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RSPT 2314 Unit1 EXAM
Modes of Ventilation/Intubation/Extubation/Weaning/ETT/Artificial Airways
| Question | Answer |
|---|---|
| Indications for Intubation impending or actual: | -Airway compromise -Respiratory failure -Need to protect the airway |
| Indications for Mechanical Ventilation | -Apnea -Acute ventilatory failure -Impending ventilatory failure -Severe oxygenation problems |
| Readiness to breathe "weaning parameters" | |
| Criteria for weaning trial | |
| What is the phases of ventilation and phase variable? | -Initiation of inspiration - trigger variable -Inspiration - limit variable -End of inspiration - cycle variable -Expiration - baseline variable |
| Modes of Ventilation | -Assist Control (AC/CMV) -Controlled Ventilation -Intermittent Mandatory Ventilation (IMV) -Synchronized Intermittent Mandatory Ventilation (SIMV) -Pressure Support (PS) -Continuous Positive Airway Pressure (CPAP) |
| Trigger variable | initiates inspiration (causes a breath to begin) |
| Limit variable | limits a parameter during inspiration |
| Cycle variable | ends inspiration or starts expiration |
| baseline variable | describes what happens during expiration. |
| A trigger variable can be | patient initiated or ventilator initiated |
| Trigger variable that are Patient initiated | -pressure -flow -volume |
| Trigger variable that are ventilator initiated | Time (when it's a mandatory breath) |
| Pressure triggering | Patient initiates breath when inspiratory effort causes the pressure in the circuit to drop. (Usually set at 0.5 - 2.0 cmH2O) |
| Flow triggering | Patient initiates breath when flow at exhalation valve falls below flow coming out of vent (Usually set at 1-3 lpm) Generally decreases WOB as compared to pressure triggering |
| Time triggering | Occurs when ventilator delivers breath at preset time interval |
| Limit variable | pre-set variable that can be reached but not exceeded during inspiration but does not end inspiration. |
| Volume and flow | are limited variables in volume control |
| Pressure | is the limited variables in pressure control |
| IPPB | is pressure cycled because a preset pressure is met and ends inspiration |
| Volume control (AC, CMV) | is volume cycled because inspiration ends when a preset volume is met |
| Pressure support | is flow cycled because when a preset inspiratory flow level is reached inspiration ends |
| Time cycling | occurs when inspiration ends at a preset time |
| Patient cycling | occurs if the patient can change the inspiratory time by making breathing efforts |
| Machine cycling | occurs if the machine ends inspiration or sets the IT |
| Baseline variables are | Positive End Expiratory Pressure (PEEP) Negative End Expiratory Pressure (NEEP) Zero End Expiratory Pressure (ZEEP) |
| PEEP | positive end expiratory pressure is the pressure above atmospheric, it keeps the alveoli open Most commonly used to prevent airway collapse and atelectasis |
| NEEP | negative end expiratory pressure Sub-atmospheric Can cause collapsed airways and atelectasis |
| ZEEP | zero end expiratory pressure is the end pressure is atmospheric Exhalation valve opens to atmospheric pressure during exhalation |
| Control ventilation | mode of ventilation in which the frequency of breathing is determined by the ventilator according to a preset cycling pattern without initiation by the patient (time triggered) Should be done with a paralytic or sedative |
| Assist Control / Continuous Mandatory Ventilation (CMV) | the minimum breathing rate is predetermined, but the patient can initiate ventilations at an increased rate Patient can trigger breaths and vent will deliver pre-set tidal volume. No spontaneous breaths – only assisted breaths |
| Assist Control / Continuous Mandatory Ventilation (CMV) 2 | Provides good control of ABG values Can change flow setting to patient comfort Breaths are patient or time (machine) triggered, flow limited, and volume cycled |
| Intermittent Mandatory Ventilation (IMV) | Mandatory breaths are given at a set rate Can provide partial or full support Patient can breathe spontaneously between mandatory breaths but does not synchronize with the patient Spontaneous breaths can be pressure supported |
| Synchronized Intermittent Mandatory Ventilation (SIMV) | Synchronizes patient efforts with mandatory breaths Assisted breaths can occur and are responsive to patient demand |
| Continuous Spontaneous Ventilation/ Continuous Positive Airway Pressure (CPAP) | a method of ventilatory support whereby the patient breathes spontaneously without mechanical assistance against threshold resistance, with pressure above atmospheric maintained at the airway throughout breathing (100% spontaneous) |
| CPAP | All breaths are spontaneous I-time, tidal volume and peak flow are all controlled by the patient Can be used for weaning trials Ex: Patient on CPAP +5 cm H2O for a period of time and ABG examined |
| Pressure Support Ventilation (PSV) | mode of ventilatory support designed to augment (increase) spontaneous breathing Can be used for weaning |
| What are the phase variables for PSV? | Patient triggered Pressure Limited Flow cycled PEEP baseline Pressure support lets the inspiratory part of the breath get down to 30% of the peak flow |
| What Patients commonly need Mechanical Ventilation? | -Acute respiratory failure -COPD exacerbation -Coma -Neuromuscular disease -Post op Respiratory failure -Sepsis -Heart Failure -Pneumonia -Trauma -ARDS -Aspiration |
| Goals of Ventilatory Support | -Maintain adequate alveolar ventilation and Oxygen delivery -Restore/maintain acid-base balance -Reduce work of breathing |
| Other goals/benefits of Ventilatory Support | -Reduce increased myocardial work secondary to hypoxemia or increased WOB -Lung recruitment |
| Clinical Objective of Ventilatory Support is to: | -reverse hypoxemia -reverse acute respiratory acidosis -prevent or reverse atelectasis -Reverse ventilatory muscle dysfunction -Decrease systemic or myocardial oxygen consumption -Maintain or improve cardiac output -Reduce ICP -Stabilize the chest |
| Indications for Intubation assessment of need: | -Airway protection -Airway obstruction -Apnea -Oxygenation (hypoxemia) -Ventilation (hypercarbia) -Respiratory distress |
| Contraindications for Intubation: | -Legally documented DNR |
| Equipment needed for Endotracheal Intubation: | Oxygen flowmeter and tubing Flexible sterile suction catheters BVM Colorimetric CO2 detector Laryngoscope and blade ETT Tongue depressor Stylet Stethoscope Tape or endotracheal tube holder 10 cc syringe Water-soluble lubricating jelly Towels |
| Post Extubation Failure: | -Subglottic edema -increased WOB from secretions -airways obstruction -Postextubation laryngospasm |
| Postextubation glottal edema | -Can result in partial airway obstruction, causing stridor -Commonly treated with a cool aerosol supplemented with oxygen and/or nebulized racemic epinephrine |
| Postextubation laryngospasm | -May occur and usually is transient (come and go). -Persistent laryngospasm may respond to positive pressure delivered with oxygen (e.g., Bag-Mask Device) -If it continues, a neuromuscular blocking agent and reintubation may be necessary. |
| Aspiration | Factors that may increase the risk of aspiration after Extubation Use of muscle relaxants Presence of gastric tube Inability to close the glottis mechanically Excessive amounts of secretions Inability to clear secretions effectively |
| Other factors that may contribute to Extubation failure | -Type of patient (i.e., medical vs surgical) -Older age -Severity of illness at weaning onset -Repeated or traumatic intubations -Use of continuous IV sedation -Duration of mechanical ventilation |
| NIPPV after Extubation | NIPPV after Extubation appears to have the following benefits: -Improves survival -Lowers the mortality rate -Reduces the risk of VAP -Lowers the incidence of septic shock -Shortens the ICU and hospital stays |
| Criteria for NIPPV after failure to wean in extubated patients | Resolution of problems leading to respiratory failure Ability to tolerate SBT for 10-15 mins Strong cough reflex Hemodynamic stability Minimal airway secretions Low FiO2 requirements Functioning GI tract hard to weaning with muscle weakness |
| What ventilator setting affects oxygenation? | PEEP and FiO2 |
| What ventilator settings affect ventilation? | Rate and tidal volume |
| Patient on MV: AC/VC- 16 (bpm)/550 ml (Vt) /+5 mmHg (PEEP)/40% (FiO2) ABG values: 7.50, 30, 80, 97% What setting changes should be made? | Decrease the rate or tidal volume |
| Patient on MV: AC/VC- 12 (bpm)/600 ml (Vt) /+15 mmHg (PEEP)/50% (FiO2) ABG values: 7.39, 42, 160, 99% What setting changes should be made? | Decrease Peep by 2 or 3 because FiO2 is less than 60%. (pick the smaller change or less severe change) |
| Oxygenation Assessed with PaO2 & SpO2 | Target ranges: *SaO2 > 90% *PaO2 > 60 mmHg |
| FIO2 and PEEP settings affect oxygenation | Target ranges: *FIO2 < 40 – 50% *PEEP < 5-8 cmH2O |
| Ventilation Assessed with pH & PaCO2 | Target ranges: Within normal ranges *PaCO2 < 50 mmHg *pH > 7.35 |
| Minute volume (minute ventilation) affects PaCO2 & pH | RR & Tidal volume determine minute volume *Minute volume < 10 L/min (for a normal PaCO2) *Pilbeam says <10-15 L/min |
| Weaning | the gradual reduction of MV support that allows the patient to resume spontaneous breathing in an incremental manner |
| Basic Methods for weaning | SBT- Spontaneous Breathing Trials SIMV- Synchronized Intermitted Mandatory Ventilation PSV- Pressure Support Ventilation |
| Global criteria for discontinuing ventilatory support | Ventilatory workload vs. ventilatory capacity Oxygenation status Cardiovascular function Psychological factors |
| Ventilatory Workload (Demand) | Determined by Level of ventilation needed Compliance of lung or thorax Resistance of gas flow through the airways Any imposed WOB due to mechanical factors |
| Ventilatory Workload: Level of Ventilation Needed | Determined by Metabolic rate (increased CO2 production) CNS drive Ventilatory dead space (increased in COPD & pulmonary emboli) |
| Ventilatory Workload: Compliance | As compliance decreases, ventilatory workload increases Atelectasis Pneumonia ALI/ARDS Pulmonary edema Obesity |
| Ventilatory Workload: Resistance | Increased airway resistance increases ventilatory workload Bronchospasm Secretions Mucosal edema |
Created by:
trobin1
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