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NSG 478 > Acute resp failure/ARDS/ mechanical vent > Flashcards

Acute resp failure/ARDS/ mechanical vent Flashcards

1
Q

Acute resp failure overview

A
  • Failure for the lungs to provide adequate ventilation and perfusion
    • Hypoxia+hypercapnia+acidosis
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2
Q

Acute resp failure patho

A
  • Most common organ failure seen in critical care environment and can be observed with other disease states
  • Fluid or some other disease process interferes with the alveoli, impaired gas exchange
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3
Q

Causes of Acute resp failure

A
  • Impaired CNS function: Drug, head trauma, infection, hemorrhage, sleep apnea
  • Neuromuscular dysfunction (MG, GBS, ALS. SCI)
  • Musculoskeletal dysfunction: Chest trauma, kyphosis, malnutrition
  • Pulmonary dysfunction:COPD asthma, CF, pneumonia, ards, PE
  • Post op period: Due to anesthesia and sedation
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4
Q

Three acute respiratory failure categories

A
  • Failure in oxygenation
  • Failure in ventilation
  • Failure in perfusion
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5
Q

Acute resp failure categories: Oxygenation failure

A
  • V/Q mismatch
  • Hypoventilation
  • Intrapulmonary shunting
  • PE
  • Pulmonary edema
  • COPD
  • Bronchitis
  • Pneumonia
  • Decreased CO anemia= Hypoxemic resp failure

Anemia is a huge one

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6
Q

Acute resp failure categories: Ventilation failure

A
  • Hypercapnia
  • Alveolar and art oxy levels are low due to not getting into lungs
  • CO2 increased (Its not exhaled)
  • Alveolar hypoventilation
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7
Q

3 diagnostic test for resp failure

A
  • Chest X ray
  • ECG
  • ABG
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8
Q

PH: 7.5
PaCO2: 28 mmHg
PaO2: 58 mm Hg
HCO3: 24 mEq/L

SaO2 of 89% and RR of 28

What is the issues

A
  • Resp alk that is uncompensated
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9
Q

Hypoxemic Oxygenation failure: PaO2 and PaCO2

A
  • PaO2 less than 60 mmHg and a low or normal PaCO2
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10
Q

Hypercapnic Ventilation failure: PaCO2

A
  • PaCO2 will be greater than 50 mmHg
  • Ph will likely be acidotic can be (alkylytic as well)
  • Buffers like bicarb will be normal or a mild increase
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11
Q

Early signs of resp failure

A
  • Restlessness/ anxiety
  • Fatigue
  • Headache
  • Dyspnea
  • Air hunger
  • Tachycardia
  • Hypertension
  • Use of accessory muscles and decreased breath sounds
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12
Q

Later signs of resp failure

A
  • Hypoxemia progresses
  • Increased confusion
  • Lethargy
  • tachypnea
  • Central cyanosis
  • Diaphoresis
  • Resp arrest
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13
Q

Venturi mask

A
  • High flow O2 system
  • The most precise, in delivering O2
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14
Q

Medical mgmt of acute resp failure

A
  • Correct underlying cause
  • Restore adequate gas exchange
  • Non-invasive or invasive ventilation
    • BIPAP, CPAP
    • intubation
    • Mechanical ventilation
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15
Q

Nursing mgmt of acute resp failure

A
  • Assess reso status, LOC, ABG vitals
  • T/P/ ROM
  • Can they protect their airway/ or they getting vented
  • Skin care
  • Mouth care
  • Emotional support, update family, alternative communication methods
  • Assist with intubation and mechanical vent
  • Tach care and suctioning
  • Preventing aspiration
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16
Q

Acute resp distress syndrome (ARDS) : Overview

A
  • Clinical syndrome: (Collection of all the S+S)
    • Severe Inflammatory process with alveolar dmg
    • Pul edema, lung infiltrates, Hypoxemia
    • Hypoxemia is Unresponsive to O2 supplementation
  • Super high mortality rate, 27-50% HCAP or sepsis
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17
Q

Can you give O2 supplementation with ARDS

A
  • You can, but it wont do anything. There is dmg to the alveoli so it won’t help with oxygenation
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18
Q

Patho of ARDS

A

ACUTE lung injury
* Initiation of inflammatory immune response
* Release of mediators
* Increased capillary membrane permeability
* Alveolar flooding with Fluid after loss of surfactant
* Alveolar collapse
* Increased work of breathing
* Decrease in airway diameter
* Increase in airway resistance, decreased lung compliance
* Increased work of breathing
* Injury to pulmonary vasculature
* Pulmonary vasoconstriction, micro emboli formation and pulmonary hypertension
* Alveolar dead space leading to increased work of breathing
* Decreased cardiac output

Increased work of breathing leading to alveolar hypoventilation and intrapulmonary shunting –> Hypoxemia

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19
Q

P/F ratio

A

Po2 divided by the FiO2 in an ABG.
Normal is 400 anything less than 300 is bad

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20
Q

Causes of ARDS: Direct injury

A
  • Aspiration of gastric content
  • Pulmonary contusion (Bruising)
  • Near drowning
  • Inhalation of smoke or toxic substances
  • Viral and bacterial pneumonia
  • O2 tox
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21
Q

Causes of ARDS: Indirect injury

A
  • Systemic Sepsis
  • Hypovolemic shock associated with chest trauma or sepsis (Did not respond to antibiotics)
  • Acute pancreatitis
  • Fat emboli
  • Trauma
  • Disseminated intravascular coagulation (DIC)
  • Massive blood transfusions
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22
Q

PEEP

A
  • Positive end expiratory pressure
  • Helps with conditions like ARDS to keep the alveoli open
  • 10-15 cm/H2O is recommended amount of pressure to provide the most benefit with the least amount of trauma
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23
Q

Continuous Positive airway pressure (CPAP)

A
  • Form of PEEP
  • Delivers the same continuous pressure throughout the respiratory cycle
  • Decreases alveolar dead space and improves intrapulmonary shunt by opening the alveoli
  • Decreases atelectasis, reduces work of breathing and reduces hypoxia
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24
Q

Bilevel Positive airway pressure (BiPAP)

A
  • Provides two pressure levels, inspiratory and expiratory (IPAP/EPAP) pressure during inspiration is greater than expiratory
  • BIPAP helps maintain open airways and increase tidal volume and alveolar ventilation. Improves hypercarbia and decreases the work of breathing using pressure support at inspiration
  • EPAP helps increase functional residual capacity and improves hypoxemia by keeping alveoli inflated during expiration
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25
Adverse effects of PEEP (CPAP/BiPAP)
* Increased end expiratory pressure causes increased intrathoracic pressure **leading to decreased BP/ CO** * Barotrauma is also a risk especially with higher levels of peep than needed * Pressure of **10-15** is usually adequate to provide the most positive benefits of PEEP
26
Mild ARDS
* P/F ratio of 200-300 with CPAP or Peep value of at least 5 cm H20
27
Moderate ARDS
P/F ratio of 100-200 with CPAP or PEEP value of at least 5 cm H2O
28
Severe ARDS
P/F ratio of under 100 with CPAP or PEEP value of at least 5 cm H20
29
PH: 7.21 PaCO2 60.7 PaO2 65 mmHg HCO3 24 mEq/L SaO2: 86.9 with PF ratio of 100 Echo within normal limits Whats the acid base
Resp acidosis, uncompensated
30
Chest X ray with an ARDS patient
White out, full of fluid
31
Assessment and diagnostics findings ARDS
* Pul: intercostal retractions with crackles and persistent hypoxia * Diagnostic test * BNP, Echo, Pa catheterization * Pulmonary edema * Worsening pulmonary infiltrates * Increased alveolar dead space (Vent to alveoli but poor perfusion because fluid * Decreased pulmonary compliance/ stiff lung making it difficult to vent
32
When should a patient get intubated
* When they can no longer protect their airway and PEEP isn't working
33
Medical mgmt of ARDS
* Identify and treat underlying cause * Supportive therapy: ET intubation and mechanical vent * Volume and nutritional support: IV fluid and tube feeding (Prevent ileus and get cal) * Hypovolemia due to leakage of fluid to interstitial spaces and decreased CO (Vasopressors) * Prone positioning * Sedation (Pt doesnt like tube in their face)
34
Is there a specific pharm treatment for ARDS
Nah there isn't a cure or treatment Its supportive care
35
ARDS considerations
* ICU care * Resp modalities, nebulizer therapy, Chest physio, intubation and mechanical intubation **Suctioning (PRN)** bronchoscopy * Frequent repositioning, prone is great * Use of specialty beds * Assess and intervene with pt anxiety to decrease o2 consumption (Calm them down)
36
Mechanical ventilation
* Pressure controlled device that maintains vent and o2 delivery * Supports the process of gas exchange (Alveolar vent and art oxygenation) * Invasive positive pressure, ET or trach
37
Non invasive mechanical ventilation
CPAP and BiPAP
38
Endotracheal tube intubation: indication
* Anesthesia purposes during surgery * Inability to protect airway * Altered mental status (Head injury/ drugs) * Anticipated airway obstruction(Facial burns, epiglottitis, major facial or oral trauma) * Apnea * Ineffective clearance of secretions * High risk of aspiration * resp distress * Planned post op short term vent
39
Reasons to intubate: Overview
* Taken into context with the situation * Abnormal Abg * Decreased PaO2, below 60 * Increased PaCO2 * Decreased PH * Changes in LOC * Diminished airway exchange * Needs for increased o2 or vent despite use of supplemental O2 or NIPPV * Used in cases of worsening resp failure | Cant protect their airway
40
Capnography
* Measuring the readings of CO2 in an ET tube for monitoring for placement and effectiveness * used to diagnose early resp depression and airway disorders
41
ETT intubation considerations: Failure to protect airway
* Decreased LOC * Impaired swallowing * Airway obstruction
42
ETT intubation considerations: Is the patient a candidate for noninvasive positive pressure ventilation (NIPPV)
* Exacerbation of COPD * Acute cardiogenic pulmonary edema
43
ETT intubation considerations: Is there a failure to oxygenationate or ventilate
* Oxy: PaO2<60 mmHg and low or normal CO2 * Ventilation: acidosis with PaCO2
44
Vent settings: Assist control (AC)
Does all the breathing for the pt
45
Vent settings: Synchronized intermittent (SIMV)
Patient has the drive to breath, so the vent acts as supplementary assistance to them
46
Vt Tidal volume
4-1ml/Kg
47
Vent settings
* Mode (AC or SIMV) * Tidal volume (Vt) * FiO2) * PEEP (5-10 cmH20) * RR
48
Causes of low pressure alarms
* Vent tubing disconnection * Airway cuff leak or displacement
49
Nursing actions: Vent, low pressure alarm
* Assess pt and vent circuit * Reconnect tubing | Always assess pt first
50
Causes of Vent high pressure alarms
Occurs when the pressure needed to vent the pt exceeds the present pressure limit * Excessive secretions * Biting the ET tube, Kink in the line * Coughing, sneezing, gagging , attempting to talk * Pulmonary edema, bronchospasm, pneumothorax/hemothorax * Increased airway resistance, decreased lung compliance
51
High pressure alarms: Nursing actions
* Correct the underlying cause * Critically ill pts can quickly decompensate so make it fast * May need more sedation if biting
52
safety for a pt on ETT ventilation
* Bag valve mask (BVM) * Reintubation kit * Suction set up High pressure alarm can indicate need for this
53
Sedation vacation
* Done once a day for pts on vent * Done to see how they are doing, neuro checks and resp drive
54
Nursing interventions Vent: Promoting gas exchange
Auscultate lung sounds * T+P * Suction PRN * Pain control * Observe for hypoxia * Humidification, O2 is very dry * Nebulization
55
Nursing interventions Vent: Prevent injury and infection
* Prevent accidental extubation, monitor cuff pressure every 8 hrs * Sedation and reassurance, pain control, restraints * Pressure prevention with securement device * Oral hygiene with chlorhexidine * OOB, ROM exercies (If able)
56
What do you inflate cuff Vent
20-25 mmHg
57
Nursing care: preventing complications of Vent
* Prevent skin breakdown around tube * Note location of ETT marking at teeth, gums or nare, this is the reference point in future assessments to make sure tube isn't moving * Assess for airway injury and or displacement of the tube * Prevent ventilator associated events (VAE), pneumonia is common * Communicate with pt who are awake, this may be accomplished with the use of a communication board or writing notes
58
Nursing care: preventing complications of Vent, Barotrauma and pneumothorax
Note PEEP, 5-10 mm H20
59
Nursing care: preventing complications of Vent: Delirium and post ICU syndrome
* Early extubation * Early mobility * Early family involvement * Use of appropriate sedation
60
ABCDE bundle
* Awakening * Breathing * Coordination * Delirium, monitoring and mgmt * Early mobility * Family engagement and empowerment Used in vent pts
61
Ventilator acquired events (VAE) Prevention
* Elevate HOB 30+ degrees * Routine oral care with chlorhexidine * Weaning protocol: sedation vacations * Prevent stress ulcers (Peptic ulcer prophylaxis) use a PPI * VTE prophylaxis, SCD and pharmacotherapy
62
Vent weaning
* Process of withdrawing the pt from depending of the vent (Not everyone comes off vent) * Physiologically and hemodynamically stable * Spontaneous breathing , reversed resp failure * Recovered from acute medical or surgical issues (Sepsis) * Stable abg * Interdisciplinary approach * Vent mode: **SIMV**, patient has resp drive * Mask: extubate within 2-3 hours after weaning, prob gunna need o2 * May need pulmonary rehab, Cough, deep breathing, turn and position, incentive spiro, gradual increase in activity

NSG 478 (23 decks)

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