SESAP ICU - Respiratory

Question 1

ARDS: Definition

Answer 1

ACUTE RESPIRATORY DISTRESS SYNDROME

1. Acute (1 week onset)
2. LUNG INJURY - diffuse,inflammatory
3. Respiratory failure
4. Severe hypoxemia

Non-hydrostatic pulmonary edema

Question 2

ARDS: Berlin Criteria

1. What are the components?
2. What is NOT included anymore?

Answer 2

Updated in 2012 -

1. Acute onset - ONE WEEK
2. XR criteria - bilateral pulmonary opacities
3. NON-cardiogenic etiology - confirmed with echocardiography
4. Severe hypoxemia - P:F Ratio - Pa02: FI02; PEEP; corrected expiratory volume/minute
5. PA wedge pressure requirement.

Question 3

ARDS: Berlin Criteria

1. What does P:F mean?
2. Mild v. Moderate v. Severe and associated mortality rates?

Answer 3

1. P:F –> PaO2: FI02….this measures the degree of patient’s hypoxemia
2. Mild: P:F 200-300 –> 27%
   Moderate: P:F 100-200 –> 32%
   Severe: P:F <100 –> 45%

Question 4

ARDS: Berlin Criteria expanded

Answer 4

1. P:F ratio
2. PEEP requirement >/= 10 mmHg
3. corrected expiratory volume/min of 10L/min
4. XR severity of pulmonary edema – bilateral opacities,

Question 5

ARDS: Treatment

Answer 5

Mechanical ventilation. Lung protective strategies

Question 6

ARDS: Treatment - Initial ventilator settings

Answer 6

Long protective strategies - low tidal volume and high initial PEEP (escalating PEEP as needed)
TV: 6-8 ml/kg
PEEP: 5-10
RR: 10-12 (titrate to pH of 7.25)
FI02: 100% (goal O2sat:88-95% or pa02 50-85%)

Question 7

ARDS: Treatment - ADJUNCT

Answer 7

1. prone positioning
2. paralysis - neuromuscular blockade x 48 hrs (decrease 90 day mortality –> survival benefit)

steroids, nitric oxide - no improvement in mortality or survival benefit.

Question 8

ARDSNet Trial

Answer 8

demonsrated that low tidal volume ventilator settings (6 mL/kg vs 12 mL/kg ideal body weight) significantly improved survival in patients with any degree of acute respiratory distress syndrome (ARDS; 31% vs 40%).

Question 9

Non-invasive ventilation - Types

Answer 9

1. Positive pressure - BiPAP or CPAP

2. Negative pressure - iron lung

Question 10

Non-invasive ventilation - CPAP

Answer 10

Constant positive airway pressure.

fixed positive pressure through inspiration/expiration –> airways open ==> reduces WOB.

Question 11

Non-invasive ventilation - BiPAP

Answer 11

Bi-level positive airway pressure.

Generally, iPAP > ePAP to allow for improved ventilation during iPAP and improved alveolar recruitment during ePAP.

Question 12

Contra-indications to Non-invasive ventilation

Answer 12

1. airway obstruction - need an intact airway
2. Hemodynamic instability, cardiac arrect, unstable arrythmias –> need ET tube for ACLS
3. Depressed mental status, GCS <8, encephalopathy –> need to protect airway
4. ileus/vomitting relatively speaking –> increased aspiration risk

Question 13

HFNC

Answer 13

1. Heated humidified O2
   - low rate of 10-60 L/minute
   - FiO₂ up to 1.0
   - INCREASE End-expiratory volume
   - DECREASE dead space
   - DECREASE WOB

Question 14

Weaning parameters - Subjective

Answer 14

1. cough
2. no NMB
3. no excess secretions
4. resolution of underlying etiology for resp failure

Question 15

Weaning parameters - objective not resp

Answer 15

Stable CV exam. HR > 140, no MI, SBP: 90-160, resolving septic shock.

Question 16

Weaning parameters - objective

Answer 16

adequate oxygenation and ventilation
TV: 5 mL/kg
RR < 35
proper inspiratory effort, MIF/NIF < -20 to - 25
PEEP minimized 5-8 mmHg
RSBI (rapid shallow breathing index = respiratory frequency/tidal volume) < 105
PaO2 > 60; PaCO2<60

Question 17

Weaning parameters - adjuncts

Answer 17

1. cuff leak - no leak = swelling and higher risk of re-intubation. RECOMMENDATIONS - steroids up to 4 hours pre-extubation

Question 18

Ventilation settings

Answer 18

Tidal volume - 6 mL/kg
PEEP/FI02 to maintain a plateau pressure > 40 cm H20
Ventilation - RR to maintain O2sat 85-95%, or pA02 55-85