Pulmonary II Flashcards
When HCO3 is low due to loss you will see…
increase in chloride ions
All the positive charges in your body and all the negative charges in your body have to..
remain equal
Normal Anion gap is…
12
Normal Bicarb is….
24
Normal pH is…
7.4
Normal pCO2 is
40
What makes up the majority of the anion gap…
Albumin
Albumin of 4 makes up the anion gap of…
12
Predicted anion gap should be…
Albumin x 3
Acute respiratory acidosis
Bicarb has not had a chance to increase
Chronic respiratory acidosis
Bicarb has had a chance to increase
Indications for intubation
Airway support (altered mental status, secretions, airway anatomy) Pulmonary disease (ARDS, pulmonary edema, failed NIV) Circulatory causes (cardiopulmonary arrest, shock)
Two types of positive pressure ventilation
Volume controlled ventilation
Pressure controlled ventilation
Trigger of MV
Trigger initiates inspiration
Pressure, flow, or time
Usually Flow
Cycle of MV
Cycle terminates inspiration
Pressure, volume, flow or time
Limit of MV
Maximum level that can be reached and sustained during inspiration
Can be pressure, volume or flow
Ventilator breath phases
Trigger (when to deliver) Control variables (how to deliver) Cycle phase (how much to deliver-terminate) Expiratory phase
Conditions that affect compliance
ARDS, Pulmonary edema, pneumothorax, atelectasis
Complications of Volume ventilation
Barotrauma
uneven gas distribution
may induce ARDs
Pressure ventilation advantages
Improved gas distribution
improved alveolar filling
reduced barotrauma
improved comfort
Winter’s formula ratios
Metabolic acidosis- 1 bicarb/1CO2
Metabolic alkalosis- 2 bicarb/ 1 pCO2
Acute respiratory acidosis- 1 bicarb/10pCO2
Chronic respiratory acidosis- 1BIcarb/3pCO2
Acute respiratory alkalosis- 1Bicarb/5pCO2
Chronic respiratory alkalosis- 1Bicarb/2pCO2
Anion gap metabolic acidoses
Methanol Uremia DKA-all sorts of ketones Paraldehyde Isoniazid Lactic acidosis Ethylene glycol, ethanol Salicylates
Non anion gap metabolic acidosis
Diarrhea
Renal tubular acidosis
Carbonic anhydrase inhibitors- medications
Addisons disease- the only one of the three that causes hyperkalemia
Metabolic alkalosis
Vomiting- chloride responsive
Cushings disease- nonchloride responsive
Acute respiratory acidosis
COPD exacerbation
Drug overdose
Chronic respiratory acidosis
COPD
Acute respiratory alkalosis
Asthma exacerbation
hyperventilation anxiety
Chronic respiratory alkalosis
Pregnancy
High peak pressures with low plateau pressures
Mucus plug
bronchospasm
ET tube blockage
Biting
High peak pressures
High plateau pressures
ARDS Pulmonary edema Pneumothorax ET tube migration to a single bronchus Effusion
CMV ventilation
Controlled mandatory ventilation
delivers a preset number of breaths per minute of a predetermined tidal volume
additional breaths cannot be initiated by the patient
AC ventilation
Set RR and TV
Every breath is supported by the ventilator
A back up rate is sent and the patient may choose any rate above that rate
AC advantages
Controlled ventilation with breath support
Increased ventilatory support on demand
May help critically ill patients who need constant TV or near full support
AC disadvantages
Excessive patient work
May be poorly tolerated
May lead to respiratory alkalosis
May worsen air trapping in COPD
IMV ventilation
Intermittent mandatory ventilation
Combines a present number of ventilator breaths of a preset tidal volume with the capability of intermittent patient initiated breaths
Spontaneous breaths above the set rate will be whatever TV the patient can generate
IMV advantages
Patient can perform a variable amount of work with a preset level of mandatory ventilation
IMV disadvantages
Risk of dyssynchrony between patient effort and machine delivered volume
SIMV ventilation
Synchronized mandatory intermittent ventilation
Will sense if the patient is trying to initiate a breath and will deliver the mandatory breath in synchrony with the patients effort
PSV ventilation
Pressure support ventilation
Amount of positive pressure is pre set, each breath must be initiated by the patient
Applications for PSV
used to improve patient tolerance and decreased work in spontaneous breathing
Used as sole ventilatory mode for patients under consideration for weaning or during the stabilization period
PSV disadvantages
Tidal volume not controlled: may be poorly tolerated in patients with high airway resistance. requires very careful monitoring in unstable patients
