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CCRN > Respiratory > Flashcards

Respiratory Flashcards

1
Q

Minute ventilation

A
  • TV X RR
  • volume inspired/expired per minute
  • 5-10 L/min
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2
Q

Vital capacity

A
  • Volume of air that can be maximally expired after a maxima inspiration
  • Global measurement of the ability to ventilate
  • Takes into account inspiratory and expiratory muscle strength & pulmonary compliance
  • Measured at the bedside with a spirometer or with a pulmonary function test
  • Depending on age, height, and weight, the normal is 50-70 ml/kg
  • <10 ml/kg = hypoventilation & hypercapnia
  • Used to determine the severity of GBS or MG
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3
Q

Partial pressure of arterial oxygen (PaO2)

A
  • One of the most accurate measurements that directly tell how efficiently the patient is oxygenating
  • 75-100 mmHg
  • tells how well the patient is ventilating
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4
Q

Saturation of arterial oxygen (SaO2)

A
  • Reflects how much hemoglobin is saturated with oxygen; ABG component
  • 95-100%
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5
Q

Saturation of peripheral oxygen (SpO2)

A
  • Peripheral oxygen saturation measured with pulse oximetry
  • Closely correlate with SaO2 on ABG
  • Late indicator of hypoxemia
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6
Q

Oxyhemoglobin Dissociation Curve

A
  • Relationship between oxygen tension (PaO2) and saturation (SaO2)
  • Affinity of hemoglobin to release oxygen changes based upon the temperature, pH, and PaCO2
  • Right shift, hgb release O2 in hot and acidic environments like muscles
  • Left shift, hgb will grab O2 in a cool, alkalotic environment like the lungs
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7
Q

Pulmonary arterial hypertension (PAH)

A
  • Impaired perfusion caused by high pressure in pulmonary vasculature
  • Causes: left heart disease, chronic lung disease/hypoxia, chronic arterial obstructions, idiopathic, drugs - methamphetamines, Fen/Phen
  • S/S: SOB, tachycardia, fatigue, CP, syncope, leg swelling, Rt heart failure from increased pulmonary vascular resistance (PVR) and increase in PA pressure
  • Strains RV causing hypertrophy, tricuspid regurgitation (systolic murmur heard at 4th ICS, left sternal border), and Rt HF = Cor Pulmonale

Dx: Echo (RV enlargement); PAC measurement of MPAP >25 mmHg (golds standard)

-Tx: pulmonary vasodilation - epoprostenol (prostacyclin) or Treprostinil, inhaled NO (dilates pulmonary vessels and improves perfusion), PDE5 inhibitor (dilates pulmonary vessels), strict I/O, anti-inflammatory, bronchodilators, O2, lung transplant (only cure)

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8
Q

Patient position to optimize ventilation

A
  • Unilateral lung disease (e.g., pneumonia, pneumothorax, atelectasis), good lung down to optimize perfusion; bed lung up to optimize ventilation.
  • Pneumonectomy - position on the operative side (good lung up/operated lung down)
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9
Q

V/Q mismatch

A
  • Alveolar minute ventilation (V)/pulmonary perfusion (Q) = 4L/5L = 0.8
  • High V/Q - perfusion problem (i.e., pulmonary embolism); air in the alveoli is a “dead space”
  • Low V/Q - ventilation problem (i.e., atelectasis); physiological shunt
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10
Q

Pulmonary embolism (PE)

A
  • Obstruction of blood flow to the lungs by a clot or embolus in a pulmonary vessel
  • Emboli (thrombus, cholesterol, fat, air, septic)
  • V/Q mismatch (impaired perfusion) –> dead space
  • Bronchioles dilate in response to CO2 –> bronchoconstriction; surfactant secretion decreased –> alveolar collapse –> atelectasis, decreased lung compliance, hypoxemia, pulmonary vasoconstriction can lead to pulmonary HTN & cor pulmonale
  • Risk factors for DVT: Virchows Triad: 1. Stasis of blood flow, 2. Endothelial injury, 3. Hypercoagulability
  • S/S: tachypnea, anxiety, tachycardia, febrile, increased intensity of pulmonary S2 - pressure in PA higher d/t obstruction or construction in the pulmonary vessels, PEA arrest (dilated RV compress LV)
  • Dx: ECG (not specific to PE, right axis deviation, transient RBBB, ST depression/T inversion in V1-V4, Tall peaked II, III, aVF), D-dimer, US (r/o DVT), pulmonary angiography (CTPA) - gold standard
  • Tx: O2 to keep sat >90%, restore perfusion, fluid, and vasopressors for hypotension, anticoagulants (heparin, warfarin, LMWH), IVC filter (for +DTV), thrombolytic (if hemodynamically unstable), embolectomy
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11
Q

Acute respiratory failure

A
  • Q>V
  • Uncompensated respiratory acidosis: pH <7.3, PaO2<60, PaCO2 >45
  • S/S: respiratory distress (hypoxia, tachypnea, dyspnea, accessory muscle use, cough, retractions, cyanosis); neurologic impairment (irritability, confusion, and restless d/t hypercapnia)
  • Late failure = increased CO2
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12
Q

Chronic Obstructive Pulmonary Disease (COPD)

A
  • a common, preventable, and treatable disease characterized by persistent limitation of airflow d/t abnormalities (resistance and/or obstruction) in the airway and/or alveoli
  • An umbrella term for a subset of lower airway disease (e.g., chronic bronchitis, emphysema)
  • Dx: spirometry (pre- and post-bronchodilator) - measures the forced expiratory volume (FEV) divided by the forced vital capacity (FVC)
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13
Q

Emphysema

A
  • The enlargement of air spaces distal to the terminal bronchioles that causes air trapping (hyperinflation/auto-PEEP) and alveolar wall destruction that causes bronchioles to collapse during exhalation
  • Barrel chest from prolonged exhalation/chest wall remodeling, clubbed fingers, enlarged Rt heart, elevated CVP, intrinsic PEEP from chronic air trapping
  • Tx: prevention, smoking cessation, vaccination, bronchodilators (B2 agonist/albuterol to relax bronchiole), Atrovent (anticholinergic), corticosteroids
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14
Q

Asthma

A
  • Chronic hypersensitivity of histamine and other mediators in the airway that results in inflammation, airway narrowing, and spasms of the bronchial smooth muscle, making it difficult to exhale –> air trapping and alveolar hyperinflation
  • Histamine stimulates excessive mucous production
  • Tachypnea increases insensible water loss –> dehydration –> mucus plug
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15
Q

Status asthmaticus

A
  • Acute exacerbation of asthma unrelieved by bronchodilators & corticosteroids after 24 hours
  • Medical emergency
  • S/S: extreme anxiety, SOB, wheezing, chest tightness, coughing with thick tenacious sputum, tachycardia, tachypnea, accessory muscle use, peak expiratory flow rate significantly decrease, confusion, drowsiness, late signs of respiratory acidosis, hypercapnia, acute respiratory failure
  • Tx: Bronchodilator (albuterol), anticholinergic (atrovent), corticosteroids, hydration, magnesium sulfate (bronchodilator effect), heliox (replaces nitrogen and help improve airflow by decreasing airway resistance)
  • Ventilatory settings: low TV, low RR, Low MV, and longer expiration time (I: E set at 1:3 or 1:4), FiO2 to maintain O2 sat>90%, low PEEP to prevent air trapping and auto-PEEP
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16
Q

Acute Respiratory Distress Syndrome (ARDS)

A
  • Global lung inflammation and increased alveolar-capillary permeability
  • Injury to the lungs results in activation of the inflammatory immune system: coagulation pathway release mediators (e.g., cytokines) that alter alveolar permeability –> protein-rich edema fluid leak and fill up alveoli –> diffuse pulmonary edema –> inactivates surfactant production = decreased compliance, decreased functional reserve capacity, alveolar collapse, and massive atelectasis
  • Inadequate ventilation, oxygenation, and perfusion –> refractory hypoxemia
  • Causes: sepsis, aspiration, pneumonia, trauma, TRALI, drowning, pancreatitis
  • Berlin criteria: P/F ratio (<300 mild, <200 moderate, <100 severe) 1. acute lung injury within 1 week of insult; 2. unexplained bilateral opacities (“ground glass”) on chest imaging; 3. Non-cardiogenic respiratory failure
  • Decreased PaO2/FiO2 ratio <300 in setting of PEEP >5 mmHg

Tx:
Lung protective ventilation
- Low TV (4-6 ml/kg) to prevent over-inflating & rupturing (volutrauma)

  • High PEEP >10 cmH2O to prevent distal airway collapse (barotrauma) and help with alveolar recruitment (monitor PEEP increasing intrathoracic pressure: hypotension & decreased CO)
  • Plateau pressures (Pplat) <30 cmH2O - measurement of static lung compliance (high Pplat >40 indicates ARDS, pneumonia, pneumothorax, pulmonary edema); if elevated, decrease Vt
  • Permissive hypercapnia; pH >7.2
  • Conservative fluid management: Do NOT overload, diuretics
  • Prone therapy: faced down for 12-16 hr/day for an average of 4 days; absolute contraindication = unstable spinal fracture
  • Inhaled pulmonary vasodilators (Epoprosternol, NO) - reduces PAP & rt heart strain
  • Optimize O2 delivery: dobutamine (improve CO), PEEP (increase PaO2); transfusion only if necessary
  • Neuromuscular blockade - for ventilator dysynchrony
  • ECMO - complete lung support
17
Q

Pulmonary fibrosis

A
  • Restrictive lung disease where permanent scars formed in the lung tissues cause perpetual SOB & thickening of alveolar walls (decrease oxygen diffusion capacity and irreversible oxygenation impairment
  • Causes: idiopathic; amiodarone pulmonary toxicity
  • S/S: SOB, dry cough, pleuritic CP, fatigue, unexplained weight loss, clubbed fingers as a result of chronic hypoxemia
  • Dx: CXR - diffuse scaring, CT chest - honeycomb w/ extensive fibrosis, lung biopsy
  • Tx: No cure, slow progression, avg. life expectancy of 3-5 years, corticosteroids, pulmonary rehabilitation, supplemental O2, mech ventilation, lung tx
18
Q

Thoracic trauma

A
  • Blunt: pulmonary contusions and rib fractures (3 or more consecutive = at risk for frail chest - paradoxical movement of the chest wall that decreases lung compliance)
  • Penetrating: gunshots or stabbings; higher mortality over blunt (e.g., hemothorax, pneumothorax, cardiac tamponade, tracheal perforation)
19
Q

Hemothorax

A
  • Bleeding in the pleural space that compresses lung tissue and collapses alveoli –> dullness to percussion, absent breath sounds on the affected, tracheal deviation towards the unaffected side
  • Massive hemothorax: >1500 ml of blood, progress to hypotension and shock
  • Tx: thoracostomy/chest tube; thoracotomy when chest tube output exceeds 200 ml/hr x3 or causes cardiac tamponade, great vessel injury, or tracheal perforation, or video-assisted thoracoscopic surgery (VATS) if stable
20
Q

Tension pneumothorax

A
  • Respiratory distress and hypotension after a traumatic event
  • Air cannot escape, intrathoracic pressure increases and collapses the lung, which can lead to PEA arrest
  • Tracheal deviation away from the affected side and diminished breath sounds on the affected side
21
Q

Volume-controlled ventilation (PC)

A
  • Assist control or Continuous Mandatory Ventilation (CMV) delivers gas until the set Vt is reached and then cycles into exhalation; the most common
  • Each breath is assisted or controlled; aka assist control (AC, AMV, CMV)

-Patient can alter rate & pattern, but not Vt; reduces WOB

  • Disadvantages: hyperventilation, barotrauma, increased intrathoracic pressure (decreased venous return back to the right heart)
22
Q

Pressure-controlled (PC)

A
  • Delivers a targeted inspiratory pressure limit for a set time/rate
  • Vt will vary based on resistance and compliance
  • Disadvantages: if increased resistance or decreased compliance, pressure is achieved quicker but at the cost of sufficient Vt- may retain more CO2 and acidosis and higher WOB, may need more sedation.
23
Q

Respiratory acidosis causes

A
  • Late respiratory failure
  • oversedation
  • Drug OD that. cause respiratory depression
  • COPD
  • Brain stem dysfunction
  • Pulmonary edema
  • Decreased cardiac output/shock
  • V/Q mismatch, pulmonary embolism, PNA
  • Guillian Barre
  • Excessive CO2 production (sepsis, TPN, burns)
  • Severe obesity
  • Hypoventilation (retain CO2)
24
Q

Respiratory alkalosis causes

A
  • Early respiratory failure
  • Rapid breathing
  • Anxiety, severe pain
  • Excessive TV
  • ARDS
  • HF
  • Neurologic disorders
  • Pulmonary embolus
  • Salicylate OD
  • PaO2 <60
  • hyperventilation (blow off CO2)
25
Q

Metabolic acidosis causes

A

MUD SLIDE
- Methanol
- Uremia
- DKA
- Propylene glycol
- Isoniazid
- Lactic acidosis
- Ethylene glycol
- Salicylates (ASA overdose)

  • Anion gap >12 associated with metabolic acidosis
26
Q

Metabolic alkalosis causes

A
  • NG tube to suction
  • Emesis
  • Hypokalemia
  • Hypochloremia
  • Antacid abuse
  • Excessive bicarb infusion
  • Inadequate renal perfusion
  • Diuretics
  • Excessive albuterol use
  • Hyperaldosteronism
27
Q

3 reasons for hypoxemia

A
  • Hypoventilation: decreased minute ventilation, decreased phosphate or magnesium, OSA
  • V/Q mismatch (PE, PNA, shunt)
  • DO2/VO2 imbalance: decreased CO, severe anemia
28
Q

Intrapulmonary shunt

A
  • V/Q mismatch (excessive blood flow in relation to ventilation, ventilation with decreased perfusion - increased dead space)
  • PaO2 decreases as shunt increases (e.g., asthma, pulmonary edema, atelectasis, pulmonary embolism)
29
Q

Oxygen

A
  • vasoconstrictor in all vascular beds except in lungs (vasodilator)
  • Excessive O2 has negative inotropic effects on the heart
30
Q

Albuterol

A
  • Beta 2 agonist; bronchodilators
  • Side effects: tachycardia, tremors, hyperglycemia, hypokalemia, hypomagnesemia, hypophosphatemia
31
Q

Postop care for lung cancer surgery

A
  • Wedge resection, lobectomy, pneumonectomy
  • DO NOT fluid overload
  • Monitor for pulmonary edema
  • Permissive lower hemoglobin
  • Pain management
  • Chest tube: will have prolonged air leak, often water seal, pneumonectomy - NEVER place CT to suction, may see mediastinal shift, sudden bleed contact provider STAT, assess for coagulopathy
  • Positioning: operative lung DOWN, good lung UP; early mobility
  • Monitor for cardiac ischemia, afib (30% of patients) - don’t use amiodarone d/t pulmonary fibrosis (lobectomy ok), use BB or CCB
32
Q

Chest tube

A
  • suction to re-expand the lungs
  • 20 cmH20 common
  • Follow CXR
  • Tidaling is normal (fluctuation with breathing)
  • No tidaling = check for obstruction (kink or clot)
  • Do NOT strip - cause an increase in negative pressure
  • Intermittent bubbling normal if pt has pneumothorax
  • Continuous bubbling - loose connection or break in system
33
Q

Endotracheal tubes

A
  • Placement confirmed via wave for capnography
  • Auscultate the chest and upper abdomen
  • CXR to verify the position: 3-4 cm above carina
  • Cuff pressure 20-30 cmH2O
  • Assess and doc tube placement at the level of teeth or gum line
  • Tube often migrates to right lung (right is shorter/wide, with less angle)
  • ABG within 20-30 min of intubation to assess acid-base status
34
Q

Synchronized Intermittent Mandatory Ventilation (SIMV)

A
  • Preset rate & Vt
  • Allows patient to spontaneously breathe between breaths; synchronize with patient-initiated breaths
  • Reduces competition between patient and ventilator
  • Can use IMV + pressure support
35
Q

Pressure support (PS)

A
  • Delivery of positive pressure
  • Patient decides when, how fast & flow
  • Assist during inspiration; must initiate breath
  • Set back up apnea mode
  • Ideal pressure support to achieve Vt 6-8 L/kg
  • Used for weaning
36
Q

Ventilator alarms

A
  • Low pressure: leak or disconnection
  • High pressure: secretion, water, kinks
  • Low minute ventilation: the amount of air inhaled per minute drops below set Vt (usually indicates a leak or disconnect in the system)
37
Q

Weaning/”liberation” from ventilator

A
  • Determine readiness
  • Lighten sedation/analgesia
  • Spontaneous Awakening Trial (SAT)
  • Spontaneous Breathing Trial (SBT): Vital capacity (highest volume of air exhaled with the deepest effort of breath), RR during SBT, Negative Inspiratory Force (NIF): >30 cmH2O for extubation, adequate phosphate - low phosphate causes muscle weakness)
  • <2 hours, CPAP or PS can be sued, oximetry & PEtCO2 monitoring
  • If EtCO2 increase, not ready
  • check cuff leak - no cuff leak, not ready (edema)

CCRN (9 decks)

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