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Anatomically, what are the positions of the pharynx, larynx and trachea
The pharynx is aboe the larynx and trachea.
Remmber: PLT
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What is the role of the pharynx
The pharynx is a passageway for food and air
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What is the purpose of he larynx
The larynx does the major function of speech
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TF: The epiglottis helps precent food from entering the lungs
- True
- located at the opening of the larynx (only way you are getting to the lungs from the pharynx)
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Which lung has 3 lobes and which has 2?
The right lung has 3 lobes; left has 2
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Describe generations of airway, what is involved in gas exhange
There are 23 generations of airways; 16 of which are dead space. Only the last 7 are involved in gas exchange
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Which lung is most often mistakenly intubated or is involved in aspiration and why.
The right; it is shorter and straighter than the left. Recall that is has 3 lobes
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What happens to the cilia in the lower airways in response to smoking?
The cilia lose the wavelike functions that serves as a defense mechanism to move offenders up and out
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What is the role of surfactant?
The surfactant keeps the alveoli from collapsing
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What is the role of the negative pressure in the pleural space
The negative pressure helps the lung adhere to the chest wall. The loss of negative pressure does not allow the lung to expand
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What is the best way to listen to someone's lower and middle lobes
Posteriorly and under the arms
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Explains what happens during inspiration
- 1. the diaphragm flattens -->
- 2. the thoraric space enlarges -->
- 3. intrathoracic pressure decreases -->
- 4. air enters the thoracic cavity
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What accessory muscles are used for inspiration when work of breathing is increased
- intercostals
- scalenes
- sternomastoclastoids
Remember: ISS
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TF: Expiration is normally a passive process
True, but it may become active with diseases
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How is the elastic recoil of the lungs during passive expiration counterbalanced
The elastic recoil is counterbalanced by the coupling of the pleural membrane/space to the chest wall
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Define compliance
Compliance defines the elastic ability of the lung
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Explain Ventilation/Perfusion
Ventilation/Perfusion is a matching (1:1) ratio of blood glow to gas exchange in the lung; this is ideal. There is a mismatching with disease
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Explain what is happening when perfusion > ventilation
There is blood flow, but limited gas exchange; the airway are affected. Here, some common causes are atelectasis, pneumonia, tumors, mucous plugs.
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Explain what is happening when ventilation > perfusion
There is gas exchange, but limited blood flow; the arteries are affected. Here, a common cause is a pulmonary embolism .
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What is the most important protein for gas exchange?
hemoglobin
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The transit time of a red blood cell through the pulmonary capillary is less than one second, how long does it take for the hemoglobin to become oxygenated?
1/3 second in a healthy lung
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O2 binds to the hemoglobin molecule as _________________
oxyhemoglobin
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TF: A large amount of Oxygen is dissolved in plasma as O2 moves through the interstitial space between the alveoli and the capillary
False; it binds to the hemoglobin as oxyhemoglobin
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The diffusion of gas exhange is affected by what factors?
- youth
- exercise
- supine position
- male sex
- smaller body size
- disease free lungs
*these are positive factores
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TF: Astham is most often a disease of the young and the poor
True
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TF: African americans are more likely to get and then die from lung cancer
True
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What groups are less likely to receive pneumonia and flu caccines
African americans and Native americans
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Lung disease is the # ____ killer in America
three
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What respiratory side effest do ACE inhibitors have?
dry cough
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What respiratory side effect do cholesterol lowering agents have?
Shortness of breath
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What is the #1 sign of respiratory disease?
cough
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How much sputum is normal?
90cc/day
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TF: Pulmonary pain is made worse by tourching or pressing over the area.
False; it is not usually made worse
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paroxysmal nocturnal dyspnea
intermittent dyspnea during sleep that will awaken
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orthopnea
SOB that occurs when lying down but is relieved when sitting up
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dyspnea scale - classes, ADL key
- class1. no significant restrictions: ADL key 4
- class2. climbing stairs: ADK key 3
- class3. usual activities; not employable: ADL key 2
- class4. needs helps in ADLS; little activity outside home: ADL key 1
- class5. at rest; confined to home: ADL key 0
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How does cyanosis play in role in respiratory assessment
It's a pretty late sign; it is not reliable and is affected by size and skin color
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When percussing lungs, what shoud you hear?
resonance
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What should you hear when auscultating the lungs?
vesticular lung sounds: inspiration > expiration
Note: bronchial is over the larynx and bronchovesticular are over the trachea
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TF: bronchial breath sounds, inspiration > expiration
- false:
- bronchial inspiration < expiration
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define crackles
crackles are fine crackling sounds made as air moves through wet secretions in the lungs
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define wheezes
continuous, high pitched squeak or musical sound made as air moves through narrowed or partially obstructed airway passages
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How long do you have to get a sputum culture to the lab?
2 hours
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what's important to note about pulse oximetry
- Measures the saturation of hemoglobin
- hemoglobin may be saturated with CO
- affected by temperature, vasoconstriction, ambient light; ages
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bronchoscopy: inserted, for, NPO?
- Invasive procedure to visualixe the trachea and bronchi (lung and airways);
- inserted through nose, mouth or trachea
- can detect tumors, take samples, remove secretions, improve airlow
- NPO for 48 hours prior
- NPO for 2-3 hours after (gag must return)
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thoracentesis: inserted, for, NPO?
- Invasive procedure to aspirate fluid or air from the pleural space
- Inserted in intercostal space
- aspirate fluid or air from the pleural space
- no need for NPO
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How do you monitor someone after a bronchoscopy?
- monitor:
- oxygen sat
- vital signs
- breath sounds
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TF: When you aspirate fluid or air from the pleural space using thoracentesis, it will not reaccumulate
False; it is often a temporary measure
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What are interventions after thoracentesis?
- chest x ray to ensure that lung wasn't nicked (pneumothorax)
- check for crepitus
- look for drainage
- access for pain
- access for dyspnea
- position patient on side to apply pressure to site
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If you notice crepitus after a thoracentesis, what do you do?
- mark the site to see how far out it extends
- notify physician immediately
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Define tidal volume
inspiratory volument during quiet respirations
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define vital capacity
maximum amount that can be inhaled or exhaled
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define functional residual capacity
amount of air remianing in lungs after a maximal expiration
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define total lung capacity
sum of the vital capacity and the residual volume
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define forced vital capacity
max amount of air that can be exhaled as quickly as possible after a max inspiration
Remember: flows are "forced"
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define forced expiratory volume1
amount of air exhaled in the first second; should be 70%
- Remember: flows are "forced"
- 35% of where you should be is "severe"
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Classify obstructive and restrictive lung diseases in terms of problems with flows or volumes
flows - obstructive diseases
restrictive diseases - volumes
Remember "forv" as in forever
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obstructive diseases are marked by ____________________
increased airway resistance
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restrictive diseases are marked by ____________________
reduction in the expansion of the thorax or lung tissue
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Normal arterial pH range
7.35 - 7.45
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the lower the pH, the more _______
acidic
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the higher the pH, the more _______
alkaline
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Increase in H+ leads to a _____________
decrease in pH (--> acidic)
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Decrease in H+ leads to a _____________
increase in pH (-->base)
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Describe levels of potassium in terms of the pH scale
- acid = more H+ = more K
- basic = less H+ = less K
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What are the sources of acid
- protein metabolism
- glucose metabolism
- fat metabolism
- anaerobic metabolism
- cell destruction
- carb metabolism
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what are the sources of bases
- breakdown of carbonic acid
- absorption of bicarb by the intestines
- reabsorption of bicarb by the kidneys
- production of bicarb by the pancreas
- intracellular movement
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What are diet considerations for someone with acidosis
fat, protein, and carb metabolism produce acids
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What are the three lines of defense in keeping the acid-base balance in the body
- 1. buffers
- 2. respiratory mechanisms
- 3. renal mechanisms
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Explain buffers in relation to acid-base balance
- Buffers are the first line of defense
- There are chemical buffers and protein buffers
- The buffers act to soak up the extra H+ ions in the body fluid or release H+ ions when needed to maintain balance
- The chemical buffers are bicarbonate and phosphate
- Protein buffers are hemoglobin and albumin
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Explain the respiratory mechanism to maintain acid-base balance
- Second line of defense
- acts quickly
- Sensitive to CO2 levels
- if high, hyperventilate to blow off CO2
- if low, hypoventilate to keep CO2
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Explain the renal mechanism to achieve acie-base balance
- third line of defense
- takes effect at 24-48 hours
- There is reabsorption or excretion of HCO3 to buffer the H+ ions
- If HCO3 is formed and then reabsorbed in the kidneys, it leaves the urine negatively charged with phosphate which attacts H+ into the urine, forming acids for excretions
- Ammonium is formed from the breakdown on ammonia which attracts H+ ions and allows them to be excreted in urine
- All leads to less H+ which decreases acidity and increases pH
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what are the manifestations of acidosis?
- CNS depression
- decrease in muscle tone
- increased rate and depth of respirations
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What are the manifestations of alkalosis?
- CNS excitement
- seizures
- tetany
- cramps
- twitches, but weakness
- myocardial irritability
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TF: When determining whether compensation in uncompensated or not, look at whether the other mechanism value is normal or not.
True
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How do you evaluate a PaO2 less than 80 mmHG (Arterial blood gas)
Increase oxygen delivery in order to figure out underlying cause
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What is the percentage concentration of oxygen in the atmosphere?
21%
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TF: the central receptors in the brain that control breathing are responsive to the body's levels of O2
False; they are sensitive to CO2
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Chronic increases in CO2 levels > _____ can lead to a decrease in sensitivity o f central receptors in the brain
60
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What is oxygen toxicity? Manifestations
- An occurrence where O2 concentration is more than 50% for 48 hours.
- fatigue
- chest pain
- cough
- edema
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In atelectatis, _______________ replaces oxygen in the alveoli
Nitrogen
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You must provide humidification with oxygen greater than __L /minute
4
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What is a way to make sure a pt receives oxygen without increasing the amount?
increase the pressure
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What are some sources of infection related to oxygen delivery?
- humidifier
- nebulizer
- cannulas
- masks
*humidification increases risk
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TF: Room air is still involved with low flow delivery systems
True; the total concentration of oxygen received by pt is dependent on resp rate and tidal volume -->variable
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What are examples of low flow delivery systems
- nasal cannula 1 - 6 L/min
- simple face mask 6-8 L/min
- partial rebreather 6-11 L/min
- non-rebreather 12L/min
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What are examples of high flow delivery systems
Venturi Makd 8-15 L/min
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What are some problems with prolonged intubation?
Fistulas in/near your esophagus. recall that the esophagus is on the back side of the trachea.
After 7-10 days, advance to a tracheostomy
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What is postop care after a tracheostomy
- breath sounds
- bleeding
- pulsatio nof the tube
- bed elevation to reduce swelling &promote drainage
- humidify air (since upper airways won't be doing this)
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what are complications of a tracheostomy
- obstruction
- dislodgement
- pneumothorax - rare
- subQ emphsema (crepitus)
- bleeding
- pressure ulcers
- pulsating - life threatening
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TF: It is okay to suction during insertion when performing trach care
False
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How should you suction during trach care on the way out
intermittently
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What are the rules for suctioning in trach care
- 2-3 passes
- 10-15 seconds at a time
- never on insertion
- intermittently during extraction
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When suctioning trachs, the ideal pressure is
80-120 mm
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TF: hyperventilate the pt prior to trach care
True; before each suctioning pass for 30 seconds to 3 minutes (3 times max) until heart rate and sat are normal
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TF: Trach care is always sterile
False; in hospital, suctioning is a sterile technique. At home, it is a clean technique
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Nebulizers are ________ driven and disperse meds through tiny particles
oxygen
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Chest physiotherapy contains five areas....
- 1. cough and deep breathing
- 2. ambulation
- 3. postural drainage
- 4. chest percussion
- 5. vibration
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In order to perform postural drainage, lobes need to be in what position
higher than mouth
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When performing vibration PT, the person is shaken upon ________________(exhalation/inhalation)
exhalation
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What are the obstructive lung diseases?
- asthma
- chronic bronchitis
- emphysema
THINK: ACE
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reversibility of obstructive lung diseases
- asthma is most reversible
- following by chronic bronchitis
- followed by emphysema (least)
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sputum production of obstructive lung diseases
- chronic bronchitis has the most
- asthma and emphysema - least
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alveolar damage as it relates to obstructive lung disease
- none w/ asthma
- most with emphysema
- less with chronic bronchitis
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with asthma, is mortality higher in men or women
men
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How is asthma obstructive
air way narrowing due to inflammation (smooth muscle contraction)
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Is there damage with asthma?
Yes, even though reversible and no alveolar damage, there can be scarring of the airways (resulting in permanent narrowing)
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What are the manifestations of asthma?
- audible wheeze and cough
- initially wheeze heard on expiration
- progresses to both inspiration and expiration
- longer respiratory cycle - harder to get out (think narrowing on expiration) --> barrell chest
- use of accessory muscles
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ABGs of asthmatic early in attack vs later in the attack
- early:
- fast and hard breathing --> low CO2, pH up
- later:
- tired, breathing slows --> high CO2, pH down
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How can an xray and/or CBC help you in asthma diagnosis?
They won't show anything, but rather help to exclude other things i.e. lung tumor
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Bronchodilators: Describe:
1. beta 2 agonists
2. cholenergic antagonists
3. methylxanthines
- Beta 2 relax smooth muscle
- Cholenergic inhibit the parasympathetic to rest and digest
- Methylxanthines relaxes smooth muscle working like caffeine
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short acting beta 2 agonist
- albuterol
- bitolterol
- levalbuterol
- pirbuterol
- terbutaline
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long acting beta 2 agonist
- salmeterol
- atrovent
- formoterol
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methylxanthines
throphylline
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Describe the step approach - asthma
- 1. mild intermittent
- 2. mild persistant
- 3. moderate intermittent
- 4. sever persistent
- 5.6 severe persistent
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which inhaler can give you thrush
steroid; rinse mouth
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leuokotrient antagonist
singulair
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emphysma
irreversible increases in size of airspaces
- centrilobular - diffuse upper lobes - more bronchioles
- panlovbular - lower lobes - entire alveolus
- hyper inflated lungs
- flattened diaphragm
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how do the airways become larger in emphysema
elastases and proteases destroy elastic properties; these enzyymes are released by alveoli and there is a defiency of the antitrypsin which protects lungs
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chronic bronchitis
hypertrophy and hyperplasia of submucosal glands
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has is chronic bronchitis defined in terms of sputum
daily production of sputum for greater than 3 months for 2 years
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COPD =
chronic bronchitis and emphysema
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What is the number 1 cause of COPD?
smoking
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Classic picture of COPD (Acidosis/alkalosis)
- chronic respiratory acidosis
- (CO2 may not always go up)
- PO2 decreases
- elevated white count
- Red blood cell count up to get mmore oxygen
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bacteria that causes respiratory infections in COPD
- -streptococcus pneumonia
- -H influenza
- -staph
- -pseudomonas
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Who gets cor pulmonle (right sided heart failure) and what does it look loke
- edema
- distended neck veins
- large livers
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What does someone with COPD look like
- thin
- axious
- sitting forward
- barrel chest
- limited diaphragm movments
- right sided heart failure
- wheezing, ronchi
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COPD PFTs
- Residual volume up
- Functional residual capacity up
- total lung capacity up in emphysema
- total lung capacity normal in bronchitis
- forced expiratory volumes decreased
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What's an acceptable oxygen sat for COPDer
90-91
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Do you give asthma drugs to a COPDer?
- long acting like spyriva and steroids
- can add mucolytics too
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diaphramatic & purse lip breathing are useful for ....
COPD
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what is a bullectomy?
In COPD, big air sacs can be deflated so they don't rupture causing a pneumothorax
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what is volume reduction surgery?
very strict criteria that most can't meet: end stage emphysema with minimal bronchitis and others
remove dead weight
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what are the restrictive lung diseases
- problems with volumes, remember
- sarcoidosis
- idiopathic pulmonay fibrosis
- kyphoscoliosis
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what's characteristic of restrictive lung diseases
- slow onset
- SOB w/ activity
- can get air in and out, but problems with volumes
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idiopathic pulmonary fibrosis
- lethal, generally
- scarring and fibrosis
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atelectasis
closure or collapse of alveoli
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what does atelectasis look like?
- Increased wob
- Dyspnea
- Cough
- Elevation in temp
- Reduction in breath sounds
- Crackles
- Decrease in saturation
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small cell lung cancers are ____% of all lung cases
20% - slow growing and usually metastasized at diagnosis
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lung cancer symptoms can often be attributed to ____ and ingored
aging
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do you expect to see a chest tube after a pt has had a pneumonectomy?
No, the entire lung was removed; there i nothing to expand
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what chest tube output is considered ezcessive
greater than 100c/hr
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bubbling in chest tube is normal with ___________--
exhalation and cough and position changes;
the water seal is what keeps air from entering the chest
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what is the cure rate for cancer
5 year survival rate
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TF: laryngeal cancer is a rare cancer
true
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with a total laryngectomy, is there a risk for aspiration?
No, pharynx is gone
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what does a pulmonary embolism look lie
- sudden onset dyspnea and tachypnea
- cough, hemoptysis
- pleuritic chest pain
- paO2 down
- O2 sat done
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pulmonary embolism prophalatic
low dose heparin subQ
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TF: heparin does not do anything to the existing clot; prevents additional clots and the existing clot from getting bigger
True
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PPT is monitored with ___________
- heparing
- 1.5 - 2.5 x control
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