Session 16a_Oxygenated Ventilator Management Flashcards
List 4 principles of rehab:
- early mobilization of the patient
- mobilization can occur with ventilator weaning
- a pt who gains overall strength will be more likely to wean off the ventilator and be less likely to develop side effects of bed rest
- Progress is guided by vital signs, not by the volume of apparatus
List some common causes of respiratory failure:
- drugs - narcotics
- metabolism - hyponatremia, hypercapnia
- neoplasm
- infection - meningitis, WNV, polio
- trauma - flail chest, contusion of lung
- ALS, MS, OSA, GB, obesity, COPD, CF, ILD, atelectasis, PE
Respiratory failure is classified by what 2 values?
- Severe hypoxemia (PaO2 40 mmHg)
How do you measure respiratory failure?
- pulse oximetry gives a measure of the % O2 in the blood. It does not tell you the PCO2 level
- Observe the patient. Are they more combative or confused (could be a sign of climbing PCO2). Have they turned pale, labored breathing?
- Patients may not have labored breathing with respiratory failure - look for other signs
Name 5 types of lines and tubes for respiratory support:
- nasal cannula
- non-rebreather mask
- face mask
- bipap/ Cpap: Noninvasive ventilation
- Heated hi-flow
Nasal cannula can deliver from and up to how much?
Nasal cannula 1 to 6 L/min O2
If more than 6 L/min of O2 is needed, what is the next option?
• high flow tubbing (green) •simple mask • non rebreather mask (w/ pendant oxymizer as an option - captures oxygen and helps deliver more)
Bpap is a bridge to and from:
mechanical ventilator
cpap is continuous, what is bipap?
Cpap is also more cost effective
bilevel pump. get push with inspiration and push with expiration
Describe the mechanisms of bilevel positive airway pressure:
- patient has to be able to breathe independently
- positive airway pressure during inspiration and exhalation
- can be used as a temporary way to “blow out” residual CO2 to reduce confusion and improve oxygenation
- “the inspiratory positive airway pressure is higher and supports a breath as it is taken in. Conversely, the expiratory positive airway pressure is a lower pressure that allows you to breathe out. These pressures are preset and alternate just like your breathing pattern.”
Which is more comfortable and effective? Cpap or Bipap?
Bipap
Bipap and cpap are non invasive ventilation (NIV). They are used for:
- sleep apnea
* temporary artificial ventilation
Describe Cpap:
- continuous positive airway pressure
- non-invasive form of positive end expiratory pressure (PEEP)
- can be provided through a ventilator or via an independent machine
- provides constant end-expiratory pressure that keeps the airway open
- used with OSA
Heated high-flow O2, why ?
machine adds both heat and moisture, providing more “normal” air. especially with patients that are needing a lot of O2.
More than 6L –> major dry out
Ventilators provide control for what?
volume (set tidal volume, the peak inspiration pressure varies, set rate, set PEEP, and set FiO2) and pressure (set inspiration pressure, volume varies, set rate, set PEEP and set Fi O2)
FiO2 = fraction of inspired oxygen
What are the 3 modes of ventilation?
- full support. set # of breaths. Gives additional full breath once patient initiates breath
- Intermittent ventilation (patient can spontaneously breathe in between breaths given by machine)
- Continuous positive airway pressure (ventilator mode, nasal mask, also used for sleep apnea as a unit separate from a ventilator)
CMV =
controlled mandatory ventilation (full)
SIMV =
synchronized intermittent mandatory ventilation (give and take)
CPAP =
continuous positive airway pressure
PS =
pressure support
PEEP =
positive end expiratory pressure
ETT =
endotracheal tube
What are the 3 principles behind weaning?
- resting settings alternate with weaning settings/ time off the ventilator
- time off the ventilator increases by 2-4 hours per day
- tidal volume, RR, HR, O2 sat and blood gases indicate tolerance for vent weaning
What are 5 reasons for a tracheostomy?
- need for artificial/ mechanical ventilation greater than 2 weeks
- inability to swallow. often due to a stroke or other neuromuscular disease
- blockage of the airway (such as laryngectomy)
- obstructive sleep apnea
- frequent suctioning needed due to ineffective cough
What are 5 types of tracheostomies:
- cuffed (holds the trach in place and prevents air flow to nose and mouth)
- uncuffed (allows air flow over vocal cords - patient can talk)
- fenestrated (allows patient to talk)
- Brands: Bivona, shiley, jackson
- Some have an inner cannula that slides out for cleaning, some are plastic, some are metal
When analyzing trachs what to look for?
- how the trach looks both outside and body and inside
2. Note the cuff
How is the trach positioned?
- the trach does not interfere with the passage of food
- the trach is below the vocal cords
- the cuff holds the trach in place
- the cuff prevents air passing up through the vocal cords
What is the purpose of aerosol collars?
Aerosol collars deliver humidified O2 and are sometimes called trach collars
Describe portable circuits:
- wide and connects to the T collar
* narrow end to the portable tank
Explain the specifics of oxygen settings:
- room air is 21% O2
- add about 3% for each extra liter of O2 up to 6 L/min
- 6L/min IS CONSIDERED AN FiO2 OF 0.4 OR 40%
How is O2 set-up with a portable set up - aerosal collar?
The O2 is set as a %. The liter flow needed to deliver that % of O2 is written on the device
Can patients with trachs shower?
Yes, patients with trachs can shower: avoid water entering the trach with a light dressing to cover
Myth busters:
• Myth 1: you can never work a patient with SaO2 lower than 90%
• Myth 2: ventilated patients need sedation
• Myth 3: Ventilated patients can’t walk
• Myth 4: ventilated patients can’t eat
* It all depends on the individual pateint
Describe the circumstances involving Passy Muir valves for speaking:
- A joint decision between the MD, the SLP and the RT
- The trach must be cuffless or the cuff must be deflated
- The patient must be able to swallow
How does eating and talking work with a ventilator?
- Coordinate w/ speech therapy
* most patients want to eat and talk
Example of goals utilizing test and measures:
- Patients complete sup–> sit w/ RPE 88%
* pt will tolerate 20 consecutive minutes of recumbent bike at RPE 6-8
