Test 3 Study Guide Flashcards by Savannah Robbins

CPAP will not assist with _____

Ventilation

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CPAP enhances ____ and preserves lung inflation by improving the FRC.

oxygenation

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CPAP does not provide _____ breathing support

Tidal breathing support.

Patient must be breathing on their own

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NIV provides positive pressure above_____

continuous distending pressure

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Indications for CPAP and NIV

Reduces mucosal and tracheal injury
reduces risk of nosocomial infections
decreases need for sedation
increased tolerance for feeds
improve ability to ambulate

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Common indications for CPAP/NIV

impending respiratory failure, (pulmonary disease, NM disease, airway obstruction, infectious process)
post-extubation management
to avoid intubation

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CPAP is not recommended for children with _____

Severe disease or immunocompromised

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Diseases that benefit from CPAP

Pneumonia
Asthma
Bronchiolitis
PARDS
Atelectasis
Pulmonary Edema
Heart failure
Cystic Fibrosis
Sleep Apnea
Postextubation

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All noninvasive interfaces are associated with _____

system leaks

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____ is popular interface choice for NIV when leaks are ≤30%; outperformed oronasal or nasal mask

RAM cannula

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Factors for selecting interface

skin ulcerations
gastric insufflation
aspiration

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With risk of aspiration, select a ______

nasal interface

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Challenges and contraindications for NIV

Interface intolerance
Asynchronized breath
Selection of appropriate interface
Interfaces’ air leaks
Use of sophisticated PICU ventilators to provide NIV in patients less than 20 kg

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Goal of CPAP

To restore FRC to correct, reverse, or minimize alveolar collapse

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CPAP >_____ H2O in disorders associated with low lung compliance

≥10 cm

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CPAP may be discontinued when patient has been stable on ___ cm H2O with FiO2 <____ %

5–6 cm H20 with FIO2 <40%

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NIV can be administered in what 3 forms

spontaneous
spontaneous/timed
timed mode

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EPAP setting goal

To minimize alveolar collapse and should be increased if lung volume loss is present.

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EPAP setting limits

<7-8 for infants
<- for older children

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IPAP goal

Applied on top of EPAP and translates to to volume delivery.

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Difference between IPAP and EPAP

Delta P

Key in volume delivery. IPAP should be titrated to achieve adequate tidal volume, chest expansion and CO2 removal.

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Excessively long Inspiratory time can lead to:

May be uncomfortable and increase WOB, may result in air trapping.

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Set so that the patient can easily initiate a spontaneous or assisted breath without auto-triggering

Trigger Sensitivity

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Set to maximize patient comfort

Rise Time

Set for adequate transition from inhalation to exhalation

Cycle Time

Set to assist with patient tolerance and comfort

Ramp time

Drugs often used for sedation during NIV

Versed (Midazolam) and Precedex

Uses a specifically designed catheter to detect and use diaphragmatic electrical activity as a trigger mechanism

NAVA

REcommended HFNC temperature for pediatric patients

34-35 C

Indications for CPAP and NIV in neonates

Delivery room management PARDS Apnea of prematurity Postextubation Hypotonia CPAP ONLY FOR OBSTRUCTIVE AIRWAY DISEASES

Contraindications for CPAP or NIV

CO2 >65 PH < 7.25 Frequent and severe apnea Diaphragmatic hernia Gastric insufflation Tracheoesophageal fistula Cranial facial abnormalities Neuromuscular disorders Pneumothorax

Flow rates greater than ___ L/min are generally considered high flow in the neonatal patient

1 L/min

Classification of BPD

Mild - required 28 days of supplemental oxygen, no oxygen requirement at 26 weeks corrected gestational age or at discharge Moderate - Required 28 days of supplemental oxygen, oxygen requirement of <0.30 at 36 weeks gestational age or at discharge Severe - Required 28 days of supplemental oxygen. Oxygen requirement of >0.30 at 36 weeks gestational age or at discharge

Primary indication for invasive mechanical ventilation

Respiratory failure

Challenges influencing mechanical ventilation in neonates

- lack of surfactant -development of BPD -Highly compliant state of the chest wall and low pulmonary compliance -Immature alveolarization, dynamic elastic recoil, high airway resistance, poor collateral ventilation -premature birth

Permissive hypercapnia is allowing CO2 to stay between

45 and 55 while maintaining pH >7.20

AKA Assist Control (AC) Provides full support or mandatory breath Can be patient triggered or machine triggered May reduce WOB

Continuous Mandatory Ventilation (CMV)

Provides a present number of mandatory breaths and allows patient to take spontaneous breaths between mandatory ones.

Synchronized Intermittent Mandatory ventilation (SIMV)

Include pressure support ventilation and neutrally adjusted ventilatory assist ventilation. Patient's own respiratory drive controls rate of ventilation

Continuous spontaneous ventilation

Delivers a constant tidal volume and flow at a set mandatory breath rate Pressure it not held constant and is dependent on lung compliance and airway resistance Often results in a higher peak airway pressure during mandatory breath delivery

Volume Control Ventilation

AKA Adaptive Ventilation Utilizes algorithmic technology that monitors volume delivery and provides automatic pressure adjustment to maintain the preset targeted tidal volume

Volume Targeted Ventilation

For preterm infants, inspiratory time ranges between ___ and ___ when lung compliance is low and between ____ and ___ in neonates with BPD

0.25 - 0.30 when lung compliance is low 0.35-0.40 with BPD

Blood gas values for normal compliance

pH - 7.35-7.45 CO2 35-45 PaO2 60-100

Blood gas for decreased compliance (permissive hypercapnia)

pH - 7.25-7.35 CO2 - 45 - 60 PaO2 - 50-70

Blood gas for pulmonary hypertension

pH - 7.30-7.40 CO2 - 40-50 PaO2 - 80-100

High oxygen delivery will result in vasodilation of the pulmonary vessels and should be provided in patients with ____ sided cardiac defects

Right sided cardiac defects

a Higher ____ will improve pulmonary circulation and is achieved with slightly lower Co2 levels

A higher PH

It is important to limit pulmonary blood flow for infants with ductal dependent ___ sided lesions

Left sided lesions.

Consider extubation of neonate if:

FiO2 less than 40% RR less than 15 breaths/min PIP less than 20 PEEP less than 5

CPAP is used when:

Neonate has a strong respiratory drive but has a lung condition associated with loss of lung volume

NIV is used when:

Patient has a weak respiratory drive or respiratory muscle fatigue

HFNC is used to:

Flush out anatomical dead space and provide oxygen enriched gas flow, improving oxygenation status. Must be heated and humidified and can be used at flows of 1-8 in a neonate.

Mandatory breath rate by age:

30 days to 1 year: 25-40/min >1-3 years: 20-35/min >3-5 years: 20-30/min >5-10 years: 18-25/min >10 years: 12-20/min

___ triggered is common in infants and children, while ___ triggering may be seen in older children

Flow triggering for infants Pressure triggering for older children

Weaning should be targeted first on _____ or settings that are most toxic to the lungs

Ventilator parameters (excessive pressures and FIO2)

A respiratory therapist is reviewing the medical record of a preterm infant born at 30 weeks’ gestation presenting with respiratory distress. The chest radiograph (CXR) shows a ground-glass appearance of the lungs. The following data are available: Heart rate: 130 beats/minute Respiratory rate: 72 breaths/minute FIO2: 0.60 by nasal cannula at 1 L/minute Arterial blood gases are as follows :pH: 7.28p CO2: 50 mm Hg pO2: 56 mm Hg SpO2: 88% HCO3: 22.7 mm/ LBE: –3.2 Which of the following should the respiratory therapist do? A. Increase the FIO2 to 0.70. B. Initiate CPAP at 5 cm H2O. C. Change to oxygen delivery by hood. D. Intubate and provide ventilatory support.

B. Initiate CPAP at 5 cm H20

Which of the following conditions contributes to patient-ventilator asynchrony in an intubated infant receiving pressure control ventilation? A. Inspiratory time set at 0.9 seconds B. PIP set to deliver a VT of 6 mL C. Judicious use of a neuromuscular blockade D. Mandatory rate set at 30/min

A. Inspiratory time set at 0.9 seconds

The respiratory therapist is evaluating a preterm infant who is intubated and receiving pressure support ventilation. The respiratory therapist notes that the flow at the beginning of inspiration exceeds the infant's inspiratory demand. Which of the following should the therapist do? A. Change the cycle termination B. Adjust the rise time C. Initiate PC-CMV D. Recommend administration of midazolam

B. Adjust the rise time

A child with SMA-I requiring long term invasive ventilation at home is undergoing initial placement of a tracheostomy tube. The child weighs 3.5 Kg. To meet the child's postoperative mechanical ventilatory needs, which of the following should the respiratory therapist recommend? A. Transition from an ICU to a portable ventilator B. Initiation of HFOV until the stoma heals C. CPAP trials 1 hour after the child returns from the ICU D. Mechanical ventilatory support with an ICU ventilator.

D. Mechanical ventilatory support with an ICU ventilator