2nd Edition Respiratory Notes Respiratory Therapist s Pocket Guide Gary C. White, M.Ed., RRT, RPFT Purchase additional copies of this book at your health science bookstore or directly from F. A. Davis by shopping online at www.fadavis.com or by calling 800-323- 3555 (US) or 800-665-1148 (CAN) A Davis s Notes Book
F. A. Davis Company 1915 Arch Street Philadelphia, PA 19103 www.fadavis.com Copyright 2013 by F. A. Davis Company All rights reserved. This product is protected by copyright. No part of it may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without written permission from the publisher. Printed in the United States of America Last digit indicates print number: 10 9 8 7 6 5 4 3 2 1 Acquisitions Editor: T. Quincy McDonald Manager of Content Development: George W. Lang Developmental Editor: Dean W. DeChambeau Art and Design Manager: Carolyn O Brien Reviewers: Charity Bowling, MA, RRT; Tammy Crump, PhD, RRT; Susan Dunington, MA, BSc, RRT; Paul E. LaMere, MS, RRT; Geraldine Twomey, RRT, RN, MEd, CPFT As new scientific information becomes available through basic and clinical research, recommended treatments and drug therapies undergo changes. The author(s) and publisher have done everything possible to make this book accurate, up to date, and in accord with accepted standards at the time of publication. The author(s), editors, and publisher are not responsible for errors or omissions or for consequences from application of the book, and make no warranty, expressed or implied, in regard to the contents of the book. Any practice described in this book should be applied by the reader in accordance with professional standards of care used in regard to the unique circumstances that may apply in each situation. The reader is advised always to check product information (package inserts) for changes and new information regarding dose and contraindications before administering any drug. Caution is especially urged when using new or infrequently ordered drugs. Authorization to photocopy items for internal or personal use, or the internal or personal use of specific clients, is granted by F. A. Davis Company for users registered with the Copyright Clearance Center (CCC) Transactional Reporting Service, provided that the fee of $.25 per copy is paid directly to CCC, 222 Rosewood Drive, Danvers, MA 01923. For those organizations that have been granted a photocopy license by CCC, a separate system of payment has been arranged. The fee code for users of the Transactional Reporting Service is: 8036-2922/13 0 + $.25.
HIPAA Compliant OSHA Compliant Waterproof and Reusable Wipe-Free Pages Write directly onto any page of Respiratory Notes, 2 nd Edition with a ballpoint pen. Wipe old entries off with an alcohol pad and reuse. BASICS ASSESS PHARM PULM PROC AIR VENT NEO PEDS TOOLS
Look for our other Davis s Notes titles available now! Respiratory Notes: Respiratory Therapist s Pocket Guide ISBN-13: 978-0-8036-1467-3 ECG Notes: Interpretation and Management Guide ISBN-13: 978-0-8036-1347-8 EMS Notes: EMT & Paramedic Field Guide ISBN-13: 978-0-8036-2038-4 LabNotes: Guide to Lab & Diagnostic Tests, 2nd edition ISBN-13: 978-0-8036-2138-1 Critical Care Notes: Clinical Pocket Guide ISBN-13: 978-0-8036-2084-1 MedNotes: Nurse s Pharmacology Pocket Guide, 3rd Edition ISBN-13: 978-0-8036-2139-8 IV Med Notes: IV Administration Pocket Guide ISBN-13: 978-0-8036-1446-8 IV Therapy Notes: Nurse s Clinical Pocket Guide ISBN-13: 978-0-8036-1288-4 Assess Notes: Assessment and Diagnostic Reasoning ISBN-13: 978-0-8036-1749-0 DocuNotes: Nurse s Clinical Pocket Guide to Effective Documenting and Reporting ISBN-13: 978-0-8036-2092-6 MedSurg Notes: Nurse s Clinical Pocket Guide, 2 nd edition ISBN-13: 978-0-8036-1868-8 NCLEX-RN Notes: Core Review & Exam Prep ISBN-13: 978-0-8036-1570-0 NutriNotes: Nutrition & Diet Therapy Pocket Guide ISBN-13: 978-0-8036-1114-6 Coding Notes: Medical Insurance Pocket Guide ISBN-13: 978-0-8036-1493-2 PsychNotes: Clinical Pocket Guide, 2nd edition ISBN-13: 978-0-8036-1853-4 PFT Notes: Pulmonary Function Testing Pocket Guide ISBN-13: 978-0-8036-2249-4 For a complete list of Davis s Notes and other titles for health care providers, visit www.fadavis.com.
113 Obstructive Diseases 114 Restrictive Diseases 118 Neuromuscular Diseases 120 Infectious Diseases 127 Circulatory Diseases 131 Neoplastic Disease 134 Chest Trauma 135 Pediatric Diseases 138 Neonatal Diseases 140 PULM
PULM Chronic Smoking bronchitis history Air pollution Chronic infections Gastric reflux Obstructive Diseases Accessory muscle use Increased anteroposterior (A-P) diameter Cough/sputum production Diminished breath sounds Hyperresonance on percussion Arterial blood gases (ABGs): Compensated acidosis may be hypoxemic Pulmonary function tests (PFTs): Decreased FVC, FEV 1, FEV 1/FVC, FEF25% 75%; Increased RV, FRC, RV/TLC Increased radiolucency, enlarged lung fields, flattened diaphragms, increased retrosternal airspace Antibiotics for infections Sympathomimetic bronchodilators Inhaled corticosteroids Bronchial hygiene O 2 therapy for Smoking cessation Pulmonary rehabilitation 114
115 Asthma Allergic triggers Infections Exercise or cold air exposure Gastric reflux Air pollution Accessory muscle use Prolonged expiratory phase Increased A-P diameter Cough/sputum production Hyperresonance on percussion Diminished breath sounds and wheezing ABGs: Acute (early) alkalosis with Severe (late/status asthmaticus) acidosis with PFTs: Decreased FVC, FEV 1, FEV1/FVC, PEFR, FEF 25% 75%; Increased RV, FRC, RV/TLC Increased retrosternal airspace, hyperinflation, flattened diaphragms, increased radiolucency O2 therapy for IV corticosteroids (ER treatment) Sympathomimetic bronchodilators Inhaled corticosteroids Bronchial hygiene Mechanical ventilation for failure Continued PULM
PULM Emphysema Genetic (alpha-1- antiprotease deficiency) Cigarette smoking Occupational exposure Air pollution Dyspnea Accessory muscle use Increased A-P diameter Cough/sputum production Hyperresonance on percussion Diminished breath sounds, wheezing, crackles, and rhonchi ABGs: Compensated acidosis with PFTs: Decreased FVC, FEV 1, FEV1/FVC, FEF 25% 75%; Increased RV, FRC, RV/TLC Hyperinflation, flattened diaphragms, increased radiolucency, increased retrosternal airspace O2 therapy for Bronchial hygiene Sympathomimetic bronchodilators Antibiotics for pulmonary infections Prolastin replacement therapy for alpha-1 deficiency Pulmonary rehabilitation 116
117 Cystic fibrosis Genetic Dyspnea Accessory muscle use Increased A-P diameter Digital clubbing Cough/sputum production Diminished breath sounds, wheezing, crackles, and rhonchi ABGs: Compensated acidosis with PFTs: Decreased FVC, FEV 1, FEV1/FVC, FEF 25% 75%; Increased RV, FRC, RV/TLC Hyperinflation, flattened diaphragms, increased radiolucency, increased retrosternal airspace O2 therapy for Bronchial hygiene Inhaled medications: Bronchodilators Corticosteroids Antibiotics PULM
PULM Restrictive Diseases Interstitial lung disease Inhalation of inorganic dusts Inhalation of organic dusts Drugs (nitrofurantoin, aspirin, bleomycin, cyclophosphamide, methotrexate, amiodarone, heroin, methadone) Idiopathic Dyspnea Digital clubbing Dull percussion note Bronchial breath sounds, crackles, wheezing ABGs: Increased Pa-AO 2, PFTs: Decreased FVC, FEV 1; Normal or increased FEV 1/ FVC, FEF 25% 75%, PEF; Decreased RV, FRC Patchy infiltrates, granulomas, pleural plaques, air bronchograms O2 therapy for Inhaled medications Sympathomimetic bronchodilators Corticosteroids 118
119 Pleural disease Congestive heart failure Nephrotic syndrome Pulmonary embolus Malignant metastasis Malignant mesotheliomas Pneumonia Tuberculosis Dry cough Dull percussion note Diminished breath sounds ABGs: Respiratory alkalosis with PFTs: Decreased FVC, FEV 1, normal or increased FEV 1/ FVC; Decreased RV, FRC, TLC Blunted costophrenic angle(s), fluid evident on lateral decubitus film, depressed diaphragm(s) O2 therapy Thoracentesis Hyperinflation therapy Corticosteroids PULM
PULM Neuromuscular Diseases Myasthenia gravis Immunological from circulating antibodies Rapid, shallow breathing Diminished breath sounds, crackles, and rhonchi Drooping eyelids (ptosis) Double vision (diplopia) Dysphagia Fatigue ABGs: Early normal, with progression PFTs: Decreased VC, FEV 1, FEF25% 75%, PEF, RV, FRC, TLC Early normal, with progression atelectasis/ consolidation Cholinesterase inhibitors Immunosuppressants O2 therapy Bronchial hygiene Hyperinflation therapy Mechanical ventilation for failure 120
121 Amyotrophic No known lateral etiology sclerosis (Lou Gehrig s disease) Progressive weakness of distal muscle groups Dysphagia Muscle twitching and tremors Dyspnea Diminished breath sounds Respiratory failure ABGs: Early normal, with progression PFTs: Decreased VC, FEV 1, FEF25% 75%, PEF, RV, FRC, TLC Early normal, with progression atelectasis/ consolidation Treat symptoms Mechanical ventilation for failure Continued PULM
PULM Guillain- Barré syndrome Autoimmune disorder Recent upper illness Ascending muscle weakness/ paralysis Loss of deep tendon reflexes Dysphagia Elevated cerebrospinal fluid protein levels (>100 mg/ dl) Decreasing V T, MIP, VC ABGs: Early normal, with progression PFTs: Decreased VC, FEV 1, FEF 25% 75%, PEF, RV, FRC, TLC Early normal, with progression atelectasis/ consolidation Plasmapheresis Anti-inflammatory agents Mechanical ventilation for failure 122
123 Poliomyelitis Infectious disease: poliovirus Headache, back pain, muscle stiffness, sore throat Drooling, muscle contractions in calf, neck, or back Dysphagia Decreasing V T, VC, MIP ABGs: Early normal, with progression PFTs: Decreased VC, FEV 1, FEF 25% 75%, PEF, RV, FRC, TLC Early normal, with progression atelectasis/ consolidation Treat symptoms Analgesics Mechanical ventilation for failure Continued PULM
PULM Muscular dystrophy Genetic Progressive muscle weakness Drooping eyelids (ptosis) Inability to walk Limited range of motion Decreasing V T, VC, MIP ABGs: Early normal, with progression PFTs: Decreased VC, FEV 1, FEF 25% 75%, PEF, RV, FRC, TLC Early normal, with progression atelectasis/ consolidation Physical therapy Occupational therapy (activities of daily living) Corticosteroids Ventilatory support 124
125 Botulism Infectious disease: Clostridium botulinum ingestion or wound contamination Diplopia Drooling Dysphagia Muscle weakness in arms and legs Dyspnea Decreasing V T, VC, and MIP ABGs: Early normal, with progression PFTs: Decreased VC, FEV 1, FEF 25% 75%, PEF, RV, FRC, TLC Early normal, with progression atelectasis/ consolidation Antitoxin Mechanical ventilation for failure Continued PULM
PULM Tetanus Clostridium tetani: Deep wound contamination or burn contamination Headache/ irritability Stiffness, neck rigidity, dysphagia Muscle rigidity in descending pattern from the jaw inferiorly Reflex muscle spasms Tetanic seizures Dyspnea Decreasing V T, VC, and MIP Respiratory failure ABGs: Early normal, with progression PFTs: Decreased VC, FEV 1, FEF 25% 75%, PEF, RV, FRC, TLC Early normal, with progression atelectasis/ consolidation Tetanus immune globulin (TIG) antitoxin Wound débridement Anticonvulsants Antibiotics Neuromuscular blocking agents Early intubation Mechanical ventilatory support 126
127 Infectious Diseases Pneumonia Infectious disease: bacteria, viruses, fungi Fever Chest pain Cyanosis Cough, sputum production Diminished breath sounds Crackles/rhonchi Dullness to percussion ABGs: Early alkalosis with ; late PFTs: Decreased FVC, FEV 1, FEF25% 75%, normal PEF Increased density (consolidation), air bronchograms, pleural effusions O2 therapy () Antibiotics Bronchial hygiene therapy Analgesics Continued PULM
PULM Tuberculosis Infectious disease: Mycobacterium tuberculosis Chest pain Cyanosis Cough, sputum production, hemoptysis Bronchial breath sounds Crackles/rhonchi Dullness to percussion ABGs: Respiratory alkalosis with Late PFTs: Decreased FVC, FEV 1, FEF 25% 75%, normal PEF Increased opacity, cavity formations (upper lobes), pleural effusion Antibiotics (isoniazid, rifampin, pyrazinamide, ethambutol, streptomycin, ethionamide) O2 for Bronchial hygiene therapy 128
129 Lung abscess Infectious disease: Klebsiella or Staphylococcus May occur secondary to bronchial obstruction Cyanosis Cough, sputum production Diminished breath sounds Crackles, rhonchi Dullness to percussion Bronchial breath sounds ABGs: Respiratory alkalosis with PFTs: Decreased FVC, FEV 1, FEF 25% 75%, normal PEF Increased opacity, cavity formation, fibrosis, pleural effusion Surgery (drainage or resection) O2 for Bronchial hygiene therapy Continued PULM
PULM Fungal disease Infectious disease: fungi (Histoplasmosis, Aspergillosis) Chest pain Cough, sputum production Bronchial breath sounds Crackles, rhonchi Dullness to percussion ABGs: Respiratory alkalosis with PFTs: Decreased FVC, FEV 1, FEF 25% 75%, normal PEF Increased opacity, cavity formation, pleural effusion Surgery (resection) Antifungal drugs O2 for Bronchial hygiene therapy 130
131 Circulatory Diseases Pulmonary edema Cardiogenic: Congestive heart failure Cardiac arrhythmias Excessive fluid administration Mitral valve disease Non-Cardiogenic Allergic response Drug overdose Alveolar hypoxia Acute distress syndrome (ARDS) Toxic gases (chlorine, sulfur dioxide, nitrogen dioxide) Radiation injury Orthopnea Cyanosis Cough, sputum production Diminished breath sounds Crackles, rhonchi, wheezing ABGs: Respiratory alkalosis with Late PFTs: Decreased FVC, FEV 1, FEF25% 75%, normal PEF Hilar fullness, dense fluffy infiltrates, batwing sign (clear periphery with dense hilum), enlarged left ventricle, Kerley A and B lines O2 for Bronchial hygiene therapy Positive inotropic agents Afterload reduction agents Morphine sulfate Diuretics Continued PULM
PULM Pulmonary emboli Pulmonary vasculature embolus: Thrombi Fat emboli Cyanosis Dyspnea Chest pain Cough, hemoptysis Crackles, wheezing ABGs: Respiratory alkalosis with PFTs: Decreased FVC, FEV 1, FEF25% 75%, normal PEF Increased density in affected areas, right ventricular enlargement Positive V/Q scan (ventilation without perfusion), positive pulmonary angiography O2 for Thrombolytic agents Heparin or warfarin Compression stockings Bronchodilator therapy Mechanical ventilation for failure 132
133 Acute Aspiration Pulmonary emboli distress Fluid overload syndrome Inhalation injury (ARDS) Immunological reaction Oxygen toxicity Radiation-induced injury Shock Trauma Cyanosis Dull percussion Bronchial breath sounds, crackles ABGs: Early alkalosis with Late PFTs: Decreased FVC, FEV 1, FEF25% 75%, normal PEF Increased opacity, diffuse patchy infiltrates ( ground glass ) O2 for Hyperinflation Mechanical ventilation for failure PULM
PULM 134 Lung cancer Smoking Radon gas exposure Asbestos fibers Sulfur dioxide Cough, sputum production, hemoptysis Crackles, wheezing ABGs: Early Chemotherapy alkalosis with Radiation therapy Late acidosis Surgery with O2 for PFTs: Decreased FVC, FEV 1, Bronchial FEF 25% 75%, normal PEF hygiene therapy Small lesions, irregularly shaped masses, alveolar consolidation, atelectasis CT scan: Positive for lesions Neoplastic Disease
135 Flail chest Chest trauma: Blunt chest trauma Motor vehicle accident Industrial accident Crushing injury Chest Trauma Chest pain Paradoxical chest wall movement Diminished breath sounds ABGs: Early alkalosis with Late PFTs: Decreased FVC, FEV1, FEF 25% 75%, PEF Increased opacity on affected side, multiple rib fractures, atelectasis O2 for Hyperinflation (incentive spirometry, deep breathing, coughing, intermittent positive pressure breathing [IPPB]) Mechanical ventilation for ventilatory failure, chest wall stabilization Continued PULM
PULM Pneumothorax Chest trauma: Penetrating injuries, sudden chest compression Spontaneous: Cough Chest pain Diminished breath sounds on affected side Hyperresonant percussion on affected side Tracheal shift Displaced heart sounds ABGs: Early alkalosis with Late PFTs: Decreased FVC, FEV 1, FEF25% 75%, PEF Air present in the pleural space in the upright view. An expiratory upright posteroanterior exposure may show a smaller pneumothorax more readily. Air is usually seen apically. O2 for Chest tube placement Pleurodesis Hyperinflation therapy 136
137 Hemothorax Chest trauma: Penetrating injuries, blunt chest trauma Post operative Chest pain Diminished breath sounds on affected side Dull percussion on affected side Tracheal shift Displaced heart sounds ABGs: Early alkalosis with Late PFTs: Decreased FVC, FEV 1, FEF25% 75%, PEF Increased density on affected side; blunting of costophrenic angle O2 for Chest tube placement Thoracentesis Hyperinflation therapy PULM
PULM Pediatric Diseases Laryngotracheobronchitis Parainfluenza virus Influenza A,B virus Respiratory syncytial virus Slow onset Dyspnea Inspiratory stridor Barky, harsh cough Substernal and intercostal retractions Accessory muscle use ABGs: Early O2 for Corticosteroids alkalosis with Aerosolized racemic Late epinephrine Cool aerosol therapy Lateral neck Intubation and radiograph: mechanical Swollen tracheal ventilation for tissue (subglottic) failure 138
139 Acute epiglottitis Hemophilus influenza B (bacterial) Sudden onset Low-grade fever Dyspnea Drooling Dysphagia Substernal and intercostal retractions Accessory muscle use ABGs: Early O2 for Corticosteroids alkalosis with Antibiotics Aerosolized Late racemic epinephrine Cool aerosol Lateral neck therapy radiograph: Intubation and Swollen epiglottis mechanical ( thumb or ventilation for steeple sign ) failure PULM
PULM 140 Transient tachypnea of the newborn (TTN) Unknown: Suspect delayed absorption of fetal lung fluid ABGs: Intercostal retractions Breath sounds: Wheezing, crackles, rhonchi Expiratory grunting Early alkalosis with Late Initially normal, increased pulmonary vascular congestion; later, patchy infiltrates O2 for Bronchial hygiene Continuous positive airway pressure (CPAP) Mechanical ventilation for failure Neonatal Diseases
141 Meconium aspiration Aspiration of meconiumstained amniotic fluid Intercostal and substernal retractions Breath sounds: Wheezing, crackles, rhonchi Expiratory grunting Meconium staining on fingernails, toenails, and skin wrinkles ABGs: Early alkalosis with Late May show hyperlucency with obstruction, may show atelectasis and consolidation with patchy infiltrates Suction the airway Intubation for lower airway aspiration O2 for Bronchial hygiene CPAP Mechanical ventilation for failure Continued PULM
PULM Diaphragmatic hernia Congenital diaphragmatic hernia Intercostal and substernal retractions Diminished breath sounds on affected side Expiratory grunting Barrel chest ABGs: Early alkalosis with Late Intestines present in chest cavity above the diaphragm, mediastinal shift away from affected side, atelectasis Placement of nasogastric tube to decompress the stomach/ intestines O2 for Intubation and mechanical ventilation for failure Surgical repair 142
143 Idiopathic (infant) distress syndrome Unknown but suspect: Surfactant deficiency Hypoxic hypoperfusion Apnea Intercostal and substernal retractions Bronchial breath sounds, crackles Expiratory grunting ABGs: Early alkalosis with Late Increased opacity with diffuse patchy infiltrates ( ground glass ) CPAP Exogenous surfactant replacement therapy Mechanical ventilation for failure Continued PULM
PULM Bronchopulmonary dysplasia (BPD) Low gestational age Mechanical ventilation High oxygen concentrations Apnea Intercostal and substernal retractions Breath sounds, crackles, wheezing, rhonchi Expiratory grunting ABGs: Early alkalosis with Late Increased opacity with diffuse patchy infiltrates ( ground glass ), later bilateral diffuse opacification, late areas of patchy irregular densities from atelectasis Mechanical ventilation to support symptoms: minimize FIO2, minimize mean arterial pressure Bronchodilators Bronchial hygiene Monitor fluid balance 144