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RCP > RCP 105 (VENTS) midterm > Flashcards

RCP 105 (VENTS) midterm Flashcards

1
Q

What are the effects of High PEEP?

A

INCREASED PAP, INCREASE CVP, DECREASE PCWP

Example sentence: High PEEP can lead to increased pulmonary artery pressure (PAP), increased central venous pressure (CVP), and decreased pulmonary capillary wedge pressure (PCWP).

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2
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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3
Q

Pulse oximetry

A

A device that measures the patient’s arterial oxygen saturation (SpO2) by emitting dual wavelengths of light through a pulsating vascular bed.

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4
Q

PaO2

A

oxygenation

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5
Q

SpO2

A

pule oximetry

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6
Q

Double-lumen tube

A

as 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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7
Q

OPA

A

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

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8
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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9
Q

ET tube

A

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

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10
Q

Trachea 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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11
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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12
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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13
Q

Laryngoscope handle

A

used to displace the tongue and soft tissues

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14
Q

Blade

A

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)

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15
Q

ET tube intubation

A

size 7.5 to 8 typical male size and 7.0 to 7.5 for adult females

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16
Q

10mL syringe

A

used to test the pilot balloon and inflate the cuff after intubation

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17
Q

water souble lubricant

A

used to lubricate the distal end of the ET tube for easy insertion into the trachea

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18
Q

tape

A

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

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19
Q

sethoscope

A

needed to auscultate bilateral breath sounds immediately after intubation

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20
Q

stylet

A

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

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21
Q

topical anesthetic

A

may be used to numb and vasoconstrict the mucosal membrane

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22
Q

Magill forecps

A

used to perform nasal intubation under direct vision

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23
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

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24
Q

Determine if the ET tube is in the correct place

A

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

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25
Q

Explain how to calculate the I:E ratio for a time-cycled, pressure-limited ventilator.

A

Minute volume x sum of I:E ratio (add)

ex:

Given= 12 L/min, 1:3
12 L/min x (1+3)
12 L/min x 4
= 48 L/min

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26
Q

Mechanical deadspace

A

volume of gas contained in the equipment and supplies that does not take part in gas exchange (going to vary depending on machine and patient)

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27
Q

Anatomic deadspace

A

volume occupying the conducting airways that does not take part in gas exchange (150mL adults)

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28
Q

Bronchitis

A

= inflammation of the lining of the bronchial tubes, which carry air to and from the air sacs (alveoli) of the lungs. It’s characterized by daily cough and mucus (sputum) production

General Appearance: barrel chest, clubbing and cyanosis

Respiratory Pattern: dyspnea, accessory muscle use, pursed-lip breathing

Breath Sounds: diminished aeration with bilateral expiratory wheeze

Diagnostic Chest Percussion: tympanic or hyperresonant

Cough: congested, productive thick sputum

Chest- Xray: hyperlucency, hyperinflation, increased A-P diameter, flattened diaphragm

ABG: compensated respiratory acidosis with hypoxemia and hypercapnia

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29
Q

Pneumonia

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

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

CBC: Increased WBC with bacterial infection, decreased with viral
Culture and Sensitivity to determine cause

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30
Q

Emphysema

A

= the alveoli at the end of the smallest air passages (bronchioles) of the lungs are destroyed as a result of damaging exposure to cigarette smoke and other irritating gasses and particulate matter

Anatomic alterations:

Permanent enlargement and destruction of the air spaces distal to the terminal bronchioles

Destruction of alveolar-capillary membrane

Weakening of the distal airways, primarily the respiratory bronchioles

Air trapping and hyperinflation

Chest- Xray: hyperlucency, hyperinflation, increased A-P diameter, flattened diaphragm

ABG: compensated respiratory acidosis with hypoxemia and hypercapnia

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31
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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32
Q

CHF

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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33
Q

Pulmonary embolus

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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34
Q

Atelectasis

A

= abnormal condition of the lungs characterized by the partial or total collapse of previously expanded alveoli

Diagnosis:

Physical Exam

Chest X-ray: Provides pictures of the chest to help identify areas of collapsed lung tissue (GOLD Standard)

Computed tomography (CT) scan: Creates detailed images of the lungs and chest cavity to help determine the cause of atelectasis

Bronchoscopy: A thin, flexible tube with a camera is inserted into the windpipe to detect and remove blockages

Vital signs: Increased Respiratory rate (tachypnea), Heart rate (pulse), Blood pressure

Cyanosis

Chest assessment findings:

Increased tactile and vocal fremitus

Dull percussion note

Bronchial breath sounds

Diminished breath sounds

When atelectasis is caused by mucous plugs:

Crackles

Whispered pectoriloquy

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35
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

ABG for large pneumothorax= Acute ventilatory failure with hypoxemia (acute respiratory acidosis)
pH= DECREASED
PaCO2= INCREASED
HCO3-=INCREASED
PaO2= DECREASED
SaO2= DECREASED

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36
Q

Flail chest

A

= The result of double fractures of at least three or more adjacent ribs

Causes the thoracic cage to become unstable

The affected ribs paradoxically cave in (flail) during inspiration as a result of the generated subatmospheric intrapleural pressure

Compresses and restricts the underlying lung

Sharp rib fragments may also damage underlying tissue and large blood vessels

Causes a restrictive lung disorder

Anatomic alterations:

Double fracture of numerous adjacent ribs

Rib instability

Lung volume restriction

Atelectasis

Lung collapse (pneumothorax)

Lung contusions

Secondary pneumonia

Vital signs:

Increased respiratory rate (tachypnea), Heart rate (pulse), Blood pressure

Paradoxical movement of chest wall\

Pain/anxiety

Cyanosis

Diminished breath sounds: on both the affected and the unaffected sides

ABG= Acute alveolar hyperventilation with hypoxemia (acute respiratory alkalosis)

pH= INCREASED

PaCO2= DECREASED

HCO3-= DECREASED but normal

PaO2= DECREASED

SaO2= DECREASED

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37
Q

Bronchiectasis

A

= Chronic dilation and distortion of one or more bronchi as a results of excessive inflammation and destruction of bronchial walls, blood vessels, elastic tissue and smooth muscle. This results in impaired mucociliary clearance causing accumulation of copious amounts of bronchial secretions

Chest X-ray: hyperlucent lung fields, depressed or flattened flattened diaphragm, enlarged or elongated heart.

ABG: Mild to moderate cases :acute alveolar hyperventilation with hypoxemia

Severe cases: chronic ventilatory Failure with hypoxemia

Bronchogram or CT: dilated bronchi, increased bronchial wall opacity

Patient Assessment

History of pulmonary infections

General appearance: cyanosis, barrel chest, clubbing\

Respiratory Pattern: tachypnea, dyspnea, accessory muscle use, pursed-lip breathing.

BS: wheezing, diminished breath sounds

Diagnostic percussion: hyperresonat or tympanic notes

Cough: productive of purulent, foul-smelling secretions, hemoptysis, sputum will separate into 3-layers

Increased hematocrit and hemoglobin

Elevated white blood count if acutely elevated

Sputum examination:
Streptococcus pneumoniae
Haemophilus influenzae
Pseudomonas aeruginosa
Anaerobic organisms

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38
Q

TB

A

= A contagious chronic bacterial infection that primarily affects the lungs

TB pathogen, Mycobacterium tuberculosis—a rod-shaped bacterium with a waxy capsule

It may involve almost any part of the body

Anatomic:

Alveolar consolidation

Alveolar-capillary destruction

Caseous tubercles or granulomas

Cavity formation

Fibrosis and secondary calcification of the lung parenchyma

Distortion and dilation of the bronchi

Increased bronchial airway secretions

Diagnosis:
Mantoux tuberculin skin test
Acid-fast bacilli (AFB) sputum cultures
The QuantiFERON-TB Gold (QFT-G) test
The rapid Xpert MTB/RI assay

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39
Q

Pleural 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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40
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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41
Q

Sleep apnea

A

OSA= common sleep disorder that often requires lifelong care (blocked airflow)

Presence of:
Snoring
Sleep fragmentation
Periods of apnea during sleep
Nonrefreshing sleep
Persistent daytime sleepiness

Central sleep apnea= disorder characterized by the repetitive stopping or reduction of both air flow and ventilatory effort during sleep. Brain fails to transmit signals for muscles to breaths

Examples associated with it is Cheyne-Stokes breathing (CHF), medical conditions, brain stem infarction, spinal surgery, hypothyroidism, high altitude periodic breathing

Diaphragm doesn’t move

AFIB

Patients diagnosed with CSA are evaluated carefully for:

The presence of cardiac disease

Lesions involving the cerebral cortex and the brainstem

AHI =# of apneas and hypopneas

—-—————————

TST (hr)

Physical:

Apnea or hypopnea

Cyanosis

ABG: Acute alveolar hyperventilation superimposed on chronic ventilatory failure

Possible impending acute ventilatory failure

Acute ventilatory failure (acute hypoventilation) superimposed on chronic ventilatory failure

CXR:
Often normal
Right-or left-sided heart failure

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42
Q

ARDS

A

In response to injury:

Pulmonary capillaries become engorged

Permeability of the alveolar-capillary membrane increases

Interstitial and intra-alveolar edema and hemorrhage

Scattered areas of hemorrhagic alveolar consolidation

Result in a decrease in alveolar surfactant and in alveolar collapse, or atelectasis

*Create a restrictive lung disorder

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

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43
Q

Modes of ventilation you can use pressure support (PS) in

A

SIMV/VC

SIMV/PC

PS/CPAP

BiPAP

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44
Q

How PS helps when using SIMV

A

PS commonly applied in the SIMV mode when the patient takes a spontaneous breath since PS is not active during mandatory breaths. Typically used to facilitate weaning in a difficult-to-wean patient

Pressure support:
increases the patient’s spontaneous tidal volume
decreases the patient’s spontaneous frequency
decreases the work of breathing

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45
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.

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46
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

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47
Q

Weaning faliure

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

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48
Q

Sinus tachycardia

A

heart rate greater than 100 bpm (normal P-QRS-T pattern)

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49
Q

sinus bradycardia

A

heart rate less than 60 bpm (normal P-QRS-T pattern)

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50
Q

premature ventricular contractions (PVCs)

A

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

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51
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

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52
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

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53
Q

Asystole

A

= complete absence of electrical and mechanical activity

cardiac activity and blood pressure fall to 0

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54
Q

Heart blocks

A

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

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55
Q

Sensorium

A

what is their level of consciouness

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56
Q

Static compliance

A

= reflects the elastic properties of the lung and chest wall (resistance)

Corrected Tidal volume፥(plateau pressure-PEEP)

57
Q

Dynamic compliance

A

= reflects the airway resistance and elastic properties of the lung and chest wall

Corrected tidal volume፥(PIP-PEEP)

58
Q

Airway resistance

A

(0.5-2.5 cmH2O)= airflow obstruction in the airways

radius of the airway decreases and airway resistance increases

hypoventilation may result if patient is unable to overcome airway resistance by increasing work of breathing

59
Q

Physiological effects of mechanical ventilation

A

acute airflow obstruction

deadspace ventilation

congenital heart disease

cardiovascular decompensation

shock

increased metabolic rate

drugs

decreased compliance

60
Q

Propofol- aka Diprivan

A

used for hypnotic effect

Intravenous use

GABA-activated chloride ion channel

Adverse effects:
Apnea
Bradycardia
Laryngospasm and bronchospasm
Coughing
Dyspnea
Hypotension
Burning or pain at infusion site
Discoloration of urine to green or brown
Increased calories because of the oil-in-water formulation

61
Q

Haloperidol- aka Haldol

A

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

62
Q

Dexmedetomidine- aka Precedex

A

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

Provides sedation and anxiolysis via receptors within the locus coeruleus (group of neurons in the pons)

Provides analgesia via receptors in the spinal cord

Adverse effects:
Hypotension, bradycardia, and sinus arrest are potential adverse effects because dexmedetomidine reduces sympathetic activity
Transient hypertension may occur
Transient neurological abnormalities may occur in children upon discontinuance

63
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

Adverse effects:
When combined with oxygen, NO is converted to NO2 (nitrogen dioxide)
At a level of >10 ppm, NO2 can cause cell damage, hemorrhage, pulmonary edema, and death
NO and NO2 may be converted to nitric acid (HNO3) and nitrous acid (HNO2)
HNO3 and HNO2 may cause lung inflammation (interstitial pneumonia)
NO is inactivated by combining with hemoglobin to form methemoglobin (methemoglobinemia)
NO causes inhibition of platelet aggregation and negative inotropic effect

64
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

65
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

66
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

67
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

68
Q

SIMV/VC

A

= patient spontaneously breathes while giving mandatory breathes when needed

ventilatory support

patient provides part of minute ventilation

69
Q

SIMV/PC

A

= patient spontaneously breathing while time triggered by present frequency

severe ARDS (need high PIP)

70
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

71
Q

AC/PC

A

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

severe ARDS (need high PIP)

72
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

73
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

74
Q

CPAP

A

Its positive pressure that is applied to a patient that is spontaneously breathing.

when PEEP is applied to spontaneous breathing patient, airway pressure is called CPAP

75
Q

PEEP

A

= airway pressure strategy, and ventilation that increases the end, expiratory or baseline airway pressure to value greater than atmospheric pressure

76
Q

EPAP

A

= airway pressure that is above 0cm H2O during the expiratory phase of a respiratory cycle

Physiology:

if the force of elastic recoil is increased due to decrease in compliance, the alveolar volume will decrease

if lung compliance continues to deteriorate → elastic recoil forces become great enough to overcome normal alveolar distending pressure → alveolar collapse and intrapulmonary shunting

77
Q

Poiseuille’s Law and how it relates to work of breathing

A

= work of breathing increases by a factor of 16-fold when the radius of the airway is reduced by half its original size

driving pressure=airflow/radius 4

78
Q

Extubation procedure

A

procedure explained to patient

patient in Fowles (semi-sitting) positon

hyperinflation and oxygenation provided with manual resuscitator via ET tube

ET tube suction

cuff deflated

ET tube removed

encourage patient to breathe deeply and cough

suction secretions

vital signs, ABG, signs of tissue value assessed

79
Q

CVP measured

A

= by a central venous catheter placed through either the subclavian or internal jugular veins, measured in the vena cava or right atrium

how much blood is getting pumped to right side of the heart

80
Q

Low exhaled volume

A

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

alarm triggered if patient does not exhale an adequate tidal volume

81
Q

Low inspiratory pressure

A

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

alarm triggered if PIP is less than alarm setting

82
Q

High inspiratory pressure

A

= should be set 10-15cmH2O above observed PIP

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

83
Q

Apnea

A

= should be set 15-20 seconds time delay

triggered in circuit disconnection, ET suctioning

84
Q

High frequency

A

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

triggering is a sign of respiratory distress

85
Q

High/Low FIO2

A

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

86
Q

PEEP benefits/complications

A

Benefits:
reinflates collapsed alveoli and supports
maintains alveolar inflation during exhalation

Complications:
decreased venous return
decrease cardiac output
barotrauma
increased intracranial pressure
alterations of renal functions
alterations in water metabolism

87
Q

Square (constant) flow

A

provides an even, peak flow during the entire inspiratory phase

88
Q

Accelerating (ascending) flow

A

may improve distribution of ventilation in patients with partial airway obstruction

89
Q

Decelerating (descending) flow

A

produces a high initial inspiratory pressure and the decrease in flow may help improve distribution of tidal volume and gas exchange

COPD → may reduce PIP, MAP, physiological deadspace, and PaCO2

90
Q

Sine wave

A

improve distribution of ventilation and therefore improve gas exchange (similar to spontaneous breathing flow)

91
Q

ET suctioning

A

wash hands and glove
gather all suction supplies
explain procedure to patient
adjust vacuum to 100mmHg
preoxygenate patient
put sterile water in container
test vacuum with suction
insert catheter and advance until resistance (cough)
pull catheter back (10-15 seconds)

Complications:
suction induced hypoxemia
impeding airflow
dislodging of bacteria into lower airway

92
Q

Ventilatory faliure

A

= failure of the respiratory system to remove CO2 from the body, resulting in an abnormally high PaCO2. Occurs when the patient’s minute ventilation cannot keep up with the CO2 production

93
Q

Hypoexmia

A

= reduced oxygen in the blood

ABG used to evaluate patient’s oxygenation status

94
Q

prevent or treat skin breakdown caused by ET tubes or BIPAP masks

A

area clean, dry

adjustment of tube every vent check

proper oral care

95
Q

prevent drying of the airway in BIPAP and mechanically ventilated patients

A

heated humidification, heated wire circuit, a heat-moisture exchanger (HME)

96
Q

Alpha/Beta receptors

A

Alpha 1= peripheral blood vessels

Alpha 2= presynaptic sympathetic neurons, CNS

Beta 1= heart

Beta 2= smooth muscle (bronchial), cardiac muscle

Beta 3= lipocytes

97
Q

Basic ventilator settings on mechanical ventilator

A

mode

frequency

tidal volume

FIO2

I:E ratio

inspiratory flow pattern

alarm limits

98
Q

NPPV successfull in

A

= in the management of airflow obstruction in sleep apnea and in the reduction of respiratory workload in gross obesity

99
Q

Indications for mechanical ventilation

A

Drug overdose (central hypoventilation/acute respiratory insufficiency)

Acute spinal cord injury (respiratory paralysis)

Head trauma (abnormal respiratory pattern)

Neurologic dysfunction (coma/stroke)

sleep disorders (CSA/OSA)

metabolic alkalosis

acute airflow obstruction (COPD)

Dead space ventilation (pulmonary embolism/decreased in CO)

Congestive heart diseases

Cardiovascular decompensation (decreased CO/VQ mismatch)

Shock (blood loss/CHF)

Increased metabolic rate (fever/increased WOB)

Decreased compliance (ARDS/atelectasis)

drugs (acute pulmonary edema/bronchospasms)

chest trauma (flail/pneumothorax)

premature births (idiopathic respiratory distress syndrome)

electrolyte imbalance (hyperkalemia)

Geratric patients (fatigue)

100
Q

Circuit change

A

The more we break the circuit, the more we introduce to the circuit (infection control)

101
Q

Nasal mask (interface NPPV)

A

= a mask that covers only the nose

Benefits:
comfort
patient compliance

Risk:
gas leaks
nasal dryness
drainage

102
Q

Oronasal mask (NPPV interface)

A

= covers the nose and mouth

Benefits:
good seal
more effective ventilation

Risk:
claustrophobia
patient noncompliance
regurgitation/aspiration
asphyxiation in power or gas outage
alarm/monitor necessary

103
Q

Nasal pillow (NPPV interface)

A

= smaller nasal mask

nasal congestion
gas leaks
nose bleed
dry/sore mouth

104
Q

Full face mask (NPPV interface)

A

= covers entire patients face

105
Q

Control circuit on vent

A

= the system that governs or controls the ventilator drive mechanism or output control value/ responsible for characteristics output waveforms

106
Q

Open loop

A

=desired output is selected and ventilatory achieves the desired output

107
Q

Closed loop

A

=desired output is selected and ventilatory achieves the desired output

108
Q

Indwelling arterial catheter

A

= a thin, flexible tube inserted into an artery to provide continuous access to arterial blood and blood pressure

109
Q

Oral intubation

A

= done in emergency situations

110
Q

Nasal intubation

A

= time consuming and suitable in elective intubation

111
Q

Stroke volume index

A

SV= CO/HR

Normal range → 40-80 mL

112
Q

Hypoxemia levels

A

Normal → 80-100mmHg

Mild → 60-79mmHg

Moderate → 40-59

Severe → less than 40

113
Q

SIMV

A

mode in which the ventilator drives either assisted breaths to patient at the beginning of a spontaneous breath or time-triggered mandatory breaths

time triggered or patient triggered

114
Q

AC

A

each control breath provides the patient with a present, ventilator-delivered tidal volume

Assisted- patient triggered

Control- time triggered

does not allow spontaneous breathing

115
Q

Acetylcholine

A

Acetylcholine is released when the parasympathetic system is stimulated

116
Q

Pulmonary artery catheter

A

pressure readings and waveforms are monitored to determine the catheter’s position as it moves through the right atrium (RA), right ventricle (RV), pulmonary artery (PA), and into a pulmonary capillary wedge pressure (PCWP) position

after the PCWP reading, the balloon is deflated to allow blood to flow past the tip of the catheter

117
Q

ET tube intubation/use complications/hazards

A

trauma to teeth and soft tissues

esophageal intubation

vomiting/aspiration

hypoxia

arrhythmias

bradycardia

obstruction

pneumonia

kinking

mucosal injuries

laryngeal damage

improper tube position

pressure sore

inadvertent extubation

sinusitis

118
Q

Hemoglobin affecting SaO2/SpO2

A

= protein continuing iron that facilitates the transports oxygen in RBC

PaO2 measures the amount of oxygen dissolved in the plasma whereas vast majority of oxygen in the blood is combined with or carried by hemoglobins

PaO2 may be inadequate if patients hemoglobin levels are below normal (anemia)

119
Q

RSI

A

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

Steps:
preparations
pre-RSI medications
cricoid pressure
intubation
post RSI stabilization

120
Q

RSI MEDS

A

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

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

121
Q

VAP

A

= infection of the lung parenchyma that is related to any or multiple events that the patient undergoes during mechanical ventilation that happens after 48 hours

Prevent:
proper handwashing techniques
closed suction systems
continuous feed humidification systems
change of ventilator circuit only when visibly soiled
elevated head of 30-45 degrees

122
Q

Kidneys

A

= filters dissolved particles from blood and selectively reabsorbs the substances that are needed to maintain normal composition of body fluid

123
Q

Impending ventilatory faliure

A

= A gradual increase of PaCo2 caused by deteriorating lung functions with increased work of breathing/minute ventilation to compensate

PaCo2 increases and pH falls → initiated mechanical ventilation

124
Q

Gram stain

A

identifies whether bacteria are gram positive or gram negative takes 1 hour

125
Q

Acid-fast sputum

A

performed to determine acid fast bacilli (Mycobacterium tuberculosis)

126
Q

Silver stain

A

can be used as a diagnostic tool for bacterial and fungal infections such as infections caused by Pseudomonas app, Treponema palladium, Helicobacter pylori, Legionella, Leptospira, Bartonella, Pneumocystis, Candida, Histoplasma, Cryptococcus

127
Q

Culture test

A

identifies the bacteria present and takes 48 to 72 hours

128
Q

Sensitivty test

A

identifies what antibiotics will kill the bacteria takes 48 to 72 hours

129
Q

Hypokalemia signs

A

Hypokalemia (below 3):

Decreased muscle functions

Flattened T wave and depressed ST segment on ECG

Arrhythmias

Decreased bowel activity, diminished or absent bowel sounds

130
Q

Hyperkalemia signs

A

Hyperkalemia (above 5):

Increased neuromuscular conduction

Elevated T wave and depressed ST segment on ECG (mild)

Cardiac arrest

Increased bowel activity

131
Q

Flow

A

= the volume of gas delivered over time, usually measured in liters per minute

Unit of volume፥unit of time

132
Q

Explain how to lower the I:E ratio on a volume-controlled, flow-limited ventilator.

A

I time= time for each breath x [I ratio/sum of I:E ratio]

ex:

Given= f=16/min → 60፥16 = 3.75 seconds

Desired I:E ratio 1:4
= 3.75 sec x [1/(1+4)]
3.75 x (⅕)
3.75 sec ፥5
= 0.75 sec

133
Q

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

A

= 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.

134
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 deadspace
  2. Increase Tidal Volume
  3. Increase Respiratory Rate
135
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
136
Q

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

A
  1. Increase Deadspace
  2. Decrease the Respiratory Rate
  3. Decrease the Tidal Volume
137
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)
138
Q

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

A

Mode: control or AC

Frequency: 10-12/min

Tv: 10-12 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

139
Q

Why do we monitor the PIP.

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

RCP (8 decks)

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