RRT- Lindsey Jones 2023 with verified questions and answers

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" C.E.: Medical hx or patient complaint of recent influenza-type sickness. Complaint off sluggish lower limbs. Shrinking Vt, VC, MIP. Spinal Tap-- will show increased protein in the spinal fluid ABG: impending or current ventilatory failure K.I.: Be primarily concerned w loss of ventilation, monitor vent volumes (VC, Vt) & MIP. Be patient about intubation and MV. Onset can be slow. Primary tx will involve MV and letting the syndrome run its course. Prolonged weaning is not neccesary (but is ok) once the disease has run its course. Such evidence is simply manifested by the return of VC, Vt, MIP Shock : Definition, Clinical Evidence, ABG & Key interventions **EXAM Challenge: Shock will test your ability to recognize it and monitor the patient for vent. failure. D: Condition whre tissues oxygenation is in jeopardy due to a sudden decrease in blood flow. C.E.: Historical evidence of an event or massive trauma or hypothermia, etc. General appearance-- cold, clammy, dusky, cyanotic. Tachycardia, tachypnea, hypotensive. Temperature may be below normal. Reduction in urine output. Reduction in common hemodynamic values (CVP,PAP, PCWP & CO) ABG: Impending or current ventilatory failure K.I.: Mechanically Ventilate with vent failure. O2 is key. Start it as evidence of shock is presented in the very beginning. Use O2 of at least 40% but can use up to 100% Main tx involves treating the original problem (that caused shock) This is variable. Heart Surgery : Definition, Clinical Evidence ABG & Key interventions **EXAM Challenge: This case is not too complicated. You may feel hesitant to do CPR on someone fresh out of surgery. JUST DO IT! D: Any kind of surgery on the heart C.E.: Do well rounded assessment prior to surgery including vital signs, family hx of cardiac illness. Preoperative assess. of breath sounds. baseline data including basic spirometry of all types including FEV1/FVC% and pre/post bronchodilator studies ABG: preoperative for baseline K.I.: Always assess ventilatory volumes and be prepared to mechanically ventilate. IS eveery hour after surgery for lung expansion and alveolar ventilation. If unable (unconscious) use simple ventilatory assisting devices such as IPPB or CPAP with mask. Be on the alert for cardiac arrest--perform CPR w/o reservation or consideration for heart surgery Pulmonary Edema/ CHF : Definition, Clinical Evidence, Chest xray, ABG & Key interventions **EXAM Challenge: It's usually easily ID'd by pink frothy secretions and butterfly pattern on the chest Xray. You may need to make the distinction between pulmonary edema caused by cardiac problems and that which is caused by alveolar capillary membrane problems (ARDS). If it is cardiac, then you must treat the heart. D: Significant reduction in CO. Involvement of fluid penetrating the alveolar capillary membrane into the lungs. C.E.: Hx of CHF or pulmonary hypertension, tachypnea, tachycardia, anxiety, cold, clammy, diaphoretic, pink frothy secretions (marked congestion) Edema of fluids (pedal edema) pitting edema (+2,+3) Increased hemodynamic pressure (PCWP, PAP, CVP) XR: Butterfly pattern, fluffy infiltrates ABG: ventilatory failure with moderate to severe hypoxemia K.I.: Treat as an emergency, 100% O2, Administer diuretic medication furosemide (Lasix) Cardiac intatropic stimulating drugs such as digoxin, digitalis if increased PCWP & PAP Be prepared to treat ventilatory failure with MV Myocardial Infarction/ Arrhythmia : Definition, Clinical Evidence, ABG, ECG & Key interventions **EXAM Challenge: Will likely need to treat arrhythmias with appropriate medication and/or defibrillation D: Ischemia to the heart causing muscle damage and potential failure. C.E.: Hx of chest pain, radiating pain down the left arm. Family history of disease. Diaphoretic, nausea, tachycardia. Cold, diaphoretic and clammy to the touch. Dypnea ABG: hypoxemia ECG: (EKG) pronounced Q waves and S-T segment elevation Just prior to the MI, may see flipped T waves. Cardiac enzymes including CPK, LDH, SGOT are elevated K.I.: Emergency!= 100% O2. O2 at adult therapeutic level (40-60%) upon suspicion or first presentation so signs and/or symptoms. Treat arrhythmias-- bradycardia = atropine, PVCs = lidocaine or O2, pulseless ventricular tachycardia = defibrillation & chest compressions, Ventricular Fibrillation = defibrillation Pulmonary Emboli : Definition, Clinical Evidence, Chest xray, CBC, ABG,PFT & Key interventions **EXAM Challenge: This case primarily involves recognizing the pulmonary emboli and treatingit with anticoagulation meds. You will likely have to monitor clotting times, PTT or PT. Otherwise, involves general respiratory therapy. D: Situation where the pulmonary artery becomes obstructed and dead-space ventilation results. Sometimes called deadspace disease. C.E.: Hx of recent major surgery or trauma (amputations, clotted massive bleeding sites) Complaint of chest pain and dyspnea. Elevated vitals. Br/S = wheezing and medium rales PECO2 decreasing during normal PaCO2. V/Q scan will show ventilation without adequate perfusion. Patient will be described as "OK one minute, but suddenly became short of breath ABG: Persistent hypoxemia in spite of increasing FiO2 K.I.: Anticoagulation therapy with heparin or coumadin, *must monitor clotting tests (PTT for heparin, PT for coumadin)* Clot-busting medication such as streptoKinase. May also use a bolus of heparin. MV is needed. Emergency level O2=100% Newborn Assessment : Definition, Clinical Evidence & Key interventions D: Involves delivery of an infant and is complicated by various problems C.E.: APGAR= Appearance or color, Pulse, Grimace or reflex irritability, Activity or flexion, Respiratory effort. (0-2 points) A= 2-pink, 1-acrocyanosis, 0-blue or pale; P= 2- 100, 1- 100, 0-none; G= 2- cough or sneeze, 1- facial grimace, 0-none; A= 2-active movement, 1- some flexion of limbs, 0- limp or no move; R= 2- strong cry, 1- weak cry, 0- no cry. If poor APGAR, may be pre-term, congenital heart problem, meconium aspiration IRDS, transient tachypnea, gestational age, weight K.I.: If APGAR Score is: 0-3 PERFORM CPR, 4-6 administer O2, place infant in warm, neutral thermal environment, stimulate 7-10 monitor the baby normally Sudden Infant Death Syndrome : Definition, Clinical Evidence & Key interventions D: Sudden apnea occuring in newborn infants as a result of an immaturity central control of ventilation C.E.: Hx of pre-term birth, family genetic predisposition, observed, irregular respirations, bradycardia may increase risk of SIDS, Cold air on infants face may induce apnea, Diminished or absent Moro and Babinski reflexes K.I.: Provide O2 when in crisis (30-50%), Must sent infant home with an apnea monitor and parental education, if offered, teach parents CPR Meconium Aspiration : Definition, Clinical Evidence, Chest xray, ABG & Key interventions **EXAM Challenge: This is a very common case on the test. It is fairly straight forward and easily recognized. The key to this is repeated suctioning and clearing of the airway. D: Infant born having meconium in ventilation spaces C.E.: Hx of meconium-colored amniotic fluid, Often with full-term infants, Infant may have meconium staining about the body May demonstrate grunting, retractions, nasal flaring, Cyanosis, APGAR 0-6 XR: Bilateral densities and widespread atelectasis ABG: Hypoxemia with resp. acidosis, met. acidosis or mixed K.I.: Remove the meconium from the airway. If possible, suction the baby as soon as the head appears from the birth canal. Intubate to facilitate suctioning. Reintubate if tube becomes clogged for any reason (may do this repeatedly) Mobilize secretions with chest physiotherapy, Mechanically ventilate only if needed, Apply supplemental oxygen as needed. Infant Respiratory Distress Syndrome : Definition, Clinical Evidence, Chest xray, ABG, L/S & Key interventions **Exam Challenge: Key is remembering to address lung maturity. Also, if prolonged ventilation is required, Brochopulmonary dysplasia may develop. be patient and treat moment to moment. D: Condition in infants where alveolus maturity is below normal C.E.: Hx may show pre-term infant, Onset can be immediately after birth or within a few hours, General resp. distress- grunting, flaring, retractions, Cyanosis, APGAR 0-6, XR: radiological description such as ground glass, honey comb, reticulogranular **NOTE: if xray changes from signs of IRDS to hyperinflation & fibrosis, then the problem may have developed into Bronchopulmonary Dysplasia ABG: persistent hypoxemia in spite of elevated FiO2 L/S ratio: 2:1 or higher is normal; Less shows lung immaturity K.I.: Help lung maturity through surfactant therapy with agents like exosurf or survanta, Surf therapy involves dividing doses, administering down the ET tube with the infant in different positions, Provide O2 via Oxyhood, May use CPAP to oxygenate Mechanically ventilate with vent failure, use time-cycled--pressure limited on all infants. May consider reverse I:E **NOTE: Treat prolonged IRDS (bronchopulm. dyspl) by- Maintiaing pH of 7.25 to 7.40, PaCO2 46-60, PaO2 55-70. Use low FiO2, Keep mean airway pressure at a minimum, wean only gradually and as tolerated, often fails initial attempts. Congenital Heart Defects (Infant) : Definition, Clinical Evidence, Coarction of the Aorta, Transposition of the Great Vessels, Patent Ductus Arteriosis, etc & Key interventions **EXAM Challenge: Your skills in recognizing common congenital heart problems will be tested. Otherwise, you will be simply providing supportive care until surgery. D: Infant is born with an anatomical malady of the heart or the vessels that emanate from the heart C.E.: Hx of pre-term birth, General signs of resp. distress- grunting, nasal flaring, retractions, cyanosis persists in spite of high FiO2, Heart sounds are abnormal upon auscultation (murmur present), Echocardiogram is the best diagnostic test for all cardiac defects. K.I.: Specific Defect Attributes-- CoArc: narrowing of the aorta- Hypertension in the upper extremities, hypotension in lower extremitites. TGV: Aorta and pulmonary artery are switched. "Aorta rising from the right heart, pulmonary artery rising from the left heart" PDA: Diagnosed by comparing blood gases from the radial artery and the umbilical artery. Pos for PDA if difference is greater than 15 torr. (PDA with a Right to Left shunt) Other Problems : Tetralogy of Fallot - boot-shaped heart, overriding aorta. Atrial Septal Defect, Ventricular Septal Defect, Truncus arteriosis- Pulm artery and Aorta combined vessel. ALL CONGENITAL DEFECTS TREATED W SURGERY!! Prior to surgery simply provide supportive care such as: O2 to keep PaO260, MV when Vent failure is present by ABG Neonatal Diaphragmatic Hernia : Definition, Clinical Evidence, Chest xray, ABG & Key interventions D: Condition where the diaphragm never grows closed. Usually occurs on the left side. C.E.: General respiratory distress (grunt, flare, retrac) Cyanosis, Barrel chest or scaphoid abdomen, mediastinal shift, breath sounds absent (left side) XR: Show intestinal parts in the chest area. Also may see mediastinal shift away from the affected side ABG: poor K.I.: Surgery!, Use low vent pressures, Do not use manual bag and resuscitation if possible, May use gastric tube to decompress stomach and intestines, all other care is supportive Choanale Atresia : Definition, Clinical Evidence, Chest xray & Key interventions D: Infant is born with a non-patent nasal passage and is unable to breath during breast and bottle feeding. C.E.: Normal appearing, normal color, cyanosis during feeding, during breast or bottle-feeding, baby becomes apneic and cyanotic, slight inspiratory stridor, diagnosis by attempting to pass a suction catheter through the nares, if unable to pass- then positive XR: neck and chest x-rays rule out airway inflammation K.I.: Care in feeding, Correct with surgery Methemoglobinemia : Definition, Clinical Evidence & Key interventions D: Presence of methemoglobin in the circulating blood- caused by use of recreational drugs. C.E.: Central cyanosis in spite of high FiO2 and very elevated PaO2, Fatigue, Shortness of breath, Headache K.I.: IV Methylene Blue Laryngotracheobronchitis : Definition, Clinical Evidence, Chest xray & Key interventions **EXAM Challenge: You will likely be tempted to treat this like Acute Epiglottitis in an emergency fashion D: AKA croup. Results from a viral infection that illicit inflammation in the upper airway. C.E.: Hx of cold in the past few days, barking cough, age is 6mos to 3yrs, stridor, thachypnea, Afebrile or very low-grade fever (because it is viral, not bacterial) XR: Lateral neck- swelling below the glottis sometimes described as steeple sign or pencil point K.I.: Priority--placement in an oxygen tent with 30-40%, Aersolized Racemic Epinephrine if stridor is moderate, cool aerosol if stridor is mild, Intubation if patient is described as lethargic, markedly diminished breath sounds, severe or marked stridor, extreme acc. musc. use, extubation should be done when swelling has ceased. Acute Epiglottitis : Definition, Clinical Evidence, Chest xray, CBC, ABG,PFT & Key interventions **EXAM Challenge: This case will test your immediate ability to realize that it is an emergency. Stridor may tempt you to treat it more casually like croup. D: Condition where the epiglottis and adjacent upper airway tissues are infected with a bacteria causing inflammation and commonly threatening airway patency. C.E.: Sudden onset of sickness, within 12 hours, often in the evening, age 3-10, general appearance may show DROOLING, hoarseness, quiet cough, May hear a softened inspiratory stridor Tachypnea & tachycardia, Patient unable to swallow, will usually not be crying, eyes are big, significantly elevated body temp-- taken axillary or tympanically XR: lateral neck-- will show supraglottic inflammation K.I.: Primary and immediate concern is establishing an airway as complete closure from inflammation. Since inadvertent stimulation from oral intubation attempts could immediately illicit an inflammatory response, intubating in a surgical environment is very helpful. There may be need to place a tracheostomy tube. DO NOT visualize the oropharynx with a tongue depressor or any other object-- could cause inflammation and complete closure. Antibiotic therapy to correct bacterial infection, O2 therapy at 30-40%, Extubate only when inflammation is gone. Bronchiolitis / RSV : Definition, Clinical Evidence, Chest xray & Key interventions D: Acute vital infection of lower respiratory tract usually occurring in infants less than 18mos old. Commonly caused by the respiratory syncytial virus. C.E.: General signs of respiratory distress including retractions and accessory muscle use, Tachypnea, tachycardia, Hx of recent sickness from ages 2mos - 3yrs, low grade fever, wheezing, rales and rhonchi XR: shows scattered infiltrates and hyperlucency K.I.: Primary treatment is delivery of the drug ribavirin which must be administered via a SPAG unit. Utilize a scavenger system, filters, and masks. Cystic Fibrosis : Obstructive Definition, Clinical Evidence, Chest xray, Sweat Chloride test, PFT & Key interventions D: An inherited disorder resulting in the mass production of thick mucus in the lungs C.E.: Family hx of disease, siblings may have it. Emaciated, body frame may be small for age. Sputum production of thick voluminous purulent secretions. Can look like a young COPD pt. XR: Like COPD- hyperinflation, increase A-P diameter, diaphragm flattening, barrel-chested Sweat Chloride: show sweat chloride 60 mEq/L PFT: Decreased flow rates, such as FEV1 K.I.: Primary treatment relates to the need to mobilize and remove secretions. Secretion removal promotion therapies: PEP therapy, Chest physiotherapy with postural drainage, Hydration devices such as heated aerosol or ultrasonic nebulization, Vibration therapy, O2 as needed, Antibiotic therapy when infection is present (often is), Medications used commonly include: Tobramyacin, and pulmozyme (dornase alpha) Hypothermia : Definition, Clinical Evidence, Chest xray, CBC, ABG,PFT & Key interventions D: Exposure to cold such that body temp falls significantly C.E.: Hx of exposure to cold. May see in homeless, Lethargy & unconsciousness, bradycardia, bradypnea, body temp 36' C K.I.: O2 via a heated aerosol at 40-100%, Keep resuscitation efforts going until body temp is normal, MV is needed, Keep in mind that blood gas values may be altered because of the difference in blood temperature and analyzed temperature. Burn Trauma/CO Poisoning : Definition, Clinical Evidence, Chest xray, CBC, ABG,PFT & Key interventions **EXAM Challenge: Fairly common case on the test. Remember to focus on the airway and on O2 carrying capacity of the blood, Remember to employ isolation techniques. Otherwise, provide general respiratory therapy D: Results from direct exposure to fire and or smoke. Directly threatens airway and O2 carrying capacity of the blood. C.E.: Diagnoses is based largely on hx-exposure to fire/smoke Often occurs in occupational related cases (fire fighter) Visible burns about the body and face, Singed nasal and/or eyebrow hairs, "Cherry-red" color of the face w CO poisoning, Patient is often confused or unresponsive, stridor, hoarsness, Br/s- wheezing, rhonchi, rales XR:may be clear at first but later may show pulmonary edema and markedly decreased lung compliance CBC: COHb=20% or more ABG: Initially decreased PaCO2, decreased saturation, Latter may develop into resp. acidosis K.I.: Protect AW by establishing an artificial AW immediately. (esp. if burns on face) For CO poisoning- start 100%O2 immediately- even if only suspect it-- do not wait for COHb results. Continue O2 therapy until COHb level is below 10%-- may use hyperbaric medicine if offered. Practice Reverse isolation (protect from staff) MechVent as needed. Diabetes : Definition, Clinical Evidence, Chest xray, Blood Glucose, ABG & Key interventions **EXAM Challenge: May be tempted by profoundly acidodic pH. Only determine resp. failure through the CO2, or a sudden decrease in ventilatory volumes and breathing rate. D: Condition related to failure of the renal system resulting in the inability to dispose of CO2. Respiratory result is often respiratory ketoacidosis. C.E.: Hx of diabetes, lethargy, confusion, unresponsiveness, RR & pattern-- significant in depth and rate with an irregular rhythm (Kussmaul's) Pedal Edema, Urine output is markedly decreased (less than 20mL per hour) B.G.: 160mg (Norm=80-120mg) ABG: Profound metabolic acidosis K.I.: Must watch for ventilatory failure from prolonged ventilatory effort and fatigue, Administer electrolytes (K+, Na+, HCO3-, Cl-) as needed. Correct ketoacidosis. AIDS : Definition, Clinical Evidence, Chest xray, CBC, ABG,PFT & Key interventions **EXAM Challenge: Sometimes is combine with tuberculosis D: Disease of the immune system commonly resulting in pneumocystis carinii, a type of pneumonia C.E.: Previous hx of HIV positive test results, Emaciation, unexplained weight-loss, diarrhea, low-grade fevers, night sweats, commonly homosexual activity or drug use is admitted, positive HTLV III, ELISA test-- positive for HIV, Bronchoscopy-- from lung washings or biopsy may show pneumocystis carinii K.I.: Exercise Universal Precautions, Aerosolized Pentamaadine-- usually done monthly, When administering pentamadine, use one-way valves and filters. Pneumonia : Definition, Clinical Evidence, Chest xray, CBC & Key interventions D: Collection and/or consolidation of sputum as a result of a bacterial or viral agent entering the lung on inhalation. C.E.: Fever, dyspnea, chills, cyanosis, rhonchi and rales XR: scattered infiltrates CBC: Increased WBC if bacterial, decrease WBC if viral K.I.: O2 therapy first, suctioning and other bronchial hygiene efforts. Antibiotics: Penicillin for gram positive organisms, Gentamycin, or other 'mycin antibiotics for gram negative organisms. Pleural Effusion : Definition, Clinical Evidence, Chest xray & Key interventions D: Development of excess fluid in the pleural space causing some amount of lung space shrinkage or collapse. C.E.: Sharp chest pains in the area, mediastinal shift away from the effusion, Fluid may shift when patient is in different positions XR: Obliteration of costophrenic angles (lateral decubitus) K.I.: Thoracentesis to remove fluid if small, Chest tubes in the pleural space if lung is more than 20% collapsed Pulmonary Tuberculosis : Definition, Clinical Evidence, Chest xray & Key interventions D: Pulmonary tissue destructive disease as a result of inhalation of the tubercle bacilli C.E.: Night sweats, Hemoptysis (frank or non-frank blood), Expectoration of lung tissue during coughing XR: Formation of cavitations in the lung K.I.: Isoniazid (INH) and other medications (Rifampin, Ethambutol, Streptomycin), Strict Respiratory Isolation, minimizing coughing