RESP LECTURE

Question 1

Aetiology

Answer 1

A study of the causes, origins and reasons for disease process

Question 2

Pathophysiology

Answer 2

A study of the functional changes that occur within an individual due to a disease or pathologic state

Question 3

Review of respiratory terminology

Hypoxia

Answer 3

Less than normal levels of O2 in the cell(tissue)

HYPOXADMIA IS Less than normal levels of O2 in blood
PaO2 < 80mmHg (< 60mmHg significant hypoxaemia)

Question 4

Review of respiratory terminology

Hypoxaemia

Answer 4

Less than normal levels of O2 in the cell
Less than normal levels of O2 in the blood
PaO2 < 80mmHg (< 60mmHg (significant)

Question 5

Review of respiratory terminology

Hypercapnia

Answer 5

Greater than normal levels of CO2

PaCO2 > 45mmHg

Question 6

Review of respiratory terminology

Hypocapnia

Answer 6

Less than normal levels of CO2

PaCO2 < 35mmHg

Question 7

Efficient gas exchange is dependent on adequate:

Answer 7

VQ ratio - ventilation and perfusion

Question 8

Blood flow can be redirected from a poorly ventilated alveolus to a well-ventilated alveolus through

Answer 8

vasoconstriction = shunt

Question 9

Mechanical and functional insufficiency (mechanical changes that can affect V/Q)- Medication

Answer 9

CNS depressants - morphine, massive CNS and RESPIRATORY depressant

Question 10

Mechanical and functional insufficiency (mechanical changes that can affect V/Q) - Functional (Factors affecting gas exchange
)

Answer 10

Cardiac compromise
Pulmonary embolism - clots can block up huge sections of lungs
Hb - has four binding O2 cells
Tumour
Infection - necrotic tissue, or build up of mucus/pus
COPD
Compliance
Resistance
Surface area - if someone only has one lung, surface area is significantly reduced

Question 11

Difference between a ventilation problem to a perfusion problem?

Answer 11

Ventilation problem (air in/air out)
Perfusion problem (blood to lungs and body)

Question 12

Ventilation problem (air in/air out) - name some main causes

Answer 12

Inflammation of bronchial walls, Exudate in lower airways, Exudate in alveoli, Inflammation in alveolar wall

Question 13

Ventilation problem (air in/air out) - Describe the cause and process of this problem - Inflammation of bronchial walls

Answer 13

causing epithelial oedema = ↓ air entry, ↓ gas exchange

Question 14

Ventilation problem (air in/air out) - Describe the outcome and process of this problem - Exudate in lower airways

Answer 14

causing obstruction to air flow = ↓ air entry, ↓ gas exchange

Question 15

Ventilation problem (air in/air out) - Describe the outcome and process of this problem - Exudate in alveoli

Answer 15

causing increased diffusion distance = ↓ gas exchange

Question 16

Perfusion problem (blood to lungs and body) - name some common perfusion problems

Answer 16

Partial or complete obstruction to pulmonary artery and Ineffective functioning alveoli (from exudate or oedema)

Question 17

Perfusion problem (blood to lungs and body)) - Describe the outcome and process of this problem - Partial or complete obstruction to pulmonary artery

Answer 17

Partial or complete obstruction to pulmonary artery causing reduced blood flow = ↓ gas exchange

Question 18

Perfusion problem (air in/air out) - Describe the outcome and process of this problem - Ineffective functioning alveoli (from exudate or oedema)

Answer 18

Ineffective functioning alveoli (from exudate or oedema) causing vasoconstriction of surrounding pulmonary capillaries = further ↓ gas exchange

Question 19

Work of breathing5 signs of respiratory distress - what acronym/framework/mnemonic can we use

Answer 19

DiapHRaGM - Diaphoresis
Hypoxia
respiratoryRate
Gasping 
accessoryMuscle

Question 20

Clinical presentationWhat can we MEASURE?

Answer 20

*Respiratory rate, depth and pattern
Arterial blood gas (ABG) analysis
Peak flow measurement
Specialist tests

Question 21

How and what does this measure? Arterial blood gas (ABG) analysis

Answer 21

Measurement of partial pressure of O2, CO2, HCO3¯, pH (as well as other values)
Assessment of respiratory function
Information about the body’s response to changes in pH

Question 22

How and what does this measure? Peak flow measurement

Answer 22

Measurement of maximum forced exhaled air flow (L/min)
Baseline and to measure effectiveness of interventions
Useful for people with asthma

Question 23

Specialist tests - name some that can measure

Answer 23

Spirometry
CT/MRI
CXR
Pulmonary angiogram
VQ scan

Question 24

Chronic Obstructive Pulmonary Disease - Explain what this is?

Answer 24

Progressive chronic disease characterised by irreversible airway obstruction, hindering expiratory flow

Umbrella term encompassing EMPHYSEMA, CHRONIC BRONCHITIS & other conditions

Each has their own pathophysiology but all contribute to airway inflammation initiated by a noxious irritant

Question 25

Emphysema is

Answer 25

the destruction of elastin in alveoli, inhibiting full relaxation of alveoli, resulting in gas trapping [hypercapnia]

Question 26

Emphysema | Air or gas trapping - explain what this is, what it results in and what it causes

Answer 26

Loss of elasticity allows the alveoli to expand with inspiration, but reduces its ability to recoil in expiration Results in CO2 being ‘trapped’ increasing the alveolar PCO2 *Bronchiole constriction also contributes to air/gas‘trapping’ A rise in alveolar PCO2 means CO2 cannot diffuse readily from pulmonary capillaries, causing a build up in arterial blood = hypercapnia

Question 27

EmphysemaDamaged alveolar walls. this results in REDUCED surace area. what does this cause? result in?

Answer 27

Accumulation of damage causes large air spaces to develop Surface area is reduced, reducing gas exchange between alveoli and pulmonary capillaries = hypoxaemia and hypercapnia Direct contact of alveoli with capillary beds is reduced, reducing gas exchange

Question 28

John was admitted to your ward overnight following an acute exacerbation of his COPD. You have just received a shift report and proceed to John’s room to assess him. Using the ABCDE rapid assessment framework, consider what your expected findings might be on assessing him? AIRWAY & BREATHING ONLY

Answer 28

Airway Patent but potentially under threat if ↓ LOC due to hypercapnia/hypoxaemia Breathing Increased WOB and accessory muscle use in response to hypercapnia Pursed lip breathing to assist with expiration and overcome gas trapping Tachypnoeic (RR> 20/min, TACHY means OVER - like tacycardic (HB over 100). SpO2 <90% due to hypoxaemia – supplemental oxygen if hypoxaemia severe Depth of breathing likely to be shallow due to gas trapping and hypercapnia

Question 29

John was admitted to your ward overnight following an acute exacerbation of his COPD. You have just received a shift report and proceed to John’s room to assess him. Using the ABCDE rapid assessment framework, consider what your expected findings might be on assessing him? CIRCULATION & DISABILITY ONLY

Answer 29

Circulation Cool pale peripheries and/or cyanosis due to hypoxaemia CRT > 3 seconds due to peripheral vasoconstriction Possible elevated core temperature due to increased metabolic rate or infection Diaphoresis due to ↑ WOB or hypercapnia Disability Anxiety or fear of dying due to dyspnoea Possible disorientation or confusion due to hypoxaemia > hypoxia Reduced LOC due to hypercapnia and/or hypoxaemia Low mood or reduced cognition due to long-term effects of inflammatory mediators

Question 30

John was admitted to your ward overnight following an acute exacerbation of his COPD. You have just received a shift report and proceed to John’s room to assess him. Using the ABCDE rapid assessment framework, consider what your expected findings might be on assessing him? ENVIRONMENT ONLY

Answer 30

Environment Elevated EWS due to > RR, HR and < SpO2 (remember to identify trends) Increased falls risk due to dyspnoea, dizziness and/or confusion Increased Braden score due to corticosteroids, reduced mobility and possible oedema COLDSPA of irritants/triggers and previous exacerbations (plus treatment/length of hospital stay) to help inform nursing plan of care Identify allergies or drug reactions to avoid further complications

Question 31

Nursing interventions for JOHNNursing care of the patient with acute exacerbation of COPD AIRWAY & BREATHING ONLY

Answer 31

Airway Suction. Breathing Ensure patient upright to optimise air entry and facilitate gas exchange Encourage pursed lip breathing to facilitate exhalation of CO2 (reduce gas trapping) and reduce dyspnoea Administer oxygen as prescribed to reverse hypoxaemia – caution especially with CO2 retainers Administer bronchodilators/corticosteroids as prescribed for relaxation of smooth muscle in airways to facilitate gas exchange Obtain a sputum sample for microbiology, culture and sensitivity for antibiotic selection

Question 32

Nursing interventionsNursing care of the patient with acute exacerbation of COPD CIRCULATION & DISABILITY ONLY

Answer 32

Circulation Administer IV fluids as prescribed to prevent dehydration and thin secretions Administer DVT prophylaxis as prescribed to prevent clot formation from venous stasis/polycythaemia Administer antibiotics as prescribed to treat infected exacerbation Encourage patient to foot pedal to encourage venous return to prevent venous stasis Consider elevation of lower limbs to reduce peripheral oedema Disability Maintain a low stimulus environment to reduce anxiety and further dyspnoea Educate the patient on interventions and plan of care to reduce anxiety and encourage compliance with therapeutic interventions Consider hospital aide special or a family member to sit with the patient if confused to maintain patient safety and/or to reduce anxiety and further dyspnoea

Question 33

2 patients are admitted lastnight due to resp distress. What basic interventions would you use?

Answer 33

Administer medications as prescribed (bronchodilators/corticosteroids) either through nebuliser or spacer Administer oxygen as prescribed Sit patient upright to maximise air entry for gas exchange Reassure/educate patient and family members to lower anxiety and reduce SNS stimulation ↓RR, ↓WOB Observe/educate patient re: use of spacer Mobilise/rest as tolerated Education re: use of asthma plan on discharge

Question 34

Asthma: how would we treat it?

Answer 34

Bronchodilators Corticosteroids Metered Dose Inhaler (puffer)/spacer/nebuliser use Oxygen therapy Positioning (sit upright) Reassurance to decrease anxiety which reduces SNS response

Question 35

The two different types of bronchodilators are?

Answer 35

The two different types of bronchodilators are? Long acting (LABAs) = Controllers and Short acting (SABAs) = relievers

Question 36

Bronchodilators: β2-agonists - difference between Short acting (SABAs) = relievers and Long acting (LABAs) = Controllers with examples of both

Answer 36

``` Short acting (SABAs) = relievers Provide relief for 4-6 hrs Rapid onset of action – 5-10 mins Can be used in an acute asthma attack (usually blue inhalers) Examples: Salbutamol (Ventolin) Terbutaline (Bricanyl)) ``` ``` Long acting (LABAs) = Controllers Long duration of action (12hrs) Slow onset of action Not to be used to relieve acute symptoms Examples: Salmeterol (Serevent) Eformoterol (Oxis) ```

Question 37

Inhaled corticosteroids - ICS (preventers) = what are these? and some nursing considerations?

Answer 37

Potent anti- inflammatory agents Given via inhalation route greatly reduces systemic adverse effects Must be taken continuously

Question 38

Effects of hypercapnia are

Answer 38

Tachypnoea (↑ RR) to “blow off” excess CO2 | Use of accessory muscles to increase chest expansion and help with forced exhalation to expel CO2 and recruit O2

Question 39

Effects of hypoxaemia are

Answer 39

Tachypnoea once PO2 < 60mmHg to recruit more O2 Activation of SNS response (↑ HR, BP) to increase O2 circulation to tissues Peripheral vasoconstriction (poor peripheral perfusion) to preserve O2 for vital organs

Question 40

EMPHYSEMA vs chronic bronchitis - difference?

Answer 40

Emphysema Damage to alveoli sacs, inability to inflate and deflate properly. Alveoli loses elasticity and results in gas trapping. Chronic bronchitis Inflammation of bronchi walls due to increased production of goblet cells secreting mucous, damage due to noxious irritant

Question 41

Hypoxaemia: is and causes what to increase?

Answer 41

< 02 in arterial blood = < Pa02 | (Normally causes HR and RR to increase)

Question 42

Normal values of PA02 and Sp02?

Answer 42

PaO2 > 80mmHg (amount 02 dissolved in plasma) found on an ABG SpO2 > 95% (amount of 02 bound to haemoglobin compared to amount of 02 haemoglobin can carry) found on a sats probe

Question 43

How will you evaluate whether oxygen therapy has been effective? What are some measured signs e.g. < RR

Answer 43

↓ respiratory rate > in depth of respirations > tissue oxygenation (mucous membranes, not just SpO2) ↓ work of breathing/accessory muscle use SpO2