Week 10 Flashcards
Name some reasons for admission to the ICU.
failure of one or more organs
need for one on one nursing
post major surgery or major risk factors
postoperative respiratory failure
medical respiratory failure i.e. pneumonia
weakness of respiratory muscles i.e. GBS
major injuries i.e. multi-trauma, chest, trauma, spinal injury, head injury
How is blood pressure monitored in the ICU patient?
usually via an arterial line (invasive) to get a constant read on mean arterial pressure (MAP), aiming for >60mmHg), rather than with a cuff every 1 hour or so
allows detection of BP changes in real-time
What is a central venous line for? Where is it typically inserted?
monitoring central venous pressure (CVP, aiming for 5-15 where a loss of pressure could indicate dehydration and a rise being vessels overloaded/stiff lungs) and delivering multiple drugs at the same time
typically inserted into a large vein at the neck or chest i.e. jugular, subclavian, or even femoral in the leg, these do not ‘tissue’ (where fluid enters the surrounding area and the IV fails) like IV lines in the hand or elbow can
Why is a CXR performed each time a central venous line is inserted?
to check that the lungs have not been punctured
What needs to be done if a patient’s pupils are unequal in size or non-responsive to light?
refer to medical staff for CT ASAP as possible brain lesion
What is the purpose of insulin therapy in ICU patients?
used in both diabetic and non-diabetic patients to control blood sugar levels
research shows reduces morbidity in long-stay ICU patients and reduces time spent in ICU
What are inotropes used for in ICU patients? What are the implications for physiotherapy?
to increase cardiac output, blood pressure, and heart rate
physio implications, do not mobilise the patient (unstable BP)
How do modern-day ventilation machines use positive pressure to ventilate patients?
air is applied under positive pressure via an airway which forces gas flow into the lungs
differs to our natural negative pressure mechanism where we draw air into our lungs using the pressure gradient created between the lungs and the atmosphere
How can positive pressure ventilation affect venous return?
it decreases venous return because the intra-thoracic pressure remains positive throughout inspiration and expiration, compressing the vena cava which increases resistance to blood flow
What does PEEP stand for?
positive end-expiratory pressure
What does PS stand for
pressure support
What is the difference between PEEP and PS?
PEEP prevents the patient from moving into their closing capacity by splinting the airways open
PS provides pressure support to the patient’s inhalation/exhalation during spontaneously triggered breaths
What are some precautions to using PEEP?
patients with low BP/cardiac output or high intracranial pressure (as PEEP reduces venous return and increases ICP)
What is the implication for treating a patient with a high PEEP setting i.e. >10cmH20?
generally do not disconnect from ventilator for treatment as they need high levels of PEEP to maintain airways and anything we do in treatment will not outway that need
What is peak airway pressure? What is a normal reading or peak airway pressure?
the total pressure needed to overcome the:
-inspiratory flow resistance
-elastic recoil of the lung and chest wall
-the alveolar pressure present at the beginning of the breath (PEEP)
normal peak airway pressure 22-24
What are the different modes of ventilation?
synchronised intermittent mandatory ventilation (SIMV)
pressure controlled ventilation (PCV)
pressure support ventilation (PSV)
What is synchronised intermittent mandatory ventilation (SIMV) useful for?
both supporting and weaning intubated patients
it provides a set RR & inspiratory volume, but can use mandatory, assisted or spontaneous breaths
Describe pressure controlled ventilation.
a short term ventilation type used in heavily sedated/paralysed patients
uses a set inspiratory pressure as the patient who needs this type of ventilation requires a set pressure (i.e. due to lung injury, obstruction, risk of barotrauma etc)
implications for physio: avoid MHI or VHI if at risk of barotarauma, avoid percs/vibes if related to bronchospasm
Describe pressure support ventilation (PSV).
patient triggered (spontaneous breath) ventilation with PS and PEEP
What are some complications of mechanical ventilation?
barotrauma caused by excessive pressure
oxygen toxicity from FiO2 of >0.6 for >72 hours
hypotension from increased intrathoracic pressure
airway/vocal cord damage from intubation
muscle de-conditioning
inability to wean (restart spontaneous breathing)
malnutrition due to inability to eat
venous thrombosis due to immobility
psychological i.e. depression, anxiety, PTSD
What physio techniques can be used in the ICU setting to increase lung volume?
manual hyperinflation/ventilator hyperinflation
inspiratory holds/deep breathing exercises
demand ventilation via mobilisation (gait/active/passive movements)
position for optimal ventilation (i.e. affected lung up)
Compare laerdel/air viva and mapleson C manual hyperinflation circuits.
mapleson C can do holds and simulate a cough through a fast expiratory phase leading to greater secretion clearance, however can cause barotrauma due to incorrect technique/too high pressures being delivered. Also harder for novices. Add attachment for PEEP valve.
air viva reduces risk of barotrauma due to valve that automatically opens under excessive pressure, is easy to use with one hand and appropriate for novice clinicians. Cannot however do inspiratory holds or fast expiration.
Can add a PEEP attachment for either.
What are some benefits of using ventilator hyperinflation?
able to continuously monitor peak airway pressure and tidal volumes
allows for specific control of parameters
may be a safer recruitment option for patients at risk of barotrauma
no need for circuit disconnection
one person technique
may be better tolerated than MHI by awake or agitated patients
What are some disadvantages of ventilator hyperinflation?
requires careful patient monitoring and observation
if patient stars to cough, risk of high pressure and need to quickly return all parameters to normal prior to suctioning
difficult to make adjustments in parameters from breath to breath
How does the evidence compare VHI & MHI?
similar secretion clearance, hemodynamics and oxygenation between techniques
VHI has greater improvements in respiratory mechanics with less metabolic disturbance
MHI has greater peak expiratory flow rates
What physio techniques can be used in the ICU setting for airway clearance?
postural drainage
MHI, VHI, deep breathing
perc/vibes
humidification
stimulated cough/suction
What are some physio implications for sepsis in the ICU?
patient may have cardiovascular instability, avoid MHI for the first 3 days
caution with hyperinflation techniques due to the risk or presence of acute respiratory distress syndrome
may bleed & bruise easily due to haematological factors
muscle mass is lost quickly so need for early passive movements
