Physics exam 3

CXR

Chest x ray, evaluates the lungs, heart, pleura and tube placement

CT

Computed tomography, uses x ray to get cross sectional images of lung lesions, diseases

MRI

Magnetic Resonance imaging, magnetic fields to see soft tissue, vascular and mediastinal issues

Ultrasound

Sound waves to see pleural effusions, pneumothorax and to guide procedures

V/Q

Ventilation/ perfusion scan compares air reaching the lungs with blood flow to the lungs

What can a V/Q scan indicate?

Pulmonary embolism: sudden blockage of an artery in the lung

PET

Positron emission tomography, shows metabolic activity combined with CT to see cancers

How to read a CXR

Is the trachea midline or shifted due to fluid or air buildup, are the lungs clear, collapsed, opaque , dark, is the heart enlarged, is the diaphragm flatted from excess air ?

What are the components of the chest tube collection system

(1) Suction control chamber , (2) Water seal chamber, (3) Collection chamber,

What does the collection chamber do?

collects fluid and blood from the pleural space

What does the water seal chamber do?

one way valve that allows air to escape but prevents liquid from entering

What does the suction control chamber do?

regulates suction, wet suction systems will have a gentle bubble, if its a dry system a bubbling will mean that there is a leak 

Where does the chest tube go for a pneumothorax?

The apex of the lung since air is in the upper space of the pleural cavity

Where does the chest tube go for a pleural effusion?

posterior or lateral since the fluid collects in dependent regions, they sit lower and are affected by gravity 

What is a pleural effusion?

abnormal build up of fluid in the pleural cavity

What is a hemothorax?

blood pooled in the pleural space

Where does the chest tube go for a hemothorax?

dependent pleural region

What is empyema?

Collection of PUS in the pleural space

Where does the chest tube go for a empyema?

Must be determined by the x-ray but it is placed wherever the fluid is built up

What do you do if the chest tube collection system is nonstop bubbling in the water seal chamber?

This indicates that there is a leak present, check all tubing and move patient if needed

What are indications for a chest tube insertion?

Pneumothorax to release air, tension pneumothorax to decompress, hemothorax to remove blood, pleural effusion to remove pleural fluid, empyema to remove pus, thoracic surgery to remove any fluid or air

What are common contradictions for chest tubes?

Infections, emergency situations, distorted anatomy, pleural adhesion that causes the pleural walls to stick, nearby organs are at risk and an unstable patient

What is a Spontaneous pneumothorax?

Occurs without an external injury or procedure, a collapsed lung from blebs with no prior disease history

What is a Primary spontaneous pneumothorax?

No history of disease pneumo/ collapsed lung

What is a Secoundary spontaneous pneumothorax?

Occurs in someone with an underlying lung disease, still spontaneous and more life threatening than a primary

What is a Traumatic pneumothorax?

Occurs from blunt or penetrating chest injuries such as car crashed, falls, stabbings

What is a Iatrogenic pneumothorax?

Accidental pneumothorax caused by medical intervention such as biopsies or a thoracentesis to remove fluid from around the lungs

What is a Open pneumothorax?

Sucking chest wound, opening in the chest wall that lets air enter and exit the pleural space, can be caused by trauma or accidental medical intervention

What is a Tension pneumothorax?

When air gradually enters the pleural cavity and has no where to escape to, results from a one way valve into the pleural space

What is atmospheric pressure?

760 mmHg

What is intrapulmonary pressure?

The pressure inside of the alveoli, it drops -1 during inspiration but is usually at 0 or atmospheric pressure

What is Intrapleural/ Intrathoracic pressure?

the pressure within the pleural cavity, inspiration is -8 and expiration is -4

What is the inspiration intrapleural pressure?

-8

What is the expiration intrapleural pressure?

-4

What is the trans pulmonary pressure

the pressure difference between the alveoli and the pressure in the pleural cavity

What is the order of pleural layers, from outer to inner

1. Partietal pleura

2. Pleural cavity

3. Visceral Pleura

What is a tracheostomy?

A stoma in the neck passed the vocal cords to maintain airway access, indicated by prolonged intubation, upper airway obstruction and difficulty clearing secretions

What equipment should a trach patient always have?

Trach tube, inner cannula, obturator for insertion, trache collar and ties, cuff and pilot balloon , suction yonker and sterile catheter , O2 delivery device, humification, spare trach tube the same size and one size small

When should the trach cuff be inflated/ Deflated?

The cuff should be deflated for patients who can clear secretions, aren’t on mechanical vent and those who are learning to speak again

Inflated for patients on mechanical ventilation, post operative and high aspiration risks

What is an ETT tube

Endotracheal tube that is inserted through the mouth or nose to secure an airway through the trachea indicated by respiratory failure, inability to protect their airway, severe hypoxemia, inadequate ventilation, controlled ventilation and surgery

What equipment is needed for ETT?

ETT the correct size, laryngoscope, AMBU bag and O2 delivery device, suction, syringe to inflate/ deflate the cuff, ETT face holder

When should the cuff be inflated on an ETT tube?

Once the tube is inserted into the vocal cords

When should the cuff be deflated on an ETT tube?

When intubating or extubating a patient

What pressure should the ETT cuff be at?

25-30

When do you know that the cuff is deflated on an ETT tube?

The patient will make a gurgling sound

Where should the ETT be place?

Through the vocal cords 3-5 cm above the carina

What is a combitube?

Dual lumen rescue airway that is inserted blindly indicated by an emergency airway management when intubation isn’t possible.

Combitube equipment?

Two lumens, two cuffs, ventilation ports and a syringe for the cuffs

What is a LMA?

Laryngeal Mask Airway, a supraglottic airway device positioned above the vocal cords indicated by an emergency airway rescue situation when intubation isn’t possible or during a surgery

LMA equipment

Correct LMA size tube, lube, AMBU bag, O2 delivery device, suction yonker

Where is a LMA positioned?

Over the laryngeal opening confirmed by chest rises and SPO2%, only used in emergencies because it doesn’t offer protection from aspiration like the ETT does

What is a Laryngoscope?

A tool used to visualize the vocal cords and larynx during intubation, includes the handle , blade and light source/ camera

What are the different types of laryngoscopes?

Macintosh- curved blade in the vallecula

Miller- straight blade to life the epiglottis

What is the adult amount of pressure for suction?

-100 t0 -150 mmHg

What is the child amount of pressure for suction?

-80 to -120 mmHg

What is the infant amount of pressure for suction?

-60 to -100 mmHg

What is the neonate amount of pressure for suction?

-60 to 080 mmHg

What is excessive pressure and suction bad?

It can cause trauma, hypoxia and atelectasis/ lung collapse from barotrauma

What is the Adult catheter size?

10 to 16 french but it depends on the ETT size and the quality of the secretions

What is the Child Cather size?

6 to 10 french depending on the airway size

What is the infant/ neonate Cather size?

5 to 8 french

Boyles law and how it applies to chest tubes

When volume increasing, pressure decreases; when volume decreases, pressure increases

during inspiration the chest expands increasing the volume and lowering the pressure

During expiration the chest deflates decreasing the volume and increasing the pressure

• chest tube systems are a lower pressure so the trapped air and liquid gravitate towards the chest tube exit instead of staying in the pleural cavity

When does the mediastinum shift towards the problem?

When the affected side is collapsed from atelectasis

When does the mediastinum shift away from the problem?

When the affected side is filled of air or fluid —> tension pneumothorax, pleural effusion , emphysema and hyperinflation

What does air look like on a CXR?

Black, radiolucent, doesn’t absorb well

What does Fat look like on a CXR?

Dark gray, absorbs a small amount

What does Water/ Soft tissue look like on a CXR?

Medium gray

What does bone look like on a CXR?

Radiopaque, absorbs large amounts of the x ray

what is indicated by gray to white on a CXR?

Pneumonia, edema, masses, pleural fluid

what is indicated by abnormally dark on a CXR?

Extra pleural AIR, pneumothorax with no lung markings, flattened diaphragm

Which film makes the heart look enlarged?

AP, anteroposterior

Where does the beam go in for AP and PA

AP- beam goes in the front, anterior

PA- beam goes in the back, posterior

What does Pneumonia look like on a CXR?

Patchy dense opacities

What does Pulmonary edema look like on a CXR?

bilateral hazy congestitises

What does Atelectasis look like on a CXR?

Opacity with signs of volume loss and lung collapse

What does Pneumothorax look like on a CXR?

Dark pleural space with absent lung markings

What does Emphysema look like on a CXR?

Hyperinflation with flattened diaphragm from excess air

What does it mean to have the ability to protect your airway?

The body is able to keep saliva and food out of the trachea, able to swallow, cough, gag, and prevent aspiration

What is decannulation

Process of removing the tracheostomy tube from the neck after being weened off