move a little bit quicker through things if it gets too fast just tell me slow down or ask me to repeat okay so here we go again um exam number two uh if we're looking at the Matrix we're still talking about patient data but this exam talks about clinical assessment procedures to get information looking at those procedure results and then recommending um other diagnostic procedures so it's all about procedures so number one 28 week gestational AG neonate on pcv suddenly becomes to kidnic with unilateral chest expansion okay one of the main things adult NE uh neonatal pediatric unilateral chest expansion one of the things we often think of is maybe a thorax okay um so Topia unilateral chest expans which of the following should the therapist recommend and so when we're looking at all of these answers thinking unilateral and disorders or diseases that can cause that Anum X being one the only thing here that really comes down to the root of that would be transillumination of the chest right normally when we put that transilluminator on there there should be a nice tight halo around the light but if you have a big pocket of light that means there's air in that space so one is C that goes to chapter 13 moving on to number two we've got the stat on on a 75 kilo patient on a 40% aerosol Mass the patient's title volume is 500 the rate's 12 but they're asking for the patient's alveolar minute volume and if you're a fast test taker you glossed over that word alveolar okay they're not asking for minute volume which would be just tital volume times respiratory rate they're asking for the minute volume in the alveoli which means you have to subtract anatomical dead space I don't like the algebraic form for this it just makes it look so much more complicated than what it really is but basically if a person's breathing in 500 MLS part of that tial volume is caught up in that anatomic Dead Space it doesn't participate in gas exchange and so anatomic Dead Space is 1 ml per pound of uh body weight so we're saying 165 pounds so from that 500 165 MLS is caught up in the Airways not doing anything which means what actually gets down here is 335 MLS so now we're in the alveoli we just have to figure out alveolar minute volume you multiply that by whatever the respiratory rate is which is 12 and that gets you 4,000 milliliters or 4 liters now if you really love algebra and you love mathematical equations there it is right there okay so minute volume alveol minute volume is title volume minus Dead Space anatomic Dead Space times respiratory rate all right so two is a that goes to chapter three so these are things on the exam man if you're a fast test taker it's not a hard concept it's just reading too fast and skipping over words okay so read every word if you're a fast test taker number three a chest xay x-ray reveals the tip of the patient's ET tube is located the level of the fourth rib anytime they're talking anatomically on the chest and they say four fourth intercostal space fourth rib four is Corina level all right so what they're saying is that tubes on the Corina and they go over go ahead and give you a little bit more saying the tubes tape that the 27 Mark when have you ever seen a tube that is orally intubated at the 27 I mean the person has to be really really tall it's not usually there so that tube is too deep so what would you do you would do a withdraw the tube to the 23rd cimer Mark okay I am going to share my screen here because as far as two placement on the board exam let me tell you they ask about Airway care a lot on the board exam so other things you need to know that Corina we said was located at the fourth rib four thoracic vertebrae so four think Corina they may ask about the tip of the ET tube okay so the tip of the ET tube needs to be about two to five centimeters above the Corina be careful because I've seen test questions you look you're thinking two to five in your head and they have centimeters and inches in units of measurement okay so there may be B be something that it says two to five but they put the the uh units of measurement as inches be careful there so it's 2 to five cmers and then sometimes they can use tube marking so an average sized woman or average sized man maybe about 21 to 25 uh two centimeters less for women all right so three is a goes to chapter 4 four which of the following increases the potential for damage to the tracheal mucosa by the endot tral tube so um the endot tral tube needs to be maintained at 20 to 30 cmers of water pressure okay and used to the board exams asked about cuff pressures in terms of M millimeters of mercury but in clinical practice forever we've been using cufflator and things that measure centimeters of water pressure so they there's been a transition to centimeters of water pressure so 20 to 30 cm of water pressure is what we want and the question is asking which of the following is going to increase the potential for damage and so B would be doing that maintaining the cuff pressure at 40 is going to damage the tracheal mucosa we've got a little bit of something here about minimal leak technique and I'm really hoping they're not you're not going to see many questions on this so minimal leak technique used to be a way that we put the least amount of volume in the cuff to seal off the airway well there might have been a little bitty leak at Peak inspiration all the evidence suggest that shouldn't be done anymore because it's a cause of Silent aspiration meaning people were aspirating because there is that leak in the cuff so I'm going to share my screen I'm going to tell you if they do ask what they're probably going to talk about um so minimal leak technique or minimal minimal uding volume okay they may ask about those minimal uding volume is better than minimal leak technique because the airway is occluded meaning the cuff seals off the whole entire Airway so we don't have aspiration okay um if you see a question about minimal leak technique here's what you need to know you have to look at the ventilating pressures on the vent the peak inspiratory pressures when you do a minimal leak technique okay because if those pressures change significantly if they drop you have to do the minimal leak technique again you have to reestablish that minimal Leak with varying pressure changes just remember that and I'll test you on it in a little while I'm G show you you remember that so anytime the peak pressure changes if you're using minimal leak you're going to have to redo minimal leak okay just remember that all right four is B goes to chapter four five let's just talk about transcutaneous oxygen monitoring okay we can monitor CO2 or we can monitor O2 now this is from an electrode on the skin it can only be done in neonates because everybody else's skin is too thick for the gases to diffuse from the bloodstream through the skin into that electrode okay so only for neonates remember that you're going to have to calibrate these things so here's how you calibrate it basically you just take it off the baby and hold it up to room air and you hit the calibration button and what that electrode's going to do is read the partial pressure of oxygen in room air okay and then when it's done you put it back on the baby all right when it's on the baby that electrode is heated up so it it's warm okay it it um up to 40 de 40 degrees celsius yeah 42 42 to 44 degrees Celsius okay it has to be heated because that causes vasodilation of all those vessels which allows that gases to come out and diffuse easier into the electrod okay so one of the things about calibrating if it doesn't come into calibration It's usually the sensors these are notorious for the sensors uh becoming damaged or not working properly or being membraned incorrectly all right so the therapist is having difficulty calibrating the transcutaneous oxygen the most likely cause of this problem is be the membrane is damaged because it can't be a it's not attached to the patient properly well it should never be attached when we're calibrating we hold it up to room air it's not C because it's always going to be warm because it's always heated so it's not that and then perfusion to the sensor side is poor which would mean you've got it on the baby instead of exposing it to room air okay so 13 is B little things to remember that probe is heated 42 to 44 degrees now if you have a premature neonate their skin is even thinner so you may have to change that that sight more often so the baby doesn't burn you cannot decrease the temperature okay you have to check change the site more frequently they recommend every four hours unless you're seeing redness on the site then you can change it more often um once you attach it back to the baby after you calibrated it takes about 5 to 10 minutes before it starts reading right so don't expect instant results and this is often used from pre- and postductal studies um so if there's a patent ductus arteriosis they look at um the the blood gas from the UAC versus the the gas that's attached to it or the tcom on the arm all right so five is B that goes to chapter 13 all right six I'm going to explain this Blood gas and then we're going to talk about adding oxygen and what should happen Okay so this person's on 40% and we look at this Blood gas and you notice one of the first things you notice is their hypoxemic right 58 anytime the body's hypoxemic a patient's going to naturally increase their respiratory rate now follow me through this when we increase respiratory rate CO2 should drop because you blow off CO2 and pH should fall so this hyperventilation that you are seeing is caused by hypoxemia does that make sense what's going on with that gas because when we add oxygen let's just follow this when we add oxygen to this patient here's what should happen that pao2 should increase we should fix that hypoxemia hopefully when that happens their respiratory rate should decrease CO2 should climb back to its normal value so we should see an increase in CO2 and a decrease in PH as it returns to its normal value okay so that's exactly what this question is asking the therapist increases the oxygen to 50 which of the following blood gas value should increase after this change well the pa2 should increase because that's what the oxygen does but because the respiratory rate slows down the CO2 will increase also all right so six is C and that goes to chapter one okay now listen to me every patient's population from newborn to geriatric COPD every patient population will respond the same way if they're hypoxemic and hyperventilating when we put oxygen on them what should happen is their their po2 should rise and their CO2 should rise also because they're not hyperventilating anymore okay that's is a normal response in every patient don't forget that okay so six C chapter one seven the therapist obtains a speedum specimen that is odor green and separates into layers anytime secretions are stinky and they separate into layers you need to think bronch easis that's a classic textbook sign of bronchiectasis 7 is C chapter 12 all right eight a COPD patient is being weaned using SV which of the following blood gases result indicate that the sinv rate should decreased be decreased so basically we're saying if we have these four sets of gases which one of these gases would we be comfortable weaning okay and so questions like this there's a whole lot of numbers to look at I don't like to do that when I take a test so I'm going to share my screen I'm going to show you how to get at it a little bit faster without having to look at all the numbers so I don't look for an answer that's right going across and looking at every number I weed out going vertically okay and for me we're talking about weaning well let's just think about pa2 normal pa2 is 8 to 100 normal pao2 for a COPD patient 50 to 65 okay am I G to wean any patient with the pa2 of 45 a I'm not even gonna look at again it's just wrong okay not even looking at it again b64 will COPD patient that's right in its normal range so I may come back to B I'm not going to wean anybody with p242 c's not even an option not looking at anything else and a pao2 of 85 okay I would think that that's weable but I got to remember that this is a COPD patient and it should be 50 to 65 this is too high and as a result they're not breathing as much as they should and they're acidotic this Blood gas should not be weak so that leaves us B and this is an example of a COPD patient that's over ventilating so let's back off of the machine rate let's not ventilate him as much with the machine and see what he does on his own so the answer here should be B so eight is B and that goes to chapter 11 so does that make sense how you can instead of trying to get a lot of numbers in your brain and comparing them you can just pick one value and weed out some things and then you have less to have to Jumble your brain up with all right number nine 5' 5 inch 9 90 kilogram patients arterial blood pressure has increased over the past three months the patient complains of daytime sleepiness okay daytime sleepiness your brain goes to well maybe they have sleep apnea all right so which of the following procedures should the respiratory therapist recommend and if we're going to diagnose sleep apne the only diagnostic test is b a polym polyram all right so a lot of people say well what about um overnight pulse oxymetry that just tells you about oxygen desaturations that doesn't diagnose sleep apnea it may lead you to believe you need a sleep study to diagnose it but if we're wanting to come to the the root cause of it we're going to do a sleep study so nine is B chapter 12 10 we have got to talk about optimal peep n BRC exams are probably going to ask you about optimal peep one of four ways okay so let's just let's just talk about the four ways the first one is the easiest one so it's probably not be going to be the one they use all right optimal peep is the peep that gives us the highest pao2 without cardiovascular side effects so basically when we turn the p uh the peep up um the pao2 should rise but we don't want blood pressure to drop that would be a cardiovascular side effect all right so that's one way that's the easiest way probably not the it's not the best way it's probably not the way they're going to ask this is one of the ways they're going to ask optimal peep is the peep that gives you the highest static compliance so if they're doing a peep study one of the main things you need to be looking at is static compliance because as they add peep the Alvi should recruit and you should have lower Plateau pressures and higher compliances all right so this is one of the best ways to look at optimal peep another way you can do it if you have a very fancy Swan Gans catheter pulmonary artery catheter that pulmonary ottery catheter can do Venus mixed Venus saturation monitoring okay so you can monitor mixed Venus saturation or mixed Venus oxygenation okay so drawing from the pulmonary artery you can measure the saturations or measure the pvo2 the best peep optimal peep is the peep that gives you the highest svo2 or the highest pvo2 if you start out with a lot of oxygen the tissues take what they need you should come back to the right side of the heart with quite a bit of oxygen and then the fourth way is using a pressure volume Loop all right so if you have your graphic analysis on the vent and you pull up the pressure volume Loop um this is pressure this is volume and I'm going to draw somebody that really needs peep okay so do you see that if we start here we have zero Peak because that's where the breath starts and do you see how this travels along Baseline I'm like we haven't gotten any volume into those alveola all we've done is built up a lot of pressure until about right here and alveoli finally open up and we can push volume in okay this is a really bad thing to do with the lungs to put so much pressure and pop them open and then let them close again and then the next breath they have to pop open and then they close again and this ends up tearing the alveolar walls and they'll have a amoric as a result of it okay so we don't want this this recruitment collapse we want to keep it recruited so this place where we had liftoff this is called the lower level inflection point and this is where optimal around here is where optimal peep is because that's the point that we're recruiting the Alvi all right so these are the four ways for optimal peep that they're probably going to ask you okay one of these four so like number 10 so optimal peep is indicated by which of the following so when we look at these and you look at all the information you have here which one of these are you going to use static compliance yeah you're going to you're going to have to use static compliance so you're going to have to be able to assess the formula for static compliance for all of these so basically I just told you you have to do static compliance four different times to find find the best static compliance didn't I that's a lot of math isn't it and you can do it you have a calculator do you want the shortcut okay here's a shortcut let's make sure we understand the math first okay so the formula for static compliance let me not start out there let me let's just get a mathematical relationship down if I take the number 10 and I divide it by five the answer is two okay I take the number 10 and I divide it by two the answer is five and you're like what's going on okay it it's G to make sense we can only get high numbers when we divide by Little Numbers that's a mathematical relationship we want the highest static compliance so here's a formula for static compliance title volume divided by plat minus P okay we can only get high static compliances when we divide by Little Numbers so really all I have to do because we understand that mathematical relationship is on each one of these I just have to go Plateau minus peep so like on the first one 23 minus 5 is 18 so this is not the compliance this is just the bottom part of that formula in understanding a mathematical relationship the next one 25 minus 8 is 17 the next one 27 - 11 is 16 and the last one 31 - 14 is 17 we only get high compliances when we divide by a small number the smallest number here is C that's where we should be setting the peep which C is 11 okay now if you don't believe me tonight you can calculate static compliance on all of those and See's going to be the highest compliance all right so it keeps you from having to work a lot of math on the exam all right so 10 C chapter 11 because it's optimal Peep and Peep's vent so we'll put it in the vent chapter 11 therapist is assessing a patient spontaneous ventilatory parameter the CO2 is 50 in padle CO2 is 30 title volume 600 and they want to know what the Dead Space volume is so we have to do Paco Pico Paco okay P CO2 minus entitle CO2 I'm GNA share my screen all right 50 minus 30 is 20 divided 50 is 40% what this means is that 40% of the title volume is not removing CO2 and they want to know how much title volume that actually is so you take 600 times 04 so of that 600 what that's saying is40 MLS ain't doing anything okay it's not removing CO2 it's just wasted but that's acceptable anything less than 60 is acceptable so 11 is B chapter 11 how are we doing after lunch is usually the hardest time are y'all okay okay all right 12 uh physical assessment patient in ICU notes paradoxical chest movement anytime you see paradoxical chest movement you should be thinking FL chest yeah 12 D chapter 3 and you're going to have a lot of questions like this that just are are super easy and then the next thing you know they'll give you one that's really really hard 13 though isn't one of those uh it's pretty easy it there's a lot of words to just really the last sentence is what matters we've got a COPD patient comes to the ER you put them on four liters per minute then you notice the patient is breathing shallow and becoming lethargic and see this makes me think maybe we've knocked out their hypoxic drive and the question asked how do we evaluate their ventilatory status well I need their CO2 to do that I need their CO2 and pH and so the only way to do that is to out of these four options is to obtain an ABG does that make sense okay this is an important concept two places in the book so if you missed it on a double dinga you have to do chapter 10 and chapter 12 14 is an important concept also all right call to bedside of a patient that's on a vent you get to the room you notice the high pressure alarm is alarming with every breath the low volume alarm is activated the nurse tells you the patient had a pulmonary artery catheter inserted in the right subclavian so they they stuck right up underneath the collarbone 30 minutes beforehand you assess the patient there's unilateral expansion diminished breath sounds in the right upper lobe no tracheal deviation is present heart rate is 103 respiratory ratees 18 blood pressure is 110 over 60 what should you suggest all right so this whole big old long scenario hopefully your mind went to a numor did it okay good deal here's what you do when you think this on the test don't look at the answers yet look at your scenario and ask yourself this question is this just a regular pneumothorax or is this a tension numo thorax you have to answer that question before you can treat it regular pneumothorax I'm not saying it's a good thing but it's better than a tension pneumothorax a regular pneumothorax the trachea will not deviate okay a regular pneumothorax while they may have a little bit of an elevation in the heart rate they're not going to have an astronomical elevation like heart rate of 160 and they should be holding their blood pressure all right so if you look at this no tracheal deviation heart rate's a little high blood pressure is okay this is a normal thorax which means we have time to get a chest x-ray and put a chest tube in but here's what a tension Numa thorax looks like when we assess the trachea will be deviated because all of that air pushes the medium over so that trachea will be deviated number two it's compressing on the heart so the heart cannot pump blood out okay and blood pressure Falls so the heart thinks oh gosh blood pressure is falling I'm not pumping a lot of blood out I got to pump faster really high heart rates really low blood pressures with tension and athora tension numos lifethreatening you don't have time to do anything except stick a needle in their chest okay needle decompression is how we treat attention num thorax all right 14 on the exams you have to differentiate between a regular numo and a tension numo super super important so important three places in the book so 14 is a and if you missed it chapter three chapter 5 and chapter 12 all right 15 it's just asking you to calculate a to a difference all right so you have to calculate the pbo2 subtract the little ao2 and when you do that you should have gotten a roughly 134 so now if you know the formula I'm going to show you a shortcut and but I'm going to say this if you know the formula use the formula because you have a calculator because to memorize a shortcut you're going to have to memorize a shortcut and if you already know how to do it and you have a calculator that's not worth burning brain cells to memorize something else okay but if you wanted to use the short did somebody say something I'm sorry no okay so here's the shortcut if you wanted to use it you can take the barometric pressure as long as it's over 700 drop the last two digits okay just use seven and this works out mathematically because when we use the F2 we're going to use the whole number okay we're not going to use the decimal so 7 time e fi2 is a whole number and instead of going C CO2 times 1.25 just take CO2 okay from that you take CO2 just add 10 to it and that'll get you close enough okay so this is a way to shortcut the P big ao2 part and so the P big ao2 is 228 now here's where the problem really becomes you probably can get 228 but you think oh my gosh I've done so much math I've got to be done no it ask for the a to a difference so don't forget to subtract that little a from it and when you do 138 if if we use a shortcut if you long handed it out 134 choose the closest one on the test all right so 15 is a we're going to put that in chapter one and chapter 10 all right 16 the patient with osma has been receiving 28% oxygen with an air entrainment mass for 30 minutes the pa2 is increased from 48 to 52 when we put oxygen on somebody their po2 should increase right we said that while ago okay and then there CO2 increases from 50 to 53 well that's fine also remember I told you every patient population has an increase in CO2 because you fixed their hyperventilation status so 50 53 that's fine also so what do you want to do continue oxygen at 28% and sometimes because we got in our mind so so much if when you put oxygen on a patient if they quit breathing and their CO2 Rises you put too much oxygen on them and so a lot of people on this want to decrease to 24 but this is exactly what should happen when we give oxygen to somebody and we treat hypoxemia they should breathe slower their CO2 will rise a little bit and their pH will fall back to their normal all right so 16d chapter one 17 ICU pulmonary edema which of the following best determines if this is cardiogenic pulmonary edema cardiogenic means left side the pressure that measures the left side of the heart is pulmonary capillary wedge pressure so 17 is a and that goes to chapter nine 18 patients on a vent had had chest trauma in an NBA over the past 24 hours their fluid intake has has been 3,800 MLS with an output of 900 so they're fluid overloaded right they have more in than out they're fluid it overloaded which of the Fallen has most likely increased lung compliance increasing that means it's getting better okay so if somebody's got fluid overload and probably some pulmonary edema their compliance is going to worsen so it's not a a to a difference that's what's going to increase remember when it increases bigger numbers lungs are bad sick yeah so B's the answer it cannot be serum potassium because you've got so much fluid in the bloodstream when you pull off a certain amount of blood you have more fluid than the potassium part so you'll actually have a decreased potassium and the hematocrits the same way that's the reflection of hemoglobin and so your fluid overloaded you have more fluid in the vial of blood than what you do hemoglobin so 18 is B chapter one and chapter 10 19 which of the following parameters indicate a patient is most likely ready to be weaned you may not see weaned a lot you may see the term liberated because we're freeing them from event so this slide right here slide number 38 super important slide got to know it and it's so important you're going to see it again tomorrow so these are the values that say yes you can start your weaning process or your liberating process MP of at least -20 if it's -19 they're not strong enough vital capacity greater than 10 meaning they can take a good deep breath to sustain ventilation spontaneous TI of volume 56 rapid shallow breathing Index this is spontaneous rate divided by spontaneous tile volume that value should be less than 105 physiologic Dead Space less than 60 AA difference on 100% less than 350 this is the one get catches people a PF ratio needs to be greater than 200 don't eyeball it don't just say they have an f240 their p265 that's good enough run your PF ratio because if it's not greater than 200 they have some acute they they have an Ute lung injury or something going on somewhere PF ratio needs to be greater than 200 and the peep really should be less than 10 okay if we needed if we need peeps higher than 10 something's going on the now west still all right so that being said 19 which one are we going to wean all of these um none of these are ready to be weaned except B an MIP of 32 because we're not going to wean at an rsbi of 135 nor a person that has a vital capacity of seven nor or spontaneous title volume of three so B is the weable value goes to chapter 11 20 is super easy it's optimal Peep and they're looking at pvo2 and pa2 so that covers two of the things on our our chart of the pa2 and pvo2 pvo2 is much much more important so optimal peep is the peep that gives you the highest pvo2 highest pvo2 is 39 that's a peep of nine that's how easy that is you just got to know all right so 20 C chapter 11 21 they're just asking you to calculate static lung compliance tital volume divided Plateau minus peep all right so got it on the screen still um so 600 ID 25 - 5 600 - 20 is 30 MLS per centimeter water pressure that's a very straightforward question I'd have taken it further I would have taken it which of the following disease processes could probably cause this so that's a low static compliance which is an Alvar disease problem that we've got going on that's what that number means let me also say this on the board exam most of the time it's set tile volume that they're going to give you so you configure your compliances with set title volume unless if they give you a set title volume and an exhale title volume use the exhale title volume because that's the way the formula really should be okay so if they give you both use exhale tital volume if they only give you set T ofine that's what you're going to use 22 with this Matrix of the exam this is one of the newer things they start started asking was about U more about uh inflammation in asmatics so which F values would indicate Airway inflammation out of these four that's going to be a the exhaled nitric oxide people call it pheno okay so in your mind I've got I've got it on the slide but in your mind here's how I want you to line this up asthma one of the main anatomic alterations is Airway inflammation the byproduct of Airway inflammation is the production of nitric oxide and so if they have if they start exhaling higher levels of nitric oxide the higher the nitric oxide the more inflammation they have asthma inflammation nitric oxide all right so children they're asking about when you start corticosteroid therapy basically when they ask about pheno levels so a child anytime their pheno levels are above 35 you need to start inhale corticosteroids in an adult anytime that's over 50 you need to start corticosteroid therapy okay this slide is important okay this concept is important and these values are important so kind of star this 22 is that goes to chapter 12 23 patients with empys osma is being observed um they have petal edema jugular Venus distension so the therapist should note in the patient's chart that this is most likely the result of well that right ventricle has failed and blood has backed up and you're seeing it in the jugular vein and then also if you travel it that down it's a backup of blood in the Venus system which is causing in The Petal EMA so this is 23 is D the right side of the heart is failed and so when the right side of the heart fails it hypertrophies or gets bigger than it what it's supposed to so 23 is D that goes to chapter three 24 is like my favorite question on the whole test I think because it starts out saying the patient just been resuscitated following carbon monoxide poisoning and that sentence throws everybody off okay because what they're really asking is which of the following values would best determine the patient's oxygen carrying capacity and because you've got now carbon monoxide in your head you might have put hemoglobin but what they've asked about is oxygen carrying capacity which is this hemoglobin and sat ation and P ao2 did it catch you did you say hemoglobin or did you say cao2 It's Tricky isn't it and they're tricky like that they're just mean so 24 is C every single word matters all right that goes to chapter one and chapter 10 five got the screen up with the blood gas we got a person that comes to the ER after being removed from a berning house here's the ABG they're on a non-rebreather all right and so when you look at this they have an acidosis well it's not respiratory in nature they're ventilating fine it's this B carb that's causing the acidosis but we look at the pa2 this is what's dissolved in plasma it's 320 and that makes sense on a non-rebreather but that sat of 65 this means a lot of carbon monoxide is on that hemoglobin rather than oxygen this person is hypoxemic for sure okay because we've got carbon monoxide poisoning so the question asks which of the following statements are true we're looking for the true statement the pulse the SP2 should be measured due to a discrepancy in the pao2 and sat what they're saying is put a pulse on that person that you suspect of carbon monoxide poisoning should you ever do that I mean you can do it but it's going to read 100% because a pulsox doesn't know what's on the o the hemoglobin it just knows something is it doesn't differentiate between oxygen or carbon monoxide so don't put a pulseox on it it will not tell you anything the oxygen should be decreased no because the patient is hypoxic their sats are 65% you got to keep that oxygen on it knocks that that carbon monoxide off the hemoglobin faster okay the patient is hypoxic yep because her sats are 65 so that's the true statement because D is false because this is not a respiratory acidosis it's a metabolic acidosis and let me tell you why it's a metabolic acidosis a lot of people say well it's because we're dumping bicarb and no it's not this is this bicarb is calculated not measured by the blood Gas machine and so what's going on is the tissues have gotten so hypoxic they've started developing lactic acid and lactic acid shows up on a blood gas as a low bicarb so this metabolic acidosis is caused by lactic acid production you see this type of blood gas a metabolic acidosis often time with carbon monoxide poisoning um cardiopulmonary arrest and and near drowning patients because they're so hypoxic the body produces lactic acid as a result of it all right 26 okay this slide is going to take care of 26 and 27 all right so probably about oh gosh 10 years ago there was a transition instead of just asking about disease states with chest x-rays wanting to know if people knew how to assess for an accurate chest x-ray before they started looking within the lungs looking for different degrees of black whites and Grace okay the patient's got to be set up properly so to do that you think rip okay think rip rotation is what the r stands for so when we're getting a chest x-ray whether it be AP or PA the spine should be in the middle of the clavicles okay the patient needs to be straight if on an AP film if the patient is turned this way that x-ray is shooting through the shoulder and that shoulder is going to make a shadow on the right upper lobe if it's if it's turned this way and you'll interpret that shadow that that whiteness in the right upper lobe as an opacity that's not really there so they have to be positioned straight they have to be fully inspired okay a deep inspiration and when they are the diaphragm should be between N9 and 11 ribs now the right diaphragm is typically a little higher than the left so I use the right when I count okay N9 to 11 ribs and then the P stands for penetration how well the X-ray penetrates through the chest into the chest film it's also called exposure but but the E didn't make a word where the rip did okay so P penetration or exposure is what it's really called all right so we've checked for exposure by looking at a film and looking at the spiny processes behind the heart if you can see you see how you see those spiny processes so little bumps on the spine if you see that behind the heart you've got a good exposure all right if you cannot see the spine behind the heart the X-ray is underexposed and everything looks really white and when everything looks white you think something's in the lung all right if you can really see the spine behind the heart and the lungs are really black that's overexposure some people call it a burnt out film okay and it's really black so you got to pay attention to exposure also so think rip and knowing these things let's go to 26 on a chest x-ray how many ribs should be visible above the diaphrag if the patient has a efficient inspiratory effort we said 9 to 11 so that would be D 10 chapter 3 and then 27 um on assessing the chest x-ray of a COPD patient now normally copds air trapped so it should be darker in the lungs right more black the respiratory therapist notes that the vertebral processes are barely visible and the lung Fields appear to have more opacity so this doesn't make sense because COPD that should be more air everything's white like it's not so what should the therapist suspect D that we have an underexposure of the film it's wider than what's really going on in the chest so on the exams right yes under Expos C all right so you got to think about that quality of the film on this exam well you really should be thinking about that in real life also because there have really a lot of poorly shot chess films that you have to work around all right uh 28 this picture where you practice where you're at school at do y'all use entitle CO2 monitoring sometimes a lot of people don't some hospitals do some hospitals don't and it's really a lot times depending on the Physicians that that work in the ICU you may not be familiar with entitle CO2 monitoring but let me say it like this when it works and when it's reading right you can think of it like pac2 okay when everything's working beautifully just think of it because it should correlate with the pac2 so this is what it looks like as the patient exhales they're exhaling Co CO2 and when you measure that CO2 it's into exhalation uh so where these circles are right here is where you catch that reading from okay because that's the end of them exhaling and then this downward sweep is them inhaling again all right when you set it up and everything's calibrated and everything's normal well normal in the pulmonary capillary bed okay this should correlate with the CO2 on the blood gas within 2 to 5 millimet of Mercury all right so let's just stop there if we're looking at a capnometer and then we have no pulmonary vascular disease nothing's wrong with pulmonary capillary bed we can think of it as CO2 so now 28 all of the following are potential causes for this cogram and so when we look at this cogram what we see is an elevation in the CO2 so what I have to assume is there's an elevation in the PA CO2 also so all the volume can cause that except well if you decrease minute volume you increase CO2 so yeah that could cause it we're looking for the exception esophageal incubation we put a tube in the stomach and we bag and the patient exhales there's no CO2 in the stomach and so we will not get a CO2 reading it would be Flatline or really close to Flatline okay it would be zero so the exception is B Because entitle CO2 should be close to zero within esophageal intubation hypothermia when a person has a temperature has a fever they produce more CO2 so you'll see a rise in the entitle CO2 and hypoventilation means they're not removing CO2 which is a rise in CO2 so your exception is B all right here's another thing with entitle CO2 to think about the difference between the two um do it like this all right right lung left lung here's the pulmonary capillary bed in each so really what happens normally is CO2 comes from the bloodstream up through the Alvi right and is exhaled and so if we've got uh a CO2 of 45 here we should have something around 40 to 43 being exhaled because it all comes up and gets exhaled all right so now the problem becomes if we have a problem within the pulmonary vascular bed so now let's say that we have oh thank you there we go sorry okay so now if we have a big blood clot here so the CO2 is trying to get to the alveoli but but it hits that clot and so the only CO2 now coming out of the system is from this lung out and you're going to see this drop considerably so if this was 45 here but we're only getting we're getting significantly less there's a huge difference between these two numbers right anytime there is a big difference between what's in the alv or in the capillary bed compared to what's being exhaled you have a problem in the pulmonary capillary bed something's wrong with your profusion down here okay so 29 a patient presents to Ed with a sudden onset of disy and chest pain the patient's heart rate's 115 the respiratory rate's 33 they're breathing fast they're on 2 liters a minute they're a little acidic their CO2 is 48 I want to stop there if they're breathing 33 times a minute should their CO2 be 40 eight this is my first indication that something's really wrong with CO2 being able to come out of the bloodstream because it's not coming out the bloodstream okay um you put a capnometer on and the capnometer is 18 so it's stuck CO2 is stuck in the blood because it can't be released because there's something wrong in the capillary bed okay a blood clot more likely uh air embolism a fat embolism all right the these disorders in the pulmonary capillary bed in the profusion part of that relationship these are called Dead Space disorders and they keep you from being able to remove CO2 physiologic Dead Space CO2 removal all right so 29 is a a dead space defect so Paco Pico paco right tells us about not being able to remove CO2 from the bloodstream all right so that goes to chapter 1 and chapter 12 number 30 a question on that I understand the whole concept of um dead space and shunting but in regards to this question where it says 18 millimeters per Mercury you know I was thinking you know it's possible that even if you have like a diffusion problem that could have happened right because you have minim minimal excuse me minimal amount of exchange occurring so therefore you would have you know less CO2 being exchange got oygen and that makes a lot of sense with what you're saying I agree that that the the diffusion relationships are different but typically when we have something wrong in the alvioli or the bloodstream we're talking diffusion problems we're typically talking about about the transfer of oxygen to the bloodstream because you remember something about solubility coefficients the rate of diffusion of those gases are different so when we say diffusion defect typically that's an oxygenation problem a VQ mismatches typically known of as an oxygenation problem because of the rate of diffusion of those two different gases thank you all right and then 30 got a patient that comes into emergency Department with a Benzene exposure and you're probably thinking oh my gosh I don't know anything about Benzene because neither do I really and they're wanting to know what you would suggest okay so here's the deal and then they throw this weird stuff on broncoscopy capnometry administration of atropine or hem oximeter hemoximetry and co-oximetry are the same thing okay so let's talk about this a co-oximeter when we draw blood gas we can put hang on just a second to mute their mic when we are looking at a coax symmetry this is what a coax measures it measures oxyhemoglobin or how much Oxygen's attached to the hemoglobin it measures how much carbon monoxide carboxy hemoglobin how much carbon monoxide is attached to the hemoglobin it tells you about your reduced hemoglobin remember we said this is when nothing's on it and then it measures in an adult met hemoglobin all right here's a normal co co oximeter like if you don't smoke and nothing's wrong with your lung this is a normal co-oximeter you've got about 98% of your hemoglobin saturated with oxygen 2% is De oxygenated because we have that normal anatomic shunt through the theasian vein so all of this equals 100% okay everything's good here the one we talk about a lot in school is this one so you're probably comfortable with this one so what if I tell you all right this is carbon monoxide poisoning and the reason this is the problem is carbon monoxide is attached rather than oxygen and the tissues are going to be hypoxic so what do you do with this you keep them on 100% maybe you initiate some hyperbaric oxygen with it okay we talk about this in school a lot what we don't talk about a whole lot of is this met hemoglobin inia now we do probably talk about it a little bit when we talk about Nitro n oxide Administration okay because one of the things we have to monitor in nitric oxide Administration is the development of met hemoglobin okay but other things that produce met hemoglobin met hemoglobin are um Benzene and um Benzene exposures and um nitrate exposures Benzene and nitrates are the two big ones and most of the time when you see this this is a result of some type of industrial accident like a a food processing plant that uses nitrates and food processing or a Plastics plant that uses some of these chemicals in the production of plastic all right so anytime you see industrial accident you need to think oh I got to run a coox but they also call it a hemo symet coox Symmetry and hemo symmetry is the same thing all right so this is still a problem because the tissues are hypox when something's on the hemoglobin other than oxygen the tissues get hypoxic so we got to monitor for that in certain situations so 30 is D that goes to chapter 10 okay how you feeling good okay all right we only have two more tests I only ever get through the fourth test today and it's we're still going to we're still going to count how's this pace is it too fast I try to slow down on the more important are we okay okay we're going to keep going the same way I'm going to give you a little break can we make do with a five minute break I'm really really wan to try to do two clinical simulations before we leave today which is why I'm shortening your break can we deal can we live with five minutes all right five minutes Ready Set Go