What type of cell secretes surfactant?
What are the 4 critical life functions?
Ventilation: air in and out
Oxygenation: o2 into blood
Circulation: moving blood through body
Perfusion: getting blood and o2 into tissue
What is water vapor pressure?
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
What is the Aa gradient?
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
What is FRC?
Volume present in lung @ end of normal expiration b4 start of inspiration
What is in atmosphere aka barometric pressure?
78% N2, 21% O2, .95% Argon, .05% C02. At sea level its 760 mmHg or 1 atm.
What is the Alveolar air equation?
- Approximate Alveolar partial pressure of o2.
- PAo2=[(Pb-PH20)× fio2] - PaC02 × 1.25
What is normal CO and what is the formula?
What is the anatomical dead space?
1 mL/Lb or 2.2mL/kg
What is the formula for true alveolar VE?
[VT- Vd] × breathes per minute
Normal breathing at rest: what happens to the diaphragm and what is the intrapleural pressure?
Diaphragm drops 1.5 cm and intrapleural prrssure is 3-6 cwp or 2-4 mmHg
When there is no air movement @ end expiration, what does that tell us about pressures?
CaO2 calculation. Short cut...
- Look @ SaO2, PaO2, Hb, if they are normal, pick normal and move on. Short cut to calculate:
- CaO2=Hb x 1.34
Shortcut to calculate alveolar air equation
(7 x fio2 as a whole#) - (PaC02 + 10)
How do u calculate pulse pressure?
Systolic - diastolic. Normal: 40 mmHg
How do u calculate map?
(2 x diastolic) + systolic ) ÷ 3. Normal is 120/80
What 3 factors control bp?
Heart, blood, vessel
Normal QT (cardiac output)
Normal CI (cardiac index)
Left heart (4-12mmHg)
Right heart (2-6 mmHg or 4-12 cwp)
2-6 mmHg or 4-12 cwp
17-20 vol% ml/dL
A-a gradient range for V/Q mismatch
66 -300 mmHg. Tx with o2
A-a gradient range for shunting
>300 mmHg. Tx with o2, peep or cpap
Normal A-a gradient
25-65 mmhg on 100% fio2
No chloride channel. Causes thick mucus accumulation.
Drowsy state, may have decreased cough or gag reflex
Assess ADL to determine 6 things
- -Nursing home admission
- -need for home health care providers
- -living arrangements
- -use of hospital services
- -insurance coverage
Describes tx pt would want if he became terminally ill (<6 months to live)
Normal RR, depth, and rhythm
Responds only 2 painful stimuli
What are the 6 criterias for ADL?
- -urine and bowel incontinence
- -toilet use
What do you want to review in a pt. chart?
- 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
How do you measure ventilation?
RR, VT, chest movement, BS, PaCO2
How do you monitor oxygenation?
Heart rate, color (if cyanotic, waited too long), sensorium, PaO2
How do you monitor Circulation?
- Pulse/heart rate and strength, cardiac output
- -Strong and bounding: hypoxic, need O2
- -Weak and thready: Heart failure=> circulation is at risk
How do you monitor Perfusion?
Blood pressure, sensorium, temperature (cold and clammy), urine output, hemodynamics
Respiratory care orders must include...
- 1. Type of tx
- 2. Frequency
- 3. Med dose and dilution
- 4. Physician signature
Normal urine output?
- 40 ml/hr (Minimum)
- => if <40, then we should be concerned with perfusion problems. Poor perfusion of kidneys=poor urine output
How do we know if intake exceeds output?
- 1. weight gain
- 2. electrolyte imbalance
- 3. increased hemodynamic pressures
- 4. decreased lung compliance
Changes in CVP pressures indicate what?
Decreased CVP <2 mmHg indicates...
Incresed CVP >6 mmHg indicates...
Somnolent, lethargic, sleepy
think COPD O2 overdose or sleep apnea
responds inappropriately, think drug overdose, intoxication
4 reasons why pt may be uncooperative
- 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
Katz ADL scoring
0: pt unable to perform or need assistance in performing ADL
1: pt needs NO direction or assistance in performing ADL
Interpretation of Katz scoring
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
Grades for dyspnea
- 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
8 characteristics to identify symptoms of pain (all are important)
- 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
symptoms of nose and throat
excessive nasal seretions from irritants, pollutants, allergies
itching, buring sensation of nose and thoat
dysphagia and hoarsness
Definition of assessing pt learning needs
influencing pt behaviou and producing changes in knowledge, attitudes, and skills necessary to maintain and improve health
use of medication and equipment
nutrition (eating more or less)
Pt/ Family history
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
Clubbing of the fingers
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
Define diaphoresis and list common causes.
A state of heavy/perfuse sweating.
- Heart failure
- Fever, Infection
- Anxiety, nervousness
- TB (night sweats)
Abnormal skin color (ashen, pallor) due to..
anemia or acute blood loss. (vasoconstriction will cause color to change by reduction of blood flow). Tx with O2
Increased bilirubin in blood and tissue causes
Jaundice. It appears mostly in the face and trunk
What is Erythema?
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
Unequal (asymmetrical) movement may indicate what underlying pathologies?
- 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)
Normal Adult RR
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
Normal Muscles of ventilation
- 1. Diaphragm
- 2. External intercostals
- 3. Exhalation is normally passive
Accessory muscles of ventilation
- 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
Evidence of Difficult Airway
- 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
Pulse (2nd life function)
>100 indicates hpoxemia, anxiety, stress
Tx with O2
<60 indicates heart failure, shock, code/emergency (inc. o2 consumption in muscle)
Atropine with O2
what do you do if there is increased heart rate > 20 beats/min
it's an ADVERSE REACTION, stop therapy, notify nurse and doctor
Paradoxical pulse/ Pulsus paradoxus
pulse/bp varies with respiration. May indicate severe air trapping (status asthmaticus or cardiac tamponade).
Emphysema: define and dx
alveoli distention resulting in rupture of elasticiy of the lung
- Increased Hb/HCT
- Barrel Chest, Increased AP diameter
- Accessory muscle use
- Digital clubbing
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)
Chronic Bronchitis: define and dx
Productive cough for more than 3 months out of the year for 2 or more consecutive years
- Smoking hx with chronic infxns
- Productive cough with Purulent Sputum
- 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
How do you tx Emphysema?
- 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
How do you tx Chronic bronchitis?
- good bronchial hygiene (CPT)
- Antibiotics for infxn
- Bronchodilator therapy
- O2 for hypoxemia
Bronchiectasis: define and dx
Abnormal dilation of bronchi secreting large amounts of purulent secretions
- Hx of recurrent gram negative infxn
- Digital clubbing
- Productive cough involving hemoptysis
- 3 Layer Sputum
- CXR: Normal
- Bronchogram: BEST DIAGNOSTIC TEST Show "A Tree in Winter Pattern"
- Pulmonary Fxn: Decreased Flows (FEV1) (obstruction)
How do you TX Bronchiectasis?
- Good bronchial hygiene (CPT)
- Abs for infxn (senormyocin, tobermyocin)
- Aerosol Therapy with Bronchodilators
- Surgical resection of involved segments is an option
He/O2 mixtures using an o2 flowmeter 70/30 mixture
Actual flow is 1.6 times greater than the L/min on an o2 flowmeter with an 70/30 mixture
Patient's maximum heart rate
220 - age in years
Volume lost through chest tubes
Delivered Vt - exhaled Vt
He/O2 mixtures using an o2 flowmeter
Actual flow is 1.8 times greater than L/min on o2 flowmwter with an 80/20 mixture
Air - o2 ratio for various o2
(100-X) / X-20
Factor X Liter flow
Tank Factors: E cylinder, H cylinder
E cylinder = .28% L/psi (0.3)
H cylinder= 3.14 L/psi (3.0)
Duration of flow (cylinder duration in minutes)
Guage pressure (psi) x Tank factor / liter flow
To approximate fiO2 with a nasal cannula
20 + (4 x Liter flow) = approximate FiO2
Calculating minimum flow rate
Flowrate= (tidal volume x rate) x (I+E)
Work of breathing
Change in pressure x change in volume
IBW formula for females
105 lb + 5 lb/in over 5 ft
Ibw formula males
106 lb + 6 lb/in over 5 feet
Airway resistance (raw) - (estimate)
Raw = peak pressure - plateau pressure
Exhaled volume/ plateau - peep
Exhaled vol / pip - peep
Diagnostic chest percussion, norm
Norm heart sounds
S1 and s2
Norm cerebral perfusion pressure
12-16 gm/100 ml blood
5000-10,000 per mm3
Norm potassium (k+)
4.0 mEq/L, range 3.5 -4.5 mEq/L
Norm sodium (Na+)
140 mEq/L, range 135-145 mEq/L
Normal Chloride (Cl-)
90 mEq/L, range 80-100 mEq/L
Normal bicarbonate (HCO3-)
24 mEq/L, range 22-26 mEq/L
0.7 - 1.3 mg/dL
Norm Blood Urea Nitrogen (BUN)
Norm Clotting time
Up to 6 minutes
Norm platelet count
Activated partial thromboplastin time (APTT)
Norm Prothrombin (PT)
Norm Thrombin time
Norm term infant (gestational age)
Normal infant temp
Norm heart rate (infant)
110 - 160/min
Norm RR (infant)
30-60 breaths min
Normal BP (infant)
Normal birth weight (term infant)
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
Flat percussing sound
heard over the sternum, muscle, or areas of atelectasis
**LOSS of Air**
Dull percussing sound
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**
Tympanic percussion sound..
heard over air filled stomach. This is a drum like sound and when heard over the lungs, indicates increased volume.
**loss of Air**
Hyperresonant percussion sound...
found in areas of the lung where pneumothorax (absent bs with tracheal shift) or emphysema is present. this is a booming sound.
Bronchial breath sounds
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
Adventitious breath sounds
Abnormal breath sounds
Rales (crackles) indicate..
Coarse rales (rhonchi) indicates...
Large airway secretions. Pt needs suctioning
Medium rales indicate
MIddle airway secretions, Pt needs CPT
Fine rales (moist crepitant rales) indicate...
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
Unilateral wheeze indicates ...
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)
- a. racemic epi for swelling and edema
- b. suctioning and /or bronchoscopy for secretions and foreign body aspiration
- c. intubation for severe swelling.
Pleural friction rub...
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)
5 things to note on a normal 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, 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
Aid in localizing lesions behind bones or unusal places
Pt lying on affected side
Good for detecting small pleural effusions
projection from lung apices
End expiratory film
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
position of Ng tube
2-5 cm below the diaphragm
Solid, normal for bones and organs, heart shadow
solid, PNA/Pleural effusion
EXTRA air, COPD, asthma attack
Fluffy infiltrates, Butterfly/Batwing pattern
Patchy infiltrates, Platelike infiltrates
Gound glass, homeycomb pattern, diffuse bilateral rediopacity
Pna fills small airways with fluid, big airways are full of air so they stand out
Peripheral wedge shaped infiltrate
Concave superior interface/border, basilar ifiltrates with meniscus
A sprial CT with contrast dye is used to dx..
Resusitation Equipment for MRI should be...
In V/Q scan, if ventilation is normal but perfusion is abnormal, this indicates...
If pt has dysphagia, what kind of therapy would be inappropriate and may cause the pt to aspirate?
Bronchography (bronchogram) is an injection of radio-opaque contrast medium into that tracheobronchial tree that is helpful for what disease process?
Bronchiectasis, helps id location of involved areas that will allow better administration of postural drainage
Indications for EEG
Traumatic brain injuries
Evaluation of sleep disorders
Indications for Echocardiograpy
Cardiac anomaliles in the infant (ASD, VSD, PDA, etc)
Abnormal heart sounds
treatment of ICP > 20mmHG
hyperventilation until PaCO2 is 25-30 torr
Shortcut for remembering RBC, Hgb, Hct
Magic # is 3
5 (norm rbc) x 3 = 15 (norm hgb) x 3 =45% (norm hct)
Increased vs Decreased WBC
Norm: 5000-10,000 per mm3
Increased (leukocytosis):::bacterial infection
Decreased (leukopenia)::: viral infection
Hypokalemia occurs with
Metabolic alkalosis, excessive excretion, renal lowss, flattened T wave on EKG
Metabolic Acidosis, Spiked T wave, Kidney Failure
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)
Bicarbonate (HCO3-) ::: total Co2 content
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+
Mucoid white/grey sputum
presence of WBC, bacterial infxn
gram neg. bacteria, bronchiectasis, pseudamonas
bright red sputum
hemoptysis (bleeding , tumor)
pink, frothy sputum
Which is considered a "Quick" assessment for sputum tests?
a) Gram Stain
b) Sputum culture & sensitivity
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
what is the difference between Neurtrophil bands and segs?
Bands: immatures cells, 4% of wbc, INCREASED BACTERIAL INFXN
Segs: mature cells, 60% of wbc, DECREASED BACTERIAL INFXN
What pathology is associated with increased eosinophils?
Athma, 2% of wbc, Increased with ALLERGIC rxn produce yellow sputum
Pulmonary angiogram is used to dx what pathology?
Tx is recommended when ICP increases above what level?
> 20 mmHg
Define cerebral perfusion pressure (CPP)
pressure gradient that measures cerebral perfusion
What is the formula to calculate cerebral perfusion pressure (CPP)
CPP=MAP - ICP
What is the normal value for CPP?
What is exhaled nitric oxide (NIOX) testing used for?
monitor asthma pt's response to antiinflammatory (corticosteroid) through monitoring pt level of nitric oxide in pt exhaled breath
Decrease in FEno level suggests...
decrease in airway inflammation
What are the indications for a barium swallow test?
Suspected esophageal malignancy
A ballon tipped, flow directed catheter positioned in the pulmonary artery with the balloon inflated measures which pressure?
A balloon tipped, flow directed catheter is positioned in the pulmoary arter with the balloon deflated, which pressure is being measured by the proximal lumen?
Symptoms of Pleural Effusion
Dullness to Percussion
Decreased Tactile Fremitus
Dry, Non productive cough
Diminished Breath Sounds
What is a Galvanic Cell used for?
to monitor o2 concentration
which is the best aerosolized bronchodilator fo ra pt with acute asthma exacerbation?
B) Albuterol. A fast acting beta 2 agonist is the appropriate tx for acute bronchospasm
In VCV, which controls can be changed to adjust the I:E ratio?
- Volume (affects i time)
- Mandatory Rate(affects e time)
- Inspiratory Flow (affects i time)
Drug: Dornase alfa (Pumozyme)
ususally used with what kind of pts? and what does it do?
It decreases the viscosity of sputum in CF pts to decreased exacerbations that req. hospitalization
If pt has increased PaCo2 during weaning trial, this indicates...
respiratory muscle fatigue with resulting hypercapnia
MIP, VT, VC measures what exactly in weaning from mechanical ventilation?
Suction pressures for Infant, Child, Adult??
Infant: -60 to 80mmHg
Child: -80 to -100 mmHg
Adult: -100 to -120 mmHg
Drug: Pentamidine Isethionate (NebuPent)
What is it and what side effect may be caused by it?
Anti-Viral for tx of Viral PNA. Side effect: Bronchospasm
Bilateral fluffy infiltrates in cxr indicative of...
Pulmonary Edema from increased interstitial and alveolar fluid
when calibrating a thermal conductivity helium analyzer, what should the analyzer read when calibrated in air?
A) 0%. Air contains no helium; therefore, it should read 0
When in proper position, the tip of the CVP catheter should be where?
in the lower portion of the superior vena cava
the is the correction factor for heliox mixture 80/20 and 70/30?
1.8 for 80/20 mix, 1.6 for 70/30 mix
If a pt is on a beta blocker medication and requires bronchodilator therapy, which medication should the RT recommend in leu of Albuterol?
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.
Cuff pressures > 30 ktorr on the tracheal wall will cause obstruction of...
What device is used to deliver Pentamidine (NebuPent)?
A filtered exhalation nebulizer to prevent environmental contamination
what is the appropriate location of a chest tube for a pt with a hemothorax?
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