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Paramedic--> FPC > Airway/Ventilator Management > Flashcards

Airway/Ventilator Management Flashcards

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1
Q

Indications for Airway Management

A

Can not ventilate/oxygenate
Respiratory failure
Expected clinical course

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2
Q

Critical ABG Values

A

CRITICAL VALUES: pH <7.2, CO2 >55, PaO2 <60

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3
Q

Difficult Intubation Predictors:LEMON

A

Look
Evaluate 3-3-2
3 fingers in mouth
3 fingers between jaw and hyoid
2 fingers between hyoid and thyroid
Mallampati (I-IV)
Obstructions
Neck Mobility

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4
Q

Mallampati (Airway Grading)

A
  • Mallampati I - Soft palate, uvula, anterior/posterior tonsillar pillars visible Tall, thin neck No difficulty
  • Mallampati II - Tonsillar Pillars hidden by tongue
    No difficulty
  • Mallampati III - Only the base of the uvula can be seen
    Moderate difficulty
  • Mallampati IV - Uvula cannot be seen
    Short, fat or muscular neck (difficult airway)
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5
Q

Difficult Intubation Predictors: HEAVEN

A
  • Hypoxemia-O2 saturation less than 93% at the time of initial laryngoscopy
  • Extremes of size-Patient less than or equal to 8 years of age or clinical obesity
  • Anatomic challenges-Trauma, mass, swelling, foreign body, or other structural abnormality limiting view
  • Vomit/blood/fluid-Clinically significant fluid in the pharynx or hypopharynx
  • Exsanguination/anemia-Suspected anemia that could potentially accelerate the rate of decompensation during RSI apneic period
  • Neck mobility issues
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6
Q

How do you preform ramping for airway management?

A

Ear to sternal notch positioning
* Improved upper airway patency
* Decreased work of breathing
* Prolonged safe apnea period

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7
Q

What is External Laryngeal Manipulation (ELM)?

A

Provider performing laryngoscopy brings cords into view, then the airway assistant maintains positioning

Current standard of practice if airway manipulation is needed

Fun fact: Overtook the Sellick’s Maneuver: BURP: Backward, Upward, Rightward Pressure

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8
Q

ETT Cuff Pressure

A

Between 20-30 mmHg
25 mmHg is standard

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9
Q

7 P’s for RSI

A
  1. Preparation Make sure equipment is serviceable
  2. Preoxygenate 3-5 minutes, passive oxygenation via NC 10-15+ LPM
  3. Pretreatment LOAD medications if required
  4. Paralysis with induction Induction agent, paralytic, and pain control
  5. Protect and position Ear to sternal notch, ramping, pad behind shoulders for pediatrics
  6. Placement with proof Visual confirmation, capnography, chest x-ray
  7. Post intubation management Maintain sedation and pain control, oxygenation, etc
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10
Q

LOAD (RSI Pretreatment)

A
  • Lidocaine blunts the cough reflex preventing ICP increase
  • Opiates blunts the pain response
  • Atropine for infants prevents reflexive bradycardia in infants <1 y/o
  • Defasiculating Dose 1/10 dose of Rocuronium or Vecuronium
  • Lidcocaine,Atrpopine and Defasicualing dose are old medicine and have been disproven for pretreatment before RSI
  • USE Push dose presures epi/Neoepi
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11
Q

What is Tidal Volume (Vt)? What is the normal ventilator setting ?

A
  1. How much air the patient breathes in a normal breath
  2. 4-8 cc/kg IBW (ideal body weight)

Note: Excessive tidal volume can cause Ventilator-Induced Lung Injury (VILI)

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12
Q

Inspiratory Reserve Volume (IRV)

A

The amount of air that can be forcefully inhaled in addition to a normal tidal volume breath

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13
Q

Expiratory Reserve Volume (ERV)

A

The amount of air that can be forcefully exhaled after a normal tidal volume breath

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14
Q

Vital Capacity (VC)

A

Tidal Volume + Inspiratory Reserve Volume + Expiratory Reserve Volume

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15
Q

Residual Volume (RV)

A

The amount of air left in the respiratory tract following forceful exhalation

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16
Q

Total Lung Capacity (TLC)

A

Inspiratory Reserve Volume + Tidal Volume + Expiratory Reserve Volume + Residual Volume

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17
Q

Dead Space

A

The surfaces of the airway that are not involved in gaseous exchange
Gas exchange ONLY occurs in the alveoli

Dead Space Formula = 2ml/kg

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18
Q

Chemoreceptors: Central Vs Peripheral

A

Central
Located in the medulla/pons
Response is driven by CO2 and H+ levels in cerebral spinal fluid (CSF) This is a slowly responding system

Peripheral
Located in the aortic arch/carotid bodies
Response is driven by O2, CO2, H+
Your body’s “pulse ox

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19
Q

Abnormal Respiratory Patterns: Apneustic

A

Deep, gasping inspiration with a pause at full inspiration followed by a brief, insufficient release

Associated with decerebrate posturing

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20
Q

Abnormal Respiratory Patterns:Ataxic

A

Complete irregularity of breathing, with irregular pauses and increasing periods of apnea

Caused by damage to the medulla secondary to trauma or stroke
Very poor prognosis

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21
Q

Abnormal Respiratory Patterns: Biot’s

A

Groups of quick, shallow inspirations followed by regular or irregular periods of apnea

Caused by damage to the medulla by stroke (CVA) or trauma, or pressure on the medulla secondary to brainstem herniation

22
Q

Abnormal Respiratory Patterns: Cheyne-Stokes

A

Progressively deeper and sometimes faster breathing, followed by a gradual decrease that results in atemporary apnea

Associated with decorticate posturing (Cushing’s ∆, brainstem herniation)

23
Q

Abnormal Respiratory Patterns: Kussmaul’s

A

Respirations gradually become deep, labored and gasping
Associated with DKA

24
Q

Gold Standard for oxygenation

A

Pulse oximetry (SpO2)

25
Q

Gold Standard for ventilation

A

Waveform capnography (ETCO2)

26
Q

What is the #1 cause of iatrogenic death in the U.S.?

A

VAP-Ventilator acquired pneumonia

27
Q

Hypoxic Respiratory Failure

A

Inability to diffuse O2 -ARDS, Pneumonia, CHF

Lab Value ABG low pO2 < 60 mmHg

Treatment– ↑ O2 concentration (FiO2) and PEEP

28
Q

Hypercarbic Respiratory Failure

A

Inability to remove CO2-Damage to pons or upper medulla
Stroke & trauma

Lab Value respiratory acidosis EtCO2 > 45 mmHg

Treatment- ↑ tidal volume (Pplat), then ↑ rate
Double Minute Volume (Ve), normal 4-8 L/min

29
Q

What is the normal ventilator setting for Rate (F)?

A

12-20/min

How many times a minute the patient is breathing (respiratory rate)

30
Q

What is Minute Volume (Ve)? What is minute volume?

A

How much air is breathed by the patient in one minute.
Rate x Tital volume = Ve

Normal Ve is 4-8 L/min

31
Q

Inspiratory: Expiratory Ratio (I:E)

A

1:2
The ratio of inspiration vs. expiration

32
Q

Fraction of Inspired Oxygen (FIO2)

A

0.21 to 1.0

Allows for very precise delivery of oxygen concentrations
21% - 100% O2 concentration
Measuring oxygen with liters per minute (lpm) is much less accurate

33
Q

Positive End Expiratory Pressure (PEEP)

A

0-20 cm H2O
PEEP is what keeps the alveoli open so that oxygen can diffuse
Adequate PEEP, increased FRC, and driving pressure helps prevent atelectasis (alveolar collapse), by reopening and stabilizing collapsed or unstable alveoli

34
Q

Ventilator Delivery Methods and Explain

A

* Volume mode- A preset tidal volume is delivered
Once tidal volume is delivered the exhalation begins
Volumes are consistent breath to breathe
Pressures are continuously monitored

* Pressure Control-A preset inspiratory pressure is delivered
Once pressure is achieved the exhalation begins
Volumes are dynamic from breath to breath
Volumes need to be continuously monitored

35
Q

Peak Inspiratory Pressure (PIP)

A

Amount if resistance to overcome the ventilator circuit, any appliances, the ETT, and the main
airways

<35 cmH2O

36
Q

Plateau Pressure (Pplat)

A

This is a measurement of the pressure applied
during positive pressure ventilations to the small
airways and alveoli
Represents the static end inspiratory recoil pressure of the respiratory system, lung and chest
wall respectively
Measured during an inspiratory pause (i-hold) while on mechanical ventilation

<30 cmH20

37
Q

Ventilator Modes: Controlled Mandatory Ventilation (CMV)

A

All breaths are triggered, limited, and cycled by the ventilator

Patient has NO ability to initiate their own breaths

38
Q

Ventilator Modes: Assist-Control Ventilation (AC)

A

Ventilator supports every breath, whether it’s initiated by the patient or the ventilator Full tidal volume (Vt) regardless of respiratory effort or drive

Note: Preferred mode for patients with respiratory distress, Mode can leads to “breath stacking” or “auto-PEEP” Risk of Ventilator-Induced Lung Injury (VILI)

39
Q

Ventilator Modes: Synchronized Intermittent Mandatory Ventilation (SIMV)

A

Assisted mechanical ventilation synchronized with the patient’s breathing,The ventilator senses the patient taking a breath, then delivers a breath.If the patient fails to take a breath the ventilator will provide a mechanical breath

Note:Preferred for patients with an intact respiratory drive

40
Q

Ventilator Modes: Pressure Support Ventilation (PSV)

A

Pressure support makes it easier for the patient to overcome the resistance of the ET tube and is
often used during weaning because it reduces the work of breathing
“Supports” or provides pressure during inspiration to decrease patient’s overall work of
breathing
Patient determines tidal volumes, rate (minute volume)

Note:Requires consistent ventilatory effort by the patient

41
Q

Continuous Positive Airway Pressure (CPAP)

A

The use of continuous positive pressure to maintain a continuous level of PEEP
CPAP uses mild air pressure to keep an airway open

42
Q

Bi-Level Continuous Positive Airway Pressure (BPAP)

A

Uses alternating levels of PEEP to maintain oxygenation through pressure support during
inhalation and exhalation, commonly used in pneumonia, COPD, asthma
The term BiPAP
TM refers to a specific manufacturer, not a vent setting

43
Q

Ventilator Alarms-DOPES

A

Dislodged low pressure alarm
Obstructed high pressure alarm
Pneumothorax high pressure alarm
Equipment machine failure, dead batteries, etc.
Stacked breaths high pressure alarm

44
Q

Ventilator Alarms-DOPES

A
45
Q

Ventilator Alarms-Low Pressure

A

Patient disconnection from machine (most common cause)
Chest tube leaks
Circuit leaks
Airway leaks

Note- Start from the ventilator and go to the patient.

46
Q

Ventilator Alarms-High Pressure

A

Kinked line (most common cause)
Coughing
Secretions or mucus in the airway
Patient biting the tube
Reduced lung compliance (Pneumothorax, ARDS)
Increased airway resistance

Note- Start from the patient then got to the ventilator.

47
Q

Ventilator Dyssynchrony

A

Caused by:
Respiratory demands not being met
Inadequate pain control
Inadequate sedation

Effects on the patient: Increased RR,O2 demand, BP,HR and ICP

Treatment:Administer analgesia and sedation and adjusted Settings as needed

48
Q

Ventilator Dyssynchrony

A

Caused by:
Respiratory demands not being met
Inadequate pain control
Inadequate sedation

Effects on the patient: Increased RR,O2 demand, BP,HR and ICP

Treatment: Administer analgesia and sedation and adjusted Settings as needed

49
Q

V/Q Ratio

A

Ratio of alveolar ventilation and blood travelling through the capillaries

V/Q Formula = alveolar ventilation/cardiac output
Normal V/Q = (4 L/min)/(5 L/min)
V/Q = 0.8

50
Q

How do you find a V/Q mismatch

A

V/Q Scanning

A nuclear medicine study used to evaluate the circulation of air and blood within a patient’s lungs
The ventilation portion evaluates the ability of air to reach all parts of the lungs
The perfusion portion evaluates how well blood circulates throughout all parts of the lungs
Used to help determine presence of a pulmonary embolism
Other diagnostics include Well’s criteria, CT Pulmonary Angiogram (CTPA)

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