Pulmonary - CCRN Flashcards
(177 cards)
1
Q
Which area of the brain controls respiration?
A
Medulla
2
Q
Which part of the C-spine contains the phrenic nerve and therefore controls the diaphragm?
A
C 3,4,5
3
Q
Describe the process of inspiration.
A
Diaphragm contracts, moves downward
Intrathoracic pressure decreases
Air flows in
O2 is exchanged at the alveolar/capillary bed
4
Q
Describe expiration
A
Diaphragm relaxes (moves up)
Thoracic volume decreases
Intrathoracic pressure increases
Gas flows out
5
Q
What factors/processes can change lung compliance?
A
Age - infants have increased lung compliance
Compliance decreased by:
Pulmonary edema
Pneumothorax
Atelectasis
6
Q
Name 2 types of collapsed lungs and describe them.
A
Pneumothorax - puncture to pleural lining
Atelectasis - pleural lining intact, lung cannot expand
7
Q
Causes and risk factors for a pneumothorax
A
-Trauma
-Spontaneously - part of the lung ruptures
More common with existing lung condition:
COPD, TB, pertussis, asthma, CF, chronic bronchitis, emphysema
Procedures - line insertion
Infection
Risk factors:
Being tall and thin
Previous hx of collapsed lung
Smoking
8
Q
What are the causes of atelectasis?
A
Usually from a blockage of the airway:
Mucous, tumors, small objects
Can result from pressure outside the lungs
9
Q
Fill in the blank:
Resistance is ______________ related to airway diameter.
Give examples
A
Resistance is INVERSELY related to airway diameter.
Increased in: Asthma, CF, BPD, bronchiolitis, increased secretions.
This causes a DECREASE in air that reaches the lungs.
10
Q
What is BPD?
A
Inflammation and scarring of lung tissue during development.
Most common in premies.
11
Q
Describe the affect fetal circulation has on the lungs.
A
In utero:
Increased pulmonary vascular resistance leads to decreased pulmonary blood flow.
On delivery the pulmonary vascular resistance drops to allow for increased pulmonary blood flow.
12
Q
Explain how to look at V/Q as a ratio.
A
Think ventilation first.
1:1 is normal.
The lower number is the problem!
High/low refers to the first number’s relationship to the second number.
13
Q
What is ventilation?
A
Ventilation (V)
How fast O2 and CO2 are exchanged
14
Q
What is perfusion?
A
Perfusion (Q)
The speed at which blood flows through the lungs.
15
Q
Explain a high V/Q, give an example and a cause.
A
High V/Q is caused by inadequate perfusion (i.e. Shock)
5:1 ratio
V - 5 is good ventilation
Q - 1 poor perfusion
16
Q
Explain a low V/Q, give an example and a cause.
A
A low V/Q is when there is not enough O2 available.
1:5
V - 1 - poor ventilation
Q - 5 - good perfusion
17
Q
What is pulmonary vascular resistance?
A
The amount of resistance the R ventricle has to overcome to pump blood through the pulmonary vasculature by way of the pulmonary artery.
18
Q
What can cause an increase in pulmonary vascular resistance?
A
An decrease in surface area (i.e. CF)
An increase in blood viscosity (as seen in cyanotic heart disease)
19
Q
What physiological differences exist in the lungs/thorax/upper airway of an infant/young child that increase the likelihood of respiratory distress?
A
- Lung volume increases x4 in the first year.
- Kids have smaller alveoli, more likely to collapse.
- Infants have cylindrical chests - the AP diameter > the transverse diameter until 3 y.o.
- Elongated epiglottis that lies high in the pharynx and is more anterior
- Obligatory nose breathers until 6 months old.
- Infants/young children have greater chest compliance.
- Infants/young children have weaker intercostal muscles that cannot stabilize the chest wall against the diaphragm - leading to retractions
20
Q
What type of blade is generally used to intubate an infant? Why?
A
Miller blade.
An infant has a high and anteriorly placed epiglottis that is floppy - the straight blade can move the epiglottis out of the way.
21
Q
What type of blade is used to intubate older children and adults?
A
Mac Blade
Older children/adults have stiff epiglottis’ - curved blade appropriate.
22
Q
What anatomical feature is the narrowest part of the airway?
A
Cricoid cartilage -
Acts as a natural cuff until 8 yrs old
Theoretically children under the age of 8 should not need a cuffed tube for intubation.
23
Q
What anatomical features are included in the larynx?
What is the pedestrian name for the larynx?
A
The larynx includes: Epiglottis Supra glottis Vocal cords Glottis Sub-glottis
Commonly called the “voice box”.
24
Q
What structures does the larynx connect?
A
The larynx connects: Pharynx Thyroid cartilage Cricoid cartilage Trachea
25
TLC
Total Lung Capacity
The volume o the lungs at max inspiration
TLC = FRC + VC + RV
26
VC
Vital Capacity
Max volume expired with max effort
27
FRC
Functional Residual Capacity
| Volume remaining in the lungs after normal expiration
28
RV
Residual Volume
| Volume remaining in the lungs after forced expiration.
29
What compensatory mechanisms does the body employ to change the pH of the blood?
Lungs
- increased rate and depth to increase tidal volume to blow off more CO2 makes the blood more alkalotic.
- Decreased rate and depth to decrease tidal volume to retain CO2 makes the blood more acidotic.
Kidneys
- change absorption of H+ ions and bicarbonate.
- decreased absorption of H+ ions leaves more H+ ions in the blood makes the blood more acidotic.
30
What function does PaCO2 provide information about?
Alveolar ventilation
31
What numerical level defines hypercarbia?
PaCO2 > 55 mmHg
32
What does the PaO2 provide information on?
Oxygenation status.
33
What numerical level defines hypoxia?
PaO2 <60 mmHg
34
State high/low for each: pH, PCO2, HCO3 for
| Respiratory acidosis with metabolic compensation:
pH: L
PCO2: H
HCO3: H
35
State high/low for each: pH, PCO2, HCO3 for
| Metabolic and respiratory acidosis
pH: L
PCO2: H
HCO3: L
36
State high/low for each: pH, PCO2, HCO3 for
| Metabolic alkalosis with respiratory compensation
pH: H
PCO2: H
HCO3: H
37
State high/low for each: pH, PCO2, HCO3 for
| Metabolic and Respiratory Alkalosis
pH: H
PCO2: L
HCO3: H
38
List the causes and symptoms of respiratory acidosis and high/low for pH, PCO2 and HCO3.
Due to inadequate ventilation - CO2 builds and increases H+ ions leading to acidosis
- Inadequate ventilator settings
Symptoms:
- Tachycardia
- Tachypnea
- Atrial and ventricular dysrhythmias
- Increased ICP
pH: low
PCO2: High, >45 mmHg
HCO3: Normal or high
39
List the causes and symptoms of respiratory alkalosis and high/low for pH, PCO2.
pH >7.45
PaCO2 <35 - lungs blow off too much CO2
```
Symptoms:
Diaphoresis
Dizziness
ST changes - dysrhythmias
Muscle spasm
```
Causes:
- seen in adults who hyperventilate
- uncommon in children unless ventilator setting require adjusting.
40
List the causes and symptoms of metabolic acidosis and high/low for pH and HCO3.
pH < 7.35
HCO3 < 22
```
Symptoms:
Tachycardia
Tachypnea
Vision changes
H/A
N/V/D
```
Causes:
DKA
Renal issues - acute renal injury
41
List the causes and symptoms of metabolic alkalosis and high/low for pH and HCO3.
pH > 7.45
HCO3 > 26
Dysrhythmias
Tachycardia
Lethargy
Muscle weakness
Causes:
Prolonged emesis or NG suctioning
42
When suctioning a trach how big should the catheter be?
50% of the size of the trach tube.
43
When suctioning a trach what should the suction pressure be?
80-100
44
What events lead to cardiopulmonary arrest?
Hypoxia
Hypercarbia
Bradycardia
Respiratory arrest
45
DOPE
If a mechanically ventilated pt suddenly deteriorates use DOPE to determine the cause:
D- displacement
O- obstruction
P- pneumothorax
E- equipment failure
46
When is NPPV used?
| Name 2 types.
Noninvasive positive pressure ventilation is used when a pt needs to keep his airway open AND can breathe independently
Types: CPAP, BiPAP
47
CPAP
Continuous positive airway pressure:
| Administers same constant pressure during inspiration and expiration.
48
BiPAP
Biphasic Positive Airway Pressure:
Difference in Pressure
Can sense inspiratory effort.
49
Name 2 main types of invasive ventilation/ventilators.
Volume control - Tv is controlled, but allows passive expiration
Pressure Control - Pt determines Tv
50
Explain positive pressure ventilation:
Positive pressure ventilation forces air into the lungs by exceeding alveolar pressure.
Mode can be spontaneous or mandatory.
51
Explain controlled ventilation
Predetermined number of breaths per minute is set.
| Requires sedation and paralyzation.
52
Explain AC ventilation
Assist-Control Ventilation
Rate is set, volume/min is set
with Volume Guarantee- if pt initiates low volume breath vent will finish the breath at the set volume.
This can lead to excessive ventilation (increased minute volume)
Which can lead to respiratory alkalosis, especially if the pt respiratory rate increases for non-respiratory reasons.
53
SIMV
Synchronized intermittent mandatory ventilation:
R is set, Tv- min set
Additional breaths initiated by the pt are permitted but not assisted by the ventilator.
By setting a high rate you provide total respiratory support
54
Explain spontaneous ventilation on a ventilator.
Allows pt to take breaths on own without any vent support.
Allows for monitoring of exhaled volumes and airway pressures.
Requires slight increased WOB over T piece (must overcome resistance created by vent circuit to initiate flow).
55
What is PEEP?
Positive end expiratory pressure.
Applied to keep alveoli from prematurely collapsing during exhalation.
It increases compliance and V/Q matching.
56
When is PEEP appropriate/necessary?
Tx hypoxia from lung injury
| Prevent alveolar collapse in restrictive airway when the FRC is decreased.
57
What ventilator modes can PEEP be applied to?
All ventilator modes.
58
What are complications from applying PEEP?
Increasing mean and peak airway pressures can lead to barotrauma.
High pressure in the lungs = increased intrathoracic pressure = increased RA pressure, decreased venous return (and therefore decreased RA fill) = DECREASED CO
{If CO drops but O2 increases, fluid bolus may correct CO}
```
PEEP (and CPAP) can also:
Increase ICP
Decrease renal perfusion
Increase hepatic congestion (increased intrathoracic pressure)
Worsen intracardiac shunts
```
59
List normal values for PIP, based on age:
Newborns: 10-12 mmHg
Older infants/Children: 12-15 mmHg
Teens/Adults: <20 mmHg
60
What factors determine PIP?
- Lung compliance
- I time
- Airway resistance
- Tv
61
What is a normal tidal volume?
4-7 mL/kg
62
What is dead space ventilation?
It is the 1/3 of the Tv gas that occupies the airway lumen but does not participate in gas exchange.
63
Explain what HFJV is and how it works.
High frequency jet ventilation.
Rate, I- time, Pressure and Peep and volume are set
Rate is 100-600 breaths/min
Passive exhalation
Tv are small 1-3mL/kg
Higher mean airway pressure but lower peak airway pressure than conventional ventilator.
The jet (small tube) is placed as low as possible into the lungs, spiraling gas stream, high velocity
64
What are the advantages of HFJV?
Reduced chance of barotrauma (low Tv and pressures)
| Forces CO2 against walls, penetrating dead space.
65
What is HFJV used for?
BPD
Chronic lung disease
Pulmonary interstitial emphysema
66
Which uses greater pressures, the JET or the Oscillator?
Oscillator
67
What are the advantages of using an oscillator?
Helps expand alveoli
Decreases pulmonary vascular resistance
Improves VQ matching
Decreases risk of barotrauma
68
What type of conditions are tx with the use of an oscillator?
RDS
{young infants with RDS may be placed directly on oscillator, skipping a conventional vent to avoid barotrauma}
Primary Pulmonary Hypertension (PPHT) r/t:
Meconium aspiration
Air leak syndrome
Pulmonary interstitial emphysema
Congenital Umbilical hernia
69
Describe the general function of HFOV.
Disperses gas throughout lungs at high frequency
Constantly infuses fresh gases and evacuates old ones
Active inspiratory and expiratory phases - completely controlling pt respiratory cycle
70
What is ECMO?
Extracorporeal Membrane Oxygenation
Provides prolonged cardiopulmonary bypass with membrane oxygenation by pumping blood outside of the body for oxygenation with a cardiopulmonary bypass machine
71
Indications for ECMO:
Resolvable organ failure with potential for good neuro outcomes
72
Contraindications for ECMO:
Irreversible conditions
Previous head bleeds in neonates
Pulmonary hemorrhages
Contraindications to heparinization
73
Describe Cardiac bypass ECMO
Used in cardiac and pulmonary failure
Cannulate major artery (carotid) and a major vein (subclavian or femoral)
A-V ECMO
74
Describe Pulmonary Bipass ECMO
Pt must have good cardiac output
Lungs bypassed
2 major veins cannulated to divert blood from and return it to R atrium
V-V ECMO
75
List complications of mechanical ventilation:
```
VAP - ventilator associated pneumonia
VILI - ventilator induced lung injury:
- valutrauma - from high volumes
- barotrauma - from high pressures
- atelecotrauma - from alveoli being forced open and closed
```
```
Can lead to =
Pneumomediastium
Pneumopericardium
Pneumothorax
Cardiac arrest
```
76
List VAP prevention techniques:
Elevate HOB
Avoid gastric distention
Maintain closed system (no saline lavages)
Vigilant mouth care
77
What is a normal range for I:E ratios?
1:2 to 1:5
78
List 2 types of acute respiratory failure and examples of causes of each.
Hypoxic - PaO2 <60mmHg
(Ex: asthma, smoke inhalation)
Hypercarbic - high CO2, generally from increased dead space
(Ex: scoliosis)
79
List signs and symptoms of respiratory distress:
```
Tachypnea
Tachycardia
Nasal flaring
Grunting
Head bobby
Retractions
Prolonged expiratory phase
Wheezing
Stridor
Diaphoresis
Agitation
Apnea
Cyanosis
Pulsus Paradoxus
```
80
List signs of impending respiratory failure:
```
Decreased air entry
Severe retractions
Cyanosis despite O2 delivery
Irregular respiratory pattern/apnea
Altered LOC
Diaphoresis
```
81
What is the formula for determining ET tube size?
16 + age (years)/4
82
What is pneumonia?
| What can cause it?
Pneumonia is the inflammation of the lung parenchyma
Alveoli fill with exudate = alveolar edema (good for bacterial growth)
Leads to:
Lung consolidation = decreased compliance, decreased VC and decreased TLC
Can be viral or bacterial
Viral can turn into bacterial
Can be caused by inspiration, aspiration or systemic circulation
83
What populations of pts are at risk for developing pneumonia?
Artificial airway
Increased risk for aspiration (neuro changes/head injury)
Chronic underlying conditions (i.e. CF)
84
List the s/sx of pneumonia:
Hx of URI
Hx of decreased appetite and restlessness (infants)
Fever
Cough
Respiratory distress
Abd distention (from swallowing air with increased WOB
Liver may feel enlarged (from downward displacement of diaphragm from hyper inflated lungs)
85
Indications of bacterial pneumonia:
Tends to be lobular
| WBC count tends to be >15,000
86
Indications of Viral Pneumonia:
Tends to be interstitial
| Hazy, diffuse x-ray
87
What is the definition of HAP (hospital acquired pneumonia)?
| Name 2 types of bacterial HAP.
Pneumonia that develops at least 72 hrs AFTER admission.
Pseudomonas Aeruginosa - most lethal HAP
- common in chronic conditions and trach S
Klebsiella - high mortality rates
88
What bacteria is the most frequent cause of bacterial pneumonia?
Streptococcus Pneumonia
Gram + cocci
Incidence has decreased since introduction of heptavalent pneumonia conjugate vaccine in 2000.
89
Describe the pathophysiology of streptococcus pneumonia.
Usually follows URI
| Protein rich fluid fill alveoli and interstitium (the space around the alveoli)
90
List potential complications of streptococcus pneumonia.
Pleural effusions
Supra infections
Pericarditis
91
What is the tx for streptococcus pneumonia?
Abx - penicillin
92
What are pleural effusions?
An abnormal buildup of fluid in the pleural space.
93
What is Hemophilus Influenzae?
Bronchial or lobar pneumonia with areas of alveolar collapse and subsequent tissue hardening.
Can appear 2-6 weeks after URI with slow onset
94
List potential complications of Hemopilus Influenzae.
Pleural effusions
Lung abscesses
Epiglottitis
Pericarditis
95
What is the standard tx for Hemophilus Influenzae?
Tx with abx:
| Cephalosporins and macrolides
96
What age group is most susceptible to viral pneumonias?
Children <5 yrs old
97
Describe Mycoplasma Pneumoniae, sx, ages affected.
Pleomorphic organism.
Alters cilia function and activates inflammatory response.
Gradual onset, may appear less ill-looking than other pneumonias but can worsen quickly
```
Sx:
Paroxysmal cough
Diarrhea
Low grade fever
Pharyngitis
Erythematic rash
```
98
What is a pleomorphic organism?
One that changes shape and size in response to the environment.
99
List the most common causative organisms of epiglottitis.
Strep pyogenes
Strep pneumonia
Staph Aureus
100
Explain the course and pathophysiology of epiglottitis.
Bacteria causes thickening of the epiglottis and surrounding folds =
Obstruction and turbulent gas flow
Life threatening - kids go from minimally sick to extremely sick very quickly
Peaks at ages 2-6 yrs
101
What is the tx for epiglottitis?
Vaccine to prevent occurrence
Position for comfort and minimize agitation
Abx
Intubate in ICU/OR with trach set at bedside - only get one try
Only extubate when there is an air leak
102
List the s/sx and course of epiglottitis.
```
Inspiratory stridor
Muffled focalization
Dysphasia
High fever
Wants to remain in sitting position
Drooling
Lateral x-ray shows thumb sign
```
Lasts 36-48 hours
103
Describe the pathophysiology of croup.
Laryngotracheobronchitis
Inflammation of mucosa in the subglottic area
With large amounts of thick secretions
Can be viral or bacterial
104
List the s/sx and coarse of croup.
Inspiratory/expiratory stridor - worsens at night
Barking cough (seal-like)
Hoarse focalization
Low grade or no fever
On an AP x-ray visualization of steeple sign
Lasts 3-4 days
105
What is the management for croup?
```
Cool mist humidification
Racemic epinephrine - vasoconstricts the vessels but can have a rebound effect
Corticosteroids use is controversial
Heliox - lighter gas to decrease WOB
Hydration to liquify secretions
If intubating - decrease ETT by 1 size
```
106
What is acute tracheitis and what are the causative organisms?
Super infection
Similar sx to croup but doesn't always respond to the same tx
Care is supportive
```
Causative organisms:
Staph aureus
Group B-hemolytic strep
CA - MRSA
H. Influenzae
```
107
How long can RSV live on hard surfaces?
| On clothes and hands?
Hard surfaces - 6 hrs
| Clothes and hands - 1 hr
108
What populations are at the most risk for developing bronchiolitis?
Preemies
Infants not breastfed
Crowded conditions
Exposure to smoke
109
What is the pathophysiology of bronchiolitis?
Respiratory epithelium is injured from a virus =
| Inflammation of the lower respiratory tract/edema and abnormal airway secretions = blockage of airways = V/Q mismatch
110
What are the most common viruses to cause bronchiolitis?
```
RSV
Influenza
Parainfluenza
adenovirus
M. Pneumonia
```
111
List the s/sx of bronchiolitis
Hx of URI
Fever
Respiratory distress
Chest x-ray - hyper inflation or infiltrates
112
What is the tx for bronchiolitis?
Hospitalization for monitoring of respiratory distress
Supportive care
Consider pneumothorax if pt condition worsens.
Prevent with hand washing
113
What age group most commonly suffers a foreign body aspiration?
60-80% of occurrences are with children under 3 yrs.
114
List the s/sx and tx for foreign body aspiration and the most commonly aspirated object.
Clinical course dependent on type of object, location, available assistance and degree of obstruction the object causes.
Most common location for objects is right bronchus
40% of the time the chest x-ray is normal
Nuts are the most common object.
115
List the criteria for ARDS/ALI.
```
Acute onset
Severe hypoxemia, refractory to O2 administration
Bilateral infiltrates on chest x-ray
Absence of L atrial HTN
Pulmonary HTN present
```
116
Describe the pathophysiology of ARDS.
Progressive hypoxemia
Blood and fluid leak into alveoli of injured lungs preventing O2 from entering alveoli
Inflammation leads to scar tissue formation
117
List the s/sx of ARDS/ALI:
Crackles,rales, wheezes
Tachypnea with expiratory grunting
Starts with respiratory alkalosis that develops into respiratory acidosis
High O2 requirement
MODS
Diffuse infiltrates, bilaterally but cardiac vessels are normal
118
What is the tx for ARDS/ALI?
O2
PEEP if intubate
IV fluids - take care not to fluid overload lungs
Enteral nutrition
Prone positioning where the chest and hips are supported but the abd is not.
119
Why does prone positioning facilitate recovery in ARDS/ALI?
```
Exact reasons unknown. Thought to:
Mobilize secretions
Decrease V/Q mismatch
Recruit alveoli
Increase FRC
Decrease shunting
```
Improvement with repositioning can generally be predicted in trend of improvement in 1st 30 minutes.
120
Broadly speaking, what is an acute pulmonary embolism?
| What are the three types?
```
An acute obstruction of the pulmonary artery bed.
Types:
Thromboemboli
Air emboli
Fat emboli
```
121
Describe the pathophysiology of a pulmonary thromboemboli.
Venous status leads to the formation of venous thrombi =
Emboli travel through venous circulation to pulmonary circulation =
Emboli become trapped in pulmonary artery bed
122
Describe the pathophysiology of pulmonary air emboli.
Air enters the venous system = travels to the R heart and into pulmonary circulation = causes damage to pulmonary endothelium = increases capillary permeability = causes flooding of the alveoli
123
Describe the pathophysiology of a pulmonary fat embolus.
Fat emboli most often form from long bone fx.
| Injures pulmonary endothelial lining= increased capillary permeability = flooding to alveoli
124
List s/sx of acute pulmonary embolism.
```
Decreased breath sounds
Dyspnea
Tachypnea
Pulmonary HTN
Hemoptysis
Fever
Tachycardia
Increased pulmonary artery pressure = decreased CO = Shock
CXR shows diffuse alveolar filling with pulmonary emboli
```
125
How do diagnose and treat pulmonary emboli?
```
Spiral CT
O2
Anticoagulants (if thromboemboli)
Surgery to remove emboli
Early dx!
```
126
What is bronchitis and what is the tx?
Inflammation of tracheobroncial tree
Usually starts as a viral URI with hacking cough
Symptomatic treatment
127
What is asthma?
```
Chronic d/o of the airway
Characterized by:
Recurring sx
Airflow obstruction
Bronchospasm
Underlying inflammation
```
128
Describe the pathophysiology of asthma.
Mediators (histamine and bradychyman) are released when IgE binds to mast cells = constriction of bronchial smooth muscle, inflammation of bronchial mucosa and thick secretions.
129
List the s/sx of asthma.
```
Wheezing
Dyspnea
Tachypnea
Productive cough
Decreased minute volume
Rales
Prolonged expiratory phase
Tires easily
```
130
List tx options for asthma (including medications, med classes).
```
O2
Fluids
If intubated - need longer expiratory times
Meds:
Beta 2 agonists
Anticholinergics
Magnesium sulfate
Leukotriene inhibitors
Aminophylline
Corticosteroids
Ketamine gtt
```
131
Asthma medication: Albuterol
| List class, S/E, action
```
Inhaled beta 2 agonist
Short acting
Causes bronchodilation
S/E:
Tachycardia
Increased myocardial contractility and O2 consumption
```
132
Asthma medications: Epinephrine
| Class, action, efficacy
Beta 2 agonist
Bronchodilation
No proven advantages over aerosol tx
133
Asthma medications: Terbutaline
| Class, action, efficacy
Beta 2 agonist
Bronchodilation
No proven advantages over aerosol tx
134
Asthma medications: Ipratropium
| List name, class, mechanism of action, concurrent meds
```
Atrovent
Anticholinergic
Blocks parasympathetic receptors = bronchodilation
Used wth beta 2 agonist
Can be mixed wth albuterol
```
135
Asthma medications: Singulair
| List class, mechanism of action, effects, efficacy
Leukotriene inhibitor
Blocks action of cysterinyl leukotriene. Cysternyl leukotriene causes:
Bronchoconstriction
Mucous secretions
Increases vascular permeability
Migration of eosinophils
Takes effect in 24 hrs - not first line tx
136
Asthma Medications: Methylprednisolone, PO Prednisone
| List drug class, mechanism of action, effects
```
Corticosteroids
Suppress mine response and histamine release
Effects:
Decreased edema
Decreased secretions
Decreased hyperreactivity
```
137
Asthma medications: Amnophilline
No longer first line tx: narrow window of efficacy/toxicity
Need to monitor blood levels
Weak bronchodilator
Anti inflammatory properties
138
Asthma medications: magnesium sulfate
| Drug class, mechanism of action, administration
Calcium antagonist
Causes muscle relaxation by preventing calcium re uptake
Give IV
Monitor blood levels
Have calcium chloride on hand to reverse toxicity
139
What use does ketamine have in the tx of asthma?
A ketamine drip can cause bronchodilation.
140
What is status asthmaticus?
Acute episode that fails to respond to conventional out pt or ER treatments.
141
List causes of pulmonary hemorrhage.
```
Chest Trauma
Infection
Increased pulmonary vascular pressure
AV malformation
Pulmonary emboli
Autoimmune disease
Asphyxia
```
142
What is a pulmonary AV malformation?
Blood flow by passes the capillary system causing Right to Left shunting between the pulmonary artery and the pulmonary vein.
Rare occurrence
143
What is BPD?
Chronic lung disease with alveolar damage from inflammation and scar tissue
Occurs after mechanical ventilation with O2 dependency persisting beyond 36 weeks corrected gestational age.
144
What are risk factors for BPD?
Preemie
Low birth weight
RDS at birth
Need for long term ventilation or O2
145
What is the tx for BPD?
Surfactant
Ventilaton assistance - PEEP with Low Tv
Diuretics to decrease preload
Nutrition (poor nutrition is thought to exacerbate BPD
146
What is a diaphragmatic hernia?
Protrusion of abd contents into the thoracic cavity.
147
What are the developmental complications of a diaphragmatic hernia?
Pulmonary hypoplasia which includes decrease in size of lungs and the size and number of alveoli.
Typically affects the L side to a greater degree.
148
What are the s/sx of a CDH?
```
Congenital Diaphragmatic Hernia :
Scaphoid abd
Barrel - shaped chest
Cyanosis
Respiratory distress
Altered breath sounds on the affected side
Pulmonary HTN
```
149
How s CDH managed/tx?
```
Gastric decompression
Avoid BVM ventilation
Low PIP
Low PEEP
Rapid respirations
ECMO
Surgery to repair after respiratory status stabilizes
```
150
What s a Tracheoesophageal fistula and what other anomaly is commonly associated with it?
A communication between the trachea and esophagus.
| Commonly associated with an esophageal atresia (esophagus ends in blind-ended pouch instead of normally in the stomach)
151
What are the s/sx associated with a TEF?
```
Coughing
Cyanosis
Choking
Drooling
Inability to Pass OGT
Distended abd - TEF
Scaphoid abd - EA
```
152
What is the Tx for TEF?
```
NPO
Surgery
Elevate HOB
Avoid BVM
IVF
TPN
Abx
May need G tube
```
153
What is choanal atresia?
Congenital d/o where the back of nasal passage is blocked by abnormal bony or soft tissue
Unilateral or bilateral
Surgery to correct
154
What are the s/sx of choanal atresia?
Difficulty breathing unless crying
| Respiratory distress
155
What is Pulmonary Hypoplastia?
Incomplete development of the lungs due to inadequate pulmonary parenchyma tissue and pulmonary blood flow.
Often associated with other malformations
156
What are some causes of Pulmonary Hypoplastia?
Inadequate intrathoracic space (i.e.: tumor, pleural effusions, CDH)
Prolonged oligohydramnios
Renal agensis
Absent or decreased fetal breathing movements
CNS lesions
157
What are the s/sx of Pulmonary Hypoplastia?
```
Immediate respiratory distress:
Tachypnea
Retractions
Cyanosis
Hypercarbia
Acidosis
```
158
What is the management for pulmonary hypoplastia?
Fetal surgery
AC ventilation
HFOV
ECMO
159
What s tracheomalacia?
Weakness,floppiness of tracheal walls
Widening of the posterior wall = reduced anterior-posterior caliber
= tracheal collapse with coughing, crying, feeding
160
List 3 types of tracheomalacia:
Congenital intrinsic: resolves by 6 to 12 months
Extrinsic - vascular rings
Acquired - caused by medical interventions: prolonged intubation
161
Describe tracheal stenosis, list 2 types, sx and tx.
```
Narrowing of trachea
Types: idiopathic
Traumatic
Sx: dyspnea, stridor
Tx: bronchodilation (effects may be temporary)
Resection, reconstruction
```
162
What is pulmonary hypertension?
Mean pulmonary artery pressure >25 mmHg
| Should be less than 1/4 of systemic pressure
163
What is the cause of pulmonary HTN?
Increased pulmonary blood flow
Increased pulmonary vascular resistance
Primary: unknown cause
Secondary: CHD
Chronic lung disease
Phen-Phen (diet drug)
164
Describe the pathophysiology of pulmonary HTN:
```
V/Q mismatch = blood shunted to lower pressure areas
Hypoxic vasoconstrictions
Obliteration of pulmonary vasculature
Volume overload
Pressure overload
```
165
List the s/sx of pulmonary HTN:
```
Chest pain
Dyspnea
Fatigue, lethargy
Syncope with exertion
Right-sided heart failure
Systolic ejection murmur
Rarely: Cough
Hemoptysis
Hoarseness
```
166
What is the management for pulmonary HTN?
```
O2
Calcium channel blockers (amlodipine)
Digoxin
Diuretics
Vasodilators (prostacyclin agents)
Surgery - to correct underlying problem
Transplant - heart and/or lung
```
167
List 4 air leak syndromes:
Pneumothorax
Pneumomediastium
Pneumopericardium
Perivascular interstitial emphysema (PIE)
168
What is a pneumothorax?
Air in the pleural cavity.
169
List the s/sx of a pneumothorax
```
Hypoxia
Decreased perfusion
Restlessness
Dyspnea
Sudden respiratory distress
Hypotension (increased intrathoracic pressure decreases preload)
Shift of PMI
```
170
What is a pneumopericardium?
| List complication/tx
Air in pericardial space
Fill of heart is compromised = can lead to cardiac tamponade
Tx with needle decompression
171
What is a pneumomediastinum?
Is it an emergency?
List complications.
Air between R and L pleural sacs
| Can lead to a pneumothorax or pneuomediastinum
172
List H's and T's of cardiac tamponade.
Hypotension
Hypoxia
Tachypnea
Tachycardia
173
What is PIE?
| Explain the pathophysiology of PIE.
Pulmonary Interstitial Emphysema
Over distended alveoli from increased pressure and tidal volume
=Alveolar rupture
=Air moves into interstitial tissue
=if ventilation continues air moves into the subcutaneous tissue
174
Why is thoracic trauma generally worse in children?
They have compliant chest walls and a mobile mediastinum = look fine with a LOT of internal injuries
175
What should a pt with rib fx be evaluated for?
Less than 3 y.o. = abuse
R/O: spinal injury
Liver and spleen injury
Great vessel involvement (rare)
176
List complications of Lung Contusions.
Hemorrhage and edema
V/Q mismatch (from blood in alveoli)
Pneumothorax/hemothorax
177
What can tracheal perforation result from?
Rare complication of intubation = subcutaneous emphysema
| Requires IMMEDIATE surgical repair
