1
Q
The effect of anesthesia on respiratory function depends on? (3)
A
Depth of general anesthesia
Patient’s preoperative respiratory condition
Presence of special intra-operative and surgical conditions
2
Q
What are the 6 effects of anesthesia on respiratory function?
A
- Altered breathing pattern
- Decreased respiratory drive
- Decreased FRC
- Decreased lung compliance and increased resistance
- Increased V/Q matching
- Depressed of abolished cough reflex, decrease mucocilary escalator
3
Q
Describe the breathing pattern change w/ anesthesia (light, deepening, deep and very deep anesthesia).
A
Light = respiration may be irregular
Deepening = regular, more than normal VT, prolonged forceful expiration
Deep = rapid, shallow breathing (panting)
Very deep = jerky, gasping, irregular
4
Q
Name 3 general characteristic of the altered breathing pattern w/ anesthesia.
A
Chest wall asynchrony
Elevation of Vd/Vt (total dead space)
Monotonous breathing = loss of sigh or yawn
5
Q
What is the normal sighing/yawning rate in an hour for an awake and healthy human?
What is the purpose of that normal yawning/sighing?
A
10/hour
Allow to take deep breaths = stimulates surfactant production
6
Q
What causes the chest wall asynchrony w/ anesthesia?
A
Loss of intercostal ms contribution to inspiration
7
Q
What causes decreased respiratory drive w/ anesthesia? (2)
A
- Progressive decrease in VE as anesthesia deepens
2. Decrease central chemoreceptor sensitivity = decrease VE response to CO2 stimulation
8
Q
What happens when we bring lung closer to RV? (3)
A
- Increased airway closure
- Increased airway resistance
- Atelectasis and shunting
9
Q
What are the causes of decreased FRC w/ anesthesia? (5)
A
- Supine position during Sx = diaphragm displaced up into the chest wall by the abdo viscera
- Reduced rib cage ms tone = no expansion of rib cage
- Increased abdo ms tone = contributes to lengthening of diaphragm
- Additional loss of ms tone w/ ms paralysis
- Manipulation of the lung/diaphragm
10
Q
Why decreased lung compliance is related to reduced lung volume w/ anesthesia?
A
If FRC decreases, airways become more narrow which increased airway resistance
11
Q
Why mucociliary action is reduced w/ anesthesia?
A
Anesthesia, intubation, pain meds, suppl. O2 all have a drying effect on the cilia which decrease its ability to beat
12
Q
Why V/Q mismatching is increased w/ anesthesia? (3)
A
- Change in shape and motion of the chest wall = decreased thoracic excursion/maintained abdominal motion
- Inhaled anesthetics –> inhibition of hypoxic pulmonary vascoconstriction
- Non dependent regions (upper lung) better ventilated w/ mechanical ventilator
13
Q
What are 8 the patient-related risk factors to have post-op complications?
A
- Pre-existing pulmonary impairment of neuromuscular illness (ASA > or = class 2)
- Increasing age: > 60 y.o
- Inactivity
- Active smoking (w/i last 8 weeks)
- Presence of skeletal deformities
- Malnutrition-serum albumin level < 30 g/L
- Noncompliant patient
- Obesity
14
Q
T or F
There’s an increased rate of post-op pulmonary complication in COPD.
A
T
15
Q
Pt in ASA class 2 are more at risk of post-op pulmonary complications, what are risky spirometry values? VC FEV1 DLCO VO2
A
VC < 50% predicted
FEV1 < 2L or 50% FVC
DLCO < 50% predicted
VO2 < 15mL/kg/min during exs
16
Q
Why older pts are more at risk of post-op pulmonary complication? (2)
A
- Coexistent medical problems
2. Alterations in pulmonary function w/ age = increased closing capacity
17
Q
Why is active smoking a patient-related risk for post-op pulmonary complications? (2)
A
- Reduces ciliary action
2. Irritation of airways w/ increased mucous production
18
Q
What are the 2 surgery-related risk factors for post-op pulmonary complications?
A
- Type of Sx
2. Prolonged operative procedures
19
Q
Classify the most risky cardioresp Sx to the least risky.
A
AAA > Thoracic > upper abdo > lower abdo > non abdo/non-thoracic
20
Q
Diaphragm dysfunction is possible to occur during abdo/thoracic Sx:
- What is the consequence of this?
- What causes this?
- Is it reversible?
A
- Decrease FRC and ventilation in dependent (lower) lung zones
- Splanchnic/abdo receptor stimulation during Sx = inhibition of central drive/decrease phrenic motor input OR phrenic nerve irritation during Sx
- Yes, goes back to normal 1 week post-op
21
Q
With duration of anesthesia, when does the risk for post-op complication becomes important?
A
Duration of anesthesia > 3 hrs
22
Q
T or F
Higher risk of post-op complication w/ epidural/spinal anesthesia and video-assisted horoscopic surgery than general anesthesia.
A
F
Lower risk
23
Q
Who am I?
Submammary incision extending from near midline to the 4th or 5th intercostal space at the misaxillary line.
A
Anterolateral thoracotomy
24
Q
What are the ms cut in anterolateral thoracotomy? (3)
A
- Pectoralis major
- Serratus anterior
- Internal and external intercostals
25
Who am I?
Incision extending laterally from an area btw the scapula and vertebrae to the anterior axillary line of the 5th intercostal space (may also 4-6 or 7-8 for esophagus Sx).
Posterolateral thoracotomy
26
What is the major problem w/ posterolateral thoracotomy?
Scapular instability
27
What posture pts usually adopts w/ posterolateral thoracotomy?
Scoliosis towards operated side
28
What are the ms cut in posterolateral thoracotomy? (5)
1. Lower fibers of trapezius
2. Latissimus dorsi
3. Serratus anterior
4. Lower fibers of rhomboids
5. Internal and external intercostals
29
What is a thocaroplasty?
Permanent collapse of part of a lung by removal of all or a portion of ribs 1-7
30
free card
free card
31
What are the ms cut w/ thoracoplasty? (6)
1. Trapezius
2. Rhomboids
3. Lat dorsi
4. Serratus anterior
5. Pec major
6. Scalene
32
What are the postural deformity usually observed w/ thoracoplasty? (3)
1. Lack of structural support
2. Limitation of shldr and trunk mvt = long lean of trunk on ipsilateral side so that shldr are out of alignment w/ hips
3. Paradoxical breathing (bcs no more ribs to support lungs)
33
Who am I?
Vertical incision of the sternum usually used for cardiac Sx or of the mediastinum.
Median sternotomy
34
What are the 2 main problems w/ median sternotomy?
1. Kyphosis and splinting due to pain
| 2. Reduced chest expansion
35
Who am I?
Incision from 8th to 9th intercostal space at posterior axillary line to midline of the abdo.
Thoracoabdominal incision
36
Thoracoabdominal incision are big incision and allow surgery of which structures? (6)
```
diaphragm
esophagys
biliary tract
kidney
thoracic aorta
upper abdo aorta
```
37
What are the ms cut w/ Thoracoabdominal incision? (4)
1. Lat dorsi
2. Serratus anterior
3. External oblique
4. Rectus abdominus
38
What is a common posture observed w/ Thoracoabdominal incision?
Forward flexion posture = splinting
39
What are the 3 main problems w/ Thoracoabdominal incision?
Difficulty coughing
Difficulty deep breathing
Difficulty thoracic expansion
40
Who am I?
Resection of one or more lobes of the lungs.
Lobectomy
41
Where's the incision for lobectomy?
Depends on the site of the lesions and surgeon's preference
42
What happens to the remaining lung in lobectomy?
expands to fill much of the remaining space
43
When are these procedures used?
1. Simple lobectomy
2. Lobectomy by sleeve resection
1. Bronchial carcinoma
| 2. If neoplasm has spread to mainstem bronchus = end-to-end anastomosis of the main bronchus and remaining lobe bronchus
44
Who am I?
Surgical procedure that removes une segment of a lobe and used for localized lesions (abscesses, benign tumors, cysts, TB, etc)
Segmental resection
45
Who am I?
Removal of a small area of the lung.
Used for large bullae cysts, biopsies, peripheral tumors, localized fungus disease.
Wedge resection
46
Who am I?
Total excision of one lung.
Used for extensive carcinoma.
Pneumonectomy
47
During a pneumonectomy, what happens to:
1. Parietal and visceral pleura
2. Mainstem bronchus
3. Pulmonary artery and vein
1. Removed
2. Stapled off
3. Ligated and cut
48
What happens to diaphragm post-pneumonectomy?
Rises
49
Post-pneumonectomy, mediastina and thoracic structure will shift to the operated side, what eventually prevents that from happening?
Effusion of serous fluid and blood forms fibrous tissue which eventually prevents the mediastinal shift
50
Who am I?
Removal of the pleural sac of a segment or entire lung which makes the lung tissue adheres to the internal chest wall.
Pleurodectomy
51
For which condition pleurodectomy is usually used?
Recurrent spontaneous pneumothorax
52
Who am I?
Stimulation of a reaction of the pleural space lining causing adhesion of the visceral and parietal pleura.
Pleurodesis
53
For what pleurodesis is usually performed?
To prevent lung collapse in recurrent pneumothorax or malignant pleural effusions.
54
Who am I?
Removal of a restrictive membrane from the surface of the lung (i.e thickened pleura following empyema)
Decortication
55
What are the 4 most common types of lung biopsies?
1. Percutaneous needle method
2. Transbronchial method
3. VATS
4. Open lung = thoracotomy
56
Who am I?
Removal of a portion of the emphysematous lung to reduce hyperinflation and improve lung mechanics of the remaining tissue.
Lung volume reduction surgery (LVRS)
57
What are the consequences on respiratory function of LVRS? (6)
1. Decrease dyspnea
2. Increase FEV1
3. Improved lung volumes
4. Decrease CO2 retention
5. Decrease need of suppl. O2
6. Increase exs capacity (6MWT)
58
What is the purpose of chest tubes?
To evacuate air, blood and other body fluid/
59
What are the possible insertion sites for chest tubes? (3)
Pleural
Pericardial
Mediastinal
60
For what conditions chest tubes are used? (6)
```
Pneumothorax
Pleural effusion
Hemothorax
Empyema
Pericardial effusion
Post- thoracic/cardiac surgery
```
61
What is the purpose of the water seal bottle in chest tube?
To prevent drainage back into the chest cavity
62
For chest tubes, how is the swing w/:
1. quiet breathing
2. coughing/increased respiratory effort
1. Small mvt
| 2. Large mct
63
T or F
If attached to suction, the swing in the chest tubes is reduced.
T
64
How much should the fluid in the tube or the water-sealed chamber should move when pt is breathing?
+/- 5 cm
65
In chest tube, what's happening if there's no swing?
Tubing may be occluded or lying outside the pleural space --> URGENT, report to med team
66
What does bubbling indicate in chest tubes?
Air leak from pleural space which is good (this is what we want the tube to do)
67
How will bubbling be in chest tube if:
1. No air leak
2. Air leak w/ forced expiration
3. Air leak w/ passive expiration
4. Continous air leak
1. no bubbling = we can remove the tube, air has been drained
2. bubbling on coughing (small air leak)
3. bubbling on expiration (moderate air leak)
4. bubbling throughout inspiration and expiration (large air leak)
68
T or F
| In chest tubes, drainage can increase during pt's mvt (transfers, exercises).
T
69
What does a large amount of blood draining over a short period of time may indicate in a chest tube?
hemorrhage
70
T or F
A sudden increase of drainage volume is normal in a chest drain.
F
| Not normal, alert the nurse/MD ASAP
71
When is the chest tube usually removed by the MD?
When drainage is < 100 mL in 24hrs
72
T or F
Patient can lie on the chest tube.
T
73
T or F
Chest collection device should be kept above the chest tube insertion site.
F
Device should be kept lower than the insertion site to avoid drainage of fluid back to patient
74
Which kind of exs should be encouraged for pt w/ chest tubes?
Shldr ROM exs
75
What are the 4 main objectives of perioperative PT?
1. Decrease postoperative incidence of complications
2. Decrease hospital stay
3. Decrease pt anxiety
4. Increase pt self-efficacy
76
What are the 5 things PT assess pre-op?
1. Cognitive status
2. Capacity to cooperate
3. Language and communication skills
4. Attitudes towards Sx and care
5. Risk factors
77
On what do you educate pts pre-op? (7)
1. Smoking cessation
2. Sx procedure
3. Effects of anesthesia
4. Systemic effects of bed rest and immobility
5. Monitoring and supportive device used post-op
6. Post-op procedures (recovery room, ward, ICU)
7. Rx rationale (prevention or reversal of post-op complications)
78
What are the primary goals of preoperative PT?(9)
1. Aid lung expansion and prevent atelectasis
2. Remove excess secretions = to decrease occurance of atelectasis and chest infection
3. Prevent circulatory problems (DVT, PE)
4. Maintain and restore ROM and STRG
5. Control anxiety and modify pain
6. Maximize chest mobility and prevent postural deformities
7. Restore exs tolerance
8. Maintins skin integrity
9. Provide instruction for Rx btw Rx
79
When do we start PT post-op?
Day after Sx
80
What is the purpose of inspiratory holds?
Increase lung volume
| To open up atelectatic areas
81
Post-op what specifically do you practice w/ pt for early mobilization? (3)
1. Rolling
2. Sitting (if hemodynamically stable) = in crease FRC
3. Ambulation
82
Post-op how often should interventions be?
every hour (pt do them by themselves)
83
What are the pulmonary benefits of ambulation post-op? (3)
1. Increase alveolar ventilation
2. Enhances V/Q matching
3. Optimizes DLCO by stimulating dilatation and recruitment of alveolar capillaries
84
T or F
You can put pts head down post-op for postural drainage.
F
Better not. Used modified position and sidelying
85
If unilateral lung disease, to improve PaO2 how do you position pt? Why?
Lying on unaffected side
| Gravity dependent portion of the lung receives the greatest airflow (V/Q matching)
86
What is the main post-op complication?
| When does it usually occur?
Atelectasis
| 24-48h post-op
87
What causes atelectasis post-op? (3)
1. Hypoventilation (most common)
2. Airway obstruction by retained secretions
3. Decreased FRC and ERV
88
Why do pts are more likely to retain secretions post-op? (3)
1. Reduced ciliary function due to anesthetic
2. Reduced cough reflex
3. Pain
89
What are the consequences of atelectasis post-op? (3)
1. V/Q mismatch, shunt, hypoxemia
2. Increase rate and depth of breathing
3. Decrease PaCO2
90
T or F
Pts breathing O2 have an increased risk of atelectasis.
T
91
What are the potential factors contributing to atelectasis? (5_
1. Insufficient pain management
2. Overuse of sedation and analgesics
3. Manual percussion, vibration and coughing w/o emphasis on thoracic expansion
4. Improper positioning
5. Improper use of incentive spirometry and excessive accessory ms use
92
What is a specificity for pneumonectomy regarding positioning?
Lying on the operated side is recommended bcs we don't want blood to flood the remaining lung
93
What is the best position early post op to optimize V/Q matching for thoracotomy pts?
Why?
```
Semi prone (1/4 towards stomach)
Bcs prone position may be difficult due to pain, lines, tubes, etc
```
94
Can thoracotomy pts lie on their operated side?
YES
95
What is THE intervention for thoracotomy pt?
Lower lateral thoracic expansion for the side of the incision
96
What are the 2 reasons for ICU admission?
1. Requires invasive hemodynamic monitoring and MV
| 2. Requires more intensive nursing care
97
Who am I?
I am a line inserted into a peripheral vein.
I enable administration of fluid, basic nutrition and meds.
Peripheral intravenous line (IV)
98
T or F
It is better not to bend the involved joint when an IV line is installed on a pt.
T
Its better to avoid traction and kinking of any lines.
99
What the location of an arterial line?
Inserted in a peripheral artery
100
What are the 2 purposes of an arterial line?
1. Allows arterial blood to be drawn painlessly for frequent analysis or ABGs
2. Continuous hemodynamic monitoring of blood pressure
101
What does an dicrotic notch represent on an EKG?
Closure of the aortic valve and the backsplash of blood against a closed valve.
102
T or F
Diastole counts twice as much as systole because 2/3 of the cardiac cycle is spent in diastole.
T
103
What's the normal MAP range?
70-110 mmHg
104
What MAP is necessary for normal perfusion of organs?
> 60
105
What are the 4 main possible complications for arterial line?
1. Ecchymosis/hematoma
2. Disconnection/hemorrhage
3. Occlusion/thrombosis formation
4. Infection
106
What's the implication for PT with femoral line?
Consider risk to benefit ratio
107
T or F
No catheter related adverse events reported for in-bed exs, standing/walking, sitting, supine ergometry have been reported in the litterature.
T
108
When the femoral line is discontinued how much time should we wait for mobilizing a patient?
6 hours
109
Who am I?
Inserted thru the subclavian/internal jugular/external jugular vein and threaded into the superior vena cava OR thru the femoral vein into the common iliac vein
Central line
110
What value is recorded with a central line?
Central venous pressure (CVP)
111
What is the normal value for CVP?
| What's the normal range?
5 mmHg
| 3-10 mmHg
112
The CVP provides info about cardiac function of which side of the heart?
R
113
What are the factors that increase CVP? (6)
1. Increased vascular volume = when blood is backing up into the venous circulation
2. Decrease R ventricular function = decrease stroke volume = more blood backing up into the venous circulation
3. Global heart failure
4. Increase pulmonary vascular resistance
5. Systemic vasoconstriction = increase venous return to heart
6. PEEP > 7.5 cm HO = increase pressure in thorax, thus in the heart also
114
What are the factors that decrease CVP? (3)
1. Hypovolemia = decreased blood volume
2. Posture, legs lowered to the floor = decrease venous return
3. Inspiration = -ve intra-thoracic, thus cardiac, pressure
115
What are the possible complications with central venous lines? (5)
1. Pneumothorax
2. Hemothorax
3. Cellulitis
4. Catheter infection
5. Sepsis = release of bacteria into the bloodstream
116
What is the implication to PT with central venous lines?
Cautious ROM to jt near insertion taking care not to kink the line
117
What is the implication for PT with PICC lines? (4)
1. Caution for bending the elbow beyond 45° initially in the hospital
2. Not carry bags on side of PICC
3. NOT lift more than 10 lbs with arm and avoid strenuous repetitive mvt
4. Avoid wetting = no bath or swimming (plastic wrap for shower)
118
Who am I?
I am an alternative to central venous lines and i am inserted in the periphery usually the upper arm.
PICC line
119
Where the PICC line is usually inserted? Which veins and goes where?
Cephalic/basilic vein and slid to the distal superior vena cava
120
What is the advantages (2) of a PICC line compared to a central venous line?
Decreased complication rates and lower infection rates
121
Who am I?
Central venous device implanted subcutaneously instead of port being outside the body.
Port-a-cath
122
What are the 2 main contraindications with port-a-cath?
1. pt should avoid contact sports
| 2. manual techniques over the device is NONO
123
T or F
Pt with a port-a-cath can resume regular activities after the pocket is healed, including swimming, sports, etc.
T
124
Who am I?
I am a catheter that monitors cardiac and pulmonary status as well as maintains fluid balance.
Pulmonary artery catheter (aka "Swan Ganx catheter"
125
What does a pulmonary artery catheter measure?
Pulmonary artery pressure (PAP)
126
What is the normal values for systolic and diastolic PAP?
Systolic 20-30 mmHg
| Diastolic = 8-15 mmHg
127
What does the PAP measure?
the lung milieu and what's ahead
128
What is a caution to keep in mind when mobilizing with pulmonary artery catheter?
can trigger arrhythmias
129
Where travels a pulmonary artery catheter (where it's inserted and where it goes)
Introduced into internal jugular/subvlacian antecubital vein -> R atrium -> R ventricule -> pulmonary artery -> small vessels (possibly)
130
Which factors increase PAP? (2)
1. Mitral stenis and L ventricular insufficiency = back pressure directed towards the lung
2. Increase pulmonary resistance (pulmonary HT, PE)
* Anything that increase pressure in lung will increase PAP
131
What is the pulmonary artery wedge pressure (PAWP)?
Pulmonary artery catheter has a ballon at the end of it. When ballon inflates, no longer registers pressure in pulmonary capillaries; provides info on filling pressures of L side of heart (end-diastolic L ventricular pressure)
132
When in PAWP used?
As a Dx tool to measure how much edema (and if it's interstitial or pulmonary)
133
Who am I?
Hydrostatic pressure in the capillaries of force pushing fluids out of the capillary into the pulmonary tissues.
End-diastolic L ventricular pressure
134
What are the values for:
1. normal PAWP
2. optimal filling pressure
3. interstitial edema
4. pulmonary (alveolar) edema
1. 5-12 mmHg
2. 12-18 mmHg
3. 18-30 mmHg
4. > 30 mmHg
135
PAWP will be elevated in the presence of: (3)
1. global or L cardiac insufficiency
2. mitral valve stenosis or insufficiency = heart has to work very hard to pump blood out
3. overhydradation (renal failure)
136
When PAWP is increased, 2 things will be observed on ABGs and auscultation, what are they?
Hypoxia = fluid in lung decrease gas exchange
| Crackles/rhonchi on I and E = fluid in alveoli = decrease gas exchange
137
What are the possible complications for a pulmonary artery catheter? (6)
1. pneumothorax
2. hemothorax
3. PAC related infection
4. ventricular arrhythmias
5. pulmonary artery infarction, damage or rupture
6. accidental dislodgment into the R ventricle
138
What does literature say about PAC and PT?
| What is usually done in hospital ?
```
Litterature = no complications with participation in bed mobility, transfers, ambulation and stair climbing
Hospital = ask MD and team before doing anything with a pt that has a PAC
```
139
If PAC is inserted via the femoral vein, when it is removed, pt will be flat on bedrest for how long?
4-6 hours usually
140
Who am I?
My purpose is to provide nutrition and decompress/remove gastric content via suction.
NG tube
141
What are the 2 main concerns with NG tube?
1. Displacement
| 2. Aspiration
142
How pt should be positioned when feeding with NG tube?
During feeding, HOB elevated to 45° and maintained 30-45 min after the feeding (intermittent feeding)
143
What are the 4 low-flow systems for administration of O2?
1. Nasal prongs/nasal cannula
2. Face mask
3. Partial rebreathing mask
4. Non-rebreathing mask
144
What are the 2 high-flow systems for administration of O2?
1. Air entrainment devices = Venturi mask
| 2. High-flow nasal cannula
145
In nasal prongs, every 1L/min increase in flow, increased FiO2 by __%.
4
146
In nasal prongs, flow is limited to __ L/min. Why?
6
| To avoid excessive irritation to nasal passages.
147
In nasal prongs, the FiO2 delivered is __ to __%
24-44
148
Increasing Ve ____ FiO2
decreases
149
The larger the Vt or the faster the RR the ___ the FiO2
lower
150
T or F
Pt with deviated nose septum can have nasal prongs.
F, nasal passages should be patent
151
What are the PT consideration when pt has nasal prongs?
Ensure that have no kinks or external compress during and after a Rx session.
152
What FiO2 face masks generally deliver?
40-60%
153
In face masks, flow should be more than ___.
| Why
> 5L/min
| Otherwise exhaled air is accumulated in the mask reservoir and is rebreathed.
154
In face mask, the increase in FiO2 is small when flow is ___.
>8L/min
155
What is the FiO2 in partial rebreathing mask?
> 60%
156
In partial rebreathing mask, an O2 flow of 6-10L/min provides what FiO2?
30-80%
157
What is the volume of the reservoir added in partial rebreathing mask?
500-1000mL
158
Where the air goes on expiration with a partial rebreathing mask?
Beginning of expiration goes to the bag (first 1/3) than additional exhaled breath escapes through exhalation ports.
159
In non-rebreathing mask, in reality with flows of 8-10L/min provide which FiO2?
Theoretically?
60-80%
| 100%
160
What is the purpose of the one-way valve in non-rebreathing mask?
Prevents exhalation into the bag and inhalation from the exhalation ports.
161
On the next breath in non-rebreathing mask, the bag fills with what for the next breath?
pure O2
162
T or F.
Venturi mask is dependent of breathing pattern.
F
163
Who am I?
Pressurized O2 creates a sheering effect that causes room air to be entrained though ports.
Venturi mask
164
In Venturi mask,
1. A larger entrainment port = ___ FiO2.
2. A smaller entrainment port = ___ FiO2
1. lower
| 2. higher
165
What is the range of flows and %O2 venturi masks can administer?
4-15L/min
| 24-50%
166
In Venturi mask, the total flow through the mask must be over of equal to what?
Patient's peak inspiratory flow rate
167
What are the advantages of Venturi masks? (3)
1. Consistent and predictable FiO2
2. Patient's pattern do not affect the FiO2
3. Temperature and humidity of the gas may be controlled
168
Which O2 administration device also provides a PEEP to improve gas exchange?
High-flow nasal cannula
169
For High-flow nasal cannula, up to how much FiO2 and flow can be delivered?
100%
| 60L/min
170
What is the purpose of humidifying the O2 in High-flow nasal cannula?
Increase comfort
171
What is an advantage of High-flow nasal cannula compared to face mask?
Pt can eat, drink, talk while being on O2.
172
O2 tanks last how much time usually w/ High-flow nasal cannula?
15 min
173
What is the kind of patients that has High-flow nasal cannula? (4)
Pulmonary fibrosis
Severe lung disease
Infants
COVID
174
What is a normal PaO2 and normal SaO2?
80-100mmHg
| >95%
175
PaO2 and SaO2 for mild hypoxemia if not shift in the HbO2 curve?
60-80mmHg
| 90-95%
176
PaO2 and SaO2 for moderate hypoxemia if not shift in the HbO2 curve?
40-59 mmHg
| 60-89%
177
PaO2 and SaO2 for severe hypoxemia if not shift in the HbO2 curve?
<40mmHg
| < or = 60%
178
T or F
| As PaO2 decreases, SpO2 increases.
F
| SpO2 also decreases
179
When can the oxyhemoglobin dissociation curve shift to the right?
during exs
180
When can the oxyhemoglobin dissociation curve shift to the left?
hypoxemia
181
What happens physiologically when PaO2 < 55mmHg with decrease in PaCO2?
Increase minute ventilation
182
In hypoxemia what happens to peripheral vascular beds, why and what dos this cause?
They dilate bcs organs that are working needs more O2 so they dilate --> tachycardia and increase CO to increase O2 delivery
183
Pulmonary hypoxia causes what to pulmonary vessels?
Vasoconstriction
184
In hypoxemia, what happens to erythropoietin secretion?
Increase
| To increase RBCs and O2 carrying capacity
185
What are the 4 consequences of long-term hypoxemia ("cascade of events")?
Polycynthemia = increase # RBCs
Pulmonary hypertension
Cor pulmonale
Cellular changes = decrease mitochondrial function, anaerobic glycolysis
186
What is the 2 scenarios where continuous O2 will be prescribed long-term?
1. Resting PaO2 = 55 mmHg
2. Resting PaO2 = 56-59mmHg OR SaO2 = 89% in the presence of any of these:
- Cor pulmonale
- Polycythemia (hematocrit >56%)
- Nocturnal hypoxemia = desaturated at night
- Pulmonary hypertension
187
What is the indication for long-term discontinuous supplemental O2 during exs?
PaO2 = 55 mmHg OR SaO2 = 88% with a low level of exertion
188
What is the indication for long-term discontinuous supplemental O2 during sleep?
PaO2 = 55 mmHg OR SaO2 = 88% with also complications:
- Pulmonary hypertension
- Daytime somnolence
- Cardiac arrhythmias
189
What are short term benefits of supplemental O2? (2)
1. Decrease dyspnea with exercise in patients with COPD
| 2. Increase exs tolerance
190
What are long term benefits of supplemental O2? (5)
1. Decrease cor pulmonale
2. Increase QoL
3. Increase sleep
4. Decrease exacerbations and hospital admissions
5. Improvement or stabilization of disease progression
191
PTs are allowed to administer and adjust O2 if pt has a MD prescription EXCEPT in 2 situations, which ones?
1. Invasive ventilation
| 2. Non-invasive positive pressure ventilation
192
What can happen w/ supplemental O2 in COPD pts who are CO2 retainers when their PaO2 > 60mmHg?
Why?
Suppression of respiratory drive
| Primary ventilatory drive = chronic hypoxemia. High O2 concentration abolishes the hypoxic respiratory drive.
193
What 2 complications can happen w/ supplemental O2 if FiO2>0.5 for prolonged periods?
1. Absorption atelectasis
| 2. O2 toxicity = can cause lung and CNS damage
194
A PaO2 > 80 mmHg with supplemental O2 can contribute to what?
Retinopathy of prematurity
195
What can be done to avoid the risk of atelectasis with suppl O2?
O2 should be humidified to reduce the drying effects of the gas on the respiratory mucous membranes
196
What does a pulse oximeter actually measure?
% of hemoglobin saturated with O2
197
What are 4 factors that can hinder accuracy of pulse oximeter?
1. Motion and WB = noise interferes with signal transmission
2. Probe location
3. Dirt, fingernail polish
4. Low perfusion/dysrhythmias = weak signal in pts with poor perfusion or irregular HR
198
What is the optimal location for an accurate read of the pulse oximeter?
3rd or 4th finger
199
T or F
Pulse oximeter is a good substitute for a clinical Ax of pt's status.
F
Goof quality clinical Ax is better than the pulse oximeter
200
What is a caution to keep in mind with anemia and pulse oximeter?
In anemia, less hemoglobin carry O2 so all HB molecules may be fully sat with O2 (pulse oximeter may read 100% sat) but still body's need in O2 are not met.
Check the PaO2 and it should be low in anemia even tho Sat is 100%.
201
Who am I?
Failure of the pulmonary system to meet the demands of the body.
Respiratory failure
202
Who am I?
Gas exchange failure manifested by hypoxemia.
Lung failure
203
Who am I?
Ventilatory failure manifested by hypercapnia
Pump failure
204
What are the 2 types of noninvasive positive pressure ventilation (NIPPV)?
1. Mask CPAP
| 2. Biphasic intermittent positive airway pressure (BIPAP)
205
What is the difference btw CPAP and BIPAP?
```
CPAP = continuous
BIPAP = different pressures for inhalation and exhalation
```
206
What are the advantages of NIPPV? (3)
1. Noninvasive
2. Prevent intubation
3. Short term ventilation
207
In which conditions NIPPV is used? (5)
1. COPD exacerbation
2. Failed intubation
3. Pneumonia
4. CHF
5. Pulmonary edema
208
What are possible complications for NIPPV? (8)
1. Leaks
2. Mask discomfort
3. Eye irritaiton
4. Sinus congestion
5. Oronasal drying
6. Patient-ventilator asynchrony = pt fights the MV flow
7. Gastric insufflation
8. Hemodynamic compromise = too much +ve pressure = decrease venous return
209
What are the indications for intubation? (5)
1. Airway obstruction that cannot be simply relieved
2. Failure of noninvasive ventilation
3. PaO2 < 60 mmHg on suppl. O2
4. Secere head injury or pt unconscious (protection of airway)
5. Anticipated Sx
210
What are the 3 kinds of intubation?
Orotracheal
Nasotracheal
Trachostomy
211
T or F
Cough is more effective when pt are intubated.
F
Cough is less effective bcs glottis cannot close.
212
T or F
Pts intubates cannot speak, eat, drink.
T
213
Where is the tube placed when intubated?
Midway btw carina and vocal cords OR about 5-7 cm from the carina
214
What does the cuff at the end of the ET allow? (3)
1. Positive pressure ventilation
2. Airways protection (blocks aspiration or foreign materials)
3. Removal of secretions (suctioning)
215
Who am I? Nasal or oral intubation
```
More comfortable
Easily anchored in place
Produces less stimulation of gag reflex/vomiting
Less risk of laryngeal ulceration
Suctioning more difficult
More difficult to insert
```
Nasal
216
Who am I? Nasal or oral intubation
Less comfortable
Tends to migrate more
More risk of airway obstruction
Larger tubes which makes suctioning easier
Oral
217
At which tracheal level a tracheostomy is usually performed?
2dnd or 3rd tracheal rings
218
In which situation a tracheostomy is usually performed?
When pt cannot be extubated within 10 days
219
What are the indications for tracheostomy?
1. Unrelieved upper-airway obstruction
2. Need for prolonged MV (comatose, GBS)
3. Airway protection
4. Need for airway access for secretion removal
220
T or F
Tracheostomy can be permanent or temporary.
T
221
What are the advantages of tracheostomy? (5)
1. Increased comfort for pt
2. Ease of mouth care
3. Reduction of anatomical dead space
4. Reduction of sinusitis and oral infective complications
5. Less damage to the vocal cords (as trachea is below them)
222
What are the possible complications of tracheostomy? (4)
1. Stomal infections
2. Hemorrhages
3. Subcutaneous emphysema
4. Pneumomediastinum = air in the mediastinum
223
What are the 4 goals of invasive MV?
1. Restore ABGs to normal
2. Reduce WOB --> reduce O2 consumption
3. Rest fatiguing respiratory ms
4. Promote absorption of fluid in pulmonary edema
224
What are the 3 major types of invasive MV?
1. Pressure-controlled
2. Time-controlled
3. Volume-controlled
225
What are the 7 modes of invasive MV seen in this class?
1. Controlled (CMV)
2. Assist-control (AC)
3. Intermittent mandatory ventilation (IMV)
4. Synchronized intermittent mandatory ventilation (SIMV)
5. Pressure support ventilation (PSV)
6. PEEP
7. Continous positive airway pressure (CPAP)
226
What happens with pressures and Respiratory ms during spontaneous breathing?
Respiratory ms produce airflow by lowering pleural, alveolar and airway pressure
227
What happens with pressures and Respiratory ms during positive pressure ventilation?
Air is forced into the lungs by application of +ve pressure into the airway and alveoli
Pleural pressures increase throughout inspiration
228
What kind of invasive MV am I?
Gas flows into lungs until preset pressure is reached.
Form of intermittent positive pressure ventilation.
Pressure-controlled MV
229
In pressure-controlled ventilators, Vt varies with what (3)?
Airway resistance = more resistance, lung not gonna inflate as much
Lung compliance = decreased compliance (stiff), lung not gonna inflate as much
Integrity of circuit = leak, lung not gonna inflate as much
230
What kind of invasive MV am I?
Gas flows to the patient until a preset inspiratory time is reached.
Time-controlled MV
231
In Time-controlled MV, desired Vt is achieved by adjusting what (2) or (by setting what (2)).
Adjusting inspiratory time and flow rate
| Setting Ve and RR
232
What kind of invasive MV am I?
Gas flows to the patient until a preset volume is delivered even if this requires a very high pressure.
Volume-controlled MV
233
How to prevent barotrauma in Volume-controlled MV?
A safety "pop-off" pressure limit is set; when the limit is reached, excess volume is vented into the atmosphere.
234
T or F
Pt with increased lung resistance and with volume-controlled ventilator have more odds of reaching the pop-off pressure limit.
T
235
In which kind of patients CMV mode is used. (3)
Sedation
Ms paralysis
Brain damage
236
What kind of invasive ventilation mode am I?
Fully ventilatory support.
Ventilators delivers a present # of breaths/min of a predetermined volume to deliver a constant Ve.
CMV
237
What kind of invasive ventilation mode am I?
Ventilator delivers a breath when triggered by the patient's inspiratory effort or independently if effort does not occur within a preselected time period.
AC
238
T or F
In AC ventilatory mode, patient's triggering effort can exceed the preset rate.
T
i.e if patients breaths at 20 breaths/min, but ventilator is set at 15 breaths/min, then ventilation will follow pt and deliver 20 breaths/min
239
T or F
In AC ventilatory mode, if patient's rate drops below the "preset backup" rate, controlled ventilation is stoped and machine assist the patient on the next inspiration.
F
controlled ventilation is provided until the patient's rate exceeds the backup rate
240
What kind of invasive ventilation mode am I?
Patient breathes spontaneously but additionally receives periodic positive-pressure breathes at a preset volume and rate from the ventilator
IMV
241
T or F
In IMV ventilatory mode, IMV mandatory breath is stacked upon spontaneous efforts.
T
242
What kind of invasive ventilation mode am I?
Patient breathes spontaneously but additionally receives synchronized mandated breath.
SIMV
243
In SIMV, if RR is 20 breaths/min and machine is set at 10 breaths/min, patient will therefore take how many spontaneous breaths?
10
| 20-10=10
244
Which mode is sometimes used to wean off patients from invasive MV?
SIMV
245
What kind of invasive ventilation mode require an intact respiratory drive?
PSV
246
What does the patient controls in PSV? (4)
RR
Vt
Ve
I:E ratio
247
What kind of invasive ventilation mode am I?
Respiratory effort sensed by the ventilator responds by delivering a set pressure painted as a plateau.
PSV
248
In PSV, inspiration ends when?
When the flow rate drops to a given % of peak inspiratory flow
249
Which kind of invasive ventilation mode can be used with all the other modes?
PEEP
250
What are the main effects of PEEP on lungs? (5)
1. Increase FRC by opening airways
2. Recruitment of collapsed alveoli
3. Improves V/Q
4. Prevents atelectasis
5. Redistribution of excess fluid within the lungs (possibly)
251
What kind of invasive ventilation mode am I?
Positive pressure maintained in the airways at the end of expiration
PEEP
252
What kind of disease PEEP is used? (2)
ARDS
| Pulmonary edema
253
What are the disadvantages of PEEP? (5)
1. Decrease venous return
2. Decrease cardiac output
3. Hypotension
4. Hypoxemia
5. Barotrauma can occur
254
What kind of invasive ventilation mode am I?
Airway pressure remains positive during both inspiration and expiration.
CPAP
255
What kind of invasive ventilation mode am I?
Dual control mode within a breath.
Allow a feedback loop within a breath.
Switches within a breath from pressure control to volume control if min tidal volume has not been reached.
Volume-assured pressure support (VAPS)
256
What are the 2 kind of invasive ventilation mode used in dual control modes breath to breath?
Volume support
| Pressure-regulated volume control (PRVC)
257
In volume support mode, what is used as feedback to adjust the pressure level to achieve the set volume?
Tidal volume
258
T or F
In volume support mode, patient is the trigger, pressure is limited and flow is cycled.
T
259
Volume support mode is a closed loop control of which other ventilatory mode?
PSV
260
T or F
In PRVC, pressure is set, time is cycled and rate is limited.
F
Pressure is limited
Time is cycles
Rate is set
261
What kind of invasive ventilation mode am I?
Ventilator delivers a target volume using the lowest possible airway pressure.
Volume feedback control for continuous adjustment of the pressure limit.
PRVC
262
What are the 4 main possible complications with invasive MV?
Infections
Barotrauma
Volutrauma
Hemodynamic effects
263
What is the difference btw barotrauma and volutrauma?
```
Barotrauma = alveolar rupture from high peak inspiratory pressures
Volutrauma = lung injury secondary to overdistention of alveoli
```
264
What ratio is considered severe hypoxemia and with which disease it is associated to?
PaO2/FiO2 < 300
| ALI/ARDS
265
For ALI/ARDS, what is usually seen on CXR?
diffuse bilateral pulmonary infiltrates
266
For ALI/ARDS, how is the PAP and why?
high, hypoxic vasoconstriction
267
For ALI/ARDS, how is PAWP and hy?
< 18 mmHg (normal), no generalized overhydratatiohn or L heart failure
268
Which disease represents the most severe form of ALI?
ARDS
269
What is ALI?
non-cardiogenic pulmonary edema
270
What causes a non-cardiogenic pulmonary edema?
1. Accumulation of vascular fluid + proving in the interstitial spaces and alveoli
2. Increase permeability of alveolar epithelial and capillary endothelial
271
What kind of acute pulmonary condition am I?
Epithelial damage, breaks in alveolar basement membrane.
Increase lung surface tension and alveolar collapse.
Fibrinogen in fluids leaking into alveoli = pulmonary fibrosis and decrease lung compliance.
ARDS
272
What is the clinical presentation of ALI/ARDS? (3)
1. Dyspnea
2. Severe hypoxemia: V/Q mismatch and shunting
3. Decreased FRC
273
T or F
In ALI/ARDS, pts are characteristically unresponsive to increased FiO2.
T
274
T or F
High PEEP is often used in ALI/ARDS to help push fluid back into the interstitial space.
T
275
What are the 3 main PT intervention for ALI/ARDS?
1. Positioning as tolerated - prone
2. Airway clearance techniques if indicated (secretion retention)
3. Bed exs; gradual increase in mobility to pt tolerance; sitting and upright ASAP
276
Who am I?
A systemic reposes to an infection that can cause tissue damage.
Sepsis
277
What are the 5 common symptoms of sepsis?
1. Fever
2. HR > 90 beats/min
3. Tachypnea (RR > 20 breaths/min)
4. Leucocytosis/leucopenia
5. Altered mental state
278
What is the name of the most severe manifestation of sepsis?
Septic shock
279
What is the pathophysiology of septic shock? (4 steps)
1. Tisuue and organ hypoperfusion
2. Decrease O2 delivery with accumulation of lactic acid
3. Hormonal and metabolic changes: increased stress hormones and hyperglycemia
4. Deterioration in cell and organ function
280
Name 5 common causes of septic shock.
```
Hypovolemia
Sepsis
Heart failure
Direct insult to CNS
Allergic reaction
```
281
What are clinical features (signs) of septic shock (8)
```
Hypotension
Decrease CO
Tachycardia
Diaphoresis, pallor
Hyperventilation
Decrease urine output
Nausea
Confusion
```
282
Name 4 predisposing conditions associated with multiple system organ failure.
Systemic inflammatory response syndrome
Severe sepsis
Trauma
Tissue hypo perfusion
283
Who am I?
Lipid base drug used in the ICU at low dose to sedate patients or in the OR as an anesthetic.
Propofol
284
How is propofol usually administered? (2)
Bolus dose or continuous infusion
285
T or F
Propofol has a long half life to it will take a lot of time to wear off.
F
Has a short half life so will wear off rapidly.
286
Who am I?
Drug used in the ICU to back neuro-musular conduction and paralyzes patients.
Neuromuscular blockers
287
Neuromuscular blockers must be used with what?
Sedative agent
288
T or F
Neuromuscular blockers can be used to induce patient-ventilator synchrony during MV.
T
289
What are the adverse effects of bed rest on the CNS? (3)
Decrease congnitive function, memory and concentration
Neuropathy/myopathy
Decrease standing and walking balance
290
What are the adverse effects of bed rest on the respiratory functions? (6)
```
Decrease FRC and RV
Decrease lung compliance
Retained secretions
Atelectasis
Pneumonia
Hypoxemia
```
291
What are the adverse effects of bed rest on skeletal ms? (3)
Decrease ms bulk, strg, endurance
Transformation in type II fibers (a->b)
Decrease number and density of mitochondria
292
What are the adverse effects of bed rest on cardiovascular function? (7)
```
Resting tachycardia
Decrease CO, SV and increase HR during exs
Decrease VO2max
Decrease plasma and blood volume
Venous stasis
Increase risk of trombosis
Orthostatic intolerance
```
293
What are the adverse effects of bed rest on body composition? (4)
Bone demineralization
Joint contractures
Protein wastage
Decrease body weight and increase in % fat
294
Name 3 types of psychological adverse effects a pt in ICU can experience.
Depression
PTSD
Delirium
295
What Rx can be used w/ pt who have psychological adverse effects in ICU? (3)
Awareness
Psycho support
Encouragement
296
What are 3 types of ICUAW? Describe.
```
Polyneuropathy = sensory-motor axonopathy
Myopathy = metabolic, inflammation and bioenergetic ms derangements and/or functional inactivation
Polyneuromyopathy = combined nerve and ms involvements
```
297
ICUAW is multifactorial. Name 10 possible factors that can cause ICUAW.
```
Disease severity (APCHE II score)
Systemic inflammation response syndrome/sepsis
Multi-organ failure
Meds (corticosteroids, neuromuscular blocking agents)
Duration of MV
ICU length of stay
Physical inactivity, ms unloading
Hyperglycemia
Perenteral nutrition
Renal replacement therapy = dialysis
```
298
Name 8 PT goals with critically ill patient.
1. Prevent atelectasis by mobilizing and assisting removal of secretions.
2. Assist in maintaining adequate ventilation to all areas of the lungs = maximing V/Q matching
3. Aid venous return and prevent thrombus = ankle mpumping
4. Maitain jt mobility at all jt= ROM exs
5. Maintaint ms strg
6. Prevent deformitites
7. Assist in prevention of bed sores
8. Psycho support
299
What PT intervention for clearing of secretions in ICU?
Postural drainage
| *Modified position for pt unable to tolerate Trendelenberg positions
300
T or F
In unilateral disease and positioning the involved lung uppermost, PaO2 is not improved in the uninvolved lung lower most.
F
| The PaO2 in lowermost lung is still improved.
301
What are the 7 contraindications for prone positioning?
```
Spinal instability
Multiple trauma
Unstable cardiac arrhythmias
Hemodynamic instability
Increased ICP
Active intra-abdo processes
Facial trauma, burns, open chest, or abdo wounds
```
302
What are 5 benefits of prone positioning?
```
Improves V/Q matching
Redistributes pulmonary edema
Increase FRC, increase basal lung volume
Increase respiratory system compliance
Allows heart to lay on sternum so thet its compressive force on dorsal lung regions ins eliminated
```
303
Prone positioning is used with which types of pt usually?
ALI/ARDS
304
Transient arrhythmias during positioning should return to normal in ___. If not, pt should be put back in its original position.
30 sec
305
What is continuous renal replacement therapy (CRRT)?
Continuous dialysis
306
What are 3 types of vascular access for hemodialysis?
Arteriovenous (AV) fistula
AV graft
Central venous catheter
307
Is PT feasible when pt is on CRRT?
Bedside PT is feasible and appears sae
308
What consideration is important w/ pt w/ flail chest?
Unable to lie on there # ribs
309
Are intubated pt able to cough? Why?
No
| Absence of glottic closure with ET tube
310
If pt is unable to cough, what is the PT Rx? (2)
Assisted coughing w/ pressure on the abdo (lower costal margins)
Suctioning to stimulate a cough and remove secretions
311
Which mode of MV is a contraindication for breathing exs? Why?
Control mode
| Pt are often paralyzed/heavy sedated so unable to breath spontaneously
312
What are 2 goals of breathing exs with pts able to make an independent inspiratory effort?
1. Prevent/reverse atelectasis
| 2. Maintain/improve respiratory ms endurance, strg, coordination (esp. during weaning off MV)
313
Which modes of ventilation have greater inspiratory volumes during spontaneous breaths? (2)
IMV and SIMV
314
Which cycle of ventilation has larger volume?
Pressure-cycled
315
Which PT Rx is appropriate to maintain chest wall compliance? (2)
Segmental breathing with chest-wall stretching
| Inspiratory ms facilitation techniques
316
What is a good exs pt can do to relieve pressure from ischial tuberosity?
sitting in chair, push ups
317
What are 2 things not to forget concerning lines and MV when transferring a dependent pt to a chair?
Clamp chest tube
| Temporarily disconnect from MV = prevent unnecessary trauma to the trachea
318
What 3 things should be done before ambulation to reduce WOB and facilitation tolerance to ex?
Pulmonary hygiene
Bronchodilator therapy
Suctioning
319
Name 6 benefits of PT in ICU including early mobility.
```
Decrease complications
Decrease mortality
Increase ventilator weaning
Decrease ICU and hospital LOS
Increase physical function
Increase QoL
```
320
When ambulating a pt, can abdo sums and drains, ECG leads, CVP lines be disconnect?
Yes
321
What is the role of a vasopressor?
Increase vasoconstriction -> increase systemic vasoresistance -> increase BP
322
What is the role of an inotrope?
Increase heart contractility
323
What is the role of a chronotrope?
Increase HR
324
What is the use of the APACHE II system?
Severity of illness in critical care = predicts individual survival
325
The higher the score in the APACHE II, the ____ the death rate.
higher
326
What are the standardized 5 questions?
1. Open/close your eyes
2. Look at me
3. Open your mouth and put out your tongue.
4. Nod your head
5. Raise your eye brows when I have counted up to 5
327
What is the cutoff to the standardized 5 questions to continue with treatment?
4-5/5
328
What is the scale used in ICU to Ax for delirium?
| Btw which score you can mobilize pt and of PT?
RASS
| +1 and -1
329
What are the 2 types of delirium? Describe.
| Which one is more common?
1. Hypoactive = withdrawal, flat affect, apathy, lethargy, decreased responsieness = more common
2. Hyperactive = agitation, restlessness, attempts to remove tubes and lines
330
T or F
Delirium is independently associated w/ worse outcomes.
T
331
What are the 4 features assessed in the CAM-ICU?
1. Aucune onset of mental status changes or fluctuating course
2. Inattention
3. Disorganized thinking
4. Altered level of consicousness
332
What are the general indications for LT candidates? (2)
Chronic end-stage pulmonary disease
| Ineffective or unavailable other medical/surgical Rx
333
What is a PT absolute contraindication for LT?
Limited functional status w/ poor potential for post-transplant rehab
334
What are the main 5 high risk factors for LT?
1. Age > 70 y.o
2. Severe coronary disease
3. BMI too low or too high
4. Limited functional status w/ potential for post-transplant rehab
5. Unreliable support system or caregiving plan
335
What are 3 risk factors for LT?
1. Age 65-70 y.o
2. BMI
3. Frailty
336
What do you Ax in an intial PT Ax for LT? (7)
1. QoL
2. Respiratory S&S
3. Use of PEP device or other (if applicable)
4. Strg
5. Frailty
6. Endurance = 6MWT
7. O2 needs
337
In LT, why can comorbidities and risk factors have an impact on recovery after surgery?
They stimulate the metabolic response to stress
338
Who am I?
Clinically recognizable state of increased vulnerability resulting from agin-associated decline in reserve and function across multiple physiologic systems such that the ability to cope with everyday or acute stressors is compromised.
Frailty
339
What is the main goal of pre-hab?
Enhancing and optimizing functional capacity
340
What are 3 essential components that should be included in an effective surgical pre-hab in LT?
Physical
Nutritional
Psychological
341
What kind of exs is included in a pre-hab LT program?
Aerobic training OR aerobic + resistance
342
Where can pre-hab LT be delivered?
Outpt
| Home
343
Who are on the emergency list for LT?
Advanced disease or poor prognosis in the short term
344
What are the 3 decisive factors for pt to be put of the emergency list for LT?
Right ventricular fct
PAP/PAH
O2 needs
345
Reassessment during waiting time, à quelle frequency?
each 3 months
346
What is the duration of a LT surgery? Single vs Double.
```
Single = 2-4h
Double = 4-6h
```
347
What is sequential ventilation during LT surgery?
Ventilate one lung while the other one is being resected
348
What kind of scar for :
1. Single LT
2. Double LT
3. Heart-lung
1. Thoracotomy posteralateral
2. Thoracotomy clamshell
3. Median sternotomy
349
Pt post LT usually stay in ICU how long?
2-5 days min
350
Pt post LT are extubated when?
early -> less than 24h usually
351
When does PT intervention start post LT?
ASAP -> POD 0
352
What is the major cause of death 1 st year post-LT?
Infection
353
What are the 3 PT goals in ICU post LT?
Ventilation
Secretion clearance
Mobility
354
What kind of breathing exs you do w/ pt on MV post-LT?
Deep breathing
355
What kind of breathing exs you do w/ pt once extubated post-LT?
```
Incentive spirometry (5min/h)
Coughing w/ splinting
```
356
What is the average hospital stay with LT?
3-4 weeks
357
Is clapping/vibrations contraindicated with LT?
Nooo
358
What you put in their HEP before D/C in LT? (3)
1. Respiratory routine and stretching = daily
2. Morderate cardio training = 30 min, daily
3. Weight training = 3x/wk
359
No driving for how many weeks with LT?
6
360
No UE WB > 10 lbs for how long w/ LT?
3 months
361
Protection of incision for how lung with LT?
3 months
362
Reintegration of moderate level leisure activities after how lung with LT?
6 months (can be less depending on pt)
363
Once D/C, LT pt must visit the out-pt PT clinic at which frequency?
1x/wk for 1st month
| Decreasing frequency down to 2x/year
364
Life expectancy w/ LT?
4-6 years
365
After 1 year post-LT, what is the major cause of death?
chronic rejection
366
Can you do PT when pt on ECMO?
Yes
367
In ICU, in which conditions active mobilization (out of bed) should not occur? (20)
1. O2 sat < 90%
2. Ventilator more HFOV
3. Prone positioning
4. Intravenous antihypertensive therapy
5. MAP below target range and causing sumptoms
6. Pacemaker and aystole
7. Bradycardia requiring pharmaco Rx
8. Ventricular rate > 150 bpm
9. Femoral IABP
10. Femoral/subclavian ECMO
11. Cardiac ischemia
12. RASS below -2 or above +2
13. ICP not in desired range
14. Open lumbar drain not clamped
15. Spinal precautions
16. Uncontrolled seizures
17. Unstable major # pelvic, spinal, LL long bone
18. Large open wound chest, abdo
19. Uncontrolled active bleeding
20. Femoral sheaths
368
In ICU, in which conditions even in-bed exs should not occur? (8)
1. Prone positioning
2. Intravenous antihypertensive therapy
3. Bradycardia requiring pharmaco Rx
4. RASS > +2
5. ICP not in desired range
6. Spinal precautions
7. Uncontrolled seizures
8. Uncontrolled active bleeding
369
T or F
Suctioning should be carried out only when needed.
T
370
Suction catheter can be be introduced in respiratory tract thru which orifices? (3)
Nose
Mouth
ET or tracheo
371
The suction catheter only goes down as far as ___.
Carina
372
Pressure for suctioning:
1. Normal
2. Thick secretions
3. Indants
1. 100-125
2. 125-150
3. 20-40
373
In suctioning, which hand remains sterile?
Dominant
374
How long should you pre-oxygenate your pt before suctioning?
1-2 min
375
When is the suction applied when in the tube?
when you go back out only
376
Catheter should not be in the airway longer than ___.
10-15 sec
377
After suctioning hyperoxygenate the pt for how long and why.
3 min
| Since suctioning causes desaturation.
378
How do you nasotracheal suctioning?
Direct catheter upwards and posterior towards the ear
Stop when feel resistance
Roll and advance slowly
Once in pharynx ask pt to breath deeply (to open glottis)
Catheter only advance during inspiration (usually stimulates a cough)
379
Possible complications for suctioning (7)
```
Airway trauma and bleeding
Hypoxemia
Cardiac arrhythmias
Hypotension
Bacterial contamination
Bronchospasm and laryngeal spasm
Pneumothorax
```
380
What is the goal of manual hyperinflation before suctioning?
Elastic recoil of lungs/chest wall enhances expiratory flow and moves secretions up towards the carina
381
With manual hyperventilation, the volume delivered is __ greater than baseline Vt.
50%
382
What are the contraindications for manual hyperinflation? (6)
```
Subcutaneous emphysema
Pneumothorax w/o chest tube
High PEEP dependence
Hemoptysis
Bronchospasm
Raised ICP
```
383
T or F
Hyperinflation reduces blood flow to the heart thus reduce BP.
T
384
Normal pH
7.35-7.45
385
Normal PaCO2
35-45
386
Normal PaO2
80-100
387
Normal HCO3-
22-26
388
FEV1 mild COPD
> 80%
389
FEV1 moderate COPD
50-80%
390
FEV1 severe COPD
30-50%
391
FEV1 very severe COPD
< 30%
392
PaO2 and PaCO2 for respiratory failure
PaO2 < 55
| PaCO2 > 45
393
PaO2 for hypoxemia
<80
394
PaO2 for hypoxemia attributed to respiratory failure
< 60
395
Increased vocal fremitus
Less air = consolidation
396
Decreased vocal fremitus
More air =
397
Egophony, bronchophony, whispered pectoriloquy
Less air = consolidation
398
Dull/flat percussion
less air = consolidation
399
Hyperresonant
more air
400
Lower or upper airways
1. Crackles
2. Stridor
3. Wheeze
4. Rhonchi
1. Lower
2. Upper
3. Lower
4. Upper
401
What are the 5 tasks assessed in the FSS ICU?
```
Rolling
Supine to sit
Sitting
Sit to stand
Walking
```
402
In FSS ICU, which score is given if pt is fully independent?
7
403
In FSS ICU, which score is given if pt is unable to do the task completely?
0
404
In FSS ICU, which score is given if pt requires min assistance?
4
405
In FSS ICU, which score is given if pt is able to do the task but with cues?
5
406
In FSS ICU, which score is given if pt can only do a flicker of the mvt?
1
407
In FSS ICU, which score is given if pt required max assistance?
2
408
In FSS ICU, which score is given if pt is able to do the task by using the bedrail or an object to pull themself?
6
409
In FSS ICU, which score is given if pt required mod assistance?
3
410
In MRC sum score, which score is considered ICUAW?
48/60
411
What are the 6 ms mvt tested in MRC sum score?
```
Sh ABD
elbow flex
wrist ext
hip flex
knee ext
ankle DF
```
412
What are the 4 test components of the PFIT?
Sh flexion strg
Knee ext strg
Sit to stand assistance
Step cadence
PHTH564
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