Test 1 Ch. 19 Basic Concepts of NPPV Flashcards
1
Q
The delivery of mechanical ventilation to the lungs using techniques that do not require an endotracheal airway
A
Noninvasive ventilation
2
Q
What are the three methods of applying NIV
A
- negative pressure ventilation
- positive pressure NIV
- abdominal- displacement ventilation
3
Q
Negative pressure ventilators peaked during a
A
worldwide polio epidemic that peaked in the 1950
4
Q
What is another name for negative pressure ventilators?
A
body ventilator
5
Q
Negative pressure ventilators operated on the principle of increasing
A
lung volumes by intermittently applying negative pressure to the entire body below the neck or just to the upper region of the chest
6
Q
The first successful negative pressure ventilator commonly referred to as the
A
iron lung
7
Q
Iron lung Is consistent of a large metal cylinder that enclosed the pt’s the entire body below the neck, leaving the
A
head protruding through an airtight rubber neck seal
8
Q
What is the name of the smaller, portable negative pressure device?
A
chest cuirass (shell ventilator)
9
Q
2 versions of the chest cuirass were primarily used to apply
A
negative pressure to the thorax and abdomen
10
Q
_______ used a pressure-targeted ventilator (PTV) and a mask, later was used primarily to treat ARF complicated by COPD and asthma
A
Intermittent positive pressure ventilation (IPPV)
11
Q
Intermittent positive pressure breathing (IPPB) used a
A
mask or mouthpiece; became a means of simply delivering aerosolized medication periodically w/ positive pressure breaths
12
Q
What replaced IPPB?
Which treated?
A
Continuous positive airway pressure (CPAP);
OSA
13
Q
The application of low levels of continuous airway pressure through a mask interface created a…..
which prevented….
A
pneumatic splint that prevented airway collapse during sleep
14
Q
The use of NIV is successful in the treatment of chronic ventilatory insufficiency and
A
muscle weakness in pts w/ various neuromuscular illness
15
Q
NIV has been used to treat both
A
acute and chronic respiratory failure
16
Q
What is the primary goal for NIV in the acute care settings? (2)
A
To avoid the need for endotracheal intubation and invasive ventilation
17
Q
What are some goals for NIV in the Acute Care Settings?
A
- Reduces the need for ET intubation
- Reduces incidence of VAP
- Shortens stay in ICU
- Shortens hospital stay
- Reduces mortality
- Preserves physiologic airway defense
- Improves pt comfort
- Reduces need for sedation
18
Q
What is considered to be a lifesaving application for ARF?
A
Noninvasive positive pressure ventilation (NPPV)
19
Q
The physiological goal of NIV in ARF is to improve
A
gas exchange by resting the respiratory muscles and increasing alveolar ventilation
19
Q
What are some benefits of NIV in the Chronic Care Setting (4)
A
- Alleviates symptoms of chronic hypoventilation
- Improves duration and quality of sleep
- Improves functional capacity
- Prolongs survival
20
Q
NIV reduces diaphragmatic pressure swings, which suggest that the
A
Respiratory muscles are being rested
21
Q
When PEEP is applied during PSV, PEEP helps offset…
which reduces the work required to
A
auto-PEEP;
initiate inspiration
22
Q
Pressure Support (PS) facilitates ______________, thus increasing the _____
A
inspiratory;
Vt
23
Q
Pts w/ COPD who have experienced acute exacerbations have shown that NIV reduces inspiratory muscle activity and RR and increases Vt and minute volume, allowing for better
A
gas exchange and Respiratory muscle rest
24
Pts receiving NIV have shown significant improvement in (5) **Within the first hour of use**
- vitals signs
- pH
- Blood gasses
- RR
- breathlessness
25
What are 2 examples of IPPV
- metaNeb
- IPV
26
NIV is typically used for
chronic vent failure
27
NIV= continuous ____________ _________
pressure breaths
28
IPPV= some of the breaths are….
given with pressure
29
What is the physiological goal of NIV in ARF in the acute and chronic care settings?
To improve gas exchange by resting the respiratory muscle and increasing ventilation
30
In pts who have COPD NIV has been
very successful
31
NIV in pts w/ asthma have been shown to be controversial, however it is used
in pts w/ status asthmatic
32
List 4 clinical disorders that manifest in chronic respiratory failure and require NIV as supportive therapy
- Acute Exacerbation of COPD
- Cardiogenic Pulmonary Edema
- Hypoxemia Respiratory failure
- Community-acquired PNA
33
NIV Community-Acquired PNA is considered controversial however success has been shown in pts w/
PNA and COPD
34
______ and mask _______ have been shown to be effective in the tx of acute cardiogenic pulmonary edema (ACPE)
BiPAP;
CPAP
35
NIV and mask CPAP w/o2 may expand fluid-filled alveoli, resulting in the following: (5)
- Increased oxygenation
- Increased FRC
- Increased lung compliance
- Reduced WOB
- Reduced need for invasive ventilation
36
NIV CPAP w/ mask to treat ACPE has shown success w/ using
PSV plus PEEP
37
What is the recommendation range to use CPAP in the initial tx of ACPE
10 - 12 cm H2O
38
NIV is used in _____ ______ deformities and _____________ conditions that result in ___________ weakness, _______________, and eventually respiratory failure
chest wall;
neuromuscular;
muscle;
hypoventilation;
39
In Restrictive thoracic disorders NIV use......
is normally successful in these pts nocturnally
40
In CF NIV is
not often used
41
In CF _____________ use of NIV could help support these pts for several months while they......
intermittent ;
await a lung transplant
42
What does nocturnal hypoventilation include? (4)
- CSA
- obesity hypoventilation syndrome
- OSA combined w/ COPD
- CHF
43
What is the choice of NIV therapy used for OSA
CPAP
44
For OSA CPAP is typically used _____________ for ____ to ____ hrs and is used to overcome ______________ and ______________.
nocturnally;
4 to 6;
obstruction and desaturation
45
NIV provides a viable weaning alternative for pts who demonstrate
respiratory muscle fatigue post extubation
46
NIV reduces
WOB and maintains adequate gas exchange as effectively as invasive vetilation
47
What role does NIV play in "end of life" situations? (3)
- it may relieve severe dyspnea
- reduce sedation require intent
- preserve pt comfort
48
In **acute care** settings NIV process must be based on the: (3)
- Pt's diagnosis
- clinical characteristics
- the risk of failure
49
The assessment process may be viewed as a two-step process. What are they?
1st step- establishing the need for ventilatory assistance
2nd step- exclude pts at increased risk for failure and complication
50
The final consideration in the selection of pts w/ ARF is the
potential reversibility of the disease process
51
Exclusion Criteria for NIV
- Respiratory arrest or the need for immediate intubation
- Hemodynamic instability
- **Inability to protect the airway**
- Excessive secretions
- Agitated and confused pts
- Facial deformities or conditions that prevent mask from fitting
- Uncooperative or unmotivated pts
- Brain injury w/ unstable respiratory drive
52
Typical symptoms of nocturnal hypoventilation and poor sleep quality include (5)
- Excessive fatigue
- Morning headache
- Daytime hypersomnolence
- Cognitive dysfunction
- Dyspnea
53
What are some other indications for NIV in pts
- Obesity hypoventilation syndrome
(extremely overweight pts who take short breaths, which causes a chronic high CO2)
54
What are the equipment generally required for NIV? (3)
- ventilators
- humidifiers
- interfaces or mask
55
Types of ventilators (3)
- Portable homecare ventilators
- Adult acute care ventilators
- Portable pressure support (pressure- targeted) ventilators
56
The choice of ventilators should be based on the
level of support required and the advantages and disadvantages of the appropriate machines
57
What are another name(s) for pressure-targeted ventilators (PTVs)? (3)
- Bilevel CPAP ventilators
- Pressure support ventilators
- Bilevel pressure ventilators
58
PTVs are _____________-controlled electrically powered units that use a blower to regulate _____ flow to the pt’s ________ to maintain the preset __________ levels at the pt’s connection
microprocessor;
gas;
ciruit ;
pressure
59
PTVs typically delivers a
Vt
60
Some PTVs are
pneumatically powered which means it needs a gas source to run
61
PTVs are.... (3)
- Pressure limited
- Flow and time triggered
- Flow and time cycled
62
Pressure limited means it will only
reach a certain pressure; the pressure that was set and that will be the highest pressure it can go to
63
Flow triggered means it will
sense what the pt is doing and it will allow the pt to trigger a breath
64
Time trigger is a
set rate; the machine will give a breath, weather the pt wants to or not
65
Flow cycled means
the pt can end the breath
66
Time cycled means if the pt
does not end the breath, the machine can
67
PTVs are designed to improve gas exchange and increase VE using
IPAP and EPAP
68
What is the calibrated pressure range for IPAP and EPAP?
IPAP= 2 to 30 cm H2O
EPAP= 2 to 20 cm H2O
69
Most PTVs offer the following modes of ventilatory support: (3)
- CPAP (spontaneous)
- PSV (IPAP/EPAP)
- Spontaneous/timed (S/T)
70
In CPAP mode the pt breaths spontaneously at a set…..
The pt controls both the
baseline pressure;
rate and depth of breathing
71
CPAP mode is 1 ____________ positive pressure
continous
72
CPAP is typically used for (2)
- Hypoxemic Respiratory Failure
- Cardiogenic Pulmonary Edema
73
With PSV (bilevel) mode, the difference between……..
2 pressure levels (IPAP and EPAP) determines the level of pressure support for each assisted breath
74
In S/T mode the clinican set the (3)
- IPAP and EPAP
- RR
- Inspiratory time ( IPAP%)
75
In S/T spontaneous breaths are given, however
timed breaths are given as well
76
S/T is similar to
SIMV
77
PSV=
IPAP and EPAP
78
S/T=
IPAP & EPAP
RR
I times
79
What is the difference between PSV and S/T
PSV- set IPAP and EPAP and hope that the pt breathes as they should breathe
S/T- set RR and I-times to give breaths, if the pt does not
80
Average volume-assured pressure support (AVAPS) automatically
adapts the pressure support to match a pts ventilatory needs by delivering an average Vt (Vt= 200-1500 mL)
81
How do you figure out the Pressure support is being applied to the pts airway
The difference between IPAP and EPAP
(ex. pt has an IPAP of 10 and an EPAP of 5. The pt is getting 5 of pressure support. 10-5= 5)
82
AVAPS devices operate w/ several modes of ventilation including: (5)
- CPAP
- S/T,
- spontaneous
- timed
- PCV
83
What does Auto- Trak+ option allows the clinician to do what?
Adjust thresholds that manage trigger and cycling and the level of Auto-Trak sensitivity
84
AVAPS include a target Vt of __, minimum IPAP of ____, minimum EPAP of ___, RR ___ to ___ below resting RR, and an inspiratory time of ____ seconds
8 mL/kg IBW
25 cm H2O;
+4 cm H2O;
2 to 3 beats/min;
1.5
85
PTVs allow adjustment of the amount of time required to reach IPAP, which is called?
Rise-time control
86
Rise time is the amount of time until you reach the
maximal pressure or maximal volume.
87
In NIV rise time control is the time to
reach IPAP
88
**Ramp** allows positive pressure to
increase gradually over a set interval (delay time).
89
Ramp rate generally can be set in increments of..
1, 2, 3 cm H2O
90
Delay can be set in increments of ___ minutes between
5 ; between 5 and 30 minutes
91
When are ramp and delay time more likely to be used in? (2)
- homecare
- chronic care NIV
92
Portable PTVs have certain limitations. When supplemental O2 is required, what must be done?
It must be bled into the system via the mask or into the circuit near the machine outlet
93
Therefore the FiO2 can vary and can be affected by 4 factors. What are they?
1. O2 flow rate
2. Type of leak port in the system
3. Site where O2 is bled into the circuit
4. IPAP and EPAP
94
Rebreathing of CO2 is a concern w/ any PTV that uses a single-circuit gas delivery system b/c....
exhalation occurs through the intentional leak port and depends on the continuous flow of gas in the circuit
95
What are the advantages of portable homecare ventilators?
- electrically powered, microprocessor-controlled ventilators
96
Portable homecare ventilators were capable of providing
- patient-or time-triggered
- pressure-limited
- volume - or pressure-cycled
97
This type of vent has no graphic display and very basic alarms. Low pressure, high pressure, power switchover, apnea
portable homecare vents
98
How could PEEP be obtained w/ PHV?
attaching an external threshold resistor to the pt circuit exhalation valve
99
PHV were not equipped w/ internal blenders and therefore
precise O2 concentration was not possible
100
As with PTVs, PHV, O2 had to be
bled into the system through an adapter O2 source
101
Vents used in adult care units offer additional ventilatory support options and...
alarms and a precise FiO2 and monitoring features than portable PTVs
102
What is the most significant disadvantage of using an acute care vent?
The inability of machines to compensate for leaks
103
Leaks at the interface interfere w/ triggering and __________ functions of the vent and results in pt- ____________ _____________ and increased WOB
cycling;
ventilatory asynchrony;
104
Using a heated humidifier can significantly
reduce drying of the nasal mucosa in nasal CPAP
105
What are the 2 different modes for heated humidifcation
Invasive and Noninvasive
106
Passover-type heated humidifiers are often used b/c
heated bubble humidifier and HME can increase Raw in the ventilator circuit and interfere w/ pt triggering and increase inspiratory WOB
107
The effectiveness of NIV is greatly influenced by the __________ chosen to deliver __________ pressure
interface;
positive
108
Carefully explaining the process and repeating the explanations as the process continues can
improve patient compliance
109
What are the **initial** pressure for NIV?
EPAP and IPAP
- EPAP pressure of 4 to 5 cm H2O
- IPAP pressure of 8 to 10 cm H2O
110
Pt tolerance and comfort w/ the system are important to ensuring the effectiveness of NIV at alleviating
respiratory distress
111
Improvement in pt comfort w/ NIV is indicated by (3)
- decreased RR
- decreased inspiratory muscle activity
- synchronization w/ the vent
112
Insufficient IPAP levels often result in sustained or increased…
RR caused by inadequate Vt delivery
113
Slowly increasing the IPAP to maintain the exhaled Vt at (#)
6 to 8 mL/kg may result in a decrease in the RR
114
The FiO2 is adjusted to maintain SpO2 at (range)
90% to 92%
115
Shortly after the initiation of NIV, (1 to 2hrs) the adequacy of ventilatory support is determined by
ABG results
116
When is NIV terminated in favor of invasive measures?
- pH and PacO2 continue to worsen or show no improvement, accompanied by Respiratory distress
- Worsening level of consciousness
- hemodynamic instability
- worsening oxygenation
117
Complications w/ NIV are usually related to (3)
- mask discomfort (most common)
- air pressures
- gas flow
118
When can you discontinue NIV?
Depends on how quickly the cause of the respiratory failure can be reversed
119
Pt w/ ARF successful weaning from NIV may occur within
hours or a few days
120
Standard weaning techniques have not been established most common approach involves increasing
periods off mask ventilation
121
In the same manner of SBT, periods off the ventilator lengthen as the underlying condition improves and the pt shows (3)
- acceptable vital signs
- good gas exchange
- no respiratory distress
122
_______________ _____ is administered as necessary during these times off the vent
Supplemental O2
123
Studies have shown that more time is required during an intial
8hr shift to institute NIV than to establish conventional invasive ventilation
124
CPAP main goal is to help w/
oxygenation
125
For CPAP, to improve o2 you must
increase pressure and FiO2
126
CPAP has ___ continuous pressure
1
127
BPAP has __ pressures _____ and _______
2;
IPAP & EPAP
128
IPAP (CO2)=
Vt and PIP
129
EPAP (O2)=
PEEP
130
IPAP-EPAP=
Pressure support
131
For BiPAP if you have high CO2,
increase IPAP (Larger Vt) to **blow off** CO2
132
For BiPAP if you have low CO2 then you
decrease IPAP to **retain** CO2
133
To increase oxygenation on BiPAP you
increase EPAP
134
To lower O2 or weaning from BiPAP you
decrease EPAP
135
Criteria for Terminating NIV and Switching to Invasive MV (Box 19.6)
1. Worsening pH and PaCO2
2. Tachypnea (>30 breaths/min)
3. Hemodynamic instability
4. SpO2 < 90%
5. Decreased level of consciousness
6. Inability to clear secretions
7. Inability to tolerate interface
136
What is the criteria for Acute Respiratory Failure in adults (NIV)
- pH <7.35
- PaCO2 > 45 mm Hg
- PaO2/FiO2 < 200
137
To prevent CO2 rebreathing, EPAP level should be set at ___ cm H2O or higher so adequate gas exchange can flush CO2 from the breathing circuit
4
138
**Chart 19.1**
What are the symptoms indicating the need for NIV (4)?
- Moderate to severe dyspnea
- RR greater than 24 breaths/min
- Accessory muscle use
- Paradoxical breathing
139
What is the corrective action for the complication that is associated w/ Mask CPAP/NIV therapy?
**Hypotension**
Avoid excessively high peak pressures (<20 cm H2O)
140
What is the corrective action for the complication that is associated w/ Mask CPAP/NIV therapy? (3)
**Mucous plugging** (3)
- Ensure adequate hydration
- Adequate humidification
- Avoid excessive O2 flow rates
141
What is the corrective action for the complication that is associated w/ Mask CPAP/NIV therapy?
**Aspiration**
Adhere to proper selection of pts who can protect their own airway.
142
What is the corrective action for the complication that is associated w/ Mask CPAP/NIV therapy?
**Aerophagia, gastric distention**
Use lowest effective pressures for adequate VT delivery
143
What is the corrective action for the complication that is associated w/ Mask CPAP/NIV therapy?
**Pressure sores**
Use wound-care dressing over nasal bridge
144
What is the corrective action for the complication that is associated w/ Mask CPAP/NIV therapy?
**Excessive leaks around mask** (2)
- Minimize headgear tension
- Switch mask style
145
What is the corrective action for the complication that is associated w/ Mask CPAP/NIV therapy?
**Nasal/oral dryness or nasal congestion** (4)
- Add or increase humidification
- Irrigate nasal passages w/ saline
- Apply topical decongestant
- Use a chin strap to keep mouth closed
146
What is the most common complication of NIV
Mask discomfort
147
Insufficient ______ levels often result in sustained or increased RR caused by inadequate Vt delivery
IPAP
148
You notice a drop in exhale Vt on a pt on BiPAP. What is the most appropriate action to take?
Adjust the interface
(#1 reason for exhale Vt to be lower or less than expected is a **LEAK**. The first place you will have a leak is the face mask)
149
What is the most appropriate type of humidifier for NIV?
Pass-over
(except for transport)
150
Pt is on mask CPAP w/ FiO2 80% and CPAP of +8. ABG values are pH 7.37, PaCO2 37, PaO2 55. What is the most appropriate thing to do next??
Increase CPAP
(If FiO2 is between 50% to 60% or up then you will increase the pressure)
151
A pt w/ COPD is on BiPAP w/ the following settings: IPAP 8, EPAP 4, Vt 350mL. Their ABGs values are: pH 7.27, PaCO2 77, PaO2 50. What is the most appropriate thing to do next?
Increase IPAP
(Fixing IPAP should increase pH and o2 as well)
