.

1. Inhale as deeply as possible. 2. Place the mouthpiece in your mouth, sealing the lips around the mouthpiece. 3. Forcefully exhale until I tell you to stop.

Describe and demonstrate the procedure for Peak Expiratory Flow Rate (PEFR) to the patient.

1. Inhale as deeply as possible. 2. Place the mouthpiece in your mouth, sealing the lips around the mouthpiece. 3. Quickly exhale, forcing the air out as hard as possible generating the greatest possible force/flow. Try to get all of the air out of your lungs in one big blast.

Describe and demonstrate the procedure for Slow Vital Capacity (SVC) to the patient.

1. Inhale as deeply as possible. 2. Place the mouthpiece in your mouth, sealing the lips around the mouthpiece. 3. Slowly exhale until I tell you to stop.

Describe and demonstrate the procedure for Maximum Inspiratory Pressure (MIP) to the patient.

1. Inhale deeply. Then exhale completely. 2. Quickly inhale as hard and as deeply as possible (Assure the patient that although it will feel odd, because no air will be inhaled, that this will only be for a single breath.)

What are the required equipment for Peak Expiratory Flow Rate (PEFR)?

1. Peak Flow meter 2. Mouthpiece 3. Noseclips (optional)

What are the steps to perform Bedside PFTs using Forced Vital Capacity (FVC)?

What are the steps to perform Bedside PFTs using Peak Expiratory Flow Rate (PEFR)?

EVALUATION AND PATIENT MONITORING: What are the parameters to be monitored?

1. Pulse before, during, and after. 2. EKG before, during, and after, if available. 3. Repiratory rate before, during, and after. 4. Breath sounds before, during, and after. 5. Level of Consciousness (LOC) before, during, and after. 6. Spontaneous and Positive Pressure volumes. 7. Ventilator settings, especially PIP required to deliver the Vt. 8. PF and VC before and after. 9. Sputum production. 10. Cough. 11. Blood pressure, if available, before, during, and after. 12. SpO2, if available, before, during, and after. 13. ICP in patients for whom ICP is of critical importance. 14. Chest radiograph, if available. 15. Patient's subjective response to therapy: pain, discomfort, dyspnea, improved, same, worse.

Instructions for using Spacers and Chambers (Holding vs. Mixing):

1. Shake medication 2. Blow out slowly 3. Breath in through spacer & Pump A. Holding Chamber Pump then breath in B. Mixing Chamber ( Pump after starting to breath in) 4. Hold breath for 6-10 seconds 5. "don't count a bad puff" 6. How much medicine do I have left

What are the Red Zone signs for the Peak Flow Meter?

1. Short of breath while not moving 2. Sucking in at neck or under sternum 3. Blue color on fingers, hands, lips, gums 4. Feeling worse after using inhaler

IPPB - Contraindications

1. Tension pneumothorax 2. ICP>15 mmHg 3. Hemodynamic instability 4. Recent facial, oral, esophageal or skull surgery 5. TE fistula 6. Active hemoptysis 7. Nausea 8. Air swallowing 9. Radioactive evidence of bleb (often COPD pt.s) 10. Singulation (hiccups)

What are the indications for IPPB Therapy?

1. The need to improve lung expansion. 2. The need for short-term ventilatory support as an alternative to tracheal intubation and continuous mechanical ventilation (CMV) a. Pulmonary Edema b. Acute Hypoventilation 3. The need to deliver aerosol medications. a. Severe Bronchospasm b. Fatigue due to muscle weakness c. Severe hyperinflation

What are the objectives for the Bedside Pulmonary Function Testing (PFTs)?

1. To assess the impact of disease on pulmonary function. 2. To assess the progression of a disease process. 3. To assess the effectiveness of interventions. 4. To screen for possible pulmonary disease. 5. To evaluate surgical risk. 6. To evaluate the patient's ability to breathe independently.

What are the objectives for IPPB Therapy?

1. To assist the patient in taking in deeper breaths than he/she could do spontaneously (usually > the patient's spont Vt). 2. To maintain normal oxygenation and ventilation until medical interventions can correct the cause of hypoventilation. 3. To deliver medications to the lung.

What are the required equipment for Forced Vital Capacity (FVC)?

1. Volume measuring device capable of handling high flowrates. 2. Mouthpice or mask 3. Noseclips (optional)

IPPB - Hazards/Complications

1. increased airway resistance 2. barotrauma, pneumothorax 3. infection 4. hypocarbia 5. hemoptysis 6. hyperoxia (when O2 is the gas source) 7. hypoxia (when air is the gas source) 8. gastric distention 9. increased V/Q mismatch 10. air trapping

IPPB Administration - Documentation

1. medication given 2. pressure used 3. volume achieved 4. assessment before, during and after treatment 5. patient's ability to do treatment and perceived outcome 6. SOAP (subjective, objective, assessment, plan)

IPPB Administration - Medical record review for

1. order 2. indications 3. contraindications

Bird Mark 7 general info

1. pneumatically powered 2. time, pressure or manually triggered a) time - set leak over time b) pressure - inhaled neg. pressure quickly turns it on before reversing pressure to pos. c) manual - button 3. pressure limited 4. time, pressure or manually cycled (same as triggered) 5. FIO2: 100% or approximately 45% a) button in - 100%; button out - approx. 45% 6. can set a rate, so can be used for short term ventilation

IPPB Administration - Procedure

1. position patient (sitting unless contraindicated) 2. give instructions a) noseclips b) tight seal with lips on mouthpiece c) breathe in and let machine fill your lungs d) when lungs full, mach. will shut off, exh. normally e) do not let cheeks puff out f) keep lips tight

IPPB Administration - Initial settings

1. set sensitivity a) turn down until it self triggers (chatters) b) then turn back up until it stops 2. set pressure (10-15 cmH2O) 3. set flow rate (10-15 LPM) 4. set oxygen a) if pt. is on >50%, set to 100% b) if pt. is on <50%, set to air-mix 5. turn expiratory time off

Assessment of outcome

1. tidal volumes: 10-15 ml/kg IBW or 70% of predicted IC 2. increase in FEV1 or PF 3. effective cough 4. improved secretion clearance 5. improved CXR (takes atleast 72 hours for improvement) 6. improved breath sounds (may get worse before better) 7. patient subjective response (need to chart this)

Unheated bubble humidifiers are of limited effectiveness at flows above _____ L/min.

10L/min

What level has ANSI set as the minimum water vapor content to avoid damage to the upper airway in non intubated patients (those with normal upper airways)?

10mg/L

What are suction catheter sizes for adults?

12 - 14 fr

Brovana: Duration

12 hrs.

What is the flow rate conversion of Heliox?

1:4 to 1 L/min.

Describe the assessment tools and bedside skill needed to assess the need for oxygen therapy

1st- laboratory measures of hypoxemia: draw blood, saturation monitoring 2nd- Specific clinical problems or conditions 3rd- Manifestations of hypoxemia: Tachypnea, cyanosis, overall appearance and distress 4th-Bedside assessment: SpO2

You are planning a patient transport that will take about 11/2 hours. The patient requires manual ventilation with 10 L/min of O2. What is the minimum number of full E cylinders you would take with you?

Atrovent: MDI Dosage

2 - 4 puffs (.07mg each) QID

Albuterol: MDI Dose

2 - 4 puffs (.09 mg each) Q4-6H PRN

The typical pressure pop-off incorporated into most simple bubble humidifiers releases pressure above which of the following?

2 psig

Racemic Epinephrine: Dosage

2.25% - .25 - .50 ml's in 3 cc's NS q1 - q4hr prn

What is internal diameter sizes for endotracheal tube?

2.5 - 10 mm

Albuterol: Nebulized dosage

2.5 mg in 3 ml NS

Albuterol: Peak

20 min.

When giving artificial ventilations to a child, how many ventilations should you give per minute?

20 ventilations per minute

What symptoms usually indicates a chest tube?

20% Pneumothorax

One cubic foot of any gas is equivalent to how many liters of gas?

28.30

The peak pressure on a ventilator reads 40 cm H2O. What is the equivalent pressure in mm Hg?

29.6 mm Hg

Typical pressure pop-off incorporated into most simple bubble humidifiers releases pressure above _____ psig.

2psig

Albuterol: Duration

3 - 4 hrs.

Serevent: Peak

3 - 5 hrs.

(CPT) Each position should be generally be maintained for ...

3-5 minutes

What water vapor levels (exhaled and returned) describe the performance of a typical hygroscopic condenser HME?

40 mg/L water vapor *exhaled* 27 mg/L *returned*

A patient is receiving nasal O2 at 5 LPM. His respiratory rate is normal and consistent. What is the approximate FIO2 he is receiving?

40%

76. A 27-year old woman received from the emergency department is on a nasal cannula at 5 L/min. approximately what FIO2 is the patient receiving ?

40% 1L=24, 2L=28, 3L=32, 4L=36, 5L=40

14. A patient has a record of body temperature of 106° F. What is this temperature in Celsius?

41° C 106° F to °C (°F-32) / 1.8

A patient has a recorded body temperature of 106° F. What is this temperature in degrees Celsius?

41°C

32. What is the absolute humidity water vapor content of saturated gas at normal body temperature 37° C?

43.8 mg /L

The absolute humidity (water vapor content) of saturated gas at normal body temperature (37°C) is ______ mg/L

43.8 mg/L

What is the absolute humidity (water vapor content) of saturated gas at normal body temperature (37°C)?

43.8 mg/L

How much water per liter of gas can air hold at 37 degrees Celcius?

44 mg/H2O

What is the capacity of water at body temperature?

44 mg/L

When inspired air is fully saturated (100%) at 37 degrees C it holds what?

44 mm H2O per liter of gas and exerts a water vapor pressure of 47 mmHg

What is the capacity of water at body temperature?

44 mm/L

Question 3 What is the normal value for water vapor content in mmHg or torr if a gas is 100% saturated at body temperature?

44mg/L / 44mg/L = 1 x 100 = 100%

Serevent: Onset

5 min.

Serevent: Dosage

50mcg

36. The American National standards institute has set a water vapor content level of 30 mg/L as the minimum Absolute humidity required for patients whose upper airways have been bypassed. This equals what body humidity (BH)?

68%

OBJECTIVES FOR IPPB THERAPY: A Vt of _____ - _____ ml/Kg of ideal body weight should be sufficient in this case.

6; 8

60. One cu/ft of liquid O2 is the equivalent of about how many cu/ft of gaseous O2?

860

What is the FDA standard for the purity of oxygen?

99%

On patient extubation, is it safe to cut the pilot balloon instead of deflating cuff?

Securing ETT Tubes and Tracheostomy Tubes: How is ETT placement confirmed?

Securing ETT Tubes and Tracheostomy Tubes: What are the indications an ETT is too high?

Securing ETT Tubes and Tracheostomy Tubes: What are the indications an ETT is too low?

Securing ETT Tubes and Tracheostomy Tubes: What are the risks of using adhesives?

Securing ETT Tubes and Tracheostomy Tubes: What is proper placement of an ETT?

What are the 3 major risks / hazards of extubation? How can these risks be minimized?

What are the advantages of an uncuffed trach?

What are the risks & advantages of a cough to remove the tube during extubation?

What are the signs of an obstructed ETT?

What is a Jackson trach?

Which type of V/Q mismatch is caused by atelectasis?

Why do we administer humidity or cool aerosol after extubation?

What is a "Murphy Hole" in a single use suction catheter kits?

A "Murphy Hole" is the hole right above the tip of the suction catheter. Its purpose is to increase suction surface area.

Newsgroup

A computer based interactive discussion group: chat room, aol instant messenger, share ideas

Define "oropharyngeal airway."

A curved device inserted through the patient's mouth into the pharynx to help maintain an oral airway.

Define "pressure regulator."

A device connected to an oxygen cylinder to reduce cylinder pressure to a safe amount for delivery of oxygen to a patient.

Define "humidifier."

A device connected to the flowmeter to add moisture to the dry oxygen coming from an oxygen cylinder.

Flowmeter

A device that controls and measure gas flow

Define "airway adjunct."

A device that helps maintain an open airway.

Nebulizers

A device which produces an aerosol and uses a baffle

Oral Pharyngeal Airways: Describe the Guedel

A single airway down the middle of the tube

What are the four components of any suctioning device?

A suction source, a collection container, tubing, and suction tips or catheters

Define "flowmeter."

A valise that indicates the flow of oxygen in liters per minute.

Thorpe Tube

A variable orifice, constant pressure flow metering device

Which of the following best describes the performance of a typical hygroscopic condenser HME? A. 40 mg/L water vapor exhaled; 27 mg/L returned B. 40 mg/L water vapor exhaled; 20 mg/L returned C. 27 mg/L water vapor exhaled; 40 mg/L returned D. 44 mg/L water vapor exhaled; 37 mg/L returned

A. 40 mg/L water vapor exhaled; 27 mg/L returned

What is the diagnostic benefit of thoracentesis?

A. Clear, serous, or transudate associated w/ CHF B. Opaque, milky, cloudy, bloody or exudate fluid associated w/ infections, trauma, tumors - indicates need for cytology & chemistry testing

What are the risks of bronchoscopy?

A. bleeding B. edema / spasm - broncho & larygospasm C. pneumothorax D. trauma E. hypoxia

What is the primary goal of humidity therapy? A. maintain normal physiologic conditions B. deliver drugs to the airway C. decrease airway reactivity to cold D. reduce upper airway inflammation

A. maintain normal physiologic conditions

A design that increases surface area and enhances evaporation by incorporating an absorbent material partially submerged in a water reservoir that is surrounded by a heating element best describes what type of humidifier? A. wick B. cascade C. bubble D. hygroscopic

A. wick

Long acting / Control medications -" stays at home"; Inhaled Steroids Servent & Flovent combinations in dry inhaler Dosages 100/ 50 , 250/ 50, or 500 mcg Flovent/50 mcg Serevent

ADVAIR Discus

Oxygen therapy is least to be of benefit in hypoxia that is due to:

Abnormalities in tissue utilization

stimulate sympathetic system (epinephrine, norepinephrine); not selective

Adrenergic

At high flow rates, what do some bubble humidifiers produce?

Aerosol Particles

At high flow rates, what do some bubble humidifiers produce?

Aerosol particles

How do you inflate a rebreather bag?

After hooking up to oxygen and starting flow at 12-15 LPM, cover the exhaust port or the connection between the mask and reservoir

What does "ABC" stand for when you're doing the patient assessment?

Airway, Breathing, and Circulation

90. Before administering a helium-O2 mixture to a patient with large airway obstruction, what should you do?

Analyze the O2 concentration of the mixture

Before administering a helium-O2 mixture to a patient with large airway obstruction, what should you do?

Analyze the O2 concentration of the mixture.

An acute blood loss would cause ______ hypoxia.

Anemic

Laryngeal Mask Airways (LMA): Indications:

Anesthesia and in emergency medicine for airway management. A patient who is trapped in a sitting positing. Patient with suspected trauma to the cervical spine When intubation is unsuccessful

blocks sympathetic system - blocks receptor site for epinephrine

Antiadrenergic

blocks parasympathetic system - blocks receptor site for acetylcholine; Parasympatholitic

Anticholinergic

Fiberoptic Endotracheal Intubation: Indications

Anticipated difficult intubation (upper airway abnormality) Endotracheal intubation when neck extension is not desirable (cervical spine injury, rheumatoid arthritis)

What is the main drawback of using a Bourdon gauge flowmeter?

Any blockages or kinks will result in a higher than actual reading.

Define the anatomic "dead space" of the respiratory system.

Areas of the lungs outside the alveoli where gas exchange with the blood does not take place.

How is Body Humidity expressed?

As a %

How is Absolute Humidity expressed?

As mg/L

In compressed gases, what will occur as the volume of the gas is depleted and why?

As the volume of gas is depleted the pressure will go down because the volume of a gas is directly proportional to the pressure if at a constant temperature.

Long acting / Control medications -" stays at home"; Inhaled Steroids Mometasone furoate - "Twisthaler" - Ped and adult doses - Q Day

Asmanex

What is Mometasone Furoate? What is the dosage?

Asmanex - Mometasone furoate - "Twisthaler" - Ped and adult doses - Q Day

Peak Expiratory Flow Rate (PEFR) is typically performed before and after bronchodilator therapy to ________ the ____________ of therapy.

Assess; effectiveness

10. The majority of respiratory care education programs in the United States offer what degree?

Associate's degree

How can you remember what percentage of oxygen is being administered by a nasal cannula?

At 1 LPM, a nonrebreather mask will deliver 24% oxygen. For every additional LPM,add 4% oxygen, up to 6 LPM (for a maximum of 44% oxygen)

If patient at 40% it is 1:3, flowmeter is 8L/min: total flow: 32L/min. If you increase to 10 L / min did you change the oxygen percentage?

At 10 L/min flow to the patient is 40 L/min. you only increased the flow. The oxygen percentage stayed the same.

Long acting / Control medications -" stays at home"; Inhaled Steroids (Triamcinolone acetonide), 2- puffs BID

Azmacort

What is Triamcinolone Acetonide? What is the dosage?

Azmacort (Triamcinolone acetonide), 2- puffs BID

An ideal heat-moisture exchanger (HME) should have an efficiency rating of at least which of the following? A. 50% B. 70% C. 30% D. 90%

B. 70%

Clinical indications for delivering cool humidified gas include which of the following? I. postextubation edema II. upper airway inflammation III. croup (laryngotracheal bronchitis) IV. epiglottitis A. I, II, and III B. I, II, III, and IV C. II, III, and IV D. II and III

B. I, II, III, and IV

Which of the following are types of heat-moisture exchangers (HMEs)? I. simple condenser II. hygroscopic condenser III. hydrophobic condenser A. II and III B. I, II, and III C. I and II D. III

B. I, II, and III

Which type of humidifier "traps" the patient's body heat and expired water vapor to raise the humidity of inspired gas? A. bubble B. heat-moisture exchanger C. membrane D. passover

B. heat-moisture exchanger

All of the following are contraindications for heat-moisture exchangers except: A. presence of a large leak around artificial airway B. when a patient is suffering from hyperpyrexia C. presence of thick, copious, or bloody secretions D. when a patient's minute ventilation exceeds 10 L/min

B. when a patient is suffering from hyperpyrexia

The use of a BVM is often reffered to as ______ the patient.

Bagging

BASIC TERMINOLOGY: 1. Basic definition is an injury due to excessive pressure. 2. Pulmonary barotrauma is defined as extra-alveolar air from lung damage secondary to changes in intrathoracic pressure.

Barotrauma

Why aren't humidifiers used widely on ambulances?

Because they're an infection risk and generally unnecessary for short trips.

Why must you be careful when suctioning the pharynx?

Because you might trigger additional vomiting, and you might trigger the vagus nerve in the back nof the pharynx, thus slowing the heart rate.

American Standard Safety Systems (ASSS)

Big tanks. Specification for threaded high pressure gas cylinders and their attatchments

Type of IPPB Ventilator: • Leak compensating IPPB ventilator with Mark-7 features.

Bird Mark - 10

Type of IPPB Ventilator: • Leak compensating IPPB ventilator with Mark-7 features plus extended range of flow and pressure.

Bird Mark - 14

Type of IPPB Ventilator: • Pneumatically powered assist/controller pressure ventilator for delivery of IPPB therapy. • Requires gas source of 50 pounds per square inch.

Bird Mark - 7

CONTRAINDICATIONS FOR IPPB THERAPY: A superficial, subpleural collection of air is referred to as a _______.

Bleb

Atrovent: Characteristics

Blocks signals that are closing the airways

What is Relative Humidity at body temperature and is expressed as a %?

Body Humidity

The temperature at which the vapor pressure of a liquid equals the pressure exerted on the liquid by the surrounding atmosphere is ____________ ______.

Boiling Point

How would you coach the patient to increase gas distribution?

Breathe Slowly

Terbualtine Sulfate is another name for:

Brethine

What are the two large branches that originate at the trachea and bring air into the right and left lungs?

Bronchi

What is the formula for Compliance?

C = change in Volume/change in Pressure

Which of the following inspired conditions should be maintained when delivering medical gases to the nose or mouth? A. l00% RH at 20° to 22°C B. 80% RH 28° to 32°C C. 50% relative humidity (RH) at 20 to 22° C D. 100% RH at 32° to 35°C

C. 50% relative humidity (RH) at 20 to 22° C

For which of the following patients would you select a heated humidifier? I. patient receiving oxygen through a bypassed upper airway II. patient receiving long-term mechanical ventilation III. patient receiving oxygen through an oronasal mask A. II and III B. II C. I and II D. III

C. I and II

All of the following are features of an ideal heat-moisture exchanger (HME) except: A. minimal dead space B. 70% or higher efficiency C. high compliance D. minimal flow resistance

C. high compliance

The greater the temperature of the gas, the: A. less water vapor it can hold B. less efficient the humidifier is C. more water vapor it can hold D. more water vapor is lost

C. more water vapor it can hold

Which pulmonary function cannot be measured by spirometery alone

CANNOT BE MEASURED: Functional Residual Volume, Residual volume, total lung volume >Need helium dilution CAN BE MEASURED with spirometry: Tidal volume, vital capacity, etc.

Frequent causes of obstructive lung disease

COPD Asthma Cystic fibrosis Bronchiolitis obliterans

The ______ (at the level of the angle of Louis, about T5) is the point of airway bifurcation, leading to the left and right main stem bronchi.

Carina

Another name for a Diffuser Humidifier is?

Cascade Humidifier

Stimulates parasympathetic system (acetylcholine)

Cholinergic

How do you determine the best size of oropharyngeal airway for a patient?

Choose an airway that extends from the corner of the patient's mouth to the tip of the earlobe.

Which of the following devices would you select if the goal was to accurately meter the flow through a jet nebulizer?

Compensated Thorpe tube

Medications: Which patients use sedation prior to intubation? Proper sedation should be used in all.

Conscious and hemodynamically stable patients

How do you determine the size of the Oral Pharyngeal Airways?

Corner of the mouth to the angle of the jaw

Type of steroids that are natural substance found in the body that help fight inflammation. It is used to treat asthma because they reduce swelling and irritation in the walls of the small air passages and ease breathing problems. It helps prevent asthma attacks.

Corticosteroids

Fiberoptic Endotracheal Intubation: Disadvantages

Costs associated with the need for special equipment and skill

What should you do before attaching a pressure regulator to the valve on an oxygen cylinder?

Crack the valve for a moment to clear any dirt.

(Flutter Valve Thearpy) may not be as effective as PEP in the management of ....

Cystic Fibrosis

What are the five common oxygen cylinder sizes, and what are their oxygen capacities?

D cylinder: 350 liters\nE cylinder: 625 liters\nM cylinder: 3000 liters\nG cylinder: 5300 liters\nH cylinder: 6900 liters

A heated humidifier should trigger both auditory and visual alarms and interrupt power to the heater when the delivered temperature exceeds which of the following? A 25°C B 30°C C. 35°C D. 40° C

D. 40° C

A patient has been supported by a mechanical ventilator using a heat-moisture exchanger for the last 3 days. Suctioning revealsan increase in the amount and tenacity of secretions. Which of the following actions is indicated? A. Reassess the patient's secretions over the next 24 to 48 hours. B. Replace the hygroscopic condenser humidifier with a new one. C. Increase the hygroscopic condenser humidifier temperature. D. Switch the patient to a large-volume heated humidifier.

D. Switch the patient to a large-volume heated humidifier.

Conditions that can cause temperature "overshoot" with servo-controlled heated humidifiers include all of the following except: A. Flow is decreased during normal operation. B. The airway temperature probe becomes dislodged. C. The unit is allowed to warm up without flow. D. The unit reservoir is refilled with sterile water.

D. The unit reservoir is refilled with sterile water.

What are the cylinder constants?

D=0.16\nE=0.28\nM=1.56\nG=2.41\nH=3.14\nK=3.14

A fibrotic lung would exhibit which of the following characteristic?

Decreased lung compliance

22. According to Pasqual's, the pressure exerted by a liquid in a container depends on which of the following?

Depth of the liquid and density of the liquid

What factors should be used in selecting an oxygen delivery system?

Design: Low flow, Reservoir & High flow systems enclosures Performance How much oxygen can it deliver FIO2 fixed or variable FIO2 low: less than 35%, moderate (35 - 60%), high (>60%), full range (21 to 100%)

35. What is the term for the temperature at which the water vapor in a gas begins to condense back into a liquid

Dew point

Passover humidifier

Directs gas over a water surface

Where would you measure the FIO2 in an NO delivery system used with a mechanical ventilator?

Distal to the NO titration site

What important things must you remember when using a face mask on a patient with a spinal injury?

Do NOT tilt the head backward!

When must you NOT use a nasopharyngeal airway?

Do not use a nasopharyngeal airway in the case of a severe head injury, ESPECIALLY when you can see clear cerebrospinal fluid coming from nose or ears.

Laryngeal Mask Airways (LMA): Contraindications:

Does not protect from aspiration.

What are the Specialized ET Tubes?

Double Lumen Tubes

8. Which two names are linked with the development of the iron lung, which was extensively used to treat the polio epidemic in the 1950s?

Drinker and Emerson

A phase of Principles of Pharmacology that is delivered to respiratory tract via aerosol. • Advantages: topical delivery vs. systemic • Lower dosages • Rapid onset • Targeted delivery • Less systemic effect

Drug Administration

In Principles of Pharmacology, The course of drug action from dose to effect comprises of what 3 phases?

Drug Administration Pharmacokinetics Phase Pharmacodynamic Phase

Exhalation into which device can result in loss of drug delivery?

Dry power inhaler

What is the mixture of Atrovent and Albuterol in nebulizer pre mix called?

Duo Neb

Be prepared to calculate the duration of flow for an E and H and K oxygen cylinder

Duration of Flow(min)= Pressure(psig) x cylinder factor (E=0.28, H&K 3.14) / Flow (L/min) Ex Claculate how long a full H cylinder will last running at 8 L/min 2200 psig x 3.14 = 6908 / 8 L/min = 863.5/60 min = 14.39 hr

What are the cylinder factors for an E and H and K oxygen cylinder?

E = 0.28 H & K= 3.14

What is the formula for Elasticity?

E = change in Pressure/change in Volume

What lung expansion therapy device is used to aggressively treat atelectasis?

EZPAP Therapy

Designed to be used with micro-nebulizers to give aerosolized bronchodilators with PEP (uses flow to adjust PEP)

EZPAP therapy

Nasal Pharyngeal Airways: How do you determine the length of the Nasal Pharyngeal Airways?

Earlobe to tip of the nose

Methacholine challenge data obtained

Effects of a bronchoconstrictor on FEV1

I have a patient who had gastric bypass surgery three days ago. She is on a 3 LPM nasal cannula has a weak cough and you have noticed that her breath sounds reveal fine crackles in the bases. As this patient's respiratory therapist what would you suggest as the best therapy for this patient?

Encourage deep breathing and coughing to clear lungs because your lungs are warm and moist and you are at a high risk of getting an infection Inform patient on proper use of incentive spirometer Inform doctor that this patient appears to be getting atelectasis and suggest a CRX and IPPB therapy

What is flexible suction to remove secretions from trachea - main stem Bronchi?

Endotracheal Suction

What are the indications for endothracheal intubation?

Endotracheal intubation is indicated in several clinical situations including • acute hypoxemic • hypercapnic respiratory failure • impending respiratory failure • This procedure is also used to protect the airway in conditions of upper airway obstruction, either mechanical or from airway pathology. • Patients at risk for aspiration, most commonly from central nervous system derangements may benefit from elective intubation. • performed for many operative procedures; at times to facilitate certain diagnostic procedures (ex. computed tomographic scan /bronchoscopy); and to aid in respiratory hygiene. • Another potential indication for EI includes the ne Endotracheal intubation is indicated in several clinical situations including • acute hypoxemic • hypercapnic respiratory failure • impending respiratory failure • This procedure is also used to protect the airway in conditions of upper airway obstruction, either mechanical or from airway pathology. • Patients at risk for aspiration, most commonly from central nervous system derangements may benefit from elective intubation. • performed for many operative procedures; at times to facilitate certain diagnostic procedures (ex. computed tomographic scan /bronchoscopy); and to aid in respiratory hygiene. • Another potential indication for EI includes the need to hyperventilate by mechanical ventilation, attempting to reduce intracranial pressure • ed to hyperventilate by mechanical ventilation, attempting to reduce intracranial pressure

Which liquids have very low surface tension?

Ethyl Alcohol

26. Which of the following liquids has the lowest surface tension?

Ethyl alcohol campared to: whole blood, plasma, mercury

29. What is the change in a state of the substance from liquid to gaseous form occurring below its boiling point

Evaporation

What is the change in state of a substance from liquid to gaseous form occurring below its boiling point?

Evaporation

Fiberoptic Endotracheal Intubation: Advantages

Excellent airway visualization Minimal hemodynamic stress

What occurs when the temperature of a saturated gas drops down to its dew point?

Excess water vapor will condense as visible droplets.

Why must you avoid prolonged suctioning?

Excessive suctioning will cause hypoxia and death.

Liquids

Exhibit mutual attraction Forces are weaker than solids thus molecules move about freely Take shape of container and flow Dense and can't be easily compressed Ex: Medication inside of Nebulizer

ERV

Expiratory Reserve Volume the maximum volume that can be exhaled after a normal exhalation

The maximum volume that can be exhaled after a normal exhalation.

Expiratory Reserved Volume (ERV)

Assessment of need

Extensive Medical Record Review 1. presence of atelectasis by CXR 2. reduced pulmonary function 3. neuromuscular disorders or kyphoscoliosis 4. fatigue or muscle weakness 5. presence of acute severe bronchospasm or exacerbation of COPD that fails to respond to other therapy 6. patient preference

"Manally Assisted Coughing"

External application of mechanical pressure to the epigastric region or thoracic cage coordinated with forced exhalation. Also primarily used for patients who have normal lungs but do not have the muscular strength/control to produce an effective cough. (i.e. Paraplegia, Quadriplegia, & Muscular dystropy)

What is the risk to the patient with the suction catheter weighing down the ET Tube?

Extubation

Antidiabetic Agents inhaled human insulin • Not indicted for COPD, lung disease, or smoking patients • Bronchospastic

Exubera

True or False: "Lower temperatures result in an increased humidity"

FALSE! Higher temperatures result in an increased humidity

COMBINED VENTILATORY DEFECT

FEV1/FVC < 80% and TLC < 80% of predicted

64. Which of the following is False about a Bourdon Gauge?

False it will register zero flow when the outlet is completely blocked false

• Sympathomimetics - mimic rescue systems - BETA 1 & BETA 2 • Increases nerve signals to open airway - "broncho-dilator" = BETA 2 • Side effects - HR, tremors, nausea, headaches, "allergic" / rebound bronchospasm, • Underdosing or too little too late - • Overdosing - sign of loss of control of disease - • Loss of effectiveness / tolerance • Daily use > Q 4 hours indicates need for long acting medication

Fast acting / Rescue medications - "stays in your pocket"

When used to control the flow of medical gases to a patient, how is a Bourdon gauge classified?

Fixed-orifice, variable-pressure flowmeter device

What type of bronchoscope allows observation of peripheral locations in the lung & avoids mechanical distortion of the airways? It is indicated in Diagnostic Bronch's.

Flexible Bronchoscope

What is Formeterol?

Foradil

FRC

Functional Residual Capacity -Residual volume + ERV= FRC -Normal volume of gas in the lung at rest -*Helium dilutions* help measure FRC -Is determined by a balance between the elastic recoil of the lung and chest wall.

FRC

Functional Residual Capacity (ERV+RV) the total amount of volume in the lungs after a normal exhalation

The total amount of volume in the lungs after a normal exhalation. (ERV + RV)

Functional Residual Capacity (FRC)

L/T Ratio: Systemic absorption from oral pharynx and usually have side effects.

G.I. Tract

What measure is used to describe the variability of particle diameters in an aerosol?

GSD

List 3 physiologic responses can occur when inserting & placing an oral airway?

Gag Reflex

What is the contraindication of Oral Phanyngeal Airways on conscious or semi-conscious patients?

Gag Reflex

What 3 things must be known to calculate duration of flow left in a cylinder?

Gas flow, Cylinder size (cylinder factor), cylinder pressure at start of therapy.

What are common ways to increase the surface area ratio of humidifiers?

Generate a water Droplet Aerosol Expose the gas to a saturated wick Use a Bubble or Diffusion head

How would you intervene if you found a patient that was in respiratory arrest?

Give artificual ventilations with a pocket face mask, a bag-valve mask, FROPVD, or ATV at 10-12/minute for adults, 20/minute for a child.

How would you intervene if you found a patient that was breathing inadequately?

Give assisted ventilations with a pocket face mask, bag-valve mask, or FROPVD. Do NOT use FROPVD on children or infants.

How would you intervene if you found a patient that was breathing adequately but required supplemental oxygen due to a medical or traumatic condition?

Give supplemental oxygen via nonrebreather mask or nasal cannula

Generally what is the best oxygen system for a patient with COPD that has acute on chronic hypoxemia present?

Goal: ensure adequate arterial oxygenation without depression ventilation. SaO2 88-90 % PaO2 50-60 mmHg -Low flow nasal cannula or low concentration (24-28%) Less stable the patient, greater need for AEM

List 3 techniques that can use you minimize upper airway bleeding and trauma?

Good lubrication Gentle steady echnique Nasal airway

Flow-volume loops data obtained

Graphic evaluation of inspiration and expiration

What colors on an oxygen cylinder let you know that it does indeed contain oxygen?

Green, white, stainless steel.

What are the 2 types of Oral Pharyngeal Airways?

Guedel Berman

What is the formula for calculating Humidity Deficit?

HD = Body Humidity - actual humidity (mg/L) or as a % deficit --------- x 100 44 mg/L

Rules to inserting OPA. \n\n(used when airway is opened, this helps maintain airway)

Have suction ready.\nWear gloves, mask and goggles.\nOpen airway manually first. \nDon't push tongue into pharynx.\nMaintain head-tilt or jaw-thrust when adjunct in place. \nRemove immediately if regains consciousness or gag reflex.

(CPT) Reverse Trendellenburg

Head high than the feet

(CPT) Trendellenburg Position

Head lower than the feet

HME

Heat and moisture exchanger: Active type: actively adding heat and or water to device Passive type: recycling exhaled heat and humidity from the patient

Conduction

Heat transfer in solids Direct contact between hot and cold molecules Quantified by measuring thermal conductivity Solids have high lvls Gases have low lvls Metals feel cold due to high level of thermal conductivity

Convection

Heat transfers in both liquids and gasses Mixing of fluid molecules @different temperature Convection current: Fluid movement carrying heat energy. ex furnace and incubators

Which type of humidifier "traps" the patient's body heat and expired water vapor to raise the humidity of inspired gas?

Heat-moisture exchanger

HME

Heated moisture exchanger

What is a good clinical example of using the principle of convection to transfer heat?

Heated, enclosed infant incubations

Which of the following is a good clinical example of using the principle of convection to transfer heat?

Heated, enclosed infant incubators

Hazards and complications of bland aerosol therapy include all of the following except:

Hemoconcentration

CONTRAINDICATIONS FOR IPPB THERAPY: What is an IPPB Therapy contraindication that includes hypotension, hypovolemia, and arrhythmias. This is a relative contraindication as the positive pressure may worsen these conditions.

Hemodynamic Instability

The patient is inhaling. What receptor would make him stop inhalation to begin exhalation?

Hering-Breuer

What is the clinical importance of Dalton's Law?

High altitudes impair O2 available for gas exchange at the lungs. Different proportions of gases have different effects so you need to know the partial pressure of each gas. Barometric changes are primarily a function of altitude.

Which of the following is used by the USN to produce aerosol droplets?

High-frequency vibrations

2.Who is considered to be the father of medicine?

Hippocrates

1.Where are the majority of respiratory therapist employed?

Hospitals or acute care settings

What is used in order to add water and/or heat to a dry gas during Oxygen administration?

Humidification

What device adds molecular water to gas?

Humidifier

Term for water that is in a gaseous or vapor form is?

Humidity

The term for a physiological difference between inspired gas's water content and the water content of a gas at body temperature, is?

Humidity Deficit

What is the physiologic term that refers to the difference between inspired gas's water content and the water content of a gas at body temperature.

Humidity Deficit

Shifts is the ISB affect the body's normal heat and moisture exchange mechanism resulting in the need for what?

Humidity Therapy

Question 2 Given the water vapor content of a gas be able to determine the humidity deficit

Humidity deficit = capacity - content for body humidity it would be 44mmHg - content 44mmHg - content (absolute humidity 10) = 34mmHg

Archimedes' principle is applied clinically in what device?

Hydrometer

(Nasotracheal Suctioning) ______ & _______ reduces ______ ________

Hyperventilation & Hyperoxygenation ; Cardiac arrhythmias

For what should sputum collected by aerosol therapy induction be inspected? I. Color II. Volume III. Odor IV. Consistency

I II, III, and IV

Primary safety concerns in the application of hyperbaric oxygenation include which of the following? I. Sudden decompression II. Electrical fires III. CO2 accumulation

I and II

What factors affect the combustion-supporting properties of O2? I. Concentration II. Partial pressure III. Humidity

I and II

Which of the following medical gases can be maintained in the liquid form at room temperature? I. Nitrous oxide II. Carbon dioxide III. Oxygen IV. Helium

I and II

For which of the following patients might you recommend administration of a hypertonic saline aerosol? I. Acquired immune deficiency syndrome (AIDS) patient with severe pneumonia symptoms. III. Patient suspected of having tuberculosis.

I and III

What does 1 atmospheric pressure absolute (ATA) equal? I. 101 kPa II. 50 psi III. 760 mm Hg

I and III

Which of the following would indicate a need for O2 therapy for an adult or child? I. SaO2 less than 90% II. PaCO2 greater than 45 mm Hg III. PaO2 less than 60 mm Hg

I and III

Air for medical use in a hospital should be which of the following? I. Particle-free II. Oil-free III. Dry

I and IIII

In which of the following clinical situations would you recommend hyperbaric oxygen (HBO) therapy, if available? I. Carbon monoxide poisoning II. Respiratory or cardiac arrest III. Severe trauma IV. Cyanide poisoning

I and IV

One atmosphere (1 atm) of pressure is equivalent to which of the following? I. 29.9 inches Hg II. 14.7 lb/in2 III. 1034.0 g/cm2 IV. 760.0 mm Hg

I, II, III, and IV

What are some key patient considerations in selecting O2 therapy equipment? I. Type of airway (natural or artificial) II. Severity and cause of the hypoxemia III. Age group (infant, child, adult) IV. Stability of the minute ventilation

I, II, III, and IV

Which of the following are necessary features to look for in selecting a heated humidifier? I. Water level readily visible II. Over-temperature protection III. Auditory and visual alarms IV. Minimal temperature overshoot

I, II, III, and IV

key facts about boiling

I. Boiling a liquid requires more energy than does evaporating it. II. A liquid's boiling point varies with the atmospheric pressure.

Name the types of humidifiers used in clinical practice.

I. Heat moisture exchanger II. Passover humidifier III. Bubble humidifier

Inhalation of dry gases can do?

I. Increase viscosity of secretions. II. Impair mucociliary motility. III. Increase airway irritability.

What are some types of passover humidifiers?

I. Simple reservoir II. Membrane III. Wick

Which of the following equipment could be powered by a small diaphragm or turbine air compressor? I. Small-volume medication nebulizer II. All-purpose large-volume jet nebulizer III. Intermittent positive-pressure breathing device

I. Small-volume medication nebulizer

key facts about molecular water vapor

I. Water vapor exhibits kinetic activity. II. Water vapor exerts pressure.

What are the characteristics of a servo-controlled heated humidifier?

I. adjusts heater power automatically. II. provides automatic heater shutdown. III. includes temperature safety alarms.

VT + IRV =

Which of the following factors determine the actual O2 provided by an air-entrainment system? I. O2 reservoir II. Air-to-O2 ratio of the device III. Resistance downstream from the jet

II and III

A lung expansion device which is: • Used primarily as a preventative or prophylactic treatment • Patient are encouraged to take slow - deep inspirations ten times every hour • Patients are taught to perform 5-10 second breath holds at maximal inhalation for each of the 10 hourly breaths

INCENTIVE SPIROMETRY

When do you NOT use NPA?

If CSF coming from EARS or nose. indicates skull fracture. really don't use when head injury suspected.

Diffusive lung disease

Impaired trans-alveolar gas exchange of oxygen -Pulmonary fibrosis (thickened alveolar capillary membrane) example >Uncommon in isolation-> usually associated with restrictive lung disease *At alveolar-capillary membrane*

What are disadvantages of Bourdon Gauge?

Inaccuracy when pressures distal to the orifice change. -If downstream pressures rise (high resistance equipment) Pressure difference across the orifice falls Actual output flow decreases Gauge reading will be falsely higher than actual delivered flow -Should not be used with high resistance equipment

Define "hypoxia."

Inadequate oxygen being delivered to cells

A patient receiving 35% O2 through an air-entrainment mask set at 6 L/min input flow becomes tachypnea. Simultaneously you notice that the SpO2 has fallen from 91% to 87%. Which of the following actions would be most appropriate in this situation?

Increase the devices input flow to 10 L/min

80. A patient is receiving O2 through a non-rebreathing mask set at 8 L/min. You notice that the mask's reservoir bag collapses completely before the end of each inspiration. Which of the following actions is appropriate in this case?

Increase the liter flow (bag should not completely collapse)

What is the best way to increase the humidity output of a humidifier?

Increase the temperature of either the water or the gas.

Inhalation of dry gases can do which of the following?

Increase viscosity of secretions Impair muco-cilliary motility Increase airway irritability

When lung compliance decreases the patient commonly has a/an:

Increased Respiratory Rate Decreased Tidal Volume

Obstructive lung disease

Increased airway RESISTANCE to gas flow -Worse on exhalation -Cannot get air out of the lungs -Acute: Asthma -Chronic: COPD, bronchitis *Airway problem due to increased resistance*

The primary feature of obstructive lung disease

Increased airway resistance

What are the visual signs of airway obstruction?

Increased respiratory rate Gasping Use of accessory muscles Retractions - Intercostal muscles Cyanosis Diaphoresis - stress Fear, anxiety, thrashing Unconsciousness

Indications for Amphtericin B:

Indication: Treat patients at risk(i.e. CF, Lung transplant , & chronic steroid use.) from fungal infections & minimize toxic effects of systemic antifungal agents -

Sputum Collection using Suction: Indication

Ineffective cough to produce secretions because of weakness or artificial airway

Which of the following is FALSE about liquid bubbles?

Inflation pressure can be lowered if surface tension is increased.

Which one of these processes is active: inhalation, or exhalation?

Inhalation -- it requires energy in the form of muscle contractions.

Diffusing capacity of CO technique

Inhalation of fixed concentration of CO and helium, breath holding for 10 seconds, then expiration with measurement of end tidal CO and helium.

Methacholine challenge technique

Inhalation of increasing doses of methacholine (a bronchoconstrictor) followed by forced exhalation

Why use a humidifier when administering oxygen?

Inhaling humidified oxygen is more comfortable for patients, especially for children and patients with COPD.

Simple mask:

Input flow range 6-12 L/min FIO2 range .35 to .55 -Flows greater than 12 L/min to maintain oxygenation, you should switch to a different system. Flows at 5L/min or less causes CO2 rebreathing. Used in ambulance

An ultrasonic nebulizer is not putting out any mist After confirming a good electrical power supply are in good working order that carrier gas is actually flowing through the device and that the output control is set at maximum what should you do?

Inspect the couplant chamber to confirm cleanliness and fill level.

Total lung capacity is made up of:

Inspiratory Capacity Expiratory Reserve Volume Residual Volume

The maximum amount of gas that can be inspired after a normal exhalation. ( VT + IRV)

Inspiratory Capacity (IC)

Inspiratory Capacity (IRV+VT) the maximum amount of gas can be inspired after a nomral exhalation

IRV

Inspiratory Reserve Volume the maximum volume that can be inhaled after a normal inspiration

The maximum volume that can be inhaled after a normal inspiration.

Inspiratory Reserve Volume (IRV)

Inspiratory capacity -Tidal volume + IRV

What is "Viscosity"

Internal force that opposes the flow of fluids (equivalent to friction between solid substances)

Intermittent Positive Pressure Breathing AKA

Ippy Bippy

Slow Vital Capacity (SVC) (is/is not) an "effort dependent procedure."

Maximum Inspiratory Pressure (MIP) (is/is not) an "effort dependent procedure."

Is not. (This procedure may be completed on patients who are unresponsive to verbal stimuli.)

Two questions you must consider when assessing a patient's airway:

Is the airway open?\n\nWill the airway stay open?

In what processes of gas compression or expansion does the temperature remain constant?

Isothermal

What happens to air as it reaches the carina?

It has been warmed to body temperature of 37 degrees C and is 100% saturated

What is the effect of surface tension forces in the air-filled lung?

It increases the elastic recoil of the lung (promoting collapse) It makes the lung harder to inflate than if it were filled with fluid.

What effect does Temperature have on Humidifiers?

It increases the kinetic activity

50. Which of the following statements about CO2 is FALSE?

It is a flammable gas false (it is used in fire extinguishers)

45. Which of the following statements regarding O2 is false?

It is flammable-false Oxygen supports combustion

Which of the following statements about alveolar pressure during quiet breathing is true?

It is negative during inspiration and positive during expiration

How is the oxygen delivered to the facility from the bulk oxygen supply system?

It is stored in white tanks outside of the hospital and piped into the facility from this source and then utilized from outlets in the wall.

What is the importance of VC measurement?

It is typically generally performed to assess the ability of the patient to increase VE (minute volume) to meet physiologic needs

To ensure a stable FiO2 under varying patient demands, what must a oxygen delivery system do?

It must supply a given O2 concentration at a flow equaling or exceeding the patients peak inspiratory flow.

Which of the following is considered an advantage of the transtracheal catheter?

It requires 40% to 60% less O2 flow than the nasal cannula.

Which of the following is FALSE about a Bourdon gauge?

It will register zero flow when the outlet is completely blocked.

What advantage does a nasopharyngeal airway have over an oropharyngeal airway?

It's less likely to initiate the gag reflex.

Assuming a constant flow, what will happen to a fluid if the cross-sectional area of the tube in which it flows decreases?

Its velocity will decrease.

5. Who is credited with first describing the law of Partial pressure for a gas mixture?

John Dalton

4. Who discovered oxygen in 1774 and described it as "dephlogisticated air

Joseph Priestley

Ratio that focuses on the efficiency of aerosol delivery to lungs • Lungs - topical delivery = therapeutic effect • GI Tract - systemic absorption from oral pharynx = side effects

L/T Ratio

What is the pattern of flow in which a fluid moves in discrete cylindrical streamlines?

Laminar

43. What is the pattern of flow in which a fluid moves in discrete cylindrical streamlines?

Laminar a. Laminar flow patter is seen mainly in very small airways b. Turbulent flow pattern is seen in the trachea and larger airways, especially with higher velocity (e.g., exercise) c.Transitional flow pattern (combination of laminar and turbulent) is seen in most medium sized airways especially at branch points.

What is the most common device to deliver bland aerosol?

Large volume nebulizer

device to deliver bland aerosol?

Large volume nebulizer

Which sizes endotracheal tubes have less airway resistance and allow for better suctioning and less work of breathing?

Larger size endotracheal tubes

The nasopharynx and oropharynx lead to the ______________.

Laryngopharynx

What is an intubation equipment that is comprised of 2 separate parts; a handle which contains a light source and a blade? These blades are ether curved or straight.

Laryngoscope

What is sterile saline used for while suctioning?

Lavage

A galvanic fuel cell uses a ____ and a ____ to measure FIO2.

Lead anode Gold cathode

IPPB: What does pressure alarms and volume alarms indicate?

Leaks

Graham's Law

Lighter gases diffuse rapidly Heavy gases diffuse slowly Helium will diffuse more quickly than oxygen Basis for Heliox therapy Anything that increases molecular activity will increase diffusion

Compare and contrast compressed gas cylinder and liquid gas cylinder Liquid gas Cylinder

Liquid gas cylinder: Filled according to specified filling density rather then a filling pressure. - Filling density is ratio between the weight of liquid gas put into cylinder and weight of water the cylinder could contain if full. Ex: co2 has filling density of 68%. Cylinder can be filled with liquid co2 up to 68% of the weight of water the cylinder could hold. -Filling pressure much lower then compressed gases. A liquid does not fill the entire volume of the tank, thus gas above liquid is at equilibrium with the liquid. Pressure in cylinder equals the pressure of the vapor to keep the gas liquified at any given temperature. -With liquid vapor on top it will leak even if closed. This does not happen in gas compressed. -Most maintained in cryogenic state. -Some may be stored as lquids at room temperature. Gases with critical temperatures above room temperature. These include carbon dioxide and nitrous oxide

What equation can be used to calculate the pressure exerted by a liquid?

Liquid pressure = Liquid density X Liquid depth

77. You enter the room of a patient who is receiving nasal O2 through a bubble humidifier at 5 L/min. You immediately notice that the humidifier pressure relief is popping off. Which of the following actions would be most appropriate in this situation?

Look for a crimped or twisted delivery tubing

Why is hypoxia a hazard to endotracheal suctioning?

Loss of FRC / Increased Atelectasis

6. Who was the first scientist in 1865 to suggest that many diseases were caused by microorganisms?

Louis Pasteur

Define and contrast low flow and high flow devices (including minimum and maximum flows) high flow

Low Flow: Nasal cannula, .5 to 6 L/min, FiO2: 24-44%, stability: variable use humidifier over 4L Nasal catheter, 1/4 to 8L/min, FiO2: 22-45%, stability: variable Transtracheal, 1/4 - 4L/min, FiO2: 22-35%, stability: variable Reservoir, 1/4 - 4L/min, FiO2: 22-35%, stability: variable Simple Mask, 6-12L/min, FiO2: 35-55%, stability: variable Partial rebreathing, 6-15+L/min, FiO2: 60-80% stability: variable Nonrebreathing, 6-15+L/min, FiO2: 80-95%, stability: variable AEM/venturi, 3-15L/min, FiO2: 24-55%, stability: fixed below 35% aerosol mask with air entrainment nebulizer: 6-15L/min, FiO2: 28-100%, stability: fixed High flow nasal cannula: 35-90%, fixed or variable Oxygen Hoods: 22-100% 6-15+L/min Oxygen Tents: 22-50% 8-15+L/min

51. What key property of He makes it useful as a therapeutic gas?

Low density

What key property of helium (He) makes it useful as a therapeutic gas?

Low density

All of the following are TRUE about humidification and contact time except:

Low flows decrease and high flows increase relative humidity output.

Nasal Pharyngeal Airways: What should be used to minimize nasal airway irritation & bleeding before the airway is inserted? What position should the patient's head be in?

Lubrication; Sniffer's Position

increased transpulmonary pressure Gradient (P alv - P plueral) is done by:

Lung Expansion Therapy

What are the 2 types of blades on the laryngoscope?

Macintosh (curved blade) and Miller (straight blade)

Capacities

Made up of two or more of the primary lung volumes -The total lung capacity includes all four primary lung volumes

Obstructive lung disease

Major defect is a decrease in the expiratory flow rate Spirometry is the best test for evaluation. Decreasesd FEV1, increased TLC, VC is decreased, RV is increased, concave expiratory pattern on flow-volume loops

What additional step must one take when applying a bag-valve mask with two rescuers?

Make sure an assistant stabilizes and immobilizes the head and neck.

What can you do to avoid gastric distension?

Make sure that the chest is rising when ventilating artificially. This shows that air is entering the lungs, not the stomach. Be especially careful when using a FROPVD.

In a PRE-FILLED Bubble Humidifier, if the Oxygen fails to flow from the Humidifier, what should you check?

Make sure the reservoir has been pierced and that the gas can flow through it

Flow volume loop (Obstructive)

Marked increase in residual volume and total lung capacity due to *gas trapping* as airways close early in exhalation -A reduction in FVC. -Peak expiratory gas flow rate is dramatically reduced below normal -Reduced gas flow rate is due to increased airway resistance to flow on exhalation. -The slope of late exhalation in CONCAVE due to more airway closure as lung volumes decrease *Gas cannot get OUT*

• 1-2 puffs ( .20 mg each) 4-6 hours • A rescue inhaler for asthma • A breath-actuated inhaler- no coordination necessary • Not available in nebulized form

Maxair(Maxair™ Autohaler™ pirbuterol acetate inhalation aerosol)

Helium lung volumes technique

Maximal expiration, then inhalation of a known concentration of helium until steady state is reached

Spirometry technique

Maximal inhalation followed by maximal exhalation, measuring volume of air and time

The maximum negative pressure generated when a maximum inspiratory effort is performed against a closed glottis.

Maximum Inspiratory Pressure ((MIP or NIF))

This Bedside Pulmonary Functional Test (PFT) is typically performed to evaluate the strength of the patient's diaphragm as part of the assessment for the need for mechanical ventilation. Note: This test evaluates the strength of the diaphragm, but not endurance.

Maximum Inspiratory Pressure (MIP)

This procedure is typically performed on a patient with an artificial airway in place. However, it may also be performed on a patient without an artificial airway. In this case, a mouthpiece is connected to the Briggs adapter.

Maximum Inspiratory Pressure (MIP)

Typically performed to assess muscle strength as part of the evaluation of the need for continuous mechanical ventilation.

Maximum Inspiratory Pressure (MIP)

(Bedside PFT) Typically perfromed on a patient with/without an artificial airway & to evaluate the strength of the patient's diaphragm as part of the assessment for the need for mechanical ventilation

Maximum Inspiratory Pressure (MIP) OR Negative Inspiratory Force (NIF)

MIP or NIF

Maximum Inspiratory Pressure or Negative Inspiratory Force the maximum negative pressure generated when a maximum inspiratory effort is performed against a closed glottis

Inspiratory reserve volume (IRV)

Maximum volume of additional air that can be expired from the end of a normal expiration

Inspiratory capacity (IC)

Maximum volume of air that can be inspired from end expiratory position. Called a capacity because it is the sum of tidal volume and inspiratory reserve volume. This capacity is of less clinical significance that the other three. IC=TV+IRV

What measure is used to identify the particle diameter, which corresponds to the most typical settling behavior of an aerosol?

Mean mass aerodynamic diameter (MMAD)

If using a flexible suction catheter, how do you measure the proper length?

Measure from patient's earlobe to corner of patient's mouth.

How does one determine the correct sizing for a nasopharyngeal airway?

Measure the nasopharyngeal airway from the nostril to the earlobe.

Spirometer

Measure vital lung volumes and capacities which are important clues to restrictive lung diseases

Measuring Liquid gas cylinder contents

Measured pressure is the vapor pressure above the liquid. - Pressure is not related to the amount of liquid remaining in the cylinder. As long as some liquid remains(and temperature remains constant), the vapor pressure remains constant as does the reading on the gauge. - When liquid is completely vaporized and nears depletion, the gauge pressure will begin to fall in proportion to volume. -Accurate quantity only by weighing it and knowing what weight was when full. -Pressure gauge is only useful when liquid is gone

Tests that measure diffusing capacity for carbon monxide

Measuring CO across the alveolar capillary membrane to rule out diffusive lung disease and gas dilution techniques that help assess functional residual capacity and residual volume of the lung

Bedside PFT Measuring Devices: 1. Very commonly used to measure pressures. 2. Those used in Respiratory Care typically display results in cm H2O pressure. However, they can display results in any pressure measurement. 3. Most are modified Bourdon Gauges. 4. Can be used for static or dynamic measurements. 5. May be used to measure positive or negative pressures.

Mechanical Aneroid Manometers

Which liquids have very high surface tension?

Mercury

What is the preferred method for delivering bronchodilators to spontaneously breathing and intubated, ventilated patients?

Metered-dose inhaler

Open loop system

Microprocessor controlled system that provides clinical data or advice but defers to the *user to take appropriate action*

Open loop system

Microprocessor controlled system that provides clinical data or advice but defers to the user to take appropriate action

Minute Volume the amount of gas inhaled/exhaled over the course of a minute VE = RR x VT

Minute Volume the volume of gas inspired OR expired in one munite during normal, tidal breathing

BASIC TERMINOLOGY: 1. The amount of gas inhaled or exhaled over the course of a minute.

Minute Volume (VE)

The volume of gas inspired or expired in one minute during normal, tidal breathing.

Minute Volume (Ve)

What are the 2 types of Spacers?

Mixing Chamber Holding Chamber

What is the primary fate of inhaled aerosol particles that are between 1 and 0.5 µm?

Most are cleared during exhalation.

What are the two most basic classifications of suctioning units?

Mounted suction systems and portable suction units.

Nonsteroidal Antiasthma Medications, break down proteins to thin secretions

Mucolytics

Nonsteroidal Antiasthma Medications Mast Cell Stabilizers - blocks production of mucous. i.e. chronic asthma

Mucous Blockers

When minimal fluctuations in pressure and flow are critical factors, which of the following pressure-reducing valves would be the best choice?

Multiple-stage pressure-reducing valve

52. According to the U.S. Department of commerce, a gas cylinder that is color coded blue should contain which of the following?

N2O Nitrous Oxide (air yellow/oxygen green/He Brown/Co2 Grey/ Nitrogen Black)

Safety Precautions

NFPA - National Fire Prevention Agency Sets standards for design, construction, placement, and use of bult oxygen systems - Established protocol provides a method to identify and prioritize affected patients if there is a system failure. Move appropriate backup equipment to bedside. -Trained personnel bypass the failed system and provide patient needed support

Contraindications for Endotracheal Suctioning

NO ABSOLUTE CONTRAINDICATION (1) Patient's risk of developing adverse reactions / worsening clinical condition as result of the procedure

Contraindications for Pulmonary Clearnace Procedures

NOTE: ALL are "Relative Contraindications" unless otherwise indicated (1) Intracranial Pressure (ICP) is greater than 20 mm Hg (2) Patients in which ICP are to be avoided (e.g. neurosurgery, aneurysms, eye surgery) (3) Unstable head and/or neck injuries (4) Active hemorrhage with hemodynamic instability (5) Acute spinal injruy (6) Active hemoptysis

Which intubation route is used in certain emergency situations which can be used with blind insertion to secure the airway?

Nasal Intubation

75. A cooperative and alert postoperative patient taking food orally required a small increment In FIO2, to be provided continuously. Precise FIO2 concentrations are not needed. Which of the following devices would best achieve this end?

Nasal cannula

9. What organization has developed an examination to enable respiratory therapist to become licensed?

National Board for Respiratory Care

CONTRAINDICATIONS FOR IPPB THERAPY: What is the IPPB contraindication that increases gas in the stomach and may worsen nausea, causing uncontrolled vomiting and possible aspiration.

Nausea, Air Swallowing, and Singulation (hiccups)

Type of inhalers that gives higher doses & require less patient effort than MDI. It require a compressed gas source.

Nebulizers

67. When determining a need for (O2 therapy, the respiratory therapist should assess which of the following?

Neurologic status, pulmonary status, cardiac status (I II III)

Medications: What type of medications are often used to facilitate intubation?

Neuromuscular blockers

Does bubbling occur in the membrane-type humidifier?

Does bubbling occur with wick humidifiers?

If a membrane-type humidifier were inspected while in use, would liquid water be seen in the humidifier chamber?

If you increase the L/flow to the patient in a high flow system do you increase the amount of flow they are getting?

Bubble Humidifiers are also called?

Non-Heated Bubble Humidifiers

A patient has been brought to your ER. He has been seriously injured in an auto accident. He is in severe shock. The MD tells you to put him on some O2. You should select which of the following devices?

Non-rebreather mask

Which device is used for smoke inhalation?

Non-rebreather mask at 15 LPM

What's the best device for delivering high concentrations of oxygen to a breathing patient?

Nonrebreather mask

Nasal Cannula

Normal FIO2 ranges .24- .44 FIO2 -Disposable plastic device - .5-6L/min -Use of humidifier above 4 L/min or if patient has drying or nose irritation -Flows above 6-8 L/min cause patient discomfort. Nasal dryness, bleeding High flow N/C with humidity have solved some of these problems -Newborn infants not to exceed 2 L/min

What are suction catheters used for?\n\nDescribe measurements.

Not large enough for vomitus or thick secretions. Used when rigid tip cannot be used. It can be passed through OPA, NPA, or endotracheal tube. \n(bulb suction can also be used to suction nasal passages).\n\nlarger the number, larger the catheter. "14 french" is larger than "8 french"

84. An O2 delivery device takes separate pressurized air and O2 sources input, then mixes these gases through a precision valve. What does this describe?

O2 blending

An O2-delivery device takes separate pressurized air and O2 sources as input then mixes these gases through a precision valve. What does this describe?

O2 blending system

Unlike CO2 or N2O, O2 cannot be stored as a liquid at room temperature but must be kept in special cryogenic containers. Why is this so?

O2 has a critical temperature well below room temperature.

70. A patient with chronic hypercapnia placed on an FIO2 of 0.6 start hypoventilating. What is the probable cause of this phenomenon?

O2 induced hypoventilation (knocked out drive)

According to the National Institute of Standards and Technology of the U.S. Department of Commerce, a gas cylinder that is color-coded brown and green should contain which of the following?

O2-He mixture

A patient with chronic hypercapnia on a FIO2 of .6 starts hypoventilating. What is the cause of this phenomenon?

O2-hypoventilation

Pulmonary Disease results in decreased (expiratory) flowrate

Obstructive

1. Difficulty exhaling normal flowrates caused by decreasing airway lumen size. 2. Decrease flowrate

Obstructive Disease

Results in decreased flow rates. Disorders may also result in increases in RV and, therefore, FRC.

Obstructive Pulmonary Disease

Note: A comparison of FVC and SVC values is sometimes used as a quick method for assessing the presence of obstructive disease. FVC for the _________ process and the SVC for the ___________ process.

Obstructive; Restrictive

What is the most difficult part of using a BVM?

Obtaining an adequate seal around the edges of the mask.

Radiation

Occurs without direct physical contact usually associated with light Can occur in a vacuum how sun warms earth Used clinically on newborn infants " Radiant Warmers" Larger surface area and lower surrounding temp, greater radiant heat loss.

If no spine injury is suspected, what position should the patient's head be in during suctioning?

On its side.

How much should you tighten the regulator onto the oxygen cylinder?

Only hand-tight, in case of any malfunctions of the air cylinder, or in case the cylinder runs out and you need to quickly disconnect it.

What are the types of Airway Suctioning?

Oral Airway Suction Endotracheal Suction Nasotracheal Suction Oral Tracheal Suction

Which endotracheal intubation technique is more commonly used?

Oral Intubation

Tracheal Airways: Which airway tubes are inserted through the pharynx into the trachea?

Oral and Nasal Tubes

Endotracheal intubation can be performed either _______ or _________.

Orally; Nasally

Simple unheated bubble humidifiers are commonly used to humidify gases with what type of devices?

Oronasal oxygen delivery

Simple unheated bubble humidifiers are commonly used to humidify gases with what type of systems?

Oronasal oxygen delivery

What are the two most common airway adjuncts?

Oropharyngeal and nasopharyngeal airways.

Identify the color codes of each gas found in a gas cylinder and differentiate between the USA and Canadian color code for oxygen.

Oxygen (O2) USA: Green, Canada: white Carbon Dioxide (CO2) USA: Gray Nitrous Oxide(N2O) USA: Blue Helium (He) USA: Brown Carbon dioxide/oxygen(CO2-O2) USA: Gray/Green Helium Oxygen (He-O2): USA: Brown/green Nitrogen (N2) : USA: Black Air: USA: Yellow, Canada: black/white Nitrogen-oxygen N2-O2: Black/Green

Most oxygen delivery systems include what three key components?

Oxygen cylinder, pressure regulator, and delivery device (nonrebreather mask or cannula)

Fiberoptic Endotracheal Intubation: Complications

Oxygen desaturation Bronchospasm (inadequate local anesthesia)

List *diagnostic application* for computer usage in hospital

PFT, x ray, echo

List diagnostic application for computer usage in hospital

PFT, x ray, echo

Pin Index safety system (PISS)

Part of the ASSS. Specifications apply only to the valve outlets of small cylinders. Up to and including size E. Use a yoke type connection.

PISS Pin index safety system

Part of the American standard system -Applies only to small cylinders Up to and including E cylinders -Cylinders use yoke type of connection -Upper yoke fits over the lower valve stem -Two pins mate with two pin holes -Designed to prevent accidental misconnections between equipment -Exact position of pins varies with each gas -Six holes make up the entire system with 10 possible connections -Must line up perfectly for regulator to fit

What are the risks of Hyperventilation and Pre-oxygenation in suctioning the patient? What techniques can you use?

Patient becomes bradicardic, apnic, ICP; Ventilate patient normally.

You connect an intubated patient to an air-entrainment nebulizer system through a t-tube set at 60% with an input flow of 15 LPM. Toward the middle of inspiration you observe that mist stops exiting from the open end of the t-tube what does this indicate?

Patient is not receiving 60% O2

What is the term for the ratio of the actual water vapor present in a gas compared with the capacity of that gas to hold the vapor at a given temperature?

Percent Body Humidity

A phase of Principles of Pharmacology that focuses on drug actions/effects on the body.

Pharmacodynamic Phase

A phase of Principles of Pharmacology that is focusses on time, course, and disposition of a drug. Based on: • Absorption • Distribution - Ionized ( Atrovent) vs.Non Ionized ( atropine) • Metabolism • Elimination

Pharmacokinetic Phase

48. Which of the following methods of producing O2 is commonly used in the Home Care setting

Physical separation

Which of the following methods of producing O2 is commonly used in the home care setting?

Physical separation

List clinical application for computer usage in hospital

Physicians orders, progress notes, discharge summary

What is the generic name for Maxair Autohaler?

Pirbuterol Acetate inhalation aerosol

Which of the following devices is most commonly used to deliver continuous aerosol with oxygen to a patient with a Trach?

Pneumatic Jet Nebulizer

CONTRAINDICATIONS FOR IPPB THERAPY: 1. A collection of air in the mediastinal area of the chest. 2. Diagnosed radiographically. 3. Usually not a problem in itself, but it indicates the presence of barotrauma which may worsen with positive pressure.

Pneumomediastinum

Which of the following may be a result of inadequate humidification in a patient whose upper airway has been bypassed?

Pneumonia Necrosis of cilia Atelectasis Retained secretions Inflammatory changes

Uses positive pressure against a variable flow resistance to keep the airways open and increase mucous movement

Positive Expiratory Pressure (PEP) Thearpy

BASIC TERMINOLOGY: Graph

Positive Pressure Breathing

All of the following are potential hazards of using heat-moisture exchangers except:

Potential electrical shock

IPPB Machines are"_______ cycled".

Pressure

To protect against obstructed or kinked tubing, simple bubble humidifiers incorporate _________ ________ ______.

Pressure Relief Valve

What is the primary goal of a heated humidification system?

Primary goal is to *match the output* of the humidifying *device* to the normal inspiratory *conditions occurring* at the *level of the trachea*

What is the primary goal of a heated humidification system?

Primary goal is to match the output of the humidifying device to the normal inspiratory conditions occurring at the level of the trachea

What is the problem with input flows greater than 10 to 15 L/min in an infant Oxy-Hood?

Production of harmful noise levels.

Most of the spray generated by the majority of metered-dose inhalers consists of which of the following?

Propellant

What is checked and verified before using the laryngoscope?

Proper light source

72. To ensure a stable FIO2 under varying patient demands, what must an O2 delivery system do?

Provide all the gas needed by the patient during inspiration

Long acting / Control medications -" stays at home"; Inhaled Steroids Nebulized form of Pulmicort. • .25 to 1.0 mg in 2ml unit dose 1-2 times per day • do not mix with other inhaled medications • may be mixed with Xopenex • used for chronic Asthma to reduce use of prednisone

Pulmicort Respules

What is the nebulized form of Pumicort?

Pulmicort Respules

What are examples of nebulizers?

Pulmo-aide or Pari Neb

Restrictive lung disease (Acute disease)

Pulmonary Edema -Result in thickening of the alveolar capillary membrane which also impairs diffusion of oxygen into the blood (Acute)

Type of Puritan Bennett Ventilators: • Electrically powered IPPB with AP-5 features plus cover and handle modifications for storage and transport. Convenient for homecare or hospital use.

Puritan Bennett AP-4

Type of Puritan Bennett Ventilators: • Electrically powered IPPB therapy unit with internal motor/compressor. Ideal for homecare or hospital use.

Puritan Bennett AP-5

Brovana: Dosage

Q12 BID

63. To clean a cylinder valve outlet of foreign material, what should you do

Quickly open, then close, the valve

To clean a cylinder valve outlet of foreign material, what should you do?

Quickly open, then close, the valve.

What is the formula for calculating Relative Humidity?

RH = Absolute (content) humidity ----------------------------------- x 100 Capacity

TLC - VC =

Helium lung volumes data obtained

RV, ERV, IRV, TV with calculation of TLC, VC, FRC, IC

of, relating to, or constituting a compound or mixture that is composed of equal amounts of dextrorotatory and levorotatory forms of the same compound

Racemic

Original Emergency treatment for Asthma. • Strong sympathomimetic - not specific • Beta 1 - increase HR - Used in ACLS to treat profound bradycardia & asystole • Beta 2 - fast acting Bronchodilator - • Onset 3-5 minutes • Peak 5-20 minutes • Duration - 0.5 - 2hours ( Beta 1 & alpha systemic effects can last longer) • Alpha effects - vasoconstriction = Increase BP & decreased topical edema • Dosage - 2.25% - .25 - .50 ml's in 3 cc's NS q1 - q4hr prn • Brand names - Vaponephrin, asthmanefrine, micronefrin & Primatene mist (over the counter inhaler) Indications: • Upper airway / laryngeal edema -

Racemic Epinephrine

What is the original tx for asthma?

Racemic Epinephrine

55. What is the usual method of monitoring the remaining contents in a gas-filled cylinder

Read the pressure gauge

54. In clinical practice, how is a positive identification made of the contents of a medical gas cylinder?

Reading the cylinder label

78. A physician orders 2 L/min O2 through a simple mask to a 33 year old postoperative woman with moderate hypoxemia breathing room air ( PaO2=52 mm Hg). What would be the correct action at this time?

Recommend a flow of at least 5 L/min to wash out carbon dioxide (CO2)

Which zone in the Peak Flow Meter do I decide to go to the doctor or ER?

Red Zone - esp. if you've used your inhaler and you're still in the "RED" When the Plan's not working!!!!!!!

If you had to power a ventilator from a large cylinder of compressed gas, which of the following devices would be required?

Reducing valve

If the Bubble Humidifier's PERMANENT reservoir is low, what should you do?

Refill with sterile water

What device is used to reduce the pressure and control the flow of a compressed medical gas?

Regulator

CONTRAINDICATIONS FOR IPPB THERAPY: A history of spontaneous pneumothorax is a (absolute/relative) contraindication.

Relative

CONTRAINDICATIONS FOR IPPB THERAPY: Bullae are a (absolute/relative) contraindication for IPPB Therapy

Relative

If the Bubble Humidifier is DISPOSABLE, what would you do if the water level in the reservoir is low?

Replace the set-up

An SVN is set at 8 L/min flow. A patient asks that the head of the bed be in a lower position. Immediately after doing so, you observe a significant drop in the SVN aerosol output despite there being at least 3 ml of solution left in the reservoir. What would you do?

Reposition the patient so that the SVN is more upright.

Residual Volume the volume of gas remaining in the lungs after a maximal exhalation

The volume of gas remaining in the lungs after a maximal exhalation.

Residual Volume (RV)

BASIC TERMINOLOGY: _____________ to ventilation is due to the anatomical structure of the conductive airways, and the tissue resistance of the lungs and adjacent structures. In clinical situations, viscosity, density, and tube length remain fairly constant, and attention is paid to airway lumen size and the flow rate of gas.

Resistance

42. The resistance to flow of a fluid through a tube can be computed according to which of the following formulas?

Resistance = pressure / by flow

RR or f

Respiratory Rate the number of ventilatory cycles per minute

BASIC TERMINOLOGY: The number of ventilatory cycles per minute. Each cycle includes one complete inhale and one complete exhale.

Respiratory Rate (RR)

What conditions will require oxygen?

Respiratory arrest, cardiac arrest, heart attack, stroke, shock, blood loss, lung diseases, broken bones, head injuries, drug overdose, severe chest injuries, and more.

Define "respiratory distress."

Respiratory distress is characterized by a sensation of shortness of breath, and physically presents as labored breathing. It's basically having to put forth effort to keep breathing adequate.

List clinical signs of hypoxia

Respiratory: Mild to Moderate: Tachypnea, dyspnea, paleness Severe: Tachypnea, dyspnea, cyanosis

Pulmonary Disease results in decreased volume and flowrates are typically normal

Restrictive

1. Difficulty inhaling normal volume due to structure, musculature, and trauma/disease. 2. Decrease volumes

Restrictive Disease

Results in decreased volume. Flow rates are typically normal.

Restrictive Pulmonary Disease

Nasotracheal Suction: Indications

Retained secretions without an artificial airway

You can determine that a nasal O2 catheter is properly positioned when its tip is where?

Retracted just above the uvula.

What type of bronchoscope with the hollow tube functions as airway and allows ventilation? It is the preferred method for foreign body removal form large airways.

Rigid Bronchoscope

What are the 2 types of bronchoscopes?

Rigid Bronchoscope Flexible Bronchoscope

To minimize a patient's infection risk between drug treatments with a small-volume jet nebulizer (SVN), what would you do?

Rinse the SVN with sterile water; air dry.

3. In 1662 a chemist published a book that describes the relationship between gas, Volume, and pressure. What is the chemist Name?

Robert Boyle

Which type of Humidifiers have a large reservoir, which may lead to nosocomial infections due to the increase of bacterial growth?

Room Humidifers

Which type of Humidifiers work off of the principle of Centrifugal Force?

Room Humidifiers

Which of the following would indicate a need for O2 therapy for an adult or child?

SaO2 less than 90% Pao2 less than 60 mmHg

What structure is found on a Bubble Humidifier in order to relieve the pressure in case the path becomes obstructed?

Safety Relief Valve

Flow-volume loops technique

Same as spirometry, maximal inhalation followed by maximal exhalation, measuring volume of air and time, but data are recorded in a graph of flow versus volume

30. What is the equilibrium condition in which a gas holds all the water vapor molecules that it can

Saturation

Without humidification, what happens to the secretions in the patient?

Secretions become thicker, dryer, and more difficult to mobilize and get rid of

What type of maneuver can be used to facilitate intubation and reduce the risk of aspiration?

Sellick Manneuver?

Oxygen concentrator

Semi permeable plastic membrane that vacuums out and filters nitrogen from the air. Oxygen and water vapor pulls through faster than nitrogen producing 40% O2 concentration. Seen most often in home use

BASIC TERMINOLOGY: 1. How much effort the patient must exert to begin gas flow from the ventilator. 2. Usually a result of changes in flow or pressure. 3. If pressure is used, usually this control is adjustable from 0.5 to 2.0 cm H2O. 4. If flow is used, usually this control is adjustable to respond to a drop of 1 to 5 lpm from a base flow of 5 to 10 lpm.

Sensitivity

Oral Airway Suction: Hazards/Precautions

Sepsis, Trauma, Infection

Long Acting Broncho-dilator adrenergic/sypathomimetic ( Salmeterol Xinfoate) 50 mcg - • alsoy available in discus or in combo with Flovent ( Advair) BID • typically used for exercise induced or nocturnal asthma • Onset 5 min , Peak - 3- 5 hours, Duration - 12hours • Associated with asthma deaths - when used as a rescue medication

Serevent

What is Salmeterol Xinfoate?

Serevent

Compare and contrast bulk, cylinder and manifold oxygen storage systems Manifold

Series of large compressed oxygen cylinders. Normally H or K size banked together is series. Pressure reducing valves and low pressure alarms.

When speaking of mechanical ventilation, it is necessary to differentiate between:

Set RR, Spontaneous RR, and Combined RR

When speaking of mechanical ventilation it is necessary to differentiate between the various tidal volumes:

Set Vt, Delivered Vt, Exhaled Vt, and Spontaneous Vt

When speaking of mechanical ventilation, it is necessary to differentiate between:

Set minute volume, Spontaneous minute volume, and Total minute volume

Combined/ Ideal gas law

Show the relationship that exists between Volume, Pressure, and Temperature. A combination of boyle's, Charles and gay laws P1V1/T1 = P2V2/ T2

The particle size produced by an ultrasonic nebulizer depends mainly on which of the following?

Signal frequency

Which of the following devices would be contraindicated for a patient whose upper airway has been bypassed?

Simple bubble humidifier

Flow restrictor

Simplest and least expensive -Consists of a fixed orifice calibrated to deliver a specific flow at a constant pressure(50psig) -Fixed orifice, constant presure flow metering device as long as pressure remains constant (50psig) -Usually 0.5 to 7 L/min, used from aerosol deliver from wall outlet

Non-Steroidal Antiasthma Agents: (Helps to relieve a broad range of seasonal allergy symptoms for a full 24 hours • Is a seasonal allergy medicine that specifically blocks leukotrienes, an underlying cause of allergy symptoms • Is a once-a-day tablet • Is available in oral granules and cherry chewable tablets for children as young as 2 years • Is approved to help control asthma • Is not a steroid

Singulair

Nasal Pharyngeal Airways: How do you determine diameter size of the Nasal Pharyngeal Airways?

Size of the nail bed on the little finger.

SVC

Slow Vital Capacity a VC measurement performed without maximum forced expiratory effort

(Bedside PFT) Indicated for the evaluation of restrictive processes - measures volume

Slow Vital Capacity (SVC)

1. Used to measure VC (Volume measurement only) 2. Most useful in restrictive processes 3. ≥80% of predicted is normal.

Slow Vital Capacity (SVC)

A VC measurement performed without maximum forced expiratory effort.

Slow Vital Capacity (SVC)

small compressors

Small Medical compressors: Bedside or home use, Not 50psig, No reservoir (diaphragm or turbine), limits the pressure and flow capabilities, cant be used to power equipment needing 50psig, (ventilator needs 50 psig), traditional method to deliver SVN medication in home setting

What is the key difference between small compressed gas cylinders (sizes AA to E) and their larger counterparts (sizes F to K)?

Small gas cylinders use a yoke (not threaded) connector.

restrictive lung disease

Small lungs Total lung capacity "small lungs"

Which sizes endotracheal tubes are the easiest to insert?

Smaller size endotracheal tubes

40. Which of the following factors Determines how much of a given gas Can dissolve in a liquid?

Solubility coefficient of the gas, Temperature of the liquid, Gas pressure above the liquid (Henry's law)

Case #2 pulmonary function

Spirography: Vt: 500mL (95%) FVC: 3.1L (60%) FEV1.0: 1.3L (30%) FEV1.0/FVC: (43%) FEF25-75: 1.8L/S (30%) -ABG-PaO2: 70 (RA) -PaCO2= 40 -pH=7.38 -HCO3=26 -DX: Moderate obstructive lung disease -Rx: Cessation of smoking >erosol broncho-dilator Normal indexed to: Height, weight, gender, age, and a little from ethnicity

Pulmonary function tests

Spirometry Flow-volume loops Diffucing capacity of CO Helium lung volumes Methacholine challenge

BASIC TERMINOLOGY: Graph

Spontaneous Breathing

What is breathing to an ETT w/o vent support called?

Sprinting

Hypoxia in a patient suffering form congestive heart failure (CHF) is due to:

Stagnant blood flow

(Endotracheal Suctioning) is consder a _________ procedure

Sterile

What does Non-Steroidal Antiasthma Agents do?

Stops cascade of inflamation

What is the advantage of the Miller blades?

Straight blades are inserted posterior to the epiglottis, thus providing better visualization of the larynx.

Bedside PFT Measuring Devices: 1. A fine wire screen is placed in the flow of gas. 2. As the gas flow passes through the screen, it deforms the screen slightly. 3. Results may be affected by moisture and/or medication deposits. 4. May be used to measure volume or pressure.

Strain Gauges

A partially obstructed airway can cause what sounds?

Stridor - severely restricted in upper airway. nearly complete obstruction\nHoarseness - narrowing of upper airway. voice changes are useful in reassessment of airway issue.\nSnoring - decrease in mental status can cause diminished airway muscle tone, so soft tissue of upper airway impedes airflow. airway needs assistance to stay open.\ngurgling - fluid obstructing. immediate suctioning.

What are 2 common causes of acute upper airway edema that typically indicate the use of racemic epinephrine SVN tx's?

Stridor and Extubation

24. After placing a liquid into a small diameter glass to, you observe the formation of a convex (upwardly curved) meniscus. What conclusion is correct?

Strong cohesive forces exist among the liquid molecules (like mercury strong attraction to self :-( , concave attraction to others :-) )

Alupent: Side Effects

Stronger HR and tremor

Which intubation equipment can be inserted inside the endotracheal tube to help the tube conform to the airway and may facilitate insertion into the larynx and trachea.

Stylets

What is downside to the use of Stylet during intubation?

Stylets have been associated with pharyngeal or laryngeal trauma.

What do you do when you hear gurgling?

Suction! Fast!

Definition: Use of negative pressure to remove secretions from Upper airway - main stem bronchi

Suctioning

Increasing the water ________ _________ (2 words) will increase the humidity

Surface Area

25. 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

Tracheal Airways: How is Tracheostomy performed?

Surgically inserted into the trachea

FRC + IC =

TLC

The earliest sign of hypoxemia in the adult is:

Tachycardia

A rapid breathing pattern is called:

Tachypnea

Venti-masks are needed for patients who demonstrate:

Tachypnea

68. Which of the following signs and symptoms are associated with the presence of hypoxemia

Tachypnea, tachycardia, cyanosis (NOT Bradycardia)

Question #15 What is the most important factor for ^ humidifier performance?

Temperature

What is the most important factor determining a humidifier's performance?

Temperature

Charles's Law

Temperature and volume of gas system vary directly mass and pressure are constant V1/T1 = V2/T2 Temp down = volume down Charles wanted to watch tv. Application = hot air balloon, correction for ATPS to BTPS

What three factors are added to Humidifiers to increase their effectiveness?

Temperature, Surface Area, and Contact Time

If a patient is visibly short of breath and is speaking in 3-4 word sentences with anxiety increasing, is that patient breathing adequately or inadequately?

That patient is on the cusp. A nonrebreather mask might be a good idea.

What decreases the humidity output?

The CONTACT TIME!

FEV1

The VOLUME of gas exhaled from the lung capacity in the first one second *Forced expiratory volume in 1 second*

Humidity deficit

The amount of water vapor the body must add to the inspired gas to achieve saturation. capacity - content = humidity deficit

How can you tell if the catheter is leaks?

The bag inflates

What clinical signs would indicate a catheter being left on the ET Tube?

The bag inflates

How do you check the cuff of the endotracheal tube before using?

The balloon should be checked by inflating 10 cc of air with a syringe. Make sure that the cuff has no leaks.

Define "ventilation."

The breathing in of air or oxygen or providing breaths artificially

What do you call the site at which the trachea branches into the bronchi?

The carina

When the air reaches what structure, has the air been warmed to body temperature of 37 degrees Celcius and is 100% saturated?

The carina

What ring of cartilage is found just inferior to the thryoid cartilage?

The cricoid cartilage

What is the muscle inferior to the lungs that's the major muscle responsible for inspiration?

The diaphragm

Which of the following statements is FALSE about PISS standards?

The exact positions of pins and pinholes do not vary for each gas.

In checking a servo-controlled heated-wire humidifier system, you notice that a few drops of condensate tend to form but only near the patient's airway. Based on this observation, what can you conclude?

The gas at the airway is fully saturated.

What maneuver would you use to open the airway of an unconscious patient with suspected spine injuries?

The jaw-thrust maneuver

What important organ protects the trachea and has many components, including the thyroid cartilage and cricoid cartilage?

The larynx

What do you call the cavity between the lungs?

The mediastinum.

What functions as the normal airway humidifier?

The nose

What do you call the area directly posterior to the oral cavity?

The oropharynx

What do you call the area that is composed of the nasopharynx and oropharynx?

The pharynx

A clogged inlet on a Bubble Humidifier would prevent what?

The pop-off alarm from sounding

19. Which of the following is FALSE about evaporation?

The process of evaporation warms the surrounding air false. (This is true: evaporation is the type of vaporization evaporation is the change of a liquid substance into a gas or evaporation to occur, heat energy is needed.)

What ring of cartilage is found just superior to the cricoid cartilage?

The thyroid cartilage

Total lung capacity (TLC)

The volume of air contained in the lungs at the end of a maximal inspiration. Called a capacity because it is the sum of the 4 basic lung volumes. TLC=RV+IRV+TV+ERV

Advantages of passover humidifiers include what?

They add little flow resistance to breathing circuits *Does Not* generate bacteria Maintain water vapor saturation at high flow

What does "inspissated" mean?

Thickened due to dehydration

Which of the following are not goals of aerosol therapy?

To slow the muco-cilliary escalator

When the patients upper airway is bypassed, what must be done to ensure adequate humidification?

Traditionally HME have been limited to providing humidification to patient with artificial airway who require ventilatory support

Causes of inadequate mist production with pneumatically powered jet nebulizers include all of the following except:

Tripped circuit breaker.

True/False: Albuterol is commonly used as "Rescue Medication".

True

True/False: Atrovent is fast acting and drying.

True

True/False: Brethine is also available in tablet form.

True

True/False: EZPAP increases and sustains patient's FRC.

True

True/False: EZPAP increases mucokinesis via PEP (Positive Expiratory Pressure).

True

True/False: EZPAP use high and patient exhales against positive pressure as a form of lung expansion.

True

Neonate ETT Size: 3 kg Tube Size (mm) Oral Tube Length at Lip (cm) Suction Tube Size (Fr)

Tube Size (mm) = 3.0 Oral Tube Length at Lip (cm) = 8.5 Suction Tube Size (Fr) = 6

Diffusing capacity of CO data obtained

Uptake and diffusing capacity of CO

What to do in reduced LOC but intact gag reflex?\nwhen else would you use this?

Use NPA instead of OPA. \nOr use when teeth clenched, or oral injuries.

How do pressure regulators attach to oxygen cylinders size M and larger?

Using a threaded outlet.

How do pressure regulators attach to oxygen cylinders size E or smaller?

Using a yoke assembly with pins and holes.

IC - IRV =

What are the brand names for Racemic Epinephrine?

Vaponephrin, asthmanefrine, micronefrin & Primatene mist

Inhaled Pulmonary Vasodilators • Administered with I-neb or Prodose nebulizer • Synthetic prostacyclin PGi = pulmonary vasodilation • Side effects - syncope , cough, and headaches

Ventavis - Iloprost

23. What is the internal force that opposes the flow of fluids (Equivalent to friction between solid substances)?

Viscosity

What is the internal force that opposes the flow of fluids (equivalent to friction between solid substances)?

Viscosity

BASIC TERMINOLOGY: 1. Basic definition is an injury due to excessive volume. 2. Many authors feel that it is more responsible for damage to the lungs than barotrauma, but the topic is still under discussion. 3. It causes barotrauma

Volutrauma

Which type of Humidifier utilizes a Cylinder of absorbent paper paper to draw water from the reservoir by capillary action?

Wick Humidifier

7. Who discovered the X-ray and opened the door for the modern field of radiology?

William Roentgen

What are the contraindications for the nasal route intubation? What is used instead?

With known or suspected neck trauma or cervical spine instability, nasal bleeding, upper facial fractures, and certain skull fractures, the nasal route is contraindicated. Instead, spine stabilization and use of a bronchoscope with cricoid pressure is preferred.

Do bag-valve-mask units come in multiple sizes?

Yes, sizes for adults, children, and infants.

Aerosolized Antinfectious Agents antiinfluenza agent - antiviral - neuraminidase inhibitor Indication : treatment for high risk ( cardio - pulmonary disease) patients for influenza A+B • Binds Virus agents together to prevent spread of disease • Hazards / precautions: • Bronchospasm • Allergic reactions • Under treat of underlying bacterial infection hidden by viral infection Dosage : • Dry powder dose - 5 mg per inhalation BID x 5 days

Zanamivir ( Relenza)

Non-Steroidal Antiasthma Agents: Zieluton

Zyflo

What is a humidifier?

a device that adds molecular water to gas

Any device that generates an aerosol, poses what?

a high risk of spreading infection

Failure of a pop-off to sound, may be an indication of what?

a leak of faulty pop-off valve

In cold weather, the formation of condensates exceed the ability of mucus to reabsorb water results in what?

a runny nose

What do hydrophobic condenser humidifiers use?

a water-repellent element with a large surface area and low thermal conductivity

Retention of secretions can result in full or partial airway obstruction. Mucus plugging can result in which of the following? I. hypoxemia II. atelectasis III. shunting a. I, II, and III b. I and II c. I and III d. II and III

a. I, II, and III

Which of the following clinical findings indicate the development of atelectasis? I. opacified areas on the chest x-ray film II. inspiratory and expiratory wheezing III. tachypnea IV. diminished or bronchial breath sounds a. I, III, and IV b. I, II, III, and V c. I and IV d. II, III, and IV

a. I, III, and IV

All of the following are goals of bronchial hygiene therapy except: a. Reverse the underlying disease process. b. Help mobilize retained secretion. c. Improve pulmonary gas exchange. d. Reduce the work of breathing.

a. Reverse the underlying disease process.

The greater the temperature of the gas, the: a. more water vapor it can hold b. less water vapor it can hold c. less efficient the humidifier is d. more water vapor is lost

a. more water vapor it can hold

What does "active" mean?

actively adds heat and /or water to the device-patient interface

What is "absolute humidity?"

actual content or weight of water present in a given volume of air

Humidity Therapy

adding water to vapor and (sometimes) heat to the inspired gas

No bubbling means what is not produced?

aerosol

Nebulizer

aerosol creating mist

What is the biggest problem in spreading infection?

aerosol particles or liquid in circuits

At high flow rates, what can bubble humidifiers produce?

aerosols

to be effective, suction devices must furnish an air intake....

air take > 30 L/min at open end of collection tube\n(must generate vacuum of >300 mmHg when tube is clamped).

74. Low-flow O2 delivery systems used in respiratory care include all of the following except:

air-entrainment mask aka venture mask (include: nasal cannula, nasal catherter, transtracheal catheter)

Hypoxemia

an abnormal deficiency of oxygen in the arterial blood

59. The gauge on an E cylinder of O2 reads 800 psig. About how long would the contents of this cylinder last, until completely empty, at a flow of 3 L/min?

approx. 1 hr 15 min. 800*.28 cylinder factor/3 L flow / 60 minutes per hour

58. The gauge on an H cylinder of O2 reads 2000 psig. About how long would the contents of this cylinder last, until completely empty at a flow of 6L/min?

approx. 17.5 hours 2000*3.14 cylinder factor / 6L flow /60 minutes in an hour

What should the inspired humidity be when given though a tracheal airway?

at least 60% of BTPS conditions

What is the usual method of monitoring the remaining contents in a gas-filled cylinder? a. Weigh the cylinder. b. Read the pressure gauge. c. Compute the gas density. d. Read the cylinder label.

b. Read the pressure gauge.

All of the following drug categories can impair mucociliary clearance in intubated patients except: a. general anesthetics b. bronchodilators c. opiates d. narcotics

b. bronchodilators

What device adds molecular water to gas? a. agitator b. humidifier c. nebulizer d. atomizer

b. humidifier

Delivery of cool humidified gases are mostly used with what?

bland aerosol delivery

What is Parasympatholitic?

block parasympathetic signals such as bronchoconstriction & bradycardia

BTPS

body temp @ atmosphere pressure saturated

BTPS

body temperature, barometric pressure, saturated 37C, 760 mmHg, 100%RH(47 mmHg)

How does a humidifier add molecular water to gas?

by evaporation of water from a surface

When turning a critically ill patient, one should be on guard for which of the following "plumbing" problems? I. aspiration of circuit condensate II. disconnection of vascular lines III. ventilator disconnection IV. accidental extubation a. II and IV b. I, II, III, and IV c. I and III d. II and III

c. I and III

A normal cough reflex includes which of the following phases? I. irritation II. inspiration III. compression IV. expulsion a. I, II, III b. I and IV c. I, II, III, and IV d. II and III

c. I, II, III, and IV

What can properly applied O2 therapy decrease? I. ventilatory demand II. work of breathing III. cardiac output a. II and III b. I and II c. I, II, and III d. I and III

c. I, II, and III

How do you determine the humidity deficit?

capacity - content

Define "evaporation"

change in state of a substance from liquid to gaseous form occurring below its boiling point

If a person on a HME has lots of secretions what do you do?

change them to a heated humidifier (COPD) wick or membrane type

Question 24 If a person on a HME has lots of secretions what do you do?

change them to a heated humidifier (COPD) wick or membrane type

Instructions for DPI:

click & breath - Turbohaler, Advair, Maxair

normal I:E ratio is 1:2 or 1:3 what should it be with positive pressure

closer to 1:4

How do you determine relative humidity?

content/capacity x 100% =

What is the U.S. Food and Drug Administration (FDA) purity standard for O2? a. 21% b. 90% c. 95% d. 99%

d. 99%

Which of the following factors should be used in properly selecting an O2 delivery device? I. knowledge of general performance of the device II. physician's preference III. individual capabilities of the equipment a. II and III b. I and II c. I, II, and III d. I and III

d. I and III

If you have to deliver medical gas to a patient from a compressed gas cylinder, which of the following devices would you select to control gas flow? a. regulator b. oxygen blender c. reducing valve d. flowmeter

d. flowmeter

Indications for warming inspired gases include all of the following except: a. treating a patient whose airways are reactive to cold b. providing humidification when the upper airway is bypassed c. treating a patient with a low body temperature (hypothermia) d. reducing upper airway inflammation or swelling

d. reducing upper airway inflammation or swelling

Barotrauma

damage to the lungs due to excessive pressure

Volutrauma

damage to the lungs due to excessive volume

Breathing dry gas through an endotracheal tube can cause what?

damage to tracheal epithelium within minutes

38. What is the physical process whereby atoms or molecules tended to move from an area of higher concentration or pressure Two an area of lower concentration or pressure?

diffusion

bubble diffusion humidifiers

directs a stream of gas under water were it broken up into tiny bubbles - smaller the bubble greater water/air surface ratio

Explain the bubble-diffusion technique.

directs a stream of gas underwater, where it is broken up into small bubbles. As the gas bubbles rise to the surface, evaporation increases the water vapor content within the bubble. The smaller the bubble, the greater is the water/air surface-area.

Pulmicort Respules: Contraindications

do not mix with other inhaled medications

65. What is the only major factor limiting the use of pressure-compensated Thorpe tube flowmeters?

effect of position (gravity) must be upright

The _________ serves as a protective mechanism for preventing aspiration by covering the opening of the larynx (i.e. the glottis) during swallowing.

epiglottis

The greater the area of contact between water and gas gives opportunity for what?

evaporation to occur

Condensation occurs on the mucosal surfaces during what?

exhalation

How does the nose affect normal airway humidification?

filters, warms, and humidifies inspired air

Question #8 bubble humidifier most commonly used

flows are greater than 4L/min on low O2 device bubble humidifier would be added

By what means is air for medical use in a hospital most commonly produced? a. chemical decomposition b. electrolysis c. fractional distillation d. physical separation

fractional distillation

The mouth is less efficient in reclaiming what?

heat and water

Which type of humidifier "traps" the patient's body heat and expired water vapor to raise the humidity of inspired gas?

heat-moisture exchanger (HME)

What are simple reservoir type used with and for?

heated fluids for use with mechanical ventilation. may be used with room temperature fluids with noninvasive ventilatory support (nasal continuous positive airway pressure or bilevel ventilation)

What does the hygroscopic salt do?

helps capture extra moisture from the exhaled gas

Simple condenser humidifiers contain a condenser element with what?

high thermal conductivity, usually with metallic gauze, corrugated metal, or parallel metal tubes

Define stridor.

high-pitched sound generated from partially obstructed air flow in the upper airway.\n\ncan be present on inhalation or exhalation.

if RR is high, inspiratory time is

higher (faster)

Peak Inspiratory Pressure (PIP)

highest manometer pressure during inspiration measured in cm H2O

HIS

hospital information system -large scale multi user database management system

left side sensitivity control - what does this control

how easy it is for patient to turn machine on by inhaling (don't want them to work hard) move to chatter point and then back off to reach neg. 1 or neg. 2 cmH2O

Sensitivity

how much effort the patient must exert to begin the flow of gas

A membrane-type humidifier separates the water from the gas stream by means of a what?

hydrophobic membrane

How is Relative Humidity measured?

hygrometer

What effect do dry medical gases administered to the upper airway at more than 4 L/min cause?

immediate heat and water loss. structural damage to the epithelium if prolonged

Ventilatory Cycles

inspiration to the start of the next inspiration

Forced Vital Capacity (FVC) (is/is not) an "effort dependent procedure."

Change kg into lb

kg x 2.2 = lb

what is the most common impediment to an open airway?

lack of airway muscle tone.

What does "Percussion & Vibration" do?

loosens secretions

if RR is low, inspiratory time is

lower (shorter)

Hygroscopic condenser humidifier(HME)

more efficient due to: -retain heat due thermal conductive material -hydroscopic salt captures extra moisture - 70%

During exhalation, the relative humidity of expired gas varies little between what?

mouth and nose breathing

Change Liters into Milliliter

move decimal over three spaces right

can the Bennett AP-4 be used as a ventilator

What happens if the down tube becomes obstructed?

no bubbling or alarm will occur. Compensated flow meter will read ZERO

vapor humidity

not visible and its not:(s.a.m. v) -steam -aerosol -mist -vapor trail

How do aerosols spread infections?

not visible to the naked eye, the water-droplet suspensions can transmit pathogenic bacteria from the humidifier reservoir to the patient

simple condenser (HME)

on insp air cools condenser element, on exp water vapor condenses directly on it's surface and warms it. on next insp cool, dry air is warmed and humidified as it passes over condenser. 50% pt moisture is recapture

What are unheated bubble humidifiers commonly used with?

oronasal oxygen delivery systems

How do passover humidifiers work?

pass gas over a large surface area of water

How is proper function checked?

pinching the connected tubing and listening for the alarm

At what point does inspired gas achieve BTPS?

point approximately 5 cm below the carina

What do wick technologies use to increase surface are?

porous water-absorbent materials

What psig is typically found in hospital setting

pounds per square inch gauge. 50 psig. Pressure above atmospheric registered on a meter or guage

right side pressure control dial - if calibration is good

pressure control numbers should match pressure on manometer (not always the case) Barb usually starts pressure at "15"

Nebulizers

produces an aerosol and uses a baffle

PHNS

public hospital networks service

Compliance

quantifies how easy/difficult is to change the shape, or deform, an object (i.e. lungs) measured in cc/cm H2O Volume/Pressure

88. Physiologic effects of inhaled nitric oxide (NO) include all of the following except:

recruitment of collapsed alveoli (Physiologic effects include: improved blood flow to ventilated alveoli, decreased pulmonary vascular resistance, reduced intrapulmonary shunting)

What does "passive" mean?

recycles exhaled heat and humidity from the patient

Reducing valve

reduces gas pressure

Below the ISB, temperature and relative humidity what?

remain constant (BTPS)

What should be done if water is low in a bubble humidifier?

replace set-up if disposable. refill with sterile water if permanent

What is the benefit of using a condensing element of low thermal conductivity?

retain more heat unlike simple condenser humidifiers

What are signs - especially in children - of inadequate breathing?

retractions (pulling in of the muscles) above clavicles and between and below the ribs. \nnasal flaring

The (RIGHT/LEFT) main stem bronchus is less angulated from the trachea than is the left main stem bronchus (25 versus 45 degrees) and therefore is more prone to intubation if an endotracheal tube (ETT) is inserted too far.

right

List *non technical* application for computer usage in hospital

schedules, billing

List non technical application for computer usage in hospital

schedules, billing

IPPB: The ability of machine to detect the patients need for a breath is called "__________"

sensitivity

Why is it important to keep room humidifiers clean and change the water in the reservoir frequently?

source of nosocomial infections. large reservoir is source for bacterial growth

What is an alternative to dispersing gas bubbles in water?

spraying water particles into the gas by generating an aerosol in the gas stream.

89. Potential uses for inhaled NO include all of the following except:

status asthmaticus (Uses do include uses such as: ARDS acute respiratory distress syndrome, persistent pulmonary hypertension of newborn, primary pulmonary hypertension)

while opening the airway, what equipment must you ready for immediate use?

suction unit to clear the airway if necessary.

What is an aerosol?

suspension of water droplets

86. Physiologic effects of hyperbaric oxygen (HBO) therapy include all of the following except:

systemic vasodilation (these are true: neovascularization, bubble reduction, enhanced immune function)

closed loop

takes action : ventilators

what is the name of the most common IPPB device

the Bird Mark 7

Flow Rate (LPM or L/min)

the amount of gas passing a specific point over a specific period of time

IPPB is

the application of inspiratory positive pressure to a spontaneously breathing patient as an intermittent or short term therapeutic modality.

how does the Bird Mark 7 run

totally pneumatic - 50 psi

how is transpulmonary pressure increased by IPPB

transpulmonary pressure is increased by increasing intraalveolar pressure

how long should IPPB treatment last

treatment should last approximately 15-20 minutes

Do Not use ABBR

u/unit iu/ international unit Q.D, QD, q.d/ daily trailing zero(x.0 mg) write x mg leading zero (.x mg) write 0.5 mg add 0 ms morphine sulfate/ magnesium sulfate write out ms04, mgso4

How much heat and moisture does an HME return to the patient during their next inspiration?

up to 70%

What is the delivery of cool humidified gas used to treat?

upper airway inflammation resulting from: 1) croup 2) epiglottitis 3) postextubation edema

Question #12 If pt upper airway bypassed, what must be done to ensure adequate humidification?

use wick passover humidifier - used on pt with bypassed airway, mechanically ventilated

Name a device that will give a specific percentage of oxygen regardless of the patients respiration's and Vt

venturi mask

membrane type humidifier

water and gas seperated by hydrophobic membrane, water vapor can pass through but liquid water cant

How do wick technologies work?

wick draws water into its fine honeycombed structure by means of capillary action.

Bird Mark 7 - if doing IPPB, is expiration time turned off?

yes

Patient Assessment: What are the signs of potentially difficult airways?

• Difficulties with positioning of the neck: arthritis, trauma, or previous surgery • Anatomical variations: small mouth, large tongue, bull neck, receding lower jaw, high arched palate, marked obesity • Limitation of mouth opening • Stridor or other signs of upper airway inflammation from epiglottitis, laryngeal infection or burn • Trauma to the larynx or trachea • Congenital malformation of face, head and neck

What is the 2 techniques done to remove the endotracheal tube from the patient?

• During deep inspiration • During cough

Hazards/Precautions of Prednisone:

• Edema / fluid retention- "moon face" • Petechia - small hemorrhage or blood vessel rupture near skin • Osteoporosis • Immune suppression - increase infection risk - esp. respiratory of opportunistic organisms

What are the techniques to increase gas distribution.

• Gas takes time: Fick's first law of diffusion : V gas =[ A x D ] (P1 - P2)/T • Apply pressure evenly i.e. plateau • Variable Flow delivery i.e. Ramp flowrate vs. square • Increase pressure gradient • Breathe Slowly

Closed Suction Catheter Kits: Minimize risk of Hypoxemia

• Hyper oxygenate • Maintain PEEP - avoid hand bagging, Closed suction

Endotracheal Suction: Hazards

• Hypoxia: Why? = Loss of FRC / Increased Atelectasis • Vagal nerve response • Airway spasm • Bleeding • Increased ICP • Pain • Interruption of mechanical Ventilation • Infection - invasive

Respiratory Indications of Prednisone:

• Initial assessment of COPD • Acute exacerbation of COPD • Severe chronic asthma - failure to respond to inhaled steroids or other meds. • Idiopathic Pulmonary fibrosis - bronchiolitis common

Oral Pharyngeal Airways: Insertion Techniques

• Inserted into mouth & over tongue • Initial insertion is with tube upside down then twisted into position as it is inserted past the tongue. (tongue may also be displaced using a tongue depressor) • Jaw Trust maneuver may also be used to assist insertion

Endotracheal Tubes: What is the advantages of Oral Intubation?

• Insertion is faster • Less trauma to nasal airway • Tolerates larger tube = decreased airway resistance ( Poiseuille's law) • Less nasal inflammation=Decreased inflammation & nasal secretions i.e. sinusitis • Easier passage of bronchoscope

EZPAP uses venture entrainment system to generate:

• Inspiratory Positive pressure - 8 - 10 cm H20 • Variable high flow • Constant expiratory pressure - 10 - 20 cm H20

What are the benefits of Xopenex?

• Less cardiac side effects - indicated for heart patients • Possible beneficial anti-inflammatory effects • Can improve benefits in combination therapy with Atrovent & Pulmicort

What visual description show a reduced FRC/Lung Volume in a Chest X-ray image?

• shift of trachea, heart or mediastinum • elevated diaphragm • displacement of interlobular fissures • crowding of pulmonary vessels • narrowing of space between ribs • air bronchogams ( lung condensed around airways - indicates mucous blocked airways

Indications for Zanamivir:

• treatment for high risk ( cardio - pulmonary disease) patients for influenza A+B • Binds Virus agents together to prevent spread of disease • Hazards / precautions: • Bronchospasm • Allergic reactions • Under treat of underlying bacterial infection hidden by viral infection

do you need to give mediation when doing IPPB?

yes, typically a bronchodilator

(Endotracheal Suctioning) Determining the suction catheter size

{ (3) (Airway ID) } / 2

What results do you expect from your patient for using the peak flow meter that indicates a red zone?

½ of the patient's best day

Heliox: Delivery Percentage (%)

• 60% He & 40% O2 • 70% He & 30 % O2

What are the characteristics of Pressure Cycling in IPPB?

• Any leak in the "circuit" or in the patient will cause the machine to not end inspiration (cycle off) Patient can easily end the breath by: • blowing back into the mouthpiece • putting their tongue over the mouthpiece • Pressure cycled machine can NOT guaranteed to deliver any specific volume to the patient Volume delivered is based upon; • the patient's ability to relax and let the machine deliver the breath • the pressure level set by the therapist • the higher the pressure level set - the greater the volume delivered to the patient (ideally)

What are the basic steps to perform an endotracheal intubation?

• Assemble & check equipment • Position the patient • Preoxygenate the patient • Insert laryngoscope • Visualize glottis • Displace epiglottis • Insert tube • Assess position • Stabilize ETT/ confirm placement

Extubation Technique: Procedure

• Assemble equipment - i.e. oxygen, bag & mask, suction, medication??? • Preoxygenate patient • Suction endotracheal tube • Suction above cuff • Deflate cuff. • Remove tube - 2 techniques • During deep inspiration • During cough - What are the risks & advantages? • Administer oxygen • Administer humidity or cool aerosol. • Assess patient ( Egan mini clinic page 690)

Closed Suction Catheter Kits: Procedure

• Assess for indications & potential risk • Assemble equipment • Pre-oxygenate or hyper ventilate. • Insert catheter • Apply suction - 10 15 seconds. Rotate during withdrawal. • Patient recover & reoxygenate • Reinsert catheter • Monitor patient

List of Anticholinergics:

• Atrovent (Ipratropium Bromide) • Spriva • Atropine Sulfate

Hazards of the Use of CPAP

• Barotrauma (pneumothorax) • Gastric distension • Air-trapping • Decrease in BP • Can be very uncomfortable to the face of patient using mask CPAP

What are the hazards and complications of IPPB?

• Barotrauma (pneumothorax) • Hyperventilation (dizziness) • Gastric distension (secondary to air swallowing) • Decrease in venous return (possible drop in BP) • Increased airway resistance • May actually cause bronchospasm in some patients!

What are the complications of endotracheal intubation?

• Esophageal Intubation • Mainstem Intubation • Perforation or laceration of upper esophagus, vocal cords, larynx • Laryngospasm or bronchospasm • Dental and soft-tissue trauma • Dysrhythmias • Hypertension/Hypotension • Aspiration of oral or gastric contents

What are the Key Elements of IPPB Instruction?

• Explain what is IPPB • Why is the patient going to be receiving IPPB treatments • How long is each treatment & how often will they receive it • What should they do during the treatment • Any questions they have of you

What breath sounds do we hear if a patient has atelectasis?

• Fine late crackles • Diminished BS

How to instruct patients to use Peak Flow Meters?

• Breath in Deep • Blast the air out "blow out the fire" • Green Zone - your best day • Yellow Zone - ¾ th of your best day Relax Use your rescue inhaler Check your self again in 20 minutes

What are the types of Atelectasis?

• Gas Absorption (Reabsorption) Atelectasis • Compressive Atelectasis • Passive Atelectasis

Closed Suction Catheter Kits: Minimize risk of Airway Obstruction

• Check catheter is completely withdrawn • Infection - Sterile technique, closed suction, good oral suction

List of Mucous Blockers:

• Chromolyn Sodium (Intal, Nasalcrom)

Indications of Tobramycin (TOBI):

• Chronic Pseudomonas - common infection in chronic respiratory disease patients such as CF

Closed Suction Catheter Kits: Advantages

• Decreased infection control issues - patient & staff • Reusable system - cost effective • Ventilator circuit is not opened = minimal O2 , PEEP, FRC ,heliox, or Nitric oxide loss • Easily Performed by one person • Easy to instill saline lavage • Can measure depth of catheter for insertion - color coded

airflow obstruction

"Slow lungs" FEV1/FVC ratio or FEV1%

A HME has been describes as what?

"artificial nose"

What is the formula for calculating % predicted SVC?

% Predicted = measured value/predicted value x 100

How do you determine percent body humidity?

%body humidity/100 = x 44 =

(Nasotracheal Suctioning) Repeat the procedures until what ONE of the following occurs ....

(1) Breath sounds are clear, OR (2) Suctioning is non-productive, OR (3) The patient experiences an adverse reaction (ie. hypoxia & bradycarida)

Parameters to be monitored during IPPB

(1) Subjective response (2) Pulse (3) EKG (4) RR (5) LOC (6) BP (7) ICP and more...

Objectives for IPPB

(1) To assist in taking a deep breath (2) To maintain oxygenation/ventilation short term (3) To deliver medications to the lung

What is the formula for increased transpulmonary pressure gradient?

(P alv - P plueral)

What is the formula for the Alveolar Air Equation?

(PAO2) = [(PB - PH2O) x FiO2)] - (PaCO2 x 1.25) PAO2= partial pressure Oxygen in alveoli PB = Barometric pressure PH2O = Partial pressure of water vapor 47 mmHg FIO2 = Fraction of Inspired Oxygen concentration PACO2 = Partial pressure of CO2 in arterial blood -1.25 Is a physiologic constant

The effectiveness of Huff Coughing may be compromised...

(Same as Coughing)

Which of the following are clinical findings that indicate the development of atelectasis?

(Something) areas on chest x-ray film Tachypnea Diminished or bronchial

The efficiency of the bubble humidifier depends on what?

(contact) water level in reservoir.

(Endotracheal Suctioning) Vacuum control should be in range of ______ to ______ mm Hg

-80 to -100

What cylinder factor is used to compute the duration of flow for a 22 cu/ft O2 or air E cylinder?

0.28

Atrovent: Nubulizer Dosage

0.5 mg in 3 ml

What is the average amount of dead volume in a small-volume jet nebulizer after the device runs dry?

0.5 to 2.5 ml

Name the 3 primary types of humidifiers.

1) bubble humidifiers 2) passover humidifiers 3) HME (heat and moisture exchangers)

Name 3 variables that affect the quality of a humidifier's performance.

1) temperature 2) surface area 3) time of contact

What are the indications for the Bedside Pulmonary Function Testing (PFTs)?

1. Known or suspected obstructive pulmonary disease. 2. Known or suspected restrictive pulmonary disease. 3. Known or suspected exposure to substances which may cause pulmonary disease. 4. Surgery requiring general anesthesia. (ex: open heart surgery)

IPPB - Indications

1. Need to improve lung expansion a) clinically significant pulmonary atelectasis when other therapy has been ineffective b) inability to clear secretions 2. The need for short-term ventilatory support 3. The need to deliver aerosol medication a) asthma b) muscle fatigue c) COPD

What are the required equipment for Maximum Inspiratory Pressure (MIP)?

1. Negative pressure manometer 2. Briggs adaptor 3. One-way valve system 4. Mouthpiece and noseclips if the patient does not have an artificial airway in place.

IPPB Administration - Post treatment assessment

1. vital signs 2. breath sounds 3. cough 4. appearance and level of sensorium 5. breathing pattern 6. measurement of VC, PF, and tidal volume per protocol 7. ask patient if treatment was helpful

Xopenex: Nebulization Dosage

1.25mg (adults), .63mg (infants and peds)

(Endotracheal Suctioning) The suction catheter should be no longer than _________ the internal diameter of the airway

1/2

What is the peak flow rate of most FROPVDs?

100 percent oxygen at up to 40 liters/minute

What percentage represents air being fully saturated?

100%

Which of the following inspired conditions should be maintained when delivering medical gases directly into the trachea through an endotracheal tube or a tracheotomy tube?

100% RH at 32° to 35° C

A BVM bag will hold between _____ and _____ mL of air.

1000 and 1600

OBJECTIVES FOR IPPB THERAPY: During Pulmonary Edema a Vt of _____ - _____ ml/kg of ideal body weight is adequate.

10; 15

Formeterol: Duration

12 hrs.

Serevent: Duration

12 hrs.

You are given a 80% He: 20% O2 mixture to an asthmatic patient through a non-rebreathing mask with a compensated Thorpe tube O2 flowmeter set at 8 LPM. What is the actual flow being delivered to the patient?

14 LPM

CONTRAINDICATIONS FOR IPPB THERAPY: Increased intracranial pressure (ICP) > _____ mm Hg

Nasotracheal Suctioning should not be more than _____ seconds

At room temperature, unheated bubble humidifiers can provide absolute humidity levels of what?

15 - 20 mg/L

Formeterol: Onset

15 min.

Just as suctioning with MIP, how many seconds can you occlude the adapter for?

15 seconds

What is the typical water vapor output of an unheated bubble humidifier? _____ mg/L

15-20 mg/L

OBJECTIVES FOR IPPB THERAPY: An adequate volume is _____ - _____ ml/Kg of ideal body weight.

15; 20

A patient has a tumor occluding half of his airway; his resistance to flow is increased ____ times.

What size needle is used for evacuation in thoracentesis?

16 gauge needle

Spriva: Dosage

18mcg (once a day)

Alupent: MDI dosage

2 - 4 puffs (.65 mg each) 4 - 6 PRN

What is external diameter sizes for endotracheal tube?

2 - 9 French

Oral Pharyngeal Airways: Describe the Berman

2 channels down each side of the airway

The temperature of gas delivered to a patient's airway by a servo-controlled heated humidifier should not vary by more than _____ degrees C.

2 degrees C.

You start a chronic obstructive pulmonary disease (COPD) patient on a nasal O2 cannula at 2 L/min. What is the maximum time that should pass before assessing this patient's PaO2 or SaO2?

2 hours

Non-Heated Cascade/Diffuser Humidifiers pop-offs are set at?

2 psi

What is the safe residual pressure reading on an oxygen cylinder?

200 psi. Below this level, oxygen delivery systems cannot operate properly.

A full oxygen cylinder should read a pressure of ___ psi.

2000-2200

What percent oxygen does the atmosphere provide?

21%

What size needle is used for local anesthesia before performing Thoracentesis?

22 - 23 gauge needle

How long are HME generally used?

24-48 hours

Brethine: Dosage

25 - .50 mg - .25 - .5 Ml in 3ml NS

Nasal Pharyngeal Airways: Sizes

26 - 32 Fr

A patient's new pressure is 30 cmH2O for this pressure he receives a volume of 800 ml. What is his compliance?

26.6 ml/cmH2O

What is the pharyngeal temperatures when a person inhales through the mouth?

3 degrees less than when breathing through the nose, with 20% less relative humidity

IPPB Administration - Procedure (continued)

3. assess pt. and adjust parameters as appropriate to achieve patient goals a) adjust pressure for volume b) adjust sensitivity for trigger c) adjust FIO2 for SpO2 (theoretical) 4. monitor pt. throughout treatment a) exhaled volumes b) pulse midway c) appearance d) level of consciousness e) watch for fatigue

56. What cylinder factor is used to compute the duration of flow for a 244 cu/ft (H/K) O2 or air cylinder?

3.14

OBJECTIVES FOR IPPB THERAPY: An ideal volume could also be _____ ml/kg of ideal body weight.

Formeterol: Peak

30 - 60 min.

Question 19 What level has ANSI set as the minimum water vapor content to avoid damage to the upper airway in intubated patients?

30 mg/L

Question 27 According to ANSI, what is the minimum absolute humidity level for intubated patients?

30 mg/L - temperature 33C

37. If the absolute humidity In a Medical Gas is being delivered to a patient Is 14 mg per liter, then what is the body humidity (BH)?

32%

If the absolute humidity in a medical gas being delivered to a patient is 14 mg/L, then what is the body humidity (BH)?

32%

82. A 45 year old patient with congestive heart failure is receiving O2 through a 35% air entrainment mask. With an O2 input of 6L/min, what is the total output gas flow? A. 16 L/min B. 24 L/min C. 28 L/min D. 34 L/min

34 L/min (100-32)/(35-21) = (65/14) -> (65/14)/(14/14)= 4.6/1 4.6+1=5.6 -> 5.6*6L/min = 33.6 ~ 34 L/min

Brethine: Duration

4 - 6 hrs.

Maxair: Duration

4 - 6 hrs.

Administration of dry medical gases to the upper airway should never have flows great than what?

4 L/min

If inspired air is saturated at 100% at 37 degrees Celcius, how much water vapor pressure is being exerted?

47 mm Hg

33. What is the water vapor pressure of saturated gas at normal body temperature 37° C?

47.0 mm Hg

What is the water vapor pressure of saturated gas at normal body temperature (37°C)?

47.0 mm Hg

The water vapor pressure of saturated gas at normal body temperature (37°C) is _____ mmHg

47.0 mmHg

What inspired conditions (RH and Temp) should be maintained when delivering medical gases to the nose or mouth?

50 % relative humidity (RH) at 20°C- 22°C

What is the psig reduced to in central piping systems?

50 psi at the outlet station

61. The pressure of O2 or air in bulk supply system is reduced to what standard working pressure?

50 psig

The pressure of O2 or air in a bulk supply system is reduced to what standard working pressure?

50 psig

How much of a patient's exhaled moisture can a simple condenser humidifier recapture?

50%

What is the maximum FIO2 expected to be delivered by most air-entrainment Masks?

50%

What is the maximum FIO2 expected to be delivered by most air-entrainment masks?

50%

What is the relative humidity when the absolute humidity is 10 mg/L of water and the capacity is 18 mg/L of water?

55%

A venti-mask that delivers 1 liter of air for each liter of oxygen delivers ____ O2:

What are the safe pressure ranges for infants while using a suction regulator?

60 - 80 mm Hg

The American National Standards Institute has set a water vapor content level of 30 mg/L as the minimum absolute humidity required for patients whose upper airways have been bypassed. This equals what body humidity (BH)?

68%

Albuterol: Continuous Nebulizer Dosage

7.5 - 20 mg per hour (ER tx)

An ideal heat-moisture exchanger (HME) should have an efficiency rating of at least which of the following?

70%

What is the efficiency of the hygroscopic and hydrophobic condenser humidifiers?

70%

What is the Inspiratory Positive Pressure range in EZPAP?

8 - 10 cm H2O

A value of > _____% of predicted is considered normal in Forced Vital Capacity (FVC).

A value of > _____% of predicted is considered normal in Slow Vital Capacity (SVC).

What are the safe pressure ranges for children while using a suction regulator?

80 - 100 mm Hg

To minimize the risk of retinopathy of prematurity (ROP) the American academy of pediatrics recommends keeping the PaO2 below what level?

80 mmHg

A value of > _____% of predicted is considered normal in a Peak Expiratory Flow Rate (PEFR). A value of < ______% of predicted is generally considered to be indicative of a bronchospastic crisis requiring further interventions in a Peak Expiratory Flow Rate (PEFR).

80; 50

A near drowning patient has a recorded body temperature of 30℃ . What is the equivalent temperature in Fahrenheit?

86° F 30° C *1.8 + 32 -> 54+32=86

You design an air-entrainment system that mixes air with 02 at a fixed ratio of 1:7 (1 L Air to 7 L O2). About what O2 will this device provide?

90%

81. You design an air-entrainment system that mixes air with O2 at a fixed ratio of 1:7 (1L air to 7L 2). About what O2 will this device provide?

90% (1x21)+(100x7)/1+7=721/8 = 90.125 ~90%

What is the level of SpO2 typically associated with discontinuation of O2 therapy?

92%

How often is trach care performed?

Differentiate between a reducing valve and a flowmeter

A Reducing valve reduces the pressure A flowmeter controls the gas flow

Serevent is associated with asthma deaths when it is used as:

A Rescue Medication

Define "automatic transport ventilator."

A device that provides positive pressure ventilations. It includes settings designed to adjust ventilation rate and volume, is portable, and is easily carried on an ambulance.

Define "pocket face mask."

A device, usually with a one-way valve, to aid in artificial ventilation. A rescuer breathes through the valve when the mask is placed over the patient's face. It can be used with supplemental oxygen when fitted with an oxygen inlet.

What is "capillary action?"

A liquid that moves upward against the force of gravity

Define "stoma."

A permanent surgical opening in the neck through which the patient breathes.

What is the formula for calculating Absolute Humidity?

AH = RH x mg H2O/L =

Chest Physical Therapy (CPT)

AKA: Percussion and Postural Drainage Invasive procedure best for all patients who have less muscle to control to cough.

During a normal breath, what percentage of each inhalation rests in the anatomic dead space of the respiratory system?

About 30%.

When fired inside the mouth, what percentage of the drug dose delivered by a simple metered-dose inhaler (MDI) deposits in the oropharynx?

About 80%

CONTRAINDICATIONS FOR IPPB THERAPY: An acute pneumothorax without a chest tube is an (Absolute/Relative) contraindication to IPPB Therapy.

Absolute Note: Absolute contraindication means do not do this. Relative contraindication means to think --- do the benefits outweigh the risks?

31. What is the term for the actual content or weight of water present in a given volume of air?

Absolute humidity (relative humidity is express as a percentage % the term for the ratio of the actual water vapor present in a gas compared with the capacity of that gas to hold the vapor at a given temperature)

Xopenex is a refined form of what medication?

Abuterol

Non-Steroidal Antiasthma Agents: (Zafirlukast) ( age 5-11) or 20 mg( 12 - adult) twice a day

Accolate

What is the primary hazard of aerosol drug therapy?

Adverse drug reactions

Long acting / Control medications -" stays at home"; Inhaled Steroids (flunisolide), 2 puffs BID

Aerobid

What is Flunisolide? What is the dosage?

Aerobid (flunisolide), 2 puffs BID

What are examples of psio-electric nebulizers?

Aeroneb or ultrasonic neb

Which of the following would be the worst heat conductor?

Air

Chest Tubes: What type of drainage occurs when a tube is inserted on anterior chest 2nd intercostal space at mid clavicular line?

Air Drainage

Proventil and Ventolin is another name for:

Albuterol

Type of receptors that causes major vasoconstriction (increases blood pressure), mild bronchoconstriction, and a small amount of increased cardiac contractility.

Alpha 1 Receptors

Medication that is commonly used for patients that have allergic or poor tolerance to Albuterol.

Alupent

Metaprotenol is another name for:

Alupent

• Nebulizer dosage.2 cc's - .3 cc's (10-15 mg)in 3 ml NS • MDI dosage 2-4 puffs (.65 mg each) 4-6 PRN • ( stronger HR & tremor side effects but is commonly used for patients that have allergic or poor tolerance to Albuterol ) • NEVER USE MORE THAN ONE SYMPATHOMIMETIC

Alupent ( Metaproterenol)

What do you call the sacs at the end of the bronchioles that are encircled by capillaries and are integral in oxygen/carbon dioxide exchange?

Alveoli

ATPS

Ambient temperature and pressure saturated with water vapor Room temperature, ambient pressure, 100% relative humidity(47mmHg), pulmonary functions

Aerosolized Antinfectious Agents antifungal agents - No FDA approved aerosolized antifungal agents Indication: Treat patients at risk(i.e. CF, Lung transplant , & chronic steroid use.) from fungal infections & minimize toxic effects of systemic antifungal agents - • Dosage - no standard dose response yet.

Amphotericin B

A Pop-Off alarm sounding off on a Cascade/Diffuser Heated Humidifier, what is this an indication of?

An OCCLUSION!! NOT a leak!

Define "hypoxia."

An insufficiency of oxygen in the body's tissues.

When is a bubble humidifier most commonly used?

Anytime flow greater than 4 L/min

Abnormal collapse of distal lung parenchyma (reduced FRC - typically the basal or dependent lobes)

Atelectasis

• Dosage .5 - 1 ml ( .4 mg per 1 ML injectable vial) • No MDI form

Atropine Sulfate -

(fast acting & drying) • 0.5 mg in 3 ml unit dose for nebulizer • MDI dose 2-4 puffs (.07 mg each)QID • Blocks signals that are closing the airway • Atrovent & Albuterol = "Combivent"- MDI or "Duo Neb" - nebulizer pre mix • Can dry airways - • Peanut allergy alert & Glaucoma alert

Atrovent

What is another name for Ipratropium Bromide?

Atrovent

What is the formula for calculating Body Humidity?

BH = absolute humidity ----------------------- x 100 44 mg/L

Formeterol: Dosage

BID

What conditions does gas moving into the lungs achiev e?

BTPS - body temp 37 degrees C, barometric pressure, saturated with water pressure (100% RH at 37 degrees C)

Why is Heliox actual flow higher than the set flow?

Because Heliox is low density (less dense) which gives it a higher flow.

small jet orifice causing high resistance what upper flow range for LVN

Because a small jet is used with this type of nebulizer and a high resistance is created, the upper flow rate available through a *flowmeter is 12 -15 L/min*

When using a chamber-style adapter with a metered-dose inhaler (MDI) to deliver a bronchodilator to a patient receiving mechanical ventilation, with what would you coordinate MDI firing?

Beginning of inspiration

electric IPPB machine with mini compressor is the

Bennett AP-4

Type of receptors that are primarily cardiac in action, increasing heart rate and contractility (strength of the heartbeat). (Not Alpha Receptors)

Beta 1 Receptors

What are the most common units used to deliver IPPB?

Bird Mark Series Ventilators

What is the term for the Relative Humidity at body temperature?

Body Humidty

28. What is the temperature at which the vapor pressure of a liquid equals the pressure exerted on the liquid by the surrounding atmosphere?

Boiling point

What happens to the turbulence and resistance when flow rate increases?

Both turbulence and resistance increase.

( comes in injectable vials) • 25 - .50 mg - .25 - .5 Ml in 3ml NS • weaker beta 1 & Beta 2 typically used in patients sensitive to other Beta 2 - i.e. Albuterol • duration 4- 6 hours ( also available in tablet form)

Brethine (terbuatline sulfate)

(PEP) is not effective to ...

Bronchitis

How does EZPAP increases and sustains the patient's FRC?

By improving gas distribution to bases and dependent lung areas.

• A simple approach which maintains some positive pressure in the airway at the end of exhalation • There is a high correlation between improvement of atelectasis and the patient having a higher than normal FRC • Generates pressure using high flow.

CPAP (Continuous Positive Airway Pressure)

Name the three types of centrally located gas systems and briefly explain how they function

CYLINDER MANIFOLD: two sides Primary bank and reserve Pressure falls to certain level, switches to reserve bank When switch occurs the primary bank is taken off line and the tanks are replaced. When switch occurs the primary bank is taken off line and the tanks are replaced. The new tanks now become the reserve bank. Alternates back and forth. -Commonly used in off site facilities (sleep labs) and operating rooms CYLINDER: Primary supply, secondary supply and a reserve supply. - Primary depleted, automatically switches to secondary -Master panel (maintenance dept) indicates that changeover has occurred. Reserve kicks in if other two depleted(safety). -Liquid can be used as primary and secondary. Reserve supply is made up of high pressure gas cylinders A safety since low pressure liquid containers can lose 3% of their supply per day LIQUID BULK OXYGEN: Most commonly used in large health care facilities. Economic, safe and convenient -Small volume of liquid oxygen provides a very large amount of gaseous oxygen. Liquid storage also minimizes space requirements

Atrovent: Contraindications

Can dry airways Peanut allergy alert & Glaucoma alert

Criteria for initiating hyperbaric oxygen (HBO) therapy on an adult patient suspected of suffering from acute carbon monoxide poisoning include all of the following except:

Carboxyhemoglobin saturation less than 20%.

Restrictive lung disease

Characterized by decreased lung volumes (TLC less than 80% of predicted)

What is the treatment for gas or fluid in pleural space? > 20%

Chest Tubes

What is the mixture of Atrovent and Albuterol in MDI form called?

Combivent

Compare and contrast compressed gas cylinder and liquid gas cylinder Compressed Gas Cylinder:

Compressed gas cylinder: Normally filled to its service pressure. if + symbol on tank add 10%. -We measure pressure to see how much gas left in cylinder. ex: E tank 2200, at half would be 1100 -H & K also full at 2200

Type of Atelectasis that occurs when something outside the lung presses on lung tissue causing it to collapse. This occurs when there is a decreases in the Transpulmonary Pressure Gradient ( PL) PL = Alveolar Pressure (Pav ) - Pleural pressure (Ppl)

Compressive Atelectasis

Why should you NOT heat the reservoirs of a bubble humidifier used with an oronasal oxygen delivery system?

Condensate will obstruct the delivery tubing

What is the physical process whereby the gaseous form of a substance is changed back into its liquid state?

Condensation

During the evaporation of water, the adjacent air is ___________.

Cooled

If you increase orifice size on the jet of a nebulizer the entrain gas or fluid would:

Decrease

What are the 2 most common vagal responses?

Decrease HR, Decrease BP

66. Specific clinical objectives of oxygen (O2) therapy include which of the following?

Decrease the symptoms caused by chronic hypoxemia, decrease the workload hypoxemia imposes on the heart and lungs, correct documented arterial hypoxemia (I II II)

Goals of O2 therapy include?

Decreased Work of Breathing Treatment of Hypoxia Decreased Intracranial Pressure

Advantages of small-volume ultrasonic nebulizers for drug delivery include all of the following except:

Decreased cost

Dosage of Methylxanthines:

Dosage - based on maintaining blood level in therapeutic range 8-10 mg / ml • 300 - 1200 mg mg / day divided by Q6 to until therapeutic range is reached

Flow volume loop (Restrictive)

Dramatic decrease in both the residual volume and total lung capacity -Increased STIFFNESS of the lung and/or chest wall in restrictive lung disease results in an inability to get the gas into the lungs during inspiration lead secondarily to less gas back out during exhalation. *Gas cannot get IN*

Why do Pass-Over Humidifiers have low humidification?

Due to the decreased contact time and the limited surface area

Expiratory Reserve Volume

ERV -The max amount of air that can be exhaled following a normal exhalation from the resting level/relaxed volume (FRC) -About 1L -ERV slightly decreases with age -ERV= FRC-RV

The FRC is made up of which of the following?

ERV (Expiratory Reserve Volume) RV (Residual Volume)

How are Room Humidifiers powered?

Electrically

Expiratory Flows (Graph)

FEV1 is a VOLUME measured over one second of time. -FEF25-75 is an actual FLOW of measurement: Slope of the line showing volume change over time. -FEV1 and FEF25-75 are recorded during forced exhalation from total lung capacity to residual volume.

FEV1/FVC

FEV1= 4.0 L FVC= 5.0L Then FEV1/FVC= 4.0/5.0= 80 percent of their forced vital capacity in the first one second of exhalation. -Helps determine if patient has obstructive or restrictive long disease

Which of the following is false about air entrainment systems?

FIO2 values are directly proportional to their total flow

Flow volume loops (Graph)

FOR EXHALATION

Convert Celsius to Fahrenheit

Fahrenheit = (C x 1.8) + 32

True/False: Maxair is available in nebulized form.

False, Maxair is not available in nebulized form

True/False: Bronchoscopy can be done in the NICU.

False; Bronchoscopy is not typically done in NICU due to small airways

Long Acting Broncho-dilator adrenergic/sypathomimetic ( Formoterol) • BID- onset 15 minutes , Peak 30 - 60 minutes, duration 12 hour • Dry powder MDI only

Foradil

FVC

Forced Vital Capacity a VC measurement performed with maximum forced expiratory effort

(Bedside PFT) Indicated for the evaluation of obstructive processes - measures flows to determine degree of obstruction & often perfromed before & after bronchodilators

Forced Vital Capacity (FVC)

FVC

Functional vital capacity -Maximum inspiration to maximum expiration >Volume breathed out after deepest inhalation -Vital capacity includes the IRV, ERV, and Tidal Volume. -IC + ERV

How do Bubble Humidifiers function?

Gas passes down a capillary tube under the surface of the water, then exits through a diffuser at the lower end of the tube.

The ability of gas to flow through the conductive airways depends on:

Gas viscosity Gas density The lenght and diameter of the tube The flowrate of the gas

Define "condensation"

Gaseous substance is changed back into its liquid state

12. Which of the following statements correctly describes gases?

Gases exhibit the phenomenon of Flow, molecular forces of attraction are minimal ,Gases are easily compressible , Gases expand to fill their container

What type of Humidifier are also called an "Artificial Nose"?

HME

Name the type of Humidifier that traps the patient's body heat and expired water vapor to raise the humidity of inspired gas.

HME (Heat-Moisture Exchanger)

What test is most helpful in diagnosing restrictive lung disease?

Hard to get gas into the lungs Volume/time-> FLOW (NOT answer) *VT* *FVC: Still can breath normally but CANNOT do maximal and will be able to detect*

Liquid - solid phase change

Heating a solid increases its kinetic energy Enough heat causes a solid to break free of the attractive forces causing it to become a liquid.

Solids

High degree of internal order Maintain their shape by strong mutual attractive forces Not easily compressed Ex; Nebulizer to deliver meds

Inhaled Pulmonary Vasodilators inhaled gas @ 10 - 40 parts per million • Selective Pulmonary Vasodilator • Active agent for smooth muscle relaxation = vasodilation • Combines with oxygen quickly - eliminated as Meth hemoglobin

INOmax - Inhaled Nitric Oxide

Definition: Lung expansion therapy utilizing positive airway pressure for periods of 15 - 25 minutes to enhance resting lung ventilation by increasing the patients tidal volume (Vt.)

IPPB (Intermittent Positive Pressure Breathing)

What are the devices used for Lung Expansion Therapy?

IPPB (Intermittent Positive Pressure Breathing) IS (Incentive Spirometry) CPAP (Continuous Positive Airway Pressure) PEP Therapy (Positive Expiratory Pressure)

How much time does the patient should pass without ventilation if the intubation is delayed? What should be done to the patient if this time period has passed?

If intubation is delayed, no more than 30 seconds should pass without ventilation.3Therefore, if intubation is not performed within this time period, the procedure should be stopped and the patient ventilated with bag-mask ventilation prior to reattempting the procedure.

To assure a stable FiO2 under varying patient demands, what must an O2 delivery system do?

If you want it to be stable you must have it deliver all the patients inspired gas. If the device delivers only some of the inspired gas, the patients needs are not met. -FIO2 variable based on patients Vt, VE(minute volume), RR and patients anatomical reservoir (oral and nasal cavity, normally around 50 ml) high volumes higher rates lower FIO2 -more room air is pulled in Lower volumes lower rater higher FIO2 -Less room air is pulled in

Fiberoptic Endotracheal Intubation: Contraindications

Inability to oxygenate Major bleeding

Which of the following is an indication for the use of helium-O2 mixtures?

Large-airway obstruction

Which of the following is an indication of the use of helium-O2 mixtures?

Large-airway obstruction

What two states of matter are considered liquids? Why?

Liquids and gasses. Both are able to flow

Atelectasis: If obstruction occurs in a large bronchus.

Lobar Atelectasis

L/T Ratio: Topical delivery to this part of the body that creates a therapeutic effect.

Lungs

What three sizes of oxygen cylinders would you find used in fixed systems on an ambulance?

M, G, H

Type of inhaler in gas and liquid form of medicine?

MDI

How can inhaled medications be administered?

MDI DPI Nebulizers

What are the types of inhalers?

MDI DPI Spacers Nebulizers

Systemic Corticosteroids Indications: ( questionable results) • COPD - debilitating COPD despite other treatments • Acute severe Asthma - controversial older method - not common front line therapy • Nocturnal Asthma • Apnea of prematurity - used in NICU on premature neonates to prevent apnea Hazards / Precautions: • Must be in therapeutic range to be effective - 8 - 10 mg / ml ( blood level) • Above therapeutic range = toxic > 15 mg / ml • Toxic levels can cause cardiac arrhythmias • High levels can be increased by : • Hepatic metabolism disorders • Acute viral infections • Cardiac failure • Drug interaction i.e. erythromycin, cimetidine • Low levels can be caused by • Cigarette smoking • Phenobarbital ( increase liver clearance ) • Nausea, vomiting , tremors, palpitations, headaches, seizures Dosage - based on maintaining blood level in therapeutic range 8-10 mg / ml • 300 - 1200 mg mg / day divided by Q6 to until therapeutic range is reached

Methylxanthines : aminophylline/theophyllin - Thodur, Slo Bid

PaO@

Partial Pressure Oxygen in Alveoli [(PB - PH2O) x FIO2] - (PACO2 x 1.25) PH2O is partial pressure of water vapor always 47mmHg FIO2 is .21 in room air

49. Air for medical use in a hospital should be which of the following?

Particle - free, oil-free, dry

A nebulizer is a device that produces:

Particulate water

Which type of Humidifier functions by having gas passing over the surface area of the water, picking up the moisture and delivering it to the patient?

Pass-Over Humidifier

Which type of Humidifier is the simplest of all humidifiers?

Pass-Over Humidifier

What is the simplest of all humidifiers?

Pass-Over humidifier (non-heated)

Type of Atelectasis that occurs when patients do not take periodic deep breaths (sighs).

Passive Atelectasis

Which of the following is consistent with the radiographic appearance after prolonged exposure to O2?

Patchy infiltrates

71. Retinopathy of prematurity (ROP) is potentially serious management problem mainly in the care of whom?

Premature or low-birth-weight infants

Boyle's Law

Pressure and volume of a gas system will vary inversely Mass and Temperature constant P1V1 =P2V2 V down = P Up Boyle wants to b vice president clinical application: breathing and O2 stored in cylinders

What are the 2 things that control inspiration and expiration in a Bird Ventilator?

Pressure gradient and Magnetism

How is airway resistance (Raw) computed? Change in:

Pressure/Flow

CONTRAINDICATIONS FOR IPPB THERAPY: The increased airway pressure may increase the bleeding, so this is a relative contraindication. However, in severe cases, IPPB may help to increase the surface area available for gas exchange (as discussed with Pulmonary Edema).

Pulmonary Hemorhage

What are Inhaled Pulmonary Vasodilators indicated for?

Pulmonary Hypertension

Measuring forced expiratory gas flows

Pulmonary functioning testing also assesses forced expiratory gas flows to determine if there are obstructive elements due to high airway resistance.

17. Which of the following methods of heat transfer requires no direct contact between the warmer and cooler substances?

Radiation

Which method of heat transfer requires no direct contact between the warmer and cooler substances?

Radiation

Why is it important to use a clear face mask?

So you can observe the patient's mouth and nose for vomiting or secretions that need to be suctioned.

69. Which of the following typically occurs first when monitoring the earliest physiologic response to breathing 100% O2?

Substernal chest pain

How is bronchoscopy used diagnostically (Diagnostic Bronch's)?

Suspected Foreign Body Suspected pathology Congenital abnormality Persistent problems

Give an example when a chronic obstructive pulmonary disease patient may need high FIO2

The *less stable* the patients condition, the *greater *the need for *high flow AEM*

What happens during normal inspiration?

The Ppl decreases further below atmospheric The Transpulmonary pressure gradient widens Palv drops below that at the airway opening

Give an example when a chronic obstructive pulmonary disease patient may need high FIO2

The less stable the patients condition, the greater the need for high flow AEM

What do you call the area directly posterior to the nasal cavity?

The nasopharynx

Which intubation route is preferred for endotracheal intubation? Why?

The oral route for intubation is preferred since it can usually be performed more rapidly and provides for better visualization. In addition, the mouth can accommodate a larger tube than the nose.

Define "airway."

The passageway by which air enters or leaves the body. The structures of the airway are the nose, mouth, pharynx, larynx, trachea, bronchi, and lungs.

Define "respiratory failure."

The reduction of breathing to the point where oxygen intake is not sufficient to support life.

If there is no alarm on a Bubble Humidifier, what is the cause?

There is a leak

Bedside PFT Measuring Devices: 1. Uses the principle of heat transfer from a hot wire to the gas flow. 2. A fine wire is placed in the gas flow. 3. The wire is heated electronically. 4. As the gas flow passes over the wire, the wire is cooled. 5. The degree of cooling is affected by the flowrate. 6. May display flowrate or volume.

Thermistors

If a Reservoir runs dry on a Cascade/Diffuser Heated Humidifier, what safety system functions to automatically cut off the Humidifier?

Thermostat

21. 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

The major problem with air entrainment systems is ensuring that the set FIO2 is actually delivered to the patient. Explain causes and solutions to this problem

This can be caused if there is entrainment in the tubing. To fix this you would need to drain all the excess water form the tubing. You can also watch the mist come out the expiratory side of the T tube. If there is mist, they are getting enough FIO2

A procedure of removing the fluid from the pleural space.

Thoracentesis

What is the therapeutic benefit of thoracentesis?

Thoracentesis removes fluid to reduce cardio-pulmonary stress.

Which of the following patient categories are at high risk for developing atelectasis?

Those who are heavily sedated Those with abdominal or thoracic pain Those with neuromuscular disorders

ASSS American standard safety system

Threaded high pressure connections -Between large compressed gas cylinders and their attatchments F through H&K -Misconnection is difficult due to threading design

Tidal Volume the amount of air moved in/out of the lungs in a single normal breath

Tidal Volume the volume of gas inspired OR expired during one normal breath

BASIC TERMINOLOGY: 1. The amount of air moved in or out of the lungs in a single breath. 2. Typically measured as exhale volume.

Tidal Volume (Vt)

The volume of gas inspired or expired during one normal breath.

Tidal Volume (Vt)

Aerosolized Antinfectious Agents antibiotic - pseudomonas aeruginosa pneumonia Indication: - • Chronic Pseudomonas - common infection in chronic respiratory disease patients such as CF Hazards / Precautions ( Egan Box 29-5) • Cannot be mixed or nebulized with other aerosolized medications • Less side effects with aerosolized TOBI • Possible ototoxicity ( hearing damage) • Staff exposure issues - filter, thumb valve / PARI neb,& isolation mask • Fetal harm - avoid exposure to pregnant women • Bronchospasm & airway irritation Dosage: 300 mg / 5m l ampule ( adults & children > 6 ) ( 20 30 mg in NICU) BID - 28 days on & 28 days off

Tobramycin (TOBI)

Most airway problems are caused by the ______.

Tongue

The total amount of gas in the lung at __________ inspiration. (VT + IRV + ERV + RV)

Total Lung Capacity (TLC)

TLC

Total lung capacity

Dalton's Law

Total pressure of a gaseous mixture is equal to the sum of the partial pressures of all the gases Barometric Pressure = P(A) + P(B) + P(C)

True/False: Xopenex is longer acting than Albuterol

True

Neonate ETT Size: Less than 1 kg Tube Size (mm) Oral Tube Length at Lip (cm) Suction Tube Size (Fr)

Tube Size (mm) = 2.5 Oral Tube Length at Lip (cm) = 5.5 Suction Tube Size (Fr) = 6

Bedside PFT Measuring Devices: 1. Measure airflow using a windmill effect. 2. May not be accurate in the face of high flowrates due to the effects of momentum and inertia, therefore are not appropriate for FVC measurements. 3. Results may be affected by moisture and/or medication deposits. 4. May display results as either flow or volume.

Turbinometers

The AHA recommends that BVM artificial ventilation is performed by ___ rescuers.

Two

Advantages of the dry power inhaler (DPI) drug delivery systems include all of the following except:

Unaffected by humidity.

The risk of airway obstruction by the tongue is even greater when the patient is __________.

Unconscious

What is the *water output range* for an *unheated and heated LVN?*

Unheated 26-35 mg/L water output Heated: 33 - 55 mg/L water output

What is the water output range for an unheated and heated LVN?

Unheated 26-35 mg/L water output Heated: 33 - 55 mg/L water output

Wick humidifiers

Use a water absorbent material to increase surface area. The wick draws water like a sponge to a fine honeycombed structure by means of capillary action .... like bounty -The surface of the wick increase the area of contact between the water and the gas.

Define "suctioning."

Use of a vacuum device to remove blood, vomitus, and other secretions or foreign materials from the airway.

What to do in case your peak flow meter results indicate a red zone?

Use your inhaler Now!!!!!! Check your self again If you are not a lot better get help

What does "Postural Drainage" do?

Uses body positioning and gravity to cause the secretions to move toward lung airway

Evaporation

Vaporization - change of state from liquid to gas. Req heat energy Heat is taken from air surrounding the liquid. cools the air (warm weather body sweats to cool)

Vital Capacity (IRV+VT+ERV) the total amount of gas that can be exhaled after a maximum inspiration

The delivered Vt must exceed the patient's spontaneous _____.

Vital Capacity (VC)

What are the types of I.S. devices?

Volume Oriented Devices Flow Oriented Devices (Tri Flow)

Bedside PFT Measuring Devices: 1. Consists of an ultrasonic transmitter and receiver positioned on either side of the flow of gas. 2. An obstructing strut causes eddies (vortices) of known volumes (usually 1 cc per vortex). 3. Results may be affected by moisture and/or medication deposits. 4. Results may be displayed as flow or volume.

Vortex-Shedding Devices

Heat-moisture exchangers (HMEs) are mainly used to do what?

Warm and humidify gases delivered to the trachea via ventilator circuits.

Does a warm gas or a cold gas have a greater capacity for water vapor?

Warm gas

Suction Chest Drainage systems: A chamber with 2 centimeters of water and shows respiration effort (spontaneous vs. mechanical) and air leaks if bubbling.

Water Seal Chamber

Bedside PFT Measuring Devices: 1. The bench standard for all volume and flow measuring devices. 2. Uses a cylinder submerged in water. 3. Graphs are produced on paper, then flows and volumes are calculated. 4. Difficult to move from place to place.

Water Sealed Spirometer

Gases

Weak, molecular attractive forces Rapid, random motion with freq collisions No inherent boundaries Easily compressed and expanded Able to flow

All of the following are contraindication for heat-moisture exchanger except:

When a patient is suffering for increase body temperature

All of the following are contraindications for heat-moisture exchangers except:

When a patient is suffering from hyperthermia.

Define "respiratory arrest."

When breathing completely stops.

Nasal Pharyngeal Airways: Indications

When oral airway cannot be used: • Semiconscious or conscious patient • Unable to open jaws • Severe oral airway trauma • Assist with nasal tracheal suction

Wick

Which type of Humidifier is SERVO-CONTROLLED?

Wick Humidifier

Which type of Humidifier is capable of producing 70% BH?

Wick Humidifier

Which type of Humidifier is ideal for patients on a mechanical ventilation?

Wick Humidifier

Levalbuterol is another name for:

Xopenex

refined form of Albuterol - (Single R isomer of Racemic Albuterol) • Dosage 1.25 mg adults - .63 mg infants & peds • Longer acting 6-8 hours • Less cardiac side effects - • Possible beneficial anti-inflammatory effects • Can improve benefits in combination therapy with Atrovent & Pulmicort • More expensive • available in MDI form now.

Xopenex - Levalbuterol

What is the rigid suction tube that is used to suction above the vocal chords? (Used for suctioning the Oral airway suctioning)

Yankauer Suction

Which zone in the Peak Flow Meter do I have to stay home?

Yellow Zone after using my inhaler

Is the mouth less effective than the nose for heat and moisture exchange?

Yes

Increasing the flow through an unheated bubble humidifier has which of the following effects? a. decreasing the water vapor content b. decreasing the relative humidity c. increasing the water vapor content d. increasing the relative humidity

a. decreasing the water vapor content

Intermittent positive-pressure breathing is associated with a passive exhalation. a. true b. false

a. true

Which of the following statements regarding O2 is false? a. It is only slightly soluble in water. b. It is odorless and transparent. c. It is flammable. d. It is heavier than air.

c. It is flammable.

Regulator

controls both pressure and flow

Air for medical use in a hospital should be which of the following? I. particle-free II. oil-free III. dry a. I and II b. I and III c. II and III d. I, II, and III

d. I, II, and III

Inhalation of dry gases can do which of the following? I. increase viscosity of secretions II. impair mucociliary motility III. increase airway irritability a. I and II b. III c. I and III d. I, II, and III

d. I, II, and III

Which of the following types of humidifiers are used in clinical practice? I. heat-moisture exchanger II. passover humidifier III. bubble humidifier a. I and II b. II and III c. I and III d. I, II, and III

d. I, II, and III

Which of the following conditions alter normal mucociliary clearance? I. bronchospasm II. cystic fibrosis (CF) III. ciliary dyskinesia a. I, II, and III b. I and II c. I and III d. II and III

d. II and III

Which of the following can provoke a cough? I. anesthesia II. foreign bodies III. infection IV. irritating gases a. II and IV b. I, II, and III c. III and IV d. II, III, and IV

d. II, III, and IV

Which of the following statements about He is false? a. It is an inert gas. b. It is odorless. c. It is nonflammable. d. It is heavier than air.

d. It is heavier than air.

simple reservoir

directs gas over water surface used heat w/mechanical ventilation use room temp nasal CPAP and BPAP

Question #11 at what level may use of humidifiers be unnecessary 4 pt receiving low flow O2 therapy?

flows that are at or below 4L/min low O2 devices

If the alarm sounds without intentional occlusion, what may be the problem?

gas flow is too high. kink in the tubing. obstruction at the outlet.

HTTP

hypertext transmission protocol -Internet protocol used to transmit web pages -World wide web technology. Its the set of rules that govern the software that transports hyperlinked files along internet

mmHg(torr) to cm H2O

mmHg(torr) x 1.36 = cm H2O

What is a servo-controlled heating system?

monitors temperature at or near the patient's airway using a thermistor probe

A cooperative and alert postoperative patient taking food orally requires a low percentage of oxygen to be provided continuously. A precise oxygen concentration is not needed. What is the best choice for this patient?

nasal canula.

PHNS

public hospital service networks

Hydrophobic condenser

water repellant element -70%

Brethine: indication

weaker beta 1 & Beta 2 typically used in patients sensitive to other Beta 2 - i.e. Albuterol

What are the needed equipment for IPPB?

• IPPB Ventilator - • Bennett "PR series" ventilator OR Bird "Mark series" ventilator • IPPB tubing circuit • "Universal" disposable circuits now used • Additional equipment "possibly" needed; • Mouthseal & noseclips for patients who cannot use mouthpiece • Mask (if mouthseal is not available) • Connector for using circuit with trach patient

Contraindications to CPAP

• If blood pressure is very low • Diastolic of <50 mm Hg • If patient has one or more of the following; • Facial trauma (cannot use mask CPAP) • Nausea • Untreated pneumothorax • Elevated intracranial pressure (ICP)

How Positive Pressure Ventilation Differs from Normal?

• In normal breathing, inspiratory pressures are negative while expiratory pressure are positive • In IPPB, both inspiratory pressures & expiratory pressure are positive

Endotracheal Suction: Indications

• Inability to generate an effective cough • Evidence ( x-ray ) of retained secretions • Increased PIP on VC or decreased VT on PCV • Visible or easily heard secretions in airway • Obtain Sputum specimen • Suspected aspiration of oral or gastric secretions

What Does CPAP Accomplish?

• Increases the FRC by increasing the amount of air in the chest at the end of exhalation • The net effect of increasing FRC is to; • Re-open any atelectasis areas • Improve any hypoxemia that may be resulting from the atelectasis • CPAP is also used to treat sleep apnea secondary to upper airway obstruction

Tracheostomy Tubes: Hazards/Precautions

• Infection control - i.e. colonization of pathogens • Hemorrhage - erode innominate artery or airway trauma • Permanent scar • Greater expense • Persistent open stoma • Bypass upper airway humidification • Reduce airway diameter = fixed increased airway resistance

Closed Suction Catheter Kits: Disadvantages

• Initial Cost is more than 1or 2 suction kits • Additional weight on ETT. • Catheter can be left in ETT= airway obstruction. • Potential leak in Ventilator circuit = vol. loss. • Less control / stiffer catheter = potential inability to reach deep into airway • Airway damage from catheter hitting same location

Oral Airway Suction: Indications

• Large secretions or soft foreign body obstruction • Minimize oral secretions from pooling around cuff of ETT • Minimize oral secretions draining into lungs esp. with uncuffed ETT's ( i.e. neonate) • Minimize risk of aspiration for oral / gastric secretions into lungs • Prior to deflating cuff for ETT reposition or extubation • Good oral care minimizes need for invasive endotracheal suction

Tracheostomy Tubes: Indication

• Long term artificial airway • Assist with mechanical ventilation • Chronic ineffective cough i.e. neuromuscular patients • Permanent upper airway obstruction • Radical neck surgery - i.e. cancer, trauma, burn • Emergency laryngeal edema i.e. epiglottitis

Requirements of Pnetamidine:

• MMAD 1- 2 um • "respirgard" filter on exhalation - prevent aerosol exposure • negative pressure room or isolation chamber ( Aerostar) • HEPA fit tested mask

What are the features of IPPB Circuit?

• Main bore outlet connection • Nebulizer drive line and Exhalation valve drive line adapter • Patient connection & mouthpiece • Nebulizer cup • Exhalation valve outlet

What should the therapist emphasize during the treatment?

• Make sure patients keep lips sealed tight around the mouthpiece • Coach patient to not actively breath • "Relax and let the machine fill your lungs!" • Make sure patient does not breath too rapidly during treatment • This will cause dizziness secondary to hyperventilation

What are the Clinical Signs of Atelectasis?

• Medical history - Identify potential risk What are they? • Increased RR • Auscultation • Fever ( if pneumonia is present) • Tachycardia ( indicates pain or hypoxia)

Closed Suction Catheter Kits: Minimize risk of Atelectasis

• Minimize suction time • Minimize suction pressure

Endotracheal Tubes: What is the advantages of Nasal Intubation?

• More comfortable over long term use • Less gag & retching • Easier to keep tube secured • Insertion can be performed blind (with minimal sedation) • Easier & more effective oral care • Patient cannot bite ETT - no need for oral airway

Tracheostomy Tubes: Advantages

• More comfortable over long term use - eliminates oral hygiene & pain issues. • Patient can be fed • Patient "looks" better - face is not obstructed • Easier to keep secured • Easier to reinsert or exchange - RT procedure using obturator • Can use uncuffed tubes • Patient can talk - i.e. fenestrated tubes & passey Muir speaking valves

Hazards/Precautions of Methylxanthines:

• Must be in therapeutic range to be effective - 8 - 10 mg / ml ( blood level) • Above therapeutic range = toxic > 15 mg / ml • Toxic levels can cause cardiac arrhythmias • High levels can be increased by : • Hepatic metabolism disorders • Acute viral infections • Cardiac failure • Drug interaction i.e. erythromycin, cimetidine • Low levels can be caused by • Cigarette smoking • Phenobarbital ( increase liver clearance ) • Nausea, vomiting , tremors, palpitations, headaches, seizures

List of Nasal Steroids:

• Nasonex, Vancenase, Flonase

Heliox: Delivery Method

• Non Rebreather with humidifier • Circulaire nebulizer • supplemental oxygen - a 6 l o2 nasal cannula of may be used along with Heliox

What are the alternative techniques to establish airway?

• Oral Airway • Nasal Airway • Mask Ventilation • Transtracheal Jet Ventilation • Retrograde Intubation • Laryngeal Mask Airway • Light Wand • Blind Nasal Intubation • Combitube • Emergency Cricothyrotomy Devices

What are the indications for IPPB?

• Patient has an atelectasis that is not responding to I.S. therapy • Patient cannot perform I.S. therapy • This may also be a problem with IPPB!! • Poor cough effort & secretion clearance due to inability to take a deep breath • Short term ventilator support when patient is hypercapnic • Enhancement of aerosol medication delivery in patient unable to take a deep breath

What are the Key Aspects & Terms Associated with IPPB ventilators?

• Patient initiates the breath and machine is able to detect the patient's effort and then starts delivering gas into the mouthpiece • The ability of machine to detect the patients need for a breath is called "sensitivity" • Sensitivity should be set so that machine will begin breath at a pressure that is 1 or 2 cmH2O pressure below zero (or -1 to -2 cmH2O pressure)

What are the reasons why Incentive Spirometer may not be appropriate to use by the patient?

• Patient is not alert or cannot follow instructions • Patient cannot hold mouthpiece in their mouth • Patient has a large atelectasis that must be treated with more aggressive measures • Patient cannot create a large enough breath for I.S. to be of any real value (VC< 10 cc's per Kg IDBW)

What SHOULD the patient do during IPPB?

• Patient starts their breath; the machine cycles on • Patient relaxes and lets the machine fill their lungs • Patient should NOT be actively breathing after the machine cycles (turns on) • Patient will exhale normally in a relaxed way through the mouth when machine ends inspiration (pre-set pressure is reached)

What are the advantages of Incentive Spirometer Therapy?

• Patients can self-administer as often as they like • Relatively easy to learn and perform • Very rare side effects • Inexpensive way of preventing pulmonary complications

List of Aerosolized Anti-infectious Agents

• Pentamidine Isethoionate • Ribaviran • Tobramycin (TOBI) • Zanamivir • Amphotericin B • Colistimethate Sodium (Colistin)

What are the ETT tube components?

• Pilot balloon • Cuff - high vol. low pressure • 15 mm adapter • tapered tip • I.D • O.D. • Centimeter marks • Murphy holes • Radiopaque indicator marks

What are the complications/risks associated with Atelectasis?

• Pneumonia • Increased length of stay • Decrease respiratory reserve • Reduced surfactant production • Increased V/Q mismatch = hypoxia • Decreased mucokinesis • Low grade fever • Increased pain / splinting

What Patients Are "at-risk" for Atelectasis?

• Post-op thoracic or abdominal surgery patients • Any heavily sedated patient • Patients who have neuromuscular diseases / spinal cord injuries. These diseases may weaken breathing muscles • Patients who are unable to ambulate / bedridden • Patients with chest trauma or chest wall injury • Poor nutrition / weak patients • Incisions close to diaphragm = increase risk

List of Systemic Corticosteroids:

• Prednisone • Methylxantines

What are the Asthma Plan Basics?

• Prevent attack - know my triggers • Know my signals - "signs & symptoms" - Red, yellow or green • Take my rescue medicine • Relax, relax, relax - blow out slow - "pursed lip breathing" • How am I now? - Is my plan working? • If it's not working try it again or get more help • Knowing what to do means "No Fear" = Control

Types of doctors that treat asthma

• Primary care doctors • ER doctors • Pediatricians • Allergists • pulmonologists

What are the beneficial effects of CPAP?

• Recruitment of collapsed alveoli • The work of breathing is decreased as lung compliance (stretchability) improves • Improvement of gas distribution • Improvement in secretion removal

Which emergency equipment should always be readily available during intubation procedures?

• Resuscitation equipment • Medications • Oxygen • Alternative airway equipment

Nasotracheal Suction: Hazards/Precautions

• Same as endotracheal • Upper airway bleeding & trauma • Contamination of lungs ( sterile) with upper airway secretions ( non-sterile)

Indications of Pentamidine:

• Second line therapy to prevent PCP in high risk patients ( HIV +) • Previous PCP episodes • CD4 ( T4 cell helper) lymphocyte < 200/ mm • Has been shown to be effective if given in IV form ( eliminates exposure issue with aerosol)

List of Long-Acting Bronchodilators:

• Serevent (Salmeterol Xinfoate) • Foradil (Formetorol) • Brovana (Arfomoterol)

List of Non-Steroidal Antiasthma Agents:

• Singulair • Zyflo • Accolate • Xolair

Heliox: Contraindications/Hazards

• SpO2 <92% on 6l n/c & 60% He / 40% O2 non Rebreather (discontinue Heliox and return to 100% Hi Flow O2) • Do not use inline with any Puritan Bennett ventilator • Never Use Heliox without humidity or Aerosol • Mucous plugging

What equipment is used for collecting sputum samples?

• Sputum trap ( Luken's trap or De Lee) • Saline for lavage

Indications of Ribaviran:

• Treat seasonal RSV ( self limiting respiratory disease in infants & children • questionable effectiveness vs. cost

Indications for Use of CPAP

• Treatment of post-operative atelectasis • Should be used continuously • Has been used in the treatment of cardiogenic pulmonary edema

What are the contraindications to IPPB?

• Untreated pneumothorax • High intracranial pressure (>15 mm Hg) • Active hemoptyisis • Radiographic evidence of a bleb • Nausea - risk for aspiration • Tracheo-esophagel fistula • Recent esophageal surgery

Closed Suction Catheter Kits: Minimize risk of Airway Trauma

• Use Correct suction depth - don't bang on the carina • Soft catheter - i.e. red robin • Murphy hole arrangement • Correct suction setting

What does the Double Lumen tubes do?

• Used to ventilate only one lung. • Used to assist jet high frequency ventilation.

Extubations Technique: Indications

• Weaning patient from need of mechanical ventilation. • Removal of obstructed or suspected obstructed endotracheal tube. • Removal of endotracheal tube to be replaced with tracheostomy tube

How do you present the Incentive Spirometer when you are going to instruct patients on how to use them?

• What is I.S. • Why is the patient going to learn how to perform it • How often should the patient perform it • Does the patient have any questions

What do we monitor while we are giving IPPB treatment to patients?

• What is the pulse & respiratory rate prior to treatment? • What are the patients breath sounds; their color; respiratory effort; mental state - prior to the Tx? • What is the patients SpO2 or peakflow before the treatment (if giving bronchodilators) • VT, RR, Effort, Tolerance, Position • Mask vs MP vs Trach • Sputum Production

What needs to be prepared in place prior to performing endotracheal intubation?

• all equipment • medication • emergency supplies • support staff

Side Effects of Colistin:

• bronchospasm - • eliminated through urinary system • Neurotoxic - and neuromuscular

Pulmicort Respules: Indications

• may be mixed with Xopenex • used for chronic Asthma to reduce use of prednisone

Hazards/Precautions of Ribaviran:

• rashes, conjunctivitis, eyelid erythema • can effect or occlude ventilator expiratory valves or filters ( what precaution should be taken if this is nebulized inline on a vent pt?) • Small Particle Aerosol Generator ( SPAG) large volume small particle nebulizer required to deliver to small aerosol to small airways • Expiratory " respirgard" filter to minimize staff exposure • RSV patients - respiratory / aerosol isolation - mask

Final

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