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PilbeamCHAPTER 19
Student Study Note Cards
| Question | Answer |
|---|---|
| The 3 basic methods of applying noninvasive ventilation are?(RQ)(TM) | Negative-pressure, abdominal-displacement, and positive-pressure(RQ)(TM) |
| A pt is admitted to the coronary ICU for acute cardiogenic pulmonary edema. The physician wants to use NIV support. What mode of ventilatory support would be most appropriate to use at this time?(ApQ)(TM) | CPAP(ApQ)(TM) |
| A pt has been on a nasal mask NIV for almost 24 hrs and complaining of nasal congestion and dry mouth. What would you recommend to do and why?(AzQ)(TM) | Add a humidifier because it will add humidity to the air and keep their nose and throat moist and not dry(AzQ)(TM) |
| Define noninvasive mechanical ventilation. (RQ) | The delivery of mechanical ventilation to the lungs using techniques that do not require an et tube. (CG) |
| How does NIV assist in weaning from a ventilator? (ApQ) | Supports respiratory muscles to prevent respiratory muscle fatigue. (CG) |
| Given an ABG of 7.28/58/65/26, what treatment would you recommend? (AzQ) | NIV via Bipap. (CG) |
| TRUE OR FALSE: Deacrease in PaCO2 levels is a physiological benefit of NIV? (RQ) | True (AT) |
| Name three things that will happen when a patient's comfort is improved after you have adjusted their NIV. (ApQ) | decreased respiratory rate, decreased use of inspiratory muscles, ventilator synchronizes (AT) |
| A new patient in need of ventilation is admitted to your floor presenting with a restrictive thoracic cage disorder. ABG's have shown PaCO2 levels in the 50's. Would they be a good candidate for NIV? Why? (AzQ) | If they're PaCO2 level is over 45, yes. NIV helps to decrease PaCO2 levels. (AT) |
| What are the 3 goals/benefit for NIV? (AH) | Improve gas exchange, Support respiratory muscles, and Prevent intubation. |
| IPAP improves_________ and EPAP improves _________. (AH) | Ventilation, Oxygenation |
| The BiPap settings are: IPAP- 10cmH2O EPAP- 3chH2O RR- 10bpm FiO2- 30% Which setting should be corrected? (AH) | EPAP- must be at least 4cmH2O to prevent CO2 rebreathing |
| What settings should be changed on the BiPAP machine if you notice an increase in PaCO2 and a decrease in pH? (AH) | Either increase IPAP. If they are not achieving adequate volumes, then increase IPAP (increments of 2-3cmH2O). |
| what is the number 1 indication for CPAP? (KJ) RQ | Obstructive Sleep Apnea (KJ) |
| A pt is admitted to the ER with an exacerbation of COPD, and the ER doc doesn't want to ventilate this specific pt. We would use _____ and why? (ApQ) (KJ) | We wouldn't want to ventilate COPD pts right away if we can use non invasive ventilation first, BiPAP. We will try and reverse the exacerbation and the BiPap will help strengthen the respiratory muscles. (KJ) |
| A 25 year old man was admitted to the ER in mid afternoon, and was a in a ATV accident. He has been found to have a spinal cord injury with a TBI. Would this man be a good canidate for NIV? Why? (azQ)(KJ) | No. This man would not be a canidate because of his brain injury, and isn't able to protect his own airway. We would want to ventilate this man right away, to get ventilation and diffusion going. (KJ) |
| What are the two types of NIV and what does each stand for? (ApQ) (KMH) | CPAP-continuous positive airway pressure--one pressure throughout inspiration and expiration BiPAP-bilevel positive airway pressure--one pressure during inspiration and one during expiration (ApQ) KMH) |
| What are the three modes of NIV? (RQ) (KMH) | Spontaneous, Spontaneous/Timed and Timed (RQ) (KMH) |
| A COPDer has been admitted on your floor and is requiring BiPAP. What would you set his I time at and why? (AzQ) (KMH) | 0.8 seconds- they like a short inspiratory times and long expiratory times (AzQ) (KMH) |
| What is the normal range for high and low pressure alarms? (RQ) | 3-5 cmH2O below IPAP (AB) |
| After receiving ABG results for a pt who is on BiPAP, you see that their pH is decreased and PaCO2 has increased. During your assessment, you note that their volumes are normal. What should you do? (ApQ) | Increase RR to allow your pt to blow off more CO2 which will increase pH. (AB) |
| What should you do after removing a patient from BiPAP and why is it important? (AzQ) | You should always obtain an ABG to determine if the patient is oxygenating and ventilating well. This will help you confirm if it is safe to keep your pt off of BiPAP or if they should be put back on. (AB) |
| What would an ABG look like if the pt needed BiPAP? (AzQ) | 7.29/60/50/26. The pH would be between 7.28-7.35, a CO2 between 45-80 or O2 <60 (KAH) |
| What does IPAP improve? And what does EPAP improve? (RQ) | IPAP improves ventilation and EPAP improves oxygenation (KAH) |
| A pt is in respiratory distress with an ABG of 7.28/69/48/25, what NIV would you use and what initial settings? And what would there pressure support be? (ApQ) | BiPAP S/T IPAP 13cmH2O EPAP 6cmH2O RR 12bpm I-time 1 sec Rise time .2sec FiO2 100% pressure support 7cmH2O (KAH) |
| What are some tips for helping your pt. tolerate NIV? ApQ (AC) | frequent small meals, anti-anxiety meds, give breaks 5-10 minutes every few hours |
| If your patient is on 60% fio2 and there is little to no change in your PaO2, what type of hypoxia is this? RQ (AC) | refractory hypoxia |
| Which settings would you possibly need to change if your pt isnt breathing deep enough (not ventilating). Would you change all these settings or one setting at a time? (AzQ (AC) | IPAP or RR these setting can fix a ventilatory problem. Only change one setting at a time. |
| What is the criteria would you need for PaCO2 to mechanically ventilate a patient (RQ) | >80mmHg (MK) |
| What ventilatory changes would you need to change if you have an increase PaCO2 and decrease pH? (ApQ) | increase IPAP (MK) |
| You have a patient and their SpO2 suddenly drops to 78% and their PaO2 is now 67mmHg. what type of problem is this? And what would you do to fix the problem? (ApQ) | oxygenation problem, Increase FiO2 or increase EPAP (MK) |
| What should be the tidal volume for a patient who is 63kg on a spontaneous/time ventilator? If the patient is not reaching this Vt, what single thing on the vent can you change to improve it? ApQ (BL) | spontaneous/ventilated is 7-10ml/kg (63x7) to (63x10) or 441ml-630ml. Increase the IPAP to take a deeper and breath and in turn improve the Vt. |
| Where is the most common location for pressure sores? RQ (BL) | bridge of the nose |
| The patient is hooked up to BiPAP and it states the patient leak is 1LPM. Is this normal; if not what is normal range? What does this indicate? Is there any further action to take? AzQ | No, the leak should be 5-30Lpm. It means the mask is too tight on the patient and it should be loosened to avoid pressure sores, breakdown, and easier for patient to remove if need be. |
| What does BiPAP stand for? (recall) (MC) | Bilevel Positive Airway Pressure (MC) |
| Where should your low pressure alarm be set for an IPAP or 12 and EPAP of 6? (APP) (MC) | Low pressure alarm should be set in between the IPAP and EPAP so in this case it should be set anywhere from 8-10. (MC) |
| If a Pt has been on BiPAP for 1 hr and your next ABG is as follows 7.32/50/65/27 what settings do you need to change to help normalize ventilation and oxygenation levels? (AzQ) (MC) | Need to increase IPAP to help ventilate the Pt better and increase EPAP or Itime to help oxygenate the pt. Increase FiO2 if that has not been done. (MC) |
| What does NIV stand for (RQ) | Non-Invasive Ventilation (RK) |
| What RR alarm would you have set for a pt breathing 18 and set to 15? (ApQ) | High: 28 Low: 10 (RK) |
| What are the patient interfaces available? (Marianne B.) | Nasal masks, full facemasks, nasal pillows, mouthpieces. (RQ) |
| Why would we not want to use NIV if the patient can't protect their airway? (Marianne B.) | Because if the patient can't protect their airway there is the risk of aspiration. (ApQ) |
| a copd pt assessed at HR 140 bpm, RR 30, spo2 65 on a venture mask of 50%. ABG 7.28/75/55/30. what settings and alarms would you set if Bipap is used. (AzQ) | fio2- 100%, ipap-12. epap-6 rise time- .2% i time .8sec rr10. alarms- highP 26 lowP 10 apnec20 sec, low RR 8 high RR 40 low vt 3LPM. (RK) |
| When does most weaning occur, what do we look at before weaning, and how is a patient weaned? (Marianne B.) | Most weaning occurs within a few hours to a few days. We can look at ABGs, RR, and/or WOB. IPAP can be reduced so the patient has a higher WOB or the device can be removed for gradually longer periods. AzQ |
| True or False, patient controls their RR and VT on CPAP. (RQ) | True (JB) |
| If you have a pt with their SpO2 of 94% and their PaCO2 in there blood gas is 59 and a PaO2 of 85. Do they have a ventilation problem or an oxygenation problem? (azQ) | ventilation (JB) |
| If you have a pt with a oxygentation problem what are two setting on your BiPAP that will help you correct this problem? (apQ) | increase EPAP and FiO2 (JB) |
| Name 3 things that can help a patient with their anxiety from NIV? (JAB) | Anti-anxiety medication, giving them 5-10 minute breaks, letting them know when their next break will be. |
| If a patient's IBW is 75kg and the Bipap shows thier volumes are reaching 450ml, is this sufficient? If not, what needs to be adjusted? (JAB) | For IBW of 75kg the patient should have TV of 525-750ml so 450ml is not enough. You need to increase their IPAP. |
| What will adjusting the bipap mask at the point between the forehead pads and the bridge of the nose do? (JAB) | Take pressure off the bridge of the nose and reduce discomfort and pressure sores. |
| The biggest contraindication of NPPV is what? RQ (JM) | If pt is unable to protect their airway. |
| Given the ABG of 7.22/82/62/22, what type of ventilator would you choose for this pt and why? ApQ (JM) | Invasive ventilator due to pH below 7.28 and PaCO2 above 80 |
| A pt on a NIV with a full mask is complaining of ear pain. What can you do to resolve this? AzQ (JM) | Decrease ventilating pressure. |
| If a patient on Bipap shows increasingly worse PaCO2 as shown by their ABG results, what should you do? (JDB) | Assess the patients volumes, if they are not reaching the ideal 7-10ml/Kg of body weight, then increase IPAP by 2-3cmH20. If they are reaching ideal volumes, then increase RR. (JDB) |
| What problems could be caused by making the patients mask too tight. (JDB) | Sores, the patient may not be able to remove the mask if needed. (JDB) |
| When can a full face mask NOT be used? (JDB) | At home due to the possibility of suffocation. (JDB) |
| Name three key ways to tell if the patient has improved comfort levels with NIV. (RQ)(CZ) | Improvement in patient comfort can be indicated when the patient has a decreased RR, decreased activity of the inspiratory muscles, and their breathing is in-sync with their ventilator. CZ |
| What is the number one indication for CPAP? At what SpO2 does the person have to be under for 5 consecutive minutes while sleeping? (ApQ)(CZ) | The number one indication for CPAP is OSA. They have to have a SpO2 of under 88% for five straight minutes while sleeping during a sleep study. (CZ) |
| A patient is brought into the ER and has a decreased LOC. The attending physician orders BiPAP. The patient becomes combative at their BiPap mask. Their grown child arrives and signs a Do Not Intubate order. What happens next? (AzQ)(CZ) | NIV is a form of life support and if they do not want it any longer it should be removed if that is what they wish. The patient's combativeness is also a contraindication of the NIV. |
| What is I Rise time and what is a good value to have this set at? (KM) | It is the time it take the patient to reach IPAP and a good value is .2 seconds (KM) |
| What are the two weaning techniques? (KM) | Increase break time-this is mostly used here in lincoln. Decrease pressure-slowly decrease IPAP and EPAP until they are at the lowest level. (KM) |
| What are the patient criteria to be a good candidate for BiPAP? (KM) | pH between 7.28-7.35, PaCO2 <80, PaO2/FiO2 100-200, Pt tolerance, RR >24 and disease reversibility. (KM) |
| What does NIV stand for? (RQ) | It stands for Non-Invasive Ventilation(MJB) |
| You have a patient with CHF and has increased SOB at rest, What Pap therapy would be indicated with this information? (ApQ) | CPAP would be great for this patient to give relief by pushing and fluid that may be in the lung back into the vasculature. (MJB) |
| What I-time would you set for a COPD patient that would be beneficial? (ApQ) | A good I-time for a COPD patient would be .8 sec so that they get a quicker breath. (MJB) |
| Name 3 changes that can be made to increase oxygenation. (RQ) | -Increase FiO2 -Increase EPAP -Increase Pressure Support (BH) |
| If a patient with COPD came in with an ABG of 7.29/85/55/28 what type of ventilation would we want to use and why? (ApQ) | BiPAP, because the pH is above 7.28 and the CO2 is acceptable because of the history of COPD. We also want to try to avoid mechanical ventilation because of this history. (BH) |
| You have the following orders for BiPAP settings for your patient: IPAP- 16 cmH2O EPAP- 8 cmH2O I-time- 1 second Rise time- .2 FiO2-100% Vt- 432-618 mL Set the alarms needed for this patient. (AzQ) | High pressure- 26 cmH2O Low pressure- 10 cmH2O Apnea- 20 seconds High RR- 35 bpm Low RR- 8 bpm Low Ve- 3 lpm (BH) |
| What is the number 1 contraindication for NIV? (RQ) ACE | Inabilty to protect airway. |
| What are the different masks used for NIV?(Ap Q) ACE | Nasal mask- for nasal breathers Face mask- for mouth breathers Total face mask- for those with claustrophobia & Nasal Pillows |
| Where should the alarms be set? IPAP: 14 cwp, EPAP: 5 cwp, RR: 12bpw, Itime: 1.0 second, Rise time %: 0.1, FiO2: 40% (Az Q) ACE | Hi P: 24 cwp, Lo P: 9, Apnea: 20-30 seconds, Lo VE: 2-4 Lpm, Hi RR: 35 bpm, Lo RR: 8 bpm |
| How does BIPAP assist an eligible patient during a COPD exacerbation? (NMB) | By supporting fatigued muscles with positive pressure. (RQ) |
| A patient is suffereing from obstructive sleep apnea and their Sats are indicating respiratory distress. What type of NIV should be used for this Pt? How will this particular type of NIV correct the underlying issue? (NMB) | CPAP should be used for this patient. It will correct the pt's distress by splinting open the air way with positive pressure allowing a patent air way. (ApQ) |
| Central sleep apnea requires what kind NIV device? RT RQ | BiPap |
| If there is a leak on a C-Pap machine, what will the machine do? RT ApQ | Increase flow |
| Spirometry checks have been .58, .61, .61. What should you do if the patient has been on BiPap all day? RT AzQ | Increase FiO2 and/or increase Ipap |
| The patient controls what when using a CPAP? (RQ) | RR & Vt (AB) |
| A pt is admitted into the ER in respiratory distress, when looking through their chart you note that they do not have a gag reflux. Is this pt a good candidate for NIV? Why? (AzQ) | No, if the pt does not have a gag reflux then they are unable to adequately protect their airway. (AB) |
| While using NIV your pt develops a problem with gastric distention, what can you do to resolve this situation? (ApQ) | Use the lowest effective pressures for adequate Vt delivery. (AB) |
| Your patient has now been on BiPAP for 10hrs. their vitals prior to BiPAP- RR-24 HR-92 BP-131/86 SPO2-88% Temp- 98* Post Bipap (current) RR-32 HR-123 BP- 128/78 SPO2-89% Temp- 98.3* At this time what adjustments might you make to this pt & why? (NMB) | Terminate NIV & Switch to invasive Mechanical Ventilation. Supporting criteria- RR> 30bpm (pt tachypnea) SpO2<90% (Oxygen Saturation is not reflection adequate oxygenation with NIV. (AzQ) |
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