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final 140! Flashcards

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1
Q

static compliance formula

A

Cst= Vt/ Pplat- PEEP

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2
Q

dynamic compliance formula

A

CDYN= Vt/ PIP – PEEP

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3
Q

airway resistance formula

A

*Raw= PIP-Pplat / FLOW (in LPS /60)
*Normal intubated value- 5 to 7cmH2o

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4
Q

Recall the causes of increased airway resistance

A

*Gas flow rate
*Diameter of airway
*Gas density and viscosity
*Length of tube

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5
Q

Review short and long-time constants and recall appropriate ventilator parameters
for each

A

TC= Cl X Raw
*Short time constants- decreases with decreased compliance. Happens with restrictive lung disorders, lungs will fill and empty rapidly.
*Long time constant- increases due to an increase in Raw and/or increase in lung compliance, obstructive lung diseases, lungs will fill and empty slowly.

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6
Q

Recall what PIP is and what affects it

A

*PIP- is the highest recorded pressure at the end of inspiration.
*Compliance effects PIP- decreased compliance increases PIP, increased compliance decreased PIP
*Resistance affects PIP- increased Resistance increases PIP, while decreased Resistance will decrease PIP

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7
Q

using phase variable describe PSV

A

PSV:
*Trigger- Patient triggered
*Limit- Pressure-limited
*Cycle- Flow cycle (breath stops when insp flow drops to a set percentage usually 25% of peak insp flow)
*Baseline variable- PEEP
Ventilator delivers preset pressure during insp once it senses pt effort. Pt determines rate, insp flow, and insp time. Tidal volume is determined by the pressure gradient (set pressure- PEEP) lung characteristics, and pt effort.

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8
Q

recall plat and what effects it

A

*Pplat- pressure measured during an inspiratory pause at the end of inspiration. Reflects the elastic recoil of the lungs and chest wall with Raw removed
*Compliance effects Pplat- Pplat will increase with decreased lung compliance, it will decrease with increased lung compliance.
*Resistance effects Pplat- increased resistance will not change Pplat

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9
Q

using phase variable describe VCV

A

VCV:
*Trigger- pt or time triggered (mandatory or assisted)
*Limit- Volume-limited
*Cycle- volume-cycled (insp stops when preset Vt has been delivered)
*Baseline variable- PEEP

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10
Q

Recall how to identify a breath (spontaneous, mandatory and assisted), based on phase variables

A

*Mandatory: breath started by either the vent or the pt, but is controlled and terminated by the vent
*Spontaneous: breath is started, controlled, and terminated by the pt
*Flow-cycled = Spontaneous breath
(Think: flow goes down → patient decides when to end breath → spontaneous.)
*Time-cycled = Mandatory breath
(Think: vent ends the breath on a timer → mandatory.)
*Volume-cycled = Mandatory breath
(Think: vent delivers the full set volume → mandatory.)
*Pressure-cycled = Mandatory breath
(Think: vent stops when pressure hits the set limit → mandatory.)

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11
Q

Recall and define the phase variables (trigger, limit, cycle, and expiration)

A

1.Trigger: variable that starts inspiratory. Can either be the vent (I time) or patient- RR will be set on the vent, but the vent will also sense patient effort needing to take an inspiratory breath. Pt effort may be sensed from flow, pressure, volume (uncommon) it is important to have trigger settings set accurately so the pt is comfortable and not having to work harder.
2.Limit- a variable that will not be exceeded during inspiration
3.Cycle- variable that ends the inspiratory phase, beginning of exhalation.
*Pressure cycle- insp ends when preset pressure is reached at the upper airway
*Time cycle- insp phase ends when predetermined time has passed (I- time)
*Flow cycle- insp phase ends when flow has decreased to predetermined set value during inspiration (at least 4 lpm flow was used and drew back)
*Volume cycle- insp phase ends when set volume is delivered
4.Expiration- known as baseline, once insp phase ends- enters exhalation phase, exp valve on vent opens for expiratory flow to begin. (insufficient time to exhale leads to air trapping or auto PEEP)

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12
Q

Identify patient trigger on waveforms

A

-Pt trigger: will dip under the base line pressure prior to inspiration (due to small negative pressure or a change in flow)
-vent trigger: will not dip but will be a flat baseline prior to inhalation.

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13
Q

Troubleshooting triggers

A
  • if sensitivity is too low, the vent may not sense patient effort
  • if sensitivity is too high, it may cause the vent to auto trigger
  • leak in circuit
  • trigger may be set to the inappropriate mode (flow vs pressure)
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14
Q

advantages of VCV

A

VCV advantages:
*Guaranteed tidal volume delivery each breath despite changes in lung conditions
*Allows for better control of maintaining a certain PaCO2 level

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15
Q

disadvantages of VCV

A

VCV disadvantages:
*Increasing pip and plateau pressures with worsening lung conditions
*Patient-ventilator dyssynchrony due to:
*Fixed flow delivery may not match patient demand
*Inappropriately set sensitivity levels
*Results in increased WOB

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16
Q

advantages of PCV

A

PCV advantages:
*Limits pressure and helps prevent lung overdistention
*Flow delivery variable; based on pt effort (decreased WOB)

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17
Q

disadvantages of PCV

A

PCV disadvantages:
*Clinician does not get to directly control Vt
*As lung conditions worsen, Vt and Ve decrease

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18
Q

Recall factors affecting pressure during volume ventilation; factors affecting volume during pressure ventilation.

A

Volume-controlled ventilation (VCV): pressure depends on
*Lung compliance
*Airway resistance
*Tidal volume
*Inspiratory flow
Pressure-controlled ventilation (PCV): volume depends on
*Lung compliance
*Airway resistance
*Set inspiratory pressure
*Inspiratory time

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19
Q

Recall contraindications for NIPPV

A

1.Cardiac arrest
2.Respiratory arrest
3.Inability to protect the airway
4.Active vomiting or high risk for aspiration
5.Fixed upper airway obstruction
6.Facial trauma
7. uncooperative pts
8. pts who are unable to clear secretions

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20
Q

recall how patient lung characteristics affect PC and VC breath types
Changes in compliance and resistance in PCV

A

1.When lung compliance decreases, volume will decrease, and pressure remains constant
2.When airway resistance increases, volumes will decrease, and pressure remains constant
3.Increased airway resistance = decreased peak expiratory flows due to obstruction
4.Decreased lung compliance = increased peak expiratory flow due to stiff lungs emptying rapidly

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21
Q

Effect of PEEPI in PCV

A

In PCV, the inspiratory pressure is fixed, so intrinsic PEEP reduces the pressure gradient available to inflate the lungs, which decreases the delivered tidal volume instead of increasing pressures like it does in VC.

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22
Q

HME indications and contraindications

A

Indications:
1.Mechanical ventilation
2.Typically, short term
3.Normal secretions and normal body temperature
Contraindications:
1.Presence of thick copious or bloody secretions
2.Presence of a large leak around an endotracheal tube (TEF, or leaking cuff)
3.Body temperature <32C
4.Ve > 10 L/min

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23
Q

Humidity level delivered via humidifier

A

-Should provide at least 30 mg H2O/L of absolute humidity at a temperature range of 33-37 degrees Celsius.

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24
Q

Know initial settings for normal lungs

A
  • VT 6-8 ml/kg IBW
  • RR 10-20
  • Ve 5-15
  • PEEP 5-8
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25
increasing Vt in PC
-Pressure gradient: increasing PEEP (PEEPe and PEEPi) while PC remains constant causes a decreased pressure gradient and a decreased VT -Inspiratory time (Ti): increased inspiratory time increases Vt (only if inspiration ends before zero flow) -Inspiratory pressure: primary mechanism for determining your tidal volume
26
Increasing Vt in PSV
Tidal volume is determined by the pressure gradient (set pressure – PEEP), lung characteristics, & patient effort To increase tidal volume= increase pressure support
27
Effect of auto-peep and COPD pts. ability to trigger vent
-If auto-PEEP is present, patient will have a harder time triggering the vent because it doesn’t sense the effort this results in asynchrony and increased WOB. -Expiratory hold is how to determine auto-PEEP -Increased PEEP without being resolved can cause lung damage
28
waveforms for PC and VC
-Volume Control: Characterized by a square/constant waveform accompanied by a slow rising pressure waveform (can also use decelerating flow pattern) -Pressure Control: Always has a decelerating flow pattern (if paired with a square pressure waveform, it confirms pressure control)
29
difference between constant and decelerating waveform
Constant waveform: -With a constant flow pattern, the pressure-time waveform better reflects lung mechanics (under recruited vs overdistended) -Can result in higher peak airway pressures Decelerating (ramp): -Associated with lower peak airway pressures -Associated with better gas distribution which leads to a higher mean airway pressure -Increased mean airway pressure = increases oxygenation (may impede venous return and cardiac output)
30
calculation for Ti
Ti: Vt/ flow (LPS) /60
31
calculation for flow
Flow (LPM): Vt/Ti
32
calculation for desired frequency
desired frequency (RR): current F X current PaCO2/ desired PaCO2
33
IBW calculation
IBW & Vt: IBW men= 106 + 6 (height in inches- 60) / by 2.2 for kg IBW women= 105 + 5 (height in inches – 60) / 2.2for kg Multiply 6-8 for VT
34
calculation for F
F=Ve/Vt
35
Assessment of flow waveform, how to fix auto peep
1.Increase flow: decreased I-time allowing more time for expiration(E-time) 2.Decrease Vt: will shorten I-time, increased E-time 3.Decrease RR: increases total cycle time, thus increasing E-time (will decrease Ve) 4.Increase PEEP: helps keep distal airways open, facilitating better exhalation 5.Administer bronchodilators: opens airways for improved airflow during exhalation
36
scoop in the loop and what causes It
Scoop in the loop, shows a distinctive inward scoop during exhalation caused by: -Airway obstruction (could be due to bronchospasm, excessive secretions, foreign body, or tumors) -Conditions like emphysema (obstructive lung disease)
37
what is overdistention of the P-V loop caused by
“beaking”- appears as a sharp upward curve or “beak” shape at the top-right of the loop (more pressure, with little change in volume caused by lung overdistension)
38
GCS levels
<8= intubate
39
setting appropriate PEEP
Lower inflection point (LIP): marks the onset of significant alveolar recruitment during inflation Upper inflection point (UIP): indicates the beginning of alveolar over distention Use the PV curve, identify the LIP and setting PEEP 2 cmh2o above the LIP Other approach to setting PEEP is the PEEP that yields the best compliance without cardiac compromise other approach: Middle is ideal best compliance with a good range of MAP 70-100 for proper oxygenation: Lower PEEP/higher FiO2 is better for recruitable lung, avoids alveolar overdistention -Higher PEEP/ lower FiO2 better for refractory hypoxemia or shunting to gain recruited alveoli
40
pharmacology drugs and classes
Sedatives- Benzodiazepines: - Diazepam (valium) - Midazolan (Versed) - Lorazepam (Ativan) Alpha 2-adrenergic agonist: - Dexmedetomidine (precedex) Neuroleptics: - Haloperidol (Haldol) Anesthetic agents: - Propofol (Diprivan) Analgesics- Opioids: - Morphine sulfate - Fentanyl - Hydromorphone (Dilaudid) - Oxycodone - Hydrocodone - Codeine Paralytics- Depolarizing agents: - Succinylcholine (Anectine) Non-depolarizing agents: - Pancuronium (Pavulon) - Vecuronium - Cisatracurium (Nimbex) - Rocuronium
41
reversal agents
-reversal agent for benzodiazepines such as diazepam (valium), Midazolam (versed), Lorazepam (Ativan) is Romazicon (flumazenil) comes with negative side effects like an increased risk in seizures -Reversal agent for Opioids such as morphine sulfate, fentanyl, hydromorphone (dilaudid) is Naloxone (Narcan) Less adverse side effects -Reversal agents for non-depolarizing agents such as pancuronium (pavulon), Vecuronium, Cisatracurium (Nimbex), and Rocuronium is Tensilon, neostigmine
42
criteria for ARDS
Criteria: -Timing: within one week of a known clinical insult or new/worsening respiratory symptoms -CXR: bilateral opacities (not fully explained by effusions/lung collapse) -Origin of edema: ARF not fully explained by cardiac failure/fluid overload -One of the most complex respiratory disorders to treat mortality rates between 30-70%
43
classification of ARDS
Classification of ARDS: -Mild: P/F 200-300 w PEEP >5 cmh2o -Moderate: P/F 100-200 mmHg w PEEP >5 cmh2o -Severe: P/F <100 mmHg w PEEP >5 cmh2o
44
proning for ARDS
Proning: -Prone when severe hypoxemia is present -Increased oxygenation with prone positioning -Blood is redistributed to areas that are better ventilated -Improved alveolar recruitment -Improved V/Q -Changes heart position -Pleural pressure more uniformly distributed -Heart isn’t pushing on the lungs with expansion, increase 10 mmHg for PaO2
45
what does PVR determine and calculation
The resistance that the right ventricle must overcome to eject volume of blood. (Right ventricle afterload) Normal values: 1.38-3.13 mmHg/LPM Calculated by (MPAP-PCWP)/ QT(CO)
46
complications of PAC
Used primarily to measure pressures within the heart and the pulmonary artery, pivotal for critical patient assessments. Inserted through a central vein (jugular or subclavian) and advanced to pulmonary artery. Used in the management of heart failure and shock. Complications: -Cardiac arrythmias -Infections -Pneumothorax -Air embolism -Pulmonary artery rupture -Pulmonary infarction
47
What PCWP reflects and normal values
-Measurement of pressure in the left side of the heart -Balloon at tip of catheter is inflated to obtain measurement (wedges into branch of pulmonary artery) -Normal value: 5-10 mmHg ->18 mmHg = cardiogenic pulmonary edema
48
SVR calculation and normal values
SVR: (MAP-CVP)/ QT(CO) Normal values 11-17 mmHg/LPM
49
Parameters indicating weaning readiness
-f: < 35 breaths/min -f/VT (RSBI): < 105 breaths/min/L -Ventilatory pattern: synchronous and stable -pH ≥ 7.25 -MIP: ≥ - 20 to -30 cm H2O -VC: > 15 ml/kg -VE: < 10-15 L/min -VT: > 4-6 ml/kg -PaO2 ≥ 60 mmHg (FI02 < .40) -PEEP ≤ 5-8 cmH20 -PaO2 / FIO2 > 150-200 -PaO2 / PAO2 ≥ 0.47 -QS/QT < 20-30% -**P0.1: > -6 cmH20 the negative airway pressure generated by the patient during the first 0.1 sec against an occluded airway. Considered to be an estimate of the neuromuscular drive to breathe which could be a potential surrogate for patient’s inspiratory effort. -**P0.1/MIP: <0.30 -WOB < 0.8 J/L -CDYN > 25 ml/cmH20 -VD/VT < 0.6
50
Weaning with PS
-Begin with spont breathing with PS level sufficient to maintain adequate Ve (5-15cmh2o) and RR of 15-25 bpm -Gradually decrease the PSV as tolerated -Inappropriate PS levels result in: Tachycardia, hypertension, tachypnea, diaphoresis, paradoxical breathing, excessive accessory muscle use Consider extubation at PS of 5 cmh2o, adequate ABG’s and ventilatory rate pattern
51
what is Airway occlusion pressure
Measurement of drive to breathe: Airway Occlusion Pressure (P0.1 or P100) -The negative airway pressure generated by the patient during the first 0.1 sec against an occluded airway. -Considered to be an estimate of the neural drive to breathe -P0.1: > -6 cmH20 (more positive) -Strength of the signal from the brain to the diaphragm and their drive to breathe associated with it, how well is the brain telling you to breathe?
52
chest tube trouble shooting
Chest tube trouble shooting -If there is continuous bubbling present in the chamber a leak is present either at the patient or in the drainage system -To isolate the cause of air leak briefly camply tube at the pt: -If leak stops, it’s in the pt -If leak continues it in the system -If no bubbling is present in water seal chamber, obtain CXR to assess resolution of pneumothorax -Always keep chest tube drainage system below the patient’s chest
53
effect of tension pneumothorax and treatment
1Needle decompression, done on collapsed side and done mid clavicular line, in 2nd intercostal space 2Lung collapses, causes alveoli to compress and atelectasis forms 3Tracheal shift away from affected side 4Typically caused by trauma or ball valve like obstruction causes increased pleural pressure, mediastinal and unaffected lung compression
54
Types of pleural effusions
-If fluid is infectious empyema -Transudate: caused by chronic disease states with low protein count <3.0 g/dl such as CHF(most common), cirrhosis, and kidney disease -Exudate: caused by high protein count >3.0 g/dl such as infection, malignancy, or tumors
55
Complications of bronchoscopy
1.Hypoxemia 2.Laryngospasm/ bronchospasm 3.Arrhythmias 4.Pneumothorax 5.Respiratory depression 6.hemorrhage
56
Diagnosis of VAP
1.Fever >38.5C 2.Elevated WBC >11,000 3.Purulent secretions 4.New infiltrates on CXR 5.Gram-neg Pseudomonas aeruginosa 6.gram-pos Methicillin resistant staphylococcus aureus
57
Normal compensatory mechanisms to maintain BP:
-Decreased SV increased HR and increases SVR (constriction) -Systemic vasoconstriction shunts blood flow to priority organs (brain, heart, and lungs)
58
Biotrauma vs barotrauma
Barotrauma: trauma associated with high pressures, occurs when PPV causes alveolar rupture (physical injury) Biotrauma: the release of inflammatory mediators from over-distended lungs (biological injury)
59
Recall effects of in-line SVN
-When using vibrating mesh nebulizers there are no significant changes with inline SVN. (external gas flow) -With SVN in line with a flow meter, it increases pressures and volumes due to the increase in flow from the neb that is constant in the circuit the vent senses it as an increase in volume. -It may also trigger apnea alarms because the set sensitivity is expecting a period of flow absence in the circuit but the flow from the neb keeps a constant flow in the circuit.
60
Setting changes/lung changes and what they affect in PC & VC
Volume control: Decreased compliance= increased pressure Increased compliance= decreased pressure Increase in resistance= increased peak pressure (plat unchanged) Decrease in resistance= decrease in peak pressures Pressure control: Decreased compliance= decreased Vt Increased compliance= increased Vt Increase in resistance= decreased Vt Decrease in resistance= increased Vt
61
proper alarm settings
High F: 10-15 > total RR Apnea: 20 seconds High pressure: 10cmH2O above PIP Low pressure: 5-10 cmH2o below PIP Low exhaled minute ventilation: 10% to 15% below average of minute ventilation Low PEEP/CPAP: 2-4 cmH2O below set PEEP Low exhaled Vt: 10% below set Vt
62
description of VC
VCV: volume provided is constant and pressure will vary depending on changes in lung characteristics
63
description of PC
PCV: pressure provided is constant and volume will vary depending on changes in lung conditions
64
description of Full vent support
Full ventilatory support (FVS): assist control, ventilator provides all the energy necessary to maintain effective alveolar ventilation
65
description of PVS
PVS: the patient and ventilator share the work necessary to maintain adequate alveolar ventilation (SIMV, PSV)
66
description of SIMV
SIMV: synchronized intermittent mandatory ventilation, mandatory breaths are synchronized with the patient spontaneous breaths, spont breaths may be pressure supported (increased WOB and dyssynchrony with SIMV)
67
spont modes
CPAP or spont breathing
68
description of PSV
PSV: vent delivers a preset pressure during inspiration once it senses patient effort, pt determines rate flow, and Ti.
69
description of dual control modes PRVC
pressure regulated volume control (PRVC) Pressure Ventilation with Breath-by Breath Volume Target * Breath-by breath volume target with patient or time-triggered, pressure limited, time-cycled breaths * Adjusts pressure progressively over several breaths to achieve set VT
70
Monitoring of artificial airway and positional
With neck flexion (chin toward chest), the tube moves down toward the lungs. With neck extension (head tilted back), the tube moves up toward the mouth.
71
VCV variables with a paralyzed apneic pt
time triggered flow limited time cycles
72
for lungs with a long time constant disease, the time constant is increased due to what
increase in compliance and/or RAW
73
for lungs with a short time constant disease, there is a decrease due to what
decrease in compliance and increase in elastance
74
with the hyperextension of the neck, the tip of the endotracheal tube will move in which direction
up and away from the carina
respiratory therapy
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