ARDS + respiratory

Question 1

bronchial circulation

Answer 1

does not participate in gas exchange
left bronchiole circulation is rooted from aorta
right sided bronchioles are supplied by arteries (intercostal, subclavian, mammary)
veins empty into vena cava

Question 2

ventilation

Answer 2

mechanical act of moving air into and out of respiratory tree
involves musculoskeletal and nervous sustems

Question 3

respiration

Answer 3

process of transporting O2 and CO2 across alveolar capillary membranes by diffusion across concentration gradient

Question 4

physiology of ventilation

Answer 4

diaphragm contracts and flattens
increases volume of thoracic cavity
creates a relative negative intrapulmonary pressure

Question 5

compliance

Answer 5

ability of lungs and thorax to stretch and expand given a change in pressure
decreased in pulmonary fibrosis
increased in emphysema and COPD

Question 6

age related changes

Answer 6

decreased cough/laryngeal reflexes
decrease in alveoli, respiratory muscle strength
increased VQ mismatches, AP diameter, residual volume

Question 7

autonomic respiration

Answer 7

controlled by brainstem

Question 8

voluntary ventilatory effort

Answer 8

controlled by cerebral cortex

Question 9

central chemoreceptors

Answer 9

detect level of H ion in blood

Question 10

peripheral chemoreceptors

Answer 10

sensitive to oxygen, CO2, and H levels

Question 11

dead space units

Answer 11

ventilation exceeds perfusion

pulmonary embolism or pulmonary infarct

Question 12

shunt unit

Answer 12

perfusion exceeds ventilation

pneumonia or atelectasis

Question 13

silent unit

Answer 13

ventilation and perfusion are impaired

severe ARDS or pneumothorax

Question 14

oxyhemoglobin dissociation curve

Answer 14

97% of O2 is bound to Hgb (SaO2)

3% dissolved in serum (PaO2)

Question 15

shift right

Answer 15

fever
acidosis
rise in CO2 (hypercapnia)
rise in 2, 3 diphosphoglycerate

Question 16

shift left

Answer 16

hypothermia
rise in pH (alkalosis)
low CO2

Question 17

PaO2

Answer 17

80-100 mm Hg

reflects the partial pressure of O2 in arterial blood

Question 18

SaO2

Answer 18

93-100%

represents saturation of Hgb with O2

Question 19

type 1 respiratory failure

Answer 19

hypoxemic failure

stems from a disruption of O2 transport from alveolus to arterial flow

Question 20

type 2 respiratory failure

Answer 20

hypoxemic hypercapnic failure
originates in musculoskeletal or anatomical lung dysfunction/suppression
high concentration of CO2 in alveolus = hypercapnia
inability to replace CO2 with O2 = hypoxemia

Question 21

type 1 respiratory failure nursing dx

Answer 21

impaired gas exchange

r/t: alterations in alveolar capillary membrane, excessive secretions, VQ mismatch

Question 22

type 1 respiratory failure interventions

Answer 22

provide supplemental O2
positioning
maintain airway patency
treat underlying causes of ACM alterations, VQ mismatches

Question 23

type 2 respiratory failure nursing dx

Answer 23

ineffective breathing pattern

r/t: alveolar hypoventilation, musculoskeletal dysfunction, neurological trauma

Question 24

type 2 respiratory failure interventions

Answer 24

provide mechanical ventilation as needed
treat causes of alveolar hypoventilation
optimize musculoskeletal dysfunctions
optimize neurological defects

Question 25

s/s of hypoxia

Answer 25

``` tachypnea, dyspnea tachycardia, dysrhythmias HTN confusion, restlessness lethargy ```

Question 26

low flow O2 therapy

Answer 26

``` nasal cannula (up to 6 LPM) simple mask (8-12 LPM) nonrebreather mask (prevent room air from being inhaled) Venturi mask (adjustable dial with desired FiO2 and LPM flow) ```

Question 27

high flow O2 therapy

Answer 27

delivers O2 at higher rate than pt's inspiratory flow rate may have some positive pressure effect wide nasal cannula, nasal pillow, face mask

Question 28

mechanical ventilation

Answer 28

NIV or invasive

Question 29

mechanical ventilation desired outcomes

Answer 29

``` relief of sx of respiratory distress rest fatigued muscles of respiration improved oxygenation, ventilation pH balance stabilization of chest wall provision of sedation/anesthesia ```

Question 30

noninvasive ventilation (NIV) indications

Answer 30

COPD exacerbation obesity hypoventilation syndrome cardiogenic pulmonary edema lung contusions

Question 31

noninvasive ventilation contraindications

Answer 31

apnea | recent airway or GI surgery

Question 32

noninvasive ventilation

Answer 32

supports ventilation without insertion of artificial airway ventilation through upper airway using an interface with a tight seal most common: CPAP, BIPAP

Question 33

CPAP

Answer 33

continuous positive airway pressure allows more lung units to be available for gas exchange helps open alveoli and prevent atelectasis during expiration increases partial pressure of O2 in the alveoli

Question 34

BiPAP

Answer 34

bilevel posiive airway pressure allows clinician to set higher inspiratory pressure and lower expiratory pressure reduces work of breathing

Question 35

noninvasive ventilation concerns

Answer 35

skin protection anxiolytics tissue ischemia 2/2 tight fit of mask

Question 36

invasive mechanical ventilation

Answer 36

provided by positive pressure ventilator | positive pressure is applied at patient's airway by means of naso/endotracheal tube or tracheostomy

Question 37

endotracheal intubation

Answer 37

larygnoscope stethoscope to auscultate for placement suction with orotracheal device bag valve mask

Question 38

nursing actions during endotracheal intubation

Answer 38

alert physician to decreases in SaO2 below 90% auscultate for correct tube placement note marking on tube at lip monitor for patient to wake because of choking sensation

Question 39

tracheostomy indications

Answer 39

pts requiring long term mechanical ventilation (?21 days) | pts with airway obstruction

Question 40

tracheostomy

Answer 40

incision in the neck at cricothyroid membrane to access trachea and create a stoma to insert tube

Question 41

tracheostomy complications

Answer 41

``` bleeding infection ulceration dysphonia tube obstruction fistula ```

Question 42

controlled mandatory ventilation

Answer 42

tidal volume delivered at a set rate independent of patient effort

Question 43

assist-control ventilation (AC)

Answer 43

patient regains some control of rate of breathing

Question 44

synchronized intermittent mandatory ventilation (SIMV)

Answer 44

patient receives a minimum number of breaths with set Vt | may take additional breaths as determined by the pt

Question 45

CPAP ventilator setting

Answer 45

used frequently as pts become ready for extubation | often used in conjunction with pressure support ventilation to offer bilevel vent pressures

Question 46

pressure control ventilation

Answer 46

less frequently used | provides a set pressure instead of tidal volume during respiratory cycle

Question 47

apnea alarm low minute volume alarm

Answer 47

check if pt is connected to ventilator ensure pt is not overly sedated pt may require higher level of ventilatory support

Question 48

high pressure alarm

Answer 48

ensure tubing is not kinked or compressed assess need for suctioning assess for ventilator dyssynchrony report alarm to responsible clinician

Question 49

high minute volume alarm

Answer 49

assess for anxiety assess for s/s hypoxia (tachycardia, HTN, restlessness, cyanosis) pt may require higher level of vent support or sedation

Question 50

endotracheal suction

Answer 50

every 2-4 hours | facilitates airway patency

Question 51

ventilators and restraints

Answer 51

restraints prevent accidental extubation

Question 52

ventilators and nutrition

Answer 52

early enteral nutrition reduces risk of nutritional deficiencies routine GI assessment aspiration risk

Question 53

weaning protocols

Answer 53

``` is pt: hemodynamically stable? SaO2 > 92% ? able to follow simple commands? FiO2/ABGs ```

Question 54

acute respiratory distress syndrome (ARDS)

Answer 54

inflammatory disorder that damages the alveolar capillary membrane and interferes with gas exchange 2/2 sepsis usually

Question 55

ARDS criteria

Answer 55

1. acute onset hypoxemia 2. diffuse b/l opacities on chest radiography that cannot be explained by HF or nodules 3. moderate to severe impairment of oxygenation

Question 56

exudative phase of ARDS patho

Answer 56

capillary membranes leak and protein rich fluid fills alveoli type 1 alveolar cells destroyed hyaline membranes are formed

Question 57

exudative phase of ARDS assessment

Answer 57

chest x-ray may be normal or show dependent infiltrates tachypnea, dyspnea change in LOC lung sounds may be clear

Question 58

fibroproliferative phase of ARDS patho

Answer 58

``` type II alveolar cells are damaged surfactant production declines peak inspiratory pressure increases compliance declines V/P mismatch ```

Question 59

fibroproliferative phase of ARDS assessment

Answer 59

``` chest x ray shoes diffuse b/l infiltrates and elevated diaphragm refractory hypoxemia with hypercarbia crackles on auscultation right HF develops agitation ```

Question 60

recovery/fibrotic phase of ARDS patho

Answer 60

development of fibrotic tissue in the ACM resulting in alveolar disfigurement decreased compliance pulmonary HTN dead space ventilation increased

Question 61

recovery/fibrotic phase of ARDS assessment

Answer 61

``` leukocytosis, fever worsening infiltrates on CXR decreased tissue perfusion tachycardia + hypotension lactic acidosis end-organ dysfunction ```

Question 62

early s/s of ARDS

Answer 62

``` dyspnea, tachypnea cyanosis abnormal breath sounds change in LOC confusion retrosternal discomfort fever ```

Question 63

vent management of ARDS

Answer 63

``` tidal volume 4-8mL/kg plateau pressure <30 cm H2O FiO2 > 60% judicious use of PEEP permissive hypercapnia maintain SaO2 88-95% ```

Question 64

extracorporeal life support (ECMO) indications

Answer 64

ARDS with: severe hypoxemia uncompensated hypercapnia, pH <7.15 end expiratory plateau pressures >35-45 cm H2O who fail prone positioning trial

Question 65

ARDS medications

Answer 65

``` neuromuscular blocking agents statins corticosteroids vasodilators surfactant beta agonists ```

Question 66

contraindications for prone positioning

Answer 66

spinal injuries elevated ICP abdominal compartment syndrome hemodynamic instability