RRT- Lindsey Jones 100% correct answers already graded A+

Emphysema : Obstructive Definition, Clinical Evidence, Chest Xray, CBC, ABG, PFT & Key interventions **EXAM Challenge: You may be tempted to utilize high FiO2 because of the severity of hypoxemia. You may also be tested with an emergency, the only time it is appropriate to use 100% O2 on a COPD patient D: Abnormal condition of the alveoli resulting destruction and loss of elasticity C.E.: Barrel chest, Access. musc. use, Clubbing, Smoking hx, Occupational hazard (smoke, asbestos, other pulm. irritant) XR: ^ AP diameter, flattened diaphragm, hyperlucency, diminished pulmonary markings. CBC: Polycythemia, ^ WBC - possible infection ABG: Comp. Resp. Acidosis (H PaCO2, N pH) & Hypoxemia PFT: flows are decreased (FEF 25-75% & FEV1), wheeze, dim. K.I.: O2 (L FiO2 0.24-0.28), Liq. O2 or trans-trach cannula, home care education, aids to quit smoking, bronchodilators & corticosteroids Chronic Bronchitis : Obstructive Definition, Clinical Evidence, Chest xray, CBC, ABG,PFT & Key interventions **EXAM Challenge: The most distinguishing characteristic is that the cough is productive and has been so for a good portion of the year. D: Condition where the patient has a productive cough 25% of the year, for at least 2 consecutive years. C.E.: Productive cough, purulent sputum, exposure to pulm. irritants, frequent infections. XR: May be normal, may show hyperlucency, diminished pulmonary markings CBC: Possible increased WBC due to possible infection ABG: May be normal, may show slight Resp. Acidosis & hypox. PFT: flows are decreased (FEF 25-75% & FEV1 K.I.: Anything that promotes good pulm. hygiene, fluid therapy if dyhyd, O2 if hypox, bronchodialator, Tetracycline Bronchiectasis : Obstructive Definition, Clinical Evidence, Chest xray, Sputum Culture, Bronchogram & Key interventions D: Abnormal condition where the bronchi secrete large volumes of pus during abnormal dilation C.E.: Productive cough, often bloody, clubbing, recurrent infections, dyspnea XR: generally normal S.C.: gram negative bacteria Bronchogram: Primary test. "tree in winter pattern" K.I.: Chest Physio, hydration therapy (thick sputum), fluid therapy (dehydrated), O2 therapy, bronchodilator, Surgical intervention Obstructive & Central Sleep Apnea Definition, Clinical Evidence, ABG,Polysomnography & Key interventions **EXAM Challenge: It is important to remember to avoid sending the patient home without some sort of ventilatory support. D: The cessation of breathing during sleep. Most commonly obstructive in nature, can be central, or both. (mixed) C.E.: Spouse complains of snoring and witnessed apnea for 10 second or longer. Excessive upper airway tissue, obesity or thick neck. Ability to fall asleep quickly. Dyspnea, Frequent urination during sleeping hours ABG: Could be normal, or show slight resp. acid. or hypoxemia P.: Determines OSA or CSA. If no nasal flow AND no chest movement = CSA, If no nasal flow WITH chest mvmt. = OSA K.I.: CSA= ventilatory stim. meds (Doxapram) OSA= use of CPAP or BiPAP, initially indicated follow up weight loss or upper airway tissue removal. Must be corrected immediately.. If sending home, send equipment. in the absence of titration studies initial order Pressure is 10-20 cmH2O Asthma : Obstructive Definition, Clinical Evidence, Chest xray, CBC, ABG,PFT & Key interventions **EXAM Challenge: When doing PFTs, always do a pre & post bronchodilator study. Consider effective if 12% or more improvement is noted. Always start oxygen first when presenting in the ER-- part of the national Asthma Guidelines D: Abnormal construction of the bronchial's resulting in sputum production and narrowed airways. C.E.: Accessory muscle use, Tachycardia, dyspnea, wheezing, congested cough, wet-clammy skin XR: hyperinflation, scattered infiltrates, flat diaphragm CBC- Allergic cases, maybe elevate eosinophils -> yellow sput. ABG: possible Resp. Acid, could be hypoxic PFT: Decreased flows in FEV1 but diffusion is normal (DLCO) K.I.: O2 therapy, bronchodilator, xanthenes via IV, pulm. hyg, if repeated bronchodilator use doesnt work think status asthmaticus, patient asthma action plan!! Status Asthmaticus: Definition, Clinical Evidence, Chest xray, ABG,PFT & Key interventions **EXAM Challenge: Questions on this will challenge your ability to recognize impending vent. failure. It is very important that you treat it before full vent failure. There is a frequent need to repeat actions, such as bronchodilator treatments, which may make you uncomfortable. Do not be afraid to administer several bronchdilators in succesion. The same is true of the subcutaneous epinephrine. If you give one dose, you will likely have to give another, and possible another. Continue if symptoms show no signs of relief. D: Asthma that will not respond to bronchodilators, persists 24' C.E.: HX non-response to bronodilators "needs many tx" to feel better, acc. musc. use and retractions, dyspnea, wheezing, congested cough, wet-clammy skin, pulses paradoxes XR: hyperinflation, scatter infiltrates, flat diaphragm ABG: Pos. Resp. Acid., alkalosis due to anxiety, maybe hypoxic K.I.: May deteriorate quickly, intubate and MV before full vent fail. Use sub-cue epi-- 1mL of 1:1000 strength, may need to give Q 20min for up to 3 consecutive doses. Address 3 parts of asthma INFLAMMATION- corticosteroids BRONCHOCONSTRICTION- bronchodilators SPUTUM- airway clearance, hydration, thinning of sputum if needed. Myasthenia Gravis : Restrictive- neural Definition, Clinical Evidence & Key interventions **EXAM Challenge: This can be a very tricky simulation and it is likely that it will show up on the exam. Especially important is your use of Tensilon to diagnose it and an understanding of the dangerous effects it could have. Must always be prepared to assume ventilation. Vt, VC, MIP are key in monitoring this patient for degradation in ventilatory status. D: Neuromuscular abnormality where muscles experience paralysis starting from the head to the feet. C.E.: Hx of MG if not initial onset, droopy facial features (ptosis) patient will describe slowly feeling weakness generally but feels better with rest, diplopia, dysphagia, shrinking Vt, VC, MIP, tensilon challenge test-- pos. for myasthenia crisis if improvement up the administration. K.I.: If crisis noted, anticholinesterase therapy is indicated including: neostigmine (prostigmine), Mestinon (Pyridostigmine) Ok to do additional tensilon challenge to check progression, if symptoms improve with tensilon and then worsen, must reverse anticholinesterase with atropine. Always monitor spontaneous Vt, VC & MIP. Be prepared to intubate. When VC falls below 1.0L the intubate and MV. Drug Overdose : Definition, Clinical Evidence, ABG & Key interventions **EXAM Challenge The most important part of this pathology is the need for immediate intubation while recognizing that there may not be a need to MV until Vent status deteriorates. D: Potential loss of ventilatory drive as a result of OD. Usually narcotics. C.E.: Hx of drug use, sometimes poor hygiene, emaciated (thin) RR and pattern is low and or shallow ABG: often show pur resp. acidosis and/or vent failure K.I.: #1 priority in this case is intubation to protect the airway, prevent aspiration of stomach contents and facilitate manual ventilation. monitor closely as ventilation can cease in an instant (due to suppresion of the CNS) If narcotic OD, then use narcotic reversing meds such as NARCAN (nalaxon) Support ventilation until drugs are of system Other Neuromuscular : Definition, Clinical Evidence & Key interventions **EXAM Challenge: If faced with these diseases, simply apply general respiratory monitoring principles and facilitate ventilation when needed. D: Other neuromuscular diseases include poliomyelitis, tetanus, muscular dystrophy, and botulism poisoning. C.E.: history of illness, shrinking VT, VC, MIP K.I.: monitor for ventilatory failure generally through VT, VC, MIP and ABGs Head Trauma : Definition, Clinical Evidence & Key interventions **EXAM Challenge: Unique to this situation is the need to monitor ICP readings and avoid anything that increases MAP. You will likely need to suction this patient to keep peak pressures down but the very act of doing so may elevate ICPs. D: Potential loss of ventilatory drive as a result of damage to the head/brain C.E.: Sometimes trauma is visual with blood contusions on the head, trauma hx - car accident, looks and acts sleepy, difficult to arouse, RR and pattern is low and or shallow and irregular, papillary response to light may be unequal or inadequate, if intracranial pressure monitor is in place may see ICP greater than 20 cmH20 K.I.: Must constrict vessels in the head by keeping PaCO2 between 25-30 mmHg. Adjust FiO2 to maintain high normal levels (PaO2 of 100mmHg) Avoid increased ICP by minimizing PEEP use. Suction only when needed (due to H peak pressure) Avoid increasing MAP, Sedation is important, but should be monitor exhaled volumes and pressures closely. Use of drugs such as mannitol when ICP is >20. Use Dilantin and establish an airway if seizure activity is observed. Chest Trauma : Definition, Clinical Evidence, Chest xray & Key interventions **EXAM Challenge: This case is usually easy to recognize. You may be tempted by options that address the broken ribs when, in fact, you simply need to address ventilation. Very commonly, this case will lead to pneumothorax or partial pneumo or hemothorax D: Any traumas leading to rib fractures or flail chest C.E.: Circumstantial hx, RR and patternis fast and shallow due to pain. May have obvious trauma on chest, sharp chest pain, paradoxical chest movement if ribs are broken in 2 places (flail) pneumothorax is possible, XR: may reveal broken ribs, usually isolated in same area K.I.: Encourages deep breaths- IPPB, IS, coughing, watch for ventilatory failure, MV when vent failure is approaching, treat partial pneumos >20%-insert chest tube, treat hemothorax w chest tubes or thoracentesis, Tx tension pneumo w large bore needle, MV at lower tidal volumes--initial 6-7mL/kg, PEEP 5-10 Thoracic Surgery : Definition, Clinical Evidence, Chest xray & Key interventions **EXAM Challenge: Your ability to deal with and troubleshoot chest tube maintenance is tested in this simulation. Sometimes this case is combined with chest trauma. D: Can have variety of complications from thoracic surgery C.E.: Always monitoring chest tube drainage adequacy, looking for potential complications i.e.-- hypovolemic shock, low hemodynamic values including BP, subcutaneous emphysema,, elevated ventilatory pressures XR: to confirm proper re-inflation of the lung and proper placement of chest tubes K.I.: anything that promotes expansion of the lungs including incentive spirometry, IPPB, and positive pressure MV, if a lobectomy or pneumoectomy, vent volumes should be set lower, fluid therapy if volume is a problem (often is) Neck/Spinal Injury : Definition, Clinical Evidence & Key interventions **EXAM Challenge: Your knowledge of special intubation techniques is what is being tested in this type of simulation. D: Any trauma threatening the physical structure of the neck. C.E.: Hx of some sort of accident, visible damage to the neck, altered conscious level, pulse must be palpated, brachially or femorally, Vt, VC, PEFR and other ventilatory volumes may quickly deteriorate XR: neck xray will show injury K.I.: Always be prepared to quickly assist and/or promote ventilation, if intubation is required, always use MODIFIED thrust if given option, always intubate with a bronchoscope so damage can be visualized and care can be taken to avoid inflicting further damage. **Alternatively, a blind nasal intubation is accepted. Abdominal Surgery : Definition, Clinical Evidence, PFT & Key interventions **EXAM Challenge: Abdominal surgery is usually a very general, non-complicated case involving preventative care and follow up. D: Surgery of the abdominal area for various reasons C.E.: All general visual assessments, All general bedside assessments including all vital, PFT- ventilatory volumes (VC, Vt, FEV1) compared to pre-surgery baselines K.I.: Establishing baselines in pulmonary function testing flows and volumes, start patient on IS- SMI therapy prior to surgery, every hour after surgery,Initial SMI therapy goals should be 1/2 the pre-surgical baseline value. If unable to achieve 1/2 the pre-surgical volume, then lower the goal to just above what the patient can accomplish. Use Pos. pressure (IPPB) if needed after surgery if patient is unconscience Adult Respiratory Distress Syndrome (ARDS) Restrictive : Definition, Clinical Evidence, Chest xray, CBC, ABG,PFT & Key interventions **EXAM Challenge: ARDS can be a very disquieting case. Usually persistent increases in PEEP are needed. Do not be afraid to increase PEEP sig. Also, most often, cardiac output or some other hemodynamic value will fall indicating a need to decrease PEEP in spite of profound hypoxemia. When doing so always return to the previous acceptable setting and then increase FiO2 as needed. D: A condition that results in significantly decrease lung compliance and consequent profound hypoxemia C.E.: Record may show a variety of insults to the lung including massive surgery, near drowning, inhalation of gasoline, hypothermia and others. Rapid RR and cyanosis, Decreased lung compliance as manifested by increased plateau pressures (decreasing static compliance) XR: show granular or ground glass, reticulogranular or honeycomb patterns, often combined w diffuse infiltrates All hemodynamic values could deteriorate when positive ventilatory pressures become significant. ABG: persistent hypoxemia in spite of elevated FiO2 (may be refractory) K.I.: As positive pressure is required increasingly, negative effects may be seen. All should be done to minimize the mean pressure being put on the pulmonary system, while trying to balance the need to ventilate with higher pressures an utilize PEEP to maintain oxygenation. If underlying cause is known, treat it. *After emergency situation is passed, keep FiO2 at 0.6 and use PEEP* Keep increasing PEEP until an obvious degradation in hemodynamic values (esp. C.O) is witnessed. As ventilator pressure get higher, OK to consider alternate methods of ventilation including pressure control, high freq Laryngectomy : Definition, Clinical Evidence & Key interventions **EXAM Challenge: In this case, you are always looking for post-surgical complications like blood clots in the laryngeal tube. Often you will have to MV this patient through the laryngectomy tube. D: Surgery done to address or remove cancer of the larynx. C.E.: Surgical record- surgery radical (entire larynx) or simple (cord removal) Medical history will show cancer in upper airway. Signs of airway obstruction after surgery. Usually caused by blood within a few hours after the surgery. K.I.: If radical surgery the the tracheostomy become permanent. If not radical then a temporary laryngectomy tube is placed but must be replaced in 3-6 weeks ***Prevent aspiration!! Wait at least a week before oral ingestion of liquid and longer for food. Thorough pulmonary hygiene through suctioning. Use cool aerosol or ultrasonic nebulizer to keep secretions thin and hydrated. Once the surgery is done, you can no longer, orally intubate the patient. Even if the temporary larygectomy tube is in place you must intubate and/or ventilate through that tube!! Guillain-Barre' Syndrome : Neural/Restrictive Definition, Clinical Evidence, ABG & Key interventions **EXAM Challenge: Like most neuromuscular cases, you will be tested in your ability to recognize deterioration in vent. musc. (Only when VC is <1.0L D: An insidious neuromuscular problem involving muscle paralysis. Paralysis moves from "ground to brain"