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N928 - Basics of Anesthesia > Lung Protective Ventilation (LPV) > Flashcards

Lung Protective Ventilation (LPV) Flashcards

1
Q

physiologic respiration

A
  • occurs through negative pressure
  • negative Ppl (intrapleural pressure) provides a positive transpulmonary pressure to minimize atelectasis at baseline [Ptp = Palv - Ppl]
  • anesthetic and surgical factors alter chest wall muscle tone which alters Ppl pressure gradient
  • maintaining positive Ptp during surgery is dependent on maintaining Palv
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2
Q

anesthesia/surgical effects on lungs

A
  • loss of muscle tone
  • elevated intraabdominal pressure
  • reduction in FRC
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3
Q

loss of muscle tone

A
  • upper airway muscles –> lead to obstruction

- chest wall and diaphragm - abdominal contents cephalad displacement, alveolar compression

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4
Q

elevated intraabdominal pressure

A
  • increased BMI
  • pneumoperitoneum
  • trendelenburg or lithotomy position
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5
Q

FRC decrease with supine position

A

transition from upright to supine decreases FRC by 0.8-1L

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6
Q

FRC decrease with induction agents

A

further reduce FRC by 0.4-0.5 L

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7
Q

total FRC reduction

A

1.2-1.5 L, brings lung volume closer to residual volume

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8
Q

normal FRC

A

30 mL/kg of IBW

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9
Q

recruitable lung area

A
  • general anesthesia
  • loss of FRC
  • atelectasis
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10
Q

non-recruitable lung area

A
  • ARDS
  • cellular debris
  • edema
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11
Q

factors that contribute to alveolar collapse

A
  • position
  • induction
  • FiO2
  • maintenance
  • emergence
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12
Q

position on alveolar collapse

A

increased closing pressure –> decreased FRC

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13
Q

induction on alveolar collapse

A

loss of muscle tone –> decreased FRC

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14
Q

FiO2 on alveolar collapse

A
  • resorption behind closed airways –> atelectasis

- increased FiO2 –> faster resorption

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15
Q

maintenance on alveolar collapse

A

progressive airway closure with decreasing compliance

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16
Q

emergence on alveolar collpase

A
  • high FiO2 promotes post-operative atelectasis

- absence of CPAP –> continued lung collapse

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17
Q

ventilation induced lung injury (VILI)

A

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

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18
Q

ventilation associated lung injury (VALI)

A

ventilator induced lung injury specific to the OR setting

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19
Q

volutrauma

A

lung injury associated with high volumes on the ventilator, even in the presence of moderate peak inspiratory pressures; damaged endothelium, decreased surfactant, increased capillary leak

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20
Q

barotrauma

A

lung injury associated with high pressures on a mechanical ventilator; damage from positive pressure effects

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21
Q

atelectrauma

A

injury specifically to the alveoli that results from repeated atelectasis and re-inflation of the alveoli; damage from repeated collapse and re-inflation

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22
Q

biotrauma

A

damage from release of inflammatory mediators; refers to the the release of various inflammatory mediators due to injury from different ventilatory modes which can cause injury to the lungs and other distal organs

23
Q

conventional lung ventilation

A
  • strategy that promotes VALI
  • not individualized
  • Vt 10-15 mL/kg TBW (YIKES)
  • PEEP 0-5 cmH2O
  • I:E ration no greater than 1:2
  • FiO2 provider preference (but usually 60% or higher)
24
Q

lung protective ventilation (LPV)

A
  • protects against VALI
  • individualized to patient and surgery
  • adjust settings based on patient monitors and ventilator data
25
Q

LPV initial maintenance settings

A
  • low VT 6-8 mL/kg IBW
  • minimize FiO2 < 30%
  • individualized PEEP 30% of BMI (usually 8-10 as starting)
  • alveolar recruitment maneuvers after induction
  • I:E ratio 1:1.5
26
Q

LPV emergence settings

A
  • FiO2 < 80%; decreases amount of atelectasis, 100% has been shown to have MORE atelectasis
  • positive pressure ventilation –> maintenance of lung volume; PEEP must be greater than closing pressure
  • elevate HOB to shift contents caudad
27
Q

induction LPV strategies

A
  • goal - attenuate anesthesia related changes
  • initial FiO2 100%
  • elevated HOB > 30 degrees; reverse trendelenburg > back up
  • tightly sealed face mask - apply CPAP; use APL valve or CPAP mode on ventilator
  • OPA or NPA as needed
28
Q

maintenance LPV strategies

A
  • restore lung volume with alveolar recruitment maneuver (ARM)
  • maintain lung volume and minimize atelectasis formation (individualize PEEP)
  • maximize lung compliance - use lowest possible driving pressure (Pplat - PEEP); look at compliance curves/loops
29
Q

TV LPV

A
  • initial setting 6-8 mL/kg

- purpose - maintain physiologic tidal volume

30
Q

maintenance FiO2 LPV

A
  • initially 30%
  • maintain SpO2 >/= 94%
  • purpose - reduce resorption atelectasis; use SpO2:FiO2 curve as monitor to assess if we are maintaining open-lung ventilation
31
Q

high FiO2 dangers

A
  • at 21% if saturation less than 97% we known that greater than 10% intrapulmonary shunting is occurring
  • high FiO2 has the potential to mask what is occurring in the lungs; could be shunting or have atelectasis and don’t know it
32
Q

alveolar recruitment maneuvers (ARM) definition

A
  • initial performance post intubation
  • need sufficient CPAP to exceed critical opening pressure
  • purpose - to create an open-lung state
33
Q

types of ARMs

A
  • bag squeezing technique
  • vital capacity maneuver - CPAP
  • cycling maneuver
  • stepwise Vt changes
34
Q

minimum recruitment pressure required for BMI <30

A

40 cmH2O

35
Q

minimum recruitment pressure required for BMI 30-40

A

40-50 cmH2O

36
Q

minimum recruitment pressure required for BMI 40-50

A

50-55 cmH2O

37
Q

minimum recruitment pressure required for BMI >/=50

A

50-60 cmH2O

38
Q

minimum recruitment pressure required for BMI >/=50

A

50-60 cmH2O

39
Q

PEEP

A
  • initial setting BMI x 0.3 (between 27-33%); max starting usually 15
  • purpose - maintain end expiratory lung volume, reduce atelectasis formation, BMI specific levels of be must be proceeded by ARM
40
Q

PEEP LPV

A
  • initial setting BMI x 0.3 (between 27-33%); max starting usually 15
  • purpose - maintain end expiratory lung volume, reduce atelectasis formation, BMI specific levels of be must be proceeded by ARM
41
Q

I:E Ratio LPV

A
  • initial setting BMI < 45 1:1.5; BMI >/= 45 1:1

- purpose - reduce airway pressure, increase homogenous ventilation

42
Q

I:E Ratio LPV

A
  • initial setting BMI < 45 1:1.5; BMI >/= 45 1:1

- purpose - reduce airway pressure, increase homogenous ventilation

43
Q

emergence goals of LPV

A
  • maintain open-lung throughout emergence

- minimize anesthesia induced changes during post-operative period

44
Q

emergence FiO2

A
  • maintain FiO2 = 80% throughout

- purpose - reduce atelectasis formation

45
Q

positive pressure ventilation in emergence

A
  • maintain CPAP and PEEP throughout

- purpose is to prevent atelectasis formation and maintain open lung state

46
Q

HOB elevation in emergence

A
  • elevated HOB >/= 30 degrees

- purpose is to decrease chest wall compression and increase lung compliance

47
Q

monitoring lung compliance

A
  • trend of compliance throughout the case

- a down trend represents atelectasis or anything favoring poor ventilation of lungs

48
Q

pressure volume loop

A
  • assessment of driving pressure <15 cmH2O; pressure required to deliver set volume
  • want to maximize volume delivered at lowest pressure
49
Q

flow volume loop

A
  • representation of expiratory flow

- acute angle represents expiratory flow limitation

50
Q

Bag squeezing technique ARM

A

squeeze bag with APL closed to allow you to deliver enough pressure to keep the lungs open; need to make sure you maintain pressure on your bag while you flip over to the vent so that you don’t get collapse

51
Q

Vital capacity or CPAP maneuver ARM

A

put patient on the ventilator, hit procedures button, tell vent to give a certain amount of pressure for a specified period of time

52
Q

cycling maneuver ARM

A

set inspiratory pressure and step PEEP up in a cyclic fashion to open up the patients lungs; then step PEEP back down

53
Q

stepwise Vt changes ARM

A

set PEEP then gradually increase the tidal volumes (so that you get enough pressure) to open the lungs up; make sure to bring Vt back down

N928 - Basics of Anesthesia (17 decks)

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