Lecture Week 2

Question 1

How does an intraaortic ballon pump work

Answer 1

cath goes from the femoral artery into the aortic arch. During ventricular diastole (when the aortic valve closes) the ballon inflates pushing blood back toward the left ventricle where it can enter the coronary artery orifaces

Question 2

what should you do to decrease cardiac workload

Answer 2

1. give o2

2. decrease SVR

Question 3

what are the two types of respiratory failure

Answer 3

1. hypoxic (such as in pneumonia)

2. hypercapnic (such as in COPD)

Question 4

what are the early signs of hypoxic respiratory failure

Answer 4

1. restless

2. premature ventricular contractions

Question 5

what are the early signs of hypercapnic respiratory failure

Answer 5

1.lethargic

Question 6

what do you do to treat hypercapnic respiratory failure

Answer 6

give BiPaP to reduce CO2 levels, but the patient needs to be awake because unlike cPAP it does not push the air in and the patient actually has to breath.

Question 7

normal CO2 levels for COPD patients

Answer 7

60-70 you really dont wanna drop them lower then that because their instinct to breath is dependent on CO2 rather then O2 like us

Question 8

what kind of people end up getting elective intubations

Answer 8

surgery and CVA patients

Question 9

what are the ET sizes in men vs women

Answer 9

women: 7-7.5
men: 7.5-8

Question 10

where is a normal ET placement? what happens if the ET tube gets pushed down? what happens if it gets pulled up?

Answer 10

about 1 inch above the carina. If it gets pushed down it will go down the right lung and cause the left lung to collapse. If it goes up neither lung will receive proper oxygenation.

Question 11

what drugs do you give patients before intubation

Answer 11

1. benzo(versed)

2. paralytic agent (succenylcholine, proprofol, vecuronium)

Question 12

which patients are hardest to put an ET in? what are they at risk for? how do you care for these patients

Answer 12

1.short necks
2.obese
at risk for hypoxia (due to multiple attempts) watch for bradycardia and hypoxia(observe monitor) during insertion

Question 13

how do you confirm ET placement and which landmark is the carina at?

Answer 13

CXR, 4th intercostal space at the nipple line.

Question 14

what will happen if you have no fully inflated an ET cuff

Answer 14

you will hear gurgling

Question 15

What are the different modes on a vent and what do they do

Answer 15

1. AC (assisted control)-machine does all the work
2. SIMV(synchronized intermittent mandatory ventilation) -it will help the patient reach some goal. such as if the patient inhales 200 it will push the extra 300 in.
3. CPAP (continous positive airway pressure)-patient does all the work the machine just helps keep the alveoli open
4. PEEP (positive end expiratory pressure) - increases oxygenation by keeping the alveoli open. It is contraindicated in hypotension because it increases intrathoracic pressure which decreases preload. You need an order to add PEEP to patients post CABG. Normal PEEP (5-10)

Question 16

What is the VT setting on vent

Answer 16

Tidal volume, it is dependent on weight normal tidal volume is 6-8 ml/kg

Question 17

what is the normal RR on a vent

Answer 17

14 plus minus 2

Question 18

what vent setting would you adjust first if a patient is hypoxic

Answer 18

set FiO2 to 100%

Question 19

what is hyperventilation

Answer 19

has nothing to do with oxygen and everything to do with RATE of respirations and flushing of CO2

Question 20

what vent setting would you adjust to lower CO2

Answer 20

increase the RR

Question 21

what is the difference between O2 sat and PO2

Answer 21

1. O2 sat is the % of hemoglobin that has oxygen attached to it
2. PO2 is the amount of oxygen dissolved in blood. (80-100)

Question 22

what is the difference between hypoxemia and hypoxia

Answer 22

hypoxemia means the PO2 levels are dropping (60-80)
hypoxia means that the PO2 levels have dropped below 60 and due to the oxyhemoglobin dissociation curve the tissues are now not getting enough oxygen.

Question 23

describe the oxyhemoglobin dissociation curve

Answer 23

O2 sat lateral and PO2 level horizontal. It looks like the graph of pH buffers the magic numbers being PO2 of 60 and O2 sat of 90%

Question 24

what is the general purpose of the pulmonary function test (PFT)

Answer 24

tell us how good the lungs are

Question 25

what can you do with a bronchoscopy other then visualize the throat

Answer 25

1. deep suctioning | 2. bronchial wash(biopsy)

Question 26

distinguish between a pneumothorax | hemothorax, pleural effusion and pulmonary edema

Answer 26

1. pneumothorax is air trapped within the pleural space 2. hemothorax is blood trapped in the pleural space 3. pleural effusion-transudate/exudate in the lungs 4. pulmonary edema-fluid in the lungs

Question 27

what is the difference between an open pneumothorax vs a closed(tension) pneumothorax

Answer 27

1. open requires penertration of the chest wall (e.g: stabbing) air goes in and doesnt come out 2. closed is worse because its not obvious you have a one way leak

Question 28

what is a major risk for clients on vents and why

Answer 28

tension pneumothorax because of the high pressure

Question 29

does CPR help in pneumothorax?why

Answer 29

no, the pressure increase pushes down on organs and vessels. The heart will not be able to accept venous return.

Question 30

how would you poisiton a patient for CXR for fluid in the lungs

Answer 30

sitting upright so that the fluid collects at the bottom

Question 31

describe what you see on xrays and what they mean for example what does black mean

Answer 31

black means air | white are fluids

Question 32

what diagnositic do you have to run before and after placement of a swan gauz

Answer 32

CXR

Question 33

indiciation for chest tube insertion

Answer 33

if you do a CXR and there are fluids from ICS 8-12

Question 34

how is patient positioned for chest tube insertion

Answer 34

lying on unaffected side

Question 35

what do you do first if a chest tube gets disconnected from the machine?

Answer 35

put the end of the tube into sterile water to maintain negative pressure

Question 36

how much chest tube drainage is to much per hour

Answer 36

over 70 mL you should call the doctor

Question 37

are air bubbles normal in the water seal chamber?

Answer 37

kinda, up to the 2 cm mark is okay because the lung is damaged as it heals the bubbles will go away. Once they fully go away it indicates the lung is fully healed. Also it should not continously bubble

Question 38

what is subcutaneous emphysema

Answer 38

a chest tube complication where air collects inside the skin causing it to swell. It will crackle on paplitation

Question 39

should you milk a chest tube?

Answer 39

no you risk pulling it out instead hit the tube with a clamp to break up clots

Question 40

what diagnostics should be done for PE

Answer 40

pulmonary angiogram(gold standard) V/Q scan D-Dimer (.44-2.33)

Question 41

what drugs do you give for PE

Answer 41

TPA then lovenox 1mg/kg

Question 42

what is ARF

Answer 42

severe lung injury that causes insufficent O2 transfer to blood and insufficent removal of CO2

Question 43

what drugs do you give in ARF

Answer 43

sedation(benzos) paralytics(proprofol, vecuronium) These are to decrease the metabolicc requirements of the body lasixs-to remove fluid from capillary leaks

Question 44

s/s of tension pneumothorax

Answer 44

1. mediastinal shift(severe) 2. dyspnea 3. assymeterical chest rise

Question 45

how much water should be added to the water seal chamber? suction control chamber?

Answer 45

1. 2cm | 2. 20 cm

Question 46

procedure for Chest tube removal

Answer 46

one quick movement while patient does Valsalva maneuver. Apply sterile cause. Monitor respiratory status. Get chest xray

Question 47

s/s of PE

Answer 47

1. chest pain 2. dyspnea 3. hemoptysis 4. tachycardia 5. low grade fever 6. pleural effusion 7. anxiety - impending doom 8. petechiae 9. cough 10. diaphoresis 11. hypotension

Question 48

s/s of PE again

Answer 48

1. vitals - tachycardia, hypotension, low grade fever, chest pain, hypoxia, tachypnea(decrease CO2) 2. Respiratory - dyspnea, cough, crackles, pleural effusion, hemoptysis 3. Integumentary - Petechiae,diaphoresis

Question 49

causes of hypercapnic RF

Answer 49

1.CNS problems -drug overdose, brainstem infarction, spinal cord injury 2.chest wall problems -flail chest, kyphosis,obesity fracture 3.Neuro -Muscular dystrophy, MS, guillain barre syndrome

Question 50

what is the main problem in ARDS

Answer 50

capillary membrane is dilated due to injury to the alveolar-capillary membrane. therefore it leaks into the pulmonary interstitum(pulmonary edema)

Question 51

what are the two possible outcomes of injury to the alveolar capillary membrane

Answer 51

1. damage to the type 2 alveloar cells | 2. release of inflammatory mediators

Question 52

what occurs when type 2 alveolar cells are damaged

Answer 52

1. decreased surfactant production - >decreased alveolar compliance and recoil - >atelectasis - >(1)hyaline membrane formation ->impaired gas exchange (2) decreased lung compliance->impaired gas exchange

Question 53

what happens when inflammatory mediators are released

Answer 53

1. Bronchoconstriction (1) ->impaired gas exchange (2) pulmonary HTN - >impaired gas exchange 2. Increased alveolar capillary membrane permeability - >capillary leak of blood cells and fluids - >pulmonary edema - >impaired gas exchange

Question 54

what kind of breathing will patients with ARDS present with

Answer 54

1.rapid shallow with dyspnea

Question 55

what signs will ARDS present with

Answer 55

1. severe morning headaches 2. early signs - tachycardia,tachypnea, mild hypertension

Question 56

interventions ARDS

Answer 56

1. maintain PaO2 above 55 2. Positive pressure ventilation - BiPaP, CPAP,vent 3. mobilize secretions - hydration,chest physiotherapy, suction 4. for airway inflammation use steroids 5. for pulmonary congestion use diuretics and nitrates if HF is present

Question 57

what are the features of moderate sedation

Answer 57

1. can respond to verbal stimuli 2. has gag reflex 3. independently maintains patent airway