NPPV/mechanical ventilation

Question 1

What are the indications for NPPV?

Answer 1

1. COPD exacerbations (unstable)
2. Cardiogenic pulmonary edema
3. Acute respiratory failure in immunosuppressed patients
4. Prevention of recurrent respiratory failure in extubated high risk patients

Question 2

What are contraindications for NPPV and instead should be intubated?

Answer 2

Respiratory arrest
Arterial blood pH<7.10
Medical instability
Inability to protect airway and/or excessive secretions
Uncooperative/agitated patient

Question 3

When should u consider intubation?

Answer 3

If angry does not improve after 2 hours of NPPV

Question 4

When managing the vent after intubation, what should be settings be?

Answer 4

Volume-targeted, tidal volume 6-8mg/kg ideal body weight (<=6mg/kg of ideal body weight for ARDS)

8-14 RR

Question 5

If 2 hours after intubation, ABG shows pCO2 7.5 and BP low, next step?

Answer 5

Decrease tidal volume

Question 6

If after intubation, Chest X-ray show atelectasis, next step?

Answer 6

Increase tidal volume

Question 7

If after intubation, ABG pH 7.5 and experienced wheezing, restlessness, and ventilator showed continuous expiratory flow until start of inspiratory flow, next step?

Answer 7

Auto-peep, decrease respiratory rate and tidal volume, increase peak inspiratory flow

Question 8

If intubated patient has respiratory alkalosis and Is breathing faster than ventilator rate, next step?

Answer 8

Check to see why alkalotic (sepsis, PE, liver disease, pain)

Can paralyze or sedate patient

Question 9

If u want to improve respiratory acidosis on an intubated pt, next step?

Answer 9

Increase respiratory rate, increase tidal volume (volume control) or increase inspiratory support pressure (in pressure control) to increase tidal volume

Question 10

Pt with ARDS ph7.2, next step?

Answer 10

Tolerate, don’t increase tidal volume above 6mg/kg

Question 11

If patient has respiratory alkalosis in intubated patient, next step to vent?

Answer 11

Decrease respiratory rate if pt not breathing to fast (otherwise sedate), look for cause

Decrease tidal volume

Question 12

If would like to improve oxygenation on vent, what do You change?

Answer 12

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

Question 13

Alarm for elevated peak inspiratory pressure, what should be considered?

Answer 13

Bronchospasm
Secretions in ET tube
Mucus plug
Agitation/ dyssynchrony with ventilator

Question 14

If increase in BOTH peak inspiratory and plateau pressures, what should be considered?

Answer 14

Right mainstem intubation
Pneumothorax
Worsening airspace disease (ARDS, pneumonia, pulmonary edema)

Question 15

What are measures to reduce VAP?

Answer 15

Semirecumbent position

Selective decontamination of oropharynx (topical gentamicin, coliseum, vancomycin)

Question 16

When should should spontaneous breathing trials be considered?

Answer 16

O2 saturation >90%, fiO2 <=0.5, PEEP<5, pH>7.3

Question 17

What is unique to cardiogenic shock compared to other shock syndromes?

Answer 17

Elevated PCWP >=18

Question 18

In patient w urticaria, wheezing/stridor s/p intubated, high cardiac output, normal PCWP, low SVR, what type of shock?

Answer 18

Anaphylactic shock

Question 19

Hypovolemic and obstructive (cardiac tamponade, PE, pneumothorax) shock share what parameters in common?

Answer 19

Low cardiac output , low PCWP, high SVR

Question 20

Pt w fever leukocytosis, hypotension, s/p intubated, right heart cath show high CO then becomes low and low SVR, what type of shock?

Answer 20

Septic shock

Question 21

How much fluid should be given for sepsis and septic shock?

Answer 21

2-4 L in first 6hrs (30mg/kg)

Question 22

If unresponsive to fluids in septic shock, next step?

Answer 22

Norepinephrine
MAP>=65
Drop lactic acid by 10-20% in first 6 hrs

Question 23

What is recommended abx for septic shock?

Answer 23

Low PSAR risk: vanc + 1 antipseudamonas drug

High PSAR risk: vanc + 2 antipseudamonas drugs

Question 24

If hypotension despite IV fluids and vasopressors, next step?

Answer 24

Add 200mg/day of hydrocortisone

No mineralcorticoid and don’t check cortisol stimulation test!!!!

Question 25

How should ones blood glucose be controlled if in septic shock and diabetic?

Answer 25

Insulin therapy, 140-200 mg/dL

Question 26

What is preferred for nutrition when intubated?

Answer 26

Enteral nutrition 24-48 hrs if stable. If can’t tolerate start TPN day 7 of illness

Question 27

What are the risks of TPN?

Answer 27

GI mucosa atrophy, translocation of gut bacteria, predispose to infection