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mech vent Flashcards

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1
Q

What are side effects of increased PEEP?

A
  • barotrauma
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2
Q

Increase intrathoracic pressure from mech vent will?

A

decrease venous return = decreased preload and decreased CO

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3
Q

If you have an O2 prob you can change?

A
  • PEEP

- FiO2

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4
Q

if you have a vent prob you can change

A
  • RR

- TV (if on Bipap- you can increase IPAP to increase TV) and get rid of CO2)

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5
Q

what is IPAP used for?

EPAP

A

IPAP- positive inspiratory pressure.
- ventilation PaCO2. If PaCO2 is high, increase IPAP to increase TV
EPAP- expiratory positive pressure.
- oxygenation and gas exchange PaO2. improves lung compliance. If PaO2 is decreased then increase EPAP or FiO2

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6
Q

how do you know if you should use BiPAP or CPAP?

A

look at ABG. Is it O2 or CO2 issue? if CO2 is normal use CPAP

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7
Q

perfusion

A

deliver blood to cap bed

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8
Q

diffusion

A

across membrane

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9
Q

what is right shift curve?

A
  • decreased pH
  • increased temp
  • increased CO2

difficult pick up and the lungs but releases for tissues more easily

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10
Q

what do you look at when you want to wean someone from the vent?

A
  • PaO2 and Oxy/Hgb curve
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11
Q

inhale is what? and on the vent its what?

A
  • Active. - pressure intrathoracic

- on vent inhale is + intrathoracic pressure

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12
Q

what is a normal MAP? what does MAP indicate

how do you measure

A

> 65 normal
indicates best global EOP

(Diastolic x2) + systolic/ 3 =

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13
Q

Indicators for invasive mech vent:

QUIZ

A
  1. RR > 35
  2. PaCO2 > 55 with pH < 7.2
  3. PaO2 (with supplement O2) < 55
  4. severe dyspnea with use accessory muscles/trouble speaking/fatigue
  5. Resp arrest
  6. low TV/shallow resps
  7. cardiovascular complications (shock, HF, Hypotension)
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14
Q

what is the best indicator for ventilation?

A

PaCO2

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15
Q

COPD can have decrease in ? and increase in?

A

decrease in PaO2 and increase in PaCO2

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16
Q

what do we watch for on the vent?

A

Trends:

what did they start with? are the getting worse

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17
Q

Common meds for intubation

A
  • ketamine
  • Rocuronium (NMBA)
  • Phenylepherine (vasoconstrict)
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18
Q

What to monitor pre-intubation

A
  • position, Equip, moniotr (ECG, stats, BP…), Meds
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19
Q

What to do during intubation

A
  • Cricoid pressure (maybe)

- monitor

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20
Q

what to do post-intubation

QUIZ**

A
  • Bag PT
  • confirm position (auscultate, chest rise, tube at teeth, CO2 detector, secure tube
  • attach to vent
  • confirm with X-ray
  • put in OG
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21
Q

What is volume cycle vent?

advantage

disadvantage

A

Delivers preset or predetermined volume

advan: vol gas is controlled, constant O2 delivery

Disadvan: potential for excess airway pressures, barotrauma

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22
Q

What is pressure cycle vent?

A

deliver gas to the PT until predetermined system pressure is reached

  • TV will vary** depending on lung compliance
  • used for: when vol vent is not effective. For decreased lung compliance** and increased risk of barotrauma
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23
Q

when vol is a set parameter?

when pressure is a parameter?

A
  • pressure will vary

- vol will vary

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24
Q

goals of vent

A
  1. decrease WOB
  2. support/improve vent
  3. improve oxygenation
  4. balance pH
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25
what variable initiates change from exhalation to inhalation?
Trigger
26
the classification of + pressure is based on this variable
cycle
27
what is flow cycle vent
- set flow rate has been achieved
28
what is timed cycle vent
- set or predetermined time has elapsed
29
VT setting
6-10cc/kg normal 4-7cc/kg protective lung poor compliance
30
normal PEEP
5-15
31
Peak flow
Rate of gas delivery to a PT (40-100L/min)
32
I:E ratio
1:1-1:4 | normal is 1:3
33
sensitivity
amount of - pressure the PT has to generate to initiate own breath (ex. - 2 cmH2O)
34
airway pressure
Set in pressure cycled modes (PSV PCV)(pressure support and pressure controlled) ; peak inspiratory pressure (PIP) monitored in volume cycled modes (AC SIMV)
35
questions to ask when you see a vent
1. Vent settings 2. what is the PT doing? 3. What are my alarms set at?
36
controlled breath
- PT does no work, vent does all
37
Assisted breath
- PT starts to breath, vent takes over
38
Supported breath
- Pt can do some or most of the work, vent assists or finishes the work (pressure support)
39
assisted AC mode When do you use it? What is set What can the PT do? What to monitor
- To initiate vent. when full vent needed - RR, TV (PEEP, FiO2, alarms) - Pt can breath above set RR but receives pre-set TV - monitor RR (above set), MV (TVxRR), PIP/PLAT pressures
40
Assisted PC mode When do you use it? What is set What can the PT do? What to monitor
pressure controlled normal 15-25 - for decreased lung compliance - set RR, pressure (upper limit pressure) (PEEP, FiO2, alarms) - Pt can breath above RR but receives set pressure - monitor: RR (above), MV, TV
41
Spontaneous pressure support When do you use it? What is set What can the PT do? What to monitor
- weaning mode ICU - set pressure (boost), NO RR, NO TV (PEEP, FiO2, alarms) - Pt has to be able to breath spontaneously - monitor: RR, TV, MV
42
Hybrid SIMV + PS When do you use it? What is set What can the PT do? What to monitor
- weaning PACU - Set RR, TV (PEEP, FiO2, Alarms) (PS- added on spontaneous breaths) - PT can breath above RR but received OWN TV - monitor: RR (above), MV, PIP/PLAT pressures
43
All vent settings common assess
- ABGs - WOB - alarms
44
Ppeak
pressure airway peak - calc PEEP + set pressure = Ppeak
45
PIP
- the highest airway pressure generated by the delivery of the set Vt - elevated inspiratory pressure. indicates changes in lung compliance or something obstructing airflow delivery (secretions)- the whole system - pressure with each breath in entire system (lungs, tubes, ETT...) Normal is < or = 50
46
side effects of PEEP?
barotrauma and increased intrathoracic pressure
47
Plat pressure
pressure at the end of inhalation, like holding your breath - lung compliance - norm < or = 30
48
settings are?
on the bottom screen
49
what is PT doing?
on the left side screen
50
SIMV + PC
synchronized intermit mandatory vent - assist with spontaneous breathing - the PT can initiate breaths in between mandatory breaths - PTs own TV, varies by PT lung compliance - lung compliance reflects pressure - inspired pressure varies - PC normal 15-25
51
when do you extubate from SIMV?
wean PS down to 5 for 12-24hrs and then can extubate (5 is min)
52
TV is set at ...... for lung trauma
4-7cc/kg, when trying to protects against lung trauma
53
sensitivity determines
how much effort the PT has to make to trigger a breath or gas delivery from the vent
54
Peak or PIP is...
- determines the flow rate for gas to the PT | - may be 40-100L/min
55
For PT on AC mode, which changes to vent setting would decrease PaCO2?
increase RR or TV
56
on PC vent, which changes would you make to decrease PaCO2?
increase set pressure
57
increasing PEEP on a vent...
- increases baseline intrathoracic pressure | - can decrease venous return and preload
58
in AC mode, what is not monitored
set pressure
59
in PS mode, what is not monitored?
Set Tv
60
in PC mode what is not monitored?
Set Tv
61
Which parameter occurs in SIMV but not in AC?
spontaneous MV
62
in PCV and PSV, _______ influences_______ so minute vol must be closely monitored
compliance, TV
63
what does it mean if PIP increases?
lung compliance is decreasing
64
Pt is getting 10cm H2O PSV, exhaled TV has been decreasing from 450--> 375, what does that mean for lung complinace?
decreasing
65
Pt getting 10 cm H2O PSV, in 3 hrs their RR increased from 14--> 26, what does this indicate?
not enough PS
66
on SIMV mode, in the last 3 hrs Vt has decreased and their spontaneous RR has increased. what might this indicate?
Pt is fatiguing
67
Pt is vented with PCV with PS of 20cm H2O, iTime 1 sec, RR 16. you care concerned that lung compliance is deteriorating. What parameters will provide best indication that this is occurring
Exhaled TV
68
Responses to mech vent
-barotrauma - hemodynamic alterations - fluid retention (ADH secretion) - O2 related issues: atelectasis, toxicity - upper airway damage -
69
Nurse management of mech vent
- assess PT/moniotr/alarms - troubleshoot alarms - know complications of mech vent
70
vent alarm always start at the?
PT. if in doubt of airway patent/inadequate vent. the bag the PT with O2 connected - work from PT to vent
71
apart from secretions what else causes high pressure alarm?
- kink vent tube - biting on ETT - bronchospasm
72
low pressure alarm causes
- loose connections - low cuff pressure/cuff leak - crack in tubing
73
cause of low exhaled TV alarm
- PT tiring in weaning mode - cuff leak, low cuff pressure - bronchospasm
74
Low VT alarm and Pt cough and becomes restless, you?
listen to breath sounds and suction
75
increasing PEEP will? watch for? 3
- increase intrathoracic pressure and falsely increase CVP - drop in BP - preload - barotrauma
76
what would you want to give if you increase PEEP and have a low CVP?
NS bolus to increase preload
77
Pt is on PCV and has resp acidosis with mild hypox, what changes do you want to make
increase set pressure and increase PEEP increased PEEP = increased intrathoracic pressure = decreased venous return
78
PT on PCV and has resp acidosis, what do you change
increase pressure support
79
Pt on ACV set RR 20/24, Vt 350, FiO2 0.35, PEEP 5. Pr has resp alkalosis what is most approp intervent?
decrease Vt
80
what causes barotrauma?
rising PIP keep < 50!! more important to watch the trend
81
how does a fluid imbalance happen when vented?
positive pressure decreases venous return (increased intrathoracic pressure). This triggers the RAAS and increased ADH secretion. - watch urine O/P, CVP, and other indicators of preload
82
Pt has resp acidosis with mild hypoxic. On PC. what is the prob and what do you change?
Prob. Ventilation increase the pressure support will indirectly increase the Vt
83
Decreasing PEEP, you need to watch for potential for?
changes in lung compliance
84
positive pressure vent can lead to what lung complications?
- volutrauma | - pneumothorax
85
mech vent impacts GI system by?
- increase risk gastric ulceration and gastric distension
86
absorption atelectasis?
when FiO2 is close to 1.0 (100%)
87
high levels of O2 can lead to? 5
1. release of free radicles 2. increase lung inflam 3. atelectasis 4. pulm fibrosis 5. localized lung edema
88
how do you minimize high levels of O2
use or increase PEEP
89
Pt has metabolic acidosis with hypoxemia | FiO2 is 0.8 on PC 15, PEEP 5, Vt 250-325, RR12
potential complication for oxygen toxicity increase PEEP so that you can decrease FiO2
90
Airway management
- suction - warm humidified air to thin secretions (tenacious secretions) - mucolytics (aerosolized mucomyst) - reposition to mobilize secretions - bronchodilators to decrease airway resistance
91
suctioning
- If PIP increasing - pre-oxygenate for 30-60 sec 100%- for PT who desat easy or have high O2 needs - insert cath no longer than carina - less than 15 sec max - cont not int
92
increase in PIP could be from?
decreased compliance
93
what are the concerns with an increasing PIP for a PT on ACV
- barotrauma | - worsening pneumonia
94
beside changing vent settings, how can you decrease PIP?
- - provide sedation - chemically paralyze - provide verbal reassurance - ensure adequate analgesia
95
when switched to PC what would you monitor for lung compliance?
Tv
96
what do you want to change with partial comp metabolic acidosis
- decrease FiO2 and decrease PC
97
weaning methods
1. spontaneous breathing trials** ICU 2. progressive decrease in the level of pressure support in PSV** ICU (NOT decreasing PC- pressure) 3. progressive decrease in vent-initiated breaths in SIMV mode ** PACU 4. decreasing SIMV RR
98
SBT
lasts: 30-120 min - gradual decrease PSV to 5 bfr extube Short term- from OR: can use T-tube, CPAP, or low PS. Low rate SIMV 30 min then extubate
99
the RSBI calc readiness to wean
rapid shallow breathing index RR and TV
100
RSBI is 40-50 (RR/Tv)
<105 | indicates she is ready to be weaned
101
essential criteria for indicating PT readiness to wean
- PEEP 5-7 - FiO2 < or = .5 - low to no vasopressors - condition resolved or almost resolved - ability to initiate insp effort
102
a - inspiratory force of _____ and a VC of _____ ml/kg are parameters that are indicative of readiness to wean
< -10, >10
103
how do you know if a PT is not tolerating the SBT
1. sweating, agitation, anxiety 2. SpO2 < 88 3. PaCO2 increased by 10mmHg 4. HR >140 5. RR> 35 for > 5min with increased WOB 6. SBP <90 or >180
104
for long-term vents, approp weaning?
- regular decreases in PS - PS followed by AC rest periods - complete when able to breathe spontaneous for 24 hrs
105
common causes of failure to wean:
- source of resp failure not corrected - fluid vol overload - cardiac dysfunction - neuromuscular weakness - delirium - metabolic disturbances - anxiety
106
not ready to be extubated
- pH< 7.25 | - PaCO2 51
107
mech vent CVP goal
Now 8-12
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