Respiratory Emergencies

Question 1

Components of good quality X-ray

Answer 1

•Rotation- identify if spine is center and straight. Clavicle should line up as well
•Inspiration- did they take a deep breath and hold it. Count anterior ribs. 5-7 need to line up with diaphragm at the mid-clavicular line.
*anterior ribs are swooping down and in
•Penetration- should be able to see the spinus processes through the heart

Question 2

PA vs AP X-ray view

Answer 2

Posterior/Anterior view vs Anterior/Posterior view
• PA view is Preferred route if chest X-ray
•AP view will exaggerate the the size of the heart
• most patients end up getting an AP view because they are in bed and can’t stand up.

Question 3

What do bone and air filled spaces look like in an X-ray

Answer 3

•Bone or solid things appear more white
•Air filled spaces look more dark

Question 4

What is consolidation

Answer 4

A region of normally compressible lung tissue that has filled with liquid instead of air

Question 5

Hilar point

Answer 5

Area of the lung where all the vessels are coming out from the center. Left Hilar point will be a little higher up than the right due to the hearts position in the chest cavity

*should be able to see congestion in these areas

Question 6

Chronic Bronchitis

Answer 6

•Excessive mucus production
•Airway obstruction
•Hypoxemia, polycythemia, and increased CO2 retention occurs
•These individuals have signs of R heart failure(exurtional dyspnea, cor pulmonal, fatigue, tachypnea)
•Known as blue bloaters

Question 7

Emphysema

Answer 7

• destruction of airways
• destruction of pulmonary capillary beds
• V/Q mismatch
• Muscle wasting
• Considered pink puffers
• decrease in surface area in alveolar membranes

Question 8

COPD Tx

Answer 8

•stop smoking
•bronchodilator (short and long acting)
•Anticholinergic drugs(Ipratropium, atropine)
•Phosphodiesterase inhibitors(help bronchodilation, improves contractility of diaphragm, and increase stimulation in respiratory center in the brain) *Theoflen, airflow
•Corticosteroids-decrease airway inflammation and reduce airway edema by reducing immune response
•Mucolytic agents(musinex)- thin secretions and help move them out.

Question 9

Abnormal Chest X-ray(CXR)

Answer 9

•Flattened diaphragm
•increased AP diameter of the chest (lateral view)
•long narrow heart
•abnormal air collections in the lung(bullae)

Question 10

Asthma info

Answer 10

•Complex patho
•Many different causes
•may have increased breath sounds on exhalation
•beware of the SILENT CHEST(no air movement)
•Pulsus paradoxus may be present(not the only situation you can see this in) -abnormal decrease in BP on inspiration(<10mm/hg)
•How to check for pulsus paradoxus-#1auscultate heart while palating radial pulse. You should hear the beat but not feel the pulse.
#2 look at amplitude on ECG. If the amplitude decreases during inhalation and then returns to baseline, positive for pulsus paradoxus.

Question 11

Asthma Tx

Answer 11

• bronchodilators
• anticholingerics (ipratropium)
•corticosteroids
•heliox(helium-oxygen mixture. 80:20 or 70:30 ratio.
•Intubation is last resort!
• Ketamine is a bronchodilator so use K if possible/needed.

Question 12

ARDS info

Answer 12

•Caused by an acute accumulation of inflammatory mediators and neutrophils
•Diffuse alveolar damage and lung capillary endothelial injury
•Associated with increased pulmonary vascular permeability
•Increased dead space
•Decreased lung compliance
•fluid build up in the interstitial space causes gas exchange to be more difficult
•Most diagnoses are not true ARDS and most cases are iatrogenic.
•Iatrogenic factors: volume overload, effusions, atelectasis.
•use PEEP

Question 13

Causes of ARDS(direct lung injury)

Answer 13

•Pneumonia(most common)
•aspiration
•near drowning
•inhalation injury
•pulmonary contusion
•pulmonary edema from reperfusion therapy

Question 14

Causes of ARDS(indirect lung injury)

Answer 14

2 most common:
•Sepsis
•Trauma from shock
Other causes:
•CABG
•OD
•Blood product admin
•acute pancreatitis

Question 15

ARDS X-ray findings

Answer 15

•Rapid deterioration
•bilateral
•patchy or ground glass”hazy” areas
•pleural effusions

Question 16

ARDS Tx

Answer 16

•Tx underlying cause
•Supportive care(strict I/O)
•Noninvasive or mechanical ventilation
-lower Vt, lung protective, high PEEP & FIO2
-(APRV) Airway pressure release ventilation
• early admin of antibiotics
**conservative volume resuscitation(don’t volume overload) vasopressors instead of fluid!!!

Question 17

Pneumonia

Answer 17

•Inflammation/infection
•Consolidation of affected area
•CXR findings: Consolidation(white) and Opacities

Question 18

Pneumonia Tx

Answer 18

•Antibacterial Tx within 4 hrs of admission
•Bronchodilators
•Oxygen
•CPAP/Ventilator support if needed
•Fluid resuscitation (be cautious, don’t fluid overload)
•supportive care

Question 19

Tension Pneumothorax on CXR

Answer 19

•If you see vascular markings then the lung is not deflated completely. If you don’t have vascular markings, the lung is deflated.
•Shifting of trachea and mediastinum(late signs)
•if you see the outlining of the pleura, it’s partially deflated.

Question 20

ARDS definition

Answer 20

AECC:
•Acute onset
•bilateral infiltrates
•pulmonary artery wedge pressure <18mmHg
•PaO2/FIO2 ratio <200 = ARDS
•PaO2/FIO2 ratio <300 = acute lung injury(ALI)

Question 21

Correct NGT position

Answer 21

•NGT tip >10cm distal to the gastroesophageal junction(where it turns and goes into stomach)
•below the left hemidiaphragm
•ask to look at X-ray to confirm before using equipment.

Question 22

ETT position

Answer 22

•ETT tip 5cm +/- 2cm above the carina
•at the level of the medial ends of the clavicles

Question 23

Central venous catheter(CVC)

Answer 23

•Right side: 1-1.5cm above the level of the carina
•Left side: below the level of the carina

Question 24

Chest tube position

Answer 24

•5th intercostal, mid-axillary
•for pneumothorax, the tube tip is positioned upper pleural cavity
•for pleural effusion, the tube tip is positioned lower pleural cavity

Question 25

PE info

Answer 25

•Venous thromboembolism complication
•symptoms: tachycardia/tachypnea, Rales, diaphoresis, S3 or S4 gallop, cardiac murmur, CP, maybe syncope.
•EKG changes: S1 Q3 T3, tachycardia, RBBB, T wave inversion in V1-V4 and sometimes inferior, RA enlarged-P-wave >2.5mm in lead 2.
•gas exchange issues: v/Q mismatch, decreased PaO2, right to left shunt, increased total dead space, respiratory alkalosis.
•they will not be hypercapneic

Question 26

PE Tx

Answer 26

•Hemodynamic Tx
—be cautious with sedatives and volume. Early vasopressors is best if hypotensive
•Immediate anticoagulation
•Thrombolytic therapy
•Surgery/filter placement

Question 27

Quick question:
What is the secondary complication to COPD?

Answer 27

Answer:
Polycythemia
Possibly a reaction to chronically low oxygen levels

Question 28

Quiz question:
What best describes pulmonary embolus

Answer 28

Answer:
Causes increased alveolar dead space.
Alveolar dead space occurs with no perfusion, but continued ventilation. An intra-pulmonary shunt would occur when there is no perfusion or ventilation. A pulmonary embolus will cause the patient to hyperventilate, causing the patient to become very fatigued.

Question 29

Quick question:
What is the leading indirect cause of ARDS?

Answer 29

Answer:
Shock
Specifically septic shock, because blood is shunted away from the longest to the heart and brain to maintain essential organ function. Shock also triggers, the systemic, inflammatory response, cascade, which will increase the permeability of the alveolar capillary membrane.

Question 30

Quick question:
How far past the gastroesophageal junction should the tip of an NGT be located?

Answer 30

Answer:
At least 10 cm

Question 31

Quick question:
Why would you intubate a near drowning patient with these ABGs?
pH 7.32, PaCO2 48, PaO2 46, HCO3- 20?

Answer 31

Answer:
The patient is suffering from a mixed disturbance with associated hypoxia. The patient needs to be evaluated for intubation and mechanical ventilation based on the near journey incident. Further care would consist of CPAP or NIPPV and potential intubation.

Question 32

Quick question:
Reasons and acute asthma exacerbation would need intubation

Answer 32

Answer:
Decline in level of consciousness, hypo ventilation, secondary to muscle fatigue, and uncompensated respiratory acidosis.
Uncompensated respiratory acidosis will lead to muscle fatigue, which will lead to hypo ventilation, which will lead to respiratory failure.

Question 33

Quick question:
What is the most common cause of diminished breath sounds after surgery especially in smokers

Answer 33

Answer:
Atelectasis