Pathology Review

LindseyJones

Emphysema

Defined: Abnormal condi-tion of the alveoli result-ing destruction and loss of elasticity.

Information Gathering Visual Assessment Cyanosis Barrel chest Accessory muscle use Digital clubbing of the nail beds Significant history of smoking and/or occupational exposure to smoke or other pulmonary irritant Bedside (Patient Contact) Assessment Dyspnea Basic Laboratory Assessment Chest X-ray—increased AP Diameter, flattened diaphragms, hyperlucency, diminished pulmonary markings. CBC—polycythemia, increased WBC due to possible infection. ABGs—Compensated respiratory acidosis (high PaCO2, normal pH), moderate to severe hypoxemia. Sputum culture—often positive for bacteria. Special Assessments PFT—flows are decreased especially middle sized airways (FEF 25-75%) and FEV1

Decision Making Oxygen therapy—low FIO2 (0.24 to 0.28) or 1 to 2 lpm nasal cannula Oxygen conserving devices such as liquid oxygen or trans-tracheal oxygen Home care education on devices and equipment cleaning Rehabilitation efforts (specifics not usually required) Aids to help quit smoking such as nicotine replacement therapy Bronchodilation medication via MDI or aerosol nebulizers

What to expect

You will usually be tempted to utilize high FIO2 because of the severity of the hypoxemia. You may also be tested with an emer-gency, the only time it is appropri-ate to use 100% oxygen on a chronically obstructed patient. There are usually two obstructive simulations on the exam and they are not extremely challenging.

Chronic Bronchitis

Defined: Condition where the patient has a produc-tive cough 25% of the year for at least two con-secutive years

Information Gathering Visual Assessment Productive cough, purulent sputum production Exposure to pulmonary irritants, like history of smoking Frequent infections Bedside (Patient Contact) Assessment Dyspnea Basic Laboratory Assessment Chest X-ray—could be normal, or may show hyperlucency, diminished \ pulmonary markings. CBC—possibly increased WBC due to possible infection. ABGs—could be normal or very slight respiratory acidosis and hypoxemia Special Assessments PFT—flows are decreased especially middle sized airways (FEF 25-75%) and FEV1

Decision Making Anything that promotes good pulmonary hygiene such as chest physiotherapy, hydration therapy when sputum is thick. Fluid therapy if dehydrated. Oxygen therapy for hypoxemia Aerosolized bronchodilator therapy

What to expect The most distinguishing charac-

teristic is that the cough is produc-tive and has been so for a good

portion of the year.

Bronchiectasis

Defined: Abnormal condi-tion where the bronchi secrete large volumes of pus during abnormal dila-tion

Information Gathering Visual Assessment Productive cough, often with blood Digital clubbing of the nail beds Significant history if infections (recurrent) Bedside (Patient Contact) Assessment Dyspnea Basic Laboratory Assessment Chest X-ray—generally normal Sputum culture—gram negative bacteria Special Assessments Bronchogram is the primary test. Characterized as a “tree in winter pattern”

Decision Making Anything that promotes good pulmonary hygiene such as chest physiotherapy, hydration therapy when sputum is thick. Fluid therapy if dehydrated. Oxygen therapy for hypoxemia Aerosolized bronchodilator therapy May have consider surgical intervention on some highly affected segments

What to expect

Central to this is the Bronchogram diagnostic test. Usually, you will be told of the suspicion of Bron-chiectasis. Increasingly less common on the test

Sleep Apnea Syndrome

Defined: the cessation of breathing during sleep. Is usually obstructive in nature but sometimes can be central or a com-bination of the two (mixed).

Information Gathering Visual Assessment Spouse or bed partner will complain of snoring and will often report witnessing periods of apnea that exceed 10 seconds. Excessive upper airway tissue, obesity, thick neck Ability to fall asleep quickly Bedside (Patient Contact) Assessment Dyspnea Frequent urination during sleeping hours Basic Laboratory Assessment ABGs—could be normal or very slight respiratory acidosis and hypoxemia Special Assessments Polysomnography (Sleep study) - determines if obstructive or central

Decision Making If central, ventilatory stimulant medication may be used If obstructive, use of CPAP or BiPAP is usually initially indicated with follow-up weight loss or upper airway tissue removal through surgery. Problem must be corrected immediately, so even if discharging, send devices home with patient. In the absence of a titration study, initially ordered pressure should be 10 to 20 cm H20.

What to expect This is still somewhat rare on the

test but it does show up.

It is important to remember to avoid sending the patient home

without some sort of ventilatory support.

Asthma

Defined: Abnormal con-striction of the bronchials resulting in sputum pro-duction and narrowed airways.

Information Gathering Visual Assessment Accessory muscle use Tachycardia Bedside (Patient Contact) Assessment Dyspnea Wheezing Congested cough Wet, clammy skin Basic Laboratory Assessment ABGs—possible respiratory acidosis, could be hypoxic Chest X-ray—hyperinflation, scattered infiltrates, flattened diaphragms. Special Assessments PFT—Decreased flows in FEV1 but diffusion is normal as manifested by DLCO

Decision Making Oxygen therapy for hypoxemia Aerosolized bronchodilator therapy Xanthine medication given IV (Aminophylline, etc) Promote pulmonary hygiene

What to expect

When doing PFTs, always do a pre and post bronchodilator study. Consider effective if 15% or more improvement is noted. There are no significant traps in this simulation except that the patient may be unresponsive to bronchodilators. In such a case, you are dealing with Status Asth-maticus. Refer to that disease

Status Asthmaticus

Defined: Asthma that will not respond to bron-chodilation therapy, usu-ally persists more than 24 hours.

Information Gathering Visual Assessment Historically non-responsive to bronchodilators. Patient will report the need to take many bronchodilator treatments before feeling better. Accessory muscle use and retractions Dyspnea Wheezing Congested cough Wet, clammy skin Bedside (Patient Contact) Assessment Pulses paradoxus Basic Laboratory Assessment ABGs—possible respiratory acidosis when tiring, alkalosis at first due to anxiety, could be hypoxic Chest X-ray—hyperinflation, scattered infiltrates, flattened diaphragms. Special Assessments

Decision Making May deteriorate quickly, so if progression is shown, intubate, mechanically ventilate be-fore full ventilatory failure. Use subcutaneous epinephrine—1 mL of 1:1000 strength. May need to give every 20 minutes for up to three consecutive doses

What to expect This simulation will challenge

your ability to recognize impend-ing ventilatory failure. It is very important that you treat it before

full ventilatory failure.

There is a frequent need to repeat actions in this simulation which

will make you uncomfortable. Do not be afraid to administer several

bronchodilators in succession. The same is true of the subcutane-

ous epinephrine. If you give one dose, you will likely have to give

another, and possibly another. Continue if symptoms show no

signs of relief.

Myasthenia Gravis

Defined: Neuromuscular abnormality where mus-cles experience paralysis starting from the head down to the feet includ-ing ventilatory muscles.

Information Gathering Visual Assessment May have a history of Myasthenia Gravis if not the onset Droopy facial muscles and eyelids (Ptosis) Bedside (Patient Contact) Assessment Patient will describe slowly feeling weakness generally but feels better with rest. Double vision (diplopia) Dysphagia (difficulty swallowing) Shrinking Vt, VC, MIP Basic Laboratory Assessment Special Assessments Tensilon Challenge Test—positive for Myasthenic crisis if improvement is noted upon the administration of Tensilon

Decision Making If Tensilon improves condition then, anticholinesterase therapy is indicated including: Neostigmine (prostigmine) Mestinon (pyridostigmine) Ok to do additional Tensilon challenge test to observe progression. If symptoms improve with Tensilon and then worsen, the must reverse the anticholinesterase with Atropine. Always monitor spontaneous ventilatory volumes (Vt and VC) as well as MIP. Never treat Myasthenia gravis with Tensilon—only use to diagnose. Use the above men-tioned drugs to provide maintenance. Be totally prepared to intubate and mechanically ventilate prior to Tensilon challenge since it could take out the respiratory drive When VC falls off rapidly (especially if below 1.0 L) , then intubate and mechanically venti-late.

What to expect

This can be a very tricky simula-tion and it is likely that it will show up on the exam. Especially important is your use of Tensilon to diagnose it and an understand-ing of the dangerous affects it could have. Must always be pre-pared to assume ventilation. Vt, VC, and MIP are key in moni-toring this patient for degradation in ventilatory status. Intubate prior to full failure if possible.

Drug Overdose

Defined: Potential loss of ventilatory drive as a re-sult of drug overdose (usually a narcotic)

Information Gathering Visual Assessment Historical drug use as told by previous admissions or family Sometimes poor self-hygiene, emaciated Bedside (Patient Contact) Assessment Look and act sleepy, difficult to arouse Respiratory rate and pattern is low and/or shallow Basic Laboratory Assessment ABG—often show pure respiratory acidosis and/or ventilatory failure Special Assessments

Decision Making #1 priority in this case is intubation to protect the airway, prevent aspiration of stomach contents, and facilitate manual ventilation. If narcotic overdose (usually is) then use narcotic reversing medication such a Narcan (Nalaxon) Support ventilation until drugs are out of system.

What to expect The most important part of this

simulation is the need for immedi-ate intubation while recognizing

that there may not be a need to mechanically ventilate until venti-

latory status deteriorates.

Other Neuromuscular

Defined: Other neuro-muscular diseases or states include Poliomyeli-tis, Tetanus, Muscular dystrophy, and even botulism poisoning.

Information Gathering Visual Assessment History of illness Bedside (Patient Contact) Assessment Shrinking Vt, VC, MIP Basic Laboratory Assessment Special Assessments

Decision Making Monitor for ventilatory failure generally through Vt, VC, MIP and ABGs

What to expect

If faced with these diseases, sim-ply apply general respiratory monitoring principles and facili-tate ventilation when needed. These are somewhat rare.

Head Trauma

Defined: Potential loss of ventilatory drive as a re-sult of drug overdose (usually a narcotic)

Information Gathering Visual Assessment Sometimes trauma is visual with blood contusions on the head History is trauma related, often automobile accident Bedside (Patient Contact) Assessment Look and act sleepy, difficult to arouse Respiratory rate and pattern is low and/or shallow and irregular Pupillary response to light may be unequal or inadequate Basic Laboratory Assessment Special Assessments If intracranial pressure monitor is in place, may see ICP greater than 20 cm H2O

Decision Making Must constrict vessels in the head by keeping PaCO2 between 25-30 mm Hg. Adjust FIO2 to maintain high normal levels (PaO2 of 100 mm Hg). Avoid increased ICP by minimizing PEEP usage. Suction only when needed due to elevating peak pressures. Avoid anything that will increase mean arterial pressure (MAP). Sedation is important, but should monitor exhaled volumes and pressures closely Use of drugs such as Manitol (cerebral diuretic medication) when ICP is above 20 cm H20 Use Dilantin and establish an airway if seizure activity is observed

What to expect Unique to this simulation is the

need to monitor ICP readings and avoid anything that increases

MAP. You will likely need to suction this patient to keep peak

pressures down but the very act of doing so my elevate ICPs.

Chest Trauma

Defined: May any trauma leading to fractured ribs or flail chest

Information Gathering Visual Assessment Circumstantial history (motor vehicle accident, etc) Respiratory rate and pattern is fast and shallow due to pain May have obvious trauma (bruising) on chest wall Bedside (Patient Contact) Assessment Sharp chest pain, especially at the top of each breath Paradoxical chest movement if ribs are broken in two places (flail chest) Pneumothorax is possible (see signs and symptoms of pneumothorax) Basic Laboratory Assessment Chest x-ray—may reveal broken ribs, usually isolated in same area Special Assessments

Decision Making Anything that encourages deep (adequate) breathing in spite of pain such as IPPB, incentive spirometry, coughing. Watch for ventilatory fatigue and eventual ventilatory failure Mechanically support ventilation when it is evident ventilatory failure is impending. If possi-ble do not wait until full ventilatory failure. Treat partial pneumothorax if greater than 20% - ie insert chest tubes Treat hemothorax, with chest tubes or thoracentesis Treat tension pneumothorax with a large-bore needle

What to expect

This case is usually easy to recog-nize. You may be tempted by options that address the broken ribs when, in fact, you simply need to address ventilation. Very commonly, this case will lead to pneumothorax or partial pneumothorax or hemothorax.

Hemothorax/Pneumothorax

Defined: Loss of adher-ence of the lung to the pleural wall causing the space to be filled with air or fluid (bloody).

Information Gathering Visual Assessment Rapid and shallow respirations Bedside (Patient Contact) Assessment Percussion: hyperresonant if pneumothorax, dull if hemothorax Tracheal shift: to affected side if pneumothorax, away if tension pneumothorax Severe dyspnea Very diminished or absent breath sounds Pulses paradoxes Basic Laboratory Assessment Chest x-ray—definitive—show hyperlucency, tracheal or mediastinal shift Special Assessments

Decision Making Usual treatment is insertion of chest tubes Treat partial pneumothorax if greater than 20% - ie insert chest tubes Treat hemothorax, with chest tubes or thoracentesis Treat tension pneumothorax with a large-bore needle

What to expect Pneumothorax, hemothorax, ten-

sion pneumothorax occurs very frequently on the exam

May include the troubleshooting

of chest tube drainage devices

Thoracic Surgery

Defined: Can have vari-ety of complications from throacic surgery

Information Gathering Visual Assessment Bedside (Patient Contact) Assessment Always monitoring chest tube drainage adequacy Looking for potential complications: Hypovolemic shock, low hemodynamic values including blood pressure Subcutaneous emphysema Elevated ventilatory pressures Basic Laboratory Assessment Chest x-ray—to confirm proper re-inflation of the lung and proper placement of chest tubes Special Assessments

Decision Making Anything that promotes expansion of the lungs including incentive spirometry, IPPB, and positive pressure mechanical ventilation If a lobectomy or pneumonectomy, ventilatory volumes should set lower Fluid therapy if volume is a problem (often is).

What to expect

Your ability to deal with and trou-bleshoot chest tube maintenance is tested in this simulation. Sometimes this case is combined with chest trauma.

Neck/Spinal Injury

Defined: Any trauma threatening the physical structure of the neck. Can include neck or spi-nal surgery.

Information Gathering Visual Assessment Historical relevance, some sort of accident such as diving, automobile. Visible damage to the neck Altered conscious level Pulse must be palpated brachially or femorally Bedside (Patient Contact) Assessment Vt, VC, PEFR, and other ventilatory volumes may quickly deteriorate Basic Laboratory Assessment Neck x-ray—will show injury Special Assessments

Decision Making Always be prepared to quickly assist and/or promote ventilation. If intubation is required, always use MODIFIED jaw thrust. If given option, always intubate with a bronchoscope so damage can be visualized and care can be taken to avoid inflicting further damage. Alternatively, a blind nasal intubation is acceptable.

What to expect Your knowledge of special intuba-

tion techniques is what is being tested in this type of simulation.

Abdominal Surgery

Defined: Surgery of in the abdominal area for various reasons.

Information Gathering Visual Assessment All general visual assessments Bedside (Patient Contact) Assessment All general beside assessment including all vitals Basic Laboratory Assessment Ventilatory volumes (VC, Vt, FEV1) compared to pre-surgery baselines Special Assessments

Decision Making Establishing baselines in pulmonary function testing flows and volumes. Start patient on incentive spirometry prior to surgery, every hour after surgery Use positive pressure (IPPB) if needed after surgery if patient is unconscious.

What to expect

Abdominal surgery is usually a very general, non-complicated case involving preventative care and follow up.

Adult Respiratory Distress Syndrome

Defined: A condition that results in significantly decrease lung compli-ance and consequent profound hypoxemia

Information Gathering Visual Assessment Record may show a variety of insults to the lung including massive surgery, near drowning, inhalation of gasoline, hypothermia, and others. Rapid respiratory rate Cyanosis Bedside (Patient Contact) Assessment Decreased lung compliance as manifested by increased plateau pressures (decreasing static compliance) Basic Laboratory Assessment ABGs—persistent hypoxemia in spite of elevated FIO2 (may be refractory) Chest x-ray—show granular, or ground glass, or reticulogranular, or honeycomb patterns. Often accompanied by diffuse infiltrates. Special Assessments All hemodynamic values could deteriorate when positive ventilatory pressures become significant.

Decision Making As positive pressure is required increasingly, negative effects may be seen. All should be done to minimize the mean pressure being put on the pulmonary system, while trying to balance the need to ventilate with higher pressures an utilize PEEP to maintain oxygena-tion. If underlying cause in know, treat it. After emergency situation is past, keep FIO2 at 0.6 and use PEEP Keep increasing PEEP until an obvious degradation in hemodynamic values is witnessed. As ventilatory pressure get higher, OK to consider alternate methods of ventilation includ-ing pressure control, high frequency, etc

What to expect ARDS can be a very disquieting

case to deal with. Usually persis-tent increases in PEEP are needed. Do not be afraid to increase PEEP

significantly.

Also, most often, cardiac output or some other hemodynamic value

will fall indicating a need to de-crease PEEP in spite of profound

hypoxemia.

Laryngectomy

Defined: Surgery done to address or remove can-cer of the larynx.

Information Gathering Visual Assessment Surgical record : Surgery radical (entire larynx) or simple (cord removal) Medical history will show cancer in upper airway Bedside (Patient Contact) Assessment Signs of airway obstruction after surgery. Usually caused by blood within a few hours after the surgery. Basic Laboratory Assessment Special Assessments

Decision Making If radical surgery (entire larynx removed) then the tracheostomy become permanent. If not radical then a temporary laryngectomy tube is placed but must be replaced in 3 to 6 weeks. Prevent aspiration ! Wait at least a week before oral ingestion of liquid and longer for food. Thorough pulmonary hygiene through suctioning Use cool aerosol or ultrasonic nebulizer to keep secretions thin and hydrated. Once the surgery is done, you can no longer, orally intubate the patient. Even if temporary laryngectomy tube is in place, you must intubate and/or ventilate through that tube !

What to expect

In this case, you are always look-ing for post-surgical complica-tions like blood clots in the laryn-geal tube. Often, you will have to mechanically ventilate this patient through the laryngectomy tube.

Guillain-Barre’ Syndrome

Defined: An insidious neuromuscular problem involving muscle paraly-sis. Paralysis begins in the lower extremities and moves upward, including the ventilatory muscles.

Information Gathering Visual Assessment Medical history or patient complaint of recent fluenza-type sickness. Bedside (Patient Contact) Assessment Complaint of sluggish lower extremities Shrinking Vt, VC, MIP Basic Laboratory Assessment ABGs—impending or current ventilatory failure. Special Assessments Spinal tap—will show increased protein in the spinal fluid

Decision Making Be primarily concerned with loss of ventilation, monitor ventilatory volumes (VC, Vt) and MIP. Be patient about intubation and mechanical ventilation. Onset can be slow. Primary treatment will involve mechanical ventilation and letting the syndrome run its course.

What to expect Like most neuromuscular cases, you will be tested in your ability

to recognize deterioration in venti-latory muscles. In this case, onset

can be slow, so don’t jump-the-gun and mechanically ventilate

too early. Only do so as VC falls below 1.0 L.

Otherwise, you will be manipulat-

ing the ventilator and possibly weaning.

Shock

Defined: Condition where tissues oxygenation is in jeopardy due to a sudden decrease in blood flow.

Information Gathering Visual Assessment Historical evidence of an event or massive trauma or hypothermia, etc General appearance—cold, clammy, dusky, cyanotic Tachycardia, tachypnea Bedside (Patient Contact) Assessment Hypotensive Temperature may be below normal Reduction in urine output Basic Laboratory Assessment ABGs—hypoxemia and ventilatory failure Special Assessments Reduction in common hemodynamic values (CVP, PAP, PCWP) and cardiac output.

Decision Making Mechanically ventilate with ventilatory failure. Oxygen is key. Start it as evidence of shock is presented. Use oxygen at least 40% but may use up to 100% Main treatment involved treating the original problem (that which caused the shock). This can be highly variable.

What to expect

Shock will test your ability to recognize it and monitor the pa-tient for ventilatory failure. Most of the simulation is dealing with typical ventilatory considerations such as ventilator manipulation.

Heart Surgery

Defined: Any kind of sur-gery on the heart Information Gathering

Visual Assessment Do well rounded assessment prior to surgery including vital signs, family history of cardiac illness. Bedside (Patient Contact) Assessment Preoperative assessments of breath sounds Baseline data including basic spirometry of all types including FEV1/FVC and pre and post bronchodilator studies Basic Laboratory Assessment ABGs—preoperative for baseline Special Assessments

Decision Making Always assess ventilatory volumes and be prepared to mechanically ventilate Incentive spirometry every hour after surgery for lung expansion and alveolar ventilation. If unable (unconscious) use simple ventilatory assisting devices such as IPPB or CPAP with mask. Be on the alert for cardiac arrest—perform CPR without reservation or consideration of the heart surgery.

What to expect This case is not too complicated. You may feel hesitant to do CPR on someone fresh out of surgery.

Just do it.

Pulmonary Edema / CHF

Defined: Significant re-duction in cardiac output. Involvement of fluid penetrating the alveolar capillary membrane into the lungs.

Information Gathering Visual Assessment History of CHF or pulmonary hypertension Tachypnea, tachycardia, anxiety Bedside (Patient Contact) Assessment Cold, clammy, diaphoretic Pink frothy secretions Edema of fluids (especially pedal edema) Pitting edema (+2, +3) Breath sounds reveal fine, wet rales Basic Laboratory Assessment ABGs—ventilatory failure with moderate to severe hypoxemia Chest X-ray—Butterfly pattern, fluffy infiltrates Special Assessments Increased hemodynamic pressure (PCWP, PAP, CVP)

Decision Making Treat as an emergency ! 100% oxygen Administer diuretic medication furosemide (Lasix) Cardiac intatropic stimulating drugs such as digoxin, digitalis if increased PCWP and PAP Be prepared to treat ventilatory failure with mechanical ventilation

What to expect

This case may feel complicated because it involves the heart and hemodynamic values. It is usually easily identified by pink frothy secretions and butterfly pattern on the chest X-ray. You may need to make the dis-tinction between pulmonary edema caused by cardiac prob-lems and that which is caused by alveolar capillary membrane prob-lems (ARDS). If it is cardiac, then you must treat the heart.

Myocardial Infarction/Arrhythmia

Defined: Ischemia to the heart causing muscle damage and potential failure.

Information Gathering Visual Assessment History of chest pain, radiating pain down the left arm Family history of disease Diaphoretic History of nausea Tachycardia Bedside (Patient Contact) Assessment Cold and clammy to the touch Dyspnea Basic Laboratory Assessment ABGs—hypoxemia ECG (EKG) - pronounced Q waves and S-T segment elevation Special Assessments Cardiac enzymes including CPK, LDH, SGOT are elevated

Decision Making Not necessarily an emergency. Oxygen at adult therapeutic level (40 to 60 %) upon suspicion or first presentation so signs and/or symptoms Treat arrhythmias Bradycardia with Atropine or Isuprel PVCs with lidocaine or oxygen Pulseless ventricular tachycardia with defibrillation Ventricular Fibrillation with defibrillation Note: For Ventricular fibrillation, defibrillate at ascending watt/sec or joule settings 200 — 300 — 360 joules Do not exceed 360 joules Note: For Atrial fibrillation or flutter, do synchronized cardioversion—start at 50 joules

What to expect Will likely need to treat arrhyth-

mias with appropriate medication and/or defibrillation

Pulmonary Emboli

Defined: Situation where the pulmonary artery be-comes obstructed and dead-space ventilation results. Sometimes called deadspace dis-ease.

Information Gathering Visual Assessment History of recent major surgery or trauma (amputations, clotted massive bleeding sights) Complaint of chest pain and dyspnea Bedside (Patient Contact) Assessment Elevated vitals including pulse, respirations, and blood pressure Breath sounds - wheezing and medium rales PECO2 (Capnography) decreasing PECO2 during normal PaCO2 Basic Laboratory Assessment ABGs—persistent hypoxemia in spite of increasing FIO2 Special Assessments V/Q scan will ventilation without adequate perfusion

Decision Making Anticoagulation therapy with Heparin or Coumadin Note: must monitor clotting tests PTT for Heparin PT for Coumadin Mechanical ventilation as needed. Therapeutic oxygen at 40 to 60%

What to expect

This case primarily involves rec-ognizing the pulmonary emboli and treating it with anticoagula-tion medications. You will likely have to monitor clotting times, PTT or PT. Otherwise, involves general respi-ratory therapy.

Newborn Assessment

Defined: Involves deliv-ery of an infant is compli-cated by various prob-lems

Information Gathering Newborn Assessment APGAR 2 points 1 point 0 points Color pink pink body blue or pale blue extremities all over Pulse above 100 below 100 none Reflex irritability cough or facial grimace none (Grimace) sneeze Activity active some flexion limp or no (flexion) movement of limbs movement Respiratory effort strong cry weak cry no cry History If poor APGAR, may be pre-term, congenital heart problem, meconium aspiration IRDS, transient tachypnea Other helpful assessments Gestational age Weight

Decision Making If APGAR Score is: 0 to 3 PERFORM CPR 4 to 6 Administer oxygen, place infant in warm, neutrally thermal environment, generally stimulate the baby 7 to 10 Monitor normally

What to expect Will commonly have to do an

APGAR score. You may have to pick the 5 essential elements from

a list. Don’t be tempted by any tests other than APGAR criteria

unless they can be done by simply looking at the infant.

Or, you may be given the ele-

ments and asked what you want to do about it.

Meconium Aspiration

Defined: Infant born hav-ing meconium in ventila-tion spaces

Information Gathering Visual Assessment History of meconium-colored amniotic fluid Often with full-term infants Infant may have meconium staining about the body May demonstrate grunting, retractions, nasal flaring Poor color (cyanosis) Bedside (Patient Contact) Assessment APGAR score between 0 and 6 Basic Laboratory Assessment ABGs—hypoxemia with respiratory acidosis, metabolic acidosis or mixed Chest X-ray—Bilateral densities and widespread atelectasis Special Assessments

Decision Making Remove the meconium from the airway. If possible, suction the baby as soon as the head appears from the birth canal. Intubate to facilitate suctioning Reintubate if tube becomes clogged for any reason Mobilize secretions with chest physiotherapy. Mechanically ventilate only if needed Apply supplemental oxygen as needed.

What to expect

This is a very common case on the test. It is fairly straight-forward and easily recognized. The key to this is repeated suctioning and clearing of the airway.

Sudden Infant Distress Syndrome

Defined: Sudden apnea occurring in newborn in-fants as a results of an immaturity central con-trol of ventilation.

Information Gathering Visual Assessment History of pre-term birth Family genetic predisposition Observed, irregular respirations, bradycardia may increase risk of SIDS Bedside (Patient Contact) Assessment Cold air on infant’s face may induce apnea Diminished or absent Moro and Babinski reflexes Basic Laboratory Assessment Special Assessments

Decision Making Provide oxygen when in crisis (30 and 50%) Do not send infant home without an apnea monitor and parental education If offered, teach parents CPR.

What to expect Somewhat rare case on the test.

Nothing particularly challenging.

Infant Respiratory Distress Syndrome

Defined: Condition in in-fants where alveolus ma-turity is below normal.

Information Gathering Visual Assessment History may show pre-term infant Onset can be immediately after birth or within a few hours General respiratory distress, ie grunting, nasal flaring, retractions Cyanosis Bedside (Patient Contact) Assessment APGAR score between 0 and 6 Basic Laboratory Assessment Chest-Xray—radiological description such as ground glass, honeycomb, reticulogranular ABGs—persistent hypoxemia in spite of elevated FIO2 Special Assessments L/S ratio—2:1 or higher is normal. Less than that shows lung immaturity

Decision Making Help lung maturity through surfactant therapy with agents like Exosurf or Survanta 2 to 5 ml/kg split among 2 to 4 doses Administer directly down the airway Change infant’s position after every dose for 30 seconds to distribute the agent Provide oxygen via a hood. May use CPAP to oxygenate Mechanically ventilate with ventilatory failure, use SIMV mode on all infants. May consider reverse I:E ratio Note: If X-ray changes from signs of IRDS to hyperinflation and fibrosis, then the problem may have developed into Bronchopulmonary Dysplasia. Treat as prolonged IRDS by: • maintaining pH of 7.25 to 7.40, PaCO2 45 to 60 torr, PaO2 55 to 70 torr. • Use low FIO2 • Keep mean airway pressure at a minimum • Wean only gradually and as tolerated, often fails initial attempts • Extubate if respiratory rates are between 5 and 15 breaths

What to expect

This is a common case on the test. Key is remembering to address lung maturity. Also, if prolonged ventilation is required, Bronchopulmonary Dys-plasia may develop. Be patient and treat moment to moment.

Congenital Heart Defects (Infant)

Defined: Infant is born with an anatomical mal-ady of the heart or the vessels that emanate from the heart.

Information Gathering Visual Assessment History of pre-term birth General signs of respiratory distress (grunting, nasal flaring, retractions) Cyanosis that persists in spite of high FIO2 Bedside (Patient Contact) Assessment Heart sounds are abnormal upon auscultation (murmur present) Special Assessments Echocardiogram is the best diagnostic test for all cardiac defects

Decision Making Specific Defect Attributes Coarctation of the Aorta (narrowing of aorta) Hypertension in the upper extremities, hypotension in lower extremities Transposition of the Great Vessels Aorta and pulmonary artery are switched. “Aorta rising from the right heart, pulmonary artery rising from the left heart” Patent Ductus Arteriosis (ductus arteriosis never closes) Diagnosed by comparing blood gases from the radial artery and the umbilical artery. Positive for PDA if difference is greater than 15 torr. (PDA with a right to left shunt) Other Problems Tetralogy of Fallot Atrial septal defect (ASD) Ventricular septal defect (VSD) Truncus arteriosis (pulmonary artery same as aorta—combined vessel) ALL CONGENITAL DEFECTS ARE TREATED WITH SURGERY !! Prior to surgery simply provide supportive care such as: oxygen to keep PaO2 > 60 mm Hg. mechanical ventilation when ventilatory failure is shown by ABGs

What to expect Your skills in recognizing com-mon congenital heart problems

will be tested.

Otherwise, you will be simply providing supportive care until

surgery.

Neonatal Diaphragmatic Hernia

Defined: Condition where the diaphragm never grows closed. Usually occurs on the left side

Information Gathering Visual Assessment General respiratory distress, ie grunting, nasal flaring, retractions Cyanosis Barrel chest or scaphoid abdomen Bedside (Patient Contact) Assessment Breath sounds absent (usually on left) Basic Laboratory Assessment Chest-Xray—show intestinal parts in the chest area. Also may see a mediastinal shift away from the affected side. ABGs—Poor Special Assessments

Decision Making TREATMENT IS SURGERY Use low ventilatory pressures Do not use manual bag and resuscitation if possible May use gastric tube to decompress stomach and intestines. All other care is supportive

What to expect

This case is more about what you should not do. Otherwise use general supportive care.

Laryngotracheobronchitis

Defined: Otherwise known as Croup. Results from a viral infection that illicits inflammation in the upper airway.

Information Gathering Visual Assessment History of cold in the past few days Barking cough Age is 6 months to 3 years Stridor Tachypnea Bedside (Patient Contact) Assessment Special Assessments Lateral Neck X-ray—swelling below the glottis sometimes described as steeple sign or pencil point.

Decision Making Priority—placement in an oxygen tent with 30 to 40% Aerosolized Racemic Epinephrine Intubation if patient is described as lethargic, markedly diminished breath sounds, severe or marked stridor, extreme accessory muscle use Extubation should be done when swelling has ceased.

What to expect You will likely be tempted to treat

this like Acute Epiglottitis in an emergency fashion.

Repeated racemic epinephrine treatments may make you feel

uncomfortable

Acute Epiglottitis

Defined: Condition where the epiglottis and adja-cent upper airway tissues are infected with a bacte-ria causing inflammation and commonly threaten-ing airway patency.

Information Gathering Visual Assessment Sudden onset of sickness, within 12 hours, often occurs in the evening Age 3 to 10 years General appearance may show drooling, hoarseness, quiet cough May hear a softened inspiratory stridor Tachypnea and tachycardia Bedside (Patient Contact) Assessment Patient unable to swallow, will usually not be crying, eyes are big Significantly elevated body temperature, taken axillary, or tympanically Basic Laboratory Assessment Special Assessments Lateral neck x-ray will show supraglottic inflammation

Decision Making Primary and immediate concern is establishing and airway as complete closure from inflam-mation. Since inadvertent stimulation from oral intubation attempts could immediately illicit an inflammatory response, intubating in a surgical environment is very helpful. There may be need to place a tracheostomy tube. Antibiotic therapy to correct bacterial infection Oxygen therapy at 30 to 40% Extubate only when inflammation is gone

What to expect

This case will test your immedi-ately ability to realize that it is an emergency. Stridor may tempt you to treat it more casually like croup. There is a good chance you will see Epiglottitis or Croup on the test.

Bronchiolitis /RSV

Defined: Acute vital in-fection of lower respira-tory tract usually occur-ring in infants less than 18 months old. Com-monly caused by the res-piratory syncytial virus.

Information Gathering Visual Assessment General signs of respiratory distress including retractions and accessory muscle use. Tachypnea and tachycardia History of recent sickness from ages 2 months to 3 years old Bedside (Patient Contact) Assessment Low grade fever Wheezing, rales, and rhonchi Basic Laboratory Assessment Chest X-ray show scattered infiltrates and hyperlucency

Decision Making Primary treatment is delivery of the drug Ribavirin which must be administered via a SPAG unit (small volume particle aerosol). Utilize a scavenger system, filters, and masks.

What to expect There is nothing particularly diffi-cult about this case. You must be prepared to recommend the use of

a SPAG unit.

Not commonly seen on the exam.

Cystic Fibrosis

Defined: An inherited disorder resulting in the mass production of thick mucus in the lungs.

Information Gathering Visual Assessment Family history of disease, siblings may have it. Emaciated in appearance and body frame may be small or age Sputum production of thick voluminous purulent secretions Can look like a young COPD patient, barrel-chested Bedside (Patient Contact) Assessment Decreased flow rates such as FEV1 Basic Laboratory Assessment Chest X-ray—looks like COPD, hyperinflation, increased A-P diameter, diaphragm flattening Special Assessments Sweat Chloride Test—show sweat chloride > 60 mEq/L

Decision Making Primary treatment relates to the need to mobilize and remove secretions. Secretion removal promotion therapies: PEP therapy devices Chest physiotherapy with postural drainage Hydration devices such as heated aerosol or ultrasonic nebulization Vibration therapy Oxygen as needed Antibiotic therapy when infection is present—often is Medications used commonly include Tobramycin and Pulmozyme

What to expect

Not commonly seen on the exam. Tests your ability to recognize secretion removal therapies and may check your understanding when and how to modify therapy. Ex, when CPT doesn’t work, use PEP therapy or ultrasonic nebuli-zation.

Hypothermia

Defined: Exposure to cold such that body tem-perature falls signifi-cantly.

Information Gathering Visual Assessment History of exposure to cold. May be seen in homeless persons. Lethargy and unconsciousness Bradycardia, bradypnea Bedside (Patient Contact) Assessment Body temperature less than 36 deg C Basic Laboratory Assessment Special Assessments

Decision Making Oxygen via a heated aerosol at 40 to 100% Keep resuscitation efforts going until body temperature is normal. Mechanically ventilate as needed. Keep in mind that blood gas values may be altered because of the difference in blood tem-perature and analyzed temperature. Watch out of oxygen (PaO2). In cold, uncorrected blood, PaO2 may appear higher than it actually is.

What to expect Not very common. However

when seen, may be seen in con-junction with other problems such

as AIDS, or tuberculosis.

Burn Trauma/CO Poisoning

Defined: Results from direct exposure to fire and or smoke. Directly threatens airway and oxygen carrying capacity of the blood.

Information Gathering Visual Assessment Diagnosis is based largely on history—exposure to fire or smoke. Often occurs in occupational related cases (fire fighter) Visible burns about the body and face Singed nasal and or eyebrow hairs “Cherry-red” color of face with CO poisoning Patient is often confused or unresponsive Stridor, hoarseness Bedside (Patient Contact) Assessment Breath sounds—wheezing, rhonchi, rales Basic Laboratory Assessment ABGs—initially decreased PaCO2, normal PaO2, decreased saturation. Latter may develop into respiratory acidosis Chest X-ray—may be clear at first, but later may show pulmonary edema and markedly decreased lung compliance Special Assessments COHb– 20% or more

Decision Making Protect airway by establishing an artificial airway immediately. Particularly if there is respi-ratory distress and there are burns about the face. For CO poisoning—start 100% oxygen immediately— even if only suspect it—do not wait for COHb results Continue oxygen therapy until COHb level is below 10%.—may use hyperbaric medicine if offered—often will not be offered. Practice Reverse isolation (protect the patient from staff) Mechanically ventilate as needed.

What to expect

Fairly common case on the test. Remember to focus on the airway and on oxygen carrying capacity of the blood. Remember to em-ploy isolation techniques. Other-wise, provide general respiratory therapy.

Diabetes

Defined: Condition re-lated to failure of the re-nal system resulting in the inability to dispose of CO2. Respiratory result is often respiratory keto-acidosis

Information Gathering Visual Assessment History of diabetes Lethargy, confusion, unresponsiveness Respiratory rate and pattern—significant in depth and rate with an irregular rhythm (Kussmaul’s) Bedside (Patient Contact) Assessment Pedal Edema Basic Laboratory Assessment ABGs—Profound metabolic acidosis Urine output is markedly decreased (less than 20 ml per hour) Special Assessments Blood glucose - > 160 mg (Normal 80-120 mg)

Decision Making Must watch for ventilatory failure from prolonged ventilatory effort and fatigue. Administer electrolytes (K+, Na+, HCO3-, Cl-) as needed. Provide fluid as needed. Correct ketoacidosis.

What to expect May be tempted by profoundly

acidodic pH. Only determine respiratory failure through the CO2, or a sudden decrease in

ventilatory volumes and breathing rate.

AIDS

Defined: Disease of the immune system com-monly resulting in pneu-mocystis carinii, a type of pneumonia

Information Gathering Visual Assessment Previous history of HIV positive test results Emaciation, unexplained weight-loss, diarrhea, low-grade fevers, night sweats, Commonly homosexual activity or drug usage is admitted Bedside (Patient Contact) Assessment Basic Laboratory Assessment Special Assessments Positive HTLV III ELISA test— positive for HIV Bronchoscopy—from lung washings or biopsy may show pneumocystis carinii

Decision Making Exercise Universal Precautions Aerosolized Pentamadine—usually done monthly When administering Pentamadine, use one-way valves and filters.

What to expect

Increasing in frequency on the exam. Sometimes is combined with tuberculosis, hypothermia, and others. Suspect them all.

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Copyright © 2003 LindseyJones Publishing. All Rights reserved. The enclosed material is intended to facilitate preparation for the associated credentialing exam. The information is not intended to direct healthcare practitioners on methods of practice.