Lab 104 Homework Question Flashcards
List 15 Items needed for endotracheal intubation
- Oxygen flow meter and tubing
- Suction apparatus
- Flexible sterile suction catheter
- Sterile gloves
- Yankaver
- Manual resuscitation bag and mask
- CO2 detector
- Laryngoscope (2) with assorted blades
- Endotracheal tubes (3 sizes)
- Tongue depressor
- Stylet
- Stethoscope
- 10- or 12-mL Syringe
- Tape or endotrachael tube holder
- Water soluble lubricating gel
List 5 bedside methods to assess endotracheal tube position/placements
- Auscultation of chest and abdomen
- Observation of chest movement
- light wand
- Capnometry
- Colorimetry
What is the tube size that a woman and man are intubated with
Woman: 7 or 7.5 tube
Men: 8 or 8.5 tube
What hand do you hold the laryngoscope with
Left hand
What is the most common size laryngoscope used for adults
A No. 3 curved Macintosh or straight Miller Laryngoscope blade
How long should one be allowed to attempt to intubate
No more than 30 seconds should be devoted to any intubation attempt
Explain the difference between the Miller and Macintosh blades and how they displace the epiglottis
Macintosh Blade is curved. The epiglottis is displaced indirectly by advancing the tip of the blade into the vallecula (at the base of the tongue), and the laryngoscope is lifted up and forward.
Miller Blade is straight. The epiglottis is displaced directly by advancing the tip of the blade over its posterior surface and the laryngoscope is lifted up and forward.
In general, initially where should the ETT be secured at for men at the teeth and woman at the teeth
Men: 21-23 cm
Woman: 19-21 cm
The tip of the ETT should be approximately (what) above the carina
3-5 cm above
To prevent tracheal mucosal injury, it is recommended to inflate the cuff to
20-30 cmH2O
What equation do we use to estimate the proper suction catheter size per Egan
Multiply tube’s inner diameter by 2. Then use the next smallest size catheter. Example: 6mm ETT 2x6=12 the next smallest tube is 10. I would use a 10F suction catheter
List 4 indications for use of closed suction technique
- Positive End Expiratory Pressure (PEEP) >= 10 cmH2O
- Mean Airway Pressure (MAP) >= 20 cmH2O
- Inspiratory Time >= 1.5 sec
- FiO2 >= 0.60
How can you prevent hypoxemia while inline suctioning (2)
- Minimized by preoxygenating Pt.
- Minimized by using closed suction technique
How can you prevent atelectasis during inline suctioning (4)
- Limit amount of negative suction pressure used
- Keep duration of suctioning less than 15 seconds
- Use appropriate size catheter
- Avoid disconnection from vent by using closed suction technique
What suction pressure would you use for an adult per Egan and per Instructor
Egan: 120-150 mmHg
Instructors: 100-120 mmHg
According to Egan, how long should you wait after changes in ventilatory support have been applied before taking a blood gas sample
Healthy Lungs: 5 minutes
COPD: 30 minutes
A patient is ready to be extubated when? List 4 things
- The ability to maintain adequate oxygenation and ventilation w/out mechanical support
- The ability of the patient to protect the airway by presence of a gag reflex
- The ability to manage secretions based on cough strength
- The patency of the upper airway
List 4 items needed for extubation
- Two suction kits with correct size sterile suction catheters and gloves
- Tonsil-lar suction tip (Yankauer)
- Manual resuscitation bag with mask (AMBU)
- 10-mL or 12-mL syringe
List 3 things that must be performed before the ETT is removed
- Oxygenate the patient before and well after suctioning
- Suction ETT and Pharynx above the cuff
- Deflate the cuff completely
When should the ETT be removed? when the vocal cords are?
Maximally abducted
What needs to be assessed post extubation. List 4 items
- Auscultation is performed to check for good air movement and post extubation stridor.
- Patient’s vitals (HR, RR, BP, SPO2, BS)
- ABG Values
- Monitor for nose bleeds (After Nasotracheal Extubation)
List 3 common problems that occur after extubation
- Hoarseness
- Sore throat
- Cough
What are acceptable values for the following indices for discontinuing Vent Support?
- FiO2
- PEEP
- PaO2
- PaCO2
- PH
- Vt
- RSBI
- MIP
- PaO2/PAO2
- PaO2/FiO2
- P(A-a)O2
- Qs/Qt
- Static Compliance
- VC
- FiO2 <= 0.40 - 0.50
- PEEP <= 5 - 8 cmH2O
- PaO2 >= 60 cmH2O
- PaCO2 < 50 mmHg
- PH >= 7.35
- Vt > 5 mL/Kg
- RSBI < 105 BPM/L
- MIP < -20 to -30 cmH2O
- PaO2/PAO2 >= 0.35
- PaO2/FiO2 > 150 - 200
- P(A-a)O2 <350 mmHg
- Qs/Qt < 15% - 20%
- Static Compliance > 25 mL/cmH2O
- VC > 10 - 15 mL/Kg
List atleast 10 factors that should be optimized before discontinuing vent support
- Anemia
- Pain
- Fear/Anxiety
- Depression
- Humidification
- Ventilation
- Oxygenation
- Respiratory Alkalosis
- Metabolic Alkalosis
- Metabolic Acidosis
A gradual increase in PETCO2 could indicate what?
- Hypoventilation - Increase in CO2 production
A sudden low PETCO2 could indicate what? List atleast 2 items
- Sudden decrease in Cardiac Output
- Massive Pulmonary Embolism
List two common problems that cause false PETCO2 readings
- Contamination or obstruction of the sampling system or monitor by secretions or condensate
- No reading with cable disconnection or condensate in sensor or monitoring tubing
What is the normal value for PETCO2 in healthy individuals
35 - 43 mmHg
List 5 indications for obtaining an inpatient CXR
- Placement of ETT
- Placement of Pulmonary Artery Catheter
- Placement of Central Venous Pressure Catheter
- Sudden onset of dyspnea or chest pain
- Sudden decline in oxygenation
How can you determine if someone is rotated or not on a CXR
- Looking at the clavicles of a patient. They should look the same length. If one looks longer than the other, the patient is rotated.
How can one determine if there was a good inspiratory effort on a CXR
- The visualization of 6 anterior or 10 posterior ribs above the level of the diaphragm on a PA Chest view indicates a good inspiratory effort by the patient
List 4 indications for Mechanical Ventilation (MV)
- Apnea or impending respiratory arrest
- Acute exacerbation of COPD w/dyspnea, tachypnea, acute respiratory acidosis, and acute cardiovascular instability
- Acute ventilatory insufficiency in cases of neuromuscular disease with acute respiratory acidosis
- ## Need for endotracheal intubation to maintain or protect the airway or manage secretions
- PH < 7.25
- PaCO2 > 55 mmHg and rising
- PaO2 < 70 mmHg (on O2 >= 0.6)
- VD/VT > 0.6
List 5 hazards of Mechanical Ventilation (MV)
- Ventilator associated lung injuries (Barotrauma, Pneumothorax)
- Ventilator Associated Pneumonia (VAP)
- Oxygen Toxicity
- Auto PEEP = Air trapping
- Complications related to volume (Volutrauma, atelectrauma)
While assessing your patient, what would indicate the need for MV for the following
1. ABG (PH, PaCO2, PaO2)
2. RR
3. VT
4. VC
5. VE
6. MIP
7. MEP
8. VD/VT
9. Qs/Qt
10. Cst
11. P(A-a)O2
12. P/F
- ABG (PH < 7.25, PaCO2 > 55 mmHg & rising, PaO2 < 70 mmHg on O2 >= 0.60)
- RR > 35 BPM
- VT < 5 mL/Kg
- VC < 10-15 mL/Kg
- VE > 10 LPM
- MIP -20 to -30 cmH2O
- MEP < 40 cmH2O
- VD/VT > 0.6
- Qs/Qt > 20%
- Cst < 25 mL/cmH2O
- P(A-a)O2 > 450 mmHg on 100 O2
- P/F < 200 mmHg
What is IBW equation for male/female
MEN: IBW = (Height in (In) - 60)6 + 106/ 2.2 = Kg
WOMEN: IBW = (Height in (In) - 60)5 + 105/ 2.2 = Kg
You have a 5’9” Male Pt. What VT range would you recommend?
Male 5’9” = 69”
IBW = (69-60)6 +106/2.2 = 73Kg
“Rule of thumb” Initial VT = 6-8 mL/Kg of IBW
VT = 6 x 73 = 440 mL
VT = 8 x 73 = 580 mL
VT recommended range is 440mL - 580mL
What are the initial adult settings for MV
1. VT
2. PC
3. RR
4. FiO2
5. PEEP
6. I:E
7. Flow
8. Sensitivity
- VT = 6-8 mL/Kg
- PC = 10-15 cmH2O
- RR = 10-20 BPM
- FiO2 = 100% when Pt. is unknown (Wean ASAP)
- PEEP = 5 cmH2O
- I:E = <= 1:2
- Flow = 40-80 LPM
- Sensitivity = 1-2 LPM (flow) or -1 to -2 cmH2O (pressure)
How to set the following alarms
1. High Pressure
2. Low Pressure
3. Low PEEP
4. Apnea
5. Low VT
- High Pressure = 10 cmH2O above PIP
- Low Pressure = 10 cmH2O below PIP
- Low PEEP = Don’t set to 0, 3-5 cmH2O below PEEP
- Apnea = 20 sec
- Low VT = 100 mL below set VT
What are indications for PEEP? List 4
- Bilateral infiltrates on CXR
- Recurrent atelectasis with low FRC (functional residual capacity)
- Reduced lung compliance
- PaO2 < 60 mmHg on FiO2 > 0.5 (50%)
Explain Mechanical Deadspace
- the amount of trapped air in circuit that a patient can rebreathe
- The amount of rebreathed volume in a ventilator circuit
- Dmech Increases CO2 in body
Explain Anatomical Deadspace
- Airways and lung tissue that do not participate in gas exchange
- 1 mL/LB. The average person has about 150 mL of anatomical deadspace in their body
Explain Alveolar Deadspace
Alveoli are ventilated, but not perfused by pulmonary capillary blood flow. (e.g. Pulmonary Embolism)
When would you recommend adding deadspace
To increase CO2. When you need to increase the patients PaCO2 levels
When would you recommend removing deadspace
To decrease CO2. When you need to decrease the patients PaCO2 levels
What is the difference between dynamic compliance and static compliance
- Dynamic Compliance: Considers the total impedance to volume change. (i.e., flow resistive, and elastic characteristics of the patient -vent interface
- Static Compliance: Is only influenced by the elastic characteristics of the lung -thorax unit
How do you calculate dynamic and static compliance (Equations)
- Dynamic: Cd = Volume / PIP-PEEP =cmH2O
- Static: Cs = VT / Pplat-PEEP = cmH2O
What is the normal values for Dynamic and Static Compliance
- Dynamic: 35 - 50 mL/cmH2O
- Static: 70 - 100 mL/cmH2O
How do you calculate Raw? What is the normal value for an intubated and non-intubated patient
- Raw = PIP - Pplat / Flow (L/Sec)
- Normal Intubated Pt. = 0.6 to 2.4 cmH2O
- Normal Non-Intubated Pt. = Approximately 6 cmH2O
When venting a head injury, where should you maintain the following parameters?
1. PaCO2
2. ICP
3. Flow
- PaCO2: 25 - 30 mmHg
- ICP: <= 10 mmHg
- Flow: > 60 L/Min
While in VC (Volume Control) how does adjusting the following parameters change the I:E?
1. VT
2. Flow
3. RR
- VT: Increase VT = Increase I:E / Decrease VT = Decrease I:E
- Flow: Increase Flow = Decrease I:E / Decrease Flow = Increase I:E
- RR: Increase RR = Increase I:E / Decrease RR = Decrease I:E
ABG (What vent setting would you change)
PH: 7.50
PaCO2: 27
PaO2: 89
HCO3: 24
A/C 10 mL/Kg, Rate 14, Total Rate 15, +5, 45%
- Patient is uncompensated Resp Alk with nml Oxygenation
- Pt. is over ventilating
- Decrease VT 9 mL/Kg
ABG (What vent setting would you change)
PH: 7.30
PaCO2: 65
PaO2: 118
HCO3: 29
A/C 7 mL/Kg, Rate 14, Total Rate 20, +5, 60%
- Patient is partially compensated Resp Acid with hyperoxygenation
- Increase VT to 8 mL/Kg
ABG (What vent setting would you change)
PH: 7.42
PaCO2: 36
PaO2: 127
HCO3: 25
A/C 650 mL, Rate 15, +10, 75%
- Patient is normal with hyperoxygenation
- Decrease FiO2 to 70%
List 4 things that can reduce VAP’s
- Minimize sedation and interrupt it daily
- Assess readiness to extubate daily
- Perform spontaneous breathing trials with sedation turned off
- Facilitate early mobility
Explain Auto PEEP
- Air trapped in lungs at the end of exhalation
- Pressure above atmospheric remaining in the alveoli at end-exhalation due to air trapping
How can you prevent/treat auto PEEP? List 3 things
- Decrease Inspiratory Time (I-Time)
- Decrease VT
- Decrease Rate
- Decrease PEEP
- Bronchodilator
How can you determine Optimal PEEP
- Best PEEP or Optimal PEEP is defined as the PEEP that maximizes O2 delivery. PEEP is increased in increments of 2 cmH2O until there is a decline in O2 delivery, at which point the Optimal PEEP has been exceeded. PEEP is adjusted down to previous level that represents the “Best PEEP”
- Look at CL (compliance). You want it to improve without compromising the Heart (blood pressure)
- When PVO2 decreases from normal (35-45 mmHg). When PVO2 decreases after an increase of PEEP this equals to much PEEP.