1
Q
Severe Resp Failure=
A
Low pH, lower than 7.25 and PaCO2 above 55
2
Q
obtunded
A
Sort of out of it
3
Q
combative
A
fighting it
4
Q
diaphoretic
A
sweaty and cold
5
Q
AA gradient when to intubate?
A
3-30
6
Q
Hypoxic Resp Failure:
A
PaO2 < 60 (PEEP, CPAP, EPAP)
7
Q
Hypercapnic (vent. failure):
A
PaCO2 > 50 (consider bipap or intubate)
8
Q
Shunt
A
purfusion with no ventilation, alveoli collapse
-Does not respond to oxygen
9
Q
Deadspace
A
Ventilation without perfusion
-Low SpO2 or PaO2 that responds to O2
10
Q
Obstructed lung diseases
A
COPD, Asthma, Bronchiectasis, bronchitis
-they are not getting oxygen ( 70-80%pts)
11
Q
Restricted lung diseases
A
Small lungs, stiff lungs. can lead to obstructed.
-All other lung disease
12
Q
Pt hypoventilating A/a gradient will
A
come out normal
13
Q
Chronic Resp. Failure
A
Combination of hypoxic and vent. failure
-Increase in PaCO2 lead to kidneys retaining bicarbonate to normalize the pH
=fully compensated resp acidosis
14
Q
Cardiovascular Complication of mech vent
A
Reduced venous return, reduced cardiac output, hypotension
15
Q
Neuromuscular of mech vent
A
Sleep deprivation, Increased intracranial pressure, critical illness weekness
16
Q
Ventilator monitors and adjusts airway pressure needed to deliver target volume
A
PRVC
17
Q
Respiratory failure is divided into two major categories, each of which includes many different diseases and conditions that can lead to respiratory failure.
A
- Type 1 Respiratory failure: Hypoxemic Resp Failure
- Type II Respiratory failure: Hypercapnic Resp Failure
18
Q
Hypoxemic Resp Failure
A
involves inadequate blood oxygenation and low to normal levels of carbon dioxide. (oxygenation failure)
19
Q
Hypercapnic Resp Failure
A
involves inadequate blood oxygenation with high levels of carbon dioxide. This condition is also referred to as ventilatory failure.
20
Q
These four broad conditions are considered the primary indicators for mechanical ventilation:
A
- Apnea
- Acute ventilatory failure
- Impending ventilatory failure
- Severe oxygenation defect
21
Q
Various VAP prevention strategies include:
A
- Elevating the head of the bed
- Frequent oral care
- Careful management of the airway cuff pressure
- Limiting circuit changes to an as-needed basis
- Use of specially designed antimicrobial endotracheal tubes
22
Q
Control Variable
A
which is pressure or volume
- is the designated independent variable between pressure, volume, and flow as they relate to the equation of motion.
- If volume is the designated control variable, the shape of the pressure waveform is dependent on the volume setting and the resistance and compliance of the respiratory system. Volume is constant and pressure varies.
23
Q
Breath Sequence
A
which is a pattern of mandatory or spontaneous breaths
24
Q
targeting scheme
A
Which is the feedback control scheme used to shape the breath and determine the breathing sequence
25
Breath sequence can be subdivided into three categories:
- Continuous mandatory ventilation (CMV), where all breaths are mandatory
- Intermittent mandatory ventilation (IMV), where breaths can be mandatory or spontaneous
- Continuous spontaneous ventilation (CSV), where all breaths are spontaneous
26
Ms. Garcia's illness has improved dramatically over the past few days and her doctor wants to determine how she may breathe if the ventilator is discontinued. Which mode of ventilation is most appropriate for the given situation?
PSV
| -PSV is a purely spontaneous mode that will allow evaluation of the patient's tidal volume and respiratory rate.
27
PRVC
Adaptive Pressure Control; is a dynamic mode of ventilation that allows delivery of a set tidal volume at the lowest possible inspiratory pressure. APC is one of the modes of mechanical ventilation that goes by varying names depending on the manufacturer, but the underlying mechanics remain the same.
-A desired tidal volume is set; the ventilator monitors and adjusts the airway pressure needed to deliver the target volume.
28
APRV
(BiVent) Airway pressure release ventilation; is a time-cycled, pressure-controlled modification of SIMV that allows the patient to breathe spontaneously throughout the set ventilator pressures. APRV allows the clinician to set two levels of pressure and the time in which the ventilator provides the two pressures.
- PHigh/ low
- Thigh/low
29
The high pressure, Phigh, influences
the degree of lung inflation and the time spent at this pressure is Thigh.
30
The low pressure, P Low, influences
The level and duration of lung deflation is determined by the low-pressure setting, Plow, and the release time, termed Tlow.
31
During PRVC ventilation, pressure is the target variable. T/F
FALSE.
-a desired tidal volume is set and the ventilator monitors and adjusts the airway pressure needed to deliver the target volume.
32
```
Cut offs
NIF
Vc
Vt
Ve
RSBI
RR
```
```
NIF -20
Vc 10ml/kg
Vt 5ml/kg
Ve less than 5 or greater than 10
RSBI 105
RR 35bpm
```
33
Modes
CMV (A/C), SIMV, CPAP, PCV (breath type), PSV (most common)
34
Breath sequence
Continuous Mandatory Ventilation (CMV)- all mandatory,
Intermittent Mandatory Vent. (IMV)- Both,
Continuous Spontaneous Vent (CSV)- all spontaneous
35
Acute ventilatory failure can be the result of
respiratory muscule dysfunction, excessive ventilatory load, impaired ventilatory drive, or dysfunctions of the lung parenchyma affecting gas exchange
36
Impending Ventilatory Failure based on
patient presentation and clinical judgement.
-known factors such as hx of pulmonary disease and acute physical manifestations such as increased WOB, Decreasing OX and or ventilation, and progressive worsening of symptoms such as dyspnea, may lead to clinician to suspect the acute vent failure is close at hand
37
PIP
Peak inspiratory Pressure, highest level of pressure applied to lungs during inhalation
38
Factors that impact PIP during VC ventilation
-Peak inspiratory flow setting
-Inspiratory flow pattern
-Auto-PEEP
-Tidal Volume
-Resistance
-Compliance
A higher set peak inspiratory flow results in higher PIP
--The decelerating flow pattern is associated with lower PIP
39
driving pressure
difference between PIP and PEEP
40
Higher levels of PEEP may be required in pts with serious oxygenation defects as seen with
ARDS and ALI, in order to maintain oxygenation, also useful in overcoming the breath triggering problems associated with auto PEEP
41
Gas distribution is better with what waveform
decelerating, there also may be improvements in synchrony between pt and vent
42
During positive control ventilation, which alarms can alert the clinician to changes in respiratory mechanics?
- High and Low Vt
- during pressure control, volume is variable and dependent on the pressure setting and respiratory system mechanics. Changes such as decreased compliance can be detected with low Vt alarms and improved compliance with a high Vt alarm.
43
Ventilation strategies for obstructive lung disease include
using a Vt low enough to maintain a Pplat of less than 30 cm H2O, usually in the range of 6 mL/kg of PBW.
- RR is used to normalize the pH as much as possible, but high rates- air trapping, inadequate exp time= hypercapnia
- I time is set as low as possible to maximize exp time and reduce auto peep
- FiO2 is titrated to the lowest level possible to maintain acceptable oxygenation
44
Acceptable oxygenation in obstructive lung disease may be
- SpO2 greater than 88%
| - PaO2 greater than 55 mm Hg
45
Settings that need to be ordered
Mode, Tidal volume or pressure set, rate, FiO2, PSV, and PEEP
46
triggering settings
Set as sensitive as possible
- Pressure: -0.5 to 2.0
- Flow: 2-3 below base flow (default)
47
Vt equation
Ti x flow
48
flow patterns
Square, descending ramp, ascending ramp, and sine
-Square shortest
Less effects on the heart
Higher peak pressure
-Descending ramp
Longer Ti
better gas distribution improving oxygenation
Higher mean airway pressure causing more cardiac impairment
49
Inspiratory cycle off
Used to help end a PSV breath
-swine wave
Either a percentage or a set flow rate
Makes it easier to end the breath so pt does not have to go to zero flow before the pressure is released
50
Inspiratory pause
Used to improve gas distribution and improve oxygenation
- Increases mean airway pressure causing more cardiac impairment
- Temp for determining lung compliance and airway resistance
- Set for 0.5 seconds for three breaths
- average number
- remember to turn off if not automatic
- remember it can affect cardiac output
51
Normal lungs (Post Op, Neuro-muscular, CNS, Etc) vent settings
A/C or SIMV
- Vt volume type breaths 6-10 ml/kg IBW
- RR to obtain desired Minute Ventilation
- Insp Flow/Ti: 60 Lpm or Ti 1 sec (longer=improve O2)
- FiO2 should be below 0.50 but is very pt dependant
- PEEP start at 3-5
52
Obstructive airway disease, invasive management
A/C or SIMV (SIMV preferred)
- Vt volume type breaths 6ml/kg IBW
- RR 10-12 , so they can spontaneously breathe in between
- Insp flow/ Ti: 60-100LPM or Ti <1 sec, try to keep E time long to reduce airtrapping
- FiO2 should be lowest possible to maintain SpO2 in low 90s
- PEEP to match auto-PEEP
53
How do you measure lung disease
FEV1
54
BE
Base Excess: represents the amount of an acid required to return pH to normal levels
Norm ranges -2 to 2
55
BD
Base Deficit represents the amount of a base required to return pH to normal levels.
56
SaO2
is a measure of the percentage of hemoglobin saturated with oxygen in arterial blood; it is a more accurate depiction of oxygenation than the noninvasive Spo2 provided through pulse oximetry.
57
Flow Volume Loop
help identify asynchrony
| -also be used to evaluate the degree of airway obstruction and the response to a bronchodilator medication.
58
One of the main causes of oxygenation defects is
V/Q mismatch
59
Factors that contribute to Paw (MAP) during mech. ventilation, including
PIP
PEEP
I:E ratio
Flow
60
With a current Paco2 of 56 mm Hg and a RR of 16 bpm, we are close to the patient's normal value, but the pH remains acidic. In an attempt to correct it, we can estimate what the Paco2 will be if we increase the RR to 18 bpm.
Current PaCO2 x Set RR = changed RR x X
56 x 16 = 18 x X
896 = 18x
x = 49.7
61
While a Pao2 of 110 mm Hg is great by most standards, remember that the patient is on 100% Fio2. We need to wean Fio2 as soon as possible, but we do not want the patient's oxygenation to fall below acceptable standards. We can predict how much Fio2 is needed to obtain our minimum standard of a Pao2 of 55 mmHg.
Current PaO2/ Current FiO2 = Desired PaO2/ x
110/ 100% = 55/ x
110 x 55/ 100 = x
x = 60.5 or 60% FiO2
62
Alveolar Ventilation factor of
RR, Vt, Deadspace (Vd/Vt)
63
Desired RR
Known PaCO2 x known RR/ Desired PaCO2
64
Desired Vt
Known PaCO2 x known Vt/ Desired PaCO
65
Effects of PEEP
```
Increases FRC by recruiting alveoli
increases lung compliance
improves gas distribution
improves oxygenation
by reducing shunting
```
66
influction point seen on
pressure. vol loop
| beaking= overdistention
67
What does static compliance tell us
stiffness of the lungs and chest wall
68
Compliance values for intubated pt
```
Norm 70-100 unusual for vent pt
mild 40-70
moderate 30-40
Severe <30
ARDS <25 unweanable
```
69
Airway resistance equation
Peak - Plateau
70
Ranges for Airway Resistance
norm 0-10cmH2O/L/s
moderate 11-15
severe >15
71
airway pressures and their ranges
Peak: great concern over 50
Plateau: kept below 30-35 (below 30, O2 problems)
-consider PCV if pressure excessive
-Mean airway pressures increase for better oxygenation reduce to keep side effects down to a minimum
72
Trouble shooting-Causes of sudden respiratory distress, Patient:
```
Airway
Pneumothorax
Secretions
Anxiety
Asynchrony
```
73
Trouble shooting-Causes of sudden respiratory distress, Vent:
```
Leak(ETT, Humidifier, Tubing connections)
Trigger
Flow
Circuit
Asynchrony
```
74
alarm settings
High/low volume = 10% or 100 mL above/below set value
High/low V̇e = 20% or 1 to 2 L above/below set value
High/low PIP= 10 cm H2O above/below PIP
High/low Fio2 = 5% above/below set Fio2
High RR = 10 breaths above
Apnea time = less than 20 seconds
75
norm inspiratory flow rates
40-100
76
Static compliance represents
lung compliance during periods of zero air flow, and as such, uses Pplat in its equation.
77
Dynamic Compliance represents
lung compliance during periods where gas flow is present, and as such, uses PIP in its equation.
78
With increased resistance, PIP/plat
PIP rises and Pplat remains the same.
79
With decreased compliance, PIP/plat
PIP rises and Pplat rises a commensurate level.
80
Asynchrony can be categorized in accordance with its cause:
Trigger asynchrony
Flow asynchrony
Cycle asynchrony
81
Other factors that impact the strength of the respiratory muscles include: (besides diaphragm)
Disease
Disuse
Hypoxia
Electrolyte imbalances
82
Which of the following factors encountered during mechanical ventilation may result in weakened respiratory muscles and an impaired ability to breathe spontaneously?
A.Increased O2
B. Electrolyte imbalance
C. Use of assist control (AC) mode of ventilation
D. Use of synchronized intermittent mandatory ventilation (SIMV) mode
E. Inadequate nutritional intake
B, C, D, E
83
respiratory load
is the WOB imposed on the respiratory muscles. Several different factors contribute to an increased respiratory load, which may prevent or otherwise make weaning from mechanical ventilation difficult.
- Minute ventilation
- Increased Resistance load
- Increased Elastic load
84
Strategies to minimize the respiratory load during and after mechanical ventilation include:
- Use of medications to treat pain, anxiety, and bronchospasm to reduce the need for high a V̇e
- Nutritional approaches that minimize the amount of excess carbon dioxide production
- Secretion clearance therapy and airway suctioning to reduce airway resistance
- Use of pressure support to provide gradually decreasing levels of ventilatory support
85
One method of evaluating the strength of the respiratory muscles is measuring
Maximum inspiratory pressure (MIP) or negative inspiratory force (NIF)
norm More negative than -20
86
Secretions increase the what instead of the what
load not the capacity
87
```
Which of the following are potential strategies for balancing respiratory muscle load and capacity?
A. Airway Suctioning
B. Use of Humidity
C. Use of pressure support
D. Use of bronchodilator
E. Optimizing nutritional status
```
A, C, D, E
88
adequate o2
Pao2/Fio2 ratio greater than 150 to 200
PEEP of 5 to 8 cm H2O
Fio2 less than or equal to 40% to 50%
pH greater than 7.25
89
Some of the spontaneous weaning parameters include:
A tidal volume (Vt) greater than 5 mL/kg
Respiratory rate (RR) less than 30 bpm
Minute ventilation ((V̇e) less than 12 L/min
Vital capacity (VC) greater than 15 mL/kg
-RSBI
90
SBTs have been conducted in a number of ways, including:
Spontaneous Breathing trials:
- SIMV with a gradual reduction in mandatory breaths (SIMV wean)
- Continuous positive airway pressure (CPAP) with gradual reductions in pressure support
- Disconnection from the ventilator and application of a T piece connected to a large-volume nebulizer with supplemental oxygen and cool or warmed aerosol
91
Aside from the patient possibly indicating that they are in distress, commonly used criteria that represent a need to return to ventilatory support include:
RR greater than 35 bpm for 5 minutes or longer
Hypoxemia with an Spo2 of less than 90%
Heart rate higher than 140 bpm or a sustained 20% increase above baseline
Bradycardia or a sustained 20% decrease below baseline heart rate
Hypertension (systolic pressure greater than 180 mm Hg)
Hypotension (systolic pressure less than 90 mm Hg)
Agitation
Diaphoresis
Anxiety
92
Patients being considered for weaning fall into 3 categories
Quick and routine (post op)
Slower more deliberate (TID weans)
"unweanable"- C1 fracture
93
Three stages of weaning
preweaning:access
Weaning: anyone with resp drive
Extubation: getting the ET out
94
Weaning Methods
- Daily SBT: 30min -2hrs
- TPiece: has 0 help on wean, Ve, Vt=difficult
- CPAP and PSV: 5-8 of PEEP, make sure pt has big enough Vt. should not offer support, min CPAP 5, and PSV 5-8
- SIMV
- Computer controlled wean: VC->VS
95
failure to wean: Systolic blood pressure
<90 or >180
96
Failure to wean HR
Sustained >20% above or below baseline or over 140
97
Vent Parameters, acceptable to extubate
```
RR <30
Ve <12
NIF >-20 (some say -30)
VC >15ml/kg or 1L
RSBI <105
```
98
RSBI equation
f/Vt ex. 16/0.5=80
99
Alarm important on weaning
high rr
100
Alarm important for leaks
ve
101
How to measure volumes
Wright respirometer- measure exhaled Vt for one minute.. giving you a Ve
manometer-NIF
102
single best indicator for extubation success
rsbi
103
NIV
is a means of providing ventilatory support without an artificial airway, and it can be provided through both positive and negative pressure.
104
General guidelines suggest that if a patient fails to demonstrate improvement within what on NIV
Module says 1-2 hours, cindy says .5-1 hour NIV initiation, alternatives should be considered
105
Indicators for NIV, first line therapy for several conditions
- COPD Exacerbation
- Acute Cardiogenic pulmonary Edema: CHF
- Resp Failure following transplantation
- Resp failure following lung resection
106
Strongest indicators for the use of NIV, which is a first line therapy and standard of care in this population
Acute worsening of COPD
107
Potential Contraindications of NIV, where the evidence doesnt support or is inconclusive regarding the use of NIV
- Acute Hypoxemic Respiratory Failure (ALI, ARDS)
- Asthma (unclear)
- Pts with do not intubate or do not resuscitate orders
- Failed extubation
108
NIV has been used successfully in the chronic care setting to treat chronic respiratory failure due to
restrictive lung disease, Stable COPD, and nocturnal hypoventilation, Chronic Respiratory Failure
-Full time use of NIV in the chronic care setting is most common in pts with chronic resp failure secondary to neuromuscular disease. Can serve as an alternative to tracheostomy
109
Which of the following are reasonable goals of NIV in the chronic care setting?
A. Reverse Disease condition
B. Prevent decreases in PaO2 while sleeping
C. Eliminate morning headache
D. Decrease Fatigue
E. Decrease PaCO2
B, C, D, E
110
For Critical Care vents, pressure
PSV is applied as additional pressure above the PEEP
111
In bilevel vents, pressure
IPAP and EPAP are set, with the difference between two designating the level of PS
112
ramp
More often found on machines used in the chronic care setting, ramp allows the positive pressure to increase gradually over a set delay-time control.
113
hypopnea
reduction in airflow associated with lower than normal rates of breathing
114
Most home CPAP machines can deliver pressures ranging from
3 to 20 cm H2O, with pressure titrated to the level needed to minimize apnea and hypopnea.
115
systems add heat and moisture to the inspired gas, reducing drying of the mucosa and improving patient comfort and compliance. NIV
passover type heated humidity
116
Ve and Va
Minute ventilation and alveolar ventilation, the main factors that facilitate the rate of removal of Carbon Dioxide from the blood
117
Alveolar Ventilation
determines the true amount of gas that reaches the alveoli to participate in gas exchange. It also controls for the amount lost through factors such as dead space and , if mechanically ventilated, the amount of compressible volume
118
Deadspace is defined as
areas of ventilation where there is no perfusion of blood to promote gas exchange.
-An example of this is the volume of air that remains in the conducted airways that never reaches the alveoli for gas exchange
119
Anatomical deadspace, and VA
Anatomical deadspace is estimated as 1ml/ilb of predicted body weight
- Va can be estimated as: (Vt- deadspace volume) x RR
- Excessive tubing or various adapters that are added to the vent circuit further increase the deadspace volume, impacting the Va
120
VILI
is the result of overdistention of the alveoli
121
Commonly measured pressures in lungs include
PIP
Pplat
PEEP
AutoPEEP
122
increases and decreases compliance?
- Elastance of the lung
- Obstructive diseases such as Emphysema increases the cl
- Restrictive diseases such as pulmonary fibrosis decreases it
123
Two points that can assist in setting PEEP and targeting a Pplat threshold level that maintains alveolar recruitment while avoiding overdistension
- the lower inflection point (LIP)
| - The upper inflection point (UIP)
124
LIP
lower inflection point (LIP)- represents the pressure at which a large number of alveoli are recruited. Setting the PEEP at this level helps improve oxygenation and prevents alveolar collapse
125
UIP
Upper inflection point (UIP)- represents the point at which a large number of alveoli are overdistended. Using volume or pressure control strategies that maintain Pplat below this threshold helps prevent alveolar overdistension and VILI
126
stress index method
evaluates the level of PEEP to avoid overdistension and underrecruitment of alveoli
-Used during constant flow tidal volume delivery (square flow waveform)
127
An upwardy concave sloping pressure-time curve suggests
Improved Cl and is scored as a stress index of less than 1, indicating additional potential for recruitment and increase levels of PEEP
128
A downwardly concave sloping pressure-time curve is scored as
a stress index of greater than 1, representing alveolar overdistension and the need to decrease PEEP and/or tidal volume
129
What increases minute ventilation in respiratory muscle load? Resistive load? Elastic load?
- Minute ventilation: Pain and anxiety, Sepsis, Increased deadspace, excessive feeding
- Increased Resistive Load: Bronchospasm, Secretions, Small artificial airways
- Increased Elastic Load: Low lung compliance, Low chest wall compliance, AutoPEEP
130
Norm BP range
```
Systolic = 90–140 mm Hg
Diastolic = 60–90 mm Hg
```
131
Normal MAP
65-105
132
Normal PAP
Pulmonary Artery Pressure
Systolic = 15–30 mm Hg
Diastolic = 4–12 mm Hg
133
Normal CVP
Central venous Pressure
| 0-8
134
Pulmonary Artery Wedge Pressure (PAWP)
2-12
135
he normal range for cardiac index (CI)
2.5-3.5l/min/m
136
Positive pressure applied intrathoracically during mechanical ventilation can impact
renal function and fluid balance.
- Mechanical ventilation has been shown to reduce the blood supply to the renal system, resulting in increased levels of antidiuretic hormone (ADH) and decreased atrial natriuretic peptide (ANP).
- The changes in these fluid-regulating hormones reduce urine output and promote fluid retention
137
Normal urine output is estimated at
1 mL/kg/hr of predicted body weight (PBW).
138
can help determine if reductions in cardiac output and changes in fluid balance are due to mechanical ventilation.
PA cath
139
Which of the following changes associated with mechanical ventilation may lead to increased fluid retention and a decrease in urine output?
Decreased ANP, Cardiac output, Increased ADH
140
Laryngeal edema
is a common occurrence after intubation and mechanical ventilation.
-It is caused by an inflammatory response to the irritation of the larynx during intubation or after extubation. Laryngeal swelling can result in significant airway resistance, making it difficult to breathe.
141
Normal alveolar stretching limits are reached in the range of
30 to 35 cm H2O; transpulmonary pressures in excess of this value can result in VILI.
-Repetitive tidal volume stretch with volumes greater than 9 mL/kg of PBW without maximum airway pressure exceeding 30 cm H2O may also contribute to VILI.
142
Which of the following conditions are classified as pulmonary barotrauma?
Subcutaneous Emphysema
Pneumothorax
pneumomediastinum
143
Positive pressure can impact the following body systems
Cardiovascular
Renal
Gastrointestinal
Pulmonary
144
PIP is the
pressure in the lungs at the end of inspiration
145
Pplat is
positive pressure in the lungs during inhalation and is measured during a period of zero gas flow, such as during an inspiratory pause
146
O2 toxicity leads to
ALI/ARDS
147
Signs of pneumothorax
subcutaneous emphysema
148
signs of tension pneumo
-Increased Peak Pressures
-Increased WOB
-Absent BS on affected side
-Mediastinal shift away
-Increase in HR and decrease Spo2
-Loss of BP/CO
CHEST XRAY IS BEST DX
149
Emergent tx for tension pneumo
14 guage needle
- anterior 2nd and 3rd on affected side, midclavicular space
- pt head up position
150
Cheyenne stokes breathing
increase in ICP, CHF, Hyoxia
151
ICP Monitoring
normal mean ICP is 10-15 in a supine position
15-20 compress the capillary bed and compromise circulation
30-35 venous drainage is impeded and edema develop
40-50 perfusion cannot be maintained
152
Cerebral perfusion pressure (CPP)
blood flow through brain
MAP-ICP
wanna maintain above 70
153
Glasgo Coma Scale
Scale 3-15
9-13 need ICU
8 or less need an ICP
154
Endocrine effects
increase in anti-diuretic hormone(ADH) causes lower urine output
several other hormone changes that may lead to lower urine output
155
Risks of VAP
```
nasal intubation
Reintubation
Low endotracheal tube cuff pressures
Supine position
Enteral feeding
Hyperglycemia
Blood transfusion
Inadequate staff
```
156
Does rate affect Pressures and volumes
no
157
Used to calculate volume
Flow control
158
Pressure, Volume, and Flow are dependent
time control
159
Sine Flow pattern
Sinusoidal, Flow gradually increases and decreases throughout inspiration
160
Pressure Alarms cause
Obstruction, Leaks, AutoPEEP
161
Descending flow
Longer Ti, better gas distribution improving O2, Higher MAP causing more cardiac impairment
-Set PK flow rate on PRVC
162
Ti and how to shorten or lengthen
Vt/ Flow
To shorten= increase flow rate, use square waveform (increases Pk, use when airtrapping), or decrease Vt.
-Decreasing Vt is usually not a good option due to CO2 changes
To lengthen= Decrease flow rate, use ramp waveform
163
Factors that affect flowrate on Ti set breaths
Vt, Ti
-Vt set and Ti set
Flow=Vt/Ti
To increase flow= shorten Ti, shorten rise time if available
To reduce flow= lengthen Ti, Lengthen rise time if available,
164
Phase Variables
Trigger-How breath is started
Cycled- How breath is ended
limited- How the breath is controlled after triggering and before cycling
Baseline- how the breath is controlled during exhalation (PEEP)
165
Triggering
time and pt triggering
166
patient triggered
pressure and flow triggered
167
Limiting (between triggering and cycling)
Pressure limited, volume limited, flow limited
168
Cycling (end of exp)
Volume Cycled, Time Cycled (most com), Pressure Cycled, Flow Cycled
169
Types of Breaths
```
Volume Breaths
-Flow limited time cycled
-Pressure Regulated Volume Control
Pressure Breaths
-Pressure limited time cycled
-Pressure limited flow cycled
Spontaneous
```
170
How breaths delivered
Full Support
Partial Support
Spontaneous
Automode
171
AutoMode Breaths
Changes modes dependent on the patient’s need for assistance.
Volume Control ↔Volume Support
PRVC ↔Volume Support
Pressure Control ↔Pressure Support
172
Full Support Modes are used for pts that
Full Support modes are used for patients that cannot breathe on their own or have very little ability to breathe on their own. Seriously ill patients (pneumonia, ARDS), patients that need a rest (COPD/Asthma for 1stday or so), Apneic patients (post-op,neuromuscular disease that cause paralysis, drug induce
173
Support Modes are for patients that can
Support modes are for patients that can breathe on their own but not adequately enough. Recovering patients (any of above as they get better), neuromuscular diseases (those that cause weakness), moderate respiratory failure (COPD, Asthma )
174
Pressure support that is okay to extubate
6-7
175
What would increase Expiratory time
increase flow rate
176
A patient on AC Volume Ventilation is experiencing airtrapping. What changes would reduce it?
decrease Ti
177
In PCV if you increase the pk pressures which parameter would also increase
Vt
Mechanical Ventilation
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