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
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
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
4
Q
Explain how an acute asthma attack should be treated.
A
With a quick acting bronchodilator (Albuterol)
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
6
Q
OPA
A
designed to relieve obstruction in the unconscious patient caused by the tongue and other soft tissue
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.
8
Q
Endotracheal Tube
A
artificial airway that is passed through the mouth or nose and advanced into the trachea
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
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
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
12
Q
Desired PaCO2 calculation
A
New RR= RR x PaCO2 ÷ Desired PaCO2
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)
14
Q
ABG
A
provides information on patients ventilation (PaCO2), oxygenation (PaO2), and acid-base (pH) status
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
16
Q
Capnography
A
a measurement of the partial pressure of carbon dioxide in a gas sample
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)
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.
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
- Decrease or remove dead space
- Increase Tidal Volume
- Increase Respiratory Rate
20
Q
Explain how to normalize a high PaO2 on a vent or BIPAP.
A
- FIRST- decrease FIO2 to less than .60
- THEN - decrease PEEP
21
Q
Explain how to normalize a low PaCO2 on a vent or BIPAP
A
- Increase Dead Space
- Decrease the Respiratory Rate
- Decrease the Tidal Volume
22
Q
Explain how to normalize a low PaO2 on a vent or BIPAP.
A
- FIRST - increase Fio2 by 5-10% (up to 60%)
- THEN - Increase PEEP levels by 5cmH20 until:
- acceptable oxygenation is achieved
- unacceptable side-effects occur (decrease in compliance, decrease in cardiac function, barotrauma)
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
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.
25
Explain why increasing Peep/EPAP/CPAP increases oxygenation. (All of these things increase Mean Airway Pressure and FRC)
Increases the solubility of oxygen and its ability to cross the alveolocapillary membrane and increase the oxygen content in the blood
26
Explain why suction equipment is needed during an intubation.
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
27
Pulmonary effusion
= 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)
28
COPD
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
29
Asthma
= 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
30
PNA
= 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
31
Myasthenia Gravis
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
32
Guillain-Barre
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
33
Pneumothorax
= 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
34
ILD
= 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
35
Lung cancer
= 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
36
Right heart failure (cor pulmonale)
= enlarged heart/ right side heart failure
chest pain
cyanotic
lethargic
edema
wheezing
37
Pulmonary Embolism
= 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)
38
CHF (left side heart failure)
= 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
39
Hypervolemia
Tachycardia
Bounding pulse
Hypertension
Tachypnea
Increased central venous pressure
Crackles
Cough
Increased respiratory rate
Dyspnea (caused by excess fluid within the body and lungs)
40
Hypovolemia
Tachycardia
Thready pulse
Hypotension
Orthostatic Hypotension
Decreased central venous pressure
Tachypnea
Hypoxia
41
E tank
0.28
2200 x 0.28 ➗ LPM
42
H tank
2200 x 3.14➗ LPM
43
Explain the suction procedure and what to do in emergency situations
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
44
Explain the different modes that can be used for weaning.
SIMV, PSV, VS, VAPS, VAV, MMV, APRV
45
Low exhaled volume alarm
= should be set at 100mL lower than expired mechanical tidal volume
alarm triggered if patient does not exhale an adequate tidal volume
46
Low inspiratory pressure alarm
= should be set at 10-15cmH2O below the observed PIP
alarm triggered if PIP is less than alarm setting
47
High inspiratory pressure alarm
= should be set 10-15cmH2O above observed PIP
alarm triggered when PIP is equal or higher than the high pressure limit
48
Apnea alarm
= should be set 15-20 seconds time delay
triggered in circuit disconnection, ET suctioning
49
High frequency alarm
= should be set at 10/min over the observed frequency
triggering is a sign of respiratory distress
50
High/low FIO2 alarm
= should be set 5-10% over and under analyzed FIO2
51
Explain how to change TV in pressure-controlled ventilation
increase respiratory rate
52
Explain how we can reduce the work of breathing in spontaneously breathing patients.
Increase the flow rate and can increase I:E time
53
Explain the goal of mechanical ventilation. Include values you want to see on an ABG
improve gas exchange
relieve respiratory distress
improve pulmonary mechanics
permit lung and airway healing
avoid complications
54
Explain possible errors you can get when running an ABG and how to correct the user or machine error.
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
55
Why do we monitor the PIP, mean airway pressure and plateau pressure.
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
ABG complications
not expelling air bubbles
heparin can affect pH reading
error values
57
Explain the use of a wick humidifier.
Used an absorbent wick to INCREASE surface area for gas to water interface
58
Explain why cuff pressure is monitored. (know normal)
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
Explain how to improve air trapping on a mechanical vent.
1.Decrease RR
2.Decrease I-time
3.Increase flow
60
Explain how to improve Oxygenation and recruit collapsed alveoli.
prone positioning patient
inflating the lungs to a pressure of 40 cm H2O for 7–8 seconds, or incrementally increasing PEEP
61
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.
= 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
Premature ventricular contractions (PVCs)
= not preceded by a P wave and QRS complex is wide, bizarre, and not normal
63
Ventricular tachycardia
= P wave is generally not noticeable and QRS is wide, bizarre, and T wave may not be separated from QRS complex
64
Ventricular Fibrillation
= 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
Asystole
= complete absence of electrical and mechanical activity
cardiac activity and blood pressure fall to 0
66
Heart blocks
= First-degree AV block involves the consistent prolongation of the PR interval due to delayed conduction via the atrioventricular node
67
Explain when to instill saline when suctioning a vent patient. (Textbook)
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
Propofol
aka Diprivan used for sedation
- Intravenous use
- GABA-activated chloride ion channel
69
Haloperidol
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
Dexmedetomidine
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
Nitric oxide
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
Phenobarbital
a long-lasting barbiturate and anticonvulsant used in the treatment of all types of seizures, except for absent seizures.
73
Theophylline
used to treat patients with asthma and COPD and acute phases and apnea of prematurity
74
Lasix (furosemide)
Loop diuretic used to filter out NaCl and H2O through the urine for hypertension and CHf patients
75
Cortisone
It has been used in replacement therapy for adrenal insufficiency and as an anti-inflammatory agent
76
Morphine sulfate
opioid agonist used for the relief of moderate to severe acute and chronic pain
77
Valium (Diaxepam)
ong-acting benzodiazepine with rapid onset commonly used to treat panic disorders, severe anxiety, alcohol withdrawal, and seizures
78
Pancuronium bromide
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
Lidocaine
local anesthetic used in a wide variety of superficial and invasive procedures
80
Midazolam
a short-acting benzodiazepine with rapid onset that is commonly used in seizures, anesthesia and anxiety disorders
81
Povidone-iodine
topical antiseptic agent used for the treatment and prevention of infection in wounds
82
Aspirin cream
salicylate used to treat pain, fever, inflammation, migraines, and reducing the risk of major adverse cardiovascular events
83
Explain the different Levels of consciousness and how they are determined
Glasgow coma scale
13-14= mild injury
9-12= moderate injury
3-8= severe injury
84
Explain how you would tell a patient to care for their equipment at home.
warm water and soap
vinegar
85
Explain the difference and when to use an HME vs Heated Humidifier circuit.
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
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.
High flow oxygen
High flow nasal cannula
IPPB
Percussion
PT sit in fowler position
87
Explain the use of a luken’s trap.
= specimen trap that can be placed in the vacuum circuit, when suctioning a patient, to obtain a sample for culture and analysis
88
Explain pulmonary vascular resistance (PRV)
= 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
Explain how to use and troubleshoot a NRB
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
PSV
= 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
CPAP
= 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
BIPAP
= 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
CMV
= 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
SIMV/VC
= patient spontaneously breathes while giving mandatory breathes when needed
ventilatory support
patient provides part of minute ventilation
95
SIMV/PC
= patient spontaneously breathing while time triggered by present frequency
severe ARDS (need high PIP)
96
AC/VC
= 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
AC/PC
= mandatory pressure-controlled breathes are time-triggered by a preset frequency (pressure plateau created)
severe ARDS (need high PIP)
98
PRVC
= 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
MMV
= 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
Orthopnea
= Difficulty breathing when lying down on back
101
Explain the intubation procedure
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
Explain the intubation equipment
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
Explain RSI
= describes an urgent need to gain control of a patient's airway
preparations
pre-RSI medications
cricoid pressure
intubation
post RSI stabilization
104
RSI meds --> Etomidate (Amidate)
= 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
RSI meds --> Succinylcholine= paralytic agent
= 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
Weaning process
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
Weaning success
= 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
Weaning failure
= 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
Explain how to treat hypoxemia related to hypoventilation, diffusion defects, V/Q mismatch and shunts.
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
Explain CPP.
= 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
Explain auto-PEEP and how to reduce it.
= 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
Explain the four parameters for the classification of ALI and ARDS
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
Explain clinical signs of ARDS
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
Explain ways of preventing or reducing barotrauma.
low tidal volume
low PIP
low plateau pressure
115
Cranial nerve 3
= connect directly to the brain and control eye movement
116
Cranial nerve 7
= controls facial movement and expression on the same side of the face
117
Cranial nerve 9
= mixed nerve that provides sensory, motor, and parasympathetic information to the throat and mouth
118
Cranial nerve 10
= (vagus nerve) longest cranial nerve in the body and has both motor and sensory functions
119
Cranial nerve 12
= controls the muscles of the tongue
120
Explain the indications of for a chest tube
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
Explain what would happen if there is an obstruction of a chest tube.
notify physician
occlusive dressing if chest tube becomes disconnected
clamping to see where the obstruction is coming from
122
Explain a chest tube insertion including the equipment used and placement.
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
Operative tube thoracostomy
= dissection of the plural, digital inspection of the pleural space, and insertion guided with the finger and hemostat
124
Tocar tube thoracostomy
= incision of plural, insertion of trocar chest tube, and withdrawal of trocar
125
1 chamber chest collection system
= initially contains 100mL sterile water
long tube submerged in exactly 2cm of water (water seal)
126
2 chamber collection system
= chamber 1 collects all pleural fluids. chamber 2 remains constant and the work of spontaneous breathing is unaffected
127
3 chamber collection system
= 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
Explain what could cause bubbling in the water seal chamber and how to troubleshoot the issue.
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
Explain what should be done once the chest tube is sutured in place.
sterile dressing
x-rays to see proper placement
avoiding kinking of the tubes
130
Explain how to assess chest tubes.
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
Explain tidaling
= fluctuations in the fluid level of a chest tube's water-seal chamber when a patient breathes
132
Explain what wave forms are used for, how they are plotted and what each type of waveform is able to show.
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
Explain how a waveform can show breath efforts.
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
Explain what is meant if the waveform does not return to baseline or zero.
vent is holding pressure inside the chest = PEEP
leaks
135
What does beaking on a waveform show?
= overdistension of the lung
lower tidal volume
136
Explain Clinical Assessment of Hemodynamics.
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
