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Chapter 6 Fluids, Electrolyte, and Acid-Base Homeostasis Fluid Distribution • Consist of water and solutes • Fluid components • Structures involved in fluid distribution • Extracellular and intracellular fluid • Varies based on gender and age • Muscle mass, fat composition, and body water Fluid Movement • Constant circulation to maintain homeostasis • Exchange between compartments to compensate for gains or losses • Dependent on hydrostatic and osmotic pressures • Tonicity versus osmotic activity • Isotonic, hypotonic, and hypertonic solutions • Fluid ingestion from food and fluids Fluid and Electrolyte Balance • Fluid regulation • Compensatory mechanisms • Suppress or excrete hormones influencing water and sodium • Electrolytes • Minerals with electrical charges • Found in blood, urine, and other body fluids Fluid and Electrolyte Imbalances • Disorders of intake or elimination impairment • Resulting imbalance exceeds body’s compensatory ability • Kidney • Primary organ regulating electrolyte and fluid imbalance • Systems serving as a catalyst for imbalance • Neurologic, cardiovascular, liver Water, Sodium, and Chloride • Link between water and sodium • Chloride attraction to sodium • Shifts in ICF and ECF, changes in tonicity • Isotonic, hypertonic, or hypotonic fluid shifts • Volume imbalances and intravascular compartment • Euvolemic, hypervolemia, and hypovolemia • Considerations for determining cause Fluid Excess (1 of 4) • Ideal fluid intake • Most common issue • Too much retainment of sodium with water • Occur in different compartments • Interstitial or intracellular spaces • Transcellular increases • Concept of third spacing Fluid Excess (2 of 4) • Often a problem of fluid distribution, not overload • Edema • Hydrostatic forces greater than osmotic forces • Impact on venous system • Factors increasing venous pressure • Sodium/water imbalances • Venous insufficiency, venous obstruction, medications Fluid Excess (3 of 4) • Water intoxication • Fluid excess in the intracellular space • Ingesting water faster than its elimination • Kidney excretion abilities • Edema characteristics • Localization • Unilateral or bilateral • Acute or chronic • Dependent or nondependent areas • Pitting or nonpitting Fluid Excess (4 of 4) • Clinical manifestations • Edema • Dyspnea • Bounding pulse, tachycardia, hypertension • Jugular vein distension • Crackles • Bulging fontanelles • Diagnosis: physical examination • Treatment: management of fluid excess Fluid Deficit (1 of 3) • Total body fluid levels insufficient to meet body’s needs • Most common issue • Too little sodium with inability to retain water • Dehydration • Water loss resulting in hypernatremia • Hypovolemia • Fluid deficit in intravascular compartment • Result of total volume loss Fluid Deficit (2 of 3) • Tonicity changes and alterations of ECT and ICF volume • Neurological manifestations • Sodium alterations • Dependent on sodium lost relative to water • Manifests as thirst and altered levels of consciousness • Hypotension, tachycardia • Signs opposite of edema Fluid Deficit (3 of 3) • Diagnosis • Based on physical examination • Focused on determining cause • Treatment • Procedure choices determined by clinical suspicion • Management focused on identifying and treating underlying causes • Oral and intravenous fluid replacement Sodium (1 of 3) • Most significant cation • Most prevalent electrolyte within ECF • Controls serum osmolality and water balance • Helps maintain acid-base balance when combined with bicarbonate • Regulated by kidneys and sympathetic nervous system • Sodium-potassium pump for transport across cell membrane Sodium (2 of 3) • Primarily brought into body through dietary intake • Conditions for normal sodium loss • Hypernatremia • Results from high serum sodium levels • Hyponatremia • Results from low serum sodium levels Sodium (3 of 3) • Clinical manifestations • Hypernatremia • Lethargy, headache, confusion, irritability, seizures, and coma • Hyponatremia • Similar neuromuscular manifestations • Gastrointestinal symptoms with 130 mEq/L • Diagnosis based on serum levels • Management focused on treating underlying cause Chloride (1 of 2) • Mineral electrolyte and major extracellular anion • Assists in fluid distribution • Binding with sodium • Binding with hydrogen • Diet as main source Chloride (2 of 2) • Hyperchloremia and hypochloremia • No distinct set of clinical manifestations • Diagnosis • History, physical examination, blood chemistry, urine analysis, ABGs measurement • Treatment of underlying causes • Diuretics and bicarbonate Potassium (1 of 2) • Primary intracellular cation • Role in electrical conduction, acid-base balance, and metabolism • Serious issues from fluctuation • Diet as main source • Hyperkalemia, serum levels over 5 mEq/L • Hypokalemia, serum levels under 3.5 mEq/L Potassium (2 of 2) • Imbalance affects several body systems • Chemistry panel as diagnostic test • Determining reason for alteration • Hyperkalemia management • Increase excretion • Treatment of acidosis • Hypokalemia • Increasing potassium • Oral or intravenous administration Calcium (1 of 3) • Most found in bones and teeth • Remainder in ionized form in blood • Used for several physiological processes • Bound to albumin and chelated with phosphate, citrate, and sulfur • Inverse relationship with phosphorus • Synergistic relationship with magnesium Calcium (2 of 3) • Absorbed from dietary sources in GI tract • Role of vitamins in absorption • Excreted in urine and stool • Regulated by parathyroid hormones and calcitonin • Hypercalcemia, levels over 10.3 mg/dL • Hypocalcemia, levels under 8.8 mg/dL Calcium (3 of 3) • Clinical manifestations • Often nonspecific • Imbalances affect cell excitability • Tetany specific to hypocalcemia • Trousseau’s and Chvostek’s signs • Diagnosis • History and physical exam • Blood chemistry and 12-lead EKG • Treatment: resolving underlying cause Phosphorus (1 of 2) • Key role in: • Bone and tooth mineralization • Cellular metabolism • Acid-base balance • Cell membrane formation • Diet as main source • Hyperphosphatemia, levels above 4.5 mg/dL • Hypophosphatemia, levels under 2.5 mg/dL Phosphorus (2 of 2) • Manifestations similar to those of calcium imbalances • Diagnostic procedures • History and physical examination • Blood chemistry • Treatment of hyperphosphatemia • Aluminum hydroxide and aluminum carbonate • Treatment of hypophosphatemia • Oral supplements and IV potassium phosphate Magnesium (1 of 2) • Intracellular cation mostly stored in bone and muscle • Functions of magnesium • Diet as main source • Hypermagnesemia, levels above 3.0 mg/dL • Renal failure or excessive intake • Hypomagnesemia, levels under 1.8 mg/dL • Inadequate intake or decreased absorption Magnesium (2 of 2) • Clinical manifestations • Neuromuscular and cardiovascular system effects • Diagnostic procedures • History, physical exam, blood chemistry • Treatment strategies for hypermagnesemia • Diuretics and IVF administration • Treatment strategies for hypomagnesemia • Oral or IV Acid-Base Balance • Crucial to sustain life and maintain health • Achieved through buffer systems and compensatory mechanisms • Body fluids, kidneys, and lungs • Measured by examining pH • Causes of changes in pH • Infection, organ failure, or trauma pH Regulation • pH measure • Negative logarithm that reflects hydrogen concentration • Hydrogen • Necessary for maintaining cellular membranes and enzyme activities • Produces acids as byproducts • CO2 and carbonic acid • Organic acids • Nonvolatile acids Buffers (1 of 2) • Chemicals that combine with acid or base to change pH • Counteract pH variations until compensation is initiated • Bicarbonate-carbonic acid system • Most significant buffering mechanism • Carbonic anhydrase enzyme • Process in lungs and kidneys Buffers (2 of 2) • Protein system • Acts as acid or base • Bind to or release hydrogen • Albumin and other plasma proteins • Phosphate system • Acts as weak acids or bases • Movement of potassium and hydrogen • Maintains pH balance Respiratory Regulation • Manages pH deviations by changing carbon dioxide excretion • Increase of ventilation and higher excretion • Decreases acidity • Decrease of ventilation and lower excretion • Increases acidity • Change triggered by chemoreceptors sensing pH and PCO2 fluctuations Renal Regulation • Slowest mechanism to react to changes • Longest lasting • Kidney excretion or retention of hydrogen or bicarbonate • Only system for removing hydrogen ions • Urinary buffers necessary to eliminate hydrogen • Phosphate and ammonia Compensation • Adjustment of pH to within normal range • Cause of imbalance determines compensatory change • Degree of compensation determined by severity of imbalance • Indications of affected compensating system Metabolic Acidosis (1 of 2) • Deficiency of bicarbonate or excess of hydrogen • Due to increased production or decreased exertion • pH under 7.35 • Causes • Manifests along with existing condition • Often neurologic in nature • Headache, malaise, weakness, fatigue, confusion, and coma Metabolic Acidosis (2 of 2) • Gastrointestinal, cardiovascular, and respiratory manifestations • Diagnostic procedures • History and physical exam • ABGs, blood chemistry, and CBC • Treatment • Vital to identify and treat causative condition • Administration of IV sodium bicarbonate • Correcting electrolyte disturbances • Improving oxygenation Metabolic Alkalosis • Results from excess bicarbonate • Increased intake or retention, deficient acid, or both • Causes • Neuromuscular manifestations • Diagnosis • History and physical exam • ABGs, blood chemistry, and CBC • Treatment: • Resolution of underlying cause • Fluid replacement Respiratory Acidosis • Results from carbon dioxide retention • Conditions causing hypoventilation and/or impaired gas exchange • Acute or chronic • Acute manifestations • Hypoxemia, dyspnea, cyanosis, neurologic manifestations, behavioral changes • Treatment focus on improving respiratory status Respiratory Alkalosis • Results from excess exhalation of carbon dioxide • Conditions causing: • Hyperventilation • Stimulus of medullary respiratory center • Manifests as paresthesia, dizziness, syncope, and neuronal hyperexcitability • Treatment • Resolving underlying cause • Increasing carbon dioxide levels Mixed Disorders • Respiratory and metabolic disorders resulting in acidotic or alkalotic state • Imbalance of acid or base in both respiratory and renal systems • Evaluated by history and compensatory response of: • Kidneys • Respiratory system • Common in critically ill patients and those with comorbid conditions Arterial Blood Gas Interpretation (1 of 2) • Principal diagnostic tool for evaluating acidbase balance • Single point in time • Often need serial measurements • Description of the results • pH, PaCO2, HCO3, PaO2, base excess or deficit • Focus on pH, PaCO2, and HCO3 for interpretation Arterial Blood Gas Interpretation (2 of 2) • Systematic examination of results • Start with the pH for acidic or basic • Check the PaCO2 for acidic or basic • Examine the HCO3 for acidic or basic • Match up results for acidity and alkalinity for the primary change • Compensation indicated by third unpaired result Chapter 5 Pulmonary Function Anatomy and Physiology (1 of 4) • Provides gas exchange functions • Air-conducting portion • Passage of air through pulmonary system • Structures of pulmonary system • Air filtration structures • IgA cells in pulmonary system • Moistens and warms air Anatomy and Physiology (2 of 4) • Gas-exchange functions • Alveoli for gas-exchange with bloodstream • Requires adequate ventilation and sufficient perfusion of blood to alveoli • VQ ratio • Diffusion by pressure • Factors affecting the delivery of oxygen • Surface tension of the lungs Anatomy and Physiology (3 of 4) • Control from medulla oblongata • Inspiration phase • Active neural process • Contractions from nerve impulses • Expiration phase • Passive process • Pressure changes Anatomy and Physiology (4 of 4) • Atmospheric, intrapulmonary, and intrapleural pressures • Measurement of air flow • Pulmonary function tests • Evaluates lung volume and capacities • Structures that regulate breathing • Lungs’ role in regulating pH • Acidity of CO2 Infectious Rhinitis • Viral upper respiratory infection • Rhinovirus and other viruses as causative organisms • Highly contagious and transmission modes • Manifests as nasal discharge, laryngitis, systemic symptoms • Diagnosis based on signs and symptoms • Symptomatic treatment • Possible secondary bacterial invasions Rhinosinusitis (1 of 2) • Inflammation of one or more paranasal sinuses • Infectious and noninfectious causes • Acute, subacute, chronic, recurrent types • Clinical manifestations • Painful pressure in sinus cavity, nasal congestion • Purulent nasal discharge, hyposmia, halitosis Rhinosinusitis (2 of 2) • Diagnosis • Pointed to by clinical manifestations • Further evaluation for complicated presentations • Treatment • Decongestants, analgesics, nasal corticosteroid spray, nasal irrigation Upper Respiratory Tract Infections • Pharyngitis/tonsillitis • Inflammation of the pharynx or palatine tonsils respectively • Often occur together • Viral pharyngitis • Infectious • More prevalent in children • Sore throat as main complaint Infectious Mononucleosis • Most commonly caused by Epstein-Barr virus • Transmission via saliva, rarely with other fluids • Lymphocytosis • Possible clinical silence with EBV and CMV infection • Classical presentation in 12-25 age group • Monospot blood test • Symptom management for treatment • Complications of EBV and CMV Herpangina and Hand-FootMouth Disease • Enteroviruses, particularly Coxsackievirus • Transmission from contaminated hands, respiratory secretions, fecal matter • 4- to 6-day incubation period • Vesicles on buccal mucosa and tongue for HFM • Lesions on soft palate, uvula, and tonsils for herpangina Bacterial Pharyngitis (1 of 2) • Result in exudate on tonsils and oropharynx • Streptococcus pyogenes • Group A beta-hemolytic (GABHS) bacteria • Resist phagocytosis • Bind with CD44 • Transmission via saliva and nasal secretions Bacterial Pharyngitis (2 of 2) • Clinical manifestations • Sudden sore throat, painful swallowing, fever • Cervical lymphadenopathy, tonsillar erythema, hypertrophy, exudates, and petechiae on palate • Scarlatinoform rash • Sexually transmitted causes • Treatment: antibiotics Epiglottitis (1 of 2) • Life-threatening condition of the epiglottis • Quick swelling and air blockage • Common causes • Haemophilus influenzae type b (Hib) • GABHS bacteria • Throat trauma • Clinical manifestations • High fever, sore throat, muffled speech, dysphagia, drooling, inspiratory stridor, hypoxemic signs Epiglottitis (2 of 2) • Priority to maintain airway and stabilize respiratory status • Diagnosis • Visualization of the epiglottis • Treatment • Intravenous antibiotics • Encouragement of Hib vaccinations • Prevention strategies Peritonsillar Abscess • Complications of tonsillitis or pharyngeal infection • Polymicrobial infections • Manifestations similar to other pharyngeal infections • Considerations for physical examination • Airway management • Intravenous antibiotics, hydration, pain control, and drainage Laryngitis • Inflammation of the larynx • Infectious and noninfectious causes • Manifests as hoarseness, weak voice or aphonia, tickling or raw sensations • Diagnosis based on clinical presentation • Comfort-based treatment • Acute versus persistent laryngitis • Vocal cord paralysis Laryngotracheobronchitis • Subglottic area edema leading to airway narrowing and obstruction • Causes • Parainfluenza viruses • Other infectious and noninfectious causes • Manifests as hoarseness, seal-like barking cough • Usually self-limiting • Supportive therapy for severe cases • Cool humidity, corticosteroids, humidified oxygen, and hydration Influenza (1 of 4) • Type A, most common type • Responsible for epidemics and pandemics • Highly adaptive and constantly mutating • Found in humans and many animals • Type B, milder disease • Isolated primarily to humans • Type C, sporadic cases and minor outbreaks • Antigenically stable • Humans, pigs, and dogs Influenza (2 of 4) • Transmission through airborne droplets • 2015-2016 and 2017-2018 flu seasons • Two surface glycoproteins for type A • Hemaglutinin (HA) • Neuraminidase (NA) • Impact of viral infection • Shut down of host cell protein synthesis • Immune response Influenza (3 of 4) • Clinical manifestations • Result of the immune response • Less commonly nasal congestion, sore throat, and watery rhinorrhea • Diagnosis • Considerations for diagnostic tests • Symptomatic and supportive treatment • Antiviral medications, NA inhibitors, and polymerase acidic endonuclease inhibitor Influenza (4 of 4) • Flu complications • Prevention strategies • Similar to common cold prevention • Vaccinations for seasonal flu and H1N1 flu • Four types of seasonal flu vaccinations • CDC recommendations • Process of vaccine development • Egg allergy considerations Acute Bronchitis • Inflammation of the tracheobronchial tree • Caused by wide range of viruses • Bacterial invasions, secondary bacterial infections, and noninfectious causes • Manifests mildly with lingering cough • Absent pulmonary consolidation signs • Diagnosis based on clinical evaluation • Generally self-limiting • Supportive treatment • Pharmacologic treatment Bronchiolitis • Acute inflammation of bronchioles resulting from viral infection • Most commonly respiratory syncytial virus (RSV) • Manifestations varying in severity • Rhinorrhea, cough, decreased appetite, malaise, and fever • Degrees of respiratory distress • Clinical evaluation, CBC, and ABGs • Symptomatic treatment • Prevention strategies Pneumonia (1 of 4) • Inflammatory process of the lung parenchyma • Causes: usually infectious agents • Treatment and prognosis • Based on cause • Categorizations • Individual risks characteristics • Anatomic lung distribution involvement • Location of acquisition Pneumonia (2 of 4) • Types • Community acquired pneumonia • Hospital acquired pneumonia • Atypical pneumonia • Ventilator-associated pneumonia • Entrance of pathogens into lung parenchyma • Activation of innate immune defenses • Accumulation of exudate and cell debris • Consolidation Pneumonia (3 of 4) • Legionnaires’ disease • Viral pneumonia • Severe acute respiratory syndrome (SARS) • Middle East Respiratory Syndrome • Fungal exposure • Risk factors for development • Aspiration pneumonia Pneumonia (4 of 4) • Clinical manifestations • Productive or nonproductive cough, fatigue, pleuritic pain, dyspnea, fever, chills, • Crackles, consolidation signs, decreased breath sounds • Pleural rub, tachypnea, and mental status changes • Positive outcomes dependent on early diagnosis and treatment • Chest X-ray and clinical prediction scores • Management of respiratory distress Tuberculosis (1 of 2) • One of world’s deadliest conditions • Caused by Mycobacterium tuberculosis • Modes of transmission • Activation dependent on strength of immune system • Primary and secondary infection stages Tuberculosis (2 of 2) • Clinical manifestations • • • • • Latent TB Productive cough Night sweats, fever, chills Fatigue Unexplained weight loss, anorexia • Diagnosis • Tuberculin skin test • Interferon gamma release assays • Treatment • 6 to 9 months of antimicrobial therapy Asthma-Obstructive (1 of 3) • Chronic pulmonary disease characterized by: • Chronic airway inflammation • Bronchial hyperresponsiveness • Mechanisms underlying asthma development • Early and late response phases for asthma episodes • Asthma severity • Atopic and nonatopic Asthma-Obstructive (2 of 3) • Variability in response to glucocorticoids • Exercise-induced asthma • Factors triggering or influencing asthma manifestations • Clinical manifestations • Classified by severity • Expiratory wheezing, dyspnea, chest tightness, cough, anxiety, tachypnea, and tachycardia • Considerations for status asthmaticus Asthma-Obstructive (3 of 3) • Diagnosis • History and physical examination • Pulmonary function tests • Treatment • Focus on controlling symptoms • Short acting beta agonist (SABA) • Long-term management guided by Stepwise approach Chronic Obstructive Pulmonary Disease (1 of 3) • Chronic respiratory disorders characterized by: • Recurrent respiratory symptoms • Airway obstruction • Attributed to irreversible airway/alveolar abnormalities • Caused by inflammatory response and damage from smoking • Prevalence and incidence Chronic Obstructive Pulmonary Disease (2 of 3) • Emphysema damage from cigarette smoking • Other influences on COPD development • Clinical manifestations • Dyspnea, cough, chest tightness, wheezing • Results in hypoventilation, hypoxemia, and hypercapnia • Acute exacerbations Chronic Obstructive Pulmonary Disease (3 of 3) • Spirometry to evaluate COPD • Confirmatory diagnostic criteria • Chest X-rays for other diagnosis • Pulse oximetry and ABGs for oxygenation status • Management strategies • Smoking cessation • Bronchodilators and anticholinergic inhalers • Pulmonary rehabilitation • Antibiotics Sleep Apnea-Obstructive (1 of 2) • Recurrent cessation or limitation of airflow through the mouth and nose • Despite continued breathing efforts • Results in hypercapnia, hypoxemia, and disturbed sleep • Obstructive (OSA) or central (CSA) • Factors influencing prevalence and incidence of OSA Sleep Apnea-Obstructive (2 of 2) • CSA associated with heart or brain abnormalities • Cheyne-Stokes respirations • Clinical manifestations • Snoring, apnea, nighttime choking, gasping, or breath holding, nonrestorative sleep • Diagnosis: • History, physical exam, and sleep study • Behavioral measures and CPAP for treatment Cystic Fibrosis-Obstructive (1 of 2) • Inherited respiratory disorder causing severe lung damage and nutritional deficits • Mutation in gene that makes CFTR protein • Problems with chloride movement across cell membrane • Imbalances in sodium and water transport • Occlusions from secretions Cystic Fibrosis-Obstructive (2 of 2) • Clinical manifestations • Varying severity of disease and symptoms • Meconium ileus in newborn • Respiratory manifestations • Gastrointestinal manifestations • Prenatal diagnosis and newborn screening • Interdisciplinary approach for treatment • Diligent family involvement • Respiratory care and infection control strategies Lung Cancer (1 of 3) • Arise from epithelial cells lining bronchi or bronchioles • Impact of smoking • Lung environment for tumor development and growth • Small cell and non-small cell carcinomas • Airway obstruction and inflammatory changes from tumors Lung Cancer (2 of 3) • Clinical manifestations • Insidious, mimic signs of smoking • Persistent cough • Dyspnea • Hemoptysis • Frequent respiratory infections • SIADH • Hypercalcemia Lung Cancer (3 of 3) • Diagnostic procedures • History and physical exam • Chest X-ray, CT, MRI, PET • Bronchoscopy, pulmonary function tests • Sputum studies • Biopsy, bone scans • Treatment • Based on staging and cancer treatments • Usually palliative Pleural Effusion (1 of 2) • Accumulation of excess fluid in pleural cavity • Transudative effusions • Exudative effusions • Empyema • Hemothorax • Chylothorax • Pleurisy/pleuritis Pleural Effusion (2 of 2) • Clinical manifestations • Depend on type, location, amount, and fluid accumulation rate • Tachypnea, tachycardia, pleurisy, diminished or absent lung sounds • Diagnostic procedures • History and physical exam • Chest X-ray, CT • ABGs, CBC • Treatment: fluid removal Pneumothorax (1 of 3) • Presence of atmospheric air in pleural cavity • Damage to visceral or parietal pleura • Types • Spontaneous pneumothorax • Primary vs. secondary • Traumatic pneumothorax • Tension pneumothorax Pneumothorax (2 of 3) • Clinical manifestations • Sudden chest pain over affected lung • Chest tightness • Anxiety • Dyspnea • Physical findings • Tachypnea and/or tachycardia • Decreased breath sounds • Asymmetrical chest expansion Pneumothorax (3 of 3) • Diagnostic procedures • History and physical exam • Chest X-ray • CT • ABGs • Treatment • Air removal • Reestablishment of negative pressure Acute Respiratory Distress Syndrome-Restrictive (1 of 3) • Sudden failure of the respiratory system • Massive alveolar capillary membrane injury • Acute lung inflammation • Conditions precipitating ARDS • Transfusion-related acute lung injury (TRALI) • Exudative, proliferative, and fibrotic phases Acute Respiratory Distress Syndrome-Restrictive (2 of 3) • Clinical manifestations • Suddenly or insidious development • Early signs of tachypnea, dyspnea, and tachycardia • Worsening respiratory efforts • Coarse crackles in lung sounds • Symptoms of multiple organ dysfunction syndrome (MODS) • Diagnostic procedures • ABGs, chest X-ray, CT, CBC, and other tests Acute Respiratory Distress Syndrome-Restrictive (3 of 3) • Berlin criteria for ARDS prognosis and diagnostic criteria • Treatment • Maintain adequate oxygenation and respiratory status • Mechanical ventilation • Extracorporeal membrane oxygenation (ECMO) • Pharmacologic therapy Atelectasis-Restrictive • Incomplete alveolar expansion or collapse of alveoli • Conditions causing atelectasis • Manifests as dyspnea, cough, anxiety, and restlessness • Diagnostic procedures: chest X-ray, CT, bronchoscopy, ABGs, and CBC • Treatment • Remedying underlying causes • Reinflating alveoli Acute Respiratory Failure • Very low oxygen levels (life threatening) • Development of respiratory acidosis • Manifestations • Usually evident from impaired gas exchange • Diagnosis • ABGs, chest X-ray, EKG, and CBC • Treatment • Resolving cause • Maintaining adequate respiratory status
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