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Interventions 3 > Review > Flashcards

Review Flashcards

1
Q

Normal Neonatal Ti

A

0.3-0.4

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2
Q

Normal Vt for Neonatal

A

5 ml/kg

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3
Q

Venoarterial (VA) ECMO

A

Will offload both the heart and the lungs

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4
Q

Single Site Approach to Venovenous ECMO Cannulation

A

A dual lumen cannula is inserted into the jugular vein

Venous blood is withdrawn through one lumen that has ports in both superior and inferior vena cava

Reperfusion will occur in second lumen located in right atrium and will dump blood into the right ventricle, this is designed to reduce recirculation of blood

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5
Q

How Long is ECMO Used for Compared to Cardiopulmonary Bypass

A

ECMO is a longer therapy compared to cardiopulmonary bypass

Cardiopulmonary bypass is only used for hours

ECMO can be used for up to 10 days

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6
Q

What is the Main Reason Why ECMO is Use in Neonates

A

PPHN which results from different diseases such as pneumonia, MAS, RDS

CHD

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7
Q

What is the Main Reason Why ECMO is Use in Adults

A

Severe Asthma and ARDS

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8
Q

What are the risk factors that are associated with ECMO

A

Bleeding

Thrombosis

Infection

DIC

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9
Q

Nova Lung

A

Provides pumpless arterio-venous extrapulmonary lung support, because it is pumpless the blood pressure of the patient is needed to circulate the blood

Uses diffusion to provide oxygenation and ventilation

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10
Q

Venovenous (VV) ECMO

A

Will only support the lung

Venous blood will be divided into two semi-permeable membranes, and gas exchange will occur along the membrane

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11
Q

Indication for ECMO

A

Potentially reversible severe cardiac or pulmonary failure that is unresponsive to other treatment

Hyoxemic Resp Failure

Hypercapnic respiratory failure with an arterial pH <7.20

Refractory cardiogenic shock

Cardiac arrest

Failure to wean from cardiopulmonary bypass after cardiac surgery

As a bridge to either cardiac transplantation or placement of a ventricular assist device

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12
Q

Independent Lung Ventilation

A

A double lumen will allow for separate ventilation of each lung which can be done synchronously or asynchronously

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13
Q

Prone Positioning Indications

A

Severe ARDS-Main

Acute lung injury where there is V/Q mismatching

Cardiogenic pulmonary edema

Pneumonia

Pulmonary embolism

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14
Q

Prone Positioning Absolute Contraindication

A

Acute Bleeding

Spinal instability

Pregnancy in the third trimester

Increased ICP

Traction

Weight > 136 kg

Unstable sternum (open heart surgery)

Ventricular assist device

Intraortic balloon pump

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15
Q

Prone Positioning Relative Contraindication

A

Multiple trauma

Continuous renal replacement therapy

Temporary pacemaker

Hemodynamic instability

Large abdomen

Gross ascites

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16
Q

How to Position the Prone Patient

A

Reverse trendelenburg, 30 degrees if possible in order to limit risk of aspiration

Use pillows/positioning devices to maximize diaphragmatic excursion

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17
Q

According to AHS How Long Should We Prone

A

Prone 3 hours and supine 1

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18
Q

Discontinuation of Proning

A

FiO2 < 0.60

Deterioration of patient status related to prone position

Positioning demonstrates no improvement in patient status or becomes no longer beneficial

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19
Q

Airway Pressure (Paw)

A

Paw=Ptp - Ppl

Reflects pressure required to inflate both the lungs and the chest wall

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20
Q

Paw Measuremnets

A

Plateau pressure during inspiratory pause

Total PEEP during an expiratory

So Paw = Palv during pause maneuvers because there is no flow

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21
Q

Drawback of Airway Protective Ventilation

A

Assumes that pleural pressure is negitable

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22
Q

Pleural Pressure (Ppl)

A

Pressure in pleural space and will be affected in intra-abdominal pressure and decrease in chest wall compliance

This can be measured through esophageal pressure monitoring,

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23
Q

What will Increase Ppl

A

Anything that will increase intra-abdominal pressure

Obesity

Ascites

Ileus

Bowel Edema

Post Fluid Resuscitation

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24
Q

Transpulmonary Pressure

A

Requires the measure of esophageal pressure through a esophageal balloon

The Peso is though to represent Ppl

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25
Q

Esophageal Balloon Pressure Measurement

A

The catheter is measuring the pressure in the thoracic cavity and you need to subtract this from the pressure that the ventilator is giving you can isolate the pressure in the lungs

Ptp = Paw – Pe

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26
Q

Inserting Esophageal Catheter

A

Insert 60 cm and then pull back to 40 cm looking for cardiac oscillation

Can push on belly as a check to see temp spike in pressure

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27
Q

Performing an Esophageal Pressure Monitoring

A

Do an inspiratory hold to determine Ptp which can be used to make sure that the pressures are <30

Do an expiratory hold to see if Ptp is positive which is needed in order to maintain recruitment of alveoli

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28
Q

Bladder Pressure and Abdominal Pressure

A

Bladder pressure and abdmonial pressure are correlated and not predictive

When there is an increase in bladder pressure that is a red flag

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29
Q

Lung Volume Recruitment Manoeuvre

A

LVRM are used to open up alveoli with high inspiratory pressure and determine appropriate PEEP

One way to perform a LVRM is to use a high PEEP of 30-40 for 30-60 seconds and make sure to monitor vitals while you are doing this

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30
Q

LVRM Indication

A

CXR with bilateral infiltrates (AIL or ARDS)

Atelectasis

Increase OI

High PEEP

Suctioning/Discontection

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31
Q

Contraindication to LVRM

A

Pulmonary air leaks: Recent, active pneumothorax, PIE, etc

Bronchopleural fistula

Hemodynamic instability (eg. low BP)

Head Injury

Obstructive lung disease

Pregnancy

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32
Q

When to Stop a LVRM

A

SpO2 falls < 80%

MAP < 60 or 20% change from baseline

HR < 60 or 20% change from BL

New arrhythmia

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33
Q

APRV Definition

A

Inverse ratio, pressure controlled, and time cycled ventilation mode

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34
Q

Advantages of APRV

A

Lung protective, and can help oxygenation and ventilation

Easy to manipulate MAP and I:E

May be more comfortable as allow for spontaneous breathing (positive effect comes from spontaneous breathing)

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35
Q

Disadvantages of APRV

A

May result in muscle atrophy

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36
Q

Link Between Thigh and Expiratory Flow Rate

A

Tlow begins once Phigh is over and at this point the expiratory flow rate is highest at this point and equal to PEF

Tlow should terminate at the time that PEF is reduced to 25-50% of peak

Expiratory flow is not finished before inhalation occurs so that PEEP can be maintained

37
Q

Total PEEP in APRV

A

Plow + Auto PEEP

38
Q

Frequency in APRV

A

Frequency is 60 seconds divided by the sum of Tlow plus Thigh

APRV is most successful with a limited number of releases.

Ventilator frequency should remain around the 10- 12 range. Increases outside this range promotes derecruitment, and risks a return to refractory hypoxaemia.

39
Q

APRV Settings When Switching From Conventional Ventilation

A

Phigh: Match Pplat on current mode (max 30 cmH2O)

Plow: Set to 0 cmH2O

Thigh: 4.0 sec

Tlow: 0.5-1.0 sec (often 0.8 sec)

40
Q

I:E in APRV

A

4:1 or greater

We want to spend 90-95% of the time in Phigh

41
Q

APRV Setting When Starting On APRV

A

Phigh: Set at 30 cmH2O

Plow: Set to 0 cmH2O

Thigh: 4.0sec

Tlow: 0.5-1.0 sec (often 0.8 sec)

42
Q

Increasing Ventilation When On APRV

A

Decreasing PaCO2

Weaning sedation/increasing spontaneous ventilation

Increase Phigh (increase your Vt and MV)

Decrease Thigh

Optimize Tlow to between the 25-50%

Increase Tlow

43
Q

Increasing Oxygenation in APRV

A

Increase FiO2

Increase Phigh

Increase Thigh

Decrease Tlow

44
Q

Weaning of APRV

A

Weaning is achieved through decreasing Phigh and increasing Thigh to get a low CPAP

The minute volume generated by release volumes decreases and is gradually supplemented by increased spontaneous minute volume, until the patient has essentially been weaned to pure CPAP.

45
Q

Barriers to the Use of APRV

A

Lack of clinician knowledge and comfort

Concerns about over-distension/over-stretching

No RCT showing improved outcome in humans (yet

May be contraindicated in air leak syndromes and conditions of TBI/high ICP due to hypercapania

46
Q

Tube Compensation

A

Nullify the resistance imposed on the tube to help facilitate a proper SBT

Will be similar to pressure support

Reduce of risk of air trapping

Will set % of compensation you want and whether you want inspiratory and/or expiratory help

47
Q

Assessing Optimal Tlow in APRV

A

Tlow should be re-evaluated every 1-2 hours for the first six hours as that is when the lung will undergo the most recruitment and we need to ensure that volumes do not exceed 8ml/kg

Tlow should also be re-evaluated after a change in the pressure setting

48
Q

Why is ARPV Helpful in ARDS

A

ARDS reduces FRC and compliance and increases WOB

Applying Phigh will restore FRC and create a better pressure volume relationship to help faciliate spontaneous ventilation and oxygenation

49
Q

Mean Airway Pressure in APRV

A

Mean Airway Pressure in APRV= (Phighx Thigh) + (Plow x Tlow__)

(Thigh+ Tlow)

50
Q

Timing of APRV

A

Most effective as treatment for ARDS when used as initial mode of ventilation

May be used with the spontaneous breathing COPD pt

51
Q

High Frequency Ventilation

A

Frequencies >150 bpm

Tidal volumes are so small that they can be smaller than deadspace

52
Q

Frequency of HFV

A

Frequencies is measured in Hertz (Hz) which is cycles per second

1 Hz=1 cycle/sec=1 breath per second=60 bpm

53
Q

What Are the Indications for HFV

A

Acute Lung Injury (Severe Oxygenation Failure)

Ventilation failure

Upper airway surgery and bronchoscopy

BP Fistula or pulmonary air leaks in neonates (eg. PIE)

54
Q

High Frequency Jet Ventilation (HFJV)

A

Passive exhalation which means there is the risk of breath stacking

Combines the use of a jet ventilator and a conventional ventilator

The conventional vent provides the PEEP (which = MAP) and +/- sigh breaths and then the jet ventilator will pulse above this

55
Q

High Frequency Oscillation (HFO)

A

Most common

Active exhalation

56
Q

MMV

A

When the patient is breathing above the set MV the vent will only deliver pressure supported breaths

When the patient is not meeting the set MV the vent will deliver mandatory breath

57
Q
A
58
Q

ASV Breath

A

Based on set % MV

Mandatory breaths will be PRVC

Spontaneous breaths PS and volume targeted

59
Q

% MV for ASV

A

Based on 100 ml/kg IBW for 100% setting

Normal Pt 100%

COPD 90%

ARDS 120%

Extra for hyperthermia with 10% extra per oC increase

Extra for altitude with 5% per 500 m above sea level

Add 10% when an HME has been added

60
Q

Managing Severe Acidosis with ASV

A

Increase PEEP and/or FiO2

Increase %MV

61
Q

Managing High Oxygenation Needs in ASV

A

Increase PEEP and FiO2

62
Q

Managing High Respiratory Drive in ASV

A

Increase %MV

63
Q

Managing Respiratory Alkalosis with ASV

A

Decrease %MV

64
Q

Basic Theory of Jet Ventilation

A

The small Vt will move through the deadspace instead of pushing the deadspace in

Exhaled gas will cycle out through counter current

65
Q

Equitment Needed for Neo and Ped Transport

A

O2 Supply and blender and O2 analyzer

Mech vent

Mechanical Resuscitator

Pressure monitor

O2 monitor (X2)

ECG

Suction

Intubation Equitment

Feeding Tube

O2 hood

O2 tubing

Hand held neb with tubing

66
Q

Tank Calculation

A

Duration of Flow =

Oxygen Tank Conversion Factor * Remaining Tank Pressure (psi) / Continuous Flow Rate (L/min)

67
Q

Oxygen Cylinder Conversion Factors

D Tank

A

D Tank = 0.16

68
Q

Oxygen Cylinder Conversion Factors

E Tank

A

E Tank = 0.28

69
Q

Oxygen Cylinder Conversion Factors

G Tank

A

G Tank = 2.41

70
Q

Oxygen Cylinder Conversion Factors

H/K Tank

A

H/K Tank = 3.14

71
Q

Oxygen Cylinder Conversion Factors

M Tank

A

M tank = 1.56

72
Q

Total Arterial O2 Content

A

CaO2= (1.34 x Hb x SpO2) + (PaO2 x 0.003)

73
Q

How to Determine Pt Inspiratory Flow

A

Flow= Volume (L)/time (min)

74
Q

Determining the total flow in a high flow delivery device

A

If air/O2 is for example 30 then it is 8:1 so for every 1 litre of oxygen 8 L is being entrained into the device

for total flow add the two toegther (=9) and then multiple by the set flow

75
Q

Calculating Flow in Liquid Oxygen System

A

Gas Remaining= (Liquid Weight [lb]) x 860/ 2.5 L/Ib

Duration of Contents (min)= Gas Remaining (L)/ Flow (L/min)

Remeber 1 L of Liquid O2 = 2.5 lb

76
Q

Rigid Bronchoscope

A

Mainly used for removal of foriegn bodies

77
Q

Parts of the Flexible Bronchoscope

A

Light Transmission Channel: Light source at distal end of bronchoscope

Visulization Channel: Has lens to produce an image at the proximal end

Working Channel: Suction, tissue sample, O2 administration

78
Q

Indications for Bronchoscope

A

Bronchogenic Carcinomas

Investigation

Therapeutic

79
Q
A
80
Q

Absolute Contrindications for Bronchoscope

A

—No consent

—No driver

—No garage

—No ability to oxygenate/ventilate

81
Q

Relative Contrindicationsfor Bronchoscope

A

—Uncontrolled bleeding

—Uncontrolled severe COPD

—Uncontrolled hypoxemia

—Unstablehemo-dynamics (arrhythmias etc.)

82
Q

Complications of Bronchoscope

A

—Hypoxemia & hypercapnea

—Vasovagal response (Hypotension, Bradycardia)

—Airway irritation

—Epistaxis

—Pneumothorax

—Hemoptysis

83
Q

—Anticholinergic “drying” agent to decrease secretions

A

—Atropine

—Glycopyrrolate

84
Q

Bronchoscope Premedication Administration

A

—Prior to the bronchoscopy procedure, outpatients are admitted to a day stay unit & nursing staff help prepare them…

—Ensuring the consent form is signed

—Inserting an IV

—Premedicatingif called for:

  • —Morphine
  • —Ventolin: prophylactic prevention of bronchospasm
  • —Atropine: decreases bronchial and salivary secretions & helps prevent bradycardia from excessive vagal stimulation
85
Q

Bronchoscope Brushing

A

—Usually performed for cytology or histology analysis

86
Q

Bronchoscope

Transbronchial Needle Aspiration

A

—Used to sample areas on other side of bronchial wall (extrabronchialor transbronchial)

—Performed under fluoroscopy

—Advanced through suction channel with needle retracted

—On physician’s request, needle advanced exposing it past sheath

—Manipulated by thumb control

—Physician darts desired site

—Syringe attached to proximal end of the needle to aspirate sample

87
Q

Bronchial Alveolar Lavage

A

—Performed when area sampled distal to segmental or sub-segmental bronchi in which bronchoscope is resting

—Bronchoscope advanced and wedged totally occluding airway

—On physician’s request 6Occ of sterile NS is instilled through suction channel

—Often 30cc aliquots

—Sample aspirated and collected in BAL trap (70ml)

—Much of saline instilled recovered

—If < 35 cc of NS recovered, another 60 cc of sterile NS instilled and aspirated again

—Recovered sample contain cells for analysis

—Samples sent to microbiology

—Visually inspect for foamy head on sample indicating presence of surfactant and indicating good sample

88
Q

BLES Dosing

A

5 ml/kg

Interventions 3 (34 decks)

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