AHA Exam 3 the better one

How are bronch used today?

Valves for Oxygen

suctioning

biopsies

Improved anesthesia

Improved Visualization

Flexible Scope

Where did the first bronch take place?

1904

- Pork Chop Bone

Ultrathin Bronchoscope

Used for babies / infants

Large Diameter Bronchoscope

Used for suctioning airway or large foreign bodies

Digital Scopes

To visualize

Laser Scopes

Used for removing or obliterate mass with suctioning

What are the indications of Bronch?

Diagnostic

Therapeutic

CXR would be what kind of bronch?

Diagnostic

What kind of bronch would the cause for infection for antibiotic?

Therapeutic

Hemoptysis is?

coughing up blood

- Large Bore then Flexible

- Both Therapeutic & Diagnostic

Pneumonia bronch would be?

BAL

(instill fluid and suction out)

- therapeutic and diagnostic

Interstitial Lung Disease bronch

Because ILD infiltrates into the small bronchioles, we typically need a tissue biopsy through the bronch

Foreign Bodies Bronch

Create a patent airway!

- Remove it

- Bronch depends on what size

Complications for Bronch

Bleeding

Bronchspasm

Hypoxemia

Arrhythmias

Aspiration

Pneumo

What is the number one complication?

Bleeding

- use Epi to stop

Outpatient Flexible Bronchoscopy: Why perform as an outpatient procedure?

Most popular

- saves the hospital money and it's cheaper

Why would you choose not to perform an outpatient Bronch?

Critical issues, recent MI or unstable

Role of RT

Preparation:

Fast

Understand Procedure

Consent

IV Started

Sedation

What kind of medication is used for numbing of gag reflex?

Xylocaine

When to check vital signs?

Every 5 mins

What if you have bleeding after the biopsy?

Epi should be used

Small Sample

2-3 drops between slides

Large Lavage Sample

Speci Trap to lab

Post Procedure:

Vitals every 5-15 minutes

Observe for Discomfort

- SOB

- bleeding

When to discharge?

- alert and oriented

- good gag

- no bleeding

- throat feel normal

- normal vitals

Charting for Bronch:

Include procedural notes, indications, medications given, specimens collected, all tests requested.

Make note of any complications

Specimen to lab should include:

Patient's name, ID number, Date, Site of origin, and Staff Identification

What is Sleep Apnea?

Sleep-related breathing disorders are characterized by abnormal breathing patterns during sleep

What are the sleep disorders?

Obstructive sleep apnea syndrome

Central sleep apnea syndrome

Mixed sleep apnea

Sleep-related hypoventilation/hypoxemia syndromes

How many people have sleep disorders worldwide?

40 Million

How many people have sleep apnea worldwide?

18 Million

Sleep apnea

Repeated episodes of no airflow for 10 seconds

Obstructive sleep apnea

Effort but no airflow due to upper airway obstruction

Central sleep apnea

CNS fails to signal respiratory effort

Mixed apnea

Elements of obstructive & central apnea

Hypopnea

Decrease in breathing but still airflow

Overlap syndrome

Chronic obstructive pulmonary disease (COPD) with coexisting OSA

What are the two steps of sleep?

NREM - Non-Rapid Eye Movement

REM - Rapid Eye Movement

How many stages does NREM have?

3

- Each stage of NREM is a progressively deeper stage of sleep

NREM - Non-Rapid Eye Movement

- Considered our Restorative Sleep

- 75% of Sleep Cycle

- 3 Stages of Progressively Deeper Sleep

What is the deepest stage of sleep in NREM?

Stage 3

What is associated with Stage 3?

- Increase PaCO2

- Decreased VE

- Decreased BP

REM - Rapid Eye Movement

Dreams Begin to Occur

Can have Skeletal Muscle Paralysis

HR & BP may vary

Possible Arrhythmias

What is OSA?

Obstructive Sleep Apnea

- is a common sleep disorder that often requires lifelong care

What are the characteristics of OSA?

Obstructive apneas

Hypopneas

May exhibit strong respiratory effort during apnea

Respiratory effort-related arousals (RERAs)

What are the causes of OSA?

Caused by recurring collapse of the upper airway during sleep

Causes: Something anatomic that creates a blockage of the airway: Enlarged Tonsils, Tongue, Under developed Jaw, Deviated Septum, Double Chin

Why do OSA patients sometimes suddenly GASP and wake up?

Afferent neuron response tells brain that it is not breathing enough while efferent tells them to breathe

What are the consequences of UNTREATED OSA?

Daytime sleepiness impairing ability to operate machinery or a vehicle

High blood pressure

Heart failure

Stroke

What are the signs and symptoms of OSA?

Habitual, loud snoring

Falls asleep while driving

Slowed responses

Morning tiredness and feeling a lack of rest even after sleeping

Morning headache

Depression

CSA is a disorder characterized by?

The repetitive stopping or reduction of both air flow and ventilatory effort during sleep

No Airflow & No Effort

CSA can be classified as?

Primary CSA (idiopathic or unknown cause of CSA)

Secondary CSA (CNS injury)

< 10% of adults with Sleep Disorder Breathing have?

CSA

Potential Causes of CSA include?

Stroke, Brainstem Lesion, Encephalitis, Cervical Spine Radiation, or unknown

Signs and Symptoms of CSA include?

Lack of Restorative Sleep

Neurological Signs: Swallowing, weakness, numbness

Cheyne-Stokes Breathing

Mixed Sleep Apnea (MSA) is?

A combination of OSA and CSA

Usually begins as central apnea followed by the onset of ventilatory effort without air flow (obstructive apnea)

Clinically, patients with predominantly mixed apnea are classified and treated as?

OSA

What must you do first to diagnose MSA?

MUST have Polysomnography testing to identify

* Treat OSA first, then address CSA

Sleep-Related Hypoventilation/Hypoxemia Syndromes include?

a broad range of sleep disorders

Obesity hypoventilation syndrome is?

Co-existing with COPD, the so-called "Overlap Syndrome"

Typically obese smokers with moderate to severe nocturnal desaturations

Undiagnosed OSA complicates COPD patients with nightly arousals, dyspnea, desaturations resistant to O2

What is the primary symptom for children with sleep apnea?

SNORING

Sleep Apnea in Children

Often present differently than adults: Hyperactive, Aggressive Behavior, Social Withdrawal, Poor Academic Performance

Premature Infants and Mild Apnea

SIDS possibly due to?

CSA, but no specific evidence found

How do you diagnosis OSA?

Begins with a comprehensive sleep evaluation, which includes:

- A history from the patient and/or the patient's bed partner

Especially noting the presence of:

- Snoring

- Sleep fragmentation

- Periods of apnea during sleep

- Nonrefreshing sleep

- Persistent daytime sleepiness

What are some screening standards for OSA?

The Epworth Sleepiness scale

The Fatigue Severity Scale (FSS)

The Visual Analogue Fatigue Scale (VAFS)

The Mallampati classification score - size of tongue

The patient's blood may be evaluated for the presence of:

Polycythemia

Reduced thyroid function

Bicarbonate retention*

ABGs

Chest x-ray

Electrocardiogram (ECG-looking for arrythmias)

The diagnosis and type of sleep apnea is confirmed by?

Polysomnography (PSG)

What is a PSG?

Sleep test that monitors and records a number of physiologic parameters that occur during sleep to help determine the type of sleep disorder

Administered as in-laboratory polysomnography

What does the RT do for OSA?

They are helpful when determining the best level of CPAP to help eliminate APNEA

The degree of sleep apnea is determined by?

Apnea-hypopnea Index (AHI)

# of apneic episodes / hour

-primary diagnostic calculation used to confirm and classify sleep apnea.

Normal AHI

Mild AHI

5-15

Moderate AHI

15-30

Severe AHI

>30

T/F: Anything classified as Moderate or above, should be treated.

True

What is treatment for OSA?

Behavioral interventions

Positional therapy (avoid supine position)

Oral appliances (second-line therapy)

Devices that enlarge airway by:

Moving mandible forward

Keeping tongue forward

Medications treatment for OSA

Ineffective for most patients with sleep apnea

Antidepressants may be useful for mild cases (rare)

Oxygen helps avoid desaturations

What is the first-line therapy for OSA?

Positive pressure therapy

CPAP of 7.5-12.5 cm H2O

CPAP of 7.5-12.5 cm H2O alleviates?

upper airway obstruction in most patients

Positive pressure therapy shown to:

Decrease incidence of pulmonary hypertension & right heart failure

Decrease ventilation-related arousals & nocturnal cardiac events

Improved daytime oxygenation & ventilation

CPAP therapy:

primarily works by pressure splinting airway open

should reduce number of apnea episodes & hypopneas

Overall Improved sleep

What is the key to CPAP success?

Patient compliance

Bilevel pressure therapy (BiPAP)

Better tolerated by patients with high CPAP levels

Assists in ventilation & airway splinting

Autotitrating devices (smart CPAP)

Adjust to varying patient needs

Use computer algorithm to adjust CPAP to changes in airflow and/or vibration (snoring)

Average pressures may decrease

Claustrophobia & skin irritation?

change interface

Nasal congestion, rhinorrhea, nasal dryness, irritation?

Topical steroids, antihistamines, nasal saline sprays, lotions

Sensation of too much pressure?

Ramp-up of pressure over number of minutes MAY be useful

Pressure leaks?

Mouth breathers have problems with nasal masks

Add chin strap to close mouth or change to full mask (oronasal)

Uvulopalatopharyngoplasty (UPPP)

Reconstructs portions of uvula, soft palate, soft tissue of pharynx

Success is less than 50%

Not currently recommended for management of OSA

Maxillofacial surgery (more promising)

Phase I: UPPP, genioglossal advancement, hyoid bone resuspension

Phase II: Only if phase I is unsuccessful, then advance maxilla & mandible

In worst cases (nonresponsive to all other management techniques)?

tracheostomy may be performed that bypasses obstruction in OSA

Role of Respiratory Therapist for OSA

Management of patients with sleep disorders

Observe evidence of abnormal breathing during sleep

Recommend testing of patients

Team member of sleep laboratory

Assist in titration of CPAP, interface fitting & management

spores

- organisms in a resting, resistant stage

- very difficult to kill

- pose a threat to rt equipment

- ex. bacteria: clostridium and bacillus

disinfection

- kills all vegetative forms of organisms

- does NOT kill spores

- disinfectants

-cidal

- KILLS bacteria

- ex. bactericidal

-static

- refers to PREVENT GROWTH

- bacteriostatic

bacilli

- rod shaped bacteria

- frequently on respiratory equipment

- non-spore forming bacteria

cocci

sphere shaped bacteria

spirillum

spiral shaped bacteria

autoclave

- decontamination method: steam under pressure