Test 3 Study Guide Flashcards
CPAP will not assist with _____
Ventilation
CPAP enhances ____ and preserves lung inflation by improving the FRC.
oxygenation
CPAP does not provide _____ breathing support
Tidal breathing support.
Patient must be breathing on their own
NIV provides positive pressure above_____
continuous distending pressure
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
Common indications for CPAP/NIV
- impending respiratory failure, (pulmonary disease, NM disease, airway obstruction, infectious process)
- post-extubation management
- to avoid intubation
CPAP is not recommended for children with _____
Severe disease or immunocompromised
Diseases that benefit from CPAP
Pneumonia
Asthma
Bronchiolitis
PARDS
Atelectasis
Pulmonary Edema
Heart failure
Cystic Fibrosis
Sleep Apnea
Postextubation
All noninvasive interfaces are associated with _____
system leaks
____ is popular interface choice for NIV when leaks are ≤30%; outperformed oronasal or nasal mask
RAM cannula
Factors for selecting interface
skin ulcerations
gastric insufflation
aspiration
With risk of aspiration, select a ______
nasal interface
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
Goal of CPAP
To restore FRC to correct, reverse, or minimize alveolar collapse
CPAP >_____ H2O in disorders associated with low lung compliance
≥10 cm
CPAP may be discontinued when patient has been stable on ___ cm H2O with FiO2 <____ %
5–6 cm H20 with FIO2 <40%
NIV can be administered in what 3 forms
spontaneous
spontaneous/timed
timed mode
EPAP setting goal
To minimize alveolar collapse and should be increased if lung volume loss is present.
EPAP setting limits
<7-8 for infants
<- for older children
IPAP goal
Applied on top of EPAP and translates to to volume delivery.
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.
Excessively long Inspiratory time can lead to:
May be uncomfortable and increase WOB, may result in air trapping.
Set so that the patient can easily initiate a spontaneous or assisted breath without auto-triggering
Trigger Sensitivity
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
