Mechanical Ventilation Flashcards
1
Q
Respiratory Anatomy
what % of each?
A
Two Zones:
Conducting = trachea branching → bronchi, segmental bronchi → terminal bronchioles, (none of which contain any alveoli) only serves to deliver air to the respiratory zone
– 5% of lung volume
Respiratory = Bronchioles and alveolar ducts; responsible for gas exchange
– 95% of lung volume
2
Q
Anatomical Dead Space
A
Conductive airway
-Does not participate in gas exchange
3
Q
Lung Compliance
A
– Ability of the lungs to expand
– determined by elasticity or tendancy of form to return to its original state
C =ΔV ÷ ΔP
4
Q
“Work of breathing”
A
Energy expended to created pressure gradient that allows airflow easily in and out of the lungs
– Air flows from high-pressure region (mouth/nouse) to low-pressure (lungs)
5
Q
Tidal Volume
A
Tidal volume is the volume of air inspired and expired during one breath
– dead space volume and volume of fresh gass entering alveoli for gas exchange
6 to 8 ml/kg for Lung dz; 10-12 ml/kg for healthy lungs
6
Q
Minute Volume
A
Minute volume is the volume of air inspired and expired during 1minute
7
Q
Resistance
2 types
A
Resistance to breathing is a combination of frictional forces that must be overcome for negative intrathoracic pressure to be created and for air to enter the lungs
– Tissue resistance = need to move or displace the lungs, abdominal organs, ribcage, and diaphragm to create negative pressure
–Air resistance = air moving through the conductive airway dependent on the viscosity and density of the gas, and the length and diameter of the airway
* Ex; bronchospasm, increased secretions, mucosal edema, and physical narrowing or occlusion of endotracheal tubes
8
Q
Hypoxemia criteria
A
– PaO2 less than 80 mmHg
– less than 60 mmHg (SpO2 > 90%) being severe hypoxemia
9
Q
Causes for Hypoxemia
#5
A
- hypoventilation
- dysfunctional diffusion
- low inspired oxygen
- ventilation/perfusion mismatch caused by dead space ventilation or shunting
- Intrapulmonary shunt
10
Q
Hypercapnia definition
what can cause it? #4
A
PaCO2 of more than 45 mmHg, with values over 60 mmHg being considered severe
–can be caused by hypoventilation, high inspired CO2, increased CO2 production, and dead space ventilation
11
Q
What value is responsible for controlling CO2 levels?
A
Alveolar ventilation created by breathing
– Amount of fresh gas that moves in and out of the respiratory zone, which participates in gas exchange
–Alveolar ventilation inversely proportional to CO2 levels
(tidal volume - physiological dead space) x RR
12
Q
Indications for Mechanical Ventilation
#4
A
- severe hypoxemia despite oxygen supplementation
- severe hypercapnia despite therapy
- excessive respiratory effort and risk of respiratory fatigue or arrest
- severe hemodynamic compromise to reduce oxygen consumption by removal of the work of breathing and change in metabolic rate from drug administration
13
Q
Causes for hypoventilation that might indicate MV
#7
A
- Upper airway obstruction
- Respiratory depressant drugs
- Drug overdose
- Neuromuscular toxins
- Neurological disorders
- Pleural space disease
- Excessive dead space
MV needed if therapy not effective
14
Q
Relation of PaCO2 and TBI
A
- Hypercapnia leads to vasodilation
- Hypocapnia to vasoconstriction
- affects ICP
15
Q
MV for Post Arrest Care
Target PaCO2 for cats vs dogs
A
Effort to reduce tissue oxygen demand by removing the work of breathing, or as a part of respiratory optimization to provide ventilation due to apnea
– Control of PaCO2 to 32–43 mmHg in dogs and 26–36 mmHg in cats to prevent intracranial hypertension
16
Q
Control Variables for MV
A
Pressure, Volume, Flow
17
Q
“Dead Space” Definition
#3
A
Portion of the tidal volume that does not participate in gas exchange
Characterized as:
1. Apparatus = circuit from the Y-piece to the nose of the patient comprises apparatus dead space
2. Anatomic = conducting airways from the nose to the level of the alveoli
3. Alveolar = alveoli that are ventilated but not perfused in pulmonary capillaries
18
Q
Physiological Dead Space
A
Anatomic + Alveolar dead space
–sum of portions that do not participate in gas exchange
–normally should be about the same as anatomic dead space however with V/Q inequality → PDS increases due to increase in alveolar dead space
19
Q
Ventilator Breath Types: Mandatory
Trigger, Inspiration, Termination
A
Trigger: ventilator
Inspiratory Flow: ventilator
Termination cyce: ventilator
20
Q
Ventilator Breath Types: Assisted
Trigger:
Inspiratory Flow:
Termination cycle:
A
Trigger: Patient
Inspiratory Flow: Ventilator
Termination cycle: Ventilator
21
Q
Ventilator Breath Types: Spontaneous
A
Trigger: Patient
Inspiratory flow: Patient
Termination Cycle: Patient
22
Q
Ventilator Breath Types: Supported
Trigger:
Inspiratory flow:
Termination cycle:
A
Trigger: Patient
Inspiratory flow: Ventilator
Termination cycle: Patient
23
Q
Ventilator Mode Classifications
#3
A
- Continuous mandatory ventilation: All mandatory breaths are delivered
- Intermittent mandatory ventilation: Both mandatory and spontaneous breaths
- Continuous spontaneous ventilation: All spontaneous breaths
24
Q
Pressure-controlled MV
what becomes the variable?
A
Pressure-controlled breath = the machine will maintain airway pressure as determined by the operator, and inspiration ends when a preset inspiratory time is reached
– TV and flow rate dependent on the magnitude of the preset airway pressure as well as the resistance and compliance of patient
25
Volume - controlled MV
Machine will deliver the preset TV over the preset inspiratory time
-- Airway pressure reached is dependent on the magnitude of the preset TV and subsequent flow rate
## Footnote
Flow and Volume controll essentially the same
26
Cycle Variable
Determines the termination of inspiratory flow
Ex: time is the cycle variable for a pressure-controlled breath (I:E Ratio)
27
Trigger Variable
| #4 types
Parameter that initiates breath
--typically set RR
--with synchronization;
-- change in airway pressure **(pressure trigger)**
--- or gas flow **(flow trigger)**
-- **Volume trigger** = drop in airway circuit volume as air moving into the patient from spontaneous effort to initiate a breath
-- **Time trigger** =ventilator initiates inspiration at set time intervals = set ventilation rate
28
Limit Variable
Parameter that the breath cannot exceed during inspiration, (but does not terminate the breath)
-- Ex: in Volume control setting → pressure-limit breath = the ventilator will generate the breath by delivering a preset tidal volume, but will not exceed the limit set for airway pressure
29
Intermittent mandatory ventilation
Set number of mandatory breaths are delivered but between set breaths patient can breath
-- Advanced machines will try to synchronize breaths with patients spontaneous one = **SIMV**
-- operator can only control the minimum RR and MV; there is no control over the Max rate or Max MV since this is determined by the patient
--useful in providing partial respiratory support in patients with unreliable respiratory drive
30
Intermittent mandatory ventilation complications
Breath stacking can occur in IMV mode when spontaneous breaths and time‐triggered mandatory breaths occur in an overlapping manner, potentially leading to increased incidence of barotrauma and volutrauma to lung tissue
--the use of SIMV helps prevent this
31
Continuous Spontaneous Ventilation
| 2 types
what does patient control?
--Breath, RR, I Time, and TV determined by patient
-- CPAP and Pressure supported ventilation (PSV)
32
CPAP
| what does patient control?
what are the benefits?
Constant positive airway pressure
--Patients allowed to spontaneously breathe by dictating the timing and depth of every breath through their respiratory drive while still connected to the mechanical ventilator
-- increases functional residual capacity and compliance, enhancing gas exchange and oxygenation.
-- improve oxygenation in patients by increasing functional residual capacity and compliance
33
PSV
when is it used?
| what type of MV?
Inspiratory flow is raised to a preset level of inspiratory pressure
-- form of **assisted ventilation** where ventilator supplies constant pressure to the airway during the inspiratory phase of the breath
-- useful in patients with adequate respiratory drive **but compromised ventilatory strength** as the positive pressure can help overcome airway resistance
-- reduces the effort required to maintain spontaneous breathing in patients with adequate respiratory drive and inadequate ventilatory strength
34
I:E Ratio
| Normal vs dz lungs
I:E ratio of 1:2 typically utilized to ensure the patient has fully exhaled prior to the onset of the next breath
-- As RRs are increased, expiratory time will be sacrificed to “squeeze” in the necessary number of breaths → need for reverse or inverse I:E ratio ventilation
-- **inverse I:E ratio can = breath stacking or intrinsic PEEP** as the animal is not able to fully exhale before the start of the next inspiration (has been used to improve oxygenation)
## Footnote
1:1–1:2 for lung dz
35
PEEP
| Amount used for normal and dz lungs
Positive end expiratory pressure
-- maintains elevated intrathoracic pressures during exhalation
--Can ↑ O2 efficiency of diseased lungs by recruiting previously collapsed alveoli, preventing further alveolar collapse, and reducing ventilator-induced lung injury
-- setting depends on severity of lung dz
## Footnote
5 to 8 cmH2o for lung dz; 0-5 cmH2o for healthy lungs
36
Negative Effects of PEEP
-- ↑ intrathoracic pressure can compromise venous return
-- must be calculated with PIP → PEEP of 5 cmH2o will be given WITH PIP of 20 for total pressure = 25 cmH2O (over pressurized)
37
# Control of Breathing
Respiratory center
Area in the **medulla oblongata** of the brainstem
-- Contain individual control centers for functions such as inspiration, expiration, and breath holding
38
Rise Time
-- time it takes to reach peak airway pressure
-- Faster rise times indicated in patients with rapid RRs, although caution is advised in animals with small endotracheal tubes due to increased resistance to flow
## Footnote
0.1 to 0.3 seconds
39
Peak Airway Pressure
| Normal vs Dz lungs
kept below 20 cm H2O, often closer to 10 cm H2O in patients with normal lungs
-- with pulmonary dz lung compliance is reduced and requires higher pressures in order to deliver an adequate TV
--airway pressures up to 30 cm H2O may be necessary for severe dz
40
Alveolar Minute Ventilation
MV = RR xTV but **portion of volume inspired does not participate in gas exchange (dead space)** and therefor does not contribute to CO2 elimination
Alveolar minute ventilation = RR x (TV - dead space volume)
-- ↑ in dead space = ↓ in effective alveolar ventilation = hypercapnia
41
Oxygen MV settings
-- first priority in titrating ventilator settings is to reduce the FiO2 to ≤60% as soon as possible to reduce the risk of oxygen toxicity
-- After any reduction in oxygen concentration, the PaO2 should be reevaluated
42
MV adjustments in the face of hypoxemia with FiO2 100%
Increases in PEEP, PIP or VT, and/or RR may help improve the oxygenating efficiency of the lung
43
MV complications
| #4
1. cardiovascular compromise
2. ventilator-induced lung injury
3. ventilator-associated pneumonia
4. pneumothorax (> 35 cmH2o plateau pressure)
44
ventilator-associated pneumonia
## Footnote
when does it typically occur?
what contributes to increase risk of VAP?
* pneumonia occurring more than 48 hours after endotracheal intubation for mechanical ventilation
* chance of VAP occurring increases as the time on ventilation increase
* Because an intubated patient has a physical barrier preventing the mucociliary ladder from functioning properly (endotracheal cuff) and does not cough (placed under anesthesia or sedation), the physical defense mechanisms are dysfunctional
* critically ill patients often are immunocompromised, preventing proper immunological response to the pathogens and leading to higher chances of infection
45
Causes of Ventilation induced Lung Injury
| #5
1.**Volutrauma** overdistention and shearing injury (TV exceed 40 mL/kg)
2.**Barotrauma** high airway pressures possibly leading to alveolar rupture and pneumothorax (PIP exceed 30 cmH2O)
3.**Biotrauma** lung injury 2nd to release of inflammatory mediators during prolonged mechanical ventilation
4. Repetitive alveolar opening and collapse **(shear injury)**
5. **Atelectrauma**: Cyclic recruitment – derecruitment injury
46
Patient Ventilator Asynchrony
-- mismatch between the needs of the patient (with regards to flow, volume, time or pressure) and the ventilator-assisted breath
-- rely on waveform analysis as a noninvasive way of detecting PVA (pressure, flow, volume)
47
Lung protective ventilation
-- means to limit overdistention of alveoli that may contribute to VILI
--strategy involves lower tidal volumes and limited plateau airway pressures
-- uses pressure-controlled modes of ventilation
--PEEP used to improve oxygenation by increasing the recruitment of alveoli, reducing VILI, and decreasing shunt fraction
-- Low TV reduces volutrauma/barotruama/biotrauma
48
Target Oxygentation with MV
below normal, but compatible with adequate organ oxygenation:
PaO2 55–80 mm Hg
oxygen saturation (SpO2) of 88%–95%
using the least aggressive settings.
49
Settings for Refractory Hypoxemia
-- recruitment maneuvers to open up (“recruit”) alveoli quickly with an increased transpulmonary pressure, followed by a high PEEP to keep them open at end expiration
-- requires deep general anesthesia ± paralytics, and it is often difficult to determine the optimal PEEP following recruitment.
50
ARDSnet Protocol for PEEP Titration
Lower PEEP/higher FiO2
OR
Higher PEEP/lower FiO2
51
Advanced mechanical ventilation: Pressure modes
Airway pressure release ventilation (APRV)
-- utilizes sustained high levels of CPAP and only brief periods of a “release phase” that offers an opportunity for more efficient alveolar ventilation and CO2 removal
--time cycled, pressure-controlled, intermittent mandatory ventilation mode with extreme inverse I:E ratios
--**mandatory mode that allows for unrestricted patient breathing during P-high **and therefore may help to reduce asynchrony
--**relies on spontaneous breathing**
52
Pressure-regulated volume control
-- automatically adjusts breath to breath inspiratory pressure based on a set TV and changing lung mechanics
-- time- or patient-triggered, pressure-limited, and time cycled used with patients in either assist control or simultaneous intermittent mechanical ventilation
-- **set a target TV** and then a series of test breaths **helps to establish the PC necessary to achieve the target TV**
53
# Waveforms
Scalars vs Loops
Scalar → single parameter is plotted over time (typically have 6 charateristic shape forms)
Loops → two parameters plotted simultaneously
54
# Waveforms
Typical shapes of scalars
| $6
square
ascending ramp
descending ramp
sine
exponential rise
exponential decay
55
Sine waveforms
characteristic of patient efforts such as are seen with spontaneous breaths CPAP or SIMV.
56
Square waveforms indicate that the given parameter changes abruptly but is then held at a near constant value for a time
57
Ramp and exponential waveforms indicate that a parameter is changing gradually over time, with a rate of change that is either constant (ramp) or variable (exponential)
## Footnote
appear in pressure flow or volume settings
58
## Footnote
Which ventilation mode is this?
what does the highlighten area show?
pressure, flow, and volume scalars typical of **volume control modes** of ventilation are shown. -- inspiratory hold is in place (shaded zones), which gives the pressure scalar (A) the classic appearance of a shark fin with a bite taken out of it
-- highlighted area denotes a period of inspiratory hold, = time for intrapulmonary redistribution of gas (“pendelluft”) with a **resultant pressure decline from peak inspiratory pressure (PIP) to plateau pressure (Pplat).**
-- delivery of flow at a constant rate allows for meaningful assessment of airway resistance (Raw).
59
## Footnote
Which ventilation mode is this?
what do each dashed circle respresent?
pressure, flow, and volume scalars typical of **pressure control modes** of ventilation are shown
-- **inspiratory hold** = encircled, and this will result in plateau of the volume scalar (C).
-- scalars for the second breath are typical of pressure support modes of ventilation.
* PC modes = pressure waveform is now the one with the characteristic shape, whereas the flow waveform typically assumes the shape of an exponential decay.
* inspiratory flow is not expected to reach zero before expiration begins.
* Bc the termination of inspiratory flow occurs **when flow is low but not zero** the volume waveform shows a minimal plateau **(lower dashed circle)**.
## Footnote
SIMV-PC PSV,
60
## Footnote
What type of wave forms are these?
Where is PIP and Pplat defined? a,b,c
**Pressure waveforms**
* Point **(a)** represents **PIP** and point **(c)** indicates **Pplat.**
* **B:** shows that when (PEEP) is being applied it is expected that pressure never returns to baseline, but rather remains at this preset level above atmospheric pressure between breaths (dashed line).
* Both PIP (denoted “a” on the figure) and Pplat (denoted “c” on the figure) can be determined. These pressures **can be used to calculate dynamic and static compliances,**
61
## Footnote
What type of mode is this?
Define each scalar
Waveform in **pressure‐controlled ventilation**
-- Pressure rises quickly w/ inspiration to set pressure w/ correlating volume increase and positive flow (towards the patient)
-- With expiration → pressure instantly lost, volume rapidly decreases and eventually drops to zero as the recoil pushes the air out
--Flow immediately changes to **negative (away from patient)** and gradually dies down as recoil is satisfied
62
## Footnote
What type of mode is this?
Define each scalar
Waveform in **volume‐controlled** ventilation
--Pressure increases linearly during inspiration as target breath volume is achieved through consistent positive flow
--Expiration, the pressure is instantly lost, volume rapidly decreases and eventually drops to zero as the recoil pushes the air out
--Flow immediately changes to negative and gradually dies down as recoil is satisfied.
63
## Footnote
What type of loops are these?
What is the difference between A and B?
**Pressure-Volume loops** for **machine-triggered (A)** and **patient-triggered (B)** breaths are depicted.
* represent the relationship between **changes in pressure and changes in volume** in the ventilator circuit
* the loop does not begin at a pressure value of zero. This indicates the **patient is on PEEP**.
* vertical line and arrow indicate the PEEP value, and one can note that the patient efforts bring airway pressure below this resting value
64
## Footnote
What does the slope ultimately represent?
what happens if resistance increases?
* dash line connects start and end inspiratory points
* measure of pulmonary compliance
* bowing of the inspiratory limb away from this line reflects the additional pressure required to overcome airway and circuit resistances
65
## Footnote
what is the difference between the purple and blue loop?
What does loop bowing indicate?
* purple loop is the initial tracing, and the blue loop shows the changes expected to occur with an increase in airway or circuit resistances
loop bows out farther from the dynamic compliance line = **greater applied pressure required to overcome resistance** and reach a given volume
* ↑ bowing of PV loop should prompt to investigate whether the ETT is kinked or obstructed, heat-moisture exchanger occlusion has occurred, or airway suctioning or bronchodilator needed.
66
## Footnote
What is beaking?
* Excessively large tidal volumes = “beaking” of the terminal portion of the inspiratory limb.
* Beaking reflects further increases in circuit pressure with minimal additional volume increase → alveoli expanded excessively and can only accept additional volume with large pressure increases
67
## Footnote
What is the difference between LIP and UIP
* lower inflection point (LIP) = point at which pulmonary compliance significantly increases.
* upper inflection point (UIP) = point at which pulmonary compliance significantly decreases because of alveolar overdistention and risk of alveolar injury (volutrauma) is increased
* leak in the ventilator circuit = open, broken, incomplete loop
68
## Footnote
What is the difference between A, B, C?
Circuit leaks and excessive airway secretions can be detected on flow–volume loops
A. FV loops w/ increased Raw
B. circuit leaks
C: example of a FV loop with saw-tooth appearance to the effort-independent portion of the expiratory limb → reliable indicators of the need for tracheal suction
69
Ventilator respiratory cycle: Phase I
| relation to patient ventilator dsysynchrony? (PVD)
* (phase 1) is the initiation of inspiration, which is also called the trigger mechanism
* PVD during phase 1 referred to as trigger asynchrony
* ineffective triggering, auto-triggering, and double triggering
70
Phase I: PVD ineffective triggering
| what causes it?
* patient-generated decrease in airway pressure with a simultaneous increase in airflow without triggering a machine-delivered breath
* result of an inappropriately set sensitivity setting
* should look for evidence of an improper triggering threshold, auto-PEEP (PEEPi), significant muscle weakness/fatigue, reduced respiratory drive, or an excessively deep level of anesthesia.
71
Phase I: PVD Auto-triggering
* occurs when a breath is delivered by the ventilator because of a change in airway pressure or flow not caused by patient effort
* due to an inappropriately small threshold/sensitivity setting.
72
Phase I: PVD Double triggering
* defined as two delivered breaths separated by an expiratory time less than half the mean expiratory time.
* patient’s inspiratory effort continues throughout the ventilator’s preset I-time and thus remains present after the I-time has been completed.
* prolonged effort triggers another breath.
73
Flow asynchrony
| Definition
what does it look like on tracing?
how to address it?
-- Flow asynchrony is the result of ventilator supply of fresh gas to the inspiratory circuit that is either too fast or too slow for the individual patient
-- breaths have a “scooped out,” concave appearance on the upswing of the pressure tracing and saw-tooth appearance to the plateau phase
--addres by: increasing inspiratory flow until the two types of breaths have similar appearing waveforms
74
Expiratory asynchrony
| definition
how is it adjusted?
-- manifests as auto-PEEP (gas trapping)
-- If auto-PEEP is detected, adjustment of parameters serve to prolong expiratory time needed
-- e.g., trigger sensitivity, peak flow, flow pattern, rise time, I-time, cycle threshold, inspiratory to expiratory ratio’ with (I:E) ratio, and respiratory rate).
-- Auto-PEEP increases the difficulty the patient faces in reaching the triggering threshold.
-- Increasing PEEP to account for auto-PEEP may improve triggering sensitivity and efficacy.
75
Comparison of pressure waveform in intermittent mandatory ventilation (IMV) and synchronous intermittent mandatory ventilation (SIMV). Both modes allow for spontaneous breaths in between mandatory breaths.
76
## Footnote
What type of loop is this and what do the arrows represent?
-- typical pressure‐volume loop
-- peak represents PIP on the pressure axis and TV on the volume axis.
-- inspiratory limb is represented by the upward arrow while the expiratory limb is represented by the downward arrow.
77
How does lung compliance affect Pressure-volume loops?
As compliance ↓ (as it can with pulmonary dz), the lungs are stiffer = smaller TV with the same pressure = flattening the loop
-- opposite is true for ↑ compliance
-- direction in which the loops deviate is different based on whether the ventilator is in pressure‐ or volume‐controlled mode
78
## Footnote
What mode is this?
What does each loop represent?
* PV loop changes depending on lung compliance in pressure‐controlled ventilation
* blue loop represents normal compliance.
* red loop represents decreased compliance with the ventilator achieving lower tidal volume with the same pressure
* green loop represents increased compliance with the ventilator achieving higher tidal volume with the same pressure
79
## Footnote
What mode does this represent?
What does each loop represent?
PV loop changes depending on lung compliance in volume‐controlled ventilation
* blue loop represents normal compliance
* red loop represents decreased compliance with the ventilator producing higher pressure to achieve the same tidal volume
* green loop represents increased compliance with the ventilator producing lower pressure to achieve the same tidal volume
80
Airway Managment
* ETT should be sterile and use a low pressure cuff
* Cuff pressure exceeding 30 cmH2O has been observed to obstruct mucosal blood flow within the trachea
* Cuff pressure of at least 20 cmH2O should be maintained instead of repositioning the cuff routinely to reduce the chances of ventilator‐associated pneumonia (VAP)
81
Benefits of Humidification
help keep ET tubes patent,
reduce tracheal inflammation
promote ciliary function
82
Why are inhalant anesthetics avoids with MV?
-- inhalants inhibit hypoxic pulmonary vasoconstriction, possibly potentiating the severity of hypoxemia
-- a mechanism which helps shunt pulmonary blood flow away from alveoli with lower oxygen concentration to alveoli with higher oxygen concentration
-- TIVA has less effect on immune function than inhalants
83
Neuromuscular blocking agents risks with MV
| #3
-- NMBAs has been associated with quadriplegic myopathy syndrome
-- critical illness polyneuropathy
-- ventilator-induced diaphragmatic dysfunction.
84
When is NMB agents beneficial?
ARDS patients
-- significant PVD despite setting adjustments
-- shown to prevent volutrauma and barotrauma associated with patient–ventilator dyssynchrony.
85
CVS effects from MV
| What causes it? #3 examples
Hemodynamic instability can occur 2nd to changes in intrapleural pressure from PPV, PEEP, effects of sedatives or anesthetic agents, and the underlying disease process itself.
-- Acute reduction in venous return
-- more pronounced in hypovolemic patients or those with inappropriate vasodilation secondary to sepsis
-- ↓ CO 2nd to PPV from high airway pressures (increases in Mean Airway Pressures have a more negative effect on CO than changes in PIP), ↑ lung compliance, and ↓ circulating volume.
86
Arrhythmias during MV
| 2 examples
-- Bradyarrhythmias from high vagal tone 2nd to resp. dz, manipulation of the airway or ETT, gastric distention, TBI, or electrolyte abnormalities.
-- Ventricular and supraventricular ectopy are also common and may precipitate with given changes in volume, sympathetic and parasympathetic tone or as a result of myocardial ischemia
87
ETCO2 in relation to PaCO2
ETCO2 is a value obtained from the plateau of the CO2 waveform and in healthy patients is 1–5 mm Hg less that the PaCO2
-- Sudden increases or decreases in ETCO2 may be associated with equipment malfunction, changes in CO and obstruction of pulmonary blood flow as may occur with PTE or air embolism.
88
P(a-ET)CO2 gradient
P(a-ET)CO2 gradient is the result of dilution of alveolar gas by gas in the physiologic dead space
-- mechanically ventilated patients with abnormal lung function, there is much more variability in the P(a-ET)CO2 gradient
89
Common Factors Reducing the Likelihood of Successful Ventilator Weaning
| #5
1. Lack of resolution of primary disease process
2. Acquired respiratory muscle weakness
3. Inadequate recovery from anesthetic and
4. sedative drugs and/or neuromuscular blocking agents
5. Increased work of breathing
90
Criteria for Readiness for a Spontaneous Breathing Trial
| #6
* Improvement in the primary disease process
* PaO2:FiO2 ratio >150–200 with FiO2 <0.5
* PEEP ≤5 cm H2O
* Adequate respiratory drive
* Hemodynamic stability
* Absence of major organ failure
91
Complications of weaning for MV periods of 48+ hours
* Acquired respiratory muscle weakness
* causes inspiratory muscle weakness that is proportional to the duration of ventilation
= **ventilator-induced diaphragmatic dysfunction**
92
MV approaches to weaning
| Modes utilized
-- weaning process must force the patient to assume some of the work of breathing to recondition the inspiratory muscles.
-- spontaneous breathing without ventilator support, pressure support ventilation (PSV), and synchronized intermittent mandatory ventilation (SIMV).
-- continuous positive airway pressure (CPAP) with or without PSV
93
Criteria for Failure of a Spontaneous Breathing Trial
| 10
* Tachypnea (RR >50)
* PaO2 <60 mm Hg or SpO2 <90%
* PaCO2 >55 mm Hg or PvCO2 >60 mm Hg or ETCO2 >50 mm Hg
* Tidal volume <7 ml/kg
* Tachycardia
* Hypertension
* Hyperthermia or increase in temperature of >1°C
* Anxiety
* Signs of increased respiratory effort or distress
* Clinical judgment
94
Plateau pressure
-- represents the pressure applied to the lung as it is not impacted by resistance of the system.
-- measured during an inspiratory hold maneuver
-- Protective lung ventilation strategies in human medicine recommend targeting a plateau pressure of less than 30 cm H2O
95
Ventilator-associated pneumonia (VAP)
diagnosed based on the presence of systemic inflammation, worsening pulmonary function, and new or progressive pulmonary infiltrates on thoracic imaging occurring after at least 48 hours of intubation
96
Preventative Measures that May Decrease the Incidence of VAP
**Nonpharmacologic**
* Provide educational program for caregivers and monitoring of compliance
* Use of strict alcohol-based hand hygiene
* Minimize time of intubation with weaning protocols
* Do not change ventilatory circuit unless contamination occurs
* Aspiration of subglottic secretions
* Maintain endotracheal tube cuff pressure ≥25 cm H2O
* Minimize nurse to patient ratio
**Pharmacologic**
* Perform oral care with dilute chlorhexidine
* Avoid increasing gastric pH prophylactically
