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PHTY3250 > L15-16: Mechanical Ventilation > Flashcards

L15-16: Mechanical Ventilation Flashcards

1
Q

What are the 3 principles of mechanical ventilation?

A
  1. Positive pressure ventilation involves delivering mechanically generated ‘breath’ to get O2 in and CO2 out
  2. Gas pumped in during inspiration (Ti) and patient passively expires during expiration (Te)
  3. Sum of Ti and Te is respiratory cycle or ‘breath’
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2
Q

_______ involves delivering mechanically generated ‘breath’ to get O2 in and CO2 out

A

Positive pressure ventilation

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3
Q

Gas pumped in during _____ and patient ______ during______

A

inspiration (Ti); passively expires; expiration (Te)

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4
Q

What are 4 indications for mechcnical ventilation?

A
  1. Respiratory failure ie Type I or II
  2. In patients who are at risk of respiratory failure due to unsustainable levels of cardiac work or work of breathing
  3. Major insult to body eg burns, head injury, multi-trauma, tetanus, sepsis – allows oxygen used for breathing to be diverted to other organs
  4. Airway protection or large secretion load
  5. Spontaneous ventilation inadequate to maintain gas exchange
    1. Defined as PaO2 < 60mmHg and PaCO2 > 49mmHg
  6. Other symptoms taken into account
    1. Eg ↑ WOB, accessory muscle use, sweating ++ ↑ HR, ↑ RR, ↑ BP, confusion, aggression, secretions
    2. If critically ill, metabolic cost of breathing increases to 30% from 5% in normal person
    3. “End of Bedogram”
  7. Condition must be reversible
  8. Will never get off mechanical ventilator –> so this needs to be considered carefully
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5
Q

What are 6 effects of mechanical ventilation?

A
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6
Q

What are the 2 types of mechnical ventilation?

A

Non invasive vs Invasive

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7
Q

What is invasive mechanical ventilation?

A

Invasive means they are intubated with either an endotracheal tube or tracheostomy

  • Need some sedation to tolerate tube (endo or trachy)
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8
Q

What is non-invasive mechanical ventilation?

A

Non invasive ventilation means the positive pressure breaths are delivered by a tight fitting mask.

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9
Q

Sicker patients will have _____ ventilation

A

Invasive

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10
Q

What are postitive pressure ventilators?

A
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11
Q

What are the 3 modes of mechanical ventilation (depending on how much the patient is in control)?

A
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12
Q

What are 5 charcateristics of controlled mandatory ventilation as a mode of mechanical ventilation?

A
  1. Control mode: Set number of breaths/min
  2. No spontaneous breaths
  3. Requires heavy sedation ± paralysing agents
  4. Usually only in Theatre, tetanus, severe head injury
  5. Causes respiratory muscle weakness & ? infection
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13
Q

What are the 3 indications of Synchronised intermittent mandatory ventilation (SIMV) as a mode of mechanical ventilation?

A
  1. Used in most patients
  2. Set respiratory rate, ↓ as patient improves
  3. Weaning from mechanical ventilation
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14
Q

What are the 3 advantages of Synchronised intermittent mandatory ventilation (SIMV) as a mode of mechanical ventilation?

A
  1. Improved comfort, synchronised mandatory breaths.
  2. No breath stacking.
  3. Reduced respiratory muscle atrophy as some spontaneous ventilation
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15
Q

What are the 3 types of breathes of synchronised intermittent mandatory ventilation (SIMV) as a mode of mechanical ventilation?

A

Breaths - controlled (C), assisted (A) or spontaneous (S)

  1. Controlled mandatory breaths - triggered and delivered by the ventilator according to prescribed settings
  2. Assisted breaths - triggered by Pt, assisted by Ventilator give characteristics of controlled (C) breath – this occurs if a controlled breath is due – looks the same shape as a controlled breath
  3. Spontaneous breaths - triggered by Pt, assisted by ventilator (with PS) but volume not controlled.
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16
Q

What are patient triggered breaths?

A
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17
Q

What are 6 adjuncts to ventilators?

A
  1. Positive end expiratory pressure
  2. Pressure support
  3. Flow-by
  4. Humidification
  5. Nebuliser
  6. Peak flow
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18
Q

What are 4 advantages to postitive end expiratory pressure (PEEP) as an adjunct to ventilators?

A
  1. Reduces bronchiolar and alveolar collapse ie holds them open at end of expiration
  2. Increases FRC
  3. Allows lower FiO2
  4. Reduces shunting

Continuous exchange (due to half open bronchioles when using PEEP)

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19
Q

What are 2 disadvantages to postitive end expiratory pressure (PEEP) as an adjunct to ventilators?

A
  1. Reduces cardiac output (Stops venous return to heart)
  2. Increases airway pressure

Increase oxgyen but decrease blood pressure

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20
Q

What does PEEP look like?

NOT IN EXAM

A
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21
Q

What are 3 (3) characteristics of pressure support as an adjunct to ventilators?

A
  1. Augmented pressure during spontaneous breaths
    1. ↓’s work of breathing (WOB)
    2. ↑ tidal volume
    3. As pt initiates breath, PS “lifts up” the breath
  2. Patient regulates own tidal volume and respiratory rate
  3. Like being in the ocean
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22
Q

What are 3 characteristics of humidifier as an adjunct to ventilators?

A
  1. Airway bypasses natural filtering and humidification
  2. HME Humidifier moisture exhangers – for short term ventilation
  3. Electric humidifier – for long term, can overheat, catch fire, become water logged
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23
Q

What are 2 types of accessory modes as an adjunct to ventilators?

NOT IN EXAM

A
  1. Flowby (Helps with getting air up)
    1. Continuous baseline flow
      1. reduces dead space
      2. reduces WOB to trigger a breath
  2. Nebuliser (Eg. ventalin or antibiotics)
    1. Can administer aerosols during ventilation
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24
Q

What is flow by as a types of accessory modes as an adjunct to ventilators?

NOT IN EXAM

A

Continuous baseline flow

  1. reduces dead space
  2. reduces WOB to trigger a breath
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25
Q

What is nebuliser as a types of accessory modes as an adjunct to ventilators?

NOT IN EXAM

A

Can administer aerosols during ventilation

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26
Q

What are 5 characteristics of peak flow as an adjunct to ventilators?

A
  1. How quickly flow enters lungs
  2. How steep curve is
  3. COPD patients prefer high peak flow ie fast breath in
  4. Variable between patients even normals
  5. Slower ie lower peak flow favours recruitment ie slow breath has laminar flow
    • Slow laminar flow (slow inspiration) is better
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27
Q

What are 4 characteristics of pressure support with PEEP as a mode of ventilation?

A
  1. One of most commonly used modes
  2. Full spontaneous mode
  3. Patient triggered breaths only
  4. No set tidal volume (VT)
  • Cannot set rate or tidal voluming (done by patient)
  • Less sedation and more spontaneous breathing
    • Can exercise
    • Less infection (more pneumonia and DVT with more sedation and sedentary behaviour)
    • Less muscle atrophy/wasting
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28
Q

Why do we prefer patient to be spontaneously breathing?

A
  1. Less disuse atrophy of respiratory muscles
  2. Decreased weaning time
  3. Less need for sedation
  4. Less sedation – can exercise and mobilize more easily
  5. Less infection eg ventilator associated pneumonia
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29
Q

What are 2 characteristics of volume controlled ventilation? What are 4 (3) other characteristics?

A
  1. Controlled mechanical ventilation
  2. Synchronized intermittent mechanical ventilation
  3. Set tidal volume – breath cuts off at set volume
  4. Set flow rate (high VS low)
  5. Set respiratory rate ie how many breaths/minute
  6. Variable pressure – PIP peak inspiratory pressure
    1. If stiff lung high pressure
    2. If compliant lung low pressure
    3. If PIP > 35cmH2O high – stiff lung
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30
Q

What are 8 characteristics of pressure controlled ventilation?

A
  1. Set inspiratory pressure – breath cuts off at set pressure
  2. Set respiratory rate
  3. Set inspiratory time
  4. Variable flow - flow synchrony
  5. Variable tidal volume – will reflect how stiff lung is
  6. Improved recruitment – long time constants, so beneficial for lung with uneven atelectasis
  7. Better for patients with high flow requirements or where lung will be easily damaged by high pressure
  8. Used in paediatrics, severe asthma, COPD
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31
Q

What is the difference between pressure support and pressure control?

A

Pressure support = adjunct (for spontaneous breathing

Pressure controlled = type of method

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32
Q

What is volume vs pressure control?

A
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33
Q

What are 4 characteristics of volume control?

A
  1. Tidal volume preset
  2. RR set
  3. Airway Pressure is Variable
  4. When reaches preset TV breath cuts off
34
Q

What are 4 characteristics of pressure control?

A
  1. Inspiratory Pressure preset
  2. RR set
  3. Tidal Volume is Variable
  4. When reaches preset pressure breath cuts off
35
Q

What are 10 characteristics of assessment prior to PT with ventilated patient?

A
  1. Check mode eg SIMV
  2. Accessories eg PEEP, Pressure support
  3. If on Pressure controlled ventilation check pressure limit,
  4. Inspiratory:Expiratory ratio (I:E) ratio
  5. Check Tidal volume (Vt) and respiratory rate (RR) - patient and machine – will tell you how much patient is doing vs machine
  6. Check expiratory tidal volumes - should be equal to set tidal volumes
  7. Minute ventilation
  8. Check Peak inspiratory pressure – amount of pressure required to deliver set volume
  9. Check FiO2
  10. Alarms, alarm limits
36
Q

What is the peak inspiatory pressure (PIP) VS Plateau pressure (Pplat)?

A
37
Q

What are 9 things you can set and control in regards to the settings on the ventilator?

A
  1. Mode, ie CMV, SIMV
  2. Level of FiO2
  3. Tidal volume (if volume cycled)
  4. Pressure (if pressure cycled)
  5. Respiratory rate
  6. I:E ratio
  7. PEEP, Pressure support
  8. Flow By
  9. Peak Flow
38
Q

What are 5 things you cannot set and control (but should observe) in regards to the settings on the ventilator?

A
  1. Peak inspiratory pressure (if volume controlled)
  2. Volume (if Pressure controlled)
  3. Mean airway pressure
  4. Minute volume (TV x RR)
  5. Paw – airway pressure
39
Q

What is the perfect clinical progression of post-operative abdominal surgery?

A
  1. Admitted to ICU post-operatively & ventilated for high risk factors
  2. In OT – totally anesthetized – controlled mandatory ventilation
  3. Day 1 – SIMV with PEEP + Pressure support – ceasing sedation gradually
    1. 14 breaths/min  2 breaths/min
    2. TV8mls/kg/ PEEP 5cmH2O/PIP 22cmH2O FiO2 0-.4 (Compliant lungs)
  4. Day 2 – Stop sedation – Pressure Support/PEEP only
    1. PS 10cmH2O/PEEP 5cmH2O
    2. Taking 15 breaths/min
    3. TV – 650mls
  5. EXTUBATED
40
Q

What is the poor clinical progression of 60 yo female - Severe COPD + Bullae?

A
  1. Admitted to Emergency with severe exacerbation of COPD
  2. Bullae in lung
  3. pH 6.9 PaO2 60 PaCO2 85 HCO3 22
  4. Need to control inspiratory pressure
41
Q

What are 10 advanced ventilation techniques?

NOT IN EXAM

A
  1. BiLevel
  2. Inverse ratio ventilation
  3. Permissive hypercapnia
  4. Proportional assist ventilation (PAV)
  5. Airway Pressure release Ventilation (APRV)
  6. High frequency ventilation (HFPPPV)
    1. high frequency jet ventilation
    2. high frequency oscillation
  7. Independant lung ventilation
  8. Partial liquid ventilation
  9. Inhaled nitric oxide
  10. Extra corporeal membrane oxygenation - ECMO
42
Q

What are 5 characteristics of BiLevel ventilation?

NOT IN EXAM

A
  1. Form of Pressure controlled ventilation
  2. 2 levels of PEEP maintained to inflate alveoli
  3. Less injury to lungs
  4. Allows spontaneous breaths – less muscle atrophy
  5. Assists patient initiated breaths with pressure support
43
Q

What BiLevel or Biphasic ventilation?

NOT IN EXAM

A
44
Q

What is the normal I:E ratio?

NOT IN EXAM

A
45
Q

What are 5 characteristics of Nitric Oxide?

NOT IN EXAM

A
  1. Used to improve oxygenation (↑ PaO2)
  2. Vasodilator of pulmonary circulation
  3. Most commonly used in acute respiratory distress syndrome (ARDS) / pulmonary hypertension (PHT)
    • Can be expensive
  4. Inhaled NO dose
    1. 1 - 40 parts/million
    2. ↓’s systemic effects
  5. 40-70% responders- Used in neonates

If they need 100% O2 –> with nitric oxide –> only need 50% O2

46
Q

What are 6 indications (management) for inhaled nitric oxide iNO?

A

Don’t offer physiotherapy (usually)

  1. Pulmonary hypertension (2o)
  2. Hypoxaemia eg ARDS
  3. Primary pulmonary hypertension
  4. Heart failure= Paediatrics
  5. Diaphragmatic hernia= Paediatrics
  6. Respiratory distress syndrome= Paediatrics
47
Q

What are 6 characteristics of high frequency oscillation?

NOT IN EXAM

A
  1. Delivers small volumes & very high rate (300b/min)
  2. Oscillation → removes CO2
  3. Lung alveoli open at constant less variable airway pressure → atelectrauma
  4. HFOV ↑ gas mixing and ↑V/Q matching
  5. Often very difficult to include physiotherapy with these patients
  6. May be able to do some manual techniques
48
Q

What is extra corporeal membrane oxygenation (ECMO)?

A
49
Q

What are the 10 main side effects of ventilation?

A
  1. Pulmonary
    1. maldistribution of ventilation
    2. progressive atelectasis
    3. hyperinflation - auto PEEP
    4. ventilation-perfusion mismatch
    5. decrease in surfactant
    6. increased extravascular lung water
  2. Ventilator induced lung injury
  3. Barotrauma, volutrauma, atelectrauma, biotrauma
  4. Ventilator associated pneumonia
  5. Haemodynamic effects
    • Decrease cardiac output
  6. Deep venous thromboses
  7. Gastric ulceration
  8. Critical care myopathy
  9. Disuse atrophy of diaphragm
  10. “ICU psychosis”

Physio can prevent this in treatment

50
Q

What are the 6 pulmonary side effects of ventilation?

A
  1. maldistribution of ventilation
  2. progressive atelectasis
  3. hyperinflation - auto PEEP
  4. ventilation-perfusion mismatch
  5. decrease in surfactant
  6. increased extravascular lung water
51
Q

What is a ventilator induced lung injury side effects of ventilation?

A

Barotrauma, volutrauma, atelectrauma, biotrauma

52
Q

What is a ventilator associated pneumonia side effects of ventilation?

A

Physio can prevent this in treatment

53
Q

What are 4 characteristics of protective or “open lung” strategies?

A
  1. Ventilator induced lung injury
    • Barotrauma, volutrauma, atelectrauma, biotrauma
  2. PEEP - to hold alveoli open, but not to overdistend alveoli
  3. Keep tidal volume low  8mls/kg
  4. Prevent overdistension of lung regions at end inspiration (<30-35cmH2O).
54
Q

What are 3 characteristics of old protective ventilation?

A
  1. TV > 10 mls/kg
  2. High inspiratory pressure > 40mmHg
  3. PEEP ≤ 5cmH20
55
Q

What are 3 characteristics of new protective ventilation?

A
  1. TV ≤ 8ml/kg
  2. Low inspiratory pressure < 32mmHg
  3. PEEP 5-15cmH20 not disconnected
56
Q
A

X

57
Q

Clinical example:

  • Multi-trauma – multiple injuries #’s, ruptured spleen
  • Worsening overnight - decreased gas exchange, lung becoming stiffer ie PIP increasing
  • ON SIMV
    • FiO2 ↑ to 80% - PaO2 60mmHg
    • Peak inspiratory pressure ↑ 23mmHg to 40mmHg
    • What is recommended Vt in ARDS?
    • Vt = 6 ml/kg
      • Vt < 6 ml/kg if Pplateau > 30 – 35 cmH2O
  • On Pressure controlled ventilation
    • Paralyzed, sedated
    • Inspiratory pressure controlled at 30mmHg
    • TV only 200mls
    • Reverse I:E ratio ventilation applied
    • PaO2 still 55-60cmH2O
    • PEEP ↑ to 15cmH2O
  • Nitric oxide added into circuit
  • Patient turned into Prone (Prone helps with inflammatory disease)
  • Still low PaO2
  • → Changed to high frequency oscillation – HFO
  • Still low PaO2
  • → Changed to ECMO
A
58
Q

What are 5 characteristics of advanced ventilation techniques?

A
  1. eg BiLevel, HFO, Nitric oxide, ECMO, permissive hypercarbia
  2. Unlikely to see these unless in a major tertiary level ICU
  3. These patients may be too sick to have physiotherapy
  4. Need to discuss management with medical staff and/or senior physiotherapists
  5. More senior physiotherapists will treat these patients and be aware of how to manage them/ weigh up risk /benefit
59
Q

How can we prevent side effects?

A
60
Q

What are 4 characteristics of waveform analysis?

A
  1. Previously if patient “fighting ventilator or abnormal waveform, increased sedation
  2. Now analysis of waveform and suiting pt to ventilator is important
  3. Examples sawtooth (secretions)
  4. Intrinsic PEEP (hyperinflation)
61
Q

What is hyperinflation for intrinsic PEEP?

A
62
Q

What is the summary in acute respiratory deterioration?

NOT IN EXAM

A
63
Q

What is Peak Inspiratory Pressure (PIP) vs Plateau Pressure (Pplat)?

A
64
Q

What are 7 causes of Hypoxaemia during MV?

NOT IN EXAM

A
  1. Incorrect settings
  2. Circuit disconnection
  3. Secretions
  4. Malposition of tube
  5. Pneumothorax
  6. Onset of new medical problem
  7. Medications
65
Q

What are 7 actions of Hypoxaemia during MV?

NOT IN EXAM

A
  1. Increase FiO2
  2. Auscultation
  3. Check settings
  4. Suction tube
  5. Chest X-ray
  6. Manually bag
  7. Bronchoscope
66
Q

What are 2 causes of low pressure alarms?

NOT IN EXAM

A
  1. Disconnection of equipment
  2. Malfunction of ventilator
67
Q

What are 3 actions of low pressure alarms?

NOT IN EXAM

A
  1. Manually bag patient
  2. Check connections
  3. Check function of ventilator
68
Q

What are 3 characteristics of other alarms?

NOT IN EXAM

A
  1. Low Tidal volume
    1. Machine
      1. as for low pressure alarms
      2. biting of ETT
    2. Spontaneous -
      1. fatigue, oversedation
  2. High Respiratory rate
    1. anxiety, pain, fatigue, may need increased pressure support
  3. Apnea
    1. fatigue, over sedation
69
Q

What does weaning look like for mechanical ventilation?

A

The longer they use –> less likely they are to get off the machine

70
Q

How do we wean?

A
  1. Decrease rate on SIMV
  2. Change to PS/PEEP ASAP
    • Decrease level of PS and PEEP
  3. If on tracheostomy – T piece
  4. Extubate → high flow nasal prongs or non invasive
  5. ventilation
71
Q

What is T piece breathing?

A
72
Q

What 10 clinical parameters need to be met before weaning?

A
  1. Original cause of admission resolved or improved
  2. Adequate gas exchange SaO2 >90%, FiO2  0.4, PaO2/FiO2 >200, PEEP  8 cmH20
  3. MIP < -20, TV > 5 ml/kg, VC > 10ml/kg
  4. RR/TV < 105 breaths/L
  5. Absence of fever
  6. Normal Hb (for ICU)
  7. Stable cardiovascular function
  8. Appropriate neurological and muscular status
  9. Correction of metabolic and/or electrolytes disorders
  10. Adequacy of sleep, no sedation, adequate mentation
    • Have day and night differences (for allowing them to sleep naturally)
73
Q

What are 3 criterion for extubation?

A
  1. All of above
  2. Adequate cough
  3. Minimal secretions
74
Q

What 7 types of patients that have trouble weaning?

A
  1. COPD
  2. Chronic heart failure
  3. Chronic renal failure
    • Respiratory muscles are 40% weaker (due to electrolytes) –> depends on when they have dialysis (will have a better chance)
  4. Spinal injury
  5. Phrenic nerve palsy
  6. Obese
  7. Long stay ICU patient -weak
75
Q

What is our role (5) in weaning?

A
  1. Exercise early, mobilize early to prevent weakness
  2. Advise when you think they are ready
  3. Monitor while weaning for criteria
  4. Avoid exercising or treating when just placed on a lower level of ventilation
  5. As part of your assessment, note if they are being weaned, if they coped with a lower level of ventilation, for how long
76
Q

What are 7 signs of not coping with weaning?

A
  1. Patient anxiety, discomfort or progressive obtundation
  2. High RR, shallow breaths, high HR, Low SpO2
  3. Rapid shallow breathing
  4. Recession of suprasternal notch
  5. Retraction in intercostal spaces
  6. Accessory muscle recruitment
  7. Abdominal paradoxical motion, Respiratory alternans
    • Changes in abdominal wall motion result of exhausted and flaccid diaphragm sucked into abdomen by negative intrapleural pressure
77
Q

What approach should be used for weaning?

A

Gentle approach has been shown to be better (might cause temporary problems with diaphragm –> might not be able to do spontaneous breathing for couple days after)

  • Don’t just let them get pushed/struggle
  • Allow very gentle weaning
78
Q

What are the 5 parts of the acroynm as criteria for extubation?

A
  • C - Consciousness
  • O – Oxygenation PaO2
  • V – Ventilation PaCO2, Tidal volume, Respiratory Rate
  • E – Expectoration Cough strength & effectiveness
  • S – Sputum load
79
Q

What are 5 characteristics of becoming proficient in MV?

A
  1. Observe what modes and settings patient is on
  2. How are they coping?
  3. Observe patient
  4. Observe waveforms
  5. Ask questions ++
80
Q

What are the 4 main summaries of MV?

A
  1. Difference between modes
  2. If on SIMV, PEEO <10cmH20, Fi02 <60% usually okay to do Rx with PT ie. MHI, suction
  3. If on advanced mode eg. ECMO, HFV, pressure controlled ventilation with PEEP >10cmH20, FiO2 > 60%, usually too difficulty to Rx, passive movements or repositioning
  4. Understand complications of MC and how PTS can reverse these

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