Mech. Vent Review + strategies Flashcards
1
Q
What are the physiological objectives for mech. ventilation for neonate/pediatric Pts?
A
Apnea, not breathing, bagging for a prolonged period of time
Overarching goals:
- To manipulate alveolar ventilation
- Improve oxygenation
- To optimize lung volume
- To reduce WOB
- Minimize risks associated w/vent. induced lung injury (VILI)
- How can you get the Pt. off of the vent
2
Q
Do pediatrics/neonates have different mech. ventilation complications as adults?
A
No, they mainly share the same complications
3
Q
What are risks you have to keep in mind when managing PPV for neonates/peds
A
- Can decrease venous return and increase pulmonary artery pressures
- Have to limit O2 for babies especially for eyes and vents
means there’s airway complications like damages from
intubation attempts and accidentally going too deep - Infection: keep it clean and sterile, inline suction, and avoid
disconnection to reduce infection and ventilation
associated pneumonia
4
Q
What are the primary goals of mech. ventilation for neonates/peds?
A
- Improve O2 delivery
- Eliminate CO2/maintain pH > 7.25
- Reduce WOB
5
Q
Why aren’t HME’s added to the ventilator circuit for neonates?
A
They add deadspace, so heated humidity is used instead.
6
Q
What temperatures should be be used for neonates on mech. ventilation?
A
35-37C
7
Q
Which mode of mech. ventilation is the preferred initial choice for neonates?
A
Volume control (precise volume targets)
8
Q
What mode of ventilation is typically used for kids?
A
PRVC or PCCMV adaptative or pressure control
9
Q
Why wouldn’t you use pressure support for kids?
A
Their vessels are small, the vent would miss their targets?
10
Q
When would you use pressure control ventilation for kids?
A
When plataeu pressure rise, PC is better at maintaining volume. So for conditions like:
- airleak syndromes
- pneumothorax
- PIE
11
Q
When would you use HFO or Jet Ventilation?
A
When babes are in troubling.
12
Q
What are the benefits to using PRVC?
A
You set a volume target and it can adapt to improvements in patient.
- Allows Target VC
- Control of Ti and Pplat
- Better control of mean airway pressure and distribution of ventilation.
13
Q
What is a con of using pressure control for children?
A
Have better control of pressure but you don’t have a VC target.
- their airways are smaller, meaning you need more precision of volumes to not cause VILI or ROP.
14
Q
What procedure uses pressure control for neonates/kids?
A
BLES, PC is can be used for surfactant admin.
- Surfactant is thick, if you use PC you need to crank it to send it deep.
15
Q
What is the Pplat max for adults?
A
Keep under 30cmH2O
16
Q
What is the Pplat max for neoantes?
A
Keep it under 25cmH2O
17
Q
What is the neonate rule of 5 for mech. ventilation?
A
Vt: 5 mL/kg
RR: 50
PEEP: 5
18
Q
What should your Ti goals be for mech. ventilating neonates?
A
Make sure we hit the inspiratory plateaus, they indicate whether the lungs are being fully filled.
- aim for 0.3-0.4
19
Q
How to manage high WOB
A
Increase RR to match or exceed Pts RR.
- The idea is that you want to take over their whole breathing, full control.
20
Q
What do you do if your PEEP exceeds 6?
A
CxR to guide further changes
21
Q
How to manage low oxygenation?
A
- High FiO2 and increase PEEP
- admin surfactant
22
Q
ABG targets for infants (>1month) and toddlers (< 2)
A
- pH (7.3-7.4)
- PaCO2 (30-40)
- PaO2 (80-100)
- HCO2 (20-22)
Generally keep pH above 7.2
23
Q
What is the PaCO2 for permissive hypercapnia
A
up to 60
24
Q
ABG targets for extremally low birth weight (ELBW) babes?
aka <1000gs
A
- pH above 7.20
- PaCO2 (45-55)
- PaO2 (45-65)
- HCO3 (15-18)
25
ABG Targets for Very low birth weight (VLBW) < 1.5kg
- pH above 7.2
- PaCO2 (45-55)
- PaO2 (50-70)
- HCO3 (18-20)
26
ABG targets for children and adults?
- pH (7.35-7.45)
- PaCO2 (35-45)
- PaO2 (80-100)
- HCO3 (22-24)
27
What is a step up treatment from normal mechanical ventilation for infants?
HFO
28
What conditions are needed for a patient to transition from vents to HFO/HFV?
- hint the Pts getting worse
- RR<80
- Vt<5ml/Kg
- PIP>25cmH2O
- MAP>12 and/or FiO2>0.40
29
What pathology is commonly associated/at a higher chance of developing with low birth weight (LBW)?
RDS
- More common because LBW babes are most have less developed lungs
- surfactant deficiency
30
ABG Targets for a Infant with Respiratory Distress Syndrome (IRDS)?
- PaO2 (50-80)
- PaCO2 (40-55)
- pH < 7.25
31
Managements of Infant Respiratory Distress Syndrome (IRDS)?
The goal is to improve oxygenation.
1. Manage/support underlying conditions like hypoxia, lung injury, edemas, or metabolic demands
2. Surfactant Replacement
3. Consider HFO or Nitric Oxide
32
why is it helpful to allow permissive hypercapnia in the early delivery of surfctant?
Surfactant delivery may be more successful when the infant's lungs are already well-ventilated and relatively stable.
- basically easier to do when lungs are not occupied with more work or at risk of/or already at VILI
33
Why would HFO be helpful with IRDS management?
IRDS = low surfactant = low compliance.
- Stiffer lungs cause PIPs to rise.
- need oscillation pressures to manage that (support PEEP/alveoli)
34
What should CPAP on babes max out at?
8
35
What is the cause of Bronchopulmonary Dysplasia (BPD)?
BPD results from treatments given to kids.
- higher risk for younger kids
- those born immature and have aggressive therapy results in lung damage and gets BPD
36
What are lung protective strategies to prevent BPD for infants?
- Low Vt
- Allow higher PaCO2 (permissive hypercapnia) -> pH (7.20-7.25)
- Aim for lower SpO2 goals (85-90)
- iNO (pulmonary vasodilators)
- Bronchodilators/steroids
- NCPAP if possible (instead of vents)
37
PPV goals for Bronchopulmonary Dysplasia (BPD)
- **Lowest PIP necessary**
- PEEP 4-6
- PaO2 above 50mmHg
- PaCO2 50-60mmHg
- Maintain acceptable pH
38
How does Transient Tachypnea of the Newborn (TTNB) present?
High WOB w/RR 60-80bpm
- remember TTNB is fluid in the lungs.
39
Treatment for Transient Tachypnea of the Newborn (TTNB)?
Goal is to use PPV to increase development, so theres more surface area for the fluid to move in. CPAP may also help move liquids.
- Oxygen therapy (less than FiO2 0.4)
- CPAP 3-5cmH2O w/higher FiO2
- Rarely requires mech vents
40
Indications of Pneumonia in newborns?
- Fetal Tachycardia & Low Apgars
- Supplemental O2 required-resuscitation at birth
- Increased WOB, grunting, tachypnea, retractions, nasal flaring, cyanosis, apnea, progressive resp. failure
41
Managements of pneumonia for infants
- O2 therapy, **CPAP** , and mech ventilation as required to **alleviate WOB**
- suction appropriately
42
what procedure is not recommended for patients w/Meconium Aspiration Syndrome (MAS)?
Intubation. Intubation to suction meconium is a last resort. (intubate and suction w/mec aspirator)
43
Vent strategies for Meconium Aspiration Syndrome (MAS)?
- mild cases w/usual settings (rule of 5)
- Hyperventilation & hyperoxygenation to induce pulmonary vasodilation if PPHN develops
- Low PaCO2, high PaO2
- HFV as a step up
44
What are 3 types of Neonatal Apneas?
1. Centrally = brain
2. Obstructive = blocked airway
3. Mix = Brain and obstruction
45
Management of Neonatal Apnea
Maintain acceptable SpO2.
- Caffeine or theophylline (bronchodilators) can help stimulate the babe
- minimal vent. settings bc theirs no disease present
46
What are 4 primary air leak syndromes that require early recognition in babes?
- why do we want early diagnosis of this pathologies?
PPV makes these worse if not careful.
- Pulmonary Interstitial Emphysema (PIE)
- Pneumothorax
- Pneumomediastinum
- Subcutaneous Emphysema
47
Clinical presentation of Air leak Syndromes in infants?
- Sudden deterioration occurs
- Increased RR
- Grunting
- Increased pallor (pale) or cyanosis (shock)
- O/A: Possible Cardiac shift (decrease in affected side or celerity of heart sounds)
48
Air leak managements for a mild pneumothorax?
O2 therapy at 1
49
Air leak managements for a Symptomatic pneumothorax?
- Needle Aspiration, Chest tubes
- Low PEEP and min. vent settings
- Consider PCV
50
Clinical manifestations of Persistent Pulmonary Hypertension of the Newborn (PPHN)
- Rapid O2 saturation changes w/no corresponding changes in FiO2.
- Tachypnea, mild/mod resp. distress w/cyanosis/hypoxemia that is poorly responsive to o2 therapy.
- pre and post ductal SpO2 > 10% diff
51
Management of Persistent Pulmonary Hypertension of the Newborn (PPHN)
Need to decrease PVR and increase pulmonary blood flow, the goal is to dilate the pulmonary artery:
- O2 to promote pulmonary vasodilation (lower PCO2 in the lungs will dilate)
- Surfactant if related to RDS
- iNO to treat PA Vasoconstriction
- **restrict handling/suctioning**
- Intubation/vent or HFOV to vent to normal PaCO2/pH (if necessary), followed by ECMO in severe cases
52
What is the main purpose of Lung Volume Recruitment (LVRM)?
1. Alveolar oxygenation when on the vent
2. non-vent is to aid secretion clearance and alveolar oxygenation.
2. Prevent decruitment
53
How do Lung Volume Recruitment Maneuvers improve oxygenation for non-vented Pts?
Increases surface area for O2 to diffuse.
- avoids lung injury by ventialting Pts. below inflection point.
- Inflection point increases lung compliance, PEEP, and Plateau Pressures.
- A *con though* physiolgic dead space increaess bc not invovled in gas exchange?
54
When does decruitment occur?
When a Pt. is disconnected from a circuit, pressure is released.
55
What factor is important to stabilize and maintain inflation of alveoli?
PEEP is most important factor in maintaining inflation of of alveoli
56
What can assist in determining optimal peep?
looking at the upper and lower inflection points on a pressure volume curve.
57
Indications for a Lung Volume Recruitment Maneuver (LVRM)?
- AKA when would you do them?
- After disconnecting Pt from vent.
- After suctioning
- Evidence of atelectasis
58
What are contraindications for Lung Volume Recruitment Maneuvers (LVRM)?
Chest tubes or air leaks
- evidences of barotrauma, pneumothorax, subcutaneous emphysema, pulmonary insertsistal emphysema
- Air trapping with COPD and high pressures makes it worse
59
What are the 2 main components of a Lung Volume Recruitment Maneuver (LVRM) procedure?
Sustained inflation and Intermittent sighs
60
What is sustained inflation and how long is it?
CPAP for 30 seconds.
- Applies high amount of CPAP
- Amount of CPAP depends on weight of kid
- Helps reopen regions
61
What are Intermittent sighs?
Slow big breaths to maximize lung inflation and improve lung compliance.
- on vents, set regular RR and Vt. there is a option to give big breaths every 10 seconds.
62
What should you monitor during a LVRM procedure?
SpO2, EtCO2, HR AND low inflection point analysis of pressure-volume curve.
- any major changes should be charted
- Discontinue if Pt desaturates or HR changes by 20%
63
Mechanical Ventilation Indications PaCO2
PaCO2 > 55mmHg
64
Mechanical ventilation indications pH?
pH < 7.25
65
PF ratio mechanical ventilation indications
PF ratio < 200
66
Goals of mechanical ventilation?
- Reverse hypoxemia
- Reverse severe acute respiratory acidosis
- Relieve WOB,
- Improve CO
- Decrease ICP
- Stabilize chest
- Decrease myocardial O2 demand
67
IBW males?
50 + 2.3 (height in inches - 60)
68
IBW females
45.5 + 2.3 (in. - 60)
69
what does it mean when the the following is described:
- Larynx funnel shaped
cricoid more narrow and prone to obstructions
70
what does it mean when the the following is described:
- Anterior/ higher glottic opening
harder to visualize cords on intubation
71
What does it mean when the Cartilage is more compliant?
Higher collapse risk (tracheomalacia)
72
Risks of a larger tongue?
collapse easily against posterior pharynx
73
Risks of Larger tonsils and adenoids
Bleeding easily, inflammation can obstruct
74
What increases risk of tearing and swelling?
Fragile mucosa
75
Un VCCMV, increasing RR will cause
Increase in only PIP and MAP
76
Controlled settings in VCCMV
- Rate
- FLow
- Vt
- Ti pause
- PEEP
77
Trigger in VC
Time/patient
78
Cycle in VC without pause?
volume
79
Cycle in VC with pause?
Time
80
Limit in VC?
Flow/volume
81
Benefits of pressure control?
- Improve oxygenation
- Better control of pressures
- Better distribution of ventilation
82
Trigger PC
Time/ patient
83
Limit PC
Pressure
84
Cycle in PC
Time
85
Set settings PC
- PC level
- Rate
- Ti
- PEEP
- FiO2
- Sensivity
86
What does it mean when there is no pressure equilibration on flow waveform?
Flow will not reach 0, meaning that the entire set pressure did not enter lungs
87
Square flow waveform would change Ti in volume control
Shorter
88
If compliance increases, what would happen to volumes in PC, PRVC, and VC?
1. Volumes would increase (if not equilibration)
2. Pressures would decrease in PRVC and PC
89
If compliance decreases, what would happen to volumes in PC, PRVC, and VC?
1. Volumes will decrease in PC (if no equilibration)
2. Pressure will increase in PRVC and VC
90
PRVC benefits?
MV control and pressure control
Limits pressure lungs are exposed to (uses lowest pressure needed. )
better distribution of ventilation and improved oxygenation.
91
Trigger PRVC
time patient
92
Limit PRVC
Pressure limited volume cycled
93
Cycle in PRVC
Time
94
PS trigger?
Patient
95
PS limit
limit
96
Cycle PS
Flow/patient cycled
97
How do you fix autopeep
1. Increase flow or Te
2. Reduce MV
3. Reduce Ti
4. Reduce RR
98
What increases mean airway pressure (MAP)?
- PEEP
- PC
- Volumes
- Increased RR with not locked I:E
99
Pressure change in absolute pressure control?
Will effect volumes when you change the delta.
Ex (PEEP 5 Abs 30, change to PEEP 7 abs 30 will decrease the delta by 2.- smaller driving pressure will reduce the volumes)
100
ph increase calculation (Correct acidosis)
PaCo2 - ( (pH goal - pH present) / 0.01)
101
pH decrease calculation ( correct alkalosis)
PaCo2 + ( (pH present - pH goal) / 0.01)
102
Premature ABG goals
>7.25 / 45-55 / 45-65 / 15-18
103
Term neonates ABG goals
> 7.25 / 45-55 / 50-70 / 18-20
104
Term- 2yr ABG goals
7.3-7.5 / 30-40 / 80-100 / 20-22
105
Ped and adult ABG goals
7.35-7.45 / 35-45 / 80-100 / 22-26
106
Mechanical ventilator Pediatrics Settings
Ideally PRVC
- Vt 5-7ml/kg - 6ml/kg is a good place to start
- PEEP 5
- FiO2 match
- Ti ~ 0.6-1.2 (depending on age)
- RR 20-35 toddler, 20-30 child, 12-20 older child
107
Mechanical ventilator preemie settings
- RR 40-60
- 4-6ml/kg
- Ti 0.25-0.4
- PEEP 5
- FiO2 10% above blender set
108
Term neo ventilator settings
RR 25-40
Vt 4-6
Ti 0.3-0.5
PEEP 5
FiO2 10% above blender set
109
Preductal target
60-65 1 min
65-70 2min
70-75 3min
75-80 4 min
80-85 5 min
85-95 10min
110
Post birth questions
TERM TONE BREATHING
111
Indications for CPAP NRP
Grunting, high WOB, Low O2
112
indications for PPV NRP
APneic, gasping, HR <100bpm
113
CPAP settings to start NRP
+5, FiO2 0.30
114
PPV settings NRP
PIP 20 / 5 PEEP
FiO2 0.21-0.30 depending on GA
115
Sign of good ventilation?
Increasing HR
116
FiO2 set >35wks gestation
21% O2
117
FiO2 <35wks gestation
21-30% O2
118
Intubation indications NRP
Prolonged PPV
- HR is decreasing even with
-ventilation correction steps
- CPR <60bpm
- CDH
- Surfactant administration
119
What to do if Hr is still 60-100bpm
Assess chest ventilation effectiveness.
- Good ventilation = rising HR
120
What to do if HR is under 60bpm
Try to get 30sec effective ventilation.
Once effective, and still under 60bpm, do chest compressions and 100% FiO2.
121
When is APGAR conducted
1 and 5 min
10min if 5min is less than 6
122
When does grunting occur?
on expiration to try and keep airways from collapsing
- Babes do this to maintain FRC
123
Types of CPAP
1. Mechanical ventilators
2. Bubble CAP
3. SiPAP
4. high flow NP at 8lpm
124
Start SIPAP levels
4-6cmH2O
125
When would you transition or switch CPAP to mechanical ventilation?
- Increased WOB
- Decreasing pH
- PaCO2 > 60mmhg
- High FiO2 requirements
frequent apnea with cyanosis
126
Indicators of a comfortable infant on CPAP
Comfortable infant
reduced RR
Minimal or no chest retractions
SpO2 88-95%
Improvement of chest radiograph appearance
Reduction in severity and apneic episodes
127
When to consider weaning of CPAP
Low WOB
Low FiO2
128
What to wean first on CPAP?
Turn down FiO2 in increments until <0.25, and then reduce the CPAP by 1cmh2o.
alternate weaning each one until at CPAP 4 and FiO2 0.21
129
When can yo take an infant off CPAP
Low WOB on CPAP 4 and FiO2 0.21
130
risks with uncuffed tubes
Increased aspiration risk
- Easily kinked, causing increased resistance
- Helps minimize aspiration and prevents tube occlusion
131
What can retained secretions lead to?
Increased resistance
Increased WOB
Hypoxemia, hypercapnea, atelectasis and infection
132
What to do if patient vagals or decreased SpO2 whie suctioning
STOP STAY STABLE
- stop suctioning, put back on ventilator at same settings, and treat
133
PEA characteristics
No palpable pulse
- Rate may be slow or fast
- ECG may display normal or wide QRS
- May be caused by reversible conditions (H/T)
134
Ett size estimate
age in years / 4 + 4
135
Cardiopulmonary compromise and HR <60bpm
Chest compressions and epinephrine admin
136
Cardiopulmonary compromise with HR > 60bpm
Atropine or epinephrine.
137
What is Cardiopulmonary compromise according to ACLS?
- Hypotension
- Acutely altered mental status
- Signs of shock
138
Bradycardia medications
- Epinephrine- for everyone
- Atropine for vagal response and heart blocks
- Dopamine??
139
Tacycardia medication
Adenosine
Amiodarone
Procainamide
140
Treatment of sinus tachycardia
Treat underlying cause (pain, anxiety)
141
Treatment of stable SVT
Vagal maneuvers and adenosine
142
Treatment of unstable SVT
- Synchronized cardioversion and adenosine
- Vagal maneuvers while waiting
143
Cardioversion dose
0.5 - 2.0 J/kg (0.5-1 first does)
144
Stable VT treatment
Adenosine and possible amiodarone or procainamide
145
Unstable VT treatmet
Cardioversion
146
Characteristics of Sinus tachycardia
- HR <180
- Normal P waves and PRI
- Narrow QRS
- Variable R-R interva;
147
SVT characteristics
HR > 180
Infant showing signs of CHF
Ped showing signs of palpatations
Abrupt onset
148
What are indications for mechanical ventilation?
- Apnea/cessation of breathing
- Acute ventilatory failure (pH <7.30, PaCO2 > 50)
- Impending failure (Primary, Secondary)
- Inability to oxygenate
149
What affect does PPV or PEEP have on intrapleural pressures and CO?
PEEP increases intrapleural pressures and dampens venous return/decreases CO
150
What affect does PEEP have on compliance?
PEEP increases lung compliance by shifting the compliance curve.
- Too much = overdistension
151
What affect does PEEP have on dead space
PEEP increases FRC and in turn increases deadspace with COPD and normal lungs
152
Does PEEP increase or decrease intrapulmonary shunt?
PEEP decreases intrapulmonary shunt.
- Keeps alveoli open for better V/Q matching
153
How does PEEP affect preload?
PEEP is used to decrease right side preload in CHF/Cor pulmonale patients
- PEEP lowers/dampens venous return
154
What is optimal PEEP if hemodynamics are stable?
Optimal PEEP is 15
155
What is Primary impending failure associated with?
Pulmonary related
1. ARDS
2. Pneumonia
3. Pulmonary Emboli
156
What is Secondary Impending Failure associated with?
(Non Pulmonary)
1. Sepsis
2. Muscle Fatigue
3. Nutritional deficiencies
4. Chest Injury
5. Thoracic Abnormalities
6. Neurological Disease
157
Trigger/cycle/limit for all vent settings?
158
What are 3 opposing forces of resistance to ventilation?
Opposing Forces:
1. Elastic Resistance - surface tension, lung complaince
2. Non-Elastic Resistance - airway resistance, tissue resistance
3. Inertia - during ventilation effort - thorax is moved
159
What are characteristics of HFO?
- Inspiration is positive pressure (opposite of normal, its being pushed in)
- Exhalation is negative pressure (push and pull)
- Force of oscillation = delta pressure
- Resistance to bias flow = MAP
- Keeps lungs in state of hyperinflation
- Does not affect surfactant levels like conventional ventilation
160
Indications for HFO?
- Ards/ RDS in babes
- BP fistula
161
What does ventilation in HFO depend on?
1. Rate (increasing rate will further drop Vt when amplitude is minimal)
2. Delta Pressure/ Amplitude
3. Bias Flow → controls MAP
- Increasing pressure (amplitude) and bias flow increase Vt
- CO2 elimination is inversely related to rate (decrease rate to increase CO2 elimination)
- Lower rates allow for greater Vt delivery time (larger Vt)
162
What does oxygenation depend on in HFO?
Depends on MAP
- Greater MAP = greater FRC and PEEP
- Longer I times = Increase MAP (low rates)
- Increased Bias Flow = Increased MAP
163
