Shannon's kettering study set

mast cell stabilizers

"sodium" drugs will help prevent an asthma attack by inhibiting the degranulation of mast cells and preventing the release of histamine and leukotrienes recommended for pts w/ exercised induced asthma (EIA) or aka exercise induced bronchospasm (EIB) these drugs are not effective once the asthma attack has begun (pt will continue to have wheezing) Cromolyn Sodium (Intal, Aarane) Nedocromil Sodium (Tilade)

perfusion scan

-albumin, tagged with radioactive iodine, is injected into a peripheral vein and when it passes into the pulmonary circulation, lodges in the capillaries -a scanning device is passed over the chest and produces a pattern of radiation that indicates a distribution and volume of perusion *normal ventilation and abnormal perfusion=pulmonary embolism.

autogenic drainage

-breathing exercises utilized to improve mucus clearance, primarily in pt with CF and bronchiectasis -pt is instructed to initally breathe low lung vol (ERV range) to loosen secretions from the small airways -pt then increases their vol by breathing in the normal VT range but exhaling to ERV -this range of breathing volumes helps to accumulate secretions in the middle airways -during the last stage the pt breathes at high lung vol

spirometers

-measures volumes and flow rates -used for spirometry in the PFT lab - portable ones are also available for testing at bedside or in outpatient settings

hypotonic saline

0.45% saline for liquefying secretions & humidifying the airway may be irritating & can cause swelling of dried retained secretions or bronchospasm

Basophils

1% of WBC

normal CVP is

2-6 mmHg

decreased CVP is

< 2 mmHg which can indicated hypovolemia (recommend fluid therapy)

vascular markings

Lymphatics, vessels, lung tissue Increased with CHF Absent with pneumothorax

mean arterial pressure (MAP)

MAP = (2x diastolic) + systolic/3

(PIP-Pplat)

Raw can be estimated by

lateral curvature of the spine (lean side to side); cant take a deep breath

Scoliosis

Level 3: responds to verbal commands (conscious sedation)

Sedation should be adjusted to achieve what level on the Ramsay Sedation Scale

scalar graphics

Waveforms that plot flow, airway pressure or volume on the vertical (Y) axis against time on the horizontal (X) axis

hypokalemia (K+ depletion)

a side effect of Lasix is

vagal response

a sudden drop in heart rate would indicate a

monitor- routine care (celebrate)

action based on APGAR score 7-10

infiltrate

any ill-defined rediodensity; atelectasis

forced expiratory flow 200-1200 (FEF200-1200)

average flow during the first 1000mL after the first 200 mL expired decreased values are associated with large airway obstruction (large airway tumors, vocal cord paralysis) typical value: 6.0 L/sec LARGE AIRWAYS

inspiratory muscle training (MIT)

benefits pts by increasing their muscle strength and endurance decreasing dyspnea, the need for meds and hospital visits; based on the concept of progressive resistance, meaning over time greater resistance is imposed on the inspiratory muscles this should increase muscle strength and endurance which should improve the pts exercise tolerance; before training MIPS are taken to compare

short acting beta agonists (SABA)

beta adrenergic bronchodilator (front door bronchodilator) rescue/quick-relief medications indicated for treatment of acute episodes of bronchoscpasm -albuterol (Ventolin or Proventil): dose is 2.5 mg in 3mL NS Q1-Q6 hours -levalbuterol (Xoponex) Q8 relievers

size 2

blade size for a pediatric

size 0

blade size for a pre-term infant

size 1

blade size for a term infant

size 3

blade size for an adult

capillary refill

blanching the infants skin to see how long it takes for normal color to return; longer than 3 seconds may indicate a decreased cardiac output

hemo

blood

decreased RR (less than 12 breaths/min) with variable depth and irregular rhythm

bradypnea (oligopnea)

hemoptysis (bleeding tumor, TB)

bright red sputum indicates

normal BS hear over the trachea or bronchi

bronchial BS

old blood, anaerobic lung infection

brown/dark sputum indicates

alveolar air equation

calculates the partial pressure of oxygen (PO2) in the alveoli; R formula: PaO2= (PB-PH2O) FiO2-PaCO2/R R is normally 0.8 and PH2O is normally 47 torr normal value varies directly with pts FiO2 and PB

3 L Range: 2.895-3.105 L (+ or - 3.5)

calibration syringe for PFT

culture, sensitivity, and gram stain

can also be performed on blood urine and pleural fluid samples

Spacers and Holding Chambers

can be used to overcome coordination difficulties; improves efficacy of MDI by allowing larger particles to attach to walls of device and decrease oral deposition; pt must still be able to understand/control his/her breathing pattern. if pt exhales immediately following activation of the inhaler pt will clear the med from the device and waste the dose; can also be used for drug delivery by MDI to intubated and mechanically ventilated pts

indication of peripheral circulation; blanching the hand and watch for color to return; color should return within three (3) seconds

capillary refill

gas diffusing capacity (DLCO, DCO)

carbon monoxide diffusion capacity measures all the factors that affect the diffusion of a gas across the alveolar-capillary membrane normal- 25 mL CO/min/mm Hg (STPD) is decreased in pts that are restricted decreased values (decreased diffusion) occurs in pts with: -pulmonary fibrosis -sarcoidosis -ARDS -pulmonary edema -emphysema (the only obstructive disease)

FVC maneuver

carefully instruct pt demonstrate procedure for pt a minimum of 3 acceptable procedures should be recorded ( no false starts, and tests should not differ by more than 5% or 200 mL) the best test should be used for reporting results and the best test is the trial that results in the largest sum of FVC + FEV1

hemoglobin

carries O2 (1.34 mL per gram Hb) normal value: 12-16 g/100 mL blood

ID size x 3/2

catheter size =

neuromuscular blocking agents (all end in "ium")

cause paralysis of skeletal muscle -pancuronium (Pavulon) -vecuronium (Norcuron) -rocuronium (Zemuron) -cisatracurium (Nimbex) -atracurium (Tracrium) all nonrepolarizers; the only one that depolarizes is succinylcholine

Mucosal vasoconstrictors/Decongestants

cause vasoconstriction to reduce blood flow and mucosal edema indications: upper airway conditions such as croup and post extubation swelling where mild/moderate stridor is present Aerosolized Racemic Epinephrine (Vaponefrin)

automated external defibrillator (AED)

computerized device w/ adhesive chest pads that are attached to a pulseless victim will recommend shock delivery only if the victim's heart rhythm is one that a shock can treat indications: no response, no breathing, no pulse

an elevated brain natriuretic protein (BNP) level would be consistent with a diagnosis of

congestive heart failure

egophony would indicate

consolidation of the lung tissue as with a pneumonia-like condition

-refractory hypoxemia -bleeding disorders -cardiovascular isntability -status asthmaticus -marked hypercapnea

contraindications for bronchoscopy

Lidocaine

control of PVC, stable ventricular tachycardia

palliative care

control of pain and other symptoms (i.e dyspnea) of terminally ill pts and maximizing the psychological, social, and spiritual well-being of ps nearing the end of life

the RT has measured the exhaled nitric oxide concentration (FENO) of a pt with asthma. The therapist notes a decrease in the pt's FENO levels from his last visit one month ago. These results would be consistent with increased use of

corticosteroids

stertor

creaky noise caused by inflammation so treat with steroids and possibly antibiotics; noisy breathing that occurs with inhalation; low pitched snoring type of sound that usually arises from the vibration of the fluid or the vibration of the tissue that is relaxed or flabby

atelectasis

crowding of ribs (close together) is associated with

extrapulmonary air

defined as air found outside the lungs; ex. pneumothorax, pneumoperitoneum, pneumomediastinum, pneumopericardium, and subcutaneous emphysema

Aerosol masks, trach collars, and face tents

delivered FiO2: 0.21-1.0 and depends upon the aerosol source and nebulizer output RA will not enter device's exhalation ports as long as devices flow exceeds pts inspiratory flow (>40 L/min)

extended tracheostomy tubes

designed to accommodate variation in the distance from the skin to the trachea; indicated for pt who are obese or use cervical collars

Reservoir Cannula

designed to maintain FiO2 at lower fowrates by using a reservoir; used commonly in the home to reduce costs and increase duration of cylinder flow; they save money for the pt

100%

desired FiO2 range for emergency conditions

24-28%

desired FiO2 range for pt with COPD

30-60%

desired FiO2 range for therapeutic conditions

peak flow meters

device used to measure and monitor PEFR for pts with asthma pt exhales forcefully through a device which incorporates a resistor and a moveable indicator accuracy is affected by pt effort; moisture and debris can also affect accuracy

one half the diameter of the chest; otherwise cardiomegaly

diameter of the heart should be

a state of profuse/heavy sweating; heart failure (recommend diuretics, positive inotropic agents [increase contractility of heart]); fever infection (recommend antibiotics); anxiety, nervousness (recommend sedatives); tuberculoses/ night sweats (recommend anti tubercular drugs)

diaphoresis

pt does not wish to have cardiopulmonary resuscitation performed

do not resuscitate order (DNR)

increase

during CPR the PETCO2 should

what are some symptoms of nose and throat

excessive nasal secretions from irritants, pollutants, allergies, upper respiratory infection, itching or burning sensations of the nose and throat, dysphagia (difficulty swallowing) and hoarseness are also common symptoms

15 L/min or low range of flush

excessively high flow may cause valves to jam use

same level prior to ventilation

for adults FiO2 for pt currently on O2 should be set at

40-60%

for adults FiO2 for pt on room air or no prior info should be set at

Pplat from VC or tp achieve target VT or < or equal to 35 cm H2O

for adults initial pressure (PC) should be set at

5-10 ml/kg of ideal body weight

for adults initial tidal volume (PC) should be set at

aerosol therapy

goals: to relieve bronchospasm and mucosal edema; to thin thick and tenacious secretions; to humidify resp. tract; to administer drugs hazards: bronchospasm (tx w/ bronchodilator); secretion swelling and airway obstruction (tx w/ sx) fluid overload [CHF, renal fail. and especially infants] (tx w/ monitoring I & O and weight; cross contamination (especially large volume, heated aerosol devices)

subtract

gradient means

stagnant sputum, gram negative bacteria (bronchiectasis, pseudomonas)

green sputum indicates

in an adult the presence of an S3 sounds is abnormal and may suggest

heart failure

bradycardia indicates

heart failure, shock, code, emergency; recommend atropine

maximum expiratory pressure (MEP)

helpful in evaluating pt's ability to maintain an airway and clear secretions (ability to cough effectively) expiratory pressures are described with positive numbers normal is 160 cm H2O; measurements of 40 cm H2O indicate poor ability to clear airway secretions pt inhales to total lung capacity (TLC); then pt blasts air out as quickly and forcefully as possible with the expiratory port occluded observe the pressure indicated on the manometer and repeat maneuver 2 more times

supplemental O2 in use, bubble in sample, or technical error

higher PaO2 values (>140) would indicate

family history includes

history of heart disease, diabetes, cystic fibrosis, asthma etc.

PaCO2 decreases towards 0 torr PaO2 increases or decreases toward 150 torr pH increases

how can air bubbles affect your ABG

PaCO2 increases PaO2 decreases pH decreases

how can improper cooling (sample not iced) affect your ABG

PaCO2 decreases toward 0 PaO2 increases or decreases towards room air (150 torr) pH decreases toward 7.0

how can too much liquid heparin affect your ABG

immerse scope in alkaline glutaraldehyde (20 mins disinfects; 24 hrs sterilizes)

how do you disinfect a bronchoscope

the dicrotic notch; the presence of a double spike is normal for the arterial pressure waveform (both pulmonary and systemic) and occurs when the pulmonic or aortic valve closes

how do you know your swan Ganz is in the pulmonary artery?

check latency of scope lumen, light source, function of optical fibers, and operation o video recording equipment

how do you prepare for bronchoscopy

O2, lidocaine, consider other causes

how do you treat multifocal premature ventricular contractions (PVC)

O2, lidocaine, consider other causes

how do you treat premature ventricular contractions (PVC)

temporarily decreases ICp results in cerebral vasoconstriction- temporary effect may be effective for minutes to hours-discontinue after 48 hrs (2 days)

how does hyperventilation and a target paco2 of 25-30 torr help reduce ICP

avoid neck flexion, head turning or tracheostomy ties that are too tight minimize increases in central venous pressure by keeping the HOB elevated > or = to 30 degrees, minimizing straining, retching, and coughing, minimize PEEP

how to lower jugular venous pressure help reduce ICP

take the pulse

how would you trouble shoot ECG

1. bronchodilator and/or anticholinergic (albuterol and/or ipratropium bromide) 2. corticosteroid (Fluticasone) 3. antibiotics (Tobramycin)

if pt is receiving multiple inhaled medications administer in this sequence:

it is an acceptable range-compensated

if pts pH is 7.35-7.45

alkalosis- uncompensated (caused by increased HCO3- or low CO2)

if pts pH is above 7.45

acidosis- non-compensated (caused by increased CO2 or low HCO3-)

if pts pH is below 7.35

was sample obtained correctly, processed promptly and correctly, and were results reported verbally

if reported lab values dont match pts clinical condition consider

restrictive

if the FEV1 is decreased but the FEV1/FVC ratio is normal then the pt has _______________ disease only

Obstruction

if the FVC cannot be completed in 3 seconds indicates

a leak; check mouthpiece/mask seal, cuff leaking, fenestrated trach tube open, loose equipment connection

if the bird mark 7 fails to cycle off it is caused by

adjust sensitivity; make sure there is a tight seal around mouthpiece

if the bird mark 7 for IPPB fails to cycle into inspiration then you

infant is straddled over rescuer arm face down (prone) the head lower than the trunk and the head is supported by firmly holding the jaw deliver 5 black blows with the heel of the hand between the infants shoulder blades turn the infuse over and apply five chest thrusts repeat the sequence until the obstruction is relieved or the infant becomes unresponsive

if the infant is responsive what are the steps for treating severe airway obstruction in an infant

-pt disconnect (vent circuit) -low spontaneous VT

if the low exhaled tidal volume alarm goes off consider

-pt disconnect -leak in vent circuit -insufficient flow -ETT cuff leak

if the low pressure alarm goes off consider

Patent ductus arteriosus with a right to left shunt; recommend an echocardiogram to determine the cause of the shunt

if the pre-ductal (right radial artery) PaO2 is 15 torr higher than the post-ductal (umbilical artery) PaO2, then the pt has a

Level 4

if the pt has a brisk response to light touch then the pt is what level on the Ramsay Sedation Scale

underexposed (under penetrated)

image does not allow visualization of the interverterbral discs through he heart shadow

over exposed (over penetrated)

image will show black lung parenchyma without blood vessels

bands

immature cells; normally 4% of WBC; increased with bacterial infections

over 60 yrs old those w/ chronic respiratory or cardiac disorders healthcare workers

immmunization against staphylococcus pneumonia z9zpneumovax) is recommended for individuals

bacterial infection

in pts with fever, chills, yellow/green sputum and elevated WBC (> 10,000 mm^3) suspect

level

in x ray the head of the clavicles should be

BP

increase in contractility will increase the

BP

increase in heart rate will increase the

leukocytosis

increased WBC is called

Positron Emission Tomography (PET scan, PET imaging)

is a procedure used to detect and diagnose disease earlier than MRI or CT scans. it can also be used to monitor a pt's response to treatment; useful in determining the presence of cancer, brain disorders and heart disease; pt is injected with a radioactive substance which is given time to distribute throughout the body; when scanning the pt lies on a table that moves through a ring-like scanner; scanning can take anywhere from 15 to 120 mins

esophageal tracheal combitube (ETC)

is an option for pre-hospital emergency airway management; should be removed and replaced with an ETT asap

huff coughing

keeps glottis open while coughing, more effective w/ COPD and head trauma to prevent increased intracranial pressures

is a combination of kyphosis and scoliosis that causes a restrictive pattern (reduced lung volumes)

kyphoscoliosis

convex curvature of the spine (lean forward); cant take a deep breath

kyphosis

supraglottic airways

laryngeal mask airway and king LT airway are both

liquid bulk O2 systems

last longer than cylinders, used often in the home non-electrical, portable units are easily filled for trips liquid systems will vent the O2 over time if not used. they are NOT to be used as a back-up system can burn fingers off w/ this 1 cubic ft will give you 24,000 L of O2

preterm infant (premature)

less than 38 weeks of gestational age

bacterial infection (recommend antibiotics)

leukocytosis indicates a

a viral infection (recommend antiviral agents)

leukopenia indicates a

Ramsay Sedation Scale

level of sedation is monitored with

how high you can go

limit variable is

salmeterol, formoterol

long-acting beta agonist

treat with fluids or blood products

loss of fluids- decrease pressure

metabolic acidosis

low CO2 content reflects low HCO3-; leading to

that the ETT is in the esophagus

low ETCO2 readings immediately following intubation would indicate

anemia

low Hct is referred to as

respiratory problems

low birth weight infants are at higher risk for

simple mask

low flow device Delivered FiO2: 0.40-0.55 Flow: 6-10 L/min Flow must be at least 6 liters to flush out exhaled CO2

partial rebreather mask

low flow device delivered FiO2: 0.60-0.65 Flow: 6-10 L/min has no one-way flap valves

anemia (type 1)

low hemoglobin content normal ABG can be misleading if PaO2 and SaO2 are normal; watch for Hb <12 g occurs in post-op pts, trauma victims pt may be hypoxic (PVC, tachycardia, distress) but not cyanotic treatment is to restore normal Hb levels; give O2 to support pt until transfusion is completed

anemia

low hemoglobin is referred to as

sodium (Na+)

major extracellular cation controlled by the kidneys normal range: 135-145 mEq/L is retained in exchange for K+

potassium (K+)

major intracellular cation; important for acid-base balance and muscle function, including cardiac muscle normal range: 3.5-4.5 mEq/L

manual resuscitation bag (Self-inflating)

mask design: well fitting, malleable, transparent Reservoir: provides 95-100% O2 at 15 L/min optional peep valve

trachea shifts away from

massive pleural effusion tension pneumothorax neck or thyroid tumors large mediastinal mass

cromolyn sodium, nedocromil sodium

mast cell stabilizer

segs

mature cells; normally 60% of WBC; decreased with bacterial infections

pulmonary artery

may be enlarged as a result of pulmonary hypertension or embolism

plateau pressure

measured at the end of inspiration while the pt is forced to hold the volume momentarily (using inflation hold, pause or plateau)

blood pressure (systemic arterial)

measures the systolic and diastolic pressures; use a sphygmomanometer to measure cuff pressures

Intra-hospital transport

moving pts within the hospital to perform diagnostic procedures (CT scan, MRI, etc.) or to transfer pt to different level of care (ED, ICU, ICU to OR, etc.)

chronic bronchitis

mucoid (white/gray) sputum indicates

standard sx catheter aka whistle tip

must have a beveled tip with at least 2 openings to decrease tracheal damage and a thumb port to provide intermittent sx

flaring of nostrils during inspiration; a sign of respiratory distress in infants

nasal flaring

obstructive sleep apnea (OSA)

nasal flow decreases while respiratory effort continues

infarction

necrosis or death of tissue (end result of ischemia and injury); may be recent (acute) or old; diagnosed by significant Q waves

asystole tx: confirm in 2 leads first, CPR, epinephrine

no rhythm; cant shock bc there is nothing to shock

spontaneous

pt controls all variables pertaining to ea. breath

vital capacity (VC)/ slow vital capacity (SVC)

pt is instructed to take a maximal inspiration followed by a maximal exhalation without force

prone

pt lying face down

supine

pt lying on spine

lateral decubitus position

pt lying on the affected side; valuable for detecting small pleural effusions; shows blunting of costephrenic angles

if the pt is alert and responsive it is

normal

straight spine no alterations in chest size; no leaning forward (kyphosis) or side to side (scoliosis)

normal A-P diameter

Slightly acidotic

normal ABG values for a newborn are

7-10

normal APGAR score is

-2-+2

normal BE

120/80 mm Hg

normal BP

50/30 mmHg

normal BP for preterm infant

60/40 mmHg

normal BP for term infant

range: 90/60 - 140/90 mm Hg

normal BP range

< 50 torr

normal PaCO2 for newborn

1 mL/lb of ideal body weight

normal anatomic deadspace for bedside pulmonary function

98% 95-100% 70-75%

normal arterial SO2 value: normal acceptable arterial range for SO2: normal venous range for SO2:

7.40 7.35-7.45 7.35

normal arterial pH value: normal acceptable arterial range for pH: normal venous value for pH:

0 -2 - +2 0

normal arterial value for BE: normal acceptable arterial range for BE: normal venous value for BE:

20 vol% 17-20% vol%

normal arterial value for CaO2: normal acceptable arterial range for CaO2: normal venous value for CaO2:

24 mEq/L 22-26 mEq/L 24 mEq/L

normal arterial value for HCO3: normal acceptable arterial range for HCO3: normal venous value for HCO3:

14 g 12-16 g 14g

normal arterial value for Hb: normal acceptable arterial range for Hb: normal venous value for Hb:

< 20 m/Hg/L/min or 1600 dynes/sec/cm^-5

normal systemic vascular resistance (SVR)

120 mmHg

normal systolic pressure for an adult

36.5 degrees celsius

normal temperature for an infant is

36.5 degrees Celsius

normal temperature for infant is

38-42 weeks

normal term infant is

< 0.1 ng/mL

normal troponin

Atrial Flutter tx: digoxin, beta blockers, calcium channel blockers

occurs when a single ectopic focus in the atria fires rapidly this creates a series of identical P waves that take on the "saw-tooth" appearance

anterior protrusion of the sternum

pectus carinatum

2

pediatric laryngoscope blade size

intracranial pressure (ICP) monitoring

performed to track the dynamics inside the skull such as volume-pressure relationships, pressure waves, and cerebral perfusion pressure

getting oxygen into the tissue is

perfusion

Phosphatidylglycerol (PG)

phospholipid appearing at about 36 weeks gestation and rising until term; most reliable indicator of pulmonary maturity even with diabetes; only performed on abiotic fluid

pulmonary edema

pink frothy sputum indicates

a grating sensation felt on the chest wall due to roughened pleural surfaces rubbing together

pleural rub fremitus

bird mark 7 ventilator for IPPB therapy

pneumatically powered; pressure cycled; turning knob to a higher number causes a greater flow into the mainstream breathing circuit and nebulizer (decreases insp. time) the opposite occurs if flow control is turned to a lower number (increases inspiratory time)

if bronchial BS are hear on the R lower lobe then the pt may have

pneumonia

prone position

position that may enhance oxygenation for ARDS

unequal (asymmetrical) movement of the chest can indicate underlying pathology such as

post lung resection atelectasis pneumothorax flail chest endotracheal tube inserted in right or left mainstem bronchi

hand held small volume nebs (SVN)

powered by gas source; 1-3 sec breath hold to enhance med delivery; sputtering sound indicates most of solution has been nebulized; given if pt is unable to use a MDI or DPI medications that can be delivered: albuterol, levalbuterol; ipratropium bromide, tiotropium bromide, fluticasone, budesonide, triamcinolone, acetylcysteine, Pulmozyme, tobramycin

2.5-3.0

pre-term infant ETT size

Cerebral Perfusion Pressure (CPP)

pressure gradient that determines cerebral perfusion; formula: CPP= MAP-ICP; normal value: 70-90 mmHg; must be at least 70 mmHg

Incentive Spirometry (IS)

prevention/treatment of atelectasis for pts who are willing and able to spontaneously take a deep breath; should be performed hourly while pt is awake for about 10 breaths

built in shut off device

prevents aspirated secretions from entering the regulator and vacuum system when the bottle is full

>20 mm Hg

recommend initiating treatment for ICPs:

hyperchloremia

refers to high Cl- metabolic acidosis

electrolytes

required by the body for normal metabolism; abnormal levels indicate abnormal body function; closely associated with fluid levels, muscle function (cardiac) and kidney function

Normal diagnostic chest percussion

resonant

normal air filled lung; this gives a hollow sound

resonant

palpable rhonci secretions in the airways

rhoncal fremitus

coarse crackles

rhonchi that clear with a cough; large airway secretions; (suction pt or instruct to cough)

crackles (rales)=

secretions/fluid

Paradoxical pulse/pulsus paradoxus may indicate

severe air trapping status asthmaticus tension pnuemothorax cardiac tamponade (should consider this an emergency)

CO2

severinghouse electrode

albuterol, levalbuterol

short acting beta agonists

occluded

should adjust vacuum pressures with tubing

the cuff

should not extend over the end of the endotracheal or tracheostomy tube

severe airway obstruction

signs: poor or no air exchange; weak ineffective cough or no cough at all; high-pitched noise while inhaling or no noise at all; increased respiratory difficulty; possible cyanosis; unable to speak or cry; clutching neck with thumb and fingers (universal choking sign)

sinus arrhythmia

sinus rhythm with irregular rate; has p wave

sinus bradycardia tx: O2, atropine

sinus rhythm with rate <60

Sinus Tachycardia tx: O2

sinus rhythm with rate >100

bronchospasms *remember some beta drugs are not beta 1 specific meaning they could block beta 2 and cause bronchospasms

some beta 1 and beta 2 drugs can cause

CO poisoning, anemia, or pulmonary embolus

some pts will have ABG results that do not match their clinical appearance type 1: if the ABG looks good and the pt looks and feels bad then consider

COPD

some pts will have ABG results that do not match their clinical appearance type 2: if the ABG looks bad and the pt looks and feels fine then consider

normal heart sounds

sounds created by the closure of the heart valves; 1st sound (S1): created by the normal closure of the mortal and tricuspid valves at the beginning of ventricular contraction 2nd sound (S2): is normal and occurs when systole ends; the ventricles relax and the pulmonic and aortic valves close

autoclave

steam under pressure

extubation

sx the airway below and then above the cuff deflate the cuff have the pt inspire deeply remove the tube at peak inspiration to prevent vocal cord damage have the pt cough to clear any remaining secretions administer oxygen and humidity as indicated observe for any complications (laryngeal edema (stridor) and airway obstruction

subjective info, those things that the pt must tell you (dyspnea, pain, nausea, muscle weakness, etc)

symptoms

vibrations that are felt by the hand on the chest wall

tactile fremitus

end expiratory image

taken when the pt is at end-exhalation; valuable for detecting a small pneumothorax; can measure diaphragmatic excursion; should be done after bronch and a-line being done

0.28 L/psi (0.3)

tank factor for E cylinder

3.14 L/psi (3.0)

tank factor for H cylinder

arterial-venous oxygen content difference (C(a-v)O2)

the CvO2 is subtracted from the CaO2 measures the O2 consumption of the tissues formula: C(a-v)O2 = CaO2-CvO2 Shortcut: C(a-v)O2 = (SaO2-SvO2) x 0.2 normal. value: 4-5%

nitrogen wash out (open method)

the FRC is washed out of the lung by having the pt inspire 100% O2 to replace the nitrogen in the FRC the amount of nitrogen removed is used to calculate FRC

exhaled VT

the actual volume delivered to pt will be lower than the set VT bc a portion of the volume (compressible gas volume) remains in the expanded ventilator circuit

edema, secretions, tumors, aspirated foreign bodies, (most of these conditions would be identifiable on an appropriate chest or neck x-ray)

the airway can also be narrowed by

blood

the amount of fluid in the circulatory system will affect the blood pressure

mediastinum

the area between the lungs where the heart, lymphatics, blood vessels and major bronchi are found; may shift with a pleural effusion or pneumothorax

Auto-trigger (auto-cycle)/Oversensitive trigger

the breath is not mandatory nor is it pt-initiated (no diaphragmatic contraction) causes: -leaks in circuit or airway -inappropriate trigger setting which is too sensitive -condensation in vent ciruit -bounding pulse or cardiac movement causing vent to trigger Correction: recognize and adjust trigger sensitivity

cardiac index (CI)

the cardiac output (QT) divided by the body surface area (BSA) in meters-squared (m2) Cl = QT/BSA normal value: 2.5-4.0 liters/min/m2 for pts of all sizes

SA node (pacemaker)

the electrical impulse is generated by the SA node

no greater than 1/2 the inside diameter (ID) of endotracheal or trach tube

the external diameter of the sx catheter should be

the process of ensuring that a pts medication list is as accurate and up to date as possible should be carried out within

the first 24 hours of admission to hospital

airway resistance (Raw)

the frictional force that must be overcome during breathing

20-22 inches

the ideal sx catheter length is

Cardiac Output (CO/QT)

the modified Fick equation used to calculate cardiac output when O2 consumption (VO2) and O2 content difference are known (Ca-vO2) formula: VO2/ C(a-v)O2 (10) normal value: 4-8 L/min

down and to the left

the normal direction and electrical activity

decelerating wave

the normal flow pattern for a pressure control or pressure support breath

square wave

the normal flow pattern for a volume control breath

systemic vascular resistance (SVR)

the pressure gradient across the systemic circulation divided by the cardiac output SVR= (MAP-CVP)/ cardiac output normal value: <20 mmHg/L/min or 1600 dynes/sec/cm-5 is increased with systemic hypertension and/or vasoconstriction (especially form alpha type drugs)

lung compliance

the relative ease which distends the lung/thorax structure

obstructive

the shape of the flow volume is diagnostic; a short and wide loop is

tube is obstructed- unable to pass a sx catheter, remove tube, ventilate, and insert new tube tube is too small- very high cuff pressures (>25 mmHg) needed to seal cuff; change to a larger tube punctured cuff- unable to seal the cuff; replace the tube if a seal is required

the tracheostomy tube should be changed if

cycling variable

the variable that ends (terminates) inspiration the inspiratory phase of a positive pressure breath

p wave (atrial depolarization)

the wave of depolarization that moves through the atria causing contraction

Croup (laryngotracheobronchitis)

the xray of the neck will reveal tracheal narrowing with subglottic swelling in a classic pattern called: -steeple sign -picket fence sign -pencil point sign hourglass sign

quad cough

therapist applies pressure to pts abdomen during exhalation

pressure control (PC) or pressure target

therapist sets a pressure to be delivered; volume varies

volume control (VC) o volume target

therapist sets a volume to be delivered while pressure varies

-hyoerventlation: target paco2 25-30 torr -lower jugular venous pressure -sedation and analgesia osmotic agents to remove fluid from brain

therapy to reduce ICP:

-recommend initiate MV -recommend/ select initial vent settings

there are three phases to MV; phase 1 is

-monitor pt receiving MV -recommend/initiate changes to vent settings -identify and correct problems w/ pt and/or ventilator

there are three phases to MV; phase 2 is

-assess the pts readiness for weaning -implement weaning procedures -monitor the pt during weaning

there are three phases to MV; phase 3 is

anticholinergics (parasympatholytics) (back door bronchodilators)

these drugs work against the bronchoconstriction caused by the parasympathetic nervous system (decrease cyclic GMP) act by blocking cholinergic parasympathetic receptors -ipratropium bromide (Atrovent) -tiotropium bromide (Spiriva) -oxitropium bromide (Oxivent) these bronchodilators can be given with short acting beta adrenergic (SABA) bronchodilators for persistent bronchospasm for maximum effect

radial, brachial, femoral (if BP is low -60/40)

three primary sites for ABG

gestational age

time since the estimated date of conception

below vocal chords; approx. 2-6cm above carina; at level of aortic knob or aortic arch

tip of endotracheal tube should be positioned:

inspect-look auscultate- bilateral BS capnography/CO2 detectors- color change from purple to yellow/gold chest xray-tip of tube should be 2-6cm above carina or at the aortic knob/notch

to assess tube position post intubation you

multiply by 80

to convert mmHg/L/min to dynes

culture sensitivity or gram stain

to identify causative organism by

lidocaine, benzocaine, cetacaine, or novocain (Caine = numbing med)

to prepare pt for bronchoscopy administer local (topical) anesthetic to control cough/gag reflex such as

Bicarbonate (HCO3-)

total CO2 content

when assessing airway patency you look for signs of changes to upper airway such as:

tracheal shift/deviation enlarged thyroid short receding mandible enlarged tongue (macroglossia) bull neck limited range-of-motion of the neck or cervical spine

should be approx 26-29 cm mark at pt's nare

tube distance marking for nasal intubation

should be approx 21-25 cm mark at pt's lips

tube distance marking for oral intubation

Procainamide (Pronestyl)

tx of ventricular ectopic beats, ventricular tachycardia & atrial arrhythmias

normally heard over air-filled stomach. this is a drum-like sound and indicates increased volume when heard over the lungs (more air)

tympanic

neutrophils, eosinophils, basophils, lymphocytes, monocytes

types of WBCs

Troponin and Brain Natriuretic Peptide (BNP)

types of cardiac enzymes/biomarkers

-cardiogenic -neurogenic or vasogenic -anaphylactic -septic -hypovolemic -traumatic

types of shock

6.0 L/sec or 80% of predicted or higher

typical value for FEF200-1200

4.7 L/sec or 80% of predicted or higher

typical value for FEF25-75%

4000 mL or 4.0 L or 80% of predicted or higher

typical value for FEV1

83%

typical value for FEV1/FVC

4800 mL or 4.8 or 80% of predicted or higher

typical value for VC

0.6-2.4 cm H2)/L/sec

typical values fir airway resistance

25 mL CO/min/mmHg (STPD)

typical values for DLCO

10 L/sec (600 L/min) or 80% of predicted

typical values for peak expiratory flowrate (PEFR)

prothrombin time (PT)

used for monitoring Warfarin (coumadin) therapy; normal value: 12-15 secs

loop graphics

waveforms that plot two of the primary ventilator parameters against each other (i.e., pressure-volume loop and flow-volume loop)

-SIMV -SIMV w/ PSV -CPAP -CPAP w/ PSV -T-piece (sink or swim)

weaning methods include:

- identify & quantify changes in pulmonary function - evaluate need and quantify therapeutic effectiveness - perform epidemiologic surveillance for pulmonary disease - assess pts for risk of postoperative pulmonary complications - determine pulmonary disability

what are indications for pulmonary function testing (PFT)

-accumulated secretions -obstructed airway -depressed cough -inability to swallow

what are indications for sis

-volume cycled -pressure cycled -time cycled -flow cycled

what are the four types of cycling variables

-inverse ratio ventilation -airway pressure release ventilation (APRV) -pressure regulated volume control (PRVC) -proportional assist ventilation (PAV, PAV+)

what are the secondary modes of ventilation

-continuous positive airway pressure (CPAP) -pressure support (PS, PSV) -volume support (VS)

what are the spontaneous breathing mode options on the ventilator

heart, blood and vessels

what are the three factors that control blood pressure

rigid bronchoscope flexible bronchoscope

what are the two main types of bronchoscopes

assist/control (A/C) mode and synchronous intermittent mandatory ventilation (SIMV) mode

what are the two primary modes of ventilation

1. turbine device (wright respirometer) 2. pressure differential (fleisch) pneumotachometer

what are the two types of pneumotachometers

galvanic fuel cell and polarographic

what are two types of O2 analyzers

-20 cm H2O

what is acceptable maximum inspiratory pressure (MIP)/Negative inspiratory force (NIF):

< 10 L/min

what is acceptable minute ventilation (VE) L/min

<10 L/min

what is acceptable minute ventilation (VE) L/min

<100

what is acceptable rapid shallow breathing index (RSBI) RR/VT

> or equal to 5 mL/kg

what is acceptable spontaneous VT

97 torr

what is normal PO2

80-100 torr

what is normal PO2 range

mild epistaxis (nasal bleeding)

what is the most common complication when the nasal route for bronchoscopy is used

-maintain airway patency -collect sputum specimen -0stimulate cough

what is the purpose of suctioning

<80 torr

what is unacceptable PO2

>45 torr

what is unacceptable PaCO2

<7.35

what is unacceptable pH

flexible bronchoscopy

what kind of bronchoscopy for intubated pts with suspected neck fracture

pulse ox and electrocardiogram

what kind of monitoring equipment do u need for bronchoscopy

narcotics and benzodiazepines avoid hypotension (versed/pain meds)

what kind of sedation and analgesia help manage ICP

PaCO2

when deciding if a pt is ventilating you look at

PaO2 and FiO2

when looking at a pt's oxygenation you are looking at

compensated or chronic

when the pH is inside the acceptable range (7.35-7.45) then it is

non-compensated or acute

when the pH is outside the acceptable range then it is

leak or insufficient flow

when there is a loss of pressure in bird mark 7 ventilator for IPPB it may mean

obstruction or excessive flow

when there is excessive pressure in bird mark 7 ventilator for IPPB it may mean

pt valve may be stuck open or closed

when trouble shooting a manual resuscitation bag (self-inflating) if bag becomes difficult to compress and pt compliance is normal then

-first: decrease FiO2 to less than 0.60 -then: decrease PEEP

when you wish to decrease a high PaO2

normal HR in adults

60-100/minute

pulmonary ventilation/ perfusion scan (V/Q scan)

1. ventilation scan 2. perfusion scan -a normal ventilation scan with an abnormal perfusion scan indicates a pulmonary embolism

ET sx

100% pre and post sx required; ECG monitoring is important to detect problems caused by iatrogenic hypoxemia; sterile catheter solutions and gloves should be used each time sx ETT first thn mouth; change catheter after sx mouth then sx ETT

normal RR in adults is

12-20 breaths/min

lymphocytes

30% of WBC

antianginal agents

Relief of pain (angina pectoris) is almost immediate - Nitroglycerine - Isordil

determine if the current care plan is appropriate, recommend or modify as necessary (case management plans, therapy protocols, disease management, pt and family education needs)

Respiratory care plan

Plethysmograph/ Body Box

- based on boyle's law - measures thoracic gas volume at FRC -pt pants at FRC while pressures and volumes are obtained -measures gases trapped inside the lung and otherwise excluded from the FRC with the other procedures (He dilution and N2 washout) -the advantage of this is that it will more accurately measure FRC in pts with obstructive lung disease -pt performance standards include: a min of 3 acceptable maneuvers with VTG values within 5% of ea. other; reported VTG should be the average of 3 or more acceptable maneuvers - in pts with normal lungs or a restrictive disorder FRC will be equal when measured by He dilution, N2 washout, and body plethysmograph

Exhaled nitric oxide (FEno) testing

- measurement of nitric oxide concentration in patient's exhaled breath - used to monitor patient's response to anti-inflammatory (corticosteroid) treatment - a decrease in FEno suggests a decrease in airway inflammation -useful in monitoring pts with asthma, cystic fibrosis, or COPD - measured using handheld device (NIOX) that provides accurate reproducible and immediate measurement of fractional exhaled nitric oxide (FEno)

Activated partial thromboplastin time (APTT)

- measures the length of time required for plasma to form a fibrin clot - used for monitoring heparin therapy -normal value: 24-32 secs

bradycardia is

<60/minute

increased CVP is

> 6 mmHg which can indicate hypervolemia (recommend diuretics-LASIX)

tachycardia is

>100/minute

resuscitate

action based on APGAR score 0-3

support- stimulate, warm, administer O2

action based on APGAR score 4-6

a closed system or inline sx catheter (Ballard)

allows pt to receive ventilation and oxygenation during sx; consists of a plastic sleeve surrounding catheter to prevent catheter contamination when not being used indicated for pts with high O2 and/or PEEP requirements; pulmonary infection; need for frequent sx; hemodynamic instability

trouble shooting

always provide manual ventilation first when

disinfection process

alcohol is a

predicted normal values

all measured values are compared with the predicted normal values for that individual the relationship is expressed as a percent actual value/predicted value = % of predicted predicted values are primarily based on: -age, height, sex/gender, race/ethnicity > or equal to 80% = normal PFT < 80% = mild disorder < 70% = moderate disorder < 60% = moderately severe disorder < 50% = severe < 35% = very severe

bode adapter

allows pt to continue receiving positive pressure ventilation during the procedure

inflection point

an abrupt change in direction of a loop graphic. may be seen on the pressure-volume loop and used to identify the best PEEP level (lower inflection point) and the best volume (upper inflection point)

ARDS (acute respiratory distress syndrome)

an acute illness or injury to the lungs that results in reduced lung compliance, diffuse atelectasis and refractory hypoxemia etiology: sepsis (most common cause); aspiration; pneumonia; severe trauma; massive blood transfusion; drug abuse pt assessment: -cyanotic -tachypnea, substernal or intercostal retractions -BS: bronchial, crackles -flat/dull note -VS: tachycardia, hypertension Dx: -chest x-ray: increased opacity, diffuse alveolar infiltrates w/ a honeycomb or ground glass appearance -ABG: refractory hypoxemia, acute alveolar hyperventilation w/ hypoxemia -pulmonary function: decreased volumes and capacities (VT, RV, FRC, and TLC) -hemodynamic monitoring reveals elevated PAP w/ normal PCWP Tx: -treat underlying cause -O2 therapy -CPAP/PEEP to treat refractory hypoxemia/ pulmonary shunting -closely monitor hemodynamics -hyperinflation therapy (SMI/IS, IPPB) for atelectasis -MV as indicated: reduce VT to 6 mL/kg; maintain Pplat pressure < 30 cm H20; initiate recruitment maneuvers -consider alternative approaches to MV: inverse ratio ventilation (IRV); airway pressure release ventilation (APRV); pressure regulated volume control (PRVC); high frequency ventilation (HFV) -consider proning pt to improve oxygenation -consider inhaled nitric oxide (iNO) or epoprostenol to tx elevated pulmonary artery pressure -reference for evidence-based practice: ARDSnet ventilator protocol

a decrease in ventilation (ventilatory failure)

an increase in the PECO2 or PETCO2 would indicate

nosocomial infection

an infection acquired at least 72 hrs after admission to a hospital or other health care facility

a productive cough may indicate

an infection or chronic lung disease

pneumonia

an infectious inflammatory process that primarily affects the gas exchange area of the lung causing capillary fluid (serum) to pour into the alveoli pt assessment -diaphoretic, cyanotic -tachynea -crackles, bronchial, whispered pectoriloquy -flat or dull note over affected area -cough productive of yellow/green sputum, may also be rust colored -febrile, tachycardia, hypertension Dx: -chest x-ray: increased density from consolidation and atelectasis, air bronchograms, pleural effusion -ABG: acute alveolar hyperventilation with hypoxemia -Pulmonary Function: decreased volumes and capacities (VT, VC, and TLC) -CBC: increased WBC w/ bacterial infection, decreased WBC w/ viral infection -sputum: recommend culture and sensitivity evaluation of sputum; culture results will identify causative organisms Tx: -O2 therapy -bronchial hygiene therapy -hyperinflation therapy (IS/SMI, IPPD) -MV for ventilatory failrue -VAP protocol for intubated pts -antibiotics as indicated from sputum culture and sensitivity -thoracentesis for pleural effusion -bedrest -adequate fluid intake -OTC meds to reduce fever aches pain and control cough

RBC red blood cells

contain hemoglobin necessary for oxygen transport normal value: 4-6 mil/mm3

foam cuff (kamen- Wilkinson, Bivona)

foam-filled cuff; air is evacuated prior to insertion; pilot tube is left open to the atmosphere and foam expands to seal trachea; air must be evacuated to extubatne pt; do not inflate the cuff with a syringe; has no inner cannula; does not have a pilot balloon

increase FiO2 to 100% increase high pressure alarm

for a bronchoscopy you must

dont change ventilation

for a pt with COPD that has an abnormal PaCO2 with a normal pH

same level prior to ventilation

for adult pts currently on CPAP PEEP should be set at

4 mL/kg

for adult pts with severe asthma recommend an initial VT of

10-20 breaths per min

for adults what should initial RR (f) be set at

2-6 cm H2O (In real life 5-8)

for adults with no prior info PEEP should initial be set at

when the pt is instructed to say "E" and it sounds like an "A".

egophony

obstructive sleep apnea

exhaled CO2 levels may also be elevated in pts with

Do Not Resuscitate (DNR) orders

explicit instructions from the pt regarding his/her care in the event of cardiopulmonary arrest may specifically address blood transfusions, intubation, MV, defibrillation, cardiopulmonary resuscitation

hyperlucency

extra pulmonary air; COPD, asthma attack, pneumothorax

sepsis

extreme response to an infection; infection can occur in lungs, GI tract, urinary tract, nasal sinuses, surgical sites, etc highest risk in: -immunocompromised pts, especially those with cancer or HIV -pts takin steroids & anti-rejection drugs -very young babies -the elderly especially those with other health problems -any hospitalized pts -post-operative pts -pts w/ diabetes pt assessment -chills, diaphoretic, nausea, vomiting -dyspnea, tachypnea -BS: crackles, rhonchi -flat or dull note over affected area in presence of pneumonia -cough: productive yellow/green sputum in presence of pneumonia -febrile, tachycardia, hypotension Dx: -chest x-ray: increased density from consolidation and atelectasis in presence of pulmonary involvement otherwise may be normal -ABG: acute alveolar hyperventilation w/ hypoxemia -CBC: increased WBC w/ bacterial infection, decreased WBC w/ viral infection -blood cultures: should be drawn prior to initiating antimicrobial therapy -sputum: gram positive or gram negative organisms in presence of pulmonary involvement Tx: -support circulation & perfusion -IV hydration -antimicrobial therapy based on results of culture -standard precautions to prevent spread of infection

shock

failure of the cardiovascular system to adequately perfuse tissues that results in widespread impairment of cellular metabolism; a reduction in blood flow to the tissues that is inadequate to sustain life pt assessment -pale or cyanotic, cold, clammy, lethargic, unresponsive, diaphoretic, poor capillary refill -tachypneic, SOB Dx: -ABG: hypoxemia -decreased CVP, PAP, PCWP, QT -urine output: decreased Tx (depends on cause): -MV for ventilatory failure -vasopressors for vasogenizc shock (dopamine, dobutamine) -inotropic agents for Heart failure (digitalis, digoxin) -antibiotics for infection -tx hypovolemia w/ IV fluids

normally heard over the sternum muscle or areas of atelectasis (normal)

flat

pressure support ventilation

flow cycle is

flow asynchrony (flow starvation/mismatch)

flow rate does not meet pts inspiratory flow demands illustrated by a dip or drop in the inspiratory pressure graph corrected by: -increasing flow -decreasing inspiratory time -increasing expiratory time

partial vocal cord paralysis (large airway obstruction)

flow-volume loops can evaluate

pulmonary edema

fluffy infiltrates, butterfly pattern, batwing pattern diffuse whiteness, infiltrate in shape of butterfly tx w/: diuretics, digitalis, digoxin

changes in central venous pressure (CVP) can indicate changes in

fluid balance

increasing airway resistance (Raw) common causes: secretions, bronchospasm Tx: sx, bronchodilator

if peak inspiratory pressure (PIP) INCREASES plateau pressure REMAINS CONSTANT it can mean

Adrenergic + anticholinergic

be careful to administer only one drug from ea. category ipratropium bromide (Combivent, DuoNeb) bronchodilation; more control of bronchospasm for pts with COPD & asthma; reduced drug dosages; avoidance of steroids

debris form entering the regulator

before attaching regulator open cylinder valve slowly to discharge gas, then close. this cracking of the tank valve prevents

fowlers, semi-fowlers or reverse trendelenburg

best position for hypoxic pts, obese pts with dyspnea, post-op abdominal surgery pts, and pts with pulmonary edema

lateral flat

best position to prevent aspiration

Long Acting Beta Agonists (LABA)

beta adrenergic bronchodilator (front door bronchodilator) maintenance/long term control medication indicated for long term control of bronchospasm in pts with asthma & COPD taken twice daily to control symptoms should not be used for acute episodes of bronchospasm -Salmeterol (Serevent) -Formoterol (Foradil) -Arformoterol (Brovana) Q12 relievers

disinfection process; most appropriate for surface disinfection, used to clean blood spills, equipment surfaces, etc.

bleach is a

hemothorax

blood accumulated in the pleural space pt assessment: -cyanosis, tracheal and/or mediastinal shift away from the affected side bruising over the infected area -tachypnea, productive cough (hemoptysis) -BS: diminished or absent on affected side -flat/dull percussion note on affected side Dx: -chest x-ray: increased radio density, tracheal shift away from the affected side -ABG: acute alveolar hyperventilation w/ hypoxemia -CBC: reduced RBC/Hb/Hct Tx: -thoracentesis or chest tube to drain fluid -O2 for hypoxemia -hyperinflation therapy (IS/SMI IPPB) after chest tube insertion -MV w/ PEEP for acute ventilatory failure

acyanosis

blueish extremities and is not true cyanosis

pleural effusion

blunting/obliteration of costophrenic angle, basilar infiltrates with meniscus, concave superior interface/border fluid level on affected side, possible mediastinal shift to unaffected side Tx w/: thoracentesis, chest tube, antibiotics, steroids

Geriatric care

caring for older adults (> or equal to 65 yrs old) w/ serious illness presents special challenges factors that affect the ability to survive a serious illness -severity of the illness -co-morbidities -reason for and duration of MV pt assessment -pre-admission health status -cognitive and functional ability -current medication list and compliance -nutritional status -identify pulmonary and cardiovascular disorders -determine presence of swallowing problems -risk of aspiration Tx: -early & frequent mobilization/ambulation -effective pain control -careful management of fluid status -encourage and assist w/ deep breathing & coughing -VAP prevention for pts requiring MV -monitor O2 and tx any hypoxemia -early weaning trials and extubation

neuromuscular blocking agents

cause paralysis of skeletal muscle indicated for pts receiving MV to: -reduce spontaneous breathing -prevent movement that can dislodge airways, catheters, chest tubes etc. -reduce O2 consumption in pts w/ poor cardiopulmonary status -improve pt synchrony w/ the vent 2 types: depolarizing neuromuscular blocking agents and nondepolarizing neuromuscular blocking agents

COHb levels in blood, exhaled CO levels (FECO), and cotinine levels in blood and urine

compliance of smoking cessation can be monitored by

provide humidity, oxygen and/or racemic epinephrine as necessary

complications from extubation: mild distress/stridor, sore throat can be managed by

oxygen, cool mist aerosol, racemic epinephrine, heliox therapy

complications from extubation: moderate distress/ stridor can be managed by

reintubate the pt

complications from extubation: severe respiratory distress and/or marked inspiratory stridor can be managed by

meconium aspiration syndrome (MAS)

condition in which a fetus aspirates a mix of fetal stool (meconium) and amniotic fluid during episodes of ffetal hypoxemia; occurs most commonly in full-term or post-term infants; results in chemical pneumonitis, upper airway obstruction, and hypoxia-induced pulmonary artery hypertension pt assessment: -cyanosis; stained with meconium -grunting, retractions, nasal flaring, gasping w/ tachypnea -BS: wheezes, rhonchi, crackles, expiratory grunting -tachycardia, hypertension Dx: -chest x-ray: irregular densities throughout the lungs w/ atelectasis & consolidation -ABG: acute alveolar hyperventilation w/ hypoxemia Tx: -sx the nasopharynx & oropharynx thoroughly when amniotic fluid is stained -if the infant is vigorous active & crying (pulse >100, strong RR, good muscle tone): 1. sx mouth & nose to clear pharynx 2. warm, dry & observe 3. blow-by O2 as needed -if infant is not vigorous (pulse <100, limp, depressed, poor tone, absent or gasping respirations 1. initiate positive pressure ventilation if infant is not breathing or if HR is less than 100/min 2. support ventilation & oxygenation, which may include intubation & sx I f airway is obstructed -stabilize infant & transfer to ICU 1. vigorous pulmonary hygiene (postural drainage, percussion, sx) 2. O2 therapy 3. MV for ventilatory failure 4. consider alternate ventilation/oxygenation strategies (high frequency ventilation/high frequency oscillatory ventilation; inhaled nitric oxide; or extracorporeal membrane oxygenation (ECMO) 5. drug therapy (antibiotics; steroids)

chest tubes

conditions requiring chest tubes: -pneumothorax (air enters the pleural space with little or no fluid; <10% pneumothorax may not require tx unless pt shows significant distress; >20% pneumothorax will usually require a chest tube); if this air is not allowed to escape it will not only collapse the lung but also affect the mediastinum by pushing it away from the affected side, this is referred to as a tension pneumothorax -hemothorax or pleural effusion: fluid that enters the pleural cavity w/ no air -if pt is unstable, immediate action should be taken to insert a large bore needle to relieve the pressure, then insert a chest tube and apply the most appropriate chest-tube drainage system -one or more may be inserted into pleural space -to drain air from the pleural space the tube is placed in the 2nd intercostal space in the midclavicular line (air is anterior) -to drain fluid from the pleural space tube is placed in 5th-7th intercostal space in the midaxillary line (fluid is lateral)

Laryngeal mask airway (LMA)

consists of an inflatable mask that is positioned directly over the opening into the trachea (hypopharynx); a standard ETT can be inserted directly through the airway (LMA) into the trachea if necessary spontaneous breathing is possible through this airway but high-pressure assisted ventilation has been shown to create gastric insufflation contraindicated if a risk of aspiration exists inflate cuff with just enough air to obtain seal corresponding to a cuff pressure of approx. 60 cm H2O; frequently only half of the maximum volume is necessary to achieve an adequate seal-do not over inflate cuff airway can be removed when pt is alert enough to open mouth on command indicated for short term ventilation and when intubation is not possible by oral or nasal route (i.e. facial or nasal injuries)

opaque

fluid, solid; consolidation

decreasing lung compliance common causes: atelectasis, pulmonary edema, ARDS, pneumonia Tx: increase PEEP, treat underlying cause

if peak inspiratory pressure (PIP) increases plateau pressure (Pplat) increases it can mean

insufficient flow

if pressure does not rise normally (reads low or negative) on the bird mark 7 then there is

sx then place in opposite position for postural drainage

if pt aspirates while in a particular body position first

pick the other arm w/out shunt to obtain ABG; never attempt arterial punctures on pts with an indwelling dialysis shunt (radial or brachial), use another site

if pt has a shunt in one arm and you need to get an ABG

place the affected lung up to allow it to drain and to increase perfusion to the unaffected lung

if pt has unilateral consolidation

-pt obstruction (ETT, pneumothorax, Raw, secretions, etc) -equipment obstruction (vent circuit)

if the high pressure alarm goes off consider

defibrillation

is similar to cardioversion except that it is used when life-threatening cardiac dysrhythmias are present indications: pulseless ventricular tachycardia and ventricular fibrillation (Vfib you Dfib) synchronizing switch is turned off

heart

is the pump that creates the BP; changes in the HR and contractility will affect the BP directly

ideal breathing pattern

is the same regardless of what tube of therapy is given (SMI, IPPB, aerosol therapy, etc): -slow deep inspiration (from resting exhalation) -inspiratory pause (1-3 secs) -exhalation slow, passive and relaxed -ot may relax in between maneuvers with normal VT breathing

magnetic resonance imaging (MRI)

is used to obtain two-dimensional views of an organ or structure without the use of radiation; useful for determining thoracic aneurysms, congenital abnormalities of the aorta and major thoracic. vessels, especially in the hilarity area; has the ability to to determine the precise position of tumors, soft tissue abnormalities and the involvement of surrounding structures; pts who are claustrophobic may not be able to tolerate the procedure and those who are very obese may not fit into the narrow confines of the machine; fluidic (non-electric, gas-powered) ventilators are used for pts requiring MV bc the magnetic fields would disrupt electronic devices; manual resuscitation equipment should have additional tubing length and detachable non-rebreathing valves made of non-ferrous (non-metallic) materials; aluminum gas cylinders are used instead of steel cylinders

no head extension is performed whereas jaw thrust may or may not include this

modified jaw thrust implies

fine crackles

moist crepitant rales; =alveoli fluid; associated with CHF/ pulmonary edema; (recommend O2, positive pressure therapy, positive inotropic agents, diuretics)

post term infant

more than 42 weeks gestational age

110-160 beats/min (preterm infants have faster rates)

normal heart rate for a term infant is

40-50%

normal hematocrit

12-16 gm/100 mL blood

normal hemoglobin (Hb)

2-6 mmHg

normal left atrial pressure

120/0 mmHg

normal left ventricle pressure

60-100 mL/cm H2O

normal lung compliance is

160 cm H2O

normal maximum expiratory pressure

80 cm H2O

normal maximum inspiratory pressure (MIP)

5-10 cm H2O

normal mean airway pressure (Paw) for bedside pulmonary function

93-94 mm Hg

normal mean arterial pressure (MAP)

93 mmHg

normal mean pressure for an adult

7.40 range: 7.35-7.45

normal pH

> 7.30

normal pH for newborn

150,000-400,000/mm^3

normal platelet count

3.5-4.5 mEq/L

normal potassium (K+)

12-15 seconds

normal prothrombin time (PT)

25/8 mmHg Mean 13-14 mmHg

normal pulmonary artery pressure (PAP)

4-12 mm Hg

normal pulmonary capillary wedge pressure (PCWP)

<2.5 mmHg/L/min or 200 dynes/sec/cm^-5

normal pulmonary vascular resistance (PVR)

40 mmHg

normal pulse pressure

93-97%

normal range for SpO2 is

30-60 breaths/min

normal respiratory rate for infants is

2-6 mmHg

normal right atrial pressure

25/0 mm Hg

normal right ventricle pressure

adding PaO2 and PaCO2, the total should be between 110-140 torr

normal room air ABG can be evaluated by

135-145 mEq/L

normal sodium (Na+)

60-100 mL/cm H20

normal static lung compliance for bedside pulmonary function

60-80 mL/cm/H2O

normal static lung compliance is

40 mL/hr

normal urine output

5-10 mmHg

normal value for ICP is

15 vol%

normal venous value for CvO2

65-75 mL/kg or 10 x VT

normal vital capacity (VC) for bedside pulmonary function

subcutaneous emphysema

occurs when air (hyper lucency) is seen in the surrounding soft tissue

if pt is semi comatose then the pt responds only to

painful stimuli

if the pt is in a coma then the pr does not respond to

painful stimuli

the body's first respone to hypoxemia is

tachycardia

increased RR (greater than 20 breaths/min)

tachypnea

25-30

target CO2 for head injury

3.0-3.5

term infant ETT size

1

term infant laryngoscope blade size

30 mg/dL

term infants should have blood glucose values greater than

pulse/blood pressure varies with respiration

paradoxical pulse/pulsus paradoxus

atelectasis

patchy infiltrates, platelike infiltrates, crowded pulmonary vessels, crowded air bronchograms, crowded ribs scattered densities, thin-layered densities Tx w/: Lung Expansion Therapy: SMI/IS, IPPB, CPAP, PEEP

Depression of part or entire sternum, which can produce a restrictive lung defect.

pectus excavatum

done by placing the middle finger between two ribs and and tapping the middle figner's first joint with the middle fingertip of your opposite hand; compare anterior and posterior and top to bottom

percussion

presence of excessive fluid in the tissue known pitting edema; occurs primarily in arms and ankles; caused by congestive heart failure (CHF) and renal failure; rated +1, +2, +3 etc. (the higher the number the greater the swelling, the worse off); recommend diuretic

peripheral edema

pulmonary embolus

peripheral wedge-shaped infiltrate may be normal tx w/ heparin, streptokinase (eats clots but cant recognize good clot from bad clots so have to stay in ICU)

Phosphatidylcholine (PC) or Dipalmitoylphosphatidylcholine (DPPC)

phospholipid-lecithin makes up the majority of the weight of surfactant ; indicator for lung maturity and will rise as lungs mature

the RT discovers that a pr has dyspnea and diminished BS with a flat percussion note on the left. the chest radiograph indicates a tracheal shift to the right. which of the following disease states should the RT suspect is affecting the pt

pleural effusion

transudate fluid (transudative pleural effusion)

pleural fluid analysis: -is usable clear and has a light straw color -is also called serous fluid -this type of fluid would be associated with congestive heart failure

pressure differential (Fleisch) pneumotachometer

pneumotachometer that measures flow and can be used to continuously measure minute ventilation (VE)

Turbine device (Wright respirometer)

pneumotachometer that measures flow and may display volume

Holter monitor/event monitor

portable version of an electrocardiograph that is worn under under the clothes by the pt for a 24-48 hr period to detect cardiac arrhythmias; video sends info to the office

stroke/acute brain attack/cerebral infarction/cerebrovascular accident (CVA)

portion of the brain loses blood supply as a result of vascular occlusion or hemorrhage pt assessment: -past med hx: cerebral thrombin emboli (most common) atherosclerosis, hypertension, transient ischemic attacks (TIA) -motor and speech loss -bradypnea, cheyne-stokes respirations -hypertension, fever Dx: -CT/MRI of brain, cerebral angiogram -ICP may be elevated Tx: -tx should be intimated w/in 6 hours of symptoms onset -drug therapy: anticoagulation therapy, vasodilators, thrombolytic therapy (for acute ischemic stroke); tissue plasminogen factor (tPA) -MV for ventilatory failure (hyperventilation may be helpful to reduce ICP; avoid use of PEEP which increases ICP

fowler's

position that may enhance oxygenation for CHF

lateral fowlers position

position that may enhance oxygenation for obese pts

good lung down

position that may enhance oxygenation for unilateral lung disease

Acute Epiglottitis

potential airway emergency caused by inflammation. of the supraglottic structures (epiglottis , aryepiglottic folds, & false vocal cords) just above the vocal cords. most often a bacterial infection caused by haemophilus influenza B pt assessment: -sudden onset w/in 6-8hrs -pale or cyanotic, lifeless, drooling, hoarseness, inspiratory stridor, difficulty swallowing (dysphagia), Tonge thrusts forward during inspiration, voice and cry muffled, jaw jutted forward -tachypnea -BS: diminished, inspiratory stridor Dx: -lateral x-ray: haziness in the supraglottic area (epiglottis), supraglottic swelling (above the glottis) or "thumb sign" -ABG: acute alveolar hyperventilation w/ hypoxemia CBC: elevated WBC Tx: -immediate placement of an artificial airway (ETT; tracheostomy if unable to intubate) -transfer to ICU -sedate to prevent accidental extubation -place on T-piece or CPAP w/ O2 -antibiotics -criteria for extubation: child's condition is stable; swelling in the airway has diminished (leak around the airway)

2.5-3.0 mm

pre-term infant ETT size

0

pre-term infant laryngoscope blade size

lipid soluble

precedex is long acting and has no fat calories so it is not

head-tilt/chin-tilt

preferred method of establishing the airway during CPR advantages: easy to perform; permits control of loose dentures which may be left tin place to obtain better seal during mouth to mouth ventilation; successful with all age groups contraindications: fractured neck, or suspicion of neck fracture

20 mg/dL

premature infants should have values greater than

causes of apneustic

problem with respiratory center trauma tumor associated with CNS some type of drugs

bronchoalveolar lavage (BAL)

procedure for obtaining specimens from the lung at the alveolar level assists in the diagnosis & tx of: -alveolar proteinosis -interstitial pneumonia -cystic fibrosis (CF) -pneumocystis pneumonia -alveolar hemorrhage for a diagnostic lavage a flexible bronchoscope is used to instill and then aspirate small volumes of saline, the fluid is then analyzed in the lab therapeutic lavage involves a larger volume of saline (for lavaging a segment or lobe a flexible bronchoscope is used; for an entire lung a double lumen ETT (carlens) is used to ventilate one lung while the other is filled with saline and a complete lavage is done, the procedure can be done on the other lung several days later

lateral position

projection from wither the left or right side; adds a third dimension to structures viewed on AP or PA image

mother's with diabetes

prone to have premature and large-for-gestational age infants

of fat calories its lipid soluble

propofol is white bc

APGAR Score

provides a clinical method for evaluating the infant immediately after birth. allows for rapid appraisal of infant in determining the need for resuscitation; routinely done at 1 and 5 minutes; five factors are evaluated: color, HR, reflex irritability, muscle tone and respiratory effort

Oscilloscope (ECG monitor)

provides a continuous visual image of the electrical activity of the heart on a screen

disaster plan

provides a response procedure for both internal and external disaster situations that might affect hospital staff, pts, visitors and the community, it should identify individual and department responsibilities; should be practiced periodically; triage (decisions regarding allocation of physical and personnel resources, particularly when demand exceeds supply RT Role: have established call-in list, keep adequate supply of humidifiers, cannulas, masks and flowmeters, be prepared to assist in treatment areas, keep resuscitation equipment in working order and easily accessible, be prepared to obtain additional equipment needed for the situation

air compressor

provides compressed gas source without using an air cylinder; can be used to power hand held neb for pt with COPD (acute-on-chronic-respiratory failure) in the home setting

oblique position

slanting or diagonal view, aid in localizing lesions

causes of bradypnea (oligopnea) can include

sleep (normal) drugs alcohol metabolic disorders

if the pt is lethargic, somnolent, and sleepy then consider

sleep apnea or excessive O2 therapy in pt with COPD

serial coughs

small breath and cough, larger breath and cough, then deep breath and hard cough

gum elastic bougie

small diameter semi-flexible tube; acts as a stylet; ETT slides over it and into trachea; used to replace damaged ETTs; no oxygenation or ventilation possible thru bougie

Airway exchange catheter

small diameter tube, allows oxygenation and ventilation, acts as a stylet, ETT slides over it and into trachea, used to replace damaged ETTs

pneumothorax

small pneumothorax gas or free air accumulated in the pleural space pt assessment -possibel diaphoresis, cyanosis, tracheal and/or mediastinal shift day from the affected side, bruising over the affected area -tachypnea, reduced movement on affected side -BS: diminished or absent on affected side -hyperresonant/tympanic note over affected side -tachycardia, pulsus paradoxus, hypertension -Heart sounds may be displaced Dx: -chest x-ray: hyperlucency w/ absence of vascular markings on the affected side, tracheal shift to the unaffected side, depressed diaphragm, lung collapse -ABG:acute alveolar hyperventilation w/ hypoxemia Tx: -small pneumothorax (less than 20% of lung collapsed) may only require bed rest and limited physical activity. absorption usually occurs w/in 30 days -larger pneumothorax (greater than 20% of lung collapsed) should be evacuated by chest tube -needle aspiration of the chest necessary if pt is unstable (bradycardia, hypotension, cyanosis, etc.) -O2 for hypoxemia -hyperinflation therapy (IS/SMI, IPPB) after chest tube insertion -MV w/ PEEP for acute ventilatory failrue

cleaners

soaps and detergents are not antimicrobial agents but are used as

which of the following structures are visualized in a pt with mallampati class II

soft palate uvula and fauces only

Mallampati classification class 3 you see

soft palate, base of uvula (2 things)

Mallampati classification class 2 you see

soft palate, uvula, facues (3 things)

Mallampati classification class 1 you see

soft palate, uvula, fauces, pillars (4 things)

consolidation

solid white area; pneumonia (shows inside lung); pleural effusion (shows outside lung)

pulmonary vasodilators

specifically dilate the pulmonary blood vessels indications: pulmonary hypertension, ARDS, right ventricular failure/ cor pulmonale Prostacyclins: epoprostenol (Flolan) Illoprost (Ventavis) Sildenafil (Viagra, Revatio)

hematocrit (Hct)

spin the whole blood and measure the % of RBC in the original blood volume normal value: 40-50%

diffuse

spread throughout; atelectasis/pneumonia

ethylene oxide sterilization (ETO, gas sterilization)

sterilizes equipment by alkylation of enzymes; biological indicators are necessary to verify that the conditions for sterility have been met -ex. Bird mark II, flowmeter, or non-disposable resuscitation bag removed from HIV pts room

methylxanthines (phosphodiesterase inhibitors) (side door bronchodilators)

still used for chronic bronchitis pts improves contractility & stimulates head to breathe this inhibitor drug indirectly increases the amount of cAMP w/in smooth muscle. the increased level of cAMP causes bronchodilation safe therapeutic blood level of theophylline is 10-20 mcg/mL to optimize bronchodilation. blood levels are important to monitor in pts receiving these drugs theophylline is also given to increase diaphragmatic contractility & stimulate the CNS in infants w/ apnea of prematurity. Serum levels are kept at 5-10 mcg/mL in neonates and children -Theophylline (aminophylline) -Theo-Dur -Oxtriphylline (Choledyl) -Theolair -Caffeine side effects: tachycardia, palpitations, jitters, irritability and diuresis toxicity is serious and occurs when serum levels exceed 20 mcg/mL; signs of toxicity include: tremors, nausea & vomitting, nervousness, seizures, tachycardia & other arrhythmias that may lead to cardiac arrest

air trapping

straight or horizontal ribs are characteristics of

lung transplantation

transfer of one (single) or two (double) lungs from a donor to recipient; may be recommended for pts w/ COPD, pulmonary fibrosis, or cystic fibrosis most significant complication is organ rejection shich is tx w/ immunosupressive drugs POST-OP management: -monitoring pt for signs of organ rejection -maintain adequate ventilation, oxygenation, circulation & perfusion -early mobilization and ambulation -aggressive ventilator weaning -VAP prevention POST-SURGICAL complications: -hypoxemia may result from 1. hypoventilation caused by residual anesthesia or muscle relaxant -reverse paralytics w/ neostigmine, edrophonium, pyridostigmine -reverse narcotics w/ naloxone (Narcan) -reverses sedatives w/ flumazenil (Romazicon) -initiate/resume MV as needed 2. upper airway obstruction from decreased/altered level of consciousness 3. pulmonary edema caused by CHF, aspiration, IV hydration -pain & post-op stress: uncontrolled pain leads to sympathetic nervous stimulation; upper abdominal & thoracic pain reduces ability to breathe deeply and cough resulting in atelectasis and retained secretions -post-op delirium: tx w/ antipsychotic agents (haloperidol)

missed triggers

trigger asynchrony, ineffective triggering, insensitive trigger causes: -autoPEEP/dynamic hyperinflation -inappropriate trigger setting -weak pt effort correction: adjust trigger setting

set 100 mL below exhaled VT

what should the minimum exhaled tidal volume alarm be set at

5% above and below FiO2

what should the oxygen alarm be set at

control or target variable

what variable is pressure or volume control; the primary variable the ventilator adjusts to achieve inspiration

trigger variable

what variable starts inspiration; starts the inspiratory phase of a positive pressure breath

t wave

what wave is it after a short delay (S-T segment) the heart repolarizes

double the normal IV dose, flush with 10mL of saline, and hyperventilate for 30 seconds

when administering medication through the ETT

-pt should be off ventilator for shortest possible amount of time -manual ventilation w/ resuscitation bag is necessary while new circuit is attached and tested by another person -pre and post oxygenate with 100% to prevent iatrogenic hypoxemia

when changing the circuit:

Central Sleep Apnea (CSA)

when nasal flow decreases and respiratory effort decreases

TB, atelectasis, or fibrosis

when the heart is pulled to the left by the upper lobe usually indicates

RUL emphysematous bull, fluid, gas, or tumor

when the heart is pushed to the left usually indicates

normal sinus rhythm (NSR)

when the heart rate is normal has no skips extra beats etc

inlet valve

when trouble shooting a manual resuscitation bag (self-inflating) if bag fills rapidly and collapses easily on minimal pressure then check

-first: increase FiO2 by 5-10% (up to 60%) -then: increase PEEP levels by 2-5 cm H2O until acceptable oxygenation is achieved or unacceptable side effects occur (decreased compliance, decreased cardiac function, barotrauma, increased C(a-v)O2 etc.)

when you wish to increase a low PaO2

-remove mechanical deadspace -increase VT or PIP -increase RR

when you wish to normalize a high PaCO2 you should

-evaluate the cause (hypoxemia, pain, fever, and anxiety) -decrease RR -decrease VT or PIP

when you wish to normalize a low PaCO2 you should

capillary samples or heel sticks

where else can a blood gas be obtained in infants results will show a consistent correlation with arterial pH and PCO2 PO2 values do not correlate well with actual arterial blood. this is especially true when the arterial PO2 is above 60 torr

radiodense/opacity

white pattern, solid, fluid; normal for bones, organs

standard tracheostomy tubes

white plastic trash tube; may have a removable inner cannula for easy cleaning; has a soft cuff; the obturator is used to facilitate insertion of the tube

fatigue wheezing air trapping may occur

why is it important to avoid coughing too hard or too long

inspection and auscultation

will quickly determine tube position before a chest x ray is taken

proper exposure (penetration)

will show the intervertebral disc spaces thru the shadow of the mediastinum

presence of WBC (eosinophils), bacterial infection

yellow sputum indicates

echocardiogram

(ultrasound of the heart); noninvasive method for monitoring cardiac performance; used to assess overall cardiac function including left ventricular volume and ejection fraction; indications: valvular disease or dysfunction, myocardial disease, abnormalities of cardiac blood flow, cardiac anomalies in the infant, abnormal heart sounds

pack years =

# of packs/day x # of years smoked

cardiopulmonary stress (exercise) testing

- A diagnostic exam used to evaluate the ability of the heart and lungs to provide oxygen and remove carbon dioxide from the bloodstream. indications: -complaint of dyspnea upon exertion (primary indication) -determine ventilatory or cardiac limitations to work -determine maximum workload for developing an exercise plan or adjusting daily activites -for disability purposes -pt has resting 12 lead ECG on and walks on atradmill or rides bike while VS (HR, BP, RR) ECG and SpO2 are monitored slope of the treadmill or speed of bike is increased incrementally until pt reaches maximum HR or us unable to continue workload then gradually decreased and pt monitored until VS return to pre-exercise levels -normal response: HR, BP, RR, and VT should increase; CO2 production and O2 consumption should increase; Deadspace (VD/VT) should decrease

wick humidifiers

- Concha system, Fischer-Paykel, etc. - wick increases surface area of gas-water interface, increasing humidifier's efficiency - can deliver 100% body humidity (44 mg/L) - low risk of cross-contamination (nosocomial infxn) because *no particles are being produced* -use with ventilators, CPAP and pts with artificial airways

small particle aerosol generator (SPAG)

- Designed specifically for administration of ribavirin for treating RSV (respiratory syncytial virus) infections not to be used with any other substance

magill forceps

- used only to aid in nasal intubation - inserted in mouth to lift tube into trachea

helium dilution (closed method)

-A known concentration of helium is diluted by the patients FRC, the change in the helium concentration is used to determine FRC.

AutoPEEP

-Also known as "intrinsic PEEP", "occult PEEP", "dynamic hyperinflation", "air trapping", or "inadvertent PEEP" -occurs when there is incomplete exhalation (expiratory flow does not return to zero) and air is trapped in the lungs, caused by insufficient expiratory time -adverse effects: -decreased venous return leading to: decreased cardiac output and BP -increased intracranial pressure (ICP) -overdistension of alveoli (potential barotrauma/volutrauma) -increased difficulty in triggering the ventilator -can be corrected by: -decrease inspiratory time -increase flowrate -increase expiratory time -consider changing mode -consider sedation and/or neuromuscular blocking agent in extreme cases

time cycled

-Apply positive pressure until a preset time is reached. -pressure, volume, and inspiratory time may Ary with changes in the pts lung compliance and/or airway resistance -normal cycling mechanism in pressure support ventilation

forced expiratory flow 25%-75% (FEF25-75)

-Average low rate during the mid portion of the FVC -Decreased in the early stages of obstructive disease -Decreased values are associated with small airway obstruction (asthma, COPD) -Typical Value: 4.7 L/sec -SMALL AIRWAYS

Arterial Oxygen Content (CaO2)

-Best measurement of oxygen delivered to the tissues, or best index of oxygen transport. -Estimates the amount of oxygen carried by hemoglobin as well as that dissolved in the plasma. -Formula: CaO2 = (Hb x 1.34 x SaO2) + (PaO2 x .003) -SHORTCUT: CaO2 = Hb x 1.34 x SaO2 normal value: 17-20 vol% (mL/dL)-

acid glutaraldehyde (Sonacide)

-Disinfection or sterilization process -Equipment must be rinsed with sterile water after soaking

alkaline glutaraldehyde (Cidex)

-Disinfection or sterilization process; equipment must be rinsed w/ sterile water after soaking -appropriate method for Reusable plastics (nebulizer, humidifier, tubing, mouthpieces) - appropriate method for sterilizing a Flexible fiberoptic bronchoscope

Radiant warmer (open incubator)

-Ideal for unstable newborns who require constant care -Provides a neutral thermal environment but will not decrease insensible water loss in premature infants because of evaporation

high frequency oscillatory ventilation (HFOV)

-Improves oxygenation in pts w/ severe lung injury, such as ARDS; gives the lungs time to heal its a diffusion technique -indications: -high inspiratory pressure (> 50 cm H2O) -air leak syndromes (bronchial fistula, pulmonary interstitial emphysema, and pneumothorax) -oscillates at high frequencies (RR) in 3-15 Hertz (Hz) range -very high RRs result in low alveolar pressure changes -very low VTs, typically 3-5 mL -amplitude (power, ^P): primary control of PaCO2 -frequency set in Hertz (Hz): secondary control of PaCO2 (the lower the frequency, the higher the VT [inversely proportional]; usually not adjusted once HFOV is initiated) -mean airway pressure (Paw) is a primary control of PaO2 -FiO2 set as with conventional ventilation -requires sedation and neuromuscular blocking agents this minimizing spontaneous breathing

mean airway pressure (MAP) -FiO2 and sensitivity dont affect MAP everything else does

-PIP -rate (f) -insp. time -PEEP (most influence) -Peak flow -tidal volume -inflation hold all directly affect

flow cycled

-Positive pressure is applied to the airway until a predetermined flow is achieved. -pressure, volume and inspiratory time may vary with changes in the pts lung compliance and/or airway resistance -normal cycling mechanism in pressure support ventilation

Mixed venous Oxygen Content (CvO2)

-Total amount of oxygen carried in the mixed venous blood -Calculated using the same formula as CaO2 except for using mixed venous PO2 (PvO2) and saturation (SvO2). -The blood is drawn from the Pulmonary Artery through a balloon-tipped, flow-directed (Swan-Ganz) catheter. -Formula: (Hb x 1.34 x SvO2) + (PvO2 x .003) -SHORTCUT: CVO2 = Hb x 1.34 x SvO2 CvO2 will decrease when cardiac output decreases SvO2 will also decrease when cardiac output decreases

Pre and Post bronchodilator Testing

-Used to measure the reversibility of am obstructive pattern -Minimum increase of 12 and 200 mL in the FEV1 post study is considered significant -All bronchodilator therapy should held 8 hours prior to testing; dont have to hold steroids

ARDS (ARRDSnet)

-VT: initial 8mL/kg IBW, then reduce to 6mL/kg IBW -maintain Pplat <30 cmH2O -consider permissive hypercapnia and subsequent respiratory acidosis -switch from volume control (VC) to pressure control (PC) if pt has ARDS, low compliance, and/or high ventilating pressure(s)

thoracentesis

-a diagnostic and/or therapeutic procedure in which a needle is inserted into the chest to remove fluid from the pleural space -the most common disorder that requires this is a pleural effusion -dull percussion note, diminished BS, and tracheal shift away from site (trachea shifts away from fluid); lateral decubitus film shows concave upper border or a continual line from the diaphragm to apices -ultrasound techniques

airway pressure release ventilation (APRV)

-a form of spontaneous breathing at a positive pressure level; similar to CPAP -occasionally the baseline pressure is released to a lower pressure allowing the lungs to deflate -uses a lower peak inspiratory pressure (PIP) resulting in lower mean airway pressure -improves oxygenation using lower mean airway pressure (Paw)

new Ballard score (NBS)

-a modification of ballard score -estimates gestational age in very low birth weight infants

Insufflation/Exsufflation Devices or manually assisted coughing (MAC)

-attach to pt via oronasal mask or to endotracheal or tracheostomy tubes -deliver deep inspiration by positive pressure, followed by 1-2 second breath hold, then negative pressure exsufflation to create a cough -indicated for pts w/ neurological problems or muscle weakness

spontaneous breathing trial (SBT)/ spontaneous awake trial (SAT)

-best method to evaluate weaning -administer CPAP with or without PSV -minimum trial of 30 minutes -maximum trial of 2 hrs -criteria for termination of SBT: -RR increases to >35 for 5 min or more -HR >130/min or 20% over baseline -cardiac arrhythmias or new arrhythmias -change in BP (systolic: > 180 mm Hg; systolic < 90 mm Hg) -excessive anxiety or agitation -O2 saturation <90% or decreased 4% or more from baseline -pH <7.30 -if physiologic parameters show failure of SBT, return pt to MV for 24 hrs do not attempt to SBT later that day

Ventilator-associated pneumonia (VAP)

-caused by aspiration of bacteria that have colonized the upper GI tract or oropharynx -secretions that pool above airway cuff are aspirated through small folds in the cuff -prevention includes: -gentle sx technique -use of closed sx systems -regular oral hygiene -post-pyloric feeding -keep pts head elevated 30-45 degrees -not routinely changing vent circuits -draining and discarding ventilator tubing condensate appropriately -use of heated-wire circuits or HME to prevent tubing condensate -use of MDI instead of SVN for medication administration -stress ulcer prevention -daily sedation vacation to evaluate readiness to wean and extubate -tubes designed for continuous aspiration of subglottic secretions (CASS) via special airway devices (mallinckrodt Hi-Lo Evac, Kimberly-Clark microcuff)

intrapulmonary percussive ventilation (IPV)

-combination of high frequency pulse delivery (100-250 cycles/min)of a sub-tidal volume and a dense aerosol -the percussive effect of gas delivery improves ventilation past obstructions in the airway thereby delivering more aerosol to the distal airways. coughing helps facilitate removal of retained secretions and further improves ventilation -dense aerosol delivery promotes bronchial hygiene, reduces edema, and relieves bronchospasm w/ appropriate medication -recommended starting source pressure for most pts is 30 psi. this control regulates the velocity of the percussive pulses -can be administered to pts who are unconscious or cannot follow directions

tuberculin skin test/mantoux test

-consists of intradermal injection of a purified protein derivative (PPD) of mycobacterium tuberculosis -most reliable test for TB sensitivity -a positive test is determined when a hardened raised red area appears 24 to 72 hours after injection; recommend antitubercular agents and isolation

galvanic fuel cell

-creates electron flow as a result of oxidation/reduction of O2 -measures a partial pressure displays FiO2 as % -accuracy can be affected by water on the sensor, high system pressures, and changes in altitude -if unable to calibrate change fuel cell

Apnea testing for brain death determination

-disconnect pt from the vent while administering 100% O2 and monitoring SpO2 -observe pt for any chest or abdominal movements that produce an adequate VT -absence of respiratory movements indicates a positive test and supports a diagnosis for brain death -diagnosis confirmed by cerebral perfusion scan (cerebral angiogram)

exhaled carbon monoxide (FEco) testing

-exhaled CO easily measured with small portable device -can be used to monitor abstinence in cigarette smokers

CPAP (continuous positive airway pressure)

-improves oxygenation; supports oxygenation at lower FiO2 -mask fits over mouth and nose or just nose; short term temporary use for improving oxygenation in pts post-op atelectasis etc; difficult to maintain seal and poorly tolerated by pts -nasal is useful with neonates since they're obligate nose breathers; can lose CPAP if baby is crying; readjust nasal prongs if losing CPAP -endotracheal is used for intubated pts; important to monitor pressure and utilize a low pressure alarm -as w/ most pressurized circuits, loss of pressure indicates: leak or insufficient flow -increased pressure indicates: obstruction or excessive flow (with excessive flow a continuous venting of the pop-off valve will occur)

Apnea Hypopnea Index (AHI)

-index of severity that combines apneas w/ hypopneas -calculated by dividing the number of apneas and hypopneas by the # of hours of sleep -Mild: 5-15 -Moderate: 15-30 -Severe: >30 (will stop, split study and put pt on CPAP)

sleep apnea (polysomnography)

-is a condition in which the pt has apnea during sleep for periods of 10 seconds or longer -there are 3 types of sleep apnea disorders: 1. central: apnea due to a loss of ventilation effort 2. obstructive: apnea due to blockage of the upper airway 3. mixed: a combination of the central and obstructive types pt will complain of day time sleepiness and insomnia at night, muscle twitching can be observed; hx of snoring and obesity while pt sleeps chest motion (respiratory effort) and breathing frequency, nasal airflow, pulse ox, # of apneas (cessation of breathing), # of hypopneas (shallow/slow breathing) are monitored

prone positioning

-is placing pt face down in the bed this may increase PaO2 by 10-50 torr and decrease the shunt by 12-25% -should be considered for pts with ALI/ARDS when: FiO2 > 60% and PEEP > 12 cm H2O or when recruitment maneuvers have failed -is successful in about 75% of pts w/ ARDS and should improve PaO2 within 30 minutes (if they haven't improved then its not working) -may also decrease PaCO2 -immediately following the pt may experience a transient O2 defat and hemodynamic instability which is short lived and can be minimized by hyper oxygenation -if causes hemodynamic compromise and/or worsening ABG, return pt to the supine position

electromagnetic navigational bronchoscopy (ENB)

-low-frequency electromagnetic waves are transmitted from a magnetic board placed beneath pts chest -CT scanner creates 3-dimensional images -useful for obtaining biopsy samples from peripheral pulmonary nodules

External Percussive Devices (High frequency of chest wall compression devices)

-non-stretch, inflatable vest covers pts chest and abdomen -variable air-pulse generator injects small gas volumes into and out of the vest creating an oscillatory motion against the pt's chest -5-25 Hz (300-1500 cycles/min) for 30 min, 1-6 times/day -for pts who cannot use or tolerate other procedures

pt-ventilator asynchrony/dysynchrony

-occurs when pt's inspiratory requirements for flow and volume are not met by the ventilator, resulting in an increased work of breathing -the goal is to adapt the vent to pt's needs not force the pt to adapt to the vent capabilities -can be detected through airway graphics

-pressure support (PS, PSV)

-overcomes resistance of vent circuit and ETT during spontaneous breathing -decreases WOB in SIMV, CPAP -pt determines RR, inspiratory time, and inspiratory flowrate -pressure support values are measured above baseline pressure -set initial PSV level by calculating the pt's airway resistance (PIP-Pplat)

mini BAL procedure

-performed to obtain a distal lung specimen for diagnosis of VAP -utilizes a protected catheter to prevent specimen contamination (combicath)

tracheostomy/tracheostomy tubes

-preferred method of providing an airway for pts who require long-term ventilation; when upper airway obstruction prevents intubation; easier to stabilize, sx and tolerate; pt is able to eat and even speak with tracheal speaking device; there are fewer hazards and less airway resistance compared to oral/nasal ETTs procedure: if not emergency should be done carefully under sterile conditions with pt intubated; ETT is removed only as trach tube inserted; percutaneous dilatation tracheostomy can be done at the bedside using a series of dilators to expand the tracheal opening -RTs role in procedure: maintain airway, provide ventilation, stabilize tracheostomy tube 1st 24 hrs complications: bleeding-major hazard, pneumothorax, air embolism, subcutaneous emphysema late complications: infection, hemorrhage (tracheoinnominate artery fistula), obstruction, tracheo-esophageal (T-E) Fistula

volume cycled

-pressure is applied to the airways until a preset volume is delivered -this is the normal cycling variable during volume controlled (VC) ventilation -advantage: minute volume will remain constant to provide stable blood gases -airway pressure will increase or decrease with changes in the pts compliance and/or airway resistance -volume-cycled ventilators can be used w/ most pts -disadvantage: as lung compliance or airway resistance worsen the PIP and Pplat increase and may result in barotrauma or volutrauma

proportional assist ventilation (PAV,PAV+)

-pressure, volume and flow are proportional to the pt's spontaneous effort -pressure delivered is dependent on inspiratory flow & volume demands by patient -amount of ventilatory support is determined by therapist -as pt flow demand increases, the ventilator delivers proportionally higher flow

-volume support (VS)

-pt breathes spontaneously -minimum VT is selected by therapist -vent adjusts the amount of positive pressure needed to achieve the set VT -as the pt's lung condition improves the vent provides less pressure to achieve the target VT -High pressure limit prevents excessive pressure levels

Pulmonary Rehabilitation Techniques

-pursed lip breathing -diaphragmatic breathing training -cough control techniques -exercise conditioning -nutritional balance (increase protein and fat, low carbohydrates) these are all:

ventilation scan

-radioisotope (xenon gas) is inhaled and the location of the gas is recorded producing a photographic pattern of distribution throughout the lungs. -any obstruction to gas flow will prevent gas from filling the area *normal ventilation and abnormal perfusion=pulmonary embolism.

Withdrawal of life support

-removal of life support & unwanted medical interventions when the goals of therapy have changed -DNR order must be in place -comfort of the pt is of utmost importance, including anxiolytics and analgesics -terminal weaning: dc of MV in the face of irreversible illness (should be accomplished by disconnection rather than progressive weaning; treat tachypnea or dyspnea with benzodiazepines or barbituates

minimal leak technique (MLT)

-slowly inject air into the cuff during positive pressure inspiration until the leak stops -a small amount of air is removed to allow a slight leak during peak inspiration

-continuous positive airway pressure (CPAP)

-spontaneous breathing at an elevated baseline pressure -breaths are pt triggered & cycled -no mandatory breaths -may be useful for weaning -monitoring capabilities of ventilator available

Laryngectomy & Laryngectomy tubes

-surigcal removal of the pts larynx -performed to treat upper airway carcinoma -no longer any connection between the pts upper and lower respiratory tract -pt will breathe through a larygectomy tube initially -pt cant be orally or nasally intubated laryngectomy tube will be removed after 3-6 weeks, then pt will have a permanent stoma These are all indications for:

recruitment maneuver (RM)

-sustained increase in pressure in the lungs w/ the goal of opening as many collapsed lung units as possible -therapeutic techniques performed when other techniques have not improved oxygenation -SpO2 and/ or PaO2 increase dramatically as alveoli are recruited (inflated) -most common RM: increase to a high level of PEEP for a short period of time (increase PEEP to 40 cm H2O for 40 seconds; or increase CPAP to 20 cm H2O for 20 seconds) -if the SpO2 rises and then falls, consider. repeating the recruitment maneuver

trach care

-sx pt to ensure airway patent -clean inner cannula by soaking it in a solution of hydrogen peroxide and water rise with sterile water -clean stoma site using cotton applicators dipped in the water-hydrogen peroxide solution, replace gauze dressing -change trach ties -replace the inner cannula -reassess the pt and record the procedure -if ventilation is difficult or pressures are high, remove the tracheostomy tube from the false tract

assist/control (A/C) mode

-the ventilator will deliver a minimum number of mandatory breaths each minute -patient can trigger assisted breaths by decreasing pressure, flow, or volume below established baseline value -can be used with either volume control or pressure control

a difficult airway

-tracheal shift/deviation -enlarged thyroid -short receding mandible -enlarged tongue (macroglossia) -bull neck -limited range of motion of the neck or cervical spine -small mouth opening -mallampati class III or IV are all signs of

flexible bronchoscope

-used for diagnosis -flexible rubber scope with fiberoptic bundles as a light source -able to enter more peripheral airways -preferred scope for diagnostic indications -can be performed in exam room, ICU, physician office, under local anesthesia

endobronchial ultrasound (EBUS)

-used for diagnosis -bronchoscope with an ultrasound probe attached to the distal end -provides real time ultrasound guidance for trans bronchial needle aspiration (TBNA)

bubble humidifier

-used for low flow O2 delivery devices -most bubble humidifiers incorporate pressure pop-off valves set at approx. 2 psig or 40 mm Hg -proper function should be checked by occluding/pinching connecting tubing and listening for the whistling sound if no sound occurs there is a leak (O2 flow is excessively high or obstruction or kinking of tubing)

rigid bronchoscope

-used for treatment -hollow metal tube that also functions as an airway -allows for ventilation through the scope during the procedure -preferred scope for therapeutic indications -is performed in the OR w/ pt under general anesthesia

heated wire circuits

-used in conjunction with ventilator humidification to minimize condensation -contains wire-like structure to maintain a set gas temperature (i.e. body temp) through circuit -condensation (rain out) is minimized -can be used on either inspiratory and expiratory limbs of a vent circuit or only insp. limb -maintains temp w/in circuit and the temp of the heated humidifier

sputum induction

-used in pts who do not have a productive cough -indicated for pts with suspected pneumonia who do not have productive cough -induced by having pt inhale a bland aerosol (containing sterile water or normal saline) or hypertonic saline (3%, 7%, to 15%); ultrasonic or high output pneumatic nebulizers generally used -specimen must be collected in sterile container and handled with sterile technique -sample must be screened to verify it came from lower respiratory tract and not saliva (accomplished by counting number of squamous epithelial cells; should be less than 25 squamous cells per low power microscope field) -terminate treatment if significant adverse reactions occur (i.e. bronchospasm wheezing etc.)

synchronous intermittent mandatory ventilation (SIMV) mode

-ventilator provides a minimum number of mandatory breaths ea. min -allows pt to breathe spontaneously between mandatory breaths -can be used with either volume control or pressure control -provides a relatively consistent minute volume -used for pts w/ tachypnea (> 20 breaths per min) to avoid hyperventilation -may achieve lower mean airway pressure than with assist/control -used w/ PEEP to reduce barotrauma

post extubation complications

-vocal cord polyps: caused by chronic inflammation -mucosal ulceration: torn mucosa, does not require reintubation -tracheomalacia: softening or dilation of tracheal cartilage -tracheostenosis: gradual obstruction (narrowing) that occurs with healing causing stridor These are all:

isotonic/normal saline

0.9% saline commonly used to liquefy secretions, to humidify the airway as a diluent for medication

60 cycles per min (1 cycle/second) ex. frequency of 5 Hz = 60 x 5 = 300 breaths per min

1 Hz =

60 cycles/min or 1 cycle/sec

1 Hz =

when you have an emergency your first priority: second priority: third priority: fourth priority:

1st: ventilation 2nd: oxygenation 3rd: circulation 4th: perfusion

hypertonic saline

1.8-15% saline; (usually 3-7%) commonly used to induce sputum specimens, can irritate the airway & cause bronchospasm or secretion obstruction

normal urine output is

40 mL/hr (approx. 1 L/day)

ideal body weight

50 kg + (2 x inches over 5ft) = ______kg then multiply ______kg by 5, 6, 8, to 10 mL/kg to get VT

Pressure Regulated Volume Control (PRVC)

A form of ventilation that keeps pressure at the lowest level by providing automatic, breath to breath pressure regulation while providing a preset volume (volume control) -breaths are pt or time triggered, volume targeted, time cycled -ventilator alters peak flow and inspiratory time in response to changing compliance and/or resistance -the desired rate and VT are preset

pulmonary angiography

A pulmonary arteriogram or angiograph is a test to diagnose a pulmonary embolism Indications: high clinical suspicion for PE; inconclusive V/Q scan and/or CT scan procedure: the catheter is inserted into the femoral vein and advanced through the right heart into the pulmonary artery; contrast medium is injected and multiple x-rays are taken to identify any filling defects

grunting

A sound heard at the end of exhalation that indicates respiratory distress (RDS) from decreased lung volume

how do you measure circulation

HR and strength, cardiac output

fibrillation

HR too fast to count

apical lordotic

Projection of the lung apices

1000g

normal brith weight for 28 week gestational age

how do you measure oxygenation

HR, color, sensorium, PaO2, SpO2

30 torr 3-5%

normal capnography (ETCO2)

0-1%

normal carboxy hemoglobin (COHB)

Appropriate for gestational age (AGA) large for gestational age (LGA) small for gestational age (SGA)

AGA, LGA, and SGA all stand for

poisoning/toxic substance ingestion

Accidental or intentional ingestion of a toxic substance pt assessment: -obtain, info about the type & amount of poison ingested -varies according to substance ingested, may have pallor, cyanosis, vomiting, convulsions, diaphoresis, altered level of consciousness, pupils may be either dilated or constricted Dx: -chest x-ray: results will determine proper tx -ABG: results will determine proper tx -electrolytes: results will determine proper tx -toxicology screening -renal & liver function test -glucose level -anion gap calculation Tx: -supportive care 1. stabilization of the cardiovascular & respiratory systems including: -maintenance of an airway; intubate when aspiration is likely -monitoring -full resuscitation if needed -venous access for drug administration -appropriate weight measurement 2. once the cardiovascular & respiratory systems have been stabilized, tx goals include: prohibit further drug absorption, improve elimination, manage complications -decontamination (remove all remaining toxins from the child's skin and mouth; remove all saturated clothing; utilize personal protective equipment; gastrointestinal decontamination through the removal or dilution of gastric contents & the use of gastric absorptive agents [activated charcoal] or whole bowel irrigation -MV for ventilatory failure

anti-inflammatory + long acting bronchodilator

Advair (flucticasone = anti-inflammatory and salmeterol long acting bronchodilator) Symbicort (budesonide =anti-inflammatory and formoterol long acting bronchodilator) indicated for pts w/ asthma (12 yrs and older) & COPD medication should be taken twice daily not recommended for tx of acute bronchospasm

2.5-4 L/min/m^2

normal cardiac index

coude tip catheter

Angled to help suction the left main stem bronchus

positive expiratory pressure (PEP) therapy

Application of expiratory positive airway pressure using a one way inspiratory valve and one way expiratory flow resistor (prevents end-expiratory pressures from failing to zero) Removes secretions, decrease hyperinflation, improve CF, pneumonia Expiratory Pressures 10-20 cm H2O @ mid exhalation Used 15-20 min. 3-4 times/day Expiration 2-3 times longer than inspiration DC if sinusitis, epistaxis, or middle ear infection occurs

modified allen's test

Assesses collateral circulation in the hand prior to drawing a radial ABG; a positive test confirms that collateral blood flow is present

dubowitz or Ballard method

Assesses gestational age - higher the score, higher the gestational age in weeks: 1. normal score is 40 corresponding to 40 weeks 2. a score higher than 40 indicates a post term infant 3. a score lower than 40 indicates a pre term infant

silverman score

Assessment of respiratory distress in the infant - Score 0 - 10 - Higher the score, greater the distress

vasoconstrictor/vasopressor drugs

Indicated to increase BP - Epinephrine - Norepinephrine (Levophed) - Dopamine - Dobutamine (Dobutrex)

Vasodilator drugs

Indicated to lower BP - Nitroprusside (Nipride): light sensitive - Milrinone (Primacor)

4-8 L/min

normal cardiac output

Nondepolarizing neuromuscular blocking agents

Bind to receptor sites to prevent stimulation of muscles, resulting in complete paralysis - rapid onset (3-5 mins) - longer duration (35-120 mins) Ex: "ium" drugs Pancuronium (Pavulon) Vecuronium (Norcuron) Atracurium (Tracrium) Cisatracurium (Nimbex) Rocuronium (Zemuron) - Can be reversed c/ anticholinesterase inhibitors if desired: - Neostigmine (Prostigmin) - Pyridostigmine (Mestinon) - Edrophonium (Tensilon)

4-12 cm H20

normal central venous pressure (CVP)

70-90 mm Hg

normal cerebral perfusion pressure

Increased bilirubin level in blood and tissue this appears mostly in the face and trunk

Jaundice

how do you measure perfusion

BP, sensorium, temperature, urine output, hemodynamics

incineration

Best method of treating contaminated disposable items and supplies

increased RR and depth with irregular periods of apnea; each breath has the same depth

Biot's

term infant

Born between 38 and 42 weeks of gestational age.

up to 6 min

normal clotting time

is in vol%

C(a-v)O2 =

0.7-1.3 mg/dL

normal creatine level

80 mmHg

normal diastolic pressure for an adult

< for non-smokers

normal exhaled carbon monoxide (FECO)

pneumonia

air bronchogram increased density from consolidation and atelectasis antibiotics

what are the types of advance directives

Do not resuscitate order (DNR) do not intubate order (DNI)

O2

Clarke electrode

Disinfection

a process to destroy vegetative pathogenic microorganisms

left heart failure; mitral valve stenosis; CHF

CVP: N PAP: ^ PCWP: ^^ QT: v

lung disorders; pulmonary embolism; pulmonary hypertension; air embolism

CVP: ^ PAP: ^^ PCWP: N/v QT: N

right heart failure; cor pulmonale; tricuspid valve stenosis

CVP: ^^ PAP: N/v PCWP: N/v QT: N

hypervolemia

CVP: ^^ PAP: ^ PCWP: ^ QT: ^

hypovolemia

CVP: vv PAP: v PCWP: v QT: v

increased blood pressure (hypertension) indicates

Cardiac stress - hypoxemia GIVE O2

depolarizing neuromuscular blocking agents

Cause total muscle contraction (twitching, fasciculation) followed by complete muscle paralysis rapid onset (1-1.5 mins) short duration of action (7-12 mins); no need for reversal primarily used for ET intubation Ex: Succinylcholine (Anectine)

Vt, VC, MIP and weakness WORSEN w/ Tensilon test

Cholinergic crisis indicating too much of drug was given (overdose of anticholinesterase drugs) - basically paralyzing pt. Admin atropine to reverse tensilon

pleural friction rub

Coarse grating raspy or crushing sound caused by inflamed surface of the visceral and parietal pleura rubbing together TB, pneumonia, PE, and hemothorax Recommend steroids and antibiotics

three bottle water-seal suction drainage system

Collection bottle: Collects fluid Water-seal bottle: Allows air to leave pleural cavity, and prevents air from entering pleural cavity; water level should be set at 2cm; in presence of a pneumothorax or air leak bubbling will be observed in this chamber (pt breathing spontaneously: bubbling during exhalation; pt on positive pressure ventilation: bubbling during inhale; Continuous bubbling should be reported (air leak) Suction control bottle: Regulates amount of negative pressure being applied; continuous bubbling indicates proper sx pressure set on vacuum regulator

Vibratory/Oscillatory PEP devices

Combine PEP w/ high frequency oscillations Removes secretions from the airway Examples: Flutter, Acapella, Quake

sterilization

Complete destruction of all microorganisms

Air-oxygen proportioners (blenders)

Control mixing of air and oxygen to obtain specific FiO2 can be used with NRB to achieve a precise FiO2

blue or blue-gray (dusky) discoloration of skin and mucous membranes caused by hypoxia from increased amount of reduced hemoglobin (5g of reduced hemoglobin)

Cyanosis

FEV/FVC ratio

FEV for a given interval expressed as a % of a FVC.

Continuous aspiration of subglottic secretions (CASS) tubes

ETTs used to prevent VAP; helps with secretions around the cuff

Vibrating mesh nebulizer

Electrically powered; Produces aerosol with small particles; has low residual drug volume--so pt will recieve more of drug compared to SVN; additional flow isn't added to pts airway or vent circuit

Redness of the skin. May be caused by capillary congestion, inflammation or infection, flushed

Erythema

normal

HR 60-100

bradycardia

HR <60

tachycardia

HR >100

dyspnea occurs after unusual exertion

Grade I

breathless after going up hills or stairs

Grade II

dyspnea while walking at normal speed

Grade III

dyspnea slowly walking short distances

Grade IV

dyspnea at rest, shaving, dressing etc

Grade V

flutter

HR >200

pressure cycled

IPPB is

obstructive disease

If the FVC is smaller than the SVC indicates

inotropic agents

Increase strength of myocardial contraction Indications: - CHF - Atrial tachycardia and fib Side effects: - nausea, vomiting, headache, arrhythmias Ex: - Digitalis (Crystodigin) - Digoxin (Lanoxin)

Causes of Cheyne-Stokes

Increased intracranial pressure brain stem injury drug overdose, associated with CNS, some type of drugs

inhaled nitric oxide (iNO)

Is a gas that acts as a potential pulmonary vasodilator, which improves pulmonary blood flow and PaO2 and does not affect systemic blood pressure indications: -primary pulmonary hypertension -refractory hypoxemia related to increased pulmonary artery pressure (PAP) -increased pulmonary vascular resistance (PVR) -right heart failure/cor pulmonale dosage: standard initial dose is 20-40 ppm (parts per million); dose should not exceed 80 ppm side effects: -methemoglobin (MetHb) levels may increase -nitrogrn dioxide (NO2) levels may increase and are toxic to body at levels > 10 ppm -rebound pulmonary hypertension (occurs when iNO is discontinued too rapidly) -iNOvent delivery system: blends NO into inspired air to maintain desired FiO2 and dose of NO; injector module & sample line added to vent circuit distal to humidifier and 24 inches after inspiratory limb; when using NO and high frequency oscillator, a one way valve must be placed between the injector module and humidifier

increased RR (usually over 20 breaths/min), increased depth, irregular rhythm, breathing sounds labored

Kussmaul's

maximum voluntary ventilation (MVV)

Largest volume of gas that can be breathed voluntarily in and out of lung in 1 minute; pt is told to breathe in and out as fast as possible until told to stop; performed for 10, 12 oe 15 seconds then extrapolated to one minute; used to evaluate respiratory muscle reserve, endurance or fatigue decreased with: -obstructive lung disease -increased airway resistance (Raw) -respiratory muscle weakness -decreased lung compliance -poor pt effort

nasal cannula

Low flow device Delivered FiO2: 0.24-0.45 Flow: 1-6 L/min to estimate FiO2: Fio2 increases 4% for every 1L/min Initial device for COPD, stable RR and VT

Lead

displays movement of electricity from one electrode to another (12 of them)

electrolyte imbalance

Muscle weakness Soreness Nausea Mental changes: - lethargy - dizziness - drowsiness (general malaise) are all associated with

Leukotriene Modifiers

Non-steroid drugs for pts c/ mild to moderate persistent asthma NOT for tx of acute asthma attacks Improve lung function, reduce symptoms & need for Beta-agonist drugs. Ex. "kast" drugs Montelukast (Singulair) Zafirlukast (Accolate) Zileuton (Zyflo)

co-oximeter/hemoximeter

Normal COHb: 0-1% COHb for smokers: 2-12% CO poisoning: >20% More accurately measures COHb and O2Hb and other non-functional hemoglobin (metHb-methemoglobin); is the best way to evaluate oxygenation in a pt with CO poisoning

26-29 cm at nare

Normal ETT markings for nasal intubation

sine wave

Normal flow pattern for a spontaneous breath

Severinghaus

PCO2 = _____________electrode

clark

PO2 = ______________electrode

<50 torr

PaCO2 for newborns should be

>60 torr

PaO2 for newborns should be

acceptable oxygenation- maintain settings check SaO2 a\& Hb

PaO2 value: < 80 (hypoxemia) FiO2 value: 0.21-0.59

hypoxemia can be caused by: poor ventilation (high PaCO2)- increase ventilation/start ventilation V/Q mismatch (normal or low PaCO2)- increase FiO2 up to 0.60

PaO2 value: < 80 (hypoxemia) FiO2 value: 0.21-0.59

shunt (if pt is receiving 60%+ O2; start CPAP), refractory hypoxemia, venous admixture (if pt is receiving 60%+ O2) start or increase CPAP or PEEP CPAP if pt is breathing spontaneously PEEP if pt is on ventilator

PaO2 value: <80 (hypoxemia) FiO2 value: 0.60 +

over oxygenation decrease FiO2, PEEP or CPAP

PaO2 value: >100 (Hyperoxemia) FiO2 value: 0.22-1.00

decreased blood pressure (hypotension) indicates

Poor perfusion- Hypovolemia, CHF GIVE FLUIDS

pressure cycled

Positive pressure is applied to airways until a preset pressure value is reached. -Peak inspiratory pressure (PIP) is usually controlled at a set level (pressure control [PC]) - Vt may be adjusted by increasing or decreasing the peak inspiratory pressure (PIP), inspiratory time (Ti) or flow -may be used as an alarm safety mechanism during Volume Controlled ventilation

splinting

Press pillow over incised area to enhance better cough

Inverse Ratio Ventilation (IRV)

Pressure or volume controlled breaths with an inverse I:E ratio - improves oxygenation and gas exchange; decreases PIP and PEEP levels -recommended for: pts requiring high FiO2 (>60%) and PEEP (>15 cm H2O), pts with a high PIP (> 50 cm H2O), low PaO2 w/ decreased compliance -pts should be paralyzed and sedated to allow the vent to control the breathing pattern -start with an I:E ratio of 2:1 or greater

troponin

Protein found in myocardial cells specific indicator of damage to heart muscle Levels > 0.1 are at high risk for MI or death pts who suffer MI would have elevated troponin levels recommend O2, morphine, aspirin, nitroglycerin

vital capacity (VC)/ slow vital capacity (SVC)

Pt is instructed to take a maximal inspiration followed by a maximal exhalation without force will provide important volumes used to identify restrictive disease decreased volumes indicate restrictive disease decreased VC is the best indicator of restrictive lung disease

liters/min

QT=

how do you measure ventilation

RR, VT, chest movement, BS, PaCO2, ETCO2

antiviral agent

Ribavirin (Virazole) tx for RSV (respiratory syncytial virus) infections given via small particle aerosol generator (SPAG) for 12-24 hrs for 3-5 days or more

point of care testing

Tests performed at the patient's bedside or work of area, using a portable instrument. (blood glucose, arterial blood gas, hematocrit, serum electrolytes, etc.); reduces time from sample to report; (i.e. i-STAT device: portable battery powered; analysis is done with disposable cartridge that contains calibration solutions and results are ready within 90 seconds; fast results)

mean airway pressure (Paw)

The average pressure transmitted to the airway from the beginning of one breath to the beginning of the next

8-20 b/min

acceptable RR (f) for MV b/min

60-90

acceptable range for diastolic blood pressure

90-140

acceptable range for systolic blood pressure

Forced Vital Capacity (FVC)

The volume that can be courted as forcefully and as rapidly as possible after maximum inspiration the maneuver/procedure will provide the important flow rates used to identify obstructive disease

aucultation- (changed/improved BS) inspection- color, chest expansion cough- sputum characteristics and amount tolerance- fatigue, WOB, pain vitals- pulse RR BP ECG chest x-ray- improved pattern A-E SHOULD BE DONE AFTER EVERY TREATMENT

To evaluate effectiveness of bronchial hygiene therapy

> or equal to 10 mL/kg (2 x VT)

acceptable vital capacity (VC) mL/kg:

desired minute volume

Used to determine what minute volume setting will deliver a desired PaCO2 formula: (current VE x current PaCO2) = (desired VE x desired PaCO2) tidal volume or frequency could be used in place of minute volume

Maximum inspiratory pressure (MIP)

Used to monitor and assess the readiness to wean in ventilator patients assesses the degree of respiratory muscle impairment in pts with Guillain-Barre and myasthenia gravis inspiratory pressures are described with negative numbers normal is 80 cm H2O; measurements of <20 cm H2O indicate inspiratory muscle weakness have pt exhale to residual volume then have pt breathe in as quickly and as hard as possible with the inspiratory port occluded for 15-20 seconds, observe pressure indicated on the manometer and repeat maneuver 2 more times

ventricular flutter/fibrillation tx: defibrillate, CPR, epinephrine, amiodarone

V-fib you dfib, completely irregular ventricular rhythm

alveolar minute ventilation

VA = (VT -VD) X f Use the estimate of 1 ml per lb of ideal body weight for VD is best increased by increasing VT

Minute Ventilation (VE)

VT x f =

oxygen consumption in mL/min

Vo2=

White Blood Cells (WBCs)

WBC count changes in response to infections normal value: 5,000-10,000 per MM3

AP projection

X-rays travel form anterior to posterior- image receptor behind back, commonly used for bedridden patients

PA projection

X-rays travel from posterior to anterior- image receptor touching the chest with pts back to x-ray tube

the presence of a fourth sound S4 is indicative of

a cardiac abnormality such as uncontrolled hypertension or aortic stenosis

these muscles are used to increase ventilation during times of stress, increased airway resistance and decreased compliance

accessory muscles

pulmonary embolus

a blodo clot which dislodges from somewhere in the body, travels to the lungs and obstructs the pulmonary vasculature, results in a deadspace condition (ventilation w/out perfusion) blood clots develop in peripheral vessels bc of -venous stasis (inactivity, prolonged bed rest or sitting, CHF, varicose veins) -fat/air emboli -trauma, fractures -recent surgery -obesity -pregnancy & childbirth pt assessment -anxious, diaphoretic, cyanotic, cool or clammy skin, SOB, tachypnea -BS: wheezing, crackles, pleural friction rub -cough: possible hemotptysis -sudden onset of signs and symptoms Dx: -x-ray increased density in infarcted area, dilation of pulmonary arteries, wedge-shaped infiltrate -ABG: respiratory alkalosis w/ hypoxemia -increased PAP -capnogrpahy (PECO2): decreasing PECO2 w/ normal PACO2 -VD/VT ratio: increased -Spiral CT scan -V/Q scan -Pulmonary angiogram Tx: -prevention -anticoagulants (high- or low-molecular-weight heparin) -anti-emboliam (compression) stockings -pneumatic compression devices -early ambulation -O2 therapy @ 100% to maintain PaO2 > 80 torr -anticoagulants (heparin) -analgesics to relive chest pain -digitalis, digoxin to maintain cirulation -thrombolytic agents- urokinase, streptokinase, tPA

interstitial lung disease (ILD)

a broad group of inflammatory lung disorders characterized by acute, subacute or chronic inflammatory infiltration of alveolar walls by cells, fluid, and connective tissue Etiology is often associated w/ occupational, environmental and/or therapeutic exposure common ILD include: -pulmonary fibrosis -sarcoidosis -asbestosis -hypersensitivity pneumonitis -rheumatoid arthritis -systemoc lupus erythematosus pt assessment: -cyanotic, digital clubbing, peripheral edema venous distension -tachypnea, non-productive cough -BS: bronchial, crackles, pleural friction rub, whispered pectoriloquy -flat/dull note -increased tactile and vocal fremitus -VS: tachycardia, hypertension Dx: -chest x-ray: bilateral reticulonodular pattern, irregular opacities, granulomas, cavity formation, pleural thickening -ABG: mild to moderate ILD-acute alveolar hyperventilation w/ hypoxemia; severe chronic ILD- chronic ventilatory failure w/ hypoxemia -pulm. function: decreased volumes and capacities (VT, RV FRC, and TLC) -special tests: DLCO (decreased lung diffusion capacity); increased hematocrit and hemoglobin Tx: -corticosteroids -immunosuppressive agents -O2 therapy -bronchial lavage

asthma

a chronic inflammatory, obstructive, non-contagious airway disease w/ varying levels of severity, characterized by exacerbations of wheezing and coughing episodes occur when pt is exposed to a specific trigger, such as dust, grass, pollen, smoke, animal dander, etc pt assessment: -SOB: pursed lip breathing, chest tightness -increased A-P diameter during episode -accessory muscle usage, retractions (especially in children) -hyperresonant/tympanic note -BS: diffuse wheezing, diminished BS, prolonged expiration -diaphoresis -tachycardia, tachypnea, pulsus paradoxes during severe episodes Dx: -chest xray: increased A-P diameter, translucent (dark lung) fields, depressed or flattened diaphragms Tx: -O2 therapy -aerosol therapy w/ SABA and anticholinergic agents (consider continuous aerosol therapy) -corticosteroids -close monitoring -intubation & MV if ventilatory failure or respiratory arrest occurs -consider helix therapy, magnesium sulfate, subcutaneous epinephrine long term control -triggers should be eliminated, minimized, or avoided to prevent acute attacks -control medications: LABA, inhaled corticosteroids, mast cell stabilizers, leukotriene inhibitors, asthma action plan based on peak flow monitoring refer pt to specialist for -difficulty confirming dx -suspected occupational asthma -persistent uncontrolled asthma or frequent exacerbations -any risk factors for asthma related death -evidence of, or risk for, significant tx side effects references for evidence based practice -National Asthma Education and Prevention Program (NAEPP) -global initiative for asthma (GINA)

noninvasive positive pressure ventilation (NPPV)

a conservative approach which avoids intubation indications: -acute exacerbation of chronic respiratory failure (COPD) -congestive heart failure (CHF) -severe dyspnea and do-not-intubate (DNI) order contraindications: -cardiac or respiratory arrest -upper airway obstruction -unable to protect airway ( aspiration risk, dysphagia [difficulty swallowing]) -unable to clear secretions -facial/head trauma or surgery -uncooperative pt advantages: -avoids vent assoc. pneumonia (VAP) -avoids complications of artificial airways -avoids complications of MV mask is most common interface -nasal mask: generally for chronic/home care -full face mask: generally for critically ill pts -nasal pillows initial settings: IPAP: 8-12 cm H2O (ventilation) EPAP: 4-6 cm H2O (oxygenation) [1/2 of whatever IPAP set]

BP

a decrease in heart rate will decrease the

an increase in ventilation or decreased perfusion (deadspace disease: pulmonary embolism, hypovolemia)

a decrease in the PECO2 or PETCO2 would indicate

obstructive disease

a decreased FEV1 is a good indicator of

if the pt is obtunded then the pt is in a drowsy state and may have

a decreased cough or gag reflex and has a risk of aspiration

basic cough

a deep breath followed by forceful exhalation

tonometer

a device that allows precision gas mixtures to be equilibrated with wholesaled blood or a buffer solution after an equilibration period, the sample is transferred to a blood gas analyzer

King LT supraglottic airway

a laryngeal tube (LT) airway management device that is a color coded airway for small, medium and large, has easy insertion and allows for positive pressure ventilation

epiglottitis

a lateral neck x-ray shows supraglottic narrowing with an enlarged and flattened epiglottis and swollen aryepiglottic folds; this presentation on x-ray is known as the thumb sign

transtracheal oxygen catheters (TTO2)

a method of delivering low flow O2 therapy directly into the airway by a surgically implanted catheter bypasses the nose and mouth by surgically inserting a soft large bore catheter into the trachea between the 2nd and 3rd tracheal rings, the catheter is then secured around the neck with a metal beaded chain necklace, O2 is supplied via O2 connecting tubing allows the upper airways and trachea to act as a reservoir for O2 during exhalation pts are taught to routinely clean and replace the catheter at home as well as note any signs or symptoms of infection at the site if the pt complains of shortness of breath with a TTO2 device, the catheter could be obstructed with secretions and the catheter should be removed and cleaned

Lecithin-Sphinogomyelin (L/S) Ratio

a ratio of 2:1 or higher is good. incidence of hyaline membrane disease (HMD) or infant respiratory distress syndrome (IRDS) approaches zero; a ratio less than 2:1 indicates high risk of HMD/IRDS; as ratio drops below 2, incidence of HMD/IRDS ranges from 40-80%. lower ratio indicating higher risk; recommend surfactant replacement therapy

heart

a small portion should be visible on the right side of the vertebral column; right cardiac border should have two bulges (superior vena cava & R atrium); left cardiac border should have three bulges (aorta, pulmonary artery, left ventricle)

air entrainment mask/venturi mask

a true high flow device delivers precise FiO2 concentrations (ideal for pts with COPD); ideal for pts with irregular tidal volumes, rates and breathing patterns; pt may use nasal cannula during meals

Double Lumen Endotracheal Tube(Carlens tube, endobronchial tube)

a tube with 2 independent lumens of different lengths (the longer lumen is inserted into left or right mainstem bronchus; shorter lumen rests in trachea above carina) ea. lumen can ventilate one lung seperately or they can be connected via wye and share a ventilation souce the tube has two cuffs: the right or left mainstem bronchus tube has a cuff that is smaller and has a high pressure low volume cuff; the other cuff in the trachea is a low pressure high volume cuff indications: independent lung ventilation, unilateral lung diseases to improve ventilation/oxygenation or to provide airway protection to the unaffected lung (i.e. lung abscess), used during surgery (pneumonectomy, lobectomy, esophageal resection, and aortic aneurysm repair), and bronchopleural fistulas leaks around cuff may require reposition of tube

a dry or nonproductive cough may indicate

a tumor in the lungs

congestive heart failure (CHF)

abnormal condition that reflects impaired cardiac pumping caused by myocardial infarction, ischemic heart disease, or cardiomyopathy

injury

acute damage to tissue (often from ischemia); is indicated by an elevated S-T segment

bronchiolitis

acute infection of the lower respiratory tract, usually caused by the respiratory syncytial virus (RSV); results in inflammation & obstruction of the. small bronchitis & bronchioles & excessive airway secretions; pts at risk include children less than 1 yr of age, children w/ weakened immune systems & children w/ chronic respiratory or cardiac disease pt assessment: -upper respiratory infection in young children -nasal discharge, lethargic, nasal flaring, cyanosis -tachypnea, apnea in severe cases, grunting, intercostal & substernal retractions, intermittent cough -BS: wheezes, crackles, upper airway noise from secretions -hyperresonance in severe cases Dx: -chest x-ray: hyperinflation w/ areas of consolidation or atelectasis -ABG: acute alveolar hyperventilation w/ hypoxemia -pulm. function: decreased flow rates (FEV1, FEV25-75%, & FEV200-1200) -detection of RSV antigen in washings from nasopharynx or oropharynx by RSV-enzyme immunoassay (EIA) or Respiratory infectious disease panel (RIDP) by polymerase chain reaction (PCR) Tx: -prophylaxis w/ resp. syncytial virus immune globulin (RespiGam) or palivizumab (Synagis) recommended for children at risk -many children can be tx at home w/ humidification & oral decongestants -for children admitted the hospital: systemic hydration, O2 therapy to maintain acceptable SpO2, bronchodilators to relieve wheezing, airway clearance therapy, MV for acute ventilatory failure

admitting diagnosis, history of present illness, chief complaint, past medical history, current medications are all apart of

admission notes

7.0-7.5

adult female ETT size

7.0-7.5 mm

adult female ETT size

3

adult laryngoscope blade size

8.0-8.5

adult male ETT size

8.0-8.5 mm

adult male ETT size

120/80

adult normal blood pressure is

jaw thrust/modified jaw thrust

advantage: allows for establishing patent airway in pts with suspected neck fracture disadvantages: difficult to perform, difficult to obtain a good seal during mouth to mouth ventilation; tiring for operators wrists; pts loose dentures not controlled

crackles (rales), wheeze, stridor, stertor, and pleural friction rub are all

adventitous BS

a change in heart raet of more than 20 beats per minute is an

adverse reaction (stop neb, notify nurse, doctor and record event)

1-2 seconds; if not use another site

after releasing ulnar artery the hand should pink up within

ABG should be drawn after 20-30 min to assess pts ventilation and oxygenation status; continuous observation for signs and/or symptoms of any problems; auscultation of BS and checking the position/patency pf the artificial airway is appropriate; monitor urine output (40-60mL/hr); recommend IPPB or SMI to prevent atelectasis. following extubation

after weaning (SBT)

general appearance includes

age, height, weight, nourishment, etc.

Croup (laryngotracheobronchitis) (LTB)

an inflammatory process that causes edema & swelling of the mucous membranes below the vocal cords; most often the result of viral infection (parainfluenza viruses most common causative agents) pt assessment: -hx of a recent cold that developed gradually into a barking cough over 2-3 days, more common in the fall and winter -alert w/ some accessory muscle usage, cyanosis, barking cough, hoarse voice -tachypnea; BS: diminished, inspiratory stridor Dx: -lateral x-ray: haziness in the subglottic area (below the glottis), steeple sign, pencil point, picket fence, or hourglass narrowing of the upper airway -ABG: acute alveolar hyperventilation w/ hypoxemia Tx: MILD CASES: -supportive care (temperature control -cool environment; adequate hydration and humidification of inspired air; closely monitor VS, degree of retractions, level of consciousness, ventilatory and oxygenation status) -O2 therapy 30-40% w/ cool aerosol mist (face mask) -drug therapy: racemic epinephrine by SVN (micronefrin, vaponefrin); corticosteroids- for children who don't respond to cool aerosol and racemic epinephrine therapy -consider helix therapy if no response to racemic epinephrine SEVERE CASES (all of the above PLUS): -child w/ severe Resp. distress and/or marked inspiratory stridor -criteria for intubation: lethargic, severe stridor at rest, diminished BS, extreme accessory muscle usage -transfer pt to icu -sedate if necessary -place on t-piece or CPAP -criteria for extubation: child's condition is stable, air leak around the tube (swelling has 1`2fgb gone down)

cystic fibrosis (CF) (mucoviscidosis)

an inherited, genetic disorder involving the exocrine glands, results in thick viscous mucus accumulation in the lungs, blocks passageways of the pancreas, & prohibits enzymes from reaching the intestines leading to inhibition of digestion of protein and fat and deficiencies of vitamins A, D, E, and K pt assessment -positive family hx, meconium ileum as newborn, recurrent respiratory infections, failure to thrive -barrel chest, cyanosis, clubbing, small for age, malnutrition, poor body development, peripheral edema -tachypnea, dyspnea on exertion, pursed lip breathing, use of accessory muscles of inspiration & expiration, cough productive of large amount of thick purulent. secretions -BS: diminished, crackles, wheezing -hyperresonant or tympanic note Dx: -chest x-ray: translucent (dark) lung. fields, depressed or flattened diaphragm, right ventricular enlargement, areas of atelectasis & fibrosis -ABG: mild to moderate stages -acute alveolar hyperventilation w/ hypoxemia; severe stage- chronic ventilatory failure w/ hypoxemia -pulmonary function; decreased flow rates (FEV1, FEF25-75% & FEF200-1200) -CBC: Elevated Hb & Hct concentration -sputum culture: often positive for staphylococcus aureus, haemophilus influenzas, pseudomonas aeruginosa -newborn screening by immunoreactive trypsin level (IRT) required in all 50 states -sweat chloride test (chloride level > 60 mEq/L) -genetic testing of CFTR mutation Tx: -airway clearance (chest percussion & postural drainage, exercise, PEP therapy, high frequency chest wall compression devices, forced expiration techniques [active cycle breathing, autogenic drainage, or huff coughing) -O2 therapy as needed -drug therapy -aerosol therapy: bronchodilator therapy, mucolytics (Dornase alpha; aka Pulmozyme), corticosteroids. (Advair; Flovent; Pulmicort) -inhaled antibiotics (tobramycin [TOBI], Colistin, Amikacin) -digestive enzymes

electrode

an object placed on the skin to conduct electric current from the body to a monitoring or measuring device (10 of them)

computed tomography (CT)

an x-ray through a specific plane of the body part to be examined. Images appear as narrow slices of the organ or body part; useful in detecting the presence of mediastinal, pleural and parenchymal masses, pulmonary nodules and lesions not visualized n a chest x-ray; may be used for the diagnosis of bronchiectasis; a spiral scan with contrast dye may be used for the diagnosis of pulmonary embolus; oxygen or MV can be provided if no metal pieces are placed inside the machine

platelet count

analysis of the number, size, and shape of the platelets should be done if a coagulation defect is suspected normal value: 150,000-400,000/mm3

costephrenic angles

angles made by the outer curve of the diaphragm and the chest wall; these angles are obliterated (blunted or blurred) by pleural effusions

heart murmurs

are sounds caused by turbulent blood flow; may be caused by heart valve defects or congenital heart abnormalities and should be investigated; can occur when blood is pushed through an abnormal opening such as an atrial septal defect or a patent ductus arterioles

Bruits

are the sounds made in an artery or vein when blood flow becomes turbulent or flows at an abnormal speed; is usually heard through a stethoscope over the identified vessel, such as the carotid artery

corticosteroids

anti-inflammatory agents w/ direct & indirect bronchodilating effects "zone" drugs are indicated for pts w/ asthma & COPD -Fluticasone (Flovent) -Beclomethasone (Beclovent, Vanceril, Qvar) -Budesonide (Pulmicort) -Flunisolide (AeroBid) -Triamcinolone (Azmacort) -Prednisone -Methylprednisolone (Solu-Medrol) side effects and hazards may be severe. they include adrenal suppression, Cushing's syndrome, hypertension and oral candidiasis (thrush) for inhaled aerosols to prevent oral candidiasis (thrush) when using ICS have pt rinse mouth w/ H2O after tx thrush infections can be tx. w/ the anti fungal agent nystatin

ipratropium bromide, tiotropium bromide

anticholinergics

neck and spinal/surgery

any injury or surgical procedure performed on the neck and/or spine etiology may include -traumatic injury -tumors -spine deformities pt assessment -bruises over affected area (neck/spine) -may be apneic w/ severe damage to spine -altered level of consciousness Dx: -CT, MRI Tx: -O2 therapy to tx/prevent hypoxemia -maintain patent airway: (utilize jaw thrust technique; or intubation -recommend using flexible bronchoscope support ventilation, oxygenation, circulation and perfusion as indicated by bedside assessment & lab testing

head trauma/surgery

any injury or surgical procedure performed on the skull and/or brain Etiology may include -traumatic brain injury (TBI) -tumors -aneurysms -cerebrovascular accidents (CVA) -seizures pt assessment -irregular rhythm, cheyne stokes or Biot's breathing -altered level of consciousness (increases risk of aspiration) -abnormal pupillary response Dx: -CT, MRI, PET scans -intracranial pressure monitoring: normal value 5-10 mm Hg Tx: -airway protection -O2 therapy: maintain PaO2 level near 100 torr -MV: maintain PaCO2 at normal levels (eucapnic ventilation); minimize mean airway pressure by utilizing low PEEP and peak inspiratory pressures -benzodiazepines or propofol for sedation -treat acute elations in ICP (>20 mm Hg) -hyperventilation; keep HOB elevated; mannitol -Dilatin for seizures

thoracic surgery

any surgical procedure performed on structures within the thoracic cavity commonly performed procedures: -lung repairs or resections -tracheal/mediastinal repairs or resections -pneumonectomy or lobectomy -cardiac surgery (valve replacements, bypass grafts) pt assessment: -post-operative incision -tachypnea, deceased chest movement over affected area -BS: may be diminished over affected area -may be dull/flat over affected area pre-op Dx: -chest x-ray: may be abnormal w/ lung pathology -pulm. function: may be abnormal w/ lung pathology Tx: -PRE-OP: hyperinflation therapy (IS/SMI, IPPB) -POST OP: hyperinflation therapy (IS/SMI, IPPB); prevention of infection, monitor chest drainage systems, observe for post-op complications; analgesics for pain -MV if indicated; may require reduced VT for pts undergoing lung resections or lobectomies

chest trauma/rib fractures/flail chest

any type of trauma to the chest wall (unintentional or intentional); may be result of: industrial accidents, vehicle accidents, falls, violence, surgery pt assessment -anxious, cyanosis, bruising over are involved -shallow, rapid respirations, paradoxical chest movement (flail chest) -BS: diminished BS over affected area hyperresonant/tympanic note Dx: -chest x-ray: increased opacity (density) from lung compression, rib fractures -ABG: acute alveolar hyperventilation w/ hypoxemia -pulmonary function: decreased volumes and capacities (RV, ERV, TLC, FRC etc) Tx: -O2 therapy for hypoxemia -analgesics -routine bronchial hygiene -hyperinflation therapy (IS/SMI, IPPB, deep breathing and coughing exercises) -prevention of pneumonia -closely monitor for acute ventilatory failure -severe cases: stabilization of chest wall; MV for pts w/ flail chest; PEEP

cessation of breathing

apnea

prolonged gasping inspiration followed by extremely short, insufficient expiration

apneustic

S3 and S4

are both low pitched and may be difficult to discriminate

Laryngectomy tubes

are designed to maintain a patent airway after a laryngectomy has been performed; are made of soft pliable material; most are available in various sizes and are generally shorter in length than a standard tracheostomy tube; may have inner cannula; laryngectomy tubes do not have an inflatable cuff; replace with cuffed endotracheal tube if positive pressure ventilation is required

central venous catheters

are inserted through the subclavian or jugular vein and should rest in the superior vena cava or right atrium of the heart (4th intercostal space, right of sternum)

exudate fluid

as more cells are added to the fluid, the fluid tends to get cloudy and it is referred to as an -empyema/pyothorax has an opaque appearance -infections would produce yellow or milky exudate fluid -bloody effusions (hemothorax, serosanguineous) may suggest malignancy or cancer -purulent: pus-filled exudate -mucopurulent: containing mucus and pus exudate -chyle: containing lymphatic exudative fluid -loculated: very thick a pleural fluid pH less than 7.30 is considered significant for an exudate an exudate also exists if the ratio of the pleural fluid protein to serum protein is greater than 0.5 recommend culture, sensitivity and gram stain of exudates

accumulation of fluid in the abdomen generally caused by liver failure

ascites edema

a decrease in color due to anemia or acute blood loss (vasoconstriction will cause color change by reducing blood flow)

ashen; pallor

cause of biot's

associated with CNS problem some type of drugs

Eosinophils

associated with asthma; 2% of WBC; increased with allergic reactions

monocytes

associated with tuberculosis; 3% of WBC

trachea shifts toward

atelectasis pneumonectomy diaphragmatic paralyis

muscle wasting, cachexia, starvation is loss of muscle tone and occurs in paralysis

atrophy

a result of air trapping in the lungs for a long period of time (obstructed); genrally due to COPD; has an increse in A-P diameter

barrrel chest

Plethysmograph (body box)

based on Boyle's law (pressure and volume vary inversely if temperature is constant) measures thoracic gas volume (TGV) which is the same as functional residual capacity (FRC) measures airway resistance (Raw) which is the difference in pressure between the mouth (atmospheric) and the alveoli related to gas flow at the mouth

infant respiratory distress syndrome (IRDS)/ hyaline membrane disease (HMD)

caused by insufficient amount of pulmonary surfactant or depressed surfactant activity that leads to massive atelectasis and hypoxemia; primarily occurs in premature of high-risk infants pt assessment: -gestational age <38 weeks, low APGAR scores, signs of respiratory distress present at birth or w/in a few hrs after delivery, L:S ratio < 2:1 -cyanosis -tachypnea and possible apnea intercostal retractions, nasal flaring, grunting -BS: bronchial or harsh, fine crackles/rales, expiratory grunting Dx: -chest x-ray: increased opacity, ground glass appearance, and air bronchograms -ABG: acute alveolar hyperventilation w/ hypoxemia Tx: -correct hypoxemia (O2 via oxyhood or NC; CPAP 4-6 cm H2O; maintain PaO2 between 50-80 torr & SpO2 between 89-90%) -maintain neutral thermal environment -recommend surfactant replacement therapy -MV w/ PEEP for ventilatory failure

tuberculosis

cavity formation often in upper lobes antitubercular agents (streptomycin etc.)

gradually increasing then decreasing rate and depth in a cycle lasting from 30-180 seconds, with periods of apnea lasting up to 60 seconds

cheyne-stokes

annually

children at risk for RSV should be immunized how often? (respiratory syncytial virus immune globulin intravenous (RespiGam); Palivizumab (Synagis)

90-100 mEq/L

chloride (Cl-)

ambulance

choice of transport may be determined by the distance to be traveled if have to travel 0-80 miles then pt will go by

helicopter

choice of transport may be determined by the distance to be traveled if have to travel 81-150 miles then pt will go by

fixed wing aircraft (airplane)

choice of transport may be determined by the distance to be traveled if have to travel >150 miles then pt will go by

myasthenia gravis

chronic disorder of the neuromuscular junction that interferes w/ chemical transmission of acetylcholine. results in descending paralysis- moves from mind to ground pt assessment: -past med Hx: gradual onset of weakness, may have previous admission for MG -general weakness that improves w/ rest, drooping eyelids (ptosis), double vision (diplopia), difficulty swallowing (dysphagia) -shallow breathing -BS: diminished w/ crackles Dx: -edrophonium test (tensilon challenge test) -electromyography -blood test for Ach receptor antibodies -ice pack test: application of ice pack to eye lids; considered positive test if ptosis improves -decreasing VT, VC, MIP -ABG: acute ventilatory failure w/ hypoxemia; watch for ventilatory failure (PaCO2 >45 torr) -pulm. function: reduced volumes (FVC, VT) -tensilon challenge test to dx & monitor therapy Tx: -closely monitor VT, VC, MIP (intubate & MV when indicated) -bedrest restriction & soft diet to reduce symptoms -O2 therapy for hypoxemia -hyperinflation therapy -pulmonary hygiene

COPD (chronic obstructive pulmonary disease) (Type 2)

chronic obstructive lung disease ABG shows compensated (chronic) respiratory acidosis with hypoxemia (low PaO2): -pH: 7.36 -PaO2: 58 torr -PaCO2: 62 torr -HCO3-: 36 mEq/L\ oxygen induced hypoventilation can result when this pt is given too much O2 the pt will become tired, sleepy lethargic, and then unresponsive

moving the blood through the body is

circulation

class ______ and _____ are considered diffucult airways

class 3 and 4; difficult intubation ned to use assisted device to help with intubation will need to utilize: fiberoptic bronchoscope and/ or video assist device

normal

clear mucus is

O2 hood

clear plastic device that completely encloses the head of the infant for the administration of O2 and humidity flow range 7-14 L/min to prevent CO2 buildup and maintain FiO2 without sealing infant's neck around the hood amplifies surrounding noise levels-use humidifier instead of nebulizer

caused by chronic hypoxia; presence of this is suggestive of pulmonary disease; thumb first finger and toes are affected; the condition is present when the angle of the nail bed and skin increases

clubbing

Heat moisture exchanger humidifier/hydroscopic condenser humidifier/artificial nose

contains absorptive material that absorbs heat and moisture from pts exhaled air and dissipates that absorbed heat and moisture back into the pt's inspired air; should be located in the ventilator circuit between the wye and pt; creates a small fixed amount of deadspace; can cause increased delivery pressure-replace HME if airway pressure increases; must be removed during aerosol therapy; may not be as effective as heated humidifier and may increase or thicken secretions- if this occurs change to heated humidifier; ideal use for pt transport an short term ventilation

3 way stopcock, syringe, & pressure manometer

cuff pressure can be measured with

radiolucent

dark pattern, air; normal for lungs

infarction

dead tissue; no electrical activity, axis will shift away from infarction

at or above 0.60; once FiO2 is below 0.60, then reduce PEEP/CPAP

decrease FiO2 first if

sedatives/hypnotics

decrease anxiety & promote relaxation indications: manage fear & anxiety; increase comfort while receiving MV; induce sleep Ex. "am" drugs

BP (occurs in CHF)

decrease in contractility will decrease the

obstructive disease (minimum acceptable FEV1.0/FVC = 70%); decreased values = obstructive disease; normal values = not obstructive disease (may still be restrictive)

decreased FEV1.0/FVC is the best indicator of

leukopenia

decreased WBC is called

obstructive disease (CBABE) -cystic fibrosis -bronchitis -asthma -bronchiectasis -emphysema

decreased flows indicate

bone marrow function and sepsis

decreased platelet values are associated with

restrictive disease -inflammatory diseases -cardiac disease -neurological/neuromuscular -pleural disease -thoracic deformities -post surgical pts -fibrotic diseases

decreased volumes indicate

sedatives (all end in lam/pam)

decreases anxiety and promote relaxation can talk to pt and they'll answer honestly but they don't remember anything when they wake up -alprazolam (Xanax) -diazepam (valium) -midazolam (versed) -lorazepam (Ativan)

creatine

excreted by kidneys; evaluates kidney function; normal value: 0.7-1.3 mg/dL; more specific for kidney failure than the BUN

MIP/MEP Device (Pressure Manometer)

device used for measurement of maximum pressures

pressure transducer

device used to convert one form of energy into another form; commonly used in hemodynamic monitoring to convert pressures (analog signal) into electrical signals (digital signals) that can be displayed; most common type is a strain gauge transducer; the transducer should be at the same level as the tip of the catheter (if transducer is above the catheter, reading are lower than actual and if the transducer is below the catheter then readings are higher than actual)

normal muscles of ventilation

diaphragm external intercostals (exhalation is normally passive)

to understand a pts nutritional status you must review

dietary history: usual food intake, food likes/dislikes, appetite, food allergies

blood gas analyzer

directly measure only: PCO2: partial pressure of carbon dioxide in sample PO2: partial pressure of oxygen in sample pH: acid base status

Pasteurization

disinfection processes using moderate temperatures to kill vegetative organisms

flow volume loop

displays the volumes and flow rates measured during the FVC pt performs an FEV followed by an FIV the flow rates are displayed on the vertical (Y) axis (expiratory flows are above the base line; inspiratory flows are below the base line volume is displayed on the horizontal (X) axis

pt does not wish to be intubated but you can administer non-invasive ventilation

do not intubate order (DNI)

tracheostomy tubes

do not pose the problem of mainstem intubation, but rather positioning outside of the trachea

apply sterile dressing and/or antibiotic to site, clean periodically with hydrogen peroxide, have pt cough to clear secretions

do not suture stoma closed instead:

-gloves -goggles/face shield -gown -mask -hand hygiene

doff (remove) PPE in what sequence

diaphragm

dome-shaped normally, flattened with COPD, left or right hemidiaphragms may shift downward with a pneumothorax; appearing flattened to one side

-hand hygiene -gown -face mask -goggles/face shield -gloves

don (put on) PPE in what sequence

if the pt is stuporous and confused and responds inappropriately then consider

drug overdose or intoxication

normally heard over iver fluid-filled organs such as the heart or liver. pleural effusion or pneumonia will cause this thudding sound (less air)

dull

-narcotics -neuromuscular blocking agents -anesthetics

during an SBT drugs that suppress ventilation should be discontinued

-instill epinephrine (vasoconstrictor) -compress the site with the scope (hold pressure with bronchiole (not always reliable bc its flexible) -insert Fogarty catheter (inflates balloon and holds pressure)

during bronchoscopy localized hemorrhage is common following tissue biopsy; most cases can be controlled with saline lavage and time if serious bleeding occurs, one or more of what steps should be taken:

20 min

during weaning (SBT) BP, RR, VT and VC should be assessed every

stop weaning and resume MV

during weaning if the HR increases 20 beats or more from baseline then

continue weaning and observe closely may increase the FiO2

during weaning if the HR increases less than 20 beats then

alert and responsive; any change in mental status or level of consciousness would indicate the need to resume MV; observe the pt for anxiety, confusion, lethargy, combativeness, unresponsiveness or loss of consciousness

during weaning pt should be

motion or movement

dynamic

a feeling of shortness of breath of difficulty breathing. there are grades of this that should be described in relation to activities of daily living Grade I-Grade V (the higher the number the worse off)

dyspnea

O2 concentrators

electrically powered and have limited portability; utilizes a molecular sieve that removes nitrogen and other gases from RA to concentrate the O2; O2 can be provided at 1-2 L/min continuously; at higher flows, O2 concentrations can fail instruct pts to routinely check and change filters; a properly grounded outlet is required, and a backup system (cylinder) must be available in case of a power failure if pt states that no flow is sensed from the cannula, ask the pt to verify this by inserting the cannula into a glass of water and checking for bubbles, if bubbles are visible the device is working correctly, if no bubbles are seen: check power source, flow setting, humidifier for leaks, and tubing for leaks, disconnections or obstructions

K+, Na+, Cl-, HCO3, (CO2 content)

electrolytes; Basic Metabolic Panel (BMP)

limit variable

establishes a max value that a variable can reach during inspiration. Inspiratory phase continues until terminated by the control variable or a back up cycling variable. Does not end inspiration and usually results in a plateau

normal respiratory rate, depth and rhythm

eupnea

qualitative leak test

evaluate the amt of leakage around the tube during positive pressure ventilation with the cuff deflated

blood urea nitrogen (BUN)

evaluates kidney function; Normal value: 8-25 mg/dL; increased levels indicates kidney failure

treat with diuretics furosemide

excessive fluids- increase pressure

pulmonary edema

excessive movement of fluid from the pulmonary vascular system to the extravascular system (interstitial space) and air spaces of the lungs (alveoli); most commonly caused by CHF

ETT

for bronchoscopy administer the topical anesthetic through the

started on a O2 therapy at 100% with NRB mask

for carbon monoxide poisoning the pt should be

mouth, tongue, and nail beds

for cyanosis check mucous membranes of the

> 20 (5 minutes later)

for heavy smokers the CO PPM in exhaled breath is

same level prior to ventilation

for infants initial FiO2 for pt currently on O2 should be set at

40-60%

for infants initial FiO2 for pt on RA or no prior info should be set at

same level prior to ventilation

for infants initial PEEP for pt currently on CPAP should be set at

2-4 cm H2O

for infants initial PEEP for pt with no prior info should be set at

20-30 breaths/min

for infants initial PIP should be

4-6 mL/kg

for infants initial VT should be set at

7-10

for light smokers the CO PPM in exhaled breath is

11-20 (5 minutes later)

for moderate smokers the CO PPM in exhaled breath is

<7

for non-smokers CO PPM in exhaled breath is

neurologic/neuromuscular diseases

for pts w/ any disorder in this category watch for ventilatory failure by monitoring VT, vital capacity (VC), and maximum insp. pressure (MIP) if the values fail below the acceptable level, institute MV

trendelenburg

for pts with very low BP or an obese pt with an order for bronchial hygiene therapy

anti-arrhythmic agents

for ventricular arrhythmias: -Amiodarone (Cordarone, Nexterone): for tx of pulseless ventricular tachycardia, and ventricular fibrillation that has not responded to defibrillation -Procainamide (Pronestyl): tx of ventricular ectopic beats, ventricular tachycardia & atrial arrhythmias -Verapamil: used to control ventricular rates in narrow complex supraventricular tachycardia -Lidocaine: control of PVC, stable ventricular tachycardia for bradycardia: -atropine -epinephrine

3.0-3.5 mm

full-term infant ETT size

irradiation

gamma rays are used to sterilize pre-packaged equipment

run down feeling, nausea, weakness, fatigue, headache (electrolyte imbalance)

general malaise

humidity therapy

goals: prevention of mucosal crusting and to compensate for a humidity deficit hazards: possible contamination source

ARDS or IRDS (ILD)

ground glass appearance, honeycomb pattern, diffuse bilateral radiopacity reticulogranular, reticulonodular Tx w/: O2, low VT or PIP, CPAP, PEEP

medical emergency response team (rapid response team)

group of healthcare workers that respond to pts w/ declining conditions & can prevent potential emergencies before they occur; RTs are essential members of these teams; reduces incidents of cardiac arrest and readmissions to ICU

lung CA

growth of abnormal tissue in the lungs referred to as a neoplasm or tumor; benign tumors are not life-threatening unless they interfere w/ lung function; malignant tumors grow rapidly and invade surrounding tissues major pathologic changes include: -inflammation, swelling and destruction of bronchial airways and alveoli -excessive mucus production -accumulation and plugging of mucus in the tracheobronchial tree -airway obstruction from tumor, mucus, oxblood -atelectasis -alveolar consolidation -cavity formation -pleural effusion risk factors -cigarette smoking (most common) -radon exposure -exposre to carcinogens such as asbestos inhaled chemicals or minerals, air pollution, etc -personal or family hx of lung CA pt assessment -cyanosis -tachypnea -BS: crackles, wheezing -flatt/dull w/ large tumors -tacycardia Dx: -chest x-ray: may include small oval or coin. lesion, large irregular mass, consolidation, atelectasis, pleural effusion -CT -PET -MRI -sputum cytology -bronchoscopy for biopsy, bronchial brushing, bronchial washing -mediastinoscopy -thoracentesis -ABG: for localized (lobar) CA- acute alveolar hyperventilation w/ hypoxemia; for extensive widespread CA- acute ventilatory failure w/ hypoxemia -pulm. function: location & severity of CA will determine whether pt has obstructive or restrictive pattern Tx: -surgery: pneumonectomy, lobectomy, segmentectomy, wedge resection -radiofrequency ablation for small tumors -radiation therapy -chemotherapy -targeted therapy drugs for non-small cell lung CA -02, airway clearance, lung expansion, bronchodilator

Mallampati classification class 4 you see

hard palate only (1 thing)

Ultrasonic Nebulizer

has the highest output range of all nebs without heating; recommended for pts w/ thick tenacious secretions; may be used for sputum induction

fenestrated tubes

have opening in outer cannula above the cuff; used for weaning and temporary mechanical ventilation with inner cannula; not used for code or in emergencies; allows pt to breathe through upper airway and speak when the tube is plugged; when plugging the tube, be sure to deflate the cuff, remove the inner cannula and then plug the tracheostomy tube

the degree to which people have the capacity to obtain, process, and understand basic health information and the services needed to make appropriate health decisions

health literacy

check oxygen source

if oxygen failure alarm goes off then

metabolic alkalosis

high CO2 content reflects high HCO3-; leading to

polycythemia

high Hb is referred to as

polycythemia

high Hct is referred to as

heart failure and increases the risk for stroke

high blood pressure can cause strain on the heart and will eventually cause

non-rebreather mask (NRB)

high flow device delivered FiO2: 0.21-1.0 indications: -used to deliver 100% O2 in emergency (pneumothorax, CO poisoning, CHF, burns, etc) -mixed gas therapy (He/O2 mixtures, CO2/O2 mixtures) has 3 one way valves flow rates must be sufficient to keep the bag form collapsing; if collapses increase the flow if pt inhales and bag does not slightly contract then mask is not tight, seal mask or the nonrebreathing valve is stuck, replace mask

T-piece (Briggs adapter)

high flow device delivered FiO2: 0.21-1.0 and depends upon the aerosol source reservoir tubing should be utilized to maintain the appropriate FiO2; if reservoir is removed FiO2 will decrease due to entrained room air should see aerosol from reservoir tubing during inspiration; if aerosol disappears: -increase flow -add more reservoir tubing -set up a device to provide more flow (blender, tandem set-up, change flowmeter, etc.)

stridor

high pitched or crowing inspiratory sound; caused by upper airway obstruction: -supraglottic swelling (epiglottitis): occurs by infection treat with topical decongestant [racemic epi] for swelling and edema -subglottic swelling (croup, post extubation): emergency intubation and antibiotics and suctioning and/or bronchoscopy for secretions and foreign body aspiration -foreign body aspiration (solids or fluids): intubation or swelling and epiglottitus

non-compensated acidosis

if pH is <7.35 then

non-compensated alkalosis

if pH is >7.45 then

cylinders

home O2 delivery system indicated for pts who use small amounts of O2 intermittently prevents waste or loss of O2 by only using when necessary can be stored indefinitely. do not store in the trunk of a car if used frequently more deliveries are necessary and can be more costly than other delivery systems appropriate for use as a back-up system when liquid or a concentrator us used for O2 delivery in the home if use <18 hrs a day; if you use >18 hrs a day you have to use a different device

HFNC (high flow nasal cannula) (i.e. vapotherm)

humidification system that can heat and humidify O2 at flow rates up to 40 L/min; O2 delivered via nasal cannula; safe easy to use and can provide almost 100% body humidity; may also generate a slight positive distending pressure (CPAP); improves pt comfort and compliance; consistent temperature and high humidity are provided without condensation in the tubing; contraindicated for pts with blocked nasal passages; monitor pt for skin erosion or irritation from nasal cannula; blocked tube alarm indicates obstruction or kinking of delivery tube or cannula; gas supply alarm indicates low or disconnected gas supply

increased RR, increased depth; regular rhythm

hyperpnea

booming sound that can be heard in an area of the lung where either a pneumothorax or emphysema may be present (more air)

hyperresonant

increase in muscle size of accessory muscles that can occur with COPD

hypertrophy

decreased CO2

hyperventilation means

shallow or slow breathing

hypopnea associated with CNS some type of drugs

increased CO2

hypoventilation means

causes of Kussmaul's

hypoxemia metabolic acidosis renal failure diabetic ketoacidosis (DKA) associated with respiratory acidosis

tachycardia indicates

hypoxemia, anxiety, stress (recommend oxygen therapy)

causes of tachypnea can include

hypoxia fever pain CNS problem

sputum culture

identifies bacteria present; takes 48-72hrs

acid fast stain

identifies mycobacterium tuberculosis

sensitivity

identifies what antibiotics will kill the bacteria takes 48-72hrs

gram stain

identifies whether bacterial are gram negative or gram positive; takes 1 hr

check power supply

if "Failure to cycle" alarm goes off then

check power supply

if "loss of power" alarm goes off then

normal ventilation dont change ventilation settings dont put pt on mechanical ventilator *maintain current settings/therapy

if PaCO2 is 35-45 torr

pt not ventilating initiate ventilation or remove/decrease mechanical deadspace or increase current ventilation

if PaCO2 is above 45

pt is ventilating but is ventilating too much dont put pt on mechanical ventilation decrease ventilation (if PaO2 is high) or consider other causes of hyperventilation (hypoxemia, metabolic acidosis, etc.)

if PaCO2 is below 35

reconnect pt to ventilator or check for leaks

if capnograph reads low or zero

give pt O2

if carbon monoxide is >20

inflate the cuff using minimal leak technique

if cuff pressure cannot be measured:

send someone to activate emergency response system; place infant on hard surface begin CPR (no pulse check); before attempting to ventilate, look for a foreign object int eh mouth and remove it; continue CPR for 5 cycles for about 2 min; if alone activate EMS system return and continue CPR

if the infant becomes unresponsive what are the steps for treating severe airway obstruction in an infant

these are all good (2)

if the infant is completely pink; HR > or equal to 100/min; coughs or sneezes; has active motion; has a regular respiratory effort and a strong cry

this is really bad (0)

if the infant's body is blue all over; has absent HR; no response; is limp has no movement; has an absent respiratory effort and no cry

these are all bad (1)

if the infants body is pink and extremities are blue (acyanosis); HR <100/min; has a grimace; has some flexion of extremities; has a slow irregular respiratory efforts and a weak cry

Level 1

if the pt is agitated anxious and restless then the pt is what level on the Ramsay Sedation Scale

Level 2

if the pt is calm , cooperative, oriented, tranquil then the pt is what level on the Ramsay Sedation Scale

Level 5

if the pt is unable to be assessed (paralyzed) then the pt is what level on the Ramsay Sedation Scale

Level 3

if the pt responds to verbal commands (conscious sedation) then the pt is what level on the Ramsay Sedation Scale

normal (60-100)

if the two R waves are between 3 and 5 large boxes then the rate is

greater than 100 (tachycardia)

if the two R waves are closer than 3 large boxes (15 small squares), then the rate is

less than 60 (bradycardia)

if the two R waves are wider than 5 large boxes (25 small squares), then the rate is

bronchial hygiene therapy

improves mobilization of secretions; prevents accumulation of secretions; improves ventilation indications: accumulated or retained secretions; ineffective cough; ciliary dysfunction/dyskinesia consider for pts with CF and bronchiectasis hazards/contraindications: unstable cardiovascular system, pulmonary system, or post op status and untreated TB

abnormal heart sounds (recommend echocardiogram)

in an adult, the presence of an S3; the presence of a fourth S4 sound; both S3 and S4 are low pitched and may be difficult to discriminate; heart murmurs; bruits

fluticasone and budesonide

inhaled corticosteroids

smoking cessation programs

includes group counseling and support, supplemental O2 (if indicated), nicotine replacement therapy, pulmonary rehabilitation, anti depressant drugs (bupropion hydrochloride [Zyban or Wellbutrin]), and Varenicline (Chantix) to reduce cravings and decrease the pleasurable effects of cigarettes and other tobacco products

congestive heart failure or pericardial effusion

increase in the cardiac shadow ir silhouette (cardiomegaly) indicates

pulmonary embolus (type 1)

increased deadspace suspect in: post-op pts, bedridden pts, hx of deep vein thrombosis (DVT), women in advanced stages of pregnancy, venous stasis (sitting for long periods of time), obesity, varicose veins, trauma, atrial fibrillation diagnosis made by hx, bedside assessment and an ABG (VD/VT is increased) bedside assessment shows hyperpnea (increased rate and depth of ventilation) blood gas reveals normal PaCO2 (no hyperventilation) confirm diagnosis with V/Q scan, CT scan or pulmonary angiography treatment: prevent w/ anticoagulants (heparin), support ventilation and oxygenation, treat existing clots w/ thrombolytic agents (streptokinase, tissue plasminogen activator [tPA])

hypertrophy

increased electrical activity; axis will shift toward

A-P diameter

increased with COPD; barrel chest; hyperinflation

that the lung is becoming more difficult to ventilate

increasing airway pressure indicates

infant apnea monitoring

indicated for an infant who may be at risk for periods of significant apnea (>20sec) also indicated when infant is considered at risk for sudden infant death syndrome (SIDS), risk factors include -one or more apparent life threatening episodes (ALTE). these occur when infant has apnea, cyanosis, choking, or lifelessness that requires stimulation or CPR -sibling of a SIDS baby -preterm infants w/ significant apnea periods -snoring in infants

Antibiotics

indicated for treatment of bacterial infections

nasopharyngeal airway

indications: conscious pt; support base of tongue; facilitate nasotracheal sx; use to decrease trauma during nasotracheal sx complications: trauma to mucosa (most common)- use water soluble or water-based lubricant; epistaxis- (nasal bleeding)- change every 24hrs; increased airway resistance - use largest size that will fit proper size determination: outside diameter or airway should be qual to inside diameter of pts external nares; length of airway is from tip of the ear lobe to center of nostrils insertion technique: inserted the way it is anatomically shaped with water soluble lubricant

Isolette (Incubator)

indications: filtered gas; temperature control will maintain a neutrothermal environment can administer O2 to neonate by cannula, oxyhood, CPAP etc. provides humidity; ideal for stable newborns hazards: thermal burns, electrical shock, oxygen toxicity, fire, toxic inhalation, hearing damage

oral and nasal intubation

indications: provide a patent airway, access for sx, means for MV, protect the airway (aspiration, obstruction), and direct instillation of meds (when IV unavailable: lidocaine [bronch], Valium/versed-sedative, Atropine-bradycardia, Narcan-narc. overdose, Epinephrine-asystole) (VANE)

bronchography (bronchograms)

injection of radiopaque contrast medium into the tracheobronchial tree; By outlining the airways it will identify obstructing lesions tumors and bronchiectasis (main indication); identifying the location of involved areas will allow better administration of postural drainage in pts with bronchiectasis; hazards include allergic reaction and impairment of ventilation

Macintosh blade (curved)

insert tip of curved blade in vallecula; indirectly raises epiglottis

miller blade (straight)

insert tip of straight blade under the epiglottis; preferred for infant intubation

cardiac catheterizattion

insertion of a catheter into a chamber or vessel of the heart, this is done for both diagnostic and therapeutic purposes; once the catheter is in place, it can be used to perform a number of procedures including angioplasty, percutaneous coronary intervention (PCI) angiography, balloon septostomy, and electrophysiology studies; diagnostic indications: confirm the presence of suspected heart pathology, quantify the severity of the pathology and its effect on the heart, measure the intracardiac and intravascular blood pressures, obtain tissue samples for biopsy, inject venous agents for measuring blood flow in the heart, detect and quantify the presence of an intracardiac shunt, inject contrast agents in order to study the shape of the heart vessels and chambers and how they change as the heart beats, reopen foramen ovale

advance directives

instructions for care that take effect at some point in the future when the pt is not capable of making deicisons

occur when the chest moves inward during inspiratory efforts instead of outward; this is caused by a severe airway obstruction or respiratory distress

intercostal/ sternal retractions

accessory muscles of ventilation

internal intercostal, scalene, sternocleidomastoid, pectoralis major abdominal muscles (oblique, rectus abdominus, etc) (indicates increased WOB)

myocardial infarction

interruption of coronary blood flow for an extended period of time causing potentially irreversible damage to the heart muscle potentially leading to sudden cardiac arrest pt assessment -diaphoretic anxious, c/o chest pain, possible cyanosis'--may be tachypneic -BS: crackles if ventricular failure is present Dx: -ABG: hypoxemia -hyperkalemia or hypokalemia -electrocardiogram: inverted T waves, elevated S-T segment -elevated troponin level Tx: -100% O2 by NRB -closely monitor SPO2, ECG -aspirin -morphine -anti-arrhythmic agents as indicated (amiodarone, procainamide, atropine) -nitrates for chest pain -maintain BP w/ fluids or vasopressors (dopamine) -defibrillate for pulseless ventricular tachycardia or ventricular fibrillation (v-fib u d-fib)

bronchoscopy

is a procedure that allows the physician and/or therapist to visualize the trachea and bronchi can be performed for diagnostic and therapeutic reasons diagnostic: -suspected foreign body -suspected malignancy -bronchial washings -hemoptysis -persistent problems therapeutic: -foreign body obstruction -secretion removal -bronchial lavage -airway stenosis -atelectasis

barium swallow or esophagram

is performed to assist in the diagnosis of abnormalities in the hypo pharynx, esophagus or stomach; a quantity of barium, which is radiopaque, is swallowed by the pt and traced through the hyphopharynx and into the esophagus by fluoroscope; the barium is then traced through the esophagus and into the stomach. generally x-rays are taken of the esophagus and stomach containing the barium at the end of the procedure; indications: suspected esophageal malignancy, dysphagia (difficulty in swallowing), congenital defect in hypo pharynx, esophagus, gastric reflux (GERD), esophageal varices

3000 g

normal birth weight for a term infant is

V/Q mismatch, diffusion defect, shunting or venous blood

lower PaO2 values may indicate

NT sx

lubricate catheter; insert catheter through nostril directing it toward septum and floor of nasal cavity; as catheter enters lower pharynx place pts head in sniffing position; advance catheter until pt coughs or resistance is felt in the airway; apply sx and withdraws catheter

bronchial BS over the lung periphery would indicate

lung consolidation

wetting agents

main uses of these substances are to liquefy secretions and as diluent for meds ex. water (given orally or intravenously is the best mucolytic; sterile distilled H2O aerosol is very irritating to airways & may cause bronchospasm) and saline solutions

neutrophils

major WBCs (bands and segs) are

bronchogenic carcinoma

major bronchi should not be narrowed at the carina or at the distal end, narrowing may indicate

chloride (Cl-)

major extracellular anion levels are closely associated with sodium (Na+) normal range: 90-100 mEq/L

> 3000g

normal birth weight for term infant

Mucolytics/Proteolytics

may be recommended when secretions are thick and tenacious (inspissated) and cannot be easily removed Acetylcysteine (Mucomyst): dissolves disulfide bonds -indications: to liquefy thick tenacious secretions or to tx acetaminophen overdose -most common side effect is bronchospasm -pts should receive a bronchodilator prior to acetylcysteine Recombinant Human DNAse (Pulmozyme) -specifically indicated for pts w/ CF -side effects: voice alteration, pharyngitis, laryngitis, rash, chest pain, conjunctivitis (pink eye)

Oxygenation Index (OI)

measures the amount of ventilatory support required to provide the level of oxygenation formula: (Paw x FiO2/PaO2) x 100 Normal value: <10 increasing values indicates that the pt's condition is worsening recommend ECMO for newborns with a value >40 (80% mortality if OI >40

A-a Gradient (A-aDO2, PA-aO2)

measures the different (gradient) between alveolar and arterial PO2 therapy to improve distribution of ventilation can be evaluated by the A-aDO2 (IPPB, IS, P&D etc.) best done after pt has been on 100% O2 for 20 min or more Formula A-aDO2 = PAO2-PaO2 normal value: 25-65 torr on 100% V/Q mismatch: 66-300 torr Shunting: >300 torr normal value varies directly with pts FiO2

Cardiac Output

measures the output of the left ventricle to the systemic arterial circulation and is measured by one of the following Fick equation: QT = VQ2/ C(a-v)O2 (10) Stroke Volume Equation: QT = HR x Stroke volume normal value: 4-8 L/min and depends upon body size

chest percussion

mechanically dislodges secretions indications: in combo with postural drainage, secretions difficult to dislodge hazards/contraindications: soft tissue trauma, rib cage trauma/fractured ribs, hemoptysis/pulmonary hemorrhage, metastatic conditions, pulmonary emboli, pleural effusion, TB, untreated pneumonia (absolute contraindication) technique: cupped hand position, rhythmic percussion over area to be drained, mechanical percussor (if malfunctions change to an alternative method-manual percussion)

bariatric conditions

medical specialty deal with causes, prevention. and treatment obesity. obesity defined body mass index > or equal 30 kg/m2 common risks for obese pts: -aspiration -difficult to provide ventilation via manual resuscitation bag -difficult intubation bc of bull neck (mallampati score > or equal to 3) -atelectasis -hemodynamic instability -DVT & pulmonary embolism Dx: -hypoxemia secondary to apnea -systemic & pulmonary hypertension -obstructive sleep apnea is prevalent leading to: -obesity hypoventilation syndrome/ [ickwickian syndrome -compensated respiratory acidosis -cor pulmonale -sleep study/ polysomnogram is important -rhabdomyolysis (pressure induced myoglobinuria) can be caused by excessive pressure on tissue from body weight Tx: -bariatric surgical procedures (gastric bypass, gastric banding, etc) places pt at risk for post op respiratory dysfunction, delayed recovery, increased ICU length of stay & mortality -Guidelines for MV: -VT should be determined by IBW not actual body weight -lung protective strategies include setting VT at 6 mL/kg of IBW -PEEP is helpful to offset weight of chest wall -elevate head of bed to prevent aspiration & VAP -consider early extubation to NIV or CPAP

inspiratory side of the Y adapter, as close to the pt as possible

medication delivery inline with an MDI should be located on the

psychiatric disorders

mental illness dx by a mental health professional that greatly disturbs the pts thinking, moods, &/or behavior & seriously increases the risk of disability, pain, death or loss of freedom most common disorders: -depression, anxiety, eating disorders, substance abuse, attention deficit disorder (ADD/ADHD) assessment of pt includes: -complete physical exam -lab tests, which may include thyroid function & screening for alcohol & drugs -psychological eval during which a physician or mental health professional talks to the pt about symptoms, thoughts, feelings & behavior patterns Tx: -meds (antidepressants, antianxiety meds, mood stabilizing meds, antipsychotic meds) -psychotherapy -in- or out pt therapy

causes of hyperpnea include:

metabolic disorder/CNS disorder

Jackson trach tube

metal trach tube; come with an inner cannula; not for resuscitation or positive pressure ventilation; replace with cuffed trach tube if necessary

medium crackles

middle airway secretions; (recommend bronchial hygiene)

wheeze

most commonly caused by bronchospasm; recommend bronchodilator therapy for diffuse/bilateral wheezing; unilateral wheeze indicative of a foreign body obstruction; (recommend rigid bronchoscopy

hx of pregnancy (prev. outcomes), age, smoking and subs abuse, nutrition, infection, hypertension/toxemia

mother's hx includes

hemodynamics

movement of blood or circulation/perfusion of blood; is simply the monitoring of blood pressures

vibration

moves secretions to larger airways;

inter-hospital transport

moving pt from one hospital/facility to another hospital/facility (between hospitals); to relocate to a more appropriate facility (specialty care, long term care, etc); or to assure pt safety during disaster (natural or man-made emergencies)

> 30 mg/dL

normal blood glucose for a term infant is

60/40 mm Hg

normal blood pressure for an infant is

8-25 mg/dL

normal blood urea nitrogen (BUN)

< 100 pg/mL

normal brain natriuretic peptide (BNP)

4-5 vol%

normal C(a-v)O2

17-20%

normal CaO2

12-16 vol %

normal CvO2

40

normal Dubowitz score

21-25 cm at lips

normal ETT markings for oral intubation

22-26 mEq/L

normal HCO3-

60-100/min

normal HR

110-160/min

normal HR for infant is

5-10

normal ICP

5-10 mm Hg

normal ICP

2:1 or higher

normal L/S ratio for infants

160 cm H20

normal MEP for bedside pulmonary function

80 cm H20

normal MIP for bedside pulmonary function

5-6 L/min

normal MVE for bedside pulmonary function

< 10

normal Oxygen Index (OI)

> or equal to 380 torr

normal P/F ratio or PaO2/FiO2

40 torr range: 35-45 torr

normal PCO2

97 torr range: 80-100 torr

normal PaO2

> 60 torr

normal PaO2 for newborn

3-5%

normal Qs/QT

4-6 mill/mm^3

normal RBC count

12-20

normal RR for bedside pulmonary function

30-60 breaths/min

normal RR for infant is

98% range: 95-100%

normal SaO2

93-97%

normal SpO2 (pulse oximetry)

20-40%

normal VD/VT

5-8 ml/kg

normal VT for bedside pulmonary function

5,000-10,000 per mm^3

normal WBCs

0.5-+0.2 J/L

normal WOB for bedside pulmonary function

0.6-2.4 cm H2O/L/sec

normal airway resistance is

0.6 - 2.4 cm H2O/L/sec; for intubated pt may be as high as 6 cm H2O/L/sec

normal airway resistance:

40 torr 35-45 torr 46 torr

normal arterial value for PCO2: normal acceptable range for PCO2: normal venous value for PCO2:

97 torr 80-100 torr 40 torr

normal arterial value for PO2: normal acceptable arterial range for PO2: normal venous value for PO2:

22-26 mEq/L

normal bicarbonate (HCO3-)

Congenital Diaphragmatic Hernia (CDH)

occurs when the diaphragm does not completely form. causes the abdominal contents to be in direct contact w/ the thoracic cavity. the majority of cases occur on the left side through the foramen of Bochdalek Pt assessment: -scaphoid abdomen, barrel chest, cyanosis -Respiratory distress @ birth, tachypnea, intercostal & substernal retraction, nasal flaring, expiratory grunting -BS: absent on affected side, bowel sounds on the affected side -apical heart sounds heard over the unaffected side Dx: -chest x-ray: fluid and air-filled loops of bowel in the chest, shift of the heart & mediastinum toward unaffected side, atelectasis & complete lung collapse, hypoplastic left lung -ABG: acute alveolar hyperventilation w/ hypoxemia Tx: -immediate O2 therapy -infant must not be manually ventilated w/ a bag & mask bc of the danger of gastric inflation -as soon as Dx is made, insert an orogastric tube to decrease gas in the bowel -prompt surgical repair is crucial -may require MV post-op (use low PIP (<30 cm H2O) and rapid respiratory rates; high frequency ventilation

atrial fibrillation tx: digoxin, beta blockers, calcium channel blockers, anticoagulants, thrombolytics

occurs when the ectopic foci are located in the atria; produces an irregular baseline with no visible P waves, the QRS complexes are also irregular; the atria are not moving just quivering

low RBC (anemia)

occurs with blood loss, hemorrhage

High RBC (polycythemia)

occurs with chronic tissue hypoxemia (i.e. COPD)

100-120 mm Hg

on a child the vacuum pressure should be

80-100 mm Hg

on a infant the vacuum pressure should be

120-150 mm Hg

on an adult the vacuum pressure should be

oropharyngeal sx

on infants can be done with a bulb syringe

vascular markings

on x rays blood vessels, lymphatics, lung tissue

equal ,visible, distinct

on xray the space between the vertebrae should be

capnography

once set up an arterial blood gas is drawn to correlate the values; normally the PETCO2 will be lower than the arterial PCO2 (Paco2 = 40 torr; PETCO2 = 35 torr); ETCO2 can also be displayed as a percent normal value is 3-5%; sensor should be placed proximal to the pts airway connection (at the ETT)

tracheal speaking devices

one way valve that attaches to tracheostomy tube; during inspiration valve opens and air enters the lungs through the tube; during exhalation valve closes and air passes around cuff and through vocal cords; cuff must be deflated; change to alternative device (i.e. fenestrated trach tube) if not tolerated

when asking the pt questions you should ask

open ended questions not yes or no questions

polarographic

operation is similar to galvanic fuel cell except for presence of a battery used to polarize the electrodes this type of device is analogous to the Clark electrode measures partial pressure; displays FiO2 as % accuracy can be affected by altitude, water and high pressure if unable to calibrate, change the battery and check electrolyte level (refill if low) after setup of a vent or O2 delivery system if O2 analyzer reads higher or lower- recalibrate analyzer and then recheck equipment; must be accurate within 2% of the known value

difficulty breathing except in the upright position (CHF)

orthopnea

if pt is not ventilating the pt is not

oxygenating

getting oxygen into the blood is

oxygenation

the most common problem pts have is

oxygenation

>7.30

pH for newborns should be

sanz

pH= ________________electrode

right ventricle

pacemaker wires/ electrodes should be normally positioned in the

a reaction of specific nervous tissue, may increase BP snd HR; lung tissue is not sensitive to this, but ribs muscle and pleura are sensitive to this

pain

congestive heart failure/ pulmonary edema

pt assessment: -peripheral/pedal edema, diaphoresis, cyanosis -tachypnea, orthopnea, paroxysmal nocturnal dyspnea (PND) -BS: crackles, wheezing -pink frothy secretions -flat or dull percussion note -increased tactile and vocal frremitus Dx: -chest x-ray: bilateral fluffy opacities, dilated pulmonary arteries, left ventricular hypertrophy (cardiomegaly), butterfly or bat wing pattern, Kelley A & B lines (if see it means lymphatics are really full of fluid) -ABG: respiratory alkalosis w/ hypoxemia -PFT: reduced volumes and capacities, normal FEV1/FVC ratio -increased PCWP, PAP -cardiac enzymes: increased brain natriuretic peptide (BNP) Tx: -high flow O2 therapy via NRB mask, HFNC -closely monitor VS and place pt in Fowler's position -hyperinflation therapy (IPPB, IPV) -diuretics: to promote fluid excretion (furosemide [LASIX]) -positive inotropic agents (digitalis, digoxin, dobutamine, dopamine) -analgesic: morphine -preload reduction agents: nitroglycerin, nitroprusside, morphine -CPAP if not indicated to support oxygenation -MV w/ PEEP for ventilatory failure -antidysrhythmic agent's: atropine (bradycardia), procainamide, metoprolol (tachycardia)

the process of influencing pt behavior and producing the changes in knowledge, attitudes and skills necessary to maintain or improve health

pt education

assisted

pt initiates the breath then the ventilator controls the reaming variables

3 months of failed weaning attempts; then they are a failure to wean and have to transfer pt out of hospital pts may be transferred to subacute or longterm care facilities or pt may be cared for at home if family has adequate resources; if pt cannot be weaned goal should be to reduce pt to the highest possible level of independent function

pts are considered vent dependent after

immunocompromised conditions

pts who have a reduced ability to fight infections & other diseases; may be caused by certain diseases or conditions such as HIV, cancer, diabetes, malnutrition, and certain genetic disorders risk factors -LGBTQ community -IV drug abuse -multiple blood transfusions -living in crowded conditions (prisons, shelters, etc) signs & symptoms -frequent & recurrent pneumonia, bronchitis, sinus infections, ear infections, meningitis or skin infections -inflammation & infection of internal organs -blood disorders such as low platelet counts or anemia Tx: -manage infections w/ rapid & aggressive tx w/ antibiotics; infections that dont respond may require hospitalization and intravenous (IV) antibiotics (pneumocystis carinii/jirovecii infections can be tx w/ aerosolized pentamidine -prevent infections w/ long-term antibiotics to prevent respiratory infections and permanent damage to the lungs and ears -tx symptoms: ibuprofen (Advil, Motrin IB, others; for pain & fever); decongestants for sinus congestion & expectorants to thin mucus in the airways might help relieve symptoms caused by infections tx to boost the immune system -immunoglobulin therapy -interferon-gamma therapy -growth factors -stem cell transplantation pt assessment: -resp. pattern: irregular rhythm, cheyne-stokes breathing -altered level of consciousness -abnormal pupillary response Dx: -CT, MRI, PET scans -intracranial pressure monitoring: normal value 5-10 mmHg

while monitoring the pressure waveform during insertion of a Swan-Ganz catheter, the RT notes the presence of a dictrotic notch. This finding indicates that the tip of the catheter is inside the

pulmonary artery

right lower lung field

pulmonary artery catheters should appear in the

happy fellow

purple to yellow =

Helium/Oxygen Therapy (HeliOx) (He/O2)

purpose: decreases the pt's WOB by delivering low density gas (most important property) that can easily maneuver around obstructions helium attaches to O2 so O2 can get lower indications: -post extubation stridor -severe asthma/status asthmaticus -obstructive tumors -foreign body aspiration -partial vocal cord paralysis concentrations used: -80% He/ 20% O2 -70% He/ 30 O2 -60% He/ 40 O2 considerations: -administered with NRB -when using an O2 flowmeter to regulate the flow, the actual flow delivered to the pt must be calculated: actual flow = indicated flow x factor factors: -80/20 mixture: 1.8 -70/30 mixture: 1.6

hyperbaric O2 therapy (HBO)

purpose: means of increasing the PO2 by increasing the barometric pressure diseases/disorders frequently treated by hyperbaric O2 therapy: -CO poisoning -decompression sickness (bends) -tissue transplants/grafts -anaerobic infections (gas gangrene) most therapy is conducted at pressures between 2-3 atmospheric pressure absolute (ATA) -typical chamber can provide pressure between 2-6 ATA -O2 is administered by mask or through the chamber at 100%

Guillian-Barre syndrome

rare autoimmune disorder of the peripheral nervous system; most likely an immune disorder that causes inflammation & deterioration of the pts peripheral nervous system; an ascending paralysis (moves from ground to the brain) Pt assessment: -past med hx: febrile illness, often viral in nature -acute weakness, especially in t he legs, cyanosis -shallow breathing -BS: diminished w/ crackles Dx: -decreasing VT, VC, MIP -ABG: acute ventilatory failure w/ hypoxemia, watch for ventilatory failure (PaCO2>45 torr) -pulm. function: reduced volumes (FVC, VT) -lumbar puncture: high protein level in CSF (>500 mg/dL) -abnormal electromyograph -elevated (IgM) immunoglobulin levels Tx: -directed @ stabilization of VS & supportive care -initially pts should be managed in ICU -closely monitor VT, VC MIP (intubate & initiate MV when indicated) -O2 therapy for hypoxemia -hyperinflation therapy (IS/SMI, IPPB) -pulm. hygiene -MV for impending or acute ventilatory failure -plasmapheresis &. intravenous immunoglobulin (IVIG) therapy are effective

respiratory quotient (RQ)

ratio of CO2 produced to O2 consumed RQ = VCO2/VO2 Normal: 0.8 normal range: 0.67-1.3 and is influenced by the type of food group metabolized by the pt for energy (carbs-1.0, fats-0.71, proteins-0.82) this may be helpful in critically ill pts to adjust their dietary intake for ex. a diet high in carbs produces excess CO2 which may increase WOB, low carb high protein and fat is good for pts with COPD

P/F ratio or PaO2/FiO2 ratio

ratio of the partial pressure of arterial oxygen to the inspired fractional concentration of oxygen (PaO2/FiO2) used in determination of acute lung injury (ALI) or acute respiratory distress syndrome (ARDS) measures the efficiency of oxygen transfer across the lung formula: PaO2 / FiO2 -normal value: 380 torr or greater -a ratio less than 300 torr signifies ALI -a ratio less than 200 torr signifies ARDS

analgesics (all end in "ine" or "one" except fentanyl

reduce sensation of pain -morphine -codeine -meperidine (Demerol) -fentanyl (Sublimaze) -hydromorphone (dilaudid) -oxycodone (oxycontin) -hydrocodone

ischemia

reduced blood flow to tissue; indicated by a depressed or inverted T wave

anesthetics

reduces pt's ability to perceive sensation onset immediate -propofol (Diprivan) -ketamine (Ketalar) -etomidate (Amidate)

VT, VC, MIP & weakness improve w/ tensilon test

referred to as a myasthenia crisis, indicating more of this medication needs to be given maintenance drug therapy (anticholinesterase therapy, cholinesterase inhibitors) including: -pyridostigmine (menstinon, regonol) -prostigmine (neostigmine)

hyperkalemia

refers to high K+; kidney failure, spiked T wave, metabolic acidosis

hypernatremia

refers to high Na+; dehydration

hypochloremia

refers to low Cl- metabolic alkalosis

hypokalemia

refers to low K+; occurs with metabolic alkalosis, excessive excretion, vomiting, flattened T waves on ECG; associated with muscle twitches/spasms/cramps

hyponatremia

refers to low Na+; fluid loss from diuretics, vomiting, diarrhea, fluid gain from CHF, IV therapy

tracheal button

rigid plastic tube about 1 inch in length that can be placed in stoma after trach tube is removed; used to maintain stoma (tracheostomy opening); used in some pts with obstructive sleep apnea; allows tracheal sx and phonation with least amount of airway resistance; uncuffed, cannot be utilized for resuscitation

Co poisoning (type 1)

saturation of Hb with carbon monoxide SaO2 result measured from ABG machine is misleading since this is a calculated value suspect in: firefighters, victims of fires or smoke inhalation, anyone exposed to vehicle exhaust measure COHb level with co-oximetry/hemoximetry tx is 100% O2 and hyperbaric oxygen therapy

Brain Natriuretic Peptide (BNP)

secreted by the cardiac muscle when heart failure develops or worsens normal value: <100 measurement of this is helpful to determine if the pts symptoms are the result of CHF or another condition such as COPD elevated levels indicate CHF: ->300 pg/mL: mild heart failure ->600 pg/mL: moderate heart failure ->900 pg/mL severe heart failure recommend diuretics, positive inotropic agents

trachea

seen as a dark area midline; shift to one side would indicate a unilateral lung problem; should be the same size as the vertebral column

chest tubes

should be located in the pleural space surrounding the lung

nasogastric tubes and feeding tubes

should be positioned in the stomach 2-6 cm below the diapragm

pt has clear BS and x-ray, is ambulating well, has a strong cough, is afebrile for 24 hrs, or if hazards occur (dizziness, SOB, cyanosis etc.)

should discontinue bronchial hygiene therapy if

objective info, those things that you can see or measure (color, pulse, edema, BP, etc)

signs

mild airway obstruction

signs: good airway exchange, responsive and can cough forcefully, may wheeze between coughs treatment: as long as good air change continues encourage the victim to continue spontaneous coughing and breathing efforts; no not interfere with the victims attempts to expel the foreign body; stay with the victim and monitor his condition; call 911 if mild airway obstruction continues

congenital heart defects

structural abnormalities of the heart present at birt; the most serious defects create right-to-left shunting resulting in severe hypoxemia. these include: -tetralogy of fallout-overriding aorta, pulmonary stenosis, ventricular septal defect and right ventricualr hypertrophy -transposition of the great vessels- aorta is switched with pulmonary artery (aorta arises from the right ventricle & the pulmonary artery arises from the left ventricle) pt assessment: -cyanosis -tachypnea -normal BS; loud heart murmur Dx: -chest x-ray: possibly an enlarged or abnormally shaped heart 1. egg shaped heart w/ transposition of the great vessels 2. boot-shaped heart w/ tetralogy of Fallot -echocardiogram is the most important dx test to identify cardiac defects -pre- and post- ductal blood gas studies 1. if pre-ductal (R radial artery) PO2 is >15torr higher than the post-ductal (umbilical artery) Po2, then the pt has a R-to-L shunt 2. can also be evaluated using 2 transcutaneous monitors, one placed on the upper right thorax (pre-ductal) & the other on the lower left thigh or left abdominal region (post-ductal) -O2 therapy -MV for ventilatory failure -prostaglandins to maintain patent ductus arteriosus -supportive care prior to surgical correction of the defect

vessels

the condition of these will cause the BP to change

pt is eating or when pt is on positive pressure ventilation

the cuff on tracheostomy tubes should be kept inflated whenever

pulse pressure

the difference between the systolic and diastolic pressure formula: pulse pressure = systolic pressure- diastolic pressure normal value: 40 mmHg

P-R interval

the impulse received by the Av node where it is delayed for a short time

smoke inhalation/thermal. lung injuries/ carbon monoxide poisoning

the inhalation of smoke and hot gases, often accompanied by body surface burns; airway obstruction is a concern in the ED; carbon monoxide poisoning is present when COHb >20% pt assessment: -firefighter or pt pulled from a burning building, pts found sitting in garage w/ car running, trash fires, etc -anxious, surface burns, singed facial hair, black soot marks, cyanosis or "cherry red" color (suspect CO poisoning) -tachypnea, cough may be productive of thick, black, sooty secretions -BS: normal in early stages, may present w/ wheezing, crackles or rhonchi, inspiratory stridor Dx: -chest x-ray: normal in early stages, pulmonary edema/ARDS in late stages -ABG: acute alveolar hyperventilation w/ hypoxemia -pulmonary function: decreased volumes and flowrates (VT, VC, FEV1, etc) and decreased DLCO -COHb levels measured by co-oximeter or hemoximeter Tx: -immediate assessment of pts airway & respiratory & cardiovascular status -elective intubation for pts who have inhaled hot gases or demonstrate signs of impending upper airway obstruction (marked or severe distress/stridor) -O2 therapy @ 100% -hyperbaric O2 therapy (if avail.) for severe cases of CO poisoning -monitor ABG, electrolytes & fluid levels -MV for ventilatory failure -bronchoscopy to clear airways of mucus plugs & evaluation of the upper airways -pulmonary hygiene -hyperinflation therapy (IS/SMI, IPPB) -aerosolized meds -bronchodilators (sympathomimetic & anticholinergic agents) -mucolytics -corticosteroids -monitor signs of infection

drug overdose

the intentional or accidental overuse of medication that exceeds the recommended dose pt assessment: -previous admissions for overdose, found by family, friends, etc. -slow, shallow respirations -BS: diminished throughout -altered level of consciousness, euphoria Dx: -drug toxicology Tx: -airway maintenance is the 1st priority -MV for ventilatory failure -reversal agents (naloxone [Narcan], flumazenil [romazicon], & acetylcysteine for acetaminophen overdose)

arterial oxygen saturation (SaO2)

the percentage of hemoglobin that is bound by O2; the value reported by a blood gas analyzer is calculated; actual saturation can be measured by a hemoximeter or co-oximeter; large differences between the calculated and measured values may be due to elevated carbon monoxide (COHb) levels normal value: 95-100% the PaO2 value can be estimated by subtracting 30 from the SaO2.

Deadspace to tidal volume ratio (VD/VT)

the percentage of the tidal volume that is deadspace (does not participate in gas exchange) ventilation WITHOUT perfusion normal value: 20-40% (up to 60% for ventilator pts) formula: (PaCO2-PECO2/ PaCO2) x 100 PECO2 is the average PCO2 of the exhaled air that can be measured by a capnograph an increase in the VD/VT ratio indicates a deadspace producing disease (pulmonary embolus)

shunt equation

the portion of the cardiac output (QT) that is shunted (QS) and does not participate in gas exchange formula: Qs/QT = (A-aDO2) (0.003)/ (A-aDO2) (0.003) + C(a-v)O2 ABG and VBGs are drawn and analyzed to determine the A-aDO2 and C(a-v)O2 normal value: 3-5%

pulmonary vascular resistance (PVR)

the pressure gradient across the pulmonary circulation divided by the cardiac output PVR= (MPAP-PCWP)/cardiac output normal value: <2.5 mmHg/L/min or 200 dynes/sec/cm-5 is increased with hypoxia, pulmonary hypertension and lung disease

10 cm below peak airway pressures

what should the low pressure alarm be set at

restrictive

the shape of the flow volume is diagnostic; a skinny and tall loop is

QRS complex

the stimulus is then sent through the bundle of His and the left and right bundle branches to the Purkinje Fibers. this produces ventricular depolarization and contract

cardioversion

therapeutic procedure that involves administering a low voltage current to the heart in an attempt to convert a cardiac dysrhythmia to normal sinus rhythm indicated for unstable atrial fibrillation, unstable atrial flutter, and stable ventricular tachycardia the electric current is synchronized with the pt's own rhythm make sure synchronizing switch is on before cardioverting electric shock is on the R wave of ECG O2 resuscitation equipment and emergency drugs should be present in event of a cardiopulmonary arrest if ventricular fibrillation occurs you dfib check pulse turn off synchronizing switch and defibrillate midazolam (VERSED) is a string short acting sedative given prior to cardioversion

Flow inflating resuscitation bag

used for resuscitation and manual ventilation of neonates "Non-self-inflating bag/Anesthesia bag" Requires gas source to ventilate - keep in mind on transports inflates only when a gas source is turned on and opening of bag is sealed (mask placed tightly on neonate's face) Can provide blow by O2 and PEEP/CPAP Most come with pressure manometer but should always use with a pressure manometer to monitor PIP and PEEP Can take skill to set up correctly -Squeeze too little, volume too small -Squeeze too much, takes longer to refill neonates receive same FiO2 as the gas flowing to the bag PIP: controlled by flow to the bag, adjustment of flow control valve, and how hard the bag is squeezed bag should be kept approx. half-full between breaths bag will not inflate in presence of: leaks, low flow to bag, opened flow control valve, and open pop-off valve

Amiodarone (Cordarone, Nexterone)

used for tx of pulseless ventricular tachycardia, and ventricular fibrillation that has not responded to defibrillation

pulse dosed oxygen delivery systems

used in place of a flow meter w. low flow O2 devices (nasal cannula, and transtracheal catheters) and connected to a 50 psi gas source device senses the start of inspiration and delivers O2 only during inspiration

electroencephalograph (EEG)

used in sleep studies; the brain produces electrical activity that can be measured as tiny fluticasone in voltage through the scalp in much the same way that an electrocardiogram records the electrical activity of the heart; this electrical current us amplified and recorded as a tracing on paper, the data is combined with other clinical assessments to diagnose many neurological conditions; indications: Brain tumors, traumatic brain injuries, loss of brain function, epilepsy/seizures, evaluation of sleep disorders

stylet

used only to aid in oral intubation; shapes the tube for easier insertion; end is to be recessed 1 cm above tip of ETT the opposite end should be bent or positioned to prevent advancement

lukens trao/sterile sx trap

used to collect a sputum specimen; placed in an upright position between the sx catheter and the sx tubing; flush catheter with sterile water and isotonic saline (not bacteriostatic or hypertonic saline); use saline for collecting samples for cytology

Verapamil

used to control ventricular rates in narrow complex supraventricular tachycardia

yankauer/tonsil sx device

used to sx mouth and throat using aseptic technique

dry powder inhalers (DPI)

used to treat asthma and COPD; medications are in powder form and do not require a propellant; easier to use than MDI; coordination or timing concern not as important as with MDI Types: -pre-metered: need to be loaded with medication prior to ea. use -device-metered: have a set # of doses in the device -pt -activated or power-assisted DO NOT breathe into device to prevent clumping of medication in inhaler from humidity from exhalation meds: salmeterol, formoterol, fluticasone, budesonide

metered dose inhaler (MDI)

used to treat asthma and COPD; pt must be able to understand and cooperate advantage is more reproducible administration of drug; upon squeezing cartridge a fine mist should be seen- indicating its working properly meds: albuterol, levalbuterol, salmeterol, formoterol, ipratropium bromide, tiotropium bromide, fluticasone, budesonide, cromolyn sodium, nedocromil sodium

Antipneumocystis Agent

used to treat pneumocystis jiroveci (carini) infections (commonly seen in pts w/ AIDS) EX. Pentamidine (NebuPent) administered w/ a special nebulizer (Respirgard II) which incorporates one-way-valves to prevent the therapist from exposure to the drug most common adverse effect is bronchospasm; pretreat the pt with a bronchodilator

Mannitol (Osmitrol)

uses: cerebral edema, drug toxicity, & drug overdose adverse effects: increased cardiac workload due to increased plasma volumes; causes metabolic alkalosis

Acetazolamide (Diamox)

uses: cerebral edema, peripheral edema, altitude sickness adverse effects: metabolic acidosis-contraindicated in renal failure or respiratory failure bc it causes excretion of bicarbonate ions; causes metabolic acidosis

Furosemide (Lasix)

uses: pulmonary edema, liver, kidney disease, CHF adverse effects: hypokalemia (potassium; K+); hypochloremia (blood chloride); causes metabolic alkalosis

-sedatives: decrease anxiety and promote relaxation -anesthetics: reduces pt's ability to perceive sensation -analgesics: reduce sensation of pain -neuromuscular blocking agents: cause paralysis of skeletal muscle

what agents would you recommend to achieve pt-vent synchrony

hospital, outpatient rehab clinics, and home care

what are 3 settings where pulmonary rehabilitation can be utilized

morphine (narcotic) for analgesic and antitussive (stops cough) effects

what other medication may be given during bronchoscopy

Midazolam (Versed), Diazepam (valium), Lorazepam (Ativan) ("am" = sedative med)

what sedatives are administered for bronchoscopy

large volume nebulizer

utilized to deliver bland aerosols to upper airway to reduce chances of edema or humidity deficit; heated jet nebs will have a much higher output of water vapor than non-heated nebs; incorporate an air-entrainment device to administer 21-100% O2; for thick secretions a heating element can be added if not misting enough: may have insufficient flow; a clogged capillary tube; a decrease in temp with heating probe causing condensation; insufficient water level if changes in FiO2: any increase in resistance (such as water collecting in tubing) will cause less air to be entrained causing FiO2 to increase intermittent aerosol produced indicates condensation in tubing this water should be emptied when prefilled nebs run low- change the unit DO NOT refill unit or allow it to run dry increased rate and depth of breathing may indicate insufficient flow to verify adequate aerosol observe aerosol coming out end of tubing during inspiration when using a blender: set blender at desired FiO2 and set air-entrainment port on large volume nebulizer at 100% (closed)

lateral neck x ray

valuable diagnostic tool for identifying upper airway obstruction in children (croup or epiglottitis-both conditions cause a localized swelling of tissues that may result in partial to complete obstruction of the airway and require prompt and effective therapy)

increased venous distention, jugular venous distention (JVD); occurs with congestive heart failure; seen during exhalation in patients with obstructive lung disease and air trapping

venous distention

moving air in and out of the lungs is

ventilation

the existence of Mallampati classification class factors may complicate

ventilation by face mask, BVM, or endotracheal intubation

what are the four critical life functions

ventilation, oxygenation, circulation, and perfusion

-circuit is grossly contaminated -malfunctioning

ventilator circuits should don't be changed on a regular basis unless

mandatory breath

ventilator controls all variables pertaining to the breath

ventricular tachycardia (v-tach) -if a pulse is present (stable VT): tx-cardiovert -if a pulse is absent (unstable VT): tx- defibrillate, CPR, epinephrine, amiodarone

ventricular rhythm with rate >100;

lateral fowlers

very obese pt with air hunger

normal breath sounds are called

vesicular

increases BP; treat with vasodilators: -direct vasodilators (nitroprusside, hydrazine, milrinone) -ACE inhibitors (lisinopril, perindopril, catopril, enalapril, ramipril)

vessel constriction

decreases BP; treat with vasoconstrictors (epinephrine, phenylephrine, dopamine, dpbutamine)

vessel dilation

what are the preferred learning styles

visual, auditory, hands-on, lecture, discussion

voice vibrations on the chest wall

vocal fremitus

Large volume syringe (Super Syringe 3.0 Liters) -accuracy +-3.5% (range 2.895 L -3.105 L) -calibrate with flows between 2 and 12 L/sec

volume calibration and leak tests are done by using a

Forced Expiratory Volume (FEV1.0)

volume of gas expired in the first second of the FVC most individuals can exhale all of their air in about 2 seconds

COPD

weakening & permanent enlargement of the air spaces distal to the terminal bronchioles often accompanied by hypertrophy of the goblet cells and mucus glands characterized by dyspnea on exertion w/ significant hypoxemia and hypercapnia chronic ventilatory failure, chronic hypercapnea, increased lung compliance, loss of elastic recoil, chronic CO2 retention pt assessment: -barrel chest (increased A-P diameter), clubbing and cyanosis -dyspnea, accessory muscle use, pursed lip breathing -BS: diminished aeration w/ bilateral exp. wheeze -typanic or hyperresonant -cough: congested, productive of thick sputum Dx: -chest x-ray: hyperrlucency, hyperinflation, increased A-P diameter, flattened diaphragm -ABG: compensated respiratory acidosis w/ hypoxemia and hypercapnea -pulmonary function testing (PFT): decreased flows (FEV1, FEV1/FVC, FEF 25-75%_ tx: -low flow O2, target SPO2 is 88-92% -aerosolized bronchodilators (SABA, LABA< anticholinergic, LAMA) -bronchial hygiene as indicated -inhaled corticosteroids -antibiotics if indicated by sputum culture -referral to smoking cessation program, including nicotine replacement therapy -pulmonary rehabilitation, propre nutrition and monitor fluid intake -consider NPPV for acute exacerbations of ventilatory failure -refer pt & fam to appropriate education programs (nutritional management, avoiding infections- signs symptoms to look for, exercise program, methods to aid secretion clearance, home O2 therapy and aerosol therapy, & meds and their use)

-apnea: not breathing (observation)- absolute indication -acute ventilatory failure/ acute respiratory failure- insufficient spontaneous ventilation to maintain normal physiologic parameters, including PaCO2 and PaO2 -impending ventilatory failure- trend of rising PaCo2 and/or decreasing VT, VC, MIP (have to wait until CO2 has reached above 45) -oxygenation- to reduce WOB *if pt has an acceptable PaCO2 oxygenation can be supported w. oxygen therapy and CPAP *initiate MV if O2 therapy is. unsuccessful & pt has increased WOB

what are indications for MV

tremors, shakes, quivering (most common side effect), tachycardia, palpitations (feeling of heart activity by the pt), hypertension/hypotension, headache, paradoxical hypoxemia, tachyphylaxis (lack of response to normal drug action over time), nausea/vomiting if any of these side effects occur, stop therapy, notify the nurse and/or doctor and chart the results if bronchospasm/wheezing persists first increase dosage to maximum then increase frequency

what are side effects of beta, adrenergic bronchodilators (front door bronchodilators)

-hematoma (disruption of blood flow) -clotting -bleeding (hold pressure for minimum of 5 min) -vessel spasm -tissue trauma -anticoagulant therapy -air bubbles -improper cooling (sample not iced) -too much liquid heparin

what are some hazards and problems with ABGs

-trauma to mucosa (most common)-lubricate catheter (nasal-tracheal sx) use gentle technique -contamination- useaseptic technique -hypoxemia- leading to tachycardia, arrhythmias (most severe) -bradycardia- from vagus nerve stimulation -sx that is too vigorous may cause bleeding

what are some hazards of sx

-nicotine patch (Nicotrol or NicoDerm) -nicotine-oral (Nicorette) -nicotine nasal spray -nicotine inhaler

what are some nicotine replacement therapies

-Bronchospasm/laryngospasm (tx w/ bronchodilators and anesthetics) -hypoxemia (monitored w/ pulse ox & ECG; prevented/treated with O2) -pneumothorax is possible when taking tissue samples

what are some other complications of bronchoscopy

-trigger variable -control or target variable -limit variable -cycling variable

what are the four variables during positive pressure mechanical ventilation

endotracheal nasotracheal oropharyngeal

what are the routes for sx

-helium dilution (closed method) -nitrogen wash out (open method) -plethysmograph/body box

what are three tests that measure FRC

airway exchange catheter and gum elastic bougie

what are two endotracheal tube changers

1. missed triggers 2. auto-trigger (auto-cycle) oversensitive trigger

what are two types of asynchrony

hypersensitivity/ allergic reaction

what causes anaphylactic shock

heart failure

what causes cariogenic shock

insufficient intravascular fluid volume

what causes hypovolemic shock

alterations in vascular smooth muscle tone

what causes neurogenic or vasogenic shock

infection

what causes septic shock

respiratory muscle strength

what does MIP and NIF measure

negative inotropic drugs (i.e. calcium channel blockers)

what drugs decrease contractility

-B-blockers or B-antagonists drugs (atenolol, propranolol, labetalol)

what drugs decrease the heart rate

positive inotropic drugs (i.e. digitalis, digoxin)

what drugs increase contractility

+ chronotropic drugs (i.e. atropine)

what drugs increase the heart rate

O2, sx, forceps, brush, lukens trap, syringes with flush solution

what equipment is required for bronchoscopy

sitting upright or leaning forward slightly

what is a good cough control technique position

multiple inhalations

what is a volume building cough control technique

66-300 torr

what is acceptable A-a DO2 (100% O2)

10-15 torr

what is acceptable A-a DO2 (21% O2)

> 25 ml/cm H2O

what is acceptable Cost (mL/cm H2O) (static compliance)

<20%

what is acceptable QS/QT (%) (shunting)

8-20 b/min

what is acceptable RR (f) b/min

< or equal to 60%

what is acceptable VD/VT deadspace (%)

> or equal to 10 mL/kg (2 x VT)

what is acceptable Vital Capacity (VC) mL/kg

40 cm H2O

what is acceptable maximum expiratory pressure (MEP)

20 cm H2O

what is acceptable maximum inspiratory pressure (MIP) and negative inspiratory force (NIF)

40 torr

what is normal PaCO2

35-45 torr

what is normal PaCO2 range

7.40

what is normal pH level

7.35-7.45

what is normal pH range

PaO2 less than 55 torr on RA

what is the criteria used to determine if a pt will benefit from O2 in the home

gauge pressure (psi) x tank factor/ liter flow

what is the formula for duration of cylinder flow

8.0 mm ID

what is the minimum ETT size for a flexible bronchoscopy

mannitol (only diuretic that can cross the blood brain barrier so it can draw the fluid out) and hypertonic saline

what osmotic agents are used to remove fluid from brain

10 cm H2O above peak airway ressure

what should the high pressure alarm be set at