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Respiratory Therapy - Lindsey Jones/Clinical Simulations 459 Questions with Verified Answers,100% CORRECT

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Respiratory Therapy - Lindsey Jones/Clinical Simulations 459 Questions with Verified Answers Information Gathering - Emphysema: (Abnormal condition of the alveoli resulting destruction and loss... of elasticity) - CORRECT ANSWER LEVEL I : Cyanosis, Barrel chest, increased A-P diameter, Accessory muscle use, Digital clubbing of the nail beds, Significant history of smoking and/or occupational exposure to smoke or other pulmonary irritant LEVEL II : Dyspnea, Wheezing breath sounds LEVEL III : Chest X-ray—flattened diaphragms, hyperlucency, diminished pulmonary vascular markings. CBC—polycythemia, increased WBC due to possible infection. ABGs—Compensated respiratory acidosis (high PaCO2, normal pH), moderate to severe hypoxemia. Sputum cultureoften positive for bacteria. LEVEL IV : FT—flows are decreased especially middle sized airways (FEF 25-75%) Fev1 and Fev1/FVC%, reduced DLCO (less than 20). Decision Making - Empysema: (Abnormal condition of the alveoli resulting destruction and loss of elasticity) - CORRECT ANSWER Oxygen therapy—low FIO2 (0.24 to 0.28) or 1 to 2 lpm nasal cannula Oxygen conserving devices such as liquid oxygen or trans-tracheal oxygen Home care education on devices and equipment cleaning Rehabilitation efforts (specifics not usually required) Aids to help quit smoking such as nicotine replacement therapy Bronchodilation medication via MDI or aerosol nebulizers Antibiotics for infection Smoking cessation products (nicotine replacement therapy). Information Gathering - Chronic Bronchitis (Defined: Condition where the patient has a productive cough 25% of the year for at least two consecutive years.) - CORRECT ANSWER LEVEL I : Productive cough, purulent sputum production Exposure to pulmonary irritants, like history of smoking Frequent infections LEVEL II : Dyspnea LEVEL III : Chest X-ray—could be normal, or may show hyperlucency, diminished, pulmonary markings. CBC—possibly increased WBC due to possible infection. ABGs—could be normal or very slight respiratory acidosis and hypoxemia LEVEL IV : PFT—flows are decreased especially middle sized airways (FEF 25-75%) FEV1, Normal DLCO Decision Making - Chronic Bronchitis (Defined: Condition where the patient has a productive cough 25% of the year for at least two consecutive years.) - CORRECT ANSWER Anything that promotes good pulmonary hygiene such as chest physiotherapy, hydration therapy when sputum is thick. Fluid therapy if dehydrated.Oxygen therapy for hypoxemia Aerosolized bronchodilator therapy, Antibiotic Tetracycline may be preferable Information Gathering - Bronchiectasis (Defined: Abnormal condition where the bronchi secrete large volumes of pus during abnormal dilation.) - CORRECT ANSWER LEVEL I : Productive cough, often with blood, digital clubbing of the nail beds, significant history if infections (recurrent) LEVEL II : Dyspnea LEVEL III : Chest X-ray—generally normal Sputum culture—gram negative bacteria LEVEL IV : Bronchogram is the primary test. Characterized by a "tree in winter pattern" Decision Making - Bronchiectasis (Defined: Abnormal condition where the bronchi secrete large volumes of pus during abnormal dilation.) - CORRECT ANSWER Anything that promotes good pulmonary hygiene such as chest physiotherapy, hydration therapy when sputum is thick. Fluid therapy if dehydrated.Oxygen therapy for hypoxemia Aerosolized bronchodilator therapy. May have to consider surgical intervention on some highly affected segments Information Gathering - OSA (Defined: the cessation of breathing during sleep. Is usually obstructive in nature but sometimes can be central or a combination of the two (mixed). - CORRECT ANSWER LEVEL I : Spouse or bed partner will complain of snoring and will often report witnessing periods of apnea that exceed 10 seconds. Excessive upper airway tissue, obesity, thick neck (greater than 16 inch collar size. Ability to fall asleep quickly Sleepiness during daytime and while watching TV or in front of a computer LEVEL II : Dyspnea, Frequent urination during sleeping hours LEVEL III : ABGs—could be normal or very slight respiratory acidosis and hypoxemia LEVEL IV : Polysomnography (sleep study) - determines if obstructive or central, If no nasal flow AND no chest movement—then CENTRAL sleep apnea. If no nasal flow WITH chest movement—then OBSTRUCTIVE sleep apnea Decision Making - OSA (Defined: the cessation of breathing during sleep. Is usually obstructive in nature but sometimes can be central or a combination of the two (mixed). - CORRECT ANSWER If central, ventilatory stimulant medication may be used, If obstructive, nocturnal nasal or full-face CPAP or BiPAP (NIPPV) is usually initially indicated with follow-up weight loss or upper airway tissue removal through surgery. Problem must be corrected immediately, so even if discharging, send devices home with patient. In the absence of a titration study, initially ordered pressure should be 10 to 20 cmH20. Information Gathering - Asthma (Defined: Abnormal constriction of the bronchials resulting in sputum productionand narrowed airways. - CORRECT ANSWER LEVEL I : Accessory muscle use, Tachycardia LEVEL II : Dyspnea, Wheezing, Congested cough, Wet, clammy skin LEVEL III : ABGs—possible respiratory acidosis, could be hypoxic, Chest X-ray—hyperinflation, scattered infiltrates, flattened diaphragms. In allergic cases, may see elevated eosinophil count which can cause yellow sputum LEVEL IV : PFT—Decreased flows in FEV1 but diffusion is normal as manifested by DLCO Decision Making - Asthma (Defined: Abnormal constriction of the bronchials resulting in sputum productionand narrowed airways. - CORRECT ANSWER Oxygen therapy for hypoxemia Aerosolized bronchodilator therapy Continuous bronchodilator therapy, Albuterol (7-10 mg/hr) Xanthine medication given IV (Aminophylline, etc) Promote pulmonary hygiene Inhaled sterioids such as oral or IV prednisone Information Gathering - Status Asthmaticus (Defined: Asthma that will not respond to bronchodilation therapy,usually persists more than 24 hours.) - CORRECT ANSWER LEVEL I : Historically non-responsive to bronchodilators. Patient will report the need to take many bronchodilator treatments before feeling better. Accessory muscle use and retractions Dyspnea, Wheezing, Congested cough, Wet, clammy skin LEVEL II : Pulses paradoxus LEVEL III : ABGs—possible respiratory acidosis when tiring, alkalosis at first due to anxiety, could be hypoxic Chest X-ray—hyperinflation, scattered infiltrates, flattened diaphragms. Decision Making - Status Asthmaticus (Defined: Asthma that will not respond to bronchodilation therapy,usually persists more than 24 hours.) - CORRECT ANSWER May deteriorate quickly, so if progression is shown, intubate, mechanically ventilate before full ventilatory failure. Use subcutaneous epinephrine—1 mL of 1:1000 strength. May need to give every 20—30 minutes for up to three consecutive doses (if no improvement between doses) Continuous beta II agonist (bronchodilator medication). Albuterol 7-10 mg/hr. Information Gathering : Myasthenia Gravis (Defined: Neuromuscular abnormality where muscles experience paralysis starting from the head down to the feet including ventilatory muscles.) - CORRECT ANSWER LEVEL I : May have a history of Myasthenia Gravis if not a new onset, Droopy facial muscles and eyelids (Ptosis) LEVEL II : Patient will describe slowly feeling weakness generally but feels better with rest. Double vision (diplopia) Dysphagia (difficulty swallowing) Drooping eyelid (Ptosis) Shrinking Vt, VC, MIP LEVEL IV : Tensilon Challenge Test—positive for Myasthenic crisis if improvement is noted upon the administration of Tensilon. Decision Making : Myasthenia Gravis (Defined: Neuromuscular abnormality where muscles experience paralysis starting from the head down to the feet including ventilatory muscles.) - CORRECT ANSWER If Tensilon improves condition then, anticholinesterase therapy is indicated including: Neostigmine (prostigmine), Mestinon (pyridostigmine) Ok to do additional Tensilon challenge test to observe progression. If symptoms improve with Tensilon and then worsen, must reverse with Atropine. This condition is termed a cholinergic crisis. Always monitor spontaneous ventilatory volumes (Vt and VC) as well as MIP. Never treat Myasthenia gravis with Tensilon—only use to diagnose. Use the above mentioned drugs to provide maintenance. Be totally prepared to intubate and mechanically ventilate prior to Tensilon challenge since it could take out the respiratory drive When VC falls off rapidly (especially if below 1.0 L) , then intubate and mechanically ventilate. Information Gathering : Drug Overdose (Defined: Potential loss of ventilatory drive as a result of drug overdose (usually a narcotic). ) - CORRECT ANSWER LEVEL I : Historical drug use as told by previous admissions or family, Sometimes poor self-hygiene, emaciated LEVEL II : Looks and acts sleepy, difficult to arouse, Respiratory rate and pattern is low and/or shallow LEVEL III : ABG—often show pure respiratory acidosis and/or ventilatory failure Decision Making : Drug Overdose (Defined: Potential loss of ventilatory drive as a result of drug overdose (usually a narcotic). ) **The most important part of this simulation is the need for immediate intubation while recognizing that there may not be a need to mechanically ventilate until ventilatory status deteriorates. - CORRECT ANSWER Important priority is to protect the airway through intubation, prevent aspiration of stomach contents, and facilitate manual ventilation. If narcotic overdose (usually is) then use narcotic reversing medication such a Narcan (Nalaxon) Support ventilation until drugs are out of system. Information Gathering : Other Neuromuscular (Defined: Other neuromuscular diseases or states include: Poliomyelitis, Tetanus, Muscular dystrophy, and even botulism poisoning.) - CORRECT ANSWER LEVEL I : History of illness LEVEL II : Shrinking Vt, VC, MIP Decision Making : Other Neuromuscular (Defined: Other neuromuscular diseases or states include: Poliomyelitis, Tetanus, Muscular dystrophy, and even botulism poisoning.) **If faced with these diseases, simply apply general respiratory monitoring principles and facilitate ventilation when needed. These are somewhat rare. - CORRECT ANSWER Monitor for ventilatory failure generally through Vt, VC, MIP and ABGs As VC falls below 1.0 L, consider intubation and mechanical ventilatory support. Paralytics are indicated if conditions, such as locked-jaw or other muscle contractions are present due to Tetanus or Botulism. Information Gathering - Head Trauma (Defined: Physical Trauma to the head) - CORRECT ANSWER LEVEL I : Sometimes trauma is visible with blood contusions on the head, History is trauma related, often automobile accident LEVEL II : Looks and acts sleepy, difficult to arouse Respiratory rate and pattern is low and/or shallow and irregular Pupillary response to light may be unequal or inadequate LEVEL IV : If intracranial pressure monitor is in place, may see ICP greater than 20cm H2O Decision Making - Head Trauma (Defined: Physical Trauma to the head) **Unique to this simulation 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 my elevate ICPs. - CORRECT ANSWER Must constrict vessels in the head by keeping PaCO2 between 25-30 mm Hg. Adjust FIO2 to maintain high normal levels (PaO2 of 100 mm Hg). Avoid increased ICP by minimizing PEEP usage. Suction only when needed, due to elevating peak pressures. Avoid anything that will increase mean arterial pressure (MAP). Sedation is important, but should monitor exhaled volumes and pressures closely Use of drugs such as Mannitol (cerebral diuretic medication) when ICP is above 20 cm H20 Use Dilantin and establish an airway if grand mal seizure activity is observed Information Gathering - Chest Trauma (Defined: May be any trauma leading to fractured ribs or flail chest.) - CORRECT ANSWER LEVEL I : Circumstantial history (motor vehicle accident, etc) Respiratory rate and pattern is fast and shallow due to pain May have obvious trauma (bruising) on chest wall LEVEL II : Sharp chest pain, especially at the top of each breath Paradoxical chest movement if ribs are broken in two places (flail chest) Pneumothorax is possible (see signs and symptoms of pneumothorax) LEVEL III : Chest x-ray—may reveal broken ribs, usually isolated in same area Decision Making - Chest Trauma (Defined: May be any trauma leading to fractured ribs or flail chest.) **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 pneumothorax or hemothorax. - CORRECT ANSWER Anything that encourages deep (adequate) breathing in spite of pain such as IPPB, incentive spirometry, coughing. Watch for ventilatory fatigue and eventual ventilatory failure Mechanically support ventilation when it is evident ventilatory failure is impending. If possible do not wait until full ventilatory failure. Treat partial pneumothorax if greater than 20% - ie insert chest tubes Treat hemothorax, with chest tubes or thoracentesis Treat tension pneumothorax with a large-bore needle Information Gathering - Hemothorax/Pneumothorax (Defined: Defined: Loss of adherence of the lung to the pleural wall causing the space to be filled with air or fluid (bloody). ) - CORRECT ANSWER LEVEL I : Rapid and shallow respirations LEVEL II : Percussion: hyperresonant if pneumothorax, dull if hemothorax, Tracheal shift: to affected side if pneumothorax, away if tension pneumothorax, Severe dyspnea, Very diminished or absent breath sounds, Pulses paradoxes LEVEL III : Chest x-ray—definitive—show hyperlucency, tracheal or mediastinal shift Decision Making - Hemothorax/Pneumothorax (Defined: Defined: Loss of adherence of the lung to the pleural wall causing the space to be filled with air or fluid (bloody). ) **Pneumothorax, hemothorax, tension pneumothorax occurs very frequently on the exam. May include the troubleshooting of chest tube drainage devices - CORRECT ANSWER Usual treatment is insertion of chest tubes Upper anterior chest tube placement for pneumothorax (involving air) Lower chest tube placement for hemothroax (involving blood and body fluid) Treat partial pneumothorax if greater than 20% - insert chest tubes Treat hemothorax, with chest tubes or thoracentesis Treat tension pneumothorax with a large-bore needle Information Gathering : Thoracic Surgery (Defined: Can have a variety of complications from thoracic surgery.) - CORRECT ANSWER LEVEL II : Always monitoring chest tube drainage adequacy Looking for potential complications: Hypovolemic shock, low hemodynamic values including blood pressure, Subcutaneous emphysema, Elevated ventilatory pressures LEVEL III : Chest x-ray—to confirm proper re-inflation of the lung and proper placement of chest tubes Decision Making : Thoracic Surgery (Defined: Can have a variety of complications from thoracic surgery.) **Your ability to deal with and troubleshoot chest tube maintenance is tested in this simulation. Sometimes this case is combined with chest trauma. - CORRECT ANSWER Anything that promotes expansion of the lungs including incentive spirometry, IPPB, and positive pressure mechanical ventilation. If a lobectomy or pneumonectomy, ventilatory volumes should set lower. Fluid therapy if volume is a problem (often is). If mechanical ventilation is used, use VT of 8-9 mL/kg to reduce ventilatory pressures. Information Gathering : Neck/Spinal Injury (Defined: Any trauma threatening the physical structure of the neck. Can include neck or spinal surgery.) - CORRECT ANSWER LEVEL I : Historical relevance, some sort of accident such as diving, automobile. Visible damage to the neck. Altered conscious level. Pulse must be palpated brachially or femorally LEVEL II : Vt, VC, PEFR, and other ventilatory volumes may quickly deteriorate LEVEL III : Neck x-ray—will show injury Decision Making : Neck/Spinal Injury (Defined: Any trauma threatening the physical structure of the neck. Can include neck or spinal surgery.) **Your knowledge of special intubation techniques is what is being tested in this type of simulation. - CORRECT ANSWER Always be prepared to quickly assist and/or promote ventilation. If intubation is required, always use MODIFIED jaw 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 acceptable to prevent neck manipulation and further injury Information Gathering : Abdominal Surgery (Defined: Surgery in the abdominal area for various reasons.) - CORRECT ANSWER LEVEL I : All general visual assessments LEVEL II : All general beside assessment including all vitals LEVEL III : Ventilatory volumes (VC, Vt, FEV1) compared to pre-surgery baselines Decision Making : Abdominal Surgery (Defined: Surgery in the abdominal area for various reasons.) **Abdominal surgery is usually a very general, non-complicated case involving preventative care and follow-up. - CORRECT ANSWER Establishing baselines in pulmonary function testing flows and volumes. Start patient on incentive spirometry prior to surgery, every hour after surgery Initial IS goal is 1/2 of the preoperative inspiratory capacity value. Use positive pressure (IPPB) if needed after surgery if patient is unconscious. Information Gathering : ARDS (Defined: A condition that results in significantly decrease lung compliance and consequent profound hypoxemia.) - CORRECT ANSWER LEVEL I : Record may show a variety of insults to the lung including massive surgery, near drowning, inhalation of gasoline, hypothermia, and others. Rapid respiratory rate Cyanosis LEVEL II : Decreased lung compliance as manifested by increased plateau pressures (decreasing static compliance) LEVEL III : ABGs—persistent hypoxemia in spite of elevated FIO2 (may be refractory) Chest x-ray—show granular, ground glass, reticulogranular, or honeycomb patterns. Often accompanied by diffuse infiltrates. LEVEL IV : All hemodynamic values could deteriorate when positive ventilatory pressures become significant. Decision Making : ARDS (Defined: A condition that results in significantly decrease lung compliance and consequent profound hypoxemia.) **ARDS can be a very disquieting case to deal with. Usually persistent increases in PEEP are needed. Do not be afraid to increase PEEP significantly. Also, most often, cardiac output or some other hemodynamic value will fall indicating a need to decrease PEEP in spite of profound hypoxemia. - CORRECT ANSWER 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 and utilize PEEP to maintain oxygenation. After emergency situation is past, keep FIO2 no more than 0.6 and use PEEP Keep increasing PEEP until an obvious degradation in hemodynamic values is witnessed. As ventilatory pressures become higher, OK to consider alternate methods of ventilation including pressure control, high frequency, APRV, inverse I:E ratio, etc If patient is described as having ARDS before being placed on a ventilator, initial ventilator setting should include a PEEP of at least 10. It is also appropriate to start right off at pressure/control ventilation as an initial setting. Information Gathering : Laryngectomy (Defined: Surgery done to address or remove cancer of the larynx.) - CORRECT ANSWER LEVEL I : Surgical record : Surgery radical (entire larynx) or simple (cord removal) Medical history will show cancer in upper airway LEVEL II : Signs of airway obstruction after surgery. Usually caused by blood within a few hours after the surgery. Decision Making : Laryngectomy (Defined: Surgery done to address or remove cancer of the larynx.) **In this case, you are always looking for post-surgical complications like blood clots in the laryngeal tube. Often, you will have to mechanically ventilate this patient through the laryngectomy tube. - CORRECT ANSWER If radical surgery (entire larynx removed) then the tracheostomy becomes permanent. If not radical then a temporary laryngectomy tube is placed but must be replaced in 3 to 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 laryngectomy tube is in place, you must intubate and/or ventilate through that tube ! Information Gathering : Guillian Barre (Defined: An insidious neuromuscular problem involving muscle paralysis. Paralysis begins in the lower extremities and moves upward, including the ventilatory muscles.) - CORRECT ANSWER LEVEL I : Medical history or patient complaint of recent influenza-type sickness. LEVEL II : Complaint of sluggish lower extremities, Shrinking Vt, VC, MIP LEVEL III : ABGs—impending or current ventilatory failure. LEVEL IV : Spinal tap—will show increased protein in the spinal fluid Decision Making : Guillian Barre (Defined: An insidious neuromuscular problem involving muscle paralysis. Paralysis begins in the lower extremities and moves upward, including the ventilatory muscles.) **Like most neuromuscular cases, you will be tested in your ability to recognize deterioration in ventilatory muscles. In this case,onset can be slow, so don't jump-the-gun and mechanically ventilate too early. Only do so as VC falls below 1.0 L. Otherwise, you will be manipulating the ventilator and possibly weaning. - CORRECT ANSWER Be primarily concerned with loss of ventilation, monitor ventilatory volumes (VC, Vt) and MIP. Begin mechanical ventilation when VC falls below 1.0 L. Be patient about intubation and mechanical ventilation. Onset can be slow. Anti-coagulant therapy and pressure leg stockings to prevent clot development Primary treatment will involve mechanical ventilation and letting the syndrome run its course. Therapies to mobilize secretions Plasmapheresis, immunosuppressor medications. Higher propensity for pulmonary embolism due to clot formation in the lower body due to inactivity. Information Gathering : Shock (Defined: Condition where tissues oxygenation is in jeopardy due to a sudden decrease in blood flow.) - CORRECT ANSWER LEVEL I : Historical evidence of an event, massive trauma, or hypothermia, etc General appearance—cold, clammy, dusky, cyanotic, Tachycardia, tachypnea LEVEL II : Hypotensive, Temperature may be below normal Reduction in urine output LEVEL III : ABGs—hypoxemia and ventilatory failure LEVEL IV : Reduction in common hemodynamic values (CVP, PAP, PCWP) and cardiac output. Decision Making : Shock (Defined: Condition where tissues oxygenation is in jeopardy due to a sudden decrease in blood flow.) **Shock will test your ability to recognize it and monitor the patient for ventilatory failure. Most of the simulation is dealing with typical ventilatory considerations such as ventilator manipulation. - CORRECT ANSWER Mechanically ventilate with ventilatory failure. Oxygen is key. Start it as evidence of shock is presented. Administer blood if needed to treat anemia. Use oxygen at least 40% but may use up to 100% Main treatment involves treating the original problem (that which caused the shock). This can be highly variable. Information Gathering : Heart Surgery (Defined: Any surgery on the heart.) - CORRECT ANSWER LEVEL I : Do well-rounded assessment prior to surgery including vital signs and family history of cardiac illness. LEVEL II : Preoperative assessments of breath sounds Baseline data including basic spirometry of all types including FEV1/FVC and pre and post bronchodilator studies LEVEL III : ABGs—preoperative for baseline Decision Making : Heart Surgery (Defined: Any surgery on the heart.) **This case is not too complicated. You may feel hesitant to do CPR on someone fresh out of surgery. Just do it. - CORRECT ANSWER Always assess ventilatory volumes and be prepared to mechanically ventilate Incentive spirometry every 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 without reservation or consideration of the heart surgery. Information Gathering - Pulmonary Edema/ CHF (Defined: Significant reduction in cardiac output. Involvement of fluid penetrating the alveolar capillary membrane into the lungs.) - CORRECT ANSWER LEVEL I : History of CHF or pulmonary hypertension Tachypnea, tachycardia, anxiety LEVEL II : Cold, clammy, diaphoretic, Pink frothy secretions Edema of fluids (especially pedal edema) Pitting edema (+2, +3) Breath sounds reveal fine, wet rales LEVEL III : ABGs—ventilatory failure with moderate to severe hypoxemia. Chest X-ray—Butterfly pattern, fluffy infiltrates LEVEL IV : Increased hemodynamic pressure (PCWP, PAP, CVP) Decision Making - Pulmonary Edema/ CHF (Defined: Significant reduction in cardiac output. Involvement of fluid penetrating the alveolar capillary membrane into the lungs.) **This case may feel complicated because it involves the heart and hemodynamic values. It is usually easily identified by pink frothy secretions and butterfly pattern on the chest X-ray.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. - CORRECT ANSWER Treat as an emergency ! 100% oxygen Administer diuretic medication furosemide (Lasix) Cardiac intotropic stimulating drugs such as digoxin, digitalis if increased PCWP and PAP Be prepared to treat ventilatory failure with mechanical ventilation Instill ethyl alcohol down the ET tube if patient is severely congested with fulminating edema. Information Gathering - M.I/Arrhythmia (Defined: Ischemia to the heart causing muscle damage and potential failure.) - CORRECT ANSWER LEVEL I : History of chest pain, radiating pain down the left arm Family history of disease, Diaphoretic, History of nausea Tachycardia, Nausea Level II : Cold, diaphoretic and clammy to the touch, Dyspnea Level III : ABGs—hypoxemia, ECG (EKG) - pronounced Q waves and S-T segment elevation Level IV : Cardiac enzymes including CPK, LDH, SGOT are elevated Decision Making - M.I/Arrhythmia (Defined: Ischemia to the heart causing muscle damage and potential failure.) **Will likely need to treat arrhythmias with appropriate medication and/or defibrillation - CORRECT ANSWER Emergency—100% oxygen. Oxygen at adult therapeutic level (40 to 60 %) upon suspicion or first presentation of signs and/or symptoms. Treat arrhythmias, Bradycardia with Atropine or Isuprel, PVCs with Lidocaine or oxygen, Pulseless ventricular tachycardia with defibrillation with synchronization OFF Ventricular fibrillation with defibrillation. Note: For ventricular fibrillation, defibrillate at ascending watt/sec or joule settings 360 joules—repeat as needed, Do not exceed 360 joules Note: For atrial fibrillation or flutter, do synchronized cardioversion—start at 50 joules Information Gathering - Pulmonary Emboli (Defined: Situation where the pulmonary artery becomes obstructed and dead-space ventilation results. Sometimes called deadspace disease.) - CORRECT ANSWER Level I : History of recent major surgery or trauma (amputations, clotted massive bleeding sites) Complaint of chest pain and dyspnea Level II : Elevated vitals including pulse, respirations, and blood pressure, Breath sounds - wheezing and medium rales PECO2 (Capnography) decreasing PECO2 during normal PaCO2 Level III : ABGs—persistent hypoxemia in spite of increasing FIO2 Level IV: V/Q scan will show ventilation without adequate perfusion Decision Making - Pulmonary Emboli (Defined: Situation where the pulmonary artery becomes obstructed and dead-space ventilation results. Sometimes called deadspace disease.) **This case primarily involves recognizing the pulmonary emboli and treating it with anticoagulation medications. You will likely have to monitor clotting times, PTT or PT.Otherwise, involves general respiratory therapy. - CORRECT ANSWER Anticoagulation therapy with Heparin or Coumadin Note: must monitor clotting tests PTT for Heparin PT for Coumadin Clot-busting medication such as steptokinase. May also use a bolus of heparin Mechanical ventilation as needed. Emergency level oxygen—100% Information Gathering - SIDS (Defined: Condition in infants where alveolus maturity is below normal.) - CORRECT ANSWER Level I : History may show pre-term infant Onset can be immediately after birth or within a few hours General respiratory distress, ie grunting, nasal flaring, retractions, Cyanosis Level II : APGAR score between 0 and 6 Level III : Chest-Xray—radiological description such as ground glass, honeycomb, reticulogranular ABGs—persistent hypoxemia in spite of elevated FIO2 Level IV : L/S ratio—2:1 or higher is normal. Less than that shows lung immaturity Decision Making - SIDS (Defined: Condition in infants where alveolus maturity is below normal.) **This is a common case on the test. Key is remembering to address lung maturity. Also, if prolonged ventilation is required, Bronchopulmonary Dysplasia may develop. Be patient and treat moment to moment. - CORRECT ANSWER Help lung maturity through surfactant therapy with agents like Exosurf or Survanta 2 to 5 ml/kg split among 2 to 4 doses Administer directly down the airway, Change infant's position after every dose for 30 seconds to distribute the agent Provide oxygen via a hood. May use CPAP to oxygenate Mechanically ventilate with ventilatory failure, use SIMV mode on all infants. May consider reverse I:E ratio Note: If X-ray changes from signs of IRDS to hyperinflation and fibrosis, then the problem may have developed into Bronchopulmonary Dysplasia. Treat as prolonged IRDS by: maintaining pH of 7.25 to 7.40, PaCO2 45 to 60 torr, PaO2 55 to 70 torr. Use low FIO2 Keep mean airway pressure at a minimum Wean only gradually and as tolerated, often fails initial attempts Extubate if respiratory rates are between 5 and 15 breaths Information Gathering : Congenital Heart Defects (Defined: Infant is born with an anatomical malady of the heart or the vessels that emanate from the heart.) - CORRECT ANSWER Level I : History of pre-term birth, General signs of respiratory distress (grunting, nasal flaring, retractions), Cyanosis that persists in spite of high FIO2 Level II : Heart sounds are abnormal upon auscultation (murmur present) Level IV : Echocardiogram is the best diagnostic test for all cardiac defects Decision Making : Congenital Heart Defects (Defined: Infant is born with an anatomical malady of the heart or the vessels that emanate from the heart.) **Your skills in recognizing common, congenital heart problems will be tested. Otherwise, you will be simply providing supportive care until surgery. - CORRECT ANSWER Specific Defect Attributes, Coarctation of the Aorta (narrowing of aorta) Hypertension in the upper extremities, hypotension in lower extremities, Transposition of the Great Vessels, Aorta and pulmonary artery are switched. "Aorta rising from the right heart, pulmonary artery rising from the left heart" "Egg-shaped heart" on x-ray. Patent Ductus Arteriosis (ductus arteriosis never closes) Diagnosed by comparing blood gases from the radial or brachial artery and the umbilical artery. Positive 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 (ASD), Ventricular septal defect (VSD), Truncus arteriosis (pulmonary artery same as aorta—combined vessel) ALL CONGENITAL DEFECTS ARE TREATED WITH SURGERY !! Prior to surgery simply provide supportive care such as: oxygen to keep PaO2 between 60 -80 mmHg. mechanical ventilation when ventilatory failure is shown by ABGs Information Gathering : Neonatal Diaphragmatic Hernia (Defined: Condition where the diaphragm never grows closed. Usually occurs on the left side.) - CORRECT ANSWER Level I : General respiratory distress, ie grunting, nasal flaring, retractions, Cyanosis, Barrel chest and scaphoid abdomen Mediastinal shift Level II : Breath sounds absent (usually on left), increased on the right Level III : Chest-Xray—show intestinal parts in the chest area. Also may see a mediastinal shift away from the affected side. ABGs—Poor Decision Making : Neonatal Diaphragmatic Hernia (Defined: Condition where the diaphragm never grows closed. Usually occurs on the left side.) ** This case is more about what you should not do. Otherwise use general supportive care. - CORRECT ANSWER TREATMENT IS SURGERY Use low ventilatory pressures Do not use manual bag and resuscitation if possible May use gastric tube to decompress stomach and intestines. All other care is supportive Information Gathering : Choanale Atresia (Defined: Infant is born with an anatomical closure of the nasal passages. - CORRECT ANSWER Level I : Normal appearing, normal color, cyanosis during feeding Level II : During breast or bottle feeding, baby becomes apneic and cyanotic, Slight inspiratory stridor Level IV : Neck and chest x-rays rule out airway inflammation Diagnosis by attempting to pass a suction catheter through the nares. If unable to pass, then positive Decision Making : Choanale Atresia (Defined: Infant is born with an anatomical closure of the nasal passages. - CORRECT ANSWER Care in feeding Correct with surgery Keep ventilatory pressure low Information Gathering : Laryngotracheobronchitis (Defined: Otherwise known as Croup. Results from a viral infection that illicits inflammation in the upper airway.) - CORRECT ANSWER Level I : History of cold in the past few days, Barking cough, Age is 5 months to 3 years, Stridor at rest, Tachypnea Level IV : Lateral Neck X-ray—swelling below the glottis (subglottic swelling) sometimes described as steeple-sign, pencil point, or haziness below the glottis. Decision Making : Laryngotracheobronchitis (Defined: Otherwise known as Croup. Results from a viral infection that illicits inflammation in the upper airway.) **You will likely be tempted to treat this like Acute Epiglottitis in an emergency fashion. Repeated racemic epinephrine treatments may make you feel uncomfortable - CORRECT ANSWER Priority—placement in an oxygen tent with 30 to 40% Aerosolized Racemic Epinephrine Intubation if patient is described as lethargic, markedly diminished breath sounds, severe or marked stridor, extreme accessory muscle use Extubation should be done when swelling has ceased. Information Gathering : Acute Epiglottitis (Defined: Condition where the epiglottis and adjacent upper airway tissues are infected with a bacteria causing inflammation and commonly threatening airway patency.) - CORRECT ANSWER Level I Sudden onset of sickness, within 12 hours, often occurs in the evening Age 3 to 10 years General appearance may show drooling, hoarseness, quiet cough May hear a softened inspiratory stridor Tachypnea and tachycardia Level II Patient unable to swallow, will usually not be crying, eyes are big Significantly elevated body temperature, taken axillary, or tympanically Level IV Lateral neck x-ray will show supraglottic inflammation Decision Making : Acute Epiglottitis (Defined: Condition where the epiglottis and adjacent upper airway tissues are infected with a bacteria causing inflammation and commonly threatening airway patency.) **This case will test your immediately ability to realize that it is an emergency. Stridor may tempt you to treat it more casually like croup. There is a good chance you will see Epiglottitis or Croup on the test. - CORRECT ANSWER Primary and immediate concern is establishing an airway as complete closure from inflammation is possible. 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. May need to immediately get an airway. Should intubate with a bronchoscope or send to surgery for a tracheostomy. Antibiotic therapy to correct bacterial infection Oxygen therapy at 30 to 50% Extubate only when inflammation is gone Information Gathering : Bronchiolitis /RSV Defined: Acute vital infection of lower respiratory tract usually occurring in infants less than 18 months old. Commonly caused by the respiratory syncytial virus. - CORRECT ANSWER Level I General signs of respiratory distress including retractions and accessory muscle use. Tachypnea and tachycardia History of recent sickness from ages 2 months to 3 years old Level II Low grade fever Wheezing, rales, and rhonchi Level III Chest X-ray show scattered infiltrates and hyperlucency Decision Making : Bronchiolitis /RSV Defined: Acute vital infection of lower respiratory tract usually occurring in infants less than 18 months old. Commonly caused by the respiratory syncytial virus. **There is nothing particularly difficult about this case. You must be prepared to recommend the use of a SPAG unit. Not commonly seen on the exam. - CORRECT ANSWER Primary treatment is delivery of the drug Ribavirin which must be administered via a SPAG unit (small volume particle aerosol). Utilize a scavenger system, filters, and masks. Information Gathering : Cystic Fibrosis Defined: An inherited disorder resulting in the mass production of thick mucus in the lungs. - CORRECT ANSWER Level I Family history of disease, siblings may have it. Emaciated in appearance and body frame may be small for age Sputum production of thick voluminous purulent secretions Can look like a young COPD patient, barrel-chested Level II Decreased flow rates such as FEV1 Level III Chest X-ray—looks like COPD, hyperinflation, increased A-P diameter, diaphragm flattening Level IV Sweat Chloride Test—show sweat chloride > 60 mEq/L Decision Making : Cystic Fibrosis Defined: An inherited disorder resulting in the mass production of thick mucus in the lungs. **Not commonly seen on the exam.Tests your ability to recognize secretion removal therapies and may check your understanding of when and how to modify therapy. Ex, when CPT doesn't work, use PEP therapy or ultrasonic nebulization. - CORRECT ANSWER Primary treatment relates to the need to mobilize and remove secretions. Secretion removal promotion therapies: PEP therapy devices Chest physiotherapy with postural drainage Hydration devices such as heated aerosol or ultrasonic nebulization Vibration therapy Oxygen as needed Antibiotic therapy when infection is present—often is Medications used commonly include Tobramycin and Pulmozyme (Dornase alpha) Information Gathering : Hypothermia Defined: Exposure to cold such that body temperature falls significantly. - CORRECT ANSWER Level I History of exposure to cold. May be seen in homeless persons. Lethargy and unconsciousness Bradycardia, bradypnea Level II Body temperature less than 36 deg C Level IV Lateral neck x-ray—Thumb sign or pencil point. Decision Making : Hypothermia Defined: Exposure to cold such that body temperature falls significantly. *Not very common. However when seen, may be seen in conjunction with other problems such as AIDS, or tuberculosis. - CORRECT ANSWER Oxygen via a heated aerosol at 40 to 100% Keep resuscitation efforts going until body temperature is normal. Mechanically ventilate as needed. Keep in mind that blood gas values may be altered because of the difference in blood temperature and analyzed temperature. Watch out for oxygen (PaO2). In cold, uncorrected blood, PaO2 may appear higher than it actually is. Information gathering : Burn Trauma/CO Poisoning Defined: Results from direct exposure to fire and or smoke. Directly threatens airway and oxygen carrying capacity of the blood. - CORRECT ANSWER Level I Diagnosis is based largely on history—exposure to fire or 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 face with CO poisoning Patient is often confused or unresponsive Stridor, hoarseness Level II Breath sounds—wheezing, rhonchi, rales Level III ABGs—initially decreased PaCO2, normal PaO2, decreased saturation. Latter may develop into respiratory acidosis Chest X-ray—may be clear at first, but later may show pulmonary edema and markedly decreased lung compliance Level IV COHb- 20% or more Decision Making : Burn Trauma/CO Poisoning Defined: Results from direct exposure to fire and or smoke. Directly threatens airway and oxygen carrying capacity of the blood. **Fairly common case on the test. Remember to focus on the airway and on oxygen carrying capacity of the blood. Remember to employ isolation techniques. Otherwise, provide general respiratory therapy. - CORRECT ANSWER Protect airway by establishing an artificial airway immediately. Particularly if there is respiratory distress and there are burns about the face. For CO poisoning—start 100% oxygen immediately— even if only suspect it—do not wait for COHb results Continue oxygen therapy until COHb level is below 10%.—may use hyperbaric medicine if offered—often will not be offered. Practice reverse isolation (protect the patient from staff) Mechanically ventilate as needed. Information Gathering : Diabetes Defined: Condition related to failure of the renal system resulting in the inability to dispose of CO2. Respiratory result is often respiratory ketoacidosis. - CORRECT ANSWER Level I History of diabetes Lethargy, confusion, unresponsiveness Respiratory rate and pattern—significant in depth and rate with an irregular rhythm (Kussmaul's) Level II Pedal Edema Level III ABGs—Profound metabolic acidosis Urine output is markedly decreased (less than 20 ml per hour) Level IV Blood glucose - > 160 mg (Normal 80-120 mg) Decision Making : Diabetes Defined: Condition related to failure of the renal system resulting in the inability to dispose of CO2. Respiratory result is often respiratory ketoacidosis. **May be tempted by profoundly acidodic pH. Only determine respiratory failure through the CO2, or a sudden decrease in ventilatory volumes and breathing rate. - CORRECT ANSWER Must watch for ventilatory failure from prolonged ventilatory effort and fatigue. Administer electrolytes (K+, Na+, HCO3-, Cl-) as needed. Provide fluid as needed. Correct ketoacidosis. Information Gathering : AIDS Defined: Disease of the immune system commonly resulting in pneumocystis carinii, a type of pneumonia. - CORRECT ANSWER Level I Previous history of HIV positive test results Emaciation, unexplained weight-loss, diarrhea, low-grade fevers, night sweats, Commonly homosexual activity or drug usage is admitted Special Assessments Positive HTLV III ELISA test— positive for HIV Bronchoscopy—from lung washings or biopsy may show pneumocystis carinii Decision Making : AIDS Defined: Disease of the immune system commonly resulting in pneumocystis carinii, a type of pneumonia. **Increasing in frequency on the exam. Sometimes is combined with tuberculosis, hypothermia, and others. Suspect them all. - CORRECT ANSWER Exercise Universal Precautions Aerosolized Pentamadine—usually done monthly Administer in semi-fowler's position When administering Pentamadine, use one-way valves and filters Staff and visitors should use masks May administer mint after the treatment. Information Gathering : Foreign Body Aspiration Defined: The accidental aspiration of a foreign body, including food or an object, in to the lungs. - CORRECT ANSWER Level I Softened cough or voice if partial obstruction Quiet (no sounds if complete obstruction) Recent history of eating for adult May be child playing with toys Onset is sudden Cough is non-productive Level III Bronchoscopy—visualize the foreign body (may also remove at that time) Chest x-ray—may be clear because food and other objects are likely radiolucent. Decision Making : Foreign Body Aspiration Defined: The accidental aspiration of a foreign body, including food or an object, in to the lungs. **Must differentiate between foreign body aspiration and pulmonary carcinoma. Foreign body aspiration is characterized by a recent, acute development of cough. A cancerous mass in the bronchials results in non-productive cough over weeks or months. - CORRECT ANSWER PRIMARY TREATMENT—Bronchoscopy Supportive therapy as needed—bronchodilator therapy, etc Information Gathering : Bronchopulmonary Dysplasia Defined: Lung disease related to prolonged mechanical ventilation of the newborn. Exact etiology is unknown but is usually associated with previous treatment of IRDS and fetal lung immaturity. - CORRECT ANSWER Level I Recent history and treatment of IRDS or fetal lung immaturity. History of prolonged or significant use of mechanical ventilation since birth. History of elevated FIO2. Level II Wheezing Level III Chest x-ray - like IRDS but then appears like chronic air-trapping with hyperinfla tion and fibrotic changes. Level IV Echocardiogram- may reveal right or left heart failure Decision Making : Bronchopulmonary Dysplasia Defined: Lung disease related to prolonged mechanical ventilation of the newborn. Exact etiology is unknown but is usually associated with previous treatment of IRDS and fetal lung immaturity. **This simulation usually involves making a care plan that covers all the symptoms, including bronchoconstriction, inflammation, under-development of lung tissue, etc. - CORRECT ANSWER Bronchodilator therapy for wheezing Keep FIO2 as low as possible Accept PaO2 of 55 to 65 mmHg. Keep CO2 below 60 mmHg. Corticosteriods to reduce inflammation. Info. Gathering : Transient Tachypnea -Type II RDS Defined: Condition related respiratory distress within 24-48 hours after birth. May be related to C-section delivery. - CORRECT ANSWER Level I Cyanosis, retractions, grunting. Often normal gestational age (38-40 weeks) Initially appears OK, but deteriorates after a day or two Level II Rhonchi from secretions Level III Chest x-ray—starts out normal but deteriorates to show increased pulmonary congestion within a day or two. Level IV Blood glucose - > 160 mg (Normal 80-120 mg) Decision Making : Transient Tachypnea -Type II RDS Defined: Condition related respiratory distress within 24-48 hours after birth. May be related to C-section delivery. **This is increasingly rare on the exam, but really has no real complexity. The exam will try to tempt you to make drastic reactions when the real therapy is to simply be supportive of symptoms. - CORRECT ANSWER Manage symptoms of respiratory distress Support ventilation if needed. Oxygen therapy by oxyhood Treat with shunt therapy (CPAP) if hypoxemia is significant on increased FIO2. Information Gathering : Infectious Pneumonia Defined: Pneumonia that is caused by bacterial or viral infection. - CORRECT ANSWER Level I Increased pulse rate Level II High temperature—bacterial pneumonia low-grade temperature—viral pneumonia Level III Chest x-ray—consolidation in the lung fields Increased WBC—bacterial pneumonia Decreased WBC—viral pneumonia Level IV ELISA test— positive for HIV Acid-fast sputum culture to check for tuberculosis Decision Making : Infectious Pneumonia Defined: Pneumonia that is caused by bacterial or viral infection. **Treated like pneumonia, regardless of source (bacterial vs viral). - CORRECT ANSWER Sputum culture and sensitivity to identify bacterial and the appropriate antibiotic. Mechanical ventilation as needed. Information Gathering : Pickwikian Syndrome Defined: Obstructive sleep apnea due to obesity. - CORRECT ANSWER Level I Obesity, especially large neck size History of sleep apnea Level IV Polysomnogram (sleep study) usually reveals obstructive sleep apnea. Decision Making : Pickwikian Syndrome Defined: Obstructive sleep apnea due to obesity. **This simulation is treated liken most obstructive sleep apnea cases. - CORRECT ANSWER Treat sleep apnea with nasal nocturnal CPAP If mechanical ventilation is required, utilize ideal body weight to calculate appropriate tidal volumes. Weight loss support (classes, medication, etc) Information Gathering : Poison Inhalation/Ingestion Defined: Condition whereby poison is inhaled or ingested. Treatment depends on the poison involved. - CORRECT ANSWER Petroleum Distillate Poisoning (petroleum based oil, glue and other solvents) Kerosene Poisoning Level I Drowsiness Dizziness, nausea, gastric expectoration (vomiting) Decreased respiratory rate and depth (caused from CNS depression) Lethargy, convulsions or coma may develop Level II Chest pain Fever Level III Chest x-ray may show pneumonitis if inhaled. Later signs of ARDS may develop Decision Making : Poison Inhalation/Ingestion Defined: Condition whereby poison is inhaled or ingested. Treatment depends on the poison involved. **Varying frequency on the exam. Important part is to know when to induce vomiting and when not to. - CORRECT ANSWER ~Kerosene Ingestion Vegetable oil Gastric lavage with 3% NaHCO3- DO NOT INDUCE VOMITING ~Kerosene Inhalation Oxygen therapy Ventilatory assistance as needed ~Petroleum Distillate Ingestion and corrosive material (strong battery acid or soapy alkali) DO NOT INDUCE VOMITING Gastric Lavage ~Otherwise MAY INDUCE vomiting with syrup of Ipecac or use activated charcoal. Activated charcoal ~Given at 10 x the suspected amount of the poison ingestion Mixed with water—given orally Liquid o2 spill on a open surface - CORRECT ANSWER NO clean up needed Oxygen bleed-in device - CORRECT ANSWER molecular sieve device good for home use Tachycardia - CORRECT ANSWER Associated With Hypoxemia Give oxygen Cold, clammy skin - CORRECT ANSWER Associated With Myocardial infarction Give oxygen, do ECG "Suddenly short of breath" - CORRECT ANSWER Associated With Pulmonary embolism 100% oxygen, V/Q scan, anticoagulants "Sudden onset of tachypnea" - CORRECT ANSWER Associated With Pneumothorax 100% oxygen, chest x-ray, chest tubes if positive Butterfly pattern on X-ray - CORRECT ANSWER Associated With Resp Distress Syndrome (ARDS) or (IRDS) Keep FIO2 low as possible, keep ventilatory pressures down Reticulogranular pattern on X-ray - CORRECT ANSWER Associated with Resp Distress Syndrome (ARDS) or (IRDS) Keep FIO2 low as possible, keep ventilatory pressures down Pitting edema - CORRECT ANSWER Associated With CHF Cardiac drugs, digitalis, digoxin Maintain good fluid balance (often diurese patient) Cyanosis - CORRECT ANSWER Associated With Hypoxemia Give oxygen Patient confused, anxious - CORRECT ANSWER Associated With Hypoxemia Give oxygen "Marked" anything - CORRECT ANSWER Address it quickly "Severe" anything - CORRECT ANSWER Address it quickly Lethargic, sleepy, somnolent - CORRECT ANSWER Associated with COPD O2 overdose Lower the oxygen Stuporous, confused, inappropriate responses - CORRECT ANSWER Associated With Drug Overdose Protect airway (may intubate) Deliver Narcan if narcotic overdose) Ventilation is at risk (unpredictable CNS depression) Anxiety, nervous - CORRECT ANSWER Associated With Hypoxemia Address the underlying problem, resolve the hypoxemia Angry, irritable, or combative - CORRECT ANSWER Associated With Electrolyte Imbalance Fix it (delivery fluids, administer specific electrolytes) Panic - CORRECT ANSWER Associated With Severe Asthma Attack Give oxygen, bronchodilators Orthopnea - CORRECT ANSWER Associated With CHF Cardiac drugs, proper fluid maintenance (often diuretics) General malaise - CORRECT ANSWER Associated With Electrolyte Imbalance Fix it Digital Clubbing - CORRECT ANSWER Associated With COPD Low oxygen delviery Diaphoresis - CORRECT ANSWER Associated With Heart failure, fever, tuberculosis if night time Address underlying problem Night sweats - CORRECT ANSWER Associated With Tuberculosis Treat the disease generally Ashen or pallor color - CORRECT ANSWER Associated With Anemia, acute blood loss Stop bleeding, give blood Increased A-P diameter - CORRECT ANSWER Associated With COPD Treat disease generally Kussmaul's breathing - CORRECT ANSWER Associated With Metabolic acidosis, diabetic, renal failure Treat underlying problem Apneustic breathing - CORRECT ANSWER Associated With Brain trauma or tumor Treat the problem Muscular hypertrophy - CORRECT ANSWER Associated With COPD treat the disease Retractions - CORRECT ANSWER Associated With Significant resp distress in infants Support ventilation, administer oxygen Paradoxical chest movement - CORRECT ANSWER Associated With Flail Chest Ensure ventilation, watch for pneumothorax Pulses paradoxus - CORRECT ANSWER Associated With Status asthmaticus, severe air-trapping Address the underlying problem Flat to percussion - CORRECT ANSWER Associated With Atelectasis Hyperinflation Therapy Dull to Percussion - CORRECT ANSWER Associated With Fluid-filled, pneumonia, pleural effusion Address the underlying problem Hyperresonant to percussion - CORRECT ANSWER Associated With Pneumothorax Chest tubes, chest X-ray Course Rales - CORRECT ANSWER Associated With Rhonci Suction patient if cannot cough, otherwise anything to mobilize secretions (CPT, IPPB, PEP therapy, etc) Medium rales - CORRECT ANSWER Needs anything to mobilize secretions, CPT, IPPB, PEP therapy, etc Fine rales - CORRECT ANSWER Associated With CHF, Pulmonary Edema Diurese the patient, provide positive pressure ventilation, IPPB, cardiac drugs such as digitalis Wheezing - CORRECT ANSWER Associated with Wheezing Administer Bronchodilator Stridor - CORRECT ANSWER Give racemic epinephrine, intubate if marked or severe Pleural friction rub - CORRECT ANSWER Assocaited With Pulmonary infarction, TB, Lung CA Treat underlying disease Steeple sign (Lat neck X-ray - CORRECT ANSWER Associated With Croup Treat the underlying disease Thumb sign (Lat Neck X-ray) - CORRECT ANSWER Associated With Acute Epiglottitis Treat the underlying disease Butterfly or Batwing (x-ray) - CORRECT ANSWER Associated With PUlmonary Edema Treat the underlying disease Fluffy infiltrates - CORRECT ANSWER Associated With Pulmonary edema Treat the underlying disease Honeycomb pattern (X-ray) - CORRECT ANSWER Associated With ARDS Treat the underlying disease Wedge-shape infiltrates (X-ray) - CORRECT ANSWER Associated With Pulmonary embolus Treat the underlying disease Concave superior interface border - CORRECT ANSWER Associated With Pleural effusion Treat the underlying disease Basilar infiltrates with meniscus - CORRECT ANSWER Associated With Pleural effusion Treat the underlying disease Flattened T waves - CORRECT ANSWER Associated With Hypokalemia Spiked T waves - CORRECT ANSWER Associated With Hyperkalemia Pink frothy sputum - CORRECT ANSWER Associated With Pulmonary Edema Treat the underlying disease Purulent sputum - CORRECT ANSWER Associated With Chronic bronchitis Treat the underlying disease 3-layer sputum - CORRECT ANSWER Associated With Bronchiectasis Treat the underlying disease "Tree in Winter pattern" - CORRECT ANSWER Associated With Bronchiectasis Treat the underlying disease Weakness in legs (lower extremities) - CORRECT ANSWER Associated With Guillain-Barre Treat the underlying disease Drooping eyelids (Ptosis), double vision (Diplopia), dysphagia - CORRECT ANSWER Associated With Myasthenia Gravis Treat the underlying disease 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 - CORRECT ANSWER 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. - CORRECT ANSWER 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 - CORRECT ANSWER 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. - CORRECT ANSWER 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 - CORRECT ANSWER 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. - CORRECT ANSWER 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. - CORRECT ANSWER 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. - CORRECT ANSWER 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. - CORRECT ANSWER 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. - CORRECT ANSWER 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 - CORRECT ANSWER 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. - CORRECT ANSWER 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. - CORRECT ANSWER 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. - CORRECT ANSWER 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. - CORRECT ANSWER 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. - CORRECT ANSWER 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 - CORRECT ANSWER 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. - CORRECT ANSWER 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! - CORRECT ANSWER 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. - CORRECT ANSWER 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 - CORRECT ANSWER 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. - CORRECT ANSWER 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 - CORRECT ANSWER 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 - CORRECT ANSWER 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. - CORRECT ANSWER 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. - CORRECT ANSWER 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. - CORRECT ANSWER 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 PaO2>60, MV when Vent failure is present by ABG Neonatal Diaphragmatic Hernia : Definition, Clinical Evidence, Chest xray, ABG & Key interventions - CORRECT ANSWER 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 - CORRECT ANSWER 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 - CORRECT ANSWER 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 - CORRECT ANSWER 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. - CORRECT ANSWER 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 - CORRECT ANSWER 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 - CORRECT ANSWER 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 - CORRECT ANSWER 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 - CORRECT ANSWER 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. - CORRECT ANSWER 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 - CORRECT ANSWER 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 - CORRECT ANSWER 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 - CORRECT ANSWER 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 - CORRECT ANSWER 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 Descriptor : Paradoxical Chest Movement Association & Action? - CORRECT ANSWER Association : Flail Chest Action : Ensure ventilation, Watch for pneumothorax Descriptor : Pulses Paradoxus Association & Action? - CORRECT ANSWER Association : Status asthmaticus, Severe air-trapping Action : Address the underlying problem Descriptor : Flat to Percussion Association & Action? - CORRECT ANSWER Association : Atelectasis Action : Hyperinflation Therapy Descriptor : Dull to Percussion Association & Action? - CORRECT ANSWER Association : Fluid-filled, pneumonia, pleural effusion Action : Address the underlying problem Descriptor : Hyperresonant to Percussion Association & Action? - CORRECT ANSWER Association : Pneumothorax Action : Chest tubes, Chest Xray Descriptor : Course Rales Association & Action? - CORRECT ANSWER Association : Rhonchi Action : Suction patient if cannot cough, otherwise anything to mobilize secretions Descriptor : Medium Rales Association & Action? - CORRECT ANSWER Association : Action : Needs anything to mobilize secretions: CPT, IPPB, PEP Descriptor : Fine Rales Association & Action? - CORRECT ANSWER Association : CHF, Pulmonary edema Action : Diurese the patient, provide positive pressure ventilation IPPB, cardiac drugs such as digitalis Descriptor : Wheezing Association & Action? - CORRECT ANSWER Association : Bronchoconstriction Action : Administer bronchodilators Descriptor : Stridor Association & Action? - CORRECT ANSWER Association : Action : Give Racemic Epinephrine, intubate if marked or severe Descriptor : Pleural Friction Rub Association & Action? - CORRECT ANSWER Association : Pulmonary Infarction, TB, Lung CA Action : Treat Underlying Disease Descriptor : Steeple Sign (Lat. Neck Xray) Association & Action? - CORRECT ANSWER Association : Croup Action : Treat Underlying Disease Descriptor : Thumb Sign (Lat. Neck Xray) Association & Action? - CORRECT ANSWER Association : Acute Epiglottitis Action : Treat Underlying Disease Descriptor : Butterfly or Batwing Pattern (Xray) Association & Action? - CORRECT ANSWER Association : Pulmonary Edema Action : Treat Underlying Disease Descriptor : Fluffy Infiltrates (Xray) Association & Action? - CORRECT ANSWER Association : Pulmonary Edema Action : Treat Underlying Disease Descriptor : Honeycomb Pattern (Xray) Association & Action? - CORRECT ANSWER Association : ARDS Action : Treat Underlying Disease Descriptor : Wedge-shape Infiltrates (Xray) Association & Action? - CORRECT ANSWER Association : Pulmonary Embolus Action : Treat Underlying Disease Descriptor : Concave Superior Interface Border Association & Action? - CORRECT ANSWER Association : Pleural Effusion Action : Treat Underlying Disease Descriptor : Basilar Infiltrates with Meniscus Association & Action? - CORRECT ANSWER Association : Pleural Effusion Action : Treat Underlying Disease Descriptor : Flattened T waves Association & Action? - CORRECT ANSWER Association : Hypokalemia Action : Treat Underlying Disease Descriptor : Spiked T waves Association & Action? - CORRECT ANSWER Association : Hyperkalemia Action : Treat Underlying Disease Descriptor : Pink Frothy Sputum Association & Action? - CORRECT ANSWER Association : Pulmonary Edema Action : Treat Underlying Disease Descriptor : Purulent Sputum Association & Action? - CORRECT ANSWER Association : Chronic Bronchitis Action : Treat Underlying Disease Descriptor : 3-Layer Sputum Association & Action? - CORRECT ANSWER Association : Bronchiectasis Action : Treat Underlying Disease Descriptor : "Tree in Winter Pattern" Association & Action? - CORRECT ANSWER Association : Bronchiectasis Action : Treat Underlying Disease Descriptor : Weakness in legs Association & Action? - CORRECT ANSWER Association : Guillian- Barre Action : Treat Underlying Disease Descriptor : Drooping Eyelids (ptosis), Double Vision (diplopia), Dysphagia Association & Action? - CORRECT ANSWER Association : Myasthenia Gravis Action : Treat Underlying Disease Descriptor : Tachycardia Association & Action? - CORRECT ANSWER Association : Hypoxemia Action : Give oxygen Descriptor : Cold, clammy skin Association & Action? - CORRECT ANSWER Association : Myocardial infarction Action : Give oxygen, do ECG Descriptor : "Suddenly short of breath" Association & Action? - CORRECT ANSWER Association : Pulmonary embolism Action : 100% oxygen, V/Q scan, anticoagulants Descriptor : "Sudden onset of tachypnea" Association & Action? - CORRECT ANSWER Association : Pneumothorax Action : 100% oxygen, chest x-ray, chest tubes if positive Descriptor : Butterfly pattern on X-ray Association & Action? - CORRECT ANSWER Association : Resp Distress Syndrome (ARDS) or (IRDS) Action : Keep FIO2 low as possible, keep ventilatory pressures down Descriptor : Reticulogranular pattern on X-ray Association & Action? - CORRECT ANSWER Association : Resp Distress Syndrome (ARDS) or (IRDS) Action : Keep FIO2 low as possible, keep ventilatory pressures down Descriptor : Pitting edmea Association & Action? - CORRECT ANSWER Association : CHF Action : Cardiac drugs, digitalis, digoxin. Maintain good fluid balance (often diurese patient) Descriptor : Cyanosis Association & Action? - CORRECT ANSWER Association : Hypoxemia Action : Give oxygen Descriptor : Pt confused, anxious Association & Action? - CORRECT ANSWER Association : Hypoxemia Action : Give oxygen Descriptor : "Marked" or "Severe" anything Association & Action? - CORRECT ANSWER Association : Usually an emergency Action : Address it quickly Descriptor : Lethargic, sleepy, somnolent Association & Action? - CORRECT ANSWER Association : COPD O2 overdose Action : Lower the oxygen Descriptor : Stuporous, confused, inappropriate responses Association & Action? - CORRECT ANSWER Association : Drug overdose Action : Protect airway (may intubate) Deliver Narcan if narcotic overdose) Ventilation is at risk (unpredictable CNS depression) Descriptor : Anxiety, nervous Association & Action? - CORRECT ANSWER Association : Hypoxemia Action : Address the underlying problem, resolve the hypoxemia Descriptor : Angry, irritable, or combative Association & Action? - CORRECT ANSWER Association : Electrolyte imbalance Action : Fix it (delivery fluids, administer specific electrolytes) Descriptor : Panic Association & Action? - CORRECT ANSWER Association : Severe asthma attack Action : Give oxygen, bronchodilators Descriptor : Orthopnea Association & Action? - CORRECT ANSWER Association : CHF Action :Cardiac drugs, proper fluid maintenance (often diuretics) Descriptor : General malaise Association & Action? - CORRECT ANSWER Association : Electrolyte imbalance Action : Fix it Descriptor : Digital clubbing Association & Action? - CORRECT ANSWER Association : COPD Action : Low oxygen delivery Descriptor : Diaphoresis Association & Action? - CORRECT ANSWER Association : Heart failure, fever, tuberculosis if night time Action : Address underlying problem Descriptor : Ashen or pallor color Association & Action? - CORRECT ANSWER Association : Anemia, acute blood loss Action : Stop bleeding, give blood Descriptor : Increased A-P diameter Association & Action? - CORRECT ANSWER Association : COPD Action : Treat disease generally Descriptor : Kussmaul's breathing Association & Action? - CORRECT ANSWER Association : Metabolic acidosis, diabetic, renal failure Action : Treat underlying problem Descriptor : Apneustic breathing Association & Action? - CORRECT ANSWER Association : Brain trauma or tumor Action : Treat the problem Descriptor : Muscular hypertrophy Association & Action? - CORRECT ANSWER Association : COPD Action : Treat the disease Descriptor : Retractions Association & Action? - CORRECT ANSWER Association : Significant resp distress in infants Action : Support ventilation, administer oxygen hodgkin's disease - CORRECT ANSWER a lymphoma that attacks people in early life and is treatable with radiation therapy curiferous vegetebles - CORRECT ANSWER vegetables of the cabbage family irradiation - CORRECT ANSWER ionizing radiation applid to food to kill microorganisms genetic engineering - CORRECT ANSWER a science of manipulating the genes of liveing things Among the medical complications and issues that can arise for a patient, problems involving _________ take precedence above all others, - CORRECT ANSWER ventilation True or False Problems with oxygenation are far more common then those concerning ventilation. - CORRECT ANSWER True Nasal cannula - CORRECT ANSWER - delivers between 24-44% -calculate about 3-4% for every liter of oxygen flow (add to 21%) -Max flow= 6 liters- limited by the nasal pharyngeal space (reservoir) -Low flow divice Simple mask - CORRECT ANSWER -delivers between 40-55% -Min flow needed to continually flush out CO2 - 6 lpm -Acceptable flow rate 6-10 lpm -Low flow divice Partial rebreather mask - CORRECT ANSWER -delivers a bout 60-65% -Acceptable flow rate 6-10 lpm - looks like a non-rebreather without any one-way valves -Low flow device -Removal of the one-way valve converts NRB mask into a partial rebreather Air-entrainment mask (Venturi Mask) - CORRECT ANSWER -delivers 24-55% -Works by mixing 100% O2 ( from the wall) and room air -delivers precise FIO2 -High flow device- usually able to meet the patients inspiratory demand -FIO2 increases as the entrainment port size is decreased -Or - FIO2 decreases as internal diameter of gas injector decreases -Bed covers my acidentally occlude the entrainment port and increase FIO2 -Not suitable for eating None-rebreather mask - CORRECT ANSWER -delivers 21-100% -high flow device- if flow rate is high enough (must keep the reservoir bag from collapsing -used in emergencies -one-way valves prevent rebreathing and entrainment of room air -Face seal is important- reservoir should collapse slightly on each inhalation True our False When using a non-rebreather, if the bag does not collapse slightly with each inhalation, the mask should be tightened and a better seal obtained - CORRECT ANSWER True, Or it may be defective , and you should replace the entire mask. If a patient remains hypoxic on 50% or greater by any other oxygen delivery device you should switch them to a _______. - CORRECT ANSWER Non-rebreather mask True or False NRB has a one-way valve to prevent rebreathing of CO2 - CORRECT ANSWER True Types of Aerosol masks - CORRECT ANSWER Trach collar -Aerosol mask Trach callar - CORRECT ANSWER -Fits loosely -easy to tolerate -used when T-piece is inconvenient for patient or comes off due to patient moving Aerosol mask - CORRECT ANSWER -good only for high flow systems -otherwise air entrainment is too great and FIO2 will be reduced significantly. Briggs adapter (T-tube, T-piece) - CORRECT ANSWER -used to deliver aerosol -Requires a high-flow supply or pre-mixed gas -Attaches to the end of an endotracheal tube or trach tube (intubated patient) -Must always see continual aerosol production during both inspiration and expiration. If not, increase flow What devices mix air and oxygen to achieve an exact FIO2? - CORRECT ANSWER -Venturi mask -Large volume nebulizer -some IPPB machines -Some pressure ventilators Complication s of Air entrainment devices - CORRECT ANSWER -Impeded flow or back pressure- causes increased FIO2 -Occluded entrainment port- causes increase in FIO2 What happens to FIO2 in the following circumstances? 1. You notice puffs of aerosol coming from the tubing of a large volume nebulizer set at FIO2 0.28. 2. The very last part of the delivered breath from a Bird IPPB machine, 3. A kink in the aerosol tubing coming from a large volume nebulizer - CORRECT ANSWER In all cases FIO2 increases If the patients inspiratory demand exceeds the total gas output of the device... - CORRECT ANSWER -the FIO2 will be decreased as the patient will entrain air on each breath -Solution- if a large volume nebulizer is used, add a second device in tandem ( Feed both nebulizers into a T configuration before delivering to the patient) Air/Oxygen mixture Ratios - CORRECT ANSWER - 24% - 25:1 - 28% - 10:1 - 30% - 8:1 - 35% - 5:1 - 40% - 3:1 -60% - 1:1 Total Flow Calculation - CORRECT ANSWER -100 - O2 %/O2%-20 = ratio -Add the ratio parts -Multiply by the flow True or False Pediatric patients may use all the adult oxygen therapy devices but in a miniaturized form - CORRECT ANSWER true Oxygen Tent - CORRECT ANSWER - for infants and small pediatric patients -useful when humidity/aerosol environment is desired -Max FIO2 40-50% -FIO2 may exist as a gradient with higher FIO2 at the bottom- because 100% O2 is heavier than other constituent gases (N2, etc) - Must use flow rates in excess of 12 lpm to continually flush out CO2 When using an oxygen Tent, if the FIO2 ( near the patients face) is difficult to keep consistent you may need to ... - CORRECT ANSWER make sure the plastic walls are tucked into the bed well. True or False When a patient is using an oxygen tent you should monitor input/output and/or weight frequently. - CORRECT ANSWER True. because a high fluid environment can lead to fluid retention If an infant or child destroys an oxygen tent due to anxiety what should you do? - CORRECT ANSWER Switch to a face mask Neonatal Oxygen therapy Devices - CORRECT ANSWER - Oxygen Tent -Oxygen Hood (Oxyhood) -Incubator -Radiant Warmer Oxygen Hood (Oxyhood) - CORRECT ANSWER - Loosely enclosed environment placed over infants head -High Flow (usually venturi) device to ensure CO2 flushing -Min Flow 7 lpm - higher is recommended to prevent build up of arterial CO2. -delivers up to 100% O2, especially with an oxygen blender -monitor FIO2 by placing O2 analyzer probe near patients mouth -Usually has a temp. probe- must monitor temp to prevent excess cooling from aerosol. 1. Too hot- infant becomes apneic 2. Too cool- could cause increase in oxygen consumpton True or False And oxygen hood could cause hearing damage and restlessness - CORRECT ANSWER True -You can reduce the risk of hearing damage by using a blender rather than an large volume nebulizer (very noisy on low FIO2 settings when a lot of air is entrainded) -Any other closed environment, such as and isolette, may also affect hearing. When analyzing the O2 in and oxygen hood, fluctuating or varying oxygen is and indication of what? - CORRECT ANSWER -Not enough Flow -you should increase the flow When using an oxygen hood, where should you analyze the FIO2 ? - CORRECT ANSWER Near the mouth of the infant Incubator - CORRECT ANSWER -Good for neonates only - Small, whole-body environment - Precise control over environment including FIO2, humidity, temp, etc -Red flag warning sign - FIO2 is 1.0 Incubator Hazards - CORRECT ANSWER -Skin burns -Hearing damage- very loud inside -Electrical shock Radiant Warmer - CORRECT ANSWER -Totally open to room air- not a good environment or O2 delivery -must be combined with Oxygen hood or other O2 delivery device (i.e nasal cannula, mask, etc.) -Allows RT to have access to the infant to provide intensive monitoring or care- good for emergency cases -useful in controlling temp. -helps decrease insensible water loss as it provides a neutral thermal environment. Oxygen Conservation Devices - CORRECT ANSWER -Reservoir Cannula -Transtracheal Oxygen catheter (TTO2) -Pulse-Dose Oxygen delivery Reservoir Cannula - CORRECT ANSWER - Like a regular cannula except with a small reservoir either directly under the nasal prongs, or as a medallion reservoir, inline, chest-level - allows for oxygen to be set at a lower flowrate Transtracheal oxygen catheter (TTO2) - CORRECT ANSWER -surgically implanted thin catheter, inserted through the tracheal wall (between the 2nd and 3rd tracheal rings) -Tracheal acts as a reservoir. Therefore flow may be reduced by as mush as 1/2 Hazards of Transctacheal oxygen catheter - CORRECT ANSWER -Bronchospasms -Trauma to the trachea, including bleeding -Risk of infection -Pneumothorax and subcutaneous emphysema upon erroneous insertion -Poor cleaning technique (must clean routinely) or higher chance of infection -may become obstructed - needs to be flushed with saline When a patients with a TTO is in distress what should you do? - CORRECT ANSWER -First provide oxygen by nasal cannula -The troubleshoot and find a remedy Pulse-Dose oxygen delivery - CORRECT ANSWER -combined with specialized nasal cannula -System senses inhalation, delivers a pulse of oxygen - Requires a 50 PSI gas source (tank or wall --nor concentrator) -humidification not usually required -has capability to switch to continuous flow- use when any problem is suspected with delivery -often used in home care settings - saves money and allows greater portability ( small tank) Cylinders Trouble shooting: Hissing leak sound - CORRECT ANSWER a. Tighten all connections b. Remove regulator c. check or replace plastic washer Cylinder Trouble shooting: No apparent flow - CORRECT ANSWER a. check adequate gas source pressure/function b. If home car patient, instruct to place cannula in glass of water and ensure bubbling occurs c. Use calibrated flow sensing device --check flow Tank Factors - CORRECT ANSWER a. E- 0.28 (0.3) b. G - 2.41 c. H - 3.14 (3.0) Tank Time equation - CORRECT ANSWER Tank pressure X Tank Factor / Liter flow Ex: 1500 PSI X 0.28 / 3lpm =140 minutes ______ _____ are good for home care patients needing mobility and as a back-up supply in case of concentrator failure. - CORRECT ANSWER Small tanks True or False You should not store oxygen tanks in hot places like the trunk of you care. - CORRECT ANSWER True Bulk oxygen systems - CORRECT ANSWER -Cylinder manifolds -Bulk liquid oxygen Cylinder manifolds - CORRECT ANSWER -several H tanks mounted to a single manifold a. usually requires two separate banks of tanks (primary and reserve) Bulk liquid oxygen - CORRECT ANSWER a. Requires a conversion unit b. Able to store mass quantity in much smaller space compared to tanks c. requires a back up system-- usually a manifold bank of H tanks d. Some are small enough that they can be carried by patients -Last longer -Easier to carry than E tanks True or False If liquid oxygen spills, no clean-up procedure is necessary since liquid oxygen immediately evaporates and forms breathable oxygen, - CORRECT ANSWER True Oxygen Concentrator (molecular sieve device) - CORRECT ANSWER -Most commonly used device for home care - Requires electricity only (must use three prong plug) - Circuit breaker is safer then a fuse in electrical panal - produces up to 6 lpm -Extracts oxygen from room air -change filter and check flow reg. (calibrated by RT) -Appropriate lode capacity ( ensure the home can handle the extra electricity) -Tank or other back up O2 source is recommended -not able to deliver 100% O2 -do not use with high flow devices (not capable of high flow) Oxygen concentrator : Patient -driven troubleshooting - CORRECT ANSWER a. check circuit breaker b. check or change the filter c. ensure the machine in plugged in d. The patient should be instructed to switch to an E cylinder FIRST before troubleshooting the device Oxygen concentrator : Therapist Troubleshooting - CORRECT ANSWER a.check the flow with a flow calibration device b. Never ask a patient to dismantle the concentrator or check the flow. This should only be done by a respiratory therapist. Oxygen blender devices - CORRECT ANSWER - Can accurately blend air and oxygen to exact percentages -will mix and deliver gas at 50 psi -When using a blender and an air-entrainment device (Large volume nebulizer) you must set the nebulizer at 100% Air compressors - CORRECT ANSWER -capable of producing at least 50 psi -used when compressed air from a wall source us not available -They are often installed in ventilators -They turn on if the ventilator is turned on without connection to a 50 psi air source. -they usually turn on automatically When a __________ activates, it can be loud and disturbing. It produces a loud trumpeting sound inside the ventilator and is often mistaken for an __________ _______. - CORRECT ANSWER compressor, internal malfunction if a ventilator is quipped with an air compressor what will occur if the air source line becomes disconnected ? - CORRECT ANSWER The air compressor will automatically compensate True or False An air compressor can be used to proveide air to and air/oxygen blender to properly misx the set FIO2 - CORRECT ANSWER True Nitric Oxide (NO) Delivery system: - CORRECT ANSWER -iNOVent is a popular version of NO delivery equipment -mixes and manages three gasses a. NO (Nitric oxide) b. NO2 (nitrogen) c. O2 (Oxygen) NO and NO2 sensor must be calibrated with _______ gases designed just for calibration . O2 sensor is calibrated using a _____ oxygen source - CORRECT ANSWER specialty, 100% Nitric oxide Delivery system: Calibration - CORRECT ANSWER -must be calibrated with the ventilator and the environment it will be used. -it cannot be calibrated in the dept. and then moved to the ICU. -vent settings must be kept consistent during calibration -Low range calibration is done on all three sensors at the same time , O2 is done using room air. - When should you replace and NO Cylinder? - CORRECT ANSWER When a pressure of 200 PSI is reached How do you perform a leak test and purge on an NO cylinder prior to use? - CORRECT ANSWER The valves is covered with soapy water while turned completely off. Foaming indicated a leak Nitric oxide Delivery system: Alarms - CORRECT ANSWER a. Low NO - cylinder may be running low or supply line may be leaking or disconnected b. High NO - sensor requires calibration- new sensor will read high until fully conditioned and calibrated c. High NO2 - sample or filter lines may be occluded or the min. ventilation is changed on the ventilator. d. injector module failure - replace Nittic oxide Delivery system: Transferring to OR - CORRECT ANSWER a. Patient should be transferred using same ventilator they use in the ICU Other NO delivery problems include: - CORRECT ANSWER a. Measured NO < set NO - do a low range calibration b. Measured No > set NO - do high range calibration c. Nitric oxide flow alarm - can be caused by changing vent flow rate d. NO sensor reads > 25 ppm - NO supply line may be leaking e. No sensor reads >5 ppm - No supply line may be leaking - do a leak test. Oxygen flow meters - CORRECT ANSWER a. Pressure type (Bourdon gauge) b. Flow type (Thorpe tube) only reads accurately when 100% is used c. helium oxygen mixtures may run through it bu t reading is less then actual gas flow. Humidity - CORRECT ANSWER water evenly dispersed in an environment Aerosol - CORRECT ANSWER consists of any larger particles ( liquid or dry) that can be inhaled _________ and large volumes of ______ are delivered by means of aerosol and humidity. - CORRECT ANSWER Medications, liqiuid True or False The human body requires 34 mg of water in every liter of inspired gas. - CORRECT ANSWER False 44 mg of water , otherwise there is a humidity deficit Passover humidifiers - CORRECT ANSWER - Gains humidity from a body of water through evaporation as gas passes over its surface -not very effective, but heating the water increases effectiveness -not used in mechanical ventilation or with intubated patients where the natural upper airway is bypassed Guillain-Barre Syndrome - CORRECT ANSWER autoimmune disease, chronic & relapsing, paralysis of body starting from legs and upward, flu-like symptoms affects diaphragm and respiratory muscles To diagnose-cerebral spinal fluid obtained, if positive for protein then pt is positive for GB Treatment: -Monitor: VC, VT, MIP -if VC < 1.0L-INTUBATE -may admit to general floor and monitor -clot prevention: leg stockings, anticoagulant therapy -bronchopulmonary hygiene -steroids -plasmapheresis NIV may be used temporarily, MV may be required Myasthenia Gravis aka Myasthenic Crisis - CORRECT ANSWER autoimmune disease, paralytic dysfunction of respiratory muscle starts at face and downward MV support required when diaphragms begin to show signs of paralysis -signs: double vision, dysphagia, slurring of speech, droopy facial muscles or eyelids To diagnose-give Tensilon(Edrophonium), if pt is relieved of weakness then pt has MG Once diagnosed-DO NOT give Tensilon. In some case, Tensilon administration will cause pt to crash and lose ventilatory drive. This is called anticholinergic crisis. It needs to be treated with Atropine. Treatment: Monitor VT, VC, MIP If VC < 1 L, need to INTUBATE -Soft diet, bed rest restriction -Meds: Mestinon(Pyridostigmine) or Neostigmine (Prostigmin, Vagostigmin)-similar to Tensilon, helps to reduce muscle weakness Wean off MV if: -VC >10 L/min -VT > 5 L/min -MIP > -20 cmH2O Muscular dystrophy - CORRECT ANSWER affects diaphragm may be chronic Vital capacity low=need MV or NIV Pulmonary edema -blood/bloody fluid leaks across alveolar capillary membrane into alveoli -acutely decreases gas exchange, resulting in ventilatory failure 2 types: -cardiogenic -non-cardiogenic - CORRECT ANSWER Cardiogenic- -associated with advanced CHF Primary issue is left heart, but it causes right heart problems as well Left heart doesn't pump effectively, difficulty ejecting all of the blood, the right heart have to pump more blood throughout the lungs to the left heart than left heart can handle. So the overload/preload of left heart causes it to fail and the blood backs up into pulmonary artery, decreasing pulmonary efficiency. Excessive BP in PA(pul.hypertension secondary to L.heart failure) forces blood to seep across the alveolar capillary membrane, filling alveolar spaces with blood and plasma. -Blood in alveoli become aerated by ventilation. Aerated bloods may become pink and frothy. Frothy secretions can fill up bronchial tree very quickly, obstructing movement of gases in lungs. Findings: -mPAP >25 torr -low EF -venous distension -orthopnea -contributing factors: kidney failure & fluid retention Treatment: -Diuretics (Lasix) -100% O2 -PPV(IPPB, PEEP, CPAP, BiPAP) -Digitalis(Digoxin)-to strengthen the left heart contractions, relieve pul.hypertension from blood backing up into pul.artery Coronary Artery Disease aka Atherosclerosis - CORRECT ANSWER Coronary arteries blocked by plaque build up or they harden so its difficult for oxygenated blood to reach heart muscle tissue. -overtime CAD can weaken heart and cause CHF and cardiac arrhythmias Pulmonary Hypertension - CORRECT ANSWER High BP of pulmonary arteries Pulmonary arteries harden and make right heart work harder Blood backs up causing right heart enlargement and right heart failure Findings: -high PAP -high PVR Treatment: Med to lower pulmonary BP: -Sildenafil(Revatio) -Hydralazine(Apresoline)-may lead to precipitous hypotension -Flolan Inhaled NO-pulmonary vasodilator -20-40 ppm -improves O2 -reduces intracardiac shunt Prostacyclin-potent vasodilator; lowers systemic BP Shocks - CORRECT ANSWER Anaphylactic-from exposure to foreign substance or chemicals(bee sting, snake, insect, drugs, cleaning chemicals) -release of histamine which dilates blood vessels(hypotension) -deadliest shock signs: -rash, facial swelling, inflammation of internal tissues Treatment: -give fluids -Epi Cardiogenic-BP failure due to damage and dysfunction of the heart. Insufficient blood flow to key body organs. -Often happens prior, during, or after MI(where significant injury and death of tissue occurred) -ECG reveals elevated S-T segments & pronounced Q waves -Administration of fluids is rarely helpful Short-term Treatment: -Dobutamine(Dobutrex) -Dopamine -Epi -Levosimendan -Milrione -Norepinephrine Long-term Treatment: -depends on cause of shock -possible CABG -cardiac catheterization & angioplasty or stent placement Other: -continous heart monitoring -O2 therapy -Ongoing fluid administration -Intra-aortic balloon pump -pacemaker Septic-loss in BP due to widespread infection of the body. Doesn't respond to any treatment. The most common cause is indwelling catheters like PICC line, IV lines. Such devices should be discontinued if septic shock suspected esp if inflammation or redness noted around the site. Treatment: -give O2 -fluid administration -CPR -Corticosteroids if refractory vasopressor-dependent shock -Drotrecogin alpha if severely ill (APACHE II >25) -management of blood sugar -appropriate antibiotic therapy -Surgery if source is internal -removal, debridement, drainage of focal infection site Hypovolemic-loss of BP due to lack of blood volume/fluid, occurs over short period, massive cuts, lacerations, loss of limbs. -associated with physical trauma -massive burns can cause massive blood/fluid loss Treatment: -administration of fluids -IV fluid (Dextran) -Blood transfusion -Blood expanding agents (Plasmenogen) Neuroge Recognition of Respiratory Failure ACI/ARDS Aspiration Atelectasis - CORRECT ANSWER -refractory hypoxemia, cyanosis -poor lung compliance & gas exchange (rising plateau pressure) -labored breathing -hypercapnia with advancing profound hypoxemia -pH <7.25 -PF ratio <300=ALI -PF <200=ARDS -CXR shows diffuse alveolar infiltrates -elevated PCWP caused by: -sepsis -near-drowning -long-term pan -aspiration of gastric contents or foreign substances(gasoline/kerosene) -major trauma inhalation of oropharyngeal, gastric, foreign substances into lungs findings: -scattered coarse and medium rales -febrile conditions -consolidation on CXR -hypercapnia and hypoxemia Aspiration of gastric contents can cause pneumonia called aspiration pneumonitis. Tube feeding aspiration-most tube feeding is artificially colored. If ETT/NT sx reveals colored sputum that matches the color of tube feeding material then its likely because of aspiration of gastric contents. In this case, tube feeding must be stopped immediately and airway should be protected. -Oral/pharyngeal secretion aspiration can cause bacterial pan -foreign body aspiration can cause acute respiratory emergency collapsing of alveoli so gas-exchange is interrupted, possibly causing respiratory failure -signs: fine crackles, trachea deviated towards atelectasis if severe, low-grade fever, decreased lung volume or inspiratory capacity Treatment: -IS(aka SMI therapy)-to prevent post-operative complications -Ambulation prompts deep breathing, pain control may be used -IPPB if pt has not fully emerged from sedation -NIPPV to reduce atelectasis -on MV, use of PEEP may be used to decrease atelectasis Drug induced Respiratory failure - CORRECT ANSWER -reverse opioids with Narcan(Naloxolone) -reverse benzodiazepines(Ativan, Zafran) with Romazicin(Flumanzenil) -provide ventilatory support(NIV) -intubate to protect airway: pt is unconscious, vomiting, diminished or absent gag reflex, heavily under influence of alcohol. -MV may be needed if: -rate <6 -VT <5 L/min -pH< 7.25 and high PaCO2 -serials ABGs shows impending ventilatory failure -prolonged somnolence post surgery Pneumonia - CORRECT ANSWER excessive secretions in lungs resulting in consolidation -alveoli do not participate in gas exchange Treatment: -O2 therapy -bronchial hygiene (PEP therapy, CPT, flutter, postural drainage, aerosol therapy, mucolytic meds for thick secretions) antibiotic therapy if bacterial infection present(Levaquin) -NIPPV if CO2 is rising -MV if pH< 7.25 Non-cardiogenic Pulmonary edema - CORRECT ANSWER seeping of blood into alveoli due to altered permeability of the alveolar capillary membrane -most commonly associated with development of ALI/ARDS -ARDS can develop from long-term MV -damage to alveoli if often caused by exposure to: gasoline, kerosene, mustard gas, acid, noxious chemical vapors, heated gas, aspiration of gastric contents. -May be caused by pneumo, pulmonary contusion, reclaiming of lung vasculature after clearing a clot, multiple blood transfusions, serious pulmonary infections -sudden changes in altitude or exposure to high altitudes Treatment: -keep FIO2 < 60% -use PEEP to manage hypoxemia -permissive hypercapnia -permissive hypoxemia(PaO2>60 torr) PCV(if PIP >50 & compliance is steadily decreasing) -treat with Sildenafil (Viagra) altitude induced pulmonary edema Pulmonary Embolism - CORRECT ANSWER Blood clot in the vessels around the lungs. Often clot develops in the body due to lack of movement esp. post op or trauma. No blood flow to alveoli is called "Deadspace ventilation" Diagnosis: -sudden SOB, inc RR & VT, cyanosis in upper body -Lab: disparity between PetCO2 & PaCO2. PetCO2 will be low as pt significantly ventilates alveoli. BUT, PaCO2 will remain normal or high because there are too many alveoli that are not receiving blood flow and therefore cannot exchange CO2 in the blood. PetCO2 will be >10 torr less than PaCO2 -V/Q scan: will show adequate ventilation with poor perfusion. -Pulmonary angiography: works by injecting radio-opaque dye into bloodstream of pul.vasculature. The movement of dye can be seen on fluoroscope. Non-perfused areas can be identified. P.A is more conclusive than V/Q scan but more expensive. V/Q scan should be tried FIRST. ECHO: helpful in identifying poor blood flow in pulmonary vasculature. May be able to see clot itself. Esp. helpful if pt too unstable to transport for V/Q scan or P.A. Restrictive Lung Disease - CORRECT ANSWER difficulty to inspire due to decreased lung compliance ("stiff lungs"). -ARDS, Pul.fibrosis, Kyphosis/Scoliosis/Kyphoscoliosis, ALI Treatment: -MV support, NIV Sleep Apnea 2 types: Obstructive and Central sleep apnea - CORRECT ANSWER -O2 deprived to the brain, natural reaction is to wake up -pt unable to have most important state of sleep-REM stage 4 -Long-term complication if untreated: Enlarged heart, CHF, Hypertension, Mental dullness, lack of mental acuity which cause driving accidents. OBSTRUCTIVE: apnea caused by upper airway soft tissue obstruction when sleeping. Pts easily aroused because they rarely attain deep sleep. Excessive tissue exist due to obesity or genetic anatomical build. It is diagnosed with Polysomnography-Sleep Study. During sleep nasal flow, chest movement, SpO2 and EEG monitored. If chest movement exists with NO nasal flow=OBSTRUCTIVE SLEEP APNEA present. If no chest movement during episode of no nasal flow=CENTRAL SLEEP APNEA present. Apnea Hypopnea Index-# of hypopnea/apnea episodes per hour. AHI <5=normal, no sleep apnea; AHI 5-15=mild sleep apnea; AHI 15-30=moderate sleep apnea; AHI >30=severe sleep apnea Nest step to do is titration study to see how much CPAP/BiPAP pressure is needed. Treatment: OSA-noctural CPAP/BiPAP, full-face mask may be used for pts who cannot keep mouth closed. Chinstrap may assists in keeping mouth closed. Surgical resection of soft tissues of upper airway. CSA-respiratory stimulating medication, Doxapram, MV Upper Airway Obstruction - CORRECT ANSWER if stridor is mild/moderate-give Racemic Epi If severe/marked stridor-establish airway,use bronch to assist w/ intubation or have anesthesiologist intubate. Tx-if not quickly resolved. Heliox may be used. Use 80%/20% if pt doesnt need O2. If hypoxemia present, Heliox of 70%/30% or 60%/40% may be used. If hypoxemai is profound <80% give 100% of O2. The higher the helium the easier it is to breathe, dec WOB. Heliox may be used for asthmatic who is unresponsive to traditional brochodilator therapy, steroids. Special Oxygenation considerations for COPD patients - CORRECT ANSWER 1. To high of PaO2 can result in hypoventilation 2. Signs are decreased RR and decreased VT 3. May be described as stuporous (indicates excessive CO2) 4. Lower oxygen immediately to treat 5. Permit hypoxemia (PaO2 50-60 mmHg may be OK) Signs of Oxygen toxicity - CORRECT ANSWER 1. Tachypnea 2. Refractory Hypoxemia a. Fixed with PEEP or CPAP -- NOT FIO2 3. Decreased compliance -- decreased surfactant in the lungs. 4. Pulmonary edema 5. Nausea signs of airway obstruction: - CORRECT ANSWER -softened cough -inspiratory stridor -paradoxical chest movement -general signs of respiratory distress (cyanosis, retractions) types of airway obstructions: - CORRECT ANSWER -soft tissue (tongue) -foreign body -supra-glotting (above the glottis) -sub-glotting (below the glottis) -inspissated (very thick) secretions An xray chest report has a batwing pattern,what is this consistent w? - CORRECT ANSWER Pulm edema,atelectasis,pleural effusion,pneumonia Answer-pulmonary edema Batwing xray is known as what diagnosis? - CORRECT ANSWER Pleural effusion,pulmonary edema,atelectasis,ARDS Answer-Pulm edema Tachycardia - CORRECT ANSWER Associated With Hypoxemia Give oxygen Cold, clammy skin - CORRECT ANSWER Associated With Myocardial infarction Give oxygen, do ECG "Suddenly short of breath" - CORRECT ANSWER Associated With Pulmonary embolism 100% oxygen, V/Q scan, anticoagulants "Sudden onset of tachypnea" - CORRECT ANSWER Associated With Pneumothorax 100% oxygen, chest x-ray, chest tubes if positive Butterfly pattern on X-ray - CORRECT ANSWER Associated With Resp Distress Syndrome (ARDS) or (IRDS) Keep FIO2 low as possible, keep ventilatory pressures down Reticulogranular pattern on X-ray - CORRECT ANSWER Associated with Resp Distress Syndrome (ARDS) or (IRDS) Keep FIO2 low as possible, keep ventilatory pressures down Pitting edema - CORRECT ANSWER Associated With CHF Cardiac drugs, digitalis, digoxin Maintain good fluid balance (often diurese patient) Cyanosis - CORRECT ANSWER Associated With Hypoxemia Give oxygen Patient confused, anxious - CORRECT ANSWER Associated With Hypoxemia Give oxygen "Marked" anything - CORRECT ANSWER Address it quickly "Severe" anything - CORRECT ANSWER Address it quickly Lethargic, sleepy, somnolent - CORRECT ANSWER Associated with COPD O2 overdose Lower the oxygen Stuporous, confused, inappropriate responses - CORRECT ANSWER Associated With Drug Overdose Protect airway (may intubate) Deliver Narcan if narcotic overdose) Ventilation is at risk (unpredictable CNS depression) Anxiety, nervous - CORRECT ANSWER Associated With Hypoxemia Address the underlying problem, resolve the hypoxemia Angry, irritable, or combative - CORRECT ANSWER Associated With Electrolyte Imbalance Fix it (delivery fluids, administer specific electrolytes) Panic - CORRECT ANSWER Associated With Severe Asthma Attack Give oxygen, bronchodilators Orthopnea - CORRECT ANSWER Associated With CHF Cardiac drugs, proper fluid maintenance (often diuretics) General malaise - CORRECT ANSWER Associated With Electrolyte Imbalance Fix it Digital Clubbing - CORRECT ANSWER Associated With COPD Low oxygen delviery Diaphoresis - CORRECT ANSWER Associated With Heart failure, fever, tuberculosis if night time Address underlying problem Night sweats - CORRECT ANSWER Associated With Tuberculosis Treat the disease generally Ashen or pallor color - CORRECT ANSWER Associated With Anemia, acute blood loss Stop bleeding, give blood Increased A-P diameter - CORRECT ANSWER Associated With COPD Treat disease generally Kussmaul's breathing - CORRECT ANSWER Associated With Metabolic acidosis, diabetic, renal failure Treat underlying problem Apneustic breathing - CORRECT ANSWER Associated With Brain trauma or tumor Treat the problem Muscular hypertrophy - CORRECT ANSWER Associated With COPD treat the disease Retractions - CORRECT ANSWER Associated With Significant resp distress in infants Support ventilation, administer oxygen Paradoxical chest movement - CORRECT ANSWER Associated With Flail Chest Ensure ventilation, watch for pneumothorax Pulses paradoxus - CORRECT ANSWER Associated With Status asthmaticus, severe air-trapping Address the underlying problem Flat to percussion - CORRECT ANSWER Associated With Atelectasis Hyperinflation Therapy Dull to Percussion - CORRECT ANSWER Associated With Fluid-filled, pneumonia, pleural effusion Address the underlying problem Hyperresonant to percussion - CORRECT ANSWER Associated With Pneumothorax Chest tubes, chest X-ray Course Rales - CORRECT ANSWER Associated With Rhonci Suction patient if cannot cough, otherwise anything to mobilize secretions (CPT, IPPB, PEP therapy, etc) Medium rales - CORRECT ANSWER Needs anything to mobilize secretions, CPT, IPPB, PEP therapy, etc Fine rales - CORRECT ANSWER Associated With CHF, Pulmonary Edema Diurese the patient, provide positive pressure ventilation, IPPB, cardiac drugs such as digitalis Wheezing - CORRECT ANSWER Associated with Wheezing Administer Bronchodilator Stridor - CORRECT ANSWER Give racemic epinephrine, intubate if marked or severe Pleural friction rub - CORRECT ANSWER Assocaited With Pulmonary infarction, TB, Lung CA Treat underlying disease Steeple sign (Lat neck X-ray - CORRECT ANSWER Associated With Croup Treat the underlying disease Thumb sign (Lat Neck X-ray) - CORRECT ANSWER Associated With Acute Epiglottitis Treat the underlying disease Butterfly or Batwing (x-ray) - CORRECT ANSWER Associated With PUlmonary Edema Treat the underlying disease Fluffy infiltrates - CORRECT ANSWER Associated With Pulmonary edema Treat the underlying disease Honeycomb pattern (X-ray) - CORRECT ANSWER Associated With ARDS Treat the underlying disease Wedge-shape infiltrates (X-ray) - CORRECT ANSWER Associated With Pulmonary embolus Treat the underlying disease Concave superior interface border - CORRECT ANSWER Associated With Pleural effusion Treat the underlying disease Basilar infiltrates with meniscus - CORRECT ANSWER Associated With Pleural effusion Treat the underlying disease Flattened T waves - CORRECT ANSWER Associated With Hypokalemia Spiked T waves - CORRECT ANSWER Associated With Hyperkalemia Pink frothy sputum - CORRECT ANSWER Associated With Pulmonary Edema Treat the underlying disease Purulent sputum - CORRECT ANSWER Associated With Chronic bronchitis Treat the underlying disease 3-layer sputum - CORRECT ANSWER Associated With Bronchiectasis Treat the underlying disease Information Gathering - Emphysema: (Abnormal condition of the alveoli resulting destruction and loss of elasticity.) - CORRECT ANSWER LEVEL I : Cyanosis, Barrel chest, increased A-P diameter, Accessory muscle use, Digital clubbing of the nail beds, Significant history of smoking and/or occupational exposure to smoke or other pulmonary irritant LEVEL II : Dyspnea, Wheezing breath sounds LEVEL III : Chest X-ray—flattened diaphragms, hyperlucency, diminished pulmonary vascular markings. CBC—polycythemia, increased WBC due to possible infection. ABGs—Compensated respiratory acidosis (high PaCO2, normal pH), moderate to severe hypoxemia. Sputum culture—often positive for bacteria. LEVEL IV : FT—flows are decreased especially middle sized airways (FEF 25-75%) Fev1 and Fev1/FVC%, reduced DLCO (less than 20). Descision Making - Empysema: (Abnormal condition of the alveoli resulting destruction and loss of elasticity.) - CORRECT ANSWER Oxygen therapy—low FIO2 (0.24 to 0.28) or 1 to 2 lpm nasal cannula Oxygen conserving devices such as liquid oxygen or trans-tracheal oxygen Home care education on devices and equipment cleaning Rehabilitation efforts (specifics not usually required) Aids to help quit smoking such as nicotine replacement therapy Bronchodilation medication via MDI or aerosol nebulizers Antibiotics for infection Smoking cessation products (nicotine replacement therapy). Information Gathering - Chronic Bronchitis (Defined: Condition where the patient has a productive cough 25% of the year for at least two consecutive years.) - CORRECT ANSWER LEVEL I : Productive cough, purulent sputum production Exposure to pulmonary irritants, like history of smoking Frequent infections LEVEL II : Dyspnea LEVEL III : Chest X-ray—could be normal, or may show hyperlucency, diminished, pulmonary markings. CBC—possibly increased WBC due to possible infection. ABGs—could be normal or very slight respiratory acidosis and hypoxemia LEVEL IV : PFT—flows are decreased especially middle sized airways (FEF 25-75%) FEV1, Normal DLCO Decision Making - Chronic Bronchitis (Defined: Condition where the patient has a productive cough 25% of the year for at least two consecutive years.) - CORRECT ANSWER Anything that promotes good pulmonary hygiene such as chest physiotherapy, hydration therapy when sputum is thick. Fluid therapy if dehydrated.Oxygen therapy for hypoxemia Aerosolized bronchodilator therapy, Antibiotic Tetracycline may be preferable Information Gathering - Bronchiectasis (Defined: Abnormal condition where the bronchi secrete large volumes of pus during abnormal dilation.) - CORRECT ANSWER LEVEL I : Productive cough, often with blood, digital clubbing of the nail beds, significant history if infections (recurrent) LEVEL II : Dyspnea LEVEL III : Chest X-ray—generally normal Sputum culture—gram negative bacteria LEVEL IV : Bronchogram is the primary test. Characterized by a "tree in winter pattern" Decision Making - Bronchiectasis (Defined: Abnormal condition where the bronchi secrete large volumes of pus during abnormal dilation.) - CORRECT ANSWER Anything that promotes good pulmonary hygiene such as chest physiotherapy, hydration therapy when sputum is thick. Fluid therapy if dehydrated.Oxygen therapy for hypoxemia Aerosolized bronchodilator therapy. May have to consider surgical intervention on some highly affected segments Information Gathering - OSA (Defined: the cessation of breathing during sleep. Is usually obstructive in nature but sometimes can be central or a combination of the two (mixed). - CORRECT ANSWER LEVEL I : Spouse or bed partner will complain of snoring and will often report witnessing periods of apnea that exceed 10 seconds. Excessive upper airway tissue, obesity, thick neck (greater than 16 inch collar size. Ability to fall asleep quickly Sleepiness during daytime and while watching TV or in front of a computer LEVEL II : Dyspnea, Frequent urination during sleeping hours LEVEL III : ABGs—could be normal or very slight respiratory acidosis and hypoxemia LEVEL IV : Polysomnography (sleep study) - determines if obstructive or central, If no nasal flow AND no chest movement—then CENTRAL sleep apnea. If no nasal flow WITH chest movement—then OBSTRUCTIVE sleep apnea Decision Making - OSA (Defined: the cessation of breathing during sleep. Is usually obstructive in nature but sometimes can be central or a combination of the two (mixed). - CORRECT ANSWER If central, ventilatory stimulant medication may be used, If obstructive, nocturnal nasal or full-face CPAP or BiPAP (NIPPV) is usually initially indicated with follow-up weight loss or upper airway tissue removal through surgery. Problem must be corrected immediately, so even if discharging, send devices home with patient. In the absence of a titration study, initially ordered pressure should be 10 to 20 cmH20. Information Gathering - Asthma (Defined: Abnormal constriction of the bronchials resulting in sputum productionand narrowed airways. - CORRECT ANSWER LEVEL I : Accessory muscle use, Tachycardia LEVEL II : Dyspnea, Wheezing, Congested cough, Wet, clammy skin LEVEL III : ABGs—possible respiratory acidosis, could be hypoxic, Chest X-ray—hyperinflation, scattered infiltrates, flattened diaphragms. In allergic cases, may see elevated eosinophil count which can cause yellow sputum LEVEL IV : PFT—Decreased flows in FEV1 but diffusion is normal as manifested by DLCO Decision Making - Asthma (Defined: Abnormal constriction of the bronchials resulting in sputum productionand narrowed airways. - CORRECT ANSWER Oxygen therapy for hypoxemia Aerosolized bronchodilator therapy Continuous bronchodilator therapy, Albuterol (7-10 mg/hr) Xanthine medication given IV (Aminophylline, etc) Promote pulmonary hygiene Inhaled sterioids such as oral or IV prednisone Information Gathering - Status Asthmaticus (Defined: Asthma that will not respond to bronchodilation therapy,usually persists more than 24 hours.) - CORRECT ANSWER LEVEL I : Historically non-responsive to bronchodilators. Patient will report the need to take many bronchodilator treatments before feeling better. Accessory muscle use and retractions Dyspnea, Wheezing, Congested cough, Wet, clammy skin LEVEL II : Pulses paradoxus LEVEL III : ABGs—possible respiratory acidosis when tiring, alkalosis at first due to anxiety, could be hypoxic Chest X-ray—hyperinflation, scattered infiltrates, flattened diaphragms. Decision Making - Status Asthmaticus (Defined: Asthma that will not respond to bronchodilation therapy,usually persists more than 24 hours.) - CORRECT ANSWER May deteriorate quickly, so if progression is shown, intubate, mechanically ventilate before full ventilatory failure. Use subcutaneous epinephrine—1 mL of 1:1000 strength. May need to give every 20—30 minutes for up to three consecutive doses (if no improvement between doses) Continuous beta II agonist (bronchodilator medication). Albuterol 7-10 mg/hr. Information Gathering : Myasthenia Gravis (Defined: Neuromuscular abnormality where muscles experience paralysis starting from the head down to the feet including ventilatory muscles.) - CORRECT ANSWER LEVEL I : May have a history of Myasthenia Gravis if not a new onset, Droopy facial muscles and eyelids (Ptosis) LEVEL II : Patient will describe slowly feeling weakness generally but feels better with rest. Double vision (diplopia) Dysphagia (difficulty swallowing) Drooping eyelid (Ptosis) Shrinking Vt, VC, MIP LEVEL IV : Tensilon Challenge Test—positive for Myasthenic crisis if improvement is noted upon the administration of Tensilon. Decision Making : Myasthenia Gravis (Defined: Neuromuscular abnormality where muscles experience paralysis starting from the head down to the feet including ventilatory muscles.) - CORRECT ANSWER If Tensilon improves condition then, anticholinesterase therapy is indicated including: Neostigmine (prostigmine), Mestinon (pyridostigmine) Ok to do additional Tensilon challenge test to observe progression. If symptoms improve with Tensilon and then worsen, must reverse with Atropine. This condition is termed a cholinergic crisis. Always monitor spontaneous ventilatory volumes (Vt and VC) as well as MIP. Never treat Myasthenia gravis with Tensilon—only use to diagnose. Use the above mentioned drugs to provide maintenance. Be totally prepared to intubate and mechanically ventilate prior to Tensilon challenge since it could take out the respiratory drive When VC falls off rapidly (especially if below 1.0 L) , then intubate and mechanically ventilate. Information Gathering : Drug Overdose (Defined: Potential loss of ventilatory drive as a result of drug overdose (usually a narcotic). ) - CORRECT ANSWER LEVEL I : Historical drug use as told by previous admissions or family, Sometimes poor self-hygiene, emaciated LEVEL II : Looks and acts sleepy, difficult to arouse, Respiratory rate and pattern is low and/or shallow LEVEL III : ABG—often show pure respiratory acidosis and/or ventilatory failure Decision Making : Drug Overdose (Defined: Potential loss of ventilatory drive as a result of drug overdose (usually a narcotic). ) **The most important part of this simulation is the need for immediate intubation while recognizing that there may not be a need to mechanically ventilate until ventilatory status deteriorates. - CORRECT ANSWER Important priority is to protect the airway through intubation, prevent aspiration of stomach contents, and facilitate manual ventilation. If narcotic overdose (usually is) then use narcotic reversing medication such a Narcan (Nalaxon) Support ventilation until drugs are out of system. Information Gathering : Other Neuromuscular (Defined: Other neuromuscular diseases or states include: Poliomyelitis, Tetanus, Muscular dystrophy, and even botulism poisoning.) - CORRECT ANSWER LEVEL I : History of illness LEVEL II : Shrinking Vt, VC, MIP Decision Making : Other Neuromuscular (Defined: Other neuromuscular diseases or states include: Poliomyelitis, Tetanus, Muscular dystrophy, and even botulism poisoning.) **If faced with these diseases, simply apply general respiratory monitoring principles and facilitate ventilation when needed. These are somewhat rare. - CORRECT ANSWER Monitor for ventilatory failure generally through Vt, VC, MIP and ABGs As VC falls below 1.0 L, consider intubation and mechanical ventilatory support. Paralytics are indicated if conditions, such as locked-jaw or other muscle contractions are present due to Tetanus or Botulism. Information Gathering - Head Trauma (Defined: Physical Trauma to the head) - CORRECT ANSWER LEVEL I : Sometimes trauma is visible with blood contusions on the head, History is trauma related, often automobile accident LEVEL II : Looks and acts sleepy, difficult to arouse Respiratory rate and pattern is low and/or shallow and irregular Pupillary response to light may be unequal or inadequate LEVEL IV : If intracranial pressure monitor is in place, may see ICP greater than 20cm H2O Decision Making - Head Trauma (Defined: Physical Trauma to the head) **Unique to this simulation 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 my elevate ICPs. - CORRECT ANSWER Must constrict vessels in the head by keeping PaCO2 between 25-30 mm Hg. Adjust FIO2 to maintain high normal levels (PaO2 of 100 mm Hg). Avoid increased ICP by minimizing PEEP usage. Suction only when needed, due to elevating peak pressures. Avoid anything that will increase mean arterial pressure (MAP). Sedation is important, but should monitor exhaled volumes and pressures closely Use of drugs such as Mannitol (cerebral diuretic medication) when ICP is above 20 cm H20 Use Dilantin and establish an airway if grand mal seizure activity is observed Information Gathering - Chest Trauma (Defined: May be any trauma leading to fractured ribs or flail chest.) - CORRECT ANSWER LEVEL I : Circumstantial history (motor vehicle accident, etc) Respiratory rate and pattern is fast and shallow due to pain May have obvious trauma (bruising) on chest wall LEVEL II : Sharp chest pain, especially at the top of each breath Paradoxical chest movement if ribs are broken in two places (flail chest) Pneumothorax is possible (see signs and symptoms of pneumothorax) LEVEL III : Chest x-ray—may reveal broken ribs, usually isolated in same area Decision Making - Chest Trauma (Defined: May be any trauma leading to fractured ribs or flail chest.) **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 pneumothorax or hemothorax. - CORRECT ANSWER Anything that encourages deep (adequate) breathing in spite of pain such as IPPB, incentive spirometry, coughing. Watch for ventilatory fatigue and eventual ventilatory failure Mechanically support ventilation when it is evident ventilatory failure is impending. If possible do not wait until full ventilatory failure. Treat partial pneumothorax if greater than 20% - ie insert chest tubes Treat hemothorax, with chest tubes or thoracentesis Treat tension pneumothorax with a large-bore needle Information Gathering - Hemothorax/Pneumothorax (Defined: Defined: Loss of adherence of the lung to the pleural wall causing the space to be filled with air or fluid (bloody). ) - CORRECT ANSWER LEVEL I : Rapid and shallow respirations LEVEL II : Percussion: hyperresonant if pneumothorax, dull if hemothorax, Tracheal shift: to affected side if pneumothorax, away if tension pneumothorax, Severe dyspnea, Very diminished or absent breath sounds, Pulses paradoxes LEVEL III : Chest x-ray—definitive—show hyperlucency, tracheal or mediastinal shift Decision Making - Hemothorax/Pneumothorax (Defined: Defined: Loss of adherence of the lung to the pleural wall causing the space to be filled with air or fluid (bloody). ) **Pneumothorax, hemothorax, tension pneumothorax occurs very frequently on the exam. May include the troubleshooting of chest tube drainage devices - CORRECT ANSWER Usual treatment is insertion of chest tubes Upper anterior chest tube placement for pneumothorax (involving air) Lower chest tube placement for hemothroax (involving blood and body fluid) Treat partial pneumothorax if greater than 20% - insert chest tubes Treat hemothorax, with chest tubes or thoracentesis Treat tension pneumothorax with a large-bore needle Information Gathering : Thoracic Surgery (Defined: Can have a variety of complications from thoracic surgery.) - CORRECT ANSWER LEVEL II : Always monitoring chest tube drainage adequacy Looking for potential complications: Hypovolemic shock, low hemodynamic values including blood pressure, Subcutaneous emphysema, Elevated ventilatory pressures LEVEL III : Chest x-ray—to confirm proper re-inflation of the lung and proper placement of chest tubes Decision Making : Thoracic Surgery (Defined: Can have a variety of complications from thoracic surgery.) **Your ability to deal with and troubleshoot chest tube maintenance is tested in this simulation. Sometimes this case is combined with chest trauma. - CORRECT ANSWER Anything that promotes expansion of the lungs including incentive spirometry, IPPB, and positive pressure mechanical ventilation. If a lobectomy or pneumonectomy, ventilatory volumes should set lower. Fluid therapy if volume is a problem (often is). If mechanical ventilation is used, use VT of 8-9 mL/kg to reduce ventilatory pressures. Information Gathering : Neck/Spinal Injury (Defined: Any trauma threatening the physical structure of the neck. Can include neck or spinal surgery.) - CORRECT ANSWER LEVEL I : Historical relevance, some sort of accident such as diving, automobile. Visible damage to the neck. Altered conscious level. Pulse must be palpated brachially or femorally LEVEL II : Vt, VC, PEFR, and other ventilatory volumes may quickly deteriorate LEVEL III : Neck x-ray—will show injury Decision Making : Neck/Spinal Injury (Defined: Any trauma threatening the physical structure of the neck. Can include neck or spinal surgery.) **Your knowledge of special intubation techniques is what is being tested in this type of simulation. - CORRECT ANSWER Always be prepared to quickly assist and/or promote ventilation. If intubation is required, always use MODIFIED jaw 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 acceptable to prevent neck manipulation and further injury Information Gathering : Abdominal Surgery (Defined: Surgery in the abdominal area for various reasons.) - CORRECT ANSWER LEVEL I : All general visual assessments LEVEL II : All general beside assessment including all vitals LEVEL III : Ventilatory volumes (VC, Vt, FEV1) compared to pre-surgery baselines Decision Making : Abdominal Surgery (Defined: Surgery in the abdominal area for various reasons.) **Abdominal surgery is usually a very general, non-complicated case involving preventative care and follow-up. - CORRECT ANSWER Establishing baselines in pulmonary function testing flows and volumes. Start patient on incentive spirometry prior to surgery, every hour after surgery Initial IS goal is 1/2 of the preoperative inspiratory capacity value. Use positive pressure (IPPB) if needed after surgery if patient is unconscious. Information Gathering : ARDS (Defined: A condition that results in significantly decrease lung compliance and consequent profound hypoxemia.) - CORRECT ANSWER LEVEL I : Record may show a variety of insults to the lung including massive surgery, near drowning, inhalation of gasoline, hypothermia, and others. Rapid respiratory rate Cyanosis LEVEL II : Decreased lung compliance as manifested by increased plateau pressures (decreasing static compliance) LEVEL III : ABGs—persistent hypoxemia in spite of elevated FIO2 (may be refractory) Chest x-ray—show granular, ground glass, reticulogranular, or honeycomb patterns. Often accompanied by diffuse infiltrates. LEVEL IV : All hemodynamic values could deteriorate when positive ventilatory pressures become significant. Decision Making : ARDS (Defined: A condition that results in significantly decrease lung compliance and consequent profound hypoxemia.) **ARDS can be a very disquieting case to deal with. Usually persistent increases in PEEP are needed. Do not be afraid to increase PEEP significantly. Also, most often, cardiac output or some other hemodynamic value will fall indicating a need to decrease PEEP in spite of profound hypoxemia. - CORRECT ANSWER 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 and utilize PEEP to maintain oxygenation. After emergency situation is past, keep FIO2 no more than 0.6 and use PEEP Keep increasing PEEP until an obvious degradation in hemodynamic values is witnessed. As ventilatory pressures become higher, OK to consider alternate methods of ventilation including pressure control, high frequency, APRV, inverse I:E ratio, etc If patient is described as having ARDS before being placed on a ventilator, initial ventilator setting should include a PEEP of at least 10. It is also appropriate to start right off at pressure/control ventilation as an initial setting. Information Gathering : Laryngectomy (Defined: Surgery done to address or remove cancer of the larynx.) - CORRECT ANSWER LEVEL I : Surgical record : Surgery radical (entire larynx) or simple (cord removal) Medical history will show cancer in upper airway LEVEL II : Signs of airway obstruction after surgery. Usually caused by blood within a few hours after the surgery. Decision Making : Laryngectomy (Defined: Surgery done to address or remove cancer of the larynx.) **In this case, you are always looking for post-surgical complications like blood clots in the laryngeal tube. Often, you will have to mechanically ventilate this patient through the laryngectomy tube. - CORRECT ANSWER If radical surgery (entire larynx removed) then the tracheostomy becomes permanent. If not radical then a temporary laryngectomy tube is placed but must be replaced in 3 to 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 laryngectomy tube is in place, you must intubate and/or ventilate through that tube ! Information Gathering : Guillian Barre (Defined: An insidious neuromuscular problem involving muscle paralysis. Paralysis begins in the lower extremities and moves upward, including the ventilatory muscles.) - CORRECT ANSWER LEVEL I : Medical history or patient complaint of recent influenza-type sickness. LEVEL II : Complaint of sluggish lower extremities, Shrinking Vt, VC, MIP LEVEL III : ABGs—impending or current ventilatory failure. LEVEL IV : Spinal tap—will show increased protein in the spinal fluid Decision Making : Guillian Barre (Defined: An insidious neuromuscular problem involving muscle paralysis. Paralysis begins in the lower extremities and moves upward, including the ventilatory muscles.) **Like most neuromuscular cases, you will be tested in your ability to recognize deterioration in ventilatory muscles. In this case,onset can be slow, so don't jump-the-gun and mechanically ventilate too early. Only do so as VC falls below 1.0 L. Otherwise, you will be manipulating the ventilator and possibly weaning. - CORRECT ANSWER Be primarily concerned with loss of ventilation, monitor ventilatory volumes (VC, Vt) and MIP. Begin mechanical ventilation when VC falls below 1.0 L. Be patient about intubation and mechanical ventilation. Onset can be slow. Anti-coagulant therapy and pressure leg stockings to prevent clot development Primary treatment will involve mechanical ventilation and letting the syndrome run its course. Therapies to mobilize secretions Plasmapheresis, immunosuppressor medications. Higher propensity for pulmonary embolism due to clot formation in the lower body due to inactivity. Information Gathering : Shock (Defined: Condition where tissues oxygenation is in jeopardy due to a sudden decrease in blood flow.) - CORRECT ANSWER LEVEL I : Historical evidence of an event, massive trauma, or hypothermia, etc General appearance—cold, clammy, dusky, cyanotic, Tachycardia, tachypnea LEVEL II : Hypotensive, Temperature may be below normal Reduction in urine output LEVEL III : ABGs—hypoxemia and ventilatory failure LEVEL IV : Reduction in common hemodynamic values (CVP, PAP, PCWP) and cardiac output. Decision Making : Shock (Defined: Condition where tissues oxygenation is in jeopardy due to a sudden decrease in blood flow.) **Shock will test your ability to recognize it and monitor the patient for ventilatory failure. Most of the simulation is dealing with typical ventilatory considerations such as ventilator manipulation. - CORRECT ANSWER Mechanically ventilate with ventilatory failure. Oxygen is key. Start it as evidence of shock is presented. Administer blood if needed to treat anemia. Use oxygen at least 40% but may use up to 100% Main treatment involves treating the original problem (that which caused the shock). This can be highly variable. Information Gathering : Heart Surgery (Defined: Any surgery on the heart.) - CORRECT ANSWER LEVEL I : Do well-rounded assessment prior to surgery including vital signs and family history of cardiac illness. LEVEL II : Preoperative assessments of breath sounds Baseline data including basic spirometry of all types including FEV1/FVC and pre and post bronchodilator studies LEVEL III : ABGs—preoperative for baseline Decision Making : Heart Surgery (Defined: Any surgery on the heart.) **This case is not too complicated. You may feel hesitant to do CPR on someone fresh out of surgery. Just do it. - CORRECT ANSWER Always assess ventilatory volumes and be prepared to mechanically ventilate Incentive spirometry every 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 without reservation or consideration of the heart surgery. Information Gathering - Pulmonary Edema/ CHF (Defined: Significant reduction in cardiac output. Involvement of fluid penetrating the alveolar capillary membrane into the lungs.) - CORRECT ANSWER LEVEL I : History of CHF or pulmonary hypertension Tachypnea, tachycardia, anxiety LEVEL II : Cold, clammy, diaphoretic, Pink frothy secretions Edema of fluids (especially pedal edema) Pitting edema (+2, +3) Breath sounds reveal fine, wet rales LEVEL III : ABGs—ventilatory failure with moderate to severe hypoxemia. Chest X-ray—Butterfly pattern, fluffy infiltrates LEVEL IV : Increased hemodynamic pressure (PCWP, PAP, CVP) Decision Making - Pulmonary Edema/ CHF (Defined: Significant reduction in cardiac output. Involvement of fluid penetrating the alveolar capillary membrane into the lungs.) **This case may feel complicated because it involves the heart and hemodynamic values. It is usually easily identified by pink frothy secretions and butterfly pattern on the chest X-ray.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. - CORRECT ANSWER Treat as an emergency ! 100% oxygen Administer diuretic medication furosemide (Lasix) Cardiac intotropic stimulating drugs such as digoxin, digitalis if increased PCWP and PAP Be prepared to treat ventilatory failure with mechanical ventilation Instill ethyl alcohol down the ET tube if patient is severely congested with fulminating edema. Information Gathering - M.I/Arrhythmia (Defined: Ischemia to the heart causing muscle damage and potential failure.) - CORRECT ANSWER LEVEL I : History of chest pain, radiating pain down the left arm Family history of disease, Diaphoretic, History of nausea Tachycardia, Nausea Level II : Cold, diaphoretic and clammy to the touch, Dyspnea Level III : ABGs—hypoxemia, ECG (EKG) - pronounced Q waves and S-T segment elevation Level IV : Cardiac enzymes including CPK, LDH, SGOT are elevated Decision Making - M.I/Arrhythmia (Defined: Ischemia to the heart causing muscle damage and potential failure.) **Will likely need to treat arrhythmias with appropriate medication and/or defibrillation - CORRECT ANSWER Emergency—100% oxygen. Oxygen at adult therapeutic level (40 to 60 %) upon suspicion or first presentation of signs and/or symptoms. Treat arrhythmias, Bradycardia with Atropine or Isuprel, PVCs with Lidocaine or oxygen, Pulseless ventricular tachycardia with defibrillation with synchronization OFF Ventricular fibrillation with defibrillation. Note: For ventricular fibrillation, defibrillate at ascending watt/sec or joule settings 360 joules—repeat as needed, Do not exceed 360 joules Note: For atrial fibrillation or flutter, do synchronized cardioversion—start at 50 joules Information Gathering - Pulmonary Emboli (Defined: Situation where the pulmonary artery becomes obstructed and dead-space ventilation results. Sometimes called deadspace disease.) - CORRECT ANSWER Level I : History of recent major surgery or trauma (amputations, clotted massive bleeding sites) Complaint of chest pain and dyspnea Level II : Elevated vitals including pulse, respirations, and blood pressure, Breath sounds - wheezing and medium rales PECO2 (Capnography) decreasing PECO2 during normal PaCO2 Level III : ABGs—persistent hypoxemia in spite of increasing FIO2 Level IV: V/Q scan will show ventilation without adequate perfusion Decision Making - Pulmonary Emboli (Defined: Situation where the pulmonary artery becomes obstructed and dead-space ventilation results. Sometimes called deadspace disease.) **This case primarily involves recognizing the pulmonary emboli and treating it with anticoagulation medications. You will likely have to monitor clotting times, PTT or PT.Otherwise, involves general respiratory therapy. - CORRECT ANSWER Anticoagulation therapy with Heparin or Coumadin Note: must monitor clotting tests PTT for Heparin PT for Coumadin Clot-busting medication such as steptokinase. May also use a bolus of heparin Mechanical ventilation as needed. Emergency level oxygen—100% Information Gathering - SIDS (Defined: Condition in infants where alveolus maturity is below normal.) - CORRECT ANSWER Level I : History may show pre-term infant Onset can be immediately after birth or within a few hours General respiratory distress, ie grunting, nasal flaring, retractions, Cyanosis Level II : APGAR score between 0 and 6 Level III : Chest-Xray—radiological description such as ground glass, honeycomb, reticulogranular ABGs—persistent hypoxemia in spite of elevated FIO2 Level IV : L/S ratio—2:1 or higher is normal. Less than that shows lung immaturity Decision Making - SIDS (Defined: Condition in infants where alveolus maturity is below normal.) **This is a common case on the test. Key is remembering to address lung maturity. Also, if prolonged ventilation is required, Bronchopulmonary Dysplasia may develop. Be patient and treat moment to moment. - CORRECT ANSWER Help lung maturity through surfactant therapy with agents like Exosurf or Survanta 2 to 5 ml/kg split among 2 to 4 doses Administer directly down the airway, Change infant's position after every dose for 30 seconds to distribute the agent Provide oxygen via a hood. May use CPAP to oxygenate Mechanically ventilate with ventilatory failure, use SIMV mode on all infants. May consider reverse I:E ratio Note: If X-ray changes from signs of IRDS to hyperinflation and fibrosis, then the problem may have developed into Bronchopulmonary Dysplasia. Treat as prolonged IRDS by: maintaining pH of 7.25 to 7.40, PaCO2 45 to 60 torr, PaO2 55 to 70 torr. Use low FIO2 Keep mean airway pressure at a minimum Wean only gradually and as tolerated, often fails initial attempts Extubate if respiratory rates are between 5 and 15 breaths Information Gathering : Congenital Heart Defects (Defined: Infant is born with an anatomical malady of the heart or the vessels that emanate from the heart.) - CORRECT ANSWER Level I : History of pre-term birth, General signs of respiratory distress (grunting, nasal flaring, retractions), Cyanosis that persists in spite of high FIO2 Level II : Heart sounds are abnormal upon auscultation (murmur present) Level IV : Echocardiogram is the best diagnostic test for all cardiac defects Decision Making : Congenital Heart Defects (Defined: Infant is born with an anatomical malady of the heart or the vessels that emanate from the heart.) **Your skills in recognizing common, congenital heart problems will be tested. Otherwise, you will be simply providing supportive care until surgery. - CORRECT ANSWER Specific Defect Attributes, Coarctation of the Aorta (narrowing of aorta) Hypertension in the upper extremities, hypotension in lower extremities, Transposition of the Great Vessels, Aorta and pulmonary artery are switched. "Aorta rising from the right heart, pulmonary artery rising from the left heart" "Egg-shaped heart" on x-ray. Patent Ductus Arteriosis (ductus arteriosis never closes) Diagnosed by comparing blood gases from the radial or brachial artery and the umbilical artery. Positive 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 (ASD), Ventricular septal defect (VSD), Truncus arteriosis (pulmonary artery same as aorta—combined vessel) ALL CONGENITAL DEFECTS ARE TREATED WITH SURGERY !! Prior to surgery simply provide supportive care such as: oxygen to keep PaO2 between 60 -80 mmHg. mechanical ventilation when ventilatory failure is shown by ABGs Information Gathering : Neonatal Diaphragmatic Hernia (Defined: Condition where the diaphragm never grows closed. Usually occurs on the left side.) - CORRECT ANSWER Level I : General respiratory distress, ie grunting, nasal flaring, retractions, Cyanosis, Barrel chest and scaphoid abdomen Mediastinal shift Level II : Breath sounds absent (usually on left), increased on the right Level III : Chest-Xray—show intestinal parts in the chest area. Also may see a mediastinal shift away from the affected side. ABGs—Poor Decision Making : Neonatal Diaphragmatic Hernia (Defined: Condition where the diaphragm never grows closed. Usually occurs on the left side.) ** This case is more about what you should not do. Otherwise use general supportive care. - CORRECT ANSWER TREATMENT IS SURGERY Use low ventilatory pressures Do not use manual bag and resuscitation if possible May use gastric tube to decompress stomach and intestines. All other care is supportive Information Gathering : Choanale Atresia (Defined: Infant is born with an anatomical closure of the nasal passages. - CORRECT ANSWER Level I : Normal appearing, normal color, cyanosis during feeding Level II : During breast or bottle feeding, baby becomes apneic and cyanotic, Slight inspiratory stridor Level IV : Neck and chest x-rays rule out airway inflammation Diagnosis by attempting to pass a suction catheter through the nares. If unable to pass, then positive Decision Making : Choanale Atresia (Defined: Infant is born with an anatomical closure of the nasal passages. - CORRECT ANSWER Care in feeding Correct with surgery Keep ventilatory pressure low Information Gathering : Laryngotracheobronchitis (Defined: Otherwise known as Croup. Results from a viral infection that illicits inflammation in the upper airway.) - CORRECT ANSWER Level I : History of cold in the past few days, Barking cough, Age is 5 months to 3 years, Stridor at rest, Tachypnea Level IV : Lateral Neck X-ray—swelling below the glottis (subglottic swelling) sometimes described as steeple-sign, pencil point, or haziness below the glottis. Decision Making : Laryngotracheobronchitis (Defined: Otherwise known as Croup. Results from a viral infection that illicits inflammation in the upper airway.) **You will likely be tempted to treat this like Acute Epiglottitis in an emergency fashion. Repeated racemic epinephrine treatments may make you feel uncomfortable - CORRECT ANSWER Priority—placement in an oxygen tent with 30 to 40% Aerosolized Racemic Epinephrine Intubation if patient is described as lethargic, markedly diminished breath sounds, severe or marked stridor, extreme accessory muscle use Extubation should be done when swelling has ceased. Information Gathering : Acute Epiglottitis (Defined: Condition where the epiglottis and adjacent upper airway tissues are infected with a bacteria causing inflammation and commonly threatening airway patency.) - CORRECT ANSWER Level I Sudden onset of sickness, within 12 hours, often occurs in the evening Age 3 to 10 years General appearance may show drooling, hoarseness, quiet cough May hear a softened inspiratory stridor Tachypnea and tachycardia Level II Patient unable to swallow, will usually not be crying, eyes are big Significantly elevated body temperature, taken axillary, or tympanically Level IV Lateral neck x-ray will show supraglottic inflammation Decision Making : Acute Epiglottitis (Defined: Condition where the epiglottis and adjacent upper airway tissues are infected with a bacteria causing inflammation and commonly threatening airway patency.) **This case will test your immediately ability to realize that it is an emergency. Stridor may tempt you to treat it more casually like croup. There is a good chance you will see Epiglottitis or Croup on the test. - CORRECT ANSWER Primary and immediate concern is establishing an airway as complete closure from inflammation is possible. 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. May need to immediately get an airway. Should intubate with a bronchoscope or send to surgery for a tracheostomy. Antibiotic therapy to correct bacterial infection Oxygen therapy at 30 to 50% Extubate only when inflammation is gone Information Gathering : Bronchiolitis /RSV Defined: Acute vital infection of lower respiratory tract usually occurring in infants less than 18 months old. Commonly caused by the respiratory syncytial virus. - CORRECT ANSWER Level I General signs of respiratory distress including retractions and accessory muscle use. Tachypnea and tachycardia History of recent sickness from ages 2 months to 3 years old Level II Low grade fever Wheezing, rales, and rhonchi Level III Chest X-ray show scattered infiltrates and hyperlucency Decision Making : Bronchiolitis /RSV Defined: Acute vital infection of lower respiratory tract usually occurring in infants less than 18 months old. Commonly caused by the respiratory syncytial virus. **There is nothing particularly difficult about this case. You must be prepared to recommend the use of a SPAG unit. Not commonly seen on the exam. - CORRECT ANSWER Primary treatment is delivery of the drug Ribavirin which must be administered via a SPAG unit (small volume particle aerosol). Utilize a scavenger system, filters, and masks. Information Gathering : Cystic Fibrosis Defined: An inherited disorder resulting in the mass production of thick mucus in the lungs. - CORRECT ANSWER Level I Family history of disease, siblings may have it. Emaciated in appearance and body frame may be small for age Sputum production of thick voluminous purulent secretions Can look like a young COPD patient, barrel-chested Level II Decreased flow rates such as FEV1 Level III Chest X-ray—looks like COPD, hyperinflation, increased A-P diameter, diaphragm flattening Level IV Sweat Chloride Test—show sweat chloride > 60 mEq/L Decision Making : Cystic Fibrosis Defined: An inherited disorder resulting in the mass production of thick mucus in the lungs. **Not commonly seen on the exam.Tests your ability to recognize secretion removal therapies and may check your understanding of when and how to modify therapy. Ex, when CPT doesn't work, use PEP therapy or ultrasonic nebulization. - CORRECT ANSWER Primary treatment relates to the need to mobilize and remove secretions. Secretion removal promotion therapies: PEP therapy devices Chest physiotherapy with postural drainage Hydration devices such as heated aerosol or ultrasonic nebulization Vibration therapy Oxygen as needed Antibiotic therapy when infection is present—often is Medications used commonly include Tobramycin and Pulmozyme (Dornase alpha) Information Gathering : Hypothermia Defined: Exposure to cold such that body temperature falls significantly. - CORRECT ANSWER Level I History of exposure to cold. May be seen in homeless persons. Lethargy and unconsciousness Bradycardia, bradypnea Level II Body temperature less than 36 deg C Level IV Lateral neck x-ray—Thumb sign or pencil point. Decision Making : Hypothermia Defined: Exposure to cold such that body temperature falls significantly. *Not very common. However when seen, may be seen in conjunction with other problems such as AIDS, or tuberculosis. - CORRECT ANSWER Oxygen via a heated aerosol at 40 to 100% Keep resuscitation efforts going until body temperature is normal. Mechanically ventilate as needed. Keep in mind that blood gas values may be altered because of the difference in blood temperature and analyzed temperature. Watch out for oxygen (PaO2). In cold, uncorrected blood, PaO2 may appear higher than it actually is. Information gathering : Burn Trauma/CO Poisoning Defined: Results from direct exposure to fire and or smoke. Directly threatens airway and oxygen carrying capacity of the blood. - CORRECT ANSWER Level I Diagnosis is based largely on history—exposure to fire or 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 face with CO poisoning Patient is often confused or unresponsive Stridor, hoarseness Level II Breath sounds—wheezing, rhonchi, rales Level III ABGs—initially decreased PaCO2, normal PaO2, decreased saturation. Latter may develop into respiratory acidosis Chest X-ray—may be clear at first, but later may show pulmonary edema and markedly decreased lung compliance Level IV COHb- 20% or more Decision Making : Burn Trauma/CO Poisoning Defined: Results from direct exposure to fire and or smoke. Directly threatens airway and oxygen carrying capacity of the blood. **Fairly common case on the test. Remember to focus on the airway and on oxygen carrying capacity of the blood. Remember to employ isolation techniques. Otherwise, provide general respiratory therapy. - CORRECT ANSWER Protect airway by establishing an artificial airway immediately. Particularly if there is respiratory distress and there are burns about the face. For CO poisoning—start 100% oxygen immediately— even if only suspect it—do not wait for COHb results Continue oxygen therapy until COHb level is below 10%.—may use hyperbaric medicine if offered—often will not be offered. Practice reverse isolation (protect the patient from staff) Mechanically ventilate as needed. Information Gathering : Diabetes Defined: Condition related to failure of the renal system resulting in the inability to dispose of CO2. Respiratory result is often respiratory ketoacidosis. - CORRECT ANSWER Level I History of diabetes Lethargy, confusion, unresponsiveness Respiratory rate and pattern—significant in depth and rate with an irregular rhythm (Kussmaul's) Level II Pedal Edema Level III ABGs—Profound metabolic acidosis Urine output is markedly decreased (less than 20 ml per hour) Level IV Blood glucose - > 160 mg (Normal 80-120 mg) Decision Making : Diabetes Defined: Condition related to failure of the renal system resulting in the inability to dispose of CO2. Respiratory result is often respiratory ketoacidosis. **May be tempted by profoundly acidodic pH. Only determine respiratory failure through the CO2, or a sudden decrease in ventilatory volumes and breathing rate. - CORRECT ANSWER Must watch for ventilatory failure from prolonged ventilatory effort and fatigue. Administer electrolytes (K+, Na+, HCO3-, Cl-) as needed. Provide fluid as needed. Correct ketoacidosis. Information Gathering : AIDS Defined: Disease of the immune system commonly resulting in pneumocystis carinii, a type of pneumonia. - CORRECT ANSWER Level I Previous history of HIV positive test results Emaciation, unexplained weight-loss, diarrhea, low-grade fevers, night sweats, Commonly homosexual activity or drug usage is admitted Special Assessments Positive HTLV III ELISA test— positive for HIV Bronchoscopy—from lung washings or biopsy may show pneumocystis carinii Decision Making : AIDS Defined: Disease of the immune system commonly resulting in pneumocystis carinii, a type of pneumonia. **Increasing in frequency on the exam. Sometimes is combined with tuberculosis, hypothermia, and others. Suspect them all. - CORRECT ANSWER Exercise Universal Precautions Aerosolized Pentamadine—usually done monthly Administer in semi-fowler's position When administering Pentamadine, use one-way valves and filters Staff and visitors should use masks May administer mint after the treatment. Information Gathering : Foreign Body Aspiration Defined: The accidental aspiration of a foreign body, including food or an object, in to the lungs. - CORRECT ANSWER Level I Softened cough or voice if partial obstruction Quiet (no sounds if complete obstruction) Recent history of eating for adult May be child playing with toys Onset is sudden Cough is non-productive Level III Bronchoscopy—visualize the foreign body (may also remove at that time) Chest x-ray—may be clear because food and other objects are likely radiolucent. Decision Making : Foreign Body Aspiration Defined: The accidental aspiration of a foreign body, including food or an object, in to the lungs. **Must differentiate between foreign body aspiration and pulmonary carcinoma. Foreign body aspiration is characterized by a recent, acute development of cough. A cancerous mass in the bronchials results in non-productive cough over weeks or months. - CORRECT ANSWER PRIMARY TREATMENT—Bronchoscopy Supportive therapy as needed—bronchodilator therapy, etc Information Gathering : Bronchopulmonary Dysplasia Defined: Lung disease related to prolonged mechanical ventilation of the newborn. Exact etiology is unknown but is usually associated with previous treatment of IRDS and fetal lung immaturity. - CORRECT ANSWER Level I Recent history and treatment of IRDS or fetal lung immaturity. History of prolonged or significant use of mechanical ventilation since birth. History of elevated FIO2. Level II Wheezing Level III Chest x-ray - like IRDS but then appears like chronic air-trapping with hyperinfla tion and fibrotic changes. Level IV Echocardiogram- may reveal right or left heart failure Decision Making : Bronchopulmonary Dysplasia Defined: Lung disease related to prolonged mechanical ventilation of the newborn. Exact etiology is unknown but is usually associated with previous treatment of IRDS and fetal lung immaturity. **This simulation usually involves making a care plan that covers all the symptoms, including bronchoconstriction, inflammation, under-development of lung tissue, etc. - CORRECT ANSWER Bronchodilator therapy for wheezing Keep FIO2 as low as possible Accept PaO2 of 55 to 65 mmHg. Keep CO2 below 60 mmHg. Corticosteriods to reduce inflammation. Info. Gathering : Transient Tachypnea -Type II RDS Defined: Condition related respiratory distress within 24-48 hours after birth. May be related to C-section delivery. - CORRECT ANSWER Level I Cyanosis, retractions, grunting. Often normal gestational age (38-40 weeks) Initially appears OK, but deteriorates after a day or two Level II Rhonchi from secretions Level III Chest x-ray—starts out normal but deteriorates to show increased pulmonary congestion within a day or two. Level IV Blood glucose - > 160 mg (Normal 80-120 mg) Decision Making : Transient Tachypnea -Type II RDS Defined: Condition related respiratory distress within 24-48 hours after birth. May be related to C-section delivery. **This is increasingly rare on the exam, but really has no real complexity. The exam will try to tempt you to make drastic reactions when the real therapy is to simply be supportive of symptoms. - CORRECT ANSWER Manage symptoms of respiratory distress Support ventilation if needed. Oxygen therapy by oxyhood Treat with shunt therapy (CPAP) if hypoxemia is significant on increased FIO2. Information Gathering : Infectious Pneumonia Defined: Pneumonia that is caused by bacterial or viral infection. - CORRECT ANSWER Level I Increased pulse rate Level II High temperature—bacterial pneumonia low-grade temperature—viral pneumonia Level III Chest x-ray—consolidation in the lung fields Increased WBC—bacterial pneumonia Decreased WBC—viral pneumonia Level IV ELISA test— positive for HIV Acid-fast sputum culture to check for tuberculosis Decision Making : Infectious Pneumonia Defined: Pneumonia that is caused by bacterial or viral infection. **Treated like pneumonia, regardless of source (bacterial vs viral). - CORRECT ANSWER Sputum culture and sensitivity to identify bacterial and the appropriate antibiotic. Mechanical ventilation as needed. Information Gathering : Pickwikian Syndrome Defined: Obstructive sleep apnea due to obesity. - CORRECT ANSWER Level I Obesity, especially large neck size History of sleep apnea Level IV Polysomnogram (sleep study) usually reveals obstructive sleep apnea. Decision Making : Pickwikian Syndrome Defined: Obstructive sleep apnea due to obesity. **This simulation is treated liken most obstructive sleep apnea cases. - CORRECT ANSWER Treat sleep apnea with nasal nocturnal CPAP If mechanical ventilation is required, utilize ideal body weight to calculate appropriate tidal volumes. Weight loss support (classes, medication, etc) Information Gathering : Poison Inhalation/Ingestion Defined: Condition whereby poison is inhaled or ingested. Treatment depends on the poison involved. - CORRECT ANSWER Petroleum Distillate Poisoning (petroleum based oil, glue and other solvents) Kerosene Poisoning Level I Drowsiness Dizziness, nausea, gastric expectoration (vomiting) Decreased respiratory rate and depth (caused from CNS depression) Lethargy, convulsions or coma may develop Level II Chest pain Fever Level III Chest x-ray may show pneumonitis if inhaled. Later signs of ARDS may develop [Show More]

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