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Critical Care > Critical Care > Flashcards

Critical Care Flashcards

0
Q

2 options for mode setting

A

Full support

Partial support

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1
Q

What do we have to set on ventilator?

A
  1. Mode
  2. Tidal volume
  3. Rate
  4. FiO2
  5. PEEP
  6. Sensitivity type a level
  7. Peak flow
  8. Alarms
  9. Insp flow waveform
  10. Humidification system
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2
Q

Tidal volume initial settings

A

8-12 mL/kg IBW

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3
Q

Tidal volume initial settings for ARDS and COPD

A

5-8 cc/ kg IBW

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4
Q

Initial vent rate settings

A

8-12 bpm w moderate tidal volume

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5
Q

Initial fio2 vent settings

A

Use whatever fio2 they were on when mechanical ventilation was initiated.
If on room air, use 100%

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6
Q

How much to wean fio2 to reduce risk of o2 toxicity?

A

60% or less

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7
Q

PEEP vent initial settings.

A

5 cm H2O of BP ok

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8
Q

2 types of sensitivity settings

A

Pressure

Flow

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9
Q

Pressure sensitivity initial vent settings

A

-1 to -2 cm H2O

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10
Q

Flow based sensitivity initial vent settings

A

5 L/min base flow

1-3 L/min usually triggers breath

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11
Q

Peak flow initial vent settings

A

40-60 L/min MINIMUM

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12
Q

Peak flow / I:E ratio relationship

A

Increase peak flow= increase I:E (longer time to exhale)

Decrease peak flow= decrease I:E (shorter time to exhale)

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13
Q

Inspiratory flow waveforms

A

Square (constant)
Decelerating (descending)
Accelerating (ascending)
Sine (normal breathing)

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14
Q

Temp of nose

A

20-22 C

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15
Q

Temp of hypo pharynx

A

29-32 C

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16
Q

Temp of trachea

A

32-35 C

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17
Q

Temp 5 cm below carina

A

37 C

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18
Q

If over 24 hrs, air needs to be

A

Heated!

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19
Q

Should avoid HME in pts w…

A

Thick secretions
Low body temp
High spontaneous minute ventilation (>10L/min)
Large air leaks

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20
Q

Normal minute ventilation

A

5-10 L/min

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21
Q

Relative humidity

A

A gas that has only part of the humidity it could have

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22
Q

Absolute humidity

A

Weight of humidity based on pressure

Measured in mg/L

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23
Q

Absolute humidity at 37C

A

44 mm Hg

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24
Q

Goals of mechanical ventilation

A
  1. Improve gas exchange
  2. Relieve respiratory distress
  3. Improve pulmonary mechanics
  4. Permit lung and airway healing
  5. Avoid complications
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25
Q

Impending resp failure tidal volume threshold

A

<3-5 mL/kg

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26
Q

Impending resp failure frequency and pattern threshold

A

> 30L/min labored or irregular

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27
Q

Impending vent failure minute ventilation threshold

A

> 10L/min

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28
Q

Impending vent failure vital capacity threshold

A

<15 mL/kg

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29
Q

Impending vent failure max inspiratory pressure threshold

A

<-20 cm H2O (ie -10cm H2O)

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30
Q

Impending vent failure PaCO2 trend threshold

A

Increasing to >50 mm Hg

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31
Q

Impending vent failure vital signs threshold

A

Inc hr

Inc BP

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32
Q

Severe hypoxemia thresholds for mechanical ventilation

A

P(A-a)O2 > 450mm Hg on 100% O2 (refractory hypoxemia)
<200 mm Hg for ARDS
*aka P/F ratio (pao2/fio2)

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33
Q

Reasons for prophylactic vent support

A

Reduce risk of pulm complications
Reduce hypoxia of major body organs
Reduce cardiopulmonary stress

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34
Q

Contraindications for mechanical ventilation

A 
Absolute: untreated tension pneumothorax
Relative: pt informed request
Medical futility
Reduction or termination of pain and Suffering
Exclusion criteria for ventilator access
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35
Q

Initial PS level for MV

A

8-10

Titrated for weaning

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36
Q

Longer E time for pts w air trapping achieved by

A 
Increasing flow rate
Increaing E time
Decreasing I time
Decreasing frequency
Decreasing tidal volume
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37
Q

Use PIFR formula to change the I:E ratio by flow

A

Ve= 12L/min
Desired I:E = 1:3

12 x 4 = 48 L/min. PIFR

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38
Q

Constant insp flow waveform

A

Square
Peak flow same as mean flow
Ideal for normal lungs

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39
Q

Accelerating insp waveform

A

Spending
Peak flow same as mean flow
Suitable for partial airway obstruction

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40
Q

Decelerating insp waveform

A

Descending
Higher initial pressure and flow
Flow tapers to end expiration
Improve distribution of tidal volume and gas exchange

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41
Q

Sine inspiratory flow wave pattern

A

Similar to normal breathing

Improves distribution of tidal volume and gas exchange

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42
Q

Maximum inspiratory pressure

A

Aka negative inspiratory force
Reflects a patients respiratory muscle strength
Should be -20 cm H2O
If -19 cm H29 to 0, then impending ventilatory failure

43
Q

Assessments for impending ventilatory failure

A 
Tidal volume
Frequency
Minute volume
Vital capacity
Maximum inspiratory pressure
Paco2 trend
Vital signs
44
Q

Severe hypoxemia

A

Pao2 less than 60 mm Hg on 50% or more fio2

Or less than 40 mm Hg on any fio2

45
Q

Common clinical manifestations of ARDS and ALI

A

Acute onset
Bilateral infiltrates
Normal PCWP

46
Q

PCWP

A

Pulmonary capillary wedge pressure
Used to rule out pulmonary edema or bilateral infiltrates caused by cardio genie pulmonary edema if less than or equal to 18 mm Hg

47
Q

BSA

A

Body surface area

48
Q

What is the primary ventilator control to regulate paco2?

A

Frequency

49
Q

Frequency/ paco2 relationship

A

Increase frequency if paco2 is too high, decrease frequency if paco2 is too low

50
Q

Factors preventing patient from receiving set tidal volume

A
  1. Gas leakage in ventilator circuit
  2. Gas leakage at et tube
  3. Circuit compressible volume loss
51
Q

Circuit compressible volume

A

Expansion of ventilator circuits during inspiration leading to a small lost volume of gas that does not reach the patient, but is recorded as part of the expired tidal volume.

52
Q

Conditions that may require lower tidal volume

A

Increase airway pressure requirement (ARDS)
Increase of lung compliance (emphysema)
Decrease of lung volumes (pneumonectomy)

53
Q

Corrected tidal volume

A

Expired tidal volume - circuit compressible volume

54
Q

Extinction can be considered when…

A

PS level reached 5-8 cm H2O for 2 hours w no signs of resp distress

55
Q

Basic ventilator alarms

A 
Low exhaled volume
Low inspiratory pressure
High inspiratory pressure
Apnea
High frequency
FiO2
56
Q

Low exhaled volume alarm

A

Should be set at about 100 mL lower than the expired mechanical tidal volume.

57
Q

Low inspiratory pressure alarm

A

Should be set at 10-15 cm H2O below observed peak inspiratory pressure

58
Q

High inspiratory pressure alarm

A

Should be set at 10-15 cm H2O above the observed peak inspiratory pressure

59
Q

Apnea alarm

A

Should be set with a 15-20 sec time delay

60
Q

High frequency alarm

A

Should be set at 10/min over the observed frequency

61
Q

Fio2 alarm

A

Should be set 5% -10% above and below set fio2

62
Q

Hazards and complications of mechanical ventilation related to ppv

A 
Barotrauma
Hypotension
Arrhythmia
Oxygen toxicity
Bronchi pleural fistula
Bronchi pulmonary dysphasia in infants
Upper gastrointestinal hemorrhage
63
Q

Hazards and complications of mechanical ventilation associated w pt condition

A

Infection
Physical and psychological trauma
Multiple organ failure

64
Q

Hazards and complications of mechanical ventilation related to equipment

A 
Ventilator and alarm malfunction
Ventilator circuit disconnection
Accidental extubation
Main bronchus intubation
Postintubation stridor
Endotracheal tube blockage
Tissue damage
Atelectasis
65
Q

Hazards and complications of mechanical ventilation related to medical professionals

A

Nosocomial pneumonia
Inappropriate vent settings
Misadventures

66
Q

Risk of barotrauma is high when…

A

PIP >50 cm H2O
Plateau pressure > 35 cm H2
mPaw >30 cm H2O
PEEP >10 cm H2O

67
Q

High airway pressures are more detrimental in patients with which type of compliance?

A

Those with high compliance

68
Q

LMA

A

Laryngeal mask airway

A tube with a small cushioned mask on the distal end that provides a seal over the laryngeal opening

69
Q

LMA indications

A

When tracheal intubation is precluded by lack of experience or equipment
When attempts at endotracheal intubation have failed

70
Q

Does the LMA protect pt from aspiration?

A

No

71
Q

Which size LMA for adults?

A

Size 4 females

Size 5 males

72
Q

Positive pressure ventilation may be provided via most LMAs at peak inspiratory pressure up to

A

20 cm H2O

73
Q

Silicone LMAs can be used up to how many times as long as it is cleaned by what method?

A

40 times

Steam autoclave

74
Q

Best measure of ventilatory status

A

PaCO2

75
Q

Strategies to Improve ventilation (ie lower paco2)

A 
Increase ventilator frequency
Increase spontaneous tidal volume 
Increase ventilator tidal volume
Reduce mechanical dead space
Consider high frequency jet or oscillatory ventilation
76
Q

How to determine new frequency to obtain a certain paco2

A

New frequency = (current frequency x current paco2) / desired paco2

77
Q

Permissive hypercapnia

A

Intentional hypoventilation of a patient by reducing the ventilator tidal volume to a range of 4-7 mL/kg.
Used to lower pulm pressures and minimize risk of ventilator related lung injuries
Acidosis is neutralized w tromethamine

78
Q

Plateau pressure should be kept at or below what to avoid pressure induced lung injuries

A

35 cm H2O

79
Q

2 main conditions that permissive hypercapnia is used for

A

Status asthmaticus

ARDS

80
Q

Oxygenation

A

Amount of oxygen available for metabolic functions

Affected by ventilation, diffusion and perfusion

81
Q

Strategies to improve oxygenation

A

Increase fio2
Improve ventilation and reduce mechanical dead space
Improve circulation
Maintain normal hemoglobin level
Initiate continuous positive airway pressure only w adequate spontaneous ventilation (CPAP)
Consider airway pressure release ventilation (APRV)
Initiate positive end expiratory pressure (PEEP)
Consider inverse ratio ventilation (IRV)
Consider prone positioning
Consider extracorporeal membrane oxygenation (ECMO)

82
Q

IRV improves oxygenation by…

A

Overcoming noncompliant lung tissues
Expanding collapsed alveoli
Increasing time for gas exchange

83
Q

HFOV initial settings

A 
Mean airway pressure= 5 cm h20 over vent setting
Power = 4
Frequency = 5-6 Hz
Insp. time= 33%
F1o2= 100%
84
Q

Low pressure alarm may be triggered in following cases:

A

Loss of circuit pressure
Loss of system pressure
Conditions leading to premature termination of inspiratory phase
Inappropriate ventilator settings

85
Q

The low volume alarm is usually triggered w what alarm?

A

Low pressure alarm

86
Q

High pressure alarm may be triggered by

A

Increase in airflow resistance

Decrease in lung or chest wall compliance

87
Q

High frequency Alarm may be triggered by

A

Patients need to increase ventilation

Excessive sensitivity setting

88
Q

What is the most frequent trigger of the apnea alarm.

A

Disconnection of the ventilator circuit from the pt’s et tube

89
Q

Ways to reduce auto PEEp

A

Reducing tidal volume or frequency
Increasing inspiratory flow
Eliminating airflow obstruction

90
Q

If an MDI is used w an HME, where must the MDI be placed?

A

Between the HME and the patient

91
Q

The tidal volume selected for patients w Ali or ARDS should result in a plateau pressure of

A

<35 cm H2O

92
Q

Brachial plexophathy

A

Decreased movement or sensation in the arm and shoulder

93
Q

TGI

A

Tracheal gas insufflation
Use of a small catheter to provide a continuous or phasic gas flow directly into the trachea during mechanical ventilation

94
Q

Weaning success

A

Absence of ventilatory support 48 hours following extubation

95
Q

Weaning failure

A

Failure of spontaneous breathing trial
Or
The need for reintubation within 48 hours following extubation

96
Q

Pts who faile SBT often exhibit the following clinical signs:

A 
Tachypnea
Tachycardia
Hypertension
Hypotension
Hypoxemia
Acidosis
Arrhythmias
97
Q

2 critical questions before attempting to wean:

A
  1. Has pt significantly recovered from the acute phase of the disease or injury that prompted the need for mechanical ventilation?
  2. Are there other clinical conditions that may interfere with the pt’s ability to sustain the work of spontaneously breathing?
98
Q

“Clinical” weaning criteria

A

Resolution of acute phase of disease
Adequate cough
Absence of excessive secretions
Cardiovascular and hemodynamic stability

99
Q

“Ventilatory” weaning criteria

A

Spontaneous breathing trial: 20-30 min
PaCo2: 10 mL/kg
Spontaneous Vt: >5 mL/kg
F/Vt: <10 L w satisfactory ABG

100
Q

“Oxygenation” weaning criteria

A 
PaO2 without PEEP: >60 mm Hg at fio2 up to .4
PaO2 w PEEP: >100 mm Hg at fio2 up to .4
Sao2: >90% at fio2 up to .4
P/F: > or = 150 mm Hg
Qs/Qt: <350 mm Hg at fio2 .1
101
Q

Pulmonary reserve weaning criteria

A

Vital capacity: >10 mL/kg

Max insp pressure: >-30 cm H2O in 20 sec

102
Q

Pulmonary measurements weaning criteria

A

Static compliance: >30 mL/ cm H2O
Airway resistance: stable or improving
Vd/Vt: <60% while intubated

103
Q

5 weaning criteria categories

A 
Clinical
Ventilatory
Oxygenation
Pulmonary reserve
Pulmonary measurements
104
Q

What are the vital capacity and tidal volume measurements that correlate w successful weaning?

A

10 mL/kg and 5 mL/kg respectively

Critical Care (1 decks)

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