Respiratory

Type 2

Ventilation: air in and out

Oxygenation: o2 into blood

Circulation: moving blood through body

Perfusion: getting blood and o2 into tissue

47 torr regardless of the inspired humidity.

Absolute humidity: 100% humidified is 44mg/L. When in the presence of gas, it behaves accoring to gas law

P(A-a)O2: PAlveolar o2 (100)- Parterial o2 (80) = 20.

Normal AC membrane o2 < 20

if its high, that means decrease in diffusion rate due to poor AC membrane fxn due to enlargement

Volume present in lung @ end of normal expiration b4 start of inspiration

78% N2, 21% O2, .95% Argon, .05% C02. At sea level its 760 mmHg or 1 atm.

• Approximate Alveolar partial pressure of o2.
• PAo2=[(Pb-PH20)× fio2] - PaC02 × 1.25

• 3.5 - 8 Lpm.
• CO=SV × CR

1 mL/Lb or 2.2mL/kg

[VT- Vd] × breathes per minute

Diaphragm drops 1.5 cm and intrapleural prrssure is 3-6 cwp or 2-4 mmHg

Pb=PA

• Look @ SaO2, PaO2, Hb, if they are normal, pick normal and move on. Short cut to calculate:
• CaO2=Hb x 1.34

(7 x fio2 as a whole#) - (PaC02 + 10)

Systolic - diastolic. Normal: 40 mmHg

(2 x diastolic) + systolic ) ÷ 3. Normal is 120/80

Heart, blood, vessel

4-8 L/m

2-4 L/min/m2

Lungs (25/8)

25/8

Left heart (4-12mmHg)

4-12 mmHg

Right heart (2-6 mmHg or 4-12 cwp)

2-6 mmHg or 4-12 cwp

17-20 vol% ml/dL

66 -300 mmHg. Tx with o2

>300 mmHg. Tx with o2, peep or cpap

25-65 mmhg on 100% fio2

No chloride channel. Causes thick mucus accumulation.

Drowsy state, may have decreased cough or gag reflex

• -Nursing home admission
• -need for home health care providers
• -living arrangements
• -use of hospital services
• -insurance coverage
• -mortality

Describes tx pt would want if he became terminally ill (<6 months to live)

Normal RR, depth, and rhythm

Responds only 2 painful stimuli

• -eating
• -dressing
• -walking/transferring
• -bathing
• -urine and bowel incontinence
• -toilet use

• 1. Admission Notes
• 2. S/Sx
• 3. Occupational hx (maybe they were a cole miner?)
• 4. Allergies/Rxns?
• 5. Prior surgery,illness, or injury
• 6. V/S (pulse,rr,bp,temp)
• 7. Physical exam of chest (percussion,auscultation, inspection, palpation)
• 8. Smoking hx

RR, VT, chest movement, BS, PaCO2

Heart rate, color (if cyanotic, waited too long), sensorium, PaO2

• Pulse/heart rate and strength, cardiac output
• -Strong and bounding: hypoxic, need O2
• -Weak and thready: Heart failure=> circulation is at risk

Blood pressure, sensorium, temperature (cold and clammy), urine output, hemodynamics

• 1. Type of tx
• 2. Frequency
• 3. Med dose and dilution
• 4. Physician signature

• 40 ml/hr (Minimum)
• => if <40, then we should be concerned with perfusion problems. Poor perfusion of kidneys=poor urine output

• 1. weight gain
• 2. electrolyte imbalance
• 3. increased hemodynamic pressures
• 4. decreased lung compliance

fluid balance

Hypovolemia

Hypervolemia

think COPD O2 overdose or sleep apnea

responds inappropriately, think drug overdose, intoxication

• 1. Language difficulties
• 2. Influence of medications
• 3. Hearing loss
• 4. Fear, apprehension, depression, etc

1. Anxiety,nervousness: watching every movement, asthmatic, rt distress, hypoxemia

2. Depressed: quiet or denial

3. Anger, combative, or irritable: electrolyte imbalance

4. Euphoria: drug overdose

5. Panic: hypoxia, tension pneumothorax, status asthmaticus

0: pt unable to perform or need assistance in performing ADL

1: pt needs NO direction or assistance in performing ADL

6: pt is independent and has full functional capability

4: pt has moderate impairment and needs some assistance

<2: pt requires assistance when performing any activity

difficulty breathing except when in upright position

CHF, heart problem

run down feeling, nausea, weakness, fatigue, headache

Electrolyte imbalance

Grades:

• 1. dyspnea occuring after unusual exertion
• 2. breathless after going up hills or stairs
• 3. dyspnea while walking at normal speed
• 4. dyspnea slowly walking short distances
• 5. dyspnea at rest, shaving, dressing, etc

• 1. location
• 2. quality (what kind is it)
• 3. severity ( on a scale of 1-10)
• 4. aggravating factors
• 5. relieving factors
• 6. hx (when did it start and how did it progress)
• 7. context (under what circumstances did it occur)
• 8. accompanying symptoms

excessive nasal seretions from irritants, pollutants, allergies

itching, buring sensation of nose and thoat

dysphagia and hoarsness

influencing pt behaviou and producing changes in knowledge, attitudes, and skills necessary to maintain and improve health

health status

disease management

use of medication and equipment

nutrition (eating more or less)

community resources

rehabilitation techniques

History of present illness: current medical/physical problems

Past medical history: previous medical problems, accidents, injuries, etc

Family history: heart disease, diabetes, cystic fibrosis, etc

Social history: smoking, substance abuse, etc

age, height, weight, sex, nourishment, etc

excessive fluid in the tissue aka Pitting edema (may cause sob)

occurs mostly in arms and ankles, but ankles is usually best choice (think of gravity)

caused by CHF.

rated +1, +2, +3, etc. the higher the #, the greater the swelling

accumulation of fluid in the abdomen

ususally caused by Liver Failure

Tx: NG Tube

caused by Chronic hypoxemia. Presence is suggestive of pulmonary disease or congenital heart defect

occurs with CHF, also seen in pts with Obstructive lung disease

JVD from chronic hypoxemia=>vasoconstriction=>heart failure

indication of peripheral circulation.

Pinching their finger to see if it fills back up again, if it doesn't then we need to be concerned with perfusion

A state of heavy/perfuse sweating.

• Heart failure
• Fever, Infection
• Anxiety, nervousness
• TB (night sweats)

anemia or acute blood loss. (vasoconstriction will cause color to change by reduction of blood flow). Tx with O2

Jaundice. It appears mostly in the face and trunk

redness of the skin. may be from capillary congestion, inflammation, or infection or a reaction or CO poisoning

blue or blue-grey dusky discoloration.

Caused by hypoxia from increased amount of reduced hemoglobin (5g reduced hgb)

Lateral curvature of the spine (side to side)

combination of both and causes severe restrictive impairment

convex curvature of spine (lean forward, hunch back)

depression of part or all of the sternum

anterior protrusion of the sternum

• 1. Chronic lung disease
• 2. Atelectasis
• 3. Pneumothorax
• 4. Flail chest-Paradoxical
• 5. Intubated pt with ET in one lung (deflate cuff, pull out, reinsert)

12-20 breaths/min

Increased RR >20 breaths/min

Causes: hypoxia, fever, pain, CNS problem

decreased rr <12 per min variable depth and irregular rhythm.

Causes: sleep (normal), drugs, alcohol, metabolic disorders

cessation of breathing

increased rr, increased depth, regular rhythm

Cause: Metabolic disorder/CNS disorders

gradually increasing then decreasing and depth in cycle lasting from 30- 180 seconds with periods of apnea lasting up to 60 seconds.

Cause: increased ICP, meningitis, drug overdose

increased RR and depth with irregular periods of apnea. Each breath is same depth.

Cause: CNS problem

increased RR (usually over 20 breaths/min), increased depth, irregular rhythm, breathing sounds labored

Cause: Metabolic acidosis, renal failure, DKA

Tx of diabetes with insuline and HCO3 with documented blood gas only

• 1. Diaphragm
• 2. External intercostals
• 3. Exhalation is normally passive

• 1. Intercostal, scalene, sternocleidomastoid, pectoralis major
• 2. Abdominal muscles (oblique, rectus abdominus, etc)
• 3. Hypertrophy (increase in muscle size) of accessory muscle occurs with COPD

increase in muscle size

muscle wasting. loss ofmuscle tone, occurs with paralysis.

May be referred to cachectic

intercostal and/or sternal retractions occur when the chest moves inward during inspiratory effors instead of outward

Causes: blocked (obstructed) airway

**Sign of RT distress in infants**

Flaring of nostrils during inspiration.

**A sign of RT distress in infants**

Retraction, Nasal flaring, Grunting is them trying to produce cpap=> give cpap for support

• 1. Look externally of evidence of face or neck pathology.
• -Enlarged tongue (macroglossia) (recommend anasthesiologist to intubate)
• -Bull Neck
• -Limited range of motion of neck
• -Short receding mandible

>100 indicates hpoxemia, anxiety, stress

Tx with O2

<60 indicates heart failure, shock, code/emergency (inc. o2 consumption in muscle)

Atropine with O2

it's an ADVERSE REACTION, stop therapy, notify nurse and doctor

pulse/bp varies with respiration. May indicate severe air trapping (status asthmaticus or cardiac tamponade).

alveoli distention resulting in rupture of elasticiy of the lung

Bedside assessment

• smoking hx
• sob
• Increased Hb/HCT
• Barrel Chest, Increased AP diameter
• Accessory muscle use
• Cyanotic
• Digital clubbing

Secondary assessment

• CXR: hyperlucency with diminished vascular markings and flattened diaphragm
• 

ABG: compensated RT acidosis with moderate to severe hypoxemia

Pulmonary fxn: decreased DLco, decreased flows (FEF 25-75% and FEV1/FVC)

Productive cough for more than 3 months out of the year for 2 or more consecutive years

Bedside Assessment

• Smoking hx with chronic infxns
• sob
• Productive cough with Purulent Sputum

Secondary Assessment

• CXR: Essentially Normal or may exhibit and Emphysemic Pattern
• ABG: Hypoxemia with Normal to slightly increased PCO2 Levels
• Pulmonary fxn: Decreased flows (FEV1, FEF 25-75%), DLco Normal

• Low Flow (FiO2) O2 Therapy @ 1-2 L/min (.24-.28)
• Antibiotics as indicated from sputum culture
• Rehab and Home Care
• Bronchodilators, MDI, Aerosol Nebulizers
• Perhaps Trans-Tracheal oxygenation
• Nicotine replacement therapy may help to quit smoking

• good bronchial hygiene (CPT)
• Antibiotics for infxn
• Bronchodilator therapy
• O2 for hypoxemia

Abnormal dilation of bronchi secreting large amounts of purulent secretions


Bedside assessment

• Hx of recurrent gram negative infxn
• Digital clubbing
• Productive cough involving hemoptysis
• 3 Layer Sputum

Secondary Assessment

• CXR: Normal
• Bronchogram: BEST DIAGNOSTIC TEST Show "A Tree in Winter Pattern"
• Pulmonary Fxn: Decreased Flows (FEV1) (obstruction)

• Good bronchial hygiene (CPT)
• Abs for infxn (senormyocin, tobermyocin)
• Aerosol Therapy with Bronchodilators
• Surgical resection of involved segments is an option

Actual flow is 1.6 times greater than the L/min on an o2 flowmeter with an 70/30 mixture

220 - age in years

Delivered Vt - exhaled Vt

Actual flow is 1.8 times greater than L/min on o2 flowmwter with an 80/20 mixture

(100-X) / X-20

(X=FiO2)

Factor X Liter flow

E cylinder = .28% L/psi (0.3)

H cylinder= 3.14 L/psi (3.0)

Guage pressure (psi) x Tank factor / liter flow

20 + (4 x Liter flow) = approximate FiO2

RR / VT (L)

Flowrate= (tidal volume x rate) x (I+E)

Change in pressure x change in volume

105 lb + 5 lb/in over 5 ft

106 lb + 6 lb/in over 5 feet

Raw = peak pressure - plateau pressure

Exhaled volume/ plateau - peep

Exhaled vol / pip - peep

5-10 mmHg

Resonant

Vesicular

S1 and s2

70-90 mmHg

4-6 mill/mm3

12-16 gm/100 ml blood

40-50%

5000-10,000 per mm3

4.0 mEq/L, range 3.5 -4.5 mEq/L

140 mEq/L, range 135-145 mEq/L

90 mEq/L, range 80-100 mEq/L

24 mEq/L, range 22-26 mEq/L

0.7 - 1.3 mg/dL

8-25 mg/dL

Up to 6 minutes

150,000-400,000/mm3

24-32 seconds

12-15 seconds

7-12 seconds

38-42 weeks

7-10

36.5 degrees

110 - 160/min

30-60 breaths min

60/40 mmHg

3000g

40

Down and to the left


Electrical impulse begins in upper right corner (sa, rt atria) and moves down and across the heart to the left

Normal air filled lung, gives hollow sound

heard over the sternum, muscle, or areas of atelectasis

**LOSS of Air**

heard over fluid fille dorgans such as the heart or the liver.

Pleural Effusion (tracheal deviation away) or PNA (tracheal deviation toward) will give this a thudding sounds.

**loss of air**

heard over air filled stomach. This is a drum like sound and when heard over the lungs, indicates increased volume.

**loss of Air**

found in areas of the lung where pneumothorax (absent bs with tracheal shift) or emphysema is present. this is a booming sound.

**Extra Air**

normal sounds over the trachea or bronchi.

These sounds over the lung periphery would indicate lung consolidation.

When the pt says "E" and it sounds like "A". This indicates Consolidation of the lung wiht PNA-like condition

Abnormal breath sounds

secretion/fluid

Large airway secretions. Pt needs suctioning

MIddle airway secretions, Pt needs CPT

fluid in the alveoli, can't suction in the alveoli. Pt needs IPPB, heart durgs, diuretics, and o2.

Pt probably has CHF/Pulmonary Edema

airway narrowing due to bronchospasm. Pt needs bronchodilator

foreign body obstruction, need bronchoscope to go down and find it to get it ous. Can't have asthma on just one side.

• due to upper airway obstruction
• a. supraglottic swelling (epiglottitis)
• b. subglottic swelling (croup, post extubation)
• c. Froeign body aspiration (solids or fluids)

• Tx:
• a. racemic epi for swelling and edema
• b. suctioning and /or bronchoscopy for secretions and foreign body aspiration
• c. intubation for severe swelling.

A coarse grating or crunching sound caused by inflamed surface of the visceral and parietal pleura rubbing 2gether.

Associated with pleurisy, TB, PNA, pulm infarct, CA

TX with abs (infxn) or steriods (inflammation)

120/80

Radiogram, CXR

1. both hemidiaphragms dome shaped

2. Right hemidiaphragm slightly higher due to liver

3. Right hemidiaphragm @ the level of 6th anterior rib (if @ 7,8,9 Emphysemic)

4. Trachea midline, bilateral radiolucency, sharp costrophrenic angles

5. head of clavicles should be level, if not (scoliosis)

Midline

Midline, will shift with pleural effusion or pneumothorax

increased with COPD, barrle chest, hyperinflation

obliterated with Pleural effusion (also dull percussion)

dome shaped normally, flattened with COPD. Left or Rt Pneumothorax may shift downward, appearing flattened on one side

engorged with CHF, absent with Pneumo or a collapsed lung

left ventricle normally seen, cardiomegaly seen with CHF

Tissue surrouding the echest and avove the neck area.

Sub Q emphysema is when hyperlucency is seen in the surrounding tissue.

projection from either the right or left side

Slanting/diagonal view.

Aid in localizing lesions behind bones or unusal places

Pt lying on affected side

Good for detecting small pleural effusions

projection from lung apices

Taken when the pt is at end exhalation.

Good for detecting small pneumothorax or if their is an obstruction

2cm or 1 inch above the carina, level with aortic knob or aortic arch

2-5 cm below the diaphragm

air, Normal

Solid, normal for bones and organs, heart shadow

atelectasis

solid, PNA/Pleural effusion

EXTRA air, COPD, asthma attack

Unilateral:: pneumothorax

fluid, consolidation

Pulmonary Edema

atelectasis

ARDS/RDS

PNA

Pna fills small airways with fluid, big airways are full of air so they stand out

Pulmonary embolus

pleural effusion

Pulmonary embolus

Non-Ferrous (non-metallic)

Pulmonary emboli

BIPAP

Bronchiectasis, helps id location of involved areas that will allow better administration of postural drainage

Traumatic brain injuries

epilepsy/seizures

Evaluation of sleep disorders

Cardiac anomaliles in the infant (ASD, VSD, PDA, etc)

Abnormal heart sounds

5-10 mmHg

hyperventilation until PaCO2 is 25-30 torr

Magic # is 3

5 (norm rbc) x 3 = 15 (norm hgb) x 3 =45% (norm hct)

Norm: 5000-10,000 per mm3

Increased (leukocytosis):::bacterial infection

Decreased (leukopenia)::: viral infection

Metabolic alkalosis, excessive excretion, renal lowss, flattened T wave on EKG

Metabolic Acidosis, Spiked T wave, Kidney Failure

Dehydration

fluid loss from diuretics, vomiting, diarrhea

low chloride: metabolic alkalosis (it follows K+ so K+ is low too)

high chloride (metabolic acidosis) (K+ is high)

co2 is carried in blood as HCO3, so total co2 contetn relfects changes in blood base

• high co2=high HCo3=Metabolic alkalosis=low K+
• low CO2=low HCo3=Metabolic acidosis=high K+

normal

chronic bronchitis

presence of WBC, bacterial infxn

gram neg. bacteria, bronchiectasis, pseudamonas

old blood

hemoptysis (bleeding , tumor)

pumonary edema

a) Gram stain: it's quick and will tell you if its a gram neg or gram pos.

If it doesn't as for "Quick Assessment" then you could pick Sputum culture and sensitivity to tell yuou the type of bacteria and what kind of abs will work. Sputum C&S takes time

Bands: immatures cells, 4% of wbc, INCREASED BACTERIAL INFXN

Segs: mature cells, 60% of wbc, DECREASED BACTERIAL INFXN

Athma, 2% of wbc, Increased with ALLERGIC rxn produce yellow sputum

Pulmonary embolism

> 20 mmHg

pressure gradient that measures cerebral perfusion

CPP=MAP - ICP

70-90mmHg

monitor asthma pt's response to antiinflammatory (corticosteroid) through monitoring pt level of nitric oxide in pt exhaled breath

decrease in airway inflammation

Dysphagia

Esophageal varices

Suspected esophageal malignancy

B) PWP

D) CVP

Dullness to Percussion

Decreased Tactile Fremitus

Dry, Non productive cough

Diminished Breath Sounds

Dyspnea

to monitor o2 concentration

D) Albuterol. A fast acting beta 2 agonist is the appropriate tx for acute bronchospasm

• Volume (affects i time)
• Mandatory Rate(affects e time)
• Inspiratory Flow (affects i time)

Cystic fibrosis

It decreases the viscosity of sputum in CF pts to decreased exacerbations that req. hospitalization

respiratory muscle fatigue with resulting hypercapnia

Muscle Strength

Infant: -60 to 80mmHg

Child: -80 to -100 mmHg

Adult: -100 to -120 mmHg

Anti-Viral for tx of Viral PNA. Side effect: Bronchospasm

Pulmonary Edema from increased interstitial and alveolar fluid

A) 0%. Air contains no helium; therefore, it should read 0

in the lower portion of the superior vena cava

1.8 for 80/20 mix, 1.6 for 70/30 mix

Atrovent. Albuterol is a beta receptor stimulator and may show reduced efficacy int eh presence of beta blocking agents. Atroven uses a different mechanism for bronchodilation.

Capillary Flow

Venous Flow

Lymphatic Flow

A filtered exhalation nebulizer to prevent environmental contamination

5th ics in mid axillary line is appropriate to drain fluids from the chest. Any higher and thorax may not adequately drain the fluid

inspiratory muscle strength