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Complex Care > ARDs/Ventilation week 5 > Flashcards

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

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2
Q

Acute respiratory failure (ARF): Cause

A

Respiratory failure occurs because of 2 reasons…

  1. hypoxia and/or hypercapnia
    - airway obstruction
    - weakness of breathing
    - muscular weakness
    - lung disease
    - chest wall abnormalities
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3
Q

Go watch the videos on advanced respiratory concepts powerpoint

A

go

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4
Q

make flashcards on oxygen devices and the hierachy

A

go babes

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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

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6
Q

Characteristics of ARDS

A
  1. 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)
  2. severe malfunction of alveoli
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7
Q

Risk factors of ARDS?

A 
Covid-19
Sepsis
Aspiration
Oxygen toxicity
Severe pancreatitis 
Pneumonia 
Trauma
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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.

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9
Q

Surfactant

A

Keeps alveoli open

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10
Q

What happens if we are losing surfactant due to fluid accumulation?

A

we can not keep alveoli open

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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
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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

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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

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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

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15
Q

What is p/f ratio?

A

a calculation to determine if patient has ARDS

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16
Q

What is FiO2

A

The amount of o2 you are receiving from vent

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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

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18
Q

ARDS assessment focuses on what

A

respiratory system, with an eye on perfusion and complication

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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)

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20
Q

What potential complications should you monitor for in someone with ARDS?

A 
pneumothorax
VAP
DVT
sepsis 
coagulopathies
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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

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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
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23
Q

What is a pan culture

A

looks for everything in the body (blood, sputum, urine)

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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

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25
Q

What treatments will be provided for ARDS?

A 
mechanical ventilation
ECMO
Prone positioning 
Nutritional support 
Glucocorticoid therapy 
Furosemide and albumin
Inhaled vasodilation
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26
Q

What does an ECMO do for someone with ARDS

A

allows lungs to rest - ECMO machine will do o2 exchange for patient

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27
Q

Why do we place ARDS patients prone?

A

helps expand dependent lung areas and opens collapsed alveoli to increase ventilation capacity

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28
Q

What are common glucocorticoids what we give ARDS patients?

A

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

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29
Q

What is an example of an inhaled vasodilator that we give ARDS patient?

A

nitric oxide - through ventilator only

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30
Q

how do furosemide and albumin work together to get fluid out of the lungs?

A

— albumin = protein in vasculature that keeps fluid in vascular system (colloid)
— then adm. furosemide to get fluid out

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31
Q

What do we focus on with treating ARDS

A

we want to treat underlying cause

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32
Q

What do we educate the patient/family if the patient has ARDS?

A

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

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33
Q

What might you say in regard to prone education

A

if proned, tell them about how gravity helps w gas exchange. specialty bed = roto bed, slowly turns patient over 24hr period

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34
Q

why would we give someone with a vent sedation/paralytics?

A

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

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35
Q

what is VAP prevention interventions

A

HOB 30, oral cares

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36
Q

What is intubation aka mechanical ventilation

A

allows us to provide oxygenation and pressure support to patients who are having trouble oxygenating on their own

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37
Q

Ventilation

A

def

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38
Q

perfusion

A

def

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39
Q

diffusion

A

def

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40
Q

Compliance

A

ability of lungs to stretch

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41
Q

What can cause lungs to have low complicant

A 
pneomothorax 
hemothorax
pleural effusion
pulmonary edema 
atelectasis 
pulmonary fibrosisi
ARDS
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42
Q

What are 3 goals of mechanical intubation

A
  1. maintain alveolar ventilation appropriate for the patient’s needs
  2. correct hypoxemia
  3. maximize oxygen transport
43
Q

.Positive pressure ventilation

A

Patient breathes via position pressure, this means air is being forces into the lungs through an ET tube or non-invasive device (BiPap)

44
Q

Negative pressure ventilation

A

Normally we breath utilizing negative pressure ventilation

The negative pressure draws air into the lungs

45
Q

what kind of environment is ventilator support

A

closed circuit – if we open it up, we lose all pressure (positive or negative)

46
Q

What are things to keep in might regarding ventilation settings?

A

provider ordered
nurses/RT can not change settings
the only thing nurses can change is the amount of 02

47
Q

describe the airflow of a ventilator

A

Out of vent –> humidifier –> into patient –> O2 in, Co2 out –> back into humidifier and vent depresses CO2

48
Q

Ventilator anatomy: for the most part, all vents have the some components, such as

A
  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
Q

What are the 4 important ventilator settings that vents have

A

Mode
FiO2
PEEP
Rate

50
Q

mode

A

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
Q

FiO2

A

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
Q

PEEP

A
53
Q

PEEP

A

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
Q

Rate

A

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
Q

Tidal volume

A

Volume of air pushed into lungs with each breath

5-15

56
Q

FiO2 range

A

21-100%

21% is room air
40-100% on vent

57
Q

PEEP range

A

5-10

58
Q

Mode: types

A

AC (assist control)
SIMV
Pressure Support

59
Q

How are vent modes categorized

A

categorized as pressure controlled and volume controlled.

60
Q

Volume-controlled modes

A

These modes deliver a certain amount of volume to the patient
- ex. Assist control

61
Q

Assist control mode on vent

A

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
Q

Pressure controlled modesThese modes will inflate the lungs to a certain pressure.

A

These modes will inflate the lungs to a certain pressure.

ex. pressure support ventilation (PSV)

63
Q

Pressure Support Ventilation (PSV)

A

is used a lot during weaning processes and the patient initiates each breath. The bigger the pressure, the b igger the breath!

64
Q

assist control mode: indication

A

often used as initial mode of ventilation

65
Q

AC pro

A

ensures vent support during every breath

each breath = same tidal volume

66
Q

AC cons

A

hyperventilation, air trapping, may require sedation and paralysis

67
Q

AC concerns

A

work of breathing may be increased if sensitivity or flow rate is too low

68
Q

Synchronized intermittent mandatory ventilation (SIMV): indication

A

often used as initial mode of ventilation and for weaning

69
Q

Synchronized intermittent mandatory ventilation (SIMV): pros

A

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
Q

Synchronized intermittent mandatory ventilation (SIMV): cons

A

patient-ventilator asynchrony is possible

71
Q

What are examples of volume cycled modes?

A

Assist-control (AC)

Synchronized intermittent mandatory ventilation (SIMV)

72
Q

What are examples of pressure cycled modes

A

Pressure support ventilation (PSV)

Continuous positive airway pressure (CPAP)

Noninvasive bilateral positive pressure ventilation (BIPAP)

73
Q

Pressure-support ventilation (PSV): indication

A

intact respiratory drive in patient necessary

used as a weaning mode, and in some cases of desynchrony

74
Q

Pressure-support ventilation (PSV): advantages

A

decreased work of breathing; increases patient comfort; can be considered with SIMV to allow a more comfy mode

75
Q

Pressure-support ventilation (PSV): cons

A

should not be used in patient with acute bronchospasms or with altered mental status with reduced spontaneous breathing

76
Q

Pressure-support ventilation (PSV): concerns

A

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
Q

Continuous positive airway pressure (CPAP): indication

A

Constant positive airway pressure for patients who breath spontaneously

78
Q

Continuous positive airway pressure (CPAP): pros

A

used in intubated or nonintubated patient

79
Q

Continuous positive airway pressure (CPAP): cons

A

on some systems, no alarm is respiratory rate falls

80
Q

Continuous positive airway pressure (CPAP): concerns

A

monitor for increased work of breathing

81
Q

Noninvasive bilateral positive-pressure ventilation (BIPAP): indication

A

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
Q

Noninvasive bilateral positive-pressure ventilation (BIPAP): pros

A

decreased cost when patient can be cared for at home; no need for artificial airway

83
Q

Noninvasive bilateral positive-pressure ventilation (BIPAP): cons

A

discomfort or claustrophobia

84
Q

Noninvasive bilateral positive-pressure ventilation (BIPAP): concerns

A

monitor for gastric distentiion, air leaks from mount, aspiration risk

85
Q

When will a high pressure alarm sound on a ventilator?

A

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
Q

What should nurse do if high pressure alarm goes off?

A

What to do when it goes off? Relieve the kink/obstruction. You may need to suction the
patient (don’t forge to preoxygenate)

87
Q

When will a low pressure alarm sound on a ventilator?

A

when something becomes disconnected. Usually this is between the ET tube and vent tubing

88
Q

What should nurse generally do if vent alarm goes off

A

start with patient and work towards vent

89
Q

Ventilator complications: airway

A

Decreased clearance of secretions
VAP
Aspiration

90
Q

Ventilator complications: ETT

A 
Kinked/plugged
Rupture of piriform sinus 
tracheal stenosis/malacia 
Mainstem intubation
cuff failure
sinusitis
otitis media
laryngeal edema
91
Q

Ventilator complications: mechanical

A

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
Q

What tube complications can a patient experience on a vent

A

tracheal mucosal trauma
bleeding
bronchospasm

93
Q

How to maintain patient comfort with a ETT ?

A

positioning of the ET tube, bite block, cuff pressures, sedation, analygesia, paralytics, oral cares

94
Q

What are interventions with VAP

A 
Sedation vacation (helps w mental)
HOB 30-50
Oral hygeine
Peptic ulcer disease prophylaxis
DVT prophylaxis
95
Q

What are sedation meds we can give to patient on vent

A 
Propofol (Diprivan) 
Benzodiazepines 
Versed
Ativan 
Etomidate/Amidate
96
Q

what are analgesics we can give patient on vent?

A

Fentanyl

Morphine

97
Q

What are paralytics we often give patients who are on a vent

A

Vecuronium

Rocuronium

98
Q

RAAS scale

A

creates a common language for healthcare providers to communicate about the patient’s mentation status

low scores - unarousable
high - combative, agitative

99
Q

When does the weaning process to get off vent start?

A

starts at intubation

100
Q

What are things to take into account when weaning patient off vent?

A
  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
Q

If any of the following occur, your patient is not ready to come off the ventilator:

A
  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
Q

Review ABG

A

go

103
Q

What are indications for chest tube removal

A

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
Q

You need to know supplemental o2 rates and hieracrchy

A

go

Complex Care (2 decks)

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