1. Atelectasis and Thoracic or abdominal surgery is an indication for incentive spirometry

1

• 1. Atelectasis and Thoracic or abdominal
  surgery is an indication for incentive
  spirometry.
• 2. The volume of air that the patient inspires
  when performing incentive spirometry should
  approximate inspiratory capacity.
• 3. Retained secretions, Respiratory muscle
  insufficiency, Hypoventilation, contribute to the
  development of atelectasis.
• 4. Hypoxemia, Postanesthesia recovery, Acute
  myocardial infarction are indications for oxygen
  therapy.

2

• 5. IPPB is indicated in all of the following
  situations,
• inability to clear secretions
• atelectasis that does not respond to other
  therapies
• short term ventilation
• aerosol delivery when muscle fatigue is present
• 6. Increased temperature, patchy markings on
  CXR, tracheal shift toward the affected area,
  elevated diaphragm, are clinical signs of
  atelectasis.

3

• 7. Maintain normoxia, decrease myocardial work,
  provide enriched oxygen environment for increased
  metabolic needs associated with severe trauma,
  are therapeutic objectives of oxygen therapy.
• 8. The optimal patient response to treatment
  with incentive spirometry would be Chest
  radiograph is negative for atelectasis.
• 9. Upper airway edema, Sputum induction,
  Postextubation edema, Bypass of the upper airway,
  are indications for aerosol therapy.

4

• 10. Asthma may be described as either
  Intrinsic, or extrinsic.
• 11. The initial ABG during an acute asthmatic
  episode usually describes the acid base status
  as Acute hyperventilation.
• 12. All of the following therapeutic agents are
  recommended for use during acute asthmatic
  episodes,
• Albuterol
• Epinephrine
• Corticosteroids
• Oxygen

5

• 13. A critical cell count in determining
  prophylactic treatment as well as monitoring
  disease progression in AIDS is CD4
• 14. Pentamidine aerosolization is found helpful
  in preventing Pneumocystis infection
• 15. All of the following are routinely used in
  the treatment of pulmonary infection in AIDS
  patients,
• Trimethoprim / sulfamethoxazole
• Aerosolized pentamidine
• Glucocorticoids
• Isoniazid

6

• 16. The key practice in preventing cross
  contamination in the health care setting is
  Practicing universal precautions
• 17. Maintain clear CXR , is an appropriate
  therapeutic goal for pentamidine aerosol therapy.
• 18. Obtaining of sputum samples , Foreign body
  aspiration , Assessment of the airway , An aid in
  intubation , are indications for flexible
  fiberoptic bronchoscopy.

7

• 19. Responsibilities involved in bronchoscopy
  assisting include
• Setup of the scope
• Cleaning of the instruments
• Specimen retrieval and preparation for
  laboratory studies
• Delivery of aerosolized drugs
• Evaluating the patient response

8

• 20. Elements of proper sputum induction include
  
• Use of hypertonic saline aerosol
• Ultrasonic nebulization
• Good patient effort
• Bronchoalveolar lavage and aspiration
• Oral cavity gargling ( preferably with
  hypertonic saline ) before procedure .
• 21. Obesity , Cor pulmonale , Excessive daytime
  Sleepiness , Abnormal heart rhythms are routinely
  associated with OSAS .

9

• 22. Presence of muscular ventilatory efforts
  during apneic period are noted on EMG , are true
  of OSAS but not Central Sleep Apnea .
• 23. After physical assessment of a patient
  presenting for sleep study , you note jugular
  venous distention , significant hypertension ,
  and a history of COPD . You also find that the
  patient is polycythemic . What problem is
  illustrated by this data ? Cor pulmonale .
  

10

• 24. During polysomnography of a person who has
  been sleeping for 4 hours , the EEG tracing
  abruptly flattens . All other parameters remain
  unchanged . The technician should Carefully
  reattach the electrode .
• 25. Indications for the institution of
  Continuous Positive Airway Pressure include all
  of the following
• gt For treatment of Obstructive Sleep Apnea
• gt To increase FRC
• gt To treat apnea of prematurity
• gt As an adjunct in bronchial hygiene .

11

• 26. Acceptable objectives for CPAP intervention
  in the treatment of Obstructive Sleep Apnea are
• gt To reduce the number of sleep apnea episodes
• gt To decrease oxygen desaturation during sleep
• gt To minimize or prevent cardiac dysrhythmias
  during sleep
• gt To minimize daytime somnolence as reported
  by patient
• gt To significantly decrease the incidence of
  symptoms including headache , agitation , and
  loud snoring

12

• 27. Alternate treatments for sleep apnea
  include
• gt Weight reduction
• gt Sleep positioning
• gt Tongue retaining devices
• gt Tracheostomy
• gt Pharmacological intervention
• 28. Diagnosis of Guillain Barre syndrome is
  supported by High protein concentration in the
  cerebrospinal fluid .

13

• 29. Relative contraindications to directed
  coughing include all of the following
• gt Inability to control possible transmission
  of infection from the patients suspected or known
  to have pathogens transmittable by droplet nuclei
  .
• gt Elevated intracranial pressure or
  intracranial aneurysm .
• gt Reduced coronary artery perfusion , such as
  in myocardial infarction .
• gt Acute head , neck , or spine injury .

14

• 30. Indications for postural drainage include
• gt Evidence of difficulty mobilizing
  secretions
• gt Presence of atelectasis
• gt Presence of foreign body in the airway .
• 31. Following are true regarding IPPB
• gt It may cause pulmonary barotrauma
• gt It should produce a Vt greater than the
  spontaneous one
• gt It is contraindicated when evidence of
  tracheoesophageal fistula is present .

15

• 32. Indications for PEP therapy include
• gt The need to reduce air trapping in
  obstructive disease
• gt The need to mobilize secretions
• gt The need to reverse atelectasis
• 33. Following pulmonary data signify an intact
  , well functioning pulmonary system
• gt Spontaneous Vt 7 mL / kg
• gt Spontaneous VC 15 mL / kg

16

• 34. Laryngotracheobronchitis ( LTB ) is usually
  Viral in nature .
• 35. The usual prodrome for LTB consists of
• gt Upper respiratory infection ( URI )
• gt Low grade fever
• 36. The drug of choice for inpatient treatment
  of LTB is Racemic epinephrine
• 37. LTB would be considered severe when
• gt PaCO2 increases with a corresponding drop
  in pH
• gt Inspiratory stridor is present
• gt Oxygen saturation lt90 percent

17

• 38. Perform CPR , Defibrillate _at_ 200 J ,
  Defibrillate at 200 to 300 J , Defibrillate _at_ 360
  J , Administer lidocaine , is the correct
  sequence for treatment of ventricular
  fibrillation .
• 39. Cao2 , Sao2 , Pao2 , Fio2 , is required to
  calculate an estimated shunt .
• 40. Following medications may be administered
  via endotracheal tube in an emergency
  resuscitation
• gt Epinephrine
• gt Atropine
• gt Lidocaine
• gt Naloxone

18

• 41. Information needed to compute a static
  compliance are
• gt Corrected tidal volume
• gt Plateau pressure
• gt PEEP
• 42. The hemodynamic factor most reflective of
  left heart function is PCWP
• 43. Following are likely causes of pulmonary
  edema
• gt Ventricular failure
• gt Pulmonary aspiration
• gt Near drowning
• gt Head injury

19

• 44. The normal gradient between arterial and
  end tidal carbondioxide ( Pa-etCO2 ) is 4.5 mm
  Hg
• 45. The ECG changes associated with myocardial
  infarction include
• gt ST segment elevation
• gt Inversion of T waves
• gt Appearance of Q waves
• 46. Following are risk factors contributing to
  coronary artery disease
• gt Obesity
• gt Smoking
• gt Sedentary lifestyle
• gt Elevated LDLC
• 47. Creatine kinase , Lactate dehydrogenase ,
  are the enzymes routinely used in diagnosing and
  monitoring myocardial infarction .

20

• NORMAL HEMODYNAMIC PRESSURES
• 1.) Heart rate ? 60 90
• 2.) systemic BP ? Systolic 90 140
• Diastolic
  60 90
• 3.) Central venous pressure ? 1 6
• 4.) Pulmonary artery pressure ?
• Systolic 15
  25
• Diastolic 5
  15
• 5.) Pulmonary capillary wedge pressure ?
• 
  5 12
• 6.) Cardiac output ? 5 8 L / min
• 7.) Arterial partial pressure of oxygen (
  Pao2 ) ? 80 100

21

• 48. When a patient is on positive pressure
  ventilation , he or she may experience the
  adverse effects of
• gt Hyperinflation of the lungs
• gt Gastric irritation
• gt Decreased transmural heart pressures
• gt Decreased renal perfusion
• 49. Current guidelines for reimbursement of
  home oxygen include Presence of Sao2 lt 85
• 50. During basic life support delivery , using
  a manual resuscitator for ventilation , the RCP
  sees that the victims abdomen becomes markedly
  distended . The RCP should recommend
  Endotracheal intubation

22

• 51. Signs associated with a tension
  pneumothorax include all of the following
• gt Absence of breath sounds over the affected
  area
• gt Lack of markings on CXR
• gt Increased inspiratory pressures
• gt A decrease in dynamic lung compliance
• 52. The first line drug for the treatment of
  ventricular dysrhythmia in adults is Lidocaine
• 53. Urine output is considered within the
  normal range if it is 30 to 50 mL / h

23

• 54. Evaluation of proper airway placement
  includes
• gt Auscultation of breath sounds
• gt Chest X ray
• gt Passage of a suction catheter through the
  tube
• gt End tidal CO2 measurement
• 55. All of the following describe the neonatal
  airway
• gt It has a relatively large tongue
• gt The narrowest part is the cricoid ring
• gt The epiglottis lies horizontally
• gt It has a very compliant chest wall

24

• 56. When the RCP suctions a nasally intubated
  neonate who has a size 3.0-mm endotracheal tube
  in place , respiratory distress is noted . To
  correct this , the RCP should Hyperoxygenate
  before the procedure
• 57. The CXR associated with meconium aspiration
  syndrome will likely reflect Hyperinflation
• 58. To drain an empyema , the chest tube should
  be inserted in The 6th or 7th interspace in the
  midaxillary or posterior axillary line

25

• 59. Following represent suctioning
  complications in the neonate
• gt Infection
• gt Atelectasis
• gt Increased BP
• gt Bradycardia
• gt Pneumothorax
• 60. When a neonate is being resuscitated in the
  delivery room and he or she is found to have a
  heart rate of 40 bpm without spontaneous
  respirations , what should be done ?
• gt Give chest compressions
• gt Perform mechanical ventilations

26

• 61. Following are limitations to the use of
  pulse oximetry
• gt Motion artifact
• gt Low perfusion states
• gt Skin pigmentation
• gt Abnormal hemoglobin's
• 62. Oxygen in the home care setting is
  indicated when Sao2 lt 85 in subjects breathing
  room air
• 63. Respiratory distress syndrome ( RDS ) is
  generally associated with Low-birth-weight
  neonates

27

• 64. Fluid status may be evaluated by assessing
  
• gt Urine output
• gt Blood pressure
• gt Skin turgor
• gt Jugular venous distention
• 65. Measurement of central venous pressure is
  most closely reflected by Right atrial pressure
• 66. Hypokalemia is detected when
• Potassium lt 3.5 mEq / L

28

• 67. If a patient were to contract a nosocomial
  staphylococcal infection , IMPROPER HANDWASHING
  is the most likely transmission route .
• 68. Respiratory distress may occur when
  carboxyhemoglobin levels reach 5 to 10 percent
• 69. An absolute contraindication to the use of
  postural drainage is Acute spinal injury

29

• 70. Respiratory failure is the inability to
  maintain either the normal delivery of oxygen to
  the tissues or the normal removal of
  carbondioxide from the tissues
• 71. Acute respiratory failure is identified by
  a Pao2 lt 60 mmHg and / or a PaCo2 gt 50 mmHg in
  otherwise healthy individuals at sea level .
• 72. Type 1 ( Hypoxemic ) respiratory failure
  occurs when the primary problem is inadequate
  oxygen delivery .

30

• 73. The primary causes of hypoxemia are
• gt Ventilation / Perfusion mismatch
• gt Shunt
• gt Alveolar hypoventilation
• gt Perfusion / diffusion impairment
• gt Decreased inspired oxygen
• 74. Type 2 ( Hypercapnic ) respiratory failure
  describes bellows failure of the lungs
  resulting in elevated carbondioxide levels .
  Hypercapnic respiratory failure is also known as
  Ventilatory failure .

31

• 75. The three major disorders responsible for
  hypercapnic respiratory failure ( ventilatory
  failure ) are
• gt Decreased ventilatory drive
• gt Respiratory muscle fatigue or failure
• gt Increased work of breathing
• 76. The use of PEEP during mechanical
  ventilation allows the clinician to Splint the
  lung in a position of function by increasing
  the FRC . An increase in the FRC opens collapsed
  alveoli and small bronchioles , thereby improving
  Ventilation Perfusion ratios .

32

• 77. PEEP is defined as the maintenance of
  positive airway pressure at the end of expiration
  .
• 78. The main goal of PEEP is to achieve a Pao2
  of greater than 55 60 mmHg with an Fio2 of less
  than or equal to 60 while avoiding significant
  cardio-vascular sequelae .
• 79. COPD is a chronic disorder , that limits a
  patients ability to work and , in severe cases ,
  impairs the activities of daily living .
• 80. The most prominent symptoms of COPD are
  ,dyspnea and an impaired exercise capacity .
• 81. Rehabilitation - restoration of the
  individual to the fullest mental , emotional ,
  social , and vocational potential of which he
  (or) she is capable .

33

• 82. Patients with COPD manifest decreased
  exercise tolerance . The most important factors
  thought to contribute to this limitation are -
• gt Alterations in pulmonary mechanics .
• gt Dysfunction of the respiratory muscles
  .
• gt Peripheral muscle dysfunction .
• gt Abnormal gas exchange .
• gt Malnutrition .
• gt Development of dyspnea .
• gt Active smoking .

34

• 83. The first heart sound ( S1 ) is created by
  closure of the Tricuspid valve and Mitral valve
• 84. In most respiratory illness , what symptom
  is present in 80 to 90 of the patients ? Cough
• 85. What is the name for the sensation of
  difficult or uncomfortable breathing ? Dyspnea
• 86. What type of chest pain is characterized by
  a crushing tightness often radiating to the
  neck , shoulders , and arms ? Angina pectoris
• 87. Patients who have chronic pulmonary disease
  with swelling of the lower extremities may have
  Cor pulmonale
• 88. Bradycardia is a heart rate less than 60
  beats / min

35

• 89. What is the normal range of adult blood
  pressure ? 110 - 130 / 70 - 80 mmHg
• 90. What is the normal inspiratory expiratory
  ratio ( I E ) of bronchial breath sounds in
  adults ? 1 1.5
• 91. Chest percussion is a useful diagnostic
  clinical tool in which of the following entities
  ? The level of diaphragmatic excursions
• 92. In which clinical entities would
  hyperresonance over the thorax be heard ?
  Pneumothorax
• 93. What added lung sound is characterized as
  high pitched , sibilant , or whistling from
  partial obstruction of airways ? Wheeze
• 94. Heart sounds heard over the right second
  intercostal space near the right sternal border
  originate from the Aortic valve

36

• 95. According to the 1987 statement of
  standardization of spirometry by the ATS ,
  spirometers must meet the following minimal
  standards for measuring vital capacity ( VC ) ?
• gt Accumulate volume for at least 30
  seconds
• gt Be capable of measuring volumes of at
  least 7 L
• gt Measure volume independent of flow
  between 0 and 12 L / sec
• gt Have an accuracy of at least or 3
  of reading or 50 mL , whichever is greater
• 96. How should the adult patient be positioned
  when a pulmonary function test is performed ?
  Sitting or Standing
• 97. For forced vital capacity ( FVC )
  reproducibility to be present according to ATS
  standards , what criteria must be met ? The best
  two of at least three acceptable attempts should
  be within or 5 or 100 mL , whichever is
  greater

37

• 98. In what time period is the maximum
  voluntary ventilation ( MVV ) maneuver performed
  ? 12 seconds
• 99. All actual spirometry values should be
  converted to Body temperature , ambient
  pressure , saturated with water vapor ( BTPS )
• 100. Following methods can be used to determine
  FRC
• gt Helium dilution
• gt Nitrogen washout
• gt Body plethysmography
• 101. What gas law describes how the body
  plethysmograph operates ? Boyles law
• 102. What gas analyzer measures concentration
  by actually counting the relative number of
  ionized molecules of each gas ? Mass spectrometer

38

• 103. What device is used to determine
  physiologic dead space ? Douglas bag
• 104. The respiratory quotient is defined as
  CO2 production / O2 consumption
• 105. What type of oxygen electrode is in
  arterial blood gas analyzers ? Polarographic
• 106. When a blood sample is introduced into a
  blood gas analyzer , carbondioxide diffuses
  across the membrane according to what gas law ?
  Henrys law
• 107. Carboxyhemoglobin and Methemoglobin can be
  determined by spectrophotometry

39

• 108. Bronchial breath sounds over lung
  periphery indicate ? Pneumonia
• 109. Flattening of the diaphragms on chest film
  are generally consistent with which clinical
  entity ? Emphysema
• 110. Elevated serum creatinine is indicative of
  Renal disease
• 111. Which of the following would be the
  darkest on an X ray film ? Air
• 112. What is a desirable platelet count to
  prevent spontaneous bleeding ? gt 40,000
• 113. Hypoalbuminemia and hypoproteinemia may
  lead to Pulmonary edema
• 114. What technique can be used to visually
  inspect the airways ? Bronchoscopy

40

• 115. What is the advantage of magnetic
  resonance imaging ( MRI ) over a lateral X ray
  film ? Better three dimensional perspective
• 116. What estimate of postoperative forced
  expiratory volume in 1 second ( FEV1 ) indicates
  that pulmonary resection will usually be
  tolerated ? gt 800 mL
• 117. An ( FEV1 / FVC ) which is gt 73 usually
  rules out Obstructive lung disease
• 118. Which pulmonary function test should be
  used to evaluate the reversibility of small
  airway diseases ? Pre and postbronchodilator
  spirometry
• 119. Which agent is used to image pulmonary
  perfusion ? Technetium macroaggregated albumin

41

• 120. Following are considered risks for surgery
  ?
• gt Cigarette smoking
• gt Old age
• gt Obesity
• gt Chronic lung disease
• 121. Which of the following tests evaluates the
  patients motivation to cooperate following
  surgery ? MVV
• 122. Which tests evaluates the surface area of
  the alveolar capillary membrane ? DLco

42

• 123. The ventilatory pump is a bellows
  comprised of the ribs , bony thorax , and
  respiratory muscles .
• gt Contraction of the diaphragm during
  inspiration causes an enlargement of the thoracic
  cage , producing relatively negative pressures at
  the alveolar level . This causes atmospheric air
  to be drawn into the alveoli . With expiration
  the diaphragm relaxes , the thorax becomes
  smaller , and air flows from the alveoli back out
  into the atmosphere through the same system of
  conducting airways . Ventilation is therefore a
  to and fro movement of air .

43

• 124. Motor innervation to the diaphragm occurs
  via the phrenic nerve , which is derived from the
  third through fifth cervical nerves
• 125. The visceral and parietal pleura join
  one another at the lung hila
• 126. The parietal pleura contains abundant
  pain fibers derived from the intercostal nerves
• 127. The visceral pleura does not contain
  pain fibers
• 128. At rest , average intra pleural
  pressure is about 4 cm H2O
• 129. The upper respiratory tract is primarily
  designed to purify , warm , and humidify the air
  it consists of the nose , paranasal sinuses ,
  pharynx , and larynx

44

• 130. Resistance to airflow is higher in the
  nose than in the mouth because of this intricate
  system of baffles ( the nose contains baffles
  that are bathed by thin , watery secretions
  designed to trap foreign particles and add
  moisture to the inspired air ) . This explains
  mouth breathing during vigorous exercise . In
  this case , the valuable air conditioning
  function of the nose is lost , and dry , cold air
  may enter the lower airways . In patients with
  abnormal irritability of the bronchi ,
  inspiration of cold air through the mouth during
  exercise may initiate bronchospasm
• 131. Normally , there are about 23 generations
  of airways , of which the first 16 are conducting
  airways and the last 7 are respiratory airways
• 132. Hoarseness is an ominous sign in patients
  with carcinoma of the lung . Other diseases ,
  such as granulomas , lymphomas , and aortic
  aneurysms , may also interrupt the left recurrent
  laryngeal nerve in the mediastinum

45

• Mechanisms in Asthma
• 1. Triggers - ( Allergens , Viruses ,
  Bacteria , Fungi , Irritants )
• 2. Cell Activation - Antibodies and immune
  cells activate leukocytes and tissue cells
• 3. Mediator Release - Cell activation and
  subsequent release of cell toxic mediators like
  ECP ( Eosinophil Cationic Protein ) , EPX (
  Eosinophil Protein X ) , EPO ( Eosinophil
  Peroxidase ) , MPO ( Myeloperoxidase ) destroy
  the epithelium and other tissue . This open up
  for direct contacts between allergens and other
  triggers and nerve cells , resulting in direct
  irritation , secretion , leakage , oedema , and
  bronchoconstriction as well as formation of new
  connective tissue
• 4. Physiological responses - Oedema ,
  Glandular secretions , Plasma leakage ,
  Epithelial permeability , Connective tissue
  formation , Muscle constriction , Nerve
  activation
• 5. Symptoms - Wheezing , Shortness of breath ,
  Coughing , Phlegm , Chest - tightness

46

• Postural Drainage Positions
• Upper Lobes -
• 1. ) Apical Segments of both Upper
  Lobes ? Sitting Upright
• 2. ) Posterior Segment of Right
  Upper Lobe ? Left side lying , turned 45 degree
  towards prone
• 3. ) Posterior Segment of Left Upper
  Lobe ? Right side lying , turned 45 degree
  towards prone , shoulders raised 30 cm
• 4. ) Anterior Segments of both Upper
  Lobes ? Supine

47

• Middle Lobe -
• 1. ) Lateral and Medial Segments ?
  Supine , quarter turned to left , foot of bed
  raised 35 cm
• Lingula -
• 1. ) Superior and inferior Segments
  ? Supine , quarter turned to right , foot of bed
  raised 35 cm

48

• Lower Lobe -
• 1. ) Apical Segments of both lower
  lobes ? Prone , head turned to side
• 2. ) Anterior basal Segments of
  both Lower Lobes ? Supine , foot of bed raised 45
  cm
• 3. ) Posterior basal Segments of
  both Lower Lobes ? Prone , head turned to side ,
  foot of bed raised 45 cm
• 4. ) Medial basal Segment ? Right
  side lying , foot of bed raised 45 cm
• 5. ) Lateral basal segment ? Left
  side lying , foot of bed raised 45 cm
• -----------------?
  ?-----------------

49

• Mechanical Ventilation
• Indications -
• 1. ) Severely impaired gas exchange
• 2. ) Rapid onset of respiratory failure
• 3. ) An inadequate response to less
  invasive medical treatments
• 4. ) Increased work of breathing with
  evidence of respiratory muscle fatigue

50

• Parameters that can help to guide the decision as
  to whether mechanical ventilation is needed
  include respiratory rate ( gt35 ) vital capacity
  ( lt10-15 ml / kg ) PaO2 ( lt60 mmHg with FiO2
  gt60 ) PaCO2 ( gt50 mmHg with pH lt7.35 ) and
  an absent gag ( or ) cough reflex
• Arterial blood gases should be checked 15 minutes
  after initiation of mechanical ventilation , and
  settings changed accordingly

51

• Complications of Mechanical Ventilation -
• 1. ) Barotrauma has traditionally referred to
  the rupture of small airways and alveolar walls
  by high pressure
• 2. ) Volutrauma has been described as
  pulmonary edema , diffuse alveolar damage , and
  epithelial and microvascular permeability
  resulting from overdistention of airspaces rather
  than actual rupture

52

• To minimize lung trauma resulting from excessive
  airway and alveolar pressure and volume , two
  measurements are noted
• 1. ) Plateau pressure ( P plat )
  , is static pressure measured at end inspiration
  . P plat represents the pressure imposed on
  distended alveoli
• 2. ) Auto-PEEP , is the pressure
  remaining in airways and alveoli at the instant
  before inspiration

53

• Auto-PEEP develops when a positive-pressure
  breath is delivered before complete exhalation of
  the previous breath . As a result , air becomes
  trapped and pressure within the lungs increases .
  This can lead to complications such as barotrauma
  and pneumothorax

54

• Ventilator is an electro-mechanical device ,
  that an amount of air is pushed to the
  Respiratory system
• ? Two forms of therapeutic device
  may be used ,
• 1. ) Positive pressure ventilation
• 2. ) Negative pressure ventilation
• Positive pressure ventilation - Delivering
  positive pressure to the airway
• Negative pressure ventilation - Providing
  intermittent negative pressure within pleural
  space / around the thoracic cage

55

• Primary function of ventilators -
• To facilitate the movement of gas into the lungs
• To ensure adequate oxygenation
• To ensure adequate elimination of CO2
• To control the rate of alveolar ventilation
• To increase the lung volume
• To increase the chest wall compliance
• To decrease the work of breathing

56

• As a general rule , the cuff on an endotracheal
  ( or ) tracheostomy tube should be inflated . The
  pressure within the cuff should be the lowest
  possible that allows delivery of adequate tidal
  volumes and prevents pulmonary aspiration .
  Usually the pressure is maintained at less than
  25 cm H2o to prevent injury and at more than 20
  cm H2o to prevent aspiration . Cuff pressure must
  be monitored at-least every 8 hours

57

• Complications of Intubation
• Tube malposition
• Esophageal intubation
• Significant aspiration
• Laryngeal damage
• Pneumothorax
• Tube malposition can be identified shortly after
  intubation by auscultation of bilateral axillae

58

• Causes of Respiratory acidosis -
• COPD
• Severe asthma
• CNS depression
• Mechanical under ventilation
• Neuromuscular disease
• Causes of Respiratory alkalosis -
• Asthma
• Mechanical over ventilation
• Restrictive lung disease
• Hepatic failure
• Hypoxemia

59

• In mechanically ventilated patients , respiratory
  acidosis is corrected by an increase in the
  minute ventilation ( Vt RR )
• Oxygenation may be improved by an increase in
  FiO2 ( or ) PEEP
• Mean arterial pressure SBP 2 ( DBP )
• 
  / ( divided by )
• 
  3
• 70
  105 mm Hg
  

60

• The most common complication of mechanical
  ventilation is barotrauma . High pressure can
  lead to rupture of the alveolar wall , which in
  turn can lead to pneumomediastinum , pneumothorax
  , pneumoperitoneum , and subcutaneous emphysema .
  Other common complications include increased
  intracranial pressure , fluid retention , local
  trauma to the nares and mouth , tracheal necrosis
  , renal failure .

61

• PEEP ( Positive End Expiratory Pressure ) is
  defined as the maintenance of positive airway
  pressure at the end of expiration . In so doing ,
  the alveoli fail to collapse and functional
  residual capacity increases . The end result is
  improved ventilation-perfusion matching in the
  pulmonary circulation . PEEP is usually set at
  2.5 ( or ) 5.0 cm H2o . It can be applied to the
  spontaneously breathing patient in the form of
  CPAP ( or ) to the patient who is receiving
  mechanical ventilation . The appropriate
  application of PEEP usually increases lung
  compliance and oxygenation while decreasing the
  shunt fraction and the work of breathing . PEEP
  is used primarily in patients with hypoxic
  respiratory failure ( e.g., ARDS Cardiogenic
  Pulmonary Edema ) . Low levels of PEEP ( 3-5 cm
  H2o ) may also be useful in patients with COPD ,
  to prevent dynamic airway collapse from occurring
  during expiration . The main goal of PEEP is to
  achieve a PaO2 of greater than 55-60 mm Hg with
  an FiO2 of less than ( or ) equal to 60 while
  avoiding significant cardiovascular sequelae .
  Usually , PEEP is applied in 3 to 5 cm H2o
  increments during monitoring of oxygenation ,
  organ perfusion , and haemodynamic parameters .
  Patient who receive significant levels of PEEP (
  i.e., gt 10 cm H2o ) should not have their PEEP
  removed abruptly , because removal can result in
  collapse of distal lung units , the worsening of
  shunt , and potentially life threatening
  hypoxemia .

62

• Modes of Ventilation
• CMV ( Continuous Mandatory Ventilation or
  Controlled Mechanical Ventilation ) - In this
  mode , the rate and tidal volume are controlled
  by the machine . All breaths are mandatory
  breaths and there is no mechanism for patient
  triggering ( if patients can trigger , it becomes
  Assist Control ) . CMV is used for patients who
  are unconscious ( or ) whose respiratory muscles
  are paralysed and for those who need their PaCO2
  tightly controlled .

63

• In Assist-Control Ventilation , the patient can
  breath at his own rate assisted by the machine
  but in addition , the machine delivers a minimum
  set number of controlled breaths at the rate set
  on the machine .
• In Intermittent Mandatory Ventilation ( IMV ) ,
  the patient is allowed to breath spontaneously
  with no machine assistance but the machine
  delivers a minimum set rate and tidal volume .
  The potential danger is that the timing of
  machine rate has no correlation to the
  inspiratory effort of the patient so stacking
  of breaths can occur ( the machine could try to
  force a tidal volume during a spontaneous
  exhalation phase ) .

64

• 4. In Synchronised Intermittent Mandatory
  Ventilation ( SIMV ) , which is similar to IMV ,
  breath stacking is sought to be avoided by
  synchronising the mandatory breath delivered by
  the machine to the patients inspiratory effort
  i.e. the mandatory breath is triggered by the
  patient . If no triggering occurs for a specified
  duration , the mandatory breath is delivered .

65

• Pressure Support -
• Set inspiratory assist pressure
• No set tidal volume ( or ) rate
• Patient must be able to initiate breaths , after
  which the ventilator delivers a preset airway
  pressure
• May need to convert to another mode if patient is
  sedated and can no longer initiate breaths
• Monitor RR , exhaled Vt and patient effort

66

• Acclimatisation to altitude involves progressive
  increase in ventilation over days and progressive
  polycythaemia over weeks . Too rapid an ascent to
  altitude risks life-threatening pulmonary and
  cerebral oedema
• The presence of a pneumothorax , recent sub aqua
  diving ( or ) severe respiratory failure are
  contraindications to commercial aircraft flight
• Pulmonary infections , especially tuberculosis (
  or ) pneumocystis carinii may be the presentation
  of , as well as a complication of , AIDS
• HIV infection impairs immunity by the slow ,
  steady attrition in CD4Th lymphocyte numbers .
  PCP becomes inevitable when CD4-lymphocyte counts
  fall below 200 mm3
• In COPD the airways obstruction is due
  principally to loss of airway supports and small
  airway fibrosis rather than the potentially more
  reversible obstruction due to bronchial
  inflammation in asthma

67

• The most relevant , sleep-associated ,
  respiratory changes are the diminution of muscle
  tone , especially during REM sleep . This risks
  both respiratory under ventilation and increased
  upper airway resistance ( or ) closure .
• Thoracoscopy - Traditionally , a single , rigid
  , viewing scope with an operating channel is
  inserted percutaneously into the pleural space .
  Thoracoscopy allows both pleural surfaces to be
  inspected , biopsies to be taken and insufflation
  of a sclerosant for pleurodesis .

68

• Emergency Medications
• Adrenaline
• Nor-adrenaline
• Atropine
• Dopamine
• Dobutamine
• Lignocaine
• Pethidine
• Morphine
• Aminophylline

69

• Aminophylline ? Reversible airways obstruction
  Severe acute asthma
• Adrenaline ? To treat mucosal congestion of
  rhinitis and acute sinusitis to relieve
  bronchial asthmatic paroxysms
• Nor-adrenaline ? is a vasopressor used in shock
• Atropine ? Pre-operative medication to inhibit
  secretions and salivation
• Lignocaine ? In treatment of ventricular
  arrhythmias
• Sibutramine ? is an orally administered agent
  for the treatment of obesity

70

• Antiasthmatics
• 1. ) Inhalational corticosteroids
• Beclomethasone inhalers
• Aminophylline
• Levosalbutamol
• Budesonide inhalers
• Formoterol inhalers
• Fluticasone inhalers
• 2. ) Systemic corticosteroids
• Prednisolone

71

• Antiarrhythmics
• Lignocaine
• Digoxin
• Propranolol
• Amiodarone
• Adenosine

72

• Antihypertensives
• Reserpine
• Propranolol
• Sodium Nitroprusside
• Hydralazine

73

• Antivirals
• Amantadine
• Ribavirin
• Interferon-Alpha
• Acyclovir

74

• Antifungals
• Amphotericin-B
• Fluconazole
• Griseofulvin

75

• Anti-infective Drugs
• Providone Iodine
• Chloramphenicol
• Sulfonamides
• Nystatin

76

• Antihistamines ( Non-Sedative )
• Levocetirizine
• Astemizole
• Terfenadine
• Loratadine
• Cetirizine

77

• Anti-tussives
• are used for suppression of cough
• are used mainly for unproductive dry cough and
  if the cough is hazardous . ( e.g. Cardiac
  disease , Hernia , Ocular surgery )
• The principal antitussives are Codeine ,
  Dextromethorphan , Oxolamine , Morphine

78

• Retreatment Agents ( for MDR-TB )
• Capreomycin
• Ethionamide
• Kanamycin
• Neuromuscular Drugs
• Succinyl choline
• Pancuronium

79

• Expectorants
• are drugs which reduce viscosity of bronchial
  secretion , hence the removal is facilitated by
  coughing
• E.g. - Potassium iodide , Ammonium chloride ,
  Potassium and Sodium citrate , Vasaka , Balsum of
  Tolu

80

• Oxygen delivery techniques
• 1. ) Nasal cannula -
• ? Flow rate ( L / min ) - 1 - 6
• ? Conc. delivered ( ) - 24
  44
• ? Other - Inspired O2 conc.
  depends on flow rate and patients tidal volume
• 2. ) Simple face mask -
• ? Flow rate ( L / min ) - 6
  10
• ? Conc. delivered ( ) - 35
  60
• ? Other - May promote CO2
  retention at lower flow rates

81

• 3. ) Venturi mask -
• ? Flow rate - 2 12 lts /
  min
• ? Conc. delivered - 24 60
• ? Other - Accurately controls
  proportion of inspired O2 . Use in patients with
  chronic hypercarbia ( i.e., COPD )
• 4. ) Face mask with O2 reservoir -
• ? Flow rate - 12 15 lts /
  min
• ? Conc. delivered - 60 90
• ? Other - Provides high
  inspired O2 concentration
• 5. ) BagValvemask -
• ? Flow rate - 15 lts / min
• ? Conc. delivered - 100
• ? Provides the highest
  inspired O2 concentration

82

• Spirometry
• Spirometry is a precise diagnostic test used to
  determine the condition of a patients lungs
• An instrument called a spirometer quickly and
  accurately measures the flow rate ( speed of air
  ) and the volume ( amount ) of air exhaled by the
  patient while performing a standardized maneuver
• A spirometer can assist a physician in early
  diagnosis and detection of pulmonary disease .
  Once treatment has begun , a spirometer can
  determine the response to therapy and document
  the course of the disease
• Spirometry is often performed as a screening
  procedure
• Spirometry is recommended as the gold standard
  for diagnosis of obstructive lung disease
• Behavior modification such as smoking cessation
  can be reinforced by spirometry
• Spirometry is a reimbursable test both by
  Medicare and third party carriers

83

• Spirometry is a patient dependent test . If the
  patient does not do the maneuver properly the
  results are not meaningful
• The flow / volume curve is more sensitive than
  the volume / time curve . In addition , when an
  inspiratory breath is included in the FVC
  maneuver , a complete flow / volume loop can be
  generated
• The purpose of the curve is to confirm that the
  test was done correctly and that the patient gave
  their best effort
• The patients effort is compared to a set of
  normal values ( or ) predicted values based on
  the age , height , sex and race of the patient
• The inability to reach the normal level of
  volume could indicate the possibility of
  restriction ( or ) restrictive lung disease
• If the flow rate is less than normal it could be
  an indication of obstruction ( or ) obstructive
  lung disease

84

• The American Thoracic Society suggests that
  individuals meeting any one of the following
  criteria should have at least one spirometry test
  performed annually
• Smokers over 40 years old
• History of shortness of breath upon exertion (
  or ) at rest
• History of chronic cough ( or ) sputum
  production
• History of wheezing ( or ) chest tightness
• History of frequent colds ( or ) allergic
  rhinitis
• Occupational exposure to inhaled dust ( or )
  chemicals
• All patients with asthma , bronchitis and other
  lung diseases
• All patients on bronchodilator
• Pre-operatively for all patients scheduled for
  thoracic ( or ) upper abdominal surgery

85

• Restrictive Defects
• This category of disease includes chest wall
  dysfunction , neurologic diseases resulting in
  paralysis of the muscles of inspiration ,
  dysfunction of the diaphragm , absent lung tissue
  , and scarring of the lungs as with interstitial
  lung disease .
• Atelectasis and obesity are two of the more
  common causes of a restrictive lung defect .
• Atelectasis , is caused by persistent
  ventilation with small tidal volumes ( or ) by
  resorption of gas distal to obstructed airways .
• Patients who have undergone upper abdominal (
  or ) thoracic surgery are at the greatest risk
  for atelectasis .
• Lung expansion therapy ( Incentive Spirometry ?
  Sustained , maximal inspiration ) corrects
  atelectasis by increasing the transpulmonary
  pressure gradient . This can be accomplished by
  deep spontaneous breaths ( or ) by the
  application of positive pressure .
• The most common problem associated with lung
  expansion therapy is the onset of respiratory
  alkalosis , which occurs when the patient
  breathes too fast .

86

• Combined Defects
• Certain diseases can result in both obstructive
  and restrictive defects . Two examples are ,
• i. ) Sarcoidosis
• ii. ) Severe emphysema
• i. ) Sarcoidosis , in its final stages severely
  reduces volume and limits airflow .
• ii. ) Severe emphysema , which results in
  obstruction to airflow out of the lungs . Thus
  the residual volume gas in the lung slowly
  increases and eventually restricts the volume of
  air that can be inspired . The net result is a
  combined obstructive and restrictive defect .

87

• Vital Capacity
• Both restrictive and obstructive diseases can
  decrease VC .
• i. ) Restrictive lung disorders reduce FVC
  by shrinking the lung .
• ii. ) Obstructive lung dysfunction , causes
  a decrease in the FVC by causing a slow rise in
  the RV .
• A slow exhalation may allow more air to be
  exhaled from the lung because , a slow exhalation
  helps reduce air trapping . In some patients ,
  forceful exhalation causes airways to close
  prematurely because of the high intrathoracic
  pressures produced . This early closure may
  spuriously decrease the measured VC volume as gas
  is trapped distal to the airway closure and
  cannot be exhaled .

88

• Vital capacity is an important pre-operative
  assessment factor . Significant reduction in VC (
  less than 20 ml / kg of ideal body weight )
  indicates that the patient is at a high risk for
  post-operative respiratory complications . This
  is because VC reflects the patients ability to
  take a deep breath , to cough , and to clear the
  airways of excess secretions .
• VC is also useful in evaluating the patients
  need for mechanical ventilation . A vital
  capacity of less than 15 ml / kg indicates that
  the adult patients ventilatory reserve is
  decreased significantly .

89

• Closed-system Helium Dilution Method
• Helium is used because , it is an inert gas and
  is not significantly absorbed from the lungs by
  the blood .
• This test is based on the principle that if a
  known volume and concentration of helium are
  added to the patients respiratory system , the
  helium will be diluted in proportion to the size
  of the lung volume to which it is added .
• Helium is breathed at Vt , while oxygen is added
  to replace the oxygen that is consumed by the
  patient during the test .
• The CO2 must be absorbed out of the closed
  system to prevent an increase in the dilutional
  effect on the helium and a falsely enlarged FRC
  measurement .
• If leaks occur with this method , the measured
  volumes will be overestimated . Other factors
  influencing the quality of the test include 1.
  ) the blower speed of the device . 2. ) how soon
  the technician stops the test after equilibrium
  is achieved . 3. ) the ventilatory pattern of the
  patient being tested . 4. ) if parts of the lung
  communicate poorly with the atmosphere , the
  results will be inaccurate .

90

• The use of helium in laryngeal ( or ) tracheal
  obstruction , is based on the relationship of
  breathing energy to gas density . If obstruction
  is significant and the work of breathing air ( or
  ) oxygen is very high , mixtures of helium and
  oxygen may be respired with less effort .
• Helium is an inert gas with limited medical
  applications its widest use is probably in deep
  diving . Helium is usually mixed with 20 oxygen
  for this purpose to replace nitrogen .
• Among its advantages are low density ( one
  seventh that of nitrogen ) , which allows easier
  breathing of the mixture under hyperbaric
  conditions , and lower solubility in tissue
  lipids than nitrogen ( one third ) . The result
  is less stress in breathing , with reduced
  decompression sickness and decompression time .

91

• Clinical features of hypoxaemia
• Cyanosis
• Tachypnoea
• Tachycardia ? arrhythmias / bradycardia
• Peripheral vasoconstriction
• Respiratory muscle weakness
• Restlessness ? Confusion ? Coma .
• Clinical features of hypercapnia
• Flapping tremor of hands
• Sweating
• Tachypnoea
• Tachycardia ? Bradycardia
• Peripheral vasodilation leading to warm hands and
  headache
• Respiratory muscle weakness
• Drowsiness ? Hallucinations ? Coma .

92

• Diffusion Capacity
• The ability of gas to diffuse across the
  alveolar-capillary membrane can be measured .
• The determinants of gas exchange across the
  membrane include the following -
• 1. ) Diffusion coefficient of the gas
  used in testing .
• 2. ) Surface area of the membrane .
• 3. ) Thickness of the membrane .
• 4. ) Blood volume and flow in the
  pulmonary capillary tree .
• 5. ) Distribution of the inspired gas
  .
• 6. ) Hematocrit ( is the ratio of red
  cell volume to that of whole blood ) .

93

• Diffusion , is measured by using carbon-monoxide
  at minute levels ( 0.4 ) .
• Because of carbon-monoxides intensive affinity
  for hemoglobin ( over 200 times greater binding
  power to hemoglobin than oxygen ) , the ability
  of carbon-monoxide to diffuse is limited by the
  membrane and not by capillary blood flow . It is
  therefore , a diffusion-limited gas rather than a
  perfusion-limited gas .
• ------------------------------------------
  -------------------------------
• Obesity is a multifactorial disorder of energy
  balance in which chronic calorie intake is
  greater than energy output .
• Obesity hinders movement of the diaphragm and
  increases the work of breathing ( making
  inspiration more difficult ) .
• The main treatment of obesity is a suitable diet
  and increased exercise . There are , at present
  only two drugs licensed for the treatment of
  obesity , Sibutramine and Orlistat .

94

• Disorders of the Neuromuscular Junction
• Myasthenia gravis
• Lambert-Eaton syndrome
• Poisoning ( Organophosphate , Tetanus , Botulism
  )
• Disorders of the Nerves
• Guillain-Barre syndrome
• Phrenic Nerve damage and Diaphragmatic Paralysis
• Disorders of the Spinal Cord
• Amyotrophic Lateral Sclerosis
• Poliomyelitis
• Disorders of the Brain
• Stroke

95

• Disorders of the Thoracic Cage
• Kyphoscoliosis
• Flail Chest
• Ankylosing Spondylitis
• Lower Respiratory Tract Infections
• Pneumonia
• Lung abscess
• Tuberculosis
• Neonatal Cardio-pulmonary Disorders
• Respiratory distress syndrome
• Bronchopulmonary dysplasia
• Meconium aspiration

96

• Airway Disorders of the Pediatric Patient
• Epiglottitis
• Laryngotracheobronchitis ( Croup )
• Bronchiolitis
• Cystic Fibrosis
• Foreign Body Aspiration
• Chronic Obstructive Pulmonary Disease
• Emphysema
• Chronic bronchitis
• Asthma
• Cystic Fibrosis
• Bronchiectasis

97

• Forced Vital Capacity - is the maximum volume of
  gas that can be expired when the patient exhales
  as forcefully and rapidly as possible after a
  maximal inspiration .
• Criteria for Acceptability FVC maneuver -
• Maximal effort no cough ( or ) glottic closure
  during the first second no leaks ( or )
  obstruction of the mouthpiece .
• Good start-of-test back-extrapolated volume
  less than 5 of FVC ( or ) 150 ml
• Tracing shows 6 seconds of exhalation ( or ) an
  obvious plateau no early termination ( or )
  cutoff .
• Three acceptable spirograms obtained two
  largest FVC values within 200 ml two largest
  FEV1 values within 200 ml .

98

• Look at the FEV1 / FVC ratio first if obstruction
  is suspected . If the FEV1 / FVC ratio is lower
  than expected , obstruction is present . If the
  ratio is normal ( or ) elevated , check the
  percent predicted for FVC and FEV1 . If FVC and
  FEV1 are both reduced compared with the expected
  values , and FEV1 / FVC is normal ( or ) high ,
  restriction may be present .

99

• The term air trapping is sometimes used to
  describe an increase in FRC and RV .
• The term hyperinflation is used to describe
  the absolute increase in TLC .
• Total Lung Capacity ( TLC ) is an important
  diagnostic tool in both obstructive and
  restrictive lung diseases . In restriction , the
  TLC is usually less than 80 of the predicted
  value . In obstruction , the TLC is either normal
  ( or ) increased ( hyperinflation ) .
• FRC values greater than approximately 120 of
  predicted values represent air trapping .
• FRC , RV , and TLC are typically decreased in
  restrictive diseases .

100

• Bronchial challenge testing is used to identify
  and characterize airway hyperresponsiveness .
• Challenge tests are performed in patients with
  symptoms of bronchospasm who have normal
  pulmonary function studies .
• Bronchial challenge tests are sometimes used to
  screen individuals who may be at risk from
  environmental ( or ) occupational exposure to
  toxins .
• Several commonly used provocative agents can be
  used to assess airway hyperreactivity . These
  include the following
• 1. ) Methacholine challenge
• 2. ) Histamine challenge
• 3. ) Eucapnic voluntary
  hyperventilation
• 4. ) Exercise
• Methacholine is a chemical that increases
  parasympathetic tone in bronchial smooth muscle .
  Histamine triggers a similar response producing
  bronchoconstriction .
• Hyperventilation , either at rest ( or ) during
  exercise , results in heat and water loss from
  the airway . This provokes bronchospasm in
  susceptible patients .

101

• If FEV1 / FVC ratio is greater than 70 and FEV1
  is also greater than 70 we should do
  Bronchoprovocation test .
• Patients to be tested should be asymptomatic ,
  with no coughing ( or ) obvious wheezing . Their
  baseline FEV1 should be greater than 70 of their
  expected value .
• If the patient has an FEV1 less than 1.0 to 1.5 L
  , there is a risk that a large drop in FEV1
  following methacholine challenge might leave the
  individual with compromised lung function .
• Bronchial challenge by inhalation of methacholine
  is performed by having the patient inhale
  increasing doses of the drug . Most clinicians
  consider the test positive when inhalation of
  methacholine precipitates a 20 decrease in FEV1
  . The methacholine concentration at which this
  20 decrease occurs is called the Provocative
  Concentration ( or ) PC20 .
• Patients who truly have asthma usually display a
  20 decrease in FEV1 . The lower the dose of
  methacholine , the more sensitive , ( or )
  hyperresponsive , the patients airways are .
• If FEV1 decreases 20 after the diluent ( or )
  the first dose of methacholine , PC20 should be
  reported as less than the lowest concentration
  administered . If FEV1 does not decrease by at
  least 20 after the highest dose , PC20 should be
  reported as greater than 16 mg/ml .

102

• Some patients whose FEV1 drops 20 ( or ) more at
  low doses of methacholine may not have asthma .
  Hyperreactive airways are also found in some
  patients with COPD who smoke ( or ) in patients
  who have allergic rhinitis .
• A negative methacholine challenge ( i.e., a
  decrease in FEV1 lt 20 at the highest dose ) may
  occur in patients who have asthma that has been
  suppressed by anti-inflammatory medications .
• Some asthmatics may have their asthma triggered
  by exposure to a specific agent such as cold dry
  air .
• ----------------------------------------
  ---------

103

• When the PaCO2 is chronically above 50 mmHg the
  respiratory center becomes relatively insensitive
  to CO2 as a respiratory stimulant , leaving
  hypoxemia as the major drive for respiration .
  Oxygen administration may remove the stimulus of
  hypoxemia , and the patient develops
  Carbondioxide narcosis unless the situation is
  quickly reversed . Therefore , oxygen is only
  administered with extreme caution .
• Certain infections , such as Mycobacterium
  tuberculosis atypical tuberculosis
  Pneumocystis carinii histoplasmosis and
  mycoplasma are readily diagnosed by Broncho
  Alveolar Lavage .
• Moraxella Catarrhalis is being increasingly
  recognized as a cause of bacterial pneumonia ,
  especially in the elderly . It is the second most
  common bacterial cause of acute exacerbation of
  COPD .

104

• Indications for Flexible Bronchoscopy
• Diagnostic -
• ? Lung Cancer
• ? Positive Sputum Cytology
• ? Paralyzed Vocal Cord
• ? Unexplained Pleural Effusion
• ? Hemoptysis
• ? Cough
• ? Diffuse interstitial infiltrates
• ? Immuno Compromised patient with
  Pulmonary infiltrates
• ? Ventilator-associated Pneumonia
• ? Endotracheal tube position / patency
• ? Atelectasis
• ? Tracheal esophageal fistula
• ? Acute inhalation injury
• ? Bronchography

105

• 2. Therapeutic -
• ? Mucous plugs
• ? Foreign body removal
• ? Difficult intubation
• ? Stent placement
• ? Balloon dilation
• ? Laser ablation
• ? Brachy therapy
• ? Acute lobar collapse
• ? Electrocautery
• ? Hemoptysis
• -------------------------------------------
  -----------------

106

• Sleep ? a period of rest for the body and mind ,
  during which volition and consciousness are in
  abeyance and bodily functions are partially
  suspended also described as a behavioral state
  , with characteristic immobile posture and
  diminished but readily reversible sensitivity to
  external stimuli .
• Snore ? rough , noisy breathing during sleep ,
  due to vibration of the Uvula and Soft palate .
• Sleep is regulated by the reticular formation .
• Epilepsy , brain tumor , brain abscess , cerebral
  trauma , subdural hematoma , meningitis ,
  encephalitis , cerebral vascular accident , and
  congenital defects of the brain represent types
  of conditions in which electroencephalography is
  useful .
• The electroencephalogram is widely used as a
  guide in surgery of the epileptic .
• German psychiatrist Hans Berger , introduced the
  term electroencephalogram ( EEG ) to denote the
  record of the variations in brain potential . The
  interpretation of the EEG depends on the
  frequency , amplitude , form , and distribution
  of the wave activity present .

107

• Sleep Disorders -
• Insomnia - It can be relieved temporarily by
  Sleeping Pills , especially benzodiazepines ,
  but prolonged use of any of these pills is unwise
  .
• Sleep-walking ( Somnambulism ) - Episodes of
  sleep-walking are more common in children than in
  adults and occur predominantly in males . They
  may last several minutes . Somnambulists walk
  with their eyes open and avoid obstacles , but
  when awakened they cannot recall the episodes .
• Bed-wetting ( nocturnal enuresis ) .
• Narcolepsy - is a disease in which there is
  episodic sudde