Final Flashcards
Bronchial hygiene outcomes
- Increase aeration
- To clear and thin sputum
- CXR- Residue of consolidation (white now)
- Improved SpO2 with less O2
- ABG normalized
- Vitals and labs- Trend toward norm or resolve
Hydrated sputum=
thin and clear
Flutter Valve- PEP device
- Gravity Dependent (must remain upright, have pt sitting up)
- Start with flutter horizontal with floor (Up-increases frequency, down- decreases)
- Creates PEP and Oscillation
- Oscillation Frequencies are b/w 2-32hz
Hz
measurements of cycles in seconds, know: 0-30 hz
EzPAP
-Positive airway pressure is created with flow/ 50psi gas source
-Parts:
A: ambient air inlet
B: Gas inlet port
C: Pressure monitoring port with cap (cap if not monitoring)
-Can use with a mask (create a seal)
-Able to deliver a neb tx
-EzPAP flow setting is norm 5-7lpm
-Therapeutic PAP pressures are 10-20cmH2O
NO BREATH HOLD-CONTINUOUS PRESSURE
Acapella
- Can be used in any position, with mask
- Can deliver a neb treatment
- Produces PEP with oscillation (breath hold)
- Active exhalation for 1:3 or 1:4 ratio
- Oscillation frequencies produced 0-30Hz
-Adjustable: increasing the frequency (+) increases the PEP pressure which can be measured with pressure manometer
TheraPEP
- Exhaling actively but not foreful
- Therapeutic pressures 10-20cmH20 are indicated between lines
- Resistance can be increased or decreased
Metaneb
- Can use on vent
- CHFO: continuous high frequency oscillation
- CPEP: continuous positive exp pressure
- Blue ring= changes resistance
- Black ring= used when delivering therapy through vent (covers resistance holes)
- Requires special circuit and adaptors
- Therapy can be delivered through: mouthpiece, mask, trach, and in line with vent circuit
Fitting the vest
a. Full vest- Top of the hipbone snug without being restricted
b. Wrap!!- fasten to pt during deep inspiration , snug without restriction, disposable
c. Chest vest- inhale deeply and secure flaps to the front under the arm
Generic settings of vest
-10-30 min treatments
-Frequency- 10-14Hz
-Pressure: 1-4 for the front vest/ 5-6 for the full vest
DONT NEED TO DO POSTURAL DRAINAGE
How does HFCWO work
Changes intrapulmonary pressures
-Oscillates air through the lungs/ mucus moves secretion out on exhalation
Cough Assist
- Delivers a positive pressure to assist with a deep breath (produces an effective cough)
- Insp pressures: 25-32cmH2O for 1 to 2 seconds followed by
- Expiratory Vacuum Pressure: -30 to -40 cmH2O for 1 to 2 seconds (this cycle mimics a cough by pulling the air out of the airways)
- Perform 5 cycle breaths followed by normal breathing for 30 seconds, repeat until secretions are cleared
- It is also known as insufflation (inspiration)/ Exsufflation (expiration)
- Can be used with trach tube, mouthpiece, or mask
Postural Drainage
- Each position is held for 5-10 minutes
- Total treatment time 20-30 minutes up to an hour
- Head down positions should exceed 25 degrees below horizontal
- Must have adequate hydration for secretion mobility
- Avoid strenuous coughing
- Usually performed with percussion and vibration
- Return pt to original resting position
During an intubation attempt, what two landmarks should you see as you advance the laryngoscope
Arytenoid cartilage, Epiglottis
Term intubation
passing of a tube into a body apature (vocal cords)
What size blades is/ are used to intubate an adult pt
3 and 4
What are two different laryngoscope blades and how are they used to visualize the vocal cords
- Miller: Directly lifts the epiglottis in order to visualize the vocal cords
- Macintosh: inserted into the vallecula, which is the space between the epiglottis and the tongue, indirectly lifts epiglottis
When is placing an artificial airway (intubation) contraindicated
Pt is DNI
What is the norm range for cuff pressure? what are you trying to prevent
20-30cmH2O- minimize aspiration, avoid cutting off blood supply
Can you intubate with a LMA (laryngeal mask airway)
no, its above the glottis (not passing through apature)
How much time do you have when attempting to intubate a pt
30 seconds
What are the different techniques used to monitor cuff pressure? how are they performed
- Min. Leak technique-check during inspiration
- MOP/MOV
- Cuff manometer
What initial FiO2 do we choose on the vent.
Whatever patient was on before, safe 60%< and add pressure to improve O2 from there
Vt Range
6-8ml/kg
How do we provide humidity and heat to an intubated pt
HME-Passive
Heated wire circuit
VAP protocol; what can we influence?
Keep head elevated 30-45%, Perfrom subglottic suctioning, Keep cuff pressure adequate (20-30cmH2O), methylene blue dye test, Make sure appropriate size tube
IBW
50+2.3 (PtH x 60)
Common vent wean settings
Decrease vent: decrease VT, and RR.
-Go from setting volumes and rates to observ- giving O2 support
PEEP +5 , PS 5, FiO2 <50%
Spontaneous awake trial (SAT) and spontaneous breathing trial (SBT)
SAT- removing sedation
SBT- Readiness to wean, removing/ reducing vent support
do for 2 min- looks good? check pt and do for 2 more hours
What is a cuff leak test
test airway edema
- Deflate cuff, few seconds
- Hear air moving through upper airway (nothing? not able to substain airway)
NIF/ VC/ RSBI
NIF- diaphragm strength, more neg than -20 (breath/cough)
VC- 1 L for adults or 10ml/kilo (take deep breath=cough)
RSBI- Rapid shallow breathing index < 105
What is stridor and how is it treated?
Racemic epi or cool aerosol
- distress
- 0.5 and 2.5 ml norm saline
How to treat resp acidosis
Increase ventilation and decrease FiO2
Blood gas machine/ analyzer directly measures 3 values, what are they
pH
PaCO2
PaO2
What part of the blood gas machine will directly measure CoHgb, SaO2, and methemoglobin
Co-Oximetry
When performing an Allen’s test, why do you release only the ulnar artery
Show there is collatural circulation between ulnar and radial artery
Suction settings for adults, pediatric, and infants
suction for 15 seconds
adult: 120-150
Ped: 100-120
infant: 80-100
List two absolute contraindications specific to nasotracheal suctioning
Epiglotitis and croup
mini-BAL suctioning procedure
Collecting sputum sample in intubated pt
“bronchial alveolar lavage”
What type of airway can be used on an unconscious pt
Oral/ nasopharyngeal
What type of airway is mostly used to facilitate suctioning
nasal
When should you use oral suction, what is the other name for oral suction
Removing secretions from pharynx in order to visualize vocal cords during intubation - yankauer
How can you collect sputum while suctioning a pt
luken trap
how do you measure a nasal trumpet? how do you choose correct diameter? how are they labeled for measurement
Nose to tragus + 2cm
-Largest diameter that will slide with ease
How do you measure an oral airway? what type of pt is this appropriate for
Even with pts mouth to the corner of the jaw
-Unconscious patients
PEEP valve
positive exp pressure placed on exhalaton port on bag valve
- improves oxygenation by improving pressures in the lungs
- Absolutely have on when placed on positive pressure on a vent requires a PEEP of 10 on vent
VAP protocol- consistent cares
- Elevate head of bed
- Daily sedation vacation
- Daily assessment of readiness for extubation
- Peptic ulcer disease prophylaxis
- Deep vein thrombosis(thinners)
- oral care
Initial vent settings
- IBW: tidal volume
- RR: normal
- Minute ventilation
- PEEP
- LPM converted to %
- I:E ratio
Vent settings findings
IBW: 50+2.3(PtH-60) FiO2: Lpm x 4 = # + 21= % RR: PEEP: +5 Vt: (x6-x8 of FiO2)
LMA- Laryngeal Mask Airway
Above glottis
- Insirted into the oropharynx, the tip resting at the upper esophageal sphincter
- used predominantly in surgery
- Airway is covered in ACLS, an alternative to standart ETT intubation
- Placed blindly
- Dont protect from aspiration
Two major limitations of LMA
- Pt must be unconscious
- If vent pressures are higher than 20cmH2O then there is a risk of gastric distention
- Do not protect against aspiration
Combitube
Blind intubation: landing in either esophagus or trachea
- 2 lumens: stomach, passively vent lungs
- Two cuffs: seal oropharynx, esophagus or trachea
Special ET tubes
Mallinckrodt Hi-Lo Evac ET tube
-Suction lumen above the cuff-continuous suction of 20-30cmH2O
Wire Reinforced ET tube
-Prevent kinking
Carlens Tube
- Intubate left mainstem
- hook that is designed to catch the carina
Robertshaw Tube
-Selective for either right or left main stem
Double Lumen
- For independent lung ventilation
- Stiffer and bulkier
- Must be rotated into specific bronchi
- Ensured placement with bronchoscope
- Increased resistance because of smaller lumen with each tube
High Frequency Jet ventilation
- Port that allows injection of high flow
- port for monitoring pressures
Intubation- RSI- Medications
Rapid sequence intubation Sedative drugs -Propofol: white , fast acting -Ketamine -Etomidate
Paralytic drugs
-Succinylcholine: fast acting
-Rocuronium
(they have no neurological assessment)
Cricoid pressure
- Close esophagus off so gastric cant leak into airway (oropharynx)
- Bring anterior airway into view
- Apply until tube is in place
Laryngoscope blade sizes
00- preemie 0- preemie 1- infant 2- child 3- adult 4-adult
ETT sizes
infant: 2.5-4.0 mmID (same diameter as pinky)
6mo-3 years: 3.0-5.0mm
5-12 years: 4.5-7.0 mm
16- adult: 6.5-9.0 mm
Tube placement- oral intubation
Males: between 21-23 cm
Females: between 19-21
Placement 3-5 cm above carina
Bedside assessment for correct tube placement
- Listen to bilateral breath sounds: bases first
- Observe for bilateral chest rise (no rise=rt mainstem)
- Note tube length- condensation
- Colorimetry
- Listen over stomach right away
- Capnometry(co2 detector)
- Light wand-stylet(glow in trachea)
- Fiberoptic laryngoscope/bronchoscope
- Esophageal detection device (bulb)
- Order chest xray
Thomas tube holder
temp hold
-no access to mouth= poor oral care
Nasotracheal intubation
-Performed blindly or direct visualization
-insertion depth at nare
28cm-hub males
26cm- hub females
-Risk of sinitus
Micro aspiration
patient aspirating without no one being aware of it
