Respiratory

VQ san

An accumulation of fluids, solids that enters into lungs. 

Blood clots are most common

• Obesity
• smoking
• FX in long bones
• cancer
• prolonged immobilization (like on a plane)
• trauma
• oral contraception
• surgery
• CVC (central venous cath) placement

• taking steroids
• DVT
• Fat
• Air
• Tumors
• foreign objects
• pus (yummy) :)

• apprehension, restlessness
• cough
• dyspnea (trouble breathing)
• Feeling impending doom
• Hemoptysis (bloody sputum with cough)
• Sharp and stabbing chest pain

• Tachypnea
• tachycardia
• crackles
• decreased SaO2
• diaphoreses
• S3 and S4 heart sounds
• low grade fever
• petechiae over chest and axilla

• Anticoagulants, like heparin
• IF suspected large enough...fibrinloytic 
• therapy.

• Surgery...embolectomy (removes clot)
• inferior vena cava filtration. (this is put in if a DVT is suspected)

bleeding...gums, bruising, black stools, leaky IV site, decrease LOC if bleeding on brain.

• Lab values?
• Ptt and/or aPTT ...need a baseline first

start hep drip, then lab draws 6 hrs later.

Sooooo, if coming on shift, ask when was last pTT drawn? last adjustment made? figure when next lab needs to be drawn.

Protamine Sulfate

• get INR/PT drawn
• bleeding precautions... soft toothbrush, electric shaver, blah blah
• keep diet choices consistant
• avoid NSAIDS

• Elevalute HOB
• O2 nasel cannula , start at 2L
• Monitoring VS, auscultate lungs and breathing
• make sure IV access, in case ct scan= place in AC, at least 20 gauge for dye insertion pushed in with force.  
• PT hypotensive? give vasopressors like epi, dopamine
• order labs

• MONITOR anticoagulant use
• Call RT if patient condition declines

• R-respiratory
• O-opposite
• M-metabolic
• E-equal

• RANGES-
• pH= 7.35-7.45

PCO2= 35-45 (the higher number more acidic)

HCO3= 22-26

Qxygenation failure=perfusion is somehow off. blood flow to the lungs is impeded.

Ventilatory Failure= air movement moving in and out.

• PaO2= <60
• PaCo2= >45, occuring with low pH
• O2 Saturation= <90 in both cases.

note- understand the true measure of 02 sat monitoring is only takes in consideration of oxygen bound to hemoglobin. If pt. has low HgB, not a true reflection. look at whole patient.

• lungs or chest wall not working properly, like SCI patients above C5
• defect in resp centers of brain, like from TBI
• Poor function of res muscles and diaphragm

ventilation, not oxygenation

ventilation is how we get rid of carbon dioxide.

Whenever respiratory depression is a possibility (ex patients on PCA, sedation issues and history of sleep sleep apnea)

Normal values is 35-45

• EtCO2 <35 mmHg=hyperventilating/hypocapnia...think perfusion, psychological problem when this is low
• EtCO2 >45 mmHg= hypoventilation/hypercapnia (or not breathing)....think respiratory failure when ETCO2 is high

• First, try to arose them, if they do, monitor every 15 min.
• assess all Vital signs, looking for decompensation
• assess pain and consider maybe decreasing narcotic dose or frequency
• reposition sampling line

• IF STILL <45, call physician
• IF after 5 min, no improvement, call rapid response
• consider getting ABG's
• need narcan now to reverse sedation?

It means that air moves in and out, but unable to oxygenate blood, due to perfusion problems. (VQ mismatch)

• PE
• breathing air w a low oxygen level (change of altitudes, closed in spaces, carbon monoxide)
• VQ mismatch (ARDS)
• impaired gas exchange
• pneumonia
• HF
• hypovolemia

• Spo2 (pulse ox) Saturation
• and PaO2

normal-25-35 seconds

We want their PTT to be 1.5-2.5 seconds x the normal. (longer to prevent clotting)

1. for some reason, the patient is unable to take anticoagulants.

2. someone frail or elderly and are at risk of falling. So if she falls on an anticoagulant they will bleed too much.

70%

Carbon dioxide is low (very basic), so I would decrease the RR rate so that my patient retains more carbon dioxide.

I would look at the fiO2 and the peep because its an oxygenation issue. If the FiO2 is 60% and the PEEP is at 5, I would have wiggle room to increase PEEP.

• hypoventilation
• impaired gas exchange
• combined ventilatory & oxygenation failure
• VQ mismatch=PE
• Profound hypoxemia

• *Hallmark sign=dyspnea
• shallow, irregular breathing
• elevated BP
• rapid RR
• abdominal and intercostal muscle use
• tachy
• irritability and HA and lethargy are indications of poor perfusion to brain.
• *cyanosis and hypotension=late signs

• Sit-up and apply oxygen
• have a patent IV 

• Meds..brochodialator (albuteral)
• or corticosteroids (solumedral)

• ABG's!!!
• chest xray
• cardiac markers
• EKG 
• CBC
• BMP
• coags
• d-dimer
• have pneumonia?-get lactic acid

Res alkalosis

• Monitor PTT
• monitor platelets (watch for heparin induced thrombocytopenia
• bleeding precautions
• have antidote protamine sulfate on hand

• ambulate patients as soon as possible
• use compression stockings if appropriate
• evaluate patient criteria to be on anticoagulants?
• avoid pressure under the popliteal space,do not place pillow
• instruct patient to not cross their legs
• do ROM exercises of extremities especially if patients are immobililzed or post surgical
• administer low dose anticoagulant and anti platelet drugs
• avoid restricting clothing
• encourage smoking cessation
• do not massage legs
• change position q 2 hours or ambulate as tolerated.

• hypoxemia despite being on 100% oxygen
• difficulty breathing
• dense pulmonary infiltrates (called ground glass) on xray
• see mostly blk on xray
• decrease lung compliance
• pulmonary edema, not cardiac related

1 Indirect lung injury

AND 

2.Direct lung injury

• SEPSIS most common
• Pancreatitis
• shock
• serious nervous system damage

hold the shape, keeps lungs(alveoli) open and from collapsing

• BAD pnuemonia
• drowning
• toxic fumes
• aspiration of acidic gastric contents
• fat and amniotic fluid emboli
• multiple blood transfusions

• work of breathing
• mental status
• vital signs

• ABG'S
• CXR
• EKG
• sputum cultures
• PA catheter to evauate fluid and heart status

• is the actual amount of oxygen in arterial blood.
• Normal range is between 90-100

minimum, of 60mmHg

• help with intubation and mechanical ventilation
• Administer nutrition (more protein, less carbs please)
• administrate drugs (antibiotics, steroids, etc)
• Position patient for optimal oxygenation.
• Maintain optimal fluid balance 
• supine with HOB up
• AND
• prone too, helps with better lung expansion.

if they can cough, the patient has a gag reflex.

if you insert an airway adjunct, they could vomit and aspirate.

chin tilt

jaw thrust

• First sedate pt. with versed or ketamine.
• paralyze pt. ..then bag valve mask pt while doc intubates
• get a chest xray to verify placement

• check bilateral lung sounds
• equal rise & fall of chest
• tube misting?
• absent abdominal sounds
• CO2 device.."Gold is good"
• stabilize tub per hospital protocol
• document size of tub, level of tube,placement was verified.

• Improve oxygenation
• improve ventilation
• help decrease work of breathing

• restraint limbs
• adequate nutrition
• ROM exercises
• reposition Q2

BiPAP and CPAP

a device that generates flow of gas into a patients airways

• **Think external ventilator because it can be set to one pressure for inhaling and exhaling.
• requires patient compliance because you have to have a tight seal.

HF..do diuretics, then BiPAP them

• puts a constant steady stream of air pushed into lungs. (positive pressure)
• It keeps tongue from obstructing airway

Sleep Apnea

Assist Control (AC)

and 

Synchronized intermittent mandatory ventilation (SIMV)

• preset tidal volume and respiratory rate
• TAKES OVER THE WORK OF BREATHING

Stacking is when patient breaths along with ventilator, cause barotrauma (alveoli rupture) sooo yes SEDATE them always.

• Ventilator works with patients breathing
• It is set to let patient breathe on their own at their own tidal volume, lessoning chance of barotrauma

It provides pressure on inspiration.

The amount of air transported in and out of the lungs during the resp cycle.

FORMULA- 7-10 x the persons weight in kg.

6 x kg=tidal volume for ARDS pt.

• BPM= 10-14
• Ratio 1:2
• *How much oxygen is determeind by ABG's.

at 5

you would see alkalosis, and decrease in O2.

CO2 will INCREASE, because you are hypoventilating. <45 

pH will decrease.

PaO2 (partial pressure of arterial oxygen= <60 OR PaCO2 is >45

pH <7.35

AND O2 sat of <90%

• Patient is ALWAYS hypoxic!
• Iggy (p 610)

Ventilation failure is when there is some problem with getting air into lungs. 

Oxygenation is a gas exchange failure. Perfusion is decreased or absent

• broken ribs
• defect in resp control center in brain
• poor function of resp muscles, like diaphragm.

• ARDS
• Pneumonia
• Lung disorders

Because getting the air in is intact, however having it perfuse to the body is impaired.

Measures ventilation

• Pneumonia
• hypoventilation
• abnormal hemoglobin
• CHF with pulmonary edema
• ARDS
• High altitudes
• smoke inhalation
• carbon monoxide poisoning
• R to L shunting of blood in the pulmonary vessels

PEEP Em!

• A) pH 7.50, PaO2 59, CO2 32, HCO3 22
• EARLY ARDS, it will be a Respiratory Alklosis.
• Pt breathing fast, trying to bring in oxygen.

D) pH 7.20, PaO2 50, CO2 64, HCO3 18

We want PaO2 @ 55-80 or SpO2 @88-95%

Use minimum of PEEP at 5 at first. Use of incremental FiO2/PEEP combinations.

• TV at 6mL/kg
• PEEP start at 5cm H20
• Want the Fio2 less than 70%. Adjust to ABG readings
• O2 Sat at 88-95%
• Steriods, in small doses over short period of time. 
• If O2 Sat is dropping, increase PEEP
• ** As you increase PEEP, monitor BP!!

a disconnection or a cuff leak in the ET tube

High risk of developing pneumonia because it is painful to breath and therefore do not do so, which can lead to statis of bacteria, causing pneumonia.

Fractures of 2 or more neighboring ribs in 2 or more areas.

they are hypotensive and tachycardic.

there are lacerations in the trachea, can result in a tension pneumothorax and usually caused by MVA's. Must intubate below the area of injury.

essentially means that there is no air movement in and out of your patient.

• First stimulate, assess VS and check patient
• consider reducing opiod.
• reposition the sampling. 
• IF it remains >45, call MD.

• could be too much secretions in airway
• patient fights the ventilator
• patient coughs, gags or bites ET tube
• tubing kink
• pneumothorax occurs
• an increasing PIP which indicates decreased lung compliance.

pH would be low....acidotic, because you are retaining a lot of carbon dioxide. 

on the contrary if RR is very high, you are more likely to be alkaline (or high pH)because you are blowing too much CO2 off.

• Prepare ...
• Airway, if not breathing then bag patient
• Medications-RSI
• Sedate with versed or ketamine and paralyze.
• set up bedside with intubation kit and suction equipment

have bil breath sounds?

• equal rise and fall of chest?
• tube misting?
• absent bowel sounds?
• CO2 detector is GOLD! yay!
• Direct verification if CXR
• stabilize tube (per hospital P&P)
• Document size of tube, level of tube, placement verification