Review for RSPT 1166Review for RSPT 1166clinical written finalclinical written final

By Elizabeth Kelley Buzbee By Elizabeth Kelley Buzbee AAS, RRT-NPS, RCP.AAS, RRT-NPS, RCP.

Question: Case studyQuestion: Case study

You walk into a patient’s room and You walk into a patient’s room and notice that his RR is 3 bpm and that notice that his RR is 3 bpm and that his skin is dusky. You feel no pulse his skin is dusky. You feel no pulse rate at the carotid artery.rate at the carotid artery.

What is the first thing you do?What is the first thing you do?

answeranswer

Call for help;Call for help; Establish an airway and give 2 good Establish an airway and give 2 good

breathes with a bag/mask with 100% breathes with a bag/mask with 100% 0202

Question Question

When you give your two breathes, When you give your two breathes, you notice that the chest doesn’t you notice that the chest doesn’t rise.rise.

What do you do?What do you do?

answeranswer

Manipulate the head and neck and Manipulate the head and neck and try againtry again

questionquestion

While you give two breaths and the While you give two breaths and the chest rises, the second RT in the chest rises, the second RT in the room should be doing what? room should be doing what?

answeranswer

They should start chest They should start chest compressions at a rate of 100 bpm at compressions at a rate of 100 bpm at 30:2 ratio until the AED or the 30:2 ratio until the AED or the defibrillator arrivesdefibrillator arrives

QuestionQuestion

If the patient responds to the AED If the patient responds to the AED and has a carotid pulse of 70 bpm, and has a carotid pulse of 70 bpm, but still is unconscious and apnic, but still is unconscious and apnic, what do you do?what do you do?

answeranswer

with a pulse of 70 bpm, we can stop chest with a pulse of 70 bpm, we can stop chest compressions, but because the patient is compressions, but because the patient is unconscious we need to ask for an unconscious we need to ask for an artificial airway [intubation] artificial airway [intubation]

and because he is apnic, we rescue-and because he is apnic, we rescue-breathe with bag/mask at 100% at a rate breathe with bag/mask at 100% at a rate of 10-12 bpm.of 10-12 bpm.

Once we stop compressions, we can trust Once we stop compressions, we can trust the Sp02 reading, so we can use that to the Sp02 reading, so we can use that to monitor the success of our bagging.monitor the success of our bagging.

End of case studyEnd of case study

questionquestion

Identify the effect of severe Identify the effect of severe hypoxemia on the heart.hypoxemia on the heart.

answeranswer

any hypoxemia can cause tachycardia, any hypoxemia can cause tachycardia, even arrhythmias if the heart is already even arrhythmias if the heart is already irritable irritable

but moderate to severe hypoxemia will but moderate to severe hypoxemia will result in vasoconstriction of pulmonary result in vasoconstriction of pulmonary capillaries so that right ventricular work capillaries so that right ventricular work of the heart is increasedof the heart is increased

Cor pulmonale is right heart failure Cor pulmonale is right heart failure secondary to long-standing lung diseasesecondary to long-standing lung disease

QuestionQuestion

Your patient has a Pa02 of 65 torr, Your patient has a Pa02 of 65 torr, PaC02 40 mmHg on an Fi02 of 45%. PaC02 40 mmHg on an Fi02 of 45%. Assume that the PB is 760 torrAssume that the PB is 760 torr

Calculate his P(A-a)Calculate his P(A-a) Calculate his a/A ratioCalculate his a/A ratio

answeranswer

To figure the P(A-a)D02 & a/A, we To figure the P(A-a)D02 & a/A, we must first find the PA02must first find the PA02

PA0PA022 = [ (P = [ (PBB – H – H220) X FI00) X FI022] – (PaC0] – (PaC022/.8)/.8)

PA0PA022 = [ (713) .45] – (40/.8) = [ (713) .45] – (40/.8)

PA0PA022 = 270 mmHg = 270 mmHg

P(P(A-aA-a)D0)D022 = 270 – 65 = 205 = 270 – 65 = 205

a/A ratio = Pa02/PA02a/A ratio = Pa02/PA02

65/270 = .2465/270 = .24

questionquestion

List the s/s of chronic lung disease:List the s/s of chronic lung disease: What do you hearWhat do you hear What do you seeWhat do you see What do you feelWhat do you feel

answeranswer

You will see a person with increased AP You will see a person with increased AP diameterdiameter

You might see use of accessory muscles of You might see use of accessory muscles of inspiration and exhalationinspiration and exhalation

You will hear wheezing, prolonged You will hear wheezing, prolonged exhalation, ‘distant’ Breath sounds [this is exhalation, ‘distant’ Breath sounds [this is different from ‘diminished.’]different from ‘diminished.’]

On percussion, you will hear hyper-On percussion, you will hear hyper-resonance.resonance.

On palpation of the belly, you might feel On palpation of the belly, you might feel muscle tensing during forced exhalationmuscle tensing during forced exhalation

questionquestion

Your patient has a Pa02 of 48 torr on Your patient has a Pa02 of 48 torr on room air. His Sp02 is 85%room air. His Sp02 is 85%

What do you recommend?What do you recommend?

answeranswer I would give supplementary 02 to get the Sp02 I would give supplementary 02 to get the Sp02

above 90-92%above 90-92% Because I have the Pa02 48 torr on an Fi02 of .21, Because I have the Pa02 48 torr on an Fi02 of .21,

I could calculate the required Fi02 to get an I could calculate the required Fi02 to get an predicted Pa02 of 80 torr. predicted Pa02 of 80 torr.

Pa02Pa0211: Fi02: Fi0211 as Pa02 as Pa0222 : Fi02 : Fi0222

48: .21 as 80: x48: .21 as 80: x48x = .21 (80)48x = .21 (80)

X = 16.8/48X = 16.8/48X= .35X= .35

We need to increase the Fi02 to 35% to get We need to increase the Fi02 to 35% to get the Pa02 back to normal [80 torr]the Pa02 back to normal [80 torr]

questionquestion

Your patient has Your patient has the following ABG the following ABG on 2 lpm:on 2 lpm:

How do we correct How do we correct this Pa02?this Pa02?

Is this patient some Is this patient some one in whom we one in whom we need to worry need to worry about 02 induced about 02 induced hypoventilation?hypoventilation?

pH PaC02 HC03- Pa02

7.369 43 24 57

answeranswer To correct a Pa02 of 57 on 2 lpm.To correct a Pa02 of 57 on 2 lpm. First we estimate the Fi02 is 20 + (2 x4) First we estimate the Fi02 is 20 + (2 x4)

= .28= .28 Pa02Pa0211: Fi02: Fi0211 as Pa02 as Pa0222 : Fi02 : Fi0222

57: .28 as 80: x 57: .28 as 80: x 57x = .28 (80)57x = .28 (80)

X = 22.4/57X = 22.4/57X =.39= increase the Fi02 to 39% or 40%X =.39= increase the Fi02 to 39% or 40%

This patient This patient doesn’tdoesn’t have chronic have chronic hypercapnia because the PaC02 is normal hypercapnia because the PaC02 is normal [35-45][35-45]

QuestionQuestion

Your patient’s ABG Your patient’s ABG are as follows:are as follows:

Is this patient a Is this patient a person with chronic person with chronic hypercapnea?hypercapnea?

How would we How would we correct this correct this patient’s Pa02 if this patient’s Pa02 if this ABG was on 28% ABG was on 28% entrainment mask? entrainment mask?

pH PaC02 HC03- Pa02

7.36 51 28 43

answeranswer

This patient’s ABG is consistent with COPD This patient’s ABG is consistent with COPD because it has a high PaC02 with a normal because it has a high PaC02 with a normal pHpH

I need to correct the Fi02 to get a Pa02 I need to correct the Fi02 to get a Pa02 between 55 and 60 torr.between 55 and 60 torr.

Pa02Pa0211: Fi02: Fi0211 as Pa02 as Pa0222 : Fi02 : Fi0222

43: .24 as 60: x 43: .24 as 60: x 43x = .24 (60)43x = .24 (60)

X = 14.4/43= increase the Fi02 33% to get X = 14.4/43= increase the Fi02 33% to get predicted Pa02 of 60 torrpredicted Pa02 of 60 torr

QuestionQuestion

In the patient situation that was just In the patient situation that was just completed, why can we safely completed, why can we safely increase this patient’s to Fi02 33% increase this patient’s to Fi02 33% when we ‘know’ 1-2 lpm or 24-28% when we ‘know’ 1-2 lpm or 24-28% is considered ‘safe’ for persons with is considered ‘safe’ for persons with chronic hypoxemia and chronic chronic hypoxemia and chronic hypercapnia?hypercapnia?

answeranswer

Once we have an ABG, we can use the Once we have an ABG, we can use the actual Pa02 to figure our next step.actual Pa02 to figure our next step.

We use 1-2 lpm as a ‘safe place to We use 1-2 lpm as a ‘safe place to start,’ but if we need to give our COPD start,’ but if we need to give our COPD patient a NRM to get the Pa02 between patient a NRM to get the Pa02 between 55-60 torr, we do so.55-60 torr, we do so.

only by getting the only by getting the Pa02 above 65Pa02 above 65 torr torr can we cause 02 induced hypoventilationcan we cause 02 induced hypoventilation

So it’s not a safe Fi02 but a safe Pa02So it’s not a safe Fi02 but a safe Pa02

QuestionQuestion

The patient is on The patient is on 50% entrainment 50% entrainment by bland aerosol by bland aerosol mask.mask.

How do we correct How do we correct this ABG?this ABG?

pH PaC02 HC03- Pa02

7.369 43 24 188

answeranswer

Because the PaC02 is normal, we can Because the PaC02 is normal, we can correct to 80 mmHgcorrect to 80 mmHg

We would decrease the Fi0We would decrease the Fi022

Pa02Pa0211: Fi02: Fi0211 as Pa02 as Pa0222 : Fi02 : Fi0222

188: .50 as 80: x 188: .50 as 80: x 188x = .50 (80)188x = .50 (80)X = 40/188= .21X = 40/188= .21

While monitoring the HR, RR and Sp02, you While monitoring the HR, RR and Sp02, you should be able to safely discontinue the 02should be able to safely discontinue the 02

QuestionQuestion

Your patient has a RR 35 bpm with a Your patient has a RR 35 bpm with a estimated VTof 500.estimated VTof 500.

If he is getting 02 via a 60% If he is getting 02 via a 60% entrainment mask running at 10 entrainment mask running at 10 LPM, is this a high flow system LPM, is this a high flow system for for himhim??

Explain your answer.Explain your answer.

answeranswer His VE = 35BPM x .500 VT = 17.5 LPMHis VE = 35BPM x .500 VT = 17.5 LPM The total flow of a 60% device at 10 LPM is The total flow of a 60% device at 10 LPM is

10 LPM + [10 x 1] = 20 LPM10 LPM + [10 x 1] = 20 LPM Remember 60% is an air : 02 ratio of 1:1Remember 60% is an air : 02 ratio of 1:1 To be a To be a truetrue high flow system for this high flow system for this

patient, his total flow must be equal to VE patient, his total flow must be equal to VE ( I + E )( I + E )

So 17.5 [1+ 1.5] = 17.5 x 2.5 =43.7 LPM. So 17.5 [1+ 1.5] = 17.5 x 2.5 =43.7 LPM. He needs 43.7 LPM of total flow to avoid He needs 43.7 LPM of total flow to avoid

entrainment of air. He is only getting 20 entrainment of air. He is only getting 20 LPM so there will be air entrainment so the LPM so there will be air entrainment so the delivered Fi02 will be less than 60%delivered Fi02 will be less than 60%

questionquestion

Describe the effects of going too long Describe the effects of going too long between checking on a heated between checking on a heated aerosol going to a patient with a aerosol going to a patient with a tracheostomy collar. tracheostomy collar.

answeranswer aerosols will rain out into the tubing and heated aerosols aerosols will rain out into the tubing and heated aerosols

will rain out even faster.will rain out even faster. The RCP The RCP must checkmust check a trach collar patient at least Q 3-4 a trach collar patient at least Q 3-4

hours & drain the hose and a heated trach collar may need hours & drain the hose and a heated trach collar may need to be dumped even more often [Q2-3 hours]to be dumped even more often [Q2-3 hours]

The extra water in the tube can obstruct the flow to the The extra water in the tube can obstruct the flow to the patient and it can literally drown the patient if this water patient and it can literally drown the patient if this water tips into the unprotected airway.tips into the unprotected airway.

Because this water is dirty compared to the lower airway, Because this water is dirty compared to the lower airway, this can be a source of infectionthis can be a source of infection

Even if you have placed a water trap into the circuit, the Even if you have placed a water trap into the circuit, the weight of the water could pull the hose apart or pull the weight of the water could pull the hose apart or pull the collar off the patient’s neck.collar off the patient’s neck.

Heated hoses are helpful, but even they will need to be Heated hoses are helpful, but even they will need to be drained periodicallydrained periodically

questionquestion

Explain what would happen to the Explain what would happen to the ability of a tracheostomy collar to ability of a tracheostomy collar to deliver 02 correctly if water was to deliver 02 correctly if water was to collect in the low spot [dependent] in collect in the low spot [dependent] in the tubing.the tubing.

answeranswer This is kinda tricky:This is kinda tricky: The back pressure created by the obstruction The back pressure created by the obstruction

down stream from the entrainment device down stream from the entrainment device will cause the lateral pressure to rise so that will cause the lateral pressure to rise so that less air is entrained into the device. Fi02less air is entrained into the device. Fi02

At the outlet of the aerosol generator, we will At the outlet of the aerosol generator, we will get an increased Fi02 with a decreased flow get an increased Fi02 with a decreased flow raterate

As the water fills up the hose, there will be As the water fills up the hose, there will be less flow rate downstream from the less flow rate downstream from the obstruction, so even if there is a higher Fi02, obstruction, so even if there is a higher Fi02, it may not get to the patient. it may not get to the patient. So the So the patient’s delivered Fi02 is less.patient’s delivered Fi02 is less.

questionquestion

Identify the approximate Fi02 of a Identify the approximate Fi02 of a nasal cannula at 2 lpm and at 5 lpm.nasal cannula at 2 lpm and at 5 lpm.

Why is this only approximate?Why is this only approximate?

answeranswer

The Fi0The Fi022 of a N/C at 2 lpm is 20 + (2 of a N/C at 2 lpm is 20 + (2 x 4) or .28.x 4) or .28.

The Fi0The Fi022 of a N/C at 5 lpm is 20 + (5 of a N/C at 5 lpm is 20 + (5 x 4) or .40.x 4) or .40.

These are only estimates because These are only estimates because the nasal cannula is a low flow the nasal cannula is a low flow system & the more the patient’s VE system & the more the patient’s VE rises, the lower the delivered Fi0rises, the lower the delivered Fi022..

questionquestion

How do we add humidity to a simple How do we add humidity to a simple mask?mask?

answeranswer

We use a cool bubble humidifier We use a cool bubble humidifier

questionquestion

Explain what will happen if the flow Explain what will happen if the flow rate going to the simple mask was to rate going to the simple mask was to exceed the ability of the bubble exceed the ability of the bubble humidifier to allow the flow through humidifier to allow the flow through the devicethe device

answeranswer

the soft plastic sides of the humidifier the soft plastic sides of the humidifier will swell and if there is a pressure pop-will swell and if there is a pressure pop-off, it will alarm as the pressure rises off, it will alarm as the pressure rises above 2 psig.above 2 psig.

and if it is compensated, the flow meter and if it is compensated, the flow meter will show the correct [lower] flow ratewill show the correct [lower] flow rate

The patient’s delivered Fi02 will drop The patient’s delivered Fi02 will drop and no twisting of the flow meter knob and no twisting of the flow meter knob will increase the flow to the patientwill increase the flow to the patient

questionquestion

Your patient Your patient has the has the following following OrdersOrders: keep: keepSp02 Sp02 above 92%.above 92%.What Fi02 What Fi02 should should he be on?he be on?

TimeTime devicedevice Flow Flow rate/Fi02rate/Fi02

Sp02Sp02 HR/HR/

RRRR

900900 N/CN/C 2 lpm/ 2 lpm/ 28%28%

89%89% 118/29118/29

11001100 N/CN/C 3 lpm/ 3 lpm/ 32%32%

93%93% 115/22115/22

13001300 N/CN/C 4 lpm/ 4 lpm/ 36%36%

94%94% 115/22115/22

answeranswer

The order says The order says keep Sp0keep Sp022 above 92% above 92% soso

We need to decrease the flow rate to 3 We need to decrease the flow rate to 3 lpm where the Sp02 rose to 93%.lpm where the Sp02 rose to 93%.

While there is nothing wrong with a While there is nothing wrong with a 94% Sp02, the order only requires 94% Sp02, the order only requires getting the oxygenation above 92%. getting the oxygenation above 92%.

You always go with the lowest amount You always go with the lowest amount that can do the jobthat can do the job

questionquestion

Your patient Your patient has the has the following following OrdersOrders: keep: keepSp02 Sp02 above 92%.above 92%.What Fi02 What Fi02 should should he be on?he be on?

TimeTime devicedevice Flow Flow rate/Fi02rate/Fi02

Sp02Sp02 HR/HR/

RRRR

900900 N/CN/C 1 lpm/ 1 lpm/ 24%24%

86%86% 118/29118/29

11001100 N/CN/C 2 lpm/ 2 lpm/ 28%28%

89%89% 115/28115/28

13001300 Simple Simple maskmask

6 lpm/ 6 lpm/ 44%44%

95%95% 110/27110/27

answeranswer

We need to decrease the flow rate on We need to decrease the flow rate on the simple mask to 5 LPM and the simple mask to 5 LPM and recheck the Sp02.recheck the Sp02.

If the patient’s Sp02 is still above If the patient’s Sp02 is still above 92%, then we must put the nasal 92%, then we must put the nasal cannula back on at 4 LPM because cannula back on at 4 LPM because we cannot have a flow rate on the we cannot have a flow rate on the simple mask below 5 LPM.simple mask below 5 LPM.

questionquestion

Explain why we cannot keep the Explain why we cannot keep the simple mask at 4 lpm?simple mask at 4 lpm?

answeranswer

We need at least 5 lpm to blow off We need at least 5 lpm to blow off the exhaled C0the exhaled C022..

As a patient re-breathes his C02, the As a patient re-breathes his C02, the PaC02 will rise making him to PaC02 will rise making him to breathe faster and deeper as his CNS breathe faster and deeper as his CNS reacts to the increased H+ in the CSF reacts to the increased H+ in the CSF

questionquestion

Your patient has been sent home. Your patient has been sent home. The doctor orders an MDI of Flovent The doctor orders an MDI of Flovent 2 puffs BID at home. List the things 2 puffs BID at home. List the things the patient needs to know about the patient needs to know about giving himself a MDI of Flovent.giving himself a MDI of Flovent.

answeranswer

1.1. The Flovent is an inhaled steroid-not a Beta II so The Flovent is an inhaled steroid-not a Beta II so it is it is notnot a rescue drug a rescue drug

2.2. He needs to use a He needs to use a spacerspacer to keep medication to keep medication out of his mouth & to get more into his airwaysout of his mouth & to get more into his airways

3.3. He needs to He needs to rinse his mouth rinse his mouth to minimize oral to minimize oral fungal infectionsfungal infections

4.4. He needs to take a slow deep breath with each He needs to take a slow deep breath with each puff followed by an inspiratory hold for 5-10 puff followed by an inspiratory hold for 5-10 secondsseconds

5.5. He needs to take this BID which means in the He needs to take this BID which means in the AM and in the PM [about 12 hours apart]AM and in the PM [about 12 hours apart]

questionquestion

Your patient is going home and he is Your patient is going home and he is get get MDI of Albuterol 2 puffs Q 6 get get MDI of Albuterol 2 puffs Q 6 hours & PRN. He will also get hours & PRN. He will also get Atrovent MDI QID and Flovent TID.Atrovent MDI QID and Flovent TID.

What will you tell him about What will you tell him about scheduling?scheduling?

answeranswer

Q 6 hours means that he will take MDI Q 6 hours means that he will take MDI of Albuterol every 6 hoursof Albuterol every 6 hours

PRN means that he can take a few PRN means that he can take a few extra as neededextra as needed

TID means that he takes the Flovent 3 TID means that he takes the Flovent 3 x a day, basically with mealsx a day, basically with meals

QID means that he takes the Atrovent QID means that he takes the Atrovent 4 x a day. Meal times and bedtime4 x a day. Meal times and bedtime

questionquestion

At what At what time you time you give the give the next next treatment treatment of Albuterol of Albuterol & Atrovent & Atrovent if both are if both are ordered Q4 ordered Q4 hours?hours?

timetime devicedevice Flow Flow raterate

/Fi02/Fi02

commentscomments

830830 SVN w/ 2.5 mg SVN w/ 2.5 mg AlbuterolAlbuterol

.5 mg .5 mg ipratropium ipratropium

bromidebromide

6 lpm6 lpm HR 89/23HR 89/23

HR 89/22HR 89/22

Wheezing Wheezing unchanged.unchanged.

answeranswer

We would schedule the next We would schedule the next treatment for 12:30 noon.treatment for 12:30 noon.

questionquestion

Describe the effect of an obstruction Describe the effect of an obstruction in the 02 line coming from a Thorpe in the 02 line coming from a Thorpe tubetube

answeranswer

If the Thorpe tube is compensated If the Thorpe tube is compensated for backpressure, the rise in pressure for backpressure, the rise in pressure upstream from the obstruction will upstream from the obstruction will cause the flow meter to read the cause the flow meter to read the correct flow rate.correct flow rate.

If the Thorpe tube wasn’t If the Thorpe tube wasn’t compensated, the rise in back compensated, the rise in back pressure would result in an pressure would result in an erroneously lower flow than the erroneously lower flow than the patient is actually gettingpatient is actually getting

questionquestion

Describe the effect of an obstruction Describe the effect of an obstruction in the 02 line on the delivered flow in the 02 line on the delivered flow rate coming from a Bourdon gauge rate coming from a Bourdon gauge that is calibrated for flow rate.that is calibrated for flow rate.

answeranswer

Bourdon gauges are not flow meters; Bourdon gauges are not flow meters; they read pressure only, but they read pressure only, but occasionally they are calibrated in occasionally they are calibrated in LPM so that a Bourdon gauge may be LPM so that a Bourdon gauge may be used as a uncompensated flow meter.used as a uncompensated flow meter.

When there is an obstruction When there is an obstruction downstream, the Bourdon gauge will downstream, the Bourdon gauge will read the back pressure as increased read the back pressure as increased flow rate, so it will display an flow rate, so it will display an erroneouslyerroneously high flow rate high flow rate

questionquestion Your patient is being transferred from the Your patient is being transferred from the

ER to the ICU. He is on a NRM at 12 lpm. ER to the ICU. He is on a NRM at 12 lpm. His Sp02 displays 90%/HR 89 bpm.His Sp02 displays 90%/HR 89 bpm.

After going through various doorways, you After going through various doorways, you notice that the NRM reservoir bag is notice that the NRM reservoir bag is deflated, the Sp02 is showing: 88%/HR deflated, the Sp02 is showing: 88%/HR 115 bpm. The flow meter on the Bourdon 115 bpm. The flow meter on the Bourdon gauge shows a flow rate of 15 lpm.gauge shows a flow rate of 15 lpm.

The humidifier is alarmingThe humidifier is alarming Is there a disconnection or is the tubing Is there a disconnection or is the tubing

pinched? pinched?

answeranswer If there was a disconnection, the bag would be If there was a disconnection, the bag would be

deflated due to drop in flow.deflated due to drop in flow. If there was a disconnection, the flow rate would If there was a disconnection, the flow rate would

be the same.be the same. There is no humidifier alarm for disconnectionThere is no humidifier alarm for disconnection

If there was a pinched line, the bag would be If there was a pinched line, the bag would be deflated due to drop in flow.deflated due to drop in flow.

If there was a pinched line the Bourdon gauge If there was a pinched line the Bourdon gauge would show the back pressure as increased flow would show the back pressure as increased flow rate.rate.

Many bubble humidifiers have excessive pressure Many bubble humidifiers have excessive pressure pop-off valves and these valves will alarm in the pop-off valves and these valves will alarm in the face of an occlusion that results in high pressure.face of an occlusion that results in high pressure.

questionquestion

Your E cylinder has 1500 and the Your E cylinder has 1500 and the patient’s flow rate is 2 lpm.patient’s flow rate is 2 lpm.

How long will a tank last if your How long will a tank last if your hospital policy is to change out a hospital policy is to change out a tank when there is 15 minutes left.tank when there is 15 minutes left.

answeranswer Your E cylinder has 1500 and the patient’s Your E cylinder has 1500 and the patient’s

flow rate is 2 lpm.flow rate is 2 lpm.

Duration = psig x factor/ LPMDuration = psig x factor/ LPM

Duration = 1500 x .28/ 2 LPMDuration = 1500 x .28/ 2 LPM

Duration = 420 liters/ 2 LPMDuration = 420 liters/ 2 LPM

Duration = 210 minutesDuration = 210 minutes

210-15 = 195 minutes210-15 = 195 minutes

195minutes/60 = 3.25 hours195minutes/60 = 3.25 hours

.25 hours x 60 = 15 minutes.25 hours x 60 = 15 minutes

So this tank will run out in 3 hours & 15 So this tank will run out in 3 hours & 15 minutesminutes

questionquestion

Your H cylinder has 1150 and the Your H cylinder has 1150 and the patient’s flow rate is 5 lpm.patient’s flow rate is 5 lpm.

How long will a tank last if your How long will a tank last if your hospital policy is to change out a hospital policy is to change out a tank when it reaches 500 psig?tank when it reaches 500 psig?

answeranswer

Your H cylinder has 1150 and the patient’s Your H cylinder has 1150 and the patient’s flow rate is 5 lpm.flow rate is 5 lpm.

In this case we first subtract 500 psig so In this case we first subtract 500 psig so that we start with 650 psigthat we start with 650 psig

Duration = 650 x 3.14/ 5 LPMDuration = 650 x 3.14/ 5 LPMDuration = 2041/ 5 LPMDuration = 2041/ 5 LPM

Duration =408.2 minutesDuration =408.2 minutesDuration = 6.8 hours Duration = 6.8 hours

Duration = 6 hours + [.8 x 60]Duration = 6 hours + [.8 x 60]Duration = 6 hours and 48 minutesDuration = 6 hours and 48 minutes

QuestionQuestionCase studyCase study

You patient is 1 day post op You patient is 1 day post op abdominal surgery. His Sp02 is 93% abdominal surgery. His Sp02 is 93% HR 92 bpm, RR 23 bpm. His HR 92 bpm, RR 23 bpm. His respirations are shallow and without respirations are shallow and without retractions. retractions.

You hear diminished basal BS and You hear diminished basal BS and crackles over the RML.crackles over the RML.

What would you suggest for this What would you suggest for this patient?patient?

answeranswer

His Sp02 is good and he shows no His Sp02 is good and he shows no s/s of respiratory distresss/s of respiratory distress

One day post op, his respiratory rate One day post op, his respiratory rate may be decreased because of pain or may be decreased because of pain or sedationsedation

His BBS demonstrate the presence of His BBS demonstrate the presence of atelectasis, so we need to start him atelectasis, so we need to start him on on Incentive SpirometerIncentive Spirometer

questionquestion

What would be the clinical What would be the clinical significance of this patient’s LOC for significance of this patient’s LOC for successful Incentive Spirometry?successful Incentive Spirometry?

answeranswer

He He must co-operatemust co-operate, so while he can be , so while he can be sleepy or even lethargic [this means sleepy or even lethargic [this means arousal with stimulation] he cannot be arousal with stimulation] he cannot be comatose or in a vegetative state.comatose or in a vegetative state.

If he is severely mentally retarded or have If he is severely mentally retarded or have dementia, he may not be able to follow dementia, he may not be able to follow directions.directions.

If he is alert, but suffers a neuromuscular If he is alert, but suffers a neuromuscular disorder, he may lack the muscle strength disorder, he may lack the muscle strength or co-ordination to follow directionsor co-ordination to follow directions

questionquestion

If the patient in the above question is If the patient in the above question is a 35 YO BM who is 5 feet 8 inches a 35 YO BM who is 5 feet 8 inches tall, what would be a reasonable goal tall, what would be a reasonable goal to start him on with the IS?to start him on with the IS?

answeranswer

To cough effectively he needs to get 15 To cough effectively he needs to get 15 ml/Kg IBWml/Kg IBW

IBW = 105 + [8 x 6]IBW = 105 + [8 x 6]105 + 48 = 153 pounds 105 + 48 = 153 pounds

To convert to kg = 153/2.2 = 69.5 kgTo convert to kg = 153/2.2 = 69.5 kgTo cough effectively he needs to get To cough effectively he needs to get

[69.5kg x 15ml.kg] or 1042 ml IC[69.5kg x 15ml.kg] or 1042 ml IC Before surgery he could easily have gotten Before surgery he could easily have gotten

3 x that, so over the next couple of days 3 x that, so over the next couple of days we will work up to [1042 x 3] or 3.1 Liters we will work up to [1042 x 3] or 3.1 Liters

questionquestion

On his first IS, your patient gets 850 On his first IS, your patient gets 850 ml on his goal.ml on his goal.

What would you tell him?What would you tell him?

answeranswer

You did a wonderful job with this but You did a wonderful job with this but we need to increase the goal to we need to increase the goal to 1000.1000.

Try this again and this time hold your Try this again and this time hold your breath for 5-10 secondsbreath for 5-10 seconds

We need to do this for at least 10 We need to do this for at least 10 breathsbreaths

questionquestion

To assess the success of this To assess the success of this patient’s IS treatment, you would patient’s IS treatment, you would want to recommend what actions?want to recommend what actions?

answeranswer

I would compare HR & RR before & after ISI would compare HR & RR before & after IS I would listen to BBS and should hear I would listen to BBS and should hear

increased basal breath sounds and increased basal breath sounds and decrease in crackles after sucessfull deep decrease in crackles after sucessfull deep breathing and coughingbreathing and coughing

Over the next few days:Over the next few days: I would monitor the temperature for I would monitor the temperature for

infection resolutioninfection resolution the X-ray for resolution of atelectasisthe X-ray for resolution of atelectasis

questionquestion

If this patient complains [c/o] pain on If this patient complains [c/o] pain on deep inspiration, what can you deep inspiration, what can you recommend?recommend?

answeranswer

If he complains of pain on deep If he complains of pain on deep inspiration, I would alert the nurse inspiration, I would alert the nurse that he needs pain medication.that he needs pain medication.

If it is an IV, I can try the IS in about If it is an IV, I can try the IS in about 5-10 minutes5-10 minutes

If it is a shot in the arm or buttocks, I If it is a shot in the arm or buttocks, I will have to wait for 30 minuteswill have to wait for 30 minutes

If it is a pill, I will have to wait 30-45 If it is a pill, I will have to wait 30-45 minutesminutes

questionquestion

How would you recognize the How would you recognize the presence of atelectasis in your post-presence of atelectasis in your post-op patient?op patient?

answeranswer On inspection, the increased WOB associated On inspection, the increased WOB associated

with decreased compliance seen with with decreased compliance seen with significant atelectasis would be obvious in significant atelectasis would be obvious in retractions, increased RR and HR and use of retractions, increased RR and HR and use of accessory musclesaccessory muscles

If severe decreased gas diffusion, we might If severe decreased gas diffusion, we might start getting decreased Sp02 & cyanosis from start getting decreased Sp02 & cyanosis from hypoxemic hypoxiahypoxemic hypoxia

On auscultation, we would hear crackles and On auscultation, we would hear crackles and diminished basal breath soundsdiminished basal breath sounds

On palpation we might have poor chest On palpation we might have poor chest excursionexcursion

On percussion there will be dullnessOn percussion there will be dullness

questionquestion

What would you want to recommend What would you want to recommend if the Incentive spirometry seems to if the Incentive spirometry seems to be failing to treat the atelectasis?be failing to treat the atelectasis?

answeranswer

If this patient cannot get an IC of 10 If this patient cannot get an IC of 10 ml/kg, we need to start IPPB at 15 ml/kg, we need to start IPPB at 15 ml/Kg IBWml/Kg IBW

If the patient can get an IC of 10 or If the patient can get an IC of 10 or more but there is documented [X-more but there is documented [X-ray] worsening atelectasis, we need ray] worsening atelectasis, we need to start IPPB at 15 ml/Kg IBWto start IPPB at 15 ml/Kg IBW

End of case studyEnd of case study

questionquestion

You charted the wrong HR after a You charted the wrong HR after a SVN with 2.5 mg Albuterol and 3 ml SVN with 2.5 mg Albuterol and 3 ml of 20% acetylcystiene.of 20% acetylcystiene.

How do you correct this entry? How do you correct this entry?

answeranswer

I would draw a single line through the I would draw a single line through the wrong word and put the correct HR wrong word and put the correct HR just above it. just above it.

Then I would initial and date the Then I would initial and date the error.error.

questionquestion

Why can we not use erasable ink or Why can we not use erasable ink or pencil on charting?pencil on charting?

answeranswer

The chart is a legal document that The chart is a legal document that can be used in court. All entries can be used in court. All entries must must be legiblebe legible even the ones that have even the ones that have been noted as ‘errors.’been noted as ‘errors.’

questionquestion

If your patient had a PEFR that was If your patient had a PEFR that was 300 lpm and his predicted was 600 300 lpm and his predicted was 600 lpm, do you think this patient has a lpm, do you think this patient has a restrictive defect or a obstructive restrictive defect or a obstructive defect?defect?

AnswerAnswer

If your patient had a PEFR that was If your patient had a PEFR that was 300 lpm and his predicted was 600 300 lpm and his predicted was 600 lpm, he has a decreased PERF which lpm, he has a decreased PERF which means he has narrowed airway and means he has narrowed airway and increased RAWincreased RAW

So he has an obstructive defectSo he has an obstructive defect

Case study # 2Case study # 2QuestionQuestion

Your patient is a 45 YO WF whose Your patient is a 45 YO WF whose IBW is 65 kg. She has X-rays w/ IBW is 65 kg. She has X-rays w/ atelectasis in the RML and RLL. atelectasis in the RML and RLL.

She has crackles everywhere and She has crackles everywhere and diminished BS over the RLL.diminished BS over the RLL.

Her RR is 29 bpm and HR is 103 bpm Her RR is 29 bpm and HR is 103 bpm & she has a fever of 103& she has a fever of 103

What do you recommend?What do you recommend?

answeranswer

Incentive spirometer and deep Incentive spirometer and deep breathing can breathing can prevent atelectasisprevent atelectasis, , but once it is severe enough we need but once it is severe enough we need to start IPPB at 15 ml/Kg IBW.to start IPPB at 15 ml/Kg IBW.

If the patient cannot get 10 ml/Kg If the patient cannot get 10 ml/Kg IBW on IS, we need to advance to IBW on IS, we need to advance to IPPBIPPB

QuestionQuestion

You start the IPPB at a rate of 6-8 You start the IPPB at a rate of 6-8 bpm. You see that the manometer bpm. You see that the manometer goes back to -2 then moves up to goes back to -2 then moves up to +12. the inspiratory time is about 3 +12. the inspiratory time is about 3 seconds long.seconds long.

You measure a VT of 500 ml at these You measure a VT of 500 ml at these parameters.parameters.

What do you recommend right now?What do you recommend right now?

AnswerAnswer a rate of 6-8 bpm is OK for IPPB. Too fast a rate of 6-8 bpm is OK for IPPB. Too fast

and we worry about air trapping and and we worry about air trapping and decreasing the Cardiac Out putdecreasing the Cardiac Out put

The sensitivity needs to be set so that the The sensitivity needs to be set so that the patient can trigger the breath by -2 cmH20 patient can trigger the breath by -2 cmH20 or less pressure. This is OKor less pressure. This is OK

An inspiratory time of 3 seconds is too long; An inspiratory time of 3 seconds is too long; increase the flow rate to decrease the increase the flow rate to decrease the inspiratory time.inspiratory time.

a 500 ml is too low [500/65 Kg] or 7.9 ml/Kg a 500 ml is too low [500/65 Kg] or 7.9 ml/Kg IBW…so we need to increase the VT by IBW…so we need to increase the VT by increasing the PIP to get 15 mL /Kg [or 975 increasing the PIP to get 15 mL /Kg [or 975 ml.]ml.]

End of reviewEnd of review