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Respiratory > Interventions (Initiation and Modification) > Flashcards

Interventions (Initiation and Modification) Flashcards

1
Q

Incentive Spirometer Indications

A

-PREVENT ATELECTASIS (only in conscious patients)
-Help post-operative patients achieve their pre-operative values
-MOST HELPFUL AT PREVENTING PULMONARY COMPLICATIONS

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2
Q

Indications to use IPPB

A

-Decreases work of breathing
-Helpful post-operatively for UNCONSCIOUS PATIENTS or patients who are too sedated to perform incentive spirometry
-Correct and/or prevent ATELECTASIS
-Improve cough effectiveness
-Provide bronchodilation (mechanical)
-Mobilize secretions
-Deliver medications (increase favorable deposition)
-Treat/prevent pulmonary edema

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3
Q

What are reasons IPPB is not used?

A

-untreated pneumothorax
-current pulmonary hemmorhage
-active tuberculosis

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4
Q

IPPB

A

-Used as a therapy to improve ventilation but can also provide complete ventilation
-The problem is that ventilatory support by mask is only effective during the therapy. Patient may have a return of ventilatory problems when the treatment is over.

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5
Q

Non-invasive ventilation or NIPPV

A

-it is done by mask
-may be provided without a rate (pt must initiated all breaths)
-MOST helpful at preventing the need for full, invasive, mechanical ventilatory support

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6
Q

NIV is ideal for:

A

-COPD: to avoid long term dependence on invasive mechanical ventilation
-assisting ventilation temporarily

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7
Q

How does NIV assist with ventilation temporarily?

A

-it provides ventilatory assistance while sedation wheres off or diuretics have a chance to take effect
-helpful when a pt has a condition that makes it hard for them to breathe such as: fluid overload, sedation onboard, bronchoconstriction
-Helpful at blowing off a littel PaCO2 that has not yet reached a level consistent with ventilatory failure (pH < 7.25)

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8
Q

Although a patient may have only slightly elevated CO2 and may benefit from NIV, if the patient is unable to protect his or her own airway, what is preferred?

A

intubation and mechanical ventilation is preferable

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9
Q

What are NIV key settings?

A

-IPAP
-EPAP
-Rate is not typically part of non-invasive ventilation, HOWEVER, most Bi-Level machines come with the ability to provide a backup rate.
-Oxygen may be set on the machine or given by bleed-in from a flow meter.

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10
Q

IPAP

A

inspiratory positive airway pressure, primary control used to blow off CO2.

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11
Q

EPAP

A

expiratory positive airway pressure – like PEEP or CPAP – used primarily to address oxygenation.

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12
Q

How is the amount of ventilation determined in NIV mode?

A

The amount of ventilation is NOT determined by the IPAP pressure setting alone. RATHER it is determined by the distance between the IPAP and EPAP pressure settings.

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13
Q

INITIAL NIV (BIPAP, BiLevel) SETTINGS

A

-IPAP 10-12 cm H2O
-EPAP 4-6 cm H2O

-FIO2 as low as possible to maintain an SpO2 of 90% or greater

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14
Q

When should you choose invasive (intubated) ventilation?

A

-pH <7.25 due to rising CO2 values (not because of diabetic ketoacidosis)
-Patient is unable to protect his or her airway (even if pH not yet 7.25 or less)

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15
Q

You should intubate if the patient?

A

-Unconscious or comatose
-Unable to follow commands or instructions
-Patient is confused or disoriented.
-Is described as obtunded
-Shows evidence of aspiration or has a history of it
-Has neck trauma with unknown anatomic changes

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16
Q

Choose non-invasive (non-intubated) ventilation if

A

-Patient has not yet reached complete ventilatory failure (pH of 7.25 or less)
-pH is between 7.26 - 7.32 due to rising PaCO2 (increasing ventilation deficiency).
-The patient is able to cough on command and is able to expectorate.
-Patient is NOT disoriented or confused.

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17
Q

What are indications of full ventilatory support?

A

-acute ventilatory failure (High PaCO2, pH < 7.25)
-impending ventilatory failure
-observed cessation of breathing

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18
Q

How is impending ventilatory failure determined?

A

-Determined by serial ABGs
-Shows a degradation of ventilation (climbing PaCO2, decreasing pH)
-Do not wait until absolute ventilatory failure – look for a downward trend.

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19
Q

Initiation of mechanical vent settings:

A

-Rate: 10-20/min
-FIO2: 30-60% (100% if pt requires mechanical ventilation due to an emergent situation; may use previous FIO2 if pt was receiving O2 by mask
-Peep: 4-6cm
-VT: 6-10ml/kg
-Minimum flow: 40-60L/min

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20
Q

Things to known about PEEP

A

-therapeutic PEEP starts. at 10
-If the patient was receiving any end-expiratory pressure, should set the initial PEEP to match the CPAP level or the EPAP level if BiLevel is in use.
-Used to treat refractory hypoxemia.
-If the patient has ARDS, then PEEP is a primary treatment. An initial PEEP setting of 10 cm H2O is appropriate.

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21
Q

Volume-controlled (VC)

A

best for patient who have a problem inside the lung(s)

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22
Q

Pressure-controlled (PC)

A

best for patient who have problem outside the lungs or have low pulmonary compliance (ARDS and ALI)

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23
Q

SIMV

A

preferred mode because it is most comfortable to the patient.

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24
Q

A/C

A

second best mode

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25
Q

PSV

A

pressure support ventilation is suitable if the patient can breathe on their own but only needs of a small amount of assistance by increasing their spontaneous tidal volume size (elevated PaCO2 but pH between 7.28 and 7.35)

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26
Q

Ventilator Minimum Flow Calculation

A

Step 1: Add I:E ratio
Step 2: Multiply the minute ventilation X (I+E)

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27
Q

Complications associated with positive pressure ventilation:

A

-Decreased venous return
-DECREASED URINE OUTPUT- MOST LIKELY THING TO HAPPEN
-Loss of dignity (due to inability to talk)
-Development of ventilator dependency

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28
Q

What is the central objective for a patient on mechanical ventilation?

A

TO GET THEM OFF THE VENTILATOR

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29
Q

What are the weaning parameters?

A

-All vitals stable
-ABGs are good and within normal values
-VT: at least 5ml/kg
-VC: at least 10mL/kg
-MIP > 20 cm H20
-QS/QT (shunt) must be 20% or less
-Vd/VT must be 60% or less
-A-a(DO2) must be less than 300 mm Hg
-RSBI < 106
-Underlying issue must have been resolved

30
Q

Dynamic Compliance

A

-Usually associated with INCREASED airway resistance (RAW)
-Suction if sputum is present
-Give bronchodilator if wheezing

31
Q

Pulmonary compliace:

A

Refers to the pliability or stiffness of the lung tissue. This is also referred to
as elastance

32
Q

What does a Lack of compliance (poor pulmonary compliance) indicate?

A

stiff lungs, which requires greater pressures to ventilate and causes increased work of breathing for patients breathing spontaneously

33
Q

How is pulmonary compliance measured?

A

plateau pressures may be evaluated to determine the degree of lung compliance

34
Q

As plateau pressures climb, lungs are becoming less or more compliant (stiffer)?

A

LESS

35
Q

What are considered normal plateau pressures for a normal pt?

A

10-20 cm H2O

36
Q

What does it mean if plateau pressures approach 30-35 cm H2O?

A

the patient is likely in need of a special ventilator modes such as Pressure Control

37
Q

STATIC COMPLIANCE

A

Pulmonary compliance as determined by the plateau pressure

38
Q

What does a decrease in compliance indicate?

A

stiffening of lungs

39
Q

How is a decrease in compliance treated?

A

With PEEP

40
Q

If PIP may increase because of increased airway resistance it is
SHOWN BY?

A

an INCREASE IN PEAK PRESSURE ONLY
Ex:
~secretions in the airway
~kinked ET tube
~excess water in the ventilator circuit
~bronchoconstriction (wheezing)

41
Q

If PIP may increase due to decreasing lung compliance (lungs becoming stiff) it is
SHOWN BY?

A

An INCREASE IN PLATEAU PRESSURE AND PEAK PRESSURE
Ex:
~ARDS
~pulmonary fibrosis
~pulmonary edema
(if pulmonary compliance is changing – get a chest x-ray)

42
Q

Mean airway pressure (Paw) Normal:

A

5-10 cm H2O

43
Q

When to change mode from A/C or SIMV to Pressure Control (PC)?

A

-The patient’s lungs are becoming stiff (non-compliant)
-Peak ventilatory pressures rise above 50 cm H2O due to a change in compliance (increase in plateau pressures)

44
Q

Do not change to PC ventilation if?

A

if the patient’s elevated peak pressures are merely the result of secretions in the airway, bronchoconstriction, or from the patient biting on the airway. Those types of issues are temporary and can be solved by other means (ie, suctioning, giving a bronchodilator, or offering sedation)

45
Q

Change from A/C to SIMV mode when?

A

-The patient is “bucking the ventilator” due to being alert and uncomfortable.
-The patient is ready to wean from the ventilator slowly (like a COPD patient).
-Sedation is being discontinue to allow the patient to awaken. SIMV is more comfortable to awaken to.

46
Q

Increase TIDAL VOLUME if PaCO2 is off range by a small amount.

A

1) Choose this option if PaCO2 values are, for example, 46, 47, 48, 49 mm Hg
2) Remember, the tidal volume must remain inside the range for the patient’s ideal body weight.

47
Q

Increase RATE if PaCO2 is off range by a lot.

A

Choose a rate increase if PaCO2 is 49 mm Hg or higher.

48
Q

Remove DEADSPACE if PaCO2 needs to be changed by only

A

1 or 2 mm Hg

49
Q

Decrease VENTILATION by:

A

-Decreasing VT if PaCO2 if off by just a few points (31-34 mm Hg)
-Decrease RATE if PaCO2 is off by more than 4 mm Hg (30 mm Hg or less)
-Add DEADSPACE to adjust PaCO2 by 1 or 2 mm Hg

50
Q

How do you fix oxygenation on the ventilator?

A

Step 1: Look at FIO2 and PEEP
Step2: Adjust FIO2 1st up to 50-60%
Step3: Then increase peep

51
Q

When do you increase the FIO2?

A

When the PaO2 is less than 80mm Hg, and the current FIO2 is less than 60%. If the FIO2 is already at 60%, then increase PEEP. Cardiac output is at least at 4L/min.

52
Q

When do you decrease the FIO2?

A

When the PaO2 is above 100 mmHg and the current FIO2 is 60% or greater.

53
Q

When should you decrease PEEP?

A

When the PaO2 is above 100mmHg and the current FIO2 is 55% or less.

54
Q

When should a patient who has no pulmonary complications start weaning?

A

as soon as they wake

55
Q

When should an ABG be drawn following the removal of ventilatory support?

A

20-30mins

56
Q

What is the most important alarm to use if a patient is paralyzed?

A

Low PEEP alarm

57
Q

How to determine tube size?

A

patients weight in kg/ 10

58
Q

How is proper tube positioning determined?

A

-FIRST – examine chest movement and symmetry
-FIRST (alt) may also use a capnometer or color-changing CO2 detector (EZ Cap®)
-SECOND – listen for bilateral breath sounds
-THIRD – obtain a chest x-ray for confirmation

59
Q

When is nasal intubation used?

A

if the patient will remain awake

60
Q

What do you do if a patient has severe stridor?

A

immediately intubate the patient

61
Q

What do you do if a patient has moderate stridor?

A

consider racemic epinephrine aerosol treatment

62
Q

What do you do if a patient has mild stridor?

A

cool mist and /or racemic epinephrine and close observation

63
Q

Assessment of positioning determining position: (in order)

A

-Look at chest rise (expansion) – VISUAL (Level I)
-Auscultate for bilateral sounds - BEDSIDE (Level II)
-Chest X-ray – LABORATORY (Level III)

64
Q

Suctioning Procedure

A

-Hyper oxygenate with 100% oxygen for 1-2 minutes
-Remain sterile (use gloves or an in-line closed suction catheter)
-Suction no longer than 15 seconds. (less if signs of distress are witnessed)
-Immediately stop suctioning if any signs of distress are present (cardiac and otherwise)
-Oxygenate with 100% after the procedure

65
Q

To increase suction effectiveness with thick secretions:

A

-Consider increasing the diameter of the catheter (higher French), but stay within limits - no more than 1/2 the internal diameter of the artificial airway.
-Increase suction pressure (but stay within the limit (ie 100-120 mm Hg for an adult, 80-100 mm Hg for a child, etc)
-Instill 5-10 cc normal saline to hydrate secretions
-Instill Mucomyst (Acetylcysteine)

66
Q

Indicated when a long-term airway is needed:

A

-Reduces airway resistance
-Helpful in difficult weaning situations
-Good for long-term ventilatory support

67
Q

Inflatable cuffs should be INFLATED only:

A

-During positive pressure ventilatory support
-During positive pressure treatment (IPPB)
-When patient is eating
-When there is an established risk for aspiration AND there is anything in the stomach (tube feeding, etc)

68
Q
A
68
Q

Holes in the outer cannula allows air to pass through the tube, past the vocal cords to facilitate speech while the patient is intubated. For this to happen:

A

-The cuff must be deflated
-The inner cannula must be removed
-A cap must be placed over the tracheostomy tube to direct exhaled air over the vocal folds
-When the trach tube is configured to allow speech, this is called a speaking configuration. (cuff deflated, inner cannula removed, button or cap placed)

68
Q
A
69
Q
A
69
Q
A

Respiratory (2 decks)

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