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Pulmonary

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Anatomy and Physiology
•  Concepts
–  Major Function - exchange of 02 - CO2
•  Inspiration - diaphragm contracts - medulla oblongata
•  Expiration - intercostals contract - passive - pons
•  Surfactant - reduce surface tension - Hyaline membrane and
ARDS
•  Fluid Causing Respiratory Stimulation - pH of CSF
•  Acidosis - Increases respiration
•  Alkalosis - Decreases respiration
•  KEY: PaCO2
•  CO2 + H2O <-> H2CO3
•  Pulmonary system is low pressure 15-20 mmHg

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Anatomy and Physiology

•  What is the FEV1?


–  Most important spirometric value
–  The volume of air expired in the first
second of an FVC maneuver
–  A normal FEV1 is a value greater than 80%
of predicted normal.
–  Decrease = Obstruction

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Anatomy and Physiology
•  Which pulmonary function value best
predicts prognosis/mortality in COPD?
–  FEV1

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Anatomy and Physiology
•  What is the normal pressure around the lung
(intrapleural pressure)?
–  Subatmospheric
–  This is necessary to keep the lung and chest wall
in close proximity
•  Think about how the lungs are passively
inflated

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Anatomy and Physiology
•  What do crackles (rales) in the lungs indicate?
–  The alveoli are fluid filled

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Anatomy and Physiology
•  What are the most important defense
mechanisms of the lung to environmental
and infectious agents?
–  The Mucociliary transport system and the
cough reflex

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Respiratory Failure and Ventilation
•  What are the four common respiration
patterns?
–  Central Neurogenic Hyperventilation -
regular, deep, rapid without apnea
–  Cheyne - Stokes - apnea, maximum depth
and rate, followed by apnea
–  Kussmaul - tachypnea labored, deep breaths
–  Biot - regular, fast, shallow breaths with
irregular abrupt periods of apnea

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Respiratory Failure and Ventilation
•  What is CPAP and PEEP?
–  Continuous positive airway pressure (CPAP)
–  Positive airway pressure at the end of exhalation
(PEEP)
–  What do CPAP and PEEP have in common?
•  Improve oxygen by the same mechanism
•  Stabilize airways during expiration

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Respiratory Failure and Ventilation
•  What is Auto-PEEP and what are the complications?
–  Trapping of air in alveoli producing PEEP as a result of insufficient
exhalation time
–  Risks - COPD, asthma, >60 with cardiopulmonary disorders, those
increased minute ventilation
–  Measure by obstructing the exhalation port prior to an inspiratory effort
–  Complications
•  Increased work breathing
•  Barotrauma
•  Hemodynamic compromise
•  Misinterpretation of PCWP readings
•  Increased ICP
•  Decreased renal function
•  Hepatic congestion
•  Increased intrapulmonary shunt
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Respiratory Failure and Ventilation

•  A 35 y/o woman is admitted for pyelonephritis;


she initially responded to antibiotics in the ICU;
she suddenly experiences respiratory distress
and requires intubation; PE is ruled out; what is
going on?
–  ARDS
–  Sepsis, trauma, aspiration, multiple transfusions,
shock and pulmonary contusions can cause this
disorder

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Respiratory Failure and Ventilation

•  Why is the pulmonary artery wedge


pressure an important feature in the
diagnosis of ARDS?
–  PCWP - less 18 mmHg ARDS
–  PCWP - high LV failure

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Respiratory Failure and Ventilation

•  Does PEEP improve ARDS?


–  PEEP commonly improves oxygenation.
–  Does not reduce the amount of total lung water.
–  CXR ground glass appearance eventually “white
lung”

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Respiratory Failure and Ventilation

•  What complications are associated with


ARDS?
–  Pneumothorax
–  Pulmonary infection
–  Pulmonary hypertension
–  Multisystem organ failure

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Respiratory Failure and Ventilation

•  What are the negative effects of PEEP on


cardiac output?
–  PEEP may decrease cardiac output by
decreasing venous return

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Respiratory Failure and Ventilation

•  How long after an initial insult does ARDS


usually occur?
–  12-72 hours

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Respiratory Failure and Ventilation

•  In patients diagnosed with ARDS, what are


the most common causes of death?
–  Sepsis
–  Organ failure
•  Mortality is 50% or higher

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Respiratory Failure and Ventilation

•  What is a hallmark lab sign of ARDS?


–  Refractory hypoxemia
–  The PaO2 level continues to fall despite
administering higher levels of oxygen

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Respiratory Failure and Ventilation

•  What diffuse neuromuscular diseases can cause


respiratory muscle weakness and are acute in
onset?
–  Myasthenia gravis
–  Guillain-Barré
–  Eaton-Lambert syndrome
–  Organophosphate poisoning
–  Botulism
–  Aminoglycosides toxicity

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Respiratory Failure and Ventilation

•  What is an early behavioral sign of


hypoxia?
–  Anxiety

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Respiratory Failure and Ventilation
•  One hour after extubation, the physician orders
arterial blood gasses and wants to be called if
they are abnormal. The ABG’s are as follows:
pO2: 90, pCO2: 40, pH: 7.36, HCO3: 24. Should
you notify the physician?
–  No
–  What are normal blood gas values?
•  pH 7.35-7.45
•  02 90-100
•  CO2 35-40
•  HCO3 24-26
–  Increased HCO3= more Base
–  Increased PCO2 = more Acid
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Respiratory Failure and Ventilation
•  Who wins blood Gas evaluation method?
–  Step 1: Evaluate pH (low-acid, high-base)
•  Respiratory acidosis (increased pCO2,
increased HCO3, <pH)
•  Metabolic acidosis (decreased HCO3,
decreased pCO2, <pH)
•  Respiratory alkalosis (decreased pCO2,
decreased HCO3, >pH)
•  Metabolic alkalosis (increased HCO3, increased
PCO2, >pH)
–  Step 2: Who wins? pCO2 or HCO3 (Which follows
the pH)
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Respiratory Failure and Ventilation

•  Interpret the following blood gases: pH:


7.49, PaCO2: 26, HCO3: 23, PaO2: 100.
–  pH Alkalosis
–  CO2 way low
–  Respiratory alkalosis

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Respiratory Failure and Ventilation

•  What are some of the causes of a


respiratory alkalosis?
–  Pulmonary embolism
–  Asthma
–  Severe hypoxia
–  High fever
–  Hyperventilation syndrome

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Respiratory Failure and Ventilation

•  Interpret the following blood gases: pH:


7.49, PaCO2: 36, HCO3: 40, PaO2: 92.
–  pH Alkalosis
–  Bicarb way high
–  Metabolic alkalosis

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Respiratory Failure and Ventilation

•  Interpret the following blood gases: pH:


7.30, PaCO2: 50, HCO3: 24, PaO2: 80.
–  pH low - acidosis
–  CO2 way high - respiratory
–  Respiratory acidosis

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Respiratory Failure and Ventilation

•  Interpret the following blood gases: pH:


7.30, PaCO2: 40, HCO3: 20, PaO2: 95.
–  pH acidosis
–  Bicarb way low
–  Metabolic acidosis

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Respiratory Failure and Ventilation

•  Following a lung lobectomy, you assess


the incision line and feel a crackling
sensation. What is this called?
–  Subcutaneous emphysema

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Respiratory Failure and Ventilation

•  During the postoperative period, how


often should a patient cough and deep
breath?
–  Every 2 hours
–  To prevent Atelectasis

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Pneumonia and Lung Infections
•  T/F: In all patients with pneumonia, a follow-up
chest radiograph should be obtained
–  True - Rule out tumor
–  Why? Check resolution of infection
–  Lobar infiltrates =Strep pneumoniae
•  Nugget: Fevers, rigors, and rust brown sputum
Patch infiltrates =Staph or Haemophilus
(smokers)
–  Cavitary = Klebsiella, TB

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Pneumonia and Lung Infections

•  T/F: 4-20 year olds are those most commonly


affected with pneumonia secondary to
Mycoplasma pneumoniae infection.
–  True
–  Pneumonia from Mycoplasma pneumoniae
infection is most common in young healthy
people.
–  What are two synonyms? walking pneumonia,
atypical pneumonia
–  How do these patients generally appear? not sick
–  What physical findings? dry cough and TM (ear)
bullae
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Pneumonia and Lung Infections
•  What is bronchiectasis?
–  Abnormal dilation of medium size bronchioles
–  Destruction of the muscular and elastic
components of their walls
–  Usually associated with chronic bacterial infection
most commonly seen in COPD and in the disease
cystic fibrosis

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Pneumonia and Lung Infections

•  What is cystic fibrosis (CF)?


–  CF is a multisystem disorder affecting children and
young adults
–  Characterized by abnormal mucus production
resulting in chronic airway obstruction

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Pneumonia and Lung Infections
•  What are the diagnostic criteria for CF?
–  Primary
•  Characteristic pulmonary manifestations and/
or,
•  Characteristic gastrointestinal manifestations
and/or,
•  A FAMILY history of CF plus an abnormal
sweat chloride test
–  Secondary Criteria
•  Documentation of dual CF mutations and
evidence of one or more characteristic
manifestations
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Tuberculosis
•  What are the classic signs and symptoms of TB?
–  Night sweats, fever, weight loss, malaise, cough,
and a green/yellow sputum most commonly seen
in the mornings.
–  Diagnosed with acid fast staining

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Tuberculosis

•  What constitutes a positive tuberculin


test?
–  10 mm or more of induration at the
injection site
–  Should be read 48 -72 hours after
administration

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Case
•  35 y/o male, HIV+ for 6 years, doing well on his protease
cocktail regimen, presents with increasing cough, malaise,
and fever for 3 days. His CXR is shown. What is going on?
–  Pneumocystis carinii pneumonia (PCP)
–  Most common presentation of AIDS
–  Symptoms may include non-productive cough and dyspnea.
–  Chest x-ray may show diffuse interstitial infiltrates or
uncommonly, it may be negative.
–  Gallium scanning is more sensitive but results in false
positives.
–  Initial treatment includes Bactrim/Septra
–  Pentamidine is an alternative.

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Case
•  Circa 1978; a group of elderly gentleman at a
convention began to display a rapidly progressive
fever, malaise, productive cough along with mental
status changes. A large percentage of these patients
eventually died. What happened?
–  Legionnaires disease
•  25% mortality rate
– This figure should be interpreted cautiously
because of possible underreporting of comorbid
disease

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Legionnaires Disease
•  T/F: Legionnaires disease may involve renal
complications
–  True
–  How did it get its name? American Legion
meeting, Philadelphia PA
–  Rhabdomyolysis and subsequent renal failure are
severe complications of Legionnaires disease
–  Other complications include dehydration and
syndrome of inappropriate secretion of antidiuretic
hormone

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Case
•  A 56 y/o smoker with COPD presents with chills,
fever, green sputum and extreme shortness of
breath. CXR shows a right lower lobe
pneumonia. What is expected from the sputum
culture
–  Haemophilus influenza
–  This organism is generally found in COPD patients
who develop pneumonia and bronchitis.
–  The two other common organisms in COPD
patients are Streptococcus pneumoniae and
Moraxella catarrhalis

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Case
•  A 67 y/o alcoholic was found in an alley, covered
in his own vomit and beer. Upon examination, he
is shaking, has a fever of 103.5o F and is
coughing up currant jelly sputum. What is the
most likely diagnosis?
–  Pneumonia induced by Klebsiella pneumoniae.
–  This is a likely etiology in alcoholics, the elderly,
the very young and immunocompromised patients
–  Other gram-negative bacteria, such as E. coli and
other Enterobacteriaceae, may cause pneumonia
in alcoholics

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•  Describe a pulmonary embolus
–  Thrombus forms in the deep veins of either the leg or
pelvis
–  Less commonly a fat embolus (post skeletal trauma or
orthopedic surgery)
–  Less commonly venous air emboli
–  Clot dislodges, travels to the heart, is pumped by the
right side of the heart into the pulmonary artery system
–  Blocks circulation from the heart to the lungs
–  Most common lower right lobe b/c increased regional
blood flow
–  Risk Factors - Virchow’s triad - damaged vascular
endothelium, venous stasis, hypercoagulability
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Pulmonary Embolism
•  How does a PE present?
–  SOB, restlessness, anxiety, chest pain, syncope,
nausea
–  Fever, hemoptysis, cough, palpitations
–  RR > 20, HR > 100, crackles, decreased chest
wall excursion, S3, S4, gallop, diaphoresis
–  Edema, cyanosis, fever, pleural friction rub
–  Nugget: % DVT have PE? 50%

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Pulmonary Embolism
•  What diagnostic tests should be obtained in suspected PE
–  ABGs: Hypoxemia, hypocapnia, respiratory alkalosis
–  A-a gradient: usually > 10
–  CXR: can be normal; elevated hemidiaphragm, small
infiltrates, effusions, progressive over 12-36 h
–  ECG: pulmonary hypertension changes, QRS changes, tall
peaked p waves, ST and T wave changes
•  Electromechanical dissociation = massive pulmonary
emboli
–  V/Q scan
–  Spiral Chest CT
–  D-Dimer

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Pulmonary Embolism
•  How should PE be treated?
–  Supplemental oxygen
–  IV heparin: beware of heparin induced
thrombocytopenia
–  Transition to oral anticoagulation (warfarin/
Coumadin)
–  Thrombolytic therapy (tPA): may be given in the
first 24-72 h
–  IVC filter
–  Thrombolectomy
–  What about fat or air?
•  No anticoagulation
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Pulmonary Embolism
•  What is unique about venous air emboli in the
setting of PE?
–  Risk factor include: recent surgery, pulmonary
artery/central venous line, misuse of a closed
wound suction unit, cardiopulmonary bypass,
hemodialysis, endoscopy
–  Presents similarly to a PE
–  Bolus size is critical to prognosis
–  Nugget: What position should the patient be
placed in? Left Lateral Decubitus

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Pulmonary Hypertension
•  How is pulmonary hypertension defined?
–  Mean pulmonary artery pressure (MPAP) >
20 mm Hg
–  Notice how LOW these pressures are
compared to the systemic circulation

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Primary Pulmonary
Hypertension
•  What is primary pulmonary hypertension?
–  Idiopathic or unexplained pulmonary
hypertension
–  Seen primarily in children
–  Long term prognosis is poor

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Secondary Pulmonary
Hypertension
•  What is secondary pulmonary hypertension?
–  Pulmonary hypertension secondary to chronic
hypoxia resulting from another disease
–  COPD, cardiac valvular disease, obstructive sleep
apnea, recurrent PE
–  Fen/Phen (Fenfluramine and Phentermine weight
loss medication, high altitude hypoxia, congenital
heart disease

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Pulmonary Hypertension
•  What is the treatment for pulmonary
hypertension?
–  Primary: supportive
•  Oxygen
•  Diuretics
•  Digoxin
•  Bronchodilators
–  Secondary: treat underlying disease

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Pneumothorax and Plueral Effusions

•  What are the signs and symptoms of a


pneumothorax?
–  Tachypnea
–  Restlessness
–  Hypotension
–  Dyspnea
–  Hypoxia

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Pneumothorax and Pleural Effusions

•  What is the intrapleural pressure in the case of a


pneumothorax?
–  Non-tension pneumothorax at end expiration:
atmospheric
•  The lung collapses because of the intrinsic
elastic properties of the lung.
–  Intrapleural pressure is greater than atmospheric
in the case of a tension pneumothorax

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Pneumothorax and Pleural Effusions

•  What accessory x-rays may be obtained to


diagnose a pneumothorax?
–  Expiratory film
–  Lateral decubitus film on the affected side
–  Nugget: Greater 20% = Indication for chest
tube or on vent

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Pneumothorax and Pleural Effusions

•  Signs of tension pneumothorax on physical exam include


what?
–  Tachypnea
–  Unilateral absent breath sounds
–  Tachycardia
–  Pallor
–  Diaphoresis
–  Cyanosis
–  Tracheal deviation
–  Hypotension
–  Neck vein distention
–  Treat with
–  Needle decompression (2nd intercostal space,
midclavicular line)
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Pneumothorax and Pleural Effusions

•  You note a cessation of fluctuation in the


water seal bottle from a chest tube. What
is the most likely cause?
–  Chest tube obstruction

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Pneumothorax and Pleural Effusions

•  What level should the collection and


suction bottles from a chest tube be kept
at in relation to the patient?
–  Below the level of the patient’s chest

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Hemoptysis

•  What are the major causes of massive


hemoptysis?
–  Tuberculosis
–  Bronchiectasis
–  Lung cancer
–  Remember destructive process =
hemoptysis

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Hemoptysis
•  What are the major cardiovascular causes
of hemoptysis?
–  Mitral stenosis
–  Pulmonary hypertension
–  Why?
•  Increased pressure in the pulmonary
circulation

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Hemoptysis
•  How does pulmonary artery
catheterization produce hemoptysis
–  By pulmonary artery rupture, aneurysm
formation and leakage and pulmonary
infarction

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Hemoptysis

•  How does hemoptysis differ from


hematemesis?
–  Blood in hemoptysis is often frothy and
bright red
–  Alveolar macrophages may be seen on
microscopy
–  Hematemesis is often acidic with a pH less
than 2.5; Why? stomach acid

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•  What is obstructive lung disease?
–  Diseases that primarily obstruct or destroy large and small
bronchioles
–  Examples:
•  Asthma
•  Mucous plugs
•  Chronic bronchitis
•  Artificial airway obstruction
•  Bronchiectasis
•  Emphysema
–  DX of Wheezing? Name six – CCAAAT
–  COPD, CHF, Asthma, Anaphylaxis, Aspiration,
Tracheobronchitis

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•  What is restrictive lung disease?
–  Diseases that primarily affect or destroy
lung tissue or limit lung expansion

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•  What are some examples of restrictive lung
diseases?
–  Obesity hypoventilation syndrome
–  Pneumothorax
–  Atelectasis
–  Pneumonia
–  Pulmonary edema
–  Tuberculosis
–  Lung tumors/cancer

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•  What are the 3 major pathophysiological
components of airway obstruction in
asthma?
–  Airway wall narrowing from chronic
inflammation and edema
–  Mucus plugging
–  Bronchoconstriction

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•  A 20-year-old female has been seen 3 times in the
past 18 hours for treatment of an acute asthmatic
exacerbation. She has received maximal therapy.
Examination reveals significant wheezing and the
use of accessory breathing muscles. What is
going on?
–  Status asthmaticus
–  Defined as an episode of bronchospasm that is
not reversed after standard beta agonist and
theophylline therapy after 24 hours

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•  What are the criteria for ICU admission in
a severe asthma case?
–  PEFR < 30% baseline
–  PCO2> 40 mmHg
–  O2 saturation < 90%
–  Severe obstruction with evidence of
decreased air movement
–  Pulsus paradoxus >15 mmHg

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•  In addition to bronchodilator therapy what other measures
should be initiated in acute SA?
–  Oxygen
–  Possible need for intubation if not responsive to treatment
–  Intravenous corticosteroids
–  Antibiotics
–  Possibly anticholinergics (e.g., atropine)
–  Buffers (to combat metabolic acidosis); can enhance
bronchodilator effects
–  Fluid replacement
–  Avoid sedatives if possible

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•  T/F: Patients with COPD who are in acute
distress may receive too much oxygen
–  Theoretical but not clinically
–  What 2 factors drive ventilation? Decreased O2,
Increased CO2
–  Why are COPD patients possibly different? Less
sensitive CO2
–  Is this a high clinical risk? Possibly

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•  T/F: Alternatives to normal rapid-sequence
intubation for patients with COPD include
continuous positive airway pressure (CPAP) and
biphasic positive airway pressure (BiPAP).
–  True
–  BiPAP and CPAP
–  What might be a limiting factor? Tolerance
–  Consider awake nasotracheal intubation in
patients with COPD

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•  28 y/o female with asthma currently being
treated with nebs and IV steroids. Exam
reveals increased confusion, a rising
PaCO2, and disappearance of wheezing.
What is going on?
–  Status Asthmaticus

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Case
•  75 y/o female with COPD has acute respiratory
distress. Exam reveals SOB and circumoral
cyanosis. She is poorly responsive. ABGs pH
7.20, PaCO2 60, PaO2 55, HCO3 25, SaO2 .80, and
FIO2 30%. Most likely problem? Treatment?
–  Acute respiratory failure, intubate and place on
mechanical ventilation

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Bibliography
•  Urden L, Thelen’s Critical Care Nursing, Mosby, 2007
•  Critical Care Nursing Made Incredibly Easy!, Lippincott
2007
•  Essentials of Critical Care Nursing, AACN, 2005
•  Introduction to Critical Care Nursing, Saunders 2004
•  Urden L, Priorities In Critical Care Nursing, Mosby 2007
•  Core Curriculum for Critical Care Nursing, AACN 2005
•  Veenema T, Disaster Nursing, Springer 2007
•  Pulmonary Case Studies, www.emedicine.com, 2009

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