pH (acid) 7.357.

45 (alk) PaCO2 (alk) 35 45 (acid) HCO3 (acid) 2226 (alk) PaO2 80-100 PACO2 40 PAO2 100

pH Respiratory Acidosis Respiratory Alkalosis Metabolic Acidosis Metabolic Alkalosis

PaCO2

HCO3

BP 120 / 80 RR 1216 HR 60100 Sat > 95% Temp 37 C / 98.7 F Hb male 1418 female 1216 Tidal Vol. 400600

COMMON RESPIRATORY DRUGS Albuterol unit dose 0.5 ml q4-6 bronchodilator Proventil / Ventolin / Salbutamol Can be mixed w/ Atrovent or Intal Alupent / Metaprel 0.2 - 0.3 ml (5%) 10-15 mg in 2-3 ml NS Metaproterenol Sulfate Bronchodilator 4-6 prn Atrovent 0.02% 250-500 mcg T-QID Anti cholinergic Ipratropium Bromide DuoNeb 3 ml QID bronchodilator Albuterol Sulfate & Iprotopium Bromide Tornalate 1-2 mg in 2-4 ml total vol of NS TID-QID Bitolterol Bronchodilator Do not mix with other drugs Xoponex 0.63 mg or 1.25 mg (ER) q6-8 bronchodilator Levo-Albuterol less cardiac side effects than Albuterol Mucomyst 2-4 cc 10% or 1-2 cc 20% Mucolytics N-Acetylcysteine must be given with a bronchodilator MDI & DPIs Advair 100/50, 250/50, 500/50 BID max 2/day DPI combi drug Serevent & FloventSteroid & bronchodilator must rinse after tx Asthma maintenance / chronic bronchitis Aerobid 2 puffs BID Steriod MDI Flunisolide Atrovent 2.5 ml bronchodilator / Anticholinergic MDI Ipratropium bromide (Not a rescue inhaler) Combivent 18 mcg 2 inhalations QID not to exceed 12/day Albuterol sulfate & ipratropium bromide COPD with bronchospasms Flovent 44 mcg, 110 mcg, 220 mcg BID Steroid MDI Fluticasone propionate Anti inflammatoryasthma maintenance Proair 90 mcg 4-8 puffs q 20 min up to 4 hrs then 1-4 prn albuterol (MDI) Pulmicort flexhaler 1 2 puff BID Steroid DPI Budesonide Qvar HFA 1 2 puff BID Steriod MDI Beclomethasone Dipropionate Serevant Diskus 1 puff BID Bronchodilator DPI Salmeterol Xinafoate Spiriva 18 mcg1 inhalation/day bronchodilator Tiotropium Bromide (Not a rescue inhaler) COPD maintenance tx

Respiratory Acidosis hypoventilation - pulmonary disease RR - depressant drugs Ve PaCO2 acid Respiratory Alkalosis hyperventilation RR Ve PaCO2 acid

- hypoxia - stimulant drugs - anxiety - cardiac dysfunction - trauma - pain

OXYGEN DELIVERY DEVICES Low Flow Devices100% O2 delivers specific flow Nasal Cannulamax flow 8 lpm FiO2 1 lpm = 24% add 4% for each lpm Nasal Reservoir 8 lpm Transtracheal Cathetermax 4 lpm Simple Maskmin flow 5 lpm Range of O2 deliver 40 60% Partial Rebreather mask1/3 deadspace, FiO2 35 60% Non Rebreather maskno room air, FiO2 50-70% High Flow Devices >30 lpm delivers specific concentration of O2 exceeds pts expiratory demands Venuri mask / Venturi Cannula / Transtracheal Catheter 24%, 28%, 31%, 35%, 40% Can use warmed and humidified Oxygen Blender Bleed-in System COMMON RESPIRATORY PATTERNS Eupneanormal rate and rhythm 1220 bpm Tachypnearapid respirations > 25 bpm Bradypniaslow regular respirations < 10bpm Apneausticprolonged gasping insp. followed by very short & inefficient exp Cheyne Stokes rate & depth followed by rate & depth followed by periods of apnea Biotsfast deep breaths with periods of apneano set rhythm Apneaabsence SBAR FORMAT Situation: Patient identifiers: name, DOB Diagnosis, physician Respiratory status, isolation procedures Abnormal findings / results during shift BackgroundHospital course: Past medical / Respiratory history Oxygen therapy and status Therapyboth regular and PRN Ventilator settings, airways, days on vent Current and previous weaning criteria and results Course of treatment Patient progress and response to therapy Assessment: ABGs, oxygen saturation PFT results Current therapy (s) and response to therapy Vital signs, breath sounds, airway status Recommendations: Therapy changes Teaching follow up? Updates ...other diagnostic test results.concerns

PATIENT DATA COLLECTION Patient:___________ Room #:______ HR : ___/___/___ RR: ____/____ Sat: ____/____ Auscultation: ______ Cough/Sputum: _____ Pt on O2 via:_______ or RA FiO2:______LPM:____ Meds:________ Tx via: ______ Start/End Time:______ Tx Duration:______ Pt Position: ______ Appearance:_____
Auscultations: sounds, tone, pitch, timing w/resp. pattern adventitiousabnormal wheezinghigh pitched musical squeaks (mostly E) crackles (I/E) rales (I) - Fine - soft crackling, popping, bubbling rhonchi (E) - Course - bubbling, rumbling sound stridor - loud high pitch in upper airways (mostly I) rubgrating vibration, loud and harsh diminished, clear, tight, fine, course b/l, t/o, I / E, no p tx Cough: strong, good, weak, tight dry, loose, congested productive, non-productive Sputum: color, viscosity, quantity, odor clear, white, yellow, green, gray, brown, pink, red thin, mucoid, thick, tenacious, frothy small, moderate, copious Respiration: normal (WNL), shallow, labored, noisy, dyspnea, irregular, rapid, Tx Via: FFN, HHN, MP, Mask, Air, O2 Appearance: pain, mood, level of alertness, emotion conciousness: confused, lethargic, comatose diaphoreticfever, stress, WOB, metabolic problems Work of Breathing: accessory muscle use apparent supraclavicular and suprasternal notches patient position: tripod Hypoxia respiratory depth & rate WOB Anxiety

Metabolic Acidosis pH HCO3 PaCO2

- renal dysfunction - lactic acid (anerobic/metabolic) - ketone acids (diabetic) - chronic diarrhea - chronic vomitting - hypokalemia - excessive steroids

Metabolic Alkalosis pH HCO3 PaCO2

COMMON ABBREVIATIONS ATCaround the clock b.i.d.twice a day AFBacid fast bacilli sputum r/o TB Dxdiagnosis CADcoronary artery disease NPOnothing by CFcystic fibrosis mouth CTcomputed tomography r/o PE NSnormal saline CXRchest x-ray POby mouth LTBlayrngotracheobronchitis prnas needed OSAobstructive sleep apnea qevery PCPpneumocystis carinii pneumonia q.i.d.four times a day HIV without PEpulmonary embolism sxnsuction PFTsPulmonary Function Test t.i.d.three times a day pnapneumonia t/othrough out URIupper respiratory infection VOverbal order PATIENT POSITIONS Supinelying on back Pronelying face down R/L Lateral Recumbentlying on side Fowlers (F)sitting straight up Semi-Fowlers (SF) - leaning slightly back Trendelenbergsupine with head lower than feet

cardiac output dyspnea cardiac irritation

HypoxemiaPaO2 < 80 mm Hg PaO2 < 60 = severe minute ventilation WOB tachycardia SOB cyanosis clubbing strength of contraction (inotropic)

Endotracheal Tubes & Suction Catheters

Tube Internal diam. (mm)

WEANING CRITERIA Ventilation Criteria PaCO2 Vital Capacity Spontaneous Vt Spontaneous RR Minute Ventilation Oxygenation Criteria PaO2 without PEEP PaO2 with PEEP SaO2 Qs / Qt P(A-a)O2 PaO2/FiO2 < 50 mmHg with normal pH > 10 to 15 mL/kg > 5 to 8 mL/kg < 30/min < 10 L

Suction Catheters 6 8 8 8 10 10 10 10 10 12 14

Newborn 6 months 18 months 3 years 5 years 6 years 8 years 12 years 16 years Adult (F) Adult (M)

3.0 3.5 4.0 4.5 5.0 5.5 6.0 6.5 7.0 8.08.5 8.5 9.0

> 60 mm Hg @ FiO2 up to 0.4 > 100 mm Hg @ FiO2 up to 0.4 > 90% @ FiO2 up to 0.4 < 20% < 350 mm Hg @ FiO2 at 1.0 > 200 mm Hg

Pulmonary Reserve Max Voluntary Ventilation Max Inspiratory Pressures Pulmonary Measurement Static Compliance Airway Resistance Vd/Vt

2x min vent @ FiO2 up to 0.4 > 20 to 30 cm H2O in 20 secs.

> 30 mL/cm H2O Observe trend < 60%