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RCP > RCP 105 (VENTS) final > Flashcards

RCP 105 (VENTS) final Flashcards

1
Q

Explain the pathologic or structural changes related to Myasthenia Gravis.

A

Rare autoimmune disorder in which antibodies form against nicotinic acetylcholine (ACh) postsynaptic receptors at the neuromuscular junction (NMJ) of the skeletal muscles, causing muscle weakness and rapid muscle fatigue

blood in feces

orthopnea

SOB

flat hemidiaphragm

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2
Q

Explain the pathologic or structural changes related to Guillain-Barre

A

Rare but serious post-infectious immune-mediated neuropathy. It results from the autoimmune destruction of nerves in the peripheral nervous system causing symptoms such as numbness, tingling, and weakness that can progress to paralysis

thickening and contrast enhancement of the spinal nerve roots

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3
Q

What are the clinical indications for Acute Ventilatory Failure?

A

mechanical ventilation

PaCo2 greater than 50

pH less than 7.30

apnea

bradycardia

ALI

ARDS

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4
Q

Explain how an acute asthma attack should be treated.

A

With a quick acting bronchodilator (Albuterol)

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5
Q

Double-lumen tube

A

has 2 separate lumens, 2 cuffs, and 2 pilot balloons. (1) Used to provide independent lung ventilation where isolation of the lungs is desirable to prevent lung-to-lung spillage of blood or pus, (2) provide one-lung ventilation so that the non ventilated lung may undergo surgical procedure, (3) can provide ventilation by overcoming the persistent air leak through the fistulas

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6
Q

OPA

A

designed to relieve obstruction in the unconscious patient caused by the tongue and other soft tissue

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7
Q

LMA

A

small, triangle shaped, inflatable mask secured to a tube. Designed to seal the esophagus, providing a more patent and easily maintained airway.

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8
Q

Endotracheal Tube

A

artificial airway that is passed through the mouth or nose and advanced into the trachea

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9
Q

Tracheostomy tube

A

airway that is designed to be surgically placed below the larynx at the second tracheal ring. It relieves upper airway obstruction and may be cuffed or cuffless

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10
Q

NPA

A

relieve obstructions in the conscious or semiconscious patient caused by the tongue esophageal obturator airway. Can be used to facilitate ventilation or removal of secretions

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11
Q

Esophageal gastric tube airway

A

has an opening at the distal end which allows removal or aspiration of air and gastric contents from the stomach via gastric tube. There are 2 ports on the mask; resuscitation bag must be attached to ventilation port

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12
Q

Desired PaCO2 calculation

A

New RR= RR x PaCO2 ÷ Desired PaCO2

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13
Q

Desired PaCO2 calculation with TV and Minute Volume

A

New RR= (Rate x PaCO2) x (Vt – Vd) ÷ Desired PaCO2 x (New Vt – New Vd)

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14
Q

ABG

A

provides information on patients ventilation (PaCO2), oxygenation (PaO2), and acid-base (pH) status

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15
Q

Co-oximetry

A

uses signal extraction technology to measure a patient’s hemoglobin, oxygen content, carboxyhemoglobin, methemoglobin, pleth variability index, and perfusion index

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16
Q

Capnography

A

a measurement of the partial pressure of carbon dioxide in a gas sample

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17
Q

Tonometry

A

Peripheral arterial tonometry (PAT) is a noninvasive technique that can be used to identify respiratory events and diagnose obstructive sleep apnea (OSA)

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18
Q

Explain how TV is increased when using AC/PC or SIMC/PC

A

= Increase the peak inspiratory pressure (PIP) since its on a PRESSURE CONTROL setting

Increasing respiratory rate may manage this increase in minute ventilation, but if this is not feasible, increasing the tidal volume can increase plateau pressures and create barotrauma.

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19
Q

Explain how to normalize a high PaCO2 on a vent or BIPAP.

A

= minute ventilation required needs to be increased → increase ventilatory frequency

  1. Decrease or remove dead space
  2. Increase Tidal Volume
  3. Increase Respiratory Rate
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20
Q

Explain how to normalize a high PaO2 on a vent or BIPAP.

A
  1. FIRST- decrease FIO2 to less than .60
  2. THEN - decrease PEEP
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21
Q

Explain how to normalize a low PaCO2 on a vent or BIPAP

A
  1. Increase Dead Space
  2. Decrease the Respiratory Rate
  3. Decrease the Tidal Volume
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22
Q

Explain how to normalize a low PaO2 on a vent or BIPAP.

A
  1. FIRST - increase Fio2 by 5-10% (up to 60%)
  2. THEN - Increase PEEP levels by 5cmH20 until:
  • acceptable oxygenation is achieved
  • unacceptable side-effects occur (decrease in compliance, decrease in cardiac function, barotrauma)
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23
Q

Explain how and provide and example of how initial vent settings should be set.

A

Mode: PC, VC, or AC

Frequency: 12-20/min

Tv: 6-12 mL/kg

FIO2: 40%, 100% if CO2 toxicity or full cardiac arrest

PEEP: 5cm H2O

I:E ratio: 1:2 normal or 1:4 COPD/asthma

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24
Q

Explain relative humidity and its relationship to intubation and mechanical ventilation. IE what happens if it is not achieved because of intubation.

A

Humidity is necessary to prevent hypothermia, disruption of the airway epithelium, bronchospasm, and atelectasis, and it keeps airway secretions thinned.

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25
Q

Explain why increasing Peep/EPAP/CPAP increases oxygenation. (All of these things increase Mean Airway Pressure and FRC)

A

Increases the solubility of oxygen and its ability to cross the alveolocapillary membrane and increase the oxygen content in the blood

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26
Q

Explain why suction equipment is needed during an intubation.

A

Intubated patients are at risk for secretion retention because the ET tube and ventilator attachments for a closed system and do not allow removal of secretions

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27
Q

Pulmonary effusion

A

= The accumulation of fluid in the pleural space

Restrictive lung pathophysiology

Vital signs:
Increased Respiratory rate (tachypnea), Heart rate (pulse), Blood pressure
Chest pain/decreased chest expansion
BLUNTED diaphragm
Cyanosis
Cough (dry, nonproductive)

Chest assessment findings:
Tracheal shift
Decreased tactile and vocal fremitus
Dull percussion note
Diminished breath sounds
Displaced heart sounds
Pleural friction rub (occasionally)

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28
Q

COPD

A

high heart rate

high BP

high RR

leaning forward position to breathe

pursed lips

decreased tactile fremitus

bilateral diminished with scattered expiratory wheezing, basilar rhonchi

possible edema

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29
Q

Asthma

A

= A chronic, inflammatory, obstructive, non-contagious airway disease with varying levels of severity, characterized by exacerbations of wheezing and coughing

Patient Assessment-History and Physical exam

SOB-pursed-lip breathing, chest tightness

Appearance of the chest –increased A-P diameter during an attack

Respiratory Pattern- Accessory muscle usage, retractions (more so in kids)

Diagnostic Chest Percussion – hyperresonant/tympanic note

BS - Diffuse wheezing, bilateral wheezing, diminished breath sounds, prolonged expiration

Physical Appearance – diaphoresis

Vitals – tachycardia, tachypnea

Decreased blood pressure during inspiration

Increased blood pressure during expiration

Chest X-ray –During an attack increased A-P diameter, translucent lung fields, depressed or flattened diaphragm

ABG – Initially acute respiratory alkalosis with hypoxemia then acute respiratory acidosis

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30
Q

PNA

A

= An infectious inflammatory process that primarily affects the gas exchange area of the lungs causing capillary fluid to pour into the alveoli. This process leads to inflammation of the alveoli, alveolar consolidation and atelectasis.

viruses account for 50% pneumonia

Anatomic alterations:
Inflammation of the alveoli
Alveolar consolidation
Atelectasis (e.g., aspiration pneumonia)

Etiology:
Extremely Common
Causes include bacteria, viruses and aspiration
Bacteria, viruses, fungi, protozoa, parasites, tuberculosis, anaerobic organisms, aspiration, and the inhalation of irritating chemicals such as chlorine

General appearance: Diaphoretic, cyanotic

Respiratory Pattern: Tachypnea

BS: Crackles, bronchial, whispered pectoriloquy

Diagnostic Chest Percussion: Flat or dull note over consolidation

Cough Productive: yellow/green sputum, may also be rust color

Vitals: Fever, (bacteria >100° F and viral < 101° F) increased HR, RR and BP

Chest X-ray- Increased density in area of consolidation and atelectasis, air bronchograms possible pleural effusion

ABG-Acute alveolar hyperventilation with hypoxemia

PFT: decreased volumes and capacities

CBC: Increased WBC with bacterial infection, decreased with viral

Culture and Sensitivity to determine cause

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31
Q

Myasthenia Gravis

A

Rare autoimmune disorder in which antibodies form against nicotinic acetylcholine (ACh) postsynaptic receptors at the neuromuscular junction (NMJ) of the skeletal muscles, causing muscle weakness and rapid muscle fatigue

blood in feces

orthopnea

SOB

flat hemidiaphragm

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32
Q

Guillain-Barre

A

Rare but serious post-infectious immune-mediated neuropathy. It results from the autoimmune destruction of nerves in the peripheral nervous system causing symptoms such as numbness, tingling, and weakness that can progress to paralysis

thickening and contrast enhancement of the spinal nerve roots

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33
Q

Pneumothorax

A

= When gas (sometimes called free air) accumulates in the pleural space

The pleural space, the visceral and parietal pleura separate, enhances the natural tendency of the lung to recoil, or collapse, the alveoli are compressed and atelectasis ensues

A restrictive lung disorder

Closed pneumothorax= Gas in the pleural space is not in direct contact with the atmosphere

Open pneumothorax= The pleural space is in direct contact with the atmosphere such that gas can move freely in and out

Tension pneumothorax= The intrapleural pressure exceeds the intra-alveolar (or atmospheric) pressure

BS: diminished/absent on affected side

CXR: all black, not able to see outlines

Vitals:
Increased respiratory rate (tachypnea)
Decreased lung compliance/increased ventilatory rate relationship
Activation of the deflation receptors
Activation of the irritant receptors
Stimulation of the J receptors
Pain/anxiety
Increased Heart rate (pulse)/Blood pressure
Cyanosis

Chest assessment findings:
Hyperresonant percussion note over the pneumothorax
Diminished breath sounds over the pneumothorax
Tracheal shift (away from the affected side in a tension pneumothorax)
Displaced heart sounds
Increased thoracic volume on the affected side (particularly in tension pneumothorax)
Bubbling from chest occurs due to air coming out

ABG for small pneumothorax= Acute alveolar hyperventilation with hypoxemia (acute respiratory alkalosis)
pH= INCREASED
PaCO2= DECREASED
HCO3-= DECREASED but normal
PaO2= DECREASED
SaO2= DECREASED

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34
Q

ILD

A

= Refers to a broad group of inflammatory lung disorders

More than 180 diseases

Characterized by acute, subacute, or chronic inflammatory infiltration of alveolar walls by cells,

fluid, and connective tissue

If left untreated, the inflammatory process can progress to irreversible pulmonary fibrosis destruction

of the alveoli and adjacent pulmonary capillaries

fibrotic thickening of the bronchioles, alveolar ducts, and alveoli

CXR:
Granulomas
honeycombing and cavity forming
fibrocalcific pleural plaques
bronchospasms
excessive bronchial secretions
pleural effusion

Physical:
cyanosis
digital clubbing
peripheral edema
venous distension
distended neck veins
pitting edema
enlarged and tender liver
Nonproductive cough

Chest assessment findings:
Increased tactile and vocal fremitus
Dull percussion note
Bronchial breath sounds
Crackles
Pleural friction rub
Whispered pectoriloquy
Increased hematocrit and hemoglobin (polycythemia)

ABG: Acute alveolar hyperventilation with hypoxemia (acute respiratory alkalosis)
pH= INCREASED
CO2= DECREASED
HCO3= DECREASED
PaO2= DECREASED
SaO2= DECREASED

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35
Q

Lung cancer

A

= Arises from the epithelium of the tracheobronchial tree

A tumor that originates in the bronchial mucosa is called bronchogenic carcinoma

Structural changes:
Inflammation, swelling, and destruction of the bronchial airways and alveoli
Excessive mucus production
Tracheobronchial mucus accumulation and plugging
Airway obstruction
Atelectasis
Alveolar consolidation
Cavity formation
Pleural effusion

Physical findings:
A progressively worsening cough—often includes blood or rust-colored sputum
Chest pain
Hoarse voice
Poor appetite and weight loss
Dyspnea
Fatigue
Frequent bronchial infection or pneumonia episodes
Sudden onset of wheezing
Bone pain (e.g., back or hips)
Neurologic problems (e.g., headache)
Arm and leg weakness or numbness
Dizziness or balance problems
Seizures
Jaundice
Enlarged lymph nodes
Increased Respiratory rate (tachypnea)/Heart rate (pulse)/Blood pressure
Cyanosis
Cough, sputum production, and hemoptysis

Chest assessment findings:
Crackles and wheezing

ABG: Acute alveolar hyperventilation with hypoxemia (acute respiratory alkalosis)
pH= INCREASED
CO2= DECREASED
HCO3= DECREASED
PaO2= DECREASED
SaO2= DECREASED

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36
Q

Right heart failure (cor pulmonale)

A

= enlarged heart/ right side heart failure

chest pain

cyanotic

lethargic

edema

wheezing

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37
Q

Pulmonary Embolism

A

= A blood clot that becomes dislodged and travels to another part of the body

Clinical manifestations result from the pathophysiologic mechanisms caused (or activated) by:

Atelectasis

Bronchospasm

Vitals:
Increased Respiratory rate (Tachypnea)
Stimulation of peripheral chemoreceptors
Reflexes from the aortic and carotid sinus baroreceptors
Increased heart rate (pulse)
Systemic hypotension (DECREASED blood pressure)
Cyanosis
Cough and hemoptysis
Peripheral edema and venous distention
Distended neck veins
Swollen and tender liver
Chest pain/decreased chest expansion
Syncope, light-headedness, and confusion
Abnormal heart sounds
Increased second heart sound (S2)
Increased splitting of the second heart sound (S2)
Third heart sound (or ventricular gallop)
Right ventricular heave or lift

Chest assessment findings:
Crackles
Wheezes
Pleural friction rub

ABG: Acute alveolar hyperventilation with hypoxemia (acute respiratory alkalosis)
pH= INCREASED
PaCO2= DECREASED
HCO3-= DECREASED
PaO2= DECREASED
SaO2= DECREASED

Chest radiograph:
Increased density (in infarcted areas)
Hyperradiolucency distal to the embolus
Dilation of the pulmonary arteries
Pulmonary edema
Right ventricular cardiomegaly (cor pulmonale)
Pleural effusion (usually small)

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38
Q

CHF (left side heart failure)

A

= left-sided heart failure

Occurs when the left ventricle is unable to pump out a sufficient amount of blood during each ventricular contraction

Determined by means of the left ventricular ejection fraction (LVEF)

Vital signs:

Increased respiratory rate (Tachypnea), heart rate (pulse), blood pressure

Cheyne-Stokes respirations

Paroxysmal nocturnal dyspnea and orthopnea

Cyanosis

Cough and sputum—frothy and pink in appearance

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39
Q

Hypervolemia

A

Tachycardia

Bounding pulse

Hypertension

Tachypnea

Increased central venous pressure

Crackles

Cough

Increased respiratory rate

Dyspnea (caused by excess fluid within the body and lungs)

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40
Q

Hypovolemia

A

Tachycardia

Thready pulse

Hypotension

Orthostatic Hypotension

Decreased central venous pressure

Tachypnea

Hypoxia

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41
Q

E tank

A

0.28

2200 x 0.28 ➗ LPM

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42
Q

H tank

A

2200 x 3.14➗ LPM

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43
Q

Explain the suction procedure and what to do in emergency situations

A

wash hands, put on sterile gloves, and gather supplies

explain procedure to patient

adjust vacuum to 100mmHg

put sterile water in container

test vacuum and suction sterile water

hyperinflate lungs

insert catheter in ET tube until cough is initiated, pull back

limit duration for 10-15 seconds

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44
Q

Explain the different modes that can be used for weaning.

A

SIMV, PSV, VS, VAPS, VAV, MMV, APRV

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45
Q

Low exhaled volume alarm

A

= should be set at 100mL lower than expired mechanical tidal volume

alarm triggered if patient does not exhale an adequate tidal volume

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46
Q

Low inspiratory pressure alarm

A

= should be set at 10-15cmH2O below the observed PIP

alarm triggered if PIP is less than alarm setting

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47
Q

High inspiratory pressure alarm

A

= should be set 10-15cmH2O above observed PIP

alarm triggered when PIP is equal or higher than the high pressure limit

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48
Q

Apnea alarm

A

= should be set 15-20 seconds time delay

triggered in circuit disconnection, ET suctioning

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49
Q

High frequency alarm

A

= should be set at 10/min over the observed frequency

triggering is a sign of respiratory distress

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50
Q

High/low FIO2 alarm

A

= should be set 5-10% over and under analyzed FIO2

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51
Q

Explain how to change TV in pressure-controlled ventilation

A

increase respiratory rate

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52
Q

Explain how we can reduce the work of breathing in spontaneously breathing patients.

A

Increase the flow rate and can increase I:E time

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53
Q

Explain the goal of mechanical ventilation. Include values you want to see on an ABG

A

improve gas exchange

relieve respiratory distress

improve pulmonary mechanics

permit lung and airway healing

avoid complications

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54
Q

Explain possible errors you can get when running an ABG and how to correct the user or machine error.

A

air bubbles

dilution with excessive heparin

faulty handling of sample

→ should be monitored with other monitoring devices and ABG should be done in short amount of time

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55
Q

Why do we monitor the PIP, mean airway pressure and plateau pressure.

A

To measure elastic pressure, how well the lungs are reacting to treatment, if lungs are getting better or worse, and compliance. How much pressure were putting on the vessels

use pressure control or bronchodilator to fix the issue

56
Q

ABG complications

A

not expelling air bubbles

heparin can affect pH reading

error values

57
Q

Explain the use of a wick humidifier.

A

Used an absorbent wick to INCREASE surface area for gas to water interface

58
Q

Explain why cuff pressure is monitored. (know normal)

A

Normal range= 25-35mmHG

to reduce the likelihood of pressure-induced injuries to the trachea caused by excessive cuff pressure (mucosal ischemia and tracheal wall tissue necrosis)

59
Q

Explain how to improve air trapping on a mechanical vent.

A

1.Decrease RR

2.Decrease I-time

3.Increase flow

60
Q

Explain how to improve Oxygenation and recruit collapsed alveoli.

A

prone positioning patient

inflating the lungs to a pressure of 40 cm H2O for 7–8 seconds, or incrementally increasing PEEP

61
Q

Explain optimal PEEP. If given PIP, Plateau pressure PaO2 PvO2 , BP, HR, CO, SV you will need to know what the optimal PEEP is given the data.

A

= the lowest PEEP level leading to the best oxygenation status without causing significant cardiopulmonary complications

PaO2 43-PEEP 0

PaO2 67-PEEP 5

PaO2 77-PEEP 8

PaO2 83-PEEP 10

PaO2 79-PEEP 12

62
Q

Premature ventricular contractions (PVCs)

A

= not preceded by a P wave and QRS complex is wide, bizarre, and not normal

63
Q

Ventricular tachycardia

A

= P wave is generally not noticeable and QRS is wide, bizarre, and T wave may not be separated from QRS complex

64
Q

Ventricular Fibrillation

A

= chaotic electrical activity and cardiac activity, ventricles quiver out of control and no perfusion beat-producing rhythm

no cardiac output, blood pressure, PT can die in minutes without treatment

65
Q

Asystole

A

= complete absence of electrical and mechanical activity

cardiac activity and blood pressure fall to 0

66
Q

Heart blocks

A

= First-degree AV block involves the consistent prolongation of the PR interval due to delayed conduction via the atrioventricular node

67
Q

Explain when to instill saline when suctioning a vent patient. (Textbook)

A

put the saline in when testing the flushing of the catheter

irrigate 5mL of saline water to loosen secretions before hyperinflating patient to suction

68
Q

Propofol

A

aka Diprivan used for sedation

  • Intravenous use
  • GABA-activated chloride ion channel
69
Q

Haloperidol

A

aka Haldol used to control delirium in mechanically ventilated patients

Reversible causes of delirium should be ruled out before using haloperidol (see next slide)

Haloperidol blocks dopamine receptors in the CNS (limbic, basal ganglia, and brainstem) producing a calming effect

Haloperidol also has antiemetic effect

Adverse effects:

Blockade of dopamine receptors in the CNS may interfere with normal motor function

70
Q

Dexmedetomidine

A

aka Precedex for patients undergoing uncomfortable procedures (e.g., mechanical ventilation, cardiac or vascular surgeries, colonoscopy)

  • provides sedation, anxiolysis, and analgesia without respiratory depression
  • An alpha-2 adrenoreceptor agonist
71
Q

Nitric oxide

A

FDA approved for only newborns

  • Persistent pulmonary hypertension and hypoxemic respiratory failure of the newborn

-Respiratory distress syndrome and hypoxemic respiratory failure of older infants and children

  • Acute respiratory distress syndrome

-Inadequate cardiopulmonary hemodynamics in infants due to lack of pulmonary blood flow and oxygenation

  • local vasodilation of vascular smooth muscle
72
Q

Phenobarbital

A

a long-lasting barbiturate and anticonvulsant used in the treatment of all types of seizures, except for absent seizures.

73
Q

Theophylline

A

used to treat patients with asthma and COPD and acute phases and apnea of prematurity

74
Q

Lasix (furosemide)

A

Loop diuretic used to filter out NaCl and H2O through the urine for hypertension and CHf patients

75
Q

Cortisone

A

It has been used in replacement therapy for adrenal insufficiency and as an anti-inflammatory agent

76
Q

Morphine sulfate

A

opioid agonist used for the relief of moderate to severe acute and chronic pain

77
Q

Valium (Diaxepam)

A

ong-acting benzodiazepine with rapid onset commonly used to treat panic disorders, severe anxiety, alcohol withdrawal, and seizures

78
Q

Pancuronium bromide

A

neuromuscular blocker used as an adjunct to general anesthesia to facilitate tracheal intubation and to provide skeletal muscle relaxation during surgery or mechanical ventilation

79
Q

Lidocaine

A

local anesthetic used in a wide variety of superficial and invasive procedures

80
Q

Midazolam

A

a short-acting benzodiazepine with rapid onset that is commonly used in seizures, anesthesia and anxiety disorders

81
Q

Povidone-iodine

A

topical antiseptic agent used for the treatment and prevention of infection in wounds

82
Q

Aspirin cream

A

salicylate used to treat pain, fever, inflammation, migraines, and reducing the risk of major adverse cardiovascular events

83
Q

Explain the different Levels of consciousness and how they are determined

A

Glasgow coma scale

13-14= mild injury

9-12= moderate injury

3-8= severe injury

84
Q

Explain how you would tell a patient to care for their equipment at home.

A

warm water and soap

vinegar

85
Q

Explain the difference and when to use an HME vs Heated Humidifier circuit.

A

Heated humidifier on a long term patient

It helps to not break the circuit as often as an HME

There is more control with a heated circuit

HME is mainly used on acute patients (temporary)

86
Q

Explain how you would treat A patient with dyspnea in the emergency department and coughing up large amounts of frothy, pink sputum. Audible crackles are auscultated.

A

High flow oxygen

High flow nasal cannula

IPPB

Percussion

PT sit in fowler position

87
Q

Explain the use of a luken’s trap.

A

= specimen trap that can be placed in the vacuum circuit, when suctioning a patient, to obtain a sample for culture and analysis

88
Q

Explain pulmonary vascular resistance (PRV)

A

= Measures the blood vessel resistance to blood flow in the pulmonary circulation

(PRV) elevated in pulmonary hypertension or left heart obstruction

Normal range= 50-150 dynes.sec/sv⁵

PVR= (PAP – PCWP) x 80 ፥ CO

89
Q

Explain how to use and troubleshoot a NRB

A

1.Check for leaks
check connection between flowmeter and 50-PSI gas source
check connection between flow meter and humidifier
check connection between connecting tube and humidifier

2.If gas isn’t flowing from mask
verify flowmeter is n
check for kinks and connections
verify humidifier is on properly

90
Q

PSV

A

= variation of the spontaneous mode of ventilation that augments a patient’s spontaneous effort with positive pressure

patient spontaneously breathing

facilitate weaning in a difficult-to-wean patient

91
Q

CPAP

A

= PEEP applied to the airway of a patient who is breathing spontaneously

intrapulmonary shunting

refractory hypoxemia

decreased FRC

lung compliance

auto-PEEP not responding to adjustments of ventilatory settings

can sustain lung functions

92
Q

BIPAP

A

= applies independent positive pressure pressures (PAP) to both inspiration and expiration

preventing intubation of the end-stage COPD patient

supporting patient with chronic ventilatory failure

restrictive chest wall disease

neuromuscular disease

nocturnal hypoventilation

93
Q

CMV

A

= ventilator delivers the preset tidal volume at a set time interval (time-triggered frequency) (controls patients tidal volume, respiratory, minute ventilation)

if patient ¨fights¨ the ventilator in the initial stages of mechanical ventilatory support

tetanus or other seizure activity

complete rest for the patient for 24 hour period

patient with a crush chest injury

94
Q

SIMV/VC

A

= patient spontaneously breathes while giving mandatory breathes when needed

ventilatory support

patient provides part of minute ventilation

95
Q

SIMV/PC

A

= patient spontaneously breathing while time triggered by present frequency

severe ARDS (need high PIP)

96
Q

AC/VC

A

= mandatory mechanical breaths may be patient-triggered by the patient’s spontaneous inspiratory efforts (assist) or time-triggered by a present frequency (control)

provide full ventilatory support

stable respiratory drive

97
Q

AC/PC

A

= mandatory pressure-controlled breathes are time-triggered by a preset frequency (pressure plateau created)

severe ARDS (need high PIP)

98
Q

PRVC

A

= provides volume-controlled breaths with the lowest pressure possible by altering the flow and inspiratory time

achieve volume support while keeping the PIP at a lowest level possible

99
Q

MMV

A

= causes an increase of mandatory frequency when the patients spontaneously breathing level becomes inadequate (safe minute ventilation)

prevent hypercapnia

preventing hypoventilation

preventing respiratory acidosis

100
Q

Orthopnea

A

= Difficulty breathing when lying down on back

101
Q

Explain the intubation procedure

A

Patient must be assessed to rule out any potential contradictions

Mallampati classification method used

Class 1= conscious sedation, soft palate, fauces, uvula, anterior and posterior tonsillar pillars

Class 2= conscious sedation, soft palate, fauces, and uvula

Class 3= seek anesthesia consultation, soft palate, and base of uvula

Class 4= seek anesthesia consultation, soft palate only

If placed properly:
if patient is breathing spontaneous, bilateral breath sounds should be heard
pulse ox measurements should show immediate change
moisture and condensation will form inside the tube
CO2 indicator or end tidal CO2 monitor may be attached to end of ET tube
chest radiograph

102
Q

Explain the intubation equipment

A

Laryngoscope handle- used to displace the tongue and soft tissues

Blade- Miller blade used to lift up the epiglottis while Macintosh blade placed in vallecula indirectly lifts epiglottis for visualization of vocal cords (size 3 typically used)

Et tube- size 7.5 to 8 typical male size and 7.0 to 7.5 for adult females

10-mL syringe- used to test the pilot balloon and inflate the cuff after intubation

Water-soluble lubricant- used to lubricate the distal end of the ET tube for easy insertion into the trachea

Tape- used to secure the ET tube so that the tube will not move too high causing, inadvertent extubation or too low leading to main-stem intubation

Stethoscope- needed to auscultate bilateral breath sounds immediately after intubation

Stylet- flexible but semigrid wire placed inside an endotracheal tube to provide desired curvature

Topical anesthetic- may be used to numb and vasoconstrict the mucosal membrane

Magill forceps- used to perform nasal intubation under direct vision

103
Q

Explain RSI

A

= describes an urgent need to gain control of a patient’s airway

preparations

pre-RSI medications

cricoid pressure

intubation

post RSI stabilization

104
Q

RSI meds –> Etomidate (Amidate)

A

= sedation and induction

= decreases cerebral metabolic rate, cerebral blood flow, and intracranial pressure

Etomidate binds at a distinct binding site associated with a Cl- ionopore at the GABAA receptor, increasing the duration of time for which the Cl- ionopore is open

105
Q

RSI meds –> Succinylcholine= paralytic agent

A

= depolarizing skeletal muscle relaxant used adjunctly to anesthesia and for skeletal muscle relaxation during intubation, mechanical ventilation, and surgical procedures

It binds to the post-synaptic cholinergic receptors found on motor endplates, thereby inducing first transient fasciculations followed by skeletal muscle paralysis

106
Q

Weaning process

A

Spontaneous breathing trial is the diagnostic test to determine if the patient can be successfully extubated and weaned from mechanical ventilation for 20 to 30 mins. Starts PSC at 5-10cm and decrease 3-6cm until PSV reaches 6cm H2O.

107
Q

Weaning success

A

= Absence of ventilatory support for at least 48 hours following extubation

RSBI less than 100 breaths/min

PaO2/Fio2 greater than 150mmHg

Shunt less than 20%

Vital capacity greater than 10mL/kg

Maximal inspiratory pressure greater than -20 cmH2O (-30 is better)

Static compliance greater than 30mL

Deadspace want it less than 60% while intubated

PEEP less than 8cm H2O

pH greater than 7.25

PS less than 8cm

Greater than 3 mins of spontaneous breathing

108
Q

Weaning failure

A

= failure of SPT (1) increase of airflow resistance, (2) decrease of compliance, (3) respiratory muscle fatigue

Occurs within the first 20 to 30 min

Clinical signs and symptoms include

Agitation

Anxiety

Diminished mental status

Diaphoresis

Cyanosis

Increased work of breathing

109
Q

Explain how to treat hypoxemia related to hypoventilation, diffusion defects, V/Q mismatch and shunts.

A

Inhalers with bronchodilators or steroids to help people with lung disease like COPD.

Medications that help to get rid of excess fluid in your lungs diuretics

Continuous positive airways pressure mask CPAP to treat sleep apnea.

Supplemental oxygen may be used to treat an ongoing risk of hypoxemia

110
Q

Explain CPP.

A

= pressure required to provide blood flow, oxygen, and metabolites to the brain

under normal conditions the brain regulates its own blood flow regardless of the systemic blood pressure and cerebral vascular resistance

Normal range= 70-80mmHg

CPP= MAP – ICP

111
Q

Explain auto-PEEP and how to reduce it.

A

= unintentional PEEP during mechanical ventilation that is associated with excessive pressure support ventilation, significant airway obstruction, high frequency, insufficient inspiratory flow rates, relatively equal (1:1) or inverse I:E ratio

tidal volume or frequency can be reduced

bronchodilators

prolonged expiratory time by increasing flow rate

112
Q

Explain the four parameters for the classification of ALI and ARDS

A

known insult or new or worsening respiratory symptoms

profound hypoxemia

bilateral pulmonary opacities on radiography

inability to explain respiratory failure by cardiac failure or fluid overload

113
Q

Explain clinical signs of ARDS

A

Structural changes:
Intra-alveolar walls become lined with a thick, rippled hyaline membrane
Membrane contains fibrin and cellular debris
Interstitial and intra-alveolar edema and hemorrhage
Alveolar consolidation
Intra-alveolar hyaline membrane
Pulmonary surfactant deficiency or abnormality
Atelectasis

Physical:
Increased Respiratory rate (tachypnea)/Heart rate (pulse)/Blood pressure
Substernal or intercostal retractions
Cyanosis

Chest assessment findings:
Dull percussion note
Bronchial breath sounds
Crackles

CXR:
Increased opacity, diffusely throughout lungs
Ground-glass appearance

ABG: Acute alveolar hyperventilation with hypoxemia (acute respiratory alkalosis)
pH= INCREASED
CO2= DECREASED
HCO3= DECREASED
PaO2= DECREASED
SaO2= DECREASED

114
Q

Explain ways of preventing or reducing barotrauma.

A

low tidal volume

low PIP

low plateau pressure

115
Q

Cranial nerve 3

A

= connect directly to the brain and control eye movement

116
Q

Cranial nerve 7

A

= controls facial movement and expression on the same side of the face

117
Q

Cranial nerve 9

A

= mixed nerve that provides sensory, motor, and parasympathetic information to the throat and mouth

118
Q

Cranial nerve 10

A

= (vagus nerve) longest cranial nerve in the body and has both motor and sensory functions

119
Q

Cranial nerve 12

A

= controls the muscles of the tongue

120
Q

Explain the indications of for a chest tube

A

large pneumothorax → positive pressure ventilation, ruptured bleb, bronchopleural fistula, leaking subpleural cyst, chest trauma

hemothorax (blood collects in pleural space) → invasive procedures

pleural effusion → hemothorax, heart failure, intra-abdominal infection, blockage of lymphatic system

121
Q

Explain what would happen if there is an obstruction of a chest tube.

A

notify physician

occlusive dressing if chest tube becomes disconnected

clamping to see where the obstruction is coming from

122
Q

Explain a chest tube insertion including the equipment used and placement.

A

1.Trocar used to incision of chest cavity

2.large adult sizes 36-40 french (Fr)

3.Small adults and teens size 28-32 french (Fr)

Pneumothorax → CT placed 2nd to 3rd intercostal space anteriorly along midclavicular line or midaxillary line

draining blood or pleural fluids should be size 39 french (Fr)

123
Q

Operative tube thoracostomy

A

= dissection of the plural, digital inspection of the pleural space, and insertion guided with the finger and hemostat

124
Q

Tocar tube thoracostomy

A

= incision of plural, insertion of trocar chest tube, and withdrawal of trocar

125
Q

1 chamber chest collection system

A

= initially contains 100mL sterile water

long tube submerged in exactly 2cm of water (water seal)

126
Q

2 chamber collection system

A

= chamber 1 collects all pleural fluids. chamber 2 remains constant and the work of spontaneous breathing is unaffected

127
Q

3 chamber collection system

A

= chamber 1 collection chamber of pleural fluid. chamber 2 water seal chamber with 2cm of water and acts as water seal. chamber 3 suction chamber regulates amount of suction in the three-chamber system

128
Q

Explain what could cause bubbling in the water seal chamber and how to troubleshoot the issue.

A

An air leak will be characterized by intermittent bubbling in the water seal chamber when the patient with a pneumothorax exhales or coughs

clamp to troubleshoot

129
Q

Explain what should be done once the chest tube is sutured in place.

A

sterile dressing

x-rays to see proper placement

avoiding kinking of the tubes

130
Q

Explain how to assess chest tubes.

A

positioned upright and below patients chest

no kinks in tubing

gentle suction catheter

water seal chamber with 2 cm of water

drainage examination

dressing showing no signs of infection

sutures are secured

131
Q

Explain tidaling

A

= fluctuations in the fluid level of a chest tube’s water-seal chamber when a patient breathes

132
Q

Explain what wave forms are used for, how they are plotted and what each type of waveform is able to show.

A

Waveforms= gives us capacity to observe and document real-time measurements of patient-ventilator interactions

patient-ventilator synchrony, ventilator function, pulmonary status, appropriateness of ventilator adjustments

133
Q

Explain how a waveform can show breath efforts.

A

The first waveform represents a controlled mechanical breath, indicating a uniform application of pressure throughout the inspiratory phase

The second waveform exemplifies a volume-controlled breath, highlighting the patient’s peak inspiratory pressure (PIP) and the positive end-expiratory pressure (PEEP) settings

134
Q

Explain what is meant if the waveform does not return to baseline or zero.

A

vent is holding pressure inside the chest = PEEP

leaks

135
Q

What does beaking on a waveform show?

A

= overdistension of the lung

lower tidal volume

136
Q

Explain Clinical Assessment of Hemodynamics.

A

Right heart failure (cor pulmonale)- INCREASE CVP

Pulmonary Embolism- INCREASED CVP, INCREASE PAP

Pulmonary hypertension- INCREASED PAP

CHF (left side heart failure)- INCREASE CVP, INCREASE PAP, INCREASE PCWP, DECREASE PULSE

Hypervolemia- INCREASED PCWP, INCREASED PAP, INCREASED CVP, INCREASE PCWP, INCREASE PULSE

Hypovolemia- DECREASED PCWP, DECREASED PAP, DECREASED CVP, DECREASE PCWP

High PEEP effects- INCREASED PAP, INCREASE CVP, DECREASE PCWP

RCP (8 decks)

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