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Question 1

List 5 causes of increased PEEP

Answer 1

Increased resistance - kinks, mucous plugs, bronchospasm
Increased compliance- emphysema
Increased minute ventilation, low expiratory time

Question 2

How is Peep measured on a ventilator?

Answer 2

End expiratory pause maneuver

Question 3

What are the signs of AutoPEEP on a ventilator

Answer 3

• Increasing End expiratory pressure on pressure tracing
• Flow signal does not reach zero before next breath
• Progressive increase in end exp volume - dynamic hyperinflation

Autopeep= Positive end expiratory pressure that develops within the alveoli due to inadequate expiratory time or airway collapse during expiration

Question 4

List the negative concequenses of excessive PEEP

Answer 4

1. Increase risk of barotrauma and volutrauma on alveoli
2. decreased venous return
3. Increase afterload to RV and LV
4. poor CO2 clearance
5. Higher deadspace fraction, less effective TV (poorer oxygenation)
6. More work to produce flow

Question 5

List 5 ways to manage Auto-peep

Answer 5

1. Increase expiratory time and I:E ratio to 1:3-1:4
2. Increase inspiratory flow
3. Relieve obstruction - bronchodilators
4. Decrease breathing frequency if using a set rate
5. Increase sedation or add paralytics to drop breathing rate and improve syncrony with ventilator
6. Use ventilator generated PEEP at 80% autopeep to maintain flow

All else fails or arrests? Disconnect and decompress

Question 6

List the Berlin ARDS criteria

Answer 6

1. Bilateral Pulmonary edema on CXR
2. Echo showing LV with normal EF
3. Acute onset of known clinical Insult

Mortality - PF <300 - 27% ; PF<200 -32% PF <100- 45%, measured at a PEEP of 5

Question 7

List the pathologic stages of ARDS

Answer 7

1. Exudative - Diffuse alveolar damage
2. Fibroproliderative - collagen, myofibroblasts
3. Fibrotic - loss of architecture, cyst formation

Question 8

Diagnosis of Carbon monoxide poisoning

Answer 8

Carboxyhemoglobin level > 3% on arterial blood gas ( in a non-smoker). PaO2 N, O2 Sat normal (FOOLED)

clinical signs - Cherry red veins, altered LOC, acidosis

Mgmt : 100% fiO2, supportive care for aLOC (ventilation if needed)

Hyperbaric Oxygen therapy : CoHB > 25%, end organ damage (angina, renal failure, altered LOC), PH <7.1

Question 9

List 4 early and 4 late complications of tracheostomy

Answer 9

Early : Bleeding, Pneumothorax, Pneumo-medistinum, recurrent larygneal nerve injury

Long: tracheal stenosis, T-E fistula, tracheomalacia, infection

Question 10

What are three criteria for Trach decannulation

Answer 10

1. Effective cough
2. Secretion control
3. No upper airway obstruction

Question 11

List 5 ways to manage ards not on the ventilator

Answer 11

1. Improve synchrony, minimize VILI - sedation
2. Fluid management and supportive care
3. Prone positioning
4. Ecmo
5. Inhaled vasodilators