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Respiratory 3 > Respiratory Failure: Modes of Ventilatory Support > Flashcards

Respiratory Failure: Modes of Ventilatory Support Flashcards

1
Q

What is ventilation?

A
  • The cyclic process of exchange of air
  • In physiology, the exchange of air in the lungs with atmospheric air which has a higher oxygen and lower carbon dioxide content
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2
Q

Ventilator support is indicated in?

A
  • Inadequate alveolar ventilation (Acute ventilatory failure)
  • Excessive work of breathing
  • Inadequate lung expansion
  • Insufficient respiratory drive
  • Hypoxemia
  • Airway protection
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3
Q

What are the physiologic goals of respiratory support?

A
  • To improve gas exchange – Oxygenation – CO2 removal
  • To help maintain acid base balance
  • To optimize lung volumes – Improve V/Q distribution
  • To reduce the work of breathing
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4
Q

What are the types of Ventilatory support?

A

• Non-invasive • Invasive

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5
Q

Non-invasive uses what two techniques?

A

• Negative pressure • Positive pressure

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6
Q

Negative pressure non-invasive is done via?

A

– Iron lung (tank)

– Cuirass (turtle)

– Poncho (pneumosuit)

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7
Q

Positive pressure non-invasive is done via?

A

–Face mask

–Nasal masks

– High Flow Nasal Cannula (HFNC)

–Helmet

–Mouthpiece/sip ventilation

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8
Q

Explain how positive pressure non-invasives work?

A
  • A pressure is delivered either in a continuous fashion, CPAP or split between inspiration and expiration (BiPAP)
  • The patient generates a tidal volume depending on their respiratory mechanics
  • Can be used in acute or chronic respiratory failure
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9
Q

Modes of NIV? (noninvasive)

A
  • Conventional oxygen therapy (COT) – Nasal oronasal full facemask
  • Continuous positive airway pressure (CPAP)
  • Bi-level positive pressure (BiPAP)
  • High frequency nasal cannula (HFNC) for acute respiratory failure
  • Helmet ventilation
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10
Q

Indications for use of NIV?

A

– PaO2/FiO2 < 200 mmHg

– Hypercapnia PaCO2 > 45 and 7.3 < pH < 7.35

– Severe dyspnea/↑ WOB

– Tachypnea RR > 24 breaths/min

– Alert/cooperative

– Unable to protect airway

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11
Q

Use of NIV positive pressure ventilation criteria?

A

– Clinical criteria • Alert • Cooperative • Able to protect airway • Demonstrate: moderate to severe respiratory distress • Increased dyspnea • Tachypnea • Use of accessory muscle • Paradoxical breathing pattern

– Blood gas criteria • PaCO2 > 45 mmHg (> 6.0 kPa) and pH < 7.35, or PaO2/FiO2 < 200

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12
Q

Roles for NIV?

A
  • Primarily used in acute respiratory failure due to: – Acute exacerbation of COPD – Acute CHF/pulmonary edema
  • Other roles: – Weaning strategy in invasive mechanical ventilation – Prevent post-extubation failure – Chronic neuromuscular disease – Neutropenic patients with fever and pulmonary infiltrate – Chronic restrictive thoracic disorders – Palliate symptoms in end stage disease
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13
Q

NIV positive pressure ventilation is the gold standard for? failure rate?

A

Gold standard” therapy in acute hypercapnic exacerbation of COPD

Has a failure rate of around 20% in acute hypercapnic respiratory failure

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14
Q

Clinical Goals for NIV?

A
  • To correct hypoxemia
  • To correct respiratory acidosis
  • To improve V/Q (prevent/reverse atelectasis)
  • To reduce myocardial oxygen consumption
  • To stabilize the chest wall
  • To reduce intracranial pressure
  • To buy time for therapies to work/recover
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15
Q

Keys to success for NIV? Need to monitor what in the beginning?

A
  • Early Delivery in the course of respiratory failure
  • Very cooperative patient
  • Younger age
  • Lower acuity of illness (APACHE Score)
  • Appropriate blood gas criteria
  • Good interface fit (less chance of leaking, intact dentition)

Need to closely monitor ABG, HR, RR within the first ½ to 1hr and closely thereafter

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16
Q

Do not use NIV in a patient who? examples?

A

Do not use in patient who would be more safely managed invasively.

For example: • Overt respiratory distress • Cardiac/respiratory arrest • Shock • Smoke inhalation (risk of airway edema) • Severe facial trauma or deformity • Glasgow coma scale score <10 • Gastrointestinal bleed Don’t use if uncooperative or agitated Don’t use if unable to protect airway

17
Q

Adverse Side Effects & Complications of NPPV?

A
18
Q

Key facts about invasive ventilation?

A
  • A form of supportive care – a bridge
  • Need to identify and address the primary gas exchange derangement of the patient
  • DOES NOT TREAT the underlying illness
19
Q

What is themajor cause for invasive ventilation?

A

Acute Respiratory Failure is the major indication for mechanical ventilation

20
Q

What are the two basic causes of acute respiratory failure?

A

Two basic causes:

A. Hypoxic Respiratory Failure Failure to adequately oxygenate – ineffective gas exchange 1. V/Q mismatch 2. Shunt 3. Decreased FRC

B. Hypercapnic Respiratory Failure Failure to adequately ventilate 1. Reduced respiratory drive 2. Respiratory muscle fatigue 3. Decreased compliance Chest wall lung parenchyma

21
Q

What four things in the ventilatory cycle are we looking at to see if we need volume targeting or pressure?

A

Volume Targeted vs. Pressure Targeted Ventilatory Cycle

  • Trigger – what initiates the breath – Patient vs. Ventilator: Machine timer ∆ pressure ∆ flow
  • Delivery – what’s the target – Volume vs. Pressure
  • Cycling – what terminates the breath – Volume time flow pressure
  • Expiration
22
Q

What are the clinical decisions to make with mechanical invasive vents?

A
  • Ventilatory mode (volume or pressure)
  • Inspired oxygen fraction (FIO2)
  • Tidal volume
  • Respiratory rate
  • Positive end expiratory pressure (PEEP)
  • Inspiration/expiration ratio
  • Inspiratory flow rate/delivery
23
Q

Ventilatory, Volume vs pressure?

A
24
Q

Explain volume vs pressure targeted breaths?

A
25
Q

Whats a mandatory breath? Spontaneous breath?

A

Mandatory breath: An assured breath that occurs at a minimum respiratory rate and preset volume or pressure
Spontaneous breath: Determined by patient effort for initiation and duration and is not assisted

26
Q

What are volume targetted modes?

A

• Volume-targeted modes:

– Controlled mechanical ventilation (CMV)

– Assist/control (AC)

– Synchronized Intermittent Mandatory Ventilation (SIMV)

27
Q

What are common pressure targeted modes?

A

– Pressure-support ventilation (PSV)

– Pressure control ventilation (PCV)

– Pressure-regulated volume control

– Volume assured pressure support

28
Q

What is PEEP? What does normal PEEP look like?

A

Positive End Expiratory Pressure

  • Improves airflow → improves oxygenation
  • Prevents atelectasis at end expiration
  • Helps to recruit collapsed alveoli
  • Helps to lower FiO2 need thereby minimizes risk of oxygen toxicity
29
Q

Auto PEEP?

A
30
Q

Strategies to lower FiO2?

A
  • PEEP
  • Maximize O2 delivery/maximize PvO2
  • Lower VO2 to maximize PvO2
  • Prone positioning if PaO2/FiO2 < 150
31
Q

Common parameters monitored during mechanical ventilation?

A
  • Clinical: Physical exam – Vital signs – Patient’s WOB – EKG
  • Ventilator – RR, VT (tidal volume), VE (minute ventilation) – Airway pressure, especially the plateau (goal <30), peak waveforms – Compliance (static/dynamic)
  • Pulse oximetry/ABG
32
Q

Problems to address with Oxygenation using mechanical ventilation?

A
  • Barotrauma: Excessive airway pressure Try to keep plateau pressure < 30 mm H2O Try to keep driving pressure (Plat-total PEEP) < 15
  • Volutrauma: over distension of lung units Use low tidal volume (LTV) based on ideal body weight May need to accept a degree of CO2 retention: permissive hypercapnia
  • Atelectotrauma Repetitive openings and closings of terminal lung units Treatment: Positive End Expiratory Pressure to prevent alveolar collapse
  • Biotrauma Local and systemic inflammatory response to mechanical ventilation
33
Q

Mechanical ventilation requires? Associated with?

A

Requires endotracheal intubation or tracheostomy

Associated with numerous complications:
Infections: Ventilator Associated Pneumonia (VAP) from bypassing host defense mechanism Neurologic: Cognitive Decline, Delirium Respiratory: Ventilator Induced Lung Injury (VILI) Musculoskeletal: Critical Care Myopathy

34
Q

Complications with mechanical ventilation

A

• Barotrauma • Volutrauma • Atelectrauma • Oxygen toxicity • Hypotension/decreased cardiac output • Critical illness myopathy • Auto-PEEP • Increased intracranial pressure • Renal and hepatic dysfunction • Gastric distension

35
Q

Strategies for minimizing the risk of barotrauma?

A
  • In severe air flow obstruction, one may need to consider deliberate hypoventilation eg, permissive hypercapnia, although recently permissive hypercapnia use has raised some red flags regarding its physiologic effects
  • In acute hypoxemic respiratory failure, low tidal volume (6±2 cc/Kg) and high rate (26-35) should be utilized when PEEP requirement is high
36
Q

Explain weaning in mechanical ventilation?

A

Should be protocol-based considerations • Lung injury stable or resolving • Gas exchange adequate PEEP < 5-8 cm H2O and FiO2 ≤ 0.4-0.5 • Hemodynamically stable • Good cough • Suction frequency < every 2 hours • Capable of initiating spontaneous breaths • ± RSBI (Rapid Swallow Breathing Index) • PaO2/FiO2 ≥ 200

If above are met then consider spontaneous breathing trial

37
Q

Liberation from mechanical ventilation?

A
  • Use a ventilator liberation protocol
  • Use protocols attempting to minimize sedation
  • Initiate spontaneous breathing trials (SBT) conducted with inspiratory pressure augmentation (5-8 cm H2O)
  • After passing spontaneous breathing trial (SBT) extubate to preventative NIV
  • Use rehabilitation protocols directed toward early mobilization
38
Q

spontaneos breathing trials?

A

T-piece (use in all patients who require MV for Heart failure)

CPAP or pressure support ventilation

Automated tube compensation

39
Q

ExtraCorporeal Membrane Oxygenation (ECMO) explain?

A

Respiratory 3 (10 decks)

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