study guide

Quizzes and Final Exam Study Guide

Ch. 3: Quality, patient safety and communication

· Review causes of potential areas of risks to patients receiving respiratory care

· Review proper technique to lifting heavy objects

· Review organizations responsible for quality and appropriateness of care given to Medicare beneficiaries

· Review parameters that require monitoring during ambulation

· Define: Voltage, current, Ohms, Amps

· Organ most sensitive of electrical shock: Heart

· Purpose of grounding electrical equipment

· Review how O2 contributes to severity of fire

· How is static electrical discharge minimized in the presence of O2

· RACE: what does it stand for

· Definition of channel in communication

· Nonverbal communication methods

· Communicating empathy towards your patients

· Factors that impact outcomes of communication between patient and practitioner

· How do you improve listening skills

· Review communication techniques

Ch. 4: Principles of infection prevention and control

· % of patients who develop hospital associated infections

· Primary source of infection in healthcare

· How do ETT contribute to risk of infection

· What are the risk factors that contribute to hospital associated infection (age, HIV…)

· Review different types of pathogen transmission routes

· Direct vs indirect transmissions

· Distance recommended to stay away from patients with SARS, COVID…

· Which diseases are airborne and require airborne isolation and use of N95

· Definition of surveillance

· Required vaccination for hospital employees (think about the ones you obtained to go to clinic)

· Cleaning and sterilization of equipment: First step is to clean the equipment

· Review Soap and its use to clean equipment

· Review which organisms are destroyed by disinfection agents

· Review what you must do to your hands after treating patients with C-Diff

· How do we transport patients with infections

· Indication for steam sterilization

· glutaraldehyde (≥2.0%) use and indications

· Time frame for hand washing

· ETO sterilization

· Most common respiratory equipment source of patient infections

· Ventilator circuit change frequency

· Which organisms are present with poorly disinfected bronchoscopes

· Review types of isolation- what is transmitted through droplets, direct contact…

· Prevention Bundle

· SVN and associated infections

Ch. 5: Ethical legal implications

· Definition of ethics/what does ethics attempt to answer

· Sanctions that apply when one breaks the law

· Importance of privacy/HIPAA

· Review AARC code of ethics

· Review terms: Autonomy, nonmaleficence, Justice, Role fidelity, veracity, beneficence. Malevolent deception, infidelity, double effect, distributive justice, compensatory justice

· Types of advanced directives

· When can confidentiality by breached

· Consequentialism

· Virtue ethics

· Tort, felony, misdemeanor, litigation, battery, slander, assault, negligence

· Res ipsa loquitur, Respondent superior

Ch. 16. Bedside Assessment of the Patient

· Purpose of an RT interview

· Social, personal and intimate space

· Leading questions

· Causes of increase drive to breathe

· Terms: orthopnea, platypnea, eupnea, apnea

· Factors of an effective cough

· Causes of dry non productive cough

· Terms: sputum, phlegm, mucus

· Terms: fetid, mucoid, purulent

· Hemoptysis, hematemesis

· Causes for pleuritic chest pain

· Terms: angina, myalgia

· Most common cause of pedal edema

· Critical elements of a patients past medical history, social and environmental history

· What is diaphoresis

· Causes for tripoding

· Altered sensorium leads to what characteristics

· What regulates body temperature

· Causes for hypo and hyperthermia

· Causes of tachycardia, tachypnea, bradypnea, bradycardia

· What is a differential diagnosis

· Causes of pulsus paradoxus

· Normal vital sign ranges, causes for increases and decreases

· Pulse pressure

· Pursed lip breathing indications/benefits

· Central cyanosis

· Causes of tracheal shifts

· Causes for JVD

· Causes of lymphadenopathy of the neck

· Barrel chest

· Terms: kyphosis, kyphoscoliosis, pectus carinatum, evactum

· Causes for neuro breathing patterns, increased ICP

· Cheyne stokes, biots, kussmauls, paradoxical

· Characteristics of an increased WOB

· Rapid shallow, indicative of atelectasis

· Prolonged exhalation associated with asthma, COPD

· Hoover’s sign

· Tactile fremitus, bronchophony

· Subcutaneous emphysema causes

· Auscultation and percussion technique

· Breath sound review

· Terms epigastric, precordium

· PMI

Ch. 17: Interpreting clinical lab data

· Components of a CBC

· Components and what It means to have elevated or decreased WBC count

· Causes for high/low Hb

· Causes for high/low WBC

· Causes for high/low platletes

· Bands/Segs

· Critical values vs reference range

· Types of anemia, MCH

· Ranges for electrolytes: K, HCO3, Ca, Cl, Na, Glucose

· Terms for high and low electrolytes (ex: hypokalemia)

· Purpose of a sweat chloride test

· Anion gap, causes for metabolic acidosis

· Creatinine what does it represent

· Liver enzymes

· Cardiac enzymes

· Causes for increased BNP

· Sputum sample and amount of epithelial cells

· Xpert® MTB/RIF in diagnosing TB infections

Ch. 11: Ventilation

· Review all lung volumes and capacities

· Primary function of the lungs

· Review: PA, PBS, PAO, Ppl

· Review all lung pressure gradients

· Review what occurs during normal inspiration and expiration

· Review surface tension, airway resistance, elastic forces

· Hysteresis

· Presence of surfactant does what

· Compliance: how is it calculated, normal values, dynamic vs static

· Causes for increases and decreased compliance

· Review VC, MIP

· Review airway resistance and causes for increased RAW, formula, normal value

· Poiseuille’s law

· Frictional resistance where does it occur, increases

· Equal pressure point (EPP)

· Force x distance

· Volume-pressure curve characteristics

· Rapid shallow breathing vs slow and deep, causes for each

· Normal oxygen consumption percent

· Regional factors that affect distribution of gas in the normal lung

· How is time constant computed

· Optimal peep, how is it set

· Best indicator for adequacy or effectiveness of alveolar ventilation

· Definition of hyperventilation, hyperpnea, hypoventilation

· Alveolar ventilation, formula, causes for increase and decrease

· Resting metabolic CO2 production and Oxygen consumption in ml/min

· VDphy what is the normal value, how do we overcome deadspace

· What can increase VD/VT

· Modified bohr equation used to calculate dead space

· Ve calculation

Ch. 12: Gas Exchange and Transport

· Definition of diffusion

· Amount of PAO2, PaO2, O2 in cells

· Amount of PACO2, PaCO2, CO2 in cells

· Casues for increased PACO2

· Primary determinant of PAO2, formula

· Approx. PAO2 on 100% FIO2 at sea level

· a/A ratio, PF ratio, A-a gradient/normal values

· highest PAO2 while breathing room air at sea level

· gas diffusion must occur by transversing through what layers (AC membrane, RBC membrane…)

· normal values of PO2 and PCO2 in mixed venous blood

· CO2 and CO diffuse faster than O2 across AC membrane, how many times

· Minimum amount of time that blood must take for pulmonary capillary transit for equilibrium of O2 to occur across the AC membrane

· Shunting vs Deadspace ventilation, V/Q mismatches

· How is O2 and Co2 carried in the blood

· CaO2, VO2 and DO2 formula

· Hamburger phenomenon

· SVO2 value

· O2 dissociation curve

· Bohr and Haldane effect

Ch. 36: Pharmacology

· All medication names and doses, frequency including:

· LAMA, LABA, SAMA, SABA, ICS, Combination drugs, mucolytics, bland aerosol, vasodilators, anti-infectives, anti-asthma

· Including: (know generic and brand names)

· Atovent

· Spiriva

· Albuterol

· Serevent

· Tudorza

· Trelegy

· Advair

· Symbicort

· Pulmicort

· Flovent

· Anoro

· Aclidium bromide

· Breo Elipta

· Dulera

· Racemic epinephrine

· Xopenex

· Vilanterol

· Arfomterol

· Tobi

· Mucomyst

· Dornase alfa

· Hypertonic Saline

· Indacterol

· Olodaterol

· Qvar

· Survanta

· Performist

· Duoneb, Combivent

· Nitric Oxide

· Ciciesonide

· Leukotrienes

· Arnuity Ellipta

· Pentamidine

· Lloprost

· Asmanex

· Know side effects, indications

· Mode of action of all drugs

· Receptor sites: Alpha 1, Beta 1-2, Muscarinic (M1-3)…adrenergic, anti-cholinergic

· Terms: Expectorant,Tolerance, Drug administration, pharmacokinetic, pharmacodynamic, bioavailability

· Use of MDI, DPI, SMI’s, holding chambers, SVN’s. Mesh nebulizers

· Advantages of inhaled medication route

· Catechol O-methyltransferase (COMT), phosphodiesterase, cholinesterase

· Use of I-neb

Ch. 37: Airway Management

· Indications for suctioning, suction technique/procedure steps, pre suction techniques

· Side effects/complications of suctioning

· Equipment needed for suctioning

· Vacuum pressures adult/peds/babies

· Suction catheter sizes

· Open vs closed suction techniques

· Percutaneous dilation tracheostomy vs surgical tracheostomy

· Intubation indications for oral and nasal

· Tracheostomy indications

· Artificial airway types

· ETT sizes (adults, peds, babies), intubation procedure and equipment required

· Murphy eye

· Purpose of cuff, cuff pressure monitoring, troubleshooting

· Trach types and components

· Miller vs macintosh

· Sniffing position, cricoid pressure

· Time frame for intubation attempt

· ETT confirmation procedure/location on CXR, ETT placement at lip

· Use of capnography

· Complications of intubation

· local anesthesia and vasoconstriction during nasal intubation

· limitations of using a laryngeal mask airway

· post extubation complications

· complications of trachestomy tubes

· cuff pressures

· weaning off a trachestomy tube

Ch. 39: Humidity and Aerosol Therapy

· Isothermic saturation boundary- location, how is it changed/shifted

· Goal of humidity therapy

· Indications to warm inspired air

· Consequences of not adding humidity to flows >4L/min

· Goals of delivering gases to nose/mouth: 50% RH, at 20-22 degrees C

· Goals delivering gases to hypopharynx: 95% RH at 29-32 C

· Goals delivering gases through artificial airways: 100% RH at 32-35 C

· Indications for cool humidified gas

· Humidifier vs nebulizer

· Factors that effect a humidifier performance

· Most important factor for a humidifier = temperature

· Calculation of relative humidity, body humidity

· Signs and symptoms of inadequate airway humidification

· Types of humidifiers

·  relief valve on a bubble humidifier does what

· At high flow rates, what do some bubble humidifiers produce?

· Passover humidifier types

· Wick

· HME types/uses, effieicent rating/hazards

· Heated humidifier indications and operation

· Use of MDI while HME is in place

· When using nebulizers, where should you place them to minimize risk of contamination?

· heated-wire circuit use

· Hazards of bland aerosol

· Indications for water or isotonic saline aerosol, hypertonic

Ch. 40 Aerosol Drug Therapy

· Definition of a aerosol

· Types of nebulizers

· Aerosol output, density, deposition, sedimentation, inertial impaction, Brownian movement/diffusion

· Emitted dose

· Cascade impaction

· MMAD: ranges and where they deposit in the airway

· GSD

· Heterodisperse

· Know factors affect pulmonary deposition of an aerosol

· How do you increase deposition by inertial impaction

· Purpose of a sustained maximal inspiration

· Term aging

· How do you minimize risk of infection with aerosol drug therapy

·  Know which drugs or drug categories have been associated with increased airway resistance and bronchospasm during aerosol administration

· Know which agents has been associated with increased intraocular pressure

· How do you decrease risk of thrush

· Limitations of DPI and breath actuated systems

· MDI use, propellants use, use on children…

· DPI use, advantages/disadvantages

· SVN use and design, how does it work, what happens if it is not upright position, if flow is set to high…

· Dead volume left with SVN

· How do you decrease infection with SVN use

· recommended dosage for continuous bronchodilator therapy (CBT)

· use and indications of peak flow meters

Ch. 41: Storage and delivery of Medical Gases

· Review therapeutic gases

· Know characteristics of O2, NO, He, N2, CO2, air

· Know what fractional distillation is

· Purity level of O2 per FDA

· Physical separation of O2 in home care setting

· Components of medical air compressors

· Hospital air compressors capable of maintaining 50 PSI and 100L/min

· Why and how is He used as a therapeutic gas

· Tanks: Colors, Tank factors, markings, DOT, formula for duration, testing and material made of, yolk system/PISS, ASSS, DISS, storage of tanks, full PSI

· How are gas vs liquid tanks measured for contents

· Liquid tank duration

· Bourdon gauge vs Thorpe tubes; how do regulators work, multiple stage/single stage, working pressures…

Ch. 42: Oxygen delivery devices

· Hight flow vs low flow, what are the characteristics of each

· All oxygen delivery devices: know flow/troubleshooting/indications and disadvantage and benefits for

· NRM

· Partial rebreathing

· NC

· HFNC

· Simple Mask

· Transtracheal catheter

· Venturi masks

· Reservoir cannulas

· Indications and benefits of O2 therapy; review SpO2 ranges for adults/children

· Heliox use, 70/30 and 80/20 factors, what device is used to deliver it

· Carbogen use

· Symptoms of severe hypoxemia

· Symptoms of hyperoxia/substernal chest pain

· O2 toxicity, how much FIO2 and for how long, consequences of O2 toxicity

· ROP, absorption atelectasis, hyaline membrane formation

· How do we minimize risk of fire hazard with O2 in use

· Approximate FIO2 with O2 devices

· High flow systems deliver at least what flow

· Total flow calculation

· O2 blending systems vs entrainment systems

· How do you confirm proper functioning of a blending system

· Enclosure systems, minimum flows required, indications

· NO therapy, indications, hazards, amount used

· NO2 what is it, issues with it

· Hyperbaric use, indications, settings, physiological effects

Ch. 43: Lung expansion therapy

· Definitions for compression atelectasis, spontaneous pneumothorax, reabsorption atelectasis

· Who is at risk of developing ATX

· Causes of ATX in post operative patients

· CXR findings of ATX

· How do modes of lung expansion result in lung expansion

· Transpulmonary pressure gradient, how can it be increased

· Know indications/contraindications, use, goals, troubleshooting, hazards for:

· Incentive spirometer

· Pep devices

· CPAP

· **There will be no questions on IPPB, but review for your own knowledge

· Types of IS, teach IS preoperatively

· How do you know if a pt with ATX is improving?

· Explain instruction for a sustained maximal inspiration, how long should it last

· Diaphragmatic breathing

· Monitoring of IS, how many breaths, how often…

· Common cause for CPAP not to deliver set pressure

Ch. 44: Airway clearance therapy

· Know normal characteristics of a cough

· Compression

· Closure of glottis

· Deep breath

· Explusion using abdominal muscles

· What triggers coughing

· What is required to have a normal airway clearance

· What may provoke a cough?

· Consequences of having retained secretions/mucus plugs, partial or full obstructions

· Understand different causes for ineffective cough- weak inspiratory muscles, poor compression and so forth

· What impairs mucocilliary clearance in intubated patients

· Diseases that alter normal mucus clearance

· Causes of Bronchiectasis

· What effects the cough reflex

· Goals of airway clearance

· Amount of mucus produced a day expected amount after chest physical therapy

· What labs or assessments would be indicative for the need for airway clearance

· Airway clearance techniques and devices, know when to apply

· Postural drainage and percussion

· IS

· Positive airway pressure

· Contraindications to postural drainage

· Contraindications to turning patients

· How do you determine position of patient based on CXR

· Postural drainage: indications, signs of improvement with use, hazards, contraindications

· Use, indications, hazards of PEP, PAP, EPAP, CPAP…

· Huff coughing

· Oscillation / vest therapy, indications settings, use

· Flutter device, Acapella, EZPAP: indications, how the resistance works…

Ch. 45: Respiratory Failure

· How is respiratory failure diagnosed (look at FIO2, pH, PaO2, PaCO2…)

· Hypercapnic failure: Review causes

· Type I and Type II failure: Causes, treatments

· Hypoxemic failure: causes (V/Q mismatch, hypoventilation, shuting…)

· Shunting and V/Q mismatching

· Signs and symptoms of hypoxic failure, CXR appearance

· Mixed venous issues, commonest cause = Cardiac disease

· Normal A-a gradient on room air and with 100% O2

· Treatment for shunting

· Features of Gullian-Barre

· Chronic vs acute respiratory failure, how do you know someone has acute on chronic?

· WOB, signs and symptoms

· Indication to intubate, pH less than 7.2

· Parameters that indicate need to intubate: MIP, VT, VC, Ve, RR, VD/VT, A-a gradient

· Normal PF ratio

· Adequacy of alveolar ventilation

· Assessing muscle strength: FVC, MIP, MVV

· Contractile respiratory muscle fatigue

· Causes of increased WOB in intubated patients: ETT, vent circuit, Auto-PEEP

· What modes should be used for acute failure

· What mode is recommended for hypoxemic failure: CPAP

· Pressure control used with ARDS

· Greatest risk of Auto-peep = COPD

· Causes of dynamic hyperinflation (increased E-time, increased RAW, decreased exp flow)

· How do you reduce auto-peep

Ch. 46: Mechanical Ventilators

· Definition of ventilators

· Ventilator power source

· Equation of motion

· Definition of cycle, trigger, limit

· Patient vs machine trigger/cycle

· Trigger variables (pressure, flow, volume)

· Purpose of vent alarms

· Circuit compliance and resistance

· Volume control, pressure control, pressure regulated volume control breath types.

· Pressure support

· Trends, waveforms= use/purpose

· Spontaneous, assisted and controlled/mandatory breath

· Goals of mechanical ventilation

Ch. 47: Physiology of Ventilator support

· Spontaneous ventilation effects vs mandatory breathing

· **Note there will be no questions on negative pressure ventilation

· How does PPV work: Ppl pressure increases, Palv increases, alveolar pressure exceeds Ppl pressure

· Shunt: give PEEP, refractory to FIO2

· PEEP: Indications, How does it work, what does it do, how do we set it and what are the hazards

· Spont VT range: 5-7 ml/kg

· Mechanical volume range: 4-8ml/kg (restrictive 4-6 and normal 6-8)

· Rates: normally 10-20, set higher for met acidosis, ARDS, ICP (maybe), resp acidosis

· Compliance: Static vs dynamic, causes for increases/decreased, formula

· Consequence of decrease compliance

· Mean airway pressure: What can increase it (PEEP, I-time, Square to ramp waveform, PIP)

· During PC volume varies depending on: set pressure limit, patient lung mechanics, patient effort

· Know what occurs during pressure and volume ventilation

· Recruitment maneuvers

· Review modes: CPAP, CMV, IMV, PSV; when are they used, how do they work, which one would increase WOB the most

· Normal WOB: 0.6-0.9 J/L

· Plateau pressure: how is it obtained, what does it represent, what values do we try to keep it below (28 cmH2O)

· How does PEEP help with Auto-PEEP, and used with COPD

· Detrimental effects of PEEP

· Contraindications to use of PEEP

· Square vs ramp waveform

· What leads to patient ventilator asynchrony

· Why are patient turned every two hours on the vent

· What happens to PIP on VC when the RAW increases

· Causes for low volume on the vent

· What are time constants?

· Who would you use inverse ratios on

· What are the indications for APRV

· Pressure support: patient triggered, pressure limited, flow cycled

· Side effects/hazards of mechanical ventilation: decreased perfusion

Ch. 48: Patient ventilator interaction

· Causes of patient ventilator asynchrony:

· Trigger issues (poor sensitivity setting)

· Abnormal respiratory drives

· Auto-peep

· Flow asynchrony

· Change in clinical status

· Double triggering/short or long I-times

· Pain, anxiety

· Adverse effects of poor patient ventilator interaction

· How is auto-peep minimized

· How is flow asynchrony in volume ventilation corrected

· How deep should the ETT be on an adult male patient?

· How does the traches shift with severe pneumothorax

· What do you do if your patient becomes severely distressed and alarms are sounding

· Which modes cause the least asynchrony (PAV, NAVA)

· Which mode does asynchrony most commonly occur (VC)

· Auto-peep: How does it effect triggering, how do you correct it

· Normal trigger delay

· Causes of auto-triggering

Ch. 49: Initiating and adjusting invasive ventilation support

· Most common cause of acute respiratory failure requiring mechanical ventilation

· Calculation of Ve

· Calculation of VA

· Goals of mechanical vent support

· Hazards associated with the vent

· Advantages of Assist Control ventilation

· Advantages of pressure control ventilation

· Advantages of volume control ventilation

· VT ranges for normal and restrictive lungs

· How do you improve respiratory acidosis

· Low volumes, higher rates/higher PEEP= ARDS

· Vent order includes: Mode, FIO2, rate, VT, PEEP typically

· Know definition of AC

· Desired PaCO2 and PaO2 formulas

· Permissive hypercapnia: what is it, when do we do it

· Pressure support, when is it used, what does it do

· How do you decrease CO2 production on a patient

· Flow triggering

· Appropiate I:E ratios

· FIO2, what level do we use/start

· Pronning, use/indications

· Optimal peep

· When should you obtain an ABG after initiating the vent

· Alarm settings

Ch. 50: NIV

· Indications, contraindications for NIV

· Goals of NIV

· When do we use ST vs CPAP

· Correcting large air leaks

· Benefits of using CPAP and NIV

· Use of NIV for OSA, hypoventilation patients

· What occurs if you over tighten a mask

· Nasal vs face masks

· Hazards/side effects of being on NIV

· Settings, IPAP, EPAP, Rate, FIO2, Ramp, C-Flex

· IPAP – EPAP = Pressure support, used to correct CO2

· When do we add humidity

· Physiological effects of NIV

· When would you intubate a patient on NIV

· Most common complication with NIV