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Intreventions 2 > Final > Flashcards

Final Flashcards

1
Q

CBG Procedure

A
  1. Check medical history and confirm steady state of 20-30 min
  2. Obtain and assemble necessary equitment
  3. PPE
  4. Select site and warm to 42C for 10 min
  5. Puncture skin (<2.5 mm) with lancet
  6. Wipe away 1st drop of blood and do not squeeze
  7. Fill sample tube (75-100 mcl)
  8. Place metal flea in tube and mix sample
  9. Place cotton on site
  10. Analyze sample within 10-15 min
  11. Dispose of waste
  12. Document
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2
Q

How much blood should be obtained with CBG puncture

A

75-100 mcl

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3
Q

Relative Contraindications to CBG

A

Peripheral Vasoconstriction

Polycythemia caused by a shorter clotting time

Hypotension

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4
Q

CBG and Arterilization

A

CBG are only useful when properly warmed, in order to cause dilation of the underlying blood vessels and increase capillary blood flow well above what the tissues needs

Egan’s says warm to 42 Celcius

AHS does not give a proper number needs to be warmed

Blood gas values will be similar to arterial circulation which is why the sample is known as arterialized blood

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5
Q

When should a CBG not be done

A

Infant <24 hr old (poor peripheral perfusion)

Need for direct analysis oxygenation and arterial blood

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6
Q

CBG should not be performed in the following areas

A

Posterior curvature on the heel, can puncture bone

Heel of pt who has begun walking

Finger of neonates, can cause nerve damage

Swollen, cyanotic, poorly perfused, and/or infected tissue

Peripheral arteries

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7
Q

Number of CBG Punctures Allowed

A

Max number of puntures if 2 per heel as long as the heel is in good condition

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8
Q

CBG Order of Collection

A
  1. Blood Gas
  2. CBC
  3. Neonatal Screen
  4. Chemistry
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9
Q

CBG Analysis

A

Alternative to arterial access in infants and small children

Can help give estimates of arterial pH, PaCO2, but is little help in assessing oxygenation

Better than finger stick values

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10
Q

CB Troubleshooting

A

Most common error is inadequate warming of the site and squeezing the site. Squeezing the site will result in venous and lympathtic contamination. Both will result in inadequate tests.

The clinican must ensure adequate sample collection while avoiding air contamination and clotting

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11
Q

Advantage of Radial Artery

A

Collateral Circulation

Easy to palpatate, access, stabilize, and punture

No major nerves in close proximity

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12
Q

Disadvantage of Radial Artery

A

More likely to go into spasm due to the fact that it is more peripheral

There is a radial vein on either side of artery so may get a venous sample

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13
Q

The Only Absolute Contra-Indication of ABG

A

Skin Graft at Puncture Site

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14
Q

Plastic Vented Syringe

A

20-25 gauge

Prefilled with Heparin (1 000 U/ml) and higher Heparin (>10 000 IU/ml) may cause altered pH

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15
Q

Brachioradialis Tendon

A

Lateral to radial artery and inserts into styoid process of radial bone

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16
Q

Flexor Carpi Radialis Tendon

A

Medial to radial artery and inserts into second and third metacarpal

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17
Q

Flexor Pollicis Longus Tendon

A

Medial to radial artery beneath flexor carpi radialis and inserts into phalange of the thumb

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18
Q

Pronataor Quadratus Muscle

A

Lies posterior to radial artery

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19
Q

Periosteum of the Radius

A

If patient complains of a sharp pain during ABG puncture and a solid structure is encountered the needle may have made contact with this structure

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20
Q

Thrombocytopneia

A

Decreased platlet count

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21
Q

Relative Contraindications to ABG

A

*The need for ABG can outwieght any of these contraindications

Bilateral negative Allan Test

ANticoagulant or Thrombolytic Therapy

Coagulation disorder

Severe Hypotension

Deformities at puncture site

Raynaud Disease

Distal to surgical site

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22
Q

Artery Supply to Right Arm

A

Brachiocephalic artery from arch of aorta to right subclavian artery

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23
Q

Artery Supply to Left Arm

A

Via left subclavian artery dircetly off aorta

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24
Q

From subclavian artery to hand

A

The subclavian artery on both hand passes between clavicle and 1st rib to become axillary artery as it enters axilla and the brachial artery as it leave th axilla

The the elbow will become brachial arteryand then divides into ulnar and radial artery

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25
Q

Radial and Ulnar Arteries

A

Radial and ulnar arteries will meet in the palm of the hand at the superifical and deep palmar arteries

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26
Q

Radial Veins

A

2 small radial veins on either side of radial artery

Major nerves are seperated from artery by tendons at this optimal site

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27
Q

Lateral Cutaneous Nerve

A

Continuation of musculocutaneous nerve

Will pass over brachioradialis tendon

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28
Q

Median Nerve

A

Seperated from radial artery by the flexor carpi radialis tendon and deep to the pollocis longus tendon

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29
Q

Radial Nerve Superifical Branch

A

From back of the arm and is seperated from the radial artery by the brachioradial tendon and travel along the lateral side of the radius and wrist

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30
Q

Transporting the ABG Sample

A

If the analysis of the sample will take more than 10 min put it in the ice slurry

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31
Q

Why Advantage does an ABG have over CBG and Venous Sample

A

Venous samples will vary due to local tissue metabolism

Capillary samples are prone to venous admixture and air contamination

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32
Q

Deficient Sample Return

A

Slowly withdraw the needle

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33
Q

ABG Pre-Analytical Error

Air in Sample

A

Effect on Parameter: Decrease PaCO2, Increased pH

Increased low PaO2

Decreased high PaO2

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34
Q

ABG Pre-Analytical Error

Metabolic Effects

A

Effect on Parameter: Increased PaCO2, Decreased pH, Decreased PaO@

How to Recongize: Excessive time since collection and inconsistent with pt status

How to Advoid: Analye within 15 min, and place in ice slurry

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35
Q

ABG Pre-Analytical Error

Excess Anticoagulant (Dilution)

A

Effects: Decreased PaCO2, Increased pH

Increased low PaO2

Decreased high PaO2

Recognization: Visible heparin in syringe

Avoidance: Use samples with pre pared heparin amounts

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36
Q

ABG Pre-Analytical Error

Venous Admixture

A

Effect: Increased PaCO2, Decreased pH, Greatly lower PaO2

Recognize: Syringe failure to fill with pulsation

Advoidance: Advoid brachial nd femoral sites, do not aspirate sample, use short bevel

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37
Q

PaO2

A

Partial pressure of oxygen in arterial blood

Severe Hypoxemia: PaO2 < 40 mmHg

Moderate Hypoxemia: PaO2 40-60 mmHg

Mild Hypoxemia: PaO2 >60 mmHg

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38
Q

CaO2

A

Concentration of O2 in 100 ml of aerterial blood

Normal: 18-20 ml

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39
Q

What is Mixed Venous Oxygen Saturation

A

Percentage of oxygen bound to hemoglobin in blood returning to the right side of the heart and reflect the amount of oxygen left over after the tissues remove what they needs

Used to help recognize when the body is extracting more oxygen than normally

An increase in extraction is the bodies way to meet tissue oxygen needs when the amount of oxygen reaching the tissues is less than needed.

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40
Q

How to Obtain a True Mixed Venous Sample

A

A true mixed venous sample (SvO2) is obtained from the tip of the pulmonary artery catheter and includes all the venous blood returing from Superior vena cava, inferior vena cava, and coronary sinus

By the time the blood reaches the pulmonary artery, all venous blood has “mixed” to reflect the average amount of oxygen remaining after all tissues in the body have removed oxygen from the hemoglobin.

The mixed venous sample also captures the blood before it is re-oxygenated in the pulmonary capillary.

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41
Q

ScvO2 Measurement

A

ScvO2 = central venous sample.

An ScvO2 measurement is a surrogate for the SvO2.

Because pulmonary artery catheter use has declined dramatically, ScvO2 measurements obtained from internal jugular or subclavian catheters are often used

It may be used to identify changes in a patient’s tissue oxygen extraction. We usually assume (possibly incorrectly at times) that a blood gas sample obtained from the internal jugular or subclavian (which reflects only head and upper extremities) will have the same meaning as an SvO2.

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42
Q

What Does the SvO2 Show

A

Mixed venous oxygen saturation (SvO2) can help to determine whether the cardiac output and oxygen delivery is high enough to meet a patient’s needs.

It can be very useful if measured before and after changes are made to cardiac medications or mechanical ventilation, particularly in unstable patients.

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43
Q

Normal SvO2

A

Normal SvO2 60-80%.

Normal ScvO2 (from an internal jugular or subclavian vein) is > 70%.

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44
Q

Purpose of fenestration in a Trach

A

Allow the pt to talk and move air

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45
Q

Parts of a Trach Tube

A

Plastic Connector: Hook bag, ventilate

Radio Opacie Line: Check position

Cuff: Seal airway and allow ventilaiton

Pilot Balloon: Maintain cuff seal

Murphy: Allow breathing when other ports are occluded

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46
Q

TBI Protocol

A

PaCO2 35-40

Decreased PaCO2 will cause vasoconstriction and decrease cerebral blood flow (decrease ICP)

PaO2 80-120

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47
Q

VC CMV

Decreased Resistance

A

PIP Decreases

Use Equation for resistance and compliance when in volume control

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48
Q

VC CMV

Vt Increased

A

Everything will increase with the exception of Ve (I:E will increase)

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49
Q

PPV Increased Deadspace Ventilation

A

Normal Vd/Vt is 0.25-0.40, but will be increase to 0.4-0.6 when PPV is used

Distribution of PPV will go to the apices and less to the bases when compared to a spontaneous breath

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50
Q

VC CMV

Increased Resitance

A

Pip Increases

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51
Q

Correct Placement of ETT

A

Want 3-5 cm above carina as a buffer zone for when the tube moves with the neck

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52
Q

Compliance

A

A measure of distensibility of the lung

Normal is 60-100 mL/cmH2O

<25-30 cmH2O in ARDS

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53
Q

PC CMV

Delta Pressures

Resistance Decreases

A

Ti dyn Decreases

Flow Increases

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54
Q

VC CMV

PEEP Decreases

A

PIP Decreases

Pplat Decreases

Pmean Decreases

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55
Q

How to tell what changes in compliance and resistance will result in when in volume control

A

Use the compliance and resistance formulas

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56
Q

Auto PEEP in Volume Control

A

There is an increase in resistance which can be responsible for auto PEEP

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57
Q

Volume Control Set Controls

A

Control volume and flow so as lung mechanics change pressure will change

Because we are controlled volume and flow we are controlled minute ventilation

Set: Vt, RR, Flow, PEEP, Ti pause, FiO2

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58
Q

CvO2 Calculation

A

(Hb x 1.34) x SvO2 + (PvO2 x 0.003)

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59
Q

Shunt Fraction %

A

<10% Normal Lungs

10-19% Seldom Needs Ventilatory Support

20-29% May need CPAP

>30% Needs Ventilatory Support

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60
Q

Ventilatory Patameters Adult

Tidal Volume

A

6-8 ml/kg

May be as high as 10ml/kg for neuromuscular and post op pts.

Lung protective 4-6 ml/kg.

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61
Q

Ventilatory Patameters Adult

RR

A

12-16 bpm

Higher rates run the risk of air-trapping

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62
Q

Ventilatory Patameters Adult

Insp Time

A

0.8-1.2 s

I:E of 1:2 or lower

Try not to inverse unless you really need to affect MAP

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63
Q

Ventilatory Patameters Adult

PEEP

A

5 cmH2O

Typical start is 5 cmH2O

Aim for optimal PEEP

Increases typically made in increments of 2-3 cmH2O

Watch for CV compromise

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64
Q

Ventilatory Patameters Adult

Minute Volume

A

~ 100 mL/kg to start!

Also used: ♂- 4 x BSA

♀-3.5 X BSA

Febrile pt’s require higher MV

Adjusted based on PaCO2

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65
Q

Vt and Pplat

A

Plat < 25 cm H20 Vt should be 6-10 ml/kg

Pplat25-30 Vt should be ≤ 8 ml/kg,

Ppat≥ 30 Vt should be ≤ 6 ml/kg

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66
Q

Contraindications to PEEP

A

Increased ICP, untreated pneumo, hypotension

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67
Q

Weaning with SIMV

A

Weaning by SIMV with pressure support is better (reducing oxygen dependency) than SIMV alone.

Meta-analysis of volume-targeted ventilation demonstrated significant reductions in the duration of ventilation and pneumothorax, but the trials were small and of different designs.

Volume guarantee may provide more consistent blood gas control.

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68
Q

Ventilatory Parameters Neonate <32 Weeks

Mode

A

PRVC

If Leak > 40% may change to A/C PCV

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69
Q

if Neonate Ventilation there is a leak > 40% consider

A

larger ETT, extubationto NIPPVS, or A/C PC ventilation

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70
Q

Ventilatory Parameters Neonate <32 Weeks

Vt

A

4 mL/kg

What about deadspace?

  • eg. Flow transducers, ETCO2
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71
Q

Ventilatory Parameters Neonate <32 Weeks

RR

A

40 to 50 bpm

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72
Q

Ventilatory Parameters Neonate <32 Weeks

Insp Time

A

0.30 sec

Adjust to reach equilibrium

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73
Q

Ventilatory Parameters Neonate <32 Weeks

PEEP

A

6 cmH2O

Increases typically made in increments of 1-2 cmH2O. PEEP may be 8 before alternative modes trialled.

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74
Q

Ventilatory Parameters Neonate <32 Weeks

Alarms

A

MV, VTe, VTi: +- 20%

RR total 90 bpm

HiP 35cmH2O, readjust to PIP +10 (G5 in APV will have the 10 buffer so you get an alarm when you are within 10 of high pressure alarm )

PEEP +- 2 cmH2O

Flow Trigg: 0.5 Lpm– 2 Lpm, assess for auto trigg

Apnea time; 5 – 10 sec

Apnea FiO2 (Match set on vent)

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75
Q

Neonatal VLBW ABG Goals

A

28-40 weeks GA

pH >7.25

PaCO2 45-55

PaO2 50-70

HCO3 18-20

SpO2 85-92

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76
Q

Neonatal ELBW ABG Goals

A

< 28 weeks GA

pH >7.25

PaCO2 45-55

PaO2 45-65

HCO3 15-18

SpO2 85-92

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77
Q

Modern Ventilators and Ventilating Different Pt Groups

A
  • Most modern ventilators have the capabilities to ventilate all patient groups
    • May require special equipment (eg. flow transducer)
    • Consider the recommended weight ranges specified by the manufacturer!
  • The patient ventilator circuit also varies with the patient type! Consider:
    • Deadspace
    • Compressible volume
    • Humidity requirements
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78
Q

Main differences between a neonatal/pediatric and adult ventilator are the precision and ranges of:

A

Flow

Volume

Trigger sensitivity

Response time

Ranges of the settings

and…the modes available!

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79
Q

Cascade of Lung Injury

A
  • FiO2and PPV start the cascade of lung injury (VILI) that leads to lung remodeling and chronic lung disease
    • Lung disease is NOT homogeneous = PPV can cause over distension, and shear forces
  • CPAP/PEEP is GOOD!
    • Prevents surfactant deficient alveoli from collapsing
    • Promotes alveoli recruitment, increases FRC
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80
Q

Least Traumatic Flow in P/V Curve

A

Least traumatic flow occurs in the middle of the P/V curve

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81
Q

When are lung most vulnerable to injury

A

during bagging, recruitment, and high pressure ventilation

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82
Q

Common Goals Across Patient Populations

A
  • Provide adequate ventilation
  • Provide adequate oxygenation
  • Recruitment and maintenance of lung volume
    • Improve FRC and lung compliance
  • Appropriate WOB
    • Support muscles of ventilation
    • Use the correct balance of patient work vs. ventilator work
  • Promote patient/ventilator synchrony
83
Q

Provide adequate ventilation

A

Adjust alveolar minute ventilation to achieve the target PaCO2

VA= RR x (VT- VD)

Adjust/ensure VTwithin target goal

Adjust RR to achieve desired PaCO2

Mention that the Vt is less accurate in equation as Vdnot taken into account

Note: Ensure they assess if VT are appropriate before blindly choosing to change RR.

84
Q

Permissive Hypercapnia

A

Ideally we want normal PaCO2 but sometimes it is unachievable without damaging the lungs

PaCO2 levels are allowed to rise as long as pH <7.25

Typically allow the rise to occur gradually

Sedation is required

Most often used in ARDS patients, but also COPD/Asthma

Contraindicated in head injuries, intracranial lesions, and cardiac ischemia/heart failure

85
Q

PEEP and MAP

A

Intrinsic PEEP will increase MAP because of recruitemnt and increased FRV and improved C which will contribute to overall improved oxygenation and increased Map

86
Q

Providing Adequate Oxygenation

A

Adjust the following to obtain target SpO2 (and/or PaO2)

  • FIO2
  • PEEP
    • Increases MAP, recruits/stabilizes alveoli increasing SA for gas exchange, improves compliance, increases FRC
  • MAP
    • Typically via an increased inspiratory time, possibly even an inverse ratio
    • NOTE: Inverse ratios are NOT used in neonates
  • Note that as FIO2is increasing, PEEP should be increased
  • Generally increasing TInot done until FIO2 >0.60 and appropriate PEEP set
87
Q

Recruitment/ Maintenance of Lung Volume

Physiological PEEP

A

3-5 cmH2O

Maintains lung volume

88
Q

Recruitment/ Maintenance of Lung Volume

Therapeutic PEEP

A

5-15 cmH2O is used to treat atelectasis and refractory hypoxemia

> 15 cmH2O is used for severe ARDS

89
Q

Recruitment/ Maintenance of Lung Volume

Setting PEEP above LIP (or Above the LDEF)

A

Goal is “Open Lung Ventilation”

The theory states: to prevent de-recruitment, PEEP should be set above the LIP or above the lower deflection point

Need to do a static pressure-volume curve

Ensure that VTis adjusted so PIPs do not exceed the UIP

This setting is thought to give the best alveolar recruitment

Setting PEEP above LIP/LDEF really is to prevent collapse/de-recruitment (ie. It stabilizes those alveoli that open during the inspiration)

Set PEEP 2 cmH2O above LIP

90
Q

Recruitment/ Maintenance of Lung Volume

Optimal PEEP

A

PEEP at which maximal respiratory benefits occur (lung mechanics, oxygenation) with minimal impact on the cardiovascular status

Finding optimal PEEP esophageal balloon or you could do a lung volume recruitment maneuver to get a flow volume loop and then look at the inflactionpoint

91
Q

Pressure Volume Curve

A

Passive inflation of the lung in increasing increments of 50 – 100 ml

At each end point static pressure obtained (end insp pause) and plot a pressure volume curve.

Upper and lower inflection point can generally be determined

LIP thought to be where recruitment starts

UIP - Overdistention

Difficult and time consuming

92
Q

Transmission of PEEP

A

The application of PEEP increases intrapleural and intrathoracic pressures

The extent of the transmission is dependent on:

  • Amount of PEEP
  • Lung compliance
    • Low C (eg. ARDS): PEEP transmission significantly reduced
    • High C (eg. COPD): PEEP transmission is highest
    • Can be regionally affected due to disease process
      • eg. pneumonia, atelectasis
  • Thoracic compliance
    • Hemodynamic compromise is most likely to occur when thoracic compliance is low (eg. Abdominal distension, thoracic deformities-eg. Kyphoscoliosis)
93
Q

Stiff Lungs and PEEP Transmission

A

The stiffer the lungs the less easy the PEEP is transferred to affect hemodynamics more floppy lungs are more susceptible to changes in hemodynamics (COPD)

94
Q

Lung Recruitment Maneuver Indications

A

CXR showing diffuse bilateral infiltrates = ALI/ARDS

Atelectasis

Increased OI (eg.> 12; may vary with institution)

Patients requiring a high PEEP

May also be done in patients who de-sat after disconnect/suctioning

Lung recruitment maneuvers are

Typically only done in adults!

95
Q

Lung Recruitment Maneuver Methods

A

Patients should be adequately sedated

Many different procedures but generally involve high CPAP pressures (eg.30-45 cmH2O) for short periods (30 sec to 2 minutes)

The CPAP level is often based on a plateau pressure of a specified VT(ml/kg) (eg.12 mL/kg)

Ensure that the PEEP returned to is adequate

PEEP adequate as - above the LIP or the lower deflection point

96
Q

Lung Recruitment Maneuver Contraindications

A
  • Pulmonary air leaks:
    • Recent, active pneumothorax, PIE, etc
    • Bronchopleural fistula
  • Hemodynamic instability (eg.low BP)
  • Head Injury
  • Obstructive lung disease
  • Pregnancy
97
Q

Lung Recruitment Maneuver Cautions

A

oWatch vital signs during maneuver

oWatch for hypoxemia

CHR P&P-D/c maneuver if SpO2 falls < 80%, MAP < 60 or 20% change from baseline, HR < 60 or 20% change from BL, new arrhythmia

98
Q

FVS: When is it used?

A

Typical start-up strategy (as patient may be paralyzed/ sedated from intubation)

When patient is apneic

When we want the vent to do all the WOB

eg.Patient hemodynamically unstable, acute state of disorder (eg.ARDS, severe pneumonia)

99
Q

PVS: When is it used?

A

When patients are spontaneously breathing

Patients with primarily hypoxemic respiratory failure

Weaning

100
Q

Promotion of Patient/Ventilatory Synchrony

A

Sensitivity should be set at the most sensitive level that avoids auto-triggering

Patient triggering across populations:

Pressure triggering acceptable for pedsand adults

Neonates require flow or volume triggering

Minimize auto PEEP

The patient has to overcome the auto PEEP and more to create a negative pressure in the chest relative to the circuit, resulting in a triggered breath

This causes increased work to trigger the ventilator (regardless if P or flow triggering is used)

COPD applying PEEP can offset the autoPEEPbut in asthma applying PEEP is additive to auto-PEEP

101
Q

Hyaline Menbrane Disease

Surfactant Replacement Therapy

A

May be intubated and then extubated to CPAP if stable

< 28 weeks should receive surfactant immediately post-birth

102
Q

Hyaline Menbrane Disease

Lung Protective Strategy

A

Set PEEP for appropriate recruitment (CXR)

Permissive hypercapnia

VT~ 4 mL/kg

Goal pH ≥ 7.25

PaCO245-55 mmHg

Peak pressures should be < 25 cmH2O

Consider HFO for more severe cases/problems with oxygenation

103
Q

Persistent Pulmonary Hypertension (PPHN)

A

PPHN=infants whose pulm. Vasculature remains constricted due to hypoxia and acidosis secondary to lung diesease, MAS, congenital pulm. Hypoplasia, polycythemia, CHD, sepsis, CHS disorders or metabolic abn(hypocalcemia or hypoglycemia)

104
Q

Persistent Pulmonary Hypertension (PPHN)

Goals

A
  • Older strategy: hyperventilate to PaCO230-35 and pH ~ 7.50
  • New trend is target low/normal PaCO2(35-40) with pH 7.40-7.45
  • Hyperoxygenateto PaO2> 100 mmHg and higher SpO2
  • Nitric oxide therapy

Also, fluids/inotropes for good systemic pressures

PPHN Goals: 7.40-7.45 and CO2 35-40

105
Q

Persistent Pulmonary Hypertension (PPHN)

To Meet These Goals

A
  • Conventional mechanical ventilation
  • HFO
  • HFJV
  • ECMO

Sildenafil sometimes used though CPS doesn’t list PPHN as an indication for the drug

106
Q

Cyanotic Defects

A

Usually require a PDA for survival

Eg.Transposition, Tetralogy of Fallot, Hypoplastic left heart

Prostin– given via IV continuously to maintain PDA

107
Q

Cyanotic Defects

Target ABG

A

Rule of 40’s:

pH 7.40, PaCO240’s, PaO240’s

SpO2 70-80%

žThese mimic in-utero conditions and maintain a PDA

108
Q

Meconium Aspiration Syndrome (MAS)

A
  • Surfactant replacement therapy (+/-)
  • Lung protective strategy
    • Appropriate VT’s
    • Mild hyperventilation (low/normal CO2) andhyperoxygenateto treat concurrent PPHN
    • Peak pressures should be < 25 cmH2O
    • Watch for hyperinflation
    • For more severe cases consider NO, HFO, HFJV, ECMO
    • Avoid acidosis and hypoxemia!
      • (This will increase PVR and potentially cause the development of PPHN)
109
Q

Bronchopulmonary Dysplasia (BPD)= Chronic Lung Disease (CLD)

A
  • Use the lowest FIO2 possible
    • Later stages (confirmed BPD) maintain adequate oxygenation to prevent development of corpulmonale
  • Surfactant therapy
    • Done during the RDS stage…before true BPD
  • Minimize mechanical ventilation
    • Permissive hypercapnia
      • VT4-6 mL/kg
      • Goal pH ≥ 7.25
    • Peak pressures < 25 cmH2O
  • Once stable:
    • Target lower SpO285-88% up to 94%
  • Volume-targeted modes tend to work best for BPD.
110
Q

Pulmonary Interstitial Emphysema (PIE)

A
  • Reduce risk of barotrauma by using minimal ventilatory support
    • Low VT’s (~4 mL/kg) with permissive hypercapnia (pH >7.25) and low pressures ( peak < 25 cmH2O)
  • Position neonate with worst lung down
    • Improves perfusion to promote healing
    • Decreases ventilation to affected lung
  • Severe cases:
    • HFO or HFJV
    • Selective intubation of good lung side
      • Allows affected lung to collapse and heal
111
Q

Congenital Diaphragmatic Hernia

Resuscitation

A
  • Intubate immediately (avoid BVM); gastric tube
  • Use 100% O2from beginning
  • Connect to vent ASAP
112
Q

Congenital Diaphragmatic Hernia

Ventilation Strategy:

A
  • “Gentle ventilation”: AVOID vigorous chest rise
  • Preserve spontaneous efforts (ie. Minimal sedation)
  • Permissive hypercapnia
  • Avoid high pressures (pneumothorax a strong marker for mortality)
  • HFO and NO considered;
  • ECMO in severe cases (often decided antenatally)
113
Q

Congenital Diaphragmatic Hernia

ABG

A

PPHN very likely to coincide!

pH >7.25

Pre-ductal SpO2³85%, though ideal is 90-95%

Use preductal saturations to guide oxygen requirements

Preductal indicates oxygen delivery to the brain and therefore critical; postductalis non-cerebral and therefore less critical

NOTE: These babies have delayed transition from fetal circulation and it may take several hours to attain optimal oxygenation

114
Q

Gentle Ventilation

A

The most important principle in the mangement of CDH

Preservation of spontaneous respirations and avoid neuromuscular blockades uses minimal sedation

Permissive Hypercapnia- No hyperventilation, no induced alkalosis

Avoid high ventilator pressures – pneumothorax can result from high pressures and is a very strong marker for mortality.

115
Q

ABG and Post Ductal

A

Do not use post ductal O2 values to adjust ventilator settings

Use preductal oxygenation to guide oxygen requirements

116
Q

Pre ductal Oxygen Levels

A

Indicate oxygen delivery to the brain via the carotid arteries and is therefore critical.

Ideal is 90-95%

Acceptable is >85% is the baby is otherwise stable (normal lactate levels)

117
Q

Postductal Oxygen Levels:

A

Indicates non-cerebral oxygen delivery and less critical

118
Q

Pediatric ARDS and Asthma

A

Same strategies as adults

119
Q

Cystic Fibrosis

A
  • Non-invasive ventilation the preferred method for ventilatory support
  • Long-term prognosis decreases when patient is placed on conventional mechanical ventilation
  • Pt with end-stage disease should not be intubated
  • Concerns:
    • Obstructive disorder \autoPEEP, hyperinflation…
    • Allow for longer expiratory times!
    • Predisposed to development of respiratory infections
120
Q

Harmful Effects of Mechanical Ventilation

Respiratory Effects

A
  • V/Q mismatching
    • Increased intrapulmonary shunting, increased VD
    • Decreased pulmonary perfusion
  • VILI (ventilator-induced lung injury)
    • Barotrauma,volutrauma, shear stress, atelectatrauma, biotrauma
  • Air-trapping (autoPEEP)
    • Increases risk of VILI
    • Contributes to patient-ventilator dyssynchrony(which leads to increased WOB, increased need for sedation and longer weaning times)
  • Oxygen toxicity
121
Q

Harmful Effects of Mechanical Ventilation

Other systems

A

Renal, Liver, GI, Metabolism, Muscle function

122
Q

Harmful Effects of Mechanical Ventilation

ICP and CPP

A

May decrease CPP 2°to decreased MAP

ICP increases 2°to an increased CVP

123
Q

Harmful Effects of Mechanical Ventilation

Cardiovascular Effects

A

Decreased CO 2° to decreased venous return

Magnitude of effect depends on the transmission of P

Altered R and L ventricular function

124
Q

Ways to Minimize the Harmful Effects

Set Appropriate PEEP

A

Want OPEN LUNG VENTILATION

Want to recruit and prevent de-recruitment (\set above LIP)

Ensure UIP not exceeded during inspiration

125
Q

Ways to Minimize the Harmful Effects

Decrease Ventilating Pressure

A

As most of the harmful effects are a direct result of the positive pressure applied, the goal is to use the lowest minimal pressures (or VT) required

126
Q

Ways to Minimize the Harmful Effects

Appropriate Ti and Te

A
  • Ideally want pressure equilibration on inspiration
  • Allow for complete exhalation to prevent autoPEEP
127
Q

Ways to Minimize the Harmful Effects

Minimize length of mechanical ventilatory support

A
  • Attempt to avoid ventilator dependence
  • Attempt to minimize VILI and BPD
128
Q

Oxygenation in Neonates

A
  • BPD
    • Associated with high concentrations of oxygen, PPV, endotracheal intubation, duration of therapy, fluid overload, degree of pulmonary prematurity…
  • ROP
    • A complication of prematurity
    • Associated with duration of exposure to high PaO2
  • Minimize by:
    • Use lowest FIO2required
    • Make changes in small increments
129
Q

Harmful Effects of Mechanical Ventilation Specific to Neonates

A
  • Intracranial hemorrhage
    • Associated with mechanical ventilation but not necessarily caused by it (may be due to prematurity)
  • Periventricular leukomalacia
    • Softening of the white matter around the ventricles of the brain; associated with hypocarbiain preterm infants
    • Minimize by:
      • Maintain PaCO2at goal level
      • Don’t over-ventilate when bagging! Try to use a vent ASAP after resuscitation.
130
Q

Neonates Patient-Ventilatory Dssynchrony

A
  • Vent not sensing pt. effort
  • Vent not sensing due to leak (ETT)
  • Minimize by:
    • Ideally choose a newer ventilator with patient sensing
    • Tailor the settings to the patient
  • Remember: AutoPEEPwill also cause patient-ventilator dyssynchrony!
    • (This is mostly an adult problem).
131
Q

Neonates Ventilator Induced Lung Disease

A
  • Chronic lung disease (BPD)
    • Associated with prolonged PPV and oxygen toxicity
  • Air-leak syndromes
    • Pneumothorax/pneumomediastinum…
    • PIE (Pulmonary interstitial emphysema)
    • Much less common with today’s goal ventilatory parameters
  • Minimize by:
    • Use lowest pressures/volumes required
    • Wean ventilator settings when appropriate
132
Q
A
133
Q

Respiratory Failure in Infants

A

pH <7.20

PaCO2 >60 mmHg

SaO2 <85% with FiO2 40-70% and CPAP 5-10

This means we should intubate

134
Q

Infants on Mechanical Ventilation who have just been admitted into the NICU

A

Generally a pressure limited mode will be used with a sinsoidal flow

135
Q

Ti and Surfactant Administration

A

If a longer Ti is requires before surfactant administration is should be lowered to 0.3 seconds after the surfactant is administered

136
Q

Neonatal Mechanical Ventilator Modes

A

SIMV or assist control modes can help to reduce WOB and stabilize BP if properly set

Modes are generally volume controlled in order to reduce the risk of volutrauma (important with surfactant administration)

137
Q

Spontaneous Parameters in Neo

A

RR: 30-60

VC: 5-7

Vt:35

Compliance: 25-50

Resistance: 1-2

138
Q

Spontaneous Parameters in Adults

A

RR: 12-20

VC: 65-75

Vt: 4-8

Compliance: 50-170

Resistance: 0.6-2.4

139
Q

Neonatal Initial Ventilator Settings

PIP

A

Set to 15-25

Limit should be set to 30

140
Q

Neonatal Initial Ventilator Settings

Vt

A

3-5 ml/kg

141
Q

Neonatal Initial Ventilator Settings

PEEP

A

3-6 cmH2O

Set to prevent further alveolar collapse

Increases will be made in increments of 1-2 cmH2O

If PEEP reaches 8 then alternative modes should be considered

142
Q

Neonatal Initial Ventilator Settings

RR

A

Start at 50

143
Q

Neonatal Initial Ventilator Settings

Inspiratory Time

A

0.3-0.4

Start at 0.3

Adjust to reach equibrium

144
Q

Adult Ventilatory Parameters

PEEP

A

Start at 5 and aim for optimal PEEP

Increases made in 2-3 increments

145
Q

Ideal Body Weight Calculation

A

Male: 50+ 2.3 ( {Height in inches}-60)

Female: 45.5 + 2.3 ( {Height in inches}-60)

146
Q
A
147
Q

Placement of ETT

A

Below the clavicles

Above carina

~T3 and mid trachea

148
Q

Neonatal Intubation and Pre-Oxygenating

A

Pre oxygenate for 20 seconds before intubation

149
Q

Neonatal Intubation and Suctioning

A

Suction the mouth before intubation to prevent aspiration

150
Q

Intubation of the Neonate and Oxygenating

A

Try to give free flowing oxygen to the neonate durign the intubation attempt without interfering with the intubation

151
Q

When should you aspiration the stomach of a neonate after a successful intubation

A

If BMV was required for longer than 2 min before the procedure

152
Q

International Normalized Ratio

(INR)

A

Normal: 0.9-1.1

Critical: >6

153
Q

How to Shape a Breath

A

Ramp/Rise Time

Will control how quickly the limit is reached

Can affect pt comfort

Will tend to smooth out flow and lower initial peak flow

154
Q

Tube Compensation

A

Automatic tube compensation will helps by adding pressure support when weaning

WOB is directly related to size of ETT and MV

Clinicians will enter tube type and internal diameter which will nullifie the resistance imposed on the airway

Will be similar to PS in that an inspiratory pressure is used to compensate for imposed WOB

Different from PS in that TC varies the pressure depening on tube size and inspiratory flow

155
Q

Tube Compensation on 840

A

TC

Tube Compensation

156
Q

Tube Compensation on GE

A

ARC

Airway Resistance Compensation

157
Q

Tube Compensation on Hemilton G5

A

TRC

Tube Resistance Compensation

158
Q

Tube Compensation on Evita

A

ATC

Automatic Tube Compensation

159
Q

How is Tube Compensation Calulated

A

Ptrachea= Paw-KTube x Flow2

160
Q

Potential Benefits from Tube Compensation

A

Increase patient comfort over Pressure Support

Accurately predict readiness for extubation

Reduce risk of air trapping cause by expiratory resistance-Some allow inspiratory and expiratory compensation

161
Q

Volume Support

A

Spontaneous Mode that is pressure limited and volume targeted

Flow cycled

162
Q

Mandatory Minute Ventilation

A

MMV you set a MV so if the pt is not reaching the MV on their own the the vent will kick in to help

Guarantees a minmum MV even though a pts spontaneous ventilation may change

If the pt maintain MV above set MV then this mode functions like CSV-PS

If the pt MV falls below the set MV only then will mandtory breaths be dleivered

163
Q

How Mandatory Minute Ventilation Works

A

A MV is set indirectly via RR and Vt

If the patient breaths above MV than all breaths are pressure support breaths

If the patients MV falls below the set MV then the vent will delvier manadatory breaths at a set Vt to make the total MV

164
Q

Porportional Assist Ventilation

A

Used to assit spontaneous ventilation

the breath delivered is similar to PS but the pressure support level delivered is variable and porportional to spontaneous effort

The harder the pt works the more support the vent delivers and vice versa)= POSITIVE FEEDBACK

165
Q

Porportional Assist Ventilation and E Sensitivity

A

E Sensitivity set at 27% (27% of inspiratory peak flow)

Pressure support patient trigger pressure limited flow cycles (flow cycle=e sensitivity)

You will never get equilibrium on a pressure support breath

166
Q

How to manipulate tidal volume with e sensitivity

A

decrease portional will increase tidal volume and Ti unless the patient is air hungry and try to breath in more at a higher peak volume then it will cut off faster and they will get a lower breath

167
Q

What will happen to tidal volume if you decrease the resistance in pressure control

A

Volume will stay the same and Tidy will get shorter

What will happen to tidal volume if you decrease the compliance in pressure control

Decrease TC and Ti dyn and volume will go down

168
Q

ARDS Net Weaning

Oxygenation

A

FiO2 <0.40 and PEEP <8 OR

FiO2 <0.5 and PEEP <5

PEEP and FiO2 less than the previous day with spontaneous breathing

169
Q

ARDS Net Weaning

Other

A

Systolic BP >90 mmHg w/o vaso pressor

No neuromuscular blockade

170
Q

ARDS Net ABG Goals

A

7.30-7.45

171
Q

All of the following will confirm tracheal ETT placement in neonates except

a. Persistent cyanosis and bradycardia
b. Bilateral breath sounds over the chest
c. Decreasing HR
d. CO2 of 28 on CO2 detector
e. Both A and C

A

Both A and C

Persistant cyanosis and bradycardia may mean that the ETT is not in the correct placement

Bilateral breath sounds can confirm placement

Decreasing HR can confirm they neonate is getting good respiratory support but is not a confirmation for placement

Even though the CO2 is not that high we are getting a reading which means that it is in the trachea

172
Q

ARDS Net

How to check Pplat

A

0.5 seconds inspiratory pause

Should be checked q 4h and after each change in PEEP or Vt

173
Q

ARDS Net

Pplat > 30 cmH2O

A

Decrease Vt by 1 ml/kg

Minumum 4 ml/kg

174
Q

ARDS Net

Pplat <26 cmH2O and Vt <6

A

Increase Vt by 1 ml/kg until Pplat is >25 cmH2O or Vt 6 ml/kg

175
Q

ARDS Net

Pplat <30 cmH2O and Breath stacking or dsy-synchrony is occuring

A

May increase Vt by 1 ml/kg incrememts to 7-8 ml/kg

As long as Pplat remains <30 cmH2O

176
Q

PaO2/PAO2

A

Assess WOB and Oxygenation

Normal: 0.75-0.85

Critical: <0.15

177
Q

ARDS Acidosis Mangement

A

pH<7.30

Increase RR (max 35)

178
Q

ARDS <7.15

A

Increase RR to 35 and if still <7.15 Vt can increase by 1 ml/kg

May give NaHCO3

179
Q

ARDS Alkalosis Mangement

A

Decrease RR

180
Q

ARDS Net Spontaneous Breathing Trial

A

T-Piece, Trach collar, or CPAP <5 with PS <5

181
Q

ARDS Net Spontaneous Breathing Trial

Assess for tolerance

A

SpO2 > 90% and/or PaO2 >60 mmHg

Vt> 4 ml/kg

RR <35

pH>7.3

No respirtory distress

If tolerated for 30 min consider extubation

182
Q

ARDS Net Spontaneous Breathing Trial

Respiratory Distress

A

HR >120% baseline

Accessory muscle use

Abdominal paradoxus

Diaphoresus

Dsypnea

183
Q

AHS Exclusion from Extubation Pathway

A

Head injury, unstable spinal injury, inotropes and vasopressors, or planned surgery

Head and spinal injuries are relative contraindication and they can still be extubated with dr orders

184
Q

AHS Spontaneous Trial Readiness

A
  • Resolution of disease
  • Adequate oxygenation
    • PaO2 >60 mmHg
    • P/F > 200
    • SpO2 >90%
    • PEEP <5
    • FiO2 < 0.4
  • No uncompensatory respiratory acidosis
  • HR <140
  • GCS >13
185
Q

AHS Initiation of SBT

A

Place pt on PSV of 7 and PEEP of 5 unless there is automatic tube compensation which you put PSV to 0

in first 5 minute monitor tobin score (>105), sweating, anxiety, mental status, SpO2 >90%

If any negative changes occur increase PSV and inform physician

186
Q

Tobin Score

A

Also known as rapid shallow breathing index

= (RR)/ (Vt)

An RSBI < 105 breaths/min/L has been widely accepted by healthcare professionals as a criteria for weaning to extubation.

Whereas patients with RSBI > 105 will have a high chance of failure and require re-intubation.

187
Q

AHS Continue SBT

A

for pt who are ventilated for <72 hours continue SBT fot 30 min

For pt who are ventilated >72 hours continue SBT 60-120 min

Monitoring should be done first 5 min and the Q15 after

188
Q

You are ventilating an adult patient in the mode VC-CMV using a decelerating flow waveform. If you switch to a square flow waveform, which of following would occur?

The I:E ratio to increase

.The PIP to increase

The risk of air trapping

Tidal volume to increase

A

.The PIP to increase

189
Q

Cord Clamping

A

Try to delay clamping the cord for at least 60 seconds

If not possible cord milking is a reasonable alternative

190
Q

European Consensus and Delivery Room Oxygenation

A

Oxygen for resusucitation should be controlled via a blender

An initial concentration of 30% oxygen is appriopraite of babies <28 GA

For babies that are 28-10 week use an FiO2 of 21-30

191
Q

European Consensus and Spontaneous Breathing Babies

A

In spontaneous breathing babies stabilize babies with CPAP at 6 cmH2O via mask or nasal prongs

192
Q

European Consensus and Plastic Bags

A

Plastic bags or occlusive wrapping under radient warmer should be used during stabilization in babies <28 weeks

193
Q

European Consensus Saturation Goals

A

Saturation goals should be 90-94%

194
Q

European Consensus

Indications for CPAP

A

RDS

< 30 weeks gestation when intubation is not needed

195
Q

European Consensus CPAP Interface

A

The interface should short binasal prongs or mask with a starting pressure of 6-8cmH20

CPAP pressure should then be individualized based on oxygenation and ventilation

196
Q

Optimal Mangement for RDS

A

CPAP with early rescue surfactant should be considered optimal management for babies with RDS

197
Q

Synchronized NIPPV

A

Synchronized NIPPV if delivered through a ventilator rather than a bilevel CPAP device can reduce extubation failure, but may not confer long-term advantages such as reduction in BPD

198
Q

Alternative to CPAP in Weaning

A

HF may be used as an alternative to CPAP for some babies during weaning phase

199
Q

Mechanical Ventilation in Neonates European Consensus

A

Target tidal volume should be used to shorten time on mechanical ventilation

200
Q

European Consensus and Weaning

A

When weaning from MV it is reasonable to tolerate a modest degree of hypercarbia provided pH >7.22

Caffeine should be used to facilitate weaning from MV

A short tapering course of low dose dexamethasone should be considered to facilitate extubation in babies who remain on MV after 1-2 weeks

201
Q

AHS CPAP in Delivery Room

Gestation 25-28 Weeks

Principals

A

Maintain optimum lung volume and FRC in order to avoid de-recruitment and overdistension

in L&D and acute phase avoid CPAP >6

Infants >28 weeks will be intubated by a senior practitioner

“Early surfactant” does not mean “immediate surfactant”

202
Q

AHS CPAP in Delivery Room

Gestation 25-28 Weeks

Initial Steps

A

Clear airway and CPAP at +5

If the baby is not spontaneously breathing or has a HR under 100 begin PPV

If there is mild WOB with SpO2 then maintain CPAP level and move to NICU

If there is more severe WOB or SpO2 is not in range than increase CPAP by 1 and increase FiO2 by 0.10-0.20 to achieve SpO2

If the above did not help consider intubation

203
Q
A
204
Q

NRP Indications for PPV

A

Apnea

Gasping

HR less than 100

Oxygen saturadtion below target range

Intreventions 2 (19 decks)

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