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Intreventions 2 > Ventilation Goals and Strategies > Flashcards

Ventilation Goals and Strategies Flashcards

1
Q

Indications for Mechanical Ventilation- Adult

A

ASIA

  1. Apnea
  2. Severe Refractory Hypoxemia (Assessed through WOB and Oxygenation Parameters)
  3. Impending Ventilatory Failure (Assessed through WOB, and other relevant parameters)
  4. Acute Ventilatory Failure
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2
Q

Acute Ventilatory Failure

A

PaCO2 > 55 mmHg

pH < 7.25

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3
Q

Impending Ventilatory Failure

A

MIP

VC

Vt

RR

Vd/Vt

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4
Q

MIP

A

Use to assess impending ventilatory failure

Normal: -80 to -100

Critical: <-20

VC

Vt

RR

Vd/Vt

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5
Q

VC (mL/kg)

A

Use to assess impending ventilatory failure

Normal: 65-75

Critical: <10

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6
Q

Vt (mL/kg)

A

Use to assess impending ventilatory failure

Normal: 4-8

Critical: <4

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7
Q

RR (bpm)

A

Use to assess impending ventilatory failure

Normal: 12-20

Critical: >35

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8
Q

VD/ V t

A

Use to assess impending ventilatory failure

Normal: 0.25-0.4

Critical: >0.6

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9
Q

Severe Refractory Hypoxemia

A

Assess WBO and oxygenation parameters

A-a gradient

PF Ratio

PaO2/PAO2

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10
Q

A-a gradient (mmHg)

A

Assess WBO and oxygenation parameters

Normal: 25-65 (on a FiO2 of 1.0)

Critical: >350 (on a FiO2 of 1.0)

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11
Q

PF Ratio

A

Assess WOB and oxygenation parameter

Normals: 350-400

Critical: <200

Calculation= PaO2/FiO2

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12
Q

PaO2/PAO2

A

Assess WOB and oxygenation parameter

Normals: 0.75-0.85

Critical: <0.15

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13
Q

Spontaneous Parameters-Neonates

A

RR (bpm): 30-60

Vt (ml/kg): 5-7

VC (ml/kg): 35

Resistance (cmH20/L/s): 25-50

Compliance (mL/cmH2O): 1-2

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14
Q

Spontaneous Parameters-Adult

A

RR (bpm): 12-20

Vt (ml/kg): 4-8

VC (ml/kg): 65-75

Resistance (cmH20/L/s): 0.6-2.4

Compliance (mL/cmH2O): 50-170

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15
Q

Inclusion Criteria for ARDS net

A

P/F < 300

Bilateral infiltrates consistent with pulmonary edema

No clinical evidence of left atrial hypertension

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16
Q

Ideal Body Weight Calculation

A

Males: 50 + 2.3 (Height [inches]-60)

Females: 45.5 + 2.3 (Height [inches]-60)

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17
Q

ARDS Net

Lower PEEP/ Higher FiO2

A

Start with this normally (maybe not with Prost though)

FiO2 of 0.3 - PEEP of 5

FiO2 of 0.4 - PEEP of 5-8

FiO2 of 0.5 - PEEP of 8-10

FiO2 of 0.6 - PEEP of 10

FiO2 of 0.7 - PEEP of 10-14

FiO2 of 0.8 - PEEP of 14

FiO2 of 0.9 - PEEP of 14-18

FiO2 of 1.0 - PEEP of 18-24

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18
Q

ARDs Net Higher PEEP/ Lower FiO2

A

Move to this second

FiO2 of 0.3 - PEEP of 14

FiO2 of 0.4 - PEEP of 14-16

FiO2 of 0.5 - PEEP of 16-18

FiO2 of 0.5 to 0.8 - PEEP of 20

FiO2 of 0.8 - PEEP of 22

FiO2 of 0.9 - PEEP of 22

FiO2 of 1.0 - PEEP of 22-24

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19
Q

ARDS Net Plateau Pressure

A

Check Pplat (0.5 second inspiratory pause) at least q 4h and after each change in PEEP or Vt

If Pplat is > 30 cmH2O: Decrease Vt by 1 ml/kg steps (minimum= 4 ml.kg)

If Pplat is <25 cmH2O and Vt < 6 ml/kg: Increase Vt by 1 ml/kg until Pplat is >25 cmH2O or Vt 6 ml/kg

If Pplat is < 30 cmH2O and bretah stacking or dys-synchrony occurs: May increase Vt in 1 ml.kg increments to 7-8 ml/kg if Pplat remains < 30 cmH2O

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20
Q

ARDS Net ABG Goals

A

pH Goal: 7.30-7.45

Acidosis Mangement (pH< 7.30): Increase RR until pH > 7.30 or PaCO2 <25 (Maximum set RR = 35)

If pH < 7.15: Increase RR to 35. If pH remains <7.15 Vt may be increased in 1 ml/kg steps until pH> 7.15 (Pplat target of 30 may be exceeded). May give NaHCO3

Alkalosis Management: Decrease vent rate is possible

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21
Q

ARDS net Weaning

A

Conduct a spontaneous breathing trail daily when

  1. FiO2 < 0.40 and PEEP < 8 or FiO2 < 0.5 and PEEP < 5
  2. PEEP and FiO2 < values of previous day
  3. Patien has acceptable spontaneous breathing efforts
  4. Systolic BP > 90 mmHg without vasopressor
  5. No neuromuscular blocker
22
Q

ARDS Net Spontaneous Breathing Trial

A
  1. Place on a T-piece, trach collar or CPAP < 5 cmH2O with PS < 5
  2. Assess fo tolerance for up to 2 hours
    1. SpO2 > 90% and/or PaO2 > 60 mmHg
    2. Spntaneous Vt > 4 ml/kg PBW
    3. RR< 35/min
    4. pH> 7.3
    5. No Respiratory Distress (2 or more)
      1. HR > 120% baseline
      2. Accessory muscle use
      3. Abdominal paradox
      4. Diaphoresis
      5. Marked dyspnes
  3. If tolerated for 30 min consider extubation
23
Q

Normal Lung Protocol Initial Setting

A

Minute Volume: 100 mL/min/kg IBW

Vt: 6-10 ml/kg IBW (start at 8)

RR: 10-18

PEEP: 5

I:E- 1:2 or less

Autoflow or decleratign flow patteren

Oxygen 60%

24
Q

Normal Lung Protocol Ventilation Goals

A

pH 7.30-7.50

PaCO2 35-45 mmHg or ETco2 between 5-6%

PaO2 60-100 mmHg

Total RR <30

Vt 6-10 mL/kg IBW

Plateu Pressure <30 cmH2O

25
Q

Alarms- FiO2

A

If using an external analyzer set to +/- 10% of set

26
Q

Alarm PEEP

A

Low PEEP Alarm set to 2-3 cmH2O below set PEEP

27
Q

Alarms High and Low Pressure

A

In volume based ventilation, to be set at 50 cmH2O or 15-20 cmH2O above the PIP

In pressure ventilation set at 5-10 cmH20 above PIP

Set low-pressure alarm to a min of 10 or 15-20 below PIP

28
Q

Alarms High and Low Volume

A

Low Exhaled Vt: Set to 200ml or 20% below set Vt

High Exhaled Vt: In the spontaneous mode, set to 1.5-2 times the set of delivered Vt. In controlled set 200 ml above the set or delivered Vt

29
Q

Alarms High and Low MV

A

Low MV: Set to 20% below set or delivered MV

High MV: Set to 20% above set or delivered MV

30
Q

High RR Alarms

A

Set to 30-35 or 10 bpm above pt rate

31
Q

Higher Spontaneous Rate Alarm

A

Set to 10 bpm above pt spontaneous rate or at upper acceptable limit for RR orders

32
Q

Apnea Alarms

A

Apnea Interval: 20 Seconds

Apnea Vt: Adjust to set delivered Vt

Apnea Rate: Adjust to set rate and not below 8 bpm

Apnea FiO2: 1.00

Apnea Flow Rate: Do not exceed 60 lpm

33
Q

PCV Alarms

A

Apnea Pressure: Adjust to set pressure control level

Apnea I:E: Adjust to set I:E pressure control

Apnea High Pressure: Set 5-10 cmH2O above PIP

34
Q

AHS Weaning Parameters

A

Pt should be on PEEP <8 cmH2O and FiO2 < 0.60

MV should not be greater than 12

Monitor SpO2

Optimize pulmonary mechanics by elevating patient head or placing patient in the sitting position

NIF or NIP measurements can be used

35
Q

AHS Extubation Pathway

A
  1. Exclusion from Extubation Pathway
    • Head injury, unstable spinal injury, receiving inotropes or vasopressors, planned surgery.
    • Head and spinal injury are relative contraindications and can still be extubated with physician order
  2. Is the patient ready for a spontaneous trial
    • Resolution of disease
    • Adequate oxygenation (PaO2 > 60 mmHg, P/F>200, SpO2 > 90%, PEEP <5, FiO2<0.4 or as otherwise stated in protocol)
    • No uncompensated respiratory acidosis
    • HR <140 bpm and stable cardiac measure
    • Adequate GCS (>13)
  3. Initiation of SBT
    • Place the patient on PSV of 7 and PEEP of 5, and if there is automatic tube compensation then sat PSV to 0
    • In the first 5 min monitor RR, tobin score (>105), sweating, anxiety, mental status changing, SpO2>90, etc
    • If any negative changes occur increase PSV and inform physician
  4. Continue SBT
    • For pt who are ventilated <72 hours continue for 30 min
    • For pt ventilated > 72 hours continue for 60-120 min
    • Monitoring should be done for the first 5 min and then Q15 there after
  5. Extubation
36
Q

ABG in Adults

A
  • pH
    • Normal: 7.35-7.45
    • Goal:7.35-7.45
  • PaCO2
    • Normal: 35-45
    • Goal: 35-45
  • PaO2
    • Normal: 80-100
    • Goal: 60-100
  • HCO3
    • Normal: 22-26
  • SaO2
    • Normal: 95-100%
    • Goal: >90%
37
Q

Delivery Room Stabilization

A
  1. Try to delay clamping umbilical cord for at least 60 seconds. Cord milking is a reasonable alternative if this is not possible
  2. Oxygenation should be controlled with a blender
    • An initial concentration of 0.3 is good for <28 gestation and 21-30 for 28-31 weeks
  3. In spontansous breathing babies, stabilize with CPAP of at least 6 cmH2O via mask or nasal prongs. Gentle PPV using about 20-25 cmH2O PIP for persistenly apneoic or bradycardic infants
  4. Intubation should be reserved for babies who have not responsded to PPV via face mask
    • Babies who are intubated for stabilization should be given surfactant
  5. Plastic bags under radient warmers should be used in stabilization in the delivery suite for babies <28 weeks to reduce the risk of hypothermia
38
Q

Oxygen Supplementation: European Consensus Guidelines 2016

A

In preterms babies receiving O2 the saturation target should be between 90-94%

To achieve this it is suggested that alarm limits should be 89-95%

39
Q

CPAP in Neonates European Consensus

A
  • CPAP should be started for all babies at risk of RDS
    • <30 weeks gestation who do not need intubation for stabilization
  • The interface should short binasal prongs or mask with a starting pressure of 6-8cmH20
    • CPAP pressure should then be individualized based on oxygenation and ventilation
  • CPAP with early rescue surfactant should be considered optimal management for babies with RDS
  • Synchronized NIPPV if delivered through a ventilator rather than a bilevel CPAP device can reduce extubation failure, but may not confer long-term advantages such as reduction in BPD
  • HF may be used as an alternative to CPAP for some babies during weaning phase
40
Q

Mechanical Ventilation in Neonates European Consensus

A
  • After stabilization, MV should be used in babies with RDS when other methods of respiratory support have failed
    • The duration of MV should be minimized
  • Target tidal volume ventilation should be employed as this shortens the duration of ventilation and reduce BPD and intraventricular hemorrhage
  • Avoid hypocarbia as well as severe hypercarbia which are both associated with brain injury
    • When weaning from MV it is reasonable to tolerate a modest degree of hypercarbia provided pH >7.22
  • Caffeine should be used to facilitate weaning from MV
    • Early caffeine should be considered for all babies who are at high risk for MV
      • < 1 250g birth weight who are managed on non-invasive respiratory support
  • A short tapering course of low dose dexamethasone should be considered to facilitate extubation in babies who remain on MV after 1-2 weeks
  • Inhaled steroid cannot be recommend for routine use to reduce BPD until further safety data become available
41
Q

AHS CPAP in Delivery Room

Gestation 25-28 Weeks

Principals

A

Maintain optimum lung volume and FRC in order to avoid de-recruitment and overdistension

in L&D and acute phase avoid CPAP >6

Infants >28 weeks will be intubated by a senior practitioner

“Early surfactant” does not mean “immediate surfactant”

42
Q

AHS CPAP in Delivery Room

Gestation 25-28 Weeks

Main Steps

A
  1. Clear airway and then initaite CPAP at +5
  2. If the baby is not spontaneously breathing or has a HR under 100 begin PPV
  3. If there is mild WOB with SpO2 then maintain CPAP level and move to NICU
    1. If there is more severe WOB or SpO2 is not in range than increase CPAP by 1 and increase FiO2 by 0.10-0.20 to achieve SpO2
  4. If the above did not help consider intubation
43
Q

ETT Size

A

<1 000g = 2.5 ETT

1 000-2 000 = 3.0 ETT

> 2 000 = 3.5

44
Q

Suction Catheter Size

A
  1. 5 ETT= 5F or 6F
  2. 0 ETT = 6F or 8F
  3. 5 ETT = 8F
45
Q

NRP Indications for PPV

A

Apnea

Gasping

HR less than 100

Oxygen saturadtion below target range

46
Q

Delivery Room Stabilization: European Consensus Guidelines 2016

A
  • Delay clamping of cord is possible for 60 seconds in order to promote placenta to fetal transfision
    • Cord milk is an alternative if not possible
  • Oxygen for resusucitation should be controlled via a blender
    • An initial concentration of 30% oxygen is appriopraite of babies <28 GA
  • In spontaneous breathing babies stabilize babies with CPAP at 6 cmH2O via mask or nasal prongs
  • Babies who require intubation for stabilization should be given surfactant
  • Plastic bags or occlusive wrapping under radient warmer should be used during stabilization in babies <28 weeks
47
Q

Oxygen Supplementation: European Consensus Guidelines 2016

A

Preterm babies recieiving O2 that saturation target should be between 90-94%

To achieve this suggested alarm should be 89-95

48
Q

CPAP: European Consensus Guidelines 2016

A

CPAP should be started from birth in all babies at the risk of RDS such as those <30 GA who do not need intubation

The system delivering CPAP does not matter but the interface does and should be a mask or binasal prongs with a starting pressure of 6-8 cmH2O then individualized

CPAP with early rescue surfactant should be considered the optimal management for babies with RDS

Synchromized NIPPV if felivered through a ventilator rather than a bilevel CPAP device, can reduce extubation failure but may not confer long term advanatges such as reduction in BPD

HR may be used as a alternative to CPAP for some babies during weaning

49
Q

Mechanical Ventilation: European Consensus Guidelines 2016

A

After stabilization MV should be used in babies with RDS when other methods of respirtory support have failed. Duration of MV should be minimized

Targetd tidal volume should be employed as this shortens the duration of ventilation and reduced BPD and intraventricular heamorrhage

Avoid hypocarbiaas well as severe hypercarbia as these are associated with an increase in brain injury

50
Q

Mechanical Ventilation: European Consensus Guidelines 2016

Weaning

A

When weaning from MV it is reasonable to tolerate a modest degree of hypercarbia provivded the pH remains about 7.22

Ceffeine should be used to faciliate weaning from MV. Early caffine should be considered for all babies at high risk of needed MV, such as those <1250 g birth weight who are managed on non-invasive respirtory support

A short tapering course of low dose dexamethasone should be considered to facilitate extubation in babies who remain on MV after 1-2 weeks

Inhaled steriods cannot be recommenede for routine use to reduce BPD until further safety datat become avaliable

Intreventions 2 (19 decks)

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