Flashcards in Dec 6th Test Deck (160):
What kind of disease is cardiogenic pulmonary edema classified as?
restrictive lung disease
What is cardiogenic pulmonary edema also called?
hydrostatic pulmonary edema
What is cardiogenic pulmonary edema caused by?
-left side heart failure
What is pulmonary edema?
excessive amount of fluid in the lung tissue or alveoli due to an increase in pulmonary capillary pressure (resulting from abnormal left heart function)
What is the etiology of cardiogenic pulmonary edema?
-left heart failure (i.e. coronary artery disease)
-mitral valve stenosis
What is the result of cardiogenic pulmonary edema?
backup of fluid from the heart into the pulmonary capillaries, which become engorged
What happens when pulmonary capillaries are engorged?
fluid leaks into interstitial space and into the alveoli
What is the swam ganz catheter?
-it measures the back pressure from the pulmonary veins
-done from the carotid or subclavian vein and into the right atrium, tricuspid and right ventricle
Is it possible to measure the pressure from the left heart?
Is it possible to measure the pressure from the right heart?
What carries the swan ganz?
the right ventricle into the pulmonary artery
Where does the swan ganz measure pressure and what should it not exceed what?
only in front of the catheter; 5-8
How is the progress of treatment of pulmonary edema measured?
swan ganz catheter
How is pulmonary edema treated?
-ionotropic (makes left side work harder: digoxin)
-lasix (gets excess fluid out of the body)
What is atrial fibrillation?
atopic phoxi; 350-600/min
What is atrial fibrillation caused by?
congestive heart of the left ventricle
What are physical signs of pulmonary edema?
-distended neck veins
What are typical vital signs associated with pulmonary edema?
-ABG: 7.56, co2 38, hco3 20, o2 51 spo2 70%
What shows up on an xray for pulmonary edema?
-faint opacities in lower lobes bilaterally
-enlarged heart (left ventricle)
What treatment is used for pulmonary edema?
-intravenous digitalis (dobutamine)
What does digitalis do for pulmonary edema?
-increases myocardial force of contraction
-increases stroke volume
-antiarrhthmic used to treat atrial flutter and fibrillation
What does dobutamine do for pulmonary edema?
-increases myocardial contaction
-increases stroke volume without increasing systemic vascular resistance
What does furosemide do for pulmonary edema?
-causes diuresis by inhibiting reabsorption of sodium
-loss of chlorine
-loss of potassium
What kind of ABG result can furosemide cause?
What kind of breath sounds are associated with pulmonary edema?
-inspiratory crackles over lower lobes
-expiratory wheezes over lower lobes
What kind of shunt is caused by pulmonary edema?
Alveoli filled with fluid
What is venous admixture for pulmonary edema?
good lung mixing with bad lung leading to lower PaO2
What happens to lung volumes in pulmonary edema?
In pulmonary edema, what needs to be resupplied so lung volumes can return to normal?
How is FVC affected with pulmonary edema?
smaller (middle line in picture)
How is lung compliance affected with pulmonary edema?
How is WOB affected with pulmonary edema?
What is the gold standard treatment for cardiogenic pulmonary edema?
What is a pulmonary embolism?
obstruction of the pulmonary artery or one of its branches
What is an embolus?
a clot that travels through the bloodstream from its vessel of origin and lodges into a smaller vessel, resulting in flow obstruction
What are the possible sources of pulmonary emboli?
What is the most common source of emboli?
Where does an emboli usually originate?
in deep veins of the leg or pelvic area
Where does an emboli travel to?
back to the heart through the venous system where it eventually lodges in a pulmonary artery
Why does a clot usually form?
-stagnation of blood flow
-prolonged bed rest
-immobility from trauma, surgery, paralysis or pain
What are some predisposing factors for emboli?
What should be looked at carefully in traumatic injuries?
-bone fragments from pelvis
-long bones of lower extremeties
-extensive injury to soft tissue
What are some hypercoagulation disorders that cause embolis?
What does a blockage result in?
dead space ventilation (ventilation without perfusion), which causes a high V/Q mismatch
What causes a high V/Q mismatch?
What causes a low V/Q mismatch?
What is the initial V/Q ratio response and what does it lead to?
a high initial ratio which leads to a low V/Q mismatch
What causes a change from high to low V/Q mismatch?
-activation of serotonin
What is caused by the release of serotonin, histamine and prostaglandin?
What causes 10% of pulmonary emboli cases?
What dictates the pathophysiology of pulmonary emboli?
size of thromboembolism
What determines the impact of pulmonary emboli on the cardiovascular system?
size and number of pulmonary emboli
Where is the reduction of cardiac output seen with pulmonary emboli?
What heart effects are seen in the pulmonary side with pulmonary emboli?
-increased right ventricular work load
What heart effects are seen in the systemic side with pulmonary emboli?
-decreased blood flow entering the left ventricle
How does the body attempt to compensate for the systemic side?
increased heart rate
What are the most common symptoms of pulmonary emboli?
-pleuritic chest pain
What are additional findings of pulmonary emboli?
-abnormal heart sounds
-distended neck veins
-swollen and tender liver
-right ventricular heave or lift
-right ventricular distension
What breath sounds are associated with pulmonary emboli?
-pleural friction rub
When is pleural friction rub most common in pulmonary emboli?
when pulmonary infarction involves the pleura
What ABG result is commonly seen in mild to moderate pulmonary emboli?
acute alveolar hyperventilation with hypoxemia
What ABG result is commonly seen in severe pulmonary emboli with infarction?
acute ventilatory failure with hypoxemia
What happens when tissue hypoxia is severe enough to produce lactic acid?
the pH and HCO3 will be lower than expected for a particular PaCO2
Does a shunt increase or decrease the qs/qt fraction?
Is oxygen delivery increased or decreased in pulmonary emboli?
Is the oxygen extraction ratio increased or decreased in pulmonary emboli?
Does the SvO2 increase or decrease in pulmonary emboli?
Is central venous pressure increased or decreased in pulmonary emboli?
Is pulmonary arterty pressure increased or decreased in pulmonary emboli?
What is normal pulmonary artery pressure?
no greater than 25/10 mmHg
What is normal mean pulmonary artery pressure?
What is normal mean pulmonary artery pressure for patients with emboli?
excess of 20 mmHg
What are 3 major mechanisms that contribute to pulmonary hypertension?
-decreased cross sectional area of the pulmonary vascular system
-vasoconstriction induced by humoral agents
-vasoconstriction induced by alveolar hypoxia
What is seen on an xray that has infarction?
increased alveolar density in infarcted areas, which appear similar to pneumonia
What is seen on a xray when there is a cardiovascular response?
-dilation of pulmonary artery
-ventricular enlargement may cause it to appear similar to pulmonary edema
What is a ventilation test?
patient breathes in xenon gas to test ventilation
What is a perfusion test?
intravenous injection of radiolabeled particles that goes into the pulmonary vascular system. if blood flow is decreased or absent past emboli, fewer particles are present in the area
What gold standard is used to confirm the presence of pulmonary embolism?
What is pulmonary angiography?
a catheter is advanced into the right heart and a radiopaque dye is injected into an artery
How is pulmonary embolism confirmed with pulmonary angiography?
dark area appears on the angiogram distal to the emboli (radiopaque material is prevented from flowing past obstruction)
Does pulmonary angiography have risks?
none unless patient has severe pulmonary hypertension about 45 mmHg, is in shock, or has an allergic reaction to contrast medium
What is the best treatment for pulmonary emboli?
avoiding venous stasis
Besides prevention, what are other ways to treat pulmonary emboli?
-low dose heparin given subcutaneously
-tight fitting socks
-pneumatic stockings or boots
-active or passive leg movements
When are fibronolytic agents used and why?
only used when hemodynamic instability is severe due to excessive risk of bleeding
What are the respiratory care treatment protocols associated with pulmonary emboli?
What is pleural effusion?
fluid accumulation in the pleural space
What anatomic alterations of the lungs are associated with pleural effusion?
-separation of the visceral and parietal pleura
-compress the lungs
-great veins may be compressed
-cardiac venous return may be diminished
What kind of disorder does pleural effusion produce?
restrictive lung disorder
What are the two classifications of pleural effusion?
What is a transudate pleural effusion?
-develops when fluid from pulmonary capillaries moves into pleural space
-the fluid is thin and watery and contains a few blood cells and very little protein
True/False: a pleural disease causes a transudate
What is an exudate pleural effusion?
-develops when the pleural surfaces are diseased
-fluid has high protein content
-great deal of cellular debris
True/False: exudates are usually caused by inflammation
What are the major causes of transudative pleural effusion?
What are the major causes of exudative pleural effusion?
-disease of the GI system
In addition to transudate and exudate, there are other pathologic fluids that can separate the ___ pleura from the ___ pleura
What are the other pathologic pleural fluids?
What is empyema?
the accumulation of pus in the pleural cavity
Empyema commonly develops as a result of what?
How is empyema removed?
chest tube drainage
What is used to confirm a diagnosis of empyema and determine the specific causative organism?
What is chylothorax?
chyle in the pleural cavity
What is chyle?
-a milky liquid produced from the food in the small intestine during digestion
-consists mainly of fat particles in a stable emulsion
How is chyle transported?
from intestinal lymphatics through the thoracic duct (in the neck) into the venous circulation and mixed with blood
What results in chylothorax?
-trauma to the neck or thorax
-tumor that occludes the thoracic duct
What is hemothorax?
the presence of blood in the pleural space
What are the causes of hemothorax?
-trauma (i.e. penetrating or blunt chest trauma, chest wall, diaphragm, lung or mediastinum)
-rupture of small blood vessels
-iatrogenic hemothorax (trauma causes by the insertion of a central venous catheter)
What are the cardiopulmonary symptoms of pleural effusion?
-symptoms vary according to the size of the effusion
-decree of lung compression
What are the lung volume and capacity changes associated with pleural effusion?
-restrictive lung defects
-decreased lung volumes
What chest assessment findings are associated with pleural effusion?
-decreased chest expansion
-cough (dry, nonproductive)
-decreased tactile and vocal fremitus
-dull percussion note
-diminished breath sounds
-displaced heart sounds
What are the radiologic findings associated with pleural effusion?
-blunting of costophrenic angle
-possible mediastinal shift to unaffected side
What is the diagnosis of pleural effusion generally based on?
chest xray film
Pleural effusion chest xray facts
-fluid first accumulates posteriorly in the most dependent part of the thoracic cavity, between the inferior surface of the lower lobe and diaphragm
-as the fluid volume increases, it extends upward around the anterior, lateral and posterior thoracic walls
-on the typical radiograph, the lateral costophrenic angle is obliterated and the outline of the diaphragm on the affected side is lost
Pleural effusion chest xray facts cont'd
-in severe cases, the weight of the fluid may cause the diaphragm to become inverted (concave)
-first identified with a posteroanterior (PA) or lateral chest radiograph
-confirmed with a lateral decubitus radiograph
-free fluid gravitates along the horizontal plane to the lowest level
What is the treatment of pleural effusion?
-chest tube insertion (for larger pleural effusions)
What is thoracentesis?
removal of pleural fluid
When is hyperinflation therapy used and how does it treat pleural effusion?
after the removal of pleural fluid; inflates the compressed lung
What should you monitor post thoracentesis?
watch for signs of hemothorax and pneumothorax associated with accidental puncture of the lung
What is guillain-barre syndrome described as?
a relatively rare disorder of the peripheral nervous system in which flaccid paralysis of the skeletal muscles and loss of the reflexes develop in a previously healthy patient
What are the pathologic changes of the peripheral nerves associated with guillain-barre syndrome?
-microscopically the nerves show: demyelination, inflammation, edema
-nerved impulse transmission decreases leading to paralysis
What is the etiology of guillain-barre syndrome?
-probably an autoimmune disorder
-lymphocytes and macrophages attack and strip off the myelin sheath of the peripheral nerves
What are four facts about autoimmune disorders associated with guillain-barre?
-studies show high serum antibody titers in the early stages of the syndrome
-elevated levels of lgM and complement activating antibodies against human peripheral nerve myelin
-antibodies reduced rapidly during the recovery phase
What is the onset of guillain-barre?
-occurs one to four weeks after a febrile episode
-bacterial and viral
What bacterial and viral causes are associated with guillain-barre?
infectious mononucleosis associated with as many as 25 percent of cases
What vaccinations are associated with guillain-barre?
in 1976 40 million people were vaccinated for swine flu. 500 of which developed guillain-barre and 25 died from it
What are the early symptoms of guillain-barre?
-fever, malaise, nausea, prostration
-tingling sensation and numbness in the extremities (distal paresthesia)
-skeletal muscle paralysis and loss of deep tendon reflexes in the feet and lower portions of the leg
What are the progressive symptoms of guillain-barre?
the muscle paralysis moves upward (ascending paralysis):
-to the arms, neck, pharyngeal and facial muscles (cranial nerves IX and X)
-the patient's gag reflex is generally decreased or absent and swallowing is difficult (dysphagia)
-aspiration is likely unless the airway is protected
What are the common non-cardiopulmonary manifestations associated with guillain-barre?
-progressive paralysis of the ascending skeletal muscles
-tingling sensation and numbness (distal paresthesia)
-loss of deep tendon reflexes
-sensory nerves impairment
-peripheral facial weakness
-decreased gag reflex
-decreased ability to swallow
What is the progress and recovery time for guillain-barre?
-paralysis generally peaks in less than 10 days
-after paralysis reaches its maximum it usually remains unchanged for a few days or weeks
-recovery generally begins spontaneously and continues for weeks or in rare cases months
Describe open pneumothorax
air can go in and out of the chest cavity freely
What is pendelluft?
air moves from one lung into the other lung and then all back out. it is seen in open pneumothorax
Describe closed pneumothorax
air moves into the lungs then out of the lung into the pleural space
Describe open tension pneumothorax
air moves into the lung area with an open wound but when air tries to move back out, the wound closes
What do you seen on inspection of pneumothorax?
one chest wall is moving higher than the other
What do you hear on percussion of pneumothorax?
What breath sounds do you hear for pneumothorax?
diminished breath sounds
What happens to the alveoli that are affected by pneumothorax?
it becomes hypoventilated and creates a venous admixture in the blood
What is the most severe form of ARDS?
What is the mortality rate of pulmonary edema?
What type of respiratory failure occurs with pulmonary edema?
acute hypoxic respiratory failure
What is the cause of ARDS?
-increased capillary permeability
What is ARDS also called?
acute lung injury
What are the primary risk factors for ARDS?
What are the secondary risk factors for ARDS?
-prolonged systemic hypotension
-multiple blood transfusions
-fulminant hepatic failure
-sickle cell crisis
What are the other risk factors for ARDS?
-prolonged cardiopulmonary bypass
-immunologic reactions (goodpastures syndrome)
-radiation-induced lung injury
How long is the exudative phase?
How are the alveoli damaged in ARDS?
destruction of type 1 pneumocytes
How do microvascular injuries in ARDS happen?
destruction of capillaries
In ARDS, where is there an influx of inflammatory fluids?
interstitial space and alveoli
What membrane forms in ARDS?
How does a patient present with ARDS?
How long is the proliferative phase in ARDS?
What does the fribroproliferative phase begin after?
inflammatory injury is controlled
During the fibroproliferative phase, which cells experience hyperplasia (increase of cells)?
-type 2 pneumocytes
-fibroblasts (interstitial alveolar fibrosis)
What is SOAP?
getting objective information
What breath sounds are heard in ARDS?
What is seen on xray in ARDS?
bilateral fluffy infiltrates
What is a typical ABG for a patient with ARDS?
What would you seen on a hemoglobin curve with ARDS?
acute alveolar hyperventilation with moderate hypoxemia