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  1. 5 Therapeutic Objectives
    • 1. improve oxygenation
    • 2. inhaled medication
    • 3. lung reexpansion therapy
    • 4. mobilize secretions
    • 5. improve alveolar ventilation
  2. What to do if patient is SOB?
    • 1. position of comfort
    • 2. head of bed elevated 30 degrees
    • 3. trendelenberg avoided
  3. Present Illness
    • 1. what brings you here today?
    • 2. vital signs
    • 3. lab results
    • 4. imaging results
    • 5. PE
    • 6. medication hx
    • 7. progress notes
    • 8. differential dx
    • 9. advance directives
    • 10. integrate info -> what does it mean?
    • 11. determine course of action
  4. Dyspnea at rest?
    • diff
    • 1. cardiopulmonary disease
    • 2. severe lung disease
    • 3. cardiac failure
  5. Intrathoracic Sounds
    • 1. aeration: decreased in pneumonia
    • 2. wheezes: high pitched, primarily expiratory
    •     a. asthma
    •     b. COPD
    •     c. airway obstruction
    • 3. crackles/rales
    •     a. pulmonary edema
    •     b. pneumonia
    • 4. rhonchi
    •     a. secretions in large airways
  6. Extrathoracic Sounds
    • 1. high pitched
    • 2. inspiratory stridor
    • 3. usually concentrated in subglottic tissue
    • 4. in children: bacterial mediated epiglottitis
    • 5. swollen vocal cords
    • 6. in children: subglottic swelling: croup
    • 7. whooping: upper airway swelling
    •    a. infection in upper airway
    •    b. tumor
  7. Jugular Vein Distension
    suggests resistance to venous return
  8. Trachea deviates toward?
    • low volume
    •   a. atelectasis
    •   b. pneumonia
  9. Trachea deviates away from?
    tension pneumothorax
  10. Pendeluft Phenonenon
    paradoxical chest movement seen in untreated flail chest. flail segment moves in during inspiration and bulges during expiration.
  11. Weak pulse & fast heart rate?
    • a. hypovolemia
    • b. anaphylactic shock
  12. Heart Sounds: S1
    • lub-dub
    • closing of AV valves
  13. Heart Sounds: S2
    • lub-dub
    • closing of seminlunar valves
  14. Heart Sounds: S3
    • lub-dub-ta
    • may indicate fluid overload or CHF
  15. Heart Sounds: S4
    • ta-lub-dub
    • may indicate cardiac hypertrophy
  16. Normal Adult BP
    120/79
  17. Normal Child BP
    100/50
  18. Hypotension
    • <90/60
    • exsanguination
    • anaphylaxis
    • shock
    • pump failure
  19. Normal Serum Sodium
    135-145 mEq/L
  20. Normal Serum Chloride
    95-105 mEq/L
  21. Normal Serum Potassium
    3.5-5.0 mEq/L
  22. Normal BUN
    7-21 mg/dl
  23. Normal Creatinine
    0.6-1.2 mg/dl
  24. FVC
    maximum volume exhaled furing flow volume loop
  25. FEV
    • measured at 0.5, 1, 2,& 3 seconds
    • volume exhaled during a high velocity forced expiratory maneuver
  26. FEV1
    • flow divided by volume
    • normal > 80%
  27. Peak Expiratory Flow
    maximum velocity of gas at the peak of an FVC maneuver
  28. FEF 23-75
    • looks at the middle 50% of the VC maneuver
    • determines bd efficacy
  29. CO2 electrode
    Severinghaus
  30. O2 electrode
    Clark
  31. pH electrode
    Sanz
  32. Cooximetry
    measures O2 sat and O2 content (CaO2)
  33. CXR
    • ET tube placement
    • equal aeration
    • evidence of consolidation
    • hyoerinflation
  34. ET tube placement
    2-3 cm above the carina
  35. Normal Urine Output
    30 cc/hour
  36. Normal Capillary refill
    2 seconds
  37. Normal Serum Potassium
    3.5-5.0 mEq/L
  38. Normal Serum Magnesium
    1.3-2.5 mEq/L
  39. Normal Respiratory Rate
    8-24 bpm
  40. Tachypnea
    > 24 bpm
  41. Bradypnea
    < 8 bpm
  42. Normal Tidal Volume
    5-7 ml/kg
  43. Normal I:E Ratio
    1:2.5
  44. Prolonged I:E Ratio
    obstructive lung disease
  45. Decreased I:E Ratio
    restrictive lung disease
  46. Normal Pulmonary Compliance
    >100 cc/cm H2O
  47. Increased Airway Resistance
    • asthma
    • small ET tube
    • bronchospasm
  48. Normal Adult Pulse Ox
    95-99%
  49. Normal Child Pulse Ox
    91-96%
  50. Capnography
    continuous measurement of CO2 at the airway opening
  51. Transcutaneous PtcO2
    non-invasive estimate of PaO2
  52. Sinus Bradycardia
    <60/min
  53. AV Nodal Rhythm
    40-50/min
  54. 2 degree AV Block
    1/2 to 1/3 atrial rate
  55. 3 degree AV block
    <40/min
  56. Sinus tachycardia
    >100/min
  57. Premature Atrial Tachycardia
    >150-250/min
  58. Atrial Flutter
    250-350/min
  59. Atrial Fibrillation
    350-450/min
  60. Normal BP
    • systolic 95-140 torr
    • diastolic 50-90 torr
  61. Hypertension
    • systolic >140 torr
    • diastolic > 90 torr
  62. Hypotension
    • systolic <95 torr
    • diastolic <50 torr
  63. Left Arterial Pressure
    2-12 mm Hg
  64. Pulmonary Artery Systolic Pressure
    15-30 mm Hg
  65. Pulmonary Artery Dyastolic Pressure
    5-15 mm Hg
  66. Pulmonary Artery Pressure
    10-20 mm Hg
  67. Pulmonary Artery Wedge Pressure
    4-12 mm Hg
  68. Pulmonary Artery End Diastolic Pressure
    8-10 mm Hg
  69. Right Atrial Pressure
    4-6 mm Hg
  70. Right Ventricular End Diastolic Pressure
    0-8 mm Hg
  71. Central Venous Pressure
    • 2-6 mm Hg or
    • 2.5-12 cm H2O
  72. Cardiac Output
    = stroke volume x heart rate
  73. Cardiac Index
    • = CI/BSA
    • Normal = 2.7-4.3 L/m2/min
  74. Apgar Components
    • Color
    • Pulse rate
    • Grimace
    • Muscle Tone
    • Respiratory Effort
  75. Borg Dyspnea Scale
    • 0 = no dyspnea
    • 10 = severe dyspnea
  76. Pleural Effusion
    fluid in pleural space
  77. Hemothorax
    blood in pleural space
  78. Chylothorax
    chyle (from thoracic duct) in pleural space
  79. Empyema
    pus from infection in pleural space
  80. Hydrothorax
    thin fluid (from CHF or neoplasm) in pleural space
  81. Sponataneous Pneumothorax
    • Primary
    • no underlying lung disease
  82. Secondary Pneumothorax
    • underlying lung disease
    • asthma
    • COPD
    • CF
  83. Transudate
    • very low in protein & blood cells
    • CHF
    • Cirrhosis
    • Nephrotic Syndrome
    • Lymphatic Obstruction
    • Hypoalbunemia
    • Atelectasis
  84. Exudate
    • High in protein & blood cells
    • Bacterial Infection
    • Neoplastic Disease
    • Tuberculosis
    • Fungal Infection
  85. Indirect Calorimetry
    estimation of energy expenditure (caloric needs) by measurement of oxygen consumption & carbon dioxide production
  86. Respiratory Quotient
    • ratio of CO2 produced to O2 consumed
    • normal = 0.8
  87. Normal Intracranial Pressure
    5-15 mm Hg
  88. Treatment of High Intracranial Pressure
    • short-term hyperventilation
    • meds
  89. Glasgow Coma Scale: Mild Impairment
    13-15
  90. Glasgow Coma Scale: Moderate Impairment
    9-12
  91. Glasgow Coma Scale: Severe Impairment
    <8
  92. Components of Glasgow Coma Scale
    • eye opening
    • verbal response
    • motor response
  93. Acute Dyspnea: Children
    • asthma
    • croup
  94. Acute Dyspnea: Adults
    Pulmonary Embolism
  95. Chronic Dyspnea: Children
    CF
  96. Chronic Dyspnea: Adults
    CHF
  97. Signs of Respiratory Distress
    • nasal flaring
    • cyanosis
    • pursed-lip breathing
    • accessory muscle activity
  98. Apnea
    • cessation of breathing
    • respiratory or cardiac arrest
  99. Biot's
    • irregular respirations with apneic spells
    • high ICP
  100. Kussmaul
    • fast & deep respirations (>20 bpm)
    • metabolic acidosis
  101. Cheyne-Stokes
    • increasing/decreasing respiratory rate & volume with periods of apnea
    • CHF
    • CNS disorders
  102. Paradoxical Respirations
    • affected area of chest moves in opposite direction of rest of chest during respiration
    • trauma
    • diaphragmatic paralysis
  103. Tachypnea
    • fast, shallow respirations
    • anxiety
    • hypoxemia
  104. Bradypnea
    • abnormally slow (<12 bpm) respirations
    • sedation
    • hypoxemia
  105. Hyperpnea
    • abnormally deep respirations
    • fever
    • pain
  106. Hypopnea
    • shallow, slow breathing
    • sedation
  107. Digital Clubbing
    • enlargement of phlanges of fingers & toes
    • chronic CP disease
    • CF
    • bronchiectasis
    • COPD
  108. Vocal Frenitus
    • vibration caused by vocal cords during phonation;
    • access by having patient say "99"
    • increased: consolidation
    • decreased: bronchial obstruction, pneumothorax, pleural effusion, COPD
  109. Percussion
    • flat/dull: fluid from pleural effusion
    • hyperresonant: COPD
    • tympanic: pneumothorax
  110. Discontinuous Breath Sounds: Early Crackles
    • COPD
    • Asthma
    • Chronic Bronchitis
    • Emphysema
  111. Discontinuous Breath Sounds: Late Crackles
    • Pulmonary Edema
    • Atelectasis
    • Pneumonia
  112. DD: Tension Pneumothorax
    • Inspection: progressive cyanosis, distress, accessory muscle use;
    • Auscultation: distant breath sounds;
    • Palpation: tracheal displacement away;
    • Percussion: hollow, high-pitched
  113. DD: Pleural Effusion
    • Inspection: distress, accessory muscle use, asymmetrical chest expansion;
    • Auscultation: distant/absent breath sounds, E to A above effusion;
    • Palpation: reduced expansion affected side;
    • Percussion: flat to dull
  114. DD: Atelectasis
    • Inspection: distress, accessory muscle use;
    • Auscultation: wheezes/crackles, clear "99", E to A;
    • Palpation: asymmetrical unilateral expansion, increased vocal fremitus;
    • Percussion: dull
  115. DD: COPD
    • Inspection: accessory muscle use, tachypnea, tripod;
    • Auscultation: early crackles, expiratory wheezes, muffled "99";
    • Palpation: decreased vocal fremitus
    • Percussion: increased resonance to hyperresonance
  116. DD: Flail Chest
    • Inspection: distress, accessory muscle use, paradoxical inspirations;
    • Auscultation: absent/distant breath sounds;
    • Palpation: crepitus on affected side;
    • Percussion: dullness
  117. DD: Asthma
    • Inspection: accessory muscle use, tachypnea;
    • Auscultation: wheezing, early crackles;
    • Palpitation: symmetrical chest wall movement;
    • Percussion: increased resonance
  118. DD: Hemothorax
    • Inspection: distress, accessory muscle use, paradoxical respirations;
    • Auscultation: absent/distant breath sounds;
    • Palpation: crepitus, tracheal shift away
    • Percussion: dullness
  119. DD: Cardiac Tamponade
    • Inspection: accessory muscle use, jugular venous distension;
    • Auscultation: late crackles;
    • Palpation: paradoxical pulse;
    • Percussion: resonant
  120. CXR: Indications
    • SOB
    • Persistent Cough
    • Chest pain
    • Injury
    • Fever
  121. CXR: PA
    • standard view
    • able to obtain deep inspiration
  122. CXR: AP
    • bedside or portable
    • mediastinum is magnified
    • may not achieve deep inspiration
    • rotation issues
    • inferior quality to PA
  123. CXR: Lateral
    • used with PA/AP to localize masses, lesions, consolidation
    • COPD may result in increased retrosternal/retrocardiac air
  124. CXR: Lateral Decubitus
    further examination of pneumothorax
  125. CXR: Expiratory
    • look for small pneumothorax
    • FIB
  126. CXR: Apical Lordotic
    upward angled film to look at apical lung regions &/or middle lobe
  127. Lung Scan
    • ventilation/perfusion scan
    • evaluates circulation of air & blood within lung
    • ventilation looks at distribution of air
    • perfusion looks at distribution of blood
    • used to detect thrombi
  128. Pulmonary Angiography
    • F/U to uncertain scan or CT Angio
    • may use contrast
    • used to detect thrombi
  129. CT Lung Scan: Indications
    • bronchiectasis
    • pneumonia
    • COPD
    • emphysema
  130. High Resolution CT Lung Scan: Indications
    • guide needle aspiration of masses
    • catheter placement
  131. MRI Lung Scan: Indications
    • R/O pulmonary embolism
    • heart disease
    • lung tumors
    • pulmonary nodules
  132. Positron Emission Tomography (PET): Indications
    • detect Ca
    • check blood flow
  133. Endotracheal Tube Placement
    • 5-7 cm above carina
    • below vocal cords
    • C5-C6
  134. Tracheostomy Tube Placement
    • several cm above carina
    • parallel to tracheal walls
  135. Nasogastric Tube Placement
    • within stomach
    • 10 cm past gastro-esophageal junction
  136. Chest Tube Placement
    within pleural space
  137. Central Venous Catheter Placement
    within superior vena cava
  138. Pulmonary Artery Catheter Placement
    within main or lobar pulmonary artery
  139. Pacemaker Placement
    implanted in L thoracic area over pectoralis major muscle
  140. CXR: Air Bronchogram
    • Finding: bronchi surrounded by consolidated alveoli, linear branching air shadows, radiolucent;
    • Cause: pneumonia, pulmonary edema
  141. CXR: Hyperinflation
    • Finding: flattened diaphragm, elongated heart, increased retrosternal space, radiolucent;
    • Cause: COPD
  142. CXR: Atelectasis/Obstruction
    • Finding: absent ventilation, collapse of lobe or segment, radiopaque;
    • Cause: mucus plugs, aspiration
  143. CXR: Atelectasis/Compression
    • Finding: lung collapse from pleural space; radiopaque;
    • Cause: pleural effusion, pneumothorax, hemothorax
  144. CXR: Silhouette Sign
    • Finding: loss of border between structures; radiopaque;
    • Cause: pneumonia
  145. CXR: Pneumothorax
    • Finding: air in pleural space, visceral pleura outlines lung, mediastinum shifted with tension; radiolucent;
    • Cause: trauma, positive pressure, rupture of bleb
  146. CXR: Pneumomediastinum
    • Finding: radiolucent outline around heart & mediastinum;
    • Cause: air leak from alveoli, tracheal or esophageal rupture
  147. CXR: Diffuse Shadowing
    • Finding: bilateral & widespread, radiopaque;
    • Cause: ARDS
  148. CXR: Consolidation
    • Finding: patchy areas, radiopaque;
    • Cause: pneumonia
  149. CXR: Pulmonary Edema
    • Finding: ground glass appearance, air bronchograms, bilateral;
    • Cause: LHF (cardiogenic), pulmonary hypertension
  150. Silhouette Sign
    • on CXR:
    • Loss of RH Border: Middle Lobe Infiltrates
    • Loss of LH Border: LUL infiltrates
    • Loss of Anterior Hemidiaphragm: Anterior lower lobe infiltrates
  151. CXR: Pleural Effusion
    • Finding: whiteout of costophrenic angle, lober lobes meniscus sign, radiopaque;
    • Cause: CHF, pneumonia
  152. CXR: Cardiogenic Pulmonary Edema
    • Finding: Kerley's B Lines, pleural effusion (right), increased C/T ratio;
    • Cause: LHF
  153. CXR: Non-Cardiogenic Pulmonary Edema
    • Finding: air bronchograms, ground glass appearance, normal C/T ratio;
    • Cause: Pulmonary Hypertension, Aspiration
  154. CXR: Kerkey B Lines
    • Finding: lung periphery, radiopaque;
    • Cause: CHF
  155. CXR: Diffuse Shadowing
    • Finding: bilateral, widespread, radiopaque;
    • Cause: ARDS
  156. CXR: Pneumopericardium
    • Finding: rediolucent outline of heart;
    • Cause: penetrating trauma, thoracic surgery
  157. CXR: Subcutaneous Emphysema
    • Finding: radiolucent appearance in the neck, face, chest;
    • Cause: pneumothorax, barotrauma
  158. CXR: Croup
    • Finding: frontal & lateral neck xray - subglottal narrowing below vocal cords, church steeple appearance:
    • Cause: viral disease, parainfluenza
  159. CXR: Eppiglottis
    • Finding: laternal neck xray - inflammation & edema of the epiglottis, overdistension of the hypopharynx, aryepiglottic folds;
    • Cause: bacterial disease, haemophilus influenzae
  160. CXR: Foreign Body Aspiration
    • Finding: lateral xray - radiopaque object @ laryngeal level: PA film - radiopaque object in lung: lateral film - radiopaque object in front of or behind heart;
    • Cause: aspiration of food, nuts, fb
  161. Auto-PEEP
    • aka, air-trapping, dynamic hyperinflation;
    • signs: high Pplat, Increased WOB, hemodynamic effects, pneumothorax, difficulty triggering;
    • Rx: Reduce minute ventilation, treat lung function
  162. Cocci
    round shaped bacteria
  163. Diplococcus
    pair of round-shaped bacteria
  164. Tetrad
    groups of four round-shaped bacteria
  165. Streptococcus
    chain of round-shaped bacteria
  166. Staphylococcus
    cluster of round-shaped bacteria
  167. Spirochetes
    corkscrew-shaped bacteria
  168. bacilli
    rod-shaped bacteria
  169. diplobacillus
    pairs of rod-shaped bacteria
  170. Streptobacillus
    chains of rod-shaped bacteria
  171. Vibrio
    comma-shaped bacteria
  172. Gram-Positive Bacilli
    Corynebacterium diptheria
  173. Gram-Negative Bacilli
    • Klebsiella pneumonai
    • Hemophilus influenzae
    • Bordetella pertussis
    • Pseudomonas aeruginosa
    • Legionella oneumophila
    • Eschericia coli
  174. Acid-fast Bacilli
    • mycobacterium tuberculosis
    • nocardia
  175. Gram-Positive Cocci
    • streptococcus pyogenes
    • streptococcus pneumonae
    • staphylococcus aureus
  176. Gram-Negative Cocci
    • neissera meningitides
    • neissera gonorrhoea
  177. Bounding Heart Rate
    • fever
    • aortic regurgitation
  178. Weak Heart Rate
    • hypovolemia
    • heart failure
  179. Pulsus Paradoxus
    • abnormally large decrease in systolic BP during inspiration;
    • occurs in asthma & COPD
  180. CVP
    fillinf pressure in the RA
  181. Causes of Elevated Pulmonary Artery Pressure
    • LHF
    • primary lung disease
    • mitral valve disease
    • pulmonary embolism
    • hypoxemia w/ pulmonary vasoconstriction
    • idiopathic pulmonary arterial hypertension
    • L -> R shunts
  182. Causes of Elevated Pulmonary Wedge Pressure
    • LV volume overload
    • LV systolic dysfunction
    • Primary LV diastolic dysfunction
    • Myocardial ischemia or dysfunction
    • Mitral stenosis
  183. Tube-To-Shaft Trach Tubes
    short term cuff inflation (feeding, nocturnal-only ventilation)
  184. Endotrachial Tube Pressure
    air-filled: 20-30 cm H2O
  185. ECG: Indications
    • chest pain
    • SOB
    • dyspnea (esp. w/ palpitations)
    • diaphoresis
    • syncope
    • weakness or lethargy
  186. Analyze ECG Tracing
    • determine rhythm
    • examine PR interval (<5 small boxes, 0.2 sec.)
    • examine QRS complex (<2-3 small boxes, 0.12 sec.)
    • examine T wave (should be upright - inverted suggests ischemia)
    • examine ST segment (should be flat & < 1 mm above/below base line)
  187. Sinus Bradycardia
    • NSR but rate < 60
    • may be result of athletic conditioning
    • only a problem if clinical symptoms (low BP, fatigue, syncope)
  188. Atrial Fibrillation
    • atria "quivers
    • baseline erratic
    • no true P waves
    • may cause decreased CO & thrombi
    • Rx: digoxin, beta-blockers, cardioversion, coumadin, lovenox
  189. Ventricular Tachycardia
    • wide, bizarre QRS complexes
    • no P wave
    • ventricular rate of 100-250
    • may lead to V fib
    • Rx (cardioversion, anti-arrhythmics, implanted pacer/defib prn)
  190. Atrial Flutter
    • rapid atrial depolarization (250-350)
    • extra P waves for every QRS
    • QRS complex normal
    • Rx: digoxin, beta-blockers, cardioversion
  191. Ventricular Fibrillation
    • totally erratic, disorganized rhythm pattern
    • no CO
    • fatal if normal rhythm not quickly restored
    • Rx: ACLS protocol, anti-arrhythmic meds, implanted debib, cath w/ stents
  192. Transcutaneous Monitoring
    • continuous estimates of PO2 and PCO2
    • Heated Sensor
    • readings must be correlated with arterial gases
    • best application is neonates
    • useful for trending
  193. Transcutaneous Monitoring: Indications
    • need for continuous non-invasive monitoring
    • realtime quantification of interventions
    • monitoring PCO2 levels in adults undergoing general anesthesia
  194. Transcutaneous Monitoring: CI
    • very fragile skin (esp. neonates)
    • poor peripheral circulation
    • shock
    • skin allergy to adhesives
  195. Transcutaneous Monitoring: Interpretation
    • allow reading to stabilize (10-20 min)
    • correlate with blood gases
    • useful for trending
  196. Pulse Oximetry
    • uses light transmission through tissue
    • determines O2 sat and pulse
  197. Pulse Oximetry: Indications
    • need to monitor saturation levels
    • determine response to interventions
    • compliance with regulatory guidelines
    • considered standard of care
  198. Pulse Oximetry: CI
    • presence of significant levels of CO in blood
    • presence of significant levels of MetHb in blood
  199. Capnography
    • measures levels in CO2 in gases
    • usually applied to exhaled air
    • breath to breath monitoring
    • commonly used in mechanical ventilation
    • most common sensor is infrared absorption
  200. Capnography: Indications
    • evaluation of exhaled CO2
    • monitor severity of lung disease
    • monitor response to interventions
    • determining ET tube placement
    • monitor integrity of ventilator circuit
    • monitor effectiveness of mechanical ventilation
    • monitor inspired CO2 when used therapeutically
    • measure metabolic rate &/or alveolar ventilation
  201. Pplat =
    end inspiratory alveolar pressure
  202. Peak Inspiratory Pressure =
    • compliance
    • resistance
    • volume
    • flow 
    • PEEP
  203. Respiratory System Compliance =
    (Tidal Volume)/(Pplat - PEEP)
  204. Inspiratory Resistance =
    (PIP -Pplat) / Flow
  205. Compliance Decreases with:
    • mainstream intubation
    • CHF
    • ARDS
    • atelectasis
    • consolidation
    • fibrosis
    • hyperinflation
    • tension pneumothorax
    • pleural effusion
    • abdominal distension
    • chest wall edema
    • thoracic deformity
  206. Inspiratory Resistance Increases with:
    • secretions
    • bronchospasm
    • small ET tube
    • low lung volume (obstruction)
  207. Flow Volume Loop Detects:
    central & upper airway obstruction
  208. Bronchoprovocation Indications
    • asthma
    • work hx
    • bronchospasm
  209. Diffusing Capacity Indications:
    • parenchymal disease
    • CV disease
    • monitor chemotherapy effects
    • disability evaluation
  210. Exhaled Nitric Oxide is:
    index of airway inflammation
  211. Airway Inflammation can be measured with:
    exhaled nitric oxide test
  212. Exhaled Nitric Oxide Indications:
    • esosinophilic airway inflammation
    • monitor Rx effects
  213. What is preferred Rx for OSA?
    CPAP
  214. A lung volume is:
    • a single measurement
    • RV
    • ERV
    • Vt
    • IRV
  215. A lung capacity is:
    • more than one volume
    • FRC
    • VC
    • IC
    • TLC
  216. TLC =
    RV+ERV+Vt+IRV
  217. VC =
    ERV+Vt+IRV
  218. IC =
    Vt+IRV
  219. FRC =
    ERV+RV
  220. FRC Techniques
    • helium dilution
    • nitrogen washout
    • body plethysmography
    • imaging
  221. In Restrictive Disease, TLC is:
    decreased
  222. In Obstructive Disease, ERV is:
    increased
  223. In Obstructive Disease RV is:
    increased
  224. Normal IRV is what % of TLC?
    50%
  225. Normal Vt is what % of TLC?
    10%
  226. Normal ERV is what % of TLC?
    20%
  227. Normal RV is what % of TLC?
    20%
  228. Chest CT Indications
    • abnormal structures
    • pulmonary embolism
    • pulmonary contusion
    • FB aspiration
  229. Chest MR indications
    • mediastinum, large vessels
    • hilar region of lung
    • neoplasms
  230. Chest US Indications
    • evaluate cardiac function
    • locating vessels for placement of lines
  231. 3 Methods of Sputum Collection
    • induction
    • NT suctioning
    • bronchoalveolar lavage
  232. Sputum Collection Indications
    • identify pathogens from airway/lungs
    • evaluate abnormal cells
  233. Bronchoscopy Indications
    • lesions
    • recurrent pneumonia
    • collection of samples
  234. Bronchoscopy CI
    • refractory hypoxemia
    • bleeding disorders
    • unstable hemodynamics
    • elevated ICP
    • inability to sedate pt
  235. ECG Indications
    • evalaute chest pain
    • id rhythm disorders
    • evaluate rx
    • screen for chronic cardiac conditions
  236. Arterial Line Indications
    • need to continuously monitor BP
    • frequent need for arterial sampling
  237. CVP Indications
    • monitor CVP
    • assess tissue oxygenation
    • infuse drugs which cause phlebitis in peripheral veins
    • infuse TPN
    • venous access when peripheral access NA
  238. Pulmonary Artery Catheter
    • monitors pulmonary artery pressure
    • measures CO
    • measures L end-diastolic pressure
    • measures CVP
    • allows sampling of mixed venous blood
  239. ABG Indications
    • eval oxygenation
    • eval ventilation
    • eval acid-base status
    • monitor severity of disease
    • assess response to rx
  240. Pulse Oximetry Indications
    • continuous, realtime measurement of SpO2
    • monitor SpO2 during procedures
    • determine response to rx
    • comply with regs
    • standard of care
  241. Pulse Ox not accurate at:
    • low SpO2 levels
    • low perfusion states
  242. Transcutaneous Monitoring Indications
    • continuous monitoring of PaO2 & PaCO2
    • monitor response to rx
  243. Capnography Indications
    • assess effectiveness of ventilation
    • assess severity of pulmonary disease
    • monitor response to rx
    • measure metabolic rate
    • monitor levels of therapeutically administered CO2
  244. CBC Components
    • Hb
    • Hct
    • RBC count
    • WBC count & diff
    • Platelet count
  245. Increased HB, Hct, RBC count indicates:
    • polycythemia
    • chronic hypoxemia
  246. Decreased Hb, Hct, RBC count indicates:
    • anemia
    • compromised O2 transport
    • renal failure
  247. Increased WBC count indicates:
    bacterial infection
  248. Left Shift in Diff with increased neutrophils indicates:
    severe bacterial infection
  249. Very low WBC count indicates:
    overwhelming bacterial infection
  250. Elevated Sodium indicates:
    • dehydration
    • excessive diuresis
  251. Depressed Sodium indicates:
    • overhydration
    • renal faiure
    • severe vomiting/diarrhea
    • CHF
  252. Elevated Potassium indicates:
    renal failure
  253. Depressed Potassium indicates:
    • renal failure
    • severe vomiting.diarrhea
  254. Elevated Total CO2 indicates:
    ventilatory failure
  255. Increased BUN/Creatinine indicates:
    • renal failure
    • dehydration
  256. Elevated Lactate indicates:
    • anaerobic metabolism
    • sepsis
  257. Depressed Platlet Count indicates
    • thrombocytopenia
    • increased likelihood of excessive bleeding
  258. Elevated PT indicates:
    • abnormal clotting mechanism
    • increased likelihood of excessive bleeding
  259. Elevated PTT indicates:
    • abnormal clotting mechanism
    • increased likelihood of excessive bleeding
  260. Elevated D-Dimer indicates:
    • DVT
    • PE
    • likelihood of significant blood clot
  261. TB Skin Test Indications
    • recent exposure
    • R/O active TB
  262. TB Skin Test indications:
    • persistent productive cough
    • hemoptysis
    • night sweats
    • unexplained weight loss
    • chest pain
    • chills
    • fever
    • suspicious CXR
  263. Allergy Skin Testing Indications:
    • allergy to foods
    • allergy to meds
    • rhinitis
    • latex
    • dermatitis
    • insect venom
    • inhaled allergens
  264. Absolute Humidity =
    maximum amount of water vapor a gas can hold at a given temperature
  265. Relative Humidity =
    content over capacity at a given temperature
  266. Body Humidity =
    44 mg of H2O vapor
  267. Heat/Moisture Exchangers & Hygroscopic Condensation Humidifiers may be CI in:
    • pts with documented mucus production
    • CF
    • chronic bronchitis
    • bronchiectasis
    • due to increases in mechanical deadspace
  268. Nebulizers: Indications
    • delivery of meds
    • Rx/prevent humidity deficit
  269. Upper Airway Deposition Particle Size
    >10-15 microns
  270. Nasopharynx & Oropharynx Deposition Particle Size
    > 5 microns
  271. Lower Respiratory Tract Deposition Particle Size
    1-5 microns
  272. What delivery device is used for administration of pentamidine?
    Respirgard II
  273. ARDS Protocol
    • set ventilator to achieve Vt of 4-8 mL/kg IBW
    • Adjust Vt to achieve Pplat of <30 cm H2O
    • Adjust RR to achieve pH of 7.30-7.45 at a rate < 35 bpm
    • Adjust FiO2 to maintain SaO2 at 88-95%
  274. Non-Invasive Ventilation (NIV) Protocol
    • Titrate IPAP to pt comfort
    • Titrate FiO2 to SpO2 >90%
    • Titrate EPAP per trigger effort & FiO2
  275. Spirometry Indications
    • screening
    • dx
    • monitoring progression of disease
    • assessing disability
  276. Spirometry: to assure acceptability/repeatability:
    obtain >3 tests of acceptable effort
  277. Spirometry Acceptability:
    • good start
    • no hesitation or coughing during 1st second
    • FVC > 6 seconds w/ plateau of > 1 second
    • no valsalva manuever
    • no mouthpiece obstruction
    • FVC shows maximal effort
  278. Spirometry: BD Reversibility
    • >12% increase in FEV1 AND 200 ml improvement in FEV1; or
    • >12% increase in FVC AND 200 ml improvement in FVC
  279. Gas Cylinders
    • DOT certification
    • Maximum filling pressure of 2015 psi + 15% = 2200 psi
  280. Cylinder Factor
    • G or K: 3.14
    • E: 0.28
  281. Cylinder Duration
    (Current Current PSI x Factor) / lpm flow = duration in munutes / 60 = duration in hours
  282. Large Cylinder Regulators
    • hexagonal nut connection
    • American Standard Safety System
  283. Small Cylinder Regulators
    • yoke connection
    • Pin Index Safety System
  284. Safe Cylinder Pressure
    50 psi
  285. Components of regulator
    • reducing valve
    • flowmeter
  286. Wall Connections
    • 50 psi
    • Diameter Index Safety System
  287. Blenders
    used with HIGH FLOW devices (non-rebreathing masks & oxyhoods)
  288. Concentrators
    • 97% O2 at
    • 1-2 lpm
    • lower concentration @ higher flows
  289. Incubators
    • draft isolation
    • maintains normal core temperature
    • no increase in O2 consumption
  290. Sizing Oro- & Nasopharyngeal Tubes
    measure distance from lip to earlobe
  291. ET Tube Cuff Pressure
    <30 cm H2O
  292. Hemodynamic Monitoring Transducers MUST be
    level with the pts R atrium
  293. Arterial Catheter Indications
    multiple arterial blood draws
  294. Pulmonary Artery Catheter Indications
    • HF
    • Respiratory Distress
    • Shock
    • Assess effects of meds
  295. ECG Standard Leads
    • I, Ii, & III
    • bipolar - one positive & one negative electrode
  296. ECG Augmented Leads
    • aVR, aVF, aVL
    • unipolar leads
  297. ECG Lead I
    • L arm +
    • R arm -
    • Ground
  298. ECG Lead II
    • L leg +
    • R arm -
    • Ground
  299. ECG Lead III
    • L arm -
    • L leg +
    • R arm ground
  300. ECG Precordial Leads
    V1 - V6
  301. ECF Wandering Baseline
    • loose electrodes
    • body movement
    • sensing respiratory movement
    • cable not secure
  302. ECG AC or 60-Cycle Interference
    • wide baseline
    • inadequate grounds
    • damaged cable
    • cable parallel with any power cord
    • nearly high voltage source
    • defect in adjacent equipment
  303. ECG: AHA Method
    • is there a normal QRS?
    • is there a P wave?
    • what is the relationship between the P wave & the QRS complex?
  304. High Air Flow with Oxygen Enrichment (HAFOE)
    • meets/exceeds minute inspiratory volume
    • assures precise FiO2 @ < 60% O2
    • not appropriate when high FiO2 is required
  305. CPAP Indications
    • Rx/prevent airway closure
    • improve oxygenation
    • distend/recruit alveoli to rx/prevent atelectasis or penumonia
  306. Manometers
    measure pressure; gas or liquid
  307. Aneroid Manometers
    • vacuum chamber & diaphragm
    • respond to pressure change
    • accurate in prone position
  308. Water Manometers
    • glass tube partially filled with liquid
    • no moving parts
    • require no calibration
    • must be upright
  309. Digital Manometers
    • usually require power source
    • strain gauge sensing
    • convert mechanical motion into electronic signal
  310. Respirometers
    • flow sensing devices
    • used to measure bedside volumes or flows
    • use pneumotachometer
    • converts flows to volume
  311. Safe Suctioning Pressure: Adult
    < 150 mm Hg
  312. Safe Suctioning Pressure: Neonates
    80-100 mm Hg
  313. In a Pleural Drainage System, a continuous bubbling in the underwater seal column indicates:
    a leak
  314. Heliox
    • low density gas mixture
    • 80/20
    • 70/30
    • decreases WOB
    • decreases RR
    • decreases dyspnea
    • may decrease/forestall need for MV
  315. Heliox Administration
    • nonrebreather mask
    • high flows
    • aerosolized meds may be administered
  316. Oxygen Hood
    • flows > 7 lpm to prevent CO2 buildup
    • monitor temperature
    • monitor noise level
    • monitor oxygen level
  317. Incentive Spirometry Guidelines
    • IC < 33% predicted: IPPB or PEP
    • IC > 33% predicted: IS
  318. Contact Isolation Procedure
    • gloves
    • gown
  319. Droptlet Isolation Procedure
    • gown
    • gloves
    • surgical mask
  320. Airborne Isolation Procedure
    • gown
    • gloves
    • N95 mask
  321. Four Types of Sterilization
    • autoclave
    • ethylene oxide
    • ionizing radiation
    • incineration
  322. Ventilator-Associated Pneumonia Precautions
    • hand hygiene
    • mouth care
    • elevate head of bed
    • no routine circuit changes
    • avoid unnecessary antibiotics
    • use NIV when appropriate
  323. Types of Airways
    • Chin Lift & Thrust Maneuver
    • Oropharyngeal
    • Nasopharyngeal
    • Laryngeal Mask
  324. Mask Ventilation
    • can deliver high FiO2
    • avoids potential trauma of intubation
    • does not protect against aspiration
    • may result is gastric distension
    • laryngospasm can occur
    • requires use of both hands
  325. Potential Causes of Airway Obstruction
    • tongue
    • dentures
    • foodstuffs
    • vomit
    • blood
    • secretions
    • foreign bodies
  326. Mallampati Signs of Difficult Intubation
    • Class I: soft palate, uvula, fauces, pillars visible: no difficulty;
    • Class II: soft palate, uvula, fauces visible: no difficulty;
    • Class III: soft palate, base of uvula visible: moderate difficulty;
    • Class IV: only hard palate visible: severe difficulty
  327. Pre-Intubation Evaluation
    • prior hx of difficult intubation
    • tumor of head & neck
    • arthritis
    • pregnancy
    • trauma (C-spine)
    • full stomach
  328. Orotracheal Intubation: Advantages
    • quicker
    • avoids nasal trauma
    • allows for larger ET tube
  329. Orotracheal Intubation: Disadvantages
    • limited by neck mobility
    • May be poorly tolerated by patient
    • increased gag reflex
    • impairs swollowing
    • limits mouth care
  330. Nasotracheal Intubation: Advantages
    • Comfort
    • Mouth Care facilitated
    • ET tube is more secure
    • Less laryngeal injury
  331. Nasotracheal Intubation: Disadvantages
    • More difficult to perform
    • potential nasal trauma
    • ET tube needs to be smaller
    • Suctioning can be more difficult
  332. Miller Laryngoscope Blade
    directly lifts the epiglottis
  333. MacIntosh Laryngoscope Blade
    is placed in the vallecula
  334. Verification of Correct Endotrachial Tube Placement
    • symmetric chest wall movement
    • symmetrical breath sounds
    • EtCO2 > 30 for 3-5 breaths
    • condensation of water in the tube
    • palpation of cuff in suprasternal notch
    • CXR
    • fiberoptic bronchoscopy
  335. Complications of Orotracheal Intubation
    • dental &/or oral soft tissue damage
    • hypertension & tachycardia
    • cardiac dysrhytmias & myocardial ischemia
    • aspiration
    • corneal damage
  336. Complications of Oro/Nasotracheal Tubes
    • under-inflated cuff
    • over-inflated cuff
    • cuff rupture
    • mucus plugging
    • infection
    • tracheal fistula or erosion
    • obstruction
    • endobronchial intubation
    • unintended extubation
  337. Extubation Procedure
    • pre-oxygenate
    • suction ET tube & oropharynx
    • deflate cuff and withdraw the tube at end inspiration
    • place on humidified O2
    • observe for complications
  338. Extubation Complications
    • laryngospasm
    • aspiration
    • pharyngitis
    • karyngeal or subglottic edema
    • vocal cord paralysis
    • arytenoid cartilage dislocation
  339. Tracheostomy: Advantages
    • comfort
    • phonation
    • oral hygiene
    • decrease in airway resistance
    • easy to return to MV prn
  340. Tracheostomy: Disadvantages
    • surgical procedure
    • reinsertion may be difficult
    • potential infection site
  341. Tracheostomy: Indications
    • long term ventilation
    • inability to remove secretions
    • airway trauma
    • reduction of physiologic dead space & WOB
  342. Fenestrated Tracheostomy Tube
    • allows pt to breathe past tube via upper-airway
    • allows speech
  343. Single vs Double Lumen Tracheal Tube
    • double lumen allows for easy cleaning
    • single lumen has greater internal diameter
  344. Dangers of Underinflated Cuffs
    • may cause cuff to develop longitudinal folds
    • may promote microaspiration of secretions
    • may increase risk of nosocomial infection
  345. Dangers of Overinflated Cuffs
    • compression of mucosal capillaries
    • mucosal ischemia
    • tracheal stenosis
  346. Suctioning: Indications
    • secretions in tube
    • suspected aspiration of gastric or upper airway secretions
    • increase in peak airway pressure
    • increase in respiratory rate
    • sustained cough
    • decreases in ABG's
    • sudden onset of respiatory distress
  347. Tracheostomy Weaning
    • demostrate airway stability for 24 to 48 hours after MV
    • demonstrate ability to breathe around capped tube
  348. Difficult Airways
    • congenital syndromes (Down's, Pierre-Robin, Teacher-Collins)
    • infections
    • obesity
    • OSA
    • macro/microglossia
    • facial burns
    • facial/C-spine trauma
    • head/neck tumors
    • pregnancy
    • arthritis
    • hx of difficult intubation
  349. Intubation Options
    • alternative laryngoscope blades
    • awake intubation
    • laryngeal mask
    • invasive airway access
    • Mallampati IV requires fiberoptic intubation or video laryngoscopy
  350. Exchanging Airways
    • insert introducer into existing tube
    • remove existing tube
    • insert new tube over introducer
    • remove introducer
  351. Speaking Valves: Indications
    • awake, alert pt attempting to communicate
    • ability to generate sufficient expiratory flow
    • stable respiratory status
  352. Speaking Valve: CI
    • unconscious, comatose or sleeping
    • status post laryngectomy
    • ER tube
    • foam cuff trach tube
    • thick, copious secretions
    • severe airway obstruction
    • tracheal/laryngeal stenosis
    • upper/lower airway infection
  353. Speaking Valve Procedure
    • establish indications & lack of CI
    • deflate cuff (CI with foam cuff)
    • place speaking valve on tube
    • reconnect to ventilator, prn
    • monitor
    • remove speaking valve during aerosol rx
  354. Ventilator Associated Pneumonia
    • hand hygiene
    • elevate HOB >30 degrees
    • daily spontaneous breathing trial
    • oral care q 6-12 hrs
    • early enteric feeding
    • GI Bleed/DVT prophy
    • ensure cuff inflated
    • heated wire circuit humidification (not HME)
    • extubate ASAP
  355. Beta Agonists
    • Albuterol (AccuNeb, ProAir, Proventil HFA, Ventolin HFA)
    • Levabuterol (Xopenex, Xopenex HFA)
  356. Albuterol
    beta agnonist
  357. AccuNeb
    • albuterol
    • beta agonist
  358. ProAir
    • albuterol
    • beta agonist
  359. Proventil HFA
    • albuterol
    • beta agonist
  360. Ventolin HFA
    • albuterol
    • beta agonist
  361. Levalbuterol
    beta agonist
  362. Xopenex
    • levabuterol
    • beta agonist
  363. Xopenex HFA
    • levabuterol
    • beta agonist
  364. Anticholinergic Agents
    • Atropine
    • Ipratopium (Atrovent HFA)
  365. Atropine
    anticholinergic agent
  366. Ipratopium
    • Atrivent HFA
    • anticholinergic agent
  367. Atrovent HFA
    • ipratopium
    • anticholinergic agent
  368. Mucus Controlling Agents
    • N-Acetylcestine (Mucomyst)
    • Domase Alfa (Pulmozxme)
    • Aqueous aerosols
    • Hyperosmolar (7%) saline (Hyper-Sal)
    • Sodium bicarbonate
  369. N-Acetylcestine
    • Mucomyst
    • mucus controlling agent
    • available in 10% or 20% solution
    • breaks sulfide bonds to reduce viscosity
    • aerosol not been shown to be effective
    • may cause bronchospasm
  370. Mucomyst
    • N-Acertlcestine
    • mucus controlling agent
  371. Domase Alfa
    • Pulmozyne
    • mucus controlling agent
    • indicated for CF
    • improves lung function
    • improves secretion clearance
    • use with approved nebulizer
  372. Pulmozyne
    • Domase Alfa
    • mucus controlling agent
  373. Aqueous Aerosols
    mucus controlling agent
  374. Hyperosmolar (7%) Saline
    • Hyper-Sal
    • mucus controlling agent
    • Indicated for CF
  375. Hyper-Sal
    • hyperosmolar (7%) saline
    • mucus controlling agent
  376. Sodium bicarbonate
    mucus controlling agent
  377. Beta Agonists
    • bronchodilation
    • reduce airway resistance
    • increase expiratory flow rate
    • increase ciliary beat
    • increase mucus production
  378. Antichoinergic Agents
    • bronchodilation
    • reduce airway resistance
    • decrease mucus production
  379. Chest Physical Therapy
    • postural drainage
    • percussion
    • vibration
  380. Coughing Techniques
    • Huff cough
    • autogenic drainage
  381. High-Frequency Techniques
    • chest wall oscillation
    • intrapulmonary percussive ventilation (IPV)
  382. Positive Airway Pressure
    • insufflation-exsufflation
    • PEP therapy
    • Flutter Valve
    • Acapella
  383. Huff Cough
    • relaxed diaphragmatic breathing
    • deep breaths
    • forced expiration
  384. Autogenic Drainage
    • staged or varied breathing
    • secretions collect in central airways
    • large or Huff Cough to expel
  385. Chest Wall Oscillation
    • high frequency technique
    • commonly uses vest
    • variable frequency & pressure around torso
    • effectiveness in CF may be increased when inhaling Dornase Alfa during Rx
    • CPT with cough most effective in CF
  386. Intrapulmonary Percussive Ventilation (IPV)
    • small Vt delivered at high frequency
    • nebulizer can use used in line
  387. Insufflation-Exsufflation
    • Positive Airway Pressure Technique
    • positive pressure followed by negative pressure
    • used to stimulate cough
  388. PEP Therapy
    • Positive Airway Pressure Technique
    • alternative to CPT
    • prevention of atelectasis
    • can be used with mask or mouthpiece
    • can be used with inline nebulizer
    • common pressures 10-20 cm H2O
  389. Flutter Valve
    • Positive Airway Pressure Technique
    • combines PEP and oscillation of airway
    • performace varies with expiratory flow & angle in which it is held by the pt
  390. Acapella
    • Positive Airway Pressure Technique
    • similar to flutter valve
  391. Suctioning: Indications
    • pt unable to clear secretions
    • presence of secretions in airway
    • auscultation of coarse crackles
    • palpation of ronchial fremitus
  392. Suctioning: Hazards
    • hypoxemia
    • atelctasis
    • airway trauma/hemorrhage
    • arrthymias
    • infection
  393. Saline Installation
    • controversial suctioning technique
    • increased volume may worsen obstruction
    • may decrease oxygenation
    • may dislodge biofilm/bacteria from tube
    • use only if secreations cannot be mobilized
    • use saline to rinse catheter between uses
  394. Aerosol Therapy: Indications
    • need to deliver aerosolized med to lower airways
    • brochodilators
    • anti-inflammatory agents
    • antiasthmatics
    • mucolytics
    • antibiotics
  395. Small Volume Nebulizers MMAD
    MMAD = 1-5 microns
  396. Aerosol Rx in Children
    • use mask when tolerated
    • do not use blow-by
    • do not administer to crying child
  397. Metered Dose Inhalers MMAD
    MMAD = 40 microns but shrink as propellant evaporates
  398. Aerogen Nebulizer MMAD
    • new generation vibrating mesh technology
    • MMAD = 2-3 microns
  399. Metered Dose Inhalers: Indications
    • pt ability to follow instructions
    • ability to control breathing
    • adequate inspiratory capacity (>900 ml)
    • capable of inspiratory hold
    • stable ventilatory pattern
  400. Metered Dose Inhaler Spacer: Indications
    • minimizes oropharngeal deposition of meds
    • pts with poor hand-breathing coordination
  401. Directed Cough Technique
    • Forced expiratory technique (Huff Cough)
    • period of controlled relaxed diaphragmatic breathing
    • reinforced by self-compression of chest by arm adduction
  402. Directed Cough: Indications
    • retained secretions
    • atelectasis
    • prophy against PPC
    • routine in CF, bronchiectasis, chronic bronchitis, necrotizing infections, spinal cord injury
    • sputum induction
  403. Inspiratory Muscle Training Technique
    • exhale thru pursed lips
    • place hands on abdomen & concentrate on moving area out during inspiration
    • add nose clips
    • graduate adjust variable-sized opening to increase pts work of inspiratory muscles
  404. IPPB: Indications
    • improve lung expansion
    • need for short term rx of hypercapnia
    • deliver aerosolized meds
  405. Vehicles for Nebulized Meds
    • small volume nebulizer
    • breath actuated nebulizer
    • ultrasonic nebulizer
    • small particle aerosol generator
    • large volume nebulizer
  406. Meds Delivered by Endotracheal Instillation
    • Naloxone (reduce effects of opiods)
    • Atropine (anticholinergic: stablizes HR, Rx anaphylasis)
    • Vasopresin (antidiuretic: stablizes BP)
    • Epinephrine (catecholamine: stablizes BP, anaphylaxis)
    • Lidocaine (topical anesthetic; anti-arrhythmic)
  407. MV: Initial Vt
    4-8 ml/kg body weight
  408. MC: Initial Rate
    < 30 per minute
  409. MV: Initial Inspiratory Time
    < 1 second
  410. MV: Initial Peak Flow
    with volume ventilation: >60 lpm
  411. MV: initial Flow Waves
    Square or Decelerating (vol ventilation)
  412. MV: initial FiO2
    1.0
  413. MV: Initial PEEP
    5 cm H2O
  414. MV: Untriggered Breaths (Auto-PEEP)
    increase PEEP in 1-2 cm H2O steps until pt rate = vent rate
  415. MV: Inappropriate Pressure: Too Low
    increases pt demand & WOB
  416. MV: Inappropriate Pressure: Too High
    causes dyschrony, forced exhalation, air trapping & increased ventilatory demand
  417. MV: Improving Synchrony
    adjust triggering, rise time & cycling critera
  418. MV: Adjust Vent Settings: High pCO2
    • increase rate
    • increase Vt only if Vt <8 ml/kg
    • allow permissive hypercapnia
  419. MV: Adjust Vent Settings: Low pCO2
    • decrease Vt if Vt is >8 ml/kg
    • decrease rate
  420. MV: Adjust Vent Settings: High pO2
    • if FiO2 > 0.5, decrease FiO2, then decrease PEEP;
    • if FiO2 < 0.5, decrease PEEP then decrease FiO2
  421. MV: Adjust Vent SettingsL low pO2
    • if ARDS/ALI, increase PEEP, then increase FiO2
    • if not ARDS/ALI, increase FiO2
  422. MV: High Freq Vent: Initial MAP
    2-4 cm H2O above MAP during CMV
  423. MV: High Freq Vent: Initial Driving Pressure: Adults
    50-90 cm H2O
  424. MV: High Freq Vent: Initial Driving Pressure: Children
    30-50 cm H2O
  425. MV: High Freq Vent: Initial Driving Pressure: Neonates
    20-30 cm H2O
  426. MV: High Freq Vent: Adjust Settings: Oxygenation
    • MAP: directly related
    • Bias Flow: directly related
    • Inspiratory Time: directly related
  427. MV: High Freq Vent: Adjust Settingd: Ventilation
    • Frequency: inversely related
    • Driving Pressure: directly related
    • I:E Ratio: directly related
  428. CPAP: Initial Settings
    8-12 cm H2O
  429. CPAP: Therapuetic Range
    5-15 cm H20
  430. 6 Reasons For Changing Ventilators
    • poor gas delivery performance
    • lack of mode availability
    • inadequate monitoring
    • lack of adequate NIV capabilities
    • lack of battery life
    • lack of age-specific ventilation capabilities
  431. Define Mechanical Deadspace
    The amount of rebreathed volume between the airway and the Y of the circuit.
  432. Why is deadspace normally applied?
    To avoid stress on the airway.
  433. Every 6 inches of deadspace adds how much deadspace volume?
    ~50 ml
  434. What occurs in apenic pts when deadspace is added?
    PaCO2 ↑
  435. Elimination of deadspace in apneic pts results in?
    PaCO2 ↓
  436. In spontaneously breathing pts, addition or elimination of deadspace affects what?
    WOB
  437. When is deadspace most commonly used?
    In spinal cord injuries where pts desire very large Vt
  438. Criteria for assessment to D/C MV.
    • adequate oxygenation
    • hemodynamically stabile
    • very low doses of vasopressors ok
    • spontaneous respiratory effort
  439. Management of Auto-PEEP
    • appropriate level of ventilation
    • bronchial hygiene
    • aerosolized bronchodilators
    • apply PEEP if a result of dynamic airway obstruction
  440. PEEP: Assisted Ventilation
    • if Auto-PEEP measured, set PEEP @ 70-80% of measured level
    • If Auto-PEEP unmeasured, set PEEP @ 5 cm H2O
    • If untriggered breaths still present, increase PEEP in 1-2 cm H2O increments until pt rate & vent response are equal
  441. Reduction of Pressure Plateau
    • accept permissive hypercapnia
    • reduce Vt if > than 6 ml/kg
    • recruit the lung
    • measure esophageal pressure to assure plateau pressure reflects transpulmonary pressure
    • eliminate pleural effusions
    • decompress the abdomen
    • decompress any pneumothorax
  442. Racemic Epinephrine
    • type: β=agonist
    • trade: microNephrin, S2
    • mode: vasoconstriction
    • route: svn
    • indication: ↓ airway inflamation (stridor, croup, extubation)
    • adverse: tremors, nausea, headache, tachycardia
    • c/i: hypersensitivity
  443. Isoetharine
    • type: β-agonist
    • trade: Isoetharine HCl
    • mode:bd
    • route: svn
    • indication: short-acting bd
    • adverse: tremors, nausea, headache, tachycardia
    • c/i: hypersensitivity
  444. Metaproterenol
    • type: β-agonist
    • trade: Alupent
    • mode:bd
    • route:mdi, svn, tablet, syrup
    • indication: short-acting bd
    • adverse: tremors, nausea, headache, tachycardia
    • c/i: hypersensitivity
  445. Albuterol
    • type: β-agonist (selective β-2 receptors)
    • trade: albuterol sulfate, ProAir, Ventolin, Proventil
    • mode: bd
    • route: mdi, svn, tablet, syrup
    • indication: short-acting bd
    • adverse: tremors, nausea, headache, tachycardia
    • c/i: hypersensitivity
  446. Levalbuterol
    • type: β-agonist (selective β-2 receptors)
    • trade: Xopenex, Xopenex HFA
    • mode: bd
    • route: svn, mdi
    • indication: short-acting bd
    • adverse: tremors, nausea, headache, tachycardia
    • c/i: hypersensitivity
  447. Pirbuterol
    • type:β-agonist
    • trade: Maxaire Autohaler
    • mode: bd
    • route: mdi
    • indication: short-acting bd
    • adverse: tremors, nausea, headache, tachycardia
    • c/i: hypersensitivity
  448. Salmeterol
    • type: β-agonist (selective β-2 receptors)
    • trade: Serevent
    • mode: bd
    • route: dpi
    • indication: long-acting bd
    • adverse: tremors, nausea, headache, tachycardia
    • c/i: hypersensitivity
  449. Formotoral
    • type: β-agonist (selective β-2 receptors)
    • trade: Foradil
    • mode: bd
    • route: dpi
    • indication: long-acting bd
    • adverse: tremors, nausea, headache, tachycardia
    • c/i: hypersensitivity
  450. Ipratroppium bromide
    • type: anticholinergic/xanthine
    • trade: Atrovent, Atrovent HFA
    • mode: bd
    • route: svn, mdi
    • indication: maintenance COPD/asthma exaccerbations
    • adverse: dry mouth, cough, pharyngitis
    • c/i: pts w/ peanut allergy
  451. Tiotropium bromide
    • type: anticholinergic/xanthine
    • trade: Spiriva
    • mode: bd
    • route: dpi
    • indication: COPD maintenance
    • adverse: dry mouth, cough, glaucoma
    • c/i: hypersensitivity
  452. Theophylline
    • type: anticholinergic/xanthine
    • trade: Theo-dir, Theoair
    • mode: inhibits phosphodiesterase
    • route: tablets, capsules, syrup
    • indication: maintenance asthma & COPD
    • adverse: tremor, nausea, headache, vomiting
    • c/i: liver/kidney dx
  453. Aminophylline
    • type: anticholinergic/xanthine
    • trade: aminophylline
    • mode: inhibits phosphdiesterase
    • route: tablet, oral liquid, injection
    • indication: maintenance asthma & COPD
    • adverse: tremor, nausea, vomiting, headache
    • c/i: none
  454. N-acethylcysteine
    • type: mucolytic
    • trade: Mucomyst
    • mode: disrupts disulphide bonds
    • route: svn
    • indication: mucus clearance
    • adverse: bronchospasm
    • c/i: pts w/ FEV1 <25%
  455. Dornase alfa
    • type: mucolytic
    • trade: Pulmozyne
    • mode: ↓ viscosity & adhesivity of sputum, digests extracellular DNA
    • route: svn
    • indication: CF, mucus clearance
    • adverse: pharnygitis, rash, conjunctivitis
    • c/i: pts w/ FEV1 <25%
  456. Beclomethasone
    • type: corticosteroid
    • trade: QVAR HFA, Beconase AQ
    • mode: supress inflammatory response
    • route: mdi, nasal spray
    • indication: longterm rx for asthma
    • adverse: thrush, dysphonia, cough
    • c/i: no absolute
  457. Triamcinolone
    • type: corticosteroid
    • trade: Azmacort, Nasacort AQ
    • mode: supress inflammatory response
    • route: mdi, nasal spray
    • indication: longterm rx for asthma
    • adverse: thrush, dysphonia, cough
    • c/i: no absolute
  458. Flunisolide
    • type: corticosteroid
    • trade: Aerobid, Aerospan HFA, Nasarel
    • mode: supress inflammatory response
    • route: mdi, nasal spray
    • indication: longterm rx for asthma
    • adverse: thrush, dysphonia, cough
    • c/i: no absolute
  459. Fluticasone
    • type: costicosteroid
    • trade: Flovent HFA, Flovent Diskus, Flonase
    • mode: supress inflammatory response
    • route: mdi, dpi, nasal spray
    • indication: longterm rx for asthma
    • adverse: thrush, dysphonia, cough
    • c/i: no absolute
  460. Budesonide
    • type: corticosteroid
    • trade: Plumicort, Plumicort respule, Rhincort aqua
    • mode: supress inflammatory response
    • route: mdi, svn, nasal spray
    • indication: longterm rx for asthma
    • adverse: thrush, dysphonia, cough
    • c/i: no absolute
  461. Mornetasone
    • type: corticosteroid
    • trade: Asmanex Twisthaler, Nasonex
    • mode: supress inflammatory response
    • route: dpi, nasal spray
    • indication: longterm rx for asthma
    • adverse: thrush, dysphonia, cough
    • c/i: no absolute
  462. Zafirlukast
    • type: anti-asthmatic
    • trade: Accolate
    • mode: anti-leukotriene
    • route: tablet
    • indication: tx mild/mod asthma
    • adverse: headache, nausea, infection
    • c/i: hypersensitivity; don't take w/ ASA
  463. Montelukast
    • type: anti-asthmatic
    • trade: Singulair
    • mode: anti-leukotriene
    • route: tablet
    • indication: tx mild/mod asthma
    • adverse: headache, influenza, abd pain
    • c/i: hypersensitivity
  464. Zileuton
    • type: anti-asthmatic
    • trade: Zyflo
    • mode: anti-leukotriene
    • route: tablet
    • indication: tx mild.mod asthma
    • adverse: headache, dyspepsia
    • c/i: hypersensitivity: liver dz
  465. Omalizumab
    • type: anti-asthmatic
    • trade: Xolair
    • mode: monclonal antibody, blocks IgE receptor
    • route: sub-q injection
    • indication: tx mod/severe asthma
    • adverse: viral infection, URI, pharyngitis, anaphylaxis
    • c/i: no absolute
  466. Colistimenthate Na
    • type: anti-microbial
    • trade: Coly-mycin, Colistin
    • mode: antibiotic
    • route: svn
    • indication: P. aeruginosa in CF
    • adverse: bronchospasm
    • c/i: must filter exhaust gas
  467. Tobramycin
    • type: anti-microbial
    • trade: TOBI
    • mode: antibiotic
    • route: svn
    • indication: P. aeruginosa in CF
    • adverse: voice alteration; tinnitus
    • c/i: pregnancy
  468. Pentamidine isethionate
    • type: anti-microbial
    • trade: NebuPent
    • mode: anti-protzoal
    • route: svn
    • indication: prevent Pneumocystis pneumonia
    • adverse: cough, bronchospam, SOB
    • c/i: pregnancy, nursing mothers
  469. Ribavirin
    • type: anti-microbial
    • trade: Virazole
    • mode: antiviral
    • route: small particle aerosol generator
    • indication: rx RSV, influenza A & B, herpes simplex virus
    • adverse: deterioration of pulm func., CV instability
    • c/i: pregnancy, nursing mothers, ? use in adults
  470. Zanamivir
    • type: anti-microbial
    • trade: Relenza
    • mode: antiviral
    • route: dpi
    • indication: rx uncomp flu in persons > 7 yo
    • adverse: bronchospasm, deterioration of pulm func
    • c/i: underlying pulm dz
  471. 1% solution = ?
    10mg/ml
  472. SVN Flow
    normal tidal breathing, occasional deep breath or breathhold
  473. MDI Flow
    slow deep inhalation to TLC with breathhold
  474. DPI Flow
    rapid deep inhalation to TLC with breathhold
  475. Nitric Oxide
    • indication: reduce pulm hypertension
    • dose: up to 80 ppm
    • adverse: methemo-globinemia
    • route: vent, cannula, mask
  476. Heliox
    • indication: airway obstruction, asthma
    • dose: 80/20, 70/30, 60/40
    • adverse: no known
    • route: vent, mask
  477. Nitrogen
    • indication: decrease PaO2
    • dose: titrate to reduce FiO2 to as low as 18%
    • adverse: dangerously low PaO2
    • route: cannula, hood, vent
  478. Carbon Dioxide
    • indication: increase PVR
    • dose: 0.02-0.05 FiCO2
    • adverse: resp acidosis, decreased resp drive
    • route: vent, cannula
  479. Sputum Characterisitcs
    • time of day produced
    • Color
    • Quantity
    • Odor
    • Viscosity
  480. Patient-Ventilator Dyssynchrony
    • missed trigger efforts
    • double-triggering
    • flow dyssynchrony
    • cycle dyssynchrony
    • mode dyssynchrony
    • PEEP & Auto-PEEP
  481. Missed Trigger Efforts: Causes
    • effort without trigger
    • inappropriate sensitivity setting
    • presence of auto-PEEP
  482. Missed Trigger Efforts: Fixes
    • increase trigger sensitivity
    • switch to flow-triggering
    • add extrinsic PEEP in presence of auto-PEEP
  483. Double-Triggering: Fixes
    • pt demand exceeds volume or flow set
    • associated with sighing, coughing, short Ti
    • adjust flow or volume, prn
  484. Cardiogenic Triggering: Fixes
    • triggering caused by cardiac oscillation
    • rapid filling of lungs during systole causes the vent to sense flow & trigger
    • decrease trigger sensitivity
  485. Flow Dyssynchrony: Fixes
    • pts flow demand not being met by vent
    • most often occurs in volume ventilation
    • increases WOB
    • evaluate pressure/time scalar
    • increase flow
  486. Mode Dyssynchrony: Fixes
    • pts resp center unable to adjust to varying breath types
    • consider changing to PCV or SIMV
    • irregular scalars & pt distress
  487. Fluid Overload: Signs
    • coarse crackles
    • positive jugular distention
    • pitting
    • pulmonary edema
    • ↑ vascular pressures
    • difficult to wean from vent
    • difficulty in oxygenation
  488. Dehydration: Signs
    • poor sensorium, confusion
    • poor skin turgor
    • appear cachectic
    • inspissated secretions
    • decreased CO
  489. Cromolyn Sodium
    • type: non-steroidal anti-inflammatory
    • trade: NasalCrom
    • mode: ACE inhibitor
    • route: nasal spray, oral concentrate
    • indication: allergic rhinitis, prophy use asthma
    • adverse:
    • c/i:
  490. Digoxin
    • type: cardiotonic
    • trade: Lanoxin
    • mode:
    • route:
    • indication: CHF
    • adverse:
    • c/i:
  491. Dobutamine
    • type: cardiotonic
    • trade:
    • mode:
    • route:
    • indication: short term use in CHF
    • adverse:
    • c/i:
  492. Epinephrine
    • type: cardiotonic
    • trade: Adrenalin
    • mode:
    • route:
    • indication: cardiac arrest
    • adverse:
    • c/i:
  493. Endotracheal Instillation
    • NAVEL
    • Naloxone
    • Atropine
    • Vasopressin
    • Epinephrine
    • Lidocaine
  494. Alpha Binding Receptors
    • located in peripheral blood vessels
    • cause vasoconstriction
  495. Beta-1 Binding Receptors
    • located in heart
    • cause ↑ HR, resulting in ↑ CO
  496. Beta-2 Binding Receptors
    • located in smooth muscles, including bronchial smooth muscle
    • cause bronchodilation
  497. Midazolam
    • type: sedative
    • trade: Versed
    • mode:
    • route:
    • indication:
    • adverse:
    • c/i:
  498. Diazepam
    • type: sedative
    • trade: Valium
    • mode:
    • route:
    • indication:
    • adverse:
    • c/i:
  499. Alprazolam
    • type: sedative
    • trade: Xanax
    • mode:
    • route:
    • indication:
    • adverse:
    • c/i:
  500. Lorazepam
    • type: sedative
    • trade: Ativan
    • mode:
    • route:
    • indication:
    • adverse:
    • c/i:
  501. Propofol
    • type: sedative
    • trade: Diprivan
    • mode:
    • route:
    • indication:
    • adverse:
    • c/i:
  502. Succunylcholine
    • type: neuromuscular blocking agent
    • trade: Anectine
    • mode: short-acting, depolaring agent
    • route:
    • indication: intubation
    • adverse:
    • c/i:
  503. Pancuronium Bromide
    • type: neuromuscular blocking agent
    • trade: Pavulon
    • mode: longer-acting non-depolarizing agent
    • route:
    • indication: mechanical ventilation
    • adverse:
    • c/i:
  504. Beractant
    • type: surfactant
    • trade: Survanta
    • mode:
    • route:
    • indication: Neonatal RDS
    • adverse:
    • c/i:
  505. Proactant alfa
    • type: surfactant
    • trade: Curosurf
    • mode:
    • route:
    • indication: Neonatal RDS
    • adverse:
    • c/i:
  506. Calfactant
    • type: surfactant
    • trade: Infasurf
    • mode:
    • route:
    • indication: Neonatal RDS
    • adverse:
    • c/i:
  507. Improving Ventilation When Respiratory Acidosis is Present:
    • ↑ Vt
    • ↑ RR
    • If Vt @ maximum (8-10ml.kg), ↑ RR
    • If Vt not at max, ↑ Vt up to 10 ml/kg
    • Be sure mechanical deadspace is at a minimum
  508. Improving Ventilation When Respiratory Alkalosis is Present:
    • ↓ RR
    • ↓ Vt
    • Commonly, RR is ↓
  509. To Increase Mean Airway Pressure:
    • ↑ PEEP
    • ↑ PIP during PCV or PSV
    • ↑ Vt during Volume Ventilation
  510. Signs of Fluid Overload
    • peripheral edema
    • JVD
    • crackles
    • cyanosis
    • tachycardia
    • hypotension
    • hypoxemia
  511. Indications for Pulmonary Vasodilation
    • pulmonary hypertension
    • chronic lung disease
    • sickle cell disease
    • RDS
    • pulmonary embolism
    • congenital heart defects
    • heat/lung transplant
    • sepsis
  512. Inspiratory Time: Spontaneous Breathing
    Ventilator inspiratory time should equal pt desired inspiratory time, ~!1 second
  513. Mechanical Ventilation in COPD
    • minimize auto-PEEP
    • ensure pt in synchrony
    • ensure inspiratory time appropriate
    • if volume ventilation, use decelerating flow pattern
    • use high peak flow during volume A/C
  514. Initial Ventilator Settings: COPDi
    • mode: A/C (pressure or volume) or PS
    • Vt: 6-8 ml/kg, provided Pplat <30 cm H2O
    • Rate: minimize auto-PEEP
    • PEEP: level to offset auto-PEEP: start 5 cm
    • IT: -.5 to 1.0 second
    • Peak flow: vol vent: >80 lpm
    • flow waveform: vol vent decelerating
    • FiO2: minimum to maintain target PaO2
  515. Initial Ventilator Settings: Asthma
    • mode: a/c volume controlled!
    • Vt: 4-8 ml/kg, Pplat <30
    • Rate: 8-20 bpm, ensure minimum auto-PEEP
    • IT: 1.0-1.5 seconds
    • PEEP: controlled 0-5cm: spontaneous, offset auto-PEEP
    • FiO2: 1.0, maintain PaO2 >60 mm Hg
    • Flow Waveform: decelerating
    • Peak flow: >40 lpm
  516. Initial Ventilator Settings: Cardiac Failure
    • mode: A/c (pressure or volume): support each breath
    • Vt: 6-8 ml/kg, Pplat <30
    • Rate: 15-20 bpm
    • IT: 0.8 to 1.0 second
    • PEEP: 5-10 cm H2O
    • FiO2: 1.0
    • Flow Waveform: decelerating or square
    • Peak flow: >60 lpm
  517. Initial Ventilator Settings: Post Op
    • mode: A/C (pressure or volume) or PS
    • Vt: 5-8 ml/kg, Pplat <30
    • Rate: controlled 10-16 bpm
    • IT: <1 second
    • PEEP: <5 cm
    • FiO2: prn to keep PaO2 >80
    • Flow Waveform: decelerating (volume)
    • Peak Flow: >60 lpm
  518. Initial Ventilator Settings: Burns/Inhalation Injury
    • mode: A/C pressure or volume
    • Vt: 6-8 ml/kg if no lung injury - 2-8 ml/kg if lung injury
    • Rate: >15 bpm
    • IT: 1 second
    • PEEP: begin at 5 cm unless ALI/ARDS
    • FiO2: 1.0
    • Waveform: decelerating
    • Peak Flow: >80 lpm
  519. Initial Ventilator Setting: Chest Injury
    • mode: A/C (pressure or volume) or PS
    • Vt: 6-8 ml/kg, Pplat <30 & no ALI/ARDS
    • Rate: controlled 10-20 bpm
    • IT: < 1 second
    • PEEP: 5 cm, none w/ severe air leak, if ALI/ARDS 8-20 cm
    • FiO2: <0.6 or prn to meet O2 target
    • Waveform: decelerating
    • Peak Flow: >60 lpm
  520. ACCP/SCCM/AARC Ventilator D/C Guidelines
    • Adequate oxygenation
    • Hemodynamic stability
    • Spontaneous inspiratory effort
    • tolerate 30-60 spontanous breathing trial
  521. ACCP/SCCM/AARC Guideines to Remove Artificial Airway
    • airway patent
    • ability to protect airway
    • ability to clear secretions
  522. Abnormal Hemoglobin
    • anemia
    • polycythemia
    • carboxyhemoglobin
    • methemoglobin
  523. Hypokalemia
    • associated with diuresis & metabolic alkalosis
    • β=agonists (Albuterol) can ↓ K+
  524. Hyperkalemia
    associated with renal failure
  525. Lactate
    • results from anaerobic metabolism (hypoxia)
    • useful in mgmt of septic shock
  526. Increasing Ti
    Decreases Flow (time-cycled)
  527. Increasing Flow
    increases Ti (volume cycled)
  528. A time-cycled ventilator is set to deliver 0.5L, f=12, Ti=1.0 second. What is the flow?
    • flow = volume/time
    • flow = 0.5L/1 second
    • convert to lpm
    • flow = (60sec/1 min) x (0.5 L/1 sec) = 30 lpm
  529. The order states Vt of 600ml, rate = 10 and I:E ratio of 1:2. What flow should be set?
    • flow = 0.6/Ti
    • TCT = (60 sec/10) = 6 seconds
    • I:E = 1:2
    • Ti + Te must = 6 seconds
    • Ti = 2 seconds & Te = 4 seconds
    • Flow = Vt/It = (0.6L/2 sec) x (60 sec/1 min)= 18 lpm
  530. Increasing Flow
    • will decrease It &
    • increase PIP
  531. To improve distribution of Vt
    • use descending flow curve
    • add inspiratory pause
    • slow a ""fast"(>100 lpm) flowrate
  532. Indications for SIMV
    • respiratory alkalosis during A/C mode
    • in premies for apeneic periods
  533. Indications to change ET Tube
    • obstruction
    • ruptured cuff
    • broken/severed pilot tube
  534. Heat & Moisture Exchanger
    • passive
    • less effective heat & moisturization
    • adds dead space
    • adds resistance
  535. Indications to change Trach Tube
    • obstruction
    • ruptured cuff
    • broken/severed pilot tube
    • malposition
    • high cuff pressure
    • downsize to allow speaking
  536. Effects of high tracheal pressure
    • upper airway obstruction
    • phlegm
    • granulation
    • edema
    • vocal cord dysfunction
    • arytenoiditis
    • hematoma
    • synechiae
  537. To allow speaking with Trach Tube on Vent:
    • cuff down
    • increase PEEP
    • increase Vt
    • increase Ti
  538. Nasal Cannula: Flow & FiO2
    • flow = 1-6 lpm
    • FiO2 = 24-44%
  539. Simple Mask: Flow & FiO2
    • flow =  4-8 lpm
    • FiO2 = 35-55%
  540. Partial Rebreathing Mask: Flow & FiO2
    • flow = keep reservoir 1/3 full
    • FiO2 = <60%
  541. Air-entrainment Mask: Flow & FiO2
    • Flow =  prn
    • FiO2 =  24-50%
  542. Non-rebreathing Mask: Flow & FiO2
    • flow = keep reservoir 1/3 full
    • FiO2 = 100%
  543. Use High Flow Devices for:
    • irregular ventilatory patterns
    • Vt out of normal range
    • increased RR
  544. Use Low Flow Device for:
    • regular ventilatory pattern
    • normal Vt
    • RR <25
  545. Goals of O2 Therapy
    • keep PaO2 > 60 mm Hg
    • keep SaO2 > 90% on room air
  546. Antibacterials
    • Tobramycin (TOBI)
    • Aztreonam (Cayston)
    • con of p aeruginosa in CF
  547. Antivirals
    • Zanamivir (Relenza)
    • Ribavarin (Virazole)
    • treat hospitalized RSV
  548. Antiprotozoal
    • Pentamidine (NebuPent)
    • prevent pneumocystis pneumonia
  549. Analgesics
    • reduction in pain
    • can cause respiratory depression
    • Morphine is most common
    • can be reversed with Naloxone(Narcan)
  550. Succinylcholine (Anectine)
    • paralytic
    • depolarizing agent
    • short acting
    • used to facilitate intubation
  551. Pancuronium Bromide (Pavulon)
    • paralytic
    • non-depolarizing agent
    • used in ICU for pts on mech ventilation
  552. Surfactants
    • Beractant (Survanta)
    • Proactant alfa (Curosurf)
    • Califactant (Infasurf)
    • treat/prevent RDS
  553. Improve Alveolar Ventilation when Respiratory Acidosis is present
    ↑ Vt or Rate

    if Vt is at max (8-10ml/kg), ↑ Rate, otherwise ↑ Vt up to max

    assure mechanical deadspace is minimized
  554. Improve Alveolar Ventilation when Respiratory Alkalosis is present
    ↓ rate or Vt

    usually rate unless Vt exceeds max
  555. Enhance Oxygenation During Mechanical Ventilation
    • maintain safe levels of FiO2 prn
    • if FiO2 is >0.6, ↑ PEEP
  556. Refractory Hypoxemia
    • differentiate between COPD & Reduced-FRC Pathologies (pulmonary edema, ARF, ARDS)
    • in COPD, ↑ PEEP will not ↑ oxygenation
  557. Mean Airway Pressure
    • ↑ mean Paw will ↑ oxygenation
    • ↑ PEEP is effective to ↑ Paw
    • During PCV or PSV, ↑ PIP will ↑Paw
    • During VCV, ↑ Vt will ↑ PIP and Paw
  558. Signs of Hypervolemia
    • peripheral edema
    • JVD
    • crackles
    • dyspnea
    • cyanosis
    • tachycardia
    • hypotension
    • hypoxemia
  559. Pulmonary Vasodilators: Indications
    • primary & chronic pulmonary hypertension
    • persistent V/Q mismatch
    • chronic lung disease
    • sickle cell disease
    • RDS
    • pulmonary embolism
    • congenital heart defects
    • heart/lung transplant
    • sepsis
  560. Pulmonary Vasodilators
    • oxygen
    • nitric oxide
    • prostacyclins
    • phosphodiesterase inhibitors
    • endothelin receptor agonists
  561. normal hemoglobin level
    • men: 13.5 to 15.5 g/dL
    • women: 12.5 to 14.5 g/dL
  562. normal hematocrit levels
    • men 42-52%
    • women 37 to 48%
  563. Hematocrit is:
    the proportion of whole blood that is composed of RBC's
  564. Abnormal Hemoglobins
    • anemia
    • polycythemia
    • carboxyhemoglobin
    • methemoglobin
  565. normal platelet level
    150,000 to 400,000 μL
  566. normal leukocyte (WBC) level
    4,000 to 11,000 μL
  567. normal potassium level
    3.5 to 5.5 mmol/L
  568. Hypokalemia associated with:
    • diuresis and
    • metabolic alkalosis
    • beta-agonists (Albuterol) in high doses
  569. Hyperkalemia associated with
    renal failure
  570. normal HCO3 level
    22-32 mmol/L
  571. normal lactate level
    <2 mmol/L
  572. normal anion gap
    8-12 mmolL
  573. normal spontaneous breathing inspiratory time
    <1.0 second
  574. ARDS PEEP levels
    12-20 cm H2O
  575. ALI PEEP levels
    8-15 cm H2O
  576. Unilateral Lung Injury Positioning
    Non-injured lung dependent
  577. Mechanical Ventilation in ARDS
    • Pplat < 30 cm H2O
    • Vt 5-8 ml/kg
    • Higher PEEP
  578. Mechanical Ventilation in ALI
    • Pplat < 30 cc H2O
    • Vt <8 ml/lkg
    • Lower PEEP
  579. Mechanical Ventilation in COPD
    • minimize auto-PEEP
    • ensure synchrony
    • ensure appropriate inspiratory time 0.5 to 1.0 second
    • in volume ventilation, use decerlerating flow
    • use high peak flow during volume A/C
  580. Mechanical Ventilation in Asthma
    • level of air trapping best measured by Pplat
    • volume, controlled
    • 4-8 ml/kg
    • It = 1.0 to 1.5 seconds
    • PEEP 0-5 cm H2O
    • FiO2 1.0  maintain PaO2 >60 mm Hg
    • flow decelerating
    • peak flow >40 L/min
  581. Mechanical Ventilation in Cardiac Failure
    • avoid dysynchrony
    • meet pt inspiratory demand
    • sedate appropriately
    • controlled vent may be necessary to ensure HD stability
  582. Mechanical Ventilation in Post-Op Patients
    • A/C vol, press, or PS
    • Vt 6 to 8 ml/kg
    • rate 10 to 16 bpm
    • It <1.0 second
    • PEEP <5 cm H2O
    • FiO2 prn to maintain PaO2 > 80 mm Hg
    • flow waveform decelerating
    • peak flow > 60 L/min
  583. Mechanical Ventilation in Burns/Inhalation Injury
    • mode A/C pressure or volume
    • rate >15 bpm
    • Vt 6 to 8 ml/kg
    • It 1.0 second
    • PEEP  begin at 5 cm H2O
    • FiO2 1.0
    • waveform decelerating
    • peak flow >80 lpm
  584. Mechanical Ventilation in Chest Trauma
    • mode A/C pressure, volume or PS
    • Vt 6-8 ml/kg provided Pplat < 30 cm H2O
    • rate controlled 10 to 20 bpm
    • It < 1.0 second
    • PEEP 5 cm H20, none with air leak
    • FiO2 <0.6 or prn
    • decelerating flow
    • peak flow > 60 lpm
  585. Difficult to Wean Patients
    • wheezes
    • heart disease
    • electrolytes
    • anxiety aspiration
    • alkalosis
    • sepsis
    • neuromuscular
    • nutrition
    • opiates
    • obesity
    • thyroid disease
  586. ETT: Indications
    • bypass upper airway obstruction
    • protect airway from aspiration
    • apply positive pressure ventilation
    • aid clearance of secretions
    • correct hypoxemia &/or respiratory acidosis
  587. Advantages of Tracheostomy
    • less airway resistance
    • reduced tube movement in the trachea
    • greater pt comfort
    • allows pt to swallow (nourishment)
  588. Reasons to D/C Rx
    • adverse reaction
    • rx goals achieved
    • different rx indicated
  589. nasal cannula: flow & concentration
    • 1-6 lpm
    • <44% O2
  590. simple mask: concentration
    35-55% O2
  591. partial rebreathing mask: concentration & flow
    • <60%
    • keep bag 1/3 full
  592. air-entrainment mask: concentration
    24-50% O2
  593. non-rebreathing mask: concentration & flow
    • 100% O2
    • keep bag 1/3 full
  594. High Flow O2 Device: Indications
    • irregular ventilatory pattern
    • Vt out of normal range
    • RR icnreased
  595. Low Flow O2 device: indications
    • normal ventilatory pattern
    • normal Vt
    • RR < 25
  596. Goal O2 RX: paO2 & SaO2
    • keep PaO2 > 60 mm Hg
    • keep SaO2 >90% on room air
  597. Disadvantage of non-rebreather mask?
    inability to adequately humidify gas: may result in inspissation of secretions: try high flow cannula
  598. Signs of retained secretions
    coarse crackles & basilar consolidation
  599. Rx Hypoxemia 2 to decreased V/Q (asthma, COPD, pneumonia)
    low flow O2 rx
  600. Rx hypoxemia 2 to hypoventilation (opiate OD, NM dz)
    low flow O2 & restore ventilation
  601. rx hypoxemia 2 to shunt (ARDS)
    high flow O2 & CPAP/PEEP
  602. rx hypoxemia 2 to diffusion defect (HF)
    low or high flow O2 & CPAP/PEEP
  603. rx hypoxemia 2 increased deadspace (PE, emphysema)
    low or high flow O2
  604. rx retained secretions (CF)
    • CPT
    • HFCWO
  605. rx retained secretions (resorption atelectasis)
    • PEP
    • CPT
    • ACB
    • C&DB
    • IPPB/IPV
  606. rx retained secretions (G-B Syndrone, aspiration)
    • CPT
    • suction
    • MIE
    • IPPB/IPV
  607. rx retained secretions (MD, MG)
    • PEP
    • MIE
    • IPPB/IPV
  608. C&DB
    cough & deep breathing
  609. HFCWO
    high frequency chest wall oscillations (vest)
  610. ACB
    active cycle of breathing (taught cough manuevers)
  611. MIE
    mechanical insufflation/exsufflation
  612. PEP
    positive expiratory pressure (Flutter, Acapella, Quake, etc)
  613. IPV
    intrapulmonary percussive ventilation
  614. rx atelectasis (mucus plugging in obstructive diseases)
    • C&DB
    • taught cough methods
    • CPT
    • HFCWO
    • IS
    • IPPB/IPV
    • MIE
    • PEP
  615. rx atelectasis 2 contralateral ETT
    reposition ETT
  616. rx atelectasis 2 foreign body
    bronchoscopy
  617. rx atelectasis 2 passive hypopnea, lack of yawn/sigh
    • IS
    • CPAP
    • IPPB/IPV
  618. rx bronchospasm 2 asthma, COPD, pneumonia
    • aerosol
    • MDI
    • IPPB
    • DPI
  619. rx bronchospasm 2 CF
    aerosol
  620. rx bronchospasm 2 anaerobic infection
    aerosol
  621. rx resp failure 2 hypercapnia (COPD, asthma, anesthesia, opiate OD, apnea)
    • CMV
    • IMV
    • CSV
  622. CSV
    continuous spontaneous ventilation
  623. rx resp failure 2 hypoxemia (ARDS/ALI, severe pneumonia)
    • CPAP
    • APRV
  624. APRV
    airway pressure release ventilation (a form of IMV)
  625. Wheezing in Adult: Diff Dx
    • Asthma (hx allergies, cough during exacerbaction, dyspnea uncommon, reversible spirometry)
    • COPD (hx smoking, chronic productive cough, progressive dyspnea, onset later than 5th decade, partial/irreversible spirometry)
  626. Numbness/Weakness in Legs: Diff Dx
    • Myasthenia Gravis (chronic muscle fatigue, diplopia, Ptosis, weakness brought on by repetitive motion, difficult with stair climbing & lifing objects, CT or MRI demonstrated thymoma)
    • Guillain-Barre (leg muscle weakness, tingling, burning sensations, paresthesia, lower back/buttock pain, absent deep tendon reflexes, drooling, difficulty with speech, crewing, swallowing, ascending paralysis, elevated CSF protein, abnormal EEG)
  627. Diff Dx: Heart Failure
    • hx of heart failure
    • PCWP >18 mm Hg
    • enlarged heart
    • pulmonary edema
    • distended neck veins
    • peripheral edema
    • basilar crackles
  628. Diff Dx: Iatrogenic Fluid Overload
    • large volume of fluid replacement
    • increased CVP, PCWP, PAP
    • distended neck veins
    • pulmonary edema
    • basilar crackles
  629. Diff Dx: Nosocomial Pneumonia
    • new infiltrates 24-48 hrs p intubation
    • leukocytosis
    • fever
    • purulent mucus
    • lobar infiltrates
    • air bronchograms
    • bronchial breath sounds
  630. diff dx: ARDS
    • predisposing condition
    • PCWP > 18 mm Hg
    • P/F < 200
    • bilateral infiltrates
  631. Compensated Shock
    • compensatory mechanisms able to maintain some degree of tissue perfusion
    • mild tachycardia
    • mild tachypnea
    • slightly increased capillary refill time
    • weak peripheral pulses
    • decreased urine output & bowel sounds
    • cool extemities
  632. Uncompensated Shock
    • compensatory mechanisms fail to maintain tissue perfusion (BP falls)
    • tachycardia
    • tachypnea
    • diminished/absent peripheral pulses
    • pallor
    • cold extremities
    • absent urine output
    • generalized edema
    • petechiae: DIC
    • hypothermia
  633. Irreversible Shock
    tissue & cellular damage is so massive that organism dies even if perfusion is restored
  634. Application of Boyle's Law
    as altitude increases, barometric pressure decreases & air volumes (ETT cuffs. pneumothorax, air in abdomen) volume will increase
  635. Decompression of Pneumothorax
    • ID 2nd intercostal space, midclavicular line on affected side
    • prep area
    • admin local anesthetic
    • attach 18-20 gauge angiocath to 12ml syringe with stopcock
    • insert needle into skin over rib
    • puncture parietal pleura
    • aspirate air prn
    • document volume removed
  636. Ratio of compressions to ventilation with 2-person CPR
    • 30:2 with adult
    • 15:2 with child
  637. Causes of Pulseless Electrical Activity
    • hypovolemia
    • hypoxia
    • acidosis
    • potassium imbalance (↑ or ↓)

    • hypoglycemia
    • hypothermia
  638. Rule of Desbiens (PEA)
    • severe hypovolemia
    • pump failure
    • obstruction to circulation (tension pneumo, tamponade, massive pulmonary embolus)
  639. Sign of Return of Spontaneous Circulation (ROSC)
    significant ↑ in EtCO2
  640. Signs of Septic Shock
    • bounding pulses
    • warm extremities
  641. RDS Symptoms
    • cyanosis
    • apnea
    • grunting
    • nasal flaring
    • tachypnea
    • intercostal retractions
  642. Neonatal ETT size determination
    1/10th gestational age rounded down
  643. Neonatal ETT Securing Point
    add weight (kgs) to 6
  644. E Cylinder Factor
    0.28
  645. H or K cylinder factor
    3.14
  646. Cylinder Duration Calculation
    (PSI x Cylinder Factor)/Flow(LPM) = minutes of gas
  647. Significance of Transudate
    • CHF
    • atelectasis
    • cirrhosis
    • lymphatic obstruction
    • nephrotic syndrome
  648. Significance of Exudate
    • inflammation
    • infection
    • neoplastic disease
  649. Significance of empyema
    pus or bacteria on gram stain
  650. CP Exercise Testing C/I
    • unstable cardiac condition
    • syncope
    • uncontrolled asthma
    • pulmonary edema
    • respiratory failure
    • inability to cooperate/follow instructions
  651. Duration of CP Exercise Test
    > 6 minutes continuous exercise
  652. Brain Death Determination
    • coma - irreversible cause
    • normothermic
    • absence of reflexes
    • confirming tests (brain perfusion study, apnea test)
  653. Cleaning Nebulizer at home?
    rinse with distilled water after each use & air dry
  654. Types of Apnea
    • obstructive
    • central
    • mixed
  655. Rx for Obstructive Apnea
    CPAP or BiPAP
  656. Rx for Mixed Apnea
    treat OSA, & any other cause

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