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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
Q

Adverse effects of PEEP (CPAP/BiPAP)

A
  • 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
Q

Mild ARDS

A
  • P/F ratio of 200-300 with CPAP or Peep value of at least 5 cm H20
27
Q

Moderate ARDS

A

P/F ratio of 100-200 with CPAP or PEEP value of at least 5 cm H2O

28
Q

Severe ARDS

A

P/F ratio of under 100 with CPAP or PEEP value of at least 5 cm H20

29
Q

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

A

Resp acidosis, uncompensated

30
Q

Chest X ray with an ARDS patient

A

White out, full of fluid

31
Q

Assessment and diagnostics findings ARDS

A
  • 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
Q

When should a patient get intubated

A
  • When they can no longer protect their airway and PEEP isn’t working
33
Q

Medical mgmt of ARDS

A
  • 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
Q

Is there a specific pharm treatment for ARDS

A

Nah there isn’t a cure or treatment
Its supportive care

35
Q

ARDS considerations

A
  • 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
Q

Mechanical ventilation

A
  • 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
Q

Non invasive mechanical ventilation

A

CPAP and BiPAP

38
Q

Endotracheal tube intubation: indication

A
  • 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
Q

Reasons to intubate: Overview

A
  • 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
Q

Capnography

A
  • 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
Q

ETT intubation considerations: Failure to protect airway

A
  • Decreased LOC
  • Impaired swallowing
  • Airway obstruction
42
Q

ETT intubation considerations: Is the patient a candidate for noninvasive positive pressure ventilation (NIPPV)

A
  • Exacerbation of COPD
  • Acute cardiogenic pulmonary edema
43
Q

ETT intubation considerations: Is there a failure to oxygenationate or ventilate

A
  • Oxy: PaO2<60 mmHg and low or normal CO2
  • Ventilation: acidosis with PaCO2
44
Q

Vent settings: Assist control (AC)

A

Does all the breathing for the pt

45
Q

Vent settings: Synchronized intermittent (SIMV)

A

Patient has the drive to breath, so the vent acts as supplementary assistance to them

46
Q

Vt Tidal volume

A

4-1ml/Kg

47
Q

Vent settings

A
  • Mode (AC or SIMV)
  • Tidal volume (Vt)
  • FiO2)
  • PEEP (5-10 cmH20)
  • RR
48
Q

Causes of low pressure alarms

A
  • Vent tubing disconnection
  • Airway cuff leak or displacement
49
Q

Nursing actions: Vent, low pressure alarm

A
  • Assess pt and vent circuit
  • Reconnect tubing

Always assess pt first

50
Q

Causes of Vent high pressure alarms

A

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
Q

High pressure alarms: Nursing actions

A
  • Correct the underlying cause
  • Critically ill pts can quickly decompensate so make it fast
  • May need more sedation if biting
52
Q

safety for a pt on ETT ventilation

A
  • Bag valve mask (BVM)
  • Reintubation kit
  • Suction set up

High pressure alarm can indicate need for this

53
Q

Sedation vacation

A
  • Done once a day for pts on vent
  • Done to see how they are doing, neuro checks and resp drive
54
Q

Nursing interventions Vent: Promoting gas exchange

A

Auscultate lung sounds
* T+P
* Suction PRN
* Pain control
* Observe for hypoxia
* Humidification, O2 is very dry
* Nebulization

55
Q

Nursing interventions Vent: Prevent injury and infection

A
  • 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
Q

What do you inflate cuff Vent

A

20-25 mmHg

57
Q

Nursing care: preventing complications of Vent

A
  • 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
Q

Nursing care: preventing complications of Vent, Barotrauma and pneumothorax

A

Note PEEP, 5-10 mm H20

59
Q

Nursing care: preventing complications of Vent: Delirium and post ICU syndrome

A
  • Early extubation
  • Early mobility
  • Early family involvement
  • Use of appropriate sedation
60
Q

ABCDE bundle

A
  • Awakening
  • Breathing
  • Coordination
  • Delirium, monitoring and mgmt
  • Early mobility
  • Family engagement and empowerment

Used in vent pts

61
Q

Ventilator acquired events (VAE) Prevention

A
  • 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
Q

Vent weaning

A
  • 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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