Student Clinical Knowledge Evaluation 3 Flashcards
Mechanical Ventilation: Indications (4)
- IVF (VC < 10mL/kg, MIP > -20cmH2O, RSBI > 105,
VT < 5mL/kg, RR > 35, VE > 10L) - AVF (pH < 7.20, PACO2 > 55, Apnea
- Prophylactic (CHI, Smoke Abd/Thoracic surg)
- Severe Oxygenation Issues (P/F < 200, P(A-a)O2 on 100% O2 > 350, PaO2 < 60 on > 50%)
Mechanical Ventilation: Hazards/Complications/Precautions (3)
- Decreased CO, VR, and urine output, decreased gastrointestinal and liver perfusion and function
- Increased ICP
- Barotrauma from pressures
Tidal Volume Settings: Normal and ARDS
Normal: Vt 6 -8 ml/kg
ARDS: Vt 4 -8 ml/kg
Types of Ventilation/Presets and Varied
- Volume: Preset Volume & Rate, Pressures vary
- Pressure: Preset Pressure & Rate, Volumes vary
Ventilation Terms
1. Trigger
2. Cycle
3. Limit
- Trigger: Initiates the breath
- Cycle: Ends the inspiratory breath - can be pressure, volume, flow, time
- Limit: Stops the inspiration early - can be pressure, volume, flow, time
Vent Modes (4)
- CMV
- IMV
- CSV
- Dual Mode
CMV
Types: (3)
- CMV - Control or Assist
- VC - CMV
- PC - CMV, PCV
CMV - Control / Assist
1. How it works
2. Trigger’s
3. Other info
4. Hazards
- All breaths are mandatory and can be volume or pressure targeted
- a) Control Mode: Time Trigger
b) Assist Mode: Time, Flow, Pressure - a) Control Mode: All machine breaths. Pt. cannot trigger. Only used when Pt. cannot make an effort to breath
b) Assist Mode: Pt. can trigger the vent, but will get a set volume or pressure with every breath - a) CM Hazards: Cruel mode if Pt. is conscious
b) AM Hazards: Sometimes difficult to prevent Resp Alkalosis without the use of Resp depressant or muscle relaxer. IMV mode may help
VC - CMV
1. How it works
2. Trigger’s
3. Other info
4. Hazards
- Preset Volume and Rate with pressures varying
- Triggers - Time, Flow, Pressures
- None
- Need to monitor and adjust Pts. inspiratory flow by looking at the pressure-time curve for smooth and rapid peak
PC - CMV, PCV
1. How it works
2. Trigger’s
3. Other info
4. Hazards
- Preset Pressure and Rate with Volumes Varying
- Triggers - Time, Flow, Pressures
- a) Mode indicated when PIP > 40 CMH2O, Plat > 30 CMH2O on volume mode
b) Set the preset pressure by the plateau pressure on CMV or you take PIP - PEEP - None
IMV
Types: (2)
- IMV
- SIMV
IMV
1. How it works
2. Trigger’s
3. Other info
4. Hazards
- Pt. is able to breathe spontaneously between machine breaths getting their own spontaneous Vt.
- Triggers - Time, Flow, Pressure
- Can be PC or VC Mode - IMV modes can also use PS to assist with spontaneous breaths
- Lack of coordination between mandatory and spontaneous breaths causes breath stacking
SIMV
1. How it works
2. Trigger’s
3. Other info
4. Hazards
- This allows for spontaneous breaths and tries to synchronize with the patient whenever possible - preventing breath stacking
- Triggers - Time, Flow, Pressures
- Can be PC or VC Mode - IMV modes can also use PS to assist with spontaneous breaths
- None
CSV
Types: (3)
- CPAP
- PSV
- APRV
CPAP
1. How it works
2. Trigger’s
3. Other info
- All breaths are spontaneous at an elevated baseline pressure to recruit and distend alveoli
- Triggers - Flow or Pressures
- None
PSV
1. How it works
2. Trigger’s
3. Other info
- All breaths are spontaneous - Preset Pressure, Vt varies
- Trigger - Flow or Pressures
- Adjust to obtain Vt 5-7 ml/kg and RR < 28
APRV
1. How it works
2. Trigger’s
3. Other info
- Breaths are spontaneous - uses 2 levels of PEEP. Pt. breaths spontaneously at high PEEP to recruit alveoli and improve oxygenation. The high PEEP is released periodically to a low PEEP. Low PEEP is < 1.5 sec and allows for CO2 removal
- Triggers - Flow or Pressures
- Used in ARDS
a) HiPEEP - Set at previous Plat Pressure
b) LPEEP - Set at 0
c) HiPEEP - Set at Max 15 sec and Min 4 sec
d) TLow - Set between 0.5 - 1.0 sec
Dual Mode
Type: (1)
- PRVC
PRVC
1. How it works
2. Trigger’s
3. Other info
- Vt is used as feedback mechanism to control the preset pressure control level
- Triggers - Time, Flow, Pressures
- Pressure will increase or decrease by 3 CMH2O to maintain Vt. If Vt is low, the machine will increase until Vt is achieved. Highest pressure can go is within 5 of HPL
Vent Troubleshooting
Alarm Types: (7)
- High Pressure Limit
- Low Pressure Alarm
- Low PEEP
- Low Tidal Volume (Vt)
- FiO2
- Minute Volume Alarm
- Apnea Alarm
Vent Troubleshooting
High Pressure Limit (10)
Causes & How to Fix
- Coughing: AMBU/Auscultate
- Secretions: Suction
- Bronchospasms: Bronchodilator
- Water in Circuit: Drain Circuit
- Herniated ETT Tube: Deflate Cuff, Inflate
- Kinked Tubing: Unkink
- Pneumothorax: Chest Tube
- Blocked Exhalation Manifol: Unblock
- Mainstem Bronchial Intubation: Pull the tube back until 3-4 cm above Carina
- Pleural Effusion: Thoracentesis or Chest Tube
Vent Troubleshooting
Low Pressure Alarm (4)
Causes & How to Fix
- Loss of System Pressure: Power Failure, Gas Failure
- Loss of Circuit Pressure: Disconnect, Exhalation valve disconnect, ETT Cuff Volume Loose Circuit, Loose Humidifier
- Premature Termination: Excessive Peak Flow, Insufficient Inspiratory Time
- Inappropriate Vent Setting: Low pressure limit is set too high. Low Tidal Volume is set to high
Vent Troubleshooting
Low PEEP (1)
Causes & How to Fix
- Leaks, High Inspiratory Flows: Adjust Peak Flows, Look for Leaks
Vent Troubleshooting
Low Tidal Volume (Vt) (1)
Causes & How to Fix
- Leaks: Check for leaks or ETT cuffs
Vent Troubleshooting
FiO2 (3)
Causes & How to Fix
- Inappropriate FiO2 Setting: Check Settings
- Inappropriate Alarm Setting: Check Settings
- Bad Cell: Change Analyzer
Vent Troubleshooting
Minute Volume Alarm (7)
Causes & How to Fix
- High MV: 1) Pain
2) Fever
3) Anxiety
4) Hypoxemia - Low MV: 5) Apnea
6) Leaks
7) Disconnect
Vent Troubleshooting
Apnea Alarm (3)
Causes & How to Fix
- Leaks
- Disconnect
- Patient Apnea
Weaning Parameters
Minute Ventilation
1. Explain how to do it
2. Equipment used
3. Value to come off vent
4. Calculation
- Pt. must relax and breath normally for 1-minute. Count each breath during this time
- Wright Respirometer or Turbinometer
- 5-10 lpm
- VE/RR = Vt in LPM, (VE = RR x Vt) in LPM
Weaning Parameters
Slow Vital Capacity (SVC)
1. Explain how to do it
2. Equipment used
3. What does the SVC tell us about the patient
4. Value to come off vent
- Have Pt. take a deep breath in and exhale slowly
- Wright Respirometer or Turbinometer
- The Vital Capacity (VC) tells us about the Pt’s Respiratory muscle strength
- > 10 ml/kg, 1000 mL, 1L
Weaning Parameters
MIP / MEP
1. Explain how to do MIP
2. Explain how to do MEP
3. Equipment used
4. Value to come off vent
- Pt. exhales, you plug the hole and then the Pt. takes a deep breath in (MIP)
- Pt. inhales, you plug the hole and then the Pt. exhales (MEP)
- Pressure Manometer or Aneroid
- MIP < -20 CMH2O
MEP > 40 CMH2O
