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Causes of increased respiratory rate
hyperthermia, fever, acidosis, hypoxemia, anxiety, pain
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Causes of decreased respiratory rate.
hypothermia, alkalosis, hyperoxia
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Components of BP
contractility of LV, arterial resistance, blood volume
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Normal child BP
60-100/20-70
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Signs of hypokalemia
cardiac rhythm disturbances, muscle weakness
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ECG changes in hypokalemia
flat or inverted T waves, depression of ST segments, PVCs, V Fib
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ECG changes in hyperchloremia
prolongation of ST segment & QT interval
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ECG changes in hyperkalemia
high, peaked T waves, depressed ST segments, wide QRS complexes, bradycardia
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ECG changes in hypochloremia
shortened QT interval, widened and rounded T waves
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Normal adult chloride level
95-106 mEq/L
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Normal adult Potassium level
3.5-5.5 mEq/L
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Normal adult sodium level
135-145 mEq/L
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Normal adult calcium level
4.5-5.5 mEq/L
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Normal adult bicarb level
23-25 mEq/L
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Normal adult serum glucose level
70-110 mg/100 mL
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Creatine Kinase (CK-MB)
cardiac enzyme, increases 4-6 hours after MI
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Troponin I (cTnI)
cardiac enzyme, increases 2-4 hours after MI
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Troponin T (cTnT)
cardiac enzyme, increases 2-4 hours after MI
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Brain natriuretic peptide (BNP)
cardiac enzyme, elevated in pt with CHF
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C-reactive protein
non specific enzyme, marker of inflammation linked to risk for MI, stroke & PV disease
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Normal adult Hemoglobin level
13.5-18.0 g/100 mL
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Normal adult Hematocrit level
40%-54%
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Normal adult RBC level
4.6-6.2 million/mL
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Leukocytosis
elevated WBC, signals bacterial infection
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Increased Neutrophils indicates:
acute, severe bacterial infection
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Normal adult WBC level
4500-11000 mm3
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Leukopenia
low (3000-5000/mm3, suggests acute viral infection
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Normal adult PT level
11-12.5 seconds
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Normal adult PTT level
60-70 seconds
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Normal adult APTT level
30-40 seconds
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The most common types of bacteria that cause bronchitis and pneumonia are:
Gram-positive
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Clinical S&S of dehydration
tachycardia, hypotension, high urine specific gravity, oliguria, low CVP, low PCWP, poor skin turgor, slow capillary refill, mental confusion
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Clinical S&S of fluid overload
tachycardia, hypertension, low urine specific gravity, increased urine output, increased CVP, increased PWCP, peripheral edema, pulmonary edema (crackles/rales)
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Normal adult ICP level
<10 mm Hg
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Indications for CXR
significant change in CP condition, following invasive thoracic procedure, hemoptysis, suspected pulmonary infarct, suspected pneumothorax
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Clinical S&S of pneumothorax
sudden chest pain, SOB, absent breath sounds over a lung field, tracheal deviation, shifted heart sounds, assymterical chest movement, hyperresonant percussion over the pneumothorax, sudden increase in peak or plateau pressure, sub-Q emphysema
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Indications for upper airway radiograph
suspected FB aspiration, laryngeal edema, laryngeal tumor, laryngotrachealbronchitis, epiglottitis
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Indications for CT Scan
tumor, hematoma, abscess/cyst, aortic or vascular abnormality, trauma, FB
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Indications for MRI
imaging of head, spinal cord, heart, great vessels, kidneys, liver, other organs
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Indications for PET Scan
determining regional metabolism of heart or brain, measuring the size of an MI. measuring the effects of rx on a cancerous tumor, determining pulmonary perfusion or ventilation
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Indications for V/Q Scan
suspected pulmonary embolism or airway obstruction
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Quality of CXR
proper positioning, exposure
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PA CXR
standard view, accurate heart size, deep breath
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AP CXR
heart size appears larger than actual
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Lateral CXR
visualize behind heart & hemidiaphragms, localize lesions, measure AP diameter
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Oblique CXR
check heart borders, mediastinal structures, hilar structures & lung masses
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Lateral Decubitus CXR
allows visualization of fluid in pleural spaces or pulmonary cysts
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Dorsal Decubitus CXR
id small pneumothorax in an infant
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Lordotic CXR
visualization of upper lung fields
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Radiopaque items
dense, absorb more radiation, appear white
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Radiolucent items
have little density, absorb less radiation, appear darker
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Mediastinal shift toward
atelectasis or pulmonary fibrosis
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Mediastinal shift away
tension pneumothorax
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Unilateral elevation of hemidiaphragm
atelectasis, pulmonary fibrosis, hepatomegaly
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Normal adult CT Ratio
>50%
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Blunt costophrenic angles
pleural effusion
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Meniscus Sign
pleural effusion
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CXR indications of pulmonary edema
fluffy white infiltrates in one or both lung fields, more common in LL, great vessels may also be englarged
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CXR indications of consolidation
dense white shadows, air bornchograms may be visible
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Diaphoresis at rest is indicative of:
shock or hypoxemia
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Eupnea
normal respiratory pattern
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Tactile fremitus
conditions that increase density result in more intense vibrations
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Rhonchial fremitus
vibrations from airway secretions
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Increased unilateral tactile fremitus
pneumonia, atelectasis, consolidation
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decreased unilateral tactile fremitus
pneumothorax, pleural effusion, bronchial obstruction
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increased bilateral tactile fremitus
pulmonary edema, ARDS
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decreased bilateral tactile fremitus
thick chest wall, COPD
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Glasgow Coma Scale
0-15, 15 being normally awake/alert and 0 being nonresponsive
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Hypopnea
shallow breathing
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tachypnea
rapid breathing
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obstructed inspiration
croup, epiglottitis, FB, laryngeal edema, airway trauma
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obstructed expiration
asthma, COPD, CF, airway tumor, trauma
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Kussmaul respirations
rapid deep breaths, usually secondary to acidosis (eso. diabetes)
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Cheyne-Stokes respirations
waxing and waning breaths with periods of apnea: head injury, stroke, high ICP, CHF
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Biot's respirations
variable depth and frequency of respirations with periods of apnea: meningitis,brain injury, brain tumor, increased ICP
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Huff Cough
mid-inspiratory cough
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Airborne Precautions
Negative pressure room, gloves, handwashing NIOSH-approved mask (N95), eye protection: TB, varicella, rubeola, H1N1, SARS
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Droplet Precautions
in addition to Standard Precautions: private or cohort room, isolation mask; haemophilus influenza type b, meningitis, myco[lasma pneumoniae, bordetella pertussis
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Contact Precautions
In addition to standard precuations: private.cohort room, gloves, gown, dedicated equipment:C. difficile, MRSA, respiratory syncytial virus, herpes zoster
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Pneumovax 23
provides protection against 23 most prevalent or invasive types strep pneumoniae bacteria.
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Influenza
seasonal, protection against three strains of virus
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Blood spills must be cleaned up with:
chlorine compound (bleach)
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Home equipment can be cleaned with:
1.25% solution of acetic acid (vinegar) - soak 60 minutes
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Indications for hemoximetry and Co Oximetry
determine the presence & quantity of dyshemoglobins such as carboxyhemoglobin and methemoglobin
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Indications for mixed venous oxygen pressure monitoring
calculate a patient's oxygen carrying capacity
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Indications for capillary blood gas analysis
estimate the acid-base balance and adequacy of ventilation: should not be used to estimate oxygenation
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Indications for venous blood gases
evaluate pH in patients with uremia or diabetic ketoacidosis
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Effect of air bubble in blood gas sample
measured oxygen would be inaccurately higher and measured carbon dioxide level would be inaccurately lower: pH would be inaccurately high
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Effect of excessive heparin in a blood gas syringe
reduce the pH and pCO2 and increase the O2 level
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After an Allen test, hand should flush within ___ seconds.
15
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For a neonatal heel stick, the heel should be heated for 5-10 minutes to a temperature of ____?
42 degrees C
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The pH electrode is a _____ electrode.
Sanz
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The pCO2 electrode is a ______ electrode.
Severinghaus
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The pO2 electrode is a ______ electrode.
Clark
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The partial pressure of oxygen in the blood come from ______?
the oxygen that is dissolved in the plasma and not from the oxygen bound to the hemoglobin
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Accuracy/Precision in an analyzer means?
that the measured physiologic values truly reflect the actual physiologic values
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Reliability in an analyzer means?
that a high degree of confidence exists that the measured values represent the patient's actual physiologic values
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Quality Assurance (in an analyzer) means?
the results are not only accurate and reliable but also are clinically useful
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The predicted pCO2 value at a given CO2 percentage is calculated?
pCO2 = (Pb - P H2O) x % CO2, where Pb = barometric pressure and pH2O is water vapor pressure
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The predicted pO2 value at a given O2 percentage is:
pO2 = (Pb - PH2O) x % O2
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Blood gas analyzers are calculated at what temperature?
37 degrees C; if the patient is febrile, the PCO2 and pO2 will be greater than measured; if hypothermic, the actual values will be lower
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What does a hemoximeter measure?
oxyhemoglobin, carboxyhemoglobin, methemoglobin and reduced hemoglobin
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What is the effect of imaging dyes on oxymetry?
they may absorb the same wavelengths and report inaccurately lower oxygemoglobin than is actually present
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What is the effect of lipids in oxymetry?
the presence of lipids causes total hemoglobin readings that are falsely high and falsely low measurements of oxyhemoglobin and carboxyhemoglobin.
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Acceptable pO2 range in newborn
40-70 torr
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Acceptable pO2 range in children & adults
>80 torr
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Mild Hypoxemia on RA
- paO2 60-79 torr
- SaO2 90-94%
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Moderate Hypoxemia on RA
- paO2 40-59 torr
- SaO2 75-89%
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Bicarb levels indicating metabolic alkalosis
HCO3 > 24 mEq/L or BE > 1
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Bicarb levels indicating metabolic acidosis
HCO3 < 24 mEq/L or BE <-1
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PaCO2 > 45 torr indicates
respiratory acidosis, alveolar hypoventilation, ventilatory failure
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pH < 7.35 indicates
acidemia
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PaCO2 < 35 torr indicates
respiratory alkalosis, alveolar hyperventilation
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pH > 7.45 indicates
alkalosis
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PaCO2 > 45 torr and pH < 7.35 indicates
acute ventilatory failure
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PaCO2 > 45 torr and pH 7.35-7.40 indicates
chronic ventilatory failure
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pH > 7.50, PaCO2 35-45 torr
Metabolic alkalosis
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pH < 7.30, PaCO2, PaCO2 35-45 torr
metabolic acidosis
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pH > 7.50, pCO2 > 45 torr
partially compensated metabolic alkalosis
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pH 7.30-7.40, PaCO2 > 45 torr
chronic ventilatory failure
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pH < 7.30, PaCO2 > 45 torr
acute ventilatory failure
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pH > 7.50, PaCO2 < 35 torr
acute alveolar hyperventilation
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pH 7.40-7.50, PaCO2 < 35
chronic alveolar hyperventilation
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pH 7.30-7.40, PaCO2 < 35 torr
compensated metabolic acidosis
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pH < 7.30, PaCO2 <35 torr
partially compensated metabolic acidosis
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Normal Total Hemoglobin levels
15.0 g/dL
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Normal oxyhemoglobin as % of total Hbg
94-100%
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Normal carboxyhemoglobin as % of total Hbg (non smoker)
<1.5%
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Normal methemoglobin as % of total Hbg
0.5 - 3%
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Normal arterial oxygen content
15-23 g/dL
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Mixed Venous Blood Gas
Taken from PA via Swan Ganz: reveals what has happened to arterial blood as it passes through the body: reflects oxygen consumption and cardiac output
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Tissue hypoxemia
Mixed venous pO2 < 30 or mixed venous sat of <56
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Indications for pulse oximetry
during procedures, postop, when patient is sedated, during sleep studies, during periods of respiratory distress, to evaluate effectiveness of O2 rx.
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Counterindications for Pulse Oximetry
when COHb or MetHb is present, when displayed HR is different from actual HR, when SpO2 reading is < 70%, neonates <1500g
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PtO2 sensor temperatures
42-44 degrees C
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Alveolar-Arterial Oxygen Pressure Difference
should be no greater than 15 torr
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PaO2/FiO2 Ratio (P/F Ratio)
- Normal = 400-500 torr
- Weaning can be attempted = 150 torr
- ALI = 200-300 torr
- ARDS = <200
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Oxygenation Index
- OI = ((FiO2xPaw)/PaO2) x 100
- Gap widens with lung dysfunction. Supplemental O2 little benefit, use PEEP.
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