final pres-ppt

7/29/2019 Final Pres-ppt

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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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final pres-ppt

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