1
Q
What factors dictate the Partial pressure of O2 in arterial blood?
A
- Alveolar ventilation
- Ventilation/ perfusion
- FiO2
2
Q
What is the driving force for saturating hemoglobin with O2?
A
PO2 = partial pressure of oxygen in any blood
3
Q
What are the ways that H+ is removed from the blood?
A
- respiration
- renal (metabolic) mechanism
4
Q
Normal ABG ranges?
A
pH: 7.35-7.45 PaC02: 35-45 HCO3: 22-28 PaO2: 80-100mmHg SaO2: 95-100%
5
Q
What is respiratory acidosis?
A
pH decrease
PaCO2 increase
HC03 normal
Ex: lactic acidosis, keteacidosis
6
Q
What is respiratory alkalosis?
A
PpH increase
CO2 decrease
HCO3 normal
Ex: potassium depletion, Cushing’s syndrome
7
Q
What is metabolic acidosis?
A
pH decrease
CO2 normal
HCO3 decrease
Ex: hypoventilation, COPD
8
Q
What is metabolic alkalosis?
A
pH increase
CO2 normal
HCO3 increase
Ex: anxiety, hyperventilation
Respiratory compensation= min- hrs
Renal compensation= 1-5 days
9
Q
What factors cause impaired oxygenation?
A
aka: low PaO2
- hypoventilation
- decreased inspired O2
- diffusion impairment
- shunt
- ventilation perfusion mismatch
10
Q
NG tube precaution
A
Turn Off if HOB is less than 30 degrees
11
Q
List effects of Anesthetics
A
Decreases:
- deep breathing, tidal volume, coughing, FRC, increased RR, increased need for appropriate closing volume.
Causes increased:
- infections, secretion retention, atelectasis, WOB, immobility, LOS, but decreased vital capacity
12
Q
What reflex can be inhibited from Anesthetics?
A
Hypoxic pulmonary vasoconstriction reflex:
- shunting of blood from poor to well ventilated areas, causing V/Q mismatch
13
Q
Indications for O2 therapy
A
- SpO2
14
Q
When to involved an RT?
A
- O2 >40%
- SaO2
15
Q
What is a nebulizer?
A
Delivers drug into the airway by a vapor mist
16
Q
What is FiO2? How does it vary?
A
- proportion of inspired oxygen
- room air = 21%
- varies with breathing pattern, rate and TV
- 1L/m = FiO2 = 24% (add 4 % per litre)
- 5L/m = FiO2 = 40 %
17
Q
What flow rate do you use a simple mask?
A
5-10L/min
FiO2 25-50%
18
Q
What % of inspiration is controlled by the diaphragm?
A
40%
- two parts: lower 6 ribs + upper 3 Lspine to central tendon
19
Q
What are the accessory inspiratory muscles?
A
- SCM
- Scalenes
- Pec Minor
- Parastenal intercostal
- external intercostal
20
Q
Expiratory muscles:
A
- internal intercostals
- all abdominals but mostly TA
21
Q
Adaptation from inspiratory muscle training
A
Improves:
- inspiratory mm strength
- exercise tolerance / decreases dyspnea
22
Q
Pathophysiology of COPD and results.
A
- Parenchymal inflammation (emphysema) & decreased recoil
- Airway inflammation & remodelling
Results in:
- decreased expiratory flow, hyperinflation, gas exchange abnormalities
23
Q
Signs and symptoms of COPD
A
Signs:
- airway obstruction
- Hx of toxin exposure
- impaired diffusion capacity
- increased lung volume
- hypoxemia
- Anorexia
Symptoms:
- Dyspnea, chronic productive cough, wheeze, fatigue/ weakness
24
Q
How to test for COPD?
A
Spirometry w/ bronchodilator
- FEV1 decrease
Lung volume and diffusion capacity
CT Scan
25
COPD management
- smooth mm relaxation: SA & LA beta agonist
- oral Cortico steroid to reduce airway inflammation
- exercise
- O2 therapy
26
Positioning for respiratory distress
- Head, shoulders down breath in/out of mouth : pursed lip
27
Differentiate b/w hypoxia and hypoxemia
Hypoxia: cells not getting enough O2
Hypoxemia: not enough O2 in blood
28
Discuss V/Q matching in lung
```
Apex:
- Large alveoli with poor blood flow = V/Q >1
- PA>Pa>Pv
Mid zone:
- V/Q = 1------ Pa>PA>Pv
```
Base:
V/Q PvP>PA
29
To optimize V/Q how do u position a patient in unilateral lung disease?
- Bad lung up b/c perfusion is better in the dependent part of the lung.
30
What is ventilation like in restrictive diseases
Reduced compliance:
| - decrease lung volume causing increase RR + WOB
31
What is the ventilation in obstructive diseases
Increased resistance to airflow:
- higher intra pleural pressures are needed to overcome the high airway resistance due to loss of elastic recoil and alveoli destruction
32
What determines the amount of O2 in the blood?
- Hb saturation: Carrying capacity
| - SO2: Saturation of Hb with O2 (how much of the carrying capacity is being used)
33
Name 13 secretion techniques
- Cough +/- splint
- Huffing (forced expiratory technique): 2 reps followed by 3 DB
- Assisted cough: manual force to xyphoid
- Active cycle breathing: relax breath, big with hold, relax, huff
- Vibrations
- Percussions: see precaution list
- Rib springing
- PEP mask: positive expiratory pressure
- Autogenic drainage: unsticking, collecting, evacuating
- Postural drainage: special positions
- exercise:
- suction:
34
Postural drainage position for: Left upper lobe
```
Apical segment:
- sitting at 80 degrees
Posterior segment:
- Incline prone w/ left side partially up
Left lingua:
- decline, supine, left side up a bit
```
35
Postural drainage position for: Left lower lobe
```
Superior (apical) segment:
- Flat, prone, pillow under belly
Anterior segment:
- Decline, supine
Posterior segment:
- decline prone, pillows under hips
Lateral segment:
- decline, side lying
```
36
Postural drainage position for: Right upper lobe
```
Apical:
- sitting at 80 degrees
Anterior:
- flat supine, hips ER
Posterior:
- flat, prone, pillow under chest
```
37
Postural drainage position for: Right middle lobe
Middle lobe:
| - decline, supine, right side up a bit
38
Postural drainage position for: right lower lobe
```
Superior:
- flat, prone, pillow under belly
Anterior segment:
- decline supine
Posterior:
- decline, prone, pillow under hips
Lateral segment:
- decline, side lying
```
39
What are the pressure requirements for suctioning
Adults: 120-150 mmHg
Children: 80-120 mmHg
Infant: 60-80 mmHg
40
What are the indications for suctioning
- unable to clear secretion
- loss of airway control
- lung pathologies
- need a sputum sample
41
Contraindications to nasopharyngeal suctioning
Bleeding
- epiglottis or croup
- acute head or facial injury
- CSF leakage
- Nasal stenosis/ infection/ polyps
42
Define lung compliance
Ability of lung to stretch during a change in volume
43
What is atmospheric pressure
At sea level 760 mmHg
44
What is intrapulmonary pressure
- pressure in the alveoli of the lungs
| - Rises and falls with patterns of breathing but always equalizes itself with atmospheric pressure
45
Define Intrapleural pressure
- pressure within pleural cavity
| - fluctuates with breath but always ~ 4 mmHg
46
What is transpulmonary pressure
Difference between intrapulmonary and intra pleural pressure
- keeps the lungs from collapsing
47
List different breathing exercises
- Diaphragmatic: belly breathing
- Diaphragmatic plus hold: prevents atelectasis, increases diffusion time
- lateral costal breathing: lower lung zones, cue with hands
- pursed lip breathing: expiration 2x inspiration
- Segmental breathing: use tactile and pressure cues
- Incentive Spirometry: sustain for 3 seconds, no evidence
- breath stacking: when deep breathing is too painful
- SOS for SOB
- Rib springing:
48
How does a BODE index score relate to COPD
```
Score of 7+ = very poor prognosis
- FEV1
- Distance walked in 6 min (m)
- MMRC dyspnea scale
- BMI
-
```
49
Aerobic FITT for pulmonary rehab
F: 1-2x/day (3-7days/week)
I: Borg 3-5/10 (SpO2 >88%), 50-80 % of 6MWT avg speed
T: intervals
T: large mm groups
50
Resistance FITT for pulmonary rehab
KISS: more reps before weights
51
What is EIB
Increase in airway resistance following rigorous exercise
| - >10% decrease in FEV1 or peak expiratory flow rate occuring maximally at 3-15 to mins after exercise
52
How is EIB diagnosed
- FEV1, PEFR tests
- incremental exercise
- saline or mannitol challenge
- escaping voluntary hyperventilation
53
Signs and symptoms of EIB
SOB, dry cough, wheeze, chest congestion/discomfort, fatigue, decreased exercise tolerance
54
What is hyperosmolarity theory for EIB
Water loss in the airways causes narrowing of airways and creates a wheeze:
- evaporation of water causes increased osmolarit pay of airway and results in mast cell degranulation and release of brochoconstrictor mediators
- with colder air there is less H2O which is why it's more prevalent
55
What are the 3 stages of EIB
1) Early:
- most severe, cough ++, after 80% VO2max 3-8 mins
2) refractory period:
- the chemicals that cause EIB get depleted after being released
- allow the inflammation to subside, then u have 3 hrs where no brochospasm will occur.
3) Late phase:
- less severe symptoms may reoccur hours later.
56
Exercise advice for EIB
- Warm up, intervals/ built in rest periods.
- cover mouth and nose
- self monitor
- try baseball, golf, wrestling, avoid swimming and skiing.
57
How to test inspiratory muscles
Strength: MIP
Endurance: Threshold trainer
58
IMT FITT prescription
F: 4-5 days/week
I: start 9 cm H20 or 25% MIP, progress 5%/week
T: 5-15 min/day, add 1-3min up to ~ 30min
T: threshold type trainer
Monitor: fatigue, HR, BP, dyspnea, SpO2
59
What is bronchopulmonary dysphasia
- chronic lung disease in children
| - --- Crackles, wheeze, cyanosis, hypoxemia, LRTI, abnormal CXRay
60
What is croup and bronchiolitis
Virus produces inflammation and edema of upper airway (croup) and lower (bronchiolitis)
- harsh barking cough, hoarse voice, stridor
61
Common respiratory patterns for ppl with CP
- poorly developed chest or scoliosis
- diaphragm for breathing and posture
- chronic hypoventilation
- inability to take DB
- ineffective cough
- low energy/ fatigue
- risk of aspiration
62
What does respiratory distress look like in kids
- >RR, cyanosis, nasal flaring, grunting, head bob, apnea/ bradycardia, breathing pattern, structural deformities ( pectins excavatum, carinatum [pidgeon chest], scoliosis)
63
Anatomical differences of adult and new born
- different chest shape and structure
- immature alveoli structure and function
- Narrow airways
- nose breathers
- diaphragmatic breathing only
- lower TV, higher RR: new born TV= 18-29 mL, adult = 500mL
- increased WOB
- infection risk
64
Changes in body and breathing for 6-12 month child
- ribs move downward from intercostal activity / efficient diaphragm
- increased mm
- larger lung volumes and airway size: increase TV/ RRdecrease
65
Heart SA
Point 1) 5th interspace, 9 cm L of midline
Point 2) 5th rib (SC articulation)
Point 3) between the 2nd interspace at the level of sternum
66
What is IPPA?
Inspection:
Palpation:
- chest expansion, tactile fremitis, trachea position, vitals
Percussion:
- normal = resonant, fluid = dull, air = hyper-resonant
Auscultation:
- 6 anterior, 10 posterior
- bronchial = hollow breath/ short pause. Normal over large airways
- Adventitious:
--- crackles early = obstruction, late = edema/fibrosis
--- wheezes: musical snoring
--- stridor: laryngeal/ tracheal obstruction
---Pleural rubs: creaking leather
67
11 steps of reading a CXRay
1) is it PA or AP?
2) over or under exposed?
3) satisfactory inspiration (9 ribs post, 6 ant)
4) is patient rotated:
5) is heart enlarged: A/B ratio should be smaller than 50%
6) Silhouette signs:
7) position of mediastinum
8) landmarks of the mediasternum
9) Hila/ fissures normal
10) How are the bones
11) clinical reasoning skills
68
What does atelectasis/ collapse look like on CXRay
- shift of landmarks
- silhouette signs
- collapse can look white because there is no air
69
Respiratory mm innervations
Inspiration:
- accessories: C2-4
- diaphragm : C3-5
- intercostals : T1-11
Muscles of expiration:
- intercostals: t1-11
Abdominals t6- L1
PCE
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