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Describe Respiration Vs Ventilation
Respiration is the exchange of gasses where as Ventilation is the physical act of moving air into & out of the lungs
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What is diffusion?
Movement of a gas fr an area of higher concentration to one of lower concentration
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What factors affect O2 concen in blood?
- Lowered hemoglobin Concen
- Inadequate Alveolar Vent
- Lowered diffusion across pulmonary membrane
- Vent/perfusion mismatch when portion of alveoli collapse
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What is total lung capacity?
- Total vol of air @ max inhalation
- Avg adult male = 6 liters
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What is tidal vol?
- Avg vol of gas inhaled or exhaled in 1 resp cycle
- Approx 500 cc
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What is dead space?
Amt of gasses in tidal vol that remains in the airway
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What is alveolar vol?
Amt of gas in tidal vol that reaches alveoli for gas exchange
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Minute vol is & its formula is?
- Amt of gas moved in & out of resp tract in 1 min
- Minute Vol = Tidal Vol x Breathes/Min
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Inspiratory reserve Vol (IRV) is?
Amt of air that can be maximally inhaled after normal inspiration
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Expiratory Reserve Vol (ERV) is?
Amt of air that can be exhaled aft normal expiration
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What is residual vol?
Amt of remaining in lungs @ end of maximal resp
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What is functional residual vol?
Vol of gas remaining @ end of normal expiration
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What are 3 airway initial assessment questions?
- Is it patent?
- Is breathing adequate?
- Provide O2 & vent as necessary
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What are 6 parts of focused Hx for airway?
- Onset
- Symptom Development
- Assoc. Symptoms
- Past Med Hx
- Recent Hx
- Does anything make it better or worse
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What are 6 parts of Physical Hx for airway?
- Inspection
- Mentation
- Breathing Adequately?
- Pt in best position?
- Is pt breathing normally?
- Is resp pattern normal?
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What is atelectasis?
Alveolar collapse
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What is a pneumothorax?
Accumulation of air or gas in the pleural cavity
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What is a hemothorax?
Accumulation of blood or fluid in the pleural cavity
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What is hypoxemia?
Decreased partial pressure of O2 in blood
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What are the 4 types of hypoxia?
- Hypemic
- Stagnant
- Histotoxic
- Hypoxic
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What is Hypemic Hypoxia?
- Adequate O2 available
- Obstruction prevents O2 fr diffusing across alveolar membrane
- Causes= COPD, Pneumonia, PE, Pulmonary Embolism
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What is Stagnant Hypoxia?
- Adequate O2 Available.
- Blood moving slowly & not reaching cells
- Causes = AMI, Cardiomyopathy, Cardiogenic Shock, Crush Inj's
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What is Histotoxic Hypoxia?
- Adequate O2 Available
- RBCs cant use O2 due to tissue pathology or poisoning
- Causes = Cyanide Toxicity, CO poisoning, Anaphylaxis
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What is Hypoxic Hypoxia?
- Inadequate Availability of O2
- Reduces pO2 in lungs due to lower avail of O2
- Causes = Altitude, Scuba Diving Accidents
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What is the 5 airway mgmt techniques triangle?
- Basic Maneuvers
- Basic Adjuncts
- Intubation
- Bail Outs
- Surgical
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Effective ventilatory support requires tidal vol of @ least ____ of O2 @ ____ to ____ breaths/min.
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What 3 things are required for effective artificial ventilation?
- Patent Airway
- Effective Mask/Face seal
- Delivery of adequate vol
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What are 3 forms of suctioning equip?
- Yankauer
- Soft Tip Catheters
- Gastric Tubes
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How long & when should you suction?
- No longer than 10 secs
- Only while retracting the catheter
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What should always be done b/f suctioning?
Preoxygenation
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What are 4 primary O2 delivery devices & their %'s of O2?
- Nasal Cannula - 40%
- Venturi Mask - 24, 28, 35 or 40%
- Simple face mask - 40-60%
- NRB - 80 - 95%
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What are the 5 causes of airway obstruction?
- Tongue
- Foreign Bodies
- Trauma
- Laryngeal Spasm & edema
- Aspiration
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What is anoxia?
Absence or near absence of O2
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What are 6 forms of modified resp?
- Coughing
- Sneezing
- Hiccoughing (hiccups)
- Sighing
- Grunting
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What are Kussmaul's respirations?
- Deep, slow or rapid, gasping breathing
- Common in diabetic ketoacidosis
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Describe Cheyne-Stokes Respirations.
- Progressively deeper, faster breathing alternating w/shallow, slower breathing
- Indicative of brain stem inj
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Describe Biot's respirations.
- Irregular pattern of rate & depth w/sudden, periodic episodes of apnea
- Indicates ^ ICP
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Describe Central Neurogenic Hyperventilation.
- Deep, rapid resp,
- Indicates ^ ICP
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What are agonal Respiration?
- Shallow, slow or infrequent breathing
- Indicates brain anoxia
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What are the 5 sounds that point to airflow compromise?
- Snoring
- Gurgling
- Stridor
- Wheezing
- Quiet
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What causes snoring respirations?
partial obstruction of upper airway by tongue
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What causes gurgling?
An accumulation of blood, vomitus or other secretions in upper airway
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Describe Stridor.
- Harsh, high pitched sound heard on inhalation,
- assoc w/ laryngeal edema or constriction
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Describe Wheezing.
- Musical, squeaking or whistling sound heard in inspiration &/or expiration.
- Indicates bronchiolar constriction
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What are quiet respirations?
Diminished or absent breath sounds are an ominous finding & indicate a serious prob w/airway breathing or both
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What are 2 sounds that may indicate compromise of gas exchange?
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Describe Crackles (rales).
- Fine, bubbling sound heard on inspiration.
- Associated w/ fluid in lower bronchioles
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Describe Rhonchi.
- Course, rattling noise heard on inspiration
- Associated w/ inflammation, mucus or fluid in the bronchioles
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What is compliance?
Stiffness or flexibility of lung tissue
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A sudden drop of ETCO2 to 0 could indicate?
- Esophageal intubation
- Vent disconnection or defect
- Defect in CO2 analyzer
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Sudden decrease in CO2 NOT to 0 could indicate?
- Leak in vent sys or obstruction
- Partial disconnect of vent circuit
- Partial airway obstruction
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Exponential decrease in ETCO2 could indicate?
- Pulmonary Embolism
- Cardiac Arrest
- Hypotension (sudden)
- Severe Hyperventilation
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Change in CO2 baseline could indicate?
- Calibration Error
- H2O drop in analyzer
- Mechanical failure (ventilator)
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Sudden ^ ETCO2 could indicate?
- Accessing area of lung previously obstructed
- Release of tourniquet
- Sudden ^ BP
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Gradual lowering of ETCO2 could indicate?
- Hypovolemia
- Decreased cardiac output
- Hypothermia; drop in metabolism
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Gradual ^ in ETCO2 could indicate?
- ^ body temp
- Hpoventilation
- CO2 absorption
- Partial airway obstruction
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What does Phase I on a capnogram indicate?
- Respiratory baseline
- Corresponds to late inspiration & early experation
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What does Phase II on a capnogram indicate?
- Resp upstroke
- Reflects CO2 in the alveoli
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What does Phase III on a capnogram indicate?
- Resp Plateau
- Reflects airflow thru vented alveoli w/ constant CO2 level
- Highest level is called ETCO2 & is recorded as such
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What does Phase IV on a capnogram indicate?
- Resp inspiration
- Sudden downstroke & returns to baseline during inspiration
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5 Reasons to measure ventilation in non intubated pts?
- Assess acute resp disorders
- Gauge response to treatment
- Gauge severity hypoventilation states
- Assess perfusion status
- Noninvasive monitoring of pts in DKA
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6 reasons to measure ventilation in intubated pts?
- Verify & document Tube placement
- Immediately see if you lost ur tube
- Effectiveness of chest compressions
- Earliest ind of ROSC
- Indicator of probability of resus success
- Adj manual vents in pts sensitive to CO2 changes
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Arterial blood gas is PaCO2 in the rang of ____ mmHg.
35-40
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Mixed venous blood gas is PeCO2 in the range of ____ mmHg.
46-48
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Exhaled CO2 is EtCO2 in the range of ____ mmHg.
35-45
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What does LEMON in the Lemon Law mean?
- L Look externally
- E Evaluate 3-3-2 rule
- M Mallampati
- O Obstruction
- N Neck Mobility
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What should you look for when looking externally?
- Obesity or Very small
- Short muscular neck
- Lg breasts
- Buck teeth
- Receding Jaw or dentures
- Burns
- Facial Trauma
- S/S of anaphylaxis
- Stridor
- FBAO
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What Does 3-3-2 stand for?
- 3 = 3 fingers fit vertically in mouth
- 3 = 3 fingers between mentum & hyoid bone
- 2 = 2 fingers fr floor of mouth to hyoid cartilage
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Describe Class 1 Mallampati.
Visualization of soft palate, fauces, uvula & anterior & posterior pillars
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Describe Class 2 Mallampati.
Visualization of soft palate, fauces & uvula
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Describe Class 3 Mallampati.
Visualization of soft palate & base of uvula
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Describe Class 4 Mallampati.
Soft palate is not visible @ all
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Describe Cormack & Lehane Grading of trachea opening.
- Grade 1: Full aperture visible
- Grade 2: Lower part of cords are visible
- Grade 3: Only epiglottis is visible
- Grade 4: Epiglottis not visible
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What constitutes an obstruction in the LEMON law?
- Blood
- Vomit
- Teeth
- Epiglottis
- Dentures
- Tumors
- Impales Objects
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Issues w/ Neck mobility could include.....
- Spinal Precautions
- Impaled Objects
- Lack of access
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What is a quick test to chk neck mobility?
Put chin to chest then move toward ceiling
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Name 4 contraindications to ET intubation.....
- Penetrating neck trauma w/rapidly expanding hematoma
- Tracheal inj or Laryngeal Fx
- Epiglotitis
- Pt doesnt want to be intubated
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What is avg size tube for an adult male? Female?
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How do you adjust ur tube size for nasal intubation?
Go down 1/2 to a full size
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What is the formula for determining the size of a pedi tube?
Age +16 divided by 4
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What the eye of Murphy?
Dot on an ET tube marking the place where a stylet is never to pass
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What is the vocal card marker?
Black line on an ET tube that shows where to stop insertion. Once this passes the cords STOP!
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What is ELM maneuver?
Moving the thyroid cartilage & vocal cords in order to attempt to get a better view.
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Do we ever move the laryngiscope blade to get a better view?
NEVER!!!! Causes trauma
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Give 3 indications for Bougie use....
- Unsuccessful attempts
- Poor view of glottic opening
- Airway full of whatever
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Give 2 contraindications for nasal intubation.
- Basil Skull Fx
- Coumadin pt (blood thinners)
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Give 5 tricks for nasal intubation.
- Dont rush!
- Viscous/Hurricane/Neosynephrine are your friends
- Maximally deflate cuff
- Bevel AWAY fr septum
- Dont start too deep
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What are 4 things to remember when intubating?
- PRE-OXYGENATE
- One Shot one tube
- Follow the Map
- NEVER PRY
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Discuss Advantages of Combitube (a-h)
- Provides Alternate airway when tube isn't working
- Insertion rapid & easy
- Doesn't require visualization
- Balloon anchors behind hard palate
- Pt can be vented regardless of placement
- Significantly diminishes gastric disten/regurg
- Can be used when spine compromised
- Gastric contents can be suctioned thru tube
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What are disadvantages of combitube (a-g)
- Additional ET tube is difficult to place w/ ETC in the way
- Can't be used in conscious pt or w/ gag reflex
- Cuffs can cause ischemia
- Doesn't isolate or completely protect trachea
- Cant be used on pts w/ esophageal disease or caustic ingestion
- Cannot be used in pedi's
- Requires competent assessment
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What are 4 advantages of the LMA?
- Disposable
- Comes in several sizes
- Blind insertion requires less skill & training than ET
- Useful when ET insertion is unsuccessful
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What are 5 disadvantages of the LMA?
- EMS usually only caries 3 sizes
- Doesn't isolate trachea
- Doesn't protect airway fr regurg or aspiration
- Cannot be used if there is gag reflex
- Cannot be used in conscious or semi-conscious pt
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What are 6 indications for ET intubation?
- Resp or cardiac arrest
- Unconscious or obtrusion w/o gag
- Risk of aspiration
- Obstruction due to FBO, trauma, burns or anaphylaxis
- Resp extremis due to disease
- Pneomothorax or hemothorax
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Give 5 advantages of ET intubation
- Isolates trachea giving complete ctrl or airway
- Impedes gastric distention b/c of tracheal isolation
- No need for mask seal
- Gives direct route for suctioning resp tracts
- Permits med administration
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Give 5 disadvantages of ET tubes.
- Requires training & experience
- Requires specialized equipment
- Requires direct visualization of cords
- Doesn't warm, filter, or humidify air
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Give 5 possible complications of ET intubation
- Equipment malfunction
- Teeth breakage or tissue damage
- Esophageal intubation
- Right mainstem intubation
- Tension pneumothorax
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Give 6 verifications of proper tube placement.
- Direct visualization
- Chest rise
- Lack of epigastric sounds
- ETCO2 detection
- Esophageal detector devices
- Tube contents: condensation Vs vomitus
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Give 6 indications for nasotracheal intubation.
- Spinal Inj
- Clenched teeth
- Jaw Fx, oral inj or recent oral surgery
- Significant angioedema
- Obesity
- Arthritis preventing head placement
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What are 5 contraindications for nasal intubation?
- Suspected nasal Fx
- Suspected basilar skull Fx
- Deviated septum or other obstruction
- Cardiac or resp arrest
- Unresponsive pt
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Give 4 advantages of nasal intubation.
- Head & neck remains in neutral position
- Less gag response
- More easily secured
- Pt cant bite tube
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Give 6 disadvantages of nasal intubation.
- More difficult & time consuming than oro
- May cause nasal trauma
- Tube may kink or clog more easily
- ^ risk of infection
- ^ possibility of improper placement
- Pt must be breathing
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