RCP 110 Final Exam
Nonmaleficence
"First, do no harm". Obligates healthcare providers to avoid harming patients and actively prevent harm where possible
Integrated O2 Cylinders
"Grab and Go's". Pre-connected to regulators, flowmeters and tubing to deliver a selected flow immediately to the patient. Eliminates the need for separate cylinders, keys, wrenches and regulators for each room or patient. Often are E cylinders
Respondeat Superior Doctrine
"Let the master speak". Doctrine that makes an employer liable for the acts of its employees
SaO2
% O2 carrying hemoglobin in arterial blood. Normal is 95-100
SpO2/SaO2
% saturation of O2, 95-100% - Refers to: The percentage of O2 binding Hb in the blood as obtained by Pulse Ox or CO-ox - Depends on: The PaO2 and the amount of dyshemoglobins present
Da Vinci
(1452-1519) Determined sub-atmospheric (negative) pressure inflates the lungs, and fire consumes air
Vesalius
(1514-1564) Father of anatomy. Performed human dissections and resuscitation
Black
(1754) Described the properties of CO2
Priestly
(1774) Discovered oxygen as "dephlogisticated air"
Lavoisier
(1775-194) Demonstrated that oxygen is absorbed by the lungs and carbon dioxide is expelled
Charles
(1787) Relationship between volume and gas temp
Beddoes
(1798) First to use oxygen to treat conditions at the Pneumatic Institute. Birth of Respiratory Care
Dalton
(1801) Law of Partial Pressures: Two or more gasses create partial pressure
Gay-Lussac
(1811) Relationship between gas temperature and pressure
Graham
(1831) Graham's Law: Diffusion of gasses from high to low pressure
Hutchinson
(1846 )Developed the water sealed spirometer, an instrument used to measure respiratory volumes.
Pasture
(1865) Germ Theory of Disease: Disease caused by microorganisms
Macewen
(1880) Applied the first endotracheal tube successfully
Roetegen
(1896) Father of radiology, discovered X-Ray
Von Linde
(1907) Developed the large scale production of oxygen
Aerosolized Medications Developed in (year)
(1910) First was Epinephrine
Laryngoscope
(1913) Instrument used for visual examination of the larynx
Drinker
(1928) Developed the first Iron Lung
Emerson
(1940's) Developed the most common iron lung model used on Polio patients
Bronchiodilators
(1940's) Drugs used to increase airflow by dilating constricted airways through relaxation of the smooth muscles
Oxygen Technicians
(1940's) First inhalation therapists. Hauled oxygen tanks. "Tank Jockeys". Later became Inhalation Therapists
ITA
(1947) Inhalation Therapy Association
Positive Pressure Breathing Devices
(1950's) Applied to WWII pilots. First training for oxygen tech's/inhalation therapists
AAIT
(1954) American Association of Inhalation Therapists
Committee on Accreditation for Respiratory Care (CoARC)
(1954) Educational program regulation for RCP's
National Board of Respiratory Care (NBRC)
(1960) tests competancey for practicing respiratory care in all 50 states
Arterial Blood Gasses (ABG)
(1967) Rapid laboratory test for levels of oxygen and carbon dioxide present in blood. Prior to Pulse Oximeter, was the only way to test oxygen levels
AART
(1973) American Association of Respiratory Therapists
Clark Electrode
(1974) Measures the pressure of carbon dioxide/PaO2 in the blood
Polysonography
(1980's) First sleep studies
Pulse Oximeter
(1980's) Measures the oxygen saturation level in the blood in an ABG sample
Albuterol Sulfate
(1980's) Most common bronchodilator
AARC
(1982) American Association of Respiratory Care
Title II of HIPPA
(2003) Established the rules for the disclosure of Protected Health Information (PHI)
Kortokoff Sounds + Key Phases
(5 Phases) Series of sounds that correspond to changes in blood flow through an artery as pressure is released. 1st phase = first sound (Systolic BP). 3rd phase = sound absent (Diastolic BP
RC in Middle Ages
(850-1050AD) Fall of the Roman and Greek empire halts scientific advancement.
Bradycardia
(Brady=Slow) Pulse lower than 60 bpm. Caused by a diseased heart, drug overdose and sometimes found in athletes
Atalectasis
(Collapsed lung) Lack of gas exchange due to alveolar collapse, puncture or fluid build-up
4 Essential Fluids
(Hippocrates) Plegmn, blood, yellow bile and black bile
Hospital Acquired Infection (HAI)
(Nosocomial) An infection/pathogen acquired from a healthcare setting
Initial Assessment (3)
(Overlaps with stage 2) Maintain rapport and get familiar with their needs. Observe the patient's mood, general appearance and response to questions. Learn the patient's baseline condition and evaluate them for their condition and treatment being ordered
Describe the changes in pressure on expiration:
(PA) to rise - Transpulmonary pressure (PL) declines, so alveoli begin to deflate - As alveoli shrink, their PA increases until a positive pressure is reached compares to the pressure at the airway opening (Pao) - Positive pressure pushes gas rom the alveoli back into the atmosphere - End-expiration occurs when PA eventually rises to equal atmospheric pressure
Tank Duration Formula
(Pressure psi x Tank Factor)/ Flow rate in l/min. Answer in minutes, must divide by 60 for hours. Subtract whole number, multiply by 60 for hours + minutes
The steep portion of the HbO2 dissociation curve illustrates what?
(SaO2 < 90%) O2 Unloading at the tissues
The flat portion of the HbO2 dissociation curve illustrates what?
(SaO2 > 90%) O2 Loading at the lungs
Tachycardia
(Tachy=Fast) Pulse greater than 100 bpm. Caused by anxiety, hypoxemia, exercise, fever and anemia
Iatrogenic Alkalosis
(Ventilator-induced Alkalosis) Occurs when patients with Partially Compensated Respiratory Alkalosis undergo mechanical ventilation- usually COPD patients
Absolute Humidity (AH)
(Water Vapor Content) The actual weight of all water vapor suspended in a gas. AH at 100% is called Saturation
Main source of infectious pathogens
*Humans*, inanimate objects, medical devices, and other individuals present in hospitals
Nitrous Oxide (N2O)
- "Laughing Gas" - Colorless, sweet taste and odor - An anesthetic gas, must be mixed with O2 - Tank color: Blue - Produced by thermal decomposition of ammonium nitrate
Air
- 78% N, 21% O2, 1% Trace gases - Colorless, odorless, naturally occurring gas mixture - Tank color: Yellow - STPD of 1.29 g/L
Ratios and factors for Heliox Therapy
- 80% He, 20% O2: Factor 1.8 - 70% He, 20% O2: Factor 1.6
Carbogen Therapy
- 95% O2, 5% CO2 - 93% o2, 7% CO2
What two ways can ABG's be tested?
- A bedside Point of Care analyzer - Full laboratory testing
The ISB shifts distally (further down) when:
- A person breathes cold, dry air - The upper airway is bypassed - Minute ventilation is higher than normal
Hazards of Heliox Therapy
- A poor vehicle for aerosol transport - Reduces the effectiveness of coughing - Distorts voice - Hypoxemia
A tracheal shift/deviation indicates
- A tumor in the upper respiratory tract or mediastinum (Opposite side shift) - A collapsed lung (Same side shift)
Examination of the chest includes:
- A/P Diameter - Kyphosis? (indicates Emphysema or COPD) - Scoliosis?
Name 4 ways that ventilation can be assessed:
- ABG + Analysis - Capnography - Transcutaneous PO2 Monitoring
Name 4 ways that blood oxygenation can be assessed:
- ABG + Analysis - Hemoximetry - Pulse Oximetry - Transcutaneous PO2 Monitoring
What types of abnormalities can go undetected with Pulse Oximetry?
- Abnormalities in acid-base balance - Abnormalities in ventilation/PaCO2 - Anemia - Dyshemoglobins - Hyperoxemia
What are the primary causes of low CaO2?
- Absolute or Relative dyshemoglobinemia - Pulmonary dysfunction due to a decrease in PaO2 and SaO2
Absolute Vs. Relative Hb Deficiency
- Absolute: Low levels of Hb (Anemia) present - Relative: Hb molecules present, but too many are abnormal
What factors can cause a lower SaO2 for a given PaO2 (a right shift on the HbO2 Dissociation Curve)
- Acidosis (decreased pH) - Hypercapnea (increased CO2) - Fever (increased body temp) - Increased 2,3 DPG
2 Most effective ways to prevent malpractice litigation
- Active risk management practices - Appropriate patient and guest relations policies/patient satisfaction. Happy people don't sue!
Respiratory abnormalities that can cause Respiratory Acidosis include:
- Acute upper airway obstruction - Severe diffuse airway obstruction - Massive pulmonary edema
Indications for humidification and warming of inspired gases:
- Administration of dry medical gases at flows GREATER THAN OR EQUAL TO 4 l/min - Following intubation - Managing hypothermia - Treating bronchospasm caused by dry air
Hazards of aerosol therapy?
- Adverse medication reaction - Infection from other air particles - Airway reactivity (bronchospasm from sterile saline) - Pulmonary and systemic effects of bland aerosol - Eye irritation - A change in drug concentration during nebulization
Airway Appliances:
- Aerosol Mask - Face Tent (Burn patients and facial trauma) - Tracheostomy Mask - T-Tube (Trach collars)
Characteristics of Therapeutic Aerosols
- Aerosol output - Particle size - Deposition - Aging
Normal VS depends on....
- Age - Illness - Treatments being taken
How much O2 diffuses across the alveolar-capillary membrane is dependent on what 2 factors?
- Age - Presence of disease
Common barriers to patient learning
- Age (very old or very young) - Education level - Disabilities (Hearing, visual and learning) - Pain level
Indications for HBOT:
- Air Embolism - Carbon Monoxide poisoning - Lesions or ulcers
What factors can cause a higher SaO2 for a given PaO2 (a left shift on the HbO2 Dissociation Curve)
- Alkalosis (increased pH) - Hypocapnea (decreased CO2) - Hypothermia (decreased body temp) - Decreased 2,3 DPG - Dyshemoglobins - Fetal Hb
What are the key barriers to diffusion in the A/C Membrane?
- Alveolar Epithelium - The Interstitial Space - Capillary Endothelium (- RBC Membrane)
Safety Considerations for Patients
- Ambulation and movement - Electrical Safety - Fire Hazards
Harmful effects of currents on the body are effected by
- Amount of current - Direction of current flow - Length of time current is applied
Describe the effect of 2,3-DPG changes on the HbCO2 Dissociation Curve:
- An increase in 2,3-DPG shifts the curve to the RIGHT for enhanced unloading - A decrease in 2,3-DPG shifts the curve to the LEFT for enhanced loading
What are the two primary causes of Metabolic Acidosis?
- An increase in fixed acids - An excessive loss of HCO3-
Describe the effects of pH changes on the HbCO2 Dissociation Curve:
- An increase in pH (Alkalosis, >7.40) shifts the curve to the LEFT - A decrease in pH (Acidosis, <7.40) shifts the curve to the RIGHT
Describe the effect of body temperature changes on the HbCO2 Dissociation Curve:
- An increase in temperature shifts the curve to the RIGHT - A decrease in temperature shifts the curve to the LEFT
Imaginary Lines: Axillary
- Anterior Axillary Line - Midaxillary Line - Posterior Axillary Line
Average Apical, mid and Base Ppl's
- Apical: -10 cm/H2O - Mid: -5 cm/H2O - Base: -2.5 cm/H2O
What types of blood can be used to analyze a patients oxygenation status?
- Arterial Blood!!! The gold standard for ABG - Mixed venous samples from the pulmonary artery - Central venous catheter blood
Total O2 Content normals for arterial and venous blood
- Arterial: 20 mmHg - Venous: 15 mmHg
Chest auscultation technique
- Ask patient to breathe deeply - Start at bases and work to the apices (counter-clockwise) - Compare both sides listening for breath sounds and adventitious lung sounds
Examination of the neck includes:
- Assess jugular veins for distention (indicates right heart failure) - Assess for tracheal position or deviation (indicates tumor or lung collapse) - Palpate lymph nodes (indicates infection or malignancy)
Roles of the RT in assessment-based bronchodilator therapy
- Assess patient response - Patient education
Types of obstructive lung disease
- Asthma - COPD - Emphysema - Cystic Fibrosis - Bronchitis
Describe the effects of high COHb (Carbon Monoxide Poisoning)
- At COHb levels of 5-30%, patients exhibit tachypnea, headache, tachycardia, and hypoxemia - At COHb levels >40%, patients experience visual disturbances, myocardial damage and coma that can lead to death - Treatment includes high flow O2 via a nonrebreathing mask or HBOT therapy
Describe the effects of methemoglobinemia:
- At MetHb 25-50%, patients experience similar to CO poisoning - At MetHb > 50%, patients exhibit cardiac arrhythmias, severe CNS depression, profound metabolic acidosis - Treatment includes removing causative factors, administering a reducing agent like methylene blue or HBOT therapy
Nitric Oxide (NO)
- At low concentrations, regulates blood oxygen levels in hemoglobin - Colorless, nonflammable, supports combustion - Toxic at high concentrations (Methemoglobinemia) - FDA approved for the treatment of infants and premies with hypoxic respiratory failure
3 Most common aerosol devices
- Atomizers - Nebulizers - Inhalers
Complications of HBOT
- Barotrauma to closed body cavities (Ex: Trauma to ears, nose, sinuses or ear drums) - Alveolar pneumothorax - O2 Toxicity - Fire - Vision changes - Decreased cardiac output
Ways to avoid lawsuits
- Be aware of and conform to all legal aspects of licensure and standards of care - Regular and ongoing risk analyses by hospitals and institutions - Malpractice insurance
What are the 2 types of vaporization?
- Boiling Point - Evaporation
Types of pulse volumes
- Bounding - Full - Weak - Thready - Absent
What are the two Right→Left Anatomic Shunts?
- Bronchial Venous Drainage - Thebesian Venous Drainage
Uses for HBOT
- Bubble (Emboli) Reduction - Hyperoxygenation of blood and tissues - Vasoconstriction (Ex: burn victims) - Enhance immune function - Neovascularization (EX: Gangrene)
Main types of humidifiers:
- Bubble Humidifier - Passover Humidifiers - Heat-Moisture Exchanger
What 4 gases normally comprise alveolar gas?
- CO2 - O2 - N2 - H2O Vapor
What is the normal range for COHb and METHb in nonsmokers?
- COHb: < 3% - METHb: <1.5%
Common therapeutic uses for CO2
- Calibration of blood gas analyzers - Diagnostic purposes in clinical laboratories - Formerly used to treat atelectasis and hiccups
Causes of Partially Compensated Metabolic and Respiratory Acidosis?
- Cardiac arrest - COPD (chronically elevated PaCO2 levels) - Drug overdose - Poisoning
Hazards of Ribarivin
- Caregiver exposure to drug and drug precipitation - Can jam breathing valves in mechanical ventilator circuit
Chemical vs. Physical Disinfection
- Chemical: Application of a chemical solution to a chemical surface for a set length of time - Physical: Disinfection through heat (Pasteurization) or UV radiation
General Sanitation Measures
- Clean surrounding environment - Aiming to reduce pathogens - Environmental control of air and water filtration
Carbon Dioxide (CO2)
- Colorless, odorless naturally occurring gas - STPD 1.52 g/L - Tank color: Grey - Does not support combustion
Oxygen (O2)
- Colorless, odorless, tasteless and transparent - Liquid or gas form - STPD density 1.429 g/L - Not soluble in water - Tank color: Green - Nonflammable but aids in combustion and burning intensity
Types of infectious resistance varying between people
- Complete immunity - Carriers without clinical symptoms - Complete clinical disease
Compliance Vs. Resistance Issues
- Compliance: Something is limiting the lungs ability to fully expand. Ex: Obesity or a tight hug - Resistance: Something is causing resistance to normal breathing. Ex: Bronchospasm from asthma
Concave Meniscus Vs. Convex Meniscus
- Concave: Adhesion is greater than cohesion. Water sticks to the side of the tube and is lowest in the middle - Convex: Cohesion is greater than adhesion. Water sticks to itself and the highest point is in the middle
Hazards of Humidity
- Condensation - Cross-contamination
4 Methods of Heat Transfer
- Conduction - Convection - Radiation - Evaporation
Keys to expert VS Assessments
- Constant awareness of changes - Look, listen, touch - Reassess and analyze - Recognize trends
3 Major routes of transmission
- Contact - Respiratory droplets - Airborne droplet nuclei
Indications for Transcutaneous Monitoring (PtO2/PtCO2):
- Continuously monitor the adequacy of arterial oxygenation or ventilation - Continuously monitor for hyperoxemia - Quantifies real- time changes in ventilation or oxygenation in response to diagnostic or therapeutic interventions - Screen infants for critical congenital heart diseases
Objectives of O2 Therapy
- Correct documented or suspected acute hypoxemia - Decrease symptoms associated with chronic hypoxemia - Decrease the workload hypoxemia imposes on the cardiopulmonary system
3 Classifications of Malpractice
- Criminal - Civil - Ethical
Causes of Partially Compensated Metabolic and Respiratory Alkalosis?
- Critical care - Hypoxemia - Nasogastric suctioning - Anxiety or pain - Neurologic damage - Mechanical ventilation
Major infection prevention strategies
- Decreasing host susceptibility - Eliminating pathogen source - Interrupting routes of transmission
Vital Signs (VS) are used to:
- Determine the patients general status - Establish a baseline - Monitor response to therapy - Observe for trends - Determine the need for further evaluation or intervention
Indications for Hemoximetry/CO-oximetry:
- Determines the actual blood O2 saturation (not pulse ox) - Measures abnormal Hb levels (MetHb, COHb)
Disorders that can cause Metabolic Acidosis due to a loss of base:
- Diarrhea - Pancreatic Fistula - Renal Failure - Hyperalimentation
Ways to interrupt routes of transmission
- Disposable equipment - Barrier/isolation precautions - Standard/transmission based precautions
Temperature lowers due to
- Dissipation due to sweating - Hyperventilation - Peripheral vasodilation (lowers pressure)
Examination of the Extremities
- Distal clubbing? - Peripheral cyanosis? - Pedal edema?
Questions to test a patient's understanding
- Do they understand their condition or disease? - Do they know what medications they are prescribed and what they do? - Are they familiar with the procedure or equipment they will be using?
Nonrespiratory abnormalities that can cause Respiratory Acidosis include:
- Drug OD - Trauma to the head, spinal cord or thoracic cage - Neuromuscular disease (Ex: Guillain Barre) - Gross obesity
Clinical manifestations/indications of Metabolic Acidosis include:
- Dyspnea - Headache - Nausea/vomiting - Confusion - Stupor - Dysrhythmias - Vasoconstriction - Pulmonary edema
Clinical manifestations/indications of Acute Ventilatory Failure (Resp. Acidosis)
- Dyspnea - Hypoxemia - Vasodilation - Tachypnea - Tachycardia - Diaphoresis - Anxiety - Paradoxical abdominal movement
Clinical signs of Metabolic Acidosis
- Dyspnea due to hyperpnea - Kussmaul's respirations (Ketoacidosis) - Neurologic responses (lethargy to coma)
Clinical manifestations/indications of Hypoxemia:
- Dyspnea/shortness of breath - Tachycardia - Tachypnea - Hypertension - Mental confusion - Cyanosis
Parts of a stethoscope
- Ear pieces - Binaurals - Tubing - Chest Piece: Diaphragm and Bell
Respiratory Hygiene
- Education of health care personnel, patients & visitors - Posted signs with instructions - Source control measures - Hand and cough hygiene - Spatial separation greater than 3 feet
Infection control procedures aim to:
- Eliminate the sources of infectious agents - Create barriers to their transmission - Monitor the effectiveness of control
General rules for record keeping
- Entries should be printed or handwritten - No ditto marks - Don't erase - Document patient complaints - Record each patients interaction & sign entry - Don't leave blanks - Standard abbreviations only, NEVER abbreviate drugs.
Purpose of Patient Communication
- Establish rapport - Comfort anxious patients - Obtain and relay information - Persuasion - Give treatment instructions - Patient and family education
Temperature increases during:
- Exercise - Anxiety - Ovulation - Pregnancy
An elevated OCB level causes:
- Exercise intolerance - Impacts the ability to be weaned off mechanical ventilation
What factors can cause methemoglobinemia?
- Exposure to Hb-oxidizing agents - Nitrates or Nitric Oxide (NO Therapy) - Administration of cardiac agents or antibiotics
Expressing Genuine Concern
- Face the patient and look them in the eye - Active listening - Cultural awareness - Appropriate use of touch
Examination of the head includes
- Facial expression for mental status - Diaphoresis? (indicates MI/heart attack) - Cyanosis? (indicates hypoxemia) - Nasal flaring? (indicates labored breathing)
Effects of condensation on humidifiers:
- Fall risk - Wastes water - Occludes gas flow through the circuit - Can be aspirated
Ferric Vs. Ferrous Ion
- Ferric: Fe3+, cannot bind with O2 - Ferrous: Fe2+, can bind with O2
Fire hazards of O2 Therapy
- Fires in O2 Enriched Environments like surgical suites - Flash burns from smoking with a nasal cannula
3 Necessary components for a fire to start
- Flammable material present - Oxygen present - Flammable material must be heated above the ignition temp
3 Types of Flowmeters
- Flow Restrictor - Bourdon Gauge - Thorpe Tube
Properties of Gases
- Fluidity - Gaseous Diffusion - Gas Pressure/Atmospheric Pressure - Partial Pressure
What must a patient be able to do to use a DPI?
- Generate a sufficiently high Inspiratory Flow Rate (40-60%) - Follow directions
Standard Precautions include
- Hand hygiene - personal protective equipment - Injection safety - Protective medical equipment - Cough etiquette
Characteristics of liquids:
- Have a fixed volume but adopt the shape of their container - Atoms exhibit a moderate degree of mutual attraction - Shape is determined by numerous internal and external forces
What 3 types of abnormal hemoglobins effect the HbO2 dissociation curve?
- HbS (Sickle Cell) - MetHb (Methemoglobinemia) - HbCO (Carboxyhemoglobin)
Additional VS observations
- Height - Weight - LOC - Level/type of pain - General appearance
Drugs with off-label uses for respiratory care
- Heparin (anticoagulant) - Antibiotics like Tobramycin - Aerosolized Lidocaine (stops coughing)
Uses for Carbogen Therapy
- Hiccups - Carbon Monoxide (CO) Poisoning - Prevents washout of CO2 during cardiopulmonary bypass
Characteristics of solids:
- High degree of internal order - Fixed volume and shape - Strong mutual attractive force between atoms - Atoms are packed tightly with limited movement
Raw is highest and lowest where?
- Highest in the nose (50%) - Lowest in the small airways (20%)
Lung Topography: Fissures
- Horizontal Fissure - Left & Right Oblique Fissure
Causes of Metabolic Alkalosis include:
- Hypokalemia - Hypochloremia - Nasogastric suction - Persistent vomiting - Diuretic Therapy - Steroid Therapy - Excessive bicarbonate administration
Clinical manifestations/indications of inadequate Qt include:
- Hypotension - Cold extremities - Weak or absent peripheral pulses - Reduced urine output - Depressed LOC
Learning Needs Assessment
- Identify and accommodate barriers to patient learning - Assess the patient's preferred learning method - Evaluate patient's readiness to learn - Determine the specific leaning needs - Questions to test understanding - Teach-back method
Host factors increasing susceptibility to infection
- Immunodeficiency: HIV+, Oncology, Transplant - Poorly controlled diabetes - Advanced age - Placement of tubes and catheters - History of COPD or smoking - Obesity - Artificial airway recipients
What 8 factors cause abnormalities in gas exchange and transport?
- Impaired O2 Delivery (DO2) - Physiology - Deadspace Ventilation - Hb Deficiencies - Reduction in Blood Flow - Dysoxia - Impaired CO2 Removal - V/Q Imbalances
Advantages of NO Therapy:
- Improves blood flow to the lungs - Promotes vasodilation and oxygenation - Reduces shunting - Decreases pulmonary vascular resistance
When is Transcutaneous Gas Sampling the preferred method?
- In infants and children in need of continuous monitoring of oxygenation and ventilation - In hyperoxemia
Performance of a Jet Neb is affected by:
- Individual neb design - Gas pressure and density - Characteristics of the medication
Mechanisms of deposition:
- Inertial Impaction - Gravimetric Sedimentation - Brownian Diffusion
Examination of the Abdomen:
- Inspect and palpate for dissension or tenderness - Hepatomegaly? - Ascites?
4 Components of a physical examination
- Inspection: Seeing - Palpation: Feeling - Percussion: Tapping - Auscultation: Hearing
What are the 3 Phases of ventilation?
- Inspiration - Expiration - Pause at End-Expiration
Aerosol particle deposition if influenced by:
- Inspiratory flow rates - Flow pattern - Respiratory rate - Inhaled volume - I:E Ratio - Breath-holding
Factors affecting DPI performance:
- Intrinsic airway resistance - Inspiratory Flow Rates - Exposure to humidity or moisture
Disadvantages of a Transtracheal Catheter:
- Invasive - Only a short term solution - Risk of infection - Bypasses body's humidification system, allowing warm, dry air to be inspired and thickening respiratory secretions
Basic functions of Torts
- Keep the peace between individuals - Substitute a compensatory remedy for personal injury - Prevent vengance
Disorders that can cause Metabolic Acidosis due to an increase in fixed acids:
- Ketoacidosis - Renal failure - Lactic acidosis - Ingestion of acids
Assessing the need for O2 therapy includes:
- Lab documentation of levels - Specific clinical issue - Clinical findings at the bedside
Classification of medical gases
- Lab gases - Therapeutic gases - Anesthetic gases
Cardiopulmonary distress is indicated by:
- Labored, shallow, rapid or irregular breathing - Coughing, choking, wheezing, chest pain or cyanosis
Types of flow
- Laminar flow - Turbulent flow
Particle sizes and corresponding deposition methods
- Large: 5+ um (Inertial Impaction) - Small: 1-5um (Suspension) - Very small: Less than 3um (Diffusion)
Imaginary Lines: Anterior Chest
- Left & Right Midclavicular Lines - Midsternal Line
Imaginary Lines: Posterior Chest
- Left & Right Scapular Line - Midspinal Line
What does a LEFT shift indicate on an HbO2 dissociation curve?
- Left = Loading - Increased pH/Alkalosis (>7.40) - Increased O2 affinity - Decreased temperature/metabolic demand - Decreased P50 value - Decreased 2,3-DPG
Advantages of bulk O2 over cylinders
- Less expensive - Less prone to continuous O2 interruption - Eliminates the inconvenience and hazards of O2 cylinder filling, transport and storage - Eliminates the need for separate pressure reducing valves for each cylinder outlet - Safer because they operate at a lower working pressure
The 3 states of matter
- Liquid - Solid - Gas (Plasma)
3 Basic O2 Delivery Systems
- Low Flow: 8 L/min or less - Reservoir System: 10 L/min or less + mask - High Flow: 20 L/min or more
Hemoglobin (Hb) Normals for Male and Female
- Male: 15 g/dL - Female: 12 g/dL
Normal Hb saturation levels for males and females
- Males: 14-18 g/dL - Females: 12-15 g/dL
Hypoxia or hypoxemia can be a result of:
- Medications - Drug overdoses
Classifications of Hypoxemia:
- Mild: PaO2 60-79 mmHg - Moderate: PaO2 40-59 mmHg - Severe: <40 mmHg
Pain is indicated by:
- Moaning - Shallow breathing/refusal to breathe deeply - Confusion - Guarding: Protecting areas of pain
Physical separation of O2 from air
- Molecular sieves - O2 concentrators with semi-permeable membranes
Indications for Pulse Oximetry:
- Monitors the adequacy of HbO2 saturation - Quantify the response of HbO2 to therapeutic intervention or to diagnostic procedure - To comply with mandated regulations - Screen infants for critical congenital heart diseases
Multiplace vs. Monoplace Hyperbaric Chamber
- Multiplace holds up to 12 patients - Monoplace holds one patient at a time
O2 Toxicity Symptoms
- Muscle twitching - Seizures - Vision loss - Bleeding - Jerky breathing - ARDS
Low Flow systems include:
- Nasal Cannula - Transtracheal Catheter - Reservoir Cannula
Parts of a Jet Neb
- Neb cup - Baffle - Reservoir tubing - T-Piece - Mouthpiece or mask - Small bore O2 tubing
3 Forms of Torts
- Negligent Torts - Intentional Torts - Strict Liability Torts
Risks of long term exposure to N2O
- Neuropathy - Fetal Disorders - Spontaneous abortion/miscarriage
Characteristics of gases:
- No fixed volume or shape - Has weak attractive forces between atoms - Considered fluids
Defenses against Intentional Torts
- No intent to do harm - Patient giving consent to action knowing the risks involved
Mechanisms for breath sounds
- Normal: Turbulent air flow - Diminished: Shallow breathing - Harsh/Bronchia: Decreased airway attenuation
Gases that can be liquified
- O2 - CO2 - N2O
Precautions and Hazards of Supplemental O2
- O2 Toxicity - Depression of ventilation efforts - Retinopathy of prematurity - Absorption atelectasis - Fire hazards
Partial pressure of room air
- O2: 21% - N: 79%
Helium (He)
- Odorless, tasteless, nonflammable, and chemically and physiologically inert .- Tank color: Brown - STDP density is 0.1785 g/L - Lightest gas - Must be mixed with 20% O2
Times baseline measurements are taken....
- On admission - Start of each shift - Before any procedure - When the patients condition changes
Storage of cylinders
- On racks or chained to the wall - Cap remains on when not in use - "No smoking" signs posted nearby - Do not store near flammable or combustible sources or near heat - Cool, well ventilated areas
Sites for taking temperature
- Oral - Rectal - Axillary - Ear
What is the difference between -osis and -emia imbalances?
- Osis = Systemic - Emia = Bloodstream
What are the two steps to systemic interpretation of blood gases?
- Oxygenation Assessment - Acid-base Assesment
What are the key determinants of PACO2?
- PACO2 - PAO2 - VA - VCO2 - VD - PIO2
A complete assessment of ABG parameters indicating the state of oxygenation includes:
- PaO2 - CaO2 - Hb - SaO2 or SpO2
Lab levels necessary to assess the need for O2 Therapy
- PaO2 - SpO2 - SaO2
Abnormalities that can cause Respiratory Alkalosis include:
- Pain/Anxiety - Stimulant Drugs - Pos pressure ventilation
Examination of the Precordium:
- Palpation of the chest above the heart for pulses - Palpation of the point of maximal impulse
Clinical signs of Respiratory Alkalosis:
- Paresthesia - Hyperactive reflexes/twitching - Dizziness - Tetanic convulsions
Partial Vs. Full Compensation
- Partial compensation is indicated by a pH that is out of normal range - Complete compensation is indicated by a pH that is within normal range
Components of bronchodilator therapy assessment:
- Patient Interviewing - Observation - Measurement of vitals (HR, RR, BP) - Auscultation of breath sounds - Blood gas analysis - Pulse Oximetry - Spirometry
Name two drugs that have associated risks for caregivers
- Pentamidine - Ribarivin
What can cause an increase in VD?
- Perfusion to well-ventilated areas of the lungs is reduced - Elevated RR or VE - Pulmonary embolism
NO Therapy is effective in treating:
- Persistent or Primary pulmonary artery hypertension - ARDS - COPD - Pulmonary Embolism - Cardiac transplantation - Congenital Diaphragmatic Hernia
Key Blood Gasses + Normals
- Ph: 7.35-7.45 - PaCo2: 35-45 mm Hg - PaO2: 80-100 mm Hg - HCo3: 2.2-2.6 mEq/L - BE: -2-+2 mEq/L
What are the 2 forms of Oxygen Transport?
- Physically Dissolved in Plasma - Chemically Bound to Hemoglobin (Hb)
Major Sources of Conflict
- Poor communication - Structural problems within a large organization - Roll conflict/being pulled in multiple directions
Hazards of NO Therapy:
- Poor or paradoxical response - Methemoglobinemia - Cardiac anomalies - Rebound hypoxemia - Pulmonary Hypertension
Benefits of a pMDI:
- Portable/compact - Easy for most adults to use - Provides multi-dose convenience
General Safety Measures for RT's
- Positioning equipment properly - Preventing the tangling of tubes and wires - Reducing fall risks
Required elements for negligence to be proven
- Practitioner owes a duty to the patient - Practitioner breaches that duty - Breach of duty is the cause of damages - Damage/harm came to the patient
What type of measurement errors are most common for blood gases?
- Preanalytic Errors - Analytic Errors - Postanalytic Errors
What can cause erroneous SpO2 readings in Pulse Oximetry?
- Presence of abnormal Hemoglobin (COHb or MetHb) - Vascular dyes - Nail polish - Poor local perfusion - Motion - Ambient light
What are the properties of liquids?
- Pressure - Buoyancy - Viscosity
Types of Thorpe Tubes
- Pressure Compensated - Uncompensated
Pros and Cons of the flow restrictor
- Pro: Ideal for delivering an unchanging flow and pressure over time - Con: Unable to be altered without changing out orifices
Pros and Cons of thorpe tubes
- Pro: Most accurate when measuring true flow - Con: Gravity dependent makes it bad for transportation
Pros and Cons of the bourdon gauge
- Pro: Not gravity dependent makes it ideal for patient transport - Con: Inaccurate with resistance because it overestimates the pressure when combined with any type of connection
2 Components of Ethical Theories or Principles
- Professional Obligations - Patient Rights
Benefits of aerosol drug therapy for targeting lung diseases:
- Provide a higher therapeutic index - Lower systemic effects
Types of restrictive lung disease
- Pulmonary fibrosis - Late pregnancy or obesity - Sarcoidosis
What arteries can ABG samples be obtained from?
- Radial*** - Brachial - Dorsalis Pedis - Femoral
Components of evaluating the pulse
- Rate - Rhythm - Strength
What are the benefits of using a spacer or holding chamber in a pMDI?
- Reduces oropharyngeal deposition - Reduces the need for hand-breath coordination
Types of cardiac rythms
- Regular - Regular Irregular - Irregularly Irregular
Situations when providers are allowed to share confidential information or health history
- Reporting HIV + status to the Health Department or spouse - Cases of child or elder neglect - Animal bites - Narcotics abuse
Types of Passover Humidifiers
- Reservoir Type - Wick Type - Membrane Type
What are the two categories of acid-base imbalances and what values do they relate to?
- Respiratory: Abnormalities in Paco2 - Metabolic: Abnormalities in HCO3-
What points in the breathing cycle require work/effort?
- Resting Inhalation - Forced Exhalation
Anxiety is indicated by:
- Restlessness - Tense posture - Fidgeting - Difficulty communicating
What is the treatment for Metabolic Alkalosis?
- Restore normal fluid volumes of K+ and Cl- - Supplemental O2 - In severe cases, IV Hydrochloric Acid to buffer high pH
Restrictive vs Obstructive Lung Disease
- Restrictive: Difficult to inhale or expand lungs - Obstructive: Difficult to exhale
What does a RIGHT shift indicate on an HbO2 dissociation curve?
- Right = Unloading - Decreased pH/Acidosis (<7.40) - Decreased O2 affinity - Increased temperature/metabolic demand - Increased P50 value - Increased 2,3-DPG
How can aerosolized medications be administered to mechanically ventilated patients?
- SVN - USN - pMDI with a third part adaptor - VM
Sats Vs. Stats
- Sats: O2 SATURATION - Stats: Vital STATISTICS
Steps to cylinder use
- Secure the cylinder at the patients bedside - Crack open the cylinder to remove dust before attaching regulator - Choose the appropriate regulator and attach using wrench if necessary - Hook regulator up to chosen tubing - Set flow rate to physician's orders
Improving Communication
- Seek to relate to others, not control them - Don't interrupt - Active listening - Share rather than tell - Nonverbal techniques
Components of Communication
- Sender - Message - Channel - Receiver - Feedback
Minute Ventilation (VE)
- Set flow of inspired or expired gas L/min - VE = RR x VT - Normal VE is 5-10L/min.
Patient factors in selecting an O2 Therapy device
- Severity and cause of hypoxemia - Patient age group (Infant, child, adult) - Degree of consciousness and alertness - Stability of Minute Ventilation
Parts of a Venturi Mask
- Simple face mask - Large bore inhalation tube - Flow valves - Aerosol entrainment collar - Small bore tubing
Patient Placement and Transport
- Single occupancy room ideal, cohorting if necessary - Limit transport of patients with contagious diseases - During transport: patient needs to wear appropriate barrier protection (masks, gowns, impervious dressings) consistent with route and risk for transmission
Stamps on a gas cylinder indicate what?
- Size - Fill pressure - Gas - Manufacturer - Serial number
What are the 4 electrolytes found in blood plasma?
- Sodium (Na+) - Potassium (K+) - Chloride (Cl-) - Bicarbonate (HCO3-)
3 Elements necessary for an infection to spread:
- Source of pathogens - Susceptible host - Route of transmission
What are the two types of non-invasive ventilation with which aerosol therapy can be administered?
- Standard bi-level ventilators - High flow nasal cannula
3-Fold Force Behind Civil Law
- State statutes regulate individual conduct - State statutes and regulatory boards regulate practice, set minimum standards for competence and requirements for continuing education - Common law of civil liberty for negligent and intentional acts imposes a duty to pay compensation to individuals who are injured
What factors determine airway size?
- Structural support (cartilage) - Transmural Pressure Gradient (Ptm)
Gas Law Variables
- T= Temp - P= Pressure - V= Volume
Symptoms of Carbon Monoxide (CO) poisoning
- Tachycardia - Tachypnea - Confusion - Nausea
Clinical manifestations/indications of Acute Alveolar Hyperinflation (Resp. Alkalosis):
- Tachypnea - Dizziness - Diaphoresis - Parasyjesoa - Muscle spasm
Four classic vital signs
- Temerature - Pulse - Respirations - Blood Pressure
Factors affecting pMDI performance:
- Temperature - Nozzle size and cleanliness (debris/buildup) - Priming - Timing of actuation intervals
Principles governing Humidity Function:
- Temperature - Surface Area - Contact Time
Examination of the eyes includes
- Testing pupillary reflexes (indicates neurological damage) - Ptosis? (indicates neuromuscular condition)
Gas diffuses across what two membranes in the process of respiration?
- The Alveolar-Capillary Membrane - RBC Membrane
Aerosol aging depends on:
- The chemical composition of the aerosol - The initial size of the particles - Ambient conditions
Particle size generated by an aerosol is dependent on:
- The substance or drug being nebulized - The method of delivery - Environmental conditions (relative humidity)
What regional distribution factors interact with gravity?
- Thoracic Expansion: The shape of the lungs and muscle action causes greater expansion and gas flow at the bases - Transpulmonary Pressure (Pl) Gradients at the apices and bases - Local CL and Raw contributing to the Time Constant
LOC is measured by orientation to:
- Time - Place - Person If aware of all 3, considered Oriented x3
What are the two components of resistance?
- Tissue Viscous Resistance (20%) - Airway Resistance/Raw (80%)
Breath Sounds
- Tracheal - Vesicular - Bronchial
Disaster Preparedness
- Transferring critically ill patients - Being ready for power outages
How can secondhand aerosol generation be prevented?
- Use of one-way valves or filters - Negative pressure rooms or treatment booths - PPE
Bulk Oxygen
- Used to meet large O2 needs for large medical facilities - Systems can old up to 20,000 cubic feet of O2 - Stored in gaseous or liquid form
Advantages of a Transtracheal Catheter:
- Uses 40-60% less O2 to achieve the same PaO2 by cannula - Can easily be hidden
Effects of high current exposure
- V-fib - Diaphragm dysfunction - Death
Causes of Hypoxemia
- V/Q MISMATCH!!!! - Hypoventilation (Resp Acidosis) - Pulmonary shunting - Diffusion deficit - Breathing gas with a low PiO2
Describe the changes in pressure on inspiration:
- When inspiratory muscles of the thorax begin inhalation, negative Transpulmonary Pressure (PL) on the alveoli increases, causing them to expand - Alveolar expansion decreases until their pressure reaches zero, at which point Transpulmonary Pressure (Ptaw) becomes completely negative and air is sucked into the alveoli - Alveolar filling slows as their pressure (PA) approaches the pressure at the airway opening (Pao) - End-inspiration occurs when PA=Pao, and Ptaw reaches zero again
When would Capnography be indicated for monitoring a patient?
- While under general anesthesia - During mechanical ventilation - During extubation or resuscitation
The calculation of BE requires measurements of:
- pH - PaCO2 - HCO3- - Hb
What values are assessed in a blood gas?
- pH - PaCO2 - PaO2 - HCO3- - BE
What 3 factors have the greatest effect on O2 loading and unloading?
- pH - Temperature - 2,3-DPG
What is the average pleural pressure on inspiration?
-10 cm/H20
At what temperature does liquid O2 boil?
-183 degrees Celsius
What is the temperature of absolute zero (Zero Point)?
-273C or 0K
What is average pleural pressure on end exhalation?
-5 cm/H20
RT's of the future will be focusing on:
-Prevention -Protocol administration -Patient assessment and care plan development -Disease management/rehabilitation -Family and patient education -Tobacco cessation counseling
How long does it take pulmonary blood exposed to alveolar gas take to diffuse to equilibrium?
.25 or 1/4th of a second
How long is pulmonary blood exposed to alveolar gas (time available for gas exchange) during exercise?
.25 or 1/4th of a second
Tank Factor for an E Tank
.28
At what size are particles so stable they can be exhaled?
.5-1um
Particles less than ______-um have the greatest retention rate in the lungs
.5um
How long is pulmonary blood exposed to alveolar gas (time available for gas exchange) at rest?
.75 or 3/4 of a second
Intimate Space
0-2ft from patient. Used during physical examination
What is the normal value for System Compliance (Csys)?
0.1 L/cm H2O
What is the average Lung Compliance (CL) in a healthy lung and chest wall?
0.2 L/cm H20
What is the normal range for VD/VT?
0.2-0.4, 20-40%
How much O2 is dissolved in the bloodstream in room air at 1 ATM?
0.3 ml/dL
What is the normal range for Raw in healthy lungs?
0.5-2.5 cm H2O L/Sec
What is the Respiratory Coefficient/Respiratory Exchange Ratio?
0.8
Isotonic Saline
0.9% NaCl
An E Cylinder with a flow rate of 10l lasts approximately how long?
1 Hour
Position of pins on an E Cylinder for medical air
1 and 5 Position
For every pound of IBW, there is _____ ml of Anatomic Dead Space
1 mL
_____ to _____% of any inhaled drug is exhaled
1 to 5%
When PaO2 drops from 100-90, there is a ____% decrease in SaO2
1%
Sections of an EMR
1. Admission data 2. Physical exam and patient history 3. Health maintenance/Immunizations 4. Physicians orders 5. Progress notes 6. Nurses notes 7. Medication record 8. Allergies 9. Vital signs flowsheet 10. Urine I/O 11. Lab results 12. Consultation notes. 13. Surgical/Treatment consent 14. Anesthesia and surgical record 15. Specialized therapy record 16. Specialized flow data 17. Advance directive
Describe the 3 steps to Acid-Base Assessment:
1. Assess pH 2. Identify if respiratory or metabolic 3. If compensated, determine the degree
5 Stages of Patient Interaction
1. Chart review/Pre-interaction 2. Introductory stage 3. Initial assessment 4. Treatment and monitoring 5. Follow-up
Name the 3 Laws of Thermodynamics
1. Energy is neither created nor destroyed 2. Entropy in any system is constantly increasing 3. At Absolute Zero, the molecular movement ceases entirely (theoretical)
Describe the 4 steps to Oxygenation Assessment:
1. Identify whether PaO2 is within normal range. If hypoxemia is present (PaO2 < 80 mmHg) and determine its cause 2. Identify Hb saturation (SaO2) and if it is within normal range. Obtain information from CO-ox about abnormal hemoglobins if present 3. Identify CaO2 from CO-ox and Hb concentration from a CBC 4. Assess the adequacy of circulation though BP, palpation of extremities, temp and capillary refill
What are the 5 main areas of ventilation?
1. Mechanics of Ventilation 2. Mechanics of Expiration 3. Work of Breathing (WOB) 4. Distribution of Ventilation 5. Efficiency and Effectiveness of Ventilation
A gram of Hb can bind to ______mL of O2
1.34 mL
Each gram of normal Hb can bind to _____mL of O2
1.34 mL
Density of O2
1.429 g/L
An H Cylinder with a flow rate of 10l lasts approximately how long?
10 Hours
A _____% increase in PEFR after the first hour of CBT is considered to be a positive response
10%
O2 Consumption and CO2 production increases by _____% for each degree celsius elevation in the body
10%. Temp of 100.6 means there is a 20% increase
Pulmonary deposition range for a pMDI?
10-20%
What is the % FiO2 in tubing connected to a flow filter?
100% before filtered through the valve to desired FiO2 and flow
What is the maximum number of Albuterol puffs that can be taken on an MDI?
12 Puffs max
How many mmol of acid does the average adult produce a day?
12,000 mmol
Normal values for: Sodium (Na+)
135-145
RC in the Rennaissance
14th-15th Century period of scientific and artistic advancement
Flush Rate on a nonrebreather mask
15 L/min. Default level for administering O2 to a noncritical patient
Due to its rich color, methemoglobin levels of _______% or less can cause cyanosis
15% or less
Absolute Humidity range of a Bubble Humidifier
15-20 mg
What is the normal atmospheric PaO2?
159 mmHg
The O2 Cascade moves downward stepwise from an atmospheric pressure of ________ to an intracellular pressure of ________
159 mmHg, 5 mmHg
Reducing the radius of an airway by half increases resistance by ________ the original amount
16 times
PO2 at normal pressure is ________ mmHg
160 mmHg
Spallanzani
17th century. Described tissue respiration
First measurement of lungs Residual Volume in (year)
1800
Spirometer and Ether Anesthesia developed in (year)
1846
Oxygen Tents and Masks Developed in (year)
1910's
Oxygen Therapy began to be prescribed in (year)
1940's
What is the ideal V/Q ratio and why?
1:1, where V and Q are in perfect balance
The ideal Inspiration to Expiration (I:E) ratio is?
1:2 or 1:3
In COPD patients, I:E Ratio ranges from...?
1:5 - 1:10
Position of pins on an E Cylinder for O2
2 and 5 Position
Only _____% of healthcare costs are related to negligence
2%
What chemical is lost in blood stored for transfusion?
2,3- DPG
Personal Space
2-4ft from patient. Used during the interview
pMDI's produce aerosols in what size range?
2-6um (respirable range)
1L of liquid O2 weighs _______ lbs and produces _______ L of gaseous O2
2.15 Lbs, 860 L
1lb = ______ kg's
2.2kgs
Tank Factor for a G Tank
2.41
Perfusion is _________ times greater at the bases
20 Times
CO has ________ times the affinity for Hb than O2
200 Times
What is normal Resting CO2 Production (VCO2)
200 mL/min
Standard psi for a full tank without a + sign?
2015 psi
What is the normal pH ratio of HCO3- to dissolved CO2?
20:1
FiO2 of room air
21%
At what temperature does water boil?
212 degrees Fahrenheit
Normal values for: Bicarbonate (HCO3-)
22-26
Standard psi for a full tank with a + sign?
2200 psi
Half life of 100% O2 in a HBOT at 3 ATM
23 Minutes
_____% of patients on mechanical ventilation develop VAP. Of those patients, _____% will die
25%, 30%
An unheated large volume jet neb produces how much humidity?
26-35 mg H2O/L
The right lung has ______ lobes, the left lung has ______ lobes.
3, 2
Tank Factor for an H/K Tank
3.14
Normal values for: Potassium (K+)
3.5-5
Normal Potassium Levels
3.5-5 mg/dL
How long does thorough education of a pMDI take?
30 Min
A blood pressure of less than ______ indicates a poor peripheral pulse
30 mm Hg
Ideal partial pressure for the immune system?
30 mm Hg
Associates, Bachelors and Masters RC Programs
300 Assoc, 50 Bach, 3 Masters
Ideal humidification level for intubated patients?
30mg/L. Passover humidifiers and HME's achieve this level. Bubble humidifiers are inappropriate
Heating system temperature range:
35-39 degrees Celsius. Ideal is 37 C or room temp
Normal lab values for PaCO2
35-45 mm Hg
A heated large volume jet neb produces how much humidity?
35-55 mg H2O/L
Normal adult temperature Celsius
37 C, ranges from 26.1-37.9 C
Humidification is ALWAYS required for nasal cannula flows greater than or equal to _______ l/min
4 l/min
FiO2 increases by ______% per liter of O2 administered
4% 1 L= 24% 2 L= 28% 3 L= 32% 4 L= 36%
____% of patients develop HAI's. ____ Million infections per year
4, 1.4 million
Social Space
4-12ft from patient. Used in initial introduction
Humidity above _____ mg/L can causes mucosal dysfunction and infection
40 mg/L
FRC occurs at ______% of TLC. This means that after, FRC ______% of TLC remains
40%, 60%
Inspiratory Flow Rate range for use of a DPI?
40-60%
What is the saturation/carrying capacity of water vapor at sea level room temperature?
43.8 mg/L at 760 mm Hg pressure in 37 degrees Celcius
Air at 1 atmosphere holds ______ mg of water per 1 L of air
43.8mg
What is the total quantity of anion buffers in arterial blood?
45-50 mEq/L, or approximately twice HCO3-
What is Water Vapor Pressure at sea level room temperature?
47 mm Hg
How far should pMDI's be held from the mount when not using a spacer or holding chamber?
4cm
Hippocrates
4th century BC Greek physician/ father of medicine. Called for physicians to follow ethical principles. Stated that air contains an essential substance (Oxygen)
Erasistratus
4th century BC philosopher/ father of physiology. Developed Pneumatic Theory of Respiration in Egypt
Aristotle
4th century BC philosopher/ first great biologist. Knowledge gained by observation
Galen
4th century anatomist. Believed air contains a substance vital to live and charges blood
Blood has a viscosity ______ times greater than water
5
Half life of room air and Carbon Monoxide
5 Hrs
Smokers typically exhibit a COHb level between _______ and _____%
5 and 10%
What is the normal arteriovenous difference?
5 mL/dL
What is the normal intracellular PaO2?
5 mmHg
If PaO2 is greater than ______ times the O2%, the results are suspect
5 times
Normal OCB is less than _______-% of total body O2 consumption
5%
Normal Minute Ventilation (VE) range
5-10 L/min
Normal VE range
5-10 L/min
In patients with a normal Hb content, if SaO2 drops below 80% (PaO2 of ______ mmHg), __________ ensues
50 mmHg, Cyanosis
Working Pressure
50 psi
From 1980-2010 the rate of fires in healthcare settings decreased by ______%, largely due to __________ and _________
50%, education and fire code enforcement
Standard PSI for an O2 wall outlet
50psi
What is the pH range that is compatible with life?
6.80-7.80
The goal with every patient is to keep their SaO2 at or above 90%, which corresponds to a PaO2 of _______ mmHg or higher
60 mmHg
At a VD/VT of ___%, it becomes difficult to wean off of mechanical ventilation
60%
FiO2 over _______% over longer than _______ hours can cause oxygen toxicity
60%, 72 hours
Normal adult pulse range
60-100 bpm
PN2 at normal pressure is ________ mm Hg
600 mm Hg
At 3 ATM, oxygenation of the bloodstream and tissues increases to
7 ml/dL
How long does it take for anoxic brain death to occur?
7-8 Minutes without O2
Normal lab values for Ph
7.35-7.45 < 7.35 is Acidotic/High CO2 > 7.45 is Alkalotic/Low CO2
A ratio of 20:1 will produce a pH of _________
7.40
An HME delivers ______% of the heat and humidity of each breath
70%
Blood that is stored for transfusion longer than 1 week looses _______% of its 2,3-DPG
70%
1 Atmosphere=?
760 mm Hg, or Sea Level
Atmospheric pressure at sea level
760 mmHg
What is the pressure of alveoli when not inhaling or exhaling?
760 mmHg (Atmospheric)
Composition of Air
78% nitrogen, 21% oxygen, 1% trace gases
Anion Gap Range + Indications
8-16 mEq/L.
Half life of 100% O2
80 Minutes
Hypoxemia is any PaO2 below _______, an SaO2 of ________%
80 mmHg, 94%
What percentage of a drug in a pMDI is deposited into the oropharynx upon actuation?
80%
Normal lab values for PaO2
80-100 mm Hg
What is the normal Anion Gap range?
9-14 mEq/L
Normal newborn pulse range
90-170 bpm
An SpO2 between __________ and _________% has been shown to reduce the risk of ROP
93-95%
Normal values for: Chloride (Cl-)
98-105
Normal adult temperature Farenheit
98.6 F, ranges from 97-99.5 F
Body temperature
98.6 ºF or 37 ºC
FDA Standards of purity for O2 and CO2
99% Pure
Hyperventilation occurs when PaCO2 is less than _______ mm Hg
< 35 mm Hg. O2 goes up, CO2 goes down
Hypoventilation occurs when PaCO2 is more than _______ mm Hg
> 45 mmHg. CO2 goes up, O2 goes down
Spacer
A VALVELESS extension device that adds distance between the pMDI outlet and the patient's mouth
Pulmonary Embolism
A blood clot that breaks off from a large vein and travels to the blood vessels of the lung, causing obstruction of blood flow.
Cyanosis
A bluish discoloration of the skin and mucous membranes due to a lack of oxygen int he blood/Hypoxemia
Cyanosis
A bluish discoloration of the skin resulting from poor circulation or inadequate oxygenation of the blood.
Air Emboli
A bubble of air in the bloodstream which can lead to cardiac arrest if it enters the heart.
Endotracheal Tube
A catheter inserted into the trachea to provide or protect an airway
Indwelling Catheter (A-Line)
A catheter that stays in the bladder for a period of time. Used when frequent blood sampling is required, often in the ICU
2,3-Diphosphoglycerate (2,3-DPG)
A chemical in RBC's that decreases hemoglobin's affinity for O2. Promotes UNloading
Any primary disturbance immediately triggers what?
A compensatory response
Emphysema
A condition in which the air sacs/alveoli of the lungs are hyperinflated. Causes air trapping and breathlessness. Destroys the elasticity of the lungs
Absolute Humidity
A direct measurement of the mass/weight of water vapor content in the air (in mg/L). Varies with temperature and pressure
Polycythemia
A disorder characterized by an abnormal increase in the number of RBC's in the blood. Causes the heart to use more energy pumping viscous blood. Often seen in smokers
Living Will
A document that indicates what medical intervention an individual wants if he or she becomes incapable of expressing those wishes
Orifice
A drilled opening in a flowmeter whose size/width sets the flow rate per minute
Respiratory Acidosis
A drop in blood pH (ACIDIC) due to hypoventilation (too little breathing) and a resulting accumulation of Co2
Venturi Mask
A face mask and reservoir bag device that delivers specific concentrations of FiO2 (oxygen mixed with air)
Non-Rebreather Mask (NRB)
A facial mask with a one-way valve and reservoir bag attached. Delivers the highest levels of FiO2 in a short period. Valves open on inhalation and shut on exhalation so that CO2 is not recycled into the reservoir bag. Must be run at a flow of 15 L/min to keep bag partially inflated
Negligent Torts
A failure to perform ones duty competently, or to perform duty at all. An action that unintentionally causes harm, or the absence of an expected action that prevents harm
Resistance
A force preventing the lungs from inflating. Could be airway constriction, spasm or a blockage
Hypercholremic Metabolic Acidosis
A form of metabolic acidosis associated with a normal anion gap where a loss of HCO3- is offset by an increase in Cl-
Interpretation of normal breath sounds:
A good exchange of gases in the lung tissue at all levels
Dry Powder Inhaler (DPI)
A handheld breath actuated aerosol device that delivers a finely milled drug powder into the lungs
Venturi (Venti) Mask
A high flow face mask that delivers specific concentrations of oxygen by mixing 100% O2 with inhaled air. Includes filters with specific FiO2 and flow levels. Achieves the most accurate FiO2
Respiratory Syncytial Virus (RSV)
A highly contagious airborne droplet virus that causes an infection of the lungs and breathing passages. Can lead to as bronchiolitis and pneumonia
Transtracheal Catheter
A hollow tube inserted by a physician within the trachea to deliver oxygen directly to the trachea. Delivers flow rates of 0.25-4 L/min. Uses 40-60% less O2 to achieve the same PaO2 by cannula, but more invasive
Anion Gap
A lab value differentiates between Metabolic Acidosis due to an increase in acids vs. a loss of base. The difference between the concentration of the major serum cations and anions
Durable Power of Attorney (POA)
A legal document that appoints another person to make decisions regarding health care if they become unable to make the decisions
Freezing
A liquid to solid phase change
Pulmonary Surfactant
A lubricating fluid at the liquid-gas interface of alveoli that reduces their surface tension so that alveoli can expand
Level of Consciousness (LOC)
A measure of cerebral oxygenation ranging from awake and alter to comatose
Entropy
A measure of disorder or randomness within a system. All closed systems tend towards disorganization
Spirometry
A measurement of breathing or lung volumes
Closed Arterial Line Sampling
A method of obtaining an ABG sample through a reservoir syringe that collects the sample, and then flushes the remaining blood back to the patient. Closed system reduces central line contamination and conserves the patients blood
Physically Dissolved O2
A minimal amount of gaseous O2 enters the blood and dissolves
Transitional Flow
A mixture of laminar and turbulent flow found in the trachea before the carina
Small Particle Aerosol Generator (SPAG)
A nebulizer designed specifically for administration of Ribavirin which incorporates drying chamber with its own flow control to produce stable aerosol - Concerns include caregiver exposure to drug and drug precipitation can jam breathing valves in mechanical ventilator circuit
Intermittent Positive Pressure Breathing (IPPB) Machine
A nebulizer that can deliver aerosolized medications to patients receiving mechanical ventilation
Ultrasonic Nebulizer (USN)
A nebulizer that uses piezoelectric crystals to vibrate at varying frequencies which determine particle size. Runs from .2-1 ml/min. Ideal for vented patients because it doesn't add to O2 volume
Pulse-Oximetry
A noninvasive technique for measuring SpO2 and Hb in the blood through light absorption. Typically accurate within 2% of oxygen saturations greater than 90%. For less than 90% saturation, CO-oximetry should be performed for accurate results
Breath Actuated pMDI
A pMDI that is trigger activated to deliver a drug upon inhalation. Reduces the need for coordination
Heat Moisture Exchanger (HME)
A passive humidifier that traps heat and moisture that naturally comes from the patient upon expiration and delivers the moisture and heat back to the patient on inspiration. Also called an artificial nose or filter. Used short term on vents and is attached to the circuit
Chronic Obstructive Pulmonary Disease (COPD)
A permanent, destructive pulmonary disorder that is a combination of chronic bronchitis and emphysema
Metabolic Acidosis
A primary decrease in HCO3- (<22 mEq/L) that causes a decreased pH. A net gain in fixed blood acids or excessive reduction in base. Lower pH, normal PaCO2, lower HCO3-
Metabolic Alkalosis
A primary increase in HCO3- (>26 mEq/L) that causes an increased pH. A net gain of buffer base or loss in fixed acids. Elevated pH, normal PaCO2, Elevated HCO3-
What would be indicated by identical values for CvO2 and CaO2?
A problem with diffusion of O2 at the tissue level
Relative Humidity (RH)
A relative percentage of the carrying capacity describing the ratio of actual water vapor content to saturated/carrying capacity (43.8 mg/L) at a given temp
Simple Reservoir Mask
A reservoir of oxygen without a bag. A low flow mask designed to fit over the patient's nose and mouth. Must have a flow rate of at LEAST 5 L/min to flush CO2 out with expiration
Bubble Humidifier
A reservoir of unheated water that connects to a flowmeter that breaks an underwater gas stream into bubbles. - Raises the water vapor content of flush o2 to ambient levels - Absolute humidity range is 15-20 mg - Attaches to nasal cannulas
Respiratory Alkalosis
A rise in blood pH (BASIC) due to hyperventilation (excessive breathing) and a resulting decrease in CO2
Partial Rebreather Mask
A simple mask with a reservoir bag that does not have a valve. No valve means that CO2 is being recycled with each breath. a flow rate of 6-10 L/min. If bag is deflated, the patient is breathing large amounts of exhaled carbon dioxide
Melting
A solid to liquid phase change
What patient adaptor delivers the most nebulized medication?
A standard mouthpiece
Hydrochloric Acid (HCI)
A strong acid produced in the stomach that aids in digestion. Used in the treatment of Metabolic Alkalosis to add acids back into the body and bring pH back down
Aerosol
A suspension of solid or liquid particles in a gas
Acute Chest Syndrome (ACS)
A symptom associated with Sickle Cell Anemia where sickle Hb cells get trapped in the lung and cause infection. The most common cause of death in Sickle Cell Anemia patients
Pursed-Lip Breathing (PLB)
A technique of exhaling against pursed lips to prolong exhalation. Prevents bronchiolar collapse, early airway closure and air trapping by increasing expiratory airway pressure
Evaporation/Vaporization
A the change of state from a liquid to a gas when water enters the atmosphereat a temperature below its boiling point. Heat is pulled from the air surrounding the liquid, cooling the air
Failure for the respiratory system to compensate appropriately for Metabolic Acidosis indicates what?
A ventilatory deficit
P2
A very loud S2 sound that indicates Pulmonary Hypertension. Common in COPD patients with chronic hypoxemia
Jugular Vein Distention (JVD)
A visual bulging of the jugular veins in the neck. Indicates right heart failure, fluid overload, cardiac tamponade, or tension pneumothorax
Carbonic Acid (H2CO3)
A weak but volatile acid formed CO2 dissolves in water under pressure. Keeps in equilibrium with PaCO2
Intentional Torts
A willful act violating another's best interest
Ohm's law
A=V/Omega A= Current amps, V= Voltage, Omega= Resistance in Ohms
What key respiratory test is done aerobically?
ABG's
Anion Gap Formula
AG= Na - (Cl + HCO3)
Corresponding safety system for an H Cylinder
ASSS
Pleural Effusion
Abnormal accumulation of fluid in the pleural space (not lungs)
Acidemia/Acidosis
Abnormal acidity of the blood indicated by a pH <7.35 - Indicates: The body is buffering acids better than bases/Abnormally high H+ - Effects: CNS depression, lethargy, decrease in myocardial contractility and Qt, reduced blood flow
Alkalemia/Alkalosis
Abnormal alkalinity of the blood indicated by a pH >7.45 - Indicates: The body is buffering bases better than acids/Abnormally low H+ - Effects: Overexcitement of the CNS and peripheral nerves, muscle spasms and cardiac dysrhythmias
Methemoglobinemia
Abnormal hemoglobin that is altered and cannot accept oxygen builds up in the blood, hindering the effective transport of oxygen to body tissues
MetHb (Methemoglobinemia)
Abnormal iron molecules cannot bind with O2 and alters its affinity to Hb. Most commonly seen in patients receiving Nitric Oxide (NO) therapy, Nitroglycerin or Lidocaine
Scoliosis
Abnormal lateral curvature of the spine
Adventitious Lung Sounds (ALS)
Abnormal lung sounds including: - Crackles (Rales) - Rhonchi - Wheezes - Stridor
Hyperoxemia
Abnormally high PO2 values. Causes Retinopathy of Prematurity (ROP) in infants
Apnea
Absence of spontaneous ventilation
Anemia demonstrates _____________ Hb Deficiency
Absolute
Iatrogenic
Accidental SE produced by treatment of a medical condition
Ascites
Accumulation of fluid in the peritoneal (abdominal) cavity. Negatively influences breathing. Related to liver or kidney failure
Plaintiff vs. Defendant
Accuser vs. Accused
CO2 functions chemically as an ________, HCO3- functions chemically as a ___________
Acid, Base
Respiratory Acidosis
Acidemia due to high H+ and increased PaCO2 (Hypercapnia + Hypoventilation). Inadequate ventilation relative to the rate of CO2 production. Elevated PaCO2 reduces pH, normal HCO3-
A decreased pH ratio <20:1 indicates what imbalance?
Acidosis
Decreased drive to breath is associated with __________. Increased drive to breathe is associated with
Acidosis, Alkalosis
Autonomy
Acknowledges patients personal liberty and their right to decide freely on their own course of treatment. The basis for informed consent
Community Onset Infection
Acquired outside a health care setting
Universal Precautions
Actions taken to prevent the spread of disease by treating all blood and other body fluids as if they contained pathogens
Respiratory Alkalosis is known clinically as:
Acute Alveolar Hyperinflation
What can develop in patients with limited respiratory function with a fever?
Acute Respiratory Dailure
Respiratory Rate is a sensitive marker of:
Acute Respiratory Distress
Respiratory Acidosis is known clinically as what?
Acute Ventilatory Failure. Sometimes called Uncompensated Respiratory Acidosis
Cardiac Tamponade
Acute compression of the heart caused by fluid accumulation in the pericardial cavity
Calibration
Adjustment of blood gas analyzing equipment to ensure proper function and accurate readings. Involves exposing the analyzer to calibration media, regular inspections and lab quality control measures
Nitric Oxide (NO) Therapy
Administration of NO gas mixed with O2 to relax blood vessels and improve circulation
The principle of beneficence led to the development of _________
Advance Directives
Scales must be ________ appropriate and regularly _________
Age, calibrated
Need for RT's increasing due to
Aging baby boomer population increases the number of elderly and those with COPD, asthma and a history of smoking. Increasing advances in technology
Principle of Utility
Aims to promote acts that will result in the most good for the most people
A smaller point of constricton means there there is more ___________________
Air entrainment
At the very least, wheezing indicates ____________
Air flow
Pneumatic Theory of Respiration
Air/ pneuma enters the lungs and goes to the heart
Raw
Airway Resistance/The change in pressure over flow
Respiratory Alkalosis
Alkalemia due to low H+ and decreases PaCO2 (Hypocapnia + Hyperventilation). Excessive ventilation relative to the rate of CO2 production. Reduced PaCO2 elevates pH, normal HCO3-
An increased pH ratio indicates ________________. A decreased pH ratio indicates ______________
Alkalemia, Acidemia
An increased pH ratio >20:1 indicates what imbalance?
Alkalosis
As surface tension increases, inward pressure of a bubble _________
Also increases
Capnograph
Also known as an end-tidal CO2 monitor. A monitoring device based on CO2 absorption of light in the infrared spectrum
Hyperchloremic Acidosis
Also known as normal anion gap acidosis; metabolic acidosis that results from the direct loss of HCO3- and an increase in Cl
Respiratory Alkalosis is also called what?
Alveolar Hyperventilation
Respiratory Acidosis is also called what?
Alveolar Hypoventilation
VA
Alveolar Ventilation
What is the primary determinant of PACO2?
Alveolar Ventilation (VA)
Absorption Atelectasis
Alveolar collapse that occurs when high concentrations of oxygen are given and O2 replaces Nitrogen in the alveoli
Alveolar Dead Space (VDalv)
Alveoli that cease to act in gas exchange due to collapse or obstruction
Residual Volume (RV)
Amount of air remaining in the lungs after a forced exhalation
Drive Pressure
Amount of pressure required to move air into and out of the lungs
What is required for accurate assessment of acid-base balance?
An ABG
High-Output Extended Aerosol Respiratory Therapy (HEART) Continuous Nebulizer
An LVN that provides CBT commonly used in the emergency department
Methemoglobinemia
An abnormal form of hemoglobin produced by toxic Nitric Oxide exposure. Causes tissue hypoxia
Methemoglobin (MetHb)
An abnormal form of hemoglobin that has been oxidized from its normal ferrous (Fe2+) to a ferric (Fe3+) state, which cannot bind with O2
Dysoxia
An abnormal metabolic state in which DO2 is normal but cells cant utilize or take up O2 (O2 can't unload). Ex: Cyanide poisoning.
What is the greatest hazard of aerosol therapy?
An adverse reaction to the medication
Ribarivin
An antiviral drug used with a SPAG to treat Respiratory Syncytial Virus (RSV) infections via nasal and oral inhalation
Atomizer
An apparatus for reducing a liquid to a fine spray, as for disinfection, inhalation, etc.
Ultrasonic Nebulizer (USN)
An electrically powered device that uses a piezoelectric crystal to convert high frequency radio waves into mechanical vibrations that produce an aerosol without adding air.
Code of Ethics
An essential part of any profession claiming to be self regulating. Seeks to establish parameters of behavior for members of a profession. Establishes legitimacy
Informed Consent
An ethical principle requiring that patients be given enough information to choose whether they wish to undergo a treatment or procedure
Hypercapnia/Hypercarbia
An excessively high level of CO2 in the blood. Due to obstructive respiratory disorders like COPD that make it difficult to exhale
What causes sublimation?
An extremely low vapor pressure
What causes a HIGH anion gap in Metabolic Acidosis?
An increase in fixed acids
Upper Airway Obstruction
An interference with air movement through the upper airway. Ex: Croup, Epiglottitis
Turbulent Flow
An irregular, mixing flow pattern from high flow rates
A/P Diameter
Anterior to posterior chest diameter. Increased diameter = Barrel Chest
Dyshemoglobins
Any abnormal form of hemoglobin, including COHb or MetHb
Impaired CO2 Removal is caused by what?
Any disorder that decreased alveolar ventilation (VA) relative to metabolic needs. Ex: Drug overdose
Causes of Metabolic Alkalosis
Any process that causes an increase in HCO3- or a loss of fixed acids. Includes: - Severe Vomiting - Excessive GI Suctioning - Diuretics - Excessive NaHCO3
Causes of Respiratory Alkalosis
Any process that increases VA so that CO2 is eliminated too quickly. Includes: - HYPOXEMIA** - Anxiety - Fever - Pain
Fomites
Any substance or inanimate object that transmits infectious material
Hypotonic Saline
Anything less than 0.9% NaCl. Drys out airways
Hypertonic Saline
Anything more than 0.9% NaCl (Usually 2-3%). Induces a sputum sample by moistening secretions for expectoration
Causes of Respiratory Acidosis
Anything that results in a VA that fails to blow off CO2 compared to VCO2 including: - CNS Depression - Neuromuscular Disorders - Trauma - Acute Obstruction - COPD - Restrictive Disorders
Standard/Universal Precautions
Applies to all secretions, excretions, non-intact skin and all other bodily fluids (except sweat),, treating them as if they carry transmittable infections. Protects physicians, patients and visitors
Room temperature
Approximately 70 ºF or 20-23 ºC
Virtue Ethics
Aristotle. Founded in the personal attributes or character or virtue. Allows establishes practices of what a "good practitioner" would do to give guidance. Asks "How should i carry out my life if i am to live well?"
PaO2
Arterial O2 Pressure, 80-100 mmHg - Refers to: The lungs ability to transfer O2 from inspired gas into circulating blood - Depends on: Barometric pressure, O2 concentration and lung function
C(a-v)O2
Arteriovenous O2 content difference, usually 5 mL/dL
How are blood gas sampling and measurement approaches classified?
As invasive or noninvasive
When should ambulation begin?
As soon as the patient is stable and free from severe pain
Guillain-Barre Syndrome (GBS)
Ascending muscle weakness. Paralysis from the ground to the brain. Can limit breathing and require mechanical ventilation
How should patients on CBT for refractory bronchospasm be monitored?
Assess every 30 minutes for the first 2 hours, then only hourly
Chest Auscultation
Assessing heart and lung sounds perceived through a stethoscope
Role of Modern RT's
Assisting physicians in diagnostic reasoning, which requires critical thinking when evaluating patients
What is indicated if systolic BP drops below 10 mm Hg on inspiration?
Asthma or Pulsus Paradoxus/Cardiac tamponade
3rd Law of Thermodynamics
At Absolute Zero, the molecular movement ceases entirely (theoretical)
At what point in the HbO2 dissociation curve does SaO2 drop significantly?
At a PaO2 of <60
Where in the lungs is the transpulmonary (Pl) pressure gradient at its widest?
At the Apex
Are alveoli larger at the base of apex of the lung?
At the apex
In an upright lung, where are ventilation/perfusion (V/Q) ratios best matched?
At the bases
Unilateral thoracic expansion indicates
Atelectasis, Pneumonia or a lung tumor
Cohesion
Attraction between like molecules of the same substance
Adhesion
Attraction between unlike molecules of different substances
Exhalation is an _________ recoiling of the lungs after inspiration
Automatic
Compensatory Mechanisms
Automatic physical responses to physiological imbalances to maintain homeostasis
Economic Damages
Awarded for economic or monetary loss
Noneconomic Damages
Awarded for such losses as pain and suffering, disability, disfigurement or mental anguish
Punitive Damages
Awarded to punish wrongful conduct and deter future unlawful conduct
What ABG value provides a pure measurement of the buffering system/metabolic component of the body's acid-base balance?
BE
What part of a Jet Neb creates the aerosol mist?
Baffle
PB/Patm
Barometric/Atmospheric Pressure. Normal is 760 mmHg
A negative BE is also called what?
Base Deficit
BE
Base Excess. -2-+2 mEq/L
Pulsus Paradoxus/Kussmaul's Pulse
Beats have weaker amplitude with respiratory inspiration, stronger with expiration. Indicates that the heart is putting pressure on the lungs (Cardiac Tamponade)
Why might patients with a high COHb level (CO Poisoning) not exhibit cyanosis?
Because COHb is a bright red color
Why are apical alveoli harder to ventilate?
Because gravity pulls O2 and blood down to the base
Why does buoyancy occur and what does it do?
Because the pressure below a submerged object always exceeds the pressure above. Keeps particles suspended in a gas (aerosol)
Why can't SaO2 ever REALLY be 100%?
Because there will always be some abnormal or damaged Hb molecules
Why are Combined imbalances hard to identify?
Because they can be confused with secondary compensation for a primary disorder
Why are gases considered to be fluids?
Because they exhibit flow
Point of Care Analyzers (PCA)
Bedside machines that analyze a small amount of an ABG sample to provide immediate indications of acid-base balance while awaiting full lab results
The ______ is used to detect heart sounds, the ________ is used to detect lung sounds
Bell, Diaphragm
Hypothermia
Below normal body temperature (lower than 97F or 36C) as a result of cold exposure of a head injury
Normal thoracic expansion
Bilateral even chest expansion with regular or deep breathing
Hypotension
Blood pressure below 90/60 mm Hg. Causes dizziness, syncope, ventricular failure, blood loss and peripheral vasodilation
Hypertension
Blood pressure greater than 140/90 mm Hg. A major risk factor for liver or renal disease, stroke, CAD, CHF and peripheral vascular disease
Cyanosis
Bluish discoloration of the skin due to lack of oxygen
The Bronhcial and Thebesian Venous Drainage shunts have what in common?
Both drain poorly oxygenated blood into arterial circulation, lowering CaO2
Avoiding
Both parties refuse to pursue concerns
Movement of a liquid's atoms
Bouncy
The majority of O2 is __________ to Hb
Bound
Chemically Bound O2 Formula
Bound O2 = Hb x 1.34 x SaO2 Hb= Grams of Hemoglobin SaO2= % O2 saturation
All DPI's are ____________ devices
Breath Actuated
Documentation Flow Sheets
Briefly report data to decrease the amount of time spent on documentation
Bronchial Venous Drainage
Bronchial veins drain poorly oxygenated blood into the pulmonary vein
Heating systems are most effective on what types of humidifiers?
Bubble and Passover Humidifiers. Primarily used for patients with a bypassed airway
Why can it be dangerous to apply additional O2 to correct a slightly acidic pH in a COPD patient with high PaCO2?
By adding O2, PaCO2 will go down, but it will push their pH towards alkalotic. They are used to retaining the CO2, so higher levels are normal for them and not necessary to correct
How is the cause of Metabolic Acidosis determined?
By analyzing the Anion Gap
How are gas cylinders classified?
By color and shoulder stamps
How it methemoglobinemia detected?
By lab CO-oximetry or multi-wavelength Pulse Oximetry
How can Iatrogenic Alkalosis be prevented?
By putting initial ventilator settings to target a PaCO2 that is consistent with that patient's (elevated) "normal"
Frick's Equation
C(a-v)O2, The O2 content difference between arterial and venous blood
Lung Compliance (CL) Formula
CL= ∆P/∆V ∆P= Change in pressures ∆V= Change in volumes
COPD patients are often referred to as Chronic _______ Retainers
CO2
What is the byproduct of aerobic metabolism in respiration?
CO2
What drives Minute Ventilation (VE)?
CO2 Production and subject size
MetHb has the same effect as an absolute anemia, causing a reduction in _________
CaO2
What is the MOST reliable measurement of oxygenation?
CaO2
O2 delivery to the tissues depends on what two factors?
CaO2 and Cardiac Output
What is the single most important parameter that reflects the quantity of O2 in arterial blood? What concentration must be present for this parameter to be normal?
CaO2. Adequate Hb must be present
CaO2 (Total O2 Content) Formula
CaO2= (PaO2 x 0.003) + (Hb x 1.34 x SaO2) Hb= Grams of Hemoglobin SaO2= % O2 saturation PaO2= Pressure/Tension of Arterial O2
CaO2 Formula
CaO2= (PaO2 x 0.003) + (Hb x 1.34 x SaO2) Hb= Grams of Hemoglobin SaO2= % O2 saturation PaO2= Pressure/Tension of Arterial O2
CvO2 (Total Venous O2 Content) Formula
CaO2= (SvO2 x 0.003) + (Hb x 1.34 x PvO2) Hb= Grams of Hemoglobin SvO2= % Venous O2 saturation PvO2= Pressure/Tension of Venous O2
Compensatory Justice
Calls for the recovery of damages that were a result of the action of others or medical malpractice
Hazards of enclosures
Can lead to heat and CO2 buildup. Require high flows to lessen these effects
Increased CO2 produces what ion?
Carbonic Acid (H2CO3)
If VO2 is constant, changes in C(a-v)O2 are due to what?
Cardiac Output (Qt)
Qt
Cardiac Output, normal range 4-8 L/min, ideal is 5L/min
Hypotensive patients will need to have their pulse taken at either the _________ or _________ artery
Carotid, Femoral
What structures support airway size?
Cartilage in the trachea and traction from the surrounding tissues
Describe the set-up for an Indwelling Catheter/A-Line
Catheter is connected to a pressurized infusion set that incorporates a pressure transducer, flush device and sampling port that is accessed through a three-way stopcock or closed reservoir
Which ions are more numerous in the body: Cations or Anions?
Cations
Low CO2 levels cause vasoconstriction of ___________ blood vessels
Cerebral
Lung Compliance (CL)
Change in lung volume caused by a given change in transpulmonary pressure; the greater the lung compliance, the more readily the lungs are expanded
What type of patients would do better with a neb mask than standard mouthpiece?
Chatty patients or those who are sedated. Not quite as good deposition but better than nothing
Disinfection
Chemical or physical process used to destroy vegetative forms of microorganisms (except spores)
Chemoprofylaxis
Chemical prevention from contracting infection. EX: Alcohol wipes
What types of surgeries do most nosocomial pneumonias occur in and why?
Chest or abdominal. Patients cough less and take fewer deep breaths, allowing mucus and pathogens to remain in the body
Compensated Respiratory Alkalosis is referred to clinically as what?
Chronic Alveolar Hyperinflation
Compensated Respiratory Acidosis is also called what?
Chronic Ventilatory Failure
Compensated Respiratory Acidosis is referred to clinically as what?
Chronic Ventilatory Failure
What electrolyte tends to be inversely associated with HCO3-?
Cl
Steps in Specialized Equipment Processing
Cleaning, disinfection and sterilization
Surveillance
Close watch over patients, visitors and coworkers to prevent the spread of infectious pathogens
C. diff
Clostridium difficile. Disruption of healthy bacteria in the colon. Caused by spores that are very difficult to kill
Distal Clubbing
Clubbing of fingers related to chronic cardiopulmonary disease or hypoxemia
A positive Ptm means small airway ________
Collapse
Carbogen Therapy
Combination of O2 and CO2. Not commonly used
Criminal Malpractice
Combination of assault (intent to cause harm) and battery (physical action of harming). Exceptions include euthanasia/physician assisted suicide
A wildly unusual pH typically indicates what type of acid-base imbalance?
Combined
Mixed means what in blood gases?
Combined
Anesthetic Gases
Combined with oxygen to provide anesthesia during surgery
Bird Mark 7
Common positive pressure ventilator developed in 1958
Compensation Vs. Correction
Compensation occurs when the noncausative system responds to balance out another system's imbalance Vs. The causative system adjusts itself directly
Electronic Medical Record (EMR)
Computerized record of providing written information pertaining to a patient and their medical history. Represents a legal document
Civil Law
Concerned with protecting citizens from others who may seek to take unfair advantage (Law suits)
Criminal Law
Concerns actions against the welfare and safety of the public. Accuser is always the state
Administrative Law
Concerns regulations set by government agencies
O2 Toxicity
Condition of oxygen overdosage caused by prolonged exposure to high FiO2 levels that raise PaO2 to an abnormally high pressure. Determine factors are length of exposure time and level of FiO2
Harm Principle
Confidentiality can be broken after evaluating the information's vulnerable risk to others
Perception Checking
Confirming or disproving more subtle components of a communication interaction, such as in noncompliance
Rhonchi
Continuous Coarse, low pitched snoring or rumbling sounds heard over inspiration and expiration. Indicates bronchi obstructed by sputum or fluid secretions
Wheezes
Continuous high-pitched whistling or blustering sounds produced on expiration. Indicates air flowing through narrow passageways at high speeds/airway constriction
What type of aerosol drug delivery device produces the greatest amount of secondhand aerosol?
Continuous pneumatically powered nebulizers (SVN/LVN)
Abdominal Paradox
Contraction of accessory muscles to aid inspiratory effort. Diaphragm pulled upward and abdomen sinks inward during inspiration. Indicates fatigue of the diaphragm
Regulator
Controls both the pressure and flow to the patient. Combo of Flowmeter and Reducing Valve
Respiratory Droplets
Coughing, sneezing or speaking causes infected droplets to be propelled up to 3ft
Flow is a function of the patients ability to ________
Create sufficient Inspiratory Flow Rates
Respiratory Care Week
Created by president Reagan. Third week of October. Yearly promote to celebrate RT's and their contribution to the medical field. Highlights the importance of cardiopulmonary health
What happens when heart valves don't close at the same time? What does this indicate?
Creates a spitting sound that indicates a problem with the hearts electrical conduction system
Ethical standards can be used as tools for ____________ in a court of law
Cross examination
Why can't aerosols be administered to crying infants/children?
Crying reduces lower airway deposition
RC in Ancient Times
Cultures developed herbal remedies to combat disease
Peripheral vs. Central Cyanosis
Cyanosis of the extremities (fingertips/toes) vs. Cyanosis of the lips/nose (VERY serious)
Ventilation is ______
Cyclic
Corresponding safety system for a Cylinder Regulator
DISS
In sepsis or ARDS, O2 debt can occur at normal levels of _______ if dysoxia is present
DO2
DO2 Formula
DO2= CaO2 x Qt CaO2: O2 Content in Arterial Blood Qt: Cardiac Output
DO2 Formula
DO2= CaO2 x Qt CaO2= O2 Content in Arterial Blood. Qt= Cardiac Output
VD
Dead Space Volume per minute
Tort Law
Deals with civil wrongs committed against and individual or property for which the court provides remedy
Public Law
Deals with relationships between private parties and the government. Includes criminal law and administrative law
Orthostatic Hypotension
Decrease in blood pressure related to positional or postural changes from lying to sitting or standing positions
A right shift indicates what?
Decreased affinity for O2 loading at the lungs and increased CO2 unloading at the tissues
A normal PaCO2 with a reduced VE indicates what?
Decreased metabolic rate
Metabolic Acidosis
Decreased pH in blood and body tissues as a result of a metabolic imbalance. High acid concentration caused by an increase in hydrogen ions or a decrease in bicarbonate
Hypoventilation
Decreased rate and depth of breathing. Triggered by low CO2. Increases CO2 by retaining it in the lungs and limiting O2 consumption
As flow increases, absolute humidity ________
Decreases
What is the effect of Pulmonary Fibrosis on CL?
Decreases CL. Increase in elastic scar tissue that prevents the lungs from fully inflating
Kussmaul respiration (hyperpnea)
Deep and fast breathing. Indicates metabolic acidosis
Hypoxemia
Deficient amount of oxygen in the blood
Hypoxia
Deficient amount of oxygen to the tissues
Hypoxemia
Deficient oxygen in the blood, any PaO2 < 80 mmHg
Hyperbaric O2 Therapy (HBOT)
Delivery of O2 at increased atmospheric pressure in a controlled hyperbaric chamber, often (2-7 times greater than sea level)
Greatest risk in medical gas delivery and how it can be prevented
Delivery of the wrong gas to the patient. Can be prevented by carefully reading cylinders and their regulators
What is the role of Peak Flow Measurements in bronchodilator therapy protocol?
Demonstrates trends in patient response from one treatment to the next if the same device is being used repeatedly
Myathenia Gravis (MG)
Descending muscle weakness. Paralysis from the mind to the ground. Can limit breathing and require mechanical ventilation
Ventilation/Perfusion (V/Q) Ratio
Describes the dynamic relationship between the amount of ventilation the alveoli receive and the amount of perfusion through the capillaries surrounding the alveoli
Humidifier
Device that adds molecular water to gas by way of evaporation of water from a surface
Congenital Diaphragmatic Hernia
Diaphragm doesn't fully develop allowing abdominal organs to migrate into the chest cavity
Pulse Pressure (PP)
Difference between Systolic and diastolic pressure PP = SP - DP
Pulse Deficit
Difference between apical pulse (what you hear) and radial (what you palpate). Very uncommon
The combination of VS and other signs and symptoms are used to determine a ________
Differential diagnosis
What is the primary deposition mechanism for particles less than 3um?
Diffusion
What is the effect of increased interstitial space due to atelectasis on diffusion?
Diffusion is reduced
In a fraction, the sum and the numerator always have a _______ relationship, whereas the sum and the denominator always have an ____________ relationship
Direct, Indirect
Trends in pH and HCO3- are _________
Direct. A rise in pH will accompany a rise in HCO3-
Types of contact transmission
Direct: Person to person. Uncommon Indirect- Intermediate source (Fomites) to person. Most common
BE is reported as a positive of negative value depending on the __________ of buffer base deviation from normal
Direction
VO2 and Qt are ________ related
Directly
How can nebulized drugs enter the room?
Directly from the nebulizer or during patient exhalation
The P50 value is ________ related to temperature, and __________ to pH
Directly, Indirectly
A fluid's viscosity is ________ proportional to the cohesive forces between its molecules. The stronger the cohesive force, the more ______ a fluid is
Directly, Viscous
Numerator is always _________ related to the solution, and the denominator is always _________ related to the solution
Directly, indirectly
Strength of the current is ________ related to voltage, and __________ related to resistance
Directly, indirectly
Passover Humidifier
Directs a flow gas over the water surface. Only used with mechanical vents. Can be heated or unheated
Crackles (Rales)
Discontinuous popping sounds heard over inspiration. Indicates the movement of excessive excretions or the opening of a collapsed lung/alveoli suddenly popping open
How to clean a nebulizer:
Disinfect completely OR rinse with sterile water and air dry between uses
Ventricular Fibrillation
Disorganized, ineffective twitching of the ventricles, resulting in no blood flow and cardiac arrest. Defibrillation via electric shock is only treatment
Dissolved O2 Formula
Dissolved O2 (mL/dL)= PaO2 x 0.003 PaO2= Pressure/Tension of Arterial O2
Baffle
Divides the ambient/exhaled air from a nebulizer mouthpiece. Breaks up the liquid medication into aerosol particles
Advance Directive
Document in which an individual specifies what medical care they desire in the future if they are unable to make those decisions. Includes a living will and a durable power of attorney
Bigemy/Trigemy
Double or triple beats in a rhythm
In an artificial airway, the ISB moves further _______ the lungs
Down
Ptosis
Drooping eyelid
At higher elevations/lower pressure, partial pressure of O2 _______
Drops
When SaO2 drops, O2's affinity for binding to Hb ________
Drops
Problems with nonmaleficence occur when _________
Drugs have a double effect, such as chemotheraphy
Why do healthy lungs waste gas?
Due to anatomic and alveolar dead space
Why is Alveolar Ventilation (VA) ALWAYS less than Minute Ventilation (VE)?
Due to dead space
Why does WOB increase in Obstructive Diseases like Asthma?
Due to increased Raw. There is a high level of resistance breathing through lungs that cant push air back out
Why does WOB increase in Restrictive Diseases like Pulmonary Fibrosis?
Due to increased elastic recoil. Scar tissue builds up and makes it harder to achieve adequate CL after recoil
Why is PaO2 usually SLIGHTLY higher than PAO2?
Due to the presence of Anatomic Shunts
Labored Breathing
Dyspnea. Breathing that requires greater than normal effort and requires the use of accessory muscles
A normal PaCO2 with an elevated VE indicates what?
EITHER and increased metabolic rate (Ex: exercise) or increased Dead Space Ventilation
What does a negative BE indicate?
EITHER the presence of excess acid or an excessive loss of base
What does a positive BE indicate?
EITHER the presence of excess base or the excessive loss of acid
Whose job is it to actively work to eliminate and prevent HAI's
EVERYONE. Healthcare professionals are the biggest factor in the spread of infectious pathogens
The most important aspect of patient care
Effective communication
What two factors provide resistance to lung stretch/elasticity?
Elastic and Collagen Fibers
What is the hallmark of Partially Compensated Metabolic and Respiratory Alkalosis?
Elevated HCO3- and reduced PaCO2, which when combined dramatically increase pH
What is the hallmark of Partially Compensated Metabolic and Respiratory Acidosis?
Elevated PaCO2 and reduced HCO3-, which when combined dramatically reduce pH
Fever
Elevated body temperature due to a disease or infection (Over 99.5 F or 37.9 C). Body temperature increases so that the heat can kill bacteria
Hyperthermia
Elevated body temperature due to physical activity/exercise
Pulmonary Hypertension
Elevated pulmonary pressure resulting from an increase in pulmonary vascular resistance to blood flow through small arteries and arterioles
What lung disease causes poor bilateral thoracic expansion?
Emphysema
In increased A/P diameter (Barrel Chest) indicates:
Emphysema. Trapped air that cannot be expelled gradually changes the shape of the chest over many years. COPD also linked
1st Law of Thermodynamics
Energy is neither created nor destroyed
Hepatomegaly
Enlargement of the liver common in patients with Cor Pulmonale
3 Safety Index Connector Systems
Ensure that only the correct gas can be connected to its regulator - American Standard Safety System (ASSS) - Diameter-Index Safety System (DISS) - Pin-Index Safety System (PISS)
2nd Law of Thermodynamics
Entropy in any system is constantly increasing
Molecules at a liquid's surface have _______ pull in all directions EXCEPT above the surface
Equal
The tendency for lungs to collapse and for the chest wall to expand are _________ at FRC
Equal
Veracity
Ethical principle that binds both patients and physicians to be truthful with one another, maintaining an environment of trust and mutual sharing of information
Airborne Droplet Nuclei
Evaporated droplets containing microorganisms that remain suspended in the air for long periods of time. EX: Tuberculosis
Metabolic Alkalosis is caused by what?
Excess retained bicarbonate. High pH and high HCO3-
What causes a NORMAL anion gap in Metabolic Acidosis?
Excessive loss of HCO3-
Kyphosis
Excessive outward curvature of the spine, causing hunching of the back.
Hyperpnea
Excessively deep breathing without increased respiratory rate
Transmission-Based Precautions
Expanded measures taken to prevent the spread of diseases from people suspected or known to be infected. Includes airborne, droplet, and contact precautions
Membrane Type Humidifier
Expensive and uncommon passover humidifier. Water and gas are separated by hydrophobic membrane, water vapor can pass through but liquid water cant
Hazards of heated systems
Exposes patients to airway burns at temperatures over 39 C
Hazards of Breaking the Circuit
Exposes the vented patient's internal airway to the external environment which invites infection
Bohr Equation
Expresses the % of how much O2 is wasted with each breath (physiologic dead space) as ratio: VD/VT
F / C Temperature Conversion Formula
F-32=1.8C
Fahrenheit to Celsius Conversion Forumla
F-32=1.8C
Tachypnea
Fast breathing. Respiratory rate above 20. Indicates hypoxemia, atelectasis or hypercapnia or metabolic acidosis. Can also be attributed to anxiety or exercise
What regulates the design, manufacturing, testing and transportation of medical gas cylinders?
Federal Regulations
_______ increases the production is CO2 in the body
Fever
PAO2 is highly dependent on _________
FiO2
Production of medical grade air
Filtering and compressing atmospheric air
RC in 1960's
First formal training for Inhalation Therapists in Chicago. Ventilators developed. RT's become responsible for ABG's and pulmonary function labs
S1
First heart sound produced by closure of the AV Valves with systole (contraction)
Bennet 7200
First microprocessor vent developed in 1980's
Positive Pressure Ventilation
First used during anesthesia
Standard testing for medical gas cylinders occurs every ______ years
Five
What alters the amount of HCO3- used in buffering?
Fixed acids
Asystole
Flat line, not able to be shocked
How to calculate the flow of Heliox Therapy?
Flow x Factor, convert to L/min
Pressure Compensated Thorpe Tube
Flowmeter that incorporates a float ball in a tapered calibrated tube. Prevents changes in pressure reading due to back flow. Calibrated to 50 psi, causes float ball to jump when connected. Gravity dependent, so a bad choice for transport
Laminar Flow
Flows in parallel lines in a smooth progression from low flow rates
Laminar Flow
Fluid (liquid or gas) moving in discrete cylindrical layers or streamlines. Center of the stream has the fastest flow and least resistance
Increased fremitus indicates:
Fluid collecting in lungs or pleural space. Vibrations travel easily though fluid. Ex: Pneumonia, Pleural Effusion or Atelectasis
Vibrations travel better though _______ than through ______
Fluid, air
Describe the effect of the CO2 Hydration Reaction on HCO3-
For every 10 mm Hg increase in PaCO2, , HCO3- will increase by 1 mEq/L
What is the goal of patient education?
For the patent to be able to self-medicate
Pulmonary Fibrosis
Formation of scar tissue in the connective tissue of the lungs
FiO2
Fraction (percentage) of inspired oxygen in the air we breathe. Air has an FiO2 of 21%, and cannot get any lower
SaO2 measured by CO-oximetry is also called what?
Fractional Saturation
HbS (Sickle Cell)
Fragile Hb molecules leads to hemolysis and thrombi (ruptured Hb). Causes Sickle Cell Anemia,ACS and crystallized Hb cells
SpO2 measured by Pulse Oximetry is also called what?
Functional Saturation
Kinetic energy makes up most of the internal energy in what state?
Gas
Efficient breathing optimizes _____________-
Gas Exchange
Anatomic Shunts prevent blood from participating in ______________ or ______________
Gas Exchange, Diffusion
General Clinical Impression
Gives clues to the patients level of distress, severity of illness, personality, culture and pain level
Accomodating
Giving in to the other person, opposite of competing
Correction of Respiratory Acidosis
Goal is to improve VA including: - Measures to improve bronchial hygiene and lung expansion - Non-invasive positive pressure ventilation/ BiPAP - Endotracheal Intubation - Mechanical Ventilation - Supplemental O2
Glasgow Coma Scale (GCS)
Gold standard for assessing patient consciousness
The bases of the lungs are the __________ _______ areas
Gravity Dependent
Gasses that diffuse quickly/easily have a ______ Diffusion Constant
Greater
Greater mass and velocity creates _______ inertial impaction
Greater
Cohorting
Grouping patients with same infection in the same room
Fixed Acids are what type of ions?
H+ Ions
pH is determined by the ratio of what?
HCO3- to dissolved CO2
HCO3- accounts for _______ of the total buffering capacity of the blood
Half
(Pressurized) Metered Dose Inhaler (pMDI)
Handheld pressurized canister containing a drug and a volatile propellant combined with a drug. Most are mechanically actuated
Proximate/Legal Causation
Harm caused that could have been prevented with logical forethought as to the following events. Determines the fairness to impose damages on a defendant. Easily seen with retrospective analysis
Bronchial Breath Sounds
Harsher/louder normal breath sounds made by air moving through the bronchi. Equal inspiratory and expiratory components
Describe the V-P Curve of an Obstructive disease
Has a high, short slope due to frictional resistance. It takes LESS pressure to maintain the same volumes
Describe the V-P Curve of a Restrictive disease
Has a low, long slope due to increased elastic recoil. It takes MORE pressure to maintain the same volumes
Fevrile Vs. Afevrile
Having a fever Vs. Not having a fever
For CaO2 to be adequate, there must be enough normal ________
Hb
"40-50-60/70-80-90" Rule
Hb Saturations (SpO2) of 70%, 80% and 90% are associated with PO2 values of 40, 50 and 60 mmHg
HbCO (Carboxyhemoglobin)
Hb binds to Carbon Monoxide (CO), which displaces the O2
Respiratory Care (Definition)
Health discipline specializing in the promotion of optimal cardiopulmonary health
A head to toe inspection utilizes what senses?
Hearing, smelling, touching, seeing and PERCEPTION
Myocardial Infarction (MI)
Heart Attack; Death of myocardial tissue (infarction) caused by ischemia (loss of blood flow) as a result of an occlusion (plugging) of a coronary artery. No oxygen to the heart causes cell death
Temperature is a measurement of what?
Heat
The primary role of the upper respiratory tract is:
Heat and moisture exchange
Reservoir and Feed Systems
Heated humidifiers can evaporate more than 1 L/day
Boiling Point
Heating a liquid to a temperature at which vapor pressure exceeds atmospheric pressure
Heaviest and lightest gases
Heaviest: CO2 Lightest: Helium
Liquid pressure depends on what?
Height and weight density
Heliox Therapy
Helium and 20% O2 used to manage severe cases of asthma by reducing the work of breathing. Creates a a lower density gas that can have a more laminar flow. Brown and green tank
Carbon monoxide has a strong affinity for _____________
Hemoglobin
What is the O2 carrying molecule in a RBC?
Hemoglobin (Hb)
What are the two most common hazards of an Indwelling Catheter/A-Line?
Hemorrhage and infection
Strong cohesive forces have ______ viscosity
High
What type of system guarantees the delivery of an accurate FiO2?
High Flow Systems
Metabolic Alkalosis
High HCO3- raises pH above normal
Respiratory Acidosis
High PaCO2 combined with a low pH
A narrow tube has ________ capillary action. A wide tube has _______ capillary action
High, Low
In a large volume jet neb, the pressure at the constrictor is _______ and the pressure at the wall is ______
High, Low
Rectal temps run ________, Axillary temps run _______
High, low
The lower the cross-sectional surface area of a tube, the _________ the capillary action
Higher
The younger the patient, the _________ the temperature and heart rate
Higher
Hot wire vs. Neutral wire
Hot wire completes the circuit, neutral wire carries the current to ground
What propellant has replaced Chlorofluorocarbons (CFC's) as the propellant in most pMDI's?
Hydrofluoroalkanes (HFA's)
HCO3
Hydrogen Carbonate (Bicarbonate). 2.2-2.6 mEq/L
Hypoventilation
Hypercapnia as a result of high PaCO2 (>45 mmHg) due to decreased RR that prevents adequate VA. The body is unable to take in enough O2 to blow off tissue CO2
With a normal metabolic rate, a decreased VE indicates what?
Hypercapnia, elevated PaCO2
Increased resonance to percussion indicates:
Hyperinflation of the lungs. Lots of air trapped in tissues. Sounds are Hyper-resonant. Ex: Emphysema or Pneumothorax
Abnormal pulsation on the precordium can indicate Right or Left __________
Hypertrophy
High CO2 causes what compensatory response?
Hyperventilation to blow off CO2
Respiratory Alkalosis is caused by what?
Hyperventilation. High pH and low CO2 caused by rapid breathing which blows off the CO2
What is the expected compensatory mechanism for Metabolic Acidosis?
Hyperventilation. Rapid breathing lowers CO2, pulling pH back up to normal within minutes.
What would be the appropriate course of action when oxygenating a patient with Respiratory Alkalosis caused by a brain bleed?
Hyperventilation/Hyperoxygenation
What is the expected compensatory response for Metabolic Acidosis?
Hyperventilation/Reduction of PaCO2
Hyperventilation
Hypocapnia as a result of low PaCO2 (<55 mmHg) due to increased RR that elevates VA. The body is taking in so much O2 that it blows off all the existing tissue CO2
With a normal metabolic rate, an increased VE indicates what?
Hypocapnia, decreased PaCO2
What is the expected compensatory mechanism for Metabolic Alkalosis?
Hypoventilation despite ensuing hypoxemia. Slow breathing raises CO2, pulling pH back down to normal (occurs within minutes)Meta
Low CO2 causes what compensatory response?
Hypoventilation to retain CO2
Respiratory Acidosis is caused by what?
Hypoventilation. Low pH and high CO2 caused by slowed breathing which retains CO2
What is the expected compensatory response for Metabolic Alkalosis?
Hypoventilation/Elevation of PaCO2
Metabolic Alkalosis blunts __________ stimulation of ventilation. Patients with this condition can have PaO2 as low as _______ mmHg with continutes compensation
Hypoxemic, 500 mmHg
What is limited in a fluid-filled lung?
Hysteresis and Surface Tension
Dehydration or fluid overload is assessed through
I/O- Hydration intake/Fluid output
Metabolic Acidosis is often caused _____________ due to medical interventions
Iatrogenically
Allen's Test
Identifies circulation or vascular compromise by testing radial and ulnar arteries at wrist before an ABG is drawn
When is a blood gas sample indicated?
If the patients symptoms, medical history, physical exam or lab data suggest abnormalities in respiratory or acid-base status
Volume-Pressure Curve + Ideal Shape
Illustrates the relationship between volume and pressure on inspiration and expiration in a particular case. A healthy lung demonstrates a football shaped curve
Methods of decreasing host susceptibility
Immunizations/vaccines and chemoprophylaxis
What effect does Heliox 80:20 have on aerosol delivery?
Improves delivery at higher flows
With a diffusion limitation or blood exposure time of less than .25/sec, there may be ________ time for equilibration
Inadequate
Holding Chamber
Incorporated 1 OR MORE VALVES that prevent the aerosol in the pMDI chamber from being cleared on exhalation
Hyperpnea
Increase in depth and rate of breathing
What is the benefit of breath holding after inhalation of an aerosol drug treatment?
Increase sedimentation and deposition of the drug
A left shift indicates what?
Increased affinity for O2 loading at the lungs and inhibition of CO2 unloading at the tissues
Effect of cross contamination on humidifiers:
Increased opportunity for bacterial colonization. Not mediated by frequently changing the circuit
Hyperventilation
Increased rate and depth of breathing. Triggered by high CO2. Lowers PaCO2 by increasing O2 consumption
Shallow breaths _______ respiratory rate
Increases
What is the effect of Emphysema on CL?
Increases CL. Loss of elasticity prevents the lungs from recoiling and keeps them inflated (No rubber in the rubber band)
Health Insurance Portability and Accountability Act (HIPAA)
Increases the ability to transfer healthcare information between providers
Venturi Mask Valves
Indicate FiO2% and approximate flow rate. The tip of the filter will have a hole that gets larger as the % FiO2 increases to allow higher concentrations of 100% O2 to pass into the the mask. Windows on the sides of the valves get smaller as the % FiO2 increases to limit the amount of room air that is mixed with the O2 being delivered and achieve a higher FiO2
Hypocapnia
Indicated by a PaCO2 <35 mmHg. Occurs when the level of VA exceeds CO2 production by the tissues, known as Hyperventilation
Hypercapnia
Indicated by a PaCO2 >45 mmHg. Occurs when the level of VA is not sufficient to remove/blow off excess CO2 production, known as Hypoventilation
HCO3-
Indicates levels of Plasma Bicarbonate, range 22-26 mEq/L.
pH
Indicates overall acid-base balance, range 7.35-7.45
Critical Point
Indicates the critical temperature and critical pressure of a substance
The Frick Equation
Indicates tissue O2 extraction in proportion to blood flow. When combined with total O2 consumption (VO2), it allows for the calculation of Cardiac Output
OCB is an _______ measurement of WOB
Indirect
Trends in pH and PaCO2 are _________
Indirect. A rise in pH will accompany a fall in PaCO2
According to Henry's Law, temperature is _________ proportional solubility
Indirectly
Failure to clean equipment properly can render all subsequent processing efforts _________.
Ineffective
What is primary deposition mechanism for particles larger than 5um?
Inertial Impaction
What is true about an infants airway size and respiratory rate compared to an adult?
Infants have a smaller airway diameter and a higher respiratory rate
Humidity invites _______
Infection
Ventiricular Hypertrophy
Inflammation or swelling of the ventricles
Parts of sphygmomanometer
Inflatable cuff, pressure bulb, manometer + stethoscope
Protected Health Information (PHI)
Information that contains one or more patient identifiers
Bacteriostatic
Inhibits bacterial growth
Treatment and Monitoring (4)
Initiate the treatment. Demonstrate its application to them and educate them about the treatment and modality. Monitor to observe to evaluate the effectiveness in treating the patient's condition. Modify or discontinue the treatment is side effects are present
Paradoxic respiration
Injured portion of the chest wall area moves in the opposite direction than the rest of the chest. Deflation of the lung during inspiration and inflation of the lung during expiration. indicates chest trauma
On a volume-pressure, the bottom line illustrates _________, and the top line illustrates __________
Inspiration, Expiration
The airway dilated on _______ and constricts on ________
Inspiration, Expiration
Y-Piece Breathing Circuit Components
Inspiratory Limb and Expiratory Limb
Teach-Back Method
Instruct the patient on the process or procedure and have them teach it back to you in their own words to test understanding
Sphygmomanometer
Instrument to measure blood pressure. Indirectly measures the pressure required to collapse an artery
Contact Precautions
Intends to reduce the risk of infectious pathogen transmission by direct/indirect contact. Requires the proper use of gowns and gloves
Droplet Precautions
Intends to reduce the risk of infectious pathogen transmission by inhalation of propelled droplets. Requires a surgical mask
Airborne Precautions
Intends to reduce the risk of infectious pathogen transmission by microscopic particles that are suspended and linger in the air. Requires an N-95 respirator, negative pressure room and HEPA filters
Prolonged expiratory time is indicative of an:
Intra-thoracic obstruction
Introductory Stage (2)
Introduction of yourself to the patient and establish a rapport. The time to verify the patients identity (2 step verification). Occurs in the social space, 4-12ft away
There is an ________ relationship between tube width and capillary action
Inverse
According to LaPlace's law, surface tension is ________ proportional to a bubble's radius
Inversely
At a constant FiO2, PAO2 varies _________ with PACO2
Inversely
Particle size is _______ proportional to frequency
Inversely
Particle size is _________ proportional to the frequency of a USN's vibration
Inversely
Compensatory Mechanisms of hypothermia
Involuntary shivering and vasodilation
Attending
Involves the use of gestures and confirming remarks
Biot respiration
Irregular breathing with long periods of apnea. Indicates increased intercranial pressure
Arrythmia
Irregular cardiac rhythm
Irregularly Irregular Rhythm
Irregular or skipped beats at random intervals
Cheyne-Stokes respiration
Irregular type of breathing in which breaths increase and decrease in depth and rate with periods of apnea. Indicates diseases of the central nervous system or CHF
Prolonged shock becomes _________
Irreversible
How does anemia effect oxygenation?
It reflects a low absolute quantity of Hb, which means that SaO2 and PaO2 are likely low as well
Celsius to Kelvin Conversion Formula
K = C + 273
What system replenishes the bulk of HCO3- in the body, the lungs or the kidneys?
Kidneys
What is the expected compensatory mechanism for Respiratory Alkalosis?
Kidneys will excrete HCO3- to push pH back down to normal over several days. Removes the stimulus for hyperventilation
What is the expected compensatory mechanism for Respiratory Acidosis?
Kidneys will reabsorb HCO3- to pull pH back up to normal (occurs over days)
The ________ maintain an HCO3- of ________ mEq/L
Kidneys, 22-26 mEq/L
Bactericidal
Kills bacteria
Sporicidal
Kills bacterial spores
Virucidal
Kills viruses
In clinical settings, weight is measured in _____, and height is measured in ______
Kilograms, Inches
The temperature of a gas is directly proportional to its _________ energy
Kinetic Energy
Most common location for fires in hospitals, nursing homes and hospice
Kitchen
In addition to strict ABG interpretation, what other considerations are important for accurate understanding of a patients condition?
Knowledge of the patient's medical history and the present circumstances of the ABG
CL is measured in what units?
L/H2O per cm
What type of flow and particle size is ideal for asthma patients?
Laminar flow of large particles 5um and greater (increased inertial impaction)
What size tubing is used with airway appliances?
Large bore
A tumor on the right side of the trachea would cause a shift to the _________. A collapsed right lung would cause a tracheal shift to the _______
Left, Right
AARCFunctions and # Members
Legislative and regulation body. Advocates for the profession, provides continuing education, and sets standards for procedure. 50,000+ members. Advocates the RRT licensure and BA education level.
Strict Liability Tort
Liability for harm in absence of fault, such as in medical device failure
Isolated measurements provide ________ info. Because of this ______ are preferred
Limited, trends
Potential energy makes up most of the internal energy in what states?
Liquid and Solid
What states of matter exert buoyant forces?
Liquids and Gases
Describe the impact of atmospheric pressure on boiling point?
Liquids boil more quickly and at lower temps in areas of low atmospheric pressure/high elevation
Total Flow Formula
Liters of Air/Liters of O2 - (100-FiO2/FiO2- 21) (Flow) + Flow - (100-X/X-21) (Flow) + Flow
What does peripheral venous blood reflect?
Local metabolism. It is of no value to assessing lung function
Ischemia
Local reductions in blood flow that can result in hypoxia and tissue death. Ex: Stroke or Myocardial Infarction
Long Term Oxygen Therapy (LTOT)
Long term use of supplementary oxygen at home through Oxygen Tanks and Pressure Boosters
Turbulent Flow
Loss of regular streamlines. Fluid (liquid or gas) molecules form irregular eddy currents in a chaotic pattern. Predicted with Reynold's Number
Tracheal Breath Sounds
Loud, high pitched sounds heard by listening over the trachea. Equal inspiratory and expiratory components
The boiling point for most LIQUIFIED GASES is relatively _______
Low
Metabolic Acidosis
Low HCO3- which pulls down pH level
Respiratory Alkalosis
Low PaCO2 increases Carbonic Acid (H2CO3) and raises pH
Nasal Cannula
Low flow system delivers oxygen through two prongs that rest in the patient's nostrils. Delivers an FiO2 of 0.24-0.40% at flow rates of 0.25-6 L/min. Levels of FiO2 dependent on how much room air the patient inhales in addition to the O2 provided
Aritifical airways put stress on the _________ respiratory tract to provide heat and moisture
Lower
Diastolic Pressure
Lowest level of arterial pressure when ventricles relax
CL
Lung Compliance/The change in lung volume per change in pressure
Ventilator-Associated Pneumonia (VAP)
Lung infection that develops in a person requiring invasive mechanical ventilation. 25% of patients on vents develop VAP, 30% of those die
What system removes the bulk of acid from the body, the lungs or the kidneys?
Lungs
The _________ maintain a PaO2 of __________ mmHg
Lungs, 35-45 mmHg
We want to promote O2 loading at the ___________, and CO2 unloading at the _________
Lungs, Tissues
Minute Volume Ventilation (VE or MV) Formula
MV or VE = VT x RR VT= Tidal Volume RR= Respiratory Rate
Are DPI's suitable for rescue or maintenance?
Maintenance only
Formula for IBW
Males: 106 + 6(H- 60) Females: 105 + 5(H- 60) H= height in inches Answered will come out in lb's and must be converted to kg's
Total Lung Capacity (TLC)
Maximum amount of air contained in lungs after the maximum inspiratory effort (TLC= IRV+ERV+RV)
Noninvasive Approach to Blood Gas Sampling
Measure blood gas parameters by sensors on the skin or evaluation of exhaled gases
Airway Resistance (Raw)
Measure of the resistance to ventilation caused by the movement of gas through the airway. Makes up 80% of total resistance
Base Excess (BE)
Measures changes in total blood buffer bases, range -2 to +2 mEq/L
PaCO2
Measures the adequacy of ventilation relative to CO2 production by the tissues, range 35-35 mmHg
PaO2
Measures the partial pressure of oxygen in arterial blood as compared to venous blood. Range: 80-100 mm Hg
Christmas Tree
Medical gas nut and stem adaptor
Dry Powder Inhaler (DPI)
Medicated delivery device that delivers a powdered (solid) aerosol to the respiratory system
Body temperature is directly related to _________ rate
Metabolic
The larger the BE, the more severe the deviation in the ______________ component
Metabolic
An increased Anion Gap indicates what?
Metabolic Acidosis
Combined Metabolic Acidosis and Respiratory Alkalosis
Metabolic Acidosis accompanied by low PaCO2 and a low pH
Combined Metabolic Alkalosis and Respiratory Acidosis
Metabolic Alkalosis accompanied by high PaCO2 and a high pH
Changes in pH due to HCO3- care caused by what?
Metabolic disturbances (renal system excretes/retains bicarb)
What does cyanosis with a normal PaO2 suggest?
Methemoglobinemia
Diffusion
Method of deposition in which very small particles less than 3um bounce against other molecules and settle in the lower airways
um =
Micrometers
Compromising
Middle ground strategy combining assertiveness and cooperation
mEq/L
Milliequivalent per Liter
In resting healthy lungs inspiratory effort is ________ while expiration is completely __________
Minimal, Passive
VE
Minute Ventilation
The respiratory system monitors acid-base balance over _________, and the renal system monitors acid-base balance over ___________
Minutes, Days
Enclosures
Mist tents and hoods that deliver bland aerosol therapy to infants and children
Air Entrainment/Blender System
Mixes Air (21% FiO2) with 100% O2 being supplied. Ultimately means that the air being delivered to the patient is slightly below the % indicated by the flow valve
Heliox Therapy
Mixture of low density Helium and O2 are administered to ease the work of breathing in patients with an airway obstruction (EX: Asthma or Croup)
Damages
Money ordered by a court to be paid for injuries or losses suffered
Stridor
Monophonic high pitched, strained sound heard on inspiration caused by an upper airway obstruction. Indicates a narrow, inflamed airway causing labored breathing. Ex: croup or extubation after traumatic intubation
Inhalation requires _______ pressure to achieve a given volume than exhalation
More
Temperature is lowest in the _______, and highest in the _______
Morning, Late afternoon
Reservoir Type Humidifier
Most common type of passover humidifier. Spikes a bag of sterile water and allows water to flow down and evaporate through a gravity-feed system
Oxygen Enriched Areas (OEA'S)
Most dangerous areas for fires because oxygen is combustible. Fires are more intense, longer burning and difficult to extinguish
Major limitation of a pMDI?
Most don't indicate the number of doses remaining, and will deliver lower doses as it runs out
The atoms that make up all matter are in constant _________ and a normal ___________
Motion, Temperature
Diffusion
Movement of molecules from an area of higher concentration to an area of lower concentration until equilibrium is reached
Electrical Energy
Moves from point A to point B
What lines our airways?
Mucous
The best physical evaluation comes from assessing __________
Multiple parameters
The HbO2 Dissociation Curve demonstrates that the relationship between PaO2 and SaO2 is _____________
NOT LINEAR
During a quiet exhalation (FRC), Ptm is ________ to maintain airway patency and caliber
Negative
With inhalation, pleural pressure becomes more ________
Negative
Iron Lung
Negative pressure mechanical ventilator where the patient is encased by the machine due to a paralyzed diaphragm. Commonly used during polio outbreak
During quiet breathing, Ptm is _________. During a forced exhalation Ptm is _________
Negative, Positive
The pleural space is a ________/_________ pressure environment, which keeps the airways open
Negative/Sub-atmospheric
Civil Malpractice
Negligence or practice below a reasonable standard
Central Piping
Network of bulk O2 piping throughout a healthcare facility that delivers compressed airs to all areas of a hospital. Alarms warn if pressure drops or flow is interrupted. Zone valves regulate pressure at 50 psi
When can aerosols be administered to crying infants/children?
Never
Most of the pressure we feel at sea level is due to what gas?
Nitrogen
Does a patient have to be removed from BiPAP to receive a breathing treatment?
No
Magnetic Resonance Imaging (MRI) Protocol
No metal devices in or around the MRI suite. Includes vents and oxygen cylinders
Double Effect Principle
No one drug has a single effect. Positive and negative effects
Is compensation possible in a combined acid-base disturbance?
No. Both are problems, so one cannot compensate
What medical interventions are indicated to correct a Metabolic Acidosis with a pH> 7.20?
None! Hyperventilation will usually bring pH back up to normal range quickly
The PaO2 in patients with methemoglobinemia is typically ___________
Normal
Moderate resonance indicates
Normal air filled lungs
Eupnea
Normal breathing
If there is a lack of normal Hb molecules, PaO2 and SaO2 can be ______, but CaO2 will be ________
Normal, Low
How much higher is PaO2 than PAO2?
Normally 5-10 mmHg higher
Heat and moisture exchange typically takes place in the _______
Nose
Why does nose breathing lower minute volumes and ventilations?
Nose breathing filters out larger particles
Helium and NO must be mixed with ________
O2
High flow _______ aids in neovascularization post surgery
O2
CaO2
O2 Content in Arterial Blood. Normal is 16-20 mL/dL. Ideal is 18 mL/dL
CvO2
O2 content of mixed venous blood. Normal is 12-16%
Anything that lowers CaO2 may decrease the availability of ______ at the ________
O2, Tissues
At what temp Fahrenheit and Celsius does water freeze?
OC, and 32F
Efficient lungs have a low _____ and produce little _______
OCB, CO2
Formalism
Observance of established rules and principles with the belief that they function apart from the consequences of an act. States that an act is justifiable if it follows the rules
Postanalytic Errors
Occur after the analysis of the blood gas. Includes: - Incorrect interpretation - Failure to perform internal and external validity checks
Analytic Errors
Occur during the testing/measurement of the sample. Includes: - Failure to calibrate the analyzer - Inadequate lab testing - Poor laboratory quality control
Preanalytic Errors
Occur in the preanalytic phase of obtaining the blood gas. Includes: - Air in sample - Venous blood or venous admixture - Excess liquid Heparin/dilution - Metabolic effects of time lag
Combined Acid-Base Disorders
Occur when two or more primary imbalances coexist, with each driving the pH in opposite directions. Typically seen in critically ill patients and suggests a poor prognosis. All Alkalotic or all Acidotic
Inertial Impaction
Occurs when large suspended particles in motion collide with and are deposited on a surface, typically in the upper airway
Sedimentation
Occurs when small aerosol particles settle out of suspension & are deposited into the mid/lower airways due to gravity
Hypoxia
Occurs when the amount of O2 available to the tissues falls short of metabolic needs (Ex: Drug OD)
What happens to temperature and relative humidity above the ISB?
On inspiration, they both decrease. On expiration they both increase
Single Patient Use
One-time use medical equipment/devices that are disposable. Includes nebulizers, bag-valve masks and suction equipment. Can be costly and low quality but effective if used properly
The lungs and chest wall recoil in _________ directions
Opposite
The body will never _________ for imbalances
Overcompensate
COPD is a disease of _______________
Overcompliance. The elastic tissues in the lungs have been damaged and they cannot properly recoil
In the present of abnormal hemoglobin, Pulse Oximeters will ______________ the true SpO2
Overestimate
Too narrow or tight of a BP cuff
Overestimates pressure
DO2
Oxygen delivery
Cerebral Hypoxia
Oxygen deprivation to brain causing confusion and eventual death of cerebral tissues/nerves
HbO2
Oxyhemoglobin (oxygen that is bound to hemoglobin)
P.A.S.S. Fire Extinguisher Training
P - Pull pin A - Aim nozzle S - Squeeze handle S - Sweep nozzle across base of fire
Laplace's Law Formula
P = 4ST/r P= Pressure in Dynes/cm ST= Surface Tension r= Radius
PACO2 Formula
PACO2= (VCO2 x 0.863)/VA VCO2= Volume of CO2 produced in a minute VA= Alveolar Ventilation
Dalton's Law helps to determine what gas value?
PAN2
PAN2 Formula
PAN2= PB- (PACO2+PAO2+47) PACO2= Pressure of Alveolar cO2 PAO2= Pressure of Alveolar O2
Ideal Alveolar Gas Equation (PAO2)
PAO2 = [PB-PH2O] FIO2 - PaCO2 (1.25) PB= Barometric pressure (usually 760) PH2O= Pressure of water vapor (usually 47) FiO2= Fractional inspired O 2PaCO2= Pressure of arterial CO2
What happens to our PAO2 and PaO2 levels as we age?
PAO2 stays constant, but PaO2 decreases. The older we get, the greater the difference between PAO2 and PaO2
Ideal Alveolar Oxygen (PAO2) Equation
PAO2= FiO2(PB-47)- (PACO2/0.8) FiO2= O2% PB= Barometric/Atmospheric Pressure PACO2= Pressure of CO2 in Alveoli
What happens to PACO2 when VCO2 increases?
PCO2 Also Increases
What happens to PACO2 when VA decreases?
PCO2 Increases
PCO2 Level Equation
PCO2= (VCO2)/VA VCO2= Resting CO2 Volume VA= Alveolar Ventilation
What is the primary determinant of PAO2?
PIO2
PIO2 Formula
PIO2= FiO2(PB-47) FiO2= Percent of O2 PB= Barometric/Atmospheric Pressure
Corresponding safety system for an E Cylinder and Regulator
PISS
Transpulmonary Pressure (PL) Formula
PL= PA-Ppl PA= Alveolar Pressure Ppl= Pleural Pressure
HCO3- levels often change as a compensatory SECONDARY response to PRIMARY changes in ________
PaCO2
Partially Compensated acid-base disorders are derangements of what values?
PaCO2 and HCO3- that drive pH in the same direction, low (Combined Resp/Met Acidosis) or high (Combined Resp/Met Alkalosis). Abnormal pH always present
What ABG value is the best factor to determine the effectiveness of ventilation?
PaCO2 in relation to VE
Hyperoxemia
PaO2 of 100 + mmHg. Impossible without supplemental O2
Normoxemia
PaO2 of 80-100 mmHg
The 5th vital sign
Pain; Pain level
Rebound Effect
Paradoxical effects that occur when a drug has been eliminated from the body. Treatment helps, but numbers go WAY down when discontinued
Tension implies what?
Partial Pressures
PaCO2
Partial pressure of carbon dioxide in arterial blood as compared to venous blood. Range: 35-45 mm Hg
Collaborating
Parties find a mutually satisfying third option
Resting exhalation should be completely __________
Passive
Wick Type Humidifier
Passover humidifier where water travels up a wick via capillary action to increase surface area upon which water can evaporate
Frequency of VS measurements id dependent on ______
Patients condition
Depression of ventilation effort
Patients with late stage COPD or chronic hypercapnia may be discouraged from taking deep regular breaths on O2 because they are getting higher quantities and flow than they are used to
If no dead space exists, Paco2 will equal ________-
PeCO2
For a high flow system to be effective, it must be set to a flow equal to or exceeding the patients ___________________
Peak Inspiratory Flow
Systolic Pressure
Peak force in the arteries during contraction of the ventricles
Reservoir Cannula
Pendant or nasal reservoir cannula designed to maintain FiO2 at lower rates by delivering a bolus of oxygen with each inspiration. Reduces O2 use by 50-75%. Delivers flow rates of 0.25-8 L/min
What blood gas is the MOST critical?
Ph
Ethics derives from _______, and asks the question "_________?"
Philosophy, How should we act?
Failure to Thrive (FTT)
Physical and developmental retardation of infants or children resulting from psychosocial or maternal deprivation
Civil courts decide if the __________ has been wronged and, if so, what damages/reparations are required by the ________
Plaintiff, defendant
At end expiration, both PL and Ptaw are equal to _______
Pleural Pressure, -5cm/H2O
Point of Maximal Impulse (PMI)
Point in the 5th intercostal space where the apex of the heart touches the anterior chest wall and heart movements are most easily palpated
Isothermic Saturation Boundary (ISB)
Point on the right and left bronchus 5cm below the Carina at which inspired gas becomes fully saturated to 100% relative humidity at 98.6F or 37C
Forced exhalation creates __________ airway pressure that can lead to alveolar __________
Positive, Collapse
Cations are _______, Anions are ________
Positive, Negative
Differential Diagnosis
Potential diagnoses compiled early in the assessment of the patient which are to be ruled out
Pneumatic (Jet) Nebulizers
Powered by high-pressure oxygen or air provided by portable compressor, compressed gas cylinder, or wall outlet. Also called a Small Volume Nebulizer (SVN) or handheld nebulizer
Role Duty
Practitioners have duty to understand limits of role and to practice with fidelity. RT's must not perform duties outside their scope of practice
Respiratory Therapists
Practitioners of respiratory care focused on identifying, preventing and treating dysfunction of the cardiopulmonary system
Poiseuille's Law + Formula
Predicts the pressure requires to produce laminar flow through a tube ∆P=(8nLV)/πr^4 V= Flow P= Pressure r= Radius L= Length n= Viscosity of gas/fluid
Infants are what type of breathers and for how long?
Preferential nose breathers until the age of 1 year old
Achieving a higher lung volume requires an increase in what?
Pressure
All gases exert __________
Pressure
Diffusion occurs along _________ Gradients
Pressure
The application of what force causes the lungs to stretch until maximum inflation?
Pressure
What causes gases to move from areas of high to lower pressure?
Pressure Gradients
Gay-Lussac's Law + Formula
Pressure exerted by a gas varies DIRECTLY with its temperature. Volume is constant P1/T1 = P2/T2
PtO2/PtCO2
Pressure of transcutaneous O2 or CO2. Monitored by Pulse Oximetry ot Transcutaneous Gas Sampling
PACO2
Pressure/Tension of Alveolar CO2. Normal is 35-45 mmHg. Ideal is 40 mmHg
PAN2
Pressure/Tension of Alveolar Nitrogen. Normal is 570 mmHg
PAO2
Pressure/Tension of Alveolar O2. Normal is 80-100 mmHg. Ideal is 100 mmHg
PIO2
Pressure/Tension of Inspired O2. Normal is 159 mmHg
PH2O
Pressure/Tension of Water Vapor. Normal is 47 mmHg
Fellow of the AARC Award (FAARC)
Prestigious award given to an AARC member by nomination for excellence in the respiratory care field
Cylinder safety relief valves
Prevents tank pressure from becoming too high by venting gas to atmosphere if tank is heated. - Frangible Disk - Fusible Plug - Spring Loaded Valve
Consequentialism
Principle states that an act is judged to be right or wrong based on its consequences. utilizes the principle of utility to promote good
Deposition
Process in which aerosol particles sediment is laid down in the lungs
Aerobic
Process that requires oxygen
What happens to levels of O2 consumption and CO2 production during hypothermia?
Production of O2 and consumption of CO2 both decrease, causing cyanosis and hypotension
What happens to levels of O2 consumption and CO2 production during a fever?
Production of O2 and consumption of CO2 both increase, causing CO2 to build up in the body
Diaphoresis
Profuse sweating. Sign of stress and common in patients having a Myocardial Infarction/heart attack
Apneustic respiration
Prolonged inspiration unrelieved by expiration attempts. Indicates brain damage
PHI
Protected Health Information
Personal Protective Equipment (PPE)
Protective equipment that blocks exposure to a pathogen or a hazardous material. Includes (sterile) gloves, masks, particulate respirators/N-95 and gowns
Reflective Feelings/Feedback
Provides an opportunity for patients to express and reflect on their emotions
Dalton's Law of Partial Pressure Formula
Pt = PO2 + PN2 (room air) OR Pt= P1 + P2 Pt= Total Pressure
Transairway Pressure (Ptaw) Formula
Ptaw= Pao-PA Pao= Pressure at the airway opening PA= Alveolar Pressure
Transmural Pressure (Ptm) Gradient Equation
Ptm = Pao - Ppl Pao= Pressure at Airway Opening Ppl= Pleural Pressure
Systems of Law
Public law and civil law
PERRLA
Pupils are equal, round, reactive to light and accommodation
Volume Cycled Ventilator
Pushes air into the lungs until a preset volume is delivered. Developed 1960-70's
Transthoracic Pressure (Pw) Formula
Pw= PA-PBS PA= Alveolar Pressure PBS= Pressure at the Body's Surface
Where is Perfusion (Q) highest in the lungs?
Q is highest in the bases, usually lower than 1V/Q (approx .66)
Hypoxia can occur with normal CaO2 if ________ is reduced
Qt
Cardiac Output (Qt) Formula
Qt= (VO2)/C(a-v)O2 x 10 VO2= Total O2 consumption C(a-v)O2= Arteriovenous O2 content difference
Diffusion Constant
Quantifies the ease of gas transfer in diffusion. The greater the constant, the easier diffusion is for that molecule
Pain intensity Scales
Quantify a subjective measure using a 1-10 scale 0- Doesn't hurt 2- Hurts a little 4- Hurts a little more 6- Hurts a good deal 8- Hurts a whole lot 10- Worst possible pain
R.A.C.E. - Core Fire Plan
R - Rescue patients in immediate area of fire A - Alert other personnel to fire C - Contain the fire; shut doors to prevent spreading of fire E - Evacuate other patients & personnel
Relative Humidity (RH) Formula
RH= (Content/43.8) x 100
RC in 1974
RT's become an official designation and join Allied Health Professionals
Beneficence
Raises the do no harm requirement to a higher level. Requires health care providers to contribute to the overall health and wellbeing of patients. Save lives at all costs
Movement of a gas's atoms
Rapid and random with frequent collisions
Cardiac murmurs are caused by:
Rapid blood flow through an incompetent valve
Airway Resistance (Raw) Formula
Raw= ∆P/*V ∆P= Change in pressures *V= Flow
Core Body temperature measured in adults Vs. Infants and children
Rectal temperature Vs. Axillary temperature
How do you take the temperature of a comatose patient?
Rectally
If the arteriovenous difference (C(a-v)O2) is low or equal, Qt is _______
Reduced
Diminished Breath Sounds
Reduced sound intensity. Indicates air is not reaching parts of the lungs. Can become completely absent
Neovasularization
Regeneration or healing of the body's vascular network after injury
What is the key of effective bronchodilator therapy protocol?
Regularly assessing patient response to therapy
National Fire Protection Association (NFPA)
Regulates storage of medical gases which are monitored by the Joint Commission (TJC)
Ethical Misconduct
Relates to violations of professional and ethical norms established by the profession as a whole
As O2 saturation falls, Pulse Oximetry becomes less __________
Reliable
Below the ISB, temperature and relative humidity _____
Remain constant
How does compensation occur for Respiratory Alkalosis?
Renal excretion/reduction of HCO3-
How does compensation occur for Respiratory Acidosis?
Renal re-absorption/increase of HCO3-
Anion Gap
Represents the difference between the concentrations of serum cations and anions
Transthoracic Pressure Gradient (Pw)
Represents the total pressure required to expand or contract the lungs and chest wall
Confidentiality
Requires healthcare providers to respect patients rights to privacy, even after death, unless it violates the harm principle
Invasive Approach to Blood Gas Sampling
Requires sampling of blood by needle puncture or indwelling catheter. ABG analysis is the gold standard and most accurate measurement
Viscocity
Resistance to flow/The force opposing fluid's flow
Ethics represents the commitment to what principle?
Respect for humanity in persons
Respiration Vs. Ventilation
Respiration = The process of gas exchange at the alveolar level Ventilation = The movement of air between the lungs and the environment. Ventilate to respirate
What is the key difference between Respiration and Ventilation?
Respiration involves gas exchange at the lungs and tissues. Ventilation does not involve gas exchange
Prolonged use of a simple mask with a flow rate of less than 5 L/min can result in __________
Respiratory Acidosis
Hypercapnia and Hypoventilation are associated with ___________
Respiratory Acidosis, Metabolic Alkalosis
Hypocapnia and Hyperventilation are associated with ___________
Respiratory Alkalosis, Metabolic Acidosis
Changes in pH due to CO2 care caused by what?
Respiratory disturbances (Hyper/Hypoventilation)
Paraphrasing
Restating the message in your own words
Rapid shallow breathing is indicative of a _________ lung disease
Restrictive
What dramatically increases WOB and OCB?
Restrictive AND Obstructive Pulmonary Diseases
Shock
Results in widespread hypoxia (blood loss) with a limited ability to compensate and VERY low BP
Buffering
Retainment of HCO3- by the kidneys to cancel out acids
Causation
Revolves around whether acts of negligence were, in fact, the direct cause of damages
Chest Percussion
Rhythmic tapping of the patient's chest to assess the resonance of the underlying tissue. Hand flat against chest, tapping on knuckles
Where is the most common place to take a pulse or ABG?
Right radial artery
Cor Pulmonale
Right ventricular hypertrophy and heart failure due to pulmonary hypertension
S.O.A.P Progress Notes
S- Subjective - what the patient/family tells you O- Objective - What you observe, labs A- Assessment - What you think is going on P- Plan of treatment
Which device has better lung deposition: MDI or SVN?
SVN
What is the difference and similarity between SpO2 and SaO2?
SaO2 is a DRIECT measurement by an ABG. SpO2 is an INDIRECT measurement by a pulse oximeter. Both measure the percentage of oxygenated hemoglobin in the blood with an ideal range between 95-100%
SaO2 % Formula
SaO2= (HbO2/Total Hb) x 100 HbO2= Oxyhemoglobin count Total Hb= Given (Men=15, women =12)
SaO2
Saturation of oxygen in arterial blood. Directly measures the percentage of oxygenated hemoglobin in arterial blood as detected by an ABG. Range: 95-100%
SpO2
Saturation of peripheral capillary oxygen. Indirectly measures the percentage of oxygenated hemoglobin in the blood as detected by a pulse oximeter. Range: 95-100%
Retinopathy of Prematurity (ROP)
Scar tissue forms behind the lens of the eye resulting from administration of excessive oxygen to newborns
Gas Cylinders
Seamless steal tanks used to store and ship compressed or liquid medical gases
S2
Second heart sound produced by closure of the Semilunar Valves with diastole (relaxation)
What is the primary method of deposition for particles 1-5um?
Sedimentation
What medical interventions are indicated to correct a Metabolic Acidosis with a pH< 7.20?
Serious cardiac arrhythmias can occur. Treat with IV NaHCO3- drip in severe cases
Prevention Bundles
Set of practices that are proven to increase positive outcomes
Hypopnea
Shallow/decreased depth of breathing
What causes a reduction in blood flow?
Shock or ischemia
Requesting Clarification
Should be nonjudgmental in nature
Combined Gas Law + Formula
Shows the interaction of gas laws. (P1 x V1) / T1 = (P2 x V2 )/ T2
HbO2 Dissociation Curve
Shows the relationship between PaO2 (Pressure of O2) and SaO2 (% oxygen binding to Hb). Has an S-shape
What physiologic factor has the most impact on gas exchange?
Shunting. Causes blood to bypass the lungs, resulting in V/Q mismatch
Metabolic Acidosis is caused by what?
Significantly decreased bicarbonate. Low pH and low HCO3-
Flow Restrictor
Simplest and least expensive type of flowmeter. Delivers a calibrated flow to a FIXED orifice at a CONSTANT pressure. Often built into medical devices like O2 compressors
Regular Rythm
Singular beats at regular intervals
Regular Irregular Rhythm
Skipped beats at regular intervals
Bradypnea
Slow breathing. Respiratory rate below 12. Indicates head injury, hypothermia or drug overdose.
Chemical production of O2
Small batches produced by electrolysis of water and decomposition of sodium chlorate
Risk of exposing PHI has increased with the growth of ___________
Social networking sites
What electrolyte has the highest concentration in the body?
Sodium (Na+)
Vesicular (Normal) Breath Sounds
Soft, low pitched sounds heard over most of the lung fields. Typically long inspirations, short expirations
Partial Compensation
Some compensation occurs but not enough to fully correct, and pH remains abnormal. The non-causative system cannot completely oppose the causative system
The Oxyhemoglobin (HbO2) Dissociation curve quantified the relationship between that two values?
SpO2 and PaO2
What is the inferred "5th" ABG value?
SpO2 or SaO2
N2 is inert, but occupies _______ and exerts ________
Space, Pressure
Pulse Oximeters use the _____________ principle of _____________ to compute fractional saturation
Spectrophotometric Principle of Light Absorption
When air meets constriction it _________
Speeds up
In Metabolic Alkalosis what takes precedent: The hypoxic drive to breathe or the need to stabilize pH?
Stabilization of pH outweighs the hypoxic drive to breathe, meaning the patient will continue to hypoventilate
The root of most ethical problems for RT's
Staffing problems. Ex: Stacking breathing treatments
Cachectic
State of profound and marked malnutrition; wasting and ill health
Debilitated
State of weakness or feebleness; lack of strength and energy
Henry's Law
States that a gas can be dissolved in any liquid at a constant temperature, and that the volume of liquid is directly proportional to the partial pressure of that gas
The Bohr Effect
States that a shift in pH always causes a left or right shift on the HbO2 dissociation curve
The Bernoulli Principle
States that as the VELOCITY of a fluid increases, the static PRESSURE, potential and internal energy exerted by the fluid decreases
Law of Electronegativity
States that cation concentration should be equal to anions in body fluids
Dalton's Law of Partial Pressures
States that the Total Pressure of a gas mixture is equal to the sum of the pressures of all the gases in the mixture
Frick's Law
States that the greater the surface area or pressure gradient, the greater the strength of diffusion
Laplace's Law
States that the stronger the surface tension of a bubble, the stronger the pull for it to collapse. The larger the bubble, the greater the surface tension must be for it to collapse
Fluid Entrainment
States that when an open tube is placed distal to such a constriction, the negative pressure can pull another fluid into the primary flow stream
Liquids that can be used in bland aerosol therapy
Sterile water or saline
Potential Energy
Stored energy that results from the position or shape of an object.
We want a ________ O2 affinity at the lungs, and a ________ O2 affinity at the tissues
Strong, Weak
Interpretation of bronchial breath sounds:
Suggests increased lung density such as in Pneumonia
Interpretation of diminished breath sounds:
Suggests shallow breathing or hyperinflation f the lungs such as in Emphysema
Hyperoxemia is only possible in patients receiving what?
Supplemental O2
Humidifiers maximize:
Surface Area
Hysteresis in a volume-pressure curve is highly dependent on what factor?
Surface Tension
What is the primary cause of lung recoil?
Surface Tension
Pedal Edema
Swelling/accumulation of fluid in the feet or ankles. Sign of right heart failure (Cor Pulmonalae)
Lymphadenopathy (LAD)
Swollen lymph nodes
Effect of respiration on blood pressure
Systolic BP drops 2-4 mm Hg with inspiration
Time Constant (TC) Formula
TC= Raw x CL
Melting Point vs Freezing Point
Temp at which an object melts vs. Temp at which an object freezes
According to Henry's Law, the solubility of a gas in a liquid is dependent on _________
Temperature
In gas laws, if a denominator is present, it is always ___________
Temperature
What important lab tests should be checked before performing an ABG?
Tests that indicate if they will have problems clotting, increased bleeding times or require additional compression time at the puncture site. Includes: - Coagulation related tests - Blood thinning agents - Platelet counts
A star stamped onto the gas cylinder indicates what?
That is has passed a 10 year safety test
A + sign stamp on a gas cylinder indicates what?
That it has been approved by the DOT for a 10% increase in filling pressure (2200 psi)
Functional Saturation
The % of normal Hb that is actually binging to O2
Fractional Saturation
The % of normal Hb that is binding to O2 AND abnormal Hb that is present
Alveolar-Arterial O2 Gradient
The 10 mmHg difference in PaO2 and PAO2 that increases with age. Indicates base PAO2 levels. Can be estimating the patients age by 0.3
RT Code of Ethics is established by
The AARC
CO2 Hydration Reaction
The Carbonic Acid Buffer System that demonstrates the relationship between CO2 and HCO3-. States that because a large portion of CO2 is transported as HCO3-, they are weakly related
Classification of medical gas cylinders is controlled by what federal department?
The Department of Transportation (DOT)
Which part of the HbO2 Dissociation Curve demonstrates the strongest affinity between O2 and Hb?
The FLAT portion (90-100 mmHg)
What formula quantifies pH and verifies the accuracy of a blood gas?
The Henderson-Hasselbalch Equation
Which part of the HbO2 Dissociation Curve demonstrates the weakest affinity between O2 and Hb?
The STEEP portion (26.6-89 mmHg)
What does the shaded area on a Volume-Pressure Curve?
The WOB
Hypercapnia
The abnormal buildup of carbon dioxide in the blood caused by shallow breaths
Actuation
The act of physically dispersing a pMDI aerosol
Ambulation
The act of walking. Decreases recovery time and prevents cardiopulmonary issues in recovering patients
Benevolent Deception
The act of withholding the truth from a patient for their own good, such as in the case of pediatrics or suicides
Oxygen Cost of Breathing (COB)
The amount of O2 used up during the act of breathing
Resonance
The amount of air trapped in the tissues
Emitted Dose
The amount/mass of drug that leaves the nebulizer mouthpiece
Output Rate
The amount/mass of the aerosol generated PER UNIT OF TIME
What does saturated/carrying capacity mean?
The atmosphere is completely saturated with water and cannot hold any more vapor
Water Vapor Pressure
The atmospheric pressure exerted by water vapor in air. Increases as the water vapor in air increases
The physical exam is most commonly performed by
The attending physician
Temperature
The balance of heat production and loss within the body
Shifts in ISB compromise what?
The body's normal heat and exchange mechanisms
Correction
The causative system adjusts itself independent of the noncausative system
Condensation
The change of state from a gas to a liquid. The opposite of evaporation/vaporization
Surface Tension
The cohesive forces of a liquid's surface that forces a bubble to keep its shape
Heat
The collision of molecules at varying speeds
What are Mixed/Combined Acid-Base states?
The combination of primary respiratory AND metabolic disorders occurring simultaneously
Absolute Zero
The concept of the lowest possible temperature that can be achieved. The temperature at which there is no kinetic energy and all molecular movement ceases. Cannot produce heat
Standard Temperature and Pressure Dry (STPD)
The conditions under which the volume of a gas is usually measured
Partial Pressure
The contribution each gas in a mixture of gases makes to the total pressure
Meniscus
The curved upper surface of a liquid in a tube. Can be concave or convex
Hysteresis
The difference between lung inflation and deflation curves. Has a direct relationship with surface tension
Vital Capacity (VC)
The difference between the minimum and maximum volume of air in the lungs (VC= TLC-RV)
The CO2 Cascade
The diffusion of CO2 from the highest concentration (intracellular) to the lowest concentration (atmosphere) via simple diffusion. Cells→Tissue→Alveoli→Trachea→Atmosphere
The O2 Cascade
The diffusion of O2 from the highest concentration (atmosphere) to the lowest concentration (intracellular) via simple diffusion. Atmosphere→Trachea→Alveoli→Tissue→Cells
What happens if the liter flow of an SVN is set above 10 l/min
The drug won't aerosolize properly, putting out large particles and decreasing treatment exposure time
Work of Breathing (WOB)
The effort required to expand and contract the lungs and respiratory muscles
Kinetic Energy
The energy an object has due to its motion
Humidity principle of contact time:
The evaporation increases with the amount of time air is in contact with water. Slower speeds maximize evaporation
What causes pressure gradients to develop in the respiratory cycle?
The expansion and contraction of the thoracic cage
Justice
The fair distribution of care
Cleaning
The first step in all equipment processing. Removes dirt and organic material from the surface through friction. EX: Washing hands with soap
Blood Pressure
The forced exhorted against the arterial walls with each heart beat. Normal 120/80 mm Hg
Respirable Mass
The fraction of a drug that is deposited into the lower airways
Respirable Dose
The fraction of a drug that is deposited into the lungs
Inhaled Mass
The fraction of an emitted dose that is inhaled through an aerosol therapy
Tissue Viscous Resistance
The friction caused by displacement of tissues (lungs, ribs, diaphragm and abdominal forces) during ventilation. Makes up 20% of total resistance
Respiration
The gas-exchange process of moving from the atmosphere O2 to the tissues for aerobic metabolism, and the removal of CO2 from the tissues back into the atmosphere
Humidity principle of surface area:
The greater the surface area, the greater the opportunity for evaporation to occur
Humidity principle of temperature:
The higher the temperature, the more moisture the atmosphere can hold
What types of patients may not be able to produce a fever?
The immunocompromised
Capillary Action
The liquid in a narrow tube moves upward against the force of gravity due to surface tension and strong adhesive forces
Pulmonary Surfactant
The liquid that reduces surface tension in alveoli - Produced in type II pneumoncytes - Stabilizes alveoli to prevent collapse - The more surface area to an alveoli, the more pulmonary surfactant is used/needed
Lung/Thorax Compliance and Resistance
The load the respiratory muscles must overcome to produce ventilation
Philosophy
The love of wisdom and pursuit of knowledge
Critical Pressure
The lowest pressure needed to maintain equilibrium between gas and liquid phases and exist as a liquid at the Critical Temperature
PaCO2 is controlled by what system?
The lungs
Conduction
The main method of heat transfer. Direct transfer of heat from molecules in contact
Chemically Bound O2
The majority of O2 is chemically bound to Hemoglobin (70x more than is dissolved)
Simple Disorders
The majority of acid-base balance disturbances which involve a primary abnormality in either PaCO2 or HCO3- that cause an increase or decrease in pH
Aerosol Output
The mass/amount of fluid or drug in a nebulizer
HCO3- primarily reflects what?
The metabolic component of acid-base balance as regulated by the kidneys
Convection
The mixing of fluid molecules (gas or liquid) at different temperatures
Fractional Distillation of Atmosphere Air
The most common and least expensive way to mass produce O2. Air is filtered and cooled until it is liquified, then heated until the nitrogen is burned off
Large Volume Jet Nebulizer
The most common device used for bland aerosol therapy. Pneumatically powered and connected directly to a flowmeter. Liquid particles are generated by passing high velocity gas through a constrictor. Produces 26-55 mg/L Humidity
Gaseous Diffusion
The movement of gas molecules from areas of high concentration to areas of lower concentration until they reach equillibrium
(Full) Compensation
The non-causative system shifts pH back to normal range by altering its values to oppose the causative system
Capnography
The noninvasive measurement of end-tidal CO2 in expired gases in a real-time graphic display during breathing. Provides information on a patient's ventilatory status, circulation, and metabolism
Ideal Body Weight IBW
The optimal weight recommended for a patient's height used to determine vent settings
Gas Tension
The partial pressure of gas within a liquid
P50 Value
The point at which the SaO2 is at 50% (50% of hemoglobin is saturated with O2) , usually at a PaO2 of 26.6 mmHg
Equal Pressure Point (EPP)
The point at which the pressure inside the airway is equal to that of the atmosphere. Causes airway compression and sometimes collapse. Ptm gradient is at 0
Anatomic Shunts
The portion of cardiac output that returns to the left heart without being oxygenated by exposure to ventilated alveoli. Venous blood bypasses the lungs and goes directly into arterial circulation
Voltage
The power behind electricity. Most common for homes and hospitals is 120v power
What is the hallmark of Compensated Metabolic or Respiratory Acidosis/Alkalosis?
The presence of chronic Respiratory or Metabolic Acidosis/Alkalosis that have driven the pH back to normal survivable range
Transmural Pressure (Ptm) Gradient
The pressure difference that occurs across the airway wall
Transairway Pressure Gradient (Ptaw)
The pressure gradient that causes gas to flow in and out of the lungs
Transpulmonary Pressure Gradient (PL)
The pressure gradient that maintains alveolar inflation
Aging
The process by which an aerosol suspension changes over time
Dose-Response Titration
The process of repeatedly administering specific levels of a drug then assessing patient response
Priming
The process of rolling/shaking a pMDI to mix the drug and propellant and releasing test doses to prime the device after long periods of not being used
Sterilization
The process that completely destroys all microbial life, including spores. Includes chemical, physical, steam and gases
What are the Fahrenheit and Celsius scales based off of?
The properties of water
RT Scope of Practice
The range of clinical procedures and activities that are allowed by law for RT's. Must not operate outside scope of practice
pH is determined by what ratio?
The ratio of HCO3- to dissolved PaCO2
Distributive Justice
The rationing or balance of health care services and the ability to pay for them
What opposing forces establish Transpulmonary Pressure?
The recoil forces of the lungs and chest wall
What does the Henderson-Hasselbalch Equation measure?
The relationship between blood pH and HCO3-/PaCO2
Ventilation facilitates what process?
The removal of CO2 and replenishment of O2 during respiration
Melting Point and Freezing Point are both ________
The same- 32F or OC
Thermodynamics
The science of studying the properties of matter/speed of reactions at various temperatures
How does Transmural Pressure Ptm support airway size?
The small airways (bronchioles to alveoli) rely on Ptm to stay inflated. They have no cartilage to prevent collapse
Who gives RT's their licences?
The state
Patency
The state of being open or unobstructed
What is a Capacity?
The sum of two volumes
Who is responsible for an RT's actions?
The supervising physician, medical director or hospital
Liquid-Gas Interface
The surface tension point on a bubble
What is the Whole Body Diffusion Gradient?
The systemic movement of gas through the entire body by simple diffusion
Critical Temperature
The temperature above which a substance cannot exist in the liquid state. Point at which liquid becomes gas
Dew Point
The temperature at which condensation begins (100% RH still exists)
Kelvin Scale
The temperature scale on which zero is the temperature at which no more energy can be removed from matter. Used by the International System of Units (USI)
Time Constant (TC)
The time required for local air filling expressed in seconds
Chart Review/Pre-interaction (1)
The time to review your patient's chart to get familiar with their name, age, chief complaint and medical history. At this point, clarify mentally what your role will be with this patient, and verify the physicians orders
Minute Ventilation (VE)
The total amount of air that flows into or out of the respiratory system in a minute
Radiation
The transfer of heat that occurs without direct contact between two substances
In local disease (Ex: Left-sided pneumonia), which lung should be angled down to increase V/Q matching?
The unaffected lung
Continuous Bronchodilator Therapy (CBT)
The use of an LVN to deliver high concentrations of bronchodilator therapy at 5-20mg/hour over 1-2 hours
Anatomic Dead Space (VD)
The volume of air remaining in conducting airways (nose and throat) in which no gas exchange can occur
Dead Space Ventilation (VD)
The volume of air remaining in conducting airways that does not reach the alveoli for gas exchange
Functional Residual Capacity (FRC)
The volume of air remaining in the lungs after a normal tidal volume expiration. FRV= ERV+RV
Compliance
The willingness/ability of the lungs to inflate. Healthy lungs have high compliance
Thebesian Venous Drainage
Thebesian Veins drain poorly oxygenated blood into the left atrial ventricle
What would happen to O2 and Hb molecules without 2,3-DPG?
Their affinity would be so strong that they could not be separated (No unloading into the tissues)
Bland Aerosol Therapy
Therapeutic application of liquid particles suspended in oxygen or room air
Why do alveoli at the apices have higher resting volumes?
They are larger
Why would a patient whose SpO2 reading is 100% still need O2 therapy?
They have carbon monoxide poisoning. Carbon monoxide molecules bind to hemoglobin causing a false reading that can lead to ARDS
Which flowmeter measures true flow?
Thorpe Tube
What patients are most likely to develop Methemoglobinemia?
Those Nitric Oxide (NO) therapy, Nitroglycerin or Lidocaine
How is the degree of ventilatory failure determined?
Through HCO3- levels: - HCO3- < 30 mEq/L = Acute - HCO3- > 30 mEq/L = Chronic
Device for administering Heliox Therapy
Tight fitting nonrebreather mask set to a high flow
What factors cause lung recoil?
Tissue Elasticity and Surface Tension
What happens when DO2 is inadequate?
Tissue hypoxia
Large transfusions can significantly impair _______________ due to a lack of 2,3-DPG
Tissue oxygenation
Hypoxia refers to a lack of O2 in the _______, Hypoxemia refers to a lack of O2 in the ___________
Tissues, Blood
Primary function of O2 distribution and regulation systems
To deliver O2 or air to the bedside at stable/working pressure
Indications for ABG Analysis:
To evaluate the status of: - Ventilation/PaO2 - Acid-Base/pH/HCO3-/PCO2 - Oxygenation/PaO2
What is the purpose of subsequent physical exams by health team members?
To record patent progress and response to treatment. To give a head to toe assessment by teams with various system specialities
CaO2
Total Arterial O2 Content, 16-20 mL/dL - Refers to: Total combined dissolved and bound O2 in arterial blood - Depends on: The amount of normal Hb in the blood
Physiologic Dead Space (VDphs) Volume
Total combined alveolar and anatomic dead space
System Compliance (Csys)
Total compliance of the lungs and chest wall which is reduced due to their opposite effect on one another.
Ptaw
Transairway Pressure/ The pressure difference between the airway opening and alveolar pressure
Sublimation
Transition from solid to vapor without ever becoming a liquid in between (Ex: Dry ice)
PL
Transpulmonary Pressure/The pressure difference between alveolar pressure and the pressure at the airway opening
Pw
Transthoracic Pressure/The pressure difference between the alveoli and the amount of pressure at the body's surface
Decreased fremitus indicates
Trapped air in the lungs or pleural space. Vibrations struggle to make through air. Ex: Emphysema, Asthma or Pneumothorax
Pneumothorax
Trapped air in the pleural cavity caused by a puncture of the lung or chest wall
Uncompensated Thorpe Tube
Tube is calibrated to atmospheric pressure and is not compensated for back flow. Any restriction causes flow meter to read lower than the patient actually receives
Breathing/Vent Circuit
Tubing connected from ventilator to patient
Capacity
Two or more total volumes
Patient Centered Care
Two way collaborative partnership between patients and physicians. Includes: - Individualized care - Patient involvement - Provider collaboration
Bourdon Gauge
Type of flow meter used with an adjustable pressure reducing valve. Delivers a calibrated flow to a FIXED orifice at a VARIABLE pressure. Often found on E Cylinders to deliver emergency gasses
Thorpe Tube
Type of flowmeter that delivers a calibrated flow to a VARIABLE orifice at a CONSTANT pressure. Increasing the size of the orifice increases the flow rate. Always attached to a 50 psi source. The most accurate flowmeter
Tension Pneumothorax
Type of pneumothorax in which air that enters the chest cavity and rapidly accumulates in the pleural space. Causes pressure that prevents the lungs from inflating and increased pressure on the heart
Fixed means what in blood gases?
Uncompensated
Competing
Uncooperative and assertive
Decreased resonance to percussion indicates:
Under-inflation of lungs. lack of air in tissues, often replaced by fluids. Sounds are dull and flat. Ex: Atelectasis, Pneumonia or Pleural Effusion
Too wide of a BP cuff...
Underestimates pressure
Any use of deceit to get a patient to reverse a decision or refuse treatment is ________-
Unethical
Weight is taken ________
Upon admission
Prolonged inspiratory time is indicative of an:
Upper airway obstruction
Heliox Therapy works in the _________ airways with ___________ flow to decrease ___________
Upper airway, Turbulent, Drive Pressure
How to avoid constant refilling in reservoir feed systems?
Use large water reservoirs and/or a gravity feed system
Lab Gases
Used for equipment calibration and diagnostic testing
American Standard Safety System (ASSS)
Used for large cylinders (E and up) operating at high pressures. Varies thread diameter bore, threads per inch and right or left handed threading on large cylinders to prevent accidental misconnections
Diameter-Index Safety System (DISS)
Used for low pressure gas connectors. Often found at outlets of pressure reducing valves, outlets of central piping systems, flow meters and vents. Uses a thread system on smaller scales to prevent accidental misconnections
Pin-Index Safety System (PISS)
Used for small cylinders (up to E). Uses a pin and pin hole placement system (Yolk-like) to prevent accidental misconnections. Each gas has its own pin and pin hole combo
"Blow-By" Technique
Used for young children or infants who don't like the mask. Provider or parent holds the mask two inches from the child's face and directs the aerosol towards the nose or mouth
Large Volume Nebulizer (LVN)
Used to deliver large volumes of continuous aerosol therapy to patients when traditional dosing strategies are ineffective. Delivers 2-3X the amount of medication than an SVN over 1-2 hours. Operates at 10-15 Lpm
Modified Allen's Test
Used to evaluate the adequacy of collateral circulation before obtaining an ABG sample from the radial artery. If the hand pinks up within 15 seconds after occluding the radial artery the test is positive and they ABG can be performed
Reducing Valve
Used to reduce gas pressure to a usable level (50 psi)
Therapeutic Gases
Used to relieve symptoms and improve oxygenation of patients with hypoxemia
Flowmeter
Used to set control the flow rate to the patient
Transcutaneous Analysis
Uses an O2 and CO2 electrode combined with a heating element to arterialize the area by increasing blood flow. Electrodes measure the gas pressures in the gel between the sensors
How are internal validity checks performed?
Using the Henderson Hasselbalch equation to identify gross errors
How to limit the effects of condensation:
Using water traps and a heated circuit
Because the body rarely overcompensates, what pH range is most most common in compensated imbalances?
Usually between 7.35-7.39 for Acidosis, 7.41-7.4 for Alkalosis. Rarely does a compensated imbalance result in a pH of 7.40
Where is Ventilation (V) highest in the lungs?
V is highest in the apices, usually greater than 1V/Q (approx 3.3, or 3x greater than the bases)
What is the most common cause of hypoxemia?
V/Q mismatch. Areas of high V/Q cannot compensate for areas of low V/Q, which causes PaO2 to drop
Alveolar Ventilation (VA) Formula
VA= (VT-VD) x RR VT= Tidal Volume VD= Anatomic Dead Space Volume RR= Resp Rate
Alveolar Ventilation (VA) Formula
VA= (VT-VD)RR VT= Tidal Volume VD= Dead Space Volume RR= Respiratory Rate
Most HAI's come from
VAP, Catheter related blood infections, and UTI's
Bohr Equation Formula
VD/VT= (PaCO2-PeCO2)/Paco2 PaCO2= Partial pressure of CO2 in arterial blood PeCO2= End-tidal CO2 (Partial pressure of exhaled CO2)
Physiologic Dead Space (VDphs) Formula
VDphs= VD + VA VD= Anatomic Dead Space VDalv= Alveolar Dead Space
A normal PaCO2 should be accompanied by a normal __________ range
VE Range
Minute Ventilation (VE) Formula
VE- VT(RR) VT= Tidal Volume RR= Resp. Rate
Minute Ventilation (VE) Formula
VE= RR x VT RR= Resp Rate VT= Tidal Volume
VS Trends
VS baselines and measurements taken over several days (graph form) that depict a decline, increase or stagnation in condition
Tidal Volume (VT)=
VT= VA + VD VA= Ventilation to alveoli VD= Anatomic Dead Space volume
Zone Valves
Valves found throughout piping system and can be closed for system maintenance or in case of fire. RT's responsible for shutting valves off in case of emergency
Fluid passing through a tube that meets constriction experiences a significant increase in ___________ increase and drop in _________
Velocity, Pressure
Changes in ________ OR _______ have the highesT effect on pressure/tensions
Ventilation, Perfusion
V/Q
Ventilation-Perfusion Ratio
V/Q
Ventilation/perfusion
S3 or S4 sounds indicate
Ventricular Hypertrophy (Gallop rhythm)
Kussmaul Respirations
Very deep, labored breathing usually associated with diabetic acidosis (Ketoacidosis) and metabolic/renal failure
Vocal/Tactile Fremitus
Vibration caused by speaking that is auditory and palpable. Ak patient to repeat "99" while systematically palpating the chest
Fremitus
Vibration of the chest wall produced by vocalization
Movement of a solid's atoms
Vibration/Jiggle
Intuitionism
Viewpoint that upholds that there are self evident truths based on moral maxims (like treating others fairly). Generally considered to be a poor decision making tool
Ethical Malpractice
Violations of professional ethics. May result in censure and disciplinary action.
In a dry gas cylinder, the ______ of the gas is directly proportional to its pressure
Volume
VCO2
Volume of CO2 produced per minute
VCO2
Volume of CO2 produced per minute. Normal is 250 mL/min
VO2
Volume of O2 consumed per minute. Normal is 200 mL/min
Expiratory Reserve Volume (ERV)
Volume of additional air that can be forcibly exhaled after a normal exhalation
Inspiratory Reserve Volume (IRV)
Volume of additional air that can be forcibly inhaled after a normal inhalation
Inspiratory Capacity (IC)
Volume of air inhaled after a normal exhale (IC= TV+IRV)
Tidal Volume (vT)
Volume of air moved per normal breath
Functional Residual Capacity (FRC)
Volume of air remaining in the lungs after a normal tidal volume expiration (FRC= ERV+RV)
Minute Volume Ventilation (VE or MV)
Volume of expired air in one minute, normal is ~8,000 mL per minute with flows of 5-8L/min
Alveolar Ventilation (VA)
Volume of fresh gas that reaches alveoli per minute
Charles' Law + Formula
Volume of gas varies DIRECTLY with its temperature. Pressure (Charles is stressed) is the constant. V1/T1 = V2/T2
Boyles Law + Formula
Volume of gas varies INVERSELY with its pressure. Temperature (BoIL) is the constant P1V1 = P2V2
What dilutes PIO2 in the lungs?
Water Vapor and CO2
What surrounds the alveoli?
Water and Pulmonary Surfactant
The warmer the temperature, the more _____________ it can hold
Water vapor
In a liquid gas cylinder, the ________ of the liquid is indicates the amount of gas inside
Weight
Formula for Liquid O2 Tank Duration
Weight in Lbs x 860/2.25. Answer is in minutes, divide by 60 for hours. Subtract whole number and multiply by 60 for hours + minutes
What determines wheter ventilation is effective?
When CO2 is actively removed as to maintain a normal pH
Under what circumstance can the respiratory coefficient (0.8) be dropped from the Ideal Alveolar O2 Equation?
When FiO2 is greater than, or equal to, 0.60 (60% FiO2)
26.6-50 Rule
When SaO2 is at 50%, PaO2 will be 26.6 mmHg. This is the beginning of the STEEP portion of the HB dissociation curve
60-90 Rule
When SaO2 is at 90%, PaO2 will be 60 mmHg. This is the beginning of the FLAT portion of the HB dissociation curve
Off-label Use
When clinicians explore nonstandard methods (doses, frequency and devices) for the administration of approved inhaled aerosol drugs to patients in an acute environment
Follow-up (5)
When treatment is discontinued, communicate with the patient. How do they feel? Are they comfortable?. Additional teaching in this stage. Let them know when you will return and how to contact you if needed
When would a dose-response titration indicate stoping bronchodilator treatment?
When tremors are present or heart rate increases by 20 beats per minute
Law of Heat Transfer
When two objects at different temperatures coexist, heat will always move from the hotter object to the cooler object until both are equal (entropy)
HAI's are categorized by:
Where they originate.
What is the classic indication of a combined acid-base disturbance?
Wildly extreme pH level
How is an aerosol generated?
With devices that physically disperse matter into small particles and suspend them into gas
The use of accessory muscles for breathing indicates
Working harder to breathe
Forced exhalation past a ________ volume increases WOB
Zero
Raw is measured in what units?
cm H2O per L/sec
Read-Back Scenario
method of confirming medical orders. Reporter reads values and gives patient ID. Receiver repeats back to verify understanding and gives patient ID
BP is measured in:
mm Hg/Millimeters of Mercury
Henderson-Hasselbalch Equation
pH = 6.1 + log [HCO3-]/(.03*Pco2) HCO3-= Renal/Metabolic/Base PaCO2= Lungs/Respiratory/Acid
What is the MOST IMPORTANT value the body is concerned with?
pH. It will compensate to keep this within a 0.1 range
What is the most commonly prescribed method of aerosol therapy?
pMDI
Airway radius has an exponential effect of _______ on Raw
r^4