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ECG 7150/7220 > Resp Insufficiency > Flashcards

Resp Insufficiency Flashcards

1
Q

Gram +

-

A

+ bacteria wall turn blue

Other: can see size and shape of walls, arrangements (chains), presents or lack of structures

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2
Q

who should use a low flow system

A

Someone who can take adequate breath and rate/depth are normal

> than RA but not sufficient to fill lungs entirely bc concentration of O2 is diluted

actual FiO2 (fraction of inspired O2) is inconsistent

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3
Q

use humidification if >

A

4 L (24-44%)

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4
Q

switch to mask if >

A

6L (60%)

Masks should be min 5L to prevent rebreathing CO2

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5
Q

low-flow reservoir system

A

partial or non-rebreather

Partial- when some PTs exhaled CO2 is inhaled during next

bag fills with O2 each inspiration so each breath contains higher FiO2

Keep bag 1/3-1/2 filled on inspiration and keep snug

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6
Q

High flow

A

3-4x higher that PT inspiration rate.

desirable if O2 concentration must be held constant (COPD)

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7
Q

what is a venturi mask?

A

uses nozzle to accelerate O2 flow and mix with RA at precise ratio (24-50%)

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8
Q

S and S of O2 toxicity

A

(IF FiO2 > 50% for > 12 hours)

dyspnea, paraesthesia in extremities, signs pulm edema

If FiO2 required at 100%, PT would be at risk for atelectasis = the normal nitrogen that we breath, keeps the alveoli open. With 100% O2 there would be no nitrogen and the alveoli would collapse

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9
Q

COPD drive to breath

A

lack of O2

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10
Q

1L NP =
6L NP =
Face mask 5= 7-8=

Mask with reservoir 6= 9=

A 
1L = 24%
6L = 44%

Mask 5 = 50% 7-8 = 60%

With reservoir 6 = 60% 9 = 90%

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11
Q

what are the 2 non-invasive ventilation systems

A
  1. CPAP - continuous positive airway pressure

2. BiPAP - Bilevel positive airway pressure

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12
Q

when and why would you use NIV

A
  • support both the PTs vent and gas exchange
  • use as bridge therapy from mechanical vent
  • best for PTs who can cooperate and protect their own airway
  • and for those who have not developed severe acid/base or gas exchange issues
  • preserves PT swallow, speech, and cough.
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13
Q

Criteria that indicate need for NIV include:

A
  1. mod-severe dyspnea
  2. tachypnea (>24/min if hypercapnic, > 30/min if hypoxic)
  3. use of accessory muscles
  4. paradoxical breathing (dysfunctional)
  5. ABG changes
    - pH < 7.35
    - PaCO2 >45
    - PaO2/FiO2 ratio < 200
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14
Q

what is a normal PaO2/FiO2 ratio and how do you calculate it?

A

Normal >350

PaO2 of 80 mmHg divided by FiO2 0.21 (RA) = 380.95

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15
Q

criteria to exclude for NIV:

A
  • respiratory arrest
  • CAP/HAP
    -hypoxic resp failure
    RI and RF
  • bridge from mechanical vent
  • medically unstable (hypotensive, uncontrolled cardiac ischemia, dysrhythmias, uncontrolled GI bleed…)
  • unable to protect own airway, risk aspiration, excessive secretions, agitated/combative, facial trauma, burns, recent upper GI bleed, airway sx, cant fit mask
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16
Q

CPAP/BiPAP machines deliver…

A
  • Mixed gas. can be controlled
  • Both use + pressure
  • Ventilator can be set to be used as CPAP or BIPAP.
  • PT data can be kept (RR, Vt, minute vol…)
  • has alarm parameters (pressure alarms, volume alarms, RR alarms, FiO2 alarms…)
  • there are a variety of interfaces avail (nasal pillows, oronasal or full face, nose/mouth, total face, mouth piece with lip seals…)
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17
Q

NIV machines control settings:

A
  • how the breath is started
  • how quickly the air/O2 is delivered to the PT (flow meter)
  • How inspiration is ended (how does delivery stop– > when PTs inspiratory effort has decreased? Predetermined air pressure has been reached? Or certain volume has been delivered
  • the degree to which a PT can exhale a breath (preventing full exhale can be beneficial)
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18
Q

Inhalation creates…. ? and is …..?

Exhalation….?

A
  • Inhalation creates negative thoracic pressure that sucks air into the lungs. It is active
  • Exhalation creates positive pressure and is passive.
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19
Q

CPAP

A
  • ** use when there is only an oxygenation issue**
    PT breathes spontaneous
  • the pressure while breathing is maintained as continuous and is always positive throughout inhale and exhale
  • back and fourth between 3-5 cm H2O
  • PEEP CPAP applied pressure at the end of expire (positive end expiratory pressure). This prevents PT from exhaling fully, which rises the baseline pressure for the whole resp cycle.
  • PEEP is created with valve in tubing
  • keeps intrapulm pressure above zero
  • increases FRC NOT Vt!!!!
  • CPAP pushes fluids down and out, thinning layer of fluid and allowing for better diffusion of O2 = improving shunt keeping alveoli open ***
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20
Q

Explain CPAP for O2 supply and demand***

A

CPAP PEEP/continuous pressure, keeps the alveoli open = increasing FRC = also thinning lung walls = increasing surface area avail for gas exchange and decreasing V/Q mismatch = improving gas exchange and ventilation and decreasing WOB

thin walls also helps lung compliance = increasing WOB

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21
Q

BiPAP pressure settings

supports:

A

Inspiration and expiration

Spontaneous breathing- can set rate. Will breathe if PT doesnt (6/min or one in 10 sec)

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22
Q

IPAP

A

Inspiratory positive pressure- machine delivers high flow O2 and air untill preset pressure level is reached and maintained throughout inspiratory phase

  • usually set to 10-16 cm H2O
  • this boost in early inspiration decreases in PT inspiratory effort, gas flow will stop, inspire will end, and PT breaths out

** reduces WOB and increases Vt = supports Ventilation ***

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23
Q

EPAP

A

Expiratory positive airway pressure- usually same as peep (3-5 cm H2O)

  • Pt will breath out until preset EPAP is reached - preventing them from completely emptying their alveoli

** maintains alveoli open and decreases A-C membrane thickness and increases surface area = increases diffusion = supports oxygenation **

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24
Q

BiPAP helps ventilation by:

A

Inspiration boost from IPAP

  • decreases WOB at the beginning - saves energy for remainder of inspire
  • gas that is delivered to create the preset IPAP actually provides some Vt for the PT

these 2 things support PT in achieving effective Vt and improve ventilation

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25
Q

what do you need to do if you want to increase the amount of support of ventilation?

A

Increase IPAP or decrease EPAP

The amount inspiratory support is the difference between IPAP and EPAP

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26
Q

What is a normal inspiratory support?

A

10 cm H2O

IPAP 15 - EPAP 5 = 10cm H2O

27
Q

What has the ability to influence gas exchange most directly

A

EPAP. By creating the same outcome as PEEP in CPAP.

it decreases alveolar collapse and improves alveolar surface area and increases FRC (thinning of alveolar-cap mem) = decreased V/Q mismatch and improves diffusion and improves gas exchange

28
Q

What does IPAP most influence?

A

Ventilation or PaCO2

If you want to decrease PaCO2 then you increase IPAP

29
Q

What does EPAP most influence?

A

Oxygenation and Gas exchange (like PEEP) PaO2

If you want to increase PaO2 then you increase EPAP

30
Q

explain how BiPAP will support PTs ventilation

IPAP 15
EPAP 5
FiO2 0.7
back up breaths 6/min

A
  • BiPAP will take breaths if PT doesnt after 10 sec by delivering gas until IPAP reaches 15
  • when PT initiates a breath, the BiPAP machine recognises the inspire effort and delivers a high flow of gas until IPAP 15 is reached (this will give him a boost of 10cm H2O)
  • this will decrease WOB (esp begin inhale) and support him achieving adequate Vt to improve vent
  • EPAP of 5 cm will thin out the alveoli-cap mem, improving lung compliance and decrease WOB
  • effects of IPAP and EPAP will decrease WOB and O2 demand
31
Q

explain how BiPAP will support PTs gas exchange

IPAP 15
EPAP 5
FiO2 0.7
back up breaths 6/min

A
  • EPAP set to 5 will enhance alveolar recruitment and minimize alveolar collapse = decrease V/Q mismatching
  • Also thins out alveolar-cap membrane = supports diffusion and gas exchange = improve O2 supply
  • FiO2 of 0.7 = increases the driving pressure a the alv-cap membrane = increase diffusion and improve O2 supply
  • The improvement in vent will bring more O2 to alveoli = enhance gas exchange and improve O2 supply
32
Q

Why did the Dr want to give Pt a bolus before putting him on BiPAP?

A
  • BC the pressure causes positive intrathoracic pressure throughout the resp cycle and particularly during inspiration = + intrathoracic pressure will inhibit venous return = decreased preload!!!
  • if preload drops too low it cannot support contractility
33
Q

to improve ventilation with a CO2 of 50 on a BiPAP machine, one could adjust the…?

A

Increase the IPAP

34
Q

To improve oxygenation, PaO2 while on BiPAP one could….?

A

increase the EPAP OR FiO2 but not past 50%

35
Q

when breathing spontaneous on inspire we create a______ pressure in our lungs

A

negative

36
Q

While on BiPAP if you need to improve the oxygenation/PaO2 by increasing the EPAP, what can you negatively impact?

A

Vt and CO2

If you increase EPAP without increasing IPAP, you decrease ventilation which will increase PaCO2***

37
Q 
pH 7.34
PaCO2 38
PaO2 60
HCO3 24
SaO2 88%

What do you need. CPAP or BiPAP?

A

CPAP bc PaCO2 is normal (not a ventilation issue)

need to improve oxygenation and gas exchange

38
Q 
pH 7.22
PaCO2 50
PaO2 59
HCO3 24
SaO2 88

CPAP or BiPAP?

A

BiPAP bc it a ventilation, oxygenation and gas exchange issue.

39
Q 
pH 7.37
PaO2 55
PaCO2 42
HCO3 24
SaO2 85%
FiO2 60%
IPAP 15
EPAP 5

What do you want to adjust on the BiPAP machine?

A

Increase EPAP. Not increase FiO2 because it is already over 50%

40
Q 
pH 7.33
PaO2 79
PaCO2 48
HCO3 24
SaO2 94%

What do you adjust?

A

Increase the IPAP bc now it is a ventilation problem

41
Q

Nursing care for PTs with NIV

A
  • assess
  • monitor PT response to determine effectiveness, VS, resp status
  • monitor and manage potential complications
  • reassure PT. they often feel claustrophobic : explain, reassure, coach breathing
  • straps firm 1-2 fingers between mask and face
  • -> small air leaks are acceptable but not toward the eyes
  • RT will prob start low and increase IPAP/EPAP to desirable level/PT tolerance, until Vt is achieved. Set alarms
  • check ABG in one hr after start BiPAP
  • SaO2 > 90% suggested/reasonable goal
  • If SaO2< 90% then increase FiO2 or EPAP (but increasing EPAP might mean that you increase IPAP so you dont decrease Vt)
  • monitor status esp preload. + pressure vent increases intrathoracic pressure = decreased venous return to heart and decreases preload
  • when you decrease PEEP/EPAP or DC the + pressure vent, a PTs hemodynamic status needs to be considered as their preload might increase
42
Q

complications with NIV

A
  • not fitting, air leaks, skin urcers

- airflow complications, dryness, gastric insufflation (risk increases with higher IPAP)

43
Q

weaning

A

can take several hrs to days

44
Q

you notice changes to a PTs RR and Vt while on BiPAP but SpO2 has not changed what do you do?

A
  1. ABC!
  2. what is causing the change? pain, anxiety, increased secretion or decreased lung compliance (pneumonia)
  3. Increased RR and decreased Vt = resp distress
  4. Auscultate lungs
  5. CXR?
  6. ABG to see PaCO2
45
Q

what do you do if the PT gets restless with the BiPAP mask?

A
  • determine the cause of discomfort… hypoxemia (SpO2??), fever, pain, anxiety, need to ee…
  • If hypoxemia is low then call RT/MRP, complete ABG to confirm PaO2 and SaO2
  • check face mask
  • coach breathing
46
Q

How do you know when things/breathing has improved?

Ventilation

A
  • access muscles not used, RR down, Vt adequate (500cc normal), less crackles, no wheeze
  • less crackles = improved compliance
  • no wheeze = improved resistance
  • improved WOB
47
Q

How do you know when things/breathing has improved?

Gas exchange

A
  • less crackles = improved V/Q matching and diffusion

- PaO2 and SaO2 improving

48
Q

How do you know when things/breathing has improved?

CO

A
  • Lower HR, decreased WOB and improved SaO2

- BP and CVP ok

49
Q

what is the gold standard measurement for ventilation

what is it affected by?

A

PaCO2

  • lung compliance, airway resistance, resp muscle function, Vt,….
50
Q

What is the gold standard measurement for gas exchange?

What is it affected by?

A

PaO2

  • Diffusion and V/Q mismatch
51
Q

3 main classifications of pneumonia

A
  1. site of acquisition
  2. casual agent
  3. Severity
52
Q

Site of acquisition 4

A
  1. Community Acquired Pneumonia (CAP)
    < 48hrs
    - thin watery sputum
    - gram +
  2. Hospital Acquired Pneumonia (HAP)
    > 48hrs
    - thick green sputum
    - gram -
  3. Vent acquired Pneumonia (VAP)
    - > 48hrs
  4. Health care acquired pneumonia (HCAP)
    - long term care
53
Q

Typical vs atypical pneumonia

A

Typical- bacterial strep
xray- consolidation lobar/bronchial

Atypical- virus, fungi, protozoa
XRAY- patchy infiltrates multiple foci

54
Q

pH 7.47
PaCO2 33
Pa 58
HCO3 23 SaO2 88%

analyze this and what do you do

A

Resp alkalosis with mod hypoxemia.

Dont fix the alkalosis. this is not the problem. Fix the hypoxemia. the alkalosis is the effects of the hypoxemia (compensation)

55
Q

how do you support pneumonia vent and gas exchange?

A
  • O2 therapy

Optimize gas exchange:

  • positioning
  • secretion removal (DBand C, hydration) diffusion and V/Q matching

Ventilation:

  • inhalers
  • nutrition and hydration (improve resp muscle function and secretion clearance)
56
Q

which is the most common to increase, IPAP or EPAP?

A

IPAP first bc of the effect EPAP has on gas exchange

57
Q

IF Pt has an increase in CO2 you ?

A

Increase IPAP

58
Q

NIPPV stands for?

A

Non Invasive Positive Pressure Ventilation

59
Q

what do you do if your PaO2 - 168?

A

Turn down FiO2 or turn down EPAP

60
Q

what is mixed acidosis?

A

when you see resp asidosis, higher PACO2 55, but you also have HCO3 opposite- high 30

61
Q

when do you have anaerobic lactic acidosis

A

when you have a low O2 supply. HCO3 is low (metabolic)

62
Q

what happens of you increase EPAP but dont increase IPAP?

A

the pressure support will likely not be high enough and the PTs PaCO2 will increase

63
Q 
pH 7.34
PaCO2 46
PaO2 80
HCO3 22
SaO2 93

On BiPAP. what do you do?

A

Increase IPAP only because you want to increase

ECG 7150/7220 (6 decks)

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