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All body systems depend on adequate O
2 |
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Purpose of breathing: + O
2 & - CO2 |
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Includes...
- Ventilation - Hgb & RBC transport |
- Gas exchange |
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ATP production is vital for cell activity & life
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Cellular hypoxemia impairs the cell's energy production, disrupts cell function
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Acute lung tissue is at the alveolar-capillary membrane level
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Concepts of airway resistance, lung compliance, opposing lung forces
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Inspiration: chest wall muscles contract, inc. intrapleural pressure = lung expands
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Expiration: lung deflates passively
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Blood flow through the lungs:
- Bronchial - Pulmonary: highly vascular capill. network |
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Pulse ox: measures O
2 bound to Hgb (3% plasma, 97% Hgb) |
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Smoking = carboxyHgb binds faster to Hgb
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Ventilation-Perfusion Ratios
V/Q Scans: r/o pulmonary embolus |
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Dead space: lung area has V/Q mismatch
- Do not participate in gas exchange - Enough O 2 but not enough blood flow |
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Shunt: blood bypasses alveoli w/o getting O
2 |
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Silent unit: pt can have dead space & shunt
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Hypoxemia: not enough O
2 in the blood |
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Hypoxia: not enough O
2 in the tissues |
2 partial pressure (mm Hg) = paO2 2 when acute, get ABG's! |
Smoking (#1) - how long, how much might not be ready to hear it but responsible to inform about risks & complications
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Allergies - year round, don't have to be allergic for things to affect breathing
- Breathing in cold air is a very powerful irritant! (at least a cough) |
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Drug use - ACEI (cough), amiodarone (cough), beta-blockers (compete for B
2 sites) |
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Travel - TB, outside country, soil
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SES - what's in home environment, pet hair, heating system in fall/winter
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Family Hx - genetics (recurr./chronic, acute)
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Occupation - if mask required, ventilation
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Chest wall: stiffer, m/s issues dec. compliance
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Pharynx & larynx: muscles atrophy, airways lose cartilage, vocal cords start to slack
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Lungs: lose elasticity dec. compliance
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Alveoli: lose starting at 35yo but breathing not impacted unless chronic disease present
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Pulmonary vasculature: alveolar-capillary membrane thickens impairs gas exchange
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Ciliary action: move mucus & filter grunge (mucociliary exhalade)
- Cilia paralyzed for 4 hr after every cigarette |
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SUBJECTIVE DATA
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Cough - cardinal symptom of respiratory disease (6-8 wk = chronic)
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Sputum - color? odor? changes? (normal = clear)
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CP - assoc. w/ other things (GI, MI, etc.)
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Dyspnea: length? onset? what helps? rate?
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OBJECTIVE DATA
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General appearance: visibly dyspneic? using accessory muscles (sternocleidomastoid, trapezius, intercostals)? position to breathe?
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Vital signs: (later) all affected w/ work of breathing
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Physical assessment: inspection, palpitation, percussion, auscultation
- Always want extent to which you hear adventitous breath sounds |
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Laboratory Assessment
- RBC (r/t Hgb transport) - Hgb - Sputum (sample for antibiotics, C&S) - ABG's (pH, CO 2 hypo-/hyperventilating; acidic/acidotic; bicarb.) |
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Radiography
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CT scan
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Pulse ox
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Capnography
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PFT's
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Bronchoscopy
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Thoracentesis
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Lung biopsy
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V/Q scan
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Etc.
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X-rays: air = black / everything else = white
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CXR - infiltrates, infusions, masses
- Daily in ICU for changes |
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Thin slices, more specific than radiography
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Often w/ contrast (more detailed)
- Assess allergies (shellfish, iodine), kidney function |
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Measure of O
2 attached to Hgb; SpO2 or SaO2 |
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Normal value: 95-100%
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Value affected by...
- Poor peripheral perfusion/cold - Nail polish - Same arm as BP cuff - Applied correctly? |
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Don't diagnose with value!
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Measure of CO
2 in exhaled air, which correlates w/ arterial CO2 |
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Normal value = 20-40
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Now checking capnography w/ PCA pumps
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Insert scope to examine upper & lower airway
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Invasive, need consent time-out!
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Therapeutic vs. diagnostic
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Labs: platelets (CBC), PT/INR (clotting)
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NPO 4-8 hr before
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Premedicate: sedation, topical to paralyze cords
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VS & Assessment: pre- & post-scope, infection, bleeding
- May cause perforation or pneumothorax - Accessory muscles - Asymmetical expansion & breath sounds - Acutely dyspneic - Tachypneic - Hypertensive |
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Therapeutic (remove fluid) vs. diagnostic
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Need consent, comfort pt
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Sterile procedure!
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Pre & Post: CXR, check puncture site, s/s of infection, VS, incentive spir. & deep breathe
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Assessment: pneumothorax, pain on affected side, mediastinal shift insert chest tube?
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Upright, leaning permits better access
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Purpose: to obtain tissue sample for eval.
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Various approaches:
- Transbronchial Bx (TBB) - Endobronchial Bx (EBB) - Mediastinoscopy - Open lung Bx (general anesthesia) |
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Conscious sedation
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Fluoroscopy
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Pre: CT for depth and density of mass
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Post: gag reflex, VS (infection), pneumothorax, bleed, hemoptysis
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Does ventilation match perfusion?
- Mismatch = ventilated not always perfused |
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Low/moderate/high probability for risk of pulmonary embolus
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Procedure: pt gets inhaled nucleotide
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Get from pulmonary arterial line
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Purpose: to eval. O
2 supply-demand balance |
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Normal value = 60-80%
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Venous gas (60-80%) < arterial (80-100%)
- Easier sample, less painful - What's going on at peripheral level |
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A collection of matter that enters venous circulation and into the lungs
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DVT's is a big risk!
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Pathophysiology:
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1) Alveolar dead space inc. as blood shunted away
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2) Vasoactive & bronchoconstrictive substances released vasoconstriction dec. bood flow to lungs worsens PE
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3) Pulmonary vascular resistance inc.
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4) Pressure in pulmonary artery inc.
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5) R ventricle workload inc.
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6) CO dec. systemic blood pressure dec.
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7) Deoxygenated blood moves into arterial circulation hypoxia & hypoxemia
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Depends on SIZE of blood clot!
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Anything causing venous stasis - vericose veins, inactivity (spinal cord/hip surgery), restrictive clothing, prolonged travel, obesity
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Hypercoagulable - obesity, trauma, cancer, factor deficiencies, birth control (estrogen)
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Venous endothelial disease - vericose veins, trauma, surgery, vascular vein disease
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Smoking - inc. fibrinogen = inc. viscosity
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Change in aging
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VIRCHOW'S TRIAD:
(1) venous stasis (2) hypercoagulability (3) venous endothelial damage/injury |
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80-90% come from venous
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RESPIRATORY
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SOB/dyspnea (worsening) - tachypneic, cyanotic, use of accessory muscles, cough, restless, panicky, confused
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CARDIAC
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Tachycardia
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Early/late HTN
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Pleuritic CP
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EKG changes
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S
3 or S4 (pooling, R-sided workload inc.) |
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paCO
2 inc. = acidotic |
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1. Improve gas exchange
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2. Improve lung perfusion
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3. Dec. risk for further clot formation
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4. Prevent complications
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Administered ASAP for therapeutic effect
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Length of time-variable
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Heparin - usually autely (unless massive)
- -Kinases (antithrombolytic) - Bridge w/ Warfarin (Coumadin) - treat 3-6 months but depends on size & risk factors |
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Other agents:
- Enoxaparin (Lovenox) - Fondaparinux (Arixtra) |
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Suggestive, not definitive
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Diagnosed w/ diagnostic tests, Sx, & labs
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Labs - CK, CRP, ESR, D-Dimer
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Radiology/CT, TEE (cardiac assess)
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V/Q scan - now more pulm. angiography
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O
2 therapy - fix hypoxemia (vent/mask/NC) |
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Anti-coagulation, Thrombolytic agents
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Surgery (embolectomy) & Filters (break up traveling clots; temporary or permanent)
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Ekos: endo catheter through blood vessels to deliver clot-busting med &/or break up clot
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Early mobilization, Freq. position changes
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Active/passive ROM
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TEDs & SCDs
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Avoid tight clothes - esp. popliteal area
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Lifestyle changes - obesity/wt loss, smoking, birth control, activity, diet (salads), hydration, medic alert bracelets
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Anti-coagulation therapy - PT/INR, UFH
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Avoid valsalva maneuver laxatives
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Assessment/eval of peripheral circulation - color, temp., & sensation in extremities
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Bleeding precautions - electric razors, hold pressure, scissors & knives
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Cheatography n. The art of mapping complex subjects into clear, instantly navigable reference guides.