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Oxygen Therapy/ Pulmonary Embolism

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Pulmonary Embolism (PE)
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Collection of particulate matter (solids, liquids, air) that enters the venous circulation and lodges in pulmonary vessels.
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How does a PE usually occur?
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A blood clot from a VTE in leg or pelvic vein breaks off and travels through vena cava into the right side of the heart.
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Pulmonary Emblous leads to ….
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Ventilation without perfusion Hypoxia and acidosis
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If a patient has a pulmonary embolism in his Left Lung, how would the nurse want to position this patient?
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On his right side
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PE risk factors
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Prolonged immobilization Surgery CVL Broken long bones Smoking Diseases that increase clotting Hx of thromboembolism Obesity Advancing age
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Which bones are at greatest risk for developing a PE?
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Long bones
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RESP Clinical manifestaions PE
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Dyspnea Tachypnea Tachycardia Severe chest pain Hemoptysis Dry cough
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Cardiac Clinical manifestations PE
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Distended neck veins Syncope Cyanosis Systemic hypotension Abnormal heart sounds Abnormal EKG
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Other PE clinical manifestations
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Low grade fever Petechiae Flu-like sxs
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What is the Pulmonary Embolism cluster?
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Distended neck vein Syncope (fainting) Cyanosis Hypotension
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If pt has hemoptysis, there is damage to the :
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alveoli
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norm pH
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7.35-7.45
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norm PaCO2
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35-45
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norm HCO3
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22-26
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norm PaO2
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80-100
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norm SaO2
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90-100
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When a person has a PE, what ABGs increase and decrease?
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Increased CO2 -> resp acidosis -> hyperventilation -> resp alkalosis
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Non-surgical PE management
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O2 therapy (NC or mask) Continuous monitoring Start IV Cont. monitor pulse ox Meds (anticoagulants & fibrinolytics)
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Common anticoagulants
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Heparin Warfarin Lovenox (used in diabetics)
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Common fibrinolytics
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Activase Strepase
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What is the top priority nursing care in anticoagulants and fibrinolytics
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monitor for airway & breathing monitor for bleeding
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Difference b/t anticoagulants and fibrinolytics?
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Anticoagulants prevent clots from getting bigger or forming Fibrinolytics dissolve clots and restore pulmonary flow
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Heparin and coumadin are often given together why?
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Heparin is short term Coumadin is long term (takes longer for it to be therapeutic)
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When a pt has a PE, what position should they be in?
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High fowlers (to promote breathing)
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Antidotes for Heparin Warfarin Fibrinolytics
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Protamine sulfate- heparin Vitamin K (phytonadione) – warfarin Fresh frozen clotting factors -fibrinolytics
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Interventions for PE
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Have antidotes Assess for bleeding Abd girth q8 hrs (bleeding ulcers) Lab values Minimize anxiety
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PE complications
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Decreased cardiac output Hemorrhage
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PE surgical Management
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Embolectomy Inferior vena cava filtration
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Most common type of thrombophelebitis is:
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Deep Vein Thrombosis
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What is virchows triad? (3 broad categories thought to contribute to thrombosis)
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hypercoagulabilty impaired blood flow damage to blood vessels
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Diagnostic test for DVT
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Venous doppler D-Dimer
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DVT tx
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rest elevate meds thrombectomy filter
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Normal INR
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2-3
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Normal PTT
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30-40
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What does an abnormal INR mean?
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Low = PTT and PT are low (blood more likely to clot)
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What does an abnormal PTT mean?
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Long PTT (blood takes longer to clot)
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Acute Respiratory Failure ABGs
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PaCO2 > 50 Pa02 < 60 SaO2 < 90% pH <7.30 ALWAYS hypoxemic ventilatory (oxygen intake)/perfusion(blood delivery) mismatch
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Acute Resp Failure manifestations
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dyspnea restlessness impaired judgment motor impairment tachycardia hypertension then hypotension cyanosis dysrhythmias decreased cardiac output
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Respiratory failure
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inadequate alveolar ventilation impaired gas exchange ventilation-perfusion mismatch
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Resp failure assessment data
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ask if they feel they are getting enough air evaluate for anxiety RR, work of breathing, SO2, vitals assess skin/nails for cyanosis
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Nursing interventions ARF
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Encourage deep breathing Encourage coughing (pop open alveoli) Encourage incentive spirometer Frequent turning & repositioning
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Respiratory dx procedures
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Pulse ox ABG Bronchoscopy Thoracentesis Sputum cultures Nose & Throat culture PFT Chest xray VQ scan CT Biopsy
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Ventilatory Failure
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Physical problem of lungs or chest wall Problem in O2 intake and blood delivery Defect in resp control center in brain Poor funct. of resp muscles Extrapulmonary causes Intrapulmonary causes
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Oxygenation failure
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Insufficient oxygenation of pulmonary blood at ALVEOLAR level Ventilation normal Perfusion decreased R to L shunting of blood V/Q mismatch Low PaO2 (<80) Abnormal Hgb
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Combined Ventilatory/Oxygenation Failure
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Poor resp movements Often occurs in patients with abnormal lungs (e.g., chronic bronchitis, emphysema, asthma attack) Diseased bronchioles and alveoli cause oxygenation failure; work of breathing increases; respiratory muscles unable to function effectively
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Types of O2 therapy
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Nasal cannula Simple face mask Partial Rebreather Nonrebreather venturi Aerosol T-peice
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Nasal Cannula flow rate & O2 concentration
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1-6 L/min 24-44%
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Simple face mask Flow rate and O2 concent.
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1-6 L/min 40-60%
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Partial Rebreather mask Flow rate and O2 Concent.
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6-11 L/min 60-75%
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Non-Rebreather Mask
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HIGHEST O2 delivery method besides intubation Can deliver FIO2 80-95% Liter flow should just be high enough to keep reservoir bag 2/3 full
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Low flow O2 delivery systems
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Nasal cannula Simple face mask Partial Rebreather Non Rebreather
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High FLow O2 delivery systems
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Venturi mask Aerosol mask T-piece
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Early sxs of Hypoxia and Hypoxemia
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Tachypnea Tachycardia Restlessness Pale skin/muc membranes Elevated BP Sxs of resp distress (accessory muscles, nasal flaring, treacheal tugging, adventitious breath sounds)
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Late sxs of Hypoxia and Hypoxemia
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Confusion Stupor Cyanotic skin/ muc membranes Bradypnea Bradycardia Hypotension Cardiac dysryth..
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Most commonly used diagnostic procedure for a PE
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CT scan
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When can H2O be added to a nasal cannula?
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When the flow is under 3 L
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Which mask has 1/3 exhaled air with room air?
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Partial rebreather mask
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What might happen if say “a patient is on NC at 7 L”
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The prongs will get obstructed….. happens when over 6 L
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High flow systems are used for:
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critically ill patients and when delivery of precise levels of O2 are needed
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Which oxygen delivery device is good for someone who has been throwing up a lot?
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Nasal cannula
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The amount of O2 delivered from a low flow O2 delivery system depends on:
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the pt’s breathing pattern
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Room air is __% O2
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21%
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Nasal cannula is used for what pts?
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Chronic lung dz Pt needing long term therapy
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Simple face mask is used for what pts?
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emergency situation short term O2 therapy
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How much of the bag should be inflated on a partial rebreather mask?
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Slightly inflated at the end of inspiration
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What is a non rebreather used for?
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unstable respiratory status and who may require intubation “hold down the fort mask”
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Which low flow mask delivers the highest O2 level?
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Non-rebreather
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High flow delivery systems deliver how much O2? flow?
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24-100% 8-15 L
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Which mask delivers the most accurate O2 concentration without intubation?
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Venturi mask
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Is humidification needed with Venturi mask?
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no
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Which high flow mask is used for pts with chronic lung dz?
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venturi
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What is an aerosol mask used for?
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-when high humidity is needed after extubation -upper airway surgery -thick secretions
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Venturi mask flow and concent
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2-10 L/min 24-55% MOST PRECISE O2 delivery
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Aerosol mask flow and concent.
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>10 L/min 24-100%
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T-piece flow and concent
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>10 L/min 24-100%
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When is a T-piece used?
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To deliver any desired FiO2 to the pt with a tracheostomy, laryngectomy, on endotrach tube
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When is a partial rebreather used?
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Pt who is a gunshot victim w/no lung hx SOB Usually hyperventilating
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Venturi mask used for
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COPD Pts with chronic lung dz
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What should the cuff pressure be on an endotracheal tube?
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<20 mmHg
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Valsalva maneuver
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Increase of intrathoracic pressure by forcible exhalation against the closed (or significantly closed) glottis. The maneuver causes a trapping of blood in the great veins, preventing it from entering the chest and right atrium. When the breath is released, the intrathoracic pressure drops and the trapped blood is quickly propelled through the heart, producing an increase in the heart rate (tachycardia) and the blood pressure. Immediately after this event a reflex bradycardia ensues. Many die from it.
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Nurse hears dull percussions in the chest, what could this signify?
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Hemothorax
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A nurse hears hypertympanic sounds when percussing the pts chest. What could this signify?
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Pneumothorax
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Hemothorax and blood volumes in the lungs…..
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under 300 can be reabsorbed back into body Over 300 could be life threatening >1500-2000 need immediate VATS
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Non-rebreather
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85-89% at 10-15 L/min keep the reservoir bag 2/3 full during inspiration and expiration highest % of low O2