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361 Cards in this Set

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  • Back
Normal Gass Exchange Unit in the Lung.
Hypoxemic or Hypercapnic
What is this image reprensenting? Respiratory Failure can be classified as _____________ or _____________
PaO2 is less than or equal to 60mm HG on 60% oxygen

PaCo2 is greater than 45mm HG and pH is less than normal 7.35 which makes is acidic pH.
Memorize this and know that in Respiratory Failure with Oxygenation Failure you have ________________________ and with Ventilatory Failure you have _____________________________
3.3
1.0
0.63
Higher
Lower
Opposite
Regional V/Q differences in the normal lung. At the lung apex, the V/Q ratio is _____ at the midpoint ____, and at the base _____. This difference causes the PaO2 to be ____________ at the apex of the lung and _________ at the base. Values for PaCo2 are the __________. Blood that exits the lung is a mixture of these values
Major function of the respiratory system is ________________
Gas Exchange
Gas exchange involves the transfer of O2 and CO2 between the _________ and __________
Atmosphere
Blood
Results when one or both of these gas exchanging functions are inadequate (O2 or Co2)
Respiratory Failure
Clinical states that interfere with adequate O2 transfer result in ____________
Hypoxemia
Hypoxemia is manefested by a/an ___________ in arterial O2 tension (PaO2) and a/an _________ in arterial O2 saturation
decrease
decrease
Insufficient removal of CO2 results in
hypercapnia
Hypercapnia is manifested by an ___________ in Arterial Co2 tension PaCO2
Increase
Respiratory Failure can be classified as __________ or __________-
Hypoxemic
Hypercapnic
Hypoxemic respiratory failure is also reffered to as _______________ becasue the primary problem is inadequate O2 transfer between the alveoli and the pulmonary capilliary bed
oxygenation failure
Hypoxemic Respiratory Failure is commonly definned as a PaO2 of _____ or less when the patient is receiving an inspired O2 concentration of _____% or greater
60mmHg 60% also known as the 60/60 club
The PaO2 of 60mmHg is at a level that indicates
inadequate O2 saturation of hemoglobin
the PaO2 level exists despite administration of supplemental O2 at a percentage _____% that is about three times that in room air (____%)
60%
21%
Disorders that interfere with O2 transfer into the blood are:
pneumonia
pulmonary edema
pulmonary embolism
alveolar injury related to inhalation of toxic gases (smoke)
Inaddition low cardiac output states
congestive heart failure
shock
anatomical shunt
Hypercapnic respiratory failure is also referred to as ______________. Its primary problem is insufficient _______ _________
ventilatory failure
Co2 removal
Hypercapnic Respiratory Failure is commonly defined as a PaCo2 __________ in combination with acidemia _________
above normal greater than 45
a pH less than 7.35
Three important concepts to remember about Hypercapnic Respiratory Failure:
1.
2.
3.
1. the Paco2 is higher than normal
2. there is evidence of the body's inability to compensate for this increase (Acidemia)
3. the pH is at a level where a further decrease may lead to severe acid base imbalance
Disorders that compromise lung ventilation and subsequent Co2 removal include:
drug overdoses with CNS depressants
neuromuscular diseases (myasthenia gravis)
trauma or diseases involving the spinal cord and its role in lung ventilation
Hypoxemic Respiratory Failure Common Causes for the Respiratory System
1.
2.
3.
4.
5.
1. ARDS
2. Pneumonia
3. Toxic Inhalation Smoke
4. Hepatopulmonary Syndrome
5. Massive Pulmonary Embolism
Hypoemic Respiratory Failure common causes for the cardia system:
1.
2.
3.
1. Anatomic Shunt (ventricular septal defect)
2. Cardiogenic Pulmonary Edema
3. Shock (decreaseing blood flow through pulmonary vasculature)
Hypercapnic Respiratory Failure common causes related to the Respiratory System:
1.
2.
3.
1.Asthma
2.COPD
3.Cystic Fibrosis
Hypercapnic Respiratory Failure Common Causes related to the CNS
1.
2.
3.
4.
1. Brainstem Infarction
2. Sedative and Narcotic Overdose
3. Spinal Cord Inury
4. Severe Head Injury
Hypercapnic Respiratory Failure Common Causes related to the Chest Wall:
1.
2.
3.
4.
1. Thoracic Trauma Flail Chest
2. Kyphocoliosis
3. Pain
4. Massive Obesity
Hypercapnic Respiratory Failure Common Causes related to the Neuromuscular System:
10 of them
1. myasthenia gravis, 2. critical illness polyneuropathy, 3. Acute myopathy, 4. Toxic ingestion 5. Amyotrophic lateral sclerosis 6. Phrenic nerve injury 7. Guillain-Barre syndromw, 8. Poliomyelitis 9. Muscular dystrophy 10. Multiple Sclerosis
Four physiologic mechanisms may cause hypoxemic and subsequent hypoxemic respiratory failure:
1.
2.
3.
4.
1. V/Q Mismatch
2. Shunt
3. diffusion limitation
4. Hypoventalation
The most common causes of Hypoxemic Respiratory failure are:
1:
2:
V/Q mismatch and shunt
Amount of blood perfusing the lungs each minute is
4-5 liters
Amount of fresh gas that reaches the alveoli each minute
4-5 liters
At the lung _______ V/Q ratios are greater than 1: more ventilation than perfusion
apex
At the lung _______ V/Q ratios are less than 1: less ventilation than perfusion
base
Many diseases and conditions alter overall V/Q matching and thus cause a V/Q mismatch. The most common are those in which increased secretions are present in the airways such as
COPD
Many diseases and conditions alter overall V/Q matching and thus cause a V/Q mismatch. The most common are those alveoli:
pneumonia
Many diseases and conditions alter overall V/Q matching and thus cause a V/Q mismatch. The most common are those in bronchospasm is present
asthma
V/Q mismatch may also result from alveolar collapse _______ or as a result from ____
atelectasis
Pain
Unrelieved or inadequately relieved pain interferes with chest and _________________ compromising ____________
abdominal wall movement
lung ventilation
Pain increases ______ and _____ tension, producing generalized muscle rigidity, causes _________ __________and activation of the stress response; and _______ O2 consumption and Co2 Production
muscle
motor
systemic vasoconstriction
increases
What affects the perfusion portion of the V/Q relationship by limiting blood flow and not having an effect on airflow to the alveoli.
Pulmonary embulous
What affects the the airflow to the alveoli but have not affect on the blood flow to the gas exchange
Unrelieved or inadequate Pain control
What is the first step to reverse hypoxemia caused by a V/Q mismatch becasue not all gas exchange units are effected
Oxygen Therapy
Explain how Oxygen Therapy works as the first line treatment in hypoxemia?
O2 increases the PaO2 in the blood leaving normal gas exchange units causing a higher than normal PaO2.
What happens to the well oxygenated blood when it mixes with poorly oxygenated blood?
It raises the over all PaO2 of blood leaving the lungs.
The optimal approach to hypoxemia caused by a V/Q mismatch is one directed at the _______
Cause
A shunt occurs when ________________________
blood exists the heart without having participated in gas exchange
A __________ is viewed as an extreme V/Q Mismatch
Shunt
There are two types of shunts:
1.
2.
1. Anatomic
2. Intrapulmonary
An anatomical shunt occurs when:
blood passes through an anatomic channel in the heart and there for does not pass throught the lungs
An intrapulmonary Shunt occurs when:
blood flows through the pulmonary capilliaries without participating in gas exchange
Intrapulmonary Shunts are seen in conditions in which the alveoli fill with fluid as seen in these diseases:
1.
2.
3.
ARDS
Pneumonia
Pulmonary Edema
If hypoxemia is due to a shunt, what is ineffective in increaseing PaO2
Oxygen therapy
Why would oxygen be ineffect for an anatomic shunt?
Becasue blood passes from the right to the leftside of the heart without passing through the lungs
Why would oxygen be ineffective for an intrapulmonary shunt?
because the alveoli are filled with fluid, which prevents gas exchange
What is an example of an anatomic shunt
(A Ventricular septal Defect)
Patients with shunt are usually more ___________ than patients with V/Q mismatch
hypoxemic
Patients with Shunts may require:
1.
2.
to improve gas exchange
1. Mechanical Ventilation
2. FIO2 (high fraction of inspired oxygen
Diffusion limitation occurs when gas exchange across the alveolar-capillary membrane is :
compromised by a process that thickens or destroys the membrane
Diffusion limitation can also be worsend by conditions that affect the pulmonary vascular bed such as severe ____________ or recurrant ______________.
emphysema
pulmonary embuli
Some disease cause the alveolar capilliary machine to become thicker (fibrotic) which would slow gas transport. Such disease are:
1.
2.
3.
1. pulmonary fibrosis
2. interstitial lung disease
3. ARDS
Diffusion limitation is more likely to occure during _________ than at ________
excercise
rest
During excercise blood moves more rapidly through the lungs. Because transit time is increased, red blood cells are in the lings for a shorter time, decreasing the time for _________________ across the alveolar-capilliary membrane.
diffusion of O2
Classical sign of diffusion limitation is:
hypoxemia that is present during excercise and not during rest
ALveolar hypoventilation is a generalized decrease in __________ that results in an increase in the ________
ventilation
PaCo2
Alveolar hypoventilation may be the result of:
1.
2.
3.
4.
restrictive lung disease
CNS disease
Chest Wall Dysfunction
Neuromuscular Disease
Alveolar Hypoventilation is primarliy a mechanism of ______________respiratory failure it can also cause __________
hypercapnic
hypoxemia
What are the four ways hypoxemic respiratory failure can occur:
1.
2.
3.
4.
V/Q mismatch
Shunt
Diffusion Limitation
Hypoventilation
A patient with acute respiratory failure scondary to pneumonia may have a combination of V/Q mismatch and shunt becasue inflammation, edema, and hypersecretions of exudate within the bronchioles and terminal respiratory units:
1.
2.
1. obstruct the airways V/Q
2, Fill the alveoli with exudate Shunt
Shunt may occur becasue of
improper positioning
if you had a patient with an affect lung which way should you position the affect lung
the affected lung should always be up allowing it to drain down
WHat causes the affected lung up to drain down?
Gravity
A shunt may be increased as with Endogenous vasodilator mediators as is the case with
Pneumococcal pneumonia
A patient may have a combination of shunt and V/Q mismatch because some alveoli are completely filled from edema (shunt) and others are partially filled with fluid (V/Q) Mismatch in these 2 situations:
1.
2.
Cardiogenic Pulmonary Edema
ARDS
Hypercapnic respiratoyr failure results from an imbalance between ____________ and ___________
ventilatory supply
ventilatory demand
Ventilatory supply is:_____________________that the patient can sustain without developing respiratory muscle fatigue
the maximum ventilation (gas flow in and out of the lungs)
Ventilatory Demand is:
the amount of ventilation needed to keep the PaCO2 with in normal limits
Why can normal individuals can engage in strenous excercise, which greatly increases CO2 production without an elevation in PaCo2
becasue the ventilatory supply far exceeds the ventilatory demand
Patients with lung disease can not effectivly increase lung ventilation in response to excercise or metabolic needs. Name an example of the lung disease that this would be
emphysema
What is typically present before ventilatory demand exceeds ventilatory supply
considerable dysfunction of the lung
When Ventilatory demand does exceed ventilatiry supply, the PaCo2 can no longer be sustained within normal limits and __________ occurs
hypercapnia
Hypercapnia reflects sustained
lung dysfunction
Hypercapnic respiratory Failure is sometimes called
ventilatory failure
Ventilatory failure's primary problem is the inability of the respiratory system to: _______________ to maintain a normal PaCo2
ventilate out CO2
Many different diseases can cause a limitation in ventilatory supply. Name the four categories:
1.
2.
3.
4.
1. airways and alveoli
2. Abnormalities of CNS
3. Abnormalities of the Chest Wall
4. Neuromuscular Conditions
Patients with asthma, emphysemia, chronic bronchitis and cystic fibrosis are at high risk for hypercapnic respiratory failure becasue the underlying pathophysiology of these condition result from:
airflow obstruction and air trapping
What is a common example of a problem that my suppress the drive of the CNS to breathe?
an overdose of a narcotic or respiratory depressant drug
A ____________ or ___________- may also interfere with the normal function of the respiratory center because the __________ does not alter the respiratory rate in response to a change in PaCo2
brainstem infarction
severe head inury
Medulla
the respiratory center is located in the
medulla
CNS dysfunction may also include ________________ that limit innervation to the respiratory muscles
spinal cord injury
In patients with a flain chest __________ prevent the rib cage from expanding normally becasue of
1.
2.
3.
FRACTURES
pain
mechanical restriction
muscle spasm
In patients with Kyphoscoliosis the change in _____________ compresses the lungs and prevents normal expansion of the chest wall.
spinal configuration
In patients with massive obesity the weight of the chest and abdominal contents may:
limit lung expansion
Patients with chest wall conditions are at risk for respiratory failure becasue
1. limits
2. limits
3. limits
limits lung expansion
limits diaphramatic movement
limits gas exchange
Certian diseases make patients at risk for respiratory failure becasue it may result in muscle weakness or paralysis. Patients with such risks are those with
1.
2.
3.
Therefore unable to maintain a normal PaCo2
Guillian Barre Syndrome
Muscular Dystrophy
Multiple Sclerosis
Bottom line is that respiratory may occur because the medulla, chest wall, peripheral nerves, or respiratory muscles are not functioning normally. Patient may have no damage to tissue but may be unable to :
inspire a tidal volume sufficient to expel CO2 from the lungs
What determines the definition of respiratory failure
Paco2 and the PaCo2
What is the major threat of respiratory failure
the inability of the lungs to meet the oxygen demands of the tissues
What determines Tissue O2 delivery?
1.
2.
the amount of O2 carried by the Hemoglobulin, and the Cardiac output
The inability of the lungs to meet the oxygen demands of the tissues may occur as a result of:
1.
2.
3.
4.
1. inadequate tissue O2 delivery
2. Tissues unable to use the O2
3. Stress response
4. Increase in tissue O2 consumption
Respiratory failure places the patient at greater risk if there are coexisting:
1.
2.
cardiac problems
anemia
Failure of O2 utilization most commonly occurs as a result of
septic shock
Adequate O2 may be delivered to the tissues, but an abnormally high amount of O2 returns in the venous blood, indicating that it is not being extracted and used at the tissue level. This is what we would classify as
septic shock
A sudden decrease in PaO2 or a rapid increase in PaCo2 implies a serious condition and may be considered a life-threatning emergancy. A clinical example of this would be a patient with ________ who develops severe ________ and a marked decrease in __________ resulting in respiratory arrest
asthma
bronchospasm
airflow
A more gradual change in PaO2 and PaCo2 is better tolerated because compensation can occur. An example of of this would be a patient with COPD who develops a progressive in PaCo2 over several days following the onset of a
respiratory infection
Becasue the respiratory infection happened over a couple of days there was time for renal compensation (retention of bicarbonate) which will minimize the change in _______ compensating from ________
arterial pH
respiratory acidosis
Manifestations of respiratory failure are related to the extent of change :
1.
2.
3.
1. Pao2 or Paco2
2. Rapidity of change acute vs chronic
3. ability to compensate for this change
When the patients compensatory mechanism fails then this happens:
respiratory failure
Becasue clinical manifestations are variable it is important to monitor trends in _______ and or _________ to evaluate the extent of change
ABG's
Pulse Oximetry
The initial indication of respiratory failure is a change in the patients
mental status
becasue the cerebral cortex is so sensitive to variations of oxygenation and acid-base imbalances __________changes will occurearly and frequenty before the ABG results are obtained
mental status
Restlessness, confusion, agitation, and combative behavior suggest _________ to the brain and should be fully investigated
inadequate O2 delivery
Nurse may detect manifestations of respiratory failure that are specific (arise from the __________ system) and nonspecific (arise from the _______ system)
respiratory
body
___________ and __________ can also be early signs of respiratory failure
tachycardia
mild hypertension
Tachycardia and hypertension may indicate an attept by the heart to _________ for the decreased O2 delivery
compensate
A severe morning _________ may indicate that hypercapnia may occured at night, increaseing cerebral blood flow by ___________ and causing a morning __________
headache
vasodilation
headache
Rapid shallow breaths may indicate that the _________ may be inadequate to remove CO2 from the lungs.
Tidal Volume
__________- is an unreliable indicator of hypoxemia and is a late sign of respiratory failure becasue it does not occur until hypoxemia is severe (Pao2 is less than or equal to 45 mm Hg
Cyanosis
__________ occurs when the PaO2 has fallen sufficiently to cause signs and symptoms of inadequate oxygenation
Hypoxia
If hypoxia or hypoxemia is severe the cells shift from ______ to ______ metabolism.
aerobic.
anaerobic
The waste product of anaerobic metabolism is ________ which is much harder to remove from the body than CO2 because _________ has to be buffered with ________
lactic acid
lactic acid
sodium bicarbonate
When the body does not have adequate amounts of sodium bicarbonate to buffer the lactic acid produced by anaerobic metabolism, ___________ results and cell death may occur
metabolic acidosis
Hypoxia and metabolic acidosis have adverse effects on the body especially in the:
1.
2.
Heart
CNS
The heart tries to compensate for the decreased O2 level in the blood by increasing the :
1.
2.
heart rate
cardiac output
As the PaO2 decreases and acidosis increases, the heart muscles may become dysfunctional and _________ may decrease. In addition
1.
2.
May occur
cardic output
Angina
Arrythmias
Permanent _________- may occure due to the decrease of oxygenation
brain damage
Renal function may also be impaired such as:
1.
2.
3.
4.
sodium retention
edema formation
acute tubular necrosis and
Uremia
GI alterations include
1.
2;
3.
1. tissue ischemia
2. increased permability of intestinal wall
3. possible translocation of bacteria from Gi into circulation
The changes that dispose to insufficient CO2 removal in respiratory failure are:
1.
2.
1. rapid shallow breathing pattern
2. respitory rate slower than normal
A common position to be in that will help decrease he work of breathing becasue propping the arms increases the anterior-posterior diameter of the chest and changes pressure in the thorax
tripod position
This technique may be used in which causes an increase in SAO2 becasue it slows respirations and allows for more time for expiration and prevents the small bronchiles from collapsing thus facilitating air exchange
purse lip breathin
Another assessment parameter is the number of pillows that the patient requires to breathe comfortably when resting, this is termed
orthopnea
When a patient is experiencing dyspnea a patient my speak with out pausing. This is an indication of the severity. Patient is speaking in sentences ___________ distress
Patient is speaking words _____ distress, Patient is speaking in phrases ______ distress.
mild or no
severe
moderate
The normal I:E ration is ____ which means the expiration is twice as long as inspiration
1:2
With patients in respiratory distress the ratio may increase to ________--
1:3-1:4
The change of I:Es signifies _________ and that more time is required to empty the lungs
aifflow obstruction
The nurse may observe _________ (inward movement) of the intercostal spaces or the supraclavicular area and use of the accessory muscles during inspiration and exhalation
retraction
use of the accessory muscles signfies _________ distress
moderate
paradoxal breathing signifies _________- distress
severe
During Paradoxal breathing the abdomen and chest move in the opposite manner- _________- during exhalation and _________ during inhalation
outward
inward
Normal breathing the thorax and abdomen move ________ on inspiration and _________ exhalation
outward
inward
This results from maximal use of repiratlory muscles in respiration
paradoxal breathing
_________ and _________ may indicate pulmonary edema or emphysema
crackles or Rhonchi
absent or diminished breath sounds may indicate
1.
2.
atelaectasis
pneumonia
Crackles and Rhonchi may indicate :
1.
2.
pulmonary edema
emphysema
The presence of bronchial breath sounds over the lung periphery often results from lung consolidation that is seen with _________---
pneumonia
a __________ may also be heard in the presence of pneumonia that has involved the pleura
pleural friction rub
Patients with end stage severe chronic lung disease may have low PaO2 values or elevated PaCo2 levels and _________- in their normal baseline
crackles
It is especially important to monitor specific and nonspecific changes in patients with ______ becasue a small change can cause significant decompensation
COPD
Any deterioration in mental status such as agitation, combative behavior, confusion, or decreased level of consciousness must be reported immediately because the change may indicate a rapid deterioration in clinical status and the need for _______-
Mechanical ventilation
After physical assessment the most common diagnostic study used to determine respiratory failure is __________-
ABG Analysis
AN _______________ may be inserted into a peripheral artery for monitoring systemic blood pressure and obtaining blood for ABGS
indwelling cathether
__________ frequently used for monitoring oxygenation status, but tells little regarding lung ventilation
pulse oximetry
Diagnostic studies that may be done include:
1.
2.
3.
4.
5.
Chest X-Ray
CBC
Serum Eletrolytes
Urinalysis
ECG
This may be used to assess tube placement within the trachea immediately following intubation:
End tidal Co2 EtCO2
EtCO2 may also be used during ventilator management to assess trends in ________ as determined by expired CO2
lung ventilation
In severe respiratory failure a pulmonary artery cathether may be inserted to measure
1.
2.
3.
This information is helpfull at determining the adequacy of tissue perfusion and the patients response to treatment
heart pressures
cardiac output
mixed venous oxygenation saturation
Pulmonary artery, pulmonary artery wedge, and left atrial pressures are monitored to determine whether the accumulation of fluid within the lungs is a result or _________ or _______ problems
cardiac
pulmonary
The overal goals for a patient with respiatory failure is :
1.
2.
3.
4.
1. ABG Valueswithin the patients baseline
2, breath sounds wth in patients baseline
3, no dyspnea or breathing sounds wiithin the patients baseline
4. effective cough and ability to clear secretions
The most important plan of care for any patient who might be At Risk for respiratory failure is to:
1,
2,
1, prevention
2,early recognition
Prevention involves
1.
2.
3.
1. Throughal Physical assessment
2. Health History to identify risk factors
3. initation of interventions
3.
Patient at risk with respiratory failure should receive appropriate patient teaching regarding:
1.
2,
3.
4.
1. coughing
2, deep breathing
3. incentive spirometry
4. ambulation
What can decrease the risk of respiratory failure in the acutely or critically ill patient?
1.
2.
3.
4.
1. Education of PREVENTION OF ATELECTASIS
2. education of prevention of pneumonia
3. Education on Optimizing hydration and nutrition
The majory goals for acute respiratory failure include
1.
2.
1. maintaing adequate o2
2. maintaing adequate ventilation
Interventions usedin respiratory therapy are
1.
2.
3.
O2 therapy
mobilization of secretions
positive pressure ventilation
Primary goal of oxygen therepy is to
correct hypoxemia
Hypoxemia is secondary to V/Q mismatch what will you do?
supplemental O2 administered 1-3 L min by nasal canula or by 24% to 32% SIMPLE FACE MASK or venturi mask
Hypoxemia secondary to an intrapulmonary shunt is usually not responsive to high O2 concentrations and the patient will usually require ___________--
PPV Positive Pressure Ventilation
PPV offers a means of :
1.
2.
3.
1. Proving O2 and Humidification
2. Decreases work of breathing
3. Reduces respiratory fatigue
Positive pressure may assist in ________________and and decreasing the shunt
opening collapsed airways
How is PPV provided?
1.
2.
1. Endotracheal Tube Most common
2. noninvasive tight fitting mask
Type of O2 delivery system chosen for the patient in acute respiratory failure should be 1. tolerated by the patient because :
_____________________ and 2. Maintain PaO2 at ________ mm Hg or more and the SaO2 at ____% or more at the lowest O2 concentration possible
anxiety caused by feelings of claustroophobia related to the face mask or dyspnea may prompt the patient to remove the mask
2. 55-60, 90%
High O2 concentration replaces the nitrogen gas normally present in the alveoli causing instability and ________--
atelectasis
In intubated patients, exposure to 60% or greater O2 for longer than 48 hours poses a significant risk for O2 ________---
Toxicity
In nonintubated patients the risk is less clear, the effects of prolonged exposure to be high levels of O2 include increased pulmonary microvascular permability, decreased surfactant production, and surfactant inactivation and fibrotic changes in the _______
alveoli
Chronic Hypercapnia may blunt the response of chemoreceptors in the medulla, and condition known as _________
Co2 narcosis
In Co2 Narcosis respirations are stimulated by _________
hypoxia
Patients with chronic hypercapnia should receive O2 through a
1.
2.
1. low flow nasal cannula at 1-2 liters/min
2. venturi mask at 24% to 28%
______________ may cause or exacerbate acute respiratory failure by blocking movement of O2 into the alveoli and pulmonary capilliary blood and removal of Co2 during the respiratory cycle.
Retained Pulmonary Secretions
Secretions can be mobilized through:
1.
2.
3.
4.
1. effective coughing
2. adequate hydration and humidification
3. chest physical therapy
4. tracheal suctioning
If secretions are obstructing the airway patient should be encouraged to
cough
This type of coughing may be benefit for patients with neuromuscular weakness from disease or exhaustion may not be able to generate sufficient airway pressures to produce an effective cough
Augmented Breathing
Explain what Augmented Coughing is and how it is done:
performed by placing the palm of the hand on the abdominal musculature below the xiphoid process. As the patient ends a deep inspiration and begins the expiration the hand shoud be moved forcefully downward increasing abdominal pressure resulting in a forceful cough
What does the Augmented Coughing actually do?
It helps increase expiratory flow and thereby facilitate secretion clearance
What kind of coughing is a series of coughs while saying a specific word
Huff coughing stating the word Huff
What does Huff coughing prevent
It prevents the glottis from closing during the cough
Patients with _____ generate higher flow rates with a huff cough than is possible with a normal cough
COPD
the Huff cough is effective in clearing only the _________- airways but it may assist in moving secretions upward
central
the Staged cough helps
move secretions upwards
Explain how the staged cough is done:
the patient sits in a chair breathes three to four times in and out through the mouth, and coughs while bending forward and pressing a pillow inward against the diaphram
What will maximize the thoracic expansion, therby decreasing dyspnea and improving secretion mobilization?
1.
2.
positioning the patient
1. elevating the head of the bed at least 45 degrees
2. reclining chair or chair bed
A sitting position improves pulmonary function and assists in venous pooling in dependant body areas such as the
lower extremities
What kind of positioning may be used in patients with disease in one lung
sidelying position
lateral position
This position termed down with the good lung, allows for ________ in the affected lung
Improved V/Q mismatch
What is optimal in dependent lung areas?
1.
2.
pulmonary blood flow and ventilation
Optimal positioning would be to place the patient on their _______ to maximize ventilation and perfusion in the good lung and facilitate secretion removal from the affected lung. This is also called
left side
Postural drainage
All patient must be __________ if there is any posibility that the tongue will obstruct the airway ot that aspiration may occur
side lying
An _____ or ____ airway should be kept by the bed side for use if necessary
oral or nasal
Adequate fluid intake is necessary to keep secretions thin and easy to expel. What is normal?
2-3 Liters per day
Some assessment signs for fluid overload include:
1.
2.
3.
crackles
dyspnea
increased central venous pressure
Aerosols of sterile normal saline may be administered through a _____ which may be used to liquify secretions
nebulizer
Mucolytic agents such as nebulized __________ mixed witha bronchodilator may be used to thin secretions but as a side effect it may also cause airway :
1.
2.
acetylcysteine Mucomyst
erythemia
bronchospasm
what procedure do we use the mucolytic agent and bronchodilator for?
bronchoscopy
Chest Physical therapy is indicated in patients who produce more than _____ml or sputum per day or have evidence of severe _______ or pulmonary iniltrates
30
atelaectasis
If a patient is unable to expectorate secretions what are we suppose to do?
blind sunctioning
Which trach may be used to suction patients who have difficulty mobilizing secretions and when blind suctioning may be difficult or ineffective
the mini trach
The mini trach is a 4mm indwelling plastic cuffless cannula inserted through the __________ membrane
cricothyroid
Contraindications for the mini-trach is
1.
2.
3.
absent gag reflex
history of aspiration
need for long term mechanical respiration
__________ may be provided invasively through an endotracheal or nasotracheal intubation or non invasively through a nasal of facial mask
PPV Positive pressure ventilation
A ________ is a mask that is placed over a patients nose or nose and mouth and the patient breathes spontaneously.
NIPPV: non invasive positive pressure ventilation
With a NIPPV it is possible to ____________ with out the need for an endotracheal intubation
Reduce the work of breathing
A form of NIPPV is called ______ in which different possitive pressure levels are set for inspiration and expiration
BIPAP Bilevel positive airway pressure
A _________ is another form of NIPPV which is a constant positive pressure that is delivered to the airway during inspiration and expiration
CPAP continous positive airway pressure
What is the most useful in managing chronic respiratory failure in patients with chest wall and neuromuscular disease
NIPPV
Certian patients may refuse mechanical vetillation by intubation but will desire NIPPV with some palliative ventilatory support for example patients who may be in
end stage COPD
NIPPV is not appropriate for the patient who has:
1.
2.
3.
absent respirations
excessive secretions
decreased level of consciouness
high o2 requirements
facial trauma
hemodynamic instability
The goals of drug therapy for patients with acute respiratory failure include:
1.
2.
3.
4.
Relief of bronchospasms
reduction of airway inflammation and pulmonary congestion
treatment of pulmonary infection
reduction in anxiety and restlessness
Short acting bronchodillators such as
1.
2.
ar frequently administered to reduce bronchospasm using either a hand held nebulizer or meter does inhaler with spacer
metaproterenol Alupent
albuterol Ventolin
During an acute bronchospasm these bronchodilators can be given how ofter?
30-60 minute intervals untila response has occured
What happend is several bronchospasms occur what can be given by IV for the patient
aminophylline
Bronchodilator effects may sometimes cause a worsening of arterial ________ by redistruibuting the inspired gas to areas of decreased perfusion
hypoxemia
What will alliviate the arterial hypoxemia. What could you give with the bronchodilators
O2-rich gas mixture
What type of medication should reduce an airway inflammation
corticosteriods
What corticosteriod may be used in conjunction with a brochodilator when inflammation if present
solumedrol methlyprednisolone
WHat kind of effect does corticosteriod have on the body when it is given by IV
immediate onset
What is the therapuetic effect of inhaled corticosteriods
4-5 days
Are inhaled corticosteriods used with acute respiratory failiure?
No becasue it takes too long to have a therapeutic effect
What type of drugs reduces pulmonary congestion
Diuretics
What can occur as a consequence of direct or indirect injury to the alveolar capilliary membrane, ARDS or from right or left side heart failure and therefore can be cardiac or non cardiac in orgion
pulmonary interstitial fluid
What happens when you have pulmonary interstitial fluid in the lungs?
You will have a decrease in ventilation and hypoxemia
What type of drug is given to reduce pulmonary congestion caused by heart failure
IV diurectis Furosemide Lasix
What may also be used if heart failure or atrial fibrilliation is present to increase contractility and decrease heart rate?
Digitalis
Pulmonary infections such as
1.
2.
result in excessive mucus roduction, fever, increased O2 consumption, inflammed fluid filled or collapsed alveoli
pneumonia
acute bronchitis
Axniety, restlessness, and agitation result from what?
cerebral hypoxia
Fear caused by the inability to breathe and a sense of loss of control may exacerbate what?
anxitey
Anxiety, pain, and agitation ________ o2 consumption which may worsen the degree of hypoxemia
increase
Anxiety , pain, and agitation _________ CO2 production affects ventilator management, and increases morbitity
increases
Certian benzodiazepines may be used to decrease anxiety, agitation and pain.
1.
2.
Ativan
Versed
Some narcotics are used to reduce anxiety, agitation, and pain.
1.
2.
morphine
fentanyl
What kind of risk for injury related to continued agitation will increased the patients wor of breathing, o2 consumption and CO2 production
accidential extubation
What kinds of depression muct the patient be monitored for when using sedatives?
respiratory and cardiovascular depression
Patients who breathe asynchronously with mecanitcal ventilation may also benefit from titration of ventilator flow rates and other settings, as well as adressing treatable causes of agitation such as:
1.
2.
3.
hypoxemia
pain
hypercapnia
Patients who remain asynchronous with mechanical ventilatio may require nueromuscular blockaid with agents such as Norcuron or Numbex to produce what effect on the body?
skeletal muscle relaxation and synchrony breathing on mechanical ventilation
_________ may also decrease the patients risk of lung injury related to excessive inspiratory/intrathoracic pressures.
Neuromuscular Blockade
What should patients receiving neuromuscular blockade receive?
sedatives and analgesic to the point of unconsciousness
Why is a patient suggested to be unconscious during neuromuscular blockade?
1.
2.
3.
Comfort
eliminate awareness to terrifying experience
and pain
What is the medical supportive therapy primary goal?
treat underlying cause
What are two other goals that the medical supportive therapy try and accomplish
1.
2.
maintain adequate cardiac output
maintain hemoglobin concentration
What does cardiac output reflect?
BLOOD FLOW REACHING THE TISSUES
WHat is an important indicator of cardiac output?
blood pressure
Usually a systolic blood pressure of at least ____ is adequate to maintain perfusion to vital organs
90
How is decreased cardiac output treated?
by administration of IV fluids and medications or both
cardiac output may also decrease by changes in intrathoracic or intrapulmonary pressures from
PPV positive pressure ventilation
WHat is the primary carrier when delivering O2 to the tissues?
Hemoglobin
If the patient is anemic tissue O2 delivery will be ________
compromised
A hemoglobin of _______ or greater is typically ensures adequate O2 saturation of hemoglobin
9-10
If patient does not have an adequate hemoglobin concentration and it can not be maintained what should be monitored? _______ what should it be transfused with? ________
blood loss
Packed RBC
Maintenance of _____ and _____ stores is especially important in patients who experience acute respiratory failure.
protein
energy
Nutritional depletion causes a loss of ______ mass including those of the respiratory system
muscle
During acute manifestations of respiratory the risk of aspiration typically prevents ________
oral nutritional intake
WHat kind of nutrition will be administered to the respiratory failure patient
enteral or parenteral
What kind of diet should be avoided in patients who retian CO2?
High Carbohydrate
Why must the patient avoid carbs?
carbs metabolize into CO2 and increase the Co2 load on the patient
Older adults are at higher risk for developing respiratory failure becasue of the ?
reduction in ventilatory capacity that accompanies aging
Physiological aging of the lung may produce?
1.
2.
3.
larger air spaces
loss of surface area
dilated alveoli
There are a few other things that happens with aging what are they?
1.
2.
3.
diminished Elastic recoil within the airways
decreased chest wall compliance
decreased respiratory muscle strength
What is a big risk factor for respiratory failure in the older adult that their PaO2 falls further and the PaCo2 rises to a higher level before the respiratory system is stimulated to alter the rate and depth of breathing
smoking
A sudden and progressive form of acute respiratory failure is called
ARDS: Acute respiratory Distress syndrome
When ArDS happens the alveolar capilliary membrane becomes damaged and more permeable to __________
intravascular fluid
The alveoli fill with fluid resulting in:
1.
2.
3.
4.
Severe dyspnea
hypoxemia
reduced lung compliance
infuse pulmonary infiltrates
Mortality rate is about ___% Patients with both gram negative septic shock and ARDS you will have a mortality rate of ___% to ___%
50%
70-90%
Direct Lung Injury: Common casues are:
1.
2.
Aspiration
Pneumonia
Less Common Causes of Direct Injury to the lungs are:
1.
2.
3.
4.
5.
embolism
trauma
near drowning
O2 toxicity
Radiation Pneumonitits
Inhalation of toxic substances
Indirect lung injury common causes include
1.
2.
Sepsis
Trauma
Less Common causes of indirect lung injury are:
1.
2.
3.
4.
5.
6.
7.
pancreatitis
anaphylaxis
cardiopulmonary bipass
disseminated intravascular coagulation
blood transfusions
overdose narcotics
nonpulmonary system distress
head injury
shock states
Injury to the alveolar capilliary membrane is by two main events
1. Damage to the Type ____ alveolar cell and by 2. release of _________ mediators
II
Inflammatory
Most common cause of ARDS is
SEPSIS
Direct lung inury my cause ARDS or ARDS may develop as a consequence of the _____
SIRS Systemic inflammatory response syndrome
SIRS may have an infectious or a noninfectious etiology and is characterized by _____________ or clinical responses to _____________ following a ariety of Psysiologic insults including:
1,
2.
3.
4.
severe trauma
gut ischemia
lung injury
sepsis
ARDS may also develop from _____which results from Organ system dysfunction that progressively increases in severity and ultimately results in multisystem organ failure
MODS multiple organ dysfunction system
Pathophysiology changes of ARDS are though to be due to stimulation of the ________ and ________ systems which causes an attraction of neutraphills to the pulmonary interstituim
inflammatory and immune systems
Neutraphils cause a release of humeral, biochemical, and cellular __________-
mediators
These changes such as : increased pulmonary apilliary membrane permeability, destruction of elastin and collagen, formation of pulmonary microemboli, and pulmonary artery vasoconstriction is by the
neutrophilsbiochemical, humeral and cellular mediators
There are three pathophysiology changes in ARDS that are divided into three phases. These phases are
1.
2.
3
injury or exudative phase
reparative or proliferative phase
fibrotic phase
in the earliest phase of injury there is engorgement of the peribronchial and perivascular interstitial space which produces ______________
interstitial edema
Neutrophils adhere to the pulmonary microcirculation causeing damage to the ____________ and increased capillary permeability
vascular endothilium
Intrapulmonary shunt develops after the fluid from the interstitial space crosses the alveolar epithelium and enters the alveolar space why??
alveoli become filled with fluid and the bloodpassing through them cannont be oxygenated
Alveolar type I and type II cells do what?
produce surfactant
the function of surfactant is to maintain alveolar stability by
decreasing alveolar surface tension and preventing alveolar collapse
Decreased synthesis of surfactant and inactivation of existing surfactant cause the alveoli to become unstable which is know also as
atelectasis
Wide spread atelectasis further does what?
decreases lung compliance,
compromises gas exchange
contributes to hypoxemia
this type of membrane is composed of necrotic cells, protein, fibrin, and lies adjacent to the alveoli wall
hyaline
Hyaline membranes contribute to the development of _____ and ______ leading to a decrease in gas exchange capability and lung compliance
atelectasis
fibrosis
Primary pathopghysiology changes that characterize in the injury or exudative phase or ARDS is
1.
2.
edema
atelectasis
this is the termed used for a severe V/Q mismatch and shunting of pulmonary capilliary blood result in hypoxemia unresponsive to increasing concentrations of O2
refractory hypoxemia
Reduced lung compliance greatly increases the patients what?
work of breathing
Hypoxemia and the stimulation of juxtacapilliary receptors in the stiff lung parenchyma (J reflex) initially cause an
increase in respiratory rate and a decrease in tidal volume
When you have a breathing pattern that increases the CO2 removal what kind of state would you be in that you would be in stated from ABGS?
respiratory Alkalosis
Cardiac Output increases in response to hypoxemia a compensatory mechanism to increase what
pulmonary blood flow
Second phase reparative or proliferative phase of ARDS begins 1-2 weeks after initial lung injury. During this phase there is an influx of neutrophils, monocytes and lymphocytes and fibroblast proliferation as part of the
Inflammatory response
The proliferated phase is complete when the diseased lung becomes characterized by dense _______
fibrious tissue
Hypoxemia worsens becasue of thickened alveolar membrane, causing diffusion limitation and ______
shunting
The third phase is the fibrotic phase which occurs 2-3 weeks. by this time the lung is completely what
remodeled by sparsely collagenous and fibrous tissues
There is a diffuse scarring and fibrosis, resulting in
decreased lung compliance
This results from pulmonary vascular destruction and fibrosis
pulmonary hypertension
Several factors seem to be important in determining the course of ARDS including
1.
2.
3.
nature of the initial injury
extent and severity of the coexisting diseases
pulmonary complication
Some symptoms that the patient may experience at first would be :
1.
2.
3.
4.
dyspnea
tachynpnea
cough
restlessness
Chest auscultation may be normal or reveal fine, scattered what
crackles
ABGS usually indicate mild hypoxemia and respiratory alkalosis casued by ______
hyperventillation
This results from hypozemia and stimulation of J receptors
respiratory alkalosis
Pulmonary function tests in ARDS reveal decreased compliance and decreased lung volumes particularily a decrease in _______
functional residual capacity FRC
As ARDS progresses chest auscultation will reveal scattered to diffuse
crackles and rhonchi
X-Ray demonstrates diffuse and extensive ?
bilateral interstitial and alveolar infiltrates
HALLMARKS of ARDS include
1.
2. ____ ratio below 200
hypoxemia
PaO2/FIO2
ARDS progresses it is associated with profound respiratory distress requiring :
1.
2.
Intubation or PPV ventillation
A chest X-Ray at this stage is usually termed :
white out or white lung
Diagnostic Findings in ARDS:
PaO2<50mm Hg on FIO2>40% with PEEP.5 cm H20 PaO2/FIO2 ration<200
Refractory Hypoxemia
Diagnostic Findings in ARDS:
New bilateral interstitial and alveolar infiltrates are found by
chest x ray
Diagnostic Findings in ARDS:
<18mm Hg and no evidence of heart failure is the
Pulmonary Artery Wedge Pressure
Complications associated with ARDS include:
Infection:
1.
2.
3.
catherter related infection
nosocomial pneumonia
sepsis
Complications associated with ARDS include:
Respiratory Complications
1.
2.
3.
4.
5.
O2 oxicity
Trauma
Emboli
Fibrosis
Complications associated with ARDS include:
Gastrointestinal
1.
2.
3.
Paralytic Ileus
Pneumoperitoneu,
Stress Ulceration and Hemorrhage
Complications associated with ARDS include:
Renal
1.
Acute Renal failure
Complications associated with ARDS include:
Cardiac
1.
2.
arrhythmias
decreased cardiac output
Complications associated with ARDS include:
Hematologic
1.
2.
3.
Anemia
disseminated intravascular coagulation
Thrombocytopenia
Complications associated with ARDS include:
ET intubation
1.
2.
3.
4.
laryngeal ulceration
tracheal malacia
Tracheal stenosis
Tracheal ulceration
The major cause of death in ARDS is often accompanied with sepsis
MODS
The vital organs most commonly involved are :
1.
2.
3.
Kidneys
Liver
Heart
the organ systems most commonly involved are
1.
2.
3.
CNS
Hematologic
gastrointestinal
These are all risk factors for what?
host defenses
contaminated medical equipment
invasive monitoring
aspiration
prolonged mechanical ventilation
well colonization of respiratory tract
nosocomial Pneumonia
In order to prevent nosocomial pneumonia we must :
1.
2.
Infection control
elevation of head of bed 45 degrees
This may result from rupture of overdistended alveoli during mechanical ventillation
Barotrauma
Barotrauma results in the presence of alveolar ____in locations where it is not usually found
air
TO avoid barotrauma patient with ARDS is sometimes ventilated with smaller _______ volumes resulting in higher PaCo2. This method of ventilation is called _______________
tidal
permissive hypercapnia
this can occur in patients with ARDS when large tidal volumes results in alveolar fractures and movement of fluids and proteins fo in to the ________--
Volu-pressure trauma
alveolar spaces
To limit Volu-pressure trauma it is reommended that smaller ______- volumes or pressure ventilation are used with these patients with ARDS
tidal
Stress ulcers occure and management strategies include correction of predisposing conditions such as
1.
2.
3.
hypotension
shock
acidosis
Prophylactic management includes antiulcer agents such as
1.
2.
3.
Pepcid
Prilosec
Carafate
Renal failure can occur from decreased ________ as a result from hypostension hypoxemia or hypercapnia
tissue oxygenation
Renal failure may also be because of administration of nephrotic drugs such as _____
aminoglycosides
The overall goals for a patient with ARDS is
1.
2.
3.
PaO2 of at least 60
good lung ventilation
normal pH
There are three main respiratory therapies for the patient with ARDS
1.
2.
3.
Oxygen Administration
Mechanical Ventilation
Positioning Strategies
Primary goal of O2 thereapy is to
correct hypoxemia
This is commonly used to monitor and assess the effectiveness of O2 therapy
Pulse Ox
during mechanical ventilation PEEP at 5 cm H20 is to compensate for loss of ______ from et tube
glottic function
ECMO and ECCO2R pass blood across a gas-exchanging membrane outside the body and then returned oxygenated blood where?
back to the body
ECCO2R with low frequency PPV allws the lungs to do what while the lung is not functioning
heal
Positioning is also a good way what position to what position is commonily used
supine to prone
what position is usually reserved for patients with refractory hypoxemia
prone
lateral rotational therapy provides continous rotation allowing 2 things
1.
2.
postural drainage
mobilize pulmonary secretions
If cardia output fails it is necessary to administer
1.
2.
crystalloid fluids
colloid solutions
Inotropic drugs such as may be necessary
dobutrex
intropin
this is a serious acute respiratory infection caused by a coronavirus spread through air droplets in the air
SARS severe acute respiratory syndrome
SARS begins with ________--
fever greater than 100.4
Other manifestations include
headache and discomfort
Patient should be placed where in the hospital
isolation
Medications given to a patient with SARS is
1.
2.
3.
antiviral meds ribavirin
antibiotics
corticosteriods
Hypercapnic respiatory failure can be casued by
asthma
Early sign of acute respiratory failure is
restlessness
O2 delivery system chosen for a patient in acute respiratory failure should be
maintain the PaO2 at 60 mm Hg or greater at the lowest O2 concentration possible
Most common early clinical manifestations of ARDS that the nurse may observe are
dyspnea and tachypnea
Maintenance of fluid balance in the patient with ARDS involves
mild fluid restriction and diuretics as necessary
Which of the following interventions is designed to prevent or limit barotrauma in the patient with ARDS who is mechanically ventillated?
the use of permissive hypercapnia