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AA NMC Portsmouth > Mechanical ventilation > Flashcards

Mechanical ventilation Flashcards

1
Q

what are the indications to begin mechanical ventilation?

A
  • severely impaired gas exchange
  • rapid onset of respiratory failure
  • inadequate response to less invasive medical treatments
  • increased work of breathing with evidence of respiratory muscle fatigue
  • absent gag or cough reflex
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2
Q

what parameters indicate increased work of breathing with evidence of respiratory muscle fatigue?

A
  • RR > 35
  • inspiratory force 25 cm H2O
  • vital capacity < 10-15 ml/kg
  • PaO2 < 60 mm Hg with FiO2 > 60%
  • PaCO2 > 50 mm Hg with pH < 7.35
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3
Q

what are the different mechanical ventilation modes?

A
  • assist control ventilation (ACV)
  • intermittent mandatory ventilation (IMV)
  • synchronized intermittent mandatory ventilation (SIMV)
  • pressure support ventilation (PSV)
  • inverse ratio ventilation (IRV)
  • pressure targeted, lung protective ventilation
  • high frequency oscillatory ventilation
  • partial liquid ventilation
  • mechanical ventilation with inhaled NO
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4
Q

what is assist control ventilation? what is a potential concern?

A
  • produces ventilator-delivered breath for every patient-initiated inspiratory effort
  • respiratory alkalosis is a concern
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5
Q

what is intermittent mandatory ventilation?

A
  • allows patient to breath at a spontaneous rate and tidal volume without triggering ventilator
  • ventilator adds additional mechanical breaths at a preset rate and tidal volume
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6
Q

what is synchronized IMV? what is a major benefit?

A
  • allows ventilator to become sensitized to patient’s respiratory efforts at intervals determined by the frequency setting
  • helps prevent stacking
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7
Q

what is pressure support ventilation? when is it mainly used?

A
  • augments each patient-triggered respiratory effort by an operator-specified amount of pressure that is usually between 5-50 cm H2O
  • used primarily to augment spontaneous respiratory efforts during IMV mode during weaning trials
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8
Q

what is inverse ratio ventilation? when is it mainly used?

A
  • uses an inspiratory-to-expiratory ratio that is greater than the standard 1:2-1:3 to stabilize terminal respiratory units (alveolar recruitment)
  • considered in patients iwth a PaO2 < 60 mm Hg despire an FiO2 > 60%, peak airway pressures > 40-45 cm H2O, or need for PEEP > 15 cm H2O
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9
Q

what is lung protective pressure targeted ventilation (permissive hypercapnia)?

A

allowed to occur with elevation of PaCO2 to minimize detrimental effects of excessive airway pressures

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10
Q

what are the important ventilator settings?

A
  • FiO2
  • minute ventilation
  • PEEP
  • inspiratory flow rate
  • trigger sensitivity
  • flow by
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11
Q

what is minute ventilation?

A

RR x tidal volume

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12
Q

close monitoring of minute ventilation is important to observe in what patients?

A
  • COPD

- CO2 retention

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13
Q

definition: PEEP

A

maintenance of positive airway pressure at the end of expiration

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14
Q

what is the main goal of PEEP?

A

to achieve a PaO2 > 55-60 mm Hg with an FiO2 < 60% while avoiding significant cardiovascular sequalae

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15
Q

how should PEEP be weaned?

A

3-5 cm H2O increments while oxygenation is monitored closely

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16
Q

what is flow by?

A

triggering of the ventilator by changes in airflow as opposed to changes in airway pressures

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17
Q

what should you consider with low pressure alarms with decreased exhaled tidal volumes?

A

leak in the circuit

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18
Q

what should you do if you suspect gas trapping and auto-PEEP?

A

reduce minute ventilation

19
Q

an acute increase in the peak airway pressure usually implies:

A
  • decrease in lung compliance or

- increase in airway resistance

20
Q

loss of tidal volume, indicated by a difference between the tidal volume setting and the delivered tidal volume, implies:

A

a leak in either the ventilator or the inspiratory limb of the circuit tubing

21
Q

when should muscle paralysis be considered?

A

patients in whom effective gas exchange and ventilation cannot be achieved with other measures

22
Q

what is auto PEEP?

A

development of end-expiratory pressure casued by airflow limitation in patients with airway disease, excessive minute ventilation, or inadequate expiratory time

23
Q

what could be the end detrimental result of auto PEEP? why?

A
  • organ hypoperfusion

- impairs CO: increases work of breathing, contributing to barotrauma

24
Q

when should pneumothorax be suspected?

A
  • airway pressures rise acutely
  • breath sounds are diminished unilaterally
  • BP falls abruptly
25
Q

what are the acid base complications of mechanical ventilation?

A
  • non anion gap metabolic acidosis
  • metabolic alkalosis
  • respiratory alkalosis
26
Q

how does non anion gap metabolic acidosis render weaning difficult?

A

minute ventilation must increase to normalize pH

27
Q

how does metabolic alkalosis compromise weaning?

A

blunts ventilatory drive to maintain a normal pH

28
Q

what is a method to slow minute ventilation?

A

switch from ACV to SIMV or PSV

29
Q

what are the detrimental sequelae of respiratory alkalosis?

A
  • arrhythmias
  • CNS disturbances (seizures)
  • decrease in CO
30
Q

what are the weaning strategies?

A
  • IMV
  • T tube
  • PSV
31
Q

how does IMV facilitate weaning?

A

allows progressive change from mechanical ventilation to spontaneous breathing be decreasing ventilator rate gradually

32
Q

how does T tube facilitate weaning?

A

intersperses periods of unassisted spontaneous breathing through a T tube with periods of ventilator support

33
Q

how does PSV facilitate weaning?

A

reduces work of breathing through the endotracheal tube and the ventilator circuit

34
Q

once a PSV leve of _________ cm H2O is reached, the patient can be extubated without further decreases in PSV

A

5-8 cm H2O

35
Q

what is the WEANS NOW acronym for failure to wean reasons?

A 
W - weaning parameters 
E - endotracheal tube 
A - arterial blood gases 
N - nutrition 
S - secretions

N - neuromuscular factors
O - obstruction of airways
W - wakefulness

36
Q

what are the guidelines for assessing withdrawal of mechanical ventilation?

A
  • mental status
  • PaO2 > 60 mm Hg with FiO2 < 50%
  • PEEP 5 cm H2O
  • PaCO2 and pH normal
  • spontaneous tidal volume > 5 mL/kg
  • vital capacity > 10 mL/kg
  • minute ventilation < 10 L/min
  • maximum voluntary ventilation double of mechanical ventilation
  • maximum negative inspiratory pressure (MIP) 25 cm H2O
  • RR < 30
  • static compliance > 30 mL/cm H2O
  • rapid shallow breathing index < 100
  • stable vital signs following a 1-2 hr spontaneous breathing trial
37
Q

what are troubleshooting considerations with respect to the endotracheal tube when assessing failure to wean?

A
  • use largest tube possible
  • consider supplemental PSV
  • suction secretions
38
Q

what are troubleshooting considerations with respect to ABG when assessing failure to wean?

A
  • avoid or treat metabolic alkalosis
  • maintain PaO2 at 60-65 mm Hg to avoid blunting of respiratory drive
  • for patients with CO2 retention, keep CO2 at or above baseline
39
Q

what are troubleshooting considerations with respect to nutrition when assessing failure to wean?

A
  • ensure adequate nutritional support?
  • avoid electrolyte deficiencies
  • avoid excessive calories
40
Q

what are troubleshooting considerations with respect to secretions when assessing failure to wean?

A
  • clear regularly

- avoid excessive dehydration

41
Q

what are troubleshooting considerations with respect to neuromuscular factors when assessing failure to wean?

A
  • avoid neuromuscular depressing drugs

- avoid unnecessary corticosteroids

42
Q

what are troubleshooting considerations with respect to obstruction when assessing failure to wean?

A
  • use bronchodilators when appropriate

- exclude foreign bodies within airway

43
Q

what are troubleshooting considerations with respect to wakefulness when assessing failure to wean?

A
  • avoid oversedation

- wean in morning or when patient is most awake

AA NMC Portsmouth (1 decks)

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