Ventilator-Dependent Patient - 28

Question 1

Proper position of ET tube

Answer 1

3-5cm above carina or midway b/w vocal cords and carina (T4-5 interspace)

Question 2

What happens with selective ventilation of one lung?

Answer 2

Atelectasis of non-ventilated lung

Question 3

How to reduce ET tube migration

Answer 3

1. Don’t allow tube to advance further than 21cm from the teeth in women, 23cm in men
2. Periodic CXR for position

Question 4

Role of subglottic drainage tubes

Answer 4

1. Drains secretions just above cuff –> red vent-assoc PNA

Question 5

Tracheostomy indications & timing

Answer 5

1. > 2wks mechanical ventilation

1. After 2 weeks of intubation as early intubation has not shown to dec PNA rate or mortality

Question 6

Techniques for Tracheostomy

Answer 6

1. Percutaneous dilational - bedside, less blood loss, fewer infections
2. Cricothyroidotomy - emergency only, high incidence of laryngeal injury and subglottic stenosis

Question 7

What do you do if a pt’s trach become decannulated w/in a few days of insertion?

Answer 7

Reintubated b4 reinserting tracheostomy tube –> can create a false tract if inserted blindly b4 stoma tract matures

Question 8

Max pressure of balloon in cuff of trach tube

Answer 8

<25mmHg

Cuff leaks are usually d/t nonuniform contact b/w cuff and trachea

Question 9

What to do when you suspect a cuff leak

Answer 9

1. remove from vent –> bag
2. check ET tube position - deflate and advance or replace tube

DO NOT add air to cuff blindly - tube could be coming out and vocal cords could be damaged

3. If trach tub - add air to cuff <25mmHg
4. Replace w/ large diameter tube

Question 10

When to suction ET tubes

Answer 10

ONLY when sections are present

NOT routine - introduces biofilms into lungs

Question 11

Why do you NOT do saline instillation

Answer 11

1. Saline won’t liquify or reduce viscosity of secretions

2. CAN dislodge biofilms from ET tube lining

Question 12

How does NAC work as a mucolytic?

Answer 12

Sulfhydryl tripeptide disrupts disulfide bridges b/w mucoprotein strands in sputum

Aerosol: 2.5ml w/ 2.5ml saline - NOT in asthmatics

Tracheal injection: 2ml w/ 2ml saline - can produce bronchorrhea if used daily (hypertonic solution)

Bronchoscopy + NAC as last resort

Question 13

Most valuable sign for pneumothorax in vent pts

Answer 13

Subcutaneous emphysema - NOT breath sounds

Basilar & subpulmonic air in supine position

Question 14

Describe the method of pleural air evacuation

Answer 14

1. Chest tube 4-5th ICS mid-axillary in ant/sup direction
2. Collection bottle - collects fluid and allows air in
3. Water seal bottle - 1 way valve allows air escape & create bubbles. Inlet tube underwater –> back pressure on pleural space prevents atmospheric air from entering
4. Suction-control bottle - negative pressure determined by height of water (20-30cmH2O)

Question 15

How do you reduce auto-PEEP?

Answer 15

Reduce Tv
Inc inspatory flow rate
Red inspiratory time
Red resp rate
Applied PEEP = auto-PEEP (eliminates end-expiratory flow)