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Interventions 2 (RESP 319) > Mech. Vent Review + strategies > Flashcards

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
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2
Q

Do pediatrics/neonates have different mech. ventilation complications as adults?

A

No, they mainly share the same complications

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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
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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
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5
Q

Why aren’t HME’s added to the ventilator circuit for neonates?

A

They add deadspace, so heated humidity is used instead.

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6
Q

What temperatures should be be used for neonates on mech. ventilation?

A

35-37C

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7
Q

Which mode of mech. ventilation is the preferred initial choice for neonates?

A

Volume control (precise volume targets)

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8
Q

What mode of ventilation is typically used for kids?

A

PRVC or PCCMV adaptative or pressure control

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9
Q

Why wouldn’t you use pressure support for kids?

A

Their vessels are small, the vent would miss their targets?

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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

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11
Q

When would you use HFO or Jet Ventilation?

A

When babes are in troubling.

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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.
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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.

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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.
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15
Q

What is the Pplat max for adults?

A

Keep under 30cmH2O

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16
Q

What is the Pplat max for neoantes?

A

Keep it under 25cmH2O

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17
Q

What is the neonate rule of 5 for mech. ventilation?

A

Vt: 5 mL/kg
RR: 50
PEEP: 5

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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
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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.
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20
Q

What do you do if your PEEP exceeds 6?

A

CxR to guide further changes

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21
Q

How to manage low oxygenation?

A
  • High FiO2 and increase PEEP
  • admin surfactant
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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

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23
Q

What is the PaCO2 for permissive hypercapnia

A

up to 60

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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)
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25
Q

ABG Targets for Very low birth weight (VLBW) < 1.5kg

A
  • pH above 7.2
  • PaCO2 (45-55)
  • PaO2 (50-70)
  • HCO3 (18-20)
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26
Q

ABG targets for children and adults?

A
  • pH (7.35-7.45)
  • PaCO2 (35-45)
  • PaO2 (80-100)
  • HCO3 (22-24)
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27
Q

What is a step up treatment from normal mechanical ventilation for infants?

A

HFO

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28
Q

What conditions are needed for a patient to transition from vents to HFO/HFV?
- hint the Pts getting worse

A
  • RR<80
  • Vt<5ml/Kg
  • PIP>25cmH2O
  • MAP>12 and/or FiO2>0.40
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29
Q

What pathology is commonly associated/at a higher chance of developing with low birth weight (LBW)?

A

RDS
- More common because LBW babes are most have less developed lungs

  • surfactant deficiency
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30
Q

ABG Targets for a Infant with Respiratory Distress Syndrome (IRDS)?

A
  • PaO2 (50-80)
  • PaCO2 (40-55)
  • pH < 7.25
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31
Q

Managements of Infant Respiratory Distress Syndrome (IRDS)?

A

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
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32
Q

why is it helpful to allow permissive hypercapnia in the early delivery of surfctant?

A

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
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33
Q

Why would HFO be helpful with IRDS management?

A

IRDS = low surfactant = low compliance.

  • Stiffer lungs cause PIPs to rise.
  • need oscillation pressures to manage that (support PEEP/alveoli)
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34
Q

What should CPAP on babes max out at?

A

8

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35
Q

What is the cause of Bronchopulmonary Dysplasia (BPD)?

A

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

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36
Q

What are lung protective strategies to prevent BPD for infants?

A
  • 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)
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37
Q

PPV goals for Bronchopulmonary Dysplasia (BPD)

A
  • Lowest PIP necessary
  • PEEP 4-6
  • PaO2 above 50mmHg
  • PaCO2 50-60mmHg
  • Maintain acceptable pH
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38
Q

How does Transient Tachypnea of the Newborn (TTNB) present?

A

High WOB w/RR 60-80bpm

  • remember TTNB is fluid in the lungs.
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39
Q

Treatment for Transient Tachypnea of the Newborn (TTNB)?

A

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
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40
Q

Indications of Pneumonia in newborns?

A
  • Fetal Tachycardia & Low Apgars
  • Supplemental O2 required-resuscitation at birth
  • Increased WOB, grunting, tachypnea, retractions, nasal flaring, cyanosis, apnea, progressive resp. failure
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41
Q

Managements of pneumonia for infants

A
  • O2 therapy, CPAP , and mech ventilation as required to alleviate WOB
  • suction appropriately
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42
Q

what procedure is not recommended for patients w/Meconium Aspiration Syndrome (MAS)?

A

Intubation. Intubation to suction meconium is a last resort. (intubate and suction w/mec aspirator)

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43
Q

Vent strategies for Meconium Aspiration Syndrome (MAS)?

A
  • 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
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44
Q

What are 3 types of Neonatal Apneas?

A
  1. Centrally = brain
  2. Obstructive = blocked airway
  3. Mix = Brain and obstruction
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45
Q

Management of Neonatal Apnea

A

Maintain acceptable SpO2.

  • Caffeine or theophylline (bronchodilators) can help stimulate the babe
  • minimal vent. settings bc theirs no disease present
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46
Q

What are 4 primary air leak syndromes that require early recognition in babes?
- why do we want early diagnosis of this pathologies?

A

PPV makes these worse if not careful.

  • Pulmonary Interstitial Emphysema (PIE)
  • Pneumothorax
  • Pneumomediastinum
  • Subcutaneous Emphysema
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47
Q

Clinical presentation of Air leak Syndromes in infants?

A
  • 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)
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48
Q

Air leak managements for a mild pneumothorax?

A

O2 therapy at 1

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49
Q

Air leak managements for a Symptomatic pneumothorax?

A
  • Needle Aspiration, Chest tubes
  • Low PEEP and min. vent settings
  • Consider PCV
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50
Q

Clinical manifestations of Persistent Pulmonary Hypertension of the Newborn (PPHN)

A
  • 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
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51
Q

Management of Persistent Pulmonary Hypertension of the Newborn (PPHN)

A

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
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52
Q

What is the main purpose of Lung Volume Recruitment (LVRM)?

A
  1. Alveolar oxygenation when on the vent
  2. non-vent is to aid secretion clearance and alveolar oxygenation.
  3. Prevent decruitment
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53
Q

How do Lung Volume Recruitment Maneuvers improve oxygenation for non-vented Pts?

A

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?
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54
Q

When does decruitment occur?

A

When a Pt. is disconnected from a circuit, pressure is released.

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55
Q

What factor is important to stabilize and maintain inflation of alveoli?

A

PEEP is most important factor in maintaining inflation of of alveoli

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56
Q

What can assist in determining optimal peep?

A

looking at the upper and lower inflection points on a pressure volume curve.

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57
Q

Indications for a Lung Volume Recruitment Maneuver (LVRM)?

  • AKA when would you do them?
A
  • After disconnecting Pt from vent.
  • After suctioning
  • Evidence of atelectasis
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58
Q

What are contraindications for Lung Volume Recruitment Maneuvers (LVRM)?

A

Chest tubes or air leaks

  • evidences of barotrauma, pneumothorax, subcutaneous emphysema, pulmonary insertsistal emphysema
  • Air trapping with COPD and high pressures makes it worse
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59
Q

What are the 2 main components of a Lung Volume Recruitment Maneuver (LVRM) procedure?

A

Sustained inflation and Intermittent sighs

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60
Q

What is sustained inflation and how long is it?

A

CPAP for 30 seconds.

  • Applies high amount of CPAP
  • Amount of CPAP depends on weight of kid
  • Helps reopen regions
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61
Q

What are Intermittent sighs?

A

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.
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62
Q

What should you monitor during a LVRM procedure?

A

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%
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63
Q

Mechanical Ventilation Indications PaCO2

A

PaCO2 > 55mmHg

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64
Q

Mechanical ventilation indications pH?

A

pH < 7.25

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65
Q

PF ratio mechanical ventilation indications

A

PF ratio < 200

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66
Q

Goals of mechanical ventilation?

A
  • Reverse hypoxemia
  • Reverse severe acute respiratory acidosis
  • Relieve WOB,
  • Improve CO
  • Decrease ICP
  • Stabilize chest
  • Decrease myocardial O2 demand
67
Q

IBW males?

A

50 + 2.3 (height in inches - 60)

68
Q

IBW females

A

45.5 + 2.3 (in. - 60)

69
Q

what does it mean when the the following is described:

  • Larynx funnel shaped
A

cricoid more narrow and prone to obstructions

70
Q

what does it mean when the the following is described:

  • Anterior/ higher glottic opening
A

harder to visualize cords on intubation

71
Q

What does it mean when the Cartilage is more compliant?

A

Higher collapse risk (tracheomalacia)

72
Q

Risks of a larger tongue?

A

collapse easily against posterior pharynx

73
Q

Risks of Larger tonsils and adenoids

A

Bleeding easily, inflammation can obstruct

74
Q

What increases risk of tearing and swelling?

A

Fragile mucosa

75
Q

Un VCCMV, increasing RR will cause

A

Increase in only PIP and MAP

76
Q

Controlled settings in VCCMV

A
  • Rate
  • FLow
  • Vt
  • Ti pause
  • PEEP
77
Q

Trigger in VC

A

Time/patient

78
Q

Cycle in VC without pause?

A

volume

79
Q

Cycle in VC with pause?

A

Time

80
Q

Limit in VC?

A

Flow/volume

81
Q

Benefits of pressure control?

A
  • Improve oxygenation
  • Better control of pressures
  • Better distribution of ventilation
82
Q

Trigger PC

A

Time/ patient

83
Q

Limit PC

A

Pressure

84
Q

Cycle in PC

A

Time

85
Q

Set settings PC

A
  • PC level
  • Rate
  • Ti
  • PEEP
  • FiO2
  • Sensivity
86
Q

What does it mean when there is no pressure equilibration on flow waveform?

A

Flow will not reach 0, meaning that the entire set pressure did not enter lungs

87
Q

Square flow waveform would change Ti in volume control

A

Shorter

88
Q

If compliance increases, what would happen to volumes in PC, PRVC, and VC?

A
  1. Volumes would increase (if not equilibration)
  2. Pressures would decrease in PRVC and PC
89
Q

If compliance decreases, what would happen to volumes in PC, PRVC, and VC?

A
  1. Volumes will decrease in PC (if no equilibration)
  2. Pressure will increase in PRVC and VC
90
Q

PRVC benefits?

A

MV control and pressure control
Limits pressure lungs are exposed to (uses lowest pressure needed. )
better distribution of ventilation and improved oxygenation.

91
Q

Trigger PRVC

A

time patient

92
Q

Limit PRVC

A

Pressure limited volume cycled

93
Q

Cycle in PRVC

A

Time

94
Q

PS trigger?

A

Patient

95
Q

PS limit

A

limit

96
Q

Cycle PS

A

Flow/patient cycled

97
Q

How do you fix autopeep

A
  1. Increase flow or Te
  2. Reduce MV
  3. Reduce Ti
  4. Reduce RR
98
Q

What increases mean airway pressure (MAP)?

A
  • PEEP
  • PC
  • Volumes
  • Increased RR with not locked I:E
99
Q

Pressure change in absolute pressure control?

A

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
Q

ph increase calculation (Correct acidosis)

A

PaCo2 - ( (pH goal - pH present) / 0.01)

101
Q

pH decrease calculation ( correct alkalosis)

A

PaCo2 + ( (pH present - pH goal) / 0.01)

102
Q

Premature ABG goals

A

> 7.25 / 45-55 / 45-65 / 15-18

103
Q

Term neonates ABG goals

A

> 7.25 / 45-55 / 50-70 / 18-20

104
Q

Term- 2yr ABG goals

A

7.3-7.5 / 30-40 / 80-100 / 20-22

105
Q

Ped and adult ABG goals

A

7.35-7.45 / 35-45 / 80-100 / 22-26

106
Q

Mechanical ventilator Pediatrics Settings

A

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
Q

Mechanical ventilator preemie settings

A
  • RR 40-60
  • 4-6ml/kg
  • Ti 0.25-0.4
  • PEEP 5
  • FiO2 10% above blender set
108
Q

Term neo ventilator settings

A

RR 25-40
Vt 4-6
Ti 0.3-0.5
PEEP 5
FiO2 10% above blender set

109
Q

Preductal target

A

60-65 1 min
65-70 2min
70-75 3min
75-80 4 min
80-85 5 min
85-95 10min

110
Q

Post birth questions

A

TERM TONE BREATHING

111
Q

Indications for CPAP NRP

A

Grunting, high WOB, Low O2

112
Q

indications for PPV NRP

A

APneic, gasping, HR <100bpm

113
Q

CPAP settings to start NRP

A

+5, FiO2 0.30

114
Q

PPV settings NRP

A

PIP 20 / 5 PEEP
FiO2 0.21-0.30 depending on GA

115
Q

Sign of good ventilation?

A

Increasing HR

116
Q

FiO2 set >35wks gestation

A

21% O2

117
Q

FiO2 <35wks gestation

A

21-30% O2

118
Q

Intubation indications NRP

A

Prolonged PPV

  • HR is decreasing even with
    -ventilation correction steps
  • CPR <60bpm
  • CDH
  • Surfactant administration
119
Q

What to do if Hr is still 60-100bpm

A

Assess chest ventilation effectiveness.

  • Good ventilation = rising HR
120
Q

What to do if HR is under 60bpm

A

Try to get 30sec effective ventilation.

Once effective, and still under 60bpm, do chest compressions and 100% FiO2.

121
Q

When is APGAR conducted

A

1 and 5 min

10min if 5min is less than 6

122
Q

When does grunting occur?

A

on expiration to try and keep airways from collapsing

  • Babes do this to maintain FRC
123
Q

Types of CPAP

A
  1. Mechanical ventilators
  2. Bubble CAP
  3. SiPAP
  4. high flow NP at 8lpm
124
Q

Start SIPAP levels

A

4-6cmH2O

125
Q

When would you transition or switch CPAP to mechanical ventilation?

A
  • Increased WOB
  • Decreasing pH
  • PaCO2 > 60mmhg
  • High FiO2 requirements
    frequent apnea with cyanosis
126
Q

Indicators of a comfortable infant on CPAP

A

Comfortable infant
reduced RR
Minimal or no chest retractions
SpO2 88-95%
Improvement of chest radiograph appearance
Reduction in severity and apneic episodes

127
Q

When to consider weaning of CPAP

A

Low WOB
Low FiO2

128
Q

What to wean first on CPAP?

A

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
Q

When can yo take an infant off CPAP

A

Low WOB on CPAP 4 and FiO2 0.21

130
Q

risks with uncuffed tubes

A

Increased aspiration risk

  • Easily kinked, causing increased resistance
  • Helps minimize aspiration and prevents tube occlusion
131
Q

What can retained secretions lead to?

A

Increased resistance
Increased WOB
Hypoxemia, hypercapnea, atelectasis and infection

132
Q

What to do if patient vagals or decreased SpO2 whie suctioning

A

STOP STAY STABLE
- stop suctioning, put back on ventilator at same settings, and treat

133
Q

PEA characteristics

A

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
Q

Ett size estimate

A

age in years / 4 + 4

135
Q

Cardiopulmonary compromise and HR <60bpm

A

Chest compressions and epinephrine admin

136
Q

Cardiopulmonary compromise with HR > 60bpm

A

Atropine or epinephrine.

137
Q

What is Cardiopulmonary compromise according to ACLS?

A
  • Hypotension
  • Acutely altered mental status
  • Signs of shock
138
Q

Bradycardia medications

A
  • Epinephrine- for everyone
  • Atropine for vagal response and heart blocks
  • Dopamine??
139
Q

Tacycardia medication

A

Adenosine
Amiodarone
Procainamide

140
Q

Treatment of sinus tachycardia

A

Treat underlying cause (pain, anxiety)

141
Q

Treatment of stable SVT

A

Vagal maneuvers and adenosine

142
Q

Treatment of unstable SVT

A
  • Synchronized cardioversion and adenosine
  • Vagal maneuvers while waiting
143
Q

Cardioversion dose

A

0.5 - 2.0 J/kg (0.5-1 first does)

144
Q

Stable VT treatment

A

Adenosine and possible amiodarone or procainamide

145
Q

Unstable VT treatmet

A

Cardioversion

146
Q

Characteristics of Sinus tachycardia

A
  • HR <180
  • Normal P waves and PRI
  • Narrow QRS
  • Variable R-R interva;
147
Q

SVT characteristics

A

HR > 180

Infant showing signs of CHF
Ped showing signs of palpatations
Abrupt onset

148
Q

What are indications for mechanical ventilation?

A
  • Apnea/cessation of breathing
  • Acute ventilatory failure (pH <7.30, PaCO2 > 50)
  • Impending failure (Primary, Secondary)
  • Inability to oxygenate
149
Q

What affect does PPV or PEEP have on intrapleural pressures and CO?

A

PEEP increases intrapleural pressures and dampens venous return/decreases CO

150
Q

What affect does PEEP have on compliance?

A

PEEP increases lung compliance by shifting the compliance curve.

  • Too much = overdistension
151
Q

What affect does PEEP have on dead space

A

PEEP increases FRC and in turn increases deadspace with COPD and normal lungs

152
Q

Does PEEP increase or decrease intrapulmonary shunt?

A

PEEP decreases intrapulmonary shunt.

  • Keeps alveoli open for better V/Q matching
153
Q

How does PEEP affect preload?

A

PEEP is used to decrease right side preload in CHF/Cor pulmonale patients

  • PEEP lowers/dampens venous return
154
Q

What is optimal PEEP if hemodynamics are stable?

A

Optimal PEEP is 15

155
Q

What is Primary impending failure associated with?

A

Pulmonary related

  1. ARDS
  2. Pneumonia
  3. Pulmonary Emboli
156
Q

What is Secondary Impending Failure associated with?

A

(Non Pulmonary)

  1. Sepsis
  2. Muscle Fatigue
  3. Nutritional deficiencies
  4. Chest Injury
  5. Thoracic Abnormalities
  6. Neurological Disease
157
Q

Trigger/cycle/limit for all vent settings?

A
158
Q

What are 3 opposing forces of resistance to ventilation?

A

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
Q

What are characteristics of HFO?

A
  • 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
Q

Indications for HFO?

A
  • Ards/ RDS in babes
  • BP fistula
161
Q

What does ventilation in HFO depend on?

A
  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
Q

What does oxygenation depend on in HFO?

A

Depends on MAP

  • Greater MAP = greater FRC and PEEP
  • Longer I times = Increase MAP (low rates)
  • Increased Bias Flow = Increased MAP
163
Q
A

Interventions 2 (RESP 319) (25 decks)

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