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NURS 425 > Exam #2: Mechanical Ventilation > Flashcards

Exam #2: Mechanical Ventilation Flashcards

1
Q

What is mechanical ventilation?

A

Process by which FIO2 (≥ 21% room air) is moved into and out of lungs by a mechanical ventilator (doesn’t help with expiration)

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2
Q

Mechanical Ventilation: Not curative

A
  • Means of supporting patients until they recover ability to breathe
  • Bridge to long-term mechanical ventilation
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3
Q

Mechanical Ventilation: Indications

A
  • Apnea or impending inability to breathe or protect the airway
  • Acute respiratory failure
  • Severe hypoxia
  • Respiratory muscle fatigue

*Read notes on slide

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4
Q

Types of Mechanical Ventilation

A
  1. Negative Pressure Ventilation

2. Positive Pressure Ventilation

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5
Q

Negative Pressure Ventilation

A
  • Involves the use of chambers that encases the chest or body
  • Intermittent negative pressure pulls chest outward → air rushes in → passive expiration
  • Similar to normal ventilation
  • It is noninvasive ventilation that does not require an artificial airway
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6
Q

Positive Pressure Ventilation

A
  • Used primarily in acutely ill patients
  • Delivers air into lungs under positive pressure during inspiration → intrathoracic pressure ↑ during lung inflation (opposite of normal)
  • Expiration occurs passively
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7
Q

Mechanical Ventilation: Modes of PPV

A
  1. Volume Ventilation

2. Pressure Ventilation

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8
Q

Modes of PPV: Volume Ventilation

A
  • Predetermined tidal volume (VT) delivered with each inspiration
  • Amount of pressure needed to deliver each breath varies
  • Tidal volume same with each breath P
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9
Q

Modes of PPV: Pressure Ventilation

A
  • Predetermined peak inspiratory pressure
  • VT varies
  • Careful attention needed to prevent hyper/hypoventilation

*Read notes

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10
Q

What do mechanical ventilation settings do?

A

-Regulate rate, VT, oxygen concentration and other characteristics of ventilation

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11
Q

Tidal Volume is based on

A
  • How much the person weighs

- Usual is 50-600

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12
Q

Mechanical Ventilator Settings: What does tidal volume measure and what is the usual volume?

A
  • Volume of gas delivered to patient during each ventilator breath
  • Usual volume: 6–10 mL/kg
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13
Q

What are mechanical ventilator settings based on?

A

Patient status:

  • ABGs
  • ideal body weight
  • current physiologic state
  • LOC
  • Respiratory muscle strength
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14
Q

Mechanical Ventilator Settings are adjusted until

A

Oxygenation and ventilation targets are reached

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15
Q

Mechanical Ventilation: Settings include

A
  • Respiratory rate
  • Tidal volume (VT)
  • Fraction of inspired oxygen (FIO2)
  • Positive end-expiratory pressure (PEEP)
  • Pressure support
  • I:E ratio
  • Inspiratory flow rate and time
    -Sensitivity
  • High-pressure limit
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16
Q

Mechanical Ventilator Settings: Respiratory Rate

A
  • Number of breaths the ventilator delivers per minute

- Usual setting: 6–20 breaths/min

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17
Q

Mechanical Ventilator Settings: What is Oxygen Concentration (FIO2) and what is the usual range?

A
  • Fraction of inspired oxygen (FIO2) delivered to patient.
  • May be set between 21% (essentially room air) and 100%.
  • Usually adjusted to maintain PaO2 level >60 mm Hg or SpO2 level >90%
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18
Q

Mechanical Ventilation Settings: Positive End-Expiratory Pressure (PEEP) what does it measure and what is the usual setting?

A
  • Positive pressure applied at the end of expiration of ventilator breaths.
  • Usual setting: 5 cm H2O
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19
Q

Mechanical Ventilation Settings: What is pressure support and what is the usual setting?

A
  • Positive pressure used to augment patient’s inspiratory pressure.
  • Usual setting: 6–18 cm H2O
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20
Q

Mechanical Ventilator Settings: What is I:E ratio and what is the usual setting?

A
  • Duration of inspiration (I) to duration of expiration (E).

- Usual setting: 1:2 to 1:1.5 unless IRV is desired

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21
Q

Mechanical Ventilation Settings: What is inspiratory flow rate and time and what is the usual setting?

A
  • Speed with which the VT is delivered.

- Usual setting: 40–80 L/min and time is 0.8–1.2 sec

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22
Q

Mechanical Ventilation Setting: What is sensitivity and what is the usual setting?

A
  • Determines the amount of effort the patient must generate to initiate a ventilator breath.
  • It may be set for pressure triggering or flow triggering.
  • Usual setting: For a pressure trigger is 0.5–1.5 cm H2O below baseline pressure and for a flow trigger is 1–3 L/min below baseline flow

*Important in assist control; want sensitivity to be high

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23
Q

Mechanical Ventilation Settings: What is high-pressure limit and what is the usual setting?

A
  • Regulates the maximal pressure the ventilator can generate to deliver the VT. When the pressure limit is reached, the ventilator terminates the breath and spills the undelivered volume into the atmosphere.
  • Usual setting:10–20 cm H2O above peak inspiratory pressure
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24
Q

Mechanical Ventilation

Modes are based on

A

Based on how much work of breathing (WOB) patient should or can perform

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25
Q

Mechanical Ventilation Modes are determined by what factors?

A
  • Ventilatory status of patient
  • Respiratory drive
  • ABGs
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26
Q

Mechanical Modes of Ventilation: Types of Support

A
  1. Controlled ventilatory support:
    Ventilator does all the WOB
  2. Assisted ventilatory support:
    Ventilator and patient share WOB
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27
Q

Mechanical Ventilation: Assist-Control Ventilation (ACV)

A
  • Delivers preset VT at preset frequency
  • When patient initiates a spontaneous breath, preset VT is delivered
  • Can breathe faster but not slower
  • Allows some control over ventilation

*Read notes

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28
Q

Assist-control ventilation: There is a potential for

A
  • Potential for hyperventilation

- Continuous monitoring required

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29
Q

Mechanical Ventilation: Synchronized intermittent mandatory ventilation

A
  • Delivers preset VT at preset frequency in synchrony with patient’s spontaneous breathing
  • Between ventilator-delivered breaths, patient is able to breathe spontaneously
  • Thus, the patient receives preset FIO2 but self-regulates rate and volume of spontaneous breaths
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30
Q

What are potential benefits of SIMV?

A
  • Improved patient-ventilator synchrony
  • Lower mean airway pressure
  • Prevention of muscle atrophy as the patient takes on more of the WOB
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31
Q

What are disadvantages of SIMV?

A
  • If spontaneous breathing decreases when the preset rate is low, ventilation might not be adequately supported.
  • Only patients with regular, spontaneous breathing should use low-rate SIMV.
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32
Q

Mechanical Ventilation: Pressure Modes include

A
  1. Pressure support ventilation
  2. Pressure-control ventilation
  3. Pressure-controlled/inverse ratio ventilation
  4. Airway pressure release ventilation
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33
Q

Pressure Support Ventilation

A
  • Positive pressure applied to airway only during inspiration in conjunction with spontaneous respirations
  • Machine senses spontaneous effort and supplies rapid flow of gas at initiation of breath
  • Patient determines inspiratory length, VT, and respiratory rate

*Read notes

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34
Q

What is PSV used for?

A

Continuous ventilation and weaning

*Read notes

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35
Q

What are advantages of Pressure Support Ventilation?

A

↑ Patient comfort
↓ WOB
↓ Oxygen consumption
↑ Endurance conditioning

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36
Q

Pressure-Control Ventilation (PCV)

A
  • Provides pressure-limited breath at a set rate
  • May permit spontaneous breathing
  • VT is not set; determined by the set pressure limit set
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37
Q

Pressure-Controlled/Inverse Ratio Ventilation

A
  • Combines pressure-limited ventilation with an inverse ratio of inspiration (I) to expiration (E)
  • Normal I/E is 1:2 or 1:3
  • With IRV, I/E ratio begins at 1:1 and may progress to 4:1
  • Progressively expands collapsed alveoli and has a PEEP-like effect
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38
Q

With Pressure-controlled/Inverse Ratio Ventilation, the patient needs what?

A

Sedation with or without paralysis

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39
Q

PC-IRV are indicated for what patients?

A

For patients with ARDS and continuing refractory hypoxemia despite high levels of PEEP

*Read notes

40
Q

Airway Pressure Release Ventilation

A

-Permits spontaneous breathing
[Preset CPAP with short timed pressure releases
-VT varies
-Patients with ARDS who need high pressure levels

*Read notes

41
Q

Mechanical Ventilation: PEEP

A
  • Positive pressure applied to airway during exhalation, preventing alveolar collapse
  • ↑ Lung volume and functional residual capacity (FRC) improves oxygenation

*Read notes

42
Q

What is the major purpose of PEEP?

A

Maintain or improve oxygenation while limiting risk of O2 toxicity

43
Q

PEEP Indications

A
  • All mechanically ventilated patients

- Patients with ARDS

44
Q

PEEP should be used with caution in

A
  • Increased ICP
  • Low CO
  • Hypoventilation
45
Q

Continous Positive Airway Pressure (CPAP)

A
  • Restores FRC (Similar to PEEP)

- Pressure delivered continuously during spontaneous breathing

46
Q

CPAP is commonly used to treat

A

Obstructive sleep apnea

47
Q

CPAP should be used with caution in what patients and why?

A

Must be used with caution in patients with myocardial compromise because it increases WOB (because the patient bust forcible exhale against the CPAP)

48
Q

BiPAP

A
  • Bilevel positive airway pressure
  • Delivers oxygen and two levels of + pressure support:
    1. Higher inspiratory positive airway pressure
    2. Lower expiratory positive airway pressure
49
Q

How is BiPAP used?

A

Noninvasive:

Via tight-fitting face mask, nasal mask, or nasal pillows

50
Q

For BiPAP, what is required of the patient?

A

Must be able to breath spontaneously and cooperate

51
Q

What are indications for BiPAP?

A
  • COPD patients with HF
  • Acute Respiratory Failure
  • Sleep apnea
  • After extubation to prevent reintubation
52
Q

What are contraindications for BiPAP?

A
  • Shock
  • Altered mental status
  • Increased airway secretions

*Due to the risk for aspiration and the inability to remove the mask

53
Q

What are complications of PPV?

A
  1. Cardiovascular complications
  2. Barotrauma
  3. Pneumomediastinum
  4. Volutrauma
  5. Alveolar Hypoventilation
  6. Alveolar Hyperventilation
  7. Ventilator Associated Pneumonia (VAP)
  8. Sodium and water imbalance
  9. Neurologic complications
  10. GI complications
  11. Musculoskeletal Complications
54
Q

PPV Complications : Cardiovascular System

A
  1. ↑ Mean airway pressure transmitted to structures of thorax → vessels compressed → decreased venous return to heart:
    • ↓ Preload
    • ↓ Cardiac output
    • ↓ BP
      * PEEP increases this effect

*Read notes

55
Q

PPV Complications: Barotrauma

A
  • Air can escape into pleural space from alveoli or interstitium, accumulate, and become trapped pneumothorax
  • Patients with compliant lungs are at an increased risk
56
Q

What can be done prophylactically to prevent barotrauma from PPV?

A

Chest tubes can be placed prophylactically

*Read notes!

57
Q

PPV Complications: Pneumomediastinum

A
  • Rupture of alveoli into lung interstitium
  • Progressive air movement into mediastinum and subcutaneous neck tissue
  • Followed by pneumothorax

*Read notes

58
Q

PPV Complications: Volutrauma

A
  • Lung injury that occurs when large VT are used to ventilate noncompliant lungs
  • Alveolar fractures and movement of fluids and proteins into alveolar spaces
59
Q

PPV Complications: Alveolar Hypoventilation

A
  • Inappropriate ventilator settings can cause leakage of air from ventilator tubing or around ET tube or tracheostomy cuff
  • Lung secretions or obstruction
  • Low ventilation/perfusion ratio

*Read notes

60
Q

PPV Complications: Alveolar Hyperventilation

A
  • Rate or VT set too high
  • Patients with COPD at risk: Alkalosis develops if decrease PaCO2 to standard normal
  • Determine cause if spontaneous hyperventilation

*Read notes

61
Q

PPV Complications: Ventilator-associated pneumonia Risk Factors

A
  • Occurs 48 hours or more after intubation
  • Contaminated respiratory equipment
  • Inadequate hand washing
  • Environmental factors
  • Impaired cough
  • Colonization of oropharynx

*Read notes

62
Q

Clinical Manifestations of VAP

A
  • Fever, elevated WBC count
  • Purulent or odorous sputum
  • Crackles or wheezes
  • Pulmonary infiltrates
63
Q

Guidelines to prevent VAP

A
  • Minimizing sedation (quicker they can breathe on their own -> weaning off of vent and therefore decreases risk for VAP)
  • Early exercise and mobilization
  • Subglottic secretion drainage port
  • HOB elevation 30- 45 degrees
  • No routine changes of ventilator circuit tubing
  • Strict hand washing, wear gloves
64
Q

PPV Complications: Sodium and Water Imbalance

A

Progressive fluid retention:
Decreased urine output
Increased sodium retention

65
Q

PPV Complications: Sodium and Water Imbalance etiology

A
  • Decreased CO
  • Intrathoracic pressure changes
  • Stress response (release of steroids and ADH)

*Read notes

66
Q

PPV Complications: Neurologic System

A

Impaired venous drainage and ↑ cerebral volume → increased ICP

67
Q

PPV Complications: Neurologic Management

A
  • Elevate HOB
  • Keep patient’s head in alignment

*REad notes

68
Q

PPV Complications: GI

A
  • Risk for Stress ulcers and GI Bleeding
  • Decreased peristalsis
  • Gastric and bowel dilation
  • REad notes
69
Q

PPV Complications: Stress ulcer prophylaxis

A
  • Histamine (H2)-receptor blockers
  • Proton pump inhibitors
  • Enteral nutrition
70
Q

PPV Complications: Gastric and Bowel dilation treatment

A

NG or orogastric tube for decompression

71
Q

PPV Complications: Decreased peristalsis (constipation) management

A

Bowel regimen

*Read notes!

72
Q

PPV Complications: Musculoskeletal

A

Loss of muscle strength and problems linked with immobility

*Read notes

73
Q

PPV Complications: Musculoskeletal interventions to prevent problems

A
  • Adequate analgesia and nutrition
  • Early and progressive ambulation
  • Physical and occupational therapy

*Read notes

74
Q

Mechanical Ventilation: Psychosocial Needs

A
  • Physical and emotional stress due to inability to speak, eat, move, or breathe normally
  • Pain, fear, and anxiety related to tubes/machines
  • Usual ADLs are extremely complicated
75
Q

Psychosocial Needs Nursing Management

A
  • Need to know (information)
  • Need to regain control
  • Need to hope
  • Need to trust
  • Need to feel safe
  • Encourage hope and build trust
  • Involve patient and caregivers in decision making.
76
Q

Read slides 44 and 45?

A

?

77
Q

Ventilator Disconnection

A

Most frequent site for disconnection is between tracheal tube and adapter

78
Q

Ventilator: Alarms

A
  • ALWAYS keep ALARMS ON
  • If alarms are paused during suctioning or removal from ventilator → reactivate before leaving

*Read notes

79
Q

Ventilator Malfunction

A

Malfunction may be due to power failure, failure of oxygen supply, etc.

80
Q

What should you do if machine malfunctions?

A
  • Disconnect patient from ventilator
  • Manually ventilate with BVM and 100% O2

*Read notes

81
Q

Nutritional Therapy: What can cause inadequate nutrition?

A

PPV and hypermetabolism can lead to inadequate nutrition

82
Q

Nutritional Therapy: Patients with difficulty with oral intake include

A
  • ET tube
  • Tracheostomy

*Consult speech therapist for swallowing study

83
Q

Inadequate Nutrition can decrease:

A
  • O2 transport
  • Exercise tolerance
  • Serum protein
  • *Weaning
  • Resistance to infection
  • Speed of recovery
84
Q

Nutritional Therapy: Limit Carbs because

A

Content may lower CO2 production

*Read notes

85
Q

Weaning: Process of

A
  • Decreasing ventilator support

- Resuming spontaneous breathing

86
Q

Weaning consists of three phases:

A
  1. Preweaning phase
  2. Weaning process
  3. Outcome phase

*Read notes

87
Q

Preweaning or Assessment Phase

A
  • Assess muscle strength: Negative inspiratory force
  • Assess endurance: Spontaneous VT, vital capacity, minute ventilation, and rapid shallow breathing index
  • Auscultate lungs
  • Assess chest x-ray
88
Q

Preweaning Phase: Nonrepsiratory Factors include

A
  • Assessment of neurologic status, hemodynamics, fluid and electrolytes/acid-base balance, nutrition, and hemoglobin
  • Drugs should be titrated to achieve comfort but not excessive drowsiness

*Read notes!

89
Q

Weaning Process

A
  • Awakening/Breathing Coordination, Delirium Monitoring/Management, and Early Mobility bundle:
    • SBT should be at least 30 minutes but not >120 minutes
    • SAT done by stopping all sedatives
90
Q

The use of weaning protocol decreases

A

Ventilator delays

91
Q

What is important during the weaning process?

A
  • Important to rest between weaning trials
  • Provide explanations regarding weaning and ongoing psychologic support

*Read notes

92
Q

What position should the patient be in during the weaning process?

A

Sitting or semirecumbent position that is comfortable

93
Q

Nursing management during weaning process

A
  • Baseline assessment: V/S And Respiratory parameters

- Monitor for S&S

94
Q

What signs and symptoms should you monitor for during the weaning process?

A
  • Tachypnea, dyspnea
  • Tachycardia, dysrhythmias
  • Sustained desaturation [SpO2 <90%]
  • Hypertension or hypotension
  • Agitation or anxiety
  • Diaphoresis
  • Sustained VT<5 mL/kg
  • Changes in mentation
95
Q

Weaning Outcome

A

Weaning stops and patient is extubated
–OR–
Weaning is stopped because no further progress is made

96
Q

Extubation Process

A
  • Hyperoxygenate and suction
  • Loosen ET tapes or holder
  • Deflate cuff and remove tube at peak of deep inspiration
  • Encourage patient to deep breath and cough
  • Supplemental O2
  • Careful monitoring after extubation

*Read notes

NURS 425 (19 decks)

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