Trachea is shorter; angle of right bronchus at bifurcation is more acute (steeper slope)

Children

What are some A&P differences in the respiratory system or that affect the respiratory system of children?

Fewer alveoli

Less flow between alveoli

Lower Hgb

Lower SV

Higher metabolic rate

Average respiratory rate for a newborn

30-60

Average respiratory rate for infants

30

Average respiratory rate for preschoolers

25

Average respiratory rate for school age

20

Average respiratory rate for adolescents & adults

12-18

Airway edema, although serious with any age, is especially dangerous with this population r/t level of diameter decrease it causes

Newborns (small airway of 4mm can decrease to 2mm)

Mechanisms that facilitate or impair the body's ability to supply oxygen to cells

Oxygenation

Which of the following individuals would be at greatest risk for pneumonia

1. A 37 year old who recently delivered via a cesarean birth
2. An 8 year old with a history of allergies and asthma
3. A 55 year old who fractured fibula
4. A 72 year old who has the flu

D. A 72 year old who has the flu

A patient is scheduled to have a ventilation/perfusion (V/Q) scan. The nurse knows this is to diagnose:

1. Asthma
2. Pulmonary fibrosis
3. Pulmonary embolus
4. COPD

3. Pulmonary embolus

When teaching the patient with asthma about the use of the peak flow meter, the nurse instructs the patient to:

1. Increase the use of rescue inhalers (albuterol) if the meter indicates the yellow zone
2. Carry the flow meter at all times
3. Close your mouth around the mouthpiece and inhale quickly when measuring peak flow
4. Go to the emergency room if the meter indicate the yellow zone

1. Increase the use of rescue inhalers (albuterol) if the meter indicates the yellow zone

You monitor your patient oxygen saturation during exercise and finds that it drops from 94% to 87%. The nurse interprets this data

1. The patient requires higher concentration of oxygen during ambulation
2. The patient needs to be on bedrest
3. The patient needs a blood transfusion to increase oxygen carrying capacity
4. The patient requires more deep breathing and use of the incentive spirometry

1. The patient requires higher concentration of oxygen during ambulation

Your patient has chronic COPD with hypercapnia. Which of the following would be the safest order for oxygen for this patient?

1. 6 l/m via nasal cannula
2. 50% oxygen via a rebreather mask
3. 28% venturi mask
4. Administer oxygen PRN only when patient complains of dyspnea

3. 28% venturi mask

Your patient is diagnosed with tuberculosis. Which of the following is most important in treatment

1. Make sure that he is placed in a positive airflow room
2. Institute droplet precautions immediately
3. Ensure that the patient complete the full course of antibiotic treatment
4. Encourage a high protein diet

3. Ensure that the patient complete the full course of antibiotic treatment

Jennie Dasher is recovering from and aortic valve replacement. Her intial blood gas values come back as: pH 7.5, PCO2 30, HCO3 22, PO2 92. These date support which acid base disturbance?

1. Compensated respiratory alkalosis
2. Uncompensated respiratory alkalosis
3. Compensated respiratory acidosis
4. Uncompensated respiratory acidosis

2. Uncompensated respiratory alkalosis

Act of inhaling & exhaling air to transport O2 to alveoli

Respiration

ACTUAL exchange of O2 & CO2 (breathing)

Ventilation

A continuous supply of oxygenated blood to every cell in the body (pumped to all parts)

Perfusion

What are the 3 main components that make up the umbrella of oxygenation?

Ventilation (breathing)

Diffusion (gas exchange)

Perfusion (pumping to all parts of body)

This age group is known for being obligated nose breathers

Newborns

Inadequate supply of O2 in the blood

Hypoxemia

What are some late S/S of hypoxemia?

Combative/coma

Dyspnea @ rest

Cyanosis

Cool, clammy skin

Low BP/HR

What are some early S/S of hypoxemia?

Irritability/restlessness

Tachypnea/dyspnea

High BP/HR

What are some red flags r/t hypoxemia?

Change in mentation:

LOC

Orientation

Irritability

Confusion

Lethargy

What other problems may result in S/S similar to SNS response to hypoxemia?

*Would require us to distinguish between whether or not it's hypoxemia

SNS response to:

Pain

Fear

Sepsis

Alphabet soup r/t oxygenation:

C = ?

Concentration

Alphabet soup r/t oxygenation:

F = ?

Fractional concentration

Alphabet soup r/t oxygenation:

E = ?

Expired

Alphabet soup r/t oxygenation:

I = ?

Inspired

Alphabet soup r/t oxygenation:

P = ?

Partial pressure

Alphabet soup r/t oxygenation:

Q = ?

Volume of blood

Alphabet soup r/t oxygenation:

S = ?

Saturation

Alphabet soup r/t oxygenation:

V = ?

Volume of gas

Alphabet soup r/t oxygenation:

a = ?

arterial

Alphabet soup r/t oxygenation:

c = ?

capillary

Alphabet soup r/t oxygenation:

v = ?

venous

Alphabet soup r/t oxygenation:

p = ?

pulse oximetry

Alphabet soup r/t oxygenation:

A = ?

Alveolar

This is a measure of the hydrogen ion concentration

pH

Alphabet soup r/t oxygenation:

pCO2 = ?

Partial pressure of CO2

Alphabet soup r/t oxygenation:

pO2 = ?

Partial pressure of O2

Alphabet soup r/t oxygenation:

SO2 = ?

Saturation of O2

Alphabet soup r/t oxygenation:

HCO3 = ?

Bicarbonate

"Gold standard" for measuring oxygenation

ABG

If performing a radial ABG, which side should you stick?

Non-dominant hand

What type of patient would we not want to perform a brachial stick to obtain an ABG?

Obese (difficult to assess for hemostasis)

Where would you obtain an ABG on a newborn?

Umbilical artery line

ABG:

Normal PaO2

80-100

ABG:

Normal SaO2

95-100%

ABG:

Normal CO2

35-45

ABG:

Normal HCO3

22-26

ABG:

Normal Base Excess (BE)

-2.0 to 2.0 mEq/L

Hgb is almost fully saturated at this pO2

80-100 mm Hg

Hg saturation with O2 is high in the __1__ and is greatest in the __2__

1. Tissues

2. Lungs

If Hg experiences an increased affinity for O2, these manifestations will ensue

Lower temp

Lower pCO2

Lower 2, 3-DPG

Increased pH

The ease with which hemoglobin releases oxygen to the tissues is controlled by this

2, 3-DPG

If Hg experiences a decreased affinity for O2, these manifestations will ensue

Increased temp

Increased pCO2

Increased 2, 3-DPG

Lower pH

In what different situations can PaO2 & SaO2 not be consistent?

SpO2 <70%

Hg abnormality

Movement/exercise

Vasoconstriction (low perfusion)

Skin color

Intravascular/intradermal dyes

Bright fluorescent lights

Anemia

Hg & O2:

__1__ is the maximum amt. of O2 that can be combined with Hg, whereas __2__ is the actual amount of O2 being carried by Hg

1. Capacity

2. Saturation

How does O2 blood saturation affect Hg saturation?

If Hg isn't fully saturated, a high O2 blood content will result in high Hg

If Hg is highly saturated, a low O2 blood content will result in low Hg

Classical cyanosis is present when 5 g/dL of __1__ or greater is present, and is usually apparent when SaO2 is less than or equal to __2__

1. Deoxyhemoglobin

2. 85%

This sign is not a good indicator of oxygenation

Cyanosis

These 3 systems regulate acid-base balance

Buffer system (metabolic)

Kidneys (metabolic)

Lungs (respiratory)

This counteracts changes to pH due to ability to either absorb or release H+ ions

First line of defense vs. pH changes

Buffer system

3 main buffers of the buffer system of pH maintenance include:

HCO3

Phosphate

Protein

Can directly affect acid-base balance status more quickly & efficiently than all the buffer systems combined

Respiratory system

Can activate pH changes within 1-3 minutes

Respiratory system

Slower process; requires 1-5 days for complete activation to correct acid-base imbalances

Kidneys

How do kidneys react to changes in pH?

Regulate excretion or conservation of H+ & HCO3

How soon are pH buffer systems operational?

In utero

*Renal system limited in newborns

Do newborns have the ability to control pH using their respiratory system?

Yes, so long as pulmonary function is adequate

The renal buffer system is limited in its capacity to respond to pH changes in this age group

Newborns

pH <7.35

pCO2 >45mm Hg

Respiratory acidosis

pH <7.35

HCO3 <22mm Hg

Metabolic acidosis

The body has accumulated too much acid & doesn't have enough HCO3 to neutralize its effects

Metabolic acidosis

This acid-base imbalance is often r/t hyperventilation

Respiratory alkalosis

pH >7.45

pCO2 <35mm Hg

Respiratory alkalosis

pH >7.45

HCO3 >26mm Hg

Metabolic alkalosis

pH is abnormal

pCO2 & HCO3 abnormal

Partial compensation

pH is normal

pCO2 & HCO3 abnormal

Full compensation

At what age will most children first have respiratory symptoms indicative of asthma?

<4 years

What is one of the first signs that a person is having airway restriction indicative of asthma?

Cough

*Wheezing is a medium-late sign of asthma

What's the most common trigger for children's asthma attacks?

Viruses

These factors often predispose children to having asthma later in life

Parental asthma

Eczema/atopy

Asthma is an INFLAMMATORY disease with these 3 characteristics

Edema

Excess mucus production

Bronchospasm

Can mild asthma have a severe exacerbation?

Yes

This doesn't disappear along with the symptoms of asthma following treatment

Airway inflammation (chronically present regardless of symptoms)

In a large number of children, asthma remits at this point in life

Early adolescence/adulthood

This medication is both a bronchodilator & anticholinergic used to treat asthma; thus, you're treating inflammation via both sympathetic & parasympathetic routes

Atrovent (ipratropium bromide)

Incidence of asthma is greater in boys up until this point in life; after this point, it's more prevalent in girls

Until puberty

What are the 2 major groups of medications used to TX asthma?

Rescue & controller medications

Types of rescue medications for asthma

Beta 2's (albuterol, atrovent)

Oral steroids

Anticholinergics (atrovent)

Types of controller medications for asthma

Inhaled corticosteroids

Anti-leukotrienes (Montelukast)

Long-active beta 2's

Combo inhaled & long-acting (Advair, Symbicort)

What objective information is needed for asthma treatment?

Peak flow meters

Spirometry for child >5 yrs (or infant spirometry)

Exhaled nitric oxide measurement (normal eNO = 5-15 ppb)

Allergy testing

This helps w/diagnosis & ongoing TX decisions r/t asthma

Provides objective data for management

Measures obstruction to airflow in airways

Spirometry

Early phase of acute asthma exacerbation:

1. What causes symptoms?

2. What is the treatment?

1. Bronchoconstriction & inflammation

2. Beta 2 agonist (i.e. bronchodilator)

Late phase of acute asthma exacerbation:

1. What is happening to respiratory A&P?

2. What is the treatment?

1. Bronchial hyperresponsiveness

2. Bronchodilator & antiinflammatory medications

Early warning signs of asthma

Cough, throat clearing

Chest tightness

SOB

EXPIRATORY wheezing

Late warning signs of asthma

Cough, vomit

Stop to breathe when walking

Trouble walking normal distances

Accessory muscle use

INSPIRATORY & EXPIRATORY wheezing

What does giving a daily inhaled mcg dose of corticosteroid controller medication prevent?

Having to take an oral milligram dose of corticosteroid medication

What are some worrisome signs during an acute asthma exacerbation?

Climbing pCO2 (35-45)

No wheezing is ominous

Unable to say more than a few words

Confusion

Don't care what's happening around them (just care about oxygen)

Asthma guidelines address these 3 different age ranges

0-4

5-11

>12

How many puffs are in a normal dose of your rescue inhaler?

4

Analyze asthma severity chart on reverse side

Along with rescue meds, this will most likely be added to the TX plan of a mild asthmatic

Low-dose ICS

Along with rescue meds, this will most likely be added to the TX plan of a moderate asthmatic

Medium-dose ICS

Along with rescue meds, this will most likely be added to the TX plan of a severe asthmatic

High-dose ICS + LABA or montelukast; potentially oral systemic corticosteroids depending on severity

What's the "Rule of 2's", as proposed by Baylor University?

Does your child use albuterol > 2x/week?

Does your child have symptoms @ night > 2x/month?

Do you refill your rescue med > 2x/year?

Peak flow < 20% from personal best blow?

What happens if there's a "yes" answer to any of the questions in the "Rule of 2's" from Baylor University?

Indicates asthma isn't under control

Chronic inflammation requiring a controller med

Indicates child has reached level of PERSISTENT asthma

The always-present inflammatory cells in the asthmatic's airway result in hyper-__1__ & hyper-__2__ airways that, when hit with a __3__, become further inflamed & edematous, increasing __4__ production & constricting of smooth muscle

1. Reactive

2. Sensitized

3. Trigger

4. Mucus

What's the ultimate goal of asthma treatment?

Prevention of exacerbations (which will prevent airway remodeling)

With a child of this age, they may help with minimal task, such as holding equipment

<2 yrs

With a child of this age, they may be able to get some equipment, ID some body parts involved in asthma, & help with TX

2-4 yrs

With a child of this age, parents are still responsible for care, but the child can learn early warning signs, triggers, and correct words to label body parts & symptoms

4-6 yrs

With a child of this age, parents are still needed, but child is starting to take more active care role; can set up equipment, recite meds & info, and link cause & effect

6-9 yrs

During normal, asymptomatic days, the asthmatic will take a/an __1__ (green zone); when entering the caution zone (yellow), where symptoms develop, the asthmatic will add a/an __2__; when symptoms are severe (red zone - danger), a/an __3__ will be added

1. Low-dose ICS

2. Rescue inhaler (albuterol)

3. Oral steroid

The nurse reviews an arterial blood gas report for a client with chronic obstructive pulmonary disease (COPD). The results are: pH 7.25; PCO2 62; PO2 70; HCO3 34. The nurse should first:

1. Apply a 100% nonrebreather mask
2. Assess the vital signs
3. Reposition the client
4. Prepare for intubation

B: Clients with chronic COPD have CO2 retention and the respiratory drive is stimulated when the PO2 decreases. The heart rate, respiratory rate, and the blood pressure should be evaluated to determine if the client is hemodynamically stable. Symptoms, such as dyspnea, should also be assessed. Oxygen supplementation, if indicated, should be titrated upward in small increments. There is no indication that the client is experiencing respiratory distress requiring intubation.

A client’s arterial blood gas values are as follows: pH 7.31; PaO2 80 mmHg; PaCO2 65 mmHg; HCO3 36 mEq/L. The nurse should assess the client for:

1. Cyanosis
2. Flushed skin
3. Irritability
4. Anxiety

B: The high PaCO2 level causes flushing due to vasodilation. The client also becomes drowsy and lethargic because carbon dioxide has a depressant effect on the central nervous system. Cyanosis is a sign of hypoxia. Irritability and anxiety are not common with a PaCO2 level of 65 mmHg but are associated with hypoxemia.