Question Answer
VD/VT ((PaCO2-PECO2)/PaCO2 )* 100, Range 20-40%
Alveolar Air Equation(PAO2) (FIO2*7) – (PaCO2 +10)
A-a Gradient (A-aDO2) PAO2- PaO2, RANGE 25-65mmHg
Arterial Oxygen Content (CaO2) (Hb*1.34*SaO2) + (PaO2 * .003), range 17-20%
Venous Oxygen Content (CvO2) (Hb*1.34*SvO2) + (PvO2 * .003), range 12-16%
Arterial-Venous Oxygen content difference, C(a-v)O2 CaO2-CvO2, Range 4-5%
Shunt Equation , QS/QT ((A-aDO2)*.003 ) / ((A-aDO2)*.003+C(a-v)O2), Range 3- 5 %
Fick Equation for Cardiac Output (QT) VO2 / (C(a-v)O2 * 10) , range 4-8 L/min
Cardiac Index CO / BSA, RANGE 2.5 – 4 L/m/m2
Types of Chest X-rays : AP(Anterior to posterior) most common in hostpitals. Good for in-bed X-rays. Use when determining proper position of an endotracheal tube.
Types of Chest X-rays : PA(Posterior to Anterior) most often done standing
Types of Chest X-rays : Lateral Helps to visualize the lungs as a 3-dimensional body
Types of Chest X-rays : Lateral decubitus Helpful in detecting pleural effusions. Described as having a concave superior border or interface.
Types of Chest X-rays : Oblique Any diagonal or non-traditional angle. Increases 3-dimensionality of lung, helpful in spotting internal issues such as masses, blebs, or lesions.
Neck X-rays : Lateral Neck a.Differentiate Croup (Subglottic inflammation/Laryngotracheobronchitis):1.Steeple Sign2.not Life-Threatening & Acute epiglottitis(Supraglottic swelling): Thumb sign.
Neck X-rays : Artificial Airway placement and function 1. Use a A-P chest radiograph. 2. Determined by radio-opaque line on the ET tube. 3. End of line should be 2cm above the carina (or 1 inch)
Placement X-rays : Chest tube placement should be in the pleural space
1) Placement X-rays : Central venous catheter placement 2)Placement X-rays : Pulmonary artery catheter placement 1)tip should rest in the right atrium or vena cava 2)distal end in the pulmonary artery, not wedged(i.e. balloon not inflamed.)
Placement X-rays : Nasogastric tube positioning should be found in the stomach or small bowel
Normal Chest X-ray description 1. Bilateral radiolucency 2. sharp costophrenic angles 3. Hemi-diaphragms dome shaped, right higher than left 4. Trachea is midline
Radiological Description : Trachea shift from midline-Associated Problem Pneumothroax, hemotorax, significant atelectasis
Radiological Description : Obliterated costophrenic angles-Associated Problem pleural effusion
Radiological Description : Flattened diaphragm-Associated Problem COPD, significant air trapping
Radiological Description : Radiolucent-Associated Problem Normal
Radiological Description : Fluffy infiltrates-Associated Problem Pulmornary edema
Radiological Description : Wedge – shaped infiltrates-Associated Problem Pulmonary embolus
Radiological Description : Air bronchogram-Associated Problem Pneumonia
Radiological Description : Butterfly or Batwing Pattern-Associated Problem Pulmonary edema
Radiological Description : Plate like or patchy infiltrates-Associated Problem Atelectasis
Radiological Description : Ground glass or Honeycomb pattern- Associated Problem ARDS/IRDS
Radiological Description : Reticulongranular pattern ARDS/IRDS
Radiological Description : Concave superior interface pleural effusion
Diagnostic Radiology : V/Q studies 1.Perfusion- abnormal when blood flow around the alveoli is hindered.2. Ventilation-abnormal/missing gas flow in areas of the lungs. Xenon gas is used to monitor gas flow. – V/Q is associated w/ pulmonary emboli.
Diagnostic Radiology : Computed Tomography CT / CAT Used to visualize 1.lung masses,lesions,or nodules 2. during scanning metals are not to be used directly.
Diagnostic Radiology : Magnetic Resonance Imaging (MRI) 1. Useful in detecting masses, lesions or nodules without use of radioactive materials. 2.Must use fluidic ventilator with no metal parts. No oxygen tank in the area (only non-ferrous items)
Diagnostic Radiology : Bronchogram 1. Primary diagnostic tool for Bronchiectasis. 2. helps to direct postural drainage and percussion efforts. 3. this procedure can lead to respiratory deterioration and distress.
Diagnostic Radiology : Barium Swallow 1. Radiographic assessment of esophagus while the pt. swallows food mixed with radiopaque paste. 2. Used to determine risk for aspiration by visualizing any food entering tracheal& protection of tracheal opening during swallowing.
K+ Potassium Major: Intracellular Cation. Important for acid-base balance. Normal: 3.5-4.5 mEq/L range HYPERkalemia-(Metabolic ACIDOSIS) Hypokalemia-(Metabolic Alkalosis)
Na+ Sodium Major: Major:Extracellular Cation. Normal: 135-145 mEq/L range HYPERnatremia Hyponatremia
Cl- Chloride Major: Extracellular Anion. Normal: 80-100 mEq/L range HYPERchloremia: (Metabolic ACIDOSIS ) Hypochloremia: (Metabolic alkalosis)
HCO3- Bicarbonate Changes in Total CO2 content reflect changes in blood base. Normal: 22-26 mEq/L range HIGH HCO3- (Metabolic ALKALOSIS) Low HCO3- (Metablolic acidosis)
Creatinine and BUN (Blood Urea Nitrogen) 1. Both indicates kidney function. 2. Ceratine is more accurate than BUN. 3.Acceptable range- 8-25 mg/dl. 4. Acceptable range- 0.7-1.3 mg/dl.
Coagulation Studies : Platelet count 1. Required for blood clotting. 2. Acceptable value – 150,000-400,000 units/mm3
Coagulation Studies : PT (Prothrombin time) PT Done when patient receiving Warfarin (coumadin). Normal Value (23-32)
Coagulation Studies : APTT(Activated partial thomblastin time) APTT done when pt. taking Heparin therapy. PTT Normal Value (12-15 secs.)
Complete Blood Count(CBC) : Hb 1. Carries 1.34mL/gm O2 2. Acceptable range-12-16 gm/dl.
Complete Blood Count(CBC) : RBC 1. cells that carry Hb. 2.Acceptable range-4-6 mill/cu mm.
Complete Blood Count(CBC) : WBC 1.Range 5000-10000/cu mm.(higher indicates infection-txt. antibiotics)2. Types:Neutrophils A)Bands4%-increased w/bacterial infection. B)Segs60%-decreases w/bacterial infection.C)Esinophills2%-causes asthma yellow sputum. D)Monocytes-elevation causes TB.
Transcutaneous PO2 and PCO2 monitoring 1. used on infants 2. electrode placed on skin & should be moved every 4 hrs. or causes burns on the skin 3. only accurate if perfusion is happening – correlates with the blood gas values.
Urine: Urinalysis 1. Helpful in checking urinary tract infections. 2. Useful when suspecting diabetes (check ketones in blood).
Sputum:Gram stain Determine if organism is gram positive/gram negative.
Sputum:Culture Identifies the actual organism.
Sputum: Sensitivity Identifies the organism-killing antibiotics.
Sputum: Acid fast stain Used to detect the organism associated w/ TB (mycobacterium TB)
Sputum: clear normal
Sputum: White or mucoid chronic bronchitis
Sputum: Yellow presence of WBC, bacterial infection.
Sputum: Green stagnant sputum- Bronchiectasis, pseudomonas.
Sputum: Red Hemoptysis – bleeding, TB.
Sputum: Brown old blood.
Sputum: Pink frothy Pulmonary edema.
Ventilation : Definition It is the act of moving air in&out of lung space. Most imp. vital function is vetilation. Ie. Ventilation must happen before oxygenation. If that never happens, oxygenation,circulation&perfusion will not occur.
Ventilation : Physical signs of ventilation 1. Chest movement 2. RR & depth 3. Vt 4. Breath Sounds
Ventilation : Physical signs of ventilatory distress 1. Intercostal & Sternal retractions – associated with upper airway obstruction 2. Accessory muscle use.
Ventilation : lab signs of ventilation PaCO2 level
Oxygenation : Definition Oxygenation probs. r imp. than circulation&perfusion. consider those 1st. consider CPR. If an object is blocking airway, dont start chest compression eventhough pt.’ve lost HR.U continue to remove object for ventilation becoz 1st priority is ventilation.
Oxygenation : Physical signs of oxygenation 1. Color 2. HR(Tachycardia is poor oxygenation) 3. Mental Status(confused, stuporous) 4. Sensorium
Oxygenation : Lab signs of oxygenation 1. Oxygen saturation 2. PaO2(blood gas)
Circulation: signs 1. Pulse rate 2. Pulse strength 3. Cardia output 4. Stroke volume
Perfusion : signs 1. BP 2. Sensorium 3. Urine Output (best indicator of perfusion)
study of circulation and perfusion is also called Hemodynamics
Visual Inspection : General Appearance 1. Height and weight. 2. age and sex. 3. body frame, nutrition. 4. Cachetic – wasted in appearance, poor skin tugor.
Visual Inspection : Color- Cyanosis Hypoxemia.
Visual Inspection : Color – ashen/pallor anemia, shock (vasodilation).
Visual Inspection : Color- jaundice excessive bilirubin.
Visual Inspection : Color – erythema redness, infection and inflammation.
Visual Inspection : Color -normal, good color good oxygentaion.
Visual Inspection : chest configuration and condition- increased A-P diameter (barrel-chest) seen in pt. with COPD or chronic air-trapping such as cystic fibrosis.
Visual Inspection : chest configuration and condition – scoliosis, kyphosis, kyphoscoliosis curvature of the spine. Kyposis is hunchback. Scoliosis curvature. PFT will show restrictive component.
Visual Inspection : respiratory rate and pattern- Eupnea normal breathing pattern.
Visual Inspection : respiratory rate and pattern: Tachypnea RR over >20 bpm
Visual Inspection : respiratory rate and pattern: Bradypnea RR less <8 also know as Oligopnea.
Visual Inspection : respiratory rate and pattern: Hperpnea Increased RR,depth and regular rhythm. Associated w/ metabolic disorders.
Visual Inspection : respiratory rate and pattern: Apnea cessation of breathing.
Visual Inspection : respiratory rate and pattern: Kussmaul breathing Increased RR,depth and irregular rhythm. Associated w/diabetic ketoacidosis/ metabolic acidosis.
Visual Inspection : respiratory rate and pattern: Biots breathing Increased RR,depth and unpredicatable periods of apnea. Associated with CNS disorders.
Visual Inspection : respiratory rate and pattern: cheyne-stokes Increase and then decreasing RR and rhythm. Each cycle takes upto 3minutes to complete and apnea lasts up to 60 secs. Associated w/ingestional errors (drug overdose) and elavated Intracranial pressure (ICP) problems (Head trauma etc.)
Visual Inspection : Acessory muscle use – normal muscles 1. External intercostals 2. Diaphragm
Visual Inspection : Acessory muscle use – associated with ventilatory difficulty 1. Intercostals 2. scalene. 3. Sternocleidomastoid 4. Oblique, rectus abdomial muscles.
Visual Inspection : Nasal flaring Relates to ventilatory difficulty in the newborn.
Visual Inspection : Presence and nature of a cough 1. strenght of cough effort. 2. frequency. 3. Productive or not:> a. Blood(hemoptysis)-TB. B. Dry or non-productive- Lung cancer/foreign body. Yellow sputum-infection.
Visual Inspection: Chest movement-symmetry of movement – Asymmetrical 1. COPD. 2. Flail chest(broken ribs. 3. Pneumothorax. 4. ET tube advanced too far into one lung. 5. Significant atelectasis.
Visual Inspection: Chest movement-symmetry of movement – Normal Pattern 1. Thorax moves out on inspiration. 2. Abdomen moves out on inspiration.
Visual Inspection: Digital clubbing 1. Increased angle of the nail bed. 2. Associated w/ chronic hypoxemia (COPD).
Visual Inspection: Venous distension 1. Veins of the neck protrude during breathing. 2. Associated w/CHF and COPD.
Visual Inspection: Diaphoresis(Heavy sweating) 1. CHF. 2. Myocardial Infarction (described as cold and clammy skin) 3. Febrile conditions. 4. Night sweats (pt. w/TB.)
Visual Inspection: Peripheral edema 1. Found in extremities esp. in the lower legs. 2. Associated w/CHF and any fluid-shift disease.
Bedside Assessment :Adventious(abnormal) Breath Sounds-Wheeze 1. It is caused by Bronchoconstriction. 2. Bilateral wheeze is treated w/ a bronchodilator. 3. Unilateral wheeze could be caused by a foreign body obstructiob or a bronchial mass as seen w/ lung cancer and treat w/ bronchoscope.
Bedside Assessment :Adventious(abnormal) Breath Sounds-Rhonchi(coarse rales) 1. secretions in the large airways. 2. Often remedied by suctioning.
Bedside Assessment :Adventious(abnormal) Breath Sounds-Rales(crackles) 1. Secretions in the middle-sized airways. 2.Treated w/ CPT including postural drainage. 3. Fine crackles/rales indicates atelectasis- treat w/ hyperinflation therapy.
Bedside Assessment :Adventious(abnormal) Breath Sounds-stridor 1. Upper airway obstruction. 2. Possible foreign body aspiration. 3. If mild- Treat w/cool mist and hydration. 4. If moderate-treat w/racemic epinephrine. 4. If severe-intubate the pt. 5. If foreign body-perform bronchoscopy. Croup and epiglottis occurs.
Bedside Assessment :Adventious(abnormal) Breath Sounds-diminished(decreased breath sounds) 1. Indicates decresed air movement in the area. 2. Egophony- associated w/consolidation of secretions such as Pneumonia. 3. Bronchophony-Indicates consolidation. Whispered pectoriloquy is similar.
Bedside Assessment :Adventious(abnormal) Breath Sounds-friction rub 1. Caused from absence of fluid in the pleural space. 2. Treat w/ steroids for inflammation and antibiotics for infection. 3. May be seen in TB, Pulmonary infarction and pleurisy.
Bedside Assessment : Breath Sounds-Vesicular Normal breath sounds indicate normal lungs.
Bedside Assessment : Breath Sounds-define Percussion Done by tapping the knuckles while placed over the thorax.
Bedside Assessment : Breath Sounds-tones Percussion-resonant normal lungs.
Bedside Assessment : Breath Sounds-tones Percussion-Hyperresonant found in cases w/significant air-trapping, such as COPD and with Pneumothorx.
Bedside Assessment : Breath Sounds-tones Percussion-Dull When done over areas of infiltrates such as seen with Pneumonia.
Bedside Assessment : Breath Sounds-tones Percussion-Flat When done over bones or consolidated lung tissue (not fluid) such as seen with atelectasis.
Bedside Assessment : Breath Sounds-Pulse-Acceptable range 60-100 bpm
Bedside Assessment : Breath Sounds-Pulse-Tachycardia >100 bpm associated w/ Hypoxemia – pt. need more O2.
Bedside Assessment : Breath Sounds-Pulse-Bradycardia <60 bpm associated w/shock, Heart failure, seizure etc.
Bedside Assessment : Breath Sounds-Pulse-Pulses Paradoxus BP rise and fall during Inspiratory and expiratory efforts. associated w/ significant air-trapping such as in severe asthma/ status asthmaticus cases.
Bedside Assessment : Breath Sounds-Ventilation-Tidal Volume(VT) Should be @least 5ml/kg otherwise pt. needs ventilatory assistance.
Bedside Assessment : Breath Sounds-Ventilation-Vital Capacity(VC) Should be @least 10ml/kg otherwise pt. needs ventilatory assistance.
Bedside Assessment : Breath Sounds-Ventilation-Maximum Inspiratory pressure(MIP/MIF/NIP/NIF) Should be @least -20 cmH20
Bedside Assessment : Breath Sounds-Tracheal Palpation-Deviation toward the problem 1. Pulmonary fibrosis. 2. atelectasis. 3. lobectomy. 4. pneumothorax.
Bedside Assessment : Breath Sounds-Tracheal Palpation-Deviation away the problem 1. Tension pneumothorax/hemothorax. 2. Pleural effusion (very large).
Bedside Assessment : Breath Sounds-Blood Pressure-Acceptable range Normal – 120/80 mmHg.
Bedside Assessment : Breath Sounds-Blood Pressure- Decreased Associated w/shock/ significant fluid loss and dehydration.
Bedside Assessment : Breath Sounds-Blood Pressure – Increased Associated w/ anxiety, stress, cardiac problems and hypoxemia.
Bedside Assessment : Breath Sounds-Heart sounds Normal- S1 and S2. Abnormal- S3 and S4 indicates cardiac dysfunction-ECG is indicated.
Patient History: Patient Medical Record – History & Physical 1. Diagnosis 2. Chief complaint 3. objective information(signs) 4. subjective information(symptoms)
Patient History: Patient Medical Record – Occupational exposure Exposure to pulmonary irritants
Patient History: Patient Medical Record – Smoking history pack years = # of yrs. X # of pack/day smoked. 1. Cigars 2. Injuries 3. Current vital signs&medication 4. current repiratory care orders 5. Progress notes.
Patient History: Interview – Orientation 1.Orientation-name,place,day,language 2.Resp. ability-Dsypnea present&Orthopnea 3.Emotional State a)angry-electrolyte imbalance b)panic-hypoxemia,asthma,pneumothorax c)Euphoria-ingestional error(drug overdose) 4.Social Support System 5.Proper ques. tech.
Patient History: Interview – Other areas to assess 1. Home environment 2. Current care plan 3. pain location, quality and persistance 4. triggers to dyspnea 5. family medical history
ECG/EKG : recording equipment & supplies-Machine Computer Manages polarity(+ve/-ve) of each electrode. Helps in tracing hearts electro physiology
ECG/EKG : recording equipment & supplies- define Electrodes & Leads A lead may be an individual electrode or a a line of electricity between 2 electrodes. There are total of 12 electrodes.
ECG/EKG : recording equipment & supplies – 6 Chest leads V1-intercostal space, rt. Of sternum. V2-intercostal space just lft. Of sternum. V3- is b/w V2 &V4. V4- 5th-intercostal space in the lft. Of mid-clavicular line. V5- b/w V4 & V6. V6-intercostal space in the lft. Of mid-axillary line.
ECG/EKG : recording equipment & supplies- 6 limb leads LeadI- Left arm to rt. Arm. LeadII-left leg to rt. Arm. LeadIIIleft leg to left arm. – AVR-rt. Arm. AVL-left arm. AVF-left leg.
ECG/EKG : recording equipment & supplies- +ve Lead All precordial leads are positive.
ECG/EKG : recording equipment & supplies- determine which lead is positive and Negative. leads involving 2 electrodes, one must be +ve & other -ve. GUIDELINES:1.(Looking @ pt.), electrode most right is +ve. 2. electrode most downward is +ve. 3. Of lead I,right arm -ve,left arm +ve. 4.Of lead II,right arm -ve,left leg +ve.
ECG/EKG : recording equipment & supplies-Interpretations- 5 Rate Definition 1. Acceptable range (60-100bpm) 2. Bradycardia(<60) 3. Tachycardia(>100) 4. Flutter(>200) 5. Fibrillations(too fast; uncountable).
ECG/EKG : recording equipment & supplies- Rhythms- Sinus rhythm Normal. All the bumps (PQRST)are there especially the P wave.
ECG/EKG : recording equipment & supplies- Rhythms- Sinus Tachycardia >100. Treated w/O2.
ECG/EKG : recording equipment & supplies- Rhythms- Sinus Bradycardia <60 Treated w/ O2 and Atropine.
ECG/EKG : recording equipment & supplies- Rhythms- Premature ventricular contraction(PVC) wide QRS and depressed T- waves. Treated w/ O2 and Lidocaine.
ECG/EKG : recording equipment & supplies- Rhythms- Asystole 1. confirm in 2 chest leads. 2. Do not defibrilliate. 3. Treated w/ chest compression, epinephrine and atropine
ECG/EKG : recording equipment & supplies- Rhythms-Ventricular Fibrillation(v-fib) 1. treat w/ defibrillation @ 360 joules.
ECG/EKG : recording equipment & supplies- Rhythms- Ventricular tachycardia(V-tach) treat w/ defibrillation if no pulse. Then treat w/defibrillation @ 360 joules.
ECG/EKG : recording equipment & supplies- Heart Blocks- 1st degree 1. The distance between the beginning of the P-wave to the beginning of the QRS-complex (P-R interval) is greater>.20 secs. 2. Caused by ischemia/digitalis. 3. Treated w/ Atropine.
ECG/EKG : recording equipment & supplies- Heart Blocks- 2nd degree 1. Normal P-wave. 2. Missing QRS-comples. 3. Irregular rhythm. Treated w/ Atropine and electrical pacemaker is made ready.
ECG/EKG : recording equipment & supplies- Heart Blocks- 3rd degree 1. PR interval cannot be determined. 2. QRS is widened. 3. cannot identify waves consistently. 4. Pt. needs a pacemaker.
ECG/EKG : recording equipment & supplies- Define Axis 1.It is the angle in which electricity flows to the heart. 2. It flows down and to the left. 2.It only deviates from the normal for 2 reasons: a. Hypertrophy and b. Infarction.
ECG/EKG : recording equipment & supplies- Axis- Hypertrophy 1. It means size of the heart has increased. Therefore will require more electricity and slower conductivity. 2.Usually to the left is the axis deviation direction as seen in the CHF.
ECG/EKG : recording equipment & supplies- Axis -Infarction It means that tissue is dead and electricity cannot flow through dead tissue. So axis deviates away from the infarct tissue.
ECG/EKG : recording equipment & supplies- 3 Myocardinal “I”s 1. Myocardial Ischemia. 2. Myocardial Injury. 3. Myocardial Infarction.
ECG/EKG : recording equipment & supplies- Myocardinal Ischemia 1. Lack of O2 to the cardiac Muscle. 2. T-wave is depressed and will show a -ve deflection.
ECG/EKG : recording equipment & supplies- Myocardinal Injury 1. Damage of cardiac tissues -is in the dying stage. 2. S-T waves will be elevated or spiked from the baseline.
ECG/EKG : recording equipment & supplies- Myocardinal Infarction 1. Dead tissue (old / fresh). 2. Will produce a permanent Q-wave (wide,ht.and depth)
PFT:Slow Vital Capacity(SVC) 1. Maximum volume a patient can exhale after a maximal inhalation 2. It is to measure restrictive lung disease.
PFT:Forced Vital Capacity(FVC) 1. Maximum volume a patient can forcefully exhale after a maximal inhalation & in least possible time 2.Important to measure FVC both volume & flow 3.FV1/FVC is a best indicator of obstruction 4.Range-normal-85% min. is 75%. Obstructive is present if <75%
PFT:Maximum Voluntary Ventilation(MVV) 1. Relates to muscle endurance & general function. 2. it is the max. amount of gas that pt. moves in & out of the lungs in 12-15 secs. 3. but this is not a good test bcoz it is difficult to get adequate cooperation.
PFT:Flow-volume Loop(FVL) 1.includes FVC 2. used to evaluate vocal cord dysfunction,paralysis&cancerous(Round loop)masses in upper airway. 3. shape of the loop:a)tall&skinny loop-restrictive b)short&fat loop obstructive c)Round loop- large fixed airway obstruction.
PFT:Lung Volumes(Nitrogen washout & Helium dilution) 1.PURPOSE to determine FRC&RV 2.procedure involves breathing 100% O2 while exhaled nitrogen is analyzed until depleted then a calculation is made to project lung volume.3.He&N analyzer must be caliberated. He should read 0% caliberated to room air.
PFT:Gas Distribution(SBN2) 1.It is to eliminate single breath nitrogen 2. consists 4 phases 3. done during exhalation.
PFT:Body Box (Plethysmography) 1. measures FRC & total thoracic gas volume(TLC). 2. replaces He&N dilution methods 3. also measures RAW
PFT:Diffusion studies(DLCO/DCO) 1. Normal DLCO=25 mL CO/min/mmHg(STPD) 2. Poor DLCO usually found in restrictive disease affecting alveolar capillary membrane(ACM) eg. ARDS. Emphysema is only obstructive disease with poor DLCO 3.DLCO measures how well gases move across ACM.
PFT:Bronchial Provocation 1. determines ability to provoke bronchoconstriction.
PFT:Pre & Post bronchodilator studies 1. needed to determine effectiveness of bronchodilator medications & help determine dosage. 2. Helpful in determining reversibility of bronchoconstriction.
PFT:Ventilatory response to CO2 Study shows change in ventilation as a response to increases CO2 while keeping PaO2 steady.
Obstructive Impairment 1. FEV1/FVC – If less than 75% then pt. is Obstructive. If FV1/FVC is not available then check or FEV1 by itself and if FEV1- less than 80% then pt. is obstructive too.
Restrictive Impairment 1. FVC- If less than 80% then pt. is Restrictive. If greater then not restrictive. Look@ SVC first. If not available then check FVC.
Diffusion impaired Vs Normal Diffusion 1. DLCO- if less than 80% of predicted (<20mlCO/min/mmHg) then pt. has diffuion impariment.
Categorizing Interpretation of Obstructie & Restrictive & Diffusion Impairment 1.Normal-80%. 2. Mild-60-80%. 3. Moderate-40-60%. 4. Severe- <40% .
Best Test Determination of FEV1 & FVC Best Test = Highest (FEV1 + FVC)
Spirometer It is caliberated using a 3.0 L syringe
5 Obstructive Diseases C BABE-1.Cystic Fibrosis 2. Bronchiectasis 3. Asthma 4. Bronchitis 5. Emphysema
Which obstructive disease is commonly associated with poor DLCO? Emphysema
Hemodynamics .
Anatomy of Circulatory system Right Atrium–>Tricupsid valve–>Right Ventricle –>Pulmonary Artery–>Lung Capillaries–>Pulmonary Vein–>Left atrium–>Bicuspid/mitral valve–>Left ventricle–>Systemic Vascular system(body&capillaries)….back to right atrium
Normal BP 120/80 mmHg(mean-93 mmHg)
Mean Pressue Formula Mean BP =((1 x systolic) + (2 x diastolic)) / 3
3 Mechanisms of BP 1. Heart 2. Blood 3. Vessels
Normal Hemodynamic values(CVP,PAP,PCWP,CO,SV,EF,CI) :Means & Ranges CVP:2-6 mmHg(mean 4-12 cmH2O) PAP:25/8mmHg(mean-14 mmHg) 3. PCWP:4-12 mmHg(normal 8 mmHg) 4. CO:4-8 L/min 5. Stroke Volume(SV):60-130mL 6. Ejection Fraction: 65-75% 7. Cardiac Index(CI):2.5-4.0m2
Central Venous Pressure(CVP) 1.measurement taken in Rt. Atrium immediately before the atrium 2. when high it relates to fluid overload- diurese pt. 3.when low it relates to dehydration/vasodilation- give fluids/vasoconstricting drugs. 4. related to function the rt. heart in general.
Central Venous Pressure(CVP)-Other Names 1. Right Atrial Pressure 2. Right side preload 3. Right ventricular filling presure 4. Right ventricular end-diastolic pressure 5. ALL descriptions use the word RIGHT for CVP.
Pulmonary Artery Pressure(PAP) 1. measurement taken with a transducer at the tip of a catheter placed in the pulmonary artery. 2. high with COPD patients. 3. best place to get a mixed-venous blood sample. 4. also know as Right Ventricular after load.
Pulmonary Capillary Wedge Pressure(PCWP) 1. Measurement taken with ballon-tipped catheter inflated and wedged in the pulmonary artery. 2. Relates to the function of left heart. 3. diastolic portion of the PAP can be substituted when a PCWP is not possible.
Pulmonary Capillary Wedge Pressure(PCWP): Other Names 1. Pulmonary venous drainage 2. Left artrial pressure 3. Left ventricular filling pressure 4. Left Preload 5. Left ventricular end-diastolic preload.
Cardiac Output(CO/QT) 1.expressed as vol. than pressure. 2.also expressed by Cardiac index CI=QT/BSA 3.relates condition of Lft.ventricle 4.measured by a computer thru thermal dilution. 5.calculated by Fick eq.& SV*HR. if QT is decreased – treat w/cardiac medications-Digitalis
Hemodynamic measurements are taken from various ports in a catheter that is inserted via the Vena Cava thru the Right Artery & Right Ventricle ending in the pulmonary artery
Hemodynamic Calculations: Systemic Vascular Resistance(SVR), Formula & Normal ((MAP-CVP)/QT) x 80, normal: 1600 dynes/sec/cm-5
Hemodynamic Calculations:Pulmonary Vascular Resistance(PVR), Formula & Normal ((Mean PAP-PCWP)/QT) x 80, normal: 200 dynes/sec/cm-5
Echocardiogram: Adults helps to visualize(ultrasonically) function of the heart (in M-mode) including ejection fraction and assess general function of the left ventricle
Echocardiogram:Infants Helps to visualize cardiac-related anatomy- especially when suspecting congenital heart and abnormalities
Echocardiogram:Infants-Anatomical Abnormalities 1. Transpostion of the Great Vessels 2. Tetralogy of Fallot 3. Atrial septal defect (ASD) & Ventricular septal defect (VSD) 4. Patent ductus arteriosis (PDA) 5. Coarctation of the aorta.
ECG Technology 1. Ultrasonic procedure combined with a computer to compose two-dimensional and M-mode ECG 2. It is Non-invasive, safe, free of radiation.
ECG Indications 1. to determine adequacy of blood flow & pump function. 2. Examine size & disease state of cardiac tissue. 3. Inspect cardiac valve function
Intracranial Pressure (ICP) Monitoring: Acceptable Range, define Increased ICP 1. 5-10 mmHg. 2. Increased ICP means -a volume of cerebral fluid in the brain is under significant pressure – should be treated if ICP > 20 mmHg
Intracranial Pressure (ICP) Monitoring: Technology 1. Requires access to the brain through a hole in the skull. A) Subarachnoid bolt – metal screw-like device inserted into the subdural space. B) Ventricular Catheter – placed in a surgical hole in the skull.
Intracranial Pressure (ICP) Monitoring: Treatment & Prevention 1. Diamox(acetazolamide) – cerebral diuretic 2. Osmitrol (mannitol) – cereberal diuretic 3. Avoid frequent & vigorous suctioning 4. keep patient sedated to avoid coughing.
Intracranial Pressure (ICP) Monitoring: Causes of increased ICP 1. Head trauma ( subdural hematoma) 2. Tumors 3. Meningitis 4. Cerebral edema.
Electroencephalography(EEG): Define Determines electrical activity of the brain
Electroencephalography(EEG): Indications 1. sleep disorders 2. Evaluate for epilepsy 3. Determine degree of retradation 4. Unexplain loss of brain function 5. head trauma.
Pulmonary Angiography 1.Useful in diagonising pulmonary embolism 2.definitive than V/Q Scan but expensive. 3.it involves injecting a contrasting solution thru a catheter into pulmonary artery. Pt. is monitored radiologically&areas of good, poor&absent blood flow are identified
Assessment of the Newborn upon Birth & Routine : APGAR 1. Appearance/color 2. Pulse 3. Grimace / Reflex Irritability 4. Activity – muscle movement & tone 5. Respiratory effort – presence of a cry.
Assessment of the Newborn upon Birth & Routine : APGAR Scoring 1. Done after 1 min.(neonatal survival) & 5min(Future neonatal brain damage). 2. Scores between 0 & 10 3. The higher the score the better: a)7-10 points – Routine care b)4-6: support with O2,warmth & general simulation. 3. 0-3:CPR (heart/lungs or both).
Assessment of the Newborn upon Birth & Routine : Routine Assessment: Vital Signs-Pulse 1. Normal Pulse:110-160bpm. 2. >170-tachycardia-give O2 3. Pulse can be taken brachially or femorally(not radially). 4. Any Cardiopulmonary challenge will cause will cause an increase in infant’s heart rate (not an increase in contractility).
Assessment of the Newborn upon Birth & Routine : Routine Assessment: Vital Signs- RR & Pattern 1.Range:30-60/min. 2. Normal Apnea:10 secs. 3. Acceptable Apnea:lasting 10-20 4. if apnea > 20 secs, infant needs further investigation & apnea monitoring
Assessment of the Newborn upon Birth & Routine : Routine Assessment: Vital Signs – BP 1. Normal : 60/40 mmHg. 2. Pre-term infants: 55/33 mmHg
Assessment of the Newborn upon Birth & Routine : Routine Assessment: Vital Signs – Temperature 1.Normal:36-37degree C. 2.Infants looses body temp. quickly& easily. 3.Servo-controlled radiant warmer/incubator should be used. 4.Servo control should be connected to a probe placed on the infant’ skin – low skin temp. alarm sound if probe comes off skin
Newborn Medical History : Perinatal History 1. Maternal History 2. Family History.
Newborn Medical History : Gestational Age 1. Term infant-38-42 weeks. 2. pre-term infant-<38 weeks. 3. post-term infant->42 weeks.
Newborn Medical History : Birth Rate 1.Normal: 3000 grams. 2. Low birth wt. – risk of complications. 3. Minimal surviable age and week – 26-28 weeks annd round 100 grams.
Newborn Physical Assessment : Color Blue extremities, pink body – called acrocyanosis.
Newborn Physical Assessment : RR Pattern sign of ventilatory distress 1)Retractions: a)Intercostal b)Subcostal c)Substernal d)Supraclavicular 2)Grunting:upon exhalation causes natural PEEP. 3) Nasal Flaring
Newborn Physical Assessment : Capillary Refill Increased refill times indicates problems with cardiac output.
Newborn Lab Assessment : ABG Normal PaO2:50-80 mmHg. 2)done conservatively because infant’s blood is scarce
Newborn Lab Assessment : ABG- How do you rule out a patent ductus arteriosis(PDA). If PaO2 from right radial artery(pre-ductal) & umbilical artery(post-ductal) is greater>15mmHg then infant is +ve for PDA then send to surgery for correction.
Newborn Lab Assessment : Blood Glucose Range- greater>30mg/dL 2)for pre-term infants Range:greater>20mg/dL
Newborn Lab Assessment : Lenithin/Sphinogomyelin(L/S Ratio) 1) Normal- 2:1 2)relates to lung maturity 3)if 1:1 is bad administer pulmonary surfactant.
Newborn Lab Assessment : Phosphatidyglycerol (PG Level) accurate lung maturity even in the presence of diabetes.
Newborn Lab Assessment : Phosphatydlchloride (PC Level) alternate indicator of lung maturity.