Pulmonary Objectives

The right lung has (2,3) lobes, and the left lung has (2,3) lobes

3, 2

does the diaphragm ascend or descend during inspiration?

descend

what nerve innervates the diaphragm and what level is it?

phrenic nerve (C3-C5)

the external intercostals are activated during (inspiration, expiration) and the internal intercostals are activated during (inspiration, expiration)

inspiration, expiration

what are the accessory muscles that contribute to inspiration?

SCM, scalenes, and pectorals

what muscles contribute to expiration

abdominals (T7-L1)

internal intercostals (T1-T12)

chest wall motion of anterior and posterior is similar to what?

pump handle

chest wall motion in frontal plane is similar to what?

bucket handle

what are typical changes with aging that increase WOB and may affect exercise response?

\-Increased stiffness of chest wall

\-Increased thoracic kyphosis reduces VC

\-Reduced elastic recoil raises RV

\-Decrease colliery function reduces ability to protect lower airway

\-decreased strength and flattening of diaphragm decrease VC

\-Changes in alveolar and capillaries cause reduced diffusion of O2 and CO2

In pt’s with COPD, which air is trapped and what volume increases

expired air is trapped, which increases residual volume

in pt’s with RLD, what volumes are decreased

all of them (IRV, TV, ERV, RV)

what is the normal percentage for forced vital capacity

80-120%

what is the normal percentage for forced expiratory volume

80-120%

what is the normal ratio for FEV1/FVC

0\.8 or 80%

for forced vital capacity, what would it look like with pt’s with COPD

decrease due to air trapping

for forced vital capacity, what would it look like with pt’s with RLD

decreased due to decreased lung flexibility, increased WOB, and decreased ventilatory muscle strength

for forced expiratory volume, what would it look like for pt’s with COPD

decreased due to air trapping and increased WOB

for forced expiratory volume, what would it look like for pt’s with RLD

decreased due to decreased lung flexibility, increased WOB, and decreased ventilatory muscle strength

for FEV1/FVC ratio, what would it look like for pt’s with RLD

normal or increased, because overall VC is smaller and the amount exhaled in the first second will be higher

for FEV1/FVC ratio, what would it look like for pt’s with COPD

decreased due to air trapping and increased WOB

what is the equation for vital capacity (VC)

IRV + TV + ERV

what is the equation for total lung capacity

IRV + TV + ERV + RV

what is the equation for functional residual capacity?

ERV + RV

what is the equation for inspiratory capacity?

IRV + TV

what is ventilation?

flow of air into and out of alveoli

what is perfusion?

passage of blood through vessels to other tissues

what is normal ratio for V:Q?

0\.8

if a pt has pulmonary embolism or pulmonary hypertension, what will their V:Q be?

V:Q >0.8, inadequate perfusion which means ventilation is bigger

if a pt has atelectasis, pneumonia, or COPD, what will their V:Q be?

V:Q

what is hypoxemia

low oxygen levels in the blood

what is hypoxia

low oxygen levels in the body tissues

what is the normal ratio of inspiration to expiration

1:2 or 1:3

what is the ratio of inspiration to expiration with pt’s with COPD

1:4

what is the formula for minute ventilation

tidal volume x respiratory rate

T/F: A pt with RLD, we want to instruct them to slow their breathing while exercising when their breathing becomes abnormal

FALSE, pt’s with RLD are unable to breath deeply which is why we see tachypnea with these pt’s. Instead reduce the intensity of the workout so their respiratory rate returns to a comfortable level

what is normal arterial partial pressure of carbon dioxide (PaCO2)

35-45mmHG

what is hypercapnia

when PaCO2 is >45mmHg

what is normal arterial partial pressure of oxygen (PaO2)

80-100mmHg

what is mild hypoxemia

60-80mmHg

what is moderate hypoxemia

40-60mmHg

what is severe hypoxemia

what is normal arterial pH

7\.35-7.45

what is normal arterial bicarbonate ion (HCO3)

22-26mEq/l

what is normal arterial oxygen saturation (SaO2)

95-100%

what are the components of the BODE index

BMI

Obstruction

Dyspnea

Exercise

what is a paradoxical breathing pattern

during inspiration, the belly goes OUT and diaphragm descends, and during expiration the belly sinks back down

what normal breath sound is medium intensity, medium pitch, and equal I-E with no pause in between

Bronchovesicular

what normal breath sound is low intensity, low pitch, short expiratory phase, and no pause b/t I-E

vesicular

this abnormal breath sound is produced during expiration and occurs because narrowing of airway. the sounds are continuous and are high or low pitch.

wheezes

abnormal breath sound that occurs during inspiratation and expiration that sounds like fire popping

crackles

abnormal breath sound that sounds like a leather saddle on a horse being stretched due to decrease fluid between visceral and partial layers which causes friction

pleural rub

What dx will we see an ipsilateral trachea

atelectasis

what diangoses will we see a contralateral trachea

pleural effusion and pneumothorax

which is the gold standard to measure oxygen in the blood/tissues?

SaO2

for patients in their 30s, what is normal SaO2 and PaO2

96% and 92mmHg

for patients in their 50s, what is normal SaO2 and PaO2

94% and 82mmHg

for patients in their 70s, what is normal SaO2 and PaO2

92% and 74mmHg

for patients in their 90s, what is normal SaO2 and PaO2

91% and 66mmHg

For pt’s with COPD or CHF, what is their SaO2 and PaO2

85-88% and 50-56mmHg

For pt’s with COPD or CHF, what may their SpO2 drop to during mod exercise

drops about 4%

what is the goal SpO2 to keep for pt’s with COPD and CHF

88-90%

what factors could lead to an unreliable reading for SpO2

\-arrhythmia

\-fingernail polish

\-poor circulation (cyanosis)

\-bright light in room

\-motion in arm

\-Raynaud’s

\-callouses

\-increased sweaty/oily hands

what can lead to falsely high SpO2 readings

\-black/brown skin

\-cigarette smoking (SpO2 can differentiate b/t CO2 and O2)

\-carbon monoxide poisoning

low readings of SpO2 may indicate what

\-tissue hypoxia

\-older patient’s

how can we tell if pulmonary system is the reason for dyspnea

\-excess secretions

\-accessory muscle use

\-nasal flaring

\-intercostal retraction

\-bronchodilator relieves

\-increase AP chest diameter

\-tripod position relieves

how can we tell if cardiac system is the reason for dyspnea

\-dyspnea only occurs with activity

\-accompanied by irregular HR OR extreme change in BP

\-syncope

\-nitroglycerin relieves it

green, brown, or rust color sputum results in

infection

pink and frothy results in

pulmonary edema

central cyanosis is due to

impaired ventilation and hypoxemia

peripheral cyanosis is due to

impaired circulation and hypoxia

what are the 8 symptoms for respiratory distress

\-dypnea

\-tachypnea

\-accessory muscle use

\-intercostal retraction

\-nasal flaring

\-cyanosis

\-stridor

\-confusion/agitation

what is considered respiratory failure

PaO2

what are the 4 cough phases

\-irritation

\-glottis closure to increase airway pressure

\-compression

\-forceful expiration

what is level of innervation for SCM

C2-3, CN XI

what is level of innervation for scalens

C2-7

what is level of innervation for Trapezius

C3-4, CN XI

what is level of innervation for pectoral

C5-T1

what is level of innervation for intercostals

T1-12

what is level of innervation for abdominals

T7-L1

what part of the lung will have the highest rate of perfusion

most gravity dependent

what are the best positions for patients to be in for optimal V:Q

upright if medically allowed

if not, prone and sidelying (not full as it increases risk of pressure ulcers)

the there is unilateral lung impairment, how do we want the pt to lay

side lie with affected side up

with bilateral lung involvement, how so we want the pt to lay

side lie on right side with heart side up

what type of incentive spirometer is the most effective in prevention of atelectasis

volume-mode

what type of incentive spirometer uses quick maximal inspiration followed by max expiration

flow velocity mode

what is FiO2 for nasal cannula @ 1 liter/min

0\.24

venturi mask requires __ lpm of oxygen to achieve an FiO2 of __

1, 0.24

what if FiO2 for nasal cannula at 2 liter/min

0\.28

what is FiO2 for nasal cannula at 3 liter/min

0\.32

what is FiO2 for nasal cannula at 4 liter/min

0\.36

what is FiO2 for nasal cannula at 5 liter/min

0\.40

what is FiO2 for nasal cannula at 6 liter/min

0\.44

FiO2 should bis less than __ and positive end expiratory pressure should be less than __ to mobilize the pt

0\.6 and 10cc H2O

hematocrit percentage for men

42-52%

hematocrit percentage for women

37-37%

hemoglobin for men

14-18g/dL

hemoglobin for women

12-16 g/dL

RBC count for men

4\.5-6.0 million/mm3

RBC for women

4\.0-5.5 million/mm3

WBC count

5,000-10,000 leukocytes/mm3