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Respiratory review. Respiratory A and P 1. Upper respiratory tract a. nose b. paranasal sinuses c.

turbinate bones (Conchae): increased surface area filters and warms air d. Pharynx, Tonsils, Adenoids e. Larynx: vocalization, protects airway f. Trachea 2. Lower respiratory tract: a. Pleura: Visceral pleura (inner layer), Parietal pleura (outer layer) b. Lobes: 3 on right, 2 on left c. Mediastinum d. Bronchi and Bronchioles e. Alveoli 3. Function of respiratory system: a. Respiration: diffusion of oxygen and CO2 across capillary and alveolar walls b. Ventilation: movement of air in and out of lungs c. Tidal volume: volume of air inhaled and exhaled with each breath d. Vital Capacity: maximum volume of air exhaled after maximum inspiration e. Diffusion: process by which O2 and CO2 are exchanged (Diffusion: Gases) f. Perfusion: blood flow through pulmonary circulation (Perfusion: Blood) 4. When perfusion exceeds ventilation: oxygen not available in alveoli, blood passes by but is not adequately oxygenated (low V/Q ratios/Shunts) a. causes: obstruction of distal airways, pneumonia, tumor, mucus plug 5. When ventilation exceeds perfusion: oxygen available in alveoli, but blood flow is diminished or absent (high V/Q ratio, Dead space) a. causes: pulmonary emboli, pulmonary infarction, cardiogenic shock Respiratory Pharmacology: 1. Bronchodilators, oral, nebulizer a. xanthines: aminophylline, caffiene b. symphathomimetics: albuterol, epinephrine, salmetrerol 2. Corticosteroids: are for maintenance, not used for emergency 3. Expectorants: thin out mucus to increase productivity of cough 4. Antibiotics: for pneumonia, bronchitis, COPD 5. Mucolytics: break up mucus 6. Decongestants: h2 blockers 7. Antitussives: anti cough Blood gases pH 7.35 - 7.45 Less than 7.35 Less than 7.35 Greater than 7.45 Greater than 7.45

PaCO2 35 - 45 Greater than 45 35 - 45 Less than 35 35 - 45

HCO3 22 - 26 22 - 26 Less than 22 22 - 36 Greater than 26

Diagnosis Homeostasis Respiratory Acidosis Metabolic Acidosis Respiratory Alkalosis Metabolic Alkalosis

1. Respiratory acidosis: rapid, shallow respirations, dyspnea, disorientation, muscle weakness a. causes: COPD, pneumonia, asthmatics, drug overdose, sedatives, conditions that obstruct

airways 2. Respiratory Alkalosis: tingling of extremities, confusion, deep rapid breathing a. causes: overexcitment, hyperventilation, extreme fevers 3. Metabolic acidosis: disorientation, muscle twitching, changes in LOC a. causes; renal disease, diabetic ketoacidosis b. bicarb for treatment 4. Metabolic alkalosis: nausea, vomiting, diarrhea, restlessness, slow respirations Acute respiratory Distress Syndrome 1. Definition: sudden and progressive pulmonary edema, will not respond to 02 (perfusion exceeds ventilation, or low V/Q ratio) 2. Patho a. inflammatory trigger initiates release of cellular or chemical mediators b. capillary membranes become injured c. alveolar collapse occurs d. results in decrease lung compliance e. severe hypoxemia f. patients can die from multi-system organ failure, due to decreases oxygenation g. respiratory acidosis occurs h. blood gas reveals arterial hypoxemia despite O2 3. Clinical manifestations: a. rapid onset of dyspnea, cyanosis, anxious, pulmonary edema, increase in bilateral infiltrates, hypoxemia, reduction in lung compliance 4. Treatment: give 02, breathing treatments, 5. Medical Management: mechanical ventilation, let lungs heal, antibiotics, nutrition a. Ventilation. PEEP: positive end expiratory pressure: minimal amount of pressure to keep lungs expanded, raising the PEEP results in lower O2 needs. Normal PEEP in body: 5ml b. treat underlying problem causing ARDS c. nutritional support is increased. Need 35 - 45 kcal/kilo Pulmonary embolism: 1. definition: obstruction of pulmonary artery or one of it’s branches (ventilation exceeds perfusion or high V/Q ratio) 2. Patho a. increased platelet clumping on valves in deep veins b. clot forms c. clot breaks off and moves to right side of heart, then to lungs d. DVT is closely associated with PE 3. Clinical Manifestations: most common: dyspnea and tachypnea a. chest pain b. anxiety, cough, fever, diaphoresis, ptosis, syncopy 4. Diagnosis made upon chest xray, V/Q scan, ABG’s: respiratory acidosis, pulmonary angiography, elevated D-dimer 5. Medical management: a. prevention is #1 b. anticoagulation, thrombolytics, surgery c. Greenfield filter or IVC: lets blood flow through but catches clots d. Load up RBC to increase oxygenation. Don’t trust finger monitor! it will show a good percentage of oxygenation, but with high V/Q ratios, not ENOUGH blood is getting to lungs, so the percentage will be high, but the person will not be receiving enough O2, similar to anemia e. INR range for PE patients is 2 to 3 Blunt Chest Trauma: 1. Patho: a. energy is transferred in chest, organs underneath are compromised.

b. heart or lungs can be bruised or punctured c. hypoxemia: from collapsed lung, leads to cardiac failure d. hypovolemia: tear in chest, aoric aneurysm e. cardiac failure/ cardiac tamponade 2. Medial management: a. aggressive treatement: ABC’s, chest tubes, treament of cardiac tamponade ect. 3. Sternal or Rib fractures a. sternal fractures more serious, possible cardiac contusion b. most common symptom with rib fractures: pain, possible pulmonary contusion c. medical management: pain control, turn cough deep breath ect. d. rib fractures 5 - 9 associated with spleen and liver, injury to spleen: blood loss e. diagnosis by symptoms of pain, and bony crepitus under skin 4. Flail Chest: 3 or more rib fractures at 2 or more places, this is bad a. paradoxical effect: when chest expands with inspiration the fractured pieces “suck” into chest, likewise, then chest recoils in during expiration, the fractured pieces push out. b. with damage lungs make more secretions, leads to atelectasis, respiratory acidosis, increase CO2 in lungs c. Medical Management: suction, pain control, intubate, surgery 5. Pulmonary Contusion: abnormal accumulation of fluid in intersitial and interaveloar spaces a. Patho: increases inflammation leads to increases vascular resistance, leads to decrease ability to blow off CO2 and Oxygenate lungs b. Clinical manifestations: tachypnea, tachycardia, chest pain, blood tinged sputum, frank blood, crackles, sever hypoxemia, respiratory acidosis b. Medical Management: maintain airway, provide O2, pain control, IV fluids, prophylactic antibiotics Penetrating Chest Trauma: knife or gun shot, penetrates pleural space Pneumothorax; collapsed lung that typically occurs when exposed to atmospheric pressures (lung cavity should be negative to atmospheric pressure to work properly) 1. Simple Pneumothorax: a. spontaneous in nature, associated with disease states such as hernia of lung, emphysema. b. treatment: Chest tube is necessary when greater than 25% of lung is compromised 2. Open Pneumothorax: a. open chest wound b. aire moves in and out of chest through hole c. treatment: cover with 4x4 until surgery , tape only on 3 sides to prevent tension pneumothorax 3. tension pneumothorax; a. open chest wound that closes, results in air that is unable to escape b. one way valve effect c. as pressure on one side increases, the other side of lung will become compromised, from deviated trachea ect. d. treatment: 14g need 2nd intercostal space, mid clavicle line to create air escape, chest tube, surgery Laryngeal Cancer: squamouse cell carcinoma is most common of cancerous cells 1. Risk factors: smokers, chewing tabacco, asbestos, men more than women, singers 2. clinical manifestations: a. hoarseness more than 2 weeks b. cough c. lumps in neck d. dyspnea e. foul breath 3. Catagories: a. Supraglottic: false vocal cords (33% make up this type)

b. Glottic: true vocal cords, this seldom metastasizes c. Subgottic: not very common 4. Partial laryngectomy a. cancer limited to 1 vocal cord b. portion of larynx removed along with one vocal cord and tumor c. all other structures remain, swallow preserved, rarely mets, voice quality hoarse 5. Supraglottic Laryngectomy (for stages 1 and 2) a. hyoid bone, glottis, false cords removed along with tumor b. true vocal cords, cricoid cartilage and trachea remain c. airway preserved, swallow preserved 6. Hemilaryngectomy (for tumors less than 1cm in size) a. portion of vocal cord removed with tumor, aryenoid cartilage and ½ thyroid removed b. airway preserved, swallow preserved 7. Total laryngectomy (indicated for advanced cancers) a. all laryngeal structures (hyoid bone, epiglottis, cricoid cartilage, two or three rings of trachea b. tongue, pharyngeal walls, trachea preserved c. permanent tracheostomy: voice loss permanent, mucus production will decrease over time d. swallow preserved e. when suctioning trach, hyper oxygenate, then suction for brief time (only 15 sec) Lung Cancer: 1. definition: transformed epithelial cells, fast growing 2. risk factors: 2nd hand smoke, chemical/occupational exposure, genetic/dietary 3. Clinical manifestations: cough, wheezes, weight loss, fluid built up in cavity 4. Diagnosis: chest xray: white cotton balls, CT, sputum samples 5. Medical Management: surgery/ removal of tumor cells, possible lobectomy ect, radiation, chemo, palliative care 5. Treatment related complications a. radiation; N/V, weight loss, pulmonary fibrosis, pericarditis, respiratory failure, scars 6. Nursing management: supportive care, increase calories, relieve breathing problems, O2, reduce faitgue, psych support. Thoracic Surgery 1. Pneumonectomy: a. removal of entire lung b. mediastinal shift c. space fills with fluid d. remaining lung over inflates 2. Lobectomy: a. removal of lobe of lung b. more common than pneumonectomy 3. Segmental Resection: portion of the lobe 4. Wedge resection: peripheral lung tissue 5. Assessments: a. PFT’s: to make sure patient can operate without the portion of lung being removed b. ABG’s, Bronchoscopy, PET scan ( to identify cancer) Chest Drainage: to reestablish pleural space 1. single chamber system: water seal and drainage collection in same chamber 2. two chamber system: water seal and drainage collection in separate chambers 3. three chamber system: water seal, drainage, and suction in separate chambers a. collection chamber: collects fluid draining from pleural space b. water seal: allows air to exit from pleural space on exhalation and stops air from entering with inhallation c. Tidaling: movement of the water level with respiration d. Bubbling: intermittent is normal, continuous bubbling is abnormal, sign of air leak or when

suction is turned on. 4. Nursing care: a. auscultate lungs b. maintain drianage system upright c. monitor dressing d. measure drainage each shift e. pre medicate prior to activity