CRT

• Objective information, those things that you can see or measure
• Color
• pulse
• Edema
• Blood pressure

• sujective information, those things that the patient must tell you
• Dyspnea
• Pain
• Nausea
• Muscle weakness

Hypovolemia

Hypervolemia

Consider COPD O2 overdose or sleep apnea

• Responds inappropriately
• drug overdose
• Intoxication

Responds only to painful stimuli

• Drowsy state
• May have a decreased cough or gag reflex

• difficulty breathing except in the upright position
• Heart problem, CHF

• Caused by chronic hypoxemia
• Pulmonary disease

Convex curvature of the spine (lean foward)

Lateral curvature of the spine (lean side to side)

• Causes of Metabolic acidosis
• Renal failure
• Diabetic Ketoacisosis

• Hypoxemia
• Anxiety
• Stress

• Heart failure
• Shock
• Code/ emergency

• normal sound over the trachea or bronchi
• These breath sounds over the lung periphery would indicate lung consolidation

of a foreign body obstruction

Should be below the vocal cords and no closer than 2 cm or 1 in above the carnia

Atelectasis

• Solid white area
• Pneumonia or pleural effusion

• Extra pulomany air
• COPD
• Asthma attack
• Pneumothorax

CHF

Pneumothorax

Pulmonary edema

Pulmonary edema

Atelectasis

Pulmonary embolus

• 5-10
• Patient should be hyperventilated until PaCO2 is 25-30

• white/gray
• Chronic bronchitis

The patient is dehydrating

• Presence of WBC
• Bacterial infection

• Stagnant sputum
• Gram negative bacteria

Pulmonary edema

Give oxygen

oxygen and atropine

oxygen and Lidocaine

• Defibrillate if no pulse
• Lidocaine if pulse is present

Defibrillate

• 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

• 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)

• 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

going away from heart

towards the heart

fits into vallecula, indirectly raises epiglottis

Fits directly under the epiglottis

Short term ventilation and when intubation is not possible by the oral or nasal route (facial or nasal injuries)

Reintubate the patient

Oxygen, cool mist aerosol and racemic epinephrine to reduce swelling

Provide humidity, oxygen and/or racemic epinephrine as necessary

• Bronchiectasis
• Cystic fibrosis
• COPD
• Acute atelectasis
• Lung abscess
• Pneumonia
• Post operative
• Prolonged bedrest

Patient lying face down

Patient laying on spine (Best for post craniotomy patients)

• Best position for hypoxic patients
• obese patients with dyspnea
• Post op abdominal patients
• Patients with pulmonary edema

patients with very low blood pressure

Very obease patients with air hunger

Best position to prevent aspiration

• Coughing with an open glottis
• More effective in patients with COPD or head trauma to prevent increased intracranial pressure

• Improve secretion expectoration
• Reduce residual volume(decrease hyperinflation)
• Improve airway maintenance

• Trauma to mucosa
• Contamination
• Hypoxemia
• Bradycardia

• To relieve bronchospasm and mucosal edema
• To thin secretion that are thick and tenacious
• To humidify the respiratory tract
• To administer drugs

• Bronchospasm
• Secretion swelling
• Fluid overload
• Cross contamination

• Can deliver 100% body humidity
• Low risk of cross contamination because no particles are bein produced

Deliver Ribavirn for treating RSV

• Short term, temporarly use for improving oxygenation in patients with CO poisoning,
• pneumonia, post op atelectasis

• PO2
• Partial pressure of oxygen in sample

• PCO2
• Partial pressure of carbon dioxide in sample

• Patient is not ventilating
• Initiate ventilation or
• Remove/Decrease deadspace
• Increase current ventilation

• Ptient is ventilating but to much
• Dont put on mechanical ventilation
• Add deadspace (If PaO2 is acceptable) or
• Decrease ventilation (If PaO2 is high)

Shunting and you need to add PEEP

Reduce PEEP/CPAP

100% oxygen and hyperbaric oxygen therapy

• All of the sudden
• Increased deadspace
• VD/VT is increased

• Post op patients
• Bedridden patients
• Obesity
• Trauma

• Prevention
• Support ventilation
• Prevent further emboli with anticoagulant therapy

Increased oxygen affinity

Decreased oxygen affinity

• Using a large volume syrine (Super syringe)
• Standard syringe volume is 3.0 Liters

• Measure partial pressure of O2, displays FiO2 as %
• If unable to calibrate change fuel cell

• used to monitor and asses the rediness to wean ventilator patients
• Assesses the degree of respiratory muscle impairment in guillain barre and myasthenia gravis

Restrictive disease

restrictive lung disease

will provide important flow rates used to identify obstructive disease

• FEV₁
• FEV_200-1200
• FEF_25-75
• PEFR

obstructive disease

Obstructive disease

Then the patient has restrictive disease only

70%

• Measures the muscular mechanics of breathing
• Decreased with obstructive disease, increased airway resistance, decreased compliance

Minimun increase of 12% and 200 ml in the FEV₁

Suspected neck fracture

Alkaline gluteraldehyde (CIdex)

• Circuit is grossly contaminated
• Malfunctioning

• Apnea
• Acute ventilatory failure-not breathing enough
• Impending ventilatory failure-rising PaCO2, decreasing Vt,VC,MIP

• PIP increases
• Plateau pressure remains the same
• Raw= PIP-Ppl
• Common causes:
• Secretions in airway
• Bronchospasms
• Treatment:
• Suction
• Bronchodilator

• PIP increases
• Ppl Increases
• Common causes:
• Atelectasis
• Pulmonary edema
• ARDS
• Pneumonia
• Treatment:
• Increase PEEP

• PIP
• Rate
• I time
• PEEP
• Peak flow
• Tidal volume
• Inflation hold

• Patients requring high FiO2 and PEEP
• High PEEP
• High PIP
• Low PaO2 and Decreased compliance

• Reduce tidal volume to 4-6 ml/Kg
• Set respiratory rate between 10-12
• Consider permissive hypercapnia

The normal flow pattern for a pressure or pressure support breath

the normal flow pattern for a spontaneous breath

The normal flow pattern for a volume controlled breath

• Analgesics- Reduced sensation of pain (morphine)
• Sedatives-Decrease anxiety and promote relaxation (Versed, Ativan)
• Anesthetics- Reduces patients ability to perceive sensation (Propofol)

• SIMV/IMV- 4 breaths per minute
• FiO2- 0.40
• PEEP- 5 cm H2O

• 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

• Gastric distention- most common
• Pneumothorax
• Gastric rupture
• Cross contamination
• Aspiration

• Rib fractures
• Fractured sternum/Clavicle
• Contusions to the heart and or lung
• Lacerated liver and or spleen
• Pulmonary/fat embolism
• Pneumothorax/hemothorax

• 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

• Electrical shock delivered on the R wave of ECG
• Non leathal dysrhythmias suck as:
• Atrial fibrillation
• Atrial flutter
• Ventricular tachycardia with a pulse

• Emergency lethal cardiac dysrhythmias
• Pulseless ventricular tachycardia
• Ventricular Fibrillation

• 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

• Left ventricular failure and lung reaction
• Excessive fluid accumulates in the lungs and affects ventilation and espically oxygenation

• 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

• 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)

Deadspace disease (ventilation without perfusion)

• Post op
• Bedridden
• History of DVT
• long periods at rest

• 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

• Oxygen therapy 100%
• Anticoagulation therapy (heparin and Coumadin)
• Thrombolytic drugs, screens, surgery

• Decreased vocal fremitus, percussion note is hyperresonant or tympanic
• X ray shows hyperlucency without vascular markings and a flattened diaphragm

• 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)

• Sustained asthma attack unresponsive to bronchodilator therapy
• Will have marked affect on ventilation and oxygenation

• Diagnosis made by history
• Retractions and pulsus paradoxus
• ABG indicating respiratory acidosis or respiratory failure (PaCO2 >45)

• 100% O2 therapy via a non rebreathing mask
• Continuous bronchodilator therapy (Albuterol and ipratropium)
• Corticosteriods IV and Oral

• Head trauma
• Chest trauma
• Neck trauma
• Burn victims
• Near drowning

• Always atart with airway, breathing and circulation
• Administer 100% oxygen

• 100% O2 via non rebreathing mask
• Hyperbaric Oxygen

Pleural effusion

To have the patient sitting up and leaning foward

Apnea due to a loss of ventilation effort

Due to blockage of the upper airway

Central apnea

It is placed in the anterior chest up high

It is placed in the fourth or fifth intercostal space in the midaxillary line

• This procedure is for the diagnosis and treatment of alveolar filling disorder
• Alveolar proteinosis
• Interstitial Pneumonitis
• Cystic fibrosis
• Pneumocystic pneumonia

• Tidal volume: 300-700
• Respiratory rate: less than 25
• Regular ventilator pattern

• 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%

• Delivered FiO2: 40%-55%
• Flow: 6-10 L/min
• Flow must be at least 6 L/min to flush out exhaled CO2

• Delivered FiO2: 60%-65%
• Flow: 6-10 L/min
• Has no one way flap valve

• 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

• Used with infants
• Flow range 7-14 L/min

• Used for children
• Set flow at 12-15 L/min

• 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

Kill the bad guys

Kill everybody

• IPPB machine
• Flowmeter
• non disposible resuscitation ag from a HIV room

• Disinfection or sterilization
• Appropiate method for resuable plastics
• (mouthpieces, tubing, nebulizers, humidifiers)

• Contact
• Respiratory droplets
• Airborne droplet nuclei

One way valves or personal sampling chambers to prevent cross infection

• 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

• Increased tidal volume
• Decrease respirate rate
• Decrease alveolar collaspe
• Prolong slow exhalation
• Most benificial for patients with emphysema

• Coughing with an open glottis
• More effective in patients with COPD and in head trauma patients to prevent increased intercranial pressures

For patients that are mobile

For patients that are home bound

• 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

• 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

• Chills, fever, cought, purulent sputum, dyspnea,cyanosis, rales and rhonchi
• Scattered patchy opacity/ consildation on x ray

• 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

• 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

• Thoracentasis or chest tube drainage
• Antibiotics

• 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

• Slow, fatigue improves with rest
• Monitor VC/MIP
• Neostigmine, pyridostigmine
• Intubation/ mechanical vent- short term

• Acute, sudden weakness
• Monitor VC and MIP
• Steriods Prophylactic antibiotics
• Mech vent/ Trach- long term

• Oxygen therapy
• Aerosol therapy with SABA and Atrovent
• Oral steriods
• Close monitoring
• Intubation and mechanical Ventilation if respiratory arrest occurs