The efficiency of external respiration is dependant on what (3) factors?1)Alveolar ventilation, Is it adequate? 2)matching of V/Q 3)membrane diffusion across A.C membrane
3 factors involved in oxygen delivery1)O2 loading 2)O2 unloading 3)O2 transport
O2 loading“external” respiration gas exchange of 02 and CO2 from the atmosphere to the alveoli at the AC membrane
02 unloading” internal” respiration gas exchange at systemic capilaries(blood and tissues)
02 transportrequires a normal Hgb concentration as well as an adequate cardiac output
Why does V/Q mismatch occur even in the normal lung?There is a normal physiologic shunt of 3% in the normal healthy adult. 2% of cardiac output bypasses the lung,and 1% relative capillary shunting also occurs
what is the normal vd/vt ratio in a spontaneous breathing individual.40 with a somewhat higher ratio being acceptable for patients on mechanical ventilatory support
The distribution of ventilation in the lung depends on regional differences in ———-and ————-.CL and RAW
A vd/vt ratio of .7 means that:70% of the vt is lost to vd. The patient would need to be placed on mechanical ventilation. Their lungs are not ventilating adequately.
Cardiac output =stroke volume X heartrate
At residual volume most gas entering the lungs would go to the apices or bases?apices
Most gas inhaled during normal breathing from normal FRC enters the apices or bases?bases
Will a change in FRC affect the distribution of ventilation?Yes
A patient’s minute ventilation is 10 lpm, her respirator rate is 22, and her PaCO2 is 55 mmHg. You would expect that she may be experiencing:increased deadspace ventilation,increased work of breathing, and decreased alveolar ventilation
A pulmonary embolus would increase shunt or deadspace in the affected area?Deadspace
A totally atelectatic alveolus would increase shunt or deadspace in the affected area?shunt
Normal anatomic shunt is approximately what percent of cardiac output2%
What diffuses about 20x faster than O2 across the a-c membrane?CO2
what are the 2 major requirements for successful pulmonary diffusion?1) adequate time for for gases to equilibrate across the Alveolar capillary membrane2) their needs to be enough surface area to permit gas exchange at the alveolar capillary membrane
Hgb tends to combine 4 oxygen molecules or none, true or falsetrue
what is the normal value range for hemoglobin in males?15 g/100ml
What is the normal value range for hemoglobin in females?13-14 g/100ml
physiological deadspacethe sum of all alveolar and anatomic deadspace
shuntblood is perfused but not ventilated
anatomic deadspacethe quantity of gas remaining in the airway at the end of each breath
anatomic shuntingthe pleural, bronchial and thebesian largely veins contribute to this form of normal shunting
mechanical deadspacerepresented by the volume of exhaled gas remaining within a ventilator circuit or an oxygen mask, which is then inspired on the next breath
relative capillary shuntingthis form of shunting would be represented by an alveolus at which the volume of perfusion exceeds the volume of ventilation to the alveolus
what is the numerical difference between the normal total base in a blood sample and the actual amount of base in the sample?base excess
What is a SPAGnebulizer designed to admin Ribavirn
What nebulizer should RTT where mask gloves gown and goggles when delivering meds withSPAG
What is a USNultrasonic nebulizer
What is the particle size of a USNfine
How does USN workradio frequency generator produces high frequency vibrations across piezoelectric transducer or crystal, breaks up meds, frequency determines particles size, amplitude determines volume
Best nebulizer of choice for pt with thick retained secretionsUSN
How does RTT control the volume on a USNamplitude, can go as high as 6 l/m (2x higher than other nebs)
Hazards of USNover hydration, bronchospasm, sudden mobilization of secretions, electrical shock, water in tube from condensation, nosocomial infections, drug dosing changes caused by reconcentrations in nebulizer as treatment continues
Why must RTT be concerned about condensation in the tubing during neb treatmentaccidental pt lavage, water in tube caused decreased flow and increased FIO2
What kind of mask is most often used with a SPAGtent or hood
You are delivering humidity to pt at 30 percent but when you analyze it, it reads 60 percent, what is the problemcondensation in the tube increases FIO2
What is a Passover humidifiernon heated low humidity appox 25 percent body humidity
What is a bubble humidifierthe most common non heated humidifier, body humidity of 35 to 40 percent, usually for nasal canulla
What is a diffuser humidifierhigh output aerosol neb often used with CPAP, heated, uses evaporation to produce high humidity at high flow (misty ox)
What is the cascade humidifierheated humidifier most often used with vent pt, water passes over a grid, capable of deliver 100 percent humidity at high flows
What is a wick or concha humidifierheated humidifier, water passes over wick made of paper, cloth or sponge, produces humidity close to 100 percent, best for artificial airway for pt on vent
What is an HMEheat moisture exchange, device placed between pt and wye on vent circuit, body humidity is collected and then used to humidify next insp, ideally 70-90 humidity is produced
How often do we change out the humidifier circuit to prevent pseudomonasevery 24 hours
Therapeutic range for aerosol meds is.5 to 3 microns
What is an HHNhand held nebulizer aka SVN
What is the volume of an SVNless than 30 ml
What is the particle size of an SVN1.5 to 7 microns
Respigard II SVN is used for whattamadine or pentamidine medication for treating C Pneumonia in AIDS pts
AeroEclipse is whatbreath actuated nebulizer used in many hospitals today, saves meds and gives shorter treatment
MDI’s are more effective with whatspacer and good pt education
DPI is whatdry powder inhaler
What is the downside of DPIpt must have a strong enough inspiratory flow to get meds
What is the upside to DPI’sdo not take the same pt coordination as MDI
What is the purpose of large volume nebsprovide continuous aerosol therapy, refill every 4 to 8 hours depending on flow and heat
Allegiance health LVNair entrainment prefilled neb for cool or heat 21 to 100 percent
Misty ox hi-fi nebair entrainment 60-90 percent on flows of 42 to 77 L/M
Misty ox gas injection neb or GIN21 to 100 percent at rates over 100 L/M not an air entrainment device, used with CPAP, requires 2 gas sources if greater that 75percent
Heart nebused if giving continuous aerosolized meds like albuterol for status asthmaticus, 240 ml reservoir
What is humiditywater in a gaseous states
What are the advantages of MDIconvenient, inexpensive, portable, no drug prep, hard to contaminate
What are the disadvantages of MDIpt coordination and activation, increased pharyngeal deposits, abuse, no high doses, not all meds available, CFC’s
What are the advantages of SVNless pt coordination, high doses, even and continuous, no CFC
What are the disadvantages of svn’sexpensive, wasteful, drug prep, contamination, not all drugs available press source required, long treatment time
Hazards of aerosols arewheezing and bronchospasm esp with copd, broncoconstriction with artificial airway, infection, overhydration, pt discomfort, rtt exposure, edema
Contraindications of aerosol areBronchoconstriction, history of airway hyperresponsive
Indications of aerosol areupper airway edema (cool), LTB, subglottic edema, post extubation edema, post op mgmt of upper airway, sputum specimen or mobilize secretions
Body humidity is44 mg/L always, regardless of body temp or outside temp
Actual humidityRH x capacity
Aerosol is whatliquid particles suspended in gas
Bland aerosol therapy is whatsterile hypo, hyper or normal saline in aerosol
What is the primary purpose of humidity therapyhumidify dry medical gases to overcome humidity deficit when upper airway is bypassed
What is the secondary purpose of humidity therapyheated to manage hypothermia or treat bronchospasm from cold air
How do you tell if a non heated humidifier has a leakall have pop off at 2 psi, kink the hose if pop off does NOT sound, you have a leak
Where do you monitor temp of humidityinsp side at wye
Passover humidifiers arewick-air flows over wick, membrane-gas passes through hydrophobic membrane, USN-prezo electronic crystal
Contraindications of HMEthick copious secretions, less than 70 VT, less than 32 body temp, great than 10 min vent
Hazards of HMEunder hydration, mucus plugging, increased WOB, hypoventilation from increased dead space, ineffective pop off, hypothermia
Contraindications for heated humidifiersthere are none
Hazards of heated humidifiershigh flow at disconnect will spray contaminated condensation, under hydration, mucus plugging, inc WOB, wrong FIO2 from condensation in tubing, hypothermia, burns, lavage
Relative humidity isactual humidity divided by capacity
Indications for humidity areall vent patients with endotrach or tracheostomy, primary – pt receiving dry gas, upper airway bypassed, secondary – mgmt of hypothermia and bronchospasm from cold air
Which nebulizer administers particles with sizes 0.5-3.0 microns and allows for the greatest deposition of aerosol?Ultrasonic nebulizers
n-acetylcysteinemucolytic,Mucomyst,acetaminophen (tylonol) poisoning
albuterol+ipratropiumbeta-agonist+anticholinergic, Combivent = Ventolin and Atrovent
albuterolsympathomimetic bronchodilator aka B2 bronchodilator Proventol, Ventolin, stimulates cAMP, strong B2, mild B1, rapid/short
atropineprototype anticholenergic,stimulant prior to surgery to decrease secretions
beclamethasonecorticosteroids,Vanceril,low systemic side effects, rapid absorb, long lasting anti-inflammatory
bitolterolsympathomimetic bronchodilator PRODRUG, Tornalate, stimulates cAMP, strong B2, mild B1, rapid and short
budesonidecorticosteroids, Pulmacort, only nebulized steroid, only in 10-20% solution special nebulizer, do not mix with other drugs
cromolyn sodiummast cell stabilizer,Intal, prophylactic anti-asthmatic, 2-4 week start up, very safe, not an anti inflammatory not for acute symptoms
Dornase alphamucolytic,Pulmozyme,purulent secretions of cf and bronchiectisis, lyces DNA of bacteria and cellular debri
Epinephrineadrenergic catecholamine, strong side effects, ultra short duration less than 1 hour, strong a, B1, B2
flunisolidecorticosteroids,Aerobid,rapid absorb, short life, several days to ramp up, long term asthma management anti-inflammatory
Fluticasonecorticosteroids,Flovent,”rapid absorb, long life, low side effects, anti-inflammatory, “
glycopyrrolateanticholenergic,Robinal,drying agent used in bronchorrhea
Ipratropiumanticholenergic,Atrovent,”blocks ACH, bronchodilation (COPD)”
Isoproterenoladrenergic catecholamine,Isuprel,very short duration ,less than 3 hours, stimulates cAMP, strong a, and B2, vasodilation bronchodilation
Levalbuterolbeta agonist-short acting,Xopenex,” single isomer, no a, no B1, very low side effects”
Metaproterenolresorcinol/beta agonist,”Metaprel,Alupent”,”strong side affects, slow to reach peak”
montelukastleukotrine blocker,Singulair,”great for kids with RAD, exercise and maintenance, allergies and asthma-no side effects”
nedocromil sodiummast cell stabilizer,Tilade,”prophylactic anti-asthmatic, 2-4 week start up, can be used for exercise “
Pirbuterolbeta agonist-short acting,Maxair,
Prednisonesteroid,”acute asthma treatment, acute bronchospasm”
Racemic epinephrineadrenergic catecholamine,Micronephrine, Vaponephrine”,”very short duration < 3 hour, strong a, B1, B2used in croup, swelling and edema from burns or post extubation (never orally), hourly”
salmeterolbeta agonist-long acting,Serevent,”not a rescue, best for treating chronic asthmatic symptoms,long acting”
salmeterol+fluticasonebeta agonist+steroid,Advair (salmeterol+fluticasone),long acting management with anti-inflammatory for long term maintenance of asthma
Sodium bicarbonatemucolytic,pH disrupts amino acid chain, not used much
terbutalineresorcinol, modified catecholamine (used to treat contractions)
theophyllinexanthine,,caffeine is first line for apnea in preemies
tiotropiumanticholenergic,Spiriva,”blocks ACH, bronchodilation (COPD)”
zafirlukastleukotrine blocker,Accolate,”side effect-liver failure, not convenient must take on empty stomach”
zileutinleukotrine blocker,Zyfloe,extended release pill
adrenergic catecholamine drugs are?epinephrine, isporoterenol (Isuprel), racemic epi(Vaponephrine)
Xanthines drugstheophylline (caffeine, used in treatment of apnea in preemies and drug of last resort for COPD
Resorcinol/beta agonist drugsmetaproterenol (Metaprel, Alupent), terbutaline (Brethine, Brethaire)
Leukotrine blocker drugsmontelukast (Singulair), Zafirlukast (Accolate), zileutin (Zyflo) (all leukotrine blockers are oral) FYI: great way to remember zafir-LUK-AST, monte-LUK-AST ARE anti-LUKkotrienes for ASThma
Mast cell stabilizer drugscromolyn sodium (Intal), nedocromil sodium (Tilad)
Mucolytic Drugsn-acetylcysteine (Mucomyst), dornase alpha (Pulmozyme), sodium bicarb
Aerosol corticosteroids drugsbeclamethasone (Vanceril), Budesonide (Pulmacort), flunisolide (Aerobid), fluticasone (Flovent), Triamcinolone (Azmacort)
Late phase anti-asthmatic anti-inflammatory drugsDecadron and salmeterol, by IV or IM
Beta agonist drugs short actinglevalbuterol (Xopenex), pirbuterol (Maxair), Albuterol (Provental, Ventolin), bitolterol (Tornalate)
Beta agonist drugs long actingsalmeterol (Serevent)
Beta agonist + steroid drugsAdvair (salmeterol + Fluticasone}
Anticholenergic drugsatropine, glycopyrrolate (Robinal), ipratropium (Atrovent), tiatropium (Spiriva)
Oral corticosteroid drugsPrednisone
Anti-asthmatic drugsmast cell stabilizers (Intal & Tilade) and leukotriene blockers (Singulair, Accolate & zileutin aka Zyflo)
aerosol Antiprotozoal drugspentadine (treatment of pneumonia in AIDS patients)
aerosol Antiviral drugsribavarin (treatment for RSV in infants and children)
Combivent(albuterol + ipratropium) B2 + anticholenergic 1+1+3
beractantSurvanta, prophylactic surface tention lowering agent given as surfactant replacement drug via direct installation to preemies
colfoscerilExosurf, synthetic surfactant replacement for preemies
ethyl alcoholEthanol, drying agent, treatment for fulminant alveolar pulomary edema, dose is 5-15 ml of 30-50% via svn
pentadineAntiprotozoal drug (treatment of pneumonia in AIDS patients)
ribavarinAntiviral drug (treatment for RSV in infants and children)FYI, remember this one because RIBAvarin treats Rsv, Influenza B, and is Anti-VIRus
AdvairBeta agonist + steroid drug (salmeterol + Fluticasone)
PrednisoneOral corticosteroid drug
theophyllineXanthines drugs caffeine, used in treatment of apnea in preemies and drug of last resort for COPD
Mucomystn-acetylcysteine, mucolytic, ,acetaminophen (tylonol) poisoning
CombiventVentelin and Atrovent Albuterol sympathomimetic bronchodilator,”Proventol, Ventolin”stimulates cAMP, strong B2, mild B1, rapid/short”
prototype anticholenergicatropine
Vancerilbeclamethasone, corticosteroids, ,low systemic side effects, rapid absorb, long lasting anti-inflammatory
Tornalatebitolterol, sympathomimetic bronchodilator, stimulates cAMP, strong B2, mild B1, rapid/short, PRODRUG
sympathomimetic bronchodilator PRODRUGTornalate/ bitolterol
Pulmacortbudesonide corticosteroids, , only nebulized steroid, only in 10-20% solution” special nebulizer, do not mix with other drugs
Intalcromolyn sodium, mast cell stabilizer, prophylactic anti-asthmatic, 2-4 week start up, very safe, not an anti inflammatory not for acute symptoms
PulmozymeDornase alpha, mucolytic, purulent secretions of CF and bronchiectisis, lyces DNA of bacteria and cellular debri
adrenergic catecholamine drugsEpinephrine, Isoproterenol (Isuprel) and racemic epi (Vaponephrine)
Aerobidflunisolide corticosteroids, ,rapid absorb, short life, several days to ramp up, long term asthma management anti-inflammatory
Floventfluticasone, corticosteroids, rapid absorb, long life, low side effects, anti-inflammatory
Robinalglycopyrrolate, anticholenergic, drying agent used in bronchorrhea
AtroventIpratropium , anticholenergic, blocks ACH, bronchodilation (COPD)
IsuprelIsoproterenol, adrenergic catecholamine, very short duration ,<3 hours, stimulates cAMP, strong a, and B2, vasodilation bronchodilation
XopenexLevalbuterol, B2-agonist, short acting, single isomer, no a, no B1, very low side effects”
Alupentmetaproterenol, resorcinol/beta agonist, strong side affects, slow to reach peak
Singulairmontelukast, leukotrine blocker, great for kids with RAD, exercise and maintenance, allergies and asthma-no side effects
Tiladenedocromil sodium, mast cell stabilizer, prophylactic anti-asthmatic, 2-4 week start up, can be used for exercise
Maxairpirbuterol, beta agonist-short acting
VaponephrineRacemic epinephrine, adrenergic catecholamine, very short duration < 3 hour, strong a, B1, B2, used in croup, swelling and edema from burns or post extubation (never orally), can be given hourly”
Sereventsalmeterol, beta agonist-long acting, not a rescue, best for treating chronic asthmatic symptoms
Advairsalmeterol+fluticasone, B2-agonist+steroid, long acting management with anti-inflammatory for long term maintenance of asthma
Spirivatiatropium, anticholenergic, blocks ACH, bronchodilation (COPD)
AzmacortTriamcinolone, corticosteroid
Accolatezafirlukast, leukotrine blocker, side effect-liver failure, not convenient must take on empty stomach
Zyfloezileutin, leukotrine blocker, extended release pill
Xanthines drug istheophylline (caffeine, used in treatment of apnea in preemies and drug of last resort for COPD
Survantaberactant, prophylactic surface tension lowering agent given as surfactant replacement drug via direct installation to preemies
Exosurfcolfosceril, synthetic surfactant replacement for preemies
What does assisting ventilation related to?It relates to an Acute need to resolve a threathening under a ventilation problem
What are the 3 devices used for assisting Ventilation?1. IPPB 2. BIPAP 3. Resuscitation Bag-valve.
What is IPPB?1. It is a therapy to improve ventilation but can also provide complete ventilation. 2. the problem is that ventilatory support by mask is only effective during the therapy. 3.Pt. may have ventilatory problems when the treatment is over.
What is BIPAP?It delivers an inspiratory & expiratory pressure. Inspiratory pressure must exceed expiriatory pressure. Actual ventilatory pressure = inspiratory pressure – expiratory pressure.
What are the other names of BIPAP?1. Bilevel Therapy 2. Non-invasive positive pressure ventilation(NPPV/NIPPV)
What is Resuscitation Bag-valve?1.Ventilatory assistance can be provided using a bag & mask. 2.It provides full ventillatory support. 3. It is not a long term solution
How do you we react in a situation in which a pt. is having a Foreign Object & is causing Airway Obstruction?1. Pt. is unable to speak 2. We may hold hand to neck to check sign of breathing & we address the problem by doing ABDOMINAL THRUSTS.
What is the procedure for an ABDOMINAL THRUST?Wrap arms around pt. from behind, place fist mid-abdomen &deliver upward thrust. Periodically check for clear airway/chest movement. Continue thrusts until airway is clear- even if pt. loses HR & Collapses. Before anything we must 1st address ventilation
In what patients are we not suppose to do the ABDOMINAL THRUST? What is the alternative for those patients?If patient is obese/pregnants/infant, use CHEST THRUSTS.
What are the hazards for these procedures – ABDOMINAL & chest thrust?1. Organ trauma 2.Fractured ribs 3. Cardiac Contusion(chest thrust 4. Pneumothorax. Even if these occurs do not stop CPR.
Anticholenergic actionblocks ACH causing bronchodilation
calculating dosemg=mL x % x 10
powder aerosolsactivated by pt breath, advantage is pt must breath correctly for device to work, no propellant
Checking MDI contentsfull=fully submerged and upside down in water, 1/2 full= upside down but not fully submerged, empty, canister will float on side
MDI techniquehold 1″ from mouth, exhale normally, squeeze MDI at beginning of slow deep inhalation, inhale fully and hold for 5 seconds, exhale-wait 2 mins and repeat.
sympathomimetic bronchodilators method of actionstimulate production of cAMP causing bronchodilation
Adrenergic agonist method of actionstimulates G protein in bronchial smooth muscle, G protein makes cAMP and cAMP equals bronchodilation
atropine and method of actionaka anticholinergic, aka antimuscarinic, blocks ACH receptor sites, causes bronchodilation by blocking ACH, competitive antagonist for M receptor
Cholinergicindirect acting, drug that acts or mimics parasympathetic action, stimulates M receptor
ACH regulation1. metabolized by enzyme ACHase aka acetylcholinesterase 2. ACH blockers like atropine, Ipratropium or Tiotropium
NE regulation at synapse1. re-uptake via active transport 2. MOA and COMT enzymes
NE regulation at cellscells regulate NE by increasing cAMP or blocking phosphodiesterase (enzyme that breaks up cAMP)
Un-ionizedun-ionized are very water and lipid soluble and absorb quickly, because they are able to pass easily through plasma membrane
Muscarinicreceptor site of ACH, parasympathetic, class of drugs that stimulate ACH, action is decreased HR, bronchoconstriction and vasodilation
Potentiationspecial case of synergism where one has no effect but can increase the effectiveness of the other 1+0=2
Nenorepinephrine, neurotransmitter of sympathetic nervous system, receptors sites are a, B1 and B2
a actionvasoconstriction, increased BP, stops bleeding,decrease swelling,
B1 actionincreased HR, increased contractility, increased cardiac output
B2 actionsmooth muscle relax, bronchodilation
Metabolismliver * alphabetically e and k come first in alphabet fallowed by l and m, so excretion = kidney and liver=metabolism
Excretionkidneys * alphabetically e and k come first in alphabet fallowed by l and m, so excretion equal kidney and liver equals metabolism, excretions also takes place in lungs and GI tract
ACHaseacetylcholinesterase aka ACHE, enzyme that metabolizes excess ACH
Drug absorptionmany membranes; stomach, capillaries and tissues-3 factors, transport mechanism, lipid solubility and drug ionization (un-ionized)
ACHaka acetylcholine, aka cholinergic, aka parasympathetic, receptor site M, action decreased HR, decreased BP, bronchoconstriction
Potencymore physiological effect with smaller dose, more potent-more toxic, lower the effective dose-more potent
Parenteralinjectable aka IM, IV
EntralGI tract, pills caplets, suppository, elixir, suspension (most common)
Topicaltransdermal, cream patch ointment, inhaled, MDI, DPI, SVN, USN, atomized, vaporized
Adrenergicreceptor site of Sympathetic NS aka adrenomimetic, receptors sites are a, B1 and B2
Pharmacokineticsquantifies the time required for drug absorption, distribution, metabolism and method of excretion
tid3 times per day
q4hevery 4 hours
qid4 times daily
bid2 times daily
drug distributionplasma protein binding, tissue affinity and blood flow
drug transportpassive diffusion (most common) moves from high to low, filtration, and active transport
prototype“a drug that acts like” i.e. atropine is prototype anticholinergic and epinephrine is prototype adrenergic
pharmacodynamicsstudies the actions of drugs on the body, how drugs work
sympathetic nervous systemfight or flight aka adrenergic, more dominant side of ANS, functions as a unit, effector site neurotransmitter is Ne. increases HR, increases BP, vasoconstriction, bronchodilation, contractility
LD 50median lethal dose
TITherapeutic Index, ratio of LD50 to ED50 indicates drugs safety, lower TI is the more toxic the drug, higher the TI, the safer the drug.
Antimuscarinicspecifically blocks m receptor sites
Competitive antagonistcompetes for receptor site, blocks but has no effect
Functional antagonisteffects of two drugs cancel each other out
ED50effective dose
Idiosyncrasyunexplained or unpredictable susceptibility to a drugs action
Tachyphylaxisrapidly developing tolerance to a drug
Anticholinesteraseblocks ACHase enzyme
COMP & MOAenzymes that metabolize excess Ne, can be injected or inhaled
Pharmacologystudy of drugs and their origin plants animals and minerals
Epinephrinenot a neurotransmitter, released by adrenal gland in response to sympathetic activation
Ceiling effectresponse increases with dose until dosage increase does not increase effect-used to check relative potency of 2 or more drugs
Phosphodiesteraseenzyme that breaks up cAMP
Choline esters actionstimulate m receptors and mimic effects of ACH
SLUDsalivation, lacrimation, urination, defecation; to much ACH to much slud, to much slud –death
Antagonist categoriescompetitive (affinity but no effect), functional (effects of 2 cancel each other), chemical (physically chemically binds in blood stream)
Additive effecttwo drugs act on receptors to have a combined effect that is the sum of the two drugs effect 1+1-2
Drug infoUSP, NF, PDR
drug class that includes Albuterol that cause bronchodilationadenergic B-agonist
Synergistic responseaka synergism when two drugs are combined and the effect is greater than the sum, 1+1-3
Parasympatheticaka cholinergic, rest and digest, neurotransmitter is ACH, receptor sites are Muscarinic and nicotinic, blocker is atropine, does not function as a unit
MDI on Mechanical Ventmedial to pt on circuit, actuate at end expiration adjust dosage as needed, minimum 8 puffs may go to 20, 15 seconds between puffs
High dosing Albuteroleffective ceiling is 15 mg, heart neb for continuous, hazard is hypovolemia, decreased k+, increased glucose
Aerosol advantagesimmediate onset of action at site, reduced systemic side effects, smaller doses, pt can be taught to self admin, convenient and rapidly effective while minimizing side effects
Aerosol disadvantagesexact dose is unknown, only 10-20% is deposited, breathing pattern effects airway deposit, 2/3 exhaled, much swallowed, wrong neb or flow effects delivery
Nebulizer flow rates6-7 L/min * however since neb can run at 10 L/min and not 4 L/min appropriate answer on test is 7-10 L/min
SVN delivery factorsinspiratory hold (3-5 seconds) is most important for distribution and retention of meds-slow deep breath, 6 L/min flow for 1-5 micron particles, 2.5-4 ml’s solution, inspiration only
MDI advantagesconvenient, inexpensive, no prep, new MDI’s are patent actuated and assures proper aspiratory flow and pattern
MDI disadvantagesrequires pt coordination, pharyngeal deposits, abuse risks, cfc’s 75% of pt’s and 50% of medical workers don’t know how to use them
Mech vent and SVNmeds tend to stick to tube or baffle, 1.5 to 3% make it to airway, SVN should be distal to pt in circuit (close to flow source) often requires double dose
Spacerreservoir, improves med delivery, holds in suspension
Bronchodilator side effectstachycardia and shakiness
SVN particle size1-5 microns
Direct installationgiving meds directly down ET tube or trach, 3-5 ml normal dose, no guarantee of dose, most often used for mucus plugging. Disadvantage, violent cough and systemic side effects
Direct installation drugsEpi-cardiac arrest, NS-sputum sample, B2, mucomyst, surfactant in premies.
Combiventventolen + atrovent combination sympathomimetic and anticholinergic, best with copd’er
Finding active ingrediancemg-mL* % * 10
Bronchodilator categoriessympathomimetic (increase cAMP), anticholinergic (block ACH), Xanthines (inhibit Phosphodiesterase increasing cAMP)
Xanthinesaka theophylline, caffeine, thrombromine & theophylline, Phosphodiesterase inhibiter, used in treating neonate apnea and bradycardia, long term COPD. Bad side effects.
Finding desired dosedesired dose/dose on hand=amount/X example morphine in 10 mg/5mL vial, need 4 mg…..10/5=4/X…..10X/10=20/10…..X=2 vials
Anticholinergic bronchodilatorsblocks ACH-blocks SLUD, causes decreased secretions, increased HR, bronchodilation, prototype is atropine (bad side effects) Ipratropium is safer alternative, good choice for bronchospasm in COPD with B2 agonist
Swelling & edema treatmentalpha (racemic epi)+ steroids. Steroids also treats secretions, treat swelling and secretions will go down too.
what is BronchoconstrictionREDUCED AIRWAY LUMEN , caused by smooth muscle bronchospasm, swelling and edema, excess secretions
the anticholinergic bronchodilators drugs areatropine (prototype), ipratropium (Atrovent) tiatropium (Spiriva) glycopyrrolate (Robinol)
Comboventalbuterol + ipratropium (Ventolen + Atrovent), B2 agonist plus anticholinergic
Albuterol dosage.5% mL or 2.5 mg (.5mL+2.5mL NS), MDI 2 puffs 3-4 hrs, rapid onset=5 mins, effective 4-6 hrs aka Provental or Ventolen,
Xopenex dosageaka levalbuteral, single isomer albuterol with no side effects, but very expensive, standard dose .63 mg, max 1.25 every 4-6 hrs
what are catecholamines and what are their actions?strong a, B1, and B2 drugs, cannot be taken orally, (because of stomach MAO & COMT), very short duration 1- 3 hrs, epi, racemic epi (Vapoenephrine), isoproterenal (Isuprel)
the recorcinol drugs aremodified catecholamines, resistant to MAO and COMT, terbuterline (stops contractions) and metaproterenol (not used now because of B1 side effects, hard on heart)
the saligenin drugs arealbuterol, levalbuterol, (Xopenex) and salmeterol (Serevent)
strong a, B1, B2 drugsepinephrine and racemic epinephrine (Vaponephrine)
Strong B2 agonist drugslevalbuterol (Xopenex) is the only single isomer B2 agonist drug, all others have some B1 effects
Strong B2, strong B1 agonist areIsoproterenol (Isuprel)
strong B2, mild B1 agonist arebitolterol (Tornalate), albuterol, (Provental, Ventolen), pirbuterol (Maxair), salmeterol (Serevent) terbutaline, metaproterenol (Alupent)
Pressure range for PEP10 to 20 cmH2O
Pressure range for flutter valve10 to 25 cmH2O
What type Pt benefit most for IPVintrapulmonary percussive ventilation- CF pt who needs meds delivered
What is an IVPairway clearance technique that uses a pneumatic ventilator t deliver a series of small VT’s at high frequency, acts like internal CPT, mostly used to deliver meds to CF
What is MIEmechanical insufflations exsufflation, artificial cough machine, used mostly for pts with neuromuscular, usually at home, press plus 30 to 50 1 to 3 secs then neg 30 to 50 2 to 3 secs, oral nasal mask or trach
What pt benefits most from MIEneuromuscular ie muscular dystrophy myasthenia gravis etc. caustion with spinal shock and avoid abdominal distention with decreased insufflations pressure
8 complications of CPT and actions to be takenhypoxemia, increased intracranial press, hypotention, pulm hemorrhage, pain or injury to muscle ribs or spine, vomit or aspiration, bronchospasm and arrhythmias…follow 3 S rule, stop stabilize stay
What action should be taken for pt who has potential for hypoxemia during CPTadmin higher FIO2
What action should be taken if a pt becomes hypoxic during CPTstop, return to resting position, give 100 percent O2, call doc
What action should be taken if a pt has increased intracranial press or gets hypotention during CPTstop, return to resting position, call doc
What action should be taken for a pt who has a pulm hemorrhage during CPTstop, return to resting position, call doc, admin O2, maintain airway til doc comes
What action should be taken for a pt who has pain or injury to muscle ribs or spine during CPTstop, use care return to resting position, call doc
What action should be taken for a pt who vomits or aspirates during CPTstop, clear airway (suction prn) admin O2, return to resting position, call doc
What action should be taken for a pt who has a bronchospasm during CPTstop, return to resting position, admin or increase O2, call doc, admin bronchodilators
What action should be taken for a pt who has arrhythmias during CPTstop, return to resting position, admin or increase O2, call doc
4 complications of PEPpulm barotraumas, increased ICP, cardio probs (hypotention), rash, air swallowing, aspirations, increased WOB
3 phases of autogenic drainage and what happens in each phase1. Full inspiration followed by breathing at low lung volume to unstuck periph 2. Breathing at low to middle volumes collects mucus in middle airways, 3 evacuation, middle to large volume then huff
4 contraindications of PEPno absolutes, sinusitis, ear infection, epitaxis (nose blead, recent head or face surgery
Frequency range for high frequency chest wall oscillation5-25 hz (vest)
Frequency range for high frequency chest wall compression is15 hz for flutter and 1.6 to 3.75 hz for IPV
Describe directed coughmimics directed cough, shoulders forward, head and spine flexed, good teaching instruct on control and exercise muscles for neuro, splint for pain
What is manually assisted coughalternative to directive cough, used for pt who is to week for directive, RT uses pressure to help with expulsion
Describe staccado coughshort low output series of coughs, use splint, helps with pain
Describe huff coughopen glottis, say huuufff, used in CF, bronchiectisis and emphysema
4 phases of a cough and what happens in each phase1 irritation, impulse to medulla, 2inspiration, breath in 1-2 liters, 3 compression, glottis close, contraction, alveolar pressure up, (100 mmhg) 4 expulsion, glottis opens press change and contraction expels 500 mph
4 mechanisms that hinder a cough and examplesirritation cns, inspiration pain or restriction, compression surgery or nerve damage, expulsion obstruction weakness copd
Absolute pre and post assessments for postural drainagept vitals (HR RR SPO2) and auscultation to confirm outcome
How do you instruct a pt for PEP therapyexplain Huff, inspiration larger thatn normal, but not full, active exhale but not forcefull, pap of 10-20 (use nuemometer), I:E is 1 to 3 10 to 20 breaths if they are still alive, 2 to 3 huffs repeat 4 to 8 times or 20 minutes
Describe ACBactive cycle breathing 1. relax and control breathing then 3 or 4 expansion breaths, 2 repeat, 3 repeat then 1 or 2 huff coughs relax control and done
Major factor in contributing to retained secretionsineffective cough, absent or increased sputum production, lobored breathing, decreased BS, crackle, rhonki, tachypnea, tachycardia, fever
Frequency when using IPV1.6 to 3.75 hz
Who controls percussive cycle in IPV(used with bland aerosol or meds) pt or rt controls
How long does the vest therapy usually last30 mins
Vest therapy may not be as effective as postural drainage or percussion in what ptCF
Position for greatest lung expansiondangling
clinical signs observed with retained secretionsaudible breath sounds, deteriorating ABG, xray with infiltrates or consolidation, atelectasis, VQ abnormalities
Areas never to be percussedtender areas, site of trauma or surgery or bony spot
Normal airway clearance requirespatent (clear) airway, functioning mucociliary escalator (cilia) and effective cough
Mucociliary clearance mechanismoperates from respiratory bronchioles to larynx, we then swallow or spit
Ciliated epithelial cells move secretionsvia coordinated wave toward the larynx
Why is the cough importantit is a protective reflex that keeps a patent airway
The 4 distinct phases of a normal cough areirritation (can be mechanical, chemical, thermal, inflammatory), inspiration (1 to 2 liters), compression (rapid rise in press), expulsion (500 mph displaces mucus from air walls)
Abnormal airway clearance isany abnormality that alters patent airway, mucociliary escalatory, normal cough, or causes retained secretions
Partial airway obstruction can causeincrease WOB, air trapping, over distention, and V/Q mismatch (vent/perfusion imbalance)
Which one of the 4 phases of a normal cough can retained secretions interfere with ?all ¬タモ retained secretions cause an ineffective clearance
Mechanisms impairing the cough irritation phaseanesthesia, cns depression
Mechanisms impairing the cough inspiration phasepain, neuromuscular dysfunction, pulm or abdominal restriction
Mechanisms impairing the cough compression phaselaryngeal nerve damage, artificial airway, abs muscle weakness, ab surgery
Mechanisms impairing the cough expulsion phaseairway compression, airway obstruction, ab weakness, inadequate lung recoil (emphysema)
Diseases associated with abnormal clearance of mucustumor, abnormality, bronchospasm (asthma, bronchitis) CF, Dyskintic Syndrome (impaired cilia)bronchiectisis, poor cough reflex (ALS, MD, etc)
Most common conditions affecting cough reflex areALS, muscular dystrophy, myasthenia gravis, poliomyelitis, cerebral palsy, and spinal muscular atrophy
The primary goal of bronchial hygiene therapy isto mobilize and remove retained secretions with the ultimate goal of improving gas exchange and reducing WOB
Acute conditions for bronchial hygiene therapy areacutely ill with copious secretions, acute respiratory failure with retained secretions, acute lobar atelectasis, and V/Q abnormalities caused by lung disease
Acute conditions that do not need bronchial hygiene therapy areCOPD, pneumonia and uncomplicated asthma
Chronic conditions that usually require bronchial hygiene therapyCF, bronchiectisis, ciliary dyskinetic Syndromes and chronic bronchitis
When getting sputum production info from a patient, use language a pt like Chris can understand, how many buggers in a shot glass?25 to 30 mL or one fluid ounce
What are the best documented preventive uses of bronchial hygiene therapybody positioning and patient mobilization for acute and PVPD with exercise for CF
PDPV ispostural drainage and percussion vibration therapy
5 methods of bronchial hygiene are1 postural drainage, 2 coughing and expulsive techniques, 3 PAP adjunct (PEP, CPAP and EPAP), 4 high frequency compression oscillation (vest and flutter) 5 mobilization and exercise
The 3 types of postural drainage are1 turning 2 Percussion (on exhalation) 3 vibration
Turningration of the body on its longitudal axis, aka kinetic therapy or continuous lateral rotational therapy, pt can do it, care giver can or rotational bed, purpose is to expand lungs and improve oxygenation, mobilize secretions, never with traction, head or
Relative contraindications of turningsevere diarrhea, agitation, increased ICP, decreased BP, dyspnea, hypoxia, arrhythmias
Proning and acute lung injuriesimproves oxygentation w/o affecting hemodynamics and lower FIO2 press on vent, may also decrease further lung injury associated with positive pressure vent in ARDS pt
Plumbing problems and turningalways drain vent tubes first, caution with vent disconnection, accident extubation, accidental aspiration of vent condensation, , IV¬タルs, and urinary catheters
Postural drainage isthe use of gravity to help move secretions from lobes or segments into central airway, by placing the segmental bronchi to be drained in a vertical position relative to gravity for 3 to 15 minutes
How long should the position be held in postural drainage3 to 15 minutes
How much sputum does effective postural drainage produce25 -30 mL/day (1 fluid ounce or 1 shot glass)
Postural drainage techniqueidentify lobe or segment, position pt, avoid aspiration wait 1.5 hrs after food, coordinate treatment with pain meds, explain procedure, take baseline (HR, RR, SPO2, BS), check wiring tubing ect rail up, pt comfortable, restore pt posit,document/follow up
Initial assessment of need for bronchial hygiene therapy from medical records includeshistory of pulm probs with secretions, admission for upper abdom or thoracic surg, artificial trach, Cxr with atelectasis or infiltrates, PFTs with decreased flow (not enough to cough), ABG or SpO2 values
Initial assessment of need for bronchial hygiene therapy from Patients includeposture and muscle tone, ineffective cough, sputum, breathing pattern, physical fitness, breath sounds and vitals
Percussion and vibration refers tomechanical energy to the chest wall by hands, electrical or pneumatic devices to augment secretion clearance. Percussion jars it loose, vibration helps move it along
Documentation and follow up includespt position, time in position, tolerance, objective and subjective response to tx, sputum color consistency, volume odor and any bad effects of treatments
Directed coughmimics spontaneous cough, helps voluntary control reflex, compensate for physical limits
What is the most effective way to clear the central airwayscoughing
What is the most effective way to clear the peripheral airwayscilia
What are the three important factors for good patient teachinginstruction of proper positioning, instruction of breathing control, exercises to strengthen expiratory muscles
Directed cough patient positionplace pt in sitting position, shoulders rotated inward, head and spine slightly flexed, forearms relaxed or supported, support feet (raise head of bed if needed)
Directed cough techniquegood deep inspiration, bear down against glottis (straining like stool)
Manually assisted coughapplying press to thorax coordinating with forced exhalation
Forced expiratory technique(HUFF cough) a modification to the directed cough, one or two forced expirations of middle to low lung volumes with out closure of glottis, followed by diaphragmatic breathing and relaxation
Active cycle of breathingFET including breathing exercises, and thoracic expansion.
ACB sequencerelaxation and breathing control, 3 to 4 thoracic exercises, relax and bc, 3 to 4 thoracic exercise, relax and bc, 1 or 2 huff coughs, relax and breath control
Thoracic expansion exercisesbig expansive inhalation with relaxed exhalation (may include percussion, vibration or compression)
ACB breathing control involvesrepeated cycles of breathing control, thoracic expansion and huff or FET
Autogenic drainage ismodification of directed cough pt uses 3 phases of inspiration capacity to unstuck, collect and evacuate
Mechanical insufflation exsuffationartificial cough machine, in at 30 to 50 for 1 to 3 seconds then abruptly reversed at negative 30 to 50 for 2 to 5 seconds
PAP adjunctsmobilize secretions and treat atelectasis, CPAP, EPAP, PEP
PEPpositive expiratory pressure for post op atelectasis, good for cf and bronchiectisis exhale through valve at 10 to 20 cmh20
Therapeutic effects of PEPimproves distribution of inspired volume, prevents airway collapse, generates pressure distal to mucus obstruction
Contraindication to PEPsinusitis, ear infection, nose bleed or epitaxis facial or head surgery, active hempotysis
How long for PEP therapyno more than 20 mins, active but not forcible breathing
What is an effective alternative to postural drainage and percussion that a pt can perform independently with few side effects?PEP
How do you clean a flutter valvedisassembled after each use and rinsed in water wash in soap every 2 days and disinfect by soaking in 1 to 3 solution of vinegar and water for 15 mins dry and reassemble
Anatomic ReservoirFills with O2 during the pause between inspiration and expiration and helps raise the FiO2 in the lungs
Normal Inspiratory Flow Rate40 to 60 LPM
Nasal Cannula is high flow or low flow system?Low Flow System
Nasal Cannula Fi021 Lpm= 24%, 2 Lpm= 28%, 3 Lpm= 32%, 4 Lpm= 36%, 5 Lpm= 40%, 6 Lpm= 44%
Nasal Catheter is high flow or low system?Low Flow System
Simple O2 mask is a high flow or low flow system?Low Flow System
Why is the minimum flow 5 Lpm for a Simple O2 mask?If flow rate is too low, patient will re breathe CO
High Flow systemsDesigned to satisfy the patients inspiratory demands. Usually use a “mixing cartridge” or other feature.
Low Flow SystemsNot designed to satisfy all the patients inspiratory demands
Is the Venturi Mask a high flow or low flow system?High Flow System
Qualifications of a Low Flow SystemRR<25, normally 8-25; Vt= 350 ml to 700 ml, Respiratory pattern regular and consistent
Is the Non Breathing Mask a high flow or low flow system?Fixed performance high flow system
Non Breathing MaskFi02= 95%, Two one way valves, Bag, Flow between 10 to 15 Lpm; Bag should never collapse. If so, flow rate is too low.
How to convert from a Non Breathing mask to Partial Rebreathing MaskRemove valves and reduce flow rate by 2-3 L. CO2 does not increase because last 1/3 of air inhaled from the air is exhaled in the bag and the rest of air (CO2) exits the mask.
Continuous Aerosol Oxygen Delivery DevicesTrach Collar, Aerosol Tree/Briggs Adapter, Aerosol Mask, Face Tent
Small Volume NebulizersUsed for short time aerosol medication administration “aerosol treatment”
Large Volume NebulizersUsed for artifical airways and patients straight off vent to moisturize throat and vocal cords. Also used on Aerosol Devices
adrenergic receptors AKAadrenoreceptors
these are a class of G- protein coupled receptors that r targets of catecholaminesadrenergic receptors
norepinephrine AKAnoradrenaline
adrenaline is AKAapinephrine
2 component of catecholamines areeponephrine & norepinephrine
mast cells possess these receptorsbinding of catecholamine 2 receptor= stimulation of sympathetic nervouse system
catecholamine receptors stimulate _ nervouse systemsympothetic
sympothetic nervouse system is responsiable for what bodys responsefight-or-flight response
most useful & potent group of Resp. care drugs primaryaly used to relax bronchial smooth muscle & dilates airway; 2ndly effects facillitate mucocilliary transport of secretion & promotes expectorationadrenergic {sympathomimetic} bronchodilators
Both A&B adrenergic activity; if inhaled =quick onset {1-5}minutes; & metabolized quickly; Duration 1-3 hrs prevents release of histamineepinephrine A&B
promote vasoconstriction both in priphery & in lungs= <capillary leakageA adrenergic effects
relax bronchial smooth muscle; ^HR & cardiac contractility & inhibit further release of nnflammatory mediatorsB adrenergic effects
Catecholamines are good forONLY the attck
all sympathomimetic B2 __ or derivatives of catecholaminecatecholamines
these sympathomimetic amines mimic epinephrine fairly closelycatecholamines
Dopamine epinephrine norepinephrine & isoproterenol are examples of..B2 sympathomimetic
these cause tachycardia elevated BP bronchial & skeletal smoothmuscle relaxation & skeletal muscle tremor & CNS stimulationcatecholamines/ epinephrine caution w/ CHF Pt
catecholamines are inactivated by_= limits actions of the drug to1.5-3 hrs; anr r inactivated by the gut {NEVER ORALLY}COMT
catecholamines R also inactivated by _; _; _ they R stored in Amber bottles & residue tubing maybe pink coloredHeat light air
these R more B2 specific COMT can longer inactivate drug= duration is > up2 6hrs Can be taken orally cuz not effected by gut or liverResorcinols
even more B2 specific {albuterol} Available as MDI; Tab.: syrupp; aerosol solution; effective by mouth & up 2 6 hrsSaligenins
levalbuterol (Xopenex) is most common B2 bronchodilator on market; others are Albuterol/Ventolin/Proventilsaligenins example drugs
serevent AKAsalmeterol
DONT USE IN ACUTE ATTCK lasts up2 12 hrs 2 puffs BIDonset 10-20 minutes w/ pk in 180 minutesSalmeterol {servent}
ion of the bronchial smooth muscle (bronchodilation) 2. inhibits mast cell release 3. stimulates mucocilliary clearanceB2 stimulation effects
vasoconstrictionA1 adrenergic
^HR ^inotropy ^conductivityB1 adrenergic
B2 stimulation~ ^ adenyl cyclase~ ^ cAMP~ <intracellular Ca+2=bronchodilation break down
in order for histamine 2 be released from the mast cells there must be free _free calcium
naturally occurs in the adrenal medulla rapid onset/ short duration do2 inactivated by COMT inhaled or S.C.Epinephrine specific adrenergic agents
synthetic form of epinephrine action same as epinephrine + vasoconstrictor effect is 1/2 do to synthetic compensation Tx croup & ^airway swelling/edemaRacemic Epinephrine
non-Catecholamineslong duration 4-6hrs good 4 maintenance dose 4 BRONCHOPASM inhalation;oral;injection slow pk effect 30-60minutes
tis drug is different cuz administration form must be converted 2 active drug in the body +(pro-drug)Bitoterol (tornalate) prodrug
tremor; tachycardia; headaches; ^BP;nervousness;dizziness N/V;E of adrenergic agents
SE <after _ weeks do to tolerance to adregic agents2 weeks
Electrical Safety in MTF AFI41-203
Hazard Report Form457
Use this if N95 not availablePAPR – powered air purifying respirator
PAPR and N95 are ____ masksHEPA – high efficiency particulate air
Hazardous Waste Management Guide AFPAM32-7043
Measures amount of radiation exposureTLD – thermolucent dosimeter
Double visionBiplopia
Fixed and dilated pupilsMydriasis
Mydriasis results fromcatecholamines, atropine, brain death
Pinpoint pupilsparasympathetic stimulants, opiates
Eyelid droopingptosis
Nystagmusinvoluntary eye movement
JVD indicatesright heart failure
Right heart failure is also known asCor pulmonale
Hemoglobin male13.5 – 16.5
Hemoglobin female12 – 15
Hematocrit male (%)40 – 54
Hematocrit female (%)37 – 47
Sodium137 – 147
Potassium3.5 – 4.8
Glucose70 – 105
Radionuclide Lung Scanning measuresventilation/perfusion and pulmonary embolism
Positron Emission Tomopgraphy (PET scan) measureslesions and cancer
Pulmonary Angiography measurespulmonary circulation
Urine output (ml/hr)40 – 80
Inspiratory pressures male (cmH2O)> -75
Inspiratory pressures female (cmH2O)> -50
Expiratory pressures male (cmH2O)> 100
Expiratory pressures female (cmH2O)> 80
Vital Capacity less than ___ (ml/kg) = respiratory failure< 10
PEFR (LPM)> 500
RR (BPM)12 – 20
VT (ml/kg of IBW)5 – 7
Minute Volume (LPM)< 10 (normal 6 – 10)
Static ComplianceVT/Pplat – PEEP
Dynamic ComplianceVT/PiP – PEEP
RAW (cmH2O/L/sec)0.6 – 2.4
PtcCO2severinghaus electrode
PtcO2clark electrode
Increase PETCO2 results indecreased ventilation
CVP (mmHg and cmH2O)< 6 or < 12
CVP measuresRight heart
Pulmonary Artery Pressure systolic (mmHg)20 – 30
Pulmonary Artery Pressure distolic (mmHg)6 – 15
Pulmonary Artery Pressure mean (mmHg)10 – 20
PAWP/PCWP (mmHg)2 -12
Increase in PAWP/PCWP indicatesleft heart
Hypertension> 160/90
Hypotension< 90/60
SVR (dynes/s/cm-5)900 -1400; left heart
PVR (dynes/s/cm-5)150 – 250; right heart
Pre-ductal PaO2right arm
Post-ductal PaO2umbilical artery
Pre/post ductal PaO2 difference > 15 torr indicatesright to left shunt
If > 15 torr measured recommend this testechocardiogram
CT scan (computed tomography)slices of body – (useful in lung tumors, pneumonia, COPD, bronchiectasis, AIDS)
MRIhigh technology radiograph imaging technique
IBW equation50 + 2.3(height inches – 60) 45.5 + 2.3 (height inches – 60) [multiply by 2.2 for pounds]
Pulse Pressure is thedifference between systolic and diastolic
Pulse Pressure (mmHg)30 – 40
MAP (mean arterial pressure) mmHg80 – 100
Cardiac outputfick equation: QC =VO2/C(a-v)O2 ;QC = HR x SV
Cardiac output (L/min)5 – 8
Polysomnographysleep study
OSA10s apnea with abdominal efforts
CSA10s apnea without abdominal efforts
SOB scaleBorg 0-10
CXR, PAscapulae are rotated away from lung
CXR, APheart size magnified
CXR, lateralviews lung bases and parenchyma
CXR, obliqueprojects abnormalities away from overlying structures
CXR, lordoticview lung apex, lingual, right middle lobe
CXR, lateral decubitusaffected side down; to determine presence of free pleural fluid or air fluid level in lung
CXR, lateral neckdistinguishes between croup and epiglottits
CXR honeycomb, ground glass, or reticulogranular indicatesARDS
CXR heart measurementhorizontal width of heart divided by widest width of thorax – 1:2 or less
CXR COPDhyperlucency and bullae
CXR Pneumoniawhite consolidations
CXR Atelectasisdisplacement of fissures toward collapsed lung; dicoid or platelike
CXR left heart failure (CHF)cardiac silhouette enlarged
Mild left heart failureinterstitial edema, pulmonary vessel margins less sharp, peripheral interstitial markings dominant
Moderate left heart failureshort lines, Kerley B Lines
Severe left heart failurealveolar edema resulting in opacification of lower lung zones
CXR pulmonary embolismwedge-shaped infiltrate, right heart failure
CXR ET tube positionT4-T5; 4-6cm above carina
ET tube diameter1/2 – 2/3 of tracheal lumen
Tracheostomy tube1/2 – 2/3 distance between stoma and carina
Transcutaneous electrode is placed onfatty tissue
Transcutaneous electrode is ___ degrees celsius44
Patient positioning preventsbed sores, thromboembolism, muscle wasting, atelectasis, pneumonia
Absolute contraindications for repositioning patientunstable spinal cord injuries and traction
Avoid leaving ____ patients in supinecomatose / helpless
Radiolucentbody tissues that are penetrated by x-rays; produces black area on CXR
Radiodensityability of object to block x-ray energy, determined by composition and thickness
Radiopaquebody tissues that cannot be penetrated produces white area on CXR
Consolidationoccurs when fluid present in lung; increase radiodensity
Infiltrate demonstratesarea of lung with increased opacity; ill defined
MIP measuresmuscle strength (diaphragm)
MEP varies depending on function ofabdominal, accessory muscles and elastic recoil
Pleural friction rub is also known aspleurisy
Stridor caused bycroup, epiglottitis, extubation
Kussmaul’sincreased RR and depth / labored (DKA patients)
Biot’sincreased RR and depth w irregular apnea
Enlarged and tender lymph nodesrespiratory infection
Enlarged, non-tender lymph nodesmalignancy, HIV
PERRLApupils, equal, round, reactive to light and accommodation
Tracheal shift towardsatelectasis
Tracheal shift awaypneumothorax, pleural effusion, tumor
Two sterile preventative procedurestracheostomy care, open suctioning
Most common method for disinfectionpasteurization
Neutropenicimmunosuppressed patient
Contactdirect and indirect
Droplet3-6 feet distance, cough, sneeze, talking, rhinovirus, influenza, rubella
Airbornehangs in air longer, legionellosis, TB, varicella
Vehiclewaterborne, foodborne
What do we identify when incident occursidentify who is involved (name and ID), identify witnesses
What 3 places can information about chemicals in hospital be foundMSDS, Bioenvironmental, CDC