ACCS Respiratory Exam 2023 Rated 100% Correct

Normal Urine Output - Answer 40 mL/hr (approx. 1 Liter/day) Decreased CVP (2 mmHg) - Answer Hypovolemia Increased CVP (6 mmHg) - Answer Hypervolemia Glasgow Coma Scale (GCS) - Answer Eye-opening response Spontaneous opening- 4 To verbal stimuli- 3 To pain- 2 None- 1 Most appropriate verbal response Oriented- 5 Confused- 4 Inappropriate words- 3 Incoherent- 2 None- 1 Most intergrated motor response (arm) Obeys commands- 6 Localizes pain- 5 Withdraws from pain- 4 Flexion to pain- 3 Extension to pain- 2 None- 1 Orthopnea - Answer ability to breathe only in an upright position (CHF, Heart problem) General malaise - Answer Run down feeling, nausea, weakness, fatigue, headache (electrolyte imbalance) Dyspnea - Answer Grade 1- occurs after unusual exertion Grade 2- breathless after going up hills or stairs Grade 3- while walking at normal speed Grade 4- slowly walking a short distance Grade 5- at rest, shaving, dressing, etc. vasovagal syncope - Answer Common dizziness and fainting, caused by loss of peripheral venous tone orthostatic hypotension - Answer Excessive drop in BP when assuming the standing position Carotid sinus syncope - Answer Associated with hypertension carotid sinus - more common in elderly patients Cough (tussive) syncope - Answer Transient loss of consciousness following severe coughing FUO - Answer fever of unknown origin heart rate - Answer 60-100 bpm Respiratory rate - Answer 12-20 breaths per minute Temperature Norm. - Answer Oral- 97.0-99.5 *F (36.5-37.5 *C) Rectal- 98.7-100.5 *F (37.1-38.1 *C) Ear- 98.7-100.5 *F (37.1-38.1*C) PERRLA - Answer pupils- equal, round, reactive to light and accommodation Miosis - Answer constricted pupils (pinpoint) Ptosis - Answer Drooping of the upper eyelid Diplopia - Answer Blurred or double vision Nystagmus - Answer involuntary, rapid, rhythmic movement of the eyeball Peripheral edema - Answer Presence of excess fluid in the tissue. Caused by CHF, pulmonary hypertension, venous insufficiency and renal failure. Rated +1,+2,+3,+4; higher numbers indicate more severs swelling. May be described as "pitting edema" ascites - Answer abnormal accumulation of fluid in the abdomen, generally caused by liver failure Clubbing of fingers - Answer Caused by chronic hypoxemia, suggestive of pulmonary disease Eupnea - Answer normal respiratory rate, depth and rhythm Tachypnea - Answer increased respiratory rate (over 20 breaths per minute) Bradypnea - Answer decreased respiratory rate (less than 12 per minute) variable depth and irregular rhythm Apnea - Answer not breathing Hyperpnea - Answer increased respiratory rate, increased depth, regular rhythm (caused by metabolic disorder, CNS disorder) Cheyne Stokes - Answer gradually increasing then decreasing rate and depth in a cycle lasting from 30-180 seconds, with periods of apnea lasting up to 60 seconds. Biot's - Answer increased respiratory rate and depth with irregular periods of apnea. Each breath has the same depth. Kussmaul's - Answer Increased respiratory rate (usually over 20 breaths/min.), increased depth, irregular rhythm, breathing sounds labored. Apneustic - Answer prolonged gasping inspiration followed by extremely short, insufficient expiration. Macroglossia - Answer Enlarged tongue Cachectic - Answer Muscle wasting Normal Pulse - Answer 60-100 bpm Tachycardia - Answer 100 bpm, indicated hypoxemia, anxiety, stress Bradycardia - Answer 60 bpm, indicates heart failure, shock, code/emergency Heart rate change more than 20 bpm - Answer Considered an adverse reaction, stop therapy, notify nurse/doctor Pulse varies with respiration - Answer May indicate air trapping (status asthmaticus or cardiac tamponade) Tracheal Deviation, Toward - Answer Pulmonary atelectasis Pulmonary fibrosis pneumonectomy Diaphragmatic paralysis Tracheal Deviation, Away - Answer Massive pleural effusion Tension pneumothorax Neck or thyroid tumors Large mediastinal mass Coarse Rales (rhonchi) - Answer large airway secretions, patient needs suctioning Medium Rales - Answer Middle airway secretions, patients needs chest physical therapy Fines Rales (moist crepitant rales) - Answer alveoli, fluid, patient has CHF/ pulmonary edema, patient needs IPPB, heart drugs, diuretics and oxygen Wheeze - Answer bronchospasm, patient needs a bronchodilator, unilareral wheeze indicative of a foreign body obstruction Stridor (Monophonic inspiratory sound, crowing) - Answer Supraglottic swelling Subglottic swelling (post extubation) Foreign body aspiration (solid or fluid) Treatment- topical decongestant (racemic epinephrine) for swelling and edema Suctioning and/or bronchoscopy for secretions and foreign body aspiration Intubation for marked/severe stridor Heart Sounds: First Sound (S1) - Answer is created by normal closure of the mitral valve and tricuspid valves at the beginning of ventricular contraction Heart Sounds: Second Sound (S2) - Answer is normal and occurs when systole ends, the ventricles relax and the pulmonic and aortic valves close. Heart Sounds: Third Sound (S3) - Answer in an adult, the presence of an S3 sound, is abnormal and may suggest CHF Heart Sounds: Fourth Sound (S4) - Answer the presence of a fourth sound, S4, is indicative of a cardiac abnormality such as myocardial infarction of cardiomegaly Adult Blood Pressure Normal - Answer 120/80 mmHg Acceptable: 90/60 - 140/90 Increased Blood Pressure (Hypertension) - Answer indicates cardiac stress, hypoxemia Decreased Blood Pressure (Hypotension) - Answer indicates poor perfusion, hypovolemia, CHF Work of Breathing Calculation (WOB) - Answer Change in pressure X change in volume Normal WOB - Answer 0.5 - 0.7 J/L (0.05 - 0.07 kg-m/L) Cannot be measured during mechanical ventilation Respiratory muscle weakness - when inspiratory muscles tire, VT decreases and RR increases Normal PaCO2 - Answer 40 torr Normal PetCO2 - Answer 34-36 torr 3-5% Normally 4-6 mmHg lower than PaCO2 Normal ETCO2 percent - Answer 3-5 % Increase PECO2 or PETCO2% - Answer indicates decreased ventilation (ventilatory failure) Decrease PECO2 or PETCO2% - Answer indicates increase in ventilation or decreased perfusion (deadspace disease: pulmonary embolism, hypovolemia) Low PETCO2 reading immediately following intubation - Answer ET tube is in the esophagus Colormetric Detection Device Normal - Answer Purple - Poor Yellow - Normal False readings can occur in patients who have been without CPR for a period of time VD - Answer Deadspace Ventilation Anatomic Deadspace - Answer amount of inspired tidal volume that does not enter the alveoli. Approx. 1 mL per lb of IBW (i.e., 150 lb = 150 mL VD) Used to approximate alveolar ventilation Alveolar Deadspace - Answer amount of alveolar ventilation that has no blood perfusion. Occurs with a Pulmonary Embolism (P.E.) Physiologic Deadspace - Answer is the sum of anatomic and alveolar deadspace and is estimated by the Deadspace to Tidal Volume (VD/VT ) Ratio VD/VT (%) Ratio - Answer Deadspace to Tidal Volume Ratio Normal 20 - 40% (up to 60% for ventilated patients) Acceptable: 60% Unacceptable: 60% Increase in VD/VT ratio indicates a deadspace producing disease (PE, ARDS) Mechanical Deadspace - Answer amount of circuit tubing between the patient and the wye adapter in the ventilator circuit. Approx. 10 mL per inch of flex tubing (i.e., 5" = 50 mL VD) Can be used to adjust PaCO2 levels Minute Ventilation (VE) Formula - Answer VE = (VT x F) Example: A patient is recieving volume ventilation with a tidal volume of 800 mL at a frequency of 10 breaths per minute. VE = 800 x 10 = 8000 mL or 8 L Alveolar Minute Ventilation (VA) Formula - Answer VA = (VT - VD) x f Example: 68 kg (150 lb) patient is recieving volume ventilation at a tidal volume of 600 mL and a rate of 10. VA = (600 - 150) x 10 = 4500 mL or 4.5 L Deadspace to Tidal Volume Ratio (VD/VT) Formula - Answer ((PaCO2 - PECO2) / PaCO2) X 100 Example: Calculate the VD/VT ratio for a patient who has a PaCO2 of 40 torr and a PECO2 of 30 torr. ((40 - 30)/40) X 100 (10/40) X 100 0.25 or 25% PECO2 - Answer Average PCO2 of the exhaled air and can be measured by a capnograph. Deadspace Ventilation (VD) Formula - Answer VD/VT x VT = VD Example: A patient with a VD/VT ratio of 25% is receiving mechanical ventilation as a tidal volume or 800 mL. What is the patients' VD? VD = 0.25 x 800 mL = 200 mL PaO2 - Answer 80-100 torr Alveolar Oxygen Tension (PAO2) The Alveolar Air Equation - Answer Calculates the partial pressure of oxygen (PO2) in the alveoli. Formula: PAO2 = (PB - PH2O) FiO2 - (PaCO2/0.8) SHORCUT: PAO2 = (FiO2 x 7) - (PaCO2 + 10) Example: Calculate the PAO2 for a patient receiving 50% oxygen with a PaCO2 of 40 torr at the barometric pressure of 747 torr. (747 - 47) .50 - (40/0.8) (.50 x 7) - (40 + 10) (700 x .50) - 50 (350) - (50) 300 torr Alveolar-Arterial Oxygen Gradient (P(A-a)O2 or A-aDO2 or A-a Gradient - Answer Estimates the difference (gradient) between alveolar and arterial PO2 Best estimated when a patient is breathing 100% O2 for 20 min or more. Formula: A-aDO2 = PAO2 - PaO2 V/Q Mismatch oxygen therapy - Answer if PaO2 increases with oxygen therapy Shunt oxygen therapy - Answer if PaO2 does not increase with oxygen therapy A-a Gradient Normal Values on 100% O2 - Answer 25-60 torr - Normal 66-300 torr V/Q Mismatch 300 torr shunting Arterial Oxygen Content (CaO2) - Answer Best measurement of oxygen delivered to the tissues, or best index of oxygen transport. Estimates the amount of oxygen carried by hemoglobin as well as that dissolved in the plasma. Formula: CaO2 = (Hb x 1.34 x SaO2) + (PaO2 x .003) SHORTCUT: CaO2 = (Hb/3) x 4 Normal CaO2 - Answer 17-20 vol % (mL/dL) Mixed Venous Oxygen Content (CvO2) - Answer Total amount of oxygen carried in the mixed venous blood. Calculated using the same formula as CaO2 except for using mixed venous PO2 (PvO2) and saturation (SvO2). The blood is drawn from the Pulmonary Artery through a balloon-tipped, flow-directed (Swan-Ganz) catheter. Formula: (Hb x 1.34 x SvO2) + (PvO2 x .003) SHORTCUT: CVO2 = Hb CvO2 will decrease when cardiac output decreases SvO2 will also decrease when cardiac output decreases Normal CvO2 - Answer 12-16 vol% (14 vol%) Arterial-Venous Oxygen Content Difference (C(a-v)O2) - Answer The CvO2 is subtracts from the CaO2. Measures the oxygen consumption of the tissues. Formula: C(a-v)O2 = CaO2 - CvO2 Used in the Fick equation to calculate cardiac output (L/min) or oxygen consumption (mL/min) C(a-v)O2 difference will increase when the CvO2 is decreasing and would indicate a decreasing cardiac output (Inverse relationship) Normal C(a-v)O2 - Answer 4-5 vol% P/F Ratio (PaO2/FiO2) - Answer Normal 380 or greater Mild ARDS 200-300 Moderate ARDS 100-200 Severe ARDS 100 (Diffuse bilateral opacities) Shunt Equation (QS/QT) - Answer The portion of cardiac output (QT) that is shunted (QS). Formula: ((A-aDO20)(.003) / (A-aDO2)(.003) + C(a-v)O2) SHORTCUT: Take first digit of A-aDO2 Add +1 Multiply by 5 Example: PAO2 = 400 torr PaO2 = 100 torr A-aDO2 = 400-100 = 300 torr First digit = 3 Add +1 - 3 + 1 = 4 Multiply by 5 - 4 x 5 = 20 Shunt of 20% Normal Shunt (QS/QT) Value - Answer 3-5%