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Resuscitation > Ventilation > Flashcards

Ventilation Flashcards

1
Q

Settings in LUNG PROTECTIVE ventilation strategy:

A

MODE Volume control eg. SIMV-VC
VT 6ml/kg ideal weight (8ml/kg pregnant)
RR 18, then titrate to pH/CO2
Pmax high enough to allow VT
FiO2 50%
PEEP 10
PEEP and FiO2 titrated in tandem
TInsp IE 1:2

If in pressure control mode, start the inspiratory pressure at 20 and titrate to 6ml/kg VT.

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2
Q

What did the ARDSNet ARMA trial show?

A

Should ventilate ARDS at 6ml/kg and limit plateau to 30

Looked at standard, high tidal volume (10-15ml/kg) ventilation versus lower volume (6ml/kg, plateau <30) IN ARDS patients.

Showed
- Lower mortality
- More vent-free days

Further meta analyses showed most patients benefit.

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3
Q

Settings in OBSTRUCTIVE ventilation strategy:

A

MODE volume control eg. SIMV-VC
VT 6ml/kg ideal weight
RR 8 then titrate to stacking. Permissive hypercapnoea to pH >7.1
Pmax high enough to allow VT
FiO2 titrate
PEEP ZERO
TInsp Long. IE 1:4+

If in pressure control mode, start the inspiratory pressure at 20 and titrate to 6ml/kg VT.

Crank PMax right up, will
need high orreasures!

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4
Q

Indications for lung protective strategy?

A

Default.

Everything other than COPD and asthma.

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5
Q

What are the 3 variables measured on ventilator waveforms?

A

Pressure
Flow
Volume

Linear/scalar or loops

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6
Q

Describe PIP, Pmax, plateau pressures and their significance.

A

PIP is a measurement = it is the net pressure in the system (vent, tube AND patient).

Generally aim PIP <35cmH2O

When high, signifies resistance or compliance issue- more pressure is being needed to achieve the breath

__________

PMax is a setting= the max pressure a vent will use to deliver the breath. Ie. It is a vent pressure, not a patient pressure.

At PMax, vent will either continue to deliver breath at this pressure, or terminate the breath —> either way usually results in lower VT than desired.

Not all the PMax gets to the patient. So fine to increase it as long as plateau still okay.

______________

Plateau pressure = alveolar pressure. THIS matters to patient. Check with inspiratory hold function to get a plateau pressure

Aim pleateau pressure <30cmH20

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7
Q

What should pleateau pressure be kept at?

A

Less than 30cmH2O

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8
Q

Differential for HIGH PIP alarm:

A

1- Indicates a resistance or compliance issue
2- Should prompt a check of plateau pressure.

VENT EQUIPMENT
Settings
Malfunction

Kinking
Condensation pooling
Wet filters

TUBE
Malposition
Kinking
Occlusion (blood, secretions)

PATIENT
In
Bronchospasm
APO
Collapse/ consolidation
Breath stacking

Around
Pneumothorax/ tension
Pleural effusion
Chest wall: rigidity, abdo distension (BO).

Other
Dysynchrony

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9
Q

Clinical approach to HIGH PIP alarm:

A

Check PLATEAU
-High PIP/normal plateau = resistance (above alveoli eg. Bronchospasm)
-High PIP/ high plateau = compliance (in alveoli eg. APO)

DISCONNECT AND BAG
—> ?feel ?compliance

Examine patient
—> ?Alert/ agitated/ triggering/coughing
—> chest movement, auscultate, abdo
—> CXR

Examine tube
—> Measurement, kinking
—> Suction
—> Look with laryngoscope
—> CXR

Examine equipment
—> Settings
—> Check function on test lung
—> Systematically along circuit, incl filters

Once addressed, may need to increase PMax/ PIP alarm, as long as pleateau remains <30.

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10
Q

What is a normal, physiological tidal volume?

A

8ml/kg

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11
Q

Differential for LOW PRESSURE alarm:

A

Leak
Disconnect

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12
Q

Differential for LOW MINUTE VOLUME alarm:

A

Check RR setting
Check VT setting and actual
Check PIP
- ?low - leak or disconnect
-?high - resistance/compliance/ cutting out

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13
Q

Differential for DYSYNCHRONY:

A

may see clinically, or note as PIP/ low minute vol/ trace

Alert
Seizure
Coughing
External pacing

Settings:
Trigger sensitivity too high
Comfort:
- IE ratio
- Trigger sensitivity too low (hard work)

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14
Q

What is the cause of hypoxia without any change to ventilator pressures/volumes?

A

SHUNT

Ie. Pulmonary embolus

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15
Q

Approach to hypotension in ventilated patient:

A

Ensure accurate: art line calibrated, height, trace
Assess perfusion- immediate action PRN
- Tilt, 20ml/kg bolus, push dose/bolus pressor
- Seek and treat AHSHITE and other causes (eg. Sepsis, abdo distension etc.)
- Reduce PEEP if able

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16
Q

Management of dynamic hyperinflation:

A
  • Disconnect and allow passive expiration (do not squeeze- barotrauma)
  • Reconnect on:
    —> Lower or no PEEP
    —> Lower RR
    —> Higher IE ratio
  • Optimise bronchodilators
  • If patient is sponting, control tachypnoea with analgesia, or deeper sedation/ paralysis.
17
Q

MODIFIER: Vent settings in HEAD INJURY:

A

Need to maintain CPP:
Low PEEP
—> Zeep, or 5.
RR to target neuroprotective CO2 30

18
Q

MODIFIER: Vent settings in PREGNANCY:

A

Higher VT- 8ml/kg, same RR
—> ie. higher minute vent
Do NOT allow hypercarbia (fetal acidosis)

19
Q

MODIFIER: Vent settings in METABOLIC ACIDOSIS:

A

Pitfall is overriding compensatory hyperventilation.

High RR to match intrinsic RR pre-intubation, or higher.
Or
Lighten and have them spont venting
Allow hypocapnoea

20
Q

MODIFIER: Vent settings in APO:

A

Ie. RV failure
High PEEP- 10-15
Hydrostatic effect
Also decreases preload in CCF physiology- good

21
Q

What is the minimum tidal volume that should be given?

A

4ml/kg

22
Q

Contraindications to NIV:

A

Base of skull fracture, facial trauma (orbit, sinus)
Vomiting, haemoptysis, haematemesis
Upper airway obstruction
Pneumothorax (without drain), oesophageal rupture
Clear need for intubation
Marked haemodynamic instability eg. (likely to precipitate arrest then crash tube)
GOC, consent

23
Q

NIV:
Starting pressures
Incrementing
Max

A

CPAP 5
BiPAP 10/5

Increment by 2-3cm 5 minutely

Max IPAP: 20-25
Max EPAP: 15
Max CPAP: 15 (8 paeds)

24
Q

Complications of NIV:

A

Distress
Pressure areas
Corneal injury
Gastric distension / aspiration
Hypotension
Impaired communication and oral intake

Delay to intubation

25
Q

Summary of evidence for NIV in:
APO
COPD
Asthma
ARDS
Other

A

APO and COPD
Strong evidence (RCTs ++)
Fewer tubes, reduced LOS and mortality benefit

ASTHMA
No conclusive evidence
Reasonable as rescue bridging, or for delayed sequence tube
Use low PEEP eg. 3

ARDS
No evidence and not recommended

OTHER
Rib fractures- limited evidence
CAP- benefit in immunocompromised

26
Q

NIV Basics:

A

EPAP is basically PEEP
IPAP is the total insp pressure
Pressure Support is the IPAP above EPAP (ie. the difference)

CPAP: Oxygenation, recruitment,
BiPAP: Augments alveolar ventilation, reduces CO2.

27
Q

Optimising NIV:

A

Position/ seal:

EPAP:
- Recruitment
—> Oxygenation
—> Prevent atelectasis
—> Compliance
—> RV afterload
—> FRC (apnoea reservoir)

IPAP:
—> WOB

OVERALL PRESSURE SUPPORT:
- Alveolar ventilation
—> CO2 clearance

VT: Can’t set but via IPAP/EPAP and coaching patient: enough for gas exchange, avoid volutrauma
FiO2: oxygenation
______

You improve O2 via recruitment (PEEP) and FiO2.
You improve CO2 via minute vent. ie. tidal volume (Vt or IPAP/ pressure) and RR

Resuscitation (10 decks)

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