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Basic Principles N928 > Lung Protective Ventilation > Flashcards

Lung Protective Ventilation Flashcards

1
Q

Physiological respiration occurs through

A

negatice pressure

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2
Q

Negative intrapleural pressures provides

A

a positive transpulmonary pressure to minimize atelectasis at baseline

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3
Q

Positive transpulmonary pressures=

A

Palveolar- intrapleural pressure

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4
Q

Anesthetic and surgical factors alter

A

chest wall muscle tone

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5
Q

Chest wall muscle tone from anesthesia and surgical factors alter

A

intraplueral pressure gradient

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6
Q

Maintaining a positive transpulmonary pressure during is dependent on

A

maintain alveolar alveolar pressure

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7
Q

Anesthesia and surgical effects on the lungs include:

A

loss of muscle tone

elevated intraabdominal pressure

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8
Q

Loss of muscle tone effects on the lungs includes

A

upper airway muscles (obstruction)

chest wall and diaphragm (abdominal contents cephalad displacement and alveolar compression)

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9
Q

Elevated intra-abdominal pressure on lungs in surgery

A

increased BMI
pneumoperitoneum
trendelenburg positioning

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10
Q

Induction of anesthesia causes

A

reduction in FRC

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11
Q

Transitioning from upright to supine position

A

decreases FRC by 0.8-1L

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12
Q

Induction agents

A

further reduce FRC by 0.4-0.5L

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13
Q

Total reduction after induction is

A

1.2-1.5L

bring lung volume close to residual volume

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14
Q

Recruitable lungs

A

general anesthesia

loss of FRC and ateletasis

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15
Q

Non-recruitable lungs

A

ARDS
cellular debris
edema

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16
Q

Factors that contribute to alveolar collapse

A 
position
induction
FiO2
maintenance
emergence
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17
Q

Position as a factor that contributes to alveolar collapse

A

increased closing pressure leads to decreased FRC

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18
Q

Induction as a factor that contributes to alveolar collapse

A

loss of muscle tone leads to decrease FRC

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19
Q

FiO2 as a factor that contributes to alveolar collapse

A

resorption behind closed airways leads to atelectasis

increased FiO2 causes faster re-absorption

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20
Q

Maintenance as a factor that contributes to alveolar collapse

A

progressive airway closure with decreasing compliance

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21
Q

Emergence as a factor that contributes to alveolar collapse

A

high FiO2 promotes postoperative ateletasis

absence of CPAP causes continued lung collapse

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22
Q

Ventilator Induced Lung injury includes

A

Mechanical ventilation can induce lung injury
ventilation induced lung injury
ventilation associated lung injury

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23
Q

Adverse effects of mechanical ventilation

A

leads to potentially irreversible structural and functional damage

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24
Q

What is ventilation induced lung injury?

A

ventilator does not cause injury but the settings of the ventilator do

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25
Q

What is ventilation associated lung injury?

A

specific to OR setting

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26
Q

Ventilation Associated Lung Injury Examples

A

volutrauma
barotrauma
atelectrauma
biotrauma

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27
Q

Volutrauma

A

damaged endothelium, decreased surfactant, increased capillary leak

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28
Q

Barotrauma

A

damage from positive pressure effects

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29
Q

Atelectrauma

A

damage from repeated collapse and re-inflation

30
Q

Biotrauma

A

damage from release of inflammatory mediators

31
Q

Conventional Lung Ventilation includes

A 
strategy that promotes VALI
not individualized
PEEP- 0-5cmH2o
Vt- 10-15m TBW
I:E no greater than 1:2
FiO2- provider preference
32
Q

Lung Protective Ventilation (LPV)

A

strategy that protects against VALI
individualized to patient and surgery
adjust setting based on: pt monitors and ventilator data

33
Q

LPV Initial Maintenance Settings

A

Low Vt 6-8ml/kg IBW
minimize FiO2 < 30% of BMI
alveolar recruitment Maneuvers
inspiratory: expiratory (I:E) ration 1:1.5

34
Q

LPV Emergence Settings

A

FiO2 < 80%
Positive Pressure Ventilation (maintenance of lung volume and must be greater than closing pressure)
Elevate Head of BEd

35
Q

Induction Strategies

A 
Initial FiO2: 100%
elevated HOB >30%
RT> Back up
Tightly sealed face mask- apply CPAP
OPA or NPA as needed
36
Q

Goal of Induction

A

attenuate anesthesia related changes

37
Q

Goals of Mainteance LPV Sequence

A

restore lung volume via ARM
maintain lung volume and minimize atelectasis formation (individualize PEEP)
Maximize lung compliance

38
Q

How can you maximize lung compliance during the maintenance phase?

A

use lowest possible driving pressure

compliance = Vt/change in pressure

39
Q

Initial Setting of TV

A

6-8ml/kg of IBW

40
Q

Purpose of TV

A

maintain physiologic tidal volume

41
Q

Maintenance of FiO2 (initial setting)

A

30%

42
Q

Maintain SpO2 during maintenance phase

A

> 94%

43
Q

Purpose of Maintenance FiO2

A

to reduce resorption atelectasis

use SpO2: FiO2 curve as monitor to assess if we are maintaining “open-lung ventilation”

44
Q

Maintenance FiO2

A

low FiO2 can be used as a surrogate monitor to assess ventilation
at 21% less then 97% we know greater than 10% intrapulmonary shunting is occurring

45
Q

Alveolar Recruitment Maneuvers- initial performance

A

post intubation

sufficient CPAP to exceed critical opening pressure

46
Q

Purpose of alveolar recruitment

A

create an open lung state

47
Q

Alveolar recruitment maneuvers

A

bag squeeze technique

vital capacity maneuvers

48
Q

Bag squeezing technique

A

arm through ventilator is ideal

APL close need to maintain pressure on bag while you switch to ventilator mode

49
Q

CPAP

A

VC maneuver
place patient on ventilator
procedure mode where amt of pressure and amt of time set to recruit lung

50
Q

Cycling Maneuver

A

set inspiratory pressure @ 20cm then and PEEP then slowly decrease PEEP

51
Q

Stepwise Vt changes

A

set PEEP and increase Pinspiratory circuit then decrease pressure

52
Q

Minimum recruitment pressure required BMI <30

A

40cmH20

53
Q

Minimum recruitment pressure required BMI 30-40

A

40-50cmH20

54
Q

Minimum recruitment pressure required BMI 40-50

A

50-55cmH20

55
Q

Minimum recruitment pressure required BMI >50

A

50-60cmH20

56
Q

initial setting of PEEP

A

BMI x 0.3

57
Q

Purpose of PEEP

A

maintain end expiratory lung volume
reduce ateletasis formation
BMI specific levels of PEEP must be proceeded by ARM
(max starting PEEP is 15)

58
Q

Initial Setting of I:E ratio for BMI < 45

A

1:1.5

59
Q

initial setting of I:E ratio for BMI > 45

A

1:1

60
Q

Purpose of setting I:E ratio

A

reduce airway pressures

increase homogenous ventilation

61
Q

Goals of LPV for Emergence

A

maintain open lung throughout emergence

minimize anesthesia induced changes during postoperative period

62
Q

Emergence FiO2

A

Maintain FiO2 < 80 throughout

63
Q

Purpose Emergence FiO2

A

reduce atelectasis formation

64
Q

Positive Pressure Ventilation

A

maintains CPAP and PEEP throughout

65
Q

Purpose of PPV

A

prevent atelectasis formation

maintain open-lung state

66
Q

Purpose of HOB >30

A

decrease chest wall compression

increase lung compliance

67
Q

Oxygen therapy post-operatively

A

does everyone need O2?

excessive O2

68
Q

Concerns of excessive O2?

A

activation of ROS (reactive oxygen species)
peripheral/coronary vasoconstriction
decreased CO
absorption atelectasis

69
Q

What does down trending compliance represent?

A

poor ventilation of lungs

70
Q

Pressure Volume Loops

A

assessment of driving pressure
“width of loop”
pressure required to deliver a set volume
want to maximize volume delivered at lowest pressure

71
Q

Flow Volume Loop

A

representation of expiratory flow

acute angle represents expiratory flow limitation

Basic Principles N928 (10 decks)

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