NPPV/mechanical ventilation Flashcards
What are the indications for NPPV?
- COPD exacerbations (unstable)
- Cardiogenic pulmonary edema
- Acute respiratory failure in immunosuppressed patients
- Prevention of recurrent respiratory failure in extubated high risk patients
What are contraindications for NPPV and instead should be intubated?
Respiratory arrest Arterial blood pH<7.10 Medical instability Inability to protect airway and/or excessive secretions Uncooperative/agitated patient
When should u consider intubation?
If angry does not improve after 2 hours of NPPV
When managing the vent after intubation, what should be settings be?
Volume-targeted, tidal volume 6-8mg/kg ideal body weight (<=6mg/kg of ideal body weight for ARDS)
8-14 RR
If 2 hours after intubation, ABG shows pCO2 7.5 and BP low, next step?
Decrease tidal volume
If after intubation, Chest X-ray show atelectasis, next step?
Increase tidal volume
If after intubation, ABG pH 7.5 and experienced wheezing, restlessness, and ventilator showed continuous expiratory flow until start of inspiratory flow, next step?
Auto-peep, decrease respiratory rate and tidal volume, increase peak inspiratory flow
If intubated patient has respiratory alkalosis and Is breathing faster than ventilator rate, next step?
Check to see why alkalotic (sepsis, PE, liver disease, pain)
Can paralyze or sedate patient
If u want to improve respiratory acidosis on an intubated pt, next step?
Increase respiratory rate, increase tidal volume (volume control) or increase inspiratory support pressure (in pressure control) to increase tidal volume
Pt with ARDS ph7.2, next step?
Tolerate, don’t increase tidal volume above 6mg/kg
If patient has respiratory alkalosis in intubated patient, next step to vent?
Decrease respiratory rate if pt not breathing to fast (otherwise sedate), look for cause
Decrease tidal volume
If would like to improve oxygenation on vent, what do You change?
Increase fiO2 or PEEP (increasing PEEP may lead to lower CO and worsening oxygen delivery)
But if no contraindication try to increase preload w IV fluids
Alarm for elevated peak inspiratory pressure, what should be considered?
Bronchospasm
Secretions in ET tube
Mucus plug
Agitation/ dyssynchrony with ventilator
If increase in BOTH peak inspiratory and plateau pressures, what should be considered?
Right mainstem intubation
Pneumothorax
Worsening airspace disease (ARDS, pneumonia, pulmonary edema)
What are measures to reduce VAP?
Semirecumbent position
Selective decontamination of oropharynx (topical gentamicin, coliseum, vancomycin)
When should should spontaneous breathing trials be considered?
O2 saturation >90%, fiO2 <=0.5, PEEP<5, pH>7.3
What is unique to cardiogenic shock compared to other shock syndromes?
Elevated PCWP >=18
In patient w urticaria, wheezing/stridor s/p intubated, high cardiac output, normal PCWP, low SVR, what type of shock?
Anaphylactic shock
Hypovolemic and obstructive (cardiac tamponade, PE, pneumothorax) shock share what parameters in common?
Low cardiac output , low PCWP, high SVR
Pt w fever leukocytosis, hypotension, s/p intubated, right heart cath show high CO then becomes low and low SVR, what type of shock?
Septic shock
How much fluid should be given for sepsis and septic shock?
2-4 L in first 6hrs (30mg/kg)
If unresponsive to fluids in septic shock, next step?
Norepinephrine
MAP>=65
Drop lactic acid by 10-20% in first 6 hrs
What is recommended abx for septic shock?
Low PSAR risk: vanc + 1 antipseudamonas drug
High PSAR risk: vanc + 2 antipseudamonas drugs
If hypotension despite IV fluids and vasopressors, next step?
Add 200mg/day of hydrocortisone
No mineralcorticoid and don’t check cortisol stimulation test!!!!
How should ones blood glucose be controlled if in septic shock and diabetic?
Insulin therapy, 140-200 mg/dL
What is preferred for nutrition when intubated?
Enteral nutrition 24-48 hrs if stable. If can’t tolerate start TPN day 7 of illness
What are the risks of TPN?
GI mucosa atrophy, translocation of gut bacteria, predispose to infection
