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Yr 4 - ACC > Respiratory: ARDS, Respiratory Support, Ventilation > Flashcards

Respiratory: ARDS, Respiratory Support, Ventilation Flashcards

1
Q

What are 5 options for respiratory support (from least to most invasive)?

A

1) O2 therapy

2) High flow nasal cannula

3) Non-invasive ventilation

4) Intubation and mechanical ventilation

5) Extracorporeal membrane oxygenation (ECMO)

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2
Q

What is acute respiratory distress syndrome (ARDS)?

A

The increased permeability of alveolar capillaries leading to fluid accumulation in the alveoli i.e. non-cardiogenic pulmonary oedema.

ARDS is a clinical syndrome characterised by acute onset of hypoxemia and bilateral pulmonary infiltrates, in the absence of cardiac failure.

A serious condition that has a mortality of around 40%.

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3
Q

What does ARDS often occur 2ary to?

A

1) Infection: sepsis, pneumonia

2) Trauma

3) Massive blood infusion

4) Smoke inhalation

5) Acute pancreatitis

6) Cardio-pulmonary bypass

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4
Q

What occurs in ARDS?

A

1) Collapse of the alveoli and lung tissue (atelectasis)

2) Pulmonary oedema (not related to heart failure or fluid overload)

3) Decreased lung compliance (how much the lungs inflate when ventilated with a given pressure)

4) Fibrosis of the lung tissue (typically after 10 days or more)

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5
Q

What is lung compliance?

A

How much the lungs inflate when ventilated with a given pressure

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6
Q

Clinical features of ARDS?

A

1) acute onset: symptoms usually develop within 1 week of an inciting event or worsening of an existing condition.

2) SOB: usually the first symptom and is often severe.

3) hypoxia: with an inadequate response to oxygen therapy

4) tachypnoea

5) crackles

6) tachycardia

7) use of accessory muscles

8) cyanosis

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7
Q

What is seen on a CXR in ARDS?

A

Bilateral infiltrates

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8
Q

What are the 2 key investigation in ARDS?

A

1) CXR

2) ABG

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9
Q

Management of ARDS?

A

Due to the severity of the condition patients are generally managed in ITU.

Management is largely supportive:

1) oxygenation/ventilation to treat the hypoxaemia

2) treatment of the underlying cause e.g. antibiotics for sepsis

3) general organ support e.g. vasopressors as needed

4) prone position (lying on their front)

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10
Q

What type of ventilation is typically used in ARDS?

A

During mechanical ventilation, low volumes and pressures are used to avoid over-inflating the small functional portion of the lungs (lung protective ventilation).

Positive end-expiratory pressure (PEEP) is used to prevent the lungs from collapsing further.

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11
Q

What is prone positioning?

A

Lying patient on their front

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12
Q

Benefits of prone positioning?

A

1) Reducing compression of the lungs by other organs

2) Improving blood flow to the lungs, particularly the well-ventilated areas

3) Improving clearance of secretions

4) Improving overall oxygenation

5) Reducing the required assistance from mechanical ventilation

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13
Q

What 4 options for oxygen therapy

A

1) nasal cannula

2) simple face mask

3) venturi mask

4) face mask with reservoir (non-rebreather mask)

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14
Q

What are venturi masks?

A

Venturi masks can be used to deliver exact concentrations of oxygen

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15
Q

what is the most common use for venturi masks?

A

The most common use for these is in patients with COPD who are at risk of retaining carbon dioxide if the FiO2 (conc of O2) is too high.

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16
Q

What is ‘end-expiratory pressure’?

A

The pressure that remains in the airways at the end of exhalation.

Additional pressure in the airways at the end of exhalation stops the airways from collapsing.

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17
Q

Purpose of types of respiratory support that add positive end-expiratory pressure?

A

Help keep the airways from collapsing and improve ventilation:
- reduces atelectasis
- improves ventilation of the alveoli
- opens more areas for gas exchange
- decreases the effort of breathing

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18
Q

What can positive end-expiratory pressure be added by?

A

1) High-flow nasal cannula
2) Non-invasive ventilation
3) Mechanical ventilation

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19
Q

Nasal cannulae can deliver high flow oxygen.

What is the benefit of his?

A

1) A high flow rate reduces the amount of room air that the patient inhales alongside the supplementary oxygen, increasing the concentration of oxygen inhaled with each breath.

2) Adds some positive end-expiratory pressure: helps prevent the airways from collapsing at the end of exhalation

3) High flow of oxygen into the airways provides dead space washout: effectively clears this and replaces it with oxygen, improving patient oxygenation.

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20
Q

What is the physiological dead space?

A

The air that does not contribute to gas exchange because it never reaches the alveoli.

Dead space air remains in airways and oropharynx, not adding anything to respiration and collecting carbon dioxide.

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21
Q

What is CPAP (continuous positive airway pressure)?

A

Involves a constant pressure added to the lungs to keep the airways expanded.

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22
Q

When is CPAP used?

A

It is used to maintain the patient’s airways in conditions where they are likely to collapse (adding positive end-expiratory pressure) e.g. in obstructive sleep apnoea.

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23
Q

Why is CPAP not technically classed as non-invasive ventilation (NIV)?

A

CPAP does not technically involve “ventilation”, as it provides constant pressure and the job of ventilation is still dependent on the respiratory muscles.

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24
Q

What is non-invasive ventilation (NIV)?

A

Involves using a full face mask, hood (covering the entire head) or a tight-fitting nasal mask to blow air forcefully into the lungs and ventilate them.

It is not pleasant for the patient but is much less invasive than intubation and ventilation.

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25
Q

What is BiPAP?

A

BiPAP is a specific machine that provides NIV. BiPAP stands for Bilevel Positive Airway Pressure

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26
Q

NIV involves a cycle of high and low pressure to correspond to the patient’s inspiration and expiration.

What is inspiratory positive airway pressure (IPAP)?

A

IPAP is the pressure during inspiration – where air is forced into the lungs

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27
Q

What is EPAP (expiratory positive airway pressure)?

A

EPAP is the pressure during expiration – stopping the airways from collapsing.

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28
Q

What is extracorporeal membrane oxygenation (ECMO)?

A

The most extreme form of respiratory support (rarely used).

Blood is removed from the body, passed through a machine where oxygen is added and carbon dioxide is removed, then pumped back into the body.

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29
Q

When does respiratory failure occur?

A

When there is a failure of gas exchange and/or ventilation, leading to abnormalities in arterial oxygen partial pressure (PaO2) and arterial carbon dioxide partial pressure (PaCO2) on ABG.

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30
Q

What does type 1 respiratory failure involve?

A

Hypoxaemia (PaO2 <8 kPa) with normocapnia (PaCO2 <6.0 kPa)

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31
Q

What does type 2 respiratory failure involve?

A

Hypoxaemia (PaO2 <8 kPa) with hypercapnia (PaCO2 >6.0 kPa).

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32
Q

What does type 1 respiratory failure usually occur due to?

A

Due to the ventilation/perfusion (V/Q) mismatch - the volume of air flowing in and out of the lungs is not matched with the flow of blood to the lung tissue.

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33
Q

How is PaCO2 normal in type 1 respiratory failure?

A

1) As a result of the V/Q mismatch, PaO2 falls, and PaCO2 rises

2) The rise in PaCO2 rapidly triggers an increase in a patient’s overall alveolar ventilation, which corrects the PaCO2 but not the PaO2 (due to the different shapes of the CO2 and O2 dissociation curves).

3) The final result is hypoxaemia (PaO2 < 8 kPa / 60mmHg) with normocapnia (PaCO2 < 6.0 kPa / 45mmHg).

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34
Q

Give some causes of type 1 respiratory failure

A

1) Reduced ventilation and normal perfusion:
- pneumonia
- pulmonary oedema
- bronchoconstriction

2) Reduced perfusion with normal ventilation:
- pulmonary embolism

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35
Q

What does type 2 respiratory failure occur as a result of?

A

Alveolar hypoventilation, which prevents patients from being able to adequately oxygenate and eliminate CO2 from their blood.

This leads to PaO2 falling (due to lack of oxygenation) and PaCO2 rising (due to lack of ventilation and elimination of CO2).

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36
Q

Give some causes of type 2 respiratory failure

A

Hypoventilation can occur for several reasons:

1) Increased resistance as a result of airway obstruction (e.g. COPD)

2) Reduced compliance of the lung tissue/chest wall (e.g. pneumonia, rib fractures, obesity)

3) Reduced strength of the respiratory muscles (e.g. Guillain-Barré, motor neurone disease)

4) Reduced respiratory drive (e.g. opioids and other sedatives)

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37
Q

What type of respiratory failure does opiate overdose cause?

A

Type 2

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38
Q

What type of respiratory failure does an exacerbation of COPD cause?

A

Type 2

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39
Q

What type of respiratory failure does a PE cause?

A

Type 1

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40
Q

What does FiO2 stand for?

A

Fraction of inspired oxygen.

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41
Q

When are nasal cannulae (NC) typically indicated?

A

Used for mild hypoxia, typically in non-acute settings.

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42
Q

Oxygen is delivered at flow rates measured in L/min.

In nasal cannulae & simple face masks, for every increase in 1L/min, what does the FiO2 increase by?

A

4%

e.g. 1L/min = 24% FiO2, 2L/min = 28% FiO2 etc).

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43
Q

What is the maximum flow rate of nasal cannulae?

A

While the maximum flow rate is 6L/min, do not exceed 4L/min as this would dry out the nasal passages, leading to irritation.

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44
Q

Why should you not exceed a flow rate of 4L/min in nasal cannulae?

A

as this would dry out the nasal passages, leading to irritation.

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45
Q

Disadvantages of nasal cannulae?

A

1) High flows will dry and irritate nasal passages

2) Do not allow close control of FiO2

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46
Q

What is the O2 flow rate of a simple face mask (Hudson mask)?

A

5-10 L/min

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47
Q

What % O2 do nasal cannulae typically deliver?

A

24 - 30% O2

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48
Q

What % O2 do simple face masks typically deliver?

A

30 - 40% O2

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49
Q

What are 2 disadvantages of a simple face mask?

A

1) They do not allow close control of FiO2

2) There is a risk of aspiration if the patient vomits whilst wearing the mask

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50
Q

Who are non-rebreathe (reservoir) masks often used in?

A

Used to treat patients with a significant degree of hypoxia (moderate to severe).

51
Q

How can non-rebreather masks can deliver high FiO2 concentrations?

A

As the oxygen is inhaled from both the reservoir bag as well as the direct oxygen source.

52
Q

What % O2 do reservoir masks typically deliver?

A

Approx 70% O2 when used with a 15L oxygen flow rate.

53
Q

What should you do before positioning a reservoir mask on a patient?

A

Ensure the reservoir bag fills by temporarily obstructing the valve before positioning the non-rebreather mask on the patient.

54
Q

What are 2 disadvantages of a reservoir mask?

A

1) For the mask to work effectively, the reservoir bag needs to be filled before the mask is fitted to the patient. To fill the reservoir bag, obstruct the valve with your finger until the bag is filled with oxygen.

2) Reservoir masks don’t have a true seal, so some entraining of the surrounding air is unavoidable. A reservoir mask is therefore not a fixed performance device.

55
Q

What is the O2 flow rate of a reservoir mask?

A

Delivers up to 15L/min, which approximately equates to 70-90% FiO2.

56
Q

Why does a reservoir mask not deliver 100% FiO2?

A

As some room air will escape into the mask due to the mask not being perfectly adherent to the face.

57
Q

How does a reservoir mask work?

A

A one-way valve prevents exhaled air from entering the reservoir bag (the exhaled air exits via vents on the sides of the mask)

58
Q

What is the main advantage of a venturi mask?

A

Delivers a precise FiO2 if the flow rate is set to a specific rate.

Details of the required flow rate and percentage of oxygen delivery are shown on the coloured mask fittings.

59
Q

Who are venturi masks indicated in?

A

They are used to deliver oxygen to patients with COPD due to the risk of type 2 respiratory failure.

60
Q

What are the 2 main disadvantages of a venturi mask?

A

1) If the flow rate of the oxygen is lower than the recommended amount for a specific Venturi mask, the mask won’t deliver the stated FiO2.

2) If you increase the oxygen flow rate beyond the rate recommended for the mask, it will not continue to increase FiO2.

61
Q

What FiO2 would a 6L flow rate mask deliver?

A

44%

62
Q

What are the 6 different colours of venturi masks?

A

1) blue
2) white
3) orange
4) yellow
5) red
6) green

63
Q

What is the flow rate & FiO2 delivered for each colour of venturi mask?

A

1) Blue: 2L/min, 24%

2) White: 4L, 28%

3) Orange: 6L, 31%

4) Yellow: 8L, 35%

5) Red: 10L, 40%

5) Green: 15L, 60%

Note how flow rate & FiO2 differs for nasal cannulae and Venturi masks.

64
Q

What is effect of standard oxygen gases on the mucous membranes?

A

Have a drying effect on the mucous membranes that can result in airway damage as well as heat and fluid loss.

65
Q

How is the drying effect of oxygen on mucous membranes prevented?

A

Use of humidified oxygen.

Humidified oxygen reduces this effect and can assist in breaking down a patient’s respiratory secretions, making them easier to clear.

66
Q

At what body temp is humidifed oxygen most effective?

A

Humidified oxygen is most effective when the gas reaching the alveoli is at body temperature (37ºC) with a relative humidity of 100%.

67
Q

How is oxygen humidified in oxygen therapy?

A

Oxygen is passed through a humidifying device producing sterile vapour before travelling in elephant tubing to a face mask covering the patient’s nose and mouth.

68
Q

What is the issue with humidified oxygen?

A

Water can pool in the oxygen tubing and obstruct the flow of oxygen if not drained regularly.

69
Q

If a patient is critically unwell and not at risk of type 2 respiratory failure (or you are unsure about their risk), what oxygen therapy should you prescribe?

What O2 sats should you aim for?

A

High-flow oxygen (15L/min) through a non-rebreather mask.

Aim for O2 sats 94-98%.

70
Q

If a patient is critically unwell and is at risk of type 2 respiratory failure, what oxygen therapy should you prescribe?

What O2 sats should you aim for?

A

It is safer to start at a lower FiO2 using a Venturi mask and up-titrate if required.

Aim for oxygen saturations of 88-92%.

71
Q

Flow chart of prescribing oxygen in acute settings (see ACC introduction document for full chart).

A

1) Is the patient critically ill e.g. shock, sepsis, status epilepticus?

1a) Yes –> start 15L/min via non-rebreathe mask (or BVM if respiratory arrest).

1b) No: move on to 2

2) Is the patient at risk of type 2 respiratory failure?

2a) Yes:
- 88-92% target sats
- start 1-2L/min via nasal cannulae OR 28% FiO2 via white venturi
- perform ABG

2b) No:
- 94-98% target sats
- perform ABG (and change to venturi if signs of hypercapnia)

72
Q

When prescribing O2, what must be specified on the drug chart?

A

1) target O2 sats

2) O2 delivery device

3) desired flow rate/FiO2

Typically document clear instructions if you wish for O2 sats to be measured at a certain frequency.

73
Q

What is the p/f ratio?

A

The ratio of partial pressure of oxygen in arterial blood (PaO2) to the fraction of inspiratory oxygen concentration (FiO2).

PaO2/FiO2 (P/F) ratio.

74
Q

What can be used to check if the patient’s pO2 responds adequately to the supplemental oxygen?

A

P/F ratio

75
Q

How is the P/F ratio calculated?

A

P/F ratio = PaO2 on ABG (P) divided by FiO2 (F)

76
Q

How must the FiO2 be expressed?

A

As a decimal (e.g. 40% FiO2 = 0.4).

77
Q

What is the normal P/F ratio?

A

55kPa or 400mmHg (depending on whether PaO2 is measured in kPa or mmHg).

78
Q

When should the oxygen flow rate be increased (or FiO2 if using a Venturi mask)?

A

If a patient’s oxygen saturations do not reach their target within 3-5 minutes of administering oxygen.

If the patient becomes critically unwell, increase to 15L/min via a non-rebreather mask.

If the patient is not critically unwell, consider increasing oxygen by increments (e.g. from 3L via nasal cannulae to a white Venturi mask – FiO2 28% at 4L/min).

79
Q

If a patient becomes critically unwell, what mask should they be put on?

A

If the patient becomes critically unwell, increase to 15L/min via a non-rebreather mask

80
Q

If a patient’s oxygen requirements increase so much that they do not respond to 15L/min via a non-rebreather mask, what should you do?

A

1) Re-assess the patient (ABCDE assessment)

2) Inform a senior clinician if you have not done so already

3) Consider the patient’s ceiling-of-care/escalation status. If they are for full escalation, they may need high-flow nasal oxygen (HFNO)/continuous positive airway pressure (CPAP)/non-invasive ventilation (NIV)/intubation and ventilation. This is a complex decision based on various factors, including the patient’s ABG results.

81
Q

When would high-flow nasal oxygen (HFNO) be an option for escalation?

A

This is an option for escalation compared to a non-rebreather mask.

Can deliver oxygen at a greater FiO2 (up to 100%) and flow rate (up to 60L/min). Usually only available in high-dependency/intensive care environments.

82
Q

When may CPAP be used?

A

Used in type 1 respiratory failure (PaO2 <8.0kPa), for example cardiogenic pulmonary oedema

83
Q

When may non-invasive ventilation be used?

A

used in type 2 respiratory failure (PaO2 <8.0kPa AND PaCO2 >6.0kPa), for example a COPD exacerbation

84
Q

When should you begin to wean down the flow rate/FiO2 of oxygen?

A

If the patient’s oxygen saturations are at least at the higher end of their target saturations for 4-6 hours consecutively.

85
Q

How should you wean down O2?

A

Wean by small increments (e.g. from a yellow Venturi/35% FiO2 to a white Venturi/28% FiO2). This is usually performed by nursing staff, but ensure you document clear instructions.

86
Q

When can oxygen be ceased completely?

A

Once the patient is stable on 1-2L/min via nasal cannulae, you can cease oxygen completely.

87
Q

How long after ceasing O2 should you monitor the patient’s O2 sats for?

A

Monitor the patient’s oxygen saturations for 5 minutes without supplemental oxygen.

If they remain within their target saturations, measure their oxygen saturations in 1 hour (and then use clinical judgment regarding when you will measure them again).

88
Q

Why is it important to wean patients off oxygen?

A

There are some possible harms of over-oxygenation and an increased risk of death in acute illnesses.

89
Q

Where are oxyge cylinders used?

A

Used in areas without a piped supply of oxygen (e.g. in pre-hospital settings or when transferring patients in hospital).

90
Q

In the UK, who supplies the majority of portable oxygen cylinders?

A

BOC

91
Q

What are the common sizes of BOC oxygen cylinders?

A

1) CD (460 litres) or ZD (600 litres): a small cylinder often found in emergency bags

2) HX (2300 litres) or ZX (3040 litres): a larger cylinder

92
Q

What does the lifespan of an oxygen cylinder depend on?

A

Oxygen cylinders contain a fixed amount of oxygen. Their lifespan will depend on the flow rate of oxygen being administered to the patient.

93
Q

How long will a CD cylinder last in a patient being given 15 L/min oxygen?

A

CD cylinder = contains 460L

460/15 = 30 mins approx

94
Q

When administering oxygen, what are some important safety considerations?

A

1) Fire risk

2) Oil/grease (portable cylinders)

3) Compressed gas (portable cylinders): should not be damaged or dropped

4) Risk of running out of oxygen

95
Q

How are oxygen cylinders a fire risk?

A

Although oxygen is not flammable, it is an oxidising agent and feeds a fire.

In an enclosed environment, the atmospheric oxygen concentration can increase with supplemental oxygen if there is inadequate ventilation.

96
Q

How can the fire risk with oxygen cylinders be mitigated?

A

1) Patients must not smoke or vape.

2) Oxygen must not be used in an area with potential ignition sources.

97
Q

Why is oil/grease a risk when using oxygen cylinders?

A

Oil or grease-based products (including hand creams and moisturisers) must not come into contact with the cylinder due to the risk of ignition.

98
Q

When should oxygen cylinders be changed?

A

Cylinders should be changed when the contents gauge reaches the red zone as the remaining volume can quickly reduce.

99
Q

What is the key advantage of an ABG over a VBG?

A

ABG gives accurate PaO2 (VBG does not).

ABG also gives better PCO2 in severe shock and in hypercapnia.

100
Q

What information do you get on a blood gas?

A

1) pH

2) PaO2

3) PaCO2

4) Base excess

5) HCO3-

6) Na

7) K

8) Hb

9) Glucose

10) Calcium

11) Chloride

12) Lactate

13) COHb

14) MetHb

101
Q

What is the normal pH range?

A

7.35 - 7.45

102
Q

What is the normal PaO2 value?

A

11 kPa (in air)

103
Q

What is the normal PaCO2 range?

A

4-6 kPa

104
Q

What is the normal HCO3- range?

A

22-30 mmols

105
Q

What is the normal base excess range?

A

-2 to +2

106
Q

Potential approach in interpreting a blood gas:

A

1) How is the patient clinically?

2) Oxygen?

3) pH?

4) CO2?

5) Bicarb

6) Other stuff e.g. electrolytes, Hb, glucose

107
Q

What acid and base derangement does raised lactate cause?

A

Metabolic acidosis

108
Q

What acid and base derangement does raised ketones cause?

A

Metabolic acidosis

109
Q

What acid and base derangement does raised urea cause?

A

Metabolic acidosis

110
Q

Is there an acute compensation for acute metabolic acidosis?

A

Leads to compensatory hyperventilation (a respiratory alkalosis) to try to reduce circulating CO2 (which is acidic).

111
Q

What acid and base derangement does excess CO2 cause (e.g. type 2 resp failure)?

A

Respiratory acidosis.

112
Q

Is there an acute compensation for acute respiratory acidosis?

A

No!

In chronic lung disease (with high CO2), bicarb levels are raised buy the kidneys to try normalise the pH. This takes days so cannot happen acutely.

113
Q

What acid and base derangement does a loss of acid or excess base cause (e.g. excessive vomiting)?

A

Metabolic alkalosis

114
Q

What acid and base derangement can anxiety cause?

A

Respiratory alkalosis (due to hypreventilation)

115
Q

What acid and base derangement can pain cause?

A

Respiratory alkalosis (due to hypreventilation)

116
Q

What acid base derangement is seen in type 1 resp failure?

A

Respiratory alkalosis

117
Q

Why is tachypnoea seen in DKA?

A

To compensate for metabolic acidosis (trying to blow off CO2).

118
Q

Does hyperthermia cause respiratory acidosis or alkalosis?

A

Respiratory alkalosis

119
Q

Does a CVA cause respiratory acidosis or alkalosis?

A

Respiratory alkalosis

120
Q

Does a PE cause respiratory acidosis or alkalosis?

A

Respiratory alkalosis

121
Q

What is agitation until proven otherwise?

A

Untreated hypoxaemia

122
Q

Note -

A

Hypotension WITHOUT tachycardia is a red flag.

123
Q
A

Yr 4 - ACC (73 decks)

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