Common Respiratory Related Diseases

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Common Respiratory Related Diseases
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2015-07-18 13:18:26
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Common Respiratory Related Diseases
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  1. What is Emphysema?
    weakening and permanent enlargement of the air spaces distal to the terminal bronchioles
  2. Cause of Emphysema
    • -cigarette smoking (> 80% of all cases)
    • -genetic predisposition
    • -occupational exposure
    • -atmospheric pollutants
  3. Emphysema Assessment
    • -SOB: dyspnea graded on 5 point scale, pursed-lip breathing
    • -cough: productive
    • -Appearance of chest: barrel chest, increased A-P diameter
    • -Resp. pattern: accessory muscle usage
    • -Color: cyanotic
    • -Appearance of nail beds: clubbing
    • -Diagnostic chest percussion: hyperresonant/tympanic note
    • -Breath sounds: wheezing, diminished
    • -CXR: hyperlucent lung fields, depressed or flattened diaphragm, long and narrow heart, increased retro-sternal air space (lateral film)
    • -ABG: mild to moderate Emphysema - acute alveolar hyperventilation with hypoxemia / severe Emphysema - chronic ventilatory failure with hypoxemia
    • -Pulmonary fx: decreased flowrates (FEV1, FEF 25-75%, FEV1/FVC) and decreased DLCO
    • -CBC: increased RBC/Hb/Hct
    • -Sputum: may indicate bacterial infection
  4. Emphysema Treatment/Management
    • -Low flow (FiO2) oxygen therapy at 1-2 L/min (0.24-0.28)
    • consider oxygen conservation devices (i.e. reservoir cannula, transtracheal catheters, etc. for home use)
    • -Antibiotics as indicated by sputum culture
    • -Pulmonary Rehab and Home care
    • -Aerosolized medications (SABA, Anticholinergics, LABA, inhaled corticosteroids)
    • -Consider NIPPV for acute exacerbation of ventilatory failure
    • -Annual flu injection
    • -Smoking cessation programs and nicotine replacement therapy
    • -Pulmonary hygiene
  5. What is Chronic Bronchitis?
    characterized by daily productive cough for at least 3 consecutive months each year for 2 years in a row
  6. Cause of Chronic Bronchitis
    • -cigarette smoking
    • -pollution
    • -infection
    • -gastroesophageal reflux disorder (GERD)
  7. Chronic Bronchitis Assessment
    • -SOB: dyspnea graded on 5 point scale, pursed-lip breathing
    • -Cough: productive with purulent sputum
    • -Appearance of chest: barrel chest, increased A-P diameter
    • -Resp. pattern: accessory muscle usage
    • -Color: cyanotic
    • -Appearance of nail beds: clubbing
    • -Diagnostic chest percussion: hyperresonant/tympanic note
    • -Breath sounds: rales/wheezing, diminished
    • -CXR: hyperlucent lung fields, depressed or flattened diaphragm, enlarged or elongated heart
    • -ABG: mild to moderate Chronic Bronchitis - acute alveolar hyperventilation with hypoxemia / severe Chronic Bronchitis - chronic ventilatory failure with hypoxemia
    • -Pulmonary fx: decreased flowrates (FEV1, FEV1/FVC, and FEF 25-75%)
    • -CBC: increased Hb/Hct
    • -Sputum: may indicate infection
    • -Electrolytes: increased HCO3 (chronic ventilatory failure)
  8. Chronic Bronchitis Treatment/Management
    • -Pulmonary hygiene therapy
    • -Antibiotics for infection
    • -Oxygen for hypoxemia
    • -Aerosolized medications (SABA, Anticholinergics, LABA, Inhaled corticosteroids)
    • -Consider NIPPV for acute exacerbations of ventilatory failure
    • -Smoking cessation programs
    • -Reduce risk factors
    • What is Bronchiectasis?
    • chronic dilation and distortion of one or more bronchi as a result of excessive inflammation and destruction of bronchial walls, blood vessels, elastic tissue and smooth muscle. Can create an obstructive or restrictive pattern
  9. Cause of Bronchiectasis
    • -acquired
    • -congenital
  10. Bronchiectasis Primary Assessment
    • -Past med hx: recurrent pulmonary infections
    • -SOB: present, possibly pursed-lip breathing
    • -Cough: productive with purulent foul smelling sputum, hemoptysis and 3 layer sputum
    • -Appearance of chest: barrel chest, increased A-P diameter
    • -Resp. pattern: accessory muscle usage
    • -Color: cyanotic
    • -Appearance of nail beds: clubbing
    • -Diagnostic chest percussion: hyperresonant/tympanic note
    • -Breath sounds: wheezing, diminished
    • -CXR: hyperlucent lung fields, depressed or flattened diaphragm, enlarged or elongated heart
    • -ABG: mild to moderate Bronchiectasis - acute alveolar hyperventilation / severe Bronchiectasis - chronic ventilatory failure with hypoxemia
    • -Pulmonary fx: decreased flowrates (FEV1, FEV1/FVC, and FEF 25-75%)
    • -CBC: increased RBC/Hb/Hct
    • -Sputum: may indicate infection
    • -Special diagnostic tests: CT scan or bronchogram indicates a "Tree in winter" pattern
  11. Bronchiectasis Treatment/Management
    • -Pulmonary hygiene
    • -Antibiotics for infection
    • -Aerosolized medications (SABA, Anticholinergics, Inhaled corticosteroids)
    • -Surgical resection of involved segments if necessary
    • -Oxygen for hypoxemia
  12. What is Sleep Apnea?
    diagnosed in patients who have more than 5 episodes of apnea per hour during sleep over a 6 hour period
  13. Central Sleep Apnea
    caused by failure of the respiratory center of the brain to send signals to the respiratory muscles
  14. Obstructive Sleep Apnea
    caused by anatomic obstruction of the upper airway in the presence of continued ventilatory effort
  15. Sleep Apnea Assessment
    • -Past med hx: daytime sleepiness, insomnia at night, loud snoring with periods of apnea, morning headaches, hypothyriodism
    • -Physical appearance: obese, short stocky neck, large tongue
    • -CXR: may be normal or demonstrate right and/or left sided heart failure
    • -ABG: chronic ventilatory failure with hypoxemia (severe sleep apnea)
    • -Pulmonary fx: decreased volumes (TLC, VC, FRC)
    • With obstructive apnea a saw tooth pattern is seen on maximal inspiratory and expiratory flow volume loops
    • -Special tests: sleep study (polysomnography) results
    • */* if both nasal flow AND respiratory effort decrease then desaturation is caused by Central Apnea
    • */* if nasal flow decreased with an increase in respiratory effort then desaturation is caused by Obstructive Apnea
  16. Treatment/Management of Central Sleep Apnea
    • -Drug therapy: REM inhibitors (Vivactil), Carbonic anhydrase inhibitors (Diamox), Respiratory stimulants (Aminophylline, caffeine)
    • -Phrenic nerve pacer
    • -Nocturnal ventilation
  17. Treatment/Management of Obstructive Sleep Apnea
    • -Weight loss
    • -Sleep posture (lateral or upright)
    • -Oxygen therapy for hypoxemia
    • -NIPPV, nasal CPAP, BIPAP
    • -Oral surgery
    • -Tracheostomy
    • -Oral appliances
    • -Neck collar
  18. What is Asthma
    a chronic, inflammatory, obstructive, non-contagious airway disease with varying levels of severity and characterized by exacerbations. A reversible condition characterized by increased responsiveness of the small airways to stimuli
  19. Cause of Asthma
    • -external or environmental agents (triggers)
    • -infections
    • -exercise
    • -cold air exposure
    • -chemical exposure
    • -GERD
    • -sleep
    • -emotional stress
    • -PMS
  20. Asthma Assessment
    • -Past med hx: smoking, allergies
    • -SOB: pursed-lip breathing, chest tightness
    • -Cough: increased and productive with presence of eosinophils, Charcot-Leyden crystals, increased IgE levels
    • -Appearance of chest: increased A-P diameter during episode
    • -Resp. pattern: accessory muscle usage
    • -Color: cyanotic
    • -Diagnostic chest percussion: hyperresonant/tympanic note
    • -Breath sounds: wheezing, diminished
    • -Physical appearance: diaphoresis
    • -Vital signs: tachycardia, pulsus paradoxus
    • -CXR: during acute episode: flattened diaphragms, hyperinflation and some infiltrates (may develop pneumothorax)
    • -ABG: acute alveolar hyperventilation with hypoxemia, hypercarbia may occur in status asthmaticus
    • -Pulmonary fx: decreased flowrates (FEV1, FEV1/FVC, and FEF 25-75%), normal DLCO, Pre and post bronchodilator improvement (at least 12% and 200 mL increase in FEV1)
    • -Sputum: may indicate infection
  21. Asthma Treatment/Management
    • -Environmental control
    • -Oxygen therapy
    • -Bronchopulmonary hygiene
    • -asthma action plan based on peak flow monitoring
  22. Rescue Medications for Asthma
    • -SABA: albuterol, xopenex, pirbuterol
    • -Anticholinergics: ipratropium bromide, tiotropium bromide
    • controller medications for Asthma
    • -LABA: salmeterol, formoterol, serevent
    • - Inhaled corticosteroids: beclomethasone, budesonide, symbicort, pulmicort
    • -Mast cell stabilizers (for prevention): intal, cromolyn sodium, tilade, nedocromil
    • systemic medications for Ashtma
    • -Corticosteroids: Fluticasone (Flovent), Budesonide (Pulmicort)
    • Mometasone (Asmanex), Beclomethasone (Qvar), Ciclesonide (Alvesco)
    • -Leukotriene Modifiers: Montelukast (Singulair), Zafirlukast (Accolate), Zileuton (Zyflo)
    • -Xanthines: Aminophylline, Theophylline, caffeine
    • -Immunomodulators: Xolair
  23. Asthma triggers
    • should be eliminated, minimized, or avoided to prevent acute attacks
    • -Common triggers include
    • -cockroaches
    • -pet dander
    • -smoke/fumes
    • -fungus and dust mites
    • -certain foods
    • to eliminate triggers be sure to...
    • -kill cockroaches
    • -keep kitchen area clean
    • -apply bleach to mold and/or fungus
    • -place stuffed animals in the freezer to reduce dust mites
  24. emergency room treatment for acute Asthma episodes should include
    • -oxygen therapy
    • -aerosol therapy with a SABA and anticholinergic (i.e. albuterol and ipratropium bromide; consider continuous aerosol therapy)
    • -steroids (IV or oral)
    • -close monitoring
    • -intubation and mechanical ventilation if respiratory arrest occurs
    • -consider adjunct therapies: heliox therapy, magnesium sulfate, subcutaneous epinephrine
  25. Status Asthmaticus
    • Status Asthmaticus sustained asthma attack unresponsive to bronchodilator therapy. Will have marked affect on ventilation and oxygenation
    • assessment for Status Asthmaticus -diagnosis made by history
    • -retractions and pulsus paradoxus
    • -ABG indicating respiraotry acidosis or respiratory failure (PaCO2 > 45)
    • treatment for Status Asthmaticus -100% O2 therapy via a non-rebreathing mask
    • -continuous bronchodilator therapy (albuterol and ipratropium)
    • -corticosteroids - IV and oral
    • -mechanical ventilation - sedate, paralyze, control if necessary
  26. What are Rib fractures/ Flail chest/ Chest trauma
    involves any type of trauma to the chest wall (unintentional/accidental or intentional)
  27. Cause of Rib fractures/ Flail chest/ Chest trauma
    • -industrial accidents
    • -vehicle accidents
    • -falls
    • -violence
    • -surgery
  28. Rib fractures/ Flail chest/ Chest trauma Assessment
    • -Past med hx: history of injury
    • -SOB: shallow rapid respirations, severe chest pain
    • -Cough: possible hemoptysis
    • -Appearance of chest: bruising over area involved
    • -Resp. pattern: paradoxical chest movement - flail chest
    • -Color: cyanotic
    • -Diagnostic chest percussion: may have s/sx of pneumothorax (hyperresonant/tympanic note, tracheal shift away from affected side)
    • -Breath sounds: diminished over affected area
    • -CXR: increased opacity from lung compression, rib fractures
    • -ABG: acute alveolar hyperventilation with hypoxemia
    • -Pulmonary fx: decreased volumes and capacities (RV, ERV, TLC, FRC, etc)
  29. Rib fractures/ Flail chest/ Chest trauma Treatment and Management
    • -oxygen therapy for hypoxemia
    • -analgesics
    • -routine bronchial hygiene
    • -hyperinflation therapy (IS/SMI, IPPB, deep breathing and coughing exercises)
    • -prevention of pneumonia
    • -closely monitor for acute ventilatory failure
    • -severe cases: stabilization of chest wall, volume control ventilation (5-10 days), PEEP
  30. What is a Pneumothorax
    gas or free air accumulated in the pleural space
  31. Cause of Pneumothorax
    • -traumatic: obvious injury
    • -spontaneous: no obvious injury
  32. Pneumothorax Assessment
    • -Past med hx.: severe chest pain
    • -SOB: present depending on severity
    • -Appearance of chest: tracheal and/or mediastinal shift away from the affected side, increased volume on affected side, bruising over the affected area
    • -Resp. pattern: tachypnea
    • -Color: cyanotic
    • -Diagnostic chest percussion: hyperresonant/tympanic note
    • -Breath sounds: diminished or absent on affected side
    • -Physical appearance: possible diaphoresis
    • -Vital signs: tachycardia, pulsus paradoxus
    • -CXR: hyperlucency with absence of vascular markings on the affected side, tracheal shift to the unaffected side, depressed diaphragm, lung collapse
    • -ABG: acute alveolar hyperventilation with hypoxemia
  33. Pneumothorax Treatment and Management
    • -small pneumothorax (< 20% of lung collapsed) may only require bed rest and limited physical activity. Absorption usually occurs within 30 days
    • -large pneumothorax (> 20% of lung collapsed) should be evacuated by chest tube
    • -needle aspiration of the chest necessary if patient is unstable (bradycardia, hypotension, cyanosis, etc.)
    • -oxygen for hypoxemia
    • -hyperinflation therapy (IS/SMI, IPPB) after chest tube insertion
    • -mechanical ventilation with PEEP for acute ventilatory failure
    • -*trachea deviated* to opposite side, *hyperresonant* percussion note and decreased breath sounds on the affected side
    • -recommend insertion of chest tube
    • assessment of Pneumothorax -sudden onset of dyspnea with decreased breath sounds and tracheal shift *away* from the affected side
    • -decreased vocal fremitus, percussion note is hyperresonant or tympanic
    • -x-ray shows hyperlucency *without vascular markings* and a *flattened diaphragm*
    • treatment for Pneumothorax -give 100% O2 via non-rebreathing mask
    • -*immediate chest tube/thoracentesis*, or relieve pressure with needle and tubing inserted into pleural space (needle aspiration)
  34. What is a Hemothorax
    blood accumulated in the pleural space
  35. Cause of Hemothorax
    -traumatic: obvious injury
  36. Hemothorax Assessment
    • -Past med hx: severe chest pain
    • -SOB: present depending on severity
    • -Cough: hemoptysis
    • -Appearance of chest: tracheal and/or mediastinal shift away from the affected side, bruising over the affected area
    • -Resp. pattern: tachypnea
    • -Color: cyanotic
    • -Diagnostic chest percussion: flat/dull percussion note
    • -Breath sounds: diminished or absent on affected side
    • -CXR: increased radiodensity, tracheal shift away from the affected side
    • -ABG: acute alveolar hyperventilation with hypoxemia
    • -CBC: reduced RBC/Hb/Hct
  37. Hemothorax Treatment/Management
    • -thoraxcentesis or chest tube to drain fluid
    • -oxygen for hypoxemia
    • -hyperinflation therapy (IS/SMI, IPPB) after chest tube insertion
    • -mechanical ventilation with PEEP for acute ventilatory failure
  38. -*trachea deviated* to opposite side, *dull* percussion note and decreased breath sounds on the affected side
    -recommend insertion of chest tube
  39. What is Thoracic surgery
    any surgical procedure performed on structures within the throracic cavity
  40. Cause of Thoracic surgery
    • -lung repairs or resections
    • -tracheal/mediastinal repairs or resections
    • -pneumonectomy or lobectomy
    • -cardiac surgery (valve replacements, bypass grafts)
  41. Thoracic surgery Assessment
    • -Past med hx.: carcinoma, heart disease
    • -SOB: may be present
    • -Cough: non productive or may include hemoptysis
    • -Appearance of nail beds: clubbing with chronic hypoxemia
    • -Diagnostic chest percussion: may be dull/flat over affected area
    • -Breath sounds: may be diminished over affected area
    • -routinely perform pre-operative basic laboratory testing
    • -CXR: may be abnormal with lung pathology
    • -Pulmonary fx: may be abnormal with lung pathology
  42. Thoracic surgery Treatment/Management
    • -Pre-operative therapy: hyperinflation therapy (IS/SMI, IPPB)
    • -Post-operative therapy:
    • >hyperinflation therapy (IS/SMI, IPPB)
    • >prevention of infection
    • >monitor chest drainage systems
    • >observe for post-op complications such as sub-q emphysema, increased pressures on ventilator, decreased static lung compliance, hypovolemic shock (decreased hemodynamic values)
    • -Mechanical Ventilation if Indicated May require reduced tidal volume for patients undergoing lung resections or lobectomies*
  43. What is Head trauma/ Surgery
    any injury or surgical procedure performed on the skill and/or brain
  44. Cause of Head trauma/ Surgery
    • -traumatic brain injury
    • -tumors
    • -aneurysms
    • -cerebrovascular accidents (CVA)
    • -seizures
  45. Head trauma/ Surgery Assessment
    • -Past med hx: tumors, headaches, cranial bleeds, trauma, seizures, hemiparalysis, slurred speech
    • -Resp. pattern: irregular rhythm, Cheyne-Stokes breathing
    • -LOC: altered level of consciousness
    • -Pupillary response: abnormal
    • -Special tests: CT, MRI, PET scans
    • -Intracranial pressure monitoring: normal value 5-10 mmHg
  46. Head trauma/ Surgery Treatment/Management
    • -Oxygen therapy: maintain PaO2 level near 100 torr
    • -Mechanical ventilation:
    • >maintain PaCO2 level between 25-30 torr to reduce ICP
    • >minimize Paw by utilizing low PEEP and peak inspiratory pressures
    • >set low pressure and exhaled volume alarms appropriately
    • -Medications:
    • >barbiturates for sedation (Amytal Sodium,Butisol Sodium, Luminal, Nembutal Sodium, Phenobarbital)
    • >Mannitol to decrease ICP
    • >Dilantin for seizures
  47. What are Neck/Spinal Injury/ Surgery
    any injury or surgical proedure performed on the neck and/or spin
  48. Cause of Neck/Spinal Injury/ Surgery
    • -traumatic injury
    • -tumors
    • -spine deformities
  49. Neck/Spinal Injury/ Surgery Assessment
    • -Past med hx: fall, accidents, tumors
    • -Appearance of neck/spine: bruises over affected area
    • -Resp. pattern: may be apneic with severe damage to spine
    • -LOC: altered
    • -Special tests: CT, MRI scans
  50. Neck/Spinal Injury/ Surgery Treatment/Management
    • -Oxygen therapy: to treat or prevent hypoxemia
    • -Maintain patent airway:
    • >utilize modified jaw thrust technique
    • >check femoral pulse if neck brace is in place
    • >intubation: recommend using flexible bronchoscope
    • -*Support ventilation, oxygenation, circulation, and perfusion as indicated by bedside assessment and laboratory testing*
  51. Abdominal surgery/ Pre & Post operative
    any surgical procedure performed on structures within the abdominal cavity
  52. Cause of Abdominal surgery/ Pre & Post operative
    • -gall bladder
    • -colon
    • -uterine
    • -appendix
  53. Abdominal surgery/ Pre & Post operative Assessment
    • -Past med hx: abdominal pain, bleeding, family and social history
    • -Resp. pattern: may be tachypneic
    • -routinely perform pre-operative basic laboratory testing
    • -pre-op pulmonary function testing (basic spirometry testing)
  54. Abdominal surgery/ Pre & Post operative Treatment/Management
    • -Pre-operative therapy: hyperinflation therapy (IS/SMI, IPPB)
    • -Post-operative therapy:
    • >hyperinflation therapy (IS/SMI, IPPB)
    • >prevention of infection
    • >analgesics as needed
    • >observe for post-op complications: increased pressure on ventilator, decreased static lung compliance, hypovolemic shock (decreased hemodynamic values)
    • -*Mechanical ventilation if indicated*
  55. Laryngectomy
    • surgical removal of the larynx
    • following surgery, there is no longer a connection between the upper and lower airways, and the patient has a permanent stoma. The patient cannot be orally or nasally intubated. If mechanical ventilation is required, insert an ET tube into ___________
    • laryngectomy opening
  56. Cause of Laryngectomy
    • -carcinoma of the upper airway
    • -trauma
  57. Laryngectomy Assessment
    • -Past med hx: upper airway carcinoma
    • -routinely perform basic laboratory testing
  58. Laryngectomy Treatment/Management
    • -use meticulous suctioning technique (watch for bleeding/ clot post-op)
    • -a cool aerosol will help keep secretions thin in the early post-op period
    • -the laryngectomy tube is removed after 3-6 weeks, at that time the stoma is considered stable and permanent
    • -monitor basic laboratory tests
  59. ARDS
    an illness or injury that affects the lung compliance that includes a multitude of etiologic factors
  60. Cause of ARDS
    • -aspiration
    • -trauma
    • -drug overdose
    • -fluid overload
    • -inhalation of toxins and irritants
    • -shock
  61. ARDS Assessment
    • -Past med hx: aspiration, trauma, drug overdose, fluid overload, inhalation of toxins and irritants, shock
    • -SOB: elevated
    • -Cough: non productive
    • -Resp. pattern: tachypnea
    • -Color: cyanotic
    • -Diagnostic chest percussion: flat/dull note
    • -Breath sounds: bronchial, crackles
    • -CXR: diffuse alveolar infiltrates with a honeycomb or ground glass appearance, radiopacity
    • -ABG: refractory hypoxemia, acute alveolar hyperventilation with hypoxemia
    • -Pulmonary fx: decreased volumes and capacities (Vt, RV, FRC, TLC)
    • -Sputum: may indicate infection
    • -Special tests: hemodynamic monitoring reveals elevated PAP
  62. ARDS Treatment/Management
    • -*Treat underlying cause
    • -Oxygen therapy up to 60%, then add PEEP
    • -Titrate oxygen to below 60%, then reduce CPAP/PEEP when pt improves
    • -Closely monitor hemodynamics
    • -Hyperinflation therapy (IS/SMI, IPPB) for atelectasis
    • -Consider alternative modes of mechanical ventilation
    • >pressure control ventilation (PCV)
    • >inverse ratio ventilation (IRV)
    • >airway pressure release ventilation (APRV)
    • >pressure regulated volume control (PRVC)
    • >high frequency ventilation (HFV)
  63. ARDSNet ventilator protocol
    • -reduce tidal volume to 6 ml/kg
    • -maintain plateau pressure < 30 cmH2O
    • -recruitment maneuvers
    • ARDS a series of reactions leading to inflammation, resulting in a decrease in lung compliance, shunting, hypoxemia
    • assessment of ARDS -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
    • -decreased FRC, shunting and respiratory failure
    • treatment for ARDS -O2 therapy: adequate arterial oxygenation without high FiO2
    • -CPAP/PEEP therapy: to increase FRC and to decrease WOB
    • -titrate PEEP and FiO2 such that the FiO2 can be reduced below 60% (decrease FiO2 then PEEP)
    • -use IMV / SIMV with PEEP
    • -consider pressure control ventilation
  64. ARDS for patients with any neurological/neuromuscular disorder, watch for ventilatory failure by monitoring...
    • -tidal volume
    • -vital capacity
    • -maximum inspiratory pressure
  65. Guillian-Barre'
    rare disorder of the peripheral nervous system. Most likely an immune disorder that causes inflammation and deterioration of the patient's peripheral nervous system
  66. cause of Guillian-Barre' syndrome
    • -precise cause is unknown
    • -onset frequently occurs after a febrile illness (1-4 weeks)
  67. Guillian-Barre' Assessment
    • -Past med hx: febrile illness, often viral in nature
    • -Physical appearance: acute weakness, especially in the legs
    • -Resp. pattern: shallow breathing
    • -Breath sounds: diminished
    • -Spontaneous vent parameters: decreasing Vt, VC, MIP
    • -ABG: acute ventilatory failure with hypoxemia, watch for ventilatory failure (PaCO2 > 45 torr)
    • -Pulmonary fx: reduced volumes (FVC, VT)
    • -Special tests: lumbar puncture - high protein level in CSF, abnormal electromyography
  68. Guillian-Barre' Treatment/Management
    • -directed at stabilization of vital signs and supportive care
    • -initially patients should be managed in the ICU
    • -bedside monitoring (urinary cath, EKG and BP monitoring)
    • -closely monitor Vt, VC, MIP
    • -oxygen therapy for hypoxemia
    • -hyperinflation therapy (IS/SMI, IPPB)
    • -pulmonary hygiene
    • -plasmapheresis: severe cases only
    • -other treatment modalities:
    • >anti-coagulant therapy
    • >physical therapy
    • >corticosteroids
  69. Guillian Barre Syndrome etiology:
    • -delayed reaction to viral infection
    • -URI: present
    • -onset: acute, sudden weakness
    • -paralysis: ascending (ground to brain)
    • -diagnostic tests: spinal tap - protein in spinal fluid / monitor VC and MIP
    • -drugs/treatment: steroids, prophylactic antibiotics / mech vent or trach - long term / plasmapheresis
  70. Myasthenia Gravis
    chronic disorder of the neuromuscular junction that interferes with chemical transmission of acetylcholine
  71. Cause of Myasthenia Gravis
    • -related to circulating antibodies of the autoimmune system
    • -clinical manifestations are provoked by:
    • >emotional upset
    • >physical stress
    • >exposure to extreme temperature changes
    • >pregnancy
    • >febrile illness
  72. Myasthenia Gravis Assessment
    • -Past med hx: gradual onset of weakness, may have previous admissions for Myasthenia Gravis
    • -Physical appearance: general weakness that improves with rest, drooping eyelids (ptosis), double vision (diplopia), difficulty swallowing (dysphagia)
    • -Resp. pattern: shallow breathing
    • -Breath sounds: diminished
    • -Special tests: Edrophonium (tensilon challenge test), electromyography
    • -Spontaneous vent parameters: decreasing Vt, VC, MIP
    • -ABG: acute ventilatory failure with hypoxemia. Watch for ventilatory failure (PaCO2 > 45 torr)
    • -Pulmonary fx: reduced volumes (FVC, Vt
    • Myasthenia Gravis: tensilon challenge test - if Vt, VC, MIP, and weakness *improve* with Tensilon
    • -referred to as a Myasthenia Crisis, indicating more of this type of drug needs to be given
    • -maintenance drug therapy (anticholinesterase therapy, cholinesterase inhibitors) including:
    • >Prostigmine (Neostigmine)
    • >Pyridostigmine (Mestinon, Regonol)
    • Myasthenia Gravis: tensilon challenge test - if Vt, VC, MIP, and weakness *worsens* with Tensilon
    • -referred to as a Cholinergic Crisis, indicating too much of this type of drug has been given
    • -administer Atropine to reverse Tensilon
    • -Atropine will relieve symptoms of cholinergic crisis
  73. Myasthenia Gravis Treatment/Management
    • -closely monitor Vt, VC, MIP (intubate and institute mechanical ventilation when indicated)
    • -bedrest restriction and soft diet to reduce symptoms
    • -oxygen therapy for hypoxemia
    • -hyperinflation therapy
    • -pulmonary hygiene
    • -other treatment modalities:
    • >corticosteroids in severe cases
    • >adrenocorticotropic hormone
    • >thymectomy
    • >plasmapheresis
  74. Myasthenia Gravis -etiology:
    • - Auto-immune response
    • -URI: absent
    • -onset: slow, fatigue improves with rest
    • -paralysis: descending (mind to ground)
    • -diagnostic tests: positive Tensilon test / monitor VC, MIP (serial testing)
    • -drugs/treatment: Neostigmine, Pyridostigmine; intubation/mech vent- short term
  75. Drug Overdose
    the intentional misuse or accidental overuse of medication that exceeds the recommended medical dose
  76. Cause of Drug Overdose
    • -history is often the most significant finding
    • -mental illness (depression, addiction)
  77. Drug Overdose Assessment
    • -Past med hx: previous admission for overdose, found by family, friends, etc.
    • -Resp. pattern: slow, shallow respirations
    • -Physical appearance: altered level of consciousness
    • -Monitor results of basic laboratory testing
  78. Drug Overdose Treatment/Management
    • -placement of an artificial airway is the first priority
    • -mechanical ventilation for ventilatory failure
    • -Naloxone (Narcan) can be used to reverse a narcotic overdose
  79. Cerebral infarction/ Cerebrovascular accident (CVA)/ Transient ischemia attack (TIA
    area of the brain loses blood supply as a result of a vascular occlusion
  80. Cause of Stroke/ Cerebral infarction/ Cerebrovascular accident (CVA)/ Transient ischemia attack (TIA)
    • -cerebral thrombi or emboli (most common)
    • -atherosclerosis
    • -hypertension
  81. Cerebral infarction/ Cerebrovascular accident (CVA)/ Transient ischemia attack (TIA Assessment
    • -Past med hx: cerebral thrombi or emboli (most common), atherosclerosis, hypertension
    • -Resp. pattern: Cheyne-stokes respirations
    • -Physical appearance: motor and speech loss
    • -monitor results of basic laboratory testing
    • -Special tests: CT/MRI of the brain
    • -Intrancranial pressure monitoring: may be elevated
  82. Cerebral infarction/ Cerebrovascular accident (CVA)/ Transient ischemia attack (TIA) Treatment/Management
    • -treatment should be initiated within 6 hours of symptom onset
    • -drug therapy*
    • >anticoagulation therapy
    • >vasodilators
    • >thrombolytic therapy (for acute ischemic stroke)
    • -*mechanical ventilation for ventilatory failure or reduce ICP
  83. Poliomyelitis/ Tetanus/ Botulism/ Muscular dystrophy
    neuromuscular disorders that involve loss of voluntary muscle action
  84. Cause of Poliomyelitis/ Tetanus/ Botulism/ Muscular dystrophy
    • -viral infection (Polio)
    • -genetic disorder (Muscular dystrophy)
    • -puncture wound (Tetanus/Botulism)
  85. Poliomyelitis/ Tetanus/ Botulism/ Muscular dystrophy Assessment
    • -Past med hx: history of present illness, previous admission for disease
    • -Current medications: drug therapy for specific disease
    • -ABG: watch for ventilatory failure
    • -Spontaneous vent parameters: decreasing Vt, VC, MIP
  86. Poliomyelitis/ Tetanus/ Botulism/ Muscular dystrophy Treatment/Management
    • -closely monitor Vt, VC, MIP
    • -drug therapy
    • >paralyzing agents to relax jaw for intubation and ventilation in case of tetanus/botulism
  87. Unstable Angina
    form of acute coronary syndrome that results in reversible myocardial ischemia and is a sign of impending failure. Sudden cardiac death can occur
  88. Myocardial Infarction
    when coronary blood flow is interrupted for an extended period of time causing irreversible damage to the heart muscle. Sudden cardiac death can occur
  89. Cause of Chest Pain/ Myocardial Infarction
    • -heart disease
    • -hypertension
    • -thrombus
  90. Myocardial Infarction Assessment
    • -Past med hx: family, social, present illness, chest pain
    • -SOB: may be present
    • -Resp pattern: may be tachypneic
    • -Color: possible cyanosis
    • -Breath sounds: crackles if ventricular failure is present
    • -Physical appearance: diaphoretic, anxious, nauseous
    • -vital signs: elevated blood pressure, pulse
    • -ABG: hypoxemia
    • -Electrolytes: hyperkalemia or hypokalemia
    • -Special tests: cardiac enzymes (CPK, LDH, SGOT), troponin
    • -Electrocardiogram: arrhythmias with significant Q waves and S-T segment changes
  91. Myocardial Infarction Treatment/Management
    • -immediate oxygen therapy at 100%
    • -closely monitor vital signs
    • -drug therapy
    • >Atropine for bradycardia
    • >defibrillate for pulseless ventricular tachycardia or fibrillation
    • >Nitrates for chest pain
    • >Aspirin, anti-arrhythmic agents
  92. CHF
    Abnormal condition that reflects impaired cardiac pumping. Caused by myocardial infarction, ischemia heart disease, or cardiomyopathy
  93. Cause of Congestive Heart Failure
    • -myocardial infarction
    • -ischemic heart disease
    • -cardiomyopathy
  94. Pulmonary Edema
    Excessive movement of fluid from the pulmonary vascular system to the extravascular system (interstitial space) and air spaces of the lungs (alveoli)
  95. Cause of Pulmonary Edema
    • -Cardiogenic: increased pulmonary capillary hydrostatic pressure, usually due to CHF
    • -Non-cardiogenic: increased capillary permeability
  96. Primary Assessment of Congestive Heart Failure/ Pulmonary Edema
    • -Past med hx: gradual or sudden onset
    • -SOB: orthopnea
    • -Cough: pink, frothy secretions
    • -Resp. pattern: tachypneic
    • -Color: cyanotic
    • -Diagnostic chest percussion: increase tactile and vocal fremitus
    • -Breath sounds: crackles, rhonchi
    • -Physical appearance: pedal edema, diaphoresis, anxious
    • -Vital signs: tachycardia
    • -CXR: fluffy opacities, butterfly or bat wing pattern
    • -ABG: respiratory alkalosis with hypoxemia
    • -Pulmonary fx: reduced volumes and capacities, normal FEV1/FVC ratio
    • -Sputum: pink frothy secretions
    • -Electrolytes: decreased potassium and sodium
    • -Hemodynamics: increased PCWP, PAP
  97. Congestive Heart Failure/ Pulmonary Edema Treatment/Management
    • -immediate oxygen therapy at 100%
    • -closely monitor vital signs and place patient in Fowler's position
    • -IPPB with 100% oxygen
    • -mechanical ventilation with PEEP for ventilatory failure
    • Drug therapy
    • -Diuretics: to promote fluid excretion
    • >furosemide-Lasix
    • >Bumex
    • >Aldactone
    • -Positive inotropic agents:
    • >Digitalis
    • >Digoxin
    • >Dopamine
    • >low dose Amiodarone
    • -Analgesics/Sedative:
    • >Morphine
    • -Afterload reduction agents:
    • >Morphine
    • >Nitroglycerin
    • >Nitroprusside
    • >ACE inhibitors
    • -Electrolyte replacement:
    • >potassium
    • >sodium
  98. Pulmonary Edema/ Congestive Heart Failure Left ventricular failure and lung reaction. Excessive fluid accumulates in the lungs and affects ventilation and especially *oxygenation*
    • assessment for pulmonary edema/congestive heart failure -orthopnea, pitting edema, distended neck veins, and increased respiratory distress
    • -pink/frothy/watery secretions
    • -fine crepitant audible rale and crackles
    • -chest x-ray: fluffy infiltrates, butterfly or batwing pattern
    • treatment for Pulmonary Edema/Congestive Heart Failure -improve gas exchange: give 100% O2 via non-rebreather, IPPB with 100% O2 and PEEP or CPAP if necessary
    • -increase strength of heart contration (inotropy) - give digitalis
    • -decrease venous return - give lasix, body position (Fowler's)
  99. Treatment and management of arrymythias
    • -PVC: treat with oxygen and consider causes
    • -Ventricular fibrillation and pulseless Ventricular tachycardia: defibrillate at 360 joules
    • -Atrial flutter, fibrillation, and Ventricular tachycardia with a pulse: not immediately life threatening. Perform synchronized cardioversion starting at 50-100 joules
  100. Shock
    • occurs when the cardiovascular system fails to adequately perfuse tissues that results in widespead impairment of cellular metabolism. A reduction in blood flow to the tissues that is inadequate to sustain life
    • cause of Cardiogenic Shock
    • heart failure
    • cause of Neurogenic or Vasogenic Shock
    • alterations in vascular smooth muscle tone
    • cause of Anaphylactic Shock
    • hypersensitivity
    • cause of Septic Shock
    • infection
    • cause of Hypovolemic Shock
    • insufficient intravascular fluid volume
    • cause of Traumatic Shock
    • components of hypovolemic and septic shock
    • Primary assessment of Shock
    • -*Past med hx*: history of present illness
    • -*SOB*: increased
    • -*Resp. Pattern*: tachypnea
    • -*Color*: pale, cyanotic
    • -*Physical appearance*: cold, clammy, lethargic, unresponsive, nausea, dizzy, diaphoretic, poor capillary refill
    • -*Vital signs*: tachycardia, hypothermic, hypotensive
    • Secondary assessment of Shock
    • -*ABG*: hypoxemia
    • -*Hemodynamics*: decreased CVP, PAP, PCWP, Qt
    • -*Urine output*: decreased
    • treatment/management of Shock
    • -*mechanical ventilation for ventilatory failure*
    • -*drug therapy*
    • >vasopressors for vasogenic hypovolemia
    • >digitalis, digoxin for heart failure
    • >antibiotics for infection
    • -*treat hypovolemia*
    • >IV fluids
    • >Blood transfusion
  101. Cor Pulmonale
    consists of right ventricular enlargement (hypertrophy, dilation, or both) and is secondary to pulmonary hypertension from disorders of the chest wall or lungs
  102. Cause of Cor Pulmonale
    increased right ventricular workload as a result of pulmonary hypertension that results in hypertrophy of the right ventricle
  103. Cor Pulmonale Assessment
    • -clinical manifestations can be obscured by underlying respiratory disease and may only appear during exercise testing
    • -Past med hx: lung disease
    • -SOB: dyspnea
    • -Appearance of chest: increased AP diameter with obstructive lung disease
    • -Physical appearance: distended neck veins, chest pain, peripheral edema
    • Secondary assessment of Cor Pulmonale
    • -Hemodynamics: decreased Qt with exercise
    • -Electrocardiogram: right ventricular hypertrophy
  104. Cor Pulmonale Treatment/Management
    • -oxygen therapy
    • -closely monitor vital signs
    • -treat underlying cause
    • -decrease workload of the right ventricle by lowering pulmonary artery pressure
    • -drug therapy:
    • >Digitalis
    • >Diuretics
    • >Pulmonary vasodilators (Nitric oxide)
  105. Croup (LBT)
    • General term used to describe the inspiratory barking sound associated with the partial airway obstruction that develops in laryngotracheobronchitis (subglottic croup)
    • clinically the inspiratory sound heard in Croup is also called inspiratory stridor
    • LTB causes airway obstruction from tissue swelling just below the vocal cords
    • Croup is a viral infection that involves the upper and lower respiratory tract that cause subglottic edema
  106. Cause of Croup (LTB)
    caused by Parainfluenza viruses 1, 2, & 3, transmitted by aerosol droplets
  107. Croup Assessment
    • -Past med hx: recent cold that developed gradually into a barking cough over 2-3 days, most common in the fall and winter
    • -Cough: barking, hoarse voice
    • -Appearance of chest: use of accessory muscles during inspiration, substernal and intercostal retractions
    • -Resp. pattern: tachypnea
    • -Color: cyanosis
    • -Breath sounds: diminished, inspiratory stridor
    • -Physical appearance: age- 6 months to 6 years, alert with some accessory muscle usage
    • -Vital signs: increased HR, BP, Qt, low grade temperature
    • Secondary assessment of Croup (LTB)
    • -Lateral neck xray: haziness in the subglottic area (below the glottis), steeple point, pencil point, picket fence, hour glass narrowing of the upper airway
    • -ABG: acute alveolar hyperventilation with hypoxemia
  108. CroupTreatment/Management (Mild Cases)
    • -Supportive care:
    • >temperature control: cool environment
    • >adequate hydration and humidification of inspired air
    • >closely monitor: VS, degree of retractions, mental status, ventilatory and oxygenation status
    • -*Oxygen therapy 30-40%*
    • -*Cool aerosol mist (face mask, tent)*
    • -*Drug therapy*
    • >racemic epinephrine
    • >corticosteroids - for pts who *do not* respond to cool aerosol and racemic epinephrine therapy
  109. Croup Treatment/Management (Severe Cases)
    • (child with severe distress and/or marked inspiratory stridor)
    • -*Criteria for intubation*
    • >lethargic
    • >severe stridor at rest
    • >diminished breath sounds
    • >extreme accessory muscle usage
    • -Temperature control - cool environment
    • -Adequate hydration and humidification of inspired air
    • -Transfer pt to ICU
    • -Sedate if necessary
    • -Place on t-piece or CPAP
    • -Criteria for extubation
    • >child's condition is stable
    • >air leak around the tube (swelling has gone down)
  110. Epiglottitis
    • life threatening emergency caused by inflammation of the supraglottic region that includes the epiglottis, aryepiglottic folds, and false vocal cords that causes swelling just *above* the vocal cords
    • Cause of Epiglottitis
    • bacterial infection caused by Haemophilus influenza B (gram negative bacteria) transmitted by aerosol droplets
  111. Epiglottitis Assessment
    • -Past med hx: sudden onset within 6-8 hours
    • -Cough: muffled cough
    • -Appearance of chest: substernal and intercostal retractions
    • -Resp. pattern: tachypnea
    • -Color: pale or cyanosis
    • -Breath sounds: diminished, inspiratory stridor
    • -Physical appearance: 2-6 years of age, lifeless, drooling, hoarseness, inspiratory stridor, difficulty swallowing (dysphagia), tongue thrusts forward during inspiration, voice and cry muffled, jaw jutted forward
    • -Vital signs: high fever (measure axillary or tympanic to avoid stimulating the child), increased HR, BP, Qt
    • -avoid any unnecessary stimulation of the child
    • -diagnosis should be made at the bedside
    • Secondary assessment of Epiglottitis
    • -Lateral neck xray: haziness in the supraglottic area (epiglottis), supraglottic swelling (above the glottis) or "Thumb sign"
    • -ABG: acute alveolar hyperventilation with hypoxemia
    • -CBC: elevated WBC
  112. Epiglottitis Treatment/Management
    • -Immediate placement artificial airway
    • >endotracheal tube
    • >tracheostomy if unable to intubate (transfer pt to ICU, sedate if necessary, place on t-piece or CPAP)
    • -*Oxygen therapy*
    • -*Drug therapy*
    • >Antibiotics
    • -*Criteria for extubation*
    • >child's condition is stable
    • >swelling in the airway has diminished
  113. Pediatric poisoning /Ingestion of toxic substance
    • Accidental or intentional ingestion of a toxic substance
    • Pediatric poisoning is defined as occurring in patients under the age of 20
    • Commonly occurs in children less than 6 years of age and generally involves only one substance
  114. Accidental poisoning
    Commonly occurs in older children (> 6 years old). Frequently involves multiple substances and a delay in seeking medical treatment
  115. Intentional poisoning
    Commonly occurs in older children (> 6 years old). Frequently involves multiple substances and a delay in seeking medical treatment
  116. Pediatric poisoning /Ingestion of toxic substance Primary Assessment
    • -Past med hx: history of present illness most significant finding
    • -Color: pallor, cyanotic
    • -Physical appearance: varies according to substance ingested (vomiting, convulsions, diaphoresis, altered level of consciousness) pupillary reflex- dilated or constricted
    • Secondary assessment of Pediatric poisoning/ Toxic substance ingestion
    • -Chest xray: indicated for treatment
    • -ABG: indicated for treatment
    • -Electrolytes: indicated for treatment
    • -Special tests: information on the dose and type of poison ingested, renal and liver function tests, glucose level, anion gap calculation
  117. Pediatric poisoning /Ingestion of toxic substance Treatment/Management Pediatric Stabilization
    • - stabilization of the cardiovascular and respiratory systems including...
    • -maintenance of an airway, intubate when aspiration is possible
    • -monitoring
    • -full resuscitation
    • -venous access for drug administration
    • -appropriate weight measurement
    • -toxicology screening
  118. Pediatric poisoning /Ingestion of toxic substance Treatment/Management Pediatric Stabilization:
    • once stabilization of the cardiovascular and respiratory systems have been obtained, treatment goals include..
    • -prohibit further drug absorption
    • -improve elimination
    • -manage complications
  119. Pediatric poisoning /Ingestion of toxic substance Treatment/Management Pediatric *Decontamination*:
    • -remove all remaining toxins from the child's skin and mouth
    • -remove all saturated clothing
    • -utilize personal protective equipment
    • -gastrointestinal decontamination through the removal or dilution of gastric contents and the use of gastric absorptive agents
  120. Pediatric poisoning /Ingestion of toxic substance Treatment/Management Pediatric
    • -supportive care
    • -decontamination
    • -mechanical ventilation for ventilatory failure
    • -antidotes as indicated (acetylcysteine for acetaminophen, Narcan for narcotics, etc.)
  121. Cystic Fibrosis
    an inherited, genetic disorder involving the exocrine glands
  122. Cause of Cystic Fibrosis
    • -caused by mutation in a pair of genes located on chromosome 7
    • -production of protein called cystic fibrosis trans-membrane regulator (CFTR)
  123. Cystic Fibrosis Assessment
    • -Past med hx: family hx, recurrent respiratory infections
    • -SOB: dyspnea on exertion, pursed-lip breathing, use of accessory muscles of inspiration and expiration
    • -Cough: large amount of thick purulent secretions
    • -Appearance of chest: barrel chest
    • -Resp. pattern: tachypnea
    • -Color: cyanosis
    • -Appearance of nail beds: clubbing
    • -Diagnostic chest percussion: hyperresonant or tympanic note
    • -Breath sounds: diminished, crackles, wheezing
    • -Physical appearance: small for age, malnutrition, poor body development, meconium ileus of newborn, peripheral edema
    • -Vital signs: increased pulse, BP, and Qt
    • -CXR: translucent (dark) lung fields, depressed or flattened diaphragm, right ventricular enlargement, areas of atelectasis and fibrosis
    • -ABG: acute alveolar hyperventilation with hypoxemia
    • -Pulmonary fx: decreased flowrates (FEV1, FEF 25-75%, FEF 200-1200)
    • -CBC: elevated Hb and Hct concentrations
    • -Sputum: common for staphylococcus aureus, haemophilus influenzae, pseudomonas
    • -Special tests: sweat chloride test - chloride level > 60 mEq/L, CFTR gene analysis (2 confirmed mutation), Immunoreactive Trypsinogen test (IRT)
  124. Cystic Fibrosis Treatment/Management
    • -Airway clearance four times a day
    • >chest percussion and postural drainage
    • >exercise
    • >PEP therapy
    • >high frequency chest wall compression
    • >forced expiration technique (active cycle of breathing, autogenic drainage, huff coughing)
    • -Oxygen thearpy
    • -Drug therapy
    • >aerosol therapy
    • =bronchodilator
    • =mucolytics - Pulmozyme
    • =anti-inflammatory: Advair, Flovent, Pulmicort
    • >inhaled antibiotics
    • =Tobramycin
    • =Colistin
    • =Amikacin
  125. Bronchiolitis
    Acute infection of the lower respiratory tract, usually caused by the respiratory syncytial virus (RSV). Results in inflammation and obstruction of the small bronchi and bronchioles
  126. Cause of Bronchiolitis
    acquired in 1 in 10 infants younger than 2 years of age. Outcome is generally good
  127. Bronchiolitis Assessment
    • -Past med hx: age 3 months to 3 years
    • -SOB: dyspnea
    • -Cough: intermittent
    • -Appearance of chest: retractions
    • -Resp. pattern: tachypnea
    • -Breath sounds: I & E wheeze
    • -Physical appearance: nasal discharge, lethargic
    • -Vital signs: slight temperature
    • -CXR: hyperinflation with areas of consolidation
    • -ABG: hypoxemia
    • -Special tests: diagnosis determined by isolating the virus or its antigens in the patient's sputum, oropharyngeal or nasopharyngeal secretions
    • -Specimens obtained by nasopharyngeal aspiration, nasal swab, or nasal lavage
  128. Bronchiolitis Treatment/Management:
    • Prophylaxis recommended for infants:
    • -less than 2 years of age who require therapy for chronic lung disease
    • -born at less than 32 weeks gestation
    • -with congenital heart disease with cardiovascular compromise
    • Drug therapy
    • -antibodies against RSV
    • >Intravenous: RespiGam
    • >Intramuscular: Synagis
  129. Bronchiolitis Treatment/Management:
    • most cases are treated at home with
    • humidification and oral decongestants
  130. Bronchiolitis Treatment/Management: severe cases (for pts with apnea)
    • are hospitalized and treatment is directed at relieving the airway obstruction and hypoxemia by utilizing:
    • -systemic hydration
    • -oxygen therapy (hood, mist tent, nasal cannula)
    • -airway clearance
    • -ribavirin aerosol: given via small particle aerosol generator (SPAG) for RSV infection
  131. Bronchiolitis Treatment and Management: mechanical ventilation for impending or acute ventilatory failure – use
    low respiratory rate and long expiratory times
  132. Foreign Body Obstruction
    Sudden onset of airway obstruction caused by aspiration of a foreign object
  133. Cause of Foreign Body Obstruction
    highest incidence is among children between 6 months and 3 years from attempting to ingest a foreign object. A major cause of death in the home
  134. Foreign Body Obstruction Assessment
    • -Past med hx: sudden onset, survey scene for pieces of food, missing objects, etc.
    • -SOB: dyspnea
    • -Cough: violent
    • -Resp. Pattern: retractions, tachypnea
    • -Color: may be cyanotic
    • -Breath sounds: varies- absent to rhonchi, frank wheezing, sometimes unilateral
    • -Physical appearance: restlessness
    • -CXR: inspiratory and expiratory films indicate air trapping, hyperinflation and unequal ventilation
    • majority of items aspirated are radiolucent and cannot be seen on a chest film (i.e. food)
  135. Foreign Body Obstruction Treatment/Management
    • -bronchoscopy: rigid
    • -postural drainage with percussion
    • -aerosol therapy with bronchodilators
  136. Delivery Room Care
    • -clear airway first with bulb syringe
    • -dry infant and keep warm
    • -APGAR score: performed at 1 and 5 minutes after delivery
    • -as neonate's condition allows evaluate:
    • >history: family, mother, pregnancy, delivery
    • >gestational age
    • >weight
    • >general appearance: color, chest configuration
    • >breath sounds
  137. Delivery Room Care Treatment/Management
    • -action based on APGAR score
    • >0-3 resuscitate: CPR
    • >4-6 support: stimulate, warm, administer oxygen, assist ventilation
    • >7-10 monitor: routine care
  138. Apnea of Prematurity
    apnea caused by immature neurologic control of ventilation resulting in death
  139. cause of Apnea of Prematurity
    • immature central nervous system
    • Primary assessment of Apnea of Prematurity
    • -Past med hx: premature, episodes of central apnea
    • -Resp. pattern: periodic apnea, irregular
    • -Color: periodic cyanotic spells
    • -Vital signs: periods of bradycardia, variations in thermal regulation
    • -Special tests: polysomnography
    • -Risk factors: prone positioning, maternal smoking, bottle feeding
  140. Apnea of Prematurity Treatment/Management
    • -oxygen therapy 30-50% as indicated by oximetry
    • -methylxanthines (caffeine)
    • -teach parents/family CPR
    • -send infant home with an apnea monitor
  141. Meconium Aspiration
    Condition in which a fetus aspirates a mix of fetal stool (meconium) and amniotic fluid during episodes of fetal hypoxemia
  142. Cause of Meconium Aspiration
    • -occurs in 8-10% of all births
    • -occurs in full-term or post-term infants
    • -cannot be prevented even with the best maternal care
  143. Meconium Aspiration Assessment
    • -Past med hx: more common in post-term infants
    • -Appearance of chest: substernal retractions/abdominal distension (seesaw movement)
    • -Resp. pattern: grunting, retractions, nasal flaring, asphyxia, gasping with tachypnea, apnea
    • -Color: cyanosis
    • -Breath sounds: wheezes, rhonchi, crackles, expiratory grunting
    • -Physical appearance: low APGAR scores, stained with meconium
    • -Heart rate: tachycardia
    • Secondary assessment of Meconium Aspiration syndrome
    • -CXR: irregular densities throughout the lungs with atelectasis and consolidation
    • -ABG: acute alveolar hyperventilation with hypoxemia
  144. Meconium Aspiration Treatment/Management
    • -suction the nasopharynx and oropharynx thoroughly when amniotic fluid is stained
    • -stabilize infant and transfer to ICU
    • >vigorous pulmonary hygiene (postural drainage, percussion, suctioning)
    • >oxygen therapy
    • >mechanical ventilation
    • >drug therapy (antibiotics, steroids)
  145. Meconium Aspiration Treatment/Management vigorous, active, and crying (pulse > 100, strong RR, good muscle tone):
    • -suction mouth and nose to clear pharynx
    • -warm, dry, and observe
    • -blow-by oxygen as needed
  146. Meconium Aspiration if infant is not vigorous (pulse < 100, limp, depressed, poor tone, absent or gasping respirations):
    • -no positive pressure ventilation
    • -visualize vocal cords with laryngoscope
    • -intubate with a meconium aspirator and suction trachea
    • -repeat until airway is clear: even if pulse is low
    • -intubate and provide airway
  147. Congenital Heart Defects
    • -*cyanotic: right to left shunt (hypoxemia)*
    • >tetrology of fallot
    • >transposition of the great vessels
    • -*acyanotic: left to right shunt (pulmonary congestion)*
    • >atrial septal defect
    • >ventricular septal defect
    • >patent ductus arteriosus
  148. Congenital Heart Defects Primary Assessment
    • -Color: cyanosis
    • -Breath sounds: heart murmur
    • -Physical appearance: respiratory distress
    • -Chest x-ray: possibly en enlarged or abnormal shaped heart
    • -Echocardiogram is the most important diagnostic test to identify cardiac defects
    • -Pre and Post ductal blood gas studies: if the pre-ductal (right radial) PO2 is > 15 torr higher than the post-ductal (umbilical artery) PO2 then the pt has a right to left shunt
  149. Congenital Heart Defects Treatment/Management
    • -Oxygen therapy - maintain PaO2 levels between 60-80 torr
    • -Mechanical ventilation for ventilatory failure
    • -Supportive care prior to surgery to correct the defect
  150. IRDS
    also called Respiratory Distress Syndrome (RDS) or Hyaline Membrane Disease (HMD). Primarily associated with prematurity or high-risk infants
  151. Cause of IRDS
    caused by insufficient amount of pulmonary surfactant or depressed surfactant activity that leads to massive atelectasis and hypoxemia
  152. IRDS Assessment
    • -Past med hx: gestational age < 38 weeks, low APGAR scores, onset present at birth or within a few hours after delivery, L:S ratio < 2:1
    • -Appearance of chest: intercostal retractions
    • -Resp. pattern: tachypnea and possible apnea
    • -Color: cyanosis
    • -Breath sounds: bronchial or harsh, fine crackles/rales, expiratory grunting
    • -Physical appearance: nasal flaring, grunting, retractions
    • -Vital signs: increased HR, BP, Qt
    • Secondary assessment of IRDS
    • -CXR: increased opacity, ground glass appearance, air bronchograms
    • -ABG: acute alveolar hyperventilation with hypoxemia
  153. IRDS Treatment/Management
    • -Correct hypoxemia:
    • >oxygen via oxyhood or nasal cannula
    • >CPAP (4-6 cmH2O)
    • >maintain PaO2 between 60-80 torr
    • -Maintain a neutral thermal environment
    • -Surfactant replacement therapy: (survanta, infasurf, curosurf, pulmactant)
    • -mechanical ventilation for ventilatory failure (time cycled pressure limited ventilation) with PEEP
  154. BPD
    • -Chronic lung disorder characterized by bronchiolar metaplasis and interstitial fibrosis
    • -a chronic lung disease that develops in newborns as a consequence of treatment of IRDS with oxygen and positive pressure ventilation for primary lung disorder (i.e. IRDS)
  155. Cause of BPD
    • -*precise cause is unknown
    • -common factors include:*
    • >low gestational age and low birth weight
    • >mechanical ventilation with high airway pressure
    • >high oxygen concentrations
    • >history of IRDS
  156. BPD Assessment
    • -Past med hx: prematurity
    • -Appearance of chest: intercostal retractions
    • -Resp. pattern: increased > 60/min
    • -Color: cyanosis
    • -Breath sounds: wheezes, rhonchi, crackles, expiratory grunting
    • -Physical appearance: nasal flaring, substernal retractions/abdominal distension (seesaw movement)
    • -Vital signs: increased HR, BP, Qt
    • -premature infant who requires mechanical ventilation and doesnt improve
    • -continued need for high oxygen concentrations
    • -signs of respiratory distress (tachypnea, retractions)
    • -CXR: ground glass pattern, air bronchograms, small lung volumes, cardiomegaly and pleural effusion may be present
    • -ABG: acute alveolar hyperventilation with hypoxemia, develop hypercarbia later
  157. BPD Treatment/Management
    • -Oxygen therapy
    • -Hyperinflation therapy
    • -Pulmonary hygiene
    • -Mechanical ventilation for vent failure
    • -Ventilation and oxygenation should be maintained at the lowest possible level
    • -Drug therapy (bronchodilators)
    • -Monitor fluid balance
    • -Surgical ligation of PDA for infants who are difficult to wean. Infants may go home with oxygen therapy
    • -Supportive care to relieve symptoms of respiratory distress and heart failure
    • -Maintain blood gas values: PaO2 55-70, PaCO2 45-60, and pH 7.25-7.40
    • -Minimize mean airway pressures
    • -Extubation done at vent rates between 5-15 breaths/min
    • -Avoid endotracheal CPAP, bc of increased Raw and WOB that can be created
  158. Transient Tachypnea of the Newborn (TTNB)/ Type II IRDS
    Occurs within 24-48 hours after birth and produces symptoms similar to the early stages of IRDS
  159. Cause of Transient Tachypnea of the Newborn (TTNB)/ Type II IRDS
    • -precise cause is unknown
    • -believed to be caused by slow absorption of fetal lung fluid
    • -commonly seen in near-term or full-term infants of normal size and gestational age
  160. Transient Tachypnea of the Newborn (TTNB)/ Type II IRDS Assessment
    • -*Past med hx*: good APGAR scores at birth and then develop respiratory distress in the next 12 hours
    • -*Cough*: depressed effort, excessive secretions and mucus
    • -*Appearance of chest*: intercostal retractions, nasal flaring
    • -*Resp pattern*: increased rate > 60
    • -*Color*: cyanosis
    • -*Breath sounds*: wheezes, rhonchi, crackles, respiratory grunting
    • -*Vital signs*: increased HR, BP, Qt
    • -*CXR*: initialyl appears normal, sign of pulmonary congestion develops 12 hours after birth, patchy infiltrates, cardiomegaly and pleural effusion may be present
    • -*ABG*: Acute alveolar hyperventilation with hypoxemia
  161. Transient Tachypnea of the Newborn (TTNB)/ Type II IRDS Treatment/Management
    • -supportive care to relieve signs of respiratory distress
    • -oxygen therapy for hypoxemia
    • -CPAP to offset pulmonary congestion and interstitial edema
    • -Pulmonary hygiene (increased bronchial hydration, postural drainage and percussion, suctioning)
    • -mechanical ventilation for ventilatory failure is rare
    • -usually self limiting. Anatomic alterations in the lungs usually begin to resolve in about 24-48 hours after birth
  162. Congenital Diaphragmatic Hernia
    Occurs when the diaphragm does not completely form. Causes the abdominal contents to be in direct contact with the thoracic cavity
  163. Cause of Congenital Diaphragmatic Hernia
    • -occurs in 1 out of 2500 live births
    • -infants are usually mature
    • -more common in males
    • -90% of cases occur on the left through the foramen of Bochdalek
    • -mortality rate is 50% within 6 hours after delivery if not treated properly
  164. Congenital Diaphragmatic Hernia Assessment
    • -*Past med hx*: respiratory distress at birth, may be detected on prenatal ultrasound
    • -*Appearance of chest*: intercostal and substernal retractions, nasal flaring, expiratory grunting
    • -*Resp. pattern*: increased > 60/min
    • -*Color*: cyanosis
    • -*Breath sounds*: absent on affected side, bowel sounds on the affected side
    • -*Physical appearance*: scaphoid abdomen, barrel chest
    • -*Vital signs*: increased HR, BP, Qt
    • -*CXR*: fluid and air filled loops of intestine in the chest, shift of the heart and mediastinum toward unaffected side, atelectasis and complete lung collapse, hypoplastic left lung
    • -*ABG*: acute alveolar hyperventilation with hypoxemia
  165. Congenital Diaphragmatic Hernia Treatment/Management
    • -always an emergency
    • -prompt surgical repair is crucial
    • -as soon as diagnosis is made, insert an oral gastric tube to decrease gas in the bowel
    • -immediate oxygen therapy
    • -place infant on affected side
    • -do not ventilate with mask
    • -may require intubation and mechanical ventilation (use low PIP < 30 cmH2O, high frequency ventilation)
    • -ECMO for severe cases
  166. Exposure/Accidental Hypothermia
    marked cooling of core temperature (below 35 degrees Celsius)
  167. Cause of Hypothermia
    generally the result of sudden immersion in cold water or prolonged exposure to cold environments
  168. Hypothermia Assessment
    • -Past med hx: young or elderly persons, hypothyroidism, malnutrition, hypopituitarism, homeless
    • -Physical appearance: shivering, sluggish thinking and coordination
    • -Vital signs: decreased HR, RR, Qt, temperature, peripheral vasoconstriction
    • -ABG: moderate to severe acidosis with hypoxemia
    • -ABG is usually analyzed at 37 degrees Celsius
    • -If pt's body temperature is < 37 degrees Celsius, then the pt's actual values will show
    • > pH increased
    • >PCO2 decreased
    • >PO2 decreased
  169. Treatment/Management Mild Hypothermia
    • -*Passive warming may be sufficient*
    • >warm, dry clothes
    • >warm drinks
    • >isometric exercises to increase heat production
    • >check core temperature as soon as possible
  170. Treatment/Management Moderate Hypothermia
    • -*Active rewarming may be required*
    • >warm water baths
    • >warm blankets
    • >heating pads
    • >warm oral fluids when patient is alert
  171. Treatment/ManagementSevere Hypothermia
    • -*Active rewarming required*
    • -*Administration of
    • >warm IV solutions
    • >warm gastric lavage or peritoneal lavage
    • >inhalation of warm gases
  172. Pneumonia
    Result of an inflammatory process that primarily affects the gas exchange area of the lung causing capillary fluid (serum) to pour into the alveoli. This is termed effusion. If the infection becomes overwhelming it is termed consolidation
  173. Cause of Pneumonia
    • -extremely common
    • -causes include: bacteria, virus, fungi, tuberculosis, aspiration and inhalation
  174. Pneumonia Assessment
    • -Past med hx: initially mimics a cold or flu, s/sx may develop quickly
    • -SOB: may be present
    • -Cough: productive, yellow/green
    • -Appearance of chest: decreased expansion
    • -Resp. Pattern: tachypnea
    • -Color: cyanosis
    • -Diagnostic chest percussion: flat or dull
    • -Breath sounds: crackles, bronchial, whispered pectriloquy
    • -Physical appearance: diaphoretic
    • -Vital signs: increased HR, BP, Qt
    • -CXR: increased density from consolidation and atelectasis, air bronchograms, pleural effusion
    • -ABG: acute alveolar hyperventilation with hypoxemia
    • -Pulmonary fx: decreased volumes and capacities (Vt, VC, TLC)
    • -CBC: increased WBC with bacterial infection, decreased WBC with viral infection
    • -Sputum: gram positive or gram negative organisms
    • -Special tests: CT scan, acid fast stain for tuberculosis, ELISA test for HIV
  175. Pneumonia Treatment/Management
    • -Oxygen therapy
    • -Pulmonary hygiene therapy
    • -Hyperinflation therapy (IS/SMI, IPPB)
    • -Mechanical ventilation for ventilatory failure
    • -VAP protocol for intubated patients
    • -Drug therapy
    • >antibiotics
    • >aerosolized antiviral agents
    • -Thoracentesis
  176. Pneumonia Breakdown
    • Pneumonia infectious bacteria or virus enters the lung via inhalation or aspiration
    • assessment of Pneumonia -chills, fever, cough, purulent sputum, dyspnea, cyanosis, rales and rhonchi on auscultation
    • -WBC count: increased in bacterial, decreased in viral
    • -scattered patchy opacity/ consolidation on x-ray
    • treatment for Pneumonia -oxygen therapy if needed (pulse ox, ABG)
    • -bronchial hygiene
    • -antibiotics: penicillin for gram positive infections (staph and streptococcus), streptomycin, gentamycin, and tobramycin for gram negative infections (serratia, klebsiella, haemophilus, pseudomonas, E. coli, proteus)
    • -mechanical ventilation if PaCO2 > 45 torr and PaO2 < 60 torr
  177. treatment and management of Burns/ Smoke Inhalation/ Carbon Monoxide Poisoning
    • -immediate assessment of pt's airway and respiratory and cardiovascular status
    • -hyperbaric oxygen therapy for severe cases if available
    • -oxygen therapy at 100%
    • -evaluate depth and percent of burns
    • -immediate insertion of an IV line
    • -isolation room
    • -monitor ABG and electrolytes and fluid levels
    • -monitor for signs of infection
    • -bronchoscopy to clear airway and mucus plugs and evaluation of the upper airways
    • -mechanical ventilation for ventilatory failure
    • -pulmonary hygiene
    • -hyperinflation therapy (IS/SMI, IPPB)
    • -aerosolized medications (sympathomimetic and parasympatholytic agents, mucolytics, anti-inflammatory agents)
  178. CO poisoning
    • CO poisoning the inability of hemoglobin to bind with oxygen due to the binding of carbon monoxide. This can seriously affect oxygenation
    • assessment for CO poisoning -history of present illness will be important (fireman, smoke filled room, burning building, etc.)
    • -redness of the skin
    • -breathing labored and deep (tachypnea, hyperpnea)
    • -tachycardia with normal ABG
    • -increase COHb on co-oximeter ( > 20%)
    • -*Do Note* rely on pulse oximetry (SpO2)
    • treatment for CO poisoning  -100% via non-rebreathing mask, CPAP mask, etc.
    • -hyperbaric oxygen
  179. Near Drowning treatment/management of first responder/transport to hospital
    • -remove victim from the water and remove clothing
    • -follow basic life support algorithm for CPR
    • -oxygen therapy at 100%
    • -cover with warm dry blankets
    • -monitor vital signs
    • -if victim has been submerged for < 60 minutes, fixed dilated pupils do not necessarily indicate a poor prognosis
  180. treatment/management of Near Drowning Hospital
    • -intubation and mechanical ventilation with PEEP therapy for apneic victims or victims who cannot maintain a PaO2 of 60 torr on a FiO2 of 50% or lower
    • -inotropic agent
    • -diuretics
    • -chest tube insertion for pneumothorax or pneumomediastinum
    • -warming of the victim
    • >IV administration of heated solutions
    • >heated lavage of the gastric, intrathoracic, pericardial, and peritoneal spaces, or the bladder and rectum
    • >heated blankets
    • >warm baths
    • >ECMO for severe cases
    • -if neck injury is suspected, intubate patient with flexible bronchoscope
  181. treatment/management of Diabetic/Renal Failure
    • -Renal failure: carefully monitor intake and output, electrolytes, watch for signs of CHF
    • -Diabetic patients: closely monitor blood glucose levels, ABG, watch for signs of respiratory failure
  182. treatment/management of AIDS
    • -Do not order culture and sensitivity tests. PCP cannot grow outside of the body
    • -Utilize standard/universal precautions
    • -PCP infection is treated/prevented with Pentamidine (NebuPent) aerosol therspy. Most commonly a monthly treatment
    • -TB is endemic in this population
    • >positive AFB in sputum confirms active TB
    • >respiratory isoloation
    • >INH, Rifampin, Ethambutol, Steptomycin (18-24 months)
  183. treatment/management for Pulmonary Emboli
    • -Oxygen therapy at 100% to maintain PaO2 > 80 torr
    • -Closely monitor vital signs and ABG
    • -Coagulation studies
    • -Active and passive exercises
    • -Early ambulation
    • -Anti-embolism stockings
    • -Intermittent pneumatic compression devices
    • Drug therapy
    • -low dose heparin (IV,SQ), coumadin, dicumarol for anticoagulation
    • -analgesics to relieve chest pain
    • -Digitalis digoxin to maintain circulation
    • -thrombolytic agents: urokinase, streptokinase
    • Surgical options
    • -Embolectomy
    • -Vena cava interruption with sutures
    • -Greenfiled filter in IVC
  184. Pulmonary Embolism
    • Deadspace disease (*ventilation without perfusion*). Caused by blood clots in the lungs and will affect oxygenation and circulation
    • patients at risk for Pulmonary Embolism -post-op
    • -bedridden
    • -history of circulation problems (DVT)
    • -long periods at rest
    • assessment for Pulmonary Embolism -sudden onset of dyspnea, tachypnea
    • -patient appears to be hyperventilating (tachypnea) but is not (ABG show normal PaCO2)
    • -chest x-ray: *peripheral wedge shaped infiltrate*
    • -ventilation/perfusion scan or spiral CT scan - shows no perfusion with ventilation = deadspace disease
    • treatment for Pulmonary Embolism -oxygen therapy 100%
    • -anticoagulation therapy (heparin/coumadin)
    • -thrombolytic drugs/ screens/ surgery

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