Respiratory Procedures Exam 4 PDF

Pulmonary resuscitation Indications - upper and lower airway obstruction - Altered respiratory drive Contraindications - pt does not want to be resuscitated and documented Failure to restore gas exchange can result in hypoxia injury or even death Relieving UAW obst...

Pulmonary resuscitation Indications - upper and lower airway obstruction - Altered respiratory drive Contraindications - pt does not want to be resuscitated and documented Failure to restore gas exchange can result in hypoxia injury or even death Relieving UAW obstruction Reposition the AW to move the tongue anteriorly away from posterior of the pharynx, thereby opening the upper AW Tilt the head and anterior mandibular displacement Head tilt - Tilt the head backward using one hand on forehead and slightly hyperextending the neck ( sniffing position ) - Do not use w/ suspected cervical spine injury Anterior mandibular displacement - Opens AW sans spinal cord manipulation, also known as jaw thrust - Grabs both side of ramus anteriorly Artificial airways are designed to maintain the pt AW Oropharyngeal airway It relieve obstruction in the unconscious pt by tongue or soft tissue It separates the tongue from posterior wall of the pharynx Size matters! - too small can cause further obstruction - Too large can cause the epiglottis to shut - Right size lift the base of tongue posterior of AW Nasopharyngeal airway It separates tongue from soft palate Indication - relieve obstruction - Frequent nasotracheal (suction )  Right size - Travis of ear to tip of nose - Too small can cause further obstruction - Too big can cause the epiglottis to shut Laryngeal mask airway - The tip rests against the upper esophageal sphincter and side face the pyriform fossae, lying under base of tongue - Seals off the esophagus - Black line should always face the upper lip Manual resuscitator Flow inflating Permanent and disposable self inflating Provide a means of delivering positive pressure ventilation to pt airway - Ventilation bradypneic or apneic pt are the most common - Hyperinflation pt with oxygen before and after suctioning procedure ( hyperoxygenation) - Generate airway pressure and large tidal volume to expand Atelectatic lung segments - Allow additional positive end expiratory pressure valve Flow inflating manual resucitators Rely on gas flow to inflate them Disposable Can deliver 100% o2 or any fio2 if set on a blender Built in resistance - Can feel lung compliance - It get harder to bag when lung compliance worsens Disposable self inflating manual resuscitator - delivers 21% in the absence of supplemental o2 - Stiffness of device makes it harder to feel compliance - An deliver up to 100% o2 depending on flow rate Resuscitator valve type Diaphragm (leaf) type - distort as P is applied and allow flow through to pt Spring and disk/spring and ball type - spring is compressed as bag is squeezed to allow flow to pt Duck bill valve  - distort with p PEEP valve PEEP is necessary in critical ill pt It uses spring tension to maintain a set P in the lung, even at end exhalation Confirm with a manometer to avoid barotrauma Can use manometer alone to maintain PEEP without valve - flow inflating Mouth to mask ventilation devices Soft seat mask + one way valve with filter added to separate pt and practitioner May have valve for supplemental o2 up to 70% fio2, if not you can wear Nasal Cannula Secure mas with both hands for tight seal Laryngoscopes and blades Miller laryngoscope blade - directly lift epiglottis Macintosh laryngoscope blade - It slip into vallecula to indirectly lift epiglottis Equipment used to assisted in intubation Mcgill forceps Stylet Yankauer suction ( tonsil tip) End tidal CO2 detection Endotracheal tubes Cuffed and uncurled tubes Mallinckrodt Hi-Lo evac endotracheal tubes - suction lumen just above the cuff Wire reinforced endotracheal tubes - used to prevent kinking Oral and nasal RAE tube - have to bend the circuit to move it from AW Endobroncial endotracheal tube - Carlene’s tube( has 2 cuffs, intubate L mainstem) - Robert Shaw tube (2 cuffs, intubate R or L mainstem) Endotracheal tube exchanger  - it removes and replace endotracheal tube - Tube can be change when there is a blown cuff, damage or upsizing - Threaded through old tube, remains in place when tube removed, new tube is fed over it ( guaranteed to go through vocal cords if old tube was properly in place) Poiseulles law Smaller AW = increase WOB As radius decreases by ½ resistance increases by 16x Small artificial AW can be more difficult due to WOB Adult: height dependent - female: 6.5 - 7.5 - Male: 7.0 - 8.0 Formula for pediatric: - ETT= (age in years + 16)/4 Forces exerted by artificial airway cuffs P= F/A High volume, low pressure cuff - ETT - Trachs Increased volume = more surface area = less P to seal tube against tracheal wall - less pressure on tracheal mucosa - Age cuff off for cuff is 8 yrs Cuff pressure measurement Techniques - minimal occlusion volume - Minimal leak Cuff pressure manometers - mechanical manometer and three way stopcock - Posey cufflator DHD Cuff mate2 Measured/filled via pilot ballon MLV ( minimal leak volume) vs MOV ( minimal occlusive volume) Minimal leak volume - auscultation upper airway - Add air to cuff until leak disappears - Remove a small amount until leak is just heard again Minimal occlusive volume - Add air to cuff until leak disappears  - Upper air way Cuff pressure manometer Measure P in cuff used to seal trachea - 20-30 cm h2o - Calibrated to atmospheric P Respironic pressure easy - helps with tube leaky cuff - Adds P to cuff during inspiration when it’s needed ( utilizes positive p from ventilation ) - Cuff P is reduced during exhalation Combitube airway Double lumen - esophageal gastric AW - ETT It’s used for blind insertion 2 cuffs inflate both - ventilate through port to confirm which produces chest rise and adequate ventilation Tracheotomy tube Bypass the entire upper AW Made between 2nd and 3rd tracheal rings Cuffed, disposable tracheostomy tube Contain cuff and pilot balloon No disposable inner cannula; entire trach is changed periodically Usually made of PVC Cuffed tracheostomy tube with disposable inner cannula Most commonly used Inner cannula is removable No need to change the entire trach unless latency of cuff is in question - most hospitals will change weekly Fenestrated tracheostomy tube Contains a removable inner cannula When inner cannula is removed and ballon is deflated, pt may breath through upper AW  Used for weaning purposes With cuff inflated and inner cannula inserted, mechanical ventilation is possible Silver Jackson tracheostomy tube Can be used as permanent trach Not very common Silver is more durable and easier to clean Communi-trach Also known as speaking tube Speech with an inflated cuff Blows O2 by vocal chords using their own expiratory gas flow - often difficult for pt to coordinate - Speech is not normal sounding Olympic trach talk A Briggs adapter with a spring loaded valve Allows pt to inspire through trach, but must expire through upper AW Trach cuff must be deflated otherwise, pt can’t exhale Pass Muir tracheostomy valve Small one way valve that vacillates speech Cuff must be deflated or pt can’t exhale Considered gold standard of speaking valve since it’s commonly used Switching to a speaking or weaning device can be difficult due to pt fear, anxiety or muscle weakness Start small, allowing pt to use the device a few minutes a day and build up from there Trach button Used to maintain the stoma after tracheostomy has been removed Plug closes the stoma so pt can breath through upper AW IPPB adapter allows mechanical ventilation ( no cuff) Kistner button Trach button with one way valve Cannot use with ventilation One way valve forces pt to exhale through upper AW  - used for speech - Allows for more effective cough Suction regulator Uses a single stage regulator to reduce high negative P < 120mmHg Must occlude to accurately read pressure Suction catheters Removes secretions, blood, or vomit from pt AW Never use catheter that has diameter > ½ ( either anatomical or artificial) While inserting catheter, apply suction as catheter being withdrawn ( no more that 10 sec) Pre- hyperoxygenate always hyperventilate if necessary Vane-type respirometers Wright respirometer - portable - Uses rotating vanes and a gear mechanism - 10-20 LPM - Flow>300 LPM can damage van Peak flowmeters Wright peak flowmeter - permanent/reusable Mini wright peak flowmeter - cheaper/ lighter/ plastic version Assess peak flowmeter - disposable; very common today Asthma care plan Green - All is good, no symptoms - PEFR 80-100% - Take controller meds Yellow - Coughing/wheezing, ^ WOB - Symptoms come on exertion, relieved with medication  - Peak flow 50-100% - Take controller meds, rescue meds as needed, and call MD if in yellow zone for over 24 hours Red - Difficulty breathing, coughing, wheezing not helped by medication - Trouble walking or talking due to symptoms - Meds not working - PEFR less than 50% - Call MD now, if no answer TO ER Hemoglobin and its variants Hgb reversible bind W/O2 - HbO2 - RHb Carboxyhemoglobin - bound to CO - Affinity = 200-250x Methemoglobin - cannot bind w/O2 - Brown in color Co oximery Determines fractional HB Uses spectrophotometry - RBCs are hemolzed to release HB - Isobestric point: wavelength where 2 or more ( Hb, HbO2, HbCO) absorb same amount of light - Concentration can be determined by the amount of light absorbed End tidal CO2 monitoring Capnography Sensor position - mainstream - Sidestream - Proximal diverting Volume displacement device Water seal spirometer - exhaled gas enters a counterweighted bell - CO2 absorber Dry rolling seal spiromter - oriented horizontally - Metal  Bellows spirometer - gas entering bellows causes it to expand Body plethysmographs Uses boyle's law to measure changes in thoracic volume P in box changes w increased or decreased in volume Pneumotachmoeter measures flow Pneumotachometers Measures gas flow May obtain V indirectly. Volume= flow x Time Thermal anemometer - measures current used to keep grid hot Fleich pneumotachometer - relies on P differential to measure flow Venturi pneumotachmeter - measures P difference along Venturi tube Pitot tube flow sensor - measures difference in incoming flow and static P Vortex sensor - uses vortex shedding principle - Turbulent flow impedes transmission of ultrasonic waves Indirect calorimetry Measures oxygen consumption and carbon dioxide production - minute ventilation - Tidal volume - Resting energy expenditure - RQ Nutritional assessment - ventilator weaning - Diet/ exercise prescriptions Apnea monitor types Inductive plethysmography Impedance plethsmography Home sleep monitors Impedance channel SpO2 channel Heart rate channel  Airflow channel