Respiratory Notes: Respiratory Therapist's Pocket Guide (Davis's Notes)

Copyright © 2008 by F. A. Davis.

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Respiratory

Notes Respiratory Therapist’s Pocket Guide

Gary C. White, MEd, RRT, RPFT Purchase additional copies of this book at your health science bookstore or directly from F. A. Davis by shopping online at www.fadavis.com or by calling 800-323-3555 (US) or 800-665-1148 (CAN) A Davis’s Notes Book

F. A. Davis Company • Philadelphia

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F. A. Davis Company 1915 Arch Street Philadelphia, PA 19103 www.fadavis.com Copyright © 2008 by F. A. Davis Company Copyright © 2008 by F. A. Davis Company. All rights reserved. This product is protected by copyright. No part of it may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without written permission from the publisher. Printed in China by Imago Last digit indicates print number: 10 9 8 7 6 5 4 3 2 1 Acquisitions Editor: Andy McPhee Manager of Content Development: Deborah J. Thorp Developmental Editor: Keith Donnellan Art and Design Manager: Carolyn O’Brien As new scientific information becomes available through basic and clinical research, recommended treatments and drug therapies undergo changes. The author(s) and publisher have done everything possible to make this book accurate, up to date, and in accord with accepted standards at the time of publication. The author(s), editors, and publisher are not responsible for errors or omissions or for consequences from application of the book, and make no warranty, expressed or implied, in regard to the contents of the book. Any practice described in this book should be applied by the reader in accordance with professional standards of care used in regard to the unique circumstances that may apply in each situation. The reader is advised always to check product information (package inserts) for changes and new information regarding dose and contraindications before administering any drug. Caution is especially urged when using new or infrequently ordered drugs. Authorization to photocopy items for internal or personal use, or the internal or personal use of specific clients, is granted by F. A. Davis Company for users registered with the Copyright Clearance Center (CCC) Transactional Reporting Service, provided that the fee of $.10 per copy is paid directly to CCC, 222 Rosewood Drive, Danvers, MA 01923. For those organizations that have been granted a photocopy license by CCC, a separate system of payment has been arranged. The fee code for users of the Transactional Reporting Service is: 8036-1467/08 0 ⫹ $.10.

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Place 2 7/8⫻2 7/8

Sticky Notes

here

For a convenient and refillable note pad

✓ HIPAA Compliant ✓ OSHA Compliant

Waterproof and Reusable Wipe-Free Pages Write directly onto any page of Respiratory Notes with a ballpoint pen. Wipe old entries off with an alcohol pad and reuse.

BASIC

BED ADV ASSESS ASSESS

PROC

CRIT CARE

NEO PEDS

PHARM

TOOLS

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Look for our other Davis’s Notes titles RNotes® Nurse’s Clinical Pocket Guide, 2nd edition ISBN-10: 0-8036-1335-0 / ISBN-13: 978-0-8036-1335-5 Coding Notes Medical Insurance Pocket Guide ISBN-10: 0-8036-1536-1 / ISBN-13: 978-0-8036-1536-6 Derm Notes Dermatology Clinical Pocket Guide ISBN-10: 0-8036-1495-0 / ISBN-13: 978-0-8036-1495-6 ECG Notes Interpretation and Management Guide ISBN-10: 0-8036-1347-4 / ISBN-13: 978-0-8036-1347-8 IV Therapy Notes Nurse’s Clinical Pocket Guide ISBN-10: 0-8036-1288-5 / ISBN-13: 978-0-8036-1288-4 LabNotes Guide to Lab and Diagnostic Tests ISBN-10: 0-8036-1265-6 / ISBN-13: 978-0-8036-1265-5 LPN Notes Nurse’s Clinical Pocket Guide ISBN-10: 0-8036-1132-3 / ISBN-13: 978-0-8036-1132-0 MedSurg Notes Nurse’s Clinical Pocket Guide ISBN-10: 0-8036-1115-3 / ISBN-13: 978-0-8036-1115-3 NutriNotes Nutrition & Diet Therapy Pocket Guide ISBN-10: 0-8036-1114-5 / ISBN-13: 978-0-8036-1114-6 MA Notes Medical Assistant’s Pocket Guide ISBN-10: 0-8036-1281-8 / ISBN-13: 978-0-8036-1281-5 OB Peds Women’s Health Notes Nurse’s Clinical Pocket Guide ISBN-10: 0-8036-1466-7 / ISBN-13: 978-0-8036-1466-6 Ortho Notes Clinical Examination Pocket Guide ISBN-10: 0-8036-1350-4 / ISBN-13: 978-0-8036-1350-8 PsychNotes Clinical Pocket Guide ISBN-10: 0-8036-1286-9 / ISBN-13: 978-0-8036-1286-0 Screening Notes Rehabilitation Specialists Pocket Guide ISBN-10: 0-8036-1573-6 /ISBN-13: 978-0-8036-1573-1 Rehab Notes Evaluation and Intervention Pocket Guide ISBN-10: 0-8036-1398-9 /ISBN-13: 978-0-8036-1398-0 IV Med Notes IV Administration Pocket Guide ISBN-10: 0-8036-1446-2 / ISBN-13: 978-0-8036-1466-8 MedNotes: Nurse’s Pharmacology Pocket Guide, 2nd Edition ISBN-10: 0-8036-1531-0 / ISBN-13: 978-0-8036-1531-1 For a complete list of Davis’s Notes and other titles for health care providers, visit www.fadavis.com.

Copyright © 2008 by F. A. Davis.

Droplet

Airborne

Contact

Private room. Cohorting is OK if the second patient has the same organism. Private room (negative pressure with 6–12 air changes per hour). Cohorting is OK if the second patient has the same organism. Private room. Cohorting is OK if the second patient has the same organism.

Gloves and Gown

Respiratory Protection

Patient Transport

Always wear gloves and Surgical mask Patient should wear gown. a mask during transport.

Always wear gloves and HEPA mask gown.

During transport the patient should wear a HEPA mask.

Wear gloves for any No mask is patient contact. Wear required. gown if you anticipate contact with patient, soiled equipment, or soiled environmental surfaces.

During transport ensure that any contact transmission by the patient is minimized.

BASICS

Isolation Category Patient Placement

1

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Isolation Categories

Age Group

Fears/ Anxieties

Verbal Strategies

Senses

Motor Skills

Cognitive Ability

Infants

Speak in a Loud Gross motor Minimal. Anxiety low, soft, noises skills. toward calm voice. may strangers. startle an Fear of infant. separation from parent(s).

Toddlers

Separation from parent(s).

Use concrete Senses are verbal comacute. munication strategies.

Special Considerations

Never leave unattended; always use side rails on cribs. Support head and neck, protecting the airway. Can under- Requires close Begin to stand develop supervision. more than fine motor Don’t leave they can skills. small objects verbalize. that may become a choking hazard.

BASICS

(Text continued on following page)

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Age-Specific Considerations

Copyright © 2008 by F. A. Davis.

Fears/ Anxieties Separation, death, disability, injury, pain.

Verbal Strategies

Senses

Motor Skills

Use conSenses crete are verbal acute. strategies.

Good motor skills.

Be more Senses Adoles- Embarrassment, loss of thorough are cent control, loss in explaacute. of consciousnations. ness, changes in appearance/function, separation from peer group.

Good motor skills.

Child

Cognitive Ability

Special Considerations

Can underDon’t leave stand more, sharps or explain why other potena child will tially hazarbenefit from dous items at treatment or the bedside. a procedure. Privacy becomes more important. May be Privacy is very capable of important. abstract Encourage thought. verbalization and participation in health-care decisions.

(Text continued on following page)

BASICS

Age Group

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Age-Specific Considerations (Continued)

BASICS

Age Group

Fears/ Anxieties

Verbal Strategies

Senses

Motor Skills

Cognitive Ability

Possesses Reflexes Hearing, Be more abstract may be taste, and thorough thought. slower, sight may in explabalance decline. nations. and coorInvolve dination the patient may be in healthdimincare deciished. sions.

Special Considerations

Be aware of values effect on patient’s care. Endurance may be diminished. Independence and fostering self-care should be encouraged. Possesses Patient’s skin is Joints are Hearing, Geriatric Loss of control, Be more more fragile. changes in stiffer and abstract taste, thorough thought. Patient may appearance/ less sight in explaDementia have function, (cataracts, mobile. nations. or other dysphasia. separation Balance macular Involve mental Patient should from spouse may be the patient degeneradiminishbe involved in (significant more tion, etc.) in healthment may decisionother), death. care decidiminmay be present. making. ished. decline. sions. Adult

Loss of control, changes in appearance/ function, separation from spouse, death.

4

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Age-Specific Considerations (Continued)

5

Characteristics

African Americans

Arab Americans

Eye contact

Establish trust and demonstrate respect.

Females may avoid eye contact with males and strangers.

Touching

Generally accept therapeutic touch. Establish trust first.

Is generally acceptable within the same gender, but is not acceptable between genders.

Gender role differences

Responsibility for decision-making varies by educational level and socioeconomic status.

Most decisions are made by men. Care for daily needs is delegated to women.

Religion and spirituality

Belong to Baptist and other Protestant sects; Muslim.

Muslim (generally Sunni branch), also Protestant, Greek Orthodox, or other Christian faiths.

Blood/organ donation

Will refuse blood if a Jehovah’s Witness. Are reluctant to donate blood or organs.

Mutilation of the body (autopsy) or organ donation may be refused. Some may donate organs because it will benefit the community.

Diet and nutrition

General, no prohibitions unless prohibited by religious beliefs (pork not eaten by Muslims).

Most Muslims do not eat pork. Avoid icy drinks when sick or hot/cold drinks together.

Death/dying & birth

Reluctant to donate organs. Death is a universal experience transcending racial, religious, and socioeconomic barriers.

Colostrum is believed to be harmful to infants.

Misc.

Silence may indicate lack of trust toward the caregiver.

Supportive family members may need to be encouraged to take breaks from caregiving. (Text continued on following page)

BASICS

Copyright © 2008 by F. A. Davis.

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Cultural Diversity

Characteristics Eye contact Touching

Gender role differences Religion and spirituality Blood/organ donation Diet and nutrition Death/dying & birth

BASICS

Misc.

Bosnian Americans

Native Americans

Looking straight into someone’s eyes during a It is important to maintain sustained eye contact during conversations. conversation shows honesty and frankness. Light touch handshake is OK. Shaking hands is OK. Strict Muslims do not Maintain a respectful distance allow male nurses to examine women. while interacting with the patient. Varies from nation to nation. Traditionally, a patriarchal family structure. Majority are Muslim or Christian, a few may May be traditional Native American belief or Christian. be Jewish. Organ donation and receiving blood products Blood and organ donation is generally not desired, but may are acceptable. be open to discussion. Restrictions will vary with Pork is prohibited by Muslims. Medications religious/spiritual beliefs. should not contain alcohol (also prohibited by Muslims). Many visitors can be expected. No cremation Full family involvement occurs throughout all stages of life. is allowed. May only want females present Circumcision may be refused. during delivery of a child. Permanent life support is unacceptable. Most Older adults may prefer the use of “American Indian” over Native consider it shameful to accept Medicaid. American. (Text continued on following page)

6

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Cultural Diversity (Continued)

Characteristics Eye contact

7

Touching Gender role differences Religion and spirituality Blood/organ donation Diet and nutrition Death/dying & birth Misc.

Mexican Americans May avoid direct eye contact with authority figures (health-care providers included). Except for handshaking, touching may be considered disrespectful. Entire family shares equally in decision-making. Primary religion is Roman Catholic.

Russian Americans Direct eye contact is OK. Nodding signifies approval. Touching is OK once familiarity or friendship has been established. Typically, both men and women share in decision-making. Primary religions are Jewish, Eastern Orthodox, and Christian. Many may not practice a faith due to past oppression. May refuse organ donation based on belief that the body is sacred. Drinks with ice should not be served.

Will vary; may be against organ donation. Catholics may refrain from eating meat on Fridays and during Lent. Strong family support during labor. Father may not attend birth, but the Most are very expressive during closest female family member usually bereavement. does. Silence may sometimes indicate a Interpreters should be used whenever disagreement with the plan of possible. care.

BASICS

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Cultural Diversity (Continued)

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BASICS

Weight, Temperature, and Length Conversions Weight Lb

Kg

300 275 250 225 210 200 190 180 170 160 150 140 130 120 110 100 90 80 70 60 50 40 30 20 10

136.4 125.0 113.6 102.3 98.5 90.9 86.4 81.8 77.3 72.7 68.2 63.6 59.1 54.5 50.0 45.5 40.9 36.4 31.8 27.3 22.7 18.2 12.6 9.1 4.5

Temperature F 212 108 107 106 105 104 103 102 101 100 99 98.6 98 97 96 95 94 93 92 91 90 89 88 87 86

C 100 42.2 41.6 41.1 40.6 40.0 39.4 38.9 38.3 37.8 37.2 37.0 36.7 36.7 35.6 35.0 34.4 34.0 33.3 32.8 32.1 31.7 31.1 30.6 30.0

Length Cm

Inches

Feet and Inches

142 145 147 150 152 155 157 160 163 165 168 170 173 175 178 180 183 185 188 191 193 196 198 201 203

56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80

4′8′′ 4′9′′ 4′10′′ 4′11′′ 5′0′′ 5′1′′ 5′2′′ 5′3′′ 5′4′′ 5′5′′ 5′6′′ 5′7′′ 5′8′′ 5′9′′ 5′10′′ 5′11′′ 6′0′′ 6′1′′ 6′2′′ 6′3′′ 6′4′′ 6′5′′ 6′6′′ 6′7′′ 6′8′′

(Text continued on following page)

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9 Weight, Temperature, and Length Conversions (Continued) Weight Lb 5 2.2 2 1

Temperature

Kg 2.3 1 0.9 0.45

F 85 75 74 73 72 71 70 69 68 32

C 29.4 23.9 23.3 22.8 22.2 21.7 21.1 20.6 19.9 0.0

Length Cm 206 208

Inches 81 82

Feet and Inches 6′9′′ 6′10′′

Lb  Kg  2.2 Lb/Kg 9 F  C    32 5

Kg  Lb  0.45 Kg/Lb 5 C  (F  32) 9

inches  cm  0.394 inches/cm

cm  inches  2.54 cm/inch





Pressure Conversions (60F) cmH2O

mmHg

KPa

5

3.68

0.49

10

7.35

0.98

15

11.03

1.47

20

14.71

1.96

25 30 35

18.38 22.06 25.74

2.45 2.94 3.43 (Text continued on following page)

BASICS

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Pressure Conversions (60F) (Continued) cmH2O

mmHg

40 45 50 55 60 65 70 75 80 85 90 95 100

KPa

29.41 33.09 36.76 40.44 44.11 47.79 51.47 55.15 58.82 62.5 66.17 69.85 73.53

3.92 4.41 4.90 5.39 5.88 6.37 6.86 7.35 7.84 8.33 8.82 9.31 9.80

1 cmH2O  0.098 KPa

1 KPa  10.21 cmH2O

1 mmHg  1.36 cmH2O

1 cmH2O  0.737 mmHg

ATPS  BTPS BTPS  ATPS 

STPD  ATPS 

 

ATPS  STPD PB  PH2o  PB  47 PB  PH2O  760

 

310  273  T

273  273  T





PB  Barometric pressure PH2O  Partial pressure of H2O at spirometer temperature  Partial pressure of H2O at body temperature and pressure saturated 310  Body temperature in Kelvin T  Spirometer temperature (C)

47

10

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Copyright © 2008 by F. A. Davis.

11 Patient Interview Purpose The patient interview facilitates the collection of subjective information regarding the patient’s present illness while establishing a professional rapport and trust with the patient.

Structure of the Interview ■ Project a genuine interest in the patient ■ Be sensitive to the patient’s concerns ■ Give undivided attention to the patient and his or her responses ■ Use eye contact effectively ■ Introduction ■ Be professional (dress, mannerisms, respect, etc.) ■ Introduce yourself to the patient using last names (Mr. Smith, I am Mrs. Lanker from respiratory care.) ■ Use eye contact ■ Professionalism ■ Conduct the interview seated beside the patient facing him or her ■ The patient should be seated upright with his or her eyes at an elevation higher than yours ■ Maintain privacy ■ Respect the patient’s beliefs and attitudes ■ Use open-ended questions (Tell me, how is your breathing this morning?) ■ Use reflection in your responses (So your chest feels tight.) ■ Be empathetic

BED ASSESS

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History Taking ■ Biographical ■ Age, gender, occupation, race/culture ■ Chief complaint ■ What resulted in the patient seeking medical attention? ■ What are the symptoms that caused the patient to seek medical attention? ■ Are there any associated symptoms (sweats/chills, fever, cough, etc.)? ■ Onset, duration, severity? ■ History of present illness ■ Detailed description of each symptom described in the chief complaint ■ P, Q, R, S, T ◆ P (Provokes/Point): What causes it, what makes it better, where is it? ◆ Q (Quality): Dull, achy, how much is involved, how does it look, how does it feel? ◆ R (Region/Radiation): Where does it radiate or spread? What makes it better? What makes it worse? ◆ S (Severity): Lichert scale 1 (no pain) to 10 (worst pain). ◆ T (Timing): When did it start? Is it constant? Is it sudden or gradual? ■ Past medical history ■ Childhood illnesses ■ Hospitalizations (injuries, accidents, emergent conditions, etc.) ■ Surgeries (elective, emergency, etc.) ■ Allergies, immunizations ■ Current medications (prescribed and over-the-counter) ■ Social history ◆ Smoking: How long? What (cigarettes, cigars, pipe, etc.)? Have you quit? How long? ◆ Alcohol: How long? What (liquor, wine, beer)? How often? How much? How long? ◆ Drug use: What? How often? How long?

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13 ■ Family history ◆ Family history for chronic lung disease (asthma, emphysema, bronchitis, cystic fibrosis)? ◆ Family history for heart disease? ◆ Family history for hypertension? ◆ Family history for renal disease? ◆ Family history for cancer? ■ Occupational/environmental history ◆ Work: Shipyard, mining, farming, foundry work, mill work, insulation installation, welding, chemical exposure, textile work, etc. ◆ Home: Air conditioning, evaporative cooling, humidifier, molds, insulation, plants, smoking, wood stove use ◆ Geographical: Histoplasmosis, coccidioidomycosis, blastomycosis

Vital Signs Vital Signs Assess vital signs upon admission as ordered; on change in status, with chest pain or any abnormal sensation; before and after administration of blood products or medications that can cause cardiovascular or respiratory changes; before and after any intervention that can affect the cardiovascular or respiratory system. Vital signs should include temperature (T), heart rate (HR), respiratory rate (RR), blood pressure (BP), SpO2, and pain assessment.

BED ASSESS

BED ASSESS

Age Preemie Term 36.8

6 mo

1 yr

3 yr

6 yr

9 yr

37.7

37.7

37.7

37

37

12 yr 15 yr 37

37

Adult Elderly

T

36.8

37

36

HR

140

RR

40–60

30–80

30–60

20–40

20–40

15–25

15–25

BP

73/55

73/55

73/55

90/55

90/55

95/57

95/57 120/80 120/80 120/80 120/80

SpO2

95%

95%

95%

95%

95%

95% 95 % 95% 95% 95%

80–180 80–140 80–140 80–140 75–120 50–90 50–90 50–90 60–100 60–100 15–24 15–20 12–20

15–20

95%

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Normal Ranges

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15 Head and Neck Assessment ■ Head—Facial expressions, cyanosis, pursed lip breathing, nasal flaring, eyes (pupil size and reaction)? ■ Neck—Jugular venous distension, use of accessory muscles, tracheal position, lymph node palpation?

Physical Examination of the Chest Inspection ■ Respiratory rate: Normal, tachypnea, bradypnea? ■ Rhythm: Regular, irregular? ■ Pattern: Eupnea, hyperpnea, hypopnea, Kussmaul’s, CheyneStokes, Biot’s ■ Chest conformation: A-P diameter, kyphosis, scoliosis, lordosis, kyphoscoliosis, pectus? ■ Digital clubbing?

BED ASSESS

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Copyright © 2008 by F. A. Davis.

Ventilatory Patterns

Normal (Eupnea)

Cheyne-Stokes

Biot’s

Kussmaul’s Palpation ■ ■ ■ ■ ■

Tracheal position: Midline, deviated right or left? Areas of tenderness? Symmetry: Do the hands move uniformly? Tactile fremitus: Present or absent? Subcutaneous emphysema present?

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17 Assessment of Chest Symmetry

Anterior

Posterior

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Percussion ■ ■ ■ ■

Hyperresonance: Air trapping? Pneumothorax? Resonance: Normal air/tissue density? Dullness: Consolidation? Atelectasis? Pleural fluid? Flatness: Pleural effusion? Pneumonectomy?

Auscultation ■ Vesicular: Low pitched and soft with inspiration longer than expiration. Normal over most of the lung fields. ■ Bronchial: Harsh, loud and higher pitched with expiration longer than inspiration. Normal over the manubrium. ■ Bronchovesicular: Moderate intensity and pitch with equal inspiratory and expiratory phases. Over sternum and lung apices. ■ Crackles: Discontinuous (starts and stops) fine, medium, or coarse (inspiratory or expiratory). Can be caused by alveoli opening (fine), fluid in bronchioles (medium), and fluid in large airways (coarse). ■ Wheezes: Continuous “musical” sound (inspiratory or expiratory). Caused by air flowing through narrowed airway lumen. A wheeze will have a higher pitch if the narrowed lumen is very small. Wheezing should be described as inspiratory, expiratory, monophonic (single pitch), or polyphonic (multiple pitches). Polyphonic wheezing occurs during the expiratory phase. ■ Rhonchi: Coarse, wet, low-pitched continuous sounds produced by large amounts of secretions in the airways. Rhonchi may clear if the patient is asked to cough. ■ Rub: Grating or creaking sound (like leather rubbing). Caused by inflamed pleural layers or pleural irritation.

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19 Positions Used in Chest Auscultation 1

1 2

2 3

3 4

4 5

5

Anterior 1

1 2

2

4

4 5

3

3 5

6

6

7

7 8 9

Posterior

BED ASSESS

8 9

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BED ASSESS

Sputum/Cough ■ Cough—Duration (acute 3 weeks, chronic 3 weeks or recurrent), productive, nonproductive, time of occurrence? ■ Sputum—Amount (30 mL/day, 30 mL/day), color, consistency, odor, hemoptysis?

Ventilation Assessment ■ VE, VT, and Frequency ■ Minute Volume (VE)—The volume exhaled or inhaled in 1 minute ◆ Normal: 5–7 L/min (adult) ■ Tidal Volume (VT)—The resting volume inhaled or exhaled during each breath ◆ Normal: 4–7 mL/kg ■ Frequency (rate)—The number of breaths per minute. Normals: ◆ Term infant: 30–80 ◆ 6-month-old: 30–60 ◆ Pediatric: 20–40 ◆ Adolescent: 15–25 ◆ Adult: 12–20 ■ Rapid Shallow Breathing Index (frequency/tidal volume [L]) ■ Normal: 100 ■ PaCO2 ■ Normal: 35–45 mmHg ■ PEtCO2 ■ Normal: 35–43 mmHg ■ Deadspace (VD ana, VD/VT) ■ Anatomic: Normal 1 mL/Lb body weight VD  1 mL  Body Weight (Lb) ■ VD/VT: Normal 0.25–0.35 VD / VT  ■ Alveolar Ventilation

PaCO2  PECO2 PaCO2

VA  (VD / VT  VT)f

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Copyright © 2008 by F. A. Davis.

21 Oxygenation Assessment PaCO2 0.8

Alveolar air

PAO2  FIO2(PB  47 mmHg) 

Oxygen content

CaO2  SaO2 (Hb  1.34)  (PaO2  0.003) Normal: 15–24 mL/dL PaO2: 80–100 mmHg SpO2: 90%

Oxygen delivery

DO2  QT  (CaO2  10) Normal: 1000 mL/min SvO2 (Hb  1.34)  (PvO2  0.003) Normal: 12–15 mL/dL CaO2 – CvO2 Normal: 4–6 mL/dL PaO2/FIO2 Normal: 200

Note: Only calculate at FIO2 of 0.21 or 1.0

Venous oxygen content Arterial-venous oxygen content difference

PaO2/PAO2 Normal: 0.8–0.9 Oxygen consumption

VO2  QT (Ca-vO2  10) Normal: 250 mL/min

Oxygen extraction ratio

O2 ER 

End capillary oxygen content

CcO2  (Hb  1.34)  (PAO2  0.003)

Pulmonary shunt

CaO2  CvO2 CaO2 Normal: 0.25

CcO2  CaO2 Qs /QT  CcO  CvO 2 2 Normal: 0.20

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Inspection

Palpation

Ventilation

Percussion Auscultation VT f

↓ Normal or Normal or ↓Breath fremitus dull sounds, crackles, rhonchi & Pursed lip wheezing breathing

Bronchi- Use of accessory tis muscles

PaCO2

Oxygenation Indices SpO2 CaO2 QS/QT

↑ ↑ ↑ (chronic)

↓

↓

↑

Asthma

Use of accessory muscles

↓ Normal or Normal or Wheezing, fremitus hyperrecrackles sonant

Pursed lip breathing

↑ ↑ ↓ (early)

↓

↓

↑

↓

↓

↑

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Physical Findings

↑ A-P Dia

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↑ (severe or late)

↑ A-P Dia

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Disease State Summary

Emphysema

Use of accessory muscles ↑ A-P Dia

↓ Normal or Hyperreso- Crackles & fremitus nant wheezing

↑ ↑ ↑

Copyright © 2008 by F. A. Davis.

Ventilation

Inspection Palpation Percussion Auscultation VT f PaCO2 Cystic Fibrosis

Use of ac- ↑Fremitus Hyper↓Breath cessory resonant sounds, muscles crackles, & rhonchi ↑ A-P Dia

Pneumonia

Dyspnea

↑Fremitus Dullness

Pulmonary Edema

Dyspnea

Pulmonary Embolus

Atelectasis

Oxygenation Indices SpO2 CaO2 QS/QT

↑ ↑ ↑

↓

↓

↑

↓Breath sounds, crackles, & rhonchi

↓ ↑ ↓

↓

↓

↑

↑Fremitus Dullness

↓Breath sounds, crackles, rhonchi & wheezing

↓ ↑ ↓

↓

↓

↑

Dyspnea

Normal

↓ ↑ ↓

↓

↓

↑

Dyspnea

↑Fremitus Dullness

Wheezing, crackles, pleural friction rub ↓Breath sounds, crackles

↓ ↑ ↑ (severe)

↓

↓

↑

Normal

BED ASSESS

Physical Findings

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Disease State Summary

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Cardiac Assessment Capillary Refill ■ Normal: 3 seconds ■ Increased: 3 seconds (low cardiac output or decreased peripheral perfusion)

Heart Rate ■ Normals ■ Newborn 80–180/min ■ 1 year 80–140/min ■ 2 years 80–140/min ■ 6 years 75–120/min ■ 10 years 50–90/min ■ 16 years 50–90/min ■ Adult 60–100/min ■ Geriatric 60–100/min ■ Points of palpation: radial, brachial, femoral, carotid, popliteal, posterior tibial, dorsal pedal

Blood Pressure ■ Normals ■ Newborn ■ 1 year ■ 2 years ■ 6 years ■ 10 years ■ 16 years ■ Adult ■ Geriatric

73/55 mmHg 90/55 mmHg 90/55 mmHg 95/57 mmHg 95/57 mmHg 120/80 mmHg 120/80 mmHg 120/80 mmHg

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25 Cardiac Palpation ■ Point of Maximal Impulse (PMI) – 5th intercostal space midclavicular line (left ventricular contraction) ■ Left shift—cardiomegaly ■ Left sternal border—right ventricular hypertrophy (COPD) ■ Reduced—emphysema, hyperinflation ■ Lobar collapse—shifts toward collapse ■ Pneumothorax—shifts away from pneumothorax ■ Pulmonic palpation—2nd intercostal space at the sternal border ■ Increased—pulmonary hypertension

Cardiac Auscultation ■ Normal heart sounds: ■ S1—Tricuspid and mitral valve closure during ventricular contraction. Auscultated at lower left sternal border. ■ S2—Pulmonic and aortic valve closure during diastole. Auscultated at 2nd intercostal space at the sternal border. ■ S3—Produced by rapid ventricular filling following systole. Auscultated at the apex of the heart (5th intercostal space midclavicular line). ■ S4—Presystolic gallop. Auscultated late in diastole at the apex (5th intercostal space midclavicular line). Lowfrequency sound and often transient, caused by decreased ventricular compliance or in increased diastolic volume.

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Positions used in heart auscultation

Pulmonary

Aortic

Tricuspid

Mitral

■ Abnormal auscultatory heart sounds: ■ Split S1—Delayed closure between the tricuspid and mitral valves (abnormally long S1 interval) can be caused by right bundle branch block, preventricular contractions (PVCs), or ventricular tachycardia. ■ Split S2—Delayed closure between the pulmonic and aortic valves (abnormally long S2 interval) can be caused by atrial septal defect, ventricular septal defect, pulmonic stenosis, pulmonary embolism, and a right bundle branch block. ■ Click—Early systolic high-frequency sound caused by rapid opening of the aortic valve. Late systolic (after S1) caused by mitral valve prolapse. ■ Snap—High-frequency sound occurring after S2 frequently caused by mitral stenosis.

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27 ■ Murmurs—Sustained heart sounds caused by turbulent blood flow through the heart. ◆ Presystolic murmur: Heard at the start of S1 with its peak occurring in the first third of systole. Caused by mitral stenosis or increased flow through the pulmonic valve. ◆ Midsystolic murmur: Heard just after S1 peaking at midsystole. Caused by narrowed aortic or pulmonic valve. ◆ Late systolic murmur: Heard during late systole. Caused by mitral valve prolapse or tricuspid valve defects. ■ Early diastolic murmur: Heard at the start of S2 peaking in the first part of diastole. Caused by aortic regurgitation. ■ Mid-diastolic murmur: Heart after S2 peaking at mid diastole. This is a low-frequency sound, caused by mitral stenosis and best heard at the apex. ■ Late diastolic murmur: Heard late in diastole, often extending into S1, can be caused by mitral and tricuspid stenosis. ■ Bruits: Auscultatory heart sounds heard over the neck (carotid arteries). The sound is caused by turbulence (obstruction to blood flow) and is of mixed frequency.

Cardiac Enzymes Enzyme Troponin (TnI) Troponin (TnT) Creatine phosphokinase (CPK) CPK-MB

Normal 0.0–0.1 ng/mL 0.18 ng/mL 150 U/L 3 ng/mL

Neurological Assessment ■ Mental status: Alert, confused, lethargic, comatose ■ Motor ability: ■ Grip Strength: Ask patient to grip your hands. Is the grip equal? Ask the patient to push/pull your hands. Is it equal? ■ Feet: Ask the patient to push/pull your hands. Is it equal?

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■ Tremors, tics, mannerisms, gestures, gait hyperactivity, restlessness, agitation echopraxia, rigidity, aggressiveness ■ Posture: decorticate (arms rigidly flexed, legs extended), decerebrate (arms extended [pronated] and legs extended) ■ Pupil size: (See Vital Signs) ■ Glasgow Coma Score (see Tab 5, Critical Care)

Nutritional Assessment Body Mass Index weight in lbs. BMI    703 (height in inches)2

Body Mass Index

Weight Status

18.5 18.5–24.9 25.0–29.9 30

Underweight Normal Overweight Obese

Body Fat

Skinfold Thickness Use calipers to measure skinfold thickness at the biceps, triceps, subscapular, and suprailiac regions. Tables are used to translate the data into relative percentage of body fat. Skinfold thickness measurements are one way to estimate total body fat.

Maximum Percentage of Body Fat 20 years of age 20–22 years of age 23–25 years of age 25–29 years of age 30 years of age

17 % 18 % 19 % 20 % 22 %

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29 Lab Tests

Serum Albumin Measure of the protein fraction in the blood that corresponds to protein reserves in the muscles. The test can be used to screen protein depletion. However, 1/2 life is long (20 days) so values can be slow to change with changes in nutritional intake.

Serum Albumin Level

Assessment

3.5–5.0 gm/dL 2.5 gm/dL

Normal Deficient

Thyroxin-binding Prealbumin This value quickly reflects changes in nutrition (1/2 life 2 days).

Thyroxin-binding Prealbumin (TBP) Level

Assessment

10–20 mg/dL  10 mg/dL

Normal Deficient

Retinol-binding Protein A measure of a transport protein of retinol in the plasma (alpha 1-globulin). This has a short 1/2 life (12 hours), and quickly reflects changes in nutritional status.

Retinol-binding Protein (RBP) 3–6 micro gm/dL 3 micro gm/dL

Assessment Normal Deficient

Urea Nitrogen Measurement of nitrogen content of the urine. An increase in urea nitrogen reflects in increase in protein catabolism.

Urea Nitrogen 8–25 mg/dL 25 mg/dL

BED ASSESS

Assessment Normal Increased catabolism of proteins

Physician Date

Race/Culture

Time

Gender

Admission DX

RCP

HISTORY

Past Medical HX

HX of Present Illness

Current Medications:

30

Height

Age

Chief Complaint

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Weight

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Name

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Basic Assessment

Social History Smoker: Yes ■ No ■ Cigarettes? Yes ■ packs/day ____ How many years? ____ Cigars? Yes ■ How many/day? _____ How many years? _____ Other? ________________ Alcohol use? Yes ■ No ■ What and how much/day? ____________ Nonprescription drug use? Yes ■ What and how often? ________________

No ■

Copyright © 2008 by F. A. Davis.

VITAL SIGNS

HEAD/NECK

MENTAL STATUS

Temp

Head

Alert:

SpO2

Neck: JVP? Yes ■ No ■ Lymph enlargement? Yes ■ No ■ Pupils

PHYSICAL EXAMINATION INSPECTION Rate: normal tachypnea bradypnea Rhythm: normal irregular Pattern: ______________________________

PALPATION Tracheal Pos: midline L R Areas of Tenderness? ______ Symmetry? ___________

Increased A-P Dia?

Yes ■

No ■

Kyphosis? ■ Lordosis? ■ Scoliosis? ■ Yes ■

No ■

Pursed lip breathing? Yes ■

No ■

Cyanosis?

Yes ■

No ■

Sub-Q Air? Yes ■

No ■

Fremitus?

Yes ■ No ■

Confused: Yes ■ No ■ Lethargic: Yes ■ No ■ Comatose: Yes ■ No ■ PERCUSSION Location Hyperresonant ________ Resonant _____________ Dullness ______________ Flatness ______________

BED ASSESS

Heart Rate BP Resp Rate

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Basic Assessment

OXYGENATION

VE

CaO2

VT

SpO2

f

PaO2

How much?

RSBI

PaO2/ FIO2

Color/Odor?

PaCO2

Ca-vO2

VD/VT

QS/QT

CARDIAC ASSESSMENT

NEUROLOGICAL ASSESSMENT

NUTRITIONAL ASSESSMENT

Capillary Refill: Normal Prolonged

Grip Strength: Normal

Weak

BMI:

Heart Rate

Push Pull: Normal

Weak

% Body Fat:

BP

Tremors, tics, etc

Serum Albumin

Posture:

TBP:_______

GCW:

RBP: ________

Cough?

BED ASSESS

Yes

No

How long? Productive?

PMI: Normal

Yes

Yes

L

No

No

R

Auscultation: Bruits:

Yes

No

Urea Nitrogen: ___________

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VENTILATION

SPUTUM/COUGH

Hemoptysis?

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Basic Assessment

Copyright © 2008 by F. A. Davis.

CHEST X-RAY

PULMONARY FUNCTION

pH

FVC

PaCO2

FEV1

HCO3

FEV1/FVC

PaO2

PEF

BE

DLCO

SaO2

FRC

Hb

RV

COHb

TLC

MetHb

RV/TLC

Current O2

BED ASSESS

ARTERIAL BLOOD GASES

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Basic Assessment

ADV ASSESS

Complete Blood Count

Men

Women

Differential

%

Red blood cells (RBC)

4.6–6.2 million/dL

4.6–6.2 million/dL

Neutrophils

40–75%

Hemoglobin (Hb)

13.5–16.5 gm/dL

12.0–15.0 gm/dL

Bands

0–5%

Hematocrit (Hct)

40–54%

38–47%

Eosinophils

0–6%

Mean cell volume (MCV)

80–90 3

80–90 3

Basophils

0–1%

Mean cell hemoglobin (MCH)

21–31 pgm

21–31 pgm

Lymphocytes

20–45%

Mean cell hemoglobin concentration

32–36%

32–36%

Monocytes

2–10%

Platelets

150,000–400,000/ mm3

150,000– 400,000/mm3

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Hematology

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35 Chemistry 

Sodium (Na ) Potassium (K) Chloride (Cl–) Carbon dioxide (CO2) Blood urea nitrogen (BUN) Creatine Total protein Albumin Cholesterol Low-density lipoproteins (LDL) High-density lipoproteins (HDL) Glucose

137–147 mEq/L 3.5–4.8 mEq/L 98–105 mEq/L 25–33 mEq/L 7–20 mEq/L 0.7–1.3 mg/dL 6.3–7.9 gm/dL 3.5–5.0 gm/dL 150–220 mg/dL 130 mg/dL 30–75 mg/dL 70–105 mg/dL

Collection and Evaluation of Pulmonary Secretions 1. Have the patient rinse his or her mouth or preferably brush teeth. 2. Have the patient strongly cough to attempt to expectorate a deep pulmonary sample. 3. If the patient is unable to bring up a sample, administer an SVN or large volume nebulizer treatment with 10% saline (hypertonic saline), and repeat step 2. 4. If the patient is unable to cooperate or is unable to expectorate an adequate sample, a sample can be obtained by nasotracheal suctioning or bronchoscopy. 5. Have the laboratory perform a Gram stain and look for squamous epithelial cells (saliva). If there is a heavy concentration of squamous epithelial cells, re-obtain the sample.

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ADV ASSESS

Microbiology Microbiological assessment (bacteriology) is performed on body fluid/substance samples to determine the cause of infection (culture) and what antibiotics are effective (sensitivity). Besides bacteria, samples can be tested for fungi, protozoa, and viruses.

Gram-Positive Bacteria Streptococcus Staphylococcus Mycobacterium tuberculosis Gram-Negative Bacteria Klebsiella Haemophilus influenzae Legionella pneumophila

Common Viruses Influenza virus Adenovirus Respiratory syncytial virus Parainfluenza virus Cytomegalovirus

Common Fungi Aspergillus Microsporum Histoplasma Blastomyces Coccidioides

Common Yeast Candida

Common Protozoa Pneumocystis carinii

Histology/Cytology Histology is the study of the microscopic structure of tissue, whereas cytology is the study of cellular structure.

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37 Sample Preparation Testing

Preparation

Microbiology Cytology Histology

0.9% saline Ringer’s lactate 95% alcohol Saccomanno’s solution Formalin

Skin Testing ■ Skin testing is the diagnosis of disease by subcutaneous injection of small amounts of protein essence of the organism. Tuberculosis (TB), coccidioidomycosis, histoplasmosis, sarcoidosis, and allergies may be diagnosed using this technique. ■ TB Testing—Skin testing for TB is performed by injecting 0.1 mL of purified protein derivative (PPD) subcutaneously. The test is read between 48 and 72 hours following injection. The injection site is evaluated for a wheal and redness, indicating a positive test.

Arterial Blood Gas Interpretation Drawing Arterial Blood Gases 1. Correctly identify the patient. 2. Verify correct oxygen/ventilator settings and record patient’s temperature. 3. Gather required equipment: ■ Blood gas collection kit (syringe, needle, antiseptic wipes [alcohol and iodine-based], stopper, container for ice) ■ Exam gloves ■ Eye protection (goggles) ■ Ice ■ Required paper work

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4. Perform modified Allen test for collateral circulation (radial puncture). 5. Don protective equipment (gloves and goggles). 6. Prep puncture site (antiseptic wipe). 7. Palpate pulse. 8. Puncture site between a 30 and 45 angle. 9. Draw sample. 10. Hold pressure on puncture site for 5 minutes following collection. 11. Expel all air from the sample. 12. Cap and ice sample.

Arterial Blood Gas Normal Values Value

Range

pH PaCO2 HCO3 BE PaO2

7.35–7.45 35–45 mmHg 22–26 mEq/L 2 80–100 mmHg

To accurately interpret arterial blood gas results, one must first memorize the normal values. Only after the normal values are committed to memory can blood gases be interpreted.

Steps to Interpret an Arterial Blood Gas

Respiratory Disturbances 1. Evaluate the pH. Alkalosis? Acidosis? 2. Evaluate the PaCO2. Is the PaCO2 moving opposite the pH? If yes, it’s a respiratory acid/base disturbance. 3. If it is a respiratory acidosis, determine if it’s acute or chronic: ■ Acute: If the PaCO2 increases by 10 mmHg the pH should decrease by 0.08 ■ Chronic: If the PaCO2 increases by 10 mmHg the pH should decrease by 0.03 4. If it is a respiratory alkalosis, determine if it’s acute or chronic:

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39 ■ Acute: For each 10 mmHg decrease in PaCO2 the pH should increase by 0.08 ■ Chronic: For each 10 mmHg decrease in PaCO2 the pH should increase by 0.03

Metabolic Disturbances 1. Evaluate the pH. Alkalosis? Acidosis? 2. Evaluate the PaCO2. Is the PaCO2 moving the same direction as the pH? If yes, it’s a metabolic acid/base disturbance.

Metabolic Acidosis If it’s a metabolic acidosis: 1. Determine if it’s an anion gap (AG) acidosis: ■ AG  Na (CI  HCO3 ) ■ Note: The HCO3 must be from an electrolyte panel not the blood gas data. ■ Normal AG  8 – 12 (2) ■ If the AG is 12 then it’s an anion gap acidosis. 2. Determine the respiratory compensation using Winter’s Formula. ■ PaCO2  1.5 (HCO3) 8 (2) ■ Note: The HCO3 must be from an electrolyte panel not the blood gas data. ■ If the PaCO2 is less than expected (Winter’s Formula), there is a primary respiratory alkalosis. ■ If the PaCO2 is greater than expected (Winter’s Formula), there is a primary respiratory acidosis. 3. Determine the Delta gap: ■ Corrected HCO3  (HCO3  [AG  12]) ■ If the Delta gap is 24 it’s a nonanion gap (AG) acidosis. ■ If the Delta gap is 24 there is a metabolic acidosis.

Metabolic Alkalosis

■ Compensation for metabolic alkalosis is not as linear as in metabolic acidosis (Note: Don’t use Winter’s Formula!). ■ Compensation will tend to depress the respiratory drive, increasing the PaCO2. ■ Calculate the expected PaCO2. ■ PaCO2  0.9 (HCO3)  9 ■ Note: The HCO3 must be from an electrolyte panel not the blood gas data.

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ADV ASSESS

■ If the PaCO2 is  than expected, there is an underlying respiratory alkalosis. ■ If the PaCO2 is than expected, there is an underlying respiratory acidosis.

Cautions/Pitfalls

1. Use the HCO3 from the electrolyte panel, not the calculated value from a blood gas. 2. Draw the ABG at the same time as the electrolyte panel. 3. Apply the formulas listed.

Respiratory Disturbance Etiologies Respiratory Acidosis Lung disease (COPD, pneumonia, etc.) Pleural disease (effusion, hemothorax, pneumothorax, etc.) Neuromuscular disorders (myopathies, neuropathies) CNS depression (sedatives, anesthesia, respiratory center lesions) Acute obstruction

Respiratory Alkalosis CNS disorders (CVA, tumor, infection) Hormones/Drugs (progesterone, salicylates, etc.) Fever (gram-negative sepsis) Hyperthyroidism Anxiety Pregnancy

Metabolic Acidosis Etiologies Anion Gap Acidosis

Nonanion Gap Acidosis Hyperalimentation Acetazolamide RTA (renal tubular acidosis) Diarrhea Urectosigmoidostomy Pancreatic fistula

Methanol Uremia (renal failure) DKA (diabetic ketoacidosis) Paraldehyde Inborn errors of metabolism (idiopathic) Lactic acidosis Ethylene glycol intoxication Salicylates

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41 Metabolic Alkalosis Etiologies

■ Extracellular fluid volume depletion (vomiting, diuretic therapy, laxative abuse) ■ Severe potassium depletion ■ Mineralocorticoid excess syndrome (Cushing’s syndrome, ectopic adrenocorticotropic hormone) ■ Bartter’s syndrome

Evaluate the PaO2 ■ ■ ■ ■

PaO2 80–100 mmHg 60 mmHg  PaO2  80 mmHg 40 mmHg  PaO2  60 mmHg PaO2 40 mmHg

Normal Mild hypoxemia Moderate hypoxemia Severe hypoxemia

Chest X-Ray Interpretation Chest x-rays are produced by passing a form of ionizing radiation through the chest, exposing a film plate. The image formed is the result of the differing radio densities of the anatomy as the energy passes through the body.

Radiodensities of Common Materials Air

Least dense

Appears black on a chest x-ray

Water

More dense than air

Appears gray on a chest x-ray

Fat

More dense than water

Appears lighter gray than water on a chest x-ray

Bone

More dense than fat

Appears white on a chest x-ray

Plastic

Similar density to fat

Appears lighter gray on a chest x-ray

Metal

Most radiodense

Appears bright white on a chest x-ray

ADV ASSESS

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Common Radiographic Views

Posterior–Anterior (PA) X-ray tube 72 inches

Film plate

Preferred view because the cardiac silhouette is not magnified.

Anterior–Posterior (AP) X-ray tube 72 inches

Film plate

Common view of a portable chest x-ray; the cardiac silhouette is magnified.

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43 Lateral X-ray tube

Film plate 72 inches

Evaluating a Chest X-Ray

Determine Technical Quality

■ Rotation—Is the spine centered between the necks of the clavicles on the PA or AP view? If not, is the rotation to the right or left? ■ Penetration—Can the vertebral columns be faintly seen through the center of the chest? If they are very distinct, it’s overpenetrated. If you can’t see them at all, it’s underpenetrated.

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ADV ASSESS

Chest X-Ray Evaluation (Outside-In Approach) Extrathoracic structures

Evaluate white tissue density against the black air space surrounding the body. Look for subcutaneous air apically (air migrates superiorly).

Bones

Trace each rib, the clavicles, and sternum looking for fractures, costochondral separation. Look for spinal fractures, scoliosis, or kyphoscoliosis.

Pleura

Evaluate the pleura for thickening or plaques (increased density). Look for pleural air (black w/o lung markings) or fluid (white water/fluid density).

Diaphragms

Should be “dome” shaped with right slightly higher than the left. Check the costophrenic angle for blunting (pleural fluid).

Lung parenchyma

If eight ribs overlie the lung fields it’s a good inspiration. More than 10 ribs is hyperinflation. Look for areas of increased density.

Hilum

Increased density due to vascular volume. Is it engorged (possible CHF)?

Heart

Cardiac silhouette should be less than 1 /2 the diameter of the chest. Has a heart border been obscured (possible pneumonia)?

Trachea

Should be mid-line to about the fourth rib. Is it shifted (possible pneumothorax or atelectasis)?

Right and left mainstem bronchi

Carina should be evident with right mainstem bronchi branching at a lesser angle than the left.

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45 Common Abnormalities Volume changes Volume increase

Volume decrease

Fluid changes

Foreign objects

ADV ASSESS

Hyperinflation (COPD): Flattened diaphragms, increased rib spacing, and darker appearance. Increased AP diameter and retrosternal airspace (lateral). Atelectasis: Elevated diaphragm on affected side. Shift of mediastinum to affected side. Increased radiodensity. Pneumothorax: Reduction in volume on affected side. Loss of lung markings in region of free air. Consolidation: Increased radiodensity (lighter than normal), often more lobar (compare PA with lateral). Pleural effusion: Blunting of costophrenic angles (PA) and posterior (lateral). A lateral decubitus projection can help to quantify. Congestive heart failure (CHF): Enlarged left ventricle (early). Increased hilar congestion. Increased fluid density with Kerley B lines along the right base. Increased size of heart silhouette. Pulmonary edema: Diffuse patchy infiltrate pattern. Chest tubes, nasogastric tubes, endotracheal tubes, feeding tubes, ECG leads, pacemakers, sternal clips, bullets, shotgun pellets.

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ADV ASSESS

Electrocardiogram (ECG) Lead Placement

RA

LA

V1

V2

V6 V3 V4

RL

V5

LL

■ Limb leads—(right arm, left leg, left arm, left leg). Left and right hip may be substituted for lead placement on the legs. ■ Precordial leads—V1 and V2 (4th intercostal space adjacent to sternum), V4 (5th intercostal space mid-clavicular line), V3 (between V2 and V4), V5 (5th intercostal space anterior axillary line), V6 (5th intercostal space mid-axillary line)

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47 Artifacts ■ Patient motion: irregular appearance of the ECG. Try to minimize motion if possible. ■ Wandering baseline: poor contact with electrodes. Change electrodes, prep skin with isopropyl alcohol. ■ 60 Hz artifact (common mode interference): poor ground, current leakage or faulty electrical outlet. Change outlets, ground ECG instrument, change leads.

ECG Assessment

■ Rate: ■ 60–100/min—Normal ■ 60—Bradycardia ■ 100—Tachycardia ■ Rhythm: Regular? Irregular? Regularly irregular? ■ P waves: One P wave with every QRS complex? ■ P-R Interval: 0.12–0.2 seconds ■ QRS: 0.08–0.12 seconds ■ ST Segment: Isoelectric? Depressed? Elevated? ■ Extra: Any abnormal or extra complexes?

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ADV ASSESS

Common Arrhythmias

Sinus Bradycardia

■ ■ ■ ■ ■

Rate: Rhythm: P waves: P-R Interval: QRS:

60/min Regular 1:1 with QRS 0.12–0.2 seconds 0.08–0.12 seconds

Atrial Fibrillation

■ ■ ■ ■

Rate: Rhythm: P waves: QRS:

Page 48

Irregular (R-R interval) Irregular Absent Normal (0.08–0.12 seconds)

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49 Premature Ventricular Contraction (PVC)

■ Rate: ■ Rhythm:

Can be irregular Long pause (compensatory pause) between PVC and next P-QRS complex Absent N/A since P wave is absent with complex Wide ( 0.12 seconds)

■ P waves: ■ P-R Interval: ■ QRS:

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ADV ASSESS Ventricular Tachycardia

■ ■ ■ ■ ■

Rate: Rhythm: P waves: P-R Interval: QRS:

100–250/min (ventricular rate) Can be irregular Absent during PVC runs N/A (no P waves) Wide ( 0.12 seconds)

Ventricular Fibrillation

■ ■ ■ ■ ■

Rate: Rhythm: P waves: P-R Interval: QRS:

Irregular and rapid Irregular Absent N/A (no P waves) Absent

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51 1 AV Block

■ ■ ■ ■ ■

Rate: Rhythm: P waves: P-R Interval: QRS:

Normal Regular Present (1:1 with QRS) Long ( 0.2 seconds) 0.08–0.12 seconds

2 AV Block (Wenckebach or Mobitz type I)

■ ■ ■ ■

Rate: Rhythm: P waves: P-R Interval:

Slow (100) Regular Present Gradual lengthening of P-R interval until it fails to trigger a QRS complex. Then the rhythm repeats itself. Normal (0.08–0.12 seconds)

■ QRS:

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ADV ASSESS 2 AV Block (Mobitz type II)

■ Rate: ■ Rhythm: ■ P waves: ■ P-R Interval: ■ QRS:

Bradycardic (60 /min) Regular Present but they don’t conduct to the ventricles (no QRS) When conduction occurs, normal 0.08–0.12 seconds

3 AV Block

■ Rate: ■ Rhythm: ■ P waves: ■ P-R Interval: ■ QRS:

Atrial and ventricular rates are different (ventricular slower) Atrial and ventricular rhythms are regular Present but they don’t conduct to the ventricles Irregular since the atria and ventricles are paced independently Usually 0.12 seconds

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53 Asystole

■ ■ ■ ■ ■

Rate: Rhythm: P waves: P-R Interval: QRS:

None None None N/A (no P waves) None

Hemodynamic Monitoring Arterial Pressure Monitoring Noninvasive monitoring can be accomplished using automated sphygmomanometer equipment. Blood pressures can be monitored at set time intervals, with alarm limits and digital displays.

Indwelling Arterial Pressure Lines

Indwelling Arterial Lines

■ Permit continuous real time monitoring of arterial pressures and waveforms. In addition, the lines may be used for arterial blood draws for labs or blood gases. ■ Sites: radial, ulnar, brachial, axillary, or femoral artery. ■ Arterial pressure waveform.

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Central Venous Pressure (CVP) Lines

■ Monitor pressures in the vena cava or right atrium. Right atrial pressures are reflective of blood volume and venous return, which are helpful in evaluating right heart function. ■ Sites: antecubital fossa, basilica, internal jugular, and subclavian veins. ■ Central venous pressure waveform.

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55

Pulmonary Artery Catheter (Swan-Ganz)

■ Monitors pressures in the pulmonary artery and when wedged, left ventricular end diastolic pressure. The line may also be used for cardiac output determination (thermal dilution) and IV infusion. ■ Sites: antecubital fossa, basilica, internal jugular, and subclavian veins. ■ Pulmonary artery pressure waveform.

ADV ASSESS

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Normal Hemodynamic Values Arterial pressures

Venous pressures

Blood pressure

Mean arterial pressure Central venous pressure Right atrial pressure Right ventricular pressure Right ventricular end diastolic pressure

100–140 mmHg systolic, 60–80 mmHg diastolic 80–100 mmHg 6 mmHg CVP  12 mmHg 2–6 mmHg 20–30/0–5 mmHg 2–6 mmHg

(Text continued on following page)

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57 Normal Hemodynamic Values (Continued) Pulmonary artery pressures

Pulmonary artery pressure Mean pulmonary artery pressure Pulmonary capillary wedge pressure Left atrial pressure Left ventricular pressure Left ventricular end diastolic pressure

20–30/6–15 mmHg 10–20 mmHg 4–12 mmHg 4–12 mmHg 100–140/0–5 mmHg 5–12 mmHg

Hemodynamic Equations Stroke volume index (SVI) Cardiac index (CI) Right ventricular stroke work index (RVSWI) Left ventricular stroke work index (LVSWI)

SV SVI 

BSA Normal: 40–50 mL/beat/m2 CO CI 

BSA Normal: 2.5–4 L/min/m2 RVSWI  SVI  (PA  CVP)  0.013 gm/mL Normal 4–12 gm/m/m2 LVSWI  SVI  (MAP  PCWP )  0.013 gm/mL Normal: 40–75 gm/m/m2

Pulmonary vascular resistance (PVR)

PA  PCWP PVR 

 80 CO Normal: 20–200 dynes·sec·cm5

Systemic vascular resistance (SVR)

MAP  CVP SVR 

 80 CO Normal: 800–1600 dynes·sec·cm5

ADV ASSESS

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Basic Hemodynamic Interpretation

Hypovolemia Hypervolemia BP RA PAP PAWP CO

↓ ↓ ↓ ↓ ↓

Right Left Ventricular Ventricular Failure Failure

↑ ↑ ↑ ↑ ↑

↓ ↑ ↑ Normal ↓

↓ Normal ↑ ↑ ↓

Pulmonary Function Testing Static Lung Volumes

Inspiratory reserve volume (IRV) Tidal volume (VT)

Expiratory reserve volume (ERV) Residual volume (RV) *

Definition

Normal*

Maximum volume inhaled after a normal inspiration Amount of air inhaled or exhaled during resting ventilation Maximum amount of air that can be exhaled after a normal exhalation Amount of air left in the lungs following a complete exhalation

3100 mL

Normal values are based on 72 inch male, 21 years old.

58

500 mL

1200 mL

1200 mL

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59 Static Lung Capacities Normal*

Definition Vital capacity (VC) Inspiratory capacity (IC) Functional residual capacity (FRC) Total lung capacity (TLC) *

ERV  VT IRV VT  IRV ERV  RV

4800 mL 3600 mL 2400 mL

RV  ERV  VT  IRV

6000 mL

Normal values are based on 72 inch male, 21 years old.

Forced Spirometry Normal*

Definition Forced vital capacity (FVC)

Forced expired volume in 1 second (FEV1) FEV1/FVC % Forced expired flow200-1200 (FEF200-1200) Forced expired flow25-75% (FEF25-75%) *

Amount of air that can be exhaled forcefully following a complete inspiration Amount of air exhaled in the first second during an FVC maneuver (FEV1 divided by the FVC)100 Expiratory flow rate between 200 and 1200 mL during the FVC maneuver Expiratory flow during the middle 50% of the FVC maneuver

4800 mL

3600–4080 mL

75–85% 6–7 L/sec

4–5 L/sec

Normal values are based on 72 inch male, 21 years old.

ADV ASSESS

ADV ASSESS

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Flow Volume Loop

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62

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SB02

ADV ASSESS

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Distribution Tests

◆

Single Breath Oxygen Test (Fowler’s Distribution Test) Nitrogen delta (N2 750-1250 mL) 1.5% or less

ADV ASSESS

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Diffusion Tests

Single Breath DLCO

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ADV ASSESS

■ Single breath diffusion (DLCO) Lung Mechanics ■ Resistance (RAW) ■ Conductance (GAW) ■ Maximal inspiratory pressure (MIP) ■ Maximal expiratory pressure (MEP) ■ Compliance

25–30 mL/min/mmHg 0.6–2.4 cmH2O/L/sec 0.42–1.67 L/sec/cmH2O –60 cmH2O 80 cmH2O 0.1 L/cmH2O

Basic Pulmonary Function Patterns in Disease FVC Asthma

FEV1/ FVC

FEV1

FRC DLCO

RAW

↓ ↑ or normal ↓ ↓

↓

↑

↓

↑

↓

↑

↓

↑

↓

↓

↑

↓

↑

↓ or ↓ or ↓ normal normal ↓ or ↓ or ↓ normal normal

↓

↓ or normal ↓ or normal

Emphysema ↓ Bronchitis Sarcoido- ↓ sis Asbesto- ↓ sis

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↓

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65 Oxygen Therapy Oxygen therapy is indicated for documented hypoxemia or when hypoxemia is suspected.

Oxygen Therapy Indications PaO2

SaO2

Other

Acute Care Hospital Adults, children, 60 mmHg breathing infants 28 room air days old

90% breathing room air

50 mmHg breathing room air

88% breathing room air

Infants 28 days old

Severe trauma Acute myocardial infarction Short-term therapy (post anesthesia, etc.) PcO2 40 mmHg (capillary blood gas)

Home or Extended Care Adults, children, infants  28 days old

55 mmHg breathing room air

PROC

56 mmHg PaO2 88% 59 mmHg or breathing SaO2  89% in room air association with cor pulmonale, congestive heart failure, erythrocythemia, etc. SaO2 88% during exercise, sleep, or other activities when SaO2 values do not qualify for oxygen when at rest

PaO2

SpO2

PaO2 55 mmHg while awake on room air at rest PaO2 56 mmHg while awake at rest

SpO2 88 % while awake at rest on room air

Adults

PaO2 56 mmHg while awake at rest on room air

SpO2 89% on room air while awake at rest

Adults

PaO2 55 mmHg during exercise on room air

SpO288% during exercise on room air

Adults

Adults

SpO2 89% on room air while awake at rest

Other

Qualification Continuous O2

PaO2 55 mmHg or SpO2 88% for 5 minutes while sleeping A decrease in PaO2 10 mmHg or decrease in SpO2 5% for 5 minutes while sleeping. With documentation of cor pulmonale, CHF, erythrocytosis, etc. Must document liter flow required to correct hypoxemia

Continuous O2

Continuous O2

O2 during exercise

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PROC

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Medicare Home Oxygen Guidelines: Group I (12 months or by physician prescription whichever is less)

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67 Medicare Home Oxygen Guidelines: Group II (3 months or by physician prescription whichever is less)

Adults

PaO2

SpO2

Other

56–59 mmHg at rest, during sleep (5 minutes), or exercise on room air

89% at rest, during sleep (5 minutes), or exercise on room air

Dependent edema (CHF), pulm hypertension, cor pulmonale, erythrocythemia

Contraindications to Oxygen Therapy No contraindications exist if clinical indications exist.

Oxygen Administration Devices Devices

Liter Flow

Approximate FIO2

Low-Flow Oxygen Devices Nasal cannula Transtracheal catheter Simple oxygen mask Partial rebreathing mask

Non-rebreathing mask

1–6 L/min 0.25–0.5 L/min 6–10 L/min To keep bag open during inspiration (typically 10 L/min). Never run 6 L/min To keep bag open during inspiration (typically 10 L/min)

24–44% 24–44% 35–55% up to 60%

up to 80%

High-Flow Oxygen Devices Venturi or Venti mask

3–15 L/min (per manufacturer for desired FIO2)

PROC

30–50%

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Cylinder Duration Cylinder

Contents Contents (cu ft) (liters)

“E”

22 ft3

623 L

Duration Factor  Pres.  ft3 (28.3 L/ft3) 2200 psi Factor  0.28 L/psi Time (min)  Factor (Pressure) Liter Flow

“H” or “K”

3

6905 L

244 ft

Time  Pres.  ft3 (28.3 L/ft3) 2200 psi Factor  3.14 L/psi Factor (Pres.) Time (min)  Liter Flow

Liquid System Duration ■ In the absence of a calibrated scale use the following formula to approximate duration.

Duration (in min)

0.8[(Weight  Empty Weight)  343 L/Lb Liquid Oxygen] Liter Flow (L/min)

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69 ■ The factor of 0.8 allows a 20% “fudge factor” prior to exhausting the contents of the reservoir. Empty weight is the weight of the reservoir without any liquid oxygen in it (owners’ or service manual data).

Hazards/Complications of Oxygen Administration ■ Ventilatory depression with PaO2 60 mmHg in patients with chronic hypercarbia (elevated PaCO2) ■ Absorption atelectasis, oxygen toxicity with FIO2 0.50 ■ Retinopathy of prematurity in preterm infants with PaO2 80 mmHg ■ Fire hazard elevated with increased oxygen concentrations ■ Infection hazard increased with application of some humidification devices

PROC

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Oxygen Administration Algorithm Oxygen Protocol is Ordered

Contact MD or Provider

Yes

Potential for complications? No

Nasal cannula/ Yes low-flow device to keep SpO2 >92%

Short-term (severe trauma, post-anesthesia), or acute MI? No

Check SpO2 (<90%) or PaO2 (<60 mmHg)?

No

No oxygen therapy is indicated

Yes Suspect patient is CO2 retainer?

Yes

No

Obtain ABG to assess PaCo2 and acid/base balance

Initiate low-flow oxygen therapy

Reevaluate SpO2 or PaO2 and titrate oxygen liter flow/ FIO2 to keep SpO2 >90% or PaO2 >60 mmHg

Reassess and monitor patient every 24 hours

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Keep SpO2 88–90% on low-flow delivery system or consider high-flow (Venturi) device

Reassess and monitor patient every 24 hours

Copyright © 2008 by F. A. Davis.

Humidity/aerosol therapy is applied to hydrate inspissated retained secretions or to humidify anhydrous medical gases.

Indications for Humidity/Aerosol Therapy

Indication Laryngotracheobronchitis Subglottic edema Postextubation edema Postoperative airway management Artificial airway (bypassed upper airway)

Cool Bland Aerosol

Heated Bland Aerosol

Humidity

Heat Moisture Exchanger (HME)

Metered Dose Inhaler (MDI), Dry Powder Inhaler (DPI), Small Volume Nebulizer (SVN)

X

PROC

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Humidity/Aerosol Therapy

X

Heated X humidifier 96 hours or X transport (Text continued on following page)

Indication Sputum induction

Low-flow oxygen  4L/min (nasal cannula, etc.) Administration of pharmacologic agents to the lower respiratory tract

Heated Cool Bland Bland Aerosol Aerosol

Humidity

Metered Dose Inhaler (MDI), Dry Heat Moisture Powder Inhaler Exchanger (DPI), Small Volume (HME) Nebulizer (SVN)

X (Hypertonic saline) X Bubble humidifier

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Indications for Humidity/Aerosol Therapy (Continued)

X

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73 Contraindications for Humidity/Aerosol Therapy ■ Bronchoconstriction ■ Airway hypersensitivity ■ Specific contraindications to pharmacologic agents (see package insert) ■ HME contraindications: ■ Thick copious or bloody secretions ■ Exhaled volumes 70% delivered (bronchopulmonary fistula, cuff leak) ■ Hypothermia (32 degrees Celsius) ■ High minute volumes (10 L/min)

Types of Humidifiers/Nebulizers and Their Application Device Room humidifier Aerosol tent

Bubble humidifier

Heated humidifier with alarms

Application

Liter Flow/Setting

Increase relative humidity of a room

Fill reservoir, connect to electrical outlet and turn unit on Pediatrics (laryngotra- Fill reservoir, maximum cheobronchitis, flow to achieve a epiglottitis, etc.) dense mist, titrate FIO2 to maintain SpO2 92% Low-flow oxygen Set liter flow delivery (nasal to achieve cannula, simple SpO2 90 % mask, etc.) Mechanical 31–35 degrees Celsius ventilation, bilevel at the airway or set positive airway for a neutral thermal pressure, CPAP, artienvironment (infant ficial airway, infant application) hood or headbox for neutral thermal environment (Text continued on following page)

PROC

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Types of Humidifiers/Nebulizers and Their Application (Continued) Device Heat and moisture exchanger (HME)

Application Artificial airway with short-term mechanical ventilation (96 hours)

Delivery of pharmacologic agents to the lower respiratory tract Delivery of Respiguard SVN pentamidine Delivery of Metered dose pharmacologic inhalers (MDI), agents to the dry powder lower respirainhalers (DPI) tory tract Administration of Large volume bland aerosol nebulizer (cool or heated) HEART (continuous) Continuous administration of nebulizer bronchodilator Small volume nebulizer (SVN)

Ultrasonic nebulizer Administration of bland aerosol

74

Liter Flow/Setting Monitor for increased airway resistance (airway pressures, use of accessory muscles, etc.) 6–8 L/min

6–8 L/min Use holding chamber (MDI)

Titrate liter flow and FIO2 to maintain SpO2 90% Set liter flow per manufacturer for desired mg/hr delivery Fill reservoir, set output control for a dense aerosol, use caution with asthmatic patients

Copyright © 2008 by F. A. Davis.

Yes

No

Medication delivery?

No

Yes

Secretion hydration? Yes

HME if duration is less than 96 hours

SVN, MDI, or DPI

Large volume nebulizer

Heated humidifier with temperature display and alarms

If patient requires continuous bronchodilator therapy, us a HEART continuous nebulizer

Ultrasonic nebulizer (contraindicated with bronchospasm/ asthma)

Nasal cannula >4 L/min? Yes Bubble humidifier

No

Subglottic edema?

No

Yes Adults: cool aerosol via large volume nebulizer

Pediatrics: mist tent

PROC

Artificial airway?

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Humidity/Aerosol Therapy Algorithm

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Hazards/Complications of Humidity and Aerosol Therapy ■ Humidity Therapy ■ Electrical shock (heated humidifiers) ■ Hypothermia (HME devices) ■ Thermal injury (heated humidifiers) ■ Swelling of inspissated secretions (heated or cool humidity) ■ Increased airway resistance (HME devices) ■ Infection ■ Aerosol Therapy ■ Bronchospasm ■ Infection ■ Overhydration ■ Airway edema ■ Exposure of caregivers to secondhand aerosol

Hyperinflation Therapy Hyperinflation therapy is used to achieve lung expansion to reverse or prevent atelectasis, to mobilize secretions, to promote effective coughing, and to improve delivery of medications.

Indications for Hyperinflation Therapy ■ Atelectasis, predisposition for atelectasis (upper abdominal or thoracic surgery) ■ Restrictive lung defect (neuromuscular) ■ Inability to clear secretions ■ Reduce air trapping in chronic obstructive pulmonary disease ■ Optimize delivery of bronchodilators

Contraindications to Hyperinflation Therapy ■ Incentive spirometry ■ Patient cannot be instructed or supervised ■ Patient is uncooperative or cannot understand instructions ■ Patient unable to deep breathe (VC 10 mL/kg)

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77 ■ PEP/oscillating PEP therapy/CPAP/bilevel positive airway pressure ■ Patient unable to tolerate increased work of breathing ■ Increased intracranial pressure ■ Cardiovascular compromise (myocardial ischemia, decreased venous return) ■ Gastric distension or risk of vomiting ■ Claustrophobia ■ Facial skin breakdown from use of a mask ■ Pulmonary barotraumas ■ Intermittent positive pressure breathing (IPPB) ■ Absolute contraindication: Untreated pneumothorax ■ Intracranial pressure 15 mmHg ■ Hemodynamic instability ■ Recent facial, oral, sinus, or skull surgery ■ Tracheoesophageal fistula ■ Recent esophageal surgery ■ Hemoptysis ■ Nausea/vomiting/gastric distension ■ Active untreated tuberculosis ■ Evidence of blebs on chest x-ray

Hyperinflation Techniques Technique

Indications

Clinical Goal

Comments

Atelectasis, Some patients Increase Incentive predisposition transairway may lack spirometry for atelectasis, ventilatory pressure or neuromusmuscle improving cular restricstrength to lung tive lung perform volumes defect therapy. Patient can perform technique independently. (Text continued on following page)

PROC

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Hyperinflation Techniques (Continued) Technique

Indications

Clinical Goal

Positive ex- Atelectasis, re- Splint airways piratory tained secreopen during pressure tions, air exhalation, (PEP) trapping improving associated distribution with COPD and ability to mobilize secretions (↑ FRC)

Oscillating PEP therapy

Atelectasis, retained secretions, air trapping associated with COPD

Comments Patient must be able to cooperate (spontaneously breathing). Can be combined with SVN for simultaneous medication delivery. Patient can perform technique independently.

Splint airways Patient must be able to coopopen during erate (spontaexhalation neously with oscillating pressure. breathing). Can be combined Improve diswith SVN for tribution of simultaneous ventilation and mobilize medication delivery. Patient secretions can perform (↑ FRC) technique independently. (Text continued on following page)

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79 Hyperinflation Techniques (Continued) Technique

Indications

Clinical Goal

Comments

Intermittent Pulmonary Application of Application positive atelectasis positive presof positive pressure (following sure during pressure during breathing failure of inspiration inspiration to (IPPB) other techto hyperhyperinflate the niques), inflate the lungs while mobilize lungs while simultaneously secretions, simultanedelivering a deliver ously delivmedication medications, ering a short-term medication ventilatory support Continuous Application Increase FRC Increase FRC and positive of positive and hyperhyperinflate the airway pressure inflate the lungs pressure (10–20 cm lungs (CPAP) H2O) during inhalation and exhalation Bilevel Application of Increase FRC Increase FRC and positive inspiratory and hyperhyperinflate the airway and inflate the lungs pressure expiratory lungs positive airway pressure

PROC

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Hyperinflation Algorithm Hyperinflation Therapy Protocol is Ordered

Contact MD or Provider

Yes Contraindications? No

Incentive spirometry, PEP therapy

Yes

Patient’s VC >10 mL/kg and able to follow directions? No Consider IPPB therapy (volume oriented) to 25%> spontaneous volume

Evaluate goals: Improved breath sounds? Resolving atelectasis? Improved vital signs? Improved VC? Improved SpO2 or PaO2?

Consider CPAP therapy via mask intermittently

Continue or modify therapy

Consider intermittent application of bilevel positive airway pressure via mask

Evaluate goals: Improved breath sounds? Resolving atelectasis? Improved vital signs? Improved VC? Improved SpO2 or PaO2?

Continue or modify therapy

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81 Hazards/Complications of Hyperinflation Therapy ■ Hyperventilation (hypocarbia) ■ Barotrauma (positive pressure techniques) ■ Hypoxemia (if supplemental oxygen is removed for extended period during therapy) ■ Increased intracranial pressures (positive pressure techniques) ■ Cardiovascular compromise (positive pressure techniques) ■ Gastric insufflation (positive pressure techniques)

Bronchial Hygiene Bronchial hygiene techniques are used to improve coughing and facilitate mobilization of secretions. Many of these techniques overlap some of the hyperinflation therapy techniques.

Indications for Bronchial Hygiene ■ Presence of or predisposition for atelectasis ■ Retained secretions or inability to effectively mobilize secretions ■ Evidence of cystic fibrosis, bronchiectasis, or cavitating lung disease ■ Difficulty clearing secretions with sputum production 25–30 mL/day (adult) ■ Evidence of retained secretions with the presence of an artificial airway

Contraindications to Bronchial Hygiene Therapy ■ PEP/Flutter valve therapy/CPAP/bilevel positive airway pressure ■ Patient unable to tolerate increased work of breathing ■ Increased intracranial pressure ■ Cardiovascular compromise (myocardial ischemia, decreased venous return)

PROC

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■ Gastric distension or risk of vomiting ■ Claustrophobia ■ Facial skin breakdown from use of a mask ■ Pulmonary barotraumas ■ Chest physiotherapy and postural drainage (CPPD) ■ Patient positioning ■ Absolute contraindications ◆ Unstable cervical fractures ◆ Hemorrhage with hemodynamic instability ■ Relative contraindications ◆ Increased intracranial pressure (20 mmHg) ◆ Recent spinal surgery ◆ Acute spinal injury ◆ Untreated empyema ◆ Bronchopulmonary fistula ◆ Pulmonary edema associated with congestive heart failure ◆ Pleural effusion ◆ Patient unable to tolerate positional changes ◆ Rib fractures ◆ Uncontrolled hypertension ◆ Frank uncontrolled hemoptysis ◆ Aspiration risk ■ External chest wall manipulation ■ Subcutaneous emphysema ■ Recent epidural or spinal anesthesia ■ Recent skin grafts ■ Burns, open wounds, or skin infections ■ Recent pacemaker implantation ■ Suspected pulmonary tuberculosis ■ Lung contusion ■ Osteomyelitis of the ribs ■ Osteoporosis ■ Coagulopathy ■ Complaint of chest wall pain

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83 Bronchial Hygiene Techniques Technique Positive expiratory pressure (PEP)

Oscillating PEP therapy

Chest physiotherapy and postural drainage (CPPD)

Indications

Clinical Goals

Comments

Patient must be able to cooperate (spontaneously breathing). Can be combined with SVN for simultaneous medication delivery. Patient can perform technique independently. Atelectasis, Splint airways Patient must be able to retained open during cooperate secretions, exhalation (spontaneously air trapping with oscillatbreathing). Can associated ing pressure. be combined with COPD Improve with SVN for distribution simultaneous of ventilamedication tion and delivery. Patient mobilize can perform secretions technique (↑ FRC) independently. Clinical efficacy is Atelectasis, Patient posilargely based retained tioning to upon anecdotal secretions, facilitate evidence. problems pulmonary clearing drainage secretions with external chest wall manipulation Atelectasis, Splint airways retained open during secretions, exhalation air trapping improving associated distribution with COPD and ability to mobilize secretions (FRC)

(Text continued on following page)

PROC

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Bronchial Hygiene Techniques (Continued) Technique

Indications

Clinical Goals

Comments

High-frequency Secretions, External manip- Patient may problems ulation of the perform chest wall clearing chest wall therapy indeoscillation 7 secretions using highpendently. (The Vest ) frequency Equipment is pressure expensive. pulses through a pneumatic vest worn by the patient Can be used for Intrapulmonary Secretions, Use of a highproblems frequency simultaneous percussive clearing ventilator to medication ventilation secretions increase delivery. (IPV) mean airway Patient may pressures be instructed while mobito perform lizing secretherapy indetions with pendently. pressure pulses

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85 Postural Drainage Positions

Posterior Apical Segments of the Right and Left Upper Lobes

■ Position the patient sitting and leaning forward at about a 45-degree angle ■ Area for percussion is just above the scapula with the fingers extending up onto the shoulders

Anterior Apical Segments of the Right and Left Upper Lobes

■ Position the patient sitting and leaning back at about a 45-degree angle ■ Area for percussion is just below the clavicle

Anterior Segments of the Right and Left Upper Lobes

■ Position the patient supine with the bed flat ■ Area for percussion is just above the nipple

PROC

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Posterior Segment of the Left Upper Lobe

■ Position the patient 1/4 turn from prone and resting on the right side with the head of the bed elevated 18 inches ■ Area for percussion is just over the left scapula

Posterior Segment of the Right Upper Lobe

■ Position the patient 1/4 turn from prone and resting on the left side with the bed flat ■ Area for percussion is just over the right scapula

Left Lingula

■ Position the patient 1/4 turn from supine and resting on the right side with the foot of the bed elevated 12 inches ■ Area to percuss is just above the left nipple and under the armpit

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87 Right Middle Lobe

■ Position the patient 1/4 turn from supine with the foot of the bed elevated 12 inches ■ Area to percuss is just above the right nipple and under the armpit

Anterior Basal Segments of the Right and Left Lung

■ Position the patient supine with the foot of the bed elevated 18 to 20 inches ■ Area to percuss is over the lower ribs

Posterior Basal Segments of the Right and Left Lung

■ Position the patient prone with the foot of the bed elevated 18 to 20 inches ■ Area to percuss is over the lower ribs

PROC

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Left Lateral Segment of the Lower Lobes

■ Position the patient on the right side with the foot of the bed elevated 18 to 20 inches ■ Area to percuss is over the lower ribs

Right Lateral Segment of the Lower Lobes

■ Position the patient on the left side with the foot of the bed elevated 18 to 20 inches ■ Area to percuss is over the lower ribs

Superior Segments of the Right and Left Lower Lobes

■ Position the patient prone and with the bed flat ■ Area to percuss is over just below the lower margin of the scapula

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89 Bronchial Hygiene Care Plan Bronchial Hygiene Protocol is Ordered

Consult MD or Provider

Yes Contraindications? No Assess patient, are indications present: Sputum prod >25 mL/day? Decreased or absent breath sounds? Atelectasis on chest x-ray? Tachypnea or tachycardia? Abnormal ABGs?

Select mode/technique: PEP therapy? Flutter valve? CPPD? HFCWO? IPV?

Reevaluate patient after 24 hours

Assess outcomes: Sputum prod <25 mL/day? Improved breath sounds? Improved chest x-ray? Improved vital signs? Improved ABGs?

Continue or modify therapy? Discontinue therapy?

PROC

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Hazards/Complications of Bronchial Hygiene Therapy ■ Hyperventilation (hypocarbia) ■ Barotrauma (positive pressure techniques) ■ Hypoxemia (if supplemental oxygen is removed for extended period during therapy) or from ventilation/perfusion mismatching with patient positioning ■ Increased intracranial pressures (positive pressure techniques and dependent head positions, excessive coughing) ■ Cardiovascular compromise, hypotension (positive pressure techniques and dependent head positions) ■ Gastric insufflation (positive pressure techniques) ■ Vomiting/aspiration

Tracheostomy Care The primary goals of tracheostomy and stoma care are to reduce infections and preserve airway patency.

Infection Control (tracheostomy site care) ■ Auscultate chest for bilateral breath sounds and correct tracheostomy placement. Assess the patient for suctioning and suction prior to the procedure if required. ■ Remove soiled dressing and tracheostomy ties (stabilize the tracheostomy tube at all times to prevent decannulation). ■ Clean the stoma site and surrounding skin with 50/50 mixture of hydrogen peroxide and sterile water using 22 gauze pads and cotton tipped swabs. Observe for redness, pus, or other signs of infection. ■ Rinse the cleansed site with sterile water after use of hydrogen peroxide mixture using 22 gauze pads and cotton tipped swabs. ■ Pat the area dry with sterile 22 gauze pads. ■ Apply clean tracheostomy ties and secure them. ■ Apply a clean dressing, slipping it under the tracheostomy flange from below the tracheostomy tube (inferior).

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91 ■ Remove the inner cannula (if it has a removable inner cannula) and clean it in hydrogen peroxide. Rinse with sterile water after it is cleaned and shake dry before reinsertion. ■ Auscultate the chest following the procedure to assess tracheostomy position.

Airway Patency ■ Routine cleaning of the inner cannula (removable inner cannula) or replacement (disposable inner cannula) preserves the patency of the tracheostomy tube. ■ Routine suctioning (when indicated by adventitious breath sounds).

Fiberoptic Bronchoscopy Assisting Fiberoptic bronchoscopy is an invasive procedure that allows visual examination of the tracheobronchial tree and collection of specimens for laboratory analysis.

Therapeutic Indications ■ Removal of excessive secretions from the airway ■ Foreign body retrieval ■ Evaluation of or placement of an artificial airway

Diagnostic Indications ■ Obtain lower respiratory tract secretions for cytology, histology, or microbiology studies ■ Evaluation of lesions (seen on x-ray or computed tomography [CT] scan) ■ Evaluation of positive sputum cytology results ■ Evaluation of injury from aspiration or inhalation of toxic agents ■ Evaluation of hemoptysis

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Absolute Contraindications to Fiberoptic Bronchoscopy ■ Lack of signed patient consent for the procedure ■ Lack of proper facilities (resuscitation equipment, personnel, etc.) ■ Inability to adequately oxygenate the patient

Relative Contraindications to Fiberoptic Bronchoscopy ■ ■ ■ ■ ■ ■ ■ ■

Lack of patient cooperation Recent myocardial infarction or unstable angina Partial tracheal obstruction Moderate to severe hypoxemia Pulmonary hypertension Lung abscess Need for laser therapy Known or suspected pregnancy if fluoroscopy (radiation) is needed during the procedure

Assisting During Fiberoptic Bronchoscopy

Prepare and Organize Equipment ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■

Bronchoscope and light source Suction source (verify operation and tubing connections) Check code cart and resuscitation supplies Oxygen therapy equipment (flowmeter, mask[s], nasal cannula) Labeled fixative/sample solutions (95% alcohol, formalin, Saccomanno’s solution, normal saline, or Ringer’s lactate) Microscope slides Suction traps (diagnostic collection traps) Biopsy forceps, brushes, and Wang needle Labeled 50 mL normal saline (have 500 mL container available) Labeled 50 mL 2% lidocaine (below the vocal cords) Labeled 20 mL 1:20,000 epinephrine Labeled 4-mL syringes of acetylcysteine

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93 ■ 10, 20, and 50 mL syringes ■ Bite block (oral route) ■ Intravenous therapy supplies

Establish Appropriate Patient Monitoring ■ ■ ■ ■

Automated noninvasive blood pressure monitoring ECG monitoring Continuous pulse oximetry monitoring Organize record keeping forms/charts

Patient Anesthesia/Analgesia

■ Apply personal protective equipment. ■ Aerosolize 4 mL of 4% lidocaine with 2.5–5.0 mg albuterol via SVN. ■ Aerosolized lidocaine may be followed by Cetacaine or Hurricane spray to further dull upper respiratory tract reflexes. ■ Cotton tipped swabs dipped in 4% lidocaine jelly can be used to dull sensations in the nares/nasal passages. ■ Establish IV access and administer diazepam, midazolam, or lorazepam for analgesia. Consult your local policy and procedure manual for IV access and conscious sedation.

Assisting During the Procedure

■ Establish supplemental oxygen (mask or nasal cannula) ■ Administer analgesia per physician request ■ Administer saline lavage per physician request (temporarily pinch off suction line) ■ Assist physician with biopsy sampling (brush, forceps, Wang needle) ■ Prepare samples for laboratory analysis (slides, brushes, tissue samples, etc.) ■ Collect aspirate as requested in Lukens traps ■ Assist in patient monitoring

Post Procedure ■ ■ ■ ■

Continue to monitor the patient, ensuring the patient is stable Prepare all documentation Perform initial cleaning of the bronchoscope Ensure correct labeling and documentation of all laboratory samples

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Hazards/Complications Fiberoptic bronchoscopy is an invasive procedure. It does have potential hazards and complications that you must be aware of. ■ Hypoxemia ■ Hypercapnia ■ Wheezing ■ Hypotension ■ Laryngospasm, bronchospasm, bradycardia ■ Bleeding/hemorrhage ■ Increased airway resistance ■ Infection

Thoracentesis Assisting Thoracentesis is a procedure used to remove fluid from the pleura for laboratory analysis. It is performed using a needle, puncturing the pleural space transcutaneously, and aspirating a sample for analysis.

Indications ■ Relieve respiratory insufficiency from pleural effusion ■ Obtain samples for cytology and cancer staging

Contraindications ■ ■ ■ ■ ■

Lack of signed patient consent Lack of patient cooperation Coagulopathy Respiratory insufficiency Hemodynamic or cardiac instability or unstable angina

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95 Assisting During the Procedure ■ If the patient is unstable, establish appropriate monitoring (automated noninvasive blood pressure, ECG, continuous oximetry) ■ Assemble supplies: ■ Iodine antiseptic ■ Sterile drape ■ Sterile gloves ■ 2% lidocaine ■ Large bore 16–19 gauge needle(s) ■ Three-way stopcock ■ Sample tubes with 0.1 mL of aqueous heparin ■ Oxygen therapy equipment (flowmeter, mask, or nasal cannula) ■ Prepare all documentation forms/records ■ Assist the physician as requested ■ Appropriately label all samples collected and prepare laboratory forms

Post Procedure ■ Dispose of any unneeded supplies ■ Monitor the patient ensuring stability ■ Order a chest x-ray

Hazards/Complications Complications are uncommon, but can occur. ■ Pneumothorax ■ Hemorrhage ■ Vasovagal response ■ Infection

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Capnography Capnography is the noninvasive measurement of end-tidal CO2 using infrared sensors. An adapter is placed at the airway, where the sample is measured directly (mainstream) or drawn distally to a remote monitor (side stream).

Indications ■ Evaluation of exhaled CO2 ■ Monitoring the severity of pulmonary disease ■ Evaluating placement of an endotracheal tube (tracheal or esophageal) ■ Monitoring the patency of the ventilator/airway circuit ■ Evaluating efficiency of ventilatory support ■ Monitoring adequacy of pulmonary and coronary blood flow ■ Graphic evaluation of the ventilator/patient interface

Contraindications ■ None

Capnography Monitoring ■ Obtain the required equipment: ■ End-tidal CO2 monitor ■ Airway adapter(s)/tubing (per manufacturer) ■ Calibration gases (per manufacturer) ■ Connect the monitor to an electrical outlet (preferably one that is on a back-up power supply) ■ Calibrate the monitor according to manufacturer’s directions/ specifications ■ Connect the monitor to the patient’s airway and observe for correct graphic and numeric response ■ Correlate the monitor’s data with arterial blood gases

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97 Hazards/Complications ■ Potential increase in dead space if the adapter is too large relative to the airway and patient ■ Potential extubation or torque on the airway due to weight of the sensor

Portable Sleep Monitoring Portable sleep monitoring has increased in the past decade in the evaluation of patients with breathing-related sleep disorders. Multichannel monitors allow noninvasive measurement of ECG, airflow, respiratory effort, and pulse oximetry.

Indications ■ Patients present with severe symptoms and standard polysomnography (PSG) monitoring is not available ■ Patients who cannot be studied in a traditional PSG sleep laboratory ■ Used for follow up following diagnosis by a PSG laboratory

Contraindications ■ No absolute contraindications exist ■ A qualified practitioner is not available for intervention (CPAP) if the study is unattended

Setting Up a Portable Sleep Monitor ■ Obtain required equipment ■ Multichannel sleep monitor ■ Disposable oximeter probe ■ Disposable airflow sensor ■ Disposable ECG leads ■ Cables/interface for monitor probes

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■ Connect the monitors to the patient ■ Attach ECG leads between the clavicle and the fourth intercostal space along the midaxillary line (white on right side, black on left side) ■ Secure the respiratory effort band snuggly around the patient’s abdomen ■ Place the oximeter probe on a finger and secure it with tape ■ Place the airflow sensor on the patient’s upper lip with the probes just entering the nares (similar to a nasal cannula) ■ Attach the snore microphone adjacent to the larynx with a self-adhesive disk and reinforce its attachment with bandage tape ■ Connect the cable(s) to the monitor ■ Connect the monitor to an electrical outlet and turn on the monitor

Hazards/Complications ■ No hazards/complications exist for home sleep monitoring ■ Limitations to unattended home monitoring ■ Loss of control over the sleep environment ■ Patients can engage in maladaptive sleep habits ■ Bed partners can disturb the outcome of the study ■ A qualified practitioner is not available to intervene if required ■ Higher rate of data loss due to technical/patient difficulties

Exercise Testing for the Evaluation of Oxygen Desaturation Exercise testing may be performed to evaluate whether and how much a patient may desaturate during exercise. It may also be used to determine what a patient’s oxygen requirements are during exercise.

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99 Indications ■ The need to quantify the adequacy of arterial oxygen saturation during exercise ■ The need to quantify the response to therapeutic intervention (oxygen therapy) during exercise ■ The need to titrate supplemental oxygen during exercise ■ The need to assess disability or evaluate the patient for disability purposes ■ Preoperative assessment for lung resection/transplantation

Contraindications

Absolute Contraindications ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■

Acute ECG changes (ischemia, serious arrhythmias, etc.) Unstable angina Recent myocardial infarction Aneurysm (heart or aorta) Uncontrolled hypertension Deep venous thrombosis Recent systemic or pulmonary embolism Acute pericarditis Symptomatic aortic stenosis Uncontrolled heart failure Uncontrolled or acute asthma Pulmonary edema Respiratory failure

Relative Contraindications ■ ■ ■ ■ ■ ■

Invalid data from pulse oximetry Noncompliant patient Severe pulmonary hypertension Known electrolyte disturbances Resting BP (diastolic 110mmHg; systolic 200mmHg) Neuromuscular, musculoskeletal, or rheumatoid disorders that prevent or are exacerbated by exercise ■ Complicated or advanced pregnancy ■ SpO2 or SaO2 85 mmHg on room air ■ Cardiomyopathy

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Performing Exercise Oximetry Evaluations ■ Assemble the required equipment ■ ■ ■ ■ ■ ■ ■

Treadmill, exercise ergometer, or other exercise media ECG monitor Pulse oximeter Noninvasive manual or automated blood pressure monitor ABG collection equipment Defibrillator and emergency resuscitation equipment Oxygen therapy equipment and flowmeter(s)

■ Appropriately instrument the patient for monitoring ■ ■ ■ ■

ECG SpO2 Blood pressure Assemble and have ready ABG supplies if indicated

■ Initiate exercise testing (ramp or steady state protocol) ■ If patient SpO2 88%, initiate oxygen therapy and titrate oxygen to maintain SpO2 90% ■ Document all monitoring data, work load, duration, and oxygen therapy intervention

Hazards/Complications ■ ECG changes (ST elevation or depression, arrhythmias, ventricular tachycardia, etc.) ■ Severe desaturation (SpO2 80%) ■ Angina ■ Hypotension ■ Light-headedness ■ Fatigue ■ Muscle cramping

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101 Assessment of the Critically Ill Patient Vital Signs Heart Rate

Respiratory Rate

Blood Pressure

Temperature

6 years—75–120/min 10 years—50–90/min 16 years—50–90/min Adult—60–100/min Geriatric—60–100/min Pediatric—20–40/min Adolescent—15–20/min Adult—12–20/min 6 years—95/57 mmHg 10 years—95/57 mmHg 16 years—120/80 mmHg Adult—120/80 mmHg Geriatric—120/80 mmHg Pediatric—36.1–37.7C Adolescent—35.8–37.3C Adult—35.5–37.5C

Physical Findings ■ Inspection ■ Work of breathing? ■ Color? ■ Nasal flaring, retractions, accessory muscle use? ■ Distressed, increased respiratory rate? ■ Able to speak in complete sentences? ■ Diaphoresis? ■ Jugular vein distention? ■ Palpation ■ Symmetrical chest motion (possible flail)? ■ Areas of pain or tenderness (contusion)? ■ Subcutaneous emphysema? ■ Percussion ■ Dullness or flatness (possible consolidation/fluid)?

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■ Hyperresonance (possible pneumothorax)? ■ Diaphragmatic excursion? ■ Auscultation ■ Adventitious breath sounds (fluid, bronchospasm, edema, consolidation)?

Ventilatory Assessment Tidal volume Minute volume Rapid shallow breathing index (frequency/tidal volume [L]) PaCO2 PECO2 Dead space (VD ana, VD/VT)

Maximal inspiratory pressure (MIP)

Normal: 4–7 mL/kg Normal: 5–7 L/min (adult) Normal: 100

Normal: 35–45 mmHg Normal: 35–43 mmHg Anatomic: Normal 1 mL/lb body weight VD/VT: Normal 0.25–0.35 Normal –50 cmH2O

Oxygenation Assessment Oxygen content CaO2  SaO2(Hb  1.34)  (PaO2  0.003) PaO2 SpO2 Oxygen delivery DO2  QT  (CaO2  10) Arterial-venous oxygen content difference (CaO2 – CvO2)

Normal: 20 mL/dL Range 15–24 mL/dL Normal: 80–100 mmHg Normal: 90% Normal: 1000 mL/min Normal: 5 mL/dL Range 4–6 mL/dL (Table continued on following page)

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103 Oxygenation Assessment (continued) PaO2/FIO2 PaO2/PAO2 Oxygen consumption VO2  QT (Ca-vO2  10) Oxygen extraction ratio CaO2  CvO2 O2ER  CaO2

Normal: 200 Normal: 0.8–0.9 Normal: 250 mL/min

Pulmonary shunt

Normal: 0.20

QS /QT 

Normal: 0.25

CcO2  CaO2 CcO2  CvO2

Cardiovascular Assessment Capillary refill

Jugular venous distention Cardiac output Cardiac index CVP PCWP Mean PA pressure ECG

Normal: 3 seconds Increased: 3 seconds (low cardiac output or peripheral perfusion) Normal: 3–4 cm above the sternal angle Normal: 4–8 L/min Normal: 2.5–4.4 L/min/m2 Normal: 0–6 cmH2O Normal: 4–12 mmHg Normal: 8–12 mmHg Rate, rhythm, P-waves, P-R interval, QRS, ST segment, extra?

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Neurological Assessment Glasgow Coma Score Response Eye Opening

Best Verbal

6

None

None

5

None

Oriented

4

Spontaneous Confused

3

To speech

Inappropriate

2

To pain

Incomprehensible

1

None

None

Best Motor Obeys simple commands Attempts to remove painful stimuli Attempts to withdraw from painful stimuli Nonpurposeful elbow flexion Elbow extension, wrist flexion, shoulder rotation None

Guidelines: Glasgow Coma Score (GCS) of 14  normal. Glasgow Coma Score (GCS) of 3  profound coma.

Fluid and Electrolytes ■ Urine output ■ Normal: 1200 mL/day (minimum 12mL/hr) ■ Signs of pedal edema? ■ Electrolytes (Normals) ■ Na 137–147 mEq/L ■ K 3.5–5 mEq/L ■ Mg 1.8–3.0 mEq/L ■ Cl 98–105 mEq/L ■ Total CO2 24–30 mEq/L

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105 Classification of Ventilatory Failure Ventilatory failure is the respiratory system’s inability to provide adequate oxygenation and/or to adequately excrete carbon dioxide produced by metabolism.

Type I Respiratory Failure Normocapnic Respiratory Failure pH PaCO2 HCO3 PaO2

7.35–7.45 25–40 mmHg 22–26 mEq/L 40–59 mmHg

Causes of Type I Respiratory Failure ■ Pulmonary shunt ■ Diffusion defect ■ Inadequate systemic blood flow ■ Anemia, cyanide poisoning, methemoglobinemia

Type II Respiratory Failure Hypercapnic Respiratory Failure pH PaCO2 HCO3 PaO2

7.35 50 mmHg Normal or ↑ 50 mmHg

Causes of Type II Respiratory Failure ■ Neurological disorders (CNS depression, drug overdose, spinal cord injury, myasthenia gravis, Guillian-Barré, etc.) ■ Respiratory muscle disorders (fatigue, muscular dystrophy, polio, etc.) ■ Chest wall impairment (pneumothorax, flail chest, kyphoscoliosis, hemothorax, pleural effusion, etc.) ■ Airway obstruction (upper or lower) ■ Pulmonary disease (COPD, pneumonia, pulmonary fibrosis, pulmonary edema) ■ Hypercapnia (sepsis, burns, etc.)

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Airway Management Airway management is important in the maintenance of a patent airway in the presence of respiratory failure or pending respiratory failure. A patent airway must be quickly established so that ventilation (spontaneous or artificial) may be resumed or continued.

Positional Maneuvers to Open the Airway

Trachea

A

Mouth

Pharynx

Mouth Trachea

B

Pharynx

■ Head tilt ■ Anterior mandibular displacement

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107 Manual Resuscitators Manual resuscitators can provide temporary ventilatory assistance to patients with or without an artificial airway.

Self-Inflating Manual Resuscitators

■ Assemble the resuscitator/mask device ■ Connect to an oxygen flowmeter and set the flow to 10–15 L/min ■ Apply mask to the patient’s face or connect the resuscitator to the artificial airway ■ Deliver manual breaths with adequate tidal volumes and a rate of 12–20 /min. ■ Assess the patient for cyanosis, gastric distention, or vomiting

Simple Airways

■ Nasopharyngeal airway ■ Oropharyngeal airway

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Combitube Airway

This airway is inserted blindly (usually into the esophagus) and has two cuffs and two lumens. Ventilation must be carefully assessed to ensure the correct lumen is being used.

Laryngeal Mask Airway (LMA)

Commonly used in the anesthesia setting. The airway is inserted into the oropharynx into the esophagus resting against the upper esophageal sphincter.

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109 Endotracheal Tube

This airway is inserted into the trachea (position verified with end tidal CO2 monitoring, breath sounds, and chest x-ray).

Double Lumen Endotracheal Tubes

Carlens’ tube Robertshaw tube

Intubation

Indications for Intubation ■ ■ ■ ■ ■ ■

Traumatic upper airway obstruction Apnea Need to protect the airway Cardiopulmonary arrest Airway hemorrhage Laryngeal or upper airway edema

Contraindications

■ Existence of signed legal documents (advance directive or living will) stating that intubation/resuscitation is not desired

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Intubation Procedure

■ Obtain required equipment ■ Oxygen flowmeter ■ Manual resuscitator (bag/mask) ■ Laryngoscope and blades ■ Yankauer suction and suction catheter/kit ■ Endotracheal tubes (multiple sizes) ■ 20 mL syringe ■ Stylet ■ 4% Xylocaine jelly ■ Suctioning supplies ■ Personal protective equipment ■ Commercial endotracheal tube holder ■ End-tidal CO2 monitor or chemical colorimetric indicator ■ Position the patient supine (head in a sniffing or “vulture” position) ■ Ventilate/oxygenate the patient with the bag/mask resuscitator ■ Insert the laryngoscope and visualize the vocal cords ■ Pass the endotracheal tube through the vocal cords ■ Inflate the cuff with air using a 20-mL syringe ■ Stabilize the tube until it is secured with a commercial holding device ■ Verify the tube’s position ■ Auscultate the chest ■ Observe for equal bilateral expansion ■ Verify end-tidal CO2 ■ Note position (depth) of the tube at the teeth or gum line in centimeters ■ Order a portable chest x-ray to verify tube’s position (2 cm above the carina)

Care of an Artificial Airway Routine care of the artificial airway is required to maintain airway patency, protect the lower airway from aspiration of secretions and reduce infection.

Techniques

■ Keep head of bed elevated 30 degrees ■ Suction as needed to remove accumulated secretions

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111 ■ Use closed suction catheters and minimize breaking the ventilator circuit ■ Once each shift perform oral care and verify endotracheal tube’s security ■ Monitor cuff pressures and maintain minimal leak or minimal occlusion volume ■ Obtain daily chest x-rays to verify tube’s position

Suctioning

■ Indications ■ Atelectasis (retained, inspissated secretions causing atelectasis) ■ Remove accumulated secretions (evidenced by auscultation, increased airway resistance, increased airway pressures) ■ Obtain lower respiratory secretions for culture/sensitivity ■ Contraindications ■ Worsening or exacerbation of the patient’s condition (hypoxemia, vago-vagal response, etc.) ■ Suctioning procedure ■ Obtain required equipment ◆ Vacuum regulator, suction canister, and suction tubing ◆ Suction catheter/kit or closed suction system ◆ Sterile water ◆ Normal saline (unit dose “bullets”) ■ Assess the need for suctioning (peak pressure, RAW, auscultation) ■ Oxygenate/hyperinflate the patient before the procedure ■ Slowly advance the catheter into the airway until a cough reflex is obtained ■ Apply vacuum upon withdrawal (80–120 mmHg) ■ Oxygenate/hyperinflate following aspiration ■ Instill normal saline as required to hydrate secretions for removal ■ Repeat aspiration as required ■ Assess patient following procedure (HR and rhythm, auscultation, SpO2, peak pressure, RAW) ■ Hazards/complications ■ Atelectasis ■ ECG arrhythmias (PVCs, etc.)

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Hypoxemia Bronchospasm Bradycardia/tachypnea Hypotension Mucosal trauma Infection

Monitoring the Critical Care Patient Vital Signs Routine monitoring of vital signs is important in the management of the critically ill patient. The following table highlights normal values for the vital signs and potential causes for abnormal values.

Adult Normal Increased Heart rate 60–100/ Tachycardia (pain, min anxiety, hypoxemia, stress, fever, medication) Tachypnea (pending Respiratory 12–20/ min respiratory rate failure, hypoxia, anxiety, fatigue) Blood pres- 110–130/ Hypotension 70–90 (hypovolemia, sure sepsis, shock, right or left heart failure, increased intrathoracic pressure) 36.5– Hyperthermia (infecTempera37.5C tion, sepsis, mediture cation, increased metabolism)

112

Decreased Bradycardia (suctioning, hypoxia, vagal stimulation, heart blocks, medication) Bradypnea (medication, head trauma, hypothermia) Hypertension (hypervolemia, anxiety, pain, CHF, increased systemic vascular resistance, polycythemia) Hypothermia (CNS injury, medication, postoperative)

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113 Breath Sounds See Bedside Assessment Tab

Fluid Balance Positive pressure ventilation and the resulting positive intrathoracic pressures can result in reduction in urine output and concomitant fluid retention.

Normal Urine 50–60 mL/hr or output 1200–1440 mL/day

Oliguria

Polyuria

Decreased renal perfusion, dehydration, renal failure, shock, decreased cardiac output

Furosemide (Lasix), diabetes, increased fluid intake

Anion Gap Anion gap is the difference between the positive ions (cations) and the negative ions (anions). ■ Anion gap  (Na  K )(Cl  HCO3) ■ Normal range: 10–14 mEq/L

Arterial Blood Gases ■ Oxygenation assessment ■ Ventilation assessment See Advanced Assessment Tab

Oximetry and Capnography See Advanced Assessment Tab

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See Advanced Assessment Tab

Hemodynamic Monitoring See Advanced Assessment Tab

Initiation Of Mechanical Ventilation Once the decision to initiate mechanical ventilation has been made, an airway must be established. Endotracheal intubation is the preferred airway for interfacing the mechanical ventilator with the patient.

Indications for Mechanical Ventilation ■ Apnea or pending respiratory arrest ■ Acute exacerbation of COPD (PaCO2 acutely above patient’s baseline and pH 7.30), Type II failure ■ Acute severe asthma ■ Neuromuscular disease ■ Acute hypoxemic respiratory failure (Type I failure) ■ Heart failure and cardiogenic shock ■ Acute brain injury ■ Flail chest

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115 Physiologic Measurements (Parameters) Indicating Ventilatory Failure

Normal Tidal volume (VT) Minute volume (VE) Respiratory rate Rapid shallow breathing index (RSBI) Vital capacity (VC) Maximal inspiratory pressure (MIP) PaCO2 PA-a O2(FIO2  1.0) PaCO2/PAO2 QS/QT VD/VT

Pending Ventilatory Failure

5–7 mL/kg 5–8 L/min 12–20/min ≤100

5 mL/kg 10 L/min 35/min 105

65–75 mL/kg 80 to 120 cmH2O 35–45 mmHg 30–50 mmHg 0.8–0.9 2–5% 0.25–0.40

10–15 mL/kg  20 to 30 cmH2O 50 mmHg 350–450 mmHg 0.15 20% 0.6

Modes of Mechanical Ventilation A ventilator mode is the means by which a ventilator achieves ventilation of the lungs. A mode can be classified according to its control variable, control type, and phase variables (pressure, volume, flow, or time) during the breath cycle.

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Volume-Controlled Ventilation (Volume is the Control Variable) Mode

Trigger Variable

Limit Variable

Cycle Variable

Alarm Cycle

CMV (volume control)

M, T

F, V

T

P

CMV-Assist (assisted ventilation, assist/ control volume ventilation, volume assist mechanical ventilation)

M, T, P, F

F, V

T

P

F, V, P

T

P, T

VC-SIMV  Pressure F, V, P M, T, P, F Support (volume F, P(spont) P(spont) control synchronized mandatory ventilation  pressure support)

T P, F(spont)

P, T

Mandatory Minute M, T, P, F P, V, F Ventilation (miniP, F(spont) P(spont) mum mandatory ventilation, augmented minute ventilation, extended mandatory minute ventilation)

T, F P,F(spont)

P, T

VC-SIMV (volume M, T, P, F control synchronized mandatory ventilation)

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117 Pressure-Controlled Ventilation (Pressure is the Control Variable) Mode Pressure-Controlled Assist Ventilation (pressure control, pressure assist mechanical ventilation) Pressure-Controlled Synchronized Intermittent Mandatory Ventilation Pressure-Controlled Inverse Ratio Ventilation Airway Pressure Release Ventilation (bi-level positive airway pressure, variable positive airway pressure) Bilevel (BiPAP, biphasic) Pressure Support Proportional Assist Ventilation (proportional pressure support)

Trigger Variable

Limit Variable

Cycle Variable

Alarm Cycle

M, T, P, F F P, F(spont) P(spont)

T

P

M, T, P, F F, V, P P, F(spont) P(spont)

T, F P, F(spont)

P

M, T

P

T

P

M, T, F

P

T, F

None

T, P, F

P

F

None

P, F M, T, P, F

P P

F T

P, T P

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Dual Control (Either Volume or Pressure is a Control Variable) Trigger Variable

Mode Pressure Augmentation Volume Assured Pressure Support (volume assisted pressure support) Adaptive Support Ventilation Autoflow Pressure Regulated Volume Control Volume Support Adaptive Support

Tube Compensation

Limit Variable F F(spont) F F(spont)

Cycle Variable

Alarm Cycle

F, T V, F(spont) V, F V, F(spont)

None

M, T, P P, F(spont) T P, F(spont)

P, P, P, P,

T, P, F P, F(spont) T, F P, 0(spont) T, P, F P, F(spont)

P P, V(spont) P

T, F

P

T

P, V

P

T

None

P, F P, F(spont) T,P,F P,F(spont)

P P, V(spont) P P(spont)

T,V

F

P

F F,T(spont) T,F T, F, P (spont) F

P

P

None

Initial Ventilator Settings A practitioner must establish and decide upon the mode, tidal volume, minute ventilation, rate, FIO2, pressure support, inspiratory flow pattern, and alarm limits when initiating mechanical ventilation. Initial ventilator settings based upon desired clinical goals or protocols are becoming more common than simply making specific individual ventilator settings or parameters.

118

Strategy

119

VolumeControlled Ventilation

Control Variable Volume

Advantages

Disadvantages

Direct control of VT and VE

Patient may be less synchronous with the ventilator.

Considerations 1. May cause overdistention and stretch lung injury. 2. If peak pressures ≥40 cmH2O or plateau pressures ≥30 cmH2O, consider pressurecontrolled ventilation. 3. Careful setting of the pressure limit/ alarm is important to safety.

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Mode Selection

Page 120

Advantages

Disadvantages

Considerations

PressureControlled Ventilation

Pressure

1. Can reduce the patient’s work of breathing. 2. Can spare normal lung units from overdistention.

VT and VE varies

1. High and low VT and VE alarms are important to safety. 2. May need to accept permissive hypercapnia.

DualControlled Ventilation

Volume or Pressure

Optimizes delivery of VT by ventilator algorithms

System leaks or patient ventilatory efforts may limit the ventilator’s ability to measure system compliance.

Proper setting of the high pressure alarm is important to safety.

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Control Variable

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Strategy

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Mode Selection

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121 Tidal Volume

■ Tidal volume is either set on a basis of milliliters per kilogram of ideal body weight or set by a target plateau pressure limit. ■ Ideal Body Weight (males)  106  (6  [height in inches 60]) ■ Ideal Body Weight (females)  105  (5  [height in inches 60]) ■ NOTE: IF HEIGHT IS 60 INCHES, IGNORE NUMBERS IN PARENTHESES ■ VT  4–12 mL/kg and ■ VT that maintains a plateau pressure ≤30 cmH2O

Minute Ventilation Minute ventilation is adjusted to meet the oxygen and carbon dioxide transport requirements of the patient. Increasing minute ventilation decreases carbon dioxide and increases alveolar PAO2. ■ Men: VE  4.0  Body Surface Area (BSA) ■ Women: VE  3.5  Body Surface Area (BSA)

Rate (frequency)

■ The rate is set to maintain the desired minute ventilation and optimal cycle time. Caution must be observed when increasing the rate so that the expiratory time does not become shortened excessively. ■ Choose a rate and manipulate minute volume to achieve a desired PaCO2.

Fraction of Inspired Oxygen (FIO2) Initially, the FIO2 is set between 0.6 and 0.9 upon ventilator commitment (if patient’s ability to oxygenate is unknown). After 20 minutes, arterial blood gases should be drawn to assess ventilation and oxygenation. ■ Maintain SpO2 ≥90% ■ Positive end expiratory pressure (PEEP) can be established at 5 cmH2O initially. Higher PEEP may be required for patients with increased shunt fractions to maintain adequate oxygenation.

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Pressure Support Initial setting of between 8 and 20 cmH2O adjusted to overcome airway resistance or augment spontaneous volumes. Maintain a plateau pressure ≤30 cmH2O.

Inspiratory Flow Pattern

■ Pressure-Controlled Ventilation: The variable flow pattern that is characteristic of this mode of ventilation may be more synchronous in patients with active ventilatory drives. ■ Volume-Controlled Ventilation: Establish the flow rate high enough to meet the patient’s demands. Adjust the flow to allow adequate time for exhalation and to prevent auto PEEP.

Alarm Limits Adjust the alarm limits using the following guidelines: ■ Low/High Exhaled Tidal Volume 100 mL of set VT ■ Low/High Exhaled Minute Volume 20% or 2.0 L ■ Low/High Pressure Alarm 10–15 cmH2O ■ Low/High Rate Alarm 10–15 breaths/minute ■ Apnea Alarm 20 second delay ■ High/Low FIO2 Alarm 5–10%

Ventilator Waveforms Contemporary ventilators all display graphically real time waveforms of flow, pressure, and volume on a breath-by-breath basis. It is important to be able to rapidly interpret and understand the morphology or shape of what is being displayed and how it relates to the patient’s condition.

Scalars Scalar wave forms are graphic depictions of flow, pressure, or volume displayed versus time.

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123

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Flow Scalar

Time (seconds)

The flow scalar waveform depicts flow versus time. Inspiration is above the iso-flow line while expiration is below it. If one were to integrate the area under the inspiratory portion of the graphic, it would equal the volume delivered (flow multiplied by time).

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16 14 12 10 8 6 4 2 0

A C

2

4

B

6

124

Pressure (cmH20)

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Pressure Scalar

8

10

12

14

Time (seconds) The pressure scalar waveform depicts pressure versus time. Note the following points; A, peak inspiratory pressure (PIP); B, plateau pressure (PALV) or alveolar pressure; and C, alveolar opening pressure (PAO). If one were to integrate the area under the pressure curve (inspiration), it would represent the mean airway pressure.

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Volume (ml)

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Volume Scalar

Time (seconds)

The volume scalar waveform depicts volume versus time. By reading the volume scale at peak inspiration, one may determine tidal volume delivery for that breath.

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Loops 800

Loops are helpful in that pressure versus volume or flow versus volume may be displayed. Loops are helpful in assessing inspiratory work, changes in resistance or compliance and the effects of bronchodilators (change in resistance), leaks, trigger sensitivity, and overdistention. Volume (ml)

Pressure Versus Volume Loop The pressure versus volume loop is helpful in assessment of ventilatory work. Patient effort or inspiratory work is depicted by the deflection of the waveform into the sub-ambient region of the loop (left of the iso-pressure line). By minimizing the deflection or the loop to the left, ventilatory work can be reduced.

600

400

200

-16-14-12 -10 -8 -6 -4 -2 -0 2 4 6 8 10 12 14 16

Pressure (cmH2O)

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127

Flow (lpm)

Flow Versus Volume Loop The flow versus volume loop is helpful in assessing airway 200 resistance and changes in compliance. Airway resistance is the hysteresis (dif100 ference) between the inspiratory and expiratory portions of the loop. Decreased airway resistance 0 causes the deflection of the expiratory portion of the loop to be greater, -100 reflecting improved expiratory flow.

Volume (ml) 200 400 600 800 1000 1200 1400 1600 1800

-200

-300

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Normal Ventilator Graphics

Volume-Controlled Ventilation Flow, pressure, and volume are three scalar waveforms normally displayed on a ventilator’s monitoring screen.

Pressure (cmH2O)

Flow (lpm)

Pressure Triggered Spontaneous Breath 50 40 30 20 10 0 -10 -20 -30 -40 -50 -60 12 10 8 6 4 2 0 -2 -4 -6 -8 -10

2

4

6

8

10

12

14

2

4

6

8

10

12

14

2

4

10

12

14

Volume (ml)

800 600 400 200 0

0

6 8 Time (seconds)

A spontaneous breath was pressure triggered when the pressure graph deviated below baseline prior to the mandatory (ventilator) breath being initiated.

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129

Pressure (cmH2O)

Flow (lpm)

Flow Triggered Spontaneous Breath 50 40 30 20 10 0 -10 -20 -30 -40 -50 -60 12 10 8 6 4 2 0 -2 -4 -6 -8 -10 800

2

4

6

8

10

12

14

2

4

6

8

10

12

14

2

4

10

12

14

Volume (ml)

600

400 200 0

0

6 8 Time (seconds)

A spontaneous breath was flow triggered when the flow waveform deviated from the baseline, initiating a mandatory (machine) breath.

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Volume (ml)

Pressure (cmH2O)

Flow (lpm)

Mandatory Breath 50 40 30 20 10 0 -10 -20 -30 -40 -50 -60 12 10 8 6 4 2 0 -2 -4 -6 -8 -10 800

2

4

6

8

10

12

14

2

4

6

8

10

12

14

2

4

10

12

14

600 400 200 0

0

6 8 Time (seconds)

A mandatory (machine) breath is seen where neither pressure or flow changes resulted in breath delivery (time triggered).

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131 PEEP

Flow (lpm)

30 20 10 0 -10

2

4

6

8

10

12

14

2

4

6

8

10

12

14

2

4

10

12

14

-20 -30 -40 -50 -60 16

Pressure (cmH2O)

14 12 10 8 6 4 2 0

0

Volume (ml)

800 600 400 200 0

0

6 8 Time (seconds)

The addition of PEEP is shown where the pressure waveform baseline becomes elevated above ambient pressure.

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Pressure-Controlled Ventilation Flow, pressure, and volume are three scalar waveforms normally displayed on a ventilator’s monitoring screen during pressurecontrolled ventilation.

Pressure Triggered Spontaneous Breath 40

Flow (lpm)

30 20 10 0 -10

2

4

6

8

10

12

14

2

4

6

8

10

12

14

2

4

10

12

14

-20 -30

Pressure (cmH2O)

-40 -50 14 12 10 8 6 4 2 0 -2 -4 500

Volume (ml)

400 300 200 100 0

0

6 8 Time (seconds)

A spontaneous breath was pressure triggered when the pressure graph deviated below baseline prior to the mandatory (ventilator) breath being initiated.

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133 Flow Triggered Spontaneous Breath

Flow (lpm)

30 20 10 0

2

4

6

8

10

12

14

0

2

4

6

8

10

12

14

0

2

4

10

12

14

-10 -20 -30

Pressure (cmH2O)

-40 -50 -60 16 14 12 10 8 6 4 2 0

Volume (ml)

800 600 400 200 0

6 8 Time (seconds)

A spontaneous breath was flow triggered when the flow waveform deviated from the baseline, initiating a mandatory (machine) breath.

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Mandatory Breath

Flow (lpm)

30 20 10 0

2

4

6

8

10

12

14

0

2

4

6

8

10

12

14

0

2

4

6

8

10

12

14

-10 -20 -30 -40 -50 -60

Pressure (cmH2O)

16 14 12 10 8 6 4 2 0

Volume (ml)

800 600 400 200 0

Time (seconds)

A mandatory (machine) breath is seen where neither pressure or flow changes resulted in breath delivery (time triggered).

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135

Pressure (cmH2O)

Flow (lpm)

PEEP 50 40 30 20 10 0 -10 -20 -30 -40 -50 14 12 10 8

2

4

6

8

10

12

14

2

4

6

8

10

12

14

2

4

6

8

10

12

14

6 4 2 0 -2 -4 600

Volume (ml)

500 400 300 200 100 0

0

Time (seconds)

The addition of PEEP is shown where the pressure waveform baseline becomes elevated above ambient pressure.

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Abnormal Ventilator Graphics

Air-trapping (Auto-PEEP) Air-trapping (Auto-PEEP) may be associated with high ventilator rates, low inspiratory flow rates, high tidal volumes, or low or equal I:E ratios (1:1).

Air-trapping in Flow Volume Loop

80 60

Flow (lpm)

40 20 Volume (ml)

0

200 400

600

-20 -40 -60 -80

136

800 1000 1200

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137 Air-trapping in Scalar Waveforms 80 60

Flow (lpm)

40 20 0

2

4

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8

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14

0

2

4

6

8

10

12

14

0

2

4

6

8

10

12

14

-20 -40 -60 -80

Pressure (cmH2O)

14 12 10 8 6 4 2 0 1200

Volume (ml)

1000 800 600 400 200 0

Time (seconds)

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Increased Airway Resistance (Raw)

Increased Airway Resistance in Volume Loops

Volume

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Pressure

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Increased Airway Resistance in Scalar Waveforms

Time

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Decreased Airway Resistance (Raw)

Decreased Airway Resistance in Volume Loops

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Decreased Compliance

Decreased Compliance in Volume Loops

Volume

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Flow

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Time

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Increased Compliance

Increased Compliance in Volume Loops

Volume

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Increased Compliance in Scalar Waveforms

Time

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Overdistention

Overdistention is best observed in the volume versus pressure loop. Notice the “beaking” that occurs where there is little or no volume change for an increase in pressure.

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Flow

146

Pressure Volume

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Trigger Asynchrony

Time

Trigger asynchrony occurs when the trigger sensitivity (pressure or flow) is adjusted inappropriately causing increased patient effort or failure of the ventilator to initiate a breath.

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147 Discontinuance of Ventilatory Support Discontinuance of mechanical ventilation reduces the risk of lung injury, reduces the risk of ventilator-associated pneumonia, improves patient comfort, and will decrease costs. Therefore, discontinuance of mechanical ventilatory support is essential in improving patient outcomes as soon as the patient has demonstrated the ability to sustain ventilation spontaneously and maintain airway patency.

Assessment for Weaning Prior to initiating a formal spontaneous breathing trial, the patient should be assessed to determine if he or she is a candidate for ventilator discontinuance. The following table summarizes the criteria that may be assessed prior to a spontaneous breathing trial. These criteria should be individualized for each patient and careful assessment of the patient is important to a successful spontaneous breathing trial.

Assessment Gas exchange PaO2/FIO2 FI O2 PEEP pH Hemodynamic stability

Ventilatory drive

Acceptable Criteria for Spontaneous Breathing Trial SpO2 ≥85–90% 150–200 mmHg 0.40–0.50 5–8 cmH2O ≥7.25 Absence of clinically significant hypotension, administration of only low-dose vasopressors (dopamine or dobutamine 5mcg/ kg/min), absence of active myocardial ischemia Able to initiate a spontaneous breath

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Spontaneous Breathing Trial A spontaneous breathing trial is a short 30–120 minute period of time that the patient is allowed to breathe spontaneously with no or little ventilatory support. Most complications occur in the first 30 minutes of trial, therefore careful monitoring is important early in the trial.

Methods CPAP (continuous positive airway pressure) Pressure support Aerosol T-piece

5 cmH2O 5–7 cmH2O Adequate flow and FIO2

Failure Failure of a spontaneous breathing trial may be manifested in the criteria summarized in the following table. Rapid shallow breathing index Respiratory rate Heart rate Respiratory pattern Hemodynamic instability Patient comfort

105 30–35/min 120/min or increased over 20% from baseline Increased work of breathing Systolic BP 90 or 180 mmHg Uncomfortable, diaphoretic, anxious, agitated

Return to Mechanical Ventilation If a patient fails a spontaneous breathing trial the patient should be returned to mechanical ventilation and provided with adequate support to rest the patient and the ventilatory muscles. After a period of 24 hours, a spontaneous breathing trial should be repeated to assess readiness for ventilator discontinuance and extubation.

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149 Recommended Modes

■ SIMV ■ SIMV  Pressure Support ■ Pressure Support ■ Volume Support ■ Volume Assured Pressure Support ■ Mandatory Minute Ventilation The selection of a specific mode does not influence the outcome of further spontaneous breathing trials. The goal should be to provide a stable, nonfatiguing, comfortable form of ventilatory support for 24 hours before repeating a spontaneous breathing trial.

Extubation Once the patient has successfully demonstrated the ability to breathe spontaneously, removal of the endotracheal tube should be the next consideration. Successful removal of the artificial airway is dependent upon the patient’s ability to have a patent and protected airway.

Criteria for Assessment of Successful Extubation

■ Cuff leak 110 mL while on assist-controlled ventilation with the cuff deflated ■ Spontaneous peak expiratory flow 160 L/min ■ Absence of excessive secretions or need for frequent suctioning

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Basic Life Support Adult One-Man CPR 1

No movement or response

PHONE 911 or emergency number Get AED or second rescuer (if available) to do this

2

3

Open AIRWAY, check BREATHING

4 If not breathing, give 2 BREATHS that make chest rise 5 If no response, check pulse: Do you DEFINITELY feel pulse within 10 seconds?

Definite pulse

No pulse

6

Text/image rights not available. Give cycle of 30 COMPRESSIONS and 2 BREATHS until AED/defibrillator arrives, ALS providers take over, or victim starts to move

Push hard and fast (100/min) and release completely Minimize interruptions in compressions 5a 7

AED/defibrillator ARRIVES

Check rhythm. Shockable rhythm?

Give 1 breath every 5 to 6 seconds Recheck pulse every 2 minutes

8 9

Shockable

Give 1 shock Resume CPR immediately for 5 cycles

Not shockable

10

Resume CPR immediately for 5 cycles Check rhythm every 5 cycles; continue until ALS providers take over or victim starts to move

Note that boxes bordered by dotted lines are performed by health-care providers and not by lay rescuers.

(From: 2005 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2005 112 [Suppl I]: IV-22, © 2005 American Heart Association, with permission.)

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151 Adult Foreign Body Airway Obstruction No

Are there signs of severe airway obstruction? Yes

Monitor the victim No Ask: Are you choking? Yes Perform abdominal thrusts to remove foreign body

No

Is the victim unconscious or unresponsive? Yes 1. Activate EMS System 2. Initiate CPR 3. When opening the airway, if object is observed, remove it

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Child One-Man CPR No movement or response Send someone to phone 911, get AED

1

Lone Rescuer: For SUDDEN COLLAPSE, phone 911, get AED 2

Open AIRWAY, check BREATHING 3

If not breathing, give 2 BREATHS that make chest rise 4

Text/image rights not available. If no response, check pulse: DEFINITE pulse within 10 seconds?

Definite pulse

5

No pulse

5a

Give 1 breath every 3 seconds Recheck pulse ever 2 minutes

6 One Rescuer: Give cycles of 30 COMPRESSIONS and 2 BREATHS Push hard and fast (100/min) and release completely Minimize interruptions in compressions Two Rescuers: Give cycle of 15 COMPRESSIONS and 2 BREATHS

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153 7 If not already done, PHONE 911, for child get AED/defibrillator Infant (<1 year): Continue CPR until ALS responders take over or victim starts to move Child (>1 year): Continue CPR; use AED/defibrillator after 5 cycles of CPR (Use AED as soon as it is available for sudden, witnessed collapse) 8

Text/image rights not available. Child >1 year: Check rhythm. Shockable rhythm?

9

Shockable

Give 1 shock Resume CPR immediately for 5 cycles

Not shockable

10

Resume CPR immediately for 5 cycles Check rhythm every 5 cycles; continue until ALS providers take over or victim starts to move

Note that boxes bordered by dotted lines are performed by health-care providers and not by lay rescuers. (From: 2005 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2005 112 [Suppl I]: IV-158, © 2005 American Heart Association, with permission.)

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Child Foreign Body Airway Obstruction No

Yes Are there signs of severe airway obstruction? Yes

Monitor the victim No Ask: Are you choking? Yes Perform abdominal thrusts to remove foreign body

No

Is the victim unconscious or unresponsive? Yes 1. Activate EMS System 2. Initiate CPR 3. When opening the airway, if object is observed, remove it

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155 One-Man Infant CPR Assess Responsiveness Victim is unresponsive Activate EMS Place victim in recovery position and observe victim

Victim is Breathing

Assess Breathing Victim is Not Breathing Open the airway: 1. Head tilt-chin lift 2. Jaw-thrust

Perform rescue breathing: 2 slow breaths (1 second per breath)

Continue rescue breathing, 1 breath every 3–5 seconds

No

Check pulse < 60/min (brachial or femoral) Yes

Begin chest compressions: 30 compression (100 per minute) to 2 rescue breaths

After 5 cycles, reassess the patient 1. Resume CPR or 2. Provide rescue breathing or 3. Place patient in recovery position

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Two-Man Infant CPR Assess Responsiveness Victim is Unresponsive Activate EMS Place victim in recovery position and observe victim

Victim is Breathing

Assess Breathing Victim is Not Breathing Open the airway: 1. Head tilt-chin lift 2. Jaw-thrust

Perform rescue breathing: 2 slow breaths (1 second per breath)

Continue rescue breathing, 1 breath every 3–5 seconds

No

Check pulse < 60/min (brachial or femoral) Yes

Begin chest compressions: 15 compression (100 per minute) to 2 rescue breaths

After 5 cycles, reassess the patient 1. Resume CPR or 2. Provide rescue breathing or 3. Place patient in recovery position

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157 Infant Foreign Body Airway Obstruction

Monitor the victim

No

Are there signs of severe airway obstruction? Yes Perform back slaps and abdominal thrusts to remove foreign body

Is the victim unconscious or unresponsive? Yes 1. Activate EMS System 2. Initiate CPR 3. When opening the airway, if object is observed, remove it

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Automated External Defibrillator (AED) Algorithm No Monitor the victim

Is the victim unresponsive? Yes Airway and Breathing 1. Check breathing 2. Open airway 3. Give 2 rescue breaths

Circulation: 1. Check pulse 2. Begin compressions 30:2

Automated External Defibrillator 1. Place AED next to victim, turn on power 2. Attach pads at sternum and apex 3. Clear victim and press “ANALYZE” 4. Clear victim and “SHOCK” if advised 5. Don't touch victim and “ANALYZE” 6. Check carotid pulse and continue CPR if indicated

Monitor the patient for: 1. Breathing 2. Pulse and circulation

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159 Notes

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Advanced Cardiac Life Support Pulseless Arrest Algorithm PULSELESS ARREST

1

• BLS Algorithm: Call for help; give CPR • Give oxygen when available • Attach monitor/defibrillator when available Not shockable

Shockable

3

VF/VT

2

Check rhythm Shockable rhythm?

9

Asystole/PEA

4 10

Give 1 shock • Manual biphasic: device specific (typically 120 to 200 J) Note: If unknown, use 200J • AED: device specific • Monophasic: 360 J Resume CPR immediately Give 5 cycle of CPR*

5

Check rhythm Shockable rhythm?

No

Resume CPR immediately for 5 cycles When IV/IO available, give vasopessor • Epinephrine 1 mg IV/IO Repeat every 3 to 5 min or • May give 1 dose or vasopressin 40 U IV/IO to replace first or second dose of epinephrine Consider atropine 1 mg /IV/IO for asystole or slow PEA rate Repeat every 3 to 5 min (up to 3 doses)

Text/image rights not available. 6

Shockable

Continue CPR while defibrillator is charging Give 1 shock • Manual biphasic: device specific (same as first shock or higher) Note: If unknown, use 200J • AED: device specific • Monophasic: 360 J Resume CPR immediately after the shock When IV/IO available, give vasopressor during CPR (before or after the shock) • Epinephrine 1 mg IV/IO Repeat every 3 to 5 min or • May give 1 dose of vasopressin 40 U IV/IO to replace first or second dose of epinephrine

Give 5 cycle of CPR*

11 Check rhythm Shockable rhythm?

Not shockable

Give 5 cycle of CPR*

160

Shockable

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161 7

12 Check rhythm Shockable rhythm?

Shockable

No

13

• If asystole, go to Box 10 • If electrical activity, check pulse. If no pulse go to Box 10 • If pulse present, begin postresuscitation care

Go to Box 4

8 Continue CPR while defibrillator is charging Give 1 shock • Manual biphasic: device specific (same as first shock or higher dose) Note: If unknown, use 200J • AED: device specific • Monophasic: 360 J Resume CPR immediately after the shock Consider antiarrhythmics; give during CPR (before and after the shock) amiodarone (300 mg IV/IO once, then consider additional 150 mg IV/IO once) or lidocaine (1 to 1.5 mg/kg first dose, then 0.5 to 0.75 mg/kg IV/IO, maximum 3 doses or 3 mg/kg) Consider magnesium, loading dose 1 to 2 g IV/IO for torsades de pointes After 5 cycle of CPR,* go to Box 5 above

Text/image rights not available. During CPR • Push hard and fast (100/min) • Ensure full chest recoil • Minimize interruptions in chest compressions • One cycle of CPR: 30 compressions then 2 breaths; 5 cycles = 2 min • Avoid hyperventilation • Secure airway and confirm placement • Rotate compressors every 2 min with rhythm checks • Search for and treat possible contributing factors:

– Hypovolemia – Hypoxia – Hydrogen ion (acidosis) – Hypo-/hyperkalemia – Hypoglycemia – Hypothermia – Toxins – Tamponade, cardiac – Tension pneumothorax – Thrombosis (coronary or pulmonary) – Trauma

* After an advance airway is placed rescuers no longer deliver “cycles” of CPR. Give continuous chest compressions without pauses for breaths. Give 8 to 10 breaths/minute. Check rhythm every 2 miniutes.

(From: 2005 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2005 112 [Suppl I]: IV-59, © 2005 American Heart Association, with permission.)

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Bradycardia Algorithm

1 • • • •

BRADYCARDIA Heart rate <60 bpm and inadequate for clinical condition

Maintain patent airway; assist breathing as needed Give oxygen Monitor ECG (identify rhythm), blood pressure, oximetry Establish IV access

2 Signs or symptoms of poor perfusion caused by the bradycardia? (e.g., acute altered mental status, ongoing chest pain, hypotension or other signs of shock)

3 4a

Adequate Perfusion

Observe/Monitor

Poor Perfusion

4

• Prepare for transcutaneous pacing; use without delay for high-degree block (type II second-degree block or third-degree AV block) • Consider atropine 0.5 mg IV while awaiting pacer. May repeat to a total dose of 3 mg. If ineffective, begin pacing • Consider epinephrine (2 to 10 μg/min) or dopamine (2 to 10 μg/kg per minute) infusion while awaiting pacer or if pacing ineffective

Text/image rights not available. 5

• Prepare for transvenous pacing • Treat contributing causes • Consider expert consultation

Reminders • If pulseless arrest develops, go to Pulseless Arrest Algorithm • Search for and treat possible contributing factors: – Hypovolemia – Hypoxia – Hydrogen ion (acidosis) – Hypo-/hyperkalemia – Hypoglycemia – Hypothermia

– Toxins – Tamponade, cardiac – Tension pneumothorax – Thrombosis (coronary or pulmonary) – Trauma (hypovolemia, increased ICP)

(From: 2005 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2005 112 [Suppl I]: IV-68, © 2005 American Heart Association, with permission.)

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Tachycardia Algorithm 1

2

• • • •

TACHYCARDIA with Pulses

Assess and support ABCs as needed Give oxygen Monitor ECG (identify rhythm), blood pressure, oximetry Identify and treat reversible causes Symptoms Persist

5

4

3

• Establish IV access • Obtain 12-lead ECG (when available) or rhythm strip Is QRS narrow (<0.12 sec)? Stable

Is patient stable? Unstable signs include altered mental status, ongoing chest pain, hypotension or other signs of shock Note: rate-related symptoms uncommon if heart rate <150/min Unstable

Wide (>0.12 sec)

Perform immediate synchronized cardioversion • Establish IV access and give sedation if patient is conscious; do not delay cardioversions • Consider expert consultation • If pulseless arrest develops, see Pulseless Arrest Algorithm

Text/image rights not available. 6 Narrow

12

NARROW QRS*: Is Rhythm Regular?

WIDE QRS*: Is Rhythm Regular? Expert consultation advised

Irregular Regular Irregular Narrow-Complex Tachycardia Probable atrial fibrillation or possible atrial flutter or MAT (multifocal atrial tachycardia) • Consider expert consultation • Control rate (e.g., dilitazem, ß-blockers; use ß-blockers with caution in pulmonary disease or CHF)

• Attempt vagal maneuvers • Give adenosine 6 mg rapid IV push. If no conversion, give 12 mg rapid IV push; may repeat 12 mg dose once

7

Does rhythm convert? Note: Consider expert consultation

11

8

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165 Convert

Does Not Convert

If rhythm converts, probable reentry SVT (reentry supraventricular tachycardia): • Observe for recurrence • Treat recurrence with adenosine or longer-acting AV nodal blocking agents (e.g., dilitazem, ß-blockers)

9 13

10 Regular

If ventricular tachycardia or uncertain rhythm: • Amiodarone 150 mg IV over 10 min Repeat as needed to maximum dose of 2.2g/24 hours • Prepare for elective synchronized cardioversion

If rhythm does NOT convert, possible atrial flutter, ectopic atrial tachycardia, or junctional tachycardia: • Control rate (e.g., dilitazem, ß-blockers; use ß-blockers with caution in pulmonary disease or CHF) • Treat underlying cause • Consider expert consultation

Irregular

14

If atrial fibrillation with aberrancy: • See Irregular Narrow-Complex Tachycardia (Box 11)

Text/image rights not available. If SVT with aberrancy • Give adenosine (go to Box 7)

During Evaluation • Secure, verify airway and vascular access when possible • Consider expert consultation • Prepare for cardioversion

If pre-excited atrial fibrillation (AF + WPW) • Expert consultation advised • Avoid AV nodal blocking agents (e.g., adenosine, digoxin, dilitazem, verapamil) • Consider antiarrhythmics (e.g., amiodarone 150 mg IV over 10 min) If recurrent polymorphic VT, seek expert consultation If torsades de pointes, give magnesium (load with 1-2 g over 5-60 min, then infusion)

Treat contributing factors: – Hypovolemia – Hypoxia – Hydrogen ion (acidosis) – Hypo-/hyperkalemia – Hypoglycemia – Hypothermia

– Toxins – Tamponade, cardiac – Tension pneumothorax – Thrombosis (coronary or pulmonary) – Trauma (hypovolemia)

* Note: If patient become unstable go to Box 4.

(From: 2005 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2005 112 [Suppl I]: IV-70, © 2005 American Heart Association, with permission.)

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Chest Discomfort/Ischemia Algorithm 1

2

Chest discomfort suggestive of ischemia

EMS assessment and care and hospital preparation: • Monitor, support ABCs. Be perpared to provide CPR and defibrillation • Administer oxygen, aspirin, nitroglycerin, and morphine if needed • If available, obtain 12-lead ECG; if ST-elevation: – Notify receiving hospital with transmission or interpretation – Begin fibrinolytic checklist • Notified hospital should mobilize hospital resources to respond to STEMI

Immediate ED assessment (<10 min) • Check vital signs; evaluate oxygen saturation • Establish IV access • Obtain/review 12-lead ECG • Perform brief, targeted history, physical exam • Review/complete fibrinolytic checklist; check contraindications • Obtain initial cardiac marker levels, initial electrolyte and coagulation studies • Obtain portable chest x-ray (<30

min) Immediate ED general treatment • Start oxygen at 4 L/min; maintain 02 sat >90% • Aspirin 160 to 325 mg (if not given by EMS) • Nitroglycerin sublingual, spray, or IV • Morphine IV if pain not relieved by nitroglycerin

Text/image rights not available. 3

4

ST elevation or new or presumably new LBBB; strongly suspicous for injury ST-Elevation MI (STEMI)

5

Review initial 12-lead ECG

ST depression or dynamic T-wave inversion; strongly suspicious for ischemia High-Risk Unstable Angina/Non-ST-Elevation MI (UA/NSTEMI)

9

Normal or nondiagnostic changes in ST segment or T wave Intermediate/ Low-Risk UA

13

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167 6

10 Start adjunctive treatments as indicated (see text for contrainidcations) Do not delay reperfusion • ß-Adrenergic receptor blockers • Clopidogrel • Heparin (UFH or LMWH)

7

11

Time from onset of symptoms <12 hours? <12 hours

8

14

Start adjunctive treatments as indicated (see text for contrainidcations) • Nitroglycerin • ß-Adrenergic receptor blockers • Clopidogrel • Heparin (UFH or LMWH) • Glycoprotein IIb/IIIa

Admit to monitored bed Assess risk status (Tables 3, 4)

Develops high or intermediate risk criteria (Tables 3, 4) OR troponin-positive? Yes

No

15 Consider admission to ED chest pain unit or to monitored bed in ED Follow: • Serial cardiac markers (including troponin) • Repeat ECG/ continuous ST segment monitoring • Consider stress test

>12 hours

Text/image rights not available. Reperfusion strategy: Therapy defined by patient and other criteria (Table 2) • Be aware of reperfusion goals: – Door-to-balloon inflation (PCI) goal of 90 min – Door-to-needle inflation (fibrinolysis) goal of 30 min • Continue adjunctive therapies and: – ACE inhibitor/ angiotensin receptor blocker (ARB) within 24 hours of symptom onset – HMG CoA reductase inhibitor (statin therapy)

12

High-risk patient (Tables 3, 4 for risk stratification: • Refractory ischemic chest pain • Recurrent/persistent ST deviation • Ventricular tachycardia • Hemodynamic instability • Signs of pump failure • Early invasive strategy, including catheterization and revascularization for shock within 48 hours of an AMI Continue ASA, heparin, and other therapies as indicated • ACE inhibitor/ARB • HMG CoA reductase inhibitor (statin therapy) Not at high risk: cardiology

16 Develops high or intermediate risk criteria (Tables 3, 4) OR troponin-positive?

Yes

No

17 If no evidence of ischemia or infarction, can discharge with follow-up

(From: 2005 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2005 112 [Suppl I]: IV-90, © 2005 American Heart Association, with permission.)

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Assessment of the Newborn Vital Signs

Normal Vital Signs Blood Blood Pressure Pressure Birthweight (mmHg) (mmHg) (g) Systolic Diastolic 500–700 700–1000 1000–1500 1500–2000 2000–3000 Term

50–60 48–58 47–58 47–60 51–72 64–72

26–36 24–36 25–35 23–35 27–46 50–55

SpO2 Respiratory (Desired Rate Range)

Heart Rate

120–170

30–60

88–94%

Neonatal Arterial Blood Gas Values pH: PaCO2: PaO2: HCO3⫺:

7.30–7.45 35–45 mmHg 50–70 mmHg 20–26 mEq/L

Apgar Score The Apgar score, named after Dr. Virginia Apgar, provides a quick assessment for depression upon delivery, performed at 1 and 5 minutes after birth. The Apgar score can be remembered with the acronym Appearance, Pulse, Grimace (reflexes), Activity (muscle tone), and Respiratory effort. Appearance Pink torso and Extremities Pink torso cyanotic extremities Cyanotic all over

168

1 Minute 2 1 0

5 Minutes

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169 Pulse Pulse ⬎100 2 Pulse ⬍100 1 Absent 0 Grimace (reflexes, irritability) Active, moving, crying 2 Frown or grimace if stimulated 1 No response to stimuli 0 Activity Actively moving, resistance to 2 extension of extremities Limited movement, some flex1 ion of the extremities Flaccid or limp 0 Respiratory effort Crying, vigorous breathing 2 Irregular, weak, hypoventilating 1 Absent 0 Totals 8–10 Normal, 4–6 Moderate Depression, Resuscitation Indicated

1 Minute

5 Minutes

1 Minute

5 Minutes

1 Minute

5 Minutes

1 Minute

5 Minutes

0–3 Immediate

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NEUROMUSCULAR MATURITY SCORE -1

0

1

2

POSTURE SQUARE WINDOW (Wrist)

-90°

90°

60°

45°

ARM RECOIL 180° POPLITEAL ANGLE

SCARF SIGN HEEL TO EAR

180°

160°

140°-180°

140°

110°-140°

120°

170

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NEUROMUSCULAR MATURITY SIGN

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SCORE 4

5

RECORD SCORE HERE

SCORE Neuromuscular: Physical: Total:

Score Weeks 30°

90°-110°

100°

0°

<90°

90°

<90°

TOTAL NEUROMUSCULAR MATURITY SCORE

-10

20

-5

22

0

24

5

26

10

28

15

30

20

32

25

34

30

36

35

38

40

40

45

42

50

44

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MATURITY RATING

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SKIN

SCORE -1

0

Sticky, friable, transparent

Gelatinous, red, translucent

Smooth pink visible veins

1

Superficial peeling and/or rash, few veins

2

None

Sparse

Abundant

Thinning

PLANTAR SURFACE

Heel-toe 40–50 mm:-1 <40 mm:-2

>50 mm no crease

Faint red marks

Anterior transverse crease only

BREAST

Imperceptible

Barely perceptible

Flat areola, no bud

Stippled areola, no bud

EYE/EAR

Lids fused Loosely:-1 Tightly:-2

Lids open Pinna flat Stays folded

Sl. curved pinna; soft; slow recoil

Well-curved pinna; soft but ready recoil

LANUGO

GENITALS (Male) GENITALS (Female)

Scrotum flat, smooth

Scrotum empty faint rugae

Clitoris prominent and labia flat

Prominent clitoris and small labia minora

Testes in upper canal, Testes descending, few rugae rare rugae Prominent clitoris and enlarging minora

Majora and minora equally prominent

172

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PHYSICAL MATURITY SIGN

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PHYSICAL MATURITY

5

Cracking, pale areas, rare veins

Parchment, deep cracking, no vessels

Leathery, cracked wrinkled

Bald areas

Mostly bald

SCORE Neuromuscular: Physical: Total: MATURITY RATING

Score Weeks -10

20

-5

22

Creases over entire sole

0

24

5

26

Full areola, 5–10 mm bud

10

28

15

30

Thick cartilage, ear stiff

20

32

25

34

Testes down, good rugae

Testes pendulous, deep rugae

30

36

Majora large, minora small

Majora cover clitoris and minora

35

38

40

40

45

42

50

44

Creases ant. 2/3

173

RECORD SCORE HERE

Raised areola 3–4 mm bud Formed and firm Instant recoil

TOTAL PHYSICAL MATURITY SCORE

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3

SCORE 4

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Evaluation of Respiratory Status: Silverman and Andersen Index Score 0

Score 1

Score 2

Chest movement

Feature

Equal

Respiratory lag

Intercostal retraction Xiphoid retraction Nasal flaring Expiratory grunt

None None None None

Minimal Minimal Minimal Audible with stethoscope

Seesaw respiration Marked Marked Marked Audible

Acute Care of the Newborn General Consideration in the Care of the Newborn ■ ■ ■ ■ Heat loss in newborns ■ Thermoregulation

■ ■ ■ Environmental

Infection control

■ ■ ■ ■ ■

Radiant warmer Incubator Blankets Cap for the head (Beanie) Radiation (heat loss without physical contact) Conduction (heat transfer to surface through contact) Convection (air currents passing over the neonate) Evaporation (evaporation of water from the skin) Light Noise Incubator blanket or cover Five-minute scrub before entering the NICU Hand washing and use of alcohol hand sanitizer

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175 Acute Care of the Newborn General Considerations in the Care of the Newborn

Neonatal jaundice

Skin care

■ Cover gown when leaving the NICU ■ Use of disposable gloves with each patient ■ Separate stethoscope for each patient ■ Phototherapy ■ Exchange transfusion ■ Medication (phenobarbital, albumin) ■ Use of cotton balls to avoid abrasion when cleansing ■ Change TCM sites at least every 8 hours ■ Use transparent dressings over IV sites ■ Heated humidification for very premature infants

Airway Management

Suctioning at Birth Is the neonate meconium stained, vigorous (strong ventilatory efforts, muscle tone, and HR ⬎100)? ■ Airway suctioning not indicated ■ If the neonate is not vigorous, suction prior to positive pressure ventilation and resuscitation

Bag/Mask Ventilation (neonate apneic, gasping or HR ⬍100)

■ Open the airway (avoid overextension of the airway) ■ Seal mask over nose/mouth ■ Administer positive pressure breaths (30–40 cmH2O) for initial breaths rate of 40–60/min using 100% oxygen ■ Assess chest wall movement and HR response

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Intubation

■ Ventilate neonate with 100% oxygen using bag/mask ■ Establish HR, and SpO2 monitors if not already in place ■ Insert stylet into the endotracheal tube just short of the tube’s tip ■ Ensure neonate is supine and airway is hyperextended (opened) but not overextended ■ Insert the laryngoscope blade into the mouth, opening the airway and visualizing the vocal cords ■ Insert the endotracheal tube stopping when the tip of the tube has passed the vocal cords ■ Resume positive pressure ventilation via endotracheal tube ■ Confirm the tube’s position ■ End-tidal CO2 detection ■ Chest x-ray ■ Auscultation ■ Observation of condensation during exhalation ■ Secure the endotracheal tube

Intubation and Suctioning Guidelines Birth Weight

Laryngoscope Blade Size

Endotracheal Tube Size

⬍1000 g 1000–2000 g 2000–3000 g ⬎3000 g

0 0 0–1 1

2.5 mm 3.0 mm 3.5 mm 3.5–4.0 mm

176

Suction Catheter Size 5 6 8 8

Fr Fr Fr Fr

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177 Neonatal Resuscitation Algorithm Is neonate vigorous? Breathing or crying? Clear amniotic fluid? Good muscle tone?

Keep the neonate warm (warmer, blankets, etc.) Position and clear airway if indicated Dry and stimulate neonate (respiratory efforts?)

Evaluate: Respirations Heart rate Color Apneic or HR <100?

Breathing or HR >100?

Yes Provide supplemental 02 with PPV

No

HR <60?

Yes

Yes 1. Provide 02 with PPV 2. Give chest compressions

HR <60?

No

1. Provide supportive care 2. Monitor the patient

Yes Give epinephrine

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Ventilator Management of the Newborn

Neonatal Ventilator Management Algorithm • • • •

Intubate patient Establish mechanical ventilation Initiate appropriate monitoring Establish thermoregulation and continuing care

• • • • •

Establish Initial Settings: Rate: 30/min <3 kg wt; 25/min >3kg wt Pressure: 15–20 cmH20 T1: 0.4–0.6 seconds PEEP: 5 cmH20 F102: Titrate for SpO2 88–92%

SpO2 >88%?

Yes

No

Yes

No

Increase Minute Ventilation (Increase rate, PIP, etc.)

Increase F102 by 0.05–0.10

SpO2 >88%?

Yes

No

No

PaCO2 >50 mmHg? Yes

• Increase PEEP • Increase IT

SpO2 >88%?

PaCO2 >50 mmHg?

Consider alternative ventilation strategy Yes Continue therapy and monitor the patient

No Consider HFOV

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179 Neonatal HFOV Ventilator Management Algorithm • • • •

Intubate patient Establish mechanical ventilation Initiate appropriate monitoring Establish thermoregulation and continuing care

• • • • •

Establish Initial Settings: MAP 2–4 cmH20 >conventional MAP ) P (adequate chest wiggle) IT – 33% PEEP: 5 cmH20 Hz 15 Hz <1 kg wt 12 Hz 1–2 kg wt 10 Hz 2–3 kg wt 8 Hz >3 kg wt Yes

SpO2 <88%?

No

No

PaCO2 >65 mmHg? Yes

Yes

Check ET tube and suction prn

Attempt lung recruitment

88<SpO2 <92%?

50< PaCO2 >65?

1. Continue therapy 2. Monitor patient 3. Progress toward weaning

Yes Increase F1O2

88<SpO2 <92% on F1O2 0.04

Yes

No

No Increase ) P Decrease the Hz

50< PaCO2 >65? Yes

Yes

No

No • Increase MAP • Consult physician

• Increase ) P and lower Hz • Consult physician

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Liter Flow Neonatal

Device

Liter Flow Pediatric

Desired SpO2 Pediatric

Desired SpO2 Neonatal

Nasal cannula

0.25–1 L/min

1–5 L/min

≥90 %

Simple mask

NA

4–8 L/min

≥90%

88–92% 50 mmHg ⬎PaO2 ⬍70 mmHg NA

Up to 15 L/min

≥90%

NA

Varies by manufacturer (24–50%) ⬎7 L/min (heated and humidified with FIO2 and temperature monitoring/ regulation)

≥90%

NA

≥90%

88–92% 50 mmHg ⬎PaO2⬍70 mmHg

Non- rebreathing NA mask NA Venturi mask Hood or headbox ⬎7 L/min (heated and humidified with FIO2 and temperature monitoring/ regulation)

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Oxygen Therapy

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Pediatric Respiratory Care Procedures

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181 Pediatric: Bland Aerosol Algorithm

Is there evidence of upper airway edema? 1. Laryngotracheobronchitis? 2. Subglottic edema? 3. Post-extubation edema? Yes

No

Is there history for? 1. Airway hyperresponsiveness? 2. Bronchoconstriction?

Monitor the patient No

Yes

Consider: Severe Disease - Oral Dexamethasone (0.6 mg/kg) to a maximum of 10–12 mg Mild Disease - Oral Dexamethasone (0.15–0.3 mg/kg)

Monitor the patient

Initiate therapy: 1. Large volume nebulizer 2. Mist tent 3. Hood 4. Ultrasonic nebulizer

Monitor the patient

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Pediatric: Bronchodilator Administration Algorithm Is there evidence of bronchoconstriction? 1. Wheezing 2. Decreased breath sounds 3. Retractions or distress 4. Tachypnea 5. Nasal flaring or grunting

No

Yes Monitor the patient Can the patient follow directions? No

Yes

Administer medication using SVN

No

Is VT or PEF adequate? Yes

Administer medication using MDI or DPI

Monitor the patient

Monitor the patient

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183 Pediatric: Mucolytic Therapy Algorithm Is there evidence of thick pulmonary secretions? 1. Rhonchi 2. Wheezing 3. Tachypnea 4. Productive cough

Yes

No

Monitor the patient

Administer mucolytic via SVN • Acetylcysteine with a bronchodilator • Dornase alfa with a bronchodilator

Monitor the patient

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Pediatric: Vasoconstrictor Administration Algorithm

No

Is there evidence of upper airway edema? 1. Stridor 2. Retractions 3. Tachypnea 4. “Barky” cough

Fever >40° C? Stridorus? Drooling? Tachycardia/tachypnea? Left shift on differential? Positive cultures?

Yes Administer Racemic Epinephrine via SVN

No

Yes Consider: 1. Severe stridor: 0.6 mg/kg oral dexamethasone up to 10–12 mg 2. Mild stridor: 0.15–0.3 mg/kg oral dexamethasone

Consider epiglottitis: 1. IV antibiotics (ceftriaxone or cefotaxime) 2. Prepare for intubation

Monitor the patient

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185 Pediatric: Hyperinflation Therapy Algorithm Is there evidence of atelectasis? 1. Chest x-ray 2. Predisposing conditions 3. Neuromuscular disease 4. Inability to clear secretions

No

Yes Monitor the patient Can the patient follow directions? No

Yes

Initiate therapy: 1. CPAP 2. Bilevel positive airway pressure 3. IPPB

Initiate therapy: 1. Incentive spirometry 2. PEP therapy 3. Deep breathe and cough

Monitor the patient

Monitor the patient

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Pediatric: Secretion Mobilization Algorithm Is there evidence of excessive secretions? 1. Atelectasis or consolidation on x-ray? 2. Bronchopulmonary dysplasia? 3. Ineffective cough? 4. Neuromuscular disease? 5. Cystic fibrosis? 6. Bronchitis? 7. Meconium/foreign body aspiration? Yes

No

Initiate therapy (see Box 1)

Yes Can the patient cough effectively?

Monitor the patient

Monitor the patient Yes

No

Do symptoms improve after coughing?

No

Initiate therapy (see Box 2)

Yes Encourage deep breathing and coughing, monitor the patient

Box 1 Techniques 1. PEP therapy 2. Autogenic drainage 3. Flutter valve therapy 4. High Frequency Chest Wall Oscillation (HFCWO) 5. Chest physiotherapy 6. Consider suctioning

Monitor the patient

Box 2 Techniques 1. PEP therapy 2. Flutter valve therapy 3. Deep breathe and cough 4. Forced exhalation technique

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187 Pediatric Advanced Life Support (PALS) Child: CPR See Critical Care Tab

Child: Post-Resuscitation Care Algorithm Does the child show signs of shock? Yes

No Monitor the patient

Administer fluid bolus (10–20 mL/kg normal saline or lactated Ringer’s solution)

Yes

Does the child show signs of shock?

Hypotensive

Consider 1. Give more fluid 2. Epinephrine (0.1–1.0 mcg/kg) or 3. Dopamine (<20 mcg/kg/min) or 4. Norepinephrine (0.1–1.0 mcg/kg/min)

No

Normal Blood Pressure

Consider 1. Give more fluid 2. Dobutamine (2–20 mcg/kg/min) or 3. Epinephrine (0.05–0.3 mcg/kg/min) or 4. Inamrinone (loading dose 0.75–1.0 mg/kg over 5 min can repeat up to 3 mcg/kg) Infusion 10 mcg/kg/min 5. Milrinone (loading dose 50–75 mcg/kg) infusion 0.5–0.75 mcg/kg/min

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Child: Bradycardia Algorithm Is bradycardia causing severe symptoms? Yes

No

Perform chest compressions give oxygen and ventilate

Monitor the patient

HR <60?

No

Yes During CPR: • Intubate and/or verify endotracheal tube position • Check: Electrode placement Paddle positions Pacer lead positions • Give: Epinephrine every 3-5 min or consider epinephrine or dopamine infusions • Identify/treat causes Hypoxema Hypothermia Head injury Heart block Toxins/poisons/drugs

Give epinephrine: • IV 0.01 mg/kg (1:10000 0.1 mL/kg) • Can repeat every 5 min at same dosage

Give atropine: • 0.02 mg/kg (min 0.1 mg) • May repeat one time

Consider pacing

Should pulseless arrest occur go to Pulseless Arrest Algorithm

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189 Child: Pulseless Arrest Algorithm • Support ABCs • Give oxygen/ventilation • Attach monitor/defibrillator

No VF/VT (including PEA and Asystole)

VF/VT VF/VT?

Defibrillate: • <3 times • Initial 2 J/kg, then 4 J/kg

Epinephrine: • IV/IO (0.01 mg/kg [1:10000 0.1 mL/kg])

Defibrillate: 4 J/kg • CPR drugs during CPR

Epinephrine: • IV/IO (0.01 mg/kg [1:10000 0.1 mL/kg])

During CPR: • Verify ET position • Establish IV access • Check electrode/ paddle positions • Give Epinephrine every 3-5 min Consider: • Vasopressors • Antiarrhythmics • Buffers Identify/Treat • Hypoxemia • Hypovolemia • Hypothermia • Hyper/hypokalemia • Tamponade • Tension pneumothorax • Toxins/poisons/drugs • Thromboembolism

• Amiodarone (5 mg/kg bolus) OR if no amiodarone available • Lidocaine (1 mg/kg bolus)

Defibrillate: 4 J/kg • CPR, drugs

Continue CPR < 3 min

NEO PEDS

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Page 190

NEO PEDS

Child: Tachycardia with Adequate Perfusion Algorithm • • • •

Support ABCs Give oxygen/ventilation Attach monitor/defibrillator Obtain 12-lead ECG

QRS >0.08 sec?

Sinus tachycardia? • Hx for rhythm? • P waves present/normal • HR varies w/activity • Variable R-R interval w/constant P-R interval? • Infants rate <220 • Child rate <180

Supraventricular tachycardia? • Hx for rhythm? • P waves absent/abnormal? • HR doesn't vary w/activity • Abrupt rate changes? • Infants rate >220 • Child rate >180

Consider vagal maneuvers

During evaluation: • Give oxygen • Support ABCs • Confirm monitor • Consider consult • Prepare for cardioversion Identify/Treat: • Hypoxemia • Hypovolemia • Hypothermia • Hyper/hypokalemia • Tamponade • Tension pneumothorax • Toxins/poisons/drugs • Thromboembolism

Probable ventricular tachycardia

• Establish IV access • Consider Adenosine (0.1 mg/kg IV to max dose of 6 mg) • May double and repeat dose once (max. 12 mg/kg) using rapid bolus

Consider: • Amiodarone (5 mg/kg IV over 20–60 min) OR • Procainamide (15 mg/kg IV over 30–60 min). Don’t give amiodarone and procainamide together OR • Lidocaine (1 mg/kgIV bolus)

• Consult pediatric cardiologist • Cardioversion (0.5–1.0 J/kg, can to 2 J/kg • Consider sedation • Repeat 12-Lead ECG

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191 Notes

NEO PEDS

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Page 192

NEO PEDS

Child: Tachycardia with Poor Perfusion Algorithm Does child have a pulse?

No

Initiate CPR

Yes • Give oxygen • Attach monitor/defibrillator

Get a 12-lead ECG

No

QRS >0.08 sec?

Evaluate rhythm

Evaluate rhythm

During Evaluation: • Give oxygen and ventilate • Support ABCs • Check monitor • Get expert consult • Prepare to cardiovert

Sinus tachycardia? • Hx for rhythm? • P waves present/normal? • HR varies w/activity? • Variable R-R interval w/constant P-R interval? • Infants (Rate <220/min) • Child (Rate <180/min)

Yes

Identify/Treat: • Hypoxemia • Hypovolemia • Hypothermia • Hyper/hypokalemia • Tamponade • Tension pneumothorax • Toxins/poisons/drugs • Thromboembolism • Pain

Supraventricular tachycardia? • Hx for rhythm? • P waves absent/abnormal? • HR doesn't vary w/activity? • Sudden rate changes? • Infants (Rate >220 min) • Child (Rate >180 min)

Ventricular Tachycardia? • Cardiovert (0.5–1 J/kg)

Perform vagal maneuvers

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193

Immediate cardioversion OR Immediate IV/IO w/adenosine: • Adenosine (0.1 mg/kg • Cardiovert (0.5–1 J/kg IV/IO [max dose 6 mg]) can to 2 J/kg) • May double and repeat • Sedate if possible once up to 12 mg • Sedation must not (use rapid bolus) delay cardioversion

Consider: • Amiodarone (5 mg/kg IV over 20–60 min) • Procainamide (15 mg/kg IV over 30–60 min). Don’t give amiodarone and procainamide together OR • Lidocaine (1 mg/kg IV bolus [wide complex only]) • Repeat 12-lead ECG

NEO PEDS

Page 194

Generic Name (Trade Name)

Availability

Strength (Dosage)

Side Effects

albuterol sulfate (Proventil, Ventolin)

1. Metered dose inhaler (MDI) 2. Inhalant solution 3. Syrup 4. Tablet

1. 90 mcg/puff (2 puffs 4  daily) 2. 0.5% or 5mg/mL (2.5 mg 4  daily) 3. 2mg/5mL (0.4mg/mL) (2–4 mg 3  or 4  daily) 4. 2 or 4 mg (2 or 4 mg 3  or 4  daily)

Tremors, tachycardia, palpitations, nausea, nervousness, dizziness, tachyphylaxis, headache

bitolterol (Tornalate)

MDI

0.37 mcg/puff (2 puffs every 8 hr)

Same as for albuterol

epinephrine (Adrenalin)

Inhalant solution

1% or 10 mg/mL (2.5–5 mg 4  daily)

Same as for albuterol

formoterol fumarate (Foradil)

Dry powder inhaler (DPI)

12 mcg/puff (1 puff 2 daily)

Same as for albuterol

isoetharine HCl (Bronkosol, Bronkometer)

1. Inhalant solution 2. MDI

1. 1% or 10 mg/mL (2.5– 5 mg 4  daily) 2. 340 mcg/puff (1–2 puffs 4  daily)

Same as for albuterol

(Text continued on following page)

194

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Sympathomimetic Agents

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Bronchodilators

Copyright © 2008 by F. A. Davis.

195

Availability

Strength (Dosage)

Side Effects

levalbuterol (Xopenex)

1. Inhalant solution 1. 0.31, 0.63 and 1.25 mg 2. MDI (1.25 mg every 6–8 hr) 2. 45 mcg/puff (2 puffs every 4–6 hr)

metaproterenol sulfate (Alupent, Metaprel)

1. 2. 3. 4.

pirbuterol (Maxair)

MDI

0.2 mcg/puff (2 puffs every 4–6 hr)

Same as for albuterol

racemic epinephrine (Micronefrin, Vaponefrin)

Inhalant solution

2.25% or 22.5 mg/mL (5.625–11.25 mg 4 daily)

Same as for albuterol

Same as for albuterol

MDI 1. 0.65 mcg/puff Same as for Inhalant solution (2–3 puffs every 4 hr) albuterol Syrup 2. 5% or 50 mg/mL Tablet (5, 10, or 15 mg 3 or 4 daily) 3. 2 mg/mL (10 mg 3 or 4 daily) 4. 10 and 20 mg (20 mg 3 or 4 daily)

(Text continued on following page)

PHARM

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Sympathomimetic Agents (Continued) Generic Name (Trade Name)

Availability

Strength (Dosage)

salmeterol (Serevent)

DPI

50 mcg/puff (1 puff 2  daily)

terbutaline (Brethaire, Brethine, Bricanyl)

1. MDI 2. DPI

1. 25 mcg/puff (2 puffs every 8 hr) 2. 50 mcg/puff (2  daily)

Side Effects Same as for albuterol Same as for albuterol

196

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Sympathomimetic Agents (Continued) Generic Name (Trade Name)

Anticholinergic Agents Generic Name (Trade Name) atropine sulfate (Atropine)

Availability Inhalant solution

Strength (Dosage) 0.2% or 2 mg/mL (0.025 mg/kg 3  or 4  daily)

Side Effects Dry mouth, dysphagia, dysphonia

(Text continued on following page)

197

Generic Name (Trade Name)

Availability

Strength (Dosage)

Side Effects

Ipratropium bromide (Atrovent)

1. Inhalant solution 2. Metered dose inhaler (MDI)

1. 0.5 mg or 500 mcg (unit dose) up to 4  daily 2. 18 mcg/puff (2 puffs 4  daily)

Same as for atropine

ipratropium bromide AND albuterol sulfate (DuoNeb, Combivent)

1. Inhalant solution 2. MDI

1. 0.083% or 3 mg Albuterol and 0.017% or 0.5 mg Atrovent (1 unit dose 4  daily) 2. 103 mcg/puff Albuterol and 18 mcg/puff Atrovent

Same as for atropine. Also dizziness, headache, nausea, nervousness, palpitations, tachycardia, tachyphylaxis, tremors

tiotropium bromide (Spiriva)

Dry powder inhaler (DPI)

18 mcg/capsule (1 capsule once daily)

Same as for atropine

PHARM

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Anticholinergic Agents (Continued)

Generic Name (Trade Name)

Availability

Strength (Dosage)

aminophylline (Aminophylline 100, Aminophylline 360)

1. Tablets 2. Elixir 3. Suppository

1. 100 mg (10–12 mcg/dL serum level) 2. 21 mg/mL (10–12 mcg/dL serum level) 3. 360 mg (10–12 mcg/dL serum level)

Headache, anxiety, restlessness, tremor, convulsions, nausea, vomiting, abdominal pain, diarrhea, tachypnea, palpitations, diuresis

Side Effects

theophylline (Aerolate, SloPhyllin, Theolair, Theo-Dur)

1. Capsules/ tablets 2. Elixir

1. 200 mg, 260 mg, 300 mg and 400 mg (10–12 mcg/dL serum level) 2. 10 mg/mL (10–12 mcg/dL serum level)

Headache, anxiety, restlessness, tremor, convulsions, nausea, vomiting, abdominal pain, diarrhea, tachypnea, palpitations, diuresis

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Xanthine

Copyright © 2008 by F. A. Davis.

beclomethasone dipropionate (Beclovent, Vanceril) beclomethasone dipropionate HFA (QVAR) budesonide (Pulmicort)

Availability

Strength (Dosage)

Metered dose 42 mcg/puff (2 puffs 3  or 4  inhaler (MDI) daily)

MDI

1. Dry powder inhaler (DPI) 2. Inhalant solution

flunisolide (AeroBid) MDI flunisolide 1. MDI (Flovent) 2. DPI triamcinolone aceto- MDI nide (Azmacort)

PHARM

Pulmonary Inhaled Corticosteroids Generic Name (Trade Name)

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Corticosteroids

Side Effects

Oropharyngeal fungal infections, dysphonia, dysphagia, cough, bronchoconstriction Oropharyngeal fungal 40 mcg and 80 mcg/puff (1–2 infections, dysphonia, puffs 2  daily) dysphagia 1. 200 mcg/cycle (1–2  2  daily) Oropharyngeal fungal infections, dysphonia, 2. 0.25 mg/mL (0.5 mg once daily) dysphagia, cough, bronchoconstriction Same as for budesonide 250 mcg/puff (2 puffs 2  daily) Same as for budesonide 1. 44, 110, or 220 mcg/ puff (2 puffs 2  daily) 2. 50, 100, or 250 mcg/puff Same as for budesonide 100 mcg/puff (2 puffs 3  or 4  daily)

Generic Name (Trade Name) fluticasone propionate and salmeterol (Flovent and Serevent)

Availability Dry powder inhaler (DPI)

Strength (Dosage) 100/50, 250/50 and 500/50 mcg/puff Flovent/Serevent (1 puff 2  daily)

Side Effects Bronchoconstriction, cough, dizziness, dysphonia, dysphagia, headache, nervousness, oropharyngeal fungal infections, palpitations

Nasal Inhaled Corticosteroids Generic Name (Trade Name) beclomethasone (Beconase, Vancenase) budesonide (Rhinocort) flunisolide (Nasalide) fluticasone (Flonase)

Availability Metered dose inhaler (MDI) MDI MDI MDI

Strength (Dosage)

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Pulmonary Combination Product

Side Effects

42 mcg/spray (1 inhalation Contact dermatitis, wheezing, per nostril 2–4  daily) nasal septum irritation, ↑ intraocular pressure 32 mcg/spray (2 sprays Same as for beclomethasone each nostril 2  daily) 29 mcg/spray (2 sprays Same as for beclomethasone each nostril 2  daily) 32 mcg/spray (2 sprays Same as for beclomethasone each nostril 2  daily)

Generic Name (Trade Name)

Availability

mometasone (Nasonex) triamcinolone acetonide (Nasacort)

MDI MDI

Strength (Dosage) 50 mcg/spray (2 sprays each nostril once daily) 55 mcg/spray (2 sprays each nostril 2  daily)

Side Effects Same as for beclomethasone Same as for beclomethasone

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Nonsteroidal Asthma Medications Generic Name (Trade Name) cromolyn sodium (Intal)

montelukast (Singulair)

Availability 1. Metered dose inhaler (MDI) 2. Inhalant solution 3. Dry powder inhaler (DPI) Tablet

Strength (Dosage) 1. 800 mcg/puff (2 puffs 4  daily) 2. 20 mg/unit dose (1 unit dose 4  daily) 3. 20 mg capsule (1 dose 4  daily) 10 mg (1 tablet daily)

Side Effects Nasal congestion, dermatitis, cough, wheezing, epistaxis

Diarrhea, laryngitis, pharyngitis, nausea, sinusitis (Text continued on following page)

PHARM

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Nasal Inhaled Corticosteroids (Continued)

Generic Name (Trade Name)

Availability

Strength (Dosage)

Side Effects Pain, fatigue, musculoskeletal pain, dizziness, dermatitis

Tablet

75 mg and 150 mg vials (150–375 mg injected subcutaneously every 2–4 weeks) 20 mg (1 tablet 2  daily)

Tablet

600 mg (1 tablet 4  daily)

omalizumab (Xolair)

Injection solution

zafirlukast (Accolate) zileuton (Zyflo)

Headache, infection, nausea, diarrhea, abdominal pain Headache, pain, abdominal pain, lethargy, elevated liver enzymes

Mucous Agents Generic Name (Trade Name) dornase Alfa (Pulmozyme) guaifenesin (Mucinex)

Availability

Strength (Dosage)

Inhalant solution Tablet

1mg/mL (2.5 mg once daily) 600 mg (1–2 tablets every 12 hr)

Side Effects Dysphonia, pharyngitis, laryngitis, rash, cough, chest pain Nausea, cardiac palpitations, nervousness, headache, dizziness, tachycardia, diarrhea (Text continued on following page)

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Nonsteroidal Asthma Medications (Continued)

Generic Name (Trade Name)

Availability Inhalant solution

sodium bicarbonate

Inhalant solution

203

N-acetylcysteine (Mucomyst)

Strength (Dosage) 10% and 20% solution or 100 and 200 mg/mL (3–5 mL [20%] or 6–10 mL [10%] nebulized 3  or 4  daily) 2% or 20 mg/mL (2–5 mL up to 4  daily)

Side Effects Bronchospasm, nausea, rhinorrhea, airway obstruction Bronchial irritation

Surfactant Agents Generic Name (Trade Name) beractant (Survanta)

Availability Inhalant solution

Strength (Dosage)

Side Effects

25 mg/mL (100 mg/kg Pulmonary compliance birth weight instilled (barotraumas), airway endotracheally) occlusion, high PaO2 values, overventilation, apnea, pulmonary hemorrhage colfosceril palmitate Powder Same as for beractant 13.5 mg/mL (5 mL/kg (Exosurf) (reconstituted birth weight instilled in sterile water) endotracheally)

PHARM

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Mucous Agents (Continued)

Generic Name (Trade Name)

Availability

Strength (Dosage)

Side Effects

pentamidine isethionate (Pentamidine)

Dry powder reconstituted in sterile water as an inhalant solution

300 mg (300 mg once every 4 wk)

Cough, bronchial irritation, dyspnea, bronchospasm

ribavirin (Virazole)

Dry powder (6 gm) reconstituted in 30 mL of sterile water for an inhalant solution

20 mg/mL (inhaled for 12–18 hr/day for 3 days minimum using a SPAG nebulizer)

Bronchospasm, hypotension, rash, conjunctivitis

tobramycin (Tobi)

Inhalant solution

300 mg unit dose (1 unit dose 2  daily for 28 days. Dosing should be followed by 28 days off the medication)

Cough, pharyngitis, rhinitis, dyspnea, fever, headache, chest pain, hemoptysis, bronchospasm

zanamivir (Relenza)

Dry powder inhaler

5 mg/dose blisters (2 inhalations 2  daily for 5 days)

Diarrhea, nausea, vomiting, bronchitis, cough, dizziness

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Inhaled Antimicrobial Agents

Copyright © 2008 by F. A. Davis.

Availability

PHARM

Cardiac Glycosides Generic Name (Trade Name)

Strength (Dosage)

Side Effects

digoxin (Lanoxin)

Capsules

50, 100, 150, 200 mcg (1.2–1.6 mg initial then 0.05–0.3 mg daily)

digitoxin (Purodigin)

Capsules, IV solution

50, 100, 200 mcg, 100 and 250 mcg/mL Inj solution (0.5 mg over 5 min then 0.125–0.5 mg daily as needed)

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Cardiac Pharmacology

CHF symptoms, arrhythmias, hypotension Same as for digoxin

Antiarrhythmic Agents Generic Name (Trade Name)

Availability

Strength (Dosage)

Side Effects

1. Capsules

1. 100 and 150 mg (300 mg initial then 150 mg every 6 hr)

1. Dry mouth, urinary retention

Class IA 1. disopyramide (Norpace)

(Text continued on following page)

Generic Name (Trade Name)

Availability

Strength (Dosage)

Side Effects

Class IA 2. procainamide (Procanbid)

2. Tablets

2. 500 mg (50 mg/kg daily)

3. quinidine (Quinaglute)

3. Tablets

3. 324 mg (2 tablets every 8 hr)

1. lidocaine (Xylocaine)

1. IV

1. 4%, 10%, 20% (1 mg/kg)

2. mexilentine (Mexitil)

2. Capsules

2. 150, 200, and 250 mg (400 mg initial then 200 mg in 8 hr)

3. tocainide (Tonocard)

3. Tablets

3. 400 mg (400 mg every 8 hr)

2. Nausea, vomiting, dizziness, headaches, hepatic toxicity 3. Diarrhea, rash, dizziness, headache, nausea, vomiting

Class IB 1. Dyspnea, respiratory depression, cardiac arrhythmias, hypotension 2. Palpitations, chest pain, nausea, vomiting, dizziness, tingling 3. PVCs, nausea, vomiting, dizziness

(Text continued on following page)

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Antiarrhythmic Agents (Continued)

Generic Name (Trade Name)

Availability

Strength (Dosage)

Side Effects

Class IC 1. flecainide (Tambocor) 2. propafenone (Rythmol)

1. Tablets 2. Tablets

1. 50 & 100 mg (50 mg every 12 hr) 2. 150, 225, 300 mg (150 mg every 8 hr)

1. Dizziness, dyspnea, headache, nausea 2. Nausea, vomiting, dizziness

1. 10 mg/mL (0.05 mg over 1 min then continuous infusion 0.05 mg/kg/min) 2. 20, 40, 80, and 120 mg (40–80 mg daily)

1. Confusion, bradycardia, chest pain, hypotension 2. Bradycardia, fatigue, depression, blurred vision 3. Fatigue, weakness, dizziness

207

Class II 1. esmolol (Brevibloc)

1. IV

2. metoprolol (Lopressor)

2. Tablets, IV

3. nadolol (Corgard)

3. Tablets

4. propranolol (Inderal)

4. Tablets, IV

3. 10, 20, 40, 60, 80 mg, 1 mg/mL Inj solution (40–320 mg/day over 3 to 4 doses, IV 1mg in 10 mL over 5 min) 4. 50 mg, IV solution 1 mg/mL (PO 50 mg 2  daily, IV 5 mg at 5 min intervals up to 15 mg)

4. Fatigue, GI upset, hypotension, dizziness

(Text continued on following page)

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Antiarrhythmic Agents (Continued)

Availability

Strength (Dosage)

Side Effects

Class II 5. Tablets, IV

5. 2 mg/mL (5 mg slow IV push over 5 min wait 10 min then give a second 5 mg dose over 5 min)

5. Bradycardia, hypotension, heart failure, SVT, VTach

1. amiodarone (Cordarone)

1. Tablets, IV

2. dofetilide (Tikosyn)

2. Capsules

3. ibutilide (Corvert)

3. IV

1. 200 mg, 50 mg/mL inj solution 1. Dizziness, fatigue, ARDS, pulmonary (400–600 mg PO daily over fibrosis, CHF symp1–2 doses, IV 150 mg over 10 toms, nausea, vomiting min then 360 mg over 6 hr, then 145 mg over 18 hr) 2. Headache, chest pain, 2. 125, 250, 500 mcg (125–500 dizziness, dyspnea, mcg 2  daily depending on creatinine clearance) nausea 3. 0.1 mg/mL in solution (2 mg 3. Polymorphic single infusion) ventricular tachycardia, nausea, headache

Class III

(Text continued on following page)

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PHARM

Generic Name (Trade Name)

5. atenolol (Tenormin) Copyright © 2008 by F. A. Davis.

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Antiarrhythmic Agents (Continued)

Generic Name (Trade Name)

Availability

Strength (Dosage)

Side Effects

Class III 4. sotalol (Betapace)

4. Tablets

4. 80, 160, and 240 mg (80 mg 2  daily can ↑ to 240–320 mg/day)

4. Dyspnea, bradycardia, fatigue, dizziness, nausea, vomiting

1. diltiazem (Cardizem)

1. Tablets, IV

1. 30, 60, 90, and 120 mg, 5mg/mL inj solution (PO 30–120 mg 3  or 4  daily, IV 0.25 mg/kg over 5 min)

1. AV block, dizziness, nausea, vomiting, headache

2. verapamil (Calan)

2. Tablets, IV

2. 40, 80, and 120 mg, IV 2.5 mg/mL inj solution (PO 80 mg 3  or 4  daily, IV 5–10 mg bolus)

2. Headache, dizziness, fatigue, nausea

209

Class IV

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Antiarrhythmic Agents (Continued)

Generic Name (Trade Name)

Availability

Strength (Dosage)

Side Effects

dobutamine (Dobutrex) dopamine (Inotropin)

IV

Blood pressure fluctuation, headache, nausea, vomiting Hypertension, ↑ myocardial O2 demand, nausea, vomiting, headache, ischemia

epinephrine (Adrenalin) inamrinone (Inocor) isoproterenol (Isuprel)

IV

250 mg vials (2–20 mcg/ kg/min) 40 mg/mL vial (low dose 1–5 mcg/kg/min, moderate dose 5–10 mcg/kg/min, high dose 10–20 mcg/kg/min) 1:10000 and 1:1000 (1 mg or 10 mL 1:10000) 5mg/mL vial (0.75 mg/kg not to exceed 1mg/kg) 1:5000 ampules (2–10 mcg/min)

milrinone (Primacor)

IV

norepinephrine

IV

IV

IV IV

1 mg in 10, 20, or 50 mL (50 mcg/kg over 10 min initial then 0.5mcg/kg/min) 1mg/mL inj solution (0.5–1.0 mcg/min)

Ischemia, angina, tachycardia Nausea, vomiting, arrhythmias, headache, dizziness, dyspnea Nervousness, headache, dizziness, tachycardia, nausea, vomiting Cardiac arrhythmias, headache, hypokalemia, tremors Nervousness, headache, dizziness, tachycardia, nausea, vomiting (Text continued on following page)

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Vasopressor and Inotropic Agents

Generic Name (Trade Name)

Availability

phenylephrine (Neo-Synephrine) vasopressin (Pitressin)

Strength (Dosage)

Side Effects

IV

10 mg/mL (10 mcg/kg/min)

IV

20 units/mL (40 units IV)

Tachycardia, nervousness, dizziness, tremor, dyspnea Headache, nausea, vomiting, ischemia

211

Calcium Channel Blockers Generic Name (Trade Name)

Strength (Dosage)

Side Effects

amlodipine (Norvasc) bepridil (Vascor) diltiazem (Cardizem)

Availability Tablets

2.5 mg (5–10 mg once daily)

Tablets

felodipine (Plendil)

Tablets

200, 300 mg (200–300 mg once daily) 30, 60, 90, 120 mg, 5mg/mL inj solution (PO 30–120 mg 3 or 4 daily, IV 0.25 mg/kg over 5 min) 2.5 mg (2.5–5 mg once daily)

Headache, fatigue, nausea, edema Headache, palpitations, nausea, drowsiness, nervousness AV block, dizziness, nausea, vomiting, headache

Tablets, IV

Headache, palpitations, nausea, edema (Text continued on following page)

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Vasopressor and Inotropic Agents (Continued)

Generic Name (Trade Name) isradipine (DynaCirc) nicardipine (Cardene) nifedipine (Procardia) nisoldipine (Sular) verapamil (Isoptin)

Availability

Strength (Dosage)

Tablets

5 and 10 mg (5–10 mg once daily) 2.5 mg/mL inj solution (5 mg/hr IV infusion) 10 and 20 mg (10–30 mg 3  to 4  daily) 10, 20, 30 and 40 mg (20–40 mg once daily) 180 and 240 mg (240–480 mg once daily)

IV Tablets Tablets Tablets

Side Effects Headache, dizziness, fatigue Headache, hypotension, nausea Dizziness, flushing, headaches, weakness Edema, headache, dizziness 1AV block, bradycardia, chest pain, dizziness

Vasodilators Generic Name (Trade Name) nesiritide (Natrecor)

Availability IV

Strength (Dosage) 1.5 mg powder for reconstitution (2 mcg/kg/min bolus then 0.01 mg/kg/min infusion)

Side Effects Hypotension, ventricular tachycardia, headache, dizziness, nausea, vomiting (Text continued on following page)

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Calcium Channel Blockers (Continued)

Generic Name (Trade Name)

Strength (Dosage)

Side Effects

IV, tablets

Hypotension, headache, nausea, vomiting

sodium nitroprusside (Nitroprusside)

IV

5 mg/mL inj solution, 0.3, 0.4 and 0.6 mg sublingual tablets (IV 5 mcg/min, PO 0.3–0.6 every 5 min) 25 mg/mL (0.1 mcg/kg/min)

213

Availability

nitroglycerin

Hypotension, hypoxic pulmonary vasoconstriction, headache, nausea, vomiting

Anticoagulants Generic Name (Trade Name) enoxaparin (Lovenox) heparin sodium (Heparin) warfarin (Coumadin)

Availability IV IV IV, tablets

Strength (Dosage)

Side Effects

100 and 150 mg/mL inj solution (1 mg/ kg subcutaneously every 12 hr) 1000 Units/mL (60 Units/kg bolus then 12 units/kg/hour) Powder for reconstitution to 2mg/mL, 1, 2, 2.5, 3, 4, 5, 6, 7.5, 10 mg tablets (2.5–10 mg/day)

Hemorrhage, nausea Hemorrhage, hypersensitivity Hemorrhage, hypersensitivity

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Vasodilators (Continued)

Generic Name (Trade Name)

Availability

abciximab (ReoPro)

IV

aspirin

Tablets

clopidogrel (Plavix)

Tablets

dipyridamole (Persantine) eptifibatide (Integrilin)

Tablets

ticlopidine (Ticlid) tirofiban (Aggrastat)

Tablets

IV

IV

Strength (Dosage) 2 mg/mL inj solution (0.25 mg/kg IV over 10 to 60 min then 0.125 mg/kg/min infusion for 12 hr) 162 and 325 mg (162–325 mg PO) 75 mg (75 mg once daily)

25, 50, and 75 mg (75–100 mg PO 4 daily) 0.75 mg/mL and 2 mg/mL inj solution vials (180 mcg/kg over 1 to 2 min, followed by 2 mcg/kg/min infusion) 250 mg (250 mg PO 2  daily) 12.5 mg/50 mL inj solution (0.4 mcg/kg/min over 30 min followed by 0.1 mcg/kg/min)

Side Effects Hemorrhage, thrombocytopenia, hypotension, bradycardia, nausea, vomiting Anorexia, nausea, epigastric pain, allergic reactions Pain, fatigue, edema, headache, dizziness, dyspnea Dizziness, abdominal pain, headache, rash Hemorrhage, allergic reactions

Diarrhea, nausea, dyspepsia, rash Edema, pelvic pain, bradycardia, dizziness

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Antiplatelet Agents

215

Generic Name (Trade Name)

Availability

Strength (Dosage)

alteplase (Activase)

IV

50 and 100 mg vials (15 mg IV bolus over 1–2 min then 50 mg over 30 min then 35 mg over 60 min)

Hemorrhage, allergic reactions

Side Effects

reteplase (Retavase)

IV

10.4 Unit powder for reconstitution (10 Units IV over 10 min, then repeat in 30 min)

Same as for alteplase

streptokinase

IV

250,000, 750,000, and 1,500,000 Unit inj solution vials (1,500,000 Units IV over 60 min)

Same as for alteplase

tenecteplase (TNKase)

IV

50 mg powder for reconstitution in 10 mL sterile water (30–50 mg depending on pt weight [kg])

Same as for alteplase

urokinase

IV

250,000 Unit powder for reconstitution in sterile water (6000 Units/min infused into blocked artery)

Same as for alteplase

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Thrombolytic Agents

Trade Name (Generic Name)

Availability

Strength (Dosage)

Side Effects

adenosine (Adenocard)

IV

3mg/mL (6mg IV push)

Flushing, light headedness, headache, diaphoresis, palpitations

amiodarone (Cordarone)

IV

50 mg/mL inj solution (IV 150 mg over 10 min then 360 mg over 6 hr, then 145 mg over 18 hr)

Dizziness, fatigue, ARDS, pulmonary fibrosis, CHF symptoms, nausea, vomiting

aspirin

Tablets

162 and 325 mg (162–325 mg PO)

Anorexia, nausea, epigastric pain, allergic reactions

atenolol (Tenormin)

IV

2 mg/mL (5 mg slow IV push over 5 min wait 10 min then give 2nd 5-mg dose over 5 min)

Bradycardia, hypotension, heart failure, SVT, VTach

atropine sulfate (Atropine)

IV

0.4 and 1.0 mg/mL (0.5–1 mg IV every 5 min)

Myocardial ischemia, PVCs, worsening AV blocks

digoxin (Lanoxin)

IV

0.1 mg/mL (10–15 mcg/kg loading CHF symptoms, cardiac dose) arrhythmias, hypotension (Text continued on following page)

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Advanced Cardiac Life Support (ACLS) Drugs

Trade Name (Generic Name) Availability

Strength (Dosage)

Side Effects

IV

5mg/mL inj solution (IV 0.25 mg/kg over 5 min)

AV block, dizziness, nausea, vomiting, headache

dobutamine (Dobutrex) dopamine (Intropin)

IV

250-mg vials (2–20 mcg/kg/min)

IV

epinephrine (Adrenalin) esmolol (Brevibloc)

IV

lidocaine (Xylocaine)

IV

40-mg/mL vial (low dose 1–5 mcg/kg/min, moderate dose 5–10 mcg/kg/min, high dose 10–20 mcg/kg/min) 1:10000 and 1:1000 (1 mg or 10 mL 1:10000) 10 mg/mL (0.05 mg over 1 min then continuous infusion 0.05 mg/kg/min) 4%, 10%, 20% (1 mg/kg)

Blood pressure fluctuation, headache, nausea, vomiting Hypertension, ↑ myocardial O2 demand, nausea, vomiting, headache, ischemia

metoprolol (Lopressor)

IV

217

diltiazem (Cardizem)

IV

IV solution 1 mg/mL ( IV 5 mg at 5 min intervals to 15 mg)

Ischemia, angina, tachycardia Confusion, bradycardia, chest pain, hypotension Dyspnea, respiratory depression, cardiac arrhythmias, hypotension Fatigue, GI upset, hypotension, dizziness (Continued text on following page)

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Advanced Cardiac Life Support (ACLS) Drugs (Continued)

Trade Name (Generic Name) Availability morphine sulfate IV

Strength (Dosage) 0.5 and 1.0 mg/mL (2–4 mg IV over 1–5 min) 5 mg/mL inj solution, 0.3, 0.4, and 0.6 mg sublingual tablets (IV 5 mcg/ min, PO 0.3–0.6 every 5 min) 1 mg/mL inj solution (40–320 mg/day over 3 to 4 doses, IV 1 mg in 10 mL over 5 min) 100 mg/mL (20 mg/min IV infusion)

nitroglycerin

IV, tablets

propranolol (Inderal)

IV

procainamide (Procanbid)

IV

sodium bicarbonate

IV

4% or 40 mg/mL solution (1 mEq/kg IV bolus)

vasopressin (Pitressin) verapamil (Calan)

IV

20 Units/mL (40 Units IV)

IV

IV 2.5 mg/mL inj solution (IV 5–10 mg bolus)

Side Effects Hypersensitivity, respiratory depression Hypotension, headache, nausea, vomiting Fatigue, weakness, dizziness Nausea, vomiting, dizziness, headaches, hepatic toxicity Metabolic acidosis, hypoxia, electrolyte imbalance, seizures Headache, nausea, vomiting, ischemia Hypotension, headache, dizziness, fatigue, nausea

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Advanced Cardiac Life Support (ACLS) Drugs (Continued)

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219 Starting an IV ■ Gather appropriate equipment ■ Exam gloves ■ Iodine and alcohol swabs ■ Rubber tourniquet ■ IV catheter ■ Tape/dressing ■ IV tubing and IV solution ■ Position the patient ■ Palpate potential sites ■ Apply the tourniquet ■ Prep the site ■ Aseptically prepare catheter and IV tubing/solution ■ Insert IV catheter ■ Observe for “flash” ■ Advance catheter ■ Apply pressure proximal to IV site ■ Attach IV tubing and IV solution ■ Remove tourniquet ■ Secure IV site with tape/dressing ■ Establish appropriate drip rate/monitoring

Dosage Calculations Ratio and Proportion Original Dose Desired Dose     Amount XAmount Desired Dose XAmount    Amount Original Dose

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Example: You have a stock solution of 5 mg/mL. You need a 2.5 mg dose. How much do you draw up? Original Dose Desired Dose      Amount XAmount 5 mg 2.5 mg    mL XAmount 2.5 mg X   0.5 mL mL 5.0 mg

Percent Solutions The key to percent solutions is to convert them to mg/mL. One percent equals 1 gram of active drug in one hundred milliliters dilute or solution. Example: You have a stock solution of 0.5% and need a 2.5 mg dose. How much do you need? 5 gm 0.005 gm 5 mg 0.5%       100 mL mL mL Original Dose Desired Dose      Amount XAmount 2.5 mg 5 mg    XAmount mL 2.5 mg X    0.5 mL mL 5.0 mg

220

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221 Frequently Used Phone Numbers Security ICU Emergency Room ER (Fast Track) CCU NICU PICU Advanced Care (ECG Telemetry) PFT LAB Surgery Short Stay Surgery Cardiology/Echocardiography X-Ray Radiology Pharmacy Laboratory Microbiology Pathology Physical Therapy Occupational Therapy Infection Control IV Therapy Medical Floor Oncology Floor Psych Floor Orthopedics Floor Pediatrics Floor Surgical Floor

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Frequently Used Phone Numbers (Continued) Women’s/Post Partum Biomedical Department Information Technology Help Desk Admitting Central Cervices/Central Supply Chaplain Patient Ombudsman Social Work/Case Management Library Maintenance Employee Health Human Resources Other Other

Physician’s Contact Information Name Specialty Office/Cell Name Specialty Office/Cell Name Specialty Office/Cell

222

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223 Physician’s Contact Information (Continued) Name Specialty Office/Cell Name Specialty Office/Cell Name Specialty Office/Cell Name Specialty Office/Cell Name Specialty Office/Cell Name Specialty Office/Cell Name Specialty Office/Cell

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Physician’s Contact Information (Continued) Name Specialty Office/Cell

Physician Consultation Physician:

Office Phone:

Cell Phone:

Specialty: Patient Name Date/Time Patient Diagnosis Vital Signs

HR

Oxygenation

PaO2

RR

BP

PaO2/FIO2 Ventilation

VE

Temp

QS/QT FIO2/liter flow

VT

Rate

RSBI

VD/VT

Breath Sounds ABGs

pH

PaCO2

HCO3

PaO2

SaO2

Hb

Chest X-Ray Ventilator Settings

Mode

Rate/Hz

PIP / ▲ P

PEEP/MAP

PS

VT

FIO2

TI

TE

I:E

VE

Concerns Suggestions Order Changes

224

SpO2

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Name Address Telephone/Fax Contact Person

Services Provided

225

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Frequently Used Home Care Companies

Oxygen ■

Nebulizers ■ CPAP ■ Apnea Monitoring ■

Home Ventilators ■

Oxygen ■

Nebulizers ■ CPAP ■ Apnea Monitoring ■

Home Ventilators ■

Name Address Telephone/FAX Contact Person

Services Provided

TOOLS Name Address Telephone/Fax Contact Person

Services Provided

Oxygen ■

Nebulizers ■ CPAP ■ Apnea Monitoring ■

Home Ventilators ■

Oxygen ■

Nebulizers ■ CPAP ■ Apnea Monitoring ■

Home Ventilators ■

226

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Frequently Used Home Care Companies (continued)

Name Address Telephone/Fax Contact Person

Services Provided

Name Address Telephone/Fax Contact Person

227

Services Provided

Oxygen ■

Nebulizers ■ CPAP ■

Apnea Monitoring ■ Home Ventilators ■

Oxygen ■

Nebulizers ■ CPAP ■

Apnea Monitoring ■ Home Ventilators ■

Name Address

08White (F)-08

Telephone/Fax Contact Person

Services Provided

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Frequently Used Home Care Companies (continued)

TOOLS Name Address Telephone/Fax Contact Person

Services Provided

Oxygen ■

Nebulizers ■ CPAP ■

Apnea Monitoring ■ Home Ventilators ■

Oxygen ■

Nebulizers ■ CPAP ■

Apnea Monitoring ■ Home Ventilators ■

228

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Frequently Used Home Care Companies (continued)

Name Address Telephone/Fax Contact Person

Services Provided

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229 Home Care Referral Notes Patient Name Patient’s Date of Birth Patient’s Address Patient’s Telephone

- Home

- Cell

Patient’s SSN Ordering Physician Patient’s Diagnosis

HX of cor pulmonale, or CHF, or erythrocythemia Y ■ N ■

Room Air SpO2 Exercise Room Air SpO2 Nocturnal Room Air SpO2 Blood Gas Results

pH PaO2

PaCO2 SaO2

HCO3 FIO2/liter flow:

SpO2 with oxygen

% Device:

Oxygen referral?

Yes ■ No ■ Oxygen order: Yes ■ No ■ Medication: Frequency: Yes ■ No ■ PSG Sleep study date: PSG results: CPAP pressure: Bilevel Positive Airway Pressure: Ramp: Heated Humidity Ordered? Yes ■ No ■

Nebulizer referral? CPAP referral?

Liter Flow/FIO2:

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Page 230

ACLS NRP Misc. Misc.

PALS CPR Misc. Misc.

230

Copyright © 2008 by F. A. Davis.

4/6/07

Schedule Planner/Organizer month_________

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Schedule Planner/Organizer

ACLS NRP Misc. Misc.

PALS CPR Misc. Misc.

TOOLS

month _________

Event

Details

232

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Event Scheduler (Projects, Term Papers, Examinations, Seminars, Classes, etc.)

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233 Frequently Used Equations Physiology

Oxygenation CvO2  SvO2 (1.34  Hb)  (PvO2  0.003) CaO2  CvO2 O2ER    CaO2 CcO2  CaO2 Qs/QT    CcO2  CvO2 CaO2  SaO2 (Hb  1.34)  (PaO2  0.003) DO2  QT  (CaO2  10) VO2  QT (Ca-vO2  10) PaCO2 PAO2  FIO2 (PB  47 mmHg)   0.8 CcO2  1.0 (Hb  1.34)  (PAO2  0.003)

Ventilation f RSBI   VT VE  VT  f Anatomic Deadspace Estimation: VD  1 mL  Body Weight(Lb) Bohr Equation (deadspace to tidal volume ratio): PaCO2  PECO2 VD/VT   PaCO2 Alveolar Ventilation: VA  (VD/VT  VT)f

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Corrected VT Static Compliance: CST   Plateau Pressure  PEEP Corrected VT Dynamic Compliance: CDYN   Peak Pressure – PEEP

Hemodynamics

SV SVI   BSA CO CI   BSA

RVSWI  SVI  (PA – CVP)  0.013 gm/mL LVSWI  SVI  (MAP – PCWP)  0.013 gm/mL PA – PCWP PVR    80 CO

Blood Gas Formulas AG  Na  (CI  HCO3)

Anion Gap:

Winter’s Formula: PaCO2  1.5(HCO3)  8(2) Delta Gap: Corrected HCO3  (HCO3 (AG – 12)) Metabolic Acidosis (Expected PaCO2): PaCO2  0.9(HCO3) 9

Nutritional weight in pounds  703 BMI   (height in inches)2 Anion gap  (Na  K) (CI HCO3)

234

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235 Equipment Calculations

Cylinder Duration 0.28[Pres(psi)] “E” Cylinder Time    L/min 3.14[Pres(psi)] “H” Cylinder Time   L/min

Liquid System Duration (in min)  0.8 [(Weight – Empty Weight)  343 L/Lb Liquid Oxygen]  Liter Flow (L/min)

Pharmacology Original Dose Desired Dose Ratio and Proportions:    Amount XAmount Percent Solution to mg/mL: 5 gm  0.005 gm  5 mg 0.5%      100 mL mL mL

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Common Abbreviations ABG . . . . . . .Arterial Blood Gas ac . . . . . . . . . . . . . .Before Meals ACS . . . . . . . . .Acute Coronary Syndrome ADLs . . . . . .Activities of Daily . . . . . . . . . . . . . . . . . . . .Living AF . . . . . . . . .Atrial Fibrillation AFB . . . . . . .Acid Fast Bacillus ALS . . . . . . . . . . .Amyotrophic Lateral Sclerosis AMA . . . . . . . .Against Medical Advice AMI . . . . . . .Acute Myocardial Infarction ANT . . . . . . . . . . . . . .Anterior A-P . . . . . . . . . . . . . .Anterior Posterior ARDS . . . . . .Adult Respiratory Distress Syndrome ARF . . . . . . .Acute Respiratory Failure ASD . . . . . . . . . . .Atrial Septal Defect AV . . . . . . . . . .Atrioventricular BE . . . . . . . . . . . . .Base Excess BBB . . . . . . . . .Bundle Branch Block bid . . . . . . . . . . . . .Twice Daily BiPAP . . . . . . .Bi-Level Positive Airway Pressure BMR . . . . . . . .Basal Metabolic Rate BP . . . . . . . . . .Blood Pressure bpm . . . . . . .Beats Per Minute BS . . . . . . . . . .Breath Sounds BSA . . . . . .Body Surface Area

BUN . . . .Blood Urea Nitrogen c . . . . . . . . . . . . . . . . . . . .With CA . . . . . . . . . . . . . . . . .Cancer CABG . . . . . . .Coronary Artery Bypass Graft CAD . . . . . . . .Coronary Artery Disease CBC . . .Complete Blood Count CHF . . . . . . .Congestive Heart Failure CHO . . . . . . . . . .Carbohydrate CMV . . . . . . . . . . .Continuous Mechanical Ventilation CNS . . . . . . . .Central Nervous System CO . . . . . . . . . .Cardiac Output COPD . . . .Chronic Obstructive Pulmonary Disease CPR . . . . . . .Cardiopulmonary Resuscitation CPT . . . . .Chest Physiotherapy C&S . . .Culture and Sensitivity CSF . . . .Cerebral Spinal Fluid CT . . . . . . . . . . .Computerized Tomography CVA . . . . . . . . .Cardiovascular Accident CVP . . . . . . . . .Central Venous Pressure CW . . . . . . . . . . . . .Chest Wall CXR . . . . . . . . . . .Chest X-Ray DC . . . . . . . . . . . . .Discontinue DIC . . . . . . . . . . .Disseminated Intravascular Coagulation

236

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237 DLCO . . .Single Breath Carbon Monoxide Diffusing Capacity DNR . . . . .Do Not Resuscitate DOA . . . . . . . .Dead on Arrival DOB . . . . . . . . . . .Date of Birth DOE . . . .Dyspnea on Exertion DTs . . . . . . .Delirium Tremens Dx . . . . . . . . . . . . . .Diagnosis ECF . . .Extended Care Facility ECG . . . . . .Electrocardiogram ECHO . . . . . . .Echocardiogram ECMO . . . . . . . .Extracorporeal Membrane Oxygenation EEG . . .Electroencephalogram EENT . .Eyes Ears Nose Throat EMG . . . . . .Electromyelogram EMS . . . . .Emergency Medical Service ENT . . . . . .Ear, Nose & Throat ER . . . . . . . .Emergency Room ESR . . . . . . . . . . . .Erythrocyte Sedimentation Rate ET . . . . . . . .Endotracheal Tube ETOH . . . . . . . . .Ethyl Alcohol FUO . . . . . .Fever of Unknown Origin Fx . . . . . . . . . . . . . . . .Fracture g, gm . . . . . . . . . . . . . . .Gram GFR . . . .Glomerular Filtration Rate GI . . . . . . . . . .Gastrointestinal gr . . . . . . . . . . . . . . . . . .Grain GSW . . . . . . .Gun Shot Wound gtt . . . . . . . . . . . . . . . . .Drops GU . . . . . . . . . . .Genitourinary GYN . . . . . . . . . . .Gynecology HAV . . . . . . . .Hepatitis A Virus Hb . . . . . . . . . . . .Hemoglobin

HBV . . . . . . . .Hepatitis B Virus Hct . . . . . . . . . . . . .Hematocrit HCV . . . . . . . .Hepatitis C Virus HEENT . .Head Eyes Ears Nose Throat HIV . . . . . . . .Human Immunodeficiency Virus HR . . . . . . . . . . . . . .Heart Rate hs . . . . . . . . . . .Hours of Sleep HTN . . . . . . . . . .Hypertension Hx . . . . . . . . . . . . . . . . .History I&O . . . . . . .Intake and Output IABP . . . . .Intra-aortic Balloon Pump ICP . . . . .Intracranial Pressure ICU . . . . . .Intensive Care Unit IDDM . . . . .Insulin Dependent Diabetes Mellitus IM . . . . . . . . . . .Intramuscular IV . . . . . . . . . . . . .Intravenous JVD . . . . . . . . .Jugular Venous Distention kg . . . . . . . . . . . . . . .Kilogram L . . . . . . . . . . . . . .Liter or Left LAD . . . .Left Anterior Descending (coronary artery) LAT . . . . . . . . . . . . . . . .Lateral LLL . . . . . . . . .Left Lower Lobe LOC . . . . . . . . . . .Level/Loss of Consciousness LP . . . . . . . . .Lumbar Puncture LUL . . . . . . . .Left Upper Lobe LV . . . . . . . . . . . .Left Ventricle LVAD . . . . . . . .Left Ventricular Assist Device MAP . . . . . . . . . .Mean Arterial Pressure or Mean Airway Pressure

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mcg . . . . . . . . . . . .Microgram MD . . . . .Muscular Dystrophy MDI . . . . . . . . . .Metered Dose Inhaler mEq . . . . . . . . .Milliequivalent mg . . . . . . . . . . . . . .Milligram MI . . . . .Myocardial Infarction mL . . . . . . . . . . . . . . .Milliliter mm . . . . . . . . . . . . .Millimeter mmHg . . . . . . . .Millimeters of Mercury MMR . . . . . .Measles-MumpsRubella MRI . . . . .Magnetic Resonance Imaging MRSA . . .Methicillin-Resistant Staphylococcus aureus NEB . . . . . . . . . . .Nebulized or Nebulizer NG . . . . . . . . . . . .Nasogastric NGT . . . . . . .Nasogastric tube NICU . . . . .Neonatal Intensive Care Unit NKA . . . . .No Known Allergies NKDA . . . . . . .No Known Drug Allergies noc . . . . . . . . . . . . . .Nocturnal NPO . . . . . .Nothing by Mouth (per os) NRB . . . . . . . .Non-Rebreather OB . . . . . . . . . . . . . .Obstetrics OD . . . . . . . . . . . . . .Overdose OR . . . . . . . . .Operating Room OT . . . . . . . . . . . .Occupational Therapy OTC . . . . . . .Over-the-Counter P . . . . . . . . . . . . . . . . .Pressure p . . . . . . . . . . . . . . . . . . . .After

PA..................Posterior-Anterior PAC..................Premature Atrial Complex PAR...................Post Anesthesia Recovery PAT ................Paroxysmal Atrial Tachycardia PDA......................Patent Ductus Arteriosus PE .............Pulmonary Embolus PEA .............Pulseless Electrical Activity PEEP....Positive End Expiratory Pressure PFT............Pulmonary Function Test PICC .........Peripherally Inserted Central Catheter PIH ..............Pregnancy Induced Hypertension PMH .........Past Medical History PMI.................Point of Maximal Impulse PND .......Paroxysmal Nocturnal Dyspnea PO ................By Mouth (per os) prn ............................As Needed PSVT.....Paroxysmal Supraventricular Tachycardia PT .................Prothrombin Time PTT........Partial Thromboplastin Time PVC.........Premature Ventricular Contraction q.........................................Every qd...............................Every Day qh .............................Every Hour q2 ........................Every 2 Hours q3 ........................Every 3 Hours

238

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239 q4 ........................Every 4 Hours q6 ........................Every 6 Hours q8 ........................Every 8 Hours q12 ....................Every 12 Hours qid...................Four Times Daily R .........................................Right RA..........................Right Atrium RLL ................Right Lower Lobe RML .............Right Middle Lobe R/O...............................Rule Out ROM ...............Range of Motion RUL ...............Right Upper Lobe Rx............................Prescription s .....................................Without SA ...............................Sinoatrial SIDS .........Sudden Infant Death Syndrome SNF ...................Skilled Nursing Facility SOB...................Short of Breath Staph................Staphylococcus STAT.......................Immediately Strep ...................Streptococcus Subq ...................Subcutaneous SV.......................Stroke Volume SVR...............Systemic Vascular Resistance T.............................Temperature T&A ..............Tonsillectomy and Adenoidectomy TB ..........................Tuberculosis TEE .................Transesophageal Echocardiogram

TIA ...............Transient Ischemic Attack tid ..................Three times daily TKO .....................To Keep Open TLC ............Total Lung Capacity TPN...................Total Parenteral Nutrition TPR . . . . .Temperature, Pulse, Respirations Tx . . . . . . . . . . . . . . .Treatment UA . . . . . . . . . . . . . .Urinalysis URI . . . . . . .Upper Respiratory Infection UTI . . . . . . . . . . . .Urinary Tract Infection UV . . . . . . . . . . . . . .Ultraviolet VC . . . . . . . . . . .Vital Capacity VF . . . . . . . . . . . . . .Ventricular Fibrillation V/Q Scan . . . . . . . .Ventilation/ Perfusion Scan VRE . . . . . . . . . . .VancomycinResistant Enterococcus WA . . . . . . . . . . .While Awake WBC . . . . . . .White Blood Cell Count WNL . . . . . . . . .Within Normal Limits w/o . . . . . . . . . . . . . . .Without wt . . . . . . . . . . . . . . . . .Weight yo . . . . . . . . . . . . . . . .Year Old yr . . . . . . . . . . . . . . . . . . . .Year

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Index description of, 22, 64 medications for, 201–202 Asystole, 53 Atelectasis, 23, 45 Atrial fibrillation, 48 Atrioventricular block, 51–52 Auscultation chest, 18–19 heart, 25–26 Automated external defibrillator, 158 Auto-PEEP, 136–137

A Abbreviations, 236–239 Adolescent, 3 Adults, 4, 65–67 Advanced cardiac life support algorithms for, 160–167 drugs used in, 216–218 pediatric, 187–190 Aerosol tent, 73 Aerosol therapy, 71–76, 181 African Americans, 5 Age-specific considerations, 2–4 Airborne precautions, 1 Air-trapping, 136–137 Airway management advanced airways, 108–109 intubation, 109–110 manual resuscitators, 107 in newborn, 175–176 positional maneuvers, 106 Airway resistance, 138–139 Alveolar ventilation, 20, 233 Anatomic deadspace, 20, 233 Anion gap, 113, 234 Anterior-posterior chest x-ray, 42 Antiarrhythmic drugs, 205–209 Anticholinergic agents, 196–197 Anticoagulants, 213 Antimicrobial agents, 204 Antiplatelet agents, 214 Apgar score, 168–169 Arab Americans, 5 Arterial blood gases assessment of, 37–41, 113 formulas, 234 in newborn, 168 Arterial pressure monitoring, 53 Artificial airway care of, 110–111 management of. See Airway management Asbestosis, 64 Assessment, 30–33 Asthma

B Bag/mask ventilation, 175 Ballard gestational age assessment, 170–171 Basic life support, 150–158 Bilevel positive airway pressure, 79 Biot’s respiration, 16 Blood gases. See Arterial blood gases Blood pressure, 13–14, 24, 112 Body fat, 28 Body mass index, 28, 234 Bohr equation, 233 Bosnian Americans, 6 Bradycardia advanced cardiac life support, 162 algorithms for, 162, 188 sinus, 48 Bronchial hygiene, 81–90 Bronchial sounds, 18 Bronchitis, 22, 64 Bronchodilators, 182, 194–198 Bronchoscopy, fiberoptic, 91–94 Bronchovesicular sounds, 18 Bruits, 27 C Calcium channel blockers, 211–212 Capillary refill, 24 Capnography, 96–97 Cardiac auscultation, 25–26 Cardiac enzymes, 27 Cardiac glycosides, 205

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241 Cardiac index, 57 Cardiac palpation, 25 Cardiopulmonary resuscitation in adults, 150 in child, 152–153 in infant, 155–156 in newborn, 177 Central venous pressure lines, 54 Chest auscultation, 18–19 inspection of, 15 percussion of, 18 symmetry assessments, 17 Chest discomfort, 166–167 Chest physiotherapy and postural drainage, 83 Chest x-rays, 41–45 Cheyne-Stokes respiration, 16 Child, 3, 152–154 Combitude airway, 108 Complete blood count, 34 Compliance in scalar waveforms, 142, 144 in volume loops, 141, 143 Congestive heart failure, 45 Consultation, 224 Contact precautions, 1 Continuous positive airway pressure, 79 Conversions, 8–9 Corticosteroids, 199–201 Cough, 20 Crackles, 18 Critically ill patients cardiovascular assessment, 103 fluid and electrolytes, 104 monitoring of, 112–114 neurological assessment, 104 oxygenation assessment, 102–103 physical findings, 101–102 ventilatory assessment, 102 ventilatory failure, 105 vital signs, 101 Cultural diversity, 5–7 Cylinder duration, 235 Cystic fibrosis, 23 Cytology, 36–37

D Double lumen endotracheal tubes, 109 Droplet precautions, 1 Dual-controlled ventilation, 118, 120 Dynamic compliance, 234 E Elderly, 4 Electrocardiogram, 46–53 Emphysema, 22, 64 Endotracheal tubes, 109 Equations, 233–234 Eupnea, 16 Event scheduler, 232 Exercise testing, 98–100 Expiratory reserve volume, 58 Extubation, 149 F Fiberoptic bronchoscopy, 91–94 Flow loop, 127, 136 Flow scalar waveform, 123 Forced expired volume in 1 second, 59 Forced vital capacity, 59 Foreign body airway obstruction in adults, 151 in child, 154 in infant, 157 Fraction of inspired oxygen, 121 Frequently used phone numbers, 221–222 Functional residual capacity, 59 G Gestational age assessment, 170–171 Glasgow Coma Score, 104 H Head assessment, 15 Heart rate, 13–14, 24, 112 Heart sounds, 25–26 Heat and moisture exchanger, 74 Hematocrit, 34 Hematology, 34 Hemodynamics, 53–58, 234 Hemoglobin, 34

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Histology, 36–37 Home care frequently used companies, 225–228 referral notes, 229 Humidifiers, 73–74 Humidity therapy, 71–76 Hyperinflation therapy, 76–81, 185 I Incentive spirometry, 77 Indwelling arterial lines, 53 Infants, 2, 155–157 Inhaled antimicrobial agents, 204 Inotropic agents, 210–211 Inspiratory capacity, 59 Inspiratory reserve volume, 58 Intermittent positive pressure breathing, 79 Interview, 11–13 Intrapulmonary percussive ventilation, 84 Intravenous line, 219–220 Intubation, 109–110, 176 Ischemia, 166–167 Isolation precautions, 1 K Kussmaul’s respiration, 16 L Laryngeal mask airway, 108 Lateral chest x-ray, 43 Left ventricular stroke work index, 57 Length conversions, 8–9 Life support advanced cardiac. See Advanced cardiac life support basic, 150–158 Loops, 126–127 Lung drainage, 85–88 M Mandatory breath, 130, 134 Manual resuscitators, 107 Mean cell hemoglobin, 34 Mean cell hemoglobin concentration, 34

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Mean cell volume, 34 Mechanical ventilation discontinuance of, 147–149 dual-controlled ventilation, 118, 120 fraction of inspired oxygen, 121 indications for, 114–115 inspiratory flow pattern, 122 loops, 126–127 minute ventilation, 121 modes of, 115–118, 149 pressure-controlled ventilation, 117, 120, 122, 132–135 return to, 148 tidal volume, 121 ventilator. See Ventilator volume-controlled ventilation, 116, 119, 122, 128–131 waveforms, 122–127 weaning, 147 Metabolic acidosis, 39–40, 234 Metabolic alkalosis, 39–41 Metered dose inhalers, 74 Mexican Americans, 7 Microbiology, 36 Minute ventilation, 121 Minute volume, 20 Mucolytic therapy, 183 Mucous agents, 202–203 Murmurs, 27 N Nasal cannula, 67, 180 Nasal inhaled corticosteroids, 200–201 Native Americans, 6 Nebulizers, 73–74 Neck assessment, 15 Neurological assessment, 27–28 Newborn acute care of, 174–193 airway management in, 175–176 Apgar score, 168–169 assessment of, 168–174 bland aerosol algorithm, 181 bronchodilators, 182 cardiopulmonary resuscitation algorithm, 177 gestational age, 170–171

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243 HFOV ventilator management algorithm, 179 hyperinflation therapy in, 185 mucolytic therapy, 183 oxygen therapy in, 180 physical maturity, 172–173 respiratory care, 180 respiratory status, 174 secretion mobilization in, 186 vasoconstrictors, 184 ventilator management, 178 vital signs, 168 Non-rebreathing mask, 67, 180 Nonsteroidal anti-inflammatory drugs, 201–202 Nutritional assessment, 28–29 O Organizer, 230–231 Overdistention, 145 Oximetry, 100 Oxygen therapy description of, 65–70 in newborn, 180 Oxygenation, 21, 233 P Partial rebreathing mask, 67 Patient interview, 11–13 Percent solutions, 220 Percussion, 18 Pharmacology equations, 235 Phone numbers, 221–222 Physician consultation with, 224 contact information for, 222–224 Platelets, 34 Pleural effusion, 45 Pneumonia, 23 Pneumothorax, 45 Point of maximal impulse, 25 Portable sleep monitoring, 97–98 Positive expiratory pressure, 78, 83, 131, 135 Posterior-anterior chest x-ray, 42 Postural drainage, 85–88

Premature ventricular contraction, 49 Pressure conversions, 9–10 Pressure loop, 126 Pressure scalar waveform, 124 Pressure-controlled ventilation, 117, 120, 122, 132–135 Pulmonary artery catheter, 55 Pulmonary artery pressures, 57 Pulmonary edema, 23, 45 Pulmonary embolus, 23 Pulmonary function testing, 58–64 Pulmonary inhaled corticosteroids, 199–200 Pulmonary secretions, 35 Pulmonary vascular resistance, 57 Pulseless arrest, 160–161, 189 R Red blood cells, 34 Residual volume, 58 Respiratory acidosis, 40 Respiratory alkalosis, 40 Respiratory failure, 105 Respiratory rate, 13–14, 112 Resuscitators, 107 Retinol-binding protein, 29 Rhonchi, 18 Right ventricular stroke work index, 57 Rub, 18 Russian Americans, 7 S Sarcoidosis, 64 Scalar waveforms airway resistance in, 139 compliance in, 142, 144 description of, 122–123, 137 Schedule planner, 230–231 Serum albumin, 29 Simple oxygen mask, 67, 180 Sinus bradycardia, 48 Skin testing, 37 Sleep monitoring, portable, 97–98 Spirometry, 59–60, 77 SpO2, 13–14

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Spontaneous breath flow triggered, 129, 133 pressure triggered, 128–129, 132 Spontaneous breathing trial, 148 Sputum, 20 Static compliance, 234 Stroke volume index, 57 Suctioning, of airway description of, 111–112 in newborn, 175 Surfactant agents, 203 Swan-Ganz catheter, 55 Sympathomimetic agents, 194–196 Systemic vascular resistance, 57 T Tachycardia with adequate perfusion, 190 advanced cardiac life support for, 164–165 algorithms for, 164–165, 192 with poor perfusion, 192–193 ventricular, 50 TB testing, 37 Temperature, 13–14, 112 Temperature conversions, 8–9 Thrombolytic agents, 215 Tidal volume, 20, 58, 121 Toddlers, 2 Total lung capacity, 59 Tracheostomy care, 90–91 Trigger asynchrony, 146 U Urea nitrogen, 29 Urine output, 113 V Vasoconstrictors, 184 Vasodilators, 212–213 Vasopressors, 210–211

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Ventilation assessment of, 20 bag/mask, 175 equations, 233–234 mechanical. See Mechanical ventilation Ventilator mandatory breath, 130, 134 in newborns, 178 normal graphics for, 128–135 settings for, 118 spontaneous breath, 128–129, 132 waveforms for, 122–127 Ventilatory failure, 105, 115 Ventilatory patterns, 16 Ventricular fibrillation, 50 Ventricular tachycardia, 50 Venturi mask, 67 Vesicular sounds, 18 Vital capacity, 59 Vital signs assessment of, 13–14 in critically ill patients, 101 in newborn, 168 Volume loops airway resistance in, 140 compliance in, 141, 143 description of, 126–127 Volume scalar waveform, 125 Volume-controlled ventilation, 116, 119, 122, 128–131 W Weaning, 147 Weight conversions, 8–9 Wheezes, 18 Winter’s formula, 234 X Xanthine, 198

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