-
Signs
- Objective information, those things that you can see or measure
- Color
- pulse
- Edema
- Blood pressure
-
Symptoms
- sujective information, those things that the patient must tell you
- Dyspnea
- Pain
- Nausea
- Muscle weakness
-
Decreased CVP can indicate
Hypovolemia
-
Increased CVP can indicate
Hypervolemia
-
Lethargic, somnolent, sleepy
Consider COPD O2 overdose or sleep apnea
-
Stuporous, confused
- Responds inappropriately
- drug overdose
- Intoxication
-
Semicomatose
Responds only to painful stimuli
-
Obtunded
- Drowsy state
- May have a decreased cough or gag reflex
-
Orthopnea
- difficulty breathing except in the upright position
- Heart problem, CHF
-
Clubbing of fingers
- Caused by chronic hypoxemia
- Pulmonary disease
-
Kyphosis
Convex curvature of the spine (lean foward)
-
Scoliosis
Lateral curvature of the spine (lean side to side)
-
Kassmaul's Breathing
- Causes of Metabolic acidosis
- Renal failure
- Diabetic Ketoacisosis
-
-
Bradycardia Indicates
- Heart failure
- Shock
- Code/ emergency
-
Bronchial breath sounds
- normal sound over the trachea or bronchi
- These breath sounds over the lung periphery would indicate lung consolidation
-
Unilateral wheeze indicative
of a foreign body obstruction
-
Position of endotracheal Tube
Should be below the vocal cords and no closer than 2 cm or 1 in above the carnia
-
-
Consolidation
- Solid white area
- Pneumonia or pleural effusion
-
Hyperlucency
- Extra pulomany air
- COPD
- Asthma attack
- Pneumothorax
-
Vascular markings are increased with
CHF
-
Vascular markings are absent with
Pneumothorax
-
Fluffy infiltrates
Pulmonary edema
-
Butterfly/Batwing pattern
Pulmonary edema
-
Patchy infiltrates
Atelectasis
-
Peripheral wedge shaped infiltrates
Pulmonary embolus
-
Normal value for ICP
- 5-10
- Patient should be hyperventilated until PaCO2 is 25-30
-
Mucoid
- white/gray
- Chronic bronchitis
-
If a patient has very thick, tenacious secretions...
The patient is dehydrating
-
Yellow sputum
- Presence of WBC
- Bacterial infection
-
Green sputum
- Stagnant sputum
- Gram negative bacteria
-
Pink frothy sputum
Pulmonary edema
-
Sinus tachycardia
Give oxygen
-
Sinus bradycardia
oxygen and atropine
-
Premature ventricular contractions
oxygen and Lidocaine
-
Ventricular tachycardia
- Defibrillate if no pulse
- Lidocaine if pulse is present
-
Ventricular fibrillation
Defibrillate
-
Transillumination
- Recommend when a pneumothorax is present
- Normally a lighted halo is seen around the point of contact
- A pneumothorax will cause the entire hemithorax to light up
-
Capnography monitoring of PetCO2
- Normally the PetCO2 will read lower than the PaCO2
- PaCO2= 40
- PetCO2= 30
- Sensor should be placed proximal to the patients airway connection (at the ETT)
-
Transcutaneous PO2 and PCO2
- Tempature has to be heated to 43- 45 C
- Best placement is over flat areas with good perfusion
- Normally on the chest just beneath the center of the right or left clavicle
- Site should be changed every four hours
-
artery
going away from heart
-
-
Curved/Macintosh blade
fits into vallecula, indirectly raises epiglottis
-
Straight/miller blade
Fits directly under the epiglottis
-
The laryngeal mask airway (LMA) is indicated for...
Short term ventilation and when intubation is not possible by the oral or nasal route (facial or nasal injuries)
-
Severe respiratory stridor and/or marked inspiratory
Reintubate the patient
-
Moderate distress/stridor
Oxygen, cool mist aerosol and racemic epinephrine to reduce swelling
-
Mild distress/stridor
Provide humidity, oxygen and/or racemic epinephrine as necessary
-
Consider bronchial hygiene therapy for patients with:
- Bronchiectasis
- Cystic fibrosis
- COPD
- Acute atelectasis
- Lung abscess
- Pneumonia
- Post operative
- Prolonged bedrest
-
Prone position
Patient lying face down
-
Supine position
Patient laying on spine (Best for post craniotomy patients)
-
Fowlers, semi fowlers, or reverse trendelenburg position
- Best position for hypoxic patients
- obese patients with dyspnea
- Post op abdominal patients
- Patients with pulmonary edema
-
Trendelenburg
patients with very low blood pressure
-
Lateral fowlers
Very obease patients with air hunger
-
Lateral flat
Best position to prevent aspiration
-
Huff coughing
- Coughing with an open glottis
- More effective in patients with COPD or head trauma to prevent increased intracranial pressure
-
PEP therapy
- Improve secretion expectoration
- Reduce residual volume(decrease hyperinflation)
- Improve airway maintenance
-
Hazards of suctioning
- Trauma to mucosa
- Contamination
- Hypoxemia
- Bradycardia
-
Goals of aerosol therapy
- To relieve bronchospasm and mucosal edema
- To thin secretion that are thick and tenacious
- To humidify the respiratory tract
- To administer drugs
-
Hazards of aerosol therapy
- Bronchospasm
- Secretion swelling
- Fluid overload
- Cross contamination
-
Heated wick humidifiers
- Can deliver 100% body humidity
- Low risk of cross contamination because no particles are bein produced
-
SPAG
Deliver Ribavirn for treating RSV
-
Mask CPAP
- Short term, temporarly use for improving oxygenation in patients with CO poisoning,
- pneumonia, post op atelectasis
-
Clark electrode
- PO2
- Partial pressure of oxygen in sample
-
Severinghaus Electrode
- PCO2
- Partial pressure of carbon dioxide in sample
-
PaCO2 value above 45
- Patient is not ventilating
- Initiate ventilation or
- Remove/Decrease deadspace
- Increase current ventilation
-
PaCO2 below 35
- Ptient is ventilating but to much
- Dont put on mechanical ventilation
- Add deadspace (If PaO2 is acceptable) or
- Decrease ventilation (If PaO2 is high)
-
If patient is hypoxemia on FiO2 greater than 60% than its due to?
Shunting and you need to add PEEP
-
Decrease the FiO2 first if at or above 60%. Once the FiO2 is below 60% then...
Reduce PEEP/CPAP
-
Treatment for CO poison!
100% oxygen and hyperbaric oxygen therapy
-
Pulmonary Embolus
- All of the sudden
- Increased deadspace
- VD/VT is increased
-
Supect pulmonary embolus in
- Post op patients
- Bedridden patients
- Obesity
- Trauma
-
Treatment for pulmonary embolus!
- Prevention
- Support ventilation
- Prevent further emboli with anticoagulant therapy
-
O2 Hb dissociation curve shift to the left
Increased oxygen affinity
-
O2 Hb dissociation curve shift to the right
Decreased oxygen affinity
-
Volume calibration and leaks test are done by...
- Using a large volume syrine (Super syringe)
- Standard syringe volume is 3.0 Liters
-
Galvanic fuel cell
- Measure partial pressure of O2, displays FiO2 as %
- If unable to calibrate change fuel cell
-
MIP Device
- used to monitor and asses the rediness to wean ventilator patients
- Assesses the degree of respiratory muscle impairment in guillain barre and myasthenia gravis
-
Decreased volumes indicates
Restrictive disease
-
Decreased vital capacity is the best indicator of
restrictive lung disease
-
Forced vital Capacity
(FVC)
will provide important flow rates used to identify obstructive disease
-
The following flows can be measured from a Forced Vital capacity
- FEV1
- FEV200-1200
- FEF25-75
- PEFR
-
A decreased FEV1 is a go indicator of...
obstructive disease
-
Decreased FEV1/FVC is the best indicator of...
Obstructive disease
-
If the FEV1 is decreased but the FEV1/FVC is normal...
Then the patient has restrictive disease only
-
The FEV1/FVC should be at least...
70%
-
MVV
- Measures the muscular mechanics of breathing
- Decreased with obstructive disease, increased airway resistance, decreased compliance
-
Pre and post bronchodilator testing
Minimun increase of 12% and 200 ml in the FEV1
-
Recommend flexible bronchoscopy for intubating in patients with...
Suspected neck fracture
-
disinfection and steralization of the Bronchoscopy is best done with...
Alkaline gluteraldehyde (CIdex)
-
Ventilator circuits should not be changed on a regular basis unless:
- Circuit is grossly contaminated
- Malfunctioning
-
Indication for Mechanical ventilation
- Apnea
- Acute ventilatory failure-not breathing enough
- Impending ventilatory failure-rising PaCO2, decreasing Vt,VC,MIP
-
Increased airway resistance (Raw)
- PIP increases
- Plateau pressure remains the same
- Raw= PIP-Ppl
- Common causes:
- Secretions in airway
- Bronchospasms
- Treatment:
- Suction
- Bronchodilator
-
Decreased lung compliance
- PIP increases
- Ppl Increases
- Common causes:
- Atelectasis
- Pulmonary edema
- ARDS
- Pneumonia
- Treatment:
- Increase PEEP
-
Controls that directs affect mean airway pressure (Paw)
- PIP
- Rate
- I time
- PEEP
- Peak flow
- Tidal volume
- Inflation hold
-
Pressure control ventilation is recommended when
- Patients requring high FiO2 and PEEP
- High PEEP
- High PIP
- Low PaO2 and Decreased compliance
-
Ventilator protocol for patients with asthma!
- Reduce tidal volume to 4-6 ml/Kg
- Set respiratory rate between 10-12
- Consider permissive hypercapnia
-
Decelerating wave
The normal flow pattern for a pressure or pressure support breath
-
Sine wave
the normal flow pattern for a spontaneous breath
-
Square wave
The normal flow pattern for a volume controlled breath
-
Pharmacological agents used for mechanically ventilated patients!
- Analgesics- Reduced sensation of pain (morphine)
- Sedatives-Decrease anxiety and promote relaxation (Versed, Ativan)
- Anesthetics- Reduces patients ability to perceive sensation (Propofol)
-
The lowest settings on the ventilator prior to extubation are as follows:
- SIMV/IMV- 4 breaths per minute
- FiO2- 0.40
- PEEP- 5 cm H2O
-
Summary of adverse condition
- Increase in heart rate by >20 beats per minute
- Change in blood pressure by 10-20 mm Hg
- Increased PaCO2 by >10 torr
- Respiratory rate increases by >10 or is >30b/min
-
Complications of ventilation
- Gastric distention- most common
- Pneumothorax
- Gastric rupture
- Cross contamination
- Aspiration
-
Complications of external cardiac compliocations
- Rib fractures
- Fractured sternum/Clavicle
- Contusions to the heart and or lung
- Lacerated liver and or spleen
- Pulmonary/fat embolism
- Pneumothorax/hemothorax
-
Evaluation of effectiveness of Cardiopulmonary resuscitation!
- Carotid pulse should be present during
- Colors returns to normal
- Do not remove cervica collar on during resuscitation- check femoral pulse
- ECG shows sinus rhythm with no pulse- continue CPR
-
Cardioversion
- Electrical shock delivered on the R wave of ECG
- Non leathal dysrhythmias suck as:
- Atrial fibrillation
- Atrial flutter
- Ventricular tachycardia with a pulse
-
Defibrillation
- Emergency lethal cardiac dysrhythmias
- Pulseless ventricular tachycardia
- Ventricular Fibrillation
-
Emergency Resuscitation Bag
- If bag fills rapidly and collapses easily on minimal pressure- check inlet valve
- If bag becomes difficult to compress and patient compliance is normal, patient valve may be stuck open or closed
- Excessively high flow may cause valves to jam. use 15 L/min or low range of flush
- When there is a problem do not attempt to fix the bag, use another form of ventilation
-
Pulmonary Edema/CHF
Description
- Left ventricular failure and lung reaction
- Excessive fluid accumulates in the lungs and affects ventilation and espically oxygenation
-
Pulmonary Edema/CHF
Assessment
- Orthopnea, pitting edema, Distended neck veins and increased respiratory distress
- Pink, frosty, watery secretions
- Fine crepitant audible rales or crackles
- Chest X ray: Fluffy infiltrates, butterfly or batwing pattern
-
Pulmonary Edema/CHF
Treatment
- Improve gas exchange- give 100% O2 via non rebreather, IPPB with 100% O2 and PEEP or CPAP if necessary
- Increase strength of heart contraction (Inotropy)- Give digitalis
- Decrease venous return- give lasix (diuretic)
- Body position (Fowlers)
-
Pulmonary Embolism
Description
Deadspace disease (ventilation without perfusion)
-
Pulmonary Embolism
Patients at risk
- Post op
- Bedridden
- History of DVT
- long periods at rest
-
Pulmonary Embolism
Assessment
- Sudden onset of dyspnea, tachycardia
- Patient appears to be hyperventilating (tachypnea) but is not (ABG shows normal PaCO2)
- Anxious, chest pain
- Chest X ray: Peripheral wedge shaped infiltrates
- V/Q scan or spiral CT scan
-
Pulmonary Embolism
Treatment
- Oxygen therapy 100%
- Anticoagulation therapy (heparin and Coumadin)
- Thrombolytic drugs, screens, surgery
-
Pneumothorax
Assessment
- Decreased vocal fremitus, percussion note is hyperresonant or tympanic
- X ray shows hyperlucency without vascular markings and a flattened diaphragm
-
Pneumothorax
Treatment
- Give 100% oxygen O2 via non rebreathing mask
- Immediate chest tube/ thoracentasis or releive pressure with needle and tubing inserted into plueral space (needle aspiration)
-
Status asthmaticus
Description
- Sustained asthma attack unresponsive to bronchodilator therapy
- Will have marked affect on ventilation and oxygenation
-
Status asthmaticus
Assessment
- Diagnosis made by history
- Retractions and pulsus paradoxus
- ABG indicating respiratory acidosis or respiratory failure (PaCO2 >45)
-
Status asthmaticus
Treatment
- 100% O2 therapy via a non rebreathing mask
- Continuous bronchodilator therapy (Albuterol and ipratropium)
- Corticosteriods IV and Oral
-
Examples of Trauma
- Head trauma
- Chest trauma
- Neck trauma
- Burn victims
- Near drowning
-
Trauma
Treatment
- Always atart with airway, breathing and circulation
- Administer 100% oxygen
-
CO poisoning
Treatment
- 100% O2 via non rebreathing mask
- Hyperbaric Oxygen
-
The most common pleural disorder that requries a thoracentasis...
Pleural effusion
-
The most common position for thoracentasis is...
To have the patient sitting up and leaning foward
-
Central apnea
Apnea due to a loss of ventilation effort
-
Obstructive apnea
Due to blockage of the upper airway
-
If nasal flow decreasesand respiratoryeffort decreases then desaturation is a result of...
Central apnea
-
Chest tube placement for air
It is placed in the anterior chest up high
-
Chest tube placement for fluid
It is placed in the fourth or fifth intercostal space in the midaxillary line
-
Bronchoalveolar lavage
- This procedure is for the diagnosis and treatment of alveolar filling disorder
- Alveolar proteinosis
- Interstitial Pneumonitis
- Cystic fibrosis
- Pneumocystic pneumonia
-
Qualifications for a low flow system
- Tidal volume: 300-700
- Respiratory rate: less than 25
- Regular ventilator pattern
-
Nasal cannula
- Delivered FiO2: 24% - 45%
- Flow:1-6 L/min
- Most appropriate intial oxygen device for COPD patients with stable respiratory rates and tidal volumes
- For every 1 L/min, increase FiO2 by 4%
-
Simple mask
- Delivered FiO2: 40%-55%
- Flow: 6-10 L/min
- Flow must be at least 6 L/min to flush out exhaled CO2
-
Partial rebreather mask
- Delivered FiO2: 60%-65%
- Flow: 6-10 L/min
- Has no one way flap valve
-
Air entrainment mask/ Venturi mask
- Delivers precise FiO2 concentrations (ideal for patients wtih COPD)
- Ideal for patients with irregular tidal volumes rates and breathing patterns
- The FiO2 remains the same with increases or decreases in the flow threw the oxygen inlet
- The FiO2 will increase as the internal diameter of the gas injector increases or with increases resistance or obstruction downstream
- The FiO2 decreases as the size of the air entrainment ports are increased
- Total flow increases as the size of the air entrainment ports are increased
-
Oxygen hood
- Used with infants
- Flow range 7-14 L/min
-
Mist tent, oxygen tent, croupette
- Used for children
- Set flow at 12-15 L/min
-
Helium/oxygen therapy
- Decreases the patients work of breathing by delivering low density gas that can easily maneuver around obstruction
- Used for patients with
- increased airway obstruction
- Edema
- foreign
- foreign object obstruction
- partial vocal cord paralysis
-
Disinfection
Kill the bad guys
-
steralization
Kill everybody
-
Ethylene oxide sterilization
ETO
- IPPB machine
- Flowmeter
- non disposible resuscitation ag from a HIV room
-
Alkaline gluteraldehyde (Cidex)
- Disinfection or sterilization
- Appropiate method for resuable plastics
- (mouthpieces, tubing, nebulizers, humidifiers)
-
Routes of transmission of infection
- Contact
- Respiratory droplets
- Airborne droplet nuclei
-
Wright respirometers and other equipment used with multiple patients should have...
One way valves or personal sampling chambers to prevent cross infection
-
Prevention of ventilator associated pneumonia
- Use of close suction system
- Regular oral hygiene
- Keep patient's head elevated 30- 45 degrees
- Not routinely changing ventilator tubing condensate appropriately
- Use of heated wire circuits or HME to prevent tubing condensate
- Use of MDI instead of SVN
-
Pursed lip breathing
- Increased tidal volume
- Decrease respirate rate
- Decrease alveolar collaspe
- Prolong slow exhalation
- Most benificial for patients with emphysema
-
Huff coughing
- Coughing with an open glottis
- More effective in patients with COPD and in head trauma patients to prevent increased intercranial pressures
-
Liquid bulk oxygen system
For patients that are mobile
-
Oxygen concentrators
For patients that are home bound
-
COPD
Assessment
- Expiratory wheeze, barrell chest, clubing, and cyanosis
- Percussion note- resonant or hyperresonant
- Hyperlucency, hyperinflation, increased A-P diameter
- Compensated respiratory acidosis with hypoxemia and hypercapnia
-
COPD
Treatment
- Low flow O2 and aerosol therapy
- Rehab therapy (pursed lip breathing), proper nutrition and monitor fluids
- If a patient comes into ER in a full arrest- resuscitate with 100% O2
-
Pneumonia
Assessment
- Chills, fever, cought, purulent sputum, dyspnea,cyanosis, rales and rhonchi
- Scattered patchy opacity/ consildation on x ray
-
Pneumonia
Treatment
- Oxygen therapy if needed
- Bronchial therapy
- Antibiotics- Penicillin for gram negative infections, streptomycin, gentamycin and tobramycin for gram negative infections
- Mechanical ventilation if PaCO2 is above 45 and PaO2 is below 60
-
Pleural effusion
Assessment
- Dyspnea, chest pain, decreased breath sounds and dry no productive cough
- Mediastinal shift to the unaffected area
- Obiliteration of the costophrenic angle, unilateral basilar infiltrate with meniscus formation
-
Pleural effusion
Treatment
- Thoracentasis or chest tube drainage
- Antibiotics
-
ARDS
Assessment
- Respiratory distress with tachypnea and cyanosis
- Refractory hypoxemia, Increased A-a DO2 gradient and work of breathing
- X ray shows diffuse alveolar infiltrates in honeycomb/ ground glass pattern
-
Myasthenia Gravis
- Slow, fatigue improves with rest
- Monitor VC/MIP
- Neostigmine, pyridostigmine
- Intubation/ mechanical vent- short term
-
Guillain Barre syndrome
- Acute, sudden weakness
- Monitor VC and MIP
- Steriods Prophylactic antibiotics
- Mech vent/ Trach- long term
-
Emergency room treatment for acute Asthma attack should include:
- Oxygen therapy
- Aerosol therapy with SABA and Atrovent
- Oral steriods
- Close monitoring
- Intubation and mechanical Ventilation if respiratory arrest occurs
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