chapter 5 pb Flashcards
Your patient has amyotrophic lateral sclerosis (Lou Gehrig’s disease) and is being released from the hospital to be taken care of at home. What form of ventilation would you suggest for this patient?
noninvasive ventilation
Your patient has amyotrophic lateral sclerosis (Lou Gehrig’s disease) and is being released from the hospital to be taken care of at home. What form of ventilation would you suggest for this patient?
noninvasive ventilation
Your patient has post-polio syndrome and is having problems breathing. What would you suggest?
NPV, most often a Chest Cuiras.
A patient can be connected to a positive-pressure ventilator by what two commonly used methods.
positive-pressure mask
an artificial airway
What does CPAP stand for?
Continuous positive airway pressure
CPAP and NPPV are most commonly administered by what means?
a face or nasal mask
CPAP has been shown to be an effective method to improve what aspect of the patients respiratory efforts?
oxygenation.
Diseases such as COPD and (asthma exacerbations) Asthma often cause air trapping. What does air-trapping do to the FRC?
Increases
You are trying to wean your COPD patient off the ventilator. You have him on a pressure trigger of -2. You notice the patient unable to trigger. What would you do?
Perform an exhalation hold maneuver to determine the patients auto-peep.
You determine your COPD patient has auto-peep and is unable to trigger. How do you fix this?
You determine how much auto-peep the patient has and subtract it from the patients given PEEP. Then add the difference to the given peep.
How does increased RAW affect the flow
Flow will become limited
How would you set Mask CPAP to reduce diaphragmatic work, dyspnea, and improve gas exchange if the patient’s issued was caused by auto-peep?
80% to 90% of the measured auto-PEEP
Your patient has acute cardiogenic pulmonary edema, RR > 35 You notice diaphoresis, the use of accessory muscles. pH 7.44, PaCO2 26, PO2 75. What would you do?
NIV, BiPAP. Patient is impending respiratory failure. Intervene before pt gets worse!
How much can NIV reduce the need for Intubation?
60-75%
Two types of ventilators can be used to provide NIV
BiPAP , Critical-care ventilators that have a variety of available modes, including in many cases NIV.
What mode is BiPAP
Pressure
What is the Trigger for BiPAP.
Pressure Trigger
What is the Cycle for BiPAP
Flow
Do you have to heavily sedate a patient on NIV
No. That is considered one of the benefits of using NIV over PPV.
What does NIV preserve?
airway defense, speech, and swallowing mechanisms.
This is because the patient does not have an artificial airway down their throat.
FVS has the energy to provide normal PaCO2 in the patient. What kind of breathing is this?
Eucapnic
In FVS what kind of Frequency do you set for the patient?
High, 8 or more.
High being in regards to PSV, (6/m or less)
Is A/C FVS or PSV?
FSV
Why are PSV rates set 6/min or less
To allow the patient to take part in the WOB.
This helps prevent diaphragm atrophy, and aids in efforts to help wean the patient off the vent.
PSV (Partial support ventilation) modes include?
SIMV, IMV, PSV(pressure support ventilation), MMV, PAV
proportional assist ventilation (PAV),
mandatory minute volume (MMV)
Don’t feel bad about not knowing those ^
Your already intubated patient has ventilatory muscle fatigue and HIGH wob. Would you use Partial support ventilation?
No.
When treating patients with acute respiratory failure, the initial goal of mechanical ventilation is to
is to supply all the necessary ventilation.
This gives the patient time to rest their ventilatory muscles.
A patient receives a breath that is patient triggered, volume-targeted, and time cycled. What type of breath is it?
A/C
the patient controls the timing and the tidal volume. The volume or pressure (or both) delivered is not preset by the clinician but rather is based on patient demand and the patient’s lung characteristics.
spontaneous breaths
characteristics of both mandatory and spontaneous breaths, all or part of the breath is generated by the ventilator, which does part of the WOB for the patient.
assisted breaths
If the airway pressure rises above baseline during inspiration, the breath is
assisted
For example, during the pressure support mode the clinician sets the target pressure but the patient initiates the breath (patient triggered). The ventilator delivers the set pressure above baseline pressure to assist the patient’s breathing effort.
Reductions in lung or chest wall compliance will do what do the patients PEAK and PLAT pressure?
higher peak and plateau pressures
Your patient has Emphysema and is on A/C what levels would you expect their peak and plat to be?
Lower
increased compliance produces lower peak and plateau pressures
Your patient has bronchitis with thick secretions in his airway. What levels would you expect their peak pressure to be?
High
Increased airway resistance produces a higher peak pressure; reductions in airways resistance produce lower peak pressures.
You want your patient to have a higher PEAK pressure. What kind of flow pattern would you give them?
Peak pressure is higher with a constant flow
and lower with a decelerating flow pattern
How will a decelerating flow pattern affect MAP
Increases it.
What pattern generates the lowest mean airway pressure
Constant flow pattern.
High volumes do what to peak and plat pressure?
produce higher peak and plateau pressures
What does high level of peep effect?
Increasing PEEP increases the PEAK and MEAN pressures.
Increases in auto-PEEP increase
the peak inspiratory pressure.
Definition: A situation in which the patient breathing pattern and ventilator breathing pattern are not harmonious
Patient-ventilator asynchrony
It has been suggested that limiting the peak pressure spares more normal areas of the lungs from being?
overinflation
What control mode is said to be a component of lung protective strategies
Pressure-control modes
You ARDS patient is on A/C. Their PLAT pressure is 40 mmgh, and you notice they are diaphoretic. You can not decrease their VT anymore. What should you do?
Switch to a Pressure Limit
When the patient makes an inspiratory effort, the negative pressure produced at the upper airway causes the ventilator to vary gas flow to match the patient’s need. This helps reduce WOB, particularly in patients with ARDS, compared with volume-control ventilation
If a patient actively participates in inspiration, how will that effect volume delivery?
Increase volume delivery.
if flow returns to zero before inspiration ends, further increases in TI can decrease volume delivery if adequate time is not provided for exhalation. WHY?
Because the patient would not be able to exhale residual volume, and this would not allow more volume to be delivered.
A physician wants to ensure that a patient’s PaCO2 remains at the person’s normal level of 50 mm Hg. Would volume-control ventilation or pressure-control ventilation best meet this requirement?
Volume Control
When it is desirable to target PaCO2, volume-control ventilation may be used because it can guarantee volume delivery and minute ventilation. With pressure-control ventilation changes in lung compliance or Raw will result in changes in VT which can ultimately affect PaCO2.
Ventilating pressure can become very high in patients with acute respiratory distress syndrome. To prevent excessive pressures, what independent variable would be most appropriate, volume or pressure?
Pressure-control ventilation should be used when the goal is to avoid high pressures.
Patients who are obtunded because of drugs, cerebral malfunction, spinal cord or phrenic nerve injury, or motor nerve paralysis may be unable to make voluntary efforts. What Mode would you select?
controlled ventilation
You’re patient has a high ICP >15mmhg. What would you suggest?
Use volume-control
(iatrogenic) hyperventilation occasionally is used to induce respiratory alkalosis to reduce ICP.
Also has been used in Reye syndrome and after neurosurgery but is controversial.
if an inspiratory effort shows a pressure reading of −3 to −5 cm H2O or more below the baseline before an inspiration is initiated, what does this indicate about the trigger sensitivity?
the machine is too insensitive to the patient’s effort, and WOB increases
In this case the sensitivity level is set too low and must be increased
Definition: is the time increment between when a patient effort is detected and when flow from the ventilator to the patient begins
Response Time
in VC-CMV. If the pressure does not rise smoothly and rapidly to peak during inspiration, what does this tell you?
flow is inadequate
A concave pressure curve indicates active inspiration. Flow must be increased until the patient’s demand is met and the curve assumes a slightly convex shape
in VC-CMV inspiration is active and the set gas flow does not match the patient’s inspiratory flow demand. How would you detect this?
Clinically, this can be observed by watching the pressure manometer or the pressure-time curve on the graphic display.
PC-CMV - Several studies have shown that the decelerating ramp flow curve does what for the patient?
improve gas distribution and allows the patient to vary inspiratory gas flow during spontaneous breathing efforts
Your patient has ARDS patient is not ventilating due to air trapping. You have tried with VC-CMV with PEEP or PC-CMV with PEEP. You have no ventilator with APRV. What should you do?
pressure-control inverse ratio ventilation. PCRIV
it has been shown that a longer TI provides better oxygenation to some patients by increasing mean airway pressure.
Your patient has ARDS patient is not ventilating due to air trapping. You have tried with VC-CMV with PEEP or PC-CMV with PEEP. You have no ventilator with APRV. What should you do?
pressure-control inverse ratio ventilation. PCRIV
Your patient has post-polio syndrome and is having problems breathing. What would you suggest?
NPV, most often a Chest Cuiras.
A patient can be connected to a positive-pressure ventilator by what two commonly used methods.
positive-pressure mask
an artificial airway
What does CPAP stand for?
Continuous positive airway pressure
CPAP and NPPV are most commonly administered by what means?
a face or nasal mask
CPAP has been shown to be an effective method to improve what aspect of the patients respiratory efforts?
oxygenation.
Diseases such as COPD and (asthma exacerbations) Asthma often cause air trapping. What does air-trapping do to the FRC?
Increases
You are trying to wean your COPD patient off the ventilator. You have him on a pressure trigger of -2. You notice the patient unable to trigger. What would you do?
Perform an exhalation hold maneuver to determine the patients auto-peep.
You determine your COPD patient has auto-peep and is unable to trigger. How do you fix this?
You determine how much auto-peep the patient has and subtract it from the patients given PEEP. Then add the difference to the given peep.
How does increased RAW affect the flow
Flow will become limited
How would you set Mask CPAP to reduce diaphragmatic work, dyspnea, and improve gas exchange if the patient’s issued was caused by auto-peep?
80% to 90% of the measured auto-PEEP
Your patient has acute cardiogenic pulmonary edema, RR > 35 You notice diaphoresis, the use of accessory muscles. pH 7.44, PaCO2 26, PO2 75. What would you do?
NIV, BiPAP. Patient is impending respiratory failure. Intervene before pt gets worse!
How much can NIV reduce the need for Intubation?
60-75%
Two types of ventilators can be used to provide NIV
BiPAP , Critical-care ventilators that have a variety of available modes, including in many cases NIV.
What mode is BiPAP
Pressure
What is the Trigger for BiPAP.
Pressure Trigger
What is the Cycle for BiPAP
Flow
Do you have to heavily sedate a patient on NIV
No. That is considered one of the benefits of using NIV over PPV.
What does NIV preserve?
airway defense, speech, and swallowing mechanisms.
This is because the patient does not have an artificial airway down their throat.
FVS has the energy to provide normal PaCO2 in the patient. What kind of breathing is this?
Eucapnic
In FVS what kind of Frequency do you set for the patient?
High, 8 or more.
High being in regards to PSV, (6/m or less)
Is A/C FVS or PSV?
FSV
Why are PSV rates set 6/min or less
To allow the patient to take part in the WOB.
This helps prevent diaphragm atrophy, and aids in efforts to help wean the patient off the vent.
PSV (Partial support ventilation) modes include?
SIMV, IMV, PSV(pressure support ventilation), MMV, PAV
proportional assist ventilation (PAV),
mandatory minute volume (MMV)
Don’t feel bad about not knowing those ^
Your already intubated patient has ventilatory muscle fatigue and HIGH wob. Would you use Partial support ventilation?
No.
When treating patients with acute respiratory failure, the initial goal of mechanical ventilation is to
is to supply all the necessary ventilation.
This gives the patient time to rest their ventilatory muscles.
A patient receives a breath that is patient triggered, volume-targeted, and time cycled. What type of breath is it?
A/C
the patient controls the timing and the tidal volume. The volume or pressure (or both) delivered is not preset by the clinician but rather is based on patient demand and the patient’s lung characteristics.
spontaneous breaths
characteristics of both mandatory and spontaneous breaths, all or part of the breath is generated by the ventilator, which does part of the WOB for the patient.
assisted breaths
If the airway pressure rises above baseline during inspiration, the breath is
assisted
For example, during the pressure support mode the clinician sets the target pressure but the patient initiates the breath (patient triggered). The ventilator delivers the set pressure above baseline pressure to assist the patient’s breathing effort.
Reductions in lung or chest wall compliance will do what do the patients PEAK and PLAT pressure?
higher peak and plateau pressures
Your patient has Emphysema and is on A/C what levels would you expect their peak and plat to be?
Lower
increased compliance produces lower peak and plateau pressures
Your patient has bronchitis with thick secretions in his airway. What levels would you expect their peak pressure to be?
High
Increased airway resistance produces a higher peak pressure; reductions in airways resistance produce lower peak pressures.
You want your patient to have a higher PEAK pressure. What kind of flow pattern would you give them?
Peak pressure is higher with a constant flow
and lower with a decelerating flow pattern
How will a decelerating flow pattern affect MAP
Increases it.
What pattern generates the lowest mean airway pressure
Constant flow pattern.
High volumes do what to peak and plat pressure?
produce higher peak and plateau pressures
What does high level of peep effect?
Increasing PEEP increases the PEAK and MEAN pressures.
Increases in auto-PEEP increase
the peak inspiratory pressure.
Definition: A situation in which the patient breathing pattern and ventilator breathing pattern are not harmonious
Patient-ventilator asynchrony
It has been suggested that limiting the peak pressure spares more normal areas of the lungs from being?
overinflation
What control mode is said to be a component of lung protective strategies
Pressure-control modes
You ARDS patient is on A/C. Their PLAT pressure is 40 mmgh, and you notice they are diaphoretic. You can not decrease their VT anymore. What should you do?
Switch to a Pressure Limit
When the patient makes an inspiratory effort, the negative pressure produced at the upper airway causes the ventilator to vary gas flow to match the patient’s need. This helps reduce WOB, particularly in patients with ARDS, compared with volume-control ventilation
If a patient actively participates in inspiration, how will that effect volume delivery?
Increase volume delivery.
if flow returns to zero before inspiration ends, further increases in TI can decrease volume delivery if adequate time is not provided for exhalation. WHY?
Because the patient would not be able to exhale residual volume, and this would not allow more volume to be delivered.
A physician wants to ensure that a patient’s PaCO2 remains at the person’s normal level of 50 mm Hg. Would volume-control ventilation or pressure-control ventilation best meet this requirement?
Volume Control
When it is desirable to target PaCO2, volume-control ventilation may be used because it can guarantee volume delivery and minute ventilation. With pressure-control ventilation changes in lung compliance or Raw will result in changes in VT which can ultimately affect PaCO2.
Ventilating pressure can become very high in patients with acute respiratory distress syndrome. To prevent excessive pressures, what independent variable would be most appropriate, volume or pressure?
Pressure-control ventilation should be used when the goal is to avoid high pressures.
Patients who are obtunded because of drugs, cerebral malfunction, spinal cord or phrenic nerve injury, or motor nerve paralysis may be unable to make voluntary efforts. What Mode would you select?
controlled ventilation
You’re patient has a high ICP >15mmhg. What would you suggest?
Use volume-control
(iatrogenic) hyperventilation occasionally is used to induce respiratory alkalosis to reduce ICP.
Also has been used in Reye syndrome and after neurosurgery but is controversial.
if an inspiratory effort shows a pressure reading of −3 to −5 cm H2O or more below the baseline before an inspiration is initiated, what does this indicate about the trigger sensitivity?
the machine is too insensitive to the patient’s effort, and WOB increases
In this case the sensitivity level is set too low and must be increased
Definition: is the time increment between when a patient effort is detected and when flow from the ventilator to the patient begins
Response Time
in VC-CMV. If the pressure does not rise smoothly and rapidly to peak during inspiration, what does this tell you?
flow is inadequate
A concave pressure curve indicates active inspiration. Flow must be increased until the patient’s demand is met and the curve assumes a slightly convex shape
in VC-CMV inspiration is active and the set gas flow does not match the patient’s inspiratory flow demand. How would you detect this?
Clinically, this can be observed by watching the pressure manometer or the pressure-time curve on the graphic display.
PC-CMV - Several studies have shown that the decelerating ramp flow curve does what for the patient?
improve gas distribution and allows the patient to vary inspiratory gas flow during spontaneous breathing efforts
The maximum pressure limit during PC-CMV should be set at about how much above the target
+10 cmh20
because the set pressure level is not the maximum pressure possible on most ventilators
Your patient has ARDS patient is not ventilating due to air trapping. You have tried with VC-CMV with PEEP or PC-CMV with PEEP. You have no ventilator with APRV. What should you do?
pressure-control inverse ratio ventilation. PCRIV
The patient can breathe spontaneously through a ventilator circuit without receiving any mandatory breaths, that mimics having the patient’s endotracheal tube connected to a Briggs adapter and a humidified oxygen source using large-bore tubing. What is this method called?
What is the T-piece method.
Your patient has a shunt, and a PF ratio of 285. What would you suggest to help this patient?
CPAP
What type of ventilation would you try first with a patient with COPD and right lower-lobe pneumonia with respiratory acidosis and increased WOB
NIV
What would you use for a trauma victim with crushed chest injuries
VC-CMV
you can control VT, and help reduce the chances of over-distention
A patient with hiccups is ventilated in the VC-CMV mode. Every time he hiccups, he triggers the ventilator. What would you recommend?
VC-SIMV
A patient with severe tetanus needs ventilatory support. Which of the following modes would you recommend?
Paralyze and sedate the patient; control ventilation using volume control (VC-CMV)
In which of these four circumstances is it appropriate to select PSV?
1As a method of weaning
2To overcome the WOB through the endotracheal tube and the circuit
3For patients on PSV using the SIMV mode
4For long-term patient support
1,2,3,4
A patient on PC-CMV has widely fluctuating changes in Raw because of secretions and bronchospasm. The low tidal volume alarm is activated every few hours; the set pressure is 18 cm H2O. The physician is concerned about consistency in ventilation. What would you recommend?
Switch to VC-CMV
A patient with acute respiratory distress syndrome has a Pplateau of 30 cm H2O and a peak inspiratory pressure of 39 cm H2O. VT is 0.7 on VC-CMV. The decision is made to switch to PC-CMV (PCV) to keep pressures at a safe level. What pressure would you set and why?
pressure of 30 cm H2O to start would provide approximately the same VT delivery in VC-CMV and would be a safe starting point. This patient requires high pressures for delivery of VT. Palv should be kept below 30 cm H2O.
A patient receiving VC-CMV is actively triggering every breath. The respiratory therapist notices that the patient is using accessory muscles (sternocleidomastoid muscles) during the entire inspiratory phase. The therapist also sees that the pressure-time curve has a negative deflection before inspiration and has a concave appearance during inspiration. What is the apparent problem in this situation?
the ventilator has a fixed flow rate and pattern during inspiration that is not adequate for the patient’s needs. The therapist should increase the inspiratory flow and see whether this solves the problem. Another solution is to switch to a newer generation ventilator that allows additional flow on demand during VC-CMV.
