ARDs/Ventilation week 5 Flashcards
1
Q
What are 3 examples of inhalation therapy?
A
From least invasive to most invasive
a. supplemental oxygen
b. non-invasive mechanical ventilation (think advanced c-pap)
c. invasive mechanical ventilation
2
Q
Acute respiratory failure (ARF): Cause
A
Respiratory failure occurs because of 2 reasons…
- hypoxia and/or hypercapnia
- airway obstruction
- weakness of breathing
- muscular weakness
- lung disease
- chest wall abnormalities
3
Q
Go watch the videos on advanced respiratory concepts powerpoint
A
go
4
Q
make flashcards on oxygen devices and the hierachy
A
go babes
5
Q
What is Acute Respiratory Distress Syndrome?
A
The most severe form of lung injury. A Sudden and progressive pulmonary edema sets in with hypoxemia refractory to O2 support
“refractory to o2 support” –> no matter how much o2 someone gets, they can’t use it
6
Q
Characteristics of ARDS
A
- noncardiogenic pulmonary edema (pt. may not have heart issues. causes malfunction of alveoli because you have fluid in lungs (issues w surfactant) and gas exchange impaired)
- severe malfunction of alveoli
7
Q
Risk factors of ARDS?
A
Covid-19 Sepsis Aspiration Oxygen toxicity Severe pancreatitis Pneumonia Trauma
8
Q
ARDS: patho
A
The lung is injured, which causes the alveoli and interstitial space to accumulate fluid. This leads to increased pulmonary pressure, decreased compliance and impaired gas exchange.
In addition, there is a release of inflammatory cytokines that leads to the release of toxic mediators. This causes further damage to the alveoli and capillaries
As a result, fluid accumulates in the interstitial space and loss of surfactant leading to alveolar collapse.
9
Q
Surfactant
A
Keeps alveoli open
10
Q
What happens if we are losing surfactant due to fluid accumulation?
A
we can not keep alveoli open
11
Q
What is the LATTE method for identifying ARDS?
A
L - how will patient LOOK A - how will you ASSESS the patient T - what TESTS will be ordered T - what TREATMENTS will be provided? E - how will you EDUCATE the patient/family
12
Q
What will a patient with ARDS look like (s/s)
A
severe respiratory distress
acute onset tachypnea
anxiety/restlessness
if we do not intervene, the patient will deteriorate into fatigue with the use of accessory muscles and crackle/course lung sounds will develop
13
Q
What will you see on a chest xray with someone with ARDS?
A
bilateral infiltrates (may be referred to as “white out” or “ground glass opacities) - indicated no o2 exchange
14
Q
What will the pulmonary function ratio (p/f ratio) be in someone with ARDS?
A
less than 200
– anything under 200 is severe
15
Q
What is p/f ratio?
A
a calculation to determine if patient has ARDS
16
Q
What is FiO2
A
The amount of o2 you are receiving from vent
17
Q
What will a patient with ADRS PaO2 and PaCO2 be?
A
The patient will have a low PaO2 and low PaCO2. This is due to hyperventilation that occurs in the beginning stages (compensation). However, as the patient tires from breathing so heavily, the PaO2 will increase and respiratory acidosis will develop
18
Q
ARDS assessment focuses on what
A
respiratory system, with an eye on perfusion and complication
19
Q
ARDS assessment
A
Respirations (rate, depth, accessory muscles)
Oxygen (pulse o2)
Cardiac status (hypoxemia can cause arrhythmias)
Mental status (low o2 and high co2 –> disorientation)
Lung sounds (fine 1st then course)
20
Q
What potential complications should you monitor for in someone with ARDS?
A
pneumothorax VAP DVT sepsis coagulopathies
21
Q
s/s low o2 and s/s high co2
A
Low o2 –> confused, disoriented, lethargic, restless, or combative
Low co2 –> e fatigued somnolent, or obtunded
22
Q
What tests will be ordered in someone who has ARDS?
A
ABG (will show respiratory acidosis) Pan culture Chest x-ray Bronchoscopy CT of chest CBC BG monitoring
23
Q
What is a pan culture
A
looks for everything in the body (blood, sputum, urine)
24
Q
Why do we monitor BG when someone has ARDS?
A
Someone really sick has a big inflammatory response going off which can increase BG levels, hyperglycemia leads to delayed healing. routine BG checks on
everyone despite a DM dx
25
What treatments will be provided for ARDS?
```
mechanical ventilation
ECMO
Prone positioning
Nutritional support
Glucocorticoid therapy
Furosemide and albumin
Inhaled vasodilation
```
26
What does an ECMO do for someone with ARDS
allows lungs to rest - ECMO machine will do o2 exchange for patient
27
Why do we place ARDS patients prone?
helps expand dependent lung areas and opens collapsed alveoli to increase ventilation capacity
28
What are common glucocorticoids what we give ARDS patients?
methylprednisolone or dexamethasone are commonly used. Ensure blood glucose levels are monitored with these medications
*remember, steroids reduce inflammation will decrease inflammation but increase BG*
29
What is an example of an inhaled vasodilator that we give ARDS patient?
nitric oxide - through ventilator only
30
how do furosemide and albumin work together to get fluid out of the lungs?
— albumin = protein in vasculature that keeps fluid in vascular system (colloid)
— then adm. furosemide to get fluid out
31
What do we focus on with treating ARDS
we want to treat underlying cause
32
What do we educate the patient/family if the patient has ARDS?
a. explain need for sedation/paralytics
b. educate need for VAP prevention
c. discuss weening process
d. if patient proned, ensure family know what to expect
e. emotional support
33
What might you say in regard to prone education
if proned, tell them about how gravity helps w gas exchange. specialty bed = roto bed, slowly turns patient over 24hr period
34
why would we give someone with a vent sedation/paralytics?
keeps patient comfortable. we do not want them to try to overbreath or be scared because then they are working too hard again and o2 demand goes up
35
what is VAP prevention interventions
HOB 30, oral cares
36
What is intubation aka mechanical ventilation
allows us to provide oxygenation and pressure support to patients who are having trouble oxygenating on their own
37
Ventilation
def
38
perfusion
def
39
diffusion
def
40
Compliance
ability of lungs to stretch
41
What can cause lungs to have low complicant
```
pneomothorax
hemothorax
pleural effusion
pulmonary edema
atelectasis
pulmonary fibrosisi
ARDS
```
42
What are 3 goals of mechanical intubation
1. maintain alveolar ventilation appropriate for the patient's needs
2. correct hypoxemia
3. maximize oxygen transport
43
.Positive pressure ventilation
Patient breathes via position pressure, this means air is being forces into the lungs through an ET tube or non-invasive device (BiPap)
44
Negative pressure ventilation
Normally we breath utilizing negative pressure ventilation
The negative pressure draws air into the lungs
45
what kind of environment is ventilator support
closed circuit -- if we open it up, we lose all pressure (positive or negative)
46
What are things to keep in might regarding ventilation settings?
provider ordered
nurses/RT can not change settings
the only thing nurses can change is the amount of 02
47
describe the airflow of a ventilator
Out of vent --> humidifier --> into patient --> O2 in, Co2 out --> back into humidifier and vent depresses CO2
48
Ventilator anatomy: for the most part, all vents have the some components, such as
1. screen that shows waveform, rr, peak pressure, end tidal volume
2. buttons, dials, knobs for adjusting ventilator settings. This adjust things like FiO2 and PEEP
3. tubing that connects air and o2 to the vent
4. tubing that delivers o2 to patient
49
What are the 4 important ventilator settings that vents have
Mode
FiO2
PEEP
Rate
50
mode
The different modes of ventilation will tell you how much support is from the machine versus how much control the patient has over their own breathing. These modes are: controlled mandatory ventilation, assist-control, synchronized intermittent mandatory ventilation, pressure support
51
FiO2
This is the fraction of inspired oxygen....essentially how much O2 we are giving to the patient. We want to give the
minimum amount to achieve the patient's needs and adequate oxygen levels in the blood. Want to avoid O2 toxicity
52
PEEP
53
PEEP
Positive End-Expiratory Pressure (PEEP). This is the amount of pressure in the alveoli at end of expiration. We have physiological PEEP. Artifically rising PEEP helps us improve gas exchange when on the ventilator.
54
Rate
Respiratory rate is very important while on the ventilator. Providers can order different respiratory rates to change
the patient's condition. For example we can increase RR to "blow-off" their CO2.
55
Tidal volume
Volume of air pushed into lungs with each breath
| 5-15
56
FiO2 range
21-100%
21% is room air
40-100% on vent
57
PEEP range
5-10
58
Mode: types
AC (assist control)
SIMV
Pressure Support
59
How are vent modes categorized
categorized as pressure controlled and volume controlled.
60
Volume-controlled modes
These modes deliver a certain amount of volume to the patient
- ex. Assist control
61
Assist control mode on vent
the patient triggers the ventilator for each breath and the ventilator "assists" the patient by delivering a controlled/pre-determined volume of air to the patient
If the patient does not trigger a breath, the ventilator will automatically trigger one to ensure a set minimal rr
62
Pressure controlled modesThese modes will inflate the lungs to a certain pressure.
These modes will inflate the lungs to a certain pressure.
| ex. pressure support ventilation (PSV)
63
Pressure Support Ventilation (PSV)
is used a lot during weaning processes and the patient initiates each breath. The bigger the pressure, the b igger the breath!
64
assist control mode: indication
often used as initial mode of ventilation
65
AC pro
ensures vent support during every breath
| each breath = same tidal volume
66
AC cons
hyperventilation, air trapping, may require sedation and paralysis
67
AC concerns
work of breathing may be increased if sensitivity or flow rate is too low
68
Synchronized intermittent mandatory ventilation (SIMV): indication
often used as initial mode of ventilation and for weaning
69
Synchronized intermittent mandatory ventilation (SIMV): pros
allows spontaneous breaths (tidal volume determined by patient) between vent breaths
weaning is accompanied by gradually lowering the set rate and allowing the patient to assume more work
70
Synchronized intermittent mandatory ventilation (SIMV): cons
patient-ventilator asynchrony is possible
71
What are examples of volume cycled modes?
Assist-control (AC)
Synchronized intermittent mandatory ventilation (SIMV)
72
What are examples of pressure cycled modes
Pressure support ventilation (PSV)
Continuous positive airway pressure (CPAP)
Noninvasive bilateral positive pressure ventilation (BIPAP)
73
Pressure-support ventilation (PSV): indication
intact respiratory drive in patient necessary
used as a weaning mode, and in some cases of desynchrony
74
Pressure-support ventilation (PSV): advantages
decreased work of breathing; increases patient comfort; can be considered with SIMV to allow a more comfy mode
75
Pressure-support ventilation (PSV): cons
should not be used in patient with acute bronchospasms or with altered mental status with reduced spontaneous breathing
76
Pressure-support ventilation (PSV): concerns
Adjust PSV level to maintain desired respiratory rate and tidal volume
Monitor for changes in compliance, with can cause tidal volume to change
Monitor rr and todal volume at least hourly
77
Continuous positive airway pressure (CPAP): indication
Constant positive airway pressure for patients who breath spontaneously
78
Continuous positive airway pressure (CPAP): pros
used in intubated or nonintubated patient
79
Continuous positive airway pressure (CPAP): cons
on some systems, no alarm is respiratory rate falls
80
Continuous positive airway pressure (CPAP): concerns
monitor for increased work of breathing
81
Noninvasive bilateral positive-pressure ventilation (BIPAP): indication
Noctural hypoventilation in patient with neuromuscular disease, chest wall deformity, obstructive sleep apnea, and COPD
to prevent intubation
to prevent reintubation initially after extubation
82
Noninvasive bilateral positive-pressure ventilation (BIPAP): pros
decreased cost when patient can be cared for at home; no need for artificial airway
83
Noninvasive bilateral positive-pressure ventilation (BIPAP): cons
discomfort or claustrophobia
84
Noninvasive bilateral positive-pressure ventilation (BIPAP): concerns
monitor for gastric distentiion, air leaks from mount, aspiration risk
85
When will a high pressure alarm sound on a ventilator?
when pressures in the circuit are too high! This can be caused by the patient coughing, a kink/occlusion in the ventilator tubing or ET tube
86
What should nurse do if high pressure alarm goes off?
What to do when it goes off? Relieve the kink/obstruction. You may need to suction the
patient (don't forge to preoxygenate)
87
When will a low pressure alarm sound on a ventilator?
when something becomes disconnected. Usually this is between the ET tube and vent tubing
88
What should nurse generally do if vent alarm goes off
start with patient and work towards vent
89
Ventilator complications: airway
Decreased clearance of secretions
VAP
Aspiration
90
Ventilator complications: ETT
```
Kinked/plugged
Rupture of piriform sinus
tracheal stenosis/malacia
Mainstem intubation
cuff failure
sinusitis
otitis media
laryngeal edema
```
91
Ventilator complications: mechanical
hypoventilation with atelectasis
hyperventilation with hypocapnia / respiratory alkalosis
barotrauma SQ emphysema
Alarms turned off
failure of alarms
inadequate nebulization or humidification
overheated inspired air = hyperthermia
92
What tube complications can a patient experience on a vent
tracheal mucosal trauma
bleeding
bronchospasm
93
How to maintain patient comfort with a ETT ?
positioning of the ET tube, bite block, cuff pressures, sedation, analygesia, paralytics, oral cares
94
What are interventions with VAP
```
Sedation vacation (helps w mental)
HOB 30-50
Oral hygeine
Peptic ulcer disease prophylaxis
DVT prophylaxis
```
95
What are sedation meds we can give to patient on vent
```
Propofol (Diprivan)
Benzodiazepines
Versed
Ativan
Etomidate/Amidate
```
96
what are analgesics we can give patient on vent?
Fentanyl
| Morphine
97
What are paralytics we often give patients who are on a vent
Vecuronium
| Rocuronium
98
RAAS scale
creates a common language for healthcare providers to communicate about the patient's mentation status
low scores - unarousable
high - combative, agitative
99
When does the weaning process to get off vent start?
starts at intubation
100
What are things to take into account when weaning patient off vent?
1. Goals for FiO2, PEEP and ventilator mode are all achieved, maintained, and stable
2. neuro status
3. How to ensure your patient's ventilation status is strong again
4. How the interdiciplinary teams works together to optimize the patient
5. General guidelines when conducting spontaneous awakening trials and spontaneous breathing trial (SAT/SBT)
6. Things to watch for after extubation
101
If any of the following occur, your patient is not ready to come off the ventilator:
1. Increased anxiety, diaphoresis, or both!
2. Evidence of respiratory or hemodynamic stress
3. Sustained HR greater than 20% from baseline
4. SBP exceeding 180 mmHg or less than 90 mmHg
5. Labored respiratory pattern or RR >35ish
6. Tidal volume 5 mL/kg or less (small volumes) 7.SpO2 less than 90%
102
Review ABG
go
103
What are indications for chest tube removal
One day after cessation of air leak
Drainage of less than 50-100 mL of fluid
Three days after cardiac surgery
Two to six days after thoracic surgery
Chest tube partially migrated out with holes visible (may require a new chest tube insertion!)
104
You need to know supplemental o2 rates and hieracrchy
go
