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CEN Review -Respiratory Emergencies Jeff Solheim

Objectives:
At the completion of this section, the learner will be able to:
Describe the components of a respiratory assessment
Recognize clinical manifestations associated with common respiratory disorders
List medical and nursing interventions for common respiratory disorders
Evaluate interventions carried out for common respiratory disorders
The CEN exam contains 18 questions on respiratory emergencies which involve the
following topics:
Tasks
Assist with tracheal intubation
Suction airway
Ventilate patient using esophageal-tracheal
combitube or laryngeal mask airway
(LMA)
Evaluate the patients response to oxygen
therapy
Interpret end-tidal CO2 results via
capnography
Manage patients with surgical airway (e.g.,
cricothyrotomy, tracheostomy)
Perform a respiratory assessment
Measure peak expiratory flow rate
Assess endotracheal/tracheal tube
placement
Initiate oxygen therapy
Care for patient on a mechanical ventilator
Assess need for needle thoracostomy
Perform arterial puncture for arterial blood
gas sample
Use BiPAP or CPAP
Manage chest tube and drainage system
Interpret results of arterial blood gas
studies
Assist with and/or administer a nebulizer
treatment
Assess for pulsus paradoxus
Identify signs and symptoms related to
respiratory emergencies
Apply physiologic principles when caring
for patients with respiratory emergencies
Administer respiratory pharmacologic
agents

Primary disease states


Aspiration
Asthma
Bronchiolitis (e.g., RSV)
Bronchitis/upper respiratory infections
Contusion (pulmonary)
COPD (chronic obstructive pulmonary
disease)
Flail chest
Hemothorax
Hyperventilation
Inhalation injuries
Obstruction (i.e., of airway)
Pleural effusion
Pneumonia
Pneumothorax (e.g., chest tubes)
Pulmonary edema noncardiac
Pulmonary embolus
Respiratory distress syndrome
Rib fractures
Ruptured diaphragm
Ruptured large airway
Tension pneumothorax (e.g., needle
decompression)

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CEN Review -Respiratory Emergencies Jeff Solheim

Respiratory patterns
Pattern
Eupnea
Tachypnea

Hyperventilation
Hyperpnea
Kussmauls
respirations
Dyspnea
Orthopnea
Bradypnea
Apnea
Biots
respirations
Ataxic
respirations
Central
neurogenic
hyperventilation
Apneustic
breathing
Cheyne-Stoke
respirations

Description
Normal rate and depth
Used to describe rapid rate regardless of depth. (Depth is variable.)
Used to describe increased depth regardless of rate. (rate is variable). Depth
exceeds metabolic demands of the body, so patient may have high oxygen and
low carbon dioxide content.
Both rate and depth are increased but they meet the metabolic demands of the
body, therefore oxygen and carbon dioxide levels may be normal.
Rapid and deep breathing without pauses. Patient appears to be air hungry,
gasping to breath. Usually associated with states of acidosis
Subjective sensation of difficult or labored breathing
Sensation of dyspnea when laying down
Used to describe decreased rate regardless of depth. (Depth is variable)
Absence of breathing
Fast and deep breathing punctuated by periods of apnea. Related to damage to
the medulla oblongata from strokes or trauma. May also be seen in meningitis.
Irregular, random pattern of deep and shallow respirations with irregular apneic
periods. Usually a poor indicator of prognosis associated with increased
intracranial pressure.
Very deep and rapid respirations with no apneic periods associated with
increased intracranial pressure
Prolonged inspiratory and/or expiratory pause of 2 3 seconds. This usually
signifies the presence of brainstem lesions usually at the level of the pons
Rhythmic crescendo and decresendo of rate and depth of respiration, which
includes brief periods of apnea. Usually associated with increases of carbon
dioxide in the cerebrum.

Signs of respiratory distress

Nasal Flaring
Intercostal
muscle
retractions
Diaphragmatic
breathing

Accessory
muscle use

Enlargement of the nostrils during inspiration


Early finding in infants and small children, later finding in adults
Inward movement of the muscles between the ribs as a result or reduced
pressure within the chest cavity.
Early finding in pediatric patients, later finding in adult patients.
Use of the stomach muscles to breath.
Normal finding in pediatric patients, early finding of respiratory distress in
adults.
Use of sternocleidomastoid, scalene, pectoralis major, trapezius, internal
intercostals, and abdominal muscles.
Early finding of respiratory distress in adults, but not as strongly associated
with pediatric patients.

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CEN Review -Respiratory Emergencies Jeff Solheim

Auscultation

Breath
sound
Wheezing
Rhonchi
Crackles
Pleural
fraction rub

Description

Significance

A whistling or musical sound


A snoring, low pitched sound
Small popping sounds
Grating sound which may be compared
to rubbing your hair between your
fingers near your ear that is heard with
inspiration and expiration.

Caused by narrowing of the lower or smaller


airways
Caused by narrowing of the larger upper
airways
Produced by the movement of air through
secretions or lightly closed airways
Caused by inflammation of the pleural
surfaces. The inflamed surfaces rub together
during the respiratory cycle to produce this
sound.

Pulmonary Embolism

Type of Emboli

Blood

Fat
Amniotic fluid
Air

Notes
A blood clot which migrates from another part of the body, typically the right side
of the heart, the pelvis or from a deep vein thrombosis in the legs.
Blood clots are the most common causative agent of a pulmonary embolus.
Risk factors include immobility, pregnancy, and increasing age
A fat embolus which can occur 24 to 48 hours after a long bone fracture, such as a
fracture of the femur, humerus or pelvis.
One symptom that is unique to fat emboli is petechiae of the chest and axilla.
Symptoms show up shortly after delivery of an infant.
Inadvertent injection through an intravenous line or from intravenous
administration of medications.
Secondary to diving injuries

o Signs and symptoms


Sudden onset of shortness of breath (most common symptom)
Tachypnea and tachycardia
Cough with possible hemoptysis
Diaphoresis
Syncope
Fever
Crackles on auscultation
Accentuated S2 heart sound
Large pulmonary emboli may cause jugular venous distension and
hypotension
Elevated erythrocyte sedimentation rate and D-Dimer
New onset right bundle branch block and right axis deviation with peaked P
waves in the limb leads as well as depressed T waves in the right precordial
leads on the electrocardiogram.

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CEN Review -Respiratory Emergencies Jeff Solheim


o Treatment
Oxygen (nasal cannula to intubation based on presentation)
Anticoagulants and fibrinolytics
Intravenous fluids and vasopressors to treat hypotension

Lung infections

Physiology

Signs and
symptoms

Acute bronchitis
Viral inflammation of
the upper airways

Upper respiratory
tract infection
(URI)
Dry, hacky
nonproductive
cough that
progresses to
productive cough.
Most troublesome
at night triggered
by deep breathing,
talking and
laughing.
Chest pain

Bronchiolitis
Viral infection leading to
profuse secretions and a
necrotic response
producing cellular debris
that can occlude the lower
airways, more worrisome
in infants/young children.
Recent URI with
progressive dyspnea
and cough.
Poor feeding,
irritability, and
lethargy
Tachypnea, possibly
apnea in infants
Grunting, nasal
flaring, intercostal
retractions, cyanosis
Wheezing on
auscultation
Indications of air
trapping on x-ray

Diagnosis

Clinically evident

Nasopharyngeal culture.
Chest radiograph may
show air trapping and
infiltrates.

Treatment

Self-limiting
Cough preparations
Humidification
Bronchodilators
Corticosteroids

Oxygen
Antivirals,
anticholinergics,
adrenergic stimulants.
Admission for signs of
respiratory fatigue,
oxygen saturations
less than 90% despite
treatment, respiratory
rates above 70 breaths
per minute and apneic
episodes.

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Pneumonia
Multiple causes including bacteria
and viruses. Viral infections have
a slower onset and are more
common in the winter. Bacterial
infections have a rapid onset.

Elevated temperature (usually


elevates higher and faster in
bacterial infections. Infants
and the elderly may have
subnormal temperatures)
Pleuritic chest pain referred
diaphragmatically and may be
mistaken for GI disturbances.
Productive cough (purulent
with bacterial pathogens)
Tachypnea and tachycardia
Breath sounds decreased over
pneumonia
Possible pleural friction rub
Hyporesonance and increased
fremitus over affected area.
WBC (higher with bacterial
causes.) Chest x-ray may show
focal, segmental or lobar infiltrates
for bacterial causes, x-ray may be
normal for viral causes.
Healthy individuals with mild
to moderate symptoms may be
discharged home.

Antibiotics administered
within four hours of admission
for bacterial causes.

CPAP, BiPAP or intubation as


required.

CEN Review -Respiratory Emergencies Jeff Solheim


o Chronic obstructive pulmonary disease (COPD)
o
o
o
o

Asthma airway reaction


Chronic Bronchitis airway inflammation
Emphysema airway collapse
Asthma
Common triggers
Allergen inhalation (animal danders, house dust mites, pollens and
molds) or air pollutants (exhaust fumes, perfumes, oxidants, sulfur
dioxides, cigarette smoke, aerosol sprays.)
Upper respiratory viral infections
Exercise (10 20 minutes after vigorous exercise)
Drugs (aspirin, NSAIDs, beta-adrenergic blockers)
Food additives, sulfites (bisulfites and metabisulfites), tartrazine
Menses
Definition: Tetrazine a synthetic lemon
GERD
yellow azo dye used as a food coloring.
Cold, dry air
Symptoms
Sensation of tightness in the chest
Cough
Increased work of breathing
Hyperresonance to percussion, crackles on auscultation, prolonged
expiratory time on expiration.
Respiratory alkalosis (early) respiratory and metabolic acidosis
(late).
Wheezing on exhalation (early) wheezing on inhalation (late)
Breath sounds decreased in lower lobes first but progress upwards
Signs of hypoxia (restlessness, somnolence, decreased respiratory
effort, bradycardia and even periodic apnea.)
Pulsus paradoxus
Peak Expiratory Flow Rate (PEFR) An objective measurement of airflow
Process
Sit upright with legs dangling
Inhale fully, seal circumference of the mouthpiece and exhale fully.
Note position of flowmeter.
Repeat 3 times and base treatment decisions on the best of the three readings.
Findings
o Expected values vary depending on a patients sex, age and height.
40 69% of expected value: moderate exacerbation
< 40 % of expected value: severe exacerbation
o PEFR at home
50 79% of personal best, use inhalers
< 50% of personal best, seek medical attention

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CEN Review -Respiratory Emergencies Jeff Solheim

Treatment

Classification

Action

Examples
Epinephrine (Adrenalin)
Racemic epinephrine (Micronefrin,
Asthma nefrin)
Terbutaline (brethaire, brethine)
Albuterol (Proventil, Ventolin)
Isoetherine (Bronkosol, Bronkometer)
Salmeterol zinaoate (Serevent)
Xopenex (Levabuterol)

Ipratropium (Atrovent)

Inhaled
Dexamethasone (Decadron,
Respinhaler)
Beclomethasone (Beclovent,
Vanceril)
Triamcinolone (Azmacort)
Flunisolide (Aerobid)
Oral outpatient treatment prednisone
Intravenous inpatient treatment Methylprednisilone (Solumedrol)

Sympathomimetics

Relax smooth muscles of the bronchioles and


produce bronchodilation, also elevate heart
rate

Parasympatholytics

Inhibits contraction of the bronchial smooth


muscle and limits the secretions of mucus, but
carries side effects such as dry mouth, pupil
dilation, increased heart rate, blurred vision.

Anti-inflammatory properties and


immunosuppressant effects, which reduces
airway inflammation, inhibits mucous
production, and decreases airway swelling
and hyperactivity

Corticosteroids

Drug delivery methods

Method
Metered Dose
Inhaler
Spacer
Dry Powder
Inhaler

Nebulizer

Notes
The drug is suspended in chlorofluorocarbon liquid propellant (Freon). Patient must be
able to hold breath and be coordinated enough to participate.
Increase vaporization of particles and increase lung penetration as well as decreasing
loss of drug in air or mouth. It takes less coordination to use a spacer and may be an
alternative to people who struggle with metered dose inhalers.
Another alternative for people who cannot use a metered dose inhaler. Capable of high
inspiratory volumes.
This method is preferred for a patient who is unable or too sick to cooperate with
metered dose inhalers and spacers.
It will deliver drugs better than other methods to lower airways.
The patient should be upright for the treatment (40 90 degrees) to allow deep
ventilation and maximal diaphragmatic movement.
If the heart rate increases more than 20 beats per minute, stop the treatment.
Never administer nebulizer treatments to a crying child as crying decreases
absorption of the medication.

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CEN Review -Respiratory Emergencies Jeff Solheim


o Instructions for using metered dose inhaler

Shake the inhaler and hold it one to


two inches from the face

Discharge Instructions Asthma


Avoid known allergens
Encase pillows and mattresses in vinyl
Wash bedding every week in water
temperature that exceeds 130F
(54.5C)
Consider carpet removal and antimite
treatment
Keep cats and dogs outside the house
Remain inside with air conditioning
during the early morning and midday
hours
Never stop steroids abruptly. They
need to be tapered.

Exhale completely
Press down on the inhaler as you
begin to inhale and continue to
inhale as deeply as you can.
Hold your breath as you count to
ten slowly.
For beta-two agonists, wait one
minute between puffs.
If the patient will be using a spacer,
the directions are similar except for
third bullet point, the patient
should press down on the inhaler
and wait five seconds before
beginning to inhale.
o Chronic Bronchitis (Chronic inflammation of the bronchi) and emphysema
(Destruction of the elastic properties of the lungs by enzymes resulting in loss of
natural recoil and support of lung tissue)
Chronic bronchitis
Emphysema
Blue bloater
Pink puffer
Productive cough
Cough uncommon
Stocky build
Thin
Onset 40 50 years
Onset 50 75 years
Normal respiratory rate
Tachypnea
Hypoxemia
PaO2 normal or slightly
Increased PaO2
PaCO2 low or normal until the end
Cyanosis
Barrel chest
Polycythemia
Accessory muscle use
Cor Pulmonale
Leans forward while sitting
Peripheral edema
Pursed-lip breathing
Risk for pulmonary embolism
Hyporesonance on percussion
Enlarged heart on x-ray
Lung overinflation and low
diaphragm on x-ray

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CEN Review -Respiratory Emergencies Jeff Solheim

Treatment
Continuous positive airway pressure (CPAP)
o No cure symptom control only
and Bi-level positive airway pressure (BiPAP)
o Patient position: sit upright and
Advantages
leaning forward
o Rests respiratory muscles
o Increases tidal volumes Maintains
o Cardiac monitoring
PEEP
o Pharmacology
o Times breaths
Beta-adrenergic agonists
o FiO2
Mucolytic agents
Risks
Steroids
o Pneumothorax
o Hypotension
Antibiotics for infection
o CPAP/BiPAP
Elevate the head of the bed 30 degrees to leak around the mask.
If pressures exceed 20 cm Hg, consider insertion of gastric tube to
decrease gastric distension.
Patient must be able to keep their mouth closed for CPAP/BiPAP to be
effective when a nasal

Oxygen therapy and COPD patients (Patients


with COPD exacerbation are hypoxic and
can tolerate oxygen therapy for a period of
time without blunting of the respiratory.)
Consider the use of oxygen devices which
carefully control oxygen delivery
(Venturi masks, low flow oxygen)
Monitor for return to baseline oxygen
saturations (will be lower than saturations
in non-COPD patients) and decrease in
respiratory rates. Oxygen delivery should
be reduced or discontinued in these cases.

Discharge Instructions Emphysema and


Chronic Bronchitis
Stress the importance of pneumococcal and
viral immunizations.
Avoid crowds and situations with high
likelihood of exposure to respiratory
infections
Eat small, frequent meals to allow maximal
excursion of the chest.
Stress the importance of adequate hydration
to keep secretions moist.
Stress the importance of exercise to keep the
lungs healthy
Stop smoking.

mask is used.

Pulmonary edema
o Causes
Acute Respiratory
Cardiogenic
Distress Syndrome
Inflammatory nonHeart failure
cardiogenic
MI
pulmonary edema
Severe Anemia
Hyperthyroidism
Hypertension
Myocarditis

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Neurogenic
This relatively rare
form of pulmonary
edema may occur
within hours of a
severe neurological
insult.

High Altitude
Occurs 2 4 days after
ascending above 8000
feet, or people who live
above 8000 feet, descend
for 2 4 weeks, than
return home.

CEN Review -Respiratory Emergencies Jeff Solheim

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CEN Review -Respiratory Emergencies Jeff Solheim


o Treatment goals
Improve
Decrease cardiac
oxygenation
workload
Administer
Position upright, legs
high flow 02
dangling
BiPAP/ CPAP Vasodilators
(Morphine, NTG,
Mechanical
Nitroprusside)
ventilation
Lasix
Digoxin (inotropy)
Dopamine

Treat underlying
conditions
Antibiotics for
infections
ACE inhibitors
for heart
failure
Etc.

High altitude

Descend below 8000


feet
Bed rest
High flow oxygen
Hyperbaric chamber
Acetazolamide may
be considered.

Airway Obstruction
Area of airway
Symptoms
Large obstructions will cause complete airway obstruction with lack of
Larynx
coughing, airway sounds or air movement.
Smaller obstructions may cause hoarseness and aphonia
Large obstructions will cause complete airway obstruction with lack of
Trachea
coughing, airway sounds or air movement.
Smaller obstructions will cause wheezing similar to asthma
Cough, unilateral wheezing and unilateral decrease in breath sounds
80 90% of aspirated objects lodge in the bronchi. In adults, foreign
Bronchi
objects are more likely to lodge in the right bronchi. In pediatric patients,
there is no difference between obstruction in the right and left bronchi.

Treatment
o Complete laryngeal or tracheal obstruction: Heimlich Maneuver
o Partial obstruction and bronchial obstruction: Endoscopic removal
Minimize crying in children while awaiting intervention.
Be prepared for alternate airway
Thoracic trauma
o Rib fractures
Fractures of the first and second ribs associated with injury to the lungs, aortic
arch, vertebral column, disruption of the subclavicular artery or vein)
Age Considerations

Kids have cartilaginous ribs which are not easily fractured.


o Rib fractures usually indicate significant underlying trauma
and lack of rib fractures does not rule out underlying trauma
o Always consider abuse with rib fractures

Elderly patients lack the pulmonary reserves necessary to compensate


for fractured ribs, may require admission to monitor respiratory status.

Key points

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CEN Review -Respiratory Emergencies Jeff Solheim


Definition:
Flail Chest Two or more
adjacent ribs are fractured in
two or more locations or
detachment of the sternum

Definition:
Paradoxical chest wall movement A
flail chest results in a free floating segment
of the chest wall drawn inward during
inspiration and outward during expiration

o Pulmonary contusion (injury of the lung resulting in edema and blood collection in
the lung parenchyma)
Symptoms (Often mild on arrival to ED and progressively worsen)
Dyspnea
Hypoxia
Hemoptysis
Treatment
Rib fractures
o Oxygen administration
o Pain management (avoid respiratory suppression)
o Oral or IV analgesia
o Intercostal nerve blocks
o Deep breathing/coughing
o Incentive spirometry
Flail chest segments
o Consider nursing on injured side
o Consider mechanical ventilation
Pulmonary contusion
o Nurse in semi-Fowlers position
o Consider mechanical ventilation
o Absence of hypovolemia - fluid
restriction/diuretics
o Ruptured diaphragm (abdominal contents herniate into the chest and compress the
lungs, heart and mediastinum)
Clinical manifestations
Lower chest, abdominal or epigastric pain that radiates to the left
shoulder
Dyspnea
Decreased breath sounds on affected side
Heart sounds shifted to the right side of chest
Signs of obstructive shock
Dysphagia
Bowel sounds in middle to lower chest
Treatment
Trauma care
Surgery

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CEN Review -Respiratory Emergencies Jeff Solheim

Problems in the pleural space


Definition Fluid in the pleural
space
- Blood = hemothorax
- Chyle = chylothorax
- Pus pyothorax
o Pneumonia
o Blood-borne infection
o Pancreatitis
- Serous fluid = hydrothorax
o Left ventricular failure
o Liver failure
o Pulmonary embolism
Signs of tension pneumothorax
- Respiratory distress
- Hyperresonance on the affected
side
- Tracheal deviation away from
the affected side.

Definition - Pneumothorax
- Air enters the pleural space, causing a
negative intrapleural pressure and collapse
of the lung
- Causes: Trauma, barotrauma (diving
incidents, explosions), spontaneous
(common in smokers of tall stature between
the ages of 20 and 40), emphysema.
Definition - Open Pneumothorax
- An opening at least 2/3 the diameter of the
trachea from the outside of the body that
penetrates the chest wall and allows
accumulation of air in the pleural space
Definition - Tension Pneumothorax
- An accumulation of air in the pleural space
that is so great it compresses the contents of
the chest cavity to one side or the other

Treatment (open pneumothorax: Apply non-occlusive dressing to wound at


the height of inspiration, taping to three sides.
Treatment (open pneumothorax): Needle thoracentesis

14 or 16 gauge needle is inserted into the second intercostals space,


midclavicular line or fifth intercostals space, midaxillary line on the
injured side.
Inserted directly over the lower rib of the intercostals space, bevel up.
Should result in an immediate rush of air.
o Clinical Manifestations
Fluid Accumulation

Air Accumulation

Breath
Sounds

Decreased over fluid

Decreased over air

Fremitus

Absent over fluid

Decreased over air

Percussion

Hyporesonance

Hyperresonance

Pain

Dull ache on side of


fluid

Sharp pain which may radiate to the


shoulder on the side of the
pneumothorax.

Egophany

Near top of fluid line

Not present over air

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CEN Review -Respiratory Emergencies Jeff Solheim


Definition:
Fremitus Have the patient say
99 while holding hands against
the chest. Vibrations will transmit
through air, but not fluid

Definition:
Egophany Have the patient say e
while holding a stethoscope near the top
of the fluid line. The e will sound like
an a through fluid.

o Chest drainage systems


Chest drainage of concern:
Initial output of more than 1500 mL of blood.
Continued blood loss of more than 200 mL/hour.
Problem

Causes

Bubbling or fluctuations in
the water seal chamber
cease
Continuous bubbling in the
water seal chamber

Considerations for autotransfusion


Considered for significant blood loss (>350 mL)
Blood should be less than 4 6 hours old
Never considered if there is risk of enteric contamination (e.g. ruptured diaphragm,
injury to lower chest)
Risk of contamination when used with penetrating trauma.

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CEN Review -Respiratory Emergencies Jeff Solheim


Practice Questions
A rodeo cowboy is trampled by a bull. He presents to the ED via ambulance with severe
abdominal pain and bruising to the upper abdomen where the animals foot landed. On
assessment, his vital signs BP 94/72 mm Hg, P 112 beats per minute, R -32 breaths per
minute, T 96.1F, and his oxygen saturation is 89% on 100% non-rebreather. His thoracic
assessment reveals no surface trauma to the chest, and the ribs are intact, with no crepitus or
other structural abnormalities noted. Breath sounds are clear to auscultation on the right and
decreased throughout the lung fields on the left. Heart sounds are shifted to the right of the
sternum and difficult to auscultate. The abdomen is tender over the bruised area, and bowel
sounds are decreased throughout all four abdominal quadrants. Based on this assessment, which
of the following diagnosis is most likely suspected?
a.
b.
c.
d.

Lacerated liver
Pancreatic injury
Ruptured diaphragm
Pericardial tamponade

The emergency nurse knows that Triamcinolone (Azmacort) is given to the asthmatic patient for
which of the following reasons?
a.
b.
c.
d.

To inhibit contraction of bronchial smooth muscle


To reverse the bronchodilation caused by the inflammatory system
To reduce airway inflammation and inhibit pulmonary mucus production
To decrease respiratory rate in an effort to improve alveolar gas exchange

Hemoptysis is most closely associated with which of the following diagnosis?


a.
b.
c.
d.

Epiglottits
Bronchiolitis
Pleural effusion
Large pulmonary embolism

A needle thoracostomy is performed for the treatment of a tension pneumothorax. Which of the
following assessment parameters indicates that the intervention has NOT had its intended effect?
a. The patients respiratory rate decreases after the procedure is performed.
b. The trachea shifts away from the needle after the procedure is performed.
c. There is a hissing sound noted from the needle immediately after the procedure is
performed.
d. The patients mean arterial pressure changes from 76 mm Hg to 92 mm Hg after the
procedure is performed.
Answers: C, C, D, B

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