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You may take breathing for granted,thinking that it is just an involuntaryreflex action. But for the millions of peoplewho suffer from respiratory diseases, each
breath is a major accomplishment. Thosepeople include patients with chronic lungproblems, such as asthma, bronchitis, andemphysema, but they also include heart
attack and accident victims, prematureinfants, and people with cystic fibrosis,lung cancer, or AIDS.
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Submitted by:Julie AlmarezGemma BobisAiro De LaraTeri Samantha FloresInna MagistradoKarla RamirezWilbert SamonteMonica Singh
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The human respiratory system not only providesoxygen to each cell of the body but also removesbody wastes, filters out infectious agents, andprovides air needed for speech. Although the
lungs are able to with stand abuse in the form ofsmoke and other pollutants, a number ofdisorders impair its function. Some of thesemaladies are temporary and relatively harmless;
others may be life-threatening. Any chronicbreathing problem or other cough should bechecked promptly. Take care of your lungsand they will take care of you.
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Worldwide, between 80,000 and 100,000kids start smoking every day.Every year, more than 400,000 die of lungdisease.
Lung disease is the number three killer,responsible for one in six deaths.More than 35 million people are now living
with chronic lung disease.
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Name the organs forming the respiratorypassageway from the nasal cavity to thealveoli of the lungs (or identify them on a
diagram or model), and describe thefunction of each.
Describe several protective mechanisms ofthe respiratory system.
Describe the structure and function of thelungs and the pleural coverings.
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Goal:
After the report, we will have aworking knowledge of the functions
of the respiratory system and willhave mastered the objectives listedbelow.
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Function Preview
The respiratory system suppliesoxygen to the blood while removing
carbon dioxide.
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Define cellular respiration, externalrespiration, internal respiration, pulmonaryventilation, expiration and inspiration.
Explain how the respiratory muscles causevolume changes that lead to air flow in andout of the lungs (breathing)
Describe the process of gas exchange in the
lungs and tissues. Describe how oxygen and carbon dioxide
are transported in the blood.
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Name different special assessment techniques,diagnostic tests and monitoring systems thatwill identify and confirm the disorders.
Name the different respiratory disorders and be
able to describe its etiology, pathophysiologyand presentation.
Describe the different patient needs andmanagement approaches that are unique for
every disorder. Name the parts of the system and
management techniques for chest tubes.
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Identify various radiologic and pulmonaryanatomic features relevant to interpretationof chest x-rays.
Describe different systems and principles ofmanagement for chest tubes.
Describe the etiology, pathophysiology,clinical presentation, patient needs and
principles of management of acuterespiratory failure.
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Compare and contrast the pathophysiology,clinical presentation, patient needs andmanagement approaches for common diseasesleading to AFP:
- acute respiratory distress syndrome - ARF in the chronic obstructive pulmonary
disease patient (asthma, emphysema, bronchitis)
- pulmonary embolism
- pneumonia - pulmonary hypertension
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The trillions of cells in the body requireand abundant and continuous supply ofoxygen to carry pit their vital functions.
We cannotdo without oxygenfor even alittle while, as we can do without food orwater. Furthermore, as cells use oxygen,they give off carbon dioxide, a waste
product the body must get rid of.
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The cardiovascular and respiratory systemsshare responsibility for supplying the body
with oxygen and disposing of carbondioxide. The respiratory system organsoversee the gas exchanges that occurbetween the blood and the external
environment. Using blood as thetransporting fluid, the cardiovascularsystem organs transport respiratory gasesbetween the lungs and tissue cells. If eithersystem fails, body cells begin to die fromoxygen starvation and accumulation ofcarbon dioxide.
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FunctionalAnatomy
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The receptors for the sense ofsmell, olfactory receptors are
found in the mucosa of the slit-like superior part of the nasalcavity, which is located beneaththe ethmoid bone. Respiratory
mucosa lines the rest of the nasalcavity and rests on a richnetwork of thin-walled veins thatwarms the air passing by.
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The Nose
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The nose is the only external partof the respiratory system and isthe part where the air passesthrough. During inhalation andexhalation, air enters the nose bypassing through the externalnares or nostrils. Nasal cavity is
found inside the nose and isdivided by a nasal septum.
The Nose
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Conchae these are three mucosa-coveredprojections or lobes that greatly increase thesurface area of the mucosa exposed to theair.
Palate a partition that separates the nasal
cavity from the oral cavity. Anteriorly, thepalate that is supported by a bone called thehard palate and the one which is unsupportedis the soft palate.
Paranasal Sinuses these are structures
surrounding the nasal cavity and are located inthe frontal, sphenoid, ethmoid and maxillarybones.
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The pharynx is a 13 cm long musculartube that is commonly called the throat.This muscular passageway serves as acommon food and air pathway. Thisstructure is continuous with the nasalcavity anteriorly via the internal nares.
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When food enters the oral cavity,it travels to the oropharynx and
laryngopharynx. However, insteadof entering the larynx, the food isdirected into the esophagus and
not to the larynx.
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Parts of pharynx:
Nasopharynx the superior portion of thepharynx. The pharyngotympanic tubes thatdrain the middle ear open in this area. This isthe main reason why children who have otitis
media may follow a sore throat or other tyoesof pharyngeal infections since the two mucosaeof these regions are continuous.
Oropharynx middle part
Laryngopharynx part of pharynx that entersthe larynx.
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Tonsils clusters of lymphatic tissuesfound in the pharynx.
Types of Tonsils:
Palatine tonsils tonsils found at the endof the soft palate.
Pharyngeal tonsils lymphatic tissueslocated high in the nasopharynx. This is
also called adenoid. Lingual tonsils located at the base of the
tongue.
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The larynx is the one that routes the airand food into their proper channels. Alsotermed as the voice box, it plays animportant role in sSpeech. This structureis located inferior to the pharynx and isformed by:
Eight rigid hyaline cartilages
Spoon-shaped flap of elastic cartilage,which is called the epiglottis.
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Thyroid cartilage this is the largesthyaline cartilage that protrudes anteriorly
in males and is referred to as the Adamsapple.
Epiglottis this is a flap of tissue thatserves as a guardian of the airways as it
protects the superior portion of the larynx. Vocal folds a pair of folds which is also
called the true vocal cords that vibratewhen air is expelled.
Glottis the slit-like passageway betweenthe vocal folds.
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Also called the windpipe, the trachea is about10 to 12 cm long or about 4 incheas andtravels dwon from the larynx to the fifththoracic vertebra. This structure is reinforced
with C-shaped rings of hyaline cartilage andthese rings are very important for the followingpurposes:
The open parts of the rings abut the esophagus
that allows the structure to expand anteriorlywhen a person swallows a large size of food.
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Pair of tubes that branch fromtrachea and enter lungs, havecartilage plates, lining is ciliated and
secretes mucus.
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Extensively branching respiratory passageways
Primary bronchi (main bronchi)- largestbronchi
Right main bronchi- wider and shorter thanthe left
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Supportive connective tissuechange C- shaped rings replaced by cartilage
plates Epithelium changes
Pseudostratified ciliated columnar
Replaced by simple columnar thensimple cuboidal epithelium
Smooth muscle becomes important
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Secondary (lobar) bronchi- threeon the right, two on the left
Tertiary (segmental) bronchi-
branch into each lung segment Bronchioles- little bronchi, lessthan 1 mm in diameter
Terminal bronchioles- less than0.5 mm in diameter
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Consists of air exchangingstructures
Respiratory bronchioles- branchfrom terminal bronchioles
Lead to alveolar ducts -> lead to
alveolar sacs
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Cup shaped structure at the endof the bronchioles that resemblebunches of grapes, are in direct
contact with capillaries (gasexchange); covered withsurfactant that keep them fromcollapsing
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Type I cells: simplesquamous cells forming lining
Type II cells: septal cellsthat secrete surfactant
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Visceral pleura also termed as thepulmonary pleura and covers eachsurface of the lings.
Parietal pleura covers the walls ofthe thoracic cavity.
Pleural fluid a slippery seroussecretion that allows the lungs to slide
along over the thorax wall duringbreathing movements and causes thetwo pleural layers to cling together.
.
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Bronchioles smallest air-conductingpassageways.
Bronchial tree or respiratory tree anetwork formed due to the branching andrebranching of the respiratorypassageways within the lungs.
Alveoli air sacs. This is the only areawhere exchange of gases takes place.
Respiratory Zone this part includes
the respiratory bronchioles, alveolarducts, alveolar sacs, alveoli
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The lungs are fairly large organs thatoccupy most of the thoracic cavity. Themost central part of the thoracic cavity, themediastinum, is not occupied by the lungs
as this area houses the heart. Apex the narrow superior portion of each
lung and is located just below the clavicle
Base the resting area of the lung. This isa broad lung area that rests on thediaphragm.
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The respiratory primarily supplies oxygen tothe body and disposes of carbon dioxidethrough exhalation. Four eventschronologically occur, for respiration to take
place. Pulmonary ventilation this process is
commonly termed as breathing. Withpulmonary ventilation, air must move outinto and out of the lungs so that the alveoliof the lungs are continuously drained andfilled with air.
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External respiration this is theexchange of gases or the loading of oxygen
and the unloading of carbon dioxidebetween the pulmonary blood and alveoli.
Respiratory gas transport this is theprocess where the oxygen and carbon
dioxide is transported to the and from thelungs and tissue cells of the body throughthe bloodstream.
Internal respiration in internal
respiration the exchange of gases is takingplace between the blood and tissue cells.
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Breathing, also called pulmonaryventilation is a mechanical processthat completely depends on the
volume changes occurring in thethoracic cavity. Thus, a when volumechanges pressure also changes, and
this would lead to the flow of gasesequalizing with the pressure.
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Inspiration also calledinhalation. This is the act of
allowing air to enter the body. Airis flowing into the lungs with thisprocess. Inspiratory muscles are
involved with inspiration whichincludes:
The diaphragm
External intercostals
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Expiration also calledexpiration. It the process of
breathing out air as it leaves thelungs. This process causes thegases to flow out to equalize the
pressure inside and outside thelungs. Under normalcircumstances, the process ofexpiration is effortless.
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Normal adult: 20 breaths perminute
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Chest radiography Provides visualization of the heart andlungs
These are obtained as:
Part of routine screening;
When respiratory disease issuspected;
To evaluate the status of
respiratory abnormalities; To confirm proper placement ofinvasive tubes or other chestinjuries.
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An x-ray is a form of radiant energywherein a radiographic image is made by anx-ray machine.
When nothing but air lies between the filmcassette and the x-ray source, the
radiographic image is blackness orradiolucency. But if the density increases,more beams are absorbed between the filmcassette or detectors and the x-ray source,
so the image is whiteness or radiopacity.ahelungs are primarily sacs of air, so normallythe lungs look black on chest films.
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Radiolucent (Black) Radiopaque (White) Gas or air (dark or black)- Examples are the lungs, trachea,
bronchi, and alveoli. Water (dark or gray)- Examples are the heart,
muscles, blood, blood vessels,diaphragm, spleen, and liver.
Fat (lighter or whitish gray)- Examples are the breasts,
marrow, and hilar streaking.
Metal or bone (lightest or white)- Examples are ribs, scapulae,
vertebrae, bullets, coins, teeth,and ECG electrodes.
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The most common method of obtaining achest x-ray is a PA view. It is done with the machine 6ft awayfrom the x-ray film;
With the patient standing with theanterior chest against the x-ray plateand the posterior chest toward the x-raymachine;
The patient is then told to take a deepbreath and hold it as the x-ray beam isdelivered through the film cassette.
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But in the critical care setting, we
often use the AP view. The patient is placed in supineposition or with slight backelevation ;
The film cassette is placed in theback of the patient and the x-raybeam is delivered through theanterior chest;
In this case, the x-ray machine isonly 3ft away from the plate.
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Postero-Anterior view Antero-Posterior view The most common method of
obtaining a chest x-ray; It is done with the machine 6ft
away from the x-ray film; With the patient standing with
the anterior chest against the x-
ray plate and the posterior chesttoward the x-ray machine;
The patient is then told to take adeep breath and hold it as thex-ray beam is delivered throughthe film cassette.
Used mostly in the critical caresetting.
In this case, the x-ray machineis only 3ft away from the plate.
The patient is placed in supineposition or with slight back
elevation ;
The film cassette is placed inthe back of the patient and thex-ray beam is delivered throughthe anterior chest.
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It is first important to ensure thatthe film has been properly labelled;
Also remember to view the film fromthe lateral boards, moving to themedial aspects of the thorax; while
doing this, be sure to follow thissteps:
St 1
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Step 1 Look at the different densities (black, gray, and
white).
Step 2 Look at the shape or form of each density and
identify which anatomic structure this is.
Step 3
Look at both the left and the right side andcompare each other.
Step 4 Look at all the other structures.
Step 5 Look for all tubes, wires, and lines present if they
are in the proper placement.
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In comparing the right and left sides of thefilm, remember the following sequence:
1) Soft tissues;2) Trachea;
3) Bony thorax;
4) Intercostal spaces;
5) Diaphragm;
6) Pleural surfaces;
7) Mediastinum;
8) Hila;
9) Lung fields;
10)Catheters, tubes, wires and lines.
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When examining soft tissues, the two sides
of the lateral chest should be symmetrical. When examining the trachea, it should be
midline and the carina should be visible atthe level of the aortic knob or 2nd ICS.
In inspecting the clavicles, it should besymmetric and may appear to have a notchin the inferior medial aspect, this is the
rhomboid fossa.
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Decrease in the density of the bones mayindicate loss of calcium in the bones.
Pleural spaces should not bee visible unlessair or fluid is present.
The heart is normally 50% the size of thethoracic diameter.
Density in x-ray films increases when water,pus, or blood accumulate in it.
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X-rays are also used to confirm properplacement of invasive equipment.
All invasive tubes have radiopaque linesrunning the length of the tube.
The technique is to identify all white linesand follow its path.
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Two common abnormal x-ray signsare the Silhouette sign and the airbronchogram. Silhouette sign is the loss of contrast,which means that two structures of the
same density have come in contact witheach other and the borders are lost.
An air bronchogram on the other hand isan air showing through a greater
density, such as water.
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These diagnostic tests allows for a three-dimensional examination of the chest.
It is advantageous over two-dimensional labtests when the examination is intended to test
anatomic parts with fluid collections on it. The disadvantage is that the patient needs to
be transported to the radiology department.
And regarding patients with ventilators, MRI
may interfere with the performance ofventilators, which may require for a manualventilation.
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Nurses should remember to provide
moral support to the patient becausemost patients had anxiety-relatedreactions. Thereby, it is a nursing responsibility to
provide proper information to the clientof what is to be done during theprocedure.
Some tips is to place the patient in aprone position, and provide relaxationlike playing of music and the presence ofa family member may help prevent
anxiety.
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The procedure is done by inserting acatheter into the pulmonary arteryand then introducing a contrast
material while filming is done. Pulmonary angiograms are seldomused because some patients tend to
have negative reactions against thecontrast material.
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A chest tube (chest drain, thoraciccatheter, tube thoracostomy,or intercostal drain) is a flexible
plastic tube that is inserted throughthe chest wall and into the pleuralspace or mediastinum.
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Rapid onset of respiratory impairment, which is
severe enough to cause potential or actualmorbidity or mortality if left untreated
Change in respiratory gas exchange (CO2 andO2) such that normal cellular function is
jeopardized
Defined as a Pao2 less than 60 mm Hg andPaco2 greater than 50 mm Hg with a pH lessthan or equal to 7.30.
Factors such as age, altitude, chronic
cardiopulmonary disease, metabolicdisturbances alter normal blood gas values.
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Impaired ventilation Impaired gas exchange
Airway obstructionVentilation-perfusionabnormalities
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Hypoxemia Restlessness
Tachypnea
Dyspnea
Tachycardia
Confusion
Diaphoresis
Anxiety
Hypercarbia
Hypertension
Irritability
Somnolence Cyanosis
Loss of consciousness
Pallor or cyanosis ofskin
Use of accessorymuscles of respiration
Abnormal breathsounds
Manifestations ofprimary disease
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ARF
Hypoxemia
Inadequate exchange of O2 and CO2
Ventilation-perfusion mismatch and shunt
Fatigue of muscles of ventilation
Increase work of breathing
Airway constriction or Bronchoconstriction
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Arterial Blood Gases- pH
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CXR-diffuse or patchy infiltrates;Pneumothorax; Pulmonary effusion;Hyperinflation; Aymmetricopacification of lung fields;Asymmetric lucency of lung fields
Pulmonary function tests- PEFR
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Provision of supplemental o2 Promotion of ventilation with theadministration of bronchodilators,
mucolytic agents, and others. Intubation and initiation ofmechanical ventilation if non-
invasive procedures fail to correcthypoxemia and hypercarbia
Treatment of underlying dissease
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Anxiety- Patients will most likely be frightened and anxious as a resultof dyspnoea.. Patients may advise which position they feel offerssome relief. Communication skills, such as asking closed questionsduring assessment, may be used if patients are breathless to a pointwhere they cannot answer in sentences.
Pulmonary secretions- Many processes leading to acute respiratoryfailure are associated with an increase in pulmonary secretions.Tissues or receptacles for sputum should be provided to assist
patients to void secretions independently. If their ability to void islimited, assistance may be required in the form oforopharyngeal/nasopharyngeal suction.
Pain management- If patients are experiencing pain, relief should beprovided and future control optimised. Expert advice may benecessary because of the respiratory depressant effects of someanalgesics. Liaison with multidisciplinary specialists such as acute orchronic pain specialists may be required.
Oxygen therapy- Unless in a medical emergency situation, the oxygenflow rate or percentage and duration of therapy should be prescribed.Nurses are best placed to select the most appropriate delivery systemfor a particular patient.
Tissue damage from a delivery device may occur in particular,oxygen masks cause soreness behind the ears after longer-term use
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oxygen masks cause soreness behind the ears after longer term useand nasal cannulas cause irritation to the nostrils. Small adaptationsto the device, such as adding gauze padding, may prevent or alleviatethis.
Other medication
If aerosol-inhaled medications are prescribed, effective delivery willonly occur through patient compliance. Therapeutic effectiveness canbe improved by providing education on inhaler technique. It isimperative that appropriate devices are chosen and patientstechnique is adequate. When administering nebulisers, patientsshould be sat upright (as tolerated), be encouraged to take normalbreaths and avoid talking in order to maximise drug delivery(Bennett, 2003). Nebulised medication may be administered using airflow or oxygen and nurses should ensure the type of gas used todeliver the drug is prescribed. Certain concentrations of oxygen maybe contraindicated in certain patients. Practitioners should also bearin mind that patients may be dependent on a certain oxygen flowbefore nebulisation and interrupting this may be contraindicated.
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ARDS is an acute physiologicsyndrome characterized bynoncardiac pulmonary edema.
It is caused by increased alveolarcapillary membrane permeability.
One of the most lethal of the diseasesor syndrome that lead to respiratoryfailure.
Motor vehicle accident typical patientwho develop ARDS.
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Dyspnea
Tachycardia (raised often>40
bpm)Intercoastal retractions
Copious secretions
Panic, fear of impending deathCrackles and/or wheezes
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Buccal peripheral cyanosis
Severe hypoxia
Anxiety Hypocapnia
decreased LOC
Decreased functional capacity
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(Primary Cause)Direct damage toalveolar capillary membrane.
Aspiration of gastric ContentPulmonary Contusion
Near Drowning
Inhalation of smoke/toxicsubstances
Diffuse pneumonia (viral &bacterial)
(S d C ) M di t d b
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(Secondary Cause) Mediated bycellular or Humoral Injury to the
Capillary Endothelium
Systemic sepsis
Hypovolemic shock associated with chesttrauma and sepsis
Acute pancreatitis
Trauma
DIC
Massive blood transfusion
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Injury to alveolar capillary membrane
Leakage of the blood and fluid into alveolar interstitial
and Alteration in the capillary bed
Fluid impairs gas exchange
Results in extensive shunting of blood in the lungs
Leads to ventilation perfusion imbalance
Ends in Non-cardiogenic Pumonary Edema
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Chest X-ray shows diffuse, bilateralpulmonary infiltrates without increasedcardiac sizePCWP < 18mmHg
Static compliance (tidal volume/inspiratory plateau pressures PEEP);
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Improving Oxygenation andVentilation
Administering high Fio2 with high
flow system/ rebreathng the mask CPAP may be tolerated in alert
cooperative pt.
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Continuous monitoring forcontraindication/ noninvasive CPAP(decreased LOC, N/V, increased
dyspnea/panic) are imperative Intubation and mechanical
ventilation if cardiovascularinstability is present(hypoxemia,fatigue)
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Decrease O2 consumption by minimizing
fever, activity level and respiratory effort. Improve oxygen-carrying with transfusion
for hemoglobin levels below normal
Minimize suctioning the airway to avoidO2 desaturation.
Reducing Anxiety Level
Achieving Effective Communication
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Maintaining Hemodynamic
Stability and AdequatePerfusion
Careful monitor during PEEP
therapyAdminister correct hypovolemia
Vasoactive drug may be required
to maintain adequate tissueperfusion.
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Preventing ComplicationBackrest elevation
Hand washingRemoval of invasive devicesas soon as possible
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Promote measure to maintainadequate airway andventilation.
Monitor fluid balance
- Assess the client for the s/sy
of fluid volume overload
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Provide adequate nutritional support- not high in carbohydrates
- Diet include 35 to 45 kcal/kg each
day- with parenteral support.
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Administer prescribed medication
EX: Corticosteroid(decreased inflammation
surrounding the alveoli- Stabilize the capillary membranes
- but remains controversial due to the effectof this drug that precipitate infection and
further impair pulmonary function.
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Individuals with COPD (Bronchitis,asthma, emphysema) are at high risk forthe development of ARF.
Chronic disease processleads to
impairment of ventilation, poor gasexchange, and airway obstruction.
Acute disease process, even a relatively
minor one, further impairs ventilation andgas exchange and increases airwayobstruction.
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Predispose the patient with COPD to frequentepisodes of ARF: Altered host defenses
Increased secretion volume and viscosity
Impaired secretion clearance and airway changes
Common pathophysiologic changes
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Causes of Acute Respiratory Failure in
ADULT Impaired Ventilation
Spinal Cord injury (C4 or higher)
Phrenic nerve damage
Neuromuscular blockage Guillain-Barre syndrome
CNS depression Drug overdose (narcotics, sedatives, illicit drugs)
Increased intracranial pressure Anesthetic agents
Respiratory muscle fatigue
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Impaired GasExchange Pulmonary edema
Acute RespiratoryDistress Syndrome
AspirationPneumonia
Airway
Obstruction Aspiration of foreignbody
Thoracic tumors
Asthma
Bronchitis
Pneumonia
Ventilation-PerfusionAbnormalities Pulmonary
embolism
Emphysema
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Patients with COPD can easilylead to ARF by: Diseases of situations that decrease
ventilatory drive Oversedation
Hypothyroidism
Brain stem lesions
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Decreased Muscle strength Malnutrition
Shock
Myopathies Hypophosphatemia
Hypomagnesem
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Decreased Chest wall elasticity Rib fractures
Pleural effusions
Ileus
Ascites
Decreased Lung Capacity for Gas exchange Atelectasis
Pulmonary edema
Pneumonia Pulmonary embolus
Heart failure
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Increase airway resistance Bronchospasm
Increased secretions
Upper airway obstructions
Airway edema Increased Metabolic oxygen requirements
Systemic infection
Hyperthyroidism
Fever
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A. Airway infections (pneumonia,
bronchitis) Frequent antibiotic administration
Hospitalization
Impaired cough and host defenses Infections are commonly caused
by: gram-negative enteric bacteria or
Legionella Haemophilus influenza
Streptococcus pnuemoniae causingacute bronchitis
B P l b l
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B. Pulmonary embolus
High incidence of right ventricularfailure in COPD increases the risk ofpulmonary embolus from rightventricular mural thrombi
C. Heart failure- In the presence of pulmonaryhypertension and right-sided heartfailure, treatment f left-sided heart
failure is often delayed due tdifficulties in early diagnosis
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D. Noncompiance with medication regime Complicated treatment regime whichincludes frequent administration of bothoral and inhaled agents leads to
underuse of medications
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Similar to ARF,but usuallymorepronounced Hypoxemia
(PaO2 50mm Hg)
Hypertension Irritability
Somnolence(late)
Cyanosis (late)
Loss ofconsciousness(late)
Pallor orcyanosis of skin
Use ofaccessorymuscles ofrespiration
Abnormalbreath sounds(crackles,wheezes)
Manifestations
ofprimarydisease
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Chest x-ray Flat diaphragms
Hyperinflation of air fields
Arterial blood gases
- PaCO2 greater than 45 mm Hg and higherthan baseline levels during stable, chronicdisease periods
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1. Treating the Underlying
Disease State Treatment is directed atboth the acute
precipitating event andthe chronic airflowobstruction problems
associated with COPD
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Higher than usual does may be necessary until theprecipitating event is resolved
Status asthmaticus severe asthma may requiresubcutaneous epinephrine administration.
Epinephrine is ONLY given to young patients withno evidence of cardiac disease
2. Treat pulmonary infections withappropriate antibiotics
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3. Improve secretion removal Secretions are thick and tenacious inasthma patients
Adequate hydration
Corticosteroids
Coughing
Heated moist aerosolization
Chest physiotherapy
2. Improving Oxygenation and Ventilation
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Frequent monitoring of arterial blood
gases Position the patient to maximizeventilator efforts and relaxation/restduring spontaneous breathing such as
High Fowlers position and leaning on anoverbed table
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3. Nutritional Support Typically, patients with COPD have Protein-calorie malnutrition,as well as low levels of phosphate,magnesium, and calcium.
Chronic nutritional deficits lead to muscle weakness and mayinterfere with the weaning process.
Early enteral or parenteral feeding to avoid further deterioration
in their nutritional status during acute illness Administration of lipid calories should account for 50% of the
nutritional support during mechanical ventilation.
4. Preventing and Managing Complications
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Arrythmia High incidence of both atrial and ventricular
arrhythmia due to hypoxemia, acidosis, heartdisease, medications, and electrolyteabnormalities
Goal is cardiac monitoring and correction of theunderlying cause with pharmacologic treatmentof arryhtmia only for life-threatening situations
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Pulmonary embolus High incidence
Observe for signs andsymptoms and follow theusual treatment and prevention guidelines
GI distention and ileus Aerophagia is common in dyspeic patients,
increasing the incidence of this complication
Auto-PEEP and barotrauma
High incidence, especially in the elderly and inindividuals with high ventilation needs.
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Is a progressive, life-threatening disorderof the pulmonary circulation characterizedby:
high pulmonary artery pressure(>25mmHg)
Leading from the right side of the heart to
the lungs
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Pulmonary Arterial hypertension (PAH)Idiopathic
Familial
Collagen vascular disease
Congenital systemic to pulmonary shunts
Portal hypertension
HIV infection
Drugs and toxins
Other( Assoc. With significant venous or capillaryinvolvement)
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Pulmonary Venous Hypertension Left-sided heart disease
(Atrial, ventricular, or valvular)
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Pulmonary Hypertension Assoc. WithHypoxia
COPD
Interstial lung disease
Sleep-disordered breathing
Alveolar hypoventilation
Chronic exposure to high altitude
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Pulmonary HPN due to chronicThrombotic and Embolic Disease
Thromboembolitic obstruction ofproximal or distal pulmonary arteries
Pulmonary embolism
oTumor
oParasitesoForeign material
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Miscellaneous
Sarcoidosis, histiocytosis X,lymphangiomatosis, compression ofpulmonary vessels
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PallorDyspnea
Fatigue
Chest pain
syncope
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Echocardiogram-Valvular heart dse., left ventriculardysfunction, and intracardiac shunts
Chest X-ray
-Enlarged hilar and pulmonary arterialshadows and enlargement of the rightventricle
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12-lead ECG-right Ventricular strain, right ventricularhypertrophy, and right axis deviation
Ventilation-perfusion scan
-Normal V/Q scan rules outthromboembolism, abnormal V/Q
warrants further testing with pulmonaryangiography
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CT chest-Assess for presence or absence ofparenchymal lung disease
6-minute-walk-rest
-measurement of distance used to
monitor exercise tolerance, responseto therapy and progression ofdisease
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Right-heart cardiaccatheterization-gold standard for diagnosis withvasodilator testing for benefit of long
term therapy with calcium channelblockers
Secrology testing-Antinuclear antibodies
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Pulmonary function testing-used to rule out any other diseasescontributing to SOB
Sleep study
Done as a screen for sleep apnea, which may alsocontribute to the pulmonary hypertension
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Current tx options can slow theprogression of the disease:
Long term anticoagulation therapy toprevent thrombosis
Avoidance of beta-blockers,decongestants or other meds thatworsen pulmonary hpn or dse right heartfailure
Symptom limited physical activity
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Oxygen to prevent additionalpulmonary vasoconstriction due tolow oxygen levels.
Diuretics to control edema andascites if right sided heart failurepresent
Calcium channel blockers of positiveresponse to vasodilator duringcardiac catherterization
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Prostacyclin therapy-potent vasodilator of both thesystemic and pulmonary arterial
vascular beds-inhibitor of platelet aggregation
Remodulin(treprostinil sodium) is acontinuous subcutaneous or intravenousinfusion
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Flolan(epoprostenol sodium) is a continuousintravenous infusion
Ventravis (iloprost sodium) is an
intermittent inhalation treatment
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Endothelin receptor antagonistsblock the neurohormoneendothelin from binding in the
endothelium and vascularsmooth muscleTracleer (bosentan) and Letairis
(ambrisentan) are oral agents
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Surgical options include the ff:Atrial septostomy to create a right-to-left shunt to help decompress a
failing right ventricle in selectpatients who are unresponsive tomedical therapies
Also leads to significant hypoxemiain an already compromised patient
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Pulmonary thromboendarterectomy forthose with suspected chronicthromboembolic pulmonary hpn to improvehemodynamics and functional status
Lung transplantation is indicated when thepulmonary hpn has progressed despiteoptimal medical and surgical therapy
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The most common
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The most common
respiratory infection and themost common cause ofrespiratory failure in critically
ill patients.
Respiratory infection is a
common cause of ARF.
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Infections developed before
hospitalization (community-
acquired) and those acquiredduring hospitalization (hospital-acquired) can lead to significantmorbidity and mortality, and critical
care management.
The young, the elderly, those with chronic
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y g, y,cardiopulmonary disease and
immunocompromised individuals are athigh risk for the development ofpneumonia.
In addition immobility, decreased LOC,and mechanical ventilation placed hospitalpatients at high risk for development of
hospital acquired pneumonias commonlyreferred as ventilator-associatedpneumonias.
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Aspiration of oropharyngeal or gastriccontents into the lungs (hospital-acquired)
Inhalation of aerosols or particles
containing the organisms (hospital-and-community acquired)
Hematogenous spread of the organisminto the lungs from another site in thebody (hospital-acquired)
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Causative organism:
Bacteria, viruses, fungi & protozoan
Risk factors:Extreme ages
Chronic diseases (CP, AIDS)
Immunocompromised state (steroids, AIDS,malignancy, transplantation)
1. Organism may enter the respiratorytract through inspiration or aspiration
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tract through inspiration or aspiration
of oral secretions; Staphylococcus andGram-negative bacilli may reach the lungsthrough circulation in the bloodstream.
2. Normal pulmonary defense mechanism(cough reflex, mucociliary transport,pulmonary macrophagus) usuallyprotect against infection. However insusceptible hosts, these defenses are
either supressed or overwhelmed by theinvading organism.
3. The invading organism multiplies andl d i i i
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releases damaging toxins, causing
inflammation and edema of the lungand parenchyma; this results inaccumulation of cellular debris andexudate.
4. Lung tissue fills exudate and fluid,changing from an airless state to a
consolidate state.
5. Severity of symptoms depends on thet t f i t ( ti l
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extent of pneumonia present (e.g., partial
lobe, full lobe [lobar pneumonia], or diffuse[broncho- pneumonia]).
6. Symptoms can include:
a) Fever
b) Chills
c) Malaise
d) h
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d) Cough
e) Pleuritic painf) Increased tactile fremitus on palpitation
g) Rales and rhonci on auscultation
h) Dyspnea
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Fever Cough, typically productive
Purulent sputum or hemoptysis
Dyspnea
Pleuritic chest pain Tachypnea
Abnormal breath sounds (crackles,bronchial breath sounds)
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Gram stain and culture of sputum forcausative organisms.
New or progressive infiltrates onchest x-ray. Infiltrates may be eitherlocalized or diffuse in nature.
Elevated WBC.
Abnormal arterial blood gases(hypoxemia, hypocapnia).
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Treat the Underlying Cause-antimicrobial therapy
-fluids to correct hypovolemia and
hypertension
Improving Oxygenation and
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VentilationSimilar to ARF management, with the
following additions:
PEEP and CPAP are unlikely to improveoxygenation in the presence of pneumonia,and may exacerbate the ventilation-perfusion abnormalities associated with
pneumonia.
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Voluminous, tenacious respiratorysecretions may require endotrachealintubation to assist with clearance. Chest
physiotherapy may be helpful to increasesecretion clearance, particularly whenlobar atelectasis is present.
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Decrease the risk of crosscontamination or colonization via
the hands hospitalizedpersonnel.
-Hand washing is the most
effective strategy.
Decrease the risk of aspiration. Avoid supine positioning and keep the head of the
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Avoid supine positioning and keep the head of thebed elevated to 30 C to 45 C at all times, unlessmedically contraindicated.
Use an endotracheal tube with a dorsal lumenabove the endotracheal cuff to remove drainagewith continuous suction.
Suction above the endotracheal tube cuff beforeremoving or repositioning the tube.
Assess for, and correct, gastric reflux problems.
Ambulate as soon as possible.
Implement a comprehensive oral hygiene
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Implement a comprehensive oral hygiene
program.
Maintain a closed system onventilator/humidifier circuits, and avoid
pooling of condensation or secretions in thetubing.
Use sterile technique for endotracheal
suctioning and suction only when necessaryto clear secretions from large airways.
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Provide nutritional support toimprove host defenses.
Eliminate invasive devices andequipment as soon as possible.
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Pulmonary Embolism (PE) is acomplication of deep venousthrombosis (DVT), long bone
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thrombosis (DVT), long bone
fracture, or air entering thecirculatory system. There aremany risk factors for PE, withcritically ill patients being
especially prone due to thepresence of central venous and PAcatheters, immobility, use ofmuscle relaxants, and heart
failure.
Th b b li
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Thromboemboli
Obesity Prior history of thromboembolism Advanced age Malignancy Estrogen Immobility Paralysis Heart failure Postpartum
Postsurgical Post trauma Hypercoagulability states Central Venous and PA catheters
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Venous thrombi form at the site ofvascular injuries or where venous stasisoccurs, primarily in the leg or pelvic veins.Thrombi that dislodge travel through thevenous circulation untli they becomewedged In a branch of the pulmonarycirculation. Depending on the size of thethrombi, and the location of the occlusion,mild to severe obstruction of blood flow
occurs beyond the thrombi.
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The major contributor to mortality ofthe pulmonary obstruction iscirculatory impairment. The physicalobstruction of the pulmonarycapillary bed increases rightventricular afterload, dilates the rightventricle, and impedes coronary
perfusion.
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A secondary consequence ofthromboemboli is a mismatching ofventilation to perfusion in gasexchange units beyond theobstruction, resulting in arterialhypoxemia. This hypoxemia furthercompromises oxygen to the ischemic
right ventricle.
Air Emboli
Neurosurgery
Liver transplant
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Harrington rod insertion
Open heart surgery
Arthroscopy
Pacemaker insertion
Cardiopulmonary resuscitation
Gastroscopy
Positive pressure ventilation
Scuba diving
Intravenous infusion
Central venous catheter insertion or removal
Air or other non-absorbable gases
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Air or other non absorbable gases
entering the venous system alsotravel to the right heart, pulmonarycirculation, arterioles, andcapillaries. A variety of surgical andnonsurgical situations predisposepatients to the development of airembolization.
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Damage to the pulmonaryendothelium occurs from theabdominal air-blood interface,leading to increased capillarypermeability and alveolar flooding.Bronchoconstriction also occurs withair embolization. In addition to
hypoxemia, PCo2 removal is alsoimpaired.
Fat Emboli
Long bone fracture
Blunt trauma to liver
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Blunt trauma to liver
Pancreatitis Lipid infusions
Sickle cell crisis
Burns Cardiopulmonary bypass
Cyclosporine administration
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Fat enters the pulmonary circulation mostcommonly when released form the bonemarrow following bone fractures. Non traumaticorigins of fat embolization also occur and arethought to be due to the agglutination of low-
density lipoproteins or liposomes fromnutritional fat emulsions. The presence of fat inthe pulmonary circulation injures theendothelial lining of the capillary, increasing
permeability and alveolar flooding.
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Dyspnea Pleuritic pain
Apprehension
Diaphoresis
Evidence of DVT
Hemoptysis
Tachypnea
Fever
Tachycardia
Syncope
Hypoxia
hypotension
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Chest x-ray Arterial blood gas analysis
ECG
PA pressures
Ventilation-perfusion scan Pulmonary angiography
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Prevention and early diagnosis andtreatment to prevent re-embolization isthe key to preventing morbidity andmortality from PE.
Objectives include the improvement ofoxygenation and ventilation,improvement of cardiovascular function,prevention of re-embolization, andprevention of pulmonary embolus.
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Oxygen therapy is usually veryeffective in relieving hypoxemiaassociated with PE.
Mechanical Ventilation isrequired when cardiopulmonarycompromise is severe.
C i h b fi f
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Controversy exist the benefits ofvasoactivedrug administration( such as norepinephrineand/or inotrophic agents) improve myocardialperfusion of the right ventricle.
Additional therapy is needed in severeembolic events ,where cardiac failure isprofound to hasten clot resolution, such as
use of thrombolytic agents and/or
interventional removal of massive emboli maybe warranted.
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Limiting activity to prevent dislodgement ofadditional clots.
Use of anticoagulation therapy with unfractionatedheparin to maintain a PTT 1.5 to 2.5 times thecontrol when no contraindication exists.
Insertion of vena cava filters to prevent emboli fromlegs, pelvis, and inferior vena cava from migratingto pulmonary circulation if anticoagulation therapyis contraindicated. Filters are placed percutaneouslyin the inferior vena cava.
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Awareness and access to a hospitalprevention policy including riskassessment is an important thing in theprevention of VTE.
A risk assessment should be done onadmission to the unit and discussion dailyon rounds should take place. Discussionshould also include current VTEprevention intervention, risk for bleeding,
and response to treatment.
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If ordered, graduated compressionstocking or IPCs(intermittent pneumaticcompression) should be in use at all timesexcept when being removed for correct
fitting or skin assessment. Early fixation of long bone fractures to
prevent fat emboli.
Early mobilization as soon as
hemodynamic is stable.
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Recommended